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Citation: Rimbawan, R.; Nurdiani, R.;
Rachman, P.H.; Kawamata, Y.;
Nozawa, Y. School Lunch Programs
and Nutritional Education Improve
Knowledge, Attitudes, and Practices
and Reduce the Prevalence of
Anemia: A Pre-Post Intervention
Study in an Indonesian Islamic
Boarding School. Nutrients 2023,15,
1055. https://doi.org/10.3390/
nu15041055
Academic Editor: Mari
Maeda-Yamamoto
Received: 27 January 2023
Revised: 12 February 2023
Accepted: 17 February 2023
Published: 20 February 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
nutrients
Article
School Lunch Programs and Nutritional Education Improve
Knowledge, Attitudes, and Practices and Reduce the Prevalence
of Anemia: A Pre-Post Intervention Study in an Indonesian
Islamic Boarding School
Rimbawan Rimbawan 1, * , Reisi Nurdiani 1, Purnawati Hustina Rachman 1, Yuka Kawamata 2
and Yoshizu Nozawa 2
1Department of Community Nutrition, Faculty of Human Ecology, IPB University,
Bogor 16680, West Java, Indonesia
2Institute of Food Sciences and Technologies, Ajinomoto Co., Inc., Kawasaki City 210-8681, Kanagawa, Japan
*Correspondence: rimbawan@apps.ipb.ac.id
Abstract:
Indonesians face serious health issues that arise from malnutrition, particularly in children
who are under unfavorable dietary environments. The present study established a school meal
program consisting of dietary and educational interventions and evaluated its impact on promoting
continuous improvement in dietary behavior among junior and senior high school students in
Indonesia. A total of 319 students belonging to an Islamic Boarding School participated in the
pre-post intervention study for 9 months. All participants were assessed based on their Knowledge,
Attitude, and Practice (KAP). A subgroup of 115 participants who were anemic and underweight
was examined for dietary intake, nutrition status, and hemoglobin level. The KAP test scores for both
nutrition and hygiene showed a significant increase for all students and the undernutrition group
post-intervention. Protein, iron, and vitamin C intake significantly improved. Although there were no
significant improvements in nutrition status, there was a significant increase in the hemoglobin level
and a reduction in the prevalence of anemia from 42.6% to 21.7%. Thus, school meal program that
combines dietary and educational interventions may effectively improve anemia in undernourished
students as well as enhance the knowledge, attitudes, and practices related to health, nutrition, and
hygiene in junior and senior high school students.
Keywords: anemia; attitudes; diet; knowledge; practices; nutrition; school lunch program
1. Introduction
Non-communicable diseases, including lifestyle diseases due to overnutrition, are on
the rise as a result of economic development, particularly in Southeast Asia and South
America, while health issues related to malnutrition, such as stunting and anemia, still
exist among low economic regions. This situation is referred to as the ‘double burden of
malnutrition’ (DBM). DBM has become a serious problem in Southeast Asia. In a joint
report with the World Health Organization (WHO) and the Association of Southeast Asian
Nations, the United Nations Children’s Fund indicated that children from middle-income
countries in Southeast Asia face the DBM [
1
]. In particular, Indonesians face serious health
issues that arise from malnutrition. According to surveys conducted by the Indonesian
government, the prevalence of anemia was 12.4% and 22.7% in male and female children
aged between 13 and 18 years, respectively, while the prevalence of stunting was 35.1% and
31.4% in children aged between 13 and 15 years and between 16 and 18 years, respectively.
Furthermore, the percentage of overweight individuals aged 16–18 years increased from
1.4% to 7.3% between 2010 and 2013 [
1
]. The government views nutritional problems
among children as a top priority [
2
]. These nutritional problems are considered to be
Nutrients 2023,15, 1055. https://doi.org/10.3390/nu15041055 https://www.mdpi.com/journal/nutrients
Nutrients 2023,15, 1055 2 of 15
caused by the unfavorable dietary environment and behavior of Indonesian children. Most
schools in Indonesia have not adopted a school meal program, and the implementation
rate of the national system for the same was 0.14% in 2016 [
3
]. Consequently, children
purchase from school stores and nearby stalls and consume unhealthy food items that
are high in sugar and fat. This dietary habit is one of the causes of the DBM [
4
]. To
address this issue, the Indonesian government has implemented a school feeding program
in which supplementary food was provided. However, challenges arise due to allocation
of resources, diversity within the country, and management issues, which resulted in low
coverage of the program (0.14% in 2016) [
3
]. Hence, the impact of such programs towards
students’ nutritional behavior and nutrition status was difficult to measure.
Since then, academic and private sectors have adopted similar meal programs to
address other target groups, such as Islamic Boarding Schools. One of them was conducted
by PT Ajinomoto together with IPB University. They conducted a School Lunch Program,
which provided a balanced nutritious lunch combined with nutrition education.
This study aims to assess the impact of the school lunch program on the Knowledge,
Attitude, and Practice (KAP) scores, dietary intake, nutritional status, and hemoglobin level
of students. The result of this study is beneficial to determine the efficacy of the program
and it is potential to be expanded in other educational institutions.
2. Materials and Methods
2.1. Research Design
A pre-post quasi-experimental study was conducted at one of the Islamic Boarding
Schools in Java Island, West Java province, Indonesia. The intervention was a 9-month nu-
trition education program combined with the provision of a balanced lunch meal. Baseline
measurements were taken in January and February 2018. The intervention was imple-
mented between February and May and continued from July to December 2018. Midline
and endline measurements were taken on the same items during the last half of each phase.
2.2. Participants
The participants of this study were male and female junior and senior high school
students aged between 13 and 18 years who had attended the selected Islamic Boarding
School for one or more years. An informed consent briefing was held in December 2017
for the parents or guardians of 450 potential participants. Students whose parents or
guardians submitted written informed consent forms were included in this study. In total,
413 participants were screened for nutrition status and hemoglobin level. Students in their
final year of school, having difficulty participating in the educational program, suffering
from an infectious disease, having a blood hemoglobin (Hb) level of 7 g/dL or lower, and
with a body mass index for age z-score (BAZ) of
−
3 or lower were excluded from the study.
The excluded students also received dietary and educational interventions.
A subgroup of 115 students who were anemic and/or underweight and/or stunted
was specifically investigated further for their nutritional intake, nutrition status, and
hemoglobin level for the specific purpose of investigating the program’s impact before and
after the intervention. As per the WHO guidelines, the definitions of anemia and under-
weight were male students with a blood Hb level of 12 g/dL or lower and female students
with a blood Hb level of 11 g/dL or lower and students with a BMI-for-age z-score of
−
2 or
lower, respectively. Stunting is defined as Height-for-age z-score of <
−
2 or lower [
5
]. The
proportion of students who were anemic was 42% (n= 49), underweight 6% (n= 7), and
stunted 70% (n= 80). Some students had multiple malnutrition, for example stunting and
anemia, hence the total is not 100%. Sample size calculations were based on WHO recom-
mendations [
6
]. The minimum sample size required for the subgroup analysis was based
on the sample size calculated to detect a minimum change of 0.57 g/dL in the participants’
hemoglobin levels, with a standard deviation (SD) of 1.01 g/dL, a 95% confidence interval,
and a statistical power of 0.80. This resulted in a minimum of 86 participants. A total of
115 participants were included to account for anticipated dropouts.
Nutrients 2023,15, 1055 3 of 15
2.3. Intervention Methods
2.3.1. Dietary Intervention
One meal per day was provided during lunchtime at the school. Recommended
dietary allowances (RDAs) and recommended daily portions by age as defined for the
Indonesian population were used [
7
,
8
]. In the present study, the following two criteria
were selected for the nutrient content in school meals and ingredients to be used based on
the average values for males and females aged between 13–15 and 16–18 years:
(a)
30% of RDA calories and proteins per school meal
- Calories: 635–776 kcal/meal
- Protein: 18–22 g/meal
(b)
Includes staple food, animal-/plant-derived menus, vegetables, and fruits
Based on these conditions, 14 menu items were developed. School meals were pro-
vided in the dormitory cafeteria between 13:00 and 14:00 h six times a week. Details on
meals provided are presented in Supplementary Table S1.
2.3.2. Educational Intervention
This was conducted 2–3 times per month for a total of 25 sessions. One session was 15
to 45 min in duration and taught by the dormitory faculty; a research staff member was
in charge once every three sessions. Twenty-five dormitory faculty members participated
in training led by the research staff prior to the intervention. Two training sessions were
conducted for each term for a total of four times. Meal caterers were educated on hygiene
management and food safety once a month during the dietary intervention. Posters and
banners were applied throughout the school to enhance the students’ knowledge, attitudes,
and practices regarding health, nutrition, and hygiene.
2.4. Survey Items
2.4.1. Primary Evaluation Items
•Knowledge, Attitude and Practice Test Scores
The KAP model is a commonly used approach for assessing knowledge, attitudes,
and practices, particularly in the field of nutrition education. The model is based on the
notion that attitudes are transformed by acquiring knowledge on nutrition and health and
that practices are transformed owing to attitude transformation [
9
]. A KAP test designed
for this study was used to assess the knowledge, attitudes, and practices of all students
regarding health, nutrition, and hygiene. The questionnaire comprised 15 questions,
including 11 questions on a balanced diet, 3 questions on hygiene, and 1 question on
exercise. Knowledge-based questions could be answered by “yes” or “no” and questions
on attitude by “agree” or “disagree”, with the score being the number of correct responses
for both cases. Questions on practice were based on the frequency of behaviors on a
scale of 5, and the score was calculated based on the responses (“always” = 4 points,
“frequently” = 3 points, “sometimes” = 2 points, “rarely” = 1 point, and “never” = 0 point)
(see Supplementary Materials).
•Blood hemoglobin level
Blood hemoglobin levels were measured using the HemoCue
®
Hb 201 DM analyzer
(Ängelholm, Sweden). The measurement was carried out at baseline, and the results were
used to select students for the undernutrition subgroup. The Hb levels in the subgroup
were measured for the midline and endline measurements.
2.4.2. Secondary Evaluation Items
•Nutrition intake and nutrient adequacy ratio (NAR)
We estimated the intake of calories, proteins, fat, carbohydrates, iron, vitamin C, and
vitamin A from daily meals and lunch using the 24 h recall method and by meal evaluation
Nutrients 2023,15, 1055 4 of 15
based on a semi-quantitative frequency questionnaire. Using the following formula, we
also calculated the NAR for daily meals and lunches based on the male/female average
values of RDA for those aged between 13–15 years and 16–18 years (Table 1).
NAR per day (%) = Daily nutritional intake/RDA
NAR during lunch (%) = Nutritional intake during lunch/1/3 RDA
Table 1. Characteristics of the participants.
Total Students Subgroup Subgroup/
Total Students
(n) (%) (n) (%) (%)
Total 319 - 115 - 36.1%
Sex
Male 140 43.9% 35 30.4% 25.0%
Female 179 56.1% 80 69.6% 44.7%
Grade
1st 119 37.3% 33 28.7% 27.7%
2nd 50 15.7% 15 13.0% 30.0%
3rd 62 19.4% 19 16.5% 30.6%
4th 32 10.0% 14 12.2% 43.8%
5th 56 17.6% 34 29.6% 60.7%
•Nutrition status items
Body weight and height were measured to calculate the body mass index-for-age
z-score. Weight was measured using a Camry body scale, and height was measured using
a microtoise. Measurements were conducted by trained enumerators a minimum of twice.
Z-score was calculated using the WHO A—315
Anthro-plus software and later classified based on the WHO Multicentre Growth
Reference Study [10].
2.5. Statistical Analysis
Statistical analysis was performed using SPSS for Windows ver.20 (IBM, Armonk, NY,
USA). The significance level was set at p< 0.05. Data from participants with missing values
were excluded. To analyze the changes in each variable and compare the results of the
baseline, midline, and endline measurements, the Friedman test was used.
2.6. Review and Approval by the Ethics Review Committee
This study was reviewed by the Ajinomoto Institutional Review Board of Ajinomoto
Co., Inc. (Approval Number: 2017-025) and by the Ethics Review Committee of Bogor
Agricultural University to ensure that ethical considerations were complied with (023/IT3.
KEPMSM-IPB/SK/2018). This study was conducted in accordance with the Declaration
of Helsinki.
3. Results
3.1. Baseline Results
Students whose data were collected for all evaluation items were analyzed. The total
number of students was 319, of which 140 were males and 179 were females. The total
number of students in the subsample was 115, of whom 35 were males and 80 were females.
We collected questionnaires and all survey items from 73.5% of the students who submitted
the study consent form. The characteristics of the analyzed participants are summarized in
Table 1. The male-to-female ratio was approximately 4:6 for all students, but the percentage
of female students was higher in the undernutrition subgroup. The male-to-female ratio
in the undernutrition subgroup was 3:7. There was no significant difference between the
students as a whole and within the subgroup in the number of students by grade level, and
each grade level comprised 10% or more of the students in the study.
Nutrients 2023,15, 1055 5 of 15
3.2. Results on the Health, Nutrition, and Hygiene Aspects of the Knowledge, Attitude, and
Practice Test
Changes in the overall score for the health, nutrition, and hygiene items of the KAP test
showed that all aspects significantly improved among the total students and undernutrition
subgroup (Table 2). Both groups showed similar improvements. We subsequently examined
the correct response rate for each question regarding knowledge and attitude (Table 3). The
results showed a similar tendency between the total group of students and the subgroup
in the correct response rate at the endline. Additionally, 12 out of the 15 questions on
knowledge, and 14 out of the 15 questions on attitude had a correct response rate of
over 70%. The scores on practice showed varied differences between the total student
group and the subgroup at baseline, midline, and endline (Table 4). Therefore, we focused
on improving practice frequency and categorized endline–baseline changes as improved
and unimproved to observe the distribution (Table 5). The results showed that a higher
percentage of participants in the subgroup demonstrated improved practice than the total
group of students.
Table 2. Scores of the KAP test in baseline, midline, and endline.
Total Student (n= 319) Subgroup (n= 115)
Median (25%, 75%) p-Value Median (25%, 75%) p-Value
Baseline Midline Endline (Friedman) Baseline Midline Endline (Friedman)
Knowledge 9 (8–10) 12 (11–13) 12 (11–13) <0.001 9 (8–10) 12 (10–13) 12 (11–13) <0.001
Attitude 12 (11–13) 14 (12–14) 14 (13–15) <0.001 12 (11–13) 14 (12–14) 14 (13–15) <0.001
Practice 29 (25–33) 37 (33–42) 39 (34–43) <0.001 29 (25–33) 37 (32–43) 39 (34–43) <0.001
Table 3.
The response rate of knowledge and attitude in the KAP test at baseline, midline, and endline.
Total Student (n= 319) Subgroup (n= 115)
Correct Response (%) Correct Response (%)
Themes Questions Baseline Midline Endline Baseline Midline Endline
Knowledge
Clean and
Healthy
Lifestyle
Dressing neatly and cutting nails
are not one of the clean and
healthy living habits.
92.2 94.7 94 88.7 94.8 93.0
Drinking
Water
We are recommended to drink
five glasses of water every day. 91.2 78.7 87.1 93.0 72.2 87.0
Breakfast
Breakfast is required as a major
energy source before starting
daily activities.
2.5 99.7 97.5 2.6 72.2 99.1
Anemia Anemia/lack of blood is due to
not eating enough iron-rich foods.
89 89.3 98.1 89.6 87.0 98.3
Vegetable
Consumption
Teenagers who do not like
vegetables tend to become obese
in adulthood.
55.8 67.4 76.5 45.2 61.7 76.5
Food Label
Food labels can provide
information about the nutritional
contribution of the food to our
daily nutritional requirements.
81.8 92.5 91.2 77.4 92.2 91.3
Salt, Sugar,
and Fat
We don’t need to limit our sugar,
salt, and fat consumption because
they benefit our bodies.
97.5 94.4 96.2 98.3 93.0 94.8
Nutrients 2023,15, 1055 6 of 15
Table 3. Cont.
Total Student (n= 319) Subgroup (n= 115)
Correct Response (%) Correct Response (%)
Themes Questions Baseline Midline Endline Baseline Midline Endline
Balanced
Diet
Indonesia has a balanced
nutrition guide which consists of
four pillars of balanced nutrition,
which are: consuming diverse
foods, doing physical activity,
clean living habits, and
weight monitoring.
53.9 96.9 91.5 56.5 95.7 95.7
Pyramid of
Balanced
Diet
The balanced nutrition guidelines
are illustrated in the form of a
food pyramid; the group of foods
containing carbohydrates is
located at the top because we eat
the most of these every day.
31.3 27.3 42.9 33.9 24.3 51.3
Protein
Source
Milk, eggs, chicken, meat, and
beans are in the building
nutrients group.
11 18.2 14.4 8.7 86.1 17.4
Physical
Activity
It is recommended to do physical
activity or exercise at least once a
week for 1 h.
32 64.9 72.1 30.4 67.0 73.0
Fiber
Consumption
Constipation is due to a lack
of protein. 27.3 38.6 28.8 31.3 35.7 31.3
Hand
Washing
The right way to wash hands is
using running water and soap. 34.8 99.4 99.7 47.0 99.1 100.0
Adolescent
Nutrition
A lack of nutrients in young
women can cause malnutrition
during pregnancy
85.3 88.4 96.2 86.1 87.0 98.3
Surroundings
Cleanness
If the surroundings are dirty and
unhygienic, a person can easily
contract diseases.
84.6 97.8 91.5 85.2 97.4 93.9
Attitude
Clean and
Healthy
Lifestyle
Dressing neatly and cutting my
nails have no effect on my health 92.5 90.6 87.5 94.8 91.3 93.0
Drinking
Water
Drinking five glasses of water is
enough to fulfill my requirements
78.7 80.9 85.9 80.9 71.3 86.1
Breakfast
Breakfast is important to me,
because otherwise I will have
trouble concentrating in school
95.3 97.5 90.9 93.9 97.4 92.2
Anemia You shouldn’t worry if someone
is tired, weak, lethargic, and pale 92.5 92.8 96.2 90.4 87.8 95.7
Vegetable
Consumption
I must consume vegetables every
day to improve my digestion 49.8 97.2 90 49.6 96.5 94.8
Food Label
I don’t consider nutrition and
health information on food labels
when choosing food
71.2 85 84.6 73.0 85.2 90.4
Salt, Sugar,
and Fat
I will choose foods with less
sugar, salt, and fat even though
these are not as tasty as foods
high in sugar, salt, and fat
76.5 73 76.2 75.7 71.3 80.0
Nutrients 2023,15, 1055 7 of 15
Table 3. Cont.
Total Student (n= 319) Subgroup (n= 115)
Correct Response (%) Correct Response (%)
Themes Questions Baseline Midline Endline Baseline Midline Endline
Balanced
Diet
I can implement the four pillars of
balanced nutrition guidelines in
my daily life
80.6 94.7 94 80.9 91.3 94.8
Pyramid of
Balanced
Diet
The balanced nutrition pyramid
helps me choose the right foods 85 96.9 93.4 83.5 94.8 94.8
Protein
Source
Eating tofu and tempeh alone is
enough for building cells and
tissues in our body
50.5 60.2 60.5 56.5 60.9 64.3
Physical
Activity
I need to do physical activity
5 times a day in a week, for at
least 30 min
64.9 71.5 81.8 66.1 74.8 85.2
Fiber
Consumption
I need to consume vegetables and
fruits to avoid constipation 96.2 95.6 91.2 93.9 97.4 91.3
Hand
Washing
Washing hands with running
water is enough, if hands do not
look dirty
70.2 89 76.8 76.5 90.4 78.3
Adolescent
Nutrition
I don’t need to worry about my
nutritional status as a future
parent now
89 90 88.1 88.7 87.0 90.4
Surroundings
Cleanness
I need to pay attention to the
cleanliness of the surrounding
environment because it will affect
my health
91.2 98.1 98.4 93.0 100.0 98.3
Table 4. Scores on practice in the KAP test at baseline, midline, and endline.
Themes Questions
Total Student (n= 319) Subgroup (n= 115)
Median (25–75%) p-Value
(Friedman)
Median (25%, 75%) p-Value
(Friedman)
Baseline Midline Endline Baseline Midline Endline
Clean and
Healthy
Lifestyle
How often are you neatly
and cleanly dressed? 4 (3–4) 4 (4–4) 4 (4–4) 0.066 4 (4–4) 4 (4–4) 4 (4–4) <0.05
Drinking
Water
How often do you drink
eight glasses of water
per day?
3 (2–4) 3 (2–4) 3 (2–4) <0.05 3 (2–4) 3 (2–4) 3 (2–4) 0.186
Breakfast How often do you have
breakfast before 9 o’clock? 4 (3–4) 4 (3–4) 4 (3–4) <0.05 4 (3–4) 4 (3–4) 4 (3–4) 0.237
Anemia
How often do you consume
a source of iron (red meat,
chicken liver, iron tablets)?
1 (0–1) 1 (1–2) 2 (1–2) 0.063 1 (1–1) 1 (1–2) 2 (1–2) <0.05
Vegetable
Consump-
tion
How often do you
eat vegetables? 3 (2–4) 4 (3–4) 3 (3–4) <0.05 3 (2–4) 4 (2–4) 3 (3–4) <0.05
Food Label
Did you read the food label
before deciding to buy
packaged food?
1 (0–2) 1 (0–2) 1 (1–2) <0.05 1 (1–1) 1 (1–2) 2 (1–2) <0.05
Salt, Sugar,
and Fat
How often do you drink
sweet drinks? 2 (1–2) 2 (2–3) 2 (1–3) 0.460 2 (1–3) 2 (2–3) 2 (1–3) <0.05
Nutrients 2023,15, 1055 8 of 15
Table 4. Cont.
Themes Questions
Total Student (n= 319) Subgroup (n= 115)
Median (25–75%) p-Value
(Friedman)
Median (25%, 75%) p-Value
(Friedman)
Baseline Midline Endline Baseline Midline Endline
Balanced
Diet
How often do you
weigh yourself? 0 (0–1) 1 (1–1) 1 (1–1) <0.05 1 (1–1) 1 (1–1) 1 (1–1) <0.05
Pyramid of
Balanced
Diet
How often do you use the
balanced food pyramid as a
food guide?
0 (0–1) 2 (1–3) 2 (1–4) <0.05 1 (1–1) 2 (1–3) 3 (1–4) <0.05
Protein Sauce
How often do you consume
sources of animal protein?
(eggs, red meat, chicken)
1 (1–2) 2 (1–3) 2 (1–3) <0.05 1 (1–2) 2 (1–3) 2 (1–3) <0.05
Physical
Activity
How often do you do
physical activity
continuously for at least
30 min?
2 (1–2) 2 (1–3) 2 (1–3) <0.05 1 (1–2) 2 (1–3) 2 (1–3) <0.05
Fiber
Consumption
How often do you eat fruit? 1 (1–2) 3 (3–4) 4 (3–4) <0.05 1 (1–2) 4 (3–4) 4 (3–4) <0.05
Hand
Washing
Did you wash your hands
after using the bathroom? 3 (2–4) 4 (2–4) 4 (2–4) <0.05 3 (2–4) 4 (2–4) 4 (3–4) 0.605
Adolescent
Nutrition
How often do you seek
nutrition and
health information?
1 (0–1) 1 (1–2) 2 (1–2) 0.736 1 (1–1) 1 (1–2) 2 (1–3) <0.05
Surroundings
Cleanness
Do you help to clean up
your neighborhood? 4 (3–4) 4 (3–4) 4 (3–4) <0.05 4 (3–4) 4 (3–4) 4 (3–4) 0.251
Table 5.
Percentage of improvement or non-improvement from baseline to endline on practice section
in the KAP test.
Themes Questions
Total Student (n= 319) Subgroup (n= 115)
Improved Not Improved Improved Not Improved
%n%n%n%n
Clean and
Healthy
Lifestyle
How often are you neatly and
cleanly dressed? 9.4% 30 69.9% 223
14.8%
17 82.6% 95
Drinking
Water
How often do you drink eight glasses of
water per day?
10.7%
34 66.1% 211
29.6%
34 66.1% 76
Breakfast How often do you have breakfast before
9 o’clock? 5.0% 16 84.0% 268
14.8%
17 83.5% 96
Anemia
How often do you consume a source of iron
(red meat, chicken liver, iron tablets)?
18.2%
58 42.3% 135
59.1%
68 32.2% 37
Vegetable
Consumption How often do you eat vegetables?
12.9%
41 58.9% 188
38.3%
44 55.7% 64
Food Label
Did you read the food label before deciding
to buy packaged food?
15.4%
49 51.4% 164
43.5%
50 49.6% 57
Salt, Sugar,
and Fat How often do you drink sweet drinks?
10.7%
34 66.1% 211
14.8%
17 82.6% 95
Balanced Diet
How often do you weigh yourself?
14.1%
45 54.9% 175
33.9%
39 60.9% 70
Pyramid of
Balanced Diet
How often do you use the balanced food
pyramid as a food guide?
23.8%
76 23.5% 75
67.0%
77 22.6% 26
Nutrients 2023,15, 1055 9 of 15
Table 5. Cont.
Themes Questions
Total Student (n= 319) Subgroup (n= 115)
Improved Not Improved Improved Not Improved
%n%n%n%n
Protein Sauce How often do you consume sources of
animal protein? (eggs, red meat, chicken)
18.5%
59 41.1% 131
53.0%
61 39.1% 45
Physical
Activity
How often do you do physical activity
continuously for at least 30 min?
14.1%
45 55.2% 176
37.4%
43 56.5% 65
Fiber
Consumption How often do you eat fruit?
27.0%
86 13.8% 44
77.4%
89 11.3% 13
Hand
Washing
Did you wash your hands after using
the bathroom? 9.4% 30 69.6% 222
26.1%
30 70.4% 81
Adolescent
Nutrition
How often do you seek nutrition and
health information?
21.0%
67 33.2% 106
67.0%
77 23.5% 27
Surroundings
Cleanness
Do you help to clean up
your neighborhood? 8.5% 27 73.4% 234
18.3%
21 79.1% 91
3.3. Blood Hemoglobin Levels and Anemia
Table 6shows changes in the blood Hb levels of the participants in the subgroup.
Blood Hb levels were significantly improved at the time of endline compared to baseline
and midline measurements. Furthermore, based on guidelines provided by WHO [
5
], the
participants with a blood Hb level of 12 mg/dL or lower were categorized as anemic and
those with a higher blood Hb level as non-anemic to observe the distribution (Figure 1).
The percentage of anemic participants decreased by 21% from baseline to endline.
Table 6. Changes in blood hemoglobin levels at baseline, midline, and endline in the subgroup.
Subgroup (n= 115)
Median (25–75 Percentile) p-Value
Baseline Midline Endline (Friedman)
Hb concentration
12.5 (11.1–14.0) 12.6 (11.5–13.4) 13.1 (12.2–14.2)
<0.005
Nutrients 2023, 15, x FOR PEER REVIEW 10 of 15
Table 6 shows changes in the blood Hb levels of the participants in the subgroup.
Blood Hb levels were significantly improved at the time of endline compared to baseline
and midline measurements. Furthermore, based on guidelines provided by WHO [5], the
participants with a blood Hb level of 12 mg/dL or lower were categorized as anemic and
those with a higher blood Hb level as non-anemic to observe the distribution (Figure 1).
The percentage of anemic participants decreased by 21% from baseline to endline.
Table 6. Changes in blood hemoglobin levels at baseline, midline, and endline in the subgroup.
Subgroup (n = 115)
Median (25–75 Percentile)
p-Value
Baseline
Midline
Endline
(Friedman)
Hb concentration
12.5 (11.1–14.0)
12.6 (11.5–13.4)
13.1 (12.2–14.2)
<0.005
Figure 1. Changes of percentage of anemic and non-anemic students in the subgroup.
3.4. Nutritional Intake
Changes in nutritional intake from daily meals and lunch were analyzed using the
dietary records of the students in the subgroup (Table 7). The results showed that the
intake of all nutrients from lunch increased significantly. There was a significant increase
in all nutrient contents except for total calories and carbohydrate contents. The NAR was
calculated when 1/3 RDA was 100% (Table 8). Before the intervention, the adequacy ratio
was below 50% for all nutrients. After the intervention, the adequacy ratio was >60% for
energy, proteins, fat, and carbohydrates.
Table 7. Average lunch or daily nutritional intake in baseline, midline, and endline (n = 115).
Lunch
Daily
Nutrients
Baseline
Midline
Endline
p-Value
(Friedman)
Baseline
Midline
Endline
p-Value
(Friedman)
Energy (kcal)
239 ± 171
387 ± 136
434 ± 137.8
<0.05
1486 ± 720
1505 ± 498
1632 ± 489
0.12
Proteins (g)
7.5 ± 6.2
11.8 ± 5.5
11.1 ± 4.7
<0.05
19.0 ± 11
35.6 ± 14.3
36.3 ± 14.3
<0.05
Fat (g)
6.6 ± 7.8
12.1 ± 5.3
16.0 ± 5.9
<0.05
13.4 ± 8.6
21.8 ± 9.7
22 ± 11.2
<0.05
Carbohydrates
(g)
37.8 ± 27.7
58.0 ± 24.4
62.0 ± 23.7
<0.05
219.8 ± 105.4
226.9 ±
77.2
238.2 ±
71.6
0.26
Iron (mg)
1.0 ± 0.9
2.1 ± 1.
2.7 ± 1.3
<0.05
2.7 ± 1
6.9 ± 0.9
7.0 ± 1.0
<0.05
Vitamin C (mg)
3.4 ± 4.3
30.9 ± 28.1
17.6 ± 15.0
<0.05
26.22 ± 39.4
55.8 ± 54.4
40.8 ± 44.1
<0.05
Table 8. Median NAR of students at baseline, midline, and endline during lunch (n = 115).
Median (25–75 Percentile)
Figure 1. Changes of percentage of anemic and non-anemic students in the subgroup.
Nutrients 2023,15, 1055 10 of 15
3.4. Nutritional Intake
Changes in nutritional intake from daily meals and lunch were analyzed using the
dietary records of the students in the subgroup (Table 7). The results showed that the
intake of all nutrients from lunch increased significantly. There was a significant increase
in all nutrient contents except for total calories and carbohydrate contents. The NAR was
calculated when 1/3 RDA was 100% (Table 8). Before the intervention, the adequacy ratio
was below 50% for all nutrients. After the intervention, the adequacy ratio was >60% for
energy, proteins, fat, and carbohydrates.
Table 7. Average lunch or daily nutritional intake in baseline, midline, and endline (n= 115).
Lunch Daily
Nutrients Baseline Midline Endline p-Value
(Friedman) Baseline Midline Endline p-Value
(Friedman)
Energy (kcal) 239 ±171 387 ±136 434 ±137.8 <0.05 1486 ±720 1505 ±498 1632 ±489 0.12
Proteins (g) 7.5 ±6.2 11.8 ±5.5 11.1 ±4.7 <0.05 19.0 ±11 35.6 ±14.3 36.3 ±14.3 <0.05
Fat (g) 6.6 ±7.8 12.1 ±5.3 16.0 ±5.9 <0.05 13.4 ±8.6 21.8 ±9.7 22 ±11.2 <0.05
Carbohydrates (g) 37.8 ±27.7 58.0 ±24.4 62.0 ±23.7 <0.05
219.8
±
105.4
226.9 ±77.2 238.2 ±71.6 0.26
Iron (mg) 1.0 ±0.9 2.1 ±1. 2.7 ±1.3 <0.05 2.7 ±1 6.9 ±0.9 7.0 ±1.0 <0.05
Vitamin C (mg) 3.4 ±4.3 30.9 ±28.1 17.6 ±15.0 <0.05 26.22 ±39.4 55.8 ±54.4 40.8 ±44.1 <0.05
Table 8. Median NAR of students at baseline, midline, and endline during lunch (n= 115).
Median (25–75 Percentile)
Nutrients Baseline Midline Endline p-Value (Friedman)
Energy
44.2 (27.3–58.4) 61.7 (52.9–74.9) 68.5 (55.6–85.9)
<0.05
Proteins
45.1 (28.8–67.0) 65.5 (52.9–80.6) 59.1 (44.5–72.5)
<0.05
Fat
33.3 (48.3–60.4) 63.8 (43.5–75.8) 76.5 (60.4–93.2)
<0.05
Carbohydrates
43.7 (27.9–69.1) 67.0 (54.1–87.8) 71.3 (56.0–91.0)
<0.05
Fe 14.6 (8.0–24.0)
30.9 (19.9–35.0) 38.3 (26.7–45.9)
<0.05
Table 9shows the change in BAZ of the students in baseline, midline, and endline.
Meanwhile, Figure 2shows the nutritional status of the students in baseline, midline, and
endline divided into underweight (BAZ <
−
1), Normal (
−
1 < BAZ < 1), and overweight
(BAZ > 1). The percentage of students with underweight nutritional status decreased
(6.1% to 4.3% then 4.3%). This condition is similar to the normal status. Meanwhile, the
percentage of overweight nutritional status shows no significant changes. The Friedman
test shows that there was no difference in the nutritional status of students between the
beginning, middle, and end of the program (p> 0.05). The condition of nutritional status of
the students at the beginning of the program was quite good (94.5% of normal nutritional
status) and remained good at the end of the program (95.1% of normal nutritional status).
Table 9. Changes in BAZ at baseline, midline, and endline of students.
Subgroup (n= 115)
Median (25–75 Percentile) p-Value
Baseline Midline Endline (Friedman)
BAZ −0.09 (−0.7–0.8) 0.04 (−0.7–0.94) −0.08 (−0.79–0.92) 0.607
3.5. Factors Affecting Blood Hemoglobin Levels
We performed a simple linear regression analysis with the rate of change in blood
Hb levels (endline to baseline) as the dependent variable and the rates of change in the
score of each practice item and in the adequacy ratio of each nutrient as explanatory
variables to investigate factors that might have affected anemia improvement (Table 10).
The energy and iron adequacy ratios and the rate of change in the practice score for protein
Nutrients 2023,15, 1055 11 of 15
consumption showed a positive correlation with changes in blood Hb levels. However, fat
and carbohydrate adequacy ratios were negatively correlated with the rate of change in the
practice score for physical activity.
Nutrients 2023, 15, x FOR PEER REVIEW 11 of 15
Nutrients
Baseline
Midline
Endline
p-Value (Friedman)
Energy
44.2 (27.3–58.4)
61.7 (52.9–74.9)
68.5 (55.6–85.9)
<0.05
Proteins
45.1 (28.8–67.0)
65.5 (52.9–80.6)
59.1 (44.5–72.5)
<0.05
Fat
33.3 (48.3–60.4)
63.8 (43.5–75.8)
76.5 (60.4–93.2)
<0.05
Carbohydrates
43.7 (27.9–69.1)
67.0 (54.1–87.8)
71.3 (56.0–91.0)
<0.05
Fe
14.6 (8,0–24.0)
30.9 (19.9–35.0)
38.3 (26.7–45.9)
<0.05
Table 9 shows the change in BAZ of the students in baseline, midline, and endline.
Meanwhile, Figure 2 shows the nutritional status of the students in baseline, midline, and
endline divided into underweight (BAZ < −1), Normal (−1 < BAZ < 1), and overweight
(BAZ > 1). The percentage of students with underweight nutritional status decreased
(6.1% to 4.3% then 4.3%). This condition is similar to the normal status. Meanwhile, the
percentage of overweight nutritional status shows no significant changes. The Friedman
test shows that there was no difference in the nutritional status of students between the
beginning, middle, and end of the program (p > 0.05). The condition of nutritional status
of the students at the beginning of the program was quite good (94.5% of normal nutri-
tional status) and remained good at the end of the program (95.1% of normal nutritional
status).
Table 9. Changes in BAZ at baseline, midline, and endline of students.
Subgroup (n = 115)
Median (25–75 percentile)
p-Value
Baseline
Midline
Endline
(Friedman)
BAZ
−0.09 (−0.7–0.8)
0.04 (−0.7–0.94)
−0.08 (−0.79–0.92)
0.607
Figure 2. Changes in nutritional status of students.
3.5. Factors Affecting Blood Hemoglobin Levels
We performed a simple linear regression analysis with the rate of change in blood
Hb levels (endline to baseline) as the dependent variable and the rates of change in the
score of each practice item and in the adequacy ratio of each nutrient as explanatory var-
iables to investigate factors that might have affected anemia improvement (Table 10). The
energy and iron adequacy ratios and the rate of change in the practice score for protein
consumption showed a positive correlation with changes in blood Hb levels. However,
fat and carbohydrate adequacy ratios were negatively correlated with the rate of change
in the practice score for physical activity.
4.3
4.3
6.1
92.2
92.2
90.4
3.5
3.5
3.5
0.0 20.0 40.0 60.0 80.0 100.0 120.0
Endline
Midline
Baseline
Nutritional Status
Underweight Normal Overweight
Figure 2. Changes in nutritional status of students.
Table 10. Single correlation analysis with the rate of change in blood Hb levels as the variable.
Variable βCoef p-Value 95% CI
Lower Limit Upper Limit
Delta Nutrient Adequacy during Lunch
Energy 5.292 0.04 0.054 2.261
Proteins −0.642 0.132 −0.258 0.035
Fat −2.774 0.03 −0.666 −0.034
Carbohydrates −3.808 0.036 −1.275 −0.044
Iron 0.334 0.009 0.021 0.143
Vitamin C −0.21 0.032 −0.028 −0.001
Delta Score KAP
Knowledge 0.221 0.039 0.002 0.055
Attitude 0.024 0.822 −0.019 0.024
Practice −0.023 0.826 −0.032 0.025
1. CHLB 0.092 0.388 −0.2 0.508
2. Drinking water 0.034 0.763 −0.262 0.355
3. Breakfast −0.195 0.075 −0.52 0.025
4. Anemia 0.044 0.68 −0.269 0.411
5. Vegetable consumption −0.006 0.955 −0.292 0.276
6. Food labels 0.039 0.676 −0.196 0.301
7. Sugar, salt, fat −0.112 0.265 −0.378 0.106
8. Balanced diet 0.033 0.731 −0.325 0.461
9. Pyramid of balanced diet −0.016 0.883 −0.235 0.202
Nutrients 2023,15, 1055 12 of 15
Table 10. Cont.
Variable βCoef p-Value 95% CI
Lower Limit Upper Limit
10. Protein source consumption 0.267 0.007 0.109 0.652
11. Physical activity −0.277 0.005 −0.561 −0.107
12. Fiber consumption 0.145 0.151 −0.075 0.474
13. Hand washing −0.139 0.191 −0.445 0.091
14. Adolescent nutrition −0.087 0.425 −0.381 0.163
15. Environmental cleanliness −0.062 0.594 −0.429 0.248
4. Discussion
In the present study, nutrition and hygiene education and nutritionally balanced
school lunches were provided to students in an Indonesian Islamic boarding school. We
evaluated the impact of the intervention program by determining the KAP test scores, the
values of biological indicators, nutritional intake, and other measurements.
The changes in the KAP scores for nutritional balance and hygiene were studied. The
average knowledge score significantly increased after the intervention in the total student
group. Upon analyzing the correct response rate, 12 out of the 15 questions accounted
for over 70%. However, the correct response rates remained low after the intervention
for “protein source”, “fiber consumption”, and “pyramid of a balanced diet” at 14.4%,
28.8%, and 42.9%, respectively. To explore which part of the educational intervention was
most effective, we looked into the “balanced diet”, “physical activity”, and “handwashing”
components, whichever showed a marked increase in the correct answer rate. These high-
scoring components had an interactive program, such as card games and interview-type
workshops. A participative approach is recommended as an effective mode of education
for knowledge enhancement, not only in nutrition but also in a wide range of fields [11].
The overall average score on the attitude section increased significantly after the
intervention. The correct response rate for attitude according to each item tended to be
higher than that for knowledge, both during pre- and post-intervention. For example, the
correct response rate at the endline for “fiber consumption” was 28.8% for knowledge
(“constipation is caused by protein deficiency”), while it was 91.3% for attitude (“whether
vegetable/fruit intake is necessary for preventing constipation”). In the KAP test, guidelines
set forth by the Food and Agriculture Organization of the United Nations were followed.
Knowledge was defined as understanding a specific topic, whereas attitude was defined
as a positive or negative emotion/perception of a specific behavior [
9
]. Therefore, it is
suggested that the perception of appropriate behavior regarding health and nutrition may
not depend on having or lacking relevant knowledge.
Finally, the results of practice showed a significant improvement in the overall score
after the intervention; however, the score was 39 out of 50 after the intervention, which was
much lower than that of knowledge and attitude. This is assumed to be because questions
on knowledge and attitude were two-choice questions, whereas questions on practice were
regarding practice frequency and used a 5-point response scale, resulting in a smaller
proportion of the total score on the test. Therefore, the students were divided in the sub-
group into an improved group and a non-improved group based on the changes in practice
frequency, and the data were compiled by item to investigate the improvement in practice
in more detail. The results showed that items such as “anemia”, “pyramid of a balanced
diet”, “protein source”, “dietary fiber consumption”, and “adolescent nutrition” improved
in more than half of the participants. Xu et al. reported that knowledge enhancement
improves attitudes and practices [
12
]. However, the results of the present study showed
that the correct response rate after the intervention for knowledge and attitude was low for
items for which marked improvement was seen in practice. There are two possible reasons
for this result. The first is that questions of items on the same topic but with different terms
Nutrients 2023,15, 1055 13 of 15
in the KAP questionnaires resulted in the low percentage of correct responses. For example,
for “anemia”, knowledge about anemia and iron intake was examined in the knowledge
questionnaire and “action to be taken in an emergency to help an anemic person” was
the phrase used in the attitude questionnaire and the “intake frequency of iron-containing
foods” in the practice questionnaire. The questions for the attitude questionnaire differed
from the other two, resulting in a non-linked improvement in scores compared with those
of the knowledge and practice section of the KAP test. The second possible reason is the
effect of the dietary intervention. The items that improved in the practice section were
related to diet and nutrition. The increase in the practice frequency was maybe due to the
results of the “school meals” that were provided in which the students had an opportunity
for semi-forcibly practicing these items.
In terms of nutrition status, the study found no significant impact of the program
on changes in the BMI-for-age z-score. This is different from the findings of a systematic
review and meta-analysis done by Wang et al., who found that school feeding programs
increased the weight and height of students after one year of intervention [
13
]. Hence,
a longer duration of the SLP program could be suggested to result in changes in BAZ.
To confirm the program’s effects on anemia status, we analyzed the distribution of the
anemic and non-anemic groups before and after the intervention. We discovered that the
percentage of those who were anemic had significantly decreased. This was most likely
due to nutritional intervention, as the intake of iron and protein significantly increased
in the subgroup. Simple linear regression analysis showed a positive correlation in the
change in the blood Hb to the differences in the iron adequacy ratio and the practice score
for “protein source”, respectively. Similar findings were observed in a school feeding
program conducted by Sekiyama et al. [
14
] and Adelman et al. [
15
], but differed from
Amani et al. [
16
], who discovered that nutrition education improves dietary practices but
not hematologic indices. It can be assumed that total protein intake during the intervention
period increased as the practice score for “protein source” increased, indicating an increase
in the intake frequency of protein-source foods. Therefore, the increase in the iron adequacy
ratio and total protein intake may have led to hemoglobin synthesis and improvement in
anemia. In contrast, there was no correlation between the protein adequacy ratio calculated
based on data from the 24 h dietary recall and blood Hb levels. These results suggest that
an increase in the frequency of the protein intake from meals may be more important for
anemia improvement than the amount of protein per meal.
The present study has two limitations. First, it is a pre-post study. As the trial was
conducted at a single school, it was difficult to acquire a control group that did not undergo
dietary and educational intervention owing to considerations regarding the conduction
of the trial and ethics. To accurately demonstrate the intervention effects adequately,
an intergroup comparison between the intervention and control groups is necessary. In
addition, to see the single effect of dietary and educational interventions, two additional
groups (educational and dietary) are needed. This issue should be addressed in future
studies. Second, lunch was the only meal that was subjected to dietary intervention. Dinner
skipping appeared as a new issue as a result of implementing dietary intervention for lunch
only and educating students on the importance of breakfast. One reason is that making
lunch more nutritionally balanced led to higher satisfaction. To improve the school meal
program, these limitations must be overcome when designing the program.
5. Conclusions
The findings of this study suggest that a program combining dietary and educational
interventions may effectively improve knowledge, attitudes, and practices regarding health,
nutrition, and hygiene among junior and senior high school students. In addition, anemia
improvement was observed in students with undernutrition.
Supplementary Materials:
The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/nu15041055/s1, Table S1: School Lunch Meal Plan of 14 Menu (Cycles).
Nutrients 2023,15, 1055 14 of 15
Author Contributions:
Conceptualization: R.R., R.N. and P.H.R.; methodology: R.R., R.N. and
P.H.R.; software: R.N. and P.H.R.; validation: R.R., R.N. and P.H.R.; formal analysis: R.N. and
P.H.R.; investigation: R.R., R.N. and P.H.R.; resources: R.N.; data curation: R.R., R.N. and P.H.R.;
writing—original draft preparation: P.H.R., Y.K. and Y.N.; writing—review and editing: R.R., R.N.,
Y.K. and Y.N.; visualization: P.H.R., Y.K. and Y.N.; supervision: R.R.; project administration: R.N.;
funding acquisition: R.N. and R.R. All authors have read and agreed to the published version of
the manuscript.
Funding: This research was funded by PT Ajinomoto, grant number LEG/PTA/171011-660.
Institutional Review Board Statement:
This study was conducted in accordance with the Declaration
of Helsinki and was reviewed by the Ajinomoto Institutional Review Board of Ajinomoto Co., Inc.
(Approval Number: 2017-025) and by the Ethics Review Committee of Bogor Agricultural University
to ensure that ethical considerations were complied with.
Informed Consent Statement:
Informed consent was obtained from the parents or guardians of all
participants involved in the study.
Data Availability Statement:
The data presented in this study are available on request from the
corresponding author. The data are not publicly available owing to ethical reasons.
Acknowledgments:
We would like to acknowledge the students and Darussalam Islamic Board-
ing School who were involved in this research and PT Ajinomoto who has funded this program
and research.
Conflicts of Interest:
Y.K. and Y.N. were full-time employees of Ajinomoto Co., Inc., at the time of
research. The authors declare no conflict of interest. The funders had no role in the design of the
study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the
decision to publish the results.
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