Good Nutrition – Key to Healthy Children A multi-country school nutrition intervention in SEA:

Malaysia experience

Prof Dr Norimah A KarimOn behalf of Malaysia Technical

Committee of GNKHC

3 July 201934th Scientific Conference of Nutrition Society of Malaysia

Multi-country initiative of Implemented in Malaysia by

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Part A: INTRODUCTION- Programme owner: SEA-PHN Network - Implementation partner: NSM- About GNKHC

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About SEA-PHN Network

Southeast Asia Public Health Nutrition (SEA-PHN) Network comprises of five nutrition societies in Southeast Asia(Indonesia, Malaysia, Philippines, Thailand dan Vietnam), and

dedicated to promoting public health nutrition among the population and alleviating nutrition problems in the region.

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Food and Nutrition Society of Indonesia

Nutrition Society of Malaysia Nutrition Foundation of thePhilippines, Inc

Nutrition Associationof Thailand

under the Patronage of HerRoyal Highness Princess Maha

Chakri Sirindhorn

Vietnam NutritionAssociation

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Activities of SEA-PHN Network4

Network MeetingsDedicated Website

Programme GNKHC

1st SEA-PHN conference

Food-Based Dietary Guidelines of Southeast Asian Countries

NPAN of SEA countries –a review

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GNKHC programmeA multi-country nutrition education programme for school-going children, conducted by teachers, utilising a specially

designed nutrition teaching module developed by members of the SEA-PHN Network.

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In Malaysia, GNKHC programme is conducted by theNutrition Society of Malaysia (NSM) in two selected schools

(SK Padang Jawa & SK Puchong) with the permission of Ministry of Education Malaysia.

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- GNKHC

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Rationale of GNKHC Programme (1)• Malnutrition is a serious public health problem in Southeast Asian

countries, including Malaysia.• The double burden of malnutrition:

- Undernutrition (eg stunting and underweight; anaemia)- Overnutrition (eg overweight and obesity)

• Malnutrion also exists amongst school children in Malaysia:o Research by NSM and other researchers showed that more than 30% of

students experienced overweight and obesity:- The rates were almost similar amongst students in primary and

secondary school students.o 7% of students experienced stunting and deficiencies of iron, Vitamin A

and Vitamin D.

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Rationale of GNKHC Programme (2)• There are many negative effects associated with undernutrition, particularly

for school students, i.e. they may not be able to achieve optimum growth.

• Overweight and obesity are the factors leading to nutrition-related non-communicable diseases (NCDs) such as heart disease, diabetes and cancer inthe future.

• Malnutrition will affect the students’ ability to learn and subsequently affecttheir academic performance.

• The two main causes of these nutrition-related problems are unhealthyeating and sedentary lifestyles.

• These two factors can be prevented through nutrition education from young,i.e. amongst primary school children.

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Rationale of GNKHC Programme (3)• Thus, it is imperative to take prevention measures starting from a young age,

i.e. to provide nutrition education to school children

To decrease the prevalence of overweight and obesity

• Implementation of the nutrition education module previously (by variousparties including NSM) has been proven to be effective in improving thenutritional knowledge of students.

• The SEA-PHN Network is conducting a multi-country nutrition educationinitiative, namely GNKHC to empower students with knowledge about healthyeating and an active lifestyle.

To ensure that the growth and development, as well as the learningpotential of the students are achieved

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Objectives of GNKHC

1. To improve children’s knowledge, attitude & practice (KAP) on diet & physical activity.

2. To increase awareness of parents on the importance of healthy eating and active living among school children.

3. To emphasise to health and education authorities the importance of improving nutrition knowledge of school children.

4. To encourage schools and national nutrition societies to utilise the SEA-PHN Network nutrition module for future promotion to other school children.

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Goal of GNKHCTo empower school children with appropriate nutrition knowledge to enable

them to adopt healthier eating habits and be physically active.

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PART B:NUTRITION MODULEof GNKHC

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Components of GNKHC programme

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1. Training-of-Trainers Nutrition Workshop

• 2-day training session• For selected teachers• Led by Nutritionists

appointed by NSM

2. Roll-out of nutrition education

/lessons

• 9 lessons• For Year 3 students• To be completed in one

year• 30-45 minutes per lesson• To be conducted during

physical education class

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Teaching Materials of theGNKHC Nutrition Module

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For each teacher

Teacher’s Guidebook

Gantt Chart

Student Attendance Form

CD (Teaching Slides and & Interactive

Activity Slides of Topic 9)

Materials for interactive activities

Teacher’s Feedback Form

For each school

Parents’ Consent Form

Student’s Workbook

Pre-lesson & Post-lesson KAP Survey Form

Student’s Feedback Form

Parent’s Leaflet

Parent’s Feedback Form

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Topic 1 The Healthy Way of Eating: From Pyramid to Plate

Topic 2 Be Active, Be Healthy

Topic 3 Cereals, Cereal Products & Tubers for Energy

Topic 4 Veggies & Fruits for Health

Topic 5 Protein Foods Make You Grow Stronger

Topic 6 Limit Fats, Sugar & Salt for Health

Topic 7 Choose Safe and Healthy Foods especially when Eating Out

Topic 8 Use Food Labels for Healthier Food Choices

Topic 9 Review: Eat Smart and Be Active

Topics inGNKHC Nutrition Module

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For the Teacher: 1. Teacher‘s Guidebook

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• There are 9 topics in teacher‘s guidebook.• Teaching materials for each topic use specific

color theme.

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Content inTeacher’s Guidebook

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Answer SchemeTeaching Slides with Notes Feedback FormObjectives, Preparations, Activities Flow, Evaluation

Each topic consists of:

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For the Teacher: 2. Interactive Activities Material

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Game Cards (31 pieces)

Folding Card

Topic 1: The Healthy Way of Eating: From Pyramid to Plate

There are interactive activities for each topic.

Activity 1: Build Your Food Pyramid Activity 2: Healthy Plate

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Topic 3: Cereals, Cereal Products & Tubers for Energy

Folding Card

Game Cards (8 pieces)

Topic 2: Be Active, Be Healthy

Jumping rope (3)

Circuit-Training Activity Activity: From Farm to Table

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Topic 4: Veggies & Fruits for Health

Folding Card

Game Cards (8 pieces)

Activity: Veggies & Fruits Riddles

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Game Cards (5 pieces)

Topic 5: Protein Foods Make You Grow StrongerActivity: Food Bingo

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Game Cards (17 pieces)

Topic 6: Limit Fats, Sugar & Salt for HealthActivity: Food Investigator Game

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Game Cards

Topic 7: Choose Safe and Healthy Foods especially when Eating Out

Activity: My Smart Menu Choices

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Folding Card Game Cards (7 pieces)

Topic 8: Use Food Labels for Healthier Food Choices

Activity: Detective of Food Packaging Label

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Game Cards (2 pieces)

Topic 9: Review: Eat Smart and Be ActiveActivity: Eat Smart and Be Active Quiz

Quiz Slides(saved in CD)

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For the Teacher: 3. Teaching Slide

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PowerPoint file for teaching slides of 9 topics will be saved in CD.

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For the Student: 1. Student’s Workbook

• There are 1-2 worksheets to be completed after the lesson for each topic.

• Each workbook consists of:

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Learning Slides Worksheet

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For the Parent: 1. Leaflets

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• 8 GNKHC nutrition leaflets will be provided to parents so that they will understand what their children have learned in school.

• Teacher will distribute the leaflets for students after each lesson.

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The English module lessons (master version) was translated to Bahasa Malaysia, to be used in National Schools (Sekolah

Kebangsaan)

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Customisation of the module

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SUMMARY OF GNKHC 29

Training-of-Trainers Nutrition Workshop

(30 & 31 May)

Roll-out of nutrition lessons (9 Topics)

Introduction Session

Interactive Session

Education Session

Practice Session

Roll-out of nutrition education/lessons in school

(Jun – Sep)

1. Post-lesson KAP Survey2. Measurement of weight

and height

1. Pre-lesson KAP Survey 2. Measurement of weight

and height

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PART C:Pictorial Reportof GNKHC 2018- Malaysia experience -

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Implementation Schedule

School 1: SK Padang Jawa

School 2: SK Puchong

TOT workshop 30 & 31 May 2018 30 & 31 May 2018

Pre-activity KAP survey 11 Jul 2018 27 Jun 2018

Roll-out of nutrition education/lessons in schools

Jul – Nov 2018 Jun – Oct 2018

Post-activity KAP survey 15 Nov 2018 21 Nov 2018

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Training-of-Trainers (TOT) Nutrition WorkshopTeachers from SK Padang Jawa and SK Puchong

Nutrition Module Briefing

Interactive Session Q&A Session

Interactive Session

Anthropometric Measurement

Group Photo

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Conducted on 30 & 31 May 2018Selangor State Library

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Schools: SK Padang Jawa & SK Puchong

Measuring height Measuring weight Pre-lesson KAP Survey

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Roll-out in Malaysia: June – September 2018

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School 1: SK Padang Jawa

Nutrition Lessons

34Roll-out in Malaysia: June – September 2018

School 2: SK Puchong

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PART D:Implementation Reportof GNKHC- Malaysia Experience-

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361. Socio-demographic Data

Table 1.2: Distribution of students (post-activity) N = 131

Gender SK Padang Jawa, n (%) SK Puchong, n (%) Total, n (%)

Boys 36 (43.9) 16 (32.7) 52 (39.7)Girls 46 (56.1) 33 (67.3) 79 (60.3)

Total 82 (100.0) 49 (100.0) 131 (100.0)

Table 1.1: Distribution of students (pre-activity) N = 131

Gender SK Padang Jawa, n (%) SK Puchong, n (%) Total, n (%)

Boys 36 (43.9) 16 (32.7) 52 (39.7)Girls 46 (56.1) 33 (67.3) 79 (60.3)

Total 82 (100.0) 49 (100.0) 131 (100.0)

• A total of 131 students were involved in this programme.

• For both schools, there are more girls than boys.

• All the students are from Year 3 classes, and are 9 years old.

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2. Nutritional Status (BMI-for-age)

Table 2.1: Nutritional status of students (pre-activity) N = 131

Variables Sk Padang Jawa, n (%) Sk Puchong, n (%) Total, n (%)

Underweight 23 (28.1) 16 (32.7) 39 (29.8)Normal 38 (46.3) 22 (44.8) 60 (45.7)Overweight 10 (12.2) 7 (14.3) 17 (13.0)Obese 11 (13.4) 4 (8.2) 15 (11.5)

Total 82 (100.0) 49 (100.0) 131 (100.0)

Table 2.2: Nutritional status of students (post-activity) N = 131

Variables Sk Padang Jawa, n (%) Sk Puchong, n (%) Total, n (%)

Underweight 24 (29.2) 25 (51.0) 49 (37.4)Normal 35 (42.7) 20 (40.8) 55 (42.0)Overweight 10 (12.2) 4 (8.2) 14 (10.7)Obese 13 (15.9) 0 13 (9.9)

Total 82 (100.0) 49 (100.0) 131 (100.0)

Comparing the pre- & post-activity data, there were no improvement to their BMI results and the prevalence of underweight and overweight/obese were still high.

As the measurement of pre-activity BMI and post-activity BMI was about 6 months apart, any changes to BMI cannot be attributed to the effect of the module.

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3. Pre- & Post-Activity KAP Score

KAP Score Categories SK Padang Jawa, n (%) SK Puchong, n (%) Total students, n (%)

A. Knowledge

Increase 52 (63.4) 19 (38.8) 71 (54.2)

Maintain 9 (11.0) 8 (16.3) 17 (13.0)

Decrease 21 (25.6) 22 (44.9) 43 (32.8)

Total 82 (100.0) 49 (100.0) 131 (100.0)

B. Attitude

Increase 37 (37.1) 26 (53.1) 63 (48.1)

Maintain 14 (17.1) 7 (14.3) 21 (16.0)

Decrease 31 (37.8) 16 (32.6) 47 (35.9)

Total 82 (100.0) 49 (100.0) 131 (100.0)

C. Practice

Increase 33 (40.2) 22 (44.9) 55 (42.0)

Maintain 6 (7.3) 5 (10.2) 11 (8.4)

Decrease 43 (52.5) 22 (44.9) 65 (49.6)

Total 82 (100.0) 49 (100.0) 131 (100.0)

Table 3.1: Changes in KAP score of SK Padang Jawa and SK Puchong students

38Malaysia

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Knowledge, attitude and practice (KAP) scores of students:• Nutrition knowledge (K) and attitude (A) scores of the students (both

schools) showed an improvement following the module implementation as indicated from the percentage of students who increase in their scores.

• However, % of students decrease in their practice (P) scores increased. It may be due to multiple factors influencing the practice of the students, i.e. foods prepared by parents, availability foods in cafeteria, etc.

• The results showed that the module taught by the teachers was understood by the students but they do not practise consistently in their daily life.

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Summary of results

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4. Monitoring Evaluationa. Feedback by teachers

i. Module ii. Overall programme

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Summary of teachers’ feedbackTeachers' feedback on the module:• The teachers assessed that the overall delivery of the information in the

topics are easy to handle (scale of 3 – 5, i.e. fair to good). However, a teacher concluded that topic 1 delivery was slightly difficult to handle (scale of 2, i.e. poor). This is probably because it is the first topic and the execution wasn’t smooth.

• Teachers commented that interactive activity in each lesson helped the students to understand the topic better (scale of 3 - 5). Interactive activity is a form of active learning which can attract the students’ attention.

• Teachers ranked that the lessons were interesting for the students (scale of 3 – 5, fair to good). This could be due to various interactive and fun components of the module.

• Teachers viewed that the students understood the education message delivered in these topics easily (scale of 3 – 5) but can be improved especially for topic 1 (3 teachers ranked scale of 3), topic 3, 8 & 9 (2 teachers ranked scale of 3).

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Teachers' feedback on the overall programme:• 3 out of 4 teachers agreed that the time allocation (45 minutes) for each lesson was

sufficient while there was a teacher (25%) who felt that the time was too short. It may be because the teacher needed more time to ensure that the students focus and understand the lessons in the module.

• All teachers agreed that the module is appropriate for Year 3 students (9 years old), students gained nutrition knowledge from this module, interactive activities were useful, the module is suitably prepared and they will use this module in the future to teach other students.

• 3 out of 4 teachers agreed that the students understood the lessons in the module, but one teacher (25%) viewed that only selected topics were understood by the students. This could be due to the execution of the topics and the students’ interest in selected topics.

• 3 out of 4 teachers commented that there were some challenges in conducting this programme which included

• difficulty to spend time teaching due to their heavy workload (3 out of 3 teachers)• students’ full schedule (2 out of 3 teachers) • there are too many tasks to perform in a lesson (2 out of 3 teachers)

• The challenges listed by the teachers were valid as the workload and commitment of a teacher is high.

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Summary of teachers’ feedback

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4. Monitoring Evaluationb. Feedback by students

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• Almost three quarters of students (71%) felt that the nutrition lessons taught bythe teachers were easy to understand. This showed that the module is appropriatefor this age group.

• Slightly more than half of the students (>50%)• enjoyed doing the exercises in the book• practising the knowledge obtained from the lessons• sharing the information• recommended the programme to others

• Slightly more than half of the students (52.7%) also brought back the leaflets andgave to their parents. Less than half (41.2%) discussed the nutrition information withtheir parents. As parents usually make decisions on the type of foods to be providedfor the kids, it is important that parents have knowledge on nutrition.

• The lesson that the students enjoyed the most was Topic 2 – physical activity (55%). This is probably because the kids love physical activities and the topic is easy to understand and can be practised in daily life.

• The lesson that the students least enjoyed is Topic 6 – limit fats, sugar and salt (10.7%). As this topic taught the students to reduce fats, sugar and salt, it involved limiting their favourite foods, hence they dislike this topic.

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Summary of students’ feedback

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• Representatives from the country nutrition society visited and monitored the lessons being conducted by teachers from time to time.

• They also reported their observations on the conditions of the school cafeteria.

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4. Monitoring Evaluationc. Field Visit by TWG representatives

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Summary of field visit• The field visit is beneficial as TWG representatives are able to evaluate the

actual conduct of the lessons by the teachers and the response of the students. TWG representatives are also able to observe the challenges faced by the teachers.

• Below are some observations from the TWG representatives: • Not all teachers are committed to conduct the lessons• Due to packed school schedule, it is difficult to find time to teach the

lessons• The observation on school cafeteria allowed us to obtain some information

whether the students are able to practise healthy eating in schools. • Below are some observations from TWG representatives:

• Very little food choices from the cafeteria• The food operators tend to sell food items that students likes rather

than healthy

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4. Monitoring Evaluationd. Parents’ feedback

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• Of the 131 students who participated in this programme, we only managed to receive 22 (16.8%) completed forms from the parents. As the students have to bring home the forms and return the next day, they may have misplaced the forms or did not inform their parents about the forms.

• From those parents who have completed the forms, 40.9% of the parents commented that there were slight improvements in their child in terms of nutrition and food choices. It may be because drastic changes cannot be made in a short time as they were already familiar with their daily habits.

• 18.1% of the parents read all the leaflets while 50% of them read some of the leaflets. The possible reasons include lack of interest among the parents, parents were busy, or they already have the nutrition knowledge.

• More than half of the parents (68.2%) said they can understand all the nutrition leaflets easily. The leaflets have simple information and interesting graphics.

• There was a suggestion to compile the leaflets into a booklet. This will help to ensure all the information are received by the parents.

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Summary of parents’ feedback

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The Good Nutrition Key to Healthy Children (GNKHC) Module were implemented by the trained teachers.

• However, due to conflict of classes and schedule, a few teachers who attended the TOT workshop and the actual teachers who conducted the lessons were not the same.

• Hence, some lessons were not conducted smoothly by the teachers.

The mean score of the nutrition knowledge and attitude of students showed improvement following implementation of the lessons by the teachers. However, the number of students decrease in their practice scores increased.

• As the availability of food choices for the students were determined by various factors, including parents’ decisions, food choices in cafeteria, etc., the practice of the students cannot be fully controlled by the students.

• However, with the improved knowledge and attitude, it is hoped that the students will be able to make healthier choices when they can decide on their foods in the future.

Most of the teachers agreed that the content of the module was suitable for year 3 students (9 years old) and appropriate for teachers to teach students about nutrition.

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6. Conclusion & Recommendations (1)

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• The feedback obtained from the teachers throughout the implementation of nutrition lessons should be taken into consideration when planning for future programmes.

• As this programme was an extra curriculum activity that were added into the teachers’ workload, they may have felt on the burden to implement it effectively.

• Hence, it is recommended to:• Condensing the module into fewer lessons• Implement as a nutrition camp (i.e. after school hours/ weekends) so that it will not

disturb the classes• Discuss with Ministry of Education/ school authority to provide incentives to the

teachers who implement this module• Continuous effort to implement a systematic nutrition programme in primary schools

should be continued to promote healthy lifestyle as this will help to prevent increasing prevalence of childhood overweight and obesity, as well as underweight.

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6. Conclusion & Recommendations (2)

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Acknowledgement• Members of the Malaysia Technical Working Group

– Dr Tee E Siong (Chair of TWG)– Prof Dr Norimah A Karim– Dr Zawiah Hashim– Assoc Prof Dr Chin Yit Siew

• Headmaster, teachers and students of the participating schools– SK Padang Jawa– SK Puchong

• Council members of the SEA-PHN Network for contributing to development of the module.

• Associate members of the SEA-PHN Network for funding this programme. • Versacomm Sdn Bhd, Secretariat of the SEA PHN Network for assistance in the

planning, implementation, monitoring and evaluation and preparation of this report

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Enquiries and further information:

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Website: https://sea-phn.org

Dr Tee E SiongChairman, SEA-PHN NetworkPresident, Nutrition Society of Malaysiapresident@nutriweb.org.my

Muhaini Hussin/Yvonne ChweeVersacomm Sdn BhdSecretariat SEA-PHN Networksecretariat@sea-phn.org

End & Thank You