SELECTED FACTORS VIS-A-VIS FOOD PREFERENCES OF SCHOOL-

AGED CHILDREN OF SCHOOLS IN MABALCAT CITY:

AN IMPLICATION FOR COMMUNITY
HEALTH NURSING

A Thesis Proposal Presented to

the Faculty of the Graduate School
ANGELES UNIVERSITY FOUNDATION

In Partial Fulfillment
of the Requirements for the Degree
MASTER IN NURSING

Submitted by:

Ylamher Claire B. Bufi, R.N., CCS

September 17, 2016

CHAPTER I
 THE PROBLEM AND ITS SETTING

INTRODUCTION

We are indeed much more than what we eat but what we eat can nevertheless help us to be
much more than what we are
-Adelle Davis

Eating is considered both as a necessity and a luxury in a person’s life. Necessity in a

sense that a person will not be able to live without it and a luxury which makes a person crave

for more. Everyday, people take pleasure in varied choices and options in many aspects of daily

living. All these social and economic changes are accompanied by shifts in dietary and physical

activity patterns. Proper food intake will supply the body with enough energy to maintain its

normal body processes. Though it has been believed that the more a person eats, the healthier a

person is in reality, the quality of the food you are eating is the best factor to make a person

healthier.

Several times a day, you make food choices that influence your body’s health for better

or worse. Each day’s choices may benefit or harm your health only a little but when these

choices are repeated over years and decades, the rewards or consequences become inevitable.

That being the case, paying close attention to good eating habits now can bring you health

benefits later. Conversely, carelessness about food choices can contribute to many chronic

diseases prevalent in later life, including heart disease and cancer. Of course, some people will

become ill or die young no matter what choices they make, and others will live long despite
making poor choices. For the majority of us, however, the food choices we make each and

everyday will benefit or impair health in proportion to the wisdom of those choices (Long, et.al,

2003).

According to the United States Department of Agriculture (USDA), most children in the

United States have a diet that needs improvement or is poor and the quality of children’s diets

tend to worsen as they age. One of the key areas of decline from age two to age nine is in how

many fruits and vegetables children eat. Only 25 percent of the children aged seven to nine eat

the recommended levels of fruits and only 22 percent eat the recommended number of

vegetables. And juice counts as a fruit, even though it does not contain the fiber of whole fruit. In

fact in the USDA’s list of the top foods eaten by children the first source of fruit appears down at

number fourteen as juice. And no vegetable other than potatoes makes it to the top thirty (Britten,

et.al, 2012). Whereas the School Food Trust (SFT) surveyed 136 8-to-10 year olds in six primary

schools in Sheffield in February and March 2007. Of those children who brought in a packed

lunch, 65% had a food item from the confectionery and snacks categories, with 28% eating both

confectionery and savory snack item. Thirty one percent of packed lunch’s contained a drink

which did not meet the food based standards. However more children with a packed lunch chose

fruit (31%) than pupils who ate a school lunch. The mean content of energy, carbohydrate, non-

milk extrinsic sugars, total fat, saturated fat, and sodium were higher and fiber content

significantly lower for school-aged children (Wordell, et.al, 2012). Encouraging take up of

healthy food is a complex task, because ultimately the pupils (particularly in school aged

children) have a choice about what to eat. If adults do not make healthy choices, as evident from

the latest National Diet and Nutrition Survey in 2008, why should we expect school-aged

children differently? They are even less well equipped than the adults in terms of knowledge and
understanding of the health consequences of poor dietary choice (Bassett, Gwen and Beagan,

2008). Another study conducted by Baranowski, et.al showed that only 2% of about 3,300

children 2-19 years old had met their recommended servings from all five food guide groups.

Clearly the diets of many school age students can stand general improvement particularly with

regard to fruit, vegetable, whole grain and dairy choices. Drinking minimal amounts of sugared

soft drinks are also advised. Another survey included in the same study school children

highlighted the need for nutrition education. On the day of the survey, 40% of the children did

not eat any vegetables except for potatoes or tomato sauce, 20% ate no fruits and 75% snacked at

least twice. Some 36% of the students ate at least four different types of snack food.

(Baranowski, et.al, 2000).

In the Philippines, according to 2001 statistics conducted by Food and Nutrition Research

Institute (FNRI) of the Department of Science and Technology (DOST), 31.8 percent of school

aged children are underweight, 32 percent are stunted, and 6.6 percent suffer from wasting. FNRI

showed that it is not only clinically severe malnutrition, but also moderate malnutrition, that

exponentially increases mortality risk in young children. Moderate malnutrition also places

children at risk of delayed cognitive and psychomotor development and of increased immunity.

(FNRI, 2001) In observance of nutrition month last July 2010, the Department of Education

(DepED) launched an information campaign with the theme, “Batang May Kinabukasan, Sa

Wastong Nutrisyon Simulan” which focuses on the importance of ensuring good nutrition among

the schoolers. Local government units on the other hand, particularly the City of Manila,

organized a series of activities in their districts, such as feeding, weighing, deworming, and

Vitamin A and Iron supplementation. The city government also conducted nutrition- related

activities including daily feeding programs for school children in the city’s 71 public elementary
schools and pre-schoolers in the city’s 340 day care and 28 home-based centers (Department of

Education, 2010). Considering that under nutrition would also diminish the cognitive and

physical development of these children into later life, the nutrition of the school-aged children

should also be emphasized thus, factors affecting food preferences of the school-aged children

should be noted.

Meanwhile, World Health Organization (2008) globally estimates that 1.5 billion adults,

20 and older, were overweight. Of these 1.5 billion overweight adults, over 200 million men and

nearly 300 million women were obese. Overall, more than one in ten of the world’s adult

population was obese. In 2010, around 43 million children under five were overweight. Once

considered a high-income country problem, overweight and obesity are now on the rise in low-

and middle-income countries, particularly in urban settings. Close to 35 million overweight

children are living in developing countries and 8 million in developed countries. These statistics,

as previously stated, the children aged 6 years old onwards has been overlooked.

There are more children of school age, and more children going to school than ever

before. Around 90% of the world’s children now survive beyond their 5th birthday. These

successes raise new concerns. Ill health and nutrition compromise both the quality of life of

school-aged children and the potential to benefit fully from what might be the only education

they receive. Nutrition problems of school-aged children may include different factors that may

be related to the food preferences in school-aged children which is greater and more widely than

previously thought (Bisogni, et.al, 2002). With this in mind, it really is also important to focus on

the children aged six and above for proper management either at school or at home. We should

take note that eating habits are established early in the life cycle and tend to carry through to
adulthood. As a result, the food that children eat now will undoubtedly influence their state of

health in later life.

BACKGROUND OF THE STUDY

Because it is easier to establish positive health attitudes than change negative ones, it is

universally accepted that appropriate food and nutrition education needs to start at an early age

(Borra, et.al, 2003). The focus of the researcher is the seemingly unique factors affecting the

food preference of school-aged children on the chosen locale and how these factors are

correlated with the subject phenomenon. Since nurses are responsible for public and community

health programs or campaigns, nurses must serve as a guide not only for the parents but also for

the child as well in contributing to a healthy lifestyle. Because children tend to eat what they

like, focusing on factors that influence the aspect of “preference” by changing what children

desire to eat could be an extremely effective avenue towards improving children’s dietary

patterns. The researcher emphasized the importance of determining the children’s food

preferences as it is strongly influenced by their experiences with foods, through a multitude of

sensory mechanisms. While some research has identified components that may affect food

preference in preschool children, little research has explored the role play food may play in

increasing food familiarity and, consequently, food preference and intake. Thus, understanding

whether and how play affects the food preferences and dietary intakes of young children may

offer direction for future interventions and policy development to promote lifelong health from

an early age. The researcher’s aim is to inform policymakers, educators, parents, and others who

work with school-aged children about the impact of food preferences and dietary intake among
these children so that the role of food, if any, can be placed in the appropriate context. This

action-oriented strategy promotes development, leads to more equitable actions and decisions,

uses valuable knowledge, and encourages leadership in the development process. These building

blocks of sustainable health among children are not isolated from each other but integral

components of a greater whole.

STATEMENT OF THE PROBLEM

MAIN PROBLEM

The study aims to determine the relationship between selected factors (sex, BMI,

family influence, peer influence, appearance, smell and familiarity/knowledge of food) and the

food preferences among Grade IV to VI students in selected schools in Mabalacat City,

Pampanga. The researcher also seek to identify which among the factors is/are most significantly

affects their food preferences.

SUBPROBLEM

Specifically, it seeks to answer the following sub problems:

1. What are the subject’s profile in terms of:

a. Sex;

b. BMI?

2. How may the following on-site assessment factors that influence the food preferences

of the school aged children be described?

 a. Family Influence;

b. Peer Influence;

c. Appearance of Food;

d. Smell of Food; and

e. Familiarity / Knowledge of Food?

3. How may the food preferences be described?

a. Main Course

a.1. Meat

a.2. Vegetables

b. Dessert

c. Beverages

d. Snacks?

4. Is there a significant relationship between the respondent’s profile and the food

preferences of Grade IV to Grade VI students?

5. Is there a significant relationship between the on-site assessment factors and the food

preferences of Grade IV to Grade VI students?

6. What is the implication of the study to community health nursing?

NULL HYPOTHESES

The null hypotheses were made by the researcher in relation to the problems addressed by

the study. These are stated in null form that exemplifies no significant relationship between the

independent variables and dependent variables.

1. There is no significant relationship between sex and the food preferences [main course

(meat and vegetables), dessert, beverages and snacks] of Grade IV to Grade VI students.

2. There is no significant relationship between BMI and the food preferences [main course

(meat and vegetables), dessert, beverages and snacks] of Grade IV to Grade VI students.

3. There is no significant relationship between family influence and the food preferences

[main course (meat and vegetables), dessert, beverages and snacks] of Grade IV to Grade

VI students.

4. There is no significant relationship between peer influence and the food preferences

[main course (meat and vegetables), dessert, beverages and snacks] of Grade IV to Grade

VI students.

5. There is no significant relationship between appearance of food and the food preferences

[main course (meat and vegetables), dessert, beverages and snacks] of Grade IV to Grade

VI students.

6. There is no significant relationship between smell of food and the food preferences [main

course (meat and vegetables), dessert, beverages and snacks] of Grade IV to Grade VI

students.
 7. There is no significant relationship between familiarity/knowledge of food and the food

preferences [main course (meat and vegetables), dessert, beverages and snacks] of Grade

IV to Grade VI students.

SIGNIFICANCE OF THE STUDY

Making informed food choices is an integral part of a child’s normal growth and

development, thus identification of these factors are of vital importance. With this, the researcher

decided to conduct a study to identify the degree of relevance of the selected factors (sex, BMI,

family influence, peer influence, appearance, smell, and familiarity/knowledge of food) to the

choices of foods school-aged children take into consideration. With this study, schools and

school teachers will be able to focus their nutrition education on the possible negative factors

that may affect their food preferences and encourage children’s participation to healthy eating.

The significant others could also be informed and taught of the proper behavior for the children

with regards to eating right. Also, dietitians and other health care providers will be able to help

schools to develop materials for parents and their children on nutrition and its programs. School-

based health and nutrition programs might be feasible and effective to have a clear potential to

improve the nutrition and growth of school-aged children. For the nursing profession, this may

serve as a guideline for nursing service to have appropriate health education regarding the factors

of food preferences so as to render the proper information to the significant others and patients.

This study could also raise the awareness of the public through information dissemination about

the selected factors affecting food preferences for the purpose of health promotion of the

community’s children.
SCOPE AND DELIMITATIONS

This study will be focusing on the selected factors, identified by the researcher, to the

food preferences of elementary students aging from 9-11 years old, with birthdates ranging from

June 1, 2005 to June 1, 2007, currently in Grade IV to Grade VI, and studying at an elementary

school at Mabalacat City. Selected factors which were included in this study were sex, BMI,

family and peer influence, and the appearance, smell, and familiarity/knowledge of food.

The gathering of data will be focusing on food groups identified namely main course

(which includes meats and vegetables), desserts, beverages and snacks. Other food groups other

than those which were not said, like rice, will not be further assessed for this has been already a

stable part of an everyday Filipino meal. The study is a descriptive-correlation quantitative in

nature and will use a descriptive statistics to analyze the gathered data.

The relationship between age and food preferences is not included because they all

belong to the same age group (9-11 years old).The current weather in the field setting will also

not be included in the factors to be assessed. During the on-site assessment, if the child did not

choose any of the food it will also not be included.

DEFINITION OF TERMS

For the purpose of clarity and better understanding of concepts that will be presented in

the study, the following definitions are offered.

Age. It is the length of time that a person has lived or a thing that existed; is a particular

stage in someone’s life (Stevenson, 2010).

In the study, it refers to the duration of being of the child. In the study, the respondents

are the school-aged children, 9-11 years old, with birthdates ranging from June 1, 2003 to June 1,

2005).

Body Mass Index. It is an index of a person’s weight in relation to height; determined by

dividing the weight (in kg) by the square of the height (in meters) (Smolin & Grosverson, 2010).

It is based on the World Health Organization – Child Growth Standards categorized as:

Severely Wasted, Wasted, Normal, Overweight, and Obese.

Community Health Nursing. It is a field of nursing that is a blend of primary health care

and nursing practice with public health nursing. The community health nurse conducts

continuing and comprehensive practice that is preventive, curative, and rehabilitative (Lundy &

Janes, 2009).

In the present study, the researcher is focused on the welfare of the community. It focuses

on the health of the whole community and the environment where it belongs.
 Energy density. It is simply the calories in a fixed weight of food. It is calculated by

summing up the total calories consumed and dividing it by the total number of grams of food

consumed (Rolls, 2005).

In the study, it refers as a category that will be used to categorize dessert, beverages and

snacks. It is calculated by summing up the total calories and dividing it by the total number of

grams of food served.

Very low energy density. It has ranges from 0 to 0.6 calories per gram.

Low energy density. It has ranges from 0.6 to 1.5 calories per gram.

Medium energy density. It has ranges from 1.5 to 4.0 calories per gram.

High energy density. It has ranges from 4.0 to 9.0 calories per gram.

Family Influence. Family food choice influences the types of food the children accept.

Parents and siblings are the primary role model for young children to imitate behavior. The

positive effects of regular family meals can last into adulthood (Samour and King, 2010).

In the study, it refers to the food attitude of parents, siblings or other family members

towards their children and the atmosphere around food and mealtime and is one of the on-site

assessment factors that may influence the food preferences of the school aged children.

Familiarity or knowledge on food. In the study, it refers to the previous experience or

knowledge of the food served. It may pertain to the foods that the child always sees, eats and is

presented to him/her. The knowledge of food may be from the teachings of the family or the

school. This is one of the on-site factors on food preference of school-aged children.
 Food Preference. It is defined by customer’s wants and is based on personal, cultural and

regional factors (Puckett, 2004).

In the study, it refers to the selection of food that will be served as a main course

(vegetables and meat), dessert, and beverages during lunch and snacks over the other of the

school-aged children. It is also considered as the dependent variable tested in the study.

Group A Vegetables. They are vegetables that do not have appreciable quantities of

carbohydrates, calories, proteins, and fats so they may be eaten liberally. They included all green

leafy vegetables and other vegetables which may be taken in unlimited quantity (Joshi, 2010).

In the study, it refers as a grouping that was used in categorizing vegetables. Group A

vegetables contain negligible carbohydrates, protein and energy if 1 exchange or less is used.

The portion size for one exchange is 1cup raw (25g) or 1/2 cup cooked (45g).

Group B Vegetables. They are vegetables that have an amount of carbohydrate, protein

and fats. (Joshi, 2010).

In the study, it refers as a grouping that was used in categorizing vegetables. The portion

for one exchange is 1/2 cup raw (40g) or 1/2 cup cooked (45g).

Level of influence. In the study, it refers to the classification of the factors of food

preference and is categorized as very high influence, high influence, low influence and very low

influence.

Main course. It is the primary portion of the meal. (Stevenson, 2010)

In the study, it refers as the course that consists of the food group meat and vegetables.
 Meats. It is the animal tissue which is used as a food including those of domestic

mammals, poultry, game birds and animals. It is composed of lean muscle, connective tissue,

fats, skin, nerves and blood vessel. It can be classified as red or white meat. If there is a higher

myoglobin content, it is red and if not then it is white (Stevenson, 2010).

In the study, it refers to food served which will be part of the main course where the

school-aged children will be choosing from.

Low-fat meat. In the study, one exchange of low-fat meat contains 8 g of protein, 1 g of

fat and 41 kilocalories. It is meat that has little or small amount of fat content.

Medium-fat meat. In the study, one exchange of medium-fat meat contains 8g of protein,

6g of fat and 86 kilocalories. It is meat that has average or regular amount of fat content.

High-fat meat. In the study, one exchange of high-fat meat contains 8g of protein, 10g of

fat and 122 kilocalories.

Nutritional Status. It is the condition of the body as it relates to the consumption and

utilization of foods (Stanfield & Hui, 2010).

In the study, this refers to the classification of the school-aged child as to emaciated,

below normal weight, normal weight, above normal weight, or obese which can be identified

through the use of the Body Mass Index.

On-site assessment. In the study, it refers to the actual assessment of the food preference

of the school aged children where foods are chosen from the list. The factors included are:
Family Influence, Peer Influence, Appearance of Food, Smell of Food and Familiarity /

Knowledge of Food

Peer influence. It is a group of people of approximately the same age, status, and interest

(Stevenson, 2010).

In the study, it refers to a person that is closely connected to the school-aged children

with the same interest, concern, and ability. It includes classmates, playmates and friends. It is

one of the factors to be identified by the researcher during the on-site assessment.
 CHAPTER II

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents the review of related literature and studies in searching for a

thorough understanding and background knowledge of the present study. It is intended to support

and strengthen the present study. The presented related literatures are arranged using the theme

approach where literature of similar findings is grouped together.

RELATED LITERATURE

FOOD

People have probably eaten at least 20,000 meals in your life. Without any conscious

effort on your part, your body uses the nutrients from those foods to make all its components,

fuel all its activities, and defend itself against diseases. How successfully your body handles

these tasks somewhat depends on your food choices. Nutritious food choices support healthy

choices. People decide what to eat, when to eat, and even whether to eat in highly personal ways,

often based on behavioral or social motives rather than on an awareness of nutrition’s importance

to health. Many different food choices can support good health. The number one reason people

choose foods is taste – they like certain flavors. Two widely shared preferences are for the

sweetness of sugar and the savoriness of salt (Kuribayashi, Roberts and Johnson, 2001). Food is

the first of the essentials of life, the world’s largest industry, our most frequently indulged

pleasure, the core of our most intimate social relationships (Bradlee, et.al 2009). In recent years
these apparently rather superficial aspects of food have begun to take on a wider significance.

Nutritionists, physiologists and other scientists now recognize what consumers have always

known- that there is more to the business of feeding people than compiling a list of nutrients in

the correct proportions (Coultate, 2009). On a basic level, food is simply a vehicle for nutrients

which provides a building blocks and energy for all the body’s structure and functions. The

decisions we make about the food we eat every day are important and we need to consider our

choices thoughtfully (Epstein, et.al, 2008).

MALNUTRITION IN THE PHILIPPINES

Malnutrition is a major problem in the Philippines. The 6th National Nutrition Survey

demonstrated that the prevalence of underweight children has practically remained unchanged

from its 1990 level. The Food and Nutrition Research Institute warns that it will take 50 years

before the Philippines can eradicate the problem of malnutrition. School-aged boys are prone to

different forms of malnutrition compared to girls. The 2001 data indicates that the number of

underweight boys is 10% higher than that of girls. There is also evidence of disparities among

regions. The Bicol region has the highest underweight prevalence among children aged 0 to 5

years old, followed by Mindanao. The National Capital Region had higher rates than the national

average in all of the indicators of malnutrition (UNICEF, 2008).

The number of undernourished Filipino children continues to increase. There are two

faces of malnutrition in the country. Our children are undernourished but our adults are

overweight, said Dr. Mario Capanzana, director of the Food and Nutrition Research Institute as

the agency disclosed Thursday the results of its 2008 National Nutrition Survey. The survey

found that about one out of four children are either small or short for his age. From 2005 to 2008,
the proportion of underweight and underheight children increased. Among children 6 to 10 years

old, 26 percent were found underweight while 1 out of 3 or 33 percent was short for his age

(FNRI, 2003). We need to show families how to properly feed children. When your malnutrition

index is high, our country has no chance to prosper, no matter what promises are made by

candidates about ending poverty, she said at a news conference. Dr. Lulu Bravo said families

should take advantage of malunggay, kangkong and mongo which are abundant and cheap yet

highly nutritious (Philippine Daily Inquirer, 2010).

A survey by the National Statistics Coordination Board (NSCB) as of 2008 showed that

26.6% of Filipino adults are overweight, higher than 16.6% in 1993. Of the number, 5.2% are

obese. Among children aged 5 to 10 years old, 6.6% are overweight against only 5.8% during the

last survey in 2003. The rise comes despite a reported drop in Filipinos' food intake to 861 grams

per day in 2008 from 803 grams in 1993, said Candido Astrologo Jr. of the NSCB during a

seminar for health journalists in Quezon City recently. However, Astrologo said the question that

should be asked is not how much food Filipinos eats, but what kind. He said households'

nutrition habits are changing. According to him, consumption of meat and poultry has been on

the rise, contributing to obesity. Intake of poultry has increased the highest, by 4.3% from 1978

to 2008, followed by other meats (3.1%) on an annual compounded basis, Astrologo said, citing

government data. On the other hand, intake of roots and tubers declined by 2.6%, and fruits by

2.2%. “Consumption of rice slightly increased by 0.1%. Intake of fruits and vegetables has been

on the downtrend because they're expensive," said Astrologo. He added, "Majority of households

now eat outside. And what do they eat? Fast food." However, while the number of fat Filipinos is

growing, it is still much less than those in neighboring countries in the region, Astrologo noted.

Only 5.2% of the population in the Philippines are obese, against 14.1% in Malaysia, 8.5% in
Thailand, 7.9% in Brunei and 6.4% in Singapore, according to the NSCB survey (ABS-CBN

News, 2011).

According to Steinberg (2011), the basic Filipino diet conforms to the tenets of what is

universally recognized as healthy eating—rice and tubers are high in carbohydrates, fish is an

excellent source of protein and omega-3 oils, and vegetables provide necessary vitamins and

minerals. While these food groups remain the basis of the Filipino diet, there have been

significant changes in dietary patterns over the years, resulting in obesity and increased

incidences of serious diseases. Filipinos are now eating copious amounts of processed foods

(including meats, instant noodles, chips and baked goods) and drinking more soda. Rice has been

the staple of a Filipino diet. Prices of some processed foods have become even more affordable

to the average Filipino than prices of fruits and vegetables. The consumption of fruits and

vegetables including roots and tubers has decreased, while consumption of animal-based foods,

as well as foods high in sugar, fats and oils, has increased. Instant noodles are overwhelmingly

popular in major source of empty calories. Many Filipinos are increasingly dependent of street

foods, not just for snacking but for their major meals as well. Most street foods are high of

calories, fats and cholesterol, but are highly patronized because of their accessibility, low cost,

and ability to fill one up. Restaurant fast foods are now fixture in the everyday Filipino diet.

Widespread and fast-growing urbanization, globalization (as evident in the rise of food imports

and preference of fast foods), and easier access to technology (cell phones, computers, videos)

have all contributed to the significant changes in the Filipino’s food-consumption habits (Albala,

2011).
MALNUTRITION IN THE WORLD

According to Doak, Renders and Seidell, most recent national data on obesity prevalence

among adults, adolescents, and children showed that more than one-third of adults and almost

17% of children and adolescents were obese in 2009–2010 (Doak, Renders and Seidell, 2010).

According to the study by Ogden et al. (2012), differences in prevalence between men and

women diminished between 1999–2000 and 2009–2010, with the prevalence of obesity among

men reaching the same level as that among women. The prevalence of obesity was higher

among older women compared with younger women, but there was no difference by age in

obesity prevalence among men. Among children and adolescents, the prevalence of obesity was

higher among adolescents than among preschool-aged children. In the statistics conducted by the

U.S. Department of Health and Human Services, there has been no change in obesity prevalence

in recent years; however, over the last decade there has been a significant increase in obesity

prevalence among men and boys but not among women and girls overall. The Healthy People

2010 goals of 15% obesity among adults and 5% obesity among children were not met. (CDC,

2010). According to England statistics in 2010, around three in ten boys and girls (aged 2 to 15)

were classed as either overweight or obese (31% and 29% respectively), which is very similar to

the 2009 findings (31% for boys and 28% for girls) (Elwood, 2012).

There are 925 million undernourished people in the world today. That means one

in seven people do not get enough food to be healthy and lead an active life.(World Food

Program, 2012) FAO estimates that a total of 925 million people are undernourished in 2010

compared with 1.023 billion in 2009 (Food and Agriculture Organization of the United Nations,

2010). Today, nearly one in six people worldwide is chronically undernourished, too hungry to
lead productive, active life. More than 70 percent of the world's underweight children (aged five

or less) live in just 10 countries, with more than 50 per cent located in South Asia alone.

(UNICEF, 2009). Over the past 10years, these problems of poverty and under nutrition are

widespread and growing-despite the fact that there is enough food available to sufficient feed all

of us. The majority (two-thirds) of undernourished people live in Asia. Realities of under

nutrition worldwide include: (1) nearly in six people worldwide is chronically undernourished,

too hungry to lead a productive, active life. This includes on third of the world’s children (2)

about 55000 people die of hunger each day- two thirds of them are children (Bradlee, et.al,

2009).

MILLENIUM DEVELOPMENT GOAL

The first Millennium Development Goal calls for the eradication of extreme poverty and

hunger, and its achievement is crucial for national progress and development (United Nations

Development Programme, 2012). Failing to achieve this goal jeopardizes the achievement of

other MDGs, including goals to achieve universal primary education (MDG 2), reduce child

mortality (MDG 4) and improve maternal health (MDG 5). One of the indicators used to assess

progress towards MDG 1 is the prevalence of children under 5 years old who are underweight, or

whose weight is less than it should be for their age. To have adequate and regular weight gain,

children need enough good-quality food, they need to stay healthy and they need sufficient care

from their families and communities (United Nations, 2011). To a great extent, achieving the

MDG target on underweight depends on the effective implementation of large-scale nutrition and

health programs that will provide appropriate food, health and care for all children in a country
(UNICEF, 2009). This study shows that the prevalence of under nutrition of children aged 6

years old onwards or categorized as school-aged children has been neglected and is not part of

the Millennium Development Goal.

FOOD PREFERENCES

The influences on choices are many and complex, some obvious, some more subtle, but

food scientists and the food industry, with careful study, started to understand them. Very few

food choices were available several hundred years ago, with the exemption of basic foods such

as meats, grains, vegetables and fruits. The number of different foods now available can actually

make it more difficult, rather than easier, to plan a nutritious diet. The food industry offers

thousands of foods, many of which are mixtures of the basic ones, and many of which include

artificial ingredients (French, et.al, 2009). Food companies compete fiercely to develop ever

newer and more attractive products for consumers to buy. This competition focuses on the

factors that cause people choose the way they choose (Falk, et.al, 2001). In countries like the

United States, where a wide variety of foods are available and people have the luxury of

selecting which foods they will eat, food choices are influenced by a wide range of factors. Of

these factors, food preference has the largest impact on food choices for most people. Food

preferences vary a good deal among individual, and lead to a wide array of specific food choices.

Rather than being inborn, food preferences are primarily learned (Bisogni, et.al, 2002).
THE PERCEPTION ON FOOD CHOICE AMONG SCHOOL-AGED CHILDREN

Food itself can be used as a means of both punishing and rewarding children (Bassett,

Gwen and Beagan, 2008). For children in particular, their ‘freedom of choice’ is very much

within the context of the family and the school. It has been observed that patterns of food choice

and consumption are developed from earliest childhood which is the primary setting for feeding

children and young people (Backett-Milburn et al. 2006). As Holsten (2009) shows for children

in the community, children themselves use different strategies to negotiate their position and

counteract and resist adults’ power and control.

Schools have become critical part of the social environment that shape children's eating

habits. With the persistence of problem of malnutrition, it was noted that intervention efforts

need to be intensified (Olenja, 2004). Until now, most approaches have focused on changing

adult feeding behavior and diet. Much of the research assessing nutrition practices in early

childhood programs has focused on adequacy of foods that are served to children. Children are

future parents, when they are provided with adequate nutrition concepts at formative stages; they

are likely to respond effectively to the dietary messages (Contento et al., 2007). They are also

likely to develop lifetime healthy eating habits, which would influence their health during

adulthood.

Research shows that the majority of children consume insufficient amounts of fruit,

vegetables and dietary fiber (Guenther, et.al, 2006), and that the most commonly eaten foods are

fruit drink, carbonated beverages, milk, and French fries (Ard, et.al, 2007). Recent research

confirms that children are eating outside the home more regularly, eating larger portion sizes,

consuming more soft drinks, and eating less fruit and vegetables (Molaison et.al, 2005).
 A variety of factors have been reported as influencing food choice, including

physiological, psychological, social, environmental, and cultural factors. Researchers have

attempted to develop conceptual models to predict children’s food choices. While these models

are limited in their capacity to predict food choices they demonstrate the complexity of these

decisions (Epstein, et.al, 2008).

Television advertising of foods aimed at children has been argued to be an important

factor in children’s eating patterns and, in turn, in the rising levels of childhood obesity.

Repeated studies across different countries have demonstrated that food advertisements are

inconsistent with dietary guidelines (Coon, et.al, 2001). However, there is limited evidence of a

direct link between food ads aimed at children and children’s eating patterns (Ofcom, 2010),

primarily because while food preferences may be influenced by child-targeted advertising, food

purchase decisions are generally made by parents.

A review of the published literature (Borra, et.al 2003) concluded that children’s eating

behaviors are strongly influenced by the family’s food environment. Factors that were found to

be important in the family food environment were the following: parental food preferences and

beliefs, children’s food exposure, role modeling, media exposure and parent child interactions

surrounding food.

Recently, researchers have proposed more comprehensive theoretical models of eating

behavior that take account of multiple interacting factors (Glanz et al., 2005). However, while a

broad range of factors has been identified in the literature as important for the food choices of

young people (Hanson and Chen, 2007), few studies have set out to qualitatively examine young

people's own views (Warrenet al., 2008). In focus groups conducted with American children,

factors perceived as important in influencing food choices included hunger, appeal of food,
lifestyle factors, food availability, parental influences, benefits of food, situation-specific factors,

mood, body image, media, habit and vegetarian beliefs (Neumark-Sztainer et al., 2009).

SCHOOL-AGED CHILDREN

Growth is slower during this period and not as observable as in the earlier infant toddler

growth spurt or the adolescent growth spurt that will occur later. However, the vigorous activity

level that most school-aged children require makes the need for adequate nutrition important

(Croll, 2001). In addition good nutrition will help the school-aged child maintain resistance to

infection and will ensure adequate stores of body building materials and nutrition needed for the

adolescent growth spurt (Hackett, et.al, 2002). Caloric requirements for energy for the school-

aged child range from 1600kcal/day for sedentary females to 2200 kcal/day for active females.

School-age males need 1800kcal/day if sedentary and 2600kcal/day if active (Cullen et.al, 2002).

The school-aged children make independent decisions as to what he or she will eat, not

only in the school cafeteria, but also in afterschool programs, or at home if caregivers were at

work. The growth rate for boys and girls in the 9-11 year age group is steadier than in infancy or

in later adolescence, but their nutrient and energy requirements are still greater than for adults

relative to their body weight. Children’s meals need to include a variety of foods in order to meet

their nutritional needs. Weight gain is common in preparation for puberty, which may begin as 9

years for girls and a few later for boys (Cullen, et.al, 2002). School-aged children are exposed to

many outside influences other children and their eating habits, snacks machines and television,

just to name a few (Birch and Davidson, 2001). Parents lose some of their influence during this

time. Thus it is very important that good nutritional habits are established before school age.
Steering children toward healthful foods, in school and at home, is likely to be more successful if

children are exposed to nutrition education. Since children spend much if their younger years in

school, it is a great place to learn about positive healthy eating habits. Such education can help

children understand why eating a proper diet will make them feel more energetic, look better and

work more efficiently. One survey of school children highlighted the need for nutrition

education. On the day of the survey, 40% of the children ate no vegetables except for potatoes or

tomato sauce, 20% ate no fruits and 75% snacked at least twice. Some 36% of the students ate at

least four different types of snack food. Another study showed that only 2% of about 3,300

children 2-19 years old had met their recommended servings from all five Food Guide groups.

Clearly the diets of many school age students can stand general improvement particularly with

regard to fruit, vegetable, whole grain and dairy choices. Drinking minimal amounts of sugared

soft drinks are also advised (Haapalahti, et.al, 2003).

According to Jean Piaget, the four stages are named sensorimotor, preoperational,

concrete operational and formal operational (Mckinley et.al, 2005). The concrete operational

spans from the age 5-11 years old. They claim that children at the first and second sub stage (age

5-7 and 7-9 respectively) bring an intuitive substage where the child starts to think in series and

begins to decrease egocentricity. At the third sub stage (age 9-11), children elaborate the

structures to integrate into higher-level structure. This time span is characterized by the

developing capability of organizing thought processes and use of deductive reasoning to

successfully anticipate consequences (Aryal, 2007).

It’s the same old story: Mommy prepares veggies; the child says no. Mommy chases,

cajoles, and pleads; the child cries, and finally mommy relents and prepares…

hotdogs. (Warren, et.al, 2008). It’s a struggle that’s repeated across Filipino households
nationwide; in fact, it may even be happening right now in your own home. And the results so

far? Well, ‘french fries’ have overtaken carrots and malunggay as the top vegetable for children.

Children worldwide are increasingly turning into picky eaters. Picky eating is a behavior that can

be ended by better equipping and educating parents and guardians on the issue, and supporting

them with quality milk supplements such as Aqiva. In fact, a 2009 TNS Global Market Research

survey reveals that 53% of Filipino mothers consider their children as picky eaters. And, heads

up, there’s so much more to picky eating than just craving hotdogs or fried chicken—it’s a battle

that may determine your child’s nutritional future. The term “picky eater” is one of the most

frequently used terms by health professionals in characterizing the eating behavior of some

children. In Filipino, these children are described as “mapili o maselan” when it comes to food.

Its most common identifiers are (1) the child consumes a limited number or an inadequate

variety of food, and/or exhibits strong food preferences (2) the child is unwilling to try new food

(food neophobia) and (3) the child eats slowly, lacks interest, and/or does not eat enough. Food

acceptance or rejection may be based on the qualities of food such as taste, texture, appearance,

smell, or temperature. In extreme cases, there are even times when entire food groups are

avoided! Picky eating is a behavior that can be ended by better equipping and educating parents

and guardians on the issue (Eertmans, Baeyens & van den Bergh, 2010).

SUBJECT’S PROFILE

Sex

Depending on sexual maturation of school age children, protein requirements for both

sexes are 34grams/day. More lean body mass is found in children who are sexually mature; they
require more protein for growth and maintenance for dietary intake. This is particularly true for

boys (Edstrom & Devine, 2001). Gender differences in food choices and dietary intakes emerge

as children move into adolescence. During childhood food intakes are similar between girls and

boys. Continuing Surveys of Food Intakes by Individuals (CSFII) showed little differences in

mean daily intakes of the Food Guide Pyramid group for grains, vegetables, fruit, dairy and meat

among boys and girls ages 2-5 years and ages 6-11 years. Among adolescents, boys ate more

servings of grains, more vegetables (including French fries) dairy and meat servings compared to

girls. Studies have shown that as a group, adolescent girls are more likely than adolescent boys to

have lower intakes of essential vitamins and minerals and fewer servings of fruits, vegetables

and dairy foods. Boys are more likely to have diets higher in total fat and saturated fat compared

to girls. On average, adolescent boys eat larger quantities of food than adolescent girls, so they

are more likely to meet daily recommended intakes for vitamins and minerals (Fraser, et.al,

2006).

According to Cook and Wardle (2005), their study was conducted to examine the

developmental patterning of food preferences in a large sample of British schoolchildren and to

investigate possible gender differences. Using a cross-sectional survey design, the study was

carried out in three primary and three secondary schools in West London, UK. A total of 1291

children aged from 4 to 16 years completed a 115-item food preference questionnaire in class

time, supervised by class teachers and assistants. Children indicated whether they had ever tried

each item and, if so, how much they liked it. We observed age-related increases in the number of

foods tried, liked and disliked. Controlling for the number of foods tried rendered the increase in

dislikes non-significant and reversed the age effect on the number liked. Girls liked fruit and

vegetables more than boys did; boys liked fatty and sugary foods, meat, processed meat products
and eggs more than girls did. Some age differences were apparent in liking for categories of

food, although the effects were not linear. Across ages and genders, children rated fatty and

sugary foods most highly, although ratings for fruit were also high. Children’s food preferences

overall are not consistent with a healthy diet. Interventions should focus on increasing the

familiarity, availability and accessibility of healthy foods and should be mindful of the need to

target messages appropriately for boys who have less healthful food preferences than girls at all

ages.

Body Mass Index

There is a significant interaction between BMI status and type of food in terms of explicit

food preferences. Implicit attitudes to high-calorie foods are better predictors of unhealthy body

weight. However, these findings are limited, as the behavioral consequences of differences in

implicit attitudes to food across BMI groups were not addressed (Mei, et.al, 2002). According to

Ogden, et.al (2010), obese children showed a stronger behavioral reaction to exposure to food

cues, with a greater difference in intake between control and exposure, whereas the normal –

weight children actually ate less than in the control condition. School-based obesity prevention

programs addressing nutrition and healthy eating behaviors within the school environment and

cultural context provide a unique opportunity to educate and engage students in healthy food

consumption practices (Downs, et.al, 2009).

The decision to eat, and to eat particular foods, varies for different individuals and

situations. Individual differences in food likes and desires develop throughout life because of

differing food experiences and attitudes. There are many internal and external cues, not just
stimulation from foods or hunger, which can trigger the immediate desire to eat or orient eating

towards certain foods. Food desires and intake are an outcome of interactions between these cues

and more stable individual physiological and psychological characteristics. Sensory and food-

intake data link obesity risk with a pattern of food liking and selection that is oriented towards

more energy-dense foods. It may be important to distinguish between the desire for or motivation

to eat certain foods and the actual pleasure derived from eating them. Thus, current research

points to the value of programs that provide a degree of structuring of the personal food

environment, while allowing room for flexibility in choices, and offer the possibility of a longer-

term weight maintenance solution. By better understanding why and where in the process of food

choice weight control efforts may be undermined, steps can be taken to insulate individuals

against the causes of failure. Additional research should be directed towards determining the

value and best methods for applying these observations (Mela, 2001). Of importance to the study

of human obesity, most human tend to prefer foods that are sweet or high in fat, and these foods

are often the most energy dense and overindulgence can result in obesity (Rosenkranz &

Dzewaltowski, 2008).

FACTORS FOR ON-SITE ASSESSMENT

Family Influence

For school children the family is the primary influence in the development of food habits.

In young children’s immediate environment, parents and older siblings are significant models.

Food attitude of parents can be strong predictors of food likes and dislikes and diet complexity in

children of primary-school age. Similarities between children’s and their parent’s food
preferences are likely to reflect genetic and environmental influences (Dalton & Kitzmann,

2008). Contrary to common belief, young children do not have the innate to choose a balanced,

nutritious diet; they can choose one only when presented with nutritious foods. A positive

feeding relationship includes a division of responsibility between parents and children. The

parents and other adults provide safe, nutritious, developmentally appropriate food as regular

meals and snacks; and the children decide how much, if any, they eat (Fisher et.al, 2002). Parents

and/adult caregivers play a central role in the development of early childhood feeding behaviors.

The proliferation of commercially available high-sugar high-fat food and beverages contributes

to the poor diet quality, but there are other influences on parents as well (Cullen, 2003).

National trends indicate that eating together at family meals is becoming less common,

partly because of family schedules, more time eating in front of the television and preparing

family meals. In a recent report school-aged children and adolescents who ate more dinners with

their families consumed more fruits and vegetables, less soda, and fewer fried foods than those

who rarely ate dinner with their families. The atmosphere around food and mealtime also

influences attitudes toward food and eating. Unrealistic expectations for a child’s mealtime

manners, arguments, and other emotional tree can have negative effect. Meals that are rushed

create a hectic atmosphere and reinforce the tendency to eat too fast. A positive environment is

set aside to eat, occasional spills are tolerated, and conversion that includes all family members

is encouraged (Gillman, 2010) According to De Bourdeaudhuij (2001), his study provides insight

into decision making about food choices in the family and its relationship with (un) healthy

eating, by including the responses of four members of the family as a sampling unit. The study

was conducted through four medical centers, visited by 69 classes from 19 different schools in

Belgium. Ninety-two family quartets, including both parents and two adolescents between 12
and 18 years old, completed questionnaires independently. Four previously investigated

measures of decision-making power (30 items on a seven-point scale) were administered, along

with a short food choice questionnaire and demographic variables. Results indicate that the

influence of fathers but more especially that of children is important in food decisions.

Moreover, the relative influence of each family member is dependent on the kind of product or

product group considered. Differences in perceptions between the four family members showed

the importance of considering the responses of all the people involved in family decision

making. Finally, it is clear that in families where adolescents have more power, food choices are

less healthy. A multidimensional approach to the issue of influence in food decision making in

the family is potentially richer and leads to different conclusions. The necessity of the

involvement of the entire family for the introduction and adoption of healthy eating is

emphasized.

Peer Influence

As children grow, their world expands and their social contacts become more important.

Peer influence increases with age and effects food attitude and choices. This may result in a

sudden refusal of a food or a request for a currently popular food. Decisions about whether to

participate in school meals may be made more on the basis of friends' choices than on the menu.

Such behaviors are developmentally typical. Positive behaviors such as willingness to try new

food can be reinforced. Parents need to set limits on undesirable influences but also need to be

realistic; struggles over food are self- defeating (Voorend,et.al, 2013). Eating is a social behavior

and for children, habits are formed in the context of many social factor and settings including
family environment, peer groups and schools (Cullen, 2003). As children move into the world,

others influence their food choices. During school years, friends rather than the menu may decide

in the school lunch program (Green, et.al, 2003).

Children and adolescents alike are also influenced by what their peers eat. In a study of

preschool children, Birch found that when children saw other children choosing and eating

vegetables the observing children did not like, preferences for and intake of disliked vegetables

increased (Birch and Davison, 2001). Peers are considered to be particularly influential in

adolescent eating behavior. In a study of adolescents, Feunekes and colleagues found that, on

food frequencies, 19% of foods consumed by adolescents were similar to those consumed by

their friends. More specifically, associations with peer intake were found for type of milk used in

coffee, alcoholic drinks, and several snack foods including French fries (Fuenekes et.al, 2003). In

a study of Costa Rican adolescents, peer influence was shown to significantly influence intake of

foods rich in saturated fats. Another study on adolescent girls’ eating behaviors found that peer

pressure was a strong predictor of eating behavior, even after controlling for other interpersonal

variables (Patrick and Nicklas, 2005).

Appearance of Food

The eyes receive the first impression of foods: the shapes, colors, consistency, serving

size and the presence of any outward defects. Color can denote the ripeness, strength of dilution

and even degree to which the food was heated. Black bananas, barely yellow lemonade and

scorched macaroni send visual signals that may alter a person’s choice. Color can be deceiving;

if the colors of two identical fruit-flavored beverages are different, people often perceive them as
tasting different even though they are exactly the same. People may judge milk’s fat content by

its color. For instance, if the color, but not the fat, is improved in reduced-fat (2%) milk, it is

often judged to be higher in fat content, smoother in texture, and better in flavor than the

reduced-fat milk with its original color. A design brief for a new product will give a description

of what the finished product is expected to look like. Factors such as size, shape and color are

described as part of the product appearance. Finishing processess, such as glazing, garnishing,

icing, piping or dusting with sugar can be used to enhance appearance. Food appearance is also

an important quality indicator and will be checked as part of quality control procedures (Guthrie,

Lin and Frazao, 2002). Of the sensory attributes of food, to be related to appearance are the most

susceptible to objective measurement, but appearance is important to the consumers. They have

certain expectations of how food should look. Two separate categories of appearance include

color attributes and geometric attributes (size and shape) (Parker, 2003).

The color palette of foods on a plate also contributes to or detracts from their appeal.

Imagine a plate containing baked flounder, mashed potatoes, boiled cabbage, and vanilla ice

cream, and then compare it to one that contains a nicely browned chicken breast, orange sweet

potatoes, green peas, and blue berry cobbler. Based on eye appeal alone, most people would

prefer the latter (Wansink, Payne & Shimizu, 2009). According to Zampollo, Kniffin, Wansink

and Shimizu (2011), given the importance of food presentation and childhood nutrition, they

aimed to test the degree to which adults and children might demonstrate different preferences for

various ways in which food can be presented on plates. Twenty-three pre-teen children and 46

adults were individually presented full-size photos of 48 different combinations of food on

plates. The photos varied according to seven dimensions (e.g. number of items, placement of

entre´e and organization of the food). Contrary to the default assumption that parents and
children share preferences for the ways in which food is presented on plates, we find that

children have notably different preferences than adults. Most remarkably, we show that children

tended to prefer seven different items and six different colors on their ideal plates, while adults

tended to prefer three different colours and three different items. The assumption that children

prefer food presentations that match adult preferences appears to be unjustified. Future research

and interventions that are designed to improve childhood nutrition should test for the impact of

diverse presentations on actual food consumption among a variety of populations across

institutional settings. However, much nutritionists and “health food” enthusiasts may wish

otherwise, it is the flavour and appearance of food rather than its vitamins and fiber that win

compliments at the dinner table (Coultate, 2009). Appearance probably the first aspect food is

judged by. Does it look attractive and fresh? The appearance of food is judged by color, size,

shape and form. The color of food is a guide to its freshness, and certain flavor are usually

associated with certain colors. Our early experiences with food conditions the way in which we

relate to the appearance of food. If a food is unfamiliar, for example black corn or red eggs, we

will reject the food because of its color (Arora, 2007).

Smell of Food

Smell is almost as important as appearance when people evaluate a food item for quality

and desirability. Although the sense of smell is not as acute in human beings as it is in many

other mammals, most people can differentiate between 2000 to 4000 odors, whereas some highly

trained individuals can distinguish as many as 10,000. Naming each of these thousands of odors

separately would tax even the most fertile imagination: researchers have categorized them into
major groups. One classification system recognizes six groups of odors: spicy, flowery, fruity,

resinous (eucalyptus), burnt and foul. The other widely used grouping scheme consists of four

categories: fragrant (sweet), acid (sour), burnt and caprylic (goaty) (A. Brown, 2011). The sense

of smell has been the subject of research both in the laboratory and in the field, and I shall argue

shortly that the sensitivity of smell out to support rather than undermine the claims of taste. As

Geldard comments, “olfaction… furnishes the most elaborate of experiences connected with

food, for it is the receptor system situated high in the nostrils that supplies the overtones for the

fundamental tastes, that add “aroma”, that transforms sheer acceptance of food into into

appreciation of flavor. Were there no sense of smell there would be no gourmets, only consumers

of nutriments” (Korsmeyer, 2002). The sense of smell is also an important determinant of food

choice. For example, increased smell sensitivity at an early stage of pregnancy was reported by

67% of pregnant women in Sweden (Reilly et. Al., 2004)

Researchers from Oregon State University discovered that when we eat something with

matching odor and taste—such as vanilla and sugar—the sense of flavor happens in the mouth.

This single sensation occurs as a result of the way our brain processes information from its

separate taste and smell centers. A third area in the brain combines taste and smell, and sends it

back to the tongue as flavor sensed in the mouth. With mismatched odor and taste—like vanilla

and salt—there is no combined flavor. The sensation of vanilla occurs in the nose as a smell, not

in the mouth as before. Even though the way we sense flavor is fixed in our bodies, much of

flavor perception is learned. When you start to like coffee or beer, you are overcoming these

built-in mechanisms. The researchers think this can be applied to vegetables that people tend to

avoid, such as brussels sprouts. Most people react negatively to their bitter smell, part of our

ancient defense mechanism. If you could change the way brussels sprouts smell, then people
might actually like eating them (Liem and Zandstra, 2012). It is interesting that smell is such an

important sense in good nutrition. If we cannot smell a food or if the smell of a food is not

pleasing, we will reject that food (Stam, 2010). The smell of food is so to speak a foretaste, and

by means of the smell of his favorite food the hungry person is invited to pleasure, just as the

satiated person is repelled by the same smell (Larson,et.al, 2006).

Familiarity / Knowledge of Food

Food familiarity refers to children’s preference for foods with which they are accustomed

to seeing on a regular basis – the more familiar the food, the more likely the child will be to taste

it. Importantly, children’s food preferences can be encouraged through their merely seeing these

foods on a regular basis, and that repeated exposure to foods can overcome the initial refusal of

them. It should follow, then, that one of the most important ways parents can encourage the

development of healthy food preferences is by increasing children’s familiarity with new foods

(Hart, et.al, 2003). A child cannot prefer a food to which he or she is not exposed, it appears that

children “like what they know and eat what they like” (Lynch, 2010). We estimate that children

who were highly familiar with the snack foods expected them to deliver twice as much satiation

as did children who knew the foods but who never or rarely consumed them (Hardman et.al,

2011). In this complex dietary environment, learning may be inhibited because the abundance

and variety of unfamiliar foods limits the opportunity for learned increases in expected satiation.

The cross-sectional study of Russel and Worsley (2008) was designed to investigate the

relationships between food preferences, food neophobia, and children's characteristics among a

population-based sample of preschoolers wherein a parent-report questionnaire is used. The

subjects are 371 two- to five-year-old Australian children. Food neophobia or fussy eating or not

picking foods which are not familiar to the children was associated with reduced preferences for

all food groups, but especially for vegetables. It was also associated with liking fewer food types,

disliking more food types, the number of untried food, a less varied range of food preferences,

and less healthful food preferences overall. The study confirms and extends results obtained in

experimental research and population-based intake studies of food neophobia to children's

everyday food preferences. The findings suggest that school children's everyday food preferences

are strongly associated with food neophobia but not with children's age, sex, or history of breast-

feeding. When aiming to influence children's food preferences, the effects of food neophobia and

strategies to reduce it should be considered. Having a better understanding of the food neophobia

in the development of eating habits and food preference is imperative, the design of effective

interventions to improve children’s diet should incorporate our understanding of neophobia.

Furthermore, the impact of food neophobia on long term food consumption should be considered

when attempting to prevent obesity as well as poor nutrition (Facligia, et.al, 2004). As Cooke et

al. (2005) suggests, “guiding parents in the technique of regular and repeated taste exposure

(particularly vegetables, fruit, meat and eggs) has the potential; to improve the diets of young

children at what may be a sensitive period for developing lifelong healthy eating patterns”.
CATEGORIES OF FOOD

Main Course

Aside from milk, most proteins are acquired from poultry, pork, fish, beef, legumes and

nuts. These foods are also good sources of iron, zinc and B vitamins. Food from animal sources

contains cholesterol, whereas those from plant sources have negligible cholesterol referred to as

β-sitosterol. In the FEL, meat exchanges are further divided into 3 according to fat and caloric

content: low fat, medium fat, and high fat. 1 exchange of meat and fish or substitute in the low

fat meat contains 8 g of protein, 1 g of fat and 41 kilocalories. With medium fat meat, it contains

8g of protein, 6g of fat and 86 kilocalories while with high-fat meat contains 8g of protein, 10g

of fat and 122 kilocalories.

Vegetables are important sources of vitamins and minerals. It is recommended to include

2-3 servings, one of which should be dark green or yellow. This is so for dark green or yellow

leafy vegetables are the best sources of vitamin A. Some vegetables also provide some essential

vitamins and minerals such as vitamin C and B, iron, calcium, potassium, zinc, and magnesium.

Vitamins are required by the body to perform specific functions that promote growth,

reproduction and sustenance of life. It has three characteristics. First, it is a vital organic

substance that does not produce energy but is utilized for energy production from fat,

carbohydrates, and protein. Second, it cannot be manufactured by the body, thus it should be

acquired in the diet. Lastly, its absence, deficiency, and overdose can cause malnutrition. Aside

from vitamins and minerals, vegetables are also rich in various types of fiber. Fibers, either

soluble or insoluble, are carbohydrates that cannot be digested since the human body has no

enzyme to do so. But nonetheless, fibers perform special functions such as facilitating the
passage of food through the digestive tract, favoring normal elimination, lowering incidence of

colon & bladder cancer, decreasing rapid absorption of glucose, and controlling blood

cholesterol levels (FEL, 2008). Group A vegetables contain negligible carbohydrates, protein and

energy if 1 exchange or less is used. When 2 exchanges are used, compute as one Group B

Vegetables. The portion size for one exchange is: Vegetable A: 1 exchange = 1cup raw (25g) or

1/2 cup cooked (45g); Vegetable B: 1 exchange = 1/2 cup raw (40g) or 1/2 cup cooked (45g)

(FEL, 2008).

Dessert

Aside from rice, sugars and sweets are also good sources of carbohydrates. All sugars

provide the same amount of energy per unit but differ in the degree of sweetness and solubility.

Sweets are useful in enhancing the palatability of diet but well planned meals are nutritionally

adequate without them. Individuals who want to reduce sugar intake may take artificial

sweeteners such as aspartame, saccharine, and acesulfame K. Another good source of vitamins,

minerals, and fiber are fruits. Fruits may be used in a variety of ways: dried, fresh, canned,

frozen, or cooked. Some can be used as “free food” as to when utilized as sauces and

flavourings. Fruits temporary increases blood sugar levels therefore exchanges are limited to no

more than 5 for diabetic patients. Fruits are also regulated and the use of whole fruits instead of

fruit juices is preferred, especially for those with diabetes (Pearson, Biddle, Gorely, 2009). Fruits

are a sweet, low-calorie source of vitamins A and C. Folate, minerals disease fighting

phytochemicals and soluble fiber. Fruits are low in fat, cholesterol-free, high in fiber, and

nutrient rich. Fresh fruit provide a wonderful alternative to a high-calorie dessert (Cummins &
Macintyre, 2002). Sugars include glucose, fructose (found in fruit), maltose and lactose (found in

milk). Sugars such as glucose can be digested quickly and provide instant energy when it is

needed (Ridgwell, 2009).

Beverages

Many beverages such as soda and juice satisfy thirst, but not hunger. The calories from

drinks consumed before a meal or during a meal add on to the food calories. Individuals may

consume SSBs to satisfy thirst or for social reasons in the absence of hunger and eat less (Connors,

Bednar & Klammer, 2001). One study in my lab found that calorie intake increased significantly

when people drank a beverage containing 150 calories with lunch, compared to when they had a

calorie-free beverage (Fisher, et. al, 2001). Calorie compensation for energy consumed as a

beverage compared to solid food is less complete at subsequent meals (Apple et al. 2005).

However, milk drinks and fruit and vegetable juices contribute fair amounts of protein, fat,

nonnutrients, vitamins, and minerals to the diet. Carbonated beverages such as colas are high in

sugar content and have no nutritional value whatsoever. Colas and some soft drinks contain large

amount of caffeine, which stimulates the metabolism. The well-documented adverse

physiological and metabolic consequences of high intake of refined carbohydrates such as sugar

include elevation of triglycerides and blood pressure and lowering of HDL cholesterol, which

would be expected to increase risks of coronary heart disease (Wang, Bleich & Gortmaker,

2008). Juices could be known as the world’s fastest food. They can be made in minutes from

fresh produce right in one’s own kitchen, and although the nutritive value of the whole fruit is

slightly higher and also includes fiber, juice is an excellent source of vitamins and minerals
necessary for the maintenance of good health. Within weeks, the skin, hair, and overall vitality

may improve. Juicing enables the body to skip a step in the digestive process, which allows for

instant absorption. The only element that interferes with the quality of the nutrients is the air that

the juice comes in contact with. Nutrients enter the system as pure and perfect as nature made

them. Fresh fruits juices usually have a pleasing flavor and are easily digested (Kirschmann,

2007).

Snacks

The majority of research shows that snacking frequency or snack food intake is not likely

to be a major risk factor associated with obesity in children. Even if they are not hungry, they

find it is fun to join in when others at work stop for a donut midmorning or cookies in the

afternoon. The problem is the choice of snacks, not the snacking. According to national surveys,

although the average size of snacks and the energy content of snacks have remained relatively

constant, only when the frequency of snacking increases (greater than two or three per day) does

snacking become a risk factor among children of all age groups. Reportedly, between one-fourth

and one-third of the energy intake of school-aged children is derived from snacks. Snacks foods

tend to have higher energy density and fat content than meals, and frequent snacking has been

associated with high intake of fat, sugar, and calories (Martens, van Assema & Brug, 2005). The

primary snacks selected by children include potato chips, ice cream, candy, cookies, breakfast

cereal, popcorn, crackers, soup, cake, and carbonated beverages. It is important not to eliminate

snacks, but to help children choose healthy snacks and watch portion sizes (Kremers, et.al,

2003).
COMMUNITY HEALTH NURSING AND NUTRITION EDUCATION IN THE

PHILIPPINES

Malnutrition in the Philippines is caused by a host of interrelated factors – health,

physical, social, economic and others. Food supply and how it is distributed and consumed by

the populace have consequent impact on nutritional status. While reports indicate that there is

enough food to feed the country, many Filipinos continue to go hungry and become

malnourished due to inadequate intake of food and nutrients. In fact, except for protein, the

typical Filipino diet was found to be grossly inadequate for energy and other nutrients. In order

to compensate for the inadequate energy intake, the body utilizes protein as energy source. Thus,

the continuing PEM problem in the country. The present economic situation of the country

further aggravates the malnutrition problem with about 28 million Filipinos unable to buy food to

meet their nutritional requirements and other basic needs (FAO, 2001). While it was reported

that the health status of Filipinos improved in terms of the decrease in the mortality rates of

mothers and infants, the rising incidence of infectious diseases such as diarrhea and respiratory

diseases contributed to the poor nutritional status of many Filipinos. The goal of both community

healths nursing through nutrition education is to ensure that every person has a standard of living

that is adequate for maintaining health and longevity as a birthright of health in the Philippines.

Community health nursing is a special field that integrates public health concerns with the skills

of nursing and social assistance as part of a comprehensive health program. Community health

nurses are trained to recognize the importance of the population as a whole and the highest good

for the largest number of people. Community health nurses work with, not just for the

community.
PARADIGM OF THE STUDY

I. Subject’s Profile Acute Otitis Media

1. Sex
2. BMI

Implication for
II. On-Site Assessment Factors Food Preferences of
1. Family Influence
2. Peer Influence Community Health
3. Appearance of Food School-Aged Chilren
4. Smell of Food
5. Familiarity / Knowledge Nursing
of Food

Otitis Media with Effusion

Figure 1
SELECTED FACTORS VIS-A-VIS FOOD PREFERENCES OF SCHOOL-AGED CHILDREN OF SCHOOLS IN
CITY OF SAN FERNANDO AN IMPLICATION FOR COMMUNITY HEALTH NURSING
 A conceptual framework provides an overview of the study for better understanding of

the reader on the research topic. It was illustrated by using a solid straight arrow, a broken

straight arrow and three rectangular boxes with equal sizes which means that the variables given

are of equal importance and priority.

The first rectangular box represents the subject’s profile affecting food preferences

among children which are: (1) Sex and (2) BMI. It also consist of on-site assessment factors

affecting food preferences among children which are; (1) Family influence, (2) Peer Influence

(3) Appearance of Food, (4) Smell of Food and (5) Familiarity/Knowledge of Food

The first box is connected to the second box by the single-headed solid straight arrow,

which indicates the direct relationship between the first and second box. The second box is the

food preferences of the students based on main course (which includes meats and vegetables),

desserts, beverages and snacks.

The second rectangle is connected to the third rectangle by a single-headed broken arrow,

which indicates the direction of the study. The last rectangle is the direction of the study which

is, the Implication for Community Health Nursing

RELATED STUDIES

FOOD PREFERENCES

In the study of Cashman, L. et. al. (2010), their main objective is to assess the food group

preferences of second through fifth grade children based on ethnic background, gender, and

grade. Food group preferences were determined by the amount of various food groups consumed

in meals served as part of the National School Lunch Program at selected schools. A survey was

administered to 1,818 3rd-12th grade students in one school district in Ohio. The researchers of

the present study also aimed to identify the different factors affecting food preferences of school-

aged children and analyze the results with reference to the review of the literature. They used

plate waste study was conducted in a culturally diverse city in four predominantly free and

reduced lunch eligible elementary schools with a large Hispanic population (58%, 69%, 82%,

and 82% of students). Over a 40 day period (10 days at each of the 4 schools), 5,400 plates were

evaluated. Individual food items in the school lunch were measured before and after the meals

were served. Food group intakes were determined by measuring the difference between the

amount served and the amount remaining of each menu item after the meal was complete.

DEVELOPMENT OF FOOD PREFERENCES

Results from the study “The development of childhood dietary preferences and their

implications for later adult health” conducted by Venter, C. and Harris, G. (2009) showed that

toddlers are fed diets high in fat, sugar and salt and that mothers are confused about what

toddlers should be eating. A healthy diet for toddlers combines foods from all the five food
groups. This combination involves mixing high-calorie and low-calorie foods. Healthy food

options should be introduced from weaning, and offered repeatedly through the infant and

toddler years. Furthermore, the whole family should model a healthy eating lifestyle in order to

foster the acceptance of foods that constitute a well-balanced diet.

GENDER DIFFERENCES

“Gender differences in food preferences of school-aged children and adolescents” is a

study by Caine-Bish, N.L. and Scheule, B (2009) which aimed to identify food preferences with

respect to gender of school-age children and adolescents in an Ohio school district. A survey was

administered to 1818 3rd- to 12th-grade students in 1 rural northeast Ohio school district.

Students filled out an anonymous questionnaire about their preferences for 80 different foods

using a 5-point rating scale. The student data were grouped according to school level attended:

elementary (3rd-6th), middle (7th-8th), and high school (9th-12th). An exploratory factor

analysis identified entrée and side dish factors. Cronbach's alpha was used to measure each

factor's internal reliability. Differences in mean scores by gender and grade for each of the entrée

and side dish factors by gender and grade were identified using analysis of variance

(ANOVA). Results showed that boys preferred the meat, fish, and poultry foods over girls; girls

preferred fruits and vegetables over boys (p < .05). Furthermore, gender differences in

preferences were also demonstrated with respect to school level.

TASTE OF FOOD

“Alternative thinking about starting points of obesity. Development of child taste

preferences” was a study by Cornwell, B. and McAlister, A (2011) which focused on whether a

sugar/fat/salt (SFS) palate is linked to children’s knowledge of food brands, experience with

products, and advertising. In study 1, the authors developed a survey measure of taste

preferences and found out that a child’s SFS palate (as reported by parents) relates significantly

to children’s self-reported food choices. Study 2 examined how knowledge of certain branded

food and drinks is related to palate. Findings show that children with detailed mental

representations of fast-food and soda brands – developed via advertising and experience – have

higher scores on the SFS palate scale.

BEVEREGES

The study entitled “Preference, liking and wanting for beverages in children aged 9–

14years: Role of sourness perception, chemical composition and background variables”

conducted by Kildegaard, H. et al (2011), aimed to examine the relationship between children’s

liking or wanting perception of sourness and food behavioral data in two types of beverages. In

total 239 children (9–14years old) evaluated apple juice and fruit drink in a design with 4

different dry matter concentrations. Multiple ranking was used to determine preference and

perception of sourness, and a 5-point facial rating scale was used to assess liking and wanting.

Children filled in questionnaires and BMI were registered. Multiple ranking showed that children

on average had a high preference for versions of beverages perceived as less sour (p =0.05). A

PCA on rating data (liking and wanting, respectively), segmented the children in 3–4 segments.
A minor segment of children with high liking and wanting for the apple juice perceived as most

sour was obvious. L-PLS regression revealed visually clear correlations between chemical

measurements, liking, wanting and behavioral data.

Similarities and Differences of present study from previous studies

The studies that were presented and the current study focused on the school-aged

children, but then the specific age range for each study differs. All of the authors, including the

researchers of the current study, saw the increase in the prevalence of malnourished children

belonging to their respective age chosen. The current study also focused on the current food

preference of those residing at their chosen locale (City of San Fernando) compared to other

studies which focused on their area of research. The presented studies also have their own

factors to relate in the food preference. The current study also has its selected factors which

include sex, BMI, family and peer influence, food advertising, and the size, smell, amount/ size

and familiarity/knowledge of food. The current study also identified food groups that will be

included in the study. These are main course (which includes meats and vegetables), desserts,

beverages and snacks. The manner on how the study will be conducted is also unique to the

present study for they will make and actual assessment of the children’s food preferences by

showing actual foods that were chosen based from the pre-survey that will be done. Furthermore,

the current study will also make use of Chi square and contingency coefficient to measure the

degree of correlation between food preference and the selected factors.

 CHAPTER III

RESEARCH DESIGN AND METHODOLOGY

This chapter depicts the plan of scientific investigation that will direct the researcher in

the collection and analysis of data. It comprises the specific research design, subject of the study,

research locale, research instruments, data collection method, the instruments, the data analysis,

and the statistical treatment which were utilized in the study.

RESEARCH DESIGN

The study will be using a Descriptive Correlational Quantitative Design. The researcher

will be examining the characteristics of just one sample population in which they will describe or

explain the relationship between two or more variables within a situation without knowing the

reason for the relationship being studied. This was chosen for this type of design because it

provides flexibility in examining a problem from many different angles.

The researcher’s main objective is to identify and establish the extent of relationship

between the different identified factors to the food preferences of selected individuals using

numeric data to describe and interpret the results obtained from the data collections done.

RESPONDENTS

The respondents chosen by the researcher to be included in the study belongs to the

Grade IV to Grade VI pupils of public elementary schools in Mabalacat City, Pampanga. These
were the respondents selected for they have qualified the criteria set by the researcher. Included

in the criteria are the following: he/she should belong to the age group of 9-11 years old (with

birthdates ranging from June 1, 2003 to June1, 2005); he/she should be enrolled at the said

elementary school belonging to Grade IV to Grade VI; he/she should not have any illness at the

present time.

The researcher will use Slovin’s formula to determine the minimum number of

respondents that should be included in the study and this revealed that they should be evaluating

a certain number of pupils as the study’s sample size. For the identification of these respondents,

they will use stratified sampling procedure, which is under probability sampling, since the pupils

are already subdivided in groups based from grade level and their respected sections.

As to ethical considerations, the teacher of the children, who will be participating in the

study, will be informed ahead of time. The researcher will also be distributing letters of consent

to the mothers or legal guardians of the participants that will verify their permission and which

will contain the assurance that all information vital to the participant’s identity and safety will be

kept private and highly confidential. Included in the informed consent are the lists of food that

will be included in the study and a checklist if their child has a known allergy with the food.

RESEARCH LOCALE

The researcher will be conducting the study at the elementary schools of City of

Mabalacat City, Pampanga. This gives the researcher an easier access in the community and
allows them the opportunity to help those pupils residing in the said place. Based on the data of

the National Nutrition Council (NNC) Region 3, out of the total 241,850 weighed children (0-17

months) in Pampanga, 8,017 were underweight; 1,894 severely underweight and 4,282

overweight.

RESEARCH INSTRUMENTS

QUESTIONNAIRE METHOD

For the questionnaires, a pre-survey will be done in San Fernando, Pampanga. The

respondents from other school for the pre-survey will also meet the criteria set by the researcher

which are Grade IV to VI students with age ranging from 9-11 years old and with no disease at

the time of survey. This will include open-ended questions requiring identification of the top five

foods that the said respondents prefer of. The results of this pre-survey will be tabulated and then

will be made as basis for the different kinds of food that will be included on the checklist.

The first draft of the questionnaire will be submitted to different experts. The comments

of the committee, the adviser and set of other experts on the draft questionnaires will be

incorporated and considered to ensure its content validity.

Furthermore, a pilot test before actual data gathering on other locale will be implemented

in order to observe the answering behaviors of the respondents on the presented statements in the

questionnaires. The respondents of the pilot study will be the same students included in the pre-

survey. Internal consistency test (homogeneity) result of the items in the quantitative

questionnaire will be measured using the Cronbach Coefficient Alpha.

 During the on-site assessment, the students will be given a checklist where they would

only pick one food per category. After the checklist, they would be given a valid questionnaire

for the assessment of the relationship of family influence, peer influence, appearance, smell,

amount and size, familiarity or knowledge of food with their food preferences. The questionnaire

will be given after the students have chosen their foods. Likert scale will also be used in this

questionnaire.

DATA COLLECTION PROCEDURE

In the process of data gathering regarding the study, the researcher came up with plans

and procedure on how the study is to be performed.

PHASE 1

Prior to the start of the study, the researcher will be making a letter of consent that will

include the purpose of the study, and the request for the permission of the individuals in charge

(such as the principals of the said schools and the Barangay Captain). This letter will then be

approved by the researcher’s adviser and the Dean of the Graduate School. This letter will serve

as a proof that the researcher was indeed conducting in a research study. Letters for the parent’s

permission will also be made and distributed to the concerned individuals.

PHASE 2

After arranging all issues concerning legality and ethics, a pre-survey will be done at a

different elementary school. The respondents for the pre-survey should also meet the criteria set
by the researcher. This will include questionnaires requiring identification of the top five foods

that the said respondents prefer of. The results of this pre-survey will be tabulated and then be

the basis for the different kinds of food that will be included on the checklist. The top five foods

must represent the different categories of main course (meat and vegetables), dessert, beverages

and snacks.

PHASE 3

The next phase will be the on-site assessment of the food preferences of the respondents.

This will be divided into two parts, the checklist type of questionnaire and the likert scale type of

questionnaire. For the checklist, the students will choose one food among the different foods in

the questionnaire per category. The results of which, will be tabulated. Next would be the Likert

scale type of questionnaire, the findings after tabulated, interpreted and analyzed will identify the

relationship of family influence, peer influence and food advertising and food preferences of

school-aged children in the on-site assessment.

PHASE 4

The gathering of data, tallying and statistical treatments will be performed. The

researcher, with the help of the statistician, will interpret and analyze the acquired results using

the statistical tool accordingly. Conclusions and recommendations will be formulated with the

use of the result obtained from the study.

STATISTICAL TREATMENT OF THE DATA

In a research study, the use of statistical treatments is valuable in order to have a reliable

means of describing accurately the data, and to serve as a tool to correlate and analyze such data.

The collected data will be arranged, tabulated, and presented to permit ready and meaningful

analysis and interpretation. The following statistical treatments will be utilized for this study:

FREQUENCY AND PERCENTAGE DISTRIBUTION TABLE

This is the arrangement of data that showed the number of responses per category, or the

number of occurrences of the value falling with arbitrary defined ranges of variables. The

number of responses per category will be divided by the total number of responses then was

converted in a percentage form. This is the simplest way of processing large mass of data.

CHI SQUARE

Chi square is a statistical test commonly used to compare observed data with the data the

researchers would expect to obtain according to the stated hypothesis. This tool will be used in

comparing nominal data such as the selected factors (sex, BMI and on-site factors) in correlation

according to specific hypothesis (food preferences and grade level of the respondents). Also, in

the study, it will be used to find out if the presented null hypothesis will either be accepted or

rejected.
Formula:

2
(𝑓𝑜 − 𝑓𝑒 )2
𝑋 𝑐=∑
𝑓𝑒

where:

(𝑇𝐶)(𝑇𝑅)
𝑓𝑒 =
𝑁

That is, chi square is the sum of the square difference between observed (𝑓𝑜 ) and the

expected (𝑓𝑒 ) frequency divided by the expected frequency in all possible categories

where:

𝑓𝑜 = observed frequency 𝑇𝐶 = total number of columns

𝑓𝑒 = expected frequency 𝑇𝑅 = total number of rows

N= total number of respondents

THE CONCEPT OF CORRELATION

Research studies deal with relationship between two or more variables. Statistics offer a

variety of tools and techniques needed in making such studies. One of these is Correlational

analysis which is specifically used to measure the nature of the relationship or association

between variables.
CONTINGENCY COEFFICIENT

This will be used to record and analyze the relationship between two or more variables,

most usually categorical variables. This is used to record and analyze the relationship between

the selected factors (sex, BMI, and on-site assessment factors) and the food preferences and

grade level of the respondents. The relationship between the sets of nominal attribute, whether it

can be ranked or not may found by using this formula.

𝑋2𝑐
𝑐𝑐 = √
𝑋2𝑐 + 𝑁

Where:

X2= computed chi square value

N= total number of subjects

To determine the extent or degree of strength of relational between two sets of variables

as revealed by the computed correlation coefficient values, the following categories or scales will

be used:

0.0- 0.19= Negligible correlation

0.20- 0.39= Low but definite correlation

0.40- 0.59= Moderate and substantial correlation

0.60- 0.89= Moderately high correlation

 0.90- 1.00= High correlation

P-VALUE

P-value or probability value is associated with test statistic. It measures of how much

evidence the study has against the null hypotheses. The smaller the p-value, the stronger the test

rejects the null hypothesis being tested.

A p-value of less than 0.05 level of significance rejects the null hypothesis, then the

results would be significant because it is more stringent than 0.05 while, a p-value of more than

0.05 accepts the null hypothesis, it indicates a non-significant relationship (Polit & Beck, 2008).
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