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Original Article
Department of Food, Health and Nutrition Science, Chinese Culture University, Taipei, Taiwan, ROC
Program of Nutritional Science and Education, Department of Human Development and Family Studies,
National Taiwan Normal University, Taipei, Taiwan, ROC
3
Institute of Biomedical Science, Academia Sinica, Taipei, Taiwan, ROC
4
Institute of Microbiology and Biochemistry, National Taiwan University, Taipei, Taiwan, ROC
5
College of Public Health, National Taiwan University, Taipei, Taiwan, ROC
2
The purpose of this study is to understand nutrition knowledge, attitude, and behavior in Taiwanese elementary
school children, and the relationship of these various components. The results indicated that childrens knowledge
was fair in nutrition basics, but poor in the physiological function of nutrients, relationships between
diet/nutrients and disease, and the daily serving requirement for different food groups. Children in general valued the importance of nutrition, but they did not concern the health benefit of foods in food selections. Their dietary quality was not satisfactory, and the diet of most children did not meet the recommended serving requirements for milk, vegetable, fruit, and cereals and grains groups. Positive relationships were found among nutrition
knowledge, attitude, caring- about-nutrition behavior and dietary quality score. The restraint or disinhibited eating
behavior of 4th to 6th graders was not serious, but a large number of children already performed some selfcontrolling practices to avoid obesity, but not frequently. One fourth of the students skipped meals, especially
breakfast, and one quarter of 4th to 6th graders prepared their own breakfast; which may have some impact on
childrens diet quality. A gap was found between nutrition knowledge, attitude and eating behavior, especially
vegetable and fruit consumption, indicating that the attitude toward eating for health was not strong in this age
group. Future nutrition education for school children should not only include food serving requirements of food
groups, but also apply appropriate theories to improve the motivation for healthy eating.
Key Words: elementary school children, nutrition knowledge, nutrition attitude, nutrition behaviour, dietary
quality
INTRODUCTION
The prevalence of childhood obesity has increased dramatically in Taiwan and other countries,1-4 which has led to a
great concern about food consumption patterns and dietary
quality of schoolchildren. Many studies have indicated that
relatively few children met the recommendations for vegetable, fruit5-10 and dairy foods.6,11,12 However, the intakes of
unhealthy snacks, fast foods, and beverages have increased.7,11-13 Studies have also shown that, as children get
older, they tend to eat breakfast alone and less frequently.5,11,14 Dietary practices during childhood not only
play an important role in growth and development, they
may also predict the occurrence of obesity, diabetes, and
cardiovascular diseases in adulthood.15,16 The development
of eating behaviors is influenced by many factors. In the
Knowledge-Attitude-Behavior (KAB) model, knowledge is
considered as a prerequisite to the intentional performance
of health-related behaviors. As knowledge in health behavior domains accumulates, changes in attitude are initiated.
When changes in attitude accumulate over a period of time,
it results in behavioral changes.17,18 In order to identify
important messages for school nutrition education, the
purpose of the present investigation is to understand the
status of nutrition knowledge, attitude, and behavior of
Taiwanese elementary school children, and the relationship
535
536
Table 1. Dietary Quality Score (DQS) scoring system (H: 4th-6th grade, L: 1st-3rd grade)
Food group
<0.5
10.5
20.5
30.5
40.5
50.5
60.5
6.5
Dairy
10
10
7.5
2.5
Vegetable
10
10
10
0
0
5
3.3
10
6.6
10
10
10
7.5
2.5
Recommendation
2 servings
H: 2 servings
L: 4/3-2 servings
2 servings
H: 3 servings
10
10
7.5
2.5
L: 2-3 servings
Food group
<2
42
82
122
162
202
242
26
Cereals and H
Grains
L
2.5
7.5
10
3.3
6.6
10
7.5
2.5
Fruit
Meat
H:16 servings
L:12 servings
Unhealthy
<0.5
snacks and
10
beverages
6.5
0
Table 2. The Pearson correlation coefficients (r) of the DQS with various nutrient intakes (adjusted for calorie intake)
from 24-hr recall (N=2398)
DQS
DQS
DQS
Protein
(0.134***)
Vit.B2
(0.117***)
Sodium
(-0.022)
Fat
(0.058**)
Niacin
(0.040*)
PUFA
(0.010)
Carbohydrate
(-0.099***)
Vit. C
(0.086***)
Vit.B6
(0.065**)
Nutrient
(r)
Calcium
Phosphorus
(0.189***)
(0.169***)
SFA
USFA
(0.077***)
(0.030)
Magnesium
Fiber
(0.119***)
(0.091***)
Iron
(0.010)
Oleic acid
(0.039)
Potassium
(0.165***)
Vit. A
(0.102***)
Cholesterol
(0.092***)
Vit.B1
(0.038)
Vit. E
(0.008)
537
654
545
54.5
45.5
642
576
52.7
47.3
455
370
95
92
96
91
37.9
30.9
7.9
7.7
8.0
7.6
461
375
94
95
95
98
37.8
30.8
7.7
7.8
7.8
8.0
Table 4. Mean and percentage of correct or positive responses on nutrition knowledge, attitudes, behavior, and dietary
quality score (DQS) scales
Scale
Nutrition knowledge-total 1
Nutrition knowledge-total 2
Nutrients in food groups
The physiological function of food groups
Relationship between diet/nutrient and disease
Comparison of foods in terms of specific nutrient content
Balanced diet-the principles of balanced diet
Balanced diet-the need for six food groups
Balanced diet- the skill of selecting a balanced diet
Balanced diet- daily serving requirements for food
groups
Nutrition attitude
Caring-about-nutrition behavior
Restraint eating behavior
DQS
Total
score
43
54
5
5
5
13
8.8 0.1*
67.5
13
10.4 0.1*
79.6
6
8
6
4.4 0.1*
6.1 0.1*
4.1 0.1*
73.6
75.6
67.4
6
8
6
5.2 0.0*
6.2 0.0*
4.6 0.1*
87.4
77.9
76.2
2.90.1
47.9
54
18
60
44.30.3*
10.90.1*
35.20.42*
73.1
40.8
58.6
54
18
30
60
46.80.2*
11.70.1*
14.1 0.1
33.60.39*
80.0
47.5
20.5
56.0
included questions used in both grade groups. questions used in 4th-6th grades only. *significant difference between 1st-3rd graders and 4th6th graders (t-test, p<0.05)
538
eating behavior of 4th to 6th graders was not serious. Onefourth of the students were always afraid of being obese,
17.4% were always trying to lose weight, 10.7% always
selected foods that were not fattening due to fear of being obese. But fewer than 5% of 4th to 6th graders performed severe restraint eating behavior, e.g. vomiting; not
eating when hungry; avoiding high starch foods; nor did
they have disinhibited eating behavior, such as: overeating to the extent that one cannot stop, regret after eating.
However, over 30% of 4th to 6th graders stated that they
sometime, but not frequently, performed 5 specific kinds
of restraint eating behaviors among the 10 listed to avoid
obesity.
Dietary quality. The Taiwanese Food Guides provide
serving size recommendations for 6 food groups, but the
intake of the fat and oil group was not assessed as a part
of FFQ, therefore, only the daily intakes (Data not shown)
of 5 food groups and snacks/beverages of elementary
school children were used for DQS calculation. Details of
the DQS scoring system is provided in Table 1.
According to the TFGR 1994, the percentages of
children meeting the requirement or ingesting more than
Table 5. Mean scores of nutrition knowledge, attitudes, and behaviors by demographic characteristics of elementary
school children
Variable
st
Nutrition knowledge-total
Nutrition attitude
654
545
28.90.4
28.90.4
n.s.
44.10.3
44.50.4
n.s.
10.90.1
10.90.1
n.s.
35.60.49
34.70.56
n.s.
455
370
95
29.40.5
28.30.5
29.21.4
44.70.3
43.70.5
44.90.9
10.80.2
11.10.2
10.90.2
35.90.57
34.00.73
36.21.74
rd
1 - 3 Grade
Gender
(1) male
(2) female
Residential area
(1) urban areas
(2) rural areas
(3) Hakka areas
(4) mountain
areas
(5) eastern areas
(6) Penghu
islands
Summary of
result of Scheffe
test*
4th - 6th Grade
Gender
(1) male
(2) female
Residential area
(1) urban areas
(2) rural areas
(3) Hakka areas
(4) mountain
areas
(5) eastern areas
(6) Penghu
islands
Summary of
result of Scheffe
test*
* p<0.05
Mean SE
Caring-aboutnutrition behavior
Restraint eating
behavior
DQS
92
24.90.8
39.80.6
10.40.4
30.60.55
96
28.01.0
42.71.6
10.60.4
34.21.19
91
27.20.6
42.60.7
9.80.4
34.81.45
(1)>(6)>(4)
(2)(3)(5)>(4)
(1)(3)>(6)>(4)
(2)>(4)
(1)(2)(3)(5)(6)>
(4)
(1)(2)(3)>(6)
642
576
38.70.4
38.40.4
n.s.
46.70.2
47.00.3
n.s.
11.60.2
11.90.2
n.s.
14.20.2
14.10.2
n.s.
34.00.49
33.30.52
n.s.
461
375
94
38.90.4
38.00.6
39.01.4
46.80.3
46.90.3
47.50.6
11.70.2
11.60.2
12.20.2
14.00.2
14.20.2
14.70.4
34.30.54
32.80.65
33.41.42
95
33.90.6
43.80.4
11.50.2
14.40.6
29.70.86
95
38.00.8
45.01.5
11.70.4
14.70.5
33.01.56
98
37.51.1
45.90.9
10.80.5
12.90.5
33.11.23
(1)(2)(3)(5)(6)>(4)
(1)(2)(3)(6)>(4)
(1)(2)(3)(4)(5)>(6)
(1)(2)(3)(6)>(4)
(3)>(2)(4)(6)
539
540
Table 6. Pearson correlation coefficients between nutrition knowledge, attitudes, behavior, and dietary quality score
(DQS) of elementary school children
Variable
1st - 3rd Grade (N=1199)
Nutrition knowledge-total
Nutrition attitude
Caringabout-nutrition behavior
DQS
4th - 6th Grade (N=1218)
Nutrition knowledge-total
Nutrition attitude
Caring-about-nutrition behavior
DQS
Nutrition knowledge-total
DQS
1.000
0.542***
1.000
0.210***
0.147***
1.000
0.210***
0.185***
0.102***
1.000
1.000
0.379***
1.000
0.195***
0.205***
1.000
0.269***
0.188***
0.246***
1.000
taught in the health class of elementary school. But children knowledge was found weak in an earlier study24 and
also in the present study. As for the relationships between diet/nutrient and disease, and the daily serving
requirement of six food groups, the result was similar to
the Taiwanese adolescent study25 and the Elderly Nutrition and Health Survey in Taiwan.26 Balanced diet (food
choice from each of the six Taiwanese food groups on a
daily basis) is one of the core themes of nutrition education, which is emphasized in dietary guidelines, and in the
daily serving requirements of six food groups.
The survey results showed that although children understood the Taiwanese concept of a balanced diet, they
do not have an in-depth understanding of how many food
servings are needed daily by children; this may become
the obstacle for practicing balanced diet. Lack of knowledge on the relationships between diet/nutrient and disease may explain why some of school children seldom or
never choose foods based on its health benefits. But
previous researches stated that knowledge or skill of instrumental or how-to nature only works for those who
wish to eat healthfully, knowledge partially mediates a
relationship between goal setting and self-efficacy but is
not related to changes in the behavior, knowledge by itself can lead to behavioral change only among the right
(motivated) people.27,28 Therefore, even if children have
the knowledge, if they were not committed to healthy
eating as indicated by their responses in some items in
nutrition attitude scale and caring-about-nutrition behavior scale, they may not have the motivation to practice a
healthy and balanced diet. Therefore, nutrition education
should not only include food serving requirements of
food groups in the future, but also apply appropriate theories to improve the motivation of healthy eating of children.
Despite the high proportion of correct responses in
regard to the principle of balanced diet, almost half of the
school children considered they should take dietary supplements daily, similar to the result found in the Taiwanese adolescent study.25 Survey results indicated about
21.9% and 22.3% of Taiwanese boys and girls, respectively, and 13% to 17% of adolescents use dietary supplements.29,30 Children probably are not the persons who
541
542
543
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
544
545
Appendix. Examples of questions of the nutrition knowledge, attitudes, caring about nutrition behavior, and restraint eating behavior scales
Nutrition knowledge
Subscale 1.The nutrients in food groups
How can we acquire the energy body needed?
(1) from exercise (2) from wearing clothes (3) from eating
Subscale 2. The physiological function of food groups
What is the main physiological function of cereals and grains group foods (e.g. rice, noodles, steamed bun, etc.)?
(1) provide energy (2) make bones strong (3) making blood
Subscale3. The relationship between diet/nutrient and disease
Which of following condition can cause heart disease?
(1) eat too much fat (fatty meat) (2) eat too much dietary fiber (fruits) (3) eat too much vitamins (rice)?
546
Original Article
Department of Food, Health and Nutrition Science, Chinese Culture University, Taipei, Taiwan, ROC
Program of Nutritional Science and Education, Department of Human Development and Family Studies,
National Taiwan Normal University, Taipei, Taiwan, ROC
3
Institute of Biomedical Science, Academia Sinica, Taipei, Taiwan, ROC
4
Institute of Microbiology and Biochemistry, National Taiwan University, Taipei, Taiwan, ROC
5
College of Public Health, National Taiwan University, Taipei, Taiwan, ROC
2