Energy and nutrient intake and acceptability of

nutritionally balanced school meals in

Filipino students

Imelda Angeles-Agdeppa, Nicole Neufingerl, Clarita Magsadia, Harry

Hiemstra, Chona Patalen, and Ans Eilander

Abstract be a healthier and acceptable alternative to regular

Background. School meals provide an excellent
oppor- tunity to improve children’s diet.
Objective. To investigate dietary intakes and accept-
ance of nutritionally balanced school meals (“nutri-
meals”) as compared with regular (“baseline”) school
meals among Filipino students.
Methods. The study employed a before–after
interven- tion design with one group. Students 13 to 16
years of age from a public school in Metro Manila (n =
112) con- sumed baseline school meals for 2 weeks
followed by con- sumption of nutri-meals for 7 weeks.
Served meals and plate waste were weighed to
calculate food and nutrient intakes. Acceptability of
meals was assessed daily in a random subsample
using a seven-point hedonic scale. Analysis of
covariance corrected for age and sex was conducted
to test for differences in nutrient intakes and
acceptability between nutri-meals and baseline meals.
Results. Feeding nutri-meals resulted in a higher
intake of vegetables (95.3 ± 13.8 g), fruit (76.5 ± 6.3
g), and fish (19.1 ± 3.3 g) than baseline meals. Energy
and protein intakes significantly increased by 140.7 ±
2.8 kcal and 3.2 ± 0.1 g, respectively. The quality of fat
intake improved compared with baseline meals (p
< .001). Micronutrient intake from nutri-meals was
significantly higher than that from baseline meals
(except for zinc), contributing 6% to 79% of
recommended daily intakes. Most students (> 90%)
liked both baseline and nutri- meals; however, the
mean acceptability score for baseline meals was slightly
higher (0.2 ± 0.07 points, p = .004).
Conclusions. Nutritionally balanced nutri-meals may
Imelda Angeles-Agdeppa, Clarita Magsadia, and Chona
Patalen are affiliated with the Food and Nutrition
Research Institute, Taguig City, Philippines; Nicole
Neufingerl, Harry Hiemstra, and Ans Eilander are affiliated
with Unilever R&D, Vlaardingen, the Netherlands.
Please direct queries to the corresponding author:
Imelda Angeles-Agdeppa, Department of Science and
Technology, Food and Nutrition Research Institute, Gen.
Santos Ave., Bicutan, Taguig City 1631, Philippines; e-
mail: iangeles- agdeppa@yahoo.com.ph.
Fili- pino school meals. Further optimization of nutri-
meals is required to meet the nutritional needs of
adolescents and reduce sodium content.
Key words: Adolescents, intake, liking, school lunch
Introduction
Adolescence is a life stage in which rapid physical
growth, cognitive development, and sexual maturation
take place [1, 2]. Nutritional demands peak during
adolescence; energy requirements go up to 2,500 kcal/
day for girls and more than 3,000 kcal/day for boys,
exceeding energy requirements for adults [3]. The
requirements for many micronutrients, particularly,
iron, zinc, calcium, and vitamin D, are also
increased during adolescence [4]. With the onset of
menarche, adolescent girls are especially at risk for
developing iron deficiency and anemia [5]. An
adequate diet that meets nutritional requirements is
crucial for healthy physical growth and cognitive
development during adolescence and can also have
an influence on health and work capacity later in life
[6].
Previous reviews showed that undernutrition in
school-aged children and adolescents is common in
developing countries, particularly in Asia and Africa
[5–7]. According to national surveys in the
Philippines, 10% to 13% of adolescents (13 to 19
years) are wasted (low weight-for-height), 33% to
37% are stunted (low height-for-age), and 17% are
underweight (low body mass index [BMI]-for-age);
iodine deficiency and anemia are present in 12% and
14% of Filipino adoles- cents, respectively [8, 9].
Adolescents spend a large part of their time at
school, where they may consume one or more meals or
snacks. Offering high-quality, nutritious meals at
school pro- vides an excellent opportunity to
improve the dietary intake of adolescents, helping
them to achieve their full developmental potential.
A Cochrane systematic

Food and Nutrition Bulletin, vol. 35, no. 3 © 2014, The Nevin Scrimshaw International Nutrition Foundation. 361
362 I. Angeles-Agdeppa et al.
and student informed
review found that school meals or snacks can have a
positive impact on growth and cognitive outcomes
in disadvantaged children in low-income countries
[10]. In the Philippines, a guideline for school
canteens was issued stating that school canteens shall
help eliminate malnutrition among adolescents and
shall serve as a venue for the development of
desirable eating habits of students. The guideline
mandates the school canteens to sell nutrient-rich
foods such as root crops, noodles, rice and corn
products, fruits and vegetables in season, and fortified
products [11]. However, many school lunches in the
Philippines currently consist of rice and meat
products, e.g., meatloaf or sausages, and are of poor
nutritional quality; vegetables are the foods least
bought by students. Therefore, there is a need to
help school caterers to develop nutritious meals and
increase awareness of healthy diets in children. In
order to have a sustainable impact on children’s
nutrition, growth, and development, school meals
not only need to be healthy but should also be
affordable and accepted by students. Therefore, the
aims of this study were to evaluate the effect of the
introduction of nutritious school lunches (“nutri-
meals”) on adolescents’ energy and nutrient intakes
and their acceptability to students compared with
regular school lunches (“baseline meals”). The
nutritious meals were developed as part of a school
meal program.

Methods

Subjects

The study was conducted at Carlos P. Garcia High

School, a public secondary school with almost 1,000
students, located in Quezon City, the largest city in
Metro Manila. The school was selected among 100
schools planning to implement the school meal pro-
gram (SoooPinoyCanTEEN program, Unilever
Food Solutions), in conformity with the following
inclusion criteria: public school, located in a densely
populated area, serving the middle-class
socioeconomic strata (i.e., in class C or D [4 or 5]
municipality), with an active operating school
canteen where at least 30% of the students regularly
buy their meals, with no other ongoing nutrition or
health intervention at the school that may affect the
dietary intake of students, and with a school head
agreeing to collaborate. The study took place
between September and December 2012.
Students were recruited to take part in the study
via verbal briefings and information sheets about the
study distributed by teachers in the classes. A total
of 208 students were interested in participating in
the study and were invited together with their
parents to attend an orientation meeting during
which the details of the study and the contents of the
informed consent were explained. Signed parental
 Intake and acceptability of nutritious school 363
lunches
SD).
consents were obtained before a student was The baseline meals, which had previously been
assessed for screening by a physician and again offered at the school’s canteen, consisted of rice, a
before enroll- ment in the study. Inclusion of protein source (pork or chicken), and some vegetables.
participants in the study was done on the basis Because the regular school meals offered only a
of enrollment, i.e., first come, first served. limited variety of meals recurrently, a baseline
Students were excluded from the study based on period of 2
the following criteria: younger or older than 13 to
16 years, school attendance 90% or less for 1
month prior to the study period according to
school records, history of food allergy, history
of chronic ill- ness and subsequent ongoing
medication, and partici- pation in another
nutrition or health program outside school. All
students who underwent screening but who
were not included in the study were referred to
the home economics teacher for nutrition
counseling. The study was reviewed and
approved by the Food and Nutrition Research
Institute (FNRI) Technical Committee and the
FNRI Institutional Ethics Review Committee.
The study was carried out in accordance with
the declaration of Helsinki, guided by the Council
for International Organizations of Medical
Sciences Ethical Guidelines for Biomedical
Research Involving Human Subjects [12] and the
National Guidelines for
Biomedical/Behavioural Research [13].

Study design and procedures

The study employed an uncontrolled before–

after intervention design. During the baseline
period (the first 2 weeks of the study), the
students were provided with baseline meals,
followed by a 7-week intervention period during
which they received nutri-meals.
Before the start of the study, information
about the general health of the students and
socioeconomic and demographic data from the
family were collected in face-to-face
interviews with the students and their parents
or guardians. The students’ weight and height
were measured at screening, at the end of the
baseline period, and at the end of the
intervention period. Students were weighed
wearing lightweight clothing (school uniforms)
without shoes. Weight was measured with a
calibrated Detecto weighing scale and recorded
to the nearest 0.1 kg. Height was measured
with a measurement tape (microtoise, Depose,
France) posted flat against a wall with the
student barefoot and stand- ing straight and was
recorded to the nearest 0.1 cm. Two readings
for weight and height were recorded per
measurement; based on the means of the two
readings, the BMI was calculated. Age-specific
BMI-for-age z-score cutoffs from the World
Health Organization (WHO) reference for
children aged 5 to 19 years were used to define
underweight (< –2 SD) and overweight (> +1
364 I. Angeles-Agdeppa et al.
the acceptability of the consumed meal. The
weeks was considered sufficient to represent the range liking
of regular school meals. Nutri-meals were
developed by chefs and nutritionists employed by
the school meal program based on dishes commonly
known to be favored by adolescents and included
meat or fish as protein source, vegetables, fresh fruit,
and rice. Extra care was taken to use nutrient-dense
foods and vegeta- ble oils with a low saturated fatty
acid (SAFA) content. The meal cycle of nutri-meals
comprised different menus for 7 weeks. Table 1
provides an overview of the food composition of
baseline meals and nutri-meals.
In order to define a cost target for nutri-meals,
sur- veys on the amount of money students usually
spend for their school lunch (20 to 45 ₱) (US$0.45–
1.02) had been conducted among Philippine
adolescents from schools of the middle-class
socioeconomic strata,. Based on this information,
nutri-meals were developed to be sold for an average
price of 35 ₱ (US$0.77).
Before the beginning of the study, all school canteen
staff took part in a 1-day training on proper hygiene,
basic meal preparation skills, and preparation of
nutri- meals delivered by staff of the school meal
program. During the study period, a contracted cook
from the school canteen prepared the meals each
day. All food items were weighed during meal
preparation, and each dish of the meal was served in a
weighed standard por- tion size. Unfortunately, during
the baseline period, salt and seasonings were not
weighed, and therefore data for sodium intake
during baseline are missing.
Baseline meals and nutri-meals were provided at
no cost for 5 days a week, from Monday to Friday,
in a central room, supervised by research assistants.
Each day, the presence of students at the school
lunch was registered, which served as the proxy
indicator for attendance. Standardized portion sizes
of meals were served on plates with partitions to
separate rice, meat, vegetable, and fruit dishes, and a
sticker with the student’s identification code was
attached to the plate. The students had no option to
choose between meals or dishes. After they finished
their meal, the students returned their plates, and
plate waste was measured separately for each dish
with an electronic weighing scale (Nutex FK
Series). Food intake from baseline meals and nutri-
meals was calculated by subtracting the weighed
plate waste from the standard portion size served.
Energy and nutrient intakes were derived from the
weighed consumption of foods using the US
National Nutrient Database [14]; for some local foods,
the Philippine Food Composition Table was used [15].
Missing nutrient values were estimated based on the
nutrient content of similar foods, nutrition labels of
commercial products, or available literature on
nutri- tional analysis of individual foods.
Following a randomized scheme, each day a dif-
ferent subsample of students (n = 22) completed a
self-administered liking questionnaire that assessed
 Intake and acceptability of nutritious school 365
lunches
TABLE 1. Average food content per meal provided during
baseline and intervention (nutri-meals) periods
Baseline meals Nutri-meals
Food Mean SD Mean SD
Meat (g) 61.6 32.8 43.4 35.0
Fish (g) 0.0 0.0 20.5 29.0
Vegetable (g) 16.1 20.3 111.0 64.3
Fruit (g) 0.0 0.0 80.2 46.6
Oil (g) 7.4 11.2 16.5 7.1
Cereal (g) 195.5 9.5 206.1 19.4
Dairy (g) 0.0 0.0 1.5 6.0
Tubers (g) 3.7 12.3 3.0 6.8
Legumes (g) 10.4 22.9 0.0 0.0
Sugar (g) 0.0 0.0 1.1 2.1
Other (g) 1.5 5.0 10.8 3.9
Total energy 654.8 119.3 491.2 137.8
(kcal)

questionnaire had been pretested among Filipino

adolescents and adjusted for use in this target group.
Students were asked to rate the meal in overall liking,
taste, and appearance on a seven-point hedonic scale.
Each student completed the liking questionnaire
approximately two times during the baseline period and
nine times during the intervention period.
The total daily food intake of the students was assessed
by 24-hour food recall conducted by a trained, registered
nutritionist/dietician. Each student was scheduled to
participate in four 24-hour recalls, two during the
baseline period and two during the inter- vention period
(one weekday and one weekend day each). The amount
of foods consumed was estimated using the Standard
Weights and Measures Manual developed by FNRI [16].
Samples of food items not found in the manual were
bought, weighed, and recorded. Energy and nutrient
intakes were calculated with the use of the Philippine Food
Composition Table [15]. Dietary data were analyzed using
the Individual Dietary Evaluation System also developed
by FNRI.

Data analysis

Sample size calculations were performed for various

effect sizes on intakes of energy, macronutrients, and
micronutrients based on a paired t-test with a two- sided
alpha level of 0.05 and a power of 0.8. To detect a
difference in energy intake of 100 kcal between baseline
meals and nutri-meals, a sample size of 14 subjects was
required. To ensure an adequate representation of boys and
girls of various ages, it was decided to stratify for age (in
years) and sex and recruit 14 subjects in each of the age-sex
strata, for a total sample size of 112 subjects. Analysis of
covariance (ANCOVA) with sex and age as covariables
was used to test for differences in energy, nutrient, and
food intakes and for differences in mean liking scores of
baseline meals and nutri-meals.
366 I. Angeles-Agdeppa et al.

A two-sided p-value < .05 was considered to indicate

baseline and intervention period, excluding intakes
a statistically significant difference for all analyses
from school lunches, were compared. ANCOVA
done. Tukey’s multiple comparison procedure was
adjusted for age and sex was used to test for a
used to control the type I error level during post hoc
significant difference. All analyses were performed
analysis [17].
with SAS, version 9.2.
Energy and nutrient intakes from intervention and
baseline meals were compared with recommended
daily nutrient intakes as set by the WHO/Food and
Results
Agriculture Organization (FAO) [3, 4], according to
the subject’s age and sex, in order to calculate the
average contribution of school meal intakes to the Subject characteristics
WHO/FAO daily recommendations.
One hundred twelve students with a mean age of
To investigate whether potential differences in
15.0 (SD 1.06) years participated in the study. Of
intake from school meals would lead to compensatory
these stu- dents, 17.0% were underweight (BMI-for-
changes in intake during the remainder of the school
age z-score
day, 24-hour energy intakes on a school day
< –2 SD) and 3.6% were overweight (BMI-for-age
during the
z-score > 1 SD). The majority of the students (54%)
TABLE 2. Subject characteristics at baseline (n = 112) came from families with a family income below the
Filipino poverty threshold [18]. For an overview of
Characteristic Mean SD characteristics of the subjects, see table 2.
Age (yr) 15.0 1.1 In the course of the study, eight subjects dropped
Height (cm) 153.8 7.6 out, one during the baseline period and seven during
Weight (kg) 43.1 7.3 the intervention period (fig. 1). On average, the stu-
BMI (kg/m2) 18.4 2.3 dents attended the school lunches on 92% of days
Height-for-age z-score –1.45 0.84 during the baseline period and on 80% of days
BMI-for-age z-score –0.90 1.03 during the intervention period. The available data
BMI, body mass index.
from all subjects who took part in both the baseline
and the intervention period were included in the
statistical analysis (n = 111).

Invited for
Screening orientation meeting
(n = 208)
74 did not attend orientation
meeting

Attended and
screened
(n = 134) 22 excluded due to
• age (n = 3)
• food allergy (n = 8)
• chronic disease (n = 3)
• no signed consent for
enrollment in study (n =
8)

Enrolled in study,
Enrollment started baseline
(n = 112)
1 dropout
• parents did not allow to
continue participation in
study
Started
intervention
(n = 111) 7 dropouts
• left school (n = 3)
• did not like to go to
lunch room (n = 2)
• did not like meals (n = 1)
• personal reasons (n = 1)

Completed
intervention
(n = 104)

FIG. 1. Subject flow chart

Intake and acceptability of nutritious school 367
lunches

Baseline meals Nutri-meals

Other Other
1.4g 10.8g
Tubers Tubers Meat
3.3g Meat 41.8g
3.0g
58.5g Fish
19.1g

Vegetables
14.8g Vegetables
Legumes Cereals 95.3g
10.7g 202.9g
Cereals Oil
194.4g 7.2g

Fruit
Oil 76.5g
Dairy
14.6g 1.5g

FIG. 2. Mean intake of foods from different groups from baseline meals and nutri-meals

Intake from school meals

Energy
The mean intakes of vegetables, cereals, and vegetable
oil were significantly higher from nutri-meals than Protein
from baseline meals, whereas the intakes of meat and
legumes were significantly lower (fig. 2) (p < .001). Carbohydrate
The lower intake of meat from the nutri-meals was
com- pensated by the higher intake of fish. Vegetable Total
intake increased more than sixfold, from 14.8 (SD 2.9)
g during the baseline period to 95.3 (SD 13.8) g during fat Baseline meals
Nutri-meals
the intervention period. Because baseline meals did
not contain fish or fruit, consumption of fish and fruit SAFA
from nutri-meals increased the variety of foods in the
diet. Plate waste was numerically, but not statistically PUFA
significantly, higher for nutri-meals, with an average
of 5.4% (SD 8.2%) of the meal left on the plate, Calcium
compared with 1.7% (SD 5.4%) for baseline meals.
Among nutri- meals, plate waste was particularly high Vitamin A
for vegetable, fish, and fruit dishes, with 33.5%,
22.8%, and 13.5% of students, respectively, not Vitamin C
finishing these dishes.
Energy and nutrient intakes were significantly Iron
higher from the nutri-meals than from the baseline
meals, except for SAFA and zinc (p < .001) (table 3). Zinc
Energy intake increased by 140.7 (SED 2.8) kcal com-
pared with baseline meals; the quality of fat intake Folate 0 10 20 30 40 50 60 70 80

improved due to significantly lower SAFA (14.5% % of WHO/FAO daily recommendations

of total energy [%en] in baseline meals and 11%en
in nutri-meals) and higher polyunsaturated fatty
acid (PUFA) intakes (3%en in baseline meals and
10
%en in nutri-meals) compared with baseline meals
(p < .001).
Energy and nutrient intakes from the nutri-meals
(except for zinc) were closer to WHO/FAO
recommen- dations [3, 4] than intakes from baseline
meals (fig. 3). Baseline and nutri-meals provided on
average 17.6%
FIG. 3. Energy and nutrient intakes from baseline meals
and nutri-meals expressed as percentage of recommended
daily intakes for 13- to 16-year-old adolescents by the World
Health Organization/Food and Agriculture Organization
(WHO/ FAO). Macronutrient intakes are compared with
WHO/FAO recommendations expressed in grams per day.
For saturated fatty acids, the recommendation represents
an upper limit, and lower values are more beneficial
368 I. Angeles-Agdeppa et al.

TABLE 3. Mean energy and nutrient intakes from baseline meals and nutri-meals
Difference
Baseline meal Nutri-meal (nutri-meal – baseline meal)
Nutrient Mean SD Mean SD Mean SED pa
Energy and macronutrients
Energy (kcal) 480.1 18.8 620.8 28.2 140.7 2.8 .000
Protein (g) 20.5 1.3 23.6 1.1 3.2 0.1 .000
Protein (%en) 17.0 0.7 15.2 0.5 –1.8 0.1 .000
Carbohydrates (g) 60.0 1.3 82.7 2.9 22.7 0.2 .000
Carbohydrates (%en) 52.4 1.7 54.0 1.3 1.5 0.2 .000
Fiber (g) 1.8 0.1 4.1 0.3 2.3 0.0 .000
Total fat (g) 16.6 1.4 21.8 1.6 5.2 0.2 .000
Total fat (%en) 28.6 1.6 30.9 1.3 2.2 0.2 .000
SAFA (g) 8.6 0.8 7.7 0.9 – 0.9 0.1 .000
SAFA (%en) 14.5 1.0 10.8 1.3 -3.7 0.1 .000
MUFA (g) 4.9 0.4 5.9 0.6 1.0 0.1 .000
MUFA (%en) 8.6 0.4 8.3 0.6 – 0.3 0.1 .000
PUFA (g) 1.7 0.1 7.1 1.1 5.4 0.1 .000
PUFA (%en) 3.0 0.1 10.1 1.2 7.1 0.1 .000
Micronutrients
Calcium (mg) 26.0 1.6 84.8 7.4 58.7 0.7 .000
Iron (mg) 4.2 0.2 4.8 0.2 0.5 0.0 .000
Zinc (mg) 2.8 0.2 2.5 0.1 –0.3 0.0 .000
Vitamin C (mg) 2.3 0.5 31.6 3.9 29.3 0.4 .000
Vitamin A (µg RAE) 123.6 58.7 213.7 26.4 90.2 6.0 .000
Folate (µg) 215.9 5.4 227.6 7.3 11.6 0.7 .000
Sodium (mg) Not Not 1,249.4 105.6 — — —
assessed assessed
a. ANCOVA, corrected for age and sex.
%en, percentage of total energy; MUFA, monounsaturated fatty acids; PUFA, polyunsaturated fatty acids; SAFA, saturated fatty acids

(SD 2.1%) and 22.8% (SD 2.6%) of adolescents’ daily

and the baseline meals; 99.0% and 93.5% of students,
recommended energy, respectively; the contribution
respectively, gave a positive response on overall liking
of micronutrient intake from nutri-meals to WHO/
(“like very much,” “like moderately,” or “like
FAO daily recommendations [4] ranged from 6.5%
slightly”) for baseline meals and nutri-meals,
(SD 0.6%) for calcium to 79.0% (SD 9.8%) for
respectively. Figure 4 provides an overview of the
vitamin C. The amount of micronutrients provided
distribution of overall liking scores.
per consumed kilocalorie of nutri-meals compared
The mean overall liking score significantly differed
with baseline meals was significantly higher for
between baseline meals and nutri-meals (p = .004).
calcium (p < .001) and vitamin C (p < .001), and
With a mean difference of 0.2 (SED 0.07) points on a
significantly lower for iron, zinc, and folic acid (all
seven-point hedonic scale, nutri-meals were slightly
p < .001). Sodium intake from nutri-meals equaled
less liked than baseline meals. Similar results were
2.0 mg per consumed kilo- calorie and contributed
found for liking of taste and appearance (p < .05) (data
62.5% to the daily maximum intake as
not shown).
recommended by WHO [19].
Post hoc pairwise comparison of overall liking
Data from the 24-hour recall showed that energy
scores between the different protein dishes revealed
and nutrient intakes during the remainder of the day
that fish dishes were significantly less liked than
(excluding school lunch) were similar for the
pork dishes (p < .001) or chicken dishes (p = .012),
baseline and intervention periods, indicating that the
independently of treatment. There also was a
increased intakes from the nutri-meals did not lead
significant interaction effect between student’s gender
to reduced intakes at home or outside school.
and the protein source of the dish (p = .010),
indicating that girls liked fish dishes less than did
Liking of school meals boys. The mean liking scores for chicken and meat
dishes did not differ between base- line meals and
The vast majority of students liked both the nutri- nutri-meals.
meals
Intake and acceptability of nutritious school 369
lunches

50 Baseline meals Nutri-meals

% of responses of students
40

30

20

10

Like
very much Dislike
very much

FIG. 4. Distribution of overall liking scores for baseline meals and

nutri-meals

Discussion the

This study showed that nutritionally balanced meals

significantly increased the intakes of energy and
most micronutrients towards meeting the
WHO/FAO recommendations [3, 4] in Filipino
schoolchildren compared with baseline meals.
Furthermore, the vast majority of students liked both
the baseline meals and the nutri-meals, although the
overall liking scores were slightly lower for nutri-
meals.
A strength of this study was the good conduct of
the study reflected by a low dropout rate and
thorough assessment of students’ actual food intake
from school meals during the whole study period.
The overall attendance of the students was high
(83%); attendance was higher during the baseline
period than during the intervention period, which
can be explained by the relatively short duration of
the baseline period.
The study population was from a highly urban
area but was representative of Filipino adolescents
with regard to nutritional status; the percentages of
students classified as underweight or overweight in
our study correspond to the findings of a national
survey among Filipino adolescents [9].
Although the study school was located in a
munici- pality typically serving the middle-class
socioeconomic strata, the majority of students
participating in the study reported a family income
below the poverty threshold. A possible explanation
for this discrepancy may be that students with a
poorer socioeconomic status may have been more
likely to sign up for the study in order to receive
free meals. Another expla- nation may be that self-
reported family income is not a reliable measure and
may have been underes- timated, particularly as
many students (37%) were living in extended
families with possibly more than one breadwinner.
The lack of a control group that did not receive
 370 I. Angeles-Agdeppa et al.
nutri-meals can be seen as a limitation of this study.
However, comparison with a control group probably
would have added little to the validity of the results
because of noise introduced by factors that would differ
between the intervention and control schools. In this
study, the subjects served as their own controls, and
within the relatively short duration of the study it has
been estimated that a possible effect of other factors on
intake or liking, beyond the meal itself, would be
negligible. The difference in duration between the base- line
and intervention periods is expected not to have
influenced the results for intake, because measuring a
limited variety of baseline meals over a shorter time
period would lead to a similar variance in estimated mean
intake data as measuring a greater variety of nutri-meals
during a longer period of time.
Where possible, we used the US National Nutrient
Database for the nutrient calculation of most foods, but for
nutrient composition of some local food items we were
dependent on the Filipino food database, which lacks
information on some of the nutrients. This may have led
to an underestimation of the intakes of specific fatty acids
and of zinc in particular.
In this study, we did not assess the effects of the nutri-
meals on micronutrient status, the prevalence of
micronutrient deficiencies, or growth. A similar study
that investigated the effects of nutritionally balanced
school meals compared with regular school meals in
primary school students in India found no differences in
height and weight gains after 1.5 years of intervention,
but significantly greater reductions in signs of vitamin A
and vitamin D deficiency, among those students who had
received the nutritious school meals [20].
The results of our study are in line with other stud- ies
that showed improvements in students’ food and nutrient
intakes upon provision of healthier school lunches [21–
23]. The Chef Initiative Study in Boston,
 Intake and acceptability of nutritious school 371
lunches

for example, modified regular school lunches with the morbidity, growth, and cognitive out- comes were
help of a professional chef to make meals more inconclusive but promising [32].
healthy and palatable [21]. Compared with children
in control schools, children in Chef Initiative schools
consumed significantly more whole grains and
vegetables and had reduced intakes of SAFA; the
sodium intake from school lunches was still above
recommended levels. Introduction of stricter
nutritional guidelines for school meals has been
shown not only to improve the nutritional
composition of the meals [24–26], but also to lead to
healthier food choices and improved nutrient intakes
[22, 23]. Among secondary school students in the
United Kingdom, the percentage of students eating
fruits, vegetables, and dairy products with school
lunch significantly increased upon introduction of
more stringent compulsory food- and nutrient-based
stand- ards, and the intakes of total fat, SAFA, and
sodium sig- nificantly decreased [23]. In the United
States, a study among more than 4,000 adolescent
students in 40 states found that the prevalence of
obesity among students was lower in states with
stricter school meal stand- ards, especially among
low-income students who were eligible for free or
reduced-price school lunches [27].
According to nutrition guidelines for school meals
in developing countries and emergency situations as
set by the World Food Programme and WHO,
school lunches should provide at least one-third of
children’s daily dietary needs [28]. Although nutri-
meals in this study increased students’ overall
intake, the energy, calcium, and iron contents of the
meals did not reach this recommended level. Cost
constraints play an important role here, as it is
challenging to provide greater portions of nutrient-
dense foods at affordable prices. Therefore, we
recommend including vegetar- ian meals that
replace meat or fish with high-quality protein from
less expensive plant sources such as leg- umes and
soybeans. Furthermore, school meals could be
enriched with energy by adding extra vegetable oil
or providing more rice. Although school meals
should provide sufficient energy for growth and
development, a surplus of energy that may lead to
excessive weight gain or food wastage should be
avoided. The school meal guidelines of the US
Department of Agriculture recommend an upper
energy limit of 700 and 850 kcal for secondary
schoolchildren of different ages [29]; the energy
content of nutri-meals was still below this limit. To
increase the micronutrient density of school meals,
micronutrient fortification should be considered.
Micronutrient fortification of foods has been identified
as the most cost-effective approach to improve
health, especially in developing and emerging
countries [30, 31]. A systematic review of
intervention studies showed that micronutrient
fortification of foods provided at school consistently
improved micronutrient status and reduced anemia
prevalence in school-aged children; the effects on
 372 I. Angeles-Agdeppa et al.
Despite the overall improvements in plate. In our study, plate waste was particularly high
nutritional intakes from nutri-meals as for fish, vegetables, and fruit. The Chef Initiative
observed in this study, sodium intake from Study reported similar findings [21], and in a
nutri-meals (2.0 mg/kcal) exceeded the WHO national Finnish study, salad and milk were the
recommendations of 2,000 mg/day, which school meal components skipped most often by
imply 1.0 mg/kcal [19]. Sodium intake from adolescent stu- dents [39]. Therefore, besides
nutri- meals was similar to that from baseline providing nutritionally
meals, as esti- mated from two baseline meals
made from processed foods with a mean
sodium content of 2.1 mg/kcal. Particularly in
Asian countries, intakes of sodium are
estimated to be well above the recommended
intakes [33]. Other studies have also shown
that high sodium content is an issue in school
meals, even if the meals otherwise comply with
nutritional guidelines [21, 34, 35]. A survey
among secondary schools in the United
Kingdom in 2011 reported that less than 20%
of sec- ondary schools met the compulsory
school meal stand- ards for sodium [23].
Besides a reduction in sodium content of
seasonings and condiments, education and
training of chefs to increase their awareness of
the adverse health effects of sodium and their
knowledge of high-sodium foods, create
demand for low-sodium alternatives, and
improve their professional skills to prepare
tasty meals with little salt might help to reduce
the sodium content of school meals. A gradual
reduc- tion in sodium content of school meals,
as imposed by the new nutritional standards for
school meals in the United States [29], might
be an effective strategy to allow time for
adaptation to less salty foods for students and for
developing tasty low-sodium alternatives by the
food industry and caterers.
Another barrier to improving the nutritional
com- position of school meals may be the
belief that stu- dents will not like healthier
meals and will resort to buying snacks from
vendors outside school instead. The nutri-
meals in our study were well accepted by
students. The lower liking scores for nutri-
meals that contained fish can be explained by the
fact that students were not used to fish dishes
provided at school and had difficulties eating
fish with utensils, as indicated by the verbatim
comments of students on the liking
questionnaire. Familiarity is an important
determinant of how children like foods and how
much of them they eat; in laboratory studies as
well as in real-life settings, repeated exposure
has been shown to increase chil- dren’s liking
and consumption of unfamiliar foods and
acceptance of vegetables [36]. Moreover, eating
habits that are established during childhood and
adolescence tend to track into adulthood [37,
38]. Hence, it is important to include nutrient-
dense foods like fish as a common component
in school meals. Yet, it is espe- cially these
“healthy” foods that children often leave on their
Intake and acceptability of nutritious school 373
lunches

balanced meals, schools should promote healthy eating

intakes of Filipino adolescents compared with baseline
habits in classes and during extracurricular activities
school meals. At the same time, nutri-meals were
to improve children’s attitude toward nutritious
acceptable to the vast majority of students, making
foods, reduce plate waste, and further optimize
them a healthier and acceptable meal option to be
nutritional intake from school meals. For instance,
served in school canteens. The composition of nutri-
behavior change interventions based on peer-
meals could be further improved by micronutrient
modeling and rewards have been shown to
fortification and substitution of salt with low-
sustainably increase fruit and vegetable intakes of
sodium alternatives. Beyond providing nutritious
primary schoolchildren during lunchtime at school
meals, nutri- tion education and behavior change
[40, 41]. Holistic approaches that involve multiple
interventions tar- geted at students and policies
stakeholders (students, teachers, can- teen operators,
restricting the availability of less nutritious foods in
and parents) have been shown effective in improving
the school environment could help to further
nutrition knowledge, attitude, and skills and
promote healthy dietary intakes by students.
increasing consumption of healthier foods [42].
Components of such holistic programs are a positive
climate toward nutrition and health at school,
increased focus on health and nutrition in the school Conflicts of interest
curriculum, training for teachers and cafeteria staff,
improved school kitchens and dining areas, and Nicole Neufingerl, Harry Hiemstra, and Ans Eilander
involvement of parents and the local community are employees of Unilever R&D. Unilever also
[43]. markets foods for the food services industry. All other
authors declare no conflicts of interest.
During this study, students received school meals
for free. However, it is unclear whether students would
actually pay for the healthier nutri-meals, even if
Authors’ contributions
they reported liking them. Especially when students
have the option to select their meal from a range of
Imelda Angeles-Agdeppa was the primary researcher;
products on offer, stimulating students to make a
Imelda Angeles-Agdeppa and Ans Eilander were
healthy choice is important. Subsidies to offer
responsible for the conception and design of the study;
healthier foods at dis- count prices or as part of meal
Imelda Angeles-Agdeppa, Nicole Neufingerl, and Ans
deals may be one way to encourage students to do so
Eilande were responsible for interpretation of the
[44]. In addition to offer- ing a broad range of healthy
results and writing the manuscript; Harry Hiemstra
meal options, guidance by governments, for example,
performed the statistical analysis; Clarita Magsadia
on limiting the availability of less healthy meal items
and Chona Patalen assisted in the feeding activity.
and restricting access to competing foods from
All authors read and edited the manuscript.
vending machines or snack bars around schools has
been shown to positively influence eating behaviors
of students at school [23, 44, 45]. Despite the fact
that nutri-meals were developed to be available at a
Acknowledgments
price comparable to that of regular school meals,
We thank all the participants in the study, as well
students from a poor socioeconomic back- ground,
as the school head and canteen staff of the Carlos P.
who usually are most affected by undernutri- tion,
Garcia High School for their cooperation. We also
may not be able to afford to buy meals at school at all.
thank the research assistants from the Food and Nutri-
Additional strategies will be needed to provide these
tion Research Institute, Philippines, who supervised
students with a nutritious school meal, such as a subsi-
the daily feeding activity, and Joy Ramos-Buenviaje,
dized school feeding program run by the
government or by nongovernmental or international Meyrick Principe, Janice Lazaga, Kathelijn van Elk,
Bart Stiggelbout, and Ria van der Maas from Unilever
organizations.
for their valuable input. This research was funded by
Unilever Netherlands BV.
Conclusions
Nutri-meals significantly improved energy and nutrient

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