Nutritional Composition of Breakfast Meals Served in All-Girl Intermediate and Secondary Public Schools in Mecca, Saudi Arabia

NUTRITIONAL COMPOSITION OF BREAKFAST MEALS SERVED IN ALL-GIRL INTERMEDIATE AND SECONDARY PUBLIC SCHOOLS IN MECCA, SAUDI ARABIA

A master’s thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science

Lamyaa Yahya

May 2017

A thesis written by

Lamyaa Yahya

B.A., Umm Al-Qura University, 2011

M.S., Kent State University, 2017

Approved by

______, Director, Master’s Thesis Committee Karen Gordon

______, Member, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee David Sharp

Accepted by

______, Director, School of Health Sciences Lynne Rowan

______, Interim Dean, College of Education, Health and Mark A. Kretovics Human Services

YAHYA. LAMYAA, M.S., May 2017 Nutrition

NUTRITIONAL COMPOSITION OF BREAKFAST MEALS SERVED IN ALL-GIRL INTERMEDIATE AND SECONDARY PUBLIC SCHOOLS IN MECCA, SAUDI ARABIA (114 pp.)

Director of Thesis: Karen Gordon, PhD., RD., LD.

This study assessed the nutritional composition of school breakfast meals served in Saudi Arabian all-girl intermediate and secondary public schools in Mecca City only.

Forty six intermediate schools and 43 secondary schools were randomly selected for breakfast meals assessment. The results from this study indicated high content of sugar, and low content of calcium, iron, and vitamin D in the breakfast meals.

Findings from this study coincide with other studies that indicated school canteen foods to be nutritionally poor (Al-Jaaly, Khalifa & Badreldin, 2016; Togoo et al., 2012).

This study also looked at obstacles to serving healthy food options and found that canteen managers’ educational background and lack of funding contributed to the quality of school breakfast meals. Results from this study indicated that schools must employ different environmental factors in order to succeed in providing healthy breakfast meals.

ACKNOWLEDGMENTS

I would like to thank my parents, Abdullah and Alawiyah, for encouraging me to continue my post-bachelor degree education, supporting me when I got accepted to study in America, and for always pushing me to be a better person. I would also like to thank the Saudi government for giving me the financial support that was necessary to pursue my master’s degree and for providing me with the opportunity to study abroad. Many thanks go to my advisor, Dr. Karen Gordon, for her patience, guidance, and her support of my approach to execute this research. Also thanks to the thesis committee members,

Dr. Natalie Caine-Bish and Dr. David Sharp, for their time and helpful feedback that were valuable in building this research. Finally, I would like to thank the head of the

General Education Department of Makkah, Mohammed Al-Harthy, and the participated schools for supporting this research.

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TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ...... iii

LIST OF TABLES ...... vi

CHAPTER

I. INTRODUCTION ...... 1 Problem Statement ...... 4 Purpose Statement ...... 5 Research Hypotheses ...... 5 Operational Definitions ...... 5

II. REVIEW OF THE LITERATURE ...... 7 Adolescence Definition ...... 7 Nutrient Status and Recommendation for Adolescents ...... 8 Fats ...... 8 Carbohydrates ...... 10 Protein ...... 12 Calcium and vitamin D ...... 14 Iron ...... 16 Benefit of Healthy Nutrition ...... 17 Common Nutrition-Related Issues of Adolescence ...... 19 Obesity ...... 19 Micronutrient Deficiency ...... 20 Eating Disorder ...... 21 Dental Carries ...... 22 Physical Inactivity ...... 23 Factors Influencing Adolescence Eating Behavior ...... 24 School Breakfast Program in the United States ...... 25 Benefits of Breakfast for Children and Adolescents ...... 29 School Canteens in Saudi Arabia ...... 31

III. METHODOLOGY ...... 34 Research Design...... 34 Study Population ...... 34 Instruments ...... 35 Procedures ...... 36 Statistical Tests ...... 37

IV. JOURNAL ARTICLE ...... 38 Introduction ...... 38 Methodology ...... 40 Study Population ...... 40 Instruments ...... 40 Procedures ...... 41 Statistical Tests ...... 43 Results ...... 43 General Characteristics and Breakfast Content ...... 44 School Education Level and Nutritional Composition ...... 52 Canteen Providers and Nutritional Composition ...... 54 Discussion ...... 55 General Characteristics and Breakfast Content ...... 56 Nutritional Composition and Educational Level ...... 57 Nutritional Composition and Canteen Providers ...... 60 Limitations ...... 61 Application ...... 62 Conclusion ...... 63

APPENDICES ...... 64 APPENDIX A. TELEPHONE RECRUITMENT SCRIPT ...... 65 APPENDIX B. TELEPHONE SURVEY ...... 67 APPENDIX C. FACE-TO-FACE SURVEY ...... 71 APPENDIX D. TRANSLATION: CANTEEN GUIDELINES FOR BOYS’ AND GIRLS’ SCHOOLS THAT ARE AFFILIATED WITH THE MINISTRY OF EDUCATION, SAUDI ARABIA ...... 75 APPENDIX E. SAMPLE OF THE COLLECTED ONE-DAY FOOD LISTS ...... 79 APPENDIX F. CONSENT FORM ...... 83 APPENDIX G. LETTER OF SUPPORT ...... 86

REFERENCES ...... 88

LIST OF TABLES

Table Page

1. Minimal Required Level of Calorie and Nutrient in School Breakfast for Standard Meal Planning for SY 2012-2013 and 2013-2014 ...... 26

2. School Breakfast Meal Pattern for SY 2013-2014 and Following Years ...... 27

3. School Breakfast Dietary Specifications for SY 2013-2014 and Following Years ...... 28

4. Mean Average of Admitted Students and Percentage of Students that Purchase from the Canteen ...... 44

5. Characteristics of Targeted Intermediate and Secondary, Girls’ Public Schools in Mecca that Served Breakfast, Provided by School Administrators .....45

6. Status of School Canteen Guidelines in Public Girls’ Schools that are Affiliated with the Ministry of Education in the City of Mecca ...... 47

7. Evaluation of Canteens and Canteen Staff by School Administrators ...... 48

8. Breakfast Content during a Typical Week, Provided by Canteen Managers ...... 49

9. Characteristics of Targeted Intermediate and Secondary Levels’ Canteens that Served Breakfast, Provided by Canteen Managers ...... 50

10. Nutritional Content of Standardized-Based Breakfast Meals in Intermediate vs Secondary Levels ...... 54

11. Nutritional Content of Standardized-Based Breakfast Meal in Caterer-Managed vs Self-Managed Canteens ...... 55

CHAPTER I

INTRODUCTION

The oil boom in the Gulf Cooperation Council (GCC) countries has led to increasing income of individuals and caused rapid transformation in their socio-economic status, eating behavior, lifestyle, and health over the last four decades (Arab Center for

Nutrition, 2009a; Al-Shammari, Khoja & Al-Subaie, 1994; Madani & Kumosani, 2001).

Changes in Saudi individuals’, including adolescents, eating behaviors represented by reduction in fiber-rich and calcium-rich foods whilst increasing in foods that are high in fat and sugar (Al-Shoshan, 1990). In addition, eating behaviors, such as eating outside home, and skipping meals, especially breakfast reported prevalence among adolescents

(Al-Shoshan, 1990). In addition to adopting energy-dense foods, the GCC countries reported prevalence of physical inactivity and sedentary behaviors among their individuals, especially children and adolescents (Al-Hazzaa et al., 2011; Musaiger et al.,

2011). In Saudi Arabia, adolescents are reported to have low rate of physical activity, high rate of sedentary behaviors, inadequate daily intake of fruits, vegetables, and milk

(Al-Hazzaa et al., 2011; Al-Muammar, El-Shafie, & Feroze, 2014). Three-quarters of adolescents reported skipping breakfast or consuming it irregularly (Musaiger, 2007), unhealthy behaviors were more noticeable among girls than boys (Al- Hazzaa et al.,

2011). In addition, female adolescents showed to have the tendency to consume energy-dense and sugar-dense foods more than once a week (Al-Faris et al., 2015). These newly adapted dietary patterns, when accompanied with a sedentary lifestyle are linked to increase in prevalence of chronic non-communicable diseases, such as obesity 1 2 and heart diseases (Madani, Al-Amoudi & Kumosani, 2000; Gordon-Larsen et al., 2004;

Nelson et al., 2006; WHO, 2005).

According to Saudi Arabian Ministry of Education (2008), the economic growth in the country in the last few years contributed to the development of the education sector projects. In addition, public budget excess are allocated for building new schools and providing means to deliver education to various regions in the country, include remote areas. The total number of boys’ and girls’ schools in the early 70’s increased from 2,602 and 496 schools, respectively, to 16,668 and 18,729 schools, respectively, in 2013. This growth was offset by an increase in the number of students. Governmental data indicated increase in the number of enrolled students from both genders in intermediate and secondary levels from 77,000 in the early 70’s to about 2.5 million students in 2013

(Ministry of Economy and Planning, 2014). Intermediate and secondary education in

Saudi Arabia are both a three-year education system that come after primary education where students receive certification upon completion of each level (International Bureau of Education, 2011). Education in the country is segregated by sex, however, both sexes receive the same curriculum and take the same examinations (World Education Services,

2001). During autumn semester, school hours in Mecca are from 6:45 A.M. to 1:00 P.M. and during winter semester are from 7:15 A.M. to 1:30 P.M. (Arabia Weather, 2013).

Majority of students eat lunch at home (Alex, 2015) and consider it the main meal of the day (Al-Muammar, El-Shafie & Feroze, 2014).

Schools can influence children and adolescents’ health behavior from early stage.

Therefore, they play an important role in promoting healthy attitudes that help in

3 preventing onsets of obesity and chronic diseases. School-based intervention to manage obesity and chronic diseases can be reached by encouraging healthy eating among all students (WHO Regional Office for Europe, 2006). Robinson-O’Brien et al. (2010) indicated that meals provided in primary schools in Minnesota are important as they contribute to the fruits and vegetable daily intake especially for children and adolescents of low socioeconomic background. School meals contribute greatly to the children and adolescents daily intake of nutrients, therefore, the school environment is considered important to promote healthy eating habits (CDC, 2009). In the United States, school breakfasts, lunches, and snacks must meet the minimum nutritional requirements to receive the federal reimbursement for the meals. Other foods available on school campus, i.e. competitive foods, must contain low sugar, high fiber, and dairy foods (CDC, 2009).

School breakfast in the United States for school year (SY) 2014-2015 must offer a minimum of 1 cup of fruits, 1 cup of milk, and 1 oz. eq. of grains per day, and must contain 0 g of trans-fat, and < 10% of saturated fat (USDA, 2014), and that half of the grain products content must come from whole grain (USDA, 2012).

In Saudi Arabia, the School Healthcare Department (2007) released guidelines for the school canteens. The department stated that the established guidelines considered the different nutritional requirements and physiological needs for the students of each educational level. Canteen foods should include fresh fruits and vegetables, and milk, and should not include high caloric foods and sugary drinks. Studies that evaluate the nutritional content of canteen foods are limited in the country (Al-Jaaly, Khalifa &

Badreldin, 2016; Togoo et al., 2012). The latter study evaluated canteen foods of primary

4 schools in Abha, based on their content of sugar. The study found that most of the items were sugary-dense, high fat, and low in nutrients. Al-Jaaly, Khalifa, & Badreldin (2016) evaluated a one-day food lists from public and private schools in Jeddah and found similar results.

Problem Statement

Since most children and adolescents spend portion of their time in school, foods and beverages provided in schools have become important contributors to the students’ daily intake. School canteens in Saudi Arabia provide students with breakfast and afterschool snack. Although the purpose of school foods is to complement students’ packed foods, two students reported canteen foods to be their main source of dietary intake during school hours (Al-Jaaly, Khalifa & Badreldin, 2016; Togoo et al., 2012).

All canteens in the country are self-supported and they function as income sources for schools, however, there are growing demands on canteens by the School Healthcare

Department to provide students with healthy food options during breakfast and snacking time. The guidelines released by the department that provided broad instructions for foods that can and cannot be sold in canteens lack instructions on the nutritional content in the served breakfast or snacks. Lack of funding and lack of nutritional requirements made canteens a source of unhealthy food options. In addition, there is lack of research in the country that studied the nutritional content of the served breakfast meals at school. A study from the United Kingdom indicated that students who consume poor nutrient-dense foods at school would have difficulties to recompensate the nutrients when they are eating outside of school (Nelson, Lowes & Hwang, 2007).

Purpose Statement

The purpose of this descriptive study was to assess the nutritional composition of breakfast meals in Saudi Arabian all-girl intermediate and secondary public schools in

Mecca.

Research Hypotheses

1) There will be a difference in the nutritional content of the meals between

intermediate and secondary levels.

2) There will be a difference in the nutritional content of the meals between caterer

managed canteens and self-managed canteens.

Operational Definitions

School canteen: A food shop in the school building that sells food and beverages to students.

Caterer: An individual that a school form a contract with and lease them the canteen to operate and function.

Canteen manager: Referred to the caterer in caterer-managed canteens and the school canteen supervisor in self-managed canteens.

Intermediate level: A three-year educational level that follows primary education. This level is equivalent to 7-9 grades.

Secondary level: A three-year educational level that follows intermediate education.

This level is equivalent to 10-12 grades. Students at this level choose the educational track that determine their university major, they can choose between the scientific and the

6 art curriculum. The final year examination of secondary level for the certification is conducted nationwide at the same time.

General education: Referring to the education system that is given to students who entered the educational levels at the specified age group for each educational level. For example, the age group for primary level is 6-11 years old, intermediate level 12-14 years old, secondary level 15-17 years old. There are different education systems in the country such as literacy education, adult education which refer to the system that is given to those who did not enter the education ladder at the specified age group, and private education.

School Healthcare Department: Subsidiary governmental body from the Ministry of

Education that supervise the school canteens.

General Education Department of Makkah: Subsidiary governmental body from the

Ministry of Education that regulate operational and administrative duties in the villages and towns affiliated with Mecca City.

CHAPTER II

REVIEW OF LITERATURE

Adolescence Definition

Adolescence is defined as the stage of lifecycle that is between childhood and adulthood, and is considered a critical period in a human’s life after infancy due to puberty (American Academy of Pediatrics, 2015; WHO, retrieved November 17, 2015).

This period consist of three stages: early adolescence between 11-14 years old, middle adolescence between 15-17 years old, and late adolescence between 18-21 years old

(American Academy of Pediatrics, 2015).

Young adolescence characteristics include physiological development, such as growth in height and weight, organ sizes, development in skeletal muscular system, and motor skills (Kellough & Kellough, 2008). Puberty starts at this stage, and by middle adolescence, most complete their physical growth (America Academy of Pediatrics,

2015). At this stage, physical maturation in girls is faster than in boys. Onset of eating disorder is common at this stage and independency from parents and deepen in bond with friends are common (CDC, retrieved November 17, 2015). Physiological and sexual changes in late adolescence are mostly completed. In this stage, adolescents develop acceptance to body image, balance relationship with parents and independency, and peer relationships have greater influence on behaviors than school and parents (State

Adolescent Health Resource Center, retrieved November 17, 2015).

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Nutrient Status and Recommendation for Adolescents

A food-based dietary guidelines (FBDG) developed by Arab countries do not exist. In the GCC countries, nutritionists have been using FBDG that are developed by other countries, mainly the United Kingdom, Canada, and the United States, to deliver nutrition information and knowledge to the public (Musaiger et al., 2012).

Fats

Fats, also known as lipids are found in animal and plant sources and is constituted of fatty acids (FA). Fatty acids are classified into saturated fatty acids, monounsaturated fatty acids, and polyunsaturated fatty acids (FAO, 2010). Trans fatty acids are hydrogenated unsaturated fatty acids where the double bond changes to a trans position

(Nishida, & Uauy, 2009). Dietary fats are important source for essential fatty acids, assess with the absorption of fat soluble vitamins, energy storage, hormone production, mediators, structural component of neuronal membrane, and protect organs (FAO, 2010;

EUFIC, retrieved November 21, 2015; Fidler et al., 1998). Certain saturated fatty acids have important roles in the body that include signaling and regulation functions. Butyric acid found in dairy products play important role in regulating genes expression and may be vital to inhibit cancer cells development (EUFIC, retrieved November 21, 2015).

Mono and polyunsaturated fatty acids are considered the healthy types of fats as they have been associated with decreasing triglycerides level and blood pressure (U.S.

National Library of Medicine, retrieved November 21, 2015). Studies from the United

States showed association between high intakes of saturated fatty acids, cholesterol, and

9 trans fat and increased risk for cardio vascular diseases and cardiovascular risk factors

(Berenson et al., 1998; McGill et al., 2001).

Studies from Saudi Arabia showed that changes in the socio-economic status and lifestyle of individuals in the last four decades had led to changes in the dietary habits and physical activity (Al-Faris et al., 2015; Al-Shammari, Khoja & Al-Sibaie, 1994; Arab

Center for Nutrition, 2009a; Musaiger, 2011). Dietary pattern among adolescents became higher in fat, sugar, and salt and lower in fruits, vegetables, and whole grains (Musaiger,

2002). Data from Riyadh showed that the percentage of targeted adolescent girls that ate fast foods ≥ 2 time per week was 25%. The study noted that adolescents with higher waist circumference were the one ordering large portion sizes of the food (Al-Faris et al.,

2015). Similar findings were reported by Al-Hazzaa et al. (2011) were female adolescents intake of fast foods ≥ 3 time per week was 25% while male adolescents was reported at

30%. The researchers suggested that difference in intakes between males and females was due to cultural reasons where males have less barriers to going outside. Fast foods are usually a source of fat, saturated fat, sugar, salt, and lesser of a source for fiber

(Bowman et al., 2004). In Bahrain, it was reported that the mean energy intake from fats among male and female children and adolescents was 32.4% and 33.6%, respectively.

Females in the study had slightly higher energy intake from saturated fat than did males

(10.8% and 9.9%, respectively), while males had higher average intake of mono and polyunsaturated fats (Gharib & Rasheed, 2011).

The minimal acceptable macronutrient distribution range (AMDR) for children between 2-18 years old was estimated between 25-35% of total energy (FAO, 2010;

Otten, Hellwig, & Meyers, 2006). Diets that contain <25% of fat, have negative effects on weight gain and growth of children. The report from FAO (2010) also indicated that children and adolescents with a case of dyslipidemia should not reduce their total fat intake, however, reduction in saturated fat intake should be done.

Carbohydrates

Carbohydrates are considered the main source of energy for the body, and are classified based on the number of sugar units in one molecule into: sugars

(monosaccharides), disaccharides, polysaccharides, oligosaccharides, starch polysaccharides, and non-starch polysaccharides (dietary fiber) (EUFIC, retrieved

November 21, 2015; FAO, 1998). The main role of carbohydrates is to provide the body with energy. The human body uses carbohydrates in its simplest form of sugar, i.e., glucose. Glucose can be stored in the liver and muscle in the form of glycogen as a fast source of energy. The brain and red blood cells depend on glucose for energy.

Approximately 130 g/d of glucose are required to meet brain energy needs. Glucose can be obtained from food, glycogen stores, or from breakdown of certain amino acids

(EUFIC, retrieved November 21, 2015). Dietary fiber is the heavy bulk cell wall part in plants that is vital for health (Anderson, 1990). A study in the 70’s linked low intake of dietary fiber to various diseases that appeared in Western countries (Burkitt & Trowell,

1975). Since then, it was recommended to consume diets rich in fiber as they have been shown to have preventative effects against hyperlipidemia, cardiovascular diseases, hypertension, obesity, certain cancers, and diabetes (Anderson & Akanji, 1991; Anderson

& Gustafson, 1988). Although there are no direct evidence that support association

11 between the etiology of obesity and high sugar and starch foods intake, overconsumption of refined carbohydrates coupled with insufficient energy expenditure will promote fat storage in the body that will lead to obesity. Centrally stored fats lead to non-insulin dependent diabetes mellitus and is a risk factor for coronary heart disease (FAO, 1998).

In Saudi Arabia, sedentary lifestyle has become prevalent among children and adolescents. It was reported in few studies that 60% of children and 71% of adolescents are physically inactive or do not participate in sufficient duration of medium-intensity physical activities (Al-Hazzaa, 2002; Al-Hazzaa, 2004). Over three-quarters of adults in some of the GCC and Eastern Mediterranean Region (EMR) countries consume < 5 servings/day of fiber rich foods, such as fruits and vegetables. Furthermore, whole grain product intakes were low compared to refined grains which noted an increase in consumption (WHO/EMRO, 2011; Ng et al., 2011). A study from Bahrain showed that the average intake of sugar among boys and girls was higher than the recommended intake of 60 g/day (101g and 89g, respectively), however their intake of fiber fell short of the recommendation (14g and 12g, respectively). The study suggested high intake of sugar was due to daily consumption of soft drinks among the sampled adolescents

(Gharib & Rasheed, 2011). This finding was consistent with Bello & Al-Hammad (2006) study that found juice boxes <100% juice and soft drinks were the main source of daily fluid intake among Saudi adolescents by 25% and 26%, respectively.

The recommended amount of carbohydrates to prevent ketosis is 50g/d. When obtained from different sources, they are not associated with negative health effects unlike protein and fat. In addition, diet high in carbohydrates decrease the chances of

12 developing obesity and its co-morbidities. A diet should include a minimum of 55% of its total energy from carbohydrates of different sources, with no more than 10-25% intakes from sweeteners (FAO, 1998; Story & Stang, 2005). The American Heart Association

(2016) indicated that children and adolescents aged 2 to 18 should consume no more than

25 g of added sugar per day. Carbohydrate intake of 75% and greater are associated with adverse consequences on nutritional status (FAO, 1998). Health organizations in the

United States and Western countries recommend an increase of 50-100% of fiber intake.

Americans’ average intake of fiber reported to be at 10-23g/d, lower than the recommendation of 20-35 g/d (Anderson, Smith, & Gustafson, 1994). Food-based dietary guidelines for the GCC countries recommend at least three servings of vegetables, two servings of fruits, and legumes daily as sources of dietary fiber (Musaiger et al., 2012).

Protein

Protein is a molecule made up of amino acid blocks. One protein molecule contains ≥ 300 amino acids. There are 20 types of amino acids found naturally in plant and animal sources. Amino acids are classified into essential amino acids (cannot be made in the body) and non-essential amino acids (can be made in the body). Protein can be found in animal and plant sources (EUFIC, 2005). Protein is important for immune function as it is involved in the synthesis of enzymes and antibodies. It is also a source of collagen, a fibrous protein that makes up 30% of bone tissue that contributes to bone strength and skin flexibility. Protein is involved in wound healing and tissue renewal, oxygen transportation, and a source of energy when there is shortage of fats and carbohydrates (Zimmerman & Snow, 2012).

Level of physical activity affect protein demands greatly. High energy intake associated with stable energy expenditure result in high protein intake and nitrogen balance and vice versa (WHO, 2007). Daily intake of protein differ in gender after infancy. Data from the United States showed mean intake of protein for boys increased rapidly during growth period, from 40.6 g at 1 year old to 106.7 g at 14 years old to 117.8 g at 20-year old. Whilst in girls, steady increased in protein was noticed, from 39.6 g at 1 year old to 70 g at 12 years, then decreased to 60 g at 18 years old (Wait, 1973). In the

United States, adolescents consume twice the amount of the required protein. Data showed that 31% of male adolescents aged 14-18 consume more than double the recommendation of protein (Gleason & Suitor, 2001). Gharib & Rasheed (2011) indicated that Bahraini adolescents’ intake of protein was 1.5 times higher than the recommendation. A finding that is consistent with data from other GCC countries that indicated intakes of animal protein increased, and replaced traditional diets in the region

(WHO, 2003b). Reports from FAO showed that the daily intake of poultry in the GCC countries during 2003-2005 was 106-163g compared to 2-73g in other Middle Eastern countries. The average intake of fish increased during 1990-2005 to 24-52g, but was still considered low compared to intakes from other animal proteins (FAO, 2009).

In general, protein requirement for adolescents is obtained by multiplying the requirement per kg based on age range to weight or median weight for age. Boys of age group of 11-14 and 15-18 years have requirements of 0.90 g/kg/d and 0.87 g/kg/d, respectively. Girls of age group of 11-14 and 15-18 years have requirements of 0.89 g/kg/d and 0.84 g/kg/d respectively. The acceptable macronutrient distribution range

(AMDR) for protein for children aged 4-18 is 10-30% of total energy intake (WHO,

2007). The Arab Center for Nutrition recommend intake of 2-4 servings of plant-based and animal-based proteins and specified intakes of red meat to be no more than 0.5 kg/week (Musaiger et al., 2012).

Calcium and Vitamin D

Scientists consider calcium the most plentiful mineral in the body and ranked it fifth after oxygen, carbon, hydrogen, and nitrogen. About 99% of calcium is stored in bones and teeth for support and strength, 1% is stored in soft tissues for metabolic functions, such as muscle contraction, vasodilation, and intra and extracellular signaling, and 0.1% in extracellular fluid (FAO, 2001; Institute of Medicine, 2010). Vitamin D is a fat soluble vitamin that exist in some foods and can be synthesized by the skin when exposed to sunlight. Vitamin D is vital as it reinforce the absorption of calcium in the gut and helps maintaining normal concentration of calcium in the blood for bone mineralization (Institute of Medicine, 2010). Calcium during adolescence periods is important due to rapid increase in skeletal growth. Around 45% of peak bone mass is achieved during this period and by the age of 17 years, 90% of peak bone mass should be achieved to reduce risk of fractures and osteoporosis (Baker et al., 1999).

The average daily intake of dietary calcium and vitamin D among children and adolescents from Mediterranean countries were found to be lower than the recommended values (816 mg and 129 μg, respectively). The study reported that only 12% and 16% of children and adolescents achieved the recommended allowance of calcium and vitamin

D, respectively (Salamoun et al., 2005). Similar findings was reported in Saudi Arabia,

15 where the average intakes of dietary calcium and vitamin D in male and female adolescents living in Riyadh, only reached 60% and 23% of the daily allowance, respectively (Al-Musharaf et al., 2012). Al-Assaf and Al-Numair (2007) reported insufficient intake of calcium by adult males in urban and rural Riyadh. The average intake of calcium among urban males was 969.7 mg while the average in rural males was

795.4 mg. High income of Saudis combined with food abundance and lack of nutritional knowledge has led to a case of over-nutrition of macronutrients and malnutrition of micronutrients (Al-Nuaim et al., 1997; Madani, Al-Amoudi & Kumosani, 2000).

Inverse relationship was observed between children and adolescent consumption of soft drinks and milk (Gharib & Rasheed, 2011; Harnack, Stang & Story, 1999). Data from the latter study showed that American adolescents who consumed high amount of soft drinks were less likely to consume calcium and vitamin C rich foods, compared to individuals who do not. Gharib & Rasheed (2011) indicated that while Bahraini children and adolescents intake of sugar-dense foods increased, such as soft drinks and sweets, their intake of milk decreased. Similar finding was reported by Siddiqui & Kamfar (2007) among female adolescents from Jeddah.

FAO (2001) reported that because high rate of skeletal calcium retention occur between 10-17 years, the require value of calcium to ensure adequate calcium retention is

1040mg and an allowance of 1300mg during rapid growth stage. The recommended allowance of vitamin D for adolescents to maintain healthy bones and calcium metabolism is 15μg daily (Institute of Medicine, 2010).

Iron

Iron has several roles in the body. It is mainly presented in the erythrocytes as a hemoglobin that transport oxygen from the lungs to tissues. Myoglobin is another molecule that contains iron, and it provides oxygen to muscles. In addition, iron is a vital component for several enzymes, such as cytochrome P450 that produces steroid hormones and bile acids, removing harmful substances in the liver, signaling some neurotransmitter, such as dopamine and serotonin in the brain. Iron is also vital for growth and development (Erdman, Macdonald & Zeisel, 2012; FAO, 2001). Iron metabolism differs from other mineral metabolism because of absence of physiological mechanism to excrete it and that 90% of needed daily intake are achieved from endogenous source, i.e. red cells breakdown. Iron losses are through skin, urinary tract, airways, and menstrual blood (Green et al., 1968). Heme iron that comes from animal sources is absorbed directly as intact iron porphyrin complex. Absorption rate of heme iron is relatively high compared to non-heme iron. Non-heme iron comes from plant and some animal sources. Absorption rate of non-heme iron is affected by iron status of individuals and absorption enhancers and inhibitors in foods (Carpenter & Mahoney,

1992). The demand for iron in male and female adolescents increase in the peak of growth and the expansion of the volume of blood and muscle (Story & Stang, 2005).

Insufficient intake of iron was reported in a Malaysian study among female adolescents. The study indicated that while female students’ intake of protein met the recommendation, their iron intake only achieved 89% - 92% of the recommendation

(Abdul Majid et al., 2016). National data from the United States pointed that almost all of

17 the male adolescents succeeded in meeting their iron daily recommendation, however half of the females (56%) failed to do so (Story & Stang, 2005). The prevalence of micronutrients deficiencies are high in Arab countries, especially iron, iodine, zinc, vitamin A and D (Madani, Al-Amoudi & Kumosani, 2000; Madani & Kumosani, 2001).

The GCC countries reported prevalence of insufficient intake of iron among its individuals, especially among infant, children, and pregnant women (Musaiger & Miladi,

1996). Sawaya, Tannous & Othiameen (1988) indicated that iron intake of Saudi children did not exceed 38% of the daily recommendation. Al-Assaf (2007) study reported that 95% of the participating women living in Riyadh failed to meet the daily recommendation of iron, while only 4.5% of the participating men did not meet the recommendation.

Iron requirements are based on several factors that include basal losses, growth, menstrual losses, expansion of tissue volume, and iron stores (Otten, Hellwig, & Meyers,

2006). Female demand at the age of menarche for iron increase. At this stage, female recommendation allowance is 15 mg/day, however if not menstruating, the recommendation decreased to 10.5 mg/day (Otten, Hellwig, & Meyers, 2006).

Benefit of Healthy Nutrition

Meeting nutrient requirements in adolescence is crucial for proper growth, in addition to maintaining appropriate metabolism and physical activity (Koletzko et al.,

1998). Nutrient requirements is defined as “the amount and chemical form of a nutrient that is needed systematically to maintain normal health and development without disturbance of the metabolism of any other nutrient” (Aggett et al., 1997). During

18 adolescence, nutrient requirement needs are affected by the spurt of growth that occurs at puberty. Growth peak occurs between the age of 11-15 years for girls and 13-16 years for boys (EUFIC, 2006).

Good nutrition contribute positively to children and adolescents learning ability.

Nourished children and adolescents have better learning ability, attendance rate, school behavior, and therefore, develop better relationships with their teacher (WHO Regional

Office for Europe, 2006). In addition, proper nutrition aid with maintaining body weight and decrease the risk to develop non-communicable chronic diseases, such as high blood pressure, diabetes, iron deficiency anemia, and osteoporosis. Lastly, proper diet is preventative against dental caries (CDC, retrieved November 18, 2015).

Poor diets are associated with slow growth and sexual development in adolescence (Story, 1992), increase the risk for overweight and obesity due to energy imbalance between consumed and burned (Institute of Medicine, 2004). Childhood and adolescents’ obesity are associated with increase the risk for all-cause mortality during adulthood, childhood and adolescents’ hyperlipidemia, diabetes, cholelithiasis, and high blood pressure (Dietz, 1998; Gunnell et al., 1998). In addition, insufficient quality diet due to hunger and food insecurity, i.e. low income status or lack of food resources, increase the risk for undernutrition. Undernutrition can affect children and adolescents’ health, cognitive maturation, and therefore, their education (Alaimo, Olson & Frongillo,

2001; Kaiser & Townsend, 2005).

Common Nutrition-Related Issues of Adolescence

As adolescents age, their food choices and preference surpass acquired eating habits from the family (Thomas, 1991). Focusing on adolescents can help preventing passing structural problems, such as poverty, violence, poor health, and nutrition-related behaviors to the next generation (WHO, 2005).

Obesity

Obesity is defined as BMI ≥ 95th percentile for children and adolescents of the same age and sex (CDC, 2015). Many children nowadays are growing up in an obesogenic environment that promotes weight gain and obesity. Energy imbalance resulted from changes in food types, availability, affordability and marketing, increase sedentary activities, and decrease in physical activity (WHO, 2016). In 2004, it was estimated that about 10% of children and adolescents worldwide were overweight and that 2-3% were obese. Prevalence rates of the condition differ between countries, from

<5% in Africa and part of Asia to >20% in Europe and >30% in America and some

Middle Eastern countries (World Obesity Federation, retrieved May 16, 2016). A study in

Saudi Arabia estimated that 27% of the adolescents are overweight while 11% of them are obese (El-Mouzan et al., 2010), other study that assessed the body mass index (BMI) and body fat indicated increasing tendency in obesity among children and adolescents in the last 20 years (Abalkhail, 2002). In 2014, a study that covered all regions in the country was released. This study targeted Saudi individuals of that age of 15 years and older and found that 24% of the male participants and 34% of the females were obese

(Memish et al., 2014).

Childhood obesity is associated with serious consequences such as premature death and disability in adulthood. Children who are obese or overweight are more likely to stay obese in adulthood and to develop non-communicable disease such as diabetes and cardiovascular diseases at young ages (WHO, retrieved May 16, 2016). In addition, obese adolescents are at higher risk for bone and join problems, sleep apnea, low self- esteem, bullying, and cancers, such as breast, colon and prostate cancers (Griffiths,

Parsons & Hill, 2010; Institute of Medicine, 2012; van Geel, Vedder & Tanilon, 2014).

Micronutrient Deficiency

Iron deficiency anemia is the main nutritional problem in adolescents. Prevalence of the condition was estimated to be 6% in developed countries and 27% in developing countries (WHO, 2005). Iron deficiency anemia is the last stage of iron deficiency

(WHO, 2012) and is characterized by hemoglobin < 12 g/dL for adolescents and women, and < 13 g/dL for men (Erdman, MacDonald & Zeisel, 2012). The risk to develop the condition for boys and girls starts from childhood. After puberty, the risk to develop iron deficiency anemia decrease for boys but remain for girls due to menstruation (Dallman,

Simes & Stekel, 1980). Anemia is associated negatively with mental development and learning ability of children and adolescents. Students with anemia are more likely to perform poorly in reading and vocabulary (Parker, 1989; WHO, 2005). The prevalence of iron deficiency anemia among children and adolescents in the GCC countries is due to poor eating behavior and insufficient nutritional knowledge (Musaiger, 1987). A finding that was reinforced by Al-Almaie (2005) study where the researcher found that the knowledge of Saudi adolescents in the Eastern Region about nutrients and healthy diets

21 was low. Iron deficiency anemia is more common among adolescents due to increase of blood volume and muscle mass during growth and development, which require more hemoglobin to carry oxygen and myoglobin for muscle (EUFIC, 2006).

Data from the United Sates indicated that adolescents’ daily intake of calcium and vitamin D are lower than the recommendation, which could result in poor calcium accrual in bone tissue and increased fracture risk and nutritional rickets and osteomalacia

(Harkness, & Bonny, 2005). Similar findings were observed in studies from Saudi Arabia

(Al-Hazzaa et al., 2011; Al-Jurayyan et al., 2012; Al-Muammar, El-Shafie & Feroze,

2014; Siddiqui & Kamfar, 2007). The first two studies reported Saudi adolescents’ daily intake of milk, a high source of calcium, was low and that only 26% of the adolescents had milk daily. Al-Jurayyan et al. (2012) indicated that the main contributor (72%) of children and adolescents’ rickets and osteomalacia in the country was nutrition-related, followed by genetic causes (11%). Manifestation of osteomalacia and rickets related to vitamin D deficiency among female adolescents and adults in Saudi Arabia is not uncommon (Sedrani et al., 1992).

Eating Disorder

Eating disorder, such as anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified are prevalent among young women in Western cultures, and make the third most common chronic health condition among them (Rosen, 2003). It is estimated that 0.3-1.0% of young females in Western countries have eating disorders

(Hoek, & van Hoeken, 2003). In recent years, Eastern cultures reported increase of eating disorder in them (Mellor et al., 2009). Anorexia nervosa can lead to decrease in the heart

22 rate and blood pressure which increases the risk for heart failure. In addition, it can lead to osteoporosis, muscle atrophy, kidney failure due to dehydration, and growth of lanugo hair to maintain temperature. (National Eating disorder association, retrieved May 16,

2016). Bulimia nervosa can also lead to heart failure, however, due to electrolytes imbalance resulted from purging. Gastric distention from bingeing can lead to gastric rupture while frequent purging (vomiting) can lead to esophagus inflammation and rupture. Bulimia can result in increase in blood pressure, cholesterol, triglycerides, and type 2 diabetes (National Eating disorder association, retrieved May 16, 2016).

Al-Lihaibi (2015) study in Mecca reported that 26% of sampled female adolescents had high Eating Attitude Test (EAT) scores indicating that they had negative eating attitudes. The study attributed prevalence of the condition among adolescents to media, where Western values regarding body shape and beauty standards have been taken in through the media.

Dental Carries

Dental caries (cavities) is a health problem prevalent among children and adolescents. The main cause of the condition is consumption of sugar-dense foods, such as soft drinks, cakes, juices < 100% juice (Sheiham 2001). WHO (2003a) and Togoo et al., 2012 indicated that oral health is associated with individual’s dietary habits as high intakes of cariogenic foods are linked to increase in susceptibility for oral disease.

Data from Saudi Arabia reported that the number of dental caries among primary school students increased from 68% to 96% (Al-Shammary, Guil & El-Buckly, 1990).

Prevalence of dental carries in developing countries was attributed to transitioning from

23 traditional diet to Western-style diet (Steyn, Myburgh & Nel, 2003). Another local study linked having higher prevalence of dental caries to increase in individuals’ BMI, as those were more likely to drink soft drinks, smoke, and live a sedentary lifestyle (Alswat et al.,

2016).

Physical Inactivity

Physical activity plays an important role in determining children and adolescents’ weight (WHO Regional Office for Europe, 2006). The Department of Health and Human

Services (2008) in the United States recommended children and adolescents to engage in

60 minutes of physical activity every day for health benefits. Data from Saudi Arabia showed that out of 1401 male adolescents and 1507 female adolescents, only half of the males and a quarter of females met the recommendation (Al-Hazzaa et al., 2011), another study reported that 71% of Saudi adolescents do not participate in moderate-intensity physical activity (Al-Hazzaa, 2002). Factors that contributed to the prevalence of physical inactivity among adolescents is reliance on cars even for commuting for short distance, high rate of sedentary behaviors, such as screen time, and lack of physical education classes in schools for girls (Al-Hazzaa et al., 2011). Physical inactivity increase the risk for all-cause mortality by 20-30% (Amin et al., 2012), it has been shown to be a contributing factor to 22% of ischemic heart disease, 11% of ischemic stroke, 14% of diabetes and 10% of breast cancer (Bull, Maslin & Armstrong, 2009). In addition,

Stettler, Signer & Suter (2004) found positive association between obesity in children and physical inactivity and sedentary behavior, such as video games and television time.

Factors Influencing Adolescence Eating Behavior

Food consumption patterns in the GCC countries have changed drastically, shifting towards high density, high energy, high saturated fat and added sugar, and low dietary fiber-rich diets (Arab Center for Nutrition, 2009a). Adolescence’s eating behaviors are strongly affected by environmental, social, and psychological factors that affect their preferences. The effect of these factors increase with age as children and adolescents go through more development changes and external factors (National Health and Medical Research Council of Australia, 2003). Environmental factors include the availability and accessibility to healthy and unhealthy foods, the cost of healthy and unhealthy foods, and social groups, such as family, friends, and peers (Birch, 1999;

Patrick & Nicklas, 2005). An umbrella review of study of factors that affect adolescents’ dietary behavior found that more than three-quarters of the reviewed studies indicated that the influence of family on intakes of fruits, vegetables, and snack among adolescents was significant (Sleddens et al., 2015). The role of parents in encouraging consumption of different kind of foods and limiting intakes of unhealthy foods have influential effect on children and adolescents’ dietary behavior (Sleddens et al., 2011). Influence of peer pressure during early adolescence can replace familial authority and can promote following fad diets (Gidding et al., 2005).

Chapman & Maclean (1993) indicated that distorted perception of some dietary behaviors could be a contributor for the adolescents to adapt these behaviors. The study showed that the sampled adolescents linked eating fast food with friends, independence, and pleasure, while they linked eating healthy foods with parents and home foods.

Knowledge of healthy foods, in addition to other factors, such as family, can influence adolescents’ intake of fruits and vegetable (Hussein, 2011). This study found that nutrition-majored late adolescents in Jeddah had better intakes of vegetables compared to nonnutrition-majored adolescents (64% and 45%, respectively). Culture pressure has a significant influential effect on the dietary behavior of children and adolescents as they could feel obligated to achieve an ideal body shape. The glory associated with thinning and the stigma associated with obesity could have significant effect on children and adolescents body image and self-esteem (WHO, 2004).

School Breakfast Program in the United States

School environment is considered an important place to learn healthy eating habits as most children and adolescents get half of their daily intake at school (CDC,

2009). Researches from Europe and the United States suggested that the availability of energy-dense snacks, high fat snacks, and sugary beverages in schools is correlated with decrease in healthy food choices and increase in unhealthy ones (Cullen et al., 2000;

Nelson, Lowes & Hwang, 2007). Regulating school foods provides a method for improving eating behavior and health among children and adolescents (Losasso, 2015).

In the United States, school breakfast program (SBP), lunch program (SLP), and afterschool snack program need to meet certain minimal nutritional requirements established by The United States Department of Agriculture (USDA) to get federal reimbursement. Competitive foods, such as foods and beverages from vending machines, school stores, and á la carte cafeteria lines should mainly consist of fruits, vegetables,

26 whole grains, and low-fat dairy products and should not be the main source of nutrition in school (CDC, 2009).

The goal of SBP in the U.S. is to provide nutritious breakfast to children and adolescents and prevent them from eating less nutritious breakfast or not eating at all, therefore, developing better nutritional intake and weight status (Romano, Sudharsanan,

& Argeseanu, 2014). SBP must provide 25% of all nutrients’ recommended allowance, however, the program can provide the minimum requirements to receive federal funds. In addition, it should provide no more than 30% calories from total fat, <10% calories from saturated fat, low levels of salt and cholesterol, and high levels of fiber (Fox & Condon,

2012). Nutrition standards for meals were modified for SY 2012-2013 to include increase in fruits, vegetables, whole grains, and low-fat or fat-free milk. The modified guidelines called for gradual reduction in salt content, monitoring saturated fat and calorie content, and eliminating trans-fat from school meals (Table 1) (Federal Register, 2012).

Table 1: Minimal Required Level of Calorie and Nutrient in School Breakfast for Standard Meal Planning for SY 2012-2013 and 2013-2014 (Federal Register, 2012).

Nutrient Minimum requirements Optional Grades K-12 Grades 7-12 Calories (kcal) 554 618 Total fat (% from total kcal) 30 30 Saturated fat (% from total < 10 < 10 kcal) RDA for protein (g) 10 12 RDA for Calcium (mg) 257 300 RDA for iron (mg) 3 3.4 RDA for vitamin A (RE) 197 225 RDA for vitamin C (mg) 13 14

Table 2: School Breakfast Meal Pattern for SY 2013-2014 and Following Years (USDA, 2012)

Item Grade 6-8 Grade 9-12 Serving/week Serving/week (minimum/day) (minimum/day) Fruits (cups) 5 (1) 5 (1) Vegetables 0 0 Grain (oz eq) 8-10 (1) 9-10 (1) Meat/meat alternative 0 0 Milk 5 (1) 5 (1)

The SBP meal component for SY 2013-2014 and following years is fruits, grains, and milk (USDA, 2012). The new meal pattern replaced vegetable component in previous school years to fruit servings only and increased the serving size (Table 2) (USDA,

2012). Schools may still offer vegetable during breakfast as a substitution to fruits, however, the served vegetables must be a dark green, red or orange vegetables, legumes, or beans. Starchy vegetables could substitute fruit servings if offered with the two cups of the previous mentioned vegetable options (USDA, 2012). Products that fall under the daily grain serving of 28 g (1 ounce equivalent) include 16 g of baked good products

(bread, bagels, etc.), 28 g of uncooked cereal grains (oatmeal, pasta, brown rice, etc.) or

½ cup of cooked cereal grains, and 28 g of ready-to-eat breakfast cereals (USDA, 2016).

The schools may offer meat and meat alternative as an extra food to compose portion of the grain serving (USDA, 2014). The school breakfast meal must consist of at least 1 cup of fruits, 1 cup of flavored, unflavored, low fat, or fat free milk, and 1 oz eq of whole grain-rich (USDA, 2014).

The school breakfast guidelines for SY 2013-2014 and following years also established weekly average standards calories, salt, saturated fat specifications, and daily average standards of trans fat specification (Table 3) (Federal Register, 2012; USDA,

2012). The average content of the specifications of meals of the each grades must be within the specified level range (Federal Register, 2012).

Table 3: School Breakfast Dietary Specifications for SY 2013-2014 and Following Years (USDA, 2012)

Specification Grades 6-8 Grades 9-12 Min-max calories (kcal) 400-550 450-600 Saturated fat (% of total < 10 < 10 kcal) Sodium (g) ≤ 470 ≤ 500 Trans fat (g) < 0.5 < 0.5

Cohen et al. (2014) examined the effect of USDA school breakfast and the new requirements for school lunches for SY 2012-2013 in low-income, urban Massachusetts schools, grades 3-8 and found that the new standards successfully increased the number of students who selected fruits from 52.7% pre implementations to 75.7% post implementations. Milk selection decreased after the policy to eliminate sugar-sweetened milk from 79.8% to 55.1%. The researchers attributed decrease in milk selection to students trying adjust to the new policy and that the study was conducted immediately after the milk policy. Vegetable selection, on the other hand, remained the same.

However, the study reported increase in the consumption of selected vegetables as the serving sizes increased. Another study assessed the impact of the new standards on school lunches over three years (2012, 2013 and 2014) and found increasing trend in fruit

29 selection 54% to 71% to 66%, respectively. (Schwartz et al., 2015). Both studies did not report increase in food waste due to increase serving sizes.

Benefits of Breakfast for Children and Adolescents

Breakfast is defined as the first meal consumed in the day before the start of any activities, within 2 hours of waking and no later than 10:00 in the morning. It provides

20-35% of total daily energy level needed (Timlin & Pereira, 2007). It is estimated that breakfast should provide 30% of the nutrients’ recommendation (Sachithananthan & Al-

Rashedi, 2014). Data from the United States showed that regular consumption of breakfast contributes to the maintenance of body weight as it reduces the intake of energy-dense snacks (Dubois et al., 2008; Nicklas et al., 2001). Data from Saudi Arabia showed that adolescents who eat breakfast had better food choices, such as greater intake of fruits, vegetables, and dairy products (Amin, Al-Sultan & Ali, 2008). Studies from different Western countries indicated that regular consumption of breakfast was associate with better cognitive functions, healthier lifestyle, and lower incidence of type 2 diabetes and cardiovascular disease (Keski-Rahkonen et al., 2003; Timlin & Pereira, 2007;

Widenhorn-Muller et al., 2008).

The type of foods consumed during breakfast is the most important factor for its benefits as they influence blood glucose levels. Slow glucose release to the blood maintains energy levels, prevents energy spikes, and gives feeling of satiety for a long period of time (Kamada et al., 2011; The University of Sydney, 2010). Skipping breakfast or consuming nutrient-poor breakfast is common among children and adults.

Studies from the EMR countries indicated that the percentage of breakfast skipping

30 among girls is higher than boys (Musaiger, 2011). This habit was noticeable more among oldre adolescents (Musaiger, 2011; Abalkhail, & Shawky, 2002). Data from Saudi Arabia showed that around 74% of adolescent girls aged 12-16 years reported skipping breakfast or had irregular intake of breakfast (Musaiger, 2007). Researchers from different countries linked breakfast skipping in children with unhealthy nutritional habits, such as inadequate grain, fruits, and milk consumption, increased rate of snacking and increased meals’ portion sizes during the day (Bellisle et al., 1988; Nicklas, O’Neil & Berenson,

1998). School performance among Saudi adolescents in Jeddah was influenced by breakfast intake. Abalkhail & Shawky (2002) indicated that adolescents with poor school performance did not consume breakfast regularly compared to students with excellent school achievement that had breakfast regularly. Although some studies in Saudi Arabia and neighboring country linked skipping breakfast with increase in the BMI of children and adolescents (Al-Hazzaa et al., 2012; Arab Center for Nutrition, 2009b), a longitudinal cohort study in Japan showed that individuals who reported skipping breakfast had lower rate of all diseases, including metabolic diseases compared to individuals who had breakfasts (Okamoto et al., 2013).

Findings from the United States indicated that the majority of children and adolescents do not eat breakfast and get third of their calories from snacking. In addition, large portion of their total energy come from sugary beverages (Ludwig, Peterson &

Gortmaker, 2001). Intakes from snacking could lead to high intakes of discretionary calories and could replace intakes from nutrient-dense foods (Strong et al., 2005).

School Canteens in Saudi Arabia

The education system in Saudi Arabia is primarily under the authority of the

Ministry of Education, the Ministry of Higher Education, and the Technical and

Vocational Training Corporation. The Ministry of Education supervises primary, intermediate, secondary, elderly education, and literacy education (International Bureau of Education, 2011). Education and healthcare sectors are the priority of the country’s budget, receiving up to 44% of the total spending. In 2015, education sector’s share of the budget was at 25% (U.S - Saudi Arabian Business Council, retrieved May 17, 2016). The education system in the country consists of preschool, primary, secondary, and higher education. Secondary education consists of two levels, intermediate and secondary levels.

Intermediate level lasts three years and is equivalent of grades 7-9. Students who pass this level receive an intermediate school certification. Secondary level lasts for three years and is the equivalent of 10-12 grades. Students in the first year of secondary level receive general curriculum. In the second year, students choose between scientific track and the literary track and upon the completion of secondary education successfully, students receive a certification (International Bureau of Education, 2011).

School canteens in Saudi Arabia provide students with breakfast and snacking options during school hours (Al-Jaaly, Khalifa & Badreldin, 2016). Lunch is consumed at home as school hours usually end at around 1 P.M. (Alex, retrieved May 17, 2016), and is considered the main meal for the majority of Saudi adolescents is lunch (Al-Muammar,

El-Shafie & Feroze). Canteens can be managed by either caterers or by schools (self- managed). Eighty per cent of the self-managed canteens’ profit go to the school fund, 5%

32 salaries for the canteen staff. The school fund allocate 15% as subsides to students of low income status, 50% extracurricular activities, 5% staff that contributed to the educational process in the school, 10% school supplies, 10% support for excelling students, and 10% for the Ministry of education’s fund. Whereas the amount paid by caterers to rent the canteens go to the school fund. (General Education Department of Taif, retrieved March

11, 2017).

The purpose of school canteen foods in Saudi Arabia is to supplement foods that students bring from home (Al-Jaaly, Khalifa, & Badreldin, 2016). However, in most cases, they are considered the students actual meals (Al-Jaaly, Khalifa & Badreldin,

2016; Togoo et al., 2012). The School Healthcare Department established guidelines for items that can and cannot be sold in the school canteens. The School Healthcare

Department stated that the guidelines were establish to emphasize the main objective of school canteen, which is to deepen the meaning of nutrition among students by providing them with nutritious foods at a reasonable price, and considered the different nutritional requirements and physiological needs for the students of each educational level (School

Healthcare Department, 2007). Canteens should provide milk (whole fat or low fat, flavored or unflavored), dates, nuts, fruits, vegetables, cheese sandwiches, whole wheat and white flour biscuits, and juice boxes of > 30% juice. Sweets, soft drinks, and juice boxes of < 30% juice are not permitted to be sold in schools (School Healthcare

Department, 2007).

Togoo et al. (2012) and Al-Jaaly, Khalifa & Badreldin (2016) evaluated school foods in Abha and Jeddah, respectively, and found the majority of the foods available

33 were high in sugar, saturated fat, and salt and did not include fruits and vegetables. In an effort to achieve control over school canteens, Educational Departments of some regions in the country conduct workshops for canteen staff to improve the service quality and increase the nutritional knowledge of the staff (SPA, 2013a; SPA, 2013b; SPA, 2015).

CHAPTER III

METHODOLOGY

The purpose of this descriptive study was to assess the nutritional content of breakfast meals in Saudi Arabian all-girl intermediate and secondary public schools in

Mecca.

Research Design

This was an exploratory, descriptive study designed to investigate the nutritional composition of breakfast in all-girl public schools. The nutritional composition was assessed in the provided serving sizes. The independent variable were school levels

(intermediate and secondary) and canteen providers (caterer and schools self-managed) and the dependent variable was the nutritional composition (i.e. calories, protein, fat, carbohydrates, calcium, iron, vitamin D, and sodium).

Study Population

The targeted population for this study was canteens of the all-girl intermediate and secondary public schools in Mecca. According to the schools list obtained from the

General Education Department of Makkah, the numbers of public intermediate and secondary schools for girls in Makkah province for the School Year 2015-2016 were 191 and 152 schools, respectively. Schools were randomly selected by covering the researcher eyes and randomly selecting the schools from the list. Forty six intermediate schools and 43 secondary schools were selected to give a total of 89 schools. Inclusion criteria included: 1) general education; 2) morning classes; 3) public schools; 4) in Mecca

City 34 35 only. Exclusion criteria included 1) other types of education system; 2) evening classes;

3) private schools; 4) outside of Mecca.

Instruments

One-day food lists were obtained from the intermediate and secondary schools

(Appendix E). Foods were recorded by weight using a household scale. To assess the nutritional content of foods prepared in the canteen, researcher asked about the cooking preparation, ingredients, and weigh the foods.

Additional information were collected by two questionnaires. First, a telephone questionnaire (Appendix B) that was adopted from the Center for Weight and Health in

University of California (2007) and the CDC food-service school questionnaire (1999).

The survey was modified to suit the current study. This questionnaire was used to collect data about general information of the schools, such as the time and length of breakfast period, pricing, meal provider, implementation of guidelines, barriers and difficulty for implementation, and an evaluation of canteen productivity and employees.

Second, a face-to-face questionnaire (Appendix C) that was conducted by the researcher upon visiting the schools. The questionnaire was adopted from the CDC food- service school questionnaire (1991) and UNESCO (2004) and was also modified to be suitable for this study. This questionnaire collected data on educational and training background of the canteen employees, food list planning, food ordering, food preparation method, any special food preparation practices, and list of available or unavailable food items.

Procedures

The current study was approved by the Institutional Review Board (IRB) at Kent

State University (KSU). Written permission to conduct the study in public schools and a list of the names of schools in Mecca were obtained from the head of the General

Education Department of Makkah.

The researcher called the randomly selected schools from September 20th to

October 3rd, 2016 to do the telephone survey. The respondents were first informed of the purpose of the study, the benefits and possible risks, privacy concern possibility, and the voluntary participation right (Appendix F). After a verbal consent to participate was obtained, the researcher started to ask the questions.

The researcher began visiting the schools from October 4th to November 7th, 2016.

Written letters of support were signed by the school administrations (Appendix G). The canteen manager and staff members were also informed of the purpose of the study, the benefits and possible risks, and privacy concerns (Appendix F) before asking the face-to- face questionnaire. The researcher then collected the one-day food list and measured the weight of foods prepared in the canteen. Parents of students were not contacted because the study did not involve students.

All of the obtained food lists consisted of two sections. First section was food of the day, and second section was options of beverages, crackers, and chocolates. Students have the freedom to choose food items to build their meals. The current guidelines

(Appendix D) do not specify the breakfast meal component, therefore, in order to evaluate the nutritional content of a breakfast meal, the researcher used the standardized

37 breakfast meal provided by some schools as a reference to build the breakfast meals provided by the canteens. Food data were entered into a food analysis program Diet

Analysis Plus, 10th Edition. Data were then analyzed by a statistical analysis program.

Statistical Tests

Using IBM SPSS Statistics 24 edition, descriptive statistics were used on variables such as breakfast serving, guidelines’ barriers, and breakfast providers.

Independent-sample t-test was used to assess nutritional composition difference between intermediate and secondary levels, and nutritional composition difference between the canteen managed by caterers and self-managed. P value was set at ≤ 0.05.

CHAPTER IV

JOURNAL ARTICLE

Introduction

Breakfast is defined as the first meal to be consumed in the day within two hours of waking that provides between 20-35% of the daily energy level and before the start of activity (Timlin, & Pereira, 2007). Several studies linked breakfast eaters with better fruits and vegetables intake (Dubois et al., 2008; Nicklas et al., 2001; Sugiyama et al.,

2012), better grain and dairy intake (Dubois et al., 2008; Nicklas et al., 2001), better school performance (Mahoney et al., 2005), and lesser fat foods and unhealthy snacking intake during the day (Dubois et al., 2008).

Schools are considered a key environmental factor for children and adolescents to adopt healthy eating and healthy lifestyle attitudes as most of them spend large portion of their time in school (Story, Neumark-Sztainer, &.French, 2002; WHO, 2017). One of the behaviors developed in schools include behavior related to weight, such as students’ eating behavior (food selection) (Crosnoe, & Muller, 2004; Story, Neumark-Sztainer,

&.French, 2002) that are influenced by the availability and accessibility of healthy and unhealthy food items (Losasso et al., 2015; Story, Neumark-Sztainer, & French, 2002).

Because adolescence is considered the second critical stage in lifecycle after the first year of life, due to rapid growth (WHO, 2000), the School Breakfast Program (SBP) in the

Unites States provides reimbursement and specific nutrient-based guidelines for participating schools to serve nutrient dense breakfast at lower costs to students, and

38 39 therefore, improve their overall health status (Romano, Sudharsanan, & Argeseanu, 2014;

USDA, 2012). The USDA’s Dietary Guidelines for Americans 2010, requires school breakfast meals to provide the quarter of the recommended dietary allowance (RDA) for all of nutrients, however, schools can be eligible for federal reimbursement if they provide the federal minimum requirements for the SBP (Romano, Sudharsanan &

Argeseanu, 2014). The School Healthcare Department in Saudi Arabia established guidelines for food items that can and cannot be sold in school canteens (School

Healthcare Department, 2007). These guidelines limit the selling of high sugar and high fat content foods, and promote the selling of dairy, fruits and vegetables, and whole wheat foods (School Healthcare Department, 2007). A modified version of the guidelines was issued in November of 2014, which permitted canteens to sell some traditional regional desserts and cooking inside the canteens (School Healthcare Department, 2014).

It was reported that in school year 2014-2015, the number of students that participated in the SBP in the United States increased by 4.2% (475,000 students) compared to the previous year, bringing the total number of participated students eligible for free and reduced-price meals to 11.7 million students (Food Research and Action

Center, 2016). Studies from Saudi Arabia indicated increase reliance on foods and beverages provided in school canteens by the students (Al-Jaaly, Khalifa & Badreldin,

2016; Togoo et al., 2012). Therefore, the purpose of this descriptive study was to assess the nutritional content of breakfast meals in Saudi Arabian all-girl intermediate and secondary public schools in Mecca.

Methodology

Study Population

The targeted population for this study was canteens of the all-girl intermediate and secondary public schools in Mecca. According to the schools list obtained from the

43 secondary schools were selected to give a total of 89 schools. Inclusion criteria included: 1) general education; 2) morning classes; 3) public schools; 4) in Mecca City only. Exclusion criteria included 1) other types of education system; 2) evening classes;

3) private schools; 4) outside of Mecca.

Instruments

One-day food lists were obtained from the intermediate and secondary schools

(Appendix E). Foods were recorded by weight using a household scale. To assess the

41 nutritional content of foods prepared in the canteen, researcher asked about the cooking preparation, ingredients, and weigh the foods.

Additional information were collected by two questionnaires. First, a telephone questionnaire (Appendix B) that was adopted from the Center for Weight and Health in

University of California (2007) and the CDC food-service school questionnaire (1999).

The survey was modified to suit the current study. This questionnaire was used to collect data about general information of the schools, such as the time and length of breakfast period, pricing, meal provider, guidelines implementation, barriers and difficulty for implementation, and an evaluation of canteen productivity and employees.

Procedures

The current study was approved by the Institutional Review Board (IRB) at Kent

State University (KSU). Written permission to conduct the study in public schools and a list of the names of schools in Mecca were obtained from the head of the General

Education Department of Makkah.

The researcher called the randomly selected schools from September 20th to

The researcher began visiting the schools from October 4th to November 7th, 2016.

(Appendix D) do not specify the breakfast meal component, therefore, in order to evaluate nutrition content of a breakfast meal, the researcher used the standardized breakfast meal provided by some schools as a reference to build the breakfast meals provided by the canteens. Food data were entered into a food analysis program Diet

Analysis Plus, 10th Edition. Data were then analyzed by a statistical analysis program.

Statistical Tests

Using IBM SPSS Statistics 24 edition, descriptive statistics were used on variables such as breakfast serving, guidelines’ barriers, and breakfast providers.

Independent-sample t-test was used to assess nutrients composition difference between intermediate and secondary levels, and nutrient composition difference between the canteen managed by caterers and self-managed. P value was set at ≤ 0.05.

Results

This study targeted the canteens of girls’ intermediate and secondary public schools in the City of Mecca only. The total number of schools that matched the study criteria was 80 intermediate schools and 76 secondary schools. A total of 95 intermediate and secondary schools were randomly selected from the list obtained from the General

Education Department of Makkah. The 95 schools were phone contacted to participate in the study (Appendix A), and of that total, 90 schools consented to participate. One school was excluded from the analysis due to failure to obtain a food list because the canteen was closed on the day of the visit. The final number of targeted sample that was analyzed was 46 intermediate schools and 43 secondary schools, to give a total of 89 schools.

More than three-quarters of the students from intermediate and secondary schools purchased foods from the canteen, with mean average of 85.1% and 77.6%, respectively

(Table 4).

General Characteristics and Breakfast Content

Results from the telephone survey showed that schools from both levels served breakfast to students, 76% of intermediate schools and 84% of secondary schools reported the average students spent on food was between 1-5 SAR (0.3-1.3 USD), 33% of

Table 4: Mean Average of Admitted Students and Percentage of Students that Purchase from the Canteen.

Variable Educational level

Intermediate Secondary N 푥̅ ± SD No N 푥̅ ± SD No respond respond Number of admitted 43 144.4 ± 54.8 3 39 172.2 ± 75.5 4 students Percentage of students that 43 85.1% ± 7.1 3 41 77.6% ± 2 purchase from the canteen 14.5 intermediate schools and 30% of secondary schools reported serving a standardized breakfast to students but only during special days, such as the first day of school and

World Health Day. Almost all of the canteens in intermediate and secondary levels were managed by a caterer (96% and 95%, respectively), while only 4% and 5% of the foregoing levels’ canteens were school managed (self-managed) (Table 5). All but one of the intermediate and secondary schools reported awareness of the guidelines for foods and beverages that are permitted to be sold on campus. The study found that most of the targeted schools reported following the guidelines completely, however, some expressed difficulties to adhering to the guidelines. Some of these difficulties were students’ refusal or low purchasing rate to items that are requested in the guidelines, such as fruits and

45 vegetables, and whole wheat products, and thusly, caused decline of the canteens’ profitability. These schools also professed that having healthier choices, such as salads, whole wheat pasta dishes do not have the popularity among students as do French fries or cheese sandwiches made with white wheat bread, and require the canteens to increase the

Table 5: Characteristics of Targeted Intermediate and Secondary, Girls’ Public Schools in Mecca that Served Breakfast, Provided by School Administrators

Variable Educational Level Intermediate Secondary N = 46 % within N = 43 % within level* level* The average the students spend 1-5 SAR (0.3-1.3 USD) 35 76.1% 36 83.7% 6-10 SAR (1.6-2.7 USD) 8 17.4% 4 9.3% >10 SAR (2.7 USD) 0 0.0% 1 2.3% No response 3 6.5% 2 4.7% Free food option Yes 36 78.3% 36 83.7% No 9 19.6% 7 16.3% No response 1 2.1% 0 0.0% Standardized breakfast Yes 15 32.6% 13 30.2% No 30 65.2% 30 69.8% No response 1 2.2% 0 **If yes, price of standardized breakfast 15 100.0% 12 92.3% Free 0 0.0% 1 7.7% 3 SAR (0.8 USD) Breakfast provider Caterer 44 95.7% 41 95.3% Directly managed by school 2 4.3% 2 4.7% Breakfast time Before 9:00 A.M. 2 4.3% 0 0.0% After 9:00 A.M. 44 95.7% 42 97.7% No response 0 0.0% 1 2.3% Breakfast time length 15-30 minutes 43 93.5% 33 76.7% 31-45 minutes 3 6.5% 8 18.6%

46-60 minutes 0 0.0% 1 2.3% No response 0 0.0% 1 2.3% pricing which resulted in students not being able to buy them or low number of them who purchase these foods. This leads to inability to cover the costs of preparing and making the foods. Even with schools that reported complete compliance to the guidelines, there were some food items that were not permitted in the guidelines. These schools explained that having these items generate income and students liked them (Table 6). When assessing the breakfast content during a typical week, the content of foods that were considered high in sugar, fat, salt, and low in fiber were higher than the content of foods that were considered high in fiber, whole wheat, and low in sugar and sodium (Table 8).

Results from the face-to-face survey showed that less than a quarter of the canteen mangers in intermediate and secondary levels had a degree and/or credential related to nutrition or food service. Managers that did not have a degree or a credential reported verbally that having one was not a condition to cater or supervise the canteens, and lack of educational and training workshops in the city. More than half of the food lists are planned by the caterers (74% intermediate schools and 58% secondary schools), and if not, the next primary persons that plan the lists are the canteen staff of intermediate and secondary levels (67% and 72%, respectively). One secondary school (5.6%) reported

“Other” persons responsible for planning the list, namely, the students. The staff said that they distribute surveys to students to ask them the type of foods they would like to have the canteen serve during the semester. Almost all of the intermediate and secondary

47 schools do not analyze the nutritional content of foods (87% and 98%, respectively)

(Table 9).

Table 6: Status of School Canteen Guidelines in Public Girls’ Schools that are Affiliated with the Ministry of Education in the City of Mecca.

Variable Educational Level Intermediate Secondary N = 46 % within N = 43 % within level* level* Awareness of guidelines Yes 45 97.8% 43 100.0% No 1 2.2% 0 0.0% Does the school follow the guidelines? Yes No 44 95.7% 43 100.0% No response 1 2.2% 0 0.0% 1 2.1% 0 0.0% **To what extent have the guidelines been implemented at this school? Not sure To a large extent 2 4.6% 3 7.0% Completely 10 22.7% 18 41.9% 32 72.7% 22 51.2% **Barriers not to follow the guidelines completely No profit due to students 8 66.7% 15 71.4% refusal/low purchasing Low income status of students 1 8.3% 1 4.8% Lack of storing space in the canteen 1 8.3% 0 0.0% Lack of employees No barriers 0 0.0% 1 4.8% Not able to answer 1 8.3% 2 9.5% 1 8.3% 2 9.5% *Monitoring adherence to guidelines by School canteen supervisor 29 65.9% 30 69.8% School health advisor 13 29.5% 9 20.9% *MOE staff 2 4.5% 4 9.3% No response 2 4.5% 0 0.0% *Variables dependent on the question above of them.

Table 7: Evaluation of Canteens and Canteen Staff by School Administrators.

Variable Educational Level Intermediate Secondary N = 46 % within N = 43 % within level* level* Canteen ability to serve students Good 18 39.1% 11 25.6% Adequate 18 39.1% 27 62.8% Insufficient 10 21.7% 5 11.6% Canteen equipment to cooking/storing Good 17 37.0% 14 32.6% Adequate 12 26.1% 16 37.2% Insufficient 13 28.3% 11 25.6% Does not apply 4 8.7% 2 4.7% Canteen equipment to plan a food list Good 19 41.3% 17 39.5% Adequate 12 26.1% 13 30.2% Insufficient 10 21.7% 7 16.3% Does not apply 4 8.7% 4 9.3% Not able to answer 1 2.2% 2 4.7% Canteen equipped to analyze food Insufficient 2 4.3% 1 2.3% Does not apply 38 82.6% 32 74.4% Not able to answer 6 13.0% 10 23.3% Canteen manager and staff services Good 31 67.4% 27 62.8% Adequate 14 30.4% 16 37.2% No response 1 2.2% 0 0.0% Canteen manager and staff cooking Good 24 52.2% 20 46.5% Adequate 13 28.3% 18 41.9% Insufficient 2 4.3% 2 4.7% Does not apply 6 13.0% 3 7.0% No response 1 2.2 0 0.0% Canteen manager and staff ability to plan a food list 6 13.0% 7 16.3% Good 6 13.0% 6 14.0% Adequate 20 43.5% 15 34.9% Insufficient 13 28.3% 15 34.9% Does not apply 1 2.2% 0 0.0% No response Canteen manager and staff ability to analyze food Adequate Insufficient 2 4.3% 1 2.3% Does not apply 3 6.5% 1 2.3% 41 89.1% 41 95.3%

Table 8: Breakfast Content during a Typical Week, Provided by Canteen Managers

Variable Educational Level Intermediate Secondary N = 46 % within N = 43 % within level level 100% Juice Yes 8 17.4% 10 23.3% No 37 80.4% 33 76.7% No response 1 2.2% 0 0.0% Juice box <100% juice Yes 45 97.8% 43 100% No response 1 2.2% 0 0.0% White wheat products Yes 45 97.8% 43 100% No response 1 2.2% 0 0.0% Whole wheat products Yes 13 28.3% 19 44.2% No 32 69.6% 24 55.8% No response 1 2.2% 0 0.0% Low fat products Yes 19 41.3% 22 51.2% No 24 52.2% 21 48.8% No response 3 6.5% 0 0.0% Full fat products Yes 43 93.5% 42 97.7% No 2 4.4% 1 2.3% No response 1 2.2% 0 0.0% Fruits Yes 8 17.4% 11 25.6% No 36 78.3% 32 74.4% No response 2 4.4% 0 0.0% Vegetables Yes 22 47.8% 25 58.1% No 23 50.0% 18 41.9% No response 1 2.2% 0 0.0% Low fat dairy Yes 15 32.6% 22 51.2% No 29 63.0% 21 48.8% No response 2 4.4% 0 0.0% Full fat dairy Yes 20 43.5% 13 30.2% No 25 54.4% 28 65.1% No response 1 2.2% 2 4.7% Pizza Yes 16 34.8% 14 32.6% No 29 63.0% 29 67.4% No response 1 2.2% 0 0.0% (Table Continues)

Table 8 (Continued)

Variable Educational Level Intermediate Secondary N = 46 % within N = 43 % within level level Burger Yes 0 0.0% 2 4.7% No 45 97.8% 41 95.3% No response 1 2.2% 0 0.0% French fries (cooked in fat) Yes 34 74.0% 38 88.4% No 11 24.0% 5 11.6% No response 1 2.2% 0 0.0% Sweets (Candies) Yes 45 97.8% 43 100.0% No response 1 2.2% 0 0.0% Salty snacks (chips, crackers, etc.) Yes 45 97.8% 41 95.3% No 0 0.0% 2 4.7% No response 1 2.2% 0 0.0%

Table 9: Characteristics of Targeted Intermediate and Secondary Levels’ Canteens that Served Breakfast, Provided by Canteen Managers

Variable Educational Level Intermediate Secondary N % within N % within level level Does the canteen manager have a degree/credential in nutrition/food service Yes No 11 24.0% 6 14.0% No response 33 71.7% 35 81.4% 2 4.4% 2 4.7% *Type of degree/credential Home economic 7 63.6% 2 33.3% Workshops in canteen 3 27.3% 2 33.3% management Food quality/safety certification 1 9.1% 0 0.0% No response 0 0.0% 2 33.3% Staff training/experience Yes 40 87.0% 41 95.3% No 6 13.0% 2 4.7% Does the canteen follow a food list? Yes 46 100.0% 43 100.0% (Table Continues)

Table 9 (Continued)

Variable Educational Level Intermediate Secondary N % within N % within level level *How often does the list change Weekly 9 19.6% 3 7.0% Monthly 3 6.5% 4 9.3% Annually 13 28.3% 22 51.2% Never 20 43.5 14 32.6% No response 1 2.2 0 0.0% *Does the caterer plan the food list? Yes 34 73.9% 25 58.1% No 12 26.1% 18 41.9% *If no, which group plan the list? Canteen staff 8 66.7% 13 72.2% School canteen supervisor 4 33.3% 4 22.2% Other 0 0.0% 1 5.6% Food analysis Yes 5 10.9% 1 2.3% No 40 87.0% 42 97.7% No response 1 2.2 0 0.0% *Type of food analysis tool Nutrition fact sheets from caterer 2 40.0% 0 0.0% Google Search No response 2 40.0% 0 0.0% 1 20.0% 1 100% Food order Canteen staff 4 8.7% 6 14.0% School canteen supervisor 2 4.4% 4 9.3% Caterer 40 87.0% 33 76.7% Is food prepared in the canteen? Yes 40 87.0% 41 95.3% No 6 13.0% 2 4.7% *Check all preparation method used Cooking from fresh ingredients 21 52.5% 27 65.9% Boxed food Frozen food 1 2.5% 1 2.4% Reheating 35 87.5% 37 90.2% 14 35.0% 14 34.1% *Main responsible for preparing food Canteen staff 40 100.0% 41 100.0% Reduce fat practices Yes 14 30.4% 16 37.2% No 25 54.3% 25 58.1% No response 7 15.2% 2 4.7% (Table Continues)

Table 9 (Continued)

Variable Educational Use Intermediate Secondary N % within N % within level level *Type of reduce fat practice Air fryer 2 14.3% 2 12.5% Reduce the amount of oil used in 6 42.9% 10 62.5% cooking Baking 5 35.7% 4 25.0% No response 1 7.1 0 0.0% Reduce sugar practices Yes 10 21.7% 15 34.9% No 29 63.0% 26 60.5% No response 7 15.2% 2 4.7% *Type of reduce sugar practice Whole wheat products 8 80.0% 15 100.0% Low sugar products 2 20.0% 0 0.0% *Variables dependent on the question above of them.

Figure 1 describes the most frequently used food items to form the standardized breakfast meals. According to the graph, juice box (<100% juice) and food of the day reported the most used food items to make the standardized breakfast meals in both levels, while the use of the rest of the food items was low.

School Educational Level and Nutritional Composition

The study hypothesized that the nutritional composition in the intermediate and secondary levels will differ. Using Independent sample t-test, there was a statistical significant difference between intermediate and secondary levels in the mean average of cholesterol content (P= 0.02). The mean average of cholesterol served by secondary schools was 10.4 mg higher than the mean average served by intermediate schools. No other statistical significant differences were found in the other nutrients (Table 10).

*Of the 28 intermediate and secondary schools, combined, that answered “Yes” to providing a standardized breakfast meal, only 16 schools reported the content of the standardized meal.

Figure 1: Content of Standardized Breakfast Meal in All-Girl Intermediate and Secondary Public Schools in Mecca.

Table 10: Nutritional Content of Standardized-Based Breakfast Meals in Intermediate vs Secondary Levels.

Variable Educational level P Intermediate (N = 46) Secondary (N = 43) 푥̅ ± SD 푥̅ ± SD Kilocalories (Kcal) 376.4 ± 117.3 349.1 ± 84.6 0.21 Protein (g) 8.2 ± 2.3 8.7 ± 2.8 0.39 Carbohydrate (g) 55.5 ± 12.9 53.7 ± 9.9 0.48 Dietary fiber (g) 2.2 ± 2.0 2.6 ± 2.0 0.38 Sugar (g) 23.7 ± 4.6 22.6 ± 2.2 0.15 Total fat (g) 14.5 ± 8.0 12.3 ± 6.8 0.16 Saturated fat (g) 5.3 ± 3.4 4.3 ± 3.3 0.19 Monounsaturated fat (g) 3.3 ± 2.0 3.6 ± 2.2 0.53 Polyunsaturated fat (g) 2.2 ± 1.6 2.4 ± 1.5 0.56 Trans fat (g) 0.4 ± 1.1 0.2 ± 0.8 0.28 Cholesterol (mg) 10.0 ± 9.0 20.3 ± 26.3 0.02* Vitamin D (µg) 0.1 ± 0.2 0.3 ± 0.8 0.08 Calcium (mg) 73.3 ± 41.2 104.0 ± 122.4 0.12 Iron (mg) 2.0 ± 1.0 1.9 ± 0.7 0.82 Sodium (mg) 833.0 ± 398.7 892.6 ± 636.3 0.60 * Represents statistical significance between intermediate and secondary levels. P ≤ 0.05.

Canteen Providers and Nutritional Composition

This study found that 44 intermediate schools and 41 secondary schools were caterer-managed and only two intermediate schools and two secondary schools were school (self- managed). The researcher hypothesized that the nutrient composition in the two canteen providers will be different. Using Independent sample t-test, the researcher found that there was a statistical significant difference between the mean average of total fat between canteens managed by caterer and school managed canteens (P=0.02) (Table

11). The mean average of total fat served by self-managed canteens was 3.8 g higher than the total fat served by caterer managed canteens. The staff of self-managed canteens reported verbally that offering foods such as cheese sandwiches with white wheat bread,

55 juice boxes < 100% juice, chips, and sweets are of the students’ liking, affordable, and do not cause deficit in the school budget.

Table 11: Nutritional Content of Standardized-Based Breakfast Meals in Caterer-Managed vs Self-Managed Canteens.

Variable Canteen providers P Caterer (N = 85) Self-managed (N = 4) 푥̅ ± SD 푥̅ ± SD Kilocalories (Kcal) 361.5 ± 104.3 400.9 ± 71.6 0.46 Protein (g) 8.5 ± 2.6 7.8 ± 1.3 0.60 Carbohydrate (g) 54.6 ± 11.5 55.0 ± 12.9 0.96 Dietary fiber (g) 2.5 ± 2.0 1.2 ± 1.5 0.22 Sugar (g) 23.1 ± 3.7 23.2 ± 1.6 0.95 Total fat (g) 13.3 ± 7.6 17.1 ± 2.0 0.02* Saturated fat (g) 4.7 ± 3.4 7.1 ± 1.6 0.18 Monounsaturated fat (g) 3.5 ± 2.1 3.6 ± 1.1 0.94 Polyunsaturated fat (g) 2.3 ± 1.6 1.6 ± 0.8 0.34 Trans fat (g) 0.3 ± 0.9 1.5 ± 1.7 0.25 Cholesterol (mg) 15.0 ± 20.3 13.8 ± 11.7 0.91 Vitamin D (µg) 0.1 ± 0.6 0.1 ± 0.1 0.68 Calcium (mg) 89.5 ± 92.5 58.9 ± 33.6 0.51 Iron (mg) 2.0 ± 0.8 1.6 ± 1.2 0.48 Sodium (mg) 847.6 ± 522.4 1163.4 ± 556.4 0.24 * Represents statistical significance between intermediate and secondary levels. P ≤ 0.05.

Discussion

The present study assessed the nutritional composition of school breakfast meals based on the standardized breakfast meals in Saudi Arabian all-girl intermediate and secondary public schools in Mecca.

Mecca is located in the Hejaz region western of Saudi Arabia. It is the capital of

Makkah province and considered the second biggest city in the province after Jeddah, and the third biggest city in the country. The 2015 census indicated that the population of

Makkah province amounted to seven million people, with more than 1.5 million of them located in Mecca (General Authority for Statistics, 2015). Therefore, any reforms or changes related to public health in the province can influence other regions.

General Characteristics and Breakfast Content

The current study showed that all targeted canteens were considered an income source for the schools. Schools that expressed barriers and schools that did not, all indicated that students were the ones who determined foods to be sold or not, since the canteens’ income depends on them. The guidelines stated specific food items that canteens are not permitted to sell, however, the opposite was observed by the researcher.

Several canteens did not follow these instructions, indicating that the current guidelines either do not provide precise guidance or do not have the needed authority on canteen managers and staff to follow. Cho & Nadow (2004) study that assessed barriers to offering quality lunches in Massachusetts schools found similar findings and indicated that students’ preference to unhealthy foods was one of the main barriers. The study indicated that schools with self-supporting lunch programs are obliged to sell unhealthy food items as they are to the students’ liking and cover costs. The study indicated that building channels with the students and consider their input can help in providing nutritious lunches that students like.

The canteen managers’ role was significant since most of them, in this study, were responsible for planning the food lists and ordering food items. However, only small percentage of them had a nutrition-related educational background as it was not a requirement to cater for the school canteen, indicating that the schools do not do

57 educational screening for caterers before hiring them or do not require attending educational workshops for the current caterers and canteen supervisors who plan the food lists. Different results were found in the United States, where the USDA (2015) established minimum occupational and annual training standards that are required to hire new school nutrition professionals and for the current school nutrition professionals who direct and run the SLP and SBP. The USDA indicated that developing specific standards ensured that the staff have minimal knowledge and training to plan and prepare meals, and purchase healthy and fresh food items to make healthy meals that the students like.

Nutritional Composition and School Educational Level

The researcher hypothesized that there would be a difference in the nutritional content between intermediate and secondary schools. However, the results of this study indicated no significant difference between the two levels in most of the nutrients, therefore, the hypothesis was rejected. This study is the first to assess unified breakfast meals’ nutritional composition based on the standardized meals provided in intermediate and secondary schools.

Although no statistical significant difference was detected in most of the nutrients, the nutrients’ level in the meals were lower than the federal minimum requirements for

SBP in the United States. Nelson, Lowes & Hwang (2007) study in the United Kingdom assessed primary and secondary level meals content and found that school meals contributed poorly to the nutrients’ daily recommendations especially among girls. The study indicated that such low level of nutrients provided from school meals would make it difficult for the students to compensate for the nutrient imbalance when they are eating

58 outside of school, and since 44% of intermediate level canteens and 33% of the secondary level canteens, in this study, reported never to changing their food lists, low micronutrient composition of the breakfast meals could significantly affect the health of adolescents. This indication is in concordant with previously mentioned studies from

Saudi Arabia and other GCC countries that reported adolescents and adults’ daily intake of nutrients such as calcium, iron, and vitamin D failed to meet the daily recommendations (Al-Assaf, 2007; Al-Musharaf et al., 2012; Gharib & Rashed, 2011;

Musaiger & Miladi, 1996; Sawaya, Tannons & Othiameen, 1988).

Several studies indicated that changes in the eating pattern in the GCC countries has led to increase emergence of diet related non-communicable diseases (Arab Center for Nutrition, 2009a; Musaiger, 2007). Abalkhail & Shawky (2002) reported that anemia among male and female adolescents in Jeddah was at 20.5% and was more noticeable among girls of ≥ 12 years of age. Similar finding was reported among adult women living in Riyadh where anemia prevalence among the sampled women was 21% (Al-Assaf,

2007). Both studies attributed anemia to insufficient intakes of iron among the sampled females. This could be an indication that females in Saudi Arabia do not consume enough iron-rich foods and/or foods that enhance iron absorption at the age of menarche. The current study showed that the average content of iron provided in the school breakfast meals was 2 mg in both levels, which means that the breakfast meals contribute to iron recommendation allowance by 13%, a value that is lower than the recommended quarter by the USDA and less than the federal minimum requirement.

Vitamin D deficiency is considered a major health problem in the country

(Abanamy et al., 1991). Although Saudi Arabia is rich in sunlight, many males and females have limited sun exposure due to traditional clothing that is worn when going outside, making dietary vitamin D the main source of the nutrient. This study showed that the breakfast meal provided very low levels of vitamin D to the students (0.1 µg in intermediate level and 0.3 µg in secondary level), reinforcing studies that indicated prevalence of vitamin D hypovitaminosis among adolescents in the country. A study in

Jeddah showed that 81% of female adolescents were found to have low vitamin D levels, ranging between 2.2-24.0 nmol/L (Siddiqui & Kamfar, 2007). Another study in Qatar that assessed vitamin D deficiency among 11-16 years old adolescents found that 68.8% of them where deficient (Bener, Al-Ali & Hoffmann, 2009). Both studies attributed deficiencies to low dietary intake and low sun exposure. In addition to previously mentioned local studies that indicated insufficient intake of dietary calcium among adolescents (Al-Musharaf et al., 2012; Gharib & Rahsed, 2011; Siddiqui & Kamfar,

2007), low level of vitamin D could contribute to osteomalacia among adolescents, and if not detected and treated early could progress into osteoporosis in adulthood. It has been indicated that osteoporosis has become a public health problem among women in Saudi

Arabia (Ardawi et al., 2005; El-Desouki, 2003).

The results of sugar content in the breakfast meals showed that its average content in intermediate level was 24 g and 23 g in secondary level, which is almost equal to the

American Heart Association daily recommendation of added sugar for children and adolescents. This result is in concordant with Al-Hazzaa et al (2012) study that indicated

Saudi female adolescents, compared with males, have higher intakes of sweets, i.e. chocolate, cakes, and sugary drinks per week, and Gharib & Rasheed (2011) study that showed Bahraini children and adolescents daily intake of added and natural sugars was higher than the recommendation, making children more vulnerable to obesity and dental carries. It has been concluded in several studies in Saudi Arabia that female adolescents are more sedentary and less physically active than male adolescents (Al-Hazzaa et al.,

2011; Al-Hazzaa et al., 2012). The imbalance between energy intake and expenditure among Saudi female adolescents put them at high risk to become overweight and obese.

It has been indicated in previously mentioned studies that obesity rates are on the rising among children and adolescents in Saudi Arabia (Abalkhail, 2002; El-Mouzan et al.,

2010).

Nutritional Composition and Canteen Providers

The Study hypothesized that there would be a difference between caterer- managed canteens and school self-managed canteens in the breakfast’ nutritional content.

The results of this study indicated no significant difference among most of the nutrients, therefore, the hypothesis was rejected. This was the first study to assess the breakfast meals’ nutritional content based on canteen providers.

Targeted school canteens played an important role as an income source for the school fund. In caterer-managed canteens, the quotation for renting the canteen goes to the school fund, whereas in school self-managed canteens, all of the canteen profits go to the school fund (General Education Department of Taif, retrieved March 11, 2017). The researcher could not find any data that indicate the amount of funding the canteens

61 receive from the school or the caterer, however, based on the obtained food lists and nutritional composition of the breakfast meals, it seemed that the canteens receive small share of the profit from the school or the caterer. Insufficient funding prevent from supplying the canteen with fruits and vegetables and improve cooked meals. Several targeted schools reported providing healthier options to the students, however, due to lack of students’ purchasing they resorted to offering foods that the students like to buy. This supports Cho and Nadow (2004) study that indicated providing schools with enough funding would not ensure quality lunches as schools need to employ other environmental factors, such as students, their families, and the media. Employing students’ input, collaborating with their families can ensure the success of the planned nutrition policy of the school.

Limitations

The total number of intermediate and secondary schools that answered “Yes” to serving a standardized breakfast was 28 schools, of that total, only 16 schools reported the foods used to form the standardized meals. Therefore, the findings from assessing the breakfast meals cannot be generalized due to small sample size. In addition, some of the canteen visitations occurred during the first month of schooling after summer vacation, which is considered a hectic period as some of the caterers only started working at the beginning of that month and their food lists was not finalized. Finally, Breakfast meal components were analyzed using a program that did not include some Arabic beverages data. The researcher analyzed the closest beverages to the listed items, therefore, the results of the analysis are approximate results.

Application

This study showed that breakfast meals formed from food lists that were planned based on current guidelines are nutritionally poor. The study also showed that canteen managers’ educational background could be a contributor to their ability to plan a healthy food list. Since the majority of canteen manager, in this study, reported not obtaining nutrition-related educational background, the School Healthcare Department can assess the schools through conducting educational training workshops. School can require attendance to these workshops to be able to cater or supervise the canteens. Educational levels, i.e. preschool, primary, intermediate, secondary, and university, are under the jurisdiction of Ministry of Education, therefore, intermediate and secondary schools in

Mecca could collaborate with Umm Al-Qura University to have senior year nutrition- majored students assessing with educational and training materials if the staff could not attend the School Healthcare Department’s workshops. In addition, the nutrition-majored students can provide extracurricular classes to students to encourage intake of calcium rich, iron rich, and fiber rich foods as volunteering project to gain experience in community nutrition. Schools should collaborate with other environmental factors, such as students’ family, to ensure educational materials that are being taught in schools are enhanced and supported at homes. Schools could utilize the parent-teacher meetings to discuss food policies that could be employed in the school to ensure the support of parents.

The current guidelines do not provide precise information about the nutrient content of the provided foods, the serving sizes, and the food component of a complete

63 meal. Nutritionists can work with the School Healthcare Department to establish a framework for the breakfast meal component that are appropriate for Saudi adolescents.

In addition, nutritionist can assess canteen staff and managers by providing recipes for healthy dishes and assess with food list planning. Canteens should also consider the students’ input regarding the food lists to ensure foods are appealing to them. Schools can collaborate with local produce farmers to supply canteens at reasonable pricing and encourage caterers to collaborate with them.

Conclusion

This study looked at the nutritional content of the served breakfast meals, using the standardized breakfast meals as a reference. The findings of this study were compatible with findings from other studies that assessed the full food lists and found them to be nutritionally poor. Targeted school canteens were the major source of foods for more than three-quarters of the students, indicating the significant role they play in contributing to the nutrient intake. However, findings from this study showed that canteen foods are sources for foods high in sugar and sodium, and poor sources of iron, calcium, and vitamin D. In addition, the lack of nutrition-related educational background by most of the canteen managers may have contributed to the low level of nutrients in the provided foods.

Adolescence is considered a critical stage in lifecycle, therefore, it is critical to use findings from this study and similar studies to establish more specified and clearer guidelines to ensure adequate availability of required nutrients in canteen foods.

APPENDICES

APPENDIX A

TELEPHONE RECRUITMENT SCRIPT

Appendix A

Telephone Recruitment Script

Hello, my name is Lamyaa Yahya. I am a master’s student in nutrition at Kent

State University. I am conducting a research on the nutritional composition of breakfast meals served in girls’ intermediate and secondary public schools in Mecca for my master’s degree. I was hoping to speak with the school principle. Is that you? I would like to investigate the provided breakfast meals’ composition. Your school participation would involve conducting a telephone survey with me. I will ask general questions that will include student enrolment, breakfast time and length, your evaluation of the canteen and the canteen staff, and questions regarding the published canteen guidelines. The survey will only take 10 minutes.

Another survey will be conducted face-to-face with the canteen staff members or manager at the school canteen. Food lists and measuring food weight will also be obtained at this time. In order to keep confidentiality, I will not use the staff name or other personal identifiers in any presentation or research paper. If you agree to participate, I would also like you to provide a letter of support that I can show the canteen managers so that they know you are supportive of the survey and data collection. I can provide you a template for the letter.

After the research paper is completed, I will be presenting it at Kent State

University as a part of the requirement for my master’s degree.

Would you be interested in participating in this research project?

APPENDIX B

TELEPHONE SURVEY

Appendix B

Telephone Survey

This questionnaire was developed in May 2016 based on existed questionnaires from the CDC food-service school questionnaire (1999) and the Center for Weight and

Health in University of California (2007). The purpose of this questionnaire is to collect information about number of students, school canteens, and served meal (breakfast). This survey will take approximately 10 minutes or less to complete. Information about the respondent and nutritionally-unrelated answers will be kept strictly confidential.

School Code: ______School level o Intermediate o Secondary

Title of the primary person who completed the questionnaire: ______

1. For the current school year, the number of students admitted to this school is: ______

2. Does the school offer breakfast to students? o Yes o No

3. What is the approximate percentage of students purchasing food from canteen? ______

4. On average, the amount the student spend on food is: ______

5. Does the school offer free food? o Yes o No

68 69

6. Does the school offer a standardized complete breakfast meal? o Yes o No  Skip to question 7

6.a. Please indicate the price of the standardized breakfast meal provided ______

7. Please indicate the canteen provider: o Caterer o Directly managed by school o Other (Specify ______)

8. Indicate the time for breakfast period ______

9. Indicate breakfast period’s length ______

10. Is the school aware of the guidelines released by the Ministry of Education in 2007 about items sold in school canteens? o Yes o No

11. does the school follow the guidelines? o Yes o No  Skip to question 12.

11.a. To what extent have the guidelines been implemented at this school? o Not sure o Not at all o To some extent o To a moderate extent o To a large extent o Completely  Skip to question 11.c. o 11.b. Indicate barriers/difficulties in the guidelines ______

11.c. Who currently monitors adherence to the Ministry of Education guidelines for school canteen? o School canteen supervisor o School health advisor o Staff from the Ministry of Education o Other (Specify: ______)

12. Please provide your evaluation of the canteen in the following area:

Variable Good Adequate Insufficient Does not Not able apply to answer Serve student efficiently Prepare meals from basic ingredients Conduct menu planning Conduct nutrient analysis

13. Please provide your evaluation of the canteen manager and staff’s work in the following area:

Variable Good Adequate Insufficient Does not apply Serve student efficiently Prepare meals from basic ingredients

Conduct menu planning Conduct nutrient analysis

APPENDIX C

FACE-TO-FACE SURVEY

Appendix C

Face-to-Face Survey

This questionnaire was developed in May 2016 based on existed questionnaire from CDC food-service school questionnaire (1999) and UNESCO (2004). The purpose of this questionnaire is to collecting information related to served foods, such as type of food, ingredients, serving size and food preparation method. This survey will take approximately 10 minutes or less to complete. Information about canteen staffer will be kept strictly confidential.

School Code: ______

Title of the primary person who completed the questionnaire: ______

A) Does the canteen manager have a nutrition-related degree and/or certification/credential in food service? o Yes (Specify ______) o No

B) Does the staff have any educational or training background in food preparation? o Yes (Specify ______) o No Food list planning and food ordering questions

1. Does the canteen follow a menu/food list? o Yes o No  skip to question 4

1.a. How often does the list change?

o Weekly o Monthly o Yearly o Never

72 73

1.b. Does the caterer plan what food to be available in the food list? o Yes  Skip to question 2. o No.

1.c. If no, which group is the second primary body to plan the food list? o Staff working in the Ministry of Education o Canteen staff o School canteen supervisor o Other (Specify ______)

2. Is the nutritional content of foods sold during breakfast period routinely analyzed? o Yes (Specify: ______) o No

3. Which group has the primary responsibility for deciding which food items to order for this school? o Canteen staff. o School canteen supervisor. o Caterer. o Other (Specify ______).

Food preparation questions 4. Is there food prepared in the canteen? o Yes o No  Skip to question 4.b.

4.a. Not counting preparing sandwiches, check that apply about the preparation method o Cooked from basic ingredients o Reheated o Mix ingredients of canned/boxed foods o Frozen food

4.b. Which of the following has the primary responsibility for preparing foods? o Canteen staff o School canteen supervisor o Caterer o Other (Specify ______)

5. Does the canteen engage in practices to reduce the fat content in served foods? o Yes (Specify ______) o No

6. Does the canteen engage in practices to reduce the content of added sugar in served foods? o Yes (Specify ______) o No.

Food variety/availability question

7. During a typical week, does the food list contain selections of any of the following: 8. Item Yes (Specify items) NO 100% fruit of vegetable juice Juice box (not 100% juice) White wheat products Whole wheat/grain products Low fat products Full fat products Fresh fruits Fresh vegetables Low fat dairy products Whole fat dairy products Pizza Burger French fries (cocked in fat) Sweets Salty snacks (chips, crackers, etc.)

APPENDIX D

TRANSLATION

Appendix D

Translation

Canteen Guidelines for Boys’ and Girls’ Schools that are affiliated with the Ministry

of Education, Saudi Arabia

Proper nutrition is the essential foundation for the healthy development of society. It is because a balanced healthy diet contribute to supplying the body with nutrients necessary for physical and mental growth of children and adults alike. Receiving a balanced diet increase its importance of the target group is the students’ community.

Scientific studies that have been made on this subject showed that nutrition have a tremendous impact on the academic achievement of the students, it was found that undernutrition is accompanied by lack of absorptive capacity for students. Despite the high economic and social levels in the kingdom and the availability of food commodities, the health indicator of students is associated with the their practiced eating patterns, such as skipping breakfast and consuming foods of low nutritional value. The canteen guidelines issued by the Ministry of Education took into account developing the school canteen in all of its aspects, with the focus on developing nutrition and health education and their educators, and therefore, making the canteen an influential factor on eating behavior and nutritional knowledge in the school community. Based on this concept, the guidelines were designed with the following important aspects into consideration:

1) Findings from previous studies on school canteens to formulate general goals for

the school canteens.

76 77

2) Main objective of the school canteen is to deepen the concept of proper nutrition

among students, and provide them nutritious foods that are affordable to their

purchasing power.

3) Difference in nutritional and physiological needs for students from every

educational level.

4) Canteen providers understand the important role the canteen play in shaping

nutritional knowledge of the students and its impact on their health.

5) Changes in the dietary pattern of the students may not be a positive thing from a

nutritional point as it is associated with increased consumption of foods and

beverages that are nutrient-poor and may contain chemical additives.

4- Food and Beverages provided in canteens

School canteen is of great importance if supplied students with balanced diets that they need in this stage of life. The School Healthcare Department was keen on including healthy foods that are suitable for students from each age group.

Frits: Foods and beverages permitted to be sold

1) Fluid milk: low fat or full fat, flavored or unflavored, fortified.

2) 100% juices: no chemical additives.

3) Juice boxes ≥ 30% juice: no chemical additives.

4) Hot beverages.

5) Water.

6) Crackers or maamoul: whole wheat or white wheat, fortified, no sugar and

chemical additives.

7) Local dates: no GMO, no chemical additives.

8) Salad: fruits, vegetable, chickpea.

9) Sandwiches: cheese, egg, peanut, jam, honey, za’atar, hummus (taking into

account special health risks, i.e. G6PD deficient), prepared daily.

10) French fries: baked.

11) Pizza: vegetarian.

12) Corn: popcorn or corn in a cup.

13) Cereals.

14) Pasta with tomato sauce.

15) Local desserts: prepared in the canteen.

16) Chocolate: with wafer or nuts.

Third: Foods and beverages not permitted to be sold

1) Soft drinks and energy drinks.

2) Juice boxes < 30% juice.

3) Chips, crisps, corn puffs.

4) Sweets (candy).

5) Meat products.

6) Chocolate: toffee or nougat, no wafer or nuts.

7) Foods containing trans fat.

APPENDIX E

SAMPLE OF THE COLLECTED ONE-DAY FOOD LISTS

Appendix E

Sample of the Collected One-Day Food Lists

Food list: 1.

Educational Level: Secondary.

Pasta with bechamel sauce, chicken slices, cabbage, and coriander.

Feta cheese sandwich.

Dala juice box, 30% juice.

Water bottle.

Tea.

Ülker Biskrem, chocolate filled biscuits.

Teashop Ringo, wafer roll.

Loacker sandwich, chocolate.

Snickers, chocolate.

Oreo, 4 biscuits.

Maltesers, chocolate.

Kinder, milk chocolate.

Galaxy, milk chocolate.

Hershey, chocolate.

Food list: 2.

Educational Level: Secondary.

Feta cheese sandwich.

80 81

Popcorn.

Dala juice box, 30% juice.

Water bottle.

Salted peanuts.

Loacker sandwich, chocolate.

Al-Batal maamoul, date filled biscuits.

Mini chocolate chips cookies.

Ülker Karaki, salted crackers.

Saray kek, chocolate cake.

Food list: 3.

Educational Level: Intermediate.

French fries, cooked in fat.

Feta cheese sandwich.

Delta juice box, 30% juice.

Water bottle.

Galaxy flutes, chocolate.

Kit Kat, chocolate.

Ülker Kat Kat Kat, chocolate filled mille-feuille pastry.

Oreo, 4 biscuits.

Salted crackers.

Food list: 4.

Educational Level: Intermediate.

Stir-fried noodles with carrots and cabbage.

Cheddar cheese croissant.

Original juice box, 30% juice.

Water bottle.

Loacker sandwich, chocolate.

SunBites, seasoned bread bites.

Vegetable flavored crackers.

Ülker sandwich, chocolate filled.

Piccadeli combo, wafer layers with caramel and crispy cereals.

APPENDIX F

CONSENT FORM

Appendix F

Consent Form

Informed Consent to Participate in a Research Study

Study Title: Nutritional Composition of Breakfast Meals Served in All-Girl Intermediate and Secondary Public Schools in Mecca, Saudi Arabia.

Principal Investigator: Karen Gordon. Co-investigator: Lamyaa Yahya.

You are being invited to participate in a research study. This consent form will provide you with information on the research project, what you will need to do, and the associated risks and benefits of the research. Your participation is voluntary. Please read this form carefully. It is important that you ask questions and fully understand the research in order to make an informed decision. You will receive a copy of this document to take with you.

Purpose: The purpose of this descriptive study is to assess the nutritional composition of breakfast meals in Saudi Arabian all-girl intermediate and secondary public schools in the city of Mecca. This Study will investigate the nutritional composition of the self-managed and catering-managed canteens’ breakfasts in the intermediate and secondary levels.

Procedures Data will be collected in two steps, first step will include conducting a telephone questionnaire with the school administration to collect information about the number of students enrolled this year, breakfast time, lengths and canteen provider. Second step will include visiting the school and conduct a face-to-face survey with the canteen manager. This step will also include collecting a food list, weighing food, and collecting information about food preparation and recipes. The co-investigator will only visit the canteen once and there will be no follow-ups.

84 85

Benefits This research will not benefit the school directly. However, the school participation in this study will help to better understand the composition of food served in public schools for potential improvement.

Risks and Discomforts There are no anticipated risks beyond those encountered in everyday life.

Privacy and Confidentiality All responses will be coded and entered in a statistical analysis file that will only be accessible to PI and co-investigator. All responses will be treated as confidential, and will not be identified under no circumstances. Data will be published in aggregate form only for confidentiality.

Voluntary Participation Taking part in this research study is entirely up to you. You may choose not to participate or you may discontinue your participation at any time without penalty or loss of benefits to which you are otherwise entitled. You will be informed of any new, relevant information that may affect your health, welfare, or willingness to continue your study participation.

Contact Information If you have any questions or concerns about this research, you may contact Lamyaa Yahya or Dr. Karen Gordon RD, LD at 330-672-2248. This project has been approved by the Kent State University Institutional Review Board. If you have any questions about your rights as a research participant or complaints about the research, you may call the IRB at 330.672.2704.

Verbal Consent Statement I have read this consent form and have had the opportunity to have my questions answered to my satisfaction. I voluntarily agree to participate in this study. I understand that a copy of this consent will be provided to me for future reference.

APPENDIX G

LETTER OF SUPPORT

Appendix G

Letter of Support

Nutritional Composition of Breakfast Meals Served in All-Girls Intermediate and

Secondary Public Schools in Mecca, Saudi Arabia.

Dear Karen Gordon and Lamyaa Yahya,

The school is aware of your proposed research project. We understand that the involvement of our school in assisting you to accomplish this project includes conducting surveys with the school administration and canteen manager, collecting food lists, and recipes.

As the principal of the school, I am able to approve research at this site. I have read through your research proposal and support the involvement of our school in this project and look forward to working with you.

Should you have any questions, please contact me at

______.

Sincerely,

School Principal

School Name______

Date______

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