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High school students' attitudes and knowledge of food consumption and body image: implications for school based education
PTiENT EdlJCATiON /wd CCUNSEhN~ Patient Education and Counseling 30 (1997) 283-288
High school students’ attitudes and knowledge of food consumption and body image: implications for school based education U. Brooka**, “Department
of Pediatrics.
Wolfson
Medical Center, Sackler hStatistical Consultarlt,
I. Teppe? School of Medicine, Ministry of Health
Tel Aviv
University.
Tel Aviv,
Israel
Received 20 April 1995; revised 25 July 1996
Abstract One-hundred-and-forty-one high schoolstudentsfrom Holon between the agesof 14 and 18 years participated in the study. The aims of the study were to investigate their nutritional habits, ascertaintheir body image,measure their knowledge concerning nutrition and finally to determine their attitudes regarding overweight, obesepeople and dieting. The study is a cross-sectionalsurvey and the students involved completed a self administered questionnaireanonymouslyat school.The responserate was 97%. Forty-four percent of the total study population expresseda subjective feeling of being obesewhile, in truth, only 10% of them were actually overweight, and 48% among all participants practised weight reduction diets (girls three times more than boys). In addition to that another 53% of the pupilsexpressedthe desireto be thinner than they were (girls four timesmore than boys). Nine percent of the study group experienced self-inducedanorectic episodesat sometimeduring the past few years. It wasobserved that the study group’s knowledgeconcerningfood compositionand nutrition remainsinsufficient. As far astheir attitude concerningobesity, it was observed that 31% of the studentsregardedobesity as a handicap. Studentswho were athleticsdemonstratedmore severeand stricter attitudes towards nutrition and obesity. Most of the information concerning nutrition was obtained through the media. School education about food and nutrition only amounted to 28.3% of the total. Seventy-nine percent of the students believe that nutrition should be integrated into their curriculum. Forty-four percent of the studentsfeel themselvesto be overweight, and 53.4% want to be thinner. Half of the studentswere on various diets. The students’knowledgeof food and nutrition, the risk of obesity and the danger of excessive diets was insufficient. Most students presented negative attitudes towards obesity and overweight people. The media was the principal source of information on all these areas. Our main conclusion is that an educational nutrition program should be given to pupils in school by physicians and dietitians during all the years of public school attendance. The instructions of these programs should emphasize the importance of balanced nutritional regimes, as well as the risk and consequences of extreme dieting. Keywords:
Nutrition.; Body image; School education; Dieting: Obesity
* Corresponding 073%3991/97/$17,00 PII SO738-3991(96
author. U. Brook, M.D. Department of Pediatrics, Edith Wolfson Medial Center. Holon 58100, Israel. @) 1997 Elsevier Science Ireland Ltd. All rights reserved )00946-9
284
U. Brook,
I. TeppG
i Patient
Educaiion
1. Introduction During adolescence, boys and girls often become preoccupied with their weight, body size and appearance. Eating disorders, obesity and dieting to extremes have reached epidemic proportions in western countries. Nutritional misconceptions and lack of knowledge among adolescents cause potential public health problems. They may predispose to organic and psycholo~cal malfunctions [1,2]. Eating disturbances may lead to or reflect impaired body image and low self esteem [3,4]. Adolescents tend to be preoccupied during that period with nutrition and body size [5,6]. Thinness is considered as the ideal of beauty, while obesity is unattractive. Obesity can cause, especially in this age group, developmental and emotional problems [3]. In the United States, the prevalence of eating disorders among adolescents is 4.8%. In addition to that, 5-10% have mild disturbances in their food consumption habits. Furthermore, 10% of the children are overweight [7]. Girls tend to have more eating disorders than boys [8]. In Israel, the prevalence of overweight adolescents is less; 12.6% among boys and 13.7% among girls. Six percent of the high school students have been on a diet; most of them were less than 3 months long [9]. In another study.. 46% of high school girls reported being on diets, and 74% reported past dieting experiences [lo]. Negative attitudes toward obesity leads to more stigmatization of body fat [ll]. The concept of body image is composed of the way one conceives his body shape, his weight and fitness and its attractiveness. This image always is compared to how an ideal body should look [X2]. That attitude of adolescents towards obesity is influenced by parents at home, peers and socio-cultural factors 1131. Obesity is frequently accompanied by development of emotions of stress and guilt. Most obese children and adolescents avoid physical activity [14]. In the US, about one third to one half of adolescents are not satisfied with their body size and image [3]. This tendency first appears among girls as young as 9-years-old [15171. Half of all such girls were among those who both expressed dissatisfaction with their body
and Counseling
30 (1997)
283-288
size and who had practised weight reducing diets. Later on within 10 years, they developed anorexia nervosa [l&19]. Only 42% of adolescent boys were dissatisfied with their weight, and 33% were displeased with the shape of their body [20]. The aims of our study were as follows: 1. To determine what are the food consumption patterns of Israeli high school students (14B-years-old). 2. To determine what is the body image concept of these Israeli adolescents. 3. To survey the students’ knowledge concerning food and nutrition; to learn about their attitudes towards obesity. 4. To discover what are the pupils’ sources of information concerning nutrition.
2. Patients and methods The target population for the study was high school students attending T.H. schools in the city of Holon. There are five high schools in that city, encompassing 5000 students. A cross-section of the socio-economic class would be the middle income level. Four high school classes out of 30 were randomized to participate in this study. One-hundred-and-foxy-one pupils were presented with anonymous questionnaires. Four students were excluded, two being absent and two had language difficulties. The mean age of the particip~ts was 15.61 1.2 years. Forty-three-point-three percent were boys and 56.7% were girls. The students average grade point level was 7.9 i 0.9 (out of 10 points). Fogy-two-point-nine percent (n = 63) practised after school sport activity. Fourteen percent of the students (n = 20) suffered from chronic medical conditions, such as abdominal pains or bronchial asthma. The questionnaire was composed by pediatricians who judged the validity of the questions with three other pediatricians, an epidemiologist, a gastroenterologist, a dietitian, a teacher and an educational advisor. In its first version, 175 items were included. Of those, only 122 questions received the approval of the reviewers and were
U. Brook.
1. Tepper
I Patient
Education
included in the final form of the questionnaire. Scores in the Alfa Cornbach Index for the sections of knowledge and attitudes were 0.8 (for both). The questionnaire was comprised of six sections: first - general information (35 items): second - habits of food consumption (24 items); third - satisfaction with body size (2 items): fourth - pupils’ knowledge concerning food, nutrition and diets (36 items), including questions on proteins, sugar, fats, cholesterol, vitamins, iron and calories; fifth - attitudes towards obesity (19 items):, and sixth - sources of information and desire to expand their knowledge (3 items). The statistical analysis was done by the second author utilizing SPSS program, ,$-test, analysis of variance (ANOVA) and correfations tests.
3. Results Pupils’ nutritional habits are shown in Table 1. Almost half of the pupils are preoccupied by weight reduction and the practice of dieting, girls more so than boys. The pupils’ body image is shown in Table 2. Forty-four percent of them
Table 1. Nutritional
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Table 2 Conceived versus ideally projected body image Body image
n
%
Obese Average Thin wish to become thinner wish no change wish to gain weight
65 62 22 79 57 12
43.6 41.6 14.8 53.4 35.5 8.1
feel themselves obese, and 53% want to reduce weight. The body image as obese increases with age (P = 0.002); 44% viewed themselves as obese, while only 10% were objectively obese. Girls feel that they are fatter more than boys (57.6 vs. 23%; P = 0.003). Girls also wish to become thinner three times more than boys (P = 0.000 001). Students answered correctly only half of the questions concerning food and nutrition. The average score was 47.6 ? 14.6 (out of a 100%). No significant difference in the students’ knowledge was found in the four age groups. The students’ score for their attitude towards obese people was 3.2% 1.7 (out of 20 points).
habits of the participants
Parameters Prevalence Measuring weight at least once a week* (girls three times more than boys; x2 = 69; P = 0.004) Eating sweet snacks while watching TV* (girls twice more than boys; xL = 10.1: P = 0.001) Express interest in changing eating habits Express interest in becoming thinner Wants to loose weight (in kg) Practice diet (at present or in the past) (girls three times more than boys: x1 T 25.8: P = 0.000 001) Diet in the family (dfing fast 2 years) Calculating calories in food (girls four times more than boys: x2 = 12.1; P = 0.0005) Experienced anorectic episodes during their lifetime at an average age of (girls 3-5 times more than boys: x’ = 4.4; P = 0.03) Experienced bulimic episodes during in their lifetime (girls seven times more than boys; x2 = 3.3: P = 0.05)
Prevalence a
%
50
26.2%
77
52%
87 85 3.08 23.85 68
5R.4% 57%
102 39 13 14.96 t 1.98 8
47.6 72% 26.2% 8.9% 5.4%
*The pupils’ body image is shown in Table 2. Forty-four percent of them feel themselves obese, and 53% want to reduce weight.
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U. Brook,
Table 3 Sources for pupils’ information diets Source
%
Newspaper TV Parents* Friends Physicians popular books School Radio
78 75.7 68.6 54.5 42.1 33.1 28.3 25.3
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regarding food, obesity and
*This source decreases with age (among boys only; x2 = 14.25; P = 0.002).
Low score reflects negative attitude. The age of the students had not changed their attitude. The attitude towards obesity is most negative among pupils practising sports (r2 = 0.3; P = 0.02); 91% of students (n = 139) believe obesity is a high risk factor for poor health; 40% of the students (n = 46) consider obese people as handicapped; and that negative attitude increases with age (x2 = 9.1; P = O.OZ), and prevalent among boys more than girls (x2 = 4.61; P = 0.03). Pupils were asked to specify the most important sources of information from which they learn about food, nutrition, risk of being overweight and dieting to reduce weight. The results are shown in Table 3. The media is the most influential source upon the students. Seventy-nine percent of the participants expressed interest in learning more about nutrition and wished that it be incorporated into the school curriculum. Fifty-threepoint-nine percent (n = 74) of the pupils expressed their willingness to spend time after school hours in learning about these topics.
4. Discussion The present study provides recent data on nutritional habits, weight, dieting behavior, knowledge and attitudes about nut~tion, obesity and body image of high school students in the center of Israel, probably representing a crosssection of the middle socio-economic income
and Cnzmseling
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level in Israel. The principal findings of the survey show that 44% of the pupils feel themselves as obese and 53.4% want to be thinner; half of the students are on diets now or had dieted in the past. Furthermore, the pupils’ scores for their knowledge about food, nutrition, obesity and diets was poor. Most students presented negative attitudes towards obese people; the negative attitudes did not change during 4 years of high school. The students‘ principal sources of information come from the media (newspapers and TV). Half of the students are concerned about their body size, and more than 60% are dissatisfied with their weight. It is similar to other studies in the US and Europe [3,19,21]. In other studies in Israel 54-74% of students expressed a desire to loose weight (9,10,22). That high percentage may suggest that these adolescents have become more aware of the risk of being overweight. At the same time the attempts of weight reduction had increased 1331. There is a familial tendency for dieting as it was pointed out in studies carried out in the US; 67% of the mothers and 44% of the fathers have dieted 119). It can be suggested that children are probably influenced by the nutritional habits of their parents. The grades level of students’ knowledge concerning nutrition was 48% and did not improve during the 4 years of high school education. It can be explained by the fact that, until now, not enough instruction on these topics is included in the high school curriculum. It is recommended that these areas be covered by physicians, dietitians and biology teachers. They can explain in detail to the students what is the optimal daily food requirements [24,25]. In the US since 1985, there is an official protocol regarding food programs [26], and it has a positive influence upon children‘s health [27]. In the study by Corley [28], 75% of college students proved to ‘have satisfactory knowledge about food and nutrition; though the level of knowledge did not increase after lectures given to the students. The pupils‘ attitudes reflect their opinions about nutrition, being overweight and diets. The attitudes can predict food cons~ption patterns 1291. The absolute majority of the pupils are familiar with the fact that over-
U. Brook,
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Education
weight is a health risk. That attitude was more common in students practising sports (P = 0.04). Thirty-one percent of the students consider obesity as a real handicap. Gupta et al. [30] describe the influence of age upon body dissatisfaction. They found statistical correlation between women‘s attitude that loss of weight is equivalent to a more youthful look. Sheperd et al. 1271 did not find any correlation between knowledge regarding caloric intake and attitude toward food. The present study also did not find any correlation between nutritional knowledge and attitude towards obesity and diets. The principal sources for the pupils’ knowledge about food, nutrition and diets are the media (newspapers and television). It corresponds to similar findings of Murray in the US [l]. In two thirds of the cases, the home eating habits have a crucial influence on these topics. The students were instructed by physicians in 42% of the cases. Only 28% of the pupils mentioned school as a valid source of information. The majority of the students expressed the desire to participate in instructional classes concerning nutrition. We suggest that nutritional programs for children be regularly taught by physicians and dietitians beginning in elementary schools. Pupils should be taught the importance of balanced nutrition. They should be cautioned to avoid excessive dieting. Pupils should be familiar with the risk and the consequences of a chronic diet. Educational advisors should invest every effort to increase pupils’ self-image and acceptance of their body weight and size so that they will avoid practising extreme forms of dieting that might develop later into anorexia nervosa.
Acknowledgements Thanks to Judy Eviatar for her skillful editing and Judy Brandt for her word processing expertise and final English language contributions.
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287
PI Huon CF. Towards the prevention of dieting-induced [31
141
I51
Fl
disorders: modifying negative food and body related attitudes. Inter J Eating Disord 1990; 9: 87-93. Fisher M, Schneider M, Pegler C, Napolitano B. Eating attitudes, health risk behaviors, self esteem and anxiety among adolescent females in a suburban high school. J Adolesc Health 1991; 12: 377-384. Killen JD, Taylor CB, Telch MJ, Robinson TM, Maron DJ, Saylor KE. Depressive symptoms and substance use among adolescent binge eaters and purgers: a defined population study. Am J Public Health 1987; 77: 15391541. Osler M, Hansen ET. Dietary knowledge and behavior among school children in Copenhagen, Denmark. Stand J Sot Med 1993; 2: 135-140. Story M, Hauck FR, Broussord BA. White LL, Resnick DK, Blum RW. Weight perceptions and weight control practices in American Indian and Alaskan Native adolescents. A national survey. Arch Pediatr Adolesc Med 1994; 148: 567-571.
[71 Borgesson M. Overweight children. Acta Paediatr Uppsala 1962; 51 (suppl 132): l-76. PI Fitzgerald M. Horgan M. Screening for abnormal eating attitudes in an unselected population of l&year-old Dublin schoolgirls. Ir J Med Sci 1991: 160: 170-172. [91 Epstein LM, Atzmoni S, Tamir A. Epstein A. Eating habits, overweight and diets among high school pupils (in Israel). Harefuah 1984; 107: 204-206. 1101Neumark-Sztainer D, Palti H, Butler R. Weight concerns and dieting behavior among high school pupils in Israel. J Adolesc Health 1995: 16: 53-59. 1111Sobel J, Nicolopoulos V, Lee J. Attitudes about overweight and dating among secondary school students. Inter J Obes 1995: 29: 376-381, 1121Rucker CE, Cash TF. Body image, body size among African American and white college women. Inter J Eating Disord 1992; 12: 291-299. [13] Tienboon P, Rutishauser IHE, Wablquist ML. Adolescents’ perception of body weight and parents’ weight for height statistics. J Adolesc Health 1994: 15: 263-268. [14] Sunnegardh J, Bratleby LE. Hagman U, Samuelson G, Sjolin S. Physical activity in relation to energy intake and body fat in 8 and 13-year-old children in Sweden. Acta Paediatr Stand 1986; 75: 955-963. [15] Kirkley BG, Burge JC. Dietary restriction in young women: issues and concerns. Ann Behav Med 1989, 11: 66-71. 1161 Wardle J, Marsland L. Adolescent concerns about weight and eating: a social developmenta perspective. Psychosom Res 1989: 34: 377-391. 1171 Nylander I. The feeling of being fat and dieting in a school population. Acta Socio-med Stand 1971; 1: 1726.
References [l] Murray S, Touyz S, Benmont P. Knowledge about eating disorders in the community. Inter J Eating Disord 1994; 16: 395-399.
[18] Schleimer K. Dieting in teenage schoolgirls: a longitudinal prospective study. Acta Paediatr Stand 1983; (suppl 312): 9-54. [19] Mahoney MJ, McGuire J. Daniels SR, Specker B. Dieting behavior and eating attitudes in children. Pediatrics 1989; 84: 482-489.
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[ZO] Moore DC. Body image and eating behavior in adolescent boys. Am J Dis Child 1990; 144: 475-479. [Zl] Edlund B, Hollquist G, Sjoden PO. Attitudes to food, eating and dieting behavior in ll- and 14-year-old Swedish children. Acta Paediatr 1994; 83: 572-577. (221 Sasson A, Lewin C, Ruth D. Dieting behavior and eating attitudes in Israeli children. Inter J Eating Disord 1995; 17: 63-72. [23] Hill JA, Oliver S. Eating in the adult world: the rise of dieting in childhood and adolescence. Br Clin Psycho1 1992; 31: 95-105. [24] Steinhausen HC, Vollrath M. The self image of adolescent patients with eating disorders. Inter J Eating Disord 1993; 13: 221-227. [Z] Fullmer S, Geiger CJ. Parent CR. Consumers’ knowledge, understanding and attitudes toward health claims on food labels. J Am Diet Assoc 1991: 91: 166-171. [26] Hamilton CY, Schiller MR, Bayne L. Nutrition attitudes,
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practice and views of selected Ohio WIC participants. J Am Diet Assoc 1994; 94: 899-901. [27J Batten S, Hirschman J, Thomas D. Impact of the special supplemental food. J Pediatr 1990; 117 (Suppl): SlOls109. [ZS] Corley G, Demarest-Litchford M. Bazzarre TL. Nutrition knowledge and dietary practice of college coaches. J Am Diet Assoc 1990; 90: 705-709. 1291 Koteski DR, McKinney S. Who does the public think should perform health care tasks? J Am Diet Assoc 1989; 88: 1281-1283. [30] Gupta M, Schork NJ. Aging. related concerns and body image: possible future implications for eating disorders. Inter J Eating Disord 1993; 14: 481-486. [3l] Sheperd R. Stockley L. Nutrition. knowledge. attitude and fat consumption. J Am Diet Assoc 1987; 87: 61% 619.
High school students’ attitudes and knowledge of food consumption and body image: implications for school based education U. Brooka**, “Department
of Pediatrics.
Wolfson
Medical Center, Sackler hStatistical Consultarlt,
I. Teppe? School of Medicine, Ministry of Health
Tel Aviv
University.
Tel Aviv,
Israel
Received 20 April 1995; revised 25 July 1996
Abstract One-hundred-and-forty-one high schoolstudentsfrom Holon between the agesof 14 and 18 years participated in the study. The aims of the study were to investigate their nutritional habits, ascertaintheir body image,measure their knowledge concerning nutrition and finally to determine their attitudes regarding overweight, obesepeople and dieting. The study is a cross-sectionalsurvey and the students involved completed a self administered questionnaireanonymouslyat school.The responserate was 97%. Forty-four percent of the total study population expresseda subjective feeling of being obesewhile, in truth, only 10% of them were actually overweight, and 48% among all participants practised weight reduction diets (girls three times more than boys). In addition to that another 53% of the pupilsexpressedthe desireto be thinner than they were (girls four timesmore than boys). Nine percent of the study group experienced self-inducedanorectic episodesat sometimeduring the past few years. It wasobserved that the study group’s knowledgeconcerningfood compositionand nutrition remainsinsufficient. As far astheir attitude concerningobesity, it was observed that 31% of the studentsregardedobesity as a handicap. Studentswho were athleticsdemonstratedmore severeand stricter attitudes towards nutrition and obesity. Most of the information concerning nutrition was obtained through the media. School education about food and nutrition only amounted to 28.3% of the total. Seventy-nine percent of the students believe that nutrition should be integrated into their curriculum. Forty-four percent of the studentsfeel themselvesto be overweight, and 53.4% want to be thinner. Half of the studentswere on various diets. The students’knowledgeof food and nutrition, the risk of obesity and the danger of excessive diets was insufficient. Most students presented negative attitudes towards obesity and overweight people. The media was the principal source of information on all these areas. Our main conclusion is that an educational nutrition program should be given to pupils in school by physicians and dietitians during all the years of public school attendance. The instructions of these programs should emphasize the importance of balanced nutritional regimes, as well as the risk and consequences of extreme dieting. Keywords:
Nutrition.; Body image; School education; Dieting: Obesity
* Corresponding 073%3991/97/$17,00 PII SO738-3991(96
author. U. Brook, M.D. Department of Pediatrics, Edith Wolfson Medial Center. Holon 58100, Israel. @) 1997 Elsevier Science Ireland Ltd. All rights reserved )00946-9
284
U. Brook,
I. TeppG
i Patient
Educaiion
1. Introduction During adolescence, boys and girls often become preoccupied with their weight, body size and appearance. Eating disorders, obesity and dieting to extremes have reached epidemic proportions in western countries. Nutritional misconceptions and lack of knowledge among adolescents cause potential public health problems. They may predispose to organic and psycholo~cal malfunctions [1,2]. Eating disturbances may lead to or reflect impaired body image and low self esteem [3,4]. Adolescents tend to be preoccupied during that period with nutrition and body size [5,6]. Thinness is considered as the ideal of beauty, while obesity is unattractive. Obesity can cause, especially in this age group, developmental and emotional problems [3]. In the United States, the prevalence of eating disorders among adolescents is 4.8%. In addition to that, 5-10% have mild disturbances in their food consumption habits. Furthermore, 10% of the children are overweight [7]. Girls tend to have more eating disorders than boys [8]. In Israel, the prevalence of overweight adolescents is less; 12.6% among boys and 13.7% among girls. Six percent of the high school students have been on a diet; most of them were less than 3 months long [9]. In another study.. 46% of high school girls reported being on diets, and 74% reported past dieting experiences [lo]. Negative attitudes toward obesity leads to more stigmatization of body fat [ll]. The concept of body image is composed of the way one conceives his body shape, his weight and fitness and its attractiveness. This image always is compared to how an ideal body should look [X2]. That attitude of adolescents towards obesity is influenced by parents at home, peers and socio-cultural factors 1131. Obesity is frequently accompanied by development of emotions of stress and guilt. Most obese children and adolescents avoid physical activity [14]. In the US, about one third to one half of adolescents are not satisfied with their body size and image [3]. This tendency first appears among girls as young as 9-years-old [15171. Half of all such girls were among those who both expressed dissatisfaction with their body
and Counseling
30 (1997)
283-288
size and who had practised weight reducing diets. Later on within 10 years, they developed anorexia nervosa [l&19]. Only 42% of adolescent boys were dissatisfied with their weight, and 33% were displeased with the shape of their body [20]. The aims of our study were as follows: 1. To determine what are the food consumption patterns of Israeli high school students (14B-years-old). 2. To determine what is the body image concept of these Israeli adolescents. 3. To survey the students’ knowledge concerning food and nutrition; to learn about their attitudes towards obesity. 4. To discover what are the pupils’ sources of information concerning nutrition.
2. Patients and methods The target population for the study was high school students attending T.H. schools in the city of Holon. There are five high schools in that city, encompassing 5000 students. A cross-section of the socio-economic class would be the middle income level. Four high school classes out of 30 were randomized to participate in this study. One-hundred-and-foxy-one pupils were presented with anonymous questionnaires. Four students were excluded, two being absent and two had language difficulties. The mean age of the particip~ts was 15.61 1.2 years. Forty-three-point-three percent were boys and 56.7% were girls. The students average grade point level was 7.9 i 0.9 (out of 10 points). Fogy-two-point-nine percent (n = 63) practised after school sport activity. Fourteen percent of the students (n = 20) suffered from chronic medical conditions, such as abdominal pains or bronchial asthma. The questionnaire was composed by pediatricians who judged the validity of the questions with three other pediatricians, an epidemiologist, a gastroenterologist, a dietitian, a teacher and an educational advisor. In its first version, 175 items were included. Of those, only 122 questions received the approval of the reviewers and were
U. Brook.
1. Tepper
I Patient
Education
included in the final form of the questionnaire. Scores in the Alfa Cornbach Index for the sections of knowledge and attitudes were 0.8 (for both). The questionnaire was comprised of six sections: first - general information (35 items): second - habits of food consumption (24 items); third - satisfaction with body size (2 items): fourth - pupils’ knowledge concerning food, nutrition and diets (36 items), including questions on proteins, sugar, fats, cholesterol, vitamins, iron and calories; fifth - attitudes towards obesity (19 items):, and sixth - sources of information and desire to expand their knowledge (3 items). The statistical analysis was done by the second author utilizing SPSS program, ,$-test, analysis of variance (ANOVA) and correfations tests.
3. Results Pupils’ nutritional habits are shown in Table 1. Almost half of the pupils are preoccupied by weight reduction and the practice of dieting, girls more so than boys. The pupils’ body image is shown in Table 2. Forty-four percent of them
Table 1. Nutritional
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Table 2 Conceived versus ideally projected body image Body image
n
%
Obese Average Thin wish to become thinner wish no change wish to gain weight
65 62 22 79 57 12
43.6 41.6 14.8 53.4 35.5 8.1
feel themselves obese, and 53% want to reduce weight. The body image as obese increases with age (P = 0.002); 44% viewed themselves as obese, while only 10% were objectively obese. Girls feel that they are fatter more than boys (57.6 vs. 23%; P = 0.003). Girls also wish to become thinner three times more than boys (P = 0.000 001). Students answered correctly only half of the questions concerning food and nutrition. The average score was 47.6 ? 14.6 (out of a 100%). No significant difference in the students’ knowledge was found in the four age groups. The students’ score for their attitude towards obese people was 3.2% 1.7 (out of 20 points).
habits of the participants
Parameters Prevalence Measuring weight at least once a week* (girls three times more than boys; x2 = 69; P = 0.004) Eating sweet snacks while watching TV* (girls twice more than boys; xL = 10.1: P = 0.001) Express interest in changing eating habits Express interest in becoming thinner Wants to loose weight (in kg) Practice diet (at present or in the past) (girls three times more than boys: x1 T 25.8: P = 0.000 001) Diet in the family (dfing fast 2 years) Calculating calories in food (girls four times more than boys: x2 = 12.1; P = 0.0005) Experienced anorectic episodes during their lifetime at an average age of (girls 3-5 times more than boys: x’ = 4.4; P = 0.03) Experienced bulimic episodes during in their lifetime (girls seven times more than boys; x2 = 3.3: P = 0.05)
Prevalence a
%
50
26.2%
77
52%
87 85 3.08 23.85 68
5R.4% 57%
102 39 13 14.96 t 1.98 8
47.6 72% 26.2% 8.9% 5.4%
*The pupils’ body image is shown in Table 2. Forty-four percent of them feel themselves obese, and 53% want to reduce weight.
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U. Brook,
Table 3 Sources for pupils’ information diets Source
%
Newspaper TV Parents* Friends Physicians popular books School Radio
78 75.7 68.6 54.5 42.1 33.1 28.3 25.3
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Education
regarding food, obesity and
*This source decreases with age (among boys only; x2 = 14.25; P = 0.002).
Low score reflects negative attitude. The age of the students had not changed their attitude. The attitude towards obesity is most negative among pupils practising sports (r2 = 0.3; P = 0.02); 91% of students (n = 139) believe obesity is a high risk factor for poor health; 40% of the students (n = 46) consider obese people as handicapped; and that negative attitude increases with age (x2 = 9.1; P = O.OZ), and prevalent among boys more than girls (x2 = 4.61; P = 0.03). Pupils were asked to specify the most important sources of information from which they learn about food, nutrition, risk of being overweight and dieting to reduce weight. The results are shown in Table 3. The media is the most influential source upon the students. Seventy-nine percent of the participants expressed interest in learning more about nutrition and wished that it be incorporated into the school curriculum. Fifty-threepoint-nine percent (n = 74) of the pupils expressed their willingness to spend time after school hours in learning about these topics.
4. Discussion The present study provides recent data on nutritional habits, weight, dieting behavior, knowledge and attitudes about nut~tion, obesity and body image of high school students in the center of Israel, probably representing a crosssection of the middle socio-economic income
and Cnzmseling
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level in Israel. The principal findings of the survey show that 44% of the pupils feel themselves as obese and 53.4% want to be thinner; half of the students are on diets now or had dieted in the past. Furthermore, the pupils’ scores for their knowledge about food, nutrition, obesity and diets was poor. Most students presented negative attitudes towards obese people; the negative attitudes did not change during 4 years of high school. The students‘ principal sources of information come from the media (newspapers and TV). Half of the students are concerned about their body size, and more than 60% are dissatisfied with their weight. It is similar to other studies in the US and Europe [3,19,21]. In other studies in Israel 54-74% of students expressed a desire to loose weight (9,10,22). That high percentage may suggest that these adolescents have become more aware of the risk of being overweight. At the same time the attempts of weight reduction had increased 1331. There is a familial tendency for dieting as it was pointed out in studies carried out in the US; 67% of the mothers and 44% of the fathers have dieted 119). It can be suggested that children are probably influenced by the nutritional habits of their parents. The grades level of students’ knowledge concerning nutrition was 48% and did not improve during the 4 years of high school education. It can be explained by the fact that, until now, not enough instruction on these topics is included in the high school curriculum. It is recommended that these areas be covered by physicians, dietitians and biology teachers. They can explain in detail to the students what is the optimal daily food requirements [24,25]. In the US since 1985, there is an official protocol regarding food programs [26], and it has a positive influence upon children‘s health [27]. In the study by Corley [28], 75% of college students proved to ‘have satisfactory knowledge about food and nutrition; though the level of knowledge did not increase after lectures given to the students. The pupils‘ attitudes reflect their opinions about nutrition, being overweight and diets. The attitudes can predict food cons~ption patterns 1291. The absolute majority of the pupils are familiar with the fact that over-
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weight is a health risk. That attitude was more common in students practising sports (P = 0.04). Thirty-one percent of the students consider obesity as a real handicap. Gupta et al. [30] describe the influence of age upon body dissatisfaction. They found statistical correlation between women‘s attitude that loss of weight is equivalent to a more youthful look. Sheperd et al. 1271 did not find any correlation between knowledge regarding caloric intake and attitude toward food. The present study also did not find any correlation between nutritional knowledge and attitude towards obesity and diets. The principal sources for the pupils’ knowledge about food, nutrition and diets are the media (newspapers and television). It corresponds to similar findings of Murray in the US [l]. In two thirds of the cases, the home eating habits have a crucial influence on these topics. The students were instructed by physicians in 42% of the cases. Only 28% of the pupils mentioned school as a valid source of information. The majority of the students expressed the desire to participate in instructional classes concerning nutrition. We suggest that nutritional programs for children be regularly taught by physicians and dietitians beginning in elementary schools. Pupils should be taught the importance of balanced nutrition. They should be cautioned to avoid excessive dieting. Pupils should be familiar with the risk and the consequences of a chronic diet. Educational advisors should invest every effort to increase pupils’ self-image and acceptance of their body weight and size so that they will avoid practising extreme forms of dieting that might develop later into anorexia nervosa.
Acknowledgements Thanks to Judy Eviatar for her skillful editing and Judy Brandt for her word processing expertise and final English language contributions.
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