Introduction

Childhood obesity has surfaced as a new challenge for healthcare providers and parents across the globe.¹ According to the WHO, the prevalence of childhood obesity is increasing in Middle Eastern countries such as Egypt, Tunisia and Kuwait. Many studies have confirmed obesity in Saudi Arabian children, however, accurate statistics have yet to be gathered.² Obesity is not restricted to western or developed countries and it is also prevalent in high income and developing countries.³ It is primarily due to the increasing consumption of energy-dense and poor nutritional value foods with high levels of sugar and saturated fats, coupled with reduced physical activity.⁴ Eyad et al., (2017) indicated that most overweight or obese pre-primary school children hail from high-income or affluent families using the growth profile z scores,⁵ due to the poor quality of school meals and low awareness of mothers.⁶ This necessitates nutrition training for children, teachers and parents to support healthy eating habits and lifestyles in school and at home.^7-12 Eating out is highly prevalent in Gulf Cooperation Council (GCC) countries, and predominantly in
middle-income countries, particularly in urban areas. Many European
and United States¹³ based fast food chains have entered Gulf Cooperation Council (GCC) countries, particularly the Kingdom of Saudi Arabia¹⁴ and the United Arab Emirates (UAE).¹⁵ This type of diet is more likely to be low in dietary fibres and high in fat, cholesterol, calories, sodium, and artificial food
additives.¹⁶
 Being overweight, obese or diabetic is correlated with the frequent consumption of sugar, savoury and crispy snacks, flavoured milk and soda drinks, and snacking between meals.¹⁷ These eating habits are prominent among pre-primary school children, which was shown in the Saudi School Meal and Home Meal Study (SSMHMS), where school meal analysis indicated that the total calories in breakfast are low (23% of total requirement) while the total calories in lunch are high (40% of total requirement) compared to the Recommended Dietary Allowance,¹⁸ where both carbohydrates and saturated fats were at a higher level at lunch (>7%).⁶ Due to the increased income and large scale urbanisation over the last 20 years, food consumption and nutrient intake have transformed¹⁹ and most calories now come from animal based²⁰ and processed foods, both of which play a major role in childhood health and obesity.²¹

Dietary habits and nutritional intake amongst Saudi kindergarten children need to be improved to ensure a healthy diet and prevent nutrition-related diseases in the adult population.²² Thus, Child Nutrition Programmes need to be initiated to educate children, teachers and parents on developing healthier eating habits.²³ In 2010, the World Health Organisation (WHO) framed its first strategic plan on nutrition for 2010–2019 for the Eastern Mediterranean region to improve the nutritional status of people throughout the lifecycle.²⁴ This involved encouraging countries to reposition nutrition as central to their development program. The World Health Organisation (WHO) set goals and a seven-point target to be achieved by member countries, including Saudi Arabia. It also provided 10 strategic approaches to be conducted by international organisations to provide a strong foundation for nutrition training programmes, including child nutrition. Nutrition training programmes include various services, such as nutrition education for children and training for teachers, staff responsible for meal preparation and the cafeteria, and parents and caregivers. We have carried a systematic review in 2018 to describe excistingChild Nutrition Programs run by the US government, such as the National School lunch Program (NSLP),²⁵ and in the United Kingdom (UK), such as the British Nutrition foundation (BNF).²⁶ In addition, we have reviewed successful non-governmental global consulting companies, such as Qua Nutrition
(India), Cafe Nutrition
(India), SR Nutrition (UK),
Judy More Child Nutrition Consultancy (UK) and Pure Vitality Nutrition Concepts Pte. Ltd. (Singapore), where we found that most effective services to improve children nutrition status and health are through improving school meals and providing education, training, and counselling to caregivers, teachers and students. Thus, among all those programmes, the nutrition curriculum run by the British Nutrition Foundation BNF was found to be more suitable for Saudi Population due to convenience and potential needs.²⁷ According to the National Centre for Education Statistics (NCES) ²⁸ in the United States,¹³ 99% of public schools offer nutrition education within the curriculum, 50% or more of all schools have district or state requirement for students to receive nutrition education from kindergarten through to eighth grade and 7% of schools report receiving nutrition lesson materials from sources outside the school. Thus, implementing programmes in Saudi kindergartens is essential. This study has three objectives; first, assess the interest of parents and schools in child nutrition programmes in kindergartens. Second, analyse bookstores to determine the availability of learning resources which support our programme. Third, identify the main factors and barriers facing global consulting companies in running child nutrition programmes in different countries. The aim of this study is to support the development of successful child nutrition programmes in Saudi kindergartens.

Materials and Methods

Study Design

Focus groups interviews were conducted in December 2017 with different target populations (kindergartens(n=48), parents (n=20), bookstores (n=2), global consulting groups (n=12), using primary/field interview based questionnaires. The focus group discussions were designed to assess teachers and parents’ needs and interest in implementing child nutrition programmes in kindergartens. With regards to bookstores, the discussion focused on the availability of learning resources to support possible existing programmes. The discussions with global consulting companies focused on the factors and barriers that influence the success of child nutrition programmes in schools. Inclusion criteria with regards to the parents and kindergartens involved are Saudi subjects with high economic status in Jeddah City, Saudi Arabia. Exclusion criteria included parents and children that are part of any child nutrition programmes.

Statistical Analysis

Descriptive data were reported as frequencies and percentages (%). SPSS (version 21) was used to analyse the date. The responses given in the customised questionnaires were “yes”, “no” and “maybe”. The statistical significance of the difference between proportions was determined by a non-parametric binomial test. p < 0.05 value (two-sided test) was accepted as statistically significant; “a” is significantly different than “b” and “c”; “b” is significantly different than “a” and “b”; and “c” is significantly different than “a” and “b”.

Results & discussion

Kindergarten schools’ interest in child nutrition programmes

Kindergartens play an essential role in preventing childhood obesity, which can be achieved by nutrition education, physical activity classes and teacher training.²⁹ The first objective of this study is to assess the need for child nutrition programmes similar to the nutrition curriculum run by the British Nutrition Foundation BNF ²⁷ in Saudi kindergartens (Table 1). The data revealed child nutrition programmes are a relatively new concept and only 5% of schools indicated running health related activities that cover health assessment, emergency management and identifying students’ health status by health professionals, which may affect educational achievement.³⁰ It was seen by the Health Promoting Schools (HPS) that both parents and children showed significant changes in their eating patterns and lifestyles following child nutrition programmes, such as consuming more fibre, healthy snacks, milk, water, fruit and vegetables, and reducing their intake of creamy, fatty and sugary foods.²³ The literature confirmed that such programmes influenced teachers as well.³¹ Saudi Arabian schools primarily focus on their students’ academic development rather than their health and diet. In our study, 80% of schools were willing to invest time and money to implement these child nutrition programmes and 79% of the respondents (school principals or representatives) had a positive attitude towards the addition of a nutrition module to the curriculum provided it complied with the Ministry of Education’s guidelines. In support of our data, 36 interventions and 21 comparison studies between preschool students and first grade students’ healthy lifestyles have shown that adding a nutrition curriculum as an afterschool setting improves the selection of healthy snacks.¹⁴ Other studies have shown that most teachers have taught nutrition as part of the curriculum, however, professional training is needed.¹⁸

Table 1: Child Nutrition Programmes and Services according to School Principal (n=48)

Percentages (%) were accepted as statistically significant with p < 0.05 value (two-sided test); a means it is significantly different to b and c; b is significantly different to a and c, and c is significantly different to a and b.

Our interviews also covered changing school meals and improving the lunch experience which has been observed with USDA Child Nutrition Program²⁷ to adopt a healthier approach which meets the recommended dietary intakes and provides healthy food choices.³² In schools, students usually consume the most available type of food presented, such as pizza and sandwiches.³³ In the Saudi School Meal and Home Meal Study(SSMHMS), 27% of children were classified as overweight, and school meals consisted of high amounts of carbohydrates and fats were above the RDA.⁶ While school nurses and counsellors care for students with special needs, such as allergies and chronic illnesses, the meals are not professionally planned. 92% of schools do not assign dietitians to plan the meals cooked and served in school cafeterias and100% of schools do not assign a dietitian to plan a diet customised according to health conditions (Table 1). Worldwide, dietitians have a significant role in schools, which includes purchasing ingredients, storage, control, meal planning and services, equipment management and waste management,³⁴ however, they are not satisfied with their salaries and work conditions.³⁵

Our study also targeted parents and their interest in child nutrition programmes. The literature showed that the main factors influencing the health of kindergarten children in KSA are the type of food presented, knowledge, household income, cost of food, individual preferences, cultural beliefs, and cultural traditions, followed by family and social influencers, such as maternal employment, and the preference for sweets.³⁶ In KSA, increased social awareness has resulted in more women joining the workforce.³⁷ Consequently, young children are routinely being fed poor quality meals by caretakers. This trend is likely to influence the dietary habits of children outside the home setting, in schools for instance, and increase the risk of developing obesity, diabetes, and allergies.³⁸ Table 2 shows that 90% of respondents are willing to receive nutrition education and training for their children. Furthermore, 80% were willing to pat an additional fee for it. Approximately 75% indicated that they would not mind spending an additional 0-3% of school fees. Slusser et al., (2011) qualitative study revealed that even mothers from a low social economic status are interested in having their children participate in child nutrition programmes, therefore governmental sectors must provide funds in order to support the implementation of such programmes.³⁹ The data showed that 50% of the respondents struggle to teach their children about healthy eating at home and 25%stated that it is quite manageable. In 2015, a cross-sectional study showed that mothers struggle to feed their children. Most of the difficulty was related to the child sitting at a table or in front of the TV while eating, the frequency of takeaway foods, mother’s control and child’s quality of diet.⁴⁰ Furthermore, 60% of the interviewed parents responded positively towards collaborating with and participating in child nutrition programmes, such as attending workshops and training in how to apply food at home. Nutrition education developed for caregivers can be delivered via mail or social media, however, some caregivers prefer to learn with their peers in a workshop.⁴¹ Another study stated that caregivers prefer to use Facebook, which is a feasible platform that they can access at their own convenience.⁴² However, in our study, half the parents responded negatively when asked about receiving a dietitian’s help at home.

Table 2: Child Nutrition Programmes and Services according to Parents (n=20)

Percentages (%) were accepted as statistically significant with p < 0.05 value (two-sided test); a means it is significantly different from b and c; b is significantly different from a and c; c is significantly different than a and b.

Table 3 Child Nutrition Programmes and Services according to Bookstores (n=2)

Percentages (%) were accepted as statistically significant with p < 0.05 value (two-sided test); a means it is significantly different from b and c; b is significantly different from a and c, and c is significantly different from a and b.

Table 4: Child Nutrition Programmes and Services according to Global Consulting Companies (n=12)

Percentages (%) were accepted as statistically significant with p < 0.05 value (two-sided test); a means it is significantly different to b and c; b is significantly different from a and c; c is significantly different from a and b. The companies interviewed include: Qua Nutrition,
Cafe Nutrition,
SR Nutrition,
Judy More Child Nutrition Consultancy, Pure Vitality Nutrition Concepts Pte. Ltd., Prime health Consultants,
 Dr. Nutrition Centre LLC,
Cooper Nutrition,
Roche Dietitians LLC,
Nutrition Consulting Services LLC, Pomegranate Nutrition Consulting, and others

The third objective of this study was to assess the availability of learning resources in bookstores, such as teaching games, books, recipes that are usually used as tools in Child Nutrition Programs.²⁷ Developing learning material suitable for children in any health promoting programme plays major role in delivering education to the community.⁴³ Governmental programmes provide sources online, as seen in the BNF and USDA, such as worksheets, recipes and activities for children which can be used by caregivers and teachers.^{25, 26} Other tools include computer-based tools,⁴⁴ or materials found in retails stores, such as, educational books, stories and games, which involve both parents and children at home.⁴⁵ In our study, we interviewed the top bookstores in Saudi Arabia, Jarir and Obeikan, which provide educational toys of all types for children of all ages. Obeikan bookstores are expected to release their books on nutrition education soon. Jariral ready provides learning materials for children, nutrition education books for certain age groups and books for mothers and caregivers, however, they are primarily cook books. In addition, both bookstores have shown an interest in introducing other learning resources, such as colouring books and games, to enhance health and nutrition among children in Saudi Arabia. According to the Bookbag programme, several benefits of Child Nutrition Programs has been relying on mostly learning materials, such as books that involve the participation of both parents and children. This has led to positive health changes, such as purchasing more fruit and vegetables.⁴⁵

Our third objective was to identify the factors and barriers to delivering child nutrition programmes in schools via global consulting companies. Therefore, weinter viewed 12 global consulting companies that deliver child nutrition programmes to schools. Table 4 shows that 83% of companies that do not provide child nutrition training programmes to schools or teachers face three challenges; lack of awareness cost coverage and high resistance and reluctance, which is supported with previous studies.⁴⁶ In addition, our interviews identified factors associated with considering nutrition education and teacher training in schools, where 92% stated parental pressure is a major factor. Furthermore, timing and school image are factors to a lesser extent and some schools adopt these programmes to improve their reputations. Personal counselling for parents is one of the most prominent additional services offered by the companies in addition to teacher training. Workshops (Private or Public), seminars, and presentations on nutrition education are the most common child nutrition training services offered by the companies globally.⁴³ The most common workshop conducted by the consultant companies was ‘Private Workshops for Mother and Child’ which gained traction in many areas on how to prepare nutritious food and provide ‘how to prepare’ sheets/papers for food preparation in cafeterias for school.⁴⁷ Some of the most common learning resources provided by the companies were videos to support the teachers such as, a teacher’s guide, Continuous Professional Development (CPD) for teacher development, games, worksheets, recipes and books.⁴⁸ Approximately 66% of school representatives expressed a positive attitude towards collaborating with third-parties for formal nutrition training for teachers, educating children and providing learning resources.

Conclusion

There is a high prevalence of childhood obesity in the Middle East, and Central and Eastern Europe, and it has been observed to be very high in KSA.⁴⁹ Our study revealed that there are no health promoting companies implementing child nutrition programmes or providing materials for kindergartens in Saudi Arabia. School representatives, parents, bookstores and global companies expressed interest, however, the cost and expenses are possible barriers to their implementation. Our findings support developing programmes with a convenient level of expenses that include nutrition education for children, training workshops for parents and teachers, and meal planning in schools and at home. Furthermore, developing materials and books suitable for children has significant potential in the Saudi market, to involve the family and support child nutrition programmes once implemented. Future work should focus on implementing a pilot child nutrition programme and measuring its effectiveness, team quality and health outcomes. Obesity is a health issue which has economic effects. As childhood obesity often persists into adolescence and adulthood, it is necessary to develop health-promoting programmes at a younger age.⁴³

Acknowledgements

We would like to give our sincere appreciation to the interviewers at the United Consulting Group (UCG) for their hard work in collecting data and all respondents who supported our research

References

1. Gungor NK. (2014) Overweight and obesity in children and adolescents. J Clin Res Pediatr Endocrinol. 6(3):129-43.
   CrossRef
2. World Health Statistics 2018 Monitoring health for the SDGs 2018 [Available from: http://www.who.int/gho/publications/world_health_statistics/2018/en/.
3. Khalid Al-Rubeaan, Nahla Bawazeer, Yousuf Al Farsi, Amira M. Youssef, Abdulrahman A. Al-Yahya, Hamid AlQumaidi, Basim M. Al-Malki, Khalid A. Naji, Khalid Al-Shehri, and Fahd I. Al Rumaih. (2018) Prevalence of metabolic syndrome in Saudi Arabia – a cross sectional study. BMC Endocr Disord. 18(1):16.
   CrossRef
4. Alazzeh AY, AlShammari EM, Smadi MM, Azzeh FS, AlShammari BT, Epuru S, Banu S, Bano R, Sulaiman S, Alcantara JC, Ashraf SA, Qiblawi S. (2018) Some Socioeconomic Factors and Lifestyle Habits Influencing the Prevalence of Obesity among Adolescent Male Students in the Hail Region of Saudi Arabia. Children (Basel).5(3).
   CrossRef
5. Eyad Alshammari, Epuru Suneetha, Mohd Adnan, Saif Khan, Alazzeh A. (2017) Growth Profile and Its Association with Nutrient Intake and Dietary Patterns among Children and Adolescents in Hail Region of Saudi Arabia. BioMed Research International.
   CrossRef
   
6. Eid N.M.S., AlJahdali, A., Albajri E., and Naseeb M. (2018) The Saudi School Meal and Home Meal Study (SSMHMS) to assess the quality of meals provided at the school and at home and relate it to childhood obesity– a pilot cross sectional study in Jeddah, Saudi Arabia in the year 2017, Submitted. The Journal of Food and Nutrition Research
7. Peterson A.D., Goodell L.S., Hegde A., Stage V.C. Teacher Perceptions of Multilevel Policies and the Influence on Nutrition Education in North Carolina Head Start Preschools. Journal of Nutrition Education and Behavior. 49(5):387-96.e1.
   CrossRef
8. Halloran KM, Gorman K, Fallon M, Tovar A. (2017) Nutrition Knowledge, Attitudes, and Fruit and Vegetable Intake as Predictors of Head Start Teachers’ Classroom Mealtime Behaviors. Journal of Nutrition Education and Behavior.
   CrossRef
9. Masis N, McCaffrey J, Johnson SL, Chapman-Novakofski K. (2017) Design and Evaluation of a Training Protocol for a Photographic Method of Visual Estimation of Fruit and Vegetable Intake among Kindergarten Through Second-Grade Students. Journal of Nutrition Education and Behavior. 49(4):346-51.e1.
   CrossRef
10. Montenegro E., Salinas J., Parra M., Lera L., Vio F. (2014) [Evaluation of a nutrition education intervention in teachers and students in pre-school and primary schools in los Andes, Chile]. Arch Latinoam Nutr.64(3):182-91.
11. Hu C, Ye D, Li Y, Huang Y, Li L, Gao Y, Wang S. (2010) Evaluation of a kindergarten-based nutrition education intervention for pre-school children in China. Public Health Nutrition. 13(2):253-60.
    CrossRef
12. Pérez-Rodrigo C., Aranceta J. (2001) School-based nutrition education: lessons learned and new perspectives. Public Health Nutrition. 4(1a):131-9.
    CrossRef
13. Sartorelli D.S., Sciarra E.C., Franco L.J., Cardoso MA. (2005) Beneficial effects of short-term nutritional counselling at the primary health-care level among Brazilian adults. Public Health Nutrition. 8(7):820-5.
    CrossRef
14. Matvienko O. (2007) Impact of a Nutrition Education Curriculum on Snack Choices of Children Ages Six and Seven Years. Journal of Nutrition Education and Behavior.39(5):281-5.
    CrossRef
15. Al-Zadjali M., Keller C., Larkey L., Evans B. (2014) GCC Women: Causes and Processes of Midlife Weight Gain. Health Care for Women International.35(11-12):1267-86.
    CrossRef
16. Moreira T., Severo M., Oliveira A., Ramos E., Rodrigues S., Lopes C. (2015) Eating out of home and dietary adequacy in preschool children. British Journal of Nutrition. 114(2):297-305.
    CrossRef
17. Rudy E, Bauer KW, Hughes SO, O’Connor TM, Vollrath K, Davey A, Correa NEM, Chen TA, Fisher JO. (2018) Interrelationships of child appetite, weight and snacking among Hispanic preschoolers. Pediatric Obesity.13(1):38-45.
    CrossRef
18. Kupolati M.D., Gericke G.J., MacIntyre U.E., Ferreira R., Fraser W., Du Toit P. (2016) Nutrition education practices of primary school teachers in a resource-constrained community in Gauteng, South Africa. Ecology of Food and Nutrition.55(3):279-91.
    CrossRef
19. Maillot M., Vieux F., Delaere F., Lluch A., Darmon N. (2017) Dietary changes needed to reach nutritional adequacy without increasing diet cost according to income: An analysis among French adults. PLOS ONE. 12(3):e0174679.
    CrossRef
20. Naude C.E., Visser M.E., Nguyen K.A., Durao S., Schoonees A. (2018) Effects of total fat intake on bodyweight in children. Cochrane Database of Systematic Reviews. (2).
    CrossRef
21. Cornwell B., Villamor E., Mora-Plazas M., Marin C., Monteiro C.A., Baylin A. (2018) Processed and ultra-processed foods are associated with lower-quality nutrient profiles in children from Colombia – CORRIGENDUM. Public Health Nutrition. 21(1):254-.
    CrossRef
22. Manal I. Al-Kloub, Froelicher ES. (2009) Factors contributing to adolescent obesity. Saudi Medical Journal 30(6).
23. Wang D., Stewart D. (2013) The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review. Public Health Nutrition. 16(6):1082-100.
    CrossRef
24. http://www.who.int/dietphysicalactivity/en/
25. https://www.fns.usda.gov/programs-and-services
26. https://www.nutrition.org.uk
27. ENM. (2018) Child Nutrition Programs in kindergarten Schools Implemented by the Governmental Sector and Global Nutrition Consulting Companies: A Systematic Review. Curr Res Nutr Food Sci 6(3).
    CrossRef
28. https://nces.ed.gov
29. Yngve A. (2012) The role of school and community in obesity control. Public Health Nutrition.15(8A):1522-3.
    CrossRef
30. Wainwright P., Thomas J., Jones M. (2000) Health promotion and the role of the school nurse: a systematic review. Journal of Advanced Nursing. 32(5):1083-91.
    CrossRef
31. Chen Y-H., Yeh C-Y., Lai Y-M., Shyu M-L., Huang K-C., Chiou H-Y. (2010) Significant effects of implementation of health-promoting schools on schoolteachers’ nutrition knowledge and dietary intake in Taiwan. Public Health Nutrition. 13(4):579-88.
    CrossRef
32. Raulio S., Roos E., Prättälä R. (2010) School and workplace meals promote healthy food habits. Public Health Nutrition. 13(6A):987-92.
    CrossRef
33. Ensaff H., Russell J., Barker ME. (2013) Meeting school food standards – students’ food choice and free school meals. Public Health Nutrition. 16(12):2162-8.
    CrossRef
34. Moon HK JY. (2002) Analysis of the Dietitian’s Job description in the school. J korean Diet Assoc.8(2).
35. Jang MR KM. (2003) Job Satisfaction of Dietitians between Elementary School and High School. J korean Diet Assoc.9(1).
36. Sliwa S.A., Must A., Peréa F, Economos CD. (2015) Maternal employment, acculturation, and time spent in food-related behaviors among Hispanic mothers in the United States. Evidence from the American Time Use Survey. Appetite.87:10-9.
    CrossRef
37. Alam A.A. (2008) Obesity among female school children in North West Riyadh in relation to affluent lifestyle. Saudi Medical Journal.29(8).
38. Erinosho T.O., Beth Dixon L, Young C, Brotman LM, Hayman LL. (2013) Caregiver food behaviours are associated with dietary intakes of children outside the child-care setting. Public Health Nutrition.16(7):1263-72.
    CrossRef
39. Slusser W., Prelip M., Kinsler J., Erausquin J.T., Thai C., Neumann C. (2011) Challenges to parent nutrition education: a qualitative study of parents of urban children attending low-income schools. Public Health Nutrition.14(10):1833-41.
    CrossRef
40. Megan Jarman, Hazel Inskip, Georgia Ntani, Cyrus Cooper, Janis Baird, Sian Robinson, and Mary Barker. (2015) Influences on the diet quality of pre-school children: importance of maternal psychological characteristics. Public Health Nutrition. 18(11):2001-10.
    CrossRef
41. Burden T., Sheeshka J., Hedley M., Lero D.S., Marsh S. (2000) Development, Implementation, and Evaluation of a Nutrition Education Program for Informal (Unlicensed) Child Caregivers. Journal of Nutrition Education. 32(2):104-10.
    CrossRef
42. Swindle T.M., Ward W.L., Whiteside-Mansell L. (2018) Facebook: The Use of Social Media to Engage Parents in a Preschool Obesity Prevention Curriculum. Journal of Nutrition Education and Behavior. 50(1):4-10.e1.
    CrossRef
43. Boyle M. (2016) Community Nutrition in Action. An Entrepreneurial Approach. Edition t, editor.
44. Kreisel K. (2004) Evaluation of a computer-based nutrition education tool. Public Health Nutrition. 7(2):271-7.
    CrossRef
45. Drozd M, Romaniello C, Wearner R, Carter V, Auld GW. (2006) Benefits of a Nutrition Book Bag Program. Journal of Nutrition Education and Behavior. 38(4):259-61.
    CrossRef
46. Oralia Garcia-Dominic LAW, Roberto P. Treviño, Arthur E. Hernandez, Zenong Yin, Jan S. Ulbrecht. (2010) Identifying Barriers That Hinder Onsite Parental Involvement in a School-Based Health Promotion Program. Home Promotion Practice, SAGE journals.11(5):703-13.
    CrossRef
47. Cafe Nutrition: Nutrition for Children 2018 [Available from: http://www.cafenutrition.com/child-nutritionist-nutrition-for-children.
48. British Nutrition Foundation: Food in Schools 2018 [Available from: (https://www.nutrition.org.uk/foodinschools.html). http://globalnutritionreport.org/the-report/