Healthy eating in children should be established while they are still in primary to elementary schools to prevent malnutrition and to shape their eating habits as adults [1]. In 2013, 8 out of 10 Filipino children aged 6–12 yrs old did not meet their daily recommended intake requirements for energy while 1 in 4 consumed less than the recommended intake for protein, according to the Philippines National Nutrition Survey [2]. Of the total food intake, 43% came from cereals and cereal products. Fruit and vegetable consumption was recorded at only 5% and 6%, respectively. Milk and milk product consumption was at 8%—with older children consuming less whole milk and more milk products. The same survey revealed that the top ten food items commonly consumed by school-age children were rice, cooking oil, bread, eggs (chicken), chicken, sugar, crackers, cookies, noodles (instant), and hotdogs. Furthermore, an evaluation study found that their diet was inadequate in energy, fat, and most micronutrients [3]. Along with the poor quantity and quality of food, undernutrition is also affecting 3 out of ten children aged 5–10 yrs [4]. This situation contributes to poor child development (e.g., physical and mental development) eventually leading to less productive adults [5].

Filipino families typically maintain a close-knit relationship with their relatives. The stronger the ties within a family, the greater the chances of their eating meals together and influencing the nutrition knowledge and healthy eating habits of the primary gatekeepers (i.e., dietary decision-makers), particularly the mothers. Frequent activities and practices shared together as a family, such as the discussion of healthy dietary practices during mealtimes develop behaviors that may improve the individual health of household members. In a study by Moxley et al. [6], family solidarity promoted a better knowledge of health and food choices.

The family plays a significant role in the dietary habits of children. Their parents primarily provide their food and influence their intake. It is important to develop healthy eating while young because eating patterns as a child will ultimately lay the foundation for the adult attitude towards food and eating behavior. Parents, especially mothers, act as models who shape the child's attitude towards eating and the formation of healthy or unhealthy eating patterns [178]. A healthy eating habit for children is defined as a dietary intake with high consumption of fruits, vegetables, milk, rice, and fish [89]. Eating together as a family is correlated with higher fruit, vegetable, and dairy food consumption [7]. The attitude and behavior of children towards certain foods are also influenced by the environment, particularly at school. Time spent and food bought in school are not usually monitored by parents. To ensure that children have continuous access to healthy foods, several policies are being implemented.

In the Philippines, the Department of Education (DepEd) issued Department Order No. 13, Series of 2017 [10] entitled “Policy and Guidelines on Healthy Food and Beverage Choices in Schools and in DepEd Offices”. This order focuses on a system to categorize and evaluate the food items and beverages sold in schools. Foods and beverages were categorized as green (always available), yellow (maybe served once or twice a week), and red (not recommended). Cooked foods served in the school canteen were also expected to adhere to the categories and fall between green and yellow depending on the ingredients. This was followed by the issuance of DepEd's Department Order No. 39, Series of 2017 [11] entitled Operational Guidelines on the Implementation of School-Based Feeding Program (SBFP) for School Years 2017–2022. Food for Education programs, particularly school feeding, has been conducted by the DepEd since 1997 [12]. The target of SBFP was to 1) improve the nutritional status of all severely wasted and wasted children from kindergarten to grade 6 by at least 70% at the end of 120 feeding days; 2) increase classroom attendance by 85% to 100%; and 3) improve children's health and nutrition values and behavior. One of the activities to complement the SBFP is the Gulayan sa Paaralan Program—a school-based gardening program. This is implemented through the DepEd Memorandum No. 293, series of 2007 [13] to encourage the establishment of school gardens in public elementary and secondary schools and increase the SBFP's access to vegetable supply.

Likewise, several non-governmental organizations (NGOs) aid in reducing the magnitude of undernutrition among Filipino children. Most of these interventions provide supplementary feeding to children; usually conducted in schools and communities during lunch or breakfast. However, the role of the family—especially the child's caregiver, is often overlooked. What is eaten at a family's dining table greatly influences the food preferences of young children [14]. Meals familiar to children are most likely to be accepted [141516], a component useful during the design and provision of a feeding program. It is also vital that aside from feeding the children, their parents or mothers/caregivers should also be provided with the necessary knowledge to enable them to practice good nutrition [71417].

This present study investigated the effectiveness of an intervention intended for school children and their mothers/caregivers in terms of improving the nutrition behavior of the children. Two components of the nutrition intervention were pilot tested: 1) lunch feeding of schoolchildren using recipes based on the Philippines' Pinggang Pinoy® that provide the recommended energy and nutrient intake for one meal; and 2) nutrition classes for school children and their mothers/caregivers using modules focused on basic nutrition knowledge and practices which were developed specifically for the intervention. Pinggang Pinoy® is a food guide that shows the right food group proportions an individual should eat per meal. Both the recipes and modules were developed by the Department of Science and Technology's Food and Nutrition Research Institute (DOST-FNRI).

This paper determined the change in behavior among schoolchildren and specifically, the change in their food intake after the intervention using the modified Child and Diet Evaluation Tool (CADET).

In response to the question “Do school-based nutrition interventions improve the eating behavior of school-age children?”, this paper presented 3 nutrition intervention approaches developed by the DOST-FNRI and one regular school-based intervention implemented by the DepEd which have resulted in improvements in the attitude and behavior of schoolchildren as perceived by their mothers. Findings revealed an overall improvement in the eating behavior of children in the intervention groups as shown by the increased number of children eating vegetables and fruits, more glasses of milk intake, higher vegetable intake, greater pieces of fruit consumed, and decreased consumption of sugar.

The study utilized the second section of the modified CADET in assessing attitude and behavior change as this has not been the focus of previous studies.

The intervention with feeding and attendance of the nutrition classes had positively influenced children's eating behavior.

The CADET primarily assessed the diet of children, particularly their fruit and vegetable intake [1820]. In the CADET questionnaire, the mothers were asked to respond by ticking the food items consumed by their children during mealtimes and to measure their average daily intake. The attitude and behavior of schoolchildren were assessed from the mothers/caregivers' perspective. Results showed that more mothers perceived better attitude and behavior in their children with regard to eating vegetables by the end of the intervention. This was evident in the presence of more vegetables in children's actual food intake at endline. This increase could be attributed to the meals provided to children during lunch as part of the intervention in the school. The school lunch feeding used a 3-week cycle menu for 16–17 weeks. A child participant with complete attendance in the intervention would have consumed the meals 5 times a week. Repeated exposure to food, particularly vegetables, helped in increasing the children's familiarity with these food items. A study conducted among preschool children in England [22] revealed that children who were exposed to tasting an unfamiliar vegetable (long white radish) developed a consistent liking for it and easily accepted it after 10 exposures. The nutrition education component of the study [22] increased the willingness of children to try the vegetable. In other studies, children who were repeatedly exposed to and tasted the target vegetables 8–12 times within a maximum of 10 weeks developed a liking and increased their consumption of the target vegetables [1623242526]. Vegetables used for these studies were unfamiliar to the children. They were either served raw or cooked using a different method. One study proposed 2 pathways to improve children's liking for vegetables: 1) changing the appearance, texture, or taste of vegetables by cooking them and 2) using repeated exposure strategies [27]. The more familiar children are with a particular food, the greater would be their liking for it [14]. Simply put, what children accept as food they would most likely eat. The same results were observed in a review where the author reassessed experimental and naturalistic studies that link children's food preferences with food exposure and acceptance [15]. Children's food experience through the school lunch may have helped in increasing their fondness for meals with vegetables, thus increasing their intake even when they are at home [222829]. These studies support the probability that a school lunch feeding intervention could help improve the nutritional status of children and aid in developing children's acceptance of vegetables, while the presence of the nutrition education component further enhanced the effect of the school lunch feeding.

In this study, the children's fruit intake had not improved. Consuming at least one fruit a day as reported in the modified CADET matched the presence of bananas in the list of commonly consumed foods by the end of the school lunch intervention. Bananas were the fruit included in the lunch meals of children due to their affordable price and abundance in the research areas. The improvement in fruit intake in this study could only be attributed to the provision of school lunch during the period of intervention. The continuous intake of fruits at least once a day after the intervention could not be assured. In a discussion paper, it was indicated that the majority of Filipino families will prioritize having rice and viands on their tables before buying other food commodities [30]. Rice forms a central part of Filipino dining tables, especially in Luzon – where the study areas were located. Cereals, such as rice and fish and fish products also shared the biggest household expenditures in rural communities [31]. One study [32] which investigated the dietary pattern in a Philippine village revealed that families resort to having one viand meal aside from rice due to the high cost of food. This viand which becomes the source of protein could either be fish, meat, or a poultry dish. Fruits may not be as easily included in the meals of children, at school and home, because of their price and availability [33]. The 2013 Dietary Component of the National Nutrition Survey revealed that Filipino children aged 6–12 yrs typically consume cereals and cereal products and fish, meat, and poultry which contributed 43.0% and 23.6% of the total food intake, respectively. Fruits only comprised an intake of 28 g/day—4.9% of the total daily consumption. The behavior of eating fewer fruits is apparent among this population. This is similar to a study among children aged 6 to 7 yrs conducted in English primary schools that explored the link between the various methods adopted by these schools to promote fruit and vegetable intake and the subsequent actual changes in the diet of children aged 6–7 yrs [33]. They found that nutrition activities such as gardening, counseling of parents, and lessons taught to children were associated with increased vegetable intake but not that of fruit. However, it should be noted that many studies are reporting the effectiveness of nutrition education in improving the fruit and vegetable intake of their target audience [223435363738]. For this study, the limitations of the capacity of households to purchase other food commodities like fruits should be accounted for. Even if these households understood the health benefits of eating fruits for their children, when accessibility and affordability are not addressed, their nutrition knowledge and attitude will not be translated into concrete behavior [3439].

The attitude of children towards milk varied in the study groups; however, their behavior as reported by the modified CADET showed more children drinking 2 or more glasses of milk especially in the group which received both feeding and nutrition classes interventions—albeit this change was insignificant. Milk drinking was also high among children in the non-intervention group which may be associated with higher purchasing power because of the group's higher household monthly income [40]. This is confirmed by the presence of milk (powdered) in the top 10 foods consumed by children. Coffee (instant) drinking, on the other hand, decreased. The information obtained from the nutrition classes component of the intervention could have provided clarity to the mothers/caregivers on the importance of nutritious beverages.

Children are genetically inclined to eating foods that taste sweet because it naturally signals a content of calories or energy [7]. In this study, adding sugar to children's powdered milk was observed as a household practice which explained why sugar (washed) is listed as a commonly consumed food. Washed sugar is a type of raw sugar that is light brown due to molasses or is the same as residue after minimal processing. However, free sugar in the diet of participating children was within 25 g or 6 teaspoons—as recommended by the American Heart Association (AHA) [41]. With sugar intake within the guidelines of the AHA, other low-calorie foods such as soft drinks, cookies, and crackers were excluded from the list of commonly consumed foods by children at the end of the study. This could be attributed to one of the key messages in the nutrition classes which says—“consume more nutrient-dense sources of energy”. The modified CADET captured the children's negative attitude towards sweet and salty foods and behavior towards sugar intake as reported by the mothers/caregivers.

The implementation of the intervention (feeding children and nutrition classes for them and their mothers/caregivers) proved to affect children's nutrition behavior. The measurement of attitude and behavior through the modified CADET may not have demonstrated consistent improvement in children since its intended use is to evaluate diet. The assessment using the modified CADET identified areas of concerns or topics (e.g., sugar consumption in the form of table sugar or other forms, salty food intake, milk consumption, and inclusion of fruits in the diet) which need to be strengthened in nutrition classes. The modified CADET could be an alternative instrument to assess the attitude and behavior of children.

The mothers' insights on children's attitudes and behavior as reported by the modified CADET were highly significant. Mothers are usually regarded as the ‘nutritional gatekeepers’ who hold responsibility for their family's food intake [42]. These mothers have the longest quality interaction with the children in terms of caring for and feeding them. They recognize their influence over their child's diet leading them to likely perceive positive food attitudes and behavior in their children, which may not always correlate with reality [42]. However, this study confirmed that the perception of mothers about their children's eating attitude and behavior was close to the actual foods commonly consumed by the children.

Again, there are various nutrition intervention programs implemented in the Philippines—by the government, private sector, and NGOs to address malnutrition among Filipino children and their families. Most of them provide supplementary food for children once a day. The importance of family involvement in improving the children's nutritional status should be emphasized. In conclusion, this study had shown that a package of nutrition intervention which comprised of feeding and nutrition classes, contributed to the substantial improvement of children's behavior and actual food intake of vegetable, milk, and sugar as measured by the modified CADET and the 24-h food recall.

Thus, the integration of interventions that combine feeding children following the Philippines' Pinggang Pinoy® recommendations and nutrition classes with the current Philippine SBFP of the DepEd in public elementary schools should be pursued. Subsequent intervention through nutrition classes should also highlight the role of the family in improving their children's food intake through various strategies. Lastly, a call for policies that will increase households' access to and consumption of fruits, vegetables, and other healthy foods is strongly recommended.