Declaration 1

Declaration
1. I declare that this dissertation is my own original work. Where other people’s work has been used (either from a printed source, Internet or any other source), this has been properly acknowledged and referenced in accordance with departmental requirements.
2. I understand that the University reserves the right to use plagiarism detection systems, and, to the best of my knowledge, the work does not breach any copyright law.
3. I solemnly declare that to the best of my knowledge, no part of this report or in full has been previously submitted here or any other institution for the award of a degree.
4. I give consent for my dissertation if accepted to be lodged with the library system and I understand that any reference or quotation of my work will receive an acknowledgement.

Full names of student: Tavonga M Muderedzwa
Student number: R145091W

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Signature:
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Supervisor: Dr TM Matsungo

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Recommended Citation:
Muderedzwa TM and Matsungo TM (2018) The nutritional status, physical activity levels and associated nutrition knowledge of primary school pupils: the case of Harare, Zimbabwe. BSc (Hons) Dissertation, Institute of Food, Nutrition and Family Sciences (IFNFS), University Zimbabwe. Harare, Zimbabwe

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Dedication
I would like to dedicate this dissertation to my loving mother Jessina Chipato who has supported and believed in me, taught me never to give up and never to accept mediocrity.

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Acknowledgements
I would like to thank the Lord Almighty my source of wisdom and strength for making the completion of this dissertation possible.
I hereby would like to acknowledge:
My loving sister Tashinga C Muderedzwa for the unwavering support in every aspect of my life and for pushing me to be a better scholar and human being.
My cousin Tariro Chipato and Pacifique Bahati for the support and help during my data collection.
My family and friends for moral and financial support.
My supervisor, Dr TM Matsungo for the support and guidance and the encouragement and criticism to become a competent student and nutritionist.
The Ministry of Primary and Secondary Education (MoPSE) for the permission to take on the study
The Institute of Food, Nutrition and Family Sciences, IFNFS, University of Zimbabwe for the support.
Mrs NG Mushonga for the support during the initial stages of the research
Anthony Chiromba for the much-appreciated assistance throughout the dissertation
The headmasters, teachers and the parents of the primary school pupils and the pupils themselves for the cooperation and participation

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Abstract
ABSTRACT
The nutritional status, physical activity levels and associated nutrition knowledge of primary school pupils: the case of Harare, Zimbabwe
Muderedzwa TM and Matsungo TM
Institute of Food, Nutrition and Family Sciences, University of Zimbabwe. POBox MP167, Mt Pleasant, Harare, Zimbabwe
Correspondence: [email protected]
Background: Nutrition education defined by FAO, “learning experiences designed to facilitate the voluntary adoption of eating and other nutrition-related behaviours conducive to health and well-being”. Children provide an opportunity promote good nutrition practices.
Objectives: The objectives were determine the nutrition knowledge and consumption patterns of primary school pupils, to assess the nutritional status and physical activity levels of primary school pupils and teachers, to assess the perception of primary school teachers on nutrition education in schools and their nutrition knowledge, to evaluate the school environment on the promotion of healthy eating and to assess the possible entry point for the introduction of comprehensive nutrition education in the primary school curriculum.
Methods: A cross-sectional study was conducted among 368 school pupils aged between 9-14 years systematically sampled and 30 teachers, conveniently sampled from 7 randomly selected schools and 22 from the 2018 Oral Health Day event. A structured questionnaire and a school checklist were used to collect the data. The nutrition knowledge was determined using percentages which were categorised as having low, adequate or high knowledge. Data was analysed using Microsoft Excel and SPSS. The level of significance of the p-value was +1SD
% ; +2SD
% ; +3SD

Combined 10-14 368 3 6 25.8 7.1 1.1
Boys 9-14 170 4.1 8.2 24.1 0 0
Girls 9-13 198 2 4 27.3 7.6 1.5

Table 4. 3 Height-for-Age, gender combined (%)
Sex Years Total number % ; -3SD % ; -2SD

Combined 10-14 368 0.3 3.9
Boys 9-14 170 0 4.1
Girls 9-13 198 0.5 3.5
Nutrition status

Figure 4. 1 Nutrition status
The results showed that 34% of the children were overweight, and of those 36.4% were female and 31.2% were male. For boys were more wasted that girls at 12.3% of the population and had a slightly higher number of stunted pupils that girls at 4.1%.
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Table 4. 4 Key Variables Table
Variable Total n (%) Boys n (%) Girls n (%) 1P-value
2Body Mass Index
Overweight
Wasted
2Height for age
Stunting
(7.3%)
(6.3%)

(3.8%)
0.555
0.871
0.423
3Nutrition knowledge score:
Low
Adequate
79 (21.5)
289 (78.5)
47 (27.6)
123 (72.4)
32 (16.2)
166 (83.8) 0.007
4Minutes spent on physical activity
60 minutes
174 (47.3)
194 (52.7)
74 (43.5)
96 (56.5)

100 (50.5)
98 (49.5) 0.181
Mode of transport used
Not specified
Car
Walk
Public transport
Cycle
14(3.8)
150 (40.8)
117 (31.8)
82 (22.3)
5 (1.4)
6 (3.5)
67 (39.4)
63 (37.1)
30 (17.6)
4 (2.4)
8 (4)
83 (41.9)
54 (27.3)
52 (26.3)
1 (0.5) 0.081
5TV and Video viewing (0-2hrs)
Weekdays
Weekends
243(66.2)
137(37.4)
108(50)
62(36.7)
135(68.5)
75(38.1)
0.313
0.785
6Recommended servings of fruits and vegetables
no
yes
295 (80.2)
73 (19.8)
124 (72.9)
46 (27.1)
171 (86.4)
27 (13.6) 0.001
7Skipped breakfast
Yes
No
112 (30.4)
256 (69.6)
49 (28.8)
121 (71.2)
63 (31.8)
135 (68.2) 0.534
8Dietary diversity
Good diversity
Poor diversity
202(54.9)
166(45.1)
85(50)
85(50)
117(59.1)
81(40.9) 0.081
9Healthy snacks
yes
no
non-consumed
71(21.5)
239(72.4)
20(6.1)
34(22.7)
107(71.3)
9(6)
37(20.6)
132(73.3)
11(6.1) 0.897
Notes:1P value for Pearson’s Chi Squared test; 2BMI for age (Z-Score) using Anthro-Plus, 3Nutrition knowledge scoring system: Low (75), 4(World Health Organization (WHO), 2011) >60minutes of moderate exercise,5AAP Recommendations (Health, 2002) 1 to 2 hours, 8 (World Health Organization (WHO), 2015) 4 or more food groups.
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The p-value is 0.007, for nutrition knowledge hence we can conclude that there is a relationship between gender and the nutrition knowledge score at 5% significant level. The girls had higher adequate nutrition knowledge compared to boys. Also, at a p-value of 0.001, a relationship between gender and intake of fruits and vegetables was observed with boys consuming more fruits and vegetables than girls.
No relationship was observed between gender and physical activity, tv viewing, mode of transport used. The p-values were about 0.05 implying no significance.
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Physical Activities
Table 4. 5 Sporting and Non-Sporting Activities
Activity Frequency categories Total
n (%) Boys
n (%) Girls
n (%) P-value
Swimming –competitive
Low frequency 255(69.3) 114(67.1) 141(71.2) 0.817

Moderate frequency 86(23.4) 42(24.7) 44(22.2)
High frequency 27(7.3) 14(8.2) 13(6.6)
Swimming –leisurely
Low frequency 227(61.7) 109(64.1) 118(59.6) 0.208

Moderate frequency 104(28.3) 41(24.1) 63(31.8)
High frequency 37(10.1) 20(11.8) 17(8.6)
Walking for pleasure Low frequency 162(44) 74(43.5) 88(44.4) 0.665

Moderate frequency 131(35.6) 58(34.1) 73(36.9)
High frequency 75(20.4) 38(22.4) 37(18.7)
Cycling for pleasure
Low frequency 220(59.8) 84(50.6) 134(67.7) 0.004

Moderate frequency 92(25) 52(30.6) 40(20.2)
High frequency 56(15.2) 32(18.8) 24(12.1)
Playing outdoors for pleasure
Low frequency 167(45.4) 70(41.2) 97(49) 0.238
Moderate frequency 94(25.5) 44(25.9) 50(25.3)
High frequency 107(29.1) 56(32.9) 51(25.8)
Competitive sport Low frequency 176(47.8) 78(45.9) 98(49.5) 0.525

Moderate frequency 119(32.3) 54(31.8) 65(32.8)
High frequency 73(19.8) 38(22.4) 35(17.7)
Non-sporting activity Low frequency 233(63.3) 70(41.2) 97(49) 0.110
Moderate frequency 85(23.1) 44(25.9) 50(25.3)
High frequency 50(13.6) 56(32.9) 51(25.8)

Since the p-value is 0.004, for cycling for pleasure we can conclude that there is a relationship between gender and the activity of cycling for pleasure at 5% significant level. Boys tend to cycle for pleasure more than girls.
29.1% of the pupils played outdoors for pleasure from 2 to 6 times a week, this being the most frequent activity done by most pupils. This was followed by walking outside for pleasure at 20.4%.
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School and Personal Environment
Table 4. 6 Activities in and around the home
Activity Frequency categories Total
n (%) Boys
n (%) Girls
n (%) P-value
Preparing food, cooking and washing up Low frequency 346(94) 163(95.9) 183(92.4) 0.346

Moderate frequency 17(4.6) 5(2.9) 12(6.1)
High frequency 5(1.4) 2(1.2) 3(1.5)
Cleaning the house
Low frequency 341(92.7) 164(96.5) 177(89.4) 0.016

Moderate frequency 21(5.7) 6(3.5) 15(7.6)
High frequency 6(1.6) 0 6(3)
Doing the laundry and ironing Low frequency 325(88.3) 150(88.2) 175(88.4) 0.286
Moderate frequency 37(10.1) 19(11.2) 18(9.1)
High frequency 6(1.6) 1(0.6) 5(2.5)
Caring for pre-school children or babies at home Low frequency 292(79.3) 135(79.4) 157(79.3) 0.216

Moderate frequency 59(16) 24(14.1) 35(17.7)
High frequency 17(4.6) 11(64.7) 6(35.3)
Caring for handicapped, elderly or disabled people at home Low frequency 266(72.3) 129(75.9) 137(69.2) 0.090
Moderate frequency 74(20.1) 26(15.3) 48(24.2)
High frequency 28(7.6) 15(8.8) 13(6.6)
For the activities around the home, cleaning the house had a p-value of 0.016 showing a relationship between gender and cleaning the house. Boys are less likely to clean the house compared to girls. The other activities are done by both the boys and girls at almost the same frequencies.

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Table 4. 7 Activities done in class
Activity Frequency categories Total
n (%) Boys
n (%) Girls
n (%) P-value
Learning facts
I like it 327(89.1) 155(91.7) 172(86.9) 0.137

I don’t like it 40(10.9) 14(8.3) 26(13.1)
Listening to the teacher I like it 357(97) 165(97.1) 192(97) 0.960
I don’t like it 11(3) 5(2.9) 6(3)
Remembering and repeating I like it 298(81) 138(81.2) 160(80.8) 0.928

I don’t like it 70(19) 32(18.8) 38(19.2)
Giving the right answers to questions I like it 351(95.6) 159(94.1) 192(97) 0.177
I don’t like it 16(4.4) 10(5.9) 6(3)
Copying from the board I like it 247(67.3) 99(58.6) 148(74.7) 0.001

I don’t like it 120(32.7) 70(41.4) 50(25.3)
Reading aloud I like it 201(54.6) 93(54.7) 108(54.5) 0.975
I don’t like it 167(45.4) 77(45.3) 90(45.5)
Sitting in rows
I like it 242(65.8) 104(61.2) 138(69.7) 0.086

I don’t like it 126(34.2) 66(38.8) 60(30.3)
Preparing for exams I like it 336(91.3) 155(91.2) 181(91.4) 0.936
I don’t like it 32(8.7) 15(8.8) 17(8.6)
Talking about/discussing my own life and things I have done I like it 237(64.6) 133(66.9) 124(62.6) 0.398

I don’t like it 130(35.4) 56(33.1) 74(37.4)
Working with friends in pairs and groups I like it 336(91.6) 149(88.2) 187(94.4) 0.031
I don’t like it 31(8.4) 20(11.8) 11(5.6)
Doing experiments, finding things out
I like it 292(79.8) 133(79.2) 159(80.3) 0.787

I don’t like it 74(20.2) 35(20.8) 39(19.7)
Imagining things I like it 270(74.4) 121(72.9) 149(75.6) 0.551
I don’t like it 93(25.6) 45(27.1) 48(24.4)
Listening to stories
I like it 344(93.5) 155(91.2) 189(95.5) 0.098

I don’t like it 24(6.5) 15(8.8) 9(4.5)
Doing drama, singing songs, playing games I like it 309(84) 139(81.8) 170(85.9) 0.286
I don’t like it 59(16) 31(18.2) 28(14.1)
Doing projects
I like it 318(86.6) 144(85.2) 174(87.9) 0.453

I don’t like it 49(13.4) 25(14.8) 24(12.1)
Drawing and modelling I like it 214(58.2) 85(50) 129(65.2) 0.003
I don’t like it 154(41.8) 85(50) 69(34.8)
Going outside the classroom I like it 124(33.7) 58(34.1) 66(33.3) 0.874
I don’t like it 244(66.3) 112(65.9) 132(66.7)
Copying from the board, working with friends in pairs and groups and drawing and modelling had p-values of 0.001, 0.031 and 0.003. At 5% significance level, there is a relationship between gender and the classroom activities. Girls prefer doing the above activities compared to their male counterparts.
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The activities that are liked by the pupils the most are listening to the teacher, giving the right answers to questions, preparing for exams, working with friends in pairs and groups and listening to stories with 97%, 95.6%, 91.3%, 91.6% and 93.5% respectively.
Table 4. 8 Behaviour participant is interested in changing
Behaviour to change Frequency n (%) P-value
Total Boys Girls
Eat more fruits and vegetables 167(45.4) 81(47.6) 86(43.4) 0.418
Eat less fast food 14(3.8) 8 (4.7) 6(3) 0.402
Drink less fizzy drinks, maheu, freezits 21(5.7) 12(7.1) 9(4.5) 0.300
Drink more water 33(9) 15(8.8) 18(9.1) 0.929
Spend less time watching tv 20(5.4) 12(7.1) 8(4) 0.203
Not yet ready to change 49(13.3) 19(11.2) 30(15.2) 0.263
Take TV out of my room 11(3) 5(2.9) 6(3) 0.960
Be more active- exercise 45(12.2) 13(7.6) 32(16.2) 0.013
Get more sleep 7(1.9) 5(2.9) 2(1) 0.176
Eat breakfast 1(0.3) 0 1(0.5) 0.353
The behaviour most pupils were willing to change was that of eating more fruits and vegetables and there was no association between the need to change the particular behaviour with gender. 12.2% of the pupils were willing to become more active and exercise and of those girls were the ones who showed more interest in being more physically active than boys as seen by the p-value of 0.013 using the significance level of 5%. 13.3% of the pupils were also not willing to change any of their behaviours or habits.
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Teachers Results
Table 4. 9 Sociodemographic data
Variable Category
Ages 42 ± 10 years
Total
n (%) Male
n (%) Female
n (%) P-value
Gender 30 5(16.7) 25(83.3)
Qualifications
Diploma 19(65.5) 2(40) 17(70.8) 0.187
Degree 10(34.5) 3(60) 7(29.2) 0.187
In-course services of nutrition education
Yes 4(13.3) 1(20) 3(12) 0.631
No 26(86.7) 4(80) 22(88)
Geographical Location
Low density area 5(17.2) 1(25) 4(16) 0.658
Medium density area 8(27.6) 1(25) 7(28) 0.901
High density area 16(55.2) 2(50) 14(56) 0.823
Nutrition knowledge score
Low 6(20) 2(40) 4(16) 0.221
Adequate 24(80) 3(60) 21(84) 0.221
Self-ranking of nutrition knowledge
Low 3(10) 0 3(12) 0.414
Moderate 18(60) 2(40) 16(64) 0.317
High 9(30) 3(60) 6(24) 0.109
Strong interest in physical health and diet
Yes 27(90) 5(100) 22(88) 0.414
No 3(10) 0 3(12)

The results show that most of the teachers have diplomas and only 4 received nutrition courses such as those of HIV/AIDS and nutrition and home economics. Also 55.2% of the teachers live in high density areas and 27.6% in medium density and 17.2% in low density.
The results also show that 80% of the teachers had adequate nutrition knowledge and 20% had low nutrition knowledge. The most difficult question for the teachers to answer was that of differentiating between trans-fats, saturated and unsaturated fats. Despite not having scored high in nutrition knowledge 30% though they had high nutrition knowledge and 10% thought they had low nutrition knowledge.
All of the teachers were interested in teaching more nutrition knowledge and viewed nutrition education as an important part of the curriculum. However, 90% admitted to having strong interest in physical health and diet.?
Body Mass Index for Teachers

Figure 4. 2 Body Mass Index for Teachers
40% of the teachers had normal weight, followed by 26.67% with an obesity I and 20% are with pre-obesity. 6.67% were obesity II and also 6.67% were obesity III.

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School and Personal Environment
Ranking of nutrition topics teachers feel are important

Figure 4. 3 Ranking of nutrition topics teachers feel are important
The teachers felt that healthy eating to prevent diseases was the most important topic to teach and sport nutrition was the least important topic to teach.
Recommendations on pupils’ diet
The teachers when asked about their recommendations to the pupils’ diet, 10(66.7%) thought there was a need for increased dietary diversity, 13(43.3%) thought there was a need to increase their fruit and vegetable intake, 9(30%) encouraged the avoidance of junk foods such as sweets, and 6(20%) expressed the need for school supplementary feeding. 4(13.3%) felt that parental involvement was necessary and 1(3.3%) felt hygiene was an important aspect in the pupils’ diet.
Barriers to effective learning
Teachers expressed the barriers to effective learning in their classrooms as follows inadequate basic facilities 18(60%), very large classes 14(46.7%), Inadequate space 12(40%), very irregular attendance by pupils 9(30%), different cultures in the same classroom 9(30%), no teaching assistants 8(26.7%), very mixed ability 7(23.3%), irregular teaching 5(16.7%), different age groups in the same class 4(13.3%), and too much clerical work 1(3.3%).

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Positive aspects of the classroom conditions
The teachers felt that the positive aspects in their classrooms were classroom amenities such as good aeration, electrical facilities etc 6(20%), positive characteristics of pupils such as good English proficiency and regular attendance 5(16.7%), parental involvement (6.7%), and adequate materials and space 7(23.3%)
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Table 4. 10: Classroom activities
Activity Frequency categories Total
n (%) Males
n (%) Females
n (%) P-value
Role-play and drama Often used 22(73.3) 4(80) 18(72) 0.712
Would like to try 8(26.7) 1(20) 7(28)
Interviews by pupils Often used 10(34.50) 2(40) 8(33.3) 0.775
Would like to try 19(65.5) 3(60) 16(66.7)
Group writing Often used 21(70) 3(60) 18(72) 0.593
Would like to try 9(30) 2(40) 7(28)
Discussions Often used 23(76.7) 3(60) 20(80) 0.334
Would like to try 7(23.3) 2(40) 5(20)
Classroom experiments Often used 23(79.3) 4(40) 19(79.2) 0.967
Would like to try 6(20.7) 1(20) 5(20.8)
Personal diaries Often used 9(31) 1(20) 8(33.3) 0.558
Would like to try 20(69) 4(80) 16(66.7)
Projects Often used 18(60) 3(60) 15(60) 1
Would like to try 12(40) 2(40) 10(40)
Group work Often used 27(93.1) 5(100) 22(91.7) 0.504
Would like to try 2(6.9) 0 2(8.3)
Listening to tapes
Often used 13(43.3) 2(40) 11(44) 0.869
Would like to try 17(56.7) 3(60) 14(56)
Presentations by pupils Often used 28(96.6) 5(100) 23(95.8) 0.642
Would like to try 1(3.4) 0 1(4.2)
Competitions and games Often used 27(93.1) 5(100) 22(91.7) 0.504
Would like to try 2(6.9) 0 2(8.3)
Songs, chants, rhymes Often used 24(82.8) 5(100) 19(79.2) 0.262
Would like to try 5(17.2) 0 5(20.8)
Listening to stories
Often used 27(93.1) 5(100) 22(91.7) 0.504
Would like to try 2(6.9) 0 2(8.3)
Taking notes Often used 24(828) 5(100) 19(79.2) 0.262
Would like to try 5(17.2) 0 5(20.8)
Pair work
Often used 27(93.1) 5(100) 22(91.7) 0.504
Would like to try 2(6.9) 0 2(8.3)
Drawing pictures Often used 27(93.1) 5(100) 22(91.7) 0.504
Would like to try 2(6.9) 0 2(8.3)
Copying from the board Often used 29(100) 5(100) 24(100)
Would like to try 0 0 0
Creating charts and tables Often used 28(93.3) 5(100) 23(92) 0.513
Would like to try 2(6.7) 0 2(8)
Reading loudly or silently Often used 28(96.6) 5(100) 23(95.8) 0.642
Would like to try 1(3.4) 0 1(4.2)
Physical activities Often used 26(89.7) 5(100) 21(87.5) 0.404
Would like to try 3(10.3) 0 3(12.5)

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A cross tab of the activities done in class by the teachers and their gender was done and there was no relationship between the activities and their gender. The teachers most often used activities such as Group work (93.1%), presentations by pupils (96.6%) listening to stories (93.1%), drawing pictures (93.1%),pair work (93.1%), creating charts and tables (93.3%), reading loudly or silently in class (96.6%) and the least done activities they would be willing to try are listening to tapes (56.7%), use of personal diaries (69%) and interviews by pupils (65.5%)
Table 4. 11. Community involvement
Contacts made with the local community Frequency n (%)
Total Male Female P-value
Contacted local organisations (e.g. public services, companies, local producers) 5(16.7) 0 5(20) 0.273
Invited a speaker or visitor to the school 9(30) 2(40) 7(28) 0.593
Advised pupils to participate in local events 11(36.7) 2(40) 9(36) 0.865
Sent pupils out to explore the environment 17(56.7) 4(80) 13(52) 0.249
Made use of the local resources/media (e.g. shops, newspapers, radio) 13(43.3) 11(44) 2(40) 0.869
Made some other contact with the community 6(20) 1(20) 5(20) 1

The three major activities done involving the community are that the teachers advised pupils to participate in local events, sent pupils out to explore the environment and made use of the local resources/media (e.g. shops, newspapers, radio) at 11(36.7%), 17(56.7%) and 13(43.3%) respectively.

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Table 4. 12 Personal opinion

Question Total
n (%) Male
n (%) Female
n (%) P-value
I need to lose weight to be healthier
Strongly Agree 13(43.3) 2(40) 11(44) 0.653
Agree 5(16.7) 0 5(20)
Neutral 6(20) 2(40) 4(16)
Disagree 5(16.7) 1(20) 4(16)
Strongly Disagree 1(3.3) 0 1(4)
I need to gain weight to be healthier Strongly Agree 1(3.3) 1(4) 0.01
Agree
Neutral 4(13.3) 3(60) 1(4)
Disagree 16(53.3) 1(20) 15(60)
Strongly Disagree 9(30) 1(20) 8(32)
My weight shows that I’m very successful in life Strongly Agree 1(3.3) 1(4) 0.766
Agree 4(13.3) 1(20) 3(12)
Neutral 15(50) 2(40) 13(52)
Disagree 7(23.3) 2(40) 5(20)
Strongly Disagree 3(10) 3(12)
My weight does not put me at risk of diseases Strongly Agree 1(3.3) 1(4) 0.893
Agree 9(30) 1(20) 8(32)
Neutral 7(23.3) 1(20) 6(24)
Disagree 10(33.3) 2(40) 8(32)
Strongly Disagree 3(10) 1(20) 2(8)
Most chronic diseases (e.g. diabetes, hypertension) can be prevented and managed by healthy eating habits Strongly Agree 19(63.3) 3(60) 16(64) 0.938
Agree 6(20) 1(20) 5(20)
Neutral 4(13.3) 1(20) 3(12)
Disagree 1(3.3) 1(4)
Strongly Disagree
I can eat what I want as long as I’m not sick Strongly Agree 0.392
Agree 4(13.3) 4(16)
Neutral 2(6.7) 1(20) 1(4)
Disagree 16(53.3) 2(40) 14(56)
Strongly Disagree 8(26.7) 2(40) 6(24)
Most food outlets around my workplace provide healthy foods Strongly Agree 1(3.3) 1(4) 0.678
Agree 2(6.7) 1(20) 1(4)
Neutral
Disagree 11(36.7) 1(20) 10(40)
Strongly Disagree 11(36.7) 2(40) 9(36)
Drinking a lot of soft drinks (such as Coke, Fanta, Sprite) has no risk to health Strongly Agree 0.546
Agree 2(6.7) 1(20) 1(4)
Neutral 1(3.3) 1(4)
Disagree 10(33.3) 1(20) 9(36)
Strongly Disagree 17(56.7) 3(60) 14(56)
Exercising is important to stay healthy Strongly Agree 26(86.7) 5(100) 21(84) 0.337
Agree 4(13.3) 4(16)
Neutral
Disagree
Strongly Disagree
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Table 4. 13 Scale of weight as a perceived potential risk to teacher’s health.
Scale Frequency n (%) P value
Male Female 0.672
0 0 5(20)
10 2(40) 3(12)
30 1(20) 2(8)
40 1(20) 3(12)
50 0 1(4)
55 0 1(4)
60 0 4(16)
65 0 1(4)
70 1(20) 1(4)
80 0 2(8)
90 0 2(8)

Associations
Table 4. 14 Relationship between nutrition knowledge score and variables of interest
B S.E. P-value Odds ratio 95% C.I.for odds ratio
Lower Upper
Recommended diversity 0.71 0.26 0.01 2.02 1.21 3.3
Obese -0.50 0.46 0.28 0.61 0.25 1.50
Boys 0.62 0.26 0.002 1.87 1.11 3.13
Age in years -0.13 0.16 0.45 0.88 0.64 1.22
Recommended Physical Activity 0.11 0.27 0.68 1.12 0.67 1.88
Constant 1.86 1.94 0.34 6.42
*level of significance P-value =0.05
Boys have more chances of having lower nutrition knowledge than girl odds ratio (95CI), 0.53 (0.32,0.89), P=0.002. The pupils who had poor dietary diversity had higher odds of having a low nutrition knowledge score than those who had good dietary diversity (95CI), 0.50(0.3,0.83), P=0.01.
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Relationship between tv and video viewing and nutrition knowledge of pupils
Weekdays
Total Recommended Not recommended P-value
Adequate 78(21.3) 59(24.3) 19(15.3) 0.047
Low/Inadequate 289(78.7) 184(75.7) 105(84.7)
Weekend
Adequate 77(21) 37(27) 40(17.5) 0.03
Low/Inadequate 289(79) 100(73) 189(82.5)

A Pearson chi-squared test was conducted using SPSS with a level of significance of 5% and an it was a two-tailed test. The p-value testing for the association between the weekday tv and video viewing and nutrition knowledge is 0.047 using cross tabs.
The p-value testing for the association between the weekend tv and video viewing and nutrition knowledge is 0.030 using cross tabs. Those with low nutrition knowledge watched TV for more than the recommended hours.
Relationship between the school environment and the snacks intake of pupils
239(72.4) pupils ate unhealthy snacks and it is assumed they it is due to the environment that is the food sold in and around the schools.

School Environment Results
All of the schools assessed did not have a written philosophy of health and well-being or a nutrition policy, which it actively promotes, however, all the schools had a pleasant, hygienic environment that is washing facilities, clean drinking water, good eating environments.
The school gardens were available at 2(28.6%). However, the schools lacked on diversity as all of them mainly grew green leafy vegetables and maize.
School Food Feeding Programmes

Figure 4. 4 School Food Feeding Programmes
There are 2 (28.57%) schools who provide lunch feeding programmes, and these schools have an under-developed programme which does not have a variety of meals.
All the schools do not have low-fat and skim milk available, meals that include appealing, low-fat choices of fruit, vegetables, grains, dairy products, a la carte offerings include appealing low-fat fruit vegetables, grains, and dairy products, sites outside the cafeteria offer appealing low-fat choices of fruit, vegetables, grains, dairy roducts. The schools also do not have food purchasing and preparation practices to reduce fat content, are also not prepared for food emergencies, and they is no collaboration between food service staff and teachers, or have food service manager, professional development of food service managers with degrees and certification in the field.
Posters or signs with food or beverage product pictures, names or logos
There were no posters or signs with food or beverage product pictures, names or logos around the schools however there were classroom displays in all schools that had various empty food packaging and containers such as cerevita boxes, pizza boxes, cornflakes boxes, juice containers etc.

Uses an of the following equipment printed with food or beverage product
names or logos
There was no use of equipment printed with food or beverage product names or logos on cups, napkins or plates used during meal period, or display cases, recycling bins, physical education or gym equipment or on school stationery
All the schools also did not have student newsletter or newspaper, therefore does not include food or beverage advertising. They also did not have a school yearbook therefore does not include food or beverage advertising.
Products Sold around the School Environment
The vendors around all but one schools sold snacks (e.g. jiggies etc.), snacks (maputi), chocolates, sweets. All of the schools did not sell soft drinks, fresh chips energy drinks (e.g. dragon, red bull), dairy blends (e.g. cascade; nutriplus), dairy products (e.g. yoghurts, ice cream) and water. Fruits were sold in 5(71.43%), the fermented products more specifically maheu 4(57.14%) (e.g. maheu) and freezits 6 (85.17%).
Products Sold within the School Environment that is tuckshop
The tuckshops all but one schools sold snacks (e.g. jiggies etc.), snacks (maputi), chocolates, sweets. all of the schools did not sell soft drinks, fresh chips, energy drinks (e.g. dragon, red bull), dairy blends (e.g. cascade; nutriplus), dairy products (e.g. yoghurts, ice cream) and water. One school sold fresh chips once a week 1 (14.29%), but the rest did not sell chips. Also, one school tuckshop sold freezits 1 (14.29%) and the rest did not.

References
World Health Organization (WHO) (2011) Physical-Activity-Recommendations-5-17Years. Geneva, Switzerland.
World Health Organization (WHO) (2015) ‘Healthy diet: key facts’. Geneva, Switzerland. Available at: http://www.who.int/en/news-room/fact-sheets/detail/healthy-diet.

Chapter 5
Discussion
5.1. Introduction
This study was set out to find out the nutritional status, physical activity and associated nutrition knowledge among primary school pupils. The results showed the students and the teachers had adequate nutrition knowledge. The physical activity a lot of the children was less than the recommended. Most of the children had good dietary diversity however the snacks they consumed were no healthy.
5.2. Nutritional status of the pupils
7.3% of the pupils were overweight, 6.3% were wasted and 3.8% were stunted. A study was done in Harare among primary school pupils which showed that stunting decreased from 10.2% to 7.4% in males, also from 7.8% to 4.4% in females between 2003 to 2011 and wasting increased from 2.7 to 4.6% in males and females (3.1-3.6%)between the years of 2009-2011(Mushonga, 2014). According to the ZDHS 2015/2016 6% of the children under 5 were overweight (ZDHS, 2015). Also for study done at a urban group A school in Kwekwe with children aged between 9 and 11 years, 27% of the boys were overweight and 28.4% of the girls were at risk of being obese (Adiele, Morgan and Carolyne, 2018) Nutrition had been indicated as an intervention that can help in the improvement of the nutritional status of school going children (Srivastava et al., 2012). The results of this particular study are almost similar to the other studies done.
5.3. Nutrition knowledge
Nutrition knowledge among primary school pupils was generally low with an average of 56±8.56 and no pupils qualified to have high or good nutrition knowledge. However, nutrition knowledge does not translate to good nutrition practices (Kigaru et al., 2016).A Kenyan study for children between the ages of 8-11 years showed that they generally had adequate nutrition knowledge at (mean score 51.6 ± 1.6, 51.6 %) (Kigaru et al., 2016). Majority of study participants found the nutrition and disease section of the questionnaire was the most challenging for them to answer correctly and the section on food safety was answered more correctly. This could be due to the fact that the topic is taught comprehensively at school and involves day to day activities that can also be done at home. Teachers in this study however identified the nutrition and disease topic as the most important topic to teach. However, it can possibly have positive effects when the pupils become adults (FAO, 2005)

The dietary diversity and gender in this study were seen predictors of nutrition knowledge according to the binary regression. Boys had higher chances of having lower nutrition knowledge compared to girls and those who had less that than the recommended food groups had higher chances of having lower nutrition knowledge scores.
5.4. Dietary intake of school pupil
Good nutrition has been associated with benefits such as improved school performance, improved growth outcomes, mental growth and optimum physical activity (Florence, Asbridge and Veugelers, 2008). Diverse meals ensure that the pupil meets their daily dietary requirements (Moursi et al., 2008). A large proportion of the primary school pupils do not meet the recommended dietary diversity, this was seen by the dietary history they were asked to complete. The diet history is based on the assumption that the participant has a typical diet that is what is eaten on a regular basis. The food groups that were used to analyse were the seven that were recommended by the WHO that include vitamin A rich fruits and vegetables, other fruits and vegetables, legumes and nuts, flesh foods (meat, fish, poultry, organ meats), eggs, dairy products (milk, yoghurt, cheese), grains, roots and tubers (World Health Organization (WHO), 2015).

166(45.1%) had poor diversity in their meals and 202(54.9%) had the required diversity. 71(21.5%) consumed healthy snacks such as fruits, 239(72.4%) had unhealthy snacks such as sweets, and 20(6.1%) did not consume any snacks. A similar study was done in the USA which showed that children were decreasing the fruit intake and increasing energy dense snacks in their diets (Piernas and Popkin, 2010). This may be due to the fact the children purchase snacks and at home there are controlled meals. Children are more likely to consume healthy snacks if the foods being sold in and around the schools(De Villiers et al., 2015). Most of the children
did not skip breakfast and this could be seen to support the smaller percentage of overweight children.

Higher BMI has been noticed in children who do not consume breakfast as seen by a systematic review done on the benefits of breakfast consumption in children and adolescents (Rampersaud, 2009). Another contributing factor to lower levels of obesity in the population is the number of days the children eat their meals as a family. This is proposed to be due to less chances of disorderly eating for children who sit down to eat as a family for at least three or more times (Hammons and Fiese, 2011). Breakfast contributes to part of the daily requirements of nutrient but will also depend healthiness breakfast. During the weekend the pupils watched TV for more than the recommended hours. This is also supported but the physical activity report card for Zimbabwe (Manyanga T., 2016). In relation to TV viewing, advertisements have been linked to poor dietary practices as children request to eat the unhealthy foods advertised on the television (Kupolati, Gericke and MacIntyre, 2015).

Of the foods listed the snacks taken by the pupils were generally unhealthy including foods such as corn snacks, freezits, ice-cream and sweets. The school environment as reported by the teachers had unhealthy food being sold around it, and the researcher during the checklist also observed that the school tuckshops and the vendors around the school sold unhealthy snacks such as biscuits and sweets which the pupils mentioned as part of their snacks. The teachers also mentioned that the pupils needed to increase their dietary diversity and reduced empty calories found in snacks such as sweets and freezits. Some teachers also acknowledged the need to involve parents in lessons of dietary practices of children, which is a recommendation done by FAO (FAO, 2005) The school environment has been observed to have an influence on the on the dietary patterns of school pupils (Adiele, Morgan and Carolyne, 2018).

Some of the schools also provided lunch under the school feeding programme. School feeding programmes have benefits such as providing a platform to learn about healthy foods, increased school attendance by children, and helping to meet the recommended daily dietary requirements. However, the schools did not have fully developed school feeding programmes that is the food provided was not diverse, mostly starchy foods and vegetables provided. This was probably due to economic reasons that is inability to afford purchasing flesh protein sources and fruits and vegetables (Sulemana, Ngah and Majid, 2013). Of the schools accessed, all of them were self-sponsored and the they couldn’t provide a diverse diet due to economic constraints. Another reason can be the that the school gardens were only growing small grains such as maize and green leafy vegetables yet the garden should be a source of nutrition education and other foods for diverse meals and reducing the economic burden on the schools and government (Ratcliffe et al., 2011).
5.5. Physical activity for pupils
A high portion of the pupils’ population had low physical activity and the average pupil had a physical activity of 1.53±0.5. The average student had low physical activity. Most of the children used cars and public transport to get to school and back home and the others walked or cycled to school. Active transport is now decreasing and vehicle transportation to school has increased (Muthuri et al., 2014). The pupils reported that their most done non-competitive activities were playing outside and walking outside for pleasure. A significant difference was seen between cycling to school for boys and girl where boys preferred it to girls. In a study done in South Africa in where TV viewing and the BMI of children was correlated, a positive association was observed (Prioreschi et al., 2017).
Cleaning of the house showed a significant different between boys and girls as girls were more likely to clean compared to boys. This could be due to the traditional gender roles of girls doing more household chores than boys. Girls were seen to prefer to change their time spent on physical activity compared to boys.
5.6. Nutrition knowledge, and perceptions of teachers on nutrition education
The teachers’ low nutrition knowledge, misconceptions of their actual body weight, high body mass index and challenges in modifying their dietary behaviours can affect their roles as educators due to poor health outcomes (NCDs) (Dalais et al., 2014; Spronk et al., 2014) The teachers generally had adequate nutrition knowledge. However, some topics had the most inaccurate answers such as the one on distinguishing between the good and the bad fat. The average nutrition knowledge was 57±8.34. In a study done in South Africa, a lack of knowledge in certain nutrition topics taught in primary schools by the teachers encouraged the teachers to request for those topics for their in-service nutrition education training (Kupolati, 2016).
The teachers also acknowledged several good dietary habits as well as bad dietary habits I need to lose weight to be healthier.
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Some of teachers showed low commitment to answering questions and misunderstood some questions which led to some questions not being answered. This can be a source for bias to the validity of the results.
5.7. Education practices for teachers
Most of the teachers did not receive in-service nutrition courses or training. Teachers need to have some training on nutrition topics for them to be effective at teaching them to the pupils (Pérez-Rodrigo and Aranceta, 2003). Despite teachers having either low or adequate nutrition scores, some ranked themselves as having high nutrition knowledge however teachers who admit to having inadequate nutrition knowledge can also express their need for training in their area of inadequacy (Nguyen et al., 2015).
The teachers were willing to teach nutrition knowledge and also thought that including nutrition knowledge in the curriculum was vital. The teachers’ intent to teach nutrition education is also based in-service training and being equipped with the right materials such as books on nutrition (Fahlman et al., 2011). The most preferred topics the teachers thought were nutrition and disease and nutrition in the life cycle and the least was sports nutrition. The topics teachers prefer are said to be the ones that are already teaching (Murimi, Sample and Guthrie, 2008) The teachers also made contact with the local communities as part of their teaching by mostly sending pupils out to explore the environment, but only a few had connected with the local organisations. However, small sample size was used for the teachers but the results were still conclusive as a similar study was done in South Africa (Kupolati, Gericke and MacIntyre, 2015).
The teachers ranked the nutrition topics they were willing to teach and the most important topic was healthy eating to prevent diseases and the one perceived to be there least important was one for sport nutrition. The teachers also expressed the positive and the negative aspects of their class rooms which can be used to improve teaching in general and also help shape how nutrition topics can be added. The major negative aspect of the classrooms were inadequate basic facilities and the major positive aspects included parental involvement and adequate materials and space for some schools. A report published by the Teaching Schools Council in the United Kingdom on effective teaching showed adequate resources, teaching assistance and enough space in classrooms is required (Keeble, 2016). Being equipped with nutrition education resources is vital to effective dissemination of knowledge to pupils (FAO, 2005; Nguyen et al., 2015).
The teachers also expressed the forms of teaching they preferred teaching the children with and these included creating charts and tables, drawing pictures, group work and presentations by pupils. The least done activities they would be willing to try were writing diaries and listening to tapes. A study done in south Africa for assessing nutrition education in primary schools showed that the most preferred teaching tools were charts, posters and videos (Oldewage-Theron and Egal, 2012). Some teachers had positive posters such as the food pyramids however some of the displays in the classrooms such as the empty pizza boxes and empty breakfast cereal containers were not a source of good nutrition education for the pupils
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References
Adiele, D., Morgan, G. P. and Carolyne, L. M. (2018) ‘An Unhealthy , Obesogenic Lifestyle?: A Case Study of Urban Primary School Children in Kwekwe , Zimbabwe’, 6(2), pp. 35–42. doi: 10.11648/j.sjph.20180602.11.
Dalais, L. et al. (2014) ‘The association between nutrition and physical activity knowledge and weight status of primary school educators’, South African Journal of Education, 34(3), pp. 1–8. Available at: http://libproxy.temple.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true%7B;%7Ddb=aph%7B;%7DAN=97585612%7B;%7Dsite=ehost-live%7B;%7Dscope=site.
Fahlman, M. et al. (2011) ‘Efficacy, intent to teach, and implementation of nutrition education increases after training for health educators’, American Journal of Health Education, 42(3), pp. 181–190. doi: 10.1080/19325037.2011.10599185.
FAO (2005) ‘Nutrition Education in Primary schools’, Nutrition, 2(Activity 2), Rome, Italy. pp. 4–9. doi: 10.1177/15648265050262S208.
Florence, M. D., Asbridge, M. and Veugelers, P. J. (2008) ‘Diet Quality and Academic Performance’, Journal of School Health, 78(4), pp. 209–215. doi: 10.1111/j.1746-1561.2008.00288.x.
Hammons, A. J. and Fiese, B. H. (2011) ‘Is Frequency of Shared Family Meals Related to the Nutritional Health of Children and Adolescents?’, Pediatrics, 127(6), pp. e1565–e1574. doi: 10.1542/peds.2010-1440.
Keeble, R. (2016) ‘Effective Primary Teaching Practice’. Available at: https://www.tscouncil.org.uk/wp-content/uploads/2016/12/Effective-primary-teaching-practice-2016-report-web.pdf.
Kigaru, D. M. D. et al. (2016) ‘Nutrition knowledge , attitude and practices among urban primary school children in Nairobi City , Kenya?: a KAP study’, BMC Nutrition. BMC Nutrition, (2015), pp. 1–8. doi: 10.1186/s40795-015-0040-8.
Kupolati, D. et al (2016) ‘Development and implementation of a nutrition education programme for primary school teachers in Bronkhorstspruit , Gauteng Province , South Africa by’, (August).
Kupolati, M. D., Gericke, G. J. and MacIntyre, U. E. (2015) ‘Teachers’ perceptions of school nutrition education’s influence on eating behaviours of learners in the Bronkhorstspruit District’, South African Journal of Education, 35(2), pp. 1–10. doi: 10.15700/saje.v35n2a1049.
Manyanga T., et al (2016) ‘Results From Zimbabwe ‘ s 2016 Report Card on Physical Activity for Children and Youth’, 13(Suppl 2), pp. 137–142.
Moursi, M. M. et al. (2008) ‘Dietary Diversity Is a Good Predictor of the Micronutrient Density of the Diet of 6- to 23-Month-Old Children in Madagascar’, Journal of Nutrition, 138(12), pp. 2448–2453. doi: 10.3945/jn.108.093971.
Murimi, M. W., Sample, A. D. and Guthrie, J. (2008) ‘Nutrition Education in Team Nutrition Middle Schools?: Teachers ‘ Perceptions of Important Topics to be Taught and Teaching Curriculum Used’, Education, pp. 1–11.
Mushonga, N. G. T. et al (2014) ‘A RESTROSPECTIVE STUDY OF THE NUTRITIONAL STATUS OF PRIMARY’, pp. 8837–8847.
Muthuri, S. K. et al. (2014) ‘Correlates of objectively measured overweight / obesity and physical activity in Kenyan school children?: results from ISCOLE-Kenya’, pp. 1–11. doi: 10.1186/1471-2458-14-436.
Nguyen, K. A. et al. (2015) ‘The feasibility of implementing food-based dietary guidelines in the South African primary-school curriculum’, Public Health Nutrition, 18(1), pp. 167–175. doi: 10.1017/S1368980013003194.
Oldewage-Theron, W. H. and Egal, A. (2012) ‘Impact of nutrition education on nutrition knowledge of public school educators in South Africa: A pilot study’, Health SA Gesondheid, 17(1), pp. 1–8. doi: 10.4102/hsag.v17i1.602.
Pérez-Rodrigo, C. and Aranceta, J. (2003) ‘Nutrition education in schools: experiences and challenges’, European Journal of Clinical Nutrition, 57, pp. S82–S85. doi: 10.1038/sj.ejcn.1601824.
Piernas, C. and Popkin, B. M. (2010) ‘Trends in snacking among U.S. children’, Health Affairs, 29(3), pp. 398–404. doi: 10.1377/hlthaff.2009.0666.
Prioreschi, A. et al. (2017) ‘Describing objectively measured physical activity levels, patterns, and correlates in a cross sectional sample of infants and toddlers from South Africa’, International Journal of Behavioral Nutrition and Physical Activity. International Journal of Behavioral Nutrition and Physical Activity, 14(1), pp. 1–14. doi: 10.1186/s12966-017-0633-5.
Rampersaud, G. C. (2009) ‘Benefits of Breakfast for Children and Adolescents: Update and Recommendations for Practitioners’, American Journal of Lifestyle Medicine, 3(2), pp. 86–103. doi: 10.1177/1559827608327219.
Ratcliffe, M. M. et al. (2011) ‘The Effects of School Garden Experiences on Middle School-Aged Students’ Knowledge, Attitudes, and Behaviors Associated With Vegetable Consumption’, Health Promotion Practice, 12(1), pp. 36–43. doi: 10.1177/1524839909349182.
Spronk, I. et al. (2014) ‘Relationship between nutrition knowledge and dietary intake’, British Journal of Nutrition, 111(10), pp. 1713–1726. doi: 10.1017/S0007114514000087.
Srivastava, A. et al. (2012) ‘Nutritional status of school-age children – A scenario of urban slums in India’, Archives of Public Health, 70(1), pp. 2–9. doi: 10.1186/0778-7367-70-8.
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Chapter 6
Summary, Conclusion, Recommendations
6.1. Summary

7.3% of the primary school pupils were overweight, 6.3% were wasted and 3.8% were stunted. Most of the primary school pupils had adequate nutrition knowledge to the questions asked. The children had diverse meals but consumed unhealthy snacks such as consuming sweets. Most of the children were had the required physical activity in a day but some of the girls mentioned that they wanted to increase the physical activity levels. The girls were involved in activities of cleaning the house more than girls. For all the pupils the use of cars and public transport was more dominant. Increasing physical activity in both boys and girls will help in maintaining normal body composition and cardiovascular benefits. The anthropometric measurements for teachers showed that 40% of the teachers had normal weight, followed by 26.67% with an obesity I and 20% are with pre-obesity. 6.67% were obesity II and also 6.67% were obesity III. The teachers mostly had adequate nutrition knowledge and were interested in nutrition knowledge being in the curriculum and teaching more of the nutrition topics. Healthier, knowledgeable teachers can be more efficient at work and imparting knowledge.
Some schools had the school feeding programmes and the school garden, however these were not up to the expected standard to qualify them as adequate for the purposes they intend to serve. Improving the two will provide healthier diets at a low cost and an opportunity to learn effectively. The foods sold in and around the schools were also not healthy with mostly junk foods being sold. The areas in and around the schools should be used as a way of promoting healthy eating. The information obtained about the activities the teachers and pupils prefer doing in class and also the positive and negative aspects of the class can potential provide possible entry point for the introduction of comprehensive nutrition education in the primary school curriculum.
6.2. Conclusion

Nutritional status of pupils was overweight 7.3%, wasted 6.3%, stunted 3.8 % and teachers obese 40.1%, overweight 20%. 52.7% met the recommended hours of physical activity and 47.3% of them did not meet the recommended hours of physical activity despite organized sports and active transport. More needs to be done to reduce sedentary lifestyles to avoid risks of NCDs when the pupils become adults. The mean scores for the nutrition knowledge for teachers and primary school pupils was good but more improvements need to be done in other topics. The primary school teachers were willing to teach more nutrition knowledge and thought NE was important in the curriculum, which is vital for encouraging the training of teachers on NE and the adoption of more nutrition topics. The school environments did not promote nutrition education or good dietary practices and these need to be addressed in order to make schools nutrition friendly and promote good dietary practices. The classroom activities and willingness of children and teachers to change their nutrition practices helps find possible entry point for the introduction of comprehensive nutrition education in the primary school curriculum
6.3. Recommendations
1. The Ministry of Primary and Secondary Education to review of the primary school curriculum to include a more comprehensive curriculum including nutrition topics, adoption of material and allocation of the recommended time as advised upon by FAO Nutrition Education in Primary Schools document, 2005
2. The primary school pupils with the support of their parents and schools to increase their physical activity levels by focusing on the activities they enjoy doing together with competitive sporting in their schools.
3. The researchers to embark in larger studies to be done concerning the nutritional status and nutrition knowledge among primary school pupils and teachers and also the perceptions of teachers in teaching nutrition related topics