Discussion
eating behavior disorders
AIDS, SECONDARY
Our study demonstrated that school-based nutrition education has the potential to increase dietary diversity among adolescent girls. It indicates that along with the regular curriculum in secondary schools, nutrition education can be added on to improve the dietary diversity of adolescent girls which corresponds with the findings of other studies [Nutrition education is a much more comprehensive enterprise than nutrition information dissemination [A study done in Ethiopia provided school-based health and nutrition education using a combination of strategies including peer-groups, school media, and health clubs, family and community participation. It showed there was a significant increase of the proportion of school children consuming diversified diet due to intervention. The positive change in dietary diversity in this study [In low- and middle-income countries, the school feeding program (SFP) has been found to be instrumental to increasing dietary diversity of adolescent girls but such a program has some limitations including irregular supply and storage of materials (i.e., food items) and loss of educational time at school [Due to our intervention, consumption of some food groups was increased among intervention arm than in control arm in endline. Findings of our study showed that 100% of adolescent girls in the baseline as well as in the end-line consumed starchy staples both in intervention and in the control group. It might be due to the fact that starchy staples are culturally and socially acceptable diets in our country. It is the main food source and most available diet in Bangladesh just like other developing countries [We also observed in our study that the consumption of organ meat increased from 12% at baseline to 32% at the endline in intervention but it remained unchanged in the control arm across the surveys. It can be assumed that awareness of organ meat and its benefit can foster the consumption of organ meat. The same reasons could be applicable to increasing the consumption of legumes, nuts and seeds, and milk and milk products. A study done in Southern Ethiopia found that the pulse and legumes intake of the beneficiary households was substantially higher (91.7%) compared with the non-beneficiaries (8.3%) which clearly indicated the effect of school-based nutrition intervention [A study done in Southeast Asia found that a considerable proportion of girls did not eat eggs, milk or dark green leafy vegetables but a larger proportion of them consumed meat and fish [EAT-Lancet commission emphasized a global planetary health diet that is healthy for both people and planet. Whole grains, fruits, vegetables, nuts and legumes comprise a greater proportion of foods consumed. Meat and dairy constitute important parts of the diet but in significantly smaller proportions than whole grains, fruits, vegetables, nuts and legumes [The strength of our study is it is the first paired-matched randomized control trial in Bangladesh that aimed to measure the efficacy of school-based nutrition education in improving dietary diversity among adolescent girls. Nutrition education was provided in a classroom setting and the participation of the students was ensured by informing them prior to the day of the nutrition education session in a week, thus the fidelity of the interventions was ensured. This study used audio-visual aids for delivering the intervention. Since the audio-visual aids are available in the secondary school settings [There are some limitations of our study which worth to be mentioned. Firstly, due to budget constraints, we conducted our study in a limited number of clusters (schools) which is likely to affect the methodological rigor of the study. Secondly, due to the COVID-19 pandemic, we had to provide intervention for two months instead of three months. We also had to forgo the midline survey because the whole country was in lockdown state. Thirdly, the increase of 1 unit in the mean score of dietary diversity in the intervened group does not have clinical significance. However, mean dietary diversity score was increased only 1 unit in intervention arm compared to control arm, it was statistically significant even after all other variables were adjusted. Moreover, this 1 unit increase in the mean score of dietary diversity could be minimal, but significant within a shorter period and with many challenges, the results indicated increase of some food groups in the intervention group. Our baseline survey was conducted in January 2020 when there was no COVID-19 pandemic situation. As we used the same questionnaire in baseline and endline, so we could not collect any data representing the effect of the COVID-19 pandemic on food availability and access. The absence of data regarding seasonality was one of the limitations of our study. We could not capture the effect of seasonality on dietary diversity since the data were not collected at the different time points (seasons) over the year. We could not collect data regarding indicators of eating behavior disorders because we had to make our questionnaire brief and short to complete the interview with the adolescent girls within a limited time (some particular times from school hours). In addition, we did not incorporate any evidence-generating tool other than quiz (quiz and recap session were taken before starting the next session) by which we could measure their knowledge of the given intervention.