ISSN2434-2688 Asian Journal of Dietetics

Vol.4 No.4, 2022
Contents
Page T Title and authors
Letter to Editor
75

Malnutrition Situation Aspects from Asian Young
Perspective
Samitti Chotsriluecha, Thao Phuong Tran, Yupa Chanwikrai

Dietitians’

Original Research
77-82

Low Physical Activity May Lead to Obesity Rather than High-Energy
Intake in Vietnamese Children
Phuong Mai Nguyen, Giang Huong Nguyen, Diep Van Nguyen, Thu Thi
Truong, Shigeru Yamamoto

Original Research
83-89

Impressions and Turning Points of Japanese Public Health Dietitians: a
Web-Based Cross-Sectional Study
Tatsuya Koyama, Yusuke Arai, Ayaka Iida，Sumie Isobe，Rie Okamoto，Osamu Kushida，Idumi Shibuya，Kazumi Tanaka，Ayumi Morooka，Katsushi Yoshita

Original Research
91-102

Exploring Perspective of On-call Dietitian Residency Program among
Healthcare Personnel in a Government Tertiary Hospital: A Pilot
Qualitative Study
Kong Jian Pei, Fatimah bte Othman, Zarina bte Samsudin, Basmawati bte
Baharom

Research Note103-108

Enhancing the Skills and Competencies of Nutrition and Dietetics
Students in the Philippines to Manage COVID-19 by Reinforcing
Hospital Practicum Programs
Cecile Klaudine C. Cabigas. Marietoni B. Pico, Cecile Leah T. Bayaga

Malnutrition Situation Aspects from Asian Young Dietitians

Letter to the Editor
Malnutrition Situation Aspects from Asian Young Dietitians’ Perspective
Samitti Chotsriluecha1, Thao Phuong Tran 2, Yupa Chanwikrai2,3*
1

Division of Clinical Nutrition, Department of Internal Medicine, Phramongkutklao Hospital andCollege of Medicine, Bangkok, Thailand
2
Asian Nutrition and Food Culture Research Center, Jumonji University, Saitama, Japan3
Department of Nutrition, School of Medical Sciences, University of Phayao, Phayao, Thailand

Dear Editor:
Malnutrition (refer to undernutrition) is public healthissue, characterized by lower than z score in children
and low body mass index (BMI < 18.5 kg/m2) in adult.
Consequences of malnutrition not only damage
individual health, but also poor immunity, delay
development and growth, lower IQ in child, reduce
quality of life and effect on higher of health care cost.
According to the Young Dietitian Workshop in the
Asian Congress of Dietetics (ACD) 2022, we reported
Asian situation of malnutrition across public health,health care community, and hospital.
For the public health data, we found that in infant
and young children had 21.8% of stunting and 8.9% of
wasting, which was improved more than 10% over the
past 20 years. Among child and adolescent, theprevalence of thinness was 17.2% and 12.5 % in boys andgirls respectively, which quite constancy during 10
years. Food, nutrition insecurity and infection are
considered as predisposing factors for malnutrition inchildren especially in the Covid situation. In some area,
school lunch meal may save children from hungry.
Moreover, in some countries happened with otherserious problem of nutrition such as anemia.
Prevalence of anemia among children in each country
was India 53.4%, Pakistan 53.0%, Myanmar 49.6%, Lao
PDR 41.4%, Indonesia 38.4%, Thailand 24.9%, Vietnam
22.9%, and Japan 16.7%. Anemia in children may causefrom poor intake of dietary or supplement iron andmaternal anemia.
Among the Asian adult community, 13.0% of
females and 11.5% of males had low BMI. Low BMI
healthy adults were more at risk of malnutrition when
they got sick. Additionally, when we discussed theissue of a low BMI cutoff point, we found that many
low BMI populations still had normal function andhealth. There was a big question of whether toinvestigate BMI criteria in Asian populations.
Hospital malnutrition was other setting and aspect ofmalnutrition. Disease, stress and inflammation also
drove on nutrition status of patient consequence to low
dietary intake and weight loss, which brought pooroutcomes. Nutrition screening tools were used to early
detection of malnutrition, which variety across country
such as Nutrition Risk Screening (NRS) 2002,
Malnutrition Universal Screening Tool (MUST), Mini
Nutrition Assessment – short form (MNA-SF), or
Subjective Global Assessment (SGA). And somecountry uses their own development of screening andassessment tools such as Thailand, applying SPENT
Screening for screening tools and Nutrition Alert Form
(NAF) or Nutrition Triage (NT) as assessment tools.
Prevalence of hospital malnutrition was varied
from 20% to 50% depend on the assessment tools andpatient characteristics, such as critically ill, cancer,
multi-comorbid disease.
Nutrition intervention for hospital malnutrition
patient was one of medical treatment demonstrated to
improve better outcomes, decrease infection rate andlength of stay. Most country has developed their own
strategies to improve patients’ intake such as modified
texture foods, combined traditional Chinese medicine
with hospital diet, hospital-made high energy andprotein smoothie.
Through our discussion with young dietitians, weshared a lot of useful experiences and knowledge andrecognized that there are still many responsibilities androles of dietitians to be explored and developed
especially in the community and hospital nutrition
fields. Considering that some Asian countries still
suffer from malnutrition. We hope to find an effective
way to assess nutrition status as well as prevention andtreatment of malnutrition across the lifespan, including
patients in hospitals, in order to improve their qualityof life.
ACKNOWLEDGEMENT
The authors would like to thank other members of
the Young Dietitian Workshop for joining thediscussion online almost 5 months before the congress.
Our gratitude goes to Prof. Dr. Shigeru Yamamoto, ouradvisor, and the committee of ACD 2022 for their kind
support.

REFERENCES
1. https: / / globalnutritionreport. org/ resources/ nutrition
nprofiles/asia/.Accessed September 25, 2022.
2. https://data.worldbank.org/indicator/SH.ANM.CHL
D.ZS?end=2019&locations=Z4&start=2000&view=ma
p&year=2019.Accessed September 25, 2022.
3. Chuansangeam M, Wuthikraikun C, Supapueng O,
Muangpaisan W. Prevalence and risk for malnutritionin older Thai people: A systematic review and metaanalysis. Asia Pac J Clin Nutr. 2022;31(1):128-41.

*To whom correspondence should be addressed:
yupa.ch@up.ac.th75

Asian Journal of Dietetics 2022

Original
Low Physical Activity May Lead to Obesity Rather thanHigh-Energy Intake in Vietnamese Children
Phuong Mai Nguyen1*, Giang Huong Nguyen1, Diep Van Nguyen2, Thu Thi Truong3, Shigeru Yamamoto1
1

Department of Food and Nutritional Sciences, Graduate School of Human Life Sciences, Jumonji
University
2
Nutrition and Food Culture Research Center, Jumonji University, Saitama, Japan3
Hai Duong Medical Technical University, 229 Nguyen Luong Bang, Hai Duong City, Vietnam
ABSTRACT Background: The prevalence of overweight and obesity in Vietnamese
school children has increased rapidly in the past decade. However, factors related tothis matter in school children were not well understood. Purpose: To identify factors
related to child obesity in Vietnamese children. Methods: A cross-sectional study was
conducted on 134 fifth-grade children at a public primary school in a Hanoi suburb.
Height and weight were measured. Dietary intake was assessed by a 24-h dietary recall
method for seven days. Children were interviewed about daily activities for seven daysby questionnaire to estimate physical activity level. Results: The study subjects
included 73 boys (54.5%) and 61 girls (45.5%). The prevalence of non-obese and obeseof all subjects were 69.4%, and 30.6%, respectively. The average energy intake forseven days in non-obese and obese groups was 1895 ± 298 and 1881 ± 296 kcal/d,respectively (p>0.05). Sugar intake was similar among all the 4 groups, being less than
30g/day. Physical activity level in the non-obese group was higher than that of theobese group (p<0.01). Conclusion: This study showed that a high prevalence of obesity
was not based on high energy intake but on low physical activity in Vietnamesechildren.
Keywords: children, overweight and obesity, energy intake, physical activity level.
INTRODUCTION

cardiovascular disease and certain cancers(5). Studies in Vietnam have suggested that obesity
increased the risk of hypertriglyceridemia (6).
Addressing overweight and obesity will contribute to
reducing deaths and increasing the years of life lived(7).

Childhood obesity is one of the most serious
global public health challenges of the 21st century,
affecting every country in the world. In just 40 years
the number of school-age children and adolescentswith obesity has risen more than 10-fold, from 11
million to 124 million (2016 estimates) (1). In
Vietnam, childhood obesity has been on a rapid riseand become a public health concern, especially in big
cities. In Hanoi, the capital city of Vietnam, theprevalence of overweight and obesity among 8–11
year-olds in 2003 was 7.5%, increasing to 12.9% in2009 and 33.3% in 2018 (2). In Ho Chi Minh City,
the largest city in Vietnam, the prevalence ofoverweight and obesity in children aged 7-9 and 1011 years old were 48.2% (3) and 53.5% (4),respectively.

In simple terms, obesity is the result of an energy
imbalance. Diet and physical activity, the risk factors
most strongly related to obesity, have changed
markedly since the onset of the obesity epidemic (5).
Interventions that are successful in the prevention andmanagement of childhood obesity are urgently needed.
Understandingtherelative
importanceofoverconsumption and physical inactivity to excess
weight gain among children can contribute to thedevelopment and evaluation of interventions andpolicies to reduce childhood obesity (8). However,whether energy intake or expenditure is the dominant
contributor to childhood obesity is a subject of debate.
In the United States, the country with the highest rateof overweight and obese children in the world, there
has been no consensus on the main driver of seculartrends in weight gain among children (8). In addition,
population-level studies on the relationship between
lifestyles and childhood obesity typically focus oneither physical activity or diet but seldom on both (9).
Therefore, this study examined physical activity anddietary intake in relation to overweight and obesity inprimary school children in a suburb of Hanoi,
Vietnam.

Previous studies reporting on the prevalence ofchildhood obesity have shown continued increases inobesity during the past decade, with plateauing ofobesity prevalence among some age groups. This is aconcern as obese children have a higher risk ofdeveloping diseases including asthma and type 2
diabetes mellitus and are reported to have low selfesteem (5). Once established, obesity tracks into
adulthood and is associated with an increased risk of*To whom correspondence should be addressed:

nguyenmaiphuong2102@gmail.com
77Energy Intake, Physical Activity and Childhood Obesity
METHODS

Statistical analysis

Participants

The physical activity level (PAL)
calculated based on the following formula:

A total of 134 children (73 boys and 61 girls) in
grade 5 (9-10 years old) at a public primary school
in suburban Hanoi participated in this study. The
school was selected by convenience sampling. Alldata were collected in October 2020. Informed
consent was obtained from the children, theirguardians, and teachers according to the
Declaration of Helsinki, and the study protocol wasapproved by the Biomedical Research Ethics
Committee of Hanoi Medical University (no.
355/HMUIRB).

was

PAL = ∑24h｛MET value of physical activity xtime (min)｝/1440
In which the MET value of physical activity
was referenced from the compendium of physicalactivities of Ainsworth et al. (13).
The time spent in each physical activity
intensity in each day was calculated using METs
for each participant: average minutes spent insedentary and light physical activity (METs< 3),
moderate to vigorous physical activity (METs ≥3.0).

Anthropometric characteristics

All statistical analyses were performed using
SPSS software (version 26; IBM Corporation,
Armonk, New York). The data were expressed as
mean±SD or n (%). The study analyses involved
comparisons between the non-obese and obese
groups. Differences between groups were assessedusing independent t-tests for continuous data andchi-squared tests for categorical data. P values lessthan 0.05 were defined as a statistical difference.

Height and weight were measured to the nearest
0.1 cm and 0.1 kg using a stadiometer (Seca 213)
and a digital scale (OMRON HBF354IT). Children
were measured with light clothing without shoes orhair ties. All measurements were conducted threetimes and the mean was calculated. The nutritional
status of the children was determined based on the
WHO growth reference for those aged 5-19 years
old. BMI-for-age z-score was determined using thesoftware WHO AnthroPlus version 1.0.4 forchildren above five years of age. Interpretation of
cut-offs is >+1SD for overweight, >+2SD forobesity, and <-2SD for thinness.

RESULTS
Figure 1 shows the weight status of all thechildren. The prevalence of overweight and obesityin children aged 10 years old was very high, at
about 30.6%. The prevalence of thinness inchildren was low at 6% and their average BMI forage z-score was -2.12 SD near the cut-off point of
the normal level. Therefore, the following results
were presented in the non-obese group consistingof thin and normal children, and the obese group
including overweight and obese children.

Dietary assessments
Dietary intake was assessed by a 24-hourdietary recall questionnaire for seven days using
standard food measures and a food photobook
published by the Vietnamese National Institute of
Nutrition during interviews to estimate portion size.
When children couldn't remember exactly what
they had eaten, we contacted the caregiver toreconfirm. The nutritional value of food was
calculated based on the Vietnam Food Composition
Table published by the Ministry of Health andVietnam National Nutrition Institute (10). Sugar
intake was estimated from reports of various foodsugar concentrations (11).

12.7

Physical activity assessments
The 7-day minute-by-minute activity record
was used to assess the physical activity level. The
activity record form is designed based on thetemplate developed by Koebnick et.al (12).
Children were instructed to name the activity andthe intensity of the activity with 3 levels of light,
moderate and vigorous, and mark the start and end
times for each activity. The recording method was
explained to teachers, children, and their guardianswith an example of a completed physical activity
form. We asked teachers and guardians to help thechildren to complete the activity record. Whencollecting the activity record form, we interviewed
children to improve the accuracy of the activity
record by adding and correcting the content
regarding omissions and unclear points.

6
Thin

17.9

NormalOverweight
63.4

Obese

Figure 1. Weight status of children assessedby BMI-for-age z-score (n=134)

78

Asian Journal of Dietetics 2022

Table 1. Characteristics of child subjects (n=134)
Girls(n=61)
123.3±3.5138.0±5.3
32.4±5.7
17.0±2.5-0.1±1.2

Boys(n=73)
123.0±3.1137.9±6.9
36.0±8.3
18.8±3.4
0.7±1.3

p-value†Age (months)
0.723
Height (cm)0.895
Weight (kg)0.006
BMI (kg/m2)
0.000
BMI-for-age z-score
0.000
Weight status (%)
Non-obese
78.7
61.6
0.008
Obese
21.3
38.4
Abbreviation: BMI, body mass index.
Values are mean±SD and %. †Independent t-test except Chi-squared test for weight status (%). Significant
difference: p<0.05.
Average energy and nutrient intakes in the 7Characteristics of children are summarized in
day nutritional survey are shown in table 2. Theretable 1. No statistically significant differences were
were no significant differences between non-obese
observed between the boys and girls with regard to
and obese children in the intakes of energy, protein,
age and height. However, the prevalence oflipid intake, fiber, and sugar in both genders.
overweight and obesity in boys was significantly
However, the carbohydrate intake of boys washigher than in girls at 38.4% and 21.3%,
significantly higher in the non-obese group than inrespectively (p=0.008).
the obese group (p<0.05).
Table 2. Energy and nutrient intakes by genders and groups (n=134)
Girls
Nonobese(n=48)
1798±24174±23
16.6±6.059±1329.7±4.8252±3856.0±4.6
3.9±1.4
28±16

Obese
(n=13)

Boys
p-value

Nonobese(n=45)
1998±32182±24
16.4±3.664±1728.6±4.9
280±4556.3±5.0
4.3±1.7
29±17

Obese
(n=28)

p-value

Energy intake (kcal/d)
1850±2090.482
1896±331
0.197
Protein intake (g/d)
73±14
0.876
81±28
0.886
Protein intake (% EI)
15.6±1.50.596
17.2±6.0
0.472
Lipid (g/d)
62±15
0.544
64±14
0.996
Lipid intake (% EI)
30.1±5.60.801
30.3±3.9
0.137
Carbohydrate (g/d)
260±340.459
253±500.021
Carbohydrate intake (% EI)
56.4±5.50.794
53.5±5.0
0.023
Fiber intake (g/d)
3.6±1.0
0.583
4.2±2.0
0.736
Sugar intake (g/d)
29±8
0.945
26±12
0.398
Abbreviation: EI, energy intake
Values are mean±SD and %. P-values were computed using an Independent t-test with significant differenceat p<0.05.
Table 3. Physical activity of children with non-obese and obese girls and boys
Girls
Non-obese(n=48)
1.44±0.11622±38730±49Obese(n=13)
1.34±0.12616±40763±55Boys
p-value†Obese(n=13)
1.48±0.12618±49717±67

Non-obese(n=48)
1.41±0.13599±46765±62p-value†

Physical activity level (PAL)
0.002
0.018
Sleeping time (min/d)
0.684
0.111
Sedentary to light physical
0.038
0.003
activity (min/d)
Moderate to vigorous physical
90±38
66±28
0.044
108±4580±31
0.005
activity (min/d)
Percentage of children
47.9
61.5
0.093
46.7
60.7
0.046
walking or biking to school(%)
Minutes spent walking or
7±9
9±9
0.513
7±9
6±7
0.743
biking to school a day
Values are mean±SD and %.
†Independent t-test except Chi-squared test for walking or biking to school (%). Significant difference: p<0.05.
PAL was calculated by ∑24h｛MET value of physical activity x time (min) ｝/1440 min. It is the same as theaverage METs.

79

Energy Intake, Physical Activity and Childhood Obesity
explained 11% of the variance (R2 = 0.13, F(3, 120) =6.33, p <0.001). Participants’ predicted BMI-for-age
z-score is equal to 1.7688 + 0.8885(GENDER) –1.8491(PHYSICALACTIVITYLEVEL)+
0.0001(ENERGY INTAKE), where gender is coded
as 1=girl and 2=boy, physical activity level ismeasured in PAL and energy intake is measured inkcal. Children’s BMI-for-age z-score increased by
0.0001 for each kcal of energy intake and decreasedby 1.85 for each PAL of physical activity and BMIfor-age z-score in boys was higher than in girls at
0.89. Gender and physical activity level weresignificant predictors of BMI-for-age z-score at
p=0.0001 and p<0.05, respectively. It was found thatenergy intake did not significantly predict BMI-forage z-score (p= 0.8513).

Table 3 shows the physical activity of children.
The physical activity level in the obese group was
significantly lower than in the non-obese group.
Obesity children spent more time in sedentary to lightactivities than non-obese children. Time spent on
moderate to vigorous physical activity in obese
children was less than in non-obese children. There
were no significant differences in sleeping time, thenumber of children walking or cycling to school, or
the time spent walking or cycling between obese
children and non-obese children.
Multiple linear regression was used to predict
BMI-for-age z-score based on gender, PAL, andenergy intake (Table 4). The regression was
statistically significant and the three predictors

Table 4: Multiple linear regression predicting BMI-for-age z-score of children.
Predictor

Estimate

Standard Error

t-statistic

p-valueConstant

1.76881.29061.37050.1729Gender

0.88850.2225

3.99350.0001

Physical activity
level (PAL)-1.8491

0.8943-2.06760.0407

Energy intake-0.0001

0.0004-0.18780.8513R2 = 0.13, F(3, 120) = 6.33, p <0.001
Abbreviation: PAL, physical activity level
PAL was calculated by ∑24h｛MET value of physical activity x time (min) ｝/1440 min. It is the same as theaverage METs.
eaten, especially with children. Such underestimate
problems can be improved with the help of parents(19). Surveys for a full week show more accurate
results than surveys for 3 days, which are often used.
In this study, the survey was 7 days and children’s
parents cooperated. Through these efforts, we believethat the reliability of this nutrition survey was greatly
improved.
Concerning the accuracy of estimations ofphysical activity, there may be some limitations. Mostof the previous studies in Vietnam were
measurements of steps or described activity levels
such as low, moderate, and high (4), (20). However
such methods do not indicate the PAL. To define
PAL more accurately, we used a time/study method.
Subjects and their parents wrote down the time inminutes spent in various activities for 7 days. PAL
was calculated using the measured time of various
activities and metabolic equivalents (METs) (13).
Energy, nutrient, and sugar intakes: Theaverage energy intakes for seven days in the nonobese and obese groups were 1895 ± 298 and 1881 ±296 kcal/d, respectively (p>0.05). Major energy
source (carbohydrate, lipid, and protein) intakes weresimilar in all the groups. The energy ratio for thesenutrients (percentages from protein, lipid, andcarbohydrate) was 16:30:54, which was similar to thatof the Japanese (21). This ratio is consistent withWHO recommendations (22).

DISCUSSION
The purpose of the present study was to findrelated factors of overweight and obesity in children
aged 10 years old in Hanoi, Vietnam. We found thatin Vietnamese children, the high prevalence ofobesity was based not on high energy intake but on
low physical activity. Most of the previous trials tocontrol obesity were focused mainly on energy intake
such as prevention by reducing/limiting junk foods
and sweet foods and beverages (14-15). However, theresults of this study suggest that this strategy ofobesity control would not be effective in Vietnamesechildren.
Obesity rate: The mixed obesity rate for girls andboys was about d 31%. These results were similar todata from the National Nutrition Survey in Hanoi in2018 (2), which showed an obesity rate of 33.3% for
8-10 years old, indicating that our subjects weregenerally representative of children in Hanoi. The
obesity rate is quite high but it is similar to that ofmost East Asian countries and other parts of theworld (26%) (16), with the exception of Japan (17).
For Japanese children of a similar age group, theobesity rate was 11% in 2020 (18), which wasperhaps the lowest in developed countries for this age.
Accuracy of the results: Results of 24-h dietary
recall nutrition surveys are often underestimatedbecause subjects forget some foods that they have80

Asian Journal of Dietetics 2022
In many countries, a high intake of sugar is an
important factor for obesity. Some countries put afine on products with high sugar concentrations (23).
In North and South American and European countries,
the sugar intake is nearly 100g a day (24-25). WHO
recommends energy from sugar at less than 10% andfurther suggests 5%, which is about 50g or 25g ofsugar a day (22). Nowadays, sugar includes not only
sucrose but isomerized sugars (fructose and glucose)made from starch is common because it is cheap andtasty at lower temperatures. Luckily, in Vietnam,
there is a sugar composition table that includes
sucrose, fructose, glucose, and lactose (11). In thisstudy, we used the composition table and calculatedsugar intake. It was similar in all groups, being lessthan
30g/day,
which
meets
the
WHO
recommendation.
Physical activity: In the present study, theclearest differences between obese and non-obese
children were physical activity level (PAL). The
multiple linear regression showed the most relevant
factor for body weight was PAL with a p-value lessthan 0.05 (Table 4).
Differences in average PAL per day between the
non-obese and obese groups were 0.1 in girls and0.07 in boys. Since the average basic metabolic rates
per day for 10-year girls and boys are 1200 kcal and1330 kcal, respectively (26), a difference in energy
expenditure was 120 kcal/day (1200 kcal x 0.1) ingirls and about 90 kcal/day (1330 kcal x 0.07) in boys.
Since they are daily differences, it is not small. Such
differences were caused by the different amounts oftime spent on activities.
Time spent in sedentary to light activities in obese
children was about 30 minutes and 50 minutes longer
than in non-obese girls and boys, respectively. On thecontrary, time spent in moderate to vigorous activity
was 25 minutes longer for non-obese girls and boys
than for obese ones (Table 3). In Vietnam, parents
take children to school by car or motorcycle because
1.

2.

3.

4.

5.
6.

7.

traffic makes walking unsafe. It is easy to think thatsuch a lifestyle is one of the major factors in obesity;
however, between non-obese and obese children inboth genders the time spent commuting to school onfoot or bicycle was short and not different (Table 3),indicating that the travel method to and from school is
not a major factor in obesity.
Many previous studies have shown that sleep
duration is negatively correlated with BMI (27-28).
However, in the present study, there was nodifference in sleep duration between non-obese andobese children.
Gender difference: Consistent with findings fromseveral previous studies assessing the weight status ofVietnamese children, the prevalence of overweight
and obesity in boys was significantly higher than ingirls (4), (29-31). The higher prevalence ofoverweight and obesity in boys could be explained by
the different social expectations about weight andbody shape for boys and girls (30), (32). In Vietnam,
society typically places more importance on males
compared to females, resulting in boys being fed andtaken care of very well (30).
In conclusion, the high prevalence of child obesity
in Hanoi was mainly caused by lower physicalactivity rather than higher energy intake. Based on
our present findings we need to consider strategies forobesity control in Vietnam once again.
ACKNOWLEDGEMENTS
The authors are grateful to all participants for theircooperation and the staff of the Asian Nutrition andFood Culture Research Center for their assistance.
We would like to thank Andrew Durkin, Prof.
Emeritus of Indiana University, for editing ourEnglish.
CONFLICTS OF INTEREST (COI)
The authors have no conflicts of interest to
disclose.

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Energy Intake, Physical Activity and Childhood Obesity
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Asian Journal of Dietetics 2022

Impressions and Turning points of Japanese public health dietitians: a web-based crosssectional study
Tatsuya Koyama1*, Yusuke Arai2, Ayaka Iida3，Sumie Isobe4，Rie Okamoto5，Osamu
Kushida6，Idumi Shibuya7，Kazumi Tanaka3，Ayumi Morooka8，Katsushi Yoshita9
1

Aomori University of Health and Welfare
Chiba Prefectural University of Health Science
3
Kanagawa University of Human Services
4
Niigata Prefecture Government
5Kanazawa University
6
University of Shizuoka
7
Aichi Prefectural Government
8
Hyogo Prefectural Government
9
Osaka Metropolitan University

2

ABSTRACT: Background/Purpose: The purpose of this study was to clarify the impressions
and turning points (hereinafter referred to as “impressions”) of each organization where
public health dietitians work in Japan. Method: In 2021, we conducted a complete Websurvey of Japanese public health dietitians working in prefectures, special wards and cities
with public health centers, and municipalities. The impressions and turning points of theparticipants were classified based on the basic guidelines for improving health promotion andnutrition and dietary habits by public health dietitians in the community. Results: The sample
of responses included 425, 323, and 914 public health dietitians working in prefectures,
special wards and cities with public health centers, and municipalities, respectively. The mostimpressionable factors for prefectural dietitians were collaborative work, work experienceother than health and sanitation departments, health crisis management, self-operated andplanned projects, work at the headquarter, and research activities. Public health dietitians in
special wards and cities with public health centers were most impressed by work experienceother than health and sanitation departments, resident support, health guidance, collaborative
work, self-planned and managed projects, and maternal and child health. Municipal publichealth dietitians were most impressed by maternal and child health, adult health, welfare forolder adults, collaborative work, changing jobs to administrative positions, and generalinterpersonal work. Conclusion: We found regardless of the organization where Japanesepublic health dietitians work meaningful experiences were similar. Support of theseexperiences may improve self-efficacy of public health dietitians.
Key Words: public health dietitians, self-efficacy, impression, turning point, duty, JapanINTRODUCTION
Public health nutrition is the art and science ofpromoting population health status via sustainableimprovements in the food and nutrition system. Basedon public health principles, it is a set of comprehensive
and collaborative activities, ecological in perspective,
and intersectoral in scope; it includes environmental,
educational, economic, technical, and legislative
measures (1). For example, public health dietitians
implement salt reduction in communities throughassessing community, informing to people, andcollaboration with stakeholders (2). Dietitians are
specialists responsible for public health nutrition
activities. The number of public health dietitians
working at public health centers and health centers issmaller than that of public health nurses in Japan (3).
To promote businesses with a small number of people,
increasing self-efficacy is essential (4).
Self-efficacy, as proposed by Bandura, is anindividual’s belief in how well they can perform theactions required to produce a certain result (4).
Individuals with high self-efficacy exhibit behavioral
characteristics such as willingness to make a great dealof effort, willingness to tackle challenges, and a highdegree of expectation for eventual success (4).
Extant literature has reported that professionalism
and self-efficacy are associated with length of service,personal development, skill improvement, meaningful
clinical experience, and participation in social andexternal activities (5). The Ministry of Health, Labourand Welfare presents the work of public healthdietitians in prefectures, special wards and cities withhealth centers, and municipalities (6). Little is known
about what working activities are meaningfulexperiences for public health dietitians.
The duties of public health dietitians working inprefectures, special wards and cities with public healthcenters, and municipalities vary (6). Therefore, thisstudy aims to clarify public health dietitians’
meaningful experiences, through investigating theimpressions and turning points in each type oforganization where public health dietitians work. The
results of this study may help improve the work of
public health dietitians.
MATERIALS AND METHODS
Participants
We conducted a cross-sectional survey among
dietitians working in prefectures, special wards andcities with public health centers, and municipalities.
The inclusion criteria for the study participants were:
1.

*To whom correspondence should be addressed:t_koyama@auhw.ac.jp

83Public health dietitians’ turning points and impressions(1) those who responded as public health dietitians ina survey by the Ministry of Health, Labour andWelfare; and (2) those with a full-time or part-time (atleast four days a week and at least six hours a day)employment status. However, those currently working
full-time in fields such as childcare, welfare for older
adults, boards of education, and medical care were
excluded.
Request letters were sent in January 2021 todietitians at supervise bureaus who met the inclusion
criteria. In the request letters, we specified the purposeof the survey and the URL and QR code linked to theonline questionnaire. The web-survey was conductedfrom January 29, 2021, to March 2, 2021 (Survey
Research Center Co., Ltd.). A request for cooperation
was presented at the beginning of the questionnaire
form. The request clearly stated the purpose of thesurvey and outlined that all responses andparticipation would be anonymous, cooperation in thesurvey was voluntary, responses would be regarded asconsent, and that there would be no disadvantage for
non-responses. Additionally, since there was a
possibility that personally identifiable information
may be transmitted to us when returning responses, we
asked the commissioning company to create screens
related to the questionnaire responses and receive all
replies. This meant that the researchers would only
receive simply entered databases obtained by theconsignment company, and no identifiable respondent
information, such as email addresses. All information
was destroyed after the survey was completed andsecondary use of the data for other purposes wasprohibited.
Due to the wide inclusion criteria, the survey
request was sent to an unknown number of publichealth dietitians in Japan, however the final sample ofresponses included 425, 323, and 914 public healthdietitians working in prefectures, special wards andcities with public health centers, and municipalities,
respectively.
Public awareness and cooperation regarding thesurvey was obtained from the public healthdepartment of the Japan Dietetic Association and theJapan association of public health center registereddietitians.
Procedures for this study were followed inaccordance with the ethical standards of the Helsinki
Declaration and were approved by the Ethicalcommittee of Osaka City University (Institutional
Review Board protocol 20-27, approval date: August
14, 2020).

participants were asked, “What was the work that left
the most impression on you, or what was the turning
point for you?” The responses were categorized basedon the Ministry of Health, Labour and Welfare’s“basic guidelines for health promotion andimprovement of nutrition and dietary habits by publichealth dietitians in the community” (6). The
impressions and turning points of dietitians working
in prefectures and special wards and cities with publichealth centers extracted from the survey responses
included: maternal and child health projects, projects
with older adults, specific health guidance, guidanceto specific food service facilities, collaboration withhealth mates, community assessments, work
experience other than health and sanitation
departments, work at the headquarters, work at publichealth centers, changing jobs to administrative
positions, planning, food environment improvements,
health crisis management, research activites, selfplanned and managed projects, presentations at
academic conferences, people in the same workplace,general collaborative work, municipal support, duties
and initiative as supervisors, human resource
development, off-duty activities, participation inworkshops, and food labeling work. The extracted
impressions and turning points of dietitians working
in municipalities included: maternal and child healthprojects, adult health projects, health guidance,
welfare for older adults, general collaborative work,changing jobs to administrative positions, generalinterpersonal work, collaboration with health mates,
health crisis management, work experience other thanhealth and sanitation departments, participation intraining sessions, community assessment, selfplanned and managed projects, presentations at
academic conferences, human resource development,
off-duty activities, and people in the same workplace.
RESULTS
Table 1 shows the basic characteristics of theparticipants. Few dietitians working in prefectures,
special wards and cities with public health centers, ormunicipalities had work experience outside ofpromoting community health and improving nutritionand dietary habits at the headquarters, public healthcenters, or health centers. Community healthpromotion and improvement of nutrition and dietary
habits refer to working with food hygiene related
departments, welfare for older adults, and boards ofeducation.
The highly ranked impressions and turning points
for dietitians working in prefectures included: generalcollaborative work, work experience other than healthand sanitation departments, health crisis management,
self-planned and operated projects, work at theheadquarters, and research activities (Table 2). The
highly ranked impression and turning points for
dietitians working in special wards and cities withpublic health centers included: work experience otherthan health and sanitation departments, resident
support, health guidance, general collaborative work,
self-planed and operated projects, and maternal andchild health. Finally, the highly ranked impressions
and turning points for dietitians working inmunicipalities included: maternal and child health,adult health, welfare for older adults, generalcollaborative work, changing jobs to administrative
positions, and general interpersonal work.

Survey items
The survey included items regarding age, sex,
and length of service for each main type of work.
Additionally, dietitians working in prefectures andspecial wards and cities with public health centerswere asked about the length of duties mainly
responsible for community health promotion andimproving nutrition and dietary habits at the healthdepartment (the headquarter), public health centers,
and health centers, food hygiene-related departments,
welfare for older adults, and boards of education. We
asked dietitians working in municipalities about thelength of their main duties, such as community healthpromotion and improving nutrition and dietary habitsat health centers, welfare for older adults, childwelfare, and boards of education.
Regarding impressions and turning points,
2.

84

Asian Journal of Dietetics 2022

Table 1. Basic characteristics of participants
Prefecture(n=452)
Age

Sex
Work
history

Local healthpromotion andimprovement of
nutrition and eating
habits at the hygiene
administration
department (maingovernment office)Community
healthpromotionandimprovementofnutrition and dietary
habits at public healthcenters and healthcenters
Departments related
to food hygiene

Departments relatedtoolder
adults/Welfare
forolder adults

Child welfare

Board of education

20s
30s
40s
Over 50s
FemaleMale
No work experience<3 years
3–5 years
5–10 years
10–20 years
20–30 years>30 years
No work experience<3 years
3–5 years
5–10 years
10–20 years
20–30 years>30 years
No work experience<3 years
3–5 years
5–10 years
10–20 years
20–30 years>30 years
No work experience<3 years
3–5 years
5–10 years
10–20 years
20–30 years>30 years
No work experience<3 years
3–5 years
5–10 years
10–20 years
20–30 years>30 years
No work experience<3 years
3–5 years
5–10 years
10–20 years
20–30 years>30 years

85

n
110
79
120
143
430
22
249
80
73
31
15
3
1
11
93
54
75
132
73
14
406
22
10
11
3
0
0
435
8
6
2
1
0
0
421
8
15
5
3
0
0

(%)
(24.3)(17.5)(26.5)(31.6)(95.1)(4.9)(55.1)(17.7)(16.2)
(6.9)
(3.3)
(0.7)
(0.2)
(2.4)
(20.6)(11.9)(16.6)(29.2)(16.2)(3.1)(89.8)
(4.9)
(2.2)
(2.4)
(0.7)
(0.0)
(0.0)
(96.2)
(1.8)
(1.3)
(0.4)
(0.2)
(0.0)
(0.0)
(93.1)
(1.8)
(3.3)
(1.1)
(0.7)
(0.0)
(0.0)

Special wards andcities with publichealth centers (n=323)n(%)
69(21.4)
87(26.9)
84(26.0)
83(25.7)
311(96.3)
12(3.7)
187(57.9)
53(16.4)
31(9.6)
34(10.5)
14
(4.3)
3
(0.9)
1
(0.3)
13
(4.0)
81
(25.1)
44(13.6)
76(23.5)
69(21.4)
32
(9.9)
8
(2.5)
293
(90.7)
15
(4.6)
4
(1.2)
9
(2.8)
2
(0.6)
0
(0.0)
0
(0.0)
291
(90.1)
18
(5.6)
7
(2.2)
4
(1.2)
3
(0.9)
0
(0.0)
0
(0.0)
258
(79.9)
17
(5.3)
15
(4.6)
19
(5.9)
11
(3.4)
3
(0.9)
0
(0.0)

Municipalities(n=914)
n
227
284
262
141
890
24
11
281
133
189
183
107
10
706
98
37
36
23
12
2
730
49
47
51
28
8
1
796
47
22
32
12
4
1

(%)
(24.8)(31.1)(28.7)(15.4)(97.4)(2.6)(1.2)(30.7)(14.6)(20.7)(20.0)(11.7)(1.1)(77.2)(10.7)
(4.0)
(3.9)
(2.5)
(1.3)
(0.2)
(79.9)
(5.4)
(5.1)
(5.6)
(3.1)
(0.9)
(0.1)
(87.0)
(5.1)
(2.4)
(3.5)
(1.3)
(0.4)
(0.1)

Public health dietitians’ turning points and impressions

Table 2. Factors that left an impression on or were a turning point for administrative dietitians
Special wards andPrefecture
cities with public Municipalities(n=452)
healthcenters (n=914)(n=323)
n
(%)
n
(%)
n
(%)
Maternal and child health
2
(0.4)
16
(5.0)
109 (12.1)
Adult health
0
(0.0)
0
(0.0)
40
(4.4)
Welfare for older adults
12
(2.7)
2
(0.6)
35
(3.9)
Health guidance
12
(2.7)
28
(8.8)
121 (13.4)
Resident support
21
(4.7)
36
(11.3)
0(0.0)
General interpersonal work
0
(0.0)
0
(0.0)
129 (14.3)
Guidance to specific food service facilities 16
(3.6)
14
(4.4)
0
(0.0)
Collaboration with health mates
7
(1.6)
8
(2.5)
34
(3.8)
General collaborative work59
(13.1)
26
(8.1)
61
(6.8)
Community assessments
15
(3.3)
4
(1.3)
14
(1.6)
Work experience other than health and 46(10.2)
39(12.2)
106 (11.7)
sanitation departments
Working at the headquarter
30
(6.7)
8
(2.5)
0
(0.0)
Working at the public health center
3
(0.7)
6
(1.9)
0
(0.0)
Changing jobs to administrative position
13
(2.9)
14
(4.4)
27
(3.0)
Planning
15
(3.3)
15
(4.7)
50
(5.5)
Food environment improvements
11
(2.4)
0
(0.0)
0
(0.0)
Health crisis management46(10.2)
11
(3.4)
11
(1.2)
Research activities
27
(6.0)
10
(3.1)
0
(0.0)
Self-planned and managed projects
36
(8.0)
21
(6.6)
17
(1.9)
Presentation at academic conferences
6
(1.3)
4
(1.3)
5
(0.6)
Work behavior of people in the same
13
(2.9)
6
(1.9)
16
(1.8)
workplace
Municipal support
6
(1.3)
0
(0.0)
0
(0.0)
Duties and initiative as supervisors
1
(0.2)
0
(0.0)
2
(0.2)
Human resource development
9
(2.0)
0
(0.0)
4
(0.4)
Off-duty activities
4
(0.9)
1
(0.3)
4
(0.4)
Participation in training sessions
6
(1.3)
1
(0.3)
0
(0.0)
Business on food labeling
12
(2.7)
6
(1.9)
0
(0.0)
None
75
(16.7)
55(17.2)
191 (21.2)

86

Asian Journal of Dietetics 2022

Relationshipwith people

•
•
•
•

•
•
•

Maternal and child health
Adult healthWelfare for older adults
General interpersonal
work

•
•
•

Health guidance
Resident support
Work experience other thanhealth and sanitation
departments
Work behavior of people in thesame workplace
Off-duty activities
Participation in training session

Cooperation andcollaboration withother organizations
•
•
•
•

•
•
•
•
•
•

•

Human resource development

Overview of thecommunity

Guidance to specificfood service facilities
Collaboration withhealth mates
Generalcollaborative work
Business on foodlabeling•

Working at the headquarter
Working at the public health center
Planning
Food environment improvements
Health crisis management
Municipal support

•
•
•
•

Community
assessments

Research activities
Self-planed and managed projects
Presentation at academic conferences
Duties and initiative as supervisiors

Figure. 1 Three elements that left an impression on or were turning point for public health dietitians.
The impressions and turning points of dietitians
are categorized into (1) relationships with people, (2)collaboration
andcooperation
with
other
organizations, and (3) overview of the community(Figure 1). However, the three categories are notindependent of each other and all have something incommon. Put differently, what left an impression or
was a turning point for dietitians may be only one
category, but it may be related to two or morecategories. Additionally, the particulars of theimpression and turning points in each category differ
from person to person, as identified in their responses.
For example, regarding the impression of the“research activities,” one participant described themas “a tough job, but I felt a great sense ofaccomplishment when I got their cooperation”;
therefore, this response was categorized as (1)relationships with people, and (2) collaboration andcooperation with other organizations. Anotherparticipant described this impression as “throughbeing involved in a large-scale nutritional survey, thereality of the community has come into view before
my eyes,” and this response was categorized as (3)overview of the community. Categories (1) to (3) inFigure 1 are only classified according to thedescriptions of the participants of this study, and thecontent of the duties were not necessarily limited tothose categories.
Regarding category (1) relationships with people,
some participants described experiences of providing
health guidance to individuals and seeing theirimproved health checkup results in the following year.
Additionally, the gratitude expressed by the people
involved was described as one that left a lasting
impression on dietitians. Residents, health mates, anddietitians working for other organizations andinstitutions were described as cooperative
organizations. Participants categorized into (2)collaboration and cooperation in other organizations
described the difficulty of conveying their thoughts asa public health dietitian to other organizations, being
able to carry out projects in collaboration with otherorganizations, and broadening their perspectives intheir responses. The region to be overlooked differs
depending on the participants’ organization and may
be a prefecture, a municipality under the jurisdictionof the public health center to which the dietitian
belongs, or a municipality to which the dietitian
belongs. While formulating plans, such as healthpromotion plans and shokuiku (food and nutrition
education) promotion plans, and conducting
community assessments, project planning, budget
acquisition, and surveys, the respondents describedbeing able to grasp the region from a bird’s-eye view,which left an impression on them. This was also
described as having led to a turning point for some
respondents.
DISCUSSION
In a previous survey of public health dietitians
working in municipalities, project management,
establishing a cooperative system, and general
education and support were extracted as factors that
constituted confidence in duties (7). These threefactors correspond, respectively, to the categories usedin this study: overview of the community, cooperationand collaboration with other organizations, andrelationships with people. The previous survey has
also reported the positive experience of theeducational effect, as the experience of independent87

Public health dietitians’ turning points and impressions
project management was associated with project
management self-efficacy (7). This further
corresponds with factors described as leaving an
impression or being a turning point in the present
study.
Bandura states that self-efficacy is acquired
through four sources: performance achievement,
vicarious experience, verbal persuasion, andemotional arousal (8). In this study, the best
impression or turning point tended to be theachievement of executive behavior and verbal
persuasion. The few descriptions of vicarious
experiences may be explained by the fact that few
public health dietitians share the same workplace.
Public health dietitians’ interactions with people
depend on their duties. In general, the health statusesof patients in hospitals are more variable than that ofcommunity-dwelling residents. Therefore, it isthought that work experience other than health andsanitation departments are more frequently described
as leaving an impression or being a turning point.
Nutrition is the foundation for people to live wellthroughout their lives and is an essential element forrealizing a vibrant and sustainable society. Nutrition isrelevant at all life stages: pregnancy, infancy,
childhood, adolescence, adulthood, and old age.
Shokuiku (food and nutrition education) initiatives aredeveloped through collaboration and cooperation
among a variety of stakeholders, including nurseryschools, schools, governments, food-related groups
and organizations, and so on (9). For public healthdietitians to respond to such wide-ranging andchallenging issues, they must not only work with otheroccupations within the organization to which they
belong but also with various relationships, including
dietitians of organizations that they do not belong toand local residents. It is, therefore, necessary to
steadily promote measures and obtain results while
cooperating with other parties.
Furthermore, it is important for public healthnutrition activities to follow the plan-do-check-act
cycle based on community assessments (10).
Moreover, it is necessary to consider the entire
community when formulating budgets and various
plans. In the course of community assessments, whose
aims are to understand the actual and potential healthissues of individuals, families, and the entire
community, and consider solutions while clarifying
the causes and backgrounds, evaluation andimprovement of implemented measures was describedas the event that led to obtaining an overview of thecommunity. Additionally, it was noted that people
working at the headquarters tended to work at theprefectural level rather than those working at the
public health centers, which left a fresh impression on
them.
The three categories in this study are included in
the career note of lifelong education system for careeradvancement
shown by the Japanese Dietetic
Association (11). Katz has shown that effective
administration depends on three basic personal skills,
which have been called technical, human, andconceptual (12). The three skills correspond to thecategories in this study. By developing the three skills
through helping experience and train the three
categories it may prove useful in improving selfefficacy of Japanese public health dietitians.
The impressions and turning points are divided
into three categories in this study, however, as

mentioned in the results, there are many overlapping
factors. Furthermore, classifications were made basedon the descriptions provided by the participants of thisstudy. Therefore, there is a possibility that certain
work contents are related to categories that were notshown in the results of this study.
In this study, more than 10% of public healthdietitians described not experiencing any impressions
or turning points in their careers. Successful
experiences are important factors in enhancing selfefficacy as they tend to leave an impression or becomea turning point. Therefore, there is a need for a support
program that allows public health dietitians toexperience success and increase their self-efficacy.
This study has two limitations. First, to increase
the response rate of this survey, we obtained thecooperation of the Japan Dietetic Association and theJapanese association of public health center registereddietitians. The recovery rate was not high; however,
the exact recovery rate was unknown because theexact number of public health dietitians in Japan is
unknown. There is a possibility that the proportion of
respondents in this study does not represent the actual
administrative dietitians in Japan. Second, because
this survey was conducted during the COVID-19
pandemic, there was a high percentage of respondents
who said that health crisis management such as
infectious disease countermeasures left an impression
on them or served as a turning point.
CONCLUSION
We conducted a survey of public health dietitians
working in prefectures, special wards and cities withpublic health centers, and municipalities. Regardlessof the organization they worked for, the factors foundto have left an impression on or be considered asturning points for public health dietitians wereclassified into (1) relationships with people, (2)collaboration with other organizations, and (3)overview of the community. These results suggest that
it is important to support these experiences to raise theself-efficacy of public health dietitians.
ACKNOWLEDGMENTS
The authors thank all of the survey participants.
1.

2.

3.

4.

88

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Kojima M, Ogawa Y, Nakagawa K, Kusano A,
Seki Y, Hatano C, Isobe S, Tochikura E, Ishida E,
Yamazaki O, Hori J, Inoue Y, Suzuki K, YanabeN, Murakami N. Positive outcomes of salt
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results. Jpn J Nutr Diet., 78: 232-242. 2020.
Ministry of Health, Labour and Welfare.
Overview of regional health and healthpromotion
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Bandura A. Self-efficacy: Toward a unifying
theory of behavioral change. Psychol Rev 84:
191–215. 1977.

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public health dietitians in the community.
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Igarashi M, Yoshida T. Project management selfefficacy and related factors in municipal dietitian.
Jpn J Nutr Diet 69: 148–159. 2011.
Bandura A. Self-efficacy: The exercise of control.
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Vogelzang J, Yang J, Jimenez EY. Dietetic
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The fourth basic plan for the promotion of89

Asian Journal of Dietetics 2022

Original
Exploring Perspective of On-call Dietitian Residency Program among Healthcare
Personnel in a Government Tertiary Hospital: A Pilot Qualitative Study
Kong Jian Pei1*, Fatimah bte Othman2, Zarina bte Samsudin3, Basmawati bte
Baharom4
1
Dietitian (Klinik Kesihatan Bintulu, Sarawak, Bintulu, Malaysia)
2
Senior Dietitian (Hospital Sultanah Aminah, Johor Bahru, Malaysia)
3
Head of Dietetic and Food Service Department (Hospital Sultanah Aminah, Johor Bahru, Malaysia)
4
Head of Dietetic Profession (Hospital Kuala Lumpur, Malaysia)
ABSTRACT Background and purpose. In Malaysia, on-call service has been well establishedand as exists as part of arrangements to provide appropriate service cover across the national
tertiary government hospital especially by the profession of medical doctors, pharmacists, andnurses. Dietitian residency on-call program has been beginning nationwide government hospitalin 2013. Therefore, the main objective of the study is to explore the different perspective of oncall dietetic program among different health care providers based on a largest government
tertiary hospital setting ranked by bed capacity in southern zone of Malaysia, Johor . Methods.
Seven healthcare personnel participated in a semi-structured focus group. The participants
invited were come from various general practices in different department with different gender,
profession, and clinical experience. Key questions examined these individuals’ perspective about
on-call dietetic program. Result. This study identified four main categories that catalytic for the
better understanding of On-call Dietitian Residency Program among healthcare providers. There
were four categories: (1) Perception On-call Dietitian Residency Program among Healthcare
Personnel; (2) Redefining On-call Dietitian Residency Program; (3) Identified challenges fromOn-call Dietitian Residency Program and (4) Various concerns in ward during on-call shift.
Conclusion. Participants expressed positive comments about the 4-hour on-call weekend cover.
Key Words: on-call service, on-call Dietitian, focus groups, tertiary hospital
INTRODUCTION‘On-call’ is a term defined as being available towork outside one’s normal working hours.
Employees who work on-call are expected to beavailable at any time of day including weekend, tocarry out their working duties (1,2). It is widely usedby many different healthcare professions.
In Malaysia, on-call service has been wellestablished and as exists as part of arrangements toprovide appropriate service cover across the national
tertiary government hospital especially by theprofession of medical doctors, pharmacists, andnurses (3). Given wide range of areas, which could
potentially require support in a tertiary government
hospital, Dietitian residency on-call program has
been began nationwide government hospital in
2013. Such system has not yet introduced orpracticed in private sector of any countries,
including Malaysia. Up to the date, no literature
review or any study has published regard theDietitian residency on-call program.
Overall, the residency on-call program wasdesigned to offer a supportive environment in which
the resident is held accountable for pursuing optimal
outcomes of direct patient care from therapeutic
diet, enteral formula and nutrition care processmonitoring aspect. During late evenings of Friday,
weekends, and holidays, the clinical dietetics service
may not be available to assess. The on-call resident
is then assigned to provide such services. Medical
Nutrition Therapy information consultation includes

recommending enteral formula, assessing adverse
enteral formula events, recommending specificenteral or diet therapeutic administration, screening
for drug and nutrition interactions, recommending
regime for enteral formula, and identifying difficulty
oral intake. The resident also responds to emergency
diet related requests submitted to the Dietetic
department after business hours and on holidays andevaluates or even attending out-patient or inpatients’ basis. Residents also participate in foodservice-related responses, and their support iscrucial when the wrong diet received or wrong dietordering event occurred. Sometimes, any
unexpected event from outsourced or centralized
food service system might require communication
between food service dietitian and clinical dietitian.
The on-call dietitian resident is the first to respondto all patient related emergencies.
The traditional working hours for hospitaldietitians are between 08:00 and 17:00, Monday to
Friday. At weekends, there are minimal clinicaldietetics and food service services although dietitianis ready to standby throughout the day if there isurgency to be handled. This set-up leaves periods oftime during the weekends where there are no
hospital dietitians on site. After Dietitian residency
on-call program started nationwide, on-call resident
is expected to deliver additional 4-hour shifts
beginning at 0830 every Saturday. During an on-callshift, residents are expected to fulfill any required
rotation duties before leaving the hospital by nolater than 1230. Due to shortage of man force, thison-call program is initiated at government hospitalwith more than 6 permanent Dietitian residents.
On-call resident services are provided*To whom correspondence should be addressed:

johnkong1988@gmail.com
91On-call Dietitian Residency Program among Healthcare Personnel
throughout the year, regardless of program
activities. Through this mechanism, clinical services
are provided by onsite dietitian resident every day. If
residents are not present to provide the services,head of clinical service are assigned to on-call shifts.
In turn, the dietetic department provides equivalent
time off once the number of on-call duty hour
exceeded 8 hours. Each resident is assigned an equal
number of shifts.
It may be impractical for an institution to haveclinical Dietitian available 24 hours a day, but
having an on-call resident monitor selected patientslike refeeding syndrome, swallowing difficulty is
crucial ideally. This model resembles the medical
house-staff cross-cover model. The resident
provides the requested service during the on-callshift which may contributes to a continuity of highlevel care in long run.
Up to now, service commitments are often met
in the form of rotations or blocks devoted to apractice area. Some hospital meets this requirement
or criteria may benefit through such longitudinalpatient care experiences. This design is commonlyused in the medical, pharmacy or primary caresetting, where the focus is on managing chronic oracute diseases and promoting continuity of care.
These same models often hold true for dietetic
practitioners with direct patient care responsibilities.
However, many dietetic departments, particularly inthe 300 bed above tertiary care setting, struggle toprovide a high level of care directly to each patientaround the clock. It became the main issue ofcurrent on-call service, mainly of each tertiary
government hospital.
Therefore, the main objective of the study is to
explore the different perspective of on-call dietetic
program among different health care providers
based on a largest government tertiary hospitalsetting ranked by bed capacity in southern zone of
Malaysia, Johor. The benefit of this study is fourfold; first of all, this is the first study to report theexperience of dietetic residency on-call program.
Secondly, it revealed the weakness and strengths incurrent implementation model, as it may vary fromother similar medical profession for example,
pharmacy, medical or laboratory officers. Thirdly,
the data may reflect the necessary of on-callprogram in Malaysia government tertiary hospitalsetting. Fourth, the suggestion collected may aid thepolicy maker in avoidance of any unintended
consequences as several studies confirmed theassociation between longer work hours and fatiguerelated injuries in residents (4,5).

regulations. No compensation was provided forstudy participation. The interview was facilitated by
the experience moderator (Pn. Fatimah Othman) andassisted by the assistant moderator (Pn. Afifah Binti
Abd Rahim and Pn. Faulina Binti Khamisan). All
participants received written information, including
a statement that participation was voluntary and theresults of the study would be anonymous.
Participants: Two medical officers, onepediatrician, two practice nurses and two resident
dietitians (subsequently referred to as HPs)
participated in a focus group interviews. The
participants invited were come from various generalpractices in different department with different
gender, profession, and clinical experience. An overrecruitment of one or two participants is to pursue incase there were ‘no-shows’. The participants werebriefed about the study purpose one week before thefocus group discussion held. The characteristics ofthe focus group participants are presented in Table
1.
Study Sites: In this qualitative study, the datacollection was conducted at Hospital Sultanah
Aminah, in setting that would be comfortable forparticipants. Focus groups interview were held at amix language between English and Bahasa Melayu.
Procedure: FGs were led by experienced
moderators an assistant moderator (observer), whotakes notes during the discussions and make sure themoderator does not overlook any participants trying
to add comments. Note takers were present during
the session. The focus group (FG) lasted between 90
and 120 minutes audiotaped with permission of theparticipants. Food was provided at the end of thesession. All text was translated to English andtranscribed. Translation integrity was verified by anative-language speaker and FG moderators
reviewed transcripts for accuracy.
Interview
guide(Semi-Structured
Questionnaire): A semi-structured question guide(Appendix 1.0) was developed by the research team,aiming to identify different perspective of on-calldietetic program among different health carepersonnel based on the five categories of questions
and probes developed by Krueger and Casey (7).
Firstly, a warm-up opening (“tell us your name) andintroductory questions (Are you aware of the on-callservices provided by Dietetic Service?)(How do you
feel if there are 4-Hour On-call Dietitian Residency
Program or in vice versa?) which allowed
participants to get acquainted and feel connected,
and to start the discussion of the topic. Transition
questions (How urgent do you need response from a
Dietitian should be?) (How well do you know about
the variety of enteral formula?) (How far can you
commit to the extended services [on-call dietetic
residency program?) were used to move into
respectively by profession. Key questions addressed
the primary concerns of the study (Which is more
beneficial during on-call shift? Nutrition statusmonitoring or responding to new referral); (Inpractice, do you initiate feeding’s prescription
yourself over the weekend? How frequent? What is
the reference used?); (Do you verify the suitabilityof therapeutic diet during weekend?); (What is thechallenge(s) on implementing the on-call dietetic
residency program?); (What do you feel about theon-call dietetic residency program in short and longterm?) The key questions were led to the focus on

MATERIALS AND METHODS
Study Design: For this study we usedphenomenological approach qualitative method (6).
Between 1st October 2020 and 30 October 2020, we
conducted focus group interviews in order toexplore understanding of On-call Dietitian
Residency Program among Healthcare Personnel
based on a largest government tertiary hospitalsetting ranked by bed capacity in southern zone of
Malaysia, Johor. The study protocol was reviewed
and approved by the Medical Research and Ethics
Committee, Malaysia (NMRR-19–3818-52373). All
respondents provided written informed consent. All
methods were performed in accordance with therelevant national and international guidelines and92

Asian Journal of Dietetics 2022
the purpose of this study, what may or may not
influence the demand of dietetic residency during
weekend or public holiday. Finally, participants
were asked to share ideas (Can you suggest us a few
appropriate ways of implementation on-call dietitian
residency program?) concerning appropriate
implementation on-call residency program tocounter issue related to on-call residency program in
tertiary hospital. A pilot focus group was conducted
to determine the appropriateness of questions for
eliciting responses to the target issues, and for the
optimal length of focus groups. Data from the pilot
focus group were not included in the analysis

transcripts were entered into NVivo 9 and reviewed
line-by-line for categories (main categories) andideas (subcategories) (9).The basic idea was toexplore the understanding of On-call Dietitian
Residency Program brought up in discussion by theparticipants. We identified and discussed the text
units that summarised the discussions to ensure
consensus and that all data were appropriately
categorised. We then identified four main categories
that catalytic for the better understanding of On-callDietitian Residency Program among healthcare
providers. There were four categories: (1)Perception On-call Dietitian Residency Programamong Healthcare Personnel; (2) Redefining On-callDietitian Residency Program; (3) Identified
challenges from On-call Dietitian Residency
Program and (4) Various concerns in ward during
on-call shift. These four categories were discussed
and agreed upon by the authors.

Data analysis: The interviews were audio taped
and transcribed verbatim. The text units were coded;
we categorised statements based on the introductory
questions, using a systematic text condensation
inspired by Corbin and Strauss (8). In addition, theTable 1. Category by panel involved in focus group session
1

2

3

Panel
4

5

6

7

Age

40

28

29

42

45

27

35

GenderFemaleFemaleFemaleMale

FemaleFemaleMale

Pediatrician

Dietitian

Staff
Nurse

Physician

Demographic

Occupation

SeniorDietitian
SeniorStaff
Medical
Nurse
OfficerFirst category: Perception On-call Dietitian Residency Program among Healthcare Personnel
First
Y
—
—
—
subcategory
SecondY—YY
subcategory
Third
Y
Y
—
Y
subcategory
Second category: Redefining On-call Dietitian Residency Program
First
Y
—
subcategory
Second——subcategory
Third
—
Y
subcategory
FourthY—subcategory
Fifth
Y
—
subcategory
Third category: Identifying the challenges

Y

—

Y

Y

Y

—

—

—

Y

—

—

Y

Y

Y

—

Y

Y

—

Y

—

Y

Y

—

Y

Y

Y

Y

—

Y

Y

Y

—

—

Y

First
—
Y
—
—
subcategory
Fourth category: Various concerns in ward during on-call shift

—

Y

—

—

—

First
Y
subcategory
Second—subcategory
Third—subcategory
FourthYsubcategory
Fifth—subcategory
Note. Y : discussed in focus group

—

Y

—

—

Y

—

Y

—

—

—

Y

—

Y

—

Y

—

—

Y

Y

—

—

—

Y

—

Y

—

Y

93

On-call Dietitian Residency Program among Healthcare Personnel

RESULTS

Therefore, the results are summarized according to
the four major categories to express the purpose ofthis study (see Tables 2, 3, 4 and 5).

The perspectives discussed were highly
consistent across different healthcare personnel.

Table 2. Representative quotes for first category: Perception On-call Dietitian Residency Program among
Healthcare Personnel
Do you aware of On-call Dietitian Residency Program started since 2013?
“Tidak”
1"No"“tidak perasan ada Dietitian Oncall ”
5"Didn't notice there was an Oncall Dietitian"“Tidak tahu”
7"Dont know"
How do you feel if there are 4-Hour On-call Dietitian Residency Program or in vice versa?
“jika ada Dietitian Oncall kerana tindakan terus dapat dijalankan terus”
5"If there is a Dietitian Oncall the action can be taken quickly"“jika ada Dietitian Oncall pada hujung minggu adalah bagus”
1"If there is an Oncall Dietitian on the weekend, that is great"“sekiranya ada Dietitian Oncall adalah baik untuk kes-kes yang tertentu”
1"If there is a Dietitian Oncall is good for certain cases"“ia adalah idea yang baik jika ada Dietitian Oncall”
4"It's a good idea to have an Oncall Dietitian"“Oleh jika ada Dietitian Oncall kami akan dapat selesaikan banyak perkara”
4" if there is an Oncall Dietitian we will be able to solve many things"“Jadi jika ada Dietitian Oncall adalah lebih baik”
5"So if there is an Oncall Dietitian, it is better"“oncall ini adalah baik untuk pesakit ”
6"This oncall is good for patients"“Saya ada bertanya kepada kawan-kawan saya juga tiada masalah sekiranya tiada Dietitian Oncall”
3"I have asked my friends that there is no problem if there is no Oncall Dietitian"“Short term wise it is good thing when Dr kew our service, it will be Medical nutrition therapy can be
6more emphasized and patient can get benefit from it”“It will be better ada oncall dietitian because we have multiple problem di hospital”
1“jika ada dietitian oncall bagusla”
3"If there oncall dietitian, it is good "“it just that if there is oncall dietitian during weekend it could be better”
1
At this moment in time, do you need On-call Dietitian to handle urgent referrals?
“kami tidak rujuk Dietitian secara ‘non- planned’ pada hujung minggu”
7"We do not consult Dietitians by 'non-planned' basis on weekends"“urgency wise tidak menjadi isu kepada kami”
7"Urgency wise is not an issue for us"“Saya rasa tidak terlalu urgent untuk rujuk kepada Dietitian ”
1"I don't think it's too urgent to consult a Dietitian"“Kita tidak harapkan Dietitian dapat datang dan manage pada masa tersebut tapi kita akan rujuk
dietitian hari esok untuk sort the feeding”
4"We do not expect the dietitian to come and manage at that time but we will consult the dietitian
tomorrow to sort the feeding"“Tidak urgent sangat”
1"Not very urgent"“Jika saya lihat wad yang saya jaga, belum lagi memerlukan kita kena berada di tempat itu untuk
oncall”
2"If I look at the ward I'm in charge of, it doesn't require us to be there to oncall"“For me until now. I don’t see a case that require dietitian attention urgently or immediately”
7
Regular font styles: Original script
Italic font styles: Translated script
Number: Panel involved

94

Asian Journal of Dietetics 2022
First category: Perception On-call Dietitian
Residency
Programamong
Healthcare
Personnel.
For first category, we identified threesubcategories: (1) Do you aware of On-callDietitian Residency Program started since
2013?,(2) How do you feel if there are 4-Hour Oncall Dietitian Residency Program or in vice versa?,
and (3) At this moment in time, do you need Oncall Dietitian to handle urgent referrals? (see Table
2) .
First subcategory: Do you aware of On-callDietitian Residency Program started since 2013?
Three out of five participants except two inhouse Dietitians clearly speculated that they did notaware and did not know of such On-call Dietitian
Residency Program existed.
Second subcategory: How do you feel if there
are 4-Hour On-call Dietitian Residency Program orin vice versa?
‘Good idea’, ‘it could be better’ wereconsistently speculated in nearly all participants todescribe how they feel about the initiated 4-Hour
On-call Dietitian Residency Program in a tertiary
hospital setting. Participants clearly attributed thisprogram enable quick action can be taken to
resolve multiple issues or handling specificreferrals especially in a tertiary government
hospital setting. Particularly, patients’ outcome will
be benefited from medical nutrition services.
However, a participant also mentioned that they did
not meet any problems without aware of thisinitiated program by far based on their experiencedespite she also agreed that it was ‘fantastic idea’ ofsuch effort implemented.
Third subcategory: At this moment in time, do
you need On-call Dietitian to handle urgent
referrals?
It was agreed that most of participants did not
required On-call Dietitian to handle urgent referrals
as ‘not so urgent’ and ‘not a problem’, wasconsistently noted. A Participants clearly attributed
their department would refer the case to in-house
Dietitians in the next working day.

Second subcategory: What is urgent referral
required attention of On-call Dietitian?
In term of urgent referral, participants
especially physician agreed that there was times
where urgent attention from On-call dietitian might
required especially patient admitted and diagnosed
with ‘Myocardia Infarct (MI)’, patient experienced
with ‘electrolyte Imbalance’ and ‘diarrhea’ or even‘intubated patient’ with complication of ‘sepsis’ and‘cardiogenic shock’. A participant also highlighted
adult with chronic diabetes can also be consideredas critical to be handled as there required longer
duration of counseling which emphasised on
behavior change.
Third subcategory: What is tangible way tohandle urgent referrals?
Participants described being ‘more responsive’,‘easily contactable via phone’ were more tangible
to handle urgent referrals. Nearly all participants
appeared be somewhat agreement to thesesuggestion by nodding their head. One participant
stressed on the ‘practicality of passive On-call’rather ‘waiting in hospital to handle any referrals
required immediate attention’. Yet, one of theparticipants representing from in-house Dietitians
speculated that ‘passive On-call have always been
put into the practice of hospital’. ‘The respective
ward has their in-house Dietitians in charge’s
personal phone number’, so ‘they can contact theirward’s Dietitians anytime in fact’.
Fourth subcategory: Suggestion to improve Oncall Dietitian Residency ProgramFirstly, ‘review follow-up referral in ward
frequently’,
particularly‘patients
initiatedparenteral nutrition therapy’. Secondly, assigned
duty of On-call Dietitian from dietetic and foodservice department to be exact ‘in inspecting thesuitability of therapeutic diet received by admitted
patients in ward’. Thirdly, ‘leaving phone numberof On-call dietitian’ in every unit of ward. Fourth,‘On-call Dietitian assigned to be duty if there werelong public holiday’. Yet, it was noted that it was
not always possible to ensure task given to be
fulfilled within 4-Hour, sometimes, ‘problem or
immediate effort might be needed right after 4Hour of duty’. Thus, ‘0800 - 1700 of On-callDietitian Residency Program was suggested to be
more realistic and practicality’ especially ingovernment tertiary hospital.

Secondcategory: Redefining
On-callDietitian Residency
For second category, we identified fivesubcategories: (1) What is the role of On-callDietitian?,(2) What is urgent referral required
attention of On-call Dietitian?, (3) What is tangible
way to handle urgent referrals?, (4) Suggestion to
improve On-call Dietitian Residency Program(seeTable 3).
First subcategory: What is the role of On-callDietitian?
Participants commented the role of On-callDietitian should emphasis on ‘optimising’,‘adjusting’ therapeutic and enteral regime infollowing-up referrals particularly. A participantalso expressed a notion that by communicatingwith On-call Dietitian, this allowed theirdepartment to obtain sufficient quantity of required
enteral product even during weekend. Besides, aparticipant also expressed that monitoring thesuitability of therapeutic diet in ward basis andchecking the raw materials during receiving
process were part of the crucial task of On-callDietitian in hospital setting.

Third category: Identifying the challenges
For third category, we identified one
subcategories: (1) What are the challenges faced by
On-call Dietitian?, (see Table 4).
First subcategory: What are the challenges
faced by On-call Dietitian?
A major challenge to On-call Dietitian was
explicit workload. Both in-house dietitianrecognised that ‘it is impossible to cover every
ward in a government tertiary hospital by On-callDietitian’. The other participants being lessresponsive but somehow appear to be agreed with
the notion. One also said: “So it’s like the objectiveof On-call is still not cleared, sharp andimmeasurable. … ‘It is like wasting time if we as
On-call Dietitian is not clear with the task to becarry out’. At the end, the goals are not met but‘affected the quality of patient care’ and‘physicians, staff nurses will be affected at the95On-call Dietitian Residency Program among Healthcare Personnel
same time if mistake happened’. Another in-housedietitian said that, ‘When she was occupied, shewould preferably ‘only to offer follow-up or
dietetic service to her own patients in her ward incharged’ as she echoed that ‘counseling is a longprocess’ and ‘it involves not just dietarymodification but also behavior change’. This
explained why there are ‘not many participants
involved in this FGs did not aware of such On-callprogram initiated since 2013’. Lastly, for thosemarried, ‘it is even difficult when she has to figureout where to send their children’. Until the present,
one mentioned that she still ‘can commit to the Oncall program as the frequency and duration of Oncall service is not high and long’. Another in-housedietitian as participant involved remained silent andless responsive in comparison to their peers whenrefer to commitment.

Table 3. Representative quotes for second category: Redefining On-call Dietitian Residency Program
What is the role of On-call Dietitian?
“jika ada apa-apa masalah yang berkaitan dengan perubahan diet atau susu pesakit pada hujung minggu”"If there are any problems related to changes in the patient's diet or oral nutrient formula over the
weekend"“mulakan special feeding kepada pesakit tertentu seperti pesakit Chylothorax”"Initiate special feeding to certain patients such as Chylothorax patients"“Agak menyusahkan jika pesakit tidak serasi, jadi jika perlu tunggu hingga ke hari Ahad kesian kepada
pesakit. ”"It's quite difficult if the patient is in difficulty, so have to wait until Sunday, feel sorry for the patient”“beliau akan fine tuning keperluan pesakit seperti tambah keperluan protein dengan menambah myotein”"He will fine tuning the patient's needs such by adding myotein"“Dietitian amat membantu untuk optimise feeding pesakit ”"Dietitian is very helpful to optimize patient feeding"“Kita perlukan Dietitian untuk adjust feeding”"We need a Dietitian to adjust feeding"“Oleh itu, saya akan menjalankan rawatan susulan untuk pesakit saya sahaja ketika oncall”"Therefore, I will conduct follow -up treatment for my patients only during oncall"“kami juga menjalankan perkhidmatan sajian seperti pemantauan ketepatan diet teraputik dan
pemeriksaan penerimaan bahan mentah”"We also run catering services such as monitoring the accuracy of therapeutic diets and checking thereceiving process of raw materials"“at least kalu kita dah spoken dengan dietitian, dia dah benarkan untuk kami dapat bekalan susu sebanyak
ni sehingga hari bekerja”"At least if we have spoken to the dietitian, he or she allowed us to get the sufficient formula supply for
until next working day"What is urgent referral required attention of On-call Dietitian?
“Terutama jika kami ada pesakit Miocardiac Infarct (MI) yang masuk wad dan tidak tahu apa diet yangsesuai ”"Especially if we have Miocardiac Infarct (MI) patients who are in the ward and do not know what theappropriate diet"“jika pesakit diarhea kita tidak tahu susu apa yang sesuai untuk diberikan kepada pesakit”"If the patient has diarrhea we do not know what formula is suitable to give to the patient"“Kami perlu lihat ‘electrolyte Imbalance’ , ada sesetengah pesakit yang tidak sesuai menggunakan susu
biasa”"We need to look at 'electrolyte imbalance', there are some patients who are not suitable to use regularformula"“pesakit yang ‘intubated’ mengalami masalah-masalah tertentu seperti…..lose, demam, cardiogenic shockatau sepsis. Berkemungkinan, kami memerlukan saranan daripada Dietitian”‘Intubated’ patients experience certain problems such as…..loose stool, fever, cardiogenic shock or
sepsis. Most likely, we need advice from the Dietitian ”“untuk pesakit dewasa adalah sangat sukar. Jadi mereka mungkin memerlukan lebih kaunseling dietterutama kepada pesakit diabetes”“For adult patients it is very difficult. So they may need longer duration of diet counseling, especially fordiabetics”
What is tangible way to handle urgent referrals?
“pada saya tiada masalah sekiranya Dietitian response dalam masa 24 jam”
"I have no problem if the Dietitian responds within 24 hours"“Saya rasa Dietitian tidak perlu ada, sekiranya Dietitian mudah untuk dihubungi”"I don't think Dietitian shoud be there during weekend, if the Dietitian is easy to contact"“Dietitian tidak perlu tunggu di hospital sahaja tunggu kes jadi seperti Pasive Oncall. Jika tidak, tidak
perlulah datang ke hospital”“Dietitians do not have to wait in the hospital, just waiting case through Passive Oncall. If there nocases, there is no need to come to the hospital "“Senang untuk kita hubungi. Macam doctor Passive Call”"It's easier for us to call for help. Like a doctor Passive Call ”“senang untuk kita hubungi jika ada apa-apa masalah”"easier for us to contact if there are any problems"

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Asian Journal of Dietetics 2022
“Kami tiada masalah sekiranya doktor HO/MO bertanya melalui telefon”"We have no problem if the HO/MO doctor asks over the phone"“Sebenarnya untuk pengetahuan doktor, kita dah jalankan pasif oncall. Jika ada masalah mereka akan
berhubung dengan Dietitian tanpa mengira waktu”"Actually, for everyone’s information, we have run passive oncall long ago. If there is a problem they
will contact the Dietitian regardless of the time"
Suggestion to improve On-call Dietitian Residency Program“Jika cuti hujung minggu yang panjang seperti ada hari Cuti Kelepasan Am, Dietitian boleh datang padawaktu pagi”"If the weekend is extended from Public Holiday, the Dietitian better come to duty in the weekend’s
morning"“Bagi saya, apa yang urgent adalah Dietitian perlu selalu follow up/regular review pesakit kerana kamiada NST yang memerlukan input daripada Dietitian”"For me, what urgent is the Dietitian should always follow up/regular review of patients because we NST(Nutrition Support Team) that requires inputs from the Dietitian"“Mesti ada sorang yang bertanggungjawab mungkin seperti pegawai catering yang mengingatkan
jururawat untuk periksa diet yang betul diterima oleh pesakit”"There must be someone in charge maybe like a catering officer who reminds nurses to check the correct
diet received by patients"“Sepatutnya, ada pegawai yang bertanggung jawab. Mungkin dari Pegawai dari bahagian Sajian atau
Dietitian”“Supposedly, there are officers in charge. Maybe from an Officer from the Catering or Dietitian ”“I rasa dietitian oncall the whole day is better dari oncall selama 4 jam, sebab kadang-kadang dalam masa
4 jam tersebut tiada masalah, tapi bila dah balik ada problem”"I think dietitian oncall the whole day is better than oncall for 4 hours, because sometimes within 4 hours
there is no problem, but after 4pm there is a problem"“jika ada dietitian oncall bagusla, tapi kena inform wad sebab selama ni, tak tau ada passive call”"If there is a oncall dietitian, that is great but have to inform the ward because so far, I don't know if
there is a passive call"“Cadangan untuk tinggalkan no telefon untuk dihubungi jika ada kes urgent yang dirujuk dari doktor”"Suggestion to leave a phone number to be contacted if there is an urgent case referred from a doctor"“contohnya tinggalkan no telefon. At least kalau tak dapat datang, at least dapat berkomunikasi”"For example, leave a phone number. At least if can't come to assist, at least we can communicate"
Regular font styles: Original script. Italic font styles: Translated script. Number: Panel involved

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Table 4. Representative quotes for third category: Identifying challenges of On-call Dietitian Residency Program
What are the challenges faced by On-call Dietitian?
“Jadi tidak terasa sangat kerana kita akan ikut giliran 2 bulan sekali. Dari segi komitmen oleh kerana tidak
terlaku kerap pada saya tiada masalah”
2"So it does not feel any discomfort because we will rotate once every 2 months. In terms of commitment, it
doesn't happen any difficulties to me"“Tetapi sekiranya seorang dietitian perlu menjalankan perkhidmatan klinikal untuk 1 hospital, tetapi hanya
untuk 4 jam, pada saya adalah sukar kerana tidak dapat cover pesakit untuk satu hospital ”
2"But if only one dietitian has to run clinical services for one hospital with only allowed 4 hours, for me it isdifficult because we cannot cover patients for one hospital in that amount of time"“Oleh itu, saya akan menjalankan rawatan susulan untuk pesakit saya sahaja ketika oncall ”
6"Therefore, I will conduct follow -up treatment for my patients only when oncall"“jika nak oncall, kena tahu objektif oncall” … Bagi saya, jika objektif tidak menepati, tak dapat diukur,
ditakuti, akan membuang masa macam tu je”
2"If you want to oncall, you need to know the objective of oncall"… For me, if the objective does not meet,cannot be measured, it will waste time like that"“kebajikan pekerja akan terjejas, objektif tak nampak, workload bertambah. … Contohnya jika ada yangada family, dia perlu kena fikir nak hantar anak kemana jika tiada pengasuh”
2"welfare of Employee will be affected, objectives are not seen, workload will increase. … For example, if
someone has a family, he needs to think about where to send the child if there is no babysitter”“satu dietitian kena cover semua wad dlm hospital dan tiada penyelesaian yang bagus, kita akan overload
dengan kerja”
6"One dietitian has to cover all the wards in the hospital and if there is no good solution, we will beoverloaded with work"“Contohnya counselling, it’s a long process, kita perlu mendapatkan diet history dan adjust from there as itis behaviour change”
6"For example counseling, it's a long process, we need to get a diet history and adjust from there as it isabout behavior change"“So if you have so many patient and you have to settle the entire ward, you can imagine the quality of theoutcome of the patient. It won’t as good as if when we have better pace to manage the patient. And if the
6
work quality isn’t good our other team such as physician, staff nurse will be affected at the same time. Not
just the dietetic service”

Regular font styles: Original script. Italic font styles: Translated script. Number: Panel involved97On-call Dietitian Residency Program among Healthcare Personnel

Table 5. Representative quotes for fourth category: Various concerns in ward during On-call shift
How well do you know about the indication of therapeutic diet?
“Saya rasa bagi jabatan Paediatrik, banyak doctor atau jururawat tidak tahu diet yang sesuai”"I think for the Pediatrics department, many doctors or nurses do not know the appropriate diet"“Kami tidak pandai lagi kirakan kalori”"We are not good at counting calories"“Saya rasa ramai yang tidak tahu. Kebanyakan jururawat hanya tahu pengetahuan asas sahaja”"I think many people do not know. Most nurses only know the basics”
How well do you know about the indication of enteral formula?
“Saya rasa 3 formula yang saya setakat tahu”"I think 3 formulas that I so far know"“Saya rasa 4. Saya faham jenis susu untuk kegunaan apa”
“I think 4. I understand what kind of these formula used for”
“kita akan lihat cara bancuhan pada tin atau paket dan kotak. Lihat berapa ml air”
"We will look at the label of the formula for dilution. See how many ml of water"“Kadang-kadang doktor akan bagi arahan RTF mengikut jumlah sukatan air”
"Sometimes the doctor will give RTF (Ryle’s Tube Feeding) instructions according to the amount ofwater"
Do you verify the suitability of therapeutic diet?
“Tiada yang mengesahkan diet teraputik yang betul diterima kepada pesakit ”"No one verify the accuracy of therapeutic diet received by patients"“jika betul-betul periksa jenis diet, tiada pegawai yang mengesahkan kerana PPK (Pembantu
Prrawatan Kesihatan) yang akan pesan diet pesakit berdasarkan BHT pesakit”"If really check the accuracy of therapeutic diet, no such proper officer will confirm because the PPK(Ward assistant) will order the patient's diet based on the patient's Bed Head Ticket (BHT)"“Saya tidak rasa jururawat atau doktor akan sempat untuk lihat diet terima dengan beban tugas di wadyang banyak”"I don't think nurses or doctors will have time to check the accuracy of therapeutic in ward level withthe workload"
Do you verify the drug-nutrients interactions?
“Jika di Wad Kardiologi, jika pesakit ada bertanya baru jururawat akan terangkan”"If in the Cardiology Ward, if the patient asks, the nurse will explain"“Saya rasa jururawat sedar kepentingan interaksi ubatan dengan diet. Seperti contoh pesakit yangmempunyai masalah thyroid mempunyai ‘Ryles Tube Feeding’ perlu ambil thyroxin 1mg dengan
perut kosong”“I think nurses are aware of the importance of the interaction of medicine with diet. For example,
patients with thyroid problems with ‘Ryles Tube Feeding’ need to take 1mg thyroxine on an empty
stomach”“Hanya ‘compliance’ daripada pesakit akan ikut atau tidak. Tapi kebiasaanya, mereka akan mengikut
arahan”"Only depend on 'compliance' from patients, whether to follow or not. But usually, they will follow the
instructions"
Regular font styles: Original script. Italic font styles: Translated script. Number: Panel involved
Fourth category: Various concerns in ward
during on-call shift
For fourth category, we identified fivesubcategories: (1) How well do you know about theindication of therapeutic diet?,(2) How well do you
know about the indication of enteral formula?, (3)Do you verify the suitability of therapeutic diet?,
(4)
Do
you
verifythedrug-nutrients
interactions?(see Table 5).
First subcategory: How well do you know about
the indication of therapeutic diet?
Nurses and medical officer participantssuggested that they might be ‘not good in calorie
counting’ and ‘insufficient knowledge oftherapeutic diet indication’. However, one staff
nurse participant highlighted that she only knew the

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‘basis knowledge of therapeutic diet’.
Second subcategory: How well do you know
about the indication of enteral formula?
Senior staff nurse participant remarked that she
only ‘knew about 4 enteral formulas’ especiallythose often used in her ward in-charged. She statedthat she ‘followed the fluid indication by medical
officer in regime dilution’ if the admitted patients
have not yet optimised by in-house dietitians
during weekend. In comparison to her peers, juniorstaff nurse participant ‘knew about 3 enteral
formulas’ up till the present, she would rather ‘referto the product labeling to dilute the formula’ on
those referrals not yet seen by in-house dietitians
particularly during weekend.
Third subcategory: Do you verify the suitability

98

Asian Journal of Dietetics 2022of therapeutic diet?
Threeparticipants
demonstrated
withaffirmative attitudes that ‘there was no one orofficer to verify the diet received by admitted
patients. A senior medical officer expressed that ‘it
was not possible for medical doctors or nurses tocarry out this duty as there were multiple concerns
in ward’.
Fourth subcategory: Do you verify the drugnutrients interactions?
Interestingly, participants demonstrated ‘staff
nurses and medical officers were aware of drugnutrients interactions. For example, medical officer
participant highlighted that ‘he often reminded
Ryle’s Tube Feeding patients diagnosed withthyroid required to administer thyroxin 1 mg withempty stomach’. However, one participant statedthe ‘compliance drug-nutrients interactions related
advice required to be addressed by patientsthemselves, whether they would want to follow ornot’.

neurology physician in a Spanish general hospital,
author believes the similar positive outcome would
be replicated in this program under long run
particularly in improving the quality of attention to
the patient, reducing the duration of admission andimproving the nutrition status of patients (11).
Since nutrition status impacts significantly on
health-related outcomes, effectiveness of medical
treatments, and cost of care (12).
In hospital, admitted patients often missmultiple meals owing to being kept on “nothing by
mouth” instructions for medical tests andprocedures. Sometimes, there were kept on NBM
due misleading instruction. Some begin to lose
muscle mass at a rate of 0.5% of total body muscle
mass per day, which can lead to malnourished very
quickly (13). Therefore, participants still
highlighted that the role of On-call dietitian should
focus on ‘initiation’, ‘adjusting’, ‘opmitising’feeding regime especially in follow up referral. The
statement is concordance with the evidenced foundby Eckert and Cahill in their CMAJ article, aneffective strategy for preventing malnutrition is to
involve the dietitian early, within 24 hours of
hospital admission (14). Nevertheless, he or sheneeds to ensure respective ward in different
departments obtain sufficient oral nutrition
supplement beverage to feed patients. Ideally,
randomly checking patients’ therapeutic diet isconsidered essential from the conversation ofparticipants. Study found inaccurate of meals
provided to patients on in a tertiary public hospitalcan be as high as 25-52% (15).
So far, there were no studies to define ‘urgent
referral’ in scope of dietitians. A latest study carriedout to identify predictors and different medical
conditions for dietitian referrals in Austrian hospitalsettings (16). Results indicated that involvement ofdietitian urgently needs to be improved. In fact,
there were no significant predictors rather thanmalnutrition to indicate dietitian referral in thisstudy. Therefore, this FDs provided a good insightthat patient experienced with diarrhea, electrolyte
imbalance, intubating, sepsis, cardiogenic shock, or
uncontrolled diabetes could be the predictors forthe attention of On-call dietitian.
To handle urgent referral, nearly all participants
agreed 24-Hour passive On-call were a better
option rather than 4-Hour On-call program held
during one of the weekends. Besides, ‘easily
contactable’ was another term emphasised by 3
participants in the FGDs. However, thesesuggestions could be most likely the participants
aware the number of On-call dietitian was merely
one man how. Unlike On-call studies from UK
hospital pharmacy services, allied healthconsidered medicines advice is an integral part ofthe pharmacy on-call service (17). Nearly 80% ofthem provided training prior being on-call withexisting standards for documentation of medicines
advice.
Similarly, to the above discussion, participants
attributed that broadcasting the 4-Hour On-callservices is the immediate action that need to betaken. As the impact of such program could hardly
be alert if there was no promotion being carriedout. Besides, leaving phone number of in-charged
On-call dietitians as respective ward is essential.
This service is utterly critically to be arranged or

DISCUSSION
This FG study is the pilot study to qualitatively
explore the perspective of On-call Dietitian
residency program among healthcare personnel in a
Malaysia government tertiary hospital. Prior to thisresearch, there is no protocol or clear objectives of
how to implement this On-call Dietitian program.
Therefore, it was all started without early planningor well-structured protocol by Ministry of Health todiscuss the term and impact in detail. For the
beneficial of patient outcomes, this On-call service
program running by in-house dietitians has been
put into practice for almost 6 years. Therefore, thisstudy is to summarise the perspective among
healthcare personnel involved in government
tertiary hospital, where authors would keen to look
for perception among healthcare personnel, atangible protocol to underline the structure of the
program, challenges, as well as other concerns
raised.
Looking in more detail at the first category, it
was found that awareness of On-call Dietitian
Residency Program is poor. Again, nearly all staff
nurse, medical officer and physician participants
agreed that they did not require On-call Dietitian tohandle urgent referrals up to this point. In thiscontext, author would wish to highlight that the
program is still considered at early infancy stage,
therefore, there were no database to support theneeds of On-call Dietitian to handle urgent
referrals. In fact, dietitians have been historicallyworking in adult acute services for few decades(10). In facing the large number of referrals in daily
routine, dietitians have to be selective and decide
which patients need the most urgent dieteticintervention and prioritise their referrals
accordingly. Therefore, it was believed that
healthcare personnel may work hand in hand to
define the urgency referrals according tocontribution of dietitian in daily acute services.
In spite of all these, majority of them gave
positive responses on this initiated effort andsupported the fact that it would provide beneficial
outcome to patients at the end. Concordant with thesimilar findings of previous On-call studies among99

On-call Dietitian Residency Program among Healthcare Personnel
might consider to be extending during long public
holiday as Malaysia is multiracial country. In spite
participants realized there is one On-called dietitianon duty, up to this point, inspection of therapeutic
diet served in ward can’t be overlooked. Author
suggested a random spot checking can be held toward where there are referrals need to be handled atthat time.
FGs conducted revealed that other professions
support the idea of 24-Hour On-call rather 4-Hourdue to beneficial of patient’s outcome and better
work flow and communication. However, resident
dietitian involved in this program attributed thatthose she might be overload with work load. She
mentioned that it creates negative impacts herself
and her family life. While on-call work scheduling
may not come with human costs, On-call
employees must plan their lives and the lives of
their families around a call schedule. Previous
study concluded workers who extend their duty inlate afternoon and evening shifts has been related toincreased stress for both workers and their families(2). It is thus not surprising that researchers havefound that on-call work patterns can have a major
influence on employees' lifestyles and theirinteractions with family members and friends (18).
However, the health effects of on-call work, where
workers are called to work either between regular
hours or during set on-call periods has not meritedas much attention.
Another challenge needs to be addressed is theunclear objectives and the lack of complete
standard of procedures at the present. Dietitianparticipants echoed there was lack of suchcompletedocumentation.
Therefore,
theimmeasurable work quality does not highlight the
impact of service but aggravate existing outcome ofwork quality. Worst, other allied health that works
close with us might be affected as well. These often
oblige employee’s willingness to restrict their oncall activities.
The current body of literature on nurses'
nutritional knowledge regarding therapeutic dietregimens revealed that most of them had limited
knowledge about low-cholesterol diets and sourcesof water-soluble fiber, fatty acids and the specificfood items (19). The study addressed that there isan urgent need to update the contents of nutrition
education for nurses. This FDs explicit similar
context where nurses and medical officer
participants suggested that they might ‘not good incalorie counting’ and ‘insufficient knowledge oftherapeutic diet indication’.
However, HCPs have reported being
inadequately equipped, in terms of knowledge andresources, to manage malnutrition due to lack ofnutritional training (20). Studies reported time
constraints have been noted as barriers. Thesefinding was coherence to our finding whereby nondietetic participants in this FGs reported there werelack of knowledge in oral nutrition supplement.
Limited evidence indicated the impact on patients’outcome, however, the inappropriate ONS usage
should be resolved or avoided at all cost.
An observational study published in 2016
demonstrated therapeutic meals of 67 patients
occurred 19.9% of errors out of total 347 meals. A
large proportion of these errors were critical(64.8%) (21). These data illustrated participants in

FDs high lighten the critical of checking
therapeutic meals at the point of ward level.
Participant also agreed the checking process
required a certain level of diet knowledge. Thus,
dietitian or food service dietitian is the best
candidate to ensure prescription of these diets able
to adequately meet their nutritional requirements.
Drugs can interact with nutritional compounds,
and their pharmacokinetics can be affected by apatient’s nutritional status (22). These effects can
be clinically positive or negative and vary insignificance. Senior staff nurse and medical doctor
in this FGs sound affirmative where they wereconfidence that most nurses and medical officers
aware of this interaction significantly affectpatients’ outcome.
In conclusion, this study has provided acommentary on the dietitian on-call service and an
in-depth look at what an on-call service can provide
based on the real life experience in a Johor
government tertiary hospital. It has found that theparticipants expressed positive comments about the
4-hour on-call weekend cover. However, to look
into much more representative result, a multicentered qualitative research is necessity to address
the role of On-call dietitian.
In order to enhance the quality of on-callservice, author would like highlight a few criteria.
Firstly, it was necessary to considered developing
competence guideline of on-call duties undernational allied health act. Under the proposed bill,it should assist in determining scope of practice ofon-call dietitian and establish systems to ensure noone practices outside his/her scope of practice.
Secondly, On-call referral should be developed.
These were largely due to inappropriate referrals.
Dietitian should not expect other disciplines tohave an in-depth understanding of the effectivenessof medical nutrition interventions in varying
circumstances. Therefore, by developing on-callreferral, it not only offers excellent opportunities to
educate others on the role of on-call dietitian but
achieve beneficial effect to patients sufferingvarying illness condition. Lastly, emergency duty
protocols need to be developed. This written
protocol should help provide a safe framework forbasic practice, enabling on-call clinical dietitian tomake clinical decisions within the scope of theirown knowledge and experience. From this study,
despite the majority of hospitals having a written
emergency duty protocol, these offered guidance on
service provision rather than guidance on patientcare. This type of protocol would therefore notassist inexperienced on-call dietitians in making
decisions and implementing appropriate treatments
for specific conditions. Professional groups should
be working to developing on-call clinicalguidelines among profession of dietitian which will
help them with decision making in the on-callsituation.
Strengths and Limitations. Concerning single
center study, the general result may not represent
the actual experience in other part of Malaysia. In
spite of language concordance was not achieved,
the moderators are familiar with the respective
communities; therefore, it has no influence to thefollow up questions. Further, participants in thisstudy contributed almost equally throughout thesession due to longer and comfortable session was100

Asian Journal of Dietetics 2022
allowed. Finally, the present study used qualitative
design with open-ended questions to encourage
discussion in the group sessions. We used thismethod to obtain an in-depth understanding of eachindividual HP’s perception toward the program.

Kesihatan
Malaysia.
https://www.pharmacy.gov.my/v2/ms/services.
2020.
4.

L.K. Barger, M.S. Runyon, M.L. Renn, C.G.,
et al. Patterson Effect of fatigue training on
safety, fatigue, and sleep in emergency
medical services personnel and their shift
workers: a systematic review and metaanalysis 22 (1): 58-68. 2018.

5.

Salminen, Simo. Shift Work and Extended
Working Hours as Risk Factors for
Occupational Injury ". The Ergonomics Open
Journal. 3: 14-18. 2010.

6.

Davidsen AS. Phenomenological approaches
in psychology and health sciences. Qual Res
Psychol 10:318–39. 2013.

7.

Krueger RA. Developing Questions for Focus
Groups. Thousand Oaks, California: Sage
Publications. 1998.

8.

Corbin, J., Strauss, A. Basics of Qualitative
Research. Thousand Oaks, CA: Sage. 2015.

9.

QSR International. NVivo qualitative data
analysis software. 9 ed. QSR 386 International
Pty Ltd. 2010.

ACKNOWLEDGEMENTS
The authors would like to thank the Director
General of Health Malaysia for his approval toconduct this study. We would like to acknowledge
the continued support and devotion from Head ofDietetic Profession (Pn.Basmawati Baharom) andHead of Dietetic and Food Service department of
Hospital Sultanah Aminah (Pn. Zarina Samsudin)
for their support and advice throughout the study.
Thanks to all field respondents who haveparticipated in the study. Our sincere appreciation
is extended to Pn.Fatimah Othman who facilitates
the interview, our field assistant moderator: Pn.
Afifah bte Rahim, Faulina bte Khamisan who
assists the interview session and not to forget all thestaffs in dietetic departments of Hospital Sultanah
Aminah for contributing their time in assisting forthe interview.
AUTHORS’ CONTRIBUTION
Semi-Structured Questionnaire was developedby the members (Kong Jian Pei, Fatimah bte
Othman,Norshariza
Jamhuri,Basmawati
Baharomfrom, Dr Hamdan Bin Mohamad, Zarina
bte Samsudin, Khalizah bte Jamli, Lina bte Isnin,
Siti Farrah Zaidah Mohd Yazid, Kartini Abdul
Karim, Hamidah Ahmad, Rozalina bte Idris,
Norafidza Ashiquin Abd Patah Muhammad Faiz
Abdul Aziz, En Muhamad Arif Abdullah) of
Technical Committee of Dietetic Quality andResearch Bureau, Ministry of Health, Malaysia(Teknikal Biro Kualiti dan Penyelidikan Profesion
Pegawai Dietetik Kementerian Kesihatan Malaysia).
The corresponding investigator involved in thedesign of the study, analysis and interpretation of
the study. Pn.Fatimah Othman involved in the datacollecting, facilitating and analysing of the study.
Mr.Kong Jian Pei participated in drafting, writing,and editing manuscript; Pn.Basmawati Baharom
has reviewed and provided second opinion to themanuscript. All authors have involved in reviewing
and approving the final version of the manuscript.
All authors affirm that the content has not been
published.

10. Priscilla Harries, HulyaGokalp, Miranda
Davies, Christopher Tomlinson, Mary
Hickson. Enhanced referral prioritisation for
acute adult dietetic services: A randomised
control trial to test a web-based decision
training tool ". Clinical Nutrition 37(5): 14561461. 2018.
11. Sopelana D, Segura T, Vadillo A, et al.
Beneficio de la instauración de guardias deneurología de presenciafísica en un hospital
general. Neurologia 22(2):72-7. 2007.
12. E. Agarwal, M. Ferguson, M. Banks, M.
Batterham, J. Bauer, S. Capra, et al.
Malnutrition and poor food intake areassociated with prolonged hospital stay,frequent readmissions, and greater in-hospitalmortality: results from the Nutrition Care Day
Survey 2010. Clin Nutr 32:737-745. 2013.

CONFLICT OF INTEREST

13. Wall BT, van Loon LJ. Nutritional strategies
to attenuate muscle disuse atrophy. Nutr Rev
71: 195–208. 2013.

The authors declared no conflict of interest.
This study was supported by Ministry of Health,
Malaysia (number: NMRR-19–3818-52373).

14. Eckert KF, Cahill LE. Malnutrition in
Canadian hospitals. CMAJ 190:E1207. 2018.

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22. White R, Ashworth A. How drug therapy canaffect, threaten and compromise nutritional
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20. C. Ziylan, A. Haveman-Nies, E.J.I. van
Dongen, S. Kremer, L.C.P.G.M. de Groot.

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Asian Journal of Dietetics, 2022

Research Note
Enhancing the Skills and Competencies of Nutrition and Dietetics Students
in the Philippines to Manage COVID-19 by Reinforcing Hospital Practicum Programs*Cecile Klaudine C. Cabigas, RND, MSc. 1 Marietoni B. Pico, RND2,
Cecile Leah T. Bayaga, RND, PhD.2
1

Nutrition Clinic, Department of Food Science and Nutrition, College of Home Economics, University of
the Philippines, Diliman, Quezon City, Philippines.
2
Breastmilk Research Laboratory, College of Home Economics, University of the Philippines, Diliman,
Quezon City, Philippines.

ABSTRACT Background: Undergraduate students of Nutrition and Dietetics (ND) in thePhilippines are required to complete 600 hours of the hospital dietetics practicum program in
the senior year. However, training hours allotted to the management of highly infectious
diseases like COVID-19, are minimal. The current health situation necessitates a review of
the undergraduate hospital practicum to enhance relevant skills and competencies. This study
aimed to improve the existing hospital dietetics training or undergraduate hospital practicum
by the inclusion of learning outcomes that would enhance skills and competencies of thestudents to manage COVID-19. Methods: In this qualitative study, individual interviews ofRegistered Nutritionist-Dietitians (RNDs) in selected dietary departments and focus group
discussions (FGDs) with the Chief Dietitians were used as the main methods of datacollection. Results from the interviews and FGDs were used as the basis for an addendum tothe hospital dietetics practicum manual that was recommended to the Council of Heads andDeans of Nutrition and Dietetics (CODHEND). Results: Interviews and FGDs substantiatedthe key challenges that the student affiliates encountered during the practicum and theinnovations the dietary departments implemented to address the limitations in operations dueto the COVID-19 pandemic. The proposed addendum to the practicum manual included
recommendations for the; (1) patient care unit, particularly on the communication systems
between admitted and discharged patients and the dietetics team; (2) food service andadministration department, specifically on the standardization of the protocol for
procurement, handling, and storage of the supplies for the dietetics department for thecontinued operations of COVID wards; and, for (3) the education and research unit,
specifically for developing appropriate materials and on the execution of nutrition education
sessions and online nutrition consultations. Conclusion: Inclusion of the recommended
learning outcomes and activities in the current hospital practicum of BSND students in thecontext of the COVID-19 pandemic was seen to be essential in ensuring that students areequipped with related knowledge and skills to provide quality nutritional care even during
unprecedented health situations.
Keywords Hospital Dietetics Practicum, COVID 19 Education
1. Identify measures employed by nutrition and
INTRODUCTION
dietetics department of hospitals to address
The COVID-19 pandemic significantly altered
COVID-19;
global health systems. Frontliners, particularly
2. Combine the findings from the preliminary
Nutritionists-Dietitians (NDs), were expected tosurvey and consultative meetings in the existing
provide essential nutritional care to COVID-19
hospital dietetics practicum program; andpatients. However, BSc Nutrition and Dietetics
3. Create the addendum for the hospital dietetics
students in the Philippines, prior to the pandemic
practicum manual
were trained mostly on how to manage nonMETHODS
communicable diseases (NCDs). Management of
Ethical clearance application: All volunteers who
infectious diseases was not given much emphasis.
participated in the study gave written informed
At present, significant changes in theconsent to the protocol, which was approved by the
implementation of the hospital dietetics practicum
College of Home Economics - Research Ethics
are needed to ensure that students are prepared toCommittee (CHE-REC), University of the
manage unprecedented situations like pandemics.
Philippines, Diliman, Quezon City (Reference #Objectives: The study aimed to enhance the existing
CHE-REC 2021-002).
hospital dietetics practicum to include additional
Study Design: This qualitative study gathered data
learning outcomes in the hospital practicum manual
through interviews and FGDs. These methods
designed to equip BSND students with the necessary
enabled the researchers to have a deeper
knowledge and competencies to manage situations
understanding of the processes and modifications
like COVID-19. Specifically, the study was also
employed by nutrition and dietetic departments inable to:tertiary hospitals in the Philippines that enabled
them to manage patients and dietetic services during
the COVID-19 pandemic. The measures taken by*To whom correspondence should be addressed:
institutions in dealing with the COVID-19 situation
cccabigas@up.edu.ph103

Enhancing the Skills and Competencies of Nutrition and Dietetics Students
were used as the basis for the additional learning
outcomes.
Study Site: The study was conducted at the
Department of Food Science and Nutrition (DFSN),
College of Home Economics (CHE), University of
the Philippines, Diliman Quezon City, as
spearheaded by the Breastmilk Research Laboratory
in collaboration with the DFSN-CHE Nutrition
Clinic. The interviews and FGDs were coursed

through remote platforms such as Google Meet andZoom.
Study Participants: Participants of the study wereselected based on the criteria outlined in Table 1.
The study used purposive sampling to achieve thestudy objectives. Tertiary hospitals were selectedbased on the following criteria: a) should be a
COVID-19 referral hospital; b) should be in places
with high recorded cases of COVID-19; and c)should be accepting BSND dietetic interns.
Table 1. Criteria for selecting participants in phases 1 and 2 of the study.
Study period

Inclusion criteria

Exclusion criteria

Withdrawal criteria

Phase 1
(Individual RND
interview)a. RND should be employed in a
hospital in moderate to high-risksites of COVID-19 as classified by
DOH
b. RND should be employed in level3 training hospitalc. RND should be employed in
hospitals that serve as referral
centers for COVID-19 patientsd. RND should be employed in
hospitals that accept BS Nutrition
and Dietetics student affiliates

RND, who is at most 1
month, employed in
the selected hospital

RND who feels/decides todiscontinue his/herparticipation in the study
for any particular reason

Phase 2
(Focus group
discussion withChief RNDs)

a. RND should be employed in a
hospital in moderate to high-risksites of COVID-19 as classified by
DOH
b. RND should be employed in level3 training hospitalc. RND should be employed in
hospitals that serve as referral
centers for COVID-19 patientsd. RND should be employed in
hospitals that accept BS Nutrition
and Dietetics student affiliates

RND who is at most 1
month employed in thehospital

RND who feels/decides todiscontinue his/herparticipation in the study
for any particular reason

For phase 1, the participants for the in
the individual interviews were RND staff from theselected hospitals. For phase 2, participants were thechief dietitians of the eligible hospitals.
During the recruitment, formal letters were sent
both directly to the dietitians and their institution for
approval to conduct the study. Among the identified
hospitals, Phase 1 of the study included RNDs fromfour hospitals in the National Capital Region (NCR),
one hospital in Visayas, and one hospital in
Mindanao. A total of nine RNDs were interviewed
in Phase 1. Phase 2 of the study included the chiefdietitians from two hospitals in NCR and one
hospital in Visayas. A total of four chief dietitians
participated in the focus group discussion of thestudy.
Study Proper: In phase 1 of the study, individual
RNDs from eligible hospitals were interviewed
remotely via Google Meet and Zoom. The interview
covered the following topics: 1) safety practices foron-site duty; 2) presence/absence of online
consultations; 3) changes in the menu/meal planning
for admitted COVID and non-COVID patients; 4)changes in the food service department in terms ofmeal preparation; and 5) changes in the managementof hospital and dietary services.
For phase 2 of the study, FGDs were conductedamong the chief dietitians of the selected hospitals.
The FGD covered the COVID-19 related skills andknowledge needed by the students to achieve thelearning objectives from the academe. Similar
questions were also asked from the staff RNDs tovalidate the results of phase 1.
For the terminal phase, the researchers presented
the results to the Board members of the Council ofDeans and Heads of Nutrition and Dietetics(CODHEND) for the discussion, approval, andincorporation of the addendum to the existing
hospital dietary practicum manual. CODHEND is anorganization composed of the deans and heads ofschools in the Philippines offering Nutrition andDietetics. It is the organization responsible for
ensuring that the recommended curriculum would
be adopted by educational institutions offering
BSND programs, as well as monitor the program’s
conduct in each educational institution to maintainexcellent standards in Nutrition and Dietetics
education (1). One of its goals is to provide activities
that will upgrade and maintain the quality ofprofessional education in nutrition and dietetics for
global competitiveness. The meeting with
CODHEND took place on May 6, 2022, through an
online platform (Zoom).
RESULTS AND DISCUSSION
Based on the interviews with the RNDs and the
FGDs among chief dietitians, the identified key
challenges were grouped into three major

104

Asian Journal of Dietetics, 2022
categories: patient care; food service andadministration; and education and research.
Patient Care: For the patient care category, it wasseen that the communication systems for theadmitted and discharged COVID-19 patients weresignificantly affected. Due to the pandemic, RNDs
had limited interaction with patients and reliedheavily on the charting system of the hospital. This
became a challenge in the conduct of soundnutritional assessment and counseling of thepatients. Similarly, this challenge has been observed
among discharged patients wherein the RNDs are
only limited to interacting with the relatives andcaretakers instead of the patients themselves. In
addition to the communication systems, anothermajor change that the pandemic brought to thecurrent practicum is the shift to remote platforms,
and this led to students to work on sample casestudies instead of observing and managing actual
patients.
For the recommendations, the researchers
suggest that students be asked to assist in thedevelopment of a more digitized and centralized
communication system both for the monitoring ofadmitted patients and monitoring of discharged
patients. To address the concern of using sample
case studies, the research team recommends thatstudents be included to provide support for theactual healthcare team even by simply allowing
them to document the delivery of nutritional care tominimize their risk of becoming infected. This
practice will allow students to become better
acquainted with the role of NDs in the overallmanagement of patients with COVID-19, or withother infectious diseases.
Food Service Administration: For the food service
administration, the change seen in the usual protocol
was in the preparation for procurement, handling,and storage of supplies that were specifically added
due to the COVID-19 pandemic. These additional
supplies included provision of disposable utensils,bottled water, and oral fluid nutritional supplements(nutritionals) for some of the hospitals. The researchteam proposes that students develop a standardized
protocol for the food service section which considers
changes for the tray line procedures and the need for
additional supplies for COVID/infectious diseases
wards. Students should be guided on how to adjust
the procurement, storage and handling of theidentified additional supplies for these wards.
Education and Research: For the education andresearch unit, the identified challenge was preparing
audience-sensitiveandaudience-appropriate
education materials and lecture plans on nutrition
and infectious diseases. As a recommendation, theresearchers propose that students be exposed to
selecting their target audience and preparing
appropriate nutrition education tools for theirseminars and webinars. Also, the researchers
suggest that the online nutrition consultations be
conducted only after both the institutions andstudents have undergone the necessary training for
conducting remote activities. Current systematic
reviews have arrived at the conclusion that online
consultations, or telemedicine, are found to beeffective as they increase efficiency in healthservices and technical usability. Telemedicine

interventions that were found effective in reducing
health service use included vital sign monitoring at
home with telephone follow-ups, computerized
education programs, and home monitoring of
diabetes patients. Technical reliability of online
consultations was also found satisfactory in thehome monitoring of heart failure patients (2). Asidefrom increased efficiency and reliability, patientswere found to be more inclined to participate inonline consultations as it cuts down on the travel
time needed to get follow-ups with their healthcare
providers (3). These identified advantages of online
consultations appear to be a significant reason for
introducing and adapting to digitized systems forhealthcare which includes nutritional care.
Table 2 summarizes the proposed addendum asrecommended by the research team. The addendum
includes recommended intended learning outcomes,
teaching-learning
activities,
major
activities/teaching aids, assessment tasks, andevaluation tools categorized into the main threeareas: a) patient care; b) food service administration;and c) education and research.
During the discussion with CODHEND, theBoard panel approved and accepted the addendum
for immediate inclusion in the existing hospital
dietary practicum manual for BSND students, which
will be available for publication in AY 2022-2023.
Studies conducted in the US (4,5), Australia (6), andNorway (7), have shown that there was a decrease in
the quality of education and internships during the
pandemic as perceived by ND students. The
pandemic has impacted not only the developing
countries, but even the more economicallydeveloped countries. The lack of face-to-facerotations and the limited learning tools that weremade available due to the abrupt shift to remotelearning during the pandemic has affected thequality of training given not only to ND students but
even to other healthcare professions. The unforeseen
need for rapid transfer from the traditional to the useof remote platforms for all learning activities
presented compulsory modifications for the hospitaldietitians, clinical instructors, and learners. One of
the challenges faced during the use of remotelearning was addressing student assessment ascertain factors had to be considered, such as
pandemic-related anxiety that might have had
negative effects on the student’s academic
performance; the effect of economic and resource
differences between students, and the capability of
instructors to effectively deliver high-quality
instructions remotely (8). Some students who wereable to experience remote learning found that thenon-traditional method raised the pressure among
students as they were expected to learn things ontheir own, not considering the gaps in the resources
available (9). Consequently, students enrolled in thesciences, such as in the fields of biology andchemistry, and those that needed to conduct
experiments, found that remote learning can be
entirely limiting as it interferes with the opportunity
to debate, deliberate, and discuss with theirprofessors and classmates, and the learning ofpractical and clinical work (10,11).

105

Enhancing the Skills and Competencies of Nutrition and Dietetics Students
Table 2. Summary of the addendum recommended by the research team for inclusion to the existing BSND
hospital practicum manual
PROPOSED ACADEMIC ACTIVITIES FOR THE HOSPITAL PRACTICUM OF
BSND STUDENTS
INTENDED
TEACHINGMAJOR
ASSESSMENTEVALUATIOLEARNING
LEARNING
ACTIVITIES/TASKN TOOLOUTCOME (ILO)
ACTIVITIES (TLA)TEACHING AIDS
(Recitation/ quiz/(e.g lecture/ videoclip)
exam)
A. PATIENT CARE
1. Develop aA. Hospital care plan
A. Documentation
A. Actual charts for
Rubrics forcommunication- Orientation on the(Charting)patients
Project Plansystem including
healthcare group of aB. Guide on writing B. Learning log
the healthcare
patient
a project plan
C. Project plan forgroup of an
B. Charting
communication
admitted patient- Orientation on reading
system development- Evaluate thepatient’s medical charts
efficiency and- Practice charting for
efficacy of thenutrition-related concerns
currentof the patientcommunication
C. Nutrition innovation
system implemented
and technology
in the institution- Assess the current- Propose ancommunication system
improvement plan
implemented in thefor theinstitution for thecommunication
healthcare group of asystem in thepatient
institution to include- Develop an automatized
all members of thecommunication system for
health care group of
the healthcare group of thea patientpatient
2. Modify themonitoring andfollow up system forout-patientindividuals andpatients released
from hospital- Organize an
automatized userfriendly monitoring
and follow up systemfor out-patientindividuals andpatients released
from hospital
3. Prepare andpresent a case study
based on an actual
patient diagnosed
with COVID-19
with and without
comorbidities

A. Nutrition innovationand technology- Propose a monitoring
and follow up system
B. Nutrition surveillance- Monitor the changes in
the nutritional status of theindividuals

A. Nutrition Care
Plan
B. Guide on writinga project plan

A. Monitoring planfor the patient
B. Project plan formonitoring andfollow up system

Rubrics for
NCP

A. Prepare a case studyof a specific patient in theaffiliated hospital
B. Present the case study
that includes the nutritionrelated pathophysiology
and the application of
Nutrition Care Process(NCP) to the dietitians of
the affiliated hospital

A. Case study
formatB. Evidence-based
information about
the case patient
C. Nutrition Care
Process (nutritionassessment tool,
nutrition care plan)
D. Dietlist/handouts
E. ClinicalNutrition Pocket
Guide

A. Nutrition Care
Process (NCP)
application
B. Personalized dietplan
C. Oral casepresentation
D. Written casereportRubrics for
Oral
Presentation

A. Diet list
B. Procurement
forms
C. Receiving andstorage protocols

A. Learning log

Rubrics forlearning log

B. FOOD SERVICE ADMINISTRATION
1. Assist in the
A. Participate in the
preparation for
preparation of
procurement andprocurement list for thereceiving of dietary
dietary department taking
department
into account the specificsupplies

106

Rubrics for
Project Plan

Rubrics for
Written ReportAsian Journal of Dietetics, 2022
PROPOSED ACADEMIC ACTIVITIES FOR THE HOSPITAL PRACTICUM OF
BSND STUDENTS
INTENDED
TEACHINGMAJOR
ASSESSMENTEVALUATIOLEARNING
LEARNING
ACTIVITIES/TASKN TOOLOUTCOME (ILO)
ACTIVITIES (TLA)TEACHING AIDS
(Recitation/ quiz/(e.g lecture/ videoclip)
exam)
considerations for COVID
ward
B. Assist in the receiving
and storage of procured
items for the dietarydepartment
C. EDUCATION AND RESEARCH UNIT
1. Devise a set of
A. Create nutrition
A. Instructional
A. Actual
Rubrics fornutrition materials
education materials
materials
instructional
nutritionfor educating
regarding the prevention
materials output
education
patients regardingof COVID-19 virus
B. Learning log
materials
COVID-19 andtransmission andinfectious diseases
infection, ways to address
both in remotewhen one gets the virus,
setup and onsite
and what to do during
treatment
2. Conduct a
A. Design a learning plan
A. Instructional
A. Actual
Rubrics for
Nutrition education for the selected target
plan for nutrition
instructional
instructionalsession aboutgroup
education session
materials output
plan and
COVID-19 and
B. Create instructional
B. Instructional
B. Actual nutritionmaterials
infectious diseases
materials for the nutritionmaterials foreducation session
on one population
education session both for nutrition education
Rubrics for thegroup in the outremote platform andsessionconduct ofpatient department
onsitenutrition
C. Conduct an actual
education
nutrition education session
sessionwith the selected target
group
Post-evaluationfrom attendees
3. Conduct a
A. Design a learning plan
A. Instructional
A. Actual
Rubrics forwebinar or afor the selected target
plan for nutrition
instructional
instructionalseminar for thegroup
education session
materials output
plan andstaff of the
B. Create instructional
B. Instructional
B. Actual nutritionmaterials
institution
materials for the nutritionmaterials foreducation session
regarding infectious education session both for nutrition education
Rubrics for the
diseases such as
remote platform andsessionconduct of
COVID-19,
onsitenutrition
typhoid, cholera,
C. Conduct an actual
education
small pox, andnutrition education session
session
AIDS
with the selected target
group
Post-evaluationfrom attendees
4. Participate in an
A. Conduct an actual
A. NCP
A. Actual
Rubrics foronline nutrition
consultation by practicing
B. Assessment
assessment
NCP
consultation dealing NCP
forms for eB. Actual conduct ofwith various
nutrition
e-nutrition
nutrition concerns
consultation
consultation
To maintain the excellence of Nutrition andDietetics programs, hospital practicums should be
able to maximize the use of remote learning to adapt
accordingly. Kaup and colleagues in 2020 stated thatshifting to remote platforms has encouraged
students to be more inclined to problem-solving,
critical thinking, and self-directed learning. It also
allows more flexibility in the learning process, as
learning materials can be given in advance andstudents will be able to go through the courses at thepace that they deem effective for their own learning.
Online learning and training have also madedistance education possible as experts from different
places may still be able to conduct synchronous

sessions, which involve online studies and live chatswith the students (12). These identified benefits of
online learning can be used as an advantage tocontinuously provide quality education and training
for BSND students despite unprecedented healthsituations. The adaptability of the education systemand training practices to varied challenging healthsituations help ensure that students get thecompetencies needed for entry-level jobs as they
enter the workforce amidst such situations. As citedby Rogus et. al, the pandemic has encouraged theacademe and other learning institutions to reinforce
additional strategies, including redesigningassignment formats, changing grading and late work

107Enhancing the Skills and Competencies of Nutrition and Dietetics Students
policies, and providing additional resources tostudents. Similarly, hospital training programs
delivered during pandemics should still be able toprovide realistic scenarios for ND students despite
limitations to mobility (13).

4.

Coakley KE, Gonzales-Pacheco D. Dietetics
students' perceptions of academic and healthimpacts of the COVID-19 pandemic. Top Clin
Nutr 37(3): 227–235. 2022.
5. Teng CWC, Lim RBT, Chow DWS,
Narayanasamy S, Liow CH, Lee JJM.
Internships before and during COVID-19:
experiences and perceptions of undergraduate
interns and supervisors. High Educ Ski WorkBased Learn 12(3): 459 – 474. 2022.
6. Pelly FE, Wiesmayr-Freeman T, Tweedie J.
Student placement adaptability during COVID19. Nutr Diet 77(4): 481–483. 2020.
7. Almendingen K, Morseth, MS, Gjølstad E,
Brevik A, Tørris C. Student's experiences with
onlineteaching
following
COVID-19
lockdown. a mixed methods explorative study.
PloS one 16(8). 2021.
8. Adedoyin OB, Soykan E. COVID-19 pandemic
and online learning: the challenges andopportunities. Interact Learn Environ. 2020.
9. Maatuk AM, Elberkawi EK, Aljawarneh S,
Rashaideh H, Alharbi H. The COVID-19
pandemic and E-learning: challenges andopportunities from the perspective of students
and instructors. J Comput High Educ 34: 21–38.
2022.
10. Mseleku, Z. A literature review of e-learningand e-teaching in the era of COVID-19
pandemic. Int J Innov Sci Technol 5(10): 588597. 2022.
11. Mukhtar K, Javed K, Arooj M, Sethi A.
Advantages, limitations and recommendations
for online learning during COVID-19 pandemic
era. Pak J Med Sci 36(COVID19-S4): S27–S31.
2020.
12. Kaup S, Jain R, Shivalli S, Pandey S, Kaup S.
Sustaining academics during COVID-19
pandemic: the role of online teaching-learning.
Indian J Opthalmol 68(6): 1220–1221. 2020.
13. Rogus K, Martin S, Phillips SG. Teaching in anundergraduate dietetics program and internshipduring COVID-19. J Fam Consum Sci 113(2):25-29. 2021.

CONCLUSION
The pandemic has forced the practice of
healthcare to evolve in the Philippines.
Accordingly, the skills, knowledge, andcompetencies of future healthcare professionals,
particularly of Nutritionist-Dietitians, need to bestrengthened in preparation for similar futurescenarios. COVID-19 may not be the only pandemic
that future healthcare professionals will face, which
is why it is imperative that students are presented
with activities that will provide them with relevant
skills to adapt. Integrating the academe's onsite
learning into more innovative and digitized systems
will benefit not just BSND students but also theentire healthcare team and the patients themselves.
ACKNOWLEDGMENT
This work is funded by the University of thePhilippines Diliman Office of the Vice Chancellor
for Research and Development Source of Solutions
Grant 2021 (202021SOS).
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