ISSN2434-2688 Asian Journal of Dietetics

Vol.5 No.2 & 3, 2023
Contents
Page T Title and authors
Original Research
43-46

Introducing A Floor Cleaner with Dust Collection Function for Hospital
Kitchen
Keiko Hirose, Mai Hara, Haruka Yamazaki, Eri Tashiro, Mari Shiono, Ryoko
Mizutani, Nagiri Enomoto, Masato Yoshioka, Shigeru Yamamoto

Original Research
47-51

A Fully Automatic Rice Cooker Was Cost-Effective in A Hospital
Kitchen
Keiko Hirose, Mai Hara, Haruka Yamazaki, Eri Tashiro, Mari Shion, Ryoko
Mizutani, Nagiri Enomoto, Masato Yoshioka, Shigeru Yamamoto

Original Research
53-61

School Lunches Have the Potential to Improve Food Awareness not only
for Children but also for Their Families
Yuko Naruse, Naoko Hirota

Original Research
63-66

Comparison of Nutrient Intake in Vietnamese Children Calculated byThree Different Food Composition Tables
Nguyen Huong Giang, Nguyen Mai Phuong, Nguyen Van Diep, Yamamoto
Shigeru

Original Research
67-76

The Prevalence and Factors Associated With Cardiometabolic Risk
Among Urban in-School Adolescents in Harare, Zimbabwe
Pencil A, Matsungo TM, Hongu N and Hayami N

Original Research
77-82

A Successful Innovative Meal Ordering System for Hospital PatientCentered Food Service in Taiwan
Fen-Ling Tseng, Yu-Wen Wang, Mei-Fang Yang.

Report83-91

Workshops for Enhancing the Collaboration Skills and Self-efficacy ofJapanese Administrative Dietitians
Tatsuya Koyama, Maya Akahori, Yusuke Arai, Ayaka Iida，Sumie Isobe，
Rie Okamoto，Osamu Kushida，Izumi Shibuya，Kazumi Tanaka，Ayumi
Morooka，Katsushi Yoshita

Note
93-99

Data Analytics to Explore the Influence of Nutritional Factors on
Adverse Reactions after Vaccination
Yuko Hisatomi, Midori Yasuda, Tomoyuki Natsume, Mami Nanri,
Tsunenobu Ueno, Tokihiro Kusaba, Kenji Kugino

Case report101-104

Nutrition Management with Crohn’s Disease – Semi Elemental
Hydrolyzed Whey Protein (HWP): A Case Report Study
Woan Yin Tan, Lina Isnin, Nurfazlin Rozlan

Special Report:
105-106

The Introduction of “The Fermented Fish Paste” - No. 1 in a Series
Ry Manydine

Asian Journal of Dietetics 2023

Original
Introducing A Floor Cleaner with Dust Collection Function for Hospital Kitchen
Keiko Hirose1, 2*, Mai Hara2, Haruka Yamazaki2, Eri Tashiro2, Mari Shiono2, Ryoko Mizutani2,
Nagiri Enomoto2, Masato Yoshioka2, Shigeru Yamamoto1
1

Jumonji University, Niiza, Saitama 352-8510, Japan
Nutrition Department, Nerima Hikarigaoka Hospital, Nerima, Tokyo 179-0072, Japan

2

ABSTRACT Background and purpose. In Japan, recent soaring prices and labor cost hikes
have put pressure on hospital food service operations, and cost-cutting measures arechallenging. We believe that cost-effectiveness can be improved by changing a kitchen witha dry systemized floor cleaning from 4 processes (conventional method) such as mop andsqueegee (drainage) to 1 process (FD method) with a floor cleaner with dust collection
function. We tried to clarify this question in this research. Methods. This research was
conducted in a kitchen with a dry systemized a 457-bed acute care hospital in Tokyo (49kitchen employees, providing approximately 1,000 meals per day). Data include
retrospectively summarized data from daily "hospital meal work diary" records in 2022, socomparative research of the first 6 months (conventional method) and the latter 6 months (FDmethod). The target of the floor cleaning was the non-contaminated area (cooking room) witha total of 134.2m2, cleaning once a day, with cleaning, sanitizing, and brushing once a month.
Results. The total work time for cleaning and disinfection was 559.5 hours for theconventional method and 182.5 hours for the FD method, with a difference of 377 hours. Thisdifference can be said to have reduced the cleaning labor time by 33%. Assuming that one
employee works 8 hours a day, work will be reduced by 47 days. Personnel costs were1,035,075 yen for the conventional method and 337,625 yen for the FD method. Labor costs
for cooking assistants vary depending on years of experience. Therefore, the calculation was
based on the average wage according to the "Salary Contract Schedule". Detergent anddisinfectant costs were 73,000 yen for the conventional method, and 37,778 yen for the FD
method, and tool costs were 9,000 yen for the conventional method and 30,000 yen for the FD
method. The total cost for six months was 1,117,075 yen for the conventional method and405,403 yen for the FD method, with a difference of about 712,000 yen. The FD purchase cost
was thus offset in about 2.4 months. Conclusion. By changing from the conventional method to
the FD method for cleaning a kitchen with a dry systemized floor area of 134.2 m2, we were able
to reduce the work time by 377 hours and the cost by about 712,000 yen over 6 months.
Keywords: a floor cleaner, hospital kitchen floor cleaning, cost-effectiveness

INTRODUCTION
In Japan, recent soaring prices and labor cost hikes
have put pressure on hospital food service operations,and cost-cutting measures are challenging. However,there are few reports on solutions, and the government
has not approved support for capital investment.
Hospital meals in Japan are hygienically managed
according to the sanitation management manual formass cooking facilities by Hazard Analysis CriticalControl Points (HACCP) (1), as in other countries (2).
It stipulates that kitchen floors should be cleaned atleast once a day and, if necessary, washed, anddisinfected. However, no specific cleaning or
washing/sanitizing methods are specified. Furthermore,
it is also stated that "it is desirable to actively promotea dry system. Not only hospitals but also the kitchens ofgroup feeding facilities, including school lunches, should
introduce dry systems and if they have not been
introduced, it is clearly stated that a dry operation should
be attempted (3). With the aging of the working
population in Japan (4), most of the employees
responsible for cleaning kitchen floors are middle-aged
and elderly. For them, cleaning floors daily is a wholebody job, and it takes a long time to complete the four
steps. In addition, the monthly cleaning, sanitizing, andbrushing work requires strength when handling the large
automatic washer for commercial use (used not only inthe kitchen but throughout the hospital) because it is large
and heavy. Therefore, we thought that the work time
could be shortened by introducing floor cleaners with adust collection function (FD). However, FD has a highcapital investment cost as a cleaning tool, and there is yet
no verification of whether labor efficiency will increase
when it is introduced for cleaning floors in hospital
kitchens. Therefore, in this research, a kitchen with a dry*To whom correspondence should be addressed:
keikohirose819@gmail.com

43Floor Cleaning was Highly Cost-effective
systemized floor cleaning was changed from 4 processes(conventional method) such as mop and squeegee(draining) to 1 process (FD method), This was carried out
to clarify the cost-effectiveness of the change.

addition, once a month, for cleaning, sanitizing, andbrushing: 1) Remove dirt and dust with a largecommercial floor cleaner, 2) Brushing and collectsewage while spraying a neutral detergent containing
a floor disinfectant such as sodium hypochlorite in alarge automatic washer for commercial use, and 3)
Wipe dry with a drainer or a dry mop.
In the FD method, a floor cleaner with dust
collection function for cleaning the dry zone (Karcher
BR 30/4 C Bp https://www.kaercher.com/jp/profes
sional/pro_hygiene.html) was used.
The instruction manual for this product explains thatthe water supply tank is 4 L and consumes 1 L ofwater per minute. Therefore, we decided to stopusing the water supply tank and use the FD to washthe floor after sprinkling a cleaning and sanitizing
solution on the floor. Because this FD is small andcordless, it is easy to handle. In general cleaning, 4
processes and once a month, for cleaning anddisinfection are required, but this FD is equippedwith a dust collector, it can vacuum floor debris while
simultaneously cleaning and sanitizing the floor witha cleaning and sanitizing solution and brush. In
addition, it can also collect sewage. This means thatdaily and monthly cleaning and sanitizing can becompleted in one process

MATERIALS AND METHODSThe hospital under research is a Tokyo hospitalwith 457 beds, and 49 kitchen employees, and serves
approximately 1,000 meals per day. The floor cleaningarea under research was a dry systemized noncontaminated area (cooking room), with a total floor
cleaning area of 134.2 m2 (excluding the area of
cooking equipment and cooking tables installed
directly and fixed above the floor), The research
period was 6 months from January to June 2022 for theconventional method and 6 months from July to
December 2022 for the FD method, Data was collectedfrom daily "hospital meal work diary" records.
The cleaning and washing/sanitizing method(conventional method) was performed as follows. At
least once a day: 1) Remove dust with a broom anddustpan, 2) Wipe with a mop soaked in a neutral
detergent (for severe oil stains, use a special cleaning
agent for oil stains), 3) Wipe a well-washed mop, 4)
Drain with a squeegee or wipe dry with a dry mop. In

RESULTS
Table 1 shows a comparison of the cleaningused a dry system, with a total floor cleaning areatime and various costs of the conventional methodof 134.2m 2 (excluding the area of cooking
and the FD method. The floor cleaning was theequipment and cooking tables installed directly
non-contaminated area (cooking room), which
and fixed above the floor).
Table 1. Comparison of time and cost spent on kitchen floor cleaning with conventional and FD methods
Conventional method
FD method
Floor space:134.2m2

Broom, neutral detergent,mop, disinfectant,…

A floor cleaner with dust
collection function,…
1
30 + 0**182.5 + 0**365

Floor cleaning time1 (day)1 (month)
6 (months)
1 (year)hours

3
90 + 2*547.5 + 12*
1,095 + 24*

labor cost
[Average hourly
wage 1,850 yen]

1 (day)1 (month)
6 (months)
1 (year)

yen

5,550
170,200
1,035,075
2,070,150

1,850
55,500337,625675,250

Detergent/disinfectant fee

1 (day)1 (month)
6 (months)
1 (year)yen

400
12,00073,000146,000

207
6,210
37,77875,555All equipment
fee

yen

55,000[3 years of useful life]

300,000[5 years of useful life]

1 (month)
6 (months)
1 (year)

yen

1,500
9,000
18,0005,000
30,00060,0001 (month)
6 (months)
1 (year)yen

183,700
1,117,075
2,23,4150

66,710405,403810,805

Tool/equipment cost

Total cost

*Major cleaning once a month,**No monthly cleaning required44

Asian Journal of Dietetics 2023
The cleaning work hours for 6 months are 559.5
hours for the conventional method (90 hours/month ×
6 months = 547.5 hours, plus 2 hours of disinfection
cleaning once a month, 2 hours × 6 months = 12 hours)
and 182.5 hours for the FD method (30 hours/month ×
6 months, plus 0 hours of disinfection cleaning once amonth).
Since the labor cost was the average wage
according to the "Salary Contract Schedule" 1,850
yen/hour, it cost 1,035,075 yen for the conventional
method and 337,625 yen for the FD method for 6
months. The cost of detergent and disinfectant was
73,000 yen (12,000 yen per month × 6 months) withthe conventional method; the FD method was
37,778 yen (6,210 yen per month × 6 months). The
cost of tools and equipment for the conventional
method (broom, dustpan, mop, bucket, squeegee)
was 9,000 yen (the total tool cost was 55,000 yen,
the hospital sets the depreciation period at 3 years,
1,500 yen per month × 6 months), but for the FD itwas 30,000 yen (FD 300,000 yen, the depreciation
period at 5 years, 5,000 yen per month × 6 months.
The total cost for six months was 1,117,075 yen forthe conventional method and 405,403 yen for the
FD method, with a difference of about 712,000 yen.
The FD purchase cost was thus offset in about 2.4
months. In addition, the cleaning work time for 6
months was 559.5 hours for the conventional
method and 182.5 hours for the FD method, with adifference of 377 hours.

559.5 hours with the conventional method and 182.5
hours with the FD method, for a difference of 377
hours. This means that the working hours needed for
one employee have been reduced by 33%, and if one
person works 8 hours a day, the working hours havedecreased by 47 days in 6 months.
kitchen employees were able to save two hours ofwork per day. Since the wage of the kitchen employees
responsible for cleaning work is an average wage of
1,850 yen per hour, it means that about 697,000 yen
was saved in half a year and about 1.39 million yen ina year.
For the kitchen employees responsible for cleaning
work, this not only reduced time, but it may have also
reduced the physical and mental burden. If you assume
that cleaning work takes 1 hour to process and that it
takes 3 hours for 4 processes, everyone will choose theformer. This is because the physical and mental burden
would be reduced by one-third. With the aging of theworking population in Japan (4), most of theemployees responsible for cleaning kitchen floors are
middle-aged and elderly. For them, cleaning floors
daily is a whole-body job and takes a long time
because it involves four processes. In addition, themonthly cleaning, sanitizing, and brushing workrequires strength when handling the large automaticwasher for commercial use (used not only in the
kitchen but throughout the hospital) because it is large
and heavy. For this reason, even if hospital kitchensrecruit employees, the lack of applicants is a chronic
problem. The reduction of mental and physicalburdens by introducing FD will help solve theimportant issue of securing employees.
The reduction in mental and physical effort
improves the quality of each task, and the time saved
helps [the cooking staff, which in turn leads to theprovision of improved meals. Hospital kitchen
operations are part of the medical service industry.
Whether or not shortening working hours has a direct
meaning for a service should be considered on a caseby-case basis. For example, in the case of the
manufacturing industry, shortening working hours
means increasing production efficiency. In service
industries such as cooking and cleaning, shortening
working hours not only reduces costs but also
improves employee satisfaction at work. We believethat this will lead to the provision of better meals witha high degree of patient satisfaction.
Teamwork is important in kitchen work. If
everyone isn’t working together with the same purpose,
teamwork will be skewed. A kitchen operation thatplaces a physical and emotional burden on only certain
tasks is a source of frustration and stress for theemployees who are responsible for them, leading topoor relationships and making it difficult for the teamto have the same purpose. This will have the adverse
effect of increasing the turnover rate. We believe that
hospital dietitians must not only improve the quality of

DISCUSSION
Switching kitchen floor cleaning from theconventional method to the FD method has resulted ina reduction in the cleaning work time and improved
cost efficiency.
This research is a "retrospective observational
research" based on one-year records. Retrospective
research can sometimes lead to ambiguous results,
however, we believe that the present case is based ontime, wage, expenses, etc. management records fromthe "hospital meal work diary" and "Salary Contract
Schedule," which provide objective and accurate data.
There are no daily variations because employees areworking according to the rules. Therefore, numericalvalues are understood as being exact and directlycomparable.
The cost of hospital kitchen cleaning is not a smallburden for many hospitals. However, we could not
find any papers about differences in the time and costby changing the method as in this research. It is hopedthat this paper will serve in the future as a good
example of research on daily activities.
When kitchen employees changed the tools, theyused to clean floors with traditional brooms, mops, andsqueegees to a floor cleaner with dust collection
function, The cleaning work time for 6 months was45

Floor Cleaning was Highly Cost-effective
meal service but also contribute to teamwork. To do so,they may have to overcome many difficulties. However,We believe that working diligently toward this goal willlead to the trust and respect of those around them and,as a result, enrich the dietitian's own life.
Regarding hygiene management, the FD canprovide safer meals than the conventional once-amonth sterilization cleaning because the FD is always
cleaned, sanitized, and brushed daily at the same time.
At the hospital under research, mops wereconventionally soaked in neutral detergent and wipedon the floor during daily cleaning. Even when neutral
detergent with floor sanitizer was used, monthly
sanitizing cleaning by the brushing function of a largecommercial floor washer was still necessary.
Purchase of FD requires permission from thehospital because the price at the time of purchase ishigher than equipment such as conventional brooms.
To justify the purchase, it is necessary to demonstrate
the benefits of buying FD. We believe this research
will help explain the benefits of purchasing FD for
many hospital dietitians.
While time and cost savings are important, we
believe the most important factor is the motivationand physical and mental health of kitchen
employees. Today, AI, robots are progressing at anaccelerated pace worldwide. However, hospital
meals are highly diverse, because of factors such as
the specific disease, food type, presence or absenceof allergies, preferences, and anorexia. No matter
how much we consult with AI about the menu, itwill only give me a notice and it will not work as abusiness. We believe that AI cannot handle thecomplexity and diversity of hospital meals or the
kitchen work that is responsible for school lunches
for the growth and health of children.

We believe that creating a kitchen system that
motivates kitchen employees to "make delicious meals
for patients," and that also takes care of their physicaland mental well-being, will improve the quality ofmeals and increase the job satisfaction of the dietitians
themselves.

ACKNOWLEDGEMENT
We would like to express our sincere gratitude to
everyone at Nerima Hikarigaoka Hospital, especially the
kitchen employees, who understood the purpose of thisresearch and willingly cooperated.

REFERENCES
1. Ministry of Health, Labour and Welfare. Sanitation
Management Manual for Large-Scale Food
Preparation Facilities. Accessed November 15,
2022.
2. Barbara M. Lund, Sarah J. O’Brien,
Microbiological safety of food in hospitals andother healthcare settings, Journal of Hospital
Infection 73, 109 – 120. 2007.
3. Ministry of Education, Culture, Sports, Scienceand Technology. School Food Hygiene
Management Standards. Accessed November 15,
2022.
4. Ministry of Health, Labour and Welfare; The 2020
White Paper on Health, Labor and Welfare: Social
Security and Work Styles in the Age of 2020.
Accessed November 15, 2022.

46

Asian Journal of Dietetics 2023

Original
A Fully Automatic Rice Cooker Was Cost-Effective in A Hospital Kitchen
Keiko Hirose１,２,※, Mai Hara２, Haruka Yamazaki２, Eri Tashiro２, Mari Shiono２,Ryoko Mizutani２,
Nagiri Enomoto２, Masato Yoshioka２, Shigeru Yamamoto１
１

Graduate School of Human Life Sciences, Jumonji University, Saitama 352-8510, Japan
２
Nutrition Department, Nerima Hikarigaoka Hospital, Tokyo 179-0072, Japan

ABSTRACT Background and purpose. Recent soaring prices and labor cost hikes have put
pressure on hospital meal service operations, and cost-cutting measures are challenging. In thisresearch, we assessed cost-effectiveness by changing from a conventional gas-type automatic
rice cooker (conventional) to a fully automatic rice cooker (FARC).
Methods. This research
was conducted in the kitchen of a 457-bed acute care hospital in Tokyo (49 kitchen employees,
providing approximately 1,000 meals per day). The data include retrospectively compiled datafrom a diary, comparative research of the conventional method (6 months from April to
September 2022,) and the FARC method (6 months from October 2022 to March 2023) with astaff of 6 cooks.
Result. The average time for rice-cooking operations for the two methods
was 57.5 ±3.09 minutes for the conventional method and 11.3 ±1.53 minutes for the FARC
method, with a difference of 46.2 minutes. If this difference is extrapolated on the assumption of
preparing rice 3 times a day (breakfast, lunch, and dinner), the reduction in preparation time willbe 2.3 hours a day, or 847.8 hours a year. This difference reduced rice-cooking labor by 106 days.
The difference in total cost (yen) is 2,717,328. The FARC purchase price can thus be offset in
about 2 years.
Conclusion. This research showed how working time could be shortened, costs
reduced and the initial cost would be offset in 2 years if kitchen equipment was changed fromthe conventional gas-powered automatic rice cooker to the FARC. The cook's workload could
also be significantly reduced.
Keywords: a fully automatic rice cooker, cost-effectiveness, Japanese hospital kitchen

INTRODUCTION
The most important staple food in Japan is rice.
According to the Diet and Lifestyle Survey - FY2022
by the Ministry of Agriculture, Forestry and Fisheries(1), rice was the most common staple food at 40%,
followed by bread at 16%. In previous research, wereported that approximately 61.5% of patients over 65
years of age admitted to an acute care hospital who
were prescribed a normal diet were malnourished (2).
In such cases, the previous study has reported that soft
rice or porridge is prescribed for medical safety
reasons (3). Therefore, cooking rice is done three times
a day, every day, as cooked rice, soft rice, and porridge
are often prescribed as staple foods for hospital meals.
In addition, it has been our experience that in acutehospitals with more than 300 beds, cooks have to cometo work around 4:00 a.m. to prepare breakfast,
contributing to cook shortages and labor cost hikes.
Placing heavy pots of rice on a wheeled cart requiresconsiderable physical effort, especially for female
cooks. Preparation for cooking rice can be done theday before, but for sanitary reasons, weighed, washed,

and watered rice must be stored in the refrigerator if it
is not cooked immediately after soaking. As forcooking rice for breakfast, the first thing the cook has
to do when they arrive is to take all the pots of rice outof the refrigerator, put them in the rice cooker, and start
the cooking process. This is one of the reasons why thecook has to come so early, and one of the factors
responsible for cook shortages and labor cost hikes.
This research aims to clarify how time for ricecooking operations can be shortened and costs reduced
if the kitchen equipment is changed from a
conventional gas-powered automatic rice cooker(conventional) to a fully automatic rice cooker(FARC), taking advantage of the hospital's move to a
new building.
MATERIALS AND METHODSThis research was conducted in the kitchen of a 457bed acute care hospital in Tokyo (49 kitchen employees,
providing approximately 1,000 meals per day). We
compared the average time for rice-cooking operations
and labor costs required for cooking rice with the two
types of rice cookers (Fig. 1) based on the working hours
recorded in the "hospital meal work diary". Both periods
were 6 months (the conventional method; April to*To whom correspondence should be addressed:
keikohirose819@gmail.com

47

Cost effectiveness of fully automatic rice cooker
September 2022, the FARC method; October 2022 toMarch 2023). Six cooks were involved in the ricecooking. For rice cooking, two conventional automatic
rice cookers (6 pots) and one fully automatic threedimensional rice cooker (6 pots) were used. About 10 kg
of rice was used for each meal, and three types of rice
were cooked: cooked rice, soft rice, and porridge. The
pots weighed 4.0 kg/ per pot and with rice and water, it
becomes 12-14 kg. Five pots were needed to cook one
batch of rice.
In the conventional method, apart from the automatic
rice cooking, weighing, washing the rice, adjusting theamount of water, and moving the pot were all done
manually. With the FARC method, simply setting an
empty kettle was all that was required, and weighing,washing the rice, adjusting the amount of water,
moving the pot, and cooking rice were all done
automatically. Time for rice-cooking operations wascalculated from the daily "hospital meal work diary".
Labor costs were calculated from the “salary contractschedule”. Accommodation costs were calculated from“rental contracts”. Equipment costs were calculated
from the equipment manufacturer's invoice.
Ethics: Subjects were informed of the purpose of thesurvey, their right not to participate in the survey,
considerations for personal information protection, anddata handling, and consent was obtained. For the
implementation of this research, a research protocol was
prepared and approved by the Research Ethics
Committee of the hospital.

Fig 1. Conventional gas-type automatic rice cooker (left), and new FARC (right).

Fig 2. Moving the pots of a conventional type of rice cooker

48

Asian Journal of Dietetics 2023

Fig 3. Photographs show a) FARC, b) feeding rice into the silo,c) inside of the rice and water supplier, and d) putting in/taking out a pot.

RESULTS
The average time for rice-cooking operation was
57.5 ±3.09 minutes for the conventional method and11.3 ±1.53 minutes for the FARC method, with adifference of 46.2 minutes. If this difference iscalculated for preparing rice 3 times a day (breakfast,
lunch, and dinner), the reduction in preparation time
will be 2.3 hours a day, or 847.8 hours per year. Thisdifference can be said to have reduced rice cooking
labor by 80%. Assuming that the cook works 8 hours
a day, total labor will be reduced by 106 days. When
converted to labor cost, the cost of the conventional
method is 3,662,000 yen per year (labor cost plus
accommodation cost) and that of the FARC method is416,100 yen per year (no accommodation), so thedifference is about 3,245,900 yen per year. The
difference in total cost (yen) was 3,947,714 –
1,230,386 = 2,717,328. The FARC purchaseprice/difference of total cost = 5,700,000 / 2,717,328= 2.1. Thus the FARC purchase price can be offset in
about 2 years.
In addition, the workload of cooks can besignificantly reduced. In the conventional process,apart from the automatic rice cooking, weighing,washing the rice, adjusting the amount of water, andmoving the pot were all done manually. The cooks had
to leave for work at 4:00 a.m. to prepare breakfast. At
the hospitals under research, for such cooks,
accommodation was prepared. With the FARC method,
once the empty pot was set the day before and thereservation program for the rice cooking operation wasset, weighing, washing the rice, adjusting the amountof water, moving the pot, and cooking the rice were alldone automatically. So in the case of the FARC
method, cooks could come at 7:00 a.m. and start
cooking rice. No accommodations were needed.

Table 1. Work time and various costs at the hospital kitchen
The Conventional method
1 (round)57.5±3.09 (minutes)
Time for1 (day)2.88
hours
rice-cooking operation
1 (month)86.25
1 (year)1,051.20
1 (day)5,760
yenLabor cost
1 (month)
172,500
1 (year)2,102,000
1 (month)
130,000
yen
Accommodation cost
1 (year)1,560,000
Cost*
2,000,000
yen
Equipment cost
1 (month)
23,8101 (year)285,714
1 (month)
326,310yen
Total cost
1 (year)3,947,714*Cost depreciation: 7 years

49

The FARC method11.3±1.53 (minutes)
0.57
16.95
203.401,140
34,200416,100
Unnecessary
5,700,000
67,857814,286
102,057
1,230,386

Cost effectiveness of fully automatic rice cooker
DISCUSSION
This research revealed that (1) equipment costs werehigh, but time for rice-cooking operations and laborcosts were saved; (2) the cooks' relationships with eachother improved as their mental and physical workload
was reduced; (3) the cooks themselves began to pursue
meal quality by making use of the saved working hours.
(1) Equipment costs were high, but time for ricecooking operations and labor costs were saved.
The FARC is expensive, so it is usually difficult toobtain approval from hospital management departments.
The price of the conventional is 2 million yen, The
FARC is 5.7 million yen. Before applying, we conducteda thorough cost comparison between the conventional
method and the FARC method. The cost comparisonsshown in Table 1 are accurate from accounting reports.
Labor costs were calculated from the “salary contractschedule”. Accommodation costs were calculated from“rental contracts”. Equipment costs were calculated
from the equipment manufacturer's invoice. Time forrice-cooking operations was calculated from the daily"hospital meal work diary". During periodic government
audits, the "hospital meal work diary" records the startand end times of work each day and is checked to see if
it is signed by a person who confirms it. If this is notdone, the government will not be able to pay medical
insurance (meal expenses) to the hospital, so thesenumbers are highly reliable. The start time and end timeof the work will be determined according to the "workprocess chart". The "work process chart" is a table thatlists all the work tasks in the kitchen. If work is notstarted and completed according to the "work process
chart"," meals cannot be provided according to the time
set by the government (7:30 a.m., 12:00 noon, and 6:00
p.m.). The above results revealed that the FARC
purchase price can be offset in 2 years due to lower
overhead costs. However, what is not included in thiscalculation is that installing the new FARC would
require renovations to the kitchen, which would further
increase costs. In the case of this hospital, it can be said
that it was fortunate that the system was introduced at atime when the kitchen was being rebuilt.
On the other hand, when it comes to capital
investment in acute care hospitals, high-priced medical
equipment is prioritized, and kitchen equipment that is
not directly related to treatment is likely to be subject tobudget cuts. So, We calculated the costs of theunprecedented implementation of expensive cooking
equipment in the hospital kitchen and determined
whether the initial costs could be offset in a short period
and whether labor could be further reduced. I explained
this to the hospital management department many times
and obtained their approval. It took a lot of effort, time,and effort. This research was intended to confirm
whether that explanation was indeed correct. Fortunately,
we were able to confirm our expectations in this research.
50

In the future, when introducing a FARC, it isdesirable to take advantage of the renovation period. We
would be happy if our results could serve as a reference
for those who are considering installing a FARC.
(2) The cooks' relationships with each otherimproved as their mental and physical workload was
reduced.
Cooking rice seems like a simple task at first glance,
as it is a daily routine in every household. However,cooking rice in hospitals is not so easy, especially whencooking rice for breakfast. The rice is prepared, washed,
and added water the day before, stored in the refrigerator,
and then started cooking at 4:00 a.m. the next day. Eachpot containing rice and water weighs 12 to 14 kg, andfive pots must be moved. In particular, removing the ricecooker from the refrigerator and setting it in the ricecooker is hard work, and cannot be done by workers ofshort stature or middle-aged or elderly female cookswith limited strength. The switch to start cooking must
be made by the cooks, sometimes the dietitians in chargeof food preparation. To arrive at the hospital at 4:00 a.m.,
one must leave home at 2:00 or 3:00 a.m. That is whenpublic transportation such as trains and buses is not in
operation. There are times when there are typhoons andtimes when there is heavy snow. For this purpose, thehospital needs to prepare accommodation, and the costfor this will exceed 1.5 million yen per year. In addition,
the physical and mental stress caused by early morning
work and heavy workloads makes it impossible toprotect their healthy minds and bodies, and it is
becoming increasingly difficult to secure employment
for dietitians and cooks. After introducing a FARC, thebreakfast cooks told us, "The rice-cooking process is
now completely automated, so I can come in at 7:00 a.m.
and start the cooking process. I don't want to leave thiskitchen because, in other hospital kitchens, the ricecooking process starts at 4:00 a.m." "Since I started
working at 7:00 a.m., I have been able to enjoy about
two hours to myself after I get home. When I used towork at 4:00 a.m., I was so tired and sleepy when I got
home that I just went to bed immediately. I didn't knowwhat on earth I was working for." "When I was on duty,
which required me to be at work at 4:00 a.m., it wasdifficult to get other cooks to suddenly change their duty.
Now I am free from the pressure of what to do if I
suddenly get sick or oversleep." "It was very scary andstressful because every time I asked another cook tomove heavy pots of rice, they would give me adisapproving look or ignore me. Now I don't have to ask
because I don't have to carry heavy pots of rice. Thanks
to this, we have a good relationship, always smiling andcooperating." We received such positive feedback.
A challenge in hospital meal service operations is thedaily conflicts between kitchen employees. Most of thecauses are emotional stress such as fatigue, which is also
the biggest reason for leaving the job. The kitchen

Asian Journal of Dietetics 2023
employee who causes the conflict may be older than the
dietitian, and the dietitian's mediation and guidance maylead to resentment. If conflicts are left unresolved,
communication errors can lead to human error, which
can lead to the dietitian bearing the brunt of the
responsibility of leaving the company. In this research,
it was not possible to prove the extent to which stress
was reduced, based on a survey of kitchen employee
satisfaction. However, the cooks have been happily
working since 7:00 a.m., humming to each other, andsmiling, talking, and helping each other, regardless ofwhether they are seniors or juniors, including the
dietitians. With the introduction of the FARC, the cooks
were relieved of their mental and physical pressure andexperienced the experience of engaging in cooking tasks
with a smile, helping each other, and being kind topatients, those around them, and the dietitians.
(3) The cooks began to pursue meal quality by using
the saved working hours.
Kitchen employees tend to be passive as theyfaithfully work according to the "work process chart"and detailed hygiene rules. We therefore hold regularmeetings to improve the menu and quality of meals. As
a result, the progress of improvement is slow, and during
this time patients are provided with unimproved meals.
With the introduction of the FARC, the cooks, who now
have more time to work, are encouraged to discuss andreflect on their own with the dietitians, accept the
dietitians' opinions honestly, and improve the quality of
their meals promptly.
This research did not show the results of thepreference survey, so it was not possible to prove theextent to which the quality of meals had improved.
However, we feel that the quality of the meals has
improved through the feedback from the patients and theopinions of the physicians and the dietitians based on thefood inspection. Of course, we have received numerous
comments from the patients, the physicians, and the
dietitians that rice cooked in the FARC tastes great. For
hospital meals, Three types of rice are cooked each time:cooked rice, soft rice, and whole porridge. The FARC
does not require any human intervention from preparing
the rice to cooking it. The precision equipment built into
the FARC does everything, so the measurement of water
depending is particularly accurate. It is assumed that the
optimum amount of moisture each time results indelicious rice. In this way, being able to cook the same
quality and delicious food every time helps to relieve thestress on the mind and body of the cooks.

51

In Japan, given the social backdrop of a declining
workforce, an aging population, and soaring prices,
there is a tendency to focus on cost reduction, work
automation, and AI. Although they are expensive,cooking equipment can increase production. However,even with high salaries offered, the number of hospitalcooks continues to decline. I think that hospital dietitians
should not make the mistake of prioritizing what is
important and in what order when managing hospital
food service operations.
Medical treatment for injuries, illnesses, etc. is called“treatment”. It includes placing the palm or fingertips ofthe hand on the affected area to check the condition,
which is a universal medical practice. I think it's thesame with hospital meals. Ultimately, the hospital meals
are delicately prepared using the palms and fingertips ofa person and then served to the patient. Isn't it up to thehospital dietitian to bring life into the hands of thecooks? We think so.
In conclusion, this research showed how working
time could be shortened and costs reduced, the cook's
workload could also be significantly reduced if kitchenequipment was changed from the conventional gaspowered automatic rice cooker to the FARC, taking
advantage of the hospital's move to a new building.

ACKNOWLEDGEMENT
We want to express our sincere gratitude to everyone
at Nerima Hikarigaoka Hospital, especially the kitchen
employees, who understood the purpose of this research
and willingly cooperated.

REFERENCES
1. Ministry of Agriculture； Forestry and Fisheries'"Survey on Dietary Habits FY2022" 188-191.
https://www.maff.go.jp/j/zyukyu/survey/attach/pd
f/lifestyle-2.pdf (accessed May 25, 2023)
2. Hirose K, Tran PT, Yamamoto S: Decreasing Salt
in Hospital Meals Reduced Energy Intake inElderly Japanese Inpatients. J Nutr Sci and
Vitaminol, 67 : 105-110, 2021.
3. Ueshima J, Shimizu A, Maeda K, et al: Nutritional
Management in Adult Patients With Dysphagia:
Position Paper From Japanese Working Group on
Integrated Nutrition for Dysphagic People. J Am
Med Dir Assoc. 23(10): 1676-1682, 2022.

Asian Journal of Dietetics 2023

Original
School Lunches Have the Potential to Improve Food Awareness not only for Children
but also for Their Families
Yuko Naruse1, Naoko Hirota2
1

Faculty of Human Health and Science, Matsumoto University, Nagano Prefecture, Japan
2
Graduate School of Health Science, Matsumoto University, Nagano Prefecture, Japan

ABSTRACT Background and purpose. With a view to reaching out to parents through school
lunch, we conducted a survey to clarify whether first-graders experiencing school lunch for the
first time and their families improve their awareness and attitudes toward eating and food throughthe provision of school lunches. Methods. The subjects of the survey were the parents of 822
children who entered 11 elementary schools in Matsumoto City, Nagano Prefecture in April 2021.
The survey was conducted in April before the start of eating school lunches and in June, July,and October after the start of school lunches. Responses were collected on paper or online(Microsoft Forms). Results. Even in October, when the novelty had worn off after six months ofeating school lunches, 69.1% of the children still talked about school lunches at home. In the
October survey, 47.3% of children increased awareness in eating and food, and 52.8% of children
increased talking about meals and food. In the October survey, 53.4% of families’ awareness ineating and food increased since stared eating school lunches. 56.5% of families’ talking about
eating and food increased. In families where children talk to their families about school lunches,
there was a significant increase in family awareness in eating and food, and talking about meals
and food compared to families where children did not (both p<0.001). Conclusion. We were able
to clarify that eating school lunches causes changes in children's attitudes toward food andbehavioral changes such as talking about food, and that this also changes the attitudes of families.
Keywords: school lunch, 1st grade elementary school student, effect on family, food awareness,Japan
INTRODUCTION
School lunch in Japan is not only to contribute toproper nutritional intake for children and students, butalso to play an important role in helping children
cultivate a correct understanding and the ability tomake appropriate decisions regarding food, according
to the School Lunch Law (1). In FY2021, the complete
school lunch coverage rate in elementary schools was
98.7%, and 89.1% in junior high schools, with a verylarge number of children eating school lunch during
their compulsory education period (2). In the third
section on “Matters Concerning Comprehensive
Promotion Including Activities to Promote Shokuiku[meaning food and nutrition education]” in the fourth
basic plan for the promotion of Shokuiku (3), it is alsomentioned that the government endeavor to educate
guardians about the importance of shokuiku andknowledge of proper nutritional management, etc. inschools. There have been studied on nutritional aspectsof school lunch (4,5) and nutrition education using
school lunch for children (6). These studies include
those that examined the educational effects of school
lunch in relation to learning attitudes and motivation,and those that examined the role of school lunch in theformation of eating behavior during childhood. Murai

et al. (7) reported that in fifth- and sixth-grade students,
those who were more interested in school lunch had
higher attitudes and motivation toward learning.
Asahina et al. (8) reported that school lunches play arole in changing eating behavior in 6th graders througheating the same meal with their peers. However, few
studies have examined the effects of school lunch
provision on the healthy dietary practices of children
and families, and the educational value of school lunch
from this perspective is not clear.
Globally, studies have been conducted on child-tofamily or child-to-parent approaches in health-related
education. Daudet IT et al. (9) conducted a systematic
reviewand meta-analysis of child-to-parent
communication of stroke information and reported
that this approach was effective in educating families.
Feng JH et al. (10) reported that an app-based
educational program delivered through elementary
schools using a child-to-parent approach was effective
in lowering salt intake and systolic blood pressure inadults.
Therefore, in this study, we conducted a survey toverify whether the provision of school lunches
improves children's own interest and awareness offood, and whether it improves the awareness andattitude of families towards healthy eating habits
through children. In April (at the beginning of theschool year), June (two months after the start of school*To whom correspondence should be addressed:
yuko.naruse@t.matsu.ac.jp53

School Lunches Improve Families’ Food Awarenesslunch), July (three months after the start of school
lunch), and October (six months after the start ofschool lunch), we conducted a questionnaire survey on
the attitudes and awareness of first graders and theirfamilies toward eating. This paper focuses on thechanges in the families in October, six months after thestart of school lunches.

children as seen by parents about four items, i.e.,“increased awareness in eating and food”, “increased
talking about meals and food themselves”, “decreasedin food likes and dislikes”, and “changed to enjoy
eating more” using a five points Likert scale. These
questions are based on the Ministry of Education,
Culture, Sports, Science and Technology's "Food
Guidance Guide (Second Revised Edition)" (11),which indicates the goals, teaching methods, andevaluation of instruction from the perspective ofpromoting Shokuiku in schools. In this guide,
examples of goals for teaching lower grade elementary
school students (1st and 2nd graders) are "to be able toenjoy eating with interest and concern for food" and"to be able to think about the importance of eating
without liking or disliking food". We also asked
responders about changes in their families as a resultof their children eating school lunch, i.e., “families’
awareness in eating and food” and “families’ talking
about eating and food, with a five points Likert scale“increased considerably”, “slightly increased”,“neither”, “slightly decreased”, and “decreased
considerably”.
In addition, we asked whether parents had read themonthly school lunch menus and the school lunch
newsletters which contain information on school
lunches and nutrition. We asked these items with four
options: "I read with a strong interest", "I read with alittle interest", "I am not interested but I read", and "Irarely read". The school lunch newsletters distributed
between April and October contained information on
the ingredients used in school lunches, nutritionalbalance, and milk (Table 1).

METHODS
1. Subjects and survey methods
The subjects were the parents of 822 children who
enrolled in April 2021 in 11 elementary schools servedby the Western School Meal Service Center in
Matsumoto City, Nagano Prefecture.
Questionnaire surveys were conducted four times in
April, June, July, and October of 2021. A descriptionof the survey months is given in the introduction. The
focus of this paper was to examine whether theprovision of school lunches improves family's
awareness and attitudes toward eating, using theresults of the survey conducted primarily in April at
the time of school entrance and in October six months
later.
The questionnaires were distributed to eachelementary school by the school lunch centers, andthen distributed to the children by their classroom
teachers. Responses were made either by survey sheet
or online (Microsoft Forms). For survey sheet
responses, the sheets were submitted by the children to
their classroom teachers and collected by the foodservice center for each class.
2. Contents of the survey
Responses to the questionnaire were requested
from those who were doing the most meal preparation
at home. The April questionnaire asked about the
respondents and their families, including theirdemographics, and their status related to eating
together at breakfast and dinner. We also asked about
the frequency of talking about eating and food in thefamily, with four options of Likert scale ranging from"very often" to "not at all”. To determine whether theprovision of school lunches was a new experience forthe family, we also asked whether the subject children
had older siblings. Additionally, to determine theimpact of the preschool lunch experience prior toentering elementary school, we also asked whether thechildren had ever been offered lunches at a preschoolor other school.
In the surveys conducted in June, July, and October,
we asked respondents about changes in their children
as seen by parents and in families' changes, since theirchildren started eating school lunch. First, we asked
how often children talk about school lunches at home.
We asked if children talk about school lunch, with five
points of Likert scale “fairly applicable”, “slightly
applicable”, “neither”, “slightly different”, and “fairly
different”. Similarly, we asked about changes in

3. Method and Analysis
Families included in the analysis were those with
April and October survey forms and matched
respondents. The 5-point Likert scale used forquestions such as changes in children and families wasgraded in order from 5 points for a positive response
to 1 point for a negative response. When asked
whether they read the monthly school lunch menus
and school lunch newsletters, the points were assigned
in order from 4 points for "I read with a strong interest"
to 1 point for "I rarely read". Mann-Whitney's U test
was used with Likert scale scores for comparisons
between the two groups, including the presence orabsence of lunch services at preschool before entering
elementary school and presence or absence of older
siblings. To examine the relationship between changes
in children and changes in families, we divided thechildren's changes into two groups: a positive response(fairly/slightly applicable) and no change group, and anegative response (neither and fairly/slightly different)group. Similarly, to examine the relationship between
parental interest in monthly school lunch menus andnewsletters and families' changes, respondents weredivided into interested (strong/ a little interest) and no54

Asian Journal of Dietetics 2023
interested groups. The Mann-Whitney U test was thenperformed using the Likert scale scores of the
responses to the questions. The effect size r was
obtained from the test statistic of the Mann-Whitney U
test as r=Z/√N. The effect sizes were judged to be 0.10
(small), 0.30 (medium), and 0.50 (large) (12). IBM
SPSS Statistics 27 was used for the analysis, and
p<0.05 was considered significant.

4. Ethical Considerations
Written explanation of free participation andanonymization process was provided in a letteraccompanying the questionnaire, and consent was
assumed to have been obtained upon submission of thequestionnaire. This study was conducted with theapproval of the Matsumoto University Ethics
Committee (Approval No. 114).

Table 1 Contents of the school lunch newsletters
April

Ingredients for school lunch (rice, bread wheat, soup stock, milk)
Preparation of clothing for serving school lunch
How to wash hands
Setting of tableware
Recommended recipe (Japanese radish and small fish salad)May

Sample of Nutritionally Balanced Meals "School Lunch" Three Color Food Groups
Explanation about the work of the school lunch center
Recommended recipe (Stamina-boosting, deep-fried bonito)

June

Encouraging Eating Together
Notice Regarding Panel Exhibit on Nutrition Education

July

Information about milk
Explanation about the work of the school lunch center
Notice about the Miso Soup Contest with a variety of ingredients
Recommended recipe (Wakame seaweed salad like a starry sky)AugustChrono-nutrition
Efforts of school lunch centers (visiting schools, guidance on breakfast)
Recommended recipes (hijiki seaweed salad, broccoli salad)

September

The Shinshu ACE Project *Impressions after eating special school lunch
Recommended recipe (natto salad)

October

Nutritionally balanced meal (staple, main and side dishes)
Ingredients used in school lunch (story about local apple farmer's cooperation)* The Shinsyu ACE Project is the Nagano Prefecture's Health Promotion PlanRESULTS
1. Respondents’ demographics and the status of
the target families at the time of enrollment
A total of 401 matched respondents (valid response
rate: 48.8%) to questionnaires submitted in April andOctober were included in the analysis.
Respondents included 8 fathers (2.0% of the valid
responses, the same below), 389 mothers (97.0%), and4 grandmothers (1.0%) of the children. There were 178
children (44.7%) with older siblings. In April, 88
families (22.3%) indicated that their child often eats
breakfast by children only and 11 families (2.8%)
indicated that their child often eats alone. However,389 families (98.7%) reported that their child often

eats dinner by the whole family together or with adults.
Regarding talking about eating and food, responses of
64 families (16.2%) were "very often" and those of
210 families (53.3%) were "occasionally". A total of
306 children (76.9%) had experienced lunch service
prior to entering elementary school (Table 2).
2. Changes in children and families since theirchildren started eating school lunch
We asked how often children talk about school
lunches at home with five points of Likert scale.
Parents who answered fairly/ slightly applicable were
266 out of 360 valid responses (73.9%) in June, 230
out of 329 (69.9%) in July, and 277 out of 401 (69.1%)

55

School Lunches Improve Families’ Food Awarenessin October. Almost 70% of the children talked aboutschool lunches with their families at home. No
significant change was seen in the six months from thestart of school lunches.
We asked about changes in children as seen byparents with a five points Likert scale. In October,children who increased interest in eating and foodwere 35 (8.8%) as "fairly applicable" and were 154(38.5%) as "slightly applicable". Children who
increased talking about meals and food themselves
were 41 (10.3%) as "fairly applicable" and were 170(42.5%) as "slightly applicable". Children who
decreased food likes and dislikes were 32 (8.0%) as"fairly applicable" and were 114 (28.5%) as "slightly
applicable". Children who changed to enjoy eating
more were 43 (10.7%) as "fairly applicable" and were136 (33.9%) as "slightly applicable" (Table 3).
Although there were differences depending on theitems, it was found that parents felt that their children
had changed regarding awareness and attitude towardfood after they started eating school lunches.
We also asked about changes in their families since
their children started eating school lunch with a five
points Likert scale. In October, 39 (9.8%) families
increased their awareness in eating and foodconsiderably and 174 (43.6%) families increasedslightly. As families’ change in talking about eating
and food in the family, 43 (10.8%) families responded,“increased considerably" and 182 (45.7%) families
responded, “increased slightly" (table 3).
There was no significant association between thepresence or absence of having received lunch service
at a preschool before entering elementary school andthe frequency of talking about school lunches at homeas of October (p=0.675). There was also no significant
association between the presence or absence of having
received lunch service at a preschool and children'schange due to eating school lunch (increased
awareness in eating and food p=0.243, increased
talking about meals and food themselves p=0.551,
decreased food likes and dislikes p=0.549, changed toenjoy eating more p=0.193) (Table 4).
3. Families’ changes in October, six months after
the child started eating school lunch
There was no significant relationship between thepresence or absence of older siblings among thesurveyed children and the families’ change inawareness in eating and food (p=0.063). However,families with older siblings were significantly
increased talking about eating and food more thanfamilies without siblings (p=0.016) (Table 5).

Table 2 Respondent demographics and the status of the target families at the time of the child's enrollment
The number ofpeopleRespondent's relationship to enrolled
child

Siblings of enrolled children

older sibling

younger sibling

Status related to eating together at
breakfast

Status related to eating together atdinner

Do families talk about eating and foodat home?

Lunch for children before admissionof elementary school

Percentage of
total number ofpeople*father8

2.0

mother389

97.0

grandmother4

1.0

presence

178

44.7

absence220

55.3

presence

180

45.2

absence218

54.8

child often eats by the whole family together

80

20.3

child often eats with adults, but not with the whole family

215

54.6

child often eats by children only

88

22.3

child often eats alone

11

2.8

does not eat00.0

child often eats by the whole family together

171

43.4

child often eats with adults, but not with the whole family

218

55.3

child often eats by children only4

1.0

child often eats alone00.0

does not eat

1

0.3

very often

64

16.2

occasionally

210

53.3

not very often

108

27.4

not at all

12

3.0

306

76.9

92

23.1

lunch service**

othersn=401* Percentage of valid responses for each question item** Children were receiving food service at preschool.

56

194(48.4)
154(38.5)
170(42.5)
114(28.5)
136(33.9)83(20.7)35(8.8)41(10.3)32(8.0)43(10.7)

Talked about school lunches at home

Increased awareness in eating and food
Increased talking about meals and foodthemselves
Decreased food likes and dislikes

Changed to enjoy eating more

174(43.6)
182(45.7)39(9.8)43(10.8)

Talking about meals and food in familyneither

171(43.0)184(46.1)

neither214(53.4)239(59.8)

177(44.3)

204(51.0)83(20.7)2(0.5)

2(0.5)

slightly decreased

8(2.0)

13(3.3)10(2.5)7(1.8)

28(7.0)slightly different57
3 (2-5)4 (1-5)3 (1-5)3 (2-5)

Increased talking about meals and foodthemselves

Decreased food likes and dislikes

Changed to enjoy eating more

195.80197.34200.72

195.68198.264 (2-5)3 (2-5)3.5(1-5)

4 (3-5)4 (1-5)maximum）

211.80204.49193.29210.00203.61mean rankabsence (n=92)
median（minimum‐The effect sizes were judged to be 0.10 (small), 0.30 (medium), and 0.50 (large)**The effect size r was obtained from the test statistic of the Mann-Whitney U test as r=Z/sqr(N).

The 5-point Likert scale used for each question was graded in order from 5 points for a positive response to 1 point for a negative response.

* Mann-Whitney's U test

4 (1-5)

Increased awareness in eating and foodmaximum）

mean rank

presence（n=306)
median（minimum‐Talked about school lunches at home

Changes in children as seen by parents since
their children started eating school lunches in
October

Experience of lunch service before entering elementary school0(0.0)

2(0.5)

2(0.5)

0(0.0)

13(3.2)

fairly different

0.193

0.549

0.551

0.243

0.675

p-value*0(0.0)

0(0.0)

0.07

0.03

0.03

0.06

0.02

effect size**

398(100.0)399(100.0)

total

401(100.0)400(100.0)400(100.0)400(100.0)

401(100.0)

total

the number of people (%)

decreased considerably

Table 4 Association between changes in children as seen by parents since their children started eating school lunches and experience of lunch service
before entering elementary school

slightly increased

increased considerably

Families' awareness in eating and food

Changes in the families since their children started eating school lunches in Octoberslightly applicablefairly applicable

Changes in the children as seen by the parents since their children started eating school lunches in OctoberTable 3 Changes in children and families since their children started eating school lunches in October

Asian Journal of Dietetics 2023

4(2-5)3(2-5)

presence (n=177)

absence (n=219)

58

258.71146.49247.12146.84263.26162.96250.884(3-5)
3(2-5)
4(3-5)
3(2-5)
4(3-5)
3(2-5)
4(3-5)

4(2-5)
3(3-5)

no interested (n=114)

3(3-5)

no interested (n=97)

interested (n=285)

4(2-5)

interested (n=302)

173.90210.44174.55208.17159.43140.283(2-5)

3(2-5)

226.624(2-5)

189.81209.25

0.002

0.006

<0.001<0.001<0.001<0.001<0.001

0.063

0.16

0.14

0.44

0.46

0.48

0.54

0.38

0.09

effect size§

no interested (n=114)

interested (n=284)

no interested (n=97)

interested (n=301)

no change and negative (n=222)

positive (n=176)

no change and negative (n=253)

positive (n=144)

no change and negative (n=189)

positive (n=208)

no change and negative (n=210)

positive (n=187)

no change and negative (n=123)

positive (n=275 )absence (n=218)

presence (n=177)

Families' talking about eating and food3(3-5)

4(2-5)

3(3-5)

4(2-5)

3(2-5)

4(3-5)

3(2-5)

4(3-5)

3(2-5)

4(3-5)

3(2-5)

4(3-5)

3(2-5)

4(3-5)

4(3-4)

4(2-5)The effect sizes were judged to be 0.10 (small), 0.30 (medium), and 0.50 (large)§ The effect size r was obtained from the test statistic of the Mann-Whitney U test as r=Z/sqr(N).

The 5-point Likert scale used for each question was graded in order from 5 points for a positive response to 1 point for a negative response.

‡ Mann-Whitney's U test

† The respondents were divided into an interested group (strong/ a little interest) and no interested group.

168.66211.88172.54208.19161.02248.04169.12251.49135.87256.37146.12258.39119.99235.06186.96211.6<0.001

0.003<0.001<0.001<0.001<0.001<0.001

0.016

medianmean rank p-value ‡（minimum‐maximum）* The respondents of changes in children were divided into a positive response group (fairly/slightly applicable) and no change and a negative response group (neither and fairly/slightly different).

school lunch newslettersschool lunch menus

Talked about school lunches at home

positive (n=276 )no change and negative(n=123)
positive (n=188)
Increased awareness in eating and foodno change and negative(n=120)positive (n=209)
Increased talking about meals and foodno change and negative
themselves(n=189)positive (n=145)
Decreased food likes and dislikes
no change and negative(n=253)
positive (n=177)
Changed to enjoy eating moreno change and negative(n=222)
Parents' interest in school lunch menus and school lunch newsletters †Changes in children as seen by parents since their children started eating school lunches*

Older siblings

Presence or absence of older siblings from the perspective of the subject childmedianmean rank p-value ‡（minimum‐maximum）

Families' awareness in eating and foodTable 5 Relationship between changes in children and changes in families since their children started eating school lunch

0.19

0.15

0.41

0.38

0.58

0.54

0.51

0.12

effect size§

School Lunches Improve Families’ Food AwarenessAsian Journal of Dietetics 2023
In the positive group in which children talk aboutschool lunches at home, both family’s interest in
eating and food and talking about eating and foodincreased significantly compared to the negative group(both p<0.001) (Table 5). A similar relationship was
found among the positive groups of children's changes
as a result of eating school lunch as seen by parents:"Increased awareness in eating and food", "Talking
about meals and food themselves”, "decreased foodlikes and dislikes" and "Changed to enjoy eating more”(all p<0.001) (table 5).
62 parents (15.5%) read monthly school lunch
menus with strong interest, 240 (59.9%) read with alittle interest, 52 (13.0%) were not interested but read,and 45 (11.2%) rarely read. Regarding school lunch
newsletters, 39 parents (9.7%) read with strong
interest, 246 (61.3%) read with a little interest, 53(13.2%) were not interested but read, and 61 (15.2%)
rarely read. The group that was interested in the school
lunch menus showed significantly greater awarenessin eating and food, and talking about meals and foodthan the group that was not interested (p=0.006 and
p=0.003, respectively). Similar results were found for"school lunch newsletter" (p=0.002 for awareness and
p<0.001 for talking) (table5).
The effect size for the comparison of the presenceor absence of interest in school lunch menus andschool lunch newsletters were small, ranging from
0.14 to 0.19. On the other hand, the effect sizes for thecomparison of positive and negative groups ofchildren's changes as seen by parents were relatively
large, ranging from 0.38 to 0.58 (Table 5).

and that this experience increased their selfconfidence and motivation to eat. Similarity, in the
results of this study, school lunch, which is eaten in anenvironment different from that of the home, isassumed to have increased the children's self-efficacy
through the experience of eating food that they had
never eaten before or disliked.
It is assumed that school lunches are a subject ofgreat interest to children as soon as they start eating
school lunches, and that they have many opportunities
to talk about school lunches to their families after they
return home. However, even in October, six months
after the start of eating school lunches, nearly 70% of
the children were talking about school lunches at home.
This situation was not significantly different from June,
two months after the start of eating school lunches.
Preschools also have guidelines on Shokuiku (14), andlunch services are provided based on these guidelines.
However, the presence or absence of lunch service
experience at a preschool, was not related to thechange since their children started eating school lunch.
These findings indicate that many children continue tohave an interest in school lunch after entering
elementary school. In addition, we found thatregardless of the children's experience with lunch
service prior to entering school, school lunch provided
an opportunity for them to learn something new about
eating and food.
Children who have just entered elementary school
are in a period of rapid growth, both physically andmentally, and it is natural that their attitudes andawareness will change as they grow. However, in thissurvey we asked parents about changes in theirchildren's attitudes and awareness in eating and foodafter they started eating school lunch. Therefore, we
considered that even if changes due to growth aresubtracted, the effects of school lunch on children's
attitudes and awareness in eating and food were
sufficient.

DISCUSSION
1. Changes in children since started eating schoollunch
In the provision of school lunches, the Ministry of
Education, Culture, Sports, Science and Technology's"Food Guidance Guide (Second Revised Edition)" isreferred to as the policy. In this guide, examples ofgoals for teaching lower grade elementary school
students (1st and 2nd graders) are "to be able to enjoy
eating with interest and concern for food" and "to beable to think about the importance of eating without
liking or disliking food" (11). With regard to children
who had experienced school lunch for six months,
47% of parents perceived that their children's interestin food had increased. In addition, 53% of parents
perceived that their children had been more likely totalk about food themselves, and 45% of parents
perceived that their children changed to enjoy eating
more. We speculate that these results are theeducational effects of school lunches. Regarding thedecrease in likes and dislikes, Furushima et al. (13), in
their one-year observation of first-grade school
lunches, reported that the number of foods that evenchildren with dislikes increased due to school lunch
rules and encouragement from friends and teachers,

2. Changes in families since their children started
eating school lunch
More than half of the parents perceive that theirfamily's awareness in eating and food has increased
since their children started eating school lunch, andthat they have more opportunities to talk about eating
and food with their families. In the group that read themonthly school lunch menus and school lunch
newsletters with interest, more families showed anincrease in their awareness in eating and food, andtalking about eating and food in family than in thegroup that did not. However, rather than providing
such information, the presence or absence of changes
in children since eating school lunches as seen parents
had a larger effect size on changes in families. In
addition, families’ awareness in eating and foodincreased regardless the subject children had older
siblings. Based on these results, we speculate that even59

School Lunches Improve Families’ Food Awarenessif school lunches were not the first experience for thefamilies, it may have been stimulating for the families
to have their first-grade children eat school lunch forthe first time. On the other hand, families with older
siblings also showed a significant increase in talking
about eating and food compared to families withoutolder siblings. Although not shown in the results, there
was also a description in the free description that thesiblings often talked about school lunches. It was
speculated that in families with older siblings, school
lunches became a common experience among siblings,
and food-related topics were likely to become a topic
of conversation at home. Based on the findings
obtained in this study, we consider that more
appropriate information should be provided bynutrition teachers and more appropriate educational
materials on school lunch should be developed in the
future.
Worldwide, studies have been conducted on thechild-to-family or child-to-parent approach to healthrelated education. Daudet IT et al. (9) and Feng JH etal. (10) reported child-to-family approaches that havebeen implemented for education about stroke, salt
intake and systolic blood pressure. School lunches inJapan, unlike these approaches, are not a simple issuefocused approach. However, this study found thateating school lunch improved children's attitudes
toward food and changed their behaviors, such as
talking more about food, and that these factors alsochanged the attitudes of their families. It wassuggested that it is possible to improve more
appropriate ways of eating for a wide range of families
through the child-to-family method through school
lunches in Japan. It has been reported that parents ofelementary school students in the 20s to 40s generation
are less motivated than other generations to improvetheir own dietary habits (15). We believe that school
lunch management that is also conscious of reachingout to parents help improve the eating habits of thisgeneration of parents.

https://www.pref.nagasaki.jp/shared/uploads/20
13/07/1374575257.pdf (Access date: January 23,2023) (in Japanese)
2. Ministry of Education. The survey of school
lunch implementation status.
https://www.mext.go.jp/content/20230125mxt-kenshoku-100012603-1.pdf (Access date:August 19, 2023) (in Japanese)
3. Ministry of Agriculture, Forestry and Fisheries.
The Fourth Basic Plan for Promotion of
Shokuiku.
https://www.maff.go.jp/j/syokuiku/attach/pdf/ka
nnrennhou-30.pdf(Access date: January 23, 2023)
4. Kyoko Morimot, Kimiko Miyahara. Nutrition
Management Implemented at School Lunch
Programs in Japan Based on the Change inCriteria for Provision of School Lunches. The
Japanese journal of nutrition and dietetics 76:
S23-S37. 2018.
5. Hideko Nagura, Sumiko Takahashi. Survey of aJapanese Elementary School Lunch Program
Menu Planning, Quality Control and Nutrition
Management: A Case Study. The Japanesejournal of nutrition and dietetics 76: S38-S49.
2018.
6. Yoko Hosoyamada, Kimiko Miyahara. Trends inIntervention Studies on Food and Nutrition
Education in Japan Utilizing the School Lunch–
A Systematic Review. The Japanese journal ofnutrition and dietetics 76: s50-s63. 2018.
7. Eriko Koshikawa, Toyoko Okuda, Yoko Murai.
The Relation between Education through School
Lunch to Health and Learning Attitude andMotivation. The 59th Annual Meeting of Japan
Society of Home Economics. 51-51. 2007. (inJapanese)
8. Reiko Asahina, Takae Yoshihara. Jidouki nosyokukoudoukeisei niokeru katei deno syokuji,
gakkoukyuusyoku no tokutyou to yakuwari[Characteristics and Roles of Home Meals andSchool Lunches in the Formation of Childhood
Eating Behaviors (Translated from Japanese)].
Research abstracts on the annual meeting, regularmeeting and seminar of the Japan Association ofHome Economics Education 46 (0), 49-49. 2003.
(in Japanese)
9. Daudet Ilunga Tshiswaka, Laura E Sikes, Juliet
Iwelunmor, et al. Transferring Stroke Knowledge
from Children to Parents: A Systematic Review
and Meta-Analysis of Community Stroke
Educational Programs. J Stroke Cerebrovasc Dis27(11):3187-3199. 2018.
10. Feng J He, Puhong Zhang, Rong Luo, et al. App
based education programme to reduce salt intake(AppSalt) in schoolchildren and their families in
China: parallel, cluster randomised controlled
tria. BMJ 376: e066982. 2022.

ACKNOWLEDGMENTS
This research was conducted with the cooperationof a school lunch center and an elementary school in
Matsumoto City, Nagano Prefecture. We express our
sincere appreciation to all concerned people and to all
the parents who responded to the questionnaire survey.
In addition, this research was carried out with theacademic research grant of General Incorporated
Association J-Milk, and we would like to thankeveryone involved.
CONFLICT OF INTEREST
The authors have no conflicts of interest to report.

1.

REFERENCES
Ministry of Education. School Lunch Program
Act.

60

Asian Journal of Dietetics 2023
11. Ministry of Education, Culltur, Sports, Scienceand Technology. Shoku ni kansuru shido no tebiki.
Dai ni ji kaitei ban [Guidance on Dietary
Education. Second Revision (Translated form
Japanese)]. p.16-22. 2019. Higashiyama Shobo
Co.,Ltd., Kyoto (in Japanese)
12. Atsushi Mizumoto, Osamu Takeuchi. Basics andConsiderations for Reporting Effect Sizes in
Research Papers. Studies in English Language
Teaching 31:57-66, 2008. ( in Japanese)
13. Sonoe Furushima, Kayoko Kaneko. The study of
dietary behavior at school lunch of the first grade
primary school children. Journal of the Collegeof Education, Yokohama National University,
The educational sciences 8: 15-31, 2006. (inJapanese)

14. Ministry of Health, Labour and Welfare.
Tanosiku taberu kodomo ni. -Shoku kara
hajimaru sukoyaka gaido- [To Nurture Children
Who Enjoy Eating -A Guide to Health Promotion
Beginning with Eating- (Translated fromJapanese)]https://www.mhlw.go.jp/shingi/2004/02/dl/s021
9-4a.pdf (Access fate: April 6, 2023) (inJapanese)
15. Ministry of Health, Labour and Welfare. National
HealthandNutrition
Survey2019.
https://www.mhlw.go.jp/content/000710991.pdf(Access date: January 23, 2023)

61

Asian Journal of Dietetics 2023

Original
Comparison of Nutrient Intake in Vietnamese Children Calculated by Three Different
Food Composition Tables
Nguyen Huong Giang1, Nguyen Mai Phuong1, Nguyen Van Diep1, Yamamoto Shigeru1
1

Nutrition and Food Culture Research Center, Jumonji University, Saitama, Japan

ABSTRACT Background and purpose. Food Composition table is an indispensable tool in
dietary study. Vietnamese food composition table is published based on domestic researches
and foreign references. However, data are not up to date, which could lead to inaccurate nutrient
intake estimates and are not comparable with data from other countries. Therefore, this study
was conducted to calculate the nutrient intakes of Vietnamese children using different foodcomposition tables from Vietnam, Japan and Thailand and to clarify the influence of thesedifferences on calculated nutrient intakes. Methods. Dietary survey was conducted by 24-hour
recall method, at a primary school in suburban of Hanoi city, Vietnam on 3 non-consecutive
days (2 school days and 1 weekend day). The subjects were 10 year old children, 21 boys, and15 girls. Energy and nutrient intakes was calculated using Vietnamese food composition table(FCT), Japanese FCT and Thai FCT. Results. Dietary fiber intake was significantly lower when
Vietnamese FCT was used for calculation than Japanese and Thai FCT. The difference could
be due to the different analysis of dietary fiber in each country. There were no significant
differences between FCTs in energy, protein, fat, and carbohydrate intake. Conclusion. This
study suggests that the low dietary fiber intake of Vietnamese children may be due to the
problem of Vietnamese FCT. Further research is needed to develop internationally comparable
national FCT.
Keywords: Food composition table, Vietnamese children, nutrient intake, low fiber intake
INTRODUCTION
Food composition tables (FCTs) are an essential
resource for nutrition research, public health policy,
and clinical practice. FCTs are used to estimate
nutrient intakes in dietary surveys, assess dietaryadequacy,anddevelopevidence-based
recommendations for healthy diets. They are also used
to examine the relationship between diet and healthoutcomes, such as chronic diseases. Many countries
have a national or regional FCT, but on the other hand,
there are still many developing and some developed
countries without such tables. These countries rely on
data from other sources such as the United States
Department of Agriculture or FCTs from neighboring
countries. The Vietnamese FCT was published basedon domestic research and analysis and with reference
to a number of international ingredient databases (1).
The Vietnamese FCT was first published in 1972 andhas been revised three time. The latest version as of2023 was published in 2017. However, there is very
little updated data, and the reference documents arevery old such as Southeast Asia FCT 1972 – Foodcomposition for international use, ASEAN FCT 2000.
“Inadequate food composition data and their use maythen lead to erroneous research results, wrong policy
decisions (particularly in nutrition, agriculture andhealth), misleading food labels, false health claims andinadequate food choices’’ (2).
FCTs vary from country to country due to technicaldifferences such as food descriptions, nutrient
definitions, and analytical methods. A comparable
FCT is critical for accurate international comparisonof energy and nutrient intakes. Unfortunately, whencomparing dietary data across countries, theimportance of FCTs is often overlooked and people
focus solely on survey methods, which can lead tovarious errors. For instance, we found that 10-year-old
Vietnamese children consumed significantly lessdietary fiber compared with Japanese children (about
4 g and 12 g, respectively) without considering thecomparability of FCTs (3,4). However, when
examining the FCTs, we found that the fiber content of
the same food was very different in the two countries.
For example, the Vietnamese FCT specifies 0.3 g of
dietary fiber in 100 g of flour, whereas the Japanese
FCT specifies 2.7 g. This discrepancy highlights thelack of comparability in fiber intake of children inthese two countries.
Japan and Thailand are the Asian countries thatgenerate and disseminate their own food composition
tables. It is possible that the foods in Vietnam, Japan,
and Thailand are quite similar. Therefore, this study
was conducted to calculate the nutrient intake ofVietnamese children using different food composition
tables from Vietnam, Japan, and Thailand and to*To whom correspondence should be addressed:
giang3900@gmail.com

63

Comparison of Food Composition Tables
clarify the influence of these differences on thecalculated nutrient intake.

Food Composition Table 2015 (6) were used to
calculate energy, protein, lipid, carbohydrate and fiber
intake.
Statistical analysis
Mean, standard deviation were calculated and thedifferences of means were tested by ANOVA andTukey-Kramer post-hoc. The Spearman correlation
analyses were performed to estimate the association
between the FCTs. p-value smaller than 0.05 wasconsidered to be statistically significant. Statisticalanalyses were performed using IBM SPSS statistics 26.

MATERIALS AND METHODS
Dietary survey
Dietary survey was conducted by 24-hour recall
method, at a primary school in suburban of Hanoi city,
Vietnam on 3 non-consecutive days (2 school days and1 weekend day). The subjects were 10 year oldchildren, 21 boys, and 15 girls. Researchers interview
each child using standard food measures and a foodphotobook published by the Vietnamese National
Institute of Nutrition to estimate portion size. Whenchildren did not remember exactly what they ate, we
contacted their parents to reconfirm.
The protocol had been approved by the Hanoi Medical
University ethics committee. Before we conducted thesurvey, all the parents and children were introduced to
the nature of the project, and signed a consent form.
Food composition tables
Vietnamese Food Composition Table 2017 (1),Japanese Food Composition Table 2020 (5) and ThaiRESULTS
Table 1 shows the comparison of energy andnutrient intake of Vietnamese children calculated by 3
different FCTs. Energy, protein, lipid and carbohydrate
intakes have no significantly difference. Fiber intakes
was significantly lower when calculated by
Vietnamese FCT. Moreover, Spearman’s correlation
coefficient. All nutrients were significantly correlated
between each FCT.

DISCUSSION
In this study, we used the food composition tablefrom Vietnam, Thailand, and Japan to analyze the
dietary intake of Vietnamese children. We found that,when calculated by Vietnamese FCT, fiber intake ofchildren is lower than when calculated by other FCTs
suggests that low fiber intake of Vietnamese children
may be caused by problem of Vietnamese FCT .
Moreover, energy and nutrient intake correlated
strongly across all FCTs.
Fiber intake calculate by 3 FCTs was very different.
Several factors may contribute to this difference.
First, the reason for this could be the disparities inmeasurement methods and the inclusion of specificfiber types. Fiber is commonly classified as soluble orinsoluble. The fiber content listed in the Vietnamese
FCT is actually crude fiber – insoluble fiber. Initially,fiber was considered an indigestible component andreferred to as "crude fiber." They were determined bymeasuring the residues in plant foods that remained
after extraction with solvent, dilute acid, and dilute

alkali (7). However, this method of measuring crudefiber content has been found to grossly underestimate
the actual fiber content of human foods (8). The error
in the crude fiber method arises from the sequential
extraction process, which dissolves 50 to 90% of thelignin, 85% of the hemicellulose, and 0 to 50% of thecellulose. This error through loss can be as high as
700%, depending on the proportions of lignin,cellulose, and hemicellulose in the fiber (9). On theother hand, fiber in Thailand and Japanese FCT
includes both soluble and insoluble fiber and follows
Association of Official Analytical Chemists (AOAC)
Official Method to analyze. Thailand used enzymaticgravimetric method to analyze fiber composition. The
method provides a measure of total dietary fiber(insoluble dietary fiber; high molecular weight soluble
dietary fiber) by enzymatic removal of available starchand solubilization and extraction of a portion of theprotein; the remaining residue is dried, weighed, andcorrected for crude protein and ash contents (10). In
Japan, in addition to the enzymatic-gravimetric64

Asian Journal of Dietetics 2023
method, people also use the Liquid Chromatographymethod to determine low molecular weight soluble
dietary fiber (11). Due to significant variations inanalytical methods and type of fiber, comparison offiber consumption results among the three countries
may not be possible. Further research is needed toestablish harmonized definitions and measurement
methods for dietary fiber to ensure accurate
assessment and comparison of fiber intake acrosscountries.
Second, environmental, genetic, and processing
differences such as feed, soil, climate, genetic
resources, storage conditions, processing, andfortification could be one of the factors. However
since protein, lipid and carbohydrate intake had no
significant differences between countries and they
were analyzed by the same method, suggesting that the
food sources are relatively similar. Minatsu Kobayashi
et al. also found that protein and carbohydrate intake
were similar and fiber intake was different whencalculated by Thailand and Japanese FCT.
Nevertheless, the reason of differences was notpointed out (12).
When using Vietnamese FCT to calculate, theamount of fiber intake was underestimated. This maylead to inaccuracies in providing dietary guidelines
and nutrition interventions. Although children’s fiber
intake was higher when calculated using Japanese andThai FCTs, it is still below the Vietnamese
recommended intake of 20-22g (13) and comparedwith Japanese children's intakes of 11.9 in boys and12.6 in girls (4). This highlights the need for additional
strategies to increase fiber intake in children. One
viable method is to intervene in school meals. To give
you an idea, Diep et al. were able to increase the fiber
intake of 10-year-old children in school lunch from
1.1g to 1.9g (calculated by Vietnamese FCT) by
increasing the number of materials and changing thecooking method without increasing the cost (14).
Vietnamese FCT still lacks information, and thedata are not up-to-date. When comparing nutrient
intakes between countries, it is better to use the better
value of another country if the FCT completion rate of
one country is low. In this study, intake levels ofenergy and all nutrients were highly correlated
between different FCTs suggesting that the Thailand
FCT or Japanese FCT can be used to calculate nutrient
intakes of Vietnamese. However, Vietnamese FCT
should be improved. It should be generated according
to international guidelines so that it is comparable andreliable.
The study is limited by a relatively small sample
size of 36 participants. In addition, the study did notcompare the vitamin and mineral contents of thedifferent food composition tables, which may differ
significantly.

CONCLUSION
This study suggests that the low fiber intake ofVietnamese children may be caused by the problem ofVietnamese FCT. Differences in nutrient values indifferent food composition tables may affect theaccuracy of nutrient intake assessments and makecomparisons between different studies difficult. To
ensure accurate and comparable nutrient intake
assessments, additional research is needed to develop
uniform techniques for nutrient analysis and toestablish standardized food composition databases.
ACKNOWLEDGEMENTS
The authors would like to thank all participants fortheir valuable contribution to this research. We also
wishes to thank Andrew Durkin, Prof. Emeritus ofIndiana University, for editing our English.
REFERENCES
1. National Institue of Nutrition, Ministry of Heath.
Vietnamese Food Composition Table, Common
Nutrients. Hanoi, Vietnam: Medical Publishing
House; 2017.
2. U. Ruth Charrondiere. Food composition
challenges. [Internet]. 2022. Available from:http://www.fao.org/infoods/infoods/foodcomposition-challenges/en/
3. Phuong NM, Giang NH, Diep N Van, Thu TT,
Yamamoto S. Low Physical Activity May Lead to
Obesity Rather than High-Energy Intake in
Vietnamese Children. Asian J Diet 4(4):77–82.
2022.
4. Giang NH, Phuong NM, Diep N Van, Sarukura N,
Takeichi H, Sano A, et al. Energy and Nutrient
Intakes and Recommendations from a Survey ofChildren in a Coastal City in Central Japan. AsianJ Diet 3(3):95–103. 2021.
5. Ministry of Education, Culture, Sports, Scienceand Technology, Japan. Standard Tables of Food
Composition in Japan 2020. Eighth Rev. 2020.
6. Puwastien P, Judprason K, Sridonpai P, Saiwan T.
Thai Food composition Tables 2015. Institute of
Nutrition, Mahidol University. 2015.
7. Dai FJ, Chau CF. Classification and regulatory
perspectives of dietary fiber. J Food Drug Anal
1;25(1):37–42. 2017.
8. Dhingra D, Michael M, Rajput H, Patil RT. Dietary
fibre in foods: a review. J Food Sci Technol
49(3):255. 2012
9. Van Soest PJ. Dietary fibers: their definition andnutritional properties. Am J Clin Nutr 31(10 Suppl).
1978.
10. McCleary B V. Measurement of Dietary Fiber:
Which AOAC Official Method of AnalysisSM toUse. J AOAC Int 106(4):917–30. 2023.
11. Ministry of Education, Culture, Sports, Scienceand Technology J. Regarding changes in theanalytical method for dietary fiber in the food65

Comparison of Food Composition Tables
composition table. 2018.
12. Kobayashi M. Estimation of Nutrient Intake inThailand: Influence of Differences in Food
Composition Tables on Estimated Intake. J Nutr
Med Diet Care 31;3(1). 2017.
13. National Institue of Nutrition, Ministry of health.

Vietnam Recommended Dietary Allowances.
Hanoi, Vietnam: Medical Publishing House; 2016.
14. Diep NV, Phuong NM, Giang NH, Ngoc TT, Hien
NTT, Trang NT, et al. Improvement of theVietnamese school lunch menu. Asian J Diet
5(1):5–9. 2023.

66

Asian Journal of Dietetics 2023

Original

The Prevalence and Factors Associated With Cardiometabolic Risk
Among Urban in-School Adolescents in Harare, Zimbabwe
Pencil A1,*, Matsungo TM2, Hongu N2 and Hayami N2
1

2

Graduate School of Human Life Science, Osaka City University.
Department of Nutrition, Dietetics and Food Sciences (DNDFS), University of Zimbabwe.
3
Graduate School of Human Life and Ecology, Osaka Metropolitan University.

ABSTRACT Background: Obesity and cardiometabolic health risks (CMR) an emerging healthproblem in Zimbabwe. Nutrition education for adolescents plays a pivotal role in preventing
both obesity and CMR. Objective: To assess the prevalence and factors associated with CMR
among adolescents in Harare, Zimbabwe. Method: A cross-sectional survey using aquestionnaire was carried out with 320 in-school adolescents. Blood measures for blood pressure(BP), glucose (FG), and total cholesterol (TC) were assessed using standard methods, and bodymass index (BMI), and waist-to-hip ratio (WHR), waist-to-height ratio (WtHR) were calculated.
Pearson`s Chi-square and binary logistic regression were used to test for associations andexplored factors associated with CMR (p < 0.05). Results: The median and IQR range age forthe participants was 16 (14;19) years. The prevalence of obesity was 17.1% and CMR was 24.7%,
both of which were higher among girls compared to boys. CMR was significantly associatedwith living in high economic status (HES) neighbourhoods [OR = 3.09(1.29, 7.38), p = 0.011],
inadequate nutrition knowledge score [OR = 1.38(1.96-7.77), p < 0.001], inadequate physicalactivity [OR = 2.28(1.25-4.15), p = 0.007] and increased BMI [OR = 1.18(1.10-1.27), p < 0.001].
Conclusions: The prevalence of obesity and high CMR appears to be higher among girls
compared to boys, particularly from affluent neighborhoods. This gender disparity could be due
to socio-cultural beliefs which may hinder the translation of nutrition knowledge to practice.
Therefore, community-based nutrition interventions to raise obesity and CMR awareness areneeded to improve nutrition knowledge while promoting healthy eating habits to increase fruitand vegetable consumption to reduce the prevalence of obesity and CMR among adolescents.
Keywords: Obesity, adolescents, diabetes, hypertension, CMR, Zimbabwe
INTRODUCTION
Adolescents are aged between 10-19 years (1).
Although this stage is seen as a healthy stage of life,
risks of preventable diseases, illnesses, and conditions
like obesity exist (2). Overweight and obesity arecaused by excess fat accumulation in the body which
presents health risks (3) and is commonly measured
using the body mass index (BMI) (4, 5). Obesity is a
global public health problem that is often associatedwith several non-communicable diseases (NCDs) andincreased cardio metabolic risk (CMR) attributable tonutrition transition and poor dietary habits (6-8),.
Low-income countries are facing an emerging
problem of obesity which often co-exists with hunger,
micronutrient deficiencies, and undernutrition,“multiple burdens of malnutrition.”(9) In Africa, theprevalence of obesity among children and adolescentsranges from 5% to 16.5% (10, 11). In Zimbabwe, therate of obesity has exponentially increased over theyears with prevalence ranging from 5.8% to 27.3%(12-15). CMR is a pattern of metabolic imbalances
manifested as central obesity, hypertension,
hypercholesterolemia, and hyperglycaemia (16, 17).
*To whom correspondence should be addressed:
ashleighpencil@gmail.com

The presence of any one or two of these constitutes
early markers of the risk (18). CMR and its earlymarkers occur in adolescents; however, its magnitude
has not been determined in Zimbabwe. It is critical toestimate the magnitude and the factors associated with
CMR across the life course considering that
Zimbabwe is experiencing nutrition transition andrapid urbanization (19). Nutrition transition is adietary shift from the consumption of wholesome andhealthy foods to ultra-processed energy-dense foods.
Due to modernization, eating away from home has
become popular (20). In Zimbabwe, ready-to-eat
sweetened, or fried and salty foods are commonly
available, especially in tuck-shops near schools or on
the roadside where students easily purchase thesefoods on the way to and from school (21).
Interestingly, sedentary lifestyles and theconsumption of unhealthy foods are the key drivers ofobesity among adolescents in urban areas (14).
Although limited studies and data exist on the factors
associated with obesity and/or CMR in Zimbabwe,socio-cultural practices and community perceptions
that an increase in body fat “obesity” is a sign ofwealth, social status, and beauty still exist (22). As aresult, there is a lack of urgency regarding CMR
screening among adolescents, “the neglected age

67Prevalence and factors associated with obesity and cardiometabolic risk.
group”, as there is still a belief that CMR only affects
adults and the elderly (23). Therefore, the purpose ofthis study was to assess the prevalence of obesity,
CMR, and associated determinants among in-school
adolescents and to propose interventions to tackle
obesity and promote healthy dietary behaviors among
adolescents in Harare, Zimbabwe. and propose
interventions to tackle obesity and promote healthyeating targeting the adolescents.
METHODS
Study setting and participants
The study was carried out in Harare, the capital of
Zimbabwe, lying in the northeastern part of thecountry. The city was founded in 1890 and has an areaof 940 km2 (371 mi2) and a population of 15,178,979
in the 2022 census (24). The participants wereadolescents aged 14 to 19 years with signed informed
consent forms and attending secondary schools in
Harare. Harare has 299 high schools with a total of355,633 adolescents (25).
Sample size and sampling technique
The sample size was calculated using the Dobson
formula (26) where Z-value = 1.96, p is the percentageof picking a choice expressed as decimal = 0.05, andc is the confidence interval = 0.95. A sample size of
437 adolescents was found to be sufficient, and with a
25% attrition adjustment, the final sample size was380. After data cleaning and consent, 320 school
adolescents successfully participated in the study. A
stratified random sampling technique was used to
select ten high schools from the registry of The
Ministry of Primary and Secondary Education. The
schools were further divided into strata based on theirlocations and socio-economic zones, class level (form
2 to form 6) based on the Zimbabwean education
system, and age groups (14–16 years and 17–19 years).
Recruited participants were asked to remain in theclassrooms, and they received an in-depth orientation
about the study’s objectives, finger prick sampling
procedure, weight, and height measurements for BMI
calculations,
waist andhip circumference
measurements, and how long it would take to fill inthe self-administered questionnaire. The participants
were informed that no incentive would be offered forparticipation, there would be no penalties for droppingout of the survey, and participation in the study wasfor participants with signed consent forms. Three
hundred and twenty (320) participants weresuccessfully enrolled in this study and on the survey
day, a team of research assistants and one nurse werealways present during the administration and blood
sampling. This survey was carried out in accordancewith the ethical standards of the responsible
committee on human experimentation (institutionaland national) and with the Helsinki Declaration of1975, as revised in 2008.

Research instruments and data collection
methods
Structured questionnaire: An intervieweradministered questionnaire was used to collectdemographic data, food habits, nutrition knowledge,
and information on physical activity (PA). The finalquestionnaire had four sections. Socio-demographic
and anthropometry (10 questions), nutrition
knowledge (20 questions), food habits (23 questions),
and physical activity (7 questions). The questionnaire
was adapted and scored as follows:
Nutrition Knowledge: This questionnaire wasadapted from (27) and was categorized as inadequate(NKS <50%) or adequate (NKS ≥50%). The
instrument was a practical and easy-to-administer toolwith acceptable reliability among high school students.
This section had three subscales: adequate andbalanced nutrition, essential nutrients, andmalnutrition-related diseases and the questions
consisted of complete sentences of correct or incorrectstatements. The Cronbach’s alpha coefficient was
0.85 overall. An example of the nutrition knowledge
question was, “We should drink at least 8-10 glassesof water every day” with (true, false, and not sure)answer options.
Food habits: This questionnaire was adapted from(28) and it had an internal reliability of Cronbach’s α= 0.82. The FHS was calculated as follows:
FHS = No. of healthy responses × (23 No.
of items completed)
Inadequate was (FHS < 50%) and adequate was(FHS ≥ 50%). An example of a food habits question
was, “I try to ensure I eat plenty of fruit andvegetables.”Physical activity: This questionnaire was adaptedfrom(29) and the physical activity score (PAS)
responses were structured in different ways according
to each question. The total score of the PA section was
categorized as inadequate (PAS < 50%) or adequate(PAS ≥ 50%). It had an internal reliability Cronbach’s
alpha of 0.71. An example of a physical activity
question was, “Do you usually practice any form ofphysical activity?”
Anthropometry: Height was measured to thenearest 0.1 m using the stadiometer (Leceister®
Height Measure, Seca, UK), weight was measured
using an electronic bathroom weighing scale(Sunbeam, South Africa), and waist and hip
circumferences using the non-elastic tape measure,(Goldfish, UK). The nutritional status of theparticipants was determined using WHO standard
protocols for children 5–19 years (30). Body Mass
Index (BMI), kg/(m2) was converted to z-scores using
WHO AnthroPlus. BMI-for-age z-scores werecategorized into underweight (<−2 SD), normal (≥−2to ≤+1SD), overweight (≥1 to +2SD), and obese(>+2SD). While waist circumference (WC) ≥90th68Asian Journal of Dietetics 2023

percentile for children and adolescents is defined
as abdominal obesity (31). Waist hip ratio (WHR) wasclassified as abnormal in males if the ratio was ≥0.9
Blood measures: Single-use disposable
nonsterile gloves were used, and a single-use
disposable lancet device was used for eachparticipant and all tests were carried out as per the
manufacturer’s instructions. The adolescents
cooperated and fasted overnight. Blood pressure(BP) was measured using an automatedsphygmomanometer(Braun,UK).
Threemeasurements were taken 10 minutes apart, and theaverage was taken as the blood pressure. Bloodpressure was classified such that normal BP: was <120/< 80 mm Hg. Elevated BP: 120/< 80 to 129/ <80 mm Hg (30) Elevated BP, Stage 1 (130/80 to
139/89 mmHg) and Stage 2 (≥ 140/90 mmHg) (33).
Glucometers were used for the blood glucose (AccuAnswer®, LBM-01, South Africa) and rapid totalcholesterol meter (Accu-Answer®, LBM-01, Southand ≥0.85 in females. Waist-to-height (WHtR) wasclassified as at high risk of abdominal obesity if theratio was ≥0.5 (32).
Africa). Fasting blood sugar levels (mmol/L) wereclassified as normal (3.9 and 5.6 mmol/L), impaired
glucose tolerance (5.6 to 6.9 mmol/L), and elevated(≥11 mmol/L) (34). While cholesterol was classified
such that normal cholesterol is ≤170 mg/dL,
moderate as >170 mg/dL and <200 mg/dL, andabnormal as ≥200 mg/dL (35).
RESULTS
Cardiometabolic indices (CMI) included fasting
glucose (FG) and total cholesterol (TC), bloodpressure (BP) waist-to-hip ratio (WHR), and waistto-height ratio (WtHR). Cardiometabolic health risk
was categorized as low risk and high risk. Low risk
was defined as the presence of any two highcardiometabolic indices and high risk was defined as
the presence of three or more indices.

Table 1: Prevalence of cardiometabolic health risk across participants' demographics
Cardiometabolic health risk
Total
Low Risk
High Risk
Variable
n (%)
n (%)
n (%)
GenderMale
122 (38.6)
93a (38.6)
29a (38.7)
Female194 (61.4)
148a (61.4)
46a (61.3)
Age Group
14-16 years
181 (56.6)
133a (54.5)
48a (63.2)
17-19 years
139 (43.4)
111a (45.5)
28a (36.8)
Education level No formal education
6 (1.9)6a (2.5)0a (0.0)
of HH
Primary education
5 (1.6)
4a (1.6)
1a (1.3)
Ordinary education
126 (39.4)
97a (39.8)
29a (38.2)
Tertiary education
183 (57.2)
137a (56.1)
46a (60.5)
Employment
Formally employed
173 (54.1)
133a (54.5)
40a (52.6)
status of HH
Unemployed21 (6.6)
16a (6.6)
5a (6.6)
Entrepreneur
126 (39.4)
95a (38.9)31a (40.8)
FamilyBoth parents
211 (65.9)
166a (68.0)
45a (59.2)
Structure
Single parent
58 (18.1)
38a (15.6)
20b (26.3)
Relatives/guardians
44 (13.8)33a (13.5)
11a (14.5)
Child headed
5 (1.6)
5a (2.0)
0a (0.0)
Other
2 (0.6)2a (0.8)0a (0.0)
Household Size Average
273 (85.3)
207a (84.8)
66a (86.8)
Above Average
47 (14.7)
37a (15.2)
10a (13.2)
Place ofHES
40 (12.5)26a (10.7)
14a (18.4)
Residence
Intermediate78 (24.4)
53a (21.7)
25b (32.9)
LES
202 (63.1)
165a (67.6)
37b (48.7)

p-value
0.990
0.184
0.544

0.957

0.159

0.666
0.011*

Notes: Cardiometabolic risk: Low risk <2 indices, high risk >3 indices *P-value is Pearson’s Chi-squared test, in cases where cell values lessthan 5, Fisher’s Exact test was used. Where HH= Household head. HES – high economic status, LES- low economic status. Different
subscript letter and (*) indicates that the CMR categories differ significantly (p<0.05).

Socio-demographic characteristics
Thesummaryofsociodemographic
characteristics of the participants are summarized inTable 1. The median and IQR range for theparticipants was 16 (14;19) years. Most of theparticipants were female (61.4%, p = 0.990) and in
the 14-16 years age group (56.6%, p = 0.184).

Concerning the household heads, most attained
tertiary education (57.2%) and were formallyemployed (54.1%). Most of the adolescents werestaying with both parents (65.9%, p = 0.157), within
an average household size of at least 5 family
members (85.3%, p = 0.666), and lived in low socioeconomic neighbourhoods (63.1%, p = 0.011). A

69

Prevalence and factors associated with obesity and cardiometabolic risk.

greater proportion of the adolescents from the LES
neighbourhood were in the low-risk category(67.6%). However, overall, adolescents who were in
the high-risk category were living in LES
neighbourhoods (48.7%).
Cardiometabolic health risk by nutrition
knowledge, food habits, and physical activity
levelsTable 2 shows the relationship between CMR
and nutrition knowledge score (NKS), food habits,

and PA. CMR was significantly associated with
NKS. Most adolescents with inadequate knowledge
were in the high-risk CMR category (30.3%, p =0.014). Adolescents with inadequate food habits(56%, p = 0.029), particularly skipping meals(90.8%, p = 0.021), were in the high-risk category
and were significantly associated with CMR. Lastly,adolescents with inadequate PA were in the highrisk category and had a significant association with
CMR (55.3%, p = 0.034).

Table 2: The interplay between cardiometabolic health risk by nutrition knowledge, food habits,
and physical activity levels
Cardiometabolic health risk
Variable
Nutrition Knowledge Score
Malnutrition relateddiseases knowledge
Essential nutrientsknowledge
Balanced nutrition
knowledge
Food Habits Score
Health Choices
SugarsFats
Fruits and Vegetables
Skipping Meals
Physical Activity Level

Inadequate
Adequate
Inadequate
Adequate
Inadequate
Adequate
Inadequate
Adequate
Inadequate
Adequate
Inadequate
Adequate
High
Low
High
Low
Low
High
Inadequate
Adequate
Inadequate
Adequate

Total
n (%)
65 (20.3)
255 (79.7)
175 (54.7)
145 (45.3)
264 (82.5)
56 (17.5)
233 (72.8)
87 (27.2)
202 (63.1)
118 (36.9)
192 (60.0)
128 (40.0)
151 (47.2)
169 (52.8)
243 (75.9)
77 (24.1)
206 (64.4)
114 (35.6)
262 (81.9)
58 (18.1)
143 (44.7)
177 (55.3)

Low Riskn (%)
42a (17.2)
202a (82.8)
131a (53.7)
113a (46.3)
195a (79.9)
49a (20.1)
170a (69.7)
74a (30.3)
146a (59.8)
98a (40.2)
140a (57.4)
104a (42.6)
113a (46.3)
131a (53.7)
187a (76.6)
57a (23.4)
163a (66.8)
81a (33.2)
193a (79.1)
51a (20.9)
101a (41.4)
143a (58.6)

High Riskn (%)
23b (30.3)
53b (69.7)
44a (57.9)
32a (42.1)
69b (90.8)
7b (9.2)
63b (82.9)
13b (17.1)
56b (73.7)
20b (26.3)
52a (68.4)
24a (31.6)
38a (50.0)38a (50.0)56a (73.7)
20a (26.3)
43a (56.6)
33a (43.4)
69b (90.8)
7b (9.2)
42b (55.3)
34b (44.7)

p-value
0.014*
0.520
0.029*
0.024*
0.029*
0.086
0.574
0.599
0.104
0.021*
0.034*

Notes: Cardiometabolic risk: Low risk <2 indices, high risk >3 indices. *P-value is Pearson’s Chi-squared test at p=0.05. NKS (nutrition
knowledge score): <50% is inadequate and ≥50% is adequate. Food habits score<5 is inadequate and ≥5 is adequate. PAL (physicalactivity level) is adequate at≥ 60 minutes and inadequate at <60 minutes. Different subscript letter and (*) indicates that the CMR categories
differ significantly (p<0.05).

Nutrition status of the adolescentsThe results of the current study (Figure 1)
revealed that obesity affected 17.1% of adolescentswith high proportions among girls compared to boys
(p=0.030), while the underweight status (23.0%)
was higher among boys than girls (p=0.030)
Summary of the cardiometabolic indices foradolescents
Cardiometabolic indices (CMI) were clusteredwith a high proportion among the 14-16-year-old
age group and more pronounced in girls, i.e.,
overweight and obesity (21.6%, p=0.030) than
WHtR (13.8%, p=0.012), TC (29.4%, p=0.023) andFG (98.9%, p=0.210). Notably, BP (58.7%,

p=0.038) and WHR (18.0, p=0.0023) were more
pronounced among boys (Table 3).
Factors associated with cardiometabolic risk
among adolescents.
CMR was significantly associated with homelocation; HES [OR = 3.09(1.29, 7.38), p = 0.011],
Intermediate [OR = 2.16(1.08-4.30), p = 0.029],
inadequate food habits score [OR= 0.66(1.02-3.64),
p = 0.043, inadequate nutrition knowledge score[OR = 1.36(1.96-7.77), p<0.001]. Inadequate PA
was also significantly associated with CMR [OR =2.28(1.25-4.15), p = 0.007]; and BMI [OR =1.18(1.10-1.27), p<0.001] (Table 4).

70

66.5
11.9

9.8
BOYS

Underweight

21.6

62.7
.23.0

PERCENTAGE (%)

Asian Journal of Dietetics 2023

GIR LS

NormalOverweight and obese

Figure 1: The distribution of nutrition status of adolescents by sex
Table 3: Clustering of cardiometabolic indices among adolescents by sex and age group
GenderVariable
BMI

WtHR
BP
WHR
TC
FG

Underweight
NormalOverweight
and obese
Low Risk
High Risk
Low risk
High risk
Low risk
High risk
Low risk
High risk
Low risk
High risk

Total
n (%)
51 (16.1)
211 (66.8)
54 (17.1)

Male
n (%)
28a (23.0)
82a (67.2)
12a (9.8)

Femalen (%)
23b (11.9)
129a (66.5)
42b (21.6)

278 (89.7)
32 (10.3)
152 (48.7)
160 (51.3)
276 (87.3)
40 (12.7)
237(75.0)
79 (25.0)
6 (1.9)302 (98.1)

116a (95.1)
6a (4.9)50a (41.3)
71a (58.7)
100a (82.0)
22a (18.0)
100a (82.0)
22a (18.0)
4a (3.4)
115a (96.6)

162b (86.2)
26b (13.8)
102b (53.4)
89b (46.6)
176b (90.7)
18b (9.3)
137b (70.6)
57b (29.4)
2a (1.1)
187a (98.9)

p-value
0.030*

VariableBMI

0.012*

WtHR

0.038*BP
WHR

0.023*
0.023*

TC

0.210

FG

Underweight
NormalOverweight
and obese
Low Risk
High Risk
Low risk
High risk
Low risk
High risk
Low risk
High risk
Low risk
High risk

Age Group

Total
n (%)
52 (16.3)
212 (66.3)
56 (17.5)

14-16 yearsn (%)
37a (20.4)
115a (63.5)
29a (16.0)

17-19 yearsn (%)
15b (10.8)
97a (69.8)
27a (19.4)

282 (89.8)
32 (10.2)
155 (49.1)
161 (50.9)280 (87.5)
40 (12.5)240 (75.0)
80 (25.0)
6 (1.9)306 (98.1)

156a (88.1)
21a (11.9)
91a (51.1)
87a (48.9)
154a (85.1)
27a (14.9)130a (71.8)
51a (28.2)
3a (1.7)
170a (98.3)

126a (92.0)
11a (8.0)64a (46.4)
74a (53.6)
126a (90.6)
13a (9.4)
110a (79.1)
29a (20.9)
3a (2.2)
136a (97.8)

p-value
0.064

0.265
0.402
0.136
0.134
0.999

Notes: FG- fasting glucose, TC- total cholesterol, BP- Blood pressure, WHR- waist-hip ratio, WtHR - Waist to height ratio. Values are above cut-off points (at-risk category). WC for females, normal is <80 andrisky when ≥80; for males, normal is <94 and risky when ≥94. FG: normal is 5.6-6.9mmol/L and at risk is ≥7.2. BP: normal is ≤139/89mmHg, and at risk ≥140/90mmHg. TC: normal >170>120mg/dl and risky when
>200mg/dl. WtHR: normal ratio 0.5, at risk >0.5. Different subscript letter and (*) indicates that the CMR categories differ significantly (p<0.05).

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Prevalence and factors associated with obesity and cardiometabolic risk.

Table 4. Factors associated with cardiometabolic health risk.
Odds Ratio
VariableB
S.E.
p-value(OR)
Age (years)
-0.07
0.12
0.549
0.93
Formally employed
-0.49
0.31
0.121
0.62
Unemployed
0.35
0.60
0.560
1.42
Location (HES)
1.13
0.44
0.011*
3.09
Location (Intermediate)
0.77
0.35
0.029*
2.16
HH Size (<5 people)
0.32
0.42
0.451
1.38
NKS (Inadequate)
1.36
0.35
<0.001*
3.90
Food habits (Inadequate)
0.66
0.32
0.043*
1.93
Physical activity (Inadequate)
0.82
0.31
0.007*
2.28
BMI (kg/(m2))
0.17
0.04
<0.001*
1.18
Constant
-5.26
2.17
0.015
0.01

95% CI (OR)
Lower
Upper
0.74
1.18
0.33
1.14
0.44
4.56
1.29
7.38
1.08
4.30
0.60
3.15
1.96
7.77
1.02
3.64
1.25
4.15
1.10
1.27

Notes: Goodness of fit: Nagelkerke R2 = 0.249, Hosmer and Lameshow test p=0.842 Where; HH- Household, NKS - Nutrition Knowledge
Score, BMI – Body Mass Index, HES- high socioeconomic status.

DISCUSSION
This study was designed to assess the prevalence
and factors associated with CMR among in-school
adolescents in Harare, Zimbabwe. Our findings
show that the prevalence of obesity was (17.1%) andhigh CMR (24.7%) among this age group. The
results showed that overweight and obesity (17.1%)
with higher proportions among girls andunderweight (15.9%) with higher proportions
among boys. These results are in line with findings
from recent Zimbabwean studies, (13, 14, 36) andstudies from other African countries (37, 38).
However, considering that 23.0% of theadolescents were underweight, our results confirm
that the “double burden” of malnutrition exists in
Zimbabwe. The emerging problem of obesity andassociated increased CMR is postulated to be mainly
driven by nutrition transition and an increasingly
obesogenic environment (39-42). Our findings showthat higher percentages of adolescents are
consuming high-fat and sugar foods and low fruits
and vegetables. This is problematic, particularly inschool environments where adolescents can easily
access more ultra-processed snacks and limited
fruits and vegetables. A national survey showed only
13% of the adult population in Zimbabwe consumed
at least 400 g per day of fruits and vegetables
recommended by WHO (36). Despite the enormous
benefits and existing dietary recommendations, mostZimbabwean adults do not meet the dailyrequirements and adolescents can easily adopt the
behaviour in a family setting (43).
A recent study on adolescent obesity in
Zimbabwe revealed that adolescents lack obesity
awareness and it is not as serious as other healthproblems and conditions (44). This shows the needto set up interventions to tackle obesity, promote PA,
and encourage healthy eating among adolescentsutilizing community-themed social behavior change
activities informed by the social-ecological model(44, 45). It has been observed that the rate of obesity
is higher among girls than boys (13,46, 47).
However, the finding that CMR risk appears to behigher in girls compared to boys as well is a cause
for concern as this could indicate problematic
dietary behaviours within this sex. On the contrary,
it is reported that boys are more obese than girls indeveloped countries like North America and Japan(49, 50). Although the cause is not well understood,
it can be speculated that the differences in obesity
prevalence and associated CMR may be driven bysocietal gender perspectives on body weight, dietary
habits as well as sex-related determinants, such as
body composition and hormones. Hormonal
fluctuation particularly women across the lifespaninfluence appetite and body fat distribution (48, 49).
This argument may be true considering that in the
African context, a mother is perceived to be big andcurvy “Bigger is better myth” is a reflection that thehusband is taking good care of his wife (51). In
Japan, girls in higher-grade classes and young
women generally want to be thin (52) due to media
influences on this body ideal (53) however, in
Zimbabwe girls want to be plump and curvy as they
believe it makes them more attractive (12, 51).
Additionally, it is a common belief that a plumpchild is healthy, and a slim child is unhealthy.
Therefore these beliefs result in parents overfeeding
their children, while adolescents voluntarily overeat(12, 44). Therefore, future studies are required to
explore these important societal risk factors, toperspectives from adolescents and adults on; “Whatis a ‘good' desirable, beautiful, impressive body?”.
Consequently, health promotion interventions forthis age group should take into account the array offactors that maintain these preferences.
Place of residence and CMR: It is known thatsocioeconomic environments have a huge influenceon obesity and cardiometabolic health (57). Our
results showed that adolescents who live in affluent

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Asian Journal of Dietetics 2023

suburbs and families have a higher CMR risk.
However, in developed countries like the USA andJapan adolescents from affluent families are slimmer
while the risk of obesity and CMR is high among
adolescents from low-income families (58, 59). In
many African countries including Zimbabwe,people believe that when they earn more, theyshould eat more because wealth and happiness are
physically shown by being fat (22). In addition tosocio-cultural beliefs, this contrast between
Zimbabwe and other developed countries could be a
result of the nutrition transition. Zimbabwe isbetween stages 3 and 4 of the nutrition transition,(12) and is far behind most developed countries
regarding health behavioural change. Stages 3 and 4
are characterised by social and economic changes
which cause receding famine and a decline in
nutritional deficiencies together with a dietary shift
from natural and wholesome foods to ultraprocessed foods resulting in the rise in obesity rate
and CMR risk (60, 61). Therefore, we recommendthat social behaviour change (SBCC) themedinterventions for health promotion, obesity, andCMR prevention in affluent communities foradolescents and families and communities raiseobesity and CMR awareness while promoting
healthy shopping and eating habits (57, 58).
Inadequate nutrition knowledge and CMR:
Nutrition knowledge is a key element for healthbehavior change by providing an individual with acognitive understanding of healthy eating habits (64).
The result contradicts a recent finding from Harare,
Zimbabwe that reported that the majority of theadolescents had adequate nutrition knowledge butwere obese (13). Although it was previously
reported to be adequate, it is possible that it is notalways translated into practice (15). To the best of
our knowledge, our paper is the first to report thatessential nutrients (p=0.029) and balanced diet
(p=0.024) knowledge were lacking among urban
Zimbabwean adolescents. This should help in the
choice of nutrition messages targeting this age groupin a country where most nutrition interventions andhealth promotion programs and policies are still
biased toward stunting and undernutrition (15, 43).
Understanding the kind of nutrition knowledge thatadolescents need, and how that knowledge can be
put into practice is the genesis of sustainable andeffective nutrition interventions to reduce obesity
and the associated CMR (65).
Obesity, food habits, and CMR: The findingthat higher BMI was a significant determinant ofhigh CMR is understandable. It is known thatobesity or fatness is a factor of poor dietary choices,
low physical inactivity or sedentaryism, genetics,
and sociocultural influences. Notably, our findingthat negative consumption patterns particularly low
fruit and vegetable consumption and skipping

breakfast were associated with obesity and high
CMR warrants further research to understand dietary
habits among adolescents from low-income
countries like Zimbabwe. In an obesity perceptions
study among urban adolescents in Zimbabwe, it wasstated that “people are obese because they don’tknow what’s in their food” (44). Nutrition education
programs particularly basic knowledge in essential
nutrients could prove beneficial in promoting
healthy food choices by eating nutrient-dense
traditional and wholesome foods and less ultraprocessed foods. Additionally, practical nutrition
education for a balanced diet using Zimbabwe’s
food guidelines could help adolescents create
healthy, balanced meals—whether served on a plateor packed in a lunch box. It is anticipated that thesefindings will enable dieticians and nutritionists in
Zimbabwe to consider obesity and CMR as healththreats and plan nutrition activities accordingly.
Strengths and limitations
Our study adds to the limited literature on
cardiometabolic risk factors and their clustering
among adolescents in the Zimbabwean context. Thisis the first study to assess the combined
cardiometabolic health risk burden by assessing all
six cardiometabolic health indices. However, there
were some limitations. Although the participants
were asked to fast for blood measurements, we had
no means to verify compliance. In addition, we
relied on the less invasive finger prick blood
sampling, and we did not collect venous blood forthe measurements which provides more definitive
results. We also acknowledge the potential for recall
bias in the estimation of food habits and any otherrecall-based questions.
CONCLUSIONS
Our results show different occurrences comparedto other developed countries where the prevalence ofobesity and CMR appears to be higher among girls
compared to boys. This gender disparity of obesity
and/or underweight and CMR could be explained bysocio-cultural beliefs which may hinder thetranslation of nutrition knowledge to practice. The
significant factors associated with CMR among
adolescents in this study were staying in HES(affluent) neighborhoods, inadequate nutrition
knowledge, low physical activity, and higher BMI(obesity).
Therefore,
community-based
interventions to raise obesity and CMR awarenessare needed to provide basic nutrition education foressential nutrients and practical education forbalanced diets while promoting healthy eating habits
to increase fruit and vegetable consumption. These
strategies should help to reduce the prevalence ofobesity and CMR among adolescents.

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Prevalence and factors associated with obesity and cardiometabolic risk.

ACKNOWLEDGEMENTS
The authors are grateful to all participants and theparents for consenting and cooperating in this study.
CONFLICTS OF INTEREST (COI)
The authors have no conflicts of interest to
disclose.
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Asian Journal of Dietetics 2023

Original
A Successful Innovative Meal Ordering System for Hospital Patient-Centered Food
Service in Taiwan
Fen-Ling Tseng1*, Yu-Wen Wang1, Mei-Fang Yang1.
１

Department of Dietetics & Nutrition, Taipei Veterans General Hospital, Taiwan

ABSTRACT Background and purpose. A general hospital in northern Taiwan was the first to
establish an electronic ordering system in 1982. However, the system requires nurses to placeorders based on physicians' diet prescriptions and patients' preferences, whereas patients can
not order meals by themselves. Methods. An innovative meal ordering system (iMOS) was
launched at this general hospital to revolutionize the meal ordering process by adopting
information technology and providing diverse meals. In addition to the traditional cycle menu,
a selective menu of stew dishes, light meals, noodle sets, and other culinary choices were
included. Patients whose diet order was non-therapeutic could order meals using their own
electronic devices or make an order on meal monitors at the nursing station. The patientsatisfaction and ordering rates pre- and post-implementing iMOS were analyzed during 20162022. Results. The findings indicated a significant improvement in flavor (3.7 vs. 4.3),
presentation (3.9 vs. 4.5), and satisfaction(4.0 vs. 4.3) after iMOS was implemented. The rateof ordering diverse meals rose from 7.3% in 2017 to 18.6% in 2022. Conclusion. the iMOS
meal ordering system successfully improved patient satisfaction and enhanced the mealordering rate, indicating that an innovative patient-centered foodservice model could beachieved by applying information technology.
Keywords: innovative meal ordering system, hospital patient food service
INTRODUCTION
Nutrition is crucial for patient care, and foodservice plays a pivotal role in mitigating malnutrition
by providing patients with adequate meals. Hospital
food service also impacts patients' perception of their
entire hospital experience, enhancing their satisfaction(1-3). Studies have demonstrated that electronic menu
systems could improve dietary intake while
maintaining cost-effectiveness, reducing waste, andensuring satisfaction.
Jamison et al. (4) found that patients preferred theelectronic-based meal ordering system (eBMOS) over
the traditional menu (TM) due to factors such as
interest,
curiosity,
convenience,
availability,
satisfaction, and motivation. McCray et al.(5) and
Maunder et al. (6) conducted surveys regarding patient
preferences for menu ordering systems. Theyobserved that a significant proportion of patients
preferred the eBMOS to the TM in both studies, withpercentages of 84% vs. 16% and 80% vs. 15%,
respectively.
Since its inception in 1982, a general hospital in
Taipei, Taiwan, has been at the forefront of healthcare
institutions by implementing an electronic orderingsystem for patient meals. In this system, dietitians
designed cycle menus based on physicians' dietprescriptions. The electronic ordering system offers anarray of options, including staple foods such as rice,

porridge, steamed buns, and mixed grain rice as well
as dietary avoidance of pork, beef, chicken, seafood,dairy, and sweets. Nurses assist patients in making
their selections, subsequently transmitting thesechoices to the nutrition department for meal
preparation.
Despite these strengths, the system has notable
limitations. It lacks the capacity to display detailed
menu contents or provide diverse meal choices, and it
does not allow patients to make autonomous dishselections. In recent years, the hospital has faced
challenges related to a shortage of nursing staff andkitchen aides. Therefore, addressing theseshortcomings and implementing a more user-friendly
system that grants patients greater autonomy inchoosing from a diverse array of meal options isimperative.
This project aims to design a web-based mealordering platform for patients and dietitians inpartnership with nurses to provide a diverse selectionof meals for patients on non-therapeutic diets andeventually to increase patient satisfaction and mealordering.
MATERIALS AND METHODS
The innovative meal ordering system (iMOS) is
created by dietitians to allow patients taking nontherapeutic diets, such as regular, soft, pediatric, andtocolytic diets, to place diverse meal orders bythemselves, as well as enables nurses to place mealorders based on the physician's diet prescriptions.

*To whom correspondence should be addressed:
fltseng@vghtpe.gov.tw77

Innovative Hospital Meal Ordering System in Taiwan
The iMOS has been developed with two distinct
meal-ordering models. The first model is to order
traditional meals, comprising three daily meals andadhering to the cycle menu. The second model offers
diverse meal choices based on the patient's
preferences, such as stew dishes, light meals, noodle
sets, and other culinary options. Orders for bothmodels can be placed by nurses, patients, or caregivers,
as illustrated in Photo 1.
Patient satisfaction is evaluated via acomprehensive questionnaire. A 5-point Likert scale isused to assess the quality of the hospital's food service.

The survey was conducted biennially between July
2016 and 2022, excluding patients in the intensive
care unit and psychological wards. All inpatients on
non-therapeutic diets were surveyed during datacollection periods. The patients or their caregivers
answered the survey questionnaire.
The statistical analysis methods to analyze the dataobtained from patient satisfaction surveys and mealorder rates, including descriptive statistics, chi-square
test, t-test, and ANOVA, were performed using
statistical software packages of SPSS.

Photo 1. Diverse meals for patient selection
RESULTS
The iMOS provides flexibility in terms of devices
for meal ordering. Patients or caregivers can place
meal orders using their own electronic devices,
including smartphones, pads, or monitors at thenursing station, and nurses operate the system using
computers in the nurse station or on mobile nursing
carts, as depicted in Figure 1.
To promote iMOS, social media by LINE accounts
and instructional videos are developed to guidepatients using the website for ordering meals via thehospital's WiFi network. The nursing station's noticeboard displays the QR code for the LINE account, as
illustrated in Photo 2.
A total of seven instruction videos are developed,
guiding patients on meal selection, WiFi connectivity,
adding food items, recipe selection, meal set choices,a la carte ordering, and bill checking (Photo 3). In
addition, diverse meal options are made available forguest trays. The menu for the iMOS is also featured on
the LINE accounts.

Fig 1. Meal order devices

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Asian Journal of Dietetics 2023

Photo 2. LINE QR code for meal ordering at the

Photo 3. Seven instruction videos for meal-

nurses' station

ordering operations on the LINE

Table 1. Characteristics of participants in the patient satisfaction survey
Years
Variables

2016

2018

2020

2022

Pre- iMOS

Post-iMOS

Total n=1298

33.8%

66.2%

male

240 (54.7) a

176 (59.5) a

230 (70.1) b

122 (51.9) afemale199 (45.3) a

120 (40.5) a98 (29.9) b

113 (48.1) a<=29

21 (4.8) a30 (10.1) b

16 (4.9) ab

17 (7.2) ab

30-49

81 (18.5) a59 (20.0) a

50 (15.2) a

38 (16.2) a

50-69

199 (45.3)

130 (43.9)

145 (44.2)

111 (47.2)>=70

138 (31.4)

77 (26.0)

117 (35.7)

69 (29.4)

Primary school

110 (25.1)

52 (17.6)

72 (22.0)

52 (22.1)

Sex

Age

Education

Junior and High school 195 (44.1)

114 (38.5)

College and University 134 (30.5)

aPatientaParticipants Relatives
Caregiver368 (83.8)

142 (43.2)

130 (43.9)b284 (95.9)bp

104 (44.3)

114 (34.8)

ab

79 (33.6)

265 (80.8)a194 (82.6) a

<.001

<.05

<.05

ab

68 (15.5) a

10 (3.4) b

47 (14.3) a

36 (15.3) a

3 (0.7) a

2 (0.7) a

16 (4.9) b

5 (2.1) ab<.001

Data presented by n(%), 2016 (n=439), 2018 (n=296), 2020 (n=328), 2022 (n=235)
Chi-square was used by analyzed data and significantly different marked by ab (p<.05)
The patient satisfaction survey involved 439
patients in 2016, 296 patients in 2018, 328 patients in
2020, and 235 patients in 2022. The demographic
characteristics of these patients are summarized inTable 1.
There is a significant improvement in flavor,
presentation, and satisfaction of non-therapeutic dietorder patients after iMOS implementation (Table 2).
Compared with pre-iMOS (2016), the flavor,
presentation, and satisfaction ratings in the post-iMOS

period (2018, 2020, and 2022) exhibited a significant
increase. (P<0.001)
Table 3 reveals a significant difference in flavor
and satisfaction with age but not in presentation after
implementing the iMOS system. Patients aged
between 30 and 49 exhibit significantly lower scoresof flavor and satisfaction than other age groups.
Table 4 displays the diverse meal order rate of
7.3% in 2017, 13.2% in 2018, 13.8% in 2019, 15.9%
in 2020, 19.1% in 2021, and 18.6% in 2022. The
results suggest an increasing trend from 2017 to 2022.

79

Innovative Hospital Meal Ordering System in Taiwan
Table 2. Comparison between Pre and Post-iMOS
Variables
Years

FlavorPresentation

Mean (SD)2016 vs 20182016 vs 20202016 vs 2022

p

Mean (SD)SatisfactionpMean (SD)2016

3.7 (0.87)

3.9 (0.90)

4.0 (0.72)

2018

4.2 (0.82)***4.5 (0.68)***4.4 (0.71)***2016

3.7 (0.87)

2020

4.0 (0.75)***2016

3.7 (0.87)

3.9 (0.90)

4.0 (0.72)

2022

4.5 (0.68)***4.7 (0.52)***4.5 (0.74)***2016

3.7 (0.87)<.001

3.9 (0.90)
4.3 (0.73)***<.001

3.9 (0.90)

Pre vs Post<.001
2018-2022 4.3 (0.80)***p

4.0 (0.72)<.001

4.3 (0.58)***4.0 (0.72)<.001

4.5 (0.72)***<.001
4.3 (0.71)***

Data presented by Mean (SD), 2016 (n=439), 2018 (n=296), 2020 (n=328), 2022 (n=235)
Paired t-test was used by analyzed data and significantly different marked by ***p<.001
Table 3. Comparison by age group for flavor, presentation, and satisfaction in post-iMOS
Ages

Number

FlavorMean (SD)Presentation
P

Mean (SD)SatisfactionP

Mean (SD)

<=29

47

4.2 (0.76)ab

4.4 (0.69)

4.3 (0.72)ab

30-49

97

4.1 (0.96)b

4.4 (0.76)

4.2 (0.78)b

50-69

333

4.3 (0.78)a

>=70

198

4.4 (0.73)a<.005

4.5 (0.70)

0.149

4.4 (0.71)a

P

<.001

4.4 (0.66)a

4.5 (0.68)

Data was presented by Mean (SD), which was analyzed by one-way ANOVA and pointed out the significant
difference as "ab" by Tukey post hoc analysis. (p<0.05)

Years

Table 4. Diverse meal order rate of the non-therapeutic diet
Diverse meal order Diverse meal order
Diet order numbers Meal order numbers
numbers from
rate
from physician's
from patientspatients
prescription
(A)
(B)
(C)
(D)=C/B

2017

341822

166831

12146

7.3%

2018

414827220591

29164

13.2%

2019

387262216089

29734

13.8%

2020

370335219852

35001

15.9%

2021

321160200422

38230

19.1%

2022

321683211781

39459

18.6%

80

Asian Journal of Dietetics 2023
DISCUSSION
The results confirm that implementing this iMOS
has significantly increased the satisfaction of nontherapeutic diet order patients. Other investigators intheir studies have also demonstrated that patients
perceived greater involvement and information
regarding their meal selection decisions, resulting inhigher satisfaction (7-11).
Furthermore, this iMOS has progressively
increased hospital meal order rates, including diverse
meal ordering rates. Roberts et al. (12) have indicatedthat patients value the flexibility and convenienceoffered by meal-ordering systems, which enables
them to access nutritional information and makeinformed menu selections. Similarly, Ottrey andPorter (13) have demonstrated that spoken and visualmenu systems can help patients have better meal
experiences by supporting them in making correct
menu selections and delivering a more individualized
meal-ordering service. The current project
implementing an innovative computerized mealordering system in hospitals allows patients to maketheir own meal decisions, resulting in moreindividualized service and steadily increasing patient
meal order rates. However, in 2022, the diverse mealorder rate experienced a decline that could be
attributed to the severe spread of COVID-19 in
Taiwan, which resulted in a shortage of hospital
kitchen workers and paused iMOS's diverse meal
service for two months.
An interesting finding of this project reveals thatyounger patients, particularly those aged 30 to 49,
exhibit lower levels of satisfaction and flavor thantheir older counterparts. The younger patients have
had ample opportunities to make meal choices before
being admitted to the hospital and are proficient inusing electronic meal order systems. In this regard,
Hussien and Mansour (14) found that younger
customers, especially those aged 25-34, were inclined
to use food applications, placing a higher value on
convenience and control than their older customers,
who expressed a greater need for human interaction.
As a solution, Hussien and Mansour's study suggests
providing a call center with human interaction to
encourage older customers to use applications for
additional assistance.
The limitation of this project underscored theimportance of promoting the iMOS approach toyounger patients to inform them of this service in thehospital. Meanwhile, providing online meal ordering
assistance to elderly patients could also be a strategy
for improving their nutritional status during their
hospital stay. With the advancement of technology, themeal ordering system should continuously update theversion of the menu selection according to the patient's
needs.
Barrington et al. (15) observed a statisticallysignificant rise in mean daily energy and protein

intake in patients using a patient-directed eBMOS
compared to a TM. Furthermore, McCray et al. (8)discovered that a considerably more significant
proportion of patients who used eBMOS fulfilled theirestimated energy and protein needs and showed asubstantial decline in plate waste compared to the TM.
Future research directions may investigate the dietaryintake of inpatients in Taiwan who choose from adiverse meal to clarify whether there is a discernible
trend of increased daily energy and protein dietaryconsumption among inpatients who utilize anelectronic ordering system for meal selection.
CONCLUSION
Implementing an innovative, patient-centered
food service model through a meal ordering system
can improve patient satisfaction and increase mealordering rates. The crucial point of success lies in
empowering patients to make diverse meal selections
using a convenient device, ultimately enhancing
patients' satisfaction and nutrition care.
ACKNOWLEDGEMENT
Grateful acknowledgments are extended to Taipei
Veterans General Hospital for providing financial
support for this system. I sincerely thank Mr. Chen
Tzu-En, RD, for his assistance in statistics. I would
also like to express my deep appreciation to Dr.
Chwang Leh-chii for her valuable encouragement andguidance on this paper.
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82

Asian Journal of Dietetics 2023

ReportWorkshops for Enhancing the Collaboration Skills and Self-efficacy of Japanese
Administrative Dietitians
Tatsuya Koyama1*, Maya Akahori2, Yusuke Arai3, Ayaka Iida4，Sumie Isobe5，Rie Okamoto6，Osamu
Kushida7，Izumi Shibuya8，Kazumi Tanaka4，Ayumi Morooka9，Katsushi Yoshita10
1

Mimasaka University
Shizuoka Prefecture Government
3
Chiba Prefectural University of Health Science
4
Kanagawa University of Human Services
5
Niigata Prefecture Government
6
Kanazawa University
7
University of Shizuoka
8
Aichi Prefectural Government
9
Hyogo Prefectural Government
10
Osaka Metropolitan University
2

ABSTRACT Background and purpose. We conducted workshops to enhance thecollaboration skills and self-efficacy of administrative dietitians working in local
governments. This study presents the results of a post-workshop questionnaire administered
to the workshop participants, which evaluated the workshop program. Methods. Participantsof the workshops were asked to answer a reflection sheet about their career. The workshops
consisted of lectures and exercises, and participants were asked to respond to questionnaires
at the end of the workshop. Free-text descriptions were analyzed using reflexive thematic
analysis. Results. A total of 61 and 43 administrative dietitians participated in the workshops
held in prefectures A and B and prefectures B and C, respectively. Participants in all theworkshops expressed their willingness to collaborate with multiple divisions and improve
the preconditions for self-efficacy. Participants found satisfaction in reflecting on their workby interacting with other administrative dietitians. Conclusion. Workshops similar to ours
should be held throughout Japan to promote a nutrition policy that accounts for everyone
and achieves sustainable societies.
Keywords: collaboration, self-efficacy, workshop, administrative dietitian, JapanINTRODUCTION
In Japan, health promotion efforts involve a varietyof specialized professionals, including registereddietitians. National and local governments are required
to develop these human resources (1). Administrative
dietitians in Japan provide nutritional guidance forresidents of local governments and work in prefectural
offices, public health centers, and municipal healthcenters. The duties of administrative dietitians varydepending on the organization they work for, but canbe organized into the following five categories:1)
developing organizational structures, 2) clarifying
health and nutrition issues and promoting measures
based on the management cycle, 3) promoting
measures to prevent the onset and severity of noncommutable diseases, 4) promoting measures tomaintain and improve functions necessary forindependent social life, and 5) promoting a social
environment through food and nutrition (2). Although
the work of administrative dietitians varies greatly, thenumber of administrative dietitians working in a single
institution is small. For example, on average, 2.0
dietitians work at a health center established by aprefecture, and 1.1 dietitians work at a municipal
health center (3). Therefore, administrative dietitians
need to collaborate with a wide variety of stakeholders
to maximize the results of adopted measures.
The perception of one's potential to perform abehavior is called self-efficacy; the stronger one's selfefficacy, the more likely one is to perform thatbehavior. In addition to the four sources of information,
Bandura identified the following antecedents of selfefficacy (4) - enactive mastery experience, vicarious
experience, verbal persuasion, and physiologicalemotional state - the following have been identified:meaningfulness or need for behavior (5, 6), behavioral
strategies (7), causal attributions (8), social support (9),and health status (10). Self-efficacy has been shown toincrease the probability of achieving a behavior (11),of challenging the targeted behavior, and of achieving
the behavior in similar situations (12) and reduce
anxiety and fear (13). However, Japaneseadministrative dietitians working at municipal health*To whom correspondence should be addressed:
koyama-ta@mimasaka.ac.jp83Workshops for Japanese administrative dietitians
centers tend to have low self-efficacy (14). Most
Japanese administrative dietitians consistently lackconfidence in their work, do not know who to talk toabout work and resolving problems, and face
uncertainty about their future (14). The competencies
and skills necessary for administrative dietitians toperform their work have been indicated (15).
Increasing the self-efficacy of administrative dietitians
may be crucial for acquiring and utilizing thesecompetencies and skills.
In Japan, workshops for administrative dietitians
have been conducted by the national and local
governments, professional associations such as theJapan Dietetic Association and the Japanese
Association of Public Health Center Registered
Dietitians, and research institutions such as the
National Institute of Public Health. Administrative
dietitians working in municipal health centers reported
that they did not have a high sense of self-efficacy incarrying out their work. However, few workshops
have been conducted with the aim of improving
collaboration with diverse stakeholders and enhancing
self-efficacy.
Our study examined the current conditions ofJapanese administrative dietitians and reviewed
existing human resource development for them. Basedon our research, we designed a plan for developing
human resources for Japanese administrative dietitians.
Therefore, we conducted workshops to enhance thecollaboration skills and self-efficacy of administrative
dietitians working in local governments. This study
presents the results of a post-workshop questionnaireadministered to workshop participants, which
evaluated the workshop program.

Time
10:35~11:05
11:05~11:50

11:50~12:00

13:00~13:40
13:40~14:50
15:00~16:00
16:00~16:25

MATERIALS AND METHODS
1. Workshops aimed at enhancing collaboration
skillsWorkshops aimed at enhancing the skills tocollaborate with diverse stakeholders were held in
Prefecture A in September 2022 and Prefecture B in
November 2022, in collaboration with prefectural staff.
Participants
The prefectural staff recruited administrative
dietitians from the prefecture for both workshops. A
total of 24 and 37 prefectural or municipal
administrative dietitians participated in the workshops
conducted in Prefectures A and B, respectively.
Programs
Prior to the workshops, participants were asked tofill out a "reflection sheet (similar to a lifeline chart, asheet used to track changes in happiness (fulfillment)from the time of employment to the present, including
affiliation, position, major accomplishments, efforts
and achievements focused on, competencies acquired,
milestones and impressions)." Additionally, they wereasked to note their "daily concerns and issues inworking," and "issues and daily thoughts regarding
human resource development for administrative
dietitians in their organizations," and to bring thesereports to the workshop.
The workshops consisted of lectures on practicalexamples and collaboration skills, and exercises withcases that required collaboration with diverse
stakeholders. The contents of the exercises were
determined by the situation in which the workshops
were held and the organizations to which the workshop
participants belonged. The schedule for the workshops
held in Prefectures A and B is presented in Table 1.

Table 1. The timetable of the workshop for enhancing collaboration skills
Contents
Lecturer
Lecture 1: Our research findings, roles of mid-career workers, University faculty
and what they need to learn
Lecture 2-1: How to build a strategy for administrative Nutrition technical officer of
dietitians: practical "strategic devices" for mainstreaming the Ministry of Health,nutrition.
Labour, and Welfare
Lecture 2-2: How to build a strategy for administrative Nutrition technical officer of
dietitians: How to proceed with policy-making, which I the Ministry of Health,learned while on secondment at the Ministry of Health, Labour, and Welfare
Labour, and Welfare.
Lecture 3: Organization and work practices
University faculty
Exercise 1: Issue clarification and negotiation skill
University faculty
Exercise 2: Dietitians in the organization
Administrative dietitian of theprefecture
Encouragement and Summary
All staff and participants

The workshops conducted in prefectures A and B
featured identical lectures. Lecture 1 outlined theintroduction to the workshop. The 30-minute lecture
explained the positioning of the workshop, ourresearch findings for the development of training
programs for public health dietitians working in local

governments, the roles of mid-career administrative
dietitians (more than ten years of work experience),
and what administrative dietitians should acquire
during and after the mid-career stage. Lecture 2
consisted of two parts. The first section presented
examples of the practice of cooperation and84

Asian Journal of Dietetics 2023
collaboration with various stakeholders. The lecturer
explained the actual activities and their background by
the nutrition technical officer of the Ministry of Health,Labour and Welfare (MHLW), including 1) how toformulate strategies, 2) the role and significance of theadministrative
dietitians(purpose),3)
themainstreaming of nutrition implemented at the MHLW,
by illustrating the creation of healthy and sustainable
food environments with an example (16), and 3) usefulideas such as the outside-in and inside-out approach,value promotion, and mindset. The second section
featured a lecture from the technical officer seconded
from the prefecture to the MHLW, who talked about
her experiences involving policymaking at the MHLW.
We included this lecture as we believed she could be arole model for the workshop participants. Lecture 3
was a 40-minute lecture on career management,
clarifying objectives, effective communication skills
for mid-career staff, and how to negotiate, which
served as an introduction to collaboration skills.
In the workshop held in Prefecture A, the groups
were initially divided according to the organization inwhich they worked and further divided so that theorganization they worked for was in the sameneighborhood. In the workshop held in Prefecture B,
the groups were divided according to the region of theorganization such that administrative dietitians fromthe prefecture and administrative dietitians from themunicipality were mixed.
Although the main theme in exercise 1 wascommon, the specific content was changed according
to the situation of the location where the workshop washeld. Exercise 1 of the workshop conducted in
Prefecture A consisted of 55 minutes of group work
using SWOT analysis and a 3-minute presentation byeach group on the integrated implementation of healthservices for the elderly (a group consisting ofadministrative dietitians from municipalities) or thedevelopment of a disaster preparedness system forfood service facilities (a group consisting ofadministrative dietitians from the prefecture or citywith a public health center). SWOT analysis is a
strategic planning and strategic management
technique used to help a person or organization
identify Strengths, Weaknesses, Opportunities, andThreats related to business competition or projectplanning.
In 2018, the basic policy on economic and fiscal
management and reforms stated that the government
would consider structures to be implemented in an
integrated manner by municipalities in partnershipwith prefectures and others. Such initiatives include
preventing the need for long-term care andcountermeasures against frailty focused mainly onvenues frequented by elderly people, the prevention ofillnesses like lifestyle-related diseases preventing said
illnesses from increasing in severity and supporting
people’s participation in work and society. It will also

apply incentives in aiming to eliminate the regional
disparities in the length of healthy lifespans (16).
Based on this policy, municipalities implemented
integrated health services for older adults. As there are
multiple laws and different departments in charge ofeach municipality, implementation tends to besegregated. Although medical specialists coordinate
the entire program and prepare laws for collaboration,these policies must be implemented in cooperation
with medical insurance personnel, nursing careinsurance personnel, and medical institutions.
One of the duties of administrative dietitians
working at public health centers in prefectures or cities
with public health centers is to provide guidance andsupport based on monitoring and evaluating nutritional
management conditions at specified food service
facilities (2). Health crisis management duties related
to specific food service facilities managed by publichealth centers were announced by the MHLW (18).
According to these guidelines, nutritionally balanced
meals should be provided safely even in disastersituations. Therefore, such facilities should be
prepared for disasters at all times and should ensurethat they are able to provide help during emergencies.
Currently, there is a need for a practical disastersupport system in which public health center dietitians
play a coordinating role in health crisis management
for their communities, and for measures to strengthen
their collaboration skills.
Exercise 1 of the workshop conducted in
Prefecture B consisted of 55-minute group work and3-minute presentations by each group, in which
participants considered internal and external
environmental issues in promoting the creation of afood environment in the region using SWOT analysis.
The creation of a food environment requires
cooperation and collaboration not only between
prefectural and municipal health and sanitation
departments but also among a wide range of foodrelated businesses, from food production to
distribution and sales (16).
Exercise 2 was identical in the two workshops. The
exercise consisted of 40 minutes of group work and 35 minutes of presentations by each group on threepoints: what they thought after listening to the lectures,issues, and solutions, and what they "can do" and"want to do" from tomorrow. After a summary andencouragement session between the lecturers and allparticipants, the workshop concluded.
Questionnaire survey
A
self-administeredquestionnairewasadministered at the end of the workshops. The survey
included the following information: organization, age,years of experience in community health, years ofexperience as a dietitian, understanding of andcomments on each lecture and exercise (free text),
reasons for attending the training, results of attending
the workshop, and what was impressive about the85

Workshops for Japanese administrative dietitians
workshop (free text).
Survey items other than the free-text responses
were calculated. Free-text descriptions were analyzed
using reflexive thematic analysis (17). The reflexive
thematic analysis consisted of the following six
recursive stages: 1) familiarization with the data, 2)
initial coding, 3) generation of the first theme, 4)
review and development of the theme, 5) refinement
and naming of the theme, and 6) writing. Specifically,
the first author read the free-text descriptions of thedata (Stage 1) and generated the codes (Stage 2). The
codes were then aggregated into subcategories ofpotential semantic patterns, which were further
aggregated into categories (Stage 3). The relationships
between the categories and their conformity to thepresupposed story were subsequently examined (Stage4), and the scope and content of the themes wererefined (Stage 5).
The survey completed by the participants included freetext, which was divided into sentences that could haveseveral meanings in the analysis, which were
subsequently converted into data. The unit of analysis
for this study was the text, which was structured bydeleting unnecessary words, generalizing, andconsolidating the writing style, and supplementing
explanations. The subcategories were created bycollectively classifying and naming them. A
subcategory is the smallest unit of data that can beanalyzed and has the potential to be grouped into asingle category. A category is the largest unit that canbe analyzed, with the subcategories grouped together
and given appropriate names. Categories andsubcategories were added to the above procedure andthe frequencies were noted.
At the end of the workshop, written and oral

Time
10:35~10:45
10:45~11:15
11:15~12:15
13:15~14:25
14:25~15:10
15:10~16:20
16:20~16:30

explanations regarding the purpose of the study,
voluntary participation and cooperation for the study,
appropriate handling of data, and publication ofresearch results were provided. Responding to thequestionnaire was deemed as informed consent. This
study was approved by the Ethics Committee of Osaka
Metropolitan University (application number 22–29;
approved 25 July 2022). The study complied with thecode of ethics of the World Medical Association(Helsinki Declaration).
2. Workshops for enhancing self-efficacy
Workshops for enhancing self-efficacy were heldin Prefecture B in November 2022 and Prefecture C in
December 2022, in collaboration with prefectural staff.
Participants
For both workshops, prefectural staff recruitedadministrative dietitians from the prefecture. A total of
30 prefectural or municipal administrative dietitians
participated in the workshops held in Prefecture B, and13 prefectural administrative dietitians participated in
the training session held in Prefecture C.
Programs
The schedule for the workshops is presented inTable 2. Prior to the workshops, participants wereasked to fill out a "reflection sheet same as theworkshop 1 from the time of employment to thepresent, including affiliation, position, major
accomplishments, efforts and achievements focusedon, competencies acquired, milestones andimpressions)." Additionally, they were asked to note
their "daily concerns and issues in working," and"issues and daily thoughts regarding human resource
development for administrative dietitians in theirorganizations," and to bring these reports to theworkshop.

Table 2. The timetable of the workshop to enhance self-efficacy
Contents
Lecturer
Introduction: Human resource development in the prefecture
Administrative dietitian of
the prefecture
Lecture 1: New training program for administrative dietitians:
University facultywhat should be learned based on their career ladderGroup work 1: Problems in daily work
Administrative dietitian of
the prefectureGroup work 2: Reflection on daily work
Administrative dietitian of
the prefecture
Lecture 2: Thinking about how to draw a career plan to reach
University faculty
your goals
Group work 3: What kind of work do you want to do in the
Administrative dietitian of
future?
the prefecture
Encouragement and Summary
All staff and participants

The workshop comprised two lectures and threegroup sessions. Lecture 1 primarily introduced thetraining, the image of administrative dietitians fromthe perspective of themselves and other professionals,
and the competencies required for administrative
dieticians according to their career. Lecture 2 lasted 45

minutes and focused on the need to improve priorrequirements to increase self-efficacy and the need forsomeone to consult with in order to improve andrespond to the environment to prevent lowering selfefficacy.
The workgroups were arranged such that the region

86Asian Journal of Dietetics 2023of the organizations where they worked was aneighboring municipality, and at least one
administrative dietitian from mid-career onward was
assigned to each group, who served as the facilitator ofgroup work. Group Work 1 was a 60-minute group
work session on the challenges encountered during
daily work. Group Work 2 involved reflecting on theirwork. Group Work 3 focused on how they wanted towork henceforth.
Questionnaire survey
The questionnaire survey was conducted as shownin Section 1.3.

RESULTS
1. Workshops aimed at enhancing collaboration
skillsQuestionnaires were completed and submitted byall 61 participants. Twenty-one (34%) participants
belonged to prefectures, 12 (20%) to cities with healthcenters, and 28 (46%) to municipalities. Of theparticipants in the workshops held in prefectures A andB, 40-year-olds were the most common age group, andmost of them had over 20 years of experience asdietitians (Table 3).
The understanding of participants of theworkshop aimed at enhancing collaboration skills isshown in Table 4.

Table 3. Participants of the workshop to acquire the skill of collaborating with multiple stakeholders (n=61)
Working organization
Prefecture (21, 34%), City with public health centers (12, 20%), Municipality(28, 46%)Age
20s (9, 15%)，30s (9, 15%)，40s (29, 48%)，50s or over (14, 23%)Yearsofexperiencein ≤5 years (19, 31%), 6-10 years (7, 11%), 11-15 years (11, 18%), 16-20 years
community health(11, 18%), >20 years (13, 21%)
Years of experience as a ≤5 years (9, 15%), 6-10 years (7, 11%), 11-15 years (7, 11%), 16-20 years
dietitian(10, 16%), >20 years (28, 46%)
Reasons for attending the 
Because I wanted to think about my growth and how I want to work inworkshop (multiple responses)
the future during the training (25, 41%)Because I wanted to get some hints for training junior staff anddeveloping my organization's human resource development system (12,20%)
Because I thought that understanding leadership theory andorganizational theory was important for policy development (12, 20%)
Because the lecturers were attractive (9, 15%)Because I was interested in the "administrative dietitian training
program focusing on public health" (6, 10%)Outcome of attending the 
I realized anew the importance of learning and decided to learn moreworkshop (multiple responses)
than ever before (37, 61%)I was able to think about my position and role in the organization (36,59%)
I was able to think about how I want to work in the future (31, 51%)My daily worries and anxieties were relieved a little (27, 44%)I found what I "can do" and "want to do" from tomorrow (20, 33%)
I was able to better visualize my future growth (11, 18%)
Participants described comments of lecture 1 thatapplication to the workshop and learning; expressing
personal intent and removing inhibiting factors forenhancing self-efficacy; recognition of the nutrition
department and role compared to other professions;
understanding of the workshop content andexpectations for our developing program; enhancing
self-efficacy and improving skills; collaboration withother professions and skill enhancement; expectation
for the evaluation system and the program; andrecognition of nutritional skills and expectations forskill development.
Participants described comments of Lecture 2-1
that professional development and strategic thinking:impactful insights and inspiration; broadening
perspectives and knowledge; collaboration andinterdisciplinary approach; personal growth andmotivation; strategic thinking and professional vision;
learning opportunity and self-reflection; purpose andcollaboration; and empowering vision and skill
development.
Participants described comments of Lecture 2-2that policy enthusiasts; challenges and importance of
creating impactful materials; the necessity of a broad
range of knowledge and skills beyond nutrition; thesignificance of incorporating field perspectives; andthe essential foundations for personal growth and skill
development.
Participants described comments of Lecture 3 andExercise 1 that impression and motivation; importanceof attitude and continuous learning; preparation andpractical examples; enhancing negotiation skills; and87

Workshops for Japanese administrative dietitians
collaboration and communication.
Participants described comments of Exercise 2 thatmutual support and fresh perspectives; networking andcollaboration; learning from different perspectives;
personal and professional growth; and building

connections and finding encouragement.
Participants described what was impressive about
the workshop application and learning; relevance andimplementation; and networking and collaboration.

Table 4. Understanding of workshop to acquire the skill of collaborating with multiple stakeholders (n=61)
Understood Understood
Somewhat poorly
Not understandwellunderstoodat allLecture 1: What our research has
34 (56%)26 (43%)
1 (2%)
0 (0%)
revealed, roles of mid-career workers,
and what they need to learn after midcareer
Lecture 2-1: How to build a strategy for
19 (31%)38 (62%)
4 (7%)
0 (0%)
administrative dietitians: practical"strategic devices" for mainstreaming
nutrition.
Lecture 2-2: How to build a strategy for
28 (46%)33 (54%)0 (0%)
0 (0%)
administrative dietitians: How toproceed with policy-making, which I
learned while on secondment at the
Ministry of Health, Labour and Welfare.
Lecture 3: Organization and work
35 (57%)25 (41%)2 (3%)
0 (0%)
practices and Exercise 1: Issue
clarification and negotiation skill
Exercise 2: Dietitians in the
30 (49%)30 (49%)1 (2%)
0 (0%)
organization
2. Workshops for enhancing self-efficacy
Questionnaires were completed and submitted by
all 44 participants. A total of 31 participants
participated in the workshop in prefecture B; 7 (23%)
belonged to prefectures, 4 (13%) to cities with healthcenters, and 13 (46%) to municipalities. Of theparticipants in the workshops held in prefectures B andC, 30-year-olds were the most common age group(Table 5).
According to the answer of outcomes of theworkshop, most or all participants answered "yes" or“somewhat yes” to the following question: "Have theworkshop relieved any of worries and anxieties in yourdaily life?” "Have you been able to think about yourposition and role in the organization?” Have you beenable to reflect on your past efforts and deepen yourthoughts about your strengths and weaknesses?” Haveyou been able to think about how you want to work in
the future?” “Have you been able to visualize yourfuture growth and development?”, “Do you think thecontents of today’s workshop will be useful for thehuman development of administrative dietitians inyour organization?”, “Have you found what you "cando" and "want to do" from tomorrow?” (Table 6)

Table 5. Participants of the workshop for enhancing self-efficacy (n=43)
Working organization
Prefecture (23, 53%), City with public health center (9, 21%) 、
Municipality (11, 26%)Age
20s (7, 16%)、30s (12, 28%)、40s (13, 30%)、50s or over(11, 26%)
Years of experience in community ≤5 years (16, 37%), 6-10 years (6, 14%), 11-15 years (5, 12%), 16-20
healthyears (7, 16%), >20 years (11, 26%)
Years of experience as a dietitian≤5 years (7, 16%), 6-10 years (10, 23%), 11-15 years (6, 14%), 16-20
years (6, 14%), >20 years (14, 33%)
Reasons for attending the workshop 
Because I wanted to think about my growth and how I want to work
(multiple responses)
in the future during the training (28, 65%)
Because I wanted to know the role and perspective of the new term
and mid-career (18, 42%)
Because I was struggling with how to conduct my day-to-day
business (15, 35%)Because I was interested in the “administrative dietitians training
program focusing on public health (15, 35%)

88

Asian Journal of Dietetics 2023

Table 6. Outcomes of the workshop for enhancing self-efficacy (n=43)
Yes
More or lessMore or less noyesHave the workshop relieved any of
17 (40%)23 (53%)
3 (7%)
worries and anxieties in your daily life?
Have you been able to think about your18 (42%)22 (51%)2 (5%)
position and role in the organization?
Have you been able to reflect on your25 (58%)18 (42%)0 (0%)
past efforts and deepen your thoughts
about your strengths and weaknesses?
Have you been able to think about how
17 (40%)24 (56%)2 (5%)
you want to work in the future?
Have you been able to visualize your6 (14%)
25 (58%)9 (21%)
future growth and development?
Do you think the contents of today’s
12 (28%)27 (63%)
3 (7%)
workshop will be useful for thedevelopment of administrative dietitianin your organization? †Have you found what you "can do" and12 (28%)29 (67%)2 (5%)"want to do" from tomorrow?
† One participant did not answer
Participants described comments of the relief
provided by the workshop to some of their worries andanxieties in their daily life promoting collaborationand support in individual work settings; empathy andinsights from cross-regional dietitians; seeking
guidance and techniques for effective work
approaches; shared concerns and lightened burdens;
encouragement and empowerment through mutual
understanding; learning from peers; sharing
experiences and challenges; building communication
channels for dietitians in different municipalities;
discovering solutions and strategies for personal
weaknesses;
overcoming anxieties throughprofessional
networking;strengthening
selfperception and problem-solving skills; exploring
common worries and fostering supportive connections.
Participants described comments of the idea ofcontemplating your position and role in theorganization has been evident that understanding
personal roles and expectations; self-reflection andgrowth within the organization; recognizing positions
and responsibilities; enhancing collaboration andprofessional development; aligning roles withorganizational growth; navigating roles andresponsibilities as dietitians; building competencies
andstrengthening
connections;bridging
administrative skills and dietitian roles; addressing
career gaps and skill development; perspectives andpositioning among peers; sharing insights and building
a common understanding; embracing challenges anddefining roles; strengthening collaboration througheffective communication; embracing office supportandstrengthening
competencies;
assessingcompetencies; and planning for growth.
Participants described comments of reflection onNo
0 (0%)
1 (3%)
0 (0%)

0 (0%)
1 (3%)
0 (0%)

0 (0%)

their past efforts and the deepening their thinking
about their strengths and weaknesses that finding
strengths
andweaknesses
throughgroup
collaboration; examining work objectively usingreflection sheets; discovering personal growth throughself-reflection;
self-assessment
for
personal
improvement; recognizing strengths and weaknesses
for career development; enhancing self-awareness forskill development; deepening thoughts throughreflection and career sheets; overcoming weaknesses;
and embracing strengths through reflection.
Participants described comments of considering
their desired approach to work in the future that
promoting work-life balance by utilizing informationand communication technology and telecommuting,expanding perspectives and career planning throughreflection, nurturing junior staff, enhancing the role ofdietitians, self-reflection, and clarifying personal
aspirations, and exploring expertise and adapting
flexibly.
Participants described comments of visualizing
their future growth and development building
knowledge and expertise; setting goals and visualizing
growth; acting and leveraging strengths; continuous
improvement and policy advocacy; and exploring
future possibilities.
Participants described comments of usefulcontents of today’s workshop for the humandevelopment of administrative dietitians in theirorganization that implementing strategies for selfefficacy and skill enhancement; promoting
collaboration and understanding across professions;setting goals and envisioning growth; cultivatingteaching roles and career planning; enhancing
understanding and collaboration in the workplace;89

Workshops for Japanese administrative dietitians
future growth and career guidance; utilizing training
and developing programs; establishing a talentdevelopment system; and seeking practicalimplementation.
Participants described comments of findings onwhat they can do and want to do from tomorrow's
professional development strategies; goal clarity andtime management; communication and networking
skills; knowledge acquisition and confidence building;long-term planning and policy collaboration;
mentorship and career growth; task prioritization andstaffing advocacy; effective communication and selfevaluation; leadership development and talentmanagement; excellence in job performance andgrowth opportunities; career expansion; andeducational pursuit.
Participants described what was impressive about
the workshop as visionary career planning, balancing
responsibilities, skill acquisition for leadership, worklife integration, and long-term goal setting.

places health on the agenda of policymakers in all
sectors and at all levels, directing them to be aware of
the health consequences of their decisions and toaccept their responsibilities for health (22). Nutritionis linked to this in several ways. Administrative
dietitians are not only required to collaborate with suchorganizations and professions but also can collaborate
with them.
The MHLW has provided pioneering examples ofmulti-departmental
andmulti-professional
collaboration in its annual report on the progress ofnutrition improvement efforts in Japan based on theTokyo Nutrition Summit 2021 (23). Human resource
development in the basic policy of Healthy Japan 21(third term) also indicates that support should be
provided to promote multidisciplinary collaboration(1). As the importance of multidisciplinary
collaboration has been recognized, skill-building forcollaboration is needed.
Administrative dietitians must not only collaborate
with other professions and organizations (24) but alsowith dietitians in other organizations and with otheradministrative dietitians. In all workshops,
participants stated that it was good to interact withother administrative dietitians. This is because anorganization rarely has more than one dietitian (3), anddietitians find few opportunities to interact with otherdietitians in the same administrative area during daily
work. Consultations related to the work of municipal
administrative dietitians are usually restricted to theworkplace, and although health centers are not utilized
frequently, they could possibly strengthen cooperationand support services with municipal health center
dietitians (25). One of the duties of prefecturaladministrative dietitians is to provide support tomunicipalities within their jurisdiction (2). To dispel
the sense of isolation among administrative dietitians,a system of mutual collaboration, led by prefecturaladministrative dietitians, should be established.
The basic policy of Healthy Japan 21 (third term)
calls for the comprehensive promotion of national
health through the development of health promotionthat leaves no one behind, and the promotion of more
effective measures toward the realization of asustainable society in which all people can live healthy
and enriched lives (1). At the Tokyo Nutrition Summit,
the Japanese government committed to developing anutrition policy that leaves no one behind (26).
Accountingforallindividuals,
especiallyadministrative dietitians, who are key players innutrition policy is necessary for achieving this. Bothtypes of workshops were conducted in only two
prefectures; however, it is hoped that they will also be
conducted in other prefectures.

DISCUSSION
Based on the responses to the questionnaire, it
seems that most of the objectives of the workshops
were understood. Reflecting on one's activities seemed
particularly effective. Kolb presented an experiential
learning model comprising concrete experience,reflective observation, abstract conceptualization, andactive experimentation (20). Reflection has greatsignificance as a tool for self-discovery, learning,
critical thinking, and interpersonal growth. By
engaging in regular reflection, we can gain valuable
insights, make better choices, and evolve as
individuals. The practice of reflection has beenfrequently reported in nursing, but not by dietitians(21). The comments described in our workshops
suggest that although it is difficult for Japaneseadministrative dietitians to reflect on their work
environments, active reflection is necessary.
Nutrition is the process by which living organisms
receive food necessary for their growth and health.
Food is provided by various groups, including
businesses engaged in the manufacturing, processing,
distribution, or sale of foods, or the provision of meals.
Nutrition is a critical component of health anddevelopment. Better nutrition is related to improved
infant, child, and maternal health; stronger immune
systems; safer pregnancy and childbirth; lower risk of
non-communicable disease; and longevity. A person in
one department or team should be ready for active
involvement and contribution to another department orteam, which is crucial for fostering cooperation andcollaboration within an organization. The benefits ofcontributing to other departments include knowledge
and experience sharing, understanding theorganization's overall vision, career growth, andexpanded opportunities. The Ottawa Charter notedthat health promotion extends beyond healthcare, and

ACKNOWLEDGMENTS
The authors are grateful to all the participants who
participated in the workshops. The authors also thank90

Asian Journal of Dietetics 2023
the Office of Nutrition, Health Service Division,
Health Service Bureau, Ministry of Health, Labor andWelfare for their cooperation and advice regarding thisstudy. This research was funded by a Grant-in-Aid for
Scientific Research from the Ministry of Health,Labour and Welfare (grant number 20FA1008).

1.

2.

3.

4.
5.

6.

7.

8.

9.

10.

11.

12.

13.

14. Igarashi M, Yoshida T. Project management selfefficacy and related factors in municipal dietitian.
Jpn J Nutr Diet 69: 148–159. 2011.
15. Ishikawa M, Abe K, Yoshiike N, et al. The
competencies according to career ladder required
for administrative dietitians -summary of on the
output from group work activity in training
session by public health division of the Japan
Dietetic Association-. J Jpn Diet Assoc 58: 726735. 2015.
16. Ministry of Health, Labour and Welfare:Strategic initiative for a healthy and sustainablefood
environment.
https://sustainablenutrition.mhlw.go.jp/en
17. Cabinet Office. Basic policy on economic andfiscal management and reform 2018～realizing
sustainable economic growth by overcoming thedecreasing birth rate and aging population ～ .
https://www5.cao.go.jp/keizaishimon/kaigi/cabinet/honebuto/2018/2018_basic
policies_en.pdf
18. Ministry of Health, Labour and Welfare.
Guidance and support for nutrition managementatspecifiedfoodservicefacilities.
https://www.mhlw.go.jp/content/10900000/0006
37208.pdf
19. Campbell KA, Orr E, Durepos P. Reflexive
thematic analysis for applied qualitative hearth
research. Qual Rep 26: 2011-2028. 2021.
20. Morris TH. Experiential learning–a systematic
review and revision of Kolb’s model. Interact
Learn Environ 28: 1064-1077. 2020.
21. Beam RJ, O'Brien RA, Neal M. Reflective
practice enhances public health nurse
implementation of nurse-family partnership.
Public Health Nurs. 27: 131-139. 2010.
22. World Health Organization. The Ottawa Charter
for
Healthpromotion.
https://www.paho.org/en/documents/ottawacharter-health-promotion
23. Ministry of Health, Labour and Welfare.
Nutrition policy in Japan to leave no one behind- for achieving sustainable societies - pioneering
examples of multi-sectoral collaboration in 2023.
https://www.mhlw.go.jp/content/001092503.pdf
24. Sudo N, Sawaguchi M, Yoshiike N. Nationwide
survey on municipalities' preparedness forprovision of food and nutrition assistance andtechnical support from public health centers after
disasters. Jpn J Public Health. 58: 895-902. 2011.
25. Yoshita K. Investigation and utilization of data
through cooperation between prefectures andcities. J Natl Inst Public Heath 61: 424-429. 2012.
26. Ministry of Health, Labour and Welfare.
Nutrition policy in Japan to leave no one behind- for achieving sustainable societies https://www.mhlw.go.jp/content/000847743.pdf

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Ministry of Health, Labour and Welfare:
Revision of a basic direction for comprehensive
implementation of national health promotion.
https://www.mhlw.go.jp/content/001102474.pdf
Ministry of Health, Labour and Welfare: Basicguidelinesforhealthpromotionandimprovements of nutrition and dietary habits byadministrative dietitians in the community.
https://www.mhlw.go.jp/content/10900000/0006
37215.pdf
Ministry of Health, Labour and Welfare:
Overview of regional health and healthpromotion
project
reportsin2019.
https://www.mhlw.go.jp/toukei/saikin/hw/choken/19/dl/R01gaikyo.pdf
Self-Efficacy: The Exercise of Control (Bandura
A). 1997. W.H. Freeman.
Minouchi Y. The effect of perceived task
importance on the generality of self-efficacy. Jpn
J Educ Physiol 41: 57–63. 1993.
Fujiu H. A study on the relationships between
kyosyu (hand raising), self-efficacy, outcomeexpectancy and outcome value. Jpn J Educ
Physiol 39: 92-101. 1991.
Ito T. Self-efficacy, casual attribution andlearning strategy in an academic achievement
situation. Jpn J Educ Physiol 44: 340–349. 1996.
Schunk DH. Ability versus effort attributional
feedback: differential effects on self-efficacy andachievement. J Physiol 75: 848-856. 1983.
Major B, Cozzarelli C, Sciacchitano AM et al.
Perceived social support, self-efficacy, andadjustment to abortion. J Personal Soc Physiol
59: 452-463. 1990.
Conn VS. Older adults and exercise: pathanalysis of self-efficacy related constructs.
Nursing Res 47: 180-189. 1998.
Bandura A, Schunk DH. Cultivating competence,
self-efficacy, and intrinsic interest throughproximal self-motivation. J Pers Soc Psychol 41:
586-598. 1981.
Bandura A, Cervone D. Self-evaluative and selfefficacy mechanisms governing the motivational
effects of goal systems. J Pers Soc Psychol 45:
1017-1028. 1983.
Bandura A, Reese L, Adams NE. Microanalysisof action and fear arousal as a function ofdifferential levels of perceived self-efficacy. J
Pers Soc Psychol 43: 5-21. 1982.

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Asian Journal of Dietetics 2023

Note
Data Analytics to Explore the Influence of Nutritional Factors on Adverse Reactions
after Vaccination
Yuko Hisatomi1, Midori Yasuda2, Tomoyuki Natsume3, Mami Nanri4, Tsunenobu Ueno1, Tokihiro Kusaba2,
Kenji Kugino2*
1

The Office of Graduate School Establishment Preparation of Nishikyushu University, Saga, Japan
2
Graduate School of Nishikyushu University, Saga, Japan3
Department of Community and Future Studies, Saga Women's Junior College, Saga, Japan
4
Department of Nursing, Nishikyushu University, Saga, Japan
ABSTRACT Background and purpose. In order to contribute to the elucidation ofnutritional approaches to reduce adverse reactions to vaccines, this study examined theinfluence of nutritional factors on the occurrence of adverse reactions after mRNA-1273
vaccination using a data analysis method based on a free, open-source application that iseasy to use in clinical practice. Methods. We decided to use a workstation to process alarge amount of data, and used MySQL to create a database of data on side effects that
occurred after vaccination and nutritional intake, and used R to perform data extraction
and statistical analysis. Results and conclusion. The results suggest that the intake of somenutrients (ash, VB1, VB2, VB6, VC, and sodium equivalents) over the past month or two,
as estimated by the Food Frequency Questionnaire (FFQ), may be somehow related to thedevelopment of adverse effects, that thinness may promote the development of adverse
effects, and that low physical activity level (PAL) may promote the development ofadverse effects. However, it is difficult to rationally understand the mechanism by which
nutrients affect the occurrence of adverse effects from this survey alone, and more detailed
collection and analysis of large amounts of data using survey techniques that canaccurately determine nutrient intake is needed in order to gather clinical knowledge in the
future. As a research technique for this purpose, the analysis of large amounts of datausing data analytics is expected to become increasingly important in the future.
Key words: mRNA-1273, Adverse Reactions, Nutritional Factors、Food Frequency
Questionnaire (FFQ), Data Analytics

INTRODUCTION
Against the backdrop of the rapid development ofcomputer networks, digital transformation has rapidly
spread throughout society and has also penetrated thefield of academic research.
Digital research technologies such as data scienceand data analytics are beginning to be introduced into
research on diet therapy, nutritional intake, and foodsafety, which are central themes in nutritional science.
Technology for monitoring an individual's physicalcondition using biometric sensors, smart wearable
devices, and mobile applications (1) is already wellestablished, and in the field of nutrition research, somecompanies are now offering online services (2) that
use AI engines to automatically calculate nutritional
intake from food image processing. Nutritional
research and its clinical applications, which deal witha large number of nutrient intakes, require efforts thatmake full use of the analysis of vast amounts of data,and it is expected that so-called data science and data
analytics methods will be increasingly used. However,in the field of nutrition, the use of data analytics anddata science methods has lagged behind, and data
analytics techniques that can be easily used in clinicalsettings have not yet been established. Therefore, thistime, we attempted a clinical nutrition research designusing data analytical methods, using as an example theanalysis of a large amount of data on side effects andnutrition of female students collected during massvaccination of mRNA-1273 vaccine conducted at
Nishikyushu University.
In response to the urgent global need for a safe andeffective vaccine to prevent coronavirus infection2019 (COVID-19), declared a pandemic by the World
Health Organization (WHO) on March 11, 2020, andto protect people at high risk of complications, amRNA vaccine(mRNA-1273 and BNT162b2) was
developed. In Japan, a university-led mass vaccination
program was implemented from 2021 to 2022 topromote emergency vaccination with these COVID-19
vaccines. This mass vaccination program was also
carried out at Nishi-Kyushu University, where theauthors work, and used the mRNA-1273 vaccine (3, 4,5), which is known to be highly effective in preventing
infection and severity of COVID-19. This mRNA1273 vaccine produces a high frequency of mild
adverse reactions after vaccination (6), but the adverse*To whom correspondence should be addressed:
kkugino@gmail.com

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Nutritional Factors on Adverse Reactions after Vaccination
reactions are, for the most part, mild and temporary(4,7). However, since a certain number of people arehesitant to be vaccinated because of adverse reactions,
it is assumed that reducing adverse reactions will be anissue for vaccine dissemination in situations where
sufficient vaccine is available. Since adverse reactions
are physiological immune responses of the human
body, nutritional approaches may be effective in
reducing adverse reactions.
Therefore, in this study, in order to help elucidate
nutritional approaches to reduce vaccine side effects,
this study examined the effects of nutritional factors
on the occurrence of adverse reactions after mRNA1273 vaccination by means of a data analytics
approach using a free, open-source application that iseasy to use in clinical practice.

clinical settings, but none of them had the processing
power to handle the large amount of data we had, so
we decided to use a workstation (Processor ; Intel Core
i9-3.00GHz 64bit, RAM: 256 GB, SSD: 20TB) was
purchased and used for analysis. The results of adverse
reactions and dietary records were cleansed, personal
data were divided into separate tables, and each data
was stored in a database with ID as the primary key.
MySQL 8.0.33 was used as the relational databasemanagement system (RDBMS). Information on thepresence or absence of adverse reactions andnutritional intake status was extracted from thedatabase, and statistical analysis was performed using
R Ver 4.3.1 (9). Fisher's exact test (Fisher's exact
probability test) and Welch's t-test (difference ofmeans test) were used for statistical analysis.
This study was conducted in accordance with the
Declaration of Helsinki (1964) (Tokyo revision (1975)
and Venice revision (1983)) and with the approval of
the Ethics Committee of the University of Western
Kyushu (No. 21YBP04).

MATERIALS AND METHODSIn this mass vaccination program, known as theuniversity-based vaccination program, vaccinations
were administered to students, faculty, staff, andresidents of the surrounding area at vaccination sites
set up on the university campus. The subjects of thisstudy were 1452 female university students who
received two doses of mRNA-1273 vaccine throughNishikyushu
University's
university-based
vaccination program.. After the first vaccination, asecond vaccination was administered 28 days apart. In
this study, we conducted a questionnaire survey to
examine the frequency of adverse reactions andnutritional intake among students who had completed
the second vaccination of the mRNA-1273 vaccine.
The questionnaire was anonymous, and responses
were requested online using Microsoft Forms(Microsoft Co. Ltd.). The questionnaire wasconducted two weeks after the second vaccination day.
The survey on adverse effects used the same items as
the "Survey on Health Status after Ingestion of the
New Corona Vaccine (Cohort Survey)" conducted byJuntendo University (8). There are 8 questions, and if
there are symptoms of adverse reactions, the answer
method is to select the details of the symptoms and theperiod during which the symptoms were observed
from the drop-down list. The survey on nutritional
status was conducted by means of the Food Frequency
Questionnaire (FFQ), which estimates energy andnutrient intakes over the past month or two based on
30 food groups and 10 cooking methods. The FFQ
response results were analyzed using FFQ analysis
application software (FFQg Ver. 6, Kenpakusha Co.
Ltd. ), and nutritional intake was calculated.
Data from 690 university students who responded
to both a survey on adverse reactions and a survey on
nutritional status were confirmed, and data from 459
students whose responses were all deemed valid wasanalyzed using a series of data analytics methods. We
attempted analysis using several laptops and personal
computers so that they could be easily operated in

RESULTSThe frequency of occurrence of adverse reactions
after the first and second vaccination with mRNA1273 vaccine is shown in Table 1. The frequency ofsystemic side effects increased 1.8-fold from 39%
after the first vaccination to 72% after the second
vaccination. In particular, those who complained offever after the second vaccination increased 2.5 times
more than after the first vaccination. The frequencyof adverse reactions at the vaccination site was high,
77% after the first vaccination and 75% after thesecond vaccination, with no significant difference
between the first and second vaccinations.
A
particularly high number of people complained of pain
after both the first and second vaccinations, reachingaround 70%. Next, about half of the respondents
complained of a warm sensation, and redness andswelling were reported by about 30%.
The relationship between the occurrence ofadverse effects after the first and second doses ofmRNA-1273 vaccine and nutrient intake during thepast month or two, as estimated by the FFQ, is shownin Table 2. After the first vaccination, there was noclear difference in nutrient intake between those who
developed systemic or vaccination site adverse
reactions and those who did not (Table 2-a).
Furthermore, even after the second vaccination, nodifference in nutrient intake was observed between
those who developed systemic adverse reactions andthose who did not. However, there was a statisticallysignificant difference of around 10% in the intake ofmany nutrients such as ash, VB1, VB2, VB6, VC, andSodium Equivalent between those who developed
adverse effects at the intake site and those who did not(Table 2-b).

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Asian Journal of Dietetics 2023

The effect of Body Mass Index (BMI) on thefrequency of adverse effects is shown in Table 3. Since
only 3 subjects were judged to be obese based on BMI
values, the influence of obesity could not be examined.
On the other hand, since those judged to be thinness
accounted for more than 14% of the total number ofsubjects, the incidence of adverse reactions was
divided into 2 groups: those who were thinness (BMI
< 18.5) and those who were not (BMI ≥ 18.5) andcompared between the groups. The results showed noclear difference in BMI between those who developed

systemic or vaccination site adverse reactions andthose who did not after the first vaccination (Table 3a). There was also no difference in BMI between those
who developed adverse reactions at the vaccinationsite and those who did not, even after the second
vaccination. However, there was a suggested effect of
BMI between those who developed systemic side
effects and those who did not, with those who werethinness having a significantly higher incidence ofsystemic side effects than those who were not (Table
3-b).

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Nutritional Factors on Adverse Reactions after Vaccination

The effect of physical activity level (PAL) on thefrequency of adverse effects is shown in Table 4. Afterthe first vaccination, there was no clear difference in
PAL between those who developed systemic or
vaccination site adverse reactions and those who didnot (Table 4-a).
There was also no difference in PAL between those
who developed systemic adverse reactions and those
who did not after the second vaccination. However,there was a slight difference in PAL between those
who developed side effects at the ingestion site andthose who did not, and a significant difference wasobserved (Table 4-b).

immune cells, and promotes immune processes thatgenerate antibodies and immune cells. When
inflammation resolves, immune cells and growth
factors that promote tissue repair and recovery are
involved, and pain and swelling gradually decreaseover a few days.
As shown in Table 1, the frequency of systemic
adverse reactions increased 1.8-fold from 39% after
the first vaccination to 72% after the second
vaccination, while the frequency of adverse reactions
at the site of inoculation was nearly 80% both after the
first and second vaccinations. This result is almost thesame as that of Ali et al. (4), and may indicate a certain
degree of reliability of this survey methodology
conducted using Microsoft Forms. The relationshipbetween the incidence of adverse reactions after
vaccination and nutrient intake is shown in Table 2,
where the nutrient intakes indicated represent thenutrient intakes during the past one to two months
from the date of the survey, as estimated by a survey
using the Food Frequency Questionnaire (FFQ). There
was no clear difference in nutritional intake between
those who developed systemic or vaccination site side
effects after the first vaccination and those who did not,nor was there any difference in nutritional intake
between those who developed systemic side effects
and those who did not after the second vaccination. On

DISCUSSION
The mRNA-1273 vaccine is a vaccine that
introduces mRNA encoding part of the spike proteinof the SARS-CoV-2 virus into the body, thereby
triggering an immune response against the spike
protein synthesized by body cells, producing
antibodies and immune cells to strengthen theinfection defense response (10). Vaccine injections
stimulate skin and muscle tissue, including localized
tissue damage, causing a localized inflammatory
response. This inflammatory response is well known
to activate the immune system, which includes therelease of inflammatory cytokines and proliferation of98

Asian Journal of Dietetics 2023
the other hand, after the second inoculation, there wasa statistically significant difference of about 10% in
the intake of many nutrients, including ash, VB1, VB2,
VB6, VC, and sodium equivalents, between those who
developed adverse reactions at the site of intake andthose who did not (Table 2-b). There is insufficient
information to draw any inference from the results ofthis study as to how differences in the intake of thesenutrients in the month or two prior to vaccination
affect the occurrence of adverse reactions at thevaccination site, and no similar studies have beenreported, so future research is expected. When theincidence of adverse reactions was comparedseparately for thinness (BMI <18.5) and not-thinness(BMI ≥18.5) individuals, the incidence of systemic
adverse reactions was significantly higher in thinness
individuals than in not-thinness individuals after thesecond vaccination (Table 3-b). This result appears tocontradict the short-term nutritional results above, but
if thinness is understood as a long-term nutritional
deficiency, it could be that the malnourished state
promotes adverse reactions by reducing normal
resilience to immune responses, but again, it isdifficult to infer this solely from the results of thisstudy. The PAL of those who developed intake site side
effects after the second vaccination was significantly
lower (Table 4-b), which may suggest that balancing
nutrient expenditure and nutrient intake at a high levelis effective in reducing the incidence of side effects.

integrating wearable data and behavioral patterns
improves metabolic health. Research Square,https://doi.org/10.21203/rs.3.rs-2362590/v1. 2023.
2. Tsunemi A, Sato J, Sugimoto S, Iwagaki Y,
Enomoto M, Someya Y, Kiya M, Matsuhashi E,
Wakabayashi Y, Funayama T, Mita T, Uchida T,
Miyatsuka T, Azuma K, Shimizu T, Kanazawa A,
Satoh H, Watada H. A Pilot Study of Intervention
with a Mobile Application Visualizing theMacronutrient Content for Type 2 Diabetes at aJapanese Center. J. Clin. Med. 13(8):425-433.
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3. Polack PF, Thomas TS, Kitchin N, Absalon J,
Gurtman A, Lockhart S, Perez LJ, Marc PG,
Moreira DE, Zerbini C, Bailey R, Swanson AK.
Safety and Efficacy of the BNT162b2 mRNA
Covid-19 Vaccine. N Engl J Med 383: 26032615. 2020.
4. Ali K, Berman G, Zhou H, Deng W, Faughnan V,
Coronado-Voges M, Ding B, Dooley J, Girard B,
Hillebrand W, Pajon R, Miller MJ, Leav B,
McPhee R. Evaluation of mRNA-1273 SARSCoV-2 Vaccine in Adolescents. N Engl J Med 385:
2241-2251. 2021.
5. Baden RL, Sahly MH, Essink B, Kotloff K, Frey S,
Novak R, Diemert D, Spector AS, Rouphael N,
Creech B, McGettigan J, Khetan S. Efficacy and
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N Engl J Med 384: 403-416. 2021.
6. Kadali R, Janagama R, Peruru S, Gajula V,
Madathala RR, Chennaiahgari N, Malayala VS.
Non-life-threatening adverse effects with COVID19 mRNA-1273 vaccine: A randomized, crosssectional study on healthcare workers withdetailed self-reported symptoms. J Med Virol 93:
4420-4429. 2021.
7. Kitagawa H, Kaiki Y, Sugiyama A, Nagashima S,
Kurisu A, Nomura T, Omori K, Akita T, Shigemoto
N, Tanaka J, Ohge H. Adverse reactions to the
BNT162b2 and mRNA-1273 mRNA COVID-19
vaccines in Japan. J Infec. Chemother. 28: 576-581.
2022.
8. Naito T, Tsuchida N, Kusunoki S, Kaneko Y,
Tobita M, Hori S, Ito S. Reactogenicity andimmunogenicity of BNT162b2 or mRNA-1273
COVID-19 booster vaccinations after two doses of
BNT162b2 among healthcare workers in Japan: aprospective observational study. Ex pert Rev
Vaccines 21(9): 1319-1329. 2022.
9. R Development Core Team. R: A language andenvironment for statistical computing. R
Foundation for Statistical Computing, Vienna,
Austria. ISBN 3-900051-07-0
10. Verbeke R, Lentacker I, Smedt S, Dewitte H. The
dawn of mRNA vaccines: The COVID-19 case. J
Control. Release 333: 511-520. 2021.

CONCLUSION
The results of this study, which indicate that the
intake of some nutrients may affect the incidence ofadverse reactions by means of an FFQ that estimates
nutrient intake over the past month or two, do notcontain enough information to infer how individual
nutrients may affect the mechanism of adverse
reactions, but they do suggest that adequate nutrient
intake may have some effect on the immune response
elicited by mRNA- 1273 vaccination may have someeffect on the immune response elicited by vaccination.
However, it is difficult to rationally understand themechanism by which nutrients affect the occurrence ofadverse effects from this survey alone, and moredetailed collection and analysis of large amounts ofdata using survey techniques that can accurately
determine nutrient intake is needed in order to gather
clinical knowledge in the future. As a researchtechnique for this purpose, the analysis of large
amounts of data using data analytics is expected to
become increasingly important in the future.
REFERENCES
1. Snyder M, McLaughlin T, Zahedani A, Palmisano
S, Saberi M, Woodward M, Joselevitz R, Ruan J,
Romasko H, Agarwal S, Tripathi S. Machinelearning-based
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Asian Journal of Dietetics 2023

Case report
Nutrition Management with Crohn’s Disease – Semi Elemental Hydrolyzed Whey
Protein (HWP): A Case Report Study
Woan Yin Tan1, Lina Isnin1, Nurfazlin Rozlan1
1

Department of Dietetic and Food Service, Hospital Melaka (Ministry of Health), Melaka, Malaysia
ABSTRACT Background and purpose. Individual with Crohn’s disease is at risk of malnourish.
Case report aimed to describe the clinical practice on a Crohn’s disease adolescence, presented
with sign and symptoms of malnourished with the underlying frequent loose stool. Case
presentation. A 16 years old, male adolescence patient with Crohn’s disease, presented
malnourished: weight-for-age and BMI-for-age were below the 5th percentile (underweight),
and stunted (<5th percentile) for height-for-age; with frequent loose stool (5 times/day). A
normal level of renal profile, blood calcium, phosphate, and magnesium level; except for a lower
value of albumin (19 g/dL) and hemoglobin (10.2 g/dl) was shown. A total of 2400kcal with 62gof protein can be consumed by patient in a day; yet, patient still experience continuous of weightloss. During the hospitalization, oral nutrition supplementation with semi-elemental hydrolyzed
whey protein was implemented, twice in a day; along with balanced, healthy diet. There was
improvement shown on patient anthropometry measurement such as body weight (gained 7.7kg)
and mid-upper arm circumference (increased 5cm on both left and right arm). There was also
clinically improve on the frequency of loose stool (reduced to 2 times/day). Discussion andconclusion. Patient with Crohn’s disease has high risk of becoming malnourish. As conclusion,
malnutrition screening is recommended for early detection of malnourish and followed by aproper assessment and intervention with semi-elemental hydrolyzed whey protein to improve
nutritional status.
Keywords: Semi elemental hydrolyzed whey protein, protein energy malnutrition, Crohn’sdisease, case study.

INTRODUCTION
Crohn’s disease is related to a group of conditions
named inflammatory bowel diseases (IBD) (1). The
most common clinical symptoms are abdominal pain,loose stool, experience lethargy, loss of weight, fever,anemia, or lesions on the perianal (1). Complicationsof Crohn’s disease comprising intestinal obstruction,
fistulas, abscesses, anal fissures, ulcers, inflammationin other areas of the body, and malnutrition (1).
Malnutrition arises in Crohn’s disease when theincidence of poor oral intake, malabsorption, severe
deficit of proteins, and outgrowth of intestinal bacteria
occur (2). It was reported that the rate of malnutrition
that occurs in IBD patients varies from 20% to 85%(3,4). And this was also reflected in patients’ weight,
where IBD patients experienced a weight loss of 70%
to 80% (5).
Malnutrition is more severe in Crohn’s disease ascompared to other IBD due to it can affect any regionof the digestive tract and is more common in children
than in adults (6). Factors that imply protein energy
malnutrition (PEM) in Crohn’s disease consist of
reduce in oral intake, underlying physiological causesthat rise the problem of malabsorption, an increase incatabolism effects, and as well side effects fromdifferent treatment strategies (2,7). It was also a rise inconcern when deficiencies such as vitamin D, iron andtrace elements happened in individuals with Crohn’sdisease (4).
Henceforth, nutritional care is essential as part of
the treatments to prevent severe PEM and as well to
optimize healthy growth and development, especiallyin children (6). Enteral nutrition (EN) therapy, either
taken orally or prescribed through tube feeding, canhelp in optimizing or restoring the nutrients that had
lost by an individual. There are three types of enteralnutrition formulas that are widely used in clinicalsettings – elemental, semi elemental, and polymericamino acid (6). Among all these, semi elemental
enteral nutrition can offer a better outcome to anindividual with severe malnourishment given the
peptides based amino acid and the medium-chain
triglyceride that can ease nutrient absorption (7).
CASE PRESENTATION
Medical History
No known medical illness and past medical history.
Nutritional Assessment and In-Patient Diagnosis
A 16-year-old, secondary school Indian boy wasadmitted to the hospital with complaints of pain in theperianal area, swelling, lethargy, bleeding with
discharge, and with loose stools after food intake.

*To whom correspondence should be addressed:
tanwoanyin@moh.gov.my101

Nutrition Management with Crohn’s Disease
Upon assessment, the patient’s height was 148cm,
with a body weight of 25.8kg. Severe malnourished
was reflected in this child as the weight-for-age and
BMI-for-age were below the 5th percentile(underweight) and stunted (<5th percentile) for heightfor-age. The patient shows a normal level of renal
profile, blood calcium, phosphate, and magnesium
level; except for a lower value of albumin (19 g/dL)
and hemoglobin (10.2 g/dl). The patient thenproceeded with a gastroscopy and colonoscopy
procedure. The patient was then diagnosed with
Crohn’s disease complicated by a complex perianal
fistula. The patient was referred to dietitian team fornutrition management in view of frequent loose stool
and malnourished.

A dietary assessment recall was carried out withboth the patient and the caretaker (mother). From the
dietary assessment, the patient can consume a highcalorie diet, an average of 2400kcal/day, with 62g ofprotein intake. There isn’t any sign of a picky eaterfrom this patient. According to the caretaker, thepatient’s appetite had improved after taking
multivitamins from a primary care setting. Yet, there
is still no increment in his body weight. Besides that,the patient also experienced very frequent loose stool
every time after a meal.
A comparative standard dietary requirement of
80kcal/kg current body weight was prescribed for thepatient. This requirement was calculated based on
Dorothy’s formula for failure-to-thrive. The protein
requirement was calculated to be 62g – 77.4g/day.

Table 1. Anthropometry measurement
Weight (kg)Height (m)Body mass index (BMI) kg/m2
Weight-for-age
BMI-for-age
Height-for-age

Dosing weight (kg)
Energy (kcal)
Protein (g)25.8kg1.48
11.8 kg/m2< 5th percentile

Table 2. Comparative standard dietary requirement
25.8kg80kcal/kg (body weight)
62g – 77.4g

logistic limitation. During these follow-up sessions,the body weight was weighed, and as well themeasurement from both left and right mid-upperarm-circumference (MUAC) as shown in Table 3
below. There was no biochemical data for revision
as it was not reassessed by the surgeon. A simple andquick dietary assessment was also carried out. The
patient can follow and consume the enteral nutritionprescription. A total of 7.7kg weight was gained bypatient, and increment of 5cm in both left and right
MUAC. For the stool frequency, the patient’s
caretaker claimed that there had been a reduction in
the patient’s loose stool as compared to the previous(from 5 times per day to 2 times per day); and will
only trigger when the patient eats high fat foodpreparation (eg: deep fried) and spicy. The stool
texture also improved from Bristol chart Type 6 toBristol chart Type 4. The patient’s caretaker also
claimed that it was a big challenge for the patientwhen need to restrict from these food preparation
choices. Follow-up sessions ended for the sixth timeas the patient was scheduled by the surgicaldepartment after 1 year

Medical Nutrition Therapy
First Visit
After the nutritional assessment, in view of theunderlying causes that leads to malabsorption fromhis usual diet intake, a balanced, semi elemental
HWP enteral nutrition formula was prescribed forthe patient as an oral nutrition supplement. The
purpose of the enteral nutrition prescription is toprovide additional calories and protein yet ease inabsorption for his underlying Crohn’s disease. Thispatient was prescribed 7 scoops of the enteralnutrition formula, twice per day.
Other than the prescription, the patient was also
required to follow a balanced diet that consists ofvarieties of carbohydrates, proteins, vegetables, andfruit; but with lower usage of cooking oil preparation
method and as well avoid sweetened beverages andfoods.
Follow up
A total of 6 follow-up sessions were carried out
with the patient and his caretaker upon his visitation
to the surgical clinic department in view of his.

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Asian Journal of Dietetics 2023

Table 3. Body weight and mid-upper-arm-circumference during follow-up sessions
Number of
BMI
Mid-upper-arm-circumference (cm)Weightfollow-up(kg/m2)(kg)
Left arm
Right arm
sessions
1
29.5
13.0
15
15
2
29.9
13.2
17
17
3
30.5
13.5
17.5
17.5
4
30.8
13.6
18
19
5
31.3
13.8
19
19
6
33.5
14.8
20
20
passage of viable bacteria from the gastrointestinal
tract to extra-intestinal sites, aids in visceral protein
combination and supports the immune system.
A piece of promising evidence was also seen
recently through a prospective observational study by
Ferriro et al (12). In this study, the subjects underwent
12 weeks of nutritional management intervention byusing semi elemental HWP. It was noticed that the
subjects’ body mass index and mean albumin levels
improved, and a significant decrease in their HarveyBradshaw Index and as well the frequency of loosestools (12). They believed that hydrolyzed whey
protein is one of the important sources of bioactive
peptides, which participate in a wide range of
biological processes, including intestinal antiinflammatory activities.
Nutritional intervention had slowly become one of
the alternative treatments as compared to conventional(medication) intervention. Studies have shown thatnutritional management for Crohn’s disease can be
more cost-effective than traditional pharmacologicaltherapies or surgery, as it can help in reducing hospital
readmissions and healthcare costs while improving
patient outcomes (13,14). One study published in the
Journal of Crohn’s and Colitis in 2017 found that
exclusive enteral nutrition (EEN), a type of nutritional
therapy, was more cost-effective than corticosteroids
for inducing remission in pediatric patients with
Crohn’s disease (15).

DISCUSSION
This case study presents the nutritional issues ofmalnourished in the setting of Crohn’s disease. We
present a case of a 16-year-old teenage boy with severe
malnourished due to underlying Crohn’s disease, andan improvement in his nutritional status after startingwith semi elemental HWP as nutritional management.
When the patient was diagnosed with Crohn’sdisease and referred to dietitian team for nutritional
management, we decided to provide him with semi
elemental HWP enteral nutrition formula. In this casestudy, the semi elemental HWP was associated withimprovement in patient’s nutritional status andreduced stool frequency, and improved stool texture.
According to the ESPEN guideline 2017,
exclusive enteral nutrition is effective and isrecommended as the first line of treatment for children
and adolescents with acute active Crohn’s disease (6).
There are three different types of enteral nutrition
formulas that are categorized based on their nitrogensize – elemental, semi elemental, and polymeric.
Elemental enteral nutrition formula is a type of
formula that can be easily absorbed by the body (8).
They are made in the form of amino acids for theprotein and medium-chain triglycerides (MCT) for thefat (8). Whereas semi elemental enteral nutrition
formula, consists of peptides in different chain lengths
and MCT (9,10) that helps in digestion, protect theintestine mucosal and better nutrient absorption (7).
Polymeric, consists of whole protein with long-chain
triglycerides that need further breakdown by our bodyfor the nutrient absorption. Semi elemental enteralnutrition formula is more expensive than polymeric
but has better taste preference when compared withelemental enteral nutrition formula (8).
Over the years, some studies looked into the effectof semi elemental formula in patients with Crohn’sdisease. This clinical evidence showed that semi
elemental HWP is able to tolerate well by the patientsin terms of digestion and absorption and results inweight gain and growth, aids in the anti-inflammatory
process, reduction in mortality rates, and lower
healthcare expenses (8). In addition to this, do notforget about the role of peptide based HWP.
According to DeLegge (11), there were several
possible benefits such as aids in nitrogen or amino acidabsorption and usage, maintenance of intestinal
homeostasis by mucosal barriers, reduction in the

CONCLUSION
In conclusion, this case study highlights theimportance of nutritional management in patients with
Crohn’s disease, particularly those who aremalnourished. Semi elemental HWP can be aneffective nutritional intervention for improving
nutritional status, reducing stool frequency, andimproving stool texture in these patients. The use ofsemi elemental HWP should be considered innutritional management guidelines for patients with
Crohn’s disease. However, individualized nutritional
management plans should also be developed for eachpatient, taking into consideration factors such ascomorbidities, medication use, and dietary preferences.
Overall, this case study emphasizes the importance ofa multi-disciplinary approach in managing Crohn’sdisease, including collaboration between healthcare
professionals such as dietitians, surgeons, and nurses

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Nutrition Management with Crohn’s Disease
to ensure the possible care for patients. By
implementing evidence based nutritional management
strategies such as semi elemental HWP, we can help
improve outcomes and quality of life for patients with
Crohn’s disease.

36(2):321–47. 2017.
8. Alexander DD, Bylsma LC, Elkayam L, Nguyen
DL. Nutritional and health benefits of semi
elementaldiets: A comprehensive summary of theliterature. World J Gastrointest Pharmacol Ther
7(2):306. 2016.
9. Diklar M. Elemental and Semi elementalFormulas:
Are They Superior to Polymeric Formulas?
Gastroenterology 59–72. 2005.
10.Chen PQ. Enteral nutrition and acute pancreatitis.
World J Gastroenterol 7(2):185. 2001. [cited 2023
Feb
17].
Available
from:/pmc/articles/PMC4723520/
11.Brody JK. Enteral feeding. Am J Nurs 110(1):13.
2010.
12.Ferreiro B, Llopis-Salinero S, Lardies B,
Granados-Colomina C, Milà-Villarroel R. Clinicalandnutritional
impactofasemi
elementalhydrolyzed whey protein diet in patientswith active crohn’s disease: A prospective
observational study. Nutrients 13(10). 2021.
13. Guariso G, Gasparetto M. Treating children with
inflammatory bowel disease: Current and new
perspectives. World J Gastroenterol 23(30):5469–
85. 2017.
14. Schwermer M, Fetz K, Längler A, Ostermann T,
Zuzak TJ. Complementary, alternative, integrativeand dietary therapies for children with Crohn’sdisease – A systematic review. Complement Ther
Med 52:102493. 2020.
15. Gomollón F, Dignass A, Annese V, Tilg H, Van
Assche G, Lindsay JO, et al. 3rd European
Evidence-based Consensus on the Diagnosis andManagement of Crohn’s Disease 2016: Part 1:
Diagnosis and Medical Management. J Crohns
Colitis 11(1):3–25. 2017. [cited 2023 Apr 25].
Availablefrom:https://pubmed.ncbi.nlm.nih.gov/27660341/

ACKNOWLEDGEMENTS
The author would like to express their gratitude to
the study participant, and also the team members inthis case report.
REFERENCES
1. Roda G, Chien Ng S, Kotze PG, Argollo M,
Panaccione R, Spinelli A, et al. Crohn’s disease.
Nat Rev Dis Prim 6(1). 2020. Available from:http://dx.doi.org/10.1038/s41572-020-0156-2
2. Balestrieri P, Ribolsi M, Guarino MPL,
Emerenziani S, Altomare A, Cicala M. Nutritional
aspects in inflammatory bowel diseases. Nutrients
12(2). 2020.
3. Goh J, O’Morain CA. Review article: Nutrition
and adult inflammatory bowel disease. Aliment
Pharmacol Ther 17(3):307–20. 2003.
4. Donnellan CF, Yann LH, Lal S. Nutritional
management of Crohn’s disease. Therap Adv
Gastroenterol 6(3):231–42. 2013.
5. Hartman C, Eliakim R, Shamir R. Nutritional
status and nutritional therapy in inflammatory
bowel diseases. World J Gastroenterol
15(21):2570–8. 2009.
6. Bischoff SC, Escher J, Hébuterne X, Kłęk S,
Krznaric Z, Schneider S, et al. ESPEN practicalguideline: Clinical Nutrition in inflammatory
bowel disease. Clin Nutr 39(3):632–53.2020.
7. Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric
Z, Schneider S, et al. ESPEN guideline: Clinicalnutrition in inflammatory bowel disease. Clin Nutr

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Asian Journal of Dietetics 2023

Special Report: The Cambodian Food Culture

The Introduction of “The Fermented Fish Paste”
No. 1 in a Series
Ry Manydine
Jumonji University, Saitama, Japan
With its good geographical condition, Cambodia is
prone to rivers and lakes, which means most of thefood sources are fish. As time passed by, Cambodiansstarted using their creativity to create many types ofdishes from fish. No exception, the fermented fish
paste was invented and it has changed the way
Cambodian food tastes since then. There’s no exact
document or research that studies since when it wasinvented but the recipe has been passed down fromgeneration to generation and is still wildly consumed
by modern-day Cambodians. Globally speaking,different countries use different types of seasoning toboost the umami. For instance, Japan uses “Hondashi”
for umami, the fermented fish or “Prohok” is theequivalent Of “Hondashi” in Cambodia. Both are
made from fish but the techniques and approach issomehow different. The purpose of this article is tospread the potential of Cambodian dishes that weremade using fermented fish paste as a seasoning or as amain dishCambodian food may be an underrated food among
other Asian countries. Perhaps, there are many hidden
charms within the overlooked dishes of Cambodia.
This article will be dedicated to the delicacy of
Cambodian traditional food, and its potential to be
wildly renounced its uniqueness and magnificence.
Talking about Cambodian food, fermented fish paste
is one of the core ingredients in many of the dishes.
The smell and the pungent taste make it stand out. In
Khmer words “Prahok” or fermented fish is the coreingredient of most soups and can also be eaten bythemselves. It is used to give the Umami that boosts
the extra flavor so that the food can be enjoyedthoroughly. Since Cambodia has many different typesof fish, fermented fish can also be made from manykinds of fish. The price can vary range on how rare ordelicious the fish are. Fermented fish paste production
can also be widely found along the local area next to
the Tonle Sap or Mekong River. Since, it is not widely
available in other countries, almost all of the products
are domestic products. As the taste is deeply carved
into the Cambodian heart and with a pinch of creativity,
there are so many dishes that can be made using fish
paste.

How to make “fermented fish paste”
Fishes that were freshly caught from rivers, such as
the Mekong River and Tonle Sap River mostly smallscale fish scientifically known as small mud carps(Henicorhynchus Entmema /H. Siamensis) Theirheads are removed and their remaining bodies arecleaned with fresh water until all the slime coat iscompletely gone. Then, it is soaked in clean water for
one day. The following day, the fish are taken out of
the soaking water and put in a container that has holes,
so then all of the excess water can be extracted bypressing heavy objects on it. Then it is sundried foraround 1 day and when it is dried the fish is mixed withsalt, the salt and fish mixture is pounded softly so thatthe fish can absorb the saltiness. The fish are tightly
put in a sealed glass container for fermentation. The
paste is stored for up to 3 months for its deliciousness
and uniqueness.

Photo1: Map of Cambodia*To whom correspondence should be addressed:
rmalydine14@gmail.com

105

The Fermented Fish Paste

Photo 2: Small mud Carps fish

Photo 3: Fermented fish paste

Figure 1: The process of making Fermented Fish Paste

vegetables and a dipping paste. With a bowl of hot
steamed white rice, Cambodians can happily enjoy thislow-cost meal.

Recipes using fermented fish paste
1. Prahok chav/ Raw fermented fish
Ingredients:
 Fermented fish paste (prahok) Ferroniella Lucida
 Lemongrass Galanga Garlic
 Shallot
 Red chili Sugar MSG

2. Somlor Mju trokoun/
Morning Glory Sour Soup Ingredients:
 Morning Glory Fresh water Fish
 Fermented fish paste Tamarind Green herb
 Salt
How to make:Boiled water in a pot, after boiling put the fermented
fish in, and strain the paste in a strainer making surethat there are no fish bones in the broth. Fish that havebeen cleaned and cut will be put into the broth. Then,close the lid and let it simmer until the fish is cooked.
Then the tamarind is also put in the broth for a hint ofsourness since the soup is called a “Sour Soup”.The
Morning Glory is then added along with a little bit ofsalt. Green herbs are added as a last-touch garnish. The
food then can be served hot to eat along with rice.
In conclusion, the above information is about the
introduction and recipes of how Cambodian fermented
fish “Prahok” is used in a dish. Along with how it ismade. Though this article is short, as a writer I hopethat readers can enjoy reading and understanding what
is so different about Cambodian dishes.

Photo 5: Ferroniella Lucida
How to make:All the ingredients (Fermented fish paste, Ferroniella
Lucida, lemongrass, Galanga, Garlic, shallot, and chili)
are all being minced together until they become one
paste. The saltiness in the fermented fish is mixed withthe sourness of the Ferroniella Lucida.
Sugar and MSG are then added to balance out all theflavors. This dish is normally eaten with a variety of106