ISSN2434-2688

Asian Journal of Dietetics
Vol.1 No.3

2019

Contents
Originals
48-52

Dysphagia Prevalence among Elderly in Some Vietnamese Hospitals
Thao Phuong Tran, Linh Thuy Nguyen, Jun Kayashita, Fumio
Shimura, Shigeru Yamamoto.

53-58

Acceptability Evaluation by Vietnamese about Non-toxic Cultured
Pufferfish in Comparison with Grouper and Mackerel
Linh Vu Thuy, Tuyen Le Danh, Hien Vu Thi Thu, Hung Nguyen Quang,Ngọc Vuong Thi Ho, Fumio Shimura, Sumiko Kamoshita, Yoshinari Ito,
Shigeru Yamamoto

59-68

Medical History of Infancy, Weaning Foods and Nutrient Intake
of Indian Type 1 Diabetic Children aged 2 to 18 years
Jagmeet Madan, Sheryl Salis, Neha Sanwalka, Kilpa Kacheria,
Himani Kabrawala, Namrata Manyal

69-74

Food Wastage in Hospital among Cancer Inpatients and its
Relation with Nutrition Impact Symptoms
Norshariza Jamhuri, Ho Chiou Yi, Betti Sharina Mohd Haniff Lai, Siti
Nuraini Ahmad Samwil, Aeininhayatey Abdullah, Zuliehaiza
Kahairudin, Ng Wai Han, Neoh May Kay, Zuwariah Abdul Rahman

Asian Journal of Dietetics 2019

ORIGINAL
Dysphagia Prevalence among Elderly
in Some Vietnamese Hospitals
Thao Phuong Tran1*, Linh Thuy Nguyen2, Jun Kayashita 3,
Fumio Shimura1, Shigeru Yamamoto 1.
1
2

Jumonji University, Niiza-City, Saitama 352-8510, Japan

Hanoi Medical University, 1st Ton That Tung, Dong Da district, Hanoi, Vietnam.
3

Hiroshima Prefectural University, Hiroshima, Japan(received May 6, 2019)

ABSTRACT Background/objective. The Vietnamese elderly population has increased
rapidly on an annual basis and dysphagia has become a common issue. However, in hospitals,
dysphagia screening has not been a concern; the automatic solution for cases ofchoking/aspiration is still a prescription for tube feeding. In developed countries, oral intake
is a priority alternative for dysphagia and has positive consequences. For suitable dysphagia
dietary treatment, early, quick and effective screening for dysphagia plays an important role.
Therefore, in this study, the aim was to determine the prevalence of dysphagia in the elderly
in some Vietnamese hospitals. Method. The study was designed as a cross-sectional study
and was conducted in three large hospitals in Vietnam. The subjects consisted of 1007 elderly
inpatients aged 65 and older. They completed dysphagia screening tests that included therepetitive saliva swallowing test (RSST), the water swallowing test (WST) and Eatingassessment tool-10 (EAT-10) questionnaires. The investigators were dietitians who weretrained to collect data. Results. The rate of dysphagia was quite high 16.5% (166) among
elderly inpatients according to the RSST and WST; and 24.6% (248) according to Eat-10
questionnaires. Specifically, according to clinical test, the rate of dysphagia was found to behigher in neurologic disorder group 40% (45/113), the esophageal disorders group 51%(32/63) and the respiratory & latrogenic disorder group 29% (19/65). Almost all subjects who
could not sit while they were being examined belonged to the dysphagia group. Conclusion.
Through a combination of simple screening tests, this study indicated that the rate ofdysphagia in elderly inpatients was quite high. Therefore, early dysphagia detection isnecessary to administer priority dietary treatment by oral intake instead of tube feeding.
Key Words: dysphagia, hospital, elderly, prevalence, Vietnamese
INTRODUCTION
Older adults are the fastest growing segment of the
population in Vietnam. The number of Vietnamese
aged 65 and older is projected to increase from 7.8%
in 2015 to 17.8% in 2050 (1). Disease risk increases
with advancing age. Dysphagia (swallowing difficulty) is a growing health concern issue in our aging
population. Swallowing is a complex neuromuscular
activity that consists of oral, pharyngeal, and esophageal phases, and involves the coordinated function ofmany muscles. Thus, many adverse health conditions
can influence swallowing function. Neurological diseases, cancers of the head/neck and esophagus, andmetabolic deficits are broad categories of diseases thatmight contribute to dysphagia. A systematic review
indicated that dysphagia affected 8.1-80 % of stroke
patients and 11-81 % of Parkinson’s disease patients(2). Dysphagia may contribute to decreased food andliquid intake and may reflect altered level of consciousness, physical weakness, or lack of coordination in
the swallowing mechanism (3). Therefore, prevention
and early detection of dysphagia are important in
improving health in the elderly.

There are many tools for screening dysphagia
depending on conditions and resources. Some previous research on Vietnamese acute stroke patients
showed that the rate of dysphagia is quite high, around33-81% (4–6). Almost these studies were carried out
on neurological disorder patients by rehabilitation
specialists and sample sizes were limited by thedysphagia screening tools that were used, which
require specialized techniques, take time, and can be
costly. Under conditions in Vietnam, almost all
hospitals have lacked speech therapy specialists andmodern equipment such as video fluoroscopy (VF)and video endoscopy (VE) (7). Screening for dysphagia has not been a major concern; even if some
hospitals have techniques for screening/assessing
dysphagia, the automatic solution for cases of choking/aspiration is still a prescription for tube feeding.
Dysphagia is related directly to nutritional status andquality of life. In developed countries, oral intake is apriority alternative for dysphagia and has positive
consequences (8, 9).
Therefore, in order to improve Vietnamesedysphagia nutrition management, dietitians also

*To whom correspondence should be addressed.
Email: tpthao95@gmail.com

48

Dysphagia Prevalence in Vietnamese Elderly Inpatientsshould have basic knowledge about how to actively
detect dysphagia patients, to prepare food for dysphagia and to apply techniques to feed dysphagia patientsby oral intake, in case the dietitians lack support fromrehabilitation specialists.
In addition, at present Vietnam is lacking data
related to dysphagia rates among general elderly
inpatients. Therefore, a simple screening tool would be
useful in determining the rate of dysphagia and more
importantly can be used by staff members such as
dietitians who are not speech or language pathologists
to identify dysphagia and aspiration risk in elderly
patients or other subjects who may have a high risk ofdysphagia. In this study, we used the repetitive thesaliva swallowing test (RSST), the water swallowing
test (WST) and the Eating assessment tool-10 (Eat-10)
as initial screening dysphagia tools. These tools are
simple, quick, low-cost procedures and in particularhave a high sensitivity and specificity compared tomodern equipment (7, 10–12). By combining clinicaltests at a specific time and questionnaires administeredover a span of time, we hoped to detect all subjects
who have a risk of dysphagia to determine theproportion of dysphagia in elderly inpatients in someVietnamese hospitals.

times or more, then the WST would be administered(10).
Water swallowing test (WST)The position while drinking water needed to beevaluated: sitting or not sitting (from 30 degrees to 60
degrees). The examiner would offer 3ml water for the
subject to drink; if patients choked or their voicechanged, patients suffered from dysphagia. If there
was no choking or voice change, subjects continued todrink 30 ml water. Subjects who had choking or voicechange were dysphagia. If there was no choking or
voice change but patients needed to swallow more thanonce or spent more than 5 seconds swallowing,
subjects were suspected to have dysphagia. Subjects
who swallowed 1 time within 5 seconds without abnormal symptoms were normal (10). In this study, nodysphagia group would be included both suspected
dysphagia and normal status.
Beside the clinical tests, the following questionnaire was also used to screen dysphagia.
Eating assessment tool (Eat-10) questionnaire
Eat-10, a self-reported validated questionnaire thatassesses perception of swallowing difficulty was used
to evaluate dysphagia risk. The Eat-10 questionnaire
was translated from English into Vietnamese. There
are 10 simple questions with a total score of 40 points
and the cut-off point is 3. If total score ≥ 3 points, itmeans the patient may have problems swallowing
efficiently and safely (13).

METHODS
Settings and Sample
The study was designed as a cross-sectional study
and was conducted for 6 months from August 2018
through January 2019. This research received
permission from Hanoi Medical University’s ethicalcommittee, number 1318. The study population consisted of elderly inpatients being treated in three large
general hospitals in Vietnam, Hanoi Medical University Hospital (500 beds), Dong Da General Hospital(800 beds) and National Geriatric Hospital (500 beds).
Subjects were recruited for the study from all
newly admitted patients, i.e., patients in the first 48
hours after admission, by random selection (using arandom number table) from admission registers.
The sample size was 1000 subjects who met theinclusion criteria: (a) hospitalized elderly in the three
above hospitals, (b) age 65 or over. The exclusion
criteria included: (a) refusal to participate in this study,(b) mute, deaf or psychosis and (c) suffering fromventilator, coma, dementia, trauma or injury. All
potential subjects completed questionnaires and werescreened using swallowing tests.

RESULTSThis selection process resulted in a total of 1007
elderly inpatients (420 males and 587 females, meanage 75.5 years). Dysphagia was observed in 62 males(6.2%), 104 females (10.3%) and a combination of 166
males and females (16.5%) out of 1007 elderly inpatients. The no dysphagia group was about 83.5% of thetotal.
Figure 1 shows that with regard to age, the highest
prevalence of dysphagia was seen in 83-91 year-old
males (25%) and in 92-100 year-old females (40%),and the lowest prevalence dysphagia was observed in
65-73 year-olds, both males and females, with thesame rate of 12%.
According to disease analysis, by clinical test, thepatients with neurologic disorders (stroke, Parkinson’s,etc.), esophageal disorders (dysfunction esophageal,
gastroesophageal reflex, etc.) and respiratory & latrogenic disorders (tracheal surgery, artificial airway,etc.) had high dysphagia incidence (40%, 45/113),(51%, 32/63) and (29%, 19/65), respectively. By theEat-10 questionnaires, neurologic disorders, esophagieal disorders and respiratory & latrogenic disorder also
had high dysphagia incidence at 50%, 75%, 46%,
respectively.
Figure 2 shows the distribution of Eat-10 scores.
There were 248 subjects (24.6%) who had an Eat-10
score ≥3, which means that they have problems
swallowing.
Figure 3 indicates the dysphagia status by clinicaltest and Eat-10 score. The dysphagia patients screened
by clinical test (94%) almost all had an Eat-10 score≥3 points and no dysphagia patients (89%) had Eat-10
score<3 points.
Figure 4 shows the sitting position to screen
dysphagia and dysphagia status of elderly inpatients.
The rate of not sitting in the dysphagia group (33%,
54/166) was higher than in the no dysphagia group(3%, 29/841).

Data collection
All the questionnaires were filled out by investigators. The investigators were dietitians who weretrained to collect study data. Before carrying out theactual study, we conducted a pilot study on 50 patientsto revise the instruments.
Below is the information that we obtained.
Demographic data
The data were collected from medical records,
caregivers and subjects.
Repetitive saliva swallowing test (RSST)
Patients were asked to swallow their own saliva as
many times as possible in 30 seconds; the examiner
determined the absence of laryngeal elevation during
swallow by observing and/or feeling laryngeal movement. If a patient was unable to perform threeconsecutive swallows with two retests, he/she sufferedfrom dysphagia. If a patient was able to swallow 349

Asian Journal of Dietetics 201992-100 (n=5)

92-100 (n=15)0%83-91 (n=75)

83-91 (n=107)25%

74-82 (n=144)

14%

74-82 (n=201)65-73 (n=196)

12%65-73 (n=264)

0%

40%
25%
19%
12%
0%

10% 20% 30% 40% 50%

20%

40%

60%

Figure 1. Prevalence of dysphagia by age in males (left) and females (right)
Table 1: Dysphagia status by clinical test (RSST & WST) and Eat-10 questionnaires in elderly inpatients
according to function analysis.
Neurologic

Esophageal

Respiratory &Otherdisordersdisorderslatrogenic disorder(n=766)(n=113)(n=63)(n=65)

Dysphagia status

Dysphagia

45 (40%)32 (51%)19 (29%)70(9%)

Eat-10≥3 score57( 50%)47 (75%)30 (46%)114 (15%)400

Clinical test

Cutoff: 3 points
332

200

≥3 points: 248<3 points: 759

100

4848
37
1815

Eat-10<3
NO DYSPHAGIA(RSST&WST)…
DYSPHAGIA
6%(RSST&WST)…

Mean±SD=2.6±4.9

126

9 9 6 4 2 3 3 4 3 3 4 7 3

2 2 4 1 4 2 1 2 2

1

1

Eat-10≥3
89%

11%

94%

0

Frequency

300

301

0

10

20
Eat-10 scores

30

40

Figure 2: Distribution of Eat-10 scores

Figure 3: Dysphagia status by clinical test
(RSST&WST) and Eat-10 score.

Not sitting
N O D Y S P H A G I A …3%
DYSPHAGIA…

Sitting
97%

33%

67%

Figure 4: Sitting position to screen dysphagia and dysphagia status of elderly inpatient50

Dysphagia Prevalence in Vietnamese Elderly InpatientsDISCUSSION
Dysphagia is a common issue in elderly
populations. World-wide, there are several swallowing
tests to screen for dysphagia. In hospitals, VF and VE
are used widely to assess dysphagia (7). However, they
are expensive and require specialized techniques sosimple swallow screening tests should be implemented
first to detect abnormal cases before using complicatedequipment. In Vietnam, dysphagia screening has notbeen a major concern. Even simple screening tests
have not been implemented as standard procedure forall patients at risk of dysphagia such as the elderly,
stroke victims, Parkinson’s disease, dementia patients,
etc.
There have been studies about simple tests such as
RSST, WST and Eat-10 questionnaires that were used
to screen for dysphagia. RSST and WST wereindicated as a useful simple task-screening tool todetect dysphagia and they have high sensitivity,
specifically as a predictor of aspiration (p<0.05)
compared with VF (7, 11). And the Eat-10 questionnaire also was a reliable dysphagia screening tool (10).
Thus, in this study, we used the simple tests to screen
for dysphagia on more than one thousand elderly
patients. Based on these results, we observed that theresults of the Eat-10 questionnaires have a rate ofdysphagia higher than the clinical tests because thequestionnaires would ask about a range of time, butdysphagia symptoms may not be present when theclinical tests are conducted.
We found that the prevalence of dysphagia was
16.5% (166/1007) by RSST and WST and 24.6% by
the Eat-10 questionnaire. These results were similar to
those reported by Okamoto et al (15.1%) by using
WST and Kawashima et al (13.8%) from questionnaires on community-dwelling individuals aged 65
and older in one prefecture in Japan (14, 15). This isalso similar to a dysphagia survey in general hospitals
by the Japanese National Institute of Longevity
Research (13.6%) (16) and research in the US (about15%) (12). Based on these results, we realized that therate of dysphagia in elderly Vietnamese inpatients wasquite high and similar to countries which have good
dysphagia management systems with screening,
dysphagia assessment and texture-modified food fororal intake by dysphagia patients. Through early
detection of dysphagia and dysphagia dietary
treatment, dysphagia status and quality of life can besignificantly improved (8, 9). Therefore, screening fordysphagia is necessary and needs to be implemented
widely in Vietnam not only in hospitals but also in thecommunity; the choice of a suitable screening method
further depends on the conditions in each country andarea.
The rates of dysphagia related to neurologic
disorders, esophageal disorders and respiratory &latrogenic disorders were quite high according to theclinical tests and the Eat-10 questionnaires. These
results are similar to a systematic review whichshowed that 8.1–80 % of stroke patients and 11–81 %of Parkinson’s disease patients have dysphagia (2).
This systematic review had large range rate may be
because of the difference method to screening dysphagia and epidemiology. These are patient groups with ahigh risk of dysphagia. Therefore, it is necessary to
screen for dysphagia as soon as possible in thesepatients.
In Vietnam, dietitians are formally trained and thenumber of dietitians is gradually increasing. Therefore,
by using the simple swallowing screening tools, thedietitian can actively screen patients for dysphagia andalso administer food for dysphagia. In addition,
dietitians determine diets for patients so it is moreconvenient for dietitians to detect dysphagia patients
through their eating behavior. These were the reasons
why in this study we selected dietitians to beinvestigators and they performed well.
Dysphagia is usually a concern in the elderly. In
this study, we also observed that the higher the age, thehigher the risk of dysphagia. The elderlies are likely tosuffer from sarcopenia, stroke, dementia and many
diseases which are closely related to dysphagia. In
addition, the ability of the elderly to recover is lessthan that of younger people because of reduced organfunction, so the risk of dysphagia is higher (12).
By comparing the two methods (clinical tests andEat-10 questionnaires, Fig 3), we observed that almost
dysphagia patients (94%) according to the clinicaltests had Eat-10 score ≥ 3 points. Therefore, the appropriate cut-off point is 3, as indicated by the questionnaire instructions.
With regard to the sitting position when the clinicaltests (RSST, WST) were administered, only 8%(83/1007) could not sit while they were being checked.
These patients would lie on a bed tilted 30 – 60 degrees
with head lying on a pillow tilted 30 degrees toadminister the test. About 65% (54/83) of bedridden
patients suffered from dysphagia. It is understandable that almost patients who cannot sit to swallow arein the dysphagia group because dysphagia usuallyoccurs in patients who are suffering from a neurological disorder such as paralysis from stroke. Therefore,
with bedridden patients, dysphagia detection needs tobe a concern.
Limitations of this study included limited resources, so we have been unable to undertake a study tovalidate the Vietnamese Eat-10 questionnaire; wemerely translated the English version into Vietnameseand did a pilot study to complete the questionnaire. In
any case, the content of the questionnaire is notdifficult, with items such as “Swallowing liquids takes
extra effort”, “Swallowing solids takes extra effort”
etc., with levels from (0) “no problem” to (4) “severe
problem”, so we felt that the possibility of translation
bias would be small.
In conclusion, through a combination of simple
screening tests, this study indicated the rate of dysphagia in elderly inpatients was quite high. Therefore,
early dysphagia detection is necessary to administer
dietary treatment by oral intake instead of tube feeding.
ACKNOWLEDGEMENTS
This research was supported by Jumonji University,
Japan and US-Japan Medical Science Programs. The
authors would like to thank all the participants for theircooperation and Hanoi Medical University Hospital,
Dong Da General Hospital, National Geriatric Hospital and the dietitians who provide assistance in thecollection of data in Vietnam. Finally, we also would
like to thank Andrew Durkin, Prof. Emeritus ofIndiana University, for editing our English.

1)

51

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Nishiwaki K, Tsuji T, Liu M, Hase K, Tanaka N,
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Hong DG, Yoo DH. A comparison of theswallowing function and quality of life by oral
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Andersen UT, Beck AM, Kjaersgaard A, Hansen
T, Poulsen I. Systematic review and evidence
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T, Onogi K. The Repetitive Saliva Swallowing
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Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow
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Prevalence of dysphagia among communitydwelling elderly individuals as estimated using aquestionnaire for dysphagia screening. Dysphagia. 2004;19(4):266-271.
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Published 2012. Acc-essed February 10, 2019.

52

Asian Journal of Dietetics 2019

ORIGINAL
Acceptability Evaluation by Vietnamese about Non-toxic Cultured Pufferfish
in Comparison with Grouper and Mackerel
Linh Vu Thuy1, Tuyen Le Danh3, Hien Vu Thi Thu3, Bat Nguyen Khac4, Ngoc Vuong Thi
Ho3, Nghia Nguyen Viet4, Hien Bui Thi Thu4, Fumio Shimura1, Sumiko Kamoshita1,
Yoshinari Ito2, Shigeru Yamamoto1
1

International Nutrition, Graduate School of Human Life Sciences,Jumonji University,Saitama 352-8510, Japan2
Mitsui Marine Products Inc, Miyazaki 889-0511, Japan
3
Vietnam National Institute of Nutrition, Hanoi, Vietnam
4Vietnam Marine Fisheries Research Institute, Hai Phong, Vietnam(Recived June 4,2019)
ABSTRACT Background and purpose. World-wide there are few countries in which pufferfish (fugu) is
eaten as in Japan. In Vietnam, pufferfish has been banned since it’s toxic ocurred due to lack of knowledge
about distinguish non-toxic species. Consequently, there is a huge amount of pufferfish inhabiting in
Vietnamese water, but whenever accidentally catching it, we have to throw or use as fertilizer. To develop
culinary culture of non-toxic pufferfish in Vietnam, it is very important and essential to recognize safe species
and culture them in good condition, then apply proper method to process that become safety foods. In order
to initial setting up for such purpose, we carried out a sensory study in Vietnamese to test whether they canaccept foods made from fugu by method of Japanese. Methods. We compared the sensory reaction to Japanesecultured Takifugu rubripes and fish from Vietnamese waters: grouper and mackerel. The 107 panelists wereVietnamese volunteers working in the field of nutrition, employees of marine companies, or government
officials who could influence the relevant laws. Each panelist tried 10 dishes which were prepared by chefs
holding a Japanese fugu license. After eating, they were asked to fill out the sensory questionnaire, used afive-point scoring method, with 5 as the highest score, and reaction rating questionnaire. Results. The averagescore for the various puffer dishes was 4.40 in the good rank flavor was rated best. For questions such as"would you like to eat more Fugu, do you want to introduce it to others, do you want fugu to become a new
food culture?", Over 90% of the panels answered "Yes". Conclusion. Fugu‘s acceptable flavor was confirmedfor Vietnamese when it was prepared properly by fugu-licensed Japanese chefs.
Key words: pufferfish, fugu-licensed, sensory test, food culture, takifugu rubripes, Vietnam, JapanINTRODUCTION
Worldwide, only Japan is well known for a special
pufferfish (fugu) food culture. Japanese Ministry of Healthand Welfare enacted a guideline of edible species, in that
only 22 species of fugu are allowed, and only the people
who has fugu license can cook (1–3). Marine fugu are
believed to accumulate tetrodotoxin (TTX) but non-toxic
fugu can be produced if they are raised with TTX-freediets in net cages at sea or aquaria on land, where theinvasion of TTX-bearing organisms is completely shut off(4). By cultured fugu, some studies showed that it wasdelicious and rich in nutrients (5,6). Fugu is high class fishand expensive in Japan and now Japanese are trying toimport fugu from the other countries such as China or
Korea.
There are more than 350 species of fugu (7), andaccording to a report by the Research Institute for Marine
Fisheries, Vietnam has about 60 species, resources areover 37,000 tons (8, 9). There are hundreds of foodpoisoning related to toxic fugu per years (10) so that the
Ministry of Fisheries (now the Ministry of Agriculture andRural Development) has implemented a ban on fugu since2003 (11). In order to lift the law which prohibits theharvesting and using Vietnamese fugu, it is necessary to*To whom correspondence should be addressed
Email: vuthuylinh.1964@gmail.com

53

carry out a toxicity test and clarify the type and partsof fugu which can be eaten. Even if a toxicity test,
which is difficult, is carried out, the effort would bepointless unless fugu is accepted as a part of foodculture by Vietnamese people. Therefore, first of all, in
this research, a sensory tests were carried out withvarious dishes of Japan cultured tiger fugu (takifugu
rubripes) that was confirmed to be safe and got
permission of Vietnam government.
METHODS
Study design: We evaluated Japanese fugu dishes
and Vietnamese luxury fish dishes of mackerel andgrouper, by using a sensory test two times in June andDecember of 2017. The first study was conducted at theVietnam National Institute of Nutrition in Hanoi and thesecond study at a hotel in Da Nang city. After trying
each dish, the panel were asked to score their reaction
on the response sheets. We used 5 point scale(extremely good:5, good:4, neither good or bad:3,
bad:2, extremely bad:1) to evaluate the flavor of eachdish at 3 items: overall taste, aroma and texture. The
panel were free to eat all dishes randomly and inunrestricted quantities. After that, panelists were asked
to fill in the questionnaire of sensory test (Table 1).

Acceptability cultured pufferfish by Vietnamese

Ethical committee and customs clearance
permission of Japanese fugu: Currently the use of
puffer fish is banned in Vietnam so that the safety has
not been guaranteed. Therefore, we can not use
Vietnamese puffer fish in this study. To conducting
research in addition to ethical permission, it was often
necessary to get approval from the Vietnamese
Ministry of Health. Japanese cultured puffer fish is ahigh-class fish, which was tested safety in Japan andpassed the customs clearance, so it was allowed tobring into Vietnam.
Materials Preparation: Cultured Takifugu
rubripes for the study were purchased at an
aquaculture company in Japan and viscera were
removed and then the fish was kept in a freezer under−20°C. The Fugu was delivered from Miyazaki,
Japan to Hanoi and Da Nang, Vietnam by air. We used
cold gel and dry ice to keep the fish under −20°C
during shipping. In Vietnam, the fugu was kept in afreezer under −20°C. One day prior to the experiment,
both mackerel and grouper were purchased at amarket in Vietnam, viscera were removed and the fish
were kept in refrigerators under 4°C. The frozen fugu
was moved to a refrigerator and defrosted at about
4°C in more than 10 hours. Other materials werechosen and prepared under the control of Japanese
fugu cooking license holders (Picture1). We used thesame recipe for fugu, mackerel and grouper in the
hotpot dish and Japanese style fried dish to make thecomparison among them.
Prior to the main study, in a pilot study (n=10),
various Japanese Fugu recipes (2) were evaluated.
Based on that pilot, the menu items for the main study
were determined: Japanese style fried dish, hot pot,sashimi (dishes with raw fish), hirezake (Japanesesake with grilled Fugu fin in it), nikogori (a kind ofjelly made from fugu skin), skin mix (boiled fugu skin

was sliced and mixed with chili, miso, and vinegar),tataki (fish grilled on the outside and kept raw inside),and shirako tofu (a kind of mousse made with fugu
milt) (Picture 2). Total the amount of fugu for 1
serving set of sensory test with 8 fugu dishes was
400g (50g per dish × 8 dishes = 400g) so at least 42.8
kg needed to be cooked. In case something happen webrought about 90kg of frozen Japanese fugu to
Vietnam. By same way, we calculate the amount ofgrouper and mackerel which were used for taste test.
All the dishes were made as close as the time of thetest at lunch time that why most of work had to bedone since previous night.
Panel selection: To evaluate Vietnamese
acceptance of Fugu dishes and to lift the law banningfugu in Vietnam in future, all 107 panelists wereVietnamese who may have influence on the law
concerning fugu. In addition, they had experience
with the sensory evaluation of food, especially fish,particularly the staff of National Institute of Nutrition,
the Research Institute for Marine Fisheries and thegovernment officials. They were adults, in good
health, had no allergies to any materials used in thistest, were not anomic, were not ageusic, had normal
colour vison and able to detect anomalies in theappearance of fish and fish food in a consistentmanner, and were able to rely on sensory perceptions
and to report them appropriately. The panel wereasked to avoid eating or drinking too much the day
before the experiment, to get enough sleep, and to eat
their usual breakfast on the day of the experiment.
Informed consent was obtained from participants. We
requested participants to report any adverse reactions
during and after eating the food items.
Statistical Analysis: Data were statisticallyanalyzed by Student t-test, and Tukey test, p < 0.05
was significant different.

Picture 2-1. Fugu sashimi

Picture 2-3.
Japanese style fried fugu
Picture 1. Fugu preparation by Japanese

Picture 2-2. Fugu tataki

Picture 2-4. Left:
Nikogori; middle: Skinmix; right: Shirako tofu

fugu cooking license holders

Picture 2. Fugu dishes for Sensory test

54

Asian Journal of Dietetics 2019

Table 1. Questionnaire of sensory test
RESULTS
The sensory evaluation panelists (age 28 - 38)
consisted of 61 males and 46 females, more than 80%
of panel liked the fish dishes, mackerel or grouper
dishes (Table 2)
Table 2. Characteristics of Panelists
Panelistsn%
Like fish dishes
98
92
Like mackerel dishes
93
87
Like grouper dishes
103
96

Figure 1 showed the results of Japanese style fried
dish, the overall taste of these three fish showedsignificant difference (p<0.05). When compared togrouper, the texture of fugu was the same, aroma waslittle lower but still in the good rank flavor was rated
best; the overall taste of both was very good and evenin the hotpot dish the score for fugu was higher inoverall taste.
Figure 2 shows the hot pot dish, overall taste ofthese three fish was significantly different (p<0.05)
and fugu got the highest score; texture of fugu
compared to grouper or mackerel had a significant
difference. In comparison with mackerel, fugu was55Acceptability cultured pufferfish by Vietnamese

more delicious, with no fish smell as with mackerelin the hotpot dish, and texture was the same in thefried dish and better in the hotpot dish. In flavor, fugu
was not only good but also better than these 2 luxury
fish.
Table 3 showed the sensory evaluation of the 8
fugu dishes, in average point, the overall taste washigher than 4.42, the texture was higher than 3.84, thearoma was higher than 4.49. All of the points were at
the good rank. The overall taste of sashimi was 4.82 the highest score.
Figure 3 showed how the panelists accept fugu
dishes; more than 92% of the panel wanted to eat
them again and would recommend them to otherpeople, 89% panel thought that fugu could become a
new food in Vietnam.

Table 3. Average score of sensory evaluation of 8 fugu dishes
Fugu

Hirezake

Fugu hot

Fugu

pot

fried

4.50±0.64

4.48±0.66

4.56±0.62

4.56±0.62

4.41±0.71

4.59±0.50

4.50±0.57

3.84±0.96

4.48±0.54

4.48±0.54

4.44±0.57

4.48±0.57

4.28±0.60

4.82±0.39

4.64±0.48

4.64±0.48

4.56±0.57

4.53±0.54

sashimiSkin mix

Nikogori

ShirakoTatakitofu

Overall4.82±0.39

4.42±0.69

taste
Texture4.46±0.54

Aroma
4.49±0.54
Values are mean ±SD

4.49±0.67

100

93

93

93

92

89

Q1

Q2

Q3

Q4

Q5

80
60
40
20
0
Figure 3. Percent of panelist answered “Yes” about questions on acceptance of Fugu dishes (%)

56

Asian Journal of Dietetics 2019DISCUSSIONIn Vietnam, the Government strictly prohibits
processing, trading, and using of pufferfish; therefore,
nobody knows the flavor of fugu dishes. However,with this sensory test, more than 90% of the panelists
scored fugu dishes as high or best flavor, 80% said
they would like to eat fugu again and hoped it would
become a new food culture in Vietnam.
Eating and cooking Vietnamese fugu is illegal in
Vietnam; therefore, when conducting this research weused Japanese fugu which was confirmed as safe inJapan. Every time when we did study we needed thepermission of Vietnam government; all cooking
period was under the control of National ResearchInstitutes.
On the other hand, only Japan has a law for fugu
culture as well as a fugu chef license system, that why
this study followed Japanese cooking methods and all
dishes were cooked by professional fugu chefs.
Grouper and mackerel are two of the mostesteemed fish in Vietnam, considered to be excellent
in overall taste, aroma, and texture. Three fish arewhite meat fish, the texture of these are considered assimilar. Vietnamese usually use the muscle of fish tocook some dishes, such as: hot pot, fried; to compare
among 3 kind of fishes we chose these 2 dishes only.
In this study, we invited 107 adults from Hanoi and
Da Nang, the number of the panelists were sufficientfor this study. According to “Sensory evaluation –guide of food practice”, at ranking test the minimum
size of panel participating in the test was 12 (12).
According to the guideline number JIS Z 9080:2004
of Japan Industrial Standards Committee about
sensory evaluation, in ranking test them minimum
sample size are 7 if they are professional, 20 if they
have experiences, 30 if they have no experience (13).
Moreover as similar previous studies about sensory ofsushi or food from liver of Japanese cultured fugu (14,15) in this study we tried to collect more than 50 panel
per test.
There are many method to evaluate sensory, forexample hedonic scaling - 9 point scale, magnitude
estimation, category-ratio scales (16) and 5 point
scale. Each method has its own feature. We used the
5 point scale which suitable with the untrained panel
and situation of this study as shown in similar studies(5, 6, 17).
In Vietnamese food culture state, most traditional
dishes are cooked well. Recently, food safety is amajor problem in Vietnam; every year there are 250500 cases of food poisoning: 7,000-10,000 victims
and 100-200 deaths, 33-49% from microorganisms(18–20). Vietnamese do not eat raw food much,especially raw fish. Fish intake in Vietnam in 2010
was only 59g (15.8% of protein intake) (21) lower
than in Japan: 73g (20.7% of protein intake) (22). Fishin Vietnam is a luxury item and many times more
expensive than meat or eggs. This may be the reason
for low fish intake. In this study, the Japanese fugu
dishes were very highly evaluated and appreciated by
Vietnamese panel. Furthermore fugu has no smallbones, usually has no fishy smell, is delicious and iseasy for even the elderly or children to consume.
In particular, sashimi got the highest evaluationeven though Vietnamese are not familiar with raw

fish; in future we hope that fugu will become a part ofVietnamese food culture, and by Japanese experien ces and cooking methods, Vietnamese can develop
the new fish food culture.
The study results also helped the government andNational Research Institutes acknowledge that “it waspossible to make delicious and safe Vietnamese fugu
food, moreover it could become a popular foodculture in Vietnam”. As a result, the National
Research Institutes will send the government
proposals for promptly legalizing safe fugu andpropagating Japanese fugu culture in Vietnam.
Previous study showed that Fugu consume
tetrodotoxin (Ttxs) holdings organisms finallybecome toxic fish. If fugu are prevented from Ttxs
holdings organisms, fugu will be nontoxic (≦10MU)(1, 3, 23). Japan have developed technique tocultivate nontoxic Fugu (5, 6) and strictly manage ment fugu food safety system. These should beestablished in Vietnam in parallel with fugu new foodculture.
In the future, we will analyze toxic in tissue andclarify the types of puffer in Vietnam can be used as
food. From those results, safe species of fugu could
be chosen to expand the new food culture in Vietnam.
We hope these will not only be a new food but will
also play a part in “international humanity andcultural understanding”, “economic development”,“the knowledge society, “technology knowledge” and“practicing globalization”.
ACKNOWLEGEMENTS
The author would like to thank all panelists
participated in the study, and deeply thanks toProfessor Andrew Durkin of Indiana University forhis help in editing the English.
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July 13, 2017]10) Le THM, Tran VD. 2014. Status of exploitation,utilization and preventive measures of somevenomous spine fish species in Nha Trang Khanh Hoa. Japanese Journal of fishery Scienceand Technology 1:52–56.
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fish poisoning. [Online] Available: https://thu
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7)58

Asian Journal of Dietetics 2019

ORIGINAL
Medical History of Infancy, Weaning Foods and Nutrient Intake of IndianType 1 Diabetic Children aged 2 to 18 years
Jagmeet Madan1, Sheryl Salis2, Neha Sanwalka3, Kilpa Kacheria, Himani Kabrawala, Namrata Manyal
1

Sir Vithaldas Thackersey College of Home Science (Autonomous), SNDT Women’s University,
Mumbai, India.
2
Nurture Health Solutions, Mumbai
3
NutriCanvas, Mumbai(received June 1, 2019)

ABSTRACT Background and purpose: Worldwide prevalence of Type 1 Diabetes in children has
been increasing. Various environmental factors have been identified as triggering agents in thedevelopment of Type 1 Diabetes. The current study assesses the medical history, weaning practices
during infancy and present nutrient intake of type-1-diabetic children. Method: A cross section study
was conducted on 126 children (63 Type-1-diabetic-mellitus) aged 2-18 years. Anthropometry,symptoms at diagnosis, insulin prescribed, medical history during infancy, food intake during weaningand present food intake of children was assessed using pretested standardized tool and techniques.
Results: More diabetic children were classified as being underweight as compared to non-diabetic
children. Common symptoms observed in diabetic children at time of diagnosis were polyuria,
unexplained weight loss, tiredness, nocturia and excessive hunger. Significantly higher percentage ofdiabetic children had received antibiotics and had suffered from jaundice, mumps and hand-mouthdisease during infancy (p<0.05). Significantly higher percentage of non-diabetic children were given
cereals, pulses and fruits during weaning foods (p<0.05). Percentage recommended intake in boys
(girls) for energy was 59.1±2.8% (57.3±2.5%) and for protein was 84.8±3.4% (79.5±3.4%). In bothboys and girls aged 10 to 12 years and more than 13 years, diabetics had significantly higher nutrient
intake as compared to non-diabetics. Conclusion: The present study highlights the correlation ofincreased morbidity and weaning practices during infancy with the precipitation of Type 1 Diabetes
in later age. A compromised nutrient adequacy was also observed in the present intake in both Type 1
diabetic and non-diabetic children.
Keywords: Type 1 diabetes, nutritional status, weaning, infections during infancy, diet, medical
history.
INTRODUCTION
Type 1 Diabetes is a lifelong heterogeneous metabolic
disorder, caused by immune-mediated destruction of β cellsof the pancreas leading to insulin deficiency in geneticallysusceptible individuals. Type 1 diabetes is the most common
chronic endocrine disorder in childhood (1). Worldwide
prevalence of Type 1 Diabetes in children has been
increasing and it represents a rising global health burden (2).
In the last few decades, there has been an overall incrementin the incidence of Type 1 diabetes by 3-5% per year and an
estimated 65,000 new cases are reported in children <15years per year (2,3). As of 2014, an estimated 387 million
people had diabetes of which Type 1 Diabetes accounts for
5-10% (4). Type 1 Diabetes contributes to ≥85 % of all
diabetes cases in youth <20years
1of age worldwide. Onset of occurrence peaks between 1014 years of age and declines after puberty, appearing tostabilize in adulthood (15-29 years) (4).
Given to the rapid rise in the last two decades it may
be said that genetic susceptibility may not be the solecontributing factor, but it may be caused largely due tochanges in lifestyle and diet. The underlying autoimmunity
in genetically susceptible individuals is triggered byenvironmental factors. This indicates significance ofinteractions between environmental factors and genetic
factors in the multi-factorial etiological components ofType 1 diabetes. Only 10% -15 % newly diagnosed cases
report a positive family history (2,5-6).

To whom correspondence should be addressed. Email: dr.jagmeetmadan@gmail.com

59

Nutritional Status of Type 1 Diabetics

Environmental factors potentiate and triggers of β cell
destruction either by directly affecting β cells or by
aggravating abnormal immune responses to proteinsnormally expressed in the cells (7). This destruction
ultimately leads to absolute insulin deficiency.
Environmental factors involved in the destruction include
nutritional factors, exposure to Vitamin D, viral infections,gut microflora, socio-economic condition, exposure to
antibiotics, pollutants, perinatal and fetal influences andpsychosocial stress. The factors may act directly on thepancreas, or provoke abnormal immune responses to proteinsnormally expressed in the cells (4-10).
Amongst nutritional factors, an early exposure to cow’s
milk or formula milk and a short breastfeeding period has
been associated with increased risk of Type 1 Diabetes inecological and analytical epidemiological studies. Besides
this, nutritional inadequacy also leads to compromised
immunity giving rise to opportunistic infections and thus
resulting in an immune mediated destruction of β cell (8).
Viruses such as enteroviruses, mumps, rubella,cytomegalovirus, rotavirus have long been implicated in thepathogenesis of Type 1 diabetes. These viruses may either
trigger an autoimmune reaction gradually causing destructionof β cell mass or may have a direct cytolytic effect (7,8).
The emerging global epidemic of Type 1 diabetes makes
it crucial to identify relevant triggering factors and generate
optimum awareness programs to prevent it from rising further.
Thus, the aim of this study was to assess the medical history,
weaning practices during infancy and present nutrient intake
of type-1-diabetic children.

stretchable tape. Body mass index (BMI) was calculated by
dividing weight in kg by height in squared meter. Weight,
height and BMI for ae Z-scores were calculated incomparison to Indian reference curves (11).
Diabetes related data:
A pre-structured questionnaire was used to identify thesymptoms that noticed at time of diagnosis in children.
Questions regarding the type of insulin were also inquired.
Details regarding birth:
The type of delivery for the child, details regarding
gestation period, health issues at birth and use of antibiotics
at birth were inquired using a pre-structured questionnaire.
Breastfeeding and weaning:
The pre-structured questionnaire was also used to inquiredetails regarding exclusive breastfeeding and foods usedduring weaning for children.
Nutrient intake:
Dietary intake was assessed by 24-hour recall on threerandom days of a week (2 weekdays and 1 holiday). Eachparent was asked about intake of food and beverage items by
their child at each breakfast, lunch, dinner and mid-meals,
using standard household measured (cups, spoons andchapati cut-outs) through face to face interview. The type offood consumed, recipe of each food item and amountconsumed at each meal were recorded. Daily nutrient intake
was calculated by applying the nutritive value tables of the
National Institute of Nutrition (NIN), India (12) with help of
Dietcal software (AIIMS, Delhi, India). Intake of energy,
proteins, carbohydrates and fats were calculated. Percentage
recommended dietary allowance was calculated for energy
and proteins using age and gender specific Indian reference(Table 1) (13).
Statistical methods:
Analyses were performed using SPSS software forWindows (version 16.0, 2007, SPSS Inc, Chicago, IL). Data
are presented as Mean ± SE or frequency (percentage).
Independent Sample T test was used to analyse difference inparameters between diabetics and non-diabetics. The
frequency distributions were tabulated for various parameters
by prevalence of Type 1 diabetes and were compared using
cross tabulations and chi-square test. p<0.05 was considered
to be statistically significant.

METHODS
A cross sectional study was conducted on 126 children[63 Type 1 diabetic (28 boys, 35 girls), 63 non-diabetics (26boys, 37 girls)] aged 2- 18 years. Diabetic children wererecruited from a pediatric endocrinologists clinic where as
non-diabetic children were recruited from community. A
written consent was obtained from parents of all children.
Ethics approval was obtained from institutional ethic
committee.
Anthropometry:
Weight of children was measured using an electronic
weighing scale. Height was measured by a wall mounted non-60

Asian Journal of Dietetics 2019

Table 1. Indian Recommended Dietary Allowance for Energy and Proteins (ICMR 2010)
RDA Energy (kcal/day)
Boy
Girl
1060
1060
1350
1350
1670
1670
2190
39.9
2750
54.3
3020
61.5

2-3 years
4 to 6 years
7 to 9 years
10 – 12 years
13-15 years
16 – 17 years

RESULTS
Data on 126 [63 Type 1 diabetic (28 boys, 35 girls), 63
non-diabetics (26 boys, 37 girls)] aged 2- 18 years ispresented in the current study.
Age and Anthropometry:
The mean age of boys (girls) was 10.8±0.5 years(10.8±0.5 years), height was 134±4.5 cm (136.2±1.5 cm),weight was 34.3±2.2 kg (35.1±1.6 kg), BMI was 18±0.6
kg/m2 (18±0.5 kg/m2), height for age Z-score was -0.6±0.2(-0.5±0.2), weight for age Z-score was -0.7±0.3 (-0.5±0.4)
and BMI for age Z-score was -0.1±0.3 (0.2±0.3).
Table 2 presents anthropometric characteristics ofdiabetics and non-diabetic children separately for boys andgirls. There was no significant difference in the age ofdiabetic and non-diabetic boys and girls (p>0.05) (Table 2).
Diabetic girls had significantly lesser weight and height forage Z-score as compared to non-diabetic girls (p<0.05)(Table 2). There was no significant difference in theanthropometric characteristics of diabetic boys and nondiabetic boys (p>0.05) (Table 2).
In comparison to reference Indian standards, 10 children
were stunted (height for age Z-score < -2). For age for

RDA Protein (g/day)
Boy
Girl
16.7
16.7
20.1
20.1
29.5
29.5
2010
40.4
2330
51.9
2440
55.5

weight Z-score, 16 children were undernourished(weight for age Z-score <-2), 5 children were overweight(weight for age Z-score between 2 to 3) and 1 child wasobese (weight for age Z-score < -3). For BMI for age Z-score,
7 children were undernourished (BMI for age Z-score < -2),
5 children were overweight (BMI for age Z-score between 2to 3) and 1 child was obese (BMI for age Z-score < -3).
Figure 1 gives children in various Z-score categories whenclassified as diabetics and non-diabetics. As seen in Figure
1, more diabetic children were underweight for whenclassified according to BMI for Z score whereas more nondiabetic children were underweight when classified
according to weight for Z-score (Figure 1).
Symptoms noticed at time of diagnosis
Parents of the 63 type 1 diabetic children were asked
about symptoms that they observed in their child at time ofdiagnosis (Figure 2). As seen in Figure 2, most common
symptoms observed in diabetic children at time of diagnosis
in the current study were polyuria, unexplained weight loss,
tiredness, nocturia and excessive hunger. Smaller number ofchildren reported symptoms of urinary tract infection, fever
and diabetic ketoacidosis (Figure 2).

Table 2. Age And Anthropometric characteristics of Diabetic and Non-Diabetic Boys and Girls

Diabetic(n=28)

Boys
Nondiabetic(n=26)

Diabetic(n=35)

Girls
Nondiabetic(n=37)

P
value

P
value

Age (years)

11.2±0.7

10.3±0.80.425

10.3±0.6

11.3±0.8

0.334

Height (cm)139.5±5.2

128.6±7.1

0.221

131.5±3.4140.8±3.5

0.059

Weight (kg)2

36.7±2.831.8±3.50.274

31.3±2.0

39.0±2.3

0.014

BMI (kg/m )18.0±0.7

18.0±0.90.980

17.6±0.618.3±0.7

0.428

Height for age Zscore
Weight for age Zscore
BMI for age Z-score-0.3 ±00-0.9 ±0.3

0.067-0.9±0.2

0.1±0.40.012-0.5±0.3-0.9±0.40.485-1.0±0.3

0.1±0.60.094

0.1±0.4-0.2±0.40.528-0.1±0.2

0.6±0.6

0.349

Data presented as Mean±SE61

Nutritional Status of Type 1 Diabetics

Percentage

Z-score classification
100
90
80
70
60
50
40
30
20
10
0
Diabetic

Non-Diabetic

Height For Age Z Score
Z score < -3

Diabetic

Non-Diabetic

Weight For Age Z Score

Z score -3 to -2

Z score 2- to 2

Diabetic

Non-Diabetic

BMI for Age Z Score

Z score 2 to 3

Z score > 3

Data presented as percentage
Figure 1. Z-score categories of Diabetic and Non-Diabetic Children

Symptom70

Percentage

60
46

50
40

65.1

63.5
50.8

34.9

30

20.6

25.4

20
10
0

Data presented as percentage
Figure 2. Symptoms observed by Diabetics at the time of diagnosis

62

25.4

Asian Journal of Dietetics 2019

Insulin Taken By Diabetic
80
70

67

70

57

Percentage

60
50
40
30
20

21

19

17

16

13

17 19

19

10

10

5

3

5

2

2

0
Before Breakfast
Regular

Before Lunch

Premix

Before Midevening

Rapid Acting

Long Acting

Before Dinner
NPH

Data presented in percentage
Figure 3. Insulin taken by type 1 diabetic children

history between diabetic and non-diabetic children withhigher percentage of diabetic children having suffered fromjaundice, mumps and hand-mouth disease as compared to
non-diabetic children (p<0.05) (Table 3). No significant
association was seen between pre-term birth or allergy with
the Type 1 Diabetes (p>0.05) (Table 3)
Foods consumed during infancy:
Of the 126 children, 123 (97.6%) were breastfed, 61(48.4%) were given water along with breastfeeding. For
weaning foods, 114 (90.5%) were given cereals, pulses; 106(84.1%) were given fruits, 94 (74.6%) were given milk and47 (37.3%) were given commercial supplement. Table 4
gives the foods given to baby during infancy. As seen in
Table 4, significantly higher percentage of children without
diabetes were given cereals, pulses and fruits during
weaning foods as compared to diabetic children (p<0.05).
There was no significant difference in the percentage ofchildren with or without diabetes who were breastfed, given
water with breastfeeding, given milk during weaning andgiven commercial supplement (p>0.05) (Table 4).

Insulin taken by Type 1 Diabetic Children:
Figure 3 gives the type of insulin taken by children in thecurrent study. As seen in Figure 3, the most common insulin
taken by children in current study was rapid acting insulin atbreakfast, lunch and dinner followed by long acting insulin.
A small percentage of children were prescribed regularinsulin, premix and NPH (Figure 3).
Type of delivery, medical history and Antibiotic usage inchildren:Of the 126 children, 63 (50%) were born of normaldelivery, 59 (46.8%) were born of C-section and 4 (3.2%)
were born of other types of delivery. Twelve (9.5%) children
were born pre-term, 14 (11.1%) children had allergies, 57(45.2%) were given antibiotic from birth and 64 (50.8%)
were given antibiotics from 1st – 3rd year of life. For
medical history, 14 (11.1%) had suffered from jaundice, 18(14.8%) had suffered from Mumps, 4 (3.2%) had sufferedfrom hand and mouth disease, 2 (1.6%) had suffered frommeasles, 29 (23%) had suffered from febrile illness and 32(25.4%) had suffered from other diseases. 27 (21.4%)
children had never suffered from any illness.
Table 3 gives information regarding type of delivery,
medical history and antibiotic usage in diabetic and nondiabetic children. Significantly higher percentage of diabetic
children had received antibiotic at birth and during 1st – 3rdyear of life as compared to non-diabetic children (p<0.05)(Table 3). There was a significant association of medical

Nutrient intake in children:
The nutrient intake in children was calculated andpercentage recommended dietary intake was assessed incomparison to Indian recommended values. The mean
intake in boys (girls) for energy was 1158±78 kcal/day(1091±45 kcal/day), protein was 31.1±1.6 g/day (29.5±1.463Nutritional Status of Type 1 Diabetics

g/day), fat was 49.0±1.7 g/day (47.8±2.0 g/day) andcarbohydrate was 137.4±9.0 g/day (128.3±7.7 g/day).
Percentage recommended intake in boys (girls) for energy
was 59.1±2.8% (57.3±2.5%) and for protein was 84.8±3.4%(79.5±3.4%).
Table 5a and 5b gives nutrient intake and percentage
recommended intake in diabetic and non-diabetic boys andgirls respectively. There was no significant difference innutrient intake of diabetic and non-diabetic boys and girls
age less than 6 years and 7 to 9 years (p>0.05) (Table 5a and5b). In boys aged 10 to 12 years, protein, fat and percentage
recommended protein intake was significantly higher indiabetics as compared to non-diabetics (p<0.05) (Table 5a).
In boys aged more than 13 years, protein, carbohydrate andpercentage recommended protein intake was significantly
higher in diabetics as compared to non-diabetics (p<0.05)(Table 5a). In girls aged 10 to 12 years, energy andcarbohydrate intake was significantly higher in diabetics ascompared to non-diabetics (p<0.05) (Table 5b). In girls aged
more than 13 years, energy, protein, carbohydrates andpercentage recommended energy and protein was
significantly higher in diabetics as compared to nondiabetics p<0.05) (Table 5b).

Table 3. Type of Delivery, Medical History and Antibiotic Usage in Diabetic and Non-Diabetic Children

Type of delivery
Normal delivery
C-section delivery
Other type
Medical history at birthPreterm birthAllergy
Antibiotics from birth
Antibiotics 1st - 3rd year of life
Medical history during infancy
Jaundice
Mumps
Hand and mouth disease
MeaslesFebrile illness
Any other
No disease

Diabetics(n=63)

Non-diabetic(n=63)

Chi square
value

P
value

27 (42.9)
34 (54)2 (3.2)36 (57.1)
25 (39.7)
2 (3.2)

2.659

0.26

5 (7.9)4 (6.3)39 (61.9)
38 (60.3)

7 (11.1)
10 (15.9)
18 (28.6)
26 (41.3)

0.368
2.893
14.10
4.573

0.544
0.089
0.001
0.032

9 (14.3)
15 (23.8)
3 (4.8)1 (1.6)13 (20.6)
9 (14.3)
13 (20.6)

5 (7.9)3 (4.8)1 (1.6)
1 (1.6)16 (25.4)
23 (36.5)
16 (22.2)

16.60

0.011

Chi square
value
0.341
0.032
9.211
5.895
15.20
0.670
0.305

P value

Data presented as frequency (%)

Table 4. Food consumed by Diabetic and Non-Diabetic Children during Infancy
Diabetics(n=63)
61 (96.8)
31 (49.2)
52 (82.5)
53 (84.1)
45 (71.4)
45 (71.4)
22 (34.9)

Breastfed
Water given along with breastfeeding
Cereals given during weaning
Pulses given during weaning
Fruits given during weaning
Milk given during weaning
Commercial supplement given during weaning
Data presented by frequency (percentage)

64

Non-diabetic(n=63)
62 (98.4)
30 (47.6)
62 (98.4)
61 (96.8)
61 (96.8)
49 (77.8)
25 (39.7)

0.559
0.859
0.002
0.015
0.001
0.413
0.581

Asian Journal of Dietetics 2019

Table 5a. Nutrient intake in boys with or without Type 1 Diabetes
Up to 6 years
Diabetic

Non -7 to 9 years
Diabetic

diabetic

Non -10 to 12 years
Diabetic

diabetic

Non –More than 13 years
Diabetic

diabeticNon –diabetic

Energy (kcal/day)

903± 180994± 1291272± 132

1099± 155

1314± 991028± 139

1363± 1211110± 79

Protein (g/day)

21.2± 2.2

20.2± 2.725.4± 2.526.2± 3.443.8± 2.624.3± 1.6*45.3± 3.4

30± 2.6*

Fat (g/day)

48.8± 5.7

46.5± 5.644.8± 7.945.4± 3.955.8± 2.644.3± 3.4*49.5± 3.554.3± 6.4

Carbohydrates

95.0± 46.1

123.6± 20.3

191.8± 19.6

144.2± 35.6

144.4± 18.5

121.1± 23.5

159.4± 17.7

104.2± 12.5*

RDA Energy (%)

66.9± 13.4

81.1± 12.075.3± 7.861.9± 6.959.7± 3.6

51.6± 7.0

49.5± 4.1

40.7± 3.0

RDA Protein (%)

105.3± 11

107± 11.6

86± 8.382.9± 5.7

104.8± 8.2

67.2± 6.2*

80.3± 6.4

55.9± 5.0*

(g/day)*p<0.05 for comparison between diabetic and non-diabetics. Data presented as Mean±SE

Table 5b. Nutrient Intake in Girls with or without Type 1 Diabetes
Up to 6 years
Diabetic

Non -7 to 9 years
Diabetic

diabetic

Non -10 to 12 years
Diabetic

diabetic

Non –More than 13 years
Diabetic

diabeticNon –diabetic

Energy (kcal/day)

971± 94892± 921050± 142930± 321467± 1131071± 139*1329± 126931± 76*

Protein (g/day)

19.5± 1.517.3± 1726.5± 1.525.0± 1.843.9± 3.2

35.3± 3.839.1± 2.925.4± 2.5*

Fat (g/day)

35.6± 3.1

47.4± 4.947.0± 4.3

40.6± 0.950.8± 5.450.7± 7.3

55.9± 8.0

46.5± 4.0

Carbohydrates

141.6± 2299.1± 19.8

130.3± 33.3

116.1± 4.3

199.8± 17.5

108.6± 16.4*

159.3± 11.7

87.8± 9.4*

RDA Energy (%)

72.1± 8.4

66.4± 7.462.1± 8.4

55.0± 1.969.4± 5.552.4± 6.7

56.8± 5.5

39.5± 3.4*

RDA Protein (%)

92.6± 10.480.2± 7.6

89.9± 5.2

84.8± 6.0

106.7± 9.1

90.4± 8.974.9± 5.749.6± 5.4*

(g/day)*p<0.05 for comparison between diabetic and non-diabetics. Data presented as Mean±SE65

Nutritional Status of Type 1 Diabetics

DISCUSSION
In the current study we have studied the growth, medical
history at birth, weaning practices and nutrient intake ofchildren suffering from Type 1 diabetes and compared themwith non-diabetic children. Higher percentage of diabetic
children had history of viral and bacterial infections ascompared to non-diabetic children. Nutrient intake also
differed between the 2 groups.
Growth impairment is a well-known complication ofType 1 diabetes. In the ICMR registry data 16% of Type 1
Diabetics had shown growth retardation (14). Factors
affecting growth in Type 1 diabetic children include include
gender, genetic endowment, puberty, metabolic control andstatus of growth hormone, Insulin like Growth Factor (IGF)
and Insulin like Growth Factor Binding Proteins (IGFBP).
The main cause of poor height and weight gain is underinsulinization leading to low circulating levels of IGF-1 and
IGFBP-3 and high circulating levels of IGFBP-1. Poor
glycemic control ultimately leads to delayed puberty, poorbone health and other health problems (15-16).
In a case controlled cohort study in children with an early
diagnosis of Type 1 diabetes (<3 months), HbA1C was
related to growth alteration during the first year of followup irrespective of other factors (17). In another study,
children with Type 1 diabetes from 1 to 18 years of age,
30.9% were stunted, 17.7% were moderately stunted and13.2% were severely stunted and was not associated withglycemic control (16). Even study conducted in Indianchildren suffering from Type 1 diabetes, it was observed thatthe mean height for age Z score and weight for age Z score
were lower in children with diabetes as compared to controls(18). In our study, diabetic girls were significantly shorter ascompared to non-diabetic.
The classic symptoms of diabetes are polydipsia,
polyuria, polyphagia and weight loss. Levy-Marchal et al(2001) observed polyuria, weight loss and fatigue as themost commonly observed symptoms (19). Other typicalsymptoms for children at diagnosis include metabolic
deterioration to diabetic ketoacidosis, presented with nausea,
vomiting and lethargy (20). Similar symptoms wereobserved in children in our study at the time of diagnosis.
Maternal and pregnancy factors such as age, parity,
gestational age (21). Higher percentage of diabetic children
in the current study were born via caesarean as compared to
non-diabetic children. Caesarean delivery has been
associated with the development of type 1 diabetes in theoffspring. Caesarean delivery may increase the risk of Type1 diabetes due to differences in gut micro biotic
compositions as compared to vaginal delivery (22-23).
Studies in mice have shown that early use of antibiotics
in life leads to changes in gut microbiota that cause anincrease the risk of developing Type 1 diabetes (24-25). Thisis also supported by literature that indicates a difference inmicrobial composition of children with and without Type 1
Diabetes (26). In the current study also, significantly higher
percentage of children suffering from Type 1 diabetes hadreceived antibiotics at birth as compared to non-diabetic
children.
Several viruses such as enterovirus, rubella, mumps,
rotavirus and cytomegalovirus have been associated withType 1 diabetes (7-8, 27-29). Various mechanisms havebeen linked to the development of Type 1 Diabetes which
depends on the type of virus (27,29). These involve nonimmune mediated cytolytic infection leading to β-cell lysis
or an immune mediated reaction. Mump, measles andrubella has been associated with type 1 diabetes as it wasnoted that children with mumps appear to have islet cell
antibodies (27,30). Similarly, viral and bacterial infections
were higher in diabetic children in our study. Neonatal
jaundice has been associated with a small increase in the riskof Type 1 Diabetes. Phototherapy used for its treatment
further increases the risk of developing type 1 diabetes. (3032). We found similar results. We also observed nosignificant association was found between allergy and type1 diabetes and is in line with results reported by Karavanaki
et al (33).
Early nutrition is clearly the first environmental exposure
to which infants are exposed. Dietary factors are criticalfactors that predispose or protect against Type 1 diabetes(34). Early exposure to cow’s milk, cereals, fruits, berries,
root vegetables and hydrolysed milk formula during
weaning increase the risk of development of type 1 diabetes.
(34-35). Similarly, in our study, higher percentage ofdiabetic children consumed cereals and fruits during
weaning.
Children with Type 1 Diabetes have been reported toconsume a diet that lacks in micronutrients. Their diets are
nutritionally inadequate compared to children without Type
1 Diabetes. Previous studies on dietary assessment indicatethat children with type 1 diabetes consume higher calories,
carbohydrates, refined sugars, saturated fat and protein ascompared to their counterparts and is in line with results
observed in the current study. This indicates a lack ofhealthy eating approaches and a need to implement
behaviour modification programs that promote wholesome
nutrition in children with Type 1 Diabetes. (36-38).
In conclusion, the present study highlights thecorrelation of increased morbidity and weaning practices
during infancy with the precipitation of Type 1 Diabetes inlater age. A compromised nutrient adequacy was also
observed in the present intake in both Type 1 diabetic andnon-diabetic children. There is a felt need to strengthenawareness programs for parents towards exclusive breast
feeding, correct weaning practices to prevent earlychildhood illness and predisposition to Type 1 diabetes.
.
ACKNOWLEDGEMENT
We thank the participating children and parents for beinga part of the study. We also thank all the pediatricendocrinologists who helped us with recruiting patients.
.

66

Asian Journal of Dietetics 201915) Demir K, Altıncık A, Abacı A, Büyükgebiz A, Böber E.:
Growth of Children with Type 1 Diabetes Mellitus. J Clin
Res Ped Endo. 2(2):72-77. 2012.
16) Kayirangwa A, Rutagarama F, Stafford D, McCall N.:
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MA, Rivera-Hernández AdJ, Garrido-Maga˜na E,
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AP, Pelletier B, Milani C, Ventura M, Bach JF,
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Asian Journal of Dietetics 2019

ORIGINAL
Food Wastage in Hospital among Cancer Inpatients and its Relation
with Nutrition Impact Symptoms
Norshariza Jamhuri1, Ho Chiou Yi, Betti Sharina Mohd Haniff Lai, Siti Nuraini Ahmad Samwil,
Aeininhayatey Abdullah, Zuliehaiza Kahairudin, Ng Wai Han, Neoh May Kay,
Zuwariah Abdul Rahman
Department of Dietetics and Food Services, National Cancer Institute (NCI), Putrajaya Malaysia(received July 3, 2019)
ABSTRACT The objective of the study is to determine the prevalence of food wastage amongcancer patient in NCI, Putrajaya. The association between the nutrition impact symptoms resulted
from cancer and side effects of cancer treatments with the rate of food wastage was also investigated.
This cross sectional study has been conducted from May to June 2015 involving oncology wards inwhich samples were randomly selected. Weighing method and visual estimation were used tomeasure weight of leftovers or food waste. Based on observational and weighing method, as high as
59.3% and 41.9% respectively of foods served during lunchtime to the NCI’s patient were discarded
or wasted which equalled to RM25,259.44 and RM17,847.73 respectively from total expenditure.
Based on weighing method, the most food groups being wasted by patient are vegetables, protein
main dish, and soft CHO. From visual estimation method, the most wasted food group is main
protein group, followed by vegetables group, carbohydrate group, side protein group and the dessert
group. Between these two methods, similar food group were reported as being highly wasted. There
are also a significant association between nausea, vomiting, loss of appetite and swallowing
difficulties with the rate of food wastage. These nutrition impaired symptoms experienced bypatients were important to be addressed appropriately to improve their diet intake and indirectlyreduces food wastage in hospital..
Keywords: Nutrition, cancer treatments, food wastage, Malaysia.

High food wastage always being linked to reduced
energy and protein intakes and has impact towards
malnutrition related complications (6) and indirectly
towards the prevalence of malnutrition in hospitalized
patients. Malnutrition has been identified as one of relatedcause in death of cancer patient and many studies findfrom 25-40% of acute hospital patients are malnourished(7). Standard guidelines and protocol had been developed
and practiced by dietitian, and provision of meals has
become an essential parts of patient’s treatment (8) but
somehow the incidence of malnutrition in hospitalized
patients especially in cancer patient still occur. In NCI,
Putrajaya, a pilot study had been done in June to July
2014, with n=41, where from observation, the rate of fooddiscarded by patient is 19.54% even though the score ofPatient Satisfactory Survey is more than 80%. BAPEN
2012 also shows that worrying amount of food waste
linked to hospital settings is approximately 40-45 %,coupled with a considerable level of malnutrition among
patients which is approximately 20-40% in Denmark.

INTRODUCTION
Food waste or food loss is food that is discarded orlost or uneaten (1). The causes of food waste or loss are
numerous, and occur at the stages of production,
processing, retailing and consumption (2).
In 2013, half of all food is wasted worldwide,
according to the British Institution of MechanicalEngineers (IME) (3). Loss and wastage occurs at all stagesof the food supply chain or value chain. In low-income
countries, most loss occurs during production, while indeveloped countries much food – about 100 kilograms perperson per year is wasted at the consumption stage (4).
The statistic shows that in developing and industrializedcountries had dissipated almost the same amount of food
which is 630 and 670 million tonnes respectively where
fruit, vegetables, root and tubers has the highest rate offood wastage of any food5. Global quantitative food losses
and waste per year are roughly 30% for cereals, 40-50%
for root crops, fruits and vegetables, 20% for oil seeds,
meat and dairy plus 35% for fish (5).
1

To whom correspondence should be addressed.

Email: dtshariza@nci.gov.my

69

Resting Energy Expenditure of Cancer Patients

In a study done in University hospital with 1200 sample
aiming to investigate the cause of continuing weight lost in
hospitalized patients, the study conclude that energy andprotein intake in patients were low and did not met theirrecommended intake despite the value of 2000 kcal dietprovided by hospital that should met patient’s requirement(6). The study reveals that high rates of food wastage morethan 40% is a proven evidence of low intake of dietprovided among patient resulting in energy and protein
received by patient is less than 80% of energy and protein
recommended (6). More than enough food is produced oravailable in hospitals but still for some reason not all
patients eat adequately, resulting in malnutrition and foodwaste (9). Clinical issues involving NIS like poor appetite
due to illness or medication, changes in sense of taste orsmell, swallowing difficulties, pain, textured modified dietand others issues such as long length of hospital stay had
been listed as reasons for food wastage in hospitals (10) andall these condition always occur in cancer patients due tocancer itself or the treatment which can impaired towards
patient’s nutritional status (11). Therefore, simply planningand providing adequate food is ineffective if it is not eaten
by patients regardless of whatever factors that contributed to
the lower oral intake. In addition to the nutritional
implication of the waste, there are financial concerns as well.
The main objective of this study is to determine thepercentage of food wastage in (National Cancer Institute(NCI), Putrajaya and to find if there is significant
association between nutritional impaired symptoms or side
effects such as nausea, vomiting, diarrhea, stomach
discomfort and others with incidence of food wastage in
hospitalized cancer patients.

Assistant Clerk as scheduled.
All data will be analysed using Microsoft Excel 2010
and the IBM SPSS Statistic 22.0, IBM Corp. Released 2010.
IBM Statistic for windows, version 22.0 (Armonk, NY: IBM
Corp). Descriptive statistic including range, means, median,standard deviation, interquartile range and frequency wereused to present patient’s demographic data, Class of diet andoccurrence of NIS, food wastage, One- way Anova test weredone to determine if the food wastage were affected with thedifference of diet class and Independent T-test were done topresent any significant correlation between NIS factors withthe rate of food wastage.
RESULTS
Socio-demographic of the study samples are described inTable 1. A total of 337 cancer patients were included: 184
males (54.6%) and 153 females (45.4%). The mean age is
53±13 and 172 samples were from patients in Class 3 (51%),
32.3% and 16.6% from Class 2 and Class 1 respectively.
The majority of the samples came from Malay patients (200,
59.3%), Chinese (107, 31.8%) and India (24, 7.1%)
respectively and the rest were from other ethnic such as
Sarawak Bumiputera.
As shown in Figure 1, all samples for this study werecollected representing 8 cycle menu from Menu Day 1 to
Menu Day 8 for therapeutic diet. There is no normal dietinvolve since in NCI, the high calorie high protein diet(therapeutic menu) were set as default diet for all patient
admitted to NCI. This therapeutic diet were divided
basically to several different types of menu including, spicy,
non-spicy, western, vegetarian, soft diet, mixed porridge,
minced diet and blended diet. Every type of menu consistsof carbohydrate source food, protein source food, vegetables,
fruits and water.
From observational method (semi quantitative 5-point
scale), overall, the data shows that 59.3% of meal served atlunch time to NCI patients has been discarded. Only 30% of
patients finished their lunch meal and another 10.7% had
discarded ¼ of their meal. Wastage foods were divided into
5 main categories which were carbohydrate group, main
protein group, side protein group, vegetables and desserts.
As illustrated in Figure 3, the most wasted dish was main
protein group (Dish), followed by vegetables group,
carbohydrate group (Rice/ ala carte), side protein group(soup/ side dish) and lastly the dessert group.
For second method which was weighing method, thefood item were categorised to 10 food groups. There werenormal CHO, Soft CHO, Main Protein, Side Dish Protein,
Vegetables, Drinks, Ala-Carte, Fruits, Desserts and Soup.
Results showed that the total weight of food wastage was118.69kg (41.9%) from the total meal weight provided topatients. Overall mean of food waste was 488.11± 256.61
gram. Mean of food wastage data according to the foodgroups was illustrated in Table 2.
The 3 tops list of the most food groups being wasted bypatient were vegetables (57.9%), protein main dish (55.7%),
and soft CHO (51.6%). The independent t-test was done to

MATERIALS AND METHODSThis cross sectional study has been conducted from Mei
to June 2015, during lunch time involving 337 samples from
4 different wards (7A, 7B, 8A and 8D). Sample is randomly
selected within these 4 wards and the selected food tray forthe selected sample is taken and labelled for data collection.
The food service system in NCI is a centralized plated
system with 8 days menu cycle and patient’s BOR is 40%
from 252 beds. In this study, food wastage has been definedas volume or percentage of the served food that is discarded.
There are two measurement methods that have been used:weighing and visual estimation.
Weighing methods had been used to measure weight ofleftovers or food waste by each food components or items
on each individual tray. Prior to that, few samples of
selected tray were weighed before it being served to thepatients. The average measurement is used as the baseline
weight to be compared with wastage weight.
Second method is a visual estimation. It is used bymeasuring proportion of leftovers food using semiquantitative 5-point scale (all, ¾, ½, ¼, none) (12). The
samples were taken at random date and being recorded
using a set of form designed specifically for this study andthe data collected by Assistant Catering Officers and70

Asian Journal of Dietetics 2019find if NIS occurs in cancer patients could affect the amountof food wastage. Below was the results produced fromcollected data as shown in Table 3.
Nausea, vomiting, loss of appetite (LOA) andswallowing difficulties had significant influence in foodwastage. Other symptoms such as abdominal discomfort,
vision disorders, chewing difficulties, diarrhoea and sleep
disorders were insignificant effects on food wastage amongcancer patients.

Table 1. Socio-demographic Characteristic
Characteristic
GenderFrequencies
184
153
200
107
24
6
31
79
176
50
56
109
172
9
51
162
115

Male
FemaleMalay
ChineseIndianOthers
No formal education
Primary
Secondary
Universities/ College
Class 1
Class 2
Class 3
13-21
22-40
41-59
60>

EthnicEducation Level

Ward ClassGroup Age (Years)%(54.6)(45.4)(59.3)(31.8)
(7.1)
(1.8)
(9.2)
(23.4)(52.2)(14.8)(16.6)(32.3)(51.0)(2.7)(15.1)(48.1)(34.1)

70

20
18

60

16
50

14

40

12
10

30

8

20

6
4

10
0

Day 1
No. of sample
54
%
16

2
Day 2
49
14.5

Day 3
35
10.4

Day 4
49
14.5

Day 5
59
17.5

Day 6
50
14.8

Day 7
8
2.4

Day 8
33
9.8

Figure 1. Total samples taken according to the 8 Days Menu Cycle and percentage.

71

0Resting Energy Expenditure of Cancer Patients

80.0%
19%

1%

69.3%

70.0%
60.3%

30%

60.0%

65.2%
59.4%

50.0%

42.2%

40.0%
30.0%
20.0%

39%
11%

10.0%
0.0%

All Meal Finished

1/4 Meal Not Finished

1/2 Meal Not Finished

3/4 Meal Not Finished

All Meal Not Finished

Figure 2. Distribution of food wastage by semiquantitative 5 point scale method

Figure 3. Distribution of most wasted dishTable 2. Food Wastage by Food Groups
Estimated Nutritional Value of Total Wastage
Characteristic

Mean (SD)

Energy (kcal)

Protein (Gram)

Normal CHO

89.09 (81.03)

10.49 – 221.16

0.19 – 4.08

Soft CHO

180.16 (134.12)

18.03 – 123.06

0.33 – 2.27

Main protein

67.83 (53.18)

21.98 – 181.52

2.70 – 22.29

Side dish protein

26.07 (23.68)

3.59 – 74.63

0.44 – 9.16

Vegetables

60.75 (50.79)

2.88 – 32.30

0.21 – 2.32

Fruits53.40 (69.08)

4.39 – 34.29

0.09 – 0.73

Drinks

36.53 (77.4)

NA- Plain water was provided during lunch time

Dessert38.13 (43.65)

10.71 – 158.65

0.10 – 1.55

Soup

141.34 (112.86)

34.46 – 307.58

1.22 – 10.85

Ala carte

86.14 (82.83)

5.73 – 292.32

0.15 – 7.60

* Estimation of nutrient value are calculated based on Atlas of Food Exchange & Portion Sizes; CHO=Carbohydrate72

Asian Journal of Dietetics 2019

Table 3. NIS influencing food wastage among cancer patients
Symptom
NauseaVomiting
Abdominal Discomfort
Loss of appetite
Vision Disorder
Chewing Difficulties
Swallowing Difficulties
Diarrhoea
Sleep Disorders

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

n
64
273
52
285
56
281
93
244
46
291
42
295
30
307
23
314
77
260

Mean (SD)
410.58 (283.54)
338.52 (253.44)
468.63 (269.71)
330.96 (253.58)
374.59 (247.22)
347.74 (263.29)
413.44 (278.75)
328.86 (249.89)
328.5 (291.66)
355.95 (255.6)
319.21 (250.34)
356.90 (262.01)
458.17 (294.71)
341.85 (255.12)
383.22 (318.16)
349.93 (256.26)
376.30 (271.69)
345.07 (257.22)

t statistic
2.001

P valuea
0.046*

3.57<0.001**

0.70

0.48

2.69

0.008**

-0.66

0.51

-0.88

0.38

2.35

0.019**

0.59

0.56

0.92

0.36

aIndependent t-test; *significant at 0.05; **significant at 0.01

DISCUSSION
This study showed that based on observational andweighing method, as high as 59.3% and 41.9% respectivelyof foods served during lunchtime to the NCI’s patient werediscarded or wasted which equalled to RM25,259.44 andRM17,847.73 respectively from total expenditure. All
patients in NCI, Putrajaya were given standardised
therapeutic diet of High Calorie High Protein diet to meetthe increased needs of nutrition in cancer patients. The
standard calorie and protein provided for High Calorie
High Protein Diet was 2000 kcal, 85gram protein. From
this study, it showed that estimated loss of energy andprotein value that can be provided towards cancer patientsfrom discarded food were between 401.24 kcal until 589.07
kcal (20.1 – 29.5%) and 17.4 gram until 39.9 gram (20.5 –
46.9%) of protein from the standard requirement.
The top 3 most wasted food groups from observational
method (semi quantitative 5-point scale) were proteingroup (Lauk), vegetables group and carbohydrate group(Nasi/ala carte) whereas based on weighing method,vegetables (57.9%), Protein Main Dish (55.7%), and SoftCHO (51.6%) were among the top food wasted. Between
these two methods, similar food group were reported as
being highly wasted.
There was also significant association between nausea,
vomiting, loss of appetite and swallowing difficulties withthe rate of food wastage. These nutrition impaired
symptoms experienced by patients were important to beaddressed appropriately to improve their diet intake andindirectly reduces food wastage in hospital. Foodpresentation could be improved further to enhance patients’appetite and encourage patient to eat more. Diet texture
modification is also important to assist patients withswallowing difficulties.
In NCI, all inpatients will be provided with a menu card
daily. Different menu will be provided for duration of 8days. Patients have the right to choose their own preferredmenu. However, dietitian in charge will provide suggestion
to change the menu to cater the need of patients. For
example, patients with swallowing difficulty may beprescribed with soft diet, liquid diet or blenderised diet.
These adjustments helped to improve patients’ food intake
and subsequently reduce food wastage.
Limitation of this study was whether the total foodwastage actually as stipulated. This was because there was
no way to tell that the meal provided were actuallyconsumed by the patient or not. Thus, the actual rate ofwastage could be much higher than the results attainedsince there were possibilities that patient’s meal actually
being consumed by patient’s next of kin or caregiverinstead of patient himself.
In the near future, if similar study to be conducted, asimple interview should be done on all patients involved toobtain a more accurate information regarding actual dietintake.

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Resting Energy Expenditure of Cancer Patients

5) SAVE FOOD: Global Initiative on Food Loss andWaste Reduction. Food and Agriculture Organizationof the United Nations. http://www.fao.org/savefood/resources/keyfindings/en/.Retrieved Apr 15. 2018
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CONCLUSION
Food wastage issue among hospitalized patients is aworldwide problem that needs to be addressed
appropriately. Insufficient calorie intake directly affects
nutritional status of patients and will result in malnutrition
especially if the patients stay longer in ward. Apart from
implication towards patient’s nutritional status, foodwastage also affects the hospital financially. A large sum ofmoney equivalent to the wasted foods can be used for otheraspect of patient’s care. Thus, effective measures need tobe taken to reduce total wastage. Besides nutrition impact
symptoms being part of the reason patients not finishingmeals provided, further study need to be done to identify
causes of specific food groups being wasted.
ACKNOWLEDGEMENT
We would like to thank the Director General of Health
Malaysia for his permission to publish this article.
.
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Huffington Post. Jan 10 2013.
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