ISSN2434-2688

Asian Journal of Dietetics
The official journal of Asian Federation of Dietetic Associations (AFDA)
http://jnl.calorie-smile.jp/

Editor-in-Chief : Shigeru Yamamoto (Japan DA)
Vice chief-editors:
1) Seema Puri (Indian DA)
2) Winnie Chee (Mala sia DA)
3) Zenaida F. Velasco (Philippine NDS)
4) Ch ang Leh-Chii (Tai an CDS)
5) Sunard Taechangam (Thailand DA)
Editor in each countr /area:
1)
Hong Kong
2)
India
3)
Indonesia
4)
Japan
5)
Korea
6)
Mala sia
7)
Pakistan
8)
Philippine
9)Singapore10)
Tai an11)
ThailandGordon Cheung
Jagmeet Madan
Martalena Purba
Shigeru Yamamoto
K eong Sook Yim
Winnie CheeFa a Khan
Zenaida F. Velasco
Lim Yen Peng
Leh-chii Ch ang
Tasanee Limsu an

AFDA affiliated member countr
12)Australia

Robert Hunt

Editorial Assistant: Ms. Phi Ngoc Qu en and Ms. Nguyen Thuy Anh
Journal office:Asian Nutrition and Food Culture Research Center,
Jumonji Univeristy, 2-1-28 Sugasawa, Niiza-City, Saitama 352-8510, Japan
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ISSN2434-2688 Aa J

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45-48

COVID-19 a d D e e c
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Fiber-focused Nutrition Counseling Through Nutrition Software
Improved HbA1c of Vietnamese Type 2 Diabetes Mellitus Patients
Nguyen Huong Giang, Nguyen Trong Hung, Vu Thi Thu Hien, Tran ThiNguyet
Nga, Bui Thu Hien, Ta Thi Ngoc, Le Danh Tuyen, Nguyen Dinh Phuc, Phan Huong
Duong, Hitoshi Iizuka, Sumiko Kamoshita, Shigeru Yamamoto

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D e a Refe e ce I a e Le e f P eaP
Ta Thi Ngoc, Ngo Thi Thu Hien, Nguyen Mai Phuongba Ra ge.

Dietitian and COVID-19

Current Issue: COVID-19 and Dietetics
The Indispensable Role of Dietitians in Asia during the COVID-19 Crisis
Chwang Leh-chii
Honorary President, The Asian Federation of Dietetic Association
President, The Chinese Dietetic Society (Taiwan)
4F-9, No.151, Section 5, Ming Sheng East Road, Taipei, Taiwan, 10582
Dear Editor: The coronavirus disease (COVID-19)
pandemic has rapidly spread to at least 200 countries
and territories around the world. According to the
WHO Situation Report, there were more than 3.4
million confirmed cases and 240 thousand deaths asof May 4, 2020.
We, as dietitians, must stay alert while fighting thiscoronavirus infection. Although the current morbidity
and mortality rates in Europe and North America
are higher than those in Asia, there is no room forcomplacency. Because the outbreak of COVID-19
occurred in Asia weeks ahead of its appearance onother continents, successive waves of its reoccurrence
may surface sooner in Asia than in Europe and North
America, for example.
As the pandemic spreads, countries have declaredstates of emergency. Measures have been taken tocontain the transmission of the coronavirus such as:
self-quarantine, isolation, staying at home orders,
lockdowns, social- distancing, and the closing ofbusinesses and schools. All of these measures have
impacted daily life with changes in diet and foodavailability, in many instances causing panic buying.
People have become instantly vulnerable during
this pandemic, thrust into a situation in which they
have limited preparation, limited resources, and little
to no experience. This is the time for
dietetic organizations to step forward and to provide
reliable nutrition advice to the general public and topracticing dietitians.
"Never let a good crisis go to waste". Nutritionis vital in managing any health crisis. Let's team up toshare information and tactics, which can better prepare
us as nutrition care professionals to combat theunprecedented pandemic.

Support dietitians with guidance on medical
nutrition therapy for COVID-19 patients
In the field: Health care providers and patientsalike are overwhelmed by the sudden outbreak and thesoaring number of suspected and confirmed
cases. Among the many challenges are the demand forfood services to supply the mobile hospital units whichhave been erected to accommodate the swarm ofpatients. The need for appropriate dietary
recommendations and interventions is critical.
In hospitals:
Among severely infected
hospitalized patients, there is higher morbidity andmortalityamong
themalnourished,
the immunocompromised and the elderly withcomorbidity. These patients require specialized
nutrition considerations. The dietitian is an importantmember of this treatment team.
The Handbook of COVID-19 Prevention andTreatment edited according to the clinical experiencein China, published online in ten languages, points outthat in some VID-19 patients, the intestinal
microbiological balance is broken. This may lead tosecondary infection.
In this case, probiotics
and nutrition support are important means to restore
this intestinal balance.
Recommendations proposed by both the European
Society for Clinical Nutrition and Metabolism(ESPEN) and the American Society for Parenteral andEnteral Nutrition (ASPEN) suggest nutritionassessment and nutrition intervention are essential tosustain adequate nutrition and to overcome
malnutrition for COVID-19 patients in hospitals andthose recovering at home.
Dietitians should apply the best available
evidence-based guidance and resources in practice.
Information from diversified sources, however, isoften hard to follow, as when information is written in
a foreign language. The Indian Dietetic Association(IDA) and the Thai Dietetic Association (TDA) havewebsites with user-friendly documents about safety
and protocols of medical nutrition therapy for COVID-19 patients. The TDA also sends messages to its
members through LINE, a free app, which can instantly
communicate with members on their mobile devices.
As COVID-19 is a new health issue, dietitians areencouraged to submit AJD journal papers aboutfirsthand nutrition care experiences of COVID-19
patients.

Inspire the public about proper nutrition to
support strong immune systems in order tosafeguard healthOpenly discussing topics dealing with everyday
dietetic issues is most helpful, such as: healthy mealplanning, grocery shopping tips during long-term
home stays, meal preparation, easy and affordable
recipes, proper hygiene, and safe food handling in the
kitchen and food delivery services. Specific nutrition
advice should also be readily available to theelderly, pregnant women and breastfeeding mothers,
as well as to people at risk of malnutrition and those
suffering from chronic diseases who are especiallyvulnerable to infection.

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Asian Journal of Dietetics, 2020

An Action Plan to Cope with the New Normal
To a large extent, COVID-19 has changed ourlives, regardless of our age, gender, race and culture.
Family reunions, holidays, special events andfestivals are always occasions for gatherings - but notthis year. Beginning with the lockdown of Wuhan,
China, on January 23, 2020, a day prior to Chinese
New Year’s Eve, there have been strict measures inplace to curtail the spread of the pandemic. Social
gatherings related to significant events all over theworld have been canceled or restricted, including, but
not limited to: Holi in India, Cherry Blossom Festival
in Japan, Buddha's Birthday and Songkran in Thailand,
Holy Week and Easter in the Philippines, and holymonth of Ramadan in Indonesia and Malaysia, only toname a few. There is virtually no public gathering
allowed, no travelling, no homecoming, nopilgrimage, and no mass gatherings in temples,churches, mosques, concert halls, stadiums, etc., until
further notice.
Social distancing is a new etiquette. Face masks
have become an integral piece of fashionwear and theThai "Wai" greeting has replaced handshaking andhugging. Looking to the near future, we probably willcontinue living this way until all restrictions are lifted.
Having been constrained for so long, people
everywhere desperately want to go back to a normal
way of life. How can we turn the worst of times into
the best of times? We can approach this in three ways.

With the emergence and rapid spread of COVID19, there was an urgent call in North America and inEurope for retired medical staff and new graduates tosupplement the much-needed supply of speciallytrained hospital personnel. There is an apparent andpressing need to expand nutrition care capacity andpreparedness for large-scale emergencies.
2. Apply new technology at work
The COVID-19 pandemic has seen a rapid change
in the way health care professionals communicate with
their patients.
Telehealth visits and nutrition
counseling via audio and video equipment provide asafe way to communicate and to interact with sickpatients while eliminating the risk of infection.
Applying new technology is an inevitable trend.
The widespread COVID-19 pandemic has accelerated
the application of artificial intelligence (AI) devices inhealthcare facilities. With regards to dietary services,for example, using a robot to deliver patient meals ina hospital minimizes person to person contact and thelikelihood of disease transmission.
3. Increase professional competency
The Deep Knowledge Group recently ranked
Korea, Taiwan, Singapore, Hong Kong and Japanamong the top ten countries displaying safety andtreatment efficiency related to the COVID-19
pandemic. This could be greatly attributed to thelessons drawn from precious combat experience inSingapore, Taiwan and Hong Kong with 2003 SARS,
and in Korea with 2015 MERS.
Since 2007, postgraduate and licensure programs
for all healthcare professionals in Taiwan, including
dietitians, have required classes related to infection
control. Considering the frequency and magnitude of
epidemic outbreaks and natural disasters in recent
years, it is imperative to incorporate these subjects into
curricula to educate dietitians who will be competentin dealing with crisis. No one knows how long the
pandemic will last. Hopefully, with confidence andsolidarity, no matter how long the night may be, thearrival of the morning is soon to come.

1. Be prepared with emergency relief schemes
In Asia, we often suffer from natural disasters suchas earthquakes, tsunamis, typhoons, floods, andvolcanic eruptions, which claim thousands of victims
in need of emergency feeding and nutrition care.
The Japan Dietetic Association (JDA) formed theJapan Assistance Team after the Tohoku earthquake
and tsunami occurred in 2011. Trained dietitianvolunteers are now at the ready to be dispatched for
emergency relief. Dietitians in Asia could also be
trained and organized to serve as an extra workforce
for urgent epidemic outbreaks.

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Asian Journal of Dietetics, 2020

Current Issue: COVID-19 and Dietetics

Nutrition Management in a Japanese Acute-Care Hospital during the COVID-19 Pandemic

Keiko Hirose1,2, Thao Phuong Tran1,2*, Shigeru Yamamoto2
1
Nutrition Department, Nerima Hikarigaoka
2

Hospital, Nerima City, Tokyo, Japan
Jumonji University, Niiza City, Saitama, Japan

Dear Editor:
Japan, like the rest of the world, is facing apandemic caused by the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2). Japan has
postponed the 2020 Olympics and has declared a stateof emergency beginning in April 2020 with about
fifteen thousand infected cases, about one third of themin the Tokyo area. The number of deaths as of May 3
is about 500. Many health facilities, especially acutecare hospitals, are becoming overwhelmed. Nerima
Hikarigaoka hospital is an acute-care hospital thatbelongs to the Japan Association for the Developmentof Community Medicine (JADECOM), with 342 beds
located in Nerima Ward, Tokyo. In April 2020, thehospital recorded the first fifty-two coronavirus cases,
including both medical staff members and inpatients.
The hospital had to temporarily stop receiving
outpatients and emergency patients.

situation for us. Our current experience which is sharedbelow is still being gradually improved and needs to beflexible depending on each hospital s situation. We
hope this experience will be useful for other nutrition
departments in hospitals in dealing with the pandemic.

Japanese hospitals food supply system always has
to follow the Hazard Analysis and Critical Control
Points (HACCP) system. All staff members have to be
trained to implement proper procedures. The HACCP
system helps to minimize risk when supplying food;especially in the hospital environment there are manyrisks of disease, so compliance with the HACCP
system is critical. COVID-19 is a new type of virus;
there is no vaccine or medicine as yet; and it is highly
infectious in the community, especially among elderly
people and people with poor resistance. Nerima
Hikarigaoka hospital s kitchen staff includes mainly
elderly people and unfortunately, we early detected
one case of a part-time kitchen cleaning staff member
with coronavirus; isolation was quickly implemented.
Coronavirus anxiety covered workplace is unavoidable.
In this situation, the nutrition department immediately
had to have a further solution to ensure maintenance ofa safe food supply for patients and to prevent spread of
the nosocomial infection.

Teamwork: Dietitians were also divided into two
teams to be in the hospital to work in different days,
and to implement distancing when communicating.
Meetings are conducted online. Kitchen staff also
work in shifts and teams. Changing the food supply
system will help to reduce the number of kitchen staff
members as much as possible to limit possible viraltransmission in the members.

1.

Human resources

Health check: for dietitians and kitchen workers,
besides the usual health check list, we implemented ahealth check list for symptoms of COVID-19 such as
fever, cough, headache, muscle ache, chills, smell
disturbance, vomiting in staff members and people
who live with them to be followed and reported to thehospital every day. If people have any abnormal
symptom, stopping work for inspection and tracking isrequired.

2.

HygieneAlmost all viruses (except norovirus) including
coronavirus will die at about 80 degrees Celsius. Thismeans that all hygiene activities have to reach at least
80 degrees including sanitation by alcohol, drying
tableware, steaming food, etc.
The food supply system in hospitals needs toguarantee the HACCP system. Hospitals must still
maintain the HACCP system in this pandemic.
However, because kitchen and medical staff
members may be temporarily replaced by new
emergency staff who are not familiar with ourprocedures, we posted reminders that all staff muststrictly follow procedures. Below are some examples

Japan is used to natural disasters such as
earthquakes and tsunamis, so nutrition management
manuals for these cases are available. However,
COVID-19 is new; there is no manual and it is a new------------------------------------------------------------------------------------------*Corresponding Author: tpthao95@gmail.com

45

Nutrition management during COVID-19 at a Japanese hospital
BeforeAt entrance of nutrition department

After

At food material input gate

At toilet gate

Announcement for nurses when using hot & cold serving carts to deliver meals for patientsx Dietitian s clothes
When coming to kitchen to check

When supporting cleaning in kitchen

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Asian Journal of Dietetics, 2020

x Kitchen staff s clothes
Cooking

Cleaning

Using elevator to transfer meal
to wardx In hospital ward
Divide into 3 areas: Yellow, Green and
Red areas

Food serving carts cannot be in red area
(Coronavirus patients area)x Hygiene in nutrition department andkitchenfrequently with alcohol or hot steam (at least 80
degrees)+ Always consciously wear mask and wash yourhands with the message: 1 Push 1 Action and 1
Wash 1 Action
Kitchen:+ Maintain hygiene according
to HACCP system

Nutrition department:+ Set up an alcoholic mat
before food elevator to transfer
serving cart from kitchen to ward.
This will help clean shoes ofkitchen staff and wheels ofserving carts+ Exchange room air frequently, use plastic
separator between work desks+ Clean shared things such as computer keyboard,
printer button, telephone, kettle, door knobs, floor

47

Nutrition management during COVID-19 at a Japanese hospital

3. Food supply system
Because of coronavirus anxiety, our hospital
decided to change temporarily to an outside foodsupply system. With this system, the kitchen staff canhave more time to rest and maintain psychologicalstability.
---

Change to outside food supply system:+ Commercial food stored at room temperature(Pic. 1)
+ Frozen foods can be stored for some days (Pic. 2)+ Outside food center kitchen ships to hospital
every day (Pic. 3)
Change menus: need to change the menus
according to outside food supplement companies
which have three main meal types including

Pic 1

-

Normal meal

normal meal, soft meal and mixed meal. All use
one-time plastic tableware. (Pic. 4)
Hospital top management had to agree and all
medical staff need to know these modified menus
before supplying them to patients.
Change nutrition products for enteral nutrition
from paper type to one-time bag type to reduce riskof infection for patients and nurses. (Pic. 5)
The nutrition software including food orders,doctor orders, etc. also need to be adjusted
according to new menus.
The individual menus paper need to change content(Pic. 6)

Soft meal

Mixed meal

Pic 2

Pic 4

Pic 5
Change from cooked foodto food box and use allplastic tableware
Pic 6

Pic 3
ACKNOWLEDGEMENT
The authors would like to thank to other members of
the nutrition department, medical staff and kitchen
staff who have continued to work at Nerima
Hikarigaoka Hospital during the pandemic. The
corresponding author would like to express gratitude
to Jumonji University and to the Otsuka Toshimi

Scholarship Foundation for financial support tostudy PhD program in Japan. Finally, we also would
like to thank Andrew Durkin, Prof. Emeritus ofIndiana University and Yuji Yamada, M.D., Asst. Prof.
Saitama Medical University for editing our English.

48

A ian Jo nal of Die e ic , 2020

Re ie
Effec

f he Gha a Sch l Feedi g P g amme N ie I ake,
N i i al S a a d Ed ca i
f Child e A Re ie
Edem M. A. Te e1, J liana Ya e Eno 2*

1

De a efC
i Heal h, U i e i f Gha a Medical Sch l, C llege
f Heal h Scie ce , U i e i f Gha a.
2
N g chi Me
ial I i e f Medical Re ea ch, C llege f Heal h Scie ce ,U i e i f Gha a, Leg(Recei ed Decembe 24, 2019)
ABSTRACT The Ghana School Feeding P og amme (GSFP) a ini ia ed b he
Go e nmen in 2005 o ed ce h nge and maln i ion, and inc ea e chool en olmen ,a endance and e en ion I a al o in ended o boo dome ic food p od c ion in
dep i ed comm ni ie b inc ea ing demand fo fa m p od ce o e ice he p og amme
Thi e iea ca ied o o de e mine he he he GSFP had achie ed he objec i eela ed o n i ion and ed ca ion A de k e ie of 22 pee - e ie ed p blica ion
emana ing f om die of he GSFP o e a en- ea pe iod (2010 o 2019) a nde aken
O come mea ed incl ded die a ade ac , n i ional aand ed ca ionalen olmen , e en ion and pe fo mance of child en A e men of he effec of he GSFP
on n i ional o come ho ed mi ed e l Some die epo ed imp o ed n i ional
a of p pil in GSFP chool compa ed o non-GSFP chool While nde -n i ion andanaemia emained p e alen in e e al chooli h and i ho he GSFP, he e ae idence ha he GSFP offe ed p o ec ion f om h nge fo ome child en and had a g ea eeffec on he n i ional a of child en f om poo e comm ni ie School-ba ed p og ame al a ion
die con i en l epo ed inc ea ed en olmen i h pa ial inc ea e ina endance, e en ion and p nc ali Be e a ge ing of beneficia ie , eliable f nding andcomp ehen i e app oache o add e ing he n i ional need of all chool-age child en,incl ding inc lca ion of po i i e n i ion- ela ed beha io in child en fo long- e m
impac a e ecommended Addi ionall , f hedie hich emplo ob me hodologo a e he impac of he GSFP on n i ion and ed ca ion o come a e neededKed Ghana, chool feeding p og am, n ien in ake, n i ional a
INTRODUCTION
School feeding p og am p o ide an oppo ni o
imp o e he n i ional aof child en, enco agechool en olmen , imp o e pe fo mance and mi iga ehe effec of po e globall (1,2,3,4). The in ol e
p o iding meal
ch a b eakfa , l nch o nack ochild en in chool (2). The meal a e ei he p epa ed inchool o b a cen ali ed ki chen o a igned ca e e ,of en ing ing edien ob ained f om local fa m andhe eb impac ing he local econom (1,2). O e ime,chool feeding p og am ha e been ho n o offe aeg la o ce of n ien olne able child en,b ild h man capi al and p o ide a ing of p o 10%of he ho ehold income of poo familie (1).
Acco ding o he Wo ld Food P og am (WFP), abo
0.25 USD i needed fo a meal pe child anddieha e ho n ha each US dolla in e ed in chool
feeding ield a 3-10 USD e n on he in e men
e l ing f om imp o ed heal h, ed ca ion andp od c i i (2).

The Ghana School Feeding P og am (GSFP) ae abli hed in 2005 a a ocial p o ec ion in e en iono p o ide child en in elec ed chool in dep i edcomm ni ie i h one n i io meal in a da , ing
locall g o n food and ca e e in hei locali (5,6,7).
The p og am a in i ed a pa of he go e nmen
effo o achie e he Millenni m De elopmen Goal
(MDG ) 1, 2 and 3 o ed ce po e , p o ide foodec i , inc ea e chool en olmen a ba ic le el ando p omo e gende e ali b p o iding an incen i eo a ac gi l o chool. C en l , i con ib e
di ec l o he S ainable De elopmen Goal (SDG )2, 4 and 5 hich aim a achie ing e o h nge , ali
ed ca ion and gende e ali
e pec i el , andindi ec l o goal o 1, 8 and 10 hich aim a ending
po e , p o iding decen o k and economic g o ha ell a ed cing ine ali ie (8) The p og am begana pa of he Comp ehen i e Af ican Ag ic l al
De elopmen P og am (CAADP) i h ini ial pilo
ca ied o in en 10 ba ic chool , mainl p ima
and kinde ga en, in he mo dep i ed a ea of heco n (6). The GSFP a e ended o co e 1695
p blic chool i h 656,624 p pil na ion- ide b heend of 2009 and co o e US$200 million fo 4 ea
(7). B 2015, he p og am had eached a o al of
1,728,681 p pil (6).

* Co e ponding A ho : j a e @gmail.com

49

School feeding p og am and n
The GSFP a ini iall implemen ed b he
Mini
of Local Go e nmen
and R alDe elopmen (MLGRD) n il 2015 hen o e igh
e pon ibili fo he p og amme a an fe ed o he
Mini
of Gende , Child en and Social P o ec ion(MoGCSP) (5,6). C en l , he P og amme ope a e
nde he pe i ion of a M l i-Sec o al Technical
Ad i o Commi ee (MTAC) of he MoGCSP, i hep e en a i e f om he Mini ie of Finance,
Ed ca ion, Heal h, Food and Ag ic l e, T ade andInd, and Local Go e nmen and R al
De elopmen (5) i h he ppo of De elopmen
pa ne (9).
Ghana chool feeding p og amme ha been in
ope a ion fo 14 ea , d ing hich pe iod he e ha ebeen e e aldie and epo on i impac . The
objec i e of hi e ie i o e amine he effec of he
Ghana School Feeding P og amme (GSFP) on childn i ional a , chool en olmen , a endance ande en ion.

e e ob ained. The Bibliog aph f om epo of UN
agenciech a he Wo ld Heal h O gani a ion(WHO), UNICEF, Wo ld Food P og amme (WFP) andFood and Ag ic l e O gani a ion (FAO) e e al oea ched fo ele an a icle .
The incl ion c i e ia fo
die incl ded in hie iee e a follo
an i a i e, mi ed de ign oe al a iondiei h mea able o comecollec ed in fficien de ail o allo a e men of achange in a o effec i e o a e he effec of
he GSFP on n i ion and ed ca ion; compa a i e
die in ol ing chooli h and i ho
chool
feeding p og amme epo ing an o come mea e ofin e e ;die
i h mea e of g o h ha e emade a lea 8 eek o mo e f om he ime ofin e en ion e e incl ded; child en aged ≤17 ea
e e incl ded ince ecipien of he GSFP e e p echool and chool-aged child en aged 3 -17 ea . Thi
e ie al o incl ded
die in hich chool meale e a e ed fo hei n i ional al e. S die hichfailed o mee he incl ion c i e ia a
ell a hefollo ing e cl ion c i e iae e e cl ded;
np bli heddiech aden di e a ion andhe i ;
die i h a chool feeding p og amme haa le han a ea ; and ho e i h a ample i e ofle han 10 bjec .
The o come mea e a e ed e e a follo
1) N i ion o comech a i) N ien con en andade ac of meal e ed in he GSFP and n ien
in ake of chool child en pa icipa ing in he GSFP; ii)
N i ional aof child en ing an h opome ic
mea e fo a e ing g o h ch aeigh ( ),heigh (h ), eigh fo age co e (WAZ), heigh fo age
co e (HAZ), eigh fo heighco e (WHZ), BMI
fo Age co e (BAZ) and mean eigh gain (MWG);
and biochemical indice
ch a mea e of
haemoglobin (Hb) and ol ble an fe in ecep o( TfR) if epo ed in he a icle e ie ed. 2) O comemea e ela ed o ed ca ion e e change in choolen olmen , female en olmen , chool a endance,e en ion, d op-oa e and chool pe fo mance.
The e o come mea e a e li ed in Table 1.

METHODS
A de k e iea ca ied ohich in ol ed
he collec ion, a e men , anal e and n he i of
info ma ion f om p bli hed li e a e. The e ieac ed o e amine he effec of he GSFP on
pecific mea able n i ion and ed ca ion o come .
Comp e i ed bibliog aphic medical da aba eeeea ched fo ele an a icle f om 2010-2019. The eda aba e incl ded MEDLINE (P bmed e ion), he
Coch ane Cen al Regi e of Con olled T ial ,Google, Google chola , Hina ii, Scop and Science
Di ec . Ke o d
ed o iden if he ele an a iclee e Ghana, chool feeding p og amme, chool meal ,chool feeding polic , impac , effec , ed ca ion,a endance, en olmen , n i ion and n i ional a .
Ab ac of he iden ified die e e e ie ed anddied. I ele an a icle e e e cl ded and f ll eof he emaining a icle ob ained.
The efe ence liof he e a iclee e al oe ie ed and ele an a icle iden ified in he li
Table 1. N

i ion and Ed ca ion O come and Mea
O c me1) N i ion O comei.
Die a Ade acii.

i ion in Ghanae

N i ional S a
An h opome ic andBiochemical IndiceO c me Mea e
N ien con en and P obabili of Ade ac (PA) fo
elec ed n ien , N ien in ake, pe cen age ofRecommended Die a In ake ( RDI) , Recommended
N ien In ake (RNI)
Weigh ( ), heigh (h ), heigh -fo -age - co e (HAZ),
eigh - fo - age - co e ( WAZ) , Weigh fo Heighco e (WHZ), BMI fo Age co e (BAZ), mean eighgain (MWG), haemoglobin (Hb) and ol ble an fe inecep o ( TfR).

2) Ed ca ion O comeSchool en olmen , female en olmen , a endance,e en ion, d op-o a e and chool pe fo mance

RESULTSA o al of 50 a icle and epo
on he Ghana
School Feeding P og amme e e ob ained, of hich 28
papee e e cl ded, g ided b he e cl ion c i e ia,
e l ing in a o al of 22 p blica ion being incl ded in
hi e ie . The e incl ded a Randomi ed Con olled
T ial (RCT), de c ip i e and c o - ec ionaldie ,mi ed de ign
ih
an i a i e andali a i e

componen , ca e
die , e al a ion
die ,a ie pe imen al de ign and modelling.
Die a
Ade ac a d N i i al S af
Child eN trient Intake and Adeq ac of MealsA
d b Dan ah e al (2012) a A imaN abiag a fo nd ha he meal e ed in he GSFP did
no p o ide he e pec ed one- hi d RNI of 720 kcal f om
chool meal , ba he an a e age eekl in ake of50

G ideline and P ac ice in P e e m N
460.4 kcal (64%), i h a mean in ake ange of 59% 68%,
hich a a ib ed o he mall amo n of meale ed (10). E en ho gh he meal had e ce
ca boh d a e f om aple
ch a ice, co n andca a a, ene g e i emene e no me . Addi ionall ,he chool meal p o ided mo e han o- hi d (11.4 +/0.9 g) of he ecommended p o ein in ake (14g) in GSFP
chool , i h ignifican l highe in ake in chool
hich con med co pea and g o ndn (P<0.05). B
he e a limi ed e of animal p o ein. The meaneekl in ake of hiamine a 0.3 mg in all chool
hich co e ponded o 75% of he RNI f om he chooll nch. Thi a al o a ib ed o he in ake of co pea .
Ob e ed ade a e i on in ake e e al o a ib ed ohe e of leg me
ch a co pea in he die . Ho e e ,ibofla in, calci m and i amin C in akeeeinade a e. Zinc e i emene e al o no me , b hedieppliedo- hi d (2.1 +/- 0.2mg) of heecommended in ake of 3.0mg. Wi h e pec o Vi amin
A in ake, all he meal in he h ee chool
pplied ana e age of 628.3 +/- 85.2 g RE, hich i mo e han heone- hi d of he RNI e i emen of 200 g RE, po ibled e o he e of palm oil in he meal . Vi amin C in hechool mena de i ed mainl f om p l e and eed
ch a co pea and g o ndn , hich pplied 59.4%
of he RNI on a e age.
A c o - ec ionale of 383 chool child enaged 5-13 ea in he Tolon-K mb ng di ic of he
No he n Region compa ed n ien in ake amongchild en pa icipa ing in he GSFP i h ho e ho didno (11) The fo nd ha child en in he GSFP had
ignifican l highe ene g in ake (2397kj; P<0.001).
The p opo ion of child en ho e ene g in ake e ebelo e i emen a 4 7% in GSFP chool compa edo 21 8% in non-GSFP chool (P< 0 001). P o ein in ake
a ade a e in bo h chool (median 19.0g). Ho e e ,in ake of animal o ce of p o ein a highe in GSFP
p pil (5% 3%; P<0 001). The p obabili of ade ac(PA) fo Fe, Zn, Ca and i amin A, C and fola e a al oignifican l highe in GSFP chool (mean PA 0 61 (SD
0 13)
0 18 (SD 0 11) P<0 001). The e of a ce ealba ed m l iple-mic on ien -fo ified co n o a blend
a fo nd o be a ke con ib o o mic on ien
ade ac in he GSFP g o p. Ho e e , he GSFP p pil
had a malle median po ion i e of meal aken ahome han p pil in he non-GSFP g o p (4561037
g; P<0 001) (11). A imila ob e a ion a made in ana ion ide d b Gelli & A ino (2019), hich fo nd
ha 4% of child en in he GSFP epo ed meal ha ingi h ibling a home and 23% epo ed ecei ing lefood a home on da in hich he had chool meal
(12)
Pa i h e . al. (2015) anal ed 170 meal f om hechool feeding p og amme in 34 di ic of 7 egion in
Ghana (13) The ade ac of he die in ela ion on ien con en and co of he meal e e de e minedh o gh a linea modelling anal i of men ob ainedf om he 34 di ic
ing he Go e nmen alloca ed
b dge of GHC 0.40 (USD $0.26) pe child pe meal andp ice of commodi ie f om ma ke in Acc a ( o he n
Ghana) and Tamale (no he n Ghana). The fo nd hedie a p o ein and fa con en of he meal o be
ade a e, p o iding 30% of he Recommended Die a
In ake. Ho e e , i amin A (3.08%) and i on con en(18.97%) e e inade a e. The calo ic con enacon ide ed ade a e onl if meal e e p oc ed a hep ice in he No he n Region.
A d in he La Nk a anang-Madina Di ic ofhe G ea e Acc a Region compa ed he n ien in akeof child en in a GSFP chool i h ho e in a p i a e

i ionchool feeding p og amme (14) The d fo nd highe
in ake of ene g (2413 626 kcal . 1988 627 kcal;
P<0.001), p o ein (63 17 g . 53 19 g; P<0.001), andinc (10 3 mg . 9 3 mg; P 0.004) in he p i a efeeding p og amme compa ed o he GSFP. In ake ofi on, i amin C and A e e imila in he o feedingp og amme . Ho e e , al ho gh calci m in ake e e
lo in bo h p og amme , he e e highe in he p i a efeeding p og amme.
In ad a La Nk a anang in he G ea e Acc aRegion ing meal ob e a ion , he a e age eigh ofa eek meal e e con e ed o ene g and n ien
e i alence and compa ed among he GSFP and a
p i a e chool feeding p og amme b P embaf, a nongo e nmen al o gani a ion (15) The p i a e chool
feeding p og amme a fo nd o ha e highe n ien
con en and me he ene g (776 427 kcal 315 24
kcal; P 0.042), p o ein (20 14g 8 2g; P 0.087), andfa (17 8g e
6 2; P 0.019) ecommenda ion
p o ided b he Wo ld Food P og amme, b he GSFP
did no . The e e e no ignifican diffe ence in hemic on ien con en of meal in bo h chool ; e en
ho gh he po ion i e f om he p i a e chool e e
la ge (416 96 g . 243 50g, P 0.007) and a a highe
co pe meal/child - 70 pe e a ($0.36 in 2013) 40
pe e a ($0.21in 2013) han he GSFP.
Gold mi h e . al. (2019) de e mined he n ien
compo i ion of a e ing of ice and oma o e - acommon men of he GSFP in he Tamale me opoli ofhe No he n Region, in hich he e ing i e angedf om 232 - 273g i h an a e age of 254g (16) Al ho gh
he fo nd ignifican a ia ion in he mac o andmic on ien con en of he food e ed, p obabl d eo ca e e di c e ion and me hod
ed o p epa e heame meal fo child en aged 4-8 ea , he oma o eme 46% of hei ca boh d a e e i emen ; 68 % of
odi m e i emen , 32% of p o ein e i emen , 31% of
i amin D e i emen , mo e han 20% of Vi amin B6,
B12 and E e i emen and onl 7% of i on and 2% of
calci m e i emen . Fo child en aged 9 - 13 ea , i
onl p o ided 18% of hei p o ein e i emen . The
ecommended he e of o flo a a b i e fo
locall p od ced p o ein o inc ea e he p o ein con en
and lo e co .
A
d b Big on e . al. (2019) in e iga ed hen ien con en of chool meal in 20 GSFP chool , 12
in Wa and 8 in Cape Coa m nicipali ie in he Uppe
We and he Cen al egion , e pec i el (17) Findingon he n i ionalali of meal e ed in ppe
p ima
chool e ealed ha he meal in bo h
M nicipal chool did no mee he FAO/WHO (2004)
n ien ecommenda ion . Wi h he e cep ion of
ca boh d a e (90.6 6.3g 69.3 5.2g) and Vi amin A(726.4 85.2
548.2 75.1 g RE) hich fa e ceeded
he efe ence limi , le el of calo ie , p o ein, calci m,i amin C, hiamine, ibofla in, i on and inc in hediee e lehan one- hi d of RNI al e andhe efo e con ide ed inade a e (16)
Agbo o e . al. (2018) e amined he n ien con enof chool l nche p epa ed b GSFP chool compa edo p i a e chool meal in he Hohoe M nicipali andfo nd he n i ional al e of he meal o be imila (18)
Meal of he GSFP chool compa ed o p i a e chool
had 420.6 462.2 kcal of ene g , 6.8 6.8 g of p o ein,23.8 27.7 g of fa , 3.0 2.8 mg of i on, 417.3 280.8
g e inol e i alen of i amin A, 25.1 16.5 mg ofi amin C, 1.3 1.2 mg of inc, and 62.6 61.4 mg ofcalci m. Onl he e i emen fo fa , i amin A, C andi on e e f ll me .

51

School feeding p og am and ni ion in Ghana

In he c o - ec ionale of 383 chool child enin he Tolon-K mb ng di ic compa ing he
n i ional a of child en pa icipa ing in he GSFP
i h ho e ho did no , no ignifican diffe ence in hep e alence ofn ing (HAZ) (23 3
28 9; P 0.09),
nde eigh (WAZ) (16 3
14 4; P 0.76) and hinne(11 9 5 6; P 0.25) e e fo nd among he o g o pof child en (11) The mean Hb a fo nd o be 100(SD16) g/l b le ele e ignifican l highe in hechool feeding g o p b 6g/l (P<0 001). The GSFP g o p
had ignifican l lo e ol ble an fe in ecep o( TfR) le el (11.2 124 mg/l; P 0.04). Ho e e , he e
a no ignifican diffe ence in he p e alence of i on
deficienc anaemia (62 7g/l 69 4 g/l; P 0.56).
In he La Nk a anang-Madina Di ic of heG ea e Acc a Region, maln i ion a p e alen inbo h GSFP and P i a e chool feeding p og am chool(14) Al oge he , 48% e en ed (HAZ), 35% had lo
BMI-fo -Age o e e hin, and o hi d (67%) had oneof he e abno mal al e . In addi ion, 1% e e
o e eigh (BAZ). Al o, 28% of he p pil e e fo nd obe anaemic i h lo Hb le el . Compa i on of hen i ional a of p pil in he GSFP (n 113) and he
p i a e chool feeding p og amme (n 216) in he Hohoe
M nicipali b Agbo o e al. (2018) e ealed ha hen i ional a of he child en in he o g o p e e
imila . The p e alence ofn ing a e ima ed a
8.9%
7.9%, nde eigh a 3.6%
5.7%, hinne a
1.8% 3.7% and o e eigh /obe i a 3.5% 4.2% (18).
Ed ca i E lme , a e da ce, e e i a de f ma ce
A mi ed me hod
d comp i ing 21 chool in
Ba k We and Uppe Ea Region ho ed ha he
GSFP e l ed in o e 100% inc ea ed en olmen o e a
12- ea pe iod, f om 4,013 in 2004/2005 o 10,589 in
2016/2017 (22). Ho e e , he d al o ho ed ha heinc ea e in en olmen began befo e he p og amme ain od ced, ho gh majo i of pa en and eachea ib ed he inc ea e o he p og amme. Ano he mi ed
me hodd of a ba ic chool in N oglo in he
Sa el g -Nan on M nicipali of he No he n egion
fo nd an inc ea e in chool a endance f om 22% befo eini ia ion of he GSFP o 65.4% af e he p og amme a
implemen ed (23) In addi ion, chool en olmen
inc ea ed f om 35.8% o 64.2% af e p og amme ini ia ion,
hile he chool d opo
a e ed ced f om 73.8% o
26.2% (X2 29.767, df 4, P 0.000), ba ed on a eco d
e ie .
Simila l , ad in he A ik ma-Odoben-B ak a
di ic of he Cen al egion al o demon a ed aninc ea e in chool en olmen i h implemen a ion of he
GSFP and a dec ea e in non-GSFP chool (24) The
d al o fo nd ignifican a ocia ion be een he
GSFP and imp o ed academic pe fo mance of p pil in
GSFP hen compa ed i h non-GSFP chool (Pa ial
E a S a ed al e 0.399, P 0.000), an a ocia ion i ha en i ene in cla (Pa ial E a S a ed al e 0.735,
P 0.000) and an a ocia ion i h en olmen in chool(Pa ial E a S a ed al e 0.752, p 0.000), af e a
m l i a ia e anal i . Ho e e , he a ocia ion be eenchool a endance and he GSFP a no a i icall
ignifican (Pa ial E a S a ed al e 0.001, P 0.746). A
compa a i ed be een 10 p ima
choolih
GSFP and 10 p ima
chool
i ho GSFP in he
We e o ci c i of K ma i Me opoli an a ea in he
A han i egion fo nd ha chool feeding had aignifican impac on chool en olmen , a endance ande en ion (25). The d epo ed ha a 100% inc ea e inchool feeding p og amme e l , an inc ea e in

N tritional Stat s of Children: Anthropometricand Biochemical Indices
The Ghana School Feeding P og amme i epo edo ha e imp o ed he n i ional aof child en in
implemen ing chool (4,9,19) A longi dinal cl e
andomi ed con ol ial b Gelli and A ino (2019),
in ol ing 2869 child en aged 5-15 ea na ion ide
epo ed ha he GSFP meal had no effec on hen i ional a (HAZ and BAZ) of child en 5-15 ea
old in he p og am (12). Ho e e , in b-g o p anal e ,he chool feeding in e en ion a a ocia ed i hinc ea ed HAZ in child en aged 5-8 ea (effec i e
0.12SD ); inc ea ed BAZ in bo aged 5-8 ea (effec
i e 0.19 SD ); and inc ea ed HAZ in gi l (effec i e
0.12SD ), e peciall gi l aged 5-8 ea li ing in he
no he n egion of Ghana (effec i e ∼0.3 SD ). Al o,he GSFP a fo nd o be a ocia ed i h inc ea ed
HAZ in child en aged 5-8 ea f om ho ehold li ing
belo he po e line (effec i e 0.22SD ) (12)In con a , a c o - ec ional d a Denk emboin he Ea e n Region of Ghana compa ing he
n i ional aof 359 child en aged 5-12 ea
a ending GSFP and ho e non-GSFP chool fo nd ahighe p e alence of o e eigh ((BAZ) 1.9%
0.0%)
among p pil in GSFP compa ed o non-GSFP chool .
The p e alence of hinne (WHZ) ao ime highe(9.3%) among p pil in GSFP compa ed o non-GSFP
chool (4.6%) (p 0.028). The al o ob e ed mo en ing among p pil f om non-GSFP chool (HAZ)
17.2%
16.2%; ( 0.284)), b he diffe ence a no
a i icall ignifican (20) The a ho
gge ed hahe mi ed o come ma be ela ed o ope a ional i e
a ocia ed i h he GSFP.
A
d in he Hohoe M nicipali of he Vol aRegion compa ed he n i ional a of 417 p pil in
GSFP and non-GSFP chool and fo nd no ignificandiffe ence among heo g o p a follonde eigh , 12.4%
16.8%;
n ing, 13.3%
8.6%;
hinne 1.8%
5.3%; and o e eigh 3.5%
5.6%,
e pec i el (21) Ho e e , he ob e ed diffe encee e no a i icall ignifican . F he mo e, logi ic
eg e ion e ealed ha being a GSFP beneficia did
no ignifican l ed ce he odd of being nde eigh ,n ed, hin o o e eigh . The al o fo nd ha heodd of being nde eigh a ignifican l highe inp pil in lo e p ima aged 5 o 9 ea (AOR; 3.0, 95%
CI; 1.4-6.6, P 0.006), hile child en f om
al a eae e fi e ime mo e likel o ben ed (AOR; 5.3,
95%CI; 1.3-21.6, P 0.021).
A c o - ec ionald in he A ima-N abiag a
di ic of he A han i Region in ol ing 234 p pil
be een he age of 9 and 17 ea , comp i ing of 114
p pil f om h ee GSFP chool and 120 p pil f om
h ee chooli ho
GSFP fo nd a ignificandiffe ence be een he mean heigh of he p pil in
GSFP non-GSFP chool (147.4cm SD 8.9) and (144.6
SD 8.6) (P 0.016), b a ib ed i o he highe age ofchild en in he GSFP chool (15-17 ea ) (mean age
13 12 ea ) (10) Compa ing GSFP chool i h nonGSFP chool , hed fo nd 47.4%
56.6% ofn ing, 48.2%
45.0% nde eigh , 4.4%
2.4% ofhinne , 4.4% 5.0% o e eigh , and 0% 4.2% obe ep pil . Al ho gh len ing a ob e ed among
p pil in GSFP chool . O e all, he fo nd noa i icall
ignifican diffe ence in he n i ional
a of child en in he o g o p and concl ded hahe e a no a ocia ion be een ha ing a chool l nch
and n i ional a .

52

G ideline and P ac ice in P e e m N

i ion

o he e change . A ca e d of he effec of he GSFPon chool en olmen in he Tamale me opoli of he
No he n Region epo ed ha af e i in od c ion in
2006/2007 academic ea , en olmen o e eadil n il
he 2009/2010 academic ea
hen i declined andinc ea ed again he eaf e f om 34.98 pe en ho andpop la ion in 2010/2011 academic ea o 40 pe en
ho and pop la ion in 2013/2014 academic ea (32).

en olmen b abo 4 pe cen age poin , an inc ea e ina endance b 98% and an inc ea e in e en ion b 99%
A d of 5 chool in he K aebibi im Di ic in
he Ea e n egion epo ed ha he e had been a g ad alinc ea e in en olmen p io o he in od c ion of he
GSFP f om he capi a ion g an , a a ene c ea ion
h o gh ed ca ion, p o i ion of chool nifo m , book ,ma e ial and inf ac e (26) Ho e e , en olmen
inc ea ed oon af e he in od c ion of he GSFP in hechool , i h he g ea e inc ea e occ ing i hin he2006/2007 o 2008/2009 academic ea . The ob e ed
inc ea e e e a ied, anging f om 3.1%, 10% and 52%,
h o gh o 66.2% inc ea e in ome chool . The eaf e , agene al dec ea e of 9.2% a ob e ed in he 2009/2010
academic ea , follo ed b a mall i e of abo 2.2% in
he b e en ea . A majo inciden a ocia ed i hhe ob e ed dec ea e in en olmenahee abli hmen of an I lamic chool in a p edominan l
Mo lem comm ni ca ing a mo emen of Mo lem
p pil o he I lamic chool. The inc ea e in en olmen
gene all fa o ed male . Ho e e ,o choolepo ed he con ai h male o female inc ea e inen olmen of 49% 89.6% and 0.5% 5%. The d al oho ed onl mode imp o emen in chool a endance
b 1% - 15 % in he chool
died, hile he d opo a eemained lo a 4%. Onl 26.3% of p pil elied olel
on he GSFP fo l nch.
A de c ip i e d a A eb K amanke e Di ic
in he Cen al Region fo nd ha he GSFP inc ea ed
en olmen , a endance and e en ion in chool (27). I
al o imp o ed chool pe fo mance in e m of pa
ma k, hinking abili , nde anding, concen a ion anddi cipline, and had ome effec on n i ional a , b
no effec on Bod ma inde (BMI) and he heigh ofp pil (27).
A d
i h a a i-e pe imen al de ign a Ga Tampene comm niof he Uppe Ea Region
e amined 360 p pil con i ing of 180 p pil in GSFP
chool and 180 p pil in non-GSFP chool and fo nda co ela ion be een GSFP and pe fo mance in co e
bjec (28,29) The pe fo mance of gi l and bo in
he GSFP chool a be e compa ed o he non-GSFP
chool and e e a follo
Engli h Lang age (63.3%
and 63.6%) (55.9% and 55.2%), Ma hema ic (62.0% and69.7%) (57.0% and 56.3%) and In eg a ed Science (68.4%
and 66.6%) (59.1% and 56.1%), e pec i el . In addi ion,
an inc ea e in g o en olmen a e b abo 24% a
al o ob e ed in GSFP chool f om 2008-2012, hile adec ea e in en olmen of 7% occ ed in non-GSFP
chool (29). The inc ea e a mo l in male in bo he ing .
A ca e d of h ee GSFP chool in he Ga Ea
M nicipali
ho ed an inc ea e in chool a endancein all h ee chool be een 2004/2005 academic ea
and 2006/2007 academic ea f om 68.4% o 94.3%;
83.9% o 92.5%; and 86.5% o 91.9% e pec i el (30).
F he mo e, an in e ie of akeholde e ealed, hahile ome den did no need o ea he chool meal ,o he a ended chool i ho b eakfa . Hence, hechool meal a hei fi and main meal fo he da .
A de c ip i ed of 4 chool in Talen i, Uppe
Ea egion ho ed ha p io o e abli hing he GSFP,
he le el of en olmen a 1,951 fo he 2010/2011
academic eahich inc ea ed b 10.9% o 2,164 in
2012/2013 academic ea af e i a e abli hed (31).
Re en ion a e al o inc ea ed f om 93.0% in he2010/2011 academic ea o 99.3% in he 2012/2013
academic ea
i h co e ponding d opo
a e of
6.98% and 0.7% e pec i el . A ali a i e
d ca iedo conc en lgge
ha he GSFP had con ib ed

DISCUSSION
C en e idence hohachool feedingp og amme
imp o e n i ional
a ,
chool
en olmen and a endance in e e al e ing globall(1,4,11,33). The o come of hi e ie demon a e
mi ed e l on he effec of he GSFP on he n i ionalaof Ghanaian chool child en. While a po i i eeffec on n i ional aa demon a ed b an RCT,he effec did no c ac o all age o e ing . Child enaged 5-8 ea , mo l gi l li ing in po e , had hemo po i i e e pon e (12) A Coch ane e ie ofchool heal h p og amme comp i ing 18
die i hnine f om highe income co n ie and nine f om lo
income co n ie ho ed an a e age eigh gain of 0.39
kg o e 19 mon h in child en f om lo income
co n ie ho e e fed a chool compa ed o con ol
ing RCT alone. In o hedie ha e e no RCT ,he gain a 0.71kg o e an 11.3-mon h pe iod (4). O
finding a e imila o he finding of ano he e en i ee ie , hich fo nd ha al ho gh chool feedingp og ammee e effec i e in imp o ing ene g andmic on ien in ake , hei effec on n i ional aa mi ed and le concl i e (33) While ome of he
GSFP chool demon a ed a po i i e effec on
n i ional
a , hia no con i en . Poon i ional aa p e alen in bo h GSFP and nonGSFP chool (20,21,10,11)Interactions bet een Po ert and the Ghana
School Feeding Programme
The ob e ed heigh gain epo ed in hi e ie b
Gelli e al (2019), a mo e p ono nced in child en
li ing in po e (effec i e 0.22) (12) We al o no ed hao e eigh and obe ie e gene all ncommon in
GSFP pa icipa ing chool , e cep in he RCT andano hedhich ho ed ha child en li ing in
po e benefi ed mo f om he GSFP (10,12,21) An
impo an ob e a ion ha eflec
he in e ac ion
be een po e and he GSFP i ha ome child en on
he GSFP ecei ed le food a home, and fo o he , hechool meal e ed a hei main meal fo he da . Some
die al o epo ed ha a mall p opo ion of hechild en ha ed ome of hei meal i h ibling ;(11,12,30) The e ob e a ion
ppo he pe cei ed
no ion ha he e a e child en ho eall need he chool
meal fo ed cing h nge , e en if he gain in n i ionala i no a p ono nced (33). Fo hi ea on, effec i e
a ge ing of he GSFP i nece a o co e all needchild en. To hi end, need child en can be be e
defined, iden ified and a ge ed, o ha choolihneed p pil can be p io i i ed and olel f nded b
go e nmen , hile o he a e f nded b go e nmen
i h ppo f om pa en , comm ni ie o de elopmen
pa ne a occ
in Ken a, Co e D I oi e and o heco n ie (9,34). In Co e D I oi e, comm ni ie
con ib e o he p og amme h o gh food amp ,ala ie of can een manage , pe i hable , cooking f el
and ag ic l al ppo (9) A imila a angemen
in ol ing he c ea ion of elf-financing chool feedingp og ammei h e e nal ppo ha been ied incocoa g o ing a ea in Ghana i h p omi ing e l(35) Th , be e engagemen i h he comm ni i

53

School feeding p og am and nc i ical o imp o ing he impac of he GSFP on
n i ion and ed ca ion o come .
N trient Intake and Dietar Adeq ac of School
Meals
Men compo i ion of GSFP meal gene all aac o he co n and change i h he ime of ea (36)
Die a ade ac of chool meal a epo ed in omeof hedie e ie ed, bhi did no nece a ilan la e in o imp o ed n i ional aamong hechild en (10,11,14) Thi ob e a ion gge
ha he ea e o he fac o , o he han he chool die , infl encing
n ien in ake and n i ional a . The be e l , ine m of die a ade ac , e e f om chool ha edco pea , hich epo ed imp o ed i on, p o ein andhiamine in ake; he addi ion of a m l iplemic on ien -fo ified co n o a blend o he foode ed b he GSFP; and a p i a e chool feedingp og amme hich p o ided la ge po ion a an
addi ional co (10,11,15) D e o he diffic l ie
ihachie ing die a
ade ac , pa ic la l in hemic on ien compo i ion of ome chool feedingp og amme , gge ion ha e been made o in od ce
fo ifica ion p og amme and o inc ea e he di e i offood p o ided (13) In addi ion o hi app oach, ca ef lmeal planning o imp o e he mic on ien aofchool child en ha been gge ed, a
ell a hede elopmen of Na ional G ideline and S anda d(NGS), hich a e c en l in p og e (3,13,36). To hi
end, a chool meal planne ha been in od ced inchool in 42 di ic o facili a e he p o i ion of
locall o ced n i io food o chool child en in
Ghana (37) I i impo an ha he e g ideline add ebo h nde eigh and o e eigh holi icall incehe e condi ion occ in bo h GSFP and non-GSFP, andin p i a e chool (3,10,20,21,36,38)
In fficien i on in he die and anaemia i a majo
p oblem of chool-aged child en in Ghana (11,13,14,39).
Ad in India ho ed ha m l iple mic on ien
d ink e e effec i e in imp o ing i on deficienc , i on
deficienc anaemia, i amin C and i amin B12 ain chool child en (40). S ch an in e en ion can al o beapplied o he chool feeding p og amme in Ghana.
Addi ionall , e ea ch in Ghana ha ha demon a edha he e of Co pea fo ified i h NaFe EDTA o in
o he fo m a effec i e in ed cing anaemia in choolaged child en, can al o be applied (10,41). Inc ea ing he
die a di e i of chool meal can be a ef l a ofenhancing ade a e n ien in ake and imp o ing i ona (18,42,43,44) Ra ion of a co n- o blend po idge
ha e al o been ed o imp o e e e al lea ning andca ch- p g o h in lean m cle ma of Mala ianchool child en (45) A lo in ake of calci m hich a
ob e ed in ome chool can be comba ed bin od cing dai foodch a milk. Since chool
meal p o ide onl a hi d of n ien e i emen ,pa en need o be
ppo ed o p o ide ade a e
no i hmen fo hei child en and p o ided acce oo he ocial p o ec ion in e en ion o ppo hieffo , he e nece a .
Ed cation
An inc ea e in chool en olmen and a endance ine pon e o chool meal ha been epo ed globall(1,4). The
die e ie ed con i en l epo ed aninc ea e in en olmen of child en in chool
ih afeeding p og amme (22,23,24,25,26,27). Some chool
al o demon a ed an inc ea e in a endance ande en ion o ed c ion in d opo
a e (23,25) In
addi ion, be e pe fo mance and p nc aliee
epo ed (26,27,28,29,46) Ho e e , he lack of anal ic

i ion in Ghana

die and RCT , a ell a he p e ence of e e alconfo nding fac o make i oo impli ic o a ib e
he e ob e a ion olel o he GSFP a ome of hedie ha e done. Mo of hedieee co ec ional i h a compa i on g o p. Tho gh he e die
p o ide ef l info ma ion, c o
ec ional
die dono de e mine ca ali . None hele , he die hiche plo ed f he anal i
ill fo nd
a i icall
ignifican ela ion hip be een inc ea ed choolen olmen and he GSFP (22,25,27). Thi ob e a ion i
imila o finding f om K i jan on e . al. RCT, hichho ed ha child en ho e e fed in chool a ended
chool a a e of abo 4 o 6 da mo e f e en l , mademo e gain on ma hema ical a k and on ome ho e m cogni i e a k han con ol (4) Thedconcl ded ha chool meal ma ha e mall ph ical
and p cho ocial benefi fo di ad an aged chool
child en hich ha e been ho n b ome of he edie (12)The e a limi ed da a on he effec of he GSFP on
female en olmen in chool . The die hich epo edan effec on gende ho ed ha , o e all, maleeefa o ed, nlike a d in B kina Fa o, hich fo nd
an inc ea e in he en olmen a e of gi l b 3.2
pe cen age poin (47) F hediei h mo eigo o de ign a e needed o demon a e he effec of
he GSFP on ed ca ion- ela ed gende o come .
CONCLUSION
The finding of hi e ie a e imila o ha of aema ic e ie , hich e amined he n i ion anded ca ional o come of he chool feeding p og ammein Ghana (48) The effec of he GSFP on n ien in ake
and n i ional aho ed mi ed e l . While ome
GSFP chool demon a ed a po i i e effec on hen i ional a of chool child en, o he ho ed nodiffe ence. In fficien f nding and dela ed pa men oca e e eem o ha e nega i el impac ed he gain in
n i ion a ome
die epo ed ha child en on he
GSFP ecei ed mall po ion i e and lo e
ali offood a a e l of inade a e f nding (7,10,15). I eem
ea onable o concl de, ha al ho gh he GSFP ed ce
h nge in ome child en and complemen ho ehold
food in ake, e peciall fo poo familie , i migh no be
ade a e o impac n i ional a fo e e al ea onincl ding f nding and logi ic .
Thi e ie fo nd hadie on he impac of he
GSFP on ed ca ion con i en l epo inc ea e inen olmen , a endance, e en ion and p nc ali .
Ho e e , i ho gain in n i ional o come , i inlikel ha he GSFP o ld imp o e cogni ion andacademic pe fo mance of chool child en ignifican l ,de pi e imp e i e doc men ed effec
on o heindica o .
Re ol ion of he pe a i e f nding p oblem ineeded o p o ide he nece a inf a
c e ande o ce o imp o e p og amme implemen a ion andield be e n i ion and ed ca ion o come . Be e
managemen and moni o ing of he p og amme,a ge ing of beneficia ie and e plo a ion of al e na emodel of chool feeding a e needed. In addi ion,comp ehen i e app oache o add e ing he n i ional
need of all chool child en, incl ding inc lca ing
po i i e
al e
ha infl ence n i ion- ela edbeha io (48) and p omo e heal h de elopmen of hemind and bodie of chool child en a e ecommended.
F hediehich emplo ob
me hodolog a
ell a he collec ion of ba eline and o ine moni o ing

54

G ideline and P ac ice in P e e m N
da a o info m p og am pe fo mance and e al a ion a e
al o needed.

14 co n ie , Impe ial College P e , London 201610) Dan ah AO. Amoah AN. S eine -A ied M.
Opa e-Obi a
C. N i ionalSaof
Pa icipa ing and Non-pa icipa ing P pil in he
Ghana School Feeding P og amme. Jo nal of
Food Re ea ch, 2012;1(3),11) Abi a i AR. B on C. K a a L. Men ah-Homiah J.
A ma -Kleme M. B o e ID. School feeding
con ib e o mic on ien ade ac of Ghanaianchool child en B J N . 2014;112(6) 1019-33. doi
10.1017/S0007114514001585. E p b 2014 J l 3.
12) Gelli A. A ino E. Fol on G. A hinf l D. Adamba C.
O ei-Ako o I. e al. A School Meal P og am
Implemen ed a Scale in Ghana Inc ea e Heigh fo -Age d ing Mid childhood in Gi l and inChild en f om Poo Ho ehold A Cl e
Randomi ed T ial, The Jo nal of N i ion,
Vol me 149, I e 8, A g
2019, Page 1434 1442. h p //doi.o g/10.1093/jn/n 079
13) Pa i h A and A Gelli. T ade-off in co , dieali and egional di e i an anal i of hen i ional al e of chool meal in Ghana. Ajfand
2015;15(4).
14) O
JS. Colec af EK. A ee e R. Vacca o JA.
H ffman F. N i ional in ake and n i ional
a of chool child en in Ghana. Jo nal of Food
Re ea ch 2017;6(2)15) O
JS, Colec af EK, A ee e RNO, Vacca o
JA, H ffman FG. Compa i on of T o School
Feeding P og amme in Ghana, We Af ica In J
of Child Heal h and N i ion, 2016;5 56-62
16) Gold mi h P. And ade J. Co neli M. A igbee M.
A im P. Tamimie C. Na ional School L nch
N i ion and Co P ofile A Ca e S d of he
Ghana School Feeding P og amme. Food N
B ll.
2019
Ma ;40(1) 41-55.
doi
10.1177/0379572119825960. Ep b 2019 Feb 8.
17) Big on K, E man EK, Boad VG, O oo GS.
N i ional
ali of meal e ed nde he
Ghana chool feeding p og amme a he Uppe
We and Cen al Region of Ghana. Af ican
Jo nal of Food Science 2019;13(4) 92-100
18) Agbo o F. A i o P. Jahn A2. Ab baka i A. N ien
compo i ion and die a di e i of on- i e l nch
meal , and an h opome of beneficia child enin p i a e and p blic p ima
chool in Ghana.
N
Heal h.
2018
A g
10 260106018793048.doi 10.1177/026010601879
3048.
19) Wo ld Food P og amme. The Impac of School
Feeding
P og amme,
Jan a
2019.
choolfeeding@o f. fp.o g acce ed 9/No /2019.
20) K abla MP. G an C. Zo o F. N i ional a ofin- chool child en and i a ocia ed fac o in
Denk embo
Di ic , ea e n egion, Ghana
compa ing chooli h feeding and non- chool
feeding policie . N i ion Jo nal (2018) 17 8 DOI
10.1186/ 12937-018-0321-6
21) Agbo o F. A i o P. Ab baka i A. N i ional S aof P pil A ending P blic Schooli h andi ho School Feeding P og amme in Hohoe
M nicipali , Ghana. Jo nal of Food and
N i ion Re ea ch, 2017;5(7) 467-474
22) Salif . Boa eng, JK. K nd o e SS. Achie ing f eecomp l oni e al ba ic ed ca ion h o ghchool feeding p og amme E idence f om a
dep i edal comm ni in no he n Ghana.
Cogen
Ed ca ion(2018),
51509429.h p //doi.o g/10.1080/2331186X.2018.15
09429 acce ed 26/12/2019

STRENGTHS AND LIMITATIONS
Thi de k e ie diffe f om he
ema ic e ieb A ojobi, 2019 (49) a hedie incl ded in hie iee e limi ed o a icle f om pee e ie ed
jo nal and he efo e did no incl dedendi e a ion ohe e . Addi ionall , oe ie
incl ded a icle and pape on n ien ade ac andin ake and epo ed mea able o come ; One (1)andomi ed con olled ial p o ided he highe le el of
e idence. A e men of die a in ake a pe fo med
ing diffe en ool and efe ence anda d hich ma
ha e affec ed compa i on ac odie . F he mo e,ince chool implemen ing he GSFP end o be in
dep i ed a ea i h highe i k of n i ional deficienc ,i i po ible ha child en in he e chool a e
n i ionall dep i ed a ba eline han he compa i on
g o p in o he chool . Longi dinal die e amining
he p og e of indi id al child en and comm ni
cha ac e i ic
o ld ha e p o ided ef l objec i einfo ma ion
1)

2)

3)
4)

5)
6)

7)

8)

9)

i ion

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2019;18(2) 42-50

57

Asian Journal of Dietetics, 2020

Original

A I

e ga

N
ea a
f Sc
Mea :
f a O e-da Mea P
ded Feed g Sc

Pa a g L a

S e a1, *Ha P a ad P

e 2, La gde D ed3, K

fBaa g De41Fac l f N ing and P blic Heal h, KGUMSB, Thim h , Bh an
Gidak m H i al, Mini
f Heal h, Thim h , Bh an
3
N i i n P g am, Mini
f Heal h, Bh an
4
Sch l Heal h and N i i n Di i i n, Mini
f Ed ca i n, Bh an
2

ABSTRACT The School Feeding Program in Bhutan was initiated in 1974 with an objective of
attracting school enrollment and retaining students in school. However, priorities have now
shifted towards serving quality meals. In a quest to improve school feeding program, a nutrient
analysis of one-day school menu was conducted. Methods Twenty-four schools from the threedifferent regions of the country were purposively sampled for data collection in three phases
corresponding to the three school seasons. Food intake information was collected using weighted
method. Result Meals served in schools were inadequate in protein (27.2 grams compared to RDA
of 29.5 grams for age group 6-9 years, 27.9 grams compared to RDA of 40.2 grams for age group
10-13 years and 29.6grams compared to RDA of 55.8 grams for age group 14-18 years
respectively). The meals were high in fat (49.9 grams compared to RDA of 30 grams for age group
6-9 years, 54.2 grams compared to RDA of 35grams for age group 10-13 years and 59.9 grams
compared to RDA of 42.5 grams for age group 14-18 years). The sodium availability in the meals
was way higher than the recommendations of the World Health Organization across all age
groups. The quality of food was homogenous across the phases and regions. Conclusion The
assessment indicates homogeneity of school meals across regions and seasons with limited
diversity. Protein and energy available in the meals served were inadequate as compared to age
appropriate Recommended Daily Allowances including some of the selected micro-nutrients.
Keywords: Food diversity, Micronutrient, School children, Bhutan.

INTRODUCTION
The School Feeding Program (SFP) in Bhutan
was initiated in the 1974 with support from World
Food Programme (WFP) (1). Back then, the primaryobjective of the feeding program was to increase
school enrollment and retain them in school. After,
over four decades into School Feeding Program, thepriority has now shifted from school enrollment andretention to improving and maintaining the healthand nutritional status of the school going populationof the country (1). The National Nutrition Survey
2015 indicated that the nutrition situation in Bhutanremains precarious, with 21.2% of children under theage of five being stunted and nearly 40% anemic,
mostly women and adolescent girls (2). In the last
five years, sporadic outbreak of peripheral
neuropathy has been reported amongst boarding
school children across the country indicating theexistence of micronutrients deficiencies, such as
Thiamine (3). The Government considers School
Feeding Program as a key program to bridge thenutritional gap, and is supported and implemented
through the Ministry of Education (MoE) (4). There*To whom correspondence
hari88pokhrel@gmail.com

shouldbewere 86,910 students in 2019 benefiting fromthe school feeding program. Of these, 41,734
students were boarders (receiving 3 meals); 25,940
were receiving two meals (breakfast and lunch) and
19,236 were receiving one meal (lunch) (5). The foodserved in feeding schools is based on dietaryguideline set by the government. Nine nonperishable commodities (rice, lentils, chickpeas,
processed cheese, vegetable oil, milk powder,sugar, tea leaves and salt) are provided by thegovernment through the Food Cooperation of
Bhutan (FCBL). Perishable commodities (such as
leafy and green vegetables, animal source proteinsand fruits) would be bought by the individual
schools with the stipend money (Nu
400/child/month, exchange rate1SUD$
73.85
Ngultrum as of 10th March 2020) (6).
Although the Royal Government of Bhutan(RGoB) has been running the School Feeding
Program for over 45 years, no formal assessments
have been conducted to ascertain whether thecurrent standard menu provides the beneficiaries
with the recommended daily allowance (RDA) of
both macro and micro nutrients. Therefore, theMinistry of Education with financial support fromaddressed59

Nutritive analysis of school meals in Bhutan
World Food Program (WFP) and in collaboration
with Ministry of Health and Khesar Gaylpo
University of Medical Sciences of Bhutan,
conducted an analysis of nutrient content of themeals served in feeding schools of Bhutan. The
general objective was to evaluate the nutrient
content, and thereafter make appropriate
recommendations to improve the overall nutrientt quality of the food in schools for the growth anddevelopment of school children.

portion, weighed again and recorded. After cooking,the entire cooked dish was weighed and recorded.
The approximate average portion size served to
students of various age-groups was weighed in thefollowing manner Three students each from classes
PP-III representing the 6-9 years, classes IV-VII
representing 10-13 years, and classes VIII-XII
representing 14-18 years old were randomly
selected from each participating school. The
randomly selected students collected food in threeincidences (beginning, middle and towards the end)of food serving. The three servings were weighed,recorded and the average of the three readings wasrecorded as the standard portion for that age group.

METHODS

Study design and site
A cross-sectional nutritional assessment was
conducted in 2017. Twenty-four schools withfeeding program were purposively selected (eightschools from each region; Western, Central andEastern) to represent feeding schools in the country.
To present seasonality, data was collected during
the three seasons (spring, summer and autumn) on arandom day including all three meals, teas andsnacks from the selected schools.

Data analysis
Data from the weighted method was entered in
Nutri-survey TM software to deduce the nutrient
content of the food(s) item(s) based on theapproximate serving size that each student
presumably would receive. The deduced data wastransferred to Microsoft excel for data management
and SPSS version 22 for analysis. Descriptive
statistics such as frequency, mean, median andpercentage was used to quantify the nutrients andcompared with the Recommended Dietary
Allowance (RDA) of various age groups. Analysis ofvariance (ANOVA) was used to compare thedifference in nutrient content of the food served inparticipating schools among various age groups,
seasons and regions.

Data collection
Data was collected in three phases (1st phasefrom April-May; 2nd phase in September and 3rdphase from October-November of 2017)
representing the different seasonal variations.
Weighted method was used to estimate the average
consumption of the food items served on a typicalday. Among the various assessment methods,
weighted method is considered as the only practical
approach in societies where it is usual for all
household members to eat from the same pot (7).
Since the selected schools were residential schools,
all three meals were provided by the schools, thus,
each school was considered as a household. First the
raw ingredients used for preparing dishes wereindividually weighed and recorded. Then, theingredients were cleaned off their non-edible

Ethical ClearanceThis project was a programmatic assessmentof quality of diet served in schools; therefore, allcommunication including permission to collect data
was overseen by the Ministry of Education, Royal
Government of Bhutan.

Table 1. Number of observations by weighted method
Class

Regions

Food Type

PP-3

4-7

8-12

n (%)

n (%)

n (%)

n (%)

Western

58 (35.6)

21 (36.8)

24 (36.4)

13 (32.5)

Central45 (27.6)

12 (21.1)

21 (31.8)

12(30.0)

Eastern

60 (36.8)

24 (42.1)

21 (31.8)

15 (37.5)

Total
Veg

163 (100)

57 (100)

66 (100)

40 (100)

153 (93.8)

54 (94.7)

61 (92.4)

38 (95.0)

Non veg

10 (6.2)

3 (5.3)5 (7.6)2 (5.0)Total

163 (100)

57 (100)

66 (100)

40 (100)*Significant an P-value < 0 0

60

61

Sodium (mg)2000

8

Zinc (mg)600

Calcium (mg)1640Vitamin C (mg)Iron (mg)13

120

Folate (mcg)

Niacin (mg)

1.6

Pyridoxine (mg)1

0.8Thiamine (mg)

Cobalamin (mcg)

600

30

29.5

RDA

Vitamin A(mcg)

Fat (gm)

Protein (gm)

Nutrients

4669.6

4.7

7.8

271.3

40.2

8.2

0.5

99.8

1

0.7

445.8

49.9

27.2

Mean

2031.9

2.5

4

113.6

19.1

4.7

0.9

31.9

0.6

0.6

192

15.7

10.4

SD

233.5

58.8

48.8

45.2

100.5

63.1

50.0

83.2

62.5

87.5

74.3

166.3

92.2

%
RDA

Nutrient availability

Class PP 3 (n= 57)

Table 2. Age-wise mean nutrient availability from meals served in schools

2000

9

24

800

40

14

1

140

1.6

1.1

600

35

40.2

RDA

4995.7

4.8

7.9

277

40.5

8.8

0.5

96.9

1

0.7

480.4

54.2

27.9

Mean

1918.8

2.1

3.3

109

21.5

6.6

1

32.8

0.5

0.5

248.1

17.7

10.2

SD

249.8

53.3

32.9

34.6

101.3

62.9

50.0

69.2

62.5

63.6

80.1

154.9

69.4

%
RDA

Nutrient availability

Class 4 7 (n=66)

2000

11.5

28.3

800

40

15.3

1

175

2

1.3

600

42.5

55.8

RDA

5007.5

5.2

8.3

314.4

44.9

8.3

0.7

104.9

1.1

0.7

546.1

59.9

29.6

Mean

1598.4

2.5

3.3

108.2

24.2

4.3

1.5

31.2

0.5

0.5

276.9

19.1

12.9

SD

250.4

45.2

29.3

39.3

112.3

54.2

70.0

59.9

55.0

53.8

91.0

140.9

53.0

%
RDA

Nutrient availability

Class 8 -12 (n=40)

Asian Journal of Dietetics, 2020

Nutritive analysis of school meals in Bhutan
Table 3. Region-wise nutrient availability from meals served in schools
Nutrients

RegionN

MeanStd. Deviation

EnergyWestern

58

1132.4289.981085(kcal)

Central45

1262.3288.751200.8Eastern60

1590.81482.931386.95

ProteinWestern

58

25.15

11.71

22.2

(gm.)

Central

45

26.37

9.73

24.6

Eastern

60

32.13

9.86

29.8

Fat

Western

58

49.92

18.51

45.6

(gm.)

Central

45

59.3

20.7

52.4

Eastern

60

54.27

13.2

51.95

Vitamin A

Western

58

489.78286.06423.95(mcg)

Central45

513.27300.48395.1

Eastern

60

457.5798.6

448.65

Thiamine

Western

58

0.48

0.13

0.5

(mg)

Central

45

0.65

0.15

0.6

Eastern

60

0.94

0.8

0.5

Pyrodoxine

Western

58

0.83

0.31

0.8

(mg)

Central

45

0.98

0.26

1

Eastern

60

1.26

0.72

0.85

FolateWestern

58

106.7827.81

101.05(mcg)

Central

45

80.18

26.25

75.5

Eastern

60

108

33.87

96.25

Cobalamin

Western

58

0.46

1.2

0

(mcg)

Central

45

0.58

0.99

0.1

Eastern

60

0.61

1.02

0.1

NiacineWestern

58

7.25

6.53

5.7

(mg)

Central

45

8.16

2.5

7.5

Eastern

60

9.76

5.77

7.25

Calcium

Western

58

249.82115.5

225.85(mg)

Central45

301.81118.71

257.9

Eastern60304.2193.33

283.85

Iron

Western

58

6.31

1.91

6.05

(mg)

Central

45

8.5

1.98

8.4

Eastern

60

9.13

4.8

7.1

Zinc

Western

58

3.89

1.74

3.5

(mg)

Central

45

4.82

1.26

4.8

Eastern

60

5.84

2.96

4.3

62

MedianANOVA
p-value

.000*

.001*

.028*

0.49

.000*

.000*

.000*

0.716

.041*

.013*

.000*

.000*

Asian Journal of Dietetics, 2020

RESULTS
During the entire data collection process a total of 163
direct observations were made for weighted methods
across 24 schools in three phases. Data was collected
on a random day of each of the three seasons. Schools
were found to serve non-vegetarian meals (meats suchas pork, beef or chicken) only during 10 observations(6.2%). More of non-vegetarian meals were served
towards the end of school season corresponding to thesecond and last phase of data collection (Table 1).
Mean age-wise nutrient availability from one-day
menu estimated using weighted method is presented
in Table 2. The menu was found to be deficient inprotein as compared to the RDA for all the three agegroups. Higher classes had higher gaps in protein as
indicated by a higher standard deviation. However fat
intake exceeded by more than 10% of the RDA in all

age groups. The mean availability of most of the
micronutrients was inadequate as compared to age
appropriate RDA except for vitamin C. Among themcalcium, iron and zinc were deficient by almost 50%
from the menu in all the age group. However, mean
sodium intake exceeded the RDA by over 50%.
Region-wise nutrient availability from meals served inschool is presented in table 3. ANNOVA test detectedsignificant difference in the mean intake of all themacronutrients and energy between the regions. The
menu from the eastern region provided significantly
higher levels of energy and protein and almost all theother micronutrients such as thiamine, pyridoxine,
iron, zinc, cobalamin, and niacin. There was no
statistical difference in phase-wise (seasonality)
analysis of nutrient intake (data not presented)
were poor in animal source protein, it also hints
towards deficiency of iron, vitamin A, zinc and othermicro nutrients, as animal source foods are considered
the best source of protein, iron and zinc (12).
The Royal Government of Bhutan (RGOB) having
realized the role of school feeding program has now
shifted the focus of school feeding program fromretaining in school to providing diverse andnutritionally wholesome meals. A System Approach to
Better Education Result (SABER) assessment
conducted by the MOE in 2014 recommended
establishing a clear policy for the school feeding
program (13). The Bhutan Education Blueprint (2014 2024) has given priority to school feeding program andrecommended for a strong school feeding policy (1).
The School Health and Nutrition Division (SHND)
under Ministry of Education is responsible for school
feeding program in providing quality meals and havebeen collaborating with other agencies / ministries
such as the ministry of Agriculture and Forestry,
Finance, Gross National Happiness Commission andthe World Food Program (4).
As an immediate measure to improve the qualityof the meals in feeding schools, the MoE withtechnical and financial assistant from WFP started
providing fortified rice towards the end of 2017(5). The
rice is fortified with six vitamins (vitamin A,
Thiamine, folic acid, vitamin B3, B6 and B12) and two
minerals (iron and zinc) by blending with the fortified
rice kernels (14). During the time of the data collection
for this study, the supply of fortified rice had notreached schools and therefore the finding of this study
is timely and informative and the fortification of ricewith vitamins and minerals are very timely for the
given situation.

DISCUSSION
The assessment found that the school meals were
deficit in protein and most of the micronutrients. Meals
were homogeneous across the regions and seasons butwith limited diversity and minimal animal source
foods with non-vegetarian meals being served only 10
times (6.2%) out of 163 observations. The World Healthorganization recommends less than 2000 milligrams of
sodium per day (8). However, the assessment also
found that the mean sodium availability from themeals served was more than 4500 milligrams in thelowest age groups with higher availability in higher
age groups. High sodium intake in the Bhutanese
population was reported by the WHO step survey of
Bhutan 2015 (9).
School meals have been under scrutiny in theregion where some similar findings have beenreported. In a narrative of a study from Allahabad
district of India, they reportedly mentioned that themean nutrient intake for energy, protein, iron andcalcium were lower than RDA but fat intake washigher in all age groups (10).
A Chinese study reported that the calories from fat
exceeded the RDA by almost 30% (11) which isconsistent with the present finding in Bhutanese
schools where fat availability in the meals exceededalmost by 50% as compared to the RDA. The study also
reported that vitamin B2 and calcium were inadequate,
whereas, vitamin C, vitamin B1, iron and zinc wereadequate. In Bhutanese schools except for vitamin C(40.2 mg, 40.5 mg and 44.9 mg for age group 6-9 years,
10-13 years and 14-18 years respectively), all othermicronutrient was far lower than the RDA. This could
be because for the Chinese student s, livestock andpoultry were served more than twice the required
amount. In contrast, of the 163 observation only 10
incidences recorded non-vegetarian (meat, chicken orpork) side dish during the study period of boarding
schools in Bhutan. Since the meals served in schools

LIMITATIONS
The project was a programmatic review on nutrient
adequacy of meals served in feeding schools. The
nutrients were analyzed from standard portion size
served and not based on actual consumption by thestudents.

63

Nutritive analysis of school meals in Bhutan
4) Ministry of Education. Mandates; School Healthand Nutrition Division, Ministry of Education
2019 cited 2020 04/02 . Available fromhttp //www.education.gov.bt/index.php/department-of-school-education/.
5) World Food Programe Bhutan. Overview ofNutrition Activities in Bhutan 2019-2023. 2019
Availablefromhttps //www.wfp.org/publications/overviewnutrition-activities-bhutan-2019-2023.
6) Royal Monetary Authority. Bhutan. 2020 cited
2020
10/03 .
Availablefromhttps //www.rma.org.bt/.
7) Rutishauser IH. Dietary intake measurements.
Public Health Nutr. 2005; 8(7A) 1100-7.
8) World Health Organization. Guideline Sodium
intake for adults and children. 2014 Available
fromhttps //apps.who.int/iris/bitstream/handle/10665/77
985/9789241504836_eng.pdf;sequence 1.
9) Ministry of Health. Bhutan. National survey for
non-communicable disease risk factors and mental
health using WHO STEPS approach in Bhutan.;
2014.
10) Singh S., Srivastavaa S. Nutrient intake and Foodadequacy of the school going children of
Allahabad District. International Journal of
Research in Applied, Natural and Social Sciences.
2016;4(3).
11) Huang Z, Gao R, Bawuerjiang N, Zhang Y,
Huang X, Cai M. Food and Nutrients Intake in the
School Lunch Program among School Children in
Shanghai, China. Nutrients. 2017;9(6).
12) Lanham-New SA, Hill TR, Gallagher AM,
Vorster HH. Introduction to Human Nutrition. 3rd
Edition ed2019.
13) Ministry of Education. Bhutan. Terms of reference
for development of strategic document for thenational school feeding program.; 2014.
14) World Food Programme. Bhutan.
Rice
Fortification Update. 2017.

CONCLUSION AND RECOMMENDATION
The assessment indicates the homogeneity ofschool meals across regions and seasons. The average
protein availability from the meals served was similar
for different age-groups, (27.2 grams, 27.9 grams and29.6 grams for age group 6-9 years, 10-13 years and 1418 years respectively) which might not be sufficient tomeet the requirements of the higher age-groups. Mostof the micro-nutrients were deficient which was evenmore pronounced in the higher age-groups. This isprobably because of the limited variety of school
meals as indicated from infrequent provision of meats
and fruits. The assessment recommends to implement
initiatives that will improve the availability of
micronutrients such as food fortification, integrationof school agriculture programs with school feeding
and linkages with local farmers, strengthen monitoringand supportive supervision and promote local
creativity and involvement of students in the menu
planning and decision making process.
ACKNOWLEDGEMENTS
The authors would like to express sincere
gratitude to the Ministry of Education and the World
Food Programs Bhutan for administrative and finicalsupport for the nutrient content assessment of theschool meals. We would also like to thank theparticipating schools and students for their cooperationand participation for successful completion of thisproject.
REFERENCES
1) Ministry of Education. Bhutan. Bhutan Education
Blueprint 2014-2024. 2014.
2) Ministry of Health. Bhutan. National Nutrition
Survey. 2015.
3) Dzed L, Dorji T, Pelzom D, Dhakal GP,
Yangchen P, Wangmo K. Status of Thiamindeficiency in boarding school children from seven
districts in Bhutan with previous history of
peripheral neuropathy outbreaks a cohort study.
Bhutan Health Journal. 2015;1(1).

64Asian Journal of Dietetics, 2020

Original

Fiber-focused Nutrition Counseling Through Nutrition Software
Improved HbA1c of Vietnamese Type 2 Diabetes Mellitus Patients
Nguyen Huong Giang1, Nguyen Trong Hung2, Vu Thi Thu Hien2, Tran Thi Nguyet Nga3, Bui Thu Hien4, Ta
Thi Ngoc1, Le Danh Tuyen2, Nguyen Dinh Phuc3, Phan Huong Duong5, Hitoshi Iizuka1, Sumiko
Kamoshita1, Shigeru Yamamoto1
1

Jumonji University, Niiza, Saitama Prefecture, Japan
National Institute of Nutrition, Hanoi, Vietnam
3
Vietnam-Cuba Friendship Hospital, Hanoi, Vietnam
4
Kagawa Nutrition University, Wakaba, Saitama Prefecture, Japan
5
National Hospital of Endocrinology, Hanoi, Vietnam
2

ABSTRACT Background and purpose Type 2 diabetes mellitus (T2DM), which is anindividual health challenge requiring ongoing management, has been rapidly increasing The
major factor affecting the rate of Vietnamese T2DM is reported by some studies as low fiber
intake In this situation, dietitian need to help T2DM patients to change their dietary habits, inorder to control their blood glucose However, in Vietnam, the number of dietitians is very
limited Calorie Smile Vietnam version (CSV) is a nutrition support software which can be asolution for dietitians, who can monitor and advise many people at the same time and also workat from any time and place Such a tool will be extremely useful in Vietnam Therefore, we
wanted to determine the effect of fiber-focused nutrition counseling thourgh the nutrition
software on improving HbA1c of Vietnamese T2DM patients. Method Sixty outpatients with
T2DM were recruited at a hospital for a 3-month randomized controlled trial study. We formed
30 pairs matched by HbA1c, sex, age, BMI, and years of diabetes, and divided them randomly
into an Intervention and a Control group. Both groups were instructed to use the CSV software.
All the nutrition surveys and nutrition counseling were carried out using CSV. The Control
group had a 3-consecutive-day nutrition survey at baseline and final and received 1-time
nutrition counseling at baseline. The Intervention group had 3-consecutive-day nutrition
survey and counseling 5 times. The counseling was focused on increasing fiber intake fromvegetables and fruits. The target was 2 bowls of vegetables/meal; the appropriate amount offruit/day. In addition, subjects were also counseled about food choices. At baseline and final,
anthropometric measurements and blood withdrawal were conducted. Result After 3 months,
the intervention group had increased fiber intake (from 6.4 ± 2.5 to 8.3 ± 3.0 g/day, p<0.0001),
while the control group had no change. As a result, HbA1c was significantly improved in theIntervention group (from 8.16 ± 0.75% to 7.79 ± 0.85%, p<0.05) compared with the Control
group (from 8.05 ± 0.77% to 8.39 ± 1.33%). There was a negative correlation between change
in fiber intake and change in HbA1c. Conclusion Real time nutrition counseling for T2DM
patients using the CSV software was effective for improving fiber intake and HbA1c.
Keywords Nutrition Software, education, dietary fiber, - \Type 2 DM, Vietnam
BACKGROUND
Diabetes mellitus is a chronic metabolic diseasecharacterized by elevated levels of blood glucose
thatoccur either when the pancreas does not produce
enough insulin or when the body cannot effectively use
the insulin it produces (1). Diabetes of all types can leadto complications in many parts of the body and canincrease the overall risk of dying prematurely.
According to the World Health Organization (WHO),
globally, in 2014 there were about 422 million people
with diabetes; in 2016, an estimated 1.6 million deaths
were directly caused by diabetes and another 2.2 million
deaths were attributable to high blood glucose in 2012
10 years. In 2002, the proportion was 2.7%, but by 2012,

it was up to 5.4% (2). In 2015, it was estimated that 5.6%of people had diabetes and about 53,458 deaths were
attributed to diabetes (3). The diabetes-related
expenditures in Viet Nam are on average 163 USD per
patient per year, more than the average monthly salaryof 150 USD in Viet Nam (4).
Nowadays, in a period of economic development
and transformation of nutrition and food security, thetraditional diet of Vietnamese, which was highcarbohydrate, low-fat and high-fiber, has been changed
to a high-carbohydrate, high-fat, and low-fiber diet.
This is a major factor affecting the rate of type 2
diabetes mellitus (T2DM) in Vietnam. If T2DM patients
do not have a proper diet, they cannot control their blood
glucose, so they may suffer from serious complications
whereby the economic burden also becomes extremely
high. Dietary management for diabetic patients has been

*To whom correspondence should be addressed:(1). In Viet Nam, the prevalence of diabetes is growing
giang3900@gmail.com
atalarming rates and has almost doubled within the past

65

Nutrition and education using a software in DM patientsshown to improve blood glucose control and reduce therisk of complications. Despite that, there are various
barriers for patients to obtaining the proper dietary
management. These include lack of dietitians, lack oftime for dietitians to provide patients with continuing
education and sometimes lack of patients access todietitians because patients do not have the time ormoney to come to the hospital.
In this situation, a solution to support patients indietary management is very necessary. There is a needfor a tool that can overcome the barriers. Systems andsoftware to support nutritional counseling become
imperative but in Vietnam, they are not available. Thus,a Japanese computer company and some Vietnamese
nutrition experts have developed nutrition software forVietnamese, called Calorie Smile Vietnam version(CSV) (5). Such a tool will be extremely useful in
Vietnam where the number of dietitians is very limited.
However, there has been no study to prove its
effectiveness with Vietnamese people. Therefore, we
wanted to determine the effect of nutrition counselingthrough CSV software on improving HbA1c in T2DM
patients.

5.

Nutritional advice: After analyzing, the dietitian
sends the patients nutritional advice to boost theirmotivation. Patients can also reply to the dietitian,so that the communication is carried out smoothly.
6. Group counseling: A team of dietitians can work
together to advise one user. This function is very
convenient for learning and sharing experiencesamong dietitians, as well as transferring
information on patients in the same group.
Study design
This was a 3-month randomized controlled trial
performed between October 2018 and April 2019 atVietnam-Cuba Friendship Hospital. T2DM patients
who had HbA1c>7%, were using oral drugs for
management of T2DM, had no severe complications,
had no intervention by dietetics professionals for T2DM,
were using smart-phones and were able to access theinternet and weren t pregnant at the time of recruitment
for the study. After screening data at the hospital, andthrough phone contact and meeting in person, 60
subjects who agreed to participate in this study wereenrolled. Sixty patients who were pair matched by
HbA1c, age group, years with T2DM, BMI, and genderthen were randomly divided into 2 groups, 30 in theControl Group and 30 in the Intervention Group. During
the intervention, drug dosage was not changed in either
the Control or the Intervention Group.
Study methods
Subjects visited us twice, at baseline and final. At
baseline, all the subjects received CSV software
instruction.
Nutrition survey
A 3-consecutive-day nutrition survey by thephotographic method was conduct at week 1 and week
12 through CSV software for all subjects. For theintervention group, subjects would have 4 more sessionsof nutrition survey in weeks 3, 6, 10, and 12. Energy andnutrient intakes were calculated.
* Patients were instructed to take photos of food:o Patients were asked what type of bowls, plates thatthey use.
o At meals, patients took photos of all the food withthe proper amounts that they intended to eat inseparate bowls/plates and took pictures from 2 angles:
straight and tilted.
o After the meal, patients would take pictures of thefood left over.
Dietary counselling
All the counselling was given through CSV
software by 5 Bachelors of Nutrition who had graduatedfrom Hanoi Medical University. Subjects in theintervention group had counseling 5 times, after thenutrition survey in week 1, and in weeks 3, 6, 10, and
12. Subjects in the control group continued theirtreatment regimen and did not receive any counsellingfrom this study during the intervention period.
Counselling method:
The counseling was focused on increasing fiber
intake and food choices.
We instructed patients to gradually increase
vegetables, using certain measuring tools such as ricebowls to measure the amount of vegetables at each meal
and we set goals for patients at each consultation. For
example, for the first consultation, we set a goal of 2/3

METHODS
Design of Calorie Smile Vietnam version (CSV)CSV is a nutrition software which has installed in
it Vietnamese language (5), and has been integrated with
the Vietnam food composition table (6), the nutrition
value of 500 common dishes from the Hanoi area (7) andthe nutrition value of common street food from the Ho
Chi Minh city (8). This software offers dietitians a new
way to conveniently exchange information with theirpatients.
CSV is designed to connect dietitians and patients
through the internet, from anywhere and at any time. So,
the dietitians can adjust the time and place of work andthe patients can get nutrition advice without going to thehospital.
CSV includes 6 functions:
1. Questionnaire: The dietitian can create a detailed
questionnaire about patients everyday dietary
habits and ask the patients to complete it. The
patients can use their smartphones to fill in thequestionnaire and return it to the dietitian. Based on
this data, the dietitian drafts an action plan tomonitor the patients daily progress.
2. Data transferring: Patient data such as meal photos,
biochemical indices, anthropometric indicators,
and physical activity indicators submitted by thepatient to the software will be transferred to theaccount of the dietitian as well as being shown on
the patient's page.
3. Daily progress: The patient s daily progress can betraced at a glance. Patient data are shown in tables
and charts, making it easy for the dietitian to check.
4. Meal analysis: Based on the patient s meal photos,
the dietitian can make a detailed nutritional analysis
and send back to the patient. CSV is integrated withdata about common dishes in Vietnam, so the mealcan be analyzed quickly. In addition, if the patient's
dishes are different from the available dishes,change can be made to meal ingredients andportions.

66

Asian Journal of Dietetics, 2020of a bowl of vegetables/meal, at the second consultation
we would check and raise the target to 1 bowl ofvegetables/meal, the 3rd consultation targeted 1.5 bowlsof vegetables/meal, the 4th consultation targeted 2
bowls of vegetables/ meal and then subjects maintained
this amount. We also advised them to choose seasonal
vegetables and to combine various kinds of vegetable in
one meal. We checked their progress through photos of
the food they ate and constantly monitored, motivated,
and reminded them to try to achieve their goals.
Besides vegetables, we encouraged patients to eat
more fruits, gave them a list of fruits they should eat andfruits they should avoid or eat only occasionally if they
craved them and we also showed them the amount they
could eat each time. For example, Guava is a low-sugar,
high-fiber fruit so we recommended that they could eat
1/2-1 guava/day.
Blood test
Intravenous fasting blood samples were taken in
the morning at baseline and final. HbA1c was analyzed.
Anthropometric measurement
Weight, height, and body fat percentage were
measured twice, at the baseline and final and the averagevalue was calculated for each individual. Body weightand height were measured in light clothing and without
shoes. Body mass index (BMI) was computed as theratio of weight (kg) per height squared (m2). Body

weight and percent body fat were measured by a digitalweight scale (OMRON HBF-354IT) with accuracy to
0.1kg and 0.1%. Body height were measured by aportable stadiometer (Seca 213) with accuracy to
0.01cm.
Statistical analysis
Quantitative variables were checked for normal
distribution and compared by the paired and unpaired
Student t-test. P-values of less than 0.05 wereconsidered statistically significant for all the analyses.
The above statistical procedures were performed using
Microsoft Excel 2013.
RESULTS
Baseline characteristics of the 60 subjects areshown in Table 1. Characteristics were similar between
the 2 groups. The overall study population was
predominantly female (66%), average age was 59.2
years (SD = 9.4), and average HbAc1 8.0% (SD = 0.7).
After 3 months, there were 2 dropout patients in theIntervention Group.
Table 2 shows the change in HbA1c from baseline
to final by study group. HbA1c values declined
significantly in the Intervention Group (p<0.05), whilein the Control Group, it increased but not significantly.

Table 1: Baseline characteristics of the subjects
Intervention Group(n 30)
8.17±0.73
57.8±9.0
6.0±4.3

HbA1c (%)
Age (years)
Year with diabetes
Sex
Female20
Male
10
2
Body mass index (kg/m )
0
<18.5
20
18.5-24.9
10≥25
P values obtained from unpaired t-test between intervention and control groups

Control Group(n 30)
8.05±0.77
60.6±8.2
6.5±5.9
20
10
0
20
10

Table 2: Comparison of biochemical parameters at baseline and final of Intervention and Control GroupIntervention Group
Control Group(n 28)(n 30)
Baseline
Final
Baseline
Final
HbA1c (%)
8.16±0.75
7.79±0.85*
8.05±0.77
8.39±1.33*Significantly different from baseline to final within the group by paired t-test; p<0.05
the group did not differ except for fiber (Table 4). As
a result, after 3 months, there were no changes in thephysical characteristics of both groups (Table 5).
Relationship between changes in fiber intake andchange in HbA1C is shown in figure 1. HbA1C
decreased as fiber intake increased.

Table 3 shows the comparison of vegetable andfruit intake at baseline and final of Intervention andControl Groups. With the Intervention Group, theintake increased significantly. Energy and nutrient
intakes of both groups at baseline and final data within

67

Nutrition and education using a software in DM patients

Table 3: Comparison of vegetable and fruit intake at baseline and final of Intervention and Control GroupIntervention Group
Control Group(n 28)(n 30)
Baseline
Final
Baseline
Final
Vegetable and fruit intake (g)234.4±129.9
326.2±173.2*
160.9±118.2
187.4±132.4*Significantly different from baseline to final within the group by paired t-test; p<0.05
Table 4: Energy and nutrient intakes at baseline and final of Intervention and Control GroupIntervention Group
Control Group(n 28)(n 30)
Baseline
Final
Baseline
Final
1399±294
1377±234
1398±315
1378±296
Energy (kcal/day)Protein (%E)
19.1±4.4
18.0±3.2
17.6±2.6
16.9±2.6
Protein (g/day)
66.4±18.3
62.6±16.961.5±15.758.9±17.1
Fat (%E)
26.3±6.2
24.9±3.1
24.7±4.3
25.5±3.8
Fat (g/day)
41.3±13.1
38.1±8.738.4±11.0
39.1±10.6
Carbohydrate(%E)
54.7±8.2
57.1±4.4
57.7±5.5
57.6±4.9
Carbohydrate (g/day)
190.4±47.5
195.7±32.7
201.5±50.6
197.6±45.2
Fiber (g/day)
6.4±2.5
8.3±3.0***
5.5±1.85.9±2.1*** Significantly different from baseline to final within the group by paired t-test (p<0.0001)
Table 5: Comparison of physical characteristics at baseline and final of Intervention and Control GroupIntervention Group
Control Group(n 28)(n 30)
Baseline
Final
Baseline
Final
Weight (kg)61.2 ± 10.4
60.9 ± 10.4
60.6 ± 8.2
60.5 ± 8.12
BMI (kg/m2)
24.4 ± 3.6
24.4 ± 3.6
24.5 ± 2.6
24.5 ± 2.7
Body fat (%)
31.8 ± 4.8
31.4 ± 4.9
31.2 ± 4.7
30.6 ± 4.9
P values obtained from paired t-test between baseline and final within the group

Figure 1: Relationship between change in fiber intake and change in HbA1c

68

Asian Journal of Dietetics, 2020

Table 6 presents the comparison of nutrition
education received by the 2 groups in 3 months. At
baseline, all patients said that they had consulted with
their general practitioner and referred to the internet
about diet for diabetics, but they had only very basic
knowledge. They had followed it for a short time, but
no one pushed them, so they quickly returned to their
old habits and ate what they liked. Subjects expected toget counseling from dietitians and to be monitored ondiet and to receive timely advice. In the 3 months of thestudy, the control group received nutrition education
only 3 times with very basic information from a general
doctor at the hospital without analysis of their diet,while the intervention group were able to receive
intensive nutrition education suited to their diet 5 times
and received it at home.

Table 6: Comparison of nutrition education received by the 2 groups in 3 months.
Intervention group
Number of nutrition
5 timescounseling/3 monthCounselor
DietitianPlace
At homeTime

At week 1,3,6,12 of the study

Content

Detailed advice according to the analyzed dietinformation
Diet goal:- Fiber: 10g/1000Kcal, Vegetable and fruit: 400500g/day- Energy: 30-35 kcal/ kg of ideal body weight/ day- Carbohydrate: 55-65% of total energy,
coordination between low glycemic load foods andhigh glycemic load foods.
- Protein: 1 -1.25g/kg of ideal body weight/day- Fat: 20-25% of total energy

DISCUSSION
This study found that nutrition counseling throughnutrition software was effective in lowering HbA1c,
and improving dietary pattern, especially fiber intake,in a community population of adults with diabetes overa 3-month period.
In order for patient to change their eating habits, it
is essential to set individual specific goals at eachconsultation, and to provide feedback, follow-up, andmotivation for the patient. If patients are motivatedregularly and given timely advice, they will be able toadopt good lifestyle behaviors, and easily control theirblood sugar well. In this study, these tasks were
facilitated by the CSV software and patients did nothave to go to the hospital, which saved them a lot oftime. Both dietitians and patients can easily exchange
data at any time of the day, wherever they may be. Thisis more efficient than making face-to-faceappointments that can be missed due to busy schedules.
Dietitians and patients can stay in constant contact tohelp patients reach their targets. Moreover, thanks to theanalytical features available on CSV software, dietitians
could analyze patients meal photos quickly; therefore,
at the same time, they could analyze for more patients.
After the 3 months of study, it was rewarding to notethat patients in the intervention group referred todietitians for diabetes nutrition counseling. Theirbehaviors were likewise improved, paralleling andControl group
3 times
General doctor
At hospital
When coming to hospital tofor re-examination and toreceive drug
Only received advice: “Yourblood glucose is too high; youshould reduce the energy andcarbohydrate intake; increase
the vegetable intake” without
analyzing their diet.

likely influencing positive clinical outcomes. In
addition, there were only 2 dropout patients, indicatingthat CSV is easy to use, convenient and had supported
patients particularly well.
After the intervention, the HbA1c of theintervention group decreased by 0.38% (p <0.05) while
the control group increased by 0.34% (p> 0.05). During
the 3 months, no patient had changed medication,
indicating regular monitoring and nutrition counselingwere effective. In order to reduce HbA1c, it is very
important to properly evaluate the current diet and todevelop an appropriate nutrition plan for patients. Afterthe first nutrition survey, we found that most subjects inthe study were consuming a moderate energy level of
1300-1400 kcal with a reasonable ratio of protein: lipid:
carbohydrate, but the food choices and distribution ofmeals were not yet appropriate. In particular, theamount of fiber consumed was very low. The low fiber
consumption may explain why the subjects BMI was
not high (about 24.4-24.5 kg/m2) even though T2DM
patients worldwide are usually obese. Therefore, if we
continue to require patients who have already reduced
energy intake to reduce energy intake more, it may not
be effective and may often lead to low compliance.
Instead, counseling on how to change the pattern ofeating, food choices and recommendations to eat more
fiber can bring greater compliance for participants.
With this counselling method, after the study, in the69

Nutrition and education using a software in DM patients

intervention group, vegetable consumption increased
from 234 to 326 g/day and fiber consumption increased
statistically, from 6.4 ± 2.5 to 8.3 ± 3.0g/day, while thecontrol group did not change. Moreover, the variety ofvegetables also increased. At baseline, almost allintervention patients ate just one kind of vegetable atmany meals. This may have made them lose theirappetite and they did not want to eat more vegetables.
We tried to tell them to choose seasonal vegetables andcombine various kinds of vegetable in 1 meal so thedishes will become more delicious and eye-catching.
We also encouraged patients to change the kind ofvegetable frequently, so they did not get bored. Hence,from 1 kind of vegetable/meal at baseline, they couldchange to 2-3 kinds of vegetables/meal at the end of thestudy.
Fiber is important for everyone and especially forpeople with diabetes. Dietary fiber can increase theviscosity of diets and cause a delay in digestion and theabsorption of sugar into the bloodstream. The positiveeffects of fiber or vegetables on blood glucose control
have been shown by many studies. The last two studies
on diabetics in Vietnam have shown similar results(9,10). A study of Okara in which the intervention groupconsumed about 6 g of fiber from Okara per day for 2
weeks showed that when dietary fiber intake increased
from 6.9 to 12.6 g (p<0.01), fasting blood glucose andfructosamine dropped from 6.3 to 5.4 mmol/L (p<0.05)
a d f
319
301
/L (p<0.05), respectively.
Another study showed that when vegetable intakes
increased from 200-300g to 300g and 450g in thecontrol and intervention group, respectively, thefructosamine concentration in the intervention groupdecreased significantly (P<0.05) but not in the control
group (P>0.05). Other studies in various countries used
a variety of grams of fiber per day in their interventions,comprising a large range, from as little as an additional
4 g/d to as much as 40 g/d; the mean increase in fiber
was approximately 18 g/d to achieve an overall
reduction in HbA1c by fiber of 0.26% (95% CI, 0.02–0.51) more than the reduction from a placebo (11).
However, in this study, only a small quantity of fiber
increase (2g) was effective in controlling blood glucose.
It may be due to the fact that the recent intake ofVietnamese is very low, only 6g/day, so an increase of
2 grams means a 1/3 increase over recent intake.
Although we observed positive results for theapplication of CSV in supporting nutrition counselingin our current research, several obstacles need to be
overcome before this software can be implemented. At
typical Vietnamese meals, all dishes except individual
bowls of rice are communal, so it is necessary toestablish common measurement methods to be able tocalculate the patient's diet accurately. Besides,
Vietnamese people are not familiar with taking photosof meals as well as posting photos and receiving advice
through the software. In this study, we had to contact
patients regularly to remind them but in reality, with theworkload of doctors and nutritionists, they would not beable to do so. This limitation can be overcome bydeveloping an automated reminder system based on thepatient's data.
This study had 3 months of intervention; but with
T2DM patients, to improve glycemic control,

maintaining long-term control is required. Therefore,
further study should have a longer time for intervention
and follow-up.
CONCLUSION
In summary, by using nutrition counseling throughnutrition software for 3 months, fiber intake wasincreased about 2g/day, were effective in decreasing
HbA1c of Vietnamese T2DM patients.
ACKNOWLEDGEMENTS
I would like to extend my great appreciation to
US-Japan Medical Science Program, Jumonji
University, and Vietnam – Cuba Friendship Hospitalfor giving the best condition to complete the study; tothe students of Hanoi Medical University for theirsupport on collecting data, and Prof. Andrew Durkin,emeritus professor of Indiana University, for careful
proof-reading of the paper.

REFERRENCES
1. World Health Organization. Global report ondiabetes. 2016. World Health Organization,
Geneva.
2. Khue NT. Diabetes in Vietnam. Ann Glob Heal
81:870. 2016.
3. International Diabetes Federation. IDF Diabetes
Atlas. 8th ed, 126-7. 2017. International DiabetesFederation, Belgium
4. World Health Organization. The growing burden of
diabetes in Viet Nam [Internet]. 2016 [cited 2018
Aug 20]. Available from:https://www.who.int/vietnam/news/featurestories/detail/the-growing-burden-of-diabetes-inviet-nam.
5. Tho PA, Hanh TTM, Hien VTT, Iizuka H,
Yamamoto S. Calorie Smile Vietnam. 2018. Quest
Computer, Tokyo, Japan.
6. National Institute of Nutrition. Vietnamese Food
Composition Table. 2007. Hanoi Medical
Publishing House, Hanoi, Vietnam.
7. Ministry of Heath, National Institute of Nutrition.
Nutrition value of 500 common dishes. 2016.
Medical Publishing House, Hanoi, Vietnam.
8. Ho Chi Minh Nutrition Center, Ho Chi Minh Food
Nutrition Association. Nutrition value of common
street food. 2017. Medical Publishing House; Ho
Chi Minh, Vietnam
9. Lieu NT, Tu NH, Linh NT, Kamoshita S, Thao TP,
Huong LT, Shimura F, Yamamoto S. Okara
improved blood glucose level in vietnamese with
type 2 diabetes mellitus. J Nutr Sci Vitaminol
65:60–5. 2019.
10.Thao TP, Linh NT, Nishiyama H, Sakai S, Shimura
F, Yamamoto S. Higher Vegetable Intake
Improved Blood Glucose Level in VietnameseWith Type 2 Diabetes Mellitus. Int J Clin Nutr Diet
3. 2017.
11. Post RE, Mainous AG, King DE, Simpson KN.
Dietary fiber for the treatment of type 2 diabetes
mellitus: A meta-analysis. J Am Board Fam Med
25:16–23. 2012.

70

Asian Journal of Dietetics, 2020

ORIGINAL
O al Fci
D, Ha dg i S e g h a d A i a i P e mhagic Olde Ad l I a ie
i Vie amia iThao Phuong Tran1,3*, Linh Thu Ngu en2, Keiko Hirose 3,
Fumio Shimura1, Shigeru Yamamoto 1
1

J

ji U i e i , Nii a-Ci , Sai a a 352-8510, Ja a

2

i Medical U i e i , 1 THa

3Ne i a Hika iga ka H

Tha T g, D g Da di

ic , Ha i, Vie ai al, Ne i a Ci , T k , Ja a
(received April 20, 2020)

ABSTRACT Backg
d bjec i e The Vietnamese older adult population has increased
rapidl on an annual basis and d sphagia has become a common issue. D sphagia and factors
related to d sphagia will effect treatment in general and dietar treatment in particular. This
stud aimed to find out the relationship between d sphagia and oral function, handgrip
strength and pneumonia in older adult inpatients in Vietnam. Me h d The stud was designed
as a cross sectional stud and was conducted from August 2018 to Januar 2019. There weremore than one thousand older adult patients who met the inclusion criteria. The data about
d sphagia status, oral function, muscle strength and pneumonia were collected b dietitians.
Re l The proportions of older adult inpatients with the abilit to open the mouth morethan three fingers, move the tongue forward, move the tongue to the left and right, push the
buccal mucosa with the tongue, inflate both cheeks and with no atroph of the tongue and no
tongue-surface dr ness in the non-d sphagia group were more than d sphagia group (p<0.001).
No difference was observed between those with and without dentures in the two groups. The
d sphagic older adult inpatients had lower muscle strength than the non-d sphagics in bothgenders (p<0.001). There were 13.5% older adult inpatients who suffered from pneumonia. The
pneumonia rate (39.2%) in the d sphagia group was higher than in the non-d sphagia group(8.4%). C cl i
D sphagia has a positive relationship with poor oral function, lowhandgrip strength and a high rate of pneumonia. Dietitians need to have an overview ofd sphagia patients in order to suppl a suitable te ture-modified diet.
Ke W d : elderl , patients, hospital, d sphagia, oral function, pneumonia, muscle strength
INTRODUCTION
Population aging is now a worldwide unavoidable
trend. D sphagia has become a common issue in older
adult populations (1). Swallowing is a comple
neuromuscular activitthat consists of oral,phar ngeal, and esophageal phases, and involves thecoordinated function of man muscles. Thus, manadverse health conditions can influence swallowing
function. Neurological diseases, head/neck andesophageal cancer, and metabolic deficits are broad
categories of diseases that might contribute tod sphagia.
The number of Vietnamese aged 65 and older is
projected to increase rapidl from 7.8% in 2015 to
17.8% in 2050 (2). In previousl published data, morethan one thousand older adult inpatients in three large
Vietnamese hospitals were screened for d sphagia
through the use of quick and simple tools. The results
showed that the rate of d sphagia was quite high,about 16.5% (3). This result is similar to other studies
in Japanese and US older adult populations (4, 5).
Therefore, d sphagia also is a main issue in older
adult inpatients in Vietnam.
In clinical practice, d sphagia patients who sufferfrom neurological conditions such as stroke disease,
Parkinson s disease ma have limited oral function
because of their neurological disorder. Theseabnormal oral functions, such as open mouth, tongue
motion, inflated cheeks, dentures, atroph of the

tongue papilla and dr ing of the tongue surface maaffect d sphagia status. These are simple tests but
based on the d sfunction of each part of the oralcavit , the dietitian can decide which kind of te turemodified diet is suitable for each patient.
Muscle weakness ma reflect a global effect ofaging. The tongue is a ke component in safe
swallowing. Poor performance of the tongue leads tohigh risk of aspiration. There was a significant
positive association between posterior tongue
strength and handgrip strength (6). Checking handgrip
strength ma be suppl information which reflects
tongue strength and muscle of the bod . On the basisof these data, a dietitian can design suitable menus forpatients.
D sphagia patients who aspirate are at anincreased risk of acquiring pneumonia. A recent largescale cross-sectional stud of Japanese older adults
showed that the risk factors for aspiration pneumonia
were sputum suctioning, d sphagia, deh dration, anddementia; pneumonia is the third leading cause ofdeath in this countr (7, 8). Pneumonia is a serious
consequence of d sphagia and a major cause ofmorbidit and mortalit in the older adult; therefore,
improving understanding of the prevalence ofd sphagia in people with pneumonia is also importantto highlight the necessar for better management ofd sphagia to prevent development of this serious
condition.

71

Ph siological functions in Vietnamese d sphagia patients
In this stud , dietitians would directl collect theoral function indicators and muscle strength andpneumonia status of subjects. We thought that b
understanding oral function, muscle strength, andpneumonia status, the dietitian can provide d sphagia
patients suitable food choices. The aim of this stud
was to find the relationship between d sphagia andoral function, muscle strength and pneumonia status
in d sphagic older adult inpatients in Vietnamese
hospitals.

to drink 30 ml water. Subjects who had choking or
voice change were d sphagic. If there was no choking
or voice change, patients were normal (9).
O al f nc i nal e
In order to check oral function, a tongue depressor
was used. Some indicators such as opening degree,
tongue motion, inflating cheeks, dentures, atroph ofthe tongue papilla and lingual surface dr ing werecollected.
M cle eng hMuscle strength was assessed using hand grip
strength. A hand d namometer (MP-HDM03-BK,
China) was used. The mean of three measurementsfrom each hand was recorded. In cases of parenteralnutrition or paral sis, a mean of three measurements
was used from the dominant hand. Missing data could
be accepted.
Pne m nia
Information was collected from the medical
record.
S a i ical a al iP-values of less than 0.05 were considered
statisticall significant for all the anal ses is theplural. The above statistical procedures were
performed using Stata version 12.0.

METHODSe i g a d Sam le
The stud was designed as a cross-sectional stud
and was conducted for 6 months, from August 2018
through Januar 2019. This research was conducted inaccordance with Declaration of Helsinki andapproved b the Hanoi Medical Universit s ethicalcommittee, number 1318. The stud populationconsisted of older adult inpatients being treated inthree large general hospitals in Vietnam Hanoi
Medical Universit Hospital (500 beds), Dong Da
General Hospital (800 beds) and National Geriatric
Hospital (500 beds).
Subjects were recruited for the stud from allnewl admitted patients, i.e., patients in the first 48
hours after admission, b random selection (using arandom number table) from admission registers.
The sample si e was about one thousand subjects
who met the inclusion criteria (1) hospitali ed older
adults in the above three hospitals, (2) age 65 or over.
The e clusion criteria included (1) refusal toparticipate in this stud , (2) mute, deaf or ps choticand (3) suffering from ventilator, coma, trauma or
injur .
All
potential
subjects
completed
questionnaires and were screened using swallowing
tests.
Da a c llec i
All the questionnaires were carried out b
investigators. The investigators were dietitians who
were trained to collect the stud data. Before carr ing
out the actual stud , we conducted a pilot stud on 50
patients to revise the instruments.
Below is the information that we obtained.
Dem g a hic da a
Data such as age, gender, diagnosed diseases werecollected from medical records.
D hagia c eening
Re e i i e ali a all i g e (RSST)
Patients were asked to swallow their own saliva as
man times as possible in 30 seconds; the e aminer
determined the absence of lar ngeal elevation during
swallowing b observing and/or feeling lar ngeal
movement. If a patient was unable to perform threeconsecutive swallows with two retests, he/she
suffered from d sphagia. If a patient was able toswallow 3 times or more, then the Water Swallowing
Test would be administered (9).
Wa e S all i g Te (WST)The e aminer would offer 3ml water for the
subject to drink; if patients choked or their voicechanged, patients suffered from d sphagia. If there
was no choking or voice change, subjects continued

RESULTS
Table 1 shows the characteristics of 1007 older
adult inpatients (420 males and 587 females, meanage 75.5 7.3 ears). D sphagia occurs more in older
patients with no difference between genders. There
were 24% of subjects who suffered from neurologic
disorders or esophageal disorders or respirator &latrogenic disorders.
Table 2 shows the comparison about oral function
between d sphagia group and non-d sphagia group.
The proportions of older adult inpatients with theabilit to open the mouth more than three fingers,
move the tongue forward, move the tongue to the left
and right, push the buccal mucosa with the tongue,
inflate both cheeks in non-d sphagia group werehigher in the non-d sphagia group than in thed sphagia group and have a significant differencewith p<0.001. There was no observed difference inhaving or not having dentures between the two groups.
The d sphagia group had rates of tongue atroph andtongue surface dr ness higher than the non-d sphagia
group and the difference was statisticall significant
with p<0.001.
Table 3 indicated the comparison about muscle
strength between d sphagia group and non-d sphagia
group. The d sphagia older adult inpatients had lower
muscle strength than non-d sphagia patients in bothgenders with a significant difference of p<0.001.
Table 4 show the comparison about aspiration
pneumonia between d sphagia group and nond sphagia group. There were 13.5% older adultinpatients who suffered from pneumonia. The
pneumonia rate (39.2%) in the d sphagia group was
higher than in the non-d sphagia group (8.4%). It had asignificant difference of p<0.0001.

72

Asian Journal of Dietetics, 2020
Table 1. Characteristics of subjects enrolled in this stud (n 1007)
Characteristics
Overall
Dysphagia(n 1007)(n 166)Age, years
75.5±7.3
78.0±7.7
Female, n (%)
587 (58.3)
104 (62.7)
Male, n (%)
420 (41.7)
62 (37.3)
Disease groups
x Neurologic disorders, n (%)
113 (11.2)
45 (27.1)
x Esophageal disorders, n (%)
63 (6.3)
32 (19.3)
x Respiratory & latrogenic disorders, n (%)
65 (6.5)
19 (11.4)
x Other, n (%)
766 (76)
70 (42.2)
Data presented as mean standard deviation or n (%)*Chi-square test # Student t-test

Non-dysphagia(n 841)75.0±7.1
483 (57.4)
358 (42.6)

P-value<0.05#
0.21*

68 (8.0)31 (3.7)
46 (5.5)
696 (82.8)

Table 2 The comparison about oral function between d sphagia group and non-d sphagia group
Oral function indicators
Overall
Dysphagia
Non-dysphagia(n 1007)(n 166)(n 841)
Mouth opening
Higher three fingers 943 (93.6%)
133 (80.1%)
810 (96.3%)
degreeLower three finger
64 (6.4%)
33 (19.9%)31 (3.7%)
Move
your
Can
981 (97.4%)
149 (89.8%)
832 (98.9%)
tongue forward
Can not
26 (2.6%)
17 (10.2%)
9 (1.1%)
Move your tongue left Can
946 (93.9%)130 (78.3%)
816 (97.0%)
and right
Can not
61 (6.1%)
36 (21.7%)
25 (3.0%)
Push the buccal
Can
941 (93.4%)
127 (76.5%)
814 (96.8%)
mucosa with yourCan not
66 (6.6%)
39 (23.5%)
27 (3.2%)
tongueInflatingbothCan
941 (93.4%)
124 (74.7%)
817 (97.1%)
cheeksCan not
66 (6.6%)
42 (25.3%)
24 (2.8%)
DenturesYes
302 (30.0%)48 (28.9%)
254 (30.2%)No705 (70.0%)
118 (71.1%)
587 (69.8%)
Atrophy of theYes
83 (8.2%)
32 (19.3%)
51 (6.0%)
tongue papillaNo
924 (91.8%)
134 (80.7)
790 (94.0%)
Tongue surface
Little saliva
112 (11.1%)
48 (28.9%)
64 (7.6%)
dryingEnough saliva
895 (88.9%)
118 (71.1%)
777 (92.4%)
Fisher s e act test

P-value
P<0.001
P<0.001
P<0.001
P<0.001
P<0.001
P<0.5
P<0.001
P<0.001

Table 3 The comparison about muscle strength between d sphagia group and non-d sphagia group
Muscle strength
Overall
Dysphagia
Non-dysphagia
P-value(kg)
Male
FemaleAll(n 384) 18.6±8.0(n 532) 11.2±5.0(n 916) 14.3±7.4
Mann-Whitne U test

(n 53) 12.6±7.4(n 87) 9.0±4.7(n 140) 10.3±6.1(n 331) 19.6±7.7(n 445) 11.6±4.9(n 776) 15.0±7.4

P<0.001

Table 4 The comparison about aspiration pneumonia between d sphagia group and non-d sphagia group
Pneumonia status
Overall
Dysphagia (n 166)
Non-dysphagia
P-value(n 1007)(n 841)
Yes
No

13.5% (136)
86.5% (871)
Fisher s e act test

39.2% (56)60.8% (101)DISCUSSION
The aging population in Vietnam is increasing
rapidl and d sphagia is becoming an issue ofconcern related directl to qualit of life andmortalit of older adults. Oral function inde es also
provide results regarding d sphagia. Limited mouth
opening, tongue movement are related strongl tod sphagia. Based on these e aminations, dietitians
were able to adjust the te ture of food and the liquid
feeding position of d sphagia patients. For e ample,
d sphagia patients cannot open the mouth easil tochew so pureed food will be the priorit of choice. In
cases of paral sis on one side where the patientcannot sit to eat, the patient s position can be adjusted

8.4% (71)
91.6% (770)P<0.0001

so that he/she lies on the health side and can turn thehead to the paral ed side; then food can be given on
the health side of the mouth.
A decline in isometric tongue strength with aging
has been previousl reported (10). There was asignificant positive association between posterior
tongue strength and handgrip strength (6). It issuggested that lower isometric tongue strength might
represent diminished functional reserve, which ma
increase risk for d sphagia and cause d sphagia omit
(11). In this stud we found handgrip strength of thed sphagia group was lower than in the non-d sphagia.
Malnutrition also leads to reduced muscle (sarcopenia
disease) which has a high risk of d sphagia. Hand grip73

Ph siological functions in Vietnamese d sphagia patientsstrength uses simple equipment to detect low muscle
strength and its relation to d sphagia. A diet shouldhave not onl suitable te ture but also sufficientenerg and protein should be considered withd sphagia patients with low muscle strength.
Pneumonia was found at a higher rate in thed sphagia group. Aspiration leading to pneumonia iscommon in d sphagia patients. Besides pneumonia
status, the bod temperature also needs to beconsidered in determining inflammation status.
Energ and water requirements will need to be
increased to speed recover and reduce risk ofmortalit . Aspiration pneumonia usuall occurs ind sphagia patients in general and in d sphagia
patients with Gastroesophageal reflu disease(GERD) in particular. D sphagia patients with tube
feeding usuall have GERD and consideration of anutrition liquid with high viscosit such as a semisolid can be effective in reducing s mptoms of GERD
(12).
Therefore, oral function, muscle strength andpneumonia have a strong relationship with d sphagia
status. From these observations, the dietitian canmake suitable adjustments to diet from te ture tonutrients to improve the nutrition status of patients.
In conclusion, d sphagia has a positive
relationship with poor oral function, low handgrip
strength and a high rate of pneumonia. Dietitians needto have an overview of d sphagia patients in order tosuppl a suitable te ture-modified diet.

REFERENCES
1) Taki awa C, Gemmell E, Kenworth J and Spe er
R. A S stematic Review of the Prevalence ofOrophar ngeal D sphagia in Stroke, Parkinson s
Disease, Al heimer s Disease, Head Injur , andPneumonia. D sphagia 31 434 441. 2016.
2) Vietnam aging population forecast 2035 Statistic
Statista
Availableathttps //www.statista.com/statistics/713671/vietnam-forecast-aging-population/. Accessed on 8
Februar 2019.
3) Tran TP, Ngu en LT, Ka ashita J, Shimura F andYamamoto S. D sphagia Prevalence among
Elderl in Some Vietnamese Hospitals. Asian
Journal of Dietetics 1: 48 52. 2019.
4) Barc i SR, Sullivan PA and Robbins J. How Should
D sphagia Care of Older Adults Differ?
Establishing Optimal Practice Patterns. Seminars
in Speech and Language 21 347 364. 2000.
5) Japanese National Institute of Longevit Research.
Report on research project on eating swallowing
disorder. 2012.
6) Butler SG, Stuart A, Leng X, Wilhelm E, Rees C,
Williamson J and Kritchevsk
SB. TheRelationship of Aspiration Status With Tongueand Handgrip Strength in Health Older Adults.
The Journals of Gerontolog Series A Biological
Sciences and Medical Sciences 66A 452 458.
2011.
7) Manabe T, Teramoto S, Tami a N, Okochi J and
Hi awa N. Risk Factors for Aspiration Pneumonia
in Older Adults. PLoS ONE 10 1 12. 2015.
8) Ministr of Health, Labour and Welfare Handbookof Health and Welfare Statistics. Japan. 2017.
9) Horiguchi S and Su uki Y. Screening Tests in
Evaluating Swallowing Function. JMAJ 54 31 34.
2011.
10) Youmans SR, Youmans GL and Stierwalt JAG.
Differences in tongue strength across age andgender is there a diminished strength reserve?
D sphagia 24 57 65. 2009.
11) Robbins J, Levine R, Wood J, Roecker EB and
Luschei E. Age effects on lingual pressure
generation as a risk factor for d sphagia. J
Gerontol A Biol Sci Med Sci 50 M257-262. 1995.
12) Ichimaru S and Amagai T. Viscosit Thickened
Enteral Formula. In Diet and Nutrition in Critical
Care. Springer New York 1 15. 2014.

DISCLOSURE OF STATE OF COI
No conflicts of interest to be declared.
ACKNOWLEDGEMENTS
This research was supported b
Jumonji
Universit and US-Japan Medical Science Programs.
The corresponding author especiall thanks Otsuka
Toshimi Scholarship Foundation supported to stud
PhD program in Japan. The authors would like tothank all the participants for their cooperation andHanoi Medical Universit Hospital, Dong Da
General Hospital, National Geriatric Hospital and the
dietitians who provide assistance in the collection ofdata in Vietnam. Finall , we also would like to thankAndrew Durkin, Prof. Emeritus of Indiana Universit ,for editing our English.

74

Asian Journal of Dietetics, 2020

Research Note
Nutrition Support Following Enhanced Recovery After Surgery Protocol
for Malnourished Cancer Elderly PatientChi

Yi H 1*, Ai i Ma i ah M ha

ad1, Ja il O a 2, A iki Fal a ad Ah ad3

1

De a men of Die e ic and Food Se ice, Na ional Cance In i e, Miniof Heal h,Mala ia2
De a men of S gical Oncolog , Na ional Cance In i e, Miniof Heal h,Mala ia3
De a men of S ge , KPJ Selango S eciali Ho i al, 40300 Shah Alam, Mala ia.
ABSTRACT Short-term nutritional optimization before surgery and Enhanced Recovery
After Surgery (ERAS) protocol aimed to achieve early recovery after surgery by maintaining
preoperative organ function and reducing the profound surgical stress response. Case
presentation: A 83-years-old female patient with Rectal Adenocarcinoma with Locoregional
Infiltration of Uterus was started intensive nutritional intervention fortnight pre-operation. The
patient was cachexia with 33 kg; loss of 2 kg within 1 month; PG-SGA score 13 (severe
malnourished); She experienced very poor oral intake for the past 1 month. Total intake was
770 kcal and 33 g/day protein. Oral nutritional support (extra 500kcal) was given. The phone
call and home-visit were conducted to ensure compliance of the nutritional intervention. Upon
admission, the patient gained 0.9 kg; increased intake 1542 kcal/day with 76g/day protein.
ERAS protocol with preoperative carbohydrate loading and postoperative early oral feeding
was implemented. Length of hospital stay was 6 days 16 hours, clear fluid toleration was 20
hours, solid food toleration was 5 days and gastrointestinal function (flatus and bowel open)
was 3.5 days. Discussion: Advanced age is a proven risk factor for postoperativecomplications. Intensive nutrition support, which involved phone call and home-visit, wasproven to facilitate compliance towards nutrition counselling. Integrating nutritional support
following perioperative ERAS protocol showed combination outcomes where increased
nutrition intervention compliance and shorten length of hospital stay without compromise
complications for the malnourished elderly patients. Conclusion: Nutrition support following
the ERAS protocol was beneficial for malnourished cancer elderly patients.
Keywords: Nutrition support, ERAS, malnourished, elderly.

INTRODUCTION
Cancers are one of the leading causes ofmorbidity and mortality worldwide. There isfrequent development of malnutrition and metabolic
derangement among cancer patients due to increasenutrients requirements and reduced oral intake.
Treatment of cancers includes surgeries,
radiotherapies, and pharmacological therapies.
Surgery leads to inflammation and metabolic stressresponse. Surgical stress and trauma will induce
further catabolism of nutrient storage in the body(glycogen, fat, and protein) among cancer patients(1,2).
Pre-operative
prehabilitation
wasrecommended to optimize nutritional status patients
before elective operation (1).
Nutrition intervention is the key element in
preoperative management phase (3). Nutritionalcounseling and provision of oral nutrition
supplement preoperative has been shown tosignificantly increase energy and protein intake (4).
As per the recommendation in Enhanced Recovery
After Surgery (ERAS) and European Society for
Parenteral and Enteral Nutrition (ESPEN) 2017,
shortening the preoperative fasting via carbohydrate(CHO) loading and postoperative early initiation oforal feeding, early mobilisation, minimal invasive
surgery, and multimodal pain management withminimal opioid usage improved postoperative
outcomes and without increased postoperative
readmission rate (1,5). The purpose of this casereport is to share our clinical experience with thepractice of nutrition support following with ERAS
protocol for malnourished surgical cancer elderly
patients.
Case presentation
An 82-years-old female patient was diagnosed
with rectal adenocarcinoma with local infiltration to
the right side of the uterus, elective admitted forcolon resection low anterior resection with Total
Abdominal Hysterectomy with Bilateral SalpingoOophorectomy operation fortnight. The patient firstpresented to a multidiscipline clinic, with low Body
Mass Index (BMI) 14.7 kg/m2, cachexia looking,and lost weight 7 kg within one month. Nutritional
assessment using PG-SGA, found that patient wasmoderately malnourished with PG-SGA score 14,
and albumin level was 30 g/L. Patient-reported*To whom correspondence should be addressed agneshcy0326@gmail.com / dtho@nci.gov.my75

Nutrition support after surgery protocol
significantly reduced appetite and poor oral intake
for the past 1 month with an estimated oral intake of
450 kcal and 15 g/day protein. Nutritional diagnosis
for her was unintentional weight loss related toinadequate oral intake as evidenced by poor oral
intake and weight loss. Intensive nutritionintervention
pre-operative
which
includedindividualized nutritional counseling (whereindividual energy and protein intake were calculated
based on Medical Nutrition Therapy protocol forcancer patients) (6), oral supplementation support,
and home-visit follow-up was started two weeks
before the operation to optimise nutritional status
before admission. After elective operation
admission, protocol (ERAS) with carbohydrateloading and early oral feeding post-operation was
implemented as well. Specific drink withcarbohydrate plus whey protein was served ascarbohydrate loading drink. As one of the elements
in ERAS (preoperative carbohydrate loading), thepatient was loaded with 100 g carbohydrate and 18
g of whey protein as evening drink and 50 g
carbohydrate and 9 g whey protein 3 hours preoperation. Postoperative early oral feeding (allowed

36
34
32
30
28
26
24
22
20

33.9

33.7

33.1

34.1

27.9

27.6

1st visit clinic

clear oral nutrition supplement 6 hours after
operation) was implemented for this patient. After
tolerated with 750 ml clear oral nutrition supplementon the post-operation day 1, the patient started asolid diet on post-operation day 2; tolerated wellwith solid food on post-operation day 5 and alloweddischarged on post-operation day 6. Anthropometry
was measured by using calibrated body composition
analyzer, TANITA model SC 330. As a summary,length of hospital stays was 6 days 16 hours, clear
fluid toleration was 0.8 day, solid food toleration
was 5 days and gastrointestinal function (flatus &bowel open) was 3.5 days. There were no incidents
regarding postoperative ileus, wound breakdown,
infection, or pneumonia recorded for this patient.
Intensive nutritional intervention (counseling andoral nutrition supplement prescription) was given to
the patient throughout the hospitalization and after
discharge. The patient reported good improvement
in appetite and more cheerful. She gained weightand muscle mass and achieved adequate oral intake
with oral nutrition supplement upon 1-month follow
up.

26.7
weight (kg)muscle mass (kg)26

admissiondischarge

follow up (1 month)Figure 1. Perioperative Anthropometric Changes

Table 1. Daily total energy and protein intake

Daily total energy intake(kcal/day)
Daily total protein intake(g/day)1st visit clinic

Admission

Discharge

Follow up (1 month)

770

1542

830

1492

33

76

42

62.4

DISCUSSION
In this study, we able to demonstrate that
intensive nutrition intervention can maintain patient
weight preoperatively, as shown in figure 1. It is
important to ensure weight loss among cancer
patients not reduce further preoperatively because
weight loss will influence survival during recovery.
For instance, Isenring et al. (2004) found that
intensive nutrition intervention with regular followup helped attenuate weight loss in the intervention
group compared to those subjects in usual care group(7). In the study, subjects in the intervention group,comprised of gastro intestine or head and neckpatients, who have received early nutrition
counseling, telephone reviews, and oral nutrition
supplement showed more weight stable among
subjects.
As shown in Table 1, the energy and protein
intake of patient improve preoperatively frombaseline. These results were similar in the study
conducted by Macfie et al. (2000). The study showsthat patients, who received oral nutrition supplement,
significantly reported higher energy and protein
intake compared to patients who are not received oral

76

Asian Journal of Dietetics, 2020
nutrition supplement during preoperative outpatient
phase (4). Other studies also documented that oral
nutrition supplement has proven effective atincreasing the nutritional intake of the patients (8).
Stratton et al suggested that positive outcome seen inpatients given with oral nutrition supplement was
associated with the minimal effect that liquid
supplements probably have on appetite and voluntary
food intake (increasing total energy and protein
intake) (8).
Our study supports the findings of many studies
that conclude that oral nutrition supplement is able toincrease total energy and protein intake. It is believedthat adherence patients toward oral nutrition
supplement regime and nutrition counseling play animportant key in the positive outcome seen. It issuggested that adherence towards dietary advice andoral nutrition supplement prescription could beachieved if patient receives encouragement by adietitian. As for this patient, we developed amonitoring system where a patient was followed upby the dietitian by phone call and a home visit.
During phone and home visit follow-up, patientswere educated on how to manage symptoms, provide
encouraging words to maximize health, and mostimportantly ensure calorie and protein requirements
achieve. These beliefs to be drivers for dietary
manipulation as well (9,10).
Phone counseling is feasible and helpful inimproving the outcome of the treatment, whereby the
respondent rated counseling relationship and level ofinterpersonal influence similar to face to facecounseling (9,10). The rapport developed duringphone counseling also believes to facilitate on-goingparticipation in the study (10). Besides, acomprehensive approach given during home visit
which includes motivation and individual education
especially for an elderly patient is proven effective in
improving nutritional outcome (12).
Elective surgery has been shown to reduce insurgery stress, minimize catabolism, and support
anabolism throughout surgical treatment andpromote speedy recovery process if compare to
emergency surgery. Traditionally, the patient was
kept nil-by-mouth before surgery. A nasogastric tube
was used to clear stomach content and withheld oral
feeding until resolution of the postoperative ileus
because the patient was believed that unable totolerate early feeding. Once bowel function returned
with bowel sound, the patient was allowed for clear
fluid as standard post-operation drink and step up
feeding/diet accordingly (3). However, researches
have proven that ERAS whereby patient was allowed
for solid food 6 hours and clear fluid 2 hours before
surgery as well as early oral feeding on the first dayof post-surgery length of hospital stays, length ofbowel function return and length of solid foodtoleration significantly (3,13,14,15,16).
Advanced age is shown as the risk factor of
postoperative complications. A study showed thatelderly patients postoperative morbidity rate andmortality rate were significantly higher if comparedwith younger patients (14). The elderly probably
takes longer time to recover from anesthesia and theirileus rate after surgery is higher if compared withyounger patient (15). Traditional perioperative carepatient s length of hospital stays after elective
colorectal surgery was reported around 10 to 15 days

and was associated with a delayed return of bowel
motility (16,17,18,19). This patient was recorded
similar outcomes with previous study findings that asignificant reduction of 2 days in length of hospital
stays was achieved after implementing ERAS (8 days
vs. 6 da ;< 0.0001) without increasing
readmission rate in elderly patients who underwent
elective colorectal surgery (21).
Good compliance with the ERAS protocols also
resulted in faster peristalsis return and earlier bowel
movement which was 2.5 days postoperatively on
average, regardless of the age of patients. Patients
hospitalized up to 10 to 15 days and with delayed
bowel motility post-operatively under traditional care
(19,20,22). Studies also proved that significantly
shorten the length of hospital stays, and reduced thenumber of postoperative complications (17,18). Postsurgery complication rate, length of hospital stays
and length of solid food toleration indicate
successfulness of ERAS protocol implementation.
There are no significant differences in length of stay
post colorectal operation between younger and older
age groups of patients; the mean of hospital stay was
5 days (18). Both younger and older groups ofpatients reported that able to tolerate early
postoperative oral fluid and food intake (21).
This case report is supported by previous studies
result whereby elderly patient benefited via ERAS
protocol post-operatively. ERAS protocol did notshow to be harmful in elderly surgical patients;
instead, it has comparable positive outcomes as
younger surgical patients (23,25).
CONCLUSION
Nutrition support following ESPEN which
recommended preoperative early nutrition supportand ERAS protocol was beneficial to this patient.
Preoperative prehabilitation optimize the nutritional
status of patients before elective operation while
ERAS protocol boosts postoperative recovery, andshortened length of hospital stays, length of bowel
function return, and length of solid food toleration
without compromised postoperative complications orreadmissions.
CONFLICT OF INTEREST
The authors declare no conflict of interest arisingfrom the findings for the reported case and its
management.
ACKNOWLEDGEMENT
We would like to thank the Director-General of
the Health Ministry of Malaysia for permission to
publish this article.
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N, Bertz H, Bozzetti F, Fearon K, Hütterer E,
Isenring E, Kaasa S, Krznaric Z. ESPEN
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Clinical nutrition. 2017 Feb 1;36(1):11-48.
2) Weimann A, Braga M, Carli F, Higashiguchi T,
Hübner M, Klek S, Laviano A, Ljungqvist O,
Lobo DN, Martindale R, Waitzberg DL. ESPEN
guideline: clinical nutrition in surgery. Clinicalnutrition. 2017 Jun 1;36(3):623-50.

77

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3) Gillis C, Buhler K, Bresee L, Carli F, Gramlich16) Ho CY, Ibrahim Z, Abu Zaid Z, Mat Daud ZA,

L, Culos-Reed N, Sajobi TT, Fenton TR. Effectsof nutritional prehabilitation, with and without
exercise, on outcomes of patients who undergo
colorectal surgery: a systematic review andmeta-analysis. Gastroenterology. 2018 Aug
1;155(2):391-410.
4) MacFie J, Woodcock NP, Palmer MD, Walker
A, Townsend S, Mitchell CJ. Oral dietary
supplements in pre-and postoperative surgicalpatients: a prospective and randomized clinical
trial. Nutrition. 2000 Sep 1;16(9):723-8.
5) Kehlet H. Multimodal approach to control
postoperative pathophysiology andrehabilitation. British journal of anaesthesia.
1997 May 1;78(5):606-17.
6) American Dietetic Association (ADA). Energy,
macronutrient,micronutrient
and
fluid
requirements. In: The Clinical guide to oncology
nutrition. 2nd ed. Chicago. 2006; 7:51-71.
7) Isenring EA, Capra S, Bauer JD. Nutritionintervention is beneficial in oncology outpatients
receiving radiotherapy to the gastrointestinal orhead and neck area. British journal of cancer.
2004 Aug;91(3):447-52.
8) Stratton RJ. Should food or supplements be usedin the community for the treatment of diseaserelated malnutrition. Proceedings of the
Nutrition Society. 2005 Aug;64(3):325-33.
9) Reese RJ, Conoley CW, Brossart DF.
Effectiveness of telephone counseling: A fieldbased investigation. Journal of counseling
Psychology. 2002 Apr;49(2):233.
10) Silvers MA, Savva J, Huggins CE, Truby H,
Haines T. Potential benefits of early nutritional
intervention in adults with upper gastrointestinal
cancer: a pilot randomised trial. Supportive Carein Cancer. 2014 Nov 1;22(11):3035-44.
11) Zalina AZ, Kathryn J, Mirnalini K & Lynne C.
Improving the nutritional status of patients withcolorectal cancer undergoing chemotherapy
through intensive individualised diet andlifestyles counselling. Malaysian Journal of
Nutrition. 2016. 22(1): 65-79.
12) Beck AM, Kjær S, Hansen BS, Storm RL, ThalJantzen K. Study protocol: follow-up home visitswith nutrition: a randomised controlled trial.
BMC geriatrics. 2011 Dec 1;11(1):90.
13) Fearon KC, Ljungqvist O, Von Meyenfeldt M,
Revhaug A, Dejong CH, Lassen K, Nygren J,
Hausel J, Soop M, Andersen J, Kehlet H.
Enhanced recovery after surgery: a consensus
review of clinical care for patients undergoingcolonic resection. Clinical nutrition. 2005 Jun
1;24(3):466-77.
14) Ljungqvist O. ERAS enhanced recovery after
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15) Bakker N, Cakir H, Doodeman HJ, Houdijk AP.
Eight years of experience with enhanced
recovery after surgery in patients with coloncancer: impact of measures to improveadherence. Surgery. 2015 Jun 1;157(6):1130-6.

Omar J, Mohd Abas MN, Abdul Rahman Z,
Jamhuri N. Impact of Enhanced Recovery after
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17) Gustafsson UO, Scott MJ, Schwenk W,
Demartines N, Roulin D, Francis N, McNaught
CE, Macfie J, Liberman AS, Soop M, Hill A.
Enhanced Recovery After Surgery Society fPC,
European Society for Clinical N, Metabolism,
International Association for Surgical M,
Nutrition. Guidelines for perioperative care inelective colonic surgery: Enhanced Recovery
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rehabilitation in elderly patients after
laparoscopic colonic resection. British journal ofsurgery. 2000 Nov 1;87(11):1540-5.
19) Kehlet H, Büchler MW, Beart Jr RW,
Billingham RP, Williamson R. Care after colonic
operation is it evidence-based? Results from amultinational survey in Europe and the UnitedStates. Journal of the American College ofSurgeons. 2006 Jan 1;202(1):45-54.
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21) Tejedor P, Pastor C, Gonzalez-Ayora S, OrtegaLopez M, Guadalajara H, Garcia-Olmo D. Shortterm outcomes and benefits of ERAS program inelderly patients undergoing colorectal surgery: acase-matched study compared to conventionalcare. International journal of colorectal disease.
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22) Staib L, Karl Heinz Link MD, Blatz A, Hans
Günther Beger MD. Surgery of colorectal
cancer: surgical morbidity and five-and ten-year
results in 2400 patients--monoinstitutional
experience. World journal of surgery.
2002;26(1):59.
23) K ci P, Whi le A, P ik l P, B ck
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H d c D, ek
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24) Veenhof AA, Vlug MS, van der Pas MH, Sietses
C, van der Peet DL, De Lange-De Klerk ES,
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78

Asian Journal of Dietetics, 2020
Re ea ch N e

Va ida i

f Ca ie S i e Vie a S f
f Mea i g F d I akea e

Nguyen Huong Giang1*, Ta Thi Ngoc1, Nguyen Mai Phuong1, Ngo Thi Thu Hien1, Nguyen Thuy Linh2,
Vu Thi Thu Hien3, Hitoshi Iizuka1, Fumio Shimura1, Shigeru Yamamoto1,
1

J m nji Uni e i Nii a, Sai ama P efec e, Ja an
Han i Medical Uni e i , Han i, Vie nam
3
Na i nal In i e f N i i n, Han i, Vie nam
2

ABSTRACT Backg nd ande. Achieving accuracy and precision in assessing dietis a challenge. Food weighing (FW) is the “gold standard method for dietary estimation.
However, this method is time-consuming, costly, and disruptive. Traditional methods suchas 24h recall, diet record and food frequency questionnaires are mostly used today but thesedepend largely on the participants memory. A new Vietnamese version of a nutrition
support software called “Calorie Smile Vietnam (CSV) has been developed and has a foodmeasuring intake function. The purpose of this study was to test the validity of CSV
software for measuring food intake compared with the weighed food method. Me h d.
Actual intake of meals (study 1) and dishes (study 2) as estimated by the CSV method werecompared with weighed food. Three dietitians independently estimated portion sizes ofeach food. Re l . Estimation of food intake by CSV was highly correlated with FW. CSV
showed small overestimates or underestimates (from 0.2% to 4%). Energy and nutrients
calculated from CSV had no difference when compared with FW, except for lipid (p<0.05).
Bland-Altman regression found the CSV yielded results comparable to FW. C ncl i n.
Calorie Smile software is a useful tool for measuring food intake with high accuracy andovercomes the disadvantages of conventional methods.
Ked Validation, Calorie Smile Vietnam software, measuring food intake
INTRODUCTION
The accuracy of evaluating nutritional
components in dietary surveys is fundamental forassessing nutritional status and analyzing therelationship between diet and a population's healthstatus (1). The most accurate method for measuring
food intake is the food weighing (FW) method:weighing food before and after eating (2). However,weighing each food item can introduce changes ineating habits, exerts a huge burden on individuals, isvery difficult to use with a large sample of people anddoes not permit assessment of past intakes (3,4). In
the context of public health nutrition, self-reporting
methods (food records, 24-hour recall, and foodfrequency questionnaires) are commonly used tocollect food intake data but these methods canencounter difficulties. Visual aids used to help
subjects remember and describe the food amounts
have been created (5). A number of studies havereported the benefits of using photographs to help
subjects assess portion sizes (6 13). Food photographs
depicting standardized portion sizes organized in anatlas are helpful in improving the accuracy of foodquantification (14,15). Therefore, the image-based
method is an innovative approach compared with theconventional ones. In addition, in order to measure
food intake accurately, we need well-trained
personnel such as dietitians.

However, recently in Vietnam, the number of
dietitians is very limited. Therefore, if we continue tofollow the traditional food estimating methods, it willtake considerable time. In this situation, a nutrition
support software has been developed, called “Calorie
Smile Vietnam (CSV) (16). This software offers
dietitians (or supporters) a new way to conveniently
exchange information with their patients (or users)
and was designed for both computer and smartphoneuse. The basic method is that users take photos of
their food, send them to the dietitian s computer, andthen the dietitian evaluates their dietary pattern andgives proper advice to users. CSV software has been
integrated with the Vietnam Food Composition Table
2007 (17), the nutrient value of 500 common dishes
from the Hanoi area (18), and the nutrient value ofcommon street foods from [the] Ho Chi Minh cityarea (19). When users meals are different or they eat
items other than those in the data base, adjustments
can be made according to the "Photo book to estimate
the weight of food" (20), so the dietitians can analyze
users meals easily and quickly.
There are many potential benefits to be gainedby using CSV software in evaluating diet, but there
has been no study to validate it. For this reason, we
carried out this study with the purpose of testing thevalidity of CSV software for measuring food intake
compared with weighed food.

*To whom correspondence should be addressed:
giang3900@gmail.com

7Validation of Vietnamese nutrition survey software(kcal), protein (g), lipid (g), and carbohydrate (g).
S a i ical Anal i
Spearman's rank correlation coefficients were
calculated to assess the association.
The differences in energy and nutrient intake
between CSV and FW were tested using one
sample t-test.
Agreement between the two methods wasevaluated according to Bland–Altman analysis.
Statistical analysis was done by SPSS 20.0. The
significance level for statistical tests was set at 0.05
for all tests.

METHODSS d de ig a d e h d
The study followed a cross-sectional study.
S d 1: 50 test meals were prepared in university
cafeterias and given to students at lunch. The meals
included 5 dishes: starches, a meat dish, 2 vegetabledishes, and soup. S d 2: 78 test dishes wereprepared in university cafeterias and given to
students. The dishes varied from a complete dish likea main dish to a single food like a cup of milk or abowl of rice or even one piece of fruit.
For both studies, the procedure was the same:
Before and after serving, each component wasweighed and a trained research staff took all of thephotographs of the food to the same standard (study
1: whole meal photo, study 2: dish photo). The food
was photographed using a smartphone mounted on a
tripod with the lens 2 feet above and 2 feet away fromthe center of the meal plate with a camera angle ofapproximately 45 . A placemat with marked regions
for placement of the food plates was fixed to the tablesupporting the camera tripod to ensure optimal
visibility of the meal in the digital photographs. All
the photos were sent to the CSV software platform
for estimation.
Three dietitians involved in this study
independently estimated portion size and thencalculated the actual food intake using CSV software.
The results as estimated by CSV were compared withweighed foods. The comparison focused on energy

RESULTS
Study 1: 50 test meals
Table 1 shows the comparison of energy andnutrient intake between FW and CSV. There was no
significant difference between the two dietaryassessment methods for intakes of energy,
carbohydrate and protein, although the meandifference in lipid/meal was statistically significant(p<0.05). The correlation between the two methods
was relatively high, ranging from 0.73 (for energy) to
0.79 (for carbohydrate).
Figure 1 shows the differences in estimatedenergy and nutrients intake from meal between the
CSV and FW methods against the FW method withthe representation of confidence interval (CI) limits
for mean. Most data points are within 95% CI with
only one or two outliers.

Table 1: Comparison of estimated energy and nutrients intake from lunch between FW and CSV
Mea i ake
Mea diffe e ce
Diffe e ce
Pea
N ie
Me h d
SD
SD
(%)
c eai
FW
605.9 69.5
E e g (kca )1.0 49.2
0.2
0.73**
CSV
606.9 61.6
FW
33.6 6.7
P ei (g)1.28 4.76
3.9
0.77**
CSV
34.9 7.2
FW
22.5 4.7
Li id (g)0.97 3.3
4.0
0.74**
CSV
23.4 4.6+
Ca b h d a eFW65.7 11.8-1.9 7.2
3.0
0.79**(g)
CSV
63.7 10.6+ -test, p<0.05** p<0.001

Figure 1: Plot of differences between CSV and FW methods against the FW method in estimating energy andnutrient intakes from meal

0

Asian Journal of Dietetics, 2020
S d 2 78 e di he
Figure 2 presents the differences of estimatedenergy and nutrient intake from dishes between CSV
and FW method against the FW method with therepresentation of confidence interval (CI) limits formean. The 95% CI were relatively narrow and mostdata points are within the limits of agreement with
only a few outliers. In addition, the scatter around thebias line tends to get larger as the intake estimated by
FW increases.

Figure 2: Plot of differences between CSV and FW methods against the FW method in estimating energy andnutrient intakes from dishes
DISCUSSION
The results of this study support the validity of
the CSV for measuring food intake. Overall, CSV washighly correlated with foods that were carefully
weighed and measured. There was no significant
difference between the two dietary assessment
methods for intakes of energy, carbohydrate andprotein intakes, although the mean difference oflipid/meal was statistically significant. It could beunderstood that lipid is a component that creates
difficulties in assessing diet via the CSV platform
because CSV operates in visual items. Moreover,energy and the three nutrients estimated from CSV
indicated a high level of association with FW withcorrelation coefficients ranging from 0.73 (energy) to
0.79 (carbohydrate), which also strongly supports thevalidity/accuracy of this method. The average
differences between the two methods were also small,ranging from 0.2% (energy) to 4.0% (lipid)
overestimated and 3% underestimated (carbohydrate).
The percentage difference in energy was only 0.2%
overestimated compared with the actual FW which
was more accurate than the novel food frequency
questionnaires with 11% underestimated (21) and theRemote Food Photography Method with an error
range of 8.8% to 6.8% (22). Lipid is the component
that has the highest percentage of differencecomparing the CSV and FW methods but thedifference is still small (4.0%). As previously
mentioned, lipid was estimated mostly on the basis ofexperience, so needless to say these experiences varyfrom individual to individual. From the comparison
with previous studies, CSV has provided positive
results in terms of assessing diet with less than 5 %estimated food difference.
An acceptable level of agreement between CSV
with FW was demonstrated by the Bland–Altman
plots. According to figure 1 and 2, the two methods

were found to be comparable in estimating energy andnutrient intakes for both meals and single dishes. The
approach involves linearly regressing the difference
depending on the average. Almost all of the points arein a band of plus or minus double the standard
deviation of the straight equality of means. Bland–
Altman analysis shows that most measures of energy
and nutrients are scattered on either side of the meandifferences and all along the line of equality(difference=0). Our data analyses of energy andnutrient intakes show that the Calorie Smile software
method was able to adequately estimate the weights
of food portions and gave results that are comparable
to the actually consumed amounts (FW).
To sum up, from the results of the study, theappearance of CSV software is actually an innovationin the nutritional field which can be considered auseful method in assessing dietary intakes in a freeliving environment as well as for clinical purposes,
given its high level of accuracy.
ACKNOWLEDGEMENTS
I would like to extend my great appreciation to
US-Japan Medical Science Program, Jumonji
University for giving the best condition to complete
the study; and to Prof. Andrew Durkin, emeritus
professor of Indiana University, for careful proofreading of the paper.
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food intake: An overview. Handbook ofassessment methods for eating behaviors andweight-related problems: Measures, theory, andresearch. 215–40. 1995. Sage Publications,1

Validation of Vietnamese nutrition survey softwareThousand Oaks, CA, US.
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12. Nelson M, Atkinson M, Darbyshire S. Food
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Y, Oráa E, Mata C. Development of aphotographic atlas of Venezuelan food portions.
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2009.

2

Asian Journal of Dietetics, 2020

Letter to Editor
Milk in School Lunch and Nutritional Adequacy, Asian Journal of Dietetics 2019
A Comment
Edem M A Tette1, Juliana Yartey Enos2*
1
2

Department of Community Health, University of Ghana Medical School, College of Health Sciences
Department of Epidemiology, Noguchi Memorial Institute for Medical Research, College of Health
Sciences, University of Ghana, Legon

Dear Editor:
The study by Matsumoto et. al. (2019) reported thatwhile calcium intake was higher among adolescent
girls who had milk as part of their school lunch,intakes of niacin, vitamin B12, iron, copper andsodium were higher among students who did not havemilk as part of their school lunch (1). They found no
significant differences in total nutritional inadequacy
and inadequacy for each nutrient among the twogroups and concluded that habitual nutrient intake
adequacy for Japanese junior high school female
students was independent of milk provision in school
lunch programs (1). This finding is disconcerting as
dairy products such as milk have been recommended
for preventing undernutrition and treating stunting inchildren (2). In addition, it has been reported that there
may be a small but limited window of opportunity tominimise stunting in adolescence due to delayed
skeletal growth (3). The milk in school lunch might
therefore be beneficial to stunted adolescents who
may have missed earlier opportunities for correction.
Stunting, which is a manifestation chronicmalnutrition, is defined by a height-for-age z-score ofmore than 2 standard deviations below the World
Health Organization (WHO) Child Growth Standards
median (4). In 2016, an estimated 154.8 million (22.9%)
children under 5 years of age globally were reported
to be stunted. This included 87 million children in
Asia, 59 million in Africa and 6 million in the Latin
American and Caribbean regions (4). Global interest in
stunting stems from its association with poorcognitive development, child mortality and poor adult
health. Furthermore, studies have documented
associations between childhood stunting and anincreased risk of degenerative diseases such as
diabetes, hypertension and coronary heart disease inlater life (5). Consequently, the Global Nutrition
Targets aim at a 40% reduction in the number ofchildren under 5 years of age who are stunted by 2025,
which is also a target of the Sustainable Development
Goals (4).
Milk is considered as a standard reference protein,a panacea in malnourished states and is used in the
preparation of F75 and F100 nutritional supplements
for treating severe acute malnutrition or wasting (2).
More recently, studies have explored its use forpreventing and treating stunting because stunting has
been associated with limited consumption of animal
food sources including milk (6). The South East Asian--------------------------------------------------------------* Corresponding Author: jyartey@gmail.com

Nutritional Survey, for instance, reported lower
stunting and underweight among children who
consumed dairy products on a daily basis comparedwith those who did not (7). One of the most successful
food policies in the last century was the Milk in
Schools Scheme for school children in post-war
Britain and Japan (8,9). Thus, providing milk forschool children may be one of the ways the world canalleviate the enormous burden of undernutrition andstunting, improve calcium and other nutrient intakes
and obtain other benefits such as improvements incognitive function (10).
In the article by Matsumoto et. al. (1), although themean height of adolescents in the milk group was
higher than the non-milk group, which is expected, theauthors concluded that providing adolescent girls inschool with milk may not always translate into
nutrient sufficiency as it also depends on the dietconsumed at home or complementing the milk. The
observation may also be related to the skipping of
breakfast among adolescents as recently reported inanother study by Matsumoto et. al. (11). While further
studies are needed to unravel these observations inother contexts, including resource-limited settings
where the home diet is often inadequate, their findings
suggest that in these school settings, milk provision
should be considered complementary and attention
should probably be focused on promoting milk
consumption in early childhood or younger school-age
children. The Food and Agriculture Organisation (FAO)
promotes milk in schools through school milk
conferences and a world school milk day (12). Suchinitiatives must be supported and strengthened bynutrition sensitive food and agricultural policies that
promote milk production and consumption bychildren and adolescents, since providing milk inschools, though expensive, can provide long-term
developmental and socioeconomic benefits to society.

REFERENCES
1.

83

Matsumoto M, Masumoto A, Sakamoto A, Saito
A, Ikemoto S. Adolescents Habitual Nutrient
Intake Adequacy was Independent of Milk
Provision in School Lunch in Japan: A Crosssectional Study of Japanese Junior High School
Female Students. Asian J of Dietetics 1(4): 90-99.
2019.

Milk in school lunch and nutrition
2.
3.

4.

5.

6.

7.

Michaelsen KF. Cow s milk in the prevention andtreatment of stunting and wasting. Food Nutr
Bull 34(2): 249-51. 2013.
Wiley A. Does Milk Make Children Grow?
Relationships Between Milk Consumption andHeight in NHANES 1999-2002. Am J Hum Biol
17(4): 425-41. 2005.
de Onis M, Onyango AW, Borghi E, Siyam A,
Nishida C, Siekmann J. Development of a WHO
growth reference for school-aged children andadolescents. Bulletin of the World HealthOrganization 85: 660-7. 2007.
WHO. WHA Global Nutrition Targets 2025:
Stunting
PolicyBrief.
https://www.who.int/nutrition/topics/globaltargets_
stunting_policybrief.pdf
Headey D, Hirvonen K, Hoddinott J. Animal
Sources of Food and Child Stunting. American
Journal of Agricultural Economics 100(5): 13021319. 2018.
Nguyen Bao KL, Sandjaja S, Poh BK,
Rojroongwasinkul N, Huu CN, Sumedi E, Aini
JN, Senaprom S, Deurenberg P, Bragt M, Khouw
I; SEANUTS Study Group. The Consumption of
Dairy and its Association with Nutritional Status

in the South East Asian Nutrition Surveys(SEANUTS). Nutrients 10(6): 759. 2018.
8. Atkins P. The milk in schools scheme, 1934 –45:
nationalization and resistance, History of
Education 34(1): 1-21. 2005.
9. Takahashi E. Secular Trend in Milk Consumption
and Growth in Japan. Human Biology 56(3): 427–
37. 1984.
10. Lee R, Singh L, van Liefde D, CallaghanGillespie
M, Steiner-Asiedu
M, Saalia
K, Edwards C et al. Milk Powder Added to a
School Meal Increases Cognitive Test Scores in
Ghanaian Children. J Nutr 148(7): 1177-1184. 2018.
11. Matsumoto M, Hatamoto Y, Sakamoto A,
Masumoto A, Ikemoto S. Breakfast skipping isrelated to inadequacy of vitamin and mineralintakes among Japanese female junior high school
students: a cross-sectional study. Journal of
Nutritional Science 9: 9. 2020.
12. Michael Griffin. Overview of worldwide school
milk
programmes.
FAO
2005.
http://www.fao.org/fileadmin/templates/est/COMM_MARKETS_MONITORING/Dairy/Documents/
Overview_of_worldwide_school_milk_program
mes.pdf

84

A a JLe eaDc , 2020

Ed
Dea

Re e e ce I a e Le e

P

e

aP

b

a Ra

e.

Ta Thi Ngoc* , Ngo Thi Thu Hien, Nguyen Mai Phuong.
Jumonji University, Saitama, Japan.
:

Dea Ed
I
c
b
acc
T b
R

x

a
,
c
a
ca
a a
a a a
a ac . H,aacca c a
,
a
a
ca
a
a
.
c c, W aaab
D ac I a (DRI).
b

Tab e 1. DRIDRI ( /

C
WHO
USA
Ja a
Ve a
T
DRI
c

a

P

ba

e

ad

BW/da )

b

.T

a
a

a

ba a c

1

ca
a DRI
WHO,
US, Ja a a
V a .Ta (g/kg body weight)
0.75, 0.8, 0.9 a
1.13,
c
.
T
a a
c a
a
b ab
.
I
?
ec

e
DRI ( /da )

Ma e

0.75
0.8
0.9
1.13
,

Tab

56
60
70

46
50
60

Estimated Average Requirement (EAR) of protein
this is expected to satisfy the protein need of 50% of
the people in general population. Recommended
Dietary Allowance (RDA) of protein the daily dietaryintake level of protein to meet the requirements of
97.5% of the general population. It is calculated basedon the EAR. RDA EAR+2SD.
Safe Upper Limit (UL) is the highest level that is
likely to pose no risk of adverse health effects inalmost all individuals in the general population and tomeet everyone s needs but could result in harmful
effects if exceeded (2)..

a. A Joint
WHO/FAO/UNU Expert Consultation analysed thenitrogen balance data of 235 adults who were using
good quality protein sources (Figure 1. Shows) (1).
Dietary Reference Intake (DRI) for Protein
include several different systems for identifying
protein levels that can be used in planning diets forhealthy people and assessing their diets as listed
below.

Number of subjects

250
RDA=Enough for

200

97.5% people.
97.5% of people

150
2SD

100

0.43

Fe a e0.66 EAR 0.83 RDA

Safe Intake

2.0 UL

Figure 1: How to determine Dietary Reference Intake (DRI) for Protein(g/kg body weight)------------------------------------------------------*Corresponding author: a c2707@ a .c85

H
Figure 1 shows EAR as 0.66 g/kg per day and
RDA as 0.83 g/kg per day. Although the UL has notbeen identified, it is stated that intakes of 2g/kg bodyweight are unlikely associated with any risk (1).
A
RDA
97.5%
ba a c
,b
,
a
ac
.F
,
ac a
a
a
a
RDA a c a
a
b a a
.
C
c ac , scientists set DRI any
figure between RDA and UL, which means that
dietitians can think menus with protein intake levelfrom RDA to UL freely.

a

DRI

REFERENCES
1.
2.

86

Holt LE., Snyderman S.E., Protein andAmino Acid Requirements of Infants andChildren., Nutr. Abstr. Rev., 35, 1 13, 1965.
Institute of Medicine 1998, Dietary
Reference Intakes: A Risk Assessment Modelfor Establishing Upper Intake Levels for
Nutrients. 1998.