ISSN2434-2688 Asian Journal of Dietetics

Vol.3 No.2, 2021
Contents
Page T Title and authors
Special Report
29-32

School Meal Program No. 2 in a Series:
History of Japanese School Lunch: A Perspective from Vietnamese Dietitians
Giang Nguyen Huong, Phuong Nguyen Mai, Diep Nguyen Van

Review
33-39

Development of Competency Framework on Clinical Nutrition in thePhilippines
Maria Theresa M. Talavera, Aimee Sheree A. Barrion, Liezl M. Atienza, Leila S.
Africa, Divine Grace C. Domingo, Merly T. Panganiban, Clarissa B. Juanico,
Sheila F. Abacan

Original Research
41-47

Snacking Pattern and Its Association with Body Mass Index and High Body
Fat Percentage in Children
Jagmeet Madan, Nikital Mahakal, Ankita Sawant, Neha Sanwalka

Research Note
49-54

Energy Rich Snacks May be Preferable to Lunch with High Lipid to
Increase Energy Intakes in Older Adults at Risk of Malnutrition,
Northern Thailand
Yupa Chanwikrai, Jukkrit Wangrath, Sunard Techangam,
Chanida Pachotikarn, Shigeru Yamamoto

Research Note
55-57

Perceptions of Dietitians about Sustainable Food Systems and Dietetic Practice
Emily Finlay, Liesel Carlsson

Research Note
59-61

Acceptability of Vietnamese Rice Noodle by Japanese
Sumiko Kamoshita, Yuki Wada, Vu Thuy Linh, Shigeru Yamamoto

Asian Journal of Dietetics 2021

Special Report: School Meal Program
History of Japanese School Lunch: A Perspective from Vietnamese Dietitians
No. 2 in a Series
Giang Nguyen Huong, Phuong Nguyen Mai, Diep Nguyen Van
Jumonji University, Saitama, JapanWe are the first generation of dietitian in Vietnam,
currently studying in a graduate program in Japan.
When we were in university, through student exchange
programs to Japan, we had opportunities to observe
school lunches in Japan. Since then, we have beeninterested in this field, so we decided to study abroadin Japan to learn more about nutrition in schools,
specifically school lunch. The most significant featureof the Japanese school lunch program is not only its
concern with the management and nutritional aspectsof the food served in schools but also its integration of
the school meal into children’s educational, social, andcultural experience. This integration is facilitated in a
number of ways. Meals are served by children
themselves in the setting of the classroom, making
lunch part of the educational continuum of the day.
More importantly, aspects of the meal are incorporated
into instruction, for instance by having students
investigate the origins, sources, and traditions of thefood they are eating. Children are introduced directly
or indirectly to the producers and preparers of theirfood, making them aware of the agricultural, economic,
and social connections of their lunch. The links of theirfood with cultural traditions are also presented, withattention to distinctive Japanese foods and methods ofpreparation, regional and seasonal specialties, as wellas the role food plays in festivals, traditional holidays,
and so on.
Central to the Japanese school lunch is the role ofthe licensed school dietitian/nutrition teacher, aspecialized profession that has developed in Japan.
The nutritionist/nutrition teacher is concerned not onlywith the planning, procurement, and preparation ofnutritionally adequate food for the children in a school
but also with raising children’s awareness of thenutritional aspects of their meal and of its social andcultural interconnections.
The purpose of this article is to introduce thehistory of Japanese school lunch and inspire the next
generations of Vietnamese dietitians, thereby
contributing to the development of school meals in
Vietnam, thereby strengthening the health ofVietnamese children.

Photo 1: First generation nutrition students of HMU
in front of a primary school
led to nutrition education. Nutrition education isprovided by professionals (licensed school
dietitian/nutrition teachers as well as by the teachers ofother subjects. They try to teach dietary habits,
gratitude for food and its producers and the people
involved in providing food. School lunch also serves
as a topic for instruction in science, social studies,
geography etc.
1) Initiation of school lunch in Japan
Providing lunch at schools began in Japan in 1889.
Lunches were provided by a Buddhist confederation
for poverty-stricken children in an elementary schoolin a city located in northern Japan. The simple lunches
that were offered consisted of “onigiri” (rice balls),
grilled fish, and pickled vegetables. A school lunch
encouraged poorer children to come to school. Other
children brought lunch boxes (bento) with food fromhome.
After World War I (1918), because of an economic
depression more than a million children were sufferingfrom malnutrition. Because of the issue of children’s
health, the importance of school lunch was recognized
and lunch was expanded to a certain extent but the
majority of school lunches were limited to
impoverished children and had the purpose ofencouraging them to attend school. During World War
II (1939-45), healthy and strong young people werenecessary for the war effort and school lunch wasmaintained until the final stages of the war in 1944.
2) After World War II
After the defeat in the Second World War (1945),
the Japanese were suffering from severe hunger. The
nutritional situation of Japanese children was
deplorable. It is estimated that sixth grade students atthe time had bodies equivalent to those of fourth gradestudents today due to stunted growth. The General
Headquarters (GHQ) of the US occupying forces
conducted a nutrition survey in Tokyo to estimate foodneeds and to arrange possible donations of food and1. HISTORY
The modern Japanese school lunch program
traces its origins to support in 1945 from the USA,
UNICEF and other organizations in 1945 to savechildren from hunger after the Second World War. In
1951, a school meal law was established under the
Ministry of Education. It was understood not only toencompass drop meals but also to be an extension of
education. The program has developed gradually fromone focusing on energy requirements, to energy andother nutrients, then to food culture and has at present*Corresponding author: giang3900@gmail.com

29

History of Japanese school lunchsuggested starting a school lunch program to theJapanese government in October 1945. GHQ and theLicensed Agencies for Relief in Asia (LARA: a U.S.
non-governmental organization) actively provided
food supplies for this purpose. Their assistanceconsisted mainly of canned foods (meat, fish, andvegetables), powdered skim milk, sugar, salt, raisins,
wheat flour, soybean flour, soybean oil, and fish meal.
In 1946 this support was limited to the Tokyo
metropolitan area, but the following year the effort
was expanded to reach children throughout the country.
In 1949, skimmed milk began to be supplied by
UNICEF and was called UNICEF Milk. A clear effecton height was observed. This milk was very effectivein improving the health of children.
At that time there were no school dietitians or
cooks; therefore, students’ parents came to school toprepare lunch. The government paid for the costs ofpersonnel and facilities. Local governments also tried
to cover other expenses for the improvement of mealquality.
3) Establishment of the school lunch law
Japan regained full independence through the San
Francisco Peace Treaty in 1951, but this brought about
the first crisis in school lunch services because Japanno longer received Government Appropriation for
Relief in Occupied Areas (GARIOA) funding, which
had financially supported school lunches but ended in
1952. The following year, support from LARA wasalso stopped. The cost of school lunch rose for families
and it became difficult for many schools to provide
meals.
The government argued for the termination ofschool lunch. However, Parent and Teacher
Associations nation-wide had initiated a broad
movement demanding that the government support
meals in schools and opposition political parties
jointly proposed legislation for school lunches and the
School Meal Law was established in 1954. Under thislaw, Japanese school lunch has developed
impressively. Initially, the law was aimed only at
primary schools. However, beginning in 1953 several
major natural calamities (typhoons and floods) struck
Japan and malnutrition increased among children in
the affected areas. Because of such problems the law
was expanded in 1956 to cover all schools providing
compulsory education as well as part-time high-schoollevel night courses (1956) and special-needs preprimary and upper secondary schools (1957). School
lunch was recognized as a part of of education,teaching about nutrition, how foods are produced, howmany people are involved by the time food is eaten,
traditional foods and customs. Fresh cow’s milk
replaced powdered milk. Various breads such as rolls,
fried bread and other forms of baked bread began to be
used. Soft noodles also became a popular staple food.
4) School dietitian
Before 1964, the position of dietitian did not exist
and appropriate job titles were not used. In thissituation the main activity was cooking; schools
struggled to satisfy dietary recommendations. Staff
mainly cooked, and planning and preparation ofnutrition education were done during the staff’s free
time. In 1964, the Ministry of Education started partial
support for salaries at kitchens covering several
schools in a given area.
In 1974, the Ministry of Education defined thetitle of school dietitian and the role of the dietitian anddecided on the legally required number of dietitians
working in kitchens at public schools and in kitchenscovering several public schools and their salaries (paidhalf by the local government and half by the central
government). This was gradually expanded to place atleast one nutrition teacher or school dietitian in eachschool kitchen or satellite kitchen, which prepares
meals for several schools in the same area.
5) Establishment of the Nutrition Teacher andthe Shokuiku Basic Act
Since the 1990s, the social environment,
including the family, has changed considerably andnutrition-related health problems have become moreprevalent. In this situation, nutrition education has
become important at school, too. To meet this need, theschool dietitian was required to have mastered highly
specialized knowledge and education techniques and a
License of Nutrition Teacher was established in 2005.
In 2014 there were 12,143 school dietitians and among
them 5,021 were diet and nutrition teachers (2014).
Shokuiku is a Japanese word meaning food andnutrition education. The “Shokuiku Basic Act” wasadopted in 2005. Under this act, school lunch plays animportant role. In 2008, curriculum guidelines wererevised and provisions relating to "the promotion of
Shokuiku" were included. From the standpoint of
Shokuiku, the School Meal Law, school lunch dietaryreference intakes were revised and additional school
lunch safety regulations were added. The guidelines
clearly indicate that school lunch should provide agood model of a daily meal. By eating school lunch
frequently, children establish desirable food habits anddevelop practical skills in choosing appropriate foods.
2. MENUS
Daily school lunch menus, totaling about 200 ayear, are drawn up by the diet and nutrition
teacher/school dietitians in the kitchen of each schoolor the area kitchen covering several schools in a given
area. Menu charts are also delivered to every student’s
family a month in advance so that family members
know what their children are eating. It is also
recommended that the menu chart, along with the fooditems and their weights, be posted in the home so thateveryone in the family can easily refer to it. Knowing
the menus is useful so that parents can avoid serving
the same items for dinner. The menus are also usefulin preventing food allergy problems. Many schools
also post the lunch of the day on line on the internet
together with comments about it by children. The factthat everyone knows what the menus are means thatparents can ask and find out whether children enjoyedlunch or not. It is also an interesting and common topic
for family conversation at home.
The cost of the school lunch is also reflected inmenu planning. The diet and nutrition teacher/school
dietitian creates menus that take into consideration therecommended school lunch allowances and costs.
The cost that parents/guardians pay is only the cost offood materials, with no labor costs. According to anation-wide survey of children by the Ministry of
Education, Culture, Sports, Science and Technology in2013, the average cost of each meal was about 240 yen(about $2) and about 280 yen (about $2.50) for
elementary and junior high school students,
respectively.

30

Asian Journal of Dietetics 2021

Photo 2. Lunch timein a class room

Photo 3. Vegetables used in today's lunch displayed
where it is easy for students to see them.

Photo 4. School lunches at a school
Table 1. Menus in Feb at a public school
Date
1 Feb
4 Feb
5 Feb
6 Feb
7 Feb
8 Feb
12 Feb
13 Feb
14 Feb
15 Feb
18 Feb
19 Feb
20 Feb
21 Feb
22 Feb
25 Feb
26 Feb27 Feb
28 Feb

Menus
Rice flour bread with pumpkin filling, Milk, Udon, Small sardines tempura, Ponkan, Setsubun beans
Rice flour bread, Reduced sugar jam, Milk, Pork and beans, Salad with mayonnaise
Bibimbap, Milk, Wakame soup
Rice, Milk, Braised Meat, Vegetable, Vegetable with sesame sauce, Small piece of cheese
Rice, Milk, Deep-fried tofu, Clear soup, Rice sprinkle
Rice flour bread with apple filling, Milk, Mushroom spaghetti, Seaweed salad with sesame dressing
Rice, Milk, Sauteed pork and burdock root, Thick vegetable omelet , Yukari pickles, Mixed nuts
Rice, Milk, Simmered lemon chicken, Satsuma soup
Curry rice, Milk, Almond jelly, Fukujinzuke
Sandwich, Milk, Shell fish, Shrimp and Mizuna soup
Fried bread sprinkled with roasted soybean powder, Milk, Pumpkin potage, Omelet
Rice , Milk , Mackerel simmered with miso, Braised dry radish, Hijiki seaweed
Rice, Milk, Simmered Chinese-style tofu, Bangbang chicken with dressing, Cream stew
Rice, Milk, Grilled Miso Marinated Fish, Fushimen soup
Rice flour bread with chocolate filling, Milk, Borscht, Japanese style salad
Rice, Milk, Grilled mackerel, Chinese cabbage garnish with ponzu soy sauce, Braised lotus root
Rice, Milk , Two-color fried chikuwa, Miso soup, Bonito flakes
Rice, Milk, Simmered deep-fried tofu, Vinegared cucumber and wakame
Kimchi Donburi, Milk, Lotus root-filled dumplings, Boiled broccoli with Mayonnaise
31

History of Japanese school lunch
Above is some information about Japan school
lunch that we have learned from our studies. We are
now serving internships at Japanese primary school
kitchens. The more we learn about the school lunch
program, the more interested we become. We
recognize the value and significance of the programthat the Japanese have developed as a society for theirchildren. The knowledge and habits formed by theschool lunch program play an important role forchildren.
The school meal program in Japan started very

early, right after World War II, with simple meals tosave children from hunger; not long after that the
School Meal Law was adopted and now school lunch
has special qualities. In Vietnam, although school
lunch was begun some time ago, the present situation
may be similar to the initial period in Japan, withsimple meals to provide energy and nutrients and a
School Meal Law has not yet been adopted. Therefore,
we want to learn about the school lunch model in Japanand to consider some aspects of it for possible
emulation in our own country.

32

Asian Journal of Dietetics, 2021

ReviewDevelopment of Competency Frameworkon Clinical Nutrition in the Philippines
Maria Theresa M. Talavera1*, Aimee Sheree A. Barrion1, Liezl M. Atienza1, Leila S. Africa1,
Divine Grace C. Domingo1, Merly T. Panganiban2, Clarissa B. Juanico1, Sheila F. Abacan1
1Institute of Human Nutrition and Food College of Human Ecology, University of thePhilippines Los Baños
2
Science Education Institute, Department of Science and Technology(Received May 28, 2021)

ABSTRACT A competency framework designed for practicing clinical dietitians andeducators was developed to help strengthen human resource capacity in the Philippine
healthcare system. The framework consists of competency domain areas categorised as core
and technical competencies specific to clinical dietitians. Competencies were identified frominterviews of key persons practicing clinical nutrition. Additional data were collected from theexisting literature and curricular programs on clinical nutrition. The framework can serve as
valuable tool for developing curriculum program in the higher education; assessing ability andperformance of clinical dietitians; and designing competency based training programs on
clinical nutrition. The framework is recommended to be used by the dietaryservices/departments, healthcare institutions, and higher education institutions.
Keywords: clinical nutrition, competency, healthcare system, Philippines
INTRODUCTION
The Philippines is one of the many countries
burdened by both communicable and noncommunicable diseases. There is an increasing trend
in the morbidity and mortality of non-communicablediseases which are preventable. The high cost ofhealth care including nutrition care, poor healthoutcomes and low interaction with the healthcare
system are contributing to the increasing prevalenceof morbidity and mortality. The need to strengthen
healthcare system to protect Filipinos especially thepoor, marginalized, and vulnerable from high cost ofhealth care; attain the best possible health outcomeswith no disparity; and improve interactions with thehealthcare system as respected, valued andempowered remains a priority (1).
Poor diet, unhealthy lifestyle and risky behaviours
are known determinants of chronic degenerative
diseases. The pronounced effects of chronic diseases
in most organ systems on food intake and metabolism
which caused nutrition-related health problems areassociated to morbidity leading to death (2). Nutrition
has a vital role in life and in the prevention, control,and management of diseases. Studies have shown thatproper diet and best nutrition practices have improved
patient outcomes and reduced health care costs (3-5).
Moreover, it has been recognized that nutrition care isvaluable before, during, and after hospitalization to
help prevent and treat malnutrition, avert hospitalacquired conditions, reduce hospital readmissions,lower infection and complications rates, and shorten
hospital stays (6).
Clinical nutrition has emerged as a relevant
discipline in medicine (7). It deals with the applicationof nutrition strategies to prevent and manage
nutritional and metabolic changes related to acute andchronic diseases and conditions caused by a lack orexcess of energy and nutrients (2,7). It can be guided
by other biological sciences such as biochemistry,
pharmacology and physiology; and its scientificprinciples and theories are applied through nutrition
care process to address nutrition-related problems andprovide safe and effective quality nutrition care (8).
Academic institutions can contribute to theimprovement of health and nutrition situation throughnutrition education either formal or non-formal
strategies. However, for more than five decades since
the nutrition and dietetics profession was establishedin the Philippines, there were only few universities
that offer advanced program on clinical nutrition thatstrengthen the skills and competencies of Registered
Nutritionist-Dietitians (RNDs). Though the practiceof clinical nutrition is not totally new, there is nonationally recognized competency framework on
clinical nutrition despite the rising demand for thisspecialization. The professional development of
RNDs in clinical nutrition requires competency based
education to increase their ability in the scope of thepatient-health care provider interaction (8). Hence,
this study aimed to identify the gaps in thecompetencies of RNDs on clinical nutrition;
determine if there is a demand for higher education onclinical nutrition; and develop a competency
framework on clinical nutrition. The framework is
expected to serve as a reference for developing
standards required for clinical nutritionists tocompetently undertake their roles in providing
nutrition care in the healthcare system. The proposed
framework can also serve as tool for developing
curricular program in the higher education; assessing
ability and performance of employees; and designingtraining programs as part of continuing professional
development program to enhance human resource
capacity, producing competent professionals that willcontribute in improving the health and well-being ofFilipinos.

*To whom correspondence should be addressed:
mmtalavera@up.edu.ph33

Competency of Clinical Nutrition in Philippine

METHODOLOGY
Data collection
A mix of data collection methods, namely, survey
and desk review, was used to identify thecompetencies on clinical nutrition and develop thecompetency framework on clinical nutrition.
Three separate surveys were done on different
groups of respondents, namely, new graduates of
Bachelor of Science in Nutrition and Dietetics(BSND) from different universities nationwide;practicing RNDs in private and government hospitals;
and existing employers of RNDs in various sectors
such as private and government hospitals, academe,
government agencies and food industries using a crosssectional study design and a purposive samplingtechnique. A total of 509 participants responded in thethree surveys. Majority of the respondents answered
the survey face to face and online through google link
sent via email. Meanwhile, existing employers of
RNDs from various sectors were all interviewed
through a scheduled phone interview.
These
participants were purposely chosen for their relevant
inputs in the identification of competencies on clinicalnutrition.
A desk review regarding curricular programs on
clinical nutrition in selected universities in thePhilippines and other countries was made. Sixty (60)universities from various countries offering a total of
66 clinical nutrition and other related masteral degree
programs were reviewed. These universities werefrom the Philippines, Asia, US, Canada, Europe, andAustralia. Features of courses offered, including thenumber of credits/units, and requirement of thesis
and/or practicum were also noted. Other relevant
policies in developing competency framework on
clinical nutrition such as guidelines for
implementation of Nutrition Care Process in hospitals(Administrative Order: 2019- 0033) and the ASEAN
University Network framework, regionalization andstandardization of professional qualifications in theregion were also checked.

Classification
Age (years)
20 – 29
30 – 39
40 – 49
50 and above*not indicated
Sex
Male
FemaleEducational Attainment
Bachelor degree
Masteral degree
Doctoral degree

Data analysis
Descriptive statistics was used to summarize andanalyse the survey results. Gaps in competencies as
identified by graduates and employers were also
identified. The results of the desk review weresummarized according to themes. On the other hand,the competency framework was developed from theanalysis of data collected. The review of existing
competency framework related to clinical nutrition,
existing curricula on clinical nutrition from different
universities, and conducted surveys were used inconstructing a proposed structure for clinical nutritioncompetency framework. Key features of reviewed
competency framework related to clinical nutrition
were identified and adapted (9-12). The identifiedcompetencies were categorised as competencies
common to all members of the healthcare team, andcore and technical competencies on clinical nutrition
designed for practicing RNDs. Core competencies
are the basic knowledge, skills, judgment andattitudes required for a clinical dietitian to function
effectively in the healthcare system as work
environment. On the other hand, technicalcompetencies are the knowledge, skills, judgement
and attitudes needed for a specialized role of clinicaldietitian.
RESULTS
Profile of Respondents
The respondents’ age ranged from 20 to 29 years
old; were mostly female; and with bachelor’s degree
as highest educational attainment (Table 1). Some
respondents who are interested to pursue a graduate
program on clinical nutrition are practicing or
currently employed RNDs. There were also 22
interviewed employers from government and private
hospitals, academe, fitness centres, government
agencies, food service and food manufacturing
companies.

Table 1. Profile of respondents
New
BSND Practicing RNDs in
Various Sectors
Graduates
n =165%n =344%Total
N = 509

%

164
1
-

99
1
-

213
68
33
21
9

62
19
10
6
3

377
69
33
21
9

74
14
6
4
2

27
138

16
84

54
290

16
84

81
428

16
84

165
-

100
-

279
56
9

81
16
3

444
56
9

87
11
2

Gaps and Demands for Clinical Nutrition Course
The gaps in clinical nutrition are limited up-todate evidence-based clinical nutrition knowledge;
deficient skills and strategies in providing effective
nutrition care for optimum patient outcomes; few
clinical nutrition course offerings in the higher
education; and limited competency-based trainings

needed for continuous professional development
among the practicing clinical dietitians andeducators.
There is a demand for a specialization on clinicalnutrition amid the increasing prevalence of nutritionrelated health problems and growing conflict of
information on nutrition making nutrition practice34

Asian Journal of Dietetics, 2021

more complex for healthcare providers (7). The
increasing number of healthcare facilities in thePhilippines to cater the increasing need for healthservices escalates opportunities for clinicaldietitians. The Nutrition and Dietetics Law of 2016
regulates the practice of the profession requiring
hospitals to hire a minimum of one RND in every 25
to 75 bed capacity (Republic Act No. 10862). Thereis a demand for continuing professional education onclinical nutrition. This is in accordance to thegovernment’s movement towards promotion ofhuman capacity development mandating an act
strengthening
thecontinuing
professional
development (CPD) program requiring all regulated
professions in the Philippines to continually gain
advanced knowledge, skills and ethical values in a
post-licensure specialization or in an inter-or
multidisciplinary field of study, for assimilation into
professional practice, self-directed research and/or

lifelong learning in the Philippines (Republic Act
No. 10912).
The gap between the demand for highly trained
clinical nutritionists and supply of clinicalnutritionists needs competency-based trainings
or/and clinical nutrition course offerings in thehigher education program in order to continue to
produce competent clinical nutritionist. Results ofthe survey showed that majority (80%) of the
respondents exhibited interest to enroll for a
graduate program on clinical nutrition. Most of the
respondents preferred a program with practicum togain upgraded knowledge and skills in clinicalnutrition and to further hone personal development.
Majority were interested to gain up-dated knowledge
on medical nutrition therapy on specific diseases,
enhance skills in diet counseling, enhancecommunication and become equally competent asother members of the healthcare team (Table 2).

Table 2. Expected knowledge, skills and attitude to be gained by the prospective students from a graduate
program on clinical nutrition
New
BSND
Practicing
Graduates
RNDs in Various
Total
Sectors
Knowledgen = 119%n = 193%
N = 312%
1. Medical Nutrition Therapy for Renal
92
77
151
78
243
78
Diseases
2. Medical Nutrition Therapy
for
86
72
135
70
221
71
Cardiovascular Diseases
3. Medical Nutrition Therapy for Cancer
86
72
140
73
226
72
4. Medical Nutrition Therapy
forChronic Obstructive
62
52
116
60
178
57
5. Pulmonary Diseases
6. Medical Nutrition Therapy for Gastro66
55
136
70
202
65
Intestinal Diseases
7. Nutrient-Drug Interaction
79
66
140
73
219
70
8. Nutrition Support
69
58
142
74
211
68
9. Management of Dietary Services
73
61
118
61
191
61
10. Pharmaconutrition
82
69
123
64
205
66
11. Sport nutrition/Wellness
90
76
133
69
223
71
12. Nutrition Care Process
66
55
119
62
185
59
13. Medico-Legal Matters
60
50
85
44
145
46
14. Nutrigenetics
37
31
90
47
127
41
15. Others
3
3
10
5
13
4
Skills1.
Diet Counseling
91
76
143
74
234
75
2.
Conduct Research
76
64
99
51
175
56
3.
Administering Nutrition Support
72
61
141
73
213
68
4.
Administrative Clinical Management
79
66
138
72
217
70
5.
Dietary Calculations
79
66
123
64
202
65
6.
Diet Prescriptions
74
62
124
64
198
63
7.
Management of Sports Nutrition
84
71
117
61
201
64
8.
Meal Planning
70
59
114
59
184
59
9.
Nutrition Assessment in Hospitals
80
67
136
70
216
69
10. Others
0
0
2
1
2
0
Attitudes/values
1.
Leadership
98
82
148
77
246
79
2.
Communication
106
89
161
83
267
86
3.
Networking/linkaging
92
77
122
63
214
69
4.
Ethics
90
76
130
67
220
71
5.
Service Oriented
95
80
131
68
226
72
6.
Equally Competent as Other
100
84
155
80
255
82
7.
Members of the Healthcare Team
*multiple answer

35Competency of Clinical Nutrition in Philippine

The competencies needed are composed ofinterdisciplinary competencies to be developed tostrengthen the knowledge and skills of RNDs inclinical nutrition (Table 3). There are competencies
on human nutrition sciences and medicine that are
related and relevant to development of competencies
on clinical nutrition for RNDs (8).

Masteral Degree Program on Clinical Nutrition in
the Philippines and Other Countries
Majority of the programs included in the review
focused on clinical nutrition, nutrition, and nutritionand dietetics. Some focused on nutritional sciences
and public health nutrition. Most of the programs
required thesis instead of practicum. The range ofequivalent units was from 12 to 60 units or 150 to 180
in terms of equivalent credits.

Table 3. Competency domains identified from reviewed course curricula and literature, and interviewed
prospective students and employer.
CourseInterviewed
Prospective
Competency domain
curriculaemployer
students
Core Healthcare Professional Competencies✓✓✓
Communication and Coordination✓

Ethics and Professionalism

✓

✓

✓

Safety and Risk Management
Core Clinical Nutrition Competencies
Nutritional Biochemistry✓✓

Nutritional Physiology and Metabolism✓✓

Nutrient-Drug Interaction

✓

✓

✓

Nutrition Care Process

✓

✓

✓

Nutrition Counseling and Education✓✓

Technical Clinical Nutrition Competencies
Medical Nutrition Therapy for Diabetes

✓

✓

✓

Medical Nutrition Therapy for Cancer

✓

✓

✓

Medical Nutrition Therapy for Renal
Diseases
Medical Nutrition Therapy for
Cardiovascular Diseases
Medical Nutrition Therapy for GastroIntestinal Diseases
Medical Nutrition Therapy for Chronic
Obstructive Pulmonary Diseases
Weight Management

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Management of Malnutrition

✓

✓

✓

Sports Nutrition

✓

✓

✓

Nutrition Support

✓

✓

✓

Pediatric Nutrition✓

Nutrition in Aging✓✓

In the Philippines, only one university offers amasteral degree program on clinical nutrition (13).
The rest of the universities are offering masteraldegree programs in Nutrition, Applied Nutrition,
Nutrition and Dietetics, and Public Health Nutrition(14-17). The MSc in Nutrition and MSc in Applied
Nutrition were designed to prepare professionals formore advance work by providing in depth
knowledge and research skills in nutrition in general;and to broaden perspective and increase
effectiveness in the application of scientificknowledge and enhance competencies in appliedresearch in food and nutrition and related fields,
respectively. A masteral program on nutrition anddietetics has been drafted by the Technical✓Committee on Nutrition and Dietetics Education in
the Commission on Higher Education, but public
consultation has been put on hold. The said
curriculum is a vertical articulation of the BSc
Nutrition and Dietetics curriculum and will set theminimum standards for a masteral program.
Filipino RNDs can also pursue education onclinical nutrition in other countries. About 66
masteral degree programs on clinical nutrition andother related fields identified are being offered invarious universities abroad. Majority of the
programs offering masteral degree on clinicalnutrition are in Europe and North America
specifically in United Kingdom and US. The review
showed that a masteral degree program on Nutrition36

Asian Journal of Dietetics, 2021

and Dietetics focuses on preparing students for awide range of careers as dietitians in health care,
community, and private settings; as food industry
specialist in public health relations and media; andas nutrition educators in health care, community or
corporate health programs (18,19). A masteralprogram on Clinical Nutrition is similar to that of
Nutrition and Dietetics Program. On the other hand,a Public Health Nutrition Program includes
approaches at community level. A masteral degree
program in Nutritional Sciences is focused inbroadening knowledge on nutrition sciences
specifically on understanding nutrients and theirrelationshiptometabolicpathwaysandphysiological function to clinical nutrition practiceand nutrition research.

malnutrition; and principles of diet therapy and life
cycle nutrition. Generally, these courses aim todeepenknowledge
inpathophysiologicalmechanism of nutrition related disease and its
therapeutic and preventive interventions (21). On theother hand, top most elective or optional courses
were research; communication, counseling andeducation; sports nutrition and wellness; clinicalnutrition and dietetics; weight management; andpediatric nutrition. Students have the prerogative toselect courses under this category. Aside fromcore/compulsory courses, other supporting topics
relevant to clinical nutrition are placed under thiscategory as part of courses for selection. Masteraldegree program on clinical nutrition from different
universities varies, depending on the demand andhow university strategize and value certain topics.
Hence, there were some courses placed either undercore/compulsory or elective/optional category.
Some of these courses were research; sports nutrition
and wellness; and communication, counseling andeducation.
Practicum aims to provide students supervised
experience in clinical dietetics through observation,practice and research in food service systems; inpatient and ambulatory nutrition care; and specialty
practice settings (18,19). Students apply theiracademic training, furthering their competency inclinical nutrition to develop an understanding of therole of the clinical dietitian and integrate theoreticallearnings in clinical nutrition as part of the healthcare
team. On the other hand, thesis aims to impartknowledge on understanding applying theprocedures and practices of scientific literature
review and writing of a research thesis; and toprovide opportunity to students to conduct a research
project related to clinical nutrition (26). Majority ofthe programs required thesis. Thesis course normallyhas higher equivalent units compare to courses undercore/compulsory and elective/optional because of
the load of work and time needed for this course.

Courses under Masteral Degree Program on
Clinical Nutrition
A total of 13 masteral programs on clinicalnutrition with complete details on curriculum werereviewed. These masteral programs were from
Philippine Women University, New York
University, University of Wisconsin-Madison,
University of Hohenheim, University of Texas
Southwestern Medical Center, Life University,
University of Nottingham, University of College
London, University of Nicosia, University ofAberdeen, University of Roehampton London, andUniversity of Glasgow (13,18-29). The courses
under the said programs were grouped according tosimilarity and category such as either to be taken as
core/compulsoryoraselective/optional.
Core/compulsory courses are required courses in the
curriculum. On the other hand, in theelective/optional courses, students have prerogative
to select courses of interest at a specified number ofunits. Other programs required components werethesis and/or practicum; residency; internship; or
culminating experience.
Top
mostrequiredcoursesundercore/compulsory course category were medical
nutrition therapy; research; nutrition andbiochemistry; nutrition and metabolism; clinicalnutrition in general; and other clinical nutritionrelated topics such as nutritional assessment; andcommunication, counselling and education.
Majority of the courses grouped under medical
nutrition therapy includes medical nutrition therapy
in acute and chronic diseases; disease relatedCompetency Framework on Clinical Nutrition
Four competency framework related to clinicalnutrition were reviewed and used in the developmentof the competency framework for Filipino RNDs (912). Key features of competency framework wereidentified as core or technical competencies (Table
4).

Table 4. Competency framework related to clinical nutrition
Framework nameAuthorCompetency type
Essential Practice Competencies for
Academy on Nutrition andCore and Functional
the Commission on Dietetic Registration’s Dietetics. Commission on Dietetic
for Credentialed Nutrition and Dietetics Registration
Practitioners
An Integrated Career and Competency
Diabetes UK. 2011
Core and Specific
Framework for Dietitians
ClinicalFramework

Leadership

Competency

International Competency Standards
for Dietitian-Nutritionists.

NHS Institute for Innovation and
Improvement and Academy ofMedical Royal Colleges. 2010
International Confederation of
Dietetic Associations. 2016.

37

Core/Technical
Core/TechnicalCompetency of Clinical Nutrition in Philippine

Common core professional
competencies for all membersof the healthcare teamCore competencies onclinical nutrition for RNDs

Technical competencies onclinical nutrition for RNDs

Competency Framework on Clinical Nutrition for
Filipino RNDs
The framework organised competencies into
domain. These competency domains were categorised
either as core or technical competencies (9). The corecompetencies describe the basic knowledge, skills,
judgment and attitudes required for a clinical dietitian.
These are the basic expectations from a RND in thehealthcare team. Meanwhile, technical competencies
describe the knowledge, skills, judgement andattitudes needed for a specialized role of clinicaldietitian. It often requires thorough research, training,and experience. Different job requirements wereidentified according to roles of clinical dietitianranging from entry-level to supervisory positions. Job
titles mentioned in the interview were clinicaldietitian, therapeutic dietitian, and nutritionistdietitian I to II for entry-level RNDs; and nutritionistdietitian III to VI, section head, supervisor or chiefdietitian for supervisory/managerial level.
There are common competencies among themembers of the healthcare team that are basic but
necessary to perform each job accordingly. These arecommunication and coordination, ethics andprofessionalism, and safety and risk management (9).
Communication
andcoordination
promotecollaboration with other healthcare team members toachieve common goals and optimize delivery ofservices. Meanwhile, ethics and professionalism lead
each team members to maintain respect to the code of
ethics, professional obligations defined in legislation,
standards and organization policies; work within theprofessional limitations and abilities; and applies
client-centered principles in practice. The safety andrisk management equip each healthcare team member
to identify, analyse and manage risk; adverse eventand safety to staff, client and public. Considering
these categories of competency, a layered approach tobuilding competencies common to all healthcare
professional, and core and technical competencies onclinical nutrition designed for RNDs is shown in
Figure 1.

CONCLUSION
The recognized important role of nutrition in theprevention, control and management of acute andchronic diseases; the expressed demand for upgradedknowledge and skills in clinical nutrition among thepracticing RNDs in the healthcare facilities; and thelack of nationally recognized competency framework
on clinical nutrition were the factors considered ininitiating a move towards developing a competencybased approach to human resource development in thefield of clinical nutrition. Hence, the Institute of
Human Nutrition and Food, as one academic
institution in the Philippines initiated a study to
propose a competency framework on clinical nutrition
specifically designed for RNDs that can serve as
guide to academic and healthcare institutions indeveloping tools and procedure in the standardizationof trainings either through formal or informal
education. However, it is recognized that the proposed
framework will require further review and discussion
with the key institutions and beneficiaries toencourage wide adoption and use of the proposed
framework.
ACKNOWLEDGEMENTS
The authors would like to acknowledge thefollowing for their cooperation, participation, andassistance in this study: IHNF-CHE-NSD faculty
members; DOST-CIP researchers; and hospitals such
as Asian Hospital and Medical Center, East Avenue
Medical Center, Fatima University Medical Center,
Makati Medical Center, National Kidney &Transplant Institute, Our Lady of Lourdes Hospital,
Philippine General Hospital, Quirino Memorial
Medical Center, San Lazaro Hospital, St. Luke’s
Medical Center and University Health Service Los
Banos; Ms. Josie Guiao, RND and Socorro T.
Balderamos, RND, adviser and president of the
Department of Health League of Registered
Nutritionist-Dietitians for their support in the survey.

38

Asian Journal of Dietetics, 2021

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39

Asian Journal of Dietetics, 2021

Original
Snacking Pattern and Its Association with Body Mass Indexand High Body Fat Percentage in Children
Jagmeet Madan1*, Nikital Mahakal2, Ankita Sawant3, Neha Sanwalka4
1

Sir Vithaldas Thackersey College of Home Science (Autonomous),
SNDT Women’s University, Mumbai, Maharashtra, India
2
Cuddles Foundation, Mumbai, Maharashtra, India
3
HealthifyMe, Amravati, Maharashtra, India
4
NutriCanvas, Mumbai, Maharashtra, India

ABSTRACT: Background and purpose: Snacking pattern is known to affect the bodycomposition. Limited data is available on effect of snacking pattern on prevalence of obesity inIndian children. The objective of the study was to assess the prevalence of obesity and highbody fat and correlate it with snacking pattern. Methods: A cross-sectional study was conductedin 155 children aged 10-11 years. Anthropometry was assessed and body composition wasmeasured using TANITA body fat analyser (MC-780 MA). Three day 24-hour diet recall wasused to analyse daily nutrient intake. A weighted food frequency questionnaire of snacks wasused to assess snacking patterns and nutrient intake from snacks. Results: Of the 155 children
27.7% were overweight and 23.2% were obese. Forty-eight percentage children had body fat
percentage above 75th percentile. Total snacks contributed around 47.3% of total daily energy,
47-48% of daily dietary fat and carbohydrates intake and about 39% of proteins intake.
Individual regression equations showed that energy (R2=0.037) and dietary fat (R2 = 0.108)
from snacks has a significant positive correlation with BMI (p<0.05). Total energy (R2=0.027)
and dietary fat (R2=0.088) from snacks also had a significant positive correlation with fat
percentage. Conclusion: Snacks contribute to almost 40-50% of daily nutrient intake inchildren. Nutrient intake from snacks had significant positive correlation with prevalence ofoverweight/ obesity. Immediate school based interventions to correct dietary and lifestylefactors need to be planned to prevent obesity.
Keywords: BMI, obesity, snacking pattern, nutrient intake
INTRODUCTION
Globally, the prevalence of childhood obesity inon rise. As per World Health Organization, worldwide
prevalence of childhood obesity increased from 4% in
1975 to 18% in 2016. In Asia alone, over 340 million
children and adolescents aged 5-19 years were
overweight or obese in 2016 (1). Similar percentage
of childhood obesity is observed in India. Pooled dataof several studies on prevalence of overweight andobesity have shown that 19.3% Indian children sufferfrom childhood overweight and obesity (2). With 14.4
million obese children, India has the second highest
prevalence of obese children in world (3).
Childhood obesity tends to continue in adulthoodwith 85% of obese children known to become obese
adults (4,5). Adolescents have an odds ratio of 17.5 of
becoming obese adults (6). Also, childhood obesity is
associated with many health problems and is a precursor for many non-communicable diseases (3)About one third of overweight or obese children
exhibit features of metabolic syndrome including
abdominal obesity, impaired glucose metabolism,hypertension and dyslipidaemia (7,8) As children
with obesity are at an increasing risk of progressing totype 2 diabetes and cardio-vascular diseases in later
life and hence early identification and preventive
measures are very important (9)Visceral fat percentage has known to affect insulin
resistance (10) and hypertension (11). Body fat
deposition is also known to contribute todyslipidaemia (12). Hence, body composition, more
specifically body fat percentage can be used as asurrogate marker to assess risk of metabolic syndrome
especially in children. Studies have shown that risk ofmetabolic syndrome can be established from body fat
percentage either using odds ratio curves or by using
body fat percentage thresholds (13).
A snack is distinguished from other food items
based on time criterion, i.e. food that is consumed in
between main meals (14). Internationally snacking
has shown to contribute approximately 27% of daily
nutrient intake in children (15). A review on snacking
and obesity showed that snacking had a significant
effect on BMI. Children who consumed large
portioned snacks frequently had higher risk of beingobese. Snacking was shown to independently affectweight gain in children (16). Recently a study
illustrated very unhealthy snacking patterns in Indianchildren with 10% snacking on sweets, 30% on
chocolates, 20% on pizza, 10% on soft drinks, and theremaining 10% on chips (17).
To the best of our knowledge, there is very limited
Indian data on snacking and its effect on overweight/
obesity. Hence, the objective of the current study wasto assess the prevalence of overweight and obesity inIndian children and to study its correlation withsnacking pattern.

To whom correspondence should be addressed:
dr.jagmeetmadan@gmail.com
41

Snacking Pattern and Obesity in India(20). As per Indian reference, children above 75 thpercentile for fat mass and percentage are at anincreased risk for obesity and hence based on body fat
percentage children were classified as: normal (<75thpercentile) and at risk (>75th percentile) (20).
Daily dietary intake
Dietary intake was assessed by 24-hour recall on
3 random days (non-consecutive) of a week including
a holiday. Each child was asked about the intake offood items consumed during the day at breakfast,
lunch, dinner, and snacks, using standard cups andspoons by trained investigators through a face-to-faceinterview. Daily nutrient intakes (energy,
carbohydrates, proteins, dietary fats) were calculatedusing DietCal Software (version 8.0, 2017, ProfoundTech Solutions). Percentage contribution of macronutrients to total calorie intake was calculated.
Percentage recommended dietary allowance (RDA)
intake for energy (boys: 2190 kcal/ day, girls: 2010
kcal/ day) and protein (boys: 39.9 g/day, girls 40.4
g/day) intake was calculated in comparison to Indian
RDA (21).
A weighted food frequency questionnaire wasused to evaluate intake of snacks in children. Children
were asked whether they consumed snacks on a 5
point scale: daily, 3 times/ week, 1/ week, once/
fortnight or never. Snacks were classified as healthy(fruit based/ steamed/ roasted) or unhealthy (fried/bakery/ confectionary & aerated drinks). Portion size
was assessed using standard cups and spoons. Daily
nutrient intake from snacks (energy, carbohydrates,
proteins, fats) were calculated using Diet Cal
Software (version 8.0, 2017, Profound Tech
Solutions) for healthy and unhealthy snacks
separately. Total nutrient intake from snacks wascalculated by adding nutrient intake from healthysnack with nutrient intake from unhealthy snacks.
Percentage contribution of macro-nutrients to total
calorie intake was calculated. Percentage RDA intake
for energy and protein intake was calculated incomparison to Indian RDA (21).
Contribution of nutrients from snacks (healthy/
unhealthy/ total) to daily nutrient intake wascalculated by dividing the nutrient intake from snacks
by daily nutrient intake * 100.
Statistical analysis
Analyses were performed using SPSS software forWindows (version 16.0, 2007, SPSS Inc, Chicago,
IL). Data are presented as Mean±SD or Mean(minimum-maximum) or percentage. Independent
sample ttest was used to analyse the genderdifference in nutrient intake of children. The
frequency distributions were tabulated for foodfrequency intake of snacks according to gender andwere compared using cross tabulations and Chisquare test. Simple linear regression was used toanalyse the correlation between BMI and total dailyenergy intake. Simple linear regression was carriedout separately for energy intake from total snacks andfat intake from total snacks on BMI or fat percentage
to avoid co-linearity of dietary data. P-value <0.05
was considered to be statistically significant.

METHODOLOGY
A cross-sectional study was conducted in 155
children (79 boys, 76 girls) aged 10 – 11 years oldstudying in private schools in Mumbai. Three private
schools were approached from suburbs of Mumbai
City using purposive sampling to conduct the study
out of which the permission was received from one
school. The school authorities were given complete
details of the study and a consent was obtained fromthe authorities to conduct the study. A written assent
was also obtained from students before enrolling themin the study. Children with chronic medical conditions
were excluded from the study. The study protocol wasapproved by ISBEC (Inter System Bio Medica Ethics
Committee), Vile Parle (West), Mumbai.
Sample size calculation
Sample size was calculated in comparison to
overall prevalence of overweight and obesity (36.6%)
found in study in Chennai (18), India in children aged
6 to 11 years using Indian contemporary cut-offs.
Hence, sample size was calculated with a known
population prevalence of 37%, expected study
incidence of 50%, to achieve 90% power of the study
at alpha level of 0.05 using the following formula:𝑝 𝑞

𝑁=

𝑝0 𝑞0 (𝑍1−∝ + 𝑍1−𝛽 √ 1 1 )

2

𝑝0 𝑞0

2

(𝑝1 − 𝑝0 )2√0.5∗ 0.5

2

0.37∗0.63 (1.96+1.28 0.37∗0.63 )== 149(0.5−0.37)2
Sample size was calculated to be 149, however the
sample taken was 155.
P0 = population incidence = 0.37, P1 = study
expected incidence = 0.50, N = Sample size of study,
α = probability of type 1 error, β = Probability of type2 error, Z = critical Z value of the given α or β, q0 = 1-p0, q1 = 1-p1
Anthropometry
Height and weight were measured and BMI was
calculated. For height, a site of vertical wall and thehorizontal floor was selected and the Stadiometer was
fixed on the wall and height was measured to thenearest 1 mm. Weight was measured using a digitalweighing scale. Average of three measurements forboth height and weight were taken. BMI was
calculated by dividing weight in kg by height in metersquare. Height, weight and BMI for age z-scores were
calculated in comparison to Indian reference data(19). Based on BMI for age z-score, children wereclassified as underweight (equivalent to adult BMI<18.5 kg/m2), normal weight (equivalent to adult BMI
18.5 – 23 kg/m2), overweight (equivalent to adult
BMI of 23-26.9 kg/m2), obese (equivalent to adult
BMI of > 27 kg/m2).
Body composition
Body fat percentage was measured using TANITA
body fat analyser machine (Model MC 780 MA)(Tanita Corporation of American Inc, Illinois, USA.
Before analysing body fat percentage, it was madesure that the children’s foot pads were clean. Care wastaken to ensure that children were not wearing any
metallic object or carrying any cell phone while thebody composition was analysed to avoid any
hindrance in output. Minimum 2 hours’ difference
was maintained between measuring bodycomposition and food intake, exercise andconsumption of caffeinated drink (as it affects
hydration levels). Body fat percentage of age z-score
was calculated in comparison to Indian reference data

RESULTS
The mean age of boys in the current study was
10.3±0.3 years and was similar to that of girls(10.3±0.3 years) (p=0.854).
Anthropometry and body composition
Table 1 gives anthropometry and bodycomposition of children in the study. There was no42

Asian Journal of Dietetics, 2021

significant difference in anthropometric parameters orbody fat percentage of boys and girls (p>0.05).
Figure 1a and 1b shows prevalence underweight,
overweight and obesity and high body fat percentage.
Overall using BMI for age z scores in comparison to
Indian reference (19), 27.7% were overweight and23.2% were obese. There was no significant
difference in prevalence of underweight, normal BMI,

overweight or obesity when classified according togender (χ2=1.158, p>0.05). When body fat percentage
was compared to Indian reference standards (20),
47.7% children had high body fat percentage (at risk
= body fat percentile >75th percentile). There was no
significant difference in prevalence of high body fat% (>75th percentile when classified according togender (χ2=4.689, p>0.05)

Table 1: Anthropometry and body composition of children
Boys (n=79)
Girls (n=76)
Total (n=155)
Height (cm)140.9 ±7.0
141.5 ±6.6141.2±6.8
Weight (kg)37.6 ±9.1
38.1 ±9.7
37.7±9.4
BMI (kg/m2)
18.6 ±3.8
18.8 ±4.1
18.7±3.9
Fat percentage (%)
22.9 ±11.6
24.5 ±12.3
23.6±11.9
Height for age z-score0.27 ±1.02
0.32 ±0.97
0.29±0.99
Weight for age z -score0.44 ±1.01
0.53 ±1.16
0.49±1.08
BMI for age z -score0.42 ±1.120.48 ±1.22
0.45±1.17
Fat percentage for age z -score0.48 ±0.91
0.32 ±1.32
0.40±1.16
Data presented as Mean±SD

P value
0.598
0.607
0.748
0.395
0.757
0.595
0.743
0.392

Fig: Prevalence of underweight, overweight and obesity using BMI categories (1a),high body fat percentage (1b)Fig 1a: Underweight: equivalent to adult BMI <18.5 kg/m2, Normal: equivalent to adult BMI 18.5 – 23 kg/m2,
Overweight: equivalent to adult BMI of 23-26.9 kg/m2, Obese: equivalent to adult BMI of > 27 kg/m2 (19).
Fig 1b: Normal: <75th percentile, At risk: >75th Percentile

Relations between BMI and body fat percentage
There was a significant association of BMI withbody fat percentage in both boys (r=0.962) and girls(r=0.976) (p<0.05). To further evaluate theassociation of BMI with body fat percentage, crosstabulation of BMI status and body fat percentiles werecomputed (χ2=161.1, p<0.01). None of theunderweight children had body fat percentile >75 thpercentile. All obese children had fat percentile >75th
percentile and 76.7% overweight children had fat
percentile >75th percentile. In fact, 7.1% of children
with normal BMI also had fat percentile >75th
percentile.
Dietary Intake
Table 2 gives dietary intake in study participants.
Total daily energy intake was about 65.7% of therecommended dietary allowance indicating thatenergy intake was 34.3% less than the daily
recommended intakes. Total protein intake was 87%
of the recommended dietary allowance. Overall
dietary fats contributed 31.6 % of the energy intake ofthe total diet. There was no significant difference innutrient intake of boys and girls (p>0.05) (data notshown).
Total snacks contributed 47.3% of total dailyenergy, 47% of daily dietary fats, 48.1%
carbohydrates intake and 38.6% of proteins intake. Of
this, healthy snacks contributed to 12.6% of total dailyenergy, 6.5% of daily dietary fats, 16.6%
carbohydrates intake and 9.8% of proteins intake.
Unhealthy snacks contributed to 34.6% of total dailyenergy, 41.4% of daily dietary fats, 33.9%
carbohydrates intake and 28.5% of proteins intake.

43

Snacking Pattern and Obesity in India

Table 2: Dietary intake in children
Total for entire From total snack
day

From
From
healthyunhealthysnackssnacksEnergy (kcal/day)
1380 (720-3440) 653 (127-1234)
174 (26-584)
478 (60-1105)
Carbohydrates (g/day)
203.8 (104-600) 95.6 (23-184)
31.3 (4-104)
64.2 (10-151)
Protein (g/day)
34.8 (17.6-62)
13.1 (2.1-24.3)
3.4 (1-13.3)
9.7 (1-22.9)
Dietary Fat (g/day)
47.8 (24.9-93.9) 23.4 (2.8-56.1)
3.1 (1-11.9)
19.9 (1.9-54.9)
RDA intake of energy (%)
65.7 (33-157)
30.9 (6-61)
8.3 (1.3-29)
22.6 (3-54)
RDA intake of Protein (%)
86.6 (44-156)
32.7 (5-60)
8.5 (0.5-33)
24.2 (2-57)
Percent energy carbohydrates (%) 59 (45-79)
59.5 (41-74)
72.8 (56-91)
54.8 (35-72)
Percent energy protein (%)
10.4 (5-15)
8.1 (5-11)
7.8 (1-11)
8.2 (5-13)
Percent energy dietary fat (%)
31.6 (15-44)
31.3 (18-51)
17.5 (8-34)
37.2 (20-55)
Data presented as Mean (minimum-maximum). RDA Energy: boys: 2190 kcal/ day, girls: 2010 kcal/ day; RDA
protein: boys: 39.9 g/day, girls 40.4 g/day (21)Table 3: Frequency of snack consumption
Never
Once
in Once per(%)
fortnight
week
(%)
(%)
Fruit and Vegetable based snacks (healthy)
Fruits/ vegetable juices
11.6
40.9
5.2
Fruits
3.2
5.8
15.5
Steamed Snacks (healthy)
Idli/ dosa/ uttapam
3.9
25.8
29.7
Dhokla/ khandavi/ patra
43.2
36.1
9
Bread & other bakery based snacks (unhealthy)
Pav/ bread
2.6
Bakery/ puff/ cakes/ pastries
16.1
Biscuits/ cookies
12.4
Khari/ toast/ butter biscuits
11
Pizza
20
Sandwich
9
Burger
35.9
Indian Snacks (unhealthy)
Samosa/ wada/ kachori
14.8
Chips/ farsan
8.4
Frankie/ rolls
31.6
Chaat/ sevpuri/ bhelpuri
20.6
Khakra/ thepla
25.8
Other snacks (unhealthy)
Instant noodles
15.5
Ice cream
9
Chocolates
2.6
Energy drinks/ aerated drinks
11.6

Thriceper week(%)

Daily (%)

9.1
14.2

2.6
61.3

38.7
11.6

1.9
-

20
66.5
28.1
14.8
65.2
18.7
58.2

34.8
7.7
26.1
18.7
5.8
30.3
1.3

35.5
9
18.3
23.2
7.1
34.8
3.3

7.1
6
15
32.3
1.9
7.1
1.3

54.8
26.6
55.5
54.2
20.6

16.1
27.3
6.5
12.3
18.7

14.2
29.2
5.2
11.6
25.2

8.4
1.3
1.3
9.7

36.1
60
16.8
23.2

21.9
14.2
31
18.7

23.2
14.2
31
22.6

3.2
2.6
18.7
23.9

Figure 2 gives correlation between BMI and total
daily energy intake. BMI was significantly positively
correlated with total daily energy intake in the current
study (R2 = 0.568)
Snacking pattern
Table 3 gives frequency of snacks consumed bychildren. The most commonly consumed healthysnack on daily basis was fruits. Steamed snacks suchas idli/ dosa/ uttapam were also consumed by mostparticipants on weekly basis. The most un-healthy
food consumed on daily basis was khari/ toast or
butter biscuits, chocolates and energy drink/ aerated
drink. Pav/ Bread, biscuits/ cookies, sandwich, instantnoodles, ice-cream and most Indian snacks wereconsumed by most children on weekly basis.
A regression analysis was run to determine theeffect of total energy and dietary fats from snacks(separately to avoid co-linearity) on BMI and body fat

Fig 2: Correlation between BMI and total daily energy
intake44

Asian Journal of Dietetics, 2021

percentage. Overall the models were significant foreffect of both energy and dietary fat intake from total
snacks on BMI and body fat percentage. Energy (R2 =0.037) (Figure 3a) and dietary fat intake (R2 = 0.108)(Figure 3b) from total snacks was significantly

correlated with BMI (p<0.05). Dietary fat intake wassignificantly correlated fat percentage (R2 = 0.088,
p<0.05) (Figure 3d) whereas energy intake fromsnacks had marginal association with fat percentage(R2 = 0.027, p=0.057) (Figure 3c).

Fig 3: Correlation between BMI and total energy intake from snacks (a), BMI and dietary fats from snacks (b),body fat percentage and total energy intake from snacks (c) andbody fat percentage and dietary fats from snacks (d)DISCUSSION
The present study was conducted in children aged
10-11 years and highlights the increase in the risk ofmetabolic syndrome in this young age group. In thepresent study, we assessed the prevalence ofoverweight/ obesity and high body fat percentage andits correlation with nutrient intake from snacks.
Almost 51% children in the study were overweight orobese in comparison to Indian reference curves for
BMI. Along with high prevalence of overweight andobesity, 47.7% of children had fat percentage above
75th percentile putting them at additional risk of
inflammation. Total energy and fat intake from snacks
had a significant effect on both BMI and body fat
percentage.
Prevalence of overweight and obesity varies
across India. As per pooled data, the prevalence ofoverweight and obesity is found to be 19.3% acrossIndia (2). Using WHO cut-offs, Pan-India prevalenceof overweight was found to be 11.1% and that ofobesity was found to be 15.9% in Indian children aged
2-17 years (22). In another study conducted in 8-18
year-old children in Northern and Western India,
using WHO cut-offs prevalence of overweight was
found to be 18.5% and that of obesity was found to be
5.3% (23). Using International Obesity Task Force(IOTF) cut-offs, in 10-16-year-old children in Delhi,
North India, prevalence of overweight was found tobe 24.7% and that of obesity was found to be 7.4%
(24). In a study conducted in Chennai, Southern India,

in children aged 6-11 years using IOTF cut-offs
prevalence of overweight was found to be 12% andprevalence of obesity was found to be 3.3%. In thesame study, using contemporary cut-offs provided by
Khadilkar et al and authors found prevalence ofoverweight to be 19% and that of obesity to be 17.6%(18). In the present study we had a higher prevalenceof overweight (27.7%) and obesity (23.2%) ascompared to other studies which may be due to thefact that we used the most recent cut-offs as proposed
by Indian Academy of Paediatrics (19) which has alower threshold cut-off to classify children as
overweight and obese.
There are very few studies describing body fat
percentage of children in India. In Delhi, bodycomposition measured in children aged 10 years using
dual energy x-ray absorptiometry showed body fat
percentage of 25.5±10.4% in boys and that of
30.8±10.8% in girls (25). In a study conducted in
Rural Health Training Centre of a medical college in
Bengaluru, the mean body fat percentage was foundto be 17.06±6.32% in boys aged 10 years and it was
found to be 14.4±6.36% n girls aged 10 years whenmeasured using bio-impedance technique (26). In a
study conducted in Mumbai in children aged 10 years
studying at private schools, body fat percentage wasfound to be 21±8.66% in boys and 21.3±5.5% in girls(27). In the same study, 11-year-old children fromprivate schools had body fat percentage of
12.06±7.94% and 15.53±9.88% in boys and girls
45

Snacking Pattern and Obesity in India

respectively. Children in the present study had bodyfat percentage varying in comparison to previous
studies, which may be due to the difference in methodof measurement, the environmental factors or theirdiet.
In the study conducted in Rural Health Training
Centre, they also found that about 18.8% children had
high body fat percentage (26) whereas in the present
study it was found that 48% children had body fat
percentage above 75th percentile. The stark differencein prevalence of high body fat percentage in both thestudy was because in the previous study authors usedarbitrary cut-offs of >30% to define children as
having high body fat percentage whereas in thepresent study smoothed Indian percentile curves wereused to identify children at high risk.
As per the Indian references curves, children
having body fat percentage above 75th percentile areat risk of developing hypertension and othermetabolic syndrome co-morbidities (20). With almost
48% of children in the present study having body fat
percentage above 75th percentile (Figure 1b), this is analarming concern to indicate that half of the young
population is at risk of poor metabolic health.
The Asian Indian urban phenotype or lean obesity
is defined as individuals having high body fat
percentage and high waist to hip ratio at relatively low
or normal body mass index (BMI) (28). That is
despite having lower prevalence of obesity based on
BMI, Asian Indians tend to have greater degree ofbody fat percentage. This phenomenon is referred to“thin-fat Indian Phenotype” (29). In the current study
also, 7.1% children with normal BMI has body fat
percentile >75th percentile.
There has been a drastic change in eating habits
and food consumption in India over the last few
decades. In a study conducted in 1155 children fromNew Delhi, India observed that 39% of children
preferred fast foods such as pizzas, French fries andonly 11% liked to eat fruits. The study also showedthat 44% of children consumed one aerated drink per
day (30). In another study from Pune, India on 760
children, it was observed that 79.07% children
preferred snacks and fast foods the most, 11.8%
preferred Indian sweets and only 3.5% preferred fruits(31). In the present study also, the frequency
consumption of chips, Indian snacks was almost on
weekly basis and some of them were even consumed
by children thrice/ week. Almost 24% of children also
consumed either energy drink or aerated drink daily.
Indicating that there is a very high intake of low
nutrient and high calorie food and snacks in children
in the age group of young to older adolescents of thatobserved in other studies in India (17, 30-31).
Several studies have associated dietary eating
habits, especially snacking with an increase inoverweight/ obesity. Snacking has been considered
one of the main contributors to increase in weight assnacking is association with an increased
consumption of energy-dense, high-sugar, high-fat
food (14). In a study on 400 children aged 11-13
years, prevalence of overweight/ obesity was 10.4%,
14.4%, 20.5%, respectively, in those consuming<15%, 15% to 10%, and >20% of their energy intake
from snacks (14).
Even though total energy intake in the current
study is only 65.7% of recommended dietary
allowance, it needs to be noted that out of the 1380
kcal/ day consumption almost 47.3% i.e. 653 kcal/day
were obtained from snacks. Apart from this it was also

observed that intake of calories from fat was veryhigh. Almost 31.6%, i.e 1/3rd of the total daily energy
intake was from fats. Thus, the composition of the dietwas very poor which may be one of the contributing
factors for high prevalence of overweight and obesityin the current study.
Intake of high dietary fat and high sugar snacks areassociated with an increase in BMI (32). Snacking onenergy dense foods such as chocolate, snack bars,
fried foods, condensed milk, fruit syrup and biscuit isshown to have a significant association withchildhood obesity (33). Similarly, in the present
study, BMI was significantly associated with total
daily energy intake from snacks. Like other studies,
total dietary fat intake from snacks was also correlatedwith both BMI and body fat indicating that
consumption of high fat snacks increases the risk ofoverweight/ obesity (Figure 3 a – 3d).
Thus, to conclude present study indicates that
almost 50% of children in India are overweight/
obese. Snacks contribute to almost 40-50% of daily
nutrient intake in children with a major part comingfrom unhealthy snacks. The present study also
highlights that the nutrient composition of snacks isshown to have a significant effect on BMI and bodyfat percentage of the children there by increasing theirpredisposition to an inflammatory state of the body.
School based interventions with a focussed inputs
towards guiding children for healthy snacking options
and lifestyle factors need to be prioritized to prevent
overweight/obesity and inflammatory state of theirbody which predisposes an early onset of noncommunicable diseases.

ACKNOWLEDGEMENTS
The authors thank the participating children andparents for being a part of the study.
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47

Asian Journal of Dietetics, 2021

Research Note
Energy Rich Snacks May be Preferable to Lunch with High Lipid to
Increase Energy Intakes in Older Adults at Risk ofMalnutrition, Northern Thailand
Yupa Chanwikrai1, 2*, Jukkrit Wangrath3, Sunard Techangam4,
Chanida Pachotikarn4, Shigeru Yamamoto1
1

International Nutrition, Graduate School of Human Life Sciences,Jumonji University, Saitama, Japan
2
School of Medical Sciences, University of Phayao, Phayao, Thailand
3
Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand
4
Thai Dietetic Association, Bangkok, Thailand

ABSTRACT Background: Our previous studies have shown that undernourished older
adults in Northern Thailand had low lipid intake, resulting in energy deficiency. To
increase energy intake, perhaps we could suggest two methods, one is to increase lipid
in lunch and the other is an energy rich snack. Aims: To investigate effects of lunch withhigh lipid or an energy rich snack on energy intakes in older adults at risk of malnutrition.
Method: Participants were 8 elderly people (average age 70.8±4.1 years) with risk ofmalnutrition (body mass index 17.8±2.0 kg/m2). A randomized cross-over design wasused to compare dietary intake under two diets: control (regular diet) and intervention(energy enhanced with lipids in meal and snack) on three days. Washout period was twodays. In this study, energy was enhanced only for lunch and snack, but not breakfast anddinner. Energy for lunch was increased with rice bran oil. Energy in the snack wasincreased with coconut milk/peanuts and a box of soy milk. A 24-hour dietary survey
using the recall method was conducted for the 3 days before, and during each of the two
periods. Results: Although the energy supply at lunch in the intervention period wasincreased to about 700 kcal from about 600 kcal in the control period, the intake wassimilar between the two periods, being about 450 kcal, suggesting that the subjects could
not eat increased lipids, maybe because of the large portion size. Average energy intakes
from energy-rich snacks increased by about 2.5 times of the control (from 122±34 to
313±48 kcal, P=0.012), maybe because the portion size was small, resulting in about a
200 kcal increase per day (from 1,312±153 to 1,511±190 kcal, P=0.012). Conclusion:
From the present study, we found that in older adults at risk of malnutrition, increasingenergy from snacks is more acceptable than lunch with high lipid.
Key words: energy intakes, snacks, meals, older adults, risk of malnutrition
INTRODUCTION
Inadequate energy and protein intakes are
frequently reported in the elderly (1), thereby
increasing the risk of malnutrition. The Thai
National Health Examination 2014 reported theprevalence of malnutrition in older aged 60 - 69
years as approximately 10% in males and 4% infemales and this increased at advanced ages (2).
Our previous study (3) that showed older adults
dwelling in community settings in northern Thailand
had inadequate energy consumption, with estimateddaily energy and lipid intakes accounting for 92%
and 40% of the Thai recommended dietary
allowances (RDA).The prevalence of underweightas determined by body mass index (BMI) < 18.5kg/m2 was reported as 18% in males and 9% infemales, which was two times as high as
underweight in the survey of the Thai National
Health Examination.
This study was conducted before the main
study. The first reason was that we did not knowwhether our undernourished participants could
consume higher lipid than their current intake. We
tried to find from various studies what kind of lipids
are better accepted by malnourished elderly. In some
papers the advantages of oleic acid were reported.

Oleic acid has a lower satiating effect than other fatty
acids such as saturated and long-chain
polyunsaturated fatty acids (4). We looked for oleic
acid-rich foods common in Northern Thailand andfound that they are peanut oil (45-53%) (5) and ricebran oil (43.9%) (6). Therefore, in the present study,
for the intervention lunch, we used rice bran oil.
Soybean oil was used in the control diet because it is
the most common oil.
In our previous study, we observed that thefrequency and the energy of snacks were low.
Therefore, in this study we tried to increase theenergy from snacks by adding ground peanuts that
contain high oleic acid and also used coconut milk,
which is rich in energy and tasty. In addition, soy
milk was offered as a substitute for milk by people
who are lactose intolerant as well as low cost andnutritious.
It is important to explore the effective strategies
to promote adequate dietary intake in community
dwelling elderly. This will be helpful in preventing
or slowing progression of chronic diseases anddiminish hospitalization. The Objective of this study
was to investigate effects of lunch with high lipid
and energy rich snack on energy intakes in older
adults at risk of malnutrition.

________________________________________________________________________*To whom correspondence should be addressed:chanwikrai.yupa@gmail.com

49Energy Rich Snacks are Recommended in Older Adults
METHODS
Study design and participantsThis study was a randomized, controlled, crossover design to evaluate dietary intakes under twodiets: control (regular diet); intervention (energy
enhanced) at lunch and snack for three days.
Washout period was two days. The potential
participants were screened from medical records of
Ban Ton Keaw District Health Promotion Hospitalin November to December 2020. Those willing toparticipate were informed about the study andscreened for inclusion criteria were aged 65 – 79
years old, body mass index less than 20 kg/m2 and/or
recent unintentional weight loss, able to eat bymouth, not having any illness that may affect taste orappetite such as cancer, chronic kidney disease andhaving no dementia or depression.
After screening, 8 participants (6 females and 2
males) were included in the study and they provided
informed consent.

All data were entered and calculated for energy andnutrient intakes (protein, lipids, carbohydrate,
saturated fatty acid, cholesterol and dietary fiber)using the INMUCAL-Nutrient version 4.0 (Instituteof Nutrition, Mahidol University, Thailand).
Ethical Considerations
This study was done in accordance with theHelsinki Declaration and was approved by theCommittee of Research Ethics in the Faculty of
Public Health, Chiang Mai University, Thailand.
Project number ET019/2020.
Statistical Analysis
Descriptive statistics such as mean, standard
deviation and percentage were used to quantify thecharacteristics of the participants and dietary intakes.
Data were analyzed using SPSS version 22. Resultsfrom the two diets’ differences were confirmed using
Wilcoxon signed ranks tests. All tests were twotailed and a P-value of 0.05 was considered asstatistically significant.

Control and Intervention diet
Daily lunch and snack were delivered to theparticipants’ homes. Lunch consisted of glutinous
rice, a main dish (meat/fish), boiled vegetable andsoup with meat/fish and vegetable.
In the intervention lunch, rice bran oil wasused, and soy bean oil was used in the control diet,general ingredients and seasoning were kept thesame in both diets. The composition, energy andmacronutrient content of the lunch and snack in thecontrol and intervention diets are shown in Table 1.
Energy, protein, lipid and carbohydrate in theintervention and control lunches were 660 - 699 and580 - 598 kcal, 29 - 43 and 28 - 43 g, 24 - 34 and 10- 19 g, 69 - 76 and 68 - 75 g, respectively.
The snack consisted of pandan jelly, sweet
pumpkin, and glutinous rice with perilla seed. In theintervention snack, coconut milk/ground peanuts
were added, and a box of soy milk (250 ml) was
offered. Energy, protein, lipid and carbohydrate in
the intervention and control snacks were 267 - 471
and 44 - 222 kcal, 7 - 11 g and 0 - 3 g, 11 - 21 g and1- 10 g and 7 - 34 g, respectively.
A five-point facial hedonic scale was used toevaluate acceptability test (appearance, aroma,
texture, taste and overall) of foods.

RESULTS
Participants
The participants were six females ( 75% ) , twomales (25%), who had an average age of 70.8 ± 4.1
years, body mass index 17. 8 ± 2. 0 kg/ m2, body fat
24.8 ± 8.1%, muscle mass 28. 1 ± 1. 4%, calf
circumference 21. 9 ± 3. 3 cm, mid upper arm
circumference 22.6 ± 3.0 cm, triceps skin fold 16.3±
3.7 mm, hand grip strength 18.9 ± 3.0 kg (Table 2).
Table 2. Baseline characteristics of
the 8 participants.
Characteristics
Mean ± SD
Gender (number male/female)
2/6
Body mass index (kg/m2)
17.8±2.0
Body fat (%)
24.8±8.1
Muscle mass (%)
28.1±1.4
Calf circumference (cm)21.9±3.3
Mid upper arm circumference (cm)22.6±3.0
Triceps skin fold (mm)16.3±3.7
Hand grip strength (kg)18.9±3.0
The acceptability of control and intervention diet
The acceptability scores of appearance, aroma,
texture, taste and overall of both diets were found tobe similar (control diet: 4.1 ± 0.2; 4.2 ± 0.1; 4.3 ±
0.2; 4.3 ± 0.2 and 4.3 ± 0.2, intervention diet: 4.2 ±
0.1; 4.2 ± 0.2; 4.4 ± 0.1; 4.3 ± 0.2 and 4.3 ± 0.2,
respectively, as shown in Table 3. No difference inacceptability scores between either control dietcompared with the intervention diet were identified.

Anthropometric measurements
Body weight and body composition wereassessed about 2 hours or more after breakfast, using
bioelectrical impedance analysis (Model HBF214,
Omron, Japan). Height was measured using a
portable, free-standing stadiometer. Triceps skinfold(TSF) was measured by using a Fat-O-caliper (Takei
Kikai Kogyo Co., Ltd.). Hand grip strength wasmeasured by a digital handgrip dynamometer(Camry, South El Monte, CA, USA). All themeasurements above were assessed before the study.

Dietary survey
Although the energy supply at lunch in theintervention period was increased to about 700 kcal
from about 600 kcal in the control period, the intake
was similar between the two periods, being about
450 kcal, suggesting that the subjects could not eat
increased lipids, maybe because the portion size wasquite large. Average energy intakes from snack
increased about 2.5 times (191 kcal) the control(from 122 ± 34 to 313 ± 48 kcal, P = 0.012), maybe
because the portion size was small enough forstomach volume.

Dietary survey
A 24-hour recall method dietary survey was
conducted 3 days before the study and in each of thetwo periods. However, to ensure that the participants
provided complete data, they were also requested tokeep an estimated record of all foods and beverages
consumed in the dietary record form. In addition, allparticipants were instructed to place all foodleftovers and containers in a labeled plastic bag andto show them to the researchers to determine intakes.

50

51

13
1
5
31
0

127
26
235
598
44

30
(15%)
14
1
1
7
5
28
2

46
(25%)
12
26
5
43
3

802
224
20
26
76
235
580
222

739
220
126
235
581
158

Lunch: cabbage
soupChili paste
Boiled vegetables
Boiled egg
Glutinous rice
Total lunch
Snack:
Sweet pumpkin

Total lunch + snack

Lunch:m ixed
vegetable soup,chickenSpicy soup withfish
Glutinous rice
Total lunch
Snack:
Glutinous rice,
perilla seed

210

P
g)%(
31
(20%)
13

E
kcal
643

Total lunch + snack

E = energy; P = protein; F =f at; C = carbohydrate

Day 3

Day 2

Total lunch + snack

Day 1

Lunch :wax gourd
soup with chicken
Chili paste withground pork, tomato
Boiled vegetables
Glutinous rice
Total lunch
Snack:
Pandan jelly

Composition

Control period

0
15
1

2

16
(20%)
13

0
0
5
0
22
10

32
(36%)
16

0
0
19
2

6

F
g)%(
21
(29%)
13

54
68
34

2

102
(55%)
13

4
5
1
54
68
31

99
(49%)
6

5
54
75
7

6

C
g)%(
82
(51%)
11

Day 3

Day 2

Day 1

Intervention period

279
146
235
660
399

Spicy soup with fish
Glutinous rice
Total lunch
Snack:
Glutinous rice, perillaseed, soymilk

1,059
Lunch :mixed
vegetable soup, chicken

Total lunch + snack

60
26
76
235
699
471

303

Lunch: cabbage soup
Chili paste
Boiled vegetables
Boiled egg
Glutinous rice
Total lunch
Snack:
Sweet pumpkin
topping with coconut
milk, soymilk

1,170

26
235
691
267

185

245

E
kcal
958

Total lunch + snack

Lunch:w ax gourd
soup with chicken
Chili paste with groundpork, tomato, egg
Boiled vegetables
Glutinous rice
Total lunch
Snack:
Pandan jelly, soymilk

Total lunch + snack

Composition

5
43
11

26

55
(20%)
12

1
1
7
5
29
8

37
(13%)
14

1
5
37
7

18

P
g)%(
44
(18%)
13

0
24
13

4

36
(31%)
20

4
0
5
0
34
21

55
(42%)
24

0
0
26
11

10

F
g)%(
38
(36%)
16

Table 1. Food composition, energy, and major nutrients content of the three-day lunches and snacks during control and intervention periods.

54
69
60

2

129
(49%)
13

4
5
1
54
70
62

131
(45%)
6

5
54
76
35

6

C
g)%(
111
(46%)
11

Asian Journal of Dietetics, 2021

Energy Rich Snacks are Recommended in Older Adults
In addition, lipid, protein, carbohydrate,
saturated fatty acid, cholesterol and dietary fiber
intakes were increased from 3.9 ± 0.9 to 13.0 ± 1.7
g, 1.4 ± 0.5 to 7.0 ± 1.0 g, 20.2 ± 6.0 to 41.9 ± 7.2 g,
3.1 ± 0.7 to 4.9 ± 1.0 g, 0.0 ± 0.0 to 6.1 ± 1.5 g and
0.9 ± 0.2 to 1.2 ± 0.3 g, respectively, as shown in
Table 4. This resulted in an increase of about 200

kcal a day from 1,312 ± 153 to 1,511 ± 190 kcal,
P = 0.012, as shown in Table 5.
The energy and major nutrient intakes fromlunch were much lower than the supply. On the other
hand, the energy and major nutrient intakes from thesnack were more similar to the supply, as shown in
Figures 1 and 2.

Table 3. Comparison the acceptability test between control and intervention diet
Menus
Chili paste, ground pork with tomato
Wax gourd soup with chicken
Cabbage soup with pork
Chili paste with dried fish
Spicy soup with fish
Mixed vegetable soup with chicken
Pandan jelly
Sweet pumpkin
Glutinous rice with perilla seed
Average

Diet
ControlIntervention
ControlIntervention
ControlIntervention
ControlIntervention
ControlIntervention
ControlIntervention
ControlIntervention
ControlIntervention
ControlIntervention
ControlIntervention

Appearance
4.1±0.6
4.3±0.7
4.0±0.5
4.3±1.0
4.1±0.6
4.4±0.5
4.4±0.9
4.3±0.7
3.9±0.4
4.1±0.6
3.9±0.4
4.1±0.4
4.3±0.9
4.1±0.4
4.1±0.8
4.3±0.7
4.1±0.8
4.3±0.7
4.1±0.2
4.2±0.1

Aroma
4.3±0.7
4.3±0.7
4.4±0.5
4.0±0.6
4.3±0.7
4.3±0.7
4.1±0.8
4.3±0.5
4.0±0.0
4.4±0.5
4.3±0.7
4.0±0.8
4.1±0.6
4.5±0.8
4.0±0.8
4.1±0.8
4.4±0.7
4.4±0.7
4.2±0.1
4.2±0.2

Texture4.4±0.5
4.4±0.5
4.3±0.5
4.4±0.8
4.4±0.7
4.4±0.5
4.4±0.7
4.3±0.7
4.4±0.5
4.4±0.5
4.3±0.5
4.3±0.5
4.8±0.5
4.4±0.5
4.4±0.7
4.4±0.5
3.9±0.8
4.4±0.5
4.3±0.2
4.4±0.1

Taste
4.3±0.7
4.4±0.7
4.4±0.7
4.0±0.8
4.4±0.7
4.6±0.7
4.8±0.5
4.3±0.9
4.1±0.4
4.5±0.5
4.4±0.5
4.4±0.5
4.4±0.5
4.4±0.5
4.4±0.7
4.1±0.8
4.0±0.5
4.1±0.6
4.3±0.2
4.3±0.2

Overall4.5±0.5
4.5±0.5
4.3±0.5
4.0±1.7
4.4±0.5
4.4±0.5
4.8±0.5
4.4±0.7
4.4±0.5
4.3±0.5
4.0±0.0
4.1±0.4
4.4±0.5
4.3±0.5
4.4±0.7
4.1±0.6
4.1±0.6
4.4±0.7
4.3±0.2
4.3±0.2

Data are shown in mean ± SD. There were no statistically difference between control and intervention diets ineach dish by Wilcoxon’s signed rank test at P < 0.05.
Table 4. Comparison of energy and nutrient intakes during control andintervention periods at lunch and snack
Lunch
Snack
P value
P value
ControlIntervention
ControlIntervention
Energy (kcal)
449±67454±1371.000
122±34313±480.012*
Lipid (g)11.2±2.4
14.5±4.6
0.161
3.9±0.913.0±1.7
0.012*
Protein (g)22.5±3.2
20.8±7.0
0.674
1.4±0.5
7.0±1.0
0.012*
Carbohydrate(g)64.6±11.1
60.0±19.1
0.484
20.2±6.0
41.9±7.2
0.012*
Saturated fat (g)3.2±0.8
3.8±1.30.327
3.1±0.7
4.9±1.0
0.012*
Cholesterol (mg)100.8±25.7 131.7±33.3
0.036*
0.0±0.0
6.1±1.5
0.011*
Dietary fiber (g)3.7±0.7
3.2±1.00.327
0.9±0.2
1.2±0.3
0.017*
P:F:C
20:22:58
18:29:53
3:30:67
9:37:54
Data are shown in mean ± SD. *P < 0.05, control vs. intervention periods, Wilcoxon’s signed rank test
P = protein; F = fat; C = carbohydrate
Table 5. Energy and nutrient intakes at before the study, control and intervention periods
Before theControl period
Intervention period
P value
study
Energy (kcal)
1,299±205
1,312±153
1,511±190
0.012*
Lipid (g)28.3±6.7
32.9±6.3
45.9±8.9
0.012*
Protein (g)48.1±5.451.7±5.0
53.7±6.9
0.674
Carbohydrate(g)213.1±38.4203.7±27.7220.9±27.4
0.036*
Saturated fat (g)7.7±2.4
10.4±4.8
15.5±3.0
0.012*
Cholesterol (mg)116.7±49.9166.2±74.5
202.2±410.575
Dietary fiber (g)8.4±2.6
10.1±2.8
7.9±1.8
0.036*
P:F:C
15:19:66
16:23:61
14:27:59
Data are shown in mean ± SD. *P < 0.05, control vs. intervention periods, Wilcoxon’s signed rank test.
P = protein; F = fat; C = carbohydrate

52

Asian Journal of Dietetics, 2021
Control diet
Supply136

Intake

171

92

284

99

260

Intervention diet
Supply144

Intake

252

84

288

126

0

100

244
200

Protein (kcal)

300

400

Lipid (kcal)

500

600

700

Carbohydrate (kcal)

Fig 1. Energy and major nutrient intakes from lunch

Control diet
Supply 8 36

96

Intake 4 3680

Intervention diet
Supply36

Intake

28
0

135
117
100

208
168
200
Protein (Kcal)

300
400
500
600
Lipid (kcal)
Carbohydrate (kcal)

700

Fig 2. Energy and major nutrient intakes from snacks

DISCUSSION
This study was a small-scale preliminary study
conducted before the main study. The main purpose
was how to increase energy intake in older adults at
risk of malnutrition. However, we found that inundernourished older adults, increasing energy fromlipid-fortified meals was difficult but that snacks
were acceptable.
We tried to use oleic acid-rich oils, e.g. ricebran oil was used in the lunch dishes, and groundpeanuts were used in some snacks because there
were reports that showed oleic acid is more
acceptable in elderly with poor appetites (4, 7).
However, before we designed the type of lipid
for the lunch dishes and snacks, we tried to use
various types and amounts of lipid and conducted an
acceptability test a small number of elderly andresearchers; after that the recipes with the highest
acceptance scores were chosen for the intervention
study.
However, our present study was not successful
in increasing energy intake at lunch. In the regularmeal diet, we gave about 600 kcal and the intake wasabout 455 kcal. We increased the intervention lunch
to about 700 kcal but the actual intake was about 450
kcal. Intake of all the 3 major nutrients was the same,
indicating that the increased lipids were not taken.
Conversely, the study of Faxén-Irving et al (7)showed the positive effect of energy-dense oleic
acid-rich supplement (30 ml, 3 times/ day), which
increased energy intake about 390 kcal higher in theintervention group compared to the control groupand indicated better appetite. This may be because
offering the small but frequent energy dense oleic
acid-rich supplement stimulated appetite andresulted in increased energy intake.
Our present study reported that energy richsnacks with coconut milk/ ground peanuts and a boxof soy milk were successful and energy intakes
became 2.5 times higher than the regular snacks(control 122 ± 34, intervention 313 ± 48 kcal,
P = 0.012).
The above results may indicate that theparticipants could not consume large portions of53

Energy Rich Snacks are Recommended in Older Adults
REFERENCES
Sharkey JR, Branch LG, Zohoori N, Giuliani C,
Busby- Whitehead J, Haines PS. Inadequate
nutrient intakes among homebound elderly andtheir correlation with individual characteristics
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2) Wichai A, Nitiyanant W, Sornpaisarn B,
Kananurak P. Thai National Health
Examination Survey, NHES V. 2016.
Available:https://kb.hsri.or.th/dspace/handle/1
1228/4604?locale-attribute=th.Accessed April
30, 2021.
3) Chanwikrai Y, Phanthurat N, Singhan C,
Thatsanasuwan N, Sajjapong W, Sinchaiyakit
P, Wangrath J. Undernutrition in Older Adults
Northern Thailand May Be Improved by
Increasing Lipid Consumption. Asian J Diet.
2020;2(3):135-138.
4) Nieuwenhuizen WF, Weenen H, Rigby P,
Hetherington MM. Older adults and patients inneed of nutritional support: review of current
treatment options and factors influencing
nutritional intake. Clin Nutr. 2010Apr; 29(2):1
60-9.
5) Ghazani S. M. , and Marangoni A. G. ( 2016)
Healthy Fats and Oils. In: Wrigley, C., Corke,
H. , and Seetharaman, K. , Faubion, J. , ( eds. )Encyclopedia of Food Grains, 2nd Edition, pp.
257-267. Oxford: Academic Press.
6) Latha RB, Nasirullah DR. Physico- chemicalchanges in rice bran oil during heating at frying
temperature. J Food Sci Technol. 2014 Feb;
51(2): 335-40.
7) Faxén- Irving G, Cederholm T. Energy dense
oleic acid rich formula to newly admitted
geriatric patients- - feasibility and effects onenergy intake. Clin Nutr. 2011;30(2):202-8.
8) Silver HJ, Dietrich MS, Castellanos VH.
Increased energy density of the home-delivered
lunch meal improves 24- hour nutrient intakes
in older adults. J Am Diet Assoc. 2008
Dec;108(12):2084-9.
9) Stubbs RJ, Whybrow S. Energy density, dietcomposition and palatability: influences on
overall food energy intake in humans. Physiol
Behav. 2004 Jul;81(5):755-64.
10) Rémond D, Shahar DR, Gille D, Pinto P,
Kachal J, Peyron MA, Dos Santos CN, Walther
B, Bordoni A, Dupont D, Tomás- Cobos L,
Vergères G. Understanding the gastrointestinal
tract of the elderly to develop dietary solutions
that prevent malnutrition. Oncotarget. 2015 Jun
10;6(16):13858-98.
11) Kruizenga HM, Van Tulder MW, Seidell JC,
Thijs A, Ader HJ, Van Bokhorst- de van der
Schueren MA.
Effectiveness and costeffectiveness of early screening and treatmentof malnourished patients. Am J Clin Nutr. 2005
Nov;82(5):1082-9.
12) Mills SR, Wilcox CR, Ibrahim K, Roberts HC.
Can fortified foods and snacks increase theenergy and protein intake of hospitalised older
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Diet. 2018 Jun;31(3):379-389.

high energy foods, especially lipids, suggesting thedigestion of lipids is not smooth but if the lipid
amount is less than about 125 kcal in each meal andsnack, they could eat the whole amount. Therefore,
we concluded that for the elderly, small, frequentportions are easier than large amounts in a few meals
and the upper limit of lipids may be approximately
125 kcal (25 - 30% of total energy).
This is supported by some reports that mention
that although foods high in energy from lipids tend
to be more palatable, the elderly may not eat them inlarge amounts because of some symptoms such as
gastric distention and emptying rates (8). Somestudies showed that the elderly have significantly
reduced enzyme secretions such as lipase,chymotrypsin, and amylase compared with younger
people (4, 10).
On average older adults eat more slowly, areless hungry, and consume smaller meals than young
people do. Small meals or snacks have been used to
improve dietary intake. For example, Kruizenga et al(11) reported that if they offered two snacks per day
to frail malnourished hospital patients, they foundthat the intervention group increased intake byapproximately 600 kcal and 12 g protein/day
compared to the control group (no snacks).
The taste, variety, familiarity, and portion sizeof the fortified foods and snacks may lead to a higher
rate of consumption and preference (12). In thisstudy, the average acceptability of appearance,
aroma, texture, taste, and overall appeal of both thecontrol and intervention diet were found to be
similar. All of the participants were satisfied with theportion size of the supply of snacks. On the other
hand, some of them informed us that the portion sizeof the supplied lunches was too large.
This study was the preliminary study for thefollowing main study to find a good method forincreasing energy. Although the number of subjects
was small and the study period brief, our finding thata higher energy lunch with fortified oil was noteffective but increasing energy with frequent snacks
with slightly higher energy may be preferable issignificant. In the subsequent main study, we will
adopt this finding (frequent and higher energy).

1)

CONFLICT OF INTERESTS
The authors declare no conflict of interests
regarding the publication of this article.

ACKNOWLEDGMENTS
The authors wish to express their gratitude toProf. Emeritus Dr. Maitree Suttajit for his valuablesuggestions during the planning of this study. We
would like to thank the Director and staff of Ban Ton
Keaw District Health Promotion Hospital, the staffof the Faculty of Public Health, Chiang Mai
University and our participants for theircollaborative effort during data collection. Finally,
we would like to express thanks to Prof. Andrew
Durkin for careful proof-reading of the paper.

54

Asian Journal of Dietetics, 2021

Research Note
Perceptions of Dietitians about Sustainable Food Systems
and Dietetic Practice

Emily Finlay and Liesel Carlsson*
School of Nutrition and Dietetics, Acadia University, Canada
ABSTRACT In an effort to better understand the role of dietitians in contributing tosustainable food systems (SFS), an exploratory survey about the perceived importance of
SFS to dietetic practice was distributed to a convenience sample of dietitians practicing in
Asian countries who attended the Asian Congress of Dietetics in Hong Kong, July 9 -11,
2018. Results from 36 participants across 8 countries emphasize that dietitians in Asian
countries place a strong importance on this topic, regardless of their age or current role inpractice, and that they can identify several important ways to approach this work. Thesefindings align very closely with similar work in other regions, however, Asia-specific dataon sustainable dietary patterns, and dietetic practice-based guidance would expedite thiswork in the Asian context. Similarly, integration of SFS into formal education and training
is an important long-term investment.
Key words: sustainable food systems, dietitians, Asia
sustainability in various areas of practice, including
their own, and the importance of various types ofapproaches/activities in carrying out this work. Data
was analyzed using descriptive statistics using
Microsoft Excel.
Ethical approval for collection of this data was
obtained by the Research Ethics Board at Acadia
University.

INTRODUCTION
Food systems are creating complex challenges toour social and ecological systems (1-2). Amidst global
calls for collaboration among disciplines, professions
and sectors to address food systems sustainability
challenges, dietitians are very well placed toparticipate. They work in many different roles with
influence throughout food systems (food industry,health care, consumer choices, institutional menus).
Sustainable food systems (SFS) "ensure food security
and nutrition for all in such a way that the economic,
social and environmental bases to generate foodsecurity and nutrition of future generations are notcompromised" (3, page 13). Some work is being donein various parts of the world to explore and define therelevance and role of dietitians in sustainable foodsystems (4-7) however, to the authors’ knowledge,
none focusses on the Asian countries. There is somework highlighting potential opportunities for publichealth nutrition to contribute to the Sustainable
Development Goals (published after the data for thisstudy was gathered), but no studies gather intelligencefrom dietitians and in the broader dietetic field ofpractice (8). The purpose of this research was toexplore, through a small pilot study, the perspectivesof dietitians and nutritionists practicing in Asian
countries about the role of dietitians and nutritionists
in sustainable food systems (SFS).

RESULTS
Thirty six conference participants from eight
countries responded to the survey. The highest
percentage of participants were employed in India(30.56%), followed by Hong Kong (25.00%) andChina (16.67%). Places of employment of the survey
participants varied. This survey included dietitians
and nutritionists working at hospitals or clinics,
universities, in the food industry, in food service, withgovernment or non-government organizations, and“other”. The greatest number of participants were
employed in a hospital or clinic (33.33%), followed by
employment at a university (22.22%). Participants ofthis survey were all above the age of 19, with the
majority of participants (75.00%) above 40 years ofage.
Participating dietitians articulated their ideas
about what sustainable food systems are, andresponses covered a range of social, economic andecological topics. Some were very comprehensive, forexample: “A sustainable food system is acollaborative network that integrates several
components in order to enhance a community'senvironmental, economic and social well-being. It is
built on principles that further the ecological, socialand economic values of a community and region.”
When asked “How important is the role ofnutritionists and dietitians in promoting SFS?” 72.2%(n=26) of participants agreed that promoting SFS is avery important role of dietitians and nutritionists. The
average importance rating was 4.58 out of 5

METHODS
A convenience sample of dietitians practicing in
Asian countries was drawn from participants who
attended the Asian Congress of Dietetics in Hong
Kong, July 9-11, 2018. Participants were recruited byword of mouth, and through invitation cards freely
circulated and left outside presentation rooms. The
invitation cards included a QR code to the online
survey. The survey asked questions about the country
in which they practice, their perceptions of sustainable
food systems, their perceived level of importance of________________________________________________________________________*To whom correspondence should be addressed:
liesel.carlsson@acadiau.ca

55

Sustainable Food Systems and Dietetic PracticeFinally, through the survey’s open comments,
dietitians recognized that there are barriers to applying
some of these ideas in practice, and they are related toknowledge. One participant expressed that we “needmore research evidence to show sustainable food is
not only good to environment, but also to health”.
Another suggested that “Dietitians should get advancetraining on sustainability and modern agricultural
methods”.

Number of Participants

Mean Ranking of Importance(Figure 1). Qualitative responses from the participants
further emphasized the importance of dietitians andnutritionists promoting SFS. For example, by sharing
messages about how to do so: “We (should) eat local
food. We (should) thank for the harvest. Do not eat too
much. Do not throw away food. We should educate
how to eat and how much we eat”, was a comment
from one participant. Many participants also strongly
expressed that it is important for everyone to promote
SFS, and to work collaboratively. One participant
wrote that “It is everybody's responsibility. Not only
dietitians. We should work together with others fromthe same work environment; food tech, food workers,
restaurants etc. To help prevent the increasing foodwaste and promote proper food distribution or
donation instead of throwing food away. This would
also help with malnutrition and food imbalance.”
Another wrote: “Engaging with ALL stakeholder(s) isessential. Need to identify the incentives within eachsector (government, industry, academia, dietetics) towork towards a sustainable food system”. Additionalcomments from participants strengthened this positive
response to SFS: “Everybody should have the mindset,
we have one earth, we have one mission (to) keep thesustainable environment.”

4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Education Helping Advocacy Research
Food
Industry

Other

Approaches for Promoting SFS

30
25
20
15
10
5
0

Fig 2.
Perceived level of importance acrossapproaches, within current roles, for promoting SFS.

1

2

3

4

DISCUSSION
Results of this exploratory work indicate that
dietitians practicing in Asian countries, like theircolleagues in other parts of the world (7, 9, 10) have anuanced understanding of what sustainable foodsystems are, and that regardless of age or roles in thefood system (e.g., clinical, food industry, etc.), themajority of participants felt that dietitians andnutritionists have an important role in promoting SFS.
Further, similar to work in other regions (6, 11),
participants identified several important approaches
that can be applied to this work, and emphasized using
education, advocacy, and research. For example,
dietitians working in food industry can advocate forsetting industry regulations that support sustainability,
and those working with clients (individuals, families,
communities, organizations) have opportunity to
educate for SFS. As many participants in this study
worked in research, participating in research teams tounderstand sustainable diets in the Asian context is one
important opportunity. Results support the idea that
dietitians are indeed well positioned to contributemeaningfully to more sustainable food systems.
It is critical to note some participants emphasizethat while dietitians have an important role, this is an
issue that requires participation and leadership frommany other disciplines and sectors – that this is a“mindset” that is needed in the work.
The question we ask ourselves now is “Where do
we go from here?” The barriers identified related toknowledge are significant, and will take time toaddress. While some good resources about sustainabledietary patterns exist (2, 12), and some specific to
Asian countries (13), further research about thecomprehensive sustainability (i.e., not only climate
impacts) of dietary patterns across Asian countries
would be a valuable contribution to supporting thiswork. Advocating for, or participating in research

5

Level of ImportanceFig 1. Perceived level of importance of the role ofdietitian and nutritionists in promoting SFS (1=Not
important, 5 = Very important)
Results show that regardless of work role
participants felt that the level of importance was atleast moderate. When the level of importance wasbroken down across five areas of work, or roles,(hospitals or clinics, universities, food industry, foodservice,governmentor
non-governmentorganizations, and other), the mean rating ofimportance was three (moderately important).
The survey asked participants to rank the level ofimportance of several approaches in contributing to
SFS in general, and in their own workplace. These
approaches included: education, helping foodindustry, advocacy, research and other. Regarding theapproaches that dietitians and nutritionists can use inpromoting SFS, in general, participants rated
advocacy (mean = 4.53) and education (mean = 4.50)
to have the highest level of importance. Whenparticipants were asked about their specific role inpromoting SFS in their own workplace, on average,
participants ranked their role in education (mean =4.24) and research (mean=4.00) to have the greatest
level of importance (Figure 2). No significant
differences emerged across age groups and places of
employment. All approaches were ranked highly
across participant roles.

56

Asian Journal of Dietetics, 2021
teams which produce research on sustainable dietary
patterns in the Asian context is needed.
Further, little is published about the level or typeof training in sustainable food systems that dietetic
trainees receive, although research from Australia
shows that more work needs to be done (14). The
International Confederation of Dietetics Associations
has been working to support international member
associations and dietitians with knowledge
development for sustainable food systems throughdevelopment of an online toolkit (15), but
acknowledge that there is a dearth of Asia-specificresources. Dietitians practicing in Asia can support
one another within the profession about how toincorporate SFS into practice, share resources, and toseek appropriate professional development in this
topic if needed. A practice network with a focus on this
topic may be helpful.
This exploratory, pilot study is limited in its
generalizability to the entire population of dietitians
and nutritionists practicing in Asia due to the small
sample size. The results suggest significant interest in
this area and invite further study.

6)

7)

8)

9)

ACKNOWLEDGEMENT
The authors gratefully acknowledge Dr. Edith
Callaghan’s contributions to survey design, and to
ACD 2018 organizers to allowing the collection ofthis data. Financial support from the International
Confederation of Dietetics Associations enabled datacollection, and from Acadia University Faculty ofPure and Applied Science enabled student support.
1)

2)

3)

4)

5)

10)

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Nexus: Addressing practices, political economy,
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Willett W. et al. Food in the Anthropocene: theEAT–Lancet Commission on healthy diets fromsustainable food systems. Lancet 393: 447–92.
2019. <https://doi: 10.1016/S01406736(18)31788-4>.
High Level Panel of Experts on Food Security
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Committee on World Food Security, Rome.
2014. <http://www.fao.org/3/a-i3901e.pdf>(accessed 19/09/2018).
Italian Association of Dietitians. Role ofdietitians in food sustainability: position of the
Italian Association of Dietitians (ANDID). 2010.
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Carlsson L, Seed B, Yeudall F. The Role ofDietitians in Sustainable Food Systems andSustainable Diets. Dietitians of Canada, Toronto.
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Carlsson L, Callaghan E, Laycock-Pederson B.
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Systems in Nutrition and Dietetics. Report to the
In ternational Co n federation o f Dietetics
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52(7):S63. 2020. <https://doi:10.1016/j.jne
b.2020.04.146>.
Vogliano CT, Brown K, Steiber A. Strategies for
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Diet.115 (9):SA73. 2015. <https://doi:10.1016/
j.jand.2015.06.259>.
Clark M, Macdiarmid J, Jones AD, Ranganathan
J, Herrero M, Fanzo J. The Role of Healthy
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11/092020).

Asian Journal of Dietetics, 2021

Research Note
Acceptability of Vietnamese Rice Noodle by Japanese

Sumiko Kamoshita, Yuki Wada, Vu Thuy Linh, Shigeru Yamamoto*
Asian Nutrition and Food Culture Research Center, Jumonji University,
Saitama, Japan
ABSTRACT There are noodles in both Japan (UDON) and Vietnam (PHO), but the
ingredients are completely different: the former are made from wheat and the latter are
made from rice (Indica rice). Japanese rice (Japonica rice) has strong adhesiveness and is
not suitable for making noodles. Currently, wheat is mainly imported to Japan from North
America, so if Vietnamese rice is used, the cost of transportation will be much lower.
However, since Japanese noodles are traditionally made from wheat flour, we do not knowwhether noodles made from rice would suit Japanese tastes. This study was conducted toclarify the question. The dish used in this test was "Kitsune Udon," which is the mostpopular noodle dish in Japan. The subjects were 53 students from a women's university in
the Tokyo area. Three surveys were conducted. The first was on the experience on eating
noodles, the second was a sensory test of Japanese-style noodle dishes and the third
investigated whether UDON can be replaced with PHO. Most of the subjects had not eaten
rice noodles previously. The results of the sensory test showed that concerning aroma,
appearance, texture, compatibility with fish and kelp-based broth. UDON was evaluateda little higher but the overall taste ranking was similar or both kinds of noodle. About 60%of the subjects answered that they could replace UDON with PHO. In conclusion,
Vietnamese rice noodles will be accepted by Japanese, especially if they become morecommonly available and familiar.
Key words: noodle, udon, pho, acceptability, Japanese young women
INTRODUCTION
In Japan and Vietnam, the main source ofcarbohydrates is rice. Noodles are common dish inboth Japan and Vietnam, but the ingredients are very
different. Japanese noodles (UDON) are made from
wheat, while Vietnamese noodles (PHO) are madefrom rice. Japanese rice is not suitable for making
noodles because the rice is too sticky. Rice contains
two types of starch; amylopectin and amylose.
Amylopectin contributes strongly to viscosity due toits branched chain structure of glucose chain, andamylose has a linear glucose chain that contributes lessto viscosity. The ratio of amylose to total starch iscalled the amylose content. Amylose-high, -medium,and –low content rice contains amylose about 22-28%,
16-18%, and 15% or less amylose (1). High- amylose
rice is not sticky but crunchy. On the other hand,glutinous rice consisting only of amylopectin is very
sticky. Generally, Vietnamese rice is mediumamylose in content and is suitable for making noodles.
Japanese rice is low-amylose rice (amylose content
less than 15%), which is too viscous to make noodles.
For this reason Japanese UDON is made from wheat.
Currently, wheat is mainly imported from North
America, so transportation costs are high. In Vietnam,
rice can be harvested two to three times a year, so theprice is low and the transportation cost to Japan is also
low. PHO is a popular dish among Japanese tourists
to Vietnam. However, PHO is rarely seen in Japan.
We suspect the reason for this is that Japanese people
have a long tradition of making UDON from wheat
and therefore do not think of making noodles fromrice. In this research, we tried to see how wellVietnamese PHO is accepted by Japanese.

Photo 1. Japanese noodle UDON Sources:

https://www.photo-ac.com/main/

Photo 2. Vietnamese noodle PHO Sources:

https://p-pho.com/shop/archives/473________________________________________________________________________*To whom correspondence should be addressed:
shigeruy@jumonji-u.ac.jp

59Sustainable Food Systems and Dietetic Practice

METHODS
A sensory test was conducted with 53 female
panelists from 18 to 22 years old at a university in theTokyo Metropolitan area. Menus with the popular
Japanese dish noodle Kitsune were served, except thatthe noodles were either UDON or PHO. First, we
conducted a survey of panelists’ experience eating
noodles by asking 5 questions: 1. do you like UDON,
2. how frequently do you eat UDON, 3. have you evereaten PHO, 4. do you like PHO, and 5. how frequently
do you eat PHO.
Secondly, we did a sensory test of UDON and
PHO scored on a 5-point scale (very good:5, good:4,
neither good or bad:3, poor:2, very poor:1) to evaluate
acceptability with regard to aroma, aroma, appearance,
texture, compatibility with fish and kelp UMAMIbased soy sauce broth and overall taste.
Finally, we asked the panelists whether theywould replace UDON with PHO using a 5-point scale;(strongly agree: 5, agree: 4, neither agree nor disagree:
3, do not agree: 2, strongly do not agree:1. Panelists
were informed of the survey method and responses
were gathered anonymously so that personal
information was not identified.
Statistical analysis was conducted by paired
Student t-test. Significant differences were evaluatedby p values less than 0.05 and 0.01.

RESULTS
Experience on eating noodles of panelists:
The results of frequency of eating noodles were:at least once a week 14.8%, more than once a month
75.9%, more than once in three months 5.6%, rarely
eat not 3.7%. On the experience of eating PHO, 68.5%
of panelists answered “yes”, and 31.5% of panelists
answered “No”. Furthermore, 81.6% of those whohave eaten PHO said that they liked it. Many of themcommented that the reason was that they were healthy,
light, easy to eat, and unique slick texture. About 4%of panelists answered that they usually use PHO in
their meals”, the others like but don't use PHO because
there not easily available and few restaurants.
Sensory evaluation of UDON and PHO:
Each panelist tasted UDON and PHO, andaccording to 5-point scale (very good: 5, good: 4,neither good or bad: 3, poor: 2, very poor: 1) ① aroma,② appearance, ③ texture, ④ compatibility with soy
sauce soup and ⑤overall taste. The mean score of
UDON was higher than that of PHO, but overall taste
scores were similar (p>0.05) (Table 1).

Table 1. Comparison of taste evaluation between UDON and PHO
Compatibility with
Aroma
Appearance
Texturefish and kelp based
soy sauce broth

Overall taste

Japanese
4.39±0.56
4.52±0.61
4.72±0.49
4.81±0.39
4.41±0.53
noodleVietnamese
3.44±0.77*
4.02±0.81* 3.93±0.89*
3.60±0.97**
4 .33±0.93
noodleValues are mean±SD n=53*, ** Significant difference from Japanese noodle by paired Student t-test at p<0.05 and p<0.01, respectively.
Possibility to replace UDON with PHO
Figure 1 shows the answer to a question whether
they would replace UDON with PHO. The panelists
answered strongly agree: 15.1%, agree45.3%, either
agree or not 34% and disagree 15.7%.

DISCUSSION
In this study, the acceptability of Vietnamese rice
noodles PHO by Japanese women students was high.
These noodles were prepared using the same method
as for Kitsune UDON (noodle dish with fried tofu).Asa result, there was not a big difference in preference
between the PHO and the UDON, suggesting that
PHO may be well accepted by Japanese.
For Japanese people, PHO is not an ingredient
they consume on a daily basis. Many of the subjects inthis study had never eaten PHO. On the other hand,
UDON is a familiar ingredient for Japanese. It is easy
to get and is an ingredient that they have beenaccustomed since their childhood. Not many people
can eat unfamiliar foods like PHO without any
hesitation. However, the evaluation of tastiness in thepresent study was similar, and about 60% of thesubjects answered that they could use PHO instead of
UDON. This result is considered to be a fairly highevaluation for PHO.
UDON does not have the smell of wheat, whether
it is fresh noodles or dried noodles, but PHO has aunique rice smell. The subjects were not accustomed
to the combination of the aroma of PHO and the scentof soy sauce soup with UMAMI of kelp and driedFig 1: Evaluation for PHO by Japanesecooking method (N=53)60

Asian Journal of Dietetics, 2021
bonito flakes. However, such reaction to differing
aromas may decrease as subjects become accustomed
to eating PHO.
In terms of texture, UDON was evaluated as
chewy but PHO was soft, which is thought to be theresult of the preference for UDON over PHO. In thisstudy the UDON was made from fresh noodles but
the PHO from dried noodles because it was imported
from Vietnam. This difference is the great limitationof this study. For a fair comparison, both noodles
should be in a similar condition.
From an economic point of view, about 80% of
the wheat used in Japan is imported from North
America (2). The distance to Japan is about 10,000
km, but it is only about 3,865km from Vietnam to

Japan. In Vietnam, rice can be harvested two to threetimes a year, so the price is low. From the economic
point of view, PHO is much superior to UDON. PHO
could be common and familar food in Japan by proper
promotion.
1)
2)

61

REFERENCES
Shizuoka Prefectural Office 1998, Rice Mini
Encyclopedia, www.pref.shizuoka.jp (accessedon June 15, 2021)
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