ISSN2434-2688 Asian Journal of Dietetics

Vol.2 No.4

2020

Contents
Page

Title and authors

Special Topic
153

Originals
155-164

165-170

The History of the Nutrition Improvement in Japan Establishment of the
National Institute of Nutrition and the Birth of the Profession of Dietitian: No.2
in a Series
Teiji Nakamura
Establishment of Child Body Image and Study on Mother’s Perception forChild Body Weight
Bui Thi Nhung, Nguyen Thuy Anh, Le Danh Tuyen, Nguyen Huu Chinh, Bui Van
Tuoc, Nguyen Mai Phuong, Tran Thanh Nam, Shigeru Yamamoto
Nutrition Education Using Nutrition Handbook and Tele-Counselling Improved
Nutritional Knowledge and Behaviour of Elderly in Northern Thailand

Jukkrit Wungrath, Pussadee Mongkol, and Yupa Chanwikrai
171-177

179-184
185-189

Acceptance of Textured Soybean Protein in Indonesian Dishes and Its Effects on
Energy in Overweight Women
Indri Kartiko Sari, Diah Mulyawati Utari, Mitsutaka Kohno, Ryuji Yamaguchi,
Shigeru Yamamoto
Predictors of food insecurity in the selected areas of SINDH Pakistan
Rubina Hakeem, Farzana Asar
Effects of the Ghana School Feeding Programme on Social Protection and the
Local Economy and Key Challenges to Programme Implementation
Edem Magdalene Tette1, Juliana Yartey Enos2*

Letter to the editor
191-192

Impact of Changing Foodservice Systems on Japanese Hospital Kitchen
Staff’s Labor Time During COVID-19 Pandemic
Keiko Hirose1,2, Thao Phuong Tran1,2*, Shigeru Yamamoto

History of the nutrition improvement in Japan
Special Topic
The History of the nutrition improvement in Japan
Establishment of the National Institute of Nutrition and the Birth of the Profession of Dietitian:No. 2 in a Series
Teiji Nakamura
President of The Japan Dietetic Association/President of Kanagawa University of Human Services
1) Background to the establishment of the National
Institute of Nutrition
In 1868, Japan began to follow the path of a modern
nation as a result of the Meiji Restoration. At thattime, nutrition science was introduced from Europe
and the United States, and the person who primarily
contributed to its development and dissemination was
Dr. Tadasu Saeki. In 1905, he studied abroad at Yale
University in the United States, and after returning toJapan began researching nutrition while treating
patients at a hospital in Tokyo. At that time, many
researchers focused on the discovery of new nutrientsand showed no interest in the practice of nutrition.
However, he thought that nutrition was meaningful inpractice and useful for people, and in 1914 heestablished the "Private Nutrition Research Institute"at his own expense in Tokyo Shiba Shirogane.
Then, in 1920, the national government
designated this institute as the “National Institute of
Nutrition: NIN” and he became its first president. In
other words, this year (2020) is the 100th anniversaryof the establishment of the NIN. The reason why the
NIN was established in Japan was that nutrition
officials led by Dr. Saeki were influencing thegovernment, but also there was the social backgroundat that time.
In Japan, due to modernization, the number ofindustrial workers increased, agricultural workers left
the farms, and rice production became sluggish. In
addition, the price of rice was soaring abnormallybecause farmers withheld rice from market rather thansell at prices set by military policy. People could not
get rice. Japan became severely undernourished, andthe rebel movement of “Give me rice” sprang up
frequently in cities, and it expanded into riots. The
government positioned nutrition and food issues as animportant national policy, and established the“National Institute of Nutrition” as a center for policy
research.
2) Origin and utilization of dietitians
The reason for the success of nutrition
improvement in Japan is that the state has actively
worked on nutrition policy and that people have beenenthusiastic about training and utilizing dietitians.
Dr. Saeki, who advocated academic independence innutrition, said that with the low level of knowledge
about nutrition among the people, it was not enoughto resolve the serious food situation only byresearching nutrition and providing information
through the media.
In 1924, he established the first " School for
Dietitians" to train nutrition professionals on the siteof a private nutrition research institute. He thought,"Since doctors don’t have kitchen knives and it isdifficult for cooks to learn medicine, we would
create dietitians as nutrition professionals withknowledge of both areas”. The school recruited topnotch researchers as professors, and since there wasno textbook, lessons were developed in line withpractice. The following year, the first 13 graduateswere awarded certificates and were called "The Hands
of Nutrition", pioneering dietitians. The graduatesworked at the forefront of nutrition improvement byfinding employment as school nutrition teachers,
culinary researchers, nutrition specialists ingovernment agencies, hospitals, school lunch facilities,
etc. However, they did not yet have a formal national
qualification.
In 1945, the year the war ended, the government
enacted the "Dietitian Regulations" in Tokyo, which
had been destroyed by US airstrikes.
Nutritional
deficiency had become a serious social problem dueto the war, and active nutritional improvement became
indispensable. Not to mention the many deaths bystarvation, in the turmoil, suspicious foods and healthpractices were prevalent, leaving people wondering
what to believe and what to eat.
The following goals were established for the“Dietitian Regulations”.
(1) To define the status and duties of dietitians
nation-wide and to unify and to provide uniform
thorough nutritional guidance for the population.
(2) To strengthen nutritional guidance in factories,
business establishments, rural areas, etc. based on theactual food situation.
The following year, the National Nutrition
Survey began, and the first "Japan Dietetic
Association General Assembly" was held at the
Takarazuka Grand Theater. In 1947, the "Dietitian
Regulations" became the "Dietitian Law" with Law
No. 245, and dietitians became subject to national
qualifications by law in both name and reality. With
the birth of dietitians, improving nutrition in Japan
became officially the national policy and rapidly
expanded as a national movement. Japan was thefirst country in the world to demonstrate that the mostimportant and effective way to resolve malnutrition
among the people is to educate and train dietitians who
are nutrition specialists.
Reference
1) Miho Ota: Modernization of a food, nutrition
and modernization and, learning p. 117 - 13 or 2016
2) National Nutritional Society writing and editing;Nutritionists law, nutrition improvement law,
“Japanese nutrition, history” p, 252-258, Shunjunsha
19813) Nakamura T.; Japan Nutrition Unraveled by Teiji
Nakamura, Daiichi Publishing 2020

Corresponding author: nakamura-t@kuhs.ac.jp153

Asian Journal of Dietetics, 2020

Original

Establishment of Child Body Image and Study on Mother’s Perception for Child Body Weight

Bui Thi Nhung1, Nguyen Thuy Anh1, Le Danh Tuyen1, Nguyen Huu Chinh1, Bui Van Tuoc1,
Nguyen Mai Phuong2, Tran Thanh Nam3, Shigeru Yamamoto2
1

National Institute of Nutrition, Hanoi, Vietnam
Nutrition and Food Culture Research Center, Jumonji University, Saitama, Japan
3
Science Research and The ARC Centre of Excellence for Children and Families over the Life Course, The
University of Queensland, Australia
2

ABSTRACT Background and purpose: Child obesity is a present important public healthproblem in Vietnam. It is accelerated by the recent rapid economic developments. There arevarious factors and one of them is a perception of parents and society, especiallymother’s. Many of them think that chubby children are healthy and beautiful, which makes
them to think that their children are thinner than real. However, obesity and dietary habit inchildhood will bring the serious non-communicable diseases in their future and mothers andsociety have to realize their wrong perception. Available body images at present are only forWestern children and adolescent. We need the one for East Asian children and those before
adolescent. We conducted two studies; the first is the establishment of body image of 6-10
year old children and the second is to find the wrong perception of mothers about theirchildren. Methods: In Study 1 we tried to establish child body image. We measured height
and weight of 8 year old students at an elementary school (233 students). Based on WHO
definition, we categorized them into 5 groups and then we made 10 groups to make image
more precise. We took photographs of all the children with light cloth and divided into 10
groups in both boys and girls and show them to artists to draw 3 styles of body silhouette foreach groups. We asked children’s mothers to choose the best silhouette from 3. Study
2 Actual BMI of children and the perception of mothers It was conducted at 6 elementary
schools in 3 cities in Viet Nam (Hai Phong, Ha Noi, and Da Nang) and total subjects was
600 pairs of mother and child. We measured height and weight of all children and ask
questions by using the silhouette. Results: Through the survey, prevalence of boys and girls
suffered from overweight and obesity were quite high, being about 40%-60%. More than
30% of mothers liked overweight and obese image and thought that they are healthy.
Moreover, more than 47.2% of mothers thought that their children were wasting in spite of
the actual prevalence of 2.7%. Conclusion: In this study body image of East Asian children
before adolescent was established first in the world. Prevalence of obesity was high in 3 big
cities in Vietnam, and also mother’s favorite and healthy BMI was higher than the actual
BMI of children, furthermore 47.2% of mothers thought that their children were underweightin spite of the real underweight was only 2.7%. While only 2.3% of mothers thought that
their children were obesity in spite of the real obesity was 26.3%.
Key words: Vietnam, child, obesity, body image, mother’s perception
INTRODUCTION
Child obesity is a present important public healthproblem in Vietnam. It is accelarated by the recent
rapid economical develpments. Overweight andobesity in children may lead to obesity in adulthood,as well as other pathological disorders related toobesity. A study in Japan showed that 30% of obese
children will be still obese when they become adults(1). For example, in Australia, in 1985, theproportion of overweight and obese aged from 2 to18 years old was 10.2% in boys and 11.6% in girls.
This proportion increased to 23.7% in boy and24.8% in girls in 2008 (2). In China, after 20 years(1985- 2005), the proportion of overweight andobese children aged 8-18 years old increased from
2% to 14% in boys and from 1% to 9% in girls (3).
In Asia, the number of children who are
overweight and obese has increased from 13 million

children in 1990 to 18 million in 2010 which ishighest in 3 Continents (4).
According to the results of general nutrition
survey 2009-2010 in Vietnam, prevalence ofoverweight and obese children aged from 5 to 19
years old was 8.5%. The prevalence in 5-19 years
old children was 15.4% in big cities, 6.6% in rural
areas and 27.4% in the municipalities (5). Survey
conducted in 1996 and 2014 in Ho Chi Minh City
showed that the prevalence of primary school
children has increased from 12.2% to 51.8%. The
survey in Hanoi in 1995 and 2013 increased from
3.3% to 40.6%
There are various factors which causing the rapid
increase of child obesity such as energy rich diet,using soft drink in the meal, eating fast food andreduced physical activity (6-12). In Viet Nam,_________________________________________________________________________________________*Correspondingauthos BTNhung: nhungvnnin@gmail.com, S. Yamamoto:shigeruy@jumonji-u.ac.jp155

Asian Child Body Image
parents and grandparents always think that fat
children are healthy and beautiful. They usuallycompare their children’s weight with other children’s
weight. So, they give a lot of food to their children
when they see that their children are not as fat as otherchildren.
Some parents take their children tonutrition counsulting room and doctors concluded
that their children are normal (their weight and height
meet World Health Organization’s standard), butparents and grandparents still think that their children
are suffering from underweight and they need to gain
weight. Similar phenomen can be seen in thedeveloped countries. In England, one research was
about parents’ awareness of their children's obese andit was implemented at a primary school with thechildren from 10-12 years old. The result showed that
29.9% of children who suffer from obesity, but only
18.3% of mothers who realize that their children areobese [13]. In Spain, there was a research aboutmothers' perception of their children's obese with thechildren from 6 to 10 years old. The result showedthat in 72 overweight children, there were only 29%
of mothers believed that their children were
overweight and in 90 obese children, only 52% of
women were aware that their children were obese(14).
But in VietNam, until now, we do not have any
study using body silhouettes to find whether mother’s
perception is one of the reasons leading to children's
obesity.
However, in 1997, the study of overweight andobese children at a primary school in District 1, Ho
Chi Minh City showed that 25% of parents withoverweight children were not aware that theirchildren were overweight, and when asked about
solution to overweight children, 20.5% of parents
still did not want their children to lose weight (15).
Furthermore, the study of body image inadolescents within Vietnam and Japan in 2005-2006
among students in 3 secondary schools in Japan and3 secondary schools in Ho Chi Minh showed a very
different trend between the desire for body shape ofJapanese students and Vietnamese students. In Japan,
children in the juvenile age often want to have aslender body, especially in girls. In this study, about
60% of the Japanese children think that obesity isunhealthy, whilst about 85% of the Vietnamesechildren think that thinness is unhealthy. Most
Japanese girls are not satisfied with their body shapes
and 78.3% of them want to lose weight, which is themain reason of underweight among the adolescentsin Japan. Meanwhile Vietnamese students tend to
gain weight.
Therefore, to build solutions of overweight andobesity prevention for school aged children, a
research "Evaluation of mothers’ awareness about
their children’s nutritional status through body
image," is implemented with two purposes: the firstis the establishment of body image of 6-10 year oldchildren and the second is to find the wrong
perception of mothers about their children. Hence, webuild the solutions for parents to prevent overweight
and obesity among school aged children.

Selection criteria included children who:
- Without malformation- Without chronic or acute diseases, acute infection
etc…
- Parent agree to participate
Time and place
This study was conducted from October 2015 toNovember 2015 in one elementary school in suburban area in Ha Noi.
2. Study design.
This study was designed as a cross sectional study.
3. Sample size and selecting subject
We have to co-operate with Hanoi Preventive
Health Care and Department of Education to choose
one elementary school to join in the study. And wechose Kim Chung elementary school to join the study.
We make student list of all 3rd grade students (8 yearsold). And we based on inclusion criteria to selectsubjects for the study. After removing people who did
not met the inclusion criteria, 233 students wereselected to join in the study.
4. Methodolody and data collection
Before conducting study 1, we trained forsurveyor about weight and height measurement. We
contacted to teacher of each class to give informed
consent to parents and got the agreement of all parents
who permited your children to join in the study. We
started to do anthropometric measurement andcalculating BMI of 233 students.
Anthropometric measurement: Body weight andheight were measured in light clothing and without
shoes to the nearest 0.1 kg and 0.1 cm respectively.
Body mass index (BMI) was calculated as weight per
square of height (kg/m2).
Calculate BMI of 233 students based on thisfomular: BMI = (weight in kilograms)/height inmeters²
After that, we classified of nutritional status of
233 children into 10 groups of BMI based on WHO
reference 2007. Based on BMI definition of WHO,
there are 5 groups of nutritional status including
severe wasting, wasting, normal, overweight andobesity.
For boy (8 years old), BMI range considered
normal is 13.3-17.4 kg/m2, severe wasting BMI under
12.4 kg/m2, wasting 12.4-13.3 kg/m2 , overweight
17.4-19.7 kg/m2, obesity BMI over 19.7 kg/m2. Forgirl (8 years old), BMI range considered normal is12.9-17.7 kg/m2, severe wasting BMI under 11.9kg/m2, wasting 11.9-12.9 kg/m2 , overweight 17.720.6 kg/m2, obesity BMI over 20.6 kg/m2 (Fig. 1).
According to WHO 2007 nutrition status isdivide into 5 categories. Range of BMI of eachcategory is too wide, so we devided into 10 groups of
BMI including severe wasting (1 group), wasting (1group), normal (4 groups), overweight (2 groups),
obesity (2 groups) in order to help mothers easily toidentify the tendency of nutrition status at different
point of BMI (Fig. 2).
We took the photos of 233 students. For eachgroup of BMI, artist draw 3 styles of body silhouette
for boy and 3 styles of body silhouette for girl basedon the photos (Fig. 3).
After that, we showed the photos and 3 styles ofbody sihouette above to ask mothers who havechildren at 8 years old to choose the most accurate
body sihouette for both boy (Fig. 4) and girl (Fig. 5).
The finnal sihouette is Fig. 6.

METHOD
Study 1: Drawing the body silhouettes
1. Study subject, time and conducting place.
Study subject: 8 years old students

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Asian Journal of Dietetics, 2020

Fig. 1. Classification of nutritional status based on WHO reference 2007
Boy BMIGroup

Severewasting

Wasting(kg/m2)

<12.4

12.4
13.2

13.3
14.3

14.4
15.4

15.5
16.5

16.6
17.4

17.5
18.5

18.6
19.7

19.8
22.7

22.8
25.8

(n)

0

7

17

26

18

13

13

12

24

9

Girl BMI
Group

Severewasting

Wasting(kg/m2)

<11.9

13.0
14.1

13.0
14.1

14.2
15.3

15.4
16.5

16.6
17.7

17.8
18.9

19.0
20.6

20.7
22.4

22.5
24.8

(n)

0

9

16

22

21

11

4

2

4

5

NormalOverweight

NormalOverweight

Obesity

ObesityFig. 2. Based in WHO standard we categorized into 10 groups of BMI for making 10 Silhouette
Study 2: Conducting survey to find mothers’
perception
1. Study subject, time and conducting place.
Study subject:
Selection criteria: Pairs of mother and child (children
are from 6 to 9 years old)
Exclution criteria:- Children are congenital malformation- Children suffer from chronic diseases- Children without mothers
2.Time & place
It was conducted from November 2015 to March
2016 at 6 elementary schools in 3 big cities Ha Noi,
Hai Phong and Da Nang in Viet Nam. In each city,
we selected 1 primary school in urban area and 1
primary school in sub-urban area.
3.Study design:This study was designed as a cross-sectional study
4.Sample size and selecting subject
Sample size
This is fomular we use to collect sample size foreach city:
N= [ z2(1-α/2) x p(1-p)]/ d2 = 175
Where: z(1-α/2) = 1.96, is standard normal variate
p = 0.337, this is overweight obesity prevalence ofchildren from 6 to 10 years old in the big city in
Vietnam, 2011
d = 0.05, absolute error or precision - has to be
decided by researcher.
By the calculation we got 175 students for eachcity. But estimated drop out rate is 10%. So weselected 200 students for 1 city. Totally, we selected
600 students for 3 cities.
Selecting subject
Firstly, we asked for the permission of 3
provincial departments of education ( Ha Noi, Hai
Phong and Da Nang) and district departments ofeducation to choose schools for the research. For
each city, we selected 2 elementary schools , 1 schoolin the urban area and 1 school in the suburban area.
Totally, we selected 6 elementary schools. For eachschool, we selected the subjects as following steps:
Step 1: For each grade, we selected 1 class ran-domly
to join in the study. In this step, we used simple
random method. Each of class in each grade is
assigned a unique number. The numbers are placedin a bowl and thoroughly mixed. Then, we selected 1
number. The classes were selected in the sample ifthey have selected numbers
Step 2: For each class, we made the student list andselected 25 students from each class randomly. In
this step, we used systematic sampling method. Total
number of students in 1 class is 50.We made anordered list of all 50 students. Next, we determined
our interval size by dividing our entire population(50) by the number of students in our sample (25) toget 50/25 = 2. This is our interval size. Lastly, fromrandom starting point, we would take every 2ndstudent from the list until we had 25 students.
So totally, we selected 600 students for 6
elementary schools at 3 provinces.
5. Methodology and data colection
Before conducting the study, we trained forsurveyor about weight and height measurement, how
to interview mothers about the body image
questionnaire. After that, we contacted to teachers tomake appointment with parents. All subjects were
informed carefully about the significance, purpose,
method, expected results, responsibilities ofparticipants. After that, subjects have to agree andsign in the informed consent before participating thesurvey. In accordance with the informed consent,
participants were allowed to withdraw from the study
at any time and by any reason.

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Asian Child Body Image

Normal(14.4-15.4 kg/m2

Overweight(17.5-18.5 kg/m2)

Obesity(19.8-22.7 kg/m2)

Normal(14.2-15.3kg/m2)

Overweight(17.8-18.9 kg/m2)

Obesity(22.5-24kg/ m2)

Fig. 3. Three styles of body silhouette for boy and girl drawn by artist

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Asian Journal of Dietetics, 2020

Fig. 4. Three styles of body silhouette for boy

Fig. 5. Three styles of body silhouette for girl
Anthropometric measurements: Body weight andheight were measured in light clothing and without
shoes to the nearest 0.1 kg and 0.1 cm respectively.
Body mass index (BMI) was calculated as weight
per square of height (kg/m2).

RESULTS
Study 1After surveying mothers, there is 55.7% of motherschose the 1st silhouette, 28.2% of mothers chose the
2nd silhouette, 16.1% of mothers chose the 3rd
sihouette. Therefore, we chose the 1st silhouette touse in the questionnaire (Fig. 6).
Study 2
Nutritional status of children at 6 elementary schools
in Ha Noi, Hai Phong and Da Nang
Table 1 shows that allocation by gender of thesubjects participating in the study is the same, there
is no difference between the 2 genders. There is
52.2% of boy and 47.8% of girl.
Figure 7 shows the actual nutritional status ofchildren at 6 elementary schools in Ha Noi, Hai
Phong and Da Nang. Prevalence of wasting in 3 cities
is very low (ranging from 2%-4.5%) but prevalenceof overweight and obesity is quite hight (ranging
from 17.5% - 26.9%)

Mothers’ perception survey: All mothers wereinterviewed by body image questionnaire.
6. Study analysis
All data were analyzed using the SPSS software(SPSS 16.0).
Chi2 test was used to compare percentage of actual
nutrition status and percentage of mothers’
identification of their child’s nutrition status.
7. Ethical approval
This study was approved by the ethical committeeof the Vietnam National Institute of Nutrition. All
personal data and each record such as informed
consent were strictly managed by responsible persons
and used only for the purposes of the study.

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Asian Child Body Image

Fig. 6. The silhouette used in the questionnaire
Table 1: Number of subjects by gender in Ha Noi, Da Nang and Hai Phong
Ha Noi (n=189)

Da Nang (n=199)

Hai Phong (n=200)

Total (n=588)

Indicator

No ofsubject

Percentage
(%)

No of
subject

Percentage
(%)

No of
subject

Percentage
(%)

No of
subject

Percentage
(%)

Boy

101

53.4

99

49.7

107

53.5

307

52.2

Girl

88

46.6

100

50.3

93

46.5

281

47.8

Wasting

Normal%Overweight

Obesity

60
50
40
30
20
10
0
Ha NoiHai Phong

Da NangFig.7. Nutrional status of children from 6-10 years old at 6 elementary schools in Ha Noi,
Hai Phong and Da Nang
Mothers’ perception
Figure 8 showed the mothers’ favorite silhouette
for boy. Their answers tended to be on the overweight
and obesity side, none of them chose severe wasting
and wasting silhouettes. And the prevalence of boy
suffered from overweight and obesity was also quite
high, it was about 60%.
Figure 9 showed the mothers’ favorite silhouettefor girl. The result was also the same with the mothers’
favorite silhouettes for boy. It tended to be on the
overweight and obesity side, none of them chose
severe wasting and wasting silhouettes.
And the prevalence of girl suffered fromoverweight and obesity was also quite high.
Figure 10 showed healthy silhouette for boy,mothers’ answer also tended to be on the overweight
and obesity side while there was not any mothers chose

severe wasting and wasting silhouette. And theprevalence of overweight and obese boy was also high.
Figure 11 showed showed healthy silhouette forgirl, mother’s answer was the same with healthysilhouette for boy, it was also tended to be on the
overweight and obesity side while there wasn’t any
mothers chose severe wasting and wasting silhouette.
And the prevalence of overweight and obese girl was
also high.
Figure 12 showed the percentage of mothers who
have son choosing unhealthy silhouette. More than
70% of mother could realize that under nutrition
silhouettes is not healthy silhouettes. But only about
50% of mother could realize that over nutrition is nothealthy.

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Asian Journal of Dietetics, 202
Figure 13 showed the percentage of mothers who
have daughter choosing unhealthy silhouette. It is thesame with Figure 10. More than 70% of mother could
realize that under nutrition silhouettes is not healthysilhouettes. But only about 50% of mother could
realize that over nutrition is not healthy.
Figure 14 showed the comparision between actual

BMI and mothers’ identification of their own child’s
nutritional status. 47.2% of mothers thought that
their children were underweight in spite of the real
underweight was only 2.7%. While only 2.3% ofmothers thought that their children were obesity inspite of the real obesity was 26.3%.

Fig.8. Mothers’ favourite silhouette and actual BMI of boy

Fig. 9. Mothers’ favourite silhouette and actual BMI of girlFig. 10. Healthy silhouette for boy and actual BMI of boy

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Asian Child Body Image

Fig. 11. Healthy silhouette for girl and actual BMI of girl
70
60
50
40
30

60.5

20
10

10.9

4.5

1.3

2.9

2.5

Wasting

Normal 1

Normal 2

Normal 3

Normal 4

5.4

19.1

11.2

24.7

0
Severewasting

Overweight 1 Overweight 2

Obesity 1

Obesity 2

Fig. 12. Unhealthy silhouette for boy
70
60
50
40
64.2

30
20
10

8.9

3.9

0.9

1.1

2

Wasting

Normal 1

Normal 2

Normal 3

Normal 4

7.1

19.6

11.6

26.5

0
Severewasting

Overweight 1 Overweight 2 Obesity 1

Obesity 2

Fig. 13. Unhealthy silhouette for girl%Wasting

NormalOverweight

Obesity

50
40
30
47.2

20

46.2
23.8

10

30.3

26.3

2.7

21.2
2.3

0
Actual BMI

Mother's identification

Figure 14. Summary of actual nutrition status and mother’s identificationof their child's nutrition status of 3 cities

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Asian Journal of Dietetics, 202
DISCUSSIONIn Vietnam many people think that overweight ishealthy and beautiful. Such wrong perception in thepresent society, especially mothers, causes the highprevalence of overweight. In this study we tried tofind how many mothers think such wrong perception
to give proper nutrition education. For it, we firstmade the body silhouette of small children in Vietnam
and other East Asian countries, which was notavailable before.
In this study, body image of East Asian children
before adolescent was established first in theworld. There are some study on implementing ofbody images reported. However, they were all for theadolescent and developed in Europe and USA for
example Stunkard silhouette. Besides, body shapechanges drammatically during adolescent from childto adult. Body shape of caucasian and East Asians arealso not the same. So, it is nessessary to make the bodysilhouettes for East Asian primary school children.
Body images of some previous studies were notbased on the scientific evidence but just drawn by
researchers and painters and no evaluation before
using. Some body images look all fine regardless theshape.
However, in this study we grouped 233 children of
8 years old into 10 groups depending upon the BMI
and asked painters to draw 10 body silhouettes for boy
and 10 body silhouettes for girl. Based on WHO
reference data 2007, BMI was categorized into only 5groups, but if we only draw 5 silhouettes based on 5
BMI groups, it was not too clear for mothers to see
which is normal silhouettes, which is obesity
silhouettes. Therefore, from 5 BMI groups, we
divided them into 10 BMI groups to help mothers to
identify the tendency of nutritional status at different
point of BMI. We believe that our present silhouettes
is more based on the evidence than the previous ones
and easier for selection by mothers.
By using the silhouette we studied the body shapeof 600 children in 3 big cities and found that theprevalence of obesity was quite high, it was about
26.3%. We believe that our result can represent thechildren in big cities in Vietnam becasuse in each city
we conduct research in one urban elementary school
and one suburban elementary school. The percentageof overweight and obesity in Hanoi was 44.4%(including the overweight rate is 26.9% and obesity
rate is 17.5%). Our findings are similar to results ofseveral studies in recent times, for instance: in 2011,
the survey on nutritional status of students in the urban
elementary schools in Hanoi showed that theprevalence of overweight and obese primary school
student in the urban area was 40.7% [16]. Similar
results have been reported. The survey on thesituation of obesity and lipid metabolic) disorders of
4-9 years old children in urban area of Hanoi (Hoan
Kiem District) in 2014 showed that the propotion of
overweight and obesity was 39.9% [17]. The resultsof a cross-sectional study among 9236 pupils in 60
primary schools in Hanoi City from October toDecember 2013 [18] expressed that the percentage ofprimary school students who were overweight,
obesity in the urban area was 40.6%, in which theobesity rate was 17%. In Ho Chi Minh City, thesurvey in 2014 over 6000 primary school children
showed that the rate of overweight and obesity was
51.8% [19].

Overweight and obesity in children may lead toobesity in adulthood, as well as other pathologicaldisorders related to obesity. The study in Japan
indicates that 30% of the fat children will become fat
adults accompanied by other medical disorders related
to obesity. So there should be interventions on school
feeding, nutrition education and family participationin the prevention of overweight and obesity among
elementary school pupils.
The main purpose of this study was to find theperception of mothers about the body weight in theirchildren. Because if they think that overweight ishealthy and beautiful, in the near future our society
will be suffered greatly from life-style related diseases
such as type 2 diabetes melltitus, heard disease , stroke
etc. According to a survey in 2014 in Ho Chi Minh
City, the percentage of overweight and obesity inprimary school students was 51.8%. One of the causesof overweight and obesity in urban children was that
their parents, grandparents liked chubby children andoften forced them to eat more. Therefore, in this study
we have developed a toolkit to learn the perception ofparents on children's body shape, since then candevelop a nutritional education program for the
students and their parents.
In this study, we also found that mother’s favorite
and healthy BMI was higher than the actual BMI ofchildren, furthermore 47.2% of mothers thought that
their children were underweight in spite of the real
underweight was only 2.7%. While only 2.3% ofmothers thought that their children were obesity inspite of the real obesity was 26.3%. We can see thesimilar phenomen in Canada. There were 22% of theparents whose children have normal weight think that
their children are skinny; 63% of the children are
overweight but their parents assess that they havenormal-weight and 63% of the parents whose children
are obese only rate that the children are only
overweight. The parents tend to evaluate their childnutritional status at a lower level than reality.
Approximately 26% of the parents of the overweightchildren and 15% of the parents of obese children do
not care about their children's weight [13].
The results of our study showed that about 40%
of mothers chose overweight and obesity silhouettes
as their favorite silhouettes. The study results are alsoquite opposite the results in Japan in 2005-2006 .
Therefore it is shown that difference in social
platforms makes changes in the awareness of nutritionand health.
In Japan before the 1970s people also thought thatfat people were healthier than thin people, because atthat time obesity rate among the Japanese was nothigh and chronic non-communicable diseases related
to nutrition was not risen. Afterwards the perceptionof Japanese people gradually changed and they foundthat overweight and obesity increased the risk of
illness and death. Currently, Vietnam is in thetransition period and the issue of body image is going
through a change as which Japan has experienced.
In conclusion, in Vietnam we found by our new
body image silhouette that many people think that
overweight is healthy and beautiful and such wrong
perception causes the high prevalence of overweight,
suggesting to change the percepiton of society andmothers can control over intake and obesity problems.

163

Asian Child Body ImageACKNOWLEGEMENT:The author would like to thank Dr. Nhung, Dr.
Van Anh, Mr. Tuoc, Mr. Long, Mr. Dung, Mr. Chinhand Mrs. Trang from Department of School andOccupational Nutrition, Vietnam’s National Instituteof Nutrition for their kind help and support. The
author is grateful to all the study participants andworkers of 6 elementary schools in 3 cities Ha Noi,
Hai Phong and Da Nang for their cooperation.

10) Tran Thi Hong Loan. Overweight status and risk
factors for overweight and obesity among
students aged 6-11 in a district of Ho Chi Minhcity. Master thesis on community nutrition. 1998
11) Nguyen Thi Kim Hung. Situation of overweight
and obesity and some risk factors of primaryschool pupils in Ho Chi Minh City. Report on
the state branch project K.C.10.05. 2004,
12) Le Thi Hai. A number of risk factors for obesityin children aged 6-12 in two primary schools in
Hanoi. 199813) Meizi He. Are parents aware that their children
areoverweightorobese?
2002.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC
2234629/, accessed 9/10/2015
14) Zonana-Nacach A, Conde-Gaxiola ME.
Mothers' perception of their children's obesity.
2010.
http://www.ncbi.nlm.nih.gov/pubmed/2095781
1, accessed 9/10/2015
15) Tran Thi Hong Loan. Overweight and risk
factors for students aged 6-11 in a precinct - Ho
Chi Minh City, Master thesis of Medicine. Hanoi
Medical University. 199816) Bui Thi Nhung, Le Thi Hop, Tran Quang Binh,
Le Nguyen Bao Khanh, Le Bach Mai, Nguyen
Do Van Anh, Nguyen Thi Lam, Tran ThanhNam, Duong Van Thanh, Pham Tran Phuong,
Pham Thi Tuyet Lan, Nguyen Thi Hong Hanh,
Le Thi Tuyet. Nutritional status of primaryschool pupils in Ha Noi in 2011. Journal ofPreventive Medicine 23(1-136):49-53. 201317) Hoang Duc Hanh, Dan Thi Lan Huong. Situationof overweight obesity among elementary
students in Hanoi in 2013. Journal of Preventive
Medicine 5(4-164):40.201318) Hoang Duc Hanh, Dan Thi Lan Huong. Situationof overweight, obesity of elementary school
students in Hanoi in 2013. Journal of Preventive
Medicine. 25(4-164). 201519) Tran Thi Minh Hanh, Do Thi Ngoc Diep, Phan
Nguyen Thanh Binh, Pham Ngoc Oanh, Vu
Quynh Hoa. Warning of overweight, obesity andhypertension among schoolchildren in Ho Chi
Minh City. Journal of Nutrition and Food. 12(4).
2016

REFERENCES
1) Ha Huy Khoi. Preventive Medicine for Chronic
Diseases. Medical Publishing House. 2002
2) Olds TS, Tomkinson GR, Ferrar KE, Maher CA.
Trends in the prevalence of childhood
overweight and obesity in Australia between
1985 and 2008.Int J Obes (Lond). 2010:34
3) Ji CY, Cheng TO. Epidemic increase inoverweight and obesity in Chinese children from1985 to 2005. Int J Cardiol 132:1-10. 2010
4) De Onis M, Borghi E. Global prevalence andtrends of overweight and obesity amongpreschool children. Am J Clin Nutr 92(5):1257 –64. 2002.
5) Ministry of Health, National Institute of
Nutrition. General Nutrition Survey 2009-2010.
Medical Publishing House, Hanoi. 20106) Ministry of Health, National Institute of
Nutrition. Overweight and obesity in children
aged 7-12 in Hanoi and evaluation of someinterventions. State-level branch report
KC.10.05. 2004.
7) Nguyen Thi Thu Hien. Study on obesity andrelated factors, and classification according totraditional medicine at ages 6-11 in a district in
Hai Phong. Master thesis on medicine. 2001
8) Bui Van Bao, Le Nghi, Nguyen Thin. Somedevelopments of overweight obesity among
elementary school children in Nha Trang city.
Journal of Practical Medicine, Nutritional
Topics, Overweight and Obesity with Public
Health, 48: 33-37. 2002.
9) Pham Van Linh. Situation of overweight andobesity among elementary school children in
Hue and some risk factors. State-level branchreport KC.10.05. 2003

164

Asian Journal of Dietetics, 2020

Original
Nutrition Education Using Nutrition Handbook andTele-Counselling Improved Nutritional Knowledge and Behaviourof Elderly in Northern Thailand
Jukkrit Wungrath1* Pussadee Mongkol2 and Yupa Chanwikrai3
1
Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand
2
Cheongdoi Sub-district Health Center, Doi saket District, Chiang Mai, Thailand
3

School of Medical Sciences, University of Phayao, Phayao, Thailand

ABSTRACT The objectives of this research were to study the effect of nutrition education for
caregivers for the elderly using nutrition handbook and tele-counseling on nutritional
knowledge and behavior among caregivers for the elderly. The sample was caregivers for theelderly in Choeng Doi Subdistrict, Doi Saket District, Chiang Mai Province. There were twogroups, namely the intervention group (n=22) and the control group (n=22). The sample wasselected based on a purposive sampling. The results showed that the intervention group had ahigher mean score of elderly nutrition knowledge and behavior after using the handbook than
before. The intervention group had a higher mean score of elderly nutrition knowledge andbehavior after using the handbook than the control group, with a statistical significance (p<0.01).
Keywords: Elderly, nutrition promotion, handbook, caregivers

INTRODUCTION
According to a survey by the National Statistical
Office, the size of the elderly (aged 60 years and over)
population in Thailand has significantly increased inrecent years. The figures from 2015 to 2019 indicate
annual increases of 15.9%, 16.5%, 16.7%, 18.0%, and19.7%, respectively (1). Moreover, Thailand has beenranked as the second most aged society ( over 20% of
the population aged 60 or older, according to thecriteria of the United Nations) in Southeast Asia, after
Singapore ( 2) . This rapid expansion suggests that
Thailand needs to make contingency plans to meet thedemands of an aging society that is growing quickly.
Since older persons are considered to be at high risk of
diseases due to the fact of deteriorating health, theyrequire special care from their younger family
members. Preparing the caregivers for the elderly inthe family is also very important because thecaregivers will manage and administer the process of
caring for the elderly, treating and responding to theelderly in all aspects as appropriate. Caregivers musthave knowledge and understanding about the elderly.
The elderly and be able to play a comprehensive rolein the care of the elderly. As a result, this will makethe care of the elderly both at the family level and at
the community level effective and the elderly will
enjoy good health and quality of life. This is a valuable
human resource and very valuable social capita (3).
The nutrition status of the elderly is dependent on
many factors, including social conditions, and is
influenced by the long-term effects of chronic disease
and overall health status. The physiological changesof aging, including
perceptual, endocrine,
gastrointestinal, renal, and muscular changes, mayalso affect nutrition needs.

Dietary allowances are recommended to meet thenutrition requirements of the healthy population anddo not consider disease states or other problems
frequently seen in the elderly. A previous study
suggests that the elderly is at an increased risk ofnutrition deficiencies because they cannot meet thesenutrient needs ( 4) . Therefor caregivers play animportant role in providing caregiving assistanceespecially with regard to food and nutrition to elderly
persons and their families.
Choeng Doi Subdistrict, Doi Saket District,
Chiang Mai Province is located in the far north ofThailand. It was found that the community there hasentered the aging society according to the criteria of
the United Nations. More than 10% of the population
is aged, with 1,945 elderly people representing
26.29% of the total population of 7,396. Most of thesepeople’ s caregivers are family members such as a
spouse, a sibling, or grandchildren. According to thepreliminary data from local health centers it was foundthat these elderly people suffered from nutritional
problems, including both malnutrition andovernutrition. In the group of malnutritional statuselderly, this is due to the fact that the elderly havecertain diseases that affect the consumption of foods,
such as dental and oral health, diabetes, hypertension,etc. , while the group with overnutrition are among
those with incorrect consumption habits, consuming
more food than necessary and thus causing overweight
and obesity. Along with the previously reported
problems, (3) it was found that the elderly have several
limitations, due to physical condition or perception.
The carrying out of activities directed to the elderly topromote and modify behaviors was difficult andpossibly unsuccessful. Therefore, this action turned
attention to caregivers who play a role in taking careof the health of the elderly in all matters including foodand nutrition. The data obtained from a preliminary
survey from community leaders found that caregivers*To whom correspondence should be addressed:
jukkrit.w@gmail.com

165

Nutrition Education of Caregivers for the Elderly
lacked sufficient knowledge of health, including
nutrition knowledge.
There are limited data on the effects of elderly
nutrition promotion using a handbook together with
tele-counseling to improve nutritional knowledge andbehavior of caregivers for the elderly in northern
Thailand. The objectives of this research were to study
the effect of nutrition education using a nutrition
handbook and tele- counseling on nutritional
knowledge and behavior regarding elder care among
caregivers in Choeng Doi Subdistrict, Doi Saket
District, Chiang Mai Province, Thailand.

who were not in the sample group and was determinedby the Kuder-Richardson formula to be 0.74.
- Knowledge average score 00. 00 - 00. 09 means low
level of knowledge- Knowledge average score 10. 00 - 15. 00 means
moderate level of knowledge- Knowledge average score 16.00 - 20.00 means goodlevel of knowledge
Part 3: Assessment of nutritional behavior. The
questions were focused on the caregiver’s usual foodhandling behavior regarding the elderly. Total of 18
questions with 3 ratings (regularly practice, sometimes
practice and not practice at all) . A positive behavior
was rated 3, 2, and 1, while a negative behavior was
rated 1, 2, and 3, respectively. The questions passed
three expert examinations for content validity. All
items were found to have an item of congruence index( IOC) of more than 0. 70. The reliability was tested
with 30 caregivers for the elderly who were not in thesample group. The Cronbach's alpha coefficient was
0.87.
- Behavior average score 18. 00 - 30. 00 means low
level of behaviour- Behavior average score 31. 00 - 42. 00 means
moderate level of behaviour- Behavior average score 43. 00 - 54. 00 means goodlevel of behaviour

METHODSThis study was a quasi- experimental researchwith a two- group pretest- posttest design, conductedfrom March 2018 to February 2019.
1. Population and sample
The population in this study were 1,945
caregivers for the elderly in Choeng Doi sub- district,
Doi Saket District, Chiang Mai province. The sample
size was determined by using the Power of test at thepower of the test was set at 0. 80, with a 0. 05 level ofsignificance and a 0. 50 effect size. The sample size
was 44 people. The sample was selected randomly
from lists of caregivers in Choeng Doi sub-district anddivided into an intervention group and a control group,with 22 persons in each group. The inclusion criteria
were those who care to older persons in their families
without pay, had provided such caregiving to older
persons for more than one year, lived in the same
house with the older persons, could communicate inThai, and finally were willing to participate in the
study.

3. Data collection
This research was conducted from December 1,
2018, to February 29, 2019. The experiment with theintervention and control groups took about 8 weeks, as
depicted below:
4. Data analysis
Demographic data were analyzed using
descriptive statistics. The means of the nutritional
knowledge and nutritional behavior between theintervention group and the control group, before andafter participated the program, were compared using
paired t- test statistics. The means of the nutritional
knowledge and nutritional behavior between theintervention group and the comparison group werecompared using independent t-test statistics. A p-value< 0.05 was considered statistically significant

2. The research instruments consisted of:
2. 1 The elderly nutrition promotion handbook. The
researcher invited the sample in the experimentalgroup to hear how to use the handbook. They took thebooks to use at home by themselves for a period of 8
weeks. The contents of the handbook ( 5) included:
definition and importance of nutritional status in theelderly, energy and nutrients requirement in theelderly, principles of selection of food ingredients forthe elderly, principles of cooking for the elderly,
guidelines for promoting nutritional status in theelderly and sample menus for the elderly. In thecontrol group, the researcher introduced the research,
the objectives and process of implementing all
activities but the implementation of the handbook was
not included.

Ethical Considerations
This study was conducted in accordance with thecode of human research ethics and approved by The
Ethical Review Committee for Human Research,
Faculty of Public Health, Chiang Mai University(ET016/2561).

2. 2 The instrument used to collect data that the
researcher developed through literature review isdivided into three parts as follows:Part 1: Demographic data relating to the participants.
Part 2: The nutritional knowledge test. A total of 20
questions with 4 choice options, which focus onassessing knowledge about proper diet and nutrition in
the elderly such as energy and nutrient requirements,
the selection of raw materials, proper cooking
methods, disease and nutrition problems in the elderly.
The test was examined by 3 experts for content
consistency. All items were found to have an item ofcongruence index ( IOC) of more than 0. 70. The
reliability was tested with 30 caregivers for the elderly

RESULTS
1. General information of the sample
Of the samples in the intervention and control
groups, most were female (70.15 and 68.50%) and theaverage age was 50. 60 and 51. 15 years, respectively.
The most common marital status was married ( 80. 87
and 80. 71% ) , they were educated at thesecondary/ vocational level ( 56. 23 and 54. 41% ) ,engaged in agriculture ( 63. 05 and 65. 21% ) , had
family incomes of 10,001- 20,000 baht per month( 40. 43 and 42. 20% ) and the number of elderly
needing care was between 1- 2 people ( 90. 70 and
84%).

166

Asian Journal of Dietetics, 2020

Experimental procedures flow diagram
Intervention: The elderly nutrition promotion handbook

Intervention group

Control group

Week 1
1. The researcher introduced the research tothe participants
2. The objectives and process of implementing
all activities were explained and a pre-test was
conducted. .

Week 1
1. The researcher introduced the research tothe participants
2. The objectives and process of implementing
all activities were explained and a pre-test was
conducted.

Week 2-3: Participants used the handbook at home by themselves.
Week 4: The researcher followed up all participants by phone,inquired about problems and obstacles in using the handbook,encouraged participants to use the handbook continuously.
Week 5-6: Participants used the handbook at home by themselves.
Week 7: The researcher followed up all participants by phone,inquired about problems and obstacles in using the handbook,encouraged participants to use the handbook continuously.
Week 8: The researcher summarized the activities and helped thegroups reflect on what they had learned and implemented in a posttest.
Week 8: A post-test was conducted, and the elderly nutrition promotion handbooks were handed out.
2. Effect of the elderly nutrition promotion handbook on the nutritional knowledge of caregivers
The pretest and post- test mean scores of theknowledge between the intervention group and thenutritional knowledge of the intervention group were
control group were 18.23(SD = 3.01) and 10.56(SD =8.65 (SD = 2.47) and 18.23 (SD = 3.01), respectively.
2 . 8 7 ) , respectively. It was also found that the mean
It was found that the post-test mean score of nutritionalscore of nutritional knowledge in the intervention groupknowledge was higher than the pretest mean score, withwas higher than that of the control group, with aa statistical significance (p < 0.05, t = -16.67), as shownstatistical significance (p < 0.05, t = -4.28), as shownin Table 1. The post- test mean scores of nutritionalin Table 2.
Table 1 Comparison mean average score of elderly care knowledge between intervention and control
group before and after the experiment.
Sample group
xˉ
SD
level
p-value
before
8.65
2.47
low
0.000*
Experimental group
after
18.23
3.01
good
before
8.84
2.29
low
0.000*
Control group
after
10.56
2.87
moderate*p < 0.01
Table 2 Comparison of mean average score of elderly care knowledge between intervention and control
group after the experiment.
VariableIntervention group
Control groupp-valuexˉ
SDxˉ
SD
Mean average score of elderly
23.18
01.3
10.56
87.2
0.000*
care knowledge
p<0.01167

Nutrition Education of Caregivers for the Elderly
Table 3 Comparison mean average score of elderly care behavior between intervention and control group
before and after the experiment.
Sample group
xˉ
SD
level
p-value
Intervention group
before28.64
7 .3 5moderate*000.0
after
42.50
56.4
high
Control group
before75.29
87.3
moderate
598.0
after
52.29
96.3
moderate*p < 0.01
Table 4 Comparison mean average score of elderly care behavior between experimental and control group
after the experiment.
VariableIntervention group
Control groupp-valuexˉ
SDxˉ
SD
Mean average score of elderly care
42.50
56.4
52.29
96.3
*000.0
behavior*p < 0.01
3. Effect of the elderly nutrition promotion
handbook on the nutritional behavior of caregivers
The pretest and post-test mean scores of thenutritional behavior of the intervention group were
28.64 (SD = 3.75) and 42.50 (SD = 4.56), respectively.
It was found that the post-test mean score of nutritional
behavior was higher than the pretest mean score, with[a] statistical significance (p < 0.05, t = -10.14), as
shown in Table3.
The post- test mean scores of nutritional behavior
between the intervention group and the control groupwere 4 2 . 5 0 ( SD = 4 . 5 6 ) and 2 9 . 5 2 ( SD = 3 . 9 6 ) ,respectively. It was also found that the mean score of
the nutritional behavior in the intervention group was
higher than that of the control group, with a statisticalsignificance (p < 0.05, t = -7.80), as shown in Table 4.
DISCUSSION AND CONCLUSION
The results of this study revealed that afterparticipation the program, nutritional knowledge
including the elder care behavior of the intervention
group was higher than before, with statisticalsignificance. The program was developed inaccordance with the active learning conceptual
framework which emphasized a learning-management
process that allows learners to learn and practice bythemselves through an effective handbook and withsupervision by phone, which enabled them to maintainstable, longer learning outcomes than with a
traditional learning process. Many studies haveindicated that participants who take part in a program
like this improve their knowledge and behavior. This
study’s findings illustrate that after receiving the
program, the mean score of nutritional knowledge andcaregiving behavior for the dependent older persons of
the intervention group was higher than that of thecontrol group. This finding supports a study by
Robrujen (6) who developed the basic elderly carehandbook and studied the effect of using the basic
elder care handbook on knowledge and behavior
regarding elder care among caregivers. The results
showed that the experimental group had a higher meanscore of elder care knowledge and behavior after using
the handbook than before. The experimental group hada higher mean score of elder care knowledge andbehavior after using the handbook than the control
group. The health caring skills were at good level,
while the overall satisfaction of the elderly who werecared by these caregivers was very high. As with theSuthimanus et al. (7) study that developed a handbook
168

for caregivers for uncontrolled blood pressure, it was
found that the caregivers had higher knowledge and /or perception of their competencies than before using
the manual. In addition, a study by Sooksa-art et al. (8),which used an educational guide for caregivers ofelderly patients with dementia, found that after using
the manual caregivers had a statistically significant
increase in knowledge scores on disease managementand drug use.
Self-care barriers for the elderly are caused bymany factors, including the environmental andcognitive factors that interfere with following therecommended treatment regimen. Because of thelimitations elderly people encounter as a result ofphysical and mental deterioration, they need assistancefrom their family members in terms of health care andthe performance of daily activities. However, caring
for elderly persons is complicated and requires
comprehensive
healthcare
knowledge
andunderstanding of elderly behavior (3). Providing
support from within the family, caregivers may be
important in overcoming barriers to self-care. The
characteristics of an elderly person’s family
environment in which diabetes management takes
place have been associated with self-management
behaviors (9-11). Fisher et al. found that family
structure and organization were associated withacceptable eating behavior and exercise among theelderly (13). In another study of predominantly older
African-American adults with diabetes, researchers
noted that family support was comprehend to thepattern of diet self-care behaviors (12).
Tana et al. confirmed that a poor nutritional statusof the older outpatient is independently moreassociated with the caregiver burden than withcognitive and physical disability. The combined
evaluation of both patients and caregivers can improveknowledge and assistance to the elderly subjects (12).
According to Correa et al. (13) the nutritional status of
the elderly is a matter of concern and that it may be
associated with a low quality of life influenced by theeducation level of the caregiver, but also by age,economic conditions and the limited autonomy of thispopulation. The education level of the caregiver wasdeterminant in the preparation of foods exclusively forthe elderly. Apparently, those with higher educationlevels prepared special foods more often. The
education level of the caregiver was a determining
factor for nutritional status; nearly all individuals
cared for by those in the tercile with the least years ofAsian Journal of Dietetics, 2020
formal education were malnourished. Higher
education levels reduced and even eliminatednutritional problems in the more privileged socialgroups (13, 14).
Consequently, if the nutritional knowledge andthe care behavior of the of caregivers were developed
to a higher level, it would contribute to bettercaregiving for older persons in general. Moreira etal.(15) showedthat improving the caregivers’ knowledge about
nutrition is one of the factors pointed out as importantfor prevention and control of avoidant food intake
behavior. In addition, it was found that there werepositive effects of nutritional education for elderly andtheir caregivers on body mass control, nutritional
status, mood, and also on the reduction of cognitive
decline in older adults with dementia (15). This is inaccordance with the study of Hsiao et al.(16), whohave investigated the effects of a family care-based
dementia dietary educational program on family
caregivers’ nutritional knowledge, healthy eating
behavior and nutritional status of people withdementia. The results found that the scores of the
caregivers’ nutritional knowledge significantly
increased after receiving the dementia dietaryeducational program and enhanced the nutritional
status of elderly with dementia. This is in line with
Robrujen’s study (5), which developed an elderly careprogram that emphasized the caregiver role. In thisprogram, an elderly health care handbook was used.
The content consisted of general health and nutrition
promotion in the elderly; it was found that after having
participated in the program and using the handbook
caregivers had higher average knowledge than before.
in other words, caregivers with adequate nutrition
knowledge are able to apply their nutritional carepractices skillfully and improve older persons’ qualityof life.
The findings of our study indicated that use of theelderly nutrition promotion handbook and telecounselling had significant effects on the caregivers’
nutritional knowledge and behavior. The literature
review showed that using media, including a
handbook, together with tele-counseling educational
programs provides services for patients’ healthmaintenance through telephone follow-up, with theadvantage of promoting accessibility for patients wholive far away from clinics. Tele-counseling is acomprehensive strategy to improve patients’knowledge and support lifestyle changes (17). It
appears that a telehealth system that includes telecounselling may significantly improve elderly persons’behavior, and also reduce the caregivers’ burden (18).
This result is expected because the lessons in thehandbook contained useful information with regards
to issues such as the nature and physiology of elderly,
nutrient needs, raw materials and food selection,
proper food menu design, nutrition problems in elderly
and basic problem-solving. A previous study also
found that using a health handbook could help
caregivers to enhance their health knowledge andbehavior (19). This may have been because after theintervention, the caregivers increased their nutritional
knowledge, which may have had some impact on their
behavior (16). This supports the social learning theory
that personal knowledge and behavioral learning canbe achieved through self-motivation, self-adjustment
and interaction with a social environment (20).
The results of this study concluded that the use ofelderly nutrition promotion handbook and tele169

counselling improved the nutritional knowledge andbehavior of the caregivers. The results weresignificantly higher than before using the handbook
and were significantly higher than in the control group.
This enables caregivers to take care of food andnutrition in the elderly effectively and as a result theelderly can enjoy a healthy and good quality of life.
Pala-ard et al. (21) and Jantriyawong (22) reported intheir studies that the knowledge and skills of
caregivers are very important in assuring that theelderly can enjoy good health and well-being. The factthat caregivers for the elderly have accurate
knowledge about nutrition aspects of the elderly will
increase their health and well-being.
The results obtained from this study could behighly beneficial as basic information for promoting
nutritional knowledge and behavior, especially for
caregivers for the elderly, as they play an importantrole in looking after dependent older persons.
However, this research has some limitations; thechanges that occurred in the elderly were not studied
after the caregivers had been encouraged to develop
better knowledge and behavior concerning nutrition.
Therefore, the researchers recommend thatinvestigators conduct further studies on the issue.
1)

2)
3)

4)

5)
6)
7)

8)

9)

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Asian Journal of Dietetics, 2020
Original

Acceptance of Textured Soybean Protein in Indonesian Dishes
and Its Effects on Energy in Overweight Women

Indri Kartiko Sari1*, Diah Mulyawati Utari2, Mitsutaka Kohno3,
Ryuji Yamaguchi4, Shigeru Yamamoto1

1

2

Asian Nutrition and Food Culture Research Center – Jumonji University, Japan
Public Health Nutrition Department, Faculty of Public Health, University Indonesia
3
Fuji Science Innovation Center, Japan
4
Nutrition Japan Public Private Platform, Japan

ABSTRACT Background and purpose: The problem of overweight and obesity has been
increasing in Indonesia year by year as well as in the rest of the world; it is commonly
caused by an unhealthy diet from excessive lipid intake. Increasing fiber intake from plantbased foods is known to control lipid absorption. Meat-like soybean product, Textured
Soybean Protein (TSP), is made by extracting oil from soybeans and turning it into dry
meat-like textured soybean which is rich in fiber, low in oil, and a high-quality protein
source. In this study, TSP was substituted for meat in popular Indonesian meat dishes andits overall acceptance and effect on health with daily consumption were observed.
Methods: The study was divided into two section: Section A, the overall acceptance of TSP
dishes and Section B, the effects of including one TSP dish in the daily food intake ofoverweight women. In Section A, the subjects (n=17), who were all housewives, sampled
5g of four TSP types with 20 dishes in total and scored the overall taste of the dishes. The
Hedonic 5-point scale was used to score overall taste. In Section B, the subjects (n=25), alloverweight housewives, consumed one dish of 50g TSP daily for 3 consecutive weeks.
Nutrition surveys using 3-day-24-hour recall methods were conducted at the baseline andfinal for dietary changes during the period of daily TSP consumption. Subjects’ tolerance
for and opinion of the new foods were assessed by a questionnaire at the final. Results: In
study Section A, the average overall taste of TSP dishes was scored: Sliced Chicken 3.6,
Minced Chicken 4.4, Sliced Beef 4.7, and Minced Beef 4.4. The overall evaluations wereconsidered better than Good (above 4) with no significant differences found among thefour types of TSP (p>0.05). In study Section B, 20 subjects completed the study. There
were significant decreases in total energy and lipid intakes and significant increases inprotein and fiber intakes (p<0.001). Questionnaire results shows that 70% of subjects felt
satisfied during the study, 80% felt 50g/day was an appropriate daily amount, and 85% had
no problem during the 21days of consumption. Conclusion: TSP dishes were well accepted
overall by Indonesian women; TSP could be used as a meat substitute, could supply more
protein and fiber, and could decrease energy and lipid intakes in overweight women.
Key words: soybean, food acceptance, overweight women, energy,
INTRODUCTION
High prevalence of overweight and obesity is
known to be one cause of lifestyle-related diseases
such as stroke, heart disease, etc. Excessive lipid
intake is one factor that causes overweight problems.
More fiber intake is known to help in reducing the riskof lifestyle-related diseases (1-5). It has also beenfound effective in weight control (6,7). If the intake ofa sufficient amount of dietary fiber is continuously
followed, this can be expected to improve or preventthese diseases by providing greater nutritional balance(2,3). The challenge is that dietary fiber is also one of
the nutrients that is difficult to consume in sufficientamounts.
Plant-based diet is becoming popular in the
movement to reduce global meat consumption (8).
There are many alternatives for a plant-based diet,including the development of meat-textured plant-

based foods in order to get more meat eaters to
consume more plant-based foods. (9). Soybeans arecommonly used as plant protein source in many
countries; it is processed into foods like tofu, tempeh,miso, natto, etc (10-12). Textured Soybean Protein(TSP) is soybean textured like meat and purposely
developed to have an appearance similar to real animal
meat. TSP is made by extracting the oil from soybeans
and then turning the soybeans into dry material. Since
it is made from soybeans, this meat-like plant productis rich in fiber (13.6g/100g dry matter), low in oil, andalso a plant-protein source (56g/100g dry matter).
According to a previous study on dietary intake inIndonesian women living in Jakarta, it was found that
their dietary patterns included 29% fried animal
protein such as fried meat, fried egg, etc., and also 6%
tempura (13). Sixty-one percent of these women were
overweight and obese, with nutrient intakes results________________________________________________________________________*To whom correspondence should be addressed:

indri.kartiko@yahoo.com

171TSP Acceptance and Effects on Energy
showing a high lipid intake of 87g/day and a low fiber
intake of about 10g/day (13). This suggested theimportance of shifting to a better dietary habit ofconsuming more fiber and less lipid. When delicious
main dishes using TSP can be developed, this maylead to higher intake of fiber so the total fiber intake ina day can be increased without any difficulty.
TSP has no attributes other than it is meattextured, easy to chew, has a light bean taste and does
not have any smell or stickiness, making it suitable forvarious recipes. There are different shapes/forms of
TSP that can be used for a variety of cooking.
Therefore, we decided to utilize TSP as the main
ingredient in Indonesian dishes and developed low-fat
high-protein and high-fiber alternative foods which
could be expected to have beneficial effects on health.
The approach of TSP utilization consists of two
sections. The first section was to develop Indonesiandishes suitable for replacing the main ingredient with
TSP and evaluate the overall scores of the dishes. The
second section was to clarify nutrient intake changes
with TSP as a daily substitute for meat in long periodof consumption with expectation that it can be analternative for a new healthy food culture forIndonesians

The seasonings were spices blended into one spicemixture. The spice mixture of the nine recipes were
Rendang, Sambal Goreng, Semur, Lada Hitam, Gulai
Ayam, Gulai Sapi, Bumbu Rujak, Bumbu Bali, Bumbu
Balado, and Opor Ayam.
There were four types of TSP with different
shapes that were used to replace the meat in dishes.
These TSPs were separated into two categories, Beeflike and Chicken-like (Figure 1), along with specificrecipes (Table 1). In total, there were 20 dishes used inthis study (Table 1). The cooking process for the TSP
is shown in Figure 2. The lists of original recipes, TSP
dishes, and ingredients are shown in Table 3. In a
duration of three days, TSP sample dishes with 5g dry
ingredients were tasted and evaluated by 17 preelderly women to evaluate overall scores the sliced
and minced forms of TSP. A 5-level hedonic scale wasused with 1= “very poor”; 2= “poor”; 3= “neither goodnor poor”; 4= “good” and 5= “very good”. Then, after
finishing Section A, the study continued to Section B
for acceptance consumption in longer period.
Section B: The assessment of TSP dishes
acceptance in daily dietary meals. There were 25
healthy overweight women (BMI≧25kg/m2) who
participated in this step. The subjects were randomly
selected from community health centers, in a periurban area in Jakarta. The subjects were asked to eat
50g of TSP every day for 3 weeks consecutively. A
different TSP menu was prepared and delivered daily
to the subjects. A nutrition survey (3 non-consecutivedays) at the baseline (normal intake) and final (withTSP intake) was conducted to assess the change intheir daily diet during the consumption of TSP. At theend of the study, a questionnaire was created tointerview the subjects about their tolerance for andopinion about the new foods (Table 4). Statisticalanalyses were conducted with Microsoft Excel 2013.

METHODS
There were two sections in this study. Section A:
The overall acceptance of TSP dishes. Ten recipes
were chosen based on the previous nutrition survey
conducted in overweight women (13). These ten
recipes were specifically chosen based on popularity,
relatively have no bulky attribute, a meat-based main
ingredient, and ease of cooking. The cooking process
for each dish required only TSP and seasoning. TSP
was first soaked in boiling water for 1 minute and thendrained before stirring and mixing with the seasoning.

Fig 1-1 Sliced Beef

Fig 1-2 Minced Beef

Fig 1-3 Sliced Chicken

Fig 1-4 Minced Chicken

Figure 1. Four types of TSP

Sliced Beef
1.Rendang
2.Sambal Goreng3.Semur
4.Lada Hitam
5.Gulai Sapi

Table 1 Total dishes of TSP (20 dishes)
Minced Beef
Sliced Chicken
6.Rendang
11.Bumbu Rujak
7.Sambal Goreng
12.Bumbu Bali
8.Semur
13.Bumbu Balado
9.Lada Hitam
14.Opor Ayam
10.Gulai Sapi
15.Gulai Ayam

172

Minced Chicken
16.Bumbu Rujak
17.Bumbu Bali
18.Bumbu Balado
19.Opor Ayam
20.Gulai Ayam

Asian Journal of Dietetics, 2020

Figure 2-1. Heating the
spice mixture (seasoning)

Figure 2-2 Mixing boiled TSP
with seasoning evenly

Figure 2-3 TSP dishready to be served

Figure 2. Cooking process of TSP dishes
Table 3. List of 10 recipes and ingredients of spice mixture (seasoning).
RecipeIngredients
RecipeRecipeIngredients1.
Beef-like
1.Chicken-like TSP
TSP (50g)(50g)
2.
Rendang
2.Balado seasoning
seasoning(chili, red chili,(candlenut, garlic,
garlic, shallot,
red chili, shallot,
galangal, daun
Opor Ayam
Bumbu
Rendangchili, ginger,
salam,lemongrass
Baladoturmeric,)
galangal,coriander, salt,
nutmeg)1. Beef-like TSP
1.Chicken-like TSP
(50g)
(50g)
2. Semur seasoning
2.Bumbu Rujak(Shallot, tomato,seasoning
red chili, ginger,(shallot, garlic,candlenut,
red chili, chili,
Bumbu
Lada Hitam
Semur
pepper,ginger, laos,
Rujak
lemongrass,turmeric, salt,
clove, nutmeg,
sugar)
salt, sweet soy
sauce, oil)
1. Beef-like TSP
1.Chicken-like TSP(50g)(50g) or Beef-like
2. Sambal goreng
TSP (50g)
ati seasoning
2.Gulai seasoning(chili, shallot,(Garlic, shallot,
Gulai Ayam
garlic, candlenut,
red chili, ginger,
SambalBumbu Bali
ginger, galangal,
candlenut, sugar,
Goreng Ati
daun jeruk,
galangal,turmeric,brown sugar, salt,lemongrass, daunsugar,
salam, daun jeruk,lemongrass,)
asam kandis, salt)
Gulai Sapi

Ingredients
1. Chicken-like TSP(50g)
2. Opor seasoning(garlic, coriander,
candlenut, ginger,
turmeric, salt,
galangal, brownsugar, tamarind)1.
Beef-likeTSP (50g)
2.
Lada hitam(Sweet soy sauce,oyster sauce,sesame oil, onion,
red chili, black
pepper, corn starch,sugar, salt)
1. Chicken-like TSP(50g)
2. Bumbu Bali
seasoning (tomato,galangal, daun
jeruk, daun salam,tamarind, sweet soy
sauce, salt, sugar,
shallot, garlic, redchili, candlenut,
ginger, lemongrass,terasi)Table 4. TSP dish tolerance and opinion questionnaire
QUESTIONNAIRE
Q1. (Satisfaction) Can you
Q2. (Amount Suggestion) Do
Q3. (Problems during
describe whether 50g TSP in 1
you have any suggestion on
Consumption) Do you have any
dish is enough to eat daily forthe amount that should be
problem after consuming TSP
three consecutive weeks?
served daily?
for 21 days?
A. Too much.
A.Higher than amount served
A. No particular problem
B. Enough.
B.The same as amount served
B. Yes, it was … (please
C. Too little.
C. Less than amount served
explain)Thank you for your cooperation!

173

TSP Acceptance and Effects on Energy

RESULTS
Table 5 shows the overall hedonic scores forchicken-like TSP dishes. The average scores for thefive TSP dishes of sliced chicken and minced
chicken were 4.2 and 4.2 points for Rujak, 4.5 and
4.1 for Balado, 4.1 and 4.3 points for Bumbu Bali,
3.9 and 4.6 points for Opor, and 3.6 and 4.4 points
for Gulai, respectively. The overall scores of TSP
dishes were close to each other and there was nodifferent found (p>0.05). Highest overall score wasfound for Minced Chicken with Opor seasoning(4.6±0.8). Lowest overall scores was found for
Sliced Chicken with Gulai seasoning.
Table 6 shows the overall hedonic scores forbeef-like TSP dishes. The average scores for the five
TSP dishes of sliced beef and minced beef were 4.2

and 4.2 points for Rendang, 4.5 and 4.1 for Semur,
4.1 and 4.3 points for Sambal Goreng, 3.9 and 4.6
points for Lada Hitam, and 3.6 and 4.4 points for
Gulai, respectively. The overall scores for TSP
dishes were close to each other (p>0.05), but there
was a significant different found for Gulai (p<0.05).
Highest overall scores were found for Sliced Beef
with Gulai seasoning (4.7±0.8). Lowest overall
scores were found for Minced Beef with Semur
seasoning. Figure 3 shows the overall scores for fourtypes of TSP using the same seasoning, Gulai of
Sliced Beef, Minced Beef, Sliced Chicken, andMinced Chicken were scored 4.7, 4.4, 3.6, and 4.4
respectively. There was no difference between TSP
types.

Table 5. Overall Evaluation Scores for Chicken-like TSP
Seasoning
SlicedMincedp-value
Chicken
Chicken(mean±SD)(mean±SD)
Rujak
4.2±1.3
4.2±1.1
0.99
Balado4.5±1.0
4.1±1.2
0.23
Bumbu Bali
4.1±1.4
4.3±1.1
0.38
Opor
3.9±1.6
4.6±0.8
0.09
Gulai Ayam
3.6±1.7
4.4±0.9
0.07
Average4.1±0.9
4.3±0.9
0.13

Table 6. Overall Evaluation Scores for Beef-like TSP
Seasoning
Sliced Beef Minced Beefp(mean±SD)(mean±SD)
value
Rendang4.4±0.94.4±1.2
0.75
Semur
4.3±1.3
4.0±1.3
0.14
Sambal
4.6±0.7
4.4±1.1
0.48
Goreng
Lada Hitam
4.5±0.8
4.5±0.9
0.58
Gulai Sapi
4.7±0.8
4.4±0.9
0.02*
Average4.5±0.8
4.3±0.9
0.13*Significant differences (p<0.05)

Figure 3. Overall scores of four types TSP

Table 7. Characteristics of the subjects (n=20)
Characteristic
Values(mean±SD)
Age (years)
56 ± 5Height (cm) 149.5 ± 4.9
Weight (kg)
62.6 ± 7.5
BMI (kg/m2)
28.3 ± 2.5

Table 7 shows the average age, weight, and BMIof the subjects and the final measurement of thesubjects. There were 20 subjects who finished thestudy, all overweight women (28.3±2.5kg/m2) withaverage age of 56±5years old.

174

Asian Journal of Dietetics, 2020
Table 8 shows the energy and nutrient intakes
in the daily diet for 3 weeks of 50g TSP
consumption. There were significant decreases intotal energy (kcal/day) from baseline 2037 to final
1666 and lipid intake (g/day) from 94 to 54. There
were significant increases in protein (g/day) frombaseline 47 to final 60 and fiber intake (g/day) from10 to 16 (p<0.001). There was no significant
difference found in carbohydrate intake (g/day)from baseline 267 to final 248.
Figure 4 shows the tolerance of TSP dishes
after 3 weeks of 50g TSP consumption. Figure 4-1
shows the answers for Q1 about satisfaction of
50g/day TSP consumption; 70% (n=14) felt satisfied

and 30% (n=6) felt that the amount was too much.
Figure 4-2 shows the suggestion of an appropriate
amount for daily TSP consumption; 80% (n=16) felt
50g/day would be appropriate, 15% (n=3) felt
50g/day was too much, and 5% felt the amount could
be more than 50g/day (n=1). Figure 4-3 shows theanswers for Q3 about any problems during the daily
50g/day consumption. 85% (n=16) felt no particular
problem and 15% (n=4) felt there was a problem. We
asked for explanations and descriptions of the
problems. These subjects had gout problems andeating TSP made them feel tingly when they didn’t
drink enough water.

Table 8. Energy and nutrient intakes in the daily diet for 3 weeks of 50g TSP consumption.
Energy and Nutrient
Baseline (n=20)
Final (n=20)
p value
Energy (kcal/day)
2037±185
1666±152<0.001*
Protein (g/day)
47±12
60±54
<0.001*
Lipid (g/day)
94±18
54±14
<0.001*
Carbohydrate (g/day)
267±35248±380.08
Fiber (g/day)
10±3.616±3.7<0.001** Significant differences (p<0.05)

Figure 4-1 Satisfaction (Q1)

Figure 4-2 Amount Suggestion (Q2)

Figure 4-3 Problem during Consumption (Q3)

Figure 4 shows the tolerance of TSP dishes after 3 weeks of 50g TSP consumption
DISCUSSION
In the first step, we found that TSP dishes using
Indonesian traditional recipes in which the main
ingredient is meat were highly evaluated with overall
scores of more than 4, which is better than good. In thenext step of the study. There were significant
decreases in energy of 371kcal/day and in lipid intake
of 40g/day, while protein and fiber intake wereincreased by 13g/day and 6g/day, respectively,
compared with their normal diet. These results showedthat TSP can be a meat substitute in Indonesian meat
dishes and have beneficial effect on health by
improving nutritional balance in daily life.
The overall scores showed results of better thangood, which means that the taste of these TSP dishes
was acceptable. Selected recipes in this study, Gulai
and Opor, include coconut milk as a soup base in the
traditional recipes. Then, we modified the recipe
without using coconut milk. Exclusion of coconut
milk as the soup base made the TSP Gulai and Opor
had much lower calorie than the traditional recipes, in
our attempt to develop low-fat high-protein high-fiber
food alternative. By this exclusion, variation of an
acceptable low-fat high-protein high-fiber foodalternative could be developed and be introduced toIndonesian food culture.
Indonesia has a culturally long-establishedtradition of a plant-based protein food: tempeh. Other
than tempeh, other plant-based protein such as tofu
and mushrooms are also commonly found inIndonesian cuisine. Unfortunately, due to theeconomic development of Indonesia, plant-based
protein often considered as `the food of the poor` since
it is not as fancy as animal protein like meat (11,12).
With the continuous increase in lifestyle-relateddiseases, dietary habits are important in assuring ahealthy life (1-3). Previous research showed that in
total, 35% of housewives` food intake comes fromfried foods, which mostly included fried animal
protein such as fried eggs, fried chicken, etc (13). It
was also found that vegetable intake was just 83g/day.
The Indonesian government recommendation forvegetable and fruit intake is 400g/day in total, so theamount of 83g/day was less than half of therecommendation (14,15). Moreover, with thisvegetable intake, fiber could only be supplied at
9.5g/day, much lower than the recommendation of
30g/day (13-16)
175

TSP Acceptance and Effects on Energy
The recommendation is intended to establish ahealthier life for people (14,16). While vegetables andfruits are good sources for micronutrients such asvitamins and minerals, vegetable and fruits also
provide fiber, which is effective in prevention oflifestyle-related diseases (1-3). Studies focusing on
higher vegetable intake have proven it effective incontrolling lifestyle-related diseases; this may be theresult of intake of fiber from vegetables (7, 17, 18).
Consumption of high-fiber pre-germinated brown rice
(PGBR) could also reduce blood glucose level andbody weight (6). Other research also found that
increasing fiber intake from a tofu side product, Okara,
can decrease glucose levels of subject[s] with diabetes
mellitus (19). For these reasons, fiber in any form canhave beneficial effects on health.
Even though there was a successful study on
weight reduction and lipid profiles improvement inIndonesian overweight women with high vegetableintake, it is still difficult to take more fiber only fromvegetables (7). When the approach is shifted to a plantbased protein such as tempeh, people still haven’t
realize the beneficial effects of eating more plantbased foods (11,12). There are many variations oftempeh recipes in Indonesian traditional cuisine, butsociety is already too familiar with tempeh taste andtends to look at tempeh as food for the poor (11,12).
Therefore, the application of meat-like, TSP in
Indonesian traditional recipes can provide morevariation of plant-based foods, especially with its fiber
content and its possibility to increase fiber intake.
From many dishes that include meat as the main
ingredient in Indonesian cuisine, our selected dishes
which meat were substituted with TSP had the resultsof averagely high overall scores. The results werecompared with tempeh acceptance in Japanese dishes,
which replace the main ingredient like meat, fish, anddairy products in Japanese dishes (10). It was scored
3.5 points for overall taste (10). If fiber intake wascompared, tempeh study can increase fiber by 2g/day,while TSP in this study could increase fiber by 6g/day.
Similar results were found on Okara study (6g/day)and PGBR study (7g/day) (6,19).
The decrease of energy intake found in thisstudy might result from the combination of higher
fiber intake and lower lipid intake. First, higher fiber
intake is commonly associated with increase of satiety,meaning that subjects feel full longer, which
eventually reduces hunger and leads to an energy
intake decrease (20-23). Digestion and absorption offiber are slow, resulting in longer stimulation ofnutrient receptors in the gastrointestinal tract,
prolonging the feedback signal to the satiety center andthus reducing hunger(20,21). In controlling bodyweight, fiber might also have effects through multiple
pathways, including through insulin secretion
modulation and satiety control (24-26).
Second, in terms of lipid intake, some studies
have shown that diets resulting in lower energy intake
including protein from vegetables can significantly
reduce lipid intake and LDL cholesterol levels (2731). A Mediterranean diet that focusses oncarbohydrate and protein sources from legumes andsoy is associated with lower risk of coronary arterydisease progression(28,29). In this study, the TSP
dishes that included only TSP and spice mixtures
showed the best effect of TSP consumption by using
minimal ingredients in the recipe. The TSP dishes
were changed daily and had a 10-day menu-cycle, soboredom with the TSP dishes could be avoided, andthe basic effect of TSP could be observed whilesubstituting TSP dishes for regular dishes resulted inlower calorie intake of the subjects.
After three consecutive weeks, the acceptanceof TSP dishes for long period of daily consumption
showed that 70% of subjects felt satisfied during thestudy, 80% felt 50g/day was an appropriate daily
amount, and 85% had no problem during the threeconsecutive week’s consumption. These suggested
that daily consumption TSP dishes in longer term has
many possibilities for further researches focusing on
its effects on health and also biochemical features.
TSP has no taste or smell, but has attributes ofa meat-like texture, which can easily be adapted forvarious dishes. The utilization of TSP in selected
Indonesian traditional cuisine exceeded expectations
that it was acceptable as substitute for meat as themain ingredient. A desirable new method of ingesting
dietary fiber from main dishes was also found throughthis study. Long period of consumption also showed
p ro p erly go o d satisfact io n. Mo re aware n e s s
concerning the benefits of plant-based foods forhealth is expected to a healthier life with lower risk oflifestyle-related disease.
ACKNOWLEDGEMENT
Acknowledgement is gratefully addressed to
NJPPP, US-Medical Science Program, and Fuji Oilfor support of this study, research assistants, allsubjects and health center crews, and Prof essor
Andrew Durkin of Indiana Bloomington University
for his careful proof-reading of this article.
1)

2)

3)

4)

5)

6)

7)

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Asian Journal of Dietetics, 2020
Original
Predictors of food insecurity in the selected areas of SINDH Pakistan
Rubina Hakeem*, Farzana Asar
Rana Liaqat Ali Khan Government College of Home Economics Karachi Pakistan
ABSTRACT Background and Purpose: Food insecurity is associated with a variety of nutrition
problems. Families vulnerable to food insecurity need to be efficiently identified to assure costeffectiveness of the interventions. In Pakistan exploration of community and family level
determinants of food insecurity is relatively rare. This paper estimated the variation in foodinsecurity and identified predictors of food insecurity in the selected areas of Sindh province ofPakistan. Methods: Data was collected from six districts of Sindh namely Karachi, Hyderabad,
Mirpurkhas, Thatta, Thar, Tando Ala Yar. Household food insecurity was assessed by Household
Food Insecurity Access Scale (HFIAS). Several socio-demographic variables that have potential
influence Food and nutrition security were measured and used to generate “Economic Score” i.e.
Economic potential for assuring Food and nutrition security”, “Care Score” i.e. Care potential forassuring Food and nutrition security”. Overall Nutrition Care Potential” Score was estimated bysumming up the score attained on “Economic score” and “Care score”. Both uni-variate andMultivariate analysis were done to identify the predictive power of individual demographic
variables and composite predictive tools. Results: A total of 573 households were surveyed.
Severe food insecurity rates were the highest in Thar: 58.8%, followed by Tando Alayar: 51.9%,
Hyderabad: 37.5%, Thatta: 35.8%, Mirpurkhas: 33.3%, and lowest in Karachi: 14.5%. Family’s“nutrition care potential” score had a significant negative correlation with food security status of
the family (r= .559; P <0.001). Association between economic score and Food Security Access
Score was stronger (r=.600 P<0.001) as compared to association between care score and Food
Security Access Score (r=.456 P<0.001). Strength of these associations varied between different
districts and families apparently having similar “care potential” were more like to be foodinsecure in districts with a lower proportion of urban population. Conclusion: Supporting young
girls formal education and decreasing the inter district disparity in access to food and relevant
resources and opportunities needs to be addressed. Role of place of residence and mother’s
education has emerged as a very important determinant of food insecurity in study and can help
in screening to identify the most vulnerable groups and plan effective interventions.
Key words: food insecurity, Sindh, malnutrition, stunting, wasting, overweight, double burden
INTRODUCTIONIn Pakistan, malnutrition rates have been rising (1) and avariety of factors could be responsible for this situation(2). Food insecurity is associated with a variety ofnutrition problems (3-7). Reduction in food insecurity is
not assured by increments in national income or foodproduction and could not be assure unless the vulnerable
groups are identified and both immediate and long term
actions are taken to reduce the inter and intra community
disparities (8). While immediate action may provide
temporary relief sustainable progress in reducing foodinsecurity is not possible without exploring andmodifying the underlying factors. Assessing andreducing Food insecurity is a major challenge that
requires understanding the dynamics of food insecurity
from a variety of perspectives. In Pakistan, while there
are a few observations reported that highlight the role ofagriculture and economy in reducing food insecurity,
exploration of community and family level determinantsof food insecurity are relatively rare. Within Pakistan
there are inter-province differences in the rates ofMalnutrition and food insecurity and has been higher in
Sindh as compared to Punjab and NWFP (1). The 2011
To whom correspondence should be addressed:
rubina.hakeem@gmail.com

National Nutrition Survey (NNS) in Pakistan showedthat Sindh province continues to have some of the worst
undernutrition rates in South Asia (9). Though reviews
have tried to explore the reasons of high rates ofmalnutrition and food insecurity in Sindh, communityand family level disparities in modifiable factors havenot been reported. This paper estimates the variation infood insecurity and explores the association between
socio-demographic factors and food insecurity in theselected areas of Sindh province of Pakistan.
METHODS
Data was collected from six districts of Sindh namely
Karachi, Hyderabad, Mirpurkhas, Thatta, Thar, Tando
Ala Yar. Districts were selected on the basis ofrepresentativeness of the district and logistic feasibilityof data collectors who were female students of Nutrition
department of RLAK college of Home economics
Karachi. From each location only family living in small
houses (80sq yards or lower) and having a 2-5 year oldchild were selected as the population to represents lower
middle to low income population.

179

Food insecurity in SINDH province of Pakistan
Sample size calculation was done on the basis of rates
of wasting in under-five children. Data was collectedfrom 573 households. Direct observation were madeabout hygiene conditions, anthropometric measurements
were taken from 2 to 5 year old children and information
about diet, food security, nutrition knowledge,
demography etc was collected from mothers. Data
collectors were trained by the principal investigator,
measuring tools were calibrated and pre-testing of thequestionnaire was done on 60 low income families of
Karachi.
The questionnaire had queries about Demographic
Information, Household Assets, Food security status,
Anthropometry, Breastfeeding practices, Householdhygiene index, Child care nutritional knowledge, Childfeeding practices, 24-hour dietary recall of mother andindex child, Recipes of dishes enlisted in 24 hours dietary
recall of mother and index child, Details of utensils andportion sizes consumed by mother & index child. The
data collection started from 9th march 2016 to 21st march2016. Data was entered on SPSS (Statistical Software
for Social Sciences) Software version 20.
Household food insecurity was assessed by
Household Food Insecurity Access Scale (HFIAS) (10).
Questions were translated in Urdu and validated for use
in local population by pretesting. Interpretation of theanswers was done as suggested by the developer of thetool.
The HFIAS is composed of a set of nine questions
that have been used in several countries and appear to
distinguish food insecure from food secure households
across different cultural contexts.
Each of the following questions is asked with a recall
period of four weeks (30 days).
1. Did you worry that your household would not haveenough food?
2. Were you or any household member not able to eat
the kinds of foods you preferred because of a lack ofresources?
3. Did you or any household member have to eat alimited variety of foods due to a lack of resources?
4. Did you or any household member have to eat somefoods that you really did not want to eat because ofa lack of resources to obtain other types of food?
5. Did you or any household member have to eat asmaller meal than you felt you needed because there
was not enough food?
6. Did you or any household member have to eat fewer
meals in a day because there was not enough food?
7. Was there ever no food to eat of any kind in yourhousehold because of a lack of resources to getfood?
8. Did you or any household member go to sleep atnight hungry because there was not enough food?
9. Did you or any household member go a whole day
and night without eating anything because there was
not enough food?
For each questions respondent can answer NO, rarely(once or twice), sometimes (three to ten times) or often(more than ten times) in the past four weeks.
Based on the responses households are categorized into
four levels of household food insecurity (access): foodsecure, and mild, moderately and severely food insecure.
Households are categorized increasingly food insecure as

they respond affirmatively to more severe conditions
and/or experience those conditions more frequently. i.e.
1. If answer to question 1 in No or rarely and answers
to all other questions are NO household iscategorized as FOOD SECURE.
2. If answer to Q 5 to 9 is NO and answer to Q 1 is 2/3,
answer to Q2 is 1/2/3, or answer to Q 3 or 4 is 1
household is categorized is MILDLY FOOD
INSECURE.
3. If answers to Q3 or Q4 is 2/3, OR answer to Q5 or
Q 6 is 1or 2 and answers to Q7 8 and 9 is NO
household is categorized is MODERATELY FOOD
INSECURE
4. If answers to Q5 or Q6 is 3, OR answer to Q7, 8 and
9 is 1/2/3 the household is categorized is
SEVERELY FOOD INSECURE
The Household Food Insecurity Access Scale(HFIAS) holds promise as an easier and more userfriendly approach for measuring the access component ofhousehold food security. HFIAS is found to be useful inapproximating adequacy of urban households' diets (11).
Several socio economic and care variables likely to
influence the food security status were studied. In orderto facilitate assessment of variation and exploration of
associate with food insecurity, relevant socioeconomic
indicators were given a numeric score. “Urbanizationlevel of the district” Urbanization level of the district wasassessed on the basis of proportion of rural population ineach district (12) . ‘Family’s economic burden’ wasassessed on the basis of number of children (age <18) in
the family. “Fathers economic performance score” wasassigned on the basis of average income of the type of
profession or business mentioned in which he wasengaged, zero was given if not working at all. “Mothers
economic performance” was assessed on the basis of
average income of the type of profession or businessmentioned in which he was engaged zero was given if
not working at all. “Family Housing Score” was assignedon the basis of housing structure, utilities, ownership andsize. “Family Assets score” was assigned on the basis ofequipment, furniture, communication devices andvehicles owned and used by the family. “Economic
Score” was estimated by summing ups the score attainedon economic parameters i.e. family’s economics burden,
economic performance housing and assets.
“Father’s education score” was determined on thebasis of years of formal education. “Mother’s education”
was determined on the basis of years of formal education.
“Family Hygiene Score” was determined by observing
the characteristics of the household by a checklist basedon the parameters used in “household hygiene index”
developed by Webb et al (13). Knowledge score wasdetermined by answers to a knowledge questionnairedeveloped on the basis of parameters used in “MaternalChild care knowledge questionnaire” developed by
Saaka et al (14).. “Care Score” was estimated bysumming ups the score attained on care parameters i.e.
parents’ education, maternal childcare nutrition
knowledge and hygiene score.
“Overall Nutrition Care Potential” Score wasestimated by summing up the score attained on“Economic Score” and “Care Score”.
Association between dependent variable (foodinsecurity) and independent variables (“Overall

180

Asian Journal of Dietetics, 2020
Nutrition Care Potential” Score and its components) was
estimated by comparison of means, exploringcorrelations between variables and comparing proportionof food insecure families within various tertiles of
independent variables.
Multivariate analysis (linear regression) was done to
exclude the impact of covariates and identify true
significant predictors of food insecurity.
Data analysis was done SPSS version 21

district and urban-rural status within the district
Collectively in the areas surveyed, overall rates of severe
food insecurity were 34.2% (Urban: 22.1%, Rural:47.5%,
P<0.001). Significant (P<0.001) between districts
differences were noted. Severe food insecurity rates were
the highest in Thar: 68.6% (Urban:54.5%, Rural:75.0%),
followed by Tando Alayar: 51.9% (Urban:35.0%,
Rural:61.8%),
Thatta:40.0%(Urban:25.0%,
Rural:50.0%), Hyderabad: 39.3% (Urban:33.9%,
Rural:45.1%), Mirpurkhas: 35.5% (Urban:11.1%,
Rural:57.9%) and lowest in Karachi: 14.7%(Urban:20.8%, Rural:0.0%).
Association between Food insecurity and socioeconomic status
Family’s nutrition care potential score had a significant
negative correlation with food security status of thefamily (r= .559; P <0.001). Means score attained byfamilies on all the indicators excluding the mothers’
economic performance, were significantly higher for thefamilies having a lower level of food insecurity (table 1).
Bivariate correlations also indicated significant negative
association between food insecurity and all the economic
and care indicators except mothers’ ‘job level’ (Table 2).

RESULTS
Demographic characterstics:
A total of 573 households were surveyed. Mothers age
ranged from 15 to 50 years (mean =28.6) and children
age ranged from 2 to 5 years (mean = 3.4).
Food security
Overall Mean Food Insecurity Access Score was
7.12±8.469, n=573) being the highest in Thar
(14.91±10.115, n=35), followed by Thatta (9.38±9.498,
n=110), Tando Alayar (8.80±7.884, n=54), Mirpurkhas(8.44±9.358, n=124), Hyderabad (6.28±6.169, n=107),
and the lowest in Karachi (2.32±4.741, n=143).
Rates of severe food insecurity differed according toIndex Childs Age
Father's Age
Mother's Age
Urbanisation level of the
district
Family’s economic burden(Number of kids)
Fathers economic
performance
Mothers economic
performance
Family Housing Score
Family Asset score
Father’s education
Mother’s education
Hygiene Score
Knowledge score
Economic Score
Care Score
Nutrition care potential Score

Table 1 Socio-demographic characteristics of subjects
Food Insecurity Levels
Not Food Mildly Food
Moderately
Severely Food
Insecure
Insecure
Food Insecure
Insecure
Mean SD Mean SD
Mean
SD
Mean
SD
3.37 1.10 3.61 1.15
3.48
1.19
3.58
1.13
33.2
6.0 33.2 6.3
34.6
7.7
36.6
8.6
28.0
5.4 27.4 5.4
28.1
6.2
29.4
7.3

Mean
3.49
34.6
28.4

SD
1.13
7.4
6.3

4.64

1.48

3.96

1.49

3.75

1.45

3.48

1.57

4.03

1.59

<0.001

2.70

1.42

2.89

1.53

3.24

1.83

3.90

2.11

3.21

1.83

<0.001

4.90

2.03

4.97

1.94

3.51

1.86

2.96

1.73

4.10

2.11

0.41

1.39

0.36

1.21

0.43

1.22

0.42

1.11

0.41

1.25

0.988

11.64 2.86 12.33
5.54 2.32 5.83
8.29 4.99 8.54
6.65 4.78 6.20
8.39 3.45 8.93
11.97 2.33 11.37
30.00 6.58 30.14
34.75 11.72 34.83
64.75 16.85 64.97

3.40
2.41
4.39
4.61
3.26
2.41
6.47
11.42
16.26

9.77
3.67
4.77
3.26
7.14
11.52
23.52
26.52
50.04

2.71
2.21
4.12
3.30
3.56
2.16
5.79
8.05
11.77

7.41
2.37
3.72
2.13
5.94
11.34
18.59
23.08
41.68

3.39
2.11
4.20
2.64
3.42
2.34
7.14
8.65
13.92

10.02 3.68
4.23 2.69
6.25 5.02
4.56 4.44
7.45 3.62
11.62 2.33
25.23 8.46
29.63 11.58
54.86 18.52<0.001<0.001<0.001<0.001<0.001<0.035<0.001<0.001<0.001

Total

Table 2: Association of various sociodemographic factors with Food Insecurity
Determinants of Food Insecurity
Correlation
Significance (P Values)
Urbanisation level of the district
R= - .313**
P<.000
Family’s economic burden (family size)
R= - .264**
P<.000Fathers economic performance
R= - .417**
P<.000Mothers economic performance
R= .006
P<.890
Family Housing Score
R= - .508**
P<.000
Family Asset score
R= - .528**
P<.000Father’s education
R= - .418**
P<.000Mother’s education
R= - .460**
P<.000Hygiene Score
R= - .303**
P<.000Knowledge score
R= - .111**
P<.008Economic status score
R= - .600**
P<.000Care potential score
R= - .456**
P<.000

181

N
559
559
480
550
559
559
545
549
559
559
559
559

Sign.
P Value
0.212<0.001
0.063<0.001

Food insecurity in SINDH province of Pakistan
Using the same variables, multiple regression analysis
was also conducted. This analysis estimates proportion ofvariability in the outcome variable that can be predictedfrom the independent variables jointly and by any one
factor exclusive (i.e while controlling for the confounding
effects of other independent variable). R-squared
measures the proportion of the variation in the dependent
variable (Y) explained by the independent variables (X)for a linear regression model. Adjusted R-squared adjusts
the statistic based on the number of independent variablesin the model. The model had R square of .397 that means
it explained 39.7% of variation in food insecurity (i.eabout 40% of difference in food insecurity was due tothese factors). It also shows that if we know about thevalues of these independent variables we can predict thelevel of food insecurity to a certain degree and we canmodify relevant situations equivalent decrease in foodinsecurity is feasible.
Unstandardized coefficients are ‘raw’ coefficients
produced by regression analysis when the analysis isperformed on original, unstandardized variables. An
unstandardized coefficient represents the amount ofchange in a dependent variable Y due to a change of 1 unitof independent variable X. Standardized coefficients,
which are normalized unit-less coefficients, an
unstandardized coefficient has units and a ‘real life’ scale.
The t statistic is the coefficient divided by its standard
error. The standard error is an estimate of the standard
deviation of the coefficient, the amount it varies acrosscases. It can be thought of as a measure of the precision
with which the regression coefficient is measured. Everyt-value has a p-value to go with it. A p-value is theprobability that the results from your sample data occurredby chance nsd indictes level of significance of theobservation.
Based on regression analysis, five of the economic
indicators, and one of the care potential indicators(mother’s lower level of formal education) emerged as thesignificant predictors of food insecurity. It indicates thatthese factors can have an important influence on level offood insecurity if other factors wer kept constant. (Table
3).
Apparent impact of economic status or care potential
on food insecurity was different in different districts(figures 1 and 2). Environmental protections against foodinsecurity needs to be strengthened.

Table 3: Predictors of Food Insecurity*
Independent Variables
Beta
t
Sig.
e1_Urban District-.160-4.123.000
e2_Smaller Family-.132-3.493.001
e3_Father’s job level-.145-3.075.002
e4_Mother’s job.level
.003
.088
.930
e5_Housing Score-.222-4.048.000
e6_Asset Score-.164-2.744.006
c1_Father’s Education
-.001
-.016
.987
c2_Mother’s Education-.136-2.415.016
c3_Household Hygeine Score
.007
.151
.880
c4_Mother’s Nutrition Knwoledge Score
-.014
-.360
.719
Multivariate regression analysis: Dependent Variable: Food Insecurity Levels; R2 = 0.392; adjusted
R2 = 0.379; F = 29.308, P <0.001

Figure 1: Proportion of Food insecure in
subgroups of families having varying
Economic in various districts of SINDH

Figure 2: Proportion of Food insecure in
subgroups of families having varying Care
Score in various districts of SINDH
182

Asian Journal of Dietetics, 2020
DISCUSSION
In Ethopia, Using the HFIAS, 17.7 % of households
were food secure. The percentage of households that weremildly, moderately and severely food insecure was 6.8 %,27.7 % and 47.8 %, respectively (15). In an urban
resettlement colony of South Delhi, India HFIAS
identified a total of 77.2% households as food-insecure,with 49.2% households being mildly food-insecure,
18.8% of the households being moderately food-insecure,and 9.2% of the households being severely food-insecure(16).
In another research that included 100 households form
Pakistan as part of a multinational study, proportion ofseverely food insecure was 17.4 % (17). In our study
34.2% households were severely food insecure.
Considering the fact that food insecurity is higher in Sindh
as compared to other provinces, and that in this study only
lower middle income group was included this difference
in rates of sever food insecurity were as per expectations.
In Psaky et al, the mean FAIS score was 8.3 and in ourstudy it was FAIS 7.12. The discrepancy is trends is
explained by difference in proportion of moderately foodinsecure household’s i.e. 48% in Psaki et al and 14 8% inthis study. If we combine two uppermost categories offood insecurity the proportion of moderately or severe
food insecurity is 60.2% in our sample and 65% in Psaky
et al that corresponds to the difference in means. Thisobservation indicates the limitations of using this tool in
different settings and on the basis of mean FIAS score. As
categorisation of families in different food insecurity
categories is not based on total score but on the
combination of answers to specific questions, differencesin answers to even one or two questions can put a family
in an extremely different category, comparison among
different subsets of populations need to consider bothmean score and all categories.
Food insecurity in Sindh has been a cause of concern
however assessment of role of family and community israrely reported. This paper has tried to explore the degreeof variability in food security in the low income
households of the selected areas of Sindh and the role ofeconomic as well other nutrition-care potential indicatorswith the level of food insecurity. As expected and as
identified in other studies all the economic indicators andmost of the other nutrition care potential indicators were
negatively associated with food insecurity.
There have been mixed observations about the role ofmother’s education in predicting food insecurity. In ourstudy mothers formal education had a negative association
with food insecurity even after controlling for otherfactors.
Role of place of residence has emerged as a very
important determinant of food insecurity in study. Living
in more urbanised districts increased the chances of being
food secure even at a lower level of economic status or
education. These observation calls of exploration of thereason for this trend and development of strategies todecrease inter district disparity in access to food andrelevant resources and opportunities.
Conflict of Interest Declaration
Manuscript title: Predictors of food insecurity in theselected areas of SINDH Pakistan

The authors whose names are listed immediately
below certify that they have NO affiliations withorinvolvement in any organization or entity with any
financial interest (such as honoraria; educational grants;
participation in speakers’ bureaus; membership,
employment, consultancies, stock ownership, or other
equity interest; and expert testimony or patent-licensing
arrangements), or non-financial interest (such as
personal or professional relationships, affiliations,knowledge or beliefs) in the subject matter or materials
discussed in this manuscript.
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Asian Journal of Dietetics, 2020
Original

Effects of the Ghana School Feeding Programme on Social Protection and the Local Economy and Key
Challenges to Programme Implementation
Edem Magdalene Tette1, Juliana Yartey Enos2*
1

Department of Community Health, University of Ghana Medical School, College of Health Sciences, Universityof Ghana, Legon
2
Noguchi Memorial Institute of Medical Research, College of Health Sciences, University of Ghana, Legon
ABSTRACT Background: School feeding is a major social protection intervention
employed to improve the nutritional wellbeing of vulnerable children where they live andprovide nutrition education. In addition to its nutritional goals, the Ghana School Feeding
Programme (GSFP) seeks to reduce hunger in deprived communities, boost domestic foodproduction through increase local demand for farm produce to service the programme, andincrease incomes of poor rural households in line with Sustainable Development Goals 1, 2,
3 and 5. This review examined the extent to which these goals were being met and challenges
encountered. Methods: A desk review was carried out by collating and reviewing all peer
reviewed publications as well as reports, both published and unpublished emanating fromvarious studies on the GSFP over the past 10 years. Altogether, 22 articles were included inthis review. Results: The evidence showed that the GSFP provides protection from hunger
especially for children for whom it was the main meal for the day. It also provides significant
economic benefit and financial savings for the family. Poor time management by caterers
reduced contact hours, meal regularity and size. While delayed and inadequate payments tocaterers for services rendered affected program gains in relation to nutrition and education,it also became a major stumbling block to attracting the participation of farmers in boosting
domestic food production and increasing household incomes. Better targeting of beneficiaries,
improved management and monitoring, funding modalities and exploring alternate models
of school feeding are required. Further studies which employ robust methodology to assess
the effect of the school feeding program on social safety nets and the local economy are alsoneeded.
Keywords: Ghana; school feeding programme; socioeconomic effects; challenges
INTRODUCTION
School feeding programmes have been shown tooffer a regular source of nutrients to vulnerable
children, build human capital and provide savings of
up to 10% of the household income of poor families(1). According to the World Food Programme, about
0.25 USD is needed for a meal per child and studies
have shown that each US dollar invested in school
feeding yields a 3-10 USD return on the investment
resulting from improved health, education andproductivity (2). These programmes are regarded associal safety nets, which ensure that vulnerable
children in the population go to school and theirlearning is improved by avoiding hunger andimproving nutritional status (3). Traditionally school
feeding programmes, have focused on outcomes
related to health, education and social protection (3,4).
In recent times, the home grown school feeding
model (HGSF) adopted by several countries
including the African union, in addition to boostingfood production, food security augment the incomesof small holder farmers by providing them with astable market (2–5). Although implementing thisintervention is a complex process, it has beensuccessfully achieved in some settings, nonetheless it
has its challenges (3–5).
The Ghana School Feeding programme is anationwide-wide social protection scheme of theGovernment of Ghana to support children in the mostdeprived communities, which became operational in2005 (5–7). Under this scheme, caterers arecontracted to provide school children in selected
kindergarten and primary schools with one hot
nutritious meal a day, usually served around mid-day(5,7). By 2015, the programme had reached a total of
1,739,357 children in 5,000 schools (7). The Ministry
for Gender, Children and Social Protection(MoGCSP) currently has oversight responsibility forthe programme and is supported by a Multi-Sectoral
Technical Advisory Committee (MTAC) withrepresentatives from the ministries of health,education, finance and other stakeholders (6).
Regional secretariats, District Implementation
Committees(DIC),
SchoolImplementation
Committees (SIC), District and Municipal assemblies
coordinate and monitor the programme at community
level. According to the policy, the principal
objectives of the programme are to promote school
enrolment, attendance and retention; and improve thehealth and nutritional status of the pupils, especiallyin deprived communities (6). In addition to theseprincipal objectives, the goal of the programme was
expanded to include, establishing effective local
catering services; increase domestic food production
and consumption; provide reliable markets for local
famers; increase the incomes of poor rural

185

Ghana School Feeding Programmehouseholds; and enhance incomes of local
communities (6). The policy also focused on
addressing sustainable financing and governance atthe local level in terms of coordination, management,
monitoring, evaluation and information management(6). This review examined the extent to which thesocial protection objectives of the GSFP and effects
on the local economy are being met and thechallenges encountered.

RESULTSA total of 49 articles and reports on the School
feeding programme in Ghana were obtained, of
which 22 papers were included in this aspect of thestudy and 27 were excluded. A sub-analysis of acluster randomised controlled trial showing theeffects of the GSFP on local farmers and households
incomes reported in an online slide presentation was
included due to limited evidence in this area.

METHODSA desk review was carried out which involved thecollection, assessment, analyses and synthesis of
information from the published literature, grey
literature such as Annual reports on the Ghana School
Feeding programme (GSFP) and other evaluation
reports. The review examined the nutritional andeducational effects of the programme as well as its
effects on household resources, social protection andthe local economy. The effect of the GSFP on local
economies, social protection and key challenges
mitigating the success of the program are presented
in this paper. The outcome measures related to social
protection were increased school enrolment ofvulnerable children, savings in household income orbeneficial effects on family income, gender parity in
education, reduction in child labour and reduction inhunger or increased satiety reported by pupils,
teachers or parents. Outcome measures related to theeffect on local economies included participation ofcaterers, farmers or other businesses in the locality in
the GSFP and income obtained from the GSFP.
Computerised bibliographic medical databases
were searched for relevant articles from 2010-2019.
These databases were MEDLINE, (Pubmed version),
the Cochrane Central Register of Controlled Trials,
Google, Google scholar, Hinarii, Scopus and Science
Direct. For this aspect of the review the key words
used to identify the relevant articles were Ghana
school feeding programme, school feeding, school
feeding policy, school meals, economy, economic,
evaluation, impact, effects, and Ghana. The abstractsof the identified studies were retrieved and studied.
Irrelevant articles were excluded and the full text of
the remaining articles obtained. The reference list ofthese articles examined and related articles from databases were obtained. The bibliography from reportsof UN agencies such as WHO, UNICEF, World Food
Programme (WFP), Food and Agriculture
Organisation (FAO) also searched for relevant
articles or the reports were included and similarly,
World Bank reports, proceedings of international
conferences, meetings and evaluation reports.
Studies included in this study mainly involved
recipients of the GSFP who are children in pre-schooland school-aged children aged 3 -17 years,
stakeholders such as caterers, farmers, parents,
teachers and community members. Studies with an
outcome measure of interest in quantitative,
qualitative and evaluation. Evaluation studies, as well
as mixed designs and comparison studies among
schools with and without school feeding programmes
were included. Studies which failed to meet theinclusion criteria as well as the following exclusion
criteria were excluded: student dissertations andthesis; studies with a school feeding programme thatwas less than a year; and those with a sample size ofless than 10 subjects.

Effect on households and social protection
There was little detail on the effect of the GSFP
on household income and social protection, however,
one study on the views of 30 parents in the
Kwaebiribirim district reported that 71% perceived
the GSFP beneficial as it reduced their expenses by
25% and made it easier for them to persuade theirchildren to go to school when they were in financial
difficulty (8). Teachers and the traditional authority
in this locality wanted the programme to be extended
to other deprived schools. A longitudinal randomisedcluster controlled trial conducted in all 10 regions of
Ghana (nationwide) reported an increase in the height
for age z-score in children aged 5-8 years particularly
among girls and those from households living below
the poverty line in this age group (9). The effect sizes
were 0.12, and 0.22 respectively. Another study
reported an increase in the enrolment of girls inschool (10). While another reported mixed effects ongender (8). Studies have consistently reported anincrease enrolment of children in schools with theschool feeding programme in deprived communities(8,10–12). A policy brief on the GSFP in cocoa
growing areas, reported a preference for schools witha GSFP by parents in these areas resulting in a decline
in attendance at schools without a programme, but it
also made children walk long distances to get to
GSFP schools (13). This is likely to have also
impacted on child labour as the policy brief reported
that self-funded school feeding programmes createdin five such districts did not only show an increase inenrolment, but also reported reductions inabsenteeism, truancy and other petty child labour
issues.
Effect on the Local economy
A cost-benefit analysis jointly done by the World
Food Programme and MasterCard found that the
GSFP transfers economic value and significant
benefits to beneficiaries (14). They estimated thatevery 1 GHC invested in the programme makes an
economic return of 3.30 GHC over the life time ofeach beneficiary. In economic terms, the estimatedNet Present Value (NPV) was USD 1,173 (GHC
5,630) to each beneficiary across their lifetime andthe total cost per beneficiary across the 8-year
support cycle of the programme was USD 44.4 (GHC
213) per year or USD 356 (GHC 1.708.8). They
deduced that the benefits accrued from theprogramme include a healthier life by providing 3040% of the child’s nutrient requirements andavoiding medical care costs as making the children
healthier prevents disease (14). In addition, theyfound that providing children with a meal at schooltransfers value to families as the meal can be regarded
as additional income for families or savings which
they can invest into other productive ventures to yield
return. Besides these benefits, they reported GSFP
would increase productivity by improving
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Asian Journal of Dietetics, 2020
educational outcomes of participants, giving them an
opportunity to earn higher wages and increase theirproductive years due to increased life expectancy
resulting from better health. This will impact thequality of the labour force and local economy,
particularly if they work there as adults. By making
these benefits equally available to both sexes the
GSFP reduces the gender gap and improves access to
education and health for the girl (14).
An impact evaluation of the school feeding
programme involving 116 schools randomised toinclude 29 schools which have the standard model ofthe GSFP, 29 school with the Home grown School
Feeding programme which were pilots of the GSFP
with agriculture/nutrition packages, and 58 schools
with no school feeding programmes was carried out(15). The survey covered more than 5,000 school
aged children, in 2,500 households from all regionsof Ghana between 2013 and 2016. They found a 5%
increase in participation in agriculture amongcommunities which had the pilot GSFP. Additionally,
the income of farmers in communities with thestandard GSFP increased by 100 Ghana Cedis (GHC),
equivalent to 26 USD at the time. They also found anincrease in the household incomes in communities
with the enhanced programme and an increase in net
enrolment in kindergarten by 11%. However, most of
the caterers bought their commodities from market
women because the farmers do not give them credit
facilities (15). Other studies also found that farmers
were unwilling to participate in the farm-to-school
lunch contracts with no immediate payments (16,17).
Besides they needed to sell their wares soon after
harvest (16).
By the 2016 budget statement, it was estimatedthat the GSFP had provided jobs to 20,000 caters andcooks (6). However, the lack of cash flow andirregular payment of caterers made integration of
local farmers into the programme difficult, so it
became preferable for caterers to buy theircommodities from market women limiting the
programmes ability to boost the local economy byenhancing the income of farmers. Additionally,
locating the farmers by the caterers posed a problem
as most of them were not organised into co-operative
associations and had to be engaged on their farms
individually, highlighting the need for a mechanism
to link these two key stakeholders (16,18). A study of
100 small holder rice farmers and 90 individual
players in 3 districts in Northern Ghana whichassessed the accessibility of rice farmers to the GSFP
also found that farmers could not access the GSFP.
This was because the caterers preferred milled riceand not the paddy rice produced by the farmers
locally. Thus, the GSFP had no effect on their output
or productivity(19).

served, it costs the caterers more especially as
enrolment increases during the school term (16). Thisaffects the ability to plan, the quantity and quality offood served and its impact on the nutritional status ofchildren. To compensate, caterers reduce the portion
sizes or feed the children irregularly instead of fivedays a week and the small portion sizes do not supply
sufficient food and nutrients to the pupils(5,16,21,22). Thus, some children remain hungry
after the meal (8,20,21). Additionally, the quantities
for the menus were not standardized affecting
monitoring and evaluations processes (16,23). It wasalso observed that most caterers did not follow a mealplan or make provision for those on a special diet in
addition to a lack of variety in the meals served (8,24).
A lack of interventions to deal with nutrition
problems such overweight or obesity, from highenergy intakes and iron deficiency anaemia was also
found in some communities (25–27).
Since caterers have to pre-finance the food servedin the program, their inability to secure funding topurchase in bulk and reduce costs was a limitation(5,16,28). Some caterers also had challenges withstorage and cooking on their own premises posed an
obstacle to the monitoring and evaluation process(16). Some schools lack canteens where children can
eat to avoid using classrooms, and lack of kitchensand logistics such as cutlery and plates were also
observed. (8,18,20). While there was a problem ofaccounting for the effect of increasing enrolment on
the catering service, some caterers reported problems
with children who were not enrolled participating in
the meals and another study reported the participationof underage children (11,28). Some children also
attended school for meals and left school after themeals were served (8).
Some schools complained about delays in the
distribution of food affecting contact hours forteaching and learning (8,21,22). Lack of effective
education of stakeholders such as parents and the
local community was also observed (18,20). Thisaffected teamwork and led to a lack of support or
misinformation, which caused some parents to send
their children to school hungry, expecting that they
will be served breakfast at school. This makes thechildren hungry and find it difficult to learn,
especially when meals are delayed (10). Anotherimportant observation was that, although increasing
enrolment is a desired outcome of the GSFP, it also
exerts pressure on the schools resources andauthorities as it results in shortfalls of teaching staff,
teaching materials, logistics, infrastructure andsupporting services such as provision of clean waterand good sanitation, which could potentially lead topoor food hygiene and disease outbreaks in schools(18,20,21). Poor management as well as politicalinvolvement in the selection of caterers were also
observed (8,10,18,20). A qualitative study
investigating the operational challenges of the GSFP
found a lack of collaboration and coordination among
the relevant government agencies and ministries
involved and recommended the need for regularmonitoring, clarification of roles and reviewing ofprices of commodities to reflect actual cost, as well

Key challenges and bottlenecks
Caterers serving schools with the GSFP have topre-finance the meals through loans, personal savings,
credit schemes to be later reimbursed by government(5,7). Although successive governments havesustained the funding of the Ghana school feeding
programme since its inception in 2005 aided by donor
agencies, payments made to key stakeholders such as
caterers are usually delayed or insufficient(5,8,16,18,20,21). These payments are not adjusted tocover the fluctuations in fuel and commodity prices
and since they are not paid by the number of meals

as making timely payments to caterers to sustain the
GSFP (29).
DISCUSSION
187

Ghana School Feeding ProgrammeThis review revealed that Caterers benefit mosteconomically from the school feeding programme in
Ghana as they are the key players (6,7,30). However,they have several challenges, which need further
attention, including financial constraints, storage
problems and transportation delays in the delivery of
supplies, food hygiene and wastage of academic time
due to the feeding program (3). Better oversight,
monitoring and time management is needed. Due tothe challenges encountered with engaging farmers
and issues with cash flow, farmers were not portrayed
as major actors in the programme. Therefore,suggestions have been made for a loan system tofacilitate payment for goods and services andformation of co-operative associations among
farmers to improve coordination with the caterers(16,26).

were few in some cases. Most of the studies reviewed
were cross-sectional studies and evaluations.
Additionally, information obtained on the challengesof the GSFP were mostly collated from reports,
which are not subjected to the rigours of scientificresearch. One (1) randomised controlled trial
provided the highest level of evidence.
CONCLUSIONSThis review provides evidence to confirm that the
GSFP protects children from hunger and has led tofamily savings in some settings. It also showed thatinvestment in the programme makes significant
economic and social returns over the life time of eachbeneficiary. The programme has been economicallybeneficial to caterers and market women but not tomost farmers in various localities. Delays inpayments to caterers appear to have affected the gains
and sustainability of the programme, as somechildren receive small portion sizes and lower qualityof food as a result. It has also affected the ability toengage with farmers. Resolution of the funding
problem is likely to improve outcomes and provide
necessary infrastructure for the program andbeneficiary schools. Better management andmonitoring of the programme as well as further
research using more rigorous scientific evaluation
study designs are needed.

It is important to note that the GSFP programme
provided actual savings to some families and was inhigh demand. We also noted that gains in height weremore pronounced in children living in poverty (9).
However, due to the small portion sizes offered bycaterers, it appeared that some children’s hunger was
not always satisfied by the school meals. It is also
concerning to note that some children were sent toschool without breakfast and remain hungry until
meals were served. Better education of parents about
the GSFP and the importance of breakfast for thegrowing child could address this problem.
Information on the effect of the GSFP on promoting
gender parity in education and the other effects of the
GSFP was limited, unlike a study in Burkina Faso
which found an increase in the enrolment rate of girls
by 3.2 percentage points (31).

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Although several challenges with the operationsof the GSFP have been outlined, addressing the
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188

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Asian Journal of Dietetics, 2020
Letter to the Editor

Impact of Changing Foodservice Systems on Japanese Hospital Kitchen Staff’s Labor Time
During COVID-19 Pandemic

1

Keiko Hirose1,2, Thao Phuong Tran1,2*, Shigeru Yamamoto2
Nutrition Department, Nerima Hikarigaoka Hospital, Nerima Ward, Tokyo, Japan
2

Jumonji University, Niiza, Saitama, Japan

Dear Editor:
In March, 2020, the World Health Organization(WHO) declared the outbreak of the coronavirus disease2019 (COVID-19) “the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-II)”, a global
pandemic. By November 1, 2020, there have been about
46 million confirmed cases of COVID-19, including
about 1.2 million deaths, reported to WHO. Japan, likethe rest of the world, is facing coronavirus. Japan has
postponed the 2020 Olympics, and by November 2020
there have been more than 100 thousand coronavirus
cases and about 1800 deaths. Many health facilities,
especially acute-care hospitals, are becoming
overwhelmed.

stabilize employees psychologically and to prevent
spread of the nosocomial infection. The solution of thenutrition department at that time was changing
temporarily from the traditional cook-serve system to acentralized foodservice system )food boxes weretransported to satellites )receiving hospital's kitchen( onetime per day(. The HACCP system is still being
maintained during the pandemic. This was the first time
for us and it is a very rare situation to change the foodsupply system like this in Japanese hospitals.
When the pandemic occurred, all tableware except
the trays of hot & cold serving carts were changed todisposable tableware so we would like to summarize thetraditional cook-serve system and the outside foodsupply system in figure 1. With the traditional cookserve system, all procedures are implemented in thehospital kitchen, from inputting and checking materials
to serving meal for patients. The outside food supply
system which replaced cook-serve at this time is a system
which uses a centralized kitchen, from inputting andchecking materials to putting food in tableware(packaging). After this, a serving car/truck with suitablestorage temperature is used to transport meals to thehospital’s kitchen. At the kitchen, the food is reheated,
placed on serving trays and served to patients.

Japanese hospitals’ food supply system always has tofollow the Hazard Analysis and Critical Control Points(HACCP) system. All staff members have to be trained
to implement proper procedures. The HACCP system
helps to minimize risk when supplying food; especiallyin the hospital environment there are many risks ofinfectious disease, so compliance with the HACCP
system is critical. COVID-19 is a new, complicated typeof virus; there is no vaccine or medicine as yet; and it ishighly infectious in the community, especially among
elderly people and people with poor resistance. The
hospital’s kitchen staff includes mainly elderly people
and unfortunately, one case of a part-time kitchencleaning staff member with coronavirus was detected
early; isolation was quickly implemented. Coronavirus
anxiety throughout the workplace was unavoidable andmany kitchen staff members suddenly wanted to taketime off. The traditional cook-serve system is a served
soon after cooking system so it requires a stable labor
resource to serve patients breakfast, lunch, and dinner ontime. Therefore, a lack of labor resouces became aserious problem.

The menus of the centralized kitchen (one-month
cycle menu) were designed with high quality foodmaterials and suitable for the chilling and reheatingprocess to maintain food quality. Dietitians needed to test
the taste and quality of the food before deciding to serve
it to patients. Because the centralized kitchen’s menus
have normal nutrition content, dietitians needed to adjust
food amounts appropriately depending on disease,allergies, etc…
Comparison of the hospital kitchen shift times of thetwo food service systems is indicated in figure 2. To
supply about 200 patients per day, compared with thetraditional cook-serve system, by using a centralized
foodservice kitchen staff members and labor hours werereduced by one-third. Therefore, this can be a timely

In this situation, the nutrition department
immediately had to implement a further solution toensure maintenance of a safe food service for patients, to*To whom correspondence should be addressed:
tpthao95@gmail.com

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Changing Foodservice System during COVID-19 Pandemic

solution for dietitians to choose in an emergency
situation, and the business contract between afoodservice company and a hospital to cover such asituation should be considered beforehand. In addition,
the frequency of inputting in material can be reduced
from many times per day as in the traditional system tojust a few. This could help to reduce the risk of infection.

Figure 1. Food service systems

Based on this experience, changing the foodservice
system in a hospital can be a worthwhile solution to deal
with emergency situations such as the COVID-19
pandemic.

Figure 2. Comparison of the hospital kitchen shift times of thetwo food service systems (supply about 200 patients)

ACKNOWLEDGEMENT
The authors would like to thank othermembers of the nutrition department, medical staff
and kitchen staff who have continued to work at
Nerima Hikarigaoka Hospital during the pandemic.
The corresponding author would like to express
gratitude to Jumonji University, and to the Otsuka
Toshimi Scholarship Foundation for financial support
to study in a PhD program in Japan. Finally, we also
would like to thank Andrew Durkin, Prof. Emeritus ofIndiana University, for editing our English.

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