ISSN2434-2688 Asian Journal of Dietetics

Vol.5 No.4, 2023
Contents
Page T Title and Authors
Original Research107-112

Determining Calcium Requirement of Vietnamese Women
Aged 55-65 Years Old.
Vu Thi Thu Hien, Nguyen Anh Tu, Nguyen Doan Dung, Le Hoang Dan, Luu
Hong Anh, Nguyen Thi Diep Anh, Pham Thuy Mai, Lai Thi Cam Nhung, Le
Anh Hoa, Ryosuke Matsuoka, Yamamoto Shigeru

Original Research
113-123

Lessons from A Meal Service Training at A Nursing Home in Japan
under Post-Disaster Utility Disruption Scenarios
Tamaki Takeda, Noriko Sudo, Reika Mizuno, Eisuke Ikuta

Original Research
125-131

Current Status of Nutrition Education by Nutrition Teachers in A
Prefecture in Japan
Mina Misawa, Saiko Shikanai, Masako Sato

Original Research133-139

Effectiveness of Peptide Based Oral Nutrition Supplement to Improve
Gastrointestinal Intolerance among Patients in Hospital Kuala
Lumpur: The E-PEG Study
Jayvikramjit Singh MS, Basmawati Baharom, Zamtira Seman, Leow Chooi
Wah, Norsuhaila Sha’ari

Special Report:
Asian Young
Dietitian Network
141
142-145
146-147
148-149
150-151
152-153154-155
156-157
158-160

1. Purpose of Asian Young Dietitian Network
Organizer: Asian Nutrition and Food Culture Research Center - Jumonji
University, Ajinomoto Global Communication Department
2. The Birth of Asian Young Dietitian Network
Trang Thu Nguyen, Andrea Wakita
3. Bangladesh Report
Sumaya Islam
4. Bhutan Report
Chimi Wangmo
5. Cambodia Report
Ry Manydine
6. India Report
Naaznin Husein
7. Indonesia Report
Ishak Halim Octawijaya, Wita Rizki Amelia, Achmed Forest Khan, Nur Ayu
Ruhmayanti
8. Japan Report
Risako Okuyama
9. Malaysia Report
Georgen Thye Choong Jean

161-162
163-164
165-167168
169-170
Special Report:
The Cambodian
Food Culture
171-172

10. Philippines Report
Marita V. De Guzman
11. Sri Lanka Report
F.A.Z.Firouse
12. Taiwan Report
Tzu-Yun Chu
13. Thailand Report
Samitti Chotsriluecha
14. Vietnam Report
Trang Thu Nguyen, Phuong Mai Nguyen, Giang Huong Nguyen
The Introduction of “The Palm Sugar” - No. 2 in A Series
Ry Manydine

Asian Journal of Dietetics 2023

Original
Determining Calcium requirement of Vietnamese women aged 55-65 years old
Vu Thi Thu Hien1*, Nguyen Anh Tu1, Nguyen Doan Dung1, Nguyen Thi Diep Anh1, Luu Hong Anh1,
Le Hoang Dan1, Pham Thuy Mai2, Lai Thi Cam Nhung2, Le Anh Hoa2, Ryosuke Matsuoka²,
Yamamoto Shigeru2
1

Vietnam National Institute of Nutrition (NIN), Hanoi City, Vietnam
Jumonji University, Asian Nutrition and Food Culture Research Center, Niiza City, Saitama, Japan

2

ABSTRACT Purpose. Research was conducted to determine Calcium (Ca) requirement for
Vietnamese women aged 55-65 years old, using the Ca balance method. Methods. There were
14 women participated in the study. Each subject was provided with a controlled diet in 2stages: the first 15 days with a Ca intake of about 300 mg/day, the next 15 days with a Ca
intake of about 600 mg/day. Ca intake is calculated based on the database of Vietnamese Food
Composition Table. Between the two stages is a 15-days of washing out, in which subjects ate
their usual diet at home. Dietary intake, feces samples and urine samples were collected during
both stages for quantitative Ca analysis using atomic absorption spectrometry (AAS). Ca
metabolic balance was calculated for each dietary Ca level. Ca requirements were estimatedbased on the linear regression correlation between Ca intake and Ca metabolic balance. Results
and conclusion. Research results show that the Ca requirement of the subjects is 625 mg/day.
The Recommended Dietary Allowance (RDA) of Ca for postmenopausal women aged 55-65
years in rural areas is 750 mg/day. More research is needed to determine RDA of Ca fordifferent age groups of Vietnamese.
INTRODUCTION
In recent years, there has been increasing evidenceof an association between Ca intake and bone health.
Adequate and continuous Ca intake throughout life
will contribute to strong bones, increase peak bonemass in adulthood and reduce bone loss in old age,
thereby contributing to the prevention of rickets inchildren, and osteoporosis in the elderly (1). Therefore,
research on Ca requirements for each age group andeach stage of life is a matter of great concern (2, 3).
Ca requirements for each age group have beenstudied decades ago. There have been many scientificresearch projects published and widely applied inmany countries around the world (1, 4, 5). However,with current knowledge, Ca requirements depend
greatly on physical activity level, nutritional status,
age, gender and race. The Ca RDA for people over 50
years old in the US and Canada is 1200 mg/day, inFrance it is 900 mg/day, in England it is 700 mg/day
and in Australia it is 800 mg/day (6-8).
There are many methods to determine Ca
requirement such as: determining the requirement by
calculating the total amount of Ca excreted in urine
and feces (factorial method), the epidemiologicalinvestigation method and the balance method. Amongthem, the balance method is accepted and used themost by scientists because of its high accuracy andfeasibility (4). According to this method, the average
Ca requirement in adults is determined by the linear

regression correlation between Ca intake and Ca
metabolic balance. Accordingly, Ca requirement iscalculated as the diet at which intake and output are
equal (balance=0) (1).
In Vietnam, the rate of osteoporosis in adults is 9%,
relatively high compared to other countries in theregion (9). Meanwhile, the average Ca intake in adults
is still <500 mg/day (10). Ca requirements have been
recommended by the National Institute of Nutrition(NIN) based on scientific evidence recommended by
the World Health Organization and consultation withother countries in the region (11). Until now, there has
been no publication about results of researches on Ca
requirements in Vietnamese’s adults. Therefore, theauthors conducted research to find the Ca requirement
in women aged 55-65 years, an age group at high riskof osteoporosis, with the hope that the research results
will contribute to enrich the scientific evidence inorder to develop Dietary Reference Intake (DRI) for
Vietnamese people.
MATERIALS AND METHODS
1. Location: Viet Hung commune, Kim Thanh
district, Hai Duong province, Vietnam
2. Time: from November 2007 to February 2008
3. Design: Estimated Ca requirement in subjects
based on the linear relationship between Ca intake andCa metabolic balance, with 2 Ca intake levels of 300
and 600 mg/day corresponding to 2 study stages.
Using a linear regression analysis model, Ca
requirement was determined as the Ca intake at whichbalance = 0 (Fig 1).

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

107

(-)

00

0

0

Balance Ca(+)

Calcium requirement of Vietnamese women

Ca requirement

Ca intakeFig 1. Linear regression analysis model between Ca intake and Ca metabolic balance to estimate Ca
requirement
Stage 1: Subject were taken a diet with Caconcentration of about 300 mg/day for 15 days
according to a calculated menu, based on the databaseof Vietnamese Food Composition table (12). The first
10 days (adaptation period) is the time for the subject
to adapt to the new menu.
5 days later was the sample collection time: subject
still ate the same diet as above. In addition, 24-hourfeces and 24-hour urine were collected for analysing
Ca concentration.
Stage 2: Subject ate a Ca diet of about 600 mg/day
for 15 days, including 10 days of adaptation period anda 5-day of collecting feces and urine samples.
Between the two stages was a 2-weeks of washingout, the subject ate the usual diet at home (4).

Collected anthropometric measurements: weight,
height to calculate BMI. Measured bone density using
quantitative ultrasound through the heel bone toidentify subjects with osteoporosis (speed of soundindex <1503 m/s). Assessed general diet by 24 hours
recording method for 3 non-consecutive days, plus
asking. Assessed Ca intake over the past 3 months
using the semi-quantitative questionnaire (SQFFQ)
method.
5.2. Analysis of Ca content in local drinking water:
By atomic absorption spectroscopy (AAS) method.
5.3. Preparing menus to achieve 2 levels of Ca
intake of approximately 300 mg/day and 600 mg/day,taking into account the amount of Ca from drinking
water and water used to prepare dishes. Other
nutritional values of the menus (energy, protein, lipid,
carbohydrate) were equivalent to usual diets ofsubjects.

4. Subject and sample size
Selection criteria: Women 55 - 65 years old, morethan 5 years postmenopausal, voluntarily participatingin the study, BMI from 18.5 to 23, has 1-2 children,bone density was normal, did not take drugs that affectCa metabolism/products containing Ca within 1month before the study, Ca intake in the past 3 months
was 300-400 mg/day.
Exclusion criteria: Have one of these diseases:
cirrhosis, duodenal ulcer, high blood pressure, colitis,
kidney disease, kidney stones, often constipated.
Sample size: 12 people (4). After adding 15% of
the subject who might give up, the estimated study
sample size is 14 people.
Selecting subject: Women aged 55-65 years in thesame village were invited to participate in screening
survey to select 14 eligible subjects for the study.

5.4. Deployment:
5.4.1. Providing subjects a controlled diet:
In each stage of study, subjects were provided withfree meals for 15 days (3 meals/day), at a centralized
dining location, under the supervision of NIN’s staff.
Subjects were asked not to eat any food or drink otherthan provided meals.
5.4.2. Collecting food samples
For each meal, the researchers prepared 15 meals(14 meals for subjects, 1 meal for analysing Ca
concentration in the meal). The 15th portion of 3 meals
a day were collected, mixed well and ground with afood processor. After grinding, 50g of food was put
into a jar with a tight lid, stored in the freezer andweekly transferred to the NIN for storage at
20°C until analysing Ca concentration.

5. Methods and applied techniques
5.1. Screening and selecting subjects:
Interviewed with general information about age,
number of children, menstrual status, medical history...

108

Asian Journal of Dietetics 2023

5.4.3. Collecting feces samples
Before the first meal of day 11, each subject
ingested 1 g of carmine marker (a red substance that is
not involved in metabolic processes in the body).
When the red color of Carmine appears in the subject's
feces, sampling begins and the red-colored portion of
the stool is removed. The subject's feces are alsocollected in the following days. On day 15, after thelast meal, 1 g of carmine was administered to eachsubject. Sampling ended when the feces turned the redcolor of carmine. The red feces were later removed.
The fecal samples from all subjects were stored for 5days at room temperature in sealed boxes labelled withthe code of each subject (each subject had 5 boxes for
5 days). After the fecal samples were collected for all
5 days, all samples in each subject's 5 boxes werecollected, shredded and mixed well. Approximately 50
g of feces were placed in a jar with a tight-fitting lid
and taken to the NIN, where they were stored at -20 °C
until analysis.

The subjects' diet was monitored throughout the study.
The subjects' physical activity was maintained as usual
throughout the study period.
5.4.6 Analysing Ca concentration in food, feces
and urine.
Food, feces, and urine samples were spiked with
HNO3 acid prior to analysis. After inorganic
combustion, the Ca concentration of the sample wasanalysed using the AAS method.
5.4.7. Method for estimating Ca requirement:
Balance of Ca metabolism (Ca balance) was
estimated based on the equation:
Balance Ca = Ca intake – Ca output
Ca output = Ca in feces + Ca in urine
Ca absorption rate (%) =Ca intake – Ca in feces
Ca intake× 100

Use a linear regression model to estimate Ca
requirement based on two dietary levels of 300 and
600 mg/day, refer to the method of Jackman and CS(4, 13)
Recommended Ca requirement (RDA) isestimated according to the following equation (4, 14):
RDA = Ca requirement x 1.2

5.4.4. Collecting urine samples
24-hour urine samples were collected immediately
after the first intake of carmine over a period of about
2 hours (subjects were asked to urinate completely
before taking carmine) until the end of the night on the
15th day. Using a special sampling device (productmade in Japan), 1/50th of the urine volume was stored
after each urination. The subjects could carry thedevice with them day and night. After each day, thisdevice was returned to the researcher, who collected,
stored and analysed the urine samples. Each subject's
urine was stored in a separate bottle (labelled with dateand code). The urine was preserved with a 6N-HCL
acid solution. (20 - 30 ml for a 24-hour urine sample)
at a temperature of 5-8°C. The 5-day urine of eachsubject was collected, mixed well, 50 ml was poured
into a bottle with a large lid and taken to the NIN
where it was stored at -20°C until analysis.

6. Data analysis
Dietary data and menus are calculated using
ACCESS software, with the database of Vietnamese
Food Composition Table.
Data was analysed by using SPSS software. Linear
regression analysis was used to estimate Ca
requirements.
RESULTS
After screening, 14 eligible subjects were invited
to participate in the study. Throughout the study, allsubjects consumed no food or drink other than themeals offered, physical activity remained as usual, andall followed the instructions for collection of feces andurine samples. All subjects consumed the offeredmeals every day and had no health problems.

5.4.5 Monitoring and evaluation.
Daily monitoring of water intake, body weight,
feces and urine, and unusual health manifestations of
the subjects during the research process. Body weight
was measured in the morning on an empty stomach.

Table 1. General characteristics of the subjects at the beginning of the study
Variables
Mean ± SD
Age (years)
58 ± 3,8
Height (cm)154,5 ± 1,6
Weight (kg)47,1 ± 3,4
BMI
19,8 ± 1,3
Ca intake in the past 3 months (mg/day)
346,8 ± 40,5Bone density (SOS, m/s)
1521,9 ± 18,1
Table 1 shows the general characteristics of thesubjects at the beginning of the study. The subjects
were on average 58 years old and had a normal BMI

of 19.8. The average Ca intake of the subjects in the 3months prior to the study was 346.8 ± 40.5 (mg/day).

109Calcium requirement of Vietnamese women

Table 2. Dietary characteristics of subjects (24-hour recording method in 3 days)
Nutritional value
Mean ± SD
Energy (kcal)
1813 ± 232.1
Protein
Total (g)56.0 ± 21.6
Animal protein (g)29.0 ± 18.5
Lipid
Total lipid (g)25.3 ± 11.3
Animal lipid/ Total lipid (%)
52.8 ± 17.8
Mineral
Ca (mg)377.5 ± 134
Fe (mg)12.9 ± 7.8
Vitamin
Vitamin A (mcg)
0.19 ± 0.94
Carotene (mg)
4.7 ± 3.9
Vitamin D (mcg)
0.28 ± 0.55
% Energy
Protein
12.3
Lipid
12.9
Carbohydrate
74.8
Table 2 shows the general diet of the subjects, withaverage energy intake is 1813 ± 232.1 (kcal/day),protein intake and lipid intake are 56.0 ± 21.6 g/day
and 25.3 ± 11.3 g/day, respectively. The subjects’
dietary energy mainly came from carbohydrates, witha P: L: C energy ratio of 12.3%:12.9%:74.8%.

3 menus for Ca levels of approximately 300
mg/day and 3 menus for Ca levels of approximately
600 mg/day had been designed with energy,
carbohydrate, protein, and lipid values approximately
equivalent to those shown in Table 2 to ensure theexperimental diet is diverse and similar to the subject's
usual diet.

Table 3. Results of analysing Ca concentration in the diet
Ca concentration in the diet (mg/day)
Menu
Stage 1
Stage 2
Menu A (n=5)
327.6 ± 15.7
605.6 ± 7.7
Menu B (n=5)
306.1 ± 21.2
595.8 ± 6.7
Menu C (n=5)
317.6 ± 8.8
605.8 ± 13.4
Average (n=15)
317.1 ± 18.1
602.4 ± 10.1
Data are presented as mean ± SD
Table 3 shows the results of analysing Ca
concentration in the diet provided to the subjects.
Results shown that Ca concentration in the dietassessed directly by food sample analysis has a valuenearly equivalent to the Ca diet estimated based on the
Vietnamese Food Composition Table (12).

Table 4. Ca balance of subjects
Stage 1
317.1 ± 18.1
309.7 ± 95.2
150.3 ± 36.4
-130.0 ± 101.6
20.2 ± 95.2
6.1 ± 28.8

Ca intake (mg/day)Amount of Ca in feces (mg/day)Amount of Ca in urine (mg/day)
Metabolism balance= Intake-Output (mg/day)Amount of Ca absorbed (mg/day)
Ca absorption rate (%)
Data are presented as mean ± SD or %Table 4 shows the average amount of Ca excreted
in feces of subjects in stage 1 is 309.7 ± 95.2 mg/day
and stage 2 and 498.2 ± 193.6 mg/day. Meanwhile, theamount excreted in urine is less, in stage 1 is 150.3 ±36.4 mg/day and stage 2 and 146,0 ± 53.7 mg/day. Ca

Stage 2602.4 ± 10.1
498.2 ± 193.6
146.0 ± 53.7
-10.1 ± 203.6
136.1 ± 193.1
21.4 ± 30.5

absorption rate in stage 1 (6.1%) is lower than stage 2(21.4%). There is a remarkable point that, Ca
metabolic balance in both stages has negative values(-130.0 ± 101.6 mg/day in stage 1 and -10.1 ± 203.6 instage 2).

110

Asian Journal of Dietetics 2023

The results of linear regression analysis areillustrated in Fig 2, according to which the Ca
metabolic balance is 0 when the Ca diet reaches
625mg/day. Therefore, the subject's Ca requirement isestimated to be 625mg/day. From that result, the RDA

of Ca for postmenopausal women aged 55-65 years inrural areas was estimated according to the method ofK. Uenishi et al (4, 14) are as follow: 625 x 1.2 = 750
mg/ day.

100

Ca requirement
625 mgCa balance

50

0
Khẩu
phần (mg)Ca (mg)Caintake
300mg

600mg

-50

-100

-150

Fig 2. Linear relationship between Ca intake and Ca metabolic balance to estimate the subject's Ca
requirement
Body weight changes:
The average body weight of the subject increased
from 47.1 kg (before intervention) to 47.5 kg (afterstage 1) and 47.8 kg (after stage 2). The change inbody weight of subjects from before the study to theend of the study was not statistically significant.

the Ca requirement of women in some white
communities is 900 mg/day, while that of Japanesewomen is 788 mg/day, while that of Vietnamese
women is 625 mg/day (4, 15). This finding is
consistent with the conclusion of previous studies that
Ca requirements vary by race (8).
The results regarding the amount of Ca absorbedby the body are almost identical to the study by K.
Uenishi et al. on Japanese women of the same age (4).
K. Uenishi used 2 levels of Ca intake (250 mg/day and
850 mg/day) to determine the Ca requirement. The
results show that the amount of Ca ingested at low Ca
intake of Vietnamese people (20.2 mg/day) is similar
to that of Japanese women (21 mg/day), but at high Ca
intake, the Ca requirement of Vietnamese women(136.1 mg/day) is much higher than that of Japanesewomen (113 mg/day). This indicates that the Ca
requirement of Vietnamese is lower than that ofJapanese because the Ca saturation point is lower.
“Recommended dietary allowance (RDA)” is adifferent term than “requirements”. While therequirements of a nutrient for the body is estimatedbased on the individual, the RDA is used to makerecommendations for the whole community.
Therefore, the RDA is usually estimated at 1.2 times
the requirement (14). The recommended Ca
requirement for some white communities are 10001500 mg/day for elderly women. The requirement forJapanese people of the same age is 650 mg/day (15),DISCUSSION
The balance method (determination ofrequirements via the metabolic balance in the body)has proven to be very accurate and practicable instudies on nutrient requirements (4). Ideally, 3 points
are used to determine nutrient requirements, whichcorrespond to 3 nutritional levels (Figure 1). In Ca
requirement studies, the method of using 2 points
corresponding to 2 intakes is still scientific if the point
corresponding to a high intake is close to the estimatedintake, as Ca balance is linearly related to Ca intake(13). The 2-point method has also been used in many
previous studies and has been shown to be reliable(4,13). In this study, we used two Ca intakes: 300
mg/day and 600 mg/day. The results show that theestimated Ca requirement is 625 mg/day, whichcorresponds to a close point of 600 mg/day (Figure 1).
Therefore, we believe that the estimated results of thestudy are relatively close to reality.
Compared to women of the same age in othercountries, the Ca requirement of the subjects in thisstudy was lower. Using the same method of utilisation,111

Calcium requirement of Vietnamese women5.

Commission of the European Communities.
Nutrient and energy intakes for the European
community. Reports of the Scientific Committee
for Food (31st Series). Office for Official
Publications of the European Communities,
Luxembourg. 1993.
6. Connie M Weaver. Calcium requirements ofphysically active people. Am J Clin Nutr
72(suppl): 579S-84S. 2000.
7. WHO. Prevention and management of
osteoporosis, Technical Report Series, No. 921.
2003.
8. A. Prentice. What are the dietary requirements for
calcium and vitamin D? Calcif Tissue Int; 70: 8388. 2002.
9. Hien VTT; Khan NC, Lam NT, et al. Determining
the prevalence of osteoporosis and related factors
using quantitative ultrasound in Vietnamese adultwomen. Am J Epidemol 161(9): 824-830. 2005.
10. National Institute of Nutrition, Ministry of Health.
General nutrition survey 2000. Hanoi Medical
Publishing House. 2003.
11. National Institute of Nutrition, Ministry of Health(1997). Dietary reference intake of Vietnamese
people. Hanoi Medical Publishing House. 1997.
12. National Institute of Nutrition, Ministry of Health.
Food composition table. Hanoi Medical
Publishing House. 2000.
13. Jackman LA, Millane SS, Martin BR, et al.
Calcium retention in relation to calcium intake
and postmenarcheal age in adolescent females.
Am J Clin Nutr 66:327-33. 1997.
14. Health Promotion and Nutrition Division, HealthService Bureau, Ministry Health and Welfare.
Recommended dietary allowances for Japanese.
5th revision. Tokyo: Dai ichi Shuppan. 1996.
15. Ministry of Health, Labour and Welfare. Dietary
Reference Intakes for Japanese. 2020.
16. NIH consensus development panel on optimal
calcium intake. Optimal calcium intake. JAMA
272: 1942-8. 1994.
17. Heaney RP. Recommended calcium intakes
revisited: round table. Nutritional aspect ofosteoporosis. Springer 317-25. 1998.
18. Food and Nutrition Board, Institute of Medicine.
Dietary reference intakes for calcium, phosphorus,
magnesium, vitamin D, and fluoride. National
Academy Press 111-7. 1997.

while Vietnamese people are 750 mg/day. If computed
the requirements by weight, with the average weightof the subjects in this study being 47.1 kg, the Ca
requirements is 15.9 mg/kg body weight. This weightbased requirement also remains lower than that ofwhite women (18.5 mg/kg) and Japanese women (18.1
mg/kg) (4, 16, 17, 18). Compared to the recommended
dietary allowance in the book "Recommended
nutritional dietary allowance for Vietnamese people"
published in 2007, our estimated results are lower.
Therefore, required studies to confirm the results ofthis study. Our research results show that, subjects
gained weight after 45 days of joining in the study,
although this weight gain was not statisticallysignificant. This may be because the study was
conducted at a time when farmers were leisured, andthe diet provided, although having total energy,
carbohydrates, proteins and lipids, was nearly
equivalent to the regular diet, the completeness was
related to Dietary restrictions that have led to weightgain. However, the menu computed in this study
closely follows the recommended dietary allowancefor energy-generating substances, so the estimated Ca
requirement is applicable.
CONCLUSIONThe Ca requirement of women aged 55 to 65 years
was estimated at 625 mg/day in this study.
The Ca requirements dietary allowance of women
aged 55 to 65 years was estimated at 750 mg/day inthis study.
RECOMMENDATION
There is a need to research Ca requirements fordifferent age groups to enrich scientific knowledge
and develop a Dietary Reference Intake (DRI) for theVietnamese population.

1.

2.
3.

4.

REFERENCES
FAO/WHO. Calcium. In: Human vitamin andmineral requirement. Report of a Joint Expert
Consultation. FAO Rome: 151-171. 2002.
Heaney RP. Calcium, dairy products andosteoporosis. J Am Coll Nutr, 2000.
Heaney RP. The important of calcium intake forlifelong skeletal Health. Calcif Tissue Int; 70: 7073. 2002.
K. Uenishi, H. Ishida, A. Kamei, et al. Calcium
requirement estimated by balance study in elderly
Japanese people. Osteoporos Int 12: 858-868.
2001.

112

Asian Journal of Dietetics 2023

Original
Lessons from a meal service training at a nursing home in Japan under post-disasterutility disruption scenarios
Tamaki Takeda1, Noriko Sudo2*, Reika Mizuno1, and Eisuke Ikuta3
1

Department of Food and Nutritional Science, Graduate School of Humanities and Sciences, Ochanomizu
University, Tokyo, Japan
2
Natural Science Division, Faculty of Core Research, Ochanomizu University, Tokyo, Japan
3
Institute of Advanced Sciences, Osaka Metropolitan University, Osaka, Japan
ABSTRACT Background and purpose. Elderly people, especially long-term care facility
residents, are vulnerable to disasters. Although meal provision is crucial during disasters, few
Japanese nursing homes have provided meal service training. To identify disaster
preparedness issues related to meal service we conducted a meal service training course at anelderly nursing home in Osaka Prefecture, Japan, on August 23, 2022. Methods. The training
course included the transportation of stockpiled supplies, meal preparation, and meal services,
assuming disruptions in electricity, tap water, and gas supplies. We analyzed 15 post-training
questionnaires completed by the trainees and observers (response rate: 93.8%). Using the KJ
method, we summarized one opinion on each card and categorized it with cards with similar
opinions. Results. Of the 31 cards regarding transportation of stockpiled supplies, 17 were
included in the main category of “transportation should be done in daylight hours or withlights.” The top two main categories related to meal preparation (67 cards) were “cooking
processes need improvement” (26 cards), “hygiene must be taken into consideration” (14cards). Of the 31 cards on meal service, 22 concerned “there were problems with eating,”with specific comments such as “porridge jelly was hard and caused a lot of choking.”
Conclusion. The training revealed issues regarding lighting, cooking processes, hygiene
management, and the food served. Particularly, inadequate sanitation and foods that are
unsuitable for impaired chewing and swallowing can threaten residents’ health and increase
the risk of aspiration pneumonia. Furthermore, it is important to assess the suitability of thestockpiled food for cooking and feeding.
Key words: Disaster preparedness, Food service, Nursing home, Natural disaster, Training
care facilities constitute an essential social
infrastructure, promoting disaster preparedness is
crucial for building a resilient society.
Malnutrition affects the immunocompetence of theelderly [7]. Therefore, meal provision must continueeven during disasters [6]. In Japan, all caregiving
service providers will be required to establish a
Business Continuity Plan (BCP) and conduct training
sessions and drills beginning FY2024 [8]. However,even among nursing homes in disaster-prone areas inJapan, only a minority (36.6%) have conducted meal
service trainings [9].
Studies of meal preparation and eating in disasterlike situations have shown that people recognize theneed to improve the quality of their stockpiles and theimportance of lifelines, such as lighting and water [1012]. However, these studies focused on young andworking-age adults. To the best of our knowledge, nostudy has examined meal service drills in nursing
homes, where dietary considerations are important.
This study used meal service training to identify
disaster preparedness issues related to meal services
in an elderly nursing home. Our findings provide

INTRODUCTION
Japan is an aging society, with the proportion of
the population aged 65 years and over at 29.0% in
2021 [1]. Indeed, global aging trends project anincrease in the elderly population worldwide from2022 to 2050 [2]. During this period, the world is
likely to experience the increasing impacts of climatechange; indeed, it has increased the scale andfrequency of natural disasters [3]. Elderly people areparticularly vulnerable to disasters, with people over
60 years accounting for over half the fatalities fromthe Great Hanshin-Awaji Earthquake and Great East
Japan Earthquake [4]. Notably, individuals over 66
years accounted for 88.6% of earthquake-related
deaths from the Great East Japan Earthquake [5]. Suchdisasters can particularly disrupt elderly carefacilities. As long-term care facility (LTCF) residents
depend heavily on these facilities for their daily lives
and healthcare, difficulties in providing services toresidents during a disaster can directly affect theirlives, health, and well-being [6]. Given that elderly*To whom correspondence should be addressed:
sudo.noriko@ocha.ac.jp113Lessons from a meal service training at a nursing homevaluable insights into disaster preparedness for meal
provision in long-term care facilities.

reflection session. The following reports particularly
focused on meal preparation and meal service
training. Table 1 shows the training outline and theparticipants. Fig 1 presents the overall flow andpreparation methods for each menu item during
training sessions. During these sessions, the trainees
prepared dinner, whereas electricity, gas, and tap
water were unavailable in the post-earthquake
scenario. Cassette stoves could be used for cooking
because the facility stockpiled them. In the reflection
session, trainees and observers gave their impressionsof the training. The second and fourth authors
mentioned both the positive aspects and challenges
observed during training (Table 2). .

MATERIALS AND METHODS
On August 23, 2022, meal service training was
conducted at the Special Elderly Nursing Home A(hereafter, Nursing Home A) in Osaka Prefecture.
Free descriptions in the post-questionnaire wereanalyzed using the KJ method to determine thefeasibility and validity of the facility’s BCP.
2.1 Training outline
The training comprised four components: BCP
initial response training (hereafter, BCP training),
meal preparation training, meal service training, andTable 1. Course outline and participants in each training sessiona
Meal preparation training
Meal service trainingTime
16:00–17:40
17:40–18:30
Content
Gathering materials fromThicken the water and miso soupstorage
Meal assistancePreparing stockpiled foods
Setting out dishes
Table setting
Participants Trainees(n = 4)(n = 8)Care staff (manager), care
Director, assistant director, registered dietitian,staff (head of a unit), general care staff member, two managerial staff members
care staff, and maintenancefrom Corporation B, and two crisis management
staff
committee members from Corporation B
Observers (n = 7)(n = 7)
Care staff (manager), care
Director, assistant director, registered dietitian, astaff (head of a unit), andcare staff member, managerial staff member fromfive general care staff
Corporation B, and two crisis management
members
committee members from Corporation BaTraining sessions were conducted on August 23, 2022. The BCP initial response training was conducted prior tothe meal preparation training (14:00–15:30). Reflection was also held after the meal service training (19:00–
20:00).

Fig 1. Overall flow and the preparation methods of each menu in meal preparationand meal service training.

114

Asian Journal of Dietetics 2023
Table 2. Comments by the authors regarding meal preparation and meal service during
the reflection session.
Contents
Comments by the authors[Hygiene] Trainees should have sanitized the worktable using alcohol and wet tissues before cooking.
 Cardboard is unclean; therefore, it is better to avoid placing it on the worktable.
 Glove usage lacked hygiene.
 Several operations were done without gloves. Gloves should be changed every time the processchanges.
 Miso soup and pre-gelatinized rice were uncovered until water was added. They should have
Preparing
been wrapped to prevent dust.
stockpiled [Cooking process]foods
 The boiling pot lacked lids. They would save fuel and prevent temperature rise.
[Safety] Pay attention to fire when using cassette stoves. Alcohol disinfectant was sprayed near the fire,
and the hem of the bib was about to touch the stove.
 A cassette stove was on a caster-equipped stand, which was dangerous because of thepossibility of hot water spilling.
[Garbage] Waste was not disposed separately.
Setting The containers of pre-gelatinized rice had lids; hence, they could be stacked and carriedout dishes
efficiently.
Meal Residents were familiar with miso soup cups.
assistancea
Reflection session was held after the training sessions (19:00–20:00). Thirteen people participated: the director,
assistant director, registered dietitian, trainee of BCP initial response training, two trainees of meal preparation
training and meal service training, two managerial staff members from Corporation B (to which the target facility
belonged), two crisis management committee members from Corporation B, and three authors. Other content of
the reflection included BCP initial response training (home oxygen therapy, sputum suction, and emergency toilet
installation), gathering materials from storage, impressions of the meals provided, oral care, and comments fromobservers.
Table 3. Menus and corresponding cooking methods during the training
Meal type
Cooking methods during the training
1. Sprinkled dried ingredients for gomoku gohan (mixed vegetable rice) on top
Normalof pre-gelatinized rice.
Pre-gelatinized rice
Porridge 2. Poured 8 L of hot water and steamed for 15 minutes.
3. For making porridge, took some of the rice, added the hot water, and heated.
Normal 1. Shaping the folding paper cups and added powdered miso inside.
Instant miso soup
Porridge 2. Poured 150 mL of boiling water into the cup and mixed well.
Canned gomokuOpened the lid of the can and served.
mame beans
Normal(Simmered
Porridge
soybeans withvegetables)
1. Added 30 g of porridge jelly powder and 180 mL of hot water in a bowl.
Rice porridge jelly
Paste
2. Mixed thoroughly using a whisk until the mixture was uniform.
Soybean pâté
Paste
Served on top of rice porridge jelly.
NormalOpened the lid of the cup and served.
Fruit jelly
Porridge
Paste
Food

In the meal preparation training, three care staff
members (two male and one female) transported
stockpiled supplies from the third floor to the kitchenon the second floor using stairs, as the elevators wereassumed to be inaccessible because of a power outage.

At Nursing Home A, a two-day supply of long-shelflife food and disposable tableware was stored on thethird floor, while seasonings and cooking utensils
used daily were stored in the kitchen on the second
floor. Subsequently, the trainees prepared menus of115Lessons from a meal service training at a nursing home
During meal service training, one lantern wasplaced on each table, where five or six residents wereseated. The trainees thickened the water and miso
soup for residents with difficulty swallowing. The
residents ate either with assistance from staff or bythemselves using disposable plastic spoons. Fig 2shows the meals served and the eating scene during
the training.

stockpiled foods with long shelf lives that the facility
had already planned to serve after the disaster. Table 3
lists the foods served, meal types, and cooking
methods used during the training. A total of 41 meals(31 residents and 10 staff) of three meal types (normal,
porridge, and paste) were prepared.

Fig 2. Served meals and eating scene during training. (A) Normal meal. (B) Porridge meal.
(C) Paste meal. (D) Eating scene.
Regarding disaster preparedness, Nursing Home A
established a BCP and manual for meal services
during emergencies in January 2022 and conducted
BCP simulation drills while serving pregelatinizedrice in March 2022. However, the staff members neverprepared or served the entire disaster menu.

2.2 Setting and Participants
2.2.1 Setting
The training course was conducted in Nursing
Home A. The facility has a capacity for 35 residents,
including 5 short-stay users with an average age of 85
years. Residents’ living spaces were divided into threeunits, and meals were prepared and served per unit.
Special elderly nursing homes in Japan provide
general nursing care services for the elderly who
require 24-hour care and are difficult to care for athome [13]. In Japan, elderly individuals in need ofnursing care are classified into five levels (care needs
levels 1–5) based on their health condition and thetime required for nursing care [14]. Each level
corresponds to the degree of care needed, with higher
levels indicating greater care requirements. To makeservices more focused and efficient, users of special
elderly nursing homes are restricted to seniors whosecare needs are level 3 or higher [15]. Since elderly
people with level 3 care needs require assistance intheir daily lives, the disaster response strategies of
special elderly nursing homes directly impact theresidents’ quality of meals and their overall wellbeing.

2.2.2 Participants
The total number of participants was 16, of whom
12 attended meal preparation training, 14 attended
meal service training, and 10 attended both.
Participants were divided into trainees and observers;
all trainees were Nursing Home A employees. In themeal preparation training, four trainees prepared
meals: a care staff member (manager) in their 40s,
another care staff member (head of a unit) in their 40s,
a general care staff member in their 20s, and amaintenance staff member in their 70s, all of whomroutinely prepare meals for residents. In meal service
training, seven care staff members were trainees (threewere also trainees in meal preparation training). All ofthem assisted residents with their meals.
The observers were the director, assistant director,
dietitian, and nursing staff of Nursing Home A as well116

Asian Journal of Dietetics 2023
as administrators and disaster prevention staff fromother facilities of Social Welfare Corporation B towhich Nursing Home A belonged.

2.5 Ethical considerations
This study was approved by the Humanities andSocial Sciences Research Ethics Committee of
Ochanomizu University (Notification No. 2021-56).
Prior to the training, we explained its contents andhow the data would be handled to the facility manager.
Subsequently, we requested the manager tocommunicate this information to the nursing staff andresidents. Consent was obtained from the facility
through a consent form signed by the president ofCorporation B.

2.3 Data collection
On the day of the training session, questionnaires
were distributed to all the participants (n = 16), and 15
days after the training date (September 7, 2022), 15
questionnaires were returned (response rate: 93.8%).
In instances where the responses were unclear, followup emails were sent to the participants and their
responses were received on September 28. The
questionnaire comprised 38 questions categorized into
five sections: toilet training (a part of BCP training),
meal preparation training, meal service training,reflection, and an overall assessment of the training
program. In this study, responses to five open-ended
questions regarding (1) transportation of stockpiled
supplies, (2) meal preparation, and (3) meal service
were analyzed.
(1) Transportation of stockpiles Please write your thoughts and insights
regarding retrieval of stockpiled supplies fromstorage.
 Please write your thoughts and insights
regarding the transportation of supplies using thestairs.
(2) Meal preparation
 Please write your observations andimpressions of cooking stockpiled foods.
 How did you feel about preparing meals when
the water supply was not available?
(3) Meal service
 Please write your thoughts and insights onmeal assistance.

RESULTS
3.1 Transportation of stockpiled supplies
Table 4 lists the results of transportation ofstockpiled supplies. A total of 31 cards from eight
respondents were divided into four main categories(numbers in parentheses are the number of cards foreach category): “transports should be done in daylight
hours or with lights” (17 cards), “carrying wentsmoothly during the training” (9), “transportation
during a disaster would be more difficult” (3), and“worried about carrying supplies” (2). Notably,problems with lighting during transportation werementioned frequently, as highlighted by “difficult tocarry supplies in the dark” (8) and “lights are a mustwhen transporting safely” (5). Furthermore, regardingsmooth transportation, “male staff can carry supplies
smoothly” (4) and “organization helps smooth
retrieval” (4) were mentioned.
3.2 Meal preparation
Table 5 lists the results for meal preparation. A
total of 67 cards from 11 respondents were divided
into the following seven main categories: “cooking
processes need improvement” (26 cards), “hygiene
must be taken into consideration” (14), “water isimportant” (11), “need to actually cook and know thecooking process” (4), “presence of residents makes
the tasks more challenging” (3), “goodcommunication among staff” (2), and “others” (7).
Further categorization within the “cooking process
challenges” revealed “caution is required for the
installation and handling of the cassette stoves” (10)as the most frequent, followed by “poor arrangement
for boiling water” (5) and “miso soup should be madein batches” (3). All comments categorized under“hygiene must be taken into consideration” werementioned by observers. Comments about cooking
without tap water emphasized the importance ofwater, with some cards such as “need to reduce wateruse” (5) and “inconvenient when water is notavailable” (4).

2.4 Data analysis
Responses from the trainees and observers werecollected for these five questions. The “KJ method,” abottom-up qualitative method developed by Japanese
ethnologist Jiro Kawakita [16], was employed toanalyze the descriptions. The first author carefully
reviewed the descriptions and summarized them into
approximately 40 characters on one card per opinion.
Subcategories were created by gathering cards withsimilar content, and sentences were posted to express
the content of each subcategory. Finally, the maincategories were developed from these subcategories
and a sentence was posted to express the content ofeach main category. Categorizations were checked by
the first, second, and third authors and discussed until
a consensus was reached. The analysis was performed
using KJ method software (Chohassoho Ultra Presen(ITEC, Minato, Tokyo, Japan)).

117

Lessons from a meal service training at a nursing home
Table 4. Thoughts and insights regarding transportation of stockpiled supplies a
Main category
Subcategory
Examples of cards
Transports should Difficult to carry supplies
 It is difficult to smoothly carry supplies in thebe done duringin the dark (8)darkness without light [2].cdaylight hours or
 It is difficult to see your feet in the dark, which may
with lights (17)b
lead to accidents, etc.
 Finding supplies in the dark is challenging.
 I am not confident in accurately and quickly retrieving
necessary items during hours of darkness.
 Going up and down stairs during a blackout isdangerous.
Lights are a must for It would be safer if one person carried supplies whiletransporting safely (5)another lit the way.
 It is possible to take out the items with a flashlight or
lantern.
 Headlights allowed the trainees to use both hands
while carrying the items.
It was bright during the During the training, surroundings were visible due totraining (3)sunlight.
Supplies should be It is better to take one day’s worth of supplies duringtransported in daylight (1)daylight.
Carrying went
Male staff can carry
 It was easy to carry out because there were no heavysmoothly during
supplies smoothly (4)items.
the training (9) It went smoothly with male staff.
 It would require more effort and time with only
female or elderly employees [2].
Organization helps smooth  Supplies stored with a clear sign on cardboard wereretrieval (4)easy to take out.
 With a post-disaster menu set in advance, the trainees
took out the supplies without confusion.
It went smoothly (1) It went smoothly.
Transportation
 It would take more time [2].
during a disaster There would be various obstacles such as falling
would be moreobjects in an actual disaster.
difficult (3)Worried about Transporting stored water is difficult.
carrying supplies
 I am not sure if I can safely go up and down the stairs(2)while carrying supplies.
a
The responses to the following two questions were analyzed using the KJ method: ‘Please write your thoughts
and insights regarding retrieval of stockpiled supplies from storage,’ and ‘Please write your thoughts and insights
regarding the transportation of supplies using the stairs. ’ Eight respondents (two trainees and six observers)
answered and 31 cards were used. The opinions of the trainees are underlined.
b
Number of cards in each category.
cNumber of specific examples of cards with similar content.

Main category
Cooking
processes need
improvement(26)bTable 5. Thoughts and insights regarding meal preparationa
Subcategory
Examples of cards
Caution is required in  It made me think about how to set up the cassette stove,
the installation andconsidering both staff workflow and safety.
handling of the It would be better to put the cassette stoves in one place.
cassette stoves (10) Placing cassette stoves in various locations may pose fire or
injury risks.
 Putting all the cassette stoves in one place can help people
recognize it as a “fire zone” and cook with care.
 Inadequate installation and handling of cassette stoves could
result in fires and injuries.
 Spraying alcohol disinfectant near the fire was concerning.
Poor arrangement for  I noticed that boiling a substantial amount of water tookboiling water (5)significantly longer than expected.
 I could not figure out why they used a pot without a lid.
 Maintaining the warmth of hot water resulted in unnecessary
gas consumption.
Kettles are suitable Using a kettle saves time and gas.
for heating water (3) Kettle usage minimizes scalding risk when pouring hot
water.
Miso soup should be Preparing miso soup packets individually was timemade in batches (3)consuming.

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Asian Journal of Dietetics 2023

Need to think about
the workflow before
starting work (3)Need to be creative inworkspace layout (2)Hygiene must be
considered (14)Hygiene is an issue(8)

During water
shortages,
consideration forhygiene is necessary(3)
Alcohol disinfection
is essential during
water disruption (3)Need to reduce wateruse (5)
Inconvenient whenwater is not available(4)

 Implementing batch preparation of miso soup in a pot
seemed beneficial.
 Making miso soup one by one is time-consuming.
 They seemed a bit confused overall because they started thetask without reading the manual.
 Streamlining and simplifying the workflow can lead to more
efficient cooking processes.
 Distinct areas for cooking, serving, and dining could havebeen delineated to enhance efficiency.
 Trainees touched the food with their hands that had touched
cardboard.
 One trainee took off her mask to taste the food andcontinued cooking while talking.
 I was uncomfortable with the trainees stacking and putting
down packaged food items.
 Since hands and utensils cannot be washed, special attention
must be paid to hygiene.
 It is important to consider hygiene.
 To what extent can hygiene be maintained?

 We have to do the best we can with alcohol.
 Alcohol disinfection is essential due to the inability to washwith water.
Water is Need to prepare meals with as few utensils as possible.
important (11) Reducing the amount of dishwashing is important.
 It is inconvenient because we cannot wash dishes dropped
on the floor.
 I thought it was hard that we were not able to wash hands
and cooking utensils.
Need much water for  I realized that we needed to stockpile more water forcooking (2)cooking than we had expected.
 I have learned that cooking requires a significant amount ofwater.
Need to actually Cooking stockpiled food was time-consuming due tocook and know
unfamiliarity.
the cooking
 It was difficult to understand the setup without actuallyprocess (4)having cooked.
The presence of Enough cooking space was available because there were noresidents makes
residents nearby.
the tasks more It would be more difficult to secure space if there werechallenging (3)residents.
 When there are residents, more things need attention.
Good Communication among staff was good.
communication
 A generous attitude is required in times of disaster, whenamong staff (2)people tend to be tense.
Others (7) Due to the inability to wash, there were many more disposable containers and muchother waste than expected.
 I felt the necessity of considering the placement of garbage disposal areas.
 I found it easy to prepare.
 Roles need to be shared to prevent food poisoning.
 Need someone who can give directions.
 It was uncomfortable to work in the absence of sounds that are usually taken for
granted (e.g., the sound of the TV).
 I thought that in times of disaster, just having a radio or other sound would becalming.
aResponses to the following two questions were analyzed using the KJ method: ‘Please write your observations
and impressions of cooking stockpiled foods’ and ‘How did you feel about preparing meals when water was notavailable?’ There were 11 respondents (3 trainees and 8 observers), and 67 cards were extracted. The opinions of
the trainees are underlined.
b
The number of cards in each category.
and “others” (3). The subcategory “served meals weredifficult to eat” received the most responses (12), withcomments such as “porridge jelly was hard and caused
a lot of choking” and “powdered miso was notdissolved perfectly.” Challenges also included

3.3 Meal service
Table 6 lists the results for meal service. A total of
31 cards from 14 respondents were divided into threemain categories: “there were problems with eating”(22 cards), “there were no problems with eating” (6),119Lessons from a meal service training at a nursing home
unfamiliar tableware usage and low lighting, such as“residents seemed to struggle to use disposable
tableware,” “it was hard to see whether there waswater in the paper cups,” and “meals eaten in the dark
were less tasty.” However, a few comments indicatedno problems with eating. Suggestions for
improvement included “more lanterns should beused” and “miso soup should be served in usual paper
cups.”

4.1 Dealing with the electricity outage
Our findings highlight the significance of adequate
lighting for the smooth transportation of supplies andwell-lit conditions for assisting with eating and fully
appreciating the taste of meals. These findings are
consistent with those of Tachibana and Sudo [12], whoemphasized the necessity of lightning for hazard
prevention, seasoning, and food hygiene. They notedthat insufficient lighting could diminish the appeal of
the food and hinder stain detection when cleaningutensils and tables. To address issues during electricity
outages, lighting sources such as headlights andlanterns should be stored and emergency supplies
should be placed in rooms with daylight for easy
retrieval [17]. Furthermore, supply transportation andmeal consumption should be planned during daylight
hours.

DISCUSSION
This study identified disaster preparedness issues
related to meal service in elderly care facilities
through practical training conducted in a special
elderly nursing home. This is the first study to reportfindings on meal service training in an elderly carefacility. Various challenges related to darkness,cooking processes, hygiene management, and menu
composition were identified.

Table 6. Comments on meal servicea
Main category
Subcategory
Examples of cards
There wereServed meals were Porridge jelly was hard [3].c
problems withdifficult to eat (12)
 Porridge jelly was hard and caused a lot of choking.
eating (22)b
 The porridge jelly was not suitable for those with difficultychewing or swallowing.
 Porridge jelly provision was called off.
 The canned beans looked hard.
 Adjusting the hardness of the porridge jelly seemedchallenging.
 Powdered miso was not dissolved completely.
Supplied disposable  It was difficult to scoop the miso soup from the bottom of thetableware was hard
suppled cup when thickening.
to use (6) When residents ate by themselves, they seemed to struggle touse tableware.
 Due to the miso soup cup’s tendency to become flexible,
residents seemed to struggle with handling it [2].
Difficult to eat
 For visually impaired residents, I believe eating was
because of darkness
particularly difficult.
(4) I thought it was hard to perceive taste when eating in the dark.
 It was hard to see whether there was water in the paper cups.
 It seemed difficult to see foods and residents’ mouth.
There were no
Residents seemed I was surprised at the feedback regarding the taste.
problems withto eat well (2) It was reassuring to see residents eating well.
eating (6)Eating was as usual  There appeared to be minimal differences from the usual.
(2)
Residents used
 Initially, residents looked curiously at their meals anddisposable
tableware, but gradually became accustomed to them.
tableware well (2) Residents used disposable tableware well.
Others (3) More lanterns should be placed.
 Paste meals were prepared smoothly since they usually make them.
aThe responses to ‘please write your thoughts and insights of meal assistance’ were analyzed using the KJ method.
There were 14 respondents (7 trainees and 7 observers), and 31 cards were extracted. The opinions of the trainees
are underlined.
b
Number of cards in each category.
cNumber of specific examples of cards with similar content.
120

Asian Journal of Dietetics 2023
verifying the suitability of the stockpiled food forresidents through training. Yamazoe and Naito
reported a real-life case in which an elderly woman
with poor masticatory function choked on a rice ball,nearly resulting in fatality [24]. Although access toappropriate forms of food was essential for protecting
the lives of the elderly, in earthquake-affected areas,adjusting the form of the food was difficult because
machines were unusable owing to power outages.
Consequently, there was a greater need for appropriate
food for people who have difficulties in swallowing
and chewing [25]. However, large quantities of special
dietary foods are difficult to obtain after a disasterbecause they are made-to-order and manufacturers
typically do not maintain stock [26]. Therefore, it isessential to select food items that match residents’chewing and swallowing abilities and stockpile a twoweek supply in advance.

4.2 Improvement of the cooking process
Regarding meal preparation, the most frequentcomment (n = 26, 39%) was that cooking processes
need improvement, with specific concerns about the
installation and handling of cassette stoves and thepoor arrangement of boiling water (Table 5). Adequate
spacing is required when setting up multiple cassettestoves to prevent fires [17]. However, even nationalguidelines that present cassette stoves as alternative
heat sources [6, 18] do not describe safety precautions
for their use. The participants’ awareness of theimportance of careful handling of cassette stoves wasa valuable training outcome. Furthermore, judicious
gas use is paramount because it is essential for
improving meal quality [19] and for heating foods
such as cold rice and bread [18].Selecting
appropriately sized pots [17] and using lidded pots is
recommended.
Observers also mentioned that preparing
individually packaged miso soup was time-consuming
and labor-intensive (Table 5). While individual
packaging simplifies distribution [20], during ourtraining, miso soup was prepared for all residents inthe kitchen, resulting in an increased workload, suchas opening the bag and adding miso powder. For massfood preparation, individual packaging may notalways be convenient. Hence, it is essential to use theitems and assess the effort and time required to cook
before selecting stockpiles.

4.5 Considering the storage space for the
garbageThrough training, the participants realized theimportance of waste storage and the unexpectedly
high volume of waste (Table 5). This is consistent withthe findings of previous training on preparing andeating emergency food [10]. Waste accumulation has
been a persistent issue during past disasters. For
example, after Typhoon Haiyan, waste remained
uncollected in evacuation centers even two weeks
after the disaster, leading to health concerns [27].
Moreover, the quantity of garbage in disaster-affectedareas and fly density were positively related, which
can be attributed to the accumulation of organic waste
and large-scale food supply [28]. Indeed, someguidelines have emphasized the necessity of securing
waste storage spaces and implementing pest control
measures [6, 17]. However, only a quarter of thenursing homes in disaster-prone areas of Japan havesuch plans [9]. Disseminating case studies of training
exercises, such as in this research, is crucial for
promoting awareness of the importance ofconsidering waste storage.

4.3 Hygienic cooking during water interruption
The second most common comment regarding
meal preparation was related to hygiene (n = 14,21%). The participants found it difficult to maintainhygiene during water supply interruptions. Tokuda etal. also reported difficulties in maintaining thehygiene of food and hands of cooks at evacuation
centers without a water supply [21]. Because older
adults have reduced infection resistance capabilities[7], particular attention to hygiene management isrequired in long-term care facilities. Therefore,
stockpiles of alcohol sanitizers, wet tissue, anddisposable gloves are required to ensure hygienic
cooking and eating even when the water supply is cut
off [17].
Interestingly, all comments on hygiene were madeby the observers. Previous research have noted thatfood handlers tend to overestimate their food safety
practices [22, 23]. Observers may be more likely thantrainees to notice hygiene problems during cooking.
Hence, feedback from observers and objective
reviews of video recordings of training sessions canbe effective in enhancing hygiene practices.

4.6 Limitations
The findings have limited generalizability as thisstudy reported a single training session at a single
facility. Because BCPs should be tailored to thesituation of each facility [6], the suggested
improvements may not necessarily apply to otherfacilities. However, because many facilities
experienced water, electricity, or gas supply
interruptions after the Great East Japan Earthquake[29], the difficulties caused by their unavailability, as
considered in this study, may also apply to otherfacilities.

4.4 Menu improvement
During training, rice porridge jelly was not offeredbecause of its hardness, which poses a risk of choking(Table 6). This underscores the importance of121

Lessons from a meal service training at a nursing home
ACKNOWLEDGEMENT
We express our sincere gratitude to everyone who
cooperated in the training and questionnaire surveys.
This work was supported by the 2020 Grant-in-Aid for
Scientific Research (KAKENHI) (issue number:
19K11190). There are no conflicts of interest thatshould be disclosed in relation to this research.

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ummary_of_results.pdf
3. Van Aalst MK. The impacts of climate change on
the risk of natural disasters. Disasters 30(1): 5-18.
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paper on disaster management FY 2011, Appendix
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earthquake and the great Hanshin-Awaji
earthquake [by age group and sex] [Internet]. 2011
(cited 2023 Dec 29). Available from:https://www.bousai.go.jp/kaigirep/hakusho/h23/bo
usai2011/html/honbun/2b_sanko_siryo_06.htm (inJapanese)
5. Reconstruction Agency. Number of disasterrelated deaths in the Great East Japan earthquake(Survey Results as of March 31, 2023). [Internet].
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Ministry of Health, Labour and Welfare.
Guidelines for work continuity at nursing carefacilities and establishments when natural disasters
occur [Internet]. 2020 (cited 2023 Dec 29).
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7. Strausbaugh LJ. Emerging health care-associatedinfections in the geriatric population. Emerg Infect
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issues in the FY2021 revision of long-term carecompensation [Internet]. 2021 (cited 2023 Dec 29).
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21. Tokuda K, Kunishima H, Gu Y, et al. A survey
conducted immediately after the 2011 Great East
Japan earthquake: evaluation of infectious risks
associated with sanitary conditions in evacuation
centers. J Infect Chemother 20(8): 498-501. 2014.
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9(3): 111-118. 2022.
25. Harada M, Ishikawa TK, Tsuboyama KN.
Analysis of necessary support in the 2011 Great

East Japan earthquake disaster area. Int J Environ
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123

Asian Journal of Dietetics 2023

Original
Current Status of Nutrition Education by Nutrition Teachers in A Prefecture in Japan
Mina Misawa1, Saiko Shikanai1, Masako Sato2
1

Faculty of Health Sciences, Aomori University of Health and Welfare, Aomori 030-8505, Japan
2
Executive Officer, Aomori School Lunch Association, Aomori 030-0132, Japan
ABSTRACT Background and purpose. Shokuiku (Japanese diet and nutrition education) in
schools is given by nutrition teachers has been expanded nationwide. Reports and informationfrom nutrition teachers in A Prefecture are limited. Methods In this study, we conducted a selfadministered questionnaire to nutrition teachers to ask about the current status of nutrition
education. Results. Forty-seven subjects responded (a response rate of 47.5%). Of these, 39.5%
were managing school lunch and nutrition education independently, and 79.1% were in chargeof multiple schools. Regarding the amount of time secured for nutrition education, 67.4% in
the home school and 44.2% in the receiving school had enough time to achieve their nutrition
education goals. However, 60.5% of teachers wanted to have more time for nutrition education.
Conclusion. The results of this survey suggest that nutrition teachers do not have sufficient time
to give classes about nutrition education and to give activities related to it. It seemed that there
were three reasons. First, most of the teachers manage school lunch independently, or twoteachers are in charge of multiple schools. Second, there is a possibility that nutrition teachers
are not able to secure enough time for nutrition education in the receiving schools. Third, we
found that many nutrition teachers wanted to implement more nutrition education.
Keywords: Shokuiku, Nutrition education, nutrition teacher

INTRODUCTION
Until the late 1960s, shokuiku in Japan focused on
improving the nutritional standards of the populationand improvements in nutritional status and dietary
habits were achieved. Currently, the focus has shiftedto preventing lifestyle-related diseases and improving
the quality of life, which requires ongoing shokuiku
focusing on the characteristics of each life stage, social
background, actual nutrition and dietary habits. And
nutrition teachers played this role in school.
In Japan, the School Lunch Program Act included
educational elements to cultivate desirable dietary
habits in 2005 (1). At the same time, diet and nutrition
teacher position was established to promote nutrition
education in schools. There are currently two types ofnutrition teachers. One is called diet and nutrition
teachers who are responsible for school lunch
management and teach nutrition education bythemselves. The other is called school dietitians who
are mainly responsible for the school lunch
management.
According to a survey conducted by the Ministryof Internal Affairs and Communications on the
promotion of shokuiku, "The number of nutrition
teachers is small, and the teachers are often
overburdened. Our school nutrition teachers go tomultiple schools to provide nutrition education. They
are also busy managing and operating school lunch
centers: the facilities that prepare school lunches anddeliver them to multiple schools. We would like to see
more nutrition teachers hired (3)”. From that survey,
the same reason and the same factors might be
explained why the class of nutrition education by
nutrition teachers has not been given in all schools in
A Prefecture. In addition, since reports andinformation from nutrition teachers in A Prefecture arelimited and almost non-existent, we decided to
conduct this survey to determine the current status ofnutrition education in elementary and junior highschools.
MATERIALS AND METHODS
Subjects and Survey Period
The subjects of this survey were nutrition teachers
at elementary and junior high schools in A Prefecture
who consented to participate in the study. A selfadministered questionnaire on "School lunch andnutrition education" was sent by mail in January andFebruary of 2022. Forty-seven subjects completed thequestionnaire, resulting in a response rate of 47.5%.
The self-administered questionnaire on "School
lunch and nutrition education"
The questionnaire was divided into five items(Table 1). Some of the questions were modified basedon a previous study by Yokoyama et al. (4)*To whom correspondence should be addressed:
2182002@ms.auhw.ac.jp

125

Nutrition Education by Nutrition Teachers
Table 1 List of questions
Items

Variables
1. Area
2. Job title
3. Place of work
4. Main place of work

I.

Basic attributes

5. The number of coworkers who are dietitians and nutritionists in the workplace
6. Having schools other than the home school and the number of schools otherthan the home school
7. The number of schools and students per survey participants in charge
8. The number of visits to schools per year
9. Years of experience

II.

About nutrition
education during
school lunch
period before theCorona epidemic

III. About thenutrition
education

10. Whether visiting school lunch period
11. The number of visits and staying time per visit
12. Things observed during visits
13. The number of classes when visited
14. Whether or not all classes could be visited during the school year
15. The degree of focus on nutrition education at the schools
16. The opportunities for their activities and the degree of involvement
17. The number of schools in which on nutrition education classes were given
during class lesson,
18. The number of lessons times on nutrition education was given during classlessons,
19. The number of lessons times on nutrition education was given during out-ofclass lessons,
20. The number of classes given,

IV. About theactivities related
to nutrition
education in 2021

21. The prioritization of the six objectives in nutrition education,
22. The number of subject classes in which survey participants were given
nutrition education,
23. The involvement during nutrition education,
24. The background of how survey participants accepted the request for nutrition
education,
25. The evaluation methods after nutrition education,
26. Whether sufficient opportunities for nutrition education,
27. Whether survey participants want to increase time on nutrition education
should give

V.

Free description

28. In an open-ended question, we asked the survey participants what they
thought were the challenges to “teaching about nutrition education”

Method of analysis
We analyzed 43 survey participants (91.5% valid
response rate) who were in charge of nutrition
education. The statistical analysis package IBM SPSSver. 29 for Windows (IBM Corporation) was used.

Ethical considerations
This study was conducted with the approval of the
Research Ethics Committee of Aomori University of
Health and Welfare (approval number 21086).

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Asian Journal of Dietetics 2023
RESULTS
I. Basic attributes
The survey participants in this study were from thefollowing areas of Aomori Prefecture: To-sei (11),Kami-Kita (10), Sanpachi (8), Sei-Hoku (7), Chu-nan(6), and Shimo-Kita (1). The job titles were 23 diet andnutrition teachers and 20 school dietitians.
The place of work was 27 (62.8%) at school lunch

centers, 9 (20.9%) at elementary schools, 4 (9.3%) atjunior high schools, and 3 (7.0%) at special education
schools. The main place of work was 35(81.4%) at
school lunch centers, 3(7.0%) at junior high schools,
and 2 (4.7%) at elementary or special support schools.
Those who didn’t have coworkers were 17 (39.5%).
And 34 (29.1%) were in charge of multiple schools.
Basic attributes are summarized in Table 2.

Table 2. I. Basic attributes (n=43)
Variables

Variables

1.Area4.Main place of work

To-sei11(25.6)

Elementary school

2

(4.7)

Chu-Nan6(14.0)

Junior High School

3

(7.0)

Sei-Hoku

7(15.9)

School lunch centers35(81.4)

Kami-Kita

10(22.7)

Special education schools

2

(4.7)

Sanpachi8(18.2)

Shimo-Kita

1

(2.3)

2.Job title

No answer
1(2.3)
5.The number of coworkers who are dietitians
and nutritionists in the workplace(Including Survey Participants)
Alone

17

(39.5)

Two9(20.9)

Diet and nutrition teachers

23(53.5)

Three

6(14.0)

School dietitian20(46.5)

Four

5(11.6)

Five

2

(4.7)

Six

3

(7.0)

No answer

1

(2.3)

3.Place of work
Elementary school9(20.9)

Junior High School

4

(9.3)

School lunch centers27(62.8)

Yes

34(79.1)

Special education schools

3

(7.0)

No

7

(16.3)

No answer

2

(4.7)

6.Having schools other than the home school

Data are shown in n (%)

The number of schools and students per survey
participants in charge were summarized by elementary
schools, junior high schools, and a total number ofschools. The average number of schools per survey
participants in charge were elementary schools as
9.0±10.6 schools, junior high schools as 4.3±5.1
schools, and total number of schools as 13.1±12.3
schools. The average number of students per survey
participants in charge were elementary schools as2242.3±3327.2 students, junior high schools as
964.4±1631.4 students, and a total number of students
as 3182.6±3676.8 students.
The majority of nutrition teachers work in multiple
locations: they manage and supervise school lunch at
the school lunch center, have a "home school" where
they work primarily as a nutrition teacher, and also

provide nutrition education at a “receiving schools”
that receive school lunches from the school lunch
center. The number of visits per year to the homeschool was 64.8±76.5 times and to the receiving
schools was 13.1±13.4 times.
The mean number of years of experience was
19.2±12.2 years.
II. About nutrition education during school lunch
period before the Corona epidemic
The question is about nutrition education during
the school lunch period. We asked about the status
before the Corona epidemic, because after the Corona
epidemic started there were times when school lunch
was not provided due to school closures, and direct
visits to schools and classrooms were limited.

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Nutrition Education by Nutrition Teachers
The survey participants who visited during theschool lunch period were 38 (88.4%). The average
number of visits per year, the staying time per visit,
and the number of classes when visited were
65.8±75.9 times/year, 1.7±15.1 minutes/visit, and
5.1±4.8 classes/visit in the home schools. In thereceiving schools, number of visits was 7.1±10.1
times/year, the staying time per visit was 15.0±15.5
minutes/visit, and the number of classes when visitedwere 3.6±3.8 classes/visit. Regarding whether survey
participants visited all the classes during the school
year, 81.6% in the home school and 28.9% in thereceiving schools. The number of visits per year was
given as 36 visits/year for those who answered "oncea week" and 180 visits/year for those who answered"every day". We excluded those who answered “allclasses” without a specific number because thespecific number was unknown (Table 3).

Table 3. II. About nutrition education during school lunch period before the Corona epidemic (n=43)
10. Whether visiting school lunch periodYes38(88.4)

No

4

(9.3)

No answer

1

(2.3)

14.Whether or not all classes could be visited duing the school year
Home Schools

Receiving Schools

Can visit all classes

31(81.6)

11(28.9)

Cannot visit all classes

7(18.4)

16(42.1)Can visit all classes in part of school

-

(-)

6

(15.8)No Answer

-

(-)

5

(13.2)

Data are shown in n (%)

III.About the nutrition education
We asked about the current status of nutrition
education. Schools that were "very" or "fairly" focusedon nutrition education accounted for 86.0% of schools(Table 4). Those who were responsible for more than
one school were asked to select the situation thatapplied most often to their school.

Table.4 III.-15. The degree of focus on nutrition education at the schools (n=43)
Very focused

8(18.6)

Fairly focused29(67.4)

Not focused

5(11.6)

Not working

1

(2.3)

Data are shown in n (%)

schools were mainly involved in preparing lessonplans (55.8%), teaching in subject classes (51.2%),
and publishing newsletters (51.2%). Many of the othersurvey participants only provided materials andinformation, and fewer than 3.0% of the survey
participants said they were not involved (Table 6).
Other activities in both the home schools and thereceiving schools included committee activities,
morning meetings, school lunch tastings, and uniquenutrition education activities (elementary and middle
school collaborations).

The opportunities for their activities and the degreeof involvement were asked in 10 categories. In theirhome schools, more than half of the survey
participants were mainly involved in preparing overallplans for nutrition education (60.5%), preparing lessonplans (62.8%), teaching in subject classes (55.8%),
teaching at lunch period (60.5%), and publishingnewsletters (76.7%). Many of the other survey
participants only provided materials and information,and fewer than 5.0% of the survey participants
responded that they were not involved (table 5). Morethan half of the survey participants in the receiving

128

Asian Journal of Dietetics 2023
Table 5. III.-16. The opportunities for their activities and the degree of involvement in the home schools(n=43)
The
opportunities
The degree of involvement
for their
activities
Involved in
activities

Mainlyinvolved

Providedmaterials andinformationNot
involvedNo
answerPreparing overall plans of nutrition
education29(67.0)

26(60.5)

3

(7.0)

0

0.0

-

(-)

Preparing lesson plans

29(67.4)

27(62.8)

1

(2.3)

1

(2.3)

-

(-)

Teaching in subject

30(69.8)

24(55.8)

4

(9.3)

2

(4.7)

-

(-)

Teaching at lunch period

35(81.4)

26(60.5)

7(16.3)

1

(2.3)

1

(2.3)

School event

11(25.6)

4

(9.3)

5

(11.6)

1

(2.3)

1

(2.3)

Parent-teacher meeting

4

(9.3)

1

(2.3)

3

(7.0)

-

(-)

-

(-)

Publishing newsletters

35(81.4)

33(76.7)

1

(2.3)

1

(2.3)

-

(-)

Homepage and E-mail5(11.6)

-

(-)

2

(4.7)

-

(-)

3

(7.0)

Individual counseling10(23.3)

6(14.0)

4

(9.3)

-

(-)

-

(-)

Other

9

(21.0)

6(14.0)

1

(2.3)

-

(-)

2

(4.7)

Data are shown in n (%)
Table 6. III.-16. The opportunities for their activities and the degree of involvement in the receiving
schools (n=43)
The
opportunities
The degree of Involvement
for their
activities
Involved in
activities

Mainlyinvolved

Providedmaterials andinformationNot
involvedNo
answerPreparing overall plans of nutrition
education9(20.9)

4

(9.3)

5

(11.6)

-

(-)

-

(-)

Preparing lesson plans28(65.1)

24(55.8)

2

(4.7)

1

(2.3)

1

(2.3)

Teaching in subject

27(62.8)

22(51.2)

3

(7.0)

1

(2.3)

1

(2.3)

Teaching at lunch period

18(41.9)

12(27.9)

5(11.6)

1

(2.3)

-

(-)

School event

6(14.0)

3

(7.0)

3

(7.0)

-

(-)

-

(-)

Parent-teacher meeting6(14.0)

3

(7.0)

3

(7.0)

-

(-)

-

(-)

Publishing newsletters

29(67.4)

22(51.2)

5(11.6)

1

(2.3)

1

(2.3)

Homepage and E-mail

3

(7.0)

-

(-)

3

(7.0)

-

(-)

-

(-)

Individual counseling7(16.3)

5(11.6)

2

(4.7)

-

(-)

-

(-)

Other

4

(9.3)

2

(4.7)

2

(4.7)

-

(-)

-

(-)

Data are shown in n (%)

129

Nutrition Education by Nutrition Teachers
IV. About the activities related to nutrition
education in 2021
The average number of schools for which survey
participants were given nutrition education was
5.8±4.5 for elementary schools and 2.0±2.1 for juniorhigh schools. The average number of lesson times onnutrition education during classes were 5.0±8.7 at thehome school, 14.4±9.4 at the receiving elementary
school, and 3.4±3.6 at the receiving junior highschools. The average number of lesson times onnutrition education during out-of-class lessons were
7.8±30.2 times at the home school, 2.1±6.3 times at
the receiving elementary schools, and 0.46±1.2 times

at receiving junior high schools. The average numberof classes taught were 4.3±3.4 at the home school,
17.3±12.7 at the receiving elementary schools, and
4.6±4.8 at the receiving junior high schools.
When survey participants were asked 26. Whether
sufficient opportunities for nutrition education, 67.4%
in their home schools and 44.2% in their receiving
schools responded that they had enough time toachieve their nutrition education goals (Table 7).
When asked 27. Whether survey participants want
to increase the time on nutrition education, 60.5% of
the survey participants responded that they would
like to do so (Table 8).

Table 7. IV.-26. Whether sufficient opportunities for nutrition education (n=43)
Home Schools

Receiving Schools

Most of schools are sufficient29(67.4)

19(44.2)

Most of schools are not sufficient7(16.3)

7(16.3)

Some schools are getting sufficient and some are not sufficient

1

(2.3)

11

(25.6)

No answer

6(14.0)

6(14.0)

Data are shown in n (%)

Table 8. IV.-27. Whether survey participants want to increase the time on nutrition education(n=43)
Yes

26(60.5)

No13(30.2)

No answer

4

(9.3)

Data are shown in n (%)
V. Free description
Survey participants were asked to write freely
about issues related to the context of nutrition
education, which can be divided into seven maincategories.
(1) Difficulty in balancing school lunch service
management and nutrition education due toinsufficient staff and heavy workload(2) Difficulties in collaborating with other teachers onnutrition education(3) Difficulties due to physical distance from theschool(4) Insufficient response from children and families(5) Difficulty securing classroom time(6) Need for opportunities to study teaching methods
and ICT environment(7) Other
The above categories indicate the difficulties thatnutrition teachers face in their work, as well as thepossibility of expanding their activities in the future.

DISCUSSION
The results of this survey suggest that nutrition
teachers do not have sufficient time to give classes
about nutrition education and to give activities related
to it. It seemed that there were three reasons.
The first is that most of the teachers manage
school lunch and nutrition education independently or
two nutrition teachers. And about 80% of the nutrition
teachers are in charge of multiple schools (Table 2).
School lunch must be provided almost every day that
school is in session, leaving little time for nutrition
education. In addition, many teachers work primarily
at school lunch centers and are required to move totheir home school or receiving school to give nutrition
education. This would be easier if the school lunch
center and school were next-door, but most schools
require more than 30 minutes’ drive. It makes difficult
to give nutrition education and related activities.
Second, about 70% of teachers at their home130

Asian Journal of Dietetics 2023
school and about 40% at their receiving school
answered that they had enough time to achieve theirnutrition education goals. Therefore, there is apossibility that the receiving schools are not able tosecure enough time for nutrition education. This was
also reflected in the numerical values, with differences
observed in the amount and content of activities(Tables 3, 5, and 6). In particular in terms of activity
content, the involvement of nutrition teachers in thecreation of overall plans remains at 20% in receiving
schools. This suggests that nutrition teachers do notplay a central role in the receiving schools.
Third, about 60% of teachers wanted to have moretime for nutrition education than they currently have
(Table 9). In addition, some teachers answered “no” inthe open-ended question, because it would be difficult
for them to devote more time to teaching. As a result,
we found that many nutrition teachers wanted to
implement more nutrition education.
These results were also stated in the report by the
Ministry of Internal Affairs and Communications(MIC) (3). In other words, it was seen that even in A
Prefecture. Nutrition education by nutrition teachers,
which has been cited as a nationwide issue, was not
sufficiently obtained. This may be due to the fact that
there are few nutrition teachers, and each nutrition
teacher is responsible for a large number of tasks andthe number of schools they are in charge of. However,
we have heard many requests from schools that havegiven nutrition education and want nutrition teachers
to give a class. This is because teachers in the homeschool and receiving school are convinced that thenutrition education will be more impressive if the classis taught by the teacher who prepares the school
lunches.
In the future, we will continue to investigate what
nutrition teachers can do to secure time for nutrition
education.

ACKNOWLEDGEMENTS
We thank Mrs. Sato, the diet and nutrition teachersand school dietitian who participated in this study,
Professor Nobuo Yoshiike and Professor Terumi
Kogawa who gave advice on this study and we also
would like to thank Professor Andrew Durkin,
Professor Emeritus of Indiana University, for editing
the English version of this paper.
REFERENCES
1. Ministry of Education, Culture, Sports, Scienceand Technology. School lunch program act.1954.
(2023/8/30)
2. Ministry of Agriculture, Forestry and Fisheries.
Basic act on shokuiku (Food and Nutrition
Education). 2005. (2023/8/30)
3. Ministry of Internal Affairs and Communications.
Shokuiku no suishin ni kannsuru annke-to chousa
kekka houkokusho (Gakkou, jidou oyobi
hogoshahen) [Report on the Results of the"Questionnaire Survey on the Promotion of
Nutrition Education" (Schools, Children, andParents).] 2015. (2023/8/28) (in Japanese)
4. Yokohama, K., & Kazuko, M. A Study on thecurrent status of dietary education and involvementof Yogo teachers at elementary school in
prefecture A. Tokyo: Japanese Association of
Health and Education. 2013. (in Japanese)
5. Ministry of Agriculture, Forestry and Fisheries.
The fourth basic plan for the promotion of
shokuiku (Food and Nutrition education). 2021.
(2023/8/30) (in Japanese)131

Asian Journal of Dietetics 2023

Original
Effectiveness of peptide based oral nutrition supplement to improve gastrointestinal
intolerance among patients in Hospital Kuala Lumpur: The E-PEG Study
Jayvikramjit Singh MS1, Basmawati Baharom1, Zamtira Seman2, Leow Chooi Wah1, Norsuhaila Sha’ari1
1

Department of Dietetics and Food Service, Hospital Kuala Lumpur, Malaysia
2
National Institutes of Health, Selangor, Malaysia

ABSTRACT Background and purpose. Gastrointestinal intolerance (GI) remains a challenge indelivering optimum nutrition support for patients receiving enteral nutrition. Role of peptide-based
products (PBP) has shown clinical benefits in improving intolerance. The objective of this study
was to determine whether a novel peptide based oral nutrition supplement will help to reduce thegastrointestinal intolerance among hospitalized patients at Hospital Kuala Lumpur. Methods. This
retrospective study used data of patients seen by Dietitians in 2022. Descriptive analysis was used todescribe patient characteristics, prevalence of GI intolerance and reduction of GI intolerance after
PBP usage. The changes of GI intolerance score between baseline and after were assessed using
the Wilcoxon Signed Rank Test stratified by PBP group. A p-value of < 0.05 was set as the cut-off
for statistical significance. Results: A total of 132 patients were recruited for this study; only 80
patients (60.6%), remained on PBP until end of study. Indications for PBP usage was mainly for
GI Intolerance 58 (60.4%) and unspecified indication 21 (60%). Significant association was
between calorie intake (p=0.047), % of PBP energy consumed from total requirement (p= 0.044),
reduced frequency of diarrhoea (p= 0.018) and lower gastric residual volume (p< 0.000). Therewas significant association (p<0.001) between resolved GI Intolerance and usage of PBP till endof study. Conclusion. This study describes that PBP is significantly effective in helping patientsachieve their energy requirements and reduction in frequency of GI intolerance. However, larger
clinical studies are required to yield better in the future.
Keywords: Peptide based product, gastrointestinal intolerance, enteral nutrition, diarrhoea, gastricresidual volume
surgical removal of a portion of the GI tract). Patientswith impaired GI function have reduced ability to digest
and absorb nutrients and need appropriate nutritional
support (4-6).
Patients with GI intolerance are usually unable totolerate oral nutritional supplements (ONS) containing
whole protein or long chain triglycerides and require a
product containing hydrolyzed protein and medium chain
triglycerides. These products reduce the need forhydrolysis of protein by the brush border peptidases in
the intestinal lumen and are more easily absorbed (7-9).
Peptide-based products contain protein that ishydrolyzed or pre-digested into peptides of different sizeand lengths. Peptide based formulas are commonly high inprotein. These products are easier to digest as protein ishydrolyzed into small chain peptides. Hydrolyzed or
peptide-based protein systems help improve absorption
and tolerance compared to protein systems composed
entirely of free amino acids or intact protein (8).
Oral nutritional supplements (ONS) have been shown
to be clinically effective in the management of GI

INTRODUCTION
Gastrointestinal (GI) intolerance has always
remained a challenge to patients, caregivers, andnutrition care providers causing a less than optimal
nutrition therapy (1). There are many studies to date that
supports the role of peptide-based products (PBP) in
managing GI intolerance with studies producing
significant reduction in symptoms of intolerance among
patients (2). Additionally, it was shown that prevention
and/or management of GI intolerance with the use of
PBP can also be cost‐effective as it has resulted inminimizing healthcare utilization and cost (3).
GI intolerance can happen in patients with conditions
such as celiac disease, chronic diarrhea, cystic fibrosis,
early enteral feeding, inflammatory bowel disease (e.g.,
Crohn's Disease and ulcerative colitis), malnutrition,
pancreatic disorders (e.g., pancreatitis), pre/postoperative feeding, and short-bowel syndrome (e.g.,*To whom correspondence should be addressed:<jayvikramjit@yahoo.co.uk>

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Peptide based oral nutrition supplement to improve gastrointestinal intolerance

diseases. Specially formulated ONS for GI intolerance
utilize ingredients that may be beneficial in patients withmalabsorption or significant GI intolerance (9). Special
formulas, including peptide-based protein products thatare quickly and efficiently absorbed compared with
intact protein, may help minimize the symptoms of GI
intolerance (10). Additionally, products containing
medium-chain triacylglycerol (MCTs) may provide amore easily absorbable lipid source compared with long
chain triacylglycerol for patients with GI disorders,
including fat malabsorption (11- 13).
Local data from Malaysia research showed thatprevalence of GI intolerance was high gastric residual
volume (GRV) (38%), diarrhea (8.4%), and vomiting(2.9%) among hospitalized patients (14-15). Meanwhile,the information on usage of peptide-based products
among Malaysian hospitalized patients are scarce withthis type of enteral nutrition. Based on this context, thisstudy was conducted to determine whether this type of
product will help to reduce the GI intolerance amonghospitalized patients at Hospital Kuala Lumpur.
The objective of this study was to evaluate theeffectiveness of peptide-based product in treating
patients having gastrointestinal intolerance (GI). The
specific objective was to investigate whether the
improvement and changes of GI intolerance wereassociated with usage of PBP.Methodology

Dietetic Care Notes (DCN) KKM/JDS/DC/OO4/2019
which is the standard documentation form used bydietitians in Malaysia for documenting their nutrition
findings and medical records from the Medical Record
Department. This study used a universal sampling
method that refers to all eligible patients referred andseen by Dietitian that used PBP during 1-year datacollection period (1st January 2022 until 31st
December 2022). Malaysian DCN consists of complete
documented nutrition care process of screening,assessing, planning nutrition intervention andmonitoring for patients referred to dietitians. Variablesof concern analyzed includes nutritional status,
sociodemographic, blood and clinical investigations,
GI intolerance (diarrhea; defined as loose stool of >4
times in a day, abdominal pain/cramping, gas/bloating,constipation and high gastric residual volume; which isdefined as residual of more than 500 ml).
Dietary intake of patients on PBP or polymeric/disease specific product were obtained from medical
records charted by nurses. Height and weight were usedin calculation for body mass index (BMI). A minimumof 5 days follow up of PBP usage by patients was
required in order to get adequate data for analysis andresults in improvements of GI intolerance as according
to Dietitian Key Performance Index (KPI) criteria ontube feeding patients follow up. For patients who weretransitioned from polymeric or standard products to
PBP, the first day of starting PBP will be considered as
Day 1 on product usage and will be followed up for atleast once in 5 days.

MATERIALS AND METHODS
Study Type and Design
This retrospective cohort study used Malaysian

Table 1. Energy and concentrations of protein, carbohydrate and lipid in oral nutritional supplement (/100g)
Per 100g
Energy468 kcalN sources
Hydrolyzed Whey Protein*
21g
Carbohydrate
Maltodextrin
60g
Lipid
Medium Chain Triglycerides Oil
9.6g
Omega 3
1.8g
Omega 60.9g
Evening Primrose Oil
3.7g* The % of hydrolyzed whey protein used
• Large Peptide (7 amino acid residues) 8.61g/100g (41%）• Medium Peptide (4 – 6 amino acid residues) 9.28g/100g (44.18%）• Di and Tri Peptides (2 – 3 amino acid residues) 1.36g/100g (6.46%）• Free Amino Acids 1.73g/100g (8.22%)

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Asian Journal of Dietetics 2023

Study Tool
Oral nutritional supplement which was used in thisstudy is a nutritionally complete, well tolerated andeasily absorbed peptide based formula for patients
experiencing GI intolerance or malabsorption. This
product contains 100% hydrolyzed whey protein. The
fat blend contains 60% medium chain triglycerides(MCT), an easily digested and well absorbed fat
source. The % of MCTs is 60% out of the total fat
content 9.60g/100g. Patients that were recruited in thisstudy were those patients that were prescribed with
PBP. Benefits of PBP was reported based on
improvement or reduction of GI intolerance among
patients after using PBP.
Study Population & Sampling Method
All adult patients seen by dietitians using peptide
based products in Hospital Kuala Lumpur during theperiod of 1st January 2022 until 31st December 2022.
Inclusion Criteria
 All patients referred to dietitian by physicians Aged 18 years and received at least 75% of theirrequirement from PBP.
 Tube feeding patients.
 Minimum of at least 5 days on PBP
Exclusion Criteria
 Patients who transitioned back to polymeric or
disease specific formula Death of patient.
 Medications that cause or induce GI intolerance
 Any malignant disease, psychiatric disorder or
obstruction of GI tract
 Patients consuming a non-UNIMED / British
Biological PBP or existing PBP product.
 Addition of probiotic/prebiotic or any fiber
supplementation
Withdrawal Criteria
Not applicable
Sample Size
We used G*Power version 3.1.9.4 to determine
the required sample size for detecting an
improvement in GI intolerance with a medium effectsize of 0.5, a significance level of 5%, and a powerof 80%. As no information on effect size wasavailable for this particular factor, we chose to use
Cohen's guidelines for effect size interpretation todetermine the target effect size. The sample size
calculation showed that a total sample size of 34
participants is required to achieve the desired level ofpower
Study Visits and Procedures
The data of concern involved patients seen by
Dietitian from 1st of January 2022 until 31st
December 2022. These data were retrieved fromcopies of Dietetic Care Notes (DCN) which was stored
at Dietetic Clinical Store Office. These data of patientsthat were followed up by dietitians from the day ofreferral up to minimum of 5 days of follow up in

Hospital Kuala Lumpur wards. The days of referraland follow ups were within the stipulated time of 1st
January 2022 until 31st December 2022. Dietitians of
Hospital Kuala Lumpur retrieved the data from theDietetic Clinical Store Office and entered thevariables of concern into SPSS for further analysis.
These data collection period commenced from 1st
August 2023 until 31st September 2023.
Statistical Analysis Plan
All data was analyzed using Statistical Package
for the Social Sciences (SPSS, IBM, Chicago, IL)
version 28 Descriptive analysis was used to describe
patient characteristics, prevalence of GI intolerance
and reduction of GI intolerance after PBP usage. Thechanges of GI intolerance score between baseline
and after were assessed using the Wilcoxon Signed
Rank Test stratified by PBP group. Fisher exact test
was applied to determine the association between
resolved status of GI Intolerance and remained on
PBP. A p-value of < 0.05 was set as the cutoff forstatistical significance.
Risk and benefit to study participants
There is no risk and benefit to the participant as
this is a retrospective study which does not involve
direct contact with any patient.
Risk Benefit Assessment
This study can help to determine valuable
insights into association between PBP and GI
intolerance. Treatment using PBP should beconsidered to treat intolerance towards polymeric or
disease specific products which might lead tosignificant improvement in relation to GI intolerance.
Any significant reduction of findings will help in
health care utilization related to nutrition therapy. As
stated above, there is minimal risk from theinvestigated product and study procedures. Study
findings shall potentially greatly improve treatment
outcomes. The expected benefit outweighs theminimal risk to subjects and thus this study should
be supported. If any injuries do occur as a direct
result of participating in the study, treatment for suchinjuries shall be provided or paid for by the sponsor
Ethics of Study
Ethical approval was approved from the Medical
Research and Ethics Committee, Ministry of Health
Malaysia. This research was registered with National
Medical Research Register (NMRR) Malaysia
bearing the registration number of NMRR ID-2302521-U1K. The study was performed in compliancewith the principles of the Declaration of Helsinki, in
accordance with the International Conference ofHarmonization Guideline for Good Clinical Practice,and in accordance with applicable regulatory
requirements.
Informed Consent/Assent Process
Waiver of consent was granted by MREC in viewof retrospective study and no patient / participant
contacts.

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Peptide based oral nutrition supplement to improve gastrointestinal intolerance

Privacy and Confidentiality
Subject’s names were kept on a passwordprotected database and was linked only with a study
identification number for this research. The
identification number instead of patient identifiers
was used on subject data sheets. All data will beentered into a computer that is password protected.
On completion of study, data in the computer wascopied to thumb drives and the data in the computererased. Thumb drives and any hardcopy data wasstored in a locked office of the investigators andmaintained for a minimum of three years after thecompletion of the study. The thumb drives and data
will be destroyed after that period of storage. The data
will be keep as confidential and monitored byprinciple investigator. All data will bedisposed/destroyed three (3) years upon publishing
this study. Study data will not be shared with any
third party.
RESULTS

Table 2. Description of sociodemographic characteristics (N= 132)
Variable
GenderMale
FemaleAge
Ethnicity
Malay
ChineseIndianOthersBMI Classification
Underweight
NormalOverweight
Obese
Diabetes Mellitus
No
Yes
Hypertension
No
Yes
Dyslipidaemia
No
Yes
Heart Disease
No
Yes
Indication of PBP Usage
Intolerance
Unspecified
Pancreatic Insufficiency
Duration on PBP
Reason for drop out
Lost follow-up
Change product
Death
Discharged
Status of GI tolerance on PBPResolved
Not resolved
Improved
Incomplete
Not Available
 PBP = Peptide Based ProductRemained on PBP until end of study
Yes, n (%)
No, n (%)

Total

46 (63.9)
34 (56.7)
62.0 (22.5)

26 (36.1)
26 (43.3)
67.0 (18.5)

72
60
132

50 (66.7)
16 (50.0)
13 (59.1)
1 (33.3)

25 (33.3)
16 (50.0)
9 (40.9)
2 (66.7)

75
32
22
3

0 (0)
21 (75.0)
5 (45.5)
2 (40.0)

1 (100)7 (25.0)
6 (54.5)
3 (60.0)

1
28
11
5

56 (64.4)
24 (53.3)

31 (35.6)
21 (46.7)

87
45

52 (64.2)
28 (54.9)

29 (35.8)
23 (45.1)

81
51

73 (62.4)
7 (46.7)

44 (37.6)
8 (53.3)

117
15

70 (60.3)
10 (62.5)

46 (39.7)
6 (37.5)

116
16

58 (60.4)
21 (60.0)
1 (100)7.0 (5.0)

38 (39.6)
14 (40.0)
0 (0)
1 (0)

96
35
1
8

0 (0)
0 (0)
0 (0)
0 (0)

48 (100)
2 (100)1 (100)1 (100)48
2
1
1

40 (100)
5 (83.3)
18 (100)0 (0)17 (51.5)0 (0)1 (16.7)0 (0)35 (100)
16 (48.5)

40
6
18
35
33

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Asian Journal of Dietetics 2023

A total of 132 patients were recruited for thisstudy; only 80 patients (60.6%) remained on PBP until
end of study. Among these 80 patients, 46 (39%) weremale while 34 (56.7%) were female. Reasons fordropouts were mainly due to loss of follow ups(36.3%), change of products (1.5%), death (0.8%),
and discharge (0.8%). Indications for PBP usage wasmainly for gastrointestinal intolerance 58 (60.4%) andunspecified indication 21 (60%).

Table 3: Description of association between resolved status of GI Intolerance and remained on PBP till end

Status of tolerance on PBPResolved
Not resolved
Improved
Incomplete
N/A

Total
N/A= Not Available

Remained on PBP until end of study
YES
NO
n
%
n
%
40
50.0
0
0
5
6.3
1
1.9
18
22.5
0
0
0
0
35
67.3
17
21.3
16
30.8
80
100
52
100

In terms of status of GI intolerance in patients who
were on PBP, resolved GI intolerance cases such as
diarrhoea and high aspiration were 40 (50%), while
improved status was 18 (22.5%). Only 5 (6.25%)
patients on PBP GI intolerance remained unresolved
throughout the study period (Table 2). Results from
Table 2 also showed that there was significant

Chisquare

p-value

93.99<0.001

association (p<0.001) between resolved GI
Intolerance and usage of PBP till end of study.
Results from Table 3 showed significant
associations were noted between PBP consumption
with calorie intake (p=0.047), % of PBP energy
consumed from total requirement (p=0.044), reduced
frequency of diarrhoea (p=0.018) and lower gastricresidual volume (p< 0.001).

Table 4. Description of median difference of parameter stratified for those remained on PBP
until end of study.
Remained on PBP until end of study
Variable
Haemoglobin
Total Protein
Albumin
Urea
Creatinine
SodiumPotassium
Calcium
Magnesium
Phosphate
Fasting Blood Serum
Calorie Intake

Before9.25 (2.33)
61.50 (12.25)
18.00 (7.75)
8.60 (16.88)
68.00 (41.50)
139.50 (7.75)
3.55 (1.03)
2.12 (0.25)
0.88 (0.14)
0.81 (0.65)
7.60 (2.83)
1494.00(646.50)
70.80 (32.75)

Yes
After
9.45 (2.25)
61.50 (11.75)
16.50 (6.75)
8.60 (10.28)
59.50 (84.25)
141.50 (9.25)
3.20 (0.45)
2.20 (0.29)
0.90 (0.12)
0.66 (0.64)
7.50 (3.15)

p-value
0.419
0.294
0.579
0.038
0.089
0.651
0.862
0.280
0.046
0.850
0.444

Before8.80 (1.65)
60.00 (8.50)
19.00 (6.00)
6.90 (30.20)
82.00 (54.00)
138.00 (13.00)
3.80 (0.55)
2.40 (0.75)
0.83 (0.17)
0.77 (0.81)
7.20 (6.10)

No
After
8.80 (1.45)
60.00 (8.50)
19.00 (6.00)
6.90 (28.30)
82.00 (54.00)
138.00 (13.00)
3.80 (0.55)
2.40 (0.75)
0.83 (0.17)
0.77 (0.81)
7.20 (6.10)

p-value
0.31730.3173>0.9990.31730.3173>0.9990.31730.3173>0.9990.3173>0.9991551.00 (288.00)

0.047

1464.00 (879.00)

1464.00 (879.00)

0.317360.50 (59.85)>0.999>0.999Protein Intake
71.00 (23.35)
0.123
60.50 (59.85)% PBP Consumed from91.00 (39.00)
93.00 (18.00)
0.044
94.00 (51.00)
total requirement
Frequency of diarrhoea 3.00 (2.00)
2.00 (1.50)
0.018
3.00 (2.00)
Gastric
Residual
160.00 (111.50) 90.00 (123.50)<0.001 110.00 (113.50)
VolumeResults represented for Median (IQR), p<0.05 was considered significant association

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94.00 (51.00)
3.00 (2.00)
110.00 (113.50)>0.999>0.999Peptide based oral nutrition supplement to improve gastrointestinal intolerance

peptide based product among GI intolerance
hospitalised patients. Clinical implications of ourfindings is that transition to peptide based diet from apolymeric or disease specific formula among GI
intolerant patients is a beneficial intervention towards
achieving nutrition therapy goals by improving GI
intolerance among patients with diarrhoea, abdominal
pain/cramping, gas/bloating, constipation and highgastric residual volume.

DISCUSSION
Our study demonstrated that more calories were
tolerated with PBP compared to other ONS products.
This may be due to the fact that this study productcontains higher energy than other standard product.
This study reported a significant association between
PBP consumption with increased calorie intake(p=0.047). It correlates with previous study conductedwhich showed that patients using PBP consumed morecalories compared to other standard products (22).
According to the same study, tolerance of gradualincrement of calorie and protein was better in patients
who received PBP compared with standard product,
allowing for higher percent of increase in calorie andprotein provided between days 3 and 7 after tube
feeding initiation (22).
However, no significant improvement in protein
consumption was found in this study. Our study
showed significant association of reduced diarrhoea(p<0.014) and reduced gastric residual volume(p<0.001) after transition of product from standard to
peptide-based product.
These results were further supported by studies
done by Wang et al, 2022 and Liu et al, 2016 (23, 4).
Literature reviews support the evidence that peptidebased products, such as the study product is effectivein patients having GI intolerance such as diarrhoea
and high aspiration (6, 7, 24-26). Nearly 73% of
patients on PBP showed improvement while using the
product.
Possible cause of improved tolerance to PBP ismainly attributed to the physiological properties of
PBP as a semi elemental formula. PBP contain larger
quantity of MCT oil which does not influence therelease of cholecystokinin; therefore, reducing
secretion of pancreatic enzymes and gallbladderemptying. It also contains hydrolysed whey protein,which may lead to better protein absorption (24). PBP
typically contains a significant amount of medium‐chain triglycerides (MCTs) in comparison withstandard products whose lipid component typicallycontain more long chain triglycerides (LCTs). Thesetypes of fat requires less lipolysis thus ensuring better
absorption and less intolerance (27). Hydrolysed
proteins and more easily digestible fats including
medium-chain triglycerides tend to supply protein andfats to the best suitability of patients with impaired
gastrointestinal function (27).
Limitations of our study was that it has a small
sample size and it was a single centre study. A
prospective intervention study with larger sample size
would yield stronger clinical results. The mainstrength of our study was that the results were similarand consistent with other studies that indicates theeffectiveness of PBP in improving GI intolerance
among hospitalised patients (2, 10, 20).
To the best of our knowledge, this is also the firststudy that has been done in Malaysia involving

CONCLUSION
This study describes that PBP is significantly
effective in helping patients achieve their energy
requirements and had a significant reduction in
frequency of GI intolerance. Further study with large
coverage may give a concrete or better results infutureCONFLIC OF INTEREST
Authors wish to declare there are no conflict ofinterest in this study.
ACKNOWLEDGMENT
The authors wish to thank the Director General of
Health Malaysia for his permission to publish thisstudy and all the team members for their participationin this study.
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Special Report: Asian Young Dietitian Network
1. Purpose of the Asian Young Dietitian Network
Organizer: Asian Nutrition and Food Culture Research Center, Jumonji University,
Ajinomoto Global Communication Department
The Asian Young Dietitian Network (AYDN)
was established with the idea of continuing theworkshop "Let's Talk about the Future of Young
Dietitians in Asia" at the Asian Congress ofDietetics (August 19–21, 2022) (photo). The
central issue was whether the social evaluation of
dietitians was appropriate and, if not, how to
improve it. Simply put, the questions are as
follows: Are dietitians’ salaries high enoughcompared to those of other medical professionals?
Is the dietitian the central figure in providing
dietetic guidance to patients? Are school lunch
teachers in Japan evaluated enough as teachers?
Most of the answers are negative, and there is aneed to consider improvement measures.
One of the reasons why dietitians are notevaluated sufficiently is probably their low
research and information dissemination abilities.
To become a university teacher, research andpapers are generally required. The fact that there
are few faculty members with RD qualifications atuniversities that train dietitians is due to a lack of
research ability. The future of young dietitians is

also uncertain due to the lack of sufficient
education for students who will become RDs in the
future.
The reason there are few studies and papers
on dietetics is probably because people do notrealize that dietetics is a challenging subject. Many
people think that dietetics is a simple science thatinvolves just preparing meals and that there is little
need for research. Is that idea correct? The coreresearch in the field of dietetics is not justknowledge of dietetics and cooking but a wide
range of fields such as medicine, food science,biochemistry, statistics, psychology, sociology,
economics, and philosophy. Dietetics for theelderly is an easy-to-understand example.
Providing delicious food alone is not enough toincrease the appetite of elderly people who have adecreased appetite; it also involves the difficult
task of motivating them to eat. Do we dietitians
have the knowledge and skills to conduct suchresearch? Unfortunately, No. AYDN was created toaddress these issues.

Fig 1. Photo of young dietitian workshop at the 8 th Asian Congress of Dietetics 2020

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Asian Journal of Dietetics 2023

2. The birth of the Asian Young Dietitian Network
Trang Thu Nguyen1*, Andrea Wakita2
1

Jumonji University (Asian Nutrition and Food Culture Research, Japan)
2
Ajinomoto Co., Inc (Global Communication Department, Japan)

In recent years, many Asian countries have faced
common nutritional issues such as “double burden”
and “triple burden” malnutrition. These issues are
significantly impacting the health and well-being ofour populations. One of the factors for these twoburdens is food habits. Dietitians have the capacity andthe skill to educate the population to eat healthily.
However, the recognition of the dietitians’ role insociety varies among Asian countries, some of themworking in national nutritional programs, and in othercountries, dietitians have less participation in the
Government or Universities. Furthermore, the sharingof knowledge and nutritional application of own
countries with other dietitians from Asian countries arelimited. To change these scenarios, it was essential tocreate opportunities for young dietitians to shareknowledge, engage in discussions, and generate newideas. These steps are vital in addressing nutritional
issues in the Asian region. Therefore, we would like toannounce to the readers of the Asian Journal of

Dietetics that in Asia a new young dietitian network
was formally established on December 1, 2023. The
kick-off of the network was conducted with theparticipation of twelve countries in Tokyo, Japan. The
objective of this network is to enhance communication
among dietitians of Asia to improve the nutritional
status of this region and improve dietitians’
reputations1.
To reach the objective of the network, it will focus
on the following three main activities (Figure 1): 1)
Sharing information and experiences about
participants’ country nutritional issues andexperiences they have which could contribute to otherparticipants, 2) Conducting researches and publish
them to an academic journal (Asian Journal of
Dietetics) to increase skills in investigation andresearch to find the problems and solutions in a logicalthinking. 3) Carry out webinars and workshops toincrease scientific and non-scientific knowledge.

Fig 1. Future activities of Asia Young Dietitian Network

Some of the activities were started in November
2023, in Tokyo, such as visiting a hospital and anelementary school to explore the school lunch. These
activities were done to understand the work of
dietitians in Japan and to know the infrastructures ofeach organization to prepare menus for patients orchildren.
Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
The visit was organized by Prof Yamamoto

Shigeru, RD., Ph.D. from Jumonji University. Young
Asian dietitians from the network toured the Nerima
Hikarigaoka Hospital, guided by Japanesecounterparts. They observed the hospital's foodoperations, from arrival to patient service, including
unique technologies like the meal tray retherm system
and various cooking appliances. They had acomprehensive discussion on the Nutrition Care
Process and nutrition management processes
providing insights into the hospital's strategic
approach to addressing patients' nutritional needs.
These discussions could be beneficial for dietitians in
the network participants' respective countries.

*To whom correspondence should be addressed:
trangnn27@gmail.com

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Fig 2. Entrance of the hospital Nerima Hikarigaoka HospitalFig 3. Meal serving method for patients.

Fig 4. Thermograph measuring food temperature
before serving.

Visit to elementary school for school lunch(Funabori Elementary School)
The visit to the elementary school was organized
by Prof. Yamamoto Shigeru, RD., Ph.D. Network
participants toured a Japanese school's kitchen andmeal service, even sampling the children's meals.

School dietitians shared their roles in monitoringchildren's health, educating them on healthy eating,using seasonal foods, and incorporating sustainability
concepts like SDGs. The cleanliness of the cooking
area, akin to a hospital's, is not typically seen in Asian
countries.

Fig 5. School lunch: rice, stir-fried vegetables withshrimp, sweet potato with sauté liver, apple, milk.

Fig 6. The trolley with the leftover food after
lunch was almost none.

143Asian Journal of Dietetics 2023
Kick-off meeting of AYDN
It was conducted at the headquarters of AjinomotoCo., Inc. building. There was a greeting from

Ajinomoto Co., Inc. (Ms. Yoko Ogiwara), Jumonji
University (Prof. Yamamoto), and a representative of
the network (Ms. Nguyen Thu Trang).

Fig 7. Ajinomoto Co., Inc. (Ms. Yoko Ogiwara), Jumonji University (Prof. Yamamoto), and representativeof the network (Ms. Nguyen Thu Trang) (From left to right)
The representative person of each country
introduced the food culture, common ingredients, andnutritional situation in their countries, as well as how
to become dietitians and workplace. Finally, theyBangladesh
SumayaIslam

Bhutan(ONLINE)
Chimi Wangmo

Malaysia
GeorgenThye

Philippines
Marita De
Guzmanshared their expectation in the network. From therepresentative countries, Bhutan representatives could
not come to Japan and, therefore, attended online.

Table 1. Representative of each country
Cambodia
India
Ry Manydine
Naaznin Husein

Sri Lanka
Amal Zaffroon
Firouaw

TaiwanChu Tzu Yun

Indonesia
Wita Rizki
AmeliaJapan
RisakoOkuyamaThailand
SamittiChotsriluecha

VietnamNguyen Thu
Trang

Fig 8. Picture during the Kick-off meeting. Ms. Sumaya Islam introduced the situation in Bangladesh

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Country

Table 2: Summary of the nutritional issues in each country
Bangladesh
BhutanCambodia
India
Indonesia

Japan

Nutritional
issues• Anemia 659 months
old• Anemia(women 1549 y-old)• Foodinsecurity• Diabetes(DBT)• Undernutri • Malnutrition
tion (child)(maternal,• NCDschildren,• Anemia
elderly)(child,• Nonwomen)
communicab• Vitamin A ↓ le diseases• Fruit & Veg ↓ (NCDs)• Salt intake ↑• Malnutrition• Anemia• Obesity• Diabetes• Cardiovasc
ular diseases
andhypertension(HT)• Chronic
EnergyDeficiency
in Women• Malnutriti
on in theelderly andunder 5 yold• Obesity(adult)• Anemia(adult)• NCDs(cancer &heartdiseases)• Obesity(child)• Malnutriti
on (elderly)• Vegetableintake ↓• Salt intake↑

Country

Malaysia

Philippines

Sri Lanka

TaiwanThailand

VietnamNutritional
issues• Overweight& obesity• Malnutrition (child)• NCDs(DBT, HT,hypercholest
erolemia)• Physicalact ↓• Fruits &Vegetable
intake ↓• Stunting• Overweight& obesity• Anemia• Highfasting
blood sugar• Physicalinactivity• Diabetes• Obesity• Anemia(women 15– 49 y-old)• Low Birth
Weight• Malnutrition (child)• Foodinsecurity• Overweight& obesity• Malnutrition (child)• NCDs• Physicalact ↓• Fruits &Vegetable
and milk
intake ↓• Overweight
and obesity• Metabolic
syndrome(adult)• Sarcopeni
a (elderly)• Malnutrition(hospitalized)• PostCovid DBT• Childhood
overweight
and obesity• Malnutrition (child,elderly)• Metabolic
syndrome*Red colored letters: issues that the representative of each country considers as the most important, currently.
From Table 2, we can clearly see the most pressing
issues in each country are quite similar to each otherwith overweight, obesity, and malnutrition withanemia as the center. Most East and Southeast Asia
countries like Malaysia and Philippines focused on
overweight and obesity while South Asian countries
like Bangladesh and Sri Lanka were more heavied on
malnutrition in children. This elucidated the current“double burden” situation in Asia which requires
dietitians in every country to work together toovercome these unbalances.
The network participants, brimming withproactivity and enthusiasm, are eager tocollaboratively enhance their home countries'
nutritional conditions and elevate the status of
dietitians across Asia. While the journey towards our
network's objectives may be long, it is not impossible.
As the authors of this letter, we look forward to seeing
how this network grows and evolves in the near future.

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3. Bangladesh’s Report
Sumaya Islam1 +1

Health and Hope Hospital, Dhaka, Bangladesh

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)Among the several places we visited according to
the Asian Young Dietitian Network (AYDN)
program schedule, the first was Nerima Hikarigaoka
Hospital. Upon entering the hospital, I felt very
inspired by the dedication of the staff and their use ofinnovative technology. I realized that it is a place
where health and well-being are not just aspirations
but a reality enjoyed by all.
The doctor-dietitian-staff coordination, teamwork,and understanding were praiseworthy. The insightfulpresentation on elderly nutrition and care foraspiration pneumonia was very helpful. The practicalstrategies shared were invaluable. We are eager toabsorb and utilize this knowledge in our own country.
The personalized, balanced, and varied meal support
with calorie and nutrient information shows
patient-centric care. The vegetables grown in the
nutrition room were also very inspiring. These
practices encourage healthy eating habits and ensure
everyone receives the necessary nourishment.
We carry the knowledge and inspiration gained at
Nerima Hikarigaoka Hospital with us and arecommitted to applying and sharing this in our own
country.

varied meals are praiseworthy. Their emphasis on
fresh, local food ingredients and some school-grownvegetables is notable. The target for preventing foodwaste is a sign of meticulous planning and portion
control. The student volunteers serving their peers
fostered a sense of community and teamwork. The
dietitian’s engagement in cooking and nutrition
education classes empowered children to makehealthy choices beyond the lunchroom, shaping
positive habits for life.
In Bangladesh, since 2010 Government with WFP
has been investing in the National School Feeding
program in Government primary schools. By 2022,
more than 3 million children in 104 sub-districts had
been reached with fortified biscuits and in the same
location hot meals. The Government is planning toinclude seasonal fruits, eggs, bun, and milk to increase
diversity. Bangladesh Government is a member of the
Global School Meals Coalition.
Finally, as a young dietitian, I left Funabori schoolwith a heart full of inspiration and actionable ideas
which I will share and try to establish in my country.
Kick-off meeting of AYDN
Bangladesh emerged as an independent andsovereign country on 16th December 1971.
According to the 2022 Bangladeshi census, its
population size is 169,828,921. The age structure of
Bangladesh is 0-14 yrs: 26.45%, 15-64 yrs: 67.72%,>64 yrs: 5.83%.
Bangladeshi food is a celebration of deliciousness,diversity, and spice. Influenced by the country's
geography and religion, it revolves around the iconic
saying, "Fish and Rice make a Bengali." It has 260
freshwater and 475 marine fish species alongside a
year-round bounty of fruits and vegetables. Winteradds another layer of delight with its array of delicious
sweet cakes (pitha). Its everyday ingredients are- rice,
fish, pulses, vegetables - and its magic-making
seasonings like salt, turmeric, chili, garlic, ginger, hot
spices (gorom moshla), and the unique five-spiceblend (panch phoron). There are many traditional
dishes in Bangladesh. Among them, the two
mentioned dishes, Panta Ilish and Soft Khichuri/Vuna
Khichuri capture the essence of Bangladeshi cuisine.
Panta –Ilish: Soaked rice forms the base, infused withthe delicate Hilsha fish fry and mashed vegetables. A
touch of salt, onion, green chili, and fried red chili
adds a vibrant spark, making every bitedelightful. This dish has its roots in tradition.
Bengalis celebrate the first day of their calendar withthis dish.

Fig 1. The vegetables are grown in the nutrition
room
Visit to elementary school for school lunch(Funabori Elementary School)
Funabori Elementary School lunch program
combines responsibility, sustainability, and healthyeating habits. The balanced, nutritious (which also
provides a portion of RDA), delicious, free-of-cost,*To whom correspondence should be addressed:
sumaya.shoma@gmail.com

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Asian Young Dietitian Network
 National Strategy on Prevention and Control ofMicronutrient Deficiencies (2015-2024): This
strategy focuses on improving access to diverseand micronutrient-rich foods.
 National Nutrition Policy and National Nutrition
Services
Across various Asian countries, food habits are
intricately woven with culture, history, geography,
weather, and religion. Rice, noodles, bread, fish, meat,and vegetables are the main food items. Countries
geographically close to each other often share a love
for similar spices and seasonings. However, there liesa complex picture of malnutrition: under-nutrition,
over-nutrition, and micronutrient deficiencies. The
prevalence of diet-related non-communicablediseases is also increasing in this region. The types ofmalnutrition and their prevalence differ significantly
across and within countries. Socio-economic
conditions, lifestyle choices, and dietary habits arepotential causes behind this scenario. While shared
food habits paint a unifying picture, the region’sbattle against malnutrition demands an understandingof its diverse forms and underlying causes.
AYDN envisions a future where young
dietitians from across Asia are not only connected but
also empowered to make a difference in the field ofDietetics and Nutrition. AYDN will foster friendshipand knowledge exchange through conferences,
workshops, and online platforms creating a
supportive network for young professionals. AYDN
will participate in collaborative research to address
regional challenges and contribute to global
knowledge.

Fig 2. Bangladesh’s traditional dish: Panta Ilish
Soft Khichuri/Vuna Khichuri: Beyond its role ascomplementary feeding for babies, this Khichuri is a
popular choice for rainy days or a special occasional
meal. Rice and pulses are cooked together withvegetables, while egg, meat, fish, or organ meat likeliver can add depth and protein. The taste is enhancedby the flavors of salt, chili powder, turmeric, cumin,coriander, and a blend of hot spices, ensuring a warmand satisfying experience. While Bangladeshi cuisine
has incredible flavor and diversity, it's crucial toacknowledge the underlying nutritional challenges
faced by the country. These challenges are often mostacute among women of reproductive age and young
children.
Alarming Rates of Nutritional Issues:
 Anemia: 37% of women aged 15-49 suffer fromanemia (1), this translates to immense health risks
for both them and their children.
 Food Insecurity: 24% experienced food insecurity
on average in August 2023 (2).
 Childhood Anemia: The situation is concerningfor younger children, with 43% of those aged
6-59 months experiencing anemia (1).
 Diet-Related
Non-Communicable
Diseases: Bangladesh had 13.14 million diabetes
cases in 2021 (3).
Government Initiatives:
The government of Bangladesh is actively
addressing these challenges through policies andprograms like:

1.

2.

3.

147

REFERENCES
World Health Organization. Global healthobservatory data repository/World Health
Statistics. 2019.
World Food Programme. Bangladesh foodsecurity monitoring, remote household foodsecurity survey brief. 2023.
International Diabetes Federation. Bangladesh
diabetes report 2000-2045. IDF Diabetes Atlas.
2021.

Asian Journal of Dietetics 2023

4. Bhutan’s Report
Chimi Wangmo
Bhutanese dietitians perceive the Asian Young
Dietitian Network (AYDN) as a networking platform
tailored for young dietitians, offering crucial support,
providing resources, and presenting opportunities - allgeared towards fostering professional development for
dietitians from various countries. AYDN is exclusively
designed for young professionals in the field.
Networks of this nature play a vital role in delivering
essential support, resources, and networking
opportunities to facilitate professional growth. The
benefits associated with such networks are diverse,
encompassing information sharing, career guidance,
improved job opportunities, and the overallenhancement of professional skills.
We think AYDN can play a crucial role in shaping
the future of nutrition in several ways:
1. Innovation and Adaptation: AYDN members
bring fresh ideas, innovation, new perspectives,and a willingness to adapt to emerging trends innutrition. These networks serve as platforms fordiscussing and implementing new ideas.
2. Collaboration and Networking: Networking
within AYDN can lead to partnerships, joint
projects, and the sharing of diverse experiences
and insights.
3. Professional
Development:
AYDN
isinstrumental in supporting ongoing professional
development, ensuring that young dietitians stay
informed and updated about the latest research.
This contributes to the continuous improvementof nutritional practices.
4. Mentorship Programs: Establishing mentorshipprograms within these networks can help bridge
the gap between experienced professionals andthose starting their careers. This fosters
knowledge transfers and skill development.
5. Global Collaboration: AYDN can facilitate
global exchanges of knowledge, best practices,and cultural perspectives on nutrition.
Therefore, we think that our country should join
this network. It will facilitate the exchange ofinvaluable knowledge and expertise among emerging
dietitians. Through participation, our country can gain
access to a diverse pool of professionals who can shareinsights, best practices, and innovative approaches tonutrition and dietary challenges. Secondly, it opens
collaborative opportunities on both national andinternational levels. Moreover, the network serves as aplatform for continuous professional development. We
can benefit from workshops, conferences, and training
programs tailored to the latest advancements in thefield. This not only enhances the skills of individual
dietitians but also contributes to the overall
improvement of nutritional practices within the
country.
Kick-off meeting of AYDN
Unfortunately, this time kick-off meeting program,none of the Bhutanese members were able to attend
physically, however, while participating virtually inthe meeting, we gained valuable insights by attentively
listening to our fellows’ presentations. The shared
information was impressive, especially the discussion
on the diverse food cultures they possess—highlighting a stark contrast to our main challenge oflimited food diversification. Furthermore, thesecountries exhibit well-updated data on nutritional
issues, demonstrating a more advanced understandingof nutrition and research, even in the face of larger
challenges and issues.
We also had the opportunity to share our country’s
presentation online. In the initial segment, we
provided an overview of Bhutan—a landlocked
country nestled in the Eastern Himalayas, recognized
for its distinctive development and governanceapproach. With a population surpassing 700,000,
Bhutan boasts an estimated life expectancy of around72 years, with Buddhism being the predominantreligion.
Moving beyond the overview, the presentation
delved into Bhutanese food culture—a unique cuisine
shaped by geography, climate, and Buddhist traditions.
Characterized by simplicity, reliance on local
ingredients, and distinct regional flavors, the cultural
significance of food is evident in shared and celebrated
meals, reflecting Bhutan's rich heritage.
Bhutanese cuisine highlights staples like red riceand buckwheat, particularly common in the central
and eastern regions. The national dish, Ema Datshi, isa spicy chili and cheese delight. The culinary
landscape further includes dairy products, momos(dumplings), and traditional beverages like Suja(butter tea). Additionally, fermented foods such as
sikam, ezay, and pickles enjoy popularity.
While Bhutan has made strides in healthcare andnutrition, it grapples with ongoing nutritional
challenges. Issues include iron deficiency anemia,
micronutrient deficiencies, and undernutrition in the
population. The double and triple burden of
malnutrition remains a concern, alongside challenges
related to limited dietary diversity, changing dietary
patterns, rural-urban disparities, and food security invulnerable communities.

*To whom correspondence should be addressed:cwangmo@mrrh.gov.bt

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Asian Young Dietitian Network
opportunities.
Expectations from the network may vary, but webelieve this network will significantly contribute toprofessional development. It will offer opportunities
for professional growth, skill enhancement, and accessto the latest advancements in the field of nutrition.
Additionally, there will be valuable networking
opportunities where members can build a strong
professional network, connect with experienced
professionals, and engage with colleagues fromdifferent countries. There is an expectation for
mentorship programs to guide and support young
dietitians in their career paths. Members can anticipate
access to educational materials, workshops, andseminars to stay updated on nutritional trends,
research, and best practices. The network is expected
to provide various career opportunities, foster
collaboration and teamwork, and advocate forrepresentation within the profession. Furthermore,
attending events and conferences organized by the
network will be a valuable aspect of membership.
Overall, being with AYDN, learning new insights andideas regarding the knowledge and understanding of
nutrition and dietetics, we will collaborate on all the
positive activities and adopt them if feasible for ourcountry’s future endeavors.

Fig 1. Bhutan’s food culture
In conclusion, we outlined the steps and requisites
for individuals aspiring to become Dietitians in Bhutan.
This involves obtaining a relevant educational
background, gaining practical experience throughtraining and internships, and registering forpreliminary and main examinations. Successful
candidates can pursue roles in hospitals, ministries,
and other sectors. The presentation also touched upon
continuing education and licensing or accreditation

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5. Cambodia’s report
Ry Manydine1
1

Phnom Penh, Cambodia

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
It was such a great experience to be able to visit
the Nerima Hikarigaoka Hospital. I received suchgreat hospitality from the staff and Dietitians there.
We started the day by listening to the presentation
relating to diseases and Nutritional solutions, hence
there were also a lot of questioning and answering
sessions among all the other members from individual
representative countries. As for my impression, I
think that the hospital had such an incredible working
system in nutrition care. Everything is so wellorganized, and every staff member is well aware of
their own responsibility. Moreover, we also had akitchen tour inside the hospital. I would say that thehospital has one of the most functional kitchens that I
have been to before. From the equipment to menu
planning, everything was done so heartedly. I was
mostly impressed by the modern rice cooker that
pipes the cooked rice straight up to the meal
preparation station. I believe that Japan's dietitiansystem is a great example for Cambodia to follow.
With this type of efficient system, it will be so muchbetter for the development of public health issues.

Fig 1. Modern rice cooker

Visit to elementary school for school lunch(Funabori Elementary School)

to also use the Japanese school lunch system to apply in
Cambodia. I am concerned that a lot of kids in Cambodia
are malnourished due to the lack of a school lunch
system.

My impression of visiting Funabori Elementary
School, I can feel that the dietitians there handle the foodfor every child with love and care. The Dietitian did agreat job in planning all the children's meals, varying
from normal healthy kids to kids with allergies. Also, to
get the children more to international cultures, meals
from different countries are also given out to them.
Moreover, the kitchen was very nice and clean. Visitors
or children can see the cooking from the outside glass,which I believe can deepen and widen our understandingof what school lunch is. I have learned that being adietitian at school is not an easy job. Many kids that are
still growing come to school every day to learn so for us
as dietitians, it is our job to make sure that they receive
a good amount of nutrients that they need to grow. I want
*To whom correspondence should be addressed:
rmalydine14@gmail.com

Fig 2. School lunch meal

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Asian Young Dietitian Network

Kick-off meeting of AYDN
For my presentation on the Kick-off meeting day, I
was slightly introduced to Cambodian food culture,eating habits, and seasoning ingredients. More
importantly, I also talked about the most important
Nutrition problem right now in Cambodia which is“Children Malnutrition”. After listening to othercountries' repetitive members ' presentations, I
understand that a lot of countries in Asia have some of
the most common Nutrition problems. With this factor,

I believe that working together as a community will help
solve some of the problems. Since the number ofCambodian dietitians is comparatively very low, I hopethat more Cambodians will be interested in learning andunderstanding more about Dietetics. Also, I hope that
all the country members can still work together as an“ASIAN YOUNG DIETITIANS NETWORK” for avery long time and see each other success as anachievement.

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6. India’s Report
Naaznin Husein1
1

Freedom Wellness, Mumbai, India

This report delves into the accomplishments andimpact of the Asian Young Dietitian Network, an
initiative led by Professor Shigeru Yamamoto, Chief
Editor of the Asian Journal of Dietetics. Established tofoster collaboration, knowledge-sharing, and friendshipamong dieticians across Asian nations, the initiative has
proven to be a valuable platform for academic, scientific,
and cultural growth. This article provides acomprehensive overview of the forum's objectives,
execution, and the significant contributions it can maketo dietetics.
Introduction:
The Asian Young Dietitian Network is an exemplaryconcept, conceived by Professor Shigeru Yamamoto
from Jumonji University, seeking to establish acollaborative network for dieticians across Asian
countries. The forum's inception gained momentum
through online meetings, creating a foundation for
camaraderie among participants.
Objectives:
The primary objectives of the forum include:a. Networking and Collaboration: Facilitating
collaborative efforts among member nations to enhance
the growth and support of dieticians.
b. Knowledge Exchange: Providing a platform
for young researchers to publish work, participate inconferences, and share insights.
c. Cultural Understanding: Utilizing country
presentations to explore both similarities and diversities
of food culture, dietary habits, and health challenges,
fostering a comprehensive understanding of eachmember nation.
Initiative Execution:
The meticulously planned visit to Japan, supported
by Ajinomoto, included a stay in Tokyo. The pre-kickoff
experienceshowcased
Japan's
technologicaladvancements and the locals' helpfulness. Academic
endeavors during the initiative involved country
presentations, delving into food culture, dietary habits,
and common health problems. In-depth discussions on
dietetic systems, ethics, and legalities were evident inwell-crafted presentations and collaborative learning
experiences.

Welcomed by the President of Jumonji University
The meeting was very engaging as the President
genuinely took time to understand the program. He
encouraged the Network and was proud of Professor
Yamamoto’s initiative of fostering the Asian Young
Dietitian Network.
The visit to the university was beautiful as it had
Mount Fuji in the background. The university grounds
were beautifully covered with trees full of autumn
orange and red trees. The vibe at the university was very
positive and interaction with all dietetic students ofMasters and Post Graduate programs and Ph.D.
Programs were interesting.

Fig 1. The picture was taken on the rooftop of
Jumonji University
Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
A hospital visit, graciously facilitated by Ms. Trangand Professor Yamamoto, allowed an immersive
experience in understanding feeding practices, meal
distributions enteral and parental feedings, nutritional
assessments, and patient care. The chief dietitian, a very
empowered and central to the dietetic department
introduced the activities they do throughout the day. The
president also walked us through detailed presentations
on the presence of Malnutrition in three out of 4 patientsin the hospital and rehabilitation centers. This was due
to high numbers of the aging population. Other conceptsof Iatrogenic Sarcopenia, Aspirational Pneumonia,
Nutrition Care Process (NCP), and nutrition
management process were deeply discussed. The
president also spoke on the new Rehabilitation Nutrition
care process. It was very insightful to see extreme
detailing on proper positions - bed whilst feeding*To whom correspondence should be addressed:naazninh@gmail.com

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Asian Young Dietitian Network
Pneumonia patients. Any occupation can evaluate
swallowing and eating without equipment was a very
interesting learning in early detection. The cooking andplating of these meals a previous day for breakfast so thatthe staff doesn’t have to rush from home at 2 am was agreat learning curve. State-of-the-art equipment at thehospital including cooking utensils, gas ranges, ovens,and the unique rice suction machine which reduces
manual labor -an innovation of the chief dietitian was
well worthy of praise. The dietetic department stoodrobust, bringing in steady income for the hospital, andplayed a pivotal role in hospital administration andleadership.

290 yen to be paid by parents. Rest all infrastructure cost,
Salaries of Food and beverage staff and Dietitian was
paid by Government. Some schools even provided lunchat no extra cost to parents. Insights into the program's
cost structure and government subsidies provide
valuable information for educators and policymakers.
Kick-off meeting of AYDN
The Kick-off meeting was attended by Global
Communication (Ajinomoto Co., Inc.), Professor
Yamamoto, and Press and media persons. The meeting
began with a welcome by the President of Ajinomoto.
That was followed by Professor Yamamoto’s Vision andpurpose of the Network. Ms. Trang gave a detailed
presentation of the Vision, Mission, and Next steps for
the Network.
This was followed by the country presentation byeach member country elucidating their cultural cuisines,
and ingredients which were mainly used as a part of theircuisine. The health challenges faced by every country,
the dietetic systems, and the Legalities of dietetic
practice were covered.
The meeting was concluded by a vote of thanks by
Ms. Andrea -Dietitian of Ajinomoto.
Conclusion
Under the guidance of Professor Yamamoto, theAsian Young Dietitian Network has successfully
achieved its objectives, fostering international
collaboration, cultural exchange, and academic growth.
It emphasizes the forum's contributions to the field ofdietetics and its role in strengthening bonds among
dieticians across Asia.
a. Continued Collaboration: Sustain and expand the
network for ongoing collaboration and knowledge
exchange.
b. Regular Conferences: Host periodic conferences
to facilitate academic discussions and updates.
c. Dietitian network Programs: Encourage practicing
dietitians and dietetic students to share clinical practices,
case studies, and research for scientific academic growth.
Future Prospects:
The Asian Young Dietitian Network has laid a robust
foundation for continued collaboration and growth. The
lessons learned and relationships formed willundoubtedly contribute to the advancement of dietetics
in the Asian region. This explores the forum's relevance,
particularly in the context of India hosting the ACD 2026
conference.

Fig 2. Proper positioning to feed patients withdysphasia.
Visit to elementary school for school lunch (Funabori
Elementary School)
A highlight of the initiative was the school lunch
program, emphasizing the role of dietitians in planningand executing menus. Students actively participated,
incorporating sustainability, and achieving UN
Sustainable Development Goals. explores the uniqueand innovative aspects of the Japanese school lunch
program, focusing on a practical learning experience
hosted by the Dietitian of Funabori Elementary School.
The central role of the dietitian is planning and executing
menus, addressing allergy and cultural dietaryrequirements, and fostering a holistic learning
environment. Students actively participate in foodrelated activities, including kitchen gardening andvegetable peeling sessions, promoting sustainability andnutritional awareness. The article underscores theachievement of UN Sustainable Development Goals,
specifically in reducing food wastage and ensuring
nutrition security for children. The school lunch costs

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Asian Journal of Dietetics 2023

7. Indonesia’s Report
Ishak Halim Octawijaya1*, Wita Rizki Amelia2, Achmed Forest Khan3, Nur Ayu
Ruhmayanti4
1School of Nutrition and Dietetics, Kanagawa University of Human Services, Yokosuka, Japan
2
Dr. Cipto Mangunkusumo National Central Hospital, Jakarta, Indonesia
3
Politeknik Kemenkes Gorontalo, Gorontalo, Indonesia
4
CV GSB, Samarinda, Indonesia

At the Asian Congress of Dietetics (ACD) 2022,
we declared the importance of nutrition and theurgency to fight malnutrition for the well-being of all
people (1). Furthermore, international cooperation andcollaboration are needed to achieve the objectives
mentioned in the Yokohama Declaration of the ACD
2022, including malnutrition issues, especially in
Asian countries. We believe that the Asian Young
Dietitian Network (AYDN) is one of the fruits of the
ACD 2022, as some initial members have beenworking together for the ACD 2022. We are honored
to represent Indonesia in the AYDN and participate in
the kick-off meeting held in Tokyo, Japan.

dietitian, Ms. Keiko, conducting a comprehensive
nutritional assessment is difficult. Every nutritional
assessment is not only obtained from the results ofeach patient’s health record, but direct assessments,
includinganthropometricmeasurements
andphysical/clinical examinations, are also necessary.
Moreover, reviewing the dietary pattern and the abilityof each patient to consume hospital food, as well as
observing medical problems through discussion with
the nutrition support team in some cases, to determine
nutritional interventions, are essential. Patientssuspected of sarcopenia have been further assessedfollowing Asian Working Group for Sarcopenia(AWGS) guidelines (3), and it is proven that quite a lotof people experience sarcopenia after undergoingtreatment in a hospital. When patients with decreased
nutritional status are discharged from the hospital, theyreceive nutritional support through oral nutrition
support (ONS) or enteral nutrition (EN). Besides
providing nutritious food, the dietitian mainly
conducts bedside counseling for every inpatient, eventhough the room for counseling is available.
The visit revealed that the Nerima Hikarigaoka
Hospital had the latest innovations. The hospital has
benefitted from its latest technology related to dietetic
services, which differs from hospitals in Indonesia.
First, the hospital has an integrated medical record
information system. Second, the hospital provides anautomated vacuum machine to carry the desired
amount of rice directly to the huge rice cooker; it could
help minimize human labor empowerment and can bedone on a scheduled basis according to foodprocessing planning. Third, the cooling and warming
system for cooked food using a tray makes it easier toprepare each meal. The foods can be produced as early
as one day before the food is served. Fourth, themanagement of quality control of the diet was handled
by catering nutritionists so that the quality of foodsafety is guaranteed. Fifth, the fee for every counselingsession provided by a registered dietitian, around2,000 JPY, was regulated by government law so that it
may increase the hospital's income. Sixth, each meal
was served on a special food-grade plate with a cover,so it may reduce the cost better than using disposable
meal covers (for example, plastic wrap).
The latest technology, especially the integrated
computerized healthcare system, might be the greatest
achievement in Indonesian hospitals for the next 10-

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
We visited Nerima Hikarigaoka Hospital on
November 29th (Fig. 1-2). Upon arrival at the hospital,
we were warmly welcomed and given a wellorganized tour. It appears this hospital is concerned
about the security of personnel and patients from thefront door. The hospital has more than 30 medical
departments with 457 beds. The hospital has
comprehensive emergency, children's, and adult,
including maternal healthcare. Not only does Nerima
Hikarigaoka Hospital provide healthcare services
independently, but it also strives to cooperate with theresidents and the surrounding healthcare facilities.
Nutrition and dietetic services have been integrated
with a computerized system. Even since dietitians
record nutritional care in the system, dietary changes
are integrated with the food service system. Thus,
changes in the diet of patients in the inpatient ward canbe directly connected to the preparation of processing
until the serving of the patient’s individualized diet.
Every new patient admitted to the hospital has been
screened for malnutrition risk using Malnutrition
Universal Screening Tool (MUST), which wasreported in the health electronic record. Furthermore,
the dietitians visit the new patients at risk ofmalnutrition by conducting a comprehensive
nutritional assessment, diagnosing the nutrition
problem, and planning the nutritional intervention
individually.
According to the discussions with the senior*To whom correspondence should be addressed:

halim-svw@kuhs.ac.jp154

Asian Young Dietitian Network
15 years. It is beneficial for hospitals in terms ofeffectiveness and cost efficiency, and it may also help
health workers to provide the best services for patients.
Despite the shortage of human resources, technology
might be the best solution to achieve better
coordination in managing health service

regarding dietitians, and how we feel as dietitians inIndonesia.
Indonesia has a rich culture due to its location,
climate, and history. For decades, the influences ofsurrounding countries have generated an indigenous
Indonesian food culture. The rich food culture and thedevelopment to access foods, among many factors,
might have contributed to increased obesity
prevalence among adults in the past decades. Parallelly,
stunting and wasting among children persist,
especially in the impoverished areas of the country,with a lack of access to resources, including food andbeverages. The government has been implementing
intervention programs to fight these issues. Dietitiansof Indonesia have a vital role to play in the intervention
programs. The regulations regarding the dietitian
professions and roles are on their development toachieve better performances and outcomes for the sakeof society’s health.
During the kick-off meeting, we recognized that
the AYDN member countries have similarmalnutrition problems in their countries. We have
faced some improvements and a lot of setbacks in ourefforts to eliminate malnutrition so far. We believe that
AYDN is a good community where passionate young
dietitians from Asia might share their insights andwork together to help many people achieve better,sustainable nutrition and health.

Visit to elementary school for school lunch(Funabori Elementary School)
We visited Funabori Primary School on November
30th, when the school had a marathon festival for the
younger students (Fig. 3-4). The school had a modern,well-furnished building, including the school kitchen
and the classrooms where the children had lunch.
Directed by a dietitian, around ten cooks prepared themeal every school day for about 800 students.
Commonly, the parents need to pay for the food costof the meal, but the authority of Edogawa Ward, where
the school is located, has started to fund the school
lunch program in their area so that the parents do nothave to pay for the meals (4, 5). They provide a uniquemeal for each day of the year, carefully deal withchildren with food allergies, and educate the students
on the importance of food daily. On the day of our visit,
the dietitian adjusted a school lunch menu fitted for theschool sports occasion. Indonesia does not have anationwide school meal program now. Learning fromJapan, we hope to establish a school meal program forIndonesian schoolchildren in the future.

1.

2.

3.

4.
Fig 1. AYDN visit to Funabori Primary School
Kick-off meeting of AYDN
We had the AYDN kick-off meeting on December
1st at Ajinomoto Headquarters in Tokyo (Fig. 5-6).
Representing Indonesia, we presented an overview of
the country, food culture, nutrition issues, regulations

5.

155

REFERENCES
The 8th Asian Congress of Dietitians (ACD2022).
A future where Asia works together to eradicate
malnutrition. Asian J Diet 4(2&3): 29-35. 2022.
Trang TN, Marita VDG, Ishak HO, et al.
Becoming a dietitian in Asian countries:
Educational aspects from young dietitians’
perspective. Asian J Diet 4(2&3): 37-40. 2022.
Chen LK et al. Asian working group for
Sarcopenia: 2019 consensus update on
Sarcopenia diagnosis and treatment. J Am Med
Dir Assoc 21(3): 300-307. 2020.
Ministry of Education Culture Sports Science
Technology Japan. School lunch program inJapan. Ministry of Education Culture Sports
Science Technology Japan 1-11. 2013.
Edogawa Board of Education. Edogawa Board of
Education. 学校給食費の無償化実施について(Implementation of free school lunch). Edogawa
Board of Education. 2023.

Asian Journal of Dietetics 2023

8. Japan’s Report
Risako Okuyama1
1

Graduate School of Aomori University Health and Welfare, Aomori, Japan

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
I visited Nerima Hikarigaoka Hospital on Nov 29.
The hospital is located in Nerima Ward, Tokyo, Japan,
and it was reformed in 2022. I felt that the equipmentin the hospital was very new, and the kitchen wheremeals were prepared was fully equipped. At that
hospital, I learned about the compassion of dietitians
who put patients first.
The first thing that I learned is that dietitians arecareful about the position when patients are eating on
the bed and the environment. In terms of nutritional
management, it did not come to my attention to theposition that patients eat, but after the visit, I realized
its importance. I learned that I must be careful thatpatients do not press her/his stomach with her/his legs
when is sit on the bed. Regarding the environment, I
learned that patients eating with other people in thecafeteria would lead to the enjoyment of their meals.
The second thing that I learned was that theappearance of food is important for patients as it is oneof the factors that greatly influences appetite. In
particular, in a dysphasia diet, if the food is put in a
blender, various ingredients are mixed, and the color
will be bad. At this hospital, I felt that it looked good
because it was well-colored and kept in shape. The
third thing that I learned was that some of thevegetables grown indoors which were grown by
dietitians are used to prepare the patient’s lunch. I
thought it was a very good idea and I thought thatpatients were happy to be able to eat fresh vegetables,
even though the amount was limited. In this way, I feltthat this hospital not only manages the nutrition ofpatients but also provides care considering how tomake patients happy.

Visit to primary school for school lunch (FunaboriPrimary School)
There were two things that impressed me the mostwhen I saw the school lunch program. The first was tocreate a menu without using ready-to-use products.
The second thing is that there was very little leftover
food. I provide school lunches at a special needs
school, and I often use ready-to-use products. This isbecause the use of these products reduces the burdenof cooking work and is less time-consuming,otherwise, we won't be able to finish making school
lunches on time. Moreover, they even made their own
desserts such as melon bread using Komatsuna, a local
vegetable. In addition, there was a wide variety ofmenus, and dishes from various countries wereincorporated into the menu. I felt that incorporating avariety of menus into school lunches would help
children accept and understand diverse cultures. In
order to provide such a wide variety of menus preparedby hand, I feel that the cooperation of the cooks andkitchen staff is indispensable. I could imagine thedietitian actively communicating with the cooks daily
by explaining the purpose of that day's meal andasking for their cooperation. In Japan, school lunches
are called "living teaching materials". This is because,through the actual school lunches provided, children
can learn such as appropriate meal intake, food culture,and manners during the meal. I felt that the school
lunch of Funabori Elementary School reaches thestandards of “living teaching materials”. In addition tofood culture, they provide school lunches related toseasons, as well as incorporate the SDGs, which is a
hot topic at present. In addition, I felt that the Principalof the school and other teachers understand theintentions of the dietitian and are reflected in the
education of children. In this way, I felt that thecooperation with other teachers on school lunches led
to the low of leftovers among children.

Fig 1. Vegetables grown in the dietitian's room.
Fig 2. Amount of leftover food for one class*To whom correspondence should be addressed:

1714005@ms.auhw.ac.jp156

Asian Young Dietitian Network
Kick-off meeting of AYDNAt this meeting, information was shared anddiscussed on the food culture of the twelve countries
that participated, major nutritional issues, and thesituation of dietitians. The most interesting topic forme was whether dietitians are respected or not in theircountries. When I work as a dietitian in Japan, I
sometimes feel a lack of respect. Therefore, I was very
interested in the situation of dietitians in other Asian
countries. When asked about the opinions of othercountries, some of them felt respected. For this reason,
I thought that dietitians in Japan were necessary to

make more appeal. As the discussion during themeeting suggested, dietitians need to write and publish
more papers. Dietitians in Japan conduct research andmake presentations. However, I feel that there aremany cases where the presentations are made only inthe local area or inside Japan without spreading theoutcome of the research abroad. I think that dietitians
in Japan need to look more abroad and actively
disseminate information. I hope that through thisnetwork, countries will be able to work together to finda way to solve their nutrition challenges and to giveback what they have learned to their own countries.

157

Asian Journal of Dietetics 2023

9. Malaysia’s Report
Georgen Thye Choong Jean1
1

Consultant Dietitian (Georgen Dietetics, Kuala Lumpur, Malaysia)

The Asian Young Dietitian Network (AYDN) held
its inaugural kick-off meeting in Japan from 28/11/23
to 3/12/2023, bringing together dietitians from diverse
Asian countries in Tokyo. This significant initiative,
generously sponsored by Ajinomoto Co., Inc., aimed
to foster collaboration and knowledge exchange
among dietitians across the region. As part of the
program, participants had the opportunity to visit
various institutions, including the Nerima Hikarigaoka
Hospital, Jumonji University, Funabori Primary
School for School Lunch, and the kick-off meeting at
Ajinomoto Co., Inc. head quarter (HQ).

dining environment was particularly impressive. The
emphasis on proper feeding positions andenvironmental considerations highlighted a holistic
approach to patient nutrition — a facet often
overlooked in other settings.
In comparison to my experience in Malaysia,
where dietitian consultations are not covered byinsurance, the Japanese model stands out as a potential
avenue for improvement. Addressing this disparity
could enhance accessibility to dietitian services andimprove patient outcomes. The successful
implementation of technology in various aspects ofhealthcare, particularly in the nutrition care process
and food service ordering system, serves as a model
for future endeavors in my home country. Learningfrom Japan’s experience, we can strive for theeffective integration of technology to streamline
processes and ensure patient safety.
Looking ahead, Malaysia has significant
opportunities for advancement over the next 10-15
years. Advocating for insurance coverage of dietitian
consultations is crucial to enhancing public health byincreasing access to nutritional expertise. Additionally,
incorporating technology into our work processes,
such as online nutrition care documentation andadvanced food service ordering systems, holds
promise for enhancing efficiency and patient care.
Continued collaboration and knowledge-sharing withJapanese institutions, like Nerima Hikarigaoka
Hospital, are essential for ongoing learning andimprovement. Strengthening relationships within the
Asian Young Dietitian Network and fostering ties withinstitutions like Ajinomoto will be crucial in
implementing positive changes in our home countries.

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital) (29/11/2023)
The visit to Nerima Hikarigaoka Hospital left alasting impression on me. From the outset, the warm
reception by the head dietitian set a positive tone. Herfriendly and bubbly personality created an inviting
atmosphere, complemented by the backdrop of ginkgo
trees with leaves turning a vibrant yellow. A group
photo beneath these trees marked a symbolic start toour insightful visit.
Upon entering the hospital, the cleanliness andorganization were immediately evident. The group
was ushered into a meeting room, where a medical
doctor and the head dietitian presented on the nutrition
support team and its initiatives. Subsequently, acomprehensive tour exposed us to various facets of thehospital, including the dietetics department, foodservice kitchen (Fig 1), and a hospital ward.
The presentations and tour provided valuable
insights into the work of dietitians at Nerima
Hikarigaoka Hospital. It became evident that dietitians
play a crucial role in the multidisciplinary approach topatient care. Every admitted patient undergoes
screening and intervention by a dietitian, emphasizing
the significance of nutritional support duringhospitalization. Notably, dietitian consultations arecovered by insurance in Japan, underscoring therecognition and importance of their role.
The integration of technology in food services
showcased Japan's Innovative practices. Fromordering systems to food preparation and quality
monitoring, technology-enhanced efficiency, resource
management, and ultimately improved patient care.
The automatic rice cooking system served as a notable
example of creative and effective technology use. The
meticulous attention to detail in creating an optimal

Fig 1. Photos of AYDN at the Nerima
Hikarigaoka Hospital*To whom correspondence should be addressed:

georgen_thye@live.com

158

Asian Young Dietitian Network
Visit to primary school for school lunch (FunaboriPrimary School) (1/12/2023)
Our visit to Funabori Primary School coincidedwith their sports day, and the lively scene of kids
running around with parents and teachers cheering set
a cheerful tone. Welcomed by the schoolteacher anddietitian, we changed into indoor slippers and went toa bright meeting room that doubled as a dining area.
The school's neat, organized, and sunny environment
left a strong impression, especially considering its
100-year history.
After a quick briefing, we got a peek into the
kitchen through large windows (Fig 2). The kitchen
staff, wearing protective gowns, showcased
impressive cleanliness. The corridor walls featured
educational posters on food and nutrition, serving as
handy learning tools (Fig 3). After that, we returned tothe meeting room for a presentation by the school
dietitian about her role, and routines, and a Q&A
session. The visit wrapped up with a chance to enjoy
the tasty school lunch.
The visit highlighted the deep importance of theschool lunch programme in Japan. It is not just about
feeding students but creating a positive relationshipwith food and nutrition from a young age. This
foundational habit-building contributes to thedevelopment of a healthy and productive nation asthese practices persist into adulthood. The
involvement of students in distributing food to theirpeers emerged as a valuable opportunity for fostering
accountability and independence—essential life skills
that echo beyond the school years.
In Malaysia, the absence of a structured school
lunch system stands in contrast to the Japanese model.
Students have the freedom to purchase food fromschool canteens based on personal preferences and use
their funds. Notably, government schools in Malaysia
lack dedicated school dietitians, a role morecommonly found in international schools. Considering
the Japanese model, there's a case for Malaysia tothink about having a school lunch system. Advocating
for its importance could create job opportunities for
dietitians. Introducing a school lunch system mightalso help with early nutrition education, addressing thehigh prevalence of Non-Communicable Diseases(NCDs) in the country. Funabori Primary School's
experience is a valuable reference for imagining ahealthier future for Malaysian schoolchildren.

Fig 2-3. AYDN visited the Funabori Elementary School lunch
Kick-off meeting of AYDN (1/12/2023)
The Kick-off meeting, hosted at the prestigious
Ajinomoto HQ, commenced with a warm welcome
from Prof Shigeru Yamamoto (Jumonji University)and senior management from Ajinomoto Co., Inc.
(Global Communication Department).. Subsequently,
each participating dietitian from various Asian
countries delivered a concise 10-minute presentation,
setting the stage for collaborative discussions andinsights.
In my presentation, I provided an overview of
Malaysia, touching on its capital, Kuala Lumpur,
population, and the rich cultural tapestry formed by its
diverse races (Fig 4). I delved into Malaysia's foodculture, illustrating how it is shaped by the influencesof various ethnicities. Two iconic Malaysian dishes,
Nasi Lemak and Asam Laksa, were highlighted, alongwith staple ingredients in Malaysian cooking. Shifting
focus, I addressed nutritional challenges in Malaysia,emphasizing the high prevalence of overweight in both
adults and children, as well as the alarming rates ofdiabetes issues exacerbated by changing eating habits
and insufficient exercise (1). I discussed government
initiatives like the KOSPEN program (2) and the
Malaysian Dietitians' Association's strategies toenhance dietitians' visibility through annual Nutrition
Month and Dietitians' Day celebrations. Concluding
my presentation, I shared my vision for AYDN, aiming
to foster collaboration among Asian countries,
enabling the exchange of knowledge, experiences, andfunding support for regional nutrition initiatives.
The presentations from fellow dietitians left alasting impression, showcasing their deep
understanding of their own country's food culture,

159

Asian Journal of Dietetics 2023
nutritional challenges, and visionary approaches for
improvement. The passion for dietetics resonated ineach presentation. A common thread emerged—theshared challenges faced by our countries, such as therising prevalence of Non-Communicable Diseases(NCDs), the double burden of childhood malnutrition,and the potential for enhancing the role of dietitians.
This collective insight highlighted the abundant
opportunities for collaboration to address these sharedconcerns.
My expectation from AYDN is to strengthen thebonds and friendships established through various
activities and initiatives. Proposed initiatives include
small-scale research projects, such as dietitian surveys,
to understand the challenges faced by young dietitians
in our respective countries. With this data, AYDN canstrategically plan activities to support the growth andsuccess of young dietitians. Additionally, envisioned
activities include webinars, monthly virtual meetings,
and annual physical meetings, providing diverse
platforms for ongoing collaboration and learning.

In conclusion, the Kick-off Meeting of the AsianYoung Dietitian Network (AYDN) has successfully
ignited collaboration and knowledge exchange among
dietitians across Asia. From insightful visits toinstitutions in Japan to presentations highlighting
common challenges, the meeting emphasized shared
dedication to addressing health issues. AYDN's
commitment to ongoing collaboration, research
projects, and supportive initiatives for young dietitians
bodes well for the network's role in advancing
nutrition and healthcare throughout Asia. The meeting
stands as a pivotal moment, laying the groundwork fora healthier, more connected future.

1.

2.

REFERENCES
Institute For Public Health, Ministry of Health
Malaysia. National health and morbidity survey.
2019.
Institute For Public Health, Ministry of Health
Malaysia. KOSPEN PLUS. 2021.

Fig 4. Presentation at the AYDN Kick-off meeting160

Asian Journal of Dietetics 2023

10. Philippines’s report
Marita V. De Guzman, RND1
1

Nutritionist-Dietitians’ Association of the Philippines (Philippines)

Being a part of the Asia Young Dietitian Network(AYDN) is both a privilege and an opportunity.
Privilege because we got to meet and interact withother Asian dietitians and Opportunity because we got
to learn and observe how Dietitians work in theircountries. From November 28th to December 1st,
Asian Dietitians were invited to Tokyo Japan for the
Kick-off meeting of the Asian Young Dietitian
Network. Alongside this, we were able to visit Nerima
Hikarigaoka Hospital and Funabori Primary School.

Visit to elementary school for school lunch(Funabori Elementary School)
Visiting Funabori Elementary School for me is themost memorable one. I know how disciplined thestudents are in Japan but it was my first time
witnessing it. Since our country does not have thatmany school dietitian and my knowledge of theirduties and responsibilities is limited, this is my firsttime to learn all of it. School dietitian work is not easy
because she deals with children and I respect the way
she and the school teach the students about nutrition.
She assesses, monitors, and keeps all data of all
students to see their progress when it comes to theirhealth. Meal planning is also a difficult task for her
especially if it needs to cater to a range of dietaryrequirements and food allergies. Aside from this, I also
learned that students are not allowed to bring snacks
or lunch. In our country, students either bring theirsnacks and lunch or buy in school canteens. If ourcountry is open to applying this practice, it means
more demand for school dietitians and fewer
malnourished children in schools.

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
For a Dietitian like me who is not exposed tohospital work, I am impressed with the cleanliness andorderliness of the hospital. The visit is only short but I
am amazed by the innovative and advanced
technologies that they use in their kitchen. I also
observed the vegetables that are grown in the nutrition
room which I think is a good practice for every
hospital to serve fresh vegetables to the patients.
Ordering and preparing meals are different in ourcountry since we do not have freezers and food heaters
to hold meals, we prepare food on the same day. Meal
supplements are prepared by the dietitian in ourcountry while here they serve ready-to-eat/drink meal
supplements. If there is anything that I would like tolearn more about and apply in my country is theirnutrition care system and data system. I think Asian
Dietitians need to understand and teach each otherhospital best practices to be able to apply them in theircountry in that way, we can uplift the respect of otherprofessionals.

Fig 2. Cooking process at the school lunch
Kick-off meeting of AYDN
It was a great honor to represent my country
Philippines at the kick-off meeting of the Asian Young
Dietitian Network.
The Philippines is an archipelago in Southeast Asia
where food culture and cuisine are a fusion of morethan a hundred distinct ethnolinguistic groups. These
groups’ cuisines evolved over the centuries with all
nearby countries with varied influences from Chinese,
Spanish, and American cuisines that melded to meet
local preferences. Rice and root crops are our staple
foods. The typical Filipino meal is composed ofvegetables, seafood, dairy, meat (pork, poultry, beef),

Fig 1. Meal dividing room in the hospital*To whom correspondence should be addressed:
marita.deguzman_events@yahoo.com

161

Asian Young Dietitian Networkand rice. The blend of flavors is a combination ofsweet, sour, and salty taste. Vinegar and soy sauce aresome of the common ingredients in dishes like Adobo
and tamarind in Sinigang. Filipino cuisine even though
it continues to evolve as new techniques, styles of
cooking, and ingredients find their way into thecountry. The Philippines is suffering from a triple
burden of malnutrition including stunting and wasting,micronutrient deficiencies, and overweight andobesity (1). The Department of Health (DOH),
National Nutrition Council (NNC), FAO, WHO, andUNICEF jointly call upon the Public, civil society
organizations, academe, and the private sector to takeaction to prevent and manage childhood overweight
and obesity (1). That being said, overweight and obese
children are more likely to stay obese into adulthoodand to develop noncommunicable diseases (NCDs)
like diabetes and cardiovascular diseases at a youngerage (1-2). Factors contributing to the increasingproblem of overweight and obesity include poor diets,
inadequate nutrition, failing food systems, and limited
physical activity (1-2). Prevention is the most feasible
option for curbing childhood obesity. Several
programs and policies were made and implemented toaddress overweight and obesity. Nutritioninterventions are a key part of obesity management
and this is led by dietitians. To become a Registered
Nutritionist-Dietitian in the Philippines, one should
finish a 4-year Bachelor course in Nutrition andDietetics with 1200 hours of on-the-job
training/internship in hospitals, food service
companies, and community health facilities. After
which, he/she can take the licensure examination with
a 75% passing rate (3). Dietitians in the Philippines
can pursue graduate studies and doctorate studies.
Renewal of license is every 3 years and to be able torenew, he/she may earn 45 CPD units from webinars
or annual conferences and secure a Certificate of Good
Standing from AIPO. Filipino RNDS have theprivilege to work in the US by taking the Registered
Dietitian exam; this is because of the Mutual
Reciprocity of 1993 (3). Being a Dietitian is a flexible
profession, it can develop a career in various fields,

hospitals, academe, public health, corporate, private
practice, etc. It is a fun learning profession eventhough it carries credibility and responsibility. But not
all people are aware of the gravity of our career that
we are either not recognized or constantly being
compared as less important to other medical
professionals. In a way, I still feel respected but stillneed to think about how to uplift the profession.
Listening to other countries’ reports, I learned thatwhen it comes to food culture and cuisines, we have
similarities and differences, especially in the taste andpresentation of the food. Some of us share the same
nutrition issues and learning about their programs andinterventions made me think of the possibilities thatcan be implemented in our country. Being a dietitian isvery different in each country and I find Indonesia andJapan a little bit complicated to become a Dietitian but
when it comes to on-the-job training both Japan and
the Philippines have almost the same hours tocomplete. I think for advantages and challenges ofbeing a dietitian are almost the same for all of us. We
share the same sentiments when it comes torecognition and low salaries from other professionals.
My expectations from the network include
connection, opportunities,
andcollaboration.
Somehow Asian Young Dietitians are now connected
and building a good relationship would be an
opportunity for us to learn more by sharing,exchanging knowledge, and learning success stories
from each country's nutrition programs for futurecollaboration. I am looking forward to AYDN’s
activities and making Asian Dietitians stronger andwell-respected.
REFERENCES
1. UNICEF. Poor diets, failing food systems, andlack of physical activity are causing overweight
and obesity in children. 2021.
2. Department of Science and Technology Food andNutrition research institute. 2021 expanded
national nutrition survey (ENNS). 2021.
3. Republic of the Philippines. Implementing rules
and regulations of republic act no. 10862,
Nutrition and Dietetics. 2017162

Asian Journal of Dietetics 2023

11. Sri Lanka’s Report
F.A.Z.Firouse1
1Asiri Surgical Hospital, Colombo, Sri Lanka

The Asian Young Dietitians Network (AYDN)
convened its inaugural meeting from 28th November to
1st December 2023 in Japan, featuring representatives
from Bangladesh, Bhutan, Cambodia, India, Indonesia,
Malaysia, Philippines, Sri Lanka, Taiwan, Thailand,
Japan, and Vietnam. Hosted by the Asian Nutrition andFood Culture Research Center at Jumonji University
and Ajinomoto Co., Inc. Global Communication,
Japan, the event provided dietitians with insights into
Japan's dietetic management system in hospitals andschool meal programs. Participants engaged in a
fruitful exchange of ideas, focusing on the uniqueaspects of each country's food culture, nutrition
practices, and health management strategies at the
kick-off meeting. The discussions also delved into the
future activities and collaborative initiatives
envisioned by AYDN.

a well-structured lunch program with a diverse menu,
offering 25 dishes monthly from South Asian,
European, and North American cuisines. This
diversity enriches students' culinary experiences andpromotes cultural understanding. A dedicatedprofessional dietitian oversees the program, carefullyplanning nutritionally balanced meals and providing
the nutrition education program for children,
contributing to overall health and academic excellence.
FPS prioritizes organic farming & food safety,
implementing stringent measures to ensure safe andhealthy meals. The school accommodates students
with food sensitivities and allergies. Government
support enables the school to provide meals for free.
The school minimizes edible food waste throughcareful planning, setting an example for sustainableliving. Learning from successful models in Japan,
implementing a sustainable school meal program in
Sri Lanka addresses immediate and long-term
nutritional needs, with a key focus on reducing foodwaste. Also, it guarantees the nutritional adequacy ofthe school meals, and a team of professional dietitians
should be engaged.

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital) on 29th of November 2023
Nerima Hikarigaoka (NH) Hospital, a 400-bed
facility in Japan, is committed to delivering
comprehensive, multidisciplinary care. NH Hospital's
Dietetic Department stands out as an excellent
example of nutrition management by using advanced
technology, standardized protocols, and a commitment
to collaborative care, The Dietetic Department
manages the nutritional needs of both inpatients andoutpatients, providing personalized and evidencebased nutritional support. Dietitians collaborateclosely with the food and beverage department tocreate well-balanced menus adhering to ensure
standard therapeutic diets, adhering to HACCP
protocols in food and nutrition services reflects NH
Hospital's commitment to patient safety. Dietitians at
NH Hospital work as integral members of amultidisciplinary team. Inspired by the advanced
healthcare practices at NH Hospital. My vision is toimplement an electronic patient medical record system,
integrating it seamlessly with the existing mealordering system. By modernizing the documentation
process, we aim to elevate the standard of nutrition
care in Sri Lanka without compromising on efficiency
and accuracy.

Fig 1. AYDN joined the school lunch
Kick-off Meeting on 2nd of December 2023
Ms.F.A, Z.Firouse, a Dietitian represented Sri
Lanka. Sri Lanka's food culture, shaped by its Silk
Route location and colonial history, reflects a diverse
tapestry, the cuisine centers around the classic rice andcurry dish. Rice, a staple, is paired with various curries,emphasizing protein sources of fish, chicken, and eggs,
with vegetables creatively integrated into dishes.

Visit to elementary school for school lunch(Funabori Elementary School) on 1st of December
2023
A visit to Funabori Primary School (FPS) revealed*To whom correspondence should be addressed:
firouseamal@gmail.com

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Asian Young Dietitian Network
Coconut milk or oil is a key cooking component,
providing significant fat. With around 20 spices andherbs like turmeric, pepper, chili, cumin, cinnamon,
etc. In Sri Lanka, the field of dietetic and nutrition carein the healthcare system established over the past 25
years. The regulatory body of dietitians is the Sri
Lanka Medical Council, while the Dietitians’
Association of Sri Lanka serves as the professional

body. To qualify as a registered dietitian in Sri Lanka,
individuals must attain a minimum education level ofa four-year degree in Food Science and Nutrition.
Alternatively, an MSc or PhD in Dietetics, and Human
Nutrition is also accepted. A crucial component is amandatory one-year internship under the guidance ofa registered dietitian.

Fig 2. Sri Lanka presentation at the AYDN Kick-off meeting
Sri Lanka faces a mounting health challenge with
the increasing prevalence of non-communicablediseases. However, the nation's major nutritional issue
lies in the triple burden of malnutrition, particularly
affecting children under the age of 5. A national
program called "Thriposha" plays a pivotal role inaddressing this issue. Additionally, Sri Lanka has
undertaken significant efforts in the revision of its
national nutrition policy and the development of
updated food-based dietary guidelines.
The participant Asian dietitians remain resilient,collectively contributing to the upliftment of nutrition
standards and the advancement of their profession in
their respective nations. Despite facing challenges
such as low wages and unethical nutrition practices,
intrusions into the dietetic field. To build relationships,
exchange information, and work together to addresscommon challenges in the field, the AYDN need aims
to provide a collaborative platform for young dietitians

throughout Asia. As involved members of AYDN,
dietitians from Sri Lanka are keen to take a role inadvancing the dietetic field in the region. To ensure theinterchange of knowledge and the growth of nutrition
practices throughout the continent

1.

2.

3.

164

REFERENCES
Mihiranie, Sachithra et al. Indigenous andtraditional foods of Sri Lanka. Journal of Ethnic
Foods 7: 1-19. 2020.
Shinsugi, Chisa et al. Correction: Double burdenof maternal and child malnutrition andsocioeconomic status in urban Sri Lanka. PLoS
ONE 15: n. pag. 2020.
Hettiarachchi, Manjula and Chandrani Liyanage.
Efficacy of 'Thriposha' supplementation in
improving the micronutrient status of preschool
children. The Ceylon medical journal 55(3): 85-9.
2010.

Asian Journal of Dietetics 2023

12. Taiwan’s Report
Tzu-Yun Chu1
1

Clinical Dietitian, Dietetics and Nutrition Department, Taipei Veterans General Hospital, Taiwan

Asian dietitians commonly face issues such as theirprofession being undervalued, inadequate exposure
and publication of academic papers, lack of respectfrom other professionals, and low salaries. To addressthese challenges, the Asian Young Dietitian Network(AYDN) was formed at ACD 2022, providing a very
valuable communication pathway and experience foryoung dietitians in Asia. I am very happy to have theopportunity to participate again in the kick-off meeting

held by AYDN in Tokyo. This kick-off meeting was
mainly divided into three parts. The first part involved
understanding the work and environment of clinicaldietitians in Japan by visiting Nerima Hikarigaoka
Hospital. The second part focused on understanding
the work of dietitians in Japanese school lunch
programs through a visit to Funabori Elementary
School. Finally, the meeting concluded withdiscussions on the future plans and goals of AYDN.

Fig 1. ACD, 2022

Fig 2. AYDN, 2023

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
Nerima Hikarigaoka Hospital is a comprehensive
hospital with 457 beds, which is different from thelarge hospitals commonly seen in Taiwan. In Japan,
the medical hierarchy and levels of specialization are
more finely divided than in Taiwan, allowing eachhospital to focus more on development in their specificfields.
Here are a few points that left a deep impression onme during the visit to Nerima Hikarigaoka Hospital:

Labor Shortage Solution: Taiwan has been facing
a severe labor shortage in recent years, especially inthe catering industry. Hospital kitchens, which need towork with shift schedules, are particularly impacted.
Nerima Hikarigaoka Hospital uses a system called"Meal Shuttle" which allows for the preparation of thenext day's breakfast in the afternoon of the previous
day. This reduces the number of chefs required tocome in at 4 a.m. to cook breakfast, thus lowering
staffing needs and costs.

Fig 3. Meal Shuttle at the hospital*To whom correspondence should be addressed:
jerrychu388@gmail.com

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Asian Young Dietitian Network
Automated Rice Cooking System: The hospital has
a fully automated rice cooking system that cancomplete the process from washing rice to cooking
with the press of a button. This also helps to mitigate
the burden of staff shortages.
Comprehensive Electronic Medical Record System:
This system facilitates clinical dietitians in writing
nutrition care records, reducing the workload inclinical settings.
Lower Dietitian-Patient Ratio: The ratio of clinicaldietitians to patients in Japan (1:40-50) is much lower
compared to Taiwan (1:200-300). This allows clinicaldietitians to provide more comprehensive care topatients.
The aforementioned points are areas where Taiwan
can learn and emulate in the future. However, aspects
that involve changes in national laws and policies will
require collective efforts and advocacy from the entire
dietitian community in Taiwan.

agriculture, and the importance of a balanced diet. Thisholistic perspective helps to instill healthy eating
habits and a deeper understanding of food andnutrition from a young age, which is an aspect thatmany countries could benefit from adopting. What
struck me the most is that the effective implementationof Food and Agriculture Education has achieved thegoal of zero waste.
Taiwan's school nutrition lunch policy faces
several challenges:
Limited Variety of Dishes: The government
mandates that meals be served in a format of four
dishes and one soup, which hampers the diversity ofmeals.
Low Meal Costs: The fees collected from students'
parents range between 1 to 2 US dollars. This amountcovers all costs including ingredients, manpower,
facility equipment, and utilities like water and gas. In
Japan, although a similar fee of around 2 US dollars is
charged, it is only used to cover the cost of ingredients,
with the government subsidizing the other expenses.
Incomplete Implementation of Food andAgriculture Education: Taiwan has not yet fully
implemented and practiced Food and Agriculture
Education. However, there is good news: in 2023,
related legislation was passed, raising hopes that
Taiwan can advance towards adopting a Food andAgriculture Education system similar to Japan's in the
future.

Visit to elementary school for school lunch(Funabori Elementary school)
Japan's school lunch program is considered amodel for the world. Beyond providing nutritionallybalanced meals, the most prominent and globally
relevant aspect of their approach is "Food andAgriculture Education." This comprehensive approach
not only focuses on the nutritional value of the meals
but also educates students about food sources,

Fig 4. Zero Waste at school lunch
Kick-off meeting of AYDN
During the kick-off meeting, I shared with othercountries the various nutritional challenges Taiwan iscurrently facing, with obesity being the most pressing
issue. As of 2023, over 50% of adults in Taiwan are
overweight or obese. This issue of obesity is also acommon problem across many Asian countries.
Therefore, AYDN can play a crucial role in the future
by facilitating ongoing exchanges and collaborations.
Through these efforts, member countries can jointly
research and find solutions to effectively address theobesity epidemic in Asia. This collective approach canleverage shared experiences and strategies, potentiallyleading to more effective and culturally sensitive

solutions to combat obesity in the region.
What impressed me during the discussions was
the severe issue of female anemia faced by many
countries, such as India, Indonesia, and Bangladesh,which is more pronounced compared to Taiwan.
Through these exchanges, Taiwan could potentiallyoffer strategies to collectively address this problem.
Moreover, concerning the issue of obesity, Thailand's
experience with implementing a sugar tax (being thefirst country in Asia to do so) could serve as a valuablereference for Taiwan in formulating future policies totackle obesity. Learning from Thailand's outcomes andthe effectiveness of the sugar tax could provide
insights into potential approaches for reducing sugar

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Asian Journal of Dietetics 2023
consumption and addressing obesity-related healthissues in Taiwan.
After the kick-off meeting, I shared myexperiences and learnings with my colleagues andsupervisors at the hospital, as well as with otherdietitians through my social media networks. There
was considerable interest in the future development of
AYDN, and the initiative received high praise for its

progress. Many young dietitians in Taiwan are also
keen to become part of AYDN, showing a growing
enthusiasm for international collaboration andexchange in the field of nutrition. This interest
highlights the recognition of the importance of global
networking and knowledge sharing in addressing
nutrition-related challenges.

Fig 5. Kick-off Meeting167

Asian Journal of Dietetics 2023

13. Thailand’s Report
Samitti Chotsriluecha1,2,3
1Doctor of Philosophy Program in Nutrition, Faculty of Medicine, Ramathibodi Hospital andInstitute of Nutrition, Mahidol University, Thailand
2
Clinical Nutrition Unit, Department of Internal Medicine, Phramongkutklao Hospital andCollege of Medicine, Bangkok, Thailand
3
Thai Dietetic Association

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
With the glad welcome from Ms. Keiko Hirose(registered dietitian, RD), Dr. Matsumoto (Medical
Physician), and her team, we were so impressed withthe organization and workflow of dietitians in Nerima
Hikarigaoka Hospital. RD has a crucial role innutrition support and nutrition management. Dietitians
not only have the potential for nutrition therapy andcounseling but also have proven to be valued of costbenefit.
From the point of view of the dietitian's role in thehospital, we appreciate the integration of IDDSI into
the hospital diet. In Thailand, during the developmentof IDDSI into hospital food standards, we alreadylaunched IDDSI in the Thai language and IDDSI
Menu which was led by Varanya Techasukthavorn.

and diverse, which contributes to the complex of taste
and flavor. According to the plenty and complexity offood and ingredients, dietitians should haveknowledge based on regional and local foodspecifications.
Second, Thailand has country-specific nutrition
problems such as metabolic syndrome in public health,an increasing number of geriatric populations, andmalnutrition in hospitalized patients, which turn tocomplicated nutrition issues in Thailand. In order tohandle these nutrition problems, the government andmedical organizations also working to collaborate todrive Thailand's nutrition status better. We endorsed adiabetic remission program to help type 2 diabetes
mellitus with obesity can be remission from thedisease. We promote healthy organization programs,
healthy food, active physical activity, balanced
working, and a better workplace, to help working
adults have better health and mental. Thai Dietetic
Association in cooperation with leaders in IDDSI
programs launched the IDDSI Framework and
Descriptors in Thai Language, and 46 menu dysphagia
diets according to IDDSI to prevent and treat
malnutrition elderly. We support the nutrition program
for the nutrition support team in collaboration with theThai Society of Parenteral and Enteral Nutrition, tomotivate the nutrition care process in the hospital.
From the third point of view, the kick-off meeting
gives us a chance to share and learn from othercountries, we can see some countries that have further
development of nutrition programs in many aspects
such as public health, public policy, school programs,
and hospital programs. These are great and valuable
experiences that we will treasure when we get back to
our country. Finally, the conclusion of the kick-off
meeting brought us to consider how to make ourpeople have better nutrition and a better life. We
should investigate the specific plans and expand thecollaboration, with the programs to enhance nutrition
by knowledge webinars, workshops, and research.
Moreover, a network of Asian dietitians keeps us morecollaborative and friendly, which further persuades us
to make better nutrition in Asia.

Visit to elementary school for school lunch(Funabori Elementary School)
Health and nutrition awareness can be started atschool, Funabori Elementary School showed me thatpoint. Without a doubt, while the Japanese school
lunch program was very strong and effective, dietitians
took an important part in creating menu plans andactivities to enhance nutrition awareness in young
children. From farm to table can be adapted into school,
plantation activities are a great activity for children togrow fruit and vegetables, and after that, your love andcare for food be a part of your dish. The children can
manipulate lunch food hygiene by helping together
food-serving, which represents that the food that you
ladle is the food your friends eat, food is the way tohold us together. I, myself never had appreciated these
little, tiny things like this before
Kick-off meeting of AYDNFirst, we shared sharing own country's food culture,
food diversity, and nutrition problems, which let us
have insight into various information about local
country food and nutrition-related problems. In
Thailand, rice was a staple food with a side dish, inwhich the main ingredients were meat, poultry, fish,seafood, and vegetables. Thai spices are highly varied*To whom correspondence should be addressed:
samitti.ch@gmail.com

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Asian Journal of Dietetics 2023

14. Vietnam’s Report
Trang Thu Nguyen1, Phuong Mai Nguyen1, Giang Huong Nguyen1
1

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

Vietnam is one of Asia's fastest-developing
countries, and with it comes an industrialized foodculture and several nutrition challenges. The Vietnamese
dietetics system, on the other hand, is still in its earlystages, with the first bachelor course in nutrition only
recently celebrating its 10th anniversary. There has beena shortage of human resources in several nutrition
disciplines; as of 2023, Vietnam has just 785 dietitians
across the country. When compared to other Asian
nations, Vietnam's dietetics still faces multiple problems,such as underdeveloped legal frameworks, a lack ofexpertise in hospital systems, and school nutrition. As aresult, as some of Vietnam's first dietitians, we are
overjoyed to be a part of the Asian Young Dietitian
Network (AYDN). We believe that by joining thisnetwork, we will be able to learn a lot from ourcolleagues from similar cultures and share our sharedconcerns, allowing us all to grow as dietitians. We havealready received a lot of valuable lessons andinformation from the members and professors in Japanafter joining the kick-off meeting program from
November 28th to December 1st, 2023, in Tokyo, Japan.
We would like to share some of our experiences andopinions from the kick-off meeting program in thisreport.

USD and the second session costs about $15 USD, withhealth insurance covering 70% of the cost.
The most remarkable aspect to us was the range of
textures on the menu while still ensuring that the foodlooked appetizing; in Vietnam, the IDDSI categorizationis poorly implemented, and even if it is, the dishes arequite monotonous or not up to grade. Meanwhile, in
Nerima Hikarigaoka Hospital, the staple food (rice)alone has many variations from normal rice, soft rice,and porridge (whole porridge, 50% porridge…) to
thickening porridge, liquidized, and jelly type.
Furthermore, the texture-modified dishes are shaped tolook like normal dishes so the patients can find themappealing. We hope that we can acquire more knowledge
on these texture-modified dishes not only from Japan but
also from our fellows in the network and apply it toVietnamese hospitals in the near future so that
Vietnamese patients with dysphagia or chewing
problems can also enjoy scrumptious meals other thanthe options of ONS or enteral feeding/parental feeding.

Visit to Japanese Hospital (Nerima Hikarigaoka
Hospital)
We were welcomed by friendly and generous
Japanese registered dietitians (RD). From the meetingand lectures of the hospital’s head of the nutrition
department, Ms. Keiko Hirose. RD, and Dr. Matsumoto,we were impressed with how well-organized the
management is, the flow of the nutrition care plan is a
corporation of nurses, and attending doctors to the RD.
Their attention to minute details is worth admiration,from the RD's dedication to making 80 menus withvarious adjustments to the texture according to theJapanese IDDSI classification to the instructions on how
to assist patients in taking their meals. Moreover, wecame to understand the importance of the RD to thefinances of the hospital, as they can bring a lot of profit
by providing nutrition counseling. In Vietnam, most
hospitals offer free nutrition counseling, however inJapan, the first 30-minute appointment costs around $20

Fig 1. Japanese hospital meal – soft diet
Visit to elementary school for school lunch (Funabori
Elementary School)
One of the very meaningful activities that weparticipated in was visiting and observing the school
lunch meal at Funabori Elementary School. Unlike manyother countries, Japan has a remarkable system where
over 30,000 dietitians are dedicated to ensuring thenutritional quality and safety of school meals forchildren. This demonstrates the high regard that theJapanese government and society have for children's
nutrition. In addition, one extremely impressive thing is*To whom correspondence should be addressed:
trangnn27@gmail.com
169

Asian Young Dietitian Networkthat lunch is completely free for the children at thisschool.
During the visit, I also had the opportunity to observe
the kitchen staff through a system of glass windows. The
kitchen design is equipped with glass windows so
students can observe the process of cooking staff
preparing their meals. The dietitian here said it is also a
way to educate children about nutrition, teaching themgratitude to those who make their meals.
Japanese school dietitians are in charge of planningmenus (about 290 menus for a school year), calculating
costs, ordering food, managing food hygiene, andcorresponding
with
food
allergies,
nutrition
education,...I was deeply moved when the principal said
that thanks to the dietitian students can have deliciousand safe school meals and praised the dietitian at thiselementary school as the best in Japan. This shows thehigh regard for the role and status of school dietitians inJapan.
There are many other useful things that I and otheryoung dietitians learned during the visit to Funabori
Elementary School. I hope that the Japanese school
lunch system and school dietitian job positions will soon
spread to other Asian countries and around the world.

factors to this issue. However, specific policies orprograms targeting overweight and obesity have yet tobe implemented. Regarding the dietetic system in
Vietnam, there are two pathways to becoming a dietitian.
One can complete a 4-year Bachelor of Nutrition course
at a university. Alternatively, one can pursue a 6-year
general doctor program followed by a nutrition
residency. Dietitians in Vietnam can work in various
settings such as hospitals, institutes/universities, andcompanies but not as school dietitians or in their clinics.
While there are legal protections for dietitians in place,the strength of these protections is not consideredsufficient.
During the meeting, we also had the opportunity tolearn about the status of the other 11 Asian countries.
The presentations from the member countries
highlighted the incredible diversity and tantalizing
nature of Asian food culture. However, it may benecessary for us to reevaluate our dietary patterns due tothe prevalent issue of overweight and obesity across thecountries. While some nations have implemented
national intervention programs, no country has achieved
significant success in addressing this problem. In termsof the dietetic system, most countries have their training
systems and protective laws for dietitians. Notably,
Japan, Taiwan, and the Philippines have specificdietitian laws that focus on dietitians, rather than being
merely a section of broader health laws. Conversely,
Bangladesh currently lacks a dedicated law for nutrition.
In terms of working opportunities for dietitians, many
places are available however, for schools, Japan stands
out as they have dietitians in all schools, while othercountries may only have them in private schools or not
at all.
Overall, participating in the AYDN provides anopportunity for countries like Vietnam and others towork together to enhance the status of dietitians. We
expect that by fostering strong friendships andrelationships among participating countries, we cancreate opportunities to share knowledge throughcollaborative research, webinars, and workshops.
Through these interactions, we can collectively propose
programs and initiatives aimed at addressing andimproving the nutritional problems specific to eachcountry. The ultimate goal is to work together towards ahealthier future for all.

Kick-off meeting of AYDNAt the kick-off meeting, we had a chance to present
about the food culture, the nutritional problem, and the
dietetic system of our country. Vietnamese food culture
is rich and diverse, with a unique blend of flavors, a
renowned street food culture, and regional varieties. Our
main ingredients are rice and rice products, meat, poultry,
freshwater fish, and vegetables and the main seasonings
are fish sauces, Fish/shrimp/crab paste, and natural
spices. When it comes to traditional Vietnamese food, it
is impossible not to mention pho and banh mi - twodishes that have gained international popularity and havebecome iconic representations of Vietnamese cuisine. In
terms of nutritional problems, Vietnam faces challenges
such as childhood overweight and obesity, childmalnutrition, elderly malnutrition, and metabolic
syndrome. Childhood overweight and obesity have seen
a rapid increase, from 8.5% and 2.5% in 2010 to 19%
and 8.1% in 2020 for overweight and obesity in children
5-19 years old, respectively. High consumption of sugarsweetened beverages/snacks, fast food, and low levels ofphysical activity have been identified as contributing

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Asian Journal of Dietetics 2023

Special Report: The Cambodian Food Culture
The Introduction of “The Palm Sugar”
No. 2 in a Series
Ry Manydine
Jumonji University, Saitama, Japan
Talking about sugar you may have thought that it isjust one of the basic ingredients that is used to enhance
the sweetness in meals or desserts. White sugar or brownsugar are very commonly used all over the world,
however in Cambodia there is a different type of sugarthat can be seen used along with other types of sugar. It
is known as the “Palm Sugar”. What makes palm sugar
different from the other is very fascinating. To slightly
introduce Cambodian palm sugar, you have to know that
palm trees only grow in a tropical country with slightly
hot weather. The type of palm tree that is used to extract
palm oil is a different type of palm tree, the one that isused to make palm sugar is often confused as a coconut
tree. The palm tree that is used to make the palm sugar
is very tall, it can reach up to 30 meters with a fanshaped leaf up to 3 meters. It is also known as“Cambodia’s National tree”.
In this study, I went to interview a local palm sugarmaker in Banteay Srey village, Siem Reap, Cambodia.
The village is known as the palm sugar village, manyfamilies in that area rely on making the sugar and sell itto the tourist, in order to make a living. It was very
fascinating to interview and learn about how sugar ismade. Many desserts and dishes can be made by using
palm sugar as the main ingredient.
How to extract Palm juice:
The tall palm tree, may looked like no one canclimbed up to the top but, in Cambodia a lot of villagers
climb up until the top to extract the juice, As you
claimed to the top of the tree, you can see there are two
types of palm fruit known as the “Male palm” and the“Female palm”. Both types contain juices that are
known to make the sugar

Fig 1. Palm tree

Fig 2. Palm sugar village shop

Fig 3. Male palm (left) and female palm (right)

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The Palm Sugar

liters of juice resulted in 4 kilograms of sugar. This
process showed the dedication and requirements inorder to make palm sugar that is served in Cambodian
dishes and dessert. The process might not becomplicated but the labor is very much needed in orderto successfully make the palm sugar.

How to make Palm sugar:
The extracted juice is directly poured into a big pot,with low heat wood fire, it's required to keep stirring
until the juice thickens and becomes a palm sugar. Someare air dry to make it into a solid form, and some arestored in an airtight container to keep as a paste form. 40

Fig 4. Making palm sugar

Recommend Recipes
Kor sach Jruk (Caramelized pork stew)
Ingredients: Pork belly, boiled egg, palm sugar,
garlic, fish sauce, soy sauce, salt, black pepper
How to make: In a separate bowl mix seasoning
together (Garlic, fish sauce, soy sauce, salt and black
pepper). In a hot pan put in the palm sugar until it
melted and give the aroma of sweetness then pour inthe mixed seasoning, mixed it well and put in the pork
belly and boiled egg. Close the pot lid, and simmer it
until the pork is well cooked. Constantly pour in somewater, to avoid burning. This dish is such a comfort
food to many Cambodians, it is easy to make anddelicious, also its one of the dishes that popularized theused of palm sugar in Cambodia.
In conclusion, I hope that this articles could reachmany audiences and spread more about Cambodian
food culture. Our food are our pride, so Palm sugar isthe delicacy that Cambodian people loved, with thisarticles. I hope that many people will start toacknowledge more of our food culture and become
more recognizable to other nation.

Fig 5. Kor sach Jruk (Caramelized pork stew)172