ISSN2434-2688

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

Editor-in-Chief :Shigeru Yamamoto (Japan DA)

Vice chief-editors:
1). Seema Puri (Indian DA)
2). Winnie Chee (Malaysia DA)
3). Zenaida F. Velasco (Philippine NDS)
4). Chwang Leh-Chii (Taiwan DA)
5). Sunard Taechangam (Thailand DA)

Editor in each country/area:
1)
Hong Kong
2)
India
3)
Indonesia
4)
Japan
5)
Korea
6)
Malaysia
7)
Pakistan
8)
Philippine
9)Singapore
10)
Taiwan11)
ThailandGordon Cheung
Jagmeet Madan
Martalena Purba
Shigeru Yamamoto
Kyeong Sook Yim
Winnie Chee
Fayza Khan
Zenaida F. Velasco
Lim Yen Peng
Leh-chii Chwang
Tasanee Limsuwan

Editorial Assistant: Ms. Phi Ngoc Quyen
Journal office: Asian Nutrition and Food Culture Research Center,
Jumonji Univeristy, 2-1-28 Sugasawa, Niiza-City, Saitama 352-8510, Japane-mail: aj-dietetics@jnl.calorie-smile.jp

FOREWORD
It is Time to Publish!
Editorial for the First Issue of Asian Journal of Dietetics
Chwang Leh-chii, DrPH, RD
Honorary President
Asian Federation of Dietetic Associations
It is with great pride and privilege that I write this editorial for the first issue of the Asian Journal of
Dietetics (AJD), the official journal of the Asian Federation of Dietetic Associations (AFDA).

Being

founded in 1991, AFDA is a professional coalition of dietetic organizations in Asia. Its aim is to pursue theadvancement of applied nutrition and dietetic practice in order to achieve better nutrition status for the
population of Asia. Evidence resources are essential for evidence-based practice in all aspects of nutritioncare. However, until the present, it has been difficult to find an academic international periodical in Asia
which could provide various subjects of interests to dietitians, whose expertise includes, but is not limited tosuch areas as: preventive and clinical dietetics, dietary culture and behavior, institutional food service
management, nutrition policy, education and epidemiology. There is an urgent need to build a platform fordietitians to document and publish their research findings. Furthermore, publication in international journals
will not only access to more readers, and impact larger communities, but also increase research credibility
and benefit professional development. At the July 2018 council meeting of AFDA held in Hong Kong, theestablishment of a web publishing and peer-reviewed journal was approved and the Asian Journal of Dietetics
began to take shape. The birth of this new journal would not have been possible without the dedication andenthusiasm of Editor-in-Chief, Shigeru Yamamoto, PhD, RD, from Japan. Special thanks also extend to theeditorial board and expert reviewers from twelve member-organizations of AFDA. The editorial board
welcomes you to share original research, research note and case reports, and to use this journal as a forum
for the progress of dietetics. As the New Year unfolds and the Asian Journal of Dietetics goes online, we
cordially hope that you will enjoy this publication and find it a useful medium for the dissemination of
information and ideas.
We look forward to your support and feedback.
January, 2019
Chwang Leh-chii, DrPH, RD___________________________________________
E-mail: lcchwang@yahoo.com

ISSN2434-2688

Asian Journal of Dietetics
Vol.1

No.1

2019

Contents
Review
1-3 The Rise of Nutrition and Dietetics in Asia
Chwang Leh-chii

Originals
4-11 A Nutrition Survey and Food Patterns in Predominantly Middle-income
Housewives in Jakarta
Indri Kartiko Sari, Dwi Oktaviana, and Diah Mulyawati Utari
12-17 Indonesian Tempeh from Soybeans Can Be Included in Japanese Main Dishes
and Can Increase Fiber Intake
Sumiko Kamoshita, Indri Kartiko Sari, Diah Mulyawati Utari, Saiko Shikanai and
Shigeru Yamamoto
18-22 Relationshipbetween

Nutritional

StatusandQuality

of

Life

in

Gastrointestinal Cancer Patients on Chemotherapy
Linh Nguyen Thuy, Tu Nguyen Huu, Phuong Duong Thi, Nhung Nguyen Thi, andHuong Le Thi

Asian Journal of Dietetics 2019

REVIEW
The Rise of Nutrition and Dietetics in Asia
Chwang Leh-chii *Honorary President, The Asian Federation of Dietetic Associations,
President of Chinese Dietetic Society (Taiwan)(Received November 30, 2018)
ABSTRACT This article overviews the history and development of nutrition and dietetics
starting from the ancient civilizations in Asia. The progress of the nutrition research on
nutrition deficiencies leading to the discovery of vitamins, and the extension of nutrition
services evolving from healthcare facilities to communities are described. The emerging
advancement in dietetic education and professionalism, and the establishment of the AsianFederation of Dietetic Associations (AFDA) aiming for improved nutrition status are
summarized.
Keywords: Asian dietetic history, AFDA

The early beginnings of nutrition and dietetics in
Asia
Ancient civilizations, among them, the Asian
cultures of China and India, noticed and studied theimportance and impact of food and diet on healthand disease of their people.
Three thousand years ago, during the Zhou
Dynasty in China, a diet doctor was a medical
specialist as delineated in the royal protocol of theancient book Zhouli. Preserved in a seventhcentury text, entitled "Essential Prescription worth
a Thousand Gold" is the following passage on diettherapy: “food is fundamental to health;unawareness of proper food intake is inadequate
for survival; physicians find the disease origin andtreat patients with food modification, thenprescribe medicine; taking prudent diet, overeating causes diseases” (1).
The traditional medical care system in India,
Ayurvedic medicine, has also been practiced
thousands of years. Ayurvedic physicians today
continue to prescribe diets, in addition to herbal
compounds, exercise regimens and lifestyle
recommendations to improve the health of theirpatients (2).

deficiencies and the discovery of nutrients became
the subjects of research and experimentation. The
high morbidity and mortality among people duringextended ocean crossings captured the interest ofresearchers. In 1747, the Scottish physician in
British Navy, Dr. James Lind, performed the firstclinical trials of test diets on the crew to study thenutritional requirements of seafarers who lacked
the availability of fresh fruits and vegetables forextended periods of time (3). His discovery of theneed for citrus fruit to prevent scurvy was alandmark achievement in the annals of maritime
history.
Later, in 1884, Dr. Kanehiro Kakaki, aJapanese naval physician, using epidemiologicalresearch, hypothesized that beriberi was due toinsufficient nutrition (4). His research results
helped to drastically reduce the incidence of thisdeficiency by improved diet. Another example ofearly research in 1897 is provided by Dr.
Christiaan Eijkman who a Dutch physician
conducted investigation in Batavia, Indonesia,
noticed that unpolished rice containing some
substance fed to chickens helped to prevent
beriberi. His work led to the discovery ofvitamins (5).

The development of a nutrition research
approachDuring its early development, nutrition anddietetics were mainly based on empiricalinformation. The research approach to thesesciences evolved slowly over the years. The
following are examples of how early research into
nutrition and dietetics helped to improve the livesof people suffering from nutrient deficiency
maladies which afflicted people worldwide. With
the Age of Exploration to the new world during thefifteenth through the eighteenth centuries, nutrition

The evolution of dietetics in the early twentiethcentury
As the twentieth century approached, nutrition
concerns, formerly focusing mainly on military
personnel, began to include children. The earliest
school lunch program was a Buddhist activity in
Yamagata Prefecture in northern Japan in 1889.
This program eventually grew into a nationwide
undertaking (6, 7).
In Japan, in 1914, Dr. Saiki Tadasu establishedthe first nutrition institute. He is also credited with
opening the first school to train dietitians in 1924(8). In Korea, in 1929, Nutrition Science and FoodManagement was offered as a major of study in the
Department of Home Economics at Ewha________________________________*To whom correspondence should be addressed.
E-mail: lcchwang@yahoo.com

1The Rise of Nutrition and Dietetics in Asia

Women’s Professional School (9, 10). Ten years
later in 1939, at the University of the Philippines,
the discipline of Foods and Nutrition was
introduced as a bachelor degree major (11).
Today, dietitians play an essential role in service inhealth care facilities. This service can trace its
origin to Turkey during the Crimean War, 18541856. In this war, Florence Nightingale,originally from Britain, found that poor diet, alongwith inadequate sanitation and lack of nursing care
were detrimental to the wounded and the sick, she
was the first to set up a diet kitchen in the militaryhospital (12, 13).
As the importance of dietetics grew, hospitals
in Asia began to hire dietitians in early twentiethcentury. In 1921, Beijing Union Hospital being
funded by Rockfeller Foundation opened in China
and had an independent nutrition department,
whose chief dietitians were from the United States(14).
Nutrition service now widely extends to thecommunity. Dr. Cicely Williams, a Jamaican
pediatrician who worked in Malaysia, began anoutreach program in the 1930’s and 1940’s tocampaign against the use of artificial milk
substitutes for infant feeding. Her famous speechon “Milk and Murder” was a landmark event at theSingapore Rotary Club in 1939 (15). Her
outspoken promotion of breastfeeding made an
everlasting and global impact on nutrition related
to infants and young children. Today, there are
two non-government organizations formed in
Penang working around the world to support andpromote breastfeeding – the International Baby
Food Action Network (IBFAN) and the World
Alliance for Breastfeeding Action (WABA) (16).

become the major venue for the sharing of
knowledge as well as research and practice among
dietitians and nutritionists. Beginning with thisnew year 2019, AFDA will start to publish the
web-based and peer-reviewed Asian Journal of
Dietetics (AJD).
The AFDA now consists of 11 full members from
Hong Kong Nutrition Association, Indian Dietetic
Association, Indonesia Dietitians Association,
Japan Dietetic Association, Korean Dietetic
Association, Malaysian Dietitians' Association,
Pakistan Nutrition and Dietetics Society,
Nutritionist-Dietitians' Associationof thePhilippines, Singapore Nutrition and Dietetics
Association, Thai Dietetic Association, Chinese
Dietetic Society (Taiwan), and one affiliatedmember from Dietitians Association of Australia(17). AFDA dietitians serve more than 20 billion
people, their responsibility is huge andtremendously important.
Looking to the future, AFDA will consolidate
more inspiring ideas, search for excellence in the
dietetic profession, and continue striving toachieve improved nutrition and health of thepeople in Asia.
ACKNOWLEDGEMENTS
I would like to extend my great appreciation to
Dr. Ching-Hwa Chiu for his constructive
comments and advices on this review, and Ms.
Karen Malick Chwang for her valuable assistancein editing this manuscript.
REFERENCES
1) Sun SM. 2014. Diet therapy. Essential
Prescription Worth a Thousand Gold 26: 893894. Dah-Jann Pub Co Ltd, Taipei(in Chinese).
2) Chopra A, Doiphode VV. 2002. Ayurvedic
medicine. Core concept, therapeutic principles,and current relevance. Med Clin North Am 86:
75-89.
3) Baron HJ. 2009. Sailors' scurvy before andafter James Lind - a reassessment. Nutr Rev
67: 315–332.
4) Sugiyama Y, Seita A. 2013. Kanehiro Takaki
and the control of beriberi in the Japanese
Navy J R Soc Med 106: 332-334.
5) Christiaan Eijkman - Facts. NobelPrize.org.
Nobel Media AB. https://www. nobelprize.org/prizes/medicine/1929/eijkman/facts/,
accessed: 02/01/2019.
6) Public Interest Group Incorporated Foundation Japan Association for Improving
School Lunch. Japanese School Lunch.
History of school lunch. https://www.
Gakkyu.or.jp/english/#japaneseschoollunche,
accessed: 26/12/2018
7) Kaneda M, Yamamoto S. 2015. The Japanese
school lunch and its contribution to health.
Nutr Today 50:268-272.
8) The Saiki Nutrition College. The history of
Saiki (in Japanese).http://www.saiki.ac.jp/sch
ool /history.html, accessed: 20/12/2018.
9) The Korean Dietetic Association. Dietetics in
Korea: History of dietetic in Korea. https://www.dietitian.or.kr /english/kdadietetics/kd
history.do, accessed: 21/06/2018

The emerging progress of dietetics
The field of dietetics has been booming in Asia
since the second half of the twentieth century. Thisis evidenced by the increasing demand for
dietitians in the workforce along with the increased
number of graduates in nutrition and dietetics from
Asian universities. The issues of curriculum,practicum and qualification requirement have beenaddressed and imposed by educational institutions
and regulatory bodies to safeguard the competency
standards of dietitians.
One of the most significant events in thehistory of Asian dietetics was in early 1990s withthe establishment of the Asian Federation of
Dietetic Associations (AFDA). The first time that
Asian dietetic leaders met was at the Asian
Symposium on Rice and Nutrition by the invitationof the Taipei Dietitian Association in 1990. Thissymposium brought about the birth of the Asian
Forum of Dietetic Professionals (AFDP) in 1991,
in Kuala Lumpur. AFDP was later renamed as
AFDA (17).
The AFDA has a three-fold mission: (1) topromote networking, (2) to organize and host the
Asian Congress of Dietetics, and (3) to pursue theadvancement of applied nutrition and dietetic
practice to achieve better nutrition status for the
Asian populations (17).
Since the first Asian Congress of Dietetics(ACD) in Jakarta in 1994, and the subsequentmeetings held every four years, this Congress has

2The Rise of Nutrition and Dietetics in Asia

10) Ewha Womans Unisversity. Department of
Nutritional Science and Food Management.
History.https://www.ewha.ac.kr/mbs/ewhaen/
jsp/organizationCon/organizationView2.jsp?id=ewhaen_030215050000&cateId=136&lan=eng, accessed: 25/12/2018.
11) University of the Philippines. College ofHome Economics. Food Science andNutrition. http://www.che.upd.edu.ph/content/food-scienceand-nutrition-fsn, accessed: 26/
12/2018.
12) Gill CJ, Gill GC. Nightingale in Scutari: Her
Legacy Reexamined. 2005. Clin Infect Dis
40:1799–1805.
13) Hertzler AA. Florence Nightingale's Influence
on Civil War Nutrition. 2004. Nutr Today
39:157-160.

14) Beijing Union Hospital. About us: The
history and current status of the Nutrition
Department, Beijing Union Hospital (inChinese).http://www.pumch.cn/detail/14221.
html, accessed: 20/06/2018.
15) Cannon G. Inspiration. Cecily Williams. Public health and child nutrition hero. 2014 World
Nutr 5:262-267.
16) Anwar Fazal Speaking Out. Anwar the activist.
https://www.anwarfazal.net/about.php, accessed: 27/12/2018.
17) The Asian Federation of Dietetic Associations.
History, Mission, Congress. http://www.afdadietitians.org/, accessed: 20/06/2018.

3

Asian Journal of Dietetics 2019

ORIGINAL
A Nutrition Survey and Food Patterns in Predominantly
Middle-income Housewives in Jakarta
Indri Kartiko Sari1*, Dwi Oktaviana2, Diah Mulyawati Utari2
1

International Nutrition, Jumonji University
Niiza, Saitama Prefecture, Japan2
Department of Public Health Nutrition Studies, Faculty of Public Health,
Universitas Indonesia. Depok, West Java, Indonesia(Received November 30, 2018)
ABSTRACT Background and purpose. Lifestyle-related diseases have become the leading
cause of death in Indonesia and are increasing along with overweight and obesity in all ages.
Currently, about half of Jakarta women are obese. Little is known of their present dietary
habits and food patterns, particularly among housewives. This study investigated energy andnutrient intakes compared with the current recommended dietary allowance, intakes ofvegetable and table sugar, and frequently consumed foods. Methods. Seven communities in
Jakarta were contacted and permission from 4 communities was obtained. Housewives wereapproached through each community health center. There were 196 housewives agreed to be
subjects. Anthropometric measurements were conducted at the health centers. A nutrition
survey by the 24 hour dietary recall method for 3 nonconsecutive days was conducted byvisiting each subject’s home. Results. Thirty-nine percent of the subjects had normal BMI,
21% were overweight, and 40% obesity. The daily nutrient intakes of energy, protein,carbohydrate, lipid, and fiber were 1962 kcal, 54g, 249g, 87g, and 10g, respectively. Energy
intake was close to RDA of 1900kcal/day, lipid intake was on upper limit level, and fiber
intake was only half of lower limit level. The vegetable intake was 96g/d, only 25% ofrecommendation. The table sugar intake was 29g/d, within recommendation of less than 10%
energy. The top three frequently consumed foods were 29% fried animal protein, 17% friedtempeh, and 15% coconut milk rice. Commonly consumed sugary food and drinks were 19%
cake and 19% added table sugar in tea or coffee. Conclusion. By the high prevalence ofoverweight and obesity whilst energy intake was close to energy RDA, it suggested that RDA
is currently overestimated. The factors for lifestyle-related diseases were suggested by thehousewives` overweight and obesity prevalence, high lipid intake and low fiber intake.
Keywords: nutrition intake, food patterns, vegetable intake, sugar intake, housewives

INTRODUCTION
In Indonesia, the tendency toward lifestyle-relateddiseases has been increasing year by year. According
to basic health research conducted by the Ministry of
Health, the three major causes of death in Indonesia
are stroke, heart diseases, and diabetes mellitus (1-4).
It was also found that the prevalence of obesity andoverweight has been increasing for the last 10 years,
basically in all age groups (1-3). In Indonesian adult
population, male obesity increased from 13.9% to19.7% and female obesity increased from 23.8% to32.9% (3). The role of nutrition intake in lifestylerelated disease is important for determining the next
steps in both prevention and cure. Excessive nutrient
intakes can lead to development of lifestyle-relateddiseases.
Almost 20 years ago, a dietary intake and food pattern
study in relation to heart disease was conducted inWest Sumatra, investigating on the food culture ofWest Sumatra food culture, which Indonesians believe

has the highest prevalence of coronary heart diseases
because of its traditional fatty and oily foods withcoconut milk, palm oil, and animal protein as the main
ingredients (5). It concluded that intakes of animal
foods, total protein, cholesterol, and total carbohydrate
were coronary artery disease predictors (5). This study
is a good example of Indonesian cuisine with noinfluence of western food, but it was limited to case ofpeople suffering from coronary heart disease andincluded both men and women (5).
From the data of the national economic survey inIndonesia, which shows per capita consumption byhouseholds and was analyzed by the Ministry of
Health (6), it was found that the average energy intake
in Indonesia, especially in women age 19 – 55 years
old, was 1607kcal/day (7). The total energy intake wasabout 77% energy of the 2000kcal Indonesian
Recommended Dietary Allowance (RDA) (7,8).
However, 40% of women, especially in Jakarta, wereobese (3) and death caused by lifestyle-relateddiseases has been increasing (1-4).
Worldwide, most women stay at home or work ashousewives. They tend to spend more time taking careof the family rather than their own health (9). Dietary_________________________________________*To whom correspondence should be addressed:
indri.kartiko@yahoo.com

4Nutrition Survey in Jakarta Housewives

habits of the family begin with the housewives, but thehousewives often care more about the family foodconsumption than their own (9). Economic
development has an effect on the normal household. It
may also change their lifestyle, which eventuallychanges their dietary habits as well.
Since little is known about the food patterns of
Jakarta housewives and nutrition surveys on them, yetalmost half of Jakarta women are obese, the purposeof the study was to find the current nutrition intake ofhousewives in Jakarta compared with the current
Indonesian RDA, including vegetable and table sugar
intakes, their current nutritional status, and foodpatterns. The nutrient intakes, food intakes, andnutritional status of the women investigated in thisstudy are considered predictors for lifestyle relateddiseases.

At the visit to the community health center, we took
their anthropometric measurements and recorded thepersonal data and addresses of the housewives.
Estimation of nutrient intake. Nutrition surveys using
the 3-day 24-hour recall method were implemented
three times: 2 weekdays and 1 weekend day. All thenutrition surveys were conducted on one by one home
visits to each subject. The nutrition survey wereconducted by nutritionists who have at least one year
experience in monitoring and supervising studies,
especially community studies. Energy, protein, lipids,
carbohydrate, fiber, vegetable, and sugar intake wereobtained from each survey. The nutrition surveys were
calculated using Indonesian food composition data
(10) in Microsoft Excel Software 2013
Estimation of table sugar intake. the intake of tablesugar was estimated using sugar composition table
which was establish previously (11) The calculationof table sugar intake was performed using Microsoft
Excel Software 2013.
Statistical Analysis. All procedures of data analysis
were performed using Microsoft Excel Software 2013.

METHODSIn Indonesia, there are community health centersavailable in every district and community. Two cities
in Jakarta, of which has 65 districts, with about 1820
communities in total. Each community has one
community health center. Every month, the healthcenters offer basic health examinations for residents
from infants to elderly people. We contacted 7
communities, but only 4 communities agreed to accept
us for the study. After that, we applied for permission
from each district social welfare service. The social
welfare service brought the application to the mayor`s
office. After the mayor`s office granted permission, we
could start the study at the community health centers.
Before the study, we trained the investigators, whohold Bachelor of Nutrition degree from the Universitas
Indonesia. Next, we contacted 4 health centers andfrom each health center we obtained a list ofhousewives who regularly visit the health center. Then
we invited them to come visit us at the health center.

RESULTS
In total there were 196 subjects who participatedin our study. The characteristics of the subjects
included an average age of 51, weight of 60kg, height
152cm and BMI of 26.5kg/m2 (Table 1). All subjects
were housewives. Thirty-nine percent of subjects had
normal BMI, 61% were overweight or obese, and nounderweight subjects found in this study (Fig 1). The
nutrient intakes and food intakes were presented as
grams per day (g/d). The energy intake was 1962
kcal/d, protein intake was 54g/d, carbohydrate intake
was 249g/d, and the total lipid intake was 87g/d, while
fiber intake was 10g/d with vegetable intake of 96 g/d,and sugar intake from table sugar of 29g/d (Table 2)

Table 1. Characteristics of the subjects (n=196)
Variables

Average±SD

Age (years)
51 ±Weight (kg)60 ±Height (cm)152 ±BMI (kg/m2)
26.5 ±
Data are shown in mean ± SD

9
10
6
4.2

Table 2. Energy and nutrient intakes of the subjects and Indonesian RDA 2013(8) (n=196)
Daily intake
RDA(8)
Daily intake/RDA(%)
Energy (kcal)
1962 ±342
1900
103.3%
Protein (g)54 ±1557
94.4%
Lipids (g)87 ±2453
163.4%
Carbohydrate (g)249 ±52285
87.2%
Fiber (g)
10 ±4
28
35.7%
Vegetable (g)96 ±38Sugar from table
29 ±14sugar only (g)Data are shown in mean ± SD

5

Nutrition Survey in Jakarta Housewives

Fig 1. Prevalence of Normal, Overweight, and Obesity (n=196)

Fig 2 Comparison of energy and nutrient intakes with RDA

Fig 3. Food pattern frequencies

Fig 4. Sugary food and drink patterns

Energy and nutrient intakes were compared withIndonesian RDA (8) in Fig 2. The RDAs for nutrient
intakes are shown in ranges (12). Protein intake was
54g (standard range 10 – 15% of energy, about 0.9–
1.5g/kgBW/day, 50 – 81g/d), total lipid intake was 87g(standard range 25 – 35% of energy, 53 – 84g/d),carbohydrate intake was 249g (standard range 40 –60% of energy, 215 – 323g/d), and fiber intake was
10g (standard 20g/d or more, 10 – 14g/1000kcal).
The food patterns of the housewives are shown infrequencies. The most frequent foods is 29% fried
animal protein which includes meat, fish, and egg,
17% fried tempeh, 15% coconut milk rice, 9% fried
rice, 6% of meatball, 6% tempura, 6% instant noodles,
and others. There are almost no vegetable dishes
among the foods most frequently consumed by thehousewives.

Sugary food and drink patterns is shown at Fig 4.
The most common sweet foods consumed is 19% cake,14% biscuit, 14% doughnut, and 14% other snacks.
For drinks, 19% drink tea and coffee with added tablesugar, 12% coffee cream powder, and 8% condensed
milk.
DISCUSSION
This study was conducted in 196 female subjects
who were housewives in Jakarta to determine theirobesity rates through BMI and dietary factors fromintakes of energy, as well as to establish major
nutrients including fiber and vegetable and table sugar.
The Jakarta area was selected since the averageoverweight and obesity there was found to be highfrom the government basic health research (1-3).
Overall there were no underweight women found6

Nutrition Survey in Jakarta Housewives

in our study, while the normal, overweight, and obesity
prevalence was 39%, 21%, and 40%, respectively. The
results support the government report on basic healthresearch, which showed the obesity prevalence inJakarta women was 40% (3). In this study, the subject
housewives were from average, middle class families.
These results support the contention that the subjects
in this study can be recognized as representative of
women in Jakarta.
The results of energy and nutrient intakes from thisstudy and the Recommended Dietary Allowance 2013
(RDA is called AKG 2013 in Indonesian) werecompared (8). The results of energy intake in thehousewives were close to the Indonesian RDA, whichmakes it difficult to explain the high prevalence ofoverweight and obesity. The Indonesian RDA wasestimated using the model formulation of Dietary
Reference Intake developed by the Institute ofMedicine, United States (12,13)
The model calculation is called EER, EstimatedEnergy Requirement, an average dietary energy intake
to predict energy required to maintain balance in ahealthy adult defined by age, gender, weight, height,
and physical activity level (PAL) in order to sustain
weight in the range desired for good health (13). Thismodel calculation was used with the Indonesian RDA
2013 with adjustment (12).
The Indonesia RDA of energy calculation was
estimated using units for weight and height for normal
median weight and height of Indonesians based onnational basic health research (8,12). For physicalactivity value, it was estimated using “Light Activities”
value, based on basic health research which shows that
more than 90% of Indonesians’ activity level was fromvery light to light activities (1-3,8.12) so the value forphysical activities was estimated 1.12 for women
above 19 years old (12,13) The model calculation of
EER for women 19 years and older is indicated below:
EER = [354 – (6.91xAge in year)] + PA x[(9.36xWeight in kg) + (726xHeight in meter)](PA = 1.12)
In determining women‘s RDA for energy, forwomen age 50 – 64 years old, the Indonesian data forweight and height used were 55kg and 159cm (8,12).
At the final regularity which was listed as Indonesian
RDA, energy RDA for women age 50 – 64 years old
is 1900kcal/day (8,12). In our study, it was found thatthe housewives with an average age of 51 had anenergy intake of 1962kcal/day. It is similar to thecurrent Indonesian RDA for 50 – 64 years old (8). In
contrast, overweight and obesity rates were found tobe high in our study. This may suggest that the current
Indonesian RDA is overestimated.
A better situation has developed in Japan, as thefemale obesity rates have been decreasing for the lastten years (14). For Japanese Dietary Recommended
Intake (DRI), the EER for Japanese is obtained bymultiplying basal metabolic rate (BMR) and PAL(15,16). Representative values for BMR per kg ofbody weight were determined based on previous
researches for Japanese people, called the reference
value for BMR (15,16). The reference BMR is basedon the reference BMR reported in 2005 DRI and BMR
values that have been reported since 1980 (15-23). The
PAL unit used for light activities is 1.5 based on PAL
research in Japanese (15,16).
For Japanese women aged 50 – 69 years old withlight activity the DRI for energy is 1650 kcal/d (15).
The current average energy intake is 1706kcal/d andthe average weight and height for women age 50 – 59
years old is 55kg and 156.6cm (14), meaning that thisis a proper recommendation for controlling healthproblems, especially obesity. As comparison, whenthese these values for average weight and height for
50years old and light physical activity were inserted in
the formulation used for Indonesian RDA, the result
will be 1855kcal, about 205kcal higher than thecurrent Japanese DRI for energy with light activities(12-14).
The Indonesia RDA is available only at one level,
as it is formulated for light activity and is used for all
age groups (8,12). However for most other countries,
the RDA for energy is listed using 3 – 4 levels ofactivity (15,16, 23,24). In comparison with women 50
years old with light activities, Japanese energy DRI is
1650kcal/d, Singaporean is 1720kcal/d, and Malaysianenergy RDA is 1660kcal/day (16,23,24). The current
Indonesian RDA for energy is 200kcal higher
compared with energy RDAs for these countries forlight activities level (8,16,23,24). Further research andreviews need to be done in order to improve the current
RDA of Indonesians, especially on deciding anequation which is properly applicable for Indonesian
people.
The lipid intake of the housewives reached 36% of
their total energy intake, which is 87g/d. It is at theupper limit of the standard range for lipid intake (12).
About 25% of EER was determined as the RDA for
lipids in the Indonesian RDA, which means that for
women age 50 – 64 years the EER is 1900kcal/d and
25% of this is 53g/d for the lipid RDA (8,12). Whenthe actual lipid intake and the RDA lipid intake arecompared, there is 34g difference, which means thatthe housewives’ lipid intake is 306kcal higher than the
RDA lipid intake (8). An explanation for this lipid
intake is suggested in the following discussion
From the subjects’ frequent food intake, it was
found in this study that almost all the frequent foods
were fried foods. The most common food consumed
by the housewives were 29% animal protein fried,such as meat, fish, and egg cooked by deep frying
methods, the second was 17% fried tempeh, and thethird was 15% coconut milk rice, known as Nasi Uduk.
Frying is one of the common, easy methods to prolong
food expiration, a tasty, attractive, and very simple
cooking method (25). The fact that it is a simple
cooking method may also be a factor in why thehousewives consumed more fried foods.
In Indonesia, the most common oil used in frying
is palm oil since the price is cheap and it is easy to findanywhere, but it contains 45 – 50% saturated fatty
acids (SFA) in one serving (10,26). As for originally
low calorie and low fat foods, they will become
energy-dense foods with oil absorption from the frying
process (27,28). Another common lipid source used inIndonesian cuisine is coconut milk, which contains
20% SFA of total calories in one serving (10,29).
Coconut milk is used to make soup and creamy savorysauces in Indonesian cuisine. Since both ingredientsare major parts of Indonesian cuisine, the SFA mightmake a significant contribution to total lipid intake inour study, which can lead to higher risk ofcardiovascular diseases (30).
The housewives SFA intake is estimated from theirfrequent food intake, of which roughly 45% is fried
foods. In 1962kcal of the housewives’ energy intake,883kcal comes from fried foods. Thus, about 36% of
the energy contribution from fried foods comes from7

Nutrition Survey in Jakarta Housewives

lipids, 317kcal. Finally, approximately 50% of
317kcal is SFA from palm oil, which is about 159kcal,
so the SFA intake of housewives is roughly 17.6g per
day just from palm oil. This amount might become
higher if it is combined with other lipid sources.
Although a SFA recommendation is currently
unavailable in the Indonesian RDA, other countries
like the USA have SFA intake recommendations which
are less than 10% of energy per day, about 21g/d (31).
This recommendation is based an American nutrition
survey in 2010, which found that the SFA intake of thewhole American population on average contributed
325calories or more than 16% of energy per day, about
36g/d (32). It was found that the SFA intake of 51 – 70
year old American females ranges between 10 – 12%of energy, which is about 22.5g/d from SFA intake
alone (31).
Unlike American dietary guidelines, therecommendation for SFA the Japanese DRI is 4.5% 7% of the total lipid intake. The lipid intake ofJapanese women age 50 – 59 years old is 55g/d, meansthat intake of SFA is 4g/d at maximum, much lower
than the SFA intake from our study (14,16). Fromthese comparisons, American women have a higher
SFA intake than Japanese women and Indonesian
women‘s SFA intake is closer to that of American
women. This excess lipid intake might be a factor in
the very high death rate from heart disease inIndonesia (4)When causes of death are compared among thesecountries, death caused by lifestyle-related diseases
are currently higher in America and Indonesia than inJapan (1-4, 33,34) Trends in mortality caused bylifestyle-related diseases among the same age group ismostly caused by circulatory system disease in
America and Indonesia. For Indonesian women, withthe high prevalence of overweight and obesity andhigh lipid intake, close to the situation in American
women, the tendency to hyperlipidemia and the risk ofcirculatory system diseases seem to be high, with heartdisease becoming one of the leading causes of death inIndonesia.
From all these facts, the real problem is overintake. If the housewives can develop better food
habits of to reduce lipid intake, 300kcal excess can beeliminated from their total energy intake and they caneventually reach a proper energy intake to lower therisk of lifestyle-related diseases. Reducing fried foods
or reducing the SFA might be good ways to improvehealth.
High lipid intake and low fiber intake have been
linked with increases of cardiovascular disease risk
(37). Fiber intake of housewives found the present
study showed only 10g/d, half of lower limit level. The
benefit of fiber to control cholesterol levels and to
decrease the risk of coronary heart disease has beenreviewed in many studies, which is found
14g/1000kcal can achieved that benefit (12,13,39).
Fiber can be a good way to modify diet with the goalof improving lipid profiles and blood pressure to
reduce cardiovascular risk (40). In other words, more
fiber will have the effect of better coronary circulationand less risk of cardiovascular disease (41).
When the subjects` food pattern was observed, it
became clear that the animal source dishes and highcarbohydrate dishes were frequently included in their
daily diet. Source of fiber like vegetable dishes andfruit were rather infrequently included. The Staple
food for Indonesian is rice as in most Asian Pacificcountries, but it doesn’t contain high fiber since theskin of the rice is removed during processing the husk.
Fiber contained in raw Indica rice, the common riceconsumed in Indonesia, is only 0.4g/100g (10,42).
Raw shorter grain rice, commonly consumed in East
Asian countries, contains 0.5gram fiber of 100g (42).
Brown rice contains more fiber, about 3g/100g.
However, for most Indonesians, brown rice isinfrequently consumed since the flavor is not as
delicious as regular white rice. In European countries
and the US, people consume cereal which contains
oats and a fiber content of 9.4g/100g or bread whichcontains wheat and has a fiber content of 10.8g/100g(42). These staple foods can be the source of fiber forthese countries (31,32). So for Indonesians, the major
source of fiber is vegetables and fruit. Indonesians
currently rely on vegetables to include more fiber intheir daily food habit. If Indonesians have a low
vegetable intake, this will result in a low fiber intake.
The FAO/WHO recommendation is 400g/d forvegetable and fruit intake (43). However from oursurvey, the intake was only 96g/d for women, which isabout 25% of the recommendation (8,43). In
comparison, for Japanese women vegetable intake was
237g/d (14). This means that Indonesian womenconsume only 40% of the Japanese intake. Despite thefact that vegetable production in Indonesia is quite
high, there are many factors that might contribute to
the low vegetable intake, from current social habitsregarding food to the economic distribution within the
country. The cooking time needed to process
vegetables might also be a factor, since the housewives
choose simpler cooking methods like frying. Givencurrent Indonesian women‘s food patterns, higher
vegetable intake in women is highly recommended,
especially to increase the fiber intake. Other strategies
should be considered to include more fiber inIndonesian daily dishes such as recommending othersources of fiber aside from vegetables.
Other possible factors related to overweight andobesity were observed, including the sugar intake ofthe housewives. The frequencies of consumption ofsugary food and beverages by the housewives wererecorded. The most frequent sweet food consumed by
the housewives was cake and a common sweet drink
was coffee or tea with regular table sugar. The
frequencies of sweet foods and drinks were low,indicating that the housewives do not regularly
consume commercially available sweet food andbeverages.
Sugary beverages are thought to be a problem inweight management since it is easy to ingest more inliquid form. However, it has been suggested that solid
foods like cakes are more satiating than sugary
beverages, which may also potentially increase thesugar consumption (44,45). In the case of thehousewives` sugar intake, sugar intake coming fromhomemade sugary foods might provide a greater
feeling of satiety than drinking sugary beverages, so
cakes are more frequent compared with sugary
beverages. Cakes are usually energy dense and its
frequent excessive intake is associated with weightgain and excess adiposity (44). In future strategies ofintegrating healthier dietary habits, the housewives
should be encouraged to replace sweet foods withhealthier food choices that provide a greater feeling ofsatiety.
The total sugar intake from table sugar was 29 g/d.
The housewives‘ sugar intake in this study can be8Nutrition Survey in Jakarta Housewives

considered to be within the WHO recommendation,
which is below 10% energy, 50g/d, with a preferable
suggestion of less than 5% energy, 25g (7,12). There
are many studies suggesting that intake of sugar fromsugar-sweetened snacks and beverages may promoteweight gain and eventually cause obesity (8,15,36).
However, in this study we found that the sugar intake
was normal and had no clear relation to the subjects’
overweight and obesity prevalence. It is suggested thatwith intake over 90g/d it may be possible to predict
overweight problems in the future (34). This may be
the case, but it depends on the situation within the
country itself. Despite the fact that the total sugar
intake meets WHO recommendations, the awarenessof varieties of sugar content and their effects on healthshould attract the attention of stakeholders and thesociety itself.
In conclusion, the current RDA is suspected to be
an overestimation. Improvement is necessary,
especially in the applicable equation to be used forIndonesian people. Lipid intake was found highespecially from fried foods. Fiber intake was low,which may be caused by low vegetable intake. Sugar
intake was considered normal. The housewives’current food habits carry lifestyle-related disease risks.
Future study can be focused on the strategies to be
employed in developing healthier food habits inwomen especially in housewives.

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ACKNOWLEDGEMENTS
Acknowledgements are gratefully given for
scholarship support from Beasiswa Unggulan
Masyarakat Berprestasi Kemendikbud Republik
Indonesia, to the members of the Laboratory of
Nutrition Universitas Indonesia, the Asian Nutrition
and Food Culture Research Center, and Prof. Andrew
Durkin of Indiana University for careful proof-readingof the paper.
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11

Asian Journal of Dietetics 2019

ORIGINAL
Indonesian Tempeh from Soybeans Can Be Included in Japanese Main
Dishes and Can Increase Fiber Intake
Sumiko Kamoshita1*, Indri Kartiko Sari1, Diah Mulyawati Utari2,
Saiko Shikanai3 and Shigeru Yamamoto1
1

International Nutrition, Graduate School of Human Life Sciences,Jumonji University, Saitama 352-8510, Japan2
Department of Public Health Nutrition Studies, Faculty of Public Health,
Universitas Indonesia. Depok, West Java, Indonesia
3
Department of Health and Science, Aomori University of Health and Welfare,
Aomori 030-8505, Japan(Received November 30, 2018)
ABSTRACT
Background and purpose. Currently, major health problems, not only inJapan, include lifestyle-related diseases such as diabetes, dyslipidemia and myocardial
infarction. Insufficient fiber intake is one of the main factors for these conditions. Although
the Japanese Recommendation Dietary Intakes for fiber are 20g/d for men and 18g/d for
women, according to a recent nation-wide nutrition survey intakes were about 15g and 14g,
respectively. An increase in dietary fiber intake is usually expected from increased
consumption of vegetables and grains but not from main dishes such as meat, fish, eggs, dairy
products, or soybean protein products, because these contain little fiber. In this study, we
focused on the use of tempeh (dietary fiber 10.2g/100g), Indonesian fermented soybeans, asa main dish. Purpose. An increase in dietary fiber intake through main dishes using tempeh.
Method. The subjects were female students, faculty and staff, security guards, and cleaners(totaling 60 people) at a university. Ten Japanese-style main dishes were prepared using theusual principal ingredients, such as eggs and meats, and ten dishes that replaced thoseingredients with tempeh. The ten dishes were: rolled thick omelet, teriyaki, Chinese-style
fried chicken, keema curry, piccata, hamburger steak, croquette, tofu in meat-and-chili sauce,
sweet-and-sour pork, and stuffed pouches of deep-fried tofu. We offered each control dish(normal ingredients) and its parallel tempeh-based dish on the same plate for lunch. Overall
taste, aroma, mouth feel and basic taste were evaluated by scores from 1 to 4 (4 very good; 3
good; 2 poor; 1 very poor). Results. The average evaluations of the 10 control dishes andtempeh dishes were 3.7 and 3.5 points for overall taste, 3.7 and 3.4 points for aroma, 3.4 and3.1 points for mouth feel and 3.7 and 3.4 points for basic taste, respectively. Evaluations oftempeh dishes were close to those of the control dishes. Especially for keema curry,
hamburger steak, and stuffed pouches of deep-fried tofu, the tempeh dishes received highevaluations. In these three dishes, we used finely chopped tempeh, which suggests that the
optimal use of tempeh was in a finely chopped form. The amount of dietary fiber increased
by about 2g with tempeh dishes. Conclusion. We found that tempeh can be used as a part ofJapanese main dishes to increase dietary fiber by about 2g from each meal.
Keywords: Tempeh, fiber, main dish, Japanese.
INTRODUCTION
Lifestyle-related diseases, such as diabetes,
dyslipidemia, and myocardial infarction, have been
increasing, not only in Japan but also globally (1). Oneof the important dietary factors for this is insufficient
fiber intake (2-3). However, it is usually difficult tomeet sufficient amounts of fiber. According to theDietary Reference Intakes (DRI) for Japanese (2015),
the recommendation is 20g/d for men and 18g/d for
women (4), while the actual intake of fiber reported bya recent Nationwide Dietary Survey was 14.5g/d formen and 13.9g/d for women in 2016 (5). This meansthat actual daily fiber intake is about 5g short. It isdifficult to satisfy the recommended intake of dietaryfiber from vegetables and staple foods. We need tolook for new fiber sources. In this study, we examinedways to increase fiber intake from main dishes. For
this purpose, we chose tempeh, which is rich in dietaryfiber and can be used as a main dish. Fiberconcentrations of tempeh are high. Fiber in 200kcal
tempeh and in natto is 10.1g and 6.7g, respectively (6).
Tempeh has been a traditional fermented soybean foodin Indonesia for more than 500 years. It can easily beobtained at a low price (about 50 Yen (half a US dollar)
per one serving size of 400g) and used in cooking in agreat variety of ways.
METHODS
Development of tempeh dishe: The subjects werefemale students, faculty and staff, security guards, and*To whom correspondence should be addressed:
da16001@jumonji-u.ac.jp

12Increase of Dietary Fiber Intake by Tempeh in Japanesecleaners at universities where the researchers work.
We explained the purpose of this research and those
who agreed to participate signed the informed consent
form (50 people in total). Prior to the main study, we
conducted a pilot study to find the best cooking
methods for 10 types of tempeh dishes. These dishes
were familiar to Japanese and did not require special
cooking skills. For some dishes, the ingredients werecompletely replaced with tempeh, while in others they
were partially replaced. Details of the cooking
methods for the 10 dishes are shown below.
Rolled thick omelet: We explored how muchtempeh could be added to the egg solution. The
tempeh was not finely chopped, but it was ground andmixed with raw beaten eggs. The trial tests started with

30% of the total solution but this resulted in a hard anddry texture. Trial production and tasting were repeated,gradually decreasing the proportion of tempeh. As aresult, we found that an 80% egg and 20% tempeh
mixture was the most delicious (Fig 1-1).
Teriyaki: Chicken was replaced with tempeh.
When tempeh was coated with potato starch and fried,
the texture became soft. This would be good for people
with chewing difficulties. When tempeh was covered
with wheat flour and fried, it was chewy and moredelicious. In this study, wheat flour was used. A
flavorful sweet sauce went well with the tempeh, so
we fried the tempeh and simmered it with the sauce;
this was the best tasting version and the one used in
the study (Fig 1-2).

Fig 1-1. Rolled thick omelet lunch
right: with tempeh
left: only eggs (control)

Fig 1-2. Teriyaki lunch
right : tempeh
left : chicken (control)

Fig 1-3. Chinese-style fried chicken lunch
right : tempeh
left : chicken (control)

Fig 1-4. Keema curry lunch
right : with tempeh
left : ground beef and pork (control)

Fig 1-5. Piccata lunch
right : tempeh
left : chicken (control)

Fig 1-6. Hamburger steak lunch
right : with tempeh
left : ground beef and pork (control)

Fig 1-7. Croquette lunch
right : tempeh
left : ground beef and pork (control)

Fig 1-8. Tofu in meat-and-chili sauce
lunchright : with tempe
left : ground pork (control)

Fig 1-10. Stuffed pouches of deep-fried
tofu lunch
right : with tempeh
left : ground chicken (control)

Fig 1. Ten lunches given to subjects

13

Fig 1-9. Sweet-and-sour pork lunch
right : tempeh
left : pork (control)Increase of Dietary Fiber Intake by Tempeh in JapaneseChinese-style fried chicken: Chicken was
replaced with tempeh. When tempeh was coated withpotato starch and fried, it was smooth and easy to eat.
The tempeh was delicious with reduced acid,especially when seasoned with soy sauce before
cooking. This taste was best and was the version usedin this study (Fig 1-3).
Keema curry: Mixed ground meat and tempeh invarious proportions and found that 30% meat and 70%
tempeh was most delicious (Fig 1-4).
Piccata: Chicken was replaced 100% withtempeh and seasoned with soy sauce. When egg andgrated cheese were added, the taste was markedly
improved (Fig 1-5).
Hamburger steak: Started with 70% groundmeat and 30% tempeh. This tasted good, but it wasdifficult to form the hamburger patty. We tried tofind the best combination for taste and shaping theburger and decided on 50% chopped meat and 50%
tempeh (Fig 1-6).
Croquette: Used 100% tempeh without meat.
The taste was good and cooking was not difficult.
With soy sauce and sugar, the taste became muchbetter (Fig 1-7).
Tofu in meat-and-chili sauce: At first we used
100% tempeh without meat. The taste was too blandwithout any fat. Therefore we increased the meat andfound finally that 70% tempeh and 30% meat was best
(Fig 1-8).
Sweet-and-sour pork: Pork was completely
replaced with tempeh and the taste was as good as theoriginal pork. However, the tempeh was easily broken
up when we cooked it with vegetables; therefore, we
cooked the tempeh and vegetables separately (Fig1-9).
Stuffed pouches of deep-fried tofu: At first we
used 100% tempeh but this was too soft. We tried tofind the best combination and found 50% ground meatand 50% tempeh was most delicious (Fig 1-10).

and the same dishes with the main ingredient partiallyor fully replaced with tempeh. The control and tempeh
dishes were placed on the same plate. We did notinform subjects which was the tempeh dish and which
was the control dish.
The subjects were female students, faculty andstaff, security guards, and cleaners at universities
where the researchers work. We explained the purposeof this research and those who agreed to participate
signed the informed consent form (50 people in total).
Overall taste, aroma, mouth feel and basic taste were
evaluated by scores from 1 to 4 (4 very good; 3 good;
2 poor; 1 very poor). Statistical analyses wereconducted by paired Student t-test and Turkey using
excel.
RESULTS
Table 1 shows the number of subjects and averageage by gender. Total number of subjects was 60 (13males and 47 females). The average age was about 39y(58y for males and 33y for females). Table 2 shows thecomparison of scores of overall taste, aroma, mouth
feel and basic taste between tempeh and control foodsin 10 different menus. Among 10 dishes, 6 dishes were
evaluated higher for the control than for the tempeh(p<0.05), however, the difference was not large. On
average for the 10 dishes, the scores for tempeh andcontrol were respectively 3.5 and 3.7 for overall taste,
3.4 and 3.7 for aroma, 3.1 and 3.4 for mouth feel and3.4 and 3.7 for basic taste.
Fig 2 shows the comparison of 3 tempeh cooking
methods (chopped, cut in blocks and ground). The
order was consistent regardless of the 4 evaluation
items, with chopped highest, block second, and groundthird. Table 3 shows comparison of evaluations for thebest 4 tempeh dishes by age. Age differences were notobserve Fig 3 shows fiber in one serving of lunch.
Average dietary fiber included in the control andtempeh dishes was 4.2 g and 6.3 g for lunch. Teriyaki
lunch increased 3.4g. By using tempeh dish as themain dish, it is possible to increase the dietary fiber
intake by 2.1g.

Sensory Evaluation
We evaluated the 10 traditional Japanese dishes
made with the usual ingredients such as egg, meat, etc.

Table 1. Number of subject and average age by gender
NumberMale
Female
Total

13
47
60

14

Age (year)
Mean±SD
58 ± 1033 ± 18
39 ± 19

Increase of Dietary Fiber Intake by Tempeh in Japanese

Table 2. Comparison of scores of overall taste, aroma, mouth feel and basic taste between tempeh and control
foods in 10 different menus

Rolledomeletthick

Teriyaki
Chinese-style
fried chicken
Keema curry
Piccata
Hamburger
steak
Croquette
Tofu in meatand-chili sauce
Sweet-andsour pork
Stuffedpouches
Averagen
46(M:10,F:36)
50(M:10,F:40)
51(M:12,F:39)
50(M:14,F:36)
45(M:12,F:33)
45(M:14,F:31)
50(M:12,F:38)
60(M:13,F:47)
51(M:12,F:39)
50(M:12,F:38)
50(M:12,F:38)

TempehControlTempehControlTempehControlTempehControlTempehControlTempehControlTempehControlTempehControlTempehControlTempehControlTempehControl

Overall taste
3.2±0.7 *3.6±0.6
3.3±0.7 *3.8±0.5
3.4±0.7 *3.7±0.5
3.8±0.4 ns
3.7±0.5
3.5±0.5 ns
3.7±0.5
3.5±0.6 ns
3.7±0.4
3.5±0.7 *3.9±0.4
3.5±0.7 *3.7±0.5
3.2±0.7 *3.6±0.6
3.8±0.4 ns
3.8±0.4
3.5±0.7 *3.7±0.5

Aroma
3.1±0.7 *3.6±0.5
3.3±0.7 *3.7±0.4
3.6±0.5 ns
3.7±0.4
3.6±0.5 ns
3.5±0.7
3.4±0.6 ns
3.5±0.6
3.5±0.6 ns
3.7±0.5
3.5±0.6 ns
3.6±0.6
3.3±0.8 *3.8±0.5
3.4±0.6 *3.7±0.5
3.6±0.5 ns
3.8±0.5
3.4±0.6 *3.7±0.5

Mouth feel
2.5±0.7 *3.5±0.6
2.7±0.8 *3.4±0.6
3.1±0.8 *3.5±0.7
3.3±0.8 ns
3.3±0.7
3.0±0.8 ns
3.3±0.7
3.3±0.7 ns
3.3±0.6
3.3±0.8 ns
3.4±0.7
3.1±0.8 *3.4±0.6
3.0±0.9 ns
3.3±0.8
3.5±0.7 ns
3.3±0.8
3.1±0.8 *3.4±0.7

Basic taste
3.2±0.7 *3.6±0.5
3.4±0.8 *3.8±0.5
3.3±0.7 *3.7±0.6
3.7±0.5 ns
3.6±0.6
3.4±0.6 ns
3.5±0.5
3.5±0.6 ns
3.7±0.5
3.5±0.7 *3.8±0.5
3.3±0.6 *3.8±0.5
3.3±0.7 *3.7±0.5
3.8±0.4 ns
3.8±0.4
3.4±0.7 *3.7±0.5

Values are mean ± SD.
* Significant difference by paired Student t-test between Tempeh and Control groups in each dish at p <0.05.
M and F stand for male and female, respectively.

* Significant difference by Turkey at p <0.05.

Fig 2. Comparison of 3 cooking methods in tempeh score

15

Increase of Dietary Fiber Intake by Tempeh in Japanese

Table 3.

Keema curry

Stuffed pouchesof deep-fried
tofu

Piccata

Hamburger
steak

Comparison of evaluation for best 4 tempeh dishes by age

Overall taste
Aroma
Mouth feel
Basic taste

20～30’sControlTempeh
3.9±0.3
3.9±0.3
3.5±0.7
3.7±0.5
3.4±0.7
3.3±0.9
3.7±0.5
3.8±0.4

40～50’sControlTempeh
3.6±0.5
3.7±0.5
3.4±0.7
3.2±0.4
3.1±0.8
3.0±0.7
3.3±0.7
3.6±0.560～70’sControlTempeh
3.3±0.8
3.6±0.5
3.5±0.8
3.5±0.5
3.1±0.7
3.6±0.5
3.3±0.8
3.5±0.5

Overall taste
Aroma
Mouth feel
Basic taste
Overall taste
Aroma
Mouth feel
Basic taste

3.9±0.3
3.9±0.4
3.1±0.9
3.9±0.3
4.0±0.0
3.8±0.5
3.5±0.7
3.8±0.4

4.0±0.0
3.7±0.5
3.5±0.7
4.0±0.2
3.8±0.4*
3.6±0.6
3.2±0.9
3.5±0.5

3.8±0.4
3.7±0.5
3.7±0.5
3.7±0.5
3.4±0.5
3.4±0.5
3.1±0.8
3.2±0.4

3.7±0.5
3.6±0.5
3.6±0.7
3.8±0.5
3.2±0.7
3.2±0.7
2.7±0.7
3.1±0.8

3.7±0.5
3.6±0.7
3.4±0.7
3.7±0.5
3.3±0.5
3.1±0.7
3.1±0.8
3.3±0.5

3.6±0.5
3.7±0.5
3.3±0.8
3.6±0.5
3.3±0.5
3.3±0.6
2.9±0.8
3.4±0.5

Overall taste
Aroma
Mouth feel
Basic taste

3.9±0.3
3.9±0.3
3.5±0.7
4.0±0.0

3.7±0.6
3.7±0.5
3.5±0.7
3.7±0.6*

3.8±0.4
3.3±0.7
3.1±0.8
3.4±0.5

3.2±0.7
3.1±0.8
3.1±0.8
3.0±0.5

3.4±0.5
3.5±0.5
3.2±0.4
3.4±0.8

3.5±0.5
3.5±0.5
3.3±0.7
3.4±0.6

Values are mean ± SD
* Significant difference by paired Student t-test between Tempeh and Control groups in each dish at p <0.05

Fig 3.

Dietary fiber in one serving lunches

DISCUSSION
With this study we found that tempeh can be used
as a part of Japanese main dishes and can increase
dietary fiber by about 2g from each meal.
The increase of fiber was quite significant.
Although the Japanese Dietary Recommended Intakes(DRI) for fiber in 2015 is 20g/d for men and 18g/d for
women (4), according to a recent nation-wide nutrition
survey in 2016, the intakes were about 15g and 14g,
respectively (5). An increase in dietary fiber intake isusually expected from increased consumption ofvegetables and grains but not from main dishes suchas meat, fish, eggs, dairy products, or soybean protein
products, because these contain little fiber. If weincrease the amount from white rice, we have to eat
400g of white rice (uncooked). On the other hand, if

we use brown rice, only 80g is sufficient; however,many people dislike its hardness and smell, so it is noteasy to increase fiber by this method. The Japanese
recommendation for vegetables is 350g/d but atpresent average intake is about 280g, which contains
about 8g fiber; this intake has been decreasing for thelast 10 years (5), indicating that in order to supply 2g
fiber from common Japanese vegetables, we would
need about 70g additional vegetables, which isdifficult. When we have difficulties in supplying fiber,
tempeh is really a good main dish.
In Japan there is a traditional fermented soybean
food "natto", but it uses a different type of
microorganism from that used in tempeh. The
microorganism for natto is a bacterium, “Bacillus
subtilis var. natto”, whereas for tempeh it is a mold,

16

Increase of Dietary Fiber Intake by Tempeh in Japanese“Rizopus oligosporus”. This is a filamentous fungus
that belongs to the genus Rizopus. In Indonesia, it is acommon mold which naturally occurs on the undersideof banana and hibiscus leaves. In Japan, tempeh ismanufactured with bacteriologically pure cultured
Rizopus oligosporus (called tempeh fungus). Tempeh
has a high dietary fiber content because the fungus
cells themselves are fibrous. The main component of
the mycelia is thought to be “chitin” (7-8). Chitin is an
insoluble dietary fiber distributed in fungi, animals
and plants. Tempeh can be a high-dietary fibercontaining food because there are many dietary fibers
in the constituents of the mycelia. Since tempeh,
unlike natto, has little smell or stickiness, it can beadapted to various dishes. It is soft and easy to chew
for persons with chewing difficulties. From these facts,
we believe that if we can use tempeh as the prime
ingredient in Japanese main dishes, we can increase
dietary fiber intake to the level meet the RDA.
Although tempeh is a new food for Japanese andcan be a significant fiber source, it will be accepted
only if people like the taste. Ten Japanese-style main
dishes were prepared using the usual principal
ingredients, such as eggs and meats, and ten dishes that
replaced those ingredients with tempeh. The ten dishes
were: rolled thick omelet, teriyaki, chinese-style friedchicken, keema curry, piccata, hamburger steak,croquette, tofu in meat-and-chili sauce, sweet-andsour pork, and stuffed pouches of deep-fried tofu. We
thought that the ordinary food dishes would havehigher evaluations than the tempeh dishes, but
surprisingly the tempeh dishes had quite highevaluations, with 4 out of 10 dishes evaluated as highas the ordinary dishes. Among the best 4 tempeh
dishes, finely chopped tempeh was used in 3 dishes.
These were keema curry, hamburger steak, and stuffed
pouches of deep-fried tofu (Table 2).
The reason why the taste of finely chopped
tempeh dishes is rated highly is that the taste of thesoybeans themselves was not noticed when the tempeh
was mixed with sufficient amounts of otheringredients. If we eat tempeh itself, not finely chopped,
we sense the smell and taste of the soybeans. In thecase of croquettes, which are fried, tempeh is lessgreasy than meat and may be easier to eat.
Tempeh piccata was evaluated one of the best 4,
but the tempeh was left as it was and not chopped. The
reason for this may be the browning of the grated
cheese added to the seasoned egg mixture. Browning
grated cheese in the egg mixture in a frying pan
produces a fragrant aroma, which may reduce theawareness of the soybean smell of tempeh.
The limitations of this study, if there are any, arethe number of male and female subjects and also thedifference in the age groups. In this study, weevaluated 10 types of tempeh dishes that were tested
by about 50 people. This total number is similar to the
published papers using panel test (9-15). Although thenumber of male and female subjects and also the age
structure were different, the results in Table 3 show
similar scores for 20-30’s, 40-50’s and 60-70’s except
for minor differences, indicating that the results
obtained in this study were not affected by such factors.
In conclusion, tempeh dishes will be easily
accepted by Japanese with proper cooking. High fiberand also soybean protein can be expected to control
blood glucose and lipids significantly. Further studies
are expected.
16)

REFERENCES
1) Sugiura R, Sakamoto M, Murata M: Risk of lifestyle related diseases in young children. 2007. The
Japanese Journal of Nutrition and Dietetics 65:
67-73 (in Japanese).
2) Pereira MA, O’Reilly E, Augustsson K, Fraser GE,
Goldbourt U, Heitmann BL, Hallmans G, Knekt P,
Liu S, Pietinen P, Spiegelman D, Stevens J,
Virtamo J, Willett WC, Ascherio A. 2004. Dietaryfiber and risk of coronary heart disease. Archivesof Internal Medicine 164: 370-376.
3) Ludwig DS, Pereira MA, Kroenke CH, Hilner JE,
Horn LV, Slattery ML, Jacobs DR, Jr. 1999.
Dietary fiber, weight gain, and cardiovasculardisease risk factors in young adults. JAMA 282:
1539-1546.
4) Ministry of Health, Labour and Welfare of Japan:
Dietary Reference Intakes for Japanese, 2015.
2015. Daiichi-shuppan Press, Tokyo (in Japanese).
5) Ministry of Health, Labour and Welfare of Japan.
The outline report of the National Health andNutrition Survey of Japan in 2016. https://www.mhlw.go.jp/file/04-Houdouhappyou-10904
750-Kenkoukyoku-Gantaisakukenkouzoushinka/kekkagaiyou7.pdf (in Japanese), accessed:
15/11/2018.
6) Ministry of Education, Culture, Sports, Scienceand Technology of Japan: Standard Tables ofFood Composition in Japan, 2015. 2016.
Ishiyaku-shuppan Press, Tokyo (in Japanese).
7) Negishi Y: Nutritional and chemical studies on
Tempe. 1993. Bulletin Kagawa Nutrition
University 1: 87-115(in Japanese).
8) Taguchi K, Kawabata M, Ohtsuki K, Tanaka Y.
1986. Changes in dietary fiber of Natto andTempeh during fermentation. J Med Sci Biol 39:
203-208.
9) Utari DM: The effect of Tempeh intervention on
lipid profile, superoxide dismutase, Ox-LDL andmalondialdehyde in postmenopausal women.
2011. Graduate School of Bogor Agricultural
University.
10) Miyazawa S, Suzuki T, Matsuo M, Sakai E: Studyon cooking and taste of Soy tempeh and Peanuttempeh. Bulletin Nagoya Bunri University 8: 2932, 200811) Vital RJ, Bassinello PZ, Cruz QA, Carvaiho RN,
Paiva JCM, Colombo AO: Production, quality,
and acceptance of Tempeh and White bean
tempeh burgers. 2018. Foods 7:136.
12) Paredes-Lopez O, Harry GI, Gonzalez-Castaneda
J: Sensory evaluation of Tempeh produced byfermentation of common beans. 1990. J Food Sci
55: 123-126.
13) Ueta K, Watanabe I: Knowledge and foodcharacteristics on Tempeh. 2009. Bulletin
Shikoku University 31: 15-19 (in Japanese).
14) Ishida M, Tezuka H, Hasegawa T, Cao L, Imada
T, Imada T, Kimura E, Matsumoto H, Kawano R,
Arai H. 2011. Sensory evaluation of a low-saltmenu created with Umami, similar to savory,
substance. J Med Sci Biol 64: 305-311.
15) Fukai Y, Suzuki I, Nishi K, Ookuma K:
Evaluation of snow room storage for lowtemperature aging of locally fermented food.
2010. Journal of Cookery Science of Japan 43:
246-259 (in Japanese).

17Asian Journal of Dietetics 2019

ORIGINAL
Relationship between Nutritional Status and Quality of Life in
Gastrointestinal Cancer Patients on Chemotherapy
Linh Nguyen Thuy1,2*,Nguyen Huu Tu3, Phuong Duong Thi1,
Nhung Nguyen Thi4, Huong Le Thi1,21Department of Nutrition and Dietetics, Hanoi Medical University Hospital,
Hanoi, Vietnam.

2

Department of Nutrition and Food safety, Institute for Preventive Medicine andPublic Health, Hanoi Medical University, Hanoi, Vietnam.
3

Department of Anaesthesia and Critical Care, Hanoi Medical University,
Hanoi, Vietnam

4Department of Pulmonology, Middle Berlin Hospital, DRK Berlin Hospitals,
Berlin, Germany.
(Received December 7, 2018)

ABSTRACT Background and purpose. Malnutrition occurs frequently among cancer
patients, especially those who having GI cancer and receiving chemotherapy. This condition
obviously affects to patient’s QoL. This study aimed to determine relationships between
nutritional status and QoL in GI cancer patients receiving chemotherapy. Method. This crosssectional study was conducted among 65 patients in HMUH from 2016 to 2018. BMI, PGSGA, Albumin and the EORTC QLQ –C30 was used to assess. Results. The rate ofunderweight was higher in gastric cancer than colorectal cancer patients, 50.0% and 27.6%
respectively (p<0.05). Malnourishment rate was significantly higher in gastric cancer patientswith 97.2% in comparing with 62.1% colorectal cancer patients (p<0.0001). Among 65
patients, 23.1% patients had low Albumin (<35g/dL). Global score, emotional functioning
score were lower and fatigue score was higher in malnourishment or underweight groups(p<0.05). Patients at risk of malnourishment had significantly lower score of physicalfunctioning (p=0.005) and higher score of nausea and vomiting (p=0.01), pain (p=0.0001),
appetite loss (p=0.047). Additionally, as PG-SGA score increased, fatigue, appetite loss andpain symptoms increased (r=0.59 0.42 and 0.43 respectively) while global score decreased(r=-0.45) (p<0.005). The correlation of BMI with global score was positive (r=0.42, p<0.005),
with fatigue and pain symptoms was negative (r= -0.25 and -0.27 respectively, p<0.005).
Conclusion. The results showed that underweight patients or patients at risk of
malnourishment had lower QoL than normal weight and well-nourished patients. Thus,
nutritional interventions are essential to improve QoL of GI cancer patients receiving
chemotherapy.
Keywords: nutritional status, quality of life, gastrointestinal cancer, chemotherapy

INTRODUCTION
Cancer incidence has been increased recently and was
the second leading cause of death worldwide in 2015(8.8 million deaths); while the third and fourth mostcommon causes were colorectal and stomach cancer(774 000 and 754 000 deaths respectively) (1). In
Vietnam, cancer is the second leading cause of deathamong non-communicable diseases (2).

Cancer affects to nutritional status and QoL
negatively due to the disease itself as a result of
metabolic alterations, symptoms, and also because oftreatment therapy’s side effects. Most common
symptoms of GI cancer and chemotherapy are anxiety,abdominal pain, weight loss as well as digestive
problems such as appetite loss, heartburn, nausea,
vomiting, indigestion, constipation and diarrhea. GI
cancer patients on treatment therapy reported various
negative effects on their nutrition and QoL such as
fatigue, body image disturbance, eating restriction,
digestive problems and neuropathy symptoms; these
symptoms can persist long time after treatment (3,4).
It is known about relationship between nutrition andrisk of complications, hospital stay, recurrence, trement outcome and survival rate. Weight loss is*To whom correspondence should be addressed. E-mail:linhngthuy@hmu.edu.vn
Abbreviations: GI = Gastrointestinal, HMUH = Hanoi
Medical University Hospital, BMI= Body mass index, PGSGA = The scored Patient-Generated Global Assessment,
EORTC QLQ–C30=European Organization for Research
and Treatment of Cancer Care Quality of Life Questionnaire18

Nutritional Status and QoL of Cancer Patients with Chemotherapy

common in patients on chemotherapy; it depends on
cancer type and stage, arranged from 20% to 58% and
up to 72% in advanced gastric cancer (5,6,7). Weightloss and low dietary intake cause higher malnutrition
rate in GI cancer patients on chemotherapy, which isreported from 37.9% to 74.3% (8,9). A study ingeriatric GI system cancer patients indicated that themalnutrition rate increased from 34.6% to 46.4%
significantly with p=0.001 after one course of
chemotherapy (8). The serum albumin level was
significantly decreased after chemotherapy treatment
and patients with hypo-albuminemia developed more
severe chemotherapy-induced toxicity symptoms.
That was a finding in a study of X. Wang and college(10). Moreover, albumin was demonstrated as amarker of prognosis of treatment outcome andmortality, higher serum albumin associated with better
survival in cancer patients (11).
Patients who at risk of malnutrition reported
significantly lower QoL than well nourishment indomains of global health, functioning, and symptoms(12, 13). These patients had lower global health, worse
psychosocial issues like physical, emotional, cognitiveand role functioning which belong to human being andsuffered from more unwanted physical symptoms likenausea, vomiting, pain, fatigue.
Thus, the demand of screening malnutrition andmanagement nutritional status, QoL of GI cancer
patients undergoing chemotherapy increased, in orderto implement nutritional intervention and also improve
QoL. However, as the best knowledge, it was limited
research in Vietnam about nutritional status of thesepatients on chemotherapy. For this reason, we
conducted this study to find out the malnutrition rate
and the relationship between nutritional status and
QoL in GI cancer patients on chemotherapy.

nourished, B: moderately malnourished or suspectedmalnutrition, C: severely malnourished). Three groupsof Albumin include: normal rank is 35-50g/L;
malnutrition is <30g/L
Quality of life (EORTC QLQ-C30) Participants’
QoL was evaluated by Vietnamese version 3.0 of
EORTC QLQ-C30. The EORTC QLQ-C30 is aquestionnaire developed to assess the QoL of cancer
patients worldwide (14,15). The questionnaire
consists of four domains (global health, five functional
scales, eight symptom scales and financial difficulties)
with totally 30 questions. A low score of global healthand functional scale, high score of symptom scale andfinancial difficulties indicate low QoL. The
Vietnamese version was validated elsewhere andshowed high/moderated validity and reliability.
Statistical analysis: The data obtained from study
was analysed by STATA 12.0 (StataCorp, College
Station, Texas, USA). The relationship between
nutritional status and QoL was assessed by t-test,
Mann-Whitney test and Pearson’s correlation. P-value<0.05 was considered statistically significant.
RESULTS AND DISCUSSION
Participants’ characteristics: Patients over 60
years old were 35.4%. Thirty-seven patients (56.9%)
were male and twenty eight patients (43.1%) werefemale. 36 patients (55.4%) had stomach cancer and29 patients (44.6%) had colorectal cancer, including
31 patients (48.5%) in stage II or III and 33 patients(51.5%) in stage IV.
Nutritional status: According to BMI classi-＾
fication of WHO, 40.0% patients were underweight,
58.5% had normal weight and only one patient (1.5%)
was overweight. The prevalence of malnutrition in
gastric cancer was non-significantly higher thancolorectal cancer (p=0.076). This underweight
prevalence is lower than the finding of a study in BachMai hospital in 2012 in colorectal cancer patients with58.6% patients had BMI <18.5 kg/m2 (16). However,
the result of the present study is higher than the reportin France of A. Nourissat et.al in 2008 with only 8.6%or the finding of Reza et al. in 2011 with 10.9% of
patients were underweight (13,17). The differences
may due to differences in population, cancer type andstage, nutrition practice. However, the BMI index isoften used to making decision about nutrition
management. So, nutrition improvement andintervention to increase BMI for the patients arenecessary.
As the classification of the scored PG-SGA, 18.5%
patients were allocated with PG-SGA A. 61.5%
patients were allocated with PG-SGA B and 20.0%
patients with PG-SGA C, giving total a malnutrition
prevalence of 81.5% patients. Especially, there was
27.8% gastric cancer patients had severe
malnourishment. This prevalence is higher than thereport of Nunilon Veergara and college in 2011 with
40.21% malnourished patients in the research or
43.4% patients in the report of A. Nourissat et al.
(17,18). However, the present study has similarfinding with another study on gastric cancer patients
receiving chemotherapy, which showed 59% of thepatients were malnourished, and 27.8% of the patients
revealed serious malnutrition (19). Another study of
AZ. Zalina et al. on patients with GI cancer showed ahigh prevalence of malnutrition with 74.3%, whereas
48.6% were classified as severely malnourished (9).
Our study indicated that patient with gastric cancer
had significantly higher risk of malnutrition than

MATERIALS AND METHODS
A cross-sectional study was carried out on GI
cancer patients who receiving chemotherapy in
HMUH, Vietnam from January 2016 to January 2018.
The study conducted 65 patients above 17 years old
with diagnose of gastric or colorectal cancer, whowere receiving chemotherapy. Excluding criteria:
patients have other diseases related cardiology, kidneydiseases, liver diseases...The patients were voluntary
to be asked and involved to this study, and wereexplained clearly about the goals and the approach ofthis study and signed in the consents. General
information include age, sex. Weight and height were
measured directly at point time of interview. PG-SGA
and EORTC QLQ C30 were completed with face toface interview or self-completed the questionnaire. By
using medical record with agreement of hospital
director board, age, type and stage of cancer, albumin
were investigated. The research was approved by
medical ethic committee of Hanoi Medical University
in 2016
Nutritional status: Nutritional status wasassessed by BMI, scored PG-SGA and Albumin
simultaneously.
The BMI was calculated from weight and heightand classified into 3 groups (underweight: BMI<18.5kg/m2, normal weight: 18.5 – 24.9 kg/m2, overweight:≥ 25 kg/m2).
The scored PG-SGA, which is widely
implemented and recommended in oncology clinicalpractice, was assessed. This scale includes patientgenerated historical components, professional
components, and classified into three groups (A: well

19

Nutritional Status and QoL of Cancer Patients with Chemotherapy

patients with colorectal cancer (97.2% and 62.1%,
p=0.000 respectively). This finding is similar to thefinding in research of Liyan Zhang et.al, that rectal
cancer patients had a lower risk of malnutrition thanthe other GI cancer (20). In this study, there was no
significant difference of malnutrition risk between
gender, age and cancer stage. From these results, GI
cancer patients undergoing chemotherapy, especiallygastric cancer, were vulnerable to be malnourishment
and needed intensive support to improve nutritional
status.
Albumin was conducted in all participants in thisstudy. Hypoalbuminemia or albumin serum level
lower than 35g/L was 23.1% and no significant
difference was found between stomach and colorectal
cancer (p=0.72). This prevalence is lower than the
result of the research on advanced non-small cell lungcancer (50%) (21). Although, the prevalence is higher
than the result of SH. Seo et al. with 14.5% or A.
Nourissat et.al with 4.6% of patients had hypoalbumineamia (13,17). Our finding pointed that anessential intervention in providing and improving
nutrition practice, dietary intake and also supplement
during treatment are needed.
Quality of life: The different parameters of QoL
across the different nutritional status classifications(PG-SGA, BMI and Albumin) are depicted in table 1.
As the result of this study, all parameter scores ofglobal and functional scales were higher in patientswith well nourishment (PG-SGA A) or normal weightin compared with malnourished and underweight.
Among the functioning domains, cognitive
functioning showed the highest score in all patientswith PG-SGA A or B and C, underweight or normal
weight. On the other hand, all parameter scores ofphysical scales and financial difficulties were higher
in malnourished or underweight patients. The highest
scores of malnourishments and underweights were
financial difficulties and fatigue. Moreover, the results
show significantly higher scores in domains of global
health and emotional functioning among wellnourished or normal weight patients thanmalnourished or underweight patients (p<0.05). Whilefatigue among patients with PG-SGA A or BMI ≥18.5
kg/m2 was lower than the others (p<0.05). There weresignificantly differences between malnourishment andwell nourishment in physical functioning, nausea andvomiting, pain and appetite loss (p<0.05). The
differences of other scales between well nourishment
and malnourishment, underweight and normal weight
had non-significant.

Table 1. Assessment of patients’ quality of life score according to their nutritional status
by PG-SGA, BMI and Albumin
PG-SGA
Variable

BMI
p

Malnutrition(<35 g/l)

Normal(≥ 35 g/l)p52.99 ± 14.4

0.02b52.8 ± 18.0

49.2 ± 13.5

0.54 b

66.7 ± 15.9

72.6 ± 14.3

0.23 b75.1 ± 12.5

68.8 ± 5.7

0.1 b

0,1b

57.1 ± 23.65

58.1 ± 23.8

0.85 b56.7 ± 28.7

58.0 ± 22.1

0.8 b

100 ± 00,13b95.5 ± 14.6

95.7 ± 12.5

0.71 b96.7 ± 9.3

95.3 ± 14.3

0.94 b87.3 ± 17.7

97.2 ± 6.5

0.03b84.9 ± 16.0

91.9 ± 16.7

0.02 b87.8 ± 12.5

89.5 ± 17.8

0.27 b65.1 ± 23.2

65.3 ± 20.7

0.95b59.0 ± 21.7

69.2 ± 22.5

0.08 b73.3 ± 20.7

62.7 ± 22.7

0.12 bFatigue

32.1 ± 20.6

5.6 ± 10.1

0.0001a36.3 ± 24.3

21.1 ± 17.6

0.01a

25.9 ± 14.9

27.6 ± 23.5

0.8a

Nausea andvomiting

5.0 ± 15.2

0±0

0.01b

7.1 ± 19.5

2.1 ± 7.8

0.3 b

0±0

5.3 ± 15.6

0.1 b

Pain

24.0 ± 16.2

5.6 ± 8.2

0.0001a25.0 ± 17.8

18.4 ± 14.7

0.05a

20.0 ± 15.7

21.3 ± 16.5

0.8a

Dyspnea

9.4 ± 20.0

0. ± 00.09b11.5 ± 20.9

5.1 ± 16.3

0.09 b

4.4 ± 11.7

8.7 ± 19.9

0.6 b

Insomnia

22.01± 29.9

11.1 ± 21.7

0.25b29.5 ± 34.4

13.7 ± 22.6

0.06 b

26.7 ± 25.8

18.0 ± 29.5

0.12 bAppetite Loss

17.6 ± 25.8

2.78 ± 9.6

0.047b

17.9 ± 27.0

12.8 ± 22.4

0.4 b

4.4 ± 11.7

18.0 ± 26.3

0.06 bConstipation

4.4 ± 14.7

2.8 ± 9.6

0.88b5.1 ± 15.5

3.4 ± 12.8

0.6 b

0±0

5.3 ± 15.6

0.16 bDiarrhea

8.2 ± 18.4

2.8 ± 9/6

0.31b7.7 ± 21.7

0.66 b

6.7 ± 13.8

7.3 ± 18.2

0.9 b

Financial
Difficulties

39.6 ± 29.3

27.8 ± 34.3

0.19b

42.3 ± 32.1

0.31 b

35.6 ± 29.5

38.0 ± 30.9

0.85 b

Global score
Physicalfunctioning
Role
functioning
Cognitivefunctioning
Emotional
functioning
Socialfunctioninga

Malnourished(B & C)

Well-nourished (A)pUnderweight(< 18.5 kg/m2)

Normal47.5 ± 13.7

61.1 ± 13.5

0.003b45.5 ± 14.0

67.9 ±115.1

80.6 ± 10.8

0.005b55.3 ± 23.6

68.1 ± 22.98

94.6 ± 14.5

Albumin: ttest6.8 ± 12.6
34.2 ± 29.1b

: Mann-Whitney test
functioning and higher score in domains of fatigue (r=0.59), nausea and vomiting, pain (r= 0.43), dyspnea,
appetite loss (r= 0.43), constipation and financial
difficulties (p<0.03). Adversely, patients with higher
BMI had higher global score (r= 0.42) and lower scoreof fatigue, insomnia and financial scale in compared

As the result of the study, a significant associationof QoL with nutritional status was found. Patients,
who had higher PG-SGA score or malnourishment,
had significantly lower score in domains of global
health status (r= -0.45), physical, role, cognitive20

Nutritional Status and QoL of Cancer Patients with Chemotherapy

with underweight patients significantly (p<0.05).
The association between nutrition and QoL wasproved in many studies. Out of the 26 publications
reviewed, 24 found that better nutritional status was
associated with improved QoL and all eight studies in
GI cancer concluded that better nutritional status was
positively associated with better QoL (22). Based on
the present study, the result indicated the same
relationship, that patients had better nutritional status(lower PG-SGA score, greater BMI), had better QoL,
or conversely, patients with malnutrition had impaired
QoL. Table 2 shows a significantly positive correlation between PG-SGA score with symptoms: fatigue,
pain and appetite loss, dyspnoea, nausea and vomiting,constipation, and negative correlation with global
health status, physical functioning, role functioning,
cognitive functioning. Other studies showed a similar
relationship between PG-SGA score and main scalesof QoL (23, 24).
Otherwise, in the present study, the correlation

between BMI index and global score was significantly
positive, while a significant negative correlation wasobserved in symptom domains: fatigue and insomnia(p<0.05). A research conducted on breast cancer
patients on chemotherapy indicated that greater BMI
was associated with better emotional and cognitive
functioning and less fatigue (25).
Both PG-SGA score and BMI were significant
associated with financial difficulties. The finding was
the same with the one of a study among Korean
intestinal cancer patients, a higher perceived economic
burden from cancer treatment affected negatively on
QoL (26).
In our study, we found no significant in thecorrelation between Albumin and QoL. The researchof Tian J, 2008 about Nutritional status and quality oflife in gastrointestinal cancer showed that patients
had high level of albumin had a significantly better
quality of life (22).

Table 2: Correlation between the QoL scores and nutritional parameters
PG-SGA score
BMI (kg/m2)
(r)
-0.45
0.42
Global score(p)0.00020.0005
(r)
-0.35
0.198
Physical functioning
(p)
0.004
0.11
(r)
-0.32
0.03
Role functioning
(p)
0.01
0.86
(r)
-0.001-0.05
Emotional functioning
(p)
0.99
0.7
(r)
-0.28
0.05
Cognitive functioning
(p)
0.025
0.7
(r)
-0.13
0.167
Social functioning
(p)
0.31
0.18
(r)
0.59
-0.25
Fatigue
(p)
0.000
0.044
(r)
0.3
-0.16
Nausea and vomiting
(p)
0.016
0.21
(r)
0.43
-0.095Pain(p)0.0004
0.45
(r)
0.34
-0.093
Dyspnea
(p)
0.006
0.46
(r)
0.23
-0.26
Insomnia
(p)
0.06
0.035
(r)
0.43
0.09
Appetite Loss(p)0.0004
0.46
(r)
0.295
-0.15
Constipation
(p)
0.017
0.24
(r)
0.07
-0.02
Diarrhea
(p)
0.57
0.86
(r)
0.31
-0.27
Financial Difficulties
(p)
0.01
0.03
Variable

CONCLUSIONS
Our study confirmed that malnutrition impaired QoL
in GI cancer patients on chemotherapy. Thus,
nutritional assessment and intervention are fundamental before, during and after treatment in order toget better nutritional status, reduced malnutrition andthrough that to optimize QoL.

Albumin (g/l)
0.001
0.99
-0.06
0.66
0.13
0.34
0.07
0.6
0.08
0.55
-0.17
0.2
-0.05
0.73
0.17
0.78
-0.125
0.36
0.08
0.55
0.02
0.88
0.075
0.58
0.18
0.17
0.025
0.85
0.14
0.3

ACKNOWLEDGMENTS
The authors would like to express our special thanksof gratitude to HMUH for giving the best condition tocomplete the study. We wish to thank all nurses andmedical doctors and patients in Oncology and
Palliative Care Department for their kind assistanceand willingness. Special thanks are extended toprofessor Le Thi Huong for our great contribution.

CONFLICTS OF INTEREST
The authors declare that there is no conflict of interest
regarding the publication of this paper.

21

Nutritional Status and QoL of Cancer Patients with Chemotherapy

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