ISSN2434-2688 Asian Journal of Dietetics

Vol.5 No.1, 2023
Contents
Page
Special Report
1-4

Title and authors
What Dietitians Need for the Future: Evidence-Based Dietetics
Shigeru Yamamoto

Original Research
5-9

Improvement of the Vietnamese school lunch menu
Nguyen Van Diep, Nguyen Mai Phuong, Nguyen Huong Giang, Ta Thi
Ngoc, Ngo Thi Thu Hien, Nguyen Thu Trang, Le Thi Huong, Yamamoto
Shigeru

Original Research
11-16

Rice Facilitates Salt Control in Japanese School Lunches
Kohei Kato

Original Research
17-22

The Risk of Refeeding Syndrome in ICU COVID-19 Patients and Some
Association Factors in the COVID-19 Hospital in Vietnam
Linh Thuy Nguyen, Ha Ngoc Le, Chinh Pham Thi Tuyet, Giang Hoang
Truong, Thao Phuong Tran, Tu Nguyen Huu

Original Research
23-29

Nutritional status and associated factors of gastrointestinal surgicalpatients at Hanoi Medical University Hospital between 2021 and 2022
Linh Thuy Nguyen, An Tuong Bui, Anh Le Thi Ngoc, Nga Thanh Ta, Dung
Duc Le, Tu Huu Nguyen

Original Research
31-41

Knowledge and practice patterns of nutrition-focused physicalexamination in dietitians in Malaysia after an in-person training
workshop with 1-year online follow-up
Cassandra DQ Lim, Rebecca A. Brody, Joachim D. Sackey, Riva E. TougerDecker, Winnie SS Chee, Seong Ting Chen, Jennifer A. Tomesko

Asian Journal of Dietetics 2023

Special report: Thinking about the ideal roles of dietitians
What Dietitians Need for the Future: Evidence-Based Dietetics
Shigeru Yamamoto
Graduate School of Jumonji University, Saitama, Japan
I attended the Annual Convention of
NUTRITIONISTDIETITIANS'ASSOCIATION OF THE PHILIPPINES(NDAP) on Feb 21-25. A symposium entitled“Dietitians
andPhysicians:
Building
Collaboration and Synergy Using the NCP”
chaired by Dr. Varsha from India was very
exciting. Speakers were Dr. Eloisa Villaraza
from Philippine, Dr. Esther Myers from USA(former president of the International
Federation and Dietetic Association) and Ms.
Sylvia Klinger (USA). The lecture by Dr.
Esther Myers was “Using NCP to Demonstrate
RD vs MD in Medical Nutrition Therapy”.
There was a role playing by Ms. Sylvia Klinger
and Dr. Esther Myers about “Dynamics ofCollaboration vs. Competition (Role Playing toAddress Various Scenarios)”.
The social role of a dietician is first andforemost to assist people through foods. In
other words, it involves practical ability. If welook at educational requirements for the field atuniversities and other institutions, the average
number of hours for an internship in Japan is
180 hours, which is too low compared to theInternational Federation of Dietetic Association(IFDA) standard of 500 hours (Fig.1). The
United States and the Philippines require morethan 1000 hours. In the Philippine, Thailand
and Taiwan, I am sure that dietitians are trusted
and respected by the people around them (Fig.
2).

1
12

12
1

1

1

US

U

Hours

1

5

5

525

5

5

25
2

1

apan

Tai anThailand Philippines Indonesia

On-ca pus training

At training sites

ietnaFig. 1 Practice hours during Bachelor of Dietician RD progra
in so e Asian countries and others*To whom correspondence should be addressed:
yamamotoshigeru426@gmail.com

1

Australia

International Standard for
Education of Dietitians-Nutritionists

What Dietitians Need for the Future: Evidence-Based Dietetics

Next, let's think about the necessity of
research. When we look at the authors of journal
articles related to clinical nutrition, most of them
are medical doctors (MD), and there are few
dietitians. If we look at nutrition journals, wefind many food scientists as authors. The

number of papers reflects the number of faculty
members in university. I believe that the reason
why there are few dietitians among faculty
members at universities is that there isinsufficient research and few papers (Fig. 3 and4).

2

Asian Journal of Dietetics 2023

Obesity is often taken up as a research theme.
The cause of obesity is simple. It is because theamount of energy taken in is greater than theamount consumed. Despite this simple fact, nocountry in the world has succeeded incontrolling obesity rates. This reality speaks to
the difficulty of obesity research. The difficultyis similar for MDs. Controlling obesity is aseemingly simple subject, but it is a broad andcomplex subject encompassing dietetics,
nutrition, medicine, physiology, biochemistry,
psychology, sociology, economics, andphilosophy. It resembles the humanities. Mostof the work by dietitians involves such fields.
Therefore, I would like to say that dietetics islike the humanities. In current science, evidence
is always sought. It is not easy to produce
evidence in obesity research. Even in modern
society where AI has reached a high level, it
seems that human behavior has not progressed atall. The war between Russia and Ukraine would
be a good example.

So let's think about the kind of research that
dietitians should do. In modern hospitals where
the number of elderly patients has increased,
there are many cases where we have no choice
but to rely on meals as treatment. For example,
diet problems such as frailty, sarcopenia anddysphagia are important. For hospital nutrition
management, medical staff from various fields
discuss how to treat patients (Fig;4). This istermed the Nutrition Support Team. The Teamwill ask for a rationale for a given treatment
policy. We can call this Evidence-based
Dietetics (EBD). Note that it's not Evidencebased Nutrition. I make a clear distinction
between Nutrition and Dietetics. That is, thetitle dietician is only for those with an RD
license, while a nutritionist does not require alicense. EBD requires advanced knowledge andresearch methods.

3What Dietitians Need for the Future: Evidence-Based Dietetics

About fifteen years ago, I was on the Review
Board for the Nutrition Education Curriculum.
At that time, a law was enacted that states thatMDs can teach about diseases but not clinicaldietetics, so they cannot become clinicalnutrition teachers. At the same time, a law wasenacted that of the 8 fields in the dietitian
training course, the teachers in 4 fields must be
RDs, and among 5 assistants 3 must be RDs. I
think this law is very sound. However, it is noteasy to quickly change the long history of theterm dietitian, and it cannot be said that it has
been successful as yet.

In other words, faculty members with RD do
not have as many publications as non-RD
members in fields such as food science,biochemistry, and epidemiology. In other words,
dietetic course students do not learn how to
conduct research at dietitians’ workplaces. Even
if RD practitioners return as university faculty
members, if they do not have adequate researchor papers, they will not be able to secure highstatus and will not be able to give guidance tostudents on the research methods that RDs
should apply. In Japan and other countries RDs
must get out of this vicious cycle.

4Asian Journal of Dietetics 2023

Original
Improvement of the Vietnamese school lunch menu
Nguyen Van Diep1, Nguyen Mai Phuong1, Nguyen Huong Giang1, Ta Thi Ngoc1, Ngo Thi Thu Hien1,
Nguyen Thu Trang1, Le Thi Huong2, Yamamoto Shigeru1
1

2

Jumonji University, Saitama, Japan
Hanoi Medical University, Hanoi, Vietnam

ABSTRACT: Background and purpose: School lunch programs have been developed andimplemented in various countries with the purpose of contributing to healthy mental andphysical development of children. In Vietnam, primary school lunch program started in 1980
but effects of this program are still limited. At present, in public schools in Vietnam, there
is no school dietitian, so school lunches are not well-planned and not attractive to children.
As a result, there is a large amount of food waste, especially vegetables, and many children
do not eat lunch at school. From our previous experiences, we thought that factors for poor
taste were; 1) lack of food materials and 2) rough cutting. In this study, we made new menus
by improving such points while maintaining cost and evaluated acceptability of students.
Methods: The study was conducted by cross-over design at a public primary school in a
suburb of Hanoi, Vietnam. Fifty students in 5th grade were randomly divided into 2 groups.
Five new best menus were developed by increasing variety of materials and choosing
suitable cutting methods. To maintain the cost, we reduced quantity of each material but still
guaranteed that energy, nutrients, and total amount of vegetables were similar between the
2 menus. One group ate the new menus in first week (5 days) and ate the current menus insecond week 2 (5 days). The other group had menus vice versa. Food intake survey andsensory test were conducted every day. Results: With the sensory test, the new menus had
higher scores for all features: color, smell, taste, texture, and overall (p <0.05). Compared tothe current menus, by the new menus, food waste was significantly decreased. Intakes withthe current menu and new menus were: energy 509 and 592 (kcal), protein 20.9 and 25.6 (g),lipid 16.7 and 20.1 (g), carbohydrates 69 to 77 (g), fiber 1.1 and 1.9 (g), and vegetables 54.7
and 79.0 (g), respectively. We increased the variety of food ingredients, but by reducing theamount, we could keep the similar cost. The work of cooks increased, but the children
enjoyed the food, which encourage cooks to work harder within the working time and thecost did not increase. Conclusion: By increasing the variety of food and choosing suitable
cutting methods, we were able to make the meals tastier and more attractive with similarcost, and the food consumption of children was increased. We recognized from this study
that the placement of school dietitian is the key to improve school lunch.

Keywords: School lunch, menu, food variety, food consumption.
INTRODUCTION
School lunch programs have been developed andimplemented in various countries with the purposeof contributing to the healthy mental and physicaldevelopment of children. In Vietnam, the primaryschool lunch program was started in 1980 but theeffects of this program are still limited because ofdifficulties in terms of society and human resources.
One of these dificulties is the lack of qualified
dietitians to design meals that could provide
balanced and tasty meals. At public schools, meals
are prepared based on the experiences of the kitchen
staff members. However, kitchen staff members are
not fully trained in nutrition; they receive only basic
knowledge of nutrition and food hygiene from shortterm training courses or learn by themselves fromtextbooks (1). Therefore, although the meals usuallyconsist of 5 dishes such as: a staple food, 2 main
dishes, a side dish and a soup, the dishes aremonotonous, use a small number of food materials,
and have poor food combinations. According to a
study comparing school lunches in Vietnam andJapan, while both countries have a similar number ofschool lunches about 200 times, Vietnam used only
53 different ingredients but 376 ingredients wereused in Japan (2). As a result, with the simple meals
and frequent repetition, children tend not to eat welland to waste food, especially vegetables. Moreover,for the same reason, many children decide not tohave lunch at school.
Eating a variety of foods is one factor that has
been shown to increase food intake (3–6). In
addition, food variety is considered a good indicatorof nutritional adequacy; it ultimately increases therange of nutrients consumed and the likelihood thata well-balanced diet is achieved. Combining various
foods may help to improve school meals in Vietnam.
However, in Vietnam, parents must pay for all theschool meals and don’t receive supports fromgovernment. Besides, in each locality, the local
government has its own policy on what materials areallowed to be used. Hence, when planning menus,
these aspects need to be considered.
In this situation, we thought that if it werepossible to combine more food materials to makenew menus but still maintain costs and the allowedmaterials then the school could adopt it and students
would consume more. With this hypothesis, we tried
to develop some new menus and this study was*To whom correspondence should be addressed:
nvdiep.hmu@gmail.com

5Improvement of the Vietnamese school lunch menu
conducted to evaluated the acceptability by students
at a public primary school in a suburb of Hanoi.

One group ate new menus for study week 1 (5days) and ate the current menus for study week 2 (5days). The other group had menus vice versa.
All the ingredients were provided from the same
suppliers for the school in the morning and then were
cooked in the school kitchen. The two groups ate
lunches in different rooms. After lunch, food waste
measurement and a sensory test for both menus wereconducted.
Instrumentation
Nutrient intake and vegetable consumption:
A total of 5 data collectors, who were graduate
students in the nutrition field, were trained to
conduct food measurements for the study. For eachday of measurement, each ingredient of each dishwas weighed after dividing into the same portions
and after eating by a digital kitchen scale (Tanita
KD-160) with an accuracy of 0.1g. Energy, protein,fat, carbohydrate, and dietary fiber intake were
calculated based on the Vietnam Food Composition
table 2007 by Microsoft Excel 2016.
Sensory test:
Sensory tests were conducted while the newmenus were being developed and also during theintervention using a Hedonic 5 point scale. Color,
Smell, Taste, Texture, and Overall were evaluated.
Data Analysis
IBM SPSS Statistics 26 was used to analyze thedata. The normality test was used. The variables
were compared by unpaired Student t-test and theMann-Whitney U test. P-values less than 0.05 wereconsidered statistically significant for all theanalyses.

METHODSThis was a crossover study performed between
September and October 2020 at one public primaryschool in Dong Anh district – suburban of Hanoi,
Vietnam.
Participants: Fifty students in 5th grade
From a list of 5th grade students who ate theschool lunch, we randomly chose 50 children anddivided them into 2 groups; each group had 25
children. Written informed consent was obtained
from parents, and verbal assent obtained from thechildren.
Procedure
Step 1: Developing new menus
We collected the current menus and the list of theingredients that the school allows us to use. Basedon this, we developed 10 new menus by increasing
the variety of materials (more than 10 kinds/meal)and choose suitable cutting methods to make new
food combinations (vegetables with meat/egg/fish,
vegetables with rice, and meat/egg). We still used
the same seasonings with current menus. To
maintain the cost, we reduce the quantity of eachmaterial but still guarantee that the energy, nutrients,
and total amount of vegetables are unchanged
between the 2 menus. After that, we conducted asensory test with 5 students and chose the best 5
menus.
Step 2: Intervention

DishesTable 1. Examples of a current menu and a new menu
Current Menu
New Menu
Ingredients
DishesWhite rice

Rice 130g

Mixed riceFried egg

Egg 40g

Meat ballStir-fried chicken
Stir-fried vegetable
Soup

Chicken 75g
Choysum 85g
Spinach 15g

Stir-fried chicken andvegetables
Soup

RESULTS
Table 2 shows the comparison of the cost andnumber of food materials between current menus
and new menus. Both menus had a similar price,
about 14,000 VND but the new menus had morekinds of food materials.
Figure 1 shows the comparison of vegetableintake in the current and new menus. In both menus,
we served 100g of vegetables but in the current
menu, children only consumed 54.7g vegetables
while in the new menu consumed 79g vegetables.
The comparison of the energy and nutrient
supply and intake in the current menu and the newmenu is presented in Table 3. The amount of supply

Ingredients
Rice 110g
Egg 17g
Chayote 10g
Carrot 10g
Minced meat 35g
Onion 5g
Carrot 5g
Tomato 15g
Scallion 2g
Chicken 30g
Choysum 30g
Carrot 15g
Spinach 8g

between current menus and new menus had not
significantly difference. However, protein, lipid, andcarbohydrate intake in the new menu were higher
than in the current menu. As a result, the energy
intake in the new menu was also higher. The fiber
intake in the current menu was 1.1±0.3g, lower than
1.9±0.2g in the new menu. All the data hadsignificantly difference.
Figure 2 shows the average scores of the sensory
test for both menus. The average scores are thescore of 5 menus so the sample sizes (n) is 5. All
the features of the new menus were evaluatedsignificantly higher than the current menus.

6

Asian Journal of Dietetics 2023
Table 2. Comparison of cost and number of food materials
between 5 current menus and 5 new menus
Current menus
New menus(Mean ± SD)(Mean ± SD)
(n=5)
(n=5)
Cost (VND)
14021 ± 1528
14320 ± 937
Food materials (number)
5.8 ± 0.4
10.8 ± 0.8*
* p<0.05, paired Student t-test

***
120
100
79
80
54.7

60
100

100

40
20
0
Current menu (n=50)

New menu (n=50)

SupplyIntakestandard deviation*** p<0.001, paired Student t-test

Figure 1. Comparison of vegetable intake in the current and new menus
Table 3. Comparison of energy and nutrient supplies and intakes in the current and new menus
SupplyIntakeCurrent menu
New menu
Current menu
New menu(Mean ± SD)(Mean ± SD)(Mean ± SD)(Mean ± SD)(n=50)(n=50)(n=50)(n=50)
Energy (kcal)
612 ± 34639 ± 32509 ± 64592 ± 40*
Protein (g)25.5 ± 2.4
27.7 ± 4.1
20.9 ± 2.2 25.6 ± 1.5*
Lipid (g)20.0 ± 3.8
20.7 ± 2.2
16.7 ± 0.9 20.1 ± 0.5*
Carbohydrate (g)82.4 ± 4.3
85.4 ± 7.5
69.1 ± 13.6 77.2 ± 8.0*
Fiber (g)1.7 ± 0.6
2.2 ± 0.4
1.1 ± 0.3
1.9 ± 0.2*
* p<0.05, paired Student t-test

5.0
4.0

**
3.9
3.5

*
3.5

*
3.9

3.5

**
3.8

*
3.6

3.1

4.0
3.5

3.0
2.0
1.0
0.0
Color

Smell
Taste
Current menus (n=5)

TextureOverall
New menus (n=5)*,** p<0.05 and <0.01, respectively, by paired Student t-test

Figure 2: Average scores of the sensory test for current menus and new menus
7Improvement of the Vietnamese school lunch menu

“mazegohan” in Japan. We mixed rice with meat oregg and vegetables and then added some spice. This
dish provided children with a new sensation; they
could taste not just rice but also many assorted
flavors and textures blended together. Children werereally excited with this dish and ate a lot. Next, De
Moura has suggested that even disliked vegetable
might become acceptable when they are part of atasty mixture(14). Thus, we mixed vegetable withsome favorite foods of children like meat balls or
fried eggs and as a result, students definitely enjoyed
them. Baxter has found that size affects children’s
acceptance of vegetables: small vegetables werepreferred to large varieties (15), so in our study,
vegetables were cut into small pieces made themeasier to eat and they could be hidden inside themeat/egg, or mixed well with other food and spices,making the food more delicious and eye catching.
Moreover, Zeinstra has shown that children prefercrunchiness in vegetables (16), so we tried to
combining crunchy vegetables like carrots or
chayote with a non-crunchy vegetables to increase
acceptance. Also, when cooking, we tried to keep thecrunchiness of vegetables or to make them crunchierby making tempura.
Last but not least, we had to find suitable cutting
methods for each food combination. "Cut" means tomake the ingredients easy to cook and eat.
Depending on how you cut it, the way the fire passes,
the texture, and the way it tastes will change, so weneed to choose the cutting method that suits the type
and purpose of the dish. If the size is uniform, it will
look beautiful and delicious. For vegetables, the tastechanges depending on whether they are "cut along
the fiber" or "cut off the fiber". For example, in thecase of bell peppers, if you slice them horizontally to
cut off the fibers, the cells will break and thebitterness will be more likely to occur, and if you cut
along the fibers, the bitterness will be suppressed. In
the case of onions, the opposite is true. If you cut thefibers so that they are cut off, the area that comes into
contact with the air is large, so the spiciness is easily
removed, and if you cut along the fibers, thespiciness remains. Thus, for each dish, we tried many
cutting methods to choose the best one. Furthermore,
Baxter has found that size affects children’s
acceptance of vegetables: small vegetables werepreferred to large varieties (15), so in our study,
vegetables were cut into small pieces made themeasier to eat and they could be hidden inside themeat/egg, or mixed well with other food and spices,making the food more delicious and eye-catching.
When applied those points to improve the meals,
people might think the cost of the meals will increase.
However, we could maintain it. In terms of foodmaterials, to increase the number of materials, wereduced the quantity of each kind but still ensure thatthe energy and nutrients intake and the total amountof vegetables were the same. For example, bothmenus used 100g of vegetables, but in the current
menus, they only used 2 kinds of vegetables with a
big amount, while in the new menus we divided into
6-7 kinds and the amount of each kind was little. In
terms of labor, it is certain that the cooking staff
needed more time than before to prepare and cut thematerials thoroughly. However, the extra time wasstill within their working time, and they were happy

DISCUSSION
This study has found that students in the newmenu group had higher energy, nutrients, andvegetable intakes than the current menu group,suggesting that improving menus by increasing thenumber of food materials and changing the way of
cutting but still maintain the cost to increase the foodconsumption for children is feasible.
Leftover food from school lunches is a major
problem in Vietnam at present. Children waste a lotof food, mainly vegetables. The reason is taste.
Although there are 5 dishes in each meal: a staple
food, 2 main dishes, a side dish and a soup, the dishes
were very simple and monotonus: only 5-6 types ofingredients are used for the whole meal; meat andvegetable are almost always cooked separately; andover-all the appearance of the meals is not eyecatching. Hence, students don’t like school meals
and tend not to eat well. Moreover, instead of eating
at school, many children go home for lunch. With theaim of improving the above limitations, our researchgroup, who are dietitians, designed new menus but
still kept the similar price and used ingredients fromthe list that the school allows to use. We learnt somerecipes and food combinations from Japanese school
meals, and adapted them to the Vietnamese school.
First, we made the meals more varied, or in otherwords, we increased the number of food materials. In
one meal, we used more vegetables, and increased
the total ingredients in the whole meal to more than10, in accordance with the recommendations ofVietnam National Institure of Nutrition. Food variety
is important for the ingestion of a good balance ofnutrients and variety within a meal is known to be
one of the most powerful ways to increase energy
intake. Some studies have explained this behavior by
the mechanism of sensory-specific satiety: in asituation with variety, the new foods will be
relatively more pleasant than the foods already eaten
and thus relatively more is consumed (3,4,7,8). In
addition, Wilkinson has argued that variety may
affect the cognitive representation of food quantities,
which in turn may increase the portions served (9).
Similarly, Rolls has shown that having a variety offoods presented in succession during a mealenhances intake, and the more different the foods are
the greater the enhancement is likely to be (3). For
vegetables, Mennella, Parizel, and Meengs haveshown that offering a variety of vegetables in a meal
can increase vegetable acceptance compared tooffering only one vegetable (10–12).
Secondly, along with the diversity of ingredients,
we made more food combinations. Some kinds ofvegetable were mixed together and/or mixed withmeat/ fish/ egg in the staple food, main dishes andside dishes. The increase in acceptance of foodcombinations might have been caused by offering avariety of foods differing in color, flavor and texture
compared to offering a single food only. Foodcombinations are emphasized in Japanese school
lunches and it has been specified in the School Lunch
Act (13) that the combination of foods should always
be improved when preparing menu. The newest
combination we made was a combination in thestaple food that we learnt from Japanese school
lunches. In Vietnam, normally the staple food isplain rice only; we changed this to mixed rice, like
8

Asian Journal of Dietetics 2023
and enthusiastic to do the work when they saw thatchildren ate more, and the leftover was reduced.
Therefore, the labor cost remained the same.
After changing the menus, both menus provided
an equal amount of vegetables, but the amount ofvegetables consumed in the new menu group was
25.7g higher than in the current menu group. This
proved not only the effectiveness of the new menus
but also the effort of the dietitians in improving thequality and quantity of the diet for children. On theother hand, in both groups, children still wasted food,especially vegetables. This is similar to the study by
Gray: children only eat about 79% of the vegetableson the tray (17). However, children in the current
menu group wasted more vegetables than the newmenu group did, similar to Sharma’s results: while
the children in the control group wasted 74.6g ofvegetables and fruits, the children in the menu
intervention group wasted 63.0g of vegetables andfruits (18). These results provide additional evidence
that schools should focus on the diversification ofingredients as well as increasing appetizing foods toincrease nutrient intake by children.
School lunch has been considered as a factor incontrolling obesity rates in children in Japan. School
lunch not only provides well-balanced lunch forchildren but also conveys an understanding of
portion size, meal balance, and gratitude for the foodand for the people who make it (13,19,20). Therefore,
school lunch may be important in controlling
overweight. Especially important is the role of the
dietitian in the school, not only to develop menus forchildren but also to develop educational programs toteach children (13). However, at present, in publicschools in Vietnam, there is no school dietitian, so
school lunches are not well-planned and not
attractive to children. It is desirable to improve,spread school lunches and establish a school dietitiansystem in Vietnam so that all children can enjoy
nutritious school lunches and have a good nutrition
education by a dietitian to change food consumption
behavior.
The limitation of this study was the shortintervention time. We had only assessed student
acceptance of the new menus but did not observe
whether schools can adopt these menus. Hence, a
study with a longer time is needed to evaluate how
school applies those menus and how long they canapply, as well as establish more menus and expand
to more school.

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Megson A, Gunary R. Variety in a meal enhances
food intake in man. Physiol Behav 26(2):215–21.
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4. Rolls BJ, Rowe EA, Rolls ET. How sensory
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5. BJ R, PM VD, ET R. Pleasantness changes andfood intake in a varied four-course meal. Appetite
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Strategies for promoting fruit and vegetable
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CONCLUSIONS
By increasing the variety of food and choosing
suitable cutting methods, we were able to make themeals tastier and more attractive with similar cost,
and the food consumption of children was increased.
We recognized from this study that the placement ofschool dietitian is the key to improve school lunch.
REFERENCES
1. Son Nguyen Trung Le D. School meal programin Ho Chi Minh city, Vietnam: reality and futureplan. Asia Pac J Clin Nutr 21. 2011.
2. Thuan NT, Indri KS, Miho N, Noriko S, Yuriko
I, Thao NT, et al. Comparison of School Lunch
Menus in Vietnam and Japan. Asian J Diet

9

Asian Journal of Dietetics 2023

ORIGINAL
Rice Facilitates Salt Control in Japanese School Lunches
Kohei Kato*
Tohoku Elementary School., Niiza city, Saitama, Japan
ABSTRACT Background and purpose. Japanese dietitians exert considerable influence
over the nation’s school lunch program. Because of the well-recognized relationshipbetween nutrition and children's health, increasing attention has been directed at the highsalt content of school lunches in Japan. Methods. We examined school lunch menus fromall prefectures, and 34 municipalities, focusing on the salt content of included menu items.
We examined the relationship between salt values and the frequency with which certain
foods (rice, seafood dishes, soup, and fruits or jelly) were served. Five municipalities
complied with Japan’s preestablished salt content standards (<2.0 g average per month).
Results. According to linear regression analysis, salt values were independently negatively
associated with the number of rice servings (P = 0.003). The adjusted R-squared for thislinear regression model was 0.305. Many elementary schools remain non-compliant withrecommended salt content, as established by the school lunch program’s nutritional
standards; however, these schools could comply by increasing the frequency with which
rice is served in schools. Conclusion. Our results may have been biased due to the small
number of menus that included average salt values. Elementary schools in Japan should
publish their lunch menu’s average salt values to further improve the nutrition of the
Nation’s schoolchildren.
Keywords: salt, rice, school lunch, elementary school, JapanINTRODUCTION
Japanese school lunches have existed for morethan 100 years. Free school lunches were introducedin 1889 in the Yamagata Prefecture to assist poorfamilies. The 1954 School Lunch Act positioned
school lunches as a key educational component. Later,
after a period of rapid economic growth, rice lunches
were introduced in 1976, and in 2009, the Revised
School Lunch Act added Shokuiku, a Japanesephilosophy of nutritional awareness, to school lunch
objectives. Article 8 of the School Lunch Act
establishes menu criteria which are used by dietitians
for menu planning. In Japan today, approximately
190 school lunches are served throughout the country
each year.
Japanese schoolchildren enjoy better nutrition ondays when school lunches are provided (1). However,school lunches are often high in salt. Reducing salt
and tobacco product intake is important for reducing
the prevalence of non-communicable diseases(NCDs) (2). The 2019 National Health and Nutrition
Survey found that Japanese citizens consume anaverage of 10.1 g of salt per day. While this issue is
widely recognized, many Japanese still exceed therecommended daily salt intake (3).
Japan requires school lunch programs to meet therecommended daily intake levels for 13 nutrients.
These nutritional standards were revised in 2018,
when the recommended daily salt intake was reduced
from <2.5 g per serving to <2.0 g per meal (4).
Meanwhile, according to the Ministry of Education,
Culture, Sports, Science and Technology (MEXT)
School Meal Nutrition Report, the salt intake ofelementary school students in 2019 was 2.3 g (5).
This makes it necessary to find out what kind of
school lunch is being served; however, little is known
about how much salt is contained in Japanese school*To whom correspondence should be addressed:
dietetics_teacher20@aol.com

lunches (6). This study examined school lunch menu
conformance with Japan’s school lunch programnutritional standards. The results generate examples
and recommendations for planning school lunch
menus that better meet Japan’s nutritional guidelines.
MATERIALS AND METHODS
Study design. Historically, school lunch menus
were only distributed to the students’ families.
Recently, these menus have been placed on school
websites and are available to all. Despite this, there
are no rules regarding the format or the labeling of
nutritional information. We examined school lunch
menus that list the average salt equivalent per monthor day. The menu collection procedure is shown in
Figure 1. The menu list was obtained using a web
search between November 29 and December 3, 2021.
The author calculated the one-month average if only
daily salt values were listed. Since the averagemonthly salt intake would be skewed during months
with fewer school lunches, we used October (rather
than November or December) menu lists closer to thesearch date. We attempted to eliminate regional bias
by sampling one menu item list from all prefecturesin Japan. The survey began with “city,” and thesearch keywords were “~city AND elementary school
AND menu list.” The next municipality was searched
if the menu list was not found after scrolling down to
the second page. If a school lunch menu was foundfor a municipality (including towns) other than the
one searched, it was still adopted. Once a school
lunch menu was identified within a prefecture, thenext prefecture was searched. A similar search fortowns was conducted if the menu list was not foundafter searching for all cities in a prefecture using thesearch terms. If a school lunch menu containing salt
information was still not found, the search proceeded
to the next prefecture and did not search villages.

11School lunch salt content in Japan
These procedures were used to examine all 47
prefectures. Since this study did not involve humansubjects, and all menu lists obtained were publicly
available on the Internet and accessible to anyone,
and were not obtained privately from nutrition
teachers or others, this study was considered exempt
from ethics committee review. Out of an abundanceof caution, municipality names are not disclosed.
Analysis method. To identify which menus compliedwith the recommended salt content per Japanesenutritional standards. We used multiple regression
analysis with salt as the objective variable and menu
items as the dependent variable. First, explanatory
variables were selected for multiple regression
analysis. Seasonings account for 56% of Japanese salt
intake, followed by seafood, soups, noodles, pickles,
and bread (7). Using this as a reference, we identified
the number of times seafood was the main ingredientin a menu item. We additionally counted the numberof times noodles and bread were served; however,
because some municipalities serve a combination ofbread and pasta or rice and udon on the same day, thecount was bracketed by the number of times rice wasserved (otherwise, bread or noodles or bread andnoodles were served on the same day). If rice andnoodles were served on the same day, they werecounted as rice. Fruits and jellies were also includedin the analysis because they do not contain salt. Thus,
the four explanatory variables were rice, soup,
seafood dishes, and fruit or jelly. We counted thenumber of times each menu list included these four
variables. The author determined which dishcorresponded to which dish from the name on themenu list. Stew, clam chowder, and pot-au-feu werecounted as soups. Pork beans and oden were
excluded from soups. When seafood was only part ofthe dish—such as Ishikari nabe and salmon
gratin—the dish was not considered a “seafood dish.”
We used statistical analysis software HAD (8) for all
analyses and a two-tailed significance level of 5%.
RESULTS
Menu lists were obtained from municipalities in
34 prefectures. Of these, 15 municipalities preparedschool lunches at the schools themselves, while 19municipalities prepared them in central kitchens. Fivemunicipalities complied with salt standards (<2.0 g
per serving). The median salt values were 2.2 [2.03–
2.40] g. Similarly, rice was served 14.0 [13.0–17.0]
times, soup 14.0 [11.0–15.0] times, seafood dishes
5.0 [3.25–8.0] times, and fruit or jelly 3.0 [2.0–5.5]
times. (Table 1)

Exclusion criteria
Lunch menus not from elementary
school (e.g., junior high school)
Lunch menus without salt equivalents

School lunch menus for October 2021 were searchedusing the internet between November 29 andDecember 3, 2021.
Search word for"○○-shi AND elementary school AND menu list".

I checked from the top of the hits.

If not found while scrolling throughtwo pages, moved on to the nextmunicipality

Decided even if it is from another city or town, as
long as it meets the requirements.

If all cities were searched and none
were found, the towns in that province
were also looked up.

recruitment

In the case of lunch menus that
only listed salt equivalents fordaily menus, monthly averages
were calculated.
I was not able to obtain it from 13
prefectures.

I got lunch menus from 34 prefectures.
Figure 1. Process for obtaining lunch menus with salt equivalents

12

Asian Journal of Dietetics 2023
Table 1. Characteristics of municipalities that supplied school lunch menus for this study
number of dishes served
averagemeal
prefectures*
salt percounts per
bread orseafoodfruits or
rice†
soup‡
month(g)monthnoodlesdishes
jelly
No.1
2.9
18
10
8
11
No.2
2.2
21
17
4
19
No.3
2.8
19
12
7
16
No.4
2.3
21
15
6
15
No.5
2.2
20
14
6
16
No.6
2.4
18
10
8
15
No.7
2.0
20
16
4
15
No.8
2.2
20
16
4
16
No.9
2.1
18
17
1
8
No.10
2.3
19
11
8
15
No.11
2.3
21
13
8
12
No.12
1.7
21
16
5
12
No.13
2.2
21
17
4
14
No.14
1.9
21
20
1
12
No.15
2.4
21
17
4
12
No.16
2.4
21
13
8
10
No.17
1.9
21
21
0
19
No.18
2.1
21
17
4
9
No.19
2.0
21
13
8
8
No.20
2.4
20
11
9
14
No.21
2.5
20
13
7
11
No.22
1.9
21
16
5
11
No.23
2.4
20
12
8
16
No.24
2.5
21
13
8
15
No.25
2.0
21
17
4
10
No.26
2.1
21
13
8
14
No.27
2.5
21
13
8
16
No.28
1.9
21
17
4
6
No.29
2.2
20
15
5
8
No.30
2.1
21
20
1
14
No.31
2.5
20
14
6
11
No.32
2.0
20
11
9
11
No.33
2.4
21
13
8
14
No.34
2.3
20
12
8
14
Mean
2.24
20.3
14.6
5.8
12.9
*Fifteen municipalities prepared school lunches in the schools, while
19 municipalities prepared them in central kitchens.
†If rice and noodles were served together, I counted it as rice.
‡ Pot-au-feu and stew counted.
The multiple regression analysis results are shownin Table 2, including the average amount of salt permonth as the objective variable and the number ofmenu items that were served (rice, soup, seafood
dishes, fruit or jelly) as the explanatory variable. Salt
values decreased significantly on menus where rice
was served more frequently (P = 0.003). The

3
9
7
5
6
6
8
8
4
8
6
9
1
10
8
8
9
2
2
5
5
6
5
9
4
3
4
5
3
9
4
3
3
3
5.6

4
8
3
8
2
1
2
6
3
4
3
6
7
2
6
3
2
4
1
4
2
8
6
6
2
0
3
2
2
2
3
3
3
1
3.6

coefficient of determination for this multiple
regression analysis was 0.389 (adjusted R2 = 0.305).
Finally, a scatter plot of salt content and the numberof times rice was served is depicted in Figure 2. The
number of times rice was served was significantly
associated with salt content (R = −0.614, P < 0.01).

13

School lunch salt content in Japan

Table 2.

Linear regression analysis results of average salt per month and the number of menu items served
Explanatory
variableIntercept
Rice
Soup
Seafood dishes
Fruit or jelly

Partial regression
coefficient
2.732−1.0690.425−0.143
0.204

95% CI
2.137−1.735−0.159−0.924−0.5673.327−0.404
1.009
0.638
0.974

P-value
0.000
0.003 **
0.148
0.712
0.593

Figure 2. Correlation between average salt content and number of times rice was served during the month.
HAD was used for statistical analysis.
DISCUSSION
Japan’s school lunch nutritional standards wererevised over three years ago. Although manymunicipalities could meet the previous standard of<2.5 g, only five had met the current standard of <2.0
g. Compared to similar prepared meals that arecommon in Japan, vegetable-focused prepackaged
lunches from convenience stores had 484 kcal (±115)
of energy and 5.0 g (±1.2) of salt (9). Meanwhile,junior high school lunches had 637 kcal (±43.51) and2.7 g (±0.34) of salt (10). Both meals exceeded therecommended salt content established by theJapanese government. Looking at other countries,
lunches served to Finnish preschoolers contained
1.37 MJ (±0.51) of energy and 1.6 g (±0.7) of salt
(11). In South Korea, a typical school lunch for a
fourth grader includes 2.44 g (±0.73) of salt (12),higher than recommended. Compared to othernutrients, it can be more difficult to meet salt
standards established for school lunches (13). In
Japan, seafood is the second-most-common

ingredient (after seasonings) responsible for highdietary salt (7); however, the average amount of salt
per serving did not increase even when seafood
dishes were served more frequently. Thus, cooks anddietitians can find ways to limit dietary salt, even fordishes where fish is the main ingredient.
School lunch nutrition attracted increasing
attention in Japan, even before national nutrition
standards were introduced. Recommendations thatelementary and junior high school meals contain <4 gsalt emerged in 1995 (14). On the other hand, school
lunches also play a role in Japan’s food culture. For
example, it would be difficult to strictly limit miso
and soy sauce (both of which are high in salt), given
the importance of these ingredients to the Japanesediet. MEXT, in its 2011 report “Establishment of
School Meal Intake Standards,” recognized the needto acclimate young children and adolescents toless-salty menu items without substantially limiting
the use of miso and soy sauce, critically important to
the nation's food culture (15). Unfortunately, if

14

Asian Journal of Dietetics 2023
dieticians don’t set out to reduce salt content ofschool menu items, such improvements may belimited.
Since rice has been served in school lunches since
1976, the percentage has been gradually increasing;in 2009, MEXT announced its promotion of ricelunches at schools. According to the MEXT School
Lunch Survey, in fiscal year (FY) 2021, Japanese
schoolchildren are, on average, served rice in school
3.5 times per week. In-compliance municipalities
included rice in their school lunches 3.8–5.0 times
per week. Thus, options other than increasing thenumber of rice servings are available. However, since
it is difficult to comply with recommended salt
standards if rice is only served a few times per week,
rice should be added to reduce the salt content ofschool lunches in Japan.
According to the Tables of Food Composition in
Japan (8th revision), 100 g of bread or cobbler bread
contain 1.2 g and 1.3 g of salt equivalent, respectively.
Since approximately 70 g is given to third- andfourth-grade students in Japan, we estimate that eachpiece of bread provides ~0.8 g of salt equivalent. On
the other hand, according to the United Kingdom’s
Food Composition tables, 100 g of bread would
contain 380–400 mg of sodium, a salt equivalent of
0.96–1.1 g (16), about 20% less than in Japan. The
United Kingdom has reduced the salt content of breadby about 20% over 10 years. In 2001, the salt content
in 100 g of bread was 1.23 ± 0.19 g (17). A similar
could help Japanese schools comply with Japan’s
revised nutritional standards.
The Japanese Food Labeling Law controls what
information is included on food labels. Since 2015,
pre-packaged processed foods must display
nutritional information, including salt equivalentcontent. On the other hand, there are no rules
governing what is included in school menus; each
local government has its own rules. Consequently, themenus varied widely in energy, protein, fat, salt, andcalcium. Some listed no nutrients at all. Notably, we
failed to obtain menu lists from 13 prefectures withnutritional labels for salt. Today, school lunches serve
as “living teaching materials” that can help
schoolchildren learn about nutrition while providing
additional information to families. We tried to obtainschool lunch menus from across the country; however,
the results may be biased because only some of themenus included average salt values. However, given
the lack of prior school lunch menu studies, ourresults will likely inform future efforts to reduce thesalt content of school lunch menu items. Future,large-scale studies are needed to advance this area of
research. In Japan, our results may encourage more
municipalities to publish the nutritional informationfrom school lunches.

CONFLICTS OF INTEREST
The author has no conflict of interest to declare.
ACKNOWLEDGEMENT
The
authorwishes
to
thank
Enago
(www.enago.com) for the English language review.
REFERENCES
Asakura K, Sasaki S. School lunches in Japan:
their contribution to healthier nutrient intake
among elementary-school and junior high-school
children. Public Health Nutr 20: 1523–1533.
2017.Wardle J. Parental influences on children's
diets. Proc Nutr Soc 54:747-758. 1995.
2. Beaglehole R, Bonita R, Horton R, et al. Priority
actions for the non-communicable disease crisis.
Lancet 377: 1438–1447. 2011.
3. Fauzi M, Kartiko-Sari I, Poudyal H. Trends of
dietary intakes and metabolic diseases inJapanese adults: assessment of national healthpromotion policy and national health andnutrition survey 1995-2019. J Clin Med 11: 2350.
2022.
4. Ministry of Education, Culture, Sports, Scienceand Technology, Japan: Partial recision ofCriteria for Provision of School Lunches. (July,31,2018).
(inJapanese).
https://www.mext.go.jp/content/20210212-mxt_k
enshoku-100003357_1.pdf(Accessed January, 12, 2023)
5. Ministry of Education, Culture, Sports, Scienceand Technology, Japan: School Lunch Nutrition
Report (FY) 2019. (in Japanese).
https://www.mext.go.jp/content/20200619-mxt_k
enshoku-000008019_1.pdf(Accessed February, 4 2023)
6. Nagura H, Yamazaki Y, Kurisaki J, et al.
Examination of the quality control of 5 school
lunch menus. J Jpnese Soc Shokuiku 11: 25–34.
2017.
7. Asakura K, Uechi K, Masayasu S, et al. Sodium
sources in the Japanese diet: difference between
generations and sexes. Public Health Nutr 19:
2011–2023. 2016.
8. Hiroshi S. An introduction to the statisticalsoftware HAD: Suggestions to improve teaching,learning and practice data analysis. JMIC. 1: 59–
73. 2016.
9. Namba T, Kushida O, Murayama N. The
relationship between amount of vegetables
energy, percentage energy from fat, and sodium
chloride equivalent in the boxed meals soled in
the convenience stores. Niigata J Health Welf 12:
28–34. 2012.
10. Horinishi E, Maruyama S: The study of makelunch environmental for femalestudent at juniorhigh school –Salt distribution of Lunch box-.
Treatises Stud Fac Kinjô Gakuin Univ 17–22.
2019.
11. Korkalo L, Nissinen K, Skaffari E, et al. The
contribution of preschool meals to the diet of
finnish preschoolers. Nutrients. 11: 1531. 2019.
12. Ahn S, Park S, Kim JN, et al. Salt content ofschool meals and comparison of perception
related to sodium intake in elementary, middle,
and high schools. Nutr Res Pract. 7: 59–65.
2013.
13. Crepinsek MK, Gordon AR, McKinney PM, et al.
1.

CONCLUSION

Five municipalities complied with salt
standards (< 2.0 g one-month average). The
amount of salt was significantly negatively
correlated with the number of rice servings. The
results suggest that although many elementary
schools are still not in compliance with the salt
standards for school lunches, it may be possible toachieve this by increasing the number of rice
servings.
15

School lunch salt content in Japan
Meals offered and served in US public schools:
do they meet nutrient standards? J Am Diet
Assoc. 109: S31–S43. 2009.
14. Morimoto K, Miyahara K. Nutritional
management implemented at school lunch
programs in Japan based on the changes incriteria for provision of school Lunches. Jpn J
Nutr Diet Suppl 1: S23–S37. 2018.
15. Research Study Collaborator Conference on
Formulation of Dietary Reference Intake of
School Children in School Lunch Program:
Formulation of the School Lunch Intake
Standards (Report). Ministry of Education,

Culture, Sports, Science and Technology, Japan.
(2011). (in Japanese).
https://www.mext.go.jp/b_menu/hakusho/nc/__ic
sFiles/afieldfile/2013/03/21/1332086_2.pdf(Accessed January, 12, 2023)
16. Composition of foods integrated dataset(CoFID):https://www.gov.uk/government/publications/co
mposition-of-foods-integrated-dataset-cofid.
17. Brinsden HC, He FJ, Jenner KH, et al. Surveysof the salt content in UK bread: progress madeand further reductions possible. BMJ Open 3: 1–
7. 2013.

16

Asian Journal of Dietetics 2023

Original
The Risk of Refeeding Syndrome in ICU COVID-19 Patients and Some Association
Factors in the COVID-19 Hospital in Vietnam
Linh Thuy Nguyen1,2*, Ha Ngoc Le3, Chinh Pham Thi Tuyet1, Giang Hoang Truong3, Thao Phuong Tran4,
Tu Nguyen Huu1,3
1

2

Hanoi Medical University Hospital, Hanoi, Vietnam
School of Training Preventive Medicine and Public Health, Hanoi Medical University
3
Hanoi Medical University, Hanoi, Vietnam
4
Jumonji University, Niiza City, Saitama 352-8510, Japan
ABSTRACT: Background and purpose: Many COVID-19 patients in ICU suffer fromacute respiratory distress syndrome (ARDS), which requires urgent respiratory andhemodynamic support. In these patients, nutrition support plays a pivotal role and should be
combined with comprehensive treatment as early as possible. Also, there are several
nutrition-specific issues in ICU COVID-19 patients that need to be taken into considerationand one of them was the risk of refeeding syndrome (RFS). In this study, we aimed todescribe the risk of refeeding syndrome in severe and critically ill COVID-19 patients at
The COVID-19 Patients Treatment Hospital (COVID-19 hospital) in 2021-2022. Methods:
A cross-sectional study was conducted among 460 patients with moderate and severe
conditions admitted to the COVID-19 hospital from September 2021 to May 2022. The riskof refeeding syndrome was evaluated by ASPEN 2020 criteria. Results: The percentage ofpatients who had the risk of refeeding syndrome was 55.3%, of which the moderate risk
was 43%, and 12.3% for severe risk; 16.9% of patients were diagnosed with the refeeding
syndrome. The most common comorbidities were hypertension and diabetes, which
occurred in 56.6 and 38.5 percent of patients respectively. There was a statisticallysignificant association between age, oxygen therapy, feeding method (EN and no EN),
nutrition status, COVID-19 condition of patients, propofol usage, and the risk of refeeding
syndrome with p < 0.05. Conclusion: RFS is a severe complication of nutritional
intervention, therefore, early diagnosis and preventive treatment of refeeding syndrome will
help prevent feeding complications in severe and critically ill patients.
Keywords: COVID-19 patients, malnutrition, Refeeding syndrome, COVID-19 Patients
Treatment Hospital

INTRODUCTION
The COVID-19 pandemic is an ongoing
global pandemic caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) (1). Thispandemic has been responsible for millions ofdeaths all over the world. Researches show that up
to 30% of COVID-19 patients presenting withacute respiratory distress syndrome (ARDS) require
urgent respiratory and other life support in theintensive care unit (ICU) (2). In these patients,
nutrition support plays a pivotal role and should be
combined with comprehensive treatment as early as
possible. Regarding nutritional management, there
are several nutrition-specific issues in COVID-19
patients in the ICU that need to be taken into
consideration and one of them was refeeding
syndrome (RFS). The refeeding syndrome isdefined by the disturbance of vital electrolytes andminerals like potassium, magnesium, andphosphorus,..and its clinical sequelae that happened
when moderate and severely malnourished patients,
often in ICU, responded to nutritional reintroduction (3). If treated inappropriately, RFS cancause serious complications to patients, including
seizures, heart failure, and comas (4).
RFS is closely related to the critical condition of

ICU patients (5). In the context of COVID-19
patients in the ICU, the management of RFS play
an important role in the overall treatment of thesepatients. COVID-19 patients in ICU are often
vulnerable (old and weak) and with comorbidities
such as diabetes, hypertension, or other chronic
diseases (6). Patients are also staying in ICU forlong periods, ranging from 6-15 days, and are
ventilated for most of their time (6-7). Therefore, it
is expected that COVID-19 patients who survived
ICU would present severe malnutrition and muscle
mass loss. As a consequence, COVID-19 patientsin ICU were susceptible to RFS and can suffer fromits complications.
Although there were many researches aboutrefeeding syndrome in ICU patients (5, 8-9), there
were few studies in the field of COVID-19 patientsin ICU. In this study, we aim to evaluate the risk of
RFS in these patients with two objectives:
1. Describe the risk of RFS in severe and critically
ill COVID-19 patients in the ICU at COVID-19
Patients Treatment Hospital 2021-2022.
2. Identify some associated factors that cancontribute to the risk of RFS in these COVID-19
patients in the ICU.

*To whom correspondence should be addressed:

linhngthuy@hmu.edu.vn

17

Refeeding Syndrome in ICU COVID-19 and Factors
MATERIAL AND METHODS
Settings and Sample
The study was designed as a cross-sectional
study that involved the convenience sampling of a
total of 342 patients in the ICU at the COVID-19
Patients Treatment Hospital from September 2021
to May 2022. The inclusion criteria were patientsdiagnosed with, severe and critical COVID-19
status. The study excluded patients who could not
get enough anthropometric measurements.
Data collection
We collected data on a convenience sample in
two ICU departments in the COVID-19 Hospitalfor six months from September 2021 to May 2022.
Variables
Demographic characteristics: age, gender,
comorbidities, the ability for self-feeding skills andmethod (independent, partial support, complete
support), oral feeding, enteral nutrition (EN),parental nutrition (PN), oxygen therapy (invasive
mechanical ventilation (IMV), Noninvasive
positive pressure ventilation (NIV), high flow nasal
cannula (HFNC), oxy mask, nasal cannula, roomair). The data were collected from electronic
medical records, medical staff (nurses, doctors,
dietitians), and subjects.
Non-volitional weight loss: we asked patients or
caregivers by mobile-phone or previous medical
staff to know patients’ weight loss status.
Reduced muscle mass: nurses or doctors or
dietitians would examine or observe some positions
on patients’ bodies. These are the temples, clavicle,
shoulder, scapula, thenar, thigh/knee, and calf. In
terms of Subcutaneous fat loss, we examine orobserve some body’s locations such as orbital fat
pads, buccal fat pads, and triceps.
Reduced food intake or assimilation: we asked
patients or caregivers or previous medical staff toknow patients’ intake status or observed patients’eating during the initial 24 hours of entering the
hospital if we could not obtain any informationfrom patients or caregivers or previous medical
staff.
COVID-19 patients stay in an inflammation
condition.
Screening refeeding syndrome according to
ASPEN guideline 2020
Screening refeeding syndrome: we based on the
ASPEN 2020 recommendation for screening
refeeding syndrome. There are two levels ofrefeeding syndrome, which have moderate andsevere levels.
Statistical Analysis
The data were entered by using Microsoft
Access (Microsoft Corporation, Hanoi, Vietnam)
and Stata 14.0 statistical software (Stata Corp LLC,
California)
foranalysis.
The
intergroupcomparisons were performed using the Chi-squared
test, Fisher's exact test, and the Mann-Whitney U
test. Statistical differences were consideredsignificant at p < 0.05.
Ethics Approval
The study has been approved by the researchreview board of Hanoi Medical University. The
study was approved by the Board of Directors ofHanoi Medical University Hospital and the Boardof Directors of Hanoi Medical University underDecision No. 1469/QD-ĐHYHN dated May 20,
2022.
RESULTS
Table 1 showed that the total participants of thestudy were 342 patients at age of 18 to 103 years
old, and the mean of age was 72.3 ±16.1. Elderly
patients who were more than 65 years old
accounted for 70.3% of the total patients. In termsof gender, males accounted for 53.2% and females
accounted for 46.8%. For the COVID-19 conditionin the first 24-48h of ICU admission, 39.8% of
patients were in severe condition and 60.2% in
critically ill condition. Regarding comorbidity, only
9.4% of ICU patients did not have any comorbidity
disease. On the contrary, the percentage of patients
who suffered from ≥3 comorbidities was thehighest, at 39.2%. Hypertension accounted for thehighest percentage with more than 70 percent of
ICU patients having this comorbidity. The
percentage of patients who had Diabetes or Obesity
was lower, at approximately 50.8 and 14 percent
respectively. When assessing the nutritional
assessment of these COVID-19 patients in the ICU
based on GLIM criteria, about 78.4 percent of thesepatients suffered from malnutrition, of which 47.7
percent were moderate and 30.7 percent for severe
malnutrition. In the first 24 to 48 hours of hospital
admission, only 7% of patients did not need any
kind of oxygen support. The percentage of patients
who needed oxygen through masks was the highest,at 38.9%. The figure for invasive mechanicalventilation (IMV) was the second highest, at
30.6%.

Table 1: The characteristics of COVID-19 patients in ICU (n=342)
̅ ± SD𝑿
71.3 ± 16.06
159.8 ± 7.60
57.2 ± 11.4
22.3 ± 3.5
4.1 ± 3.6

n=342
Age
HeightWeightBMITime from COVID-19 detection to ICU
admission

GenderCondition ofpatients in ICU

n
182
160
135
204

Male
FemaleSevereCritical ill

18

Min
18
140
35
14.8
1

Max
103
185
100
38.1
25

%
53.2
46.8
39.8
60.2

Asian Journal of Dietetics 2023

Oxygen support

Comorbidity
Most common
comorbidity
Propofol usage
Malnutrition
diagnosis based on
GLIM criteria

Room air
Oxy mask
Nasal-cannula
HFNC
NIPPV
IMV
None
1
2
>=3
Hypertension
Diabetes
Obesity
Yes
No
Normal condition
Moderate malnutrition
Severe malnutrition

24
133
46
18
16
105
32
69
107
134
252
177
48
109
233
74
163
105

7
38.9
13.5
5.3
4.7
30.6
9.4
20.2
31.2
39.2
73.7
51.8
14
31.9
68.1
21.6
47.7
30.7

Table 2. The risk of refeeding syndrome
Assessment criteria (ASPEN) (n=342)nRate (%)< 16.06

1.8

16-18.5. kg/m2

40

11.7

Weight loss
(n= 342)

Moderate loss

120

26.1

Severe loss

6

1.3

Loss of muscle mass/loss of
subcutaneous fat(n= 342)

Mild to moderate loss

135

39

Severe loss

25

7.2

< 75% estimated energy
requirement

132

38.2

< 50% estimated energy
requirement24

7

Low potassium levels(n = 57)

> 30%

6

1.8

≤ 30%

40

11.7

Low phosphorus levels(n = 14)

> 30%

5

35.7

≤ 30%

9

64.3

Low BMI (kg/m2)(n= 342)

Caloric intake(n= 342)

Table 2 showed the ASPEN evaluation of
COVID-19 patients in the ICU. Nearly half of ICU
patients suffered from losing muscle mass andsubcutaneous fat, of which about 40 percent had amoderate loss and 7 percent had a severe loss.
Similarly, more than 40 percent of patients had
reduced caloric intake, mostly lower than the 75%
estimated energy requirement.

Based on figure 1, the risk of refeeding
syndrome in COVID-19 patients was 55.3%
overall. Of these, 42.3% of patients had a moderaterisk of RFS, and 12.3% with severe risk. Of thesepatients who had the risk of RFS, 16.9% of
patients were diagnosed with the refeeding
syndrome, of which 43.7 percent for severe RFS
and 37.5 percent for moderate RFS.

19

Refeeding Syndrome in ICU COVID-19 and Factors

Risk of RFS (n=186)

RFS(n=32)

18.80%
43.70%

Moderate risk

43.2%

44.6%

Severe risk

37.50%

Mild RFS

Moderate RFS

No risk

12.2%

Severe RFS

Figure 1. Patients at risk of refeeding syndrome and RFS diagnosis
Table 3: The risk of RFS in different aged groups and comorbidities
Risk of RFS
No risk of RFS
p
n (%)
n (%)
Sex

Male
Female83 (45.6)
70 (43.8)
69.8±15.4
47 (30.7)
106 (69.3)
65 (48.5)
88 (42.3)
89 (61.2)

0.73*

<65
≥65
≥3
<3
Hypertension

99 (54.4)
90 (56.3)
72.4 ±16.6
43 (22.75)
146 (77.25)
69 (51.5)
120 (57.7)
102 (56)

Diabetes

74 (41.8)

67 (47.2)

0.34*

Obesity

14 (7.4)

34 (22.2)0.000*

Age

Comorbidities

Commoncomorbidity

0.04 ƍ
0.096*
0.26*
0.29*

OR
(95% CI)
1.07(0.70 – 1.65)
1.51(0.93 – 2.45)
0.77(0.50 – 1.21)
0.79(0.50 – 1.23)
0.80(0.51 – 1.26)
0.28(0.14 – 0.55)*: Chi-square test
ƍ: Mann Whitney test
Table 3 shows that sex, hypertension, and risk of RFS while age and obesity comorbidity arediabetes comorbidities are not associated with the associated with the risk of RFS.
Table 4: The risk of refeeding syndrome and clinical condition of patients

Oxygen support
Condition of COVID
patients
GLIM
ICU time

Variables

Risk of RFS

No risk of RFSp

OR (95%CI)

IMV

90 (74.4)

31 (25.6)

0.000*

Oxy mask

99 (44.8)

122 (55.2)

3.58(2.15 – 5.95)

Critical ill
Severe131 (64.2)
56 (41.5)

73 (35.8)
79 (58.5)

0.000*

2.53(1.60 – 4.00)

Malnutrition

188 (70.2)

80 (29.9)0.000*

Normal1 (1.4)73 (98.7)≥ 7 days

42 (53.9)

36 (46.2)

171.55(15.17
1940000)
0.93

20

0.775*–

Asian Journal of Dietetics 2023

Propofol usage

Nutrition feeding route(0.56 – 1.54)< 7 days

147 (55.7)

117 (44.3)

YesNo

75 (68.8)
114 (48.9)

34 (31.2)
119 (51.1)

0.001*

2.30(1.41 – 3.76)

No EN
EN (bolus)PN

97 (45.5)
92 (71.3)
7 (87.5)

116 (54.5)
37 (28.7)
1 (12.5)0.000*

0.34(0.21 – 0.55)

0.085**

EN + PN

16 (53.3)

14 (46.7)

6.13(0.59 – 63.68)*: Chi-square test**: Fisher‘s exact test
Table 4 showed that the types of oxygen
support,condition
inpatients,
malnutrition
condition, propofol usage, and nutrition feeding
route are associated factors with the risk of RFS,
and these associations are significant (p<0.05).
DISCUSSION
The research was carried out on 342 severe andcritically ill COVID-19 patients at COVID-19
Hospital 2021 of Hanoi Medical University
Hospital. The median age was 71.3 years old(ranging from 18-103 years old). A total of 182
males and 160 females participated in the research.
The mean age was higher than that of a similar
Korean study (57.5 years) (10). The severity of
COVID-19 was classified as pneumonia without
oxygen treatment (7%), pneumonia with oxygen
treatment by nasal cannula (13.5%), oxy mask
(38.9%), and HFNC (18%). Additionally, 35.3% of
patients needed mechanical ventilation support(both NIPPV and IMV). In terms of comorbidity,
the most common comorbidities were hypertension(73.7%), diabetes mellitus (51.8%), and obesity(14%). These figures were different in compositionof comorbidities than that of Ye Minn Htun’s study
In Myanmar in 2021 (58.3% for hypertension,
29.8% for diabetes mellitus) (11). These
comorbidities cause the COVID-19 disease more
severe and increase the risk of death in patients.
In terms of RFS, RFS is historically described
as a range of metabolic and electrolyte alterations
occurring as a result of the reintroduction and/or
increased provision of calories after a period of
decreased or absent caloric intake. In patients
experiencing refeeding syndrome, a dangerous shift
in fluids and electrolytes occurs within the body,resulting in compromised cardiovascular status,
respiratory failure, seizures, and even death. RS
diagnostic criteria are outlined as the following: A
decrease in any 1, 2, or 3 of serum phosphorus,
potassium, and/or magnesium levels by 10%–20%(mild RFS), 20%–30% (moderate RFS), or >30%
and/or organ dysfunction resulting from a decreasein any of these and/or due to thiamin deficiency(severe RFS). And occurring within 5 days ofreinitiating or substantially increasing energy
provision. Overall, in our research, 55.3 percent ofpatients in the ICU had the risk of RFS. This
percentage was higher than that of the Boot R study(36.8%) and lower than the Zahra study in2022(82%) (7, 12). This can be explained by that
we had taken a wider patient spectrum (severe andcritically ill patients) than that of the Zahra study(only critically ill patients). More specifically,
18.8% of patients suffered from severe RFS, ofwhich 5 of them had reduced blood phosphorus ofmore than 30%; 37.5% of patients suffering frommoderate RFS with 9 patients had reduced blood
phosphorus under 30%. Reduced blood phosphorus
can lead to disorientation, encephalopathy,
areflexic paralysis, seizures, coma, tetany, cardiac,
hypotension, shock, decreased stroke volume, andhematologic. In addition, the condition ofdiaphragmatic weakness, and respiratory failure
leads to patients having difficulty weaning off theventilator support. Consequently, the prevention
and treatment of RFS play an important role in theoverall therapeutic strategy of COVID-19 patients.
Regarding the exploration of associated factors,
we assessed the association between demographic
variables, medical history, and clinical indicatorswith RFS risk. There are some similarities andcomplementarities in the results when comparedwith Zahra's study (12). As for the similarities, bothstudies showed that gender was not an associatedfactor, while malnutrition was strongly associatedwith RFs risk. This is because while malnutrition
happened when a patient had been malnourished
for a long period of time, the action ofreintroduction of food to them can lead to RFS.
Similarly, both studies found a correlation between
age and the risk of RFS. As a complement toZahra's study, there were differences in results
when assessing associations with comorbidity, andfeeding routes. While Zahra reported thatcomorbidity was a risk factor for the occurrence of
RFS, our study found no association, with the
exception of Obesity. The reason for thesedifferences is that the classification of the variables
is different. In terms of comorbidity, Zahra
concluded that having one or more comorbidities
was a risk factor, and our results add to theinformation that patients with 3 or more diseases
had no difference in the risk of RFS compared withpatients with 1 or 2 diseases. Our study also foundthat there is a correlation between patients who also
had obesity and the risk of RFS. Regarding thefeeding route, when only comparing the risk of
RFS between the two groups of PN and PN+EN
routes, no association was found. However, we
further compared the EN group with the no EN
group showing that no EN group is a risk factor for
RFS. In addition, mechanical ventilation was a risk
factor for RFS compared with oxygen with an OR= 1.83. Our study also found that the propofol
usage of patients is also related to the risk of RFS
with an OR = 2.30.
CONCLUSION
In conclusion, this study investigated therefeeding syndrome and some of its associated21Refeeding Syndrome in ICU COVID-19 and Factors
factors in severe and critically ill COVID-19
patients in the ICU. The results showed that nearly
half of these patients with COVID-19 had the riskof RFS and some of the patients were diagnosed
with RFS. We also found that while sex, type ofoxygen support, and the feeding route of patientsrequired in ICU, the COVID-19 condition of
inpatients is associated with the risk of RFS, thedifference in sex and comorbidity showed noassociation. Therefore, we suggest that malnutrition
and RFS may favor the onset of COVID-19 andincrease the severity of COVID-19 disease.
Recognizing the risk and identifying, stratifying,avoiding, and managing RFS should be included in
the overall treatment of COVID-19. Further
research is needed on the impact of malnutrition
and refeeding syndrome in COVID-19.

5. Boot R, Koekkoek KWAC, van Zanten
ARH. Refeeding syndrome: relevance forthe critically ill patient. Curr Opin Crit
Care 24(4):235-240. 2018.
6. Yang X, Yu Y, Xu J, et al. Clinical course
and outcomes of critically ill patients with
SARS-CoV-2 pneumonia in Wuhan,
China: a single-centered, retrospective,
observational study. Lancet Respir Med
8(5):475-481. 2020.
7. Vignaud M, Constantin JM, Ruivard M, etal. Refeeding syndrome influences
outcome of anorexia nervosa patients in
intensive care unit: an observational study.
Crit Care Lond Engl 14(5):R172. 2010.

ACKNOWLEDGEMENTS
This research was supported by Hanoi Medical
University Hospital and the COVID-19 Patients
Treatment Hospital. The authors would like tothank all the participants for their cooperation.

8. Olthof LE, Koekkoek WACK, van Setten
C, Kars JCN, van Blokland D, van Zanten
ARH. Impact of caloric intake in criticallyill patients with, and without, refeeding
syndrome: A retrospective study. Clin Nutr
Edinb Scotl 37(5):1609-1617. 2018.

REFERENCES
1. Zhu N, Zhang D, Wang W, et al. A Novel
Coronavirus from Patients with Pneumonia
in China, 2019. N Engl J Med 382(8):727733. 2020.

9. Im JH, Je YS, Baek J, Chung MH, Kwon
HY, Lee JS. Nutritional status of patientswith COVID-19. Int J Infect Dis IJID Off
Publ Int Soc Infect Dis 100:390-393. 2020.

2. Huang C, Wang Y, Li X, et al. Clinicalfeatures of patients infected with 2019
novel coronavirus in Wuhan, China.
Lancet Lond Engl 395(10223):497-506.
2020.

10. Htun YM, Thiha K, Aung A, et al.
Assessment of depressive symptoms inpatients with COVID-19 during the second
wave of epidemic in Myanmar: A crosssectional single-center study. PLoS ONE
16(6):e0252189. 2021.

3. Runde J, Sentongo T. Refeeding
Syndrome. Pediatr Ann 48(11):e448-e454.
2019.

11. Vahdat
Shariatpanahi
Z,
VahdatShariatpanahi M, Shahbazi E, Shahbazi S.
Refeeding Syndrome and Its Related
Factors in Critically Ill Coronavirus
Disease 2019 Patients: A Prospective
Cohort Study. Front Nutr 9:830457. 2022.

4. Wirth R, Diekmann R, Janssen G, et al.
[Refeeding syndrome : Pathophysiology,
risk factors, prevention, and treatment].
Internist 59(4):326-333. 2018.

22

Asian Journal of Dietetics 2023

Original
Nutritional status and associated factors of gastrointestinal surgical patients at Hanoi
Medical University Hospital between 2021 and 2022
Linh Thuy Nguyen 1,2,4 *, An Tuong Bui1, Anh Le Thi Ngoc3, Nga Thanh Ta2,5, Dung Duc Le2,5,Tu Huu Nguyen1,2
1
Hanoi Medical University
Hanoi Medical University Hospital, Hanoi Medical University
3
Thanh Hoa Campus of Hanoi Medical University
4
School of Preventive Medicine and Public Health, Hanoi Medical University
5
Dietitian of Hanoi Medical University
2

ABSTRACT: Background/Purpose: In patients following gastrointestinal surgery, a poor
early post-operative nutritional status or risk is linked to a longer post-operative length ofstay. Thus, this study aimed to examine the prevalence of nutritional status and the somerelated factors of gastrointestinal post-operative patients. Methods: A cross-sectional study
was conducted on 101 patients with gastrointestinal surgery at the Department of General
Surgery, Hanoi Medical University Hospital from October 2021 to July 2022. We used the
Global Leadership Initiative on Malnutrition (GLIM) criteria (1), for the diagnosis ofmalnutrition,which includes the identification of a phenotype and an etiology. Besides, weused some laboratory tests for hemoglobin (Hb), serum albumin, and pre-albumin toevaluate nutritional status. Results: The proportion of malnutrition according to GLIM was
66.3%, of that, 44.5% of patients were classified as severe malnutrition. Malnutrition
according to BMI was 32.7%. The majority of gastrointestinal surgical patients have lowlevels of albumin and prealbumin. Surgical diseases with obstruction (eg: pyloric stenosis
induced by gastric cancer/tumor, intestinal obstruction) increased the odds of malnutrition
by 3.23 times, compared to diseases without obstruction. Conclusion: This study
determined that the prevalence of malnutrition in GI surgical patients was very high.
Surgical diseases with obstruction (eg: pyloric stenosis induced by gastric cancer/tumor,
intestinal obstruction increased the odds of malnutrition. Therefore, surgical patients need
to be evaluated nutritional status in order to give reasonable nutrition intervention.
Keywords: nutritional status, gastrointestinal surgical patients, malnutrition, Hanoi
Medical University Hospital.

patients undergoing surgery for gastrointestinal(GI) are particularly at risk of malnutrition in
Bach Mai Hospital (4). At Hanoi Medical
University Hospital (HMUH), malnutrition has
been noticed more frequently in every specialty.
There is limited data on the nutritional status ofgastrointestinal surgical patients. And in thesepatients, which type of surgery could be at higher
risk of malnutrition as compared to the others is
an unclear question. Because malnutrition and its
associated complications are a substantial issue
for surgical patients with GI, further research isneeded to determine which associated factors canpredict patients' nutritional status outcomes. Thus,
this study aimed to examine the prevalence ofnutritional status and some related factors ofgastrointestinal surgical patients to establish arationale and direction for future research in thisarea.

INTRODUCTION
The nutritional status is one of the
independent factors that influence postoperational outcomes. An often present
complication of perioperative sickness ismalnutrition (2). This is possibly due tointolerance to oral foods, and clinicalmanifestation includes symptoms such as nausea,
vomiting, and/or diarrhea. In malnourished or atrisk malnutrition patients, the organic response tosurgical trauma has greater repercussions andnegatively influences the results. According tostudies, 40% to 50% of surgical patients admitted
to the hospital are undernourished (3-4). In
particular, patients undergoing gastrointestinal
surgery are at risk of malnutrition as a result ofanorexia, dietary restriction, malabsorption or
increased intestinal losses.
Various methods for nutritional evaluation
have been proposed, using clinical, biochemical,
and anthropometric evaluation tests, as well as
corporal composition exams. In general, theanthropometric methods are practical, simple,
non-invasive and without additional costs and,
when associated with other objective parameters(laboratory, for example), they improve precisionand the accuracy of the diagnosis of thenutritional disorder.
In Vietnam, only one research suggests that

METHODOLOGY
Study design and subjects
A cross-sectional study was conducted on
postoperative patients with gastrointestinal
surgery at the Department of General Surgery,
Hanoi Medical University Hospital from October
2021 to July 2022. Patients who were 18 years ofage or older; (2) staying conscious and stable
hemodynamic; (3) length of stay at the
department ≥ 48 hours; (4) patients who havecomplete information and laboratory results in the*To whom correspondence should be addressed:

linhngthuy@hmu.edu.vn

23

Nutritional status and associated factors of gastrointestinal surgical patients
electronic medical record were included in ourstudy. We excluded patients requiring
postoperative transfer to the ICU or pregnancy.
We applied convenience sampling to recruit
participants. Post-operative patients met theabove-mentioned inclusion criteria were invited
to participate in the study. Thus, the total numberof selected patients was 101.
Nutritional status of all participants wasevaluated within 24 – 48 hours right after thetransmission from operation room to the General
Surgery Department. Demographic and medical
information including sex, age, date of admissionof the department, admission diagnosis, history of
diseases, and some laboratory tests regarding
nutritional status were collected.
Assessment of nutritional status
Anthropometry
Anthropometric indices of participants were
evaluated by height and weight. Bodyweight andheight were measured when participants had light
clothing without shoes. We used a Tanita scale
and a wooden parameter with an accuracy of 0.1
Phenotypekg and 0.1 cm to measure the weight and heightof participants. Body Mass Index (BMI) was
computed as the ratio of weight (kg) per heightsquared (m2). According to the Asia-Pacificclassification of BMI, BMI <18.5 kg/m2 wasconsidered underweight, 24.9 > BMI ≥ 23 wasoverweight, and BMI ≥ 25 was obesity.
GLIM criteria
We followed the Global Leadership Initiativeon Malnutrition (GLIM) (1), the diagnosis ofmalnutrition includes both the identification of aphenotype and an etiology. Phenotypic criteria
involve unintentional weight loss, low BMI, andreduced muscle mass. Etiology includes reduced
food intake or assimilation and disease burden.
Patients eligible for at least one phenotypic
criterion and one etiologic criterion would be
diagnosed as malnutrition. Then, we classified theseverity of malnutrition based on phenotype asfollows:

Weight loss (%)

Low body massindex (kg/m2)

Reduced muscle
massStage 1/Moderate Malnutrition(Requires 1 phenotypic criterion
that meets this grade)

5-10% within the past <20 if < 70 yr,
6 mo, or 10 -20% <22 if ≥ 70 yr
beyond 6 mo

Mild to moderate
deficit aStage 2/Severe Malnutrition(Requires 1 phenotypic criterion
that meets this grade)>10% within the past 6 <18.5 if < 70 yr,
mo, or >20% beyond 6 <20 if ≥ 70 yr
mo

Severe deficit b

a, b: Due to the unavailability of validated
assessment methods such as bioelectrical
impedance analysis (BIA), CT or MRI, and dualenergy absorptiometry, we used physicalexamination to evaluate muscle mass loss (5) )Determination of energy requirements: energy
target was set at 25 kcal/kg/day, as it isrecommended by the European Society of
Parenteral and Enteral Nutrition (ESPEN) (6). We
determined the reduction of caloric by the
proportion of actual oral intake and total energy
requirement.
Laboratory tests
We used hemoglobin (Hb), serum albumin,and pre-albumin to evaluate nutritional status.
According to the World Health Organization,
anemia is that Hb is less than 130g/L in adultmales, and less than 120g/L in adult females (7).
Serum albumin < 35g/L (8) was classified as
hypoalbuminemia, and pre-albumin < 20 mg/dL
was classified as low level (9).
Statistical analysis
EpiData version 3.1 was used to enter all
variables, data of general information,
anthropometry, weight loss, prefeeding serum
potassium, phosphorus, or magnesium, type of
surgery, admission diagnosis. All variables arelisted in table 2.1.

Stata version 15.0 will be used for data
analysis. Data screening will be done before
analyzing the data. Data were expressed as mean
± SD, n, %. For comparison of categoricalvariables, chi-square was used, and forcontinuous variables, student T-test and Mann –Whitney U test were used, T-test was for normal
distribution and Mann – Whitney for non-normal
distribution. The probability level of p < 0.05 was
set for statistical significance. Logistic regression
analysis test will be used to determine theassociation between malnutrition and somefactors such as types of surgery and locations ofsurgery.
RESULTS
Table 1 includes demographic information,
admission diagnosis and history of diseases of all
patients. The majority of patients were male
(62.4%). Mean age was 60.91 ± 15.1 years old. In
terms of admission diagnosis, colorectal cancer
was the most common disease, followed by acutediseases such as peritonitis of bowel obstruction.
The proportion of gastric cancer accounted for thelowest figure, which was 11.9%. There were only
1% of patients having more than 3 comorbidities,
the majority of patients had 1 comorbidity.
Among these, hypertension was the mostcommon comorbidity.

24

Asian Journal of Dietetics 2023

Table 1. General characteristics of the study participants
General information

n (%)
Male

63 (62.4)

Female38 (37.6)

Esophageal cancer

16 (15.8)

Gastric cancer

12 (11.9)

Colorectal cancer

28 (27.7)

Pyloric/duodenal stenosis

20 (19.8)

Peritonitis/ bowel obstruction

25 (24.8)

Hypertension

22 (22.2)

Diabetes

17 (17.2)

Cirrhosis

2 (2.0)

1 comorbidity

43 (42.6)

2-3 comorbidities

21 (20.8)

More than 3 comorbidities

1 (1)

Sex

Admission diagnosis

History of diseases

Age

̅ ± SD
𝑿

Min

Max

60.9 ± 15.1

28

94

Figure 1: The prevalence of malnourished patients by GLIM and BMI.

GLIM

BMI

No Malnutrition
Moderate Malnutrition
Severe Malnutrition

Normal nutrition status
Undernourishment
Overweight and obesity

16.8%
44.5%

33.7%
32.7%

50.5%

21.8%

The proportion of malnutrition according to
GLIM was 66.3%, of that, 44.5% was classified assevere malnutrition. Malnutrition according to BMI

was 32.7%. There was 17% of patients classified as
overweight and obesity according to BMI.

25

Nutritional status and associated factors of gastrointestinal surgical patients
Figure 2: The prevalence of malnourished patients (GLIM) by gender, age (%)
30.0%
24.8%

25.0%

23.8% 23.8%

20.8%

20.8%

19.9%

20.0%
16.8%
Normal
15.0%

12.8%

12.8%

Moderate malnutrition
Severe malnutrition

9.9%
8.9%

10.0%
4.9%
5.0%

0.0%
Male

≥ 60 years old

FemaleIt can be seen that severe malnutrition was
distributed similarly in all genders and age
groups. The proportion of moderate malnutrition< 60 years old

was seen as the highest in males (16.8%) and thelowest in females (4.9%).

Table 2. The percentage of symptoms according to malnutrition of GLIM criteria
Symptomsn%Moderate: <20 if < 70 yr, <22 if 70 yr

20

19.8

Severe: <18.5 if < 70 yr. <20 if 70 yr

37

36.6

Moderate

23

22.8

Severe27

26.7

Mild to moderate

22

21.8

Severe2221.8< 50% of ER

13

12.9

< 75% of ER

6

5.9

74

73.3

BMI

Weight loss in >= 6monthsReduced muscle
mass
Reduced foodintakeInflammation
Table 2 shows the percentage of individual
symptoms according to thresholds for severity
grading of malnutrition of GLIM criteria.
Regarding phenotypic criteria, severe BMI andweight loss were more common than severe muscle
mass reduction. The percentage of severe andmoderate muscle mass reduction was the same
(21.8%).In terms of etiologic criteria, 12.9% of
patients had an oral intake of less than half of theirenergy requirement, and 73.3% of patients hadmalignant diseases, categorized as inflammation.

26
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Asian Journal of Dietetics 2023

Table 3. Biochemical tests of all participants classified by gender

Hemoglobin

Albumin

Pre-albumin

Male(n, %)

Female(n, %)

Total(n, %)

Amenia32 (32.3)

17 (17.2)

49 (49.5)

No anemia

30 (30.3)

20 (20.2)

50 (50.5)

Hypoalbuminemia

30 (39.5)

22 (28.9)

52 (68.4)

No hypoalbuminemia

17 (22.4)

7 (9.2)24 (31.6)

Low prealbumin

19 (48.7)

13 (33.3)

32 (82.7)

Normal prealbumin

6 (15.4)

1 (2.6)7 (17.9)

The proportion of anemia among all study
albumin accounted for 68.4% and 82.7%
participants was very high (49.5%), of that, males
respectively. Males had higher proportion of
had higher percentage of anemia than females.
malnutrition according to both albumin and preMalnutrition according to albumin and prealbumin.
Table 4. Malnutrition and some associated factors
Malnutrition

Upper GI (n= 48)

Yes

No

(n, %)(n, %)

34 (70.8)

14 (29.2)

Locations of GI
surgery (n=101)

Types of surgery(n=101)

Characteristics ofsurgical diseases(n=101)

Lower GI (n= 53)

33 (62.3)

20 (37.7)

Emergency surgery(n= 25)

19 (76)6 (24)

Elective surgery(n= 76)48 (63.2)

28 (36.8)

Total/partial obstruction(n= 45)36 (80)9 (20)

No obstruction (n=56)

31 (55.4)

ORp(95% CI)

0.37

1.47
(0.63 – 3.42)

0.24

1.85
(0.65 – 5.24)

<0.01

3.23
(1.26 – 8.23)

25 (44.6)*Chi-square test
Some associations between surgical characteristics
and malnutrition was indicated in table 4. We foundthat surgical diseases with obstruction (eg: pyloric
stenosis induced by gastric cancer/tumor, intestinal
obstruction) increased the odds of malnutrition by

3.23 times,
obstruction.

27

comparedtodiseases

without

Nutritional status and associated factors of gastrointestinal surgical patientsDISCUSSION
Our rate of 32.7% for undernourishment of BMI
and 66.3% for malnutrition of GLIM. The report
rates of malnutrition in patients with undergoinggastrointestinal operations vary from 14% to 55%,
with the rate higher in patients with malignancy (2)(10-11). This means that our study reveals that theprevalence of malnutrition in GI surgical patientswas very high. However, there was aninconsistency of the prevalence between GLIM and
BMI. Specifically, the proportion according to
GLIM was doubled than that of BMI. This isbecause GLIM involves BMI criteria, of that, thethreshold of BMI of GLIM was wider than that ofisolated
BMI.
Besides,
the
rate
of
undernourishment of BMI in our study is 33%,
which was slightly lower than the study in BachMai Hospital has 48% of participants with
BMI<18.5 (4). In each case when BMI is less than
15 kg/m2, there is a noticeable rise in morbidity.
On the other hand, this study showed that moderatemalnutrition was more common in males (16.8%),
which was the same in other studies (12-13).
Our study found manifestations of severe
malnutrition accounted for a loud proportion of
BMI and weight loss (36.6% and 26.7%,
respectively). Malnutrition was associated with asignificant risk of anastomotic leakage and wound
infection. One research reported that preoperative
malnutrition increased the rate of anastomotic
leakage in which patients underwent low anterior
resection (12). In that research, anastomotic
leakage increased hospital length and cost. Kang etal. further supported this finding that malnutrition(OR, 2.81; 95% CI, 2.32-3.40), on multivariate
analysis, was an independent risk factor foranastomotic leakage after anterior resection forrectal cancer in patients (14). Another study
reported that malnutrition is a significant risk factor
forpostoperative
infectious
and
wound
complications in patients undergoing major surgery(15).
In the present study, both albumin and pre-albuminin GI surgical patients are at low levels. Multiple
regression analyses showed that post-operativecomplications correlated positively with old age,recent weight loss, low serum albumin, andinfrequent nutritional support, which corroborated
findings from other studies (16). A few studies
found that the other indicators of poor preoperative
nutritional status, such as low serum albumin andpreoperative weight loss, were also adversely
associated with longer lengths of stay (17-19).
Acknowledged that these findings should beinterpreted with caution because there arelimitations to the use of these parameters inassessing nutritional status. Low albumin levels
may reflect an inflammatory response related todisease severity (20); however, albumin can still
provide a significant marker of patients at risk of aproblematic recovery who may benefit fromnutrition intervention.
This study determined that pyloric/duodenal
stenosis was more frequent in malnutrition patients(p=0.049), and the rate of malnutritional patientswith and without colorectal cancer are the same
(p=0.031). But other studies have demonstrated thatpatients at nutritional risk have higher complication
rates after surgery for colorectal cancer (21). In

surgical patients, the use of nutritional support was
the attempt to correct malnutrition and,
consequently, the malnutrition-associated adverse
effects such as postoperative complications reduce.
CONCLUSION
This study determined that the prevalence ofmalnutrition in GI surgical patients was very high.
Nutritional status is a significant modifiable
preoperative risk factor associated with poor
surgical outcomes. And some related elements with
the nutritional status are admission diagnosis, andcharacteristics of surgical diseases. Therefore, if wewant to improve the nutritional status of surgicalgastrointestinal patients, we must enhance ourcapacity to detect patients at risk for perioperative
malnutrition before surgery and use approaches fornutrition optimization based on scientific data.
ACKNOWLEDGEMENTS
We would like to thank all study participants for avery reliable approach to the research, thanks towhich we were able to obtain reliable data andresults. Thank you to the authors for research idea
and progress
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resection for rectal cancer. JAMA Surg 148(1):65–
71. 2013.
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Lertsithichai P, Sumboonnanonda K. Nutrition
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methods in presence of risk adjustment. Nutr
Burbank Los Angel Cty Calif 21(6):691–7. 2005.

16. Bozzetti F, Gianotti L, Braga M, Di Carlo V,
Mariani L. Postoperative complications ingastrointestinal cancer patients: the joint role of thenutritional status and the nutritional support. Clin
Nutr Edinb Scotl 26(6):698–709. 2007.
17. Moghadamyeghaneh Z, Hwang G, Hanna MH,
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Bonomo GM. [The dehiscence of colorectal
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29

Asian Journal of Dietetics 2023

Original
Knowledge and practice patterns of nutrition-focused physical examination in dietitians
in Malaysia after an in-person training workshop with 1-year online follow-up
Cassandra DQ Lim, MS, APD1, Rebecca A. Brody, Ph.D., R.D., LDN, CNSC2, Joachim D. Sackey, Ph.D.,
MSc, MPhil2, Riva E. Touger-Decker, Ph,D., R.D., CDN, FADA2, Winnie SS Chee, Ph.D.3, Seong Ting
Chen, Ph.D.,3 & Jennifer A. Tomesko, DCN, R.D., CNSC2
1
Dietetics Department, National University Hospital, Singapor
School of Health Professions, Department of Clinical and Preventive Nutrition Sciences at Rutgers
University, USA
3
School of Health Sciences, International Medical University of Malaysia

2

ABSTRACT Background: Nutrition-focused physical examination (NFPE) is acomponent of nutrition assessment performed by dietitians. Globally, research on NFPE
practices of dietitians is limited. Purpose: This study explored changes in NFPE knowledge
and practices over 12-months among clinical dietitians in Malaysia who completed a hybrid
NFPE training program. Methods: This was secondary analysis of data from a 2019
prospective cohort pilot study. Participants attended a 2-day in-person workshop in
Malaysia with quarterly online follow-up over 12 months. A 50-item multiple-choiceknowledge test was completed by participants before and immediately, 6- and 12-months
post-training. Data collection forms with self-reported frequencies of conduct of 43 NFPE
practice tasks conducted during patient assessments were completed before and 6- and 12months post-training. Statistical analyses included descriptive statistics, one-way repeatedmeasures ANOVA for knowledge assessment scores, and Chi-square tests for changes infrequencies of NFPE performance for the study population. Results: Of the 16 clinicaldietitian participants, 81.3% (n = 13) completed the study. Participants had a mean of
9.3±6.4 years of clinical practice; 81.3% (n = 13) had no prior NFPE training. Mean NFPE
knowledge scores increased significantly from before (33.8±3.9) to immediately posttraining (44.0±3.2; p <0.001) and were maintained for 12-months post-training (43.3±2.9;
p <0.001). Performance of all 43 NFPE practice tasks increased significantly from before
to 12-months post-training (p <0.001). Conclusion: Clinical dietitian participants
demonstrated an improvement in their knowledge scores and frequency of use of NFPE
from before to 12-months post-training. Future research should include a control group to
examine the effectiveness of a hybrid NFPE training program.
Keywords: Dietitians, Nutrition-focused physical examination, knowledge, practice, allied
healthDietitians in these countries have reported that thebenefits to patient care support the use of the NCP inpractice (6). Dietetics educators and clinical dietitians
in Malaysia have also incorporated the NCP into theirdietetics curricula (7) and clinical practice,respectively (8). However, before 2019, clinicaldietitians in Malaysia do not use NFPE as part of the
NCP. Instead, they commonly use the Subjective
Global Assessment (SGA) to conduct nutritionassessments which includes a physical examinationof subcutaneous fat tissue, muscle stores, and thepresence of edema and/or ascites to identify
malnutrition (9). Thus, clinical dietitians in Malaysia
could have been practicing some components of
NFPE.

INTRODUCTION
Physical examination of a patient involves a headto-toe examination using visual observation,
palpation, auscultation, and percussion (1). Nutritionfocused physical examination (NFPE), conducted bya dietitian, includes the examination of bodycomposition (muscle and subcutaneous fat stores andfluid accumulation); inspection of the skin, hair, andnails; examination of posture and functional status,
and the head, neck, select cranial nerves and oralcavity and dysphagia screening (2, 3). An NFPE
allows the dietitian to identify factors impacting aperson's ability to consume foods and fluids and signs
and symptoms of nutrient deficiencies andmalnutrition (1).

Registered dietitians (RDs) in the U.S. havedescribed inadequate training and lack of confidence
as barriers to performing NFPE (3, 10-12). After
receiving NFPE training, U.S RDs reported increased
knowledge, confidence, and use of NFPE in clinicalpractice (3, 11). Two prior studies explored changes
in the practice of dietitians following NFPE training
in Africa and the Middle East (2, 13). Wright foundthat dietitians in Ghana demonstrated a significant
increase in knowledge, application of themalnutrition diagnosis criteria, and confidence scoresin diagnosing malnutrition after completing NFPE

The Academy of Nutrition and Dietetics(Academy) Nutrition Care Process (NCP) for
registered dietitians states that the NFPE should be
included as part of a nutrition assessment (4). The
NCP has been adopted by dietitians practicing incountries in the Asia-Pacific region, including
Australia, New Zealand, and Singapore (5, 6).
*To whom correspondence should be addressed:

cassandra_dq_lim@nuhs.edu.sg
31

NFPE training and changes in knowledge and practiceData collection tooltraining (13). Similarly, Brody et al explored changes
in the knowledge and practice of dietitians working
in long-term care settings in Israel and found thatparticipants demonstrated increased knowledge andperformance of NFPE after completing NFPE
training (2). However, there is a paucity of publishedresearch on the adequacy of training and other factors
affecting the knowledge and practice of NFPE in
Asia and other regions outside the United States.

Knowledge tests: Participants completed aknowledge pre-test with demographic questions
administered by Qualtrics (17) and the knowledge
test before and immediately, 6, and 12-months posttraining. These tests consisted of 50 questions related
to NFPE. Participants were awarded 1 point for eachcorrect answer and no points for incorrect or missing
answers, with a possible minimum score of 0 and amaximum score of 50 points. The knowledge preand post-tests had the same questions, but the orderof the questions and their multiple-choice options
were scrambled each time the test was administered.

The primary aims of this secondary analysis were
to examine the changes in NFPE knowledge andpractices for clinical dietitian participants in
Malaysia who attended an in-person NFPE workshop
and completed 12-months of online follow-up
training.

NFPE data collection form: Study investigators
instructed the participants to complete 25 datacollection forms 2 weeks before the workshop. The
form consisted of 43 NFPE practice tasks, comprisedof a patient interview, examination of the skin, fluid,muscle, and fat stores; cranial nerve and intra-oral
examination tasks, based on the Stepwise Approachto the Conduct of the Nutrition Focused PhysicalExamination developed by the Rutgers School of
Health Professions' Department of Clinical andPreventive Nutrition Sciences (RU, SHP, DCPNS).
This guide was used as a training tool during theworkshop to teach participants how to conduct a
physical examination.

MATERIALS AND METHODS
Study Design
This study is a secondary analysis of data fromone of two cohorts, comprising 16 clinical dietitianparticipants from the original prospective cohort pilot
study by Tomesko et al (14). For inclusion in the pilot
study, dietitian participants had at least 1 year ofclinical work experience and could attend a 2-day inperson NFPE training workshop conducted at
International Medical University (IMU) in Kuala
Lumpur, Malaysia in January 2019, and participatedin the 12-months of online follow-up.

Post-training, participants were asked to complete
one form for each patient they conducted a nutritionassessment on and return up to 25 forms at 6- and 12months. If participants completed the NFPE practicetask, they indicated "performed exam" and if they did
not complete the NFPE practice task, participants
indicated they "did not perform exam" on the form.

Recruitment and Study Implementation
Sixteen clinical dietitian participants enrolled in
the original study; 13 who completed all study
components, including knowledge tests and NFPE
data collection forms, were included in thissecondary analysis. Participants were invited toparticipate in an information session about the study
via an email invitation sent through the Malaysian
Dietitian Association (MDA) listserv or wereselected by Malaysia's Ministry of Health (MOH)
Head of Professions. Participants who agreed toparticipate in the study signed consent forms after the
information session.

The knowledge tests and NFPE data collection
tool were subjected to face and content validity
testing with 4 NFPE experts from RU, SHP, DCPNS,
and 2 dietetics educators from IMU. The knowledge
tests and NFPE data collection tools have also beenused with other dietitians globally (2, 3). This study
received expedited ethics approval by the Health
Sciences IRB Newark at Rutgers University(protocol #2018000733), IMU Joint-Committee on
Research and Ethics (IMU R 209/2018), andMalaysian Ministry of Health National Medical
Research Registry (NMRR18-2857-44374 (IIR)).

Study participants enrolled in a Canvas Learning
Management System (LMS) module entitled "Nutsand Bolts of NFPE" (15) that included the NFPE
training module, training resources, and ZOOM links
for online follow-up sessions. In January 2019,
participants attended a 2-day in-person NFPE
workshop conducted by 3 faculty from Rutgers
University. Day 1 consisted of didactic lectures withhands-on demonstrations, role-modeling by the
instructors, and mentored practice of NFPE
techniques. Day 2 focused on the evaluation of skills
acquisition. At the end of Day 2, clinical dietitianparticipants completed the first knowledge post-test
and a skills competency assessment. Live online
sessions were conducted quarterly for 12-months
post-training via ZOOM (16), using case studies toreinforce NFPE skills. The skills competency
assessment was repeated virtually at 6- and 12months post-intervention to assess skill acquisition
and retention. Study investigators, who are experts in
NFPE, evaluated the competency assessments.

Statistical Analyses
Descriptive statistics were used to describe thesample, responses to the knowledge tests, and selfreported NFPE practices at each time point of datacollection. One-way repeated-measures ANOVA
with Bonferroni's post-hoc analysis analyzed thechange in NFPE knowledge scores over time. Chisquare or Fisher's exact test was used to analyzechanges in practice task performance from before to
6- and 12-months post-training, and from 6- to 12months post-training. Changes in NFPE practice task
performance were based on the number of NFPE datacollection forms returned at each time point of datacollection and not by comparing individual clinicaldietitian participants' responses. We did not conduct
matched paired analysis because the same individual32

Asian Journal of Dietetics 2023
did not return the same number of forms at eachtimeframe. For these analyses, the 'n' reported is thenumber of times a clinical dietitian participant
reported that they performed or did not perform a task
on the data collection form.
RESULTSNFPE practice tasks
The participants returned a mean of 18 forms eachpre-training and a mean of 15 forms each at 6- and
12-months post-training. Self-reported conduct of
NFPE practice tasks on the NFPE data collection
forms was used as a surrogate measure forparticipants' conduct of each NFPE task. There were
43 NFPE tasks, grouped into 4 categories: "Patient
Presentation and Interview" (9 tasks), "Skin, Fluid,Muscle and Fat Assessment Components" (19 tasks),"Cranial Nerve Examination" (7 tasks), and "IntraOral Examination" (8 tasks).

Sample Description
Of the 16 clinical dietitian participants who
consented to the study, 81% (n = 13) completed thestudy. Ninety-two percent (n = 12) were female.
Participants had a mean age of 33.8±4.0 years and amean of 9.1±4.9 years of clinical practice; 76.9% (n= 10) reported that they had never received NFPE
training before this study.

The self-reported conduct of all 9 "Patient
Presentation and Interview tasks" by participants wascompleted less than 50% of the time before training.
Polypharmacy questions were self-reported as
conducted least often (17.1%, n = 42) in thiscategory. In the "Skin, Fluid, Muscle and Fat
Assessment Components" category, 16 of the 19
tasks were self-reported as performed 10% of thetime or less at baseline (Table 2). At the end of 12months, the self-reported conduct of all 19 NFPE
practice tasks in the "Skin, Fluid, Muscle and Fat
Assessment Components" increased significantly
from being performed less than 10% before training
to more than 70% of the time (p <0.001) (Table 2).
The assessment of the Cough reflex and Swallow
NFPE practice tasks increased from being performed
7.9% and 12.0% of the time before training, to 69.5%
and 79.5% at 12-months post-training. Performanceof all 7 "Cranial nerve examination tasks" increased
from 0.0% before training, to between 46.3-50.2% at
12-months post-training (p <0.001) (Table 2). For the
8 "Intra-oral exam tasks," self-reported conduct
increased significantly from being performed lessthan 10% of the time before training to 58.0% to
85.0% at 12-months post-training (p <0.001) (Table
2). At 12-months post-training, there were
statistically significant increases in self-reported
conduct of all 43 NFPE tasks from before to 12months post-training (p <0.001) (Table 2).

Knowledge scores
Participant knowledge scores for those whocompleted knowledge tests at all 4 time points were
33.8±3.9 before training, 44.0±3.2 immediately posttraining, 42.9±3.6 at 6 months post-training, and
43.3±2.9 at 12-months post-training out of a
maximum possible score of 50 points. There was astatistically significant increase in total knowledge
scores from 33.8 before training to 44.0 immediately
post-training. This increase was sustained at 6- and
12-months post-training (p <0.001) (Figure 1).

Figure 1: Graph of change in mean knowledge
scores over time of clinical dietitian participants(N = 13)DISCUSSIONNFPE knowledge

More than 50% of participants selected incorrect
answers for 14 of the 50 knowledge questions of theknowledge pre-test. At baseline, all participants
selected the correct answers for questions related toapplying NFPE and the SGA in clinical practice, thephysical identification of landmarks for examining
upper body muscle and subcutaneous fat stores, andintra-oral examination. All participants selected thecorrect responses for these questions at all 4 time
points of knowledge assessment (Table 1).

Eighty-one percent of the dietitian participants
completed all components of the study. This was ahigher retention rate than Brody et al. (60%) at theend of their one-year study with dietitians in Israel(2). Of the 3 participants that withdrew from thestudy, 2 did so due to changes in job roles and one
could not fulfill study requirements.
There was a significant increase in knowledge
scores from before to immediately post-training (p<0.001), which was sustained at 12-months posttraining. This finding is consistent with similar
studies that explored changes in NFPE knowledge indietitians after completing NFPE training (2, 11).

Questions with the lowest proportion of correct
responses before training were questions related tomalnutrition diagnosis using the Academy/ASPEN
consensus statement, extra-oral examination, andexamination of muscle stores. The number of correct
responses to these questions initially increased frombefore to immediately post-training but decreased at
6- and 12-months post-training. At the end of 12months, questions related to malnutrition diagnosis,
extra-oral examination, and examination of muscle
and fat stores continued to have the lowest proportionof correct responses (Table 1).

Participants answered questions about the SGA
and the physical identification of landmarks for
examining upper body muscle and subcutaneous fat
stores correctly 92.3-100% of the time from before to
12-months post-training. In contrast, less than 60% ofparticipants selected the correct answers before
training for questions related to cranial nerve

33

NFPE training and changes in knowledge and practice
examination, oral manifestations of nutrient
deficiencies, and identification of intra- and extraoral
cavity structures. Six months post-training, more than
70% of participants selected the correct responses forquestions related to these same topics, and by 12months post-training, only one question related tocranial nerve examination had less than 60% ofparticipants select the correct answer. Similarly,
Brody et al. found that the proportion of correct
responses to questions related to cranial nerve
examination, oral manifestations of nutrient
deficiencies, and identification of intra- and extraoral
cavity structures increased from baseline to 12months post-training in long-term care dietitians in
Israel (2).

of using a hybrid approach with in-person training
and virtual ZOOM follow-up for teaching NFPE. The
US investigators' experience in developing training
programs and conducting NFPE training globally
was also a strength (2, 3, 14). Their collaboration
with the investigators in Malaysia ensured theteaching materials and content used were culturally
appropriate and reflected the local practice in
Malaysia (14). As a result of this study, Malaysia’s
MOH now requires dietitians to include NFPE as partof their professional requirements. However, thisstudy also has some limitations. The generalizabilityof the study results are limited due to the small
sample from one geographical location in Malaysia.
Selection bias is possible as recruited participants had
volunteered via MDA’s listserv or were selected by
the MOH’s Head of Profession and may already havean interest in NFPE. Since this was a pilot study withno control group, it was not possible to determine theeffect of training on NFPE knowledge and practice inthe clinical dietitian participants.

NFPE performance
There was a significant increase in participants’
self-reported conduct of all 43 NFPE practice tasks
from before to 12-months post-training (Table 2),
which is similar to previous research that exploredchanges in NFPE knowledge and practices posttraining. Consistent with our findings, Brody et alreported significant increases in self-reported
conduct of NFPE tasks from before to 6 months posttraining in dietitians in Israel (2).

As knowledge test questions were identical at alltime points, participants may have become familiar
with the questions and reported answers frommemory. To minimize this, questions and multiplechoice options were scrambled each time theknowledge test was administered. It is also possiblethat the ZOOM sessions and the continued
documentation of NFPE practice tasks over the 1year follow-up could have also reinforced knowledge
retention and skill acquisition (14). The potential forrecall bias cannot be ruled out since the conduct of
NFPE practice tasks was self-reported (18). As
participants were aware that the study was examiningchanges in NFPE practice after training, they could
have reported the conduct of more NFPE tasks.
Although the clinical dietitian participants' actual
performance of NFPE practice tasks was notobserved, the hands-on demonstration and practice of
NFPE skills during the workshop and virtual followup sessions provided participants with theopportunity to practice and apply the skills taught.

Although dysphagia screening includes an
examination of 7 cranial nerves, participants reported
performing assessment of the Cough reflex andSwallow more frequently post-training (69.5% and79.5% of the time, respectively) than the 7 cranial
nerve examination tasks (45.3% to 50.2%). Thisfinding is consistent with prior research where
dietitians in Israel who received NFPE training
significantly increased their performance of cranial
nerve examination practice tasks and swallow
screening but performed swallow screening more
often than cranial nerve examination tasks.
Participants in this study reported significantly
increasing performance of intra-oral examination
tasks from baseline to 12-months post-training (p<0.001) (Table 2). Similarly, dietitians working in
long-term care in Israel who had received NFPE
training related to intra- and extra-oral examination
also significantly increased their performance of
intra-oral examination tasks before to 6 months posttraining (2). Dietitians who performed intra-oral
examinations reported that they were significantly
more likely to refer the patient to a relevant
healthcare professional if abnormalities wereobserved during intra-oral examinations (p <0.001)(2).

The findings from this study demonstrate thatclinical dietitians in Malaysia who completed an inperson NFPE training with 12-months of online
follow-up sessions increased their NFPE knowledge
scores from before training to immediately posttraining, and sustained it for up to 12-months posttraining. Self-reported conduct of NFPE tasks inclinical practice likewise increased significantly frombefore to 12-months post-training. Future research
may include expanding this training program's reachto dietitians in other countries throughout Southeast
Asia. Including a control group in future studies will
help determine if increases in NFPE knowledge anddietitians' practice can be attributed to the training.

Strengths and limitations
Although this pilot study had a small sample size,
the retention rate was high, reflecting the feasibility

34

Asian Journal of Dietetics 2023
Table 1: Distribution of correct and incorrect responses for knowledge tests before and immediately, 6- and 12-months post-training (N=13)
Question
Before training
Immediately post-training
6m post-training
12-m post-training
Correct
Incorrect
Correct
Incorrect
Correct
Incorrect
Correct
Incorrect
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
1. NFPE scope of practice
13 100.00
0.0
13 100.00
0.0
13 100.00
0.0
13 100.00
0.0
2. Academy and A.S.P.E.N.a1
7.7
12 92.3
8
61.5
5
38.5
3
23.1
10 76.9
1
7.7
12
923
consensus statement
malnutrition diagnostic
criteria
3. Identifying abnormalities
during intra-oral exam

6

46.2

7

53.8

10

76.9

3

23.1

13

100.0

0

0.0

12

92.3

1

7.7

4. Using the SGA in nutritionassessment

13

100.0

0

0.0

12

92.3

1

7.7

12

92.3

1

7.7

12

92.3

1

7.7

5. Identifying validated nutrition
screening tools

9

69.2

4

30.8

11

84.6

2

15.4

10

76.9

3

23.1

13

100.0

0

0.0

6. Recognition of causes that
result in failure of the soft
palate to rise

8

61.5

5

38.5

11

84.6

2

15.4

11

84.6

2

15.4

11

84.6

2

15.4

7. Identifying normal
appearance of the gingiva

12

92.3

1

7.7

12

92.3

1

7.7

13

100.0

0

0.0

11

84.6

2

15.4

8. Identifying functions of the
Wharton's and Stenson's ducts

9

69.2

4

30.8

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

9. Identifying correct fat andmuscle assessment techniques
in NFPE

9

69.2

4

30.8

12

92.3

1

7.7

10

76.9

3

23.1

11

84.6

2

15.4

10. Identification of occlusion
11. Definition of edentulism
12. Identification of factors thathide orbital fat pad wasting

5
4
7

38.5
30.8
53.8

8
9
6

61.5
69.2
46.2

10
12
6

76.9
92.3
46.2

3
1
7

23.1
7.7
53.8

13
13
2

100.0
100.0
15.4

0
0
11

0.0
0.0
84.6

13
13
8

100.0
100.0
61.5

0
0
5

0.0
0.0
38.5

13. Identification of clavicle formuscle assessment

12

92.3

1

7.7

13

100.0

0

0.0

12

92.3

1

7.7

13

100.0

0

0.0

14. Identification of acromion formuscle assessment

13

100.0

0

0.0

13

100.0

0

0.0

12

92.3

1

7.7

13

100.0

0

0.0

35

NFPE training and changes in knowledge and practice
Question

Before training
Correct
Incorrectn%n%
13 100.00
0.0

Immediately post-training
Correct
Incorrectn%n%
13 100.00
0.0

6m post-training
Correct
Incorrectn%n%
13 100.00
0.012-m post-training
Correct
Incorrectn%n%
13 100.00
0.0

16. Recognition of theappearance of a normal
tongue

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

17. Identification of the impact ofhyposalivation

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

12

92.3

1

7.7

18. Identification of the correct
method for upper arm fat
stores assessment

4

30.8

9

69.2

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

19. Identification of the causes ofangular cheilitis

2

15.4

11

84.6

11

84.6

2

15.4

11

84.6

2

15.4

9

69.2

4

30.8

20. Proper documentation of theappearance of lesions on thepalate

11

84.6

2

15.4

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

21. Identification of the functionof anterior teeth

11

84.6

2

15.4

13

100.0

0

0.0

12

92.3

1

7.7

11

84.6

2

15.4

22. Identification of appearanceof fat wasting in the thoracic/
lumbar region

12

92.3

1

7.7

11

84.6

2

15.4

13

100.0

0

0.0

13

100.0

0

0.0

23. Identification of theappearance of the temporalis
muscle in a well-nourishedindividual b

13

100.0

0

0.0

13

100.0

0

0.0

11

84.6

1

7.7

11

84.6

2

15.4

24. Identification of the impact ofa TMJ disorder

8

61.5

5

38.5

12

92.3

1

7.7

13

100.0

0

0.0

12

92.3

1

7.7

25. Facial examination
26. Extra-oral examination
27. The appearance of muscles inwell-nourished individuals

12
4
11

92.3
30.8
84.6

1
9
2

7.7
69.2
15.4

12
12
12

92.3
92.3
92.3

1
1
1

7.7
7.7
7.7

8
13
10

61.5
100.0
76.9

5
0
3

38.5
0.0
23.1

8
12
9

61.5
92.3
69.2

5
1
4

38.5
7.7
30.8

15. Identification of bicep formuscle assessment

36

Asian Journal of Dietetics 2023
Question
28. Recognition of altered cranial
nerve function

Before training
Correct
Incorrect
n
%
n
%
5
38.5
8 61.5

Immediately post-training
Correct
Incorrect
n
%
n
%
12
92.3
1
7.7

6m post-training
Correct
Incorrectn%n%
13 100.00
0.012-m post-training
Correct
Incorrect
n
%
n
%
12
92.3
1
7.7

29. Identification of signs andsymptoms of dysphagia

5

38.5

8

61.5

8

61.5

5

38.5

7

53.8

6

46.2

9

69.2

4

30.8

30. Muscle examination
technique

6

46.2

7

53.8

13

100.0

0

0.0

11

84.6

2

15.4

12

92.3

1

7.7

31. Steps of dysphagia screening

8

61.5

5

38.5

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

32. Identification of the hardpalate

10

76.9

3

23.1

12

92.3

1

7.7

12

92.3

1

7.7

12

92.3

1

7.7

33. Identification of the soft
palate

7

53.8

6

46.2

12

92.3

1

7.7

11

84.6

2

15.4

11

84.6

2

15.4

34. Identification of the buccal
mucosa

11

84.6

2

15.4

13

100.0

0

0.0

13

100.0

0

0.0

12

92.3

1

7.7

35. Identification of theoropharynx

11

84.6

2

15.4

13

100.0

0

0.0

12

92.3

1

7.7

12

92.3

1

7.7

36. Identification of the uvula

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

13

100.0

0

0.0

37. Identification of type of
dentures

5

38.5

8

61.5

10

76.9

3

23.1

10

76.9

3

23.1

11

84.6

2

15.4

38. Identification of appearanceof severe muscle wasting

13

100.0

0

0.0

12

92.3

1

7.7

13

100.0

0

0.0

12

92.3

1

7.7

39. The appearance ofinterosseous muscle

11

84.6

2

15.4

13

100.0

0

0.0

10

76.9

3

23.1

11

84.6

2

15.4

40. Proper muscle examination
techniques

8

61.5

5

38.5

10

76.9

3

23.1

11

84.6

2

15.4

12

92.3

1

7.7

41. Steps in dysphagia risk
screening

11

84.6

2

15.4

11

84.6

2

15.4

13

100.0

0

0.0

13

100

0

0.0

37

NFPE training and changes in knowledge and practice
Question

Before training
Correct
Incorrect
n
%
n
%
3
23.1
10 76.9

Immediately post-training
Correct
Incorrect
n
%
n
%
6
46.2
7
53.8

6m post-training
Correct
Incorrect
n
%
n
%
7
53.8
6 46.212-m post-training
Correct
Incorrect
n
%
n
%
4
30.8
9 69.2

43. Examination of cranial nerves

4

30.8

9

69.2

13

100.0

0

0.0

10

76.9

3

23.1

7

53.8

6

46.2

44. Identification of cranial
nerves

1

7.7

12

92.3

11

84.6

2

15.4

11

84.6

2

15.4

13

100.0

0

0.0

45. Examination of muscle storesin malnutrition

10

76.9

3

23.1

12

92.3

1

7.7

12

92.3

1

7.7

12

92.3

1

7.7

46. Identification of the degree ofmuscle wasting

9

69.2

4

30.8

10

76.9

3

23.1

9

69.2

4

30.8

11

84.6

2

15.4

47. Steps of intra-oral
examination

10

76.9

3

23.1

12

92.3

1

7.7

13

100.0

0

0.0

13

100.0

0

0.0

48. Identification of the degree ofmuscle wasting

12

92.3

1

7.7

10

76.9

3

23.1

11

84.6

2

15.4

13

100.0

0

0.0

49. Identification of the use ofhandgrip strength

10

76.9

3

23.1

9

69.2

4

30.8

8

61.5

5

38.5

10

76.9

3

23.1

50. Malnutrition diagnosis using
the SGA

8

61.5

5

38.5

7

53.8

6

46.2

9

69.2

4

30.8

9

69.2

4

30.8

42. Identification of muscle
appearance during theexaminationa Academy-Academy of Nutrition and Dietetics; A.S.P.E.N.-American Society of Enteral and Parenteral Nutrition; BMI-Body Mass Index; MNA-Mini Nutrition

Assessment; MST-Malnutrition Screening Tool (MST); NFPE-Nutrition-focused Physical Examination; SGA-Subjective Global Assessmentb Missing response for Question 23 at 6 months post-training

38

Asian Journal of Dietetics 2023
Table 2: Change in performance of NFPE practice tasks by clinical dietitian participants over time (N = 13)
NFPE Clinical Practice
Before training
6months post-traininga
12-months post-traininga
Tasks
Not
Performed
Total Not performed
Performed
Total
Not
Performed
Total
performed
performed
nb
%
n
%
n
n
%
n
%
n
n
%
n
%
n
Patient Presentation and Interview Tasks
Physique and posture
149
60.1
99
39.9
248
12
6.3
178
93.7
190
9
4.5
192
95.5
201
Functional status
152
61.3
96
38.7
248
22
11.6
168
88.4
190
9
4.5
192
95.5
201
Cognition
140
57.4
104
42.6
244
14
7.4
176
92.6
190
5
2.5
195
97.5
200
Polypharmacy
203
82.9
42
17.1
245
66
34.6
125
65.4
191
79
39.7
120
60.3
199
Xerostomia
190
77.6
55
22.4
245
31
16.3
159
83.7
190
28
13.9
173
86.1
201
Altered taste
163
66.0
84
34.0
247
34
18.0
155
82.0
189
24
11.9
177
88.1
201
Oral pain
173
70.3
73
29.7
246
33
17.8
152
82.2
185
25
12.5
175
87.5
200
Changes in ability to bite,
136
56.2
106
43.8
242
29
15.5
158
84.5
187
22
11.1
176
88.9
198
chew and swallow
Use of dentures to eat
148
61.4
93
Skin, Fluid, Muscle and Fat Assessment Components
Dorsal hand region
219
92.0
19
Biceps, triceps
221
92.5
18
Acromion process and
220
92.1
19
deltoid muscle region

38.6

241

34

19.3

142

80.7

176

22

12.4

156

87.6

178

8.0
7.5
7.9

238
239
239

37
39
47

20.6
21.3
25.4

143
144
138

79.4
78.7
74.6

180
183
185

26
25
29

13.1
12.4
14.4

173
176
172

86.9
87.6
85.6

199
201
201

ScapulaClavicle
Ribs
Patellar region
Anterior thigh region
Posterior calf region
Fluid, skin hair and nails
Edema or dehydration
Color and temperature
Texture, dryness andbrittleness

224
218
222
221
220
217

93.7
91.6
93.3
92.9
92.4
91.9

15
20
16
17
18
19

6.3
8.4
6.7
7.1
7.6
8.1

239
238
238
238
238
236

66
50
67
58
59
58

35.7
27.0
36.6
31.4
32.1
31.5

119
135
116
127
125
126

64.3
73.0
63.4
68.6
67.9
68.5

185
185
183
185
184
184

39
33
41
39
35
35

19.5
16.4
20.4
19.5
17.5
17.5

161
168
160
161
165
165

80.5
83.6
79.6
80.5
82.5
82.5

200
201
201
200
200
200

201
206
206

84.8
90.4
91.2

36
22
20

15.2
9.6
8.8

237
228
226

35
41
44

19.1
22.2
23.2

148
144
146

80.9
77.8
76.8

183
185
190

19
32
26

9.6
16.0
13.1

179
168
173

90.4
84.0
86.9

198
200
199

Potential micronutrient
deficiencies and toxicities

168

97.7

4

2.3

172

47

25.5

137

74.5

184

46

23.0

154

77.0

200

Orbital fat pads
Temporalis muscle
Temporomandibular joint(TMJ)
Muscles of mastication

212
217
224

88.7
90.8
93.7

27
22
15

11.3
9.2
6.3

239
239
239

21
34
72

11.0
17.8
38.1

170
157
117

89.0
82.2
61.9

191
191
189

2
8
71

1.0
4.0
35.3

199
193
130

99.0
96.0
64.7

201
201
201

224

93.7

15

6.3

239

69

36.3

121

63.7

190

69

34.5

131

65.5

200

39

NFPE training and changes in knowledge and practice
NFPE Clinical Practice
Tasks

Before training
Not
Performed
performed
nb
%
n
%
220
92.1
19
7.9
198
88.0
27
12.0

Cough reflex
Swallow
Cranial nerve examination tasks
Trigeminal Nerve V: motor
239
Trigeminal Nerve V:
239
sensory

n
239
225

n
67
49

%
35.3
25.8

n
123
141

%
64.7
74.2

n
190
190

12-months post-traininga
Not
Performed
Total
performed
n
%
n
%
n
61
30.5
139
69.5
200
41
20.5
159
79.5
200

Total

6months post-traininga
Not performed
Performed

Total

100.0
100.0

0
0

0.0
0.0

239
239

94
102

49.5
54.0

96
87

50.5
46.0

190
189

108
108

53.7
53.7

93
93

46.3
46.3

201
201

Facial Nerve VII: motor
Facial Nerve VII: sensory
Glossopharyngeal/ Vagus
Nerve IX/X: motor

239
239
239

100.0
100.0
100.0

0
0
0

0.0
0.0
0.0

239
239
239

94
90
96

49.7
48.1
50.3

95
97
95

50.3
51.9
49.7

189
187
191

100
102
109

49.8
50.7
54.2

101
99
92

50.2
49.3
45.8

201
201
201

Hypoglossal Nerve XII:
motor

239

100.0

0

0.0

239

92

48.2

99

51.8

191

107

53.5

93

46.5

200

Accessory Nerve XI: motor

236

100.0

0

0.0

236

98

51.3

93

48.7

191

108

53.7

93

46.3

201

Intra-oral exam tasks
Dentition:
Edentulism
218
91.6
20
8.4
238
48
25.8
138
74.2
186
36
18.1
163
81.9
199
Occlusion
223
93.7
15
6.3
238
48
25.7
139
74.3
187
37
18.6
162
81.4
199
Dentures
218
91.6
20
8.4
238
47
25.1
140
74.9
187
30
15.0
170
85.0
200
Soft tissue:
Labial mucosa
238
100.0
0
0.0
238
92
49.2
95
50.8
187
84
42.0
116
58.0
200
Buccal mucosa
238
100.0
0
0.0
238
98
52.4
89
47.6
187
84
42.0
116
58.0
200
Floor of mouth
238
100.0
0
0.0
238
97
51.9
90
48.1
187
84
42.0
116
58.0
200
Hard and soft palates
238
100.0
0
0.0
238
96
51.5
90
48.4
186
83
41.5
117
58.5
200
Tongue
235
99.6
1
0.4
236
94
50.5
92
49.5
186
82
41.2
117
58.8
199
a Analyses were conducted using Chi-squared tests. All NFPE practice tasks had a significant change in performance over time, p <0.001; Bold-faced' n’ values andfrequencies indicate the NFPE tasks with the highest frequencies of performance at each time point; b “n” refers to the number of forms submitted by participants ateach time point. As clinical dietitian participants may not complete all NFPE tasks on the data collection form, the distribution (n) varies for each task

40

Asian Journal of Dietetics 2023

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FUNDING
This study was funded by grants from Rutgers
Global and the International Medical University.
CONFLICTS OF INTEREST (COI)
The authors have no conflicts of interest to
disclose.
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