ISSN2434-2688

Asian Journal of Dietetics
Vol.1

No.2

2019

Contents
Originals
23-28 Comparison of Measured Resting Energy Expenditure between Cancer
Patients and Non-Cancer Controls
Chen Seong Ting, Wong Wei Wen, Lydianis Bahari and Ratha Krishnan Sriram
29-33 Comparison of School Lunch Menus in Vietnam and Japan
Thuan Nguyen Thi, Indri Kartiko Sari, Miho Nunokawa, Noriko Sumita, Yuriko
Ichimura, Thao Nguyen Thi, and Sumiko Kamoshita
34-39 Acceptability of Fish Meat with Okara as School Lunch
Sumiko Kamoshita, Yuriko Ichimura, Saiko Shikanai, Hitomi Takeichi, Daisuke
Kunii, and Shigeru Yamamoto
Research Note40- 47 Roles and Requirements of Japanese Dieticians in International
Cooperation Initiatives
Saiko Shikanai, Kaoru Kusama, Hiroko Miura, Midori Ishikawa

Asian Journal of Dietetics 2019

ORIGINAL
Comparison of Measured Resting Energy Expenditure between Cancer
Patients and Non-Cancer Controls
Chen Seong Ting*1, Wong Wei Wen1, Lydianis Bahari2 and Ratha Krishnan Sriram3
1

Division of Nutrition & Department, International Medical University, Kuala Lumpur,
Malaysia2
Department Dietetics and Food Service, Hospital Tuanku Jaafar, Negeri Sembilan,
Malaysia3
Department of Surgery, Hospital Tuanku Jaafar, Negeri Sembilan, Malaysia(received November 30, 2018)

ABSTRACT Background and purpose. Resting energy expenditure (REE) is generally known
to be increased in cancer patients, contributing to the development of malnutrition and cachexia.
The objective of this study is to compare the difference in measured REE between cancer patientsand non-cancer controls. Methods. A cross-sectional study was conducted from January to April
2018 to compare the REE between cancer patients and non-cancer controls. A total of 25 patientsdiagnosed with colorectal cancer and 19 non-cancer controls were recruited using purposive
sampling method. Data collection included socio-demographic characteristics, anthropometricmeasurements, dietary data and REE measured by the Fitmate GS Indirect Calorimetry
instrument. Statistical analyses used were independent sample T-test and one-way Analysis of
Covariates (ANCOVA) to compare the difference in measured REE between the two groups.
Results. There was no significant difference in measured REE (p=0.053) and REE/kilogram of
Fat-Free Mass (REE/kg FFM) [p=0.372] between cancer and control groups. The one-way
ANCOVA showed that there is no significant difference in measured REE (p=0.100) between
cancer and control groups after controlling for the covariate of fat-free mass. Similar observation
was also found in REE/kg FFM between the two groups after controlling for age (p=0.486).
Unaltered REE found in colorectal cancer patients as compared to control group with strong
confounding factors such as age and FFM controlled implicates the importance of a morereasonable and individualised approach in dietetics practice when caloric load is administered tocancer patients, as opposed to a conventional approach of supplying a caloric surplus beyond
maintenance level.
Keywords: Resting energy expenditure (REE), cancer, indirect calorimetry.
INTRODUCTION
Cancer is a global epidemic, causing around 8.8
million deaths in 2015 according to World HealthOrganization (WHO) (1). It is a fourth leading cause ofdeath in Malaysia according to Malaysian National
Cancer Registry (MNCR). A total of 64,275 cancer
deaths had been reported over the year of 2007 to 2011.
The overall cancer incidence peaks at a total of 103,507
new cases from 2007 to 2011 (2). Cancer is a collectionof genetic diseases characterised by uncontrolled cell
growth, in which the cancerous cells exhibit genetic
alterations such as DNA mutations. These genetic
changes affect how the cells function and behave.
Through their genetically altered functionality andphysiology, cancerous cells form a mass of tissue called
tumour, which invade and destroy other body parts
through a process called metastasis.

Resting energy expenditure (REE) is the amount ofenergy required to sustain basal metabolism for a 24hour period at rest (3). REE comprises the largest
proportion of human energy output, accounting up to
60-75% of total daily energy expenditure (TDEE) (4).
REE is reported to be abnormally altered in cancer
patients. Depending on the type of cancer, patients wereshown to exhibit either normal or increased REE values.
Hypermetabolic activity as in increased REE
contributes to weight loss through the creation ofnegative energy balance and progressive tissue wasting,which is a defining characteristic of malnutrition
observed in 30 to 80% of cancer patients (5). REE
alteration plays a significant role in accelerating weight
loss, which then subsequently progresses thedevelopment of malnutrition and cachexia.
Malnutrition and cachexia are poor prognostic factors
for cancer patients, and studies have

*To whom correspondence should be addressed.
Email: ChenSeongTing@imu.edu.my23

Resting Energy Expenditure of Cancer Patientsshown that it is a risk factor for negative outcomes,
treatment response and quality of life (6). Furthermore,primary cause of deaths in cancer patients was suggested
to be due to imbalances in nutrition metabolism (7).
Ironically, despite the negative health outcome
implicated and the benefits of nutritional intervention,
malnutrition is often neglected in clinical settings (8).
This demands an understanding of REE changes tofacilitate the delivery of an optimal nutritional
intervention. Determining the discrepancies of REE
between cancer patients and non-cancer controls willallow us to administer an appropriate caloric load, to
rectify the nutritional status in cancer patients without
risk of underfeeding or overfeeding (9).
REE difference in cancer patients remains uncertain
and unclear due to various methodological flaws such asheterogeneity in cancer type among studies. Also, most
relevant scientific studies were not conducted locally.
Therefore, we aim to compare the differences in REE
between cancer patients and non-cancer controls for abetter guidance of evidence-based practice by dietitians
in improving the nutritional status of cancer patients.

individuals who have experienced trauma or burn were
excluded. Cancer patients who underwent surgery one
month or anticancer treatment such as chemotherapy
before the study participation were also excluded. These
exclusion criteria were set based on their independent
effects on energy expenditure.
Measurements
A self-administered questionnaire was designed tocollect socio-demographic profile of the participants. It
included gender, ethnicity, age, occupation, marital status,
smoking status, education level, household monthly
income and medical history.
For dietary assessment, the research team interviewed
the participants on a 7-day dietary history to evaluate
usual dietary intake. A structured interview method
consisting of questions was used to prompt for thehabitual intake of foods from food groups and frequency
of consumption per week. Nutripro Software was thenused to analyse the energy and macronutrient intake. A
mean of energy and nutrient intake were recorded.
Weight was measured using a digital weighing scale(Tanita, Japan) and height was measured using a
stadiometer (SECA, Hamburg, Germany). BMI was thencalculated using the obtained weight and heightmeasurements. BMI was classified according to the
Asian Pacific cut-off criteria for adults and recorded. The
body fat percentage of participant was measured using
bioelectrical impedance analysis machine (OMRON
Karada, Omron Healthcare, Japan). Fat-free mass (FFM)
was calculated with subtracting the calculated fat massfrom body fat percentage using the formula of FFM=
Body weight (kg) – [Body fat percentage (%) x Body
weight (kg)]. All measurements were taken two times andan average of the two readings was obtained and recorded.
REE was measured using Fitmate GS Indirect
Calorimetry. Participant was informed to relax and lie
down on a bed. They were requested not to sleep or talkduring the analysis to avoid interference with normal
breathing. The Fitmate Indirect Calorimetry was firstcalibrated and the blower unit was turned on. The firstphase of REE measurement was initiated by placing thehood with veil on the patient’s head. The veil was safely
enclosed over the patient to minimise air leakage. After 5
minutes of default test phase, the data acquired was
discarded. The data collected during the first phase wasto ensure accuracy. Then, the actual data acquisition
phase commenced for 10 minutes. Flow rate of the pump
was required to be monitored so it achieves a FeO2
between 19.50% and 20.25% by adjustments with theflow selector. After a default 15 minutes of dataacquisition phase, the test was ended. The hood wasremoved from the patient and the blower unit was turned
off. REE was expressed in REE (kcal) and REE/kg FFM(kcal/kg).
Statistical Analysis
Statistical analyses were performed using the IBM
SPSS Statistics 24. Descriptive statistics were used todescribe the baseline data. The parametric data were
presented as mean±SD, where comparisons between
groups were done using independent sample T-test forcontinuous variables. The non-parametric data were
presented as median±IQR, where comparisons between
groups were done using Mann-Whitney U test. Pearson’s
chi-squared tests were used for comparison between

METHODS
Study design
This study was a cross sectional study conducted fromJanuary to April 2018 among cancer patients and noncancer controls. The study site was the Surgical
Outpatient Department of the State Hospital of Negeri
Sembilan. Ethical approval was obtained from theInternational Medical University Joint-Committee on
Research and Ethics [IMU-BDN I-2017 -13] and fromthe National Medical Research Registry, Ministry of
Health Malaysia (NMRR-17-3166-39347). Informed
consent was obtained from all study participants before
enrolment, consistent with the Helsinki Declaration andthe guidelines of the institutional review committee.
Power and sample size
The sample size was calculated based on publisheddata on REE in cancer patients (Khor SM, 2011) (10). A
standard deviation of 178 for REE in cancer patients wasused at 80% power with a type I error of 5% (α=5%)alongside with a detectable difference of 15, theestimated sample size is 31 per group taking into
consideration of 10% drop-out.
Participants
Purposive sampling method was used to select study
participants. Participants will be pre-screened by theattending surgeon for eligibility as per appointment to thesurgical outpatient clinic, having fulfilled all the
inclusion criteria and presenting none of the exclusion
criteria. Participants were provided with the information
sheet and explained by the research team regarding thestudy and written consent was obtained upon agreement
to join the study. Participants were recruited if they werecancer patients and non-cancer controls, age 20 years old
and above. For cancer patients, the inclusion criterion
was the diagnosis of colorectal cancer. Participants were
excluded if they were having severe endocrine
abnormalities
suchashypothyroidismorhyperthyroidism, using high-dose steroid medication,with presence of inflammatory diseases other than cancer
or infection, and presence of oedema or ascites. Pregnant
and breastfeeding women, smokers, individuals withdiabetes or HIV, kidney, liver, heart or lung disease and24

Asian Journal of Dietetics 2019groups for categorical data. The mean difference ofmeasured REE (kcal) and REE/kg FFM (kcal/kg)
between cancer patients and non-cancer controls werecompared using independent sample T-test. The meandifference of measured REE (kcal) controlling covariateof FFM between cancer patients and non-cancer controls
and REE/kg FFM controlling covariate of age between
groups were analysed using one-way ANCOVA. All pvalues of less than 0.05 were statistically significant.

As for the comparison of energy and macronutrient
intake between cancer and control group, Mann-Whitney
U test showed a significant difference in fat intake
between cancer and control group (46±26 g/day vs 59±23
g/day, p<0.05). The control group had significantly
higher fat intake than the cancer group. There was no
significant difference in calories intake, carbohydrate
intake and protein intake between cancer and control
group.
Fat-free mass (FFM) is a strong determinant for REE
in both genders (11). FFM is a heterogeneous component
with higher metabolic activity than fat mass, as skeletal
muscle mass and liver mass have been reported tosignificantly contribute to REE. In view of this, FFM has
been proposed to overtake body weight as an adjustment
factor in the determination of REE (12,13). Table 2
shows a one-way ANCOVA conducted to compare thedifference in measured REE between cancer and control
group whilst controlling for FFM. Levene’s test,
normality test, and homogeneity of regression werechecked, and assumptions were met. Yet, there was no
significant difference of measured REE between cancer
and control group, after controlling for FFM (p=0.100).
Age was significantly different between cancer andcontrol group (p<0.001) in this study. According to Eliaet al, aging is associated with a progressive decline in
REE of 1-2% per decade after 20 years of age. Thisdecline is closely related to a reduction of fat-free mass
(14). The one-way ANCOVA comparing the differencein REE/kg FFM between cancer and control whilst
controlling for age (Table 3) shows no significant result(p=0.486).

RESULTS
Twenty-five patients with colorectal cancer andnineteen control subjects were recruited in this study. Outof all the cancer patients, 22 of them have undergone
tumour resection surgery, after which they are following
up for check-up and palliative care, whereas the other 3of them have not undergone any tumour resection. Table
1 shows the socio-demographic characteristics of 25
colorectal cancer patients and 19 control subjects.
Independent sample t-test showed significant meandifferences in age (65.4±10.4 vs 45.0±12.4, p<0.001) andin height (155.0±9.1cm vs 160.5±8.2cm, p<0.05)
between cancer and control group. Mean age of cancer
patients was significantly older than the mean age ofcontrol subjects, and the mean height of cancer subjects
was significantly shorter than that of the control subjects.
In terms of REE and REE/kg FFM, there was no
significant difference in measured REE (1188±314
kcal/day vs 1372±287 kcal/day, p>0.05) and REE/kg
FFM (28.7±7.9 kcal/kg/day vs 30.6±5.8 kcal/kg/day,p>0.05) between cancer and control group. Pearson’s chisquared test also showed no statistically significant
association for gender and ethnicity with cancer.
Table 1. Baseline data
Parameter
Gender, Male : Female
Ethnicity, Malay : Chinese

Cancer(n=25)
11:14
12:13

Control(n=19)
8:11
4:15

P value65.4±10.4
62.0±12.5
155.0±9.1
25.7±4.142.8±10.945.0±12.4
69.4±16.9
160.5±8.2
26.9±5.646.3±12.01188±31428.7±7.91372±28730.6±5.8

0.000a0.099a0.048a0.412a0.320a0.053a0.372aMedian ± IQR
1294 ± 482
1308 ± 406
176 ± 102148 ± 7955 ± 2960 ± 25
46 ± 2659 ± 23

0.678c0.084c0.546c0.030c0.900b
0.066bMean ± SD
Age, year
Weight, kg
Height, cm
BMI, kg/m2
FFM, kg
mREE, kcal/day
REE/kg FFM, kcal/day/kg
Calories intake, kcal/day
Carbohydrate intake, g/day
Protein intake, g/day
Fat intake, g/day
a Independent sample t testb Pearson Chi-Square testc Mann-Whitney U Test

REE: Resting Energy Expenditure; FFM: Fat free mass

25

Resting Energy Expenditure of Cancer Patients

Table 2. Comparison of measured REE between cancer and control group with and without adjustment of FFM using
ANCOVAn
Mean
Mean difference
P value
Cancer251188±314-157.910
0.053 aControl191372±287
Cancer25
1208(1100, 1316)b-116.325
0.100cbControl191346(1222, 1470)
Data are expressed as mean ± SD unless specified otherwisea Independent sample T testb Mean (Lower Boundary, Upper Boundary)c ANCOVA applied (adjustment for FFM)

Table 3. Comparison of REE/kg FFM between cancer and control group with and without adjustment of age using
ANCOVAn
Mean
Mean difference
P value
Cancer2528.7±7.9-1.95
0.372 aControl1930.6±5.8
Cancer25
30.3(26.5, 30.0)b-1.20 (-3.7, 7.7)d0.486cbControl
1928.3(24.0, 32.6)
Data are expressed as mean ± SD unless specified otherwisea Independent sample t testb Mean (Lower Boundary, Upper Boundary)c ANCOVA applied (adjustment for FFM)
d Mean difference (Lower Boundary, Upper Boundary)DÍSCUSSION
Resting Energy Expenditure
Earlier studies reported that cancer patients had
significantly increased REE and untreated leukaemia
patients had been reported to exhibit elevated basal
metabolism (15,16). However, recent studies have shownthat actual energy expenditure of cancers were notaccurately captured and inconsistent findings had beenreported in a meta-analysis investigating changes of REE
in cancer patients (17,18). There is an unresolved
uncertainty due to discrepancy of results, which is a gap
to be filled. Furthermore, very limited studies andinformation are currently available with regards to REE
status in Malaysian colorectal cancer patients.
In this study, no significant difference was found inmeasured REE between cancer and control group. Thisfinding is in agreement with a large-scale study by Cao
et al featuring over 714 cancer patients and 642 controls(19) as well as other studies by Baidi et al, Fredrix et al,
Ceolin Alves et al, Dempsey et al and Nixon et al(10,20,21-23). Fat-free mass consumes more energy at
rest than their non-metabolically active counterparts suchas adipose tissue. It is an important confounding variable
that needs to be adjusted for in measurement of REE (24).
Hence, for a more meaningful comparison of REE
between individuals, expression of REE per kilogram
FFM allows us to discover metabolic rate proportional to
FFM and to eliminate this confounding variable. Upon
adjusted expression of REE for FFM, the result of thisstudy showed no significant difference of REE/kg FFM
between cancer and control group.

Using one-way ANCOVA controlling for thecovariate of FFM, no significant difference in measured
REE between cancer and control group was observed.
Since FFM is positively correlated with REE withstatistical significance (p<0.001), a lack of significant
difference in REE after adjustment for FFM indicatedthat there was no elevated energy expenditureproportional to FFM in the presence of colorectal cancer.
This result again, agrees with the study of Cao et al,which observed no significant difference in REE/kg FFM
for colorectal cancer group, the homogeneous type ofcancer subjects recruited in this study (19). In the studyof Cao et al, no significant difference was observed inmeasured REE between different types of cancer andcontrol group. Upon adjustment for FFM, significant
differences of REE/kg FFM were observed between
other types of cancer such as esophageal cancer,
pancreatic cancer, gastric cancer and control group but
no significant difference in REE/kg FFM was observed
between colorectal cancer and control group. Thisimplicated that adjustment for FFM is indicated for acorrect interpretation of REE changes in different typesof cancer, as logically reasoned by the effect of
independent effects of FFM on REE.
Furthermore, Cao et al (19) also indicated that noelevated energy expenditure per kg FFM was present incolorectal cancer patients. Nonetheless, this was inconflict with the study finding of Baidi et al and Reeves
et al, which found that significant difference in REE/kg
FFM was observed between cancer and control after
adjustment for FFM (10,25). Discrepancy in findings canbe attributed to the heterogeneous feature of cancer groupin the studies of Baidi et al and Reeves et al, which

26

Asian Journal of Dietetics 2019

included solid tumours of different cancer types andleukaemia patients. Considering REE was not altered
upon adjustment for confounder and FFM was not
significantly different from control in the presence ofcolorectal cancer, interpretation of these results
implicates that REE is not uniformly elevated in all
cancer patients, providing convincing support that REE
experiences different degree of abnormal alteration indifferent clinical disease characteristic in cancer, as
coherently suggested by the study of Fredrix et al which
reported that the type of tumour plays an important
determining factor of REE changes in cancer patients(20). Hansell et al reported in a study that in cancers withdifferent type of tumour, different effect on fat-free mass
was incurred and hence REE changes differed (26).
Considering how energy metabolism alterations can beaffected by FFM and differ from one type of cancer toanother due to numerous factors affecting metabolic
alteration in cancer (17), important considerations about
the results presented in these studies involve controllingfor homogeneity in clinical characteristics of cancer suchas type of cancer as recommended by the study findingof Hansell et al and progression of disease andadjustment for significant confounding variable (26). As
such, results generated from these studies also lack power
to validly demonstrate a clear picture of the changes in
REE of colorectal cancer patients.
Judging from a perspective for practicality from thisstudy, the colorectal cancer patients in this study featured
88% (n=22) tumour-resected subjects who were infollow-up palliative care. Hence, results obtained may beless accurate or bear less meaningful generalisability forpatients who are not under palliative care but facing amore aggressive or advanced stage of colorectal cancer
as studies have repeatedly shown that presence of tumour,aggression as in metastases and stages of cancer may
experience significantly elevated REE or metabolic rate
(27-29).
Dietary intake
In our study, 88% (n=22) of the colorectal cancer
subjects underwent surgical resection of tumour and werein routine follow-up care. Hence, an increased need forthoughtful nutrition care approach is implicated as asystematic review reported that adherence to quality
nutrition is inversely associated with overall mortality incancer survivors (30).
In our study, mean energy, carbohydrate and protein
intake were assessed and no significant differences were
found between cancer and control group. However,significant difference was observed in fat intake between
cancer and control group. The healthy control groupconsumed significantly higher fat intake than the cancergroup. This result does not agree with the cross-sectional
study of Kim et al which reported that no significant
difference was observed in total fat intake between
colorectal cancer patients and healthy controls. The mean
fat intake of cancer and control group were 46g and 58g,
which amounts to 32% and 40% of total energy intake
respectively. Fats intake in healthy control groupexceeded the upper limit of 35% total energy intake for1)fats set by RNI 2017 Malaysia (31) High diet quality
index and healthy pattern of diet as defined in low intake
of high fat foods were reported to be associated with areduced risk of mortality in cancer survivors, whereas
Western dietary pattern as defined by high fat intake wasassociated with higher risk of mortality in colorectal
cancer survivor (30). Moreover, Meyerhardt et alreported in a study that colorectal patients who scoredhigh for Western dietary pattern, who is characterized byhigh fat intake, refined grains, red and processed meathad 3-fold risk of cancer recurrence (32). The integrated
interpretation of these differing studies indicates that amore prudent nutrition education post treatment in cancer
patients would be an increase in energy and protein
intake without corresponding increase in fat content or
use of processed meats.
Limitation
There was limitations in this study as the sample sizeof colorectal cancer patients was small, which imposes
technical limitation on statistical analysis in reducing
power to detect differences that may, in fact, exist, andmay not be representative of colorectal cancer patients,
which is prerequisite for generalisability of results. As aresult, the validity of the study was undermined, andextrapolation of results to other colorectal cancer patients
have lacked in validity as well. Hence, a study with larger
sample size should be used in the future.
In conclusion, colorectal cancer patients showed nosignificant difference in measured REE as compared tohealthy, normal controls. Even after adjustment andcontrol for FFM, no significant difference was observedin the REE/kg FFM between cancer and control group.
Considering the limitations of our study, a study matched
for socio-demographics, with a larger sample size andhomogeneous feature of cancer clinical characteristics is
implicated to validate the findings from this study and as
well as providing clearer picture on the effect of cancer
on REE. As cancer is most popularly believed to elevate
REE, and together in reference with studies showing that
excessive caloric prescription for cancer patients are
detrimental and deleterious (33,34); clearly, unaltered
REE in colorectal cancer patients implicates theimportance of a more reasonable and individualised
approach in dietetics practice when caloric load is being
administered. A one-size-fit-all model of nutrition care is
ill advised. Furthermore, in post-treatment cancer
patients, nutrition education may prove to be ofsignificant usefulness as dietary intake are associatedwith recurrence or survival in cancer survivors.
ACKNOWLEDGEMENTS
The research team would like to thank the patients andsurgeons from Surgical Outpatient Department of
Hospital Tuanku Jaafar for the cooperation andparticipation in this study, International Medical
University for granting the student research fund,research assistants Mr. Julian Chooi Kok Zheng and Mr.
Chin Khuan Loan for their effort and support in datacollection

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FB, Mayer RJ, Nelson H, Whittom R, Hantel A, ThomasJ, Fuchs CS: Association of dietary patterns with cancer
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Asian Journal of Dietetics 2019

ORIGINAL
Comparison of School Lunch Menus in Vietnam and Japan
Thuan Nguyen Thi, Indri Kartiko Sari, Miho Nunokawa, Noriko Sumita,
Yuriko Ichimura, Thao Nguyen Thi, and Sumiko Kamoshita*
Asian Nutrition and Food Culture Research Center-Jumonji University,
Niiza City, Saitama Prefecture, Japan(Received January 15, 2019)
ABSTRACT Background and Objectives: Vietnamese school lunch program needs
improvements. For that purpose, this study aimed to compare Vietnamese and Japanese school
lunch menus and food materials. Methods and Study Design: The study was a cross sectional
study which data were collected throughout the year from elementary schools in both countries,
categorized the menu items into six, numbered all food items, and tabulated the occurrence
frequencies for each item. Each country had 190 lunches. Results: The menu diversities inVietnam and in Japan was 23 and 190 with item numbers were 3 and 74 for staple foods, 26
and 95 for main dishes, 9 and 107 for vegetables, 14 and 53 for soups, 1 and 41 for desserts, 0
and 5 for beverages, and total 53 and 376. Standard deviations for items were small, indicating
menus similarities from the chosen schools. Menus and food items numbers were different.
Conclusions: The factors are discussed to develop future strategies for improving theVietnamese school lunch.
Key Words : school lunch, menu, food items, primary school, children

system has developed from merely satisfying
hunger to meeting several goals, especially forthe health of children(11). In this study, we
compared school lunch menus in Vietnam andJapan for the purpose of improving the school
lunch program in Vietnam.

INTRODUCTION

Since 1986, the Vietnamese economic system
has changed and improved greatly, which
resulted in easily available and abundant foods.
Along with this, intake of high energy foods has
been increasing, which contributes to obesityand other lifestyle-related diseases(1). This
problem is growing in children, especially in big
cities(2-6).
Until about a decade ago, children usually had
lunch at home. Nowadays, parents are busy andthe time to prepare lunches is limited(1,7). For
this reason, many schools have started a school
lunch program(1). However, the school lunch
program is still under development because
meals are prepared by ordinary people without aproper knowledge of nutrition(8). The repetitionof items is frequent, making the menus
monotonous(1). As a result, children tend not to
eat well and to waste food.
In contrast, people all over the world rate theJapanese school lunch program very
highly(7,9,10). It was established under theschool lunch law of 1951(11,12). The school
lunch program is managed by school dietitians,
about half of whom also provide nutrition
education through school lunch as nutrition
teachers(10,11). Thus, the Japanese school lunch

MATERIALS AND METHODS

We contacted public schools in each country
randomly until three schools in each country
agreed to cooperate for this study. The ethicalconsideration was not required. No humanparticipation was included. The schools andstudents information were closed. The dataneeded for the research were the menus data. All
the menus in the last year were collected fromeach school. After the collection, we classified
items in the menus into 6 groups (Group 1: staple
foods, Group 2: main dishes, Group 3: side
dishes, Group 4: soups, Group 5: desserts, andGroup 6: beverages). All the daily food items ineach group throughout a year were entered in atable by school.
Statistical analyses Variables were checked
for normal distribution and compared byunpaired Student t-test. p-values of less than
0.05 were considered statistically significant for
all the analyses. The above statistical procedures
were performed using Excel (Microsoft Excelversion 10)_________________________________________________To whom correspondence should be addressed:
kemookamokamo@gmail.com

29

School Lunch Menus in Vietnam and Japana)

Different food items

b)
120

***

500.0

375.7

80

300.0

100.0

*

74.3

100

400.0

200.0

Staple foods

60
40

53.3

20

0.0
Vietnamc)

Japan

VietnamMain dishes

d)
**

120

4.0

0

Side dishes
**

150

95.3

Japan

107.3

100
100

80
60
40

26

50
9.3

20

0

0

VietnamVietnam
e)

Japan

Japan
Soups

f)

*

80

Desserts
*

60

53

40.7

50
60
40

40
30

14

20

20

10

0

1

0
Vietnam
g)

8

Japan
Drinks-10

Vietnam

Japan

*

5

6
4
2
0
0
VietnamJapan

Fig1. Foods used in a year at schools in Vietnam and Japan (number)* ,** ,*** Significantly different at p <0.05, 0.01 and 0.001, respectively.

30

Asian Journal of Dietetics 2019side dishes (p=0.0006), 14.0 ± 10.4 and 53 ±21.1 for soups (p=0.03), 1.0 ± 1.7 and 40.7 ± 8.1
for desserts (p=0.02), and 0.4 ± 0.7 and 5.0 ± 1.7
for drinks (p=0.04) (Fig.1b-g).
Fig. 2 shows the frequency of occurrence ofmain dishes (%). The frequencies in Vietnam
and Japan respectively were 85 ± 13 and 64.3 ±4.2 for meat (p=0.03), 32 ± 3.5 and 32.7 ± 3.1
for fish (p=0.41), 21 ± 3.6 and 7.3 ± 2.5 foreggs (p=0.002) and 11.7 ± 2.9 and 11.3 ± 1.5
for soybean products (p=0.43). Frequencies ofmeat were higher in Vietnam than in Japan andfrequencies of egg were vice versa. Frequencies
of fish and soybeans were similar in the twocountries.

RESULTS

Fig. 1 shows the numbers of a) different fooditems, b) staple food, c) main dish, d) side dish,e) foods in soup, f) dessert and g) drink. Values
are means ± SD. When p-values lower than 0.05
were considered statistically different between
the two countries.
The numbers of different food items in
Vietnam and Japan were, respectively 53.3 ±30.1 and 375.7 ± 21.5 (p=0.0002) (Fig.1 a). The
numbers of food items in Vietnam and Japan
were 4.0 ± 2.0 and 74.3 ± 23.8 for staple foods(p=0.05), 26.0 ± 14.7 and 95.3 ± 7.6 for main
dishes (p=0.01), 9.3 ± 6.1 and 107.3 ± 19.6 for
(%)
100
90
80
70

85
*
64.3

60
50
32

40

32.7
21

30

*
7.3

20
10
0

meat

fish

Vietnam

Japan

egg

11.7

11.3

soybeanFig.2 The frequency of occurrence of main dishes* Significantly different at p <0.05

Vietnamese school lunches are prepared byordinary people with no educational backgroundin nutrition, while professional school dietitians
are available in basically every school inJapan(1,8,14,15). Furthermore, about half ofthese dietitians have their teacher’s license andare officially designated as school nutrition
teachers. As professionals, they are required tomake nutritious, tasty, and educational menus,
which essentially increase the variety of menus
for Japanese school lunches (11,13).
The Vietnamese school lunches adopt cycled
menus for two to four week periods(8).
Obviously, menu variety is low and children
might get bored with the meals offered. This
may result in an increase in food waste. In Japanmenu charts are given to every student’s family
a month in advance so that family members

DISCUSSION

Both Vietnam and Japan have 190 lunches.
However, there were 23 menus in Vietnam and
190 menus in Japan. The number of food items
in Vietnam and Japan, respectively were staple
foods 4 and 74, main dishes 26 and 95, (sidedishes 9 and 107, soups 14 and 53, desserts 1 and41, and drinks 0 and 5. Total food items were 53
in Vietnam and 376 in Japan. This indicated thatthe two countries have a similar number oflunches, but Vietnam has fewer food items thanJapan does. We can point to some factors for thedifferences which may be useful for the
improvement of Vietnamese school lunches.
First, the placement of high quality
professional staff should be considered for theVietnamese school lunch program. The

31

School Lunch Menus in Vietnam and Japanknow what their children will be eating(11). It isalso recommended that the menu chart, alongwith the food items, be prominently posted ateach student’s home so that everyone in thefamily can easily refer to it(14). Parents andguardians can avoid serving the same items forlunch and dinner and it is also useful inpreventing food allergy problems(11). Thissystem motivates the school dietitians to taketheir task seriously. Consequently the variety ofmenu increases. Occasionally, professional
school dietitians serve food that children dislikewith the purpose of establishing good dietary
habits(11,13). They try to use various cooking
methods to provide good-tasting dishes for thechildren(7). With these trials, dietitians arecapable of providing varied menus.
The Japanese government has recommended
the use of locally available foods at home and in
the community(14). School lunch is no
exception(11). All children receive compulsory
education for 9 years from 6 to 15 years old and
99% of elementary school students and 75% ofjunior high school students have school
lunch(16). For locally produced items, the local
agricultural association provides information
about vegetables that will be available infollowing months(11). The use of locallyavailable foods also increases their seasonalvariation. Japan has spring, summer, fall, andwinter. Food products, from vegetables to fish,
thus vary according to the seasons.
Consequently, the effort to use locally available
foods increases variety in lunch menus.
Cost is an important factor for the variety offoods. The cost of school lunch in Vietnam isborne by parents, while in Japan parents need to
pay only for food materials, which contributes togreater variety of materials(1,11). When locallyavailable foods are included, the food materials
cost will become less expensive(10). In Vietnam,
the morning of each school day, kitchen workers
go to markets and purchase the most economical
foods they can find, which also the foods that are
currently in season. This consequently decreases
the variety of menus.
Dietary reference intakes (DRIs) for Japanese
school lunches may increase food variety(11).
Unfortunately, DRIs are not available inVietnam, so the aim of the school meal programis just to satisfy hunger, which is easier to dowith high energy foods. Cycle menus without
DRIs and professional supervision may
contribute to the frequent use of high energy

foods in the menus. Consequently, food variety
is reduced. It is unlikely that good dietary habits
can be formed under such conditions. DRIs withprofessional supervision are required for school
meal programs in Vietnam to foster good food
habits.
The use of greater food variety has been
positively influenced legal developments(11).
When the Second World War ended, Japanese
suffered hunger(13). In 1945, the Head of Public
Health and Welfare of GHQ suggested theintroduction of a school lunch program to theJapanese government(13,17). In 1951, a national
school lunch law was established(17). Under thislaw, Japanese school lunch has developed
impressively, including the presence of a school
dietitian in every school. In 2005, the Japanese
National Shokuiku Basic Act became law(18).
The law focusses on ‘shokuiku’, the Japaneseword for food and nutrition education, and agood model for healthy daily meals is indicatedinside(19).
A limitation of this study is the small numberof schools surveyed but schools were concerned
about student privacy. In order to collect datathat would be closer to ordinary children we
conducted the study in public schools. We
contacted about 10 schools randomly in eachcountry until three schools agreed to cooperate
in this study. Standard deviations of all the
results were small, suggesting that the threeschools chosen had similar lunches and alsosuggesting that these schools were not special
and the data may be representative.
Another limitation of this study arises fromconsidering rice as a staple food. Vietnam has 4
types of rice while Japan has 36 types. Thisoccurs because the Vietnamese use rice just theway it is, while the Japanese use rice mixed withvegetables or meats, which is counted as a staple
food(1,11). Whether it is appropriate to countmixed rice as a staple food remains debatable.
In conclusion, in this study we found that theVietnamese school lunch program should
increase the variety of menus and food items. To
achieve this, active participation by nutrition
professionals in the management andpreparation of school meals may be the mostimportant factor.
ACKNOWLEDGEMENTS
We deeply thank all the schools that allowed
us to use their data. We also thank Prof. Andrew
Durkin of Indiana University for his careful

32

Asian Journal of Dietetics 201910) Oda, Y. On Japan`s school lunch menu: A
healthy meal, made from scratch World.
https://www.washingtonpost.com/world/
on-japans-school-lunch-menu-a-healthymeal-made-fromscratch/2013/01/26/5f31d208-63a2-11e285f5-a8a9228e55e7_story.html accessed:
16/8/201511) Kaneda M, Yamamoto S (2015) The
Japanese school lunch and its contribution
to health. Nutr Today. 2012;50:268-272.
12) Japan Ministry of Education, Culture,
Sports, Science and Technology. Systemand changes in Japanese school health
http://www.mext.go.jp/b_menu/shingi/chousa/kokusai/002/shiryou/020801ei.htm
accessed: 20/2/2015 (in Japanese).
13) Iwasaki M. Memories of "LARA" relief
and skimmed milk sent to day-care
centers after World War II. J Tokyo Kasei
U. 2009;14,19–32
14) Kaneda, M. Shokuiku for infants andchildren at school.
http://www8.cao.go.jp/syokuiku/data/eng_pamph/pdf/pamph7.pdf#search=`imple
mentation+of+school+lunch+in+Japan
accessed: 16/8/2015
15) Japan Ministry of Education, Culture,
Sports, Sciences, and Technology (2004)
Establishment of position of diet andnutrition teacher. http://www.mext.go.jp/
a_menu/shotou/eiyou/04111101/008.htm
accessed: 16/8/2015 (in Japanese)
16) Japan Ministry of Education, Culture,
Sports, Sciences, and Technology.
Implementation school lunch in Japan.
http://www.mext.go.jp/b_menu/toukei/chousa05/kyuushoku/kekka/k_detail/_icsFil
es/afieldfile/2015/02/13/1354911_1.pdf
accessed: 13/2/2015 (in Japanese)17) Nishimura, S. A man who saved the livesof Japanese-Crawford F. Samas of GHQ.
Tokyo: Kodansha; 2002.
18) Office for Shokuiku Promotion Cabinet
Office, Government of Japan. Food
education basic law.
http://www8.cao.go.jp/syokuiku/more/law/law.html accessed: 20/2/2015 (inJapanese)19) Office for Shokuiku Promotion Cabinet
Office, Government of Japan (2008) Food
education.
http://www8.cao.go.jp/syokuiku/data/whi
tepaper/2008/pdf-honbun.html accessed:
20/2/2015 (in Japanese)

editing of the English of the article. No specific
grants for this research. The authors declare no
conflict of interest. We also declared that thecontents of the manuscript have not beenpreviously published and are not currently
submitted elsewhere.
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1) Le DSNT: School meal program in Ho
Chi Minh City, Vietnam: Reality andfuture plan. 2012. Asia Pac J Clin Nutr
21:139–143
2) Ho Chi Minh City Statistical Office.
Economic Growth of Ho Chi Minh City
from 1995–2003. Ho Chi Minh City:
Statistical Office; 2003.
3) Nguyen PVN, Hong TK, Hoang T,
Nguyen DT, Robert AR. High prevalenceof overweight among adolescents in Ho
Chi Minh City, Vietnam. BMC Public
Health. 2013;13:141
4) Tran TMH, Le KQ, Do TND. Nutritional
status of school aged children in Ho Chi
Minh City. Annual report of Nutrition
Center of Ho Chi Minh City. Ho Chi Minh
City: Nutrition Center of Ho Chi Minh
City; 2010.
5) Dieu HTT, Dibley MJ, Sibbritt DW, Hanh
TT. Trends in overweight and obesity inpre-school children in urban areas of Ho
Chi Minh City, Vietnam, from 2002 to
2005. Public Health Nutr. 2008;12:702–
709
6) Tran TMH, Do TND, Phan NTB, Pham
NO,
Vu
QH.
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overweight/obesity and high bloodpressure, in school-aged children in Ho
Chi Minh City. J Food & Nutr Sc.
2016;12:17–24
7) Department of Education of Ho Chi Minh
City. Annual Report. Ho Chi Minh City:
Department of Education of Ho Chi Minh
City; 2008.
8) Nerman, D. Food education the law inJapan.http://www.cbc.ca/news/health/foo
d-education-the-law-in-japan-1.2894279
accessed: 6/12/2015
9) Koshino, W. School Lunch Program inJapanese schools.
http://www.kompasiana.com/weedykoshi
no/acara-makan-siang-bersama-disekolahjepang_5636c62e917e615b048b4568
accessed: 9/11/2015 (in Indonesian)33

Asian Journal of Dietetics 2019

ORIGINAL
Acceptability of Fish Meat with Okara as School Lunch
Sumiko Kamoshita1*, Yuriko Ichimura2, Saiko Shikanai3, Hitomi Takeichi4,
Daisuke Kunii5 and Shigeru Yamamoto1
1

International Nutrition, Graduate School of Human Life Sciences,Jumonji University, Saitama 352-8510, Japan
2
Chiba 284-0015, Japan3
Department of Health and Science, Aomori University of Health and Welfare,
Aomori 030-8505, Japan
4
Faculty of Contemporary Home Economics, Kyoto Kacho University,
Kyoto 605-0062, Japan
5
Japan Nutrition Care Service Association, Tokyo 105-0014, Japan(Received December 1, 2018)
ABSTRACT Background: At present in Japan, fish consumption is decreasing. It is desirable
that through their school lunch children will learn that fish is tasty. Deficiency of fiber intake isalso a problem in Japanese people. Supplying enough fiber is a difficult task in school lunch.
Okara is a byproduct created during the process of tofu production. It is mainly fiber and has
the potential for beneficial uses. Since in the past there has been little study on supplying fiberfrom main dishes, we were challenged to address this topic. Purpose. To develop tasty main
dishes from fish meat with Okara. Methods and results: As a preliminary study, we conductedvarious trials to make a tasty base of “fish and Okara” that looked like hamburger shaped, thathas one portion (80g) of the final base could supply 2.2g fiber. We named it “hamburger styleof fish and Okara”. It was served to all the 349 children from the first to 6th grade in a school
lunch at a Japanese school and evaluated by the comparison with ordinary Japanese-style meat
hamburger (ordinary hamburger). Their evaluation about ordinary hamburger and “hamburger
style of fish and Okara” were respectively; Overall taste is good 94 and 85%, good for easy to
eat 90 and 77%, basic taste is good 93% and 83%, aroma is good 82 and 68%, appearance isgood 89 and 76%. Although the results of ordinary hamburger were more favorable than thoseof “hamburger style of fish and Okara”, the evaluation of “hamburger style of fish and Okara”
was high. Waste of them was only 2.2 and 4.6% by weight, respectively. Conclusion:“Hamburger style of fish and Okara” was highly evaluated by school students and these dishes
helped to meet the fiber requirement from school lunch.
Keywords: Okara, fish, hamburger, fiber, school lunch.
INTRODUCTION
As a problem of the current Japanese dietary habits,
there is a lack of dietary fiber intake. In the Japanese
Dietary Reference Intake reported in 2015 by the
Ministry of Health, Labor and Welfare, the target
amount of dietary fiber was 20 g/day or more for men
and 18 g/day or more for women aged 18 to 69 years(1), however, according to the National Health andNutrition Survey in 2017, the average intake was as
low as 14.6 g/day for men and 14.3 g/day for women,
and it did not meet the target amount(2). There is asimilar problem even in the young generation. The
reference value of dietary fiber for school lunch is 4
g or more at 6-7 years old, 5 g or more at 8-9 years________________________________________

old, 5 g or more at 10-11 years old, and 6.5 g or moreat 12-14 years old(3). However, the actual intake wasonly 4.6 g at elementary school (6-11 years old), 5.9
g at junior high school (12-14 years old)(4). Dietaryfiber is one of the nutrients that are difficult to meetthe requirement. In school meals, opportunities toprovide children with root dishes and legumes toincrease fiber intake. The ingredients used for theseside dishes are often foods which children dislike.
This leads to an increase in waste of vegetables(5).
"Okara" is generated as a by-product in the
production of tofu(6). Okara is a food containing a lotof dietary fiber (11.5 g/100 g)(7), and its value to use
as a source of dietary fiber is very high. However, inJapan, less than 1 % of Okara is being used foredible(8).
Another problem is the decreased intake of fish in*To whom correspondence should be addressed:
kemookamokamo@gmail.com

34

Fish Meat with Okara as School Lunch

Japan. Consumption of fish that has been eaten as aprotein source has been decreasing for a long time(9),and meat intake exceeds that of fishes and shellfishes
in 2010.

a main source, dipping the fish paste in milk for odor
reduction and increasing milk for making the productsmooth mouth feeling. In order to adjust the solidnessof the dough, we decided to add rice flour. In order tochew up and improve the coloring, carrots, edamame,burdocks were carved into about 7 mm.
In this way, we made the basic fabric anddeveloped the “hamburger style of fish and Okara” asthe main dish.

METHODS
Development of “hamburger style of fish andOkara” We tried to develop a mixture of Okara andfish meat as a hamburger-style main dish. However,fishy smell and rough mouth feeling of Okara's
texture became a problem, so we examined whether
it can be eliminated by cooking method. First of all,we examined the fish odor reduction about Surimi(paste) of Lizard fish, Surimi of Scabbard fish, Surimi
of Alaska pollack and Otoshimi (fragment) of Alaska
pollack which are easily available as materials. Fivemethods were compared, namely immersed in sake,
immersed in mirin, dipped in milk, dipped in ginger
root juice, and covered with salt. As the results wefound that dipping in milk is the best for fish odor
reduction. Next, for the reduction of roughness of
texture, we tried three methods (weight reduction of
Okara, increase of tofu, increase of milk) and foundthat the increase of milk was best. By the above
studies, we concluded to use Alaska pollack paste as

Preference test Subjects were the first to sixth
grade (total of 349 people) elementary school
children at a school near Tokyo. As a main dishschool lunch, “hamburger style of fish and Okara”,
and the tastes of ordinary hamburgers made frompork and chicken ordinary used were compared.
Questionnaire 1 is about the taste of “hamburger styleof fish and Okara” and Questionnaire 2 is about thetaste of ordinary hamburger (Fig 1). The recovery
rates were 95.7 % and 97.3 %, respectively. In orderto make it easy for elementary school children tounderstand, questions items and their expression
methods were examined. Evaluation was made inthree levels about overall taste, easy to eat, basic taste,aroma and appearance. Three levels are: good,ordinary and bad.

Questionnaire 1.

Questionnaire 2.

Taste of hamburger style of fish and Okara

Taste of ordinary hamburger

Fig 1. Questionnaire

35

Asian Journal of Dietetics 2019

Table 1 shows the food material weight of“hamburger style of fish and Okara”. For one person
is about 80 g. Table 2 shows the food material weightof ordinary hamburger. For one person is about 45 g.

Table 3 shows energy and nutrient concentrations.
Calculated in Standard Tables of Food Compositionin Japan (2015)(7).

Table 1. Food sources and their weights in 1 portion(80g) of “hamburger style of fish and Okara”

Table 2. Food sources and their weights in 1 portion(45g) of ordinary hamburger

Food material

Weight (g)Food material

Weight (g)Alaska pollack Surimi

22.7

Pork (thigh)

0.8

Okara (law)13.6

Chicken (thigh)18.0

Tofu (Momen)

9.1

Onion

12.0

Bread crumb

3.0

Ginger0.8

Rice powder

2.0

Egg

6.0

Milk

6.3

Bread crumb

3.2

Egg

3.8

Miso (red)

2.4

Onion

12.1

Sugar

0.8

Carrot2.3

Sesame0.8

Burdock

2.3

Green soybean

2.3

Nutmeg

0.05

Salt

0.5

Pepper

0.05

Table 3. Energy and nutrient concentrations of “hamburger style of fish and Okara” and ordinary hamburger
EnergyProtein

Lipids

Ca

Fe

Fiber

Salt

kcal

g

g

mg

mg

g

g

Hamburger style of fish and
Okara

81

7.0

1.8

37

0.4

2.2

0.8

Ordinary hamburger

157

11.7

9.3

23

0.6

0.6

0.4

Statistical analysis Statistical analysis was conducted by Chi-square test using Excel Statistics.

RESULTS
Their evaluation about ordinary hamburger and“hamburger style of fish and Okara” were respectively; Overall taste is good 94 and 85 %, good foreasy to eat 90 and 77 %, basic taste is good 93 and
83 %, aroma is good 82 and 68 %, appearance is good
89 and 76 %. Fig 2 shows the comparison of taste between ordinary hamburger and “hamburger style offish and Okara”. Although the results of ordinary
hamburger were more favorable than those of “hamburger style of fish and Okara”, the evaluation of“hamburger style of fish and Okara” was also high.

Ethical considerations We explained to theschool the purpose and methods of the research andthat would make every effort so that nobody can identify the school and individuals. We used only common foods. The school explained the above information to the teachers and parents and obtained theiragreement.

36

Fish Meat with Okara as School Lunch

100.0
90.0

***

93.8

85.0

***

***

93.2

89.4

83.0

77.0

80.0

Answer is good (%)

***

***
89.1

81.8

76.0

68.0

70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0

Overall taste

Easy to eat

Basic taste

Aroma

Appearance

Fig 2. Comparison of taste between ordinary hamburger () and “hamburger style of fish and Okara” (*** Significantly different by Chi-square test at p<0.001

Out of 43.49 kg of the total amount of “hamburger
style of fish and Okara”, the amount of waste was 2.01
kg and the waste rate was 4.6 %. On the other hand,out of the total volume of ordinary hamburger 26.7 kg,
the amount of waste was 0.6 kg and the waste rate was
2.2 %. From Table 3, it was found that 2.2 g of dietaryfiber is contained in 80 g of “hamburger style of fish
and Okara”. This indicates that it contains dietaryfiber about 4 times more than ordinary hamburger.

)

In this research, “fish and Okara” was main
dishes and we examined how to make delicious
dishes with them. Surimi (paste) of Alaska pollack
had a considerable fish odor. We examined using
sake, mirin, milk, salt and ginger. Alcohol containedin sake has the function of evaporating trimethylamine which is a component of the fish odor. Mirinalso has a similar function(10). Colloidal particlesof milk protein and fat tend to adsorb odor components(11). Salt exerts moisture rich in trimethylamine out of fish body due to osmotic pressure effect.
Strong fragrance ginger component cineol becomes
a component without smell when mixed with trimethylamine. For these reasons, we tried five methods.
As a result, we were able to confirm that milk is afood ingredient that eliminates of the fish odor. It
was considered that the evaluation of “aroma” ishigh because it was able to suppress the fish odor.
We studied the use of Okara to increase dietaryfiber. Okara has three types: 1) Okala obtained bytraditional production method and contains 81.1 g /100 g of water(12), 2) Okala obtained by the new
manufacturing method and contains 75.5 g / 100 gof water(7,12), and 3) Okara obtained by drying andcontains 7.1 g / 100 g of water(7).
In this study, Okara number 2) was used. This
Okara has a characteristic that the fiber is long, andI expected a role as a “tether” such as croquette andhamburger. In order to reduce roughness due to
Okara, the blending ratio of Okara, tofu and milk
was examined. As a result, milk was most effective.
It is thought to be an effect by lipid contained in milk.

DISCUSSION“Hamburger style of fish and Okara” developedby us was able to obtain high evaluation as a resultof providing it as school meal to elementary school
students. Fish and Okara contain nutrients that arelikely to be deficient in modern society, and various
advantages can be considered, but their utilization is
insufficient. Especially Okara is discarded in making tofu, but it is a food containing a lot of dietaryfiber. In order to use fish and Okara as school lunch,
it was an issue how to deliciously cook the odor offish and the texture of Okara.
Dietary fiber is one of the nutrients deficient inschool lunch(4,5). Root crops and legumes have
many dietary fiber, but it is difficult to ingest dietaryfiber sufficiently from these vegetables because
there are many children left behind. It is possible touse staple food such as brown rice, but it is not realistic because it requires a special rice cooker. Pregerminated brown rice can be cooked with ordinary
rice cooker, but the price becomes somewhat higher.
For these reasons, it is desired that intake of dietaryfiber is taken from the main dish.

37

Asian Journal of Dietetics 2019

In the cooking process, we were aware of adding
salt to surimi. The fish meat has the property thatwhen it is well kneaded by adding salt, the binding
property increases(13). As a result, I was able to alleviate more roughness.
In order to regulate the firmness of the dough, theingredients and its blending amount were examined.
As a result, 3 g / 80 g of bread crumbs and 2 g / 80
g of rice flour gave the soft texture of the dough. It
seems that the characteristics of the rice flour werealso related. The rice flour used this time is made inJapan, sucks water well and thinks it was connected
to a soft texture(14).
We examined the addition of vegetables to add
texture, crunchy, coloring to this fabric. A combination of carrots, burdocks, and green soybeans wasevaluated with good texture and color. As a result of
examining the composition of the seasoning, it was
the best evaluation with salt 0.5 g / 80 g, nutmeg andpepper 0.05 g / 80 g of the dough.
We conducted a preference study of “hamburger
style of fish and Okara”. The target school is a medium-sized elementary school with 349 children (1stto 6th grade children), the ratio of men and womenis almost the same. Even in comparison with the results such as surveys of family situations and students' tastes, physique of height/weight, lifestylesurveys such as sleeping hours and absence of
breakfast(15), national physical fitness · exercise
ability · exercise habit survey(16) etc. that school
was the average school in the area.
In this research, we aimed to be able to ingest“fish” and “dietary fiber” lacking in the eating habitsof present children at the same time, and to be able
to offer development of “delicious main dish” especially for lunch. The evaluation about ordinary hamburger and “hamburger style of fish and Okara”
were respectively; Overall taste is good 94 and 85 %,good for easy to eat 90 and 77 %, basic taste is good
93 and 83 %, aroma is good 82 and 68 %, appearance is good 89 and 76 %. Although the results ofordinary hamburger were more favorable than thoseof “hamburger style of fish and Okara”, the evaluation of “hamburger style of fish and Okara” washigh. The lowest evaluation among Okara hamburger is aroma (68%). However, the evaluationmeans that 68 % of the children answered that theysmelled good. It can not be said that “hamburger
style of fish and Okara” is not tasty. In addition,“hamburger style of fish and Okara” contains 2.2 gof dietary fiber per 80 g. This suggests that “hamburger style of fish and Okara” may meet the requirement of dietary fiber. However, I think thatwhether Surimi of Alaska pollack can obtain thenecessary amount at a price that can be used forschool lunches throughout the year is a major task
and a limit to incorporate into the menu as new meal.

ACKNOWLEDGMENTS
The author would like to thank the children, parents
and teachers for their cooperation. We are extremely
grateful to the principal and all the staff especially thenutrition teacher and cooks. We are also thankful to
Ms. R.Sasaki, Ms. Y.Kobayashi and Ms. K.Watanabe
who were the undergraduate students of Jumonji
university. This study was supported by the Maruha
Nichiro Corporation. Finally, we would like to thankAndrew Durkin, Prof. Emeritus of Indiana University,for editing our English.
REFERENCES
1) Ministry of Health, Labour and Welfare of Japan:
Dietary Reference Intakes for Japanese, 2015.
Daiichi-shuppan, Tokyo, 2015
2) Ministry of Health, Labour and Welfare of Japan:
The outline report of the National Health and Nutrition Survey of Japan in 2017 [Available online
at: http://www.mhlw.go.jp/bunya/kenkou/eiyou
09/01.html (in Japanese), accessed: 30/1/2019]3) Ministry of Education, Culture, Sports, Scienceand Technology of Japan. School lunch standard
implementation enforcement notice in 2018
[Available online at: http://www.mext.go.jp/a_menu/sports/syokuiku/__icsFiles/afieldfile/
2018/08/07/1407704_001.pdf (in Japanese), accessed: 30/1/2019]4) Ministry of Education, Culture, Sports, Scienceand Technology of Japan. The outline report of
School meal nutrition report in 2017 [Available
online at: http://www.mext.go.jp/component/b_
menu/other/__icsFiles/afieldfile/2018/07/09/
1406841_001_1_2.pdf (in Japanese), accessed:
30/1/2019]5) Sumida N: Limitation of fiber supply from vegetables and a new strategy to increase it in school
lunches. Master course thesis of Jumonji University, 2013
6) Takamura M: Application of byproducts on
Food-Product (Reuse of Okara). Bull. Chubu
Univ. 10: 56-62, 20107) Ministry of Education, Culture, Sports, Scienceand Technology of Japan: Standard Tables ofFood Composition in Japan, 2015. Official gazette co-operation of Japan, Tokyo, 20158) Japan Tofu Association. The outline report of theSuppression of food recycling law [Available
online at: http://www.maff.go.jp/j/council/seisaku/syokusan/recycle/haiki_h23_04/pdf/
111202_data2-6.pdf (in Japanese), accessed:
15/11/2018]
9) Ministry of Agriculture, Forestry and Fisheries:
The outline report of The Fisheries White Paper
in 2017 [Available online at: http://www.jfa.maff.
go.jp/j/kikaku/wpaper/29hakusyo/attach/pdf/
syusei/index-7.pdf (in Japanese), accessed:
16/11/2018]10) Japan Sake & Shochu Makers Association: The
outline report of the Cooking magician Sake utilization technique [Available online at:
http://www.sun-net.or.jp/~ookimi/sakenokatuyou-mokuzi.htm (in Japanese), accessed:
16/11/2018]38

Fish Meat with Okara as School Lunch

11) Komatsu Y, Ohmori T: A novel cream with enhanced aroma and taste made by ‘Ajiwai-Kodawari’ process suppressed unpleasant odor derived
from foodstuffs. J. Japan Association on Odor
Environment 41: 403-409, 201012) Ministry of Education, Culture, Sports, Scienceand Technology of Japan: Standard Tables ofFood Composition in Japan, 2010. Official gazette co-operation of Japan, Tokyo, 2010.
13) Aoyagi Y, Tsutsui T: General Review of Standard Food Science 2nd Ed. Ishiyaku-shuppan, Tokyo, 199814) Ministry of Agriculture, Forestry and Fisheries.
The outline report of Research to find the possibility of rice flour is underway in 2011 [Available
online at: http://www.maff.go.jp/j/pr/aff/1102/

spe1_05.html (in Japanese), accessed:
1/12/2018]15) Ministry of Health, Labour and Welfare of Japan:
The outline report of the National Health and Nutrition Survey of Japan in 2012 [Available online
at: https://www.mhlw.go.jp/bunya/kenkou/
eiyou/h24-houkoku.html (in Japanese), accessed:
20/12/2015]16) Ministry of Education, Culture, Sports, Scienceand Technology of Japan: The outline of the result of physical fitness / exercise capacity survey
results and report in 2014 [Available online at:
http://www.mext.go.jp/b_menu/toukei/chousa04/tairyoku/kekka/k_detail/1352496.html (in Japanese), accessed: 20/12/2015]39

Asian Journal of Dietetics 2019

Research Note
Roles and Requirements of Japanese Dieticians in International Cooperation Initiatives
Saiko Shikanai1, Kaoru Kusama2, Hiroko Miura3, Midori Ishikawa4
1

Department of Nutrition, Faculty of Health Sciences, Aomori University of Health and Welfare,
Aomori 030-8505, Japan2
Department of Food and Health Sciences, Faculty of Health and Human Development,
The University of Nagano, Nagano 380-0803, Japan3
Department of International Health and Collaboration, National Institute of Public Health,
Saitama 351-0197, Japan
4

Department of Health Promotion, National Institute of Public Health,
Saitama 351-0197, Japan(received November 30, 2018)

ABSTRACT Background and purpose: Nutrition-related health problems in developing countries
have been discussed for decades, but the problem is increasing owing to many factors and there is
yet no solution. Many efforts have been made in this regard, from community to governmental levels,by numerous countries, including Japan. The knowledge that Japanese dietitians who have had
experience as Japan Overseas Cooperation Volunteers (JOCV) working in developing countries
would have useful skills in developing education programs for not only Japanese dietitians but
also dietitians of other nationalities who are interested in working internationally or working fordeveloping countries as well. Therefore, in this study we would like to determine how Japanesedietitians can fulfil requests for assistance from developing countries; and to consider both the natureof the requests and the skills and knowledge required of dietitians to fulfil requests. Methods: The
study design was a cross-sectional study. Requests (n=94) made by developing countries fornutrition-related assistance from Japanese volunteer dietitians during a 5-year period (2009-2013)
were compiled and analysed by geographic region (Asia, Africa, Oceania, Central/South America).
Results: A breakdown of the requested number of nutrition-related activities for a five-year period
by country area was 21 in Asia, 22 in Africa, 11 in Oceania and 40 in South and Central America.
Activities of volunteers were requested for 7 fields, such as community health and nutrition, motherand child care, hospital meal service and administration, and others. The most commonly requested
activities involved community health and nutrition, mother and child care, and hospital meal service
and administration. For instance, school nutrition was requested most often in Asia (11%), hospital
meal service and administration in Africa (32%), and research in Oceania (14%); Central/SouthAmerica had a variety of requests. Conclusion: In conclusion, to fulfil requests, dieticians need to
combine total nutrition management with specialised knowledge based on knowledge of nutrition
education.
Keywords: Nutrition, dieticians, community health, developing countries, Japan.
INTRODUCTION
The State of Food Security and Nutrition in the world,2017 stated ‘in 2016, the number of undernourished people in
the world increased to an estimated 815 million, up from 777
million in 2015 but still down from about 900 million in theyear 2000’(1). However, health issues relating to excessenergy consumption, such as obesity and non-communicablediseases, have also recently increased in developing countries.
It also mentioned that ‘the worrisome trend in40

undernourishment indicators is, however, not reflected innutritional outcomes. Evidence on various forms of
malnutrition points to continued decreases in the prevalenceof child stunting etc. At the same time, overweight amongchildren under five is becoming more of a problem in mostregions, and adult obesity continues to rise in all regions.
Multiple forms of malnutrition therefore coexist, withcountries experiencing simultaneously high rates of childundernutrition and adult obesity (1).

Asian Journal of Dietetics 2019

For instance, from 1980 to 2008, the number of people
affected by health issues of excess energy consumption has
more than tripled, from 250 to 904 million. Currently, over
one third of all adults worldwide (1.46 billion) are obese or
overweight (2).
These nutrition-related health problems in developing
countries have been discussed for decades, but the problem isincreasing owing to many factors and there is yet no solution.
To address this issue, the Second International Conference on
Nutrition (ICN2) was held in Rome at the headquarters of theFood and Agriculture Organization of the United Nations(FAO) (3). The conference held discussions on how todevelop national policies that address issues like malnutritionand obesity. Following these discussions, the ICN2
developed and issued “The Rome Declaration on Nutrition
and the Framework for Action” which concluded thatdeveloped and developing countries must work together more
effectively to address these nutrition issues. To this end, theAcademy of Nutrition and Dietetics recognises theimportance of working with other organisations to promotesustainable agriculture and improve global health outcomes(4). This strategy promotes nutritional security by building ahealthy food system, reducing the prevalence of malnutritionand nutrition-related chronic diseases.
Many efforts have been made in this regard, from
community to governmental levels, by numerous countries,
including Japan (5). Japanese dietitians and the National
Society of Dietitians have valuable experience that is usefulfor addressing international nutrition issues. However, atpresent, most Japanese dietitians work only for domestic
agencies and rarely engage internationally, so their expertise
remains unavailable to developing countries (6). Japanesedietitians who act as volunteers in an international context are
members of the Japan International Cooperation Agency(JICA) and are known as Japan Overseas Cooperation
Volunteers (JOCVs). Since this initiative began in 1965, there
has been constant demand for Japanese dietitians indeveloping countries (7). Despite this long history ofvolunteerism, there is little accessible information concerning
the dietitians’ activities in the host countries (7, 8). Studies
have been published on support requirements during incountry service and self-efficacy among returning JOCV
dieticians (9-11), but reports using historical data on theactivities requested of volunteer dietitians are scarce. The
typical JOCV contract/working term in the field is 2 years.
The system of sending volunteers from Japan to a hostcountry is first to draw up a contract between the host country
and Japan, then the host country/local government requests
what kind of volunteers they need. That request(s) can also beclassified as “new” or “continuing”. A “new” means that a
volunteer is newly requested. On the other hand, a“continuing” means that the activity has already started and itis necessary for a new volunteer to continue the work of aprevious volunteer. Both “new” and “continuing” requests
are decided between the staff in each hostorganization/institute or working place and the in-country
office of JOCV/JICA. If a project/activity related to a
volunteer is highly rated, the in-country JICA office and local
government may extend it by involving professionals/experts
and increasing the budget and other resources. In such cases,
the scope of the project can become regional or national. By
analysing the countries’ requests, we aim to clarify what
activities are requested and the characteristics of the requests(“new”/”continuing”) as a function of geographical region(12, 13).
This knowledge will be useful in developing education
programs not only for Japanese dietitians but also for
dietitians of other nationalities who are interested in working
internationally or working for developing countries as well.
Educational materials for these dietitians are being currently
developed in Japan (14, 15) but suffer from an ineffective
sharing of information within the professional community.
Moreover, the educational material that does exist on
Japanese nutrition-related international experiences is notwidely consulted. We propose incorporating this material into
an internationally accessible database to which dietitians of
all nationalities can contribute and share knowledge. This
could be used to track requests for assistance made by
developing countries and serve as a useful resource for
improving health and nutrition. It will also allow us to
identify the knowledge and skills required to fulfil requests
from developing countries and maximise the contribution of
the Japanese (and other) dietitians. Here, we contribute to thisinitiative by compiling information on the nature of requests
made by developing countries to JOCV over a recent 5-year
period, and use this information to determine the knowledge
and skills required by dietitians to fulfil these requests.
METHODS
Requests for assistance from JOCV dieticians during a 5year period (2009–2013) were compiled and analysed bygeographic region. Survey data were provided by JICA for
countries where two-way technology agreements were inplace between Japan and a recipient country. Countries
requesting the assistance of Japanese dietitians were grouped
into four regions as follows: Asia (Vietnam, Kyrgyzstan, theKingdom of Bhutan, Nepal, Indonesia), Africa (Rwanda,
Ghana, Morocco, Nigeria, Malawi, Mali, Zambia, Kenya,
Botswana), Oceania (Solomon Islands, Fiji, the MarshallIslands, Samoa), and Central/South America (El Salvador,
Brazil, Ecuador, Panama, Honduras, Guatemala, Bolivia).
The activities included in the requests were classified into one
the following seven categories (some requests included
multiple activities):
1) Community health and nutrition: targeting local residents
and/or health center staff in the area. Volunteer dietitians

41

Asian Journal of Dietetics 2019assist local residents with nutrition improvement initiatives,
personal/group nutrition education, nutrition project
management (plan and implementation), and nutrition
workshops. Workshops are structured to empower
medical/co-medical staff in a health center to improve theirnutrition skills and knowledge.
2) Mother and child care: targeting expectant and nursing
mothers, mothers with infants, and malnourished children.
Conducted with local dietitians and/or medical/co-medical
staff, involving personal/group nutrition education andmanagement workshops and occasionally empowerment andeducation for medical/co-medical workers.
3) School nutrition: mostly targeting pupils in elementary andjunior high schools. Involving nutrition education, nutrition
improvement activities, follow-up activities for continuing
projects, and improvement of schoolteacher knowledge ofnutrition.
4) Hospital meal service and administration: involving
nutrition education/counselling for inpatients and outpatients,
hospital meal services, nutrition and hygiene administration,
hospital meal service management support, and advice for
local dietitians. If nutrition education was involved, theactivity was classified as community health and nutrition.
5) Research: involving advice on nutrition research andconducting nutrition research.
6) Product development: involving development of products
such as local agriculture products.

7) Other: including, but not limited to, instruction on nutrition
counselling for medical/co-medical workers, providing
nutrition information to locals, education on cooking using
locally available foods, and school curriculum reviews.
Activities were analysed in terms of the frequency ofrequests and by geographic region. Each request was alsoclassified as ‘new’ or ‘continuing’, and connected to a JICA
project or not. If connected to JICA, the project content wasalso analysed. It was also recorded whether the activity was
conducted by a single JOCV dietitian, or whether other
JOCVs or local health workers were also involved.
RESULTSA total of 94 requests were made to JOCV by developing
countries from 2009 to 2013. A breakdown of requested
number of nutrition-related activities for a five-year period bycountry area was 21 in Asia, 22 in Africa, 11 in Oceania and
40 in South and Central America.
The overall frequencies of activities requested are given
in Figure 1 (requests often involved multiple activities; hence,
the number of activities exceeds the number of requests).
The most commonly requested activities involved
community health and nutrition, mother and child care, andhospital meal service and administration. A breakdown of thefrequency of activities by country area is given in Figure 2.

Community Health andNutrition

1%
4%

Mother and Childcare

6%

School Nutrition

13%

41%
Hospital Meal Service andAdministration

6%

Research
29%

Product Development
Other

Figure 1. Activity ratio for five-year period (2009–2013) by activity category.

42

(%)

Asian Journal of Dietetics 2019

6
6
11
33

44

Asia

32

14

10

14
7

8
6
6

29

33

Other

3
Product Development
Research

18

50

AfricaHospital Meal Service
and Administration
School Nutrition

36

34

OceaniaSouth andCentralAmericaMother and Childcare
Community Health andNutrition

Country Area
Figure 2. Ratio of nutrition-related activity requests by activity category and country area.

(%)

Aside from the 2 most commonly requested activities,“community health and nutrition” and “mother and childcare”, results revealed that there were area-specificrequests for particular activities. For instance, school
nutrition was requested most often in Asia (11%), hospital
meal service and administration in Africa (32%), researchin Oceania (14%), and Central/South America had avariety of requests. In general, however, most requests
were for activities in community health and nutrition(Figure 1 and 2).
Of the 94 requests, 62 requests (66%) were “new” and32 (34%) were “continuing” requests from previous
activities.

27

27

30

34

73

73

70

66

52

48
Asia

AfricaOceaniaSouth andCentralAmericaCountry Area

Continuing
New

Total

Figure 3. Ratio of new and continuing requests for nutrition-related activities by country area.

43Asian Journal of Dietetics 2019

There were 79 out of the 94 requests (84%) required one
dietitian only (individual), with the remaining 15 requests(16%) involving cooperation between dietitian(s) and local
personnel on “cooperative projects”. Cooperative projects
involved a JOCV dietitian working together with one ormore local workers with different occupations. There wasseen no case of cooperative work or projects in Africa.

Knowledge of community health and nutrition is also
increasingly relevant to dieticians working in Japanesesociety. The population of elderly people in Japan isincreasing. Elderly persons hospitalised for treatment andthen discharged require transfer of their nutrition support
service from hospital to community systems. Likewise,community health staff may encounter elderly persons
requiring clinical nutrition support or transfer to a hospital.
Here, the clinical dietitians and community health workers
must work cooperatively to ensure the provision ofnecessary support.
Dietitians working in different fields (e.g., clinicalnutrition, public nutrition) require both basic knowledge andfield-specific knowledge developed through work
experience. For instance, dietitians working in thecommunity health field also need knowledge of clinicalnutrition, which is difficult to acquire without work
experience in clinical nutrition. The question of how toacquire knowledge and skills from different fields remains
unanswered, although dietitians working internationallyneed to do so to fulfil international requests.
Health promotion occurs when there is definitive andeffective community action toward setting priorities,
making decisions, and planning and implementing strategies
to achieve better population health. Health promotion can be
defined as the process of enabling people to increase control
over and improve their health (16). Community nutrition
activities are a central aspect of health promotion, and goodnutrition is one of the United Nations’ Millennium
Development Goals and Sustainable Development Goals(17). However, despite increasing evidence of community
nutrition programs improving the nutritional status ofcommunities and contributing to their development and selfsufficiency, the success of these programs is relatively
limited, mainly because of inappropriate planning,
implementation and evaluation (18). Accordingly, it isessential that we train dietitians willing to work indeveloping countries to promote better nutrition and foodsupport. Dietitians from developed countries havediscussions to identify considerations for new initiatives.
For example, for effective public health nutrition practice, aconsensus on essential competencies required (19) is needed
to be developed and reviewed, and to assess and investigate
a conceptual framework for the implementation andevaluation of strategies that enhance the practice of capacity
building approaches (20). As dietitians, we need to be awareof and engaged with health issues affecting developing
countries as well as those affecting developed countries.
Developing countries to which JOCV dietitians aredispatched frequently have no trained dietitians; therefore,
the JOCV counterpart may not be educated as a dietitian. ForDISCUSSION
The requirements of Japanese dietitians volunteering indeveloping countries included contributions to community
health and nutrition activities together with more specialised
nutrition activities, such as clinical nutrition. These results
suggest that to meet the requirements, dietitians need to
combine total nutrition management for the promotion ofcommunity health with specialist knowledge. They mustalso incorporate local communities’ requests andperspectives on nutritional issues in their area.
The most common request from developing countries
was for input from Japanese dietitians in community healthand nutrition activities. One reason for this is that requests
for community health and nutrition activities typically
included other activities. For example, a request from
Malawi (Africa) required the dietitian to work in a hospitaland carry out general hospital duties (i.e., planning meals
tailored for patients with different ailments and caring forthese patients) in addition to providing mothers withnutrition education on balanced meal for children, andvisiting communities with local health workers to conductnutrition improvement activities. Likewise, a request fromthe Kingdom of Bhutan (Asia) required the dietitian to workin a hospital and carry out routine hospital activities (mealservice management) as well as provide the community withnutrition education and disease prevention advice in their
daily life. Another reason why community health andnutrition activities are requested most often by developing
countries is financial. Budget shortages lead to inadequate
human resources and facilities (hospitals, community healthcenters) to meet demand. Existing resources must be used totheir fullest extent and community nutrition improvement
can be difficult to achieve.
In the past, requests and their accompanying activities
were relatively straightforward. For instance, hospitalrelated requests typically involved managing hospital meal
services and administration and private or group nutrition
counselling (12). However, in recent years, requests have
expanded to include nutrition improvement activities,
implementation of awareness programs, and work in thecommunity providing care and advice for both inpatientsand outpatients.

44

Asian Journal of Dietetics 2019

JOCV, operational experience is often required of dietitians
wanting to join. There is also an age limit, where JOCV
candidates must be younger than 39 years of age when theytake the program entrance examination. As a result,dietitians with 3–5 years of operational experience are theprimary JOCV applicants and participants (9), but thisexperience may be insufficient to fulfil internationalrequests. There are always dietitians interested in becoming
JOCVs (8), suggesting that some Japanese dietitians have an
existing interest in international nutrition issues and want tocontribute their expertise to the efforts of international
cooperation. The 2006 World Health Organization world
health report asserted the importance of “working together
for health”. In this report, development of human resources
was identified as the most important factor for advancing
health and medical activities. Accordingly, nutrition is
included as a key Sustainable Development Goal, signifying
the importance of human resource development in this field.
Overall, this may contribute to nutrition and food support indeveloping countries (21, 22).
To contribute to international initiatives, it is importantfor Japanese dietitians to have practical experience in Japan.
This will help to prepare them to participate in the fields ofinternational cooperation and nutrition. Thus, it is necessary
to incorporate the requests of developing countries insituations of international cooperation to build a system forhuman resource development that equips dietitians with thenecessary knowledge and skills (11).
In this study, we classified requests as “new” or“continuing” and examined the content of the requests.
Continuing requests arose when a JOCV, working with theirlocal counterpart, identified nutrition-related problems in
the community and reported them to the host organisation.
If the problem warranted input from a higher/broader level,
the JOCV, their local counterpart and other members of thehost organisation devised a plan of action for the local
community and government to implement. The local
government requests the opinions of professionals who areexperts in the field and may suggest embarking on projectsof longer duration, beyond the capacity of JOCV, such as a
JICA technical project. This course of action generallyindicates that the local government is genuinely interested insolving the problem.
The majority of requests in our study were new (62 of 94
requests). “New” and “continuing” requests associated with
JICA technical projects were only found in Central/SouthAmerica. These projects were JOCV activities that occurredas part of a JICA technical project involving experts or after
the completion of a JICA technical project, as JOCVdeveloped smaller scale activities. These activities were
national or regional, and continued as community-based
projects. However, this form of project development was notfound in the other areas. There are two possible reasons why
requests were not continued. First, the recipient country
found the volunteer dietitians’ activities ineffective and not
worth continuation. Second, the dietitian found that therequested activity was not a good fit for the community’ssituation, the activity was unnecessary at the site, or that thecommunity was not prepared to begin the activity and the
dietitian’s participation was premature. Since previous
reports have indicated that the self-efficacy of returning
JOCV dietitians was low (10), we suggest that thesesituations occurred frequently, and that there is a need to
identify what problems dietitians are having and where.
Appropriate knowledge and skills for dietitians as well as
positive perceptions of their activities will contribute to thehealth of communities. Thus, it is essential to define theknowledge and skills required by volunteer dietitians. The
causes of the problem of low self-efficacy of returning
JOCV dietitians should be identified and addressed whenplanning their activities. In this way, JOCV will be involved
in work that is satisfactory for both the volunteer and thehost organisation. It is likely that dietitians would feel higher
self-efficacy if their efforts are successful in making a
positive contribution to the community, and they receive apositive response from the host organisation.
The dieticians and the countries requesting their services
have recognised that their effectiveness in this regard
requires that: 1) dietitians have sufficient applied skills andreal experience in their field of specialisation, and 2)
dietitians have advanced training to develop the skills andknowledge required of a public health dietitian (e.g. healthpromotion, nutrition epidemiology). Currently, there is aneed for educational institutions to train dietitians not only
for domestic careers but also for service abroad. They should
also encourage students to study abroad during their training
and actively recruit international students for study in Japan,
so that Japanese dietitians could also be more outwardlooking and work more effectively.
A limitation of this study was that, although the JOCV
has a long history, only data from a recent 5-year period
were analysed. Therefore, our findings may not be
representative of previous periods. However, our analysis ofrecent requests is relevant to the development of the next
generation of dietitians who want to contribute to the fields
of international cooperation in nutrition and international
nutrition. In addition, when activity plans are developedwith the countries making the requests for assistance, it isnecessary to consult recent activity-related feedback andestablish criteria for evaluation. Our study results willcontribute to this process.
In conclusions, Japanese dietitians volunteering indeveloping countries are requested to provide assistancewith community health and nutrition activities as well as

45

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Mizumoto K, Yoshiike N.: Employment Status, Social
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Japan
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activities within other specialised nutrition fields. To fulfil
requests, dietitians need to combine total nutrition
management for community health with nutrition-related
field-specific knowledge. It is also essential that they take
into account the local community’s perspectives on theregion-specific nutrition issues being addressed.
ACKNOWLEDGEMENTS
This study was based on data prepared for research
projects supported by Grants-in-Aid for Scientific Researchfrom the Japan Ministry of Health, Labour and Welfare (Dr.
Hiroko Miura, principal investigator; H27 Global Scale/issue
General 002), and Health and Labour Sciences Research
Grant in 2018 for “Development of a food, nutrition anddietary guide for healthy development in early childhood”(H29 Sukoyaka ippan 003), and Prof. Andrew Durkin ofIndiana University for careful proof-reading of the paper, aregratefully acknowledged.
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