ISSN2434-2688

Asian Journal of Dietetics
Vol.1 No.4
2019
Contents
Originals
75-80

Low Iodine Diet Compliance before Radioactive Iodine
Treatment and scanning
Nors hariza Jamhuri, Aini Masitah Mohamed, Siti Nuraini Ahmad Samwil,
Aeininhayatey Abdullah, Zuwariah Abd. Rahman, Ho Chiou Yi

81-89

Substituting Pre-Germinated Brown Rice for White Rice
Reduced Body Weight in Healthy Overweight Vietnamese
Women
Vu Anh Linh, Bui Thi Nhung, Le Danh Tuyen, Nguyen Do Van Anh,
Yukihiko Ito, Kei Yui, Shigeru Yamamoto

90-99

Adolescents’ Habitual Nutrient Intake Adequacy Was
Independent of Milk Provision in School Lunch in Japan: A
Cross-sectional Study of Japanese Junior High School Female
Students
Mai Matsumoto, Ayumi Masumoto, Azusa Sakamoto, Aki Saito, Shinji
Ikemoto100-110

Science-Based Ratings of Safety and Effectiveness ofIngredients of Health Foods Distributed in Japan Differ
among Health Food Categories
Hiroko Hashida, Mayumi Okuma, Fumio Shimura, Yuko Yamazaki

111-120

Evaluation of Factors Affecting Food Wastage among
Hospitalized Patients on Therapeutic Diet at Ministry Of
Health (MOH) Hospitals
Norshariza J, Siti Farrah Zaidah M, Basmawati B3, Leow C, Lina,
Norafidza AAP, Khalizah J, John Kong JP, Lim SM

Case Report121-124

Role of Partial Hydrolysed Guar Gum in Chemotherapy
Induced High Output Stoma in Patient with Ileostomy
Ho Chiou Yi, Atiki Falparado Ahmad, Woo Sze Sian, Tharmasilen
Selvarajoo2,3, Norshariza Jamhuri, Zuliehaiza Kahairudin

Letter to Editor
125-126

127

Nutrition and Health between Vegetarians and NonVegetarians
Maitree Suttajit
Philippines President Rodrigo R. Duterte Supports Nutrition
Zenaida F. Velasco,

Asian Journal of Dietetics, 2019

ORIGINAL
Low Iodine Diet Compliance before
Radioactive Iodine Treatment and Scanning
Norshariza Jamhuri, Aini Masitah Mohamed, Siti Nuraini Ahmad Samwil, Aeininhayatey
Abdullah, Zuwariah Abd. Rahman, Ho Chiou Yi*
Department of Dietetics and Food Services, National Cancer Institute (NCI), Ministry of
Health Malaysia, Putrajaya, Malaysia.
(Received October 1, 2019)
ABSTRACT Radioactive iodine (RAI) therapy is commonly used in thyroid cancer patients
after surgery to destroy residual tissue and prevent disease recurrence. A low iodine diet
(LID) is prescribed two weeks before RAI and patient’s compliance with LID is essentials
to ensure the successful ablation rate. This study aimed to determine the level of LID
compliance and effectiveness of current practice in delivering the information. There were
31 respondents been recruited and level of knowledge on LID, compliances to the diet, andsources of LID information were investigated. Advice on LID was given in two weeks before
treatment and a self-answered feedback form were administered to all respondents prior toward admission. Compliance rate towards LID advice was 93.6% whereby 48.4% had
moderate knowledge on LID and 74.2% had moderate LID compliance. About 32.3%
respondents admitted that they having difficulties in LID compliance within two weeks.
Significant association were observed between levels of knowledge (p < 0.01) andoccupational status (p < 0.05) with levels of compliances towards LID. No significant
association were observed between levels of knowledge and sources of LID information.
Overall, high compliances rate towards LID were achievable among patients undergo RAI
treatment might be due to Malaysian’s general iodine intake which is below from therecommended iodine intake. Patient’s occupation and knowledge on LID had influences
person’s compliances towards restriction on iodine intake in food.
Keywords: Low iodine diet, radioactive iodine, compliance.
ablation and subsequently alter the effectiveness ofthe dose. The influence factors include the severity of
the initial disease, the amount of residual thyroid
tissue left after surgery (3), the radiation dosedelivered by I-131, initial dose rate and theradioiodine uptake in the neck (4- 6).
Studies showed that there was a positive
relationship between radioiodine uptake and dietaryiodine consumption (7). As part of the RAI treatment,a low-iodine diet (LID) is generally recommended topatients before RAI treatment (8). The LID aims todeplete whole-body iodine and then optimize RAI
uptake in thyroid cells. An optimal radioactive iodine
update might increase the effectiveness of the RAI
treatment (5). Currently, there are several LID
guidelines available which include recommendationof LID defined by an intake <50 µg/day for two
weeks before I-131 ablation by American Thyroid
Association, two-week LID before I-131 ablation by
the British Thyroid Association, a three-week LID
before I-131 administration by the European Thyroid

INTRODUCTION

Thyroid cancer is a disease with theappearance of abnormal cells in the thyroid gland.
There are anaplastic thyroid cancers, follicularthyroid cancer, hurtle cell thyroid cancer,
medullary thyroid cancer, and papillary thyroid
cancer (1). According to Malaysian National
Cancer Registry Report 2007-2011, thyroid cancer
had been ranked 17th in Malaysian males and 9thin females; the incidence rate was the highest
among Malay population in both sexes (2).
Radioactive iodine therapy (RAI) post
thyroidectomy is one of the treatments for thyroid
cancer to destroy residual tissue and prevent
disease recurrence (1). There are several factorsthat might influence the likelihood of successful*To whom correspondence should be addressed:
dtho@nci.gov.my75

Diet and Radioactive Iodine Treatment

Cancer Taskforce and LID for 2-4 weeks before
radioiodine scanning by the American Association ofClinical Endocrinologists (5, 9, 10). Sohn et al.
(2013), included 295 post-surgical papillary thyroid
carcinoma patients, showed that excessive iodine
intake (UIE >250 µg/g Cr) before RAI treatment was
associated with poor RAI outcomes (11). Yoo andcolleagues (2012) demonstrated that the success rateof RAI for patients undergoing less strict LID andvery strict LID was 80.3% and 75.6% respectively
and concluded that very strict LID may not improve
the success rate of initial RAI ablation therapy (12).
However, the extent of patients’ compliance with
LID was remained unclear. Previous studies reported
that there was patients’ feedback regarding thepalatability and facility of LID whereby they claimed
that it was hard to comply with LID before RAI andsubsequently they withdrew from medications (5, 6).
Reasons for non-compliance to LID included
unpalatable and difficult to comply with LID (10).
Moreover, studies demonstrated that misconceptions,which caused by a lack of proper counseling, would
reduce the compliance of LID (8, 13).
In the current setting, there are two methods toconvey of LID information to patients who werescheduled for RAI which were a phone call or faceto-face interview and at least two weeks before ward
admission. The level of compliance toward LID
among these patients was undetermined. Hence, thecurrent study aimed to determine patients’compliances with LID before RAI treatment andscanning as well as the effectiveness of current
practice in delivering the information on LID
towards patients’ compliances.

and treatment session. During the session, a
healthcare staff will inform respondents regarding
food to avoid such as fish, seafood and others. Thenthe respondents maintained the LID for two weeks
before RAI. Data collection was conducted via
feedback forms that were given to all consented
respondents before the admission to the nuclear
medicine ward and be filled up by respondents
themselves. The feedback form was divided into fourmain sections as follow; Section A (Sociodemographic), Section B (Knowledge on LID
Intake), Section C (Compliances towards LID) andSection D (Sources of LID information). Section A
was regarding the information on age, weight, height,
education level, marital status, ethnic, religion andemployment status were obtained from therespondents. Height and weight were measured bystaff nurse during admission using Detecto scale.
In section B, the knowledge of LID was
evaluated through five items including the type offood allowed and not allowed to eat (scale: yes, no).
Meanwhile, in section C, evaluations on respondents’compliance were done based on twelve questions on
a high iodine food item checklist (scale: yes, no, notsure). Patients were then classified as having high,moderate and low knowledge if answered 5 “No”, 34 “No” and 2 and below the question “No”,
respectively. Then, patients were classified as highcompliance, if answered 17 “No answer”. Moderate
and low compliance was indicated if patients
answered 9-16 “No” answer and 8 and below “No”
answer, respectively.
Data Analysis
All data were analysed using the IBM SPSS
Statistic version 22.0 (Armonk, NY: IBM Corp).
Continuous data such as age, weight and height were
presented in means, standard deviation while
categorical data such as educational level, marital
status, ethnic, religion and occupation were
presented in frequency and percentage. Categorical
data was analysed using Chi-square or Fisher’s exact
test. A value of p < 0.05 is considered statisticallysignificant.

METHODS
Selection of respondents
A cross sectional study was conducted among
patients two weeks before radioiodine scanning andtreatment in National Cancer Institute. Patients who
undergoing RAI treatments or scanning and able tocommunicate verbally were approached. Consented
subjects were recruited in this study. Respondents
with communication problem and those who chose
not to provide informed consent were excluded fromthis study. According to Browne RH (1995) (14),recommendation of a minimum sample size of 30
samples per group as a rule of thumb and justifies
based on rationale about feasibility and precision
about the mean and variance. Ethical approval was
obtained from Medical Research and EthicalCommittee (MREC), Ministry of Health withreference number NMRR 17-2206-37811.
Data Collection
All consented respondents involved in thisstudy were educated on the preparation andmanagement of LID before the radioiodine scanning

RESULTSA total of 31 respondents who received
radioiodine scanning and treatment, were recruited.
Socio-demographic characteristic of study group is
given in Table 1. The result shows that 48.4% and74.2% respondents had moderate knowledge on LID
and moderate compliance towards LID respectively
as in Table 2. As shown in Table 3, Fisher’s exact
test indicated that there was a significant association
between levels of knowledge and levels ofcompliances towards LID (p<0.05). However, there76

Diet and Radioactive Iodine Treatment

was no significant association between levels ofknowledge and type of information media, ethnic
group and occupation. As shown in Table 4, Fisher’s
exact test indicated that there was no significant
association between levels of knowledge with aperson of delivery information (p>0.001). In Table 5,

several questions were asked to determine the sourceof LID information that is given to respondents.
There were 96.8% of respondents admitted that they
were informed on LID and 93.6% of respondents werecompliance with LID advice.

Table 1. Socio-demographic characteristic of respondents
Characteristics
Ethnics
Malay
ChineseIndianOthersReligion
Islam
BuddhaHindu
ChristianOccupation
Employed
Unemployed
Marital Status
SingleMarriedDivorced
Education Level
Primary
Secondary
Tertiaryn (%)
21 (67.7)
4 (12.9)
5 (16.1)
1 (3.2)22 (71)2 (6.4)4 (12.9)
3 (19.7)
14 (45.1)
17 (54.8)
5 (16.1)
23 (74.2)
3 (9.7)
4 (12.9)
19 (65.5)
8 (27.5)

Table 2. Respondents’ knowledge and compliances towards Low Iodine Diet (LID)
CharacteristicLow
6 (19.4)
2 (6.5)

Level of knowledge
Level of Compliancesn (%)
Moderate
15 (48.4)
23 (74.2)

High
10 (32.3)
6 (19.4)

Table 3. Association between ethnic, occupation, media of delivery information, respondents’ level ofknowledge and compliances towards LID
VariablenLow

p value aCompliances, n (%)
ModerateHigh

5 (83.3)
14 (93.3)
4 (40.0)

0 (0)
0 (0)
6 (60.0)

16 (76.2)
1 (25.0)
5 (100.0)
1 (100.0)

3 (14.3)
3 (75.0)0 (0.0)0 (0.0)10 (71.4)
13 (76.5)

3 (21.4)
3 (17.6)

9 (69.2)
14 (77.8)

2 (15.4)
4 (22.2)<0.01*

KnowledgeLow
6
1 (6.7)
Moderate15
1 (6.7)
High
10
0 (0)
EthnicMalay
21
2 (9.5)Chinese4
0 (0.0)Indian50 (0.0)
Others10 (0.0)Occupation
Employed
14
1 (7.1)
Unemployed17
1 (58.8)
Media of Delivery Information
Phone
13
2 (15.4)
Interview18
0 (0.0)aFisher’s exact test; n = frequencies; *p<0.05

0.136

0.027*

77

0.316

Diet and Radioactive Iodine Treatment

Table 4. Association between levels of knowledge with person of delivery informationnKnowledge, n (%)
Variable
Low
Moderate
High
Person of deliver information
Staff nurse
23
5 (21.7)
11 (47.8)
7 (30.4)
Doctor8
1 (12.5)
4 (50)
3 (37.5)aFisher’s exact test; n = frequencies*p<0.05
Table 5. Source of information on low-iodine diet (LID)
Statement (Answer)
Have you been advised on low iodine diet prior to Radioactive Iodine (RAI) treatment?
Do you practice diet low in iodine before Radioactive (RAI) treatment?
Who inform you regarding a low iodine diet prior to treatment Radioactive Iodine (RAI)
treatment?
Staff nurse
DoctorWhen were you informed on the diet low in iodine?
One-month prior treatment
2 weeks’ prior treatment
Others
Where do you get information on low-iodine diet?
Phone
Interview
Do you have difficulty to follow low-iodine diet for 2 weeks?
YesNo

p value a
0.359

Yes (%)
96.8
93.6

74.2
25.8
67.7
9.7
22.6
41.9
58.1
32.3
67.7

DISCUSSION

Low iodine diet (LID) was defined by an intake
less than 50µg per day for two weeks by American,
British and European Thyroid Association (15)while Korean Thyroid Association defined LID by
an intake less than 100µg per day (16). LID wasalways prescribed to patients undergoing RAI
treatment to increase the radio-iodide accumulationin thyroid remnants. In thyroid carcinoma, decrease
uptake and shorter effective half-life of radioiodide cause negative effect towards the dose ofradiation in tumor tissue when compared to normal
tissue (4). One method used to enhance uptake is todeplete the plasma inorganic iodide pool before theadministration of radio-iodide6. A study by Lee etal. (2014) in Korea shows that a strict LID for one
week is sufficient to achieve an adequate decreasedof the body iodine pool before RAI (4). In theory,
low plasma iodide concentration will increase theexpression of sodium iodide symporter and leads toa higher specific activity of radio-iodide (15).
Prescription of LID will limit iodide intake inachieving depletion of iodide in the body andenhances the uptake of radioactive iodine byremaining thyroid cells, increasing theeffectiveness of radioactive iodine treatment (17).

The iodine content of foods varies withgeographic location ranging from 30µg/100g to800µg/100g based on the World HealthOrganisation (WHO)/Food and Agriculture
Organization of the United Nations (FAO) (18, 19).
The coastal regions of the world are much richer iniodine content than the soils further inland.
Population living near the sea and consuming
seaweeds and reef fish, such as the Korean
population have ‘more than adequate’ iodine intake
in their diet (16). Present findings showed highcompliances with LID is due to the normal eating
habits of Malaysian whereby there was moderate to
low intake of iodine in their daily food intake (11).
Urinary iodine excretion, thyroid size using
ultrasonography, thyroid-stimulating hormone(TSH) and thyroglobulin are the indicators
recommended by the WHO/United Nations
Children's Fund (UNICEF)/International Council
for Control of Iodine Deficiency Disorders(ICCIDD) (2007) for assessing iodine nutrition
iodine nutrition worldwide (19, 20). A urinary
iodine on centration of above 100µg/L corresponds
to a dietary iodine intake of 150µg/day (21).

78Diet and Radioactive Iodine Treatment

2)

Azizah AM, Nor Saleha IT, Noor Hashimah A,
Asmah ZA, Mastulu W. Malaysian national
cancer registry report 2007–2011. Malaysia
cancer statistics, data and figure. Putrajaya:
National Cancer Institute, Ministry of Health.
2016.
3) Beierwaltes WH, Rabbani R, Dmuchowski C,
Lloyd RV, Eyre P, Mallette S. An analysis of"ablation of thyroid remnants" with I-131 in 511
patients from 1947-1984: experience atUniversity of Michigan. Journal of nuclear
medicine: official publication, Society of Nuclear
Medicine. 1984 Dec;25(12):1287-93.
4) Lee M, Lee YK, Jeon TJ, Chang HS, Kim BW,
Lee YS, Park CS, Ryu YH. Low iodine diet for
one week is sufficient for adequate preparation ofhigh dose radioactive iodine ablation therapy ofdifferentiated thyroid cancer patients in iodinerich areas. Thyroid. 2014 Aug 1;24(8):1289-96.
5) Morris LF, Wilder MS, Waxman AD, Braunstein
GD. Reevaluation of the impact of a stringent
low-iodine diet on ablation rates in radioiodine
treatment of thyroid carcinoma. Thyroid. 2001
Aug 1;11(8):749-55.
6) Yang DU, Gao YH, Feng ZY, Meng FG, Fan LJ,
Sun DJ. Serum Thyroglobulin—A Sensitive
Biomarker of Iodine Nutrition Status andAffected by Thyroid Abnormalities and Disease
in Adult Populations. Biomedical andenvironmental sciences. 2017 Jul 1;30(7):508-16.
7) Pittman Jr JA, Dailey III GE, Beschi RJ.
Changing normal values for thyroidal radioiodine
uptake. New England Journal of Medicine. 1969
Jun 26;280(26):1431-4.
8) Sawka AM, Ibrahim-Zada I, Galacgac P, Tsang
RW, Brierley JD, Ezzat S, Goldstein DP. Dietaryiodine restriction in preparation for radioactive
iodine treatment or scanning in welldifferentiated thyroid cancer: a systematic review.
Thyroid. 2010 Oct 1;20(10):1129-38.
9) Maxon HR, Thomas SR, Boehringer A, Drilling
J, Sperling MI, Sparks JC, Chen IW. Low iodine
diet in I-131 ablation of thyroid remnants.
Clinical nuclear medicine. 1983 Mar;8(3):123-6.
10) Maxon HR, Thomas SR, Hertzberg VS,
Kereiakes JG, Chen IW, Sperling MI, Saenger EL.
Relation between effective radiation dose andoutcome of radioiodine therapy for thyroid cancer.
New England Journal of Medicine. 1983 Oct
20;309(16):937-41.
11) Sohn SY, Choi JY, Jang HW, Kim HJ, Jin SM,
Kim SW, Suh S, Hur KY, Kim JH, Chung JH,
Kim SW. Association between excessive urinary
iodine excretion and failure of radioactive iodine
thyroid ablation in patients with papillary thyroid
cancer. Thyroid. 2013 Jun 1;23(6):741-7.
12) Yoo ID, Kim SH, Seo YY, Oh JK, Chung SK.
The success rate of initial 131 i ablation indifferentiated thyroid cancer: comparison

The present finding resulted in higher
knowledge improved LID compliance andconsistent with study finding by Moon (2012) where
patients were confident in avoiding food with highiodine content and selecting food with low iodine
content and did not view these items as barriers (21).
Chung et al. (2013) suggested that if the respondents
adequately educated, and if their compliance wasregularly monitored, one week of LID may besufficient before RAI therapy (22). Choi et al. (2008)
also reported that most of the respondents could
achieve iodine level below recommendations, after
two weeks of stringent LID and advice from a
specialized dietitian (21, 23). The compliances
towards LID were associated with employment
status which was supported by Galobardes B. (2001)
whereby food availability in the workplaceenvironment or social network and peer-groups does
influence compliance towards dietary advice (24).
Food intake and food habit among employedpatients might be influenced by peers and social
environment. However, other factors such as
cultural, religious beliefs and food costs were notmeasured which may influence dietary intake (24).
CONCLUSION: High compliances rate towards
LID were achievable among patients undergo RAI
treatment might be due to Malaysian’s general
iodine intake is lower than the recommended iodine
intake. Proper nutrition education for thyroid
patients is effective to enhance compliance and to
reduce perceived barriers on the low iodine diet.
Acknowledgement
We would like to thank the Director General of
Health Malaysia for his permission to publish thisarticle.
Funding Statement
This study is not funded by any organization.
Conflict of Interest
This study has no conflict of interest.

1)

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Asian Journal of Dietetics, 2019

ORIGINAL
Substituting Pre-Germinated Brown Rice for White Rice Reduced
Body Weight in Healthy Overweight Vietnamese Women
Vu Anh Linh＊1, Bui Thi Nhung2, Le Danh Tuyen2, Nguyen Do Van Anh2, Yukihiko
Ito3, Kei Yui3, Shigeru Yamamoto,11International Nutrition, Graduate School of Human Life Science, Jumonji University,
Saitama 352-8510, Japan,
2
National Institute of Nutrition, Hanoi, Vietnam,
3
FANCL Research Center, Yokohama 244-0806, Japan(Received October 1, 2019)
ABSTRACT Background: Pre-germinated brown rice (PGBR) is slightly germinated bysoaking brown rice (BR) in water, which reduces the hardness of BR and makes it easierand tastier to eat. There are studies that have shown the effectiveness of PGBR on highblood glucose and cholesterol concentrations mainly in diabetes mellitus (DM) patientsbut only a few have investigated the effect on body weight, perhaps because the subjects
are usually instructed to reduce their energy intake and body weight. We observed adecrease in body weight in our previous study in pre-diabetes subjects who were not onenergy restriction or drug treatment. Therefore, for confirmation, we conducted thisstudy in healthy persons. Purpose: To study the effect of PGBR on weight reduction in
healthy overweight Vietnamese women. Design: The study was a randomized control
trial that was conducted in 72 healthy overweight women. All participants wererandomly assigned to consume PGBR or white rice (WR) as staple foods for 16-wks.
Anthropometric parameters, blood pressure, physical activity, and a nutrition survey
were conducted at baseline, 8-wk, and 16-wk. Fasting blood was withdrawn andbiochemical analysis was conducted at baseline and 16-wk. Acceptability was
ascertained by questionnaire after the study. Results: After the 16-wk intervention, bodyweight in the PGBR group decreased from 63.3 ± 6.5 kg to 61.2 ± 6.5 kg (p < 0.001),
while body weight in the WR group was maintained. Waist and hip circumferences in
the PGBR group decreased, for waist -3.6 ± 2.0 cm;( p < 0.001) and hip -1.8 ± 2.2 cm;(p < 0.001) but not in the WR group. Serum total cholesterol and triacylglycerol
concentrations (mg/dL) were abnormally high in the both groups at baseline, however,at 16-wk in PGBR group decreased from 205 to 182 (p < 0.001) and from 133 to 108 (p< 0.05), respectively, but not in WR group. Energy intakes (kcal/day) in the PGBR groupdecreased significantly (p < 0.05) at baseline, 8-wk, and 16-wk were 1912, 1857 and1803, respectively but not in the WR group (1902, 1882 and 1879, respectively).
Conclusion: These findings suggest positive effects of PGBR on controlling body weightin overweight healthy women as well as on the blood lipid and sugar profiles.
Keywords: Body weight, obesity, pre-germinated brown rice, dietary fiber, Vietnamese.
INTRODUCTIONIn Asian countries, as well as the rest of theworld, the incidence of obesity has| been rising
rapidly. For example, the percentage (%) of adultwomen aged 20 and older with Body Mass Index(BMI) higher than 25 in 2014 was 48.6 in
Malaysia, 39.7 in Thailand, 32.5 in Singapore,*1 To whom correspondence should be addressed: shigeruy@juminji-u.ac.jp81

PGBR and Overweight30.9 in Taiwan, 30.6 in Indonesia, 27.4 in China,
27.2 in Korea, 20.7 in India and 17.6 in Japan(1). For Vietnamese adults aged 25-64 years, theprevalence (%) of overweight and obesity (BMI
higher than 25) was 20.3 and that of noncommunicable diseases was: high blood pressure
20.3, diabetes mellitus and impaired fastingblood glucose 5.7 and high blood cholesterol
32.4 (2).
There are studies that whole grains canprevent obesity, diabetes and heart disease (3-8).
Brown rice (BR) is a whole grain, however,people prefer white rice (WR) because BR itself
has an unappealing taste and texture. WR ismade by polishing BR and removing its surface,which makes WR softer and tastier than BR.
According to a Vietnam national nutrition survey
in 2009-2010, more than 66% of the energy
consumption came from WR (9).
Pre-germinated brown rice (PGBR) is slightly
germinated by soaking BR in water; it becomes
softer in texture and has a taste close to that of
WR. It maintains the various qualities of BR,
for example, the fiber in BR (10, 11). We havebeen studying the effects of PGBR on blood
glucose and lipids, mostly in DM patients (1215). We did not observe the effect of PGBR on
body weight in most of these studies, because
once patients are diagnosed as DM, they aretaught to reduce energy intake and body weightdecreases. However, in our previous study westudied the effects on blood glucose and lipids in
pre-diabetes persons without any dietary or drug
management (15). Unexpectedly, we observed adecrease in body weight, which made us
interested in observing the effect of PGBR on
body weight in healthy overweight persons,
therefore this study was conducted.

eligibility criteria for participants were thefollowing: 1) age range: 30-65 y, 2) BMI: 23-35
kg/m2. The exclusion criteria for participants
were the following: 1) those who were currently
pregnant or had plans for pregnancy during thestudy period (by interview), 2) who werecurrently suffering from serious diseases suchdiabetes, kidney, mental, hepatic (by medical
history), 3) who were using or had plans forweight loss therapy during the study period, 4)
who were using or planning to use weight loss
supplements or medicine during the study period,5) who were already eating brown rice or PGBR.
After screening, 72 participants met the inclusive
criteria.
Study design: The study was a randomized
control trial that was conducted in 72 healthy
overweight women. Subjects were randomized
to be divided into PGBR (n=36) and WR (n=36)
groups. All participants in the PGBR group were
instructed to use PGBR as their staple food for
16-wk, and all participants in WR group were
instructed to use WR as their staple food for 16wk. At baseline and 16-wk of the study, blood
samples and physical activity of both groups
were determined. At baseline, 8-wk, and 16-wk,
anthropometrics parameters, blood pressure, andnutrition survey were conducted. All participants
were free-lifestyle living and instructed that theyshould not change lifestyles and food habitsduring the study period. The primary outcome
was body weight loss.
Trial foods: Both PGBR and WR samples weremade from the same Japonica rice variety named
Hoshinoyume, and obtained from Hokkaido,
Japan (FANCL Tokyo, Japan). All participants
were provided aseptic packaged boiled PGBR
and WR. They were about 160g (about 220 kcal)
which can be distributed at normal temperatureand is eatable only by heating with a microwave
oven for about 2 minutes or in boiling water for
about 15 minutes.

MATERIALS AND METHODS
Setting and participant study: The study
protocol was approval by the Scientific andEthical Committee of the National Institute of
Nutrition, Hanoi, Vietnam. The study was
designed in conformity with the Declaration of
Helsinki on Human Studies. A total of 473
women living in 2 communes in suburban Hanoi
City, Vietnam, were screened for bodyanthropometrics and were asked their medical
history. All participants were fully informed of
the content and schedule of the study. The

Anthropometric measurements and bloodpressure: Body height and weight were
measured in the morning after a 12h-night fast
and with light clothing and barefoot. Body massindex (BMI) was calculated by body weight perheight squared (kg/m2). Waist circumference
was measured at the midpoint between the lower
margin of the last palpable rib and the top of the82

PGBR and Overweightiliac crest. Hip circumference was measured
around the widest portion of the buttocks. Body
fat percentage was measured by the bioelectrical
impedance method using the Omron scale (HBF212b, Omron Co., Kyoto, Japan). Blood pressure
was measured by using a standardized automatedsphygmomano-meter (Omron HEM-6113,
Tokyo, Japan) after 10 minutes of resting inseated position.
Blood sample: Total 10 ml of blood waswithdrawn via venipuncture after a 12h-night
fast. Serum glucose was measured with the useof an enzyme-couple kinetic assay and blood
serum was kept at -80oC until analysis. Serum
total cholesterol and triacylglycerol were
measured by the enzymatic method. SerumHDL-cholesterol and LDL-cholesterol were
measured by the enzymatic and direct methods.
All measurements were conducted by AU480

analyzer-Beckman
coulter-USA
atthelaboratory of the National Institute of Nutrition,
Hanoi, Vietnam.
Nutrition survey and physical activity: We used
a 24h dietary recall for 3 days (2 weekend days
and 1 weekday) at baseline, 8-wk, and 16-wk.
Each participant was interviewed by a skilled
dietitian from the National Institute of Nutrition,
Hanoi, Vietnam. Energy, carbohydrate, lipid,
and dietary fiber intake were calculated based on
the Vietnamese Food Composition Table 2007(16). Physical activity at baseline, 8-wk, and 16wk was assessed by pedometer for steps
measurement. Each time steps were measured
for 3 consecutive days.
Acceptability: Overall taste, softness andstickiness were evaluated by scores from 1 to 3
(3, good; 2, moderate; 1, poor)

Fig.1. Flow chart of the study83

PGBR and Overweight

Statistical methods: Data were analyzed byusing JMP version 11 (SAS Institute Inc., Cary,
NC). Values are reported as means ± standard
deviations (SD). Quantitative variables werechecked for normal distribution and comparedby the Student t-test, p-values of less than 0.05
(with 2-sided) were considered statisticallysignificant for all the analyses. Baselinecharacteristics of the 2 groups were comparedusing Student’s t-test. Within-group differenceswere compared using the paired Student t-test.

= 0.68), HDL-cholesterol (p = 0.06),
triacylglycerol (p = 0.66), or blood glucose (p =0.16) between the PGBR and WR groups atbaseline. Change of body weight and bodycomposition and blood pressure:
Table 2shows that the body weight and BMI in the
PGBR group decreased from 63.3 ± 6.6 kg and27.2 ± 2.5 at baseline to 62.1 ± 6.5 kg (p < 0.001)
and 26.6 (p < 0.001) at 8-wk and 61.2 ± 6.5 kg(p < 0.001) and 26.3 ± 2.5 (p < 0.001) at 16-wk,
while those in the WR group were notsignificantly different.
In addition, body fat percentage and waist
and hip circumferences decreased significantly
from 38.3 ± 3.2 %, 87.3±6 cm and 99.4 ± 5.1 cm
at baseline to 37 ± 2.9 % (p < 0.001), 84.6 ± 6.1
cm (p < 0.001) and 97.8 cm (p < 0.001) at 8-wk,
and to 35.3 ± 2.2 % (p < 0.001), 83.7 ± 5.8 cm (p< 0.001) and 97.6 cm (p < 0.001) at 16-wk, while
only waist circumference in the WR groupdecreased significantly from 88.2 ± 7.3 cm atbaseline to 86.5± 7.1 cm (p < 0.05) at 16-wk. In
the PGBR group there was a slight decrease insystolic blood pressure (mmHg) from 127.4 ±10.8 at baseline to 123.6 ± 10 (p < 0.05) at 8-wk
and 119.8 ± 12.1 (p < 0.001) at 16-wk but in the
WR group there was slight increase from 79.6 ±7.3 at baseline to 82 ± 9.1 (p < 0.05) at 8-wk and81.7 ± 8 (p < 0.05) at 16-wk.

RESULTS
Baseline characteristic of participants: The 72
enrolled participants were randomly assigned to
the PGBR group (n=36) or the WR group (n=36).
A total of 70 participants completed the study (2participants in the WR group discontinued
intervention due to personal reasons). Table 1
shows baseline characteristics of the study
population. There was no significant differencein age (p = 0.86), body height (p = 0.80), bodyweight (p = 0.55), body fat percentage (p = 0.71),
waist circumference (p = 0.55), hip
circumference (p = 0.90), systolic blood pressure(p = 0.06), diastolic blood pressure (p = 0.94),
total cholesterol (p = 0.48), LDL-cholesterol (pTable 1. General characteristics of subjects
PGBR (n=36)
Mean ± SD
43.3 ±
7.0
152.6 ±
4.9
63.3 ±
6.6
27.2 ±
2.5
38.3 ±
3.2
87.3 ±
6.0
99.4 ±
5.1
127.4 ± 10.8
79.6 ±
7.3
204.6 ± 42.9
132.8 ± 46.1
47.7 ± 10.2
170.9 ± 60.2
94.8 ±
7.2

WR (n=34)
Mean ± SD
43.6 ±
7.7
152.3 ±
5.2
64.4 ±
8.7
27.7 ±
3.6
38.6 ±
4.0
88.2 ±
7.3
99.2 ±
6.0
122.8 ±
9.0
81.5 ±
8.0
199.0 ± 16.5
128.9 ± 29.4
43.6 ±
6.7
170.0 ± 85.1
96.9 ±
4.6

Age (year)
Height (cm)Weight (kg)BMI (kg/m2)
Body fat (%)
Waist circumference (cm)Hip circumference (cm)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Total cholesterol (mg/dL)
LDL cholesterol (mg/dL)
HDL cholesterol (mg/dL)
Triacylglycerol (mg/dL)
Blood glucose (mg/mL)
All values are means and standard deviations
P values obtain from independent sample t-test between PGBR and WR groups

84

P-values
0.81
0.83
0.53
0.61
0.66
0.61
0.94
0.09
0.84
0.48
0.46
0.08
0.73
0.28

PGBR and Overweight

However, mean values of both systolic bloodpressure and diastolic blood pressure in the
PGBR group were within normal range. The
others parameters in table 2 were notsignificantly different in comparison withbaseline data.
Blood biochemical parameters: The change inblood parameters are indicated in table 3.
Concentrations of blood parameters (mg/dL) in
the PGBR group at baseline and 16-wk
decreased; total cholesterol from 204 ± 42.9 to
182.1 ± 31.6 (p < 0.001), LDL-cholesterol from132.8 ± 46.1 to 108.4 ± 28.8 (p < 0.05),
triacylglycerol from 170.9 ± 60.2 to 135.2 ± 71.7,
and glucose from 94.8 ± 7.2 (p < 0.05) but in the
WR group none of these changed.
HDLcholesterol of both the PGBR and WR groups
increased significantly at 16th-wk in comparison
with baseline (p < 0.05).

Nutrition survey and physical activity: Table 4shows the energy and nutrient intakes andphysical activity of the PGBR and WR groups atbaseline, 8-wk, and 16-wk. In the PGBR group,
energy, protein and carbohydrate at 16-wk
decreased significantly in comparison withbaseline (p < 0.05). Dietary fiber intake of the
PGBR group at baseline was 6.5 ± 1.7 g andincreased to 12.6 ± 2.6 g (p < 0.001) at 8-wk and14.0 ± 3.6 g (p < 0.001) at 16-wk. In the WR
group, none of these items changed significantly.
Fig. 2 shows the comparison of scores ofoverall taste, softness and stickiness between
PGBR and WR. They were evaluated by scoresfrom 1 to 3 (3 good; 2 moderate; 1 poor). WR
was softer and more sticky than PGBR (p<0.05)
but the overall taste was similar.

Table 2. Change in anthropometric parameters and blood pressure

Table 3.Blood parameters of PGBR and WR groups at baseline and final

85

PGBR and Overweight

Table4.Nutrient intakes and physical activity

Fig. 2.

Acceptability of PGBR

(3 good; 2 moderate; 1 poor)** Statistically different (p<0.01)

DISCUSSION

The present 16-wk randomized, controlled
trial suggests that replacing WR with PGBR
might have beneficial effects for controllingbody weight in healthy overweight and obese
women. The main focus of the study was
reduction of body weight with PGBR; bodyweight (kg) of the PGBR group decreased from
63.3 to 61.2 (a 2.1 kg decrease in 16-wk), while
the WR group changed only slightly, from 64.4
to 63.8 (only a 0.6 kg decrease). We also
observed a decrease in waist and hip
circumferences and beneficial effects in blood
lipid profiles. It is well-known that body weightis controlled by energy balance: energy IN (foodintake) and energy OUT (physical activity). We
measured physical activity by pedometer and did
not observe any difference at baseline, 8-wk, and16-wk in either group. (Table 4). From these data
total energy intake and physical activity (steps),

it might be inferred that body weight in the
PGBR group may have decreased from reducing
their energy balance.
However, in our previous study of DM
patients who had received nutrition educationfrom doctors or dietitians (12-14), we did notobserve a reduction of body weight in the PGBR
group except for one study conducted in pre-DM
patient without nutrition education (15). In thepresent study, we selected healthy overweightsubjects without any health problems andconfirmed clearly that PGBR was useful in
reducing body weight.
In this study all the WR and PGBR was
supplied by us for the whole study period (4months). Rice is the subjects’ staple food andsubjects ate rice at least twice over 3 meal times(breakfast, lunch and dinner). Both the WR and
PGBR were same strain of rice produced in the86

PGBR and Overweightsame area and packets of about 60g (250300kcal) are available in the market. Packets
could be stored at normal temperatures and madeedible by heating in a microwave oven for about
2 minutes or in boiling water for about 15
minutes. The use of this pre-packaged rice madethe study easier for subjects as well as for the
researchers and dropouts were limited to only afew. Researchers were not concerned with ricefor other family members.
With regard to the decreased energy intake in
the PGBR group, we had to determine whether
the taste of PGBR was acceptable to the subjects.
People prefer WR to BR, because WR is softerand tastier than BR. WR is made by polishing
BR and removing its surface. PGBR is slightly
germinated by soaking BR in water. In theprocess, the BR skin is broken apart and becomessoft. From our sensory test, we found that
although the PGBR was a little harder and lesssticky than WR, the taste was evaluated as highas WR. From these results we concluded that thedecrease of energy intake in the PGBR group
was not due to its taste.
Dietary fiber might affect body weight
through multiple pathways, including throughmodulation of insulin secretion and control ofsatiety (17-19). In our study, the intake of
dietary fiber (g/day) in the PGBR group was 12.6
at 8-wk and 14.0 at 16-wk and much higher thanthat at baseline (6.5). There was no change in the
WR group being 6.5, 6.5 and 6.8 at baseline, 8wk and 14.0 at 16-wk, respectively.
Many studies have investigated the relation of
low glycemic (GI) index foods and body weight.
PGBR contains higher dietary fiber and has alower GI than WR (8). Previous studies showedthat rapid absorption of glucose after
consumption of high GI foods could lead to
sharp rises in blood glucose and insulin levels;
thus, glucose enters body tissues, inhibits
lipolysis and induces lipogenesis and obesity.
(20, 21).
Increased fiber makes the subjects feel full fora longer time, which might be associated with
reduced hunger or increased satiety, leading to
reduced total energy intake (22-25). Birketvedt
et al (26) found that the addition of dietary fiber
to a low-calorie diet significantly improved
weight loss, with the placebo group losing 5.8 kg
and the fiber-supplemented group losing 8.0 kg
in overweight subjects.

With a longer chewing time and slower
digestion and absorption, nutrient receptors in
the gastrointestinal tract are stimulated for alonger time; this will prolong feedback to thesatiety center in the brain and reduce energy
intake (22, 23).
However, fiber alone is not enough to
explain the effect of PGBR on body weight,
because PGBR has various functional
ingredients different from WR (27) and we do
not know their possible effects on body weight.
PGBR is richer than WR in vitamins, minerals
and dietary fiber, γ-oryzanol, and ferulic acid andacylated steryl glucosides.
In conclusion, the present study shows that
replacing WR with PGBR for a 16-wk intake
could reduce body weight in healthy overweight
women. From these findings, the rapid increasein overweight and obesity in Vietnam could becontrolled by the use of PGBR.
Conflict of interests
The authors declare no conflict of interests
regarding the publication of this article.
Acknowledgments
The authors are grateful to all participants andthe staff members of the National Institute of
Nutrition, Hanoi, and local public health officials
for collaborating in the study. This study was
supported by Jumonji University and the USJapan Medical Science Program. We would liketo thank Andrew R. Durkin, Professor Emeritus
of Indiana University, Bloomington, IN, USA,for his careful editing of the English of thisarticle.
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89

Asian Journal of Dietetics, 2019

ORIGINAL
Adolescents’ Habitual Nutrient Intake Adequacy was Independent ofMilk Provision in School Lunch in Japan: A Cross-sectional Study ofJapanese Junior High School Female Students
Mai Matsumoto1, 2, Ayumi Masumoto3, Azusa Sakamoto2,
Aki Saito1, Shinji Ikemoto2 *1

Department of Nutritional Epidemiology and Shokuiku, National Institutes of
Bioinnovation, Health and Nutrition., Shinjuku-ku, Tokyo, Japan2
Department of Human Nutrition, SEITOKU University., Matsudo-shi, Chiba, Japan
3
Saitama city., Saitama-shi, Saitama, Japan(Received November 30, 2019 )ABSTRACT Background and purpose. Intake of dairy products in adolescence may beof importance in improving nutritional status. Most school lunch programs provide
milk in Japan. The aim of this study was to assess the difference in habitual nutrient
intake adequacy between Japanese junior high school girls who received milk in theirschool lunch program and those who did not. Methods. Participants were students aged
12-15 years who had school lunch with (n=306) or without milk (n=210). Dietary
habits during the preceding month were assessed using a brief self-administered diethistory questionnaire for Japanese children and adolescents (BDHQ15y). Inadequacyof each nutrient intake was assessed by the cut-point method, which showed that 14
nutrients were below the estimated average requirement (EAR) and five nutrients wereoutside the range of the dietary goal (DG). The overall nutritional inadequacy inparticipants was assessed by the number of nutrients consumed, which did not meet theDietary Reference Intake for Japanese, 2015 version. Results. The intake of niacin,
vitamin B12, iron, copper, and salt-equivalent was higher, whereas intake of calcium
was lower in students that did not provide milk with their school lunch compared tothose that consumed milk (p<0.05). Total nutritional inadequacy and nutritional
inadequacy for each nutrient separately did not differ significantly between the twogroups. Conclusion. Our results showed that habitual nutrient intake adequacy forJapanese junior high school female students was independent of milk provision inschool lunch programs. Further studies are needed to determine alternative factors thatpossibly influence dietary intake among Japanese adolescent girls.
Keywords: Milk, School lunch, Adolescent, Nutritional adequacy, Japan.

INTRODUCTION
Adolescence is a critical period during which
lifetime habits are established (1). The eating
patterns in adolescence also persist into adulthood(2–4). Therefore, nutritional quality during thisperiod is important because it can influence adultmorbidity and mortality (5).
Dairy products provide an abundant source ofnutrients such as protein, vitamins and minerals
and, particularly, calcium (6). Calcium is an
essential nutrient for bone mineralisation andrigidity (7, 8). It has been suggested that nutrientsfrom dairy products are essential for building andmaintaining strong bones and increasing bonedensity (9). Especially, the bone mineral accrual
rate is the highest during lifetime andapproximately 95% of the bone mass peak is
acquired in adolescence (10). Thus, adequate
dairy intake is necessary for the development andmaintenance of the bone mass peak duringadolescence and fundamental for bone health laterin life (7, 8). Studies have also indicated that90

intake of milk and other dairy products may
improve the overall nutritional quality ofadolescents’ diets (11, 12). Moreover, thebeneficial roles of dairy products have been
examined in relation to a variety of chronic
diseases including hypertension, metabolic
syndrome, type 2 diabetes and cardiovasculardisease (6, 13-15). Higher consumption of dairy
products and calcium has been associated with alower prevalence of overweight or obesity (16).
Consumption of dairy products in adolescencemay be important in a healthy nutritional status.
Currently, 88.1% of junior high schools inJapan provide school lunches based on the School
Lunch Act enacted in 1954.17 This school lunch
program is based on the combination of main
staple food (grains), main dishes (fish, meat,
poultry or soy products), side dishes (vegetable
and soup, etc.) and milk, therefore most juniorhigh schools provide milk to students every day(full meal which provides main staple food, main

Milk in School Lunch and Nutritional Adequacy

dish, side dish and milk: 82.6%, supplementary
meal which provides main dish, side dish andmilk: 0.4%, milk only: 5.2%) (17). Under thisJapanese school lunch program, the same lunchmenu is provided to all children in each school.
There are no alternative choices except for special
cases, such as students with a food allergy. School
lunches provide approximately 30% of the daily
dietary intake and the school lunch programs inJapan appear to improve total diet quality inJapanese students (18). The nutrient content ofschoollunchesisregulatedbythe
Gakkou-Kyushoku-Jissi-Kijun (Standards for the
School Lunch Program). The nutritional standards
for most of nutrients are set at 33% of the dailyreference values of Dietary Reference Intakes forJapanese, 2015 (DRIs) (19) such as recommended
dietary allowance (RDA) or tentative dietary goal
to prevent lifestyle-related diseases (DG).
However, the nutritional standard for calcium forthe school lunches is set at 450 mg per serving,which is 50% of the RDA (900 mg per day), due
to the difficulty in obtaining calcium from thehabitual Japanese dietary intake. Indeed, milk
significantly contributes to the required calcium
intake, because 200 ml (1 serving for school
lunches) of milk provides approximately 230 mg
of calcium (20).
Previous studies examined school lunches anddietary intake in relation to dairy products or milk.
For example, a 3-day dietary record showed thatthe number of Japanese children aged 10-11 years
with insufficient calcium intake, who had aschool lunch including milk, was lower compared
to children who did not consume milk at lunch(21). Another study reported that Japanesechildren who were provided with school lunches
had greater calcium intake than children who
brought their own lunches to school from home(22). A US study showed that the daily calcium
intake of female students aged 12 to 18 years who
were drinking milk during school lunch was
greater than those who did not (23), although thefood items in school lunches were consumed by
the students ad-lib. Studies have indicated that the
intake of milk and other dairy products may
improve the overall nutritional quality ofadolescents’ diets (11, 12). Milk in school lunches
may influence the overall dietary intake among
adolescents, even though the menus of school
lunches in Japan are designed to meet the nutrient
standards. However, as milk has been regarded asa necessary item in school lunches in Japan, there
has been no study on habitual dietary intake
among students in relation to milk supply at
school. There is very rare but 0.01% of juniorhigh schools which have not always provided
milk on school lunches in Japan because milk
does not match with typical Japanese diet withrice as the main staple food. A previous study
showed that the higher frequency of meal
combining main staple, main dish and side dishled to greater nutrient intake, especially higher
calcium intake (24), which might suggest theneedlessness for milk on school lunch every day.
Here, the aim of this study was to assess theinfluence of milk in school lunch on habitualnutrient intake adequacy of Japanese junior highschool female students.

METHODS
Study population. A set of two self-administeredquestionnaires (i.e., a diet history questionnaire
and lifestyle questionnaire) were distributed byteachers to 742 junior high school female students
who attended either a public junior high schoolthat provided school lunch with milk every day(school lunch with milk group) or two private
junior high schools that did not always provide
school lunch with milk (school lunch without
milk group) in Kanto urban region, Japan in June
2016. The content of school lunch in two private
junior high schools was the same. Students wereasked to answer the questionnaires on their own,
or in cooperation with their parents, if necessary.
The completed questionnaires were examined by
the research staff, and those with missing
information were returned to the students forcompletion. Both questionnaires were completed
by 575 female students.
We excluded students with missing data
(n=17), with milk allergy (n=8) and with areported energy intake less than half the energy
requirement for the lowest physical activity
category, according to the Japanese DRIs or equal
to or more than 1.5 times the energy requirement
for the highest physical activity category (<1075kcal/day or ≥4050 kcal/day; n=34) (25). Thus, thefinal participant list consisted of 516 junior highschool female students categorized into thefollowing two groups: school lunch with milk
(n=306) and school lunch without milk (n=210).
Written informed consent was obtained from allparticipants and their parents. The present study
was granted ethical approval by the Ethics
committee of SEITOKU University in accordance
to the guidelines of Helsinki Declaration(approval number H27U056).
Dietary assessment. Habitual dietary intake per
day during the preceding month were assessedusing a brief self-administered diet history
questionnaire for Japanese children andadolescents (BDHQ15y) (26). BDHQ15y wasdeveloped based on the adult version of thevalidated a brief self-administered diet history
questionnaire (BDHQ) that enquires about the
dietary history during the preceding month (27,28). BDHQ15y is a 4-page structured
questionnaire consisting of 67 questions regarding
the frequency of intake of food items commonly
cooked and consumed in Japan. Daily food,energy and selected nutrient intake were
calculated using an ad-hoc computer algorithm
for BDHQ15y based on the Standard Tables ofFood Composition in Japan (29). The validity of
BDHQ15y was verified by a study on therelationship between selected food intake andblood biomarker levels (26). Milk was
categorised either as full-fat or low-fat milk.
Additionally, food groups were categorized basedon the previous study (27). Any self-estimateddietary assessments cannot avoid under- orover-reporting of dietary intake (30, 31).
Therefore, in order to render the comparison
between the reported nutrient intake and theJapanese DRI values practically possible, we
adjusted the reported dietary intake based on the91Milk in School Lunch and Nutritional Adequacy

assumption that each participant reported herestimated energy requirement (EER) when her
physical activity level was at the second level.
The following calculation was used: Dietaryintake (unit/day) = reported dietary intake(unit/day)/reported energy intake (kcal/day) ×
EER (kcal/day). The percentage of daily energy
intake was calculated using the crude value fortotal fat and carbohydrate intake. Additionally,
food intake values were energy-adjusted using thedensity method (i.e. the percentage of energy forenergy-providing nutrients and their amounts per1000 kcal for food groups and other nutrients) tominimise the influence of dietary misreporting.
Information regarding the school lunch menus(number of days that a main staple, main dish,side dish, soup and milk were provided in theschool lunch and the mean values of nutrient
supply through the school lunch during the survey
month) was obtained from each school dietician.
The components of each lunch were identified by
the dieticians based on the Gakkou-KyushokuJissi-Kijun and its guideline as follows: main
staple food (grains: rice, bread, noodles and pasta),main dishes (fish, meat, poultry or soy products),side dishes (vegetable, mushrooms and seaweeds)
and soup (miso soup and other soup).
Other variables. Body weight and height wereself-reported as part of the BDHQ15y. The bodymass index (BMI) was calculated as weight(kilograms) divided by the square of height(meters). In the BDHQ15y, participants also
reported the frequency of their exercise such as
sports club activities per week for the past month(everyday, 4-6 days/week, 2-3 days/week, aday/week or never). Additionally, participants
reported on the following variables by completinga self-administered lifestyle questionnaire:
employment status of father (full-time, part-time,
housekeeping or other), employment status of
mother (full-time, part-time, home manager orother), milk intake frequency at home (everyday,
5-6 days/week, 3-4 days/week, 1-2 days/week ornever) and milk intake frequency during school
lunch (everyday, 3-4 days/week, 1-2 days/week ornever).
Determination of habitual nutrient intake
inadequacy. Inadequacy of each nutrient intake
was determined by comparing nutrient levels witheach dietary reference value according to theJapanese DRIs, using a previously reported
method (22, 32, 33). In the Japanese DRIs,
different types of reference values are establishedaccording to their purpose. The estimated average
requirement (EAR) is set to avoid insufficient
intake of nutrients and DG is set to prevent
lifestyle-related diseases.
The intake level below EAR was considered
as inadequate using the cut-point method for 14
nutrients with known EARs: protein, vitamin A
expressed as retinol activity equivalents, vitamin
B1, vitamin B2, niacin expressed as niacin
equivalent, vitamin B6, vitamin B12, folate,vitamin C, calcium, magnesium, iron, zinc, andcopper. The intake level outside the range of DG

values was considered as not meeting the standard
for five nutrients with DG: total fat, carbohydrate,
total dietary fiber, sodium expressed as
salt-equivalent and potassium.
Statistical analysis. All statistical analyses
were performed using the IBM SPSS statistics
software package (version 22.0, SPSS Inc.,
Chicago, IL, USA). The differences ofcharacteristics between school lunch with milk
and without milk groups were compared using thechi-square test for categorical variables and the
independent t-test for continuous variables. The
difference of the mean nutrient supply in school
lunches per meal between school lunch with milk
and without milk was compared using an
independent t-test.
Potential confounding factors considered in
the first analysis were sex, working status andnumber of children which were found to be
substantially different (p<0.05) between groups
categorized by nutrition knowledge level. The
difference of the habitual nutrients intake of thepresent study participants was assessed byanalysis of co-variance (ANCOVA) adjusted theconfounding variables of exercise (everyday, 4-6
days/week, 2-3 days/week, a day/week or never),work status of father (full-time or others) andwork status of mother (full-time, part-time orothers). The nutritional inadequacy of eachnutrient was represented as the percentage ofparticipants whose intake was below the EAR or
outside the range of the DG in each group and thelogistic regression analysis was used to examine
the difference of the prevalence of not-meeting
DRIs adjusted the confounding variables of
exercise (everyday, 4-6 days/week, 2-3 days/week,
a day/week or never), work status of father(full-time or others) and work status of mother(full-time, part-time or others).
The overall nutritional inadequacy ofparticipants was determined based on the numberof nutrients that did not meet the DRI values of
the 14 nutrients with EAR and 5 nutrients with
DG. Differences in the number of nutrients that
did not meet DRIs between school lunch withmilk and without milk groups were assessed bycovariate analysis adjusted the confounding
variables of exercise (everyday, 4-6 days/week,
2-3 days/week, a day/week or never), work status
of father (full-time or others) and work status of
mother (full-time, part-time or others).
Additionally, the difference of the habitual
food groups intake between with and without
milk groups was assessed by analysis ofcovariance (ANCOVA) adjusted the confounding
variables of exercise (everyday, 4-6 days/week,
2-3 days/week, a day/week or never), work status
of father (full-time or others) and work status of
mother (full-time, part-time or others).
RESULTSThe characteristics of study participants areshown in Table 1. The mean BMI did not differ
significantly between the two groups, while the92Milk in School Lunch and Nutritional Adequacy

Table 1. Characteristics of 516 junior high school female students having school lunch with milk or withoutmilk
ALL（n=516）

School lunchwith milk（n=306）

School lunch
without milk
（n=210）

Grade
1

176

(34.1)

105(34.3)

71(33.8)

2
3

187
153

(36.2)(29.7)

11388(36.9)(28.8)

7465(35.2)(31.0)

Body height (cm)Body weight (kg)

154.5
45.7

± 7.8
± 7.5

155.1
45.6

± 6.2
± 7.5

153.5
45.9

± 9.6
± 7.5

0.016
0.648

Body mass index (kg/m2)
Number of days exercising

19.3

± 6.0

18.9

± 2.5

19.9

± 8.8

0.052

Everyday4-6 days/week

231
78(44.8)(15.1)

167
46(54.6)(15.0)

6432(30.5)(15.2)<0.001

2-3 days/week
1 day/week61
49(11.8)
(9.5)

26
19

(8.5)
(6.2)

35
30

(16.7)(14.3)

Never
Energy intake (kcal/day)

97
2103

(18.8)
± 547

48
2158

(15.7)
± 563

49
2024

(23.3)
± 515

0.006

Milk intake (g/1000kcal)
Work status of father

75

± 80

89

± 82

54

± 72

<0.001445
71(86.2)(13.8)

279
27(91.2)
(8.8)

166
44

(79.0)(21.0)<0.001

109(21.1)

45(14.7)

64(30.5)<0.001204203(39.5)(39.3)

129132(42.2)(43.1)

75
71(35.7)(33.8)

120(23.3)

75(24.5)

45(21.4)

5-6 days/week
3-4 days/week

38
63

(7.4)
(12.2)

26
31

(8.5)
(10.1)

12
32

(5.7)
(15.2)

1-2 days/week
Never

108
187

(20.9)(36.2)

64
110(20.9)(35.9)

4477(21.0)(36.7)-

265(86.6)-

3-4 days/week
1-2 days/week

-

11
7

(3.6)
(2.3)

-

Never

-

23

(7.5)

-

Full-time
OthersWork status of mother
Full-timePart-time
OthersNumber of days drinking
milk at home
Everyday

Number of days drinking
milk at school lunch
Everyday

p*

0.857

0.343

-

Data are represented as n (%) or mean ± standard deviation.
*The p values are shown for chi-square test for categorical variables and for independent t test for continuous
variables between school lunch with milk and without milk.

mean body height was higher in school lunch
with
milk
group
than
without
milk
group(p=0.016). The number of participants who
engaged in habitual exercise was greater in theschool lunch with milk group than in the school
lunch without milk group (p<0.001). The
percentage of fathers working full time wasgreater and mothers working full time was less inthe school lunch with milk group than in theschool lunch without milk group (p<0.001). Daily
milk intake (89±82 g/1000 kcal vs. 54±72 g/1000
kcal, p<0.001) and energy intake (2158±563kcal/day vs. 2024±515 kcal/day, p=0.006) in theschool lunch with milk group were significantly
greater than in the school lunch without milkgroup. There was no difference in the frequencyof milk consumption at home between the twogroups.

93

Milk in School Lunch and Nutritional Adequacy

Table 2. Number of days in the survey month thateach item was provided in school lunch
School lunch

School lunchwith milk

without milk

（n=19）（n=21）

Main staple

19 (100.0)

21 (100.0)

Main dish14 (73.7)

16 (76.2)

Side disj

16 (84.2)

20 (95.2)

Soup

10 (52.6)

13 (61.9)

Milk

19 (100.0)

1 (4.8)The mean values of nutrient supply throughthe school lunches with and without milk per meal
are shown in Table 3. Supply of energy, protein,carbohydrate, vitamin A, vitamin B1, vitamin B2,
and calcium was significantly greater in theschool lunch with milk than the school lunch
without milk.
The daily nutrient intake and each nutrient andoverall nutritional inadequacy among 516 juniorhigh school female students eating school lunch
are shown in Table 4. Intake of niacin, folate, ironand salt-equivalent was higher in the school lunch
without milk group than the school lunch withmilk group. The total number of nutrients notmeeting EAR and DG did not differ significantly
between the two groups. Table 5 shows the
habitual foods intake of the present study
participants. The daily intake of other vegetables,
mushrooms, and fish and shellfish among thestudents in school lunch without milk group weremore than those in with milk group (p=0.028,
0.016 and 0.007, respectively). The only dairy
products intake among the students in school
lunch without milk groups was more than those inwith milk group (p=0.003).

Data are represented as n (%).
Table 2 shows the number of days that a main
staple, main dish, side dish, soup and milk were
provided at school lunches in the two groups.
Main staple was provided every day, and main
dish and side dish was also provided in most days.

Table 3. Mean values of nutrient supply per meal by the school lunch
Referencevalue†

School lunchwith milk(total 19 meals)

School lunch
without milk
(total 21 meals)

Mean

SD

Mean

SD

p*

Energy (kcal/meal)

820

778

39

733

66

0.013

Protein (g/meal)

30

29.1

3.6

24.4

3.8

<0.00122.8 - 27.3

22.7

4.2

25.0

5.6

0.158

Carbohydrate (g/meal)

－

114.4

12.4

95.5

24.0

0.004

Vitamin A (µgRAE/meal)‡

300

471

155

194

80

<0.001

Vitamin B1 (mg/meal)

0.5

0.68

0.25

0.41

0.13

<0.001

Vitamin B2 (mg/meal)

0.6

0.61

0.08

0.36

0.11

<0.001

Vitamin C (mg/meal)

35

40.1

19.4

49.7

38.6

0.336

Calcium (mg/meal)

450

388

63

147

68

<0.001Iron (mg/meal)

4

3.2

1.2

2.9

0.9

0.329

Total dietary fiber (g/meal)

6.5

6.1

1.5

5.5

1.2

0.182

Sodium (salt equivalent) (g/meal)

<3

3.3

0.8

3.0

0.5

0.149

Number of meals milk was provided－

19

Fat (g/meal)

1

SD, standard deviation.
† Nutrient standards for school lunch for 12- to 14-year-old students by the Gakkou-Kyushoku-Jissi-Kijun(Standards for the School Lunch Program).
‡ Sum of retinol, β-carotene/12, α-carotene/24, and cryptoxanthin/24.
* p values are shown for independent t test between school lunch with milk and without milk..

94

Milk in School Lunch and Nutritional Adequacy

Table 4. Daily nutrient intakes and prevalence of not meetinｇ EAR and DG among 516 junior high school
female students eating school luncha
Referencevalueb
Nutrient with EAR
Protein (g)School lunchwith milk（n=306）Inadequacyc(%)

School lunch
without milk
（n=210）Inadeq
uacyc
(%)

p†

OR
(95% CI)‡

≥45

80

±1

0

81

±1

0

0.203

Vitamin A (µgRAE)d

≥500

793

± 23

17.3

820

± 28

18.6

0.471

Vitamin B1 (mg)

≥1.1

0.95

± 0.0180.7

0.95± 0.01

81.9

0.821

Vitamin B2 (mg)

≥1.2

1.7

± 0.036.5

1.7± 0.03

10.5

0.813

Niacin (mgNE)e

≥12

16

± 0.2

14.1

17

± 0.3

8.6

0.009

Vitamin B6 (mg)

≥1.1

1.3

± 0.0220.3

1.4± 0.02

20.0

0.050

Vitamin B12 (mg)

≥1.9

8.2

± 0.2

0.3

8.8

± 0.3

0

0.083

Folate (µg)

≥190

384

±8

4.2

411

± 10

1.9

0.034

Vitamin C (mg)

≥80

131

±3

14.4

141

±4

13.8

0.060

Calcium (mg)

≥700

874

± 17

29.7

831

± 20

37.6

0.106

Magnesium (mg)

≥240

285

±3

20.3

289

±4

19.5

0.572

Iron (mg)

≥10.0

8.6

± 0.1

77.5

9.1

± 0.1

71.4

0.025

Zinc (mg)

≥7.0

9.9

± 0.1

2.0

9.9

± 0.1

1.0

0.957

≥0.6

1.2

± 0.010

1.3± 0.02

0

0.075

1.121
(0.686 - 1.832)
0.989(0.606 - 1.614)
1.432(0.726 - 2.826)
0.592(0.316 - 1.109)
0.992(0.617 - 1.594)
0.356(0.108 - 1.175)
0.894(0.520 - 1.537)
1.300(0.873 - 1.936)
0.930(0.577 - 1.500)
0.773(0.502 - 1.191)
0.382(0.066 - 2.218)
-

-

2.9

± 0.1

-

2.8

± 0.2

-

0.622

-

Fat (%energy)

20-30

30

± 0.3

54.9

30

± 0.4

57.1

0.515

Carbohydrate(%energy)

50-65

54

± 0.4

30.4

54

± 0.5

35.7

0.930

Total dietary fiber (g)

≥16

13

± 0.2

83.0

13

± 0.3

78.6

0.082

Sodium(salt-equivalent) (g)

<7.0

12.0

± 0.1

98.4

12.6

± 0.2

100

0.022

-

Copper (mg)
Total number of nutrientswith not-meeting EAR
Nutrient with DG

Potassium (mg)
Total number of nutrientswith not-meeting DG

1.131(0.773 - 1.655)
1.344(0.897 - 2.014)
0.729(0.448 - 1.185)

≥2400

2772

± 41

30.7

2843

± 50

31.4

0.284

0.910
(0.602 - 1.376)

-

3.0

± 0.1

-

3.0

± 0.1

-

0.767

-

Data are represented as mean ± standard error or %.
CI, confidence interval; DG, tentative dietary goal for preventing life-style related disease; DRI, Dietary Reference Intakes; EAR,
estimated average requirement; OR, odds ratio.
a Adjustment of reporting error was performed according to the following: Nutrient intake = reported nutrient intake / reported
energy intake × estimated energy requirement.
b DRIs for 12-14 years old Japanese girl. The estimeated energy requirement of physical activity level Ⅱ is 2400 kcal/day.
c Percentage of subjects whose nutrient intake was not-meeting DG or EAR of DRIs. Each nutrient intake was compared with each
DRI value, using the cut-point methods.
d Sum of retinol, β-carotene/12, α-carotene/24, and cryptoxanthin/24.
e Sum of niacin and protein/6000.
† The p values are shown for covariate analysis to analyze difference between school lunch with or without milk groups adjusted
the confounding variables of exercise( everyday, 4-6 days/week, 2-3 days/week, a day/week or never), work status of father(full-time or others) and work status of mother (full-time, part-time or others).
‡ OR (95% CI) are shown for a logistic regression analysis to analyze the presence of nutritional inadequacy school lunch without
milk group compared with milk group adjusted the confounding variables of exercise( everyday, 4-6 days/week, 2-3 days/week, aday/week or never), work status of father (full-time or others) and work status of mother (full-time, part-time or others).

95

Milk in School Lunch and Nutritional Adequacy

Table 5. Daily food group intakes among 516 junior high school female students eating school luch with milk
or without milk(g/1000kcal)†School lunch
School lunchwith milk
without milkp‡（n=306）（n=210）
Cereals
Rice
Bread
Noodles
PulsesPotatos
Sugar
Confectioneries
Fat and oil
Fat
Oil
FruitsTotal vegetables
Green and yellow vegetables
Other vegetables
Pickled vegetables

208.8
160.2
21.4
27.2
29.9
15.5
2.5
44.2
7.7
0.6
7.2
33.1
120.8
45.9
60.4
4.8

± 3.7
± 4.0
± 0.8
± 1.3
± 1.1
± 0.6
± 0.1
± 1.7
± 0.2
± 0.1
± 0.2
± 1.9
± 4.3
± 1.8
± 2.3
± 0.4

208.8
157.9
21.4
29.5
31.5
14.8
2.6
43.5
7.8
0.6
7.2
36.2
134.0
48.7
68.6
5.4

± 4.6
± 4.9
± 1.0
± 1.5
± 1.4
± 0.7
± 0.2
± 2.0
± 0.2
± 0.1
± 0.2
± 2.3
± 5.2
± 2.2
± 2.8
± 0.4

0.996
0.726
0.977
0.257
0.366
0.486
0.477
0.777
0.816
0.567
0.944
0.319
0.056
0.346
0.028
0.288

Mushrooms
Seaweeds
Beverages
Fruit and vegetable juice
Green tea
Black tea
Soft drinks
Fish and shellfish
Meat
Eggs
Dairy products

4.2
5.5
310.2
28.5
195.3
35.4
51.0
29.1
37.5
18.1
137.7

± 0.3
± 0.3
± 10.4
± 2.8
± 7.5
± 4.8
± 4.5
± 1.0
± 1.0
± 0.6
± 5.6

5.3
6.0
338.5
31.9
205.5
46.0
55.2
33.6
39.7
18.4
111.0

± 0.3
± 0.4
± 12.7
± 3.4
± 9.1
± 5.9
± 5.5
± 1.2
± 1.2
± 0.7
± 6.8

0.016
0.332
0.094
0.454
0.400
0.176
0.569
0.007
0.188
0.804
0.003

Data are represented as mean ± standard error.
† Adjustment of reporting error was performed according to the following: Food group intake = reported foodgroup intake / reportedenergy intake × 1000(kcal).
‡The p values are shown for covariate analysis to analyze difference between school lunch with or without
milk groups adjusted the confounding variables of exercise (everyday, 4-6 days/week, 2-3 days/week, aday/week or never), work status of father (full-time or others) and work status of mother (full-time, part-timeor others).
DISCUSSION
The present study examined the influence of milkin school lunch on the habitual nutrition intake
among Japanese junior high school female students.
To our knowledge, this is the first study to examine
the difference in habitual nutrient intake adequacy
between junior high school students who were andwere not always provided with milk on their school
lunches. Our findings suggested that there might be
no difference in habitual nutrient intake adequacy
between school lunches with and without milk.
Our study found no difference between groups innutritional inadequacy for each nutrient and overall
nutritional inadequacy in relation to milk supply inschool lunches. Although we hypothesised that
school lunch with milk would reduce the proportionof inadequacy for calcium intake compared to school

lunch without milk, we found no difference in thepercentage of students who were below EAR for
calcium between school lunch with milk and without
milk. A previous study showed that the proportion ofelementary school students with a calcium intake
below EAR was lower in the school lunch with milk
compared to the school lunch without milk (21). In
contrast, in our study, the calcium intake andnutritional inadequacy related to calcium did not
differ between the two groups. The study design may
account for the disparate results. The previous study
compared calcium intake from 3 days’ dietary records
to calcium intake estimated by excluding milk in theschool lunches from the records, whereas our study
compared the habitual dietary intakes, assessed witha questionnaire, of junior high school female students
who had a school lunch with milk every day to thosehaving a school lunch that did not provide milk every
96

Milk in School Lunch and Nutritional Adequacyday. Therefore, the results may not be comparable,
and further study is needed. In the present study, thehabitual niacin, folate, iron and sodium intakes weresignificantly greater in the school lunch without milkgroup than the school lunch with milk group. It has
been reported that the percentages below EAR foriron and out of DG range for fat and dietary fibre
were higher, whereas only calcium intake was lower,
in elementary school female students eating
homemade lunch compared to those eating the school
lunch (22). In that previous study, daily salt and ironintakes were greater and only daily calcium waslower in the homemade lunch box group compared tothe school lunch program group. Additionally, inhomemade lunch boxes , staple foods, such as rice,
were the main item followed by some main dishitems, such as meat and fish and side dish items, suchas vegetables, but hardly any dairy products were
included (34). These studies can partly explain thecurrent results regarding the higher iron intake andlower calcium intake among our participants in theschool lunch without milk group. However, theresults on nutritional inadequacy in the present study
were different from the previous study comparing
homemade boxed lunch with school lunch. The
reason for this difference may be explained by thefact that school lunches were made according tocertain nutrient standards regardless of milk supply.
Indeed, in the present study, more side dishes andsoup were provided in the school lunches without
milk group. This may be because school lunches
without milk were required to meet the nutrient
standards for each nutrient, especially regarding
vitamins and minerals, using side dishes and soup,which mainly consisted of vegetables, pulse, andseaweeds, instead of milk. Additionally, there weredifferences in the supply per meal of energy, protein,carbohydrate, vitamin A, vitamin B1, vitamin B2, andcalcium by the school lunch between the two study
groups. In detail, the supply of nutrients such asenergy, protein, carbohydrate, vitamin A, vitamin B1,
vitamin B2 and calcium was higher in school lunchwith milk than school lunch without milk. Moreover,the number of the nutrients which met the standard
value by Gakkou-Kyushoku-Jissi-Kijun of school
lunch with milk was more than those of school lunch
without milk. Thus, milk may play an important rolein meeting the nutrient requirements in school
lunches. However, no difference was observed in the
habitual intake of these nutrients between two groups
among students who participated in the present study.
Especially, the calcium supply in the school lunchwith milk and without milk groups was 388 mg/day
and 147 mg/day, respectively, which showed that thedifference of the calcium supply between two groups
was just the amount of milk supply per day. One
possible reason of this could be that the source of
calcium intake by Japanese is not only from dairy
products but also from soybeans, fish, seaweed orvegetables, which are rich in calcium, protein,vitamin group and iron (29). A Japanese study
reported that young adults who had more frequencyof meal combining main staple, main dish and sidedish were greater consumption of calcium (24).
Indeed, the habitual intake of dairy products
including milk among participants in school lunchwith milk was more than those in without milk, while
the habitual other vegetables, mushrooms and fish
intakes by participants in the school lunch without
milk group were higher than those in the school lunchwith milk group. In other words, when the intake ofcalcium-rich food is sufficient, milk in school lunch
may be dispensable for the calcium intake adequacyin adolescents. In addition, these foods are cookedwith salt seasoning, which was reported as the main
source of sodium in the Japanese diet (35). This may
partly explain the current result that daily intakes ofniacin, folate and sodium may be higher among
participants in the school lunch without milk group.
The percentage of individuals not drinking milk
at home (35%) in this study was similar to that in a
Japanese previous study (36), and the difference indaily milk intake between the two groups of thisstudy (about 84 ml/EER) was less than 50% of theamount of milk (200 ml) provided in the school lunch.
Milk was consumed by 65% of the present study
participants at home. Therefore, the amount of daily
milk intake was mainly influenced by the amount of
milk consumed at home. Similar results have been
observed in a British study that compared dietaryintake according to lunch type (school meal vs.
packed meal). In that previous study, students that ate
the school meal consumed more milk than thoseeating packed lunch during school lunchtime,
although this difference was not observed in overall
nutrient intake (37). These results suggest that the
influence of the home/family environment is stronger
than that of the school environment on milk
consumption. Additionally, previous studies reported
that the diet of adolescents was influenced by theirparents, including the home environment (38, 39).
These may partly explain the current result that thenutrition adequacy among female junior high school
students was not likely to be affected by the school
lunch with or without milk. In other words,
nutritional adequacy among adolescents might beinfluenced by the home environment including
household income, parent’s nutrition knowledge,
employment, and dietary intake. Another study has
shown that the prevalence of inadequate nutrient
intake was clearly higher on a non-school day than aschool day for almost all nutrients among Japaneseelementary school and junior high school students(18). These results, consistent with our findings,
demonstrate that school lunches may havecontributed to the dietary intake quality duringadolescence and dietary intake may have been
influenced by the dietary habits at home rather thanschool.
Several limitations of this study need to bementioned. First, the participants were selected fromthree schools in Kanto urban region in Japan, not a
random selection. Also, there were several
demographic difference between the two groups,
which indicates the probability of that our results
might be influenced by the difference in thosecharacteristics. However, the participants in theschool lunch without milk group were of particularvalue, because they were enrolled among 0.1% ofschools in Japan that do not always provide milk
everyday on school lunch. Our selection of thesubjects was the only way to fulfil the purpose of thisstudy. Further studies are needed to validate ourfindings regarding the total Japanese adolescentpopulation. Second, we used BDHQ15y to assess
dietary intake although its ability to estimate dietaryintakes has been validated on limited foods andnutrients. Third, we could not include intake fromdietary supplements in the analysis because reliable
composition tables of dietary supplements were97

Milk in School Lunch and Nutritional Adequacylacking in Japan. Fourth, household income,education and nutritional habits of participants’parents were not investigated. Those factors werereported to influence children’s diets (38-40).
Although the employment status of participant’s
parents was examined in this study, this information
is not necessarily equivalent to household income.
Finally, we did not examine whether the participants
had their first menstruation, although the EAR foriron changes depending on menstruation. It wasreported that 585 out of 4769 female students(12.3%) aged 12-15 years did not have their first
menstruation and most of them were 12 years old(36). Because junior high school female students
were considered to have their first menstruation
shortly, they would need higher iron intake that takes
menstruation into consideration. Thus, we consideredthat the EAR for iron of female individuals withmenstruation were more appropriate to assess
nutritional adequacy in this study.

Health Nutr. 16(10):1827-1836. 2013.
6) Lamarche B. Review of the Effect of Dairy
Products on Non-Lipid Risk Factors for
Cardiovascular Disease. J Am Coll Nutr.
27(6):741S-746S. 2008.
7) Golden NH, Abrams SA. Optimizing Bone
Health in Children and Adolescents. Pediatrics.
134(4):e1229-e1243. 2014.
8) Bueno AL, Czepielewski MA. The importancefor growth of dietary intake of calcium andvitamin D. J Pediatr (Rio J). 84(5):386-394.
2008.
9) Heaney RP. Dairy and bone health. J Am Coll
Nutr. 28 Suppl 1:82S-90S. 2009.
10) Teegarden D, Proulx WR, Martin BR, et al. Peakbone mass in young women. J Bone Miner Res.
10(5):711-715. 1995.
11) Agostoni C, Rottoli A, Trojan S, Riva E. Dairy
products and adolescent nutrition. J Int Med Res.
22(2):67-76. 1994.
12) Parker CE, Vivian WJ, Oddy WH, Beilin LJ,
Mori TA, O’Sullivan TA. Changes in dairy foodand nutrient intakes in Australian adolescents.
Nutrients. 4(12):1794-1811. 2012.
13) Malik VS, Sun Q, Van Dam RM, et al.
Adolescent dairy product consumption and riskof type 2 diabetes in middle-aged women. Am J
Clin Nutr. 94(3):854-861. 2011.
14) Elwood PC, Pickering JE, Givens DI, Gallacher
JE. The Consumption of Milk and Dairy Foods
and the Incidence of Vascular Disease andDiabetes: An Overview of the Evidence. Lipids.
45(10):925-939. 2010.
15) Tremblay A, Gilbert J-A. Milk products, insulin
resistance syndrome and type 2 diabetes. J Am
Coll Nutr. 28 Suppl 1:91S-102S. 2009.
16) Keast DR, Hill Gallant KM, Albertson AM,
Gugger CK, Holschuh NM. Associations
between yogurt, dairy, calcium, and vitamin D
Intake and Obesity among U.S. children aged
8-18 years: NHANES, 2005-2008. Nutrients.
7(3):1577-1593. 2015.
17) Ministry of Education Science Sports andCulture. Survey for the School Lunch Program(in Japanese). http://www.mext.go.jp/b_menu/toukei/chousa05/kyuushoku/kekka/k_detail/icsF
iles/afieldfile/2017/01/18/1381230_1_2_1.pdf.
Published 2017. Accessed November 28, 2018.
18) 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(9):1523-1533.
2017.
19) Ministy of Health Labour and Welfare. Dietary
Reference Intakes for Japanese, 2015. Toyko:
Daiichi Shuppan Publishing Co., Ltd.; 2014.
20) The Counsil for Science and Technology
Ministry of Education Science Sports andCulture. Standard Tables of Food Composition in
Japan, 2015 (Seventh Edition). Tokyo: Official
Gazette Co-operation.; 2015.
21) Nozue M, Jun K, Ishihara Y, et al. How does
fortification affect the distribution of calcium
and vitamin B-1 intake at the school lunch forfifth-grade children? J Nutr Sci Vitaminol(Tokyo). 59(1):22-28. 2013.
22) Kohri T, Kaba N, Itoh T, Sasaki S. Effects of the
National School Lunch Program on Bone
Growth in Japanese Elementary School Children.
J Nutr Sci Vitaminol (Tokyo). 62(5):303-309.

CONCLUSION The results of this study showedthat habitual nutrient intake adequacy of Japanese
junior high school female students was independentof milk provision in school lunch, although milk may
help meet the standard requirements of school lunch
programs. Therefore, other factors such as thehome/family environment may affect the nutritional
adequacy among adolescent girls. Further studies areneeded to determine alternative factors that possibly
influence dietary intake among Japanese adolescent
girls.
Acknowledgement
The authors would like to express their thanks to N
Hiroki and A Noguchi who provided the school lunchmenu and their nutrients information and each school
teachers who distributed the questionnaires.
Conflict of interest and funding disclosure
The authors declare that they have no conflict ofinterests. This study was supported by Milk
Education Research Council and Japan Daily
Association.
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99

Asian Journal of Dietetics, 2019

ORIGINAL
Science-based Ratings of Safety and Effectiveness of Ingredients ofHealth Foods Distributed in Japan Differ among Health Food Categories
Hiroko Hashida1, Mayumi Okuma1, Fumio Shimura1, Yuko Yamazaki2*

1

Department of Food and Nutritional Sciences, Graduate School of Human Life
Sciences, Jumonji University, 2-1-28, Sugasawa, Niiza, Saitama 352-8510, Japan.
2
Department of Food and Nutrition, Faculty of Human Life. Jumonji University,
2-1-28, Sugasawa, Niiza, Saitama 352-8510, Japan.
(Received October 1, 2019)
ABSTRACT Background and purpose. Health foods are increasingly popular in Asian
countries including Japan. Professionals such as dietitians have a role to help consumers
use health foods based on scientific evidence on safety and effectiveness in order toprevent health or economic problems. This requires knowledge and utilization of healthfood legal systems and reliable information sources. Health foods in Japan are divided
into “Food with Health Claims” (FHC) as defined in the Health Promotion Act etc. and“So-called health foods” treated as general foods without legal regulations. FHC arefurther categorized into “Foods with Nutrient Function Claims” (FNFC), “Foods forSpecified Health Uses” (FOSHU), and “Food with Function Claims” (FFC). There may
be differences, as yet unknown, among categories in the safety and effectivenessevaluation of health food ingredients distributed in Japan. The verification of thesedifferences was considered to be useful for nutrition practice activities in Asia and is the
subject of the present study. Method. The safety and effective evaluation of health foodingredients in each category, FNFC, FOSHU, and “Popular Health Foods in Japan”(PHFJ), were compared and examined based on the ratings in the book version of the
Natural Medicine Comprehensive Database (NMCD). In order to enable non-parametricstatistical analysis, we converted the language ratings (nominal variables) by NMCD torating scores (ordinal variables). Results. The ratio of ingredients unlisted in the NMCD
was significantly higher for FOSHU. The average rank of FNFC ingredients was
significantly higher in safety, effectiveness, and total rating scores than those of FOSHU
and "PHFJ without FNFC+FOSHU" ingredients, but there was no significant difference
between FOSHU and PHFJ. The average rank of ingredients of “FFC in PHFJ” wassignificantly higher in safety, effectiveness, and total rating scores than those of “nonFHC in PHFJ”. Ingredients of Health foods distributed in Japan differed in their safety
and effectiveness assessments by NMCD due to differences in legal regulations andsystems. Also, the reliability of scientific evidence on safety and effectiveness seemed
to be related to sales. Conclusion. The findings obtained in this study would serve as areference for Asian professionals to know the Japanese health food regulatory systems
and promote the use of health food based on scientific evidence on safety andeffectiveness. In addition, the findings would be useful for Asian countries to develop
health food systems.
Keywords: health food, scientific evidence, safety, effectiveness, legal systems,
category

INTRODUCTIONIn Asian countries, including Japan, there has
been increasing attention to a variety of foods thatare manufactured, sold, and used with suggestions
or claims to be useful for health maintenance andpromotion (1-4). These new kinds of foods arecollectively called health foods in Japan (5, 6).

Health foods, however, are sometimes associatedwith health or economic problems because of theirdiversity in terms of quality, safety andeffectiveness (7, 8). The safe and secure use ofhealth foods without problems requires consumer
behaviour based on scientific information on safety
and effectiveness. In turn, experts such as dieticiansin charge of nutrition practice activities are required
to have basic knowledge and related skills as
information providers (4, 7). Legal systems ofhealth foods and re liable sources of information are
also key principle for providing fair and impartial
information to consumers.
In Japan, health foods are classified into “foods
with health claims” (FHC) stipulated by the Health*To whom correspondence should be addressed:
mitikawa@jumonji-u.ac.jp
Abbreviations: FHC, Foods with Health Claims;
FNFC, Foods with nutrient function claims;
FOSHU, Food for specified health uses; FFC,
Foods with Function Claims; PHFJ, popular healthfoods in Japan; NMCD, Natural Medicines
Comprehensive Database100Safety and Effectiveness of Health Food Categories

Promotion Act (7, 8) and so-called health foods thatfall under general foods. Currently, FHC are further
categorized into "Foods with Nutrient Function
Claims" (FNFC), "Foods for Specified HealthUses" (FOSHU), and "Food with Function Claims"(FFC) (4, 5, 8, 9).
FNFC products are taken for the purpose of
supplementing/complementing
nutritional
ingredients when normal dietary intake is difficult
due to aging, disorders in eating habits, etc. FNFC
is under a legal system of standard regulation. Thus,
to sell FNFC products, it is necessary to comply
with government standards established from solidand extensive scientific evidence that has been
historically accumulated on safety and effectiveness.
Products that meet the standards can claim specified
nutrient functions as FNFC (4, 10, 11).
FOSHU products contain some specificingredients and can claim by labeling that those whotake them for specified health purposes in their daily
diets can expect the purposes. FOSHU is under alegal system of individual approval. In order to sell
FOSHU products, the labeling of health claims must
be approved by the Commissioner of Consumer
Affairs Agency. The labeling is approved, as a
general rule, through science-based strict screening
by the government regarding the safety andeffectiveness of each product (7, 12).
FFC products can be labeled with function claims
based on scientific evidence under the responsibilityof each food business operator. Because FFC isunder a legal system of notification. Information on
the evidence supporting the safety and effectivenessof the product must be submitted to theCommissioner of Consumer Affairs Agency before
the product is placed on the market. FFC products
are not individually pre-approved by thegovernment unlike FOSHU and also do not comply
with the strict standards established by thegovernment unlike FNFC (4, 12). This status issimilar to that of health foods other than FHC
products in that their safety and effectiveness areunder self-assessment, do not necessarily meet thestandards established by the government, and havenot been evaluated by the government.
In a general sense, health foods that comply withthe governmental standards or approved by thegovernment are presumed to be safer and more
effective than those that do not. However, as far as
we know, this speculation has not been verified andhas to be resolved. Resolving this issue may bebeneficial for nutrition practitioners in Asian
countries to provide information on the safe andsecure use of health foods.
Based on these backgrounds, we examined andcompared how the safety and effectiveness ofingredients were evaluated for each category ofhealth foods distributed in Japan. The categories ofhealth food ingredients investigated were those of
FNFC, FOSHU, and popular health food in Japan(PHFJ). The safety and effectiveness of health foodingredients in each category were compared andexamined based on the evaluation by the bookversion of the Natural Medicines Comprehensive
Database (NMCD). For comparison between
categories by nonparametric statistical analysis, weconverted language ratings (nominal variables) by
NMCD to rating scores (ordinal variables). Throughthese procedures, we objectively demonstrated an
intuitive prediction that health foods that comply
101with or are approved by government standards aresafer and more effective than those that do not. The
knowledge gained will be useful for the practice of
Asian nutrition specialists and for the developmentof health food systems in Asian countries.
METHODS
1. Construction of ingredient lists by health foodcategories
To find the terms that correspond to ingredientsin the original lists written in Japanese, we
consulted the following information resources (13,14). The English names of the ingredients in the lists
shown below match the names used in NMCD
monographs. In this paper, the notation ofcomponent, material, and ingredient, etc. are unified
into “ingredient”.
1) Ingredients of Foods with Nutrient Function
Claims (FNFC)
As of July 2019, the ingredients of FNFC
approved for nutrient function claims are as
follows: n-3 fatty acids, 6 minerals (zinc, potassium,
calcium, iron, copper, magnesium), and 13 vitamins(niacin, pantothenic acid, biotin, vitamin A, vitamin
B1, vitamin B2, vitamin B6, vitamin B12, vitaminC, vitamin D, vitamin E, vitamin K, folic acid) (10).
A list of these nutritional ingredients wasconstructed according to the criteria described
below.
2) Ingredients of Foods for Specified Health Uses
(FOSHU)
A list of approved FOSHU products (February 12,2019 Final revision: Excel file) was downloaded
from a webpage on administrative guidance of foodlabeling under the Consumer Affairs Agency of the
Cabinet Office (15). In this FOSHU product list,
1,064 products are shown in ascending order of
permission date with serial numbers, product names,
applicants, types of food. Other items shown are as
follows: ingredients involved in health functions(also simply described as ingredients in this report),
display contents with permission, intake
instructions, standard daily intake amount,classification, permission day, permission number.
Based on this 1,064-product list, we haveconstructed a FOSHU ingredient list with 64
ingredients, using the Excel sorting function to sortingredients of the 1,064 products and consolidate
duplicate ingredients into one. This 64-ingredient
list was further cleaned up and subjected tostatistical analysis with the addition of information
on safety and effectiveness as described below.
3) Ingredients of Popular Health Foods in Japan(PHFJ)The popularity of a health food is probably
reflected in its sales amount. Therefore, in this paper,
we treated health food ingredients with high annual
sales as popular health food ingredients in Japan. In
particular, ingredients published in the annual
magazine “Health Food Report®” (16) were used
for list construction. Since the initial list thus
constructed contained ingredients of FNFC andFOSHU, these ingredients were excluded to gain
the PHFJ ingredient list composed of FFC and nonFHC ingredient
2. Collection and processing of information on theevaluation of safety and effectiveness of health foodingredients by NMCD monographWe searched information on the safety andeffectiveness of health food ingredients using theSafety and Effectiveness of Health Food Categories

book version of NMCD (17), a collection ofmonographs titled by ingredient names. NMCD is
excellent in quality and quantity as a health foodingredient database, and is characterized by a safety
and effectiveness rating (18). For the convenienceof statistical analysis, ratings by language (nominal
variables) in NMCD were converted into ratingscores (ordinal variables) as previously reported(18). In brief: Likely Safe (2), Possibly Safe (1)Possibly Unsafe (-1), Likely Unsafe (-2), andUnsafe (-3). Similarly: Effective (3), Likely
Effective (2), Possibly Effective (1), Possibly
Ineffective (-1), Likely Ineffective (-2), Ineffective(-3). A rating score of “0” was given to the language
ratingof“INSUFFICIENTRELIABLEEVIDENCE to RATE”. Ingredients unlisted in
NMCD and those with rating of “insufficientreliable information available” were not assigned
rating scores and were excluded from statisticalanalysis.
In adding rating scores to the lists for eachcategories of ingredients, a few more considerations
were taken into account. An ingredient with a higheffectiveness rating but a low safety rating cannot
be used safely and securely. Therefore, the total
score, the sum of safety and effectiveness scores,
was regarded as an index of usefulness. For thesafety rating, evaluation by intake of the health food,
dietary supplement or drug was selected. When therating in NMCD was on oral ingestion with theamount of ordinary food, the rating score wasdecreased by 1 point.
The effectiveness ratings added in the lists were
those for health and medical uses such as effects onbody structures and functions other than simple
nutrient supplementation effects, and reduction of
disease risks. The effectiveness of FNFC andFOSHU ingredients were selected only for NMCD
ratings on functions approved or specified under thegovernment regulation in Japan. When theeffectiveness rating of PHFJ ingredients involve awide range of functions, we selected the healthpurpose with the highest rating.
3. Statistical comparison between health foodcategories of the safety and effectiveness rating ofingredientsResults of mean rating score were expressed asmean ± standard deviation. In the comparison of thenumber of ingredients listed or unlisted in NMCD,
when there was a significant difference in chisquare test, residual analysis was performed. In thecomparison of the scores among 3 groups, when
there was a significant difference in the KruskalWallis test, the Steel-Dwass test was subsequently
performed. In addition, the Mann-Whitney test was
performed to compare 2 groups. BellCurve for
Excel version 3.20 (Social Survey ResearchInformation Co., Ltd.) software was used.

Table 1. Ingredients of Foods with Nutrient Function Claims (FNFC)
Rating score
EffectivenessNo.

Nutrient

1

n-3 Fatty acid

2

-

-

2

Zinc

2

1

3

3

Potassium

2

1

3

4

Calcium22

4Development of bone and teeth.

5

Iron

2

3

5

6

Copper2

2

4

Necessary in the red blood cell formation.
Form red blood cells and helps the proper function of many body enzymes andbone formation.

7

Magnesium235Development of bone and teeth. Maintain proper blood circulation, and helps
proper function of many body enzymes and energy generation.

8

Niacin2

2

4Maintain skin and mucosa health.

9

Pantothenic acid

2

3

5

Maintain skin and mucosa health.

10

Biotin2

2

4Maintain skin and mucosa health.

11

Vitamin A2

3

5

Maintain vision in the dark. Maintain skin and mucosa healthy.

12

Vitamin B1

2

3

5

Produce the energy from carbohydrate and to maintain skin and mucosa health.

13

Vitamin B2

2

3

5

Maintain skin and mucosa health.

14

Vitamin B6

2

3

5

Produce energy from protein and to maintain skin and mucosa health.

15

Vitamin B12

2

3

5

Aids in red blood cell formation.

16

Vitamin C

2

3

5

Maintain skin and mucosa health and has anti-oxidizing effect.

17

Vitamin D

2

3

5

Promotes absorption of calcium in gut intestine and aids in the growth of bone.

18

Vitamin E

2

3

5

Protect fat in the body from being oxidized and to maintain the cell health.

19

Vitamin K

2

3

5

20

Folic acid

Maintain proper blood coagulability.
Aids in the red blood cell formation, and contributes the normal growth of the
fetus.

mean ± SD

SafetyNutrient Function Claims of FNFC *

Total

2

3

5

2.00 ±

2.58 ±

4.58 ±

0.00

0.69

0.69

Maintain skin
Maintain normal taste and helps to maintain healthy skin and mucous
membranes.
Maintain proper blood pressure.

Note: This table should not use for the purpose of providing information to consumers because the information is very limited. Refer to the NMCD for
details of ingredient.
*: "Nutrient Function Claims of FNCN" are shown in simplified forms (reference 10, 11).

102

Safety and Effectiveness of Health Food Categories

RESULTS
1. Lists of Health Food Ingredients with
Information on Safety and Effectiveness1) Ingredients of Foods with Nutrient Function
Claims (FNFC)
Nutrient function claims of FNFC are regulatedby the Food Labeling Law, and 20 nutrients are
currently approved to be used as functional
Table 2.
No.

ingredients in FNFC products. NMCD contains
monographs on all these ingredients except n-3 fatty
acids. For n-3 fatty acids, monographs of theequivalent ingredients DHA (docosahexaenoicacid), EPA (eicosapentaenoic acid), fish oil, and αlinolenic acid were available instead.

Ingredients of Foods for Specified Health Uses (FOSHU)
Functional ingredient 【NMCD monograph name】

Rating score
SafetyEffectiveness

Total

Health claims approved as FOSHU *1

1

Agar 【AGAR】

1

-

-

Gastrointestinal conditions

2

Reduced molecular weight sodium alginate 【ALGIN】

1

-

-

Gastrointestinal conditions, Blood cholesterol level

3

Barley young leaf, barley 【BARELY】

2

-

-

Gastrointestinal conditions, Blood sugar levels

4

Plant sterol 【BETA-SITOSTEROL】

2

2

4

Blood cholesterol level

5

Bifidobacteria 【BIFIDOBACTERIA】

2

1

3

Gastrointestinal conditions

6

Psyllium seed coat-derived dietary fiber 【BLOND PSYLLIUM】

2

3

5

Gastrointestinal conditions

7

Calcium 【CALCIUM】

2

2

4

Osteogenesis (Reduction of disease-risk)

8

Calcium hydrogen phosphate / CPP-ACP (Casein phosphopeptide –amorphous calcium phosphate as calcium) / POs-Ca (Phosphorylated
oligosaccharide calcium) 【CALCIUM】

2

1

3

Dental health9

Lactotripeptide 【CASEIN PEPTIDE】

-

0

-

Blood pressure

10

Chitosan 【CHITOSAN】

1

0

1

Blood cholesterol level

11

DHA・EPA 【DHA・EPA】*2

2

0

2

Blood triacylglycerol level

12

Green tea-derived fluorine 【FLUORIDE】

2

3

5

Dental health13

Fructo-oligosaccharides 【FRUCTO-OLIGOSACCHARIDES】

1

0

1

Gastrointestinal conditions

14

Gamma-aminobutyric acid (GABA) 【GABA】

-

-

-

Blood pressure

15

Tea catechins, Tea polyphenol 【Green tea】

1

1

2

Blood cholesterol level

16

Guava leaf polyphenol 【GUAVA】

1

-

-

Blood sugar levels

17

Monoglucosyl hesperidin 【HESPERIDIN】

1

-

-

Blood triacylglycerol level, Blood pressure

18

Kudzu flower extract (Tectorigenin) 【KUDZU】

1

-

-

Body fat19

Lactobacillus 【LACTOBACILLUS】

2

2

4

Gastrointestinal conditions

20

Medium chain triglycerides 【MEDIUM CHAIN TRIGLYCERIDE】

2

-

-

Body fat

21

Bacillus subtilis K-2 (spore) 【NATTOKINASE】

1

-

-

Gastrointestinal conditions

22

Quercetin glycoside (as isoquercitrin) 【QUERCETIN】

1

-

-

Body fat23

Soy oligosaccharide, Soy isoflavone, Soy protein, Beta conglycinin 【SOY 】

2

1

3

Gastrointestinal conditions, Osteogenesis, Blood
triacylglycerol level, Blood cholesterol level

24High molecular weight black tea polyphenol (as theaflavin) 【TEAFLAVIN】

-

-

-

Blood triacylglycerol level

25

Vitamin K2 (menaquinone-4, menaquinone-7) 【VITAMIN K】

2

0

2

Osteogenesis

26

Wheat bran / Whole wheat and wheat hulls-derived dietary fiber 【WHEAT
BRAN】

2

1

3

Gastrointestinal conditions

27

MBP® (Milk Basic Protein) (as cystatin 20μg） 【WHEY PROTEIN】

2

-

-

Osteogenesis

28

Xylitol 【XYLITOL】 *2

Dental healthmean ± SD

12

3

1.56 ±
0.51

1.19±
1.05

3.00±
1.25

Note: This table should not use for the purpose of providing information to consumers because the information is very limited. Refer to the NMCD for details of ingredient.
*1: "Health claims approved as FOSHU" are shown in simplified forms (reference 11, 15).
*2：Approved for products at contain mixture functional ingredients (DHA and EPA), (Xylitol, maltitol, calcium hydrogen phosphate, and fukuronori extract).

103Safety and Effectiveness of Health Food Categories

Table 3. Ingredients of FOSHU products unlisted in NMCD monographs
No.

Functional ingredient

No.

Functional ingredient1

Acetic acid19

Lactulose

2

Apple-derived procyanidins20

L-arabinose

3

Broccoli, cabbage-derived S-methylcysteine sulfoxide(natural amino acid)21

Maltitol

4

Chinese gutta percha (as geniposidic acid)22

Neokotalanol
Nori (Porphyra yezoensis ) oligopeptide (as Ala-LysTyr-Ser-Tyr)
Oolong tea polymerized polyphenols (asoolonghomobisflavan B) *5

Chlorogenic acids (as 5-caffeoylquinic acid)23

6

Coffee bean mannooligosaccharide (as mannobiose)

24

7

Erythritol

25

Palatinose

8

Eucalyptus extract (as macrocarpal C)

26

Polydextrose

9

Fukuronori (Gloiopeltis furcata ) extract (as funoran)

27

Polyglutamic acid10

Galacto-oligosaccharides

28

11

Globin protein degradation product (as Val-Val-TyrPro)

29

12

Glucosyl ceramide

30

Sardine peptide (as Val-Tyr)13

Highly cross-linked phosphate cross-linked starch (asdietary fiber)

31

Sesame peptide (as Leu-Val-Tyr)

14

Indigestible dextrin

32

Streptococcus thermophilus

15

Indigestible recrystallized amylose (as α-1, 4 glucan
aggregate)

33

Water-soluble corn bran fiber

16

Isoleucyltyrosine

34

Wheat-derived albumin

17

Isomaltooligosaccharides

35

Xylooligosaccharide18

Lacto-sucrose

36

Yang long flavonoids (as hyperoside and isoquercitrin)

Products of propionic acid bacteria (as 1, 4dihydroxy-2-naphthoic acid)Royal jelly-derived peptides (Val-Tyr, Ile-Tyr, IleVal-Tyr)*: Although there is the NMCD monograph of oolong tea, it was excluded from Table 2 because there was no description as
oolonghomobisflavan.

Table 1 shows the NMCD evaluation of the safety
and effectiveness of each ingredient as rating scores(ordinal variables) converted from ratings (nominal
variables) by the procedure above. In addition, thenutrient functions that were evaluated for
effectiveness are shown in simplified forms.
NMCD has rated all the 20 nutrient function
ingredients including n-3 fatty acid-equivalent fatty
acids as “likely safe”, thus the mean rating score of
the safety of FNFC ingredients was 2.00 ± 0.00.
Table 1 excludes the effectiveness rating of n-3
fatty acid-equivalent fatty acids. This is because themonographs provide no information on theeffectiveness of the allowed nutrient function
labeling to help maintain the skin. The effectivenessratings of 19 ingredients other than n-3 fatty acidequivalent fatty acids are tallied as follows:“Effective (rating score of 3; 13)”, “Likely Effective(rating score of 2; 4)”, and “Possibly Effective(rating score of 1; 2)”. Thus, the mean rating score± standard deviation was 2.58 ± 0.69. The total
mean rating score and standard deviation of the 19
ingredients were very high at 4.58 ± 0.69, of which
13 ingredients had the highest score of 5.
2) Ingredients of Foods for Specified Health Uses
(FOSHU)FOSHU products contain some ingredients for
specified health use and can be sold with labellingof health claims approved by the Commissioner ofConsumer Affairs Agency (7, 12). The official list
(last revised on February 12, 2019) of FOSHU
products, downloaded from the website of theConsumer Affairs Agency of the Cabinet Office,contained 1,064 products (15). Functional
ingredients of these 1,064 products were organized
and integrated into 64 ingredients by putting
together the same and similar ingredients.
Searching of the 64 ingredients by the English term,
converted from Japanese name using several
sources (13, 14), we found NMCD monographs
corresponding to 28 ingredients but not to theremaining 36 ingredients. The 28 ingredients forwhich monographs were found are listed in Table 2,
together with the rating scores derived from NMCD
ratings in nominal variables of the safety andeffectiveness. The effectiveness rating scores in thistable are limited to those for specified health uses
approved to the FOSHU products. Calcium is also
approved as a “reduction of disease-risk FOSHU”
other than “ordinary FOSHU” (11). Therefore, twohealth claims, osteogenesis and dental health, areincluded in Table 2.
104

Safety and Effectiveness of Health Food Categories

Table 2 shows the 28 FOSHU ingredients whosemonographs are contained in NMCD, and aconsiderable number of them have been used asfunctional ingredients in many FOSHU products asfollows: Chitosan (49 products), Tea catechin (45products), Lactobacillus (37 products), and others.
Twenty-five of the 28 ingredients were evaluatedfor safety by NMCD as follows: “Likely safe (ratingscore of 2; 14)”, “Possibly safe (rating score of 1;11)”. The mean safety score for the 25 ingredientswas 1.56 ± 0.51.
For 16 ingredients in Table 2, NMCD
monographs have rated the effectiveness of healthfunction claims approved for FOSHU products asfollows: “Effective (rating score of 3; 2)”, “Likely
Effective (rating score of 2; 4)”, and “Possibly
Effective (rating score of 1; 5)”. Five ingredients ofthe 28 ingredients were rated as “INSUFFICIENTRELIABLE EVIDENCE to RATE (rating score of0)” for the effectiveness in health functions
approved to for FOSHU products. Ratings for
effectiveness of 12 ingredients were not describedin NMCD monographs. The mean effectivenessrating score of the 16 ingredients was 1.19 ± 1.05.
In addition, the mean total score, the sum of safety
rating score and effectiveness rating score, was 3.00
± 1.25. Of the 36 ingredients unlisted in NMCD
monographs (Table 3), indigestible dextrin (toimprove gastrointestinal condition, blood sugar
levels, blood triacylglycerol level) had an
outstanding occupancy rate of about 36.2% (385products) as a functional ingredient used in FOSHU
products. Although FOSHU products areindividually approved through a fair and strict
governmental review, most of their functional
ingredients have not been monographed by NMCD
(56%: 36/64).
3) Ingredients of Popular Health Foods in Japan(PHFJ)The popularity of a health food is probably
reflected in its sales amount. Therefore, in this paper,
we handled health food ingredients with highannual sales as popular health food ingredients inJapan. In particular, ingredients enumerated in theannual magazine “Health Food Report®”, avaluable and concise information resource on thehealth food market status in Japan, were selected forlist construction.
Table 4 shows the top 49 PHFJ ingredients
enumerated in the “Health Food Report®” in orderof sales amounts, with English keywords forsearching NMCD monographs, along with NMCD
rating scores on their safety and effectiveness. This
table also shows the overlap between the top 49
PHFJ ingredients and FHC ingredients. We could
find NMCD monographs corresponding to 40
ingredients out of the 49 PHFJ ingredients (Table 4).
However, monographs matching “Multi-vitamin”,“Amino acids”, and “Vitamin B complex” wereundetectable, because these keywords did not
specify a single ingredient. Thirty seven of the 49
PHFJ ingredients were also used for health foods inany of the FHC category. (FNFC, FOSHU, and
FFC). According to NMCD monographs, the safetyof the 37 PHFJ ingredients are rated as follows intally: “Likely safe (rating score of 2; 17)”, “Possibly
Safe (rating score of 1; 20)”. The safety of gammaaminobutyric acid and ornithine was not described105

in the monographs. The mean safety score of the 37
ingredients was 1.46 ± 0.51.
For 36 ingredients in Table 4, NMCD
monographs have rated the effectiveness on healthfunction as follows: “Effective (rating score of 3;4)”, “Likely Effective (rating score of 2; 5)”,
“Possibly Effective (rating score of 1; 16)”,“INSUFFICIENT RELIABLE EVIDENCE to
RATE (rating score of 0; 10)”, and “Possibly
Ineffective (rating score of -1; 1)”. Ratings for
effectiveness of 4 ingredients were not described in
NMCD monographs. The mean effectiveness ratingscore of the 36 ingredients was 1.03 ± 1.00. In
addition, the mean total score, the sum of safety
rating score and effectiveness rating score, was 2.57
± 1.36.
“PHFJ without FNFC + FOSHU” in Table 4shows the PHFJ ingredients excluding those thatoverlap with FNFC and FOSHU. Of the 49
ingredients of PHFJ, 28 ingredients did not overlap
with FNFC or FOSH, 3 of which were unlisted on
the NMCD. For the remaining 25 ingredients, themean safety score was 1.32 ± 0.48, the mean
efficacy score was 0.81 ± 0.81, and the mean total
score was 2.25 ± 1.12.
2. Statistical comparison between health foodcategories of the safety and effectiveness rating ofingredients
Whether the ratio of the ingredients listed in
NMCD differed among health food categories was
performed by chi-square test and subsequent
residual analysis. As shown in Table 5, the ratio ofingredients unlisted in NMCD was found to besignificantly higher in FOSHU ingredients.
In Table 6, NMCD rating scores of ingredientswere statistically compared among health foodcategories. PHFJ ingredients were analyzed
excluding those that overlapped with FNFC andFOSHU ingredients ("PHFJ without FNFC+FOSHU"). The means of the safety, effectiveness,and total scores of the ingredients in each category
increased in the order of "PHFJ without
FNFC+FOSHU" < FOSHU < FNFC. The ratingscore, however, is an ordinal variable and notsuitable for testing the difference between the meanvalues. Therefore, we used the Kruskal-Wallis test,
an independent multi-group nonparametric test
method, and found that there were significant
differences in rating scores of ingredients among thethree categories FNFC, FOSHU, and "PHFJ
without FNFC+FOSHU" (Table 6). Multiple
comparisons of post-hoc by the Steel-Dwass
method showed that the average rank of FNFC
ingredients was significantly higher in safety,
effectiveness, and total rating scores than those of
FOSHU and "PHFJ without FNFC+FOSHU"
ingredients (Table 6). PHFJ consists of FHC(FNFC, FOSHU, and FFC) and legally undefined
health foods other than FHC (Table 4). FFC is alegally defined category of health foods but isneither approved by the government nor strictly
regulated by government standards. Thus, thecomparison may be meaningful between the FFC
included in PHFJ (“FFC in PHFJ”) and PHFJ
excluding FHC (“non-FHC in PHFJ”). As shown in
Table 7, the average rank of ingredient of “FFC in
PHFJ” was significantly higher in safety,
effectiveness, and total rating scores than those of“non-FHC in PHFJ”.

Safety and Effectiveness of Health Food Categories
Table 4. Ingredients of Popular Health Foods in Japan (PHFJ)
Ranking

Ingredient 【NMCD monograph name】 *1

Rating score

SafetyEffectiveness

Total

Symptoms described in theeffectiveness of NMCD

Overlapping with
FHC *2

1

Multi-vitamin 【UNLISTED】

2

Vitamin C 【VITAMIN C (ASCORBIC ACID)】

2

3

5

Vitamin C deficiency

AA

3

Vitamin E 【VITAMIN E】

2

3

5

Vitamin E deficiency

A

4

Aojiru (green juice) 【CABBAGE (Kale)】 *3

1

0

1

Cancer, etc.

5

Protein 【WHEY PROTEIN】

2

1

3

Athletic performance

B

6

Calcium 【CALCIUM】

2

3

5

Hypocalcemia

A, B

7

Enzyme (fermented plant extract) 【UNLISTED】

8

Collagen 【GERATIN】

1

0

1

Osteoarthritis

C

9

Dietary fiber 【BLOND PSYLLIUM (Dietary fiber)】

2

3

5

Constipation

B, C

10

Amino acid 【UNLISTED】

11

Lactic acid bacteria 【LACTOBACILLUS】

2

2

4

Rotaviral diarrhea

B, C

C

12

Blueberry 【BLUEBERRY】

1

-

-

13

Royal jelly 【ROYAL JELLY】

1

0

1

Hyperlipidemia

B

14

Aloe 【ALOE】

1

1

2

C

15

Ginkgo biloba 【GINKGO】

2

1

3

C

16

Turmeric 【TURMERIC】

1

1

2

Constipation
Age-related memory impairment,
etc.
Dyspepsia

17

Glucosamine 【GLUCOSAMINE SULFATE】

2

2

4

Osteoarthritis

C

18

Yeast 【BREWER'S YEAST】

1

1

2

Premenstrual syndrome

2

1

3

Coronary artery disease0

1

Postherpetic neuralgia

19

Sesame 【UNLISTED】

20

DHA 【DHA (DOCOSAHEXAENOIC ACID)】

B

21

Vitamin B complex 【UNLISTED】

22

Reishi 【REISHI MUSHROOM】

1

23

Astaxanthin 【ASTAXANTHIN】

1

-

-

24

2

1

3

-

-

-

26

EPA 【EPA (EICOSAPENTAENOIC ACID)】
Gamma-aminobutyric acid 【GABA (GAMMA-AMINOBUTYRIC
ACID)】
Chlorella 【CHLORELLA】

1

0

1

Fibromyalgia, Glioma

27

Korean ginseng 【GINSENG, PANAX】

1

1

2

Diabetes

28

Shijimi (fresh water clam) 【UNLISTED】

25

C

A, B, CAC

Coronary artery disease

A, B, C
B, C

29

Ginger 【GINGER】

2

1

3

Morning sickness

C30

Soy isoflavone 【SOY】

2

1

3

Breast cancer (prevention)

B, C

31

Dextrin (indigestible dextrin) 【UNLISTED】

32

Nattokinase 【NATTOKINASE】

1

0

1

Deep vein thrombosis

33

Hyaluronic acid 【HYALURONIC ACID】

-

-

-

34

Polyphenol 【COCOA】

2

1

3

35

Lutein 【LUTEIN】

2

2

4

Hypertension (as cacao
polyphenol)
Lutein deficiency

36

Agaricus 【AGARICUS MUSHROOM】

1

0

1

Chemotherapy

37

Olive 【OLIVE】

2

2

4

Constipation (as olive oil)38

Ornithine 【ORNITHINE】

-

-1

-

Athletic performance

C

39

Catechin 【GREEN TEA (Epigallo Catechin Gallate)】

1

1

2

Hyperlipidemia

B, C

B, C
B
C
B, C
C
C

40

Kudzu flower-derived isoflavone 【KUDZU】

1

0

1

Alcoholism, Angina

B, C

41

Vinegar 【APPLE CIDER VINEGAR】

1

0

1

Diabetes, Gastroparesis

B, C

42

Coenzyme Q10 【COENZYME Q-10】

2

2

4

Coenzyme Q-10 deficiency

43

Ceramide (N-acylsphingosine) 【UNLISTED】

44

Garlic 【GARLIC】

45

Placenta 【UNLISTED】

46
47

2

1

3

Hypertension

Propolis 【PROPOLIS】

1

0

1

Common cold

Maca 【MACA】

1

1

2

Sexual desire

48

French marine pine bark extract 【PYCNOGENOL】

1

1

2

Allergic rhinitis

49

Lactoferrin 【LACTOFERRIN】

1
1.46 ±
0.51
1.32±
0.48

1
1.03 ±
1.00
0.81 ±
0.81

PHFJ: mean ± SD
PHFJ without FNFC+FOSHU *4: mean ± SD

C
B, C

2
Hepatitis C
2.57 ±
1.36
2.25±
1.12

C

C
C

Note: This table should not use for the purpose of providing information to consumers because the information is very limited. Refer to the NMCD for details of ingredient.
*1: This is the order of top-selling rankings from the “Health Food Report®” (Reference 16), up to 49th. The NMCD monograph name is shown in 【】. The mixture ingredients
showed 【unlisted】 because it cannot be specified as one ingredient.
*2: Overlapping ingredients with FHC, A: FNFC, B: FOSHU, C: FFC.
*3: Aojiru with index number 16056 was described as “kale juice” in “Standard food composition table in Japan-2015- (7th revised edition)”.
*4: PHFJ ingredients excluding those that overlapped with FNFC and FOSHU ingredients.

106Safety and Effectiveness of Health Food Categories

Table 5. Comparison of the number of listed and unlisted health food ingredients in the three categoriesof the NMCD monograph
Listed( % )Unlisted

FNFC

20( 100 )

0(0)

P <0.001

Listed > Unlisted

FOSHU

28

(

44 )

36

(

56 )

P <0.001

Listed < Unlisted

PHFJ without
FNFC+FOSHU

24

(

86 )

4

(

14 )

P <0.01

Listed > Unlisted

Chi-square test *1

residual analysis *2( % )p<0.001*1,2: After the chi-square test, residual analysis was performed.

Table 6. Analysis of rating score of FNFC, FOSHU, and PHFJ without FNFC+FOSHU ingredients
Safety*1

Effectiveness*1

Total*1

mean ±SDn*2

average rank(n = 67)

FNFC

2.00 ± 0.00

20

20.00 x,a2.58 ± 0.69

19

12.79 b,c

4.58 ± 0.69

19

12.21 d,e

FOSHU

1.56 ± 0.51

25

34.74

x

1.19 ± 1.05

16

32.25

b

3.00 ± 1.25

15

29.80 dPHFJ without
FNFC+FOSHU

1.32 ± 0.48

2242.84 a0.81 ± 0.81

21

37.19 c2.25 ± 1.12

20

37.60 eKruskal-Wallis test *3

mean ±SDaverage rank
n*2
(n = 56)

mean ±SDn*2

average rank(n = 54)

p < 0.001

p < 0.001

p < 0.001*1: Data are the mean ± standard deviation and average rank.
*2: The score of ingredients unlisted in NMCD was regarded as a missing value and excluded from statistical analysis.
*3: The Kruskal-Wallis test was performed on the differences between categories for each rating score, and the Steel-Dwass test was used for multiple
comparisons between three groups with significant differences. Same superscript letters are significantly different.; a, b, c, d, e: (p < 0.001); x: (p < 0.01).

Table 7. Analysis of rating score of FFC and non-FHC in PHFJ
Safety *1
mean ±SDn *2

FFC in PHFJ

1.54 ± 0.52

13

non-FHC in PHFJ *3

1.00 ± 0.00

9

Mann–Whitney U test *4

Effectiveness *1
average rank(n = 22)

mean ±SD

n *2

9.00

1.08 ± 0.86

13

13.00

0.38 ± 0.52

8

p < 0.01

Total *1

average rank(n = 21)

average rank(n = 20)

mean ±SD

n *2

8.00

2.83 ± 1.03

12

8.00

13.00

1.38 ± 0.52

8

12.00

p < 0.05

p < 0.01*1: Data are the mean ± standard deviation and average rank.
*2: The score of ingredients not listed in NMCD was regarded as a missing value and excluded from statistical analysis.
*3: PHFJ excluding FHC (FHC: Food with Health Claims, categorized into FFC, FOSHU and FFC).
*4: Mann–Whitney U test was performed on the differences between categories.

We further investigated the relationship between
the rating of health food ingredients and their sales
amounts. For PHFJ ingredients overlapping withFNFC and FOSHU (“FNFC+FOSHU in PHFJ”),
strong positive correlations were found between
effectiveness, and total rating scores and sales
amounts (r = 0.76, r = 0.74, respectively) (Fig. 1).
However, such correlations were not observed for
PHFJ ingredients other than "PHFJ without
FNFC+FOSHU".

and effectiveness in order to prevent health or
economic problems. This requires knowledge andutilization of health food legal systems and reliable
information sources. As described in the
Introduction, in Japan, due to differences in legal
regulations, health foods are classified as FHC andso-called health foods, and FHC is further
categorized as FNFC, FOSHU, and FFC (4, 5, 8, 9).
FNFC, FOSHU, and FFC are under legal systems ofstandard regulation, individual approval, andnotification, respectively. The status of FFC issimilar to that of health foods other than FHC.
Because both products neither necessarily comply
the standards established by the government nor
receive evaluation by the government for theirsafety and effectiveness. Therefore, the safety andeffectiveness of health food products may differ

DISCUSSION
Health foods are increasingly popular in Asian
countries including Japan (1-4). Professionals suchas dietitians have a role to help consumers use
health foods based on scientific evidence on safety
107Safety and Effectiveness of Health Food Categories

among health food categories. In turn, the safety andeffectiveness of health food products are probably
most strongly influenced by the safety andeffectiveness of ingredients. However, so far, it isunclear whether the evaluation of safety andeffectiveness of health food ingredients distributedin Japan differs among categories. Based on these
considerations, we examined and compared how thesafety and effectiveness of ingredients were
evaluated for FNFC, FOSHU, and popular healthfoods including FFC but excluding FNFC andFOSHU. For this purpose, the evaluations by
NMCD monographs of each ingredients wereextensively and deeply examined. NMCD is a wellestablished information source of health foodingredients with an abundant number (more than
1,100) of listed ingredients and with excellent
quality characterized by its ratings of the safety andeffectiveness of ingredients (17).
In this study, we used a unique approach ofassigning a rating score to the rating of safety andeffectiveness in NMCD monographs of each
ingredient. This enabled statistical comparison andexamination between categories of health foodingredients, so that some objective findings
described in the result2 were obtained. Here, wewill discuss these objective findings and will not

mention other interesting but detailed findings in
the list of health food ingredients by category.
As shown in Table 5, the ratio of ingredients
listed in NMCD monographs was significantly
lower in FOSHU ingredients than FNFC and "PHFJ
without FNFC+FOSHU" ingredients. This situation
is probably due to both characteristics of FOSHU
products and NMCD editorial policy. FOSHU
products are individually reviewed strictly by thegovernment for safety and effectiveness andallowed to be labeled for specified health uses (7,12). Each FOSHU product thus guarantees to someextent the safety and effectiveness of the productper se and its ingredients. Planning anddevelopment of almost all FOSHU products havebeen achieved by Japanese companies, from basic
research on their functional ingredients to productdesign. Distribution and use of FOSHU products arealso almost limited to Japan.
On the other hand, NMCD is a database compiled
by a United States civilian agency. In the US, healthclaims by foods, such as structure/function claims,
general well-being claims, and nutrient deficiency
disease claims, are exclusively permitted to dietary
supplements defined by the Dietary Supplement
Health and Education Act of 1994 (19). Unlike

Fig 1. Correlation between rating score and market size about PHFJ
"Sales amount" was referred to Reference 16. "Rating score" was based on the data in Table 4.

108

Safety and Effectiveness of Health Food Categories

FNFC and FOSHU in Japan, dietary supplements
are self-assessed for safety and effectiveness, so thatthey do not necessarily meet governmentestablished standards and also are not evaluated by
the government. NMCD evaluates the safety andeffectiveness of dietary supplements with thesecharacteristics from a third-party perspective.
NMCD is an extremely valuable information source
for consumers to use dietary supplements safely andsecurely based on scientific evidence. Therefore, it
is natural that the target of evaluation by NMCD ismainly the ingredients of dietary supplements thatare widely distributed in the United States, not the
ingredients of FOSHU that are locally distributed inJapan.
FNFC products can be marketed in compliancewith governmental standards, which are establishedbased on historically and internationally recognizedstrong and extensive evidence on safety andeffectiveness. Therefore, it can be easily assumed
that the safety and effectiveness of the FNFC
ingredients are higher than those of the othercategories. In this study, we could objectively
confirm the validity of this assumption. Post-hoc
multiple comparisons by the Steel-Dwass procedure
subsequent to the Kruskal-Wallis test showed thatthe average rank of FNFC ingredients was
significantly higher in safety, effectiveness, andtotal rating scores than those of FOSHU and "PHFJ
without FNFC+FOSHU" ingredients (Table 6).
Since FOSHU products are approved through theindividual and strict review by the government (7,12), each FOSHU ingredient is guaranteed to someextent for safety and effectiveness. However, there
was no statistically significant difference between
the safety, effectiveness and total scores of the
FOSHU ingredients and those of the "PHFJ without
FNFC+FOSHU" ingredients (Table 6). Again, oneof the reasons for this is probably that FOSHU isunique to Japan and NMCD is a database
constructed by a civilian institution in the US. Most
FOSHU ingredients are unlisted in NMCD
monographs as shown in Table 5, even though
FOSHU ingredients have scientific bases for theirsafety and effectiveness to endure various criticism
upon strict approval reviews. The fact that many
academic papers on FOSHU ingredients are written
in Japanese may also make FOSHU ingredientsdifficult to be properly evaluated.
The Mann–Whitney U test showed that the
average ranks of ingredients of “FFC in PHFJ” weresignificantly higher in safety, effectiveness, andtotal rating scores than those of “non-FHC in PHFJ”(Table 7). In other words, within the top 49 healthfoods by sales, FFC ingredients were superior interms of these evaluation indicators to theingredients of health foods legal undefined. The
results in Table 7 suggest that food business
operators are steadily committed to the research,development, and product design of FFC based on
scientific bases of safety and effectiveness rather
than the experience and the oral tradition with poor
evidence in order to fulfill their responsibilities.
Sales amounts of health foods possibly reflect
consumer preference and consumption behavior.
Interestingly, upon analysis from this point of view,
we found positive correlations between sales
amounts and effectiveness rating scores of PHFJ

ingredients (Fig. 1). Further sub-analysis revealed
positive correlations between the sales amounts andthe safety, effectiveness, and total rating scores ofingredients of PHFJ overlapping with FNFC andFOSHU (Fig. 1). Such correlations were notobserved for PHFJ ingredients other than FNFC andFOSHU ingredients. According to these results,
many consumers are presumably taking
consumption behavior based on the scientific basisof safety and effectiveness of health foods.
Although details are unknown, information on the
category of health foods, health claims in labeling,
consultation with advisory staff such as dietetics,
and other factors may facilitate consumer's
informed-choices.
In this study, we have obtained new objective
findings about Japanese health foods by assigning
rating scores for the safety and effectiveness ratingsof each ingredient in NMCD monographs. The
NMCD is a comprehensive database constructedfrom extensive surveys of research papers on theeffects of health food ingredients on human subjects
and provides rating based on predetermined criteria
for study design and scale. The information
provided by NMCD, including interactions withdrugs, is comprehensive and suitable for providing
various information to consumers. In addition toproviding information to consumers about eachproduct, NMCD can be used to statisticallyunderstand the state of health food ingredients as inthis study. The Internet version of NMCD (20),where information is constantly updated, isconvenient for providing information to consumers,
but in this study, the book version was used from theviewpoint of the invariance of information.
The overall evidence in this study suggests that
health foods distributed in Japan differed in theirsafety and effectiveness ratings by NMCD due todifferences in their legal regulations and systems.
Also, the safety and effectiveness ratings also
seemed to relate to sales amounts. Information on
the category of health foods, health claims inlabeling, consultation with advisory staffs, andothers may facilitate consumer's informed-choices.
In Asian countries where health foods are gaining
popularity, specialists such as dietitians have a roleto help consumers use health foods based on
scientific evidence on safety and effectiveness toprevent health and economic problems. The
findings obtained in this study would serve as areference for Asian professionals to understand theJapanese health food regulatory systems andpromote the use of health food based on scientificevidence on safety and effectiveness. In addition,
the findings would be useful for Asian countries todevelop health food systems of their own.
Acknowledgements:
We would like to thank Andrew R. Durkin,
Professor Emeritus of Indiana University,
Bloomington, IN, USA, for his careful editing of the
English of this article.
Conflict of interests:
The authors declare no conflict of interests
regarding the publication of this article.

109

Safety and Effectiveness of Health Food Categories

REFERENCES
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Health Industry Marketing News ONLINE.
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3.5 trillion Japanese yen in 3 countries in
FY2017)"http://www.him-news.com/news/
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2) Takeda T. "Overseas expansion of functional
food business in TPP era", Seibutsu-kogaku
kaishi. 94: 610-614. 2016. (in Japanese)3) The Health Industry News. "The health foodmarket increased 2% to 1,227 Billion Japaneseyen. The demand for the elderly is not high.
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Ide R. Foods with Health Claims: Current
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stf/seisakunitsuite/bunya/kenkou_iryou/shoku
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7) Umegaki K. Positive and Negative Aspects ofFood with Health Claims in Japan. J Nutr Sci
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8) Umegaki K. Safety and Effectiveness of Foodwith Health Claims and Its Effective Use. Jpn.
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10) Consumer Affairs Agency. <For business
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beling/food_labeling_act/pdf/food_labeling_act_180518_0001.pdf. 50-51. May 2018. (inJapanese). Accessed October 31, 2019.
11) Yamada K, Sato-Mito N, Nagata J, Umegaki K.
Health claim evidence requirements in Japan.
J Nutr. 138: 1192S-8S. 2008.
12) Consumer Affairs Agency, Government ofJapan. (Guidance for Industry) The system of"Foods with Function Claims" has beenlaunched! (Pamphlet). https://www.caa.go.jp/
policies/policy/food_labeling/information/
pamphlets/pdf/151224_2.pdf. December 2015.
p 3. Accessed October 31, 2019.
13) National Institutes of Biomedical Innovation,
Health and Nutrition, “Information system onsafety and effectiveness for health foods”.
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(in Japanese)
15) Consumer Affairs Agency. List of licenses for“food for specific health use (approved) [Excel
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19) Food and Drug Administration; FDA.
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2019.

110

Asian Journal of Dietetics, 2019

ORIGINAL
Evaluation of Factors Affecting Food Wastage among Hospitalized Patients on Therapeutic Diet
at Ministry of Health (MOH) Hospitals
Norshariza J1*, Siti Farrah Zaidah MY2, Basmawati B3, Leow C3, Lina I4, Norafidza AAP5,
Khalizah J6, John Kong JP7, Lim SM8
1

National Cancer Institute, Putrajaya
Disease Control Division, Ministry of Health Malaysia
3
Hospital Tuanku Jaafar, Seremban4
Hospital Melaka, Melaka
5
Seremban Health Clinic, Negeri Sembilan
6
Hospital Queen Elizabeth, Kota Kinabalu, Sabah
7
Bintulu Health Clinic, Sarawak
8
Hospital Teluk Intan, Perak2

ABSTRACTHigh food wastage is associated with reduced energy intakes leading to malnutritionrelated complications in hospitals. This study aims to determine food wastage
prevalence among hospitalized patients on therapeutic diets and associated factors
affecting food waste. Association of contributing factors with food waste among
inpatients on therapeutic diets in 21 study sites were investigated. This study was
conducted from October 2016 to November 2016 where 2759 subjects wererandomly recruited. Overall, 47.4% therapeutic diet were wasted. 52.4% vegetables
had been wasted followed by protein (48.4%), carbohydrate (44.5%) and desserts(44.3 %). Food wastage was significant higher among female (50.7%), centralized
food serving system (49.7%), outsource food service system (56.8%) and during
dinner time (58.5%). Physical factors like eating and swallowing difficulties;
psychological factors (alone, abandoned, stress and food belief) and food quality
factors; unclean food and delay eating time were found significantly associated withhigher food waste at p<0.01. Food wastage was also significantly affected bynutritional impact symptoms (NIS) like abdominal distension, diarrhoea, dysphagia,
lethargy, nausea, poor appetite, poor dentition and vomiting. Several factors had been
identified as associated factors affecting food waste. A negative and high correlation
was observed between energy and protein intake with food wastage suggesting that a
reduction in energy and protein intake will lead to higher food waste. With thisknowledge, necessary measures can be plan and implement to reduce food waste andimproves the therapeutic diet deliverance in improving hospitalized patients’nutritional status.
Keywords: Food waste, food wastage, nutrition impact symptoms, therapeutic diet

INTRODUCTION
Food waste is one of the issues that become a
global concern nowadays1. An estimated one-thirdof all food that is produced worldwide is wasted,which amounts to about 1.3 billion tonnes per
year2. Food waste can be defined as any edible
foods or leftover from some process, cooked or
uncooked food3. The causes of food waste are
numerous, and occur at the stage of production,
processing, retailing and consumption4. Statistics
from Solid Waste Corporation of Malaysia_______________________________________*To whom correspondence should be addressed:<dtshariza@nci.gov.my>111Factors of Food Wastage at Hospital(SWCorp) showed that in 2015 the food waste in
Malaysia reached 15,000 tonnes daily, including
3,000 tonnes that was still fit for consumption andshould not have been discarded5. According toWilliams & Walton, 2011, food waste related toclinical issue in hospital settings had become themost challenging in food waste reduction
strategies6.
Food wastage is commonly reported in
Malaysian hospitals. In a review article
summarizing literatures on the extent of plate
waste occurring in hospital settings until 2012, a
median plate waste of 30% with a wide range of
6% to 67% were reported in 32 international
studies6. In hospitals, 50% of the total waste
generated in a ward environment was food7,8.
Several studies had shown that the problem of foodwastage in hospitals ranges from 17% to 67%9,10.
It was estimated that plate waste in hospitals can
add up to 30 percent to food costs9. In year 2000,
an estimation of the cost of wasted food in British
hospitals was worth £28 million11. Food wastage in
hospitals has always been much higher than otherfood service sectors. Restaurants, cafes, hotels,
schools and workplace canteens usually havelevels of plate waste of less than 15%, in which
hospitals plate waste can be two or three times
higher7.
High food wastage is associated with reduced
energy and protein intakes and has an impact on
malnutrition-related complications in hospitals, aswell as financial and environmental costs12. The
wasted food contains energy, protein, andimportant micro nutrients that could have been
consumed by hospitalized patients of whom 40%
are at risk of under nutrition13. Hospitalmalnutrition could delay patients’ recovery, thus
extending the length of the stay and contributing
to its worsening12. There are several reasons thathave been associated with high level of plate
waste in hospitals including appetite variations.
Meal waste in hospitals could also be caused byalterations in the sensorial quality of foods
served14. In a study done in the United State ofAmerica, loss of appetite along with taste loss was
the most common reasons found which made up
28% of the reasons inpatients consumed less thanhalf of the main starter15. In a Swiss study, half of
the inpatients declared they had less appetite thanat home16. As expected, illness often can affectappetite and the senses of taste or smell. Reduced
activity during hospitalization, side effects oftreatment drugs, nausea or gastrointestinal

symptoms, can also interfere with the normal
desire to eat. Diet prescriptions, such as texture
modification or therapeutic diet like low salt diet,could reduce the sensory appeal of food, and it
has been estimated that being on a special dietdoubles the risk of insufficient energy intake17.
Reducing food waste should be of prime
concern to health care multidisciplinary teamincluding food service providers, medical andnursing staff, dieticians and catering’s staff.
Reducing in food wastage helps cut costs while
supporting patients to consume their food whichlead to better clinical outcome through improve
nutritional. This study aims to determine theprevalence of food wastage among hospitalized
patients who received therapeutic diets andevaluate its association with gender, ethnic,
mealtime, diagnosis, type of therapeutic diet
received,
nutrition
impactsymptoms,
psychological and physiological factors, foodquality as well as food serving and food service
system.
METHODS
Selections of subjects: A cross sectional study
was conducted to determine prevalence of foodwastage and its association with energy andprotein intake adequacy among inpatients
receiving therapeutic diets in 21 study sites
comprising of number of state and number hospital
specialist government hospital under the Ministryof Health, Malaysia from October 2016 toNovember 2016. Eligible subjects were inpatients
aged above 18 years old who received therapeutic
diet and able to take orally with no communication
barriers in medical wards with at least 48 hours ofadmission. In patients who received normal diet,on Ryle’s tube feeding (RT feeding) or parenteralnutrition, with psychiatric disorder, diagnosed with
HIV/AIDS, pregnant woman or bedridden and Nil
by Mouth (NBM) patients were excluded. The
sample size needed in this study was 2759
included 10% calculation for attrition andcalculated based on power sample of 80% andconfidence interval 95%, an expected difference of
5% and standard deviation (SD) of 134 thenutritional value wasted by patient in a pilot study
on nutrition impact symptoms (NIS) and foodwastage18 in National Cancer Institute, Putrajaya
and at the proportionate sampling were used torecruit the subjects in respective study sites. A

112

Factors of Food Wastage at Hospitalobtained from subject’s file and a face-to faceinterview.
Data collection: Food wastage in this study was
indicated as any food that is discarded or uneaten.
A visual estimation method was used to measureproportion of leftovers food using semiquantitative 5-point scale (all, ¾, ½, ¼, none)(Williams & Walton, 2011). An illustration of foodwastage was done according to pictograph as astandard measurement of observation for the usageof Data Collector in this study. Observation was
done during lunch or dinner only and the wastage
was categorised into 4 main groups; carbohydrate,
protein, vegetables and desserts. All observationon the food wastage was recorded in the Data
Collection Form designed for the study.

replacement of new subjects was applied when theappointed subjects refused.
Ethical approval was obtained from Medical
Ethical and Research Committee, Ministry of
Health (NMRR-16-1482-31605). Additionally,
permission to conduct the study was obtained fromthe Director of selected hospitals with informed
consent approved by the Ethical Committee signed
by subjects or authorized representative in thepresence of witness were also obtained. A total of2587 subjects were recruited in this study
constituted with 50.1% male subjects (n=1296)
and female, 49.9% (n=1291). Social-demographic
and clinical data such as age, ethnicity, gender,
marital, employment and educational status andclinical diagnosis are listed in Table 1 wereTable 1: Characteristics of the Study Population
Study Characteristic
GenderMale
FemaleEducational
No educationlevel
Primary
Secondary
DiplomaBachelor
Marital status
SingleMarriedDivorced
WidowedEthnicMalay
ChineseIndia
Bumiputera Sabah
Bumiputera Sarawak
OthersBMI (kg/m2)
Underweight
NormalOverweight
Obese
Diagnosis
Diabetes mellitus
Hypertension
Renal Disease
Hyperlipidaemia
Heart Disease
Gout
Wound
DVT/AF
Others113

Frequency (n)
1296
1291
396
824
1146
118
83
296
2100
29
153
1643
439
333
84
56
32
204
1238
713
396
1620
1643
632
357
502
100
43
40
692

Percentage (%)
50.1
49.9
15.4
32.1
44.6
4.6
3.2
11.5
81.5
1.1
5.9
63.5
17.0
12.9
3.2
2.2
1.2
8.0
48.5
27.9
15.5
62.6
63.5
24.4
13.8
19.4
3.9
1.7
1.5
28.0

Factors of Food Wastage at Hospital

Data analysis: The data analysis was conductedusing IBM SPSS version 22. Descriptive date isexpressed as mean and standard deviation.
Independent T-Test and One-way ANOVA wereconducted for analysis of the mean difference innormally distributed data. Categorical data wereanalysed using Chi-square or Fisher‘s exact test.
Pearson’s and Spearman’s correlation were used toanalyse correlation between numerical data.

Table 2: Average Food Wastage by Study Site and Food Group
Item
Overall
Study
Sites

Food Group

Type of
Carbohydrate

Type of
DessertN

Hospital Tuanku Jaafar, Seremban
Hospital Selayang
Hospital Tunku Ampuan Rahimah
Hospital Serdang
Hospital Kuala Lumpur
Hospital Sultanah Nur Zahirah
Hospital Raja Perempuan Zainab II
Hospital Sultanah Aminah
Hospital Pakar Sultanah Fatimah
Hospital Sultan Ismail
Hospital Sultanah Bahiyah
Hospital Sultan Abdul Halim
Hospital Tuanku Fauziah
Hospital Melaka
Hospital Pulau Pinang
Hospital Raja Permaisuri Bainun
Hospital Taiping
Hospital Sultan Haji Ahmad Shah
Hospital Tengku Ampuan Afzan
Hospital Umum Sarawak
Hospital Queen Elizabeth
Carbohydrate
Protein
Vegetables
Fruits/desserts
Rice
Porridge
Mixed Porridge
PureedBlended
Fruit
Jelly
Pudding

114

2587
200
141
183
44
122
52
87
133
153
84
159
134
82
193
109
192
107
51
105
139
117
2587
2587
2587
2587
2188
353
30
9
7
2067
59
79

Food Wastage (%)
Mean (±SD)
47.4 (± 31.3)
46.2 (± 31.6)
62.0 (± 29.6)
35.0 (± 31.1)
40.5 (± 28.7)
29.9 (± 28.9)
63.8 (± 27.8)
63.5 (± 25.4)
44.6 (± 28.0)
52.3 (± 36.5)
59.2 (± 28.6)
53.5 (± 27.2)
36.3 (± 30.3)
47.5 (± 28.4)
38.0 (± 32.1)
55.2 (± 26.6)
48.9 (± 33.7)
37.4 (± 24.5)
60.8 (± 29.2)
48.2 (± 30.6)
48.3 (± 31.4)
52.8 (± 24.8)
44.5 (± 37.1)
48.4 (± 39.2)
52.4 (± 40.1)
44.3 (± 45.8)
42.8 (± 36.9)
52.5 (± 35.9)
66.7 (± 39.0)
69.4 (± 46.4)
53.6 (± 50.8)
32.8 (± 42.2)
65.3 (± 40.2)
60.1 (± 43.4)

Factors of Food Wastage at Hospital

RESULTSA total of 2587 (93.7%) subjects were successfully
recruited into this study. In this study, malesubjects constituted 50.1% of the sample studiedcompared to female, 49.9% .63.5% study subjects
were Malay, followed by Chinese (17.0%) andIndian (12.9%). 44.6% subjects received secondary
education, 81.5% were married and more than
60% were diagnosed with diabetes mellitus andhypertension. The mean age of subjects was
57±14.8 years old. Based on WHO (2006) BMI
classification, most of the subjects 48.5% had
normal weight. Overweight and obese subjects
were 27.9% and 15.5% respectively. Only 8% of
study’s subjects were underweight.
.

Food Wastage: Overall food wastage intherapeutic diet served in 21 Ministry of Healthhospitals was 47.4% ranging from 16% to 79%.
Table 2 presents the average food wastage bystudy site where Hospital Sultanah Nur Zahirah,
Kuala Terengganu, Terengganu had the highest
percentage of food wastage (63.8 %), followed by
Hospital Raja Perempuan Zainab II, Kota Bharu,
Kelantan (63.5%), Hospital Selayang, Selangor(62.0%) and Hospital Sultan Ahmad Shah,
Temerloh, Pahang (60.8%). Hospital Kuala
Lumpur had the lowest percentage of food wastage(29.9%).

Table 3: Comparing Mean Food Wastage with Study Characteristics

Male
FemaleBulk
Centralised
In-house
Outsource
Yes
No
Lunch
DinnerMalay
ChineseIndia
Bumiputera Sarawak
Bumiputera Sabah
Others
No education
Primary
Secondary
DiplomaBachelor
SingleMarriedDivorced
WidowedUnderweight
NormalOverweight
Obese

1296
1291
798
1789
2203
384
617
1964
2447
138
1643
439
333
56
84
32
396
824
1146
118
83
296
2100
29
153
204
1238
713
396

Food Wastage (%)
Mean (± SD)
44.2 (± 32.5)
50.7 (± 29.7)
42.2 (± 31.6)
49.7 (± 30.9)
45.8 (± 31.4)
56.8 (± 29.1)
47.6 (± 32.2)
47.4 (± 30.9)
46.8 (± 31.4)
58.5 (± 27.3)
47.5 (± 31.1)
48.7 (± 33.0)
43.6 (± 31.2)
54.3 (± 26.0)
46.7 (± 29.3)
46.7 (± 31.3)
53.0 (± 30.5)
49.2 (± 30.5)
45.1 (± 31.2)
42.7 (± 34.1)
42.1 (± 33.8)
40.8 (± 31.9)
48.3 (± 31.5)
29.1 (± 21.9)
52.2 (± 25.5)
56.3 (± 31.6)
50.0 (± 31.2)
43.9 (± 31.2)
41.3 (± 29.7)

Young adult (18 – 30)

159

40.7 (± 32.6)

Middle age adult (30 – 50)
Senior adult (> 50)

587
1841

43.0 (± 31.0)
49.4 (± 31.0)

Study Characteristic
GenderFood Serving
SystemFood Service
SystemReferral toDietitianTime of Meal
Observed
EthnicEducational level

Marital status

BMI (kg/m2)

Age group,
years oldaN

Independent t-test; bOne – way Anova; Significant tested by p<0.05

115

p-valuea<0.001 b<0.001<0.001<0.001
0.883<0.0010.082b<0.001b<0.001 b<0.001 b

Factors of Food Wastage at Hospital

Vegetables had become the highest wastage among
the food groups (52.4%) in most of thegovernment hospitals, followed by protein(48.4%), carbohydrate (44.5%) and desserts (44.3%). Moreover, among types of carbohydrate
wasted the most was pureed diet (69.4%)
compared to others. For dessert, the data showsthat jelly had the highest food wastage (65.3%),
followed by pudding (60.1%) and fruit (32.8%).
Food wastage was significant higher among female(50.7%), centralised food serving system (49.7%),
outsource food service system (56.8%) and during
dinner time (58.5%).

Table 4: Food Wastage and Nutritional Impact Symptoms and Factors Influencing Nutritional Status(Physical, Psychological and Food Quality)
Factors
NIS
Abdominal
Distension
Yes
No
Ascites
Yes
No
Constipation
Yes
No
Diarrhoea
YesNo
Dysphagia
Yes
No
Early satiety
Yes
No
Edema
Yes
No
Lethargy
Yes
No
NauseaYes
No
Poor appetite
Yes
No

N

Food wastage(%)
Mean (SD)pvaluea<0.0011252462

57.9 (30.6)
46.9 (31.2)
0.87

61
2526

48.1 (32.9)
47.4 (31.2)

105
2482

49.2 (30.5)
47.3 (31.3)

92
2495

60.4 (30.8)
46.9 (31.2)

43
2544

70.1 (26.0)
47.0 (31.2)

132
2455

51.1 (26.2)
47.2 (31.5)

75
2512

48.3 (29.5)
47.7 (31.3)

0.56<0.001<0.0010.099
0.81<0.001299
2288

63.4 (28.2)
45.3 (31.1)<0.001

235
2352

62.2 (27.9)
45.9 (31.2)<0.001

952
1635

62.7 (26.0)
38.5 (30.7)

FactorsN

Food wastage(%)
Mean ( SD)

PhysicalDifficulties to eat
YesNo
Difficulties inswallowing
Yes
No
Delay eating timeYes
No
Psychological
Alone
Yes
No
Abandoned
Yes
No
StressYes
No
Food Belief
YesNo
Food quality
Unclean foodYes
No
Big portion
Yes
No
PhysicalContamination
Yes

Poor
<0.001
dentition
Yes
194
59.9 (26.9)
No
No
2393
46.4 (31.4)
Vomiting<0.001Yes
125
60.1 (30.2)
No
2462
46.8 (31.2)
aIndependent T-Test; Significant at p<0.05, NIS=Nutrition Impact Symptoms

116

pvaluea<0.001

209
2374

67.1 (27.2)
45.7 (31.0)<0.0011252458

71.8 (24.9)
46.2 (31.1)

26
2557

70.9 (20.8)
47.2 (31.3)

67
2516

59.5 (29.6)
47.1 (31.3)

85
2498

56.8 (28.7)
47.1 (31.3)

134
2449

64.9 (24.8)
46.5 (31.3)

97
2486

53.6 (25.7)
47.2 (31.5)

92574

63.2 (18.1)
47.4 (31.3)

79
2504

49.2 (20.2)
47.4 (31.6)<0.001<0.001

0.005<0.001

0.030

0.431
0.488
6

38.5 (30.0)

2577

47.4 (31.3)

Factors of Food Wastage at Hospital

Table 5: Correlation between Energy and Protein Intake with Food Wastage

Mean Intake ±SD

Food Wastage (%)
Mean±SDrp-valuea

47.4±31.3- 0.951<0.00147.4 ±31.3- 0.873<0.001

Energy intakes (kcal)
794.6 ±487.8
Protein intakes (g)35.2 ±24.3aPearson’s correlation test, r=Correlation Coefficient

No significant difference was observed on foodwastage among subjects whether referred todietician or not. Food wastage also differs
significantly among educational level groups,
marital status groups and BMI groups. Subjects
with no education had significantly the highest
mean food wastage and differ significantly whencompared to subjects with secondary, diploma or
bachelor education. This study also observed thatdivorced subjects had significantly the lowest foodwastage percentage when compared to married,
single and widowed subjects. Food wastage among
young adults and middle age adults was not
significantly different but both of these groups hadmean food wastage that differ significantly withthe senior adult group (p<0.001). There were no
significant difference between food wastage withethnic group and dieticians’ consultation as shownin Table 3
According to BMI group, mean total of foodwastage for underweight and normal weightsubjects was statistically significant (p<0.001)
compared to overweight group; obese group. As
observed mean food wastage was the highest inunderweight groups (56.3%), followed by normal
BMI subjects (50.0%), overweight (43.9%) andobese subjects (41.3%)
Table 4, shows findings on mean food wastage
affected by nutritional impact symptoms (NIS).
Abdominal distension, diarrhoea, dysphagia,
lethargy, nausea, poor appetite, poor dentition andvomiting are among the NIS that shows significant
difference when compared with subjects without
the symptoms. This study did observed that there
were significant associations between foodwastage with physical factors; eating difficulties(p<0.001), swallowing difficulties (p<0.001), delay
eating time (p<0.001), psychological factors; alone(p<0.001), abandoned (p=0.005), stress (p<0.001),
and food belief (p<0.001), and food quality
factors; unclean food (p<0.001).

Table 5 shows significant association between
energy and protein intake with food wastage(p<0.001). A negative and high correlation wasobserved between energy and protein intake withfood wastage. This suggests that a reduction inenergy and protein intake will lead to higher foodwastage.
DISCUSSION
Throughout this study our food wastage
findings were consistent with a local study9
conducted in a Penang district hospital involving
normal diet. Almost half (47.4%) of thetherapeutic diet served in MOH hospitals in
Malaysia had been wasted and it was expected tobe higher than the wastage of normal diet as shownin the above study. Similar findings were observed
where female subjects had a significantly higher
plate waste compared to male. Strengthened byanother local research19 states that food wastage ismore common in women for most of the fooditems. There was no apparent reason for why
female patients wasted more food other than tosurmise that females might be a little more fussy
when it comes to food intake. Among the foodcategories, it can be seen wastage consistently
reported to be highest in the vegetables groups(52.4%) compared with other categories as
observed from others studied. Probable factors
contributing to vegetables wastage include
preference towards vegetables or the preparation ofvegetables dishes9,20, or it might be a result of poor
cooking practices6.
Food serving systems practised by hospitals
under Health Ministry can be divided into twosystems, either bulk systems or centralised
systems. This study showed higher proportions offood waste in centralised systems compared tobulk systems. In the bulk systems freshly prepareddishes are wheeled in trolleys into the wards pantry
instead of at the patient bedside. It is thus able toretain the temperature of the freshly prepared117

Factors of Food Wastage at Hospital

foods and ensure foods are always warm enhancepatients’s appetite. In contrast, however two
studies reported an increase in total food waste
through the adoption of a bulk system21,22.
Additionally the pattern on dinner contributing
to the highest mean percentage food waste(58.5%), compared to lunch (46.8%). Data forbreakfast consumption could not be collected forthis study which focuses on lunch and dinner only.
Home cooked food brought by caretakers afterworking hours, and the absences of clear policy tocontrol home or retail food deliver services frompatient’s care takers or retailer may contribute tohigher food wastage during dinner.
There is greater food wastage as age increases.
These figures, however, are difficult to interpretbecause of the nature of each patient’s illness.
However, since illness can often affect appetiteand the senses of taste or smell23. According to age
group, senior adult had the highest food wastage
when compared to younger population. Age
related decline in functional ability (dysphagia andlethargy) and dental problems (poor dentition) cansignificantly affect food consumption that cancontribute towards wastage24. Difficulties to eat
and swallowing had significantly affects foodwastage as consequences of reduction in oral
intake.
Besides that, this study affirmed theobservation some of the factors that influencing tofood waste. Nutritional impacts symptoms (NIS)
were also found significantly contribute to foodwaste. According to Williams & Walton (2011),
food waste related to clinical issues is the mostchallenging issue in food waste reduction.
Approximately 30% of hospitalized patients are at
nutritional risk, often experiencing eatingproblems, unpredictable changes in appetite, andrequiring different food items and services making
the development of strategies to ensure relevant
food is provided but does not become wasted very
challenging21,25,26. In this present study, we foundthat almost all NIS was significant causes of foodwaste among patients at hospitals. This is not
unexpected, since illness can often affect appetiteand the sense of taste and smell. Drug causing
nausea and gastrointestinal symptoms can alsointerfere normal desire to eat and impaired oral
intake. These conditions can affect appetite andsense of smell which leads toward further foodwastage6.
Another important consideration in food wastestudies was the assessment of energy and protein

intakes as it can reflect nutrient intake andinfluences cost of the hospital. Food waste is agreat importance as it can reflect nutrient intakes,
and high levels of food waste can be indicative ofpoor health status27. Studies showed that foodwaste can significantly cause reduction in calorie
and protein intake. These finding applicable topatients who have a higher susceptibility changer
to preferences, reduce of appetite therefore
increase of malnutrition risk. Many dietprescriptions, such as texture modification or low
salt, reduce the sensory appeal of food, and it has
been estimated that being on a special diet doubles
the risk of insufficient energy intake6. Anotherprobable reason is that they tend to limit foodintake especially to achieve good control of blood
glucose as in a diabetic diet19.Therefore, including
effective routine monitoring of patients’ foodchoices, food intakes and food waste should bepart of strategy to ensure patients are being servedwith a portion size that will enhance consumption
and increase energy and protein contributions to
the total daily recommended intake.
There are other factors contributing tofood waste which need to be considered for
improvement. Those reason include physicalfactors (difficulties to eat, difficulties inswallowing, delay eating time), psychologicalfactor (alone, abandoned, stress, food belief) andfood quality (unclean food, big portion, physicalcontamination). Furthermore, physical constraints
such as eating in bed, having immobilized limbs or
age-related declines in functional ability and dental
problems, can all significantly affect foodconsumption6. This is a complex area of research,
but there is some evidence suggesting that dining
room environment and the consequent social
interaction can improve dietary intakes28.
CONCLUSION: This study was aimed to evaluateof factor affecting food wastage and had revealed
an important to see from various aspects andfactors that can affect food waste in hospitals.
Further evaluation should be conducted to see how
it may contribute to foods waste, before any
possible strategies can be taken as an action for
implementation. By finding the common reason
for plate waste generation among patients in thisstudy, it will help in gaining knowledge to further
improve the quality of food and services in
hospitals. A reduction in food wastage can helps
on cost-effectiveness, optimize productivity and at
the same time can encourage patients to eat their118

Factors of Food Wastage at Hospital

food and lead to better clinical outcomes throughimproved nutritional care. Acknowledgement
We would like to thank the Director General of
Health Malaysia for his permission to publish thisarticleFunding Statement
This study is not funded by any organization.

11. Baharom B. Food Wastage and Nutritional
Intake in Hospital Tuanku Jaafar Seremban:
Visual plate Waste Study. 2010.
12. Cereda E, Pedrolli C..Food waste: otherissues and settings should be considered(letter to the editor). Nutr Bull, 34, 9-238.
(2009)
13. Lisa A. Barker, Belinda S. Gout, and Timothy
C. Crowe. (2011). Hospital Malnutrition:
Prevalence, Identification and Impact on
Patients and the Healthcare System.Int. J
Environ Res Public Health;8 (2):514-527
14. Ofei, K. T., Holst, M., Rasmussen, H. H., &Mikkelsen, B. E. (2015). Effect of meal
portion size choice on plate waste generation
among patients with different nutritional
status. An investigation using Dietary Intake
Monitoring System (DIMS). Appetite, 91,
157–164.
15. Mavrommatis Y, Moynihan P J, Gosney M A,
Methven L. Hospital catering systems andtheir impact on the sensorial profile of foods
provided to older patients in the UK. Appetite
2011; 57: 14-20
16. McLymont V, Cox S & Stell F. (2003).
Improving patient meal satisfaction withroom service meal delivery. J Nurs Care
Qual. 2003 Jan-Mar; 18(1):27-37.
17. Stanga Z, Zurfluh Y, Roselli A, Sterchi A,
Tanner B, Knecht G. Hospital food: a surveyof patients’ perceptions. Clin Nut 2003; 23:241-246.
18. Thibault R, Chikhi M, Clerc A, Darmon P,
Chopard P, Genton L, Kossovsky MP,
Pichard C. Assessment of food intake inhospitalised patients: A 10-year comparative
study of a prospective hospital survey. Clin
Nut 2011; 30: 289-296.
19. Norshariza J, Zuwariah AR, Betti Sharina
HL, Kufrizan K, Nuzulliah O. Symptoms Or
Side Effects Of Cancer Or Cancer
Treatments: Does Nutrition Impact Symptoms
Will Affect Food Waste In Dietetic And Food
Service Department, National Cancer
Institute, 2015 (unpublished)
20. Shahar S, Chee K Y, Wan Chik WCP. 2002.
Food intakes and preferences of hospitalised
geriatric
patients.
BMC
Geriatrics.
http://www.biomedcentral.com/14712318/2/3

Conflict of Interest
This study has no conflict of interest
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1.

Zulkiply N.A., Chik C.T. (2015) Theory andPractice in Hospitality and Tourism Research- Proceedings of the 2nd International
Hospitality and Tourism Conference 2014,
pp. 361-364.
2. Food and Agriculture Organization of theUnited Nations (FAO), the State of Food
Security and Nutrition in the World, 2018
3. Environmental Protection Agency (EPA).
(2012). Municiple Solid Waste, fromwww.epa.gov/epawaste/non-haz/municipal/
index.htm
4. Galanakis, Charis M. (2015). Food Waste
Recovery:
Processing
Technologies
andIndustrial Techniques. San Diego:
Elsevier-Academic
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ISBN
9780128003510
5. Malaysia Kini. (2016). Battling food waste.
Malaysia
Kini.
Retrievedfrom
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6. Williams, P.; Walton, K. Plate waste in
hospitals and strategies for change. Eur. e-J.
Clin. Nutr. Metab.2011,6,235–241
7. Alam, M. M., Sujauddin, M., Igbal, G. M. A.,& Huda, S. M. S. Report: Healthcare waste
characterization in Chittagong Medical
College Hospital, Bangladesh. Waste
Management and Research, 26(3), 291–296.
(2008).https://doi.org/10.1177/0734242X070
87661
8. Mattoso, V. D. B., & Schalch, V. (2001).
Hospital waste management in Brazil: A casestudy. Waste Management & Research, 19(6),567–572.
9. Lily Zakiah MD, Saimy I, Maimunah AH.
Plate Waste among Hospital Inpatiets.2005.
10. Malaysian Journal of Public Health
Medicine.Vol. 5(2):19-24

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21. Williams P. Food preferences of 500
inpatients in an Australian teaching hospital. J
Food Nutr 1988; 45: 34-40.
22. Hartwell H, Edwards JSA. A comparative
analysis of ‘plated’ and ‘bulk trolley’ hospital
food service systems. Food Serv Technol
2003; 3: 133–42.
23. Edwards JSA, Nash AHM. The nutritional
implications of food wastage in hospital foodservice management. Nutr Food Sci 1999; 99(2): 89–98.Food and Agriculture Organization(FAO).http://www.fao.org/food-loss-andfood-waste/en/Food Loss and Food Waste.
Accessed March 7, 2018.
24. Díaz A V, García Á C. 2013. Evaluation offactors affecting plate waste of inpatients indifferent healthcare settings. Nutr Hosp.
2013; 28(2):419-427 ISSN 0212-1611 •CODEN NUHOEQ S.V.R. 318
25. Huang H-C and Shanklin C. An integrated
model to measure service management andPhysical constraints' effect on foodconsumption in assisted-living facilities. J Am
Diet Assoc 2008; 108: 785-792

26. Dupertuis, Y. M., Kossovsky, M. P., Kyle, U.
G., Raguso, C. A., Genton, L., & Pichard,
27. (2003). Food intake in 1707 hospitalised
patients: a prospective comprehensive
hospital survey. Clinical Nutrition, 22(2),115-123.
28. Hartwell, H. J., Edwards, J. S., & Symonds,
C. (2006). Food service in hospital:
development of a theoretical model for patient
experience and satisfaction using one hospitalin the UK National Health Service as a casestudy. Journal of Foodservice, 17(5‐6), 226238.
29. Deutekom EJ, Philipsen H, Ten Hoor F,
Huyer Abu-Saad H. Plate waste producing
situations on nursing wards. Int J Nurs Stud
1991; 28: 163–74.
30. Walton, K, Williams, P., Tapsell L. C. 2006.
What do stakeholders consider the key issues
affecting the quality of foodservice provisionforlong-staypatients?
JournalofFoodservice, 2006, 17(5-6), 212-22

120

Asian Journal of Dietetics, 2019

CASE REPORT

Role of Partial Hydrolysed Guar Gum in Chemotherapy Induced High Output Stomain Patient with Ileostomy
Ho Chiou Yi1,3, Atiki Falparado Ahmad2,3, Woo Sze Sian2,3, Tharmasilen A/L Selvarajoo2,3,
Norshariza Jamhuri1,3, Zuliehaiza Kahairudin1,3
1

Department of Dietetic and Food Service, National Cancer Institute, Ministry of Health, Malaysia
Department of Surgical Oncology, National Cancer Institute, Ministry of Health, Malaysia
3
Nutritional Therapy Team, National Cancer Institute, Ministry of Health, Malaysia
2

ABSTRACTIntroduction: High and excessive stoma output from ileostomy, is frequently observed inpatients with ileostomy under radiation and chemotherapy thus deteriorate illness. As part oftreatment, partially hydrolysed guar gum (PHGG) was used to resolve the problems
effectively. Case presentation: An Indian male age 68, Mr S, with no underlying illnesses,
diagnosed with rectal and prostate adenocarcinoma underwent laparoscopic anterior resection
with covering ileostomy, followed by three month chemotherapy. After second cycle ofchemotherapy, he developed persistent high stoma output (>2litres/day) leads to lethargy due
to dehydration leads to the cessation. As parenteral nutrition and semi elemental diet does notbenefit the patient, instead standard Oral Nutrition Supplement (ONS) with added PHGG andhigh protein high calories low residue diet was initiated concurrent with anti-motility and antisecretory medications. Subsequently, stoma output reduced and soft in consistency and patientable to resume treatment. Discussion: Chemotherapy induced high-output stoma, a common
problem in cancer patients, not only directly impact on patient’s nutritional status but may
also compromise treatment efficacy because of consequent dosing alterations or
discontinuation. The obstacle that often faced with ileostomy patient is consistent high stoma
output despite fluid restrictions and conservative management of stoma output with regulardoses of anti-motility and anti-secretory agents, transition period to wean off TPN, promote
gut adaptation and to achieve energy requirement with normal stoma output. PHGG is a watersoluble, non-gelling fibre that has provided therapeutic benefits which can provide a
dichotomous features whereby normalizing effect in stool. Conclusion: Incorporating PHGG
in feeding regime showed positive outcomes in quickly improves stoma output in patient with
ileostomy as well as nutritional intake.
Keywords: Partially Hydrolysed Guar Gum, ileostomy

INTRODUCTION
One of complication following radiation andchemotherapy on colorectal cancer was excessive
and high stoma output which frequently observedin patients, resulting in deterioration in nutritional
outcome that leads towards treatment
interruption. Gastrointestinal (GI) mucosal barrier
within the radiation volumes with severe
mucositis might cause diarrhoea, nausea, emesis---------------------------------------------------------Corresponding author:
Ho Chiou Yi
Email: dtho@nci.gov.myand severe malabsorption followed by infections
with dehydration and electrolyte disorders1.
Partially hydrolysed guar gum (PHGG) was
proven to be effective in the treatment of acutediarrhoea in intensive care setting2 which had
been adapted into high stoma nutritional
management. Purpose of this case report is toshare our clinical experience about role of PHGG
in chemotherapy induced high stoma output inpatient with ileostomy

Guar Gum in Ileostomy

CASE PRESENTATION: A 68 year old Indian
male, Mr S, with no underlying illnesses,
diagnosed with a double primary of rectal
adenocarcinoma Stage 3 and prostateadenocarcinoma stage 4 Gleason score of 4+3. He
underwent a laparoscopic Anterior Resection withcovering
ileostomy
andfollowedbychemotherapy.
Postsecondcycle
ofchemotherapy, he experienced 8% weight loss
within 1-month, developed persistent high stoma
output and lethargy due to dehydration even
withholding chemotherapy for seven days. Patient
was referred to Nutritional Therapy Team (NTT)consist of surgical team, dietitian and pharmacist.
Nutritional diagnosis was altered gastrointestinal
function related to compromise gastrointestinal(GI) tract function due to radiotherapy as evidenceby high stoma output. Initially, stoma output wasmore than two litres per day. Anti-motility andanti-secretory medications were prescribed withhigh protein high calories low residue diet plus
standard oral nutrition supplement (ONS) support
at first phase but stoma output remained high.
Despite dosage increment in anti-motility andanti-secretory medication, nil-per-oral andinitiation of Total Parenteral Nutrition (TPN)
strategy during the second phase, stoma output
remains unsatisfactory. Semi-elemental ONS wasprescribed concurrently with partial TPN withsame medications dosage then but patient notcomplied with semi-elemental ONS due tounpleasant taste and stoma output did not show
any improvement. Thus, standard ONS with
PHGG was initiated, four times a day withmodified high protein high calories low residue
diet and wean off TPN were allowed with same
dosage of anti-motility and anti-secretory
medications. Finally, the stoma output reducedwith soft consistency stools upon discharged. In
addition, total daily energy and protein intake
increased after started with PHGG.
DISCUSSION
Human intestine works on approximately 810litres of fluid daily, most of fluid is absorbed by
the jejunum and the ileum while estimated1.5litres reaches the colon, of which 100 ml is
excreted3. Most chemotherapeutic agents target
rapidly dividing cells, and effects on these cells
within the gastrointestinal tract can lead to avariety of symptoms. Chemotherapy treatment
might induce severe mucositis and cause highoutput stoma in patient with ileostomy. Highoutput stoma usually is considered as output
greater than 1.5litres/day4. The chemotherapyinduced high-output stoma not only directly
impact on patient’s nutritional status but may also
compromise treatment efficacy because ofconsequent dosing alterations or discontinuation5.
High-output stoma can lead to dehydration, renal
dysfunction, and electrolyte abnormalities4,6.

TOTAL DAILY ENERGY AND PROTEIN INTAKE BY CASE

1800
1600
1400
1200
1000
800
600
400
200
0

1660
1250
1000
energy intake (kcal/day)

800

protein intake (g/day)300
15
before
PHGG

25

45

D1 PHGG

D3 PHGG

5060
D5 PHGG

D7 PHGG

Figure 1: Total Daily Energy and Protein Intake

122Guar Gum in Ileostomy

The presented patient was on parenteralnutritional support and reported a consistent highstoma output despite fluid restrictions andconsuming glucose-saline solutions collectively
with regular doses of anti-motility and antisecretory agents. The challenge of high output
stoma in ileostomy patient is to wean off TPN,
promote gut adaption and achieve energy protein
requirement with normal stoma output7,8. In theeffort of reducing and controlling ileostomy
output, patient should be educated and compliedwith the management. Appropriate high stoma
output management includes restriction of fluids,
medications, and dietary modification9. Highcalories high protein low residue normal diet wasprescribed to compensate for malabsorption byhyperphagia. Oral Nutrition Supplement (ONS)
may be necessary with insufficient intake (lessthan 60% from requirement) to optimise oral
intake and minimize nutritional depletion10,11.
However, unpleasant taste and higher cost ofsemi-elemental and elemental ONS might affectthe long term compliance of ONS12.
Other than management as stated above,
soluble fibre supplement, such as guar gum, might
be considered in the intervention plan7. PHGG isa water-soluble, non-gelling fibre that has
provided therapeutic benefits. In clinical trials,
PHGG decreased symptoms in constipationpredominant and diarrhoea-predominant forms of
IBS and decreased abdominal pain. Soluble fibre
such as guar gum can provide a dichotomousfeature whereby stool normalizing effect to soften
hard stool (increase Biomass frequency) inconstipation and firm watery stool (decrease
Biomass frequency) in diarrhea9. Current casestudy showed consistent findings that PHGG
showed positive effect in improving ileostomy
consistency and output and subsequently prevent
complications of high output.

CONCLUSION: Optimal multidisciplinary
management including nutritional management is
crucial in management of high output in patientwith ileostomy induced by chemotherapy andoncologic outcomes. PHGG in ileostomy
nutritional management showed improvement ofvolume and consistency of stoma output andpositive outcomes in term of nutritional intake.
We hope this case report to can be used as an
example of the effect of integration partiallyhydrolysed guar gum in nutritional managementof oncologic treatment induced high output in
ileostomy patients.
Acknowledgement
We would like to thank the Director Generalof the Health Ministry of Malaysia for permission
to publish this article.
Conflict of interest
The authors declare no conflict of interest
arising from the findings for the reported case andits management.
REFERENCES
1) Grabenbauer GG, Holger G. Management ofradiation and chemotherapy related acutetoxicity in gastrointestinal cancer. Best
Practice&
Research
Clinical
Gastroenterology. 2016 Aug 1;30(4):65564.
2) Rushdi TA, Pichard C, Khater YH. Control
of diarrhea by fiber-enriched diet in ICU
patients on enteral nutrition: a prospective
randomized controlled trial. ClinicalNutrition. 2004 Dec 1;23(6):1344-52.
3) Kiela PR, Ghishan FK. Physiology ofintestinal absorption and secretion. Bestpractice&research
Clinicalgastroenterology. 2016 Apr 1;30(2):145-59.
4) Villafranca JJ, López-Rodríguez C, Abilés J,
Rivera R, Adán NG, Navarro PU. Protocol
for the detection and nutritional managementof high-output stomas. Nutrition journal.
2015 Dec;14(1):45.
5) Robertson JP, Wells CI, Vather R, Bissett IP.
Effect of diversion ileostomy on theoccurrence and consequences of chemotherapy-induced diarrhea. Diseases of theColon & Rectum. 2016 Mar 1;59(3):194200.
6) Baker ML, Williams RN, Nightingale JM.
Causes and management of a high‐output

Limitation
Long-term nutritional effect of PHGG was not
explained in this case report. The reduction instoma output following the introduction of PHGG
and normal diet could be a mere coincidence. As
a result, findings from a case report cannot be
generalized unless a cause-effect relationshipfrom a representative population is established.
Case reports aim to contribute to a change in theclinical practice. Numerous discoveries and majoradvancements in medicine started with a casereport.

123

Guar Gum in Ileostomy

stoma. Colorectal disease. 2011 Feb;13(2):191-7.
7) Matarese LE, O'Keefe SJ, Kandil HM, Bond
G, Costa G, Abu‐Elmagd K. Short bowel
syndrome: clinical guidelines for nutrition
management. Nutrition in clinical Practice.
2005 Oct;20(5):493-502.
8) Neelis EG, Olieman JF, Hulst JM, de Koning
BA, Wijnen RM, Rings EH. Promoting
intestinal adaptation by nutrition andmedication. Best Practice & Research
Clinical Gastroenterology. 2016 Apr
1;30(2):249-61.
9) McRorie Jr JW, McKeown NM.
Understanding the physics of functional
fibers in the gastrointestinal tract: anevidence-based approach to resolving
enduring misconceptions about insoluble

and soluble fiber. Journal of the Academy of
Nutrition and Dietetics. 2017 Feb
1;117(2):251-64.
10) Acosta PJ, Borschel MW, Reynolds PA,
Cordle CT, Duska-McEwen GO, inventors;
Abbott Laboratories, assignee. Palatableelemental medical food. United States patent
US 6,245,803. 2001 Jun 12.
11) Pironi L, Arends J, Bozzetti F, Cuerda C,
Gillanders L, Jeppesen PB, Joly F, Kelly D,
Lal S, Staun M, Szczepanek K. ESPEN
guidelines on chronic intestinal failure inadults. Clinical nutrition. 2016 Apr
1;35(2):247-307.
12) Sica J, Burch J. Management of intestinal
failure and high-output stomas. British jour-nal of nursing. 2007 Jul 12;16(13):772-7.

124

Asian Journal of Dietetics, 2019

Letter to Editor
Nutrition and Health between Vegetarians and Non-Vegetarians

Key words: Health diets, vegetarianism, non-communicable chronic diseases

Dear Editor:
As a 35 years-long lacto-ovo-vegetarian, I havebeen always asked by others why my family
converted and what health benefits had been. To
answer them, the comparison about nutrition andhealth between vegetarians and non-vegetarians
was summarized here.
There are different types of vegetarian
depending on their different food components
namely, semi-vegetarians (vegetables with dairy
products, eggs and fish), lacto-ovo-vegetarians(with milk and eggs), pescatarians (with fish) andvegans or “Jay” (no milk and eggs) (1). Generally,vegetarian foods have no meat, poultry, seafood, or
any animal products including eggs, milk, honey,
etc. Vegetarians consume more vegetables, fruits
and grains. Compared to meat foods, plant-based
foods contain more healthy compounds including
vitamins, minerals, dietary fiber and essential nonnutrients. Plant-based diets have been widely
known and popular especially among people withhealth concern. A numerous research articles havereported the health benefits of vegetarian diet in theprevention and healing of non-communicablechronic diseases (NCDs) including obesity,
cardiovascular diseases, type-2 diabetes, somecancer types and hypertension (1,2).
By the evidence-based review, the American
Dietetic Association (ADA) and Dietitians ofCanada (DC) concluded that appropriately planned
vegetarian diets, including vegetarian and vegan
diets, are nutritionally adequate and may bebeneficial to the prevention and treatment of certain
diseases (3, 4). The vegetarian diet was found tolower risk of death from ischemic heart disease. As
compared to the non-vegetarians, vegetarians had
about 32% lower cholesterol levels and bloodpressures, which reduce the risk of cardiovasculardisease (CVD) and certain types of NCDs (4, 5).
Hypercholesterolemia is a major risk factor of
CVDs including coronary heart disease andischemic stroke, as well as peripheral arterial
disease (6, 7).
The well-planned plant diets are confirmed to beappropriate for persons from birth to adults andaging stages as well as sportsman. However,statistically, vegetarians are not always healthierthan non-vegetarians. The variable difference of
dietary components among vegetarian individuals
can lead to the unbalanced diets. The deficiency ofessential nutrients such as vitamin B12 and ironcauses mild and severe anemia as well as someessential amino acids (lysine and methionine.) andfatty acids (omega-3 and -6), among vegetarians
and vegans (8-11). To have adequate and balanced
intake of the essentials, vegetarians should be
educated about sources of specific nutrients, foodingredients and right cooking for their healthy life.
However, a vegetarian diet has both advantages
and disadvantages. Its healthful benefit has beenfound to reduce the risk of heart disease, obesity,
hypertension, type 2 diabetes and some types ofcancer, leading to a longer life expectancy.
Adversely, the higher prevalence of mild hyperhomocysteinemia in vegetarians may decrease thepreventive effect of vegetarian nutrition in
cardiovascular disease. Therefore, vitamin B12
deficiency may reduce the risk of CVD prevention,
vegetarians should be advised to consume vitamin
B12 supplement, as well as fermented-plant foods
and dried purple laver (nori) which contain highvitamin B12 and its analogs (12, 13).
Most non-vegetarians are not us0ed to and do not
like such veggie foods due to the lack of meaty
flavor and taste. There are many vegetarian meatalternatives (tofu, soy products, tempeh, beans) andmocking meat products made from a mixture of
konjac, shitake mushroom and soy meal in themarket, so the main vegetarian benefits anddisadvantages are related to health rather than taste.
(13)

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Asian Journal of Dietetics, 2019
Not only for the health benefits, hasvegetarianism also emphasized the compassion to
all lives. Most of Thai and Taiwanese vegetarians
are “Jay” vegans which belong to and have faith inMahayana Buddhism, They are more restricted
than general vegetarians, since they don’t consume
meat, poultry, seafood, or any animal products
including eggs, milk, honey, etc. Besides, Jay
vegetarians also prohibit 5 kinds of pungent
vegetables including garlic, onion, single-headgarlic, chive and tobacco. Spiritually, they have tofollow basic Buddhist precepts by thinking,speaking and doing right behaviors especiallyduring the 10-days Jay Vegetarian Festival during
September October. “Jay” actually comes from a
Chinese word, Jain” (no killing) which saves a great
the number of animals.
In conclusion, there are different types ofvegetarians according to a variability of foodcomponents. Compared to non-vegetarians, theymainly consume plant foods containing moreessential compounds and non-nutrients. The healthbenefits of vegetarian diet in the prevention of
NCDs have been reported. ADA and DC concluded
that appropriately planned vegetarian diets are
nutritionally adequate and may be beneficial to theprevention and treatment of certain diseases
including CVDs, atherosclerosis and hypertension.
However, the variable difference of dietarycomponents among vegetarian individuals can leadto the unbalanced diets. To have adequate andbalanced intake of the essentials, vitamin B12 andomega-3 fatty acids, vegetarians should need moreeducation about sources of specific nutrients fortheir healthy life.

2)

Li D. Effect of the vegetarian diet on noncommunicable diseases. J Sci Food Agric.
2014 Jan 30;94(2):169-73.
3) American Dietetic Association; Dietitians ofCanada. Position of the American Dietetic
Association and Dietitians of Canada:
Vegetarian diets. J Am Diet Assoc. 2003 Jun;
103(6):748-65.
4) Craig WJ, et al. American Dietetic Association.
Position of the American Dietetic Association:
vegetarian diets. J Am Diet Assoc. 2009;
109(7): 1266-82.
5) Tammy Y N, Tong et al. Risks of ischemic
heart disease and stroke in meat eaters, fisheaters, and vegetarians over 18 years of followup: results from the prospective EPIC-Oxford
study. BMJ 2019; 366:l4897.
6) Mahmood SS, Levy D, Vasan RS, Wang TJ.
The Framingham heart study and theepidemiology of cardiovascular disease: A
historical perspective. Lancet. 2014; 383:999–
1008.
7) Kannel WB. Lipids, diabetes, and coronary
heart disease: insights from the Framingham
Study. Am Heart J. 1985;110(5):1100–1107.
8) Craig WJ. Health effects of vegan diets. Am J
Clin Nutr. 2009;89:1627S–1633S.
9) Saunders AV, Davis BC, Garg ML. Omega-3
polyunsaturated fatty acids and vegetarian
diets. Med J Aust. 2013 Aug 19; 199 (S4):S226.
10) Pawlak R. Is vitamin B12 deficiency a risk
factor for cardiovascular disease invegetarians? Am J Prev Med. 2015 Jun;
48(6):e11-26.
11) Wiwanitkit, V. et. al.. Red blood cellparameters of Thai vegansc compared with
non‐vegetarians. J Nutri Environ Med. 2009;14. 303-306.
12) Krajcovicová-Kudlácková M, et al.Homocysteine levels in vegetarians versus omnivores. Ann Nutr Metab. 2000;44(3):135-8
13) Takenaka S, et. al. Feeding dried purple laver(nori) to vitamin B12-deficient rats
significantly improves vitamin B12 status. Br J
Nutr. 2001Jun;85(6):699-703

Maitree Suttajit
Department of Biochemistry,
Faculty of Medicine, Chiangmai University,
Chiang Mai, Thailand
Email:maitree.suttajit@gmail.com
REFERENCE
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Tonstad S, Butler T, Yan R, Fraser GE. Typeof vegetarian diet, body weight, andprevalence of type 2 diabetes. Diabetes Care.
2009;32 (5):791–796.

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Letter to Editor
Philippines President Rodrigo R. Duterte Supports Nutrition

Dear Editor,
No less than the president of the Philippines,
His Excellency, Rodrigo Roa- Duterte is a staunch
supporter of nutrition. He already signed into law
Republic Act 11148 - the First 1,000 Days Law.
The law seeks to scale up the national and local
health and nutrition programs through astrengthened integrated strategy for maternal,
neonatal, child health and nutrition in the first
1,000 days of life.

The Republic Act 10862 or the Nutrition andDietetics Law of 2016 was enacted to regulate andstandardize the practice of nutrition and dietetics in
the Philippines, with a provision on Medical
Nutrition Therapy through the application of
Nutrition Care Process for purposes of disease
prevention,
treatmentandmanagement.
Administrative Order 2019-0033 was recently
signed by the Secretary of Health, Dr. Francisco T.
Duque III that shall provide the mandate anddirection for public and private hospitals to
operationalize and institutionalize the Nutrition
Care Process in their respective facilities.

Another executive order, Republic Act 11037
mandates that a national feeding program forundernourished children in public elementary
school, kindergarten and day care centers. The
feeding program will be implemented in threecomponents:

Finally, the Nutritionist-Dietitians’ Associationof the Philippines (NDAP), the Association ofIntegrated
Nutritionist-Dietitians(AIPO)
recognized by the Professional Regulations
Commission has 33 chapters nationwide and (two)
2 international chapters- Qatar and United ArabEmirates, NDAP celebrates its 65th Anniversary
and Annual Convention on February 26-28, 2020
at the Conrad Hotel, Manila where speakers fromthe Academy of Nutrition and Dietetics and the
Asian Federation of Dietetics Association shallshare their expertise on the theme “Frontiers of
Nutrition: The Cutting Edge Science in Nutrition
and Dietetics.

A. School-based Feeding Program. Undernourished children from Kindergarten to Grade 6
will be given at least one fortified meal for not lessthan 120 days in a year. This will be carried out by
the Department of Education.
B. Supplemental Feeding Program for Day
Care Children. Undernourished children from 3 to
5 years of age in day care centers will be given atleast one fortified meal for not less than 120 daysin a year. This will be implemented by local
government units and the Department of Social
Welfare and Development.
C. Milk Feeding Program. Fortified meals andcycle menu are to include fresh milk and freshmilk-based food products, to be implemented by
the Department of Agriculture, Philippine Carabao
Center and the Cooperative Development Agency.

Prof. Zenaida F. Velasco,
President of Nutrition and Dietetic Association ofPhilippine

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