ISSN2434-2688 Asian Journal of Dietetics

Vol.2 No.3

2020

Contents
Page

Title and authors

Special Topic
87
Originals
89-96
97-103105-111113-120121-127

129-134

135-138

Letter to the editor
139-140
141-152

Professional Work and Rewards for Dietitians a History of Dietitians in Japan:
No. 1 in a Series
Teiji Nakamura
School Lunch Program Could Control Snacking Habits and Decreased
Energy and Lipid Intakes of 11-year-old Students in Jakarta
Indri Kartiko Sari , Diah Mulyawati Utari, Sumiko Kamoshita, Shigeru Yamamoto
Vietnam’s New Food Culture with Textured Soybean Protein Can Save the Earth
Ta Thi Ngoc, Ngo Thi Thu Hien, Nguyen Mai Phuong, Truong Thi Thu,
Nguyen Huong Giang,Dinh Thi Dieu Hang, Nguyen Thuy Linh, Le Thi Huong,
Nguyen Cong Khan, Shigeru Yamamoto
Factors in Low Prevalence of Child Obesity in Japan

Sayako Aoki, Nobuko Sarukura,, Hitomi Takeichi,, Ayami Sano,,
Noriko Horita, Yuko Hisatomi, Kenji Kugino, Saiko Shikanai

Nutritional Assessment Tools in Patients with Pulmonary Tuberculosis: A CrossSectional Study
Badder Hina Afnan, Sahar Soomro, Saba Mughal, Syed Afnan Omer Ali,
Madiha Patel, Nadeem Ahmed
Effects of Thinly Sliced Meat on Time, Number of Chews,
and Food Intake in Elderly People with Tooth Loss
Hien Ngo Thi Thu, Ngoc Ta Thi, Yen Ma Ngoc, Phuong Nguyen Mai,
Thao Tran Phuong, Thu Truong Thi, Hang Dinh Thi Dieu, Linh Nguyen
Thuy, Khan Nguyen Cong Yoshihiro Tanaka, Shigeru Yamamoto
Analysis of fiber intake and its sources in a year school lunches
at a school in Japan
Noriko Sumida, Saiko Shikanai, Nobuko Sarukura, Hitomi Takeich,
Miho Nunokawa, Nguyen Mai Phuong, Nguyen Van Diep, Nguyen
Huong Giang, Shigeru Yamamoto
Undernutrition in older adults Northern Thailand may be improved byincreasing lipid consumption
Yupa Chanwikrai, Naritsara Phanthurat, Chomnard Singhan,
Natthaphon Thatsanasuwan, Wittawat Sajjapong, Puksiri
Sinchaiyakit, Jukkrit Wangrath
The Bhutanese Way of Eating: Food for Thought for a Country in Nutrition
Transition
Passang Lhamo Sherpa
Exclusive Breastfeeding: A Review of Barriers and Enhancers to Practice in Africa
and Asia
Freda D. Intiful, Edem M. A. Tette, Ruth Pobee, Juliana Y. EnosHistory of JDA

S ca T

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Ja a : N . 1 a S

Teiji Nakamura
P e def T e Ja a D e e c A

ca/P e def Ka a a a U

Today, Asia is a highly active region withremarkable economic development. Agriculture, foodprocessing and distribution have progressed,
nutritional deficiency has been decreasing, food isabundant, and non-communicable diseases (lifestylerelated diseases) have become social problems. On theother hand, 20 to 30 years ago, in the developed
countries of Europe and America, inpatient
malnutrition appeared to be due to problems in the
nutritional management of hospital food, which
adversely affects the treatment of diseases and was
related to the increase in medical costs. As aconsequence, the importance of clinical nutrition
management has been recognized. Enteral nutritionand central parenteral nutrition have been developed
as nutritional supplements, and advanced medical
technology has become necessary. This situation is
spreading to Asia, and the establishment and reform of
the dietitian system are progressing in each country.
About 150 years ago, Japan was the first country
in Asia to introduce nutrition science, and over the past
100 years, it has developed the current dietitiansystem. Based on that experience, I have examined
methods for further developing nutrition in Asia.
The most important aspect of nutrition
improvement is to train dietitians who are specialists
in nutrition improvement in the region or country andto establish nutrition as a profession in society. For
nutrition to become a profession, it is necessary to
clarify that nutrition is a profession and that the workof dietitians should be adequately compensated. The
reason why the dietitian system is immature in some
Asian countries is that "professional work and reward"
as a dietitian are often not established and recognized.
For example, in the latter half of the 20th century,
when the importance of clinical nutrition was widely
accepted, there were proposals in Europe and theUnited States to train medical doctors to become
specialists in clinical nutrition. The International
Confederation of Dietetic Associations (ICDA) statedthat ‘nutrition improvement cannot be solved only by
medical doctors who have medical education centeredon physiology and biochemistry but dietitians who
have knowledge and technology in food science,cooking science, life science, education and guidancetheory as well as physiology, biochemistry,
microbiology, public health, pharmacology and others
are required. The ICDA worked on these mattersthrough various international organizations andcurrently countries in Europe and North America do
not train medical doctors as nutrition specialists. In
Japan, not only medical doctors but also nurses,
pharmacists, clinical technologists, physiotherapists,
and many other specialists who are interested inCorresponding author: aka

e

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ce

nutrition for team medical care currently study
nutrition; however nutritional education, guidance
and management are tasks of dietitians.
If this “clarification of professional work andrewards” is established, for example, in medical care,it will be inevitably incorporated into the medical
system, and hospital income will increase due to thefees for dietitians. Therefore, hospitals actively
employ dietitians. For example, in Japan, if aregistered dietitian at a hospital gives "nutrition anddietary guidance" to inpatients who are admitted to thehospital, the usual charge will be 2600 yen (about 24
US $) for the first consultation, 2000 yen (about 18 US$) for the second and subsequent times, and 1800 yen(about 16 US $) for remote instruction using IT, andfor home visit instruction 5300 yen (about 50 US $)will be paid as a medical treatment fee. Suchnutritional dietary guidance is paid for in the same way
even if it is conducted for outpatients in a clinic. In
addition, medical fees will be added if a registereddietitian participates in a convalescent rehabilitation
ward, nutrition support team, palliative care, cancer
chemotherapy, intensive care unit, or bed sores
countermeasure team. It means that by hiring a
registered dietitian, the labor costs of a hospital can be
sufficiently supplemented by the contribution of
rewards for dietitians.
However, in Japan, it took about 30 years to reachsuch a situation. The initial nutritional dietary
guidance fee was only ¥50 (about half of one US $).
The current system is the result of efforts made step bystep in cooperation with administrative nutrition
specialists in the central government, politicians, andthe Japan Dietetic Association (JDA).
In Japan, when dietitian training started and theDietetic Association was established, the leaders of
JDA were medical doctors. However, the goal of theassociation was the independence and development ofdietitians. As the roles of dietitians become highly
specialized and dietitians grew in number and became
independent, medical doctors moved away from theDietetic Association, and nutritional dietary educationand hospital meal management became the duties of
dietitians.
Recently, I published a book that clarified thehistory and actual state of nutrition in Japan (1) hoping
to encourage the development of Asian dietitians anddietetic associations and to benefit people in other
Asian countries.
Rc1) “Japan Nutrition Unraveled by Teiji Nakamura”,
Daiichi Publishing 2020.

a- @k h .ac.j87

Asian Journal of Dietetics, 2020

Original
School Lunch Program Could Control Snacking Habits and Decreased
Energy and Lipid Intakes of 11-year-old Students in Jakarta
Indri Kartiko Sari 1*, Diah Mulyawati Utari2,3, Sumiko Kamoshita3, Shigeru Yamamoto1,3
1International Nutrition, Graduate School of Human Life Science, Jumonji University
Public Health Nutrition Department, Faculty of Public Health, Universitas Indonesia
3
Asian Nutrition and Food Culture Research Center – Jumonji University
2

ABSTRACT There is currently no school lunch program implemented in Indonesian publicschools. Under current conditions, children are likely to be susceptible to lifestyle-relateddiseases as indicated by the increasing prevalence of childhood overweight and obesity year by
year due to uncontrollable dietary habit. The purpose of this study was to evaluate theimplementation of a school lunch program in a Jakarta public school and its effect on students’nutrition and food intake and habitual patterns. A total of 50 students, 11-year-old 5th gradersfrom two classes, participated in this study. In a crossover study design, the intervention was aschool lunch program providing a school lunch meal for one week (5 days), termed School Lunch
Week. The control was one week of five regular days (Regular Week). Outcome parameters
were the nutrition intake and changes in habits during Regular Week and School Lunch Week
for all the children. The results showed a significant decrease in energy and lipid intakes (p<0.05)
and snacking frequency/day (p<0.001) during School Lunch Week. The energy contribution
from snack was decreased by 192 kcal/day (p<0.001) during School Lunch Week. The
implementation of a school meal program could control snacking habits and decrease energy andlipid intakes in schoolchildren. In conclusion, the establishment of a school meal program should
be considered in order to foster beneficial dietary habits in Indonesians.
Keywords: Jakarta, snacking habit, school lunch, school meal, childhood nutrition

INTRODUCTION
School life is the beginning of a lifetime healthinvestment for schoolchildren. There are many
challenges to establish an early healthy lifestyle inchildren. Dietary habits that last a significant part of ahuman life are critically established during childhood.
However, unhealthy dietary habits such as high energy
and lipid intakes are commonly found in children, which
can lead to lifestyle-related disease later in life.
According to national basic health research, it was foundthat 19% of children in Indonesia suffer fromoverweight and obesity, with Jakarta children having thehighest prevalence of 30% (1).
Currently there is no school lunch program
implemented in Indonesian public schools, even thoughschool is a perfect place to promote healthy lifestyle anddietary habits through nutrition education and healthy
lifestyle modeling (2). Indonesian public elementary
schools usually start at 7AM and finish at 2PM with ashort first break at 9AM and a longer second break at
12AM. These break times are meant not only to take arest between learning periods, but also to let the children
have their time, for playing or eating to satisfy hunger.
With a proper nutrition intervention, children`s growth
can be boosted andtheir health status eventually improved (3,4). A school
lunch program, as one nutrition intervention, can help
in solving health and nutrition problems in school-age
children (5,6). The purpose of this study is to evaluate
the implementation of a school lunch program in a
Jakarta public school and its effect on children’s food
habits and nutrition intakes.
METHODSThis study was conducted with a monocentric,
controlled, crossover design to assess the efficacy of aschool meal program in students at a public school. The
study was done in accordance with the Helsinki
Declaration and was approved by the Ethical Committeeof the Faculty of Medicine, Universitas Indonesia. The
study was conducted at a public school in Jakarta inwhich regular activities of the students were maintained(no special intervention during break time). The location
was purposively selected based on the local district
education committee‘s permission: no similarintervention had been conducted at the school and theselected school agreed to be the study site. The subjects
were 11-year-old 5th graders who had already been
assigned to two classes, with 25 students in each

*To whom correspondence should be addressed: indri.kartiko@yahoo.com
89School Lunch Program in Jakarta, Indonesia
class, for a total of 50 students. Inclusion criteria
included healthy children of 5th grader who had
obtained signed informed consent from their parents.
Exclusion criteria were 5th grader suffers any chronic
diseases.
The intervention was a school meal programproviding school lunch meals during break time for aweek (5 days) designated as School Lunch Week.
Another week without intervention and with normal
activities during break was designated as Regular Week.
The lunch menu provided on average 600kcal, about
30% of total energy RDA. School lunch menus werecreated by the researchers. The menus are shown in
Figure 1 and included rice as the staple food, a side dishof plant protein (tempeh, tofu), animal protein (egg,chicken, beef), and a vegetable dish. Data collection was
conducted on students’ characteristics and food habitswith question items shown in Table 1, anthropometricmeasurement, and nutrition intakes with 3-day/24-hour
recall methods in both Regular Week and School Lunch
Week. During School Lunch Week, there was norestriction on what could be consumed on during
afternoon break. However, there was a requirement of
eating the school lunch meal together in the classroom
first before the children could spend the rest of breaktime as they liked. During Regular Week, the rest of the
break time was spent in the students` regular activities.
Statistical analysis were conducted with paired
Student`s t-Test (p<0.05).

Figure 1. School lunch menus for one week

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

Table 1. Questions for student`s characteristics and food habits
Question items
Who does meal preparation at home?
Is your mother living with you? If yes, what does she do? (Occupation)
Who influences you to buy snacks? (Multiple answers)
Do you usually bring a lunch box from home?
Do you eat breakfast every day?
What do you eat for breakfast?
How many times do you buy snacks in one day? (Frequency)
What kind of snacks do you usually buy/eat? (Multiple answers)
What kind of beverages do you usually buy/drink? (Multiple answers)
Let`s review what you had to eat yesterday! (Food recall)90

Asian Journal of Dietetics, 2020
RESULTS
There were 48 children who completed the study.
Data for two children were dropped due to their absences
during the study and incomplete data collection. The
school lunch program was conducted during the second
break, the last break before the children finish the school
day and then go home or go for extra-curricular activities.
The subjects were 11-year-old students (5th graders in
two classes, 5A and 5B) of one Jakarta public schoolwith a total of 50 students. Of the total, two students
dropped out due to incomplete data. Table 2 shows the
BMI information of the subjects. The average BMI(kg/m2) of all students was 18.1±2.9 with average BMI
of boys and girls were 17.9±2.9 and 18.4±3.2,
respectively. Figure 2 shows subjects` BMI categories
percentages (%) whereas in boys and girls were 56 and70 normal, 20 and 22 overweight, 12 and 4 obese, and

12 and 4 underweight, respectively. Table 3 shows theresults of the subjects’ basic characteristics and food
habits in percentage. For question “Who does meal
preparation at your home?”, the percentages were 87.5%
mother, 2.1% grandparents, 8.3% housekeeper, and2.1% take-out food. For question “What is your mother‘soccupation?”, the percentage of their occupations were
36% stayed-home housewives and 64% working
mothers (entrepreneur, private employee, government
official, etc). For question “Who influences you to
buy/have snacks?”, the multiple answers show 68.4%
came from friends, 35% siblings or relatives, 28.9% TV
commercials, 28.1% parents, and 7% from online
advertisements. For question “Do you usually bring alunch box to school?”, 58% responded No and 42%
responded Yes.

Table 2. BMI information of the subjects (n=48)
BMI (kg/m2)
BMI information
mean ± SD
All student (n=48)
18.1 ± 2.9
Boys (n=22)
17.9 ± 2.9
Girls (n=26)
18.4 ± 3.2
Data are shown in mean ± SD
Figure 2. Subject`s BMI categories percentage

Table 3. Subject`s basic characteristics and food habits in percentage (n=48)
No
Subjects` characteristics and food habits
Percentage (%)
Who does meal preparation at your home?
1.
87.5
Mother
2.1
Grandparents
8.3
Housekeeper
2.1
No one, eating take-outs
What is your mother‘s occupation?
2.
36
Stay-home housewives
64
Workingmothers(entrepreneur,
privateemployee, government
official, etc)3.
Who influences you to buy/have snacks?
(Multiple answers)
68.4
Friends
35.1
Siblings, relatives
28.1
Parents
28.9
TV commercials
7
Online advertisements
Do you usually bring a lunch box to school?
4.
42
Yes
58
No

91

School Lunch Program in Jakarta, Indonesia
Table 4 shows the results of food related habitsduring Regular Week and School Lunch Week inpercentages. For question “Do you eat breakfast every
morning?” was separated into three categories of
having breakfast every morning, some mornings, andno breakfast, with results during Regular Week andSchool Lunch Week were 58.3% and 62.5% havebreakfast every morning, 37.5% and 35.4% somemornings, and 4.2% and 2.1% no breakfast,
respectively. For question “What do you eat for
breakfast?” shows the breakfast food patterns, whichwere separated into categories of milk + bread,
porridge, and rice + dish(es). During Regular Week,
students’ breakfast was 67.3% rice + dish(es), 27.2%
milk + bread, and 5.5% porridge. During School Lunch
Week, breakfast was 60.7% rice + dish(es), 30.4% milk
+ bread, and 8.9% porridge. For question “How manytimes do you buy/have snacks in a day?” was separated
into categories of snacking frequency from 1 – 6 times.
Further analysis of snacking frequency is shown indetail on Figure 3.

Table 4. Food related habits during Regular Week and School Lunch Week in percentage (n=48)
No
1

2

3

Food related habits
Do you eat breakfast every morning?
Yes, every morning
Sometimes
No, no breakfast habit
What do you eat for breakfast?
Milk + bread
Porridge
Rice + dish(es)How many times do you buy/have snacks in a day?
1 times
2 times
3 times
4 times
5 times
6 timesFigure 3 shows the average daily snacking
frequency. During Regular Week, snacking frequency
for one day was 3.2±1.0 times and it was decreased to
2.9±1.1 in School Lunch Week (p<0.05). Figure 4
shows the snack patterns for question “What kind of
snacks do you usually buy/eat?”. Snack patterns during
Regular Week include 44% fried foods, 14% coconut
rice, 8% noodles, 7% sweet bread, 7% meatballs, 4%seblak, 5% macaroni, 4% soto, 3% porridge, 2% shumai,
and 2% other. Snack patterns during School Lunch
Week include 52% fried foods, 15% coconut rice, 8%
noodles, 5% meatballs, 3% seblak, 4% macaroni, 2%

Regular Week (%)

School Lunch Week (%)

58.3
37.5
4.2

62.5
35.4
2.1

27.2
5.5
67.3

30.4
8.9
60.7

4.1
18.8
43.8
25
6.3
2.0

8.3
31.3
29.2
20.8
10.4
0

soto, 4% porridge, 4% cilok, and 3% others. Figure 5
shows beverages patterns for question “What kind ofbeverages do you usually buy/drink?”. Beverages
patterns during Regular Week include 33% sweet tea,
22% milkshake powder, 10% flavored milk, 10% ice
sweet milk, 7% mixed ice, 7% ice cream, 3% tea
beverages, 3% jelly drink, 3% juice powder, and 2%
other. Beverages patterns during School Lunch Week
include 33% sweet tea, 22% milkshake powder, 4%flavored milk, 17% ice sweet milk, 10% mixed ice, 5%
ice cream, 3% tea beverages, 2% jelly drink, 2% juice
powder, and 2% other.

Regular Week

School Lunch Week

Figure 3. Daily snacking frequency (mean ± SD) (n=48)*Significantly different at p<0.05

92

Asian Journal of Dietetics, 2020
Regular Week

School Lunch Week

Figure 4. Snack patterns during Regular Week and School Lunch Week

Regular Week

School Lunch Week

Figure 5. Beverages patterns during Regular Week and School Lunch Week

Table 5 shows energy and nutrient intakes per day
during Regular Week and School Lunch Week. There
were significant decreases in both energy and lipid
intakes during School Lunch Week (p<0.05). Protein,carbohydrate, and fiber intakes remained unchanged.

Figure 6 shows calorie contribution from breakfast,
lunch, dinner, and snack. There was a significant
increase in calorie contribution from lunch (p<0.001),
also a significant decrease in calorie contribution fromSnack (p<0.001) during School Lunch Week.

Table 5. Nutrient intakes during Regular Week and School Lunch Week (n=48)
Nutrient Intakes (per day)Regular Week (mean±SD)
School Lunch Week (mean±SD)
Energy (kcal)
1852±328
1709±297*
Protein (g)55±16.553±13.6
Lipid (g)74±18.6
67±16*
Carbohydrate (g)240±66223±47
Fiber (g)6±2.7
6.4±2.5*Significantly different at p<0.05

93School Lunch Program in Jakarta, Indonesia

Figure 6. Daily calorie contribution from breakfast, lunch, dinner, and snack (n=48)
Significantly different at *p<0.05 and **p<0.001, respectively
DISCUSSION
The study results show that 32% boys and 26%
girls were overweight and obese, which was close tonational basic health research data (1). This indicatesthat the data from this study are representative of theactual population. There were study results which canshow that school meal program have favorable impacts
in schoolchildren.
Food habits of the children in terms of bringing alunch box was that more than half of the children didn’t
bring one have the habit, which explains the habit ofbuying food during break time. From the mother`soccupation result, assuming that one third of mothers areworking at home and the remaining two thirds areworking mothers, it is understandable that meals may
not always be prepared at home and that bringing alunch box to school is less prevalent. Bringing a lunch
box meal from home usually tended to provide adequate
daily nutrition for the children (7). A lunch box meal canalso become one good tool to prevent excessive intake
of sugar, lipids, and sodium from fast foods (7-9). For
both reasons, a lunch box meal is an option to establish
favorable dietary habits which is effective if a school
meal program remains unimplemented.
The habit of having breakfast might be related withthe habit of bringing lunch meal box. Once breakfast isskipped, easy to develop the habit of skipping breakfast,and it is very likely to have a correlation with more
frequent snacking during the day (10). Another study onskipping breakfast in children and adolescents foundthat skipping breakfast was associated withoverweight/obesity and highly associated in children
with working mothers (11). However, in our study it was
found that having breakfast at home was already aregular habit. This might be another reason why thechildren didn’t have the habit of bringing a lunch box
from home aside from the mothers` occupation status,
because the children were already eating breakfast athome before school. In other words, the snacking
frequencies might be influenced by something otherthan breakfast habits, which is likely due to the fact that
there is no school meal program to satisfy children’s
hunger during the school day.
Since bringing lunch from home is an option andthere is no school meal program, children satisfy theirhunger by buying foods and drinks from the food stallsin the area around the school. There are many factorsthat affect snacking habits. About 70% of snacking
influence comes from friends, which also explains theimpact that peer pressure can have on snacking habits.
Despite no difference found in snacking patterns, thesnacking frequency showed a significant decreaseduring School Lunch Week. Seventy percent of thechildren were snacking 3-4times on a usual day. This
became less frequent, dropping to 1-3times on a School
Lunch Week. This shows that the school lunch can help
in controlling the snacking habit and in reducing dailysnacking frequency. Studies in countries like Vietnam
show the effectiveness of a school lunch in reducing
snacking frequencies and total energy from snacks (12).
As for the snacking patterns, half of the snack
patterns was fried foods. It doesn’t matter that the sizeof fried foods had changes. Although fried foods was
10% higher during School Lunch Week, the decrease of
total energy and lipid intake during the day of School
Lunch Week could be marked by lower fried foods
intake. Fried foods itself are easy to prepare, in terms offood safety and efficiency, and can be served as quickly
as possible (13-15). This means that anybody can
prepare fried foods, including meal prepper at home,much likely that the source of fried foods during School
Lunch Week came from home. For the beverages
patterns, the most popular drink was sweet tea, followedby milkshake powder drink. These drinks are also fastand easy drinks to prepare and are accessible to thechildren. The classification of snack can be separated
into quality and composition (13-15). Higher quality
snacks has richer nutrients than low quality snacks, forexample an apple and a glass of milk compared with94

Asian Journal of Dietetics, 2020
fried foods and sweets (13-15). Children usuallyconsume lower or no quality foods because the foods areeasily accessed either in the school or at home (13-15).
A previous study found that school meal programs
and nutrition education for school – children can provide
adequate intake of energy, protein, carbohydrate, andfiber (16). In our study, it was found that energy andlipid intakes were decreased during School Lunch Week.
Moreover, when the energy contribution from breakfast,
lunch, dinner, and snacks were compared, it was foundthat during School Lunch Week, energy from lunch wasincreased and energy from snacks was decreased. These
results show the favorable effects of school lunch incontrolling energy and lipid intakes and also the energy
contribution especially from snacks. School-based
nutrition intervention programs are effective inestablishing favorable dietary habits in children (16–18).
In this case, a school meal program was proven effective
even though it was conducted for only one week.
A school lunch program can improve the daily
nutrition contribution based on the RDA of children 11
years old. One third of the RDA intake can be provided
by the school lunch and our lunch meal provided on
average 600kcal/day. The energy contribution from
Lunch was increased to 32% because there is a lunch
meal to provide adequate energy despite there wascommon picky eater problem of some of the children
didn’t finish the provided lunch meal, not finishing thevegetable or not liking the tofu or tempeh we provided
for them. School lunch was served at break time and it
was mandatory to eat the school lunch meal first before
students could go on to other activities such as playing
with friends or even buying additional snacks. As for the
additional snacks the children might buy after eating theschool lunch meal, it can be assumed that the children
didn’t buy fried foods as snacks, by the reason of thedecrease in their lipid intake. Excess energy intake inschool – children mostly results from snacking habits,
despite its one purpose to satisfy hunger and eventually
to meet energy and nutrient intakes (12, 19). With noschool meal program, during the longer break timechildren will satisfy their hunger through uncontrolled
snacking. Some of the children usually consumed fast
food from fast food restaurant chains with their family
outside school time or during weekends.
There was no significant difference in protein
intake. It already met the protein recommendation fordaily protein intake. The recommendation for protein
intake in Indonesia includes three portions of animal
protein like fish, meat, egg, milk, etc and three portionsof plant protein like beans, bean products like tofu,
tempeh, and fermented soybean like oncom (20). The
lunches in this study included either one portion ofanimal protein or one portion of plant protein, which
contributed at least 30% of RDA.

95

There is a reason why a school meal program is notestablished yet. Ninety percent of Indonesian schools
are public schools. The school management is under the
Ministry of Education. Even now, the government is still
struggling to provide universal education in all areas ofIndonesia. Inequality and social disparities are still high.
Funding for education is one of the problems, not tomention funding for a school meal program. However,
if a school meal program is provided/introduced attargeted area like Jakarta at the beginning, other areas
may follow this example and may start school meal
programs as well. There are methods on how to establish
a school meal program, one example being the Japanese
school meal program. The Japanese school meal
program includes the employment of at least one
licensed registered dietitian/nutrition teacher to help
create 200 different menus/year that meet the dietaryreference intakes and have high consideration and givepriority to locally sourced food and introduce national
food culture and tradition (21–22). The dietitian will
work in the school kitchen or work at a district kitchen
to serve several schools simultaneously (21–22). On thestakeholder level, it might be necessary to have legal
developments for a school meal program in Indonesia.
In Japan, Shokuiku Basic Act involves the promotion ofnutrition education throughout the life cycle, including
the school lunch program (22). Since it starts at an earlyage, it may also be a positive force in instilling healthy
food habits during childhood (22).
This study has the limitation that the school meal
program could be implemented for only one week (fivedays). It was not possible to see the longer-term effectsof the school meal program like changes in breakfast
habits, snacking influence resources, the timely periodof snacking, and the nutritional status of the children
themselves: their BMI status. A longer period such as
one month or two months might change on thesevariables, especially when a decline in overweight andobesity is the target. In conclusion, a school meal
program could control the snacking habits and decreaseenergy and lipid intakes in Jakarta school-children andthe establishment of school meal program should beconsidered.
ACKNOWLEDGEMENTS
Acknowledgements are gratefully given for the
support from Kieikai Foundation, to the members of
the Laboratory of Nutrition Universitas Indonesia, theschool headmaster Mrs Sutiyati and teacher in charge
Mrs Windarti, school staffs, students, and parents,
members of Asian Nutrition and Food Culture ResearchCenter, and Prof. Andrew Durkin of Indiana University
for careful proof-reading of the paper.

School Lunch Program in Jakarta, Indonesia
CONFLICT OF INTEREST
There is no conflict of interest in this study.

11) Koca T, Akcam M, Serdaroglu F, Dereci S.
Breakfast habits, dairy product consumption,
physical activity, and their associations with bodymass index in children aged 6–18. Eur J Pediatr.
176(9): 1251 – 1257. 201712) Thao Nguyen Thi. A Study of energy intake bychildren with and without school lunch in Hanoi.
Thesis – Jumonji Universiy 2018. (in Japanese)
13) Ishak SIZS, Shohaimi S, Kandiah M. Assessing thechildren’s views on foods and consumption of
selected food groups: outcome from focus group
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Skuland SJ. Are School Meals a Viable andSustainable Tool to Improve the Healthinness andSustainability of Children’s Diet and Food
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Perspective. Critical Reviews in Food Science andNutrition 57:18.3942-3958. 2016.
6) Miyawaki A, Lee JS, Kobayashi Y. Impact of the
School Lunch Program on Overweight and Obesity
among Junior High School Students: a Nationwide
Study in Japan. J Public Health 41(2): 362 – 370.
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7) Roberts-Gray C, Briley ME, Byrd-Williams CE,
Sweitzer SJ, Sharma SV, Palafox MR, Hoelscher
DM. Efficacy of the Lunch is in the Bagintervention to increase parents’ packing of healthy
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96

Asian Journal of Dietetics, 2020

Original
Vie a

Ne F

dC
e i h Teed S
Ca Sa e he Ea h

bea P

ei

Ta Thi Ngoc1*, Ngo Thi Thu Hien1, Nguyen Mai Phuong1, Truong Thi Thu2,
Nguyen Huong Giang1,Dinh Thi Dieu Hang2, Nguyen Thuy Linh3, Le Thi Huong3,
Nguyen Cong Khan2, Shigeru Yamamoto1
1

J m nji Uni e i , Nii a, Sai ama P efec e, Ja an
Hai D ng Medical Technical Uni e i , Hai D ng, Vie nam
3
Han i Medical Uni e i , Han i, Vie nam
2

ABSTRACT Backg nd ande. Raising li estock to meet the demand of meat forhuman being e erts detrimental pressure on the en ironment and natural resources. With theie of sa ing the Earth b eating less meat, meat analogs are gaining popularit orld ide.
Among these foods, Te tured So bean Protein (TSP), a b -product of the oil e tracting process,is rich in fiber (13.6g/100g) and a good protein source (about 56g/100g). Substituting TSP formeat in the diet ma ha e beneficial effects in pre enting lifest le-related diseases as ell asin preser ing the Earth. P
e. To establish a ne food culture ith Te tured So bean
Protein and to assess the palatabilit of TSP dishes. Me h d. There ere t o phases in thestud . Phase 1: The research group created ne menus using TSP. From the traditional recipes,
meat as replaced ith TSP to make 16 menus. Menus that ere considered to be the tastiest
and that contained 20g of TSP ere selected for use in the ne t phase. Phase 2: The
acceptabilit of ne dishes using TSP as assessed in comparison ith the control dishes(cooked ith meat). 24 ordinar people ere randoml selected from the communit . A
sensor test as conducted, and the score for each dish as established b using a Hedonic 5point scale. Subjects (n=24) ere asked to eat 2 dishes ith 40g of TSP e er da for 4 eeks
consecuti el to e aluate their tolerance of ne food in their dail dietar pattern. A
questionnaire as created to elicit the subjects opinions after 4 eeks. Re l . The a erage
e aluations of the 10 TSP dishes and control dishes ere 3.9 and 4.2 points for o erall taste.
E aluations of the TSP dishes ere close to those of the control dishes, ith no significant
difference (p>0.05). The results from the questionnaire indicated that 75% of the subjects ere
pleased ith the amount of 40g TSP in 2 dishes per da ; the suggestion of ha ing TSP dishes
for 3-4 da s as considered reasonable and the digesti e status as acceptable for 79% ofsubjects. There as no significant difference in total energ intake, but lipid intake and animal
protein significantl decreased (p<0.001). Fiber as significantl increased, b 6g (p<0.001).
C ncl i n. We found that TSP dishes ere highl acceptable for Vietnamese people. TSP canbe a good non-meat food source and pro ide adequate fiber and protein, hich ma create
beneficial health effects as ell as pre enting detrimental effects to the en ironment caused bmeat consumption.
KEY WORDS: Te tured So bean Protein, meat analog, li estock, en ironment.

INTRODUCTION
Meat-Free Monday (2009) is an international
campaign which aims to raise awareness of thesignificant
consequencesof
globalmeat
consumption. Raising livestock for meat is
responsible for about 14.5% of total anthropogenic
greenhouse gas (GHG) emissions, including methanegas ( a gas which has an effect on global warming 28
times higher than carbon dioxide) and nitrous oxide (a* To whom correspondence
tangoc2707@gmail.com

shouldbemolecule with a global warming potential 265 times
higher than carbon dioxide) (1). Meat production
currently adds 0.15 giga metric tons of methane and0.0065 giga metric tons of nitrous oxide to theatmosphere annually. If the climate system is allowed toreach equilibrium with this level of GHG emission anddecay (which would take about a decade for methane andabout a century for N2O), then the earth would be 0.44°C
warmer. Animal agriculture is also a sector which
requires a significant amount of natural resources likewater and landmass when compared with other foods as

addressed

97

New food culture of soy bean meat in Vietnam
a protein source (2). In addition, excessive consumptionof meat and meat products is often associated withoverconsumption of energy and fat, resulting in excess
weight, obesity and an increased risk of chronic diseases,
such as cardiovascular disease and type 2 diabetes.
Besides, according to the Vietnamese general nutrition
survey 2009-2010, the average vegetable consumption
in Vietnam was about 190g/day (3). This amount wasless than the RDA for adults (300g/d). There was asimilar situation for fiber intake; Vietnamese consumed
about 9g/day, which meets only half of the RDA
recommendation at 20g/day (4). The role of fiber incontrolling metabolic disease is well documented (5).
Therefore, dietary treatment increasing fiber intake,decreasing meat consumption in the Vietnamese dietary
pattern can be important factors in making a positive
difference in slo ing climate change, preser ing Earth s
irreplaceable natural resources, and an improving health.
Textured Soybean Protein (TSP) is a meat analog which
is produced through an extrusion process. The
defatted thermoplastic protein is heated to 150 200°C,
which denatures it into a fibrous, insoluble, porous
network that can soak up as much as three times its
weight in liquids. As the pressurized molten protein
mixture exits the extruder, the sudden in pressure causes
rapid expansion into a puffy solid that is then dried. The
dried matter is called Textured Soybean Protein, which

rich in fiber (13.6g/100g) and plant protein (about
56g/100g). These features of the product are expected tohave health effects and become a meat substitute. In
addition, many foods made from soybeans are popularand it is a common ingredient in many Vietnamese
recipes, for example: soybean sauce, tofu. Therefore,
TSP, with a taste quite similar to traditional soybean
foods in Vietnam is expected to have high acceptability
for palatability among Vietnamese people.
METHODS
There ere t o phases in the stud . Pha e 1:
C ea i g ee
i g TSP. The research groupconducted a pilot stud to find the best cooking methods
for 16 t pes of traditional dishes ith TSP replacing themeat ingredient. These dishes
ere familiar toVietnamese and did not require special cooking skills.
For all dishes, the ingredients, seasoning, and sauce ere
kept the same, the onl difference as that the meat in
the recipes as replaced ith TSP. We e plored homuch TSP could be added to the dishes and the properamount as 20g of TSP for each dish. The 16 TSP menus
ere tasted and e aluated b research group members toassess palatabilit . Then the 10 tastiest menus ere
chosen to implement in the ne t phase of the stud .
Details of the cooking methods for the 10 TSP dishes arelisted belo .

Best 10 menus with textured soybean protein
Di heSpring rollIci
TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
All ingredients are ashed and cut
into small pieces, then mi ed
together ith sauce added to makea mi ture. Spread a rice sheet on aflat surface, put a spoonful ofmi ture onto the sheet and rap it.
Pre-heated oil in a pan for 3 mins,
then fr the spring until the turn
bro n.

I g edie : TSP (20g), Rice paper (5g), Tree ear (5g),
Cellophane noodle (7g), Mushroom (3g), Carrot (20g),
Onion (20g), Duck egg (10g), Oil (5g).

Di heMalabar Soup
I g edie: TSP (20g), Spinach(80g), MSG (2g).

TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
Stir-fr Katuk in a pot for 3 mins,
add TSP, MSG. After 5 mins, add
500ml ater and boil the soup.

Katuk Soup
I g edie: TSP (20g), Katuk (80g), MSG (2g)Ici
TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
All ingredients are ashed and cut
into small pieces, then mi ed
together ith sauce added to makea mi ture. Spread a rice sheet on aflat surface, put a spoonful ofmi ture onto the sheet and rap
Pre-heated oil in a pan for 3 mins,
then fr the spring until the turn
bro n.

TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
Stir-fr sliced gourd in a pot for 3
mins, add TSP, MSG. After 5 mins,
add 500ml ater and boil the soup.

Gourd Soup
I g edie98: TSP (20g), Gourd (100g), MSG (3g).

Asian Journal of Dietetics, 2020

Tomato Sauce mi ed
vegetables

TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
Chop carrot, onion into cubes.
Lea e the peel of tomato and fr it
for 5 mins to make a tomato sauce.
Add carrot, onion to the sauce andcontinue cooking the mi ture for 5
mins. When the egetables become
tender, add TSP. To finish, stir the
mi ture for about 5 mins.

I g edie : TSP (20g), Tomato (30g), Western onion (40g),
Carrot (40g), So bean oil (2g), Fish sauce (3g)

TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
Stir-fr bean sprouts ith oil in apan for 3 mins then add loofah.
Cook the egetables ell for about
3 mins. Add TSP, MSG to the pan,continue to stir the mi ture for 3
mins.
Bean Sprouts ith
Loofah Gourd
I g edie : TSP (20g), Bean sprout (30g), Loofah gourd(100g). Oil (3g).

TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
Stir-fr mustard greens in a pot for
3 mins, add TSP, MSG. After 5
mins, add 500ml ater and boil thesoup.
Mustard Green Soup
I g edieSalad: TSP (20g), Mustard green (80g), MSG (2g).

Stir-fr Water
Morning GlorI g edie : TSP (20g), Cabbage (80g), Carrot (15g),
Ke pie sauce.

TSP is soaked in ater for 5 mins
then squee ed as dr as possible.
Boil a pot of ater then put
morning glor into it for 3 mins.
Take the ell-cooked morning
glor out. Fr garlic in a pan ith
oil, add morning glor , salt, and stirfor 3 mins before add TSP.
Continue to stir the mi ture for 5mins.

I g edie : TSP (20g), Morning glor (80g), Garlic (5g),
So bean oil (3g)

Fr TSP in a pan ithout oil for 5
mins. Soak cabbage and carrot insalt ater for 10 minus, then slice
cabbage, carrot. Mi egetables
and fried TSP.
Add Ke pie sauce to the mi ture
before eating.

TSP is soaked in ater for 5 mins,
then squee ed as dr as possible.
Stir-fr loofah in a pot for 10 mins,
add jute plant, TSP, MSG. After 5
mins, add 500ml ater and boil thesoup.
Jute Plant Soup
I g edie : TSP (20g), Jute plant (80g), Loofah (50g)
MSG (3g)

Pha e 2: A e i g he a a abi i a de a ce f e
di hei g TSP: There ere 24 ordinar people ho
participated in this phase. The subjects ere randoml selected
in a communit near Hanoi. We prepared t o kinds of foodsamples, including 10 menus ith TSP and 10 menus ithmeat (control dishes), each TSP dish and its parallel control
dish ere placed on the same table for the subjects to taste. The
score for each dish in terms of appearance, aroma, taste, te ture,o erall as recorded b using the Hedonic 5-point scale (1.
Dislike er much, 2. Dislike moderatel , 3. Neither like nor
dislike, 4. Like moderatel , 5. Like er much). After
finished the sensory test, all subjects ere asked to eat 2
dishes ith 40g of TSP e er da for 4 eeks consecuti el .
The t o TSP dishes ere prepared and deli ered dail to thesubjects to eat at lunch and dinner. A nutrition sur e (3 nonconsecuti e da s) as conducted one eek before andthroughout the 4- eek inter ention period, using a food diarrecord. From the record, parameters including total energ ,total protein, animal protein/total protein, carboh drate, lipid,
and fiber ere anal sed to assess the change in dail diet after
adding the TSP dishes. At the end of the stud , a questionnaire
as created to inter ie the subjects about their tolerance forthe ne foods. Statistical anal ses ere conducted b paired

Student t-test using SPSS soft are ersion 20
QUESTIONNAIRE
Q1. Could you describe how
did you feel about the amountof 40g TSP in 2 dishes whichwere delivered to eat daily for
4 weeks?
A. Too much.
B. Enough.
C. Too little.

Q3. What would you
suggest for frequency ofusing TSP product in yourdiet per week?
A. 1-2 days per week
B. 3-4 days per week
C. 5-6 days per week
D. 7 days per week

Q2. What would you suggest
as a proper amount of TSP ineach dish?
A.Higher than amount served
B.The same as amount served
C.3/4 served amount
D.Half of amount served

Q4. After 4 weeks eating
TSP dishes, how was yourdigestive status?
A. Non-ulcer dyspepsia
B. Digest comfortably
C. Feel hungry faster
D. Others

Thank you very much for completing the questionnaire!

99

New food culture of soy bean meat in Vietnam
RESULTS
Table 1 shows the number of subjects and averageage by gender. There were 24 subjects (9 males and 15
females) who participated into the study. The average
age was about 63 years old. Table 2 shows thecomparison of the sensory test between 10 TSP dishes
and 10 control dishes. The average score of the 10 TSP
dishes and control dishes were 3.9 and 4.2 points foroverall taste, 4.1 and 4.4 points for appearance, 3.9 and4.3 points for aroma and 3.8 and 4.4 points for basic
taste, and 3.9 and 4.4 points for texture, respectively. The
palatability of TSP dishes was close to that of the control
dishes (cooked with meat) with no significant difference(p>0.05) among the 10 dishes of each kind of foodsample. Among the 10 TSP
dishes, spring roll and stir-fry bean sprouts with loofah
were the two dishes the highest overall taste scores.
Table 1. Baseline characteristics of the subjects
NumberAge(Mean±SD)Male
960.3±3.6
Female1564±6.8Total
2462.7±6.0

Table 2. The comparison of sensory test between TSP dishes and control dishes in 10 different menus.
Sensory test

Name ofdishesFood
samples

Spring roll

Tomato Saucewith vegetables

TSP dish
Control
TSP dish
Control
TSP dish
Control

4.2±0.4
4.5±0.4
3.8±0.4
4.3±0.4
3.8±0.4
4.4±0.4

Green MustardSoup

TSP dish
Control

4.2±0.5
4.4±0.4

Stir-fryMorning Glory

TSP dish
Control

Katuk

TSP dish
Control
TSP dish
Control
TSP dish
Control
TSP dish
Control
TSP dish
Control

Malabar Soup

Stir-fry Bean
Sprouts,Loofah
Gourd Soup
Salad
Jute Plant Soup
Average

Appearance(Mean±SD)

P

ns

Aroma
(Mean±SD)P

4.3±0.4
4.4±0.4
3.8±0.4
4.2±0.3
3.3±0.5
4.3±0.4ns

ns

4.1±0.5
4.3±0.4

4.3±0.3
4.5±0.5ns

4.1±0.3
4.7±0.4
4.2±0.4
4.5±0.4
4.1±0.4
4.6±0.3
3.8±0.4
4.4±0.4
4.2±0.3
4.2±0.3
4.1±0.4
4.4±0.4

ns

*
ns

ns
ns
ns
ns
ns

Taste
(Mean±SD)P

4.3±0.4
4.4±0.4
3.6±0.5
4.3±0.4
3.6±0.4
4.4±0.4ns

ns

3.9±0.5
4.4±0.4

3.9±0.4
4.3±0.4ns

3.8±0.5
4.5±0.4
4.2±0.4
4.4±0.4
3.8±0.5
4.4±0.4
3.6±0.4
4.1±0.2
3.9±0.3
4.1±0.3
3.9±0.4
4.3±0.2

ns

ns
*

ns
ns
ns
ns
ns

Textured(Mean±SD)P

4.2±0.4
4.5±0.4
3.9±0.6
4.3±0.4
3.6±0.4
4.3±0.4ns

ns

3.9±0.5
4.4±0.4

3.9±0.4
4.5±0.4ns

3.7±0.5
4.5±0.4
4.2±0.4
4.4±0.4
3.7±0.3
4.4±0.4
3.7±0.5
4.2±0.3
3.7±0.3
4.4±0.4
3.8±0.5
4.4±0.4

*

*
ns

ns
ns
*
ns
ns

Overall(Mean±SD)P

4.3±0.4
4.4±0.4
3.7±0.4
4.1±0.3
3.6±0.4
4.2±0.3ns

ns

3.9±0.5
4.2±0.3ns

4.0±0.3
4.3±0.5ns

3.9±0.3
4.4±0.4ns

4.2±0.5
4.6±0.4
4.2±0.4
4.5±0.4
4.2±0.5
4.6±0.4
3.6±0.5
4.1±0.2
3.9±0.3
4.1±0.3
3.9±0.4
4.4±0.4ns

3.9±0.4
4.5±0.4
4.2±0.4
4.4±0.4
3.9±0.4
4.4±0.4
3.6±0.4
4.2±0.3
3.8±0.2
4.2±0.3
3.9±0.4
4.2±0.3

ns

ns
ns

ns
ns
ns
ns
ns

*
ns

ns
ns
ns
ns
ns

* Significant difference by paired Student t-test between TSP dishes and Control dishes at p <0.05.
Figure 1 illustrates the tolerance of TSP dishes
after 4 weeks consumption. Each pie chart stands for
one question in the questionnaire. For 40g TSP in thediet, 75% of subjects could tolerate it, the remaining
subjects answered that it was too much for them. Therewas 54% who suggested 40g of TSP as a reasonableamount to eat and 21% wanted the amount of TSP
increased to more than 40g, 12% suggested ¾ of theamount served in the study. Almost all subjects (76%)
answered that they would like to have TSP dishes 3-4days per week. There were about 80% of subjects
whose digestive status was normal without any
problems of constipation, diarrhoea and or non-ulcer
dyspepsia.

Using TSP dishes in the daily diet for 4 weeks did
not cause significant changes in total energy intake,total protein, or carbohydrate (p>0.05) (Shown in
Table 3). Although the amount of total protein wasslightly increased (no significant different) but animal
protein was dramatically decreased from 29 g to about
17g (p<0.001), which changed the ratio of animal
protein/total protein from 51% to 28%. In addition,subjects lipid intake as also reduced significantlwith p=0.001. The data indicated that fiber intake wassignificantly increased (6g) when compared with thediet without TSP dishes.

100

Asian Journal of Dietetics, 2020

Figure 1. Assessing the acceptability of TSP dishes among subjects after 4 weeks.
Table 3. Comparison of the changes in daily diet before and after using TSP dishes for 4 weeks.
Baseline
Final
VariablesP(n=24)(n=24)
Energy (kcal/day)
1223±1741182±151
0.2
Total protein (g/day)
57.6±13.862.4±9.3
0.08
Protein (%E)(18.8%)(21.1%)
Animal protein
29.2±11.8
17.3±8.1<0.001*
Protein animal/Total protein (%)
50.6%
27.7%
Lipid (g/day)
37.8±15.6
26.5±9.2
0.001*
Lipid (%E)
27.8%
20.2%
Carbohydrate (g/day)
174.9±35.2
160.5±30.8
0.09
Carbohydrate(%E)
57.2%
54.3%
Fiber (g)6.0±2.5
11.9±3.5<0.001** Significant difference by paired Student t-test at p <0.05.

101New food culture of soy bean meat in Vietnam
DISCUSSION
The study found that the 10 new TSP dishes werehighly evaluated by the subjects scores comparable tothe meat recipes (p>0.05). In addition, by using disheswith 40g of TSP for each day substituted for meat in the
traditional Vietnamese recipes for 4 weeks, subjects cansignificantly increase their fiber intake (by 6g) comparedwith their normal diet. It is interesting to note that,
although the total energy, total protein and carbohydrate
were not significantly changed after consuming TSP in
the daily diet, animal protein and lipid witnessed a strong
decrease (p<0.001).
Vietnam has recently been facing problems ofnutrition transition, which negatively affect the meal
structure such us as increased meat, saturated fat,sweetened beverages and decreased vegetableconsumption. According to the Vietnamese general
nutrition survey 2009-2010, the average vegetableconsumption was about 190g/day (3). This amount wasless than the Vietnamese RDA for adults (300g/d) (6).
With the same situation for fiber intake, Vietnamese
consumed about 9g/day which meets only half of the
RDA recommendation of 20g/day (4). Considerable
evidence has shown the effectiveness of increasing fiber
intake in controlling lifestyle-related diseases. Metaanalysis studies have proved that increasing fiber intake
in patients with DM decreased glucose levels (7). From
another angle, meat consumption in Vietnam 2015 was
33.2kg per capita, but dramatically surged to 46.8kg per
capita in 2019 (8). Eating red meat is increasingly being
viewed as a guilty pleasure which may lead to adverse
effects on consumers as well as on the environment.
Components in meat that might be carcinogenic include
heme iron, N-nitrous compounds in many processedmeats, and heterocyclic aromatic amines and polycyclicaromatic hydrocarbons, which are formed when meat is
cooked at high temperatures; red and processed meats
might increase risk because they are usually rich insaturated fatty acids, which raise low-density lipoproteincholesterol, and processed meat might also raise bloodpressure because it is usually high in salt (2). A 4-year
observational study in the US showed that subjects who
consumed the highest levels of both unprocessed andprocessed red meat had the highest risk of all causes ofmortality, cancer mortality and cardiovascular diseasemortality. After adjusting for other risk factors, theresearchers calculated that 1 additional serving per dayof unprocessed red meat over the course of the study
raised the risk of total mortality by 13%. An extra
serving of processed red meat (such as bacon, hot dogs,
sausage and salami) raised the risk by 20%. The
researchers estimated that substituting 1 serving per dayof other foods like fish, poultry, nuts, legumes, low-fat
dairy and whole grains for red meat could lower the riskof mortality by 7% to 19%. If the participants had all
consumed fewer than half a serving per day (about 42g)of red meat, the scientists calculated, 9.3% of the deaths
in men and 7.6% of the deaths in women could have been
prevented (9). Lifestyle-related diseases such as
diabetes, dyslipidemia, cardiovascular diseases havebeen reaching alarming proportions as a result of theseabove dietary risk factors. Dietary treatment plays anessential role in controlling these diseases.
Regarding sources, fiber comes mainly fromvegetables, but most vegetables in Vietnam are low infiber with less than 2 g fiber/100g of vegetable. So, it isreally difficult to supply sufficient fiber only fromvegetables.
Textured Soybean Protein (TSP), a soy productwhich is rich in fiber (13.6g/100g) and can provide
interest in the daily diet. Hence, we wanted to takeadvantage of TSP products in Vietnam to make various
menus which would help to increase fiber intake. There
were new 16 dishes using TSP as a replacement for meatthat were created in Vietnamese cooking style. After
adjusting the taste, the 10 tastiest dishes were chosen touse in an intervention study. Evaluations of TSP dishes
were close to those of the control dishes with nosignificant difference (p>0.05) with 3.9 and 4.2 points
for overall taste. These results were compared with astudy conducted in Japan about a sensory test ofIndonesian fermented soybeans (Tempeh) (10). In thisstudy, 10 new dishes were made by replacing main
ingredients like meat, fish, diary product with Tempeh.
The average evaluations of tempeh dishes and 10 control
dishes were 3.5 and 3.7 points for overall taste. In thispresent study, the consumption of TSP dishes in the dietresulted in an increase in dietary fiber of 6g/day, which
was higher than the fiber increase in the study using
Tempeh (2g/day) (10). There was a similar result inincreasing the amount of fiber in our study and a study
using Okara (6g/day) (7) and as well as a study using
pre-germinated brown rice (about 7g) (11).
Another implication from the results of this study
is that by using TSP dishes, subjects can reduce theirmeat consumption by nearly half, from 29g/day to
17g/day. Although meat consumption decreased
significantly after consuming TSP dishes, the total
amount of protein and total energy in the diet remained
unchanged. This change in the structure of the diet isrecognized as a positive change which helps preserve theenvironment. To be specific, when livestock digest food,the bacteria in their digestive tract will ferment plants
and release a huge amount of methane gas (CH4). Whenthe animals burp, this gas is emitted into the air. The
emissions from livestock, largely from burping cows andsheep and their manure, currently make up almost 15%of global emissions, which accelerates global warming
more than cars, planes and all other forms of transport
put together. In a study, Mekonnen and Hoekstra (2010)
showed that the water footprint of any animal product islarger than the water footprint of a wisely chosen crop
product with equivalent nutritional value. They
calculated that the water footprint of a 150g soy burger
produced in the Netherlands appears to be about 160
liters, whereas the water footprint of an average 150g
beef burger is nearly 15 times larger (12). It is obviousthat consumers can reduce their water footprint by
reducing their volume of meat consumption.
To conclude, there is a strong relationship between
eating meat, health and the environment. People should
understand the effects of what they chose in their daily
diet in order to make a wise choice. TSP product could
be accepted as an edible ingredient which can be
included in the daily diet for many good health purposes
and to protect the environment as well.

102

Asian Journal of Dietetics, 2020
ACKNOWLEDGEMENT
The authors would like to thank all theparticipants for their great cooperation and Hai Duong
Medical Technical University for their huge assistance.
We are extremely grateful to Jumonji University, the
US-Japan Medical Science Program for their financial
support and Fuji Oil Company for supplying the TSP
materials. Finally, we would like to express thanks to
Prof. Andrew Durkin, Emeritus Professor of Indiana
University, for editing our English.

1)

2)

3)
4)
5)
6)

7)

Nguyen LT, Nguyen TH, Nguyen LT,
Kamoshita S, Tran TP, Le HT, Shimura F,
Yamamoto S. Okara improved blood glucose
level in vietnamese with type 2 diabetes mellitus.
J Nutr Sci Vitaminol (Tokyo). 2019;65:60 5.
8) Nguyen D, Ngo K. Vietnam meat market.
<https://www.ipsos.com/sites/default/files/2016-08/meat-market-in-vietnam.pdf>(accessed;
25/06/2020)
9) Harrison W, Erin B, Tiianna H. Risk in Red
Meat? <https://www.nih.gov/news-events/nihresearch-matters/risk-red-meat>(accessed:
30/06/2020).
10) Kamoshita S, Kartiko Sari I, Utari DM, Shikanai
S, Yamamoto S. Indonesian Tempeh from
Soybeans Can Be Included in Japanese Main
Dishes and Can Increase Fiber Intake. Asian J
Diet 2019 [Internet]. 2019;1:12 7. Available
from: http://ajt.ktug.org/
11) Bui TN, Le Hop T, Nguyen DH, Tran QB,
Nguyen TL, Le DT, Nguyen DVA, Vu AL, Aoto
H, Okuhara Y, et al. Pre-germinated brown rice
reduced both blood glucose concentration andbody weight in vietnamese women with
impaired glucose tolerance. J Nutr Sci Vitaminol(Tokyo). 2014;60:183 7.
12) Hoekstra AY. The hidden water resource use
behind meat and dairy. Anim Front. 2012;2:3 8.

REFERENCES
Grossi G, Goglio P, Vitali A, Williams AG.
Livestock and climate change: Impact of
livestock on climate and mitigation strategies.
Anim Front. 2019;9:69 76.
Godfray HCJ, Aveyard P, Garnett T, Hall JW,
Key TJ, Lorimer J, Pierrehumbert RT,
Scarborough P, Springmann M, Jebb SA. Meat
consumption, health, and the environment.
Science. 2018;361.
Krapp R. Summary report. Environ Policy Law.
2009;39:80 2.
Nguyen CK, Pham VH. Vietnam recommended
dietary allowances 2007. Asia Pac J Clin Nutr.
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Smith HW. Strategies of Social Research. Res
Methods Educ. 1991;138:183.
Vietnamfood-based
guidelines
2010(Vietnamese).pdf.

103

Asian Journal of Dietetics, 2020

Original

Factors in Low Prevalence of Child Obesity in Japan

Sayako Aoki1, Nobuko Sarukura1,, Hitomi Takeichi1,, Ayami Sano1,,
Noriko Horita2, Yuko Hisatomi2, Kenji Kugino2, Saiko Shikanai1,
1,
2

Asian Nutrition and Food Culture Research Cente, Niiza, Saitama, Japan
Department of Health and Nutrition Science, Nishikyushu University, Saga, Japan

ABSTRACT Background and Objectives: Sugars, as well as lipids, are tasty and likely to be
consumed in excess. Since until recently there was no sugar composition table for Japan,
therefore few reports about sugar intake has been existed. Lipid intakes in children areinconsistent. Since a dietary pattern of high sugar and high lipid intakes can become habitual anda factor for life-style-related diseases in adulthood, knowing the facts of dietary intakes of sugars
and lipid is important. To determine the sugar and lipid intakes in children as factors in the low
obesity prevalence in Japanese children. Method: A 3-day nutrition survey was conducted by
the weighing and 24-hour recall method at a school in Tokyo, involving 58 children aged 8 and
10 years from average families. Sugars and lipid were calculated using the Japanese sugarcomposition and food composition tables. Results and Conclusion: Sugar and lipid intakes were
not different among the ages and genders (p<0.05). Average sugar intake was 25.7 g/day waswithin World Health Organization recommendation (less than 10% of energy; about 45g) for
more than 90% of the children and within the newly proposed World Health Organization
guideline (less than 5% of energy intake; 22.4g) for almost 43% of them. Lipid and saturated
fatty acid intakes were within normal levels for about 75% of the children. Sugar and lipid intakes
were normal at a school in Tokyo. Low sugar and lipid intakes may be considered as factors fora low prevalence of obesity.
Key words: Sugar, lipid, obesity, school children, nutrition survey* To whom correspondence
saiko_shikanai@yahoo.co.jp

INTRODUCTION
The principal sugars are sucrose, glucose, fructose,
lactose, and maltose. For growing children, such sugars
are particularly important as readily absorbed energy
sources. However, sugar is tasty and can easily be
consumed in excess. According to Japanese school
statistics for 2012, the prevalence of obesity in schoolage children was 4.1~10% which was relatively low
among countries world-wide (1). Since excess sugar
intake in childhood can become habitual and play a rolein life-style related diseases in adulthood, a dietary habitof low sugar intake is important, especially in childhood.
The World Health Organization (WHO) has
recommended that sugar (excluding fruits and milk)
intake should make up less than 10 % of total energy
intake per day. This is based on the idea of chronic
diseases prevention; 23 countries use thisrecommendation as a goal, and various countries use it
as a guideline (2). WHO also further suggests that a
reduction to below 5 % of total energy intake per day
would have additional benefits, even though they haverecommended sugar intake should stay at below 10 % of
total energy intake a day (3). Until recently a sugarcomposition for Japan was not available andconsequently there have been few reports on sugarshouldbe

addressed:

intake by Japanese. Likewise, even the annual nationwide health and nutrition surveys in Japan have notincluded sugar intakes (4).
In Japanese food composition tables, mono- and disaccharides are included as carbohydrates and not shownas separate categories (5). The National Health andNutrition Survey in Japan for 2010 showed a sugar
intake of 5.3 g for children 7-10 years old, but this figure
was for sugar used in cooking at home only. And forbeverages and snacks, only weight was indicated (6). A
standard individual bottle of a sweetened beveragecontains approximately 50 g of various sugars. Intake of
Sugar-Sweetened Beverages (SSBs) increased from 196
g per day in 2001 to 294 g per day in 2007 (7,8).
Isomerized sugars are used in many SSBs. Isomerizedsugar was developed in 1969 in Japan; it is produced
enzymatically from starch to form glucose, part of whichis converted to fructose (9). The ratio of the two sugars
is approximately 1:1. The taste of isomerized sugar ishigh in sweetness but not long-lasting; in addition, it ischeaper than sweeteners obtained from other sources.
For these reasons isomerized sugar is used in large
quantities in beverages, ice cream and chilled snacks.
One study regarding the sugar intake of Japanese105Factors in low prevalence of child obesity in Japan
children has been conducted by Takeichi et al (17). Its
results showed that the sugar intake of Japanese school
children was about 25g/d. This is quite low compared toother countries. Given this background, the aim of thecurrent study is to investigate whether sugar intake is afactor for the low prevalence of obesity in elementary
school students in metropolitan Tokyo.
According the Japan National Health and Nutrition
Survey, in the ten years from 2001 to 2010, seafood
consumption decreased from 94.0 g per day to 72.5 g,
while meat consumption increased from 76.3 g to 82.5 g(10). Since 2008, consumption of meat has been greaterthan that of seafood. Since food habits originating inchildhood can persist in later life stages, it is crucial toestablish healthy habits in the early years. However,with regard to children’s lipid intake, interpretations
vary. Some maintain that lipid intake has increased
because of the Westernizing of the diet, while others
claim that it has not changed or has even decreased.
However, the proportion of lipids to total energy intake
is increasing because of a decrease in carbohydrate
intakes (11, 12). Therefore, in addition to sugar intakes,
a second purpose of this study was to investigate lipid
intakes through a 3-day nutrition survey.
Although informative labeling is important inselecting food products, it is not legally required to list
mono- and di-saccharides or fatty acids explicitly onfood labels. Because of this, full nutrition information isstill not readily available to consumers. It would be
preferable to have better information on which monoand di-saccharides and fatty acids we are consuming andin what quantities in order to assist nutrition
professionals in formulating reliable advice. Therefore
this study seeks to investigate intakes of sugars and fatty
acids by children.

Calculations of sucrose, glucose, fructose andlactose intakes from foods were done by using the sugarcomposition tables that were reported previously (13,14).
Calculations for the lipid intakes were made inaccordance with the data listed in “Standard Tables ofFood Composition in Japan, 5 revised and enlarged
Version” (5) and “Standard Tables of Lipid Compositionin Japan, 5 revised and enlarged Version” (15).

METHODS
Subjects
A nutrition survey was conducted in children ofgrade 2 (boys 17, girls 14) and grade 5 (boys 15, girl 12)
in an elementary school in Tokyo.

RESULTS
Sugar Intake
Table 1 shows that the energy proportion ofProtein, Fat and Carbohydrate intake and theirpercentage against energy (PFC ratio). Total energy
were 1596 kcal, 1689 kcal, and PFC ratios
were15:30:54, 16:30:53 for the second grade boys andgirls respectively, 2050 kcal, 1869 kcal, and PFC ratios
were 16:29:53, 15:28:55 for the fifth grade boys andgirls respectively. The mean for all was 1792 kcal, and
the PFC ratio was16:29:54. Ratios of protein, lipid andcarbohydrate against energy intakes (%) in the second
grade were 15.8, 29.6, 53.5 and in the fifth grade, 15.6,
29.1, 53.9 %. There was no significant difference among
genders and grades (p>0.05).
Table 2 shows intakes of sugars (glucose, sucrose,
fructose, lactose and the total) by grade. Total sugar
intake by grade was 25.9 ± 13.7g (boys 26.8 ± 17.7g,
girls 25.1 ± 6.9g) for the second grade, and 25.4 ± 12.9g(boys 27.3 ± 13.9g, girls 23.1 ± 11.8g) for the fifth grade.
There were no significant difference among the 4 groups(grade and gender) and total sugar intake of all thechildren was 25.7 ± 13.2g.

Ethical consideration
These studies were conducted with the approval of
the Ethics Committee in the Kagawa Nutrition
University in accordance with the Declaration of
Helsinki (1964) (revision Tokyo (1975), Venice (1983)):
Ethical principles for research involving humansubjects, with special attention paid to the following: toprevent the identification of individuals, each subject’s
personal information was carefully coded and obtained
data were strictly managed. A statement thatparticipation in the research was by free will on the partof the participants was obtained from participants’parents and guardians; explanations were provided about
the objectives and details of the investigation and theintention to use the results for oral and writtenpresentations. Even after commencement, explanations
were provided whenever subjects dropped out of thestudy, either of their own volition or at the guardian's
behest; no subjects were penalized in any way.
Statistical analysis
Statistical analysis of the data was carried out with
Excel Statistics. Data were assessed by unpaired Student
t-test and p values less than 0.05 were considered
statistically significant. Correlation between bodyweight and sugar intake was also assessed.

DesignThe 24-hour recall method on 3 days (2 weekdays
and 1 weekend day) was used; however during
weekdays, subjects were given school lunch, therefore
the school lunch was studied by the weighing method.
The subjects were given record forms for three days andall the meals (breakfast, lunch, dinner and snacks suchas between meal and bed time snack) were recorded by
students’ guardians; in some cases, older students did
this by themselves. The following day, in the case ofincomplete items or unclear descriptions on the form, theinvestigators confirmed details with the students directlyor asked their guardians to fill out the items. Regarding
school lunch, their meals were weighed before and after
eating by investigators. An investigation of height andweight was used from students’ health check-up data.
Estimation of mono- and di-saccharide and lipid
intake106

Asian Journal of Dietetics, 2020

Table 1. Energy and major nutrient intakes
EnergyProtein
Lipid
Carbohydrate
Grade
Gender(kcal)(%energy)(%energy)(%energy)Boy
1596±18315.3±1.4
29.6±3.753.8±4.1(n=17)
2
Girl
1689±18016.3±1.4
29.6±2.953.1±4.2(n=14)
Mean
15.8±1.4
29.6±3.3
53.5±4.1Boy
2050±24415.9±1.529.9±3.752.9±3.5(n=15)
5Girl
1869±21415.4±1.528.3±2.1
54.9±3.4(n=12)
Mean
15.6±1.529.1±3.1
53.9±3.5
All (n=58)
1792±27015.8±1.529.2±3.2
53.8±3.8
Mean±SD, No significant deference was observed among boys and girls in the second and fifth grade children by
Turkey (p>0.05).
Table 2. Intake of mono- and di-saccharides
Grade

2

5

GenderBoy(n=17)
Girl(n=14)
Boy(n=15)
Girl(n=12)All ( n=58)

Glucose (g)Sucrose (g)Fructose (g)Lactose (g)Total (g)3.4±4.3

17.5±11.2

3.2±4.0

2.7±3.026.8±17.7

2.6±1.617.4±4.2

2.7±1.6

2.4±1.625.1±6.9

2.9±2.619.2±10.5

3.2±3.0

2.0±1.727.3±13.9

2.6±2.815.3±8.5

3.0±3.4

2.2±2.2

23.1±11.8

2.9±3.0

17.4±9.0

3.0±3.1

2.3±2.2

25.7 ± 13.2

Mean±SD, No statistical differences in 4 subject groups and total sugars were observed among the 4 subject groups
by Turkey (p>0.05)
Figure 1 shows that the proportion of mono- anddi-saccharide intake for all subjects. Sucrose was
67.8 %, fructose was 11.9 %, glucose was 11.3 %, andlactose was 9.0 %; therefore sucrose was the highest.
Figure 2 shows contributions of 8 food groups tototal sugars intake (except sugars for cooking) per day inboth the second grade and the fifth grade. The foodgroup contributing the most was dairy snacks such as
yoghurt and lactated drinks. The second food group was
SSBs such as carbonated drinks and soft drinks. The
third food group was baked snacks. In addition fromthese results sucrose that was using for cooking was 5.9±2.6g. Mean sucrose using for cooking by grade was
5.4 ± 2.6g (boys 4.5 ± 1.5g, girls 6.1 ± 2.5g) for thesecond grade, and 6.6±2.5g (boys 6.8±2.9g, girls
5.8±1.8g) for the fifth grade.
The degree of obesity which is used as a Japanesestandard was calculated using the following equation
following equation.
Degree of obesity (%) = (Actual measured weight(kg) – Weight for height standards (kg)*) / Weight forheight standards (kg)*×100.

*weight for height standards (kg) ＝ a × Actual
measured weight (kg) －b, “a” is 0.513, 0.508 in 7 year
olds, 0.752, 0.730 in 10 year old boys and girls
respectively. “b” is 38.878, 38.867 in 7 years old,
70.461, 68.091 in 10 years [no –s] old boys and girls
respectively (16).
In addition, the correlation between mono- and disaccharide intake and body weight was calculated(Fig.3). We could not observe any relationship between
sugar intake and body weight.
Lipid intake
The lipid intake of a day (mean ± SD) was
53.6±9.9g (boys 52.0 ± 9.1g, girls 55.6 ± 9.6g）in thesecond grade, and 65.6 ± 12.1g (boys 71.0 ± 13.0g, girls
58.8 ± 5.0g) in the fifth grade. There was no significant
difference among genders and grades (p>0.05). Mean
saturated fatty acid intake of total energy a day was 9.8± 1.6 %, 9.6 ± 2.0 %, in the second grade and fifth grade,
respectively (Table 3).

107Factors in low prevalence of child obesity in Japan(％)

Figure 1. The proportion of mono- and di-saccharide intake for all subjects.

Jelly Snacks andPudding, 10%

Candies,1%

Chocolate,7%

SSBs, 24%

ChilledSnacks, 9%
Baked
Snacks,17%

Dairy
Snacks,32%

Figure 2. Contribution of various food groups on sugar intake
70.0

y = 0.046x + 21.111
R² = 0.003

Sugar Intake（g）

60.0

50.0
40.0
30.0
20.0
10.0
0.0

0.0

50.0

100.0
Obesity degree (%)

150.0

Figure 3. Correlation between body weight and sugar intake
108

200.0

Asian Journal of Dietetics, 2020
Table 3. Lipid intake (g/d)
Grade

2

5

Gender
(n)

Lipid
(g)

Saturated fatty acid(g)

MonoUnsaturated
fatty acid
(g)

Boy
N=17

52.0±9.8

10.0±1.8

16.8±3.5

1.3±0.4

7.1±0.9Girl
N=1455.6±9.6

9.7±1.3

18.7±3.2

1.6±0.4

9.2±2.0Mean

53.6±9.9

9.8±1.617.2±4.6

1.6±1.0

8.1±1.871.0±13.0

10.0±2.1

22.7±4.4

1.8±0.6

10.0±1.758.5±5.0

9.1±1.919.6±2.2

1.8±0.5

10.0±2.1

65.6±12.1

9.6±2.0

21.3±3.9

1.8±0.5

10.0±1.9

Boy
N=16
Girl
N=12
Mean

n-3
n-6
Polyunsaturated Polyunsaturated
fatty acidfatty acid(g)(g)

All (n=59) 59.2±12.4
9.7±1.819.1±4.7
1.7±0.89.0±2.1
Mean±SD, No statistical differences in 5 and total lipid intake were observed among the 4 subjects groups by Turkey(p>0.05)
DISCUSSION
We conducted a 3-day nutrition survey in secondand fifth grade students at a school in Tokyo and foundthat sugar and lipid intakes were low compared to thoseof other countries. The average daily intakes of monoand di-saccharides by the second grade and the fifth
grade children showed no statistical differences; thecombined average was 25.7 ± 13.2 g, including sugar
used in cooking (5.9 g). WHO recommends that sugars(excluding fruits and milk) intake should make up lessthan 10 % of total energy intake per day (2). WHO also
further suggests that a reduction to below 5 % of totalenergy intake (3). In the current study, the energy intakeof the second grade boys was 1683 ± 361 kcal, for girls
1686 ± 173 kcal, for the fifth grade boys it was 2050 ±235 kcal and for girls 1869 ± 205 kcal. Ten percent ofenergy for second grade children was about 169 kcal,
which was equivalent to 42 g of sugar; for fifth gradestudents it was about 197 kcal, which was 49 g of sugar.
Sugar intake of second grade children was
25.9±13.7 g, with the result that mean + 1 SD was 39.6
g and mean + 2SD was 53.3 g. Mean + 1SD covers 84
percent of subjects, while mean+2SD covers 97.5
percent. Ten percent of energy would be equivalent to
42 g of sugar for 2nd grade children and to 49 g for 5th
grade children, which falls between 1SD and 2SD.
Therefore, about 90 % of subjects were within the rangeof the WHO recommendation (10% of total energy).
The results of the current study were similar to those of
the study done in Japanese Children by Takeichi et al(17). Furthermore, sugar intake of 5% of total energy
intake would be 22.4g in the case of the current study.
Almost 43% of the children were within this WHO new
recommendation. Sugar intakes of Japanese children
might be one of the lowest among children in thedeveloped world; even given that, fewer than half ofthese children would be within 5%. In reality, it would
be difficult for other countries to meet the new WHO
guideline/recommendation.

Sugar intakes in some other countries are: The U.K
85 g (18), Holland135 g (19), and the US 142g (20).
Compared to these data, the sugar intake of Japanesechildren was low.
According to the National Health and Nutrition
Examination Survey (NHANES) in the U.S.2005-2008,
energy intake from SSBs for 6- to 11-year old children
was 125kcal (boys:141 kcal, girls:112 kcal)(21). This
mean that sugar intake from SSBs was approximately 30
g in the U.S. To compare to the results of the current
survey, sugar intake from SSBs in Japan was 4.9 g forstudents in grade 2, 5.2 g for students in grade 5. The
result of a previous study (Takeich et al (16)) was also
6.7g of sugar in the form of SSBs.
In the current study, fructose intake was 11.9 % of
the sugar intake, while glucose was 11.3 %, and the
proportion of intakes for both sugars was almost thesame, which suggests that these sugars came fromisomerized sugar. Isomerized sugar, called highfructose corn syrup (HFCS) in the U.S., is made fromstarch and contains roughly equal amount of glucose andfructose. According to Putnam et al (22), use of HFCS
went from 0.5 pound per person in 1970 to 62.4 pounds
in 1997. In the same year, beverages accounted for 72
percent of total HFCS deliveries for domestic food andbeverage use, compared with 36 percent in 1980. The
portion of HFCS in the caloric sweetener market in the
1980s was rapidly growing. Commercial products such
as SSBs and chilled/frozen snacks use mainly HFCS
rather than ordinary sugar because HFCS is cheaper andits taste is more suitable for them. As a result of that,
one quarter of the calories available from the 1994 percapita food supply came from sugars (22).
It has been said that mono- and di-saccharide, suchas HFCS, intake leads to obesity (23); however the resultin the current study did not show such a tendency, nor
did the other surveys was there only one other or more
in Japan (17). Therefore, childhood obesity in Japan is109Factors in low prevalence of child obesity in Japannot caused mainly by sugar intake but the data suggestthat other factors may be involved.
Some articles in The Washington Post discussed theJapanese school lunch and commented that the Japanese
school lunch helped slow the rise of childhood obesity(26, 27). This is a unique point of view. Actually, it isobvious that sugar intake in Japan has been significantly
lower than in the countries such as the U.S. However, inthe current study, there are some limitations that we haveto mention. Especially when we discuss beverages, wefirst of all have to consider the season/climate. There is
the possibility that the reason for decreased intake ofdrinks was caused by the weather; in November, when
the survey was conducted, the weather typically
becomes cooler in Japan. We need further research indifferent seasons. The second point is the school
environment: in the U.S, vending machines are available
in most of schools, thus children can have soft drinks
anytime they want (21). On the other hand, Japanesepublic elementary schools do not allow access to any
vending machines; in addition, the most public school
children are not allowed to bring money when they go toschool. They have no chance to have beverages or othersnacks, at least until they go home. Therefore to compare
Japanese to U.S. children, it seems that U.S. children
have easier access to SSBs and other snacks.
Regarding lipid intake, the mean lipid intake asenergetic ratio (%) was 29.2 ± 3.2 % a day. While mean
lipid intake as energetic ratio (%) is 29.2 ± 3.2%, thevalue from SD to +1 SD is 32.4 %, to +2 SD is 35.6 %,DRI for lipid is from 20 to 30 %。From these results, it
seems that almost 65 % of [the children took their lipid
within the recommendation.
While the mean saturated fatty acid intake asenergetic ratio (%) is 9.7 ± 1.8%, the value from SD to+1 SD is 11.5 %, to +2SD is 13.3 %. There is norecommended value for saturated fatty acids in theguidelines in Japan; however in the U.S. it isrecommended that should be less than 10 % of totalenergy intake (24). From these results, almost half ofthe children consumed lipids within the recommended
values.
With regard to such low lipid and sugar intakes, wewould like to mention school lunch. As an article of The
Washington Post (25, 26) stated, school lunch in Japan
may be unique and is definitely unusual for Westerners.
In Japan, most of public schools have a school nutrition
teacher/dietitian (12,036 school dietitians for wholecountry) and lunch is provided at 99.3% of elementary
schools and 79.3% of junior high schools (27). The
school nutrition teacher/dietitian are not only manages
the school lunch to provide an interesting menu with thebest balance of nutrients and adequate energy, but also
learning food culture etc. Therefore meals are often
termed useable nutrition education materials, as we
discussed above with regard to the environmental
differences between the US and Japan, Japanese children
have fewer opportunities to have SSBs and empty foods
such as high lipid and sugar-containing snacks.
Dietary habits formed in childhood can become
permanent and play a role in adulthood. Therefore, aschool lunch that provides one third of daily energy andnutrients for school age children is important, and it may
help to form children’s habits. This may help maintaina/the low rate of obesity in Japan. Low sugar and lipid

intake from food with daily habit as a daily habit may beconsidered as a factor of in the low prevalence of obesity
among Japanese school-age children. Hence, school
lunch may play a role in particular in controlling theintake of sugar and lipids. However to support thishypothesis, further study is necessary.
In conclusion, sugar and lipid intakes were normal
for more than 90 % and 75% of children, respectively, at
a school in Tokyo. It is also supported the low
prevalence of obesity in Japanese children.
ACKNOWLEDGEMENTS
The authors would like to thank all the participants
and teachers of in all our survey. The authors would liketo thank Andrew R. Durkin, Professor Emeritus ofIndiana University, Bloomington, USA, for his careful
editing of the English for this article.
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111

Asian Journal of Dietetics, 2020

Original
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Badder Hina Afnan1, Sahar Soomro2, Saba Mughal3, Syed Afnan Omer Ali4,
Madiha Patel5, Nadeem Ahmed6
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ABSTRACT Background: Nutritional counseling is a highly recommended part of the treatment
plan for Pulmonary Tuberculosis (PTB), as predominantly patients present clinically withmalnourished status. However, scarce evidence exists on the prevalence of malnourishment
among patients with PTB, particularly in Pakistan. This study therefore aims to report on theprevalence of malnutrition status, as documented using universal nutritional assessment tools on
patients with PTB, receiving first-line drug (FLD) and second-line drug (SLD) therapies.
Methods: A cross-sectional study enrolled 315 participants diagnosed with PTB, receiving FLD
or SLD treatment, recruited from a tertiary-care hospital and clinic in Karachi, Pakistan.
Inclusion criteria encompassed both genders, 18 to 55 years of age, with either new or relapsed
PTB cases. A structured questionnaire composed of various methods for assessing nutritionalparameters was conducted by a registered dietitian. The statistical analysis was carried out using
SPSS, with data expressed as percentages, mean and standard deviation (SD), and statisticallysignificant associations using p-value. Results: From 312 patients, 54.2% (n=169) were females
and 61.2% (n=191) patients were on FLD therapy. Average Body Mass Index (BMI) (kg/m2) of
the patients was 17.72 ± 3.15 (SD), whereas average calorie intake (kcal) of the patients was1321.77 ± 506.19 (SD). Patients who received FLD had lower average BMI and MAMC (mm)in comparison to those on SLD. Mean differences were found to be statistically significant
between both treatment groups for BMI (p-value=0.044) and MAMC (p-value= <0.001).
Average BMI (p-value <0.001) and calorie intake (p-value=0.030) were significantly different
when compared with the duration of treatment. Conclusion: The study reveals that patientsdiagnosed with PTB are presented with varying degrees of malnourishment, despite being oneither drug therapy as indicated through data collected using validated tools specific fornutritional assessment. Based on the results, the extent of time on drug therapy is associatedwith the outcome of improvement in nutritional status in the patient.
Keywords: pulmonary tuberculosis, nutritional assessment, malnutrition, anthropometricmeasurements, Pakistan

INTRODUCTION
Tuberculosis (TB) has been featured as a healthemergency globally over the last two decades according
to World Health Organization (WHO), along with being
one of the major community health concerns weighingon the developing country of Pakistan (1,2). Pakistan
presently ranks 6th among 22 countries with the highest
reported burden of TB worldwide, with incidence
drastically escalating, of which approximately 44% of
the tuberculosis burden in the Eastern Mediterranean
region (1, 3). Within developed or high-income
countries, patients with TB have been linked withpoverty and low socioeconomic status (4). Low-income
neighborhoods are negatively impacted fromovercrowding and malnutrition, therefore, are prone todevelop TB (5, 6). Pakistan has a spectrum of
urbanization ranging from effluent to low-income
neighborhoods with minimal access to healthcare
services and treatment (6).
Studies have reported that patients with TB are
malnourished as indicated by reduction in visceralproteins, anthropometrics indexes and macronutrients
status (7). Strong evidence shows underweight bodymass index (BMI) is exclusively a risk factor indeveloping TB (8). Although body weight has been
seen to decrease during TB treatment, recovery can be
slow and significant wasting can persist for months*To whom correspondence should be addressedbadder_hina@hotmail.com
113

Nutritional assessment in Pulmonary Tuberculosis
after the start of effective tuberculosis treatment (9, 10).
The breakdown of protein and other reserves due tofever may also worsen nutrition parameters and weaken
resistance against the infection (11). There is strong
evidence that underweight body mass index (BMI) is
exclusively a risk factor in developing TB (12). Wasting,or loss of bodily weight, has long been recognized as amain feature of tuberculosis, owing to a combination of
decrease in appetite, loss of fat and lean tissue, as a resultof decreased energy intake, complicated by alteredmetabolism as part of the bodily inflammatory
responses.
Presently, international guidelines identify twotreatment pathways to overcome TB: First-line drug
(FLD) and second-line drug (SLD) therapy. To inhibit
the resistant or slow-growing strains of TB, thecontinuation phase of the treatment is effectively
controlled by using first-line drugs (FLD) (13).
However, FLD therapy often fails to cure TB, causing
further spread of the disease, leading to the emergenceof drug-resistant bacteria. The emergence of multi-drugresistant TB (MDR-TB) is on the rise and a serious
concern within the healthcare community (17). As aresult, SLD drugs are utilized, however, they are more
toxic and expensive than FLDs (14).
Nutritional assessment is fundamental in the
management of Pulmonary TB (PTB) patients, requiring
clinical expertise in history-taking and physicalassessment, with the duties ideally being fulfilled by aregistered dietician (RD), as the evaluation is multifaceted (15). Bhargava et al. (2017) simplified the tools
comprising the nutritional evaluation, throughabbre iation of tools tili ed in the form of ABCD,
ith A standing for anthropometr , B signif ing
biochemical assessment, C being clinical assessment,
and D comprising of dietar assessment.
Anthropometry involves measurements such asheight, weight, and BMI of patients. Biochemical, or
laboratory, assessment involves evaluation of serum
hemoglobin and complete blood count (CBC), andserum electrolytes to further evaluate for undernutrition
status in patients of PTB. Clinical evaluation is often
performed by a healthcare professional with expertise to
identify signs of nutritional abnormalities, often
represented as pallor, oedema, muscle wasting, flaky
skin, and loss of buccal pad of fat along with numerous
often clinical indicators of malnutrition (15). Lastly, asignificant component of nutritional assessment
includes the dietary assessment, involving gathering
data based on the patient s dietar recall of food intake
within the past 24 hours (15). All these tools areimportant to aid in determining the prevalence ofmalnutrition of an individual with PTB on drug therapy.
There is limited and lack of relevant data
documented on the prevalence of nutritional status
gathered using proper nutritional assessment tools
specifically on TB patients within indigenous society ofPakistan. Therefore, this study is designed to provide aperspective on the prevalence of nutritional status of
malnutrition among pulmonary TB patients. The aim of
the study is to assess the nutritional status of pulmonary
TB patients on FLD and SLD treatment utilizing
universally recognized tools of nutritional assessment
for patients receiving both types of drug therapy.

METHODS
The research design involves a cross-sectional
study, by enrolling 315 patients admitted for treatment
of PTB, with either FLD or SLD, between December
2018 to March 2019. Setting of study was a publicsector, tertiary-care hospital located in Karachi, anurban city in Pakistan. A structured questionnaire wasverbally administered by a registered dietician in theofficial language of Urdu, taking approximately 20-30
minutes to administer.
The inclusion criteria for the study subjects was asfollows: patients of either gender giving informed
consent, between the ages of 18-55 years, who areadmitted & diagnosed with pulmonary TB, either as new
or relapsed cases. The exclusion criteria wereparticipants who were either pregnant, lactating, or on
oral food supplements. Furthermore, if the patients were
undergoing any other treatment or were diagnosed withother cross-infections, such as HIV, were excluded. The
sample size for this study was calculated by a statistician,which encompasses an incremental 5% for participants
to account for loss of follow-up and unwilling toparticipate in the study.
Data collection
A quantitative, structured questionnaire withphysical assessment parameters was conducted by atrained, registered dietitian (R.D.). Demographics suchas age, gender, type of treatment, educational level,
ethnicity, and occupational level was documented uponconsent. After consent, anthropometric measurements
ere assessed and the participant s blood samples ere
withdrawn and sent for laboratory biochemical analysis.
For anthropometric measurements of weight were
measured to the nearest 0.1 kg without shoes using anelectronic platform on a model weighing scale. For
height, data was documented to the nearest 0.1 cm. Body
mass index (BMI) was calculated (kg/m2) and thepatients will be classified into categories of BMI basedon the WHO population cut-offs for Asians (16). Midupper Arm Muscle Circumference (MAMC) were
measured with a flexible, measuring tape. Triceps andsub-scapular skin folds aided in determining Mid-upper
Arm Muscle Circumference (MAMC) by a skin foldtool and was calculated (17). Blood samples werecollected to determine Hemoglobin (Hgb) and Albumin
levels of each participant. Nutritional clinicalassessment was conducted to evaluate for physical signsof malnutrition. Dietary history was documented byinterviewing the participant about recalling their 24hour dietary intake to calculate energy in kilocalories
and protein in grams from Diabetic Exchange list (18).
Based on the PTB treatment international guidelines,
data related to nutritional assessment was collected atinitial visit (<1 month), at an interval where treatment
regimen was followed-up (<2 months), after thetreatment was completed (<6 months), and a follow-up
visit (<6 months) (19).
Statistical Analysis
The statistical analysis was carried out using SPSS
version 21.0. Percentage and frequency were reported
for categorical variables whereas mean and standard
deviation were reported for continuous variables.
114

Asian Journal of Dietetics, 2020
Assumption of normality was checked by using
Shapiro-wilk test of the continuous variables. Chisquare test was run to check association between
categorical variables and type of treatment. MannWhitney U-test and Kruskal-wallis test were applied tocheck mean differences between type of treatment andduration of treatment. All test results having p-values
less than or equal to 0.05 level of significance wereconsidered statistically significant.

study and data collection being initiated upon IRB
approval.
RESULTSA total of 312 pulmonary tuberculosis patientswere included in the study and 3 patients had loss offollow-up during the study. Among all the patients
45.8% (n=143) were males and 54.2% (n=169) werefemales. Patients who were married were 56.4%(n=176). There were 44.6% (n=139) patients who wereuneducated. Majority of the patients were Urdu
speaking (31.7%, n=99) and then those who belonged to
Sindhi ethnicity (26.9%, n=84). There were 61.2%(n=191) patients who were on FLD and 38.8% (n=121)
patients who received SLD. None of the demographic
variable showed any significant association with thetype of treatment. See Table 1.

Ethical Issues
The study was conducted with the highest
respect and dignity for participants. This study
underwent ethical review through institutional review
committee of Dow University at the beginning of theTable 1. Socio-Demographic characteristics of pulmonary tuberculosis patients by type of treatment (n=312)
Type of Treatment
Variables

Total

FLD (n=191)

SLD (n=121)

n (%)

n (%)

p-value*

GenderMale

143

92 (64.3)

51 (35.7)

Female169

99 (58.6)

70 (41.4)

Unmarried136

91 (66.9)

45 (33.1)

Married176

100 (56.8)

76 (43.2)

Uneducated139

79 (56.8)

60 (43.2)

Up to secondary135

88 (65.2)

47 (34.8)

Intermediate and above38

24 (63.2)

14 (36.8)

Sindhi84

49 (58.3)

35 (41.7)

Punjabi44

31 (70.5)

13 (29.5)

Balochi108 (80.0)

2 (20.0)

Pashto29

16 (55.2)

13 (44.8)

Urdu

99

66 (66.7)

33 (33.3)

Others46

21 (45.7)

25 (54.3)

466

46 (69.7)

20 (30.3)

5 9

196

110 (56.1)

86 (43.9)

1050

35 (70.0)

15 (30.0)

0.299

Marital status
0.070

Education level
0.353

Ethnicity
0.083

Number of family members*p-value has been calculated using Chi-square test.

115

0.056

Nutritional assessment in Pulmonary Tuberculosis
Anthropometric measurements were assessed of all
patients. Average age of the patients was 34.91 years
with SD ±14.62 years and ranged between 18 and 60
years. It was found that in all patients average BMI(kg/m2) was 17.72 with SD ±3.15 and ranged between
11.03 and 31.92. It was evaluated in biochemical
characteristics and dietary history that averagehemoglobin (g/dl) was 10.34 with SD ±1.02 whereas
average calorie intake (kcal) of the patients was 1321.77
with SD ±506.19 which was ranged between 365 and

2550. It was reported that patients who received FLD
had lower average BMI (kg/m2) and MACU (mm) incomparison with those who were on SLD. Meandifferences were found to be statistically significant
between both treatment groups for BMI (Meandifference=0.73, p-value=0.044) and MACU (Meandifference=18.22, p-value= <0.001). It was found thaton average calorie (kcal) and protein (grams) intake wasalso lower in those patients who received FLD. See
Table 2.

Table 2. Comparison of nutritional status of pulmonary tuberculosis patients stratified in first-line drug
(FLD) and second-line drug (SLD)
Characteristics
Overall MeanSD
Range
Anthropometric measurements
BMI (kg/m2)

17.72

3.15

11.03 - 31.92

MACU (mm)220.4940.6

127.0 - 330.2

Hemoglobin (g/dl)

10.34

1.02

7.8 - 13.6

Albumin (g/dL)

2.33

0.52

1.0 - 3.6

Calories (kcal)

1321.77506.19365 2550

Protein (grams)

49.91

23.68

10

FLD (n=191)

SLD (n=121)

Mean ± SD

Mean ± SD

Age (years)

35.56 ± 15.25

33.89 ± 13.56

BMI (kg/m2)

17.44 ± 3.15

18.17 ± 3.12

0.044

MAMC (mm)21.34 ± 3.95

23.16 ± 3.96

< 0.001

Hemoglobin (g/dl)

10.33 ± 1.04

10.35 ± 1.00

0.826Albumin (g/dL)

2.35 ± 0.52

2.31 ± 0.53

0.334

Calories (kcal)

1298.71 ± 515.19

1358.16 ± 491.56

0.347

Protein (grams)

48.59 ± 22.32

51.98 ± 25.65

0.451

Biochemical characteristics

Dietary history (24-hour recall)112

p-value*
0.377*p-value has been calculated using Mann-Whitney U Test.
Mean differences were also calculated among four
different durations of treatment. A clear increment in
BMI was seen as the duration of treatment increases andhighest significant mean BMI difference was found in
between the patients who received treatment for lessthan a month and those whose duration of treatment wasmore than six months (Mean difference=3.79, p-value=<0.001). Calorie intake (p-value=0.030) was also foundto be statistically significantly different among thegroups of duration of treatment. See Table 3.
Clinical examination data pertaining tonutritionally deficiencies in PTB patients were also
gathered. Out of all the patient participants, a mere 1.3%
reported night-blindness, dry with yellow or white spots

in eyes was reported in 7.7% of the participants. Dry,dull, or rough appearance of eyes was observed in
21.8%, while pale conjunctive was stated in 19.6%.
Softening of cornea was reported in 2.6%, while 10.6%
were examined to have cracked and reddened cornea ofeyes. Bilateral cracks or redness of lips was observed in
9.9%, vertical cracks (cheilosis) were assessed in 13.1%
of participants. In clinical examination of tongue
features, magenta was observed in 28.5%, smooth orslick or loss of papillae was observed in 19.6%. Beefy,
red-color or red/swollen mucosa was observed in 23.1%,
while decreased taste was reported by 18.9% of patients.
Clinical data observed for nails included the observationof spoon-shaped nails was seen in 43.9%, dull or lack116

Asian Journal of Dietetics, 2020
luster was seen in 30.8%, pale or mottled appearance
was observed in 21.2%. Clinical assessment of pallor
appearance was seen in 33% out of total patientparticipants. Muscle-wasting was seen in 26.0%,
difficulty in walking was reported by 26.6% ofparticipants. Musculoskeletal problems, such as pain in
calf or thighs were reported in 18.3%, joint pain or
swelling was reported in 37.8%, while a mere 10.9% of
total participants stated difficulty in walking. (See Table
4).

Table 3. Nutritional status of pulmonary tuberculosis patients by duration of FLD treatment (n=312)
During Drug Treatment
Variables< 1 month (n=191)

After Drug Treatment< 2 months(n=191)< 6 months(n=191)> 6 months (n=191)

p-value*

Mean ± SD
BMI (kg/m )16.15 ± 1.89

17.53 ± 2.82

18.86 ± 3.31

19.94 ± 4.05

<0.001

MAMC (mm)21.74 ± 3.65

22.195 ± 4.51

22.21 ± 3.9

22.06 ± 3.86

0.826

Hemoglobin (g/dl)

10.27 ± 1.02

10.33 ± 1.12

10.39 ± 0.98

10.42 ± 0.83

0.828Albumin (g/dL)

2.34 ± 0.47

2.27 ± 0.51

2.37 ± 0.54

2.43 ± 0.59

0.484

Calories (kcal)

1264.24 ± 491.16

1420.53 ± 525.12

1327.92 ± 508.70

1167.10 ± 436.52

0.030

Protein (grams)

46.88 ± 21.35

53.71 ± 24.06

50.70 ± 26.69

44.85 ± 21.13

0.119

2

*p-value has been calculated using Kruskal-wallis test.

Table 4. Nutrition based clinical assessment of pulmonary tuberculosis patients (n=312)
Physical Signs
Eyes
Night Blindness
Dry with yellow or white spot
Dry, dull, rough appearance
Pale conjunctive
Softening of cornea
Cracked and reddened corners of eyes
Lips
Bilateral cracks or redness of lip
Vertical cracks (cheilosis)
N/A*
TongueMagenta
Smooth, slick or loss of appetite
Beefy red color mucosa, red and swollen
Decreased taste
N/A*
Nails
Spoon-shaped
Dull, lackluster
Pale, mottled
N/A*
PallorYes
No
Muscle Wasting
Yes
No

N
Yes
4
24
68
61
8
33

Difficulty in Walking
YesNo
Musculoskeletal
Pain in calves or thighs
Joint pain or swollen
Difficulty in walking
N/A**N/A=Not Available

117

%
No
308
288
244
251
304
279

Yes
1.3
7.7
21.8
19.6
2.6
10.6

No
98.7
92.3
78.2
80.4
97.4
89.4

31
41
240

9.9
13.1
76.9

89
61
31
72
59

28.5
19.6
9.9
23.1
18.9

137
96
66
13

43.9
30.8
21.2
4.2

103
209

33.0
67.0

81
231

26.0
74.0

83
229

26.6
73.4

57
118
34
89

18.3
37.8
10.9
28.5

Nutritional assessment in Pulmonary Tuberculosis
DISCUSSION
Nutritional assessment is a core component, yet anoften rarely applied aspect, of a pulmonary tuberculosis
patient s treatment plan. This st d noted there is no
significant difference between gender and nutritional
status in patients on either FLD or SLD. In addition, thisresearch demonstrated that most) (20-22). Newly
diagnosed adult TB patients were underweight based on
BMI and MAMC at the time of initiating drug therapy,
with majority of the participants being moderate toseverely malnourished. Numerous evidence-based
researches have observed malnourishment being evident
in TB patients at the time of enrollment, in a spectrumof both developing and developed countries WHO(2013). This study found PTB patients had reported
lower cut-offs for BMI, mid-arm muscle circumference(MAMC), and lower ranges of serum albumin, despite
being maintained on FLD or SLD therapy. Similarly, a
study conducted in India revealed that TB patients were
11 times0 more likely to have a BMI of less than 18.5,
indicating a borderline underweight status (Shetty,
2006) (23).
Based on the results of this study, significantly
lower serum albumin levels were noted in patientstaking either treatment for PTB, which is similar tofindings of an Iranian study conducted on 120 patients(Sultan et al., 2012) (24). A study by Kumar et al.
(2014) (25) highlighted the necessity for protein
consumption in patients with multi-drug resistant PTB
as findings showed lower serum protein, serum albumin
and blood hemoglobin levels. Low albumin could be
attributed to hepatic production of acute phase reactant
proteins due to cytokines, such as interleukin-6 andtumour necrosis factor (TNF), which inhibits thecreation of serum albumin in the blood vessels, causing
severe fluctuations in the plasma concentrations ofcertain essential micro-nutrients and albumin.
Skin-fold thickness measures the amount of fat
under the skin. Patients with lower than mean averagesof skin-fold thickness within this research wereconsidered under-nourished. In comparison, a study
conducted by Nthiga et al. (2017) (26) in a referral
hospital in Kenya indicated the mean and percentages ofskin-foldthicknesses
were
lower
declaringundernourishment among PTB patients. Body wastingis a pronounced and characteristic feature among PTB
patients, which is linked with lower caloric intake due
to loss of appetite and lack of food consumption(Schwenk et al., 2000) (27). The st d s findings sholower ranges of MAMC in TB patients taking either
FLD or SLD. In Uganda, Mupere and colleagues (2010)(28) reported when compared to individuals negative for
TB, patients with TB displayed lower body mass index(BMI), body weight, body cell mass, and fat mass,
regardless of gender (29). This research showedpatient s mean hemoglobin concentrations
ere
significantly lower as compared to normal physiologic
levels.
This st d s res lts sho ed the caloric intake asfound to be statistically significant based on the durationof treatment, with a longer duration of drug treatment
being associated with greater caloric and protein intake
among the PTB patients (see Table 3). According to
WHO (2013) guidelines, approximately 40kcal/kg andproteins 1.2-1.5 grams should be ideally consumed bypatients diagnosed with TB diseases (30). This effort isto fill the gap in knowledge since there are few studies
conducted in Pakistan previously. To the best of thea thors a areness, there ha e been no previous studies
conducted to fill the gap in knowledge and clinicalpractice to best determine calories and protein
cons mption, specificall addressing TB patient s
nutrition needs within Pakistan. Based on the results ofour study, inadequate intake of calories and protein areassociated with the diseased state of PTB, as the patient
recovers with the disease, similarly, causing
impro ement in the patient s dietar intake. Inadeq ate
dietar intake is d e to patients inabilit to accessadequate nutritious foods, thus, causing malnutrition.
The use of the 24-hour dietary recall as an instrument
presents as a limitation in this study. The dietary recall
tool introduces social desirability bias and recall bias, inwhich patients may not be able to fully recollect orunder-report their past dietary intake or possibly provide
responses which will be favored by the interviewer.
CONCLUSION
The study reveals that patients diagnosed with PTB
are overall nutritionally malnourished, despite treatment
with either FLD or SLD therapy, due to thepathoph siological impact of the disease on the patient s
body. Based on the results of this study, it is understoodthat the duration of the drug therapy is associated withthe outcome of improvement in nutritional status. Thus,
it is advised to initiate drug therapy with immediate
effect to hinder the malnourished state of the PTB
patient. Nutritional counseling is often undervalued asa part of the treatment regime for PTB, especially in thedeveloping country practices of Pakistan. However,literature and research have determined that the true
nutritional parameters are assessed based on validated
tools, such as anthropometric measurements of BMI or
muscle arm circumference, biochemical laboratory
factors such as albumin, 24-dietary recall and clinicalphysical assessment, and have been found as strong
predictors to evaluate the nutritional trajectory inpatients with PTB. Majority of the patients withpulmonary TB in this study were categorized as severely
underweight accompanied by low caloric intake basedon the 24-hour dietary recall.

1)

2)

3)

118

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120

Asian Journal of Dietetics, 2020

Original
Effects of Thinly Sliced Meat on Time, Number of Chews,
and Food Intake in Elderly People with Tooth Loss
Hien Ngo Thi Thu1, Ngoc Ta Thi1, Yen Ma Ngoc2, Phuong Nguyen Mai1,
Thao Tran Phuong1, Thu Truong Thi3, Hang Dinh Thi Dieu3, Linh Nguyen Thuy2,
Khan Nguyen Cong3 Yoshihiro Tanaka4, Shigeru Yamamoto1
1

International Nutrition, Graduate School of Human Life Science, Jumonji
University, Saitama 352-8510, Japan,
2
Hanoi Medical University Hospital, Hanoi, Vietnam
3
Haiduong Medical Technical University, Haiduong, Vietnam
4Nantsune Co, Osaka, Japan
ABSTRACT Background: The loss of teeth in elderly people reduces their chewing ability
and leads to a decrease in food intake, including meat. In Vietnam, meat is a common
source of protein; most people maintain the habit of buying meat in large pieces fromtraditional markets and then slicing it at home with a knife. However, the thickness of meatsliced by hand is usually 3-5mm; the slices are large and irregular so they are difficult for
the elderly to chew. In Japan, which has the highest proportion of elderly and the longest
healthy life expectancy in the world, people generally use pre-sliced meat instead of block
meat. By using a meat slicer, we can get pieces of meat of the same size, with a thicknessof only 1.5mm (depending on the adjustment to the slicer). Purpose: To examine the effectof using thinly sliced meat compared with meat sliced by hand on time of chewing and thenumber of chews and food intake in older adults who have lost teeth. Methods: We
conducted an intervention study following a cross-over design on 38 elderly subjects. Afterevaluating sensory characteritics and recording the time and number of chews between 2
samples of meat (thinly sliced meat and hand-cut meat), they were randomly divided into
groups A and B; each group had 19 subjects. We provided subjects all the foods that they
ate with either diet, using thinly sliced meat or hand-cut meat (cooked in the same way andwith the same quantity) for 1 week. After a week washout, the diet was reversed. The
subjects did not eat anything apart from the diets that they were served. The diets were
weighed before and after eating and then the amount of food consumed was calculated.
Results: The thinly sliced meat took less over-all time for chewing and and fewer chews
than the hand-cut met (same quantity). To chew 3g of thinly sliced meat, subjects took 53± 22 times and 47 ± 23 seconds while to chew the same quantity of hand-cut meat needed
73 ± 35 times and 65 ± 33 seconds, both (p < 0.05). When subjects consumed the Thinly
sliced meat diet, energy, protein, lipid intakes were higher than with the Hand-cut meat dietin both moderate dentition subjects (21-27 teeth) and poor dentition subjects (20 teeth orless), and the differences were statistically significant (p<0.05). The average scores of thesensory test for thinly sliced meat samples were higher than for sliced by hand samples interms of taste, tenderness, and overall acceptability (p<0.05). Conclusions: Thinly sliced
meat was easier to chew and favored over meat sliced by hand in the elderly who have lost
teeth.
Keywords: food intake, elderly people, lost teeth, thinly sliced meat
INTRODUCTION
The Vietnamese aging population is increasing
rapidly. According to the United Nations Population
Fund and General Statistic Office, the proportion of

the population aged 65 and over will increase from
7.1% in 2014 to 18.1% in 2049(1). Elderly people have
many health problems, among which tooth loss has
become an issue of concern in the Vietnamese elderly.
Although the prevalence of complete tooth loss has
declined over the last decade, edentulism remains a*To whom correspondence should be addressed:
hienmeo1110@gmail.com
121Thinly sliced meat for elderly people with tooth loss
major disease worldwide, especially among older
adults (2). According to Nguyen Thuy Nga and Truong
Manh Dung (2017), the overall rate of tooth loss inelderly people in Hanoi in 2017 was very high(80.7%)(3). Another study showed that 27.8% of 258
elderly people aged 65-74 years in Danang often had
dificulty chewing foods (4).
It is necessary to provide soft diets in hospitals andnursing homes, where the majority of elderly people
have difficulty in chewing due to tooth loss. Most
elderly patients commonly avoid hard foods and areprovided soft and light meals like porridge, noodles,and soup, which are usually cooked with meat,particularly pork and beef. These types of meat arecommon sources of protein in Vietnam and are
frequently present in daily meals.
However, meat sliced by hand is usually thick (35mm), large, and irregular in size, which causes theelderly to have some difficulties in chewing.
Therefore, soft meals in Vietnam lack variety and are
repetitive because of the use of finely chopped meat.
This increases the feeling of anorexia. Consequently,
this situation has a negative effect on nutritional status
in such patients in the present and will have in the
future.
In this regard, thinly sliced meat could be afeasible solution. It is a type of meat which is cut bymachine, very thin (1.5mm), against the grain, so it iseasy to chew and is especially suitable for the elderlywith tooth loss. Sliced meat can be used daily,
prepared in various ways and combined with a variety
of foods, increasing the nutritional value of the dishes.
Not only is this a solution for hospitals in the
nutritional care of the elderly, but patients can also
learn recipes using sliced meat so they can prepare
their own meals at home. We expect that using sliced
meat is more beneficial than the currently used handcut meat in helping elderly patients improve their
daily meals, increase their food intake, and finally
improve their quality of life through their diet.
Therefore, we decided to conduct a study Using
thinly sliced meat to improve the time, number ofchews and food intake in elderly people withedentulism with the purpose of determining whether
sliced meat can improve taste and appetite for elderly
people with tooth loss problems by increasing variety
in their diet.

dysphagia. After screening, a total of 38 elderly
patients who met the inclusive criteria were selected.
Sensory evaluation: To prepare for evaluation, thesubjects were not hungry, had not consumed food or
chewed gum within 1 hour, had not consumed liquids
except water within ½ hour, were not wearing
perfume, had not brushed their teeth within 1 hour,
had not smoked within 1 hour, and were not wearing
lipstick. The evaluation area was separate from thefood preparation area, free of extraneous odors, withminimal noise level and no communication, visual ororal, between panelists during sensory evalution. The
subjects received 2 meat samples for comparison;
one was 50g boiled thinly sliced meat (thickness
1.5mm) and the other was 50g boiled hand-cut meat(thickness 3-5mm). The subjects observed, smelled,
and tasted them, and then used a Hedonic 9-point
scale to score the characteristics of the two samples
on color, aroma, taste, softness and overall
acceptability.
Time and number of chews:After the sensory test, thesubjects ate the same quantity (3g) of each meat
sample. This process was recorded by camera. Then
researches watched that and counted the over-all time
for chewing and number of chews before swallowing.
Intervention study: We conducted an intervention
study following a cross-over design. After assessing
the nutritional status of subjects by Mini Nutrirional
Assessment Tool (MNA), they were randomly
divided into groups A and B; each group had 19
people. We provided subjects all the foods that they
eat with either diet, one using thinly sliced meat and
one using hand-cut meat (cooked in the same way
and with the same quantity) for 1 week. After a week
washout, the diet was reversed. The subjects did not
eat anything apart from the diets that they wereserved.The diets were designed to meet thenutritional recommendations of
the National
Institute of Nutrition (NIN) for the elderly in
Vietnam. We made the three-day cycle menus from
Vietnamese traditional dishes which are commonly
served at home meals. They combined a variety of
locally available ingredients, also including proteinrich foods other than meat such as fish, shrimp andtofu; there was always at least one dish using meat.
The two diets used the same ingredients andquantities, were cooked in the same way by the samechef, and were different only in the kind of meat theyused. Despite being cut the same size, the thicknessof the two types of meat was different, the Thinly
sliced meat with a thickness of 1.5mm, the Hand-cut
meat with a thickness 3-5mm. Snacks were provided
in mid-morning and afternoon with lactose-free milk
and fruits.The diets were weighed before and after
eating and then the amount of food consumed was
calculated. The ratio of raw and cooked food wasconverted according to the coefficient of NIN [5].
Energy and nutrient intakes were calculated based on
the Vietnamese Food Composition Table 2016 [6].

METHOD
Subjects: Elderly patients ( 65 ea old) who wereclassified with moderate dentition (21-27 teeth) orpoor dentition (20 teeth or less) by the number ofremaining teeth (excluding the third molar) from theGeriatric Department, Internal Medicine Department,
and Traditional Medicine Department at Dong Da
General Hospital were screened. Patients withmental disorders, confusion and those with
contraindications to oral nutrition or being fed bytube were not included in our study. We used theWater Swallow Test (WST) to exclude patients with122

Asian Journal of Dietetics, 2020
Meat for study: The pork and beef used in this study
were produced in Vietnam. After being frozen under
the same conditions, half of the meat was sliced thinly
by a meat cutter with a thickness of 1.5mm, the otherhalf was sliced by hand after defrosting. Both kinds ofmeat were defrosted in a refrigerator at 5°C or lower
before cooking.
Ethics of human subject participation: The study
received permission from the ethical committee at
Hanoi Medical University, Vietnam. All subjects
were informed in detail about the purpose, theadvantages and disadvantages of this study, and theirrights and obligations. Informed consent was
obtained from all the participants.
Statistical methods: Data were analyzed by using
STATA version 14. Values are reported as means ±standard deviations (SD). Quantitative variables(energy and nutrient intake between 2 diets) werechecked for distribution and compared by the
Wilcoxon signed-rank test, p-values of less than 0.05
were considered statistically significant.

Photograph 1. Slicer and thinly sliced meat (left) and hand cut meat (right)

GenderAge
Dentition

Table 1. General characteristics of subjects
Classification
Number (n=38)
Male12
Female26
Mean age (Mean ± SD)
73.8 ± 6.7
65-79 years old
29
80 ea ld
9Moderate dentition (21-27 teeth)
29
Poor dentition (20 teeth or less)
9

16%

33%

21%

11%

Moderate dentition(21-27teeth)(n=29)

MalnourishedAt risk of malnutrition

56%

69%

Total (n=38)

76.3
23.7
76.3
23.7

10%

18%
66%

Percent (%)
31.6
68.4

Normal nutritional status

Poor dentition(20 teeth or less)(n=9)

Figure 1. Nutritional status assessment based on MNA tool
RESULTS
Table 1 shows the general information on study
subjects (including gender, age and dentition). Dataconsisted of 38 subjects: 12 subjects (31.6%) weremale while 26 subjects (68.4%) were female. The
average age was 73.8 ± 6.7 years old. There were
76.3% (n=29) patients aged 65 79 years old and23.7% (n=9) aged 80 and over. There were 76.3% of

total patients who were classified with moderate
dentition (the number of remaining teeth was 21-27
teeth), equivalent to 29 patients; 8 patients were in
the poor dentition group (20 teeth or less),accounting for 23.7% of the total. Of the total of 38,
subjects with normal nutritional status were highest,at about 66%; the percentage of patients with at risk
123

Thinly sliced meat for elderly people with tooth loss
malnutrition was 18% while the figure formalnourished was lowest, at 16% (Fig. 1). The
proportion of patients with normal nutritional status
in the Moderate dentition group was higher than in
the poor dentition group, 69% compared with 56%.
There were 10% malnourished patients in themoderate dentition group while 1/3 patients in thepoor dentition group were malnourished.
Sensory evaluation: Fig. 2 shows average points forcharacteristics of sensory evaluation. The mean

9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00

scores for the thinly sliced meat sample were higher
than for the hand-cut meat sample in appearance,
taste, softness and over-all acceptability in which
taste, softness and over-all acceptability arestatistically significant (p<0.05). The mean scoresfor the Hand-cut meat samples were higher than themean points for the Thinly sliced meat samples
only for aroma; however the differences are notstatistically significant (p>0.05).

*

8.03 7.47

7.16 7.26

Appearance

Aroma

7.74

*

8.16

6.89

Taste

Sliced meat diet

*

7.97
6.42

6.89

Softness

Over-allacceptability

Hand-cut meat diet

Figure 2. Average of points for characteristics of sensory evaluation (n=38)(*: p<0.05,by Wilcoxon signed – rank test)
To chew 3g of thinly sliced meat, subjects needed
53 ± 22 times and 47 ± 23 seconds while to chew
hand-cut meat of the same weight took 73 ± 35 times

Hand-cut meat (n=38)

and 65 ± 33 seconds (Fig.3). Both indicators were
statistically significantly different (p<0.05).

73±35

*
Thinly sliced meat (n=38)

53±22
0

20

Hand-cut meat (n=38)

65±33

Thinly sliced meat (n=38)

47±23

40

60

80

100

120
times

*

0

20

40

60

80

100

Figure 3. The time and number of times to chew the same weight (3g)(*: p<0.05, by Wilcoxon signed – rank test)
124

120
seconds

Asian Journal of Dietetics, 2020
Fig. 4 shows energy and nutrient intakes for diets
using thinly sliced meat and diet using hand-cut meat.
The results from the 38 subjects indicate that the meanenergy, protein, lipid intakes for the sliced meat dietwere higher than for the hand-cut meat diet. Values
from the Sliced meat diet were 1380 ± 164 kcal/day,
70.8 ± 8.8g protein per day, 31.1 ± 2.0g lipid per day,compared with 1337 ± 198 kcal/day, 63.8 ± 10.3g
protein per day, 29.5 ± 3.3g lipid per day. And thedifferences are statistically significant for meanenergy, protein, and lipid between the 2 diets (p<0.05).
The mean carbohydrate is the same for both diets withno statistical significance (p>0.05) 204.3 ± 30.3 g in
the Thinly sliced meat diet and 202.3 ± 34.0g in the
Hand-cut meat diet. For all energy, protein, lipid andcarbohydrate intakes, the distribution of data from theHand-cut meat diet is scattered, from low to highvalues. While in for data in the thinly sliced meat diet,the distribution of data is concentrated at high values.

1600
1500
1400
1300
1200
1100
1000
900
800

PROTEIN INTAKE

*
*
g/d

Kcal/dENERGY INTAKE

1380±1641337±198

Thinly sliced meat diet Hand-cut meat diet
(n=38)(n=38)

*

240.0
220.0

25.0

200.0

20.0

180.0

g/d

g/d

63.8±10.3

CARBOHYDRAT INTAKE

30.0

15.0

160.0

10.0

140.0

5.0

120.0

31.1±2.070.8±8.8

Thinly sliced meat diet Hand-cut meat diet
(n=38)(n=38)

LIPID INTAKE
35.0

*

90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0

29.5±3.3

204.3±30.3

202.3±34.
0Thinly sliced meat diet
(n=38)

Hand-cut meat diet
(n=38)

100.0

0.0
Thinly sliced meat diet Hand-cut meat diet
(n=38)(n=38)

Figure 4. The energy and nutrient intakes for diets using thinly sliced meat and diet using hand-cut meat(*: p<0.05, by Wilcoxon signed – rank test)
Table 2. The energy, nutrient and amount of meat intake by dentition

Energy (kcal/d)Moderate dentition (21-27 teeth) n=29

Poor dentition (20 teeth or less) n=9

Sliced meat dietHand-cut meat diet

Sliced meat dietHand-cut meat diet

1368 ± 185
66.0 ± 9.1*
26.5 ± 5.9*
1.24 ± 0.28*
30.0 ± 2.0*
206.3 ± 31.9
9.0 ± 1.6
133.7 ± 30.0*1352 ± 185
66.6 ± 10.2
26.2 ± 3.7
1.26 ± 0.28
29.8 ± 2.0
194.9 ± 33.3
7.8 ± 1.5
132.8 ± 18.1

1218 ± 219
55.7 ± 11.0*
20.4 ± 7.2*
1.13 ± 0.36
27.6 ± 3.8*
189.5 ± 39.1
8.1 ± 1.9
103.5 ± 36.5*

1400 ± 154
72.7 ± 7.5
Protein from meat (g/d)
29.4 ± 4.0
Protein/ kg BW (g/kg/d)
1.36 ± 0.26
Lipid (g/d)
31.5 ± 1.9
Carbohydrate (g/d) 207.2 ± 29.3
Fiber (g/d)
9.5 ± 1.1
Meat intake (g/d)
149.3 ± 20.1*: p<0.05, by Wilcoxon signed rank test
Protein (g/d)

125

Thinly sliced meat for elderly people with tooth loss
Table 2 shows energy, nutrient and amount ofmeat intakes by dentition. The mean energy, protein,lipid intakes in the Thinly sliced meat diet were higher
than in the Hand-cut meat diet in both the moderate
dentition group and the poor dentition group. The
results indicate that the mean amount of meat intake
for the thinly sliced meat diet was higher than from forthe hand-cut meat diet both in the Moderate dentitiongroup and in the Poor dentition group. Subjects in theModerate dentition group consumed 72.7 ± 7.5g
protein per day and 1.36 ± 0.26 g protein /kg per day
in the Sliced meat diet while the Hand-cut meat was
lower 66.0 ± 9.1g protein per day and 1.24 ± 0.28 g
protein/kg per day.
Subjects in the Poor dentition group had a protein
intake per kg lower 66.6 ± 10.2g protein per day and1.26 ± 0.28 protein/kg per day with the sliced meat
diet compared with 55.7 ± 11.0g protein per day and1.13 ± 0.36g protein/kg per day in the Hand-cut meat
diet. Protein/kg BW, protein from meat and amountof meat intakes are statistically significant between the
2 diets (p<0.05).

chews were statistically significant for the two
samples (p<0.05).
The use of thinner meat (although the same size)
makes it easier for older people to chew and eat better;
the subjects can eat more meat without too muchdifficulty, thereby significantly improving energy,
protein, and lipids intake. According to therecommendation from NIN (7) protein needs forhealthy elderly people are 60-70 g/d. However thiswas the recommendation for normal elderly who areliving in their community. For the elderly researchsubjects who were being treated in hospitals, we used
ESPEN guidelines on clinical nutrition and hydrationin geriatrics (8) as a standard of control. According to
ESPEN, protein intake in older persons should be atleast 1 g protein per kg body weight per day. Daily
amounts of 1.2-1.5 g/kg have been suggested for older
persons with acute or chronic illness and up to 2.0 g/kg
body weight per day in case of severe illness, injury or
malnutrition (9). In our study, whether eating a Thinly
sliced meat diet or a Hand-cut meat diet, subjects withmoderate dentition achieved the recommended protein
level. However, for those who with poor dentiton,
when eating the Hand-cut meat diet, it was notpossible to reach this level of recommendation (theyonly consumed 55.7 ± 11.0g/d equivalent to 1.13 ±0.36g/kg/d). These results were consistent with the
National Health and Nutrition Examination Survey
during 2005 2008, which were conducted on 9140
American adults and showed that participants in thepoor dentition group had significantly lower energy
intake than those with moderate dentition(P < 0.05)(10). In both groups, when eating thinly
sliced meat, protein intake was higher than with thehand-cut meat diet (the difference was statisticallysignificant). This is an outstanding benefit when using
thinly sliced meat (thickness 1.5mm) instead of handcut meat (thickness 3-5mm) in the diet for elderly
subjects with lost teeth. Based on Figure 4, we can see
not only the average but also the data distribution of
the energy, protein, lipid and carbohydrate intakes
when subjects ate Thinly sliced meat diet and theHand-cut meat diet. While for the diet using sliced
meat, the distribution data was concentrated in thehigher part of the graph, in the diet using Hand-cut
meat, the data were scattered, and there were evenmany values at the very low end of the figure.
The mean carbohydrate was the same for both
diets and was not statistically significant (p>0.05).
This can be explained by the traditional diet of
Vietnamese people. The main source of carbohydrates
comes from rice, which is often cooked separately,
seldom in combination with other ingredients whencooking. So, consumption of rice or carbohydrates isalmost constant at every meal. Some of the subjects inour study had a history of diabetes for many years(they had received instruction on nutrition fordiabetics before), so they controlled their own diet(limiting their foods rich in carbohydrate intake) bythemselves. Therefore, the amount of energy intake

DISCUSSION
We found in this study that thinly sliced meat iseasier to chew and is favored over meat sliced by handin the elderly who have lost teeth. These findings
suggest positive effects of thinly sliced meat onthetime, number of chew and food intake in older
adults who have difficulty in chewing from having
lost teeth.
It was surprizing that from the sensory test the
subjects liked the sliced meat better than hand-cut
meat with the overall taste score for the sliced meat
7.97 and that for hand-cut meat 6.89 (p<0.05). The
better acceptablity was mainly not only because ofsoftness but also better taste (score of sliced meat 8.16
and 7.74, that of hand cut meat 6.42 and 6.89 (p<0.05).
The results from this sensory evaluation showed thatthinly sliced meat samples were rated higher than
hand-cut meat samples in color, taste, softness,and over-all acceptability in the elderly people whohave lost teeth. Sliced meat is thin, the uniform sizeand shape make them more eye-catching. Whencooking, the meat pieces are evenly cooked so they are
better. The use of manual slicing knives does notguarantee the uniformity of the pieces resulting in adish that is less eye-catching and unevenly
cooked. Easier chewing has affected to the elderly
subjects who have difficulty in chewing due to toothloss; this can improve their taste and appetite.
By using a meat slicer we can obtain pieces ofmeat with a thickness only 1.5mm so it is easy to chew
and they are especially suitable for the elderly withlost teeth. This is shown by the time and number ofchews. To eat one piece of thinly sliced meat (3g),subjects took less time and fewer chews than the handcut meat piece of the same weight (53 ± 22 times and
47 ± 23 seconds compare with 73 ± 35 times and 65 ±33 seconds). Both the chewing time and number of126

Asian Journal of Dietetics, 2020
from carbohydrates in the subjects in our study
accounts for only about 50% of the total energy intake.
In this study, the meals were prepared and weighed
before being given to the subjects. After they had
eaten, we weighted the food remaining and caculated
the amount of food intake. During the study, subjects
were not allowed to eat anything apart from diets thatwere prepared. This helps us to accurately control theamount of food and nutrients intake by the subject andreduce recall errors or errors from images.
There are studies that have provided evidence ofan association between poor nutritional status andprolonged hospital stay, decreased quality of life, andincreased morbidity and mortality (11). Betterchewing ability of the elderly leads to better
nutritional status and quality of life, as has been
demonstrated through previous studies (12, 13).
Chewing ability is closely correlated with the numberof natural teeth present: there is a threshold of 20 21
teeth, below which chewing ability declines (14, 15).
Our results were consistent with this view. There were
only 10% malnourished patients in the moderate
dentition group while 1/3 of subjects in the poor
dentition group were malnourished. From results ofthis study, using thinly sliced meat improved theenergy and nutrients intake and it also was expected to
improve the nutritional status in the elderly. Our study
was conducted with only 38 subjects and has not yetassessed the long-term effects of sliced meat on
improving the nutritional status of subjects. However,while there are these limitations, still results of thepresent study are an important first step for further
studies with longer duration and on a larger number ofsubjects, not only the elderly in a hospital but also theelderly living in the community.
In conclusion, thinly sliced meat is easier to chew
and preferred to meat sliced by hand for the elderly
who have lost teeth. Using thinly sliced meat
improved the energy and nutrients intake in older
adult who have difficulty in chewing (the difference isstatistically significant). From these findings, besides
minced meat, thinly sliced meat can become an
optimal choice for elderly people who have lost teeth
and are having difficulty chewing thick pieces of meat
to diversify their meals. We expect the diets for elderly
people who have lost teeth in Vietnam could havemore variety and improve their daily meals, thusincreasing their food intake and finally improving
their quality of life through their diet.

and Nutritional senior students at Hanoi Medical
University for collaborating in the study. This study
was supported by Jumonji University. We would liketo thank Andrew R. Durkin, Professor Emeritus ofIndiana 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.
ACKNOWLEDGMENTS
The authors are grateful to all participants and thestaff members of the Dongda General Hospital, Hanoi,

14)

1)

2)

3)

4)

5)
6)
7)
8)
9)

10)
11)

12)
13)

15)

127

REFERENCES
United Nations Population Fund and General
Statistic Office. 2016. Vietnam Population
Projection 2014- 2049. Vietnam News Agency
Publishing House. Hanoi.
Douglass CW, Shih A, and Ostry L. 2002. Will
there be a need for complete dentures in the
United States in 2020. J Prosthet Dent. 87(1): 5
8.
Nga NT and Dung TM. 2017. The situation of
tooth loss and evaluation of the result of
removable prosthesis of plastic substrates in theelderly in Hanoi City. Hanoi Medical University.
Hanoi.
Nguyen MS, Jagomägi T, Voog-Oras Ü, et al.
2018. Oral Health Behaviour and Oral Health
Status of Elderly Vietnamese. Oral Health Prev
Dent. 16(2): 153 161.
National Institute of
Nutrition. 2017.
Coefficients of raw cooked and food weight
conversion tables, Medical publisher. Hanoi.
National Institute of
Nutrition. 2016.
Vietnamese Food Composition Table, Medical
publisher. Hanoi. (in Vietnamese)
National Institute of
Nutrition. 2006.
Recommendation dietary allowance foe
Vietnamese people.
Volkert D, Beck AM, Cederholm T, et al. 2019.
ESPEN guideline on clinical nutrition andhydration in geriatrics. Clin Nutr. 38(1): 10 47.
Bauer J, Biolo G, Cederholm T, et al. 2013.
Evidence-Based Recommendations for Optimal
Dietary Protein Intake in Older People: A
Position Paper From the PROT-AGE Study
Group. J Am Med Dir Assoc. 14(8): 542 559.
Zhu Y, Hollis JH. 2014. Tooth loss and its
association with dietary intake and diet quality in
American adults. J Dent. 42(11): 1428 1435.
Stratton RJ, King CL, Stroud MA, et al. 2006.
Malii
U i e al Sc ee i g T lpredicts mortality and length of hospital stay inacutely ill elderly. Br J Nutr. 95(2): 325 330.
Lee IC, Yang YH, Ho PS, et al. 2014. Chewing
ability, nutritional status and quality of life. J
Oral Rehabil, 41(2): 79 86.
Samnieng P, Ueno M, Shinada K, et al. 2011.
Oral health status and chewing ability is related
to mini-nutritional assessment results in an older
adult population in Thailand. J Nutr Gerontol
Geriatr. 30(3): 291 304.
Kimura Y, Ogawa H, Yoshihara A, et al. 2013.
Evaluation of chewing ability and its relationshipwith activities of daily living, depression,
cognitive status and food intake in thecommunity-dwelling elderly. Geriatr Gerontol
Int. 13(3): 718 725.
Rugg-Gunn AJ, Nunn JH. 1999. Nutrition, dietand oral health. Nutr Diet Oral Health.

A ian Jo nal of Die e ic , 2020

O
A

F

I

I S

S

L

S

J

No iko S mida, Saiko Shikanai, Nob ko Sa k a, Hi omi Takeich, Miho N noka a、
Ng en Mai Ph ong, Ng en Van Diep, Ng en H ong Giang, Shige Yamamo o
Asian N trition and Food C lt re Research Center, J monji Uni ersit , Saitama, Japan
ABSTRACT Backgro nd: Deficienc of die a fibe i he mo impo an heal h- ela ed
n i ion p oblem a p e en in Japan. I i al o e fo chool l nch. In Japan almo all heelemen a chool den ha e chool l nch h o gho he ea and he ecommenda ion offibe fo he ppe g ade
den i 6g/l nch. Ho e e , he ha e no been cce f l.
Objecti e: To anal e he con ib ion of fibe o ce in chool l nch and o find he neme hod( ) o inc ea e fibe in ake o mo e han 6g. Method: Fibe in ake b all he chooll nche in a ea (197 da ) a a p blic chool a calc la ed b
ing he Japane e S anda dFood Compo i ion Table. All he 197 mene e g o ped in o 3 ca ego ie of fibe a mo ehan 6g, 5 - 5.9g and lo e han 4.9g. F he mo e, he con ib ion of a io food g o p(ce eal , ege able , po a oe , f i , bean , o p od c , n and eed , ea eed, m h oom ,e c.) e e calc la ed. Mo e de ail anal i a cond c ed fo he ege able ( oo ege able ,alk ege able, leaf ege able , f i - ege able , flo e ege able). Res lt: S aple food of
197 mene e 141 fo ice and 56 fo hea , being abo 75 % a ice. Ho e e , among
he 18 meni h mo e han 6g fibe in ake, a he aple food , 9 and 9 ed ice and b ead,e pec i el . When he ice a he aple food, a lo of b dock , konn ak and o bean e e
ed. The e e e 27 men
i h a fibe of 5 -5.9g and onl 6 of hem ed ice a a aple food.
Fibe pplied b commonl
ed ice (85g) a onl 0.4g. The a e age in ake of fibe f om
ege able a 1.9g. The e of ice a a aple food fo mo e han 3.5 ime a eek (5 da )i ecommended b he Japane e go e nmen oain and o ac i a e he local p od c .
Undech a i a ion, e ha e o con ide he e of b o n ice. Concl sion: To mee hefibe e i emen b ege able i diffic l and fibe - ich foodch a b o n ice ma beecommended fo Japane e chool l nch.
K
: chool l nch, ege able, fibe , ice
INTROD CTION
The School L ch Laa e abli hed in 1954
in Japan, and he c en chool l nch i implemen ed
ba ed on he School L nch P ac ice S anda d (1).
Among die ain ake c i e ia, die afibe ide e mined a a n ien o e a a ge amo n fo
p ima p e en ion of life le- ela ed di ea e . A
a ge amo n pe da of 18 ea o olde fo he malei 19 g o mo e and fo female i 17 g (2). Ho e e ,he da a ela ed o he die a fibe e i emen ofchild en e e limi ed. I i diffic l o de e mine heela ion hip be een die a fibe in ake and heincidence a e of life le- ela ed di ea e . Acco dingo ann al n i ion
e of chool child en, he fibein ake of fif h-g ade child en in elemen a chool a
10-15g (3). I ha been ho n ha fibe in ake ofchild en ma be lo e han he e i emen . Gene all ,ege able a e con ide ed a an impo an o ce of
die a fibe .
In addi ion, he Miniof Ag ic l e,
Fo e
and Fi he ie ' p opo al o con me 350 g ofege able pe ad l pe da eem o ongl
ppo
he opinion ha i i nece ao ea ege able (4).
Defini ion of ege able i diffe en no onl f omco no co n b al o f om minio minii hin Japan, Ho e e , omeden a ha hea e no good a ege able beca e of a e. So fa ,n i ion eache and chool n i ion aff ha emade man epo on lef o e of ege able in chooll nche (5) b ha e e o find clea imp o emen . Inhid , e anal e he men of pa chool l nch
o cla if ha kind of men can mee he anda d

amo n of fibe , and he fibe in ake anda d ofelemen achool-aged 10 o 11 ea . The ebegge ed a iable ol ion o imp o e he amo n offibe in ake b child en in chool meal .
METHODSIn hid , e ed 197 men fo chool
meal in a ea a an elemen achool. The local
go e nmen offe a comple e chool l nch, i h 3.5
ime a eek fo ice. The age of milled ice fo he
ppe g ade of elemen a chool i 85g. In addi ion,he b ead implemen ed b
he ci
i a b eadcon aining ice flo in hich he pe cen age of flo
ed i 90% hea flo and 10% ice flo p od cedin he p efec e. In he ppe g ade , ice flo b eadi mainl p o ided i h 63 g hea flo and 7 g ofice flo .
Fibe in ake in 197 men in a ea
acalc la ed ing he Japane e Food Compo i ion Table(6). Specificall , die a fibe a cla ified in o h ee
g o p : 6g o mo e, f om 5 o 6g and le han 5g. The
aple food a cla ified in o cooked ice and b ead,and he endenc of fibe in ake pe e ing b aple
food a anal ed. We al o e ima ed he amo n of
die a fibe con ained in he aple food. F he mo e,he a io of fibe in ake a calc la ed b he foodg o p a follo ce eal , ege able , po a oe , f i ,bean , o bean p od c , eed and f i , ea eed,m h oom , e c. In pa ic la , ege able e e di idedin o fi e pe ; oo ege able , em ege able , leaf
ege able , f i and ege able (Pho o 1) and hei
cha ac e i ic
e e anal ed .F i , m h oom ,ea eed , bean , eed and po a o a e no ege ableb he Japane e defini ion (6)*To hom co e pondence ho ld be add e ed:
k -chan1225@c eam.plala.o .jp

129Fibe in ake in Japane e chool l nch

P

1. C

J

RES LTThe di ib ion of aple food in 197 da i 141 da a ice and 56 da a b ead, o 3/4 of he chool meal
ing ice e e apled food. Af e o ing he men acco ding o he amo n of fibe , he e l a 18 men
p o iding 6 g o mo e of fibe , 27 men p o iding 5g o 5.9g and 152 men p o iding 4.9 g o le . The a e age
ege able in ake a 103 g, 105 g and 82 g hen he fibe in ake a 6 g o mo e, 5 o 5.9 g and 1.9 g o le ,e pec i el . The a e age amo n of plan -ba ed fibe i 2.9 g, 2.1 g and 1.7 g fo men p o ided f om 6 g omo e, 5 o 5.9 g and 4.9 g. o le , e pec i el . The a e age amo n of plan -ba ed fibe in 193 meal i 1.9g.
Table 1 ho men ha p o ide 6g o mo e of fibe (18 men ). The a e age amo n of fibe p o idedf om hi men g o p a 6.9 0.9 g. S aple food of 18 men
i h fibe con en of 6 g o mo e a he fac ha
he n mbe of eg la meal i 9 fo ice and 9 fo b ead.

T
No
1
2
3
4
5
6
7
8

Amount offiber (g)
8.5
8.4
8.4
7.9
7.3
7.3
6.8
6.8

Staple
food
Bread
Bread
Bread
Rice
Bread
Rice
Rice
Rice

9

6.3

Bread

10
11
12
13
14
15
16
17

6.2
6.2
6.2
6.2
6.2
6.2
6.2
6.1

Bread
Bread
Bread
Bread
Rice
Rice
Rice
Rice

18

6.1

Rice

1. M

6
Menu

apple jam, milk , pork beans, seaweed salad, yuzu dressing
apple jam, milk, pork beans, cornsugar-reduced jam, milk, pork beans, boiled vegetables, mayonnaise
milk, soybean kinbira burdock, croquette, boiled cabbage, worcester sauce
milk, stewed hamburger, broccoli, pumpkin botage
milk, chicken and konjac miso stew , croquette, broccoli, worcester sauce
milk, pork and burdock stew, seaweed salad, green soybean dressing, mixed nuts
milk, Japanese style hamburger, soybean chopped burdock
small bread with rice flour, milk, spaghetti napolitan, boiled vegetables sesame dressing, frozen
mandarin orange
small bread with rice flour, margarine, milk, fried soba noodle, fried beansplain bread with rice flour, apple jam, milk, fried vegetable, university potato
apple bread with rice flour, milk, seaweed udon noodle, fried beans, mandarin orange
soybean flour fried bread with rice flour, milk, pumpkin potage, omelette ketchup
milk, soybean chopped burdock, thick roasted egg, yukari pickled
milk, soybean chopped burdock, crab egg roll, instant pickles
milk, sudachi vinegar, small fish nut
milk, soybean chopped burdock, grilled saury, sudachi
milk , simmer sour pork with burdock, thick omelet containing vegetables , yukari pickled ,mixed nuts

130

A ian Jo nal of Die e ic , 2020

F

1. O

(

Vegetable-derived dietary fiber dosage(g)

Fig e 1 ho
he o igin of die a fibe b
aple food. When ice a aple food, onl 0.4 g offibe f om ice, 2.9 g of fibe f om ege able , abo
0.9 g of fibe f om be (mo l konn ak ) and bean
i abo 0.9 g (mo l o ) and 0.5 g of fibe f om n
(mo l e ame and mi ed n ) e e con med. In
he ca e of aple food a b ead, he amo n of fibe
f om b ead a 1.7 g, 2.4 g f om ege able , abo 0.4
g f om be (mainl po a oe ), abo 1.6 g f om)(

bean (mainl o and bean ), eed and f i (mo lmi ed nha con me 0.1 g of fibe ).
Fig e 2 ho
ccon ib ion of die a fibe
f om 5 pe of ege able b able food . When aple
food a ice, 2.4g of o al 3.3g a f om oo
ege able and hen aple food a b ead, o alin ake a 2.4 g and imila in ake f om 5 pe ofege able .

4.0
3.5
3.0
2.5

0.1
0.3
0.3
0.2

Flower vegetable

2.0
1.5
1.0

2.4

0.5

0.4

Fruit vegetable

0.8

Leaf vegetable

0.3
0.5

Stem vegetable

0.4

0.0
Staple food rice)

Root vegetable

Staple food bread

Figure 2. Contribution of dietary fiber from 5 types of vegetable by riceor bread as staple foods (n=9 in each staple food)131

Fibe in ake in Japane e chool l nch
Table 2 ho 27 men ha p o ide be een 5 and 5.9g pe meal. Thi men g o p p o ide an a e age of
5.4 0.3 g of fibe . The e e e onl 5 men
ing ice a a aple food. In addi ion, hi g o p of en e ed e eddi heing oo ege able a ide di he .
T
1
2
3
4
5
6
7
8
9
10
11

Amount offiber (g)
5.9
5.9
5.8
5.8
5.7
5.7
5.6
5.6
5.5
5.5
5.5

12

5.3

Bread

13
14
15
16
17

5.3
5.3
5.3
5.2
5.2

Bread
Bread
Bread
Bread
Bread

18

5.2

Bread

19
20

5.2
5.2

Bread
Rice

21

5.2

Rice

22
23
24
25

5.1
5.1
5.1
5

Bread
Bread
Bread
Bread

26

5

Bread

27

5

Rice

No

F

2. M

5 - 5.9

Staple food

Menu

Bread
Bread
Bread
Rice
Bread
Bread
Bread
Bread
Bread
Bread
Rice

reduced sugar jam, milk, chicken and cabbage curry sauteed, abe river mochi
milk, boiled vegetable in cream, omelette ketchup, kiwi fruit,milk, wiener chili sauce, boiled vegetable mayonnaise
red rice, milk, shrimp fry, boiled cabbage, tartar sauce, kinju juice, honey peanutchocolate paste, milk, grilled rice noodle, boiled vegetable, mayonnaise
milk, Western-style boiled fruit cocktail
chocolate pate, milk, stewed hamburger, corn soupsoybean paste, milk, seaweed udon noodle, yukari pickle, cornbrown sugar bread with rice flour, milk, scotch egg, boiled vegetatble, corn bottage soupcocoa bread with rice flour, milk, borsch, Japanese style salad, Japanese dressing.
milk, chikuzenni, narutokintoki croquetteplain bread with rice flour, soybean paste, milk, spaghetti napolitan, French salad, French
dressing
half-calorie margarine, milk, stir-fried vegetable, abe river mochi
milk, stewed hamburger, corn potage soup, moonlit jelly
spaghetti with soynean flour, seaweed salad, sesame dressing
self-edd sandwich, milk, corn potage soup
sugar jam, spaghetti with meat sauce, French salad, French dressing
small butter bread with rice flour, milk, spaghetti with meat sauce, French salad, French
dressing
milk, clam of chowder meat dumpling, boiled cabbage
Milk, Braised foods, Boiled cabbage, komatsuna, mixed nuts
milk, yuzumossi oden, yuzumiso oden miso, mandarin orange, Nozawa-ha piclked withrice flour
milk, spaghetti soup, seaweed salad, blue jiso dressing
milk, mushroom spaghetti, Japanese salad, citrus fruit dressing
milk, spaghetti Napolitan, French salad, French dressing
sandwich, milk, corn potage soup
pumpkin bread, milk, gome udon, small sardine tempura, ponkan orange, setubun festibal
menus
Hayashi rice, milk, seaweed salad, green joso dressing

3. M

+1SD

Fig e 3 hoha he mean al e of ege ablede i ed fibe i 1.9g and he mean + 1SD i 2.7g ha
co e 84% of he pa icipan ( ello a o ). The
mean + 2SD i 3.5g ha incl de 97.5% of pa icipan(g een a o ). The e e l indica e ha i i ediffic l o ake mo e han 3g f om ege able.

+2SD

Fig e 4 ho
he di ib ion of a ioege able in ake of 197 l nche in a ea . In ake
f om oo ege able a 36%, em ege able 21%,leaf ege able 22%, f i ege able 15% and flo e
ege able 6%.

132

A ian Jo nal of Die e ic , 2020

F

4. D

DISC SSIONIn hid , he di ib ion of aple food in 197
daa 141 da a ice and 56 da a b ead, ino heo d 3/4 of he chool meal
ing ice aapled food. I a fo nd ha hen he aple fooda hi e ice, he men f om hich ege able canbe a i fied i h fibe e i emena e emellimi ed. S aple food of 18 men
i h fibe con en of
6g o mo e in 197 dae e 9 mening ice and 9men
ing b ead. The men
ed ice cha ac e i ed
b b dock, konjac, o bean
ed in la ge amo n .
In he chool l nch anda d fo e e child oden , effec i e Ap il 1, 2013, he anda d al e offibe a e a 6g fo elemen a child en 10 o 11
ea old. Among he men ha p o ide 6g of fibe ,9 men
e ice a aple food, he die a fibe i 0.4g
f om ice, 0.9g f om konjac, 0.9g f om o bean and
0.9g f om n and 2.9g f om ege able . Simila l , ifaple food a b ead, hen he fibe i 1.4 g f omb ead, 0.4g i f om be , 1.6g a f om bean , 0.1g
a f om he g ain and 0.1g and 2.5g e e de i ed
f om ege able . A a e l , he amo n of ege ablede i ed fibe p o ided a a chool mealaapp o ima el 3g, hich make i e diffic l o
inc ea e ege able-de i ed fibe o 3.5g o mo e. A
men i h fibe of ege able o igin of 3.5g o mo e i
ed mainli h b dock, leg me and konjac. Whenleaf ege able like cabbage and ca damom e eed, he amo n of die a fibe a
all 2g ole .
Ea ing in fficien fibe i of en ho gh o be d eo in fficien in ake of ege able . Acco ding o
FAOSTAT (Food Balance Shee ) ba ed on FAO (7)g ideline, he e l of ann al ege able con mp ion
pe capi a in 2009 in majo co n ie a o nd he o ld
ho ha Japane e ege able con mp ion i 278g, in
he Uni ed S a e i 337g, Canada i 308g. Th , hecon mp ion of Japane e ege able compa ed oo he co n ie i no la ge. Ho e e , he e i nonified defini ion of ege able and f i in he o ld
d e o he c lina c l e of each co n and he aof hinking of each co n .

In compa i on on FAO (7), Japane e andAme ican defini ion of ege able , in Japan," ege able " a e edible he baceo plan ha efe oedible plani h a high a e con en (6). The
mainl ea lea e , oo , em (incl ding hi ome ),flo e , b d , and f i a ide di he . In con a , heUni ed S a e cla ifie
ege able in o fi e
bg o p : da k g een ege able , ed and ello
ege able , leg me , a ch ege able , and o he
(8). Among hem a e po a oe ,ee po a oe ando he po a oe , a ell a ea oning
ch a oma oke ch p. If e compa e he defini ion of Japane eege ablei h he defini ion of each co n , ieem ha ege able con mp ion in Japan i nomall. In a chool l nch hi
d , he a e age die afibe in ake f om ege able
a 1.9g. The c ena ge in ake of ege able i e fo g een- ello
ege able and ligh -colo ed ege able . Fo e ample,
efe ing o he Japane e defini ion, if ege able a e
cla ified in o fi epe : oo ege able , em
ege able , leaf ege able , f i ege able , andflo e ege able (6), he die a fibe con en diffe ,and oo ege able con ain man die a fibe . I n'a anda d fo a ge in ake nece a ? If e a e ing
o fill o die a fibe i h ege able , e ill needo hink mo e abo he cien ific a ionale ha "le 'mee he 350g pe da ega dle of he he i ' leafo oo ege able ." I i al o impo an o a e a iodi he f om he ie poin of e panding he foode pe ience. Co ldn' i be be e o ea ege able mo ef eel ? We g e 100-200g fo leaf ege able and100-200g fo oo ege able .
Acco ding o a epo f om he S e and Re ea ch
Coope a ion Co ncil on he De elopmen of
S anda d fo Ea ing Child en' Meal fo School
L nch (Ma ch 1991), "I i no eno gh o impl fill 8
g of die a fibe pe 1,000 kcal of ene g . Effoop omo e he e of b o n ice (incl ding ge mina ed
b o n ice), po a oe , bean , eed , n , ege able ,m h oom , algae, e c. o inc ea e in ake hile
main aining he de i ed Japane e food c l e ho ld
be enco aged h o gh chool l nche o help child en133

Fibe in ake in Japane e chool l nch
a in hei dail die
Inc ea ing fibe in ake f om ege able i noea . We an o gge he e of p o ed b o n
ice o inc ea e die a fibe in ake. The ea on fo hi
i ha ne cook a e i e i ed o e b o n ice, b
ge mina ed b o n ice can be cooked i h he ame
e ipmen a hi e ice. Al ead , ome m nicipali ie
e ge mina ed b o n ice fo chool meal . The
amo n of ge mina ed b o n ice ed i 5 o 10% of
ha of poli hed ice, and i i
ed abo once o
icea mon h. Ho e e , in o de o ake ad an age of hefac ha b o n ice i ea o inge die a fibe , i ip efe able o e 50-100% ge mina ed b o n ice. The
e of ge mina ed b o n ice ill al o be ignificanin main aining he food c l e ha ha been c l i a ed
on ice b Japane e people. In addi ion, c l i a ing he
ea ing habi of ea ing ge mina ed b o n ice d ing
chool age ma con ib e o f
e heal h.
The e of ice a a aple food fo mo e han 3.5
ime a eek (5 da ) i ecommended b he Japane e
go e nmen oain and o ac i a e he local
p od c . Unde ch a i a ion, pe hap he onl ao inc ea e he fibe in ake o mo e han 6 g i he eof b o n ice. B o n ice need pecial cooking pan,he efo e, p e-ge mina ed b o n ice ma beecommended.
In concl ion o mee he fibe e i emen b
ege able i diffic l and fibe - ich aple foodcha b o n ice o p e-ge mina ed b o n ice mbeecommended.
1)

Japanese).https://www.gakkyu.or.jp/info/history/ Accessed August 20, 2020
2)

3)

4)

5)

6)

7)

8)

REFERENCES

Japan Association for improving school lunch.
History of Japanese school lunch (in134

Ministry of Health, Labor and welfare. Japanese
Dietary Reference Intake 2010 (in Japanese)
https://www.mhlw.go.jp/shingi/2009/05/s05294.html Accessed August 20, 2020
Ministry of Education, Culture, Sports, Scienceand Technology. Report of Japanese school
lunch nutrition (in Japanese)
https://www.pref.oita.jp/uploaded/attachment/20
21019.pdf#search Accessed August 20, 2020
FAO, Food-based dietary guidelines - Japan
http://www.fao.org/nutrition/education/fooddietary-guidelines/regions/countries/Japan/en
Accessed August 20, 2020
Japan Sport Council, Nutrition survey of school
students 2010 (in Japanese)
https://www.jpnsport.go.jp/anzen/kankobutuichi
ran/tyosakekka/tabid/534/Default.aspx Accessed
August 20, 2020
Ministry of Education, Culture, Sports, Scienceand Technology. Standard tables of foodcomposition in japan, https://www.mext.go.jp/en/policy/science_technology/policy/title01/
detail01/1374030.htm Accessed August 20,
2020
FAO, Vegetables and derived products
http://www.fao.org/waicent/faoinfo/economic/fa
odef/fdef07e.htm#7.01 Accessed August 20,
2020
USD,All about vegetable.What foods are in the
Vegetable Group?https://www.choosemyplate.
gov/eathealthy/vegetablesAccessed August 20,
2020

Asian Journal of Dietetics, 2020

Original
Undernutrition in Older Adults Northern Thailand May Be Improved by
Increasing Lipid Consumption
Yupa Chanwikrai1*, Naritsara Phanthurat1, Chomnard Singhan1, Natthaphon Thatsanasuwan1,
Wittawat Sajjapong1, Puksiri Sinchaiyakit1, Jukkrit Wangrath2
1
Sc
2

Fac

M d ca Sc c , U
P b cH a ,C a

Ma U

P a a ,P a a ,T a a d, C a Ma , T a a d

ABSTRACT Undernutrition is highly prevalent in older people. Understanding nutritional
intake and dietary pattern of older people may help to design strategies to prevent malnutrition
and improve dietary intake and nutrition status. However, there is lack of data on nutritional
intake and dietary pattern of older people. Therefore, the purposes of present study was todetermine the dietary intake and food pattern in older adults northern Thailand. The participants
were interviewed using twenty four - hour dietary recall and assessed anthropometrically.
Results showed that the mean age of the participants (n 50) was 59 ± 10 years, the prevalenceof underweight was 18% in males and 9% in females. Estimated daily energy intake were
accounting to 92% of the Thai recommended dietary allowances (RDA), mean lipid intake was
40% of the Thai RDA in males and 47.2 in females. Mean carbohydrates and protein intake
were adequate, mean sodium intake was 151% of the Thai RDA in males and 152 in females.
The food components largely consisted of vegetables, herbs, seasonings, with less meat andoils. In conclusion, the northern Thai older adults had inadequate energy and lipid consumption.
Further studies may be suggested to promote the consumption of lipids by using vegetable oils
for cooking dishes, if the older people do not have dyslipidemia.
Keywords: Undernutrition, older adults, northern Thailand, lipid consumption
INTRODUCTION
The aging population is increasing rapidly
worldwide. In Thailand, there were approximately 11
million older adults (16.7%) aged 60 years and older in
2019, and this number is expected to increase 5
percent every year (1).
Malnutrition referred to as undernutrition iscommon in older people. The estimated proportion ofolder adults who are at risk of malnutrition is about
27% in community/ outpatients and 50% in other
healthcare settings (2). Causes of malnutrition in theelderly are related to several factors, including
inadequate intake, due to deterioration of the senses ofsmell and taste, and decline in gastric emptying
associated with satiation (3). Malnutrition is associatedwithfrailty,sarcopenia,
anddecreased
immunocompetence and leads to an increased rate ofmobility and mortality (4).
In Phayao Province in the northern part ofThailand, the older adult proportion has increased
from 15.3 percent in 2012 to 20 percent in 2017 (5).
Most older adults in Phayao work in the agricultural
field. Currently, there are limited data on nutrition
intake in this population in northern Thailand.
Understanding the nutritional intake and dietary
pattern of older people may help to design strategies
to prevent or improve dietary intake and nutrition
status.
The purposes of present study was to determine
the nutritional intake and dietary pattern in older adults
who live in Chiang Kham district, Phayao Province,
Thailand.

METHODSThis study was conducted with a cross-sectional
study. The older adults (≥ 55 years old) who live in
Chiang Kham district, Phayao Province, Thailand andhaving no dementia were enrolled in the study.
The participants were interviewed using twenty four
hour
dietary
recallandassessed
anthropometrically. Trained interviewers determinedparticipants dietary intake; they were requested todescribe precisely the foods and beverages consumed
during the 24 hours prior to the interview. All data
were calculated for energy and nutrient intake( carbohydrate, protein, lipids, dietary fibre andsodium) by the INMUCAL- N software version 3,
Institute of Nutrition, Mahidol University, Thailand.
Height was measured using a portable, freestanding stadiometer, body weight and percent body
fat were measured about 2 hours or more after
breakfast, using Omron Karada scan (model HBF-375,
Japan). The body mass index (BMI) calculation is theweight in kilograms, divided by the height in meterssquared (kg/m2) and categorized into 4 groups
according WHO cut off points: underweight: BMI<18.5 kg/m2, normal: BMI 18.5-24.9 kg/m2,
overweight: BMI 25.0-29.5 kg/m2 and obesity: BMI> 30 kg/m2.
Ethical Considerations
This study was reviewed and approved by theCommittee on Human Rights Related to Human
Experimentation, University of Phayao, Phayao,
Thailand. Project number 2/039/59.

*To whom correspondence should be addressedyupa.ch@up.ac.th135Undernutrition in older adults Northern Thailand
Statistical Analysis
All procedures of data analysis were performed
using Microsoft Excel Software 2013. Descriptive
statistics such as mean, standard deviation andpercentage was used to quantify the characteristics ofthe participants, dietary intakes and compared with theThai Recommended Dietary Allowance (RDA).

recall. Energy and nutrient intake of the participants
and Thai RDA are shown in Table 2. Comparison ofenergy and nutrient intakes with Thai RDA is shownin Figure 2.
The food components largely consisted ofvegetables, herbs, seasonings, with less meat and oils.
Common animal protein sources included chicken,
fish such as Nile Tilapia (Oreochromis niloticus),snakehead fish (Channa striatus) and salt mackerel,pork belly, pork ribs, eggs and frog. Cooking oils
included palm oil, soy bean oil, and lard. Generalseasonings used included salt, shrimp paste (Kapi),
monosodium glutamate (MSG), fish sauce (Nampla),
pickled fish (Plara), crab paste (Nampu) and soy sauce.
A sample of daily foods (1 day) is shown in Figure 3.

RESULTS
From our study, we found the mean age of theparticipants (n=50) was 59 ± 10 years. Theircharacteristics are shown in Table 1. Prevalence ofunderweight, normal, overweight and obesity of themales and females in this study are shown in Figure 1.
Data on dietary intake could be obtained from 43
participants who were fully interviewed for dietary

FemaleMaleOverweight
15%

Underweight
18%

Obesity3%

Underweight9%

Normal73%

Normal82%

Figure 1. Prevalence of underweight, normal, and overweight in the males (n=17) and females (n=33)

Table 1. Characteristics of the participants (n 50)
Characteristics
Number (%)
Height (cm)Weight (kg)Body Mass Index (kg/m2)% Body fat
Data are mean ± SD

Male
17 (34)163.2 ± 6.7
59.7 ±12.8
21.6 ± 2.58
23.5 ± 3.9

Female33 (66)151.6 ± 6.0
52.9 ± 7.6
23.06 ± 3.0
32.4 ± 5.8

Table 2. Energy and nutrient intake of the participants and Thai RDAs (6) (n 43)
Daily intake
RDA a
Male (n 15)
Female (n 28)
Male
FemaleDietary energy (kcal)
1,643 ± 387(91.8)
1, 3 ± 0 (92.1)
1,790
1,560
Carbohydrate (g)304 ± 98 (112.6)
246 ± 86 (102.5)
270
240Protein (g)53 ± 18 (89.8)
54 ± 27 (108)59
50
Fat (g)24 ± 16 (40.0)
25 ± 15 (47.2)
60
53
Dietary fibre (g)6 ± 2 (24)
7 ± 4 (28)25
Sodium (mg)3,020 ± 1,481 (151)
3,035 ± 1,503 (152)2,000%Distribution of P F:Cb
74 13 13
69 15 1645-65 10-15 20-35
Data are mean ± SD; the number in blanket is %RDA; a Thai RDAs: Thai recommended dietary allowances,estimated energy requirement for Thai adult age 61 70 years (light activity). Distribution of energy:
carbohydrate%, lipids 20-3 % and protein is 1 kg/day (or 10-1 %); b P: F: C is protein, fat andcarbohydrates.

136

Asian Journal of Dietetics, 2020

50%

Figure 2. Comparison of energy and nutrient intakes with Thai RDAs

Figure 3. Examples of daily foods (1day)

DISCUSSION AND CONCLUSION
This study showed that older adults had lower
energy, lipids and fibre intake than the Thai RDA. The
percentage of carbohydrate, protein and fat to total
calorie intake per day was 74:13:13 in males and69:15:16 in females, respectively. This pattern seems
to be similar to a previous study that determineddietary intake by 3-day dietary records in for Thai
elderly in Bangkok (n 32) (7).
There are many studies demonstrating a decline infood intake with aging (8). A poor appetite is shown
to be an important determinant of poor dietary intake
in older adults and of incidence of undernutrition.
Older persons often have a poor appetite due tovarious reasons including chewing problems,
olfactory losses and poorer health.About one-fifth ofthe males and one-tenth of the females were found to
be underweight, as determined by BMI lessthan 18.5 kg/m2. This was two times as high as
underweight in the survey of the Thai National Health
Examination, NHES V 2014 that is shown in Figure 4.
Undernutrition may start in the young old (age 60 – 69
years old) and increase at advanced ages. However,the dietary patterns of older people may not changemuch compared to those of adulthood. Therefore, inorder to have appropriate nutritional status in the laterstages of life, healthy eating behaviors should bepromoted at a young age.
The northern indigenous foods generally usedlittle oil in cooking. Cooking with less oil may beappropriate for individuals who are overweight/ obese,
but some older people take in too few calories and arealso underweight; low fat/oil choices may make it
difficult for them to consume enough food to maintaina positive energy balance (9). Adequate energy intake
is necessary for optimizing protein utilization andallows the body to utilize protein for non – energy
yielding functions such as the maintenance of leanbody mass (10).
In addition, we found carbohydrates were themain energy source (72% of total calories). Related tothe data of the Thai National Health Examination
Survey IV, of adults aged 30 - 59, reported that a
carbohydrate-rich dietary pattern was popular innorthern region of Thailand and rural areas (11).

137

Undernutrition in older adults Northern Thailand

Figure 4. Percentage of Thai older adults according to BMI in 20144) Nieuwenhuizen WF, Weenen H, Rigby P,
Hetherington MM. Older adults and patients inneed of nutritional support: review of current
treatment options and factors influencing
nutritional intake. Clin Nutr. 2010; 29(2):160169. doi:10.1016/j.clnu.2009.09.003
5) Phayao Provincial Statistical Office. Central data
set of adult age 60 year and over. 2017. Phayao,
Thailand. Available from:http://pha
yao.nso.go.th/index.php?option=com_content&vi
ew=article&id=382:2019-09-05-07-1740&catid=84&Itemid=558. Accessed July 28,
2020.
6) Bureau of Nutrition, Department of Health,
Ministry of Public Health. Dietary reference
intake for Thais 2020. Bangkok.
7) Pongpaew P, Tungtrongchitr R, Phonrat B, et al.
Activity, dietary intake, and anthropometry of an
informal social group of Thai elderly in Bangkok.
Arch Gerontol Geriat. 2000 Jun; 30(3):245-260.
DOI: 10.1016/s0167-4943(00)00051-0.
8) Morley JE. Decreased food intake with aging. J
Gerontol A Biol Sci Med Sci. 2001; 56 Spec No
2:81-88. doi:10.1093/Gerona/56.suppl_2.81
9) Rolls BJ. Do chemosensory changes influence
food intake in the elderly?. Physiol Behav.
1999;66(2):193-197. doi:10.1016/s00319384(98)00264-9.
10)Pasiakos SM, Margolis LM, McClung JP, et al.
Whole-body protein turnover response to shortterm high-protein diets during weight loss: arandomized controlled trial. Int J Obes (Lond).
2014;38(7):1015-1018. doi:10.1038/ijo.2013.197
11)Aekplakorn W, Satheannoppakao W, Putwatana
P, Taneepanichskul S, Kessomboon P,
Chongsuvivatwong V, Chariyalertsak S. Dietary
pattern and metabolic syndrome in thai adults. J
Nutr Metab. 2015; 2015:468759. doi:10.1155/20
15/468759

In conclusion, the northern Thai older adults had
inadequate energy and oils consumption. Although theamount of protein intake was sufficient, it may benecessary to consider whether the quality of theprotein is good enough. Further studies may besuggested to promote the consumption of lipids byusing vegetable oils for cooking dishes such as stirfried vegetables or rice and coconut milk in curry
dishes, if the older people do not have dyslipidemia.
And to increase high biological value proteins, soybean milk may be recommended.
ACKNOWLEDGEMENTS
The authors wish to express their gratitude to Prof.
Emeritus Dr. Maitree Suttajit for his valuablesuggestions during the planning of this study. We also
thank the participants, Ms. Jintana Jumpapao and Ms.
Sukanya Kanta and staffs of School of Medical
Sciences for their collaborative effort during datacollection. This study was supported by Academic
Service Projects for society, University of Phayao.
REFERENCES
1) Department of Older Persons. Statistics, Number
Separated by Province, and Age: 2018. Bangkok,
Thailand: Ministry of Social Development andHuman Security. Available from:http://www.dop.
go.th/th/know/side/1/1/275. Accessed July 28,
2020.
2) Cereda E., Pedrolli C., Klersy C., Bonardi C.,
Quarleri L., Cappello S., Turri A., RondanelliM.,Caccialanza R. Nutritional status in older
persons according to healthcare setting: A
systematic review andmeta-analysis of prevalence
data using MNA ®. Clin. Nutr. 2016, 35, 1282–
1290.
3) Nagaratnam N. Malnutrition and Malabsorption
in the Elderly. Advanced Age Geriatric Care.
Springer, Cham, 2019. 225-233.

138

Asian Journal of Dietetics, 2020

Letter to the Editor
The Bhutanese Way of Eating: Food for Thought for a Country in Nutrition Transition
Passang Lhamo Sherpa*
Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences,
Kingdom of Bhutan
Dear Editor:
The Kingdom of Bhutan is a beautiful landlocked
country among the Himalayas in South Asia,
sandwiched between India and China. With apopulation of slightly more than 700,000, Bhutan is anagrarian society where majority of the population
depends on subsistence farming and animal husbandry.
Because of being landlocked and difficult
geographical terrain, Bhutan has been able to maintainher unique culture including the food habits for
centuries. Back in the days the Bhutanese people
worked hard and lived off their fields eating whatever
was grown, depending mostly on grains as staples,dairy products mostly butter and cheese and meat.
Bhutan may be small agrarian based economy but its
is also one of the fastest growing economy and hencewith globalization, the old ways are quickly
diminishing or being replaced by modern amenities
making people more sedentary, less active but
continued with the old method of eating habit that hasgiven ways to modern lifestyle associated diseases
such as type II diabetes, hypertension andhyperlipidemia along with malnutrition andmicronutrient deficiency. The national nutrition
survey 2015 (1), reported that the Bhutanese dietconsisted of starchy staples mostly rice, maize andpotatoes, eaten with dairy products such as butter/oil
and cheese. Meat products, vegetables and fruit
consumption was reportedly very low at around 1 to
1.5 times per week. This finding was consistent withthe result from the nutritive analysis of the one-day
school meal, where the meals provided in schools was
mainly rice with potatoes, use of fats and salts weretwice the recommended daily allowance (2).
The national dish equivalent for the Bhutanese is
red rice with spicy chili cooked with cheese and butter
gravy. Chili is considered more as a vegetable rather
as condiments whereas cottage cheese is used as acondiment cooked with chili and various othervegetables. Whatever little vegetables Bhutanese eat ismostly laced with cheese which is rich in calcium andphosphorous and when cooked with vegetables theoxalate and phytate from the vegetables could form acomplex with the calcium from the cheese, decreasing
the absorption of nutrients both from the vegetables
and cheese. Perhaps this could be one of the factorsthat might have lead to the high rates of anemia in the
country especially among children. Iron deficiency
anemia is one of the major micro-nutrition
deficiencies amongst women and children with 3. %of children below five year being mostly affected,
followed by women of reproductive age (3 . %),adolescence girls (31.3%) and pregnant women(2 .3%). In the same survey, complimentary food forbreastfed children was found low in diversity with

only 11. % receiving the minimum acceptable diet,and only 1 .3% receiving four food groups(carbohydrate, fruits, vegetables and animal source
foods). Coupled with the faculty diet, lowconsumption of nutrient rich vegetables and fruits, andminimum use of meat and meat products in the dietwere recognized as some of the factors that could havecontributed to the micro nutrient deficiency. Bhutan
being largely a Buddhist country slaughtering andraising of animal for meat is uncommon, and majorly
depend on imports. This could be one reason wheremeat is not very common in a Bhutanese diet.
The need for revision of the typical Bhutanesediet has been under discussion over a long period oftime. The Royal Government has recognized lack of
dietary diversity and iron deficiency anemia as apublic health problem especially among children
under five years of age. Thus the government has
started various programs to imminently improve thenutritional status of children and in the long term toinculcate dietary diversification among general
population. One such vital program is homefortificationofcomplementary
food
with
micronutrient powder along with promotion ofcomplementary food diversification for children (3).
This program is targeted to children between 6 – 23months where mother / caregivers will be taught how
to fortify the infant’s food with the micro nutrient
powder containing 15 micronutrients (vitamin A, B
groups, C, E and three minerals namely copper, iodine,iron, selenium and zinc). In addition they are alsotaught how to prepare complementary food using
locally available grains / cereals, vegetables and meatand meat products. Thus while the micronutrient
deficiency will be corrected by point fortification,mother will learn about the value of dietdiversification for children and the whole family. The
other program is rice fortification with micronutrients(vitamin A, B groups and minerals iron and zinc) for
children who are studying at schools with feeding
program (4). In addition the school has revised theircurriculum making agriculture and animal husbandry
as integral part of learning, teaching children the valueof food while learning about the biology of plants andanimals. The Prime minister of Bhutan Dr Lotay
Tshering has personally taken his own initiative topromote healthy lifestyle and diet by recently
launching a social media campaign through his
Facebook page called “Healthy འ ག་ ། - A PMO,
Bhutan initiative” encouraging people to eat healthy,
diversify diet including fruits and vegetables, andpromoting physical activity to reduce lifestyleassociated non communicable disease.
Since the nutrition survey in 2015, many
advocacies have happened related to the need in*To whom correspondence should be addressed splham@fnph.edu.bt
139

Nutrition transition in Bhutan
diversification of diet, replacement of rice staple withother available cereals such as buckwheat, wheat,maize and millets. With the increasing literacy rate
(71.4%) among the general population and constant
media awareness, people have become more healthconscious and are mindful on what they eat. During
the time of COVID-19 people have realized that selfsufficiency is an integral part of food and nutrient
security and micronutrient rich foods such as fruits andvegetables, and animal source proteins are essential
for immunity to fight against infection. Bhutan andher people have to be mindful about exploitation
brought about by industrialization, and its greatest
impact will be on the health of the people brought
about by change in lifestyle and food and the impact
will not always be positive. We might be conquering
hunger but the double /triple burden of nutrition
cannot be avoided. Highly industrialized nations haveequally larger and more expensive health problems

related to faulty and imbalance diet and it should be
the lesson for the Bhutanese people to eat healthybalanced with adequate physical activity.

1)
2)

3)
4)

140

REFERENCES
Ministry of Health Bhutan. National nutrition
survey of Bhutan. Nutrition Program Departmentof Public Health, Thimphu Bhutan 2015.
Sherpa PL, Pokhrel HP, Dzed L, Deki K.
Nutritive analysis of school Meal: An
investigation of a one-day meal provided in
feeding schools of Bhutan. Asian Journal of
Dietetics. 2018 (2) 2; 59 – 64.
Dorji S. ‘Sprinkles’ – a micronutrient powder forchildren. Bhutan Broadcasting service 12th
September 2019.
World Food Program Bhutan. Rice fortification
updates. Thimphu.

Asian Journal of Dietetics, 2020

Review

E cl i e B ea feedi g: A Re ie f Ba ie a d E ha ce
i Af ica a d A ia

P ac ice

Freda D. Intiful1, Edem M. A. Tette2, Ruth Pobee3, Juliana Y. Enos4*
1

De a men of Die e ic , College of Heal h Science , Uni e i of Ghana, Legon
De a men of Comm ni Heal h, College of Heal h Science , Uni e i of Ghana,Legon.
3
Eme genc Medicine De a men , Uni e i of Illinoi , Chicago, USA.
4
Nog chi Memo ial In i e fo Medical Re ea ch, College of Heal h Science ,Uni e i of Ghana, Legon.
2

ABSTRACT Background: Although the benefits of exclusive breastfeeding (EBF) are wellestablished, practice rates have declined in many countries, particularly in Africa and Asia, andhave been linked to the huge burden of child mortality in the two regions. The decline has been
largely attributed to a variety of factors that prevent mothers from effectively practicing EBF.
The objective of this review was to identify the factors that influence EBF in African and Asian
countries to identify synergies and document experiences and lessons that can be shared tofacilitate widespread practice in developing countries.Methods: A literature search was
conducted using PubMed, Cochrane Library, Google Scholar and CINAHL Complete. Studies
conducted in Africa and Asia and published between 2005 and 2020 that addressed enhancers
and barriers of EBF were included. Data on factors influencing EBF were extracted and discussed
under four major headings: maternal factors, cultural beliefs and practices, health system factors
and government policies. A total of 34 studies comprising 19 from Africa and 15 from Asia were
included in the review.Results: The key barriers to EBF identified were maternal factors such as
mothers perception of insufficient breastmilk production, cultural practices such as giving
prelacteal feeds, health system factors such as poor or inadequate education on breastfeeding andinadequate governmental policy support such as paid maternity leave for the recommended 6month period for EBF. The key enhancers identified were family support, pro-breastfeeding
governmental policies and provision of adequate information on breastfeeding to families andcommunities.Conclusions and Recommendations: Successful EBF practice is hampered byvarious individual, family and societal barriers. At the core of these barriers is inadequate
education on the benefits of EBF and poor policy and legislative environment to support thepractice of EBF. Strategies to enhance EBF should include universal education on the benefits of
EBF, which should instigate family support for EBF, and promotion of legislation such as paid
maternity leave for both parents, which would enable EBF by mothers and support by fathers.
Emphatic health education and communication messages to discourage and curtail negative
cultural practices that mitigate successful EBF, such as the practice of prelacteal feeds, areneeded. Broader consultation and stakeholder engagement to ensure community buy-in toremove barriers to EBF practice in both Africa and Asia is critical to achieving global goals from
improving young child nutrition.
Key words: exclusive breast feeding, barriers, enhancers, Africa, Asia
INTRODUCTION
The World Health Organization (WHO) defines
exclusive breastfeeding (EBF) as the feeding of an infant
with breastmilk only, without any other liquids or solids,
not even water. However, drugs and oral rehydration
solutions could be given [1]. In addition, the WHO

recommends exclusive breastfeeding for the first six
months of life and subsequent introduction ofcomplementary foods while breastfeeding continues
until the child is at least two years old [2]. The benefits
of exclusive breastfeeding for both mothers and infants
have been well documented [3-9]. These include a
reduction in child morbidity and mortality by protecting
children against infections and enhancing immunity.

*To whom correspondence should be addressed:
jenos@ug.edu.gh
141

Review of exclusive breastfeeding in Asia and Africa

Studies suggest that optimal breastfeeding in the firstyear and complementary feeding practices reduce
approximately 20% of deaths in children under 5 yearsof age [10]. In 2018, 52% of under-five mortalities in theworld occurred in just five countries: India, Nigeria,
Pakistan, Ethiopia and the Democratic Republic of theCongo, all located in Africa and Asia [21]. Nigeria andIndia alone accounted for almost one-third of these
deaths, and approximately 45% of child deaths werelinked to malnutrition [21]. In both African and Asian
regions, malnutrition is strongly associated with poor
feedings and hygienic practices that lead to infections.
Most women in Africa and Asia traditionally undertakesome form of breastfeeding. However, the practice of
exclusive breastfeeding is relatively low. For example,
in Ghana and Nigeria, 98% of children are breastfed
during childhood [11, 12]. However, in 2016, only 36%
of infants were exclusively breastfed in Sub-SaharanAfrica [13]. Although breastfeeding is almost
universally acceptable to mothers in Africa, thechallenge arises when breastfeeding has to be practiced
exclusively for the first six (6) months of infancy.
Despite the enormous challenges associated withincreasing EBF, some African countries havesuccessfully made progress, while others are still lagging
behind.
In general, the developing world recorded marked
improvements in EBF rates, particularly in the early
1990s when the baby-friendly initiative was launched[15]. The greatest improvements were seen across West
and Central Africa, with remarkable progress in Malawi
and Rwanda in East Africa. In Malawi, EBF rates
increased from 3% in 1992 to 71% in 2010 [16], and in
Rwanda, the increase was from approximately 38% in2009 to 86.9% by 2015 [17]. On the other hand, somecountries reported very low rates of EBF practice in theregion, such as 12% in Cote d Ivoire, 3% in Chad and
6% in Gabon in 2015 [18]. Unfortunately, countries suchas Ghana, which had achieved great gains in EBF
practice by 2008, recorded declines from 64% in 2008
to 52% in 2014 [19, 20]. Asia also faces a similar
challenge of low exclusive breastfeeding rates eventhough breastfeeding is generally acceptable anduniversally practiced. Countries such as Cambodia and
Sri Lanka in South East Asia made remarkable progressin increasing their exclusive breastfeeding rates [15].
Between 1995 and 2007, Sri Lanka increased its EBF
rate from 17% to 76%. Similarly, within a period of 10
years, Cambodia increased its EBF rates from 11% in2000 to 74% in 2010 [15]. Hong Kong, Thailand,
Vietnam and Myanmar also reported EBF rates ranging
from 7% to 24% between 1995 and 2010 [14]. These
indicators make it imperative to understand theunderlying drivers of these trends to inform step-up
actions across relevant sectors to improve EBF rates inAfrica and Asia.
Currently, most countries in Africa and Asia haveexclusive breastfeeding rates lower than 50% [15].
There is therefore an urgent need to understand thedrivers of exclusive breastfeeding by mothers to informworkable solutions to scale up the practice of EBF in
Africa and Asia. This review examines the factors thatmitigate EBF and those that enhance EBF in some
African and Asian countries to inform strategies toincrease EBF in countries towards the achievement of

the Global Nutrition Target of 50% exclusive
breastfeeding rates by 2025 and the Sustainable
Development Goals.
METHODS
A literature search was conducted using the searchengines PubMed, Cochrane Library, Google Scholar and
CINAHL Complete. The initial search was conducted in
October 2015 and updated in June 2020. The searchwords used were exclusive breastfeeding, breastfeeding,barriers, facilitators, enhancers, constraints, Africa andAsia. The search was restricted to articles and abstracts
that were published in English, peer reviewed,
conducted either in Africa or Asia and publishedbetween 2005 and 2020. Research articles thatspecifically looked at conditions that were
contraindications to breastfeeding, such as mothers on
chemotherapy, alcohol and drug addiction and alcohol,
were excluded, with the exception of HIV. A total of 667
articles were obtained from the various databases.
Seventy-nine of the abstracts were relevant to theresearch topic on enhancers and barriers to breastfeeding
and conducted in either Africa or Asia. After full reviewof the articles, 34 were found to have explored thebarriers and enhancers of breastfeeding. Nineteen (19)of these studies were conducted in Africa, and 15 werefrom Asia (Figure 1).
Publications identified after searching
databases and screening of titles using key
search words (n=661)
Review of abstracts(n=661)
Articles excluded (n=588)

Review of articles full text (n=79)

Articles excluded(n=44)
Articles selected for review(n=34)
Articles from Africa(n=19)

Articles from Asia
(n=15)

Figure 1. Flowchart of article selection.
RESULTSA summary of the findings of the 34 studies selected
for this review is presented in Tables 1 and 2. Table 1
presents reports on studies conducted in Africa, andTable 2 presents studies conducted in Asia. Based on thedata presented in Tables 1 and 2, Table 3 provides asummary of the barriers and enhancers of EBF across
Africa and Asia. Papers reviewed from Asia wereconducted in Myanmar, Laos Peoples Democratic
142

Asian Journal of Dietetics, 2020
Republic (LPDR), Taiwan, Pakistan, Korea, Vietnam,
China, Sri Lanka, Indonesia, Malaysia, Hong Kong,
Timor Leste, Bangladesh and India. These represent
fourteen (14) out of the forty-eighty (48) countries in
Asia. The studies included in this review for Africa werefrom Ghana, Nigeria, Kenya, Ethiopia, Zambia,
Cameroon, Zimbabwe, South Africa, DR Congo,
Malawi, Uganda and Mozambique, which constitutetwelve (12) out of fifty (54) countries in the region.
Three of the studies included in this review wereconducted among HIV-positive mothers.
A total of 15,871 adults were involved in thestudies, comprising 14,807 mothers, 284 fathers, 275
grandmothers, 136 health professionals and 84
community members and leaders. One of the studies did
not categorically state the total number of persons who
participated. Data were gathered using qualitative,
quantitative and mixed method approaches. The
sampling methods employed were convenient,purposive, random and systematic sampling techniques.
One study was a randomized controlled trial. Fifteen of
the studies were conducted in urban communities, six inrural communities, ten in both rural and urban
communities and two in peri-urban or sub-urban
communities.
Papers reviewed from Asia were conducted in
Myanmar, Laos Peoples Democratic Republic (LPDR),
Taiwan, Pakistan, Korea, Vietnam, China, Sri Lanka,
Indonesia, Malaysia, Hong Kong, Timor Leste,
Bangladesh and India. These represent fourteen (14) outof the forty-eighty (48) countries in Asia. The studies
included in this review for Africa were from Ghana,
Nigeria, Kenya, Ethiopia, Zambia, Cameroon,
Zimbabwe, South Africa, DR Congo, Malawi, Uganda
and Mozambique, which constitute twelve (12) out offifty (54) countries in the region. Three of the studies
included in this review were conducted among HIVpositive mothers.
A total of 15,871 adults were involved in thestudies, comprising 14,807 mothers, 284 fathers, 275
grandmothers, 136 health professionals and 84
community members and leaders. One of the studies did
not categorically state the total number of persons who
participated. Data were gathered using qualitative,
quantitative and mixed method approaches. The
sampling methods employed were convenient,purposive, random and systematic sampling techniques.
One study was a randomized controlled trial. Fifteen of
the studies were conducted in urban communities, six inrural communities, ten in both rural and urban
communities and two in peri-urban or sub-urban
communities.

outside the home, lack of time for EBF, perception ofbreastmilk being inadequate for the baby, health status
of mother, late decision to breastfeed and anxiety of
mother. The employment status of the mother seems tobe the utmost barrier to EBF, with similar sentiments
expressed among mothers in the studies across both
Africa and Asia [24, 30, 36, 37, 43, 44, 54, 55].
Employment outside the home consistently prevents
mothers from effectively practicing exclusive
breastfeeding even if they had the desire to do so [10, 24,
25, 30, 36, 43, 44, 46, 47, 49, 50, 54]. Considering thelevel of poverty in both Africa and Asia, it seems
plausible that mothers must work to support theirfamilies and therefore cannot afford to be at home all thetime to breastfeed their babies on demand. In mostAfrican and Asian countries, mothers are significant
contributors to family income. Therefore, they areunable to practice exclusive breastfeeding for therecommended 6-month period because they have toresume duty after the standard maternity leave period
after delivery, which is often less than 6 months.
Interestingly, we found that high income was also
identified as a barrier to exclusive breastfeeding in
Ethiopia [37]. The authors explained that mothers withhigh income were more likely to be working full-timeand tend to be outside the home often. Additionally,
these mothers may readily afford infant formula andmight not be willing to go through the demands of
exclusive breastfeeding when they have to go back to
work.
Poor maternal health was identified as a barrier to
exclusive breastfeeding in some studies [54]. Mothers
who went through caesarean delivery or vaginal delivery
with episiotomy were likely to forgo exclusive
breastfeeding [37, 48]. The pain mothers go throughgenerally can lead to delay in initiation of breastfeeding
and sometimes early introduction of other feeds apartfrom breast milk. Some mothers expressed fears ofpossibly dying as a result of breastfeeding when they
themselves were not well [29]. Mothers also indicatedthat health problems affecting the breast, such as cracked
nipples, sores and pain in the breast, often posed achallenge to exclusive breastfeeding [54]. It is clear fromthese studies that mothers perception of their general
wellbeing is fundamental to continuous, successful
exclusive breastfeeding.
The perception that milk production was
insufficient and that babies were unlikely to be satisfied
with breastmilk alone were also identified as major
barriers to exclusive breastfeeding [10, 24-25, 27-29, 3436, 38, 48-50, 56]. These concerns were echoed by mostof the participants across the various studies conductedin both Africa and Asia. Mothers perceived their babies
to be hungry even after breastfeeding [24]. In Nigeria
and Kenya, there were perceptions that babies could be
addicted to breastmilk; therefore, they should be
introduced to other foods in addition to breastmilk toincrease their exposure to different kinds of food andtaste [10,24]. In Cameroon, breastmilk was perceived to
be an incomplete meal, thus justifying the need tosupplement it with other foods [30]. Similarly,
Vietnamese mothers would give water because they felt
the child was thirsty [48]. They also believed that themouth of the child should be cleaned with water after
breastfeeding to prevent oral thrush.

DISCUSSION
The barriers and enhancers of EBF identified in thereviewed studies were discussed under four broad
domains as follows: maternal factors, cultural beliefs
and practices, health system factors and policy
environment.
Barriers to Exclusive Breastfeeding
Maternal factors
Most maternal factors identified as barriers to
exclusive breastfeeding were similar across the Africanand Asian regions and countries. These maternal factors
include mother s employment status and working
143

Author (Year) [Ref] COUNTRY
Mixed method

Study Design

Population/ Sample Size

Table 1: Summary of findings from studies in Africa
Agunbiade et al., (2012) [24]

N= 536
Mothers (n=536)

Urban

SettingBarriers
x
x
x
x
x
x
x

Key Findings on Barriers and Enhancers of Exclusive Breastfeeding

Review of exclusive breastfeeding in Asia and Africa

Urban/Rural

Barriers
x
x
x

x
x
x
Barriers
x
x
x

x
x

Enhancersxx

Enhancers
x

x
x
x
x

Perception of breastmilk insufficiency
Lack of time due to mother s employment
Lack of knowledge about EBF
Lack of support from husband and family members
Enhancersx
Financial constraints
Breast health issues and concerns
Misinformation about HIV
transmission
Prior feeding experiences

Belief that boys eat more than girls
and so will require more milk
Cultural practices such as nhova
where traditional medicine is given
to the baby
Grandmothers and mothers-in-law
opposing EBF
Gender inequalities - influence offathers.
Erroneous understanding of EBF
Perception of milk insufficiency
Perception that babies need waterand other Zulu traditional
medicines

Perception of a breastfed baby as“healthy baby”
High cost of formula milk
Perception of formula milk fed to
HIV babies

High level of formal education of
motherHigh income

Knowledge about HIV
transmission through breastfeeding
Information from clinical staff
Support from clinical staff
Other support networks
Low income of mothers which
impacts on mother s nutrition

Perception of inadequate breastmilk production and breastmilk insufficiency
Perception that babies need to be introduced to the taste of other foods
Mother s employment
Lack of time for mothers working outside the home

Negative family influence (fathers, grandmothers)
Belief that water should be given to baby
Lack of support from family and healthcare providers to initiate and continue EBF
when there are challenges

Perception of breastmilk insufficiency
Mother s employment
Myths and beliefs that breastfeeding cannot be practiced for a long time since milkturns into blood

Perception of breastmilk insufficient for baby
Fear of baby becoming addicted to breast milkPressure from in-laws to stop EBF
Mother s employment
Inadequate support from spouse
Conflicting information from opinion leaders such as grandmothers, mothers-in-law
Lack of support to initiate EBF after birth due to busy schedules of nurses, which
prevents them from adequately assisting mothers who have challenges initiating EBF

Urban

Barriers
x
x
x

Urban

Urban

N= 128Mothers

N=342
Mothers (n=95), Fathers(n=85), Grandmothers(n=82),
Nurses (n=80)
N=384
Mother- infant pair(n=384)Mixed method

Rural /Urban

x
Barriersx

Barriersxxxx
Barriersxxxx
Barriers
x
x
x
Urban

N-17
Mothers (n=17)

Rural

Qualitative /In depth interview

Mixed method

Qualitative

N= 24
Mothers (n=20)
Health workers (n=4)

N=40Pregnant and post-partum
women

Cross sectional

Qualitative/ focus group
discussions

Mixed method

N=210
Mothers (n=200)
Nurses (n=10)

NIGERIA

Alutu et al., (2006) [25]NIGERIA

Arts et al., (2011) [26]
MOZAMBIQUE

Cherop et al., (2009) [10]KENYA

Maduforo et al., (2013) [31]NIGERIA* Maman et al., (2012) [32]
DR CONGO

Muchacha et al., (2015) [33]ZIMBABWE*Nor et al., (2012) [34]
SOUTH AFRICA

144

Study Design

Population/ Sample Size

Setting

Key Findings on Barriers and Enhancers of Exclusive Breastfeeding

Asian Journal of Dietetics, 2020

Author (Year) [Ref] COUNTRY

Table 1: continued

Perception of milk insufficiency
Child refusing to breastfeed
Breast and nipple problems in
mothers
Mother s employment
Lack of support from spouse.
Fathers prefer to provide moneyfor formula than to feed mother.
Cultural practices such as notwanting to expose breast in public

Perceived breastmilk insufficiency
Belief that baby needs water
Negative grandparents/mother-inlaw s influence
Negative maternal attitude towards
EBFF
Home delivery
Caesarean section delivery

x

x

x

Enhancersxx

Enhancersxxxx
Enhancers
x
x

x

x
x

x

Positive EBFF experiences such as
reduced morbidity with older
children
EBF is inexpensive and convenient

Low income (complementary/alternate feeding not affordable.
Vaginal delivery (good healthstatus of mother)High knowledge on EBFF
Positive maternal attitude towards
EBFF.
Attendance to maternal and childhealth clinics
Supportive husband
Islamic teaching that breastfeeding
is a child s rightSelf-confidence of mothers tobreastfeed

Perception of milk insufficiency
Perception of infants needing water
Poor education on breastfeeding at antenatal and postnatal clinics
Lack of support from the community
Local beliefs: a stressed mother could pass on the stress to the baby being breastfed.
xSupportive health team with
Perceived breastmilk insufficiency
requisite knowledge inbreastfeeding
Heavy work loadxCommunity breastfeeding support
inadequate education on EBF atgroupshealth facilities
Media
Professional Associations

Perceived milk insufficiency
Food insecurity informs maternal confidence in ability to EBF

Mothers with high income canafford formula
Mother s employment
Cesarean section (poor healthstatus of mother)

Enhancers
x

Urban

x
x
Barriers
x
x
x
x
x
x
Barriersx

Perceived insufficiency of milk
Poor counselling by HIV
counsellors right after testing
mothers of their HIV status
Stigma of breastfeeding
Lack of control over breastfeeding
because mothers/ grandmothers
dictate what should happen

N=21 Mothers

Urban

Peri-urban* Østergaard et al., (2014) [35]N=648 Mothers

N=35 Mothers

Barriersx
x

Qualitative/
focus group discussions

Cross sectionalxx
BarriersxxBarriersxxxxxBarriersxxx
Enhancers
Barriers
x
x
x
x
x
x

Stable relationship with aman/husband rather than living
alone
Older age of mothers and therefore
more experienced
Mothers not living in the same
house with grandmothers/mothersin-law
Influence from other family
members such as mothers andgrandmothers who prefer mixed
feeding

Qualitative
In-depth Interviews andobservations

MALAWI

Otoo et al., (2009) [36]GHANA

Shifraw et al., (2015) [37]Urban

ETHIOPIA

Qualitative/ focus group
discussions/ interviews

N=91

Urban

Webb-Girard et al., ( 2012) [38]KENYA
Qualitative, focus group
discussions/ purposive

N=148 Mothers

Goosen et al., (2016) [39]
SOUTH AFRICA

Urban/rural

Urban/rural

N=72

N= 15

Qualitative, Focus group
discussions/ key informant
interviews

Qualitative, informant
interview

Rujumba et al., (2020) [40]UGANDA

Mohamed et al., (2020) [41]
KENYA

145

Population/ Sample Size

Mother s employment
Conflicting information from different sources
Perception that baby will be thirsty
Perception that breastmilk is not nutritious
enough for babyxxx

Health status of mother i.e. HIV infection
Lack of information on exclusive breastfeeding

x
x
x
x

x
x
x

Perceived low nutritional quality of breast milk
Mother s employment

Non-working mothers Non-smoking mothers
Mothers with more than one child
Supportive husbands

Maternal knowledgexx

Education on breastfeeding
Family support
Advice from doctors
Free cost of breastmilk

High level of health literacy
Intention to breastfeed for a long time
Greater self-efficacy
Rooming-in
Early initiation of breastfeeding

Support from fathers and grandmothersxx
Enhancersx
Enhancersxxxxx
EnhancersxxxxBelief that breastfeeding makes mother lookunattractive
Concerns about breastfeeding in public

Enhancersxxxxx
Enhancersx

Maternal knowledge
Self-motivation
Early decision to breast feed
Support from family/husband
Support from health care professionals

Infants mouth needing to be cleaned with waterto prevent oral thrush
Caesarean delivery
Vaginal delivery with episiotomy
Maternal anxiety
Advanced maternal age >30 years

Mothers with ability to decide on health-related
matters

Review of exclusive breastfeeding in Asia and Africa

Key Findings on Barriers and Enhancers of Exclusive Breastfeeding

Study Design

Table 2. Summary of findings from studies in Asia
Cross sectional

BarriersxxAuthor (Year) [Ref] COUNTRY

Barriersxx

Khanal et al., (2014) [46]N=47Mothers, Health workers
Community elders
BarriersxxMother s employment
Growth faltering of baby between 2-4 months
Cultural norms
Lack of privacy to breastfeed at home due to joint
family system
Concerns about breastfeeding in public
Lack of time
Breast engorgement
Lack of support from grandmothers
Provision of sample of formula sample atdischarge from hospital
Mothers employment
Unsupportive husbands

Perceived milk insufficiency

Living in a rural area

Barriersxx
Enhancersx
Barriersx

Perceived insufficient production of breast milk
Mothers working outside the home
Cracked nipples
Poor maternal healthMilk insufficiency
Maternal employment
Caesarean delivery
Lack of support from grandmotherNo crèche at work place
Doctor prescribed formulaEnhancersx

N=6068Mother/child dyad

BarriersxxMother earning income
Perception that new born baby is below average
size, Residency in the capital city

N=500
Infant mother pair
Barriersx
x

Qualitative/ focus
group
discussions/interviews
Purposive sampling
Qualitative/interviews

Prospective
observational
N=6Mothers

N=30
Mothers

Older age of mother
Living in a metropolis
Mother s employment

Barriers
x
x
x
x
x
x

Barriersxxxx
BarriersxxxxxBarriersx
x
x

Qualitative/
In-depth interview

Quasi experimental

Qualitative/
In depth interview

Cross sectional

Qualitative/
In depth interview

N=44
Mothers (n=24)
Fathers (n=10)Grandmothers (n=10)

N= 342 Mothers
18 in-depth interviews

N=300
Mothers

Mixed method

Qualitative

N=599 Mothers (n=163)
Fathers (n=163)
Grandmothers (n=163)
Community leaders (n=82)
Midwives (n=28)
N=682
Mothers

N=975
Mother infant pair

TIMOR LESTE
Setting Rural/urban
Lee, et al., (2013)[47]
LAO PDR
Setting Urban
Nguyen et al., (2013) [48]VIETNAM
Setting Rural/urban
Perera et al., (2012) [49]SRI LANKA
Setting Premani et al., (2011) [50]PAKISTAN
Setting Urban

Susiloretni et al., (2015) [51]INDONESIA
Setting Rural
Tan (2011) [52]
MALAYSIA PENINSULAR
Setting Rural/urban
Tengku et al., (2012) [53]
MALAYSIA
Setting Rural/urban
Thet et al., (2016) [54]
MYANMAR
Setting Rural/urban
Tsai et al., (2015) [55]TAIWAN
Setting Urban/sub-urban

Khatun et al., (2018) [56]BANGLADESH
Setting Urban*studies with HIV-positive respondents

146

Asian Journal of Dietetics, 2020
Table 3: Summary of barriers and enhancers of exclusive breastfeeding in Asia and Africa
AFRICA
Enhancers

x
x
x
x
x
x
x

Barriers

x
x
x
x
x
x
x

Enhancersx
x

Barriersxxx

Enhancersx

Barriersxx

Enhancersx

Barriers

ASIA
Maternal Factorsxxx

Formal education
Older age
Low income
Vaginal delivery
Home delivery
Attendance to maternal and child health clinics
Self-confidence /motivation

Higher formal education
Unemployed mother
Mother with more than one child / previous
experiencex
Planning and commitment to breastfeedx
Rooming inxMarried woman/ living with spousex
Self-motivationx
Living in rural areax
Non-smoking mother
Mother s employment
xMother s employment
Poor health status of motherx
Health status of mother
Perception of insufficient breastmilk
xPerception of insufficient breastmilk
productionx
Perceived poor quality of breastmilk
Inadequate timex
Lack of timeHigh income to purchase formulax
Caesarean delivery
Caesarean deliveryxPhysical attraction
Reduced physical attractionx
Older age of motherx
Late decision to breastfeed
x
Living in an urban areax
Maternal anxiety
Cultural Beliefs and Practices
Family support
Leaving away from grandmothers/mother s-inlaw
Lack of family support (Influence ofgrandmothers/mother s-in-law)Myths and beliefs about breastmilk andpractice of breastfeeding
Effect of gender inequality

x
x
x
x

Family support from husbands, grandmothers,
mother s-in-law
Presence of domestic helper
Lack of family support (husbands,
grandmothers/mother s-in-laws)
Lack of privacy to breastfeed due to extended
family system
Cultural norms

x
Health System Factors
EBF Education from health workers
x
Education on breastfeedingx
Support from healthcare professionals
Lack of education on EBF
xLack and inadequate education
Lack of education on breastmilk compositionx
Conflicting EBF educational information
Policy Environment
Cost of infant formulax
Workplace provision to breastfeedxStorage facilities at the work placex
Maternal leave less than 6 monthsx
Increased workload after maternity

In Africa (Ghana) and Asia (Myanmar), a mother sview of her physical looks and attractiveness and her
perception of how others view her was also identified asa significant issue that posed a challenge to exclusive
breastfeeding [36, 54]. Some of the mothers felt that
continuous breastfeeding would make them look lessattractive. Others felt uncomfortable breastfeeding inpublic places [36, 54]. These perceptions are influenced
by women s assessment of how society perceives
mothers breastfeeding in public and likely to be areflection of changes in societal values over time. New
adjustments are needed to support women when they
have to breastfeed in public places.
Cultural beliefs and practices
Culture or tradition tends to govern the way people
live. Breastfeeding itself is an art that thrives on acomplex interaction between biology and culture [57].
Several of the difficulties that arise with exclusive
breastfeeding tend to be entrenched in cultural beliefs,
which usually conflict with the science of breastfeeding[57]. This assertion was observed in some of the studies

reviewed, ranging from beliefs regarding the breastmilk
itself to specific roles that needed to be played byindividuals in the family or community. These beliefs
and behaviours were so culturally entrenched thatmothers had difficulty overlooking them. For example,
in some societies, colostrum was considered “bad milk”
or “does not contain any nutrients” and therefore should
not be fed to babies [27, 50]. In some cultures, babies
were expected to be fed certain “foods” that are believed
to be beneficial. In Zimbabwe, for example, it is believedthat feeding babies cooking oils and water prevents ortreats colic and sunken fontanel [24]. There is also a
belief that newborn babies need to be fed with solids
within a week after birth to signify genetic connection totheir ancestors [30].
In some cultures, as obtains in Kenya, South Africa
and Ghana, babies are fed with certain concoctions toprotect the baby because of religious beliefs, particularly
the belief that others might cast evil spells on the baby
[33, 53, 55]. In one study in Cameroon, a substancecalled Viindi, which is a solution prepared from washing147

Review of exclusive breastfeeding in Asia and Africa

off passages of the Koran that have been written withcharcoal on a wooden slate, is given to the infant forprotection [27]. Similar practices were reported in
Zimbabwe, where the baby is given concoctions usuallycomposed of tree barks, roots, juices, herbs, cooking oil
and wild fruits to treat a condition known as nhova(which is the administration of traditional medicines tobabies to prevent sunken fontanel and death) [29]. In
Cameroon, a breastfeeding mother does not engage insexual intercourse. This is because it is believed thatsexual intercourse “spoils the milk” and has the tendency
to “spoil the child” [27]. This belief implies that abreastfeeding mother cannot engage in sexualintercourse. She would have to avoid sexual intercourse
to successfully breastfeed her baby. This belief therefore
discourages breastfeeding of the baby for a significant
period.
Culturally,thecontributionoffathers,
grandmothers, in-laws and sometimes elderly persons
society in decision-making at the household level cannot
be understated. The influence of extended family andopinion leaders in African and Asian societies is still
upheld to a very large extent. In Cameroon, mothers
indicated that to “avoid confrontation” with husbands orother relatives whose opinion cannot be ignored, theysuccumbed to the pressures of introducing other feeds[27]. Similar concerns were expressed by mothers in
Ghana, Nigeria, Lao PDR, Vietnam and Mozambique,where grandmothers were found to be very influential inoffering advice on breastfeeding [20, 33, 42, 49, 52].
This implies that a decision to exclusively breastfeed
would have to be endorsed by all revered family andcommunity members in order not to incur their wrath.
This happens especially in societies where opinions of
the elderly are very highly regarded. In conclusion,
therefore, the whole community needs to be wellinformed and educated to ensure that women receive theneeded support to breastfeed successfully.
Health system factors
Breastfeeding is an art that is surrounded by many
myths and misconceptions. Several of the challenges
that arise during breastfeeding occur when information
given about breastfeeding conflicts with the individual s
own cultural beliefs [57]. Inadequate knowledge on thesubject of exclusive breastfeeding was identified as a
key barrier to exclusive breastfeeding across the various
studies. Studies in Ethiopia, Zambia, Nigeria, theDemocratic Republic of Congo, South Africa and India
clearly identified a lack of knowledge on exclusive
breastfeeding as well as a general lack of education on
appropriate infant feeding practices as barriers to EBF[25-26, 28-29, 31, 36]. When people are well educatedon the composition of breast milk and how it helps toprotect the child against infectious and other diseases,
then it is likely to be well utilized.
The perception expressed by some mothers thatbreast milk is insufficient can be successfully addressed
when well-structured educational messages andstrategies tailored to meet the needs of specificpopulations are provided, preferably through the healthsystem and during antenatal care, which is wellpatronized by mothers in Asia and Africa for at least one
visit.
Health education programmes should aim at
providing consistent messages and avoid ambiguity,which tends to confuse mothers and significant others
who support breastfeeding. These key messages wereamong the sentiments expressed by mothers in somestudies [24, 49]. The mothers expressed concern about
conflicting messages they receive from the hospitals andsignificant members of the community whose opinions
matter in breastfeeding a baby. These include basic
issues such as the definition of exclusive breastfeeding
and the addition of water to breastmilk [34, 49].
Inadequate education on exclusive breastfeeding was not
only limited to mothers but also to healthcare
professionals. For example, healthcare workers werequick to advise mothers to switch to formula whenmothers
reportedchallenges
withexclusive
breastfeeding [52]. Other mothers lamented about thelack of support from healthcare professionals when theyneeded clarification due to their busy work schedules[24, 26].
Policy-related factors
The absence of strong policies and political will to
support breastfeeding can be a major barrier to EBF. A
major barrier to EBF is the duration of paid maternity
leave. In all countries studied, maternity leave is often
less than 6 months. This makes it difficult to continue tobreastfeed exclusively when mothers have to return towork. Mothers bemoaned the absence of facilities in theworkplace that could enable exclusive breastfeeding andmake breastfeeding more comfortable for working
mothers [43]. Mothers also expressed their reservations
about breastfeeding in public due to lack of privacy [50,54]. Some policies could be enacted to ensure thatmothers are provided with private and convenient places
that could support breastfeeding in public.
Enhancers of Exclusive Breastfeeding.
Maternal factors
Enhancers to EBF were varied and included thehealth status of the mother following vaginal delivery as
well as other health and breast concerns, motivation tobreastfeed, higher formal education, being married andolder age of mother with previous breastfeeding
experience. In Kenya and Ethiopia in Africa and
Bangladesh and Lao PDR in Asia, mothers who
delivered vaginally and in good health were more likely
to exclusively breastfeed compared to those who went
through caesarean sections [37, 47, 39, 56].
Additionally, those with intent, preparedness andcommitment to breastfeed exclusively for a long time
had an enhanced ability to breastfeed [55]. Younger
mothers and those with low income who could not afford
milk formula were also more likely to exclusively
breastfeed [37, 55]. Similarly, mothers with high formal
education were more likely to EBF compared to thosewith lower education. This could be attributed to thebenefits of higher education and a better understandingof the benefits of exclusive breasfeeding [32]. In
Zimbabwe, older women were more likely to
exclusively breastfeed [32], probably due to theirprevious experiences with breastfeeding [33].
Maternal knowledge on breastfeeding as well as
formal education also contributed to enhancing
exclusive breastfeeding in Zimbabwe, Cameroon and
Kenya [27, 30, 39]. Similarly, in Asian countries such as
Bangladesh, Indonesia, Pakistan and Hong Kong, theseobservations were found to be true [43, 45, 38, 56]. In
Hong Kong, being married enhanced exclusive
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Asian Journal of Dietetics, 2020
breastfeeding [45], while higher income in South Africa
was found to be an enhancer to exclusive breastfeeding.
However, the opposite was true in Ethiopia, where
mothers with higher income were less likely tobreastfeed [34, 37]. Older maternal age proved to be anenhancer of exclusive breastfeeding among women in
Malawi. In contrast, young maternal age enhanced
exclusive breastfeeding in Taiwanese women in Asia
[35, 55]
Cultural beliefs and practices
The principal cultural factor that enhanced EBF
across both regions was support from family members.
The traditional roles of every member of the family are
well defined. It is not the norm for mothers across Africa
and Asia to receive support from their spouses, thoughstudies from this review show that support from fathers
and sometimes from other members of the family, suchas grandmothers, provided an impetus for EBF [29, 32,47]. In some cultures, babies are separated from mothers
to allow mothers to rest. However, when babies andmothers are not separated but rather allowed to be in thesame room (i.e. rooming-in), mothers chances ofbreastfeeding were enhanced [38, 48]. Rooming-in also
contributes to enhancing the early initiation ofbreastfeeding and tends to increase the chances of
exclusively breastfeeding [48].
Health System Factors
Some mothers alluded to the benefits of receiving
breastfeeding information from healthcare professionals
and reported that it enhanced their ability to exclusively
breastfeed [27, 44]. For example, among HIV-infectedmothers, knowledge about HIV transmission throughbreastfeeding enhances their chances of breastfeeding[32]. This was possible because they could appreciate
the circumstances under which transmission was most
likely to occur and make an informed decision on therisks and benefits of breastfeeding under thecircumstance. A high level of literacy appeared toenhance breastfeeding because literate mothers were
found to be more compliant with exclusive breastfeeding
guidelines when compared to illiterate mothers [30].
Lessons learned from success stories from Sri-Lanka,
Malawi and Cambodia demonstrated the impact ofpublic education on breastfeeding as an enhancer to
exclusive breastfeeding [15]. The use of mass media andtargeted home visits also greatly improved exclusive
breastfeeding rates.
Enabling policy environment
The baby-friendly initiative in countries promotes
EBF. However, some health facilities do not adhere to
this initiative because there is no strong political will to
enforce the recommendations. In Indonesia, for instance,
mothers were provided with formula samples atdischarge, which prevented them from exclusively
breastfeeding [20]. Policies that provide an enabling
environment in healthcare facilities and workplaces tosupport breastfeeding also enhance the ability of
mothers to breastfeed exclusively [43]. Places of workthat provided spaces for mothers to conveniently
breastfeed during working hours were useful inmotivating mothers to continue to breastfeed [43].
Countries that have made gains in EBF have done sothrough collaborative efforts from all stakeholders,
including government, healthcare professionals,
commercial entities, mothers and the community [15].

According to the WHO, countries that have programmes
and policies in line with the recommendations of the
WHO/UNICEF Global strategy for infant and young
child feeding have made the most gains in enhancing
EBF [16]. Therefore, the ultimate facilitator to EBF lies
with governments taking the lead in creating theenabling environment by enacting policies andlegislations such as longer paid maternity leaves formothers and making it compulsory that workplaces
create facilities that are conducive to breastfeeding.
Based on the findings from this review,recommendations to improve breastfeeding include i)addressing maternal perceptions of exclusive
breastfeeding through adequate education; ii) ensuringthat key decision makers and opinion leaders in thefamily and community, such as fathers, grandmothers
and in-laws, are educated and encouraged to support
exclusive breastfeeding; iii) enacting policies to protect
working mothers and ensure that they have adequate
time to dedicate to breastfeeding should be considered;iv) those in the formal sector could be provided withadequate duration of paid leave and those in the informal
and low income settings could be supported with astipend to ensure they abstain from work to enable thembreastfeed
adequately.
Additionally,
healthprofessionals should regularly be updated on their roleto educate mothers and the community and the need toprovide support for mothers during difficult andconfusing times. Some of these can be achieved by using
breastfeeding support groups.
LIMITATIONSThis review has some limitations. There could besome level of bias since not all the studies included inthis review primarily sought to investigate the barriersand enhancers of exclusive breastfeeding. Nonetheless,the relevant information was extracted from theirfindings, regardless of their study objectives. Second,most of the studies reviewed used qualitative datacollection methods rather than quantitative approaches.
Qualitative data collection approaches tend to be more
subjective compared to quantitative approaches.
However, the qualitative approach is very useful inproviding depth and bringing to the fore the real reasons
why people do what they do to inform the developmentof effective interventions.
CONCLUSIONS AND RECOMMENDATIONSThe key barriers to exclusive breastfeeding
identified in this review were perceptions about theadequacy of breastmilk produced by mothers to meet thenutritional needs of their babies, poor maternal health,especially following caesarian delivery, lack of adequate
information on EBF for mothers and family members,
negative cultural practices such as proving teas andconcoction for babies for medicinal and spiritual orprotective purposes, issues regarding maternal
employment and government policies such as briefmaternity leave and lack of enabling environment thatwere not in consonance with the practice of exclusive
breastfeeding. We found that the enhancers ofbreastfeeding were related to adequate information,
support from family and some government policies thatsought to improve breastfeeding. The involvement of all
stakeholders in promoting the practice of exclusive
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Review of exclusive breastfeeding in Asia and Africa

breastfeeding is paramount to the success of achieving
global goals regarding the health, nutrition and survivalof children. All stakeholders, especially governments,
have to be committed to achieving global goals throughconstant communication and education strategies aimed
at removing the specific barriers. In addition,
governments must provide leadership and the resources
needed to educate and empower all stakeholders to playtheir respective roles towards the achievement of
success. Further studies could investigate EBF
promotive intervention strategies that work. These
strategies should not only emphasize the benefits of
exclusive breastfeeding but also address the barriers thatmitigate successful breastfeeding.
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