Key project outcomes

Diversity of nutritional status

Nutrition issues and dietary habits

• In Indonesia, there remains a common group of nutritional deficiencies. At the same time, Indonesian cuisine involves a great deal of frying in palm oil, which boosts the calorie intake, leading to a high incidence of obesity and overweight issues. This is the classic double burden of malnutrition. An almost complete lack of vegetables compounds the problem.
• In Cambodia, a preliminary survey of women of reproductive age revealed deficiencies of folic acid, zinc and key vitamins. Such micronutrient deficiencies can potentially lead to serious health problems for mothers and children.
• Myanmar has one of the highest levels of rice consumption in the world. While specific data on nutrient deficiencies are not available, an analysis of the Myanmar diet revealed a high oil content and heavy use of salt and pepper (the resulting salty oil liquid condiment is typically poured over a huge bowl of rice as a meal).

Dietary environment

The diversity of meal menu is poor, most notably the low intake of vegetables. This is attributable to a general lack of infrastructure in the food industry, particularly with respect to distribution and storage. After the vegetables are harvested and sent to markets, any that are unsold will be discarded. This creates a vicious circle that forces up vegetable prices and puts them further out of reach for many.

Defined outcomes

Nutrition improvement

The obvious outcome of a nutrition improvement project is the fortification and intake of missing key nutrients. In Cambodia, the introduction of nutrition fortified rice was shown to boost the blood level of folic acid. Ideally, employers will achieve results such as increased productivity and improved absenteeism rate; the reality, however, has been that the direct outcomes of nutrition improvement projects are not so readily identifiable.

The Ministry of Health in Indonesia has expressed an interest in evaluating behavior change in relation to dietary diversification (particularly vegetable consumption) as a key outcome. The Take 10! ® checksheet from ILSI Japan CHP has a specific focus on dietary diversification and, as such, serves as a tangible indicator of success.

Presenteeism

Presenteeism refers to the condition of workers who while present at work are considered unmotivated or underperforming due to physical or mental health problems. The Health and Work Performance Questionnaire from the World Health Organization (WHO-HPQ)* quantifies this phenomenon by asking workers to answer a series of questions both before and after an intervention study. In the “Health promotion by micro-nutrient fortified rice in Cambodia” project, it was found that presenteeism rates among participants improved.

For more information about the WHO-HPQ go to <https://www.hcp.med.harvard.edu/hpq/info.php>.

Fostering corporate loyalty

Providing healthy balanced meal options to workers should lead to increased loyalty to the company. But this nexus breaks down easily if the workers themselves do not appreciate the contribution of nutritious food to their own health and well-being. In light of this, nutrition education and improvement of nutrition literacy are important factors. Ridgelinez Ltd. has developed a “Nutrition enlightenment activity applying blockchain technology” in workplace nutrition improvement in Cambodia. The educational app has gamification and is expected to keep participants motivated and to improve nutrition education and hygiene education by providing optimal incentives. This method can be deployed anywhere in the world by setting appropriate incentives.

Future challenges

The challenge of changing dietary habits

●Low motivation to “healthy diet”

1. Resistance to a new diet is to be expected. It is difficult to accept a nutritionally well-balanced diet as a countermeasure to dietary habits guided by eating experience from an early age.
2. Even if it is initially accepted, it is difficult to maintain interest over the long term.
3. In fact, many low-paid workers living in poor conditions rely on the canteen lunch as their main meal of the day. Satisfying with a restricted diet as a measure against overweight is quite reluctant.

Thus, it is necessary to have a thorough understanding of health and nutrition.

●Sticking to traditional dietary habits
(Food culture, religion or other reasons)

Dietary habits are generally born out of many years of food culture and religion-based eating experiences. It can be extremely difficult and challenging to switch to a whole new meal, “healthy diet.” A better approach is to introduce dietary diversity by making small, incremental changes to the canteen menu. Where certain food types are unavailable locally or are considered unpalatable, it may be necessary to find alternative ways to provide the required level of nutrition.

Performance indicators

●Nutrition improvement

Fortification and overnutrition measures

A pilot study of nutrition improvement using fortified rice found an increase in blood levels of insufficient nutrients. In the future, there are plans to conduct validation testing on a larger scale. It is hoped that outcomes such as improved nutrition education will translate into better health checkup results and fewer frequency of use in the medical office.
Furthermore, in order to reach productivity improvement, the understanding of the introducing factory members is essential. Employees need to understand the importance of improving nutrition through a healthy diet, and employers need to understand the cost increases associated with project promotion. A sustainable project can only be achieved with mutual agreement.
Projects for overnutrition involve dietary (calorie) restriction. The challenge therefore is to ensure that the food is still adequately satisfying. The key is to design meals that use new and different ingredients.
At the same time, it may be necessary to compensate for the decrease in satisfaction and to raise personalized motivations by “visualizing” the state of health.

●Proof of benefits to industry

Increased productivity and corporate loyalty

All ongoing projects are at the pilot testing stage and no direct evidence has been found to improve productivity. It is important to be able to provide empirical data to demonstrate the positive impacts of health and nutrition improvements on productivity.

Sound development of catering business as a food system

●Hygiene management

Hygiene management is critical from the perspective of being directly linked to health outcomes. If hygiene is poor, nutritional education cannot be expected to achieve the desired health outcomes.
Helping to introduce techniques to improve hygiene should lead to great credibility.

●Nutrition management

In Japan, the presence of many nutritionists enables adequate nutrition management. But it can be said that it is difficult to entrust nutrition management overseas because many countries do not have qualifications for nutritionists. To this end, support by dispatch of specialists is also an important aspect of improving nutrition.

Aiming for greater benefits

Systematic approach to nutrition improvement

Direct intervention—
nutritional fortification and reduction of excessive intake

Introducing non-invasive devices into the evaluation method of the fortified rice project will reduce the burden on participants. At the same time, we will “visualize” the results more easily. With respect to promoting vegetable intake in particular, we should adopt strategies that help to promote the use of measuring equipment used in validation testing.

Indirect intervention
Nudging and nutritional literacy improvement for independence development

Improving nutritional literacy is fundamental to nutrition improvement. Even if you participate in the nutrition improvement project without understanding nutritional literacy, you cannot expect continuous participation.
In order to motivate people to alter their behavior, we employ nudge theory*, a concept in behavioral economics. People need to be educated about health and nutrition so they understand the concepts involved, then they need to be provided with detailed nutritional information at the decision point where they are making a food choice or choosing a meal option.

NJPPP projects start with a preliminary survey conducted in the target country by utilizing the prior knowledge. The next step is to design an optimized nutrition intervention strategy, followed by a pilot study and evaluation. The findings from the pilot study can then be used as the basis for a larger validation study. The final stage involves rolling out the project at scale.
In order to validate the efficacy of this approach we need clear empirical data and evidence.

Nudge is a technique that guides people to voluntarily choose more desirable behaviors by means of ingenuity and mechanisms based on the knowledge of behavioral science rather than economic incentives.

Clarification of Performance indicators

Behavior change

In the Indonesian project, we are promoting “visualization” of health status by introducing non-invasive devices. By visualizing your health status, you will be able to independently select a well-balanced healthy diet.

Suppression of Presenteeism

It can be said that it takes some time for nutrition improvement projects to lead to direct productivity improvement data (quantification). As a preliminary step, the quantification of presenteeism by WHO-HPQ is considered to be significant as “visualization” of evaluation.

Improving corporate loyalty

Health and productivity management (HPM)—the idea that employee health and well-being is linked to productivity—is being promoted in Japan. The aim is to disseminate the HPM concept to NJPPP project partner countries and show how nutrition improvement programs for workers can enhance enterprise value.

Evaluation of dietary habit Improvement

Positioning the first step in improving dietary habits as “diversifying ingredients and improving cooking methods”, I plan to review the menu. First of all, eating a lot of ingredients and trying various cooking techniques is the key to improve dietary habits.