Revision of "Nutritional Reference Values for Feeding at Evacuation Shelters" and Model Menus: A Qualitative Study.

OBJECTIVE: In 2011, the Japanese government issued nutritional reference values for energy; protein; vitamins B1, B2, and C; and salt to deal with poor meal quality in evacuation shelters. Because they were not widely used owing to their impracticality, the authors had examined the values according to the experience-based opinions of public health dietitians. Furthermore, we developed a usage tool containing a model menu that meets these values. This study aimed to confirm the usability of these revised values and model menus and collect ideas for improvement. METHODS: We conducted 8 semi-structured group interviews with 12 dietitians, 9 disaster management officers, and 2 public health nurses in local governments supposed to have been affected by a large-scale disaster. RESULTS: New reference values were highly evaluated by most participants. Interviewees said that model menus were helpful for evacuees or disaster officers who are unfamiliar with nutrition because they show combinations of food items that meet the reference values instead of the amounts of energy and nutrients. To improve their understanding, it was suggested that food items be categorized by staples, main dishes, and side dishes, encouraging them to complete these three components of a balanced diet. Because it was difficult to meet all the reference values in the immediate aftermath of the disaster, it was suggested that the time-dependent priority of each nutrient and model menus that supply the nutrient should be shown by disaster phases along with the assumed availability of utility for cooking in each phase. CONCLUSION: The new reference values were feasible to meet during emergencies. Although model menus were also appreciated, further improvements were necessary for better understanding.

Meal plans for meeting the reference values using food items available in shelters.

BACKGROUND: We have suggested "Revised Nutritional Reference Values for Feeding at Evacuation Shelters" (Revised RV) as a daily nutritional recommendation for meals served at evacuation shelters where poor diets had been reported. Since there are no meal examples to satisfy the Revised RV, our objectives were, for the future meal provision, to develop nutritionally adequate meal plans using the foods served at shelters in the past and to examine if the Revised RV could be met by changing combination of foods available. METHODS: In this case study using secondary data, we analyzed food weights of 86 meals served and recorded at 12 shelters after the heavy rains in July 2020. We obtained these data from Kumamoto Prefecture that was damaged and asked us dietary assessment for nutrition assistance. Foods were classified into 3 types according to the check mark in the record sheets: food aid (commercial packaged food), boxed meal, and hot meal service. We counted serving frequency of each food and analyzed nutritional differences by their combinations. Menus were devised by choosing foods that were served more frequently or were more nutritious among those served at shelters. The target values for one meal were set at 1/3 of the Revised RV for energy, protein, vitamins B1, B2, and C, and salt. RESULTS: None of the meals served in the shelters satisfied the target. We created 2 menus using food aid only: (#1 curry doughnut, milk with long shelf-life, and orange jelly) and (#2 salmon rice ball, ham and cheese sandwich, and vegetable juice); 1 menu by combination of boxed meal and food aid: (#3 boxed meal and vegetable juice); and 2 menus by combination of hot meal service and food aid: (#4 chicken meatball soup, packaged tofu, soy sauce, preprocessed white rice, and bottled green tea) and (#5 bamboo shoots rice, chicken and vegetable miso soup, and bottled green tea). Planned menus generally contained more energy, protein, and vitamins and less salt than the meals served. Their vitamin C contents were especially higher. CONCLUSION: Nutritionally adequate meals could be planned by changing the combination of foods available in shelters.

Validity and reproducibility of food photographic estimation for evaluating meals in evacuation shelters.

Objective: The primary goal was to evaluate the validity of food photographic estimation for nutritional assessment compared with weighed food record (WFR). Methods: We evaluated the validity and reproducibility of photographic estimation of foods provided in evacuation shelters. We analyzed 35 meals served at 12 shelters in Kumamoto Prefecture in Japan, affected by a heavy rain disaster in 2020. In this context, we compared 21 senior students' portion size estimation by food photographs to WFR. In addition, we assigned five meals for each of the 21 senior students, and the same meal photograph was estimated by three students to test reproducibility. Results: No statistically significant difference was detected between the two methods regarding energy, the total grams of meal, the protein, and vitamins B1, B2, and C, except for salt. In addition, the students who never self-cooked underestimated the total grams. Conclusion: Food photographic estimation could simplify the nutritional assessment in evacuation shelters. However, unclear photographs and food items served by weight could weaken the estimation accuracy. According to previous studies and the applied postestimation questionnaire, photographs taken from specified angles and reference food photobooks for portion size estimation may improve accuracy.

Nutritional Intake Differences in Combinations of Carbohydrate-Rich Foods in Pirapó, Republic of Paraguay.

A national strategy for obesity prevention has been promoted in Paraguay, reflecting the situation where half of adults and 23.4% of children (under 5 years old) are overweight. However, the detailed nutritional intake of the population has not yet been studied, especially in rural areas. Therefore, this study aimed to identify obesity-causing factors in Pirapó by analyzing the results from a food frequency questionnaire (FFQ) and one-day weighed food records (WFRs). From June to October 2015, 433 volunteers (200 males and 233 females) completed the FFQ with 36 items and one-day WFRs. Body mass index (BMI) positively correlated with the consumption of sandwiches, hamburgers, and bread and with age and diastolic blood pressure, although pizza and fried bread (pireca) had a negative correlation in males (p < 0.05). BMI positively correlated with systolic blood pressure, whereas it negatively correlated with the consumption of cassava and rice in females (p < 0.05). The FFQ revealed that fried food with wheat flour was consumed once a day. WFRs showed that 40% of meals consisted of two or more carbohydrate-rich dishes, significantly higher in energy, lipids, and sodium than those containing only one carbohydrate-rich dish. These results imply that less oily wheat dish consumption and healthy combinations of dishes should be considered for obesity prevention.

Usefulness of Simple Meal Screening Using Dietary Assessment Sheets for Evacuation Shelters.

To maintain the health of evacuees, meals provided at emergency shelters should be monitored and improvement measures should be taken where necessary. Time and human resources are limited during devastating disasters; thus, the authors have developed the Dietary Assessment Sheets for Evacuation Shelters. This study examines whether the quality of meals can be assessed using simple check items on the Dietary Assessment Sheets.A total of 28 Dietary Assessment Sheets for 98 meals provided 16-19 days after the heavy rains in Kumamoto in July 2020 at 12 shelters were used in the analysis. Dietitians working for shelters were requested to fill the Dietary Assessment Sheets and food record sheets provided by the Prefectural Government. If any subitem was checkmarked, it was considered "checked," and if left blank, it was considered "not checked" and divided into categorical groups. Based on the food record sheets and meal photos, contents of energy, protein, and vitamins B1, B2, and C were calculated for each meal. Energy and nutrient contents were compared between the categorical groups.The study revealed that nutritionally poor meals were characterized as those comprising only "Grain dishes," those that were not "Boxed meals," and those involving "Self-Defense Forces," "Dietitians," or "Others." Their energy, protein, and vitamin B1, B2, and C content was significantly lower than that of meals with marks on other checkboxes in the same category.Shelters that provide these meals should be given priority for nutrition assistance due to their poor diets. The results imply that the Dietary Assessment Sheets could serve as a simple tool to determine the shelters that require nutritional assistance.

Attitudes toward using "Simple simulator for calculating nutritional food stocks in preparation for large-scale disasters" among local governmental personnel and public health dietitians in Japan: An explanatory mixed methods study.

The Japanese Ministry of Health, Labour and Welfare compiled an Excel sheet - "Simple simulator for calculating nutritional food stocks in preparation for large-scale disasters" (Simulator). We examined the level of recognition and use of the Simulator by local governments and identified the points for its improvement. In stage 1, we surveyed local government personnel who participated in the "Workshop for nutrition assistance during large-scale disasters" held in November 2020 (n = 458; 313 responded) with an online questionnaire on the use of the Simulator and associated issues. Stage 2 involved group interviews with 15 public health dietitians who had been involved in food assistance during past natural disasters to identify points for improving the Simulator and the problems with food assistance during natural disasters. In stage 1, 233 responders (74.4%) confirmed their awareness of the existence of the Simulator. While 85 individuals (36.6%) used the Simulator, 63 individuals (74.1%) confirmed that they would use it in the future to plan and evaluate local government stocks. In stage 2, multiple comments regarding the Simulator's applicability and improvement in a realistic situation were collected. In order for the administrative staff in charge of disaster management to understand the nutritional importance of stockpiling main/side dishes, it was suggested that specific combinations of foods that meet the required amounts should be shown and that visualization using food products and the number of people covered by stockpiled foods may be easier to understand than pure nutritional values.

Revising "Nutritional Reference Values for Feeding at Evacuation Shelters" According to Nutrition Assistance by Public Health Dietitians Based on Past Major Natural Disasters in Japan: A Qualitative Study.

It is important to provide nutritionally adequate food in shelters to maintain the health of evacuees. Since the Great East Japan Earthquake in 2011, Japan's Ministry of Health, Labour and Welfare has released the "Nutritional Reference Values for Evacuation Shelters" (Reference Values) after every major natural disaster. There is clear evidence, however, that the Reference Values have only been used infrequently. This study aims to revise these guidelines to include the actual situation in the affected areas and the feasibility of the endeavor. This qualitative study uses group interviews with local government dietitians to propose revisions to Japan's Reference Values. These revisions include the following: issuing Reference Values within 1 week of a disaster, showing one type of values for meal planning for each age group, showing the minimum values of vitamins, upgrading salt to basic components, creating three phases of nutrition (Day 1, Days 1-3, and After Day 4), stipulating food amounts rather than nutrient values, and creating a manual. Local government officials could use the Reference Values as guidelines for choosing food reserves, and dietitians could use them while formulating supplementary nutrition strategies for a model menu in preparation for disasters.

Prolonged Maternal and Child Health, Food and Nutrition Problems after the Kumamoto Earthquake: Semantic Network Analysis of Interviews with Dietitians.

Infants need sufficient nutrients even during disasters. Only qualitative descriptive analysis has been reported regarding nutritional problems of mothers and children after the Kumamoto earthquake, and non-subjective analysis is required. This study examined issues concerning maternal and child health, food and nutrition after the Kumamoto earthquake using automatic computer quantitative analysis from focus group interviews (FGIs). Study participants (n = 13) consisted of dietitians in charge of nutrition assistance of infants in affected areas. The content of the interviews was converted into text, nouns were extracted, and co-occurrence network diagram analysis was performed. In the severely damaged area, there were hygienic problems not only in the acute phase but also in the mid-to-long-term phase. "Allergy" was extracted in the surrounding area in the acute and the mid-to-long-term phase, but not in the severely damaged area as the acute phase issue. In the surrounding area, problems have shifted to health and the quality of diet in the mid-to-long-term phase. This objective analysis suggested that dietary problems for mothers and children after disaster occurred also in the mid-to-long-term phase. It will be necessary to combine the overall trends obtained in this study with the results of qualitative descriptive analysis.

Personnel Training Course for Businesses Regarding the Response to Stranded Persons Focusing on Vulnerable People from the Perspective of Business Continuity.

Businesses in urban areas have been required to accommodate stranded persons as temporary evacuation facilities during disasters. Regarding measures aimed at aiding stranded persons, aspects such as trust and the image of the business need to be considered. Therefore, in this study, a personnel training course was developed to smoothly take in stranded persons, and the outcomes of this training were evaluated by quizzes, entry sheets, and a questionnaire. This was a two-day and one-night course characterized by the use of role-play in which 20 participants experienced the series of processes that unfold during disasters, playing either the role of a stranded person or a facility member. This training included emergency food provision using real stockpiled food and accommodation training using actual bedding stored in a model facility. After the review, when the participants were taught the correct response for vulnerable people, their scores in the test regarding the points of caution in vulnerable people were significantly higher than those prior to the course, confirming that participants had acquired knowledge as a result. Furthermore, through training using real food and accommodation, the participants were able to understand victims' requirements by experiencing the need for satisfactory emergency rations and comfortable bedding.

A Training Program to Enhance Disaster Preparedness of Group Companies in the Tokyo Metropolitan Area.

Many business continuity (BC) plans do not mention food and water for BC personnel. Moreover, the BC relies on the assumption that, during an emergency or crisis, employees' basic needs and personal hygiene are satisfied. Although no one can engage in BC without these supplies, literature regarding companies' disaster stocks for their employees is limited. We evaluated the current situation of companies' stockpiles of food and other supplies and what their employees thought about them after participating in a newly-developed overnight training program that allows the participants to experience situations that they would encounter in a disaster. Thirty-three employees from eight companies in Tokyo participated in the program. Seventy-five percent of the participants' companies had food stocks for three days as instructed by the Tokyo Metropolitan Government but, after eating four stock meals, 81.3% of the participants thought it would be better if this provision were improved. The stock rate for bedding was 62.5% but less than 30% of companies stocked both blankets and mats, as suggested by the Sphere Standards. There were several people who complained of sleeplessness and a poor physical condition the next morning and this could be an obstacle in the BC.

Local Governments' Disaster Emergency Communication and Information Collection for Nutrition Assistance.

We examined local governments' disaster emergency communication and information collection and distribution systems. Postal surveys were conducted for all prefectures, cities with public health centers, and specified districts in Tokyo Metropolis in 2005 and 2013. Municipalities were included in the 2013 survey only. The response rate for the 2013 survey was 71.2% (n = 1272). Thirty-six prefectures, 41 cities with health centers, and 16 specified districts in Tokyo Metropolis answered both surveys. A majority of respondents (88.8% in 2005 and 92.1% in 2013) of respondents reported that disaster management radio broadcasting was written into their local disaster management plans, guidelines, or manuals as the main communication tool. The proportion of respondents using computer networks (41.6-60.7%) and cell phones (email) (40.4-62.9%) had significantly increased between the surveys. It was also found that municipalities that had been previously affected by disasters (39.6%) were more likely to have systems to collect information from shelters and affected communities than those without any experience (24.3%), and prefectures that had been previously affected by disasters were more likely to have food supply damage reporting systems (36.4%) than those without such experience (3.3%).

Association Between Caregiver's Perception of "Good" Dietary Habits and Food Group Intake Among Preschool Children in Tokyo, Japan.

Given that parents are mainly responsible for a preschooler's dietary management, they need to understand a child's diet. However, few studies have examined the association between parental perception of a preschool child's "good" dietary habits and actual food intake. We conducted a cross-sectional study investigating whether a child's food intake would differ depending on the caregiver's perception of their child's dietary habits among 4-year-old nursery school children at Adachi City, Tokyo, Japan. Children's dietary data were collected using the brief-type self-administered diet history questionnaire for children Aged 3-6 Years (BDHQ3y), while caregivers' perceptions of their child's dietary habits (good, normal, and poor) were inquired (N = 136). The percentage of caregivers who perceived their child's dietary habit as good, normal, and poor was 41.2, 40.4, and 18.4%, respectively. Multiple linear regression analysis revealed that children whose caregivers perceived their diet as poor showed lower intakes of vegetables [ß = -48.7, 95% confidence interval (CI): -86.1 to -11.2], beans (ß = -13.2, 95% CI: -26.1 to -0.3), and fish and shellfish (ß = -9.2, 95% CI: -17.5 to -1.0) and higher intakes of fat and oil (ß = 1.7, 95% CI: 0.4 to 3.1), confectionaries (ß = 11.9, 95% CI: 3.6 to 20.3), and soft drinks (ß = 31.2, 95% CI: 3.5 to 59.0) compared to children whose caregivers perceived their diet as good (all measures are in g/1,000 kcal per day). No significant difference was observed in other food groups, such as dairy products, an important source of protein and calcium for children. The current study may therefore guide future nutritional education programs for parents of preschool children.

Meal services after the Great East Japan Earthquake at nursery schools in a tsunami-affected town: focus group observations.

BACKGROUND AND OBJECTIVES: This study aimed to collect information on experiences in the Great East Japan Earthquake (hereafter, 3.11), current preparedness, and barriers to building up stockpiles in nursery schools in affected areas. Based on the needs heard from the staff, we decided what contents should be included in our manual developed with the Japan Dietetic Association. METHODS AND STUDY DESIGN: A group interview was held in September 2012. We interviewed a principal, nurses, and registered dietitians working for a public and a private nursery school in Town A. We also invited an administrative dietitian who was an employee of Town A. RESULTS: One of the barriers to building up stockpiles was that they did not have any idea of what and how many items they should store. To deal with this situation, we developed a formula that could be used to calculate the quantity of stockpiles for their facilities in a newly developed feeding manual. In terms of current preparedness, the registered dietitians were not prepared for alternative menus in emergencies or how to manage garbage when the garbage collection was disrupted by disasters. The manual recommends to obtain the services of at least two food service personnel and spare space for storing filled garbage bags until garbage collection resumes. CONCLUSION: Some improvements in stocks were found in both of the public and private nursery schools. To improve the situation further, more financial support and detailed guidelines should be provided by the local government and authoritative organizations. Our manual should be a great asset for all nursery schools to improve their stockpiles.

Screening Tool for Older Persons' Appropriate Prescriptions for Japanese: Report of the Japan Geriatrics Society Working Group on "Guidelines for medical treatment and its safety in the elderly".

AIM: In 2005, the Japan Geriatrics Society published a list of potentially inappropriate medication that was an extract from the "Guidelines for medical treatment and its safety in the elderly 2005." The 2005 guidelines are due for a revision, and a new comprehensive list of potentially inappropriate medications is required. METHODS: A total of 15 diseases, conditions and special areas related to their clinical care were selected. We originated clinical questions and keywords for these 15 areas, carried out a systematic review using these search criteria, and formulated guidelines applying the Grading of Recommendations Assessment, Development and Evaluation system advocated by Minds2014. If we did not find good evidence despite the drug being clinically important, we looked for evidence of efficacy and for disease-specific guidelines, and incorporated them into our guidelines. RESULTS: We selected 2098 articles (140 articles per area), and extracted another 186 articles through a manual search. We further added guidelines based on disease entity and made two lists, one of "drugs to be prescribed with special caution" and the other of "drugs to consider starting," primarily considering individuals aged 75 years or older or those who are frail or in need of special care. CONCLUSIONS: New lists of potentially inappropriate medications and potential prescribing omissions called "Screening Tool for Older Person's Appropriate Prescriptions for Japanese" were constructed. We anticipate that future studies will highlight more evidence regarding the safety of high-quality drugs, further improving the provision of appropriate medical care for the elderly. Geriatr Gerontol Int 2016: 16: 983-1001.

Development and Validation of a Data-Based Food Frequency Questionnaire for Adults in Eastern Rural Area of Rwanda.

This study aimed to develop and evaluate the validity of a food frequency questionnaire (FFQ) for rural Rwandans. Since our FFQ was developed to assess malnutrition, it measured energy, protein, vitamin A, and iron intakes only. We collected 260 weighed food records (WFRs) from a total of 162 Rwandans. Based on the WFR data, we developed a tentative FFQ and examined the food list by percent contribution to energy and nutrient intakes. To assess the validity, nutrient intakes estimated from the FFQ were compared with those calculated from three-day WFRs by correlation coefficient and cross-classification for 17 adults. Cumulative contributions of the 18-item FFQ to the total intakes of energy and nutrients reached nearly 100%. Crude and energy-adjusted correlation coefficients ranged from -0.09 (vitamin A) to 0.58 (protein) and from -0.19 (vitamin A) to 0.68 (iron), respectively. About 50%-60% of the participants were classified into the same tertile. Our FFQ provided acceptable validity for energy and iron intakes and could rank Rwandan adults in eastern rural area correctly according to their energy and iron intakes.

Roles of National and Local Governments and the Dietetic Association in Nutrition Assistance Response to Natural Disasters: Systems and Experiences in Japan and the USA.

In the first half of this symposium, the disaster response system in Japan will be introduced. The ultimate aim of nutrition assistance is to keep people in disaster areas healthy. This is a task for the Ministry of Health, Labour and Welfare and the health departments of prefectural governments. Our first speaker, Dr. Yasuhiro Kanatani, National Institute of Public Health, will briefly overview the disaster response system in Japan and its related laws. He will also mention how the Ministry responded to the Great East Japan Earthquake. In the second presentation, I will play one chapter of DVD that we released in last September. In that chapter, Ms. Makiko Sawaguchi, a registered dietitian working for a public health center in the area affected by the Great East Japan Earthquake, talks about her experience in supporting disaster victims. As an employee of Iwate Prefectural Government, she helped affected municipal governments and coordinated outside support. One type of outside support was registered dietitians dispatched by the Japan Dietetic Association (JDA). Dr. Nobuyo Tsuboyama-Kasaoka will report what those dietitians did in the affected areas. She will also explain the aim and training of the JDA-Disaster Assistance Team. Provision of food is essential in nutrition assistance. This is a task for the Ministry of Agriculture, Forestry and Fisheries. Our fourth speaker, Mr. Kunihiro Doi, analyzed the government procurement data and will discuss the limitations of government emergency food supplies and lessons learned from the Great East Japan Earthquake. As for the systems and experiences in the US, we invited Ms. Toni Abernathy from the Office of Emergency Management, Food and Nutrition Service (FNS), United States Department of Agriculture.

[A case of isolated pulmonary valve infective endocarditis in a 78-year-old woman].

A 78-year-old woman was admitted to our hospital with lumbago. Her activities of daily living had previously been completely independent. However, she developed temporary chills in January 2009, that improved without treatment, but recurred on February 7, 2009 in association with left lumbago and loss of appetite. She was then referred to our hospital with a disturbance of consciousness and high fever on February 14. A blood test performed on admission revealed an elevated inflammatory response, coagulation disorder and low platelet count, and abdominal computed tomography demonstrated findings suggestive of pyogenic spondylitis. The patient was therefore admitted and treated with antibiotic therapy; however, she died on day 8 due to complications of disseminated intravascular coagulation. An autopsy showed isolated pulmonary valve endocarditis. The patient's history was later found to include regular dental treatment, and the same Streptococcus group G was detected in cultures of the sputum, blood and vegetation. It is important to interview patients regarding their history of dental treatment, particularly elderly individuals with fever of unknown origin.

A Group Interview Regarding Disaster Preparedness for Food Assistance in a University that Offers a Training Course for Registered Dietitians.

Mass care feeding for disaster evacuees is an important component of public health preparedness. If universities that offer a training course for registered dietitians could provide food assistance to the evacuated people in their campus, it could contribute to maintain their health. Many universities are expected to become a base of support activities for people affected by disaster. This study aimed to reveal disaster preparedness in a university that offers a training course for registered dietitians, from the aspect of provision of mass care feeding. As Japan has 124 universities that offer such training courses, this case study could serve as a useful reference for them and contribute to the improvement of health of the affected people. A group interview was conducted in University A in 2012. The participants included two faculty members in the course, a vice president, a staff member, and a faculty member in charge of disaster preparedness and response. Stockpiled foods were limited to dry bread and pre-processed rice. No alternative heat sources were stored. It was concluded that to provide nutrients other than carbohydrate, hot meals should be served for the evacuees. Additionally, it would be difficult to provide meal service when the essential utilities such as gas and electricity are disrupted.