Nutritional Value of Lunches Served in The Remote Rural Area Child-Care Centers in Chiang Mai, Thailand

1. INTRODUCTION

The establishment of healthy food and eating behaviors in the context of food selection, preparation and supply both at home and in child-care centers (CCCs) is important for the growth and development of preschool children [1]. Poor eating habits are connected to the development of obesity, type 2 diabetes, cancer and other chronic diseases causing major public health problems [2, 3]. Thai school lunch guidelines recommend 40 grams of fruit, 40 grams of vegetable, 90 grams of rice and starchy food and 30 grams of meat as the daily Dietary Reference Intake (DRI) for preschool children [4], who generally have inappropriate intake levels of energy and macronutrients and do not consume enough vegetables or whole grains on a daily basis. Over 98% of Thai preschool children consume fats and sweets at higher levels than the daily DRI [5]. Previous studies reported that preschool children generally fail to meet dietary requirements; 94% fail to consume the recommended daily serving of vegetables, while over 99% consume added fats and sweets surpassing daily limits [2]. A well-balanced nutrient-dense diet is necessary for healthy growth and development [6, 7]. Undernourishment among preschool children is a problem in Thailand, and the recent National Nutrition Survey has demonstrated that in preschool children, the prevalence of underweight and stunting is 5.3% and 6.6%, respectively [5]. Eating habits are important because they have a long-term impact on dietary patterns [8].

Several studies reported on various factors that impacted the nutritional status of preschool children, including innate dietary preferences [4], child-rearing practices [7], and food availability at home or in CCCs [4, 7, 9]. Schools, including CCC settings, influence the eating habits of students [10-12]. In rural areas, especially remote rural areas, CCC services are different, with reduced state oversight and regulations, lower education and specialized training of caregivers and higher child-to-caregiver ratios that all impact access to resources and training [13]. In Thailand, more than one million preschool children are enrolled in daycare centers [14], where they eat lunch and stay for up to 8 hours every day. Menus and nutritional requirements are enforced by the government regulating authority, such as the Bureau of Nutrition, Department of Health, and Ministry of Public Health of Thailand. However, providing lunch is not a requirement for all CCCs and specific menus in each CCC are different.

The northern Thai province of Chiang Mai is known for its typical mountainous characteristics. There are some ethnic populations living in these areas with low economic status. In daytime, most parents leave their children in a day care center where care givers take care of the children [15]. A report by the Department of Local Administration, Chiang Mai Province listed 660 CCCs, with more than 100 in remote rural areas [16], while a preliminary survey conducted by Health Center Region 1, Chiang Mai revealed that each center operates various lunch management programs. No standardized lunch menus are stipulated by the authority, and these are organized by the CCC staff based on the budget received. Cooking ingredients chosen for lunch menus are readily available and inexpensive. Menus are typically created for each four-week period. Several strategies and activities have been implemented to improve healthy eating among preschool children in CCCs [17]. However, very few studies have specifically analyzed the nutrient contents of remote rural CCC lunches in Thailand. Those areas are known to be more than 200 kilometers from the city. The majority of the population is ethnic. There is a distinct style of life that differ from that of most city dwellers. The objective of this study was to determine the nutrient content of lunches served compared to 40% of the recommended daily DRI for children aged 3 to 5 years in CCCs in remote rural areas in Chiang Mai Province, Thailand.

2. MATERIALS AND METHODS

3. RESULTS

4. DISCUSSION

Results demonstrated that lunches provided in remote rural area CCCs in Chiang Mai, Thailand were insufficient in essential nutrients required for healthy growth and development. The recommended values of 40% DRI for energy, protein, carbohydrate, fat, dietary fiber, iron and vitamin B1 are 480 kcal, 14.10 g, 73.20 g, 14.40 g, 3.60 g, 2.44 mg, 280.00 mg and 0.24 mg, respectively. The CCC lunches in remote rural areas in Chiang Mai were statistically deficient in energy (338.18±110.84 kcal), protein (10.48±13.79 g), carbohydrate (48.37±18.00 g), fat (9.95±3.76 g), dietary fiber (2.09±0.68 g), iron (2.44±1.96 mg), vitamin B1 (0.14±0.05 mg) and calcium (146.09±22.18 mg), while cholesterol content (146.51±22.67) was higher (120.00 mg). Contents of vitamin A (178.72±39.34 mg), vitamin B (0.25±0.25 mg), vitamin C (13.32±7.17 mg) and iron (2.44±1.96) did not differ from the recommended DRI values. Results concurred with Martins et al. (2021), who reported that meals served in schools in the city of Porto, Portugal, did not meet international dietary guidelines for energy and macronutrients. Most meals served contained nutrient values below the age-specific lower limit [18]. Research concerning dietary adequacy in Indian rural preschool children discovered that protein and vitamin A adequacy levels were slightly higher among regularly nourished children, but the differences were not statistically significant [19]. However, similar studies focusing on CCCs are limited. This study, therefore, compared results against studies in both CCCs and elementary schools. Our findings were similar to previous studies showing that school meals frequently did not provide sufficient energy and nutrients [20-23].

Many factors have been reported to influence the nutritional content of CCC lunches, especially in remote rural areas. One important factor is that CCCs in Thailand do not have a dedicated nutritionist or dietitian [24]. Personnel generally responsible for organizing CCC lunches are caregivers who do not have adequate knowledge of food and nutrition and spend most of their time caring for the children. As a result, they do not have enough time to properly organize the lunch menu [25]. Briley et al. identified two key elements that directly influenced CCC lunches: food cost and staff perception of children's food preferences. Staff who believed or assumed that children disliked rice, meat, fruit or vegetable were more likely to serve smaller portions to reduce waste and save cost [26]. Another key factor impacting the nutritional content of CCC lunches was an insufficient budget to execute wellness initiatives [26, 27]. Chomnard et al. also highlighted financial pressure as an important factor affecting the procurement of food materials, both in quantity and quality [23].

Regional differences in consumption culture have previously been reported. Food preferences, traditional foods and lifestyles differ by region; therefore, food served in CCCs may be affected by culture [28, 29]. Among children in remote rural areas, acculturation and low socioeconomic status are significantly associated with health-related behaviors [30]. Additionally, various sociocultural factors such as beliefs and cultural taboos influence the foods children eat [31]. Yhoung-Aree et al. stated that in rural communities of Northern Thailand, sociocultural and economic limitations often obstructed the use of common protein sources such as pork, beef, poultry, milk and egg [32]. The northern region of Thailand is mountainous with plateau areas and transportation issues, access to natural water resources and a longer dry season all contribute to poor food distribution and uncertain availability of common proteins [32, 33] that impact the implementation of good nutritional quality lunches in CCCs and influence dietary preferences.

Carbohydrate is a primary source of energy, while protein and fat provide an equivalent amount of energy. These nutrients are important for children’s activities and development. Carbohydrates give energy to body cells, especially the brain, which is a glucose-dependent organ [34], while protein is essential for body tissue growth, repair and maintenance. The percentages of carbohydrates, fat and protein contributing to energy consumption are consistent with dietary guidelines, which state that carbohydrate, fat and protein supply 45-65%, 25-40% and 10-35% of energy, respectively [34, 35]. Inadequate food intake results in an insufficient supply of important nutrients, particularly macronutrients. Caregivers are a major target group for health professional teams to support children’s optimal nutritional status and healthy eating habits [36].

Nutritional quality is negatively related to metabolic disease [25, 37]. Several studies showed that high-quality school lunches increased productivity by 3.4 times, increased alertness, increased reading and comprehension scores, decreased authorized absenteeism by 14% and optimized child cognitive and behavioral functions, especially for children with poor dietary quality or low socioeconomic status [25, 38-41]. Therefore, it is vital to improving the quality of lunches served in CCCs.

Modifying CCC lunch menus to contain adequate nutrients will establish future health promotion and ensure that school meals meet the 40% target of the Thai DRI. This will reduce the risks of both chronic degenerative and dietary deficiency disorders as part of a larger effort to implement prevention-oriented health objectives in CCCs. The role of CCC nutritionists or caregivers is very important to achieve these goals for health promotion and disease prevention via the intake of an appropriate diet. Caregivers’ knowledge of appropriate foods in their right proportions given to preschool children is necessary to improve the nutritional wellbeing of the children. Incidentally, many caregivers do not have adequate knowledge about the nutrient composition of certain foods that should be given to preschool children [42]. Thus, it is essential to provide caregivers with the necessary knowledge to help them modify their feeding practices of preschool children [43]. Prior studies have recommended the use of multiple strategies and various methods to promote the caregiver's nutritional knowledge. For example, the use of nutritional education programs and social media open up multiple options to add a new dimension to learning and knowledge processes [43].

5. STUDY STRENGTHS

This study had several strengths. First, lunch sample data were collected by trained dieticians, providing accurate food sampling and nutritional analysis. Second, randomly collecting lunch samples without prior notification prevented bias from preferentially scooping food to increase nutrient content. Finally, to the best of our knowledge, this is the first study analyzing the nutritional adequacy of lunches served in CCCs in remote rural areas of Thailand.

6. STUDY LIMITATIONS

There were several study limitations. First, the data was related to a small sample size of nine CCCs in only one remote rural district in Thailand. Lunch menus at each school were only observed on two consecutive days, and this may not accurately represent the usual fare served to children or consider seasonal variability. Observing lunch menus on multiple days would provide better data concerning nutrient content. Second, this investigation compared nutrient intake, not food group, which is the focus of the new nutrition standards. Third, while research focusing on a single district can help to improve local policy and practice, such a restricted focus may limit generalizability to other parts of the country. Finally, we analyze the food served but do not analyze the food actually consumed. Therefore, to know the actual amount of nutrients that children receive. Future research should analyze the nutrient content of the foods that children actually consume.

CONCLUSION

Results indicated that CCC lunches served in a remote rural area of Chiang Mai, Thailand, did not meet the nutritional guidelines required for healthy growth and development of children. Menu planning must be improved. These concerns can be addressed by involving a registered dietitian or nutritionist to ensure that CCC lunches are a beneficial resource for regulators and parents by providing appropriate nutrients for the growth and development of preschool children. The Thai Government should implement policy decisions about CCC meals for preschool children, especially in rural areas, to ensure the provision of diverse and nutritious meals.

REFERENCES