PDF
Citation
Print
INTRODUCTION
Early childhood is a period of active growth and development that makes the formation of proper eating habits crucial. Caregivers and childcare center cooks who prepare meals can influence the eating habits, behaviors, and food preferences of infants and young children [1]. As of 2021, the number of childcare centers established and operating nationwide has increased to 33,246, from 20,097 in 2001. In the same year, the number of children enrolled in childcare centers reached 1,184,716 [2]. Meanwhile, the daily sodium intake of infants and young children is increasing annually. For children aged 1–2 years, the daily sodium intake increased steadily: 1,198.9 mg in 2019, 1,233.9 mg in 2020, and 1,354.2 mg in 2021. For children aged 3–5 years, it remained high at 1,629.2 mg in 2019, 1,730.3 mg in 2020, and 1,630.4 mg in 2021 [3]. According to the 2020 Dietary Reference Intakes for Koreans, the adequate intakes (AIs) of sodium for ages 1–2 years and 3–5 years are 810 mg and 1,000 mg, respectively, indicating that Korean infants and young children consume more than 1.6 times their AI of sodium [4].
Infants and young children enrolled in childcare centers typically spend approximately 7 hours a day, receiving at least one meal (lunch or lunch and dinner) and two snacks (morning and afternoon) daily (attached Table of the Enforcement Rules of the Infant Care Act 8). Meals provided in childcare centers are generally reported to have high sodium content. Jung et al. [5] investigated the sodium intake in 12 childcare centers in the Gyeonggi region and found that the average sodium content per meal was 582.2 mg, with soups and stews contributing the most. Another study by Song and Lee [6] analyzed the sodium content of lunch menus collected from five childcare centers in North Gyeongsang Province and reported an average sodium content of 681 mg per meal. The menu with the highest sodium content consisted of kimbap, fish cake soup, spinach side dish, pickled radish salad, and kimchi, totaling 1,370 mg of sodium.
According to the 2021 Childcare Statistics, 29,575 cooks work in childcare centers nationwide, 99% of whom are women [2]. The AI of sodium for Korean women aged 19–64 years is set at 1,500 mg [4]. However, the actual intake in 2021 was much higher: 3,134.2 mg for ages 19–29 years, 3,334.4 mg for ages 30–49 years, and 3,293.6 mg for ages 50–64 years, which is 2 to 2.2 times the AI [3]. The characteristics of cooks, who typically consume high amounts of sodium, may influence excessive sodium intake in infants and young children in childcare centers. Ongoing studies have focused on sodium reduction education for childcare center cooks and enrolled children [7,8], as well as analyses of soup salinity in childcare center meals [9,10]. Additionally, continuous salinity measurements using salinometers have been reported to effectively reduce soup salinity [9-12], supporting the need for salinometer support. However, only limited studies have investigated the importance and practice of sodium reduction by childcare center cooks or the effects of the continuous use of salinometers on these factors.
Meanwhile, as of December 2021, 793 childcare centers have been established and operating in Yongin City, Gyeonggi Province, with 29,272 children enrolled [2]. Yongin City has the third highest number of childcare centers in Gyeonggi Province, after Suwon City and Hwaseong City, and the highest number of enrolled children [2]. Therefore, this study aimed to understand the sodium-related eating habits and behaviors of childcare center cooks in Yongin City, Gyeonggi Province, and to analyze the changes in the importance and practice of low-sodium management before and after implementing a salinometer support program combined with sodium reduction nutrition education. This study provides essential data necessary for future sodium reduction education targeting childcare center cooks and suggests guidelines for desirable sodium intake in infants and young children.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of Myongji University (MJU-2022-04-001-02). All participants were informed of the study purposes and protocols, and they provided written informed consent.
1. Study participants and period
This study was conducted in cooks working in childcare centers who participated in the 2022 salinometer support program among those registered with the Yongin Center for Children’s Foodservice Management (Yongin CCFM). After collecting the pre-survey questionnaires from the study participants, salinometers were distributed along with usage instructions and sodium-related nutrition education. Subsequently, salinometers and salinity measurement recording sheets were provided. The participants were then instructed to measure the salinity of soups and stews served in childcare centers daily for 3 months using salinometers. Educational materials developed by the Yongin CCFM related to salinometer usage, the necessity of sodium intake, problems with excessive intake, and low-sodium practices were utilized. Surveys were administered before and after the salinometer support program. The program ran from June to December 2022. During the survey, questionnaires were distributed to 354 participants, and all responses were collected thereafter. After excluding 41 questionnaires with insincere responses, only 313 questionnaires were analyzed (analysis rate: 88.4%).
2. Survey methods and content
The questionnaire items were based on those used in previous studies [1,13-21] and were modified or supplemented after consultation with seven experts in the field of food and nutrition to ensure validity.
1) General information
To obtain general information about childcare centers, the facility type and number of enrolled children were surveyed. For comparative analysis, the centers were divided into childcare centers registered as group feeding facilities (FS group, n = 68) and childcare centers not registered as group feeding facilities (non-FS group, n = 245). According to Article 2, Clause 12 of the Food Sanitation Act, a group-feeding facility refers to a nonprofit facility that continuously provides food to a specific group, serving meals to 50 or more people at a time (Enforcement Decree of the Food Sanitation Act 2). Non-group feeding facilities serve meals to fewer than 50 people at a time and are not established or operated as group foodservice facilities. Foodservice facilities were classified as national/public, private, home, workplace, corporate/organization, cooperative, and social welfare corporation according to Article 10 of the Infant Care Act. The following general information of the cooks were obtained: gender, age, cooking experience, and possession of cooking certifications.
2) Sodium-related eating habits
To understand the participants’ usual sodium-related eating habits, five items were constructed based on those reported in previous studies [1,13,15,19] including “I check the sodium content when purchasing food” and “I eat soup, stew, or noodle soup without leaving any broth.” Each item was measured on a 5-point Likert scale, ranging from “always” (1 point) to “never” (5 points), with higher scores indicating “low-sodium” eating habits.
3) Importance and practice of low-sodium management
To examine the importance and practice of management strategies for sodium reduction, items were constructed based on those reported in previous studies [14,16,19,20]. Each item was modified and supplemented to suit childcare centers. The purchasing domain included three items such as “I check the sodium content when purchasing food.” The cooking domain included six items such as “I check the sodium content with a salinometer after cooking.” The serving domain includes three items such as “I serve soups and stews mainly with the solid ingredients.” Overall, 12 items were constructed. The same items were used for assessing both importance and practice. Importance was measured on a 5-point Likert scale, ranging from “very unimportant” (1 point) to “very important” (5 points), while practice was rated from “never do it” (1 point) to “always do it” (5 points).
3. Statistical methods
The collected data were analyzed using IBM SPSS Statistics 27 (IBM Co.), and the results were expressed as frequencies and percentages or means and standard deviations. Chi-square or Fisher’s exact tests were conducted to analyze the differences in distribution between the FS and non-FS groups. Independent sample t-tests or Welch’s t-tests were performed to verify the differences in the means depending on the homogeneity of variance. Paired t-tests were used to compare the importance and practices of low-sodium management before and after the salinometer support program. A P value of < 0.05 was considered significant.
RESULTS
1. General characteristics
The general characteristics of the childcare centers and cooks in this study are presented in Table 1. Among the 313 childcare centers evaluated, 68 (21.7%) comprised the FS group, while 245 (78.3%) comprised the non-FS group. The majority (75.0%) of the FS group were private centers, while the non-FS group consisted of 64.5% home-based centers and 29.0% private centers (P < 0.001). With regard to the number of enrolled children, none of the centers in the FS group had 20 or fewer children. Instead, the centers in this group were evenly split between those with 21–49 children and those with 50 or more children (50% each). By contrast, the majority (76.7%) of the non-FS group had 20 or fewer children (P < 0.001) largely due to the high proportion of home-based childcare centers in this group. The average numbers of enrolled children were 27.0, with 54.0 comprising the FS group and 19.5 comprising the non-FS group (P < 0.001).
The average age of cooks was higher in the FS group (55.1 years) than in the non-FS group (51.3 years) (P < 0.001). Cooks’ careers were also longer in the FS group (5 years and 6 months) than in the non-FS group (4 years) (P = 0.025). Approximately 92.6% of cooks in the FS group held cooking certifications, while only 18.8% in the non-FS group held such certifications (P < 0.001).
2. Sodium-related eating habits
The analysis of sodium-related eating habits before the salinometer support program is presented in Table 2. The average scores for the five items were 3.72 for the FS group and 3.81 for the non-FS group, with no significant difference between the two groups. No significant differences were also observed in any of the individual items. The item “I check the sodium content when purchasing food” scored the lowest in both groups (FS, 3.19; non-FS, 3.32).
3. Importance and practice of low-sodium management
1) Changes in the importance of low-sodium management before and after the salinometer support program
Table 3 presents the changes in the importance of low-sodium management for both groups after the program. Overall, the importance score increased significantly from 4.23 to 4.35 (P < 0.001). Both the FS (P < 0.001) and non-FS (P = 0.005) groups showed similar results, with the FS group showing the most substantial change.
Significant increases were observed in the purchasing (P = 0.017), cooking (P = 0.001), and serving (P < 0.001) areas. Within these domains, individual variables showed notable differences. In the purchasing domain, the item “I check sodium content when purchasing food” showed a significant difference (P = 0.002) in both groups. In the cooking domain, the item “I check the sodium content with a salinometer after cooking” showed a significant overall difference (P < 0.001) between the two groups. However, the item “I reduce the use of salt and sauces and instead use spices or herbs” showed a significant increase only in the FS group (P = 0.038). In the serving domain, the item “I serve soups and stews mainly with the solid ingredients” (P = 0.005) and “I post the sodium content of soups and stews” (P < 0.001) showed significant increases overall, with some differences between the groups.
2) Changes in the practice of low-sodium management before and after the salinometer support program
Table 4 shows the changes in low-sodium management practices. Overall, the practice score increased significantly from 3.74 to 4.31 (P < 0.001), with similar results observed in the FS (P < 0.001) and non-FS (P < 0.001) groups.
Significant increases were observed in the purchasing, cooking, and serving domains (P < 0.001 for all). Individual items showed some differences between the groups. In the purchasing domain, the items “I check sodium content when purchasing food” and “I buy low-sodium products for sauces” showed significant increases in both groups and the non-FS group, while only the former item showed a significant increase in the FS group. In the cooking domain, three items demonstrated significant increases overall, with some differences between groups. In the serving domain, all items showed significant increases overall, although the differences between the groups persisted.
3) Analysis of the importance and practice of low-sodium management before and after the salinometer support program
Tables 5 and 6 present the analyses of the importance and practices of low-sodium management in the FS and non-FS groups, respectively. Overall, the practice scores were significantly lower than the importance scores before the program (P < 0.001) in both groups, but this difference disappeared following the completion of the program owing to the larger increase in practice scores.
By domain, the purchasing and serving areas in the FS group showed similar trends, with the practice scores significantly lower than the importance scores before the program implementation, but no difference was observed after the program. The cooking domain showed high overall scores with no significant differences before or after the program. In the non-FS group, the cooking domain showed a trend similar to that of the FS group, while the purchasing and serving domains obtained persistently lower practice scores compared with the importance scores, even after the program.
DISCUSSION
This study surveyed 313 cooks working in childcare centers who participated in the 2022 salinometer support program among those registered with Yongin CCFM. This study aimed to examine the sodium-related eating habits of childcare center cooks and changes in the importance-practice levels of low-sodium management before and after the salinometer support program. All cooks participating in this study were women, with an average age of 52 years. In a previous study investigating the stages of behavioral change for sodium reduction among childcare center cooks in Seoul, Gyeonggi, and Chungcheong provinces [17], the average age of the participating cooks was 49 years. Another study on sodium reduction education for childcare center cooks in Seoul [7] included participants with an average age of 51 years, similar to the participants in this study. This observation indicates that most cooks working in childcare centers are middle-aged women. A previous study [22] analyzing the stages of behavioral change for sodium reduction in 553 housewives with an average age of 58 years found that the most challenging low-sodium dietary behavior was selecting food after checking the nutrition labels. Similarly, a study investigating the stages of behavioral change for sodium reduction among cooks [17] showed low scores for the item “selecting foods after checking nutrition labels.” In this study, the item “checking the sodium content when purchasing food” obtained the lowest score in the cooks’ usual eating habits domain. As childcare center cooks who prepare meals can influence the infants’ and young children’s eating habits, dietary behaviors, and food preferences [1], maintaining healthy eating habits among cooks is crucial. Therefore, providing capacity-building education for childcare center cooks to practice low-sodium eating habits, including methods for checking nutritional labels when purchasing food, is essential. In particular, Jung et al. [15], who conducted a low-sodium eating habits program, reported that longer program durations led to increased adherence to low-sodium eating habits. Thus, to achieve sustained educational effects, improvements in eating habits should be encouraged through continuous education rather than through one-time sessions.
Analysis of the importance and practice levels revealed that in the FS group, the items “checking the sodium content when purchasing food” and “buying low-sodium products for sauces” had an importance score of < 4.0 before the salinometer support program, which was lower than those of other items. The scores for practice levels were also lower than those of other items. After the support program, both the importance and practice scores increased, reflecting positive changes. However, these scores were relatively low compared with those of other items, with “buying low-sodium products for sauces” being the only item to retain a score below 4.0 after the program. In the non-FS group, the practice level for checking sodium content when purchasing food remained lower than its importance level, even after the support program. This finding suggests the need for continuous education, especially for cooks in non-group feeding facilities. Similarly, a study investigating the practices and factors hindering sodium reduction among middle school nutrition teachers/dietitians [20] showed low practice scores for using low-sodium products. Another survey on the use of low-sodium products among nutrition teachers/dietitians in elementary, middle, and high schools in the Gyeonggi area [14] found that 90.5% of the respondents did not use low-sodium products, owing to the “lack of information” and “high prices.” To achieve effective sodium reduction in childcare centers, education regarding low-sodium products that can be used in childcare centers and the methods for purchasing foods that can reduce sodium provision must be provided. In addition, various low-sodium products must be developed.
To reduce the excessive sodium content in children’s meals, the CCFM recommends a salt content of 0.5% in soups or stews served in childcare centers. To ensure appropriate salt content in menus, the use of salinometers in food service facilities is essential. However, a study on school meals in the Gyeonggi region [16] showed that although 86.6% of food service facilities possessed salinometers, only 62.7% used them to check the sodium content of soups or stews. However, a study on the sodium reduction practices of school nutrition teachers/dietitians [23] revealed that only 73.9% consistently used salinometers. This observation indicates that the utilization of salinometers in food service facilities remains unsatisfactory despite the differences in study participants. Education can enhance salinometer use. A previous study [7] on sodium reduction education for childcare center cooks in Seoul showed that the rate of salinometer use increased from 8.2% before education to 94.6% after education on the necessity and usage of salinometers. This study demonstrated that providing salinometers along with related education not only heightened the perceived importance of their use but also resulted in observable behavioral changes in checking and posting salt content. The practice level of using salinometers, initially one of the items with the lowest score (3.17 points) significantly increased to 4.55 after the program.
Previous studies have shown that food service facilities using salinometers have a lower average salt content compared with those that do not use salinometers [11]. A study monitoring the salt content of soups provided by facilities registered with the CCFM indicated a trend of salt content decreasing with repeated measurements [9]. Kim and Pie [10] reported similar results. Jo and Han’s study [12] found that providing salinometers and conducting low-sodium education in children’s food service facilities resulted in a decrease in soup salt content from 0.46% to 0.41%, supporting the need for continuous education on sodium reduction. Managing the salt content of food service menus using salinometers is practical and applicable in the field [23]; thus, creating an environment where salinometers can be used along with related education could enhance the effectiveness of sodium reduction practices. Through the salinometer support program accompanied by related education, the perceived importance and practice levels of using salinometers increased in the FS and non-FS groups. Therefore, future efforts should continue to support voluntary and practical sodium management in childcare centers through salinometer provision, education, and monitoring.
In this study, both the FS and non-FS groups showed an increase in overall average importance scores after the program. The values obtained in the current study align with the levels reported in a previous study [21] on sodium reduction status and methods used in preparing school meals, despite the differences in the study participants. The practice scores also improved after the program, with the item “seasoning soups or stews at the end of cooking” reaching levels similar to those reported in a study [14] analyzing the awareness and practices of sodium reduction among nutrition teachers and dietitians in the Gyeonggi area. Changes in the perceived importance and practices related to sodium reduction differed between the FS and non-FS groups. In the FS group, no significant differences were found in the importance and practices related to purchasing, cooking, and serving after the program. In the non-FS group, the practice levels remained significantly lower than the importance levels in the purchasing and serving areas even after the program. Nevertheless, in all areas and for most items, the importance and practice levels of the FS group were lower than those of the non-FS group both before and after the program. Therefore, future education should prioritize intensive training across all areas for childcare centers with more than 50 children that have group feeding facilities. For home childcare centers, which constitute the majority of nongroup feeding facilities, priority should be given to more vulnerable areas, such as checking sodium content when purchasing food and posting salt content.
Despite detailed upper limit standards for salt content in soup dishes consumed by adults [24], guidelines for salt content in soup dishes for infants and toddlers remain ambiguous, suggesting the need for more specific regulations. Because soups significantly contribute to sodium intake in infants and young children [5], managing their soup salt content is essential. Standards should balance reducing sodium with maintaining children’s tastes and satisfaction. Additionally, a study [25] investigating the eating habits of childcare center children in Uiwang City found a high frequency of eating out (1–2 times a week). Another study [26] comparing the sodium content in home-cooked, restaurant, and school meals in Seoul showed that restaurant meals had the highest sodium content. To foster low-sodium eating habits in infants and young children, cooperation is essential both in food service facilities and at home. Consistent operation of salinometer lending programs is needed to support sodium reduction at home. Additionally, policy support is needed to encourage restaurants to voluntarily develop and provide low-sodium menus for children.
In the future, the CCFM should provide information on the health effects of consuming high-sodium foods and guidance on checking nutrition labels based on methods for reducing salt when eating and cooking, as suggested in a previous study [13] on sodium reduction programs. Additionally, presenting low-sodium recipes that utilize various vegetables and fruits or the natural taste of foods, along with methods to minimize sodium addition during cooking, will support cooks in gradually reducing sodium content. This study was limited to cooks working in feeding facilities that participated in the 2022 salinometer support program, limiting the generalizability to all children-feeding cooks nationwide. Additionally, the 3-month duration of the program restricted the analysis of long-term changes. Therefore, future research should include a larger, geographically diverse sample based on probability sampling methods and assess long-term effects. Furthermore, given that infants and young children consume large amounts of sodium through snacks in addition to meals, studies on the importance and practice levels of childcare center staff regarding snacks consumed by children should be conducted.
CONCLUSIONS
This study analyzed the changes in the importance and practice of low-sodium management among 313 cooks working in childcare centers participating in a salinometer support program. Results show that the program contributed to an overall increase in the importance and practices of low-sodium management in both groups. However, cooks in the non-FS group still demonstrated lower practice levels compared with the importance scores in the purchasing and serving areas. Future low-sodium education should prioritize more vulnerable areas based on the type of childcare center and consider factors such as checking sodium content when purchasing food and displaying salinity.
XML Download