GROUP

UNIVERSITI MALAYSIA TERENGGANU

STM 4201 NUTRITION THERAPY

GROUP ASSIGNMENT
CASE STUDY 1: TYPE 2 DIABETES MELLITUS

LECTURER’S NAME: DR. NOOR SALIHAH BINTI ZAKARIA

MATRIC NO. NAME

S46650 MUHAMMAD HAZIQ BIN MOHD RAFI
S46655 FATIN LIYANA BINTI MOHAMMAD BADRUDIN
S46674 SITI AMANINA BINTI MOHAMAD FAKHARUDDIN
S46690 AMINAH BINTI AZLAN
S46775 SITI NURANI BINTI ZAINAL ABIDIN
S46783 WAN NUR AFIQAH BINTI WAN ABDULLAH

DATE OF SUBMISSION:10 JANUARY 2021

Sem. I 2020/2021
Bachelor of Food Science (Food Service and Nutrition)
Faculty of Fisheries and Food Science
Case Study 1
Background
Siva, 47 years old Indian male
Married, A lorry driver (8.00 am - 5 .30 pm; working hour)
Newly diagnosed with Type 2 Diabetes Mellitus
Weight: 76 kg, Height: 168 cm
Plasma glucose (FBS 9.1 mmol/L), HbA1c 15.5%
Blood pressure 125/83 mm Hg
Smoking 20 cigarettes / day
Symptoms: polyuria, polydipsia
Medication: T. Metformin 500mg BD

Diet history
Mostly eat foods prepared by his wife. His wife owns a small Indian restaurant.
LINK VIDEO PRESENTATION: https://youtu.be/iCjxHij0I_Y
MNT for the management of Type 2 diabetes mellitus
Medical nutrition therapy (MNT) is the use of specific nutrition interventions to treat an
illness, injury, or condition. Medical nutrition therapy (MNT) is important for diabetes
prevention, the management of current diabetes, and delaying complications. At any point of
diabetes management, including those on diabetes management, proper diet is a necessary
medication. Along with medicine, the goals of MNT are to obtain, and control blood glucose,
blood pressure, and the lipid profile is as healthy as possible and like normal via healthy food
choices. Also, to prevent or slow down the rate of development of chronic complications (CPG,
2015). Table 1 lists the nutrition guideline for the management of type 2 diabetes.

Table 1: Nutrition guideline for the management of type 2 diabetes

Items Nutrition guideline

Calories For overweight and obese individuals, is recommended to achieve a
weight loss of 5–10% of initial body weight over a 6–month period.
This can be achieved by:
• A reduced calorie diets. Standard weight-loss diets reduce daily
energy by 500–1,000 kcal to achieve an initial weight loss of
0.5–1.0 kg per week.
• Physical activity of 150 minutes per week i.e., 30 minutes five
days or more per week.
• A combination of lowered calorie diet, physical activity and
modification of behaviour may be used providing greater initial
loss of weight.
• Meal substitutes (MRPs) can be used as part of a comprehensive
meal plan for weight reduction and maintenance of weight.
Table 2: Estimating energy requirements for type 2 diabetes adults.

Weight status Overweight Normal Underweight

weight
Sedentary 30 kcal/kg 35 kcal/kg
Moderate activity 20-25 kcal/kg 35 kcal/kg 40 kcal/kg
Marked activity 40 kcal/kg 45 kcal/kg
 • Weight for calculation: use current body weight for all except in
obese (BMI 27.5) & underweight (BMI < 18.5) calculate based
on acceptable weight i.e. BMI 22.

Carbohydrate 45-60% daily energy intake

• Carbohydrate intake must be kept consistent on a day-to-day
basis if patient is on diet therapy alone, oral anti-diabetic agents
(OADs) or fixed insulin regime.
• If patient is adjusting their meal-time insulin doses or on insulin
pump (i.e., flexible insulin) consistency is not required.
• Insulin doses should be adjusted to match carbohydrate intake.
Self-monitoring of blood glucose is essential to adjust
carbohydrate intake and insulin dose.
• A minimum of 130 g/day carbohydrate should be provided to
ensure adequate intake of fibre, vitamins, and minerals, as well
as to prevent ketosis and to provide dietary palatability.
• Substituting high glycemic index foods with lower glycemic
index foods at mealtime reduces postprandial blood glucose
Sugar Limit consumption of sugar-sweetened beverages (SSB) to less than 2
servings a day or about 10% of total daily caloric intake for prevention
of diabetes and weight gain.
Protein 15-20% daily energy intake (In patient with normal renal function)
• In patients with impaired renal function, protein restriction of
0.8–1.0 g/kg body weight/day may be recommended.
• It is recommended to include lean sources of protein such as lean
meat, fish, chicken/poultry without skin and soy protein
Fat 23—35% daily energy intake
• Patients with diabetes should limit total fat for prevention and
treatment of cardiovascular disease.
• A healthy diet incorporating oats, nuts and legumes, green leafy
vegetables and soy protein may be beneficial for cardiovascular
health.
Saturated fat Less than 7% of total calories
• Usually found in animal fats (skin of poultry, fatty meats, full
cream dairy products) and coconut milk.
Trans fat Less than 1% of total calories
Cholesterol Less than 200 mg/day
Dietary fiber 20-30 g/day (should be derived predominantly from foods rich in
complex carbohydrates; whole grains cereal, legumes, fruits, and
vegetables)
Vitamin & mineral Patients with diabetes have the same vitamin and mineral requirements
as the general population.
Sodium < 2,000 mg/day or 5 g/day or 1 teaspoon
• For normotensive and hypertensive patients must reduce sodium
intake and consume a diet high in fruits, vegetables, and low-fat
dairy products to lowers blood pressure.
• Stop foods with high levels of sodium (soy sauce, ketchup and
other sauces, pre-mixed paste, monosodium glutamate, salt and
preserved foods, and processed foods), minimizing eating out
frequency and restricting cooking salt to 1⁄4 to 1⁄2 teaspoonful
of salt per person per day.
Alcohol Adults with diabetes who drink alcohol should do so in moderation (no
more than one drink per day for adult women and no more than two
drinks per day for adult men).
• Risks of excessive alcohol intake include hypoglycaemia/ low
blood sugar (particularly for those using insulin or insulin
secretagogue therapies), weight gain, and hyperglycaemia (for
those consuming excessive amounts).
 Carbohydrate counting
Total carbohydrate (CHO) intake should be monitored in patients with Type 2 diabetes
mellitus. Total carbohydrate percentage of 45-60% of total energy is recommended. The
percent is depending on weight, glycemic and other metabolic goals, cultural preferences and
also individual lifestyle.

A patient with Type 2 diabetes mellitus is encouraged to eat wholegrains, fruits,

vegetables and also legumes. The patient also needs to minimise the intake of sugary foods and
beverages. The amount of carbohydrate eaten at a meal will affect the blood glucose.

Carbohydrate counting can help people with diabetes to plan their meals and snacks. It
can also be used for intensive management or for basic meal planning. 1 serving of food with
carbohydrate equals to 15 grams of carbohydrate. This means that a food containing 15 grams
of carbohydrate is called as “one carbohydrate serving”. Some examples are such as one slice
of bread, a small piece of fruit, a half cup of spaghetti or a half cup of mashed potato which
have around 15 grams of carbohydrate each.

Carbohydrate counting can be done by firstly identifies which foods have

carbohydrates. Next, on the packaged foods, the patient can find and refer the total
carbohydrates stated in grams on the Nutrition Facts food label, or learn to estimate the amount
of carbohydrate grams in the foods eaten. The patient can also refer the food list using an
application of carbohydrate counting to estimate the total carbohydrate grams in the foods and
drinks taken. Lastly, the patient can total up the amount of carbohydrates grams from each food
for the particular day. A minimum of 130 g/day of carbohydrate should be taken in order to
ensure adequate intake of fiber, vitamins and also minerals, as well as to prevent ketosis and to
provide dietary palatability.
 Illustration of nutrition care process for the patient

1. Assessment
- Anthropometry assessment
Weight: 76 kg
Height: 168 cm
𝑊𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)
BMI:𝐻𝑒𝑖𝑔ℎ𝑡 (𝑚)𝑥 𝐻𝑒𝑖𝑔ℎ𝑡 (𝑚)
76 𝑘𝑔
= 1.68𝑚 𝑥 1.68𝑚

= 26.93 kg/m²
He is considered as overweight.

- Biochemical assessment
a) HbA1c: 15.5%. Considered as high HbA1c
b) Blood pressure: 125/83 mm Hg. Elevated blood pressure
c) Plasma glucose, FBS 9.1 mmol/L. High, considered as having diabetic
- Clinical assessment
Polyuria: frequent urination
Polydipsia: increasing in thirst
Newly diagnosed with type-2-diabetes
- Dietary assessment
Eat excessive of carbohydrates
Taking T. Metformin 500mg for reduce high blood glucose level

2. Diagnosis
Domain: Intake
- Excessive carbohydrate intake related to lack of food planning as evidenced by
high refined sugar intake.
- Excessive sugar intake related to continuing intake of sugar for ever meal as
evidenced by the diet history
Domain: Clinical

- Impaired carbohydrate utilization related to type-2-diabetes mellitus as

evidenced by high HbA1c value and high fasting blood sugar (FBS) level.
- Excessive secretion of urine related to type-2-diabetes mellitus as evidenced by
symptoms of Polyuria.
 Domain: Behavioural

- Not ready for lifestyle change related to lack of value to behaviour change as
evidenced by high BMI reading
3. Intervention
- Disorder eating pattern: Eat breakfast that is balanced in nutrition since the diet
history showed that he consumes a lot of biscuit that usually contains high trans-
fat and carbohydrates.
- Excessive carbohydrate and sugar intake: Need to limit carbohydrates and
reduce consumption of sugar in drinks since he was diagnosed with type 2
diabetes. Substitute the sugar with sugar substitute such as stevia or sucralose.
- Smoking addicted: Avoid smoking daily and meet doctor for smoking addict
therapy.
- Excessive sodium intake: Reduce sodium intake on a daily basis since he has a
high blood pressure.
4. Monitoring and Evaluation
Outcome assessment Expected outcomes Goal targets
Anthropometry Lose 0.5kg to 1kg on average per Normal BMI, around range of
assessment
week following the daily meal 18.5 to 24.9 kg/m²
BMI is 26.93 kg/m²
Overweight plan and do physical activity

Biochemical assessment a) The reading of HbA1c need a) Normal level is below 6%

a) HbA1c: 15.5% to be monitored b) Normal reading

Considered as high HbA1c
b) Need to do regular check for Systolic: <130

maintaining reading of systolic Diastolic: <85

b) Blood pressure: 125/83
mm Hg and diastolic blood pressure c) Normal reading for FBS
Elevated blood pressure
c) Need to do regular check for below 5.5 mmol/L

maintaining the blood glucose

c) Plasma glucose, FBS 9.1
mmol/L level
High, considered as having
diabetic
Dietary assessment 24-hour dietary recall needs to Need to be monitored

Eat excessive of be taken for at least three days regularly

carbohydrates to adequately estimate energy

Taking T. Metformin 500mg intake from the suggested daily

for reduce high blood food plan.

glucose level

Bringing his 24-hour dietary

recall record to hospital/ clinic in

order to be reviewed by a

dietitian.
 Meal plan
STEP 1: Energy requirement

Weight: 76 kg BMI: 26.9

Height: 168 cm

EER: 76 kg x 22 kcal/kg = 1672 kcal

STEP 2: Identify protein requirement

15/100 x 1672 kcal = 250.8 kcal protein

251/ 4 g protein = 62.75 protein/day

STEP 3: Determine the % of energy distribution

Carbohydrate: 55%

Protein: 15%

Fat: 30%

Carbohydrate: 55/100 x 1672 kcal = 919.6 kcal

919.6/ 4 = 229.9 g carbohydrates/day

Fat: 30/100 x 1672 kcal = 501.6 kcal

501.6/9 = 55.73 g fat/day

 STEP 4: Food distribution table

ITEM EX KCAL CHO PRO FAT BF MS L AS D S

(G) (G) (G)

MILK 3 450 30 24 27 1 1 1

FRUIT 3 180 45 - - 1 1 1

CEREAL 10 750 150 20 5 4 2 2 1 1

VEGGIE 3 - - - - 2 1

MEAT/ 1 65 - 7 4 1
POULTRY

FISH/ 1 35 - 7 1 1
LEGUME

FAT 4 180 - - 20 1 1 2

TOTAL 25 1660 225 58 57 5 3 8 1 5 3

PERCENTAGE 54 14 31

Calculation for cereal= Total CHO – (milk + fruit)

= 229.9 g – (30 g + 45 g)
= 154.9 g
1 ex CHO = 15 g CHO
? ex CHO = 154.9 g CHO
= 10 ex CHO

Calculation for fat = Total fat – (milk + cereal + meat/poultry + fish/legume)

= 55.73 g – (27 + 5 + 4 + 1)
= 18.73 g
1 serving = 5 g fat
? serving = 18.73 g fat
= 4 serving fat
Percentage:
CHO: 225/1660 x 100 Protein: 58/1660 x 100 Fat: 57/1660 x 100
= 13.55 = 3.49 = 3.43
13.55 x 4 = 54.2% 3.49 x 4 = 13.96% 3.43 x 9 = 30.87%

Meals Menu
Breakfast 2 pieces of thosai, 1/8th of avocado, 1/3 cup of full cream milk.
Morning Tea 2 pieces of putu mayam, 1/3 cup of full cream milk.
Lunch 1 whole of apple, 2 cups of rice porridge, 1 cup of cooked spinach, 1
piece of chicken drumstick, plain water.
Afternoon Snack 1 small plain roll, 1 tsp butter, plain water.
Dinner ½ whole guava, 1 cup of fresh salad, 2 tbsp of salad dressing, 2
pieces of tempe, plain water.
Supper 1 whole of chiku, 1 piece of idli, 1/3 cup of full cream milk.

Healthy eating and cooking tips

With type 2 diabetes, it is important to encourage wholegrains, fruits, vegetables, and
legumes as well as minimizing the intake of sugary foods and beverages. People with type 2
diabetes must be extra aware of the carbohydrate content of their meals so their blood sugar
levels do not rise, or if they are using injectable insulin, so they can dose insulin appropriately.
Foods to eat for a type 2 diabetic diet meal plan include complex carbohydrates such as brown
rice, whole wheat, quinoa, oatmeal, fruits, vegetables, beans, and lentils. Foods with a low
glycemic load (index) only cause a modest rise in blood sugar and are better choices for people
with diabetes. Good glycemic control can help in preventing long-term complications of type
2 diabetes. Complex carbohydrates (low glycemic load foods, or foods that are a part of a type
2 diabetes low-carb diet plan) are in their whole food form and include additional nutrients
such as fiber, vitamins, smaller amounts of proteins and fats. These additional nutrients slow
down the absorption of the glucose and keep blood sugar levels more stable. Whole grains,
such as brown rice, quinoa, and oatmeal are good sources of fiber and nutrients and have a low
glycemic load making them good food choices for type 2 diabetes patients. Whole grains also
have less of an impact on blood sugar because of the lower glycemic load. On the other hand,
some good protein choices include beans, legumes, eggs, fish and seafood, organic dairy
products, peas, tofu and soy foods as well as lean meats such as chicken and turkey (Oberg,
2019).

Meanwhile, the foods to avoid for type 2 diabetes patients are simple carbohydrates,
which are processed, such as sugar, pasta, white bread, flour, and cookies, pastries. Dietary
restrictions are including:

• Sodas: both sugar sweetened regular soda and diet soda raise blood sugar
• Refined sugars (donuts, pastries, cakes, cookies, scones, sweets, candy)
• Processed carbs (white bread, pasta, chips, saltines)
• Trans fats (anything with the word hydrogenated on the label) such as butter "spreads,"
some mayonnaise "spreads" some salad dressings, packaged sauces, bakery goods
• High-fat animal products (red meat, fatty cuts of pork, bacon, sausage)
• High-fat dairy products (whole milk, cream, cheese, ice cream)
• High fructose corn syrup (in soda, candy, packaged convenience food)
• Artificial sweeteners (in processed foods labeled "diet")
• Highly processed foods – novelty sweets, candies, chips, kettle corn, cookies)
(Oberg, 2019).

For the cooking techniques, make sure to bake or broil instead of frying to reduce fat.
Next, use extra-virgin olive oil instead of vegetable oil, because olive oil confers more heart
benefits. This is because people with diabetes are at a higher risk for heart disease than the
general population. Besides, it is crucial to completely avoid trans fats (found in some
processed foods and foods cooked in oil and limiting saturated fats (found in meats and whole
milk) to less than 20 g per day. Furthermore, it is important to limit sodium to 2,000 to 2,400
g per day, unless the patient is on a sodium-restricted diet. Type 2 diabetes patient also may
choose fresh or frozen foods, or canned foods with no salt (Salomon et al., 2020).

Patients with type 2 diabetes are prohibited to consume sugar, therefore there are some
of the best sugar substitutes such as sucralose, saccharin, aspartame and stevia. Saccharin is
excellent for people with type 2 diabetes because Splenda is 600 times sweeter than sugar, yet
those little yellow packets have no effect on blood sugar. The Food and Drug Administration
(FDA), which has approved sucralose, recommends an acceptable daily intake (ADI) of 5
milligrams (mg) or less of sucralose per kilogram (kg) of body weight per day. A 60kg
individual would need to consume 23 tabletop packets of the artificial sweetener per day to
reach that limit. Next, saccharin, the sweetener sold in pink packets under the brand name
Sweet 'N Low, is calorie-free and is about 300 to 500 times sweeter than sugar. A 60kg
individual would need to consume 45 tabletop packets of the artificial sweetener per day to
reach the ADI of 15 mg of saccharin per kg of body weight per day, according to the FDA.

Meanwhile, aspartame, which is sold in blue packets under the brand names Equal and
NutraSweet, is a non-nutritive artificial sweetener that is 200 times sweeter than sugar,
according to the FDA. Despite not being zero-calorie like some other artificial sweeteners,
aspartame is still very low in calories. A 60kg individual would need to consume a whopping
75 tabletop packets of the artificial sweetener per day to reach the ADI of 50 mg of aspartame
per kg of body weight per day. However, people with phenylketonuria (PKU), a rare condition
in which they are unable to metabolize phenylalanine (a key component of aspartame), should
not consume this sugar substitute. If the patient does not have PKU, aspartame is safe to
consume. Furthermore, steviol glycosides are sweeteners derived from the leaf of the stevia
plant, which is native to Central and South America. Truvia and Pure Via, both brands of stevia-
based sweetener, are calorie-free, and stevia is often used as a sweetener in foods and
beverages. Non-nutritive sweeteners, including stevia, have little to no impact on blood sugar.
The FDA has approved the use of certain stevia extracts, which it has generally recognized as
safe. The FDA also recommends an ADI of 4 mg or less of Truvia per kilogram of body weight
per day. An individual who weighs 60kg would need to consume nine tabletop packets of the
artificial sweetener per day to reach that limit (Salomon et al., 2019).
 References

A Beginner’s Guide to Carbohydrate Counting Prior to joining BD, Pia educated people with
diabetes about medical nutrition therapy in a private physicians office, an outpatient
clinic at a hospital and a nursing home where she counseled patients one-on-one and in
group classes. (n.d.). https://www.bd.com/resource.aspx?IDX=9850

CDC. (2019, September 19). Diabetes and Carbs. Centers for Disease Control and Prevention.
https://www.cdc.gov/diabetes/managing/eat-well/diabetes-and-
carbohydrates.html#:~:text=Carbs%20are%20measured%20in%20grams

Gray, A., & Threlkeld, R. J. (2019). Nutritional recommendations for individuals with diabetes.
In Endotext [Internet]. MDText. com, Inc..

Malaysian Endocrine & Metabolic Society et al, (2015, December). Clinical Practice
Guideline: Management of Type 2 Diabetes Mellitus (5th Edition)

Oberg, E. (2019, July 16). Type 2 Diabetes Diet Guidelines: Foods to Eat, Foods to Avoid.
Retrieved January 08, 2021, from
https://www.medicinenet.com/diabetic_diet_for_type_2_diabetes/article.htm#what_is_j
ardiance_empagliflozin

Salomon, S., Bedosky, L., Rapaport, L., Mayer, M., Upham, B., & Fetters, K. (2020, April 24).
7 Healthy Meal Tips for Type 2 Diabetes: Everyday Health. Retrieved January 08, 2021,
from https://www.everydayhealth.com/type-2-diabetes/diet/healthy-meals-for-type-2-
diabetes/

Salomon, S., Bedosky, L., Rapaport, L., Mayer, M., Upham, B., Fetters, K., & Salomon, S.
(2019, August 21). 9 Sugar Substitutes for Type 2 Diabetes: Everyday Health. Retrieved
January 08, 2021, from https://www.everydayhealth.com/type-2-diabetes/diet/sugar-
substitutes-for-diabetes/
 G10

UNIVERSITI MALAYSIA TERENGGANU

ASSIGNMENT
STM 4201: FOOD THERAPY
(CASE STUDY 2)

GROUP MEMBERS:

No. Matrix No. Name

1 S 47651 MUHAMMAD AFIQ AKASYAH BIN ISMAIL
2 S 47576 NURUL FAQIHAH BINTI MOHD PUZI
3 S 47577 FARAH NURDINI BINTI MOHAMMAD NAZREE
4 S 47579 NURAISYAH NABILA BINTI AMARI
5 S 47600 NUR HIDAYAH BINTI MOHD AZAM
6 S 47649 NUR IZZATI BINTI AMRAN

LECTURER’S NAME: DR. NOOR SALIHAH BINTI ZAKARIA

DATE OF SUBMISSION: 11 JANUARY 2021 (MONDAY)

Sem. I 2020/2021
Bachelor of Food Science (Food Service and Nutrition)
School of Food Science and Technology
QUESTION 1: MNT FOR WEIGHT MANAGEMENT

Siti’s current weight is 85.5 kilograms and her current height is 1.62 meters. From the
calculation of body mass index (BMI) by using the formula of (mass / height2), it can be
concluded that Siti BMI is 32.63 kg/m2. It can be considered as dangerous as her BMI is quite
high which can be recognized as obesity. The normal range for adult women is between 18.5
to 24.9 kg/m2. Even though currently she has no known medical illnesses, it is compulsory for
her to do an MNT to prevent unnecessary weight gain that can lead to cardiovascular diseases.

These are the recommend Medical Nutrition Therapy (MNT) of weight management for Siti:

1. Monitor daily calories intake. Since Siti’s BMI is 32.63 kg/m2 and in the dangerous level
which can be simplified as obesity, she needs to get a normal body weight by maintain the
weight within healthy BMI range 18.5-24.9 kg/m2. She needs to have a calorie deficit every
day. Based on quick method, for an average adult woman with moderately active lifestyle, the
recommended daily calorie intake is 1710 kcal (85.5 kg x 20 kcal/kg). She needs to maintain
calorie intake below the said level to have a calorie deficit and eventually lose weight by around
500-1000 kcal deficit. Check the daily energy requirement by referring to sample menu
depending on our calorie daily intake to ensure how much energy that we need in order to lose
weight. The best weight loss guidance is the loss of 5-10% of initial body weight by the period
of 6 month. Having meal replacement is the best thing to do to reduce calorie intake. Avoid or
reduce intake of condensed milk and replace it with evaporated milk because evaporated milk
has lower calories. Avoid instant drinks like Milo because it contains high amount of sugar that
can lead to spike in calorie intake. Convert the cooking method of fried fish or chicken into
steam fish or chicken to reduce calorie intake. Banana or tapioca chips should be limited to
only once or twice a week.

2. Avoid unnecessary food products or nutrients & increase highly nutritious foods
intake. Based on dietary history of Siti, she often eats on sodium food and frequently used
flavoring agents and sauces. She needs to reduce the intake of canned or processed foods to
only once a week and she can replace flavoring agents with natural flavour enhancer like
mushroom or tomato because they contain high amount of umami. She needs to avoid from
taking too much sodium foods and oily food. Choose a healthy and balance eating plan that
includes a variety of food based on Malaysia Food Pyramid. Eat more fruits, vegetables and
whole grains. Do not cut carbohydrates and fats which our body need the nutrients found in
fats and carbohydrates. She can also replace Teh and condensed milk with plain water to
significantly reduce calorie intake. She can replace banana chips with homemade dried fruits
to avoid excess sodium intake.

3. Have a physically active lifestyle. It is recommended for Siti to do moderate exercise for a
total of 30 minutes a day on most days (4-5 times a week) or a total of 150 minutes in a week.
A physically active lifestyle offers many rewards such as a healthy heart, strong bones and
stress relief. Plus, with active lifestyle can enhance the activity of burning calorie and can lead
to significant weight loss in much shorter time. It can also reduce the risk of having
cardiovascular disease in a long run.

4. Do a thorough and periodic consultations with experts. Consult a doctor, nutritionists or

dieticians to identify and correct any underlying medical, biological or physiological problems
contributing to excess weight and how to achieve healthy weight loss.
QUESTION 2: NUTRIENTS THAT WOULD PARTICULARLY BE
DISCUSSED WITH THIS PATIENT.

1. Carbohydrate - The daily recommended intake of carbohydrate is from 45-60% of total

calories. For example, on a 1600-calorie diet, that comes to around 720 to 960 kcal or 180
grams to 240 grams per day or 60 grams to 80 grams per meal. People with diabetes should
aim to get about half of their calories from natural and healthy carbohydrates like sweet
potatoes, oats, quinoa and many more. She needs to consume foods that containing complex
carbohydrate with various proportions of sugars, starches like whole grains, and fibre, like
vegetables, berries, nuts, and seeds because it has a wide range of effects on the glycemic
response and reduce simple carbohydrates. Target for a low GI foods or carbohydrates because
low GI foods does not cause sugar spikes in blood. Aim for healthy carbohydrates that can give
longer satiety compared to processed or refined carbs. Low carbohydrate diet intake between
20–90 grams per day has been shown to be effective at improving blood sugar management in
people with diabetes. Avoid refined carbohydrates such as processed foods, fast foods and
snacks because it can contribute to high calorie intake and subsequently worsens obesity and
increase risk of cardiovascular disease. Avoid any carbonated drinks and replace Teh with
plain water. Reduce the amount of sugar in cooking.

2. Fibre - She must take high fibre food that can encourage for the prevention of diabetes and
hypertension. Based on the recommendations by the Malaysia Dietary Guidelines (MDG), a
high fibre diet particularly soluble fibre is 20–30 g fibre per day that consisting of vegetables,
fruits, legumes and whole grain cereals is encouraged. This is because increasing the amount
of fibre in your diet can help you manage the risk to diabetes by slow the absorption of sugar
and fat from food, reducing blood cholesterol and improve your body's response to insulin.
Therefore, it also can help reduce and prevent high blood pressure. Moreover, increasing
your dietary fibre can also help with managing your weight. These foods are filling and
most are lower in glycemic index (GI), which can help to control your appetite and have
less of an effect on blood glucose levels.

3. Fats – Daily fat intake of an average adult woman are in the range of 20 – 35% from
total calorie intake which is around 320 kcal and 560 kcal. In order to fulfill that
requirement, Siti must consume healthy fats such as polyunsaturated fatty acids and
monounsaturated fatty acids that can significantly increase the amount of HDL level to reduce
cholesterol accumulation in her body. Fats from fish oil, olive oil, nuts, whole eggs, avocado
and et cetera must be increased. Saturated fatty acids and trans fats (natural or hydrogenated)
from fast foods, snacks and unhealthy cooking method needs to be reduced. Avoid saturated
fatty acid as much as possible because high saturated fatty acid intake will cause increase in
low-density lipoprotein in body resulting in cholesterol accumulation that can lead to formation
of plaque in a long run. Percentage of carbohydrates can be reduced and replace with healthy
fats that can cause longer satiety.

3. Protein – Daily protein intake of an average adult woman can be in the range of 12%
to 20% from total calorie intake which is around 192 kcal and 320 kcal. Eating the right
amount of it from a nutritious and healthy source of protein can increase satiety and
make Siti feel full longer. Healthy source of protein can come from white or lean meats
like chicken, seafoods like fish, beans, soy, low-fat dairy milk, eggs and many more.
High nutritious and healthy protein intake will boost thermic effects and metabolism
making Siti’s body burns calories quicker.

4. Minerals (sodium, iron, magnesium & monosodium glutamate): For sodium, Siti needed
to avoid sodium as much as she can by reducing the frequency of eating canned or processed
foods because processed and canned food contain high amount of sodium. Limit the sodium
intake to only 1000 mg only per day to improve blood pressure & avoid cardiovascular disease.
For iron, increase its intake because iron helps carry oxygen throughout the body & this will
aid in the body to burn fats effectively. The recommended iron intake for an average adult
woman like Siti is around 14.8 mg. For magnesium, a study has been conducted that high
amount of magnesium intake have a significant impact in controlling blood sugar and insulin
level in people who are diagnosed with obesity. For monosodium glutamate (MSG), Siti can
opt for a natural product that can offer the same thing such as tomato and mushroom to enhance
the flavour of the food.

5. Vitamins (vitamin D & others) – Vitamin D are said to have a significant effect in aiding
for weight loss and can enhance the effects of a reduced-calorie diet. Intake of 10-20 mcg is
sufficient.
6. Water – In order to keep a healthy lifestyle and to lose weight, water plays a crucial role in
reducing calorie intake because it acts as a replacer to teh and so on. It has zero calories and
average should have 3 liter of water daily for efficient body functions.

QUESTION 3: NUTRITION CARE FOR THIS PATIENT.

To answer this question, our group will be referring to the Nutrition Care Process steps which
are also known as nutrition screening and ADA-ADIME. ADA-ADIME is acknowledged,
approved and utilized on international scale. ADA-ADIME stands for American Dietary
Association, where ADIME stands for Assessment, Diagnosis, Intervention, Monitoring and
Evaluation.

NUTRITION SCREENING

From the screening process, it can be seen that Siti is had no known medical illness. But her
father and mother have history illness such Type II diabetes mellitus and hypertension. Her
blood pressure is 154/90 mm Hg. Siti’s diet was also irregular and needed some modification
through awareness or education according to her history diet. She also had tried weight loss
program which make her strict diet and never exercised in previous weight loss attempts. She
also complained that having limited healthy food choices at school canteen.

1. NUTRITION ASSESSMENT (ABCD)

A. ANTHROPOMETRY

Siti current weight is 85.5 kilograms and her current height is 162 cm. From calculation of
body mass index (BMI) which uses the formula of (mass / height 2), it can be concluded that
her BMI is 32.58 kg/m 2. It can be considered as dangerous as her BMI is quite high and far
from healthy BMI which is in the range of 18.5 to 24.9 kg/m 2.
B. BIOCHEMICAL

From the laboratory tab results, it can be seen that her blood glucose level is high and her blood
is saturated with sugar. The glucose test for Random Blood Sugar test (RBS) is 8.3 mmol/L
which is less than 11.1 mmol/L. then, her Fasting Blood Sugar test (FBS) is 5.9 mmol/L. a
fasting blood sugar less than 5.6 mmol/L is normal. A fasting blood sugar level from 5.6 to 6.9
mmol/L is considered prediabetes, and if it’s 7 mmol/L or higher will considered diabetes.
Thus, Siti is considered diabetes. The HbA1c test is a test that measures blood sugar over the
last three months by looking at the percentage of hemoglobin saturated with sugar. Her HbA1c
test shows that 6.5% of the hemoglobin in her blood which is diagnosed as diabetes Type II
mellitus. Besides, her blood pressure test shows that 154/90 mm Hg which is considered high.
Normal pressure is 120/80 mm Hg or lower.

C. CLINICAL

From her medical history, it shows that her father and mother have Type II Diabetes mellitus
and hypertension already. She also had attended the weight loss programs at age 35 which is
her lowest weight was 76 kilograms. There is no further data about her skin, hair, eyes or any
fluid retention that can be seen physically.

D. DIETARY

It can be seen that her calorie intake quite lower according to her previous strict diet history.
Siti also complain that she having limited healthy food choices at school canteen. According
to her diet history, she takes foods that high in sodium occasionally such canned or processed
food that contain flavouring agents (Ajinomoto), and just take fruits only when available.
2. NUTRITION DIAGNOSIS

• Her A1c test shows that she is high blood glucose (6.5%).

• Siti’s primary complain which is having limited healthy food at school canteen.

• Abnormal Body Mass Index (BMI) related to limited healthy food choice at school
canteen as evidence by diet history and no exercise

• High blood sugar level related to consumption of food that is high in carbohydrate and
sugar as evidence by diet history

• Knowledge deficit related to no previous nutrition education as evidence by diet history

• Hypertension related to high intake of sodium and processed food as evidence by diet
history

3. NUTRITION INTERVENTION

• Abnormal Body Mass Index (BMI): Patient will add the physical activity in lifestyle.
Patient will try healthy diet not the strict diet.
• High blood glucose: Patient will change the dietary strategies by reducing the calorie
intake and reducing dietary fat intake with the addition of physical activity. Patient will
implement survival skills low sugar diet principles.
• Hypertension: Patient will avoid the processed food and food that high in sodium.
Patient will attend hypertension diet program to educate more about the choices of food.

4. NUTRITION MONITORING & EVALUATON

Outcome assessment Expected outcomes Ideal/Goal Targets

Anthropometric measures Reasonable weight achieved Normal BMI which is in the

Abnormal Body Mass Index and maintained. range of 18.5 to 24.9 kg/m 2

(BMI) which is obese (32.58

kg/m2)
Biochemical data (3-6 months, if not achieved,

Glucose level intensify MNT and evaluate

again in 8 weeks)

\
-Random Blood Sugar test
Normal RBS (4.4-7.8
(RBS) is 8.3 mmol/L
mmol/L
- Fasting Blood Sugar test -Show decrease in RBS, FBS

(FBS) is 5.9 mmol/L and HbA1c test

Normal FBS <5.6 mmol/L

- HbA1c test is 6.5%

Normal HbA1c (4-5.6 %)

Blood pressure test

154/90 mm Hg -Show decrease and stable Normal Blood pressure is

blood pressure 120/80 mm Hg or lower

Clinical outcome

Family history for Type II -Blood sugar level and blood -Normal blood sugar level:
Diabetes mellitus and pressure monitoring and <7.8 mmol/L
Hypertension control

-Decrease/ achieve normal

- Normal Blood pressure is
blood sugar level and blood
120/80 mm Hg or lower
pressure

Therapeutic Lifestyle
Changes

Food selection and meal -Apply the healthy eating -Regular meals with
planning diet and able to follow appropriate food choice,
nutrient/ diet guidelines. follow dash diet plan and
Selection of good and takes medication as
nutritious food (less sugar prescribed.
and low sodium).
Physical activity -Increase the physical If no medical limitation,
activity gradually according continue the active physical
to recommendation. (e.g., activity.
brisk walk od 1-2 miles in
30 min or at least 5 times a
week).

Self-monitoring blood -Less intake of sugary foods Need to be monitored

sugar level and blood and drinks. regularly

-Less intake of processed
pressure
food and high sodium food.
- Record: food intake, blood
glucose level and blood
pressure

Stress management Able to cope with stress and Appropriate self-

apply relaxation techniques management of stress. If
effectively to reduce and necessary, get professional
control stress helps for the stress
management.
QUESTION 4

Include a meal plan, healthy eating and cooking tips for your nutritional intervention.

1. Calculate energy requirement.

Siti, 42 years old

Weight: 85.5 kg
Height: 162 cm

STEP 1:
Using Quick Method
85.5 kg × 23 = 1967 kcal

STEP 2:
Identify her protein requirement.

52 g/day × 4 = 208
208 ÷ 1967 kcal x 100% = 11%
Carbohydrate = 61%
Protein = 11%
Fat = 28%
 STEP 3: Calculate the requirements for all macronutrients.
CARBOHYDRATE PROTEIN FAT

61 × 1967 11 × 1967 28 × 1967

100
= 1199.87 100
= 216.37 100
= 550.76

1199.87 216.37 550.76

4
= 300 g 4
= 54 g 9
= 61 g

STEP 4: Plan a suitable food distribution table.

300 g 54 g 61 g
ITEM EXCHANGE KCAL CHO (g) PROTEIN (g) FAT (g)
MILK 2 125 × 2 = 250 12 × 2 = 24 8 × 2 = 16 5 × 2 = 10

FRUIT 6 60 × 6 = 360 15 × 6 = 90 - -

CEREAL 6 150 × 6 = 900 30 × 6 = 180 4 × 6 = 24 1×6=6

VEGETABLES 3 - - - -

MEAT 1 65 × 1 = 65 - 7×1=7 4×1=4

FISH 1 35 × 1 = 35 - 7×1=7 1×1=1

FAT 8 45 × 8 = 360 - - 5 × 8 = 40

TOTAL 27 1970 294 54 61

 ITEM BREAKFAST MORNING LUNCH AFTERNOON DINNER SUPPER
SNACK SNACK
MILK / /

FRUITS / / // / /
CEREALS / / // / /

VEGETABLES / / /

MEAT/ /
POULTRY
FISH /

FATS // / // / / /

(Note: / = 1 serving)

STEP 5: Plan a suitable meal planning.

MEALS MENU

BREAKFAST ⚫ 1 glass of low-fat milk

⚫ 2 slice whole-meal bread + 2 teaspoons of butter
⚫ 1 glass of plain water

MORNING ⚫ 8 small grapes

SNACK ⚫ 6 pieces biscuits
⚫ 1 teaspoon of fish oil
⚫ 1 glass of plain water

LUNCH ⚫ 1 slice of papaya & 1 whole banana

⚫ 1 cup of cooked white rice & 1 cup of sweet potato
⚫ 1⁄2 of cooked vegetables + 1 teaspoon of salad dressings
⚫ 1 serving of fried fish
⚫ 1 glass of plain water

AFTERNOON ⚫ 1 glass of low-fat milk

SNACK ⚫ ½ of guava fruit
 ⚫ 2 pieces of ‘putu mayam’
⚫ 1 teaspoon of olive oil
⚫ 1 glass of plain water

DINNER ⚫ 1 whole banana

⚫ 1 cup of brown rice
⚫ 1⁄2 cup of steamed vegetables (brocolli and carrot)
⚫ 1 piece of fried chicken
⚫ 1 glass of plain water

SUPPER ⚫ 1⁄2 cup salad with salad dressings

⚫ 1 glass of plain water

Based on the nutritional screening, it can be seen that Siti used to practice strict diet to
reduce her weight. Strict diet can lead to deficiency of crucial nutrients that her body needs
which is not good for overall health. Siti is recommended to do healthy diet or control the
calorie intake from the food that she consumed. Siti is recommended to drink a lot of plain
water and reduce the intake of sugary food and beverages in order to reduce her blood glucose
level. With the right amount of plain water, can also reduce her hunger significantly. Next, Siti
is also said to have a high blood pressure that can lead to hypertension. Siti is advised to avoid
processed or canned food that contain high amount of sodium content that can increase blood
pressure, Siti also should avoid the usage of artificial monosodium glutamate (MSG) as her
flavouring and she can opt for a substitute of salt with some spices or herbs and substitute
artificial MSG with natural MSG such as mushrooms or tomatoes as food seasonings. Siti can
also start to use different kind of cooking method by prioritizing cooking method such as roast,
steam or grill instead of frying. This is because such cooking methods can reduce the utilization
of cooking oil and the amount of oil absorbed into foods are significantly reduced. She can
make up her fat requirements by eating fish oil, olive oil and other healthy choices of oil.
 REFERENCES

Franziska Spritsler, RD, CDE (2020, Nutrition: A Guide To Healthy Low Carb With Diabetes.
Retrieved from https://www.healthline.com/nutrition/low-carb-diet-for-diabetes
Debra Manzella, RN (2020), Managing Diabetes:Ideal Daily Carbohydrate. Retrieved from
https://www.verywellhealth.com/how-many-carbs-a-day-are-right-for-me-1087029
Varsha Vats (2019), Manage Your High Blood Pressure With Fibre Rich Foods: Know Best
Food Sources Of Fibre. Retrieved from https://www.ndtv.com/health/manage-your-high-blood-
pressure-with-fibre-rich-foods-best-food-sources-of-fibre-2068401
Clinical Practice Guidelines: Management of Type 2 Diabetes Mellitus (5 th Ed) 2015. Topic
Four: Medical Nutrition Therapy & Low Glycaemix Index Diet. Access from
http://jknj.jknj.moh.gov.my/ncd/diabetes/4%20-Medical%20Nutrition%20Therapy.pdf
NIDDK (2016), Diabetes Diet, Eating & Physical Activity. Retrieved from
https://www.niddk.nih.gov/health-information/diabetes/overview/diet-eating-physical-
activity#:~:text=Instead%2C%20eat%20carbohydrates%20from%20fruit,of%20your%20diabetes%20meal
%20plan.

Gray A, Threlkeld RJ (2019), Nutritional Recommendations for Individuals with Diabetes.

Available from: https://www.ncbi.nlm.nih.gov/books/NBK279012
Pletcher, P. (2017, October 12). Magnesium for Weight Loss: Does It Help? Healthline.
https://www.healthline.com/health/food-nutrition/magnesium-for-weight-loss
Subject Code : STM 4201

Subject Title : PEMAKANAN TERAPI

Topic : CASE STUDY

Group : 3

Academic Session : SEMESTER 1 – 2020/2021

Date : 11 JANUARY 2021

No NAME MATRIC NO

1.
ANIS AMIRAH BINTI ABD NASIR S46319

2.
ABDUL AZIZ BIN ROSLI S46330

3.
NIK NURAISHA AFINA BINTI MOHD NIZAR S46373

4. HANIE HAZEERAH BINTI HILALUDDIN

S46391

5.
TENGKU NUR AQIRAH BINTI T AZMAN S46393

6.
NURNAZIRA BINTI MANZUL S46411
1. Dietary factors could optimize a patient's lipid profile

1) Fat and Cholesterol

● Saturated fat is a fat that can elevate our blood cholesterol. This fat is usually can
be found in greatest amounts in foods from animals such as fatty cuts of meat,
poultry with the skin, whole-milk dairy products, lard, vegetable oils that include
coconut and palm oils (U.S Department of Health and Human Services, 2005)
● High intake of saturated fat in the diet can lead to higher LDL cholesterol level.
Therefore, it is important to make sure that the intake of saturated fats is less than
7% of our calories per day (U.S Department of Health and Human Services, 2005)
● Thus, it is suggested to reduce the intake of saturated fats in the diet. Reducing the
intake of the dishes that contain santan or coconut milk which is one of the major
contributors to saturated fat intake also can help optimizing the lipid profile (Portal
MyHealth, 2011).
● According to Malaysian Dietary Guidelines (Key Message 8), the intake of
saturated fats can be reduced by limit the use of oils and fats (coconut oil, coconut
milk, palm kernel oil, animal fat), trim the fat and skin from meat and poultry, and
use low fat or skimmed dairy products.
● Other than that, trans fat that is also called trans fatty acids are also one of the fats
that can raise our blood cholesterol level. Trans fat can be found in a food made
with hydrogenated vegetables oils, such as margarines and shortenings.
● The main sources of trans fat are stick margarine, baked products (crackers,
cookies, doughnuts, breads), and fried food.
● Thus, it is suggested to avoid the main sources of trans fat food as stated above, and
butter or stick margarine also can be replaced with better options such as reduced-
fat, whipped, or liquid spreads.
● According to Malaysian Dietary Guidelines (Key Message 8), trans fat can be
reduced by limiting intake of margarines and shortenings made from hydrogenated
or hardened fats, and look for words such “partially hydrogenated fats or oils” on
the food label of processed food.
● As for cholesterol, the sources of cholesterol can be found in foods that are rich in
saturated fats, so limiting intake of saturated fat food will also help reduce intake
of cholesterol.
● According to Malaysian Dietary Guidelines (Key Message 8), to limit the intake of
food high in cholesterol can be achieved by limiting the organ meats (heart, kidney,
liver), and consumed eggs in moderate amounts to 3 eggs per week for people with
hypercholesterolemia.
2) Omega-3 Fats

● Omega-3 fatty acid is marine-based fatty acids that are highly potent in reducing
blood triglycerides by 25% in normal individuals and the beneficial effect is
enhanced to 34% in hypertriglyceridemic individuals (Malaysia Dietary
Guidelines, Key Message 8)
● Omega-3 fats can be found in fish and some plant sources such as walnuts, canola,
soybeans oils and flaxseed (U.S Department of Health and Human Services, 2005).
● Since omega-3 fats can help in reducing the risk of heart disease, a regular
consumption of natural sources such as fish is advisable at this point. The intake of
omega-3 fats can include a minimum 2 servings of fish per week (Malaysia Dietary
Guidelines, Key Message 8).
● Fish that are rich in omega-3 fats are mackerel, fresh sardines, tuna, and salmon.

3) Sugar Intake

● According to the Malaysian Dietary Guidelines (Key Message 10), the intake of
sugar such as sucrose is associated with an increase in HDL cholesterol level, and
plasma triglycerides concentrations.
● Minimize intake of food and beverages that contains added sugars (fruit juices,
soda, sweets, jam, condensed milk and sweetened kuih)

4) Dietary Fiber

● Fiber is known to be essential for our health. Fiber is divided into two types which
are soluble and insoluble fibers. Both have health benefits, but only soluble fiber
plays a significant role in lowering blood cholesterol (U.S Department of Health
and Human Services, 2005).
● It is recommended to take at least 5 to 10 grams of soluble fibres per day, and
preferably to take 10 to 25 grams of dietary fibers a day. In addition, increase in
soluble fiber is accompanied by an approximately 5% reduction of LDL cholesterol
(U.S Department of Health and Human Services, 2005).
● It is recommended to take a soluble fiber containing food such as wholegrain
(breads, cereals, oats, barley), fruits (guava, pears, orange), vegetables (carrots,
broccoli) and beans (lentils, legumes, chickpeas), and brown rice.

5) Alcohol

● Consumption of alcohol can increase the HDL cholesterol concentrations even if it

is just a light-to-moderates level of alcohol intake. However, triglycerides
concentration can increase fast if there is heavy alcohol consumption ( more than
60 grams per day) (U.S Department of Health and Human Services, 2005).
 ● Thus, to optimize lipid profile, the consumption of alcohol in the daily diet should
be reduced.
● Recommendation intake of alcohol is less than 2 units per day ( A unit = 5 ounces
of wine)

2. Nutrition care process

1. Assessment

Anthropometric measurement

· Weight – 66.4 kg

· Height – 158 cm

· BMI – 26.6 kg/m2 is 26.6 that indicate overweight

Biochemical

Plasma glucose level:

· Higher than normal FBS level (5.7 mmol/L) – prediabetes

Serum lipids profile:

· Normal TG level (normal 1.69 mmol/L)

· High TC level (normal 3.225 – 5.16 mmol/L)

· Normal HDL level (healthy 1.2 mmol/L or higher)

· High LDL level (healthy < 2.58 mmol/L)

Clinical

· Diagnosed with hypercholesterolemia

· Has family history of hypertension, Type 2 diabetes mellitus and strokes

· Blood pressure 110/70 mm Hg – normal

Diet history

· Irregular meal

· Frequent alcohol consumption (3-4 times a week)

2. Diagnosis

· Has prediabetic conditions related to frequent alcohol consuming which can affect the
sensitivity of insulin as evidenced by high fasting blood sugar (FBS).

· Diagnosed with hypercholesterolemia related to family history with hypertension, Type 2

diabetes mellitus and stroke as evidenced by high total cholesterol level and LDL level.

3. Intervention

· Meal plan

o Energy requirement: 1660 kcal/day

o Reduce intake of saturated fats and trans fats

§ Limit saturated fats to less than 7 percent of calories; eliminate trans

fats

o Increase intake of poly-and monounsaturated fats

§ Replace saturated fats and trans fats with poly- and monounsaturated
fats

o Consume Omega-3 Fatty Acids

§ Two servings per week of tuna or salmon

 o Increase intake of soluble fiber 5 – 10 g/day (or more)

o Low intake of carbohydrate

§ 3 – 4 servings at 15 g per serving

· Exercise regularly at least 120 minutes per week

· Get the recommended amount of sleep each night (7- 9 hours)

· Reduce consumption of alcohol to 1 drink/day for women

4. Monitoring and Evaluation

· Evaluate weight, blood pressure, diet history, energy intake, fat intake, carbohydrate
intake

· Re-check serum lipid profile and plasma glucose level in 3 months

3. Meal plan

a. Energy requirement:

May, 40 years old, yoga 2x/week, 66.4 kg, 158 cm

BMI= 66.4 kg/1.58 2 m2

= 26.6 (Overweight)

Quick method: 66.4 kg x 25 = 1660 kcal/kg

So, energy requirement for May is 1660 kcal/day

b. Protein requirement:

Protein RNI = 10 - 20 % TEI

(15/100) x 1660 = 249 kcal protein

249kcal/4 g protein = 62.25 g/day

So, the protein requirement for May is 62.25 g/day

c. % Energy distribution:

I. % Protein

Protein RNI for woman 30 to 59 years old = 52 g/day = 10 - 20 % TEI

1 g protein = 4 kcal = 52 x 4 = 208

(208/1660) x 100 = 13 %

II. % Fat

Fat RNI for woman 30 to 59 years old = 53 – 63 g/day = 20 – 30 % TEI

1 g fat = 9 kcal = 53 x 9 = 477

(477/1660) x 100 = 29 %

III. % CHO

CHO RNI = 50 – 65 % TEI

 % CHO = 100 % - 13% - 29%

= 58 %

d. Food distribution table

Table 3.1 Food distribution based on MDG and food exchange table

Ex Kcal CHO Pro (g) Fat (g) BF MS L AS D S

(g)
Items

Milk 2 250 24 8 10 1 1

Fruits 2 120 30 - - 1 1

Cereals 12 900 180 24 6 2 2 2 2 2 2

Veggie 3 - - - - 1 1 1

Meat/poultry 2 130 - 14 8 1 1

Fish/legumes 1 35 - 7 1 1

Fats 4 180 - - 20 2 2
 Total 26 1615 234 53 45

Percentage (%) 58 13 25

Cereals = 240.7 – 24 – 30 = 186.7g

1 ex = 15 g CHO

12 ex = 186.7 g CHO

e. Meal plan table

Table 3.2 Meal plan for May

Meal time Food items Amount

Breakfast (7 am) low fat milk 1 glass

wholemeal bread (toasted) 2 slices

peanut butter 2 tbsp

Morning snack (10 am) putu mayam 2 pieces

Lunch (1-2 pm) white rice 1 cup

chicken drumstick 1 piece

ikan kembung 1 medium

orange 1 whole

ulam 1 cup

plain water

Afternoon snack mee hoon soup 1 cup

spinach and bean sprout ½ cup

Dinner (6.30 pm) spaghetti bolognese 1 cup

meatball 2 pieces

mixed salad ½ cup

apple 1 whole

plain water

Supper (10 pm) low fat milk 1 glass

cream crackers 6 pieces

cream cheese 2 tbsp

Healthy Eating for Hypercholesterolemia

Hypercholesterolemia, also called high cholesterol, is the presence of high levels of

cholesterol in the blood (Durrington, 2003). It is a form of hyperlipidemia, high blood lipids, and

hyperlipoproteinemia (elevated levels of lipoproteins in the blood) (Durrington, 2003). Eating a

diet with a high proportion of vegetables, fruit, dietary fibre, and low in fats results in a modest

decrease in total cholesterol (Bhattarai et al., 2013; Hartley et al., 2013; Ito et al, 2011)

Eating dietary cholesterol causes a small but significant rise in serum cholesterol.

According to Brownawell et al., 2010; Berger et al., 2015, dietary limits for cholestero l were

proposed in the United States, but not in Canada, United Kingdom, and Australia (Brownawell et

al. 2010). Consequently, in 2015 the Dietary Guidelines Advisory Committee in the United States

removed its recommendation of limiting cholesterol intake.

A 2020 Cochrane review found replacing saturated fat with polyunsaturated fat resulted in

a small decrease in cardiovascular disease by decreasing blood cholesterol (Hooper et al., 2020).

Other reviews have not found an effect from saturated fats on cardiovascular disease (Chowdhury

et al., 2014; de Souza et al., 2015). Trans fats are recognized as a potential risk factor for

cholesterol-related cardiovascular disease, and avoiding them in an adult diet is recommended (de

Souza et al., 2015).

The National Lipid Association recommends that people with familial

hypercholesterolemia restrict intakes of total fat to 25–35% of energy intake, saturated fat to less

than 7% of energy intake, and cholesterol to less than 200 mg per day (Ito et al., 201 1). Changes

in total fat intake in low calorie diets do not appear to affect blood cholesterol (Schwingshackl &

Hoffmann, 2013).
 Increasing soluble fiber consumption has been shown to reduce levels of LDL cholesterol,

with each additional gram of soluble fiber reducing LDL by an average of 2.2 mg/dL (0.057

mmol/L) (Brown et al. 1999). Increasing consumption of whole grains also reduces LDL

cholesterol, with whole grain oats being particularly effective (Hollaender et al., 2015). Inclusion

of 2 g per day of phytosterols and phytostanols and 10 to 20 g per day of soluble fiber decreases

dietary cholesterol absorption (Ito et al., 2011). A diet high in fructose can raise LDL cholesterol

levels in the blood (Schaefer et al., 2009).

Cooking tips for Hypercholesterolemia

First tips are by reducing saturated fat in meat and poultry. The American Heart

Association recommends a diet that emphasizes fish and poultry and limits red meat. The amount

of saturated fat in meats can vary widely, depending on the cut and how it is prepared. Limit

processed meats such as sausage, bologna, salami and hot dogs. Many processed meats even those

with “reduced fat” labels are high in calories and saturated fat. Such foods are often high in sodium

too. Read labels carefully and eat processed meats only occasionally.

Next, eat more fish. Fish can be fatty or lean, but it is still low in saturated fat. Eat at least

8 ounces of non-fried fish each week. Choose oily fish such as salmon, trout and herring, which

are high in omega-3 fatty acids. Prepare fish baked, broiled, grilled or boiled rather than breaded

and fried, and without added salt, saturated fat or trans-fat. Non-fried fish and shellfish, such as

shrimp, crab and lobster, are low in saturated fat and are a healthy alternative to many cuts of meat

and poultry.
 Research has shown the health benefits of eating seafood rich in omega -3 fatty acids,

especially when it replaces less healthy proteins that are high in saturated fat and low in unsaturated

fat. Including seafood high in omega-3 fatty acids as part of a heart-healthy diet can help reduce

the risk of heart failure, coronary heart disease, cardiac arrest and the most common type of stroke

(ischemic).

Cook fresh vegetables the heart-healthy way. Try cooking vegetables in a tiny bit of

vegetable oil and add a little water during cooking, if needed. Just one or two teaspoons of oil is

enough for a package of plain frozen vegetables that serves four. Place the vegetables in a skillet

with a tight cover and cook them over very low heat until done. Add herbs and spices to make

vegetables even tastier.

Use liquid vegetable oils in place of solid fats. Liquid vegetable oils such as canola,

safflower, sunflower, soybean and olive oil can often be used instead of solid fats, such as butter,

lard or shortening. Besides that, increase fiber and whole grains intake by using brown rice instead

of white rice and try whole grain pasta.

Last but not least, consume lower dairy fats. Low-fat (1%) or fat-free (skim) milk can be

used in many recipes in place of whole milk or half -and-half. When it comes to cheeses used in

recipes, try to substitute low-fat, low-sodium cottage cheese, part-skim milk mozzarella (or ricotta)

cheese, and other low-fat, low-sodium cheeses with little or no change in consistency.
4. The strategies for healthy eating out

Almost everywhere, the frequency of eating out has been increasing among consumers
(Boo et al., 2008). Healthy eating out was important to maintain a healthy weight and reduce the
risk of getting a disease such as high blood pressure, high cholesterol, hypertension and others.
This because eating out was considered a cause of the increased consumption of sweet and bakery
goods, soft drinks and other non-alcoholic beverages (Naska et al., 2011). Several strategies can
be carried for healthy eating out.

Based on (Tarro et al., 2017), choosing restaurants that have menu labels which are
providing nutrient information and offer a high number of healthy or low fat entrees menus such
as fruit and vegetables was a basic strategy for healthy eating out. Nutrients information was
important to control the nutritional input and output also for energy level balance for individuals.

Another strategy for healthy eating out was to order more plant based foods. Based on
(Crimarco et al., 2020), individuals who generally consumed plant based food have lower BMIs
and cardiovascular disease risk factors were reduced compared to individuals that c onsumed an
omnivorous diet. Since plants have high fiber, it helps improve health by supporting immune
systems and reduce inflammation. It is because fiber helps improve the health of guts so that the
nutrients from the food can be absorbed easily.

Besides that, control portion size also can be a strategy for healthy eating out. When at
restaurants, individuals can ask for a half portion of dishes. This strategy can help individuals save
a lot of calories towards the food that has been consumed besides help in preventing overeating.
Another way to control portion size was individuals can order starter and side such as soup or salad
before going to main dishes so that individuals will take a small portion of main dishes because
they are already full with the starter and side.

Next, control fat intake when ordering food at restaurants. Individuals can order baked or
broiled dishes such as broiled chicken. Baked or boiled dishes contain less fat compared to deep
fry dishes. Individuals also can ask for a smaller portion of fatty foods such as meat and meat
products including sausages and meat patties. When ordering the food, individuals can choose fish
compared to red meat because red meat contains saturated fat. According (Kim et al., 2020), fish
were categorized as a minor source of saturated fat.

Lastly, individuals can order beverages with few or no calories as a strategy for healthy
eating out. Individuals also can start a meal with a glass of water or beverages that have few or no
calories because drinking a glass of water up to 30 minutes before a meal will naturally aid portion
control. Filling up on water will make you feel less hungry and this can cut some of the calories.
Being well hydrated was important because it can distinguish between hunger and thirst.
Nutrition Care Process

40 years old female with hypercholesterolemia, with family history of hypertension, Type 2
diabetes mellitus and stroke. Height: 158; weight: 66.4 kg.
Patient is a businesswoman, eats 4 meals a day with most of them is eating out. The patient took
irregular meals due to busy schedules. Consume 1/3 red wine up to 3-4 times per day.
Nutrition diagnosis: Has prediabetic conditions (FBS is slightly higher than normal) re lated to
frequent alcohol consuming and diet history. The patient also noted a high level of total cholesterol
and LDL level, caused by hypercholesterolemia. It also possible according to the patient’s diet
history.

From NCP, it can be concluded that the patient is classified as overweight (BMI = 26.6). She has
been reported to have slightly higher than normal FBS (fasting blood sugar) which indicated the
patient to be prediabetic. However, RBS (random blood sugar) reading is normal. Slightly higher
FBS can be caused by the patient’s frequent alcohol consumption. Lai et al. (2019) stated that
alcohol consumption is correlated with type 2 diabetes through its effects on insulin resistance,
changes in alcohol metabolite levels, and anti-inflammatory effects. To reduce this effect, alcohol
intake must be revised to be as low as possible. As stated by Pietraszek et al. (2010) alcohol should
be restricted in Type 2 diabetic patients who are overweight suffering hypertension. The statement
is compatible for the patient as she is overweight and has family history of hypertension.

The patient also has high total cholesterol and LDL level. It is expected to be high since the patients
was diagnosed with hypercholesterolemia; condition caused by a gene that is passed d own by both
parents cause the defection preventing body from ridding itself of the type of cholesterol that can
build up in your arteries and cause heart disease.
REFERENCES

Ministry of Health. (2010). Malaysian Dietary Guidelines.

Berger, Samantha; Raman, Gowri; Vishwanathan, Rohini; Jacques, Paul F.; Johnson,
Elizabeth J. (2015-08-01). "Dietary cholesterol and cardiovascular disease: a
systematic review and meta-analysis". The American Journal of Clinical
Nutrition. 102 (2): 276–94

Bhattarai, N; Prevost, AT; Wright, AJ; Charlton, J; Rudisill, C; Gulliford, MC (20

December 2013). "Effectiveness of interventions to promote healthy diet in
primary care: systematic review and meta-analysis of randomised controlled
trials". BMC Public Health. 13: 1203

Boo, H. C., Chan, L. T., & Fatimah, U. (2008). Healthy Eating Away-from-Home:
Effects of Dining Occasion and the Number of Menu Items. International Food
Research Journal, 15(2), 201–208.

Brown, Lisa; Rosner, Bernard; Willett, Walter W.; Sacks, Frank M. (1999-01-01).
"Cholesterol-lowering effects of dietary fiber: a meta-analysis". The American
Journal of Clinical Nutrition. 69 (1): 30–42

Brownawell, Amy M.; Falk, Michael C. (2010-06-01). "Cholesterol: where science and
public health policy intersect". Nutrition Reviews. 68 (6): 355–64

Chowdhury, R; Warnakula, S; Kunutsor, S; Crowe, F; Ward, HA; Johnson, L; Franco,

OH; Butterworth, AS; Forouhi, NG; Thompson, SG; Khaw, KT; Mozaffarian, D;
Danesh, J; Di Angelantonio, E (18 March 2014). "Association of dietary,
circulating, and supplement fatty acids with coronary risk: a systematic review
and meta-analysis". Annals of Internal Medicine. 160 (6): 398–406

Crimarco, A., Dias, C. H., Turner-McGrievy, G. M., Wilson, M., Adams, S. A.,
Macauda, M., Blake, C. E., & Younginer, N. (2020). Outcomes of a short term
dietary intervention involving vegan soul food restaurants on African American
adults’ perceived barriers, benefits, and dietary acceptability of adopting a plant-
based diet. Food Quality and Preference, 79(August 2019), 103788.
https://doi.org/10.1016/j.foodqual.2019.103788

de Souza, RJ; Mente, A; Maroleanu, A; Cozma, AI; Ha, V; Kishibe, T; Uleryk, E;

Budylowski, P; Schünemann, H; Beyene, J; Anand, SS (11 August 2015). "Intake
of saturated and trans unsaturated fatty acids and risk of all cause mortality,
cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis
of observational studies". BMJ (Clinical Research Ed.). 351: h3978.
Durrington, P (August 2003). "Dyslipidaemia". The Lancet. 362 (9385): 717–31

Hartley, L; Igbinedion, E; Holmes, J; Flowers, N; Thorogood, M; Clarke, A; Stranges, S;

Hooper, L; Rees, K (4 June 2013). "Increased consumption of fruit and vegetables
for the primary prevention of cardiovascular diseases". The Cochrane Database of
Systematic Reviews. 6 (6): CD009874

Hollænder, Pernille LB; Ross, Alastair B.; Kristensen, Mette (2015-09-01). "Whole-grain
and blood lipid changes in apparently healthy adults: a systematic review and
meta-analysis of randomized controlled studies". The American Journal of
Clinical Nutrition. 102 (3): 556–72ll

Hooper, Lee; Martin, Nicole; Jimoh, Oluseyi F.; Kirk, Christian; Foster, Eve;
Abdelhamid, Asmaa S. (21 August 2020). "Reduction in saturated fat intake for
cardiovascular disease". The Cochrane Database of Systematic Reviews. 8:
CD011737.

Ito MK, McGowan MP, Moriarty PM (June 2011). "Management of familial

hypercholesterolemias in adult patients: recommendations from the National
Lipid Association Expert Panel on Familial Hypercholesterolemia". J Clin
Lipidol. 5 (3 Suppl): S38–45

Kim, Y., Je, Y., & Giovannucci, E. L. (2020). Association between dietary fat intake and
mortality from all-causes, cardiovascular disease, and cancer: A systematic
review and meta-analysis of prospective cohort studies. Clinical Nutrition, xxxx.
https://doi.org/10.1016/j.clnu.2020.07.007

Muhammad Muiz. (2011). Diet For Hypercholesterolaemia - PORTAL MyHEALTH.

PORTAL MyHEALTH. http://www.myhealth.gov.my/en/dietary-for-
hypercholesterolemia/

Naska, A., Orfanos, P., Trichopoulou, A., May, A. M., Overvad, K., Jakobsen, M. U.,
Tjønneland, A., Halkjær, J., Fagherazzi, G., Clavel-Chapelon, F., Boutron-Ruault,
M. C., Rohrmann, S., Hermann, S., Steffen, A., Haubrock, J., Oikonomou, E.,
Dilis, V., Katsoulis, M., Sacerdote, C., … Peeters, P. H. M. (2011). Eating out,
weight and weight gain. A cross-sectional and prospective analysis in the context
of the EPIC-PANACEA study. International Journal of Obesity, 35(3), 416–426.
https://doi.org/10.1038/ijo.2010.142

Schaefer, EJ; Gleason, JA; Dansinger, ML (June 2009). "Dietary fructose and glucose
differentially affect lipid and glucose homeostasis". The Journal of Nutrition. 139
(6): 1257S–62S.
Schwingshackl, L; Hoffmann, G (December 2013). "Comparison of effects of long-term
low-fat vs high-fat diets on blood lipid levels in overweight or obese patients: a
systematic review and meta-analysis". Journal of the Academy of Nutrition and
Dietetics. 113 (12): 1640–61.

Tarro, L., Aceves-Martins, M., Tiñena, Y., Parisi, J. L., Blasi, X., Giralt, M., Llauradó,
E., & Solà, R. (2017). Restaurant-based intervention to facilitate healthy eating
choices and the identification of allergenic foods at a family-oriented resort and a
campground. BMC Public Health, 17(1), 1–9. https://doi.org/10.1186/s12889-
017-4333-5

U.S Department of Health and Human Services. (2005). Lowering Your Cholesterol With
TLC (Therapeutic Lifestyle Changes). National Institute of Health, 1–85.

Lai, Y. J., Hu, H. Y., Lee, Y. L., Ko, M. C., Ku, P. W., Yen, Y. F., & Chu, D. (2019).
Frequency of alcohol consumption and risk of type 2 diabetes mellitus: A
nationwide cohort study. Clinical Nutrition, 38(3), 1368–1372.
https://doi.org/10.1016/j.clnu.2018.06.930

Pietraszek, A., Gregersen, S., & Hermansen, K. (2010). Alcohol and type 2 diabetes. A
review. Nutrition, Metabolism and Cardiovascular Diseases, 20(5), 366–375.
https://doi.org/10.1016/j.numecd.2010.05.001

Familial Hypercholesterolemia Medlineplus medical

https://medlineplus.gov/ency/article/000392.htm
 Faculty of Fisheries and Food Science
STM4201 - PEMAKANAN TERAPI
Group 12
Topic: Case Study 4 (Colon cancer stage II)

Lecturer’s name: DR. NOOR SALIHAH BINTI ZAKARIA

MATRIC NUMBER NAME

S47776 NUR ALIA NAJMIN BINTI MD SULAIMAN

S47789 NURUL NABILAH BINTI MOHD ANUAR

S47792 NUR SYAFIQAH SYAMMEERA BINTI JASMI

S47794 TIA’A SHIN MEY

S47798 NURUL SYAHIRAH BINTI KAMARUDIN

S47803 LIM SHU CHYI

Background
Jane, 55 years old, a mother of four.

Recently diagnosed with stage II colon cancer. Three months prior to the diagnosis, Jane reported

weight loss along with loss of appetite and dysphagia. Physical signs such as dry mucous

membranes of the mouth have likely exacerbated her dysphagia. In the next 3 weeks,

she will undergo partial colectomy, followed by 12 cycles of FOLFOX chemotherapy.

Initial weight: 56 kg, Current weight: 51kg; Height: 158 cm

Haemoglobin 11.6 g/dL, Albumin 4.3 g/dL

1. Clinical sign of malnutrition noted in this patient.

Body Symptoms/ Description of Consequences Sign of Possible
System Condition condition Malnutrition causes
Dysphagia is
difficulty /
inability to Loss of Macro- and
Mouth -
swallow normally appetite, micronutrient
dry Colon
Dysphagia or to transfer weight loss deficiencies
mucous cancer
liquid or solid and (iron, folate,
membrane
foods from the malnutrition vitamin B12)
oral cavity to the
stomach.

The clinical sign of malnutrition noted in Jane is dry mucous membrane, dysphagia, loss of

appetite and weight loss. Dysphagia is difficulty/ inability to swallow normally or to transfer

liquid or solid foods from the oral cavity to the stomach (Tierney, 2013). Signs and symptoms of
dysphagia are often displayed as drooling, choking or coughing during and/or following meals,

inability to such from a straw, gurgling voice quality, absent gag reflex, chronic upper respiratory

infection, and holding pockets of food within buccal recesses (Tierney, 2013). Jane is at

particularly high risk of macro- and micronutrient deficiency in iron, folate and vitamin B12 (Le

Marchand et al., 2009; Waly et al., 2012).

2. Briefly describe the potential effect of cancer and its treatment on a patient’s nutritional status.

The patient will undergo partial colectomy which is a surgical procedure which cancerous

part of the colon is removes or removing part of the colon followed by 12 cycles of FOLFOX

chemotherapy. After patient done with partial colectomy, additional treatments such as

chemotherapy or radiation therapy may also be recommended to destroy any residual cancer cells

and reduce the patient’s chance of experiencing a recurrence. Chemotherapy treatments target any

rapidly dividing cells, including healthy on.

The potential effect of cancer and its treatment is unintentional weight loss due to loss of

appetite. Hence, small meals are needed like 5 to 6 meal a day to make it easier to get all the

nutrition need when dealing with appetite or weight changes, help the body ease digestion and

absorption, and also to avoid from feeling nauseous and bloated. Mouth sores is also the effect of

cancer and it cause eating and swallowing difficult or impossible. Hence patient need to eat slowly

and chew each bite fully to a mashed-potato texture before swallow to prevent from blockage.

Other than that, risk of getting an infection are increase due to reduce number of white blood cells

in blood from chemotherapy treatments where patient may change in temperature, aching muscles,
headache and shivery. Bruising and bleeding also can happen because of drop in the number of

platelets in the blood.

Next effect is diarrhea and dehydration due to the normal bacteria and enzyme functions

of the colon, such as absorbing fluid are not resumed normal functioning. So, patient need to

increase amount of water which it can aid in digestion and ease side effects like constipation and

fatigue. Proper hydration is important to prepare body for treatments like surgery and

chemotherapy. Patient need to avoid in taking coffee since it contains of caffeine that can aggravate

symptoms of nausea and diarrhea, it can increase the production of acid in the stomach which may

lead to acid reflux heartburn and difficulty swallowing. Caffeine may also worsen insomnia and

also it is stimulant which is it speeds up activity in the body including the intestines.

Other than that, patients cannot eat high-fiber diet since the stomach doesn’t fully digest

high-fiber foods like whole-grain breads and cereals. Patient can increase intake of white pasta,

cream crackers, vegetables that are well cooked and fruit that are peeled. Increase in intake of fresh

fish into meals since it full of lean protein and omega-3 fatty acids which is it essential for those

fighting colon cancer. Protein helps immune system recover from illness and helps body to repair

cells and tissues. Lastly, patient cannot intake of high-fat foods since greasy foods and fast foods

can aggravate symptoms of colon cancer and worsen side effects such as nausea vomiting and

diarrhea. These heavy fatty foods can be difficult to digest and may remain in the stomach for a

long time increasing risk for painful acid reflux as well.

3. Illustrate a nutrition care process for this patient to prepare her for the surgery

NUTRITION CARE PROCESS FOR PATIENT WITH STAGE II COLON CANCER

Step 1: Nutrition Assessment
Anthropometric Weight history:
Assessment Initial weight: 56 kg, Current weight: 51kg; Height: 158 cm

BMI = 51 kg/ (1.58)2

= 20.43 kg/m2
 Normal Body Weight (18.5– 24.9)

Energy requirement for Jane (stage II colon cancer with inactive and
non- stressed)
= 51 kg x 25 kcal/g
=1275 kcal

Percent of weight changes = [(Usual weight - Actual weight) ÷ usual

weight] x 100
= [(56 kg- 51 kg) ÷ 56 kg] x100
=9%
 Jane lose 5 kg of weight or 9% weight changes in three
months, losing 1 to 2 pounds (0.5 to 1 kilogram) a week is
acceptable and the weight loss in Jane still can manage as
her BMI still in normal range but need to concern if further
weight loss occurs.

Biochemical Data Haemoglobin level = 11.6 g/dL (< 12 g/dL)

 Low Haemoglobin level (Normal range for adult women: 12-
16 g/dL)

Albumin level= 4.3 g/dL

 Normal Albumin level (3.5 to 5.0 g/dL)

Clinical Data Medical History: Diagnosed with Stage II colon cancer

Clinical Signs: Malnutrition, Dry mucous membranes of the mouth &

Dysphagia (difficulty swallowing)

Physical Sign: Unintentionally weight loss due to loss appetite

 Dietary Evaluation - Consume coffee with added sugar and creamer every day (High
sugar and caffeine drink).
- Consume dry and solid foods such as biscuit, white rice, roasted
chicken/ beef which difficult to swallowing (loss appetize).
- Having low nutrients diet which low in macro- and
micronutrients especially protein (malnutrition).
- Energy intake less than daily requirement of 1275kcal (weight
loss).
- Water intake is not enough as only drink 2 glass of water a day
(dehydration).

Step 2: Nutrition Diagnosis

Domain intake: Inadequate of nutrients intake related to lack of food planning as evidenced by

having a low nutrients diet.

Domain clinical: Difficult swallowing of foods and loss of appetite related to stage II colon cancer

as evidenced by dry mucous membranes of the mouth and dysphagia.

Domain behavioral: Food- and nutrition- related knowledge deficit related to lack of value for

behavior change as evidenced by high sugar and caffeine intake.

Step 3: Nutrition Intervention

Diagnosis 1: Inadequate nutrients intake

 Jane will modify her diet to include adequate calories and protein through the use of

nutrient- dense food to prevent further weight loss and eventually promote weight gain.

 Jane will consume more fiber and protein food to assist in keeping the colon clean as well

as preventing infections from spreading.

Diagnosis 2: Difficult swallowing of the food and loss of appetite

 Jane will follow instructions regarding diet consistency and swallowing technique provided

by the speech pathologist.

 Jane’s food intake will be develop into texture modification of food and fluid to easy her

to consume.

Diagnosis 3: Food and nutrition related knowledge deficit

 Patients will advise to reduce the sugar and caffeine intake that can affect her health. Drinks

that contain caffeine will contribute to fluid loss. She can consume more water intake at

least 8 cups of water (64 ounce) per day to avoid dehydration.

 Patients will provide healthy food intake.

Step 4: Nutrition Monitoring and Evaluations

 Monitor patient understanding and compliance with plan and the positive or negative

outcome.

 Monitor the Dysphagia symptom and take action quickly if it getting worse to avoid affect

to weight loss and loss of appetite

 Patient will weigh herself daily and keep log, report or appoint with doctors if the weight

loss still continue.

 If nutrition status is not improving, such as Jane’s weight records and goals not being met,

Jane needs to be reassessed and develop new goals and create plans for new interventions.
4. Include a meal plan and dietary strategies in managing cancer side effects.

Age: 55 years old

Gender: Female

Current weight: 51 kg

Height: 158 cm

i. BMI = 51 kg

(1.58𝑚)2

= 20.43 kg/𝑚2 (normal weight )

ii. Jane had diagnosed with stage II colon cancer with inactive and non-stressed.

Therefore, her energy requirement is 25-30 kcal/kg/day.

Energy requirement of Jane

= 51 kg × 25 kcal/kg

=1275 kcal

iii. Protein requirement for non-stressed cancer patient is about 1.0-1.2g/kg and Jane

need to intake more protein due to colon cancer.

Estimate of protein requirement = 1.2 × body weight

= 1.2 × 51 kg

= 61 g protein
 1 g of protein equal to 4 kcal,

61 × 4 kcal = 244 kcal

𝑇𝑜𝑡𝑎𝑙 𝑝𝑟𝑜𝑡𝑒𝑖𝑛
% Protein requirement = 𝐸𝑛𝑒𝑟𝑔𝑦 𝑟𝑒𝑞𝑢𝑖𝑟𝑒𝑚𝑒𝑛𝑡 × 100%

244 𝑘𝑐𝑎𝑙
= × 100%
1275 𝑘𝑐𝑎𝑙

= 19%

iv. Carbohydrate requirement = 56% × 1275 kcal

= (714 kcal ÷ 4 kcal/g), as 1 g of fat equal to 4 kcal

= 179 g

v. Fat requirement = 25% × 1275 kcal

= (319 kcal ÷ 9 kcal/g)

= 35 g
 Food Distribution Table
CHO Protein Fat Morning Evening
Items Exchange kcal Breakfast Lunch Dinner Supper
(g) (g) (g) snack snack
Milk (low fat)/daily
2 250 24 16 10 1 1
products

Fruits 2 120 30 - - 1 1

Cereals 4 600 120 16 4 1 1 1 1

Vegetables 3 - - - - 1 1 1

Meat/poultry 1 65 - 7 4 1

Fish 2 70 - 14 2 1 1

Legumes 1 35 - 7 1 1

Fat 3 135 - - 15 3

Total 18 1275 174 60 36

Percentage 100% 56% 19% 25%

 Meal plan

Meal time Food items Amount

Breakfast Hot low-fat milk 1 glass
banana 1 whole
Morning snack Whole meal bread 2 slices
Canned baked bean 1 ½ cups
Boiled carrot Half cup
Lunch White rice 1 cup
Spinach soup 1 ½ cups
Grilled chicken 1 drumstick
Baked ikan kembung 1 medium
Evening snack Orange (small to medium) 1 whole

Mashed potato 1 bowl (2 whole)

Dinner Bihun soup 1 ½ cups
Baked salmon 1 piece
Steam broccoli Half cup
Supper Greek yogurt 1 cup
Avocado 3/8 slices
DIETARY STRATEGIES FOR CANCER PATIENT

SIDE DIETARY STRATEGIES

EFFECT

Weight loss  Eat smaller, more frequent meals throughout the day.

 Try high-protein, high-calorie foods and snacks, like peanut

butter, hard-boiled eggs, liquid nutritional supplements, or

trail mix.

 Keep nutrient-dense foods in the home, and snack frequently.

Loss of appetite  Eat in small amount but frequently

 Eat food that is nutrient dense

 Avoid having too much liquid in between meals to prevent full

early

 If liquids are more tolerable than solids, consume nutritionally

adequate, high-calorie liquids.

Dysphagia  Choose soft, moist, or blended foods that are easy to chew.

(hard to  Sit up straight when drinking and eating.

swallow)  Drink with a straw.

 Add sauces or liquids to help swallow.

From the table above, the first side effect is weight loss. For a cancer patient, it is

important to have a healthy weight as it is recommended by the American Institute of

Cancer Research Third Expert Reports. Early signs and symptoms of cancer include a

reduced capacity to consume food and vitamins, ingest or absorb them. Cancer cells

can use the energy resources of the body, or release chemicals that change the way food

produces energy from the body. A loss of appetite can also be a symptom of emotional
trauma or depression with a cancer diagnosis which result to weight loss. So, patients

need to consume food frequently and consume vegetables. Also, consuming lot of

protein helps to repair damage caused from cancer treatments.

Next, loss of appetite or appetite deficiency is called anorexia. Individuals with a

very low appetite for longer than a couple of days generally lose weight. Losing weight

because you don't eat enough can also make a person feel sluggish and tired. Plus,

according to (Richa et al., 2011), loss of appetite was among the five most distressing

symptoms suffered by cancer patients preceded only by other symptoms such as lack

of energy, dry mouth, pain, and nausea. so, it is important to ensure body stay hydrated.

Lastly, dysphagia is the medical term for “having trouble swallowing.” In cancer

patients, it can be caused by the tumor itself which blocks or narrows the food passage or as

a side effect of treatment. Patients who had dysphagia will have difficulties to have solid

and grainy food. So, they tend to have soft food such as mash potato, porridge and many

more

Here the link video presentation for this case study from my group

https://youtu.be/lZ5QXqWwNUQ
References

Anon. (2020, November 16). Colectomy Diet. Retrieved from Drugs.com:

https://www.drugs.com/cg/colectomy-diet.html

Chun, C. (2019, August 28). Everything you need to know about colon cancer. Retrieved from
MedicalNewsToday: https://www.medicalnewstoday.com/articles/150496

Dixon, S. (2020, May 18). What to Eat After Colectomy Surgery. Retrieved from
verywellhealth: https://www.verywellhealth.com/colectomy-postsurgery-diet-instructions-
797405

Elizabeth. (2019, June 13). Superfoods for Fighting Colon Cancer. Retrieved from Healthplus:
https://www.mountelizabeth.com.sg/healthplus/article/super-foods-colon-cancer

Farber, D. (2019, September 30). What Can I Eat if I Have Colorectal Cancer? Retrieved from
Insight: https://blog.dana-farber.org/insight/2016/03/what-can-i-eat-if-i-have-colorectal-
cancer/

John, L. (2010, January 15). Risk Assessment in Stage II Colorectal Cancer. Retrieved from
cancernetwork: https://www.cancernetwork.com/view/risk-assessment-stage-ii-colorectal-
cancer

Le Marchand, L., White, K. K., Nomura, A. M. Y., Wilkens, L. R., Selhub, J. S., Tiirikainen, M.,
Goodman, M. T., Murphy, S. P., Henderson, B. E., & Kolonel, L. N. (2009). Plasma Levels
of B Vitamins and Colorectal Cancer Risk: The Multiethnic Cohort Study. Cancer
Epidemiol Biomarkers Prev, 18(8), 2195–2201. https://doi.org/10.1158/1055-9965.EPI-09-
0141

Tierney, K. (2013). Case Study 3 Ischemic Stroke-Case 23. Retrieved from

http://www.nhlbi.nih.gov/health/health-

Waly, M., Al-Kafajei, A., Arafa, M., Jriesat, S., & Sallam, S. (2012). Folate and vitamin B12
deficiency is associated with colorectal cancer in Jordan. International Journal of Nutrition,
Pharmacology, Neurological Diseases, 2(1), 57. https://doi.org/10.4103/2231-0738.93127
World Cancer Research Fund/American Institute for Cancer Research. Diet, nutrition, physical
activity and cancer: A global perspective. Continuous Update Project Expert Report 2018.
Published 2018. Accessed January 20, 2020

Richa Sood, Aminah Jatoi, Integrative nutritional approaches to loss of weight and appetite in
patients with advanced cancer, European Journal of Integrative Medicine,Volume 3, Issue
3,2011,Pages e233-e236