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/