INTERNAL MEDICINE II EVALS 17

Malnutrition and Nutrition Therapy TRANS 22

Dr. Joyce Bernardino, MD

TOPIC OUTLINE history of weight loss or poor oral intake. To address this,
PART I: CAUSES AND TYPES OF PART III: NUTRITIONAL we should take a step further and ask, “WHY is this patient
MALNUTRITION THERAPY FOR PRE_DIABETES malnourished?”
I. Causes and Types of AND DIABETES .

Malnutrition III. Nutritional Therapy for 1. PHYSICAL

A. Malnutrition Pre-Diabetes and Diabetes ● HEALTH
B. Evaluation for the Cause of A. Medical Nutrition Therapy → [Malnutrition] may be due to the presence of any medical or
Malnutrition B. Total Calorie Requirement surgical condition which could affect nutrient assimilation or
C. Nutrition Assessment C. Carbohydrates digestion.
D. Body Composition D. Fiber ● MOTOR PERFORMANCE AND MOBILITY
Assessment E. Protein → Decreased motor performance and immobility can also
E. Laboratory Indicators F. Fat cause decreased muscle synthesis.
F. Types of Malnutrition G. Eating Patterns ● SENSES
G. Nutritional Therapy for H. Micronutrients → Impaired senses can cause less appreciation for food.
Undernutrition I. Non-nutritive Sweeteners ● DENTAL STATUS
PART II: NUTRITIONAL THERAPY J. Sodium → Presence of poor dentition or difficulty in chewing food may
FOR OBESITY K. Alcohol affect intake.
II. Nutritional Therapy for Obesity L. Glycemia and Targeted ● CHRONIC DISEASE
A. Negative Energy Balance Specialized Nutrition → May increase daily requirements.
B. Macronutrient Distribution M. Different Counseling ● DRUGS
C. Types of Diets Techniques → Patient’s medications may affect the absorption of certain
D. Diet Selection nutrients.
E. General Recommendations 2. PSYCHOLOGICAL
F. Nutritional Counseling and
● ETHICS OR CULTURAL FACTORS
Monitoring
→ May depend on ethics and culture, such as being vegan or

📢 - Lecturer’s notes/Audio Inputs

LEGEND
their religious restrictions.
📖 - From Book (cite sources)
IMPORTANT TERMINOLOGIES
● COGNITIVE FUNCTIONING
📝 - From Old Transes 📌
Disclaimers/Transer’s notes
→ Such as in dementia, may affect recall of intake.
🚩 - Important 💡
- Undiscussed Sections
- Nice to Know
● SENSE OF CONTROL AND HEALTH RELATED BEHAVIOR
This transcription follows the flow of Dr. Bernardino’s 2021 video lecture on moodle. ● HYPOCHONDRIASIS AND PERCEIVED INTOLERANCE
Information from the given handout is also included. → Hypochondriasis: being anxious about their health.
PART I: CAUSES AND TYPES OF MALNUTRITION → May cause patients to avoid certain foods due to a perceived
I. CAUSES AND TYPES OF MALNUTRITION intolerance.
● Objectives ● FOOD PREFERENCES
→ Given different clinical scenarios: → Can be unique to each individual.
▪ Determine the etiology and types of malnutrition in the 3. SOCIOECONOMIC
adult population ● HOUSING
▪ Formulate a nutritional plan for an adult undernourished ● RESIDENCY
patient ● MARITAL STATUS/CHILDREN
A. MALNUTRITION ● ERRONEOUS BELIEF AND FOOD FADDISM
● SEASON
● Definition by American Society for Parenteral and Enteral
Nutrition (ASPEN):
● 📢 There are also external factors such as socioeconomic
status, their living condition and location, their family
→ Deficiency or excess of energy, protein, and other nutrients
composition, their erroneous beliefs and faddism as well as
causes MEASURABLE ADVERSE EFFECTS on tissue or
season. Several of these may affect a patient with malnutrition
body function, size, shape, and composition and this will
and this is why a good history is important.
affect the clinical outcome
C. NUTRITION ASSESSMENT
B. EVALUATION FOR THE CAUSE OF MALNUTRITION
● After identifying the possible causes of malnutrition, nutrition

💡 Nice to Know | 📢 From Dr. Joyce Bernardino

● Whenever you encounter a patient, the nutrition screening
assessment is the next step.
● Used to determine the degree of malnutrition.
should be done by answering the question, “Is this patient 1. ANTHROPOMETRIC DATA
malnourished?” Some screening parameters include low BMI, ● Weight measurements

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● Body mass index ● Can also determine the amount of soft tissues such as in Figure
2. CLINICAL SIGNS AND PHYSICAL EXAMINATION 3.
● Check for changes in areas of high turnover for signs of
deficiency
→ Hair
→ Skin
→ Mouth
→ Tongue

Figure 4. DEXA.

3. CT SCAN and MRI

Figure 1. (R) GINGIVITIS, which can be seen in patients with Vitamin C
deficiency or Scurvy, and (L) ANGULAR CHEILITIS at the corner of the
mouth, as well as GLOSSITIS which can be seen in Vitamin B deficiencies.
● Subcutaneous fat loss or Muscle atrophy
→ Subcutaneous fat loss should be checked in the chest and
abdomen area.
→ Presence of muscle atrophy in the muscle groups such as
the deltoid or the calf.
● There are more advances in visualizing body tissue in these
imaging techniques.
● However, this is more costly and there is more x-ray exposure
hence this is more limited to research purposes.
4. HANDGRIP STRENGTH (FUNCTIONAL OUTCOMES)
● Form and function.
● Handgrip dynamometer is used to measure the maximum
isometric strength of the hand and forearm muscles.
● Simple and non-invasive.

Figure 5. Handgrip Dynamometer.

Figure 2. Subcutaneous fat loss in the chest. 5.PHYSICAL PERFORMANCE TEST
D. BODY COMPOSITION ASSESSMENT ● Especially in the elderly, these are used as predictive tools for
● For better accuracy, the following are the other tools used to possible disability and can aid in the monitoring of function.
measure body composition. ● May include the following:
1. BIOELECTRICAL IMPEDANCE ANALYSIS (BIA) → Balance test
● One of the more commonly used. → Gait Speed
● Based on a differential resistance of different body tissues. → Chair Stand Test

Figure 3. BIA.

2. DUAL ENERGY XRAY ABSORPTIOMETRY (DEXA)

● Used for bone density examinations such as that for
osteoporosis.

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Figure 8. Marasmus

💡 Nice to Know | 📢 From Dr. Joyce Bernardino

● This table below from the American Society of Parenteral
and Enteral Nutrition (ASPEN) shows the different types of
malnutrition.
→ If the patient has a nutrition risk, we should determine if the
patient has the presence of inflammation or disease.
→ If not, this can be pure starvation which can be seen in poor
socioeconomic status or anorexia nervosa.
→ If there is inflammation, then the condition is called cachexia.
Figure 6. Physical Performance Tests.
→ If the inflammation is of mild to moderate degree, this is a
E. LABORATORY INDICATORS chronic disease-related malnutrition seen in organ failure,
● The following are laboratory indicators affected by malnutrition, cancer, rheumatoid arthritis, or sarcopenic obesity.
although none are specific by malnutrition only, and should not → If there is a marked inflammatory response, this is Acute
be evaluated as a sole parameter. Disease or Injury Related Malnutrition seen in major
→ Serum proteins infection, ICU patient, burns, trauma, or closed head injury.
→ C-reactive proteins These conditions are very catabolic.
→ Cholesterol
→ Electrolytes
→ Complete Blood Count
→ Total Lymphocyte Count
F. TYPES OF MALNUTRITION
1. STARVATION RELATED MALNUTRITION
● KWASHIORKOR
→ A severe malnutrition characterized by edema and an
enlarged liver with fatty infiltrates.
→ Caused by sufficient calorie intake but with insufficient
protein consumption.

Figure 9. Different Types of Malnutrition.

G. NUTRITIONAL THERAPY FOR UNDERNUTRITION

Figure 7. Kwashiorkor.
● MARASMUS
→ A deficiency of both calories and proteins
→ Leads to the loss of both body fat and muscles
→ There are newer malnutrition syndrome
recognized in the setting of diseases
1. DETERMINATION OF NUTRITION REQUIREMENTS
● The first thing we need to determine is the patient’s
requirements. These can be done through:
→ INDIRECT CALORIMETRY
▪ Used to determine energy expenditure by measurements
of respiratory gas exchange.
▪ Not readily available in all hospitals.
which are

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PATHOPHYSIOLOGY OF REFEEDING SYNDROME

Figure 10. Indirect Calorimetry.

→ Weight Based Equations
▪ More readily available in all hospitals.
▪ Requirements are computed for.
2. ROUTES OF FEEDING
● These are the different routes of providing nutrients to the
patient:
→ Oral Figure 11. Pathophysiology of Refeeding Syndrome.
→ Enteral ● In starvation, there is fat and protein catabolism, as well as
→ Parenteral micronutrient depletion.
● Enteral and Parenteral Nutrition are also called SPECIALIZED ● Upon giving a carbohydrate load, there is stimulation of
NUTRITION SUPPORT. insulin secretion, thereby causing glucose uptake, utilization of
→ If the clinical condition does not allow tolerance to the oral thiamine and electrolytes.
diet for many days, then these are indicated. ● This causes electrolyte shifts causing hypokalemia,
→ These are indicated most especially for: hypomagnesemia, hypophosphatemia, thiamine deficiency, and
▪ Malnourished patients with significant cachexia edema.
▪ Conditions with a high calorie requirement → These can be detrimental as it can cause respiratory failure
→ PROCEED WITH CAUTION BEFORE GIVING FULL and arrhythmias to the patient.
FEEDING!

💡 Nice to Know |
Therapy
From Harrison’s Chapter 328, Enteral and Parenteral Nutrition

● Enteral SNS
→ Is the provision of liquid formula meals through a tube placed
into the gut.
→ This route is almost always preferred because of its relative
simplicity and safety, its low cost, and the benefits of
maintaining digestive, absorptive, and immunologic barrier
functions of the gastrointestinal tract.
→ Pliable, small-bore feeding tubes make placement relatively
easy and acceptable to patients.
→ Constant-rate infusion pumps increase the reliability of
nutrient delivery.
→ The chief disadvantage of enteral SNS is that many days
may be required to meet the patient’s nutrient requirements.
● Parenteral SNS
→ is the direct infusion of complete mixtures of crystalline
amino acids, dextrose, triglyceride emulsions, and
micronutrients into the bloodstream through a central venous
catheter or (rarely in adults) via a peripheral vein.
3. REFEEDING SYNDROME
● Patients can develop REFEEDING SYNDROME upon initiation
of nutrition intervention, especially if they are/have:
→ Underweight
→ Little or no nutrition intake for more than 5 days
→ Significant weight loss
→ No serum electrolytes
▪ Most especially, the hallmark, phosphorus
Figure 12. Refeeding Syndrome.
● In simpler terms, this is what happens when a starved cell is
given a big carbohydrate load, there are electrolyte shifts.
● Hence, feeding should be started slowly, sometimes at half the
dose, then gradually increased to attenuate this effect.
4. ORAL DIET
● If the patient can tolerate an oral diet, the following types can be
given:
→ Full/Liberal Diet
→ Texture Modified Diet
→ Disease Specific Diet
● 📢 For a malnourished patient, we can either liberalize the diet
or provide a texture modified diet for easier chewing or
swallowing.
● 📢 We can provide a disease specific diet, according to the
patient’s requirements
→ For example, a diabetic or a renal diet.
5. ORAL NUTRITION SUPPLEMENTATION (ONS)
● On top of the oral diet, we can add oral nutrition supplements.
● ONS looks like milk, but these are sterile liquids, semi-solids, or
powders, which provide macro- and micronutrients.

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● These are widely used within the acute and community settings → Volume overload
for individuals who are unable to meet their nutritional → Hypertroglyceridemia
requirements through oral diet alone. → Hepatic Dysfunction
6. SPECIALIZED NUTRITION SUPPORT ● These are commonly seen in the early era of TPN or
hyperalimentation where they thought more nutrients were
ENTERAL NUTRITION
better. This can be attenuated by regulating the amount being
● If the oral diet and oral nutrition supplement is not tolerated,
given to the patient according to the clinical condition.
then we can provide feeding through a tube through the gut
● Specialized Nutritional Support should be given if benefits of
which is ENTERAL NUTRITION.
addressing the nutritional status outweighs the risks and cost of
● This is usually given to patients with dysphagia, mechanical
the intervention.
ventilation, or through a stoma through the skin if there is
upper GI tract obstruction.
● However, enteral feeding may not always be smooth sailing so
patients should always be advised or monitored of the
following:
→ Aspiration
▪ Seen in patients with delayed gastric emptying, those with
high residual volumes, impaired sensorium, or those in
mechanical ventilators.
→ Diarrhea
▪ Although this usually happens due to the disease or
medications. This may be controlled by a fiber containing
formula.
→ Gastrointestinal Intolerance Figure 14. Parenteral Nutrition.
▪ pain, bloatedness
▪ Can be improved by routine antiemetics and prokinetics.
📢 SUMMARY and CASE APPLICATION
● 70/M came in due to cough
→ Fluid Volume, Electrolyte, and Blood Glucose Abnormalities ● Dx: Pneumonia
▪ especially in overfeeding ● Nutritional History: Decreased intake in the past week due to
→ Failure to reach the nutritional goal coughing, weight loss -10%
● If these are refractory to medical management or there are ● PE: Wt - 40 kgs Ht - 1.62m BMI: 15.2 (underweight)
conditions in the gut such as bleeding or obstruction, then we ● Risk of Malnutrition? Yes.
can proceed to parenteral nutrition. ● Nutrition Assessment:
→ Causes of Malnutrition
→ Body Composition
→ Function
→ Laboratory Parameters
● Nutrition Intervention:
→ Total Calorie Requirements: 40kgs x 30 calories/body weight
= 1200 kcal (initial)
→ Soft diet, + Oral Nutrition Supplement (ONS) twice a day
→ Monitor food intake, electrolytes (r/o Refeeding)
● Patient was ventilated.
→ Start NGT feeding with TF 1200 kcal divided into 6 equal
feedings.
→ Monitor for tolerance.

PART II: NUTRITIONAL THERAPY FOR OBESITY

II. NUTRITIONAL THERAPY FOR OBESITY
Figure 13. Enteral Nutrition. .

OBJECTIVE
PARENTERAL NUTRITION
● Formulate a nutritional plan for an ADULT OBESE PATIENT.
● Total Parenteral Nutrition (TPN) is given intravenously, either
through a central or peripheral line. This includes protein,
📌 Undiscussed Section Lifted from Handouts

carbohydrate, fat, minerals, electrolytes, vitamins, and other GENERAL RECOMMENDATIONS

trace elements. ● Reducing total energy (caloric) intake should be the main component
● There are also known complications in giving parenteral of any weight loss intervention. To implement a successful dietary
nutrition: intervention, we typically perform a brief 24-hour dietary recall during
→ Catheter related infection the office visit. We counsel patients on the importance of:
▪ prone in patients with central line → Elimination of all caloric beverages, which are often the source of
→ Hypo/Hyperglycemia unwanted calories, and processed foods

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▪ Very Low Calorie Diet

→ Portion control
▪ Intermittent Fasting
→ Self-monitoring
→ For the carbohydrates:
→ Adopting a healthy, long-term approach to eating
▪ Low Carbohydrate Diet
● Self-monitoring, often involving the use of food diaries, activity
− Lowering of the ratio of carbohydrates
records, and self-weighing, is one of the elements of a successful
− Ex: Ketogenic Diet
behavioral weight loss program.
▪ Low Glycemic Index Diet
A. NEGATIVE ENERGY BALANCE − Modification in the type of carbohydrate
→ For the protein, some would recommend:
▪ High Protein Diet
→ Limiting fat to:
▪ Low Fat Diet
▪ Very Low Fat Diet
C.TYPES OF DIETS
📌
1. LOW CALORIE DIETS ( BALANCED LOW CALORIE
DIETS)
● Strategy:
→ Total energy intake is reduced
Figure 15. Negative energy balance. ▪ Usually fall into 1200–1500 kcal/day
● It is postulated that weight loss can be achieved through a ▪ Less 500–1000 kcal/day
negative energy balance in the form of restricting calorie − Another method which is done by taking a 24-hour food
recall and subtracting 500–1000 calories per day from
intake and increasing expenditure.
the usual intake.
● LIFESTYLE MODIFICATION is part of management.
→ Macronutrient distribution is maintained:
→ Diet ▪ Carbohydrates (55–60%)
▪ Defined as a pattern for eating. ▪ Protein (10–15%)
▪ 📢 The focus of this lecture since this is one of the ▪ Fat (<30% of energy intake)
beginning points for those who would like to lose weight. ● Advantages (PRO)
→ Physical activity and exercise → Safe, Tolerability
▪ Since it is well balanced, it can be done with minimal
→ Behavioral therapy
supervision on a range of people
B. MACRONUTRIENT DISTRIBUTION ▪ Tolerated with less side effects
▪ More food choices
● Disadvantages (CON)
→ Gradual/ modest weight loss, Complexity (patients need
understanding of calories and portion sizes)
▪ Very easy to under– and overestimate portions of food.
▪ Requires calorie counting and food exchanges, which may
feel complex to a patient.
PORTION CONTROLLED MEALS
● For the patient who feels that following a meal plan can be too
time consuming, there are options to make compliance easier.
● There are options for portion-controlled meals:
→ Individually packaged frozen foods which would amount
to 250–300 kcal per package.
→ Formula diet drinks and nutrition bars.
→ Pre-packaged meals from diet delivery services.
Figure 16. Usual daily macronutrient distribution of a Filipino adult. ● Advantage
● The usual macronutrient composition of your total calories is → Ease of preparation and compliance.
composed of carbohydrates, protein, and fat. ● Disadvantage
● According to the Philippine Dietary Reference Index (2015), a → Depending on the availability, there may also be limited
Filipino adult usually requires 1600–2500 kcal per day; and this choices according to the preference of the patient.
is distributed at: 📌 Undiscussed Section Lifted from Handouts

→ 50–60% Carbohydrates
PORTION-CONTROLLED MEALS
→ 10–20% Protein
● One simple approach to providing a calorie-controlled diet is to use
→ 30% Fat
individually packaged foods, such as formula diet drinks using
● WHICH DIET IS THE BEST FOR WEIGHT LOSS?
powdered or liquid formula diets, nutrition bars, frozen food, and
→ If you want to reduce the total calories without changing the
prepackaged meals that can be stored at room temperature as the
macronutrient distribution, then this diet may be classified as:
main source of nutrients.
▪ Low Calorie Diet

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● Frozen, low-calorie meals containing 250 to 350 kcal/package can

be a convenient and nutritious way to do this. An example of this
would be the use of formula diets or breakfast bars for breakfast;
formula diets or a frozen lunch entree for lunch; and a frozen,
calorie-controlled entree with additional vegetables for dinner. In this
way, it is possible to obtain a calorie-controlled 1000 to 1500
kcal/day diet. In one four-year study, this approach resulted in early
initial weight loss, which then was maintained.

LOW-CALORIE VERSIONS OF HEALTHY DIETS

● Mediterranean Diet
→ Seen to benefit Europeans living in the Mediterranean coast
in terms of low rates of Coronary Heart Disease and long life Figure 18. DASH diet.
expectancy
→ This is characterized by a high level of monounsaturated
📌 Undiscussed Section Lifted from Handouts

fat, such as olive oil or omega-3 fatty acids. DASH DIET

→ Moderate consumption of alcohol, mainly as red wine.
→ High consumption of vegetables, fruits, legumes, and
grains.
→ Moderate consumption of milk and dairy products,
mostly in the form of cheese.
→ There is relatively low intake of meat and meat products.
● It Consists of four to five servings of fruit, four to five servings of
vegetables, and two to three servings of low-fat dairy per day, and
<25 percent dietary intake from fat.
● Has been studied in both normo- and hypertensive populations and
found to lower systolic and diastolic pressure more than a diet rich in
fruits and vegetables alone.
● Combining a calorically restricted DASH diet with approximately 25
minutes of physical activity per day has been shown to result in
an average 5.8 kg weight loss over 26 weeks.

2. VERY LOW-CALORIE DIET

● Characterized by extremely low daily food energy consumption.
● Ranging between <1000 or even <800 kcal/day.
● This can be safely done using a medically supervised diet,
using formulations which contain the daily needed calories,
proteins and micronutrients.

Figure 17. Mediterranean diet

📌 Undiscussed Section Lifted from Handouts

MEDITERRANEAN DIET
● A dietary pattern that is common in olive-growing areas of the
Mediterranean.
● Although there is some variation in Mediterranean diets, there are
some common components, which include a high level of
monounsaturated fat relative to saturated fat; moderate consumption
of alcohol, mainly as wine; a high consumption of vegetables, fruits,
legumes, and grains; a moderate consumption of milk and dairy
Figure 19. OPTIFAST VLCD Program
products, mostly in the form of cheese; and a relatively low intake of The OPTIFAST VLCD (Very Low Calorie Diet) Program showing its
meat and meat products. nutritionally complete diet regimen
● Appears to be associated with several health benefits, including ● Advantage
cardiovascular risk reduction and diabetes prevention → Rapid weight loss may be needed prior to a surgical
procedure.
● DASH Diet ● Disadvantages
→ Dietary Approaches to Stop Hypertension Diet. → Difficulty in achieving the very low-calorie intake.
→ Aims to reduce the hypertension risk of an individual. → Studies have shown that there is no advantage in a very low
→ Reduce the intake of saturated fat, trans fat and sodium. intake of 400 vs. 800 kcal due to slowing of the resting
▪ Limiting sodium to 1500 to 2300 mg per day. metabolic rate.
▪ Reducing saturated fat and trans-fat intake.
→ Same with the Mediterranean diet, this encourages intake of
📌 Undiscussed Section Lifted from Handouts

whole grains, fruits and vegetables. VERY LOW-CALORIE DIET

→ However, they allow dairy and meats in moderation, while ● Metabolic studies using state-of-the-art techniques have concluded
fats and oils are allowed in smaller amounts. that most adults will lose weight when fed <1000 kcal/day. Thus,

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● Advantage
even subjects who are concerned that they are "metabolically → Effective for weight loss and appears to be better the longer
resistant" to weight loss will lose weight if they comply with a diet of the fasting duration (ADMF > TRF).
800 to 1200 kcal/day. ▪ Improvement in metabolic parameters or biomarkers is
● More severe caloric restriction might be expected to induce weight always related to weight loss.
loss more quickly, but a comparison with 400 versus 800 kcal/day ● Disadvantages
diet formulas showed no difference in weight loss , presumably due → Might not promote healthy eating habits and may encourage
binge eating.
to slowing of resting metabolic rate.
→ The feeling of hunger during fasting may decrease
→ We thus advise diets consisting of >800 kcal/day. In addition, compliance.
because of the body’s hormonal adaptation to perceived
starvation, it is difficult to maintain a very low-calorie diet
📌 Undiscussed Section Lifted from Handouts

long-term. INTERMITTENT FASTING

→ However, these diets may be used in certain conditions when ● Intermittent fasting strategies, including alternate-day fasting and
rapid weight loss is needed (eg, to obtain metabolic control in time-restricted feeding, have been used as approaches to weight
uncontrolled type 2 diabetes mellitus or hypertension, or in loss, although evidence for their efficacy is mixed.
preparation for a surgical procedure such as joint replacement, → As examples, in a 12-week trial including 32 individuals with
bariatric surgery, or organ transplantation). obesity, alternate-day fasting (25 percent of energy consumed on
"fast" days alternating with ad libitum "feast" days) resulted in a
3. INTERMITTENT FASTING weight loss of -5.2 kg compared with a control (no caloric
● A hunger game that one must overcome during certain days or restriction) group .
hours in a day ● Time-restricted feeding (TRF) is a type of intermittent fasting in
● An umbrella term for diets that alternate between fasting and which the cessation of eating by a certain time each day (eg, in the
non-fasting periods
early afternoon) results in a prolonged period of fasting which
● Types
persists until the next day.
→ Whole Day Fasting
▪ ADF – Alternate Day Fasting ● Short-term TRF trials have shown that the alignment of the feeding
▪ ADMF – Alternate Day Modified Fasting (5:2) period with circadian rhythms may result in weight loss and improve
− 5:2 ratio - one will fast during 2 days of the week and metabolic parameters.
will be allowed to eat for 5 days ● The mechanisms by which intermittent fasting (including TRF) affect
→ Time Restricted Feeding health are incompletely understood but may include improved
▪ More common
insulin sensitivity and antiinflammatory effects.
▪ 16:8 – 16 hours fasting, 8 hours non-fasted
▪ Those who are starting on this diet can divide the day into
4. LOW CARBOHYDRATE DIET
12 hours each
− 12:12 – 12 hours fasting ● From caloric restriction, we shall now proceed to changes in
▪ Others will do with more restriction such as one meal a
day ● 🚩
macronutrient distributions starting with carbohydrates.
A LOW CARBOHYDRATE DIET can restrict carbohydrates
− OMAD/1 day meal: 23 hour fast
● 🚩
to 60-130g/day.
A VERY LOW CARBOHYDRATE DIET may need
<60g/day.
● However, there are no restrictions on total energy, protein or fat
(even the type of fat).
● One of the classic examples of this would be the ‘ATKINS
DIET’ which is known as a bacons and eggs diet.

Figure 20. The 5:2 Diet.

Figure 22. Atkins Diet.

KETOGENIC DIET

Figure 21. EAT-STOP-EAT.

Figure 23. Ketogenic Diet.

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● Under the umbrella of a low carbohydrate diet is the ‘Ketogenic
Diet’.
● Low carbohydrate.
● 🚩
● Normal protein intake.
Very high in fat (More of MCT than LCT)
→ Unlike the Atkins diet, this diet focuses more on the use of
medium chain triglycerides (MCT) from plant sources than
long chain triglycerides (LCT).
● Advantages
→ Effective for short term weight loss. Although this may not be
sustained in the long term.
→ There are also studies where there is improvement in the
metabolic parameters for diabetic patients.
▪ Decreased plasma glucose, HbA1c triglycerides,
cholesterol, improved insulin insensitivity.
● The disadvantages of this diet is that it may be associated with
a more frequent side effect.
→ A low carbohydrate diet will cause glycogen mobilization
and gluconeogenesis which will produce ketones. This can
then cause the “KETO FLU”.
▪ Fatigue, headaches, nausea, muscle weakness, fruity
breath and urine, dehydration.
▪ Since ketones may have a diuretic effect, it is important to
take lots of fluids to avoid dehydration.
📌 Undiscussed Section Lifted from Handouts
● LOW CARBOHYDRATE DIET
→ Low-carbohydrate (60 to 130 grams) and very low
carbohydrate (0 to <60 grams) diets are more effective for
short-term weight loss than low-fat diets, although probably not
for long-term weight loss. A meta-analysis of five trials found that
the difference in weight loss at six months, favoring the
low-carbohydrate over low-fat diet, was not sustained at 12
months. Restriction of carbohydrates leads to glycogen
mobilization and, if carbohydrate intake is less than 50 g/day,
ketosis will develop. Rapid weight loss occurs, primarily due to
glycogen breakdown and fluid loss rather than fat loss. In
addition, very-low-carbohydrate, ketogenic diets are associated
with a small increase in energy expenditure that wanes over time.
→ A low-carbohydrate diet can be implemented in two ways, either
by reducing the total amount of carbohydrate or by consuming
foods with a lower glycemic index or glycemic load.
→ Very low carbohydrate diets may be associated with more
frequent side effects than low-fat diets. In one of the trials, a
number of symptoms occurred significantly more frequently in the
low-carbohydrate compared with the low-fat diet group. These
included constipation (68 versus 7 percent), headache (60 versus
40 percent), halitosis (38 versus 8 percent), muscle cramps (35
versus 7 percent), diarrhea (23 versus 7 percent), general
weakness (25 versus 9 percent), and rash (13 versus 0 percent).
Despite the higher rate of symptoms, dropout rashes in clinical
trials have been similar for low-carbohydrate and low-fat diets.
5. HIGH PROTEIN DIET
● Has been recommended because (PRO):
→ more satiating
→ stimulates thermogenesis
● CONs
→ Modest weight loss
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→ Some studies show no advantage over other diets
→ Effect may be due to the adjustment of other ratios when
protein is increased.
● This may still be used to improve weight maintenance.
📌 Undiscussed Section Lifted from Handouts
● HIGH PROTEIN DIET
→ In one meta-analysis of trials comparing the long-term effects of
low-fat diets with either high or low protein content, there were no
significant differences in weight loss, waist circumference, lipids,
and blood pressure.
→ In another meta-analysis of trials evaluating short-term effects
(mean trial duration 12 weeks), there were modest reductions in
weight, fat mass, and triglycerides with a high compared with
standard protein diet.
→ If dietary fat is held constant, energy from carbohydrate sources
increases as energy from dietary protein decreases. Thus,
patients randomly assigned to the low-fat, high-protein diet had
lower carbohydrate intake than those assigned to the low-fat,
low-protein diet (typically 40 versus 55 to 65 percent of daily
caloric intake).
→ Higher-protein diets may improve weight maintenance.
6. VERY LOW-FAT DIET
● Fat < 30% of total calories
● Energy intake is reduced due to low fat intake, leading to weight
loss
● Also known as the ORNISH DIET, popularized by Dr. Dean
Ornish who also promoted lacto-ovo and vegetarian diet to limit
saturated fat intake
● Limited saturated fat
● Small amounts of meat and meat alternatives, very high intake
of fiber
● This can be achieved by being given a diet list or being taught
how to count fat through nutrition labels.
📢 From Dr. Joyce Bernardino
● SHORT TERM WEIGHT LOSS
Figure 24. Comparison of Atkins, Zone, Learn and Ornish Diets
→ Now, we shall try to answer, “WHICH DIET IS THE MOST
▪ 🚩
EFFECTIVE?”
It has been shown in this study that comparing the
different diets, the ATKINS OR THE LOW
CARBOHYDRATE DIET was the most effective in
short term weight loss in 6 months even up to 12
months.
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INTERNAL MEDICINE II Malnutrition and Nutrition Therapy

− Atkins was compared to the following diets, all of which

📌 Undiscussed Section Lifted from Handouts

showed moderate weight loss: ● Many types of diets produce modest weight loss. Options include
o ZONE: HIGH PROTEIN balanced low-calorie, low-fat/low-calorie,moderate-fat/low-calorie, or
= CHO : 40% low-carbohydrate diets, as well as the Mediterranean diet.
= Protein : 30% ● Dietary adherence is an important predictor of weight loss,
= Fat : 30%
regardless of the type of diet chosen. Thus, we advise tailoring a diet
o LEARN: HIGH CARBOHYDRATE
= CHO : 55-60% that reduces energy intake below energy expenditure to individual
= <10% Saturated fat patient preferences, rather than focusing on the macronutrient
o ORNISH: LOW FAT composition of the diet.
= <10% fat ● The addition of dietary counseling may facilitate weight loss,
o ATKINS: LOW CARBOHYDRATE particularly during the first year.
= 20-50g CHO / day ● No matter which diet or dietary pattern is chosen, continued
● EFFECT OF DIETARY COMPLIANCE
surveillance by both clinician and patient are essential for treatment
success. Return visits with the clinician, dietician, or behaviorist
should be scheduled at regular intervals to assess barriers, discuss

🚩
next steps, and offer encouragement.
● If weight loss is less than 5% in the first six months, something
else should be tried.
● RECIDIVISM
→ The regaining of lost weight is a common problem in treating
people with obesity.
● Characteristics of those who are likely to succeed in maintaining
weight loss include:
→ frequent self-weighing
→ a larger initial weight loss (> 2 kg in four weeks)
→ frequent and regular attendance at a weight loss program
→ a belief that their weight can be controlled
→ consumption of a reduced calorie (eg, 1400 kcal/day) low-fat diet
→ regular physical activity
→ participation in a lifestyle intervention program
Figure 25. One-year changes in body weight as a function of diet group
and dietary adherence level for all study participants.
→ Another study was done where patients are allowed to E. GENERAL RECOMMENDATIONS
choose their diet between low carb, high protein, caloric ● The goal in starting a diet in obese patients is REDUCTION OF
restriction, or a low-fat diet. There were no differences in the TOTAL ENERGY OR CALORIC INTAKE. This can be done by:
degree of weight change according to the diet type. → Elimination of high calorie foods (such as beverages and
However, those with a good adherence were seen to have processed food)
better weight change. → Portion control
▪ ATKINS: LOW CARBOHYDRATE
→ Self-monitoring
− 20-50 g CHO / day
▪ ZONE: HIGH PROTEIN ▪ 📌 Often involving the use of food diaries, activity records,
− CHO : 40% and self-weighing
− Protein : 30% ▪ 📌 One of the elements of a successful behavioral weight
− Fat : 30% loss program
▪ WEIGHT WATCHERS ● It should be used to adopt a healthy, long-term approach to
− Caloric Restriction eating.
▪ ORNISH: LOW FAT
− <10% fat
📌 Undiscussed Section Lifted from Handouts

● Reducing total energy (caloric) intake should be the main

D.DIET SELECTION component of any weight loss intervention. To implement a
● 🚩INDIVIDUALIZE! successful dietary intervention, we typically perform a brief 24-hour
→ The best diet will always depend on the patient. dietary recall during the office visit.
● Choose based on:
→ Comorbidities F. NUTRITIONAL COUNSELING AND MONITORING
→ Usual eating habits (such as the frequency or usual amount) ● Individualized counseling may be done by referring to a
→ Preferred learning style and capabilities to prepare their Registered Nutritionist-Dietitian, who may tailor the diet
meals according to a shared decision making.
→ Perceived ability to manage hunger, sustain adherence, and ● The patient may choose between:
maintain pleasure of eating to improve quality of life → Calorie Counting Approach
→ Meal Pattern / Menu

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INTERNAL MEDICINE II Malnutrition and Nutrition Therapy

→ Portion Controlled Food ● DECREASES HbA1c

● The patient should be coached over a series of visits to check → Medical nutritional therapy has been shown to have similar
compliance and apply cognitive and behavioral strategies. or greater HBA1c reduction than what we would expect with
currently available medication especially for Type 2 Diabetes.

📢 CASE APPLICATION
● 40/M came into the clinic due to newly diagnosed hypertension
Table 1. HBA1c Decrease in DM
DM HBA1c Decrease
● Weight: 105 kgs Type 1 DM 1.9%
● Height: 5’7”
Type 2 DM 2%
● BMI: 36.3 kg/m2 (Obese)

Nutrition Assessment 📌 Undiscussed Section Lifted from Handouts

● Weight gain, previously 97 kgs ● Refer adults living with type 1 or type 2 diabetes to individualized,
● Increase intake of convenience food while working at home
diabetes-focused MNT at diagnosis and as needed throughout the
during pandemic
● 24H food recall – intakes 2000 kcal (divided into 3 large meals lifespan and during times of changing health status to achieve
only) treatment goals. Coordinate and align the MNT plan with the overall
management strategy, including the use of medications, physical
Plan activity, etc., on an ongoing basis.
● Low Calorie Diet (1500 kcal/day) ● Refer adults with diabetes to comprehensive diabetes
● DASH dietary pattern (low sodium and low saturated fat; self-management education and support (DSMES) services.
increased fruits, vegetables, whole grains)
Diabetes-focused MNT is provided by a registered dietitian
● Refer to RND for counseling.
● Patient prefers meal delivery service initially, due to lack of time nutritionist/registered dietitian (RDN), preferably one who has
to prepare. comprehensive knowledge and experience in diabetes care.
● Food diary for monitoring, initial 2-week follow-up, then monthly. ● When counseling people with diabetes, a key strategy to achieve
glycemic targets should include an assessment of current dietary
PART III: NUTRITIONAL THERAPY FOR PRE_DIABETES intake followed by individualized guidance on self-monitoring
AND DIABETES carbohydrate intake to optimize meal timing and food choices and to
III. NUTRITIONAL THERAPY FOR PRE-DIABETES AND guide medication and physical activity recommendations.
DIABETES ● Evidence suggests that there is not an ideal percentage of calories
.
from carbohydrates, protein, and fat for all people with or at risk for
A. MEDICAL NUTRITIONAL THERAPY diabetes; therefore, macronutrient distribution should be based on
● NUTRITIONAL ASSESSMENT
individualized assessment of current eating patterns, preferences,
● COUNSELING
and metabolic goals.
● SPECIFIC DIETARY MODIFICATIONS
→ Intended for glycemic control and weight management
→ Should be done for all patients with diabetes and 💡 CASE APPLICATION: 📢 From Dr. Joyce Bernardino
● 52/M Diabetic for 2 years lost to follow up
pre-diabetes
● Medical History:
→ Can be done by the physician in partnership with a
→ CC: lightheadedness
registered nutritionist dietitian or diabetes educator
→ ROS: polydipsia, nocturia
Should be individualized according to
● Dietary History:
● Personal and cultural preferences
→ No previous nutrition counseling
● Health literacy
→ Decreased rice and sweetened beverage intake, but no
● Access to healthy food choices
other restrictions
● Willingness and ability to make behavioral changes
→ Tried ketogenic diet from the internet but not tolerated
● Barriers to change
● Anthropometrics:
1. GOALS OF MEDICAL NUTRITION THERAPY → Weight: 80 kgs
● To promote and support healthy eating patterns such as → Height: 5’7” (1.7m)
emphasizing a variety of nutrient-dense foods in appropriate → BMI: 27.6 kg/m2
portion sizes, specifically to: → IBW: 63 kgs (Tannhauser)
→ Improve HbA1c, blood pressure, and cholesterol levels Table 2. BMI Classification.
→ Achieve and maintain body weight goals
Anthropometric Asia- Pacific WHO
→ Delay or prevent macrovascular and microvascular Measures
complications
Overweight 23 kg/m2 25 kg/m2
● To maintain the pleasure of eating by providing positive
Obese 25 kg/m2 30 kg/m2
messages about food choices while limiting food choices only
when indicated by scientific evidence. This is obese according to the Asia-Pacific classification but
● To provide the individual with diabetes practical tools for overweight according to the WHO classification.
day-to-day meal planning. ● Waist Circumference (WC): 105cm (elevated)
● Hip Circumference: 92cm
2. EFFECTIVENESS OF MEDICAL NUTRITIONAL THERAPY

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● Waist-Hip Ratio (WHR): 1.14 (above 0.9 indicating abdominal the glycerol component of fat or gluconeogenic amino acids in
obesity) protein), and/or ketogenesis in the setting of very low dietary
Table 3. Waist Circumference Cutoff Value. carbohydrate intake.
WC cutoff Asia- Pacific WHO Japan
value 1. GLYCEMIC INDEX
MEN 90 cm 101.6 cm 85 cm ● A ranking of carbohydrate food by how much they raise blood
glucose levels compared to equal quantity (example: 50g) of
WOMEN 80 cm 88.9 cm 90 cm
carbohydrate in a reference food (i.e., glucose or white bread).
● Laboratories:
→ RBS: 280 mg/dL
→ FBS: 190 mg/dL
Random and fasting blood glucose are elevated. Hence,the
patient is diagnosed with UNCONTROLLED TYPE 2 DIABETES
MELLITUS.

B. TOTAL CALORIE REQUIREMENT

● Formula: TCR= IBW x 25-35 kcal/body weight/ day

💡 CASE CONTINUATION: 📢 From Dr. Joyce Bernardino

● First, we used a weight-based equation using Ideal Body
Weight (IBW) since the patient is overweight.
Figure 26. Red line. Shows that the glucose levels after 1 hour is higher in
● It is multiplied by 25-35 calories per ideal body weight (IBW)
High Glycemic Index foods like chips, biscuits, cakes etc. compared to Gray
● Since we want the patient to lose weight: line which has lower blood glucose level increase.
→ We multiply it with the lower value which is 25 kcal/body ● High Glycemic Index foods:
weight/day → Chips, biscuits, cakes, etc. (refer to image above)
● Computation: ● Low Glycemic Index foods:
TCR = IBW (63kg) x 25 kcal/kg/day → Basmati rice, vegetables, lentils, pasta, whole grain bread,
= 1575 kcal/day oats and oranges.
=rounded off 1600 kcal/day Table 5. Glycemic Index.
We distribute it as follows: GLUCOSE WHITE BREAD
Table 4. Calorie Distribution. STANDARD STANDARD
MACRONUTRIENTS PERCENTAGE
HIGH Glycemic ≥ 70 ≥ 100
Carbohydrates 50-60%
Index
Protein 10-20%
Fat 30% or less MEDIUM Glycemic 56-69 80-99
Index
LOW Glycemic Index ≤ 55 ≤ 79
C. CARBOHYDRATES
● 🚩 This macronutrient affects glycemic control the most ● In some countries, items which claim to have low GI should
● It is recommended that patients: have to be certified with GLYCEMIC INDEX FOUNDATION
→ Take nutrient dense carbohydrate sources that are high in CERTIFIED logo:
fiber and minimally processed.
▪ Emphasize non-starchy vegetables, food with minimal
added sugars, fruits, whole grains as well as dairy
products.
→ Limit processed food with added simple sugars
▪ Since these are easily absorbed and can also easily
contribute to increase in calorie intake and weight gain.
▪ Examples: cakes, cookies, donuts Figure 27. Glycemic Index Foundation Certified Logo.
→ Replace sugar sweetened beverages, including fruit juices
with water as much as possible. 📌 Undiscussed Section Lifted from Handouts
📌 Undiscussed Section Lifted from Handouts
● The glycemic index (GI) is a measure of the blood glucose-raising
● The amount of carbohydrate required for OPTIMAL HEALTH in potential of the carbohydrate content of a food compared to a
humans is UNKNOWN. reference food (generally pure glucose).
● Although the recommended dietary allowance for carbohydrate for ● Carbohydrate-containing foods can be classified as high- (≥70),
adults without diabetes (19 years and older) is 130 g/day and is moderate- (56-69), or low-GI (≤55) relative to pure glucose (GI=100).
● Consumption of high-GI foods causes a sharp increase in
determined in part by the brain’s requirement for glucose, this energy
postprandial blood glucose concentration that declines rapidly,
requirement can be fulfilled by the body’s metabolic processes, whereas consumption of low-GI foods results in a lower blood
which include glycogenolysis, gluconeogenesis (via metabolism of glucose concentration that declines gradually.

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● 🚩 The disadvantage of the glycemic index: SOLUBLE FIBER

→ Does not take into account the actual serving of an item.
● Attracts water and turns into gel, hence aiding patients with
→ Hence, glycemic load was developed since it takes into
diarrhea
account the quality and quantity of carbohydrates.
● Slows down digestion
2. GLYCEMIC LOAD ● Lowers blood cholesterol
● Glycemic load reflects both the quality and the quantity of INSOLUBLE FIBER
dietary carbohydrates ● aka “roughage”
● Examples: ● Made of non-digestible/non-soluble cellulose
→ GI of watermelon per 50g = 72% ● Speeds food through digestive tract
→ Carbohydrate in a watermelon = 8g/serving ● Adds bulk to prevent constipation
→ GL of a watermelon = 0.72 x 8g = 5.7g BOTH
▪ MEANS, despite having high GI, the watermelon actually
● Pass through body without elevating blood glucose
low GL. It may be taken in moderation.
● It is good to have an idea on these concepts. However, studies
● 📢Does not increase blood glucose
● Aid blood glucose control and insulin response
show uncertainty on its applicability due to the diversity of
carbohydrate-containing items. 📌 Undiscussed Section Lifted from Handouts

Table 6. Glycemic Load. FIBER INTAKE

GLUCOSE WHITE BREAD ● People with diabetes and those at risk for diabetes are encouraged
STANDARD STANDARD to consume at least the amount of dietary fiber recommended for the
HIGH Glycemic > 20 >27 general public; increasing fiber intake, preferably through food
Index (vegetables, pulses [beans, peas, and lentils], fruits, and whole intact
MEDIUM Glycemic 11-19 15-27 grains) or through dietary supplement, may help in modestly
Index lowering A1C.
LOW Glycemic Index <10 <14 ● The regular intake of sufficient dietary fiber is associated with lower
📌 Undiscussed Section Lifted from Handouts
all-cause mortality in people with diabetes. Therefore, people with
diabetes should consume at least the amount of fiber recommended
● The glycemic load (GL) is obtained by multiplying the quality of (minimum of 14 g of fiber per 1,000 kcal) with at least half of grain
carbohydrate in a given food (GI) by the amount of carbohydrate in a consumption being whole intact grains (8). Other sources of dietary
serving of that food. fiber include non-starchy vegetables, avocados, fruits, and berries,
● Two systematic reviews of the literature regarding GI and GL in as well as pulses such as beans, peas, and lentils.
individuals with diabetes and at risk for diabetes reported NO ● A few studies have shown modest A1C reduction (−0.2% to −0.3%)
SIGNIFICANT IMPACT on A1C and mixed results on fasting (with intake in excess of 50 g of fiber per day. However, such very
glucose. high intake of fiber may cause flatulence, bloating, and diarrhea.
● Further, studies have used varying definitions of low and high GI Meeting the recommended fiber intake through foods that are
foods, leading to uncertainty in the utility of GI and GL in clinical naturally high in dietary fiber, as compared with supplementation, is
care. encouraged for the additional benefits of coexisting micronutrients
and phytochemicals.
D. FIBER
● Carbohydrates NOT BROKEN DOWN by the human body.
E. PROTEIN
● Recommended: 14G PER 1000 KCAL
● 10-20% of total calories
● Modest Hba1c reduction of less than 0.2 to 0.3% at 50g/day
● Or by using the patient’s weight as shown in the table
→ However, it contributes to bloatedness and flatulence.
.
Table 7. Protein Requirement.

TYPES OF FIBER FOR DIABETES MANAGEMENT CONDITION PROTEIN REQUIREMENT

Stable DM 0.8 – 1.2 g/kg/day
CKD St. 3-5 (Pre-dialysis) 1 g/kg/day
CKD St. 5 (Dialysis)* 1.2 – 1.5 g/kg/day
*those on dialysis will need more protein
Case Example
● IBW = 63kg
● Protein = 63kg x 1g/BW (16%) = 63g or 65g
→ Preferably low to medium fat meat.
📌 Undiscussed Section Lifted from Handouts

PROTEIN INTAKE
● There is limited research in people with diabetes or prediabetes
without kidney disease on the impact of various amounts of protein
Figure 28. Soluble vs. Insoluble Fiber.

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INTERNAL MEDICINE II Malnutrition and Nutrition Therapy
consumed. Some comparisons of protein amounts have not
demonstrated differences in diabetes-related outcomes. A 12-week
study comparing 30% vs. 15% energy from protein noted
improvements in weight, fasting glucose, and insulin requirements in
the group that consumed 30% energy from protein. A meta-analysis
from 2013 of studies ranging from 4– 24 weeks in duration reported
that high-protein eating plans (25–32% of total energy vs. 15–20%)
resulted in 2 kg greater weight loss and 0.5% greater improvement in
A1C but no statistically significant improvements in fasting serum
glucose, serum lipid profiles, or blood pressure.
F. FAT
📢
● Mediterranean style eating pattern rich in monounsaturated
and polyunsaturated fats may be considered to improve
glucose metabolism and lower cardiovascular disease
risks.
● Eating foods rich in long chain n 3-fatty acids, (EPA and DHA)
such as fatty fish, nuts, and seeds are recommended.
1. GOOD FAT
● MONOUNSATURATED FATS are known to increase the good
cholesterol or HDL.
→ Can be found in plants such as avocado, olive oil and nuts
and seeds.
● POLYUNSATURATED FATTY ACIDS do not increase HDL
nor LDL.
→ Found in corn oil, vegetable oil, canola oil, sesame oil and
sunflower oil.
2. BAD FAT
● Comes from SATURATED FATS which can increase your
LDL.
→ Includes bacon, pork rinds, butter, and mayonnaise.
📌 Undiscussed Section Lifted from Handouts
DIETARY FAT AND CHOLESTEROL INTAKE
● The National Academy of Medicine has defined an acceptable
macronutrient distribution for total fat for all adults to be 20–35% of
total calorie intake. Eating patterns that replace certain carbohydrate
foods with those higher in total fat, however, have demonstrated
greater improvements in glycemia and certain CVD risk factors
(serum HDL cholesterol [HDL-C] and triglycerides) compared with
lower fat diets. The types or quality of fats in the eating plans may
influence CVD outcomes beyond the total amount of fat. Foods
containing synthetic sources of trans fats should be minimized to the
greatest extent possible. Ruminant trans fats, occurring naturally in
meat and dairy products, do not need to be eliminated because they
are present in such small quantities.
G. EATING PATTERNS
● There are eating patterns related to prediabetes or Type 2 DM
prevention:
→ Mediterranean style
→ Low Fat
– PREDIMED Trial compared to Mediterranean vs Low Fat
Diet and resulted in 30% lower relative risk for developing
📢
Type 2 DM for the Mediterranean diet.
Both of which (Mediterranean style and Low fat) were
compared in a large randomized controlled trial and showed
Group 5A
30% reduction and relative risk for developing type 2 DM for
the Mediterranean diet.
→ Vegetarian
→ Dietary Approaches to Stop Hypertension (DASH) Diet
▪ To lower type 2 DM risk
→ Low Carbohydrate Diet
▪ Used for glucose control
● It is unclear which is the best and should be tailored to the
individual needs.
📌 Undiscussed Section Lifted from Handouts
EATING PATTERNS
● The most robust research available related to eating patterns for
prediabetes or type 2 diabetes prevention are Mediterranean-style,
low-fat, or low-carbohydrate eating plans. The PREDIMED trial, a
large RCT, compared a Mediterranean-style to a low-fat eating
pattern for prevention of type 2 diabetes onset, with the
Mediterranean-style eating pattern resulting in a 30% lower relative
risk. Epidemiologic studies correlate Mediterranean-style,
vegetarian, and Dietary Approaches to Stop Hypertension (DASH)
eating patterns with a lower risk of developing type 2 diabetes, with
no effect for low-carbohydrate eating patterns. Several large type 2
diabetes prevention RCTs used low-fat eating plans to achieve
weight loss and improve glucose tolerance, and some demonstrated
decreased incidence of diabetes. Given the limited evidence, it is
unclear which of the eating patterns are optimal.
H. MICRONUTRIENTS
● Needed in small amounts and are usually met in an adequate
balanced and varied diet.
● No clear evidence that dietary supplementation of vitamins and
minerals, herbs or spices can improve outcomes in people with
diabetes, who do not have underlying deficiencies.
● Not recommended for glycemic control.
📌 Undiscussed Section Lifted from Handouts
MICRONUTRIENTS
● Without underlying deficiency, the benefits of multivitamins or
mineral supplements on glycemia for people with diabetes or
prediabetes have not been supported by evidence, and therefore
routine use is not recommended.
● It is recommended that MNT for people taking metformin include an
annual assessment of vitamin B12 status with guidance on
supplementation options if deficiency is present.
● The routine uses of chromium or vitamin D micronutrient
supplements or any herbal supplements, including cinnamon,
curcumin, or aloe vera, for improving glycemia in people with
diabetes is not supported by evidence and is therefore not
recommended.
I. NON-NUTRITIVE SWEETENERS
● Substances that lend a sweet taste but without the calories
unlike sugars.
● Reduces overall calorie and carbohydrate intake if substituted
for caloric (sugar) sweeteners if not compensated by intake of
additional calories from other food sources.
📌 Undiscussed Section Lifted from Handouts
Page 14 of 17
INTERNAL MEDICINE II Malnutrition and Nutrition Therapy

● In patients taking long-acting insulin or tablets, alcohol

SWEETENERS
increases the effects and makes the medication last longer and
● Replace sugar-sweetened beverages (SSBs) with water as often as
stronger.
possible.
● When sugar substitutes are used to reduce overall calorie and 📌 Undiscussed Section Lifted from Handouts

carbohydrate intake, people should be counseled to avoid ALCOHOL CONSUMPTION

compensating with intake of additional calories from other food
sources.
J. SODIUM
● Recommended daily intake for sodium is a maximum of 2.3
gms.
→ Preparation during cooking should be lightly salted and once
served, there should be no added salt in the form of soy or
fish sauce, anchovy paste, or catsup.
● It is recommended that adults with diabetes or prediabetes who drink
alcohol do so in moderation (one drink or less per day for adult
women and two drinks or less per day for adult men).
● Educating people with diabetes about the signs, symptoms, and
self-management of delayed hypoglycemia after drinking alcohol,
especially when using insulin or insulin secretagogues, is
recommended. The importance of glucose monitoring after drinking
alcohol beverages to reduce hypoglycemia risk should be
emphasized.

L. GLYCEMIA TARGETED SPECIALIZED NUTRITION (GTSN)

● GTSN or diabetes-specific formulas.
● May be used for calorie replacement or supplementation as part
of medical nutrition therapy (MNT).
● These are liquid food or beverages that can either substitute for
meals for patients who are obese or overweight and these can
be an add-on for those diabetics who are underweight.
● Contain nutrients that are designed to facilitate glycemic control.
Such nutrients include:
→ Modified maltodextrin (starch) → Soy protein
Figure 29. Example of foods that should be limited → Fructose → Fiber
● Processed and high salt foods like canned goods, salted fish, or → Monounsaturated fatty acids → Antioxidants
cured meats should also be limited.
📢 CASE APPLICATION (CONTINUATION)
● Case Dietary Prescription:
→ Diabetic Diet 1600 kcal
→ You can either write the percentages or the grams.
▪ Example:
− Carbohydrates (60%) = 240 g
o High in fiber, limit simple sugars
− Protein (16%) = 65 g (1g/BW)
o Lean to moderate fat
− Fats (24%) = 42 g fat
o MUFA > PUFA
− Divided into 3 meals and 2 snacks
− This will now be translated by the dietitian where it will
Figure 30. Example of ready-mix flavor enhancers or seasonings. now be served to the patient in the following portions.
● Limit the use of ready-mix flavor enhancers or seasoning during − When the patient is for discharge, they may be
cooking. provided with something like this: a meal plan with
● Allowed seasonings are the following: food exchange list so that the patient would know the
→ Pepper → Ginger quantity of the food options that he can have.
→ All-spices → Herbs
→ Cinnamon → Paprika
→ Curry powder → Mustard
→ Garlic → Parsley
→ Onion → Vinegar
K. ALCOHOL
● As per alcohol, a drink is defined as 12 oz of beer, ½ oz of hard
drinks, and 5 oz of wine.
● Moderate alcoholic beverage intake is defined as:
→ 1 drink or less per day - Women
→ 2 drinks or less per day - Men
● Risk of drinking with diabetes can result in a low blood sugar
especially when drinking on an empty stomach.

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Figure 33. Idaho Plate Method.

3. CARBOHYDRATE COUNTING
● Since the carbohydrate intake will mostly affect blood sugar
levels, the patient can be taught how many carbohydrates they
Figure 31. Meal plan example.
are allowed to eat per meal
M. DIFFERENT COUNSELING TECHNIQUES ● This can be the gauge how much insulin they will require if
● These are different counseling techniques that may be taught to given in bolus
the patient. 4. NUTRITION LABELS
1. FOOD PORTIONING ● Nutrition Labels: 5-20% RULE
● They may be given a food exchange list and the patients may → For some store-bought foods, patients may be taught to
be taught to portion their food items check nutrition labels.
● The hand may be used to estimate an exchange → We start by checking the serving size, how many servings
per packet, and the amount of calories per serving.
→ Patients may usually be advised to stick to one serving.
→ We check for the amount of fat and sodium, followed by the
carbohydrate, fiber, and sugar.
● Some foods are fortified and is mandated by the government by
adding vitamins and minerals to processed food to prevent
deficiency.
● Quick guide is that 5% is low and more than 20% is high.

Figure 32. Hand portioning. Bread can be the size of one hand, meat the
size of a palm, one cup is equivalent to one fist, and the fingertips can be
used to estimate one teaspoon of fat.
2, IDAHO PLATE METHOD
● Used for those who have a hard time in counting and measuring
exchanges
● They can be using their plate to include half non-starchy
vegetables, ¼ plate of starch, and ¼ plate of protein
● They can add an exchange of fruit, milk. or yogurt
● The plate size recommended is to be at 9 INCHES.

Figure 34. Nutrition Labels

📢 CASE APPLICATION (CONTINUATION)

● Patient was referred to the Dietitian
● Upon nutrition assessment of dietary preferences, patient was
amenable to be provided a meal plan with food exchange list
● Advised Food Diary for monitoring of intake
● Weekly weight monitoring

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SUMMARY ● Harrison’s Principles of Internal Medicine, 20th Ed.

● Different Dietary Patterns in the Management of Obesity as well ● Philippine Society for Parenteral and Enteral Nutrition, Basic
their advantages and disadvantages. Nutrition Support Module, 2019
● Recommendations on Diet Selection, Counseling, and ● American Society for Parenteral and Enteral Nutrition,
Monitoring. www.nutritioncare.org
● Given a patient, provide Total Calories, specify the quantity and
quality of carbohydrates, protein, and fats.
● Specify amounts of Fiber, Sodium, Micronutrients, Non-nutritive
sweeteners, Alcohol and Glycemia targeted specialized
nutrition.
● Refer to the dietitian where the different counseling methods
can be done to meet the patients' needs.
REVIEW QUESTIONS
1. A 71/M was admitted due to little to no nutritional intake for
the past week. He was recently diagnosed with Colon
Cancer, 1 month ago. Which type of malnutrition is
present?
a. Starvation related malnutrition
b. Acute disease related malnutrition
c. Chronic disease related malnutrition
2. A 80/M with progressive parkinsons has note of
progressive weight loss and difficulty swallowing. Dextrose
was started and laboratory findings show hypokalemia and
hypophosphatemia. Which is the patient at risk for?
a. Starvation Syndrome
b. Cachexia syndrome
c. Malnutrition Syndrome
d. Refeeding Syndrome
3. Which modality measures functional outcomes in patients
with malnutrition?
a. DEXA
b. Bioimpedance analysis
c. CT scan
d. Handgrip strength
4. A 35 year old female with a family history of diabetes and
hypertension, would like to know how she can start on a
Mediterranean diet. Which of the following is included in
the advice?
a. Low Sodium
b. Increased alcoholic beverage intake
c. Monounsaturated and Omega 3 Fatty Acids
d. Reduced whole grains
5. Which factor has been seen to affect the effectiveness of
weight loss diets the most?
a. Patient compliance
b. Duration of fasting
c. Carbohydrate reduction
d. Calorie restriction
6. What should be done for effective nutritional counselling?
a. Refer to a dietician for meal planning
b. Give limited food options
c. Verbalize only what not to eat
Answers: c, d, d, c, a, a

REFERENCES
● Dr. Joyce Bernardino’s 2021 Video lectures (Causes and Types
of Malnutrition; Nutritional Therapy for Obesity; Nutritional
Therapy for Pre-Diabetes and Diabetes)
● Dr. Joyce Bernadino’s 2022 Handout

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