,661 $VLDQ-RXUQDORI'LHWHWLFV

9RO1R
&RQWHQWV
3DJH 77LWOHDQGDXWKRUV/HWWHUIURP$-'
(GLWRULQ&KLHI³([SHFWDWLRQVIRU$&'´
7KLQNLQJDERXWEHFRPLQJDGLHWLWLDQZKRLVWUXVWHGDQGUHVSHFWHGE\VRFLHW\
6KLJHUX<DPDPRWR

6SHFLDO5HSRUW
6FKRRO0HDO
3URJUDP

1XWULWLRQ7HDFKHU6FKRRO'LHWLWLDQDW-DSDQHVH6FKRRO/XQFK$3HUVSHFWLYHIURP9LHWQDPHVH'LHWLWLDQV
1RLQD6HULHV
1JX\HQ+XRQJ*LDQJ1JX\HQ0DL3KXRQJ1JX\HQ9DQ'LHS

2ULJLQDO5HVHDUFK)DFWRUV ,QIOXHQFH LQ )RRG &KRLFHV DQG (IIHFW RQ 7KH %RG\&RPSRVLWLRQDPRQJ6WDIILQ,QVWLWXW.DQVHU1HJDUD0DOD\VLD&KLRX<L +R:DL +DQ 1J 1RUVKDUL]D -DPKXUL %HWWL 6KDULQD 0RKG
+DQLII /DL =XOLHKDL]D .DKDLUXGLQ 6LWL 1XUDLQL 0RKG 6DPZLO$HLQLQKD\DWH\$EGXOODK 0D\ .D\ 1HRK $LQL 0DVLWDK 0RKDPPDG=XZDULDK$EGXO5DKPDQ2ULJLQDO5HVHDUFK1XWULWLRQDO 6WDWXV DQG 'LHW &KDUDFWHULVWLFV LQ 3DWLHQWV ZLWK,QWHVWLQDO2EVWUXFWLRQ'XHWR)RRG5HVLGXHVDW+RVSLWDOLQ9LHWQDP$QK7UDQ7KL+DL/LHQ1JX\HQ.KDQK7KL&KLQK3KDP7KL7X\HW<HQ
0D 1JRF 2DQK +RDQJ9X 2DQK 1LQK7KL +DQJ +RDQJ7KL  /LQK
1JX\HQ7KX\&DVHUHSRUW

3URWHLQ (QHUJ\ 0DOQXWULWLRQ ZLWK 5HIHHGLQJ 6\QGURPH DIWHU
%DULDWULF6XUJHU\&KLRX<L+R1RUVKDUL]D-DPKXUL&DVHUHSRUW1XWULWLRQ6XSSRUWIRU&RQWUROOLQJ%ORRG*OXFRVHLQD&DVH6HULHVRI
&RYLG3DWLHQWVZLWK+\SHUJO\FHPLD<HQ0D1JRF7KDR7UDQ3KXRQJ2DQK1LQK7KL$Q%XL7XRQJ/LQK
1JX\HQ7KX\

Asian Journal of Dietetics

Asian Journal of Dietetics 2022

Letter from AJD Editor in Chief
Expectations for ACD2022
Thinking about becoming a dietitian who is trusted and respected by society
Shigeru Yamamoto, RD, PhDIn the process of teaching dietetics for more than
40 years, I feel that dreams and worries of young
dietitians are similar to what I experienced, whichreminds me of my younger days and pushes me towork for them
ACD2022 agreed with me to arrangeprogram two
symposiums and a workshop to consider how toaddress the worries and dreams of dietitians  The
tentative titles are, What should we do to be dietitians
trusted and respected by society, Let's support the
Asian Journal of Dietetics of the dietitians, by the
dietitians and, for the dietitians, ³Workshop for young
dietitians on understanding the current state of the legal
system of each country regarding dietitians and whatshould be improved¶My thoughts on such ideas come from thefollowingA dietitian is the most important expert onfood and healthHowever, it is not registered dietitians
RD  but medical doctors MD , food scientists, etc
who have defined the recommended dietary
allowances RDAs everywhere and enteral parenteral
formulas  Looking at journal articles on clinicalnutrition, most of the authors are MDs and with few
RDs  In Japan, about 20 years ago, a system wasestablished in which it is not a MD but a registereddietitian RD  who can teach clinical nutrition in the
RDA training program  It was an event at the RD
Training Curriculum Committee; the chairman who
was a MD, claimed that MDs could teach about illness,but not about dietetics, and this became the current law

However, even with such major reforms of the law, it
seems that it is not easy for RDs to conduct researchand publish their results in journal articles  In fact,
articles published by RDs, teachers and researchers in
dietetic programs are biased toward food science,biochemistry, and epidemiology, and there is only alittle about dieteticsTo improve the situation, I think
it is necessary to recognize that research in the field ofdietetics is extremely difficult  For example, it's anestablished theory that you can lose weight if you eat
less, but how to eat less is really difficultThat is, even
if the theory is understood, it cannot be applied
Research on the central role that a dietitian should play
may fall into this area of applicationapplied researchI think that it is not easy to establish a basis for theapplication of dietitians because it spans not only foodscience and medicine but also psychology, sociology,
economics, etc, making the problem very complicatedand difficult to studyA symbolic example is that eventhough there are many papers on obesity in the UnitedStates, reallife obesity has not improved However,unless dietitians are successful in overcoming suchdifficulties, dietitian will not be a profession that istrusted and respected by societyWith that in mind, I
founded the Journal of Asian Dietetics three years ago
It would be greatly appreciated if dietitians could use
this journal to improve the research ability of RDs anduse it as an opportunity to publish journal articlesI
would like us to discuss it together in the symposiums
and workshop

To whom correspondence should be addressed
ajdyamamoto@gmailcom

Asian Journal of Dietetics

1

$VLDQ-RXUQDORI'LHWHWLFV

6SHFLDO5HSRUW6FKRRO0HDO3URJUDP
1XWULWLRQ7HDFKHU6FKRRO'LHWLWLDQDW-DSDQHVH6FKRRO/XQFK$3HUVSHFWLYHIURP9LHWQDPHVH'LHWLWLDQV
1RLQD6HULHV
1JX\HQ+XRQJ*LDQJ1JX\HQ0DL3KXRQJ1JX\HQ9DQ'LHS-XPRQML8QLYHUVLW\*UDGXDWH6FKRRO6DLWDPD-DSDQ-DSDQHVH VFKRRO OXQFKHV DUH QRW RQO\ WR SURYLGHFKLOGUHQZLWKQXWULWLRXVPHDOVEXWDOVRVHUYHDVDOLYLQJ
WH[WERRN -DSDQ SODFHV D KLJK YDOXH RQ IRRG DQGQXWULWLRQHGXFDWLRQLQVFKRROVDQGFRUUHVSRQGLQJO\VR
RQ WKH SURIHVVLRQDOV ZKR SURYLGH WKLV WHDFKLQJ WR

VWXGHQWV 7KHUH LV DW OHDVW RQH QXWULWLRQ WHDFKHU RU
VFKRRO GLHWLWLDQ LQ HDFK VFKRRO NLWFKHQ FOXVWHU RI
VFKRROV RU MRLQW NLWFKHQ ZKLFK SUHSDUHV PHDOV IRUVHYHUDOVFKRROVLQWKHVDPHDUHD 7DEOH 

7DEOH/HJDOO\UHTXLUHGQXPEHURIVFKRROGLHWLWLDQQXWULWLRQWHDFKHU
6FKRRO VWXGHQWVRYHU\HDUVROG
z 6FKRRONLWFKHQ
9 6FKRROVVHUYLQJOXQFKWRPRUHWKDQFKLOGUHQKDYHWRKDYHDVFKRROGLHWLWLDQQXWULWLRQWHDFKHU
9 6FKRROVZLWKIHZHUWKDQFKLOGUHQ7KHUHPXVWEHDVFKRROGLHWLWLDQQXWULWLRQWHDFKHUFRYHULQJVFKRROV
9 &LWLHVZLWKIHZHUWKDQVFKRROVDQGHDFKVFKRROZLWKIHZHUWKDQFKLOGUHQ7KHUHPXVWEHD
VFKRROGLHWLWLDQQXWULWLRQWHDFKHUSHUFLW\
z 6DWHOOLWHNLWFKHQVVHUYLQJOXQFKWRPRUHWKDQFKLOGUHQPXVWKDYHDQXWULWLRQWHDFKHUWRWZRQXWULWLRQWHDFKHUVDQGPRUHWKDQQXWULWLRQWHDFKHUV
LQWURGXFHG E\ the Japan Dietetic Association 7KHGXWLHVLQYROYHQXWULWLRQHGXFDWLRQUHODWLQJWRPHGLFDOWUHDWPHQW IRU VLFN DQG LQMXUHG SHUVRQV QXWULWLRQHGXFDWLRQWRPDLQWDLQDQGSURPRWHKHDOWKWKDWUHTXLUHDKLJKOHYHORISURIHVVLRQDONQRZOHGJHDQGWHFKQLTXHDSSURSULDWH WR SDWLHQWuV SK\VLFDO DQG QXWULWLRQDOFRQGLWLRQDQGIRRGVHUYLFHPDQDJHPHQW
Dietitians are licensed by prefectural governments
Their work is providing food service management andworking under the supervision of a RD when in direct
patientclient nutrition care

7KHV\VWHPRIWUDLQLQJIRU-DSDQHVHGLHWLWLDQV'LHWLWLDQ LV D IRRG DQG QXWULWLRQ SURIHVVLRQDO ,Q
-DSDQWKHUHDUHUHJLVWHUHGGLHWLWLDQ 5' DQGGLHWLWLDQ$FFRUGLQJ WR 'LHWLWLDQ$FW SXEOLVKHG E\ 0LQLVWU\ RI
+HDOWK/DERUDQG:HOIDUH
Registered Dietitians are licensed by the Ministryof Health, Welfare and Labor 5' LV D WHUP WKDWRULJLQDWHG LQ WKH 8QLWHG 6WDWHV DQG QRZ XVHGFRPPRQO\ ZRUOGZLGH 2IILFLDO QDPH RI -DSDQ LV D
NDQULHL\RRVL PDQDJHPHQW OHYHO GLHWLWLDQ  DQG ZDV)LJ7KHOLFHQVLQJSURFHVVIRUGLHWLWLDQDQGUHJLVWHUHGGLHWLWLDQ 6RXUFH-DSDQ'LHWHWLF$VVRFLDWLRQCorresponding authorgiang3900@gmailcom

1XWULWLRQWHDFKHU6FKRROGLHWLWLDQ
7KH V\VWHP RI WUDLQLQJ IRU QXWULWLRQ WHDFKHUV DQGVFKRRO GLHWLWLDQV GDWHV EDFN DERXW KDOI D FHQWXU\%HIRUHWKHUHZHUHQRMREWLWOHVIRUWKHSRVLWLRQVRIGLHWLWLDQDQGDSSURSULDWHMREWLWOHVZHUHQRWXVHG$W
WKDW WLPH WKH PDLQ DFWLYLW\ RI SHUVRQQHO LQYROYHG LQ
VFKRROOXQFKHVZDVIRRGSUHSDUDWLRQ6WDIIPDLQO\GLGFRRNLQJ DQG SODQQLQJ DQG LPSOHPHQWLQJ QXWULWLRQHGXFDWLRQ ZHUH GRQH RQO\ E\ WKH UHTXHVW RI RWKHUWHDFKHU,QWKH0LQLVWU\RI(GXFDWLRQLQWURGXFHGSDUWLDO VXSSRUW IRU VDODULHV RI VFKRRO GLHWLWLDQV DW
NLWFKHQVFRYHULQJVHYHUDOVFKRROVLQDJLYHQDUHD7KLVZDVJUDGXDOO\H[SDQGHGDQGHYHQWXDOO\GLHWLWLDQVZHUH
SODFHGLQHDFKVFKRRORUFOXVWHURIVFKRROV6LQFHWKHVWKHVRFLDOHQYLURQPHQWLQFOXGLQJ
WKH IDPLO\ VWUXFWXUH KDV FKDQJHG FRQVLGHUDEO\ DQGQXWULWLRQUHODWHG KHDOWK SUREOHPV KDYH EHFRPH HYHQ
PRUH SUHYDOHQW7KH FXUUHQW -DSDQHVH OLIHVW\OH LV QRWLGHDO IRU SURPRWLQJ KHDOWK 3DUHQWV ZRUN ORQJ KRXUVDQGFKLOGUHQVWXG\DWFUDPVFKRROVXQWLOODWHDWQLJKW8QGHUVXFKVRFLDOFRQGLWLRQVRQHFDQQRWEODPHWKHP
IRUHDWLQJWDNHRXWUHDG\PDGHIRRGVIURPVKRSV:KDWZH FDQ SHUKDSV KRSH IRU LV WKDW FKLOGUHQ ZLOO PDNH
EHWWHU IRRG FKRLFHV E\ IROORZLQJ WKH H[DPSOH RI WKH
PRUH DSSURSULDWH LWHPV RIIHUHG LQ WKH VFKRRO OXQFK+RSHIXOO\ LW ZLOO IRVWHU EHWWHU IRRG FKRLFHV E\ WKHH[DPSOH RI WKH VFKRRO OXQFK ZLWK PRUH DSSURSULDWH
IRRGFKRLFHV7KHNQRZOHGJHDQGKDELWVIRUPHGE\WKH
VFKRRO OXQFK SURJUDP FDQ SOD\ DQ LPSRUWDQW UROH LQ
WKLV
7R PHHW WKLV QHHG WKH VFKRRO GLHWLWLDQ LV QRZUHTXLUHG WR KDYH PDVWHUHG KLJKO\ VSHFLDOL]HGNQRZOHGJH DQG HGXFDWLRQDO PHWKRGV $ 1XWULWLRQ7HDFKHU/LFHQVHZDVHVWDEOLVKHGLQ7KHOLFHQVH
LVVLPLODUWRWKDWUHTXLUHGIRUWHDFKHUVRIRWKHUVXEMHFWV
7KHUHDUHOHYHOVRISHUVRQQHOGHSHQGLQJXSRQWKHLU
DFDGHPLF EDFNJURXQG JUDGXDWLRQ IURP D MXQLRUFROOHJHIURPDUHJXODUFROOHJHRUXQLYHUVLW\RUIURPJUDGXDWHVFKRRO$UHJLVWHUHGGLHWLWLDQRUGLHWLWLDQFDQ
REWDLQWKHOLFHQVHDIWHU\HDUVuH[SHULHQFHZRUNLQJLQ
D VFKRRO DQG  OHFWXUH FUHGLWV,Q  WKHUH ZHUH
 QXWULWLRQ WHDFKHUV EXW E\  WKLV QXPEHUKDV
LQFUHDVHGWR

%HVLGHVPDQDJLQJVFKRROOXQFKWKH\VXSSRUWQXWULWLRQHGXFDWLRQ7KH\GRQRWJLYHFODVVHVGLUHFWO\WRFKLOGUHQEXWWKH\PD\LVVXHVFKRROOXQFKQHZVOHWWHUVRUVXSSRUWQXWULWLRQ HGXFDWLRQ JXLGDQFH SURYLGHG E\ RWKHUWHDFKHUV1XWULWLRQ WHDFKHU LV D SHUVRQ ZKR KDV D GLHWLWLDQUHJLVWHUHG GLHWLWLDQ OLFHQVHD WHDFKHU OLFHQVH DQG KDVWKH QHFHVVDU\ NQRZOHGJH RU H[SHULHQFH WR FDUU\ RXWVFKRRO OXQFK 7KH\ FDQ SURYLGH QXWULWLRQ HGXFDWLRQGLUHFWO\WRFKLOGUHQWKURXJKFODVVHVDQGVFKRROHYHQWV
DQG JLYH LQGLYLGXDO FRQVXOWDWLRQV IRU FKLOGUHQ ZLWKKHDOWKSUREOHPVSHUWDLQLQJWRIRRG
 %RWK RI WKHP DOVR ZRUN ZLWK RWKHU WHDFKHUVFKLOGUHQuV IDPLOLHV DQG WKH ORFDO FRPPXQLW\ WRFRRUGLQDWHHQKDQFHGGLHWDU\JXLGDQFH

'XWLHVRIVFKRROGLHWLWLDQDQGQXWULWLRQWHDFKHU-RE FRQWHQW RI VFKRRO GLHWLWLDQV DQG QXWULWLRQWHDFKHUV DUH GLIIHUHQW 7KH VDPH GXW\ LV SURYLGLQJVFKRRO OXQFK PDQDJHPHQW ZKLFK LQFOXGH FUHDWLQJPHQXV VHOHFWLQJ DQG SXUFKDVLQJ LQJUHGLHQWVPDQDJLQJ IRRG FRRNLQJ DQG GLVWULEXWLRQ DQGPDQDJLQJ K\JLHQH RI NLWFKHQ (DFK RI WKHP FUHDWHVDERXW  PHQXV SHU \HDU ZKLFK PXVW VDWLVI\ WKHGLHWDU\ UHIHUHQFH LQWDNHV VWXGHQWV  WDVWH ORFDO IRRGFXOWXUHDQGWUDGLWLRQV
6FKRRO GLHWLWLDQ LV D SHUVRQ ZKR KDV D OLFHQVH RI
GLHWLWLDQ UHJLVWHUHG GLHWLWLDQ DQG KDV WKH QHFHVVDU\NQRZOHGJH RU H[SHULHQFH WR FDUU\ RXW VFKRRO OXQFK,Q FRQFOXVLRQ QXWULWLRQ WHDFKHUVVFKRRO GLHWLWLDQV
DUH LQGLVSHQVDEOH LQ SURYLGLQJ GHOLFLRXV DQG VDIHOXQFKHV DV ZHOO DV LPSURYLQJ IRRG DQG QXWULWLRQNQRZOHGJH IRU FKLOGUHQ 7KH UHZDUG RI QXWULWLRQWHDFKHUV DQG VFKRRO GLHWLWLDQV ZRUNLQJ LV WR VHHFKLOGUHQHDWOXQFKZLWKKDSSLQHVVDQGJURZXSHYHU\
GD\7KHZRUNLVQRWHDV\KRZHYHUZKHQWKH\UHFHLYHFRPSOLPHQWVRUOHWWHUVIURPFKLOGUHQDQGWHDFKHUVVXFKDV,WZDVGHOLFLRXVWRGD\,ZDVDEOHWRHDWYHJHWDEOHVWKDW , ZDV QRW JRRG DW 2U (YHU\RQH KDV ILQLVKHGHDWLQJWKH\ZLOOEHHQFRXUDJHGDQGUHZDUGHGIRUWKHLUZRUN

)RRGDQGQXWULWLRQHGXFDWLRQDWVFKRROE\QXWULWLRQWHDFKHUVVFKRROGLHWLWLDQV(GXFDWLRQ DERXW IRRG DQG KHDOWK LV SURYLGHG LQ
FRQQHFWLRQZLWKWKHVFKRROOXQFKE\GLHWDQGQXWULWLRQWHDFKHUVVFKRRO GLHWLWLDQV ZRUNLQJ LQ WDQGHP ZLWKWHDFKHUV RI RWKHU VXEMHFWV%\ WKLV ZD\ FKLOGUHQ FDQOHDUQ KRZ WR PDNH KHDOWK\IRRG FKRLFHVOHDUQ DERXWDJULFXOWXUDOSUDFWLFHVIRRGSURGXFWLRQDQGGLVWULEXWLRQDQGFXOWXUDOWUDGLWLRQV)RUH[DPSOHLQDVRFLDOVWXGLHVFODVVVWXGHQWVPD\FDOFXODWHWKHGLVWDQFHWKDWYDULRXVIRRGVLQDVFKRROOXQFKRQDJLYHQGD\KDYHWUDYHOHG
IURPWKHLUSURGXFWLRQDUHDWRWKHVFKRRO6WXGHQWVDOVRFDOFXODWHWKHQHFHVVDU\IXHODQGGLVFXVVLWVHIIHFWVRQ
WKH HDUWKuV HFRORJ\ ,Q D SK\VLFDO HGXFDWLRQ FODVVVWXGHQWVUHFRUGWKHLURZQFKDQJHVLQKHLJKWDQGZHLJKWDQG OHDUQ DERXW WKH QXWULWLRQDO FRQWULEXWRUV WR WKHLUJURZWK,Q(QJOLVKFODVV(QJOLVKUHODWLQJWRWKHPHQX
RI WKH GD\ LV WDXJKW VXFK DV WKH QDPHV RI IRRGVFRRNLQJPHWKRGVWDEOHPDQQHUVQXWULHQWVHWF7KRVHH[SHULHQFHVEHFRPHJRRGRSSRUWXQLWLHVWROHDUQDERXWQXWULWLRQ DV ZHOO DV JRRG PHPRULHV 7KLV EURDGSHUVSHFWLYH RQ IRRG DQG QXWULWLRQ KHOSV LQVWLOO LQ
FKLOGUHQ D VHQVH RI JUDWLWXGH IRU WKH IRRG WKH\ DUHHDWLQJDQGDQDSSUHFLDWLRQIRUDQGLQWHUHVWLQLWVRULJLQV,QDGGLWLRQLWLVOLNHO\UHVSRQVLEOHIRUWKHUHPDUNDEO\ORZOHYHOVRIIRRGZDVWHUHSRUWHGE\PDQ\VFKRROVAsian Journal of Dietetics 202

Original
Factors Influence in Food Choices and Effect on The Body Composition among Staff
in Institut Kanser Negara, Malaysia
Chiou Yi Ho, Wai Han Ng, Norshariza Jamhuri, Betti Sharina Mohd Haniff Lai, Zuliehaiza
Kahairudin, Siti Nuraini Mohd Samwil, Aeininhayatey Abdullah, May Kay Neoh,
Aini Masitah Mohammad, Zuwariah Abdul Rahman'HSDUWPHQWRI'LHWHWLFDQG)RRG6HUYLFH,QVWLWXW.DQVHU1HJDUD0LQLVWU\RI+HDOWK-DODQ33UHVLQW3XWUDMD\D0DOD\VLD
8QLRI'LHWHWLF.OLQLN.HVLKDWDQ7HPHUORK0LQLVWU\RI+HDOWK-DODQ7ULDQJ
7HPHUORK3DKDQJ0DOD\VLD'HSDUWPHQWRI'LHWHWLFDQG)RRG6HUYLFH+RVSLWDO7XQNX$]L]DK0LQLVWU\RI+HDOWK-DODQ5DMD0XGD$EGXO$]L].XDOD/XPSXU0DOD\VLD

ABSTRACT  Background and purpose There are many factors influence individual foodchoices and intake  Unhealthy diet pattern and food choices may increase risk of obesity,
chronic diseases and malnutrition This study aims to determine the contributable factors
influence in food choices and effect on the body compositionMethodsAn observational pilot
study was carried out on participants who were staff of Institut Kanser Negara, Putrajaya,
Malaysia; females and males, mean age ±years old using crosssectional andconvenient sampling methodA structured selfadministered questionnaire was used to attain
information regarding the factors influence in food choices and the effect on the bodycomposition to assist in weight managementThere were influence in factors queried whichwere health, mood, convenience, sensory, nutrient content, price, weight control, familiarityand ethical concernParticipantsubody composition was obtained using calibrated Total Body
Composition Analyser TANITA ResultAbout 51of participants were underweightnormal
while 49 were overweightobese Weight, muscle mass and fat percentage among maleparticipants were statistically significantly higher than female, 7298 ± 1354 kg vs 6065 ±
1176 kg, 5199 ± 637 kg vs 3728 ± 526 kg and 2378 ± 748vs 3362 ± 698 respectivelyp<001 No significant differences between gender for all factorsThe top factor influence infood choices was health while the least factor was ethical concern environmental and politicalissues  for both genders Overweightobese group significantly considered health, mood,convenience, nutrient content and weight control more than underweightnormal individuals infood choicesFactors significantly associated with body weight were mood, convenience andnutrient contents while factors significantly associated with fat percentage were health, mood,convenience, sensory appeal, nutrient contents and weight control Conclusion This study
concluded that health, mood, convenience, nutrient contents and weight control were the top
influence in factors associated with body weight and fat percentage for healthcare providers
Hence, appropriate measures may be considered in regulating these factors as a potential
approach in weight management intervention among healthcare providers
KeywordsFactors, food choices, body composition
INTRODUCTION
Nutrition is essential to maintain body healthMalnutrition increases the risk of human morbidity
and mortality  Nutrition transition, from low
availability of calories mainly in the form of plant
products to diets high in fats, sugars and energydense
processed foods contribute to obesity issue  This, inturn, has been the result of rapid economic
development which has taken place in Malaysia in thelast quarter of the twentieth century  Malaysia hasrecently been ranked second highest in East andSoutheast Asia in terms of being overweight 1,2 
Prevalence of obesity, whereby excessive body
adipose tissue, increase in worldwide  World HealthOrganization WHO  criteria for Body Mass Index
BMI classifies a BMI of 25299 kgm2 as overweightand >30 kgm2 as obese 3 BMI is the most widelyused index for obesityObesity is shown as a major
determinant of noncommunicable diseases such as
To whom correspondence should be addressedagneshcy0326@gmailcom

cardiovascular disease, cancers, type 2 diabetes
mellitus, respiratory problems, gallbladder diseases,
post operative morbidity and musculoskeletal
disorders such as osteoarthritis  There has been aclearly documented dramatic increase in theprevalence of obesity in Malaysia over the last three
decades since large scale population data became
available  In the global context, alongsidedevelopment and prosperity, in many countries
especially in Asia, obesity has become a leading healthissue 1,2 
Obesity is a multifactorial disorder deriving fromgenetic and metabolic factors as well as environmental
factors, socioeconomic and behavioural 4,5   These
factors differ in their respective contributions to theobesity epidemic in recent decades6  Behaviouralfactors, however, have undergone important
modifications that might account for the epidemic in
obesity 7 Energy intake and energy expenditure areconsequences of behaviours e g  choosing foods,

5Factors Influence in Food Choices and Body Composition
eating foods, watching TV, playing sports  that are
influenced by a wide range of internal and external
determinants  These eating behaviours include thecharacteristics of the food supply, the knowledge,
attitudes, emotional state and experiences of theindividual, and the social and cultural context in which
the behaviour occurs 7,8 In this study, investigators
would like to determine the factors that influence andassociate with food choices and body composition
This study provides a baseline data for further program
planning

the questionnaire by themselves with minimal
assistance from investigators Investigators explained
to subject if there was problem in understanding thequestionnaire and stayed in the vicinity to check theanswers and to receive the questionnaires personally
The duration of data collection for each participant
was approximately 15 20 min  All parameters andvariable data were collected and recorded in datacollection form  The variables that were being
collected in the data collection form included socio
demographic age, education level , anthropometry
and body composition
weight, height, BMI,
percentage of body fat and muscle mass 

MATERIALS AND METHODS
Study design
This was an observational pilot study  Cross
sectional and convenient sampling method were used
Body composition screening and eating behaviours
assessment via questionnaire was done among Institut
Kanser Negara staffAfter screening and assessmentof eating behaviours, dietitian explained andcounselled them based on the result of screening andassessmentThis screening and assessment were aimed
to increase awareness of staff on their bodycomposition and eating behaviours  All records andquestionnaires were well kept and locked in dietitiansu
officeThere were no identifiable datainformation on
data collection form and questionnaire  Data wascollected and extracted for analysis purposes

Statistical analysis
The data analysis was done using the SPSS
version 23 0  Categorical data was analysed
descriptively and presented as frequency andpercentagesContinuous data was presented as meanand standard deviation and analysed by independent t
test which evaluated using two tailed test ofsignificance level at the p<005Pearsonus Correlation
was used for analysis since data was normally
distributed to study the association between factors
influence in food choices  A value of p < 0 05 is
considered statistically significant
RESULTS
Study recruited 106 participants whereby 29 weremales and 77 were females, with the mean of age 3797± 13 17 years old  Majority of participants 46 3 
received tertiary education degree holders  andfollowed by secondary level 274 Using WHO BMI
cut off of >24 9kg m2 as overweight, 51  werecategorized as underweight normal weight while 49
were overweight obeseWeight, muscle mass and fat
percentage among male participants were statisticallysignificantly higher than female, 7298 ± 1354 kg vs
6065 ± 1176 kg, 5199 ± 637 kg vs 3728 ± 526 kg
and 2378 ± 748 vs 3362 ± 698 respectively p <001 
The factors associated with body weightsignificantly were mood r  0 246, p  0 011 convenience r 0218, p 0025 and nutrient contentsr 0197, p 0043 The factors associated with fat
percentage significantly were health r  0 299, p 0002 , mood r 0290, p 0003 convenience r 0326, p 0001 , sensory appeal r 0232, p 0017 ,nutrient contents r  0 298, p  0 002  and weightcontrol r 0212, p 0029 

Measurement tools
Validated measurement tools were scheduledcalibrated TANITA Total Body Composition
Analyser model SC 300 which can provide bodyweight in kg up to 01kg , fat percentage up to 01 
and total muscle mass up to 0 1kg   Scheduledcalibrated SECA height measurement up to 0 1cm 
was used to measure heightSubject was requested tohave minimal clothing, empty pocket and stand up
right with bare foot on metal plate of scale Subject
needs to be bare foot, stand up right and face front
while measuring
Validated questionnaire of food choices werecollected 8   The questionnaire contains of 36
questions  Every item was rated in a 4 point scaleranging from not important at all 1 to very important4   Nine factors influence in food choices wereassessed by the questionnaire including health 6
items , mood 6 items , convenience 5 items , sensory
appeal 4 items , natural content 3 items , price 3
items , weight control 3 items , familiarity 3 items and ethical concern 3 items  8Participants answered

Height m
Weight kg
BMI kgm2
Muscle mass kg 
Fat percentage 

Table 1Body composition study participants
Male n 29
Female n 77
Total n 106
Mean ± SD
Mean ± SD
Mean ± SD
167 ± 616
157 ± 6101600 ± 758
7298 ± 1354
6065 ± 1176
6402 ± 1339
2599 ± 435
3773 ± 11120
2534 ± 625
5199 ± 6373728 ± 526
4130 ± 862
2378 ± 748
3362 ± 698
3094 ± 834

Independent ttestpvalue <001

6pvalue
0000
0000
0358
0000
0000

Asian Journal of Dietetics 2022

Factors

Table 2Factors influence in food choices among gender and BMI groups n 106
Gender groups
BMI groups
Male n 29
Mean ± SD

Female n 77
Mean ± SDpvalue

0215
0353

Underweight
Normal n 54
Mean ± SD
321 ± 069
304 ± 065

Overweight
Obese n 51
Mean ± SD
355 ± 056
343 ± 059

HealthMood

324 ± 074
313 ± 068

341 ± 062
326 ± 064

Convenience
Sensory
Nutrient
content
Price
Weightcontrol
Familiarity
Ethicalconcern

308 ± 071
322 ± 070
318 ± 085pvalue

0008
0002

326 ± 061
333 ± 060
331 ± 068

0200
0416
0425

302 ± 070
319 ± 063
308 ± 072

343 ± 049
342 ± 062
348 ± 070

0001
0061
0004

307 ± 081
303 ± 087

331 ± 066
313 ± 066

0116
0547

317 ± 070
293 ± 075

332 ± 072
330 ± 064

0260
0007

315 ± 074
292 ± 099

296 ± 067
288 ± 081

0211
0845

305 ± 062
282 ± 081

297 ± 076
300 ± 089

0547
0268

Independent ttestpvalue <001

Table 3Factors associated with body weight and fat percentage n 106
Body weightFat percentagervaluepvaluervaluepvalue
Health
0144
0142
0299
0002
Mood
0246
0011
0290
0003
Convenience
0218
0025
0326
0001
Sensory appeal
0188
0054
0232
0017
Nutrient content
0197
0043
0298
0002
Weight control
0132
0178
0212
0029
Factors

Pearson correlation testpvalue <005pvalue <001

DISCUSSION
Besides hunger stimulation, many internal andexternal cues can trigger the immediate desire to eat ororient eating toward certain foodsA study stated that
despite being an important factor of food choice, liking
or eating pleasure may make only a modest
contribution to overall variation in food choice andeating behaviours 9 Although it is widely believedthat females place more emphasis on healthy eatingcompared to males, there were no significant
differences between genders for all factors in thisstudy For both gender groups in this study, the top
factor influence in food choices was health followed
by sensory This did not concur with Wardle et al2004 that reported women as more likely than men toreport avoiding highfat foods, eating fruit and fibre,
and limiting salt to a lesser extent , besides more likely
to be dieting and attached greater importance tohealthy eating 10 The least factor for both genders
in this study was ethical concern followed byfamiliarity for female and weight control for maleAs
for food choice factors among BMI groups,
overweightobese group significantly consideredhealth, mood, convenience, nutrient content andweight control more than underweightnormal weight

individualsThis is contradictory to a study among low
income women by Dressler & Smith 2013  whereleannormal weight participants reported that health
was influential in food choice, while overweightobese
participants expressed cost as being more of a factor
11 Both BMI groups reported that taste or sensory
was of greatest importance in that studyThe outcome
difference might be contributed by the different settingof participants samplingAs this study focused on staff
working in a healthcare setting, the knowledge ofobesityassociated health risks may prompt theoverweightobese group to consider health, nutrient
content and weight control in their food choices as ameans of weight loss compared to their counterpartPrevious studies have shown that higher BMIs womendisplay frequent dieting behaviour 12  and limiting
calorie intake induces a counterregulatory response
which then leads to excessive calorie intake 13 andweight gain 14 
The abovementioned factors together withsensory appeal showed a weak but significant positive
association with body fat percentage regardless of
BMI groups Of these six factors, only mood,convenience and nutrient content showed a similarsignificantly positive but weak association with body7

Factors Influence in Food Choices and Body Composition
4. Hill JO, Melanson EL  Overview of thedeterminants of overweight and obesity  current
evidence and research issuesMedicine & Sciencein Sports & Exercise31S5151999
5. Marti A, Martinez González MA, Martinez JAInteraction between genes and lifestyle factors on
obesity  Nutrition Society Silver Medal LectureProceedings of the nutrition society67182008
6. Popkin BM, Doak CMThe obesity epidemic is aworldwide phenomenonNutrition reviews56106
141998
7. French SA, Story M, Jeffery RWEnvironmental
influences on eating and physical activity Annual
review of public health22309352001
8. Steptoe A, Pollard TM, Wardle JDevelopment ofa measure of the motives underlying the selectionof food  the food choice questionnaire  Appetite25267841995
9. Mela DJ  Determinants of food choice
relationships with obesity and weight controlObesity research9249S55S2001
10. Wardle J, Haase AM, Steptoe A, Nillapun M,
Jonwutiwes K, Bellisie F  Gender differences infood choicethe contribution of health beliefs anddietingAnnals of behavioral medicine2710716
2004
11. Dressler H, Smith CFood choice, eating behavior,and food liking differs between lean normal andoverweight obese, low income women  Appetite6514552 2013
12. Anderson LA, Eyler AA, Galuska DA, Brown DR,
Brownson RC  Relationship of satisfaction withbody size and trying to lose weight in a national
survey of overweight and obese women aged 40
and older, United States  Preventive medicine3539062002
13. Hetherington MM, Stoner SA, Andersen AE, Rolls
BJ  Effects of acute food deprivation on eating
behavior in eating disordersInternational Journalof Eating Disorders28272832000
14. Pietiläinen KH, Saarni SE, Kaprio J, Rissanen A
Does dieting make you fat? A twin studyInternational Journal of Obesity36456 2012
15. Singh M  Mood, food, and obesity  Frontiers in
psychology59252014
16. Zhao G, Ford ES, Li C, Tsai J, Dhingra S, Balluz
LSWaist circumference, abdominal obesity, anddepression among overweight and obese US
adultsNational Health and Nutrition Examination
Survey 20052006BMC psychiatry11130 2011
17. Macht MHow emotions affect eating a fivewaymodelAppetite50112008
18. Sharma S, Hryhorczuk C, Fulton S  Progressive
ratio responding for palatable high fat and highsugar food in mice  JoVE Journal of Visualized
Experiments 63e3754 2012
19. Simon GE, Von Korff M, Saunders K, Miglioretti
DL, Crane PK, Van Belle G, Kessler RCAssociation between obesity and psychiatricdisorders in the US adult populationArchives ofgeneral psychiatry63824302006
20. Blanck HM, Yaroch AL, Atienza AA, Yi SL,
Zhang J, Mâsse LCFactors influencing lunchtime
food choices among working Americans  Health
Education & Behavior362893012009
21. Gordon Larsen P  Food availability convenienceand obesityAdvances in nutrition5809172014

weight Singh stated that the interaction between
mood, emotional state, and feeding behaviours iscomplex and it is hypothesized that individuals
regulate their emotions and mood by changing bothfood choices and quantities 15 It seems to be a twoway relationship between food intake, mood andobesityDepressed mood is associated with abdominal
obesity and poor diet intake16 as such individuals
showed a preference for palatable vcomfort foodsw
which can improve negative feelings on a shortterm
basis 15, 17  When this behaviour is prolonged,
Sharma and colleague state that persistent highfat
feeding unfavourably leads to negative emotional
states, increased stress sensitivity and altered basal
corticosterone levels 18  At the same time, calorie
dense food promotes higher fat percentage and obesityThe state of being obese in itself increases thevulnerability to depression and anxiety 19 Therefore,
the vicious cycle of mood influence in food choices,increasing fat percentage and obesity risk leading tomood disorders should not be underestimated anddeserves further exploration
In a study by Blanck and colleague 2009  that
identify four determinants of food choice among
working adults, convenience was chosen as the mostimportant of the study population, followed by taste,cost, and health In the same study, BMI was
significantly related to convenience whereconvenience was a more influential factor for obese
person compared to overweight or nonoverweightindividuals 20 Such finding is similar to our findingthat shows convenience as having a significantly
positive association with body weight and fat
percentage According to Gordon  Larsen,neighbourhoods or in this case environments that offer
access to highquality foods are theorized to improve
individuallevel diet and weight outcomes of its
population 21 Therefore, it is suggested that a higher
availability, accessibility and convenience to healthierfood options may play a substantial role in weightcontrol by encouraging healthier food choices
especially among those with higher BMIThe current study provides evidence of influencein factors related to food choices such as health, mood,convenience, nutrient content and weight control
among overweight and nonoverweight individuals
working in a healthcare settingCertain factors such as
mood and convenience were found to be significantly
associated with body weight and fat percentage
Healthcare providers might consider measuresregulating these factors as a potential approach inweight management interventionACKNOWLEDGEMENT
The authors would like to thank the Director
General of Health Malaysia for the permission to
publish this paperThe authors would like to express
their deepest gratitude to thestudy participants
REFERENCES
1. Ghee LK  A review of adult obesity research in
MalaysiaMed J Malaysia717
2. Hassan H, Sade AB, Rahman MS  Obesity andoverweight issues could undermine Malaysiau scompetitiveness  International Journal of Human
Rights in Healthcare2018
3. World Health Organization  Physical status  The
use of and interpretation of anthropometry, Reportof a WHO Expert Committee1995

8

Asian Journal of Dietetics 2022

Original
Nutritional Status and Diet Characteristics inPatients with Intestinal Obstruction Due to Food Residues at Hospital in Vietnam
Anh Tran Thi Hai1*, Lien Nguyen Khanh Thi1, Chinh Pham Thi Tuyet2, Yen Ma Ngoc2,
Oanh Hoang Vu1, Oanh Ninh Thi1, Hang Hoang Thi1, Linh Nguyen Thuy1,21
Hanoi Medical University, Hanoi, Vietnam.
Department of Nutrition and Dietetics, Hanoi Medical University Hospital, Hanoi, Vietnam.

2

ABSTRACT: Background and purpose. Bezoars are collections of undigested
foreign material that accumulate in the gastrointestinal tract. Phytobezoars are themost common, which are formed from plant fibers, especially those related to theingestion of at-risk foods such as persimmon, guava, dried bamboo shoots and so on.
Patients who undergo abdominal surgery, including bariatric surgery for obesity, andparticularly gastrectomy, are prone to bezoar formation due to reduced gastricmotility, loss of pyloric function, and hypoacidity. Bezoars can form months to years
postoperatively. Our objective was to describe nutritional status, dietarycharacteristics, and some factors in patients with intestinal obstruction caused by foodresidues. Methods. A descriptive study was carried out on 43 inpatients who werediagnosed with intestinal obstruction because of bezoars. Participants will beinterviewed with a set of questions about the frequency of food consumption by using
food photobooks, scales, and height gauges. The patient opened his mouth to countthe number of missing teeth and dentures. Results. There were many patients with ahistory of eating high-risk foods such as persimmons (40.5%) with the average weighwas 168.5 grams, guava (43.6%) with the average weight was 87.4 grams. The
number of patients with stomach diseases, diabetes, dental problems accounted for
69.7%, 25.5%, 43.6% respectively. Winter season recorded the most cases ofintestinal obstruction with 44.3%. Conclusion. Research has shown that the majorityof patients consumed high-risk food groups. The frequency of eating foods quite
regularly, especially the foods enrich fiber content. The medical history was also
account for a fairly high rate, especially digestive problems up to 88.3% of people.
Therefore, screening and preventive measures for patients with risk factors, and theelderly are essential to prevent intestinal obstruction due to food residues.
Key Words: Bezoars, phytobezoar, high fiber foods, persimmons, intestinal
obstruction
INTRODUCTION
Intestinal obstruction is one of the most common
surgical emergencies caused by various conditions. It
is the second prevalence reason only after appendicitis(1,2). There are two main types of intestinal
obstruction: mechanical intestinal obstruction andfunctional intestinal obstruction (2). Depending on the
degree of gastrointestinal obstruction and duration,
intestinal obstruction is divided into acute intestinal
obstruction and subacute intestinal obstruction (1).
Intestinal obstruction caused by food residues(Bezoar) is one type of mechanical intestinal
obstruction. Bezoars are solidified substances formedby mixing indigestible exogenous substances withother substances in the gastrointestinal tract; bezoars
are commonly found inside the stomach but can enter
the small intestine via the pylorus. Once the diagnosis
of bezoar is made, the bezoar is dissolved or removed,
because it can cause gastric outlet obstruction, ileus,
ulcerations due to pressure necrosis, and subsequent
gastrointestinal bleeding (3). Bezoars are mainlyclassified into four types according to theircomposition:
phytobezoars,
trichobezoars,
pharmacobezoars, and lactobezoars (3).
The formation and development of bezoars can*To whom correspondence should be addressed:
haianh.37hmu@gmail.com

occur at any age. However, many studies showed thatthe nutritional status and dietary habits play a key rolein producing bezoars, especially in the elderly with animbalance in nutritional status, which could create anegative impact on their quality of life and cause
increased morbidity and mortality. Phytobezoar is oneof the most common bezoars around the world (4),which consists of fruit and vegetable fibers (5). Thiswas why, older people consume a large amount of foodwith high-fiber content and inadequate chewing, which
can lead to small bowel obstruction (6,7). These factors
are partly related to dietary habits. Furthermore, theaging process and some of the related physiologicchanges can predispose one to phytobezoar formation.
For example, older people can find it difficult to chew
food well if they have some abnormal characteristics,
including losing teeth, weakening teeth, and swellinggums (8). In a study conducted by NJ Talley in 1992,
the older population usually had decreased
gastrointestinal motility and elastic bowel that could
lead to a high chance of constipation (9). It isconsidered as a reason leading to the accumulate andestablishment of phytobezoar in the gastrointestinal
tract (10).
Worldwide, there has been a relative study on thecause of intestinal obstruction due to food residues, but
most of the studies are related to the formation
mechanism of food residues with the relationshipbetween stomach diseases, pancreatitis, the reduction

9

The relationship between diet and intestinal obstructionof gastric acid after gastric bypass surgery. The study
conducted by Kement et al in 2012 showed that
SDWLHQWV¶ VXUJLFDO VWRPDFK KLVWRU\ ZDV D KLJK-riskfactor, which could lead to the establishment of bezoars
and accounted for the largest number of causes at 48%(4). Similar results were found in others studies such as
Krausz et al in Israel (1984) (5) and Bowden in
Georgian (1983) (6), which showed that the percentage
of intestinal obstruction patients relating to surgicalstomach history were 20% and 93% respectively. The
treatment of peptic ulcers with proton-pump inhibitors
is also one of the risk factors for the formation of foodresidues by the drug's mechanism of reducing gastricacid secretion (7). In addition, long-term consumptionof certain food high in insoluble fiber such as cellulose,
hemicellulose, lignin, and food with an acrid taste(tannin) by these patients may also be the cause ofphytobezoars. The US Food and Drug Administration
DOORZVIRRGVWREHODEHOHGµµDJRRGVRXUFHRIILEHU¶¶RU
µµKLJKILEUH¶¶LIWKH\FRQWDLQPRUHWKDQJRUJRI
dietary fiber per serving (100g), respectively (19). In
the foods at risk also contain a large amount of fiber
such as persimmons (2.5g), guava (6g), bamboo shoots(4.1g), figs (2.9g). In terms of astringency, tea also
contains a large amount of tannins (20). Persimmons
are typical foods causing phytobezoars in some Asian
countries such as Japan with 40% (11) and Korea up to
76.4% (12) of people with intestinal obstruction. The
formation and accumulation of bezoars in thegastrointestinal tract rely on many factors, and it is not
only related to the types of fiber but also to the quantityof that fiber at each time of consumption. A few
Vietnamese studies have suggested high-risk foods, butthey did not provide comprehensive information about
the amount and the frequency of using these foods inthe advanced formation of bezoars.
In terms of diagnoses, intestinal obstruction due tofood residues does not have much difference in clinicaland subclinical manifestations compared withmechanical intestinal obstruction due to other causes.
That makes the rate of accurate diagnosis of the cause
of intestinal obstruction because of food residue inclinical practice is not high. Therefore, most cases are
diagnosed postoperatively and there will be increased
morbidity and mortality rates (13). Research on
gastrointestinal foreign bodies in the form of foodresidues in Vietnam is rare and currently, we have notfound any official documents on the frequency of using
foods with a high risk of forming bezoars.
METHODS
Study settings and subjects
This was a descriptive study that used the crosssectional study design and was conducted for a year
from January 2020 to December 2021. We collected
data on a convenience sample in all departments in
Hanoi Medical University Hospital during a year andgot a total of 43 subjects. The inclusion criteria werethat patients were diagnosed with intestinal obstruction
due to food residue. The study excluded patients who
had been diagnosed with other causes such as
postoperative adhesions, olvulus, intussusceptions,
hernia, and tumours and refused to participate in the
study.
Data collection
The established a private direct interview withparticipants at Hanoi Medical University Hospital. Theinterview usually took 45 minutes to 60 minutes, we
FDUHIXOO\ H[SODLQHG DQG OLVWHQHG WR WKH SDUWLFLSDQWV¶

10

answers. To limit the error in the quantity and thefrequency of using food, we used a picture book about
the food serving that was published by the Vietnamese
National Institute of Nutrition. The patients opened
their mouth and we counted the number of missing
teeth and dentures. Biases were controlled by using asingle equipment tool and one researcher to collect thedata for all subjects.
Statistical Analysis
The data were entered by using Microsoft Excel
Workbook 2016 (Microsoft Corporation, Hanoi,
Vietnam) and Stata 14.0 statistical software (StataCorp
LLC, California) for analysis. The results have beenpresented as frequency, percentage, and mean.
Ethics Approval
The study has been approved by the research review
board of Hanoi Medical University Hospital. All
participants were fully informed about the purposes ofthe study.
RESULTS
The study was conducted on 43 patients (23 males
and 20 females) diagnosed with intestinal obstruction
due to food residue. The average age of the study
subjects was 58.7±19.1, the youngest was 18 years old
and the oldest was 93 years old.
Table 1 shows the outcomes on the patient's clinicalfeatures and possible risk factors for bowel obstruction.
Regarding medical history, Gastroenterology diseases
accounted for the most proportion with nearly 70%,
followed by diabetes mellitus with 25.5%. Diseases ofgastric surgery, hypertension accounted for 18.6%
equally. There were 43.6% of people had trouble withdental health. These problems were mostly weak teeth,
lost teeth, alternative teeth, sensitive teeth. In terms ofanthropometric index, the study assessed nutritional
status according to BMI classification for Asian
populations. The majority of patients had normal
nutritional status (63.2%), the proportion of
malnourished patients was 29% and at least the patientswere overweight and obese (7.8%). The final section of
the table was the results on the frequency of diseases indifferent seasons of the year. The proportion of patientswith intestinal obstruction was greatest in winter(44.3%), followed by spring with 1/5 of patients.
Summer and autumn accounted for 16.2% and 18.6%
respectively.
Figure 1 shows the results of food intake andfrequency of eating high-risk foods in the 3 months
prior to the date the patient was diagnosed with bowel
obstruction. Guava was the most consumed food with43.6%, followed by persimmon with 40.5%. The
proportion of patients who had ever consumed bamboo
shoots and figs was more than a quarter. The average
weight of persimmon was 168.5 (g), and there was a
big difference between the smallest (78g) and thelargest (312g) mass. The amount of bamboo shoots
consumed was close to that of guava at 94.8 (g) withthe former and 87.4 (g) with the latter. The weight offigs consumed was the least with 41.2 (g) on averageand the smallest (28g), the largest (70g).
Table 2 provides data on the frequency of
consumption of high-risk food groups over the past
three months. High-fiber foods were regularly
consumed by patients with a frequency of 16.1±13.5.
The groups of foods with acrid taste, high in fiber andacrid taste, and beverages had a large difference
between the frequency of use of the subjects, at
2.1±4.7, 3.9±8.8, and 9.7±13.4, respectively.

Asian Journal of Dietetics 2022
Table 1. Clinical features of the patient
All (n)Medical history
Gastroenterology (Stomach ulcers, Gastroesophageal
reflux disease,..)Gastrectomy
Diabetes mellitus
Hypertension
Suffering from two diseases
Dental problems
Yes (People with dental problems)
No (People without dental problems)
BMI (kg/m2)
Underweight (BMI <18.5 kg/m2)
Normal (BMI 18.5 ± 24.9 kg/m2)
Overweight and Obese (%0,RINJP2)
Seasonal disease frequency
Spring (From January to March)
Summer (From April to June)
Autumn (From July to September)
Winter (From October to December)

Average

Min

Max

Percentage (%)

30

69.7%

8
11
8
9

18.6%
25.5%
18.6%
20.9%

19
24

43.6%
56.4%

12
27
4

29%
63.2%
7.8%

9
7
8
19

20.9%
16.2%
18.6%
44.3%

Frequency

600

50.0%

40.5%

40.0%
35.0%

312

30.0%

27.8%

26.3%

300

25.0%
20.0%

200
100

78

168.5

130

150

39

40

70

94.8

87.4

28
41.2

Guava

Figs

0
Persimmon

Bamboo shoots
Foods

15.0%
10.0%
5.0%
0.0%

Figure 1. Frequency of food consumption in the past 3 months and the average,
minimum, maximum weight per serving
Table 2. Frequency of food consumption in the past three months
Mean+SDMedianHigh-fiber food group16.1±13.5
11
Food group with an acrid taste
2.1±4.7
1
Food group high in fiber and acrid taste
3.9±8.80Beverage group9.7±13.4
2

11

Frequency (%)

Amount of foods (g)

500
400

45.0%

43.6%

The relationship between diet and intestinal obstruction
DISCUSSION
The study was conducted on 43 patients diagnosed
with intestinal obstruction due to food residue at Hanoi
Medical University Hospital in 2020-2021. The
average age of the subjects was 58.7 years old, ranging
from 18 to 93 years old. The number of males washigher than females with 53.5% of males and 46.5% offemales.
There are many risk factors for intestinal
obstruction due to food residue. Daily foodconsumption also plays an important role in theformation of bezoars in the intestinal lumen. In
Vietnam, according to a study of Dong NV in 2005,
38.1% of patients had a medical history of consuming
enriched fiber, acrid taste (tannin), and resin foods
before admitting hospitals, in which history of eating
persimmons made up the largest percentage at 26.2%,
and the percentage of patients with the history of
consuming dried bamboo shoots was about 5.9% (1).
In another study of Hung HT in 2007, the percentageof patients with a history of consuming persimmonsand patients with a history of eating dried bamboo
shoots was 53.8% and 23.1% respectively (2).
Moreover, there were some cases with a history ofeating the orange pith, tangerine, and unripe banana(14). Worldwide, in 2012, excessive consumption of
SHUVLPPRQZDVLGHQWLILHGLQLQ.HPHQW¶VVWXG\in Poland (4), also in this country, Erzurumlu et alreported that 17.6% of their 34 patients with bezoars
had a history of persimmon or cherry laurel intake (15).
Persimmon, which grows in many areas in our region
and is widely consumed, is the fruit of a number of
species of trees belonging to the genus Diospyros. A
history of persimmon intake was obtained in only 103of the 113 patients (91.2%) by Krausz et al, since at the
beginning of the study period, surgeons were not awareof the association between phytobezoar induced
intestinal obstruction and persimmon ingestion (5).
These figures were similar to our study, with 40.5% of
patients having a history of eating persimmon in threemonths before being diagnosed with intestinal
obstruction due to food residue. Furthermore, patients
often suffered from intestinal obstruction in the firstand last months of the year - these were the seasonalmonths of some high-risk foods such as persimmons,bamboo shoots, beans, oranges, and so on. In Hong
Kong, EM Chisholm et al. reported that two-thirds ofthe patients in their study became ill in the last monthsof the year. The author has also emphasized therelationship between the season and harvest season of
persimmons. In this country, persimmons are
consumed a lot during the Mid-Autumn Festival as
traditional culture, this is also the harvest month of
persimmons. Similarly in Vietnam, August to
December is also the season of persimmons, so people
will consume more persimmons than other months ofthe year. Around this time, Vietnamese peoplecelebrate the Lunar New Year, and bamboo shoots areoften eaten during Tet meals. As a result, it is possiblethat cultures and food harvest seasons influence thepatient's food intake. Besides, some foods were also
suspected to be factors that catalyze the formation offood residues such as guava, bamboo shoots, and figs
with the percentage of 43.6%, 27.8%, and 26.3%,
respectively. Most previous studies have only
investigated whether or not patients ate the risk foods.
In our study, we studied the frequency of using highfiber food groups, and foods with astringent taste
within three months of the patient's diagnosis of

12

intestinal obstruction, and we also investigated theamount of food eaten using food picture books tosuggest to the patient how much food was eaten. For
some high-fiber foods such as persimmons, bamboo
shoots and guava, the patient's average intake was
168.5 (g), 94.8 (g), and 87.4 (g), respectively. Figs arean acrid food that was also consumed regularly with anaverage weight of 41.2 (g).
In addition to the intake of large amounts ofcellulose materials, other possible risk factors include
a history of gastrointestinal surgeries (such as
gastrectomy, gastrojejunostomy, and other stomach
diseases) or diabetes caused by various factors. In ourstudy, there were 69.7% of patients with a history ofprevious gastric diseases, 18.6% of those had gastricsurgery. The percentage of people having surgery wasless than other studies around the world such as F
Serour with 34 patients (83%) having a history ofprevious gastric surgery for ulcer (16). Partial
gastrectomy can reduce gastric acid secretion, resulting
in a weakly acidic environment and a decrease ingastric motility; thus, removal of undigested solids
from the stomach is likely delayed, thereby causing
high amounts of viscous contents to form inside thestomach, which is prone to bezoar formation (17). We
also collected 25.5%% of patients with a history of
diabetes, this number was lower than Metin Kement's
study with 28.6% (4). Through these studies, werealized that gastric diseases could be a risk factor for
intestinal obstruction, so we needed to have measuresand plans to prevent early intestinal obstruction inpatients.
Moreover, we also found that 43.6% of patients had
problems with teeth, jaws, and faces. These patientswere mostly missing teeth or were using dentures. This
makes it difficult for the person to chew and swallow.
As a result, the food is not crushed enough, so when
consuming a large amount of fiber, it can cause
blockage of the intestinal lumen because the intestine
cannot be digested. People who have missing teeth or
dentures often struggle to chew all the foods they wish
to eat. Without a full set of teeth, food selection may be
QDUURZ6RPHSHRSOHFRPSODLQWKDWWKH\FRXOG¶WFKHZ
vegetables or meats. Others will suffer psychologicaleffects when they avoid socializing and eating meals
out in restaurants with friends or family. Poor
masticatory performance was associated withsignificantly lower intakes of insoluble and dietaryfiber for both sexes (18).
Based on this study, we found that patients withintestinal obstruction due to food residue in Vietnam
also regularly consume high-risk foods as in othercountries around the world. Vietnam is a tropicalcountry, so it has a wide variety of foods. Each season
will have different quality foods and very reasonable
prices, guiding people to choose foods to consume
regularly. Consuming large amounts of these foods in
combination with a medical history such as stomach
problems or dental issues increases the risk of foodresidue formation. Therefore, it is necessary to havebackup plan or instruct patients on how to choose theright food for themselves.
In conclusion, it can be seen that most patients haveconsumed high-risk food groups with a fairly regularfrequency. Fiber-rich foods were eaten by the patientsthe most, especially persimmons, with an average
serving weight of more than 168 grams. Research also
showed that the disease often occurs in the cold months

Asian Journal of Dietetics 2022
in Vietnam. In addition, a history of diseases such as
diabetes (25.5%), stomach disease (88.3%), or dental
problems (43.6%) was also common in the study
subjects. Therefore, screening and preventive measuresfor patients with risk factors, and the elderly are
essential to prevent intestinal obstruction due to foodresidues.
ACKNOWLEDGEMENTS
This research was supported by Hanoi Medical
University Hospital. The authors would like to thankall the participants for their cooperation.
REFERENCES
1. Dong Nguyen Van. Study on clinical, paraclinicalcharacteristics and treatment results of intestinal
obstruction caused by food residue. Published online
2005.
2. Nam Phan Thanh. Study on clinical, paraclinical andpathological characteristics in patients with intestinal
obstruction due to food residue at the Department ofSurgery, Bach Mai hospital. Published online 2004.
3. Iwamuro M, Okada H, Matsueda K, et al. Review ofthe diagnosis and management of gastrointestinal
bezoars. World J Gastrointest Endosc 7(4):336-345.
2015.
4. Kement M, Ozlem N, Colak E, Kesmer S, Gezen C,
Vural S. Synergistic effect of multiple predisposing
risk factors on the development of bezoars. World J
Gastroenterol 18(9):960-964. 2012.
5. Krausz MM, Moriel EZ, Ayalon A, Pode D, Durst
AL. Surgical aspects of gastrointestinal persimmon
phytobezoar treatment. Am J Surg 152(5):526-530.
1986.
6. Bowden TA, Hooks VH, Mansberger AR. The
stomach after surgery. An endoscopic perspective. Ann
Surg 197(6):637-644. 1983.
7. Iwamuro M, Tanaka S, Shiode J, et al. Clinicalcharacteristics and treatment outcomes of nineteen
Japanese patients with gastrointestinal bezoars. Intern
Med 53(11):1099-1105. 2014.
8. AKRAMI M, SASANI MR. Dietary Habits AffectQuality of Life: Bowel Obstruction Caused by
Phytobezoar. Iran J Public Health 45(8):1080-1082.
2016.

7DOOH\1-2¶.HHIH($=LQVPHLVWHU$50HOWRQ/-Prevalence of gastrointestinal symptoms in the elderly:apopulation-based
study.
Gastroenterology
102(3):895-901. 1992.
10. Oh SH, Namgung H, Park MH, Park DG. Bezoarinduced Small Bowel Obstruction. J Korean Soc
Coloproctol 28(2):89-93. 2012.
11. Williams RS. The fascinating history of bezoars.
Med J Aust 145(11-12):613-614. 1986.
12. Lee BJ, Park JJ, Chun HJ, et al. How good is colafor dissolution of gastric phytobezoars? World J
Gastroenterol 15(18):2265-2269. 2009.
13. De Cesare A, Fiori E, Bononi M, Ferraro D.
Phytobezoar-induced small bowel obstruction
associated with a concomitant gastric phytobezoar andulcer in an elderly woman. Ann Ital Chir 86(1):70-77.
2015.
14) Hung Ha Van. Research on clinical characteristics,
food in the surgical department of Bach Mai hospital.
Published online 2007.
15. Erzurumlu K, Malazgirt Z, Bektas A, et al.
Gastrointestinal bezoars: A retrospective analysis of 34
cases. World J Gastroenterol 11(12):1813-1817. 2005
16. Serour F, Dona G, Kaufman M, Weisberg D,
Krispin M. [Acute intestinal occlusion caused byphytobezoar in Israel. Role of oranges andpersimmons]. J Chir (Paris) 122(5):299-304. 1985.
17. Bedioui H, Daghfous A, Ayadi M, et al. A report of
15 cases of small-bowel obstruction secondary tophytobezoars: predisposing factors and diagnostic
difficulties. Gastroenterol Clin Biol 32(6-7):596-600.
2008.
18. Budtz-Jørgensen E, Chung JP, Rapin CH. Nutritionand oral health. Best Pract Res Clin Gastroenterol
15(6):885-896. 2001.
19. Jun Y, Bae IY, Lee S, Lee HG. Utilisation ofpreharvest dropped apple peels as a flour substitutefor a lower glycaemic index and higher fibre cake. Int
J Food Sci Nutr 65(1):62-68. 2014.
20. Praveen Kumar Ashok1, Kumud Upadhyaya.
Tannins are Astringent.
https://www.phytojournal.com/archives/2012/vol1issu
e3/PartA/8.1.pdf

13

Asian Journal of Dietetics 2022

Case report
3URWHLQ(QHUJ\0DOQXWULWLRQZLWK5HIHHGLQJ6\QGURPHDIWHU%DULDWULF6XUJHU\
Chiou Yi Ho, Norshariza Jamhuri'HSDUWPHQWRI'LHWHWLFDQG)RRG6HUYLFH,QVWLWXW.DQVHU1HJDUD0LQLVWU\RI+HDOWK3XWUDMD\D0DOD\VLD$%675$&7%DFNJURXQGDQGSXUSRVH3URWHLQHQHUJ\PDOQXWULWLRQ 3(0 ZLWKUHIHHGLQJV\QGURPHPLJKWGHYHORSSRVWEDULDWULFVXUJHU\&DVHUHSRUWDLPHGWRGHVFULEHWKHFOLQLFDO
SUDFWLFHRQDPRUELGO\REHVHSDWLHQWSRVWEDULDWULFVXUJHU\SUHVHQWHG3(0ZLWKUHIHHGLQJV\QGURPH &DVH SUHVHQWDWLRQ $  \HDUV ROGPRUELGO\ REHVH SDWLHQW SUHVHQWHG 3(0SURORQJHGLQDGHTXDWHRUDOLQWDNHZLWKNFDONJGD\DQGJNJGD\SURWHLQLQWDNHORZELRORJLFDOYDOXHSURWHLQVRXUFH ORZHOHFWURO\WHSURILOHDQGDQDVDUFD JDLQHGNJZLWKJHQHUDOL]HG HGHPD  PRQWKV SRVWEDULDWULF VXUJHU\  ZHLJKW UHGXFWLRQ  LQ EDULDWULF
FOLQLF'XULQJWKHKRVSLWDOL]DWLRQ GD\V RUDOIXOOHQWHUDOIHHGLQJZLWKVWDQGDUGIRUPXODDQGSURWHLQPRGXODUVXSSOHPHQWZDVLPSOHPHQWHGIRUWKHILUVWZHHNVDQGIROORZHGE\
KLJK SURWHLQ GLHW ZLWK RUDO QXWULWLRQ VXSSOHPHQWDWLRQ 7KHUH ZHUH FOLQLFDO DQG QXWULWLRQLPSURYHPHQW XSRQ GLVFKDUJHG LQFOXGLQJ UHVROYHG DQDVDUFD LPSURYHG HQHUJ\ SURWHLQLQWDNHLQFUHDVHGLQKDQGJULSVWUHQJWK IURPNJWRNJ DQGVHUXPDOEXPLQOHYHO IURPJ/WRJ/ 6KHDFKLHYHGSURJUHVVLYHUHFRYHU\LQERG\ZHLJKW JDLQHGNJZLWKRXWHGHPD  LPSURYHG HQHUJ\ SURWHLQ LQWDNH DQG KDQGJULS VWUHQJWK GXULQJ PRQWK SRVWGLVFKDUJHGIROORZXSLQEDULDWULFFOLQLF'LVFXVVLRQDQG&RQFOXVLRQ3(0LQREHVHSDWLHQW
SRVWEDULDWULF VXUJHU\ KDV KLJK ULVN RI UHIHHGLQJ V\QGURPH XSRQ UDSLG DGYDQFHPHQW LQ
QXWULWLRQDOLQWDNH3URJUHVVLYHO\QXWULWLRQUHFRPPHQFHPHQWZLWKIXOOHQWHUDOIHHGLQJDQG
IROORZHG E\ KLJKSURWHLQ QRUPDO GLHW ZLWK RUDO VXSSOHPHQW VXSSRUW LV SUHVFULEHG WR
RSWLPL]HQXWULWLRQVWDWXVGXULQJKRVSLWDOL]DWLRQ$VFRQFOXVLRQLQGLYLGXDOL]HGDQGURXWLQH
IROORZXSE\GLHWLWLDQSRVWEDULDWULFVXUJHU\LVUHFRPPHQGHGWRHDUO\GHWHFWLRQRI3(0DQG
IROORZHGE\DSSURSULDWHLQWHUYHQWLRQWRSUHYHQWIXUWKHUQXWULWLRQGHWHULRUDWLRQ
KeywordsProtein energy malnutrition, refeeding syndrome, bariatric surgery
INTRODUCTION
Prevalence of obesity increased in recent decades
and reach alarming level  Obesity is a chronic life
threatening disease and leads to worldwide publichealth concern 1 Studies on bariatric surgeries wereproven as an effective and enduring treatment forclinically severe obesity 2, 3   The two main
operations are laparoscopic sleeve gastrectomy andRoux en Y gastric bypass 4   Gastric bypass
procedures are associated with increased nutritional
deficiencies because the procedure is more complex
and changes the gastrointestinal anatomy  Protein
energy malnutrition PEM with refeeding syndrome
might develop postbariatric surgery 5 Case report
aimed to describe the clinical practice on a morbidly
obese patient post bariatric surgery, presented PEM
with refeeding syndrome

DQG VHFRQG IROORZ XS VHVVLRQV ZLWK GLHWLWLDQ $IWHU
DVVHVVPHQW GLHWLWLDQ LGHQWLILHG D IHZ QXWULWLRQSUREOHPVLQFOXGLQJSURORQJHGLQDGHTXDWHRUDOLQWDNHZLWKNFDONJGD\DQGJNJGD\SURWHLQLQWDNHSDVW PRQWKV ORZ ELRORJLFDO YDOXH SURWHLQ VRXUFH DQG
IRRGP\WKV'XHWRDIUDLGRIZHLJKWJDLQVKHUHVWULFWHG
KHUIRRGFKRLFHVDQGDPRXQWRIPHDOLQWDNH
'XULQJ WKH KRVSLWDOL]DWLRQ  GD\V  RUDO IXOOHQWHUDO IHHGLQJ ZLWK VWDQGDUG IRUPXOD DQG SURWHLQPRGXODUVXSSOHPHQWZDVLPSOHPHQWHGIRUWKHILUVWZHHNV ,Q RUGHU WR DGGUHVV UHIHHGLQJ V\QGURPH WKHIHHGLQJVWUHQJWKZDVLQLWLDWHGDWORZFDORULHVOHYHODQG
VWHSSHG XS JUDGXDOO\ FRQFXUUHQWO\ ZLWK HOHFWURO\WHFRUUHFWLRQ 2Q WKH WKLUG ZHHN RI DGPLVVLRQ KLJKSURWHLQ QRUPDO GLHW DQG RUDO VXSSOHPHQW VXSSRUW 
WLPHV SHU GD\ ZHUH VWDUWHG DIWHU RUDO IHHGLQJ ZDVHVWDEOLVKHG 0RUHRYHU IUHTXHQW FRPSUHKHQVLYH DQGLQGLYLGXDOL]HGQXWULWLRQFRXQVHOLQJLQFOXGHVQXWULWLRQHGXFDWLRQ FDORULHV FRXQWLQJ IRRG ODEHOLQJFXVWRPL]HGGLHWDU\SODQQLQJDQGWKHHPSRZHUPHQWVWROLYHDKHDOWKLHUOLIHVW\OHZHUHFDUULHGRXW7KHUHZHUHFOLQLFDO DQG QXWULWLRQ LPSURYHPHQW XSRQ GLVFKDUJHG
LQFOXGLQJ UHVROYHG DQDVDUFD LPSURYHG WRWDO GDLO\HQHUJ\ DQG SURWHLQ LQWDNH LQFUHDVHG LQ KDQGJULSVWUHQJWK IURP NJ WR NJ  DQG VHUXP DOEXPLQOHYHO IURPJ/WRJ/ 6KHDFKLHYHGSURJUHVVLYH
UHFRYHU\ LQ ERG\ ZHLJKW JDLQHG NJ ZLWKRXWHGHPD LPSURYHGWRWDOGDLO\HQHUJ\DQGSURWHLQLQWDNH
DQGKDQGJULSVWUHQJWKGXULQJPRQWKSRVWGLVFKDUJHG
IROORZXSLQEDULDWULFFOLQLF

CASE PRESENTATION
7KHUH$\HDUVROGPRUELGO\REHVHSDWLHQWZLWKXQGHUO\LQJ GLDEHWHV PHOOLWXV DQG K\SHUWHQVLRQXQGHUZHQWEDULDWULFVXUJHU\ JDVWULFE\SDVV LQ$XJXVW 'LDEHWHV PHOOLWXV DQG K\SHUWHQVLRQ ZHUHUHVROYHG DQG QRW RQ DQ\ PHGLFDWLRQ SRVWEDULDWULF
VXUJHU\ $ERXW PRQWKV SRVWEDULDWULF VXUJHU\ VKHDFKLHYHG  ZHLJKW UHGXFWLRQ EXW VKH SUHVHQWHG
SURWHLQ HQHUJ\ PDOQXWULWLRQ 3(0  ORZ HOHFWURO\WHSURILOHDQGDQDVDUFD JDLQHGNJ ZLWK JHQHUDOL]HGHGHPD XSRQFOLQLFIROORZXS6KHDWWHQGHGIROORZXSVHVVLRQVXQGHUVXUJHRQLQEDULDWULFFOLQLFEXWRQO\ILUVWBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBTo whom correspondence should be addressed
agneshcy0326@gmailcom

Protein Energy Malnutrition after Bariatric Surgery

Change of Body Composition and Handgrip Strengths)LJ&KDQJHRI%RG\&RPSRVLWLRQDQG+DQGJULS6WUHQJWK)LJ7RWDO'DLO\(QHUJ\DQG3URWHLQ,QWDNHDISCUSSION
Bariatric surgery is proven convincing andsuccessful treatment approach for obesity   A
sustainable weight loss, remission of obesity relatedcomorbidities and wellbeing are the recognized post
bariatric outcomes  In spite of multiple clinicalbenefits, a number of nutritional complications candevelop especially in the long term, which could cause
serious detriment to patientsuhealth 6 
After bariatric surgery, the inadequate oral intake
is considered common 7 Those patients who do notadhere to the recommended diets are at a greater riskof developing relevant malnutrition 8 Current PEM
after bariatric surgery case was due to nonadherence
to nutrition recommendation, food intolerances togood quality protein, small stomach pouch, andincreased protein requirement to maintain muscle
mass, food faddism or inability to recognize highquality protein which is in line with the previous study
9   Patients often have postoperative intolerance toproteinrich foods and protein digestion is impaired by
reduced mixing with pancreatic enzymes, which
results both from mechanical factors 1, 10 
Refeeding syndrome is a severe electrolyte
disturbance and metabolic abnormalities whenreinstitution of unrestricted enteral or parenteralnutrition in malnourished patients 11   However,obese patients who lose weight after bariatric surgery
are also susceptible to the refeeding syndrome 11 
PEM in obese patient postbariatric surgery has highrisk of refeeding syndrome upon rapid advancement in
nutritional intake 12 Energy supply in enteral feeding

16

Asian Journal of Dietetics 2022
standard formula and modular protein supplement  incurrent case was followed as recommendation whichaim 25of energy requirements and stepped up after
three days  The protein requirements is 1 2 to1 5g kg day by using the adjusted weight in obese
individuals 13 This case report demonstrated the approaches on
the refeeding syndrome of obese patient after bariatricsurgery  Concurrent with intravenous electrolyte
correction, the nutrition management was initiatedwith progressively nutrition recommencement withfull enteral feeding for two weeks and followed byhighprotein normal diet with oral supplement support
is prescribed to optimize nutrition status duringhospitalization 14   Dietitian led tailored nutrition
counseling that establish goal and create
individualized dietary plan 7 and motivation to foster
responsibility for self care 15 as well as regularnutrition monitoring are crucial to secure thecompliance with the healthy dietary recommendationand promote healthy weight loss postbariatric period
7   The current case report revealed that regularnutrition monitoring and individualized management
by dietitian is crucial to ensure healthy weight loss andprevent PEM post bariatric surgery 16   This casereport intends to strengthen a shift in the conventional
post bariatric unimodal follow up approach tomultidisciplinary approaches
As conclusion, PEM and refeeding syndrome is apotential fatal complications post bariatric surgeryHence, dietitian is a mandatory role in the
rehabilitation strategy of post bariatric surgery inoutpatient setting in order to monitor nutrition statusclosely, ensure adequacy of dietary intake andsubsequently prevent the risk of PEM and life
threatening complications

4.
5.

6.

7.

8.
9.
10.

11.
12.

$&.12:/('*(0(17The authors thank the surgical Upper
Gastrointestinal team and staff from the surgical wards
Institut Kanser Negara, Putrajaya, Malaysia for theirsupport in this case reportThe authors also express
their thanks to the study participantThe authors would
like to thank the Director General of Health Malaysia
for the permission to publish this paper

1.

2.

3.

13.

14.

15.

5()(5(1&(6Arterburn DE, Telem DA, Kushner RF,
Courcoulas AP  Benefits and risks of bariatricsurgery in adults  a review  Jama 324 879 872020English WJ, Spann MD, Aher CV, Williams DB
Cardiovascular risk reduction following
metabolic and bariatric surgery  Annals oftranslational medicine82020
Schiavon CA, Bhatt DL, Ikeoka D, Santucci EV,
Santos RN, Damiani LP, et al  Three year

16.

17

outcomes of bariatric surgery in patients withobesity and hypertension a randomized clinical
trial  Annals of Internal Medicine 173 685
932020Colquitt J, Pickett K, Loveman E, Frampton G
Surgery for weight loss in adults  Cochrane
Database Syst Rev2014
Lange J, Königsrainer A  Malnutrition as aComplication of Bariatric SurgeryyA Clear and
Present Danger? Visceral medicine 35 305
112019
Lupoli R, Lembo E, Saldalamacchia G, Avola
CK, Angrisani L, Capaldo B Bariatric surgery
and longterm nutritional issuesWorld journal of
diabetes84642017
Hosseini Esfahani F, Khalaj A, Valizadeh M,
Azizi F, Barzin M, Mirmiran PNutrient intake
and deficiency of patients 1 year after bariatricsurgery tehran obesity treatment study TOTS 
Journal of Gastrointestinal Surgery  25 91182021
Mohapatra S, Gangadharan K, Pitchumoni CS
Malnutrition in obesity before and after bariatricsurgeryDiseaseamonth661008662020
Vlassopoulos ABariatric Surgery as the Culprit
of Malnutrition  Kompass Nutrition &Dietetics15682021
Wade AN, Dolan JM, Cambor CL, Boullata JI,
Rickels MR  Fatal malnutrition 6 years after
gastric bypass surgery  Archives of internal
medicine17099352010
Chiappetta S, Stein J  Refeeding syndrome  animportant complication following obesity
surgeryObesity facts91262016
Nuzzo A, Czernichow S, Hertig A, Ledoux S,
Poghosyan T, Quilliot D, et al Prevention andtreatment of nutritional complications after
bariatric surgeryThe Lancet Gastroenterology &Hepatology6238512021
da Silva JS, Seres DS, Sabino K, Adams SC,
Berdahl GJ, Citty SW, et alASPEN consensus
recommendations for refeeding syndrome
Nutrition in Clinical Practice35178952020
Silk Z, Jones L, Heath DRefeeding syndromeanimportant complication after bariatric surgerySurgery for Obesity and Related Diseases7e21
e32011
Barbosa HC, de Queiroz Oliveira JA, da Costa
JM, de Melo Santos RP, Miranda LG, deCarvalho Torres H, et alEmpowermentoriented
strategies to identify behavior change in patientswith chronic diseases  an integrative review ofthe literaturePatient Education and Counseling
2021
OuKane MNutritional consequences of bariatricsurgeryyprevention, detection and managementCurrent Opinion in Gastroenterology 37 135
442021Asian Journal of Dietetics, 2022

Case Report:
Nutrition Support for Controlling Blood Glucose
in a Case Series of Covid-19 Patients with Hyperglycemia
Yen Ma Ngoc1*, Thao Tran Phuong2,3, Oanh Ninh Thi1, An Bui Tuong1 , Linh Nguyen Thuy1,2
1

Department of Nutrition and Dietetics, The COVID-19 Hospital, Hanoi Medical University Hospital, Vietnam.
2
Hanoi Medical University, Hanoi, Vietnam.
3
Jumonji University Graduate School, Saitama 352-8510, Japan.
INTRODUCTION

Because diabetic patients are easily affected and prone toharbor severe symptoms of COVID-19, and because
DSNF proved their efficacy in controlling blood glucose
as well as other indicators in diabetes, therefore DSNF
has been applied more frequently to decrease glucose
level, in addition to pharmacological therapy. Besides, inVietnam, many hospitals use Blenderized Tube Feeding(BTF) foods which makes by kitchen staff withrudimentary technology. Because it has a short expiry
date with 24 hours in the fridge, it is not suitable fornourishing the Covid-19 patients during the high peak of
the pandemic. In this study, we apply the Nutrition Care
Process (NCP) of The Covid-19 Hospital to improve thenutritional condition for those patients and aim to report
some cases that consumed a kind of commercial BTF
manufactured in Vietnam, which is designed for patientswith hyperglycemic. In addition, this product with areasonable price and a high convenience and therefore
become popular in Vietnam during the Covid-19
pandemic.

COVID-19 caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) was recognized
as a pandemic that has posed a threat to human being
global. As of March 2022, the total number of deaths isapproximately 6 million people and more than 450
million is the total number of cases worldwide (1).
Mortality and morbidity rates of COVID-19 disease
increase significantly in certain population groups suchas males, older adults, or patients with comorbidities.
Among these, hyperglycemia and diabetes mellitus (DM)have received a lot of attention. Hyperglycemia and DM
may be caused by the infection of SARS-CoV-2 to thepancreas through angiotensin-converting enzyme 2(ACE2), where it is highly expressed compared to otherorgans, leading to pancreatic damage with subsequent
impairment of insulin secretion and development ofhyperglycemia even in non-DM patients (2). Apart from
that, adipocyte infection and routine steroid treatment
could be attributed to insulin resistance and elevatedblood glucose (3). Many large studies proved that
hyperglycemia and DM may deteriorate the progression
and severity of COVID-19 and associate with poorer
prognosis and high mortality in suffered patients (4-6).
Many studies proved that commercial food suitable fordiabetic patients was mostly lower in carbohydrates thanthe controlling food (7). The use of diabetes-specificnutrition formula (DSNF) has consistently been shown to
improve postprandial glucose levels compared tostandard test foods such as oatmeal of similar caloric
content (8). DSNF could either affect directl\WKURXJKȕcell stimulation and insulin release and/or indirectly
through glucagon-like peptide-1 (GLP-1) secretion. In
some trials comparing DSNF and standard formula, mostDSNF used were oral nutritional supplements (ONS) (810). It can be seen that the total carbohydrate mainly
ranged from 26 ± 31 grams, equivalent to 35-55% totalenergy, compared to approximately 56 grams of oatmeal(8). A systematic review analyzing 23 different
randomized controlled trials showed that DSNF
significantly reduced the postprandial rise in blood
glucose (by 1.03 mmol/l), peak blood glucose
concentration (by 1.59 mmol/l), and glucose area under
the curve (by 7.96 mmol) (9). In the ICUs, two different
DSNFs outperformed a standard formula in terms ofinsulin use, plasma glucose, and glycemic variability (11).
*To whom correspondence should be addressed:mangocyenyly@gmail.com

METHODOLOGY
A case series was conducted at the R13 ± Intensive
Care Unit at the COVID-19 Hospital which belongs to
Hanoi Medical University Hospital. Our clinical study isa case series that includes 10 eligible patients identified
during the study registration period (consecutive, formal).
It describes the experience of a small group of patients(observational, descriptive research design), contains
demographic information about them, 24 hours dietary
records, and blood glucose (the lowest and highest blood
glucose results each day) during five days consecutive
from the initial day to day 5. We collected data on EMR(Electronic Medical Record) on the ISOFH software.
Inclusion Criteria: At admission, patients werediagnosed to have COVID-19 based on PCR testing. All
patients had severe COVID-19 infection, which
warranted their admission to the hospital. Patients wereadmitted to the COVID-19 Hospital for at least five days.
In addition, the patients were diagnosed with diabetes
and presented disorder hyperglycemia with blood
glucose above 10 mmol/dl and used nasal tube feeding.
All patients received subcutaneous basal-bolus insulin
therapy in the hospital for glucose management. Patientswere fed by FOMEAL CARE products that specificdesign for tube-fed patients with high blood glucose.

19

An Improving in a Case Series of Hyperglycemic Covid-19 Patients
Exclusion Criteria: Patients with evidence of a negative
for SARS-CoV2 and negative nasopharyngeal smear.
Patients had a normal range of blood glucose and did not
use tube feeding. In addition, we excluded covid-19
patients who were supported with extracorporeal
membrane oxygenation (ECMO), were prone positioning,and had risks of refeeding syndrome.

disorder. One portion was packed in a bottle with a net
250ml. The ingredients include macronutrients (14.5
grams protein, 6.6 grams lipid, 25.5 grams carbohydrate),
micronutrients (13 vitamins and 12 minerals, and omega
3,6,9. The noticeable characteristics are high fiber
content (4 grams per bottle) and low glycemic index (GI= 33±17).

Data collection: Nutritional assessment according to
GLIM 2018 Assessment nutritional status: we used
GLIM 2018 criteria for assessing malnutrition in
COVID-19 patients. GLIM 2018 consists of phenotypic
criteria (non-volitional weight loss, low body mass index,
reduced muscle mass) and etiologic criteria (reduced
food intake or assimilation, disease burden/inflammatory
condition). (Questionnaire 1)

Research implementation
The research was applied the Nutrition Care Process(NCP) of the Nutrition and Dietetic Department at The
COVID - 19 Hospital, which include four steps: Nutrition
Screening and Assessment, Nutrition Diagnosis
according to GLIM 2018 criteria, Nutrition Intervention
Plan (nutritional requirements: (protein, lipid,
carbohydrate, fiber, meal distribution, and so on), andreassessment a nutritional plan. In our hospital, dietitians
would carry out four steps in NCP, nurses would respondto feeding patients through tube-feeding. NST took
responsibility for assessment effective nutritional
LQWHUYHQWLRQDQGEORRGJOXFRVHLPSURYHPHQW,ISDWLHQWV¶
blood sugar was unstable and/or insufficient nutrition, thedietitian will change dietary (energy, carbohydrate, andfiber).

Body mass index (BMI): We collected the weight andthe height of patients through electronic medical records
or by asking directly caregivers. BMI category according
to WHO classification: BMI < 18.5 Kg/m2: Underweight;
BMI 18.5±24.9 Kg/m2: Normal weight; BMI 25.0±29.9
Kg/m2: Pre-obesity; BMI > 30 Kg/m2: Obesity.
Non-volitional weight loss: we asked patients or
caregivers by mobiphone or previous medical staff to
NQRZSDWLHQWV¶ZHLJKWORVVVWDWXV

Ethics/Consent: The study has been approved by the
research review board of Hanoi Medical University
Hospital. All participants were fully informed about the
purposes of the study.

Reduced muscle mass: nurses or doctors or dietitians
ZRXOG H[DPLQH RU REVHUYH VRPH SRVLWLRQV RQ SDWLHQWV¶
bodies. These are temples, clavicle, shoulder, scapula,thenar, thigh/knee, and calf. In terms of Subcutaneous fat
ORVVZHH[DPLQHRUREVHUYHVRPHERG\¶VORFDWLRQVVXFKas orbital fat pads, buccal fat pads, and triceps.

RESULTS
We presented a case series of 10 patients diagnosed
positive with COVID-19 and diabetes mellitus. They
were of age group ranging from 67 to 92 years, of which
there were five female patients (50%). The study group
had a BMI from 19.0 to 27.6 kg/m2, including twopatients with BMI over 25 kg/m2.
Most of the patients in the study had a severe COVID19 condition accounted for 80% (8/10 patients), andcritical Covid patients were 20% (2/10 patients). All
patients had comorbidities, 100% of patients withdiabetes mellitus, followed by 50% (5/10 patients) ofpatients with hypertension and 40% (4/10 patients) ofother comorbidities. In addition, seven patients had morethan two types of commorbidities. In terms of respiratory
therapy, those patients had applied with diversity
therapies. Seven patients were supported oxygen byusing invasive ventilation (intubation), followed by twopatients receiving oxygen masks, and only one patient
had non-invasive ventilation (BIPAP).
Table 2 shows that the percentage of patients over 70
years old with BMI < 20 was 30% (3 patients). The
percentage of patients with moderate weight loss was
40% (4 patients), which was lower than the proportion ofpatients without weight loss (60%). Regarding loss ofmuscle mass characteristics, seven patients did notexperience a loss of muscle mass, three patients had amild to moderate loss of muscle mass, and no patients
had a severe weight loss. All patients in our study had areduction in dietary intake under 50%. Based on GLIM
2018, all patients in our study had a risk of moderatemalnutrition at admission.
Table 3 describes the nourishing process of 10
patients during the first five days in the ICU at theReduced food intake or assimilation: we asked
patients or caregivers or previous medical staff to know
SDWLHQWV¶ LQWDNH VWDWXV RU ZH REVHUYHG SDWLHQWV¶ HDWLQJ
during the initial 24 hours entering the hospital in the casewe could not obtain any information from patients or
caregivers or previous medical staffs.
Blood glucose tests: Nurses would check patienWV¶
EORRGJOXFRVHEHIRUHSDWLHQWV¶PHDOWLPH WKHPDLQDQG
snack meals) four times a day (6 am; 11 am; 5 pm; 9 pm).
All patients had not eaten till nurses examined their blood
glucose. They used the ACCU-CHEK Guide machine(Mannheim Germany) for measuring capillary blood
glucose for all patients.
Nutrition requirement calculation: Following the
ESPEN guidelines on clinical nutrition in the intensive
care unit, dietitians calculated nutritional requirements
IRU HDFK SDWLHQW EDVHG RQ WKHLU ZHLJKW DQG SDWLHQWV¶
condition at each phase of the COVID-19 disease. After
that, they chose suitable meal codes and/or nutritional
SURGXFWV IRU HDFK SDUWLFLSDQW 7KH QXPEHU RI SDWLHQWV¶
meals (3 -  PHDOV  ZRXOG IROORZ SDWLHQWV¶ QXWULWLRQDO
requirements.
+ The patient's meals were provided according to thenutritional intervention plan, the nurse nourished thepatient and recorded the number of food intakes eachmeal. Dietitians would synthesize the 24-hour dietary
records. In our research, participants were fed by Fomealcare. Fomeal care is real food that blends meals fordiabetes patients or patients with high blood glucose
20

Asian Journal of Dietetics, 2022
COVID-19 Hospital. For the energy, it reached therecommendation in the first four days. On day 5, theaverage nourishing energy had a small reduction andachieved 80-99% of the energy requirement. In terms ofprotein intake, on day 2, day 3, and day 4 of feeding, the
DYHUDJHDPRXQWRISURWHLQLQSDWLHQWV¶GLHWDU\ZDVJRWWR
over 95% of the protein requirement. However, on day 1,
WKHDYHUDJHDPRXQWRISURWHLQDPRQJSDWLHQWV¶GLHWDU\
was achieved only 88.8% of this recommendation, andthe figure for day 5 was the lowest, at about 76,7%.
Besides, the carbohydrate and fiber were completely
satisfied with the recommendation. During the research
period, the percentage of lipid proportion was notreaching the recommendation ranging from 65% to74.9 %.

This diagram illustrates the variability of blood
glucose and fiber content in the diet of 10 patients during
the first 5 days of admission. The highest and lowest
blood glucose tended to decrease gradually in the first 5
days. The highest average blood sugar among all
participants on day 1 was 21.0 mmol/dL, peaked at 22.1
mmol/dL on day 2, and tended to decrease gradually inthe following days. The lowest average blood sugar of 10
patients on day 1 was 8.9 mmol/dL, increased to 12.2
mmol/dL on day 2, and fell to 7.4 mmol/dL on day 5. Bycontrast, the average amount of dietary fiber showed an
upward trend, and it was 14 grams on the beginning day
to 18.4 grams on the last study day.

Questtionaire 1.
ASSESSMENT OF NUTRITIONAL STATUS AND REFEEDING SYNDROME
Full name:
Diagnose

Gender:Age:

Weight (kg):I.Assessment of nutritional status ± GLIM 2018

Height (cm)Level

Normal

Mild- Moderate

SevereMild: BMI >20 if < 70 Age
RU!LIDJH
1.Body mass index (BMI)

Moderate: < 20 if < 70 age or <22 iIDJH
Moderate: < 18.5 if < 70 age or <LIDJH
Mild

2. Weight loss %(unintended)

Moderate
Severe3. Food intake (Compared
to normal)

Mild
Reduce <50% of food intake
Reduce < 75% of food intake
Mild to moderate

4. Reduced muscle massModerate
SevereClassification of malnutrition:

Classify

II. DIANOSTIC CRITERIA FOR THE RISK OF REFEEDING SYNDROME
High risk of Refeeding Syndrome if patients have a factor below:

Moderate risk of Refeeding Syndrome if patients have two
factors below:

BMI: < 16,0 kg/m2

BMI: 16-18.5 kg/m2

Weight loss level: severe

Weight loss level: moderate

Reduced muscle mass/ Subcutaneous fat loss: severe

Reduced muscle mass/ Subcutaneous fat loss: mild tomoderate

Reduced caloric intake 75% of total estimated energy
requirement
5HGXFHG3RWDVVLXP3KRVSKRUXV

Reduced caloric intake 50% of total estimated energy
requirement
Reduced Potassium, Phosphorus < 30%
21

An Improving in a Case Series of Hyperglycemic Covid-19 Patients
Table 1: Patient characteristics
Severity of
COVID-19diseaseCovid-19
severity

Patients
No.

GenderAge

Weight(kg)

Height(cm)

BMI(kg/m2)

Past medical
history

1

Male

74

61

155

25.4

2

Female

80

47.6

148

21.7

Covid-19
severity

3

Female

78

55

153

23.5

Covid-19
severity

4

Female

67

65

160

25.4

Covid-19
severity

Diabetes

5

Male

76

55

170

19.0

Covid-19
severity

Diabetes,
Hypertension

6

Female

92

45

152

19.5

Covid-19
severity

Diabetes, Heart
failure

7

Male

72

65

169

22.8

Covid-19
Critical level

Diabetes,
Hypertension

8

Male

77

54

168

19.1

Covid-19
Critical level

Diabetes, Heart
failure

9

Male

90

54.4

161

21.0

Covid-19
severeDiabetes

10

Female

74

78

168

27.6

Covid-19
severeDiabetes

Diabetes,
Hypertension
Diabetes,
Hypertension,
Heart failure
Diabetes,
Hypertension

Respiratory therapy
Breathing oxygen
through mask
Invasive mechanicalventilation(endotracheal)
Breathing oxygen
through mask
Invasive mechanicalventilation(endotracheal)
Invasive mechanicalventilation(endotracheal)
Non-invasive
ventilation (CPAP or
BIPAP)
Invasive mechanicalventilation(endotracheal)
Invasive mechanicalventilation(endotracheal)
Invasive mechanicalventilation(endotracheal)
Invasive mechanicalventilation(endotracheal)

Table 2. Diagnostic Assessment Global Leadership Initiative on Malnutrition (GLIM) 2018
Phenotypic

Assessment criteria

1

Low BMI (kg/m2)

2

Weight loss

3

Reduced muscle mass

Etiologic
1

Food intake

2

Disease burden/
Inflammatory condition

Quantity

Percentage< 18.5 (< 70 years old)
< 20 (>= 70 years old)
Mild
Moderate
SevereMild to moderate
Moderate
Severe

0
3
6
4
0
7
3
0

0%
30%
60%
40%
0%
70%
30%
0%

Mild
Reduce <50% of food intake
Reduce < 75% of food intake

0
10
0

0%
100%
0%

COVID-19

10

100%

22

Asian Journal of Dietetics, 2022

Table 3. The nourishing process of 10 patients in the first 5 days in Intensive Care Unit (ICU)
Nutritional values

Energy

Day 1

Day 2

Day 3

Day 4

Day 5

Energy (kcal)(Mean ± SD)

877± 213840 ±171861 ± 184966 ± 147

1150 ± 147

Recommended
demand- Energy

870-986 kcal/kg /day (15-20kcal/kg body weight /day)

Percentage
Recommended
demand (%)
Protein (grams)(Mean ± SD)
Protein

Lipid

Carbohyd
rate

Fiber

Achieve 100% recommended demand

1160-1411
kcal/kg/day (20-25
kcal/kg/ bodyweight /day)Achieve 80-99%
recommended
demand

51.5±14.9

58 ±11.8

59.5 ± 12.7

66.7 ± 10.1

66.7 ± 10.1

Recommended
demand - Protein

58 ± 9.6

58 ± 9.6

58 ± 9.6

69.6 ± 11.5

87 ± 14.4

Percentage
Recommended
demand (%)

88.8 %

100%

102.6%

95.8%

76.7%

Lipid (grams)(Mean ± SD)

27.7± 6.8

26.4± 5.427.1± 5.8

30.4 ± 4.6

30.4± 4.6

Recommended
demand - Lipid

40.6 ± 6.7

40.6 ± 6.7

40.6 ± 6.7

40.6 ± 6.7

40.6 ± 6.7

68.2%

65%

66.7%

74.9%

74.9%

109.2±28.6

102± 20.8

104.5 ± 22.3

117.3 ± 17.8

117.3 ± 17.8

Percentage
Recommended
demand (%)
Carbohydrate(grams) (Mean ±SD)
Recommended
demandCarbohydrate
Percentage
Recommended
demand (%)
Fiber (grams)(Mean ± SD)
Recommended
demandCarbohydrate
Percentage
Recommended
demand (%)

Minimum 100-120g/day
Achieve 100% recommended demand
14 ± 4.2

16± 3.3

16.4 ± 3.5

18.4 ± 2.8

14g fiber/1000 kcal
Achieve 100% recommended demand23

18.4 ± 2.8

An Improving in a Case Series of Hyperglycemic Covid-19 Patients

22.1
21.0

20.0

19.1
18.4

18.4
17.5

16.4

16
14
12.2

9.5

8.9

8.3

7.4

The average highest blood glucose among 10 patients (mmol/dL)
The average lowest blood glucose among 10 patients (mmol/dL)
The average amount of dietary fiber among 10 patients (g)

Day 1

Day 2

Day 3

Day 4

Day 5

Fig 1. Blood glucose status and dietary fiber content of study subjects
for 5 consecutive days

DISCUSSION

All of the candidate patients in our study wererecognized as malnutrition, according to GLIM criteria.
A retrospective, multicenter study was conducted in 85
diabetic COVID-19 patients from three hospitals in
China indicated the prevalence of undernourishment
was 41.18% according to NRS-2002. Besides, NRS2002 and serum pre-albumin were independent
predictors of the grade of severity of COVID-19. The
malnourished group had more severe illness than thenormal nutritional group and had a longer length of inhospital stay and higher mortality (19). Anotherretrospective study illustrated similar results, but theprevalence of malnutrition was even higher, at least
60% (20). Of 10 patients, there were 6 cases with mild
weight loss and 4 patients with moderate weight loss inour cases report. We did not list which patients had
moderate or severe malnutrition to discuss thedifferences between different ages and severity ofmalnutrition. Another descriptive, follow-up study used
two types of nutritional parameters, BMI and MUST,
measured at three different time points (21). According
to the Subjective Global Assessment (SGA), 27 out of
75 patients admitted due to a COVID-19 infection had
malnutrition. Patients not well nourished were older
than patients with an SGA grade A (22). We did not findany research evaluating nutritional state with Global
Leadership Initiatives on Malnutrition (GLIM) (23),possibly because GLIM has just been updated andwidely published since 2018, therefore there were notmany studies using it as a tool.

The cut-off values of BMI in our study followed the
WHO WPRO Asian (12). It can be seen that 4 out of 10
patients have the BMI of overweight and obesity,
especially a female patient with a BMI of 27.6. Obesity
is a risk factor for severe infection. It has been shownthat obesity is associated with worse cytokine storms,
the severity, and the longer duration of viral infections(13,14). A retrospective case series conducted in the UK
showed that all the patients were overweight or obese(15). Other factors may be related to the fact that obesity
may mechanically impair ventilation with reduced
aeration of the lung bases that lead to accumulation of
secretions and increased risk of infections (16). The
patients mainly had comorbidities such as hypertension
and heart failure. A case series of 5 patients who
suffered from diabetic ketoacidosis, also indicated somecommon diseases apart from hypertension andcongestive heart failure, involving dyslipidemia, endstaged renal diseases, and chronic obstructive
pulmonary disease (17). Severe COVID-19 wasdiagnosed based on Guidelines on diagnosis andtreatment the COVID-19 patients - Vietnamese
Ministry of Health - 2022 (Breathing beat over 25 orunder 10 per minutes; Sp02 < 94% without any oxygen
supportive therapies or have to use Non-invasive
ventilation (High-flow nasal cannula - HFNC, CPAP,
BiPAP) and Invasive mechanical ventilation; the imageof lungs on X-ray or CT were hurt more than 50%),
which is similar/different to a case series ofobservations among 8 patients (18).

We followed global guidelines and consensus interms of nutritional therapy for ICUs patients, which
hypocaloric nutrition (not exceeding 70% of energy
expenditure) should be prescribed (24). This is based on

Hospitalized patients with COVID-19 are at highrisk of malnutrition due to an increase in nutritional
UHTXLUHPHQWVDQGDVHYHUHDFXWHLQÀDPPDWRU\UHVSRQVH24

Asian Journal of Dietetics, 2022
the metabolic response to critical illness. In brief, theµHEE¶SKDVHLVFKDUDFWHUL]HGE\KHPRG\QDPLFLQVWDELOLW\and hormonal changes (including insulin resistance) inorder to prioritize the delivery of energy substrates tovital tissues (25,26). This phase leads to endogenous
glucose production as well as lower energy expenditurecompared to pre-LQMXU\7KHµIORZ¶SKDVHLQYROYHVWKH
breakdown of tissue to provide substrates to cover theimmediate needs for the "fight or flight" response and to
reduce the risk of bleeding and infection. The anabolic
recovery phase has been described as the resynthesis oflost tissue and the body may be more metabolically able
to process delivered nutrients (27,28). Protein acceptted
the protein amount delivered by the energy target. Afterday 3, targeted energy gradually reaches 80-100%
measured requirement. Protein target varies by different
guidelines, progressively increasing to 1.3g/kg/day(24,25), or expected to be in the range of 1.2 ± 2.0
g/kg/day (30). Energy intake of patients in our study
achieved 100% energy requirement in the first 4 days in
the ICU, but intake in day 5 seemed to be lower than
SDWLHQWV¶ GHPDQG SRVVLEO\ GXH WR WKH lack of medical
workforces during the peak time in Vietnam.

2. Al-kuraishy HM, Al-Gareeb AI, Alblihed M,
Guerreiro SG, Cruz-Martins N, Batiha GES.
COVID-19 in Relation to Hyperglycemia andDiabetes Mellitus. Front Cardiovasc Med. 2021;8.
Accessed
March
9,
2022.
https://www.frontiersin.org/article/10.3389/fcvm.2
021.644095.
3. Langouche L, Van den Berghe G, Gunst J.
Hyperglycemia and insulin resistance in COVID-19
versus non-COVID critical illness: Are they reallydifferent?
Crit
Care.
2021;25(1):437.
doi:10.1186/s13054-021-03861-6.
4. Haymana C, Demirci I, Tasci I, et al. Clinicaloutcomes of non-diabetic COVID-19 patients withdifferent blood glucose levels: a nationwide Turkish
study(TurCoGlycemia).
Endocrine.
2021;73(2):261-269.
doi:10.1007/s12020-02102789-9.
5. Wang W, Shen M, Tao Y, et al. Elevated glucose
level leads to rapid COVID-19 progression and highfatality. BMC Pulm Med. 2021;21(1):64.
doi:10.1186/s12890-021-01413-w.

Most study patients were severe and critically ill,therefore their blood glucose seemed high. Our study
shows that both the maximum and minimum
preprandial glucose experienced a downward trend
during the time of using the commercial BTF. In
contrast, fiber consumption increased day by day. Someother controlled trials that used similar specialized
nutrition formulas also concluded about the reduced
glycemic effect of DSNFs (31-33). The low glycemic
index of most DSNFs partially contributes to this effect.
The commercial BTF with an average GI is 33±17, is asuitable product for diabetes patients. This was not tomention that most of the participants found it easy totolerate this product during the feeding process. Even so,
according to FAO/WHO, the GI of this product isclassified as a low GI, therefore it is officially acceptedfor patients with critical illness, impaired glucose
tolerance and/or diabetes. Blood sugar changes after
taking this product were significantly lower than thoseafter taking glucose at 15 minutes, 45 minutes, and 60
minutes. Thus, the studied product is safe for diabetic
patients because it may gradually increase blood
glucose and help to prevent glucose instability and theprogress of diabetic complications.

6. Xiao F, Zhou YC, Zhang MB, et al. Hyperglycemia
and blood glucose deterioration are risk factors forsevere COVID-19 with diabetes: A two-center
cohortstudy.
J
Med
Virol.
n/a(n/a).
doi:10.1002/jmv.27556.
7. Huhmann MB, Yamamoto S, Neutel JM, Cohen SS,
Ochoa Gautier JB. Very high-protein and lowcarbohydrate enteral nutrition formula and plasma
glucose control in adults with type 2 diabetes
mellitus: a randomized crossover trial. Nutr
Diabetes. 2018;8(1):1-8. doi:10.1038/s41387-0180053-x.
8. Mottalib A, Mohd-Yusof BN, Shehabeldin M, Pober
DM, Mitri J, Hamdy O. Impact of Diabetes-Specific
Nutritional Formulas versus Oatmeal on
Postprandial Glucose, Insulin, GLP-1 andPostprandial Lipidemia. Nutrients. 2016;8(7): E443.
doi:10.3390/nu8070443.
9. Elia M, Ceriello A, Laube H, Sinclair AJ, Engfer M,
Stratton RJ. Enteral Nutritional Support and Use of
Diabetes-Specific Formulas for Patients With
Diabetes: A systematic review and meta-analysis.
DiabetesCare.
2005;28(9):2267-2279.
doi:10.2337/diacare.28.9.2267.

CONCLUSION
Personalize nutritional interventions for patients
through the nutritional care process (NCP) for eachindividual with suitable nutritional products for thepatient's condition, which could contribute to improving
the nutritional status and blood sugar control for thepatient. Dietitians and other medical staff play a key rolein taking care of the Covid-19 patients during the
pandemic.

10. Sanz-Paris A, Boj-Carceller D, Lardies-Sanchez B,
Perez-Fernandez L, Cruz-Jentoft AJ. Health-CareCosts, Glycemic Control and Nutritional Status in
Malnourished Older Diabetics Treated with aHypercaloric Diabetes-Specific Enteral Nutritional
Formula.
Nutrients.
2016;8(3):153.
doi:10.3390/nu8030153

REFERENCES
1. COVID-19 Data Explorer. Our World in Data.
Accessed
March
9,
2022.
https://ourworldindata.org/coronavirus-dataexplorer.

11. Mesejo A, Montejo-González JC, VaquerizoAlonso C, et al. Diabetes-specific enteral nutrition
25

An Improving in a Case Series of Hyperglycemic Covid-19 Patients
formula in hyperglycemic, mechanically ventilated,critically ill patients: a prospective, open-label,blind-randomized, multicenter study. Crit Care
Lond Engl. 2015;19:390. doi:10.1186/s13054-0151108-1

consensus report from the global clinical nutrition
community. Clin Nutr 38(1):1-9. 2019.
24. Singer P, Blaser AR, Berger MM, et al. ESPEN
guideline on clinical nutrition in the intensive careunit. Clin Nutr 38(1):48-79. 201912. 0957708211_eng.pdf. Accessed March 11, 2022.
https://iris.wpro.who.int/bitstream/handle/10665.1/
5379/0957708211_eng.pdf

25. Cuthbertson DP. POST-SHOCK METABOLICRESPONSE. The Lancet 239(6189):433-437. 1942.

13. Honce R, Schultz-Cherry S. Impact of Obesity on
Influenza A Virus Pathogenesis, Immune Response,and Evolution. Front Immunol 10:1071. 2019.

26. Marik PE, Bellomo R. Stress hyperglycemia: anessential survival response! Crit Care 17(2):305.
2013

14. Huttunen R, Syrjänen J. Obesity and the risk andoutcome of infection. Int J Obes. 2013;37(3):333340. doi:10.1038/ijo.2012.62

27.Wischmeyer PE. Tailoring nutrition therapy toillness and recovery. Crit Care 21(Suppl 3):316.
2017

15. Conway J, Gould A, Westley R, et al. Characteristics
of patients with diabetes hospitalised for COVID-19
infection-a brief case series report. Diabetes Res
Clin Pract 169:108460. 2020.

28.Tappy L. The Stress Response of Critical Illness:
Metabolic and Hormonal Aspects. In: Preiser JC, ed.
The Stress Response of Critical Illness: Metabolicand Hormonal Aspects. Springer International
Publishing 75-87. 2016

16. The effect of obesity on lung function: Expert
Review of Respiratory Medicine: Vol 12, No 9.
Accessed
March
13,
2022.
https://www.tandfonline.com/doi/abs/10.1080/1747
6348.2018.1506331
17. Gorthi RS, Kamel G, Dhindsa S, Nayak RP.
COVID-19 Presenting With Diabetic Ketoacidosis:
A Case Series. AACE Clin Case Rep 7(1):6-9. 2020.
18. Case series: COVID-19 infection causing new-onset
diabetes mellitus? Endocrinol Metab Int J 9 (1).
2021

29.

Lambell KJ, Tatucu-Babet OA, Chapple Lanne, Gantner D, Ridley EJ. Nutrition therapy incritical illness: a review of the literature forclinicians. Crit Care 24(1):35. 2020.

30.

McClave SA, Taylor BE, Martindale RG, et al.
Guidelines for the Provision and Assessment of
Nutrition Support Therapy in the Adult Critically Ill
Patient. J Parenter Enter Nutr. 2016;40(2):159-211.
doi:10.1177/0148607115621863

31. A AD, S JO, A RH, A VM. Glycemia TargetedSpecialized
Nutrition(GTSN)
improves
postprandial glycemia and GLP-1 with similar
appetitive responses compared to a healthful whole
food breakfast in persons with type 2 diabetes: arandomized, controlled trial. J Diabetes Res Clin
Metab. 2012;1(1):20. doi:10.7243/2050-0866-1-20

19. Chen J, Zhao C, Huang Y, et al. Malnutrition
predicts poor outcomes in diabetic COVID-19
patients in Huangshi, Hubei. J Biomed Res
36(1):32-38. 2022.
20. Morán-López JM. Malnutrition and nutrition
support in COVID-19: The results of a nutrition
support protocol. Endocrinol Diabetes Nutr Engl Ed
68(9):621-627. 2021

32. Voss AC, Maki KC, Garvey WT, et al. Effect of two
carbohydrate-modified tube-feeding formulas on
metabolic responses in patients with type 2 diabetes.
Nutrition 24(10):990-997. 2008.

21. Fiorindi C, Campani F, Rasero L, et al. Prevalenceof nutritional risk and malnutrition during and after
hospitalizationfor
COVID-19
infection:
Preliminary results of a single-centre experience.
Clin
Nutr
ESPEN.
2021;45:351-355.
doi:10.1016/j.clnesp.2021.07.020

33.González-Ortiz M, Martínez-Abundis E, HernándezSalazar E, Kam-Ramos AM, Robles-Cervantes JA.
Effect of a nutritional liquid supplement designed
for the patient with diabetes mellitus (Glucerna SR)
on the postprandial glucose state, insulin secretion
and insulin sensitivity in healthy subjects. Diabetes
Obes Metab 8(3):331-335. 2006.

22. Nicolau J, Ayala L, Sanchís P, et al. Influence ofnutritional status on clinical outcomes amonghospitalized patients with COVID-19. Clin Nutr
ESPEN 43:223-229. 2021.

34. Quyen Tran Chau. Determine the Glycemic Indexof product Fomeal Care. A base level of Research
National Institute of Nutrition.2020

23. Cederholm T, Jensen GL, Correia MITD, et al.
GLIM criteria for the diagnosis of malnutrition ± A

26