The effect of using okara to improve the quality of meal for diabetes patient in ha noi medical university hospital

4#
MINISTR Y OF EDUCATION A ND TRAINING MINITRY OF HEALTH
HANOI MEDICAL UNIVERSITY

NGUYEN QUYNH HOA

THE EFFECT OF USING OKARA TO IMPROVE THE
QUALITY OF MEAL FOR DIABETES PATIENTS IN
HANOI MEDICAL UNIVERSITY HOSPITAL

Major: Bachelor of Nutrition

GRADUATION THESIS BACHELOR OF MEDICINE
COURSE 2017- 2021

Supervisor: NGUYEN THEY LINH. PhD. MD

HANOI-2021
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TM/ V*:

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ACKNOWLEDGEMENT
It is ail honor to become a student of Hanoi Medical University (HMU). Four
years study in here. I’m not only gain new knowledge, but also get more skills and
especially I have wonderful teachers and friends.

First and foremost. I have to thank HMU Board of President. Department of
Undergraduate Training and Management for giving me the opportunity to conduct
and complete my graduation thesis.
I am thankful to Hanoi Medical University Hospital for giving me the best
conditions to collect the data.
I would like to give thanks Jumonji University and Asia Nutrition and Food
Culture Research Center for supporting my study and give me one chance exchange in
Japan.
I am deeply indebted to my respected teacher Professor Yamamoto Shigeru. He
is an experienced researcher and gave me valuable advice on research
Especially, my sincere thanks also go to Mrs. Nguyen Thuy Link PhD. MD.
HMU my supervisor for support my study, for her patience, motivation, enthusiasm
and immense knowledge. Her guidance helped me in all the time of research and
writing of this thesis. I have learned many things from her. I’m greatly indebted to her
a lot and could not haw imagined having a better advisor and mentor for my
graduation thesis.
I am also grateful to volunteer patients who agreed to spend their time to
complete the questionnaire and implement the diets which we prepared. Their
contribution is very important.
I submit my heartiest gratitude to my investigators my wonderful classmates.
They were very enthusiastic to participate in my research. considering it as their
research. They also accompanied me during the period of collecting difficult research
data. It is very fortunate to work with them.
Finally. I want to express the deepest thank my mother for her continuous and


unparalleled love, supporting me spiritually throughout my life. I am forever indebted
to my mother for gi\ing me tile opportunities and experiences that have made me who
I am. She encouraged me to explore new directions in life and seek my own destiny.
This journey would not have been possible if not for her. and I dedicate this milestone

to her.
Thank for all!
Hanoi. 2021

Nguyen Quynh Hoa


COMMITMENT

I declare that this diesis represents my own work and lias not been submitted
for any degree in any university previously. The data and results presented in this
thesis are to the best of my knowledge, tme and accurate. All sources of
information of information which have been used in the thesis and external
contributions are referenced and acknowledged.

Hanoi. 2021

Nguyen Quvnh Hoa


ABBREVIATION

BMI

: Body Mass Index

DALY

: The disability-adjusted life year (DALY')

DKA

: Diabetes ketoacinosid

ESPEN

: European Society for Clinical Nutrition and Metabolism

GBD

: Global Burden of Disease

GDM

: Gastrointestinal diabetes mellitus

GI

: Glycemic index

GL

: glycemic load

IDF

international Diabetes Federation

LDL

: Low density lipoprotein

MST

: Malnutrition Screening Tool

NIDDM

: Non-insulin-dependent diabetes mellitus

NIN

: National Institute of Nutrition

SGA

: Subjective Global Assessment

YLDs

: Years Lived with Disability

YLL

: Years of life lost

WHO

: World Health Organization

TABLE OF CONTENTS

REFERENCES
LIST OF TABLES


LIST OF FIGURES


SUMMARY

Diabetes Mellitus has been increasing rapidly in Vietnam, we hypothesized
that the main reason that Vietnamese people using fiber and vegetable less than the
amount of fiber rather than the recommendation of WHO. at about
10g/1000kcal/day. Regarding source, fiber comes mainly from vegetable. However,
most types of Vietnamese vegetable in Vietnam are significantly lower in fiber, at
about 2g fiber /100g vegetable. So it is very difficult for Vietnamese people,
especially with patients who has diabetes to consume enough the amount of fiber
regarding to the recommendation of WHO. In Study we tried to use okara to
improve the amount of fiber in daily meal for diabetes patient and access the
acceptability of patient with dishes which contain okara. We selected 20 patients
diagnosed with diabetes in Hanoi Medical University hospital. We divide all
participant into 2 group, each group using 3 days of okara meal and 3 days of
Hospital meal (not using okara) and take the sensory test in all patient. At tlie
baseline and final period, anthropo metric measurement, there was a significant
higher in the amount of fiber of patient who using okara. from 10,75 to 13.8 (p
<0.05). About sensory' test. Points for okara meal sample were higher than from
hospital diet sample on color, shape evenly, juiciness, tenderness, and overall. And
the differences have statistically significant for the mean points (p<0.05). Point for

okara diet was higher than hospital diet in taste 7,71+0.61 points and 7,0+0.72
points, respectively (p<0.05). Using okara in dietary meal help to improve the
amount of fiber in diabetes patient and is one of the most easily solution for patient
with diabetes
Keyword: Okara fiber. Diabetes Mellims. Hospital diet


chúng
lỏi
dưa
ra
gia
thuyết
ngun
nhân
chính
lã
do
người
Việt
nghị
Nam
cùa
sứ
WHO.
dụng
khống
ít
chất
l()g

xơ
/va
vã
lOOOkcal
rau
qua
/
hơn
ngây,
so
về
với
nguồn,
khuyến
cua
chú
Việt
ycu
Nam
den
đều
lừ
cỏ
rau
hãm
cú.
lượng
Tuy
chất
nhiên,

XƯ
hầu
thấp
het
lum
các
dáng
loại
kẻ.
rau
chi
khoang
là
2g
chất
xơ
/
tiếu
lOOg
dường
rau.
rắt
Vỉ
vậy
khó
người
tiêu
thụ
Việt
du

Nam,
lượng
dặc
chất
xơ
cổ
theo
gắng
khuyến
sử
dụng
nghị
okara
cua
dê
WHO.
cãi
thiện
Trong
lượng
nghiên
chất
cứu.
xơ
chúng
trong
tỏi
bừa
đà
án

nhận
hàng
cua
ngày
bệnh
cho
nhân
bẹnh
với
nhân
các
món
lieu
ăn
dường
có
chứa
và
tiếp
okara.
cận
Chúng
chấp
tơi
chọn
bệnh
20
viện
bệnh
Dại

nhân
học
dược
Y
Hà
chân
Nội.
đốn
Chứng
mac
lơi
bệnh
chia
tiêu
tat
đường
ca
những
tại
người
Okara
tham
và
3
gia
ngày
thành
ăn
bừa
2

nhóm,
ản
tại
mỗi
bệnh
nhóm
viện
sư
(khơng
dụng
3
sứ
ngày
dụng
bữa
ân
okara)
giai
đoạn
vả
tiến
đầu
vã
hành
giai
kiêm
đoạn
tra
cuối,
cảm

quan
do
nhãn
ờ
tất
trác
cá
học,
bệnh
lượng
nhãn.
Ớ
chắt
10,75
xơ
lẽn
cùa
13.8
bệnh
(p
nhân
<0,05)-về
sừ
dụng
kiêm
okara
tra
cao
cám
hơn

quan,
dáng
diêm
kê.
cho
tữ
mẫu
bừa
hình
ăn
dạng
okara
dồng
cao
đều,
hơn
độ
mẫu
mọng,
bừa
ăn
mềm.
tại
và
bệnh
tơng
viện
thê.
Có
màu

sự
sắc.
khác
biệt
đồng
có
đều.
ý
nghía
mùi
vị
thống
vã
mùi
kê
thơm
giừa
và
diêm
tơng
trung
thê
bính
với
p
ve
<0.05.
hình
dạng
Diem

cho
viện
chế
lần
độ
lượt
án
kiêng
là
7.45±0.59
okara
cao
hơn
7.09±0,72.
chề
độ
ân
Sứ
uống
dụng
tại
bà
dậu
bệnh
nành
trong
dường
bừa
vả
là

ăn
một
giúp
trong
cài
thiện
những
lượng
giai
pháp
chất
dẻ
xơ
dàng
ừ
bệnh
nhất
nhân
cho
tiêu
bệnh
nhân
tiêu
đường.

TM/ V*:


10

INTRODUCTION
In Viet Nam the prevalence of diabetes is growing at alarming rates and has
almost doubled within the past 10 years. Currently, it’s estimated that one in every
20 Vietnamese adults has diabetes. In addition, lite number of people with a prediabetic condition is three times higher than those with diabetes [11 Severe
complications, such as feet ulcers, gangrene and resulting amputations,
cardiovascular diseases, blindness and kidney failures are common in diabetes
patients. These complications are the main causes of death and disability for people
with diabetes. It's estimated that about 422 million people have diabetes in the
world, especially in low and middle-income countries [1]
Additionally. Vietnam has the double burden of over- and undernutrition. [2]
According to International Diabetes Federation. 80.6% of people do not consume
the recommended number of five servings of fiuit and vegetables, and they have
diets that are high in salt. fat. and sugar [3]. Studies have found that 31.3% of the
total deaths and 25.3% of the whole disability- adjusted life years (DALY) in
Vietnam were caused by an unhealthy diet [3]. The DALY combines the estimates
of years of life lost due to premature death (YLL) and years lived in ill health or
with disability (YLD) to count tire total years of functional experience lost from
diseases [4]. Researches have concluded tliat the leading risk factor for diabetesrelated diseases is lifestyle and dietary issues
Current evidence suggests that high-fiber diets, especially of the soluble
variety, and soluble fiber supplements may offer some improvement in
carbohydrate metabolism, lower total cholesterol and low-density lipoprotein
(LDL) cholesterol, and have other beneficial effects in patients with noninsulindependent diabetes mellitus (NIDDM). Although there are a closely relationship
between fiber intake and controlling diabetes, however, the amount of fiber intake
in daily meal was significantly lower than the recommendation of WHO. We
hypothesized that the main reason of tills problem may come from popular
vegetables in Vietnam are usually low in fiber (<2g'100g vegetable), so it is very
difficult for people absorb enough fiber from food and vegetable, especially in
diabetes patients. [5]

11

Due to the importance of fiber-rich food in improvement and controlling
diabetes (type 2). It is necessaty to supply and using more fiber-rich food in hospital
where the majority' of diabetes patients are hospitalized and treated with diabetes
and controlling blood glucose index. However, most of diabetes patients using
hospital diets commonly absorb lower level of fiber intake [5]. Vietnamese usual
vegetables used in hospital diet was not provide enough fiber needed for patient.
Subsequently, this situation triggers negative influence to nutritional status of them
at present and in the future.
In this regard, using Okara could be on feasible solution. Okara. soy pulp, or
tofu dregs is a pulp consisting of insoluble pans of the soybean that remain after
pureed soybeans are filtered in the production of soymilk and tofu. We can also use
them daily with various ways of processing, combined with variety of foods,
increasing the nutritional value of the dishes.
Not only is the solution for the hospital to nutritional care for the diabetes
patients, patients should also know okara (fiber - rich food) cooking recipe so they
could be able to prepare their own meals at home.
We expect using Okara in diet is more beneficial than the currently- used
only vegetable in every-day to help the diabetes patients improve their daily meals,
increasing their amount fiber intake in order to control diabetes well and finally
improving their quality of life through their diet.
Therefore, wc decided to conduct The effects of using okara food to improve
the quality of meal for diabetes patients in Hanoi Medical University Hospital”, the
purposes of this study include:
1, To assess the amount of fiber and other nutients intake per meal by using
and adding Okara to diet for diabetes patients in Hanoi Medical University
Hospital.
2, To evaluate sensory test and the acceptability of patients when they using
Okara in daily meals in hospital

CHAPTER 1: LITERATURE REMEW

1.1.

Overview of diabetes


12

1.1.1.

Define of diabetes

Diabetes is a serious, chronic disease that occurs either when the pancreas
does not produce enough insulin (a hormone that regulates blood glucose), or when
die body cannot effectively use the insulin its produce [6]. Raised blood glucose, a
common effect of uncontrolled diabetes, may. over time, lead to serious damage to
the heart, blood vessels, eyes, kidneys and nen es. More than 400 million people
live with diabetes in the world.
Type 1 diabetes (previously known as insulin-dependent, juvenile or
childhood-onset diabetes) is characterized by deficient insulin production in the
body. People with type 1 diabetes require daily administration of insulin to regulate
the amount of glucose in their blood. If they do not have access to insulin, they
cannot survive. The cause of type 1 diabetes is not known and it is currently not
preventable. Symptoms include excessive urination and thirst, constant hunger,
weight loss, vision changes and fatigue. [6]
Type 2 diabetes (formerly called non-insulin-dependent or adult- onset
diabetes) results from the body’s ineffective use of insulin. Type 2 diabetes accounts
for the vast majority of people with diabetes around the world (6). Symptoms may
be similar to those of type 1 diabetes, but are often less marked or absent. As a

result, the disease may go undiagnosed for several years, until complications have
already arisen. For many years type 2 diabetes was seen only in adults but it has
begun to occur in children. [8]
1.12. Risk factors for diabtes
Type 1. The exact causes of type 1 diabetes are unknown. It is generally
agreed that type 1 diabetes is the result of a complex interaction between genes and
enxironmental factors, though no specific environmental risk factors have been
shown to cause a significant number of cases. The majority of type 1 diabetes


13

occurs in children and adolescents. [10]
Type 2. The risk of type 2 diabetes is determined by an interplay of genetic
and metabolic factors. Ethnicity; family history of diabetes, and previous
gestational diabetes combine with older age. ovenwight and obesity, unhealthy diet,
physical inactivity and smoking to increase risk. [6]
Excess body fat a summary’ measure of several aspects of diet and physical
activity, is the strongest risk factor for type 2 diabetes, both in terms of clearest
evidence base and largest relative risk. Overweight and obesity, together with
physical inactixity, are estimated to cause a large proportion of the global diabetes
burden [7], Higher waist circumference and higher body mass index (BNÍI) are
associated with increased risk of type 2 diabetes [9]. though the relationship may
vary in different populations. Populations in South-East Asia, for example, develop
diabetes at a lower level of BMI than populations of European origin. [11]
Several dietary’ practices are linked to unhealthy body weight and 'or type 2
diabetes risk, including lũgh intake of saturated fatty’ acids, lũgh total fat intake and
inadequate consumption of dietaiy fiber. High intake of sugar- sweetened
beverages, which contain considerable amounts of free sugars, increases the
likelihood of being oxerweight or obese, particularly among children. Recent

evidence further suggests an association between high consumption of sugarsweetened beverages and increased risk of type 2 diabetes. [12]
Early childhood nutrition affects die risk of type 2 diabetes later in life.
Factors that appear to increase risk include poor fetal growth. low birth weight
(particularly if followed by rapid postnatal catch- up growth) and high birth weight
Active (as distinct from passive) smoking increases the risk of type 2 diabetes,
with the highest risk among heavy smokers. Risk remains elevated for about 10
years after smoking cessation, falling more quickly for lighter smokers.
Gestational diabetes. Risk factors and risk markers for GDM include age (the


14

older a woman of reproductive age is. the higher her risk of GDM); overweight or
obesity; excessive weight gain during pregnancy; a family history of diabetes;
GDM during a previous pregnancy; a history of stillbirth or giving birth to an infant
with congenital abnormality; and excess glucose in urine during pregnancy.
Diabetes in pregnancy and GDM increase the risk of future obesity and type2
diabetes in offspring [13].
1.13. Complication of diabetes
When diabetes is not well managed, complications develop that tlưeaten
health and endat^er life. Acute complications are a significant contributor to
mortality, costs and poor quality of life. Abnormally high blood glucose can have a
life-threatening impact if it triggers conditions such as diabetic ketoacidosis (DKA)
in types 1 and 2(14], and hyperosmolar coma in type 2. Abnormally low blood
glucose can occur in all types of diabetes and mayresult in seizures or loss of
consciousness. It may happen after skipping a meal or exercising more than usual,
or if the dosage of anti-diabetic medication is too high. [15]
Over time diabetes can damage the heart, blood vessels, eyes, kidneys and
nerves, and increase the risk of heart disease and stroke [6]. Such damage can result
in reduced blood flow, which combined with nerve damage (neuropathy) in the feet

- increases the chance of foot ulcers, infection and the eventual need for limb
amputation. Diabetic retinopathy is an important cause of blindness and occurs as a
result of long- term accumulated damage to the small blood vessels in the retina.
Diabetes is among the leading causes of kidney failure.
Uncontrolled diabetes in pregnancy can have a devastating effect on both
mother and child, substantially increasing the risk of fetal loss, congenital
malformations, stillbirth, perinatal death, obstetric complications, and maternal
morbidity and mortality. Gestational diabetes increases the risk of some adverse
outcomes for mother and offspring during pregnancy, childbirth and immediately


15

after delivery (pre-eclampsia and eclampsia in the mother; large for gestational age
and shoulder dystocia in the offspring). However, it is not known what proportion
of obstructed births or maternal arid per inatal deaths can be attributed to
hyperglycemia.
The combination of increasing prevalence of diabetes and increasing lifespans
in many populations with diabetes may be leading to a changing spectrum of the
types of morbidity that accompany diabetes [30]. In addition to the traditional
complications described above, diabetes has been associated with increased rates of
specific cancers, and increased rates of physical and cognitive disability. This
diversification of complications and increased years of life spent with diabetes
indicates a need to better monitor the quality of life of people with diabetes and asse
1.2. Epidemiology of diabetes
1.2.1.

Epidemiology of diabetes in the world

Diabetes mellitus lias been seen as a major public health problem and a

significant source of morbidity and mortality That is preventable and
underestimated. According to The Global Burden of Disease (GBD). The global
prevalence (age-standardized) of diabetes has nearly doubled since 19S0. rising
from 4.7% to 8.5% in the adult population In an analysis from a research of Betty
M. Dress - Professor of Medicine and Dean Emerita at the University of MissouriKansas City School of Medicine in Kansas City. Missouri [20]. et al on global
diabetes burden, biannual reports were published in January 2015 and provides a
comprehensive review of diabetes care and strategic goals from the DHSS.
Prevalence of diabetes varies across individual communities and counties, but
Missouri lias an overall prevalence of diagnosed diabetes mellitus in adults of
11.1% in 2014 [20]. The International Diabetes Federation estimated that there were
382 million people with diabetes in 2013 [ 16], a number surpassing its earlier
predictions. More than 60% of the people with diabetes live in Asia, with almost


16

one-half in China and India combined [18]. The Western Pacific, the world’s most
populous region, lias more than 13S.2 million people with diabetes, and the number
may rise to 201.8 million by 2035 [19].
According to Susan Van Dieren the article summarizes the burden of type 2
diabetes, impaired glucose tolerance, and their vascular complications. It is
projected that by 2025 there will be 380 million people with type 2 diabetes and
418 million people with impaired glucose tolerance [17]. Diabetes is a major global
cause of premature mortality that is widely underestimated, because only a minority
of persons with diabetes dies from a cause uniquely related to the condition
Approximately one hah- of patients with type 2 diabetes die prematurely of a
cardiovascular cause and approximately 10% die of renal failure. Global excess
mortality atttibutable to diabetes in adults was estimated to be 3.8 million deaths
[21].
1.22. Epidemiology of diabetes in Vietnam

The prevalence for diabetes, prediabetes, and gestational diabetes in Vietnam
are low relative to other parts of the world, but they are increasing at alarming rates.
These changes have occur red in the setting of economic and cultural transitions
In Van Till Thuy Nguyen and el at research on diabetes in Vietnam it showed
that In 2012. the prevalence of diabetes was 5.4% and prediabetes 13.7%. In 2005.
the prevalence of obesity was 1.7% [22]. There is a dual burden of over- and
undernutrition observed in Vietnam [2]. Diabetes is associated with an increased
waist-to-hip ratio despite normal body mass index. Nutritional transitions occurred
with increased protein, fat. and fast foods, and with decreased fresh fruits and
vegetables
According to Intel-national Diabetes Federation (IDF) Vietnam is one of the
36 countries and territories of the IDF wp region. 463 million people have diabetes
in the world and 163 million people in the WP Region: by 2045 this will rise to 212
million [22]


17

In Vietnam health statistics reveal that noncommuni cable disease deaths have
increased from 44.07% in 1976 to 73.41% in 2015 [24]. In contrast, communicable
disease death decreases frail 53.06% to 11.4% during the same period [24].
Diabetes is a leading cause of death worldwide, and it causes a 30% loss of life
expectancy. In Vietnam diabetes is projected to be one of the top seven diseases
leading to death and disability in Vietnam by 2030 [24].
1.23. Nutritional status in diabetes patients
1.23.1.

Nutrition transition and global dietary trend

The type 2 diabetes epidemic lias been atưibuted to urbanization and

environmental transitions, including work pattern changes from heavy labor to
sedentary occupations, increased computerization and mechanization, and improved
transportation. Economic growth and environmental transitions have led to drastic
changes in food production, processing, and distribution systems and increased tire
accessibility of unhealthful foods. Fast food restaurant establishments have
experienced exponential global expansion in recent decades. Even under very
conservative assumption, the World Health Organization projects diabetes
prevalence to expand from the current level of 382 million by 55% to 592 million in
2035(25].
Pans of tire world undergoing epidemiological transition have experienced a
livestock resolution, which leads to increased production of beef. pork, dairy
products, eggs, and poultry [26], Based on the United Nations Food and Agriculture
Organization data, this change has been especially drastic in Asian countries.
Another characteristic of nutrition transition is increased refinement of grain
products. Milling and processing whole grains to produce refined grains such as
polished white rice and refined wheat flour reduce the nutritional content of grains,
including their fiber, micronutrients, and phytochemicals.
1.23.2.

Positive energy balance and excess adiposity

In recent decades, men and women around the globe have gained weight,


18

largely due to changes in dietary patterns and decreased physical activity levels.ps]
Excess adiposity reflected by higher body mass index (BMI) is the sưongest risk
factor for diabetes, and Asians tend to develop diabetes at a much lower BMI than
those of European ancestry’ [28]. The risk of diabetes rises as excessive body 7 fat

increases, starting from the lower end of a healtliful BMI or waist circumference. A
meta-analysis of prospective cohort studies suggests that the risk associated with a
higher waist circumference is slightly stronger than the risk associated with a higher
BMI. In clinical practice, it is important to monitor both B.MI and waist
circumference. Weight gain since young adulthood is another independent predictor
of diabetes risk even after adjusting for current BMI.
Lifestyle intervention involving calorie-restriction and exercise to promote
wei gilt-loss. as demonstrated in the Diabetes Prevention Program, significantly
reduced conversion to diabetes among highly risk patients with impaired glucose
tolerance by 58% [29]. The beneficial effect of lifestyle modification was
documented in various populations including multiethnic American. Finnish.
Chinese, and Indian.
1.23.3.

Quantity and quality of dietary fat

While it has been hypothesized that higher total fat intake contributes to
diabetes directly by inducing insulin resistance and indirectly by promoting weight
gain, results from metabolic studies in humans do not support that high-fat diets
have a detrimental effect on insulin sensitivity. In several observational studies,
total fat intake was not associated with diabetes risk. In the Women's Health
Initiative, the incidence of diabetes was not reduced among women who consumed
a low-fat diet compared to the control group. The quality of fat is more important
than total fat intake, and diets that favor plant-based fats over animal fats are more
advantageous. In particular, greater intake of omega-6 polyunsaturated fatty acids
(PUFA) was associated with lower diabetes risk in the Nurses’ Health Study [28].
Replacing saturated fat with omega-6 PUFA was related to lower risk of developing


19

diabetes. However, the relationship between omega-3 PUFA and diabetes risk has
been inconsistent [28].
1.23.4.

Quantity and quality of carbohydrates

Prospective observational evidence suggests that the relative carbohydrate
proportion of a diet does not appreciably influence diabetes risk. However, a diet
rich in fiber, especially cereal fiber, may reduce diabetes risk. A meta-analvsis of
prospective cohort studies demonstrated an inverse association between fiber from
cereal products and type 2 diabetes risk. Compared to cereal fiber, fiber from fruits
had a weaker inverse association with diabetes risk.
Carbohydrate quality can be determined by evaluating the glycemic response
to caibohydrate-rich foods such as the glycemic index (GI) and the glycemic load
(GL). In meta-analyses of prospective studies, low GI and GL diets were associated
with lower risk for diabetes compared with diets with higher GI and GL
independent of the amount of cereal fiber in the diet.
1.23.5.

Importance offiber for diabetes patients

Indiabetes
the
the
use
past
of
high-fiber
decade,

there
diets
has
for
been
improving
considerable
blood
interest
glucose
levels
most
of
in
the
patients
studies
with
have
diabetes.
reported
With
beneficial
some
exceptions."
effects.
The
addition
postprandial
of

fiber
glucose
to
the
levels
diet
was
normal
found
subjects
lower
as
well
as
in
patients
with
individuals,
type
II
diabetes.
a
high-fiber
In
some
intake
insulin-treated
lias
been
associated

diabetic
persons
with
acoming
whose
reduction
insulin
in
insulin
doses
were
requirements,
kept
constant,
and
in
highhypoglycemic
fiber
intake
episodes.
has
been
The
reported
improvement
to
increase
carbohydrate
the
number

metabolism
levels,
lower
has
levels
been
associated
of
glucagon
with
and
normal
GIP.
and
or
lower
elevated
insulin
somatostatin
effective
in
levels.
treating
High-fiber
diabetic
and
diets
nondiabetic
have
also

patients
proved
with
hyperlipidemia.
decrease
serum
Even
cholesterol
normal
subjects
and
trihave
glycerides
experienced
after
a
consuming
effect
of
high-fiber
dietary
fiber
diets.
has
However,
not
always
this
been
hypolipidemic

found.
The
apparent
complexity
discrepancies
of
dietary
fiber.
in
results
Furthermore,
appear
to
the
be
significance
due
to
the
were
these
acute
reports
studies
is
or
difficult
lacked
suitable
to

assess
controls.
because
they
In
the
either
study
diabetes
Marc
Mcrea
showed
about
that
the
Sixteen
dietary
meta-analyses
fiber
intake
were
and
retrieved
type
2
for
comparing
inclusion
highest
in

This
versus
umbrella
lowest
review.
dietary
In
fiber
file
intake,
meta-analyses
there
was
risk
a
(RR)
statistically
of
type
2
significant
diabetes
(RR
reduction
=
0.81-0.85).
in
file
with
relative

the
greatest
However,
benefit
statistically
significant
from
heterogeneity
fibers
(RR
=
0.67-0.87).
was
observed
supplementation
in
all
of
these
studies
metaanalyses.
using
p-glucan
or
psyllium
meta-analyscs
fibers
on
reductions
type

2
diabetic
were
identified
participants,
in
both
statistically
fasting
blood
significant
glucose
concentrations
this
study
suggests
and
glycosylated
that
those
consuming
hemoglobin
the
percentages
highest
amounts
and
of
a
reduction

dietary
fiber,
in
the
especially
incidence
cereal
of
developing
fiber,
may
type
benefit
2
diabetes.
from
There
glucose
also
concentration,
appears
to
be
as
a
well
small
as
reduction
a

small
reduction
in
fasting
in
blood
glycosylated
2
who
hemoglobin
add
0-glucan
percentage
or
psyllium
for
individuals
to
their
daily
with
type
dietary
intake.


1.3.

Sensory'test

Sensory’ evaluation is defined as "a scientific discipline used to invoke,
measure, analyze, and interpret reactions to characteristics of foods and materials as
they are perceived by the senses of sight, smell, taste, touch, and hearing
Sensory evaluation is a key method to assess the flavor quality of foods
because it measures what consumers really perceive; however, it is a subjective
method. For example. one consumer may describe a sample as unpalatable while
another consumer may consider tile same sample acceptable. These differences are
common in sensory evaluation and can be explained by nationality, culture,
individual variation, etc
The most widely used scale for measuring food acceptability is the 9- point
hedonic scale. David Peryam and colleagues developed the scale at the
Quartermaster Food and Container Institute of the U.S. Armed Forces, for the
purpose of measuring the food preferences of soldiers [9]. The scale was quickly
adopted by the food industry', and now is used not just for measuring the
acceptability of foods and beverages, but also of personal care products, household
products, and cosmetics.
The hedonic scale was the result of extensive research conducted at the
Quartermaster and the University of Clãcago. Jones. Peryam & Thurstone (1955)
showed that longer scales, up to nine intervals, tended to be more discriminating
than shorter scales, and there was some indication that a scale with eleven intervals
would be even more effective. The nine-point version became the standard at the
Quartermaster, because it fit better on the typing paper used to print the ballots.
9-Point Hedonic Scale
Like Extremely


Like Very Much
Like Moderately
Like Slightly
Neither Like nor Dislike

Dislike Slightly
Dislike Moderately
Dislike Ven.' Much
Dislike Extremely

1.4.

Nutrition for patients at Hanoi Medical University Hospital

The Department of Nutrition & Dietetics. Hanoi Medical University Hospital,
was established in 2014. proriding nutrition for inpatients daily. With nearly 100
nutritional codes, including DD code (nutrition for patients with diabetes). In this
study, we use the codes DD12 and DD02 to add okara
with DD12 code, total energy is 1700kcal/day. total fiber is about 10- 12g. the
amount of protein, carbohydrate and lipid are 90g. 50g and 220g respectively.
Additionally. DD02 code including 1600-1700kcaL the amount of fiber is about 101 lg. and the figure for protein, lipid and carbohydrate are about S5g. 45-50g. 200g
respectively.


CHAPTER 2
METHODOLOGY
2.1.

Stud)- setting

This study lias been conducted Department of Internal Medicine and Endocrinology
departments at Hanoi Medical University Hospital
2.2.

Stud}- subjects

The participation in this study included diabetes patients are inpatient in Hanoi
Medical University Hospital
2.2.1.

The inclusion criteria

•

The diabetes patients are impatients more than 5 days

•

Subjects have HBA1C > 6.5%

•

Subjects using hospital diet

•

Subjects are not monitored or controlled by a specialist

•

Subjects voluntary to take part in study

2.22.
•

The exclusion criteria

Subjects are impatient less than 5 day's
. Subjects are controlled or monitored in ICU department

•

Subjects who have to use parenteral tube

2.23.

Sample size

Convienient sample
-

Choosing subjects based on inclusion criteria

-

By choosing subject based on inclusion criteria, we have 10 subjects for each group,
the total sample size is 20 patients.

2.2.4.

Research design


A cross-over studs- was using in this study.
Weight meals before and after eating at period 1 and 2

Okara diet
Hospital diet
Group A.
subjects
(1 day)

Period 1
(3 day)

ị

Washout
period
( 3 days)

Group B:
subjects
Hospital diet

Period 2
(3 day)

Okara diet

2.25. Sampling
Multistage sampling
Step 1: Convenience Sampling: Hanoi medical university hospital at Department of
internal medicine and Endocridology department.
Step 2: Purposive Sampling: From inpatient’s list, select 20 subjects who meet with all
of criteria of the StudyStep 3: Randomly distribute the subjects into 2 groups.

2.3.

Research instruments

2.3.1.

The questionnaire

There are 4 sections:
The first section is general information
The second section is used SGA tool to assess nutritional status of patients
The third section is sensory evaluation answer form
The last section is the weight meals recall before and after patients eat
2.32.

Scale

Body weight was measured with the patients in the standing position wearing light
clothing and take off 1ŨS or her shoes. Body weight was taken to the nearest 0.1 kg. Ulis


indicator was determined by Tanita BC-526-WH scale (Tanita. Tokyo. Japan).
2.33.

Height gage

Height was measured with a portable Seca 206 Bodymeter/Wall-Mount mechanical
measuring tape (Vogel & Halke. Hamburg. Germany) to the nearest 0.1 cm. The heel, the
calf, buttocks, shoulder and occipital prominence (prominent area on the back of head) should
be flat against the broad (wall). The subject should be looking straight ahead. The hands of

the subject should be by their side. The head piece should be placed firmly on the subject's
head.
Body mass Index (BMI) was calculator as the ratio of weight (kg) per height squared
(m2)
2.4.

Research indicators and variable

2.4.1.

Nutritional status

SGA tool has 4 nutritional areas including anthropometric measurements (weight,
height. BMI. mid upper arm circumference, calf circumference), a global assessment, a
dietary assessment: one question on self-perception of whether food intake is sufficient, and
one on selfexperienced health status.
2.43.

Sensors evaluation

The scoring of each sample was performed on a single sheet using a 9- point hedonic
scale (1= extremely dislike. 2=dislike very much. 3= dislike moderately. 4=dislike slightly.
5= neither like nor dislike. 6= like slightly. 7= like moderately. 8= like very much
9=extremely like) Compare between okara diet and hospital diet about:
-

Vision: eye-catching, shape evenly, good smell

-

Feeling about texture: hardness, fiber level

-

Emotion: comfortable, hurt oral

2.43.

Energy and protein, nutrient intake

Energy', fiber, protein, lipid, carbohydrate and intake each day in intervention period.
2.5.

Data collection processing

Step 1: Choose patients and make menus


-

Researcher chooses all of subject suits with inclusion criteria

-

Subjects haw to follow our diet for 3 days and they do not eat anything out of served
diet day.

-

Make menu to intervention

+ Usual hospital diet: Using DD12 and DD02 code meal for diabetes patients in the

department of internal medicine and
+ Slice meat diet: 30 grams of okara used to add to DD12 and DD02 code meal (lOg
for breakfast. lOg for lunch. lOg for dinner)
All dishes are cooked same ways between two diets.
Step 2: Sensory test u ah normal fired-egg andfired-egg with okara
All subjects were served 2 dishes (ứied-egg dish and fried-egg with okara) parallel.
The subjects observed, smelted, tasted and mouth felt then to score the characteristics of the
two sample used a 9-point liedonic scale (1 = extremely dislike. 2=dislike very much. 3=
dislike moderately. 4=dislike slightly. 5= neither like nor dislike. 6= like slightly. 7= like
moderately. 8= like very much 9=extremely like).
- Assess about
’ Vision: eye-catching, shape evenly, good smell
-

Feeling about texture: hardness, fiber level

-

Emotion: comfortable, hurt oral
-Patients were concentrated in canteen to have breakfast, lunch and dinner.
Step 3: Providing diet for 3 days consecutive
The menu is designed to meet the recommended nutritional needs for the diabetes

patients. The subjects are provided 3 meals per day for 3 da>s (including breakfast, lunch,
dinner). Main meals have dishes prepared with various processes like steamed, boiled, stirfried, fried and braised. 30 grants of okara used to add to DD12 and DD02 code meal (lOg for
breakfast. lOg for lunch. lOg for dinner)
All dishes are cooked same ways between two diets.
•