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

HANOI MEDICAL UNIVERSITYNGUYEN 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

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

ÌÌ rf

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

First and foremost I have to thank HMU Board of President Department ofUndergraduate Training and Management for giving me the opportunity to conductand complete my graduation thesis

I am thankful to Hanoi Medical University Hospital for giving me the bestconditions to collect the data

I would like to give thanks Jumonji University and Asia Nutrition and FoodCulture Research Center for supporting my study and give me one chance exchange inJapan

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, enthusiasmand immense knowledge Her guidance helped me in all the time of research andwriting 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 mygraduation thesis

I am also grateful to volunteer patients who agreed to spend their time tocomplete the questionnaire and implement the diets which we prepared Theircontribution 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 theirresearch They also accompanied me during the period of collecting difficult researchdata It is very fortunate to work with them

Finally I want to express the deepest thank my mother for her continuous andunparalleled love, supporting me spiritually throughout my life I am forever indebted

This journey would not have been possible if not for her and I dedicate this milestone

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

Hanoi 2021

Nguyen Quvnh Hoa

: Body Mass Index: The disability-adjusted life year (DALY'): Diabetes ketoacinosid

: European Society for Clinical Nutrition and Metabolism: Global Burden of Disease

: Gastrointestinal diabetes mellitus: Glycemic index

: glycemic loadinternational Diabetes Federation: Low density lipoprotein

: Malnutrition Screening Tool: Non-insulin-dependent diabetes mellitus: National Institute of Nutrition

: Subjective Global Assessment: Years Lived with Disability: Years of life lost

: World Health Organization

INTRODUCTION.— - 1

CHAPTER 1: LITERATURE REMEW - - 3

1.1 Overview of diabetes 3

1.1.1 Define of diabetes 3

1.1.2 Risk factors for diabtes 4

1.1.3 Complication of diabetes 5

1.2 Epidemiology of diabetes 7

1.2.1 Epidemiology of diabetes in the world 7

1.2.2 Epidemiology of diabetes in Vietnam s 1.3 Sensory test 13

1.4 Nutrition for patients at Hanoi Medical University Hospital 14

C HAPTER 2: METHODOLOGY — 15

2.1 Stud}’setting 15

2.2 Study subjects 15

2.2.1 The inclusion criteria 15

2.2.2 The exclusion criteria 15

2.2.3 Sample size 15

2.2.4 Research design 16

2.2.5 Sampling 16

2.3 Research instruments 16

2.3.1 Tire questionnaire 16

2.3.2 Scale 17

2.3.3 Height gage 17

2.4 Research indicators and variable 17

2.4.1 Nutritional status 17

2.4.3 Sensor}’evaluation 17

2.4.3 Energy and protein nutrient intake IS 2.5 Data collection processing 18

2.6 Variable 20

2.7 Bias and bias controlling 21

2.7.1 Bias 21

2.4.2 Bias controlling 21

2.5 Data analysis 21

2.6 Ethical consideration 21

CHAPTER 3: RESULT - -. 22

3.1 General information 22

3.2 Nutritional status of study subjects 23

3.3 The energy and nutrient intake 25

3.4 Sensory evaluation 30

CHAPTER 4: DISCUSSION .32

4.1 General information 32

4.4 Fiber intake for diabetes patients 35

4.5 Sensory Evaluation 37

CONCLUSION 39

RECOMMENTDATION 40

REFERENCES LIST OF TABLES Table 3.1 Demographic characteristic of the study subjects 22

Table 3.2 The energy and nutrient intakes by weighting method 25

Table 3.3 The energy and nutrient intake by the years of diabetes 26

Table 3.4 Average of points for characteristics of sensory'evaluation 30

Table 3.5 the overall points of sensory' evaluation for okara diet and hospital of study subject by gender- and age 31

Table 3.6 High vs Low Dietary'Fiber Intake on the Incidence of Developing Type 2 Diabetes 36

Figure 3.1 Nutritional status of study subject based on SGA tool 23Figure 3.2 Nutritional status of subjects base on age group 24Figure 3.3 The amount of fiber intake of study subjects base on the gender 27Figure 3.4 The amount of fiber intake of study subjects base on the age group 28Figure 3.5 The amount of fiber intake of study subjects base on the year of

diabetes group 29

that the main reason that Vietnamese people using fiber and vegetable less than theamount of fiber rather than the recommendation of WHO at about10g/1000kcal/day Regarding source, fiber comes mainly from vegetable However,most types of Vietnamese vegetable in Vietnam are significantly lower in fiber, atabout 2g fiber /100g vegetable So it is very difficult for Vietnamese people,especially with patients who has diabetes to consume enough the amount of fiberregarding to the recommendation of WHO In Study we tried to use okara toimprove the amount of fiber in daily meal for diabetes patient and access theacceptability of patient with dishes which contain okara We selected 20 patientsdiagnosed with diabetes in Hanoi Medical University hospital We divide allparticipant into 2 group, each group using 3 days of okara meal and 3 days ofHospital meal (not using okara) and take the sensory test in all patient At tliebaseline and final period, anthropo metric measurement, there was a significanthigher 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 fromhospital diet sample on color, shape evenly, juiciness, tenderness, and overall Andthe differences have statistically significant for the mean points (p<0.05) Point forokara diet was higher than hospital diet in taste 7,71+0.61 points and 7,0+0.72points, respectively (p<0.05) Using okara in dietary meal help to improve theamount of fiber in diabetes patient and is one of the most easily solution for patientwith diabetes

Keyword: Okara fiber Diabetes Mellims Hospital diet

Bệnh dái tháo dưỡng dang gia tàng nhanh chông ờ Việt Nam chúng lỏi dưa

ra gia thuyết nguyên nhân chính lã do người Việt Nam sứ dụng ít chất xơ vã rau quahơn so với khuyến nghị cùa WHO khoáng l()g / lOOOkcal / ngây, về nguồn, chất

Việt Nam, dặc biệt là bệnh nhân tiếu dường rắt khó tiêu thụ du lượng chất xơ theokhuyến nghị cua WHO Trong nghiên cứu chúng tỏi đà cổ gắng sử dụng okara dêcãi thiện lượng chất xơ trong bừa án hàng ngày cho bẹnh nhân lieu dường và tiếpcận sự chấp nhận cua bệnh nhân với các món ăn có chứa okara Chúng tôi chọn 20bệnh nhân dược chân đoán mac bệnh tiêu đường tại bệnh viện Dại học Y Hà Nội.Chứng lôi chia tat ca những người tham gia thành 2 nhóm, mỗi nhóm sư dụng 3ngày bữa ân Okara và 3 ngày ăn bừa ản tại bệnh viện (không sứ dụng okara) vả tiếnhành kiêm tra cảm quan ờ tất cá bệnh nhãn Ớ giai đoạn đầu vã giai đoạn cuối, donhãn trác học, lượng chắt xơ cùa bệnh nhân sừ dụng okara cao hơn dáng kê tữ10,75 lẽn 13.8 (p <0,05)-về kiêm tra cám quan, diêm cho mẫu bừa ăn okara cao hơnmẫu bừa ăn tại bệnh viện ve màu sắc hình dạng dồng đều, độ mọng, mềm và tôngthê Có sự khác biệt có ý nghía thống kê giừa diêm trung bính ve hình dạng đồngđều mùi vị vã mùi thơm và tông thê với p <0.05 Diem cho chế độ án kiêng okaracao hơn chề độ ân uống tại bệnh viện lần lượt là 7.45±0.59 va 7.09±0,72 Sứ dụng

bà dậu nành trong bừa ăn giúp cài thiện lượng chất xơ ừ bệnh nhân tiêu dường vả làmột trong những giai pháp dẻ dàng nhất cho bệnh nhân tiêu đường

pre-Additionally Vietnam has the double burden of over- and undernutrition [2]According to International Diabetes Federation 80.6% of people do not consumethe recommended number of five servings of fiuit and vegetables, and they havediets that are high in salt fat and sugar [3] Studies have found that 31.3% of thetotal deaths and 25.3% of the whole disability- adjusted life years (DALY) inVietnam 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 orwith disability (YLD) to count tire total years of functional experience lost fromdiseases [4] Researches have concluded tliat the leading risk factor for diabetes-related diseases is lifestyle and dietary issues

Current evidence suggests that high-fiber diets, especially of the solublevariety, and soluble fiber supplements may offer some improvement incarbohydrate metabolism, lower total cholesterol and low-density lipoprotein(LDL) cholesterol, and have other beneficial effects in patients with noninsulin-dependent diabetes mellitus (NIDDM) Although there are a closely relationshipbetween fiber intake and controlling diabetes, however, the amount of fiber intake

in daily meal was significantly lower than the recommendation of WHO Wehypothesized that the main reason of tills problem may come from popularvegetables in Vietnam are usually low in fiber (<2g'100g vegetable), so it is verydifficult for people absorb enough fiber from food and vegetable, especially indiabetes patients [5]

Due to the importance of fiber-rich food in improvement and controllingdiabetes (type 2) It is necessaty to supply and using more fiber-rich food in hospitalwhere the majority' of diabetes patients are hospitalized and treated with diabetesand controlling blood glucose index However, most of diabetes patients usinghospital diets commonly absorb lower level of fiber intake [5] Vietnamese usualvegetables 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, ortofu dregs is a pulp consisting of insoluble pans of the soybean that remain afterpureed soybeans are filtered in the production of soymilk and tofu We can also usethem 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 diabetespatients, patients should also know okara (fiber - rich food) cooking recipe so theycould be able to prepare their own meals at home

We expect using Okara in diet is more beneficial than the currently- usedonly 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 finallyimproving their quality of life through their diet

Therefore, wc decided to conduct The effects of using okara food to improvethe quality of meal for diabetes patients in Hanoi Medical University Hospital”, thepurposes 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

1.1.1 Define of diabetes

Diabetes is a serious, chronic disease that occurs either when the pancreasdoes not produce enough insulin (a hormone that regulates blood glucose), or whendie body cannot effectively use the insulin its produce [6] Raised blood glucose, acommon effect of uncontrolled diabetes, may over time, lead to serious damage tothe heart, blood vessels, eyes, kidneys and nen es More than 400 million peoplelive with diabetes in the world

Type 1 diabetes (previously known as insulin-dependent, juvenile orchildhood-onset diabetes) is characterized by deficient insulin production in thebody People with type 1 diabetes require daily administration of insulin to regulatethe amount of glucose in their blood If they do not have access to insulin, theycannot survive The cause of type 1 diabetes is not known and it is currently notpreventable 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- onsetdiabetes) results from the body’s ineffective use of insulin Type 2 diabetesaccounts 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 orabsent As a result, the disease may go undiagnosed for several years, untilcomplications have already arisen For many years type 2 diabetes was seen only inadults 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 generallyagreed that type 1 diabetes is the result of a complex interaction between genes andenxironmental factors, though no specific environmental risk factors have beenshown to cause a significant number of cases The majority of type 1 diabetes

occurs in children and adolescents [10]

Type 2 The risk of type 2 diabetes is determined by an interplay of geneticand metabolic factors Ethnicity; family history of diabetes, and previousgestational 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 withphysical inactixity, are estimated to cause a large proportion of the global diabetesburden [7], Higher waist circumference and higher body mass index (BNÍI) areassociated with increased risk of type 2 diabetes [9] though the relationship mayvary in different populations Populations in South-East Asia, for example, developdiabetes at a lower level of BMI than populations of European origin [11]

Several dietary’ practices are linked to unhealthy body weight and 'or type 2diabetes risk, including lũgh intake of saturated fatty’ acids, lũgh total fat intake andinadequate consumption of dietaiy fiber High intake of sugar- sweetenedbeverages, which contain considerable amounts of free sugars, increases thelikelihood of being oxerweight or obese, particularly among children Recentevidence further suggests an association between high consumption of sugar-sweetened 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 weightActive (as distinct from passive) smoking increases the risk of type 2 diabetes,with the highest risk among heavy smokers Risk remains elevated for about 10years after smoking cessation, falling more quickly for lighter smokers

Gestational diabetes Risk factors and risk markers for GDM include age (the

older a woman of reproductive age is the higher her risk of GDM); overweight orobesity; excessive weight gain during pregnancy; a family history of diabetes;GDM during a previous pregnancy; a history of stillbirth or giving birth to an infantwith congenital abnormality; and excess glucose in urine during pregnancy.Diabetes in pregnancy and GDM increase the risk of future obesity and type2diabetes in offspring [13].

1.13 Complication of diabetes

When diabetes is not well managed, complications develop that tlưeatenhealth and endat^er life Acute complications are a significant contributor tomortality, costs and poor quality of life Abnormally high blood glucose can have alife-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 bloodglucose can occur in all types of diabetes and mayresult in seizures or loss ofconsciousness 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 andnerves, 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 limbamputation Diabetic retinopathy is an important cause of blindness and occurs as aresult 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 bothmother and child, substantially increasing the risk of fetal loss, congenitalmalformations, stillbirth, perinatal death, obstetric complications, and maternalmorbidity and mortality Gestational diabetes increases the risk of some adverseoutcomes for mother and offspring during pregnancy, childbirth and immediately

after delivery (pre-eclampsia and eclampsia in the mother; large for gestational ageand shoulder dystocia in the offspring) However, it is not known what proportion

of obstructed births or maternal arid per inatal deaths can be attributed tohyperglycemia

The combination of increasing prevalence of diabetes and increasing lifespans

in many populations with diabetes may be leading to a changing spectrum of thetypes of morbidity that accompany diabetes [30] In addition to the traditionalcomplications described above, diabetes has been associated with increased rates ofspecific cancers, and increased rates of physical and cognitive disability Thisdiversification of complications and increased years of life spent with diabetesindicates a need to better monitor the quality of life of people with diabetes and asse1.2 Epidemiology of diabetes

1.2.1 Epidemiology of diabetes in the world

Diabetes mellitus lias been seen as a major public health problem and asignificant source of morbidity and mortality That is preventable andunderestimated According to The Global Burden of Disease (GBD) The globalprevalence (age-standardized) of diabetes has nearly doubled since 19S0 risingfrom 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 Kansas City School of Medicine in Kansas City Missouri [20] et al on globaldiabetes burden, biannual reports were published in January 2015 and provides acomprehensive review of diabetes care and strategic goals from the DHSS.Prevalence of diabetes varies across individual communities and counties, butMissouri lias an overall prevalence of diagnosed diabetes mellitus in adults of11.1% in 2014 [20] The International Diabetes Federation estimated that therewere 382 million people with diabetes in 2013 [ 16], a number surpassing its earlierpredictions More than 60% of the people with diabetes live in Asia, with almost

Missouri-one-half in China and India combined [18] The Western Pacific, the world’s mostpopulous region, lias more than 13S.2 million people with diabetes, and the numbermay rise to 201.8 million by 2035 [19].

According to Susan Van Dieren the article summarizes the burden of type 2diabetes, impaired glucose tolerance, and their vascular complications It isprojected 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 globalcause of premature mortality that is widely underestimated, because only a minority

of persons with diabetes dies from a cause uniquely related to the conditionApproximately one hah- of patients with type 2 diabetes die prematurely of acardiovascular cause and approximately 10% die of renal failure Global excessmortality 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 Vietnamare 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 showedthat 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- andundernutrition observed in Vietnam [2] Diabetes is associated with an increasedwaist-to-hip ratio despite normal body mass index Nutritional transitions occurredwith increased protein, fat and fast foods, and with decreased fresh fruits andvegetables

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 212million [22]

In Vietnam health statistics reveal that noncommuni cable disease deaths haveincreased from 44.07% in 1976 to 73.41% in 2015 [24] In contrast, communicabledisease 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 lifeexpectancy In Vietnam diabetes is projected to be one of the top seven diseasesleading 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 andenvironmental transitions, including work pattern changes from heavy labor tosedentary occupations, increased computerization and mechanization, and improvedtransportation Economic growth and environmental transitions have led to drasticchanges in food production, processing, and distribution systems and increased tireaccessibility of unhealthful foods Fast food restaurant establishments haveexperienced exponential global expansion in recent decades Even under veryconservative assumption, the World Health Organization projects diabetesprevalence to expand from the current level of 382 million by 55% to 592 million in2035(25]

Pans of tire world undergoing epidemiological transition have experienced alivestock resolution, which leads to increased production of beef pork, dairyproducts, eggs, and poultry [26], Based on the United Nations Food and AgricultureOrganization data, this change has been especially drastic in Asian countries.Another characteristic of nutrition transition is increased refinement of grainproducts Milling and processing whole grains to produce refined grains such aspolished 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,

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 riskfactor for diabetes, and Asians tend to develop diabetes at a much lower BMI thanthose of European ancestry’ [28] The risk of diabetes rises as excessive body7 fatincreases, starting from the lower end of a healtliful BMI or waist circumference Ameta-analysis of prospective cohort studies suggests that the risk associated with ahigher waist circumference is slightly stronger than the risk associated with a higherBMI In clinical practice, it is important to monitor both B.MI and waistcircumference 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 promotewei gilt-loss as demonstrated in the Diabetes Prevention Program, significantlyreduced conversion to diabetes among highly risk patients with impaired glucosetolerance by 58% [29] The beneficial effect of lifestyle modification wasdocumented 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 todiabetes directly by inducing insulin resistance and indirectly by promoting weightgain, results from metabolic studies in humans do not support that high-fat dietshave a detrimental effect on insulin sensitivity In several observational studies,total fat intake was not associated with diabetes risk In the Women's HealthInitiative, 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 importantthan total fat intake, and diets that favor plant-based fats over animal fats are moreadvantageous 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

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

1.23.4 Quantity and quality of carbohydrates

Prospective observational evidence suggests that the relative carbohydrateproportion of a diet does not appreciably influence diabetes risk However, a dietrich in fiber, especially cereal fiber, may reduce diabetes risk A meta-analvsis ofprospective cohort studies demonstrated an inverse association between fiber fromcereal products and type 2 diabetes risk Compared to cereal fiber, fiber from fruitshad 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 associatedwith lower risk for diabetes compared with diets with higher GI and GLindependent of the amount of cereal fiber in the diet

1.23.5 Importance offiber for diabetes patients

In the past decade, there has been considerable interest in the use of high-fiberdiets for improving blood glucose levels in patients with diabetes With someexceptions." most of the studies have reported beneficial effects The addition offiber to the diet was found to lower postprandial glucose levels in normal subjects

as well as in patients with type II diabetes In some insulin-treated diabeticindividuals, a high-fiber intake lias been associated with a reduction in insulinrequirements, and in diabetic persons whose insulin doses were kept constant, high-fiber intake has been reported to increase the number of hypoglycemic episodes.The improvement in carbohydrate metabolism has been associated with normal orlower insulin levels, lower levels of glucagon and GIP and elevated somatostatinlevels High-fiber diets have also proved effective in treating diabetic andnondiabetic patients with hyperlipidemia Even normal subjects have experienced adecrease in serum cholesterol and tri- glycerides after consuming high-fiber diets

However, this hypolipidemic effect of dietary fiber has not always been found Theapparent discrepancies in results appear to be due to the complexity of dietary fiber.Furthermore, the significance of these reports is difficult to assess because theyeither were acute studies or lacked suitable controls In the study of Marc Mcreaabout the dietary fiber intake and type 2 diabetes showed that Sixteen meta-analyseswere retrieved for inclusion in This umbrella review In file meta-analysescomparing highest versus lowest dietary fiber intake, there was a statisticallysignificant reduction in file relative risk (RR) of type 2 diabetes (RR = 0.81-0.85).with the greatest benefit coming from cereal fibers (RR = 0.67-0.87) However,statistically significant heterogeneity was observed in all of these metaanalyses Inthe meta-analyscs of supplementation studies using p-glucan or psyllium fibers ontype 2 diabetic participants, statistically significant reductions were identified inboth fasting blood glucose concentrations and glycosylated hemoglobin percentagesand this study suggests that those consuming the highest amounts of dietary fiber,especially cereal fiber, may benefit from a reduction in the incidence of developingtype 2 diabetes There also appears to be a small reduction in fasting blood glucoseconcentration, as well as a small reduction in glycosylated hemoglobin percentagefor individuals with type 2 diabetes who add 0-glucan or psyllium to their dailydietary intake.

measure, analyze, and interpret reactions to characteristics of foods and materials asthey are perceived by the senses of sight, smell, taste, touch, and hearing

Sensory evaluation is a key method to assess the flavor quality of foodsbecause it measures what consumers really perceive; however, it is a subjectivemethod For example one consumer may describe a sample as unpalatable whileanother consumer may consider tile same sample acceptable These differences arecommon 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- pointhedonic scale David Peryam and colleagues developed the scale at theQuartermaster Food and Container Institute of the U.S Armed Forces, for thepurpose of measuring the food preferences of soldiers [9] The scale was quicklyadopted by the food industry', and now is used not just for measuring theacceptability of foods and beverages, but also of personal care products, householdproducts, and cosmetics

The hedonic scale was the result of extensive research conducted at theQuartermaster and the University of Clãcago Jones Peryam & Thurstone (1955)showed that longer scales, up to nine intervals, tended to be more discriminatingthan shorter scales, and there was some indication that a scale with eleven intervalswould be even more effective The nine-point version became the standard at theQuartermaster, because it fit better on the typing paper used to print the ballots

9-Point Hedonic Scale

Like 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 100nutritional codes, including DD code (nutrition for patients with diabetes) In thisstudy, we use the codes DD12 and DD02 to add okara

with DD12 code, total energy is 1700kcal/day total fiber is about 10- 12g theamount of protein, carbohydrate and lipid are 90g 50g and 220g respectively.Additionally DD02 code including 1600-1700kcaL the amount of fiber is about10-1 lg and the figure for protein, lipid and carbohydrate are about S5g 45-50g.200g respectively

2.1 Stud)- setting

This study lias been conducted Department of Internal Medicine and Endocrinologydepartments 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

Weight meals before and after eating at period 1 and 2

Group A.

subjects

(1 day) Group B:

subjects

Okara diet Hospital 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

Study-Step 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 lightclothing and take off 1ŨS or her shoes Body weight was taken to the nearest 0.1 kg Ulis

Height was measured with a portable Seca 206 Bodymeter/Wall-Mount mechanicalmeasuring tape (Vogel & Halke Hamburg Germany) to the nearest 0.1 cm The heel, thecalf, 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 ofthe subject should be by their side The head piece should be placed firmly on the subject'shead

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, adietary assessment: one question on self-perception of whether food intake is sufficient, andone on selfexperienced health status

2.43 Sensors evaluation

The scoring of each sample was performed on a single sheet using a 9- point hedonicscale (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 much9=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

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, stir-fried, fried and braised 30 grants of okara used to add to DD12 and DD02 code meal (lOg forbreakfast lOg for lunch lOg for dinner)

All dishes are cooked same ways between two diets

•

All of diets were weighted method before and after eating then calculate the amount of food consumed The ratio of raw and cooked food is convened according to the coefficient of NIN [37] Energy and nutrients are calculated based on Vietnamese Food composition Table

2016 [38]

2.6 Variable

patients in Hanoi Medical University Hospital.

2 intake perProtein

5 Total energy-intake meal Kcal meal continuous calculate questionnaire

Okara in daily meals in hospital

n

1 Color Base on hedonicscale discrete interview questionnaữe

2 Shape evenly Base on hedonicscale discrete interview questionnaữe

3 Aroma Base on hedonicscale discrete interview questionnaữe

4 Taste Base on hedonic

scale

discrete interview questionnair

e

5 Juiciness Base on hedonicscale discrete interview questionnaữe

6 Tenderness Base on hedonicscale discrete interview questionnaire