IUCD'21 ABSTRACT BOOK

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PROF. DR. SUZANA SHAHAR

Assalamualaikum and good day to all honourable guests, distinguished delegates, ladies and
gentlemen.

It is a great pleasure for me to welcome you all on behalf of the Faculty of Health Sciences, UKM, to
our first International Virtual Undergraduates Symposium on Clinical Dietetics 2021 (IUCD ’21). The
theme of this symposium: Application of Nutrition Care Process (NCP), is an essential framework in
our dietetics profession for improved patient care, excellence in clinical research, and greater
recognition of our profession in all care settings. In addition, the NCP has been guiding dietitians in
critical thinking and decision making since its inception.

I am proud to announce that this event has been successfully planned and run by all our Year 3
Dietetics Undergraduate students headed by Nurul Aqilah Zamri with the assistance of Dr. Nurul
Huda Razalli and her team of advisors from our Dietetics Program of UKM, pioneer of dietetics
education in Malaysia. The Dietetics Program was established in 1992 and has produced eminent
dietitians, scholars, researchers and successful entrepreneurs.

I would also like to take this opportunity to thank the co-organisers of this event: Nutrition and
Dietetics students and lecturers from Universitas Gadjah Mada, Health Polytechnic Semarang,
Indonesia, and University of Santo Thomas from the Philippines and for all the assistance and
support received. Last but not least, I would like to express my warmest gratitude to all relevant
contributing parties in their efforts to make this happen.

I am delighted to see that many dietetic undergraduates, lecturers, and clinical instructors from both
local and international universities have joined us today. I hope you are able to gain a wealth of
information through the sharing of clinical experience, skills, and knowledge throughout this
symposium. To all the presenters, I wish you well.

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DR. NOR AINI BINTI JAMIL @ A. WAHAB

Assalamualaikum and a warm welcome to all.

Firstly, I would like to congratulate all the local and international organisers who have worked
tirelessly to make this event a success. The International Virtual Undergraduates Symposium on
Clinical Dietetics 2021 (IUCD ’21) is a milestone for our Dietetics Program of UKM, especially during
the pandemic. We started off with a virtual symposium with only 20 local participants last year, and
through the dedication and unrelenting efforts of all those involved, we managed to attract a much
greater number of both local and international participants this year.

This would not have been possible without our advisors and collaborators from Indonesia and
Philippines.

I would like to thank:

Associate Professor Diane Mendoza and Mr. Emmanuele Mistades from Department of Nutrition
and Dietetics, College of Education, University of Santo Thomas, Philippines; Mrs. Setyo Utami
Wisnusanti, Dr. R. Dwi Budiningsari and Ms Rahadyana Muslicah from the Department of Health
Nutrition, Faculty of Medicine and Public Health and Nursing, Universitas Gadjah Mada, Indonesia;
and Mrs. Dian Luthfita Prasetya Muninggar, Dr. Susi Tursilowati and Mrs. Meirina Dwi Larasati from
Department of Nutrition, Health Polytechnic Semarang, Indonesia.

Last but not least, I would like to thank Nurul Aqilah Zamri, Chairman of IUCD, for spearheading the
task of planning, organising and executing the symposium together with her comrades. Special
thanks goes to the advisors; Dr. Nurul Huda Razalli, Associate Professor Dr. Roslee Rajikan and Dr.
Shanthi Krishnasamy for their guidance.

To the rest of third year dietetics students who have laboured since the start of this semester to
ensure the smooth running of this symposium, you have done an excellent job, and may the
experience gained be profitable to you in the years to come. Soon, it will be your turn to be
presenters and the next batch to be the organisers.

I wish everyone a successful, safe, and fruitful symposium.

Thank you.

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"APPLICATION OF THE NUTRITION CARE PROCESS"

29 JUNE 2021 (TUESDAY)

08.30 am - 09.30 am IUCD '21 Opening Ceremony
09.30 am - 10.30 am Plenary Talk
Prof. Dr. Winnie Chee Siew Swee
11.00 am - 01.00 pm Dean of School of Health Sciences
01.00 pm - 02.00 pm International Medical University, Malaysia
02.00 pm - 04.20 pm President of Malaysian Dietitians' Association
1st Session of Symposium
Lunch Break
2nd Session of Symposium

30 JUNE 2021 (WEDNESDAY)

08.30 am - 09.30 am Round Table Discussion
Challenges In Implementing Nutrition Care
09.30 am - 11.00 am Process: Lesson Learned
10.30 am - 11.00 am 3rd Session of Symposium
11.00 am - 01.00 pm Break
01.00 pm - 02.00 pm Continuation of 3rd Session
02.00 pm - 04.20 pm Lunch Break
04.30 pm - 05.15 pm 4th Session of Symposium
IUCD '21 Closing Ceremony

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"APPLICATION OF THE NUTRITION CARE PROCESS"

29 JUNE 2021 - TUESDAY

08.30 am Arrival of VIP and Guests

08.45 am Doa Recitation

08.50 am Student Representative Speech

09.00 am Dean's Speech
Prof. Dr. Suzana Shahar
Dean of Faculty of Health Sciences
Universiti Kebangsaan Malaysia

09.10 am Opening Speech
Mdm. Basmawati Baharom
Head of Dietetics Profession
Ministry of Health Malaysia

09.20 am Opening Gimmick

09.25 am Photography Session

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"APPLICATION OF THE NUTRITION CARE PROCESS"

30 JUNE 2021 - WEDNESDAY

04.30 pm Doa Recitation

04.35 pm Closing Speech
Representative from Co-Organisers

04.45 pm Closing Speech
Prof. Dr. Winnie Chee Siew Swee
President of Malaysian Dietitians' Association

04.50 pm Display of Montage Video

04.55 pm Prize Giving

05.05 pm Photography Session & Dismiss

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INTRODUCTION

The first Undergraduate Symposium was organized and hosted by 3rd year dietetics
students from Dietetics Program, Faculty of Health Sciences, UKM in 2020. It was a
successful event despite being run virtually with 20 participants. Based on the response
rate, the program has decided to run this annually and we are pleased to inform that
this year, the program plans to open the symposium to local and international
participants. The International Virtual Undergraduates Symposium On Clinical Dietetics
2021 (IUCD ‘21) will be held from 29th of June to 30th of June 2021.

The target participants for this symposium are dietetics undergraduates from UKM,
public and private universities in Malaysia as well as universities in Thailand, Indonesia
and Philippines who will be invited as co-organisers. Participation from academicians
and clinical instructors are also encouraged.

This symposium will provide an opportunity for dietetics undergraduates to apply the
Nutrition Care Process that is essential in their practice when they graduate. By
organising this symposium, the dietetics students involved will gain valuable
transferable skills including communication, problem solving, leadership, time
management as well as analytical skills.

OBJECTIVES

The program’s objectives are to:

Provide a platform for dietetics undergraduates to present their management of
clinical cases by applying the Nutrition Care Process and provide experience for
dietetics students on how to manage and participate in a symposium in preparation
for participating in seminars, symposiums or conferences at a higher level.

Establish international relations as well as networking and sharing of expertise in the
field of dietetics.

Expose students of the dietetics program on the application of the Nutrition Care
Process in the management of clinical cases.

Provide opportunities for dietetics undergraduates to showcase their talent in
presenting clinical cases.

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ORGANISING COMMITTEE
ADVISORS

DR. SHANTHI A/P PROF. MADYA DR. DR. NURUL HUDA BINTI
KRISHNASAMY ROSLEE BIN RAJIKAN RAZALLI

HIGH COUNCIL

MUHAMMAD ASYRAF SHAUQI NURUL AQILAH BINTI ZAMRI NUR RUZAIREENA BINTI RAHIM
BIN MOHD HANAFI (CHAIRMAN) (VICE CHAIRMAN 2)
(VICE CHAIRMAN 1)

SAFIAH BINTI TAJUDDIN LIM XI TONG
(SECRETARY) (TREASURER)

SECRETARIAT COMMITTEE

NOR ZARITH IZLEEN LOO SHI YEE
BINTI MD RADZI

SCIENTIFIC COMMITTEE

CHUA EE LIN LIM YEN TING ANIS WAHIDA BINTI NORHAZIRAH BINTI
MD NAZRI AZMI

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PUBLICITY COMMITTEE

NABIHAH BINTI AHMAD ZEESHA GLORIA RAYNER SITI NURHAZLIN BINTI MOHD HAFIZUDDIN BIN
GUMISI YUSOF MOHAMMAD

PROTOCOL COMMITTEE

NUR EIZZATI FARHANI NUR SYAZANA BINTI SYAIDATUL KHAFIZAH NUR AFIQAH BINTI
BINTI ROSLE AZIZAM BINTI AHMAD HELME JOHARI

SPONSORSHIP COMMITTEE

FARHANI BINTI KHALID NUR QHARENA ALWANI
BINTI ZULKIPLI

TECHNICAL COMMITTEE

RUSMALINA BINTI JONIE JERYPIN AMON
MOHAMAD ROSLI

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INTERNATIONAL STUDENT REPRESENTATIVE
STUDENTS COMMITEE OF UNIVERSITAS GADJAH MADA

ARNITA PERMATASARI ANESTI LARAS NAIMA SABITA CONBUL

FAUZIAH ANIS ADIBAH RASIKHAH

STUDENTS COMMITTEE OF UNIVERSITY OF SANTO TOMAS

MARGARET THERESE JOHANNA MARIE DELA DWIGHT ANGELO
ROMERO LAUREL CRUZ POLINTAN

STUDENTS COMMITTEE OF POLTEKKES SEMARANG

CAITLIN ZHEFANIA HAFIKA YUNISARI
PRADINA

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1ST SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Siti Nurhaliza binti Hashidi

Institution : Universiti Putra Malaysia (UPM)

Title: Dietitian approach in managing enteral feeding during Ramadan month

Background: Home enteral nutrition (HEN) has been established as a reliable and effective nutritional
intervention which is appropriate for patient’s current condition due to limited of physical ability for
normal dietary intake. Despite that, insignificant number of studies have reported on effectiveness of
HEN to be practiced in presence of patient’s willingness to fast during fasting month.

Nutrition Assessment: This is a new case for outpatient settings that being referred to dietitian for
HEN following patient’s discharge from ward. Patient is 59 years-old, Malay woman, diagnose with left
necrotizing otitis externa, and vocal cord palsy with underlying T2DM and ESRF on HD (ROF 500cc).
Patient has normal BMI, with high level of urea and creatinine but low in sodium and hemoglobin. SGA
showed at risk of malnutrition. FEES assessment resulted not safe for oral feeding. Current HEN was
tolerated 120cc Nephro, 3hourly, 3x/day (Iftar, 10pm, Sahur). Patient very keen to continue fasting
during Ramadhan but unaware that energy and protein only achieved 50% from requirement.

Nutrition Diagnosis: Inadequate enteral nutrition infusion related to food and nutrition-related
knowledge deficit concerning appropriate formulation given for EN as evidenced by feeding history
(achieved approximately 50% of energy and protein requirement).

Nutrition Intervention: Enteral feeding was planned for fasting month that provided energy and
protein requirement at 27 kcal/kg and 1.2-1.3 g/kg of protein with current feeding regime of 220cc
Nephro, 3hourly, 3x/day (Iftar, 10pm, Sahur) with aimed to achieve at least 75% of energy and protein
requirement for optimization of nutritional status, prevention of weight loss as well as improvement in
quality of life.

Nutrition Monitoring and Evaluation: For the next visits, monitoring and evaluation focusing on
three domain consist of food and nutrition-related history (feeding tolerance and feeding adequacy),
biochemical data (renal profile and hemoglobin), and anthropometry data (weight changes).

Conclusion: The optimization of tube feeding is crucial for proper nutrition implementation in order to
optimize the nutrient needs even during fasting month.

Keywords: home enteral nutrition, fasting month, feeding optimization

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1ST SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Nurhazimatul Izzati binti Shaikh Abdul Jamal

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: A case study of nutrition care of diabetes mellitus in adult patient

Background: Poor blood glucose control contributes to increased development rate of diabetes
chronic complication in diabetic adult patient. Thus, diet modification of carbohydrate intake aims to
lead in maintaining good blood glucose control.

Nutrition Assessment: A 51 years old married Malay female was diagnosed with type II diabetes
mellitus, dyslipidemia, hypertension and ischemic heart disease. Patient was referred to dietitian for
diabetic management. Patient have normal weight with BMI 24.2 kg/m2. The latest biochemical data of
patient showing fasting blood sugar and HbA1c were high. Fasting Serum Lipid shows high total
cholesterol, triglycerides and LDL cholesterol reading. Patient did self-monitor blood glucose, averagely
10 mmol/l. Patient has a sedentary physical activity level. From the diet recall, it showed that the
patient had inconsistent carbohydrate intake throughout the day. Patient had around 15 exchanges of
carbohydrates per day with estimated intake of 1500 kcal daily.

Nutrition Diagnosis: Inconsistent carbohydrate intake related to physiological cause (Type II Diabetes
Mellitus) requiring careful timing and consistency in the amount of carbohydrate as evidenced by diet
recall revealing inappropriate carbohydrate exchanges during main meal (Lunch: 5 exchanges and
Dinner: 6 exchanges), skipping breakfast, high FBS (20.05 mmol/l) and high HbA1c (11.2%).

Nutrition Intervention: Nutrition intervention aimed at achieving or maintaining blood glucose in
normal range or as close to normal by prescribing 50% (12 exchanges) of carbohydrate from energy
requirement. Nutrition counselling, diet and lifestyle modification such as carbohydrate counting, self-
monitoring blood glucose and active lifestyle practice were included in strategies.

Follow-up: No weight changes reported. Patient reduced the carbohydrate intake to 13 exchanges/day
with 1300 kcal daily. Physical activity improved stretching to additional walk for 30 min daily. Patient
was encouraged to continue in making diet modification and practicing active lifestyle.

Conclusion: Blood glucose maintenance by emphasizing the role diet modification, physical activity
and counselling are crucial to prevent the development rate of diabetes chronic complication in
diabetic patient. It is wise to counsel regarding carbohydrate counting which helps in controlling
amount of carbohydrate taken to control blood glucose for this patient.

Keywords: diabetes mellitus, carbohydrate, blood glucose

13

1ST SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Lim Ler Sheang

Institution : International Medical University (IMU)

Title: Implementing behaviour changes on dietary and physical activity for adult weight management

Background: Dietary and exercise interventions involving behaviour changes are important aspects of
weight management. This includes intrinsic and extrinsic factors such as patient’s motivation level,
social support, and environment.

Nutrition Assessment: Patient NA, a 26-year-old married Malay female was referred for weight
management. She was diagnosed with obesity (BMI 34kg/m2), non-alcoholic steatohepatitis, and
infertility. Her measured body fat composition was 55%. Since diagnosis, patient initiated 1.3kg weight
loss for 2 months after adhering to diet tips from social media by cutting down sugar-sweetened
beverages, portions and unnecessary snacking while increasing fiber from fruits. However, she was
consuming energy-dense food specifically high-fat dishes, contributing 42% from fat. Due to long
working hours, she was sedentary and lacks motivation and support to start exercising. Energy
requirement was calculated using Mifflin St Jeor with a 500kcal calorie deficit.

Nutrition Diagnosis: The nutrition diagnoses were (1) excessive fat intake related to food and
nutrition-related knowledge deficit on weight management and appropriate fat intake as evidenced by
patient’s usual fat intake of 42% as compared to daily requirement of 30% and (2) physical inactivity
related to limited motivation and social support to implement change as evidenced by patient’s
sedentary lifestyle without structured exercise.

Nutrition Intervention: The goals of management are to promote weight loss and increase physical
activity. Patient was prescribed 1500kcal, 30% fat requirement, and minimum 15 minutes exercise per
day. Healthy eating and goal-setting incorporated through motivational interviewing were
implemented.

Nutrition Monitoring and Evaluation: Patient’s weight, body fat composition, lipid profile, and
dietary intake and physical activity progression will be monitored and evaluated at the next visit.

Conclusion: For this case, healthy eating strategy by empowering patient to choose lower-energy and
fat dishes were taught. Moreover, counselling strategies such as motivation interviewing by rolling with
patient’s resistance and goal-setting of a daily minimum 15 minutes exercise were emphasised. By
using technology, patient was encouraged to exercise following recommended online videos. Two-way
interaction by incorporating dietary and exercise interventions through behaviour change is important
in weight management intervention planning.

Keywords: weight management, sedentary, motivation, social support

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1ST SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Shekina Lyn Plana

Institution : University of Santo Tomas (UST)

Title: End-Stage Renal Disease Secondary to Glomerulonephritis and with Hypertension

Background: Chronic Kidney Disease is a progressive and irreversible loss of kidney function with End-
Stage Renal Disease (ESRD) requiring renal replacement therapy. In the Philippines, it is one of the
leading causes of hospitalization and the tenth leading cause of mortality. It is also reported that
people with chronic kidney disease of any stage can make them more likely to get severely ill from
COVID-19. These would highlight the need for sustaining nutritional well-being to delay disease
progression and improve immunity.

Nutrition Assessment: This case presents a 48-year-old woman with End-Stage Renal Disease (ESRD)
secondary to Chronic Glomerulonephritis and with Hypertension. The anthropometric assessment
reflects the patient’s normal Body Mass Index (20.6kg/m2), insignificant weight loss and an above-
normal waist-to-hip ratio (0.98). Altered nutrition-related laboratory values are present due to the
impaired kidney function with clinical manifestations that suggest uremic syndrome and anemia of
chronic disease. Dietary intake is poorly managed during dialysis with ~62% of the recommended total
energy requirement; and 80% of the recommended protein requirement.

Nutrition Diagnosis: With these assessments, the patient has limited adherence to nutrition-related
recommendations related to food and nutrition-related knowledge deficit as evidenced by undesirable
food choices, poor variety in intake and inadequate macro and micronutrient intake. The goals are to
increase caloric intake, provide adequate nutrients, and attain a variety of food.

Nutrition Intervention: Specifically, an initial diet prescription of 1300 Kcal; 160g Carbohydrates; 15g
Simple Sugar; 50g Protein; 50g Fat; ≤28g MUFA; ≤14g PUFA; <10g SFA; Low cholesterol (<300mg
Cholesterol); Low sodium (<2.3g Na); Low phosphorus (800mg P); Limited potassium (<2.5g K); 1.5g Ca;
<1L/day; and small frequent feeding is recommended.

Nutrition Monitoring and Evaluation: The monitoring would focus on a weekly calorie, protein
intake, and dry weight measurement; daily fluid intake; and monthly biochemical values such as BUN,
Creatinine, Na, P, K, FBS, and lipid profile.

Conclusion: The case recommends early assessment and diagnosis for those at high risk of
developing chronic kidney disease. This would help delay the initiation of dialysis along with early
nutrition intervention and management. Also, the need for nutrition education and counseling has a
crucial role in managing and improving the patient's overall nutritional status.

Keywords: End-stage renal disease, chronic kidney disease, hypertension, hemodialysis, recurrent
urinary tract infection, chronic glomerulonephritis, COVID-19

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1ST SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Ng Jing Wen

Institution : Universiti Putra Malaysia (UPM)

Title: Challenges of nutrition optimization on cerebral palsy patient with poor oral intake: A case study

Background: Cerebral palsy (CP) is group of disorders that affect ability to move, to balance and
maintain posture due to abnormal brain development before, during or after birth. Due to difficulty in
controlling muscle, CP patients will face several feeding difficulties such as dysphagia that lead to
malnutrition due to inadequacy in energy and protein intake. Malnutrition may lead to growth failure
and reduction in potential for development if untreated.

Client History: Patient P, 16-years-old, Malay female, diagnosed with CP, was referred to dietitian for
optimization of intake via oral nutrition supplement (ONS).

Nutrition Assessment: Patient’s body weight is 37kg, looked thin and may have undernourished
issue. Patient had GMFCS level V and she was unable to speak, had difficulty in swallowing and
possible constipation issue. From dietary assessment, patient was found to have inadequate energy
(42%), protein (58%) and fibre adequacy (18%) from blenderized diet.

Nutrition Diagnosis: Inadequate protein energy intake related to physiological causes (cerebral palsy)
lead to decreased ability to consume sufficient energy and nutrient as evidenced by diet history
showing inadequate energy adequacy (42%) and protein adequacy (58%).

Nutrition Intervention: Main objective was to achieve at least 70% of energy (2085kcal/day) and
protein requirement (74g/day). Calorie boosting technique was shared with caregiver to optimize
patient’s energy intake. Standard polymeric formula with high fiber content had been prescribed to
patient as ONS (471kcal/day) to enhance patient’s oral intake while tackling with possible constipation.
Inclusion of high fiber food in blenderized (texture-modified) diet (1614kcal/day) and sufficient fluid
intake (1.8L/day) were encouraged to prevent constipation.

Nutrition Monitoring and Evaluation: In future, patient’s dietary intake, tolerance towards ONS, GI
symptoms and weight changes will be reviewed again.

Discussion: Blenderized diet with high energy density is needed to increase patient’s energy intake
without increasing food volume. ONS can be prescribed as a mean to boost up patient’s energy,
protein and fiber intake. Nutrition management able to reduce the risk of malnutrition and other
nutrition-related issues such as constipation at the same time.

Conclusion: Combination of texture-modified diet and ONS is vital in optimizing oral intake for CP
patient. Sufficient energy and protein intake are necessary in preventing malnutrition.

Keywords: cerebral palsy, poor oral intake, blenderized diet, ONS

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1ST SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Christine Hannah R. Broqueza

Institution : University of Santo Tomas (UST)

Title: A case of a 65 year old Male with chronic kidney disease stage V with existing hypertension and
diabetes

Background: End-stage renal disease patients are at risk of malnutrition – brought by the disease and
its clinical manifestations, and the different procedures and dietary restrictions, affecting energy and
nutrient needs, and dietary intake. Nutrition management is essential to help avoid/manage
malnutrition, resulting in better prognosis and quality of life.

Nutrition Assessment: FDL is a 65-year-old Filipino male diagnosed with CKD stage V last January
2021 and currently undergoing peritoneal dialysis (every day for 8 hours). Patient is assessed to be
severely malnourished (BMI of 19kg/m2, 14.3 % weight loss in 3 months, and inadequate energy
intake). Patient’s malnutrition may be attributed to his disease condition which is catabolic in nature
along with uremia which greatly affects appetite and dietary intake. Additionally, patient is
hyperglycemic.

Nutrition Diagnosis: Inadequate Energy Intake related to end-stage kidney disease, loss of appetite,
dysgeusia, nausea, and vomiting as evidenced intake of <75% of recommended energy intake and
significant weight loss.

Nutrition Intervention: Patient is recommended to modify his energy and nutrient intake: increased
energy starting from 25kcal/kgbw to 30kcal/kgbw/day, and protein needs to 1.2g/kgbw/day. This is to
avoid further weight loss of the patient and address his uremia to help improve his appetite, feeling of
nausea and dysgeusia.

Nutrition Monitoring and Evaluation: Monitoring and evaluation plans include daily calorie and
protein counting and re-assessment of his appetite, dysgeusia and nausea.

Conclusion: Malnutrition among patients with end stage renal diseases increases their risk for
mortality and morbidity. Early identification through comprehensive nutritional assessment with
proper nutrition management may help avoid onset of more complications, longer length of stay and
improve patient’s quality of life.

Keywords: CKD; Renal Disease; Diabetes; Hypertension; Renal Replacement Therapy

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2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Amrita Tan Rui Shan

Institution : International Medical University (IMU)

Title: Management of transitional feeding in a post-surgery lower GI patient

Background: Adequate nutrition is important for those undergoing extensive gastrointestinal surgery
to achieve functional recovery and to prevent malnutrition due to a heightened catabolic response.
Optimal intake can be achieved via a parenteral or enteral route or a combination of both.

Nutrition Assessment: AA, a 37-year-old Malay male, diagnosed with obstructed descending colon
tumour with cecal perforation, was referred to the dietitian for nutrition optimisation. Patient had
undergone subtotal colectomy prior to ileal resection, and ileostomy creation. Patient was of BMI
16.3kg/m2, with unquantifiable weight loss beginning two months ago. His urea and creatinine levels
showed an increasing trend due to acute kidney injury. His C-reactive protein level was 304.4mg/dl. At
assessment, AA was already tolerating total parenteral nutrition (TPN) regime 4 which provided
1100kcal, 50g protein. His fluid balance was -292ml with greenish stoma output. Latest surgical plan
was to increase TPN to regime 5 (1600kcal, 75g protein) and trial clear fluids orally as patient had
passed swallowing test.

Nutrition Diagnosis: Inadequate oral intake RT transitional feeding AEB patient meeting 52% energy
requirement and 65% protein requirement from TPN regime 4.

Nutrition Intervention: The goal was to optimise his nutritional status and promote recovery from
previous surgeries. His prescription was 2100kcal/day with 76g protein. Along with TPN regime 5
(63ml/hr), 2 packets/day of Resource Peach was prescribed for small sips throughout the day,
providing 2100kcal/day with 93g protein in total. The enteral regime was conveyed to the staff nurse.

Nutrition Monitoring and Evaluation: His energy and protein intake, renal profile, feeding tolerance
and stoma output were monitored. The review two days later showed decreased urea and creatinine
levels due to stat dialysis. Patient only achieved 250kcal with 9g protein from Resource Peach as
caretaker was unaware of the feeding regime. Latest surgical plan was to revert to TPN regime 4 and
allow progression to nourishing fluids. Peptamen 4 scoops with 150ml water, 4 feeds/day was
prescribed and relayed to both nurse and caretaker to ensure regime adherence.

Conclusion: Close monitoring of transitional feeding not only helps ensure regime tolerance, but can
also optimise nutrition to aid recovery and prevent malnutrition.

Keywords: post-operation recovery, transitional feeding, total parenteral nutrition, clear fluid,
nourishing fluid

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2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Iffa Izzwani binti Shamsul Kamar

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: A case study of post-operative nutrition care for laparatomy adhesiolysis in rectal cancer patient

Background: Patient with surgically created stomas often experience from high stoma output with
major deficits of water, sodium and magnesium can suffer from malnutrition and long term weight
loss. Thus, this case study aims to maintain stoma output within normal range and to prevent muscle
and fat wasting.

Nutrition Assessment: A 56-year-old married Chinese man was diagnosed with adenorectal
carcinoma on July 2019 and patient had undergone abdominoperineal resection and prostatectomy
on the same year. After a year, patient experienced fecal material coming out from his meatus for a
month. Upon admission, finding showed that he had urethral ileo fistula and recurrence of rectal
cancer with small bowel obstruction. Therefore, laparotomy adhesiolysis, small bowel decompression
and ileocolic bypass was done on November 2020. He claimed his appetite has decreasing since July
2019 and has loss weight more than 20% which then categorized him under malnourished and
experiencing severe weight loss. Patient is underweight with BMI 15.2kg/m2.

Nutrition Diagnosis: Inadequate protein intake [NI-5.6.1] related to high demand for wound healing
and high stoma output as evidenced by diet history of protein intake less than 70% of requirement.

Nutrition Intervention: Nutritional intervention aimed to meet patient’s energy and protein
requirement per day as optimum to 75% of EER. Patient protein requirement is around 1.7 g per body
weight. To fulfill both energy and protein requirement, ONS was step up from 5 scoops Nutren
Optimum + 1 scoop Myotein + 250 ml H20 thrice per day to 7 scoops Nutren Optimum + 1 scoop
Myotein + 200 ml H2O thrice per day. Counselling on stoma diet was also given to minimize the stoma
output and to optimize the nutrient absorption.

Nutrition Monitoring and evaluation: To monitor diet intake, I/O chart daily meanwhile renal profile
and weight changes in a week.

Follow-up: Patient energy intake however has decreased from 90% to 76% and this can also be seen
in protein intake where it has decreased from 66.5 g to 57.5 g per day. Hence, nutrition counselling
was given to the patient to improve his oral intake.

Conclusion: Post-operative nutrition is crucial to prevent delaying in wound healing and further
complications associated with malnutrition. Since this patient has already malnourished with poor
oral intake, therefore it is best to optimize his intake with ONS and to encourage orally through
counselling.

Keywords: post-operative nutrition, high stoma output, optimization, surgery

19

2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Nurul ‘Aqilah binti Hasan Ashaari

Institution : Universiti Putra Malaysia (UPM)

Title: An Inpatient Paediatrics Case Study: Nutritional Management for Poor Weight Gain Premature
Infants with Severe Laryngomalacia

Background: Premature infants quite commonly born with low birth weight with underlying illness
such deformed structure in the larynx compromised their nutrient needs. Despite having significant
illness which may perpetuate the vicious cycle of under-nutrition, optimal nutrition is very important
to ensure that the infant’s progress is not hampered by additional factors.

Nutrition Assessment: We report a case of premature infant in age of 2 months old using corrected
age, admitted to ward due to severe laryngomalacia and for procedures of laryngoscopy,
supraglottosplasty, frenulotomy and tracheotomy. The first reason of referral to dietitian is for enteral
feeding regime in view of patient having episodes of vomiting and regurgitation. He was born at low
birth weight of 2.12kg and weight upon admission is 2.96kg (<3rd percentile weight-for-age using
WHO growth chart). During this follow up review, his weight increased from 3.73kg to 4.0kg in 3 days
which failed to achieve recommended weight gain for his age of 20-40g/d. He had no distress
worsening or episodes of vomiting and diarrhea during the follow up review and patient tolerated well
with previous regime of 3 scoops of anti- regurgitation (AR) formula with 0.5ml of fat modular in 80ml
water, 3hourly,8x/day that achieved 102% energy adequacy and 90% protein adequacy.

Nutrition Diagnosis: Growth rate below expected related to increase nutrients needs in view of
physiological causes as evidence by achieve only 27g weight gain in 3 days and current weight-for-age
<3rd percentile.

Nutrition Intervention: Short team goal of the management is ensuring adequate weight gain of 20-
40g/d, nutrition intervention aims to achieve 170kcal/bwt/d of energy and 5.0g/kgbwt/d protein
requirement. Patient prescribed with 3.5scoops AR formula+0.5ml MCT oil in 90ml water, 3hourly,
8x/d.

Nutrition Monitoring and Evaluation: After four days of monitoring, patient had significant weight
gain to 4.3kg(300g) which achieve rate weight gain of 75g/d(20-40g/d).

Conclusion: Strategies of nutrition care process to promote optimized growth and development in
low birth weight infants especially premature infants may need a proper monitoring to ensure a
better outcome.

Keywords: Premature, low birth weight, infants, growth rate, weight gain, nutrition support

20

2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Muhammad Aiman Naim bin Mahayuddin

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: Nutrition Management of Palliative Care: Elderly with Conservative Treatment of Urosepsis &
Erosive Esophagitis

Background: Urosepsis is described as a serious infection of the urinary tract and/or male genital
tract (e.g., prostate) with symptoms that are similar to those seen in SIRS. Metabolic response during
sepsis gives a greater effect on patient’s nutritional status, requiring adequate nutritional intake and
producing huge amounts of cellular waste products. Erosive esophagitis or reflux esophagitis is the
common type of esophagitis in which there is injury to the esophageal mucosa. Esophagitis always
manifests symptoms that affect and overall quality of life. This problem may lead to the inadequate
oral intake and might be at risk of malnutrition if patients do not seek for early intervention.

Client history: An 82 years old, married Pakistani male diagnosed with right staghorn calculi, bilateral
renal calculi on September 2020. He has underlying of hypertension, hypothyroidism, BPH, history of
colectomy for sigmoid volvulus in 2014 and IHD diagnosed in 2016 with ROF of 800 ml/day. Patient
was treated conservatively for his renal calculi. Then, he had multiple admission for urosepsis (last
admission was on 17 – 18/3/2021). He was recently admitted to hospital on 22nd April 2021 when he
was presented with fever for 3 days. Moreover, he was associated with poor oral intake and
nauseated. Upon admission, he was diagnosed with urosepsis with underlying bilateral renal calculi
and bladder calculus and AKI secondary to urosepsis. Patient’s family are healthy and no history of
malignancy within them. Patient is a non-smoker and none alcoholic. On the 22nd April 2021, patient
was issued with DIL due to currently very ill. Patient had first visit by dietitian on 23rd April 2021 for
nutrition optimization. The next follow up was on 26th April 2021. Upon follow up, patient was
diagnosed with septic shock secondary to urosepsis.

Nutrition Assessment: Patient’s BMI was 17.6 and underweight. Patient’s daughter reported that
patient has lost 30 kg (42%) of his previous weight for the past 5 years since post-op for colectomy in
2014. Patient’s SGA grade was B. Before admitted to the ward, patient only abled to finish half of the
usual diet at home. During the first dietitian visit, patient estimated intake was ~150 kcal and 68 g
protein per day. On the 1st follow up, patient’s estimated intake in ward was ~800 kcal, 20 g protein
per day and achieved 63% of EER.

Nutrition Diagnosis: Inadequate oral intake (N1 – 2.1) related to loss of appetite as evidenced by
estimated intake only achieved 63% of EER and 37% of protein requirement.

Nutrition Intervention: To motivate and educate patient to eat by small and frequent meal and to
suggest the caregiver to give patient ONS (Novasource renal) for 1 pack per day.

21

2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Muhammad Aiman Naim bin Mahayuddin

Institution : Universiti Kebangsaan Malaysia (UKM)

(cont)

Nutrition Monitoring and Evaluation: To monitor patient’s tolerance to oral intake, biochemical data
(Dxt, LFT, RP and FBC) and stoma output.

Follow up: Follow ups were done for 6 times. Patient had new issue of UGIB secondary to erosive
oesophagitis. He had 2 episodes of melenic stools and was kept NBM for twice. Patient’s dietary intake
fluctuated and the highest achievement was 83% of EER. Upon discharged, education was given to the
caregiver to give patient soft and moist food. A sample of menu plan was given to the daughter as a
nutritional guideline for patient. Patient was suggested to continue ONS. Advice given to the patient
include to avoid triggering food to the gut such as spicy, caffeine and acidic food in concern to his GI
tract.

Conclusion: Nutritional management in sepsis aim for preventing septic shock, meet increased
energy needs promote tissue repair and wound healing, relief GI disorders. Elimination of triggering
foods are the basis of management of esophagitis. Elderly patients who is on palliative management
should be treated to maintain their comfort and quality of life.

Keywords: urosepsis, sepsis, septic shock, upper GI bleeding, esophagitis, oral nutrition support,
elderly, palliative care

22

2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Elwina Meylentia

Institution : Universitas Gadjah Mada (UGM)

Title: Enteral and parenteral nutrition management in post-neurosurgical pediatric patient with
gastroparesis: NCP case report

Background: Post-operative patients of craniotomy were usually treated in 2-3 days and were able to
go directly home following their stay in the hospital. Gastroparesis in these patients was vaguely
associated with neural disruption and more with sedative and opioid medication or even idiopathic.

Nutrition Assessment: A 4-year-11-months-old boy (106 cm, 19 kg) was admitted to the intensive care
unit following craniotomy tumor removal due to obstructive hydrocephalus. Despite all treatment, his
condition weakens and his level of consciousness deteriorated to soporous, and on hospital day 20, he
went through another surgery for VP Shunt revision and required nutritional reassessment. Previously,
he has been prescribed 6x100 cc hydrolyzed enteral nutrition formula via nasogastric tube feeding.
However, gastric residue with murky color was constantly found for 72 hours, indicating delayed
gastric emptying and GI bleeding, hence causing poor intake. Laboratory test results revealed systemic
inflammation (elevated procalcitonin, low albumin) and partially compensated respiratory acidosis.
Normal vital signs were maintained, except for elevated systolic blood pressure.

Nutrition Diagnosis: (NI 5.1.) Increased protein needs related to wound healing and systemic
inflammation as evidenced by post-surgery condition, elevated procalcitonin, low albumin, and (NC
1.4.) Altered GI function related to gastroparesis as evidenced by murky gastric residue.

Nutrition Intervention: Intervention aimed to increase nutrition intake gradually via the parenteral
route, starting with 80% of basal metabolic rate. Estimated energy requirement was calculated with
Caldwell equation, 618 kcal/day and protein needs was 28.5 gram (1.5 gr/kg BW), which can be fulfilled
by 30 ccs of Kabiven (0.69 kcal/cc) per hour.

Nutrition Monitoring and Evaluation: During 4 days of monitoring, patient’s nutrition intake showed
improvement ranging from 55 – 90% fulfillment of basal metabolic needs. Some modifications were
made accordingly, including prokinetic administration, re-trial of enteral nutrition with 5 cc/hour
continuous feeding, and modification from Kabiven to Clinimix and Lipid 20% due to excessive
carbohydrate intake.

Conclusion: While enteral nutrition is preferred and more beneficial, in patients with gastroparesis
who did not respond to feeding, parenteral nutrition should be considered immediately, but
administered cautiously.

Keywords: enteral, parenteral, pediatric, gastroparesis, craniotomy

23

2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Nur Afifah Syahirah binti Awang Basry

Institution : Universiti Teknologi MARA (UiTM)

Title: Nutrition management in relapsed neoroblastoma paediatric

Background: Malnutrition is a major cause of morbidity and mortality in cancer patients which lead to
treatment intolerance, and susceptible for infection.

Nutritional Assessment: A 9 years old Chinese girl was diagnosed with neutropenic sepsis, relapsed
neuroblastoma and electrolyte imbalance. Patient had completed her chemotherapy protocol 6th
cycle. Her weight was 22.4 kg which fall at 5th percentile (weight-for-age) and 125.7 cm which is above
10th percentile (stature-for-age). Her ideal body weight was 25.6 kg at 50th percentile based on BMI-
for-age had reported of weight loss. Her biochemical data showed low urea, electrolytes,
haemoglobin, albumin, and white blood cell. She was febrile and had tachycardia. Patient’s estimated
calorie intake was only 28.7 kcal/kg/day and protein intake, 1.3 g/kg/day at the hospital. Her belief that
consuming chicken or egg is not good for cancer patients. Medications to correct electrolyte levels
were administered, antibiotics as well as morphine to reduce pain. The energy (ER) and protein
requirement (PR) were 62.5 kcal/kg/day based on FAO/WHO 1985 and 2.5 g/kg/day based on Dorothy
for sick children 1987.

Nutrition Diagnosis: Inadequate protein-energy intake related to decreased ability to consume
sufficient protein and energy (loss-of-appetite post chemotherapy) as evidenced by current protein
intake of 1.3 g/kg/day compared to PR of 2.5 g/kg/day and current energy intake of 28.7 kcal/kg/day
compared to ER of 62.5 kcal/kg/day.

Nutrition Intervention: The main goal was to provide adequate energy and protein to prevent
further weight loss. Education on the importance of high calorie, high protein diet for cancer patients
and tips on preparation of high energy dense meal was delivered to patient’s caretaker. She was also
prescribed with high protein ONS which provide 340 kcal and 18 g protein, softer and cold foods, non-
sour, non-spicy, and unsalted food to relieve mouth ulcers. Patient’s belief was also corrected and
advised to subsequent with other high biological value sources of protein.

Nutrition Monitoring and Evaluation: Patient able to tolerate an estimated calorie intake of 49
kcal/kg/day and estimated protein intake of 2.0 g//kg/day. Patient was seen having an improved
appetite until the day before discharge and gradually start consuming egg.

Conclusion: Adequate nutrition is important to aid cancer patients in avoiding malnutrition, healthy
body weight, strength, fighting infection and reduce effects during and after treatment.

Keywords: cancer, neutropenic sepsis

24

2ND SESSION
IN-PATIENT CATEGORY (IPD)

Name : Suraya binti Arshad

Instituition : Universiti Kebangsaan Malaysia (UKM)

Title: A case study of pre-operative nutrition care for radical cystectomy in elderly cancer patient

Background: Poor nutritional status contributes to increased postoperative complications and
delayed recovery especially in elderly patients. Thus, perioperative maintenance of nutritional status
aims to increase the functional reserve to optimize recovery after surgical procedure.

Nutrition Assessment: A 62-years old married Malay male was diagnosed with bladder cancer in
September 2017 and had undergone multiple transurethral resection of bladder (TURB) procedures
for 5 times. Patient developed hematuria for the past 2 months, and worsening with blood clots for
the past 4 days. He was admitted on 30th March 2021 with impression of hematuria secondary to
bleeding bladder cancer with symptomatic anemia. Patient was scheduled for Radical Cystectomy on
22th April 2021 and referred for pre-operation nutrition optimization 1 week prior procedure. Patient
is underweight with BMI of 20.0 kg/m2. He experienced insignificant weight loss of 0.5% in 2 weeks.
The weight reduction was indicated by suboptimal energy intake at only 50% of estimated energy
requirement and protein intake of only 6g/d due to loss of appetite since admission. Patient’s SGA was
graded as B.

Nutrition Diagnosis: Inadequate protein-energy intake related to loss of appetite as evidenced by
estimated energy and protein intake only achieved 50% and less than 10% of estimated requirement
respectively and weight loss of 0.5% in 2 weeks, SGA grade B.

Nutrition Intervention: Nutritional intervention aimed at achieving at least 75% of energy
requirement and protein 1.2 – 2.0g/kg/d prior to operation. ONS was suggested to the patient as one
of the strategies to increase protein-energy intake. Nutrition counselling, diet modification such as
high protein and proper texture were also included as strategies. CHO loading was planned prior to
operation day, however, after further discussion with the surgical team, it was not implemented.

Nutrition Monitoring and Evaluation: To monitor weight changes in a week and oral intake daily.

Follow-up: Patient achieved 122% energy requirement. Protein intake improved from 6g/day to
92.5g/d (1.4g/kg/d). Weight increment from 67.6 kg to 68.0 kg. Patient was encouraged to continue on
maintaining energy and protein intake.

Conclusion: Perioperative maintenance of nutritional status by emphasizing the role of ONS, diet
modification and counseling are important to prevent postoperative complications especially in
elderly. CHO loading helps in reducing post-operative complications. Since this patient is an elderly
with complicated procedures, it is wise to consider this case as a major surgery, emphasizing the
importance of CHO loading implementation to be carried out.

Keywords: nutritional status, perioperative nutrition, optimization, surgery

25

3RD SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Nur Alia Syuhada Binti Haris

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: Nutrition management of hyperkalemia and chronic kidney disease stage 4 with underlying
hypertension, dyslipidemia and diabetes mellitus

Background: Chronic kidney disease (CKD) is progressive damage or loss of kidney function over time
and once the kidney severely damages it can stop working which leads to kidney failure. Hyperkalemia
acts as a major driver to start chronic dialysis therapy in patients with end-stage renal disease and also
increases the risk of sudden death due to fatal arrhythmias. Along with medical therapy, nutrition
therapy also important in delaying the progression of kidney failure and prevent other complications
of CKD.

Nutrition Assessment: The patient is 70 years old Malay was diagnosed with chronic kidney disease,
hyperlipidemia, hypertension and diabetes mellitus. The anthropometry patient was measured and
the result of BMI is normal for the elderly. For the latest biochemical data, the renal profile showed
that the value of urea and creatinine is increasing from the previous value which higher than normal
ranges. The potassium level also increasing to borderline high. Based on diet recall, the total estimated
intake only achieved around 66% from the requirement and the estimated intake of protein is high
than recommended. The patient did not comply with the fluid restriction that being recommended.
From the diet history and food checklist that is done, the patient reported frequent consuming high
potassium food especially whole grain products and green vegetables.

Nutrition Diagnosis: Altered nutrition-related laboratory values (potassium, urea and creatinine)
related to kidney dysfunction and food and nutrition knowledge deficit of management of CKD as
evidenced by potassium borderline high, high level of urea and creatinine, excess intake of food which
high in potassium, estimated high intake of protein and verbalizes lack of information and knowledge
regarding CKD diet.

Nutrition Intervention: The objective of the intervention is to prevent the complication of
hyperkalemia and to delay the progression of kidney failure. The principle of dietary management is to
suggest education on low potassium and low protein diet.

Nutrition Monitoring & Evaluation: To monitor the dietary compliance and renal profile.

Conclusion: In conclusion, CKD with other underlying diseases will lead to progression of CKD and
causes altered nutritional requirement and affect their metabolism. Therefore a good education
regarding dietary management should be emphasized to the patient to optimize and maximize the
nutritional status and quality of life.

Keywords: chronic kidney disease, hyperkalemia, low protein diet, low potassium diet, fluid restriction

26

3RD SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Olivia Senjaya

Institution : Universiti Putra Malaysia (UPM)

Title: Poor weight gain in pediatric patient with Hirschsprung Disease: nutritional management in
outpatient settings

Background: Hirschsprung disease is a congenital condition characterized by absent nerve cells in the
bowel. Infants or children with this disease are often presented with abdominal distension, vomiting
and failure to thrive.

Nutrition Assessment: A 2 years 6 months old Malay boy presented at diet clinic for follow up.
Patient was born preterm at 36 weeks with normal birth weight (2.75kg). He was diagnosed with
Hirschsprung disease and poor weight gain. Weight at time of visit was 8.4kg (<3rd percentile of weight
for age, underweight) while height was 85cm (<3rd percentile of height for age, stunting). Rate of
weight gain was 140g per month (below expected). Ideal weight for height was 13.5kg. Caregiver
reported that patient is bloated and will have stomach distension post meal. Patient’s intake ranged
from 1355 to 1624 kcal (160-190kcal/kg) with milk solid ratio of 70 to 30.

Nutrition Diagnosis: Growth rate below expected related to physiological impetus for increased
nutrient needs (Hirschsprung disease) as evidenced by poor weight gain (140g/month) despite energy
and protein intake more than requirement.

Nutrition Intervention: To achieve appropriate catch up growth, 150kcal/kg actual body weight with
3.0-4.5g/kg protein were prescribed. Management aimed to achieve optimum rate of weight gain for
catch up growth through provision of high calorie diet with high protein while ensuring appropriate
type and amount of food for age.

Nutrition Monitoring and Evaluation: Monitoring and evaluation were focused on growth, intake
and possibility of malabsorption related to Hirschsprung disease.

Conclusion: Growth rate was not yet optimized despite patient has been followed up by dietitian since
the age of 6 months and efforts has been made to support optimum growth. Malabsorption related to
pathophysiology of Hirschsprung disease is suspected in this patient in consideration of slow growth
despite protein and energy intake adequacy already optimized for catch up growth.

Keywords: Hirschsprung disease, poor weight gain, underweight, stunting, malabsorption.

27

3RD SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Achmed Forest Khan

Institution : Universitas Brawijaya

Title: Outpatient nutrition care process immune thrombocytopenic pupura

Background: Immune thrombocytopenia purpura is an immune-mediated destruction of platelets and
possible inhibition of platelet release from megakaryoces. Globally, the prevalence of ITP varies from
1.6-3.9 cases per 100.000 population per year. The Complication that can occur can be bleeding from
mucocutaneous, gastrointestinal to intracranial. Stomach bleeding that causes eating disorders is one
of the challenges for dietitians to solve.

Nutrition Assessment: The patient complains of dizziness, slight nausea and stomach pain, hard
bowel movements, whole body pain and swelling of the face. With biochemical data showing anemia,
thrombocytopenia and leukocytosis. The patient has received nutrition education but still has bad
eating habits. The patient has a habit of consuming tea and its processed products at the same time as
meals and daily fiber intake that does not meet the recommended daily intake based on the results of
SQFFQ.

Nutrition Diagnosis: The nutritional diagnosis made is limited food acceptance, Increased nutrient
needs, inadequate fiber intake, altered nutrition-related laboratory values and not ready for
diet/lifestyle change.

Nutrition Intervention: The nutritional intervention provided medical food supplements especially
using moringa products, nutrition education, nutrition counseling and coordination of nutrition care.

Nutrition Monitoring and Evaluation: Monitoring and evaluation is done for six days. Nutritional
monitoring and evaluation that is considered is food and nutrient intake, medication and
complementary/alternative medicine use, behavior, anthropometric measurements, biochemical data
and nutrition-focused physical findings.

Conclusion: The results of the nutritional care process provided to patients for six days were that
there was no decrease in nutritional status, patient complaints of whole body pain, difficulty defecating
and swelling of the face getting better, food intake in quantity remains good, and there is an
improvement in the quality of the patient’s eating which shows a change in eating habits for the better.

Keywords: outpatient, nutrition care process, ITP, thrombocytopenia, Moringa

28

3RD SESSION
OUT-PATIENT CATEGORY (OPD)

Name : Siti Nor Fadzilah binti Muhammad Shihan

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: Nutrition management of anorexia nervosa

Background: Anorexia nervosa, normally involving restrictive eating or purging is a psychiatric
disorder with increased risk of organ complications and the highest rate of death. Early intervention,
including in nutritional aspects is essential in promoting behavior change for recovery. However, not
much case is reported on the specifics of nutrition management for anorexia nervosa. Therefore, this
case study is to discuss on the nutrition management of anorexia nervosa restricting type.

Nutrition Assessment: Patient was 21-year-old Chinese lady who was diagnosed with anorexia
nervosa restricting type. Patient was underweight with BMI 16.6kgm-2, with reported weight loss of
24% in seven months. Patient had low urea, creatinine, white cell count, hemoglobin and red cell
count level, all possibly indicating malnutrition. Patient experienced low blood pressure, low heart
rate, had 4 missed menses since March, indicating malnutrition. Nutrition assessment showed that
she had inadequate energy intake, only achieving 45.6% of requirement, and inadequate
carbohydrate intake (12.8% of total energy intake [TEI]) with report of restrictive behavior towards
complex carbohydrate.

Nutrition Diagnosis: Inadequate energy intake related to psychological cause as evidenced by
estimated energy intake of only 45.6% requirement, weight loss of 24% in 7 months, diagnosis of
anorexia nervosa and restrictive eating behaviour (carbohydrate).

Nutrition Intervention: The objectives of management include; 1) To gradually increase energy and
carbohydrate intake to achieve at least 80% of estimated needs, 2) To prevent further weight loss and
3) To achieve weight gain of 0.5 to 1kg per week. The intervention was to educate patient on
increasing energy and carbohydrate intake.

Nutrition Monitoring and Evaluation: The data to be monitored and evaluated are dietary
compliance, weight change, renal profile, hemoglobin and blood pressure in two months.

Follow up: Patient was able to achieve intake of 71.5% of estimated energy requirement. However,
her carbohydrate intake was still low (19.2% TEI) but slightly improving from previous session due to
hesitance in increasing carbohydrate intake.

Conclusion: Nutrition intervention plays an important role in ensuring adequate intake and
promoting behavior change for recovery.

Keywords: anorexia nervosa, eating disorder, behavior, restrictive intake, nutrition management

29

3RD SESSION
IN-PATIENT CATEGORY (IPD)

Name : Chin Hau Tung

Institution : International Medical University (IMU)

Title: Middle cerebral artery infarction in adult inpatient setting

Background: Optimal nutrition should be timely provided to dysphagic stroke patients to prevent
malnutrition. Besides meeting macronutrient needs, the prescription should also consider the
nutritional requirements of underlying comorbidities that often presents with stroke.

Nutrition Assessment: HK, a 59-year-old Malay male with left middle cerebral artery infarction was
referred to the dietitian to review his nasogastric tube (NGT) feeding regime. He had underlying
congestive cardiac failure with a 1000ml fluid allowance. HK was 167cm and 68kg (24.4kg/m2), and
reported no recent weight changes. His biochemistry values were within reference range. NGT was
inserted during admission as he had high risk of aspiration. At assessment, patient was already
tolerating Nutren Diabetik, which provided 722.8kcal/day and 32.2g protein/day, but 1120ml fluid. HK
had dysphasia, right sided body weakness and was ADL dependent.

Nutrition Diagnosis: Enteral nutritional composition inconsistent with needs RT fluid restriction due
to cardiac dysfunction AEB current regime providing 1120ml of water as compared to fluid allowance
of 1000ml.

Nutrition Intervention: The goal was to optimise his NGT feeding regimen while adhering to fluid
allowance. Prescription was 1600kcal/day and 68g protein/day. Using Nepro HP, HK was started on
100ml with 30ml of water for dilution, 6 times/day before increasing to the target rate of 150ml with
30ml of water for dilution, 6 times/day. Water flushes of 20ml was done after each feed. This would
meet his energy requirement by 102%, protein requirement by 107%, while providing a total of 960ml
fluid/day.

Nutrition Monitoring and Evaluation: Patient was followed up once 2 days later. Parameters
monitored were his protein, energy and fluid intake, plus feeding ability. Patient had tolerated his
target regimen, therefore fully meeting his nutritional needs, including fluid allowance. He was
allowed to discharge that day with NGT intact. Before discharge, patient was educated on NGT
administration at home with his target regimen. Other feeding plans using alternative formula was
also discussed as his family were concerned about Nepro HP’s availability in their vicinity.

Conclusion: Personalised nutrition care continues even after patient has met their nutrition needs.
Discharge plans should consider elements such as socioeconomic status, availability of product and
patient’s habit to help ensure compliance of the planned regime.

Keywords: cerebrovascular accident, compensated cardiac failure, medical nutrition therapy, enteral
nutrition; fluid restriction

30

3RD SESSION
IN-PATIENT CATEGORY (IPD)

Name : Farah Aisyah binti Ahmad Zailani

Institution : Universiti Teknologi MARA (UiTM)

Title: Post-pyloric feeding in polytrauma bowel

Background: Injuries may interrupt regular function of gastrointestinal tract (GIT) and always debated
on which enteral route is the best to be used.

Nutrition Assessment: A 43 years-old, Malay male with underlying epilepsy was diagnosed with
polytrauma bowel after involved in motor-vehicle-accident. The procedure of laparotomy was done,
duodenal primary repair and small bowel resection primary anastomosis. His estimated height from
knee height is 170 cm and the current weight is 49 kg with BMI 17 kg/m2 (underweight). His ideal body
weight is 65 kg. Biochemical data showed low haemoglobin, sodium, total protein and albumin. He
was comfortable under room air, have a full Glasgow Coma Scale score with attached catheter bag
drainage and normal vital sign. He looked thin but claimed to have no weight loss and able to answer
questions clearly during the assessment. He was on IV Rocephine and Tramal (1g BD and 50mg TDS).
Because of multiple GIT injury, post-pyloric feeding adheres and he was put on PEJ intermittent
feeding, started with 20 ml/hr standard enteral formula. Calories and protein provisions were 352 kcal
and 14.4 g protein which achieved only 18% of the energy requirement during the first visit. The long
term goal of this patient was to achieve energy requirement, 1950 kcal/d (30 kcal/kg/day) and 97.5 g
protein (1.5g/kg/day) by oral.

Nutrition Diagnosis: Inadequate enteral nutrition infusion related to feeding not yet optimized as
evidenced by calorie intake 352 kcal/d and 14.4 g protein/d compared to requirement, 1950 kcal/d and
97.5 g protein/d and just achieved 18% energy requirement in 2 days.

Nutrition Intervention: The feeding was step up gradually until reached 90 ml/hr which provided
1864 kcal/d (96% from ER) and 92 g protein (94% from PR).

Nutrition Monitoring and Evaluation: Patient was on PEJ feeding for 13 days and tolerated well. He
was challenged orally on day-12 and added up enterally by bolus feeding. PEJ was totally off on day-14.
He could tolerate normal diet with improving appetite. Patient was discharged with oral nutrition
supplement.

Conclusion: Adequate nutrition can still be achieved via post pyloric feeding. Patient was able to eat
orally after 13 days on post pyloric feeding once his gut function has returned.

Keywords: PEJ, post pyloric feeding, GIT injury

31

3RD SESSION
IN-PATIENT CATEGORY (IPD)

Name : Ng Li Li

Instituition : Universiti Kebangsaan Malaysia (UKM)

Title: Nutrition management for sacral sore grade 4 with underlying end stage renal failure

Background: Sacral sore is a common problem found in bed-ridden patients. A comprehensive
nutritional management is crucial in promoting the wound healing of sacral sore.

Nutrition Assessment: A 70 years old Malay female was diagnosed with Hospital-acquired
Pneumonia with Type 2 Respiratory Failure and Sacral Sore Grade 4. She has underlying hypertension,
diabetes mellitus, recurrent cerebrovascular accident and end stage renal failure on haemodialysis.
Patient developed shortness of breath and tachycardia which was gradually worsening after
haemodialysis. Patient developed fever after haemodialysis. She had productive cough one day ago
and vomited once. She was referred to dietitian due to poor nutrition and poor wound healing.
Patient’s body mass index was normal calculated using estimated weight and height through
observation. Patient was not oriented occasionally and not able to respond or communicate well. No
fat loss, muscle loss and edema was noted through observation. Patient was on Ryle’s tube feeding
with regime of 100 ml Novasource Renal, 40 ml water for flushing, 7 times per day (3 hourly).

Nutrition Diagnosis: Inadequate protein intake related to physiological causes increasing nutrient
needs due to sacral sore Grade 4 and end stage renal failure on haemodialysis as evidenced by
current protein intake less than recommendation (1.06 g/ kg BW).

Nutrition Intervention: New feeding regime was provided for patient to meet his nutritional needs.
Myotein was added to increase his protein intake. The new regime prescribed was 125 ml Novasource
Renal, 30 ml water for flushing, 6 times per day (3 hourly), add 1 scoop of Myotein in alternate feeding.

Nutrition Monitoring and Evaluation: To monitor patient’s tolerance towards regime.

Follow up: Patient was tolerating well with the feeding regime prescribed and continued with same
feeding regime. Discharge plan for the patient was to continue with the same regime.

Conclusion: Adequate protein intake plays an important role in promoting wound healing.

Keywords: sacral sore, protein, wound healing

32

3RD SESSION
IN-PATIENT CATEGORY (IPD)

Name : Annaafi’ Annuur Utoro

Institution : Universitas Gadjah Mada (UGM)

Title: Perforated appendicitis in pediatric patients: A case report

Background: : Acute appendicitis usually needs urgent surgery due to the risk of perforation and
contamination of the peritoneal region. The prevalence of appendicitis amongst children under 5
years old is 5% and relatively rare.

Nutrition Assessment: A six year old children presented with abdominal pain, distention, fever in the
past 8 days, constipation, nausea and anorexia. Patient was initially admitted with observation for
abdominal pain e.c. paralytic ileus. Nutritional screening indicated that patient was at risk of
malnutrition, but overall nutritional state based on BMI/Age was good (14,72 kg/m 2 ; -0,41 SD). Blood
tests showed low RBC, HGB, HCT, MCV, MCH, sodium and chloride; while WBC and Neutrophils were
increased indicating infection. Abdominal exam suggested that patient had paralytic ileus with ascites,
severe abdominal pain, distention and on NGT.

Nutrition Diagnosis: Nutritional diagnosis were inadequate enteral intake due to paralytic ileus as
indicated by 24 hour recall less than 20% energy requirements, and increased protein needs due to
infection as indicated by elevated WBC and neutrophils.

Nutrition Intervention: Patient was prescribed full liquid diet via NGT (8x30 ml) plus parenteral
infusion of KaEN 3B 1500ml/24 hour.

Nutrition Monitoring and Evaluation: Enteral nutrition intake (FH) patients will be able to meet
more than 75% of recommended nutritional needs, biochemical data (WBC, HB, HCT, MCV, MCH,
neutrophil), medical test and procedures, clinical physical, anthropometric measurements (weight
change).

Follow up: On the second day of admission, patient had worsening condition, NGT was pulled due to
inadequate intake and was changed to semi liquid diet plus parenteral nutrition. On the fourth day,
patient had emergency laparotomy, created a stoma drain and subsequently put on ventilator post-
surgery. Patient was on total parenteral nutrition for three days following surgery. Patient then
progressed rapidly from liquid diet on the fourth day post surgery meeting 50% energy requirements,
to soft diet on the sixth day meeting more than 80% requirements.

Conclusion: Paralytic ileus in this patient was caused by perforated appendicitis which then required
a laparotomy surgery with stoma drain. Due to the rapid condition and poor intake perioperatively,
patient’s nutritional status also deteriorated. Hence, a more progressive nutrition support is required
to minimize the risk of malnutrition in patients with this condition.

Keywords: Illeus paralitik, appendicitis, colostomy, pediatric

33

3RD SESSION
IN-PATIENT CATEGORY (IPD)

Name : Eileen Jong Yian Ching

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: Transitional feeding for patient with Guillain-Barré Syndrome (GBS) and resolving paralytic ileus

Background: GBS is an autoimmune demyelinating condition involving ascending weakness and
progressive paralysis. Paralytic ileus is the inability of the intestines to conduct peristalsis which can
lead to obstruction. Transitional feeding describes the process from parenteral to enteral/oral
nutrition and ceases parenteral nutrition; or enteral returns to oral nutrition and ceases tube feeding.
Patients may face difficulties transitioning from parenteral to enteral nutrition as the return of the
gastrointestinal function may be slow after a period of being nil by mouth. It will take time and effort
to get used to a normal diet.

Nutrition Assessment: A 48-year-old, Malay, male was admitted to HCTM on 4th December 2020 as
presented with fever, vomiting, on and off headache with blurring vision. He had no known medical
illness previously and was diagnosed with GBS variant Bickerstaff encephalitis, Candida Glabrata
fungemia, transaminitis, paralytic ileus 2° sepsis and hospital-acquired pneumonia. Patient was
referred to dietitian on 24th December for high protein high calorie to restart nasogastric feeding. His
estimated BMI was 24.9 kgm-2 (borderline overweight). His bowel sound was present and he was on
his last bag of TPN.

Nutrition Diagnosis: Parenteral nutrition administration inconsistent with needs related to
physiological causes where there is improvement in patient status which allowsreturn to enteral
nutrition as evidenced by access route that warrant modification due to resolving paralytic ileus.

Nutrition Intervention: The aim was to achieve at least 75% of the energy and protein requirements
through bolus feeding. Feeding regime using semi-elemental formula was prescribed.

Nutrition Monitoring and Evaluation: The feeding tolerance including GRV, gastrointestinal
symptoms, intake/output chart and bowel open frequency and consistency were monitored.

Follow up: Patient tolerated the feeding and achieved the energy and protein recommendation. His
feeding was transitioned to oral after passing swallowing test. Soft diet – mix porridge was indented.
Patient was not discharged but will be encouraged on regular diet after discharge if tolerated.

Conclusion: The ultimate goal of transitional feeding is to achieve nutritional needs with oral intake
alone. If oral nutrition is not possible while weaning from parenteral nutrition, enteral nutrition may
be indicated before transition to oral.

Keywords: Transitional feeding, Guillain-Barré syndrome, Paralytic ileus

34

4TH SESSION
IN-PATIENT CATEGORY (IPD)

Name : Wan Nuraishah binti Wan Hairil

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: Nutrition management for post operation of wound debridement of Fournier’s Gangrene.

Background: Fournier gangrene is an acute necrotic infection of the scrotum; penis; or perineum
which often occurs in the presence of other comorbidity illnesses especially those that weaken the
immune system including diabetes mellitus. The multiple surgeries must be done to remove the
infected areas. Along with the medical therapy, nutrition therapy helps the patient to obtain adequate
nutrition for recovery from surgery especially in protein intake.

Nutrition Assessment: In this case, a 55-year-old Chinese male was admitted to the emergency
department presented with scrotal swelling and pain. Upon admission, the patient was newly
diagnosed with type 2 diabetes mellitus with 10.8% of HbA1C. Patient was then performed EUA with
wound debridement of Fournier gangrene and referred to a dietitian for high protein diet post
operation. The current medical diagnosis of the patient are Fournier gangrene and necrotizing fasciitis
involving perineum, lower abdominal thigh. During assessment, the BMI is 19.05 kg/m2 and patient
reported weight loss since a month of hospital stay. Patient was allowed orally with an additional oral
nutritional supplement of immune modulating nutrients (arginine, glutamine and fish oil) for at least
14 days postoperative wound debridement.

Nutrition Diagnosis: Inadequate protein intake related to physiological causes increases needs of
protein optimization as evidenced by current estimated intake of protein of only 63% of requirement
and current condition of post operation.

Nutrition Intervention: The objectives of the intervention are to achieve optimal protein at 75% of
requirement to promote wound healing and aim for &lt;10mmol/l of blood glucose level. The principle
of dietary management is to suggest a high protein diet to provide adequate protein, provide a high
protein formula achieving 1.5g/kg body weight to promote wound healing and provide specialized
formula for DM to achieve less than 10mmol/l of blood glucose.

Nutrition Monitoring and Evaluation: Diet intake and blood glucose level.

Conclusion: In conclusion, Fournier gangrene with wound debridement may come with various
complications, in which nutrition intervention is needed to overcome. Adequate protein-energy
nutrition is therefore crucial to support recovery and reduce mortality rate.

Keywords: post operation, wound debridement, Fournier gangrene, type 2 diabetes mellitus,
glycaemic control, surgery, high protein

35

4TH SESSION
IN-PATIENT CATEGORY (IPD)

Name : Syarifah Hasanah Adeila Binti Hassan

Institution : International Medical University (IMU)

Title: The role of a dietitian in the management of enteral feeding transition

Background: The transition from tube feeding to an oral intake is a slow process as it is dependent on
the patient’s improvements in parameters of swallowing, gastrointestinal, or general function. Hence,
dietitians play an integral role in assessing the readiness of patients to wean off enteral feeds, initiate
the transition and monitor the nutritional progression of the patient.

Nutrition Assessment: MNJ, a 24 year old Malay Male, was admitted for severe traumatic brain injury
and poor GCS recovery, secondary to his motor vehicle accident 4 months prior. His initial
assessments indicated dysphagia, a failed swallowing dye test and an SGA score of severely
malnourished. His diet assessment indicated that he has been on Ryle’s Tube feeding for 4 months
and his regimen was meeting 65% of his energy and protein requirements. In the follow-up visit, with
the medical and nutritional intervention, MNJ’s GCS score and dysphagia improved, he has passed the
swallowing dye test and was transitioned to a soft diet by the doctors. His current intake was only 50%
of his energy requirement and he verbalised feelings of hunger once transitioned.

Nutrition Diagnosis: The initial diagnosis was inadequate protein-energy intake related to
inadequate enteral infusion provision as evidenced by diet recall showing intake of <75% energy and
protein requirement. On the follow up visit, the etiology was updated to limited access to food
provided by the ward.

Nutrition Intervention: The nutrition goal was to provide adequate protein and energy in order to
prevent further progression of malnutrition. On both visits, his intake was altered to meet the
requirement, whereby in the first visit the enteral regimen was adjusted, while in the follow-up, his
diet was altered to a high protein diet and he was supplemented with oral nutrition supplement.

Nutrition Monitoring & Evaluation: Components of energy and protein intake as well swallowing
abilities and tolerance were monitored, whereby MNJ had shown significant signs of improvement.

Conclusion: The integral role of dietitians is evident through this case whereby the dietitian’s
management impacted the improvement of the patient. Thus, an interdisciplinary approach at
transitional feeding is essential to minimise risk of deterioration.

Keywords: Enteral feeding, Transitional feeding, Role of Dietitian

36

4TH SESSION
IN-PATIENT CATEGORY (IPD)

Name : Balqis Sofeyya binti Mohd Zawahid

Institution : Univerisiti Teknologi MARA (UiTM)

Title: Medical nutrition therapy for burn patient

Background: Burn causes significant metabolic derangements which makes nutritional support is the
critical aspect in managing burn patients.

Nutrition Assessment: A 42 years-old, Malay female was diagnosed with 44% TBSA partial to full-
thickness burn injury over bilateral, upper limb, lower limb, face and neck. Her estimated height from
bed-height is 160 cm with bodyweight of 55 kg and BMI of 21.5 kg/m2 (normal). Biochemical data
showed low in sodium, creatinine, albumin, total protein and high in white blood cell and hemoglobin.
Patient was comfortable under room air, have a full Glasgow Coma Scale score and normal vital sign.
She completed fluid resuscitation within 48 hours. Upon assessment, the patient did wound
debridement and split skin graft. Hence, full 24-hour diet recalls unable to be obtained and diet recall
was taken only before she nil-by-mouth for the procedure and the estimation was 900kcal/day with
protein 30g/day. She reported loss of appetite since admission but improving. Patient was on PCA
morphine, intravenous tramal, cefuroxime and human albumin. She can tolerate orally but need
assistance to feed her. She was prescribed 2100 kcal/day based on Modified Schofield formula and 1.5
– 2.0 g/kg of protein.

Nutrition Diagnosis: Inadequate protein-energy intake related to decreased ability to consume
adequate protein and energy (immobile as burn involved in upper limb) as evidenced by current
energy intake of 900 kcal/day and protein intake of 30 g/day, lower than energy requirement of 2100
kcal/day and protein requirement of 82.5 – 110 g/day.

Nutrition Intervention: Primary goal for burn patient to provide adequate energy and protein to
enhance recovery. Patient was provided with high protein diet and oral nutrition supplement (ONS) of
standard formula as well as protein modular product to achieve 35% from requirement and 51% from
protein 1.5 – 2.0 g/kg/BW, providing 738 kcal/day and protein 42 g/day.

Nutrition Monitoring and Evaluation: Energy and protein intake was monitored. Patient finished the
hospital meal as well as ONS provided with assisted feeding after 8 days of admission.

Conclusion: Adequate energy and protein is crucial for wound healing, maintenance of lean
body mass, and immunocompetence besides fluid resuscitation for burn patient.

Keywords: burn, fluid resuscitation, Modified Schofield formula

37

4TH SESSION
IN-PATIENT CATEGORY (IPD)

Name : Ainaa Athirah binti Mohd Fadzil

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: A case study of nutrition care for patient with breakthrough seizure

Background: Poor nutrition status can contribute to prolong illness and malnutrition Hence, nutrition
support is important in patient who cannot achieve nutrition requirement.

Nutrition Assessment: Patient is a 59 years old Chinese gentleman. Patient admits on 16th April
2021 at Emergency Department. Reasons of admission are due to patient has episode of generalized
tonic-clonic seizure which lasted around 5 minutes. Patient had episode of vomiting after seizure.
Patient was diagnosed with breakthrough seizure secondary to suboptimal post infarct antileptic
medication. Patient has underlying disease such as diabetes mellitus, hypertension, dyslipidemia and
cerebellar and midbrain CVA in March 2021. Patient recently has history of admission to Pantai
Hospital for aspiration pneumonia and post infarct seizure. Patient’s estimated body weight is 65kg
and his height is 165cm. The body mass index of this patient is 23.8kg/m2 which is categorized as
normal.

Nutrition Diagnosis: Predicted Inadequate Energy Intake related to decreased ability to consume
sufficient energy as evidenced by patient kept nil by mouth for already 3 days.

Nutrition Intervention: Aim to achieve adequate energy and protein requirement through
nasogastric tube feeding by using bolus method

Nutrition Monitoring & Evaluation: To monitor feeding tolerance including GRV, I/O chart and bowel
open frequency and consistency, biochemical parameters (RP, LFT, FBC, Dxt), clinical data (blood
pressure).

Follow up: Patient achieved 99.75% of energy requirement and 71g protein per day. Patient was
discharge with nasogastric tube and continue on maintaining the same energy and protein intake at
home.

Conclusion: Nutritional support is important to provide nutrients to patient unable to reach their
nutritional requirement.

Keywords: nutritional status, enteral nutrition, nutrition support

38

4TH SESSION
IN-PATIENT CATEGORY (IPD)

Name : Adibah Rasikhah Amanto

Institution : Universitas Gadjah Mada (UGM)

Title: Clinical treatment of elderly patient with Covid-19 and anorexia in Yogyakarta

Background: One in two cases of death in Indonesia due to COVID-17 is experienced by the elderly.
Recent study indicated old age with several comorbidities including hypertension, diabetes, and
cardiac disease became a risk factor for hospital-death caused by COVID-19. Inadequate nutrition
which is often compromised in older people could contribute to many problems particularly catabolic
disease and also contribute to increased malnutrition. Anorexia of aging (AA) is a crucial public health
issue as defined as loss of appetite of food intake by aging. It leads to weight loss unintentionally
among seniors. According to Roy (2016), AA correlates to non-physiopathological aspects such as food
related properties which are potentially to modify. Hence, careful systemic treatment in nutrition is
very important in elderly patients.

Nutrition Assessment: Medical patient initial SL is 70 years old, female admitted with diabetic
mellitus type 2; confirmed Covid-19 in days 2, decompensated CHF, HT, pneumonia, hypertension,
High Risk Thrombosis Suspect, dyslipidemia. Currently doing medication: amlodipine.SL felt weak and
got a little stomach pain. SL has normal BMI (22,6) and had lost appetite in the week prior to
admission. Based on recall she ate less than energy requirements (40% day before admission). She
also has high glucose scores (150 mg/dl).

Nutrition Diagnosis: An inadequate oral food and beverage intake (NI1.2) related to geriatrics
anorexia (undesirable food choice) as evidenced by decreased appetite in week (calorie intake 40% of
diet history).

Nutrition Intervention: Hence patients were given intervention as a general diabetic diet providing
1500 calories. Low fat main diet given by oral three times a day with 3 snacks. Recommended fat
modification: 25%: 41,67 gr/day. Recommended carbohydrate controlled diet (60%: 225gram/day).

Nutrition Monitoring and Evaluation: We also propose monitoring daily intake and blood glucose
and cholesterol weekly. We plan monthly cholesterol and glucose measurements at the clinic in post-
treatment from the hospital.

Conclusion: However, elderly with comorbidities and frailty have once again been largely impacted
over the pandemic and should be supported with balanced nutrition intake.

Keywords: COVID-19; elderly, nutrition, anorexia of aging, immune

39

4TH SESSION
IN-PATIENT CATEGORY (IPD)

Name : Dayang Rohana binti Abg Amar

Institution : Universiti Teknologi MARA (UiTM)

Title: Nutrition management of refeeding syndrome in end stage renal failure patient

Background: Refeeding syndrome is a potentially fatal condition characterized by severe electrolyte
and fluid shifts because of a rapid reintroduction of nutrition.

Nutrition Assessment: Mr. Z is a 67 years old Malay male was diagnosed with reduced oral intake
secondary to gastroparesis with underlying diabetes mellitus, hypertension, ischemic heart disease,
and end-stage-renal-failure on continuous ambulatory peritoneal dialysis. Patient’s current weight and
height were 52kg and 1.57m which fall at BMI 21kg/m2 and experienced significant weight loss of 13%
within 6 months. The electrolytes profile were low level as well as the albumin, and high reading of
dextrose. Vital signs showed normal, but having large amount watery stools for five days
consecutively. Nutrition focus physical findings showed he was having bilateral edema, nausea, and
dysphagia as well as loss of appetite for 3 months. He was on Ryle’s tube feeding day-2 with glucose
control formula provided 26kcal/kg/day and 1.2g/kg/day of protein. The estimated intake at home was
9kcal/kg/day and 0.2g/kg/d of protein including calories from the dialysate. He never has a
consultation with a dietitian previously, thus he does not know proper nutrition for his condition. He
was on Syrup nystatin, T. GTN, allopurinol, CaCO3, Domperidone, Furosemide and Vidagliptin. The
Energy and protein requirement prescribed were 1560kcal/day (30kcal/kg) and 67.6g/day (1.3g/kg).

Nutrition Diagnosis: Altered nutrition related laboratory values (magnesium, and phosphate) related
to inadequate oral intake (in the past 3 months) as evidenced by low electrolytes (Mg: 0.56 mmol/L)
and (PO4: 0.47 mmol/L) compared to reference ranges (Mg: 0.7-1.15 mmol/L) and (PO4: 0.87-1.45
mmol/L) and history of prolonged starvation period.

Nutrition Intervention: Main goal was to provide appropriate energy and protein as well as to
improve electrolytes as patient. The feeding started with 15kcal/kg/day and escalated until
30kcal/kg/day within ten days. Consultation given on small and frequent meals daily, food to be
chewed thoroughly, fully cooked and soft meals as well as avoidance on carbonated and fizzy drinks.

Nutrition Monitoring and Evaluation: Toleration of the feeding was monitored. Patient had no more
episodes of vomiting and diarrhoea. Phosphate was improving and finally off nasogastric tube and
tolerated orally very well.

Conclusion: A gradual induction and progression of diet therapy should be considered in patients
who meet the criteria for developing refeeding syndrome.

Keywords: refeeding syndrome

40

4TH SESSION
IN-PATIENT CATEGORY (IPD)

Name : Nurul Suriani binti Mohd Rosli

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: A case study of nutrition management for ventilated-patient requiring fluid restriction

Background: In critically ill patient, fluid overload is related to increased mortality and also lead to
several complications such as pulmonary edema and cardiac failure. Thus, fluid restriction and
maintenance of nutritional status are important to prevent fluid overload and at the same time,
meeting the energy and protein requirements for the patient.

Nutrition Assessment: A 34-years old married Malay female was presented on 27th April 2021 with
tachycardia, on and off fever and headache, chest discomfort, loss of appetite and loss of weight. She
was diagnosed with Infective Endocarditis with Septic Emboli to the brain. Patient was on ventilator
and due to prolong ventilation, she had done tracheostomy on 11th May 2021. Patient also developed
hospital-acquired pneumonia (HAP) and required to restrict fluid 800ml/day due to fluid overload.
Patient is overweight with BMI of 26.8kg/m2. She had severe weight loss of 32% in approximately 6-7
months.

Nutrition Diagnosis: Excessive fluid intake related to physiological causes relates to medical
condition of HAP and fluid overload as evidence by requiring fluid restriction of 800ml/day and current
feeding providing 1820ml/day.

Nutrition Intervention: To change current feeding from Nutren Fiber to NovaSource Renal; 100ml
NovaSource Renal + 30ml flushing for 3 hourly 7 feedings which provides 1400kcal, 63.8 protein and
677ml free water meeting 100% energy requirement and 73% protein.

Nutrition Monitoring & Evaluation: To monitor feeding tolerance, I/O chart and bowel open, Renal
profile and Liver function test and Full blood count value daily.

Follow-up: Patient tolerated well with the feeding with no diarrhea or aspiration noted which
contributes to meeting 100% energy requirement and 73% protein requirement. Patient was required
to continue with the feeding regime.

Conclusion: A calorically dense product helps in managing fluid restrictions. Since this patient is on
ventilator, she is unable to take food orally and therefore are dependent on enteral nutrition for
provision of both energy and protein requirements.

Keywords: Fluid restriction, fluid overload, ventilation, enteral nutrition

41



IN-PATIENT CATEGORY (IPD)

Name : Nur Nadirah binti Jasmi

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: A case study of nutrition management of septic shock 2 ̊ left emphysematous pyelonephritis

Background: Poor oral nutrition from General Intensive Care Unit (GICU) to ward which required
feeding transition to optimise patient protein and energy intake for fastest recovery. Thus, frequent
follow up was needed to monitor patient progression and tolerance towards the feeding and recovery
progression.

Nutrition Assessment: Patient is 57- years old married female Malay diagnosed with Septic Shock 2 ̊
Left Emphysematous Pyelonephritis with underlying of Diabetes Mellitusfor 2 years and Hypertension
for 10 years. Patient other issue were AKI with metabolic acidosis, resolved atrial fibrillation and
myocardial ventilation and Resolved LGIB 2 ̊ mucosal bladder at anal canal. Patient admitted in GICU
on 17TH November 2020 and presented with abdominal pain x 2/7, associated with nausea and
vomiting (2 – 3x) but had no fever, diarrhoea, UTI, shortness of breath and chest pain. Patient was
scheduled for left kidney open radical nephrectomy surgery on 20th November 2020, Lumbar
puncture on 4th December 2020 and Tracheostomy on 6th December 2020. Patient estimated weight
and height was gained by measuring her Mid Upper Arm Circumference (MUAC), Knee height and Calf
circumference. Patient BMI was 25.6kg/m2 which was under overweight classification.

Nutrition Diagnosis: Enteral Nutrition Administration Inconsistent with Needs related to
physiological cause as evidenced by access type that may warrant modification (from pump feeding to
bolus feeding.

Nutrition Intervention: Nutrition intervention was aim to achieve 75% of patient energy and
requirement by providing 1.0g/kg body weight of protein. After reviewed by SLP, patient was safe for
oral intake and was indent soft diet, low salt diet and diabetic diet (Mix porridge) to make it easier for
patient to eat and munch the food properly. However, patient still continue with Oral Nutrient
Supplement to improve patient oral intake.

Nutrition Monitoring and Evaluation: To monitor patient tolerance towards feeding regime
everyday after the feeding had been step up, diet intake in ward after patient had taken oral intake.

Follow-up: Patient tolerating the Ryle’s tube feeding regime after being transferred from GICU ward.
Patient achieving less than 50% of the soft diet due to not have appetite. However, patient still
continue consume the oral nutrition supplement given.

Conclusion: Frequent follow up was importance in managing patient progression in tolerating the
feeding regime and tolerating the oral intake. Patient need to be reminded on why does she need to
eat and why the oral nutrition supplement was needed in order for patient understand the
importance of optimizing protein and energy intake for patient fastest recovery.

Keywords: Ryle’s tube feeding, septic shock, nutritional status, oral nutrition supplement

43

IN-PATIENT CATEGORY (IPD)

Name : Chang Sen Yeng

Institution : International Medical University (IMU)

Title: Implications of Nasojejunal Tube Feeding for Patient with Periampullary Cancer

Background: Periampullary cancer, a rare form of cancer among all gastrointestinal malignancies, is
an abnormal growth of cancer cells near the ampulla of Vater. Due to the anatomical changes, the
functions of liver, pancreas, and small intestine are often affected. The frequent nutritional
complications are maldigestion and malabsorption, leading to malnutrition. The objective of reporting
the case is to identify the appropriate nutritional care and the choice of enteral nutrition route
ensuring adequate nutrition to prevent or reduce the risk of these nutritional complications.

Nutrition Assessment: Mr. C is referred to dietitian for nasojejunal tube (NJ) feeding. He was
diagnosed with pancreatic cancer, periampullary cancer, and biliary obstruction. He had dyslipidemia
and macrocytic anaemia. His calculated BMI was 26.1 kg/m2 which is within the recommended BMI
range. He was presented with high fasting blood glucose level due to insulin insufficiency; declined
creatinine, total protein, and albumin levels due to prolonged poor oral intake; high bilirubin level due
to biliary obstruction; and low hemoglobin level due to macrocytic anaemia. Due to duodenal
obstruction, patient had to be on NJ tube feeding and was started on a carbohydrate modified
diabetes specific formula. However, feeding was withheld due to coffee ground aspiration. Hence,
intake was only 289 kcal and 12.9 g protein. Patient was able to sit up from bed with assistance due to
lethargic condition. He was not presented with any GI symptoms (aspiration, vomiting, diarrhoea,
abdominal distension) during visit.

Nutrition Diagnosis: Inadequate enteral nutrition infusion related to feeding interruption by
aspiration events as evidenced by 289 kcal of total energy intake (16% energy requirement) and 12.9 g
of protein intake (15% protein requirement).

Nutrition Intervention: Patient was prescribed with 1800 kcal/day and 85 g/day protein with a
carbohydrate modified diabetes specific formula in bolus interval feedings. The patient and caregiver
were educated on the feeding regimen and the feeding position to minimize aspiration. The nurse in
charge was also informed on the feeding regimen accordingly. However, during the subsequent visits,
feeding interruptions were not resolved.

Nutrition Monitoring and Evaluation: Patient was observed on the following: signs of feeding
intolerance; daily intake; blood glucose profile, renal profile specifically on sodium, potassium and
creatinine level, liver function test specifically on total protein, albumin, bilirubin, phosphate and
magnesium levels and full blood count.

Conclusion: According to literature, the nutritional complications may lead to malnutrition. In order to
prevent this, adequate nutrition is vital despite the physiological changes. The initiation of enteral
feeding may appears to have better clinical outcomes.

Keywords: periampullary cancer, pancreatic cancer, nasojejunal tube feeding, malnutrition

44

IN-PATIENT CATEGORY (IPD)

Name : Nur Diyana Dalila binti Hazwari

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: A case study of nutrition care for Miliary tuberculosis

Background: Miliary tuberculosis is a potentially life-threatening condition caused by dissemination of
tubercle bacilli via the blood stream. Palliative care can help in improving quality of life along by
reducing sign and symptoms that can positively affect the health outcome and healing progression.

Nutrition Assessment: A 72 years old married Malay man was diagnosed with Miliary Tuberculosis
(MTB), Provoked PE, NCNC Anemia, hyperactive delirium secondary to general medical condition, non-
oliguric AKI secondary to sepsis, Forrest 3 ulcer and degenerative disc disease with cervical
radiculopathy. Patient is on palliative case and DIL has been issued. He was referred for high protein
diet. His BMI was 21.4kg/m2 which is consider as underweight for elderly. His energy intake is has
achieve 82% of TER and protein 1.2g/kg.

Nutrition Diagnosis: Inadequate enteral nutrition infusion (NI-2.3) related to physiological causes
increasing needs due to chronic infection as evidenced by patient current intake only provide 82% of
energy and 77% of protein requirement.

Nutrition Intervention: Nutritional intervention aimed to meet energy requirement optimum to 75%
per day and protein intake of 1.3g/kg. Feeding with the regime of 250ml Glucerna RTD + 50ml flushing,
7 times/day by using Nasogastric Ryle’s Tube given to patient. Long term goals are to prevent muscle
loss and increase the rate of healing process.

Nutrition Monitoring and Evaluation: 1. To monitor feeding toleration. 2. To monitor weight
changes.

Follow-up: Patient has achieved 103% energy requirement and protein intake 1.5g/kg (97% TER).
Patient was encouraged to continue maintaining energy and protein intake.

Conclusion: Palliative care in clinical dietetic practice is a concept to manage issue that associated
with nutritional status to improve the improved the quality of life by resolving the sign and symptoms
that might be the main concern from patient’s current condition.

Keywords: Miliary tuberculosis, palliative care, nutritional status, optimization.

45

IN-PATIENT CATEGORY (IPD)

Name : Nurul Syamilah binti Abdul Razak

Institution : International Islamic University Malaysia (IIUM)

Title: Nutritional aspect of healing diabetic foot ulcers

Background: One of the serious diabetes complications that can impair the quality of life is diabetic
foot ulcers (DFU). Since DFU is a different wound from a pressure injury and may have different
nutrition considerations to prevent further infections or possibly lower extremity amputations,
therefore, it is important to highlight the pivotal role of nutrition in the treatment of DFU including the
wound healing process.

Nutrition Assessment: A 68 years old Malay woman with underlying dyslipidemia, hypertension and
diabetes mellitus was admitted to hospital for wound debridement and rays amputation 4th and 5th
toes. Patient had been referred to dietitian for high protein and diabetic diet. Patient had normal BMI
and her biochemical data (renal and liver function test) mostly showed abnormal values except for
blood glucose profile. Her vital signs were normal and GCS score was 15/15. Patient took
antihypertensive, diabetic, cholesterol and antibiotic medications. Patient had loss of appetite and
inconsistent carbohydrate intake throughout the day during admission. The range of energy and
protein requirement is 1650-1700 kcal/day and 68.8 – 82.5 g/day, respectively.

Nutrition Diagnosis: Inadequate protein-energy intake related to current condition (post-operation)
that cause patient to have decreased appetite as evidenced by current estimated energy and protein
only achieved 52% of energy requirement and 30% of protein requirement, respectively.

Nutrition Intervention: The goals are to achieve and maintain energy and protein requirement as
well as to maintain normal blood glucose profile. Energy and protein prescribed are 1600 kcal/day and
82.5 g/day (1.5 g/kg body weight). Nutrition Implementation: Encouraged patient to finish hospital diet
and supplemented intake of patient with oral nutrition support (ONS), Glucerna Chocolate and
Protegen.

Nutrition Monitoring and Evaluation: Monitor any weight changes, blood glucose profile, any sign
and symptoms especially related to intolerance towards ONS and dietary intake according to the
requirement including the frequency and amount of ONS consumption.

Conclusion: The standard nutrition treatment of diabetic foot ulcers includes the optimization of
glycaemic control, adequate calorie and protein intake as well as eliminate, prevent, delay or control
nutrition-related risk factor.

Keywords: diabetic foot ulcers, nutrition, wound healing, oral nutrition support

46

IN-PATIENT CATEGORY (IPD)

Name : Nabilla Ersya Audina

Institution : Universitas Gadjah Mada (UGM)

Title: Nutrition support in a critically Ill child with traumatic brain injury

Background: Understanding the nutrition support management in severely brain-injured patients is
essential due to the presence of enteral feeding intolerance in many cases.

Nutrition Assessment: An 18-year old male was admitted to ICU due to severe traumatic brain injury
(TBI) following motor vehicle accident. He had bilateral pneumonia, facial wounds, humeri and ulnar
fractures with no major disease history before admission. He had low albumin and PO2, and PCO2
levels. He was well nourished based on BMI/Age z-score (0,62 SD). He was hemodynamically stable,
sedated, and intubated. The 24-hour enteral nutrition (EN) intake via NGT was 600 ml (67% of the
initial target) which was affected by the gastric residue.

Nutrition Diagnosis: He had inadequate enteral nutrition infusion related to intolerance of EN as
evidenced by gastric residue, inadequate EN volume compared to the initial target. He also
experienced an increased protein need related to wound healing and infection as evidenced by
hypoalbuminemia, wounds, fracture, TBI, pneumonia.

Nutrition Intervention: The goal was to fulfill the patient’s basal energy expenditure started with
polymeric enteral nutrition (1 kcal/ml) by bolus feeding at 6x150 ml via NGT. Full feeding was targeted
at 8x250 ml. He was given 1,5 g/kg BW of protein and 30% of total energy was provided from fat to
maintain a satisfactory respiratory quotient status in a ventilated patient.

Nutrition Monitoring and Evaluation: He showed a progressive enteral nutrition tolerance from 150
ml to 250 ml for each feeding within 4 days. The gastric residue was found on day 3. Therefore, the
feeding rate was decreased back to 100 ml, then gradually increased to 250 ml on day 4. He showed
better GI tolerance that he could receive 5x250 ml enteral nutrition with free drainage. In addition,
higher PO2 and lower PCO2 were observed.

Conclusion: Progressive but not aggressive EN feeding containing 30% of fat could facilitate good GI
tolerance and better PO2 and PCO2 level in a critically ill young male.

Keywords: critical illness, traumatic brain injury, young male

47

IN-PATIENT CATEGORY (IPD)

Name : Anis Farhana Bt Roslan

Institution : Universiti Teknologi MARA (UiTM)

Title: Medical nutrition therapy in traumatic brain injury

Background: Patients with head-injury frequently have increases in metabolic rate and protein
catabolism. Thus, increase in nutritional needs.

Nutrition Assessment: A 23 years old, Malay female was diagnosed with Post-operative Day-4 left
pterional craniotomy, aneurysm clipping and right frontal external ventricular drain (EVD) insertion for
ruptured M1 aneurysm. Initially, she had a severe headache and already went to general practice and
was prescribed paracetamol 500mg QID until she fell for fit before brought up to the hospital. The
procedure of CT angiography showed ruptured left of middle cerebral artery aneurysm and
hydrocephalus. Based on knee height measurement, her estimated height is 148 cm and her ideal
body weight is 49 kg. Biochemical data showed low urea, sodium, creatinine, albumin, as well as total
protein. She was not intubated and sedated with 100% SpO2 under room air, full Glasgow Coma Scale
and blood pressure supported with inotropes intravenous noradrenaline. She was on Ryle’s tube
feeding (RTF) and already reached 71.9% of energy and 0.9g/kg of protein by using standard enteral
formula. She was at a stage of recovery and haemodynamically stable, thus prescribed with 30 kcal/kg
and 1.5g/kg of protein. She was prescribed antibiotics (cefuroxime), gastric medicine (pantoprazole)
also with an axative (syrup lactulose).

Nutrition Diagnosis: Inadequate enteral nutrition infusion related to feeding not yet optimized as
evidenced by food and nutrition related history of calorie intake 1100kcal and protein 45g less than
requirement of 1470kcal and protein 73.5g and the feeding still in progress.

Nutrition Intervention: The aim was to full fill the requirement orally with the aid of oral nutrition
supplement (ONS). Enteral and oral combination done and subsequently off the RTF as orally achieved
more than 50% from the energy requirement.

Nutrition Monitoring and Evaluation: She tolerates well with the enteral formula provided and
tube was off on day-6 of admission. However, the appetite was poor with inadequate energy and
protein and was prescribed with ONS. Patient discharge with protein modular provided on day 10 of
admission as she cannot tolerate much of protein sources of food.

Conclusion: Adequate energy and protein is important as TBI patients frequently have increases in
metabolic rate and protein catabolism.

Keywords: traumatic brain injury, nutritional needs

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IN-PATIENT CATEGORY (IPD)

Name : Kek Qi Wen

Institution : Universiti Kebangsaan Malaysia (UKM)

Title: Nutrition management of postoperative transurethral resection of bladder tumour and its
complications

Background: Poor appetite is common in cancer patients who are elderly or have gone through
cancer treatments or surgeries. Nutritional intervention may be beneficial in these patients. However,
quality research on the perioperative nutritional management of bladder cancer is limited. Further
research is required to evaluate nutritional interventions pre‐ and postoperatively in the surgical
treatment of people diagnosed with muscle‐invasive bladder cancer requiring radical cystectomy.

Nutrition Assessment: Patient is a 77-year-old Chinese woman and was electively admitted for a
transurethral resection of bladder tumour, right ureteroscopy and right distal ureterectomy with
ureter implant surgery. Patient weighed 40.7kg during admission and reported an estimated 11%
(5kg) weight loss for the past 6 months. Patient claimed to have been having a diminished appetite for
a prolonged period of time. PG-SGA was graded B with a score of 13. Currently, patient is prescribed
with low salt (soft) diet but mainly eats food brought by family members.

Nutrition Diagnosis: Chronic disease-related malnutrition related to physiological causes resulting in
diminished intake as evidenced by estimated energy intake of less than 500 kcal/day and estimated
protein intake of less than 20g/day and PG-SGA score of 13.

Nutritional Intervention: To achieve at least 75% of energy requirement and 1.5 g protein/kg/day. A
menu plan was given to educate patient on texture-, energy- and protein-modified diet.

Nutrition Monitoring and Evaluation: Patient was monitored on diet intake, renal profile, full blood
count, C-reactive protein, and vital signs within the next 24 hours.

Conclusion: Patient managed to achieve 70.4% energy requirement and 68.3% protein needs 6 days
after first seen by dietitian. Nutritional intervention is crucial in improving the nutritional status of
postoperative elderly patients.

Keywords: transurethral resection, bladder tumour, ureteroscopy, elderly, diminished appetite

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IN-PATIENT CATEGORY (IPD)

Name : Riani Witaningrum

Institution : Universitas Gadjah Mada (UGM)

Title: Nutritional therapy in post laparotomy exploratory surgery patient with anastomotic leakage: a
case report

Background: A 62-year-old woman presented to the Surgeon in April 2021 with a tumor mass on her
sigmoid colon. The patients underwent laparotomy exploratory surgery, hereinafter, admitted to
Intensive Care Unit (ICU) after hospitalized in the ward for 5 days due to anastomotic leakage. Patient
was also diagnosed with sepsis, acute kidney injury, and high output stoma product.

Nutritional Assessment: Patient experienced extremely poor dietary intake during 5 days of
hospitalization due to nil by mouth order. Upon admission to the ICU, nutritional assessment
indicated patient was well nourished, but with altered nutrition related laboratory values particularly
parameters of kidney function, abnormal blood test and arterial blood gas, and was on a ventilator
and nasogastric (NG) tube.

Nutrition Diagnosis: Nutrition diagnosis for the patient was altered gastrointestinal (GI) function
related to laparotomy surgery, as evidenced by high-output stoma product, nasogastric tube insertion,
and noted surgical procedure.

Nutrition Intervention: The goal was to provide at least 50% of calculated basal energy expenditure
(BEE) using Ireton-Jones formula, planned to gradually increase until full feeding rate, as tolerated.
Macronutrients were prescribed at 1 g/kg ideal body weight, 35% of the BEE and the remaining of BEE
for protein, fat and carbohydrate, correspondingly. A semi-elemental feed in combination with
parenteral nutrition was given for the first three days of monitoring and evaluation.

Nutrition Monitoring and Evaluation: On the first day, NG feed was started at 17 ml/hour (23% of
BEE) and increased until 25 ml/hour on the third day (55% of BEE). Patient tolerated the formula well
as indicated by NG intake over 80%. Mid-upper arm circumference measurement was constant and
biochemical data were slowly improved. Clinical findings showed stable hemodynamic status and
decreased gastric residual volume from 150 to 50 cc.

Conclusion: The comprehensive nutritional support during initiation of gastric feeds in critically ill
patient needs a cautionary step to prevent and minimize the risk of aspiration and refeeding
syndrome.

Keywords: nutrition care, anastomotic leakage, critical ill, colorectal surgery

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