HindawiPublishing Corporation
             International Journal of Endocrinology
             Volume2013,ArticleID679396,7pages
             http://dx.doi.org/10.1155/2013/679396
             ReviewArticle
             Transcultural Diabetes Nutrition Algorithm:
             AMalaysianApplication
                                             1                    2                     3                    4
                      ZanariahHussein, OsamaHamdy, YookChinChia, ShuehLinLim,
                                                        5                    6                      7                        8
                      SanthaKumariNatkunam, HusniHussain, MingYeongTan, RidzoniSulaiman,
                                            9                               10                      11
                      BarakatunNisak, WinnieSiewSweeChee, AlbertMarchetti,
                      RefaatA.Hegazi,12 andJeffreyI.Mechanick13
                      1 Department of Medicine, Hospital Putrajaya, Pusat Pentadbiran Kerajaan Persekutuan, Presint 7, 62250 Putrajaya, Malaysia
                      2 Division of Endocrinology, Diabetes and Metabolism, Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
                      3 Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
                      	DepartmentofMedicine, Hospital Pulau Pinang, Penang, Malaysia
                      5 Department of Medicine, Hospital Tengku Ampuan Rahimah, Selangor, Malaysia
                      6Family Medicine, Putrajaya Health Clinic, Putrajaya, Malaysia
                      7 Department of Health Care, International Medical University, Kuala Lumpur, Malaysia
                      8DepartmentofDietetics and Food Services, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
                      9Department of Nutrition and Dietetics, University Putra Malaysia, Selangor, Malaysia
                      10
                       DepartmentofNutrition and Dietetics, International Medical University, Kuala Lumpur, Malaysia
                      11Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey, Newark, NJ 07101, USA
                      12
                       Abbott Nutrition, Columbus, OH 	3219, USA
                      13
                       Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
                      CorrespondenceshouldbeaddressedtoZanariahHussein;zanariahh@hotmail.com
                      Received 27 June 2013; Accepted 27 September 2013
                      AcademicEditor:Patrizio Tatti
                      Copyright © 2013 Zanariah Hussein et al. This is an open access article distributed under the Creative Commons Attribution
                      License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
                      cited.
                      Glycemiccontrolamongpatientswithprediabetesandtype2diabetesmellitus(T2D)inMalaysiaissuboptimal,especiallyafterthe
                      continuous worsening over the past decade. Improved glycemic control may be achieved through a comprehensive management
                      strategy that includes medical nutrition therapy (MNT). Evidence-based recommendations for diabetes-specific therapeutic diets
                      are available internationally. However, Asian patients with T2D, including Malaysians, have unique disease characteristics and
                      risk factors, as well as cultural and lifestyle dissimilarities, which may render international guidelines and recommendations less
                      applicable and/or difficult to implement. With these thoughts in mind, a transcultural Diabetes Nutrition Algorithm (tDNA) was
                      developedbyaninternationaltaskforceofdiabetesandnutritionexpertsthroughtherestructuringofinternationalguidelinesfor
                      the nutritional management of prediabetes and T2D to account for cultural differences in lifestyle, diet, and genetic factors. The
                      initial evidence-based global tDNA template was designed for simplicity, flexibility, and cultural modification. This paper reports
                      theMalaysianadaptationofthetDNA,whichtakesintoaccounttheepidemiologic,physiologic,cultural,andlifestylefactorsunique
                      to Malaysia, as well as the local guidelines recommendations.
             1. Introduction                                                 anddemographicshifts,suchaspopulationagingandurban-
                                                                             ization [1, 2]. The majority of people with these conditions
             Globally, the prevalence of prediabetes and type 2 diabetes     now live in low- and middle-income countries, including
             (T2D)isincreasingasaconsequenceofsocial,epidemiologic,          manyAsiannations,wheresubstantialincreasesinincidence
             2                                                                                     International Journal of Endocrinology
             rates are anticipated by the year 2030 [2]. According to         awareness and also expanded accessibility of glycosylated
             the fourth Malaysian National Health and Morbidity Survey        hemoglobin (A1c) testing across the country. The DiabCare
             (NHMS IV) carried out in 2011, the prevalence of T2D in          Malaysia2008studyreportedameanA1cof8.66%,compared
             Malaysianadults≥30yearsofagehadrisento20.8%,affecting            with8.0%[16]in2003,ameanfastingglucoseof8.0mmol/L,
             an estimated 2.8 million individuals [3]ascomparedwith           andanelevatedmeanpostprandialglucoseof12.7mmol/Lin
             thethirdNationalHealthandMorbiditySurvey(NHMSIII),               Malaysians with T2D. Furthermore, only 22% of the patients
             whichreportedaprevalenceof1.9%in2006[].Thehetero-              achieved the glycemic target of A1c <7%, the lowest rate
             geneousnatureofAsianpopulationsgivesrisetouniqueT2D              since 1998 [15]. Data from the online registry database Adult
             features. For example, Asians tend to develop T2D at a lower     DiabetesControlandManagement(ADCM)revealedethnic
             body mass index (BMI), at younger age, and with a lower          differences in glycemic control and complication profiles
             waist circumference than Caucasians [5, 6], and their course     amongMalaysians.ChinesepatientshadthelowestmeanA1c
             ofillnessispunctuatedwithearlierchroniccomplications[7–          levels, while Malaysian Indians had the highest [17].
             9] and frequent postprandial hyperglycemia [10]. These and          Only16.%oftheMalaysianpatientsadheretothedietary
             other clinical features must be recognized and factored into     regimen provided by dietitians [20]. Interestingly, patients
             lifestyle recommendations in order to tailor management to       werefoundtoadheretotheadviceof“eatlotsoffoodhighin
             individual needs and improve the effectiveness of preventive     dietary fiber such as vegetables or oats” but found it difficult
             andtherapeutic efforts at the primary care level.                to eat five or more servings of fruits and vegetables per
                                                                              day. Self-care practices among the majority of patients with
             2. Methods and Materials                                         suboptimal glycemic control are obviously inadequate. A
             The universal tDNA template for patients with prediabetes        large proportion of Malaysian T2D patients consume four or
             and T2D was established by an international task force of        moremealsadayandmorethantwocarbohydrateportions
             experts during a two-year process that included planning         persnack[21].
             anddevelopmentalmeetings,evidencecollectionandreview,               ThecurrentMalaysiaClinicalPracticeGuidelines(CPGs)
             consensus building, and algorithm construction and face          for the managementofT2Dcontainrecommendationswith-
             validation [11]. The initial global template was designed for    out any specific reference to glycemia-targeted specialized
             simplicity, flexibility, and cultural modification. A compara-   nutrition (GTSN), that is, oral nutritional products that
             ble process was used by an appointed Malaysian task force        facilitate glycemic control and may be used as meal and/or
             to adapt the algorithm to meet the needs of practitioners        snack replacements or supplements as part of the medical
             and patients in Malaysia. The regional version emerged           nutritiontherapy(MNT)[18].Withtheincreasingprevalence
             throughthemodificationofgeneraltDNArecommendations               of prediabetes and T2D and the continued deterioration of
             to account for cultural, lifestyle, food, diet, and genetic      glycemic control among patients in Malaysia, there is a clear
             differences that exist among the Malaysian people.               need for a simple MNT algorithmic decision-making tool to
                                                                              address these issues. This paper summarizes the Malaysian
                                                                              adaptation of the universal tDNA template [11]. See Figure 1.
             2.1. PerspectivesUniquetoMalaysia. Amongthemajorethnic           Specific Southeast Asian and Asian Indian tDNA versions
             groupsinMalaysia,Indians(2.9%in2011and19.9%in2006)              have also been published [22, 23].
             hadthehighestprevalenceofT2D,followedbyMalays(16.9%
             in 2011 and 11.9% in 2006) and Chinese (13.8% in 2011 and        3. Results: Transcultural Factors for Malaysia
             11.% in 2006) [3, ]. These epidemiologic differences could     3.1. Assessment of Body Composition and Risk of Disease
             be due to the genetic makeup, diet, and cultural variants        Progression. The World Health Organization (WHO) West-
             amongthesemajorethnicgroups.                                     ern Pacific Regional Office and the International Diabetes
                 Theoverall prevalence of abdominal obesity in Malaysia,      Foundation (IDF) define overweight and obesity in Asians
             measuredbywaistcircumference,hasbeenreportedbetween                                            2              2
             55.6%and57.%[13,1].Epidemiologicstudiesinvestigating           as BMI greater than 23kg/m and 25kg/m ,respectively
             abdominal obesity in Malaysia have consistently shown an         [2]. Lower cutoff values are required for Asian populations
             ethnictrendsimilartothatseeninT2Dwithprevalencebeing             because Asians generally have a higher percentage of intra-
             highest among Indians (65.5–68.8%), followed by Malays           abdominal fat compared with Caucasians of the same age,
             (55.1–60.6%), Chinese (9.5–51.1%), and other indigenous         sex, and BMI [25]. Furthermore, Asian populations have
             groups (.9–8.3%) [13, 1]. The prevalence of abdominal        higher cardiovascular and T2D risk factors than Caucasians
             obesityisincreasedamongpatientswithT2Dandisobserved              at any BMI level [25, 26], thereby highlighting the rationale
             in 75% of T2D patients in Malaysia. Moreover, in the             for defining Asian-specific cutoff values for anthropometric
             DiabCare Malaysia 2008 study, the most recent study in an        measures.
             ongoing initiative to monitor diabetes control in Malaysia,         The Malaysian CPG for the management of obesity
                                                                                                                             2
             undesirable waist circumference was reported in a higher         categorizesoverweightasBMIof23.0–27.kg/m andobesity
             proportion of women (≥80cm in 89.%) than men (≥90cm             as BMI of 27.5kg/m2 and above [28]. Waist circumference
             in73.7%)withT2D[15].ThestudypatientswithT2D,72%of                cutoff values for abdominal obesity are 90cm for men and
                                                             2.               80cmforwomen[2].Similarly, these cutoff values are also
             whomwereobese,hadameanBMIof27.8kg/m
                 Glycemic control in Malaysia continues to deteriorate        found in the CPG for the management of T2D in Malaysia
             despite initiatives by the Ministry of Health to increase        [12] and are used as the standard throughout this paper.
                International Journal of Endocrinology                                                                                                            3
                                                                                 (1) Ethnocultural lifestyle input:
                                                                       Geographic location and ethnocultural classifications
                                                                                (2) Individual risk assessment:
                                   Family history of high-risk dietary patterns and premature cardiovascular disease, less than recommended physical activity,
                                   abnormal anthropometrics (BMI/WC/WHR over normal ranges for locale), hypertension, dyslipidemia, any cardiovascular event,
                                   any liver disease, microalbuminuria over normal range, risky alcohol intake, and any sleep disturbance, and any chronic illness
                                               Low risk                                                                             High risk
                                                                                 (3) General recommendations:
                                                                  Counseling, physical activity, and healthy eating consistent with
                                                                  current clinical practice guidelines or evidence 
                              (4) Overweight/obesity                    (5) Hypertension                (6) Dyslipidemia           (7) Chronic kidney disease
                  Physical activity consistent with guidelines;  Antihypertensive diet consistent Lipid-modifying diet                Protein restricted diet:
                  weight loss consistent with guidelines;        with sodium restriction                                        -Sodium<2,400mg/day
                  MNT consistent with guidelines;                <2.4g/day                                                      -Stage 3–5 or greater: 0.6–0.8 g/kg
                  GTSN caloric supplementation or                                                                                with adequate energy intake
                  replacement consistent with options and                                                                        (30–35 kcal/kg/day)
                  strategies 
                                                                              (8) Follow-up evaluation (1–3 months):
                                                                  History, physical (anthropometrics, blood pressure); chemistries
                                                                  (glucose, A1c, lipids, urinary albumin/creatinine, and liver enzymes);
                                                                                            urinalysis
                                                                      At goal                                      Not at goal
                                                      (9) Maintain physical activity and MNT         (10) Intensify physical activity and MNT
                                                        See text and tables throughout this report for additional information and clarifications
                                            Figure1: Transcultural Diabetes Nutrition Algorithm (tDNA): Malaysian application.
                3.2. Physical Activity in T2D Management. Physical activity                 A1c levels <7% [36]. A lifestyle intervention that includes
                andexercisehavebeenshowntolowerbloodglucoselevels,                          MNTwasfoundtobeeffectiveinpreventingordelayingthe
                improve glucose and insulin utilization, and improve carbo-                 development of T2D in middle-aged Japanese patients with
                hydratemetabolism[29,30].Benefitsofphysicalactivityhave                     impairedglucosetolerance [0, 1].
                been demonstrated in both Caucasian and Asian patients                          TheMalaysianDietitians’Association(MDA)hasformed
                with T2D [31–3]. The Malaysian CPG for the management                      an expert committee, comprising dietitians from primary
                of T2D recommends physical activity as an integral feature                  care,hospitals,andacademia,tocomposeMNTrecommen-
                in every stage of T2D management[12].Theserecommenda-                       dations for T2D. The first version was published in 2005 [2]
                tionsareechoedintheMalaysiantDNAapplication(Table 1).                       and updated in 2013 [3]. Building on the MNT guidelines
                                                                                            recommended by the MDA, the Malaysian CPG for the
                                                                                            management of T2D, and taking into consideration similar
                3.3. MNT and Weight Loss in T2D Management. MNT plays                       Malaysian CPGs for hypertension and dyslipidemia, this
                an integral role in T2D management and indeed is rec-                       panelrecommendsthenutritionalconsiderationsoutlinedin
                ommended by the American Diabetes Association as an                         Table 2 [12, 18, 19].
                importantcomponentofindividualweightlossprogramsfor                             Weight loss is an important therapeutic objective for
                T2Dpatients [35]. The benefits of MNT on glycemic control                   T2D patients to reduce insulin resistance. Moderate weight
                in Asians with prediabetes and T2D have been demonstrated                   loss of just 5–10% of body weight in patients with T2D
                in clinical trials [36–39]. On-site registered dietitian-led                has been shown to decrease insulin resistance and improve
                management of MNT has been shown to improve glycemic                        other metabolic risk factors [38, , 5]. GTSN formulae
                controlinpoorly-managedpatientswithT2Dinprimarycare                         are a component of MNT that contain nutrients to facilitate
                clinics in Taiwan. Patients with A1c levels ≥7% who received                weight management and glycemic control. These formulae
                on-site diabetic self-managementeducationhadsignificantly                   are available in Malaysia and may be utilized with nutritional
                greater improvements in fasting plasma glucose and A1c                      counselingasmealand/orsnackreplacementsforoverweight
                levels after one year than control subjects or subjects with                and obese patients and those with suboptimal glycemic
                                                                                                                       International Journal of Endocrinology
                Table 1: Physical activity guidelines for the management of type 2             3.	. Nutritional Management of Patients with Concomitant
                diabetesa [12].                                                                Hypertension, Dyslipidemia, and/or Chronic Kidney Disease
                                                          Exercise 5days a week with           (CKD). Data from the ADCM’s online registry database
                                                          nomorethan2consecutive               showed that as many as 57% of the Malaysian patients with
                                          Frequency       days without physical                T2Dexperience concomitant hypertension [6]. Among the
                                                          exercise                             ethnic groups in Malaysia, more Malay patients (62.3%)
                                                          (i) Moderate-intensity               have concomitant hypertension than Chinese (19.6%) or
                                                          activities include walking           Indian(17.0%)patients.InpatientswithT2D,hypertensionis
                                                          downstairs, cycling, fast            defined as blood pressure >130/80mmHgontworeadings2-
                                                          walking, doing heavy                 3weeksapart[12].Pharmacotherapyforhypertensionshould
                                                          laundry, ballroom dancing            be initiated in patients with T2D when the blood pressure is
                                        Intensity and     (slow), noncompetitive               persistently >130mmHgsystolicand/or>80mmHgdiastolic
                 All patients                type         badminton,and                        [12]. For patients with concomitant hypertension, salt intake
                                                          low-impactaerobics                   should be restricted to <6g/day (sodium 2g) [18].
                                                          (ii) Vigorous activities
                                                          include jogging, climbing                The ADCM also revealed that as many as 38% of the
                                                          stairs, football, squash,            patients with T2D in Malaysia suffer from concomitant dys-
                                                          tennis, swimming, jumping            lipidemia [7]. Malays were more likely to have uncontrolled
                                                          rope, and basketball                 low-density lipoprotein cholesterol (LDL-C) and triglyc-
                                                          150minperweekof                      erides comparedwithChineseandIndians;however,Indians
                                                          moderate-intensity aerobic           weretwiceaslikely to have inadequate high-density lipopro-
                                          Duration        physical activity and/or at          tein cholesterol compared with Malays [7]. A recent study
                                                          least 90min per week of              that investigated the ethnic differences in lipid metabolism
                                                          vigorous aerobic physical            among Malaysian patients with T2D demonstrated that
                                                          activity
                                                          Gradually increase physical          Malayshadsignificantlyhigherserumlevelsofglycoxidation
                 Overweightorobesepatients                activity to 60–90minutes             and lipoxidation products compared with those of Chinese
                 (BMI>23)                                 daily for long-term major            andIndianpatients[8].ForT2Dpatientswithdyslipidemia,
                                                          weight loss                          lifestyle modification focusing on the reduction of saturated
                BMI:bodymassindex.                                                             fat (<7% of total calories), trans fat (avoid), and choles-
                aPatients should be assessed for complications that may preclude vigorous      terol (<200mg/day) intake has been recommended [12, 19].
                exercise. Age and previous physical activity level should be considered.       In accordance with the Malaysian CPG for dyslipidemia,
                                                                                               patients over the age of 0 without overt cardiovascular
                                                                                               disease (CVD) should be treated with lipid lowering drugs,
                Table2:Nutritionguidelinesforthemanagementoftype2diabetes                      regardlessofthebaselineLDL-Clevels,whileallpatientswith
                [12, 18, 19].                                                                  overt CVD, irrespective of age, should be treated with lipid
                                   Foroverweightandobeseindividuals,areduced                   lowering drugs [19].
                 Calories          caloriedietof20–25kcal/kgbodyweightis                           ForT2DpatientswithconcomitantCKD,limitedprotein
                                   recommendedtoachieveaweightlossof5–10%                      intake and daily sodium <200mg are recommended. For
                                   of initial body weight over a 6-month period                those with CKD stages 3–5, daily protein should be limited
                 Carbohydrate      5–60%dailyenergyintake                                     to 0.6–0.8g/kg in a diet with adequate energy intake (30–35
                 Protein           15–20%dailyenergyintake                                     kcal/kg/day) [9].
                 Fat               25–35%dailyenergyintake
                 Saturated fat     Less than 7% of total calories                              4. Conclusions
                 Cholesterol       Less than 200mg/day
                 Fiber∗            20–30g/day                                                  The following recommendations, statements, figures, tables,
                 Sodium            <2,00mg/day                                                and graphs represent the conclusions of the Malaysian tran-
                ∗Should be derived predominantly from foods rich in complex carbohy-           scultural Diabetes Nutrition Algorithm (tDNA) task force
                drates including grains (especially whole grains), fruits and vegetables.      and constitute the current Malaysian tDNA application,
                                                                                               whichaccommodateslocaldifferencesinlifestyle,foods,and
                                                                                               customs and incorporates established local Clinical Practice
                control, including persons with high insulin requirements.                     Guidelines(CPGs)tomeettheneedsandpreferencesoftype
                These formulae are also indicated as a supplementary nutri-                    2diabetes (T2D) patients in Malaysia.
                tion for patients with diabetes and acute concurrent illness
                whoareunabletomaintainoptimalnutritionduetoreduced                             Recommendation 1. Medical nutrition therapy (MNT) is an
                appetite and calorie intake. Recommendations for the use of                    integral component of the management of T2D and must
                meal replacements will be incorporated in the revised MNT                      be prioritized in view of poor glycemic control among
                guidelines from the MDA.                                                       patients in Malaysia. Individualized care plans are essential