Protein-energy malnutrition is prevalent in 65% of Malaysian haemodialysis patients based on serum albumin concentrations of less than 40 g/L and body mass index (BMI) of less than 25 kg/m². Malnutrition leads to increased risk of morbidity and mortality in dialysis patients. This study tested the effects of oral whey protein supplementation on nutritional status, Dialysis Malnutrition Score (DMS), quality of life (QOL) scores using the SF36 questionnaire, and physical function (assessed via handgrip dynamometer, back-leg-chest dynamometer, tandem walk and step test) in chronic haemodialysis patients. A total of 82 malnourished haemodialysis patients with mean age of 50 ± 14 years were recruited from two haemodialysis centers in Hospital Kuala Lumpur and Hospital Serdang and were randomized into intervention (n=41) and control (n=41) group. The intervention group was given dietary counselling plus whey protein supplement consisting of 30 g of protein and 129 kcal of energy while the control group received only dietary counselling over the 6 months period. In the intervention group, serum albumin increased significantly after 3 months (7 ± 2%; p=0.010), but it was not sustained after 6 months of supplementation (4 ± 2%, p=0.560). Dietary protein intake improved significantly after 6 months (0.5 ± 0.1 g/day, p<0.001) with lesser increase in energy intake (0.1 ± 0.0 kcal/day, p=1.000). The intervention patients also showed significant improvement of SF36 scores, which increased by 16 ± 7%; p=0.050 at the first 3 months of supplementation and continued to increase by 22 ± 7%; p=0.003 after the 6 months of supplementation. The weight and BMI in the intervention group decreased significantly by 1.4 ± 0.5%; p=0.008 and 1.3 ± 0.5%; p=0.027 respectively after 6 months of supplementation. This was probably influenced by increased levels of extracellular fluid over the 6 months (7.3 ± 3%, p=0.041), resulting in higher fluid extraction in these patients. There were no significant changes in body composition and DMS scores after supplementation. The control group had a similar increase of serum albumin at 3 months of the study (8 ± 2%; p<0.001), but the increase was also not sustained over the 6 months (5 ± 2%, p=0.031). Weight and BMI increased in the control group by 0.7 ± 0.5%; p=0.982 and 1.4 ± 0.6%; p=0.027 respectively but this was probably due to fluid changes as there were no significant changes in body composition. The controls had a slight improvement of dietary energy intake (0.1 ± 0.1 kcal/day; p=1.000) and dietary protein intake (0.1 ± 0.1 kcal/day; p=1.000) but these improvements were not significant over the 6 months. The control patients had a decline (-3 ± 3%, p=0.567) in the SF36 scores after the 3 months but after the 6 months of the study, these patients significantly improved their SF 36 scores (12 ± 4%; p=0.011). Measurements of physical functions in both intervention and control groups did not change significantly over the 3 and 6 months period. No significant difference was seen between groups for serum albumin, body composition, DMS, SF36 and physical function measurements over the 6 months. Dietary protein intake however, was significantly higher in the intervention group (70.7 ± 16.6 g) comparing to control group (53.4 ± 14.6 g); p<0.001 over the 6 months. In conclusion, whey protein supplementation conferred benefits to improve nutritional status of haemodialysis patients but was not sustained after 3 months compared to dietary counselling.

Background: The Transcultural Diabetes Nutrition Algorithm (tDNA) was developed and validated by an international task force of independent diabetes and nutrition experts (Mechanick et al., 2012). The algorithm was culturally customised by local experts in Malaysia to suit our local populations (Zanariah et al., 2013). The tDNA aims at guiding primary care providers to recommend a healthy lifestyle intervention in a primary care setting based on initial risk evaluation. The tDNA recommends medical nutrition therapy (MNT), consisting of natural foods, a diabetes-specific formula, and increased physical activity, according to the algorithm based on initial body weight, glycated haemoglobin (HbA1c), exercise capacity and cardiovascular risk factors. Additionally, motivational interviewing counselling (MI) was included to facilitate positive behaviour changes in most lifestyle weight loss interventions. This study investigated the effectiveness of structured lifestyle intervention based on tDNA care with MI counselling compared to conventional counselling (CC) in overweight/obese T2DM patients in an outpatient clinical setting. Methodology: Two hundred and thirty overweight/obese T2DM patients, with HbA1c >7% and not treated with insulin, were randomised into tDNA care (n=115) and usual care (UC) (n=115). Patients in the tDNA group followed MNT consisting of a structured low calorie meal plan using natural foods, incorporation of diabetesii specific formulas as meal replacements, and exercise prescription of 150 min/week. Patients in the tDNA group also received either MI counselling (tDNA-MI) (n=58) or conventional counselling (tDNA-CC) (n=57). The UC group received standard dietary and exercise advice using conventional counselling. The main outcomes of the study were changes in weight and HbA1c. This study was carried for duration of 12 months. Results: At 6 months, body weight decreased significantly more in the tDNA-MI group (-6.9 ± 1.3 kg, p<0.001) than the tDNA-CC group (-5.3 ± 1.2 kg, p<0.001) and UC group (-0.8 ± 0.5 kg, p=1.000). Similarly, HbA1c decreased significantly more in tDNA-MI group (-1.1 ± 0.1%, p<0.001) than the tDNA-CC group (-0.5 ± 0.1%, p=0.001) and UC group (-0.2 ± 0.1%, p=0.260). Fasting plasma glucose decreased significantly in tDNA-MI group but remained unchanged in tDNA-CC and UC groups (tDNA-MI: -1.1 ± 0.3 mmol/L, p=0.011 vs. tDNA-CC: -0.6 ± 0.3 mmol/L, p=0.951 vs. UC: 0.1 ± 0.3 mmol/L, p=1.000). Similarly, waist circumference decreased in the tDNA-MI group but remained unchanged in tDNACC and UC groups (tDNA-MI: -4.0 ± 1.1 cm, p=0.002 vs. tDNA-CC: -2.7 ± 1.0 cm, p=0.064 vs. UC:-0.5 ± 0.5 cm, p=1.000). Percentage body fat decreased significantly in tDNA-MI group (-1.3 ± 0.4%, p=0.002) and tDNA-CC group (-1.5 ± 0.5%, p=0.017) but unchanged in the UC group (0.4 ± 0.3%, p=1.000). The systolic blood pressure decreased significantly in tDNA-MI and tDNA-CC groups but unchanged in the UC group (tDNA-MI: -9 ± 2 mmHg, p<0.001 vs. tDNA-CC: -9 ± 2 mmHg, p=0.001 vs. UC: -1 ± 2 mmHg, p=1.000). The diastolic blood pressure decreased significantly in tDNA-CC group (-6 ± 2 mmHg, p=0.008) but unchanged the tDNA-MI group (-3 ± 1 mmHg, p=0.566) and UC group (-1 ± 1 mmHg, iii p=1.000). Lipid profile was unchanged in the tDNA-MI and tDNA-CC groups, but the UC group had significant reduction in total cholesterol (-0.3 ± 0.1 mmol/L, p=0.001) and low-density lipoprotein cholesterol (-0.26 ± 0.07 mmol/L, p=0.005). Dietary energy, carbohydrate, protein and fat intake decreased significantly more in the tDNA-MI group (-574 ± 43 kcal, p<0.001; -69.5 ± 6.0 g, p<0001; -25.8 ± 2.4 g, p<0.001; and -21.9 ± 2.1 g, p<0.001, respectively) than tDNA-CC group (-458 ± 47 kcal, p<0.001; -56.4 ± 6.5 g, p<0.001; -18.5 ± 2.6 g, p<0.001; and -17.8 ± 2.3 g, p<0.001, respectively) and UC group (-171 ± 46 kcal, p=0.002; -25.1 ± 6.7 g, p=0.002; -3.6 ±1.9 g, p=0.586; and -6.1 ± 2.1 g, p=0.031, respectively). Exercise improved significantly in the tDNA-MI but unchanged in tDNA-CC and UC groups (tDNA-MI: 188 ± 16 min/week, p<0.001 vs. tDNA-CC: 149 ± 14 min/week, p=0.471 vs. UC: 106 ± 14 min/week, p=1.000). At 12 months, weight loss sustained significantly in the tDNA-MI group (-5.8 ± 1.3 kg, p<0.001) but not in the tDNACC group (-3.3 ± 1.2 kg, p=0.086) and UC group (0.5 ± 0.6 kg, p=1.000). Similarly, significant decrease in HbA1c retained in the tDNA-MI group (-0.5 ± 0.2%, p=0.006) but not in the tDNA-CC group (0.1 ± 0.2%, p=1.000) and UC group (0.02 ± 0.1%, p=1.000) at 12 months. Conclusion: Lifestyle intervention that includes structured MNT and physical activity following customised tDNA care was effective in achieving and sustaining weight loss, lowering of metabolic outcomes and dietary intake and improving exercise levels in this study. Motivational interviewing delivered by dietitian can enhance outcomes in patients with overweight/obesity with T2DM following intervention with structured MNT, such as the tDNA.