個案報告 營養組 童麗霞

個案報告 Name: 林xx ID: G1003XXXXX 性別: 男   年齡: 67 y/o 入院經過：因覺無力到院治療 PH: HCV(+), CAD, Arrhythmia, DM, HTN AMI s/p stenting

檢驗報告 Head supratentorial MRI & CT Lab. data BS GPT BUN Cr. Na K APTT 1) Acute lacunar infarcts in the subcortical region of left occipital lobe 2) Old infarct in the left frontal lobe, left PCA territory and bilateral MCA territories. 3) Cortical atrophy 4) Bilateral periventricular leukoariaosis Lab. data BS (mg/dl) GPT (u/L) BUN Cr. Na (mmol/L) K APTT (sec.) 3/12 277 65 13 0.9 136 3.8 24.8

藥物 ** **** coumadin® Heparin Lescol XL Mgo Stilnox Eurodin 劑量 頻率 3/12 3/13 3/14 3/15 3/16 3/17 3/17~4/6 coumadin® 0.5# HS ** 2# Heparin 25KU MID Lescol XL 1# **** Mgo TID Stilnox Eurodin

藥物 vs 血糖(one touch) 劑量 頻率 3/12 3/13 3/14 3/15 3/16 3/17 3/17~4/6 RI TIDAC **** NPH HS Mixtard QDAC 26U 29U 32U QNAC 13U 16U ****** 3/12 3/13 3/14 3/15 3/16 3/17 AC - 230 242 287 223 215 2PC(早) 309 275 2PC(午) 251 273 2PC(晚) 268 403 271 281

營養評估 S: (by 家屬) 1)飲食習慣:(2個月前) 早餐(7:30):饅頭1個+開水 早點(10:00):蘇打/孔雀絣乾3~4片或土司2片或包子1個 午餐(12:00):飯1碗+燙青菜(醬油)+雞肉/瓜子肉2匙/魚肉3匙 午點(15:00~16:00):同早點 晚餐(17:30~18:00):同午餐 水果:時間不定,1顆柳丁或10顆左右的葡萄/天 水量:自中風後即減少喝水(<1保特瓶/D),也沒有喝牛奶的習慣 其他：偶爾給布丁或果凍(1星期/次)

營養評估 2)活動度： 自中風後覺得自己變醜了,幾乎不出門 每天約走路15分鐘,傍晚會掃掃地,偶爾作環保義工, 其餘時間多在家裡坐著看電視 3)家中血糖控制狀況: 打濁的胰島素：上午22—24單位,傍晚14單位 沒有做血糖記錄表,印象中早上空腹約為200多 

營養評估 O/A: 1) 165cm, 61Kg, IBW: 60Kg (normal) 2) Dx: DM, embolic stroke , CAD, HCV(+), HTN, left ACA 3) BEE: 1271Kcal, TER:1525Kcal 4) 一日飲食評估約1450Kcal~1600Kcal/D; 主食過量(13~14ex), 蛋白質(≦4ex).油脂(3~4ex)及蔬菜攝食量(<1ex)不足 5) 咀嚼力弱 6) 水分攝取不足/活動量不足 7) 具DM基礎認知,但觀念不完整

營養評估 P: 1) meal plain 1500Kcal/D 2) 複習DM飲食原則 低血糖處理  軟質均衡飲食原則(優質蛋白質來源/增加纖維質攝食量) 點心攝食原則 3) 鼓勵喝水(1000~1500ml/D)及增加活動量 總份數 早餐 早點 午餐 午點 晚餐 晚點 主食類 11 3 1 蛋白質類 5 2 蔬菜類 水果類 油脂類

Postprandial glucose response to Chinese foods in patients with type 2 diabetes Journal of the American Dietetic Association Volume: 104, Issue: 12, December, 2004, pp. 1854-1858 Chan, Eliza M.Y.; Cheng, Winnie M.W.; Tiu, Sau-Cheung; Wong, Lily L.L.

受測者基本資料 24位Type 2 DM pt, in Queen Elizabeth Hospital, in Hong Kong 性別: 男性19位; 女性5位 年齡: 55.3±12.5 y/o BMI: 26.8 ±4.4 DM 病史: duration of DM 38.9 ±26.3 m.o. (6 ~ 95m.o.) 飲食控制: 7人 ; 低劑量OHA HbA1C: 7.6 ±1.7% Exclude: GI disease, autonomic dysfunction

餐食類別 Meal 1A: plain porridge + lean pork Meal 1B: plain porridge + shrimp Sho Mai Meal 2A: boiled rice + boiled egg white Meal 2B: fried rice + whole egg Meal 3A: noodles in clear poup Meal 3B: pickled vegetable + pork-flavored instant bowel noodles

營養成分分析 Test food Energy (kcal) CHO (g) Fiber (g) Prot.(g) Fat (g) Meal 1A (S +瘦肉) 220 50.0 0.6 18.0 1.6 Meal 1B (S+燒賣) 286 0.7 21.3 Meal 2A (飯+蛋白) 11.7 0.3 Meal 2B (炒飯+全蛋) 251 50.3 11.8 26.4 Meal 3A (湯麵) 246 47.0 10.6 1.8 Meal 3B (醃菜+豬肉泡麵) 396 7.0 20.0

實驗設計 1)三組在A1C,年齡,duration of DM及BMI間均無差異 2) Avoid alcohol and unusall amounts of exercise for 1 day before and during the test session

流程 空腹10小時 fasting hemoglucostick value (all < 15mmol/L) intravenous cannula into forearm vein basal fasting BS give test meal & 250ml H2O (15分內吃完) 30 min intervals for up to 4 hrs after meal (120 min & 240 min after the meal calculated according to the trapezoidal rule)

統計 SPSS 11.0 fasting BS & the AUC of groups 1, 2, 3 --- use independent t test repeat –measures analysis of variance --- analyze the postprandial glycemic profiles of different test meal

Table: Carbohydrate, protein, and fat content of test meals based on the weight of the raw materials, the test portions of the foods, and data from the supplier, and fasting plasma glucose and area under the curve values after six test meals (mean±standard deviation) Test food Energy (kcal) CHO (g) Fiber (g) Prot. (g) Fat (g) Fasting glucose (mmol/L) AUC at 120 min (mmol/min/L) AUC at 240 min (mmol/min/L) Meal 1A (S +瘦肉) 220 50 0.6 18 1.6 7.5±2.2 763±1841,2 934±285 Meal 1B (S+燒賣) 286 0.7 21.3 7.4±2.0 755±197 1,018±370 Meal 2A (飯+蛋白) 11.7 0.3 6.7±1.0 558±2551 666±276 Meal 2B (炒飯+全蛋) 251 50.3 11.8 26.4 6.5±0.8 589±219 804±267 Meal 3A (湯麵) 246 47 10.6 1.8 8.1±2.9 537±1702,3 825±342 Meal 3B (醃菜+豬肉泡麵) 396 7 20 8.0±2.6 712±2473 963±410

Figure: Plasma glucose profile after test meal. (飯+蛋白) (炒飯+全蛋) (湯麵) (豬肉泡麵)

結論 postprandial glycemic response instant-noodles meal >> plain-noodles meal porridge produced > rice & noodles

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