Anny Xiao Week 4 Endocrinology Day 1 & 2

Yesterday morning we met with the nutritionist who provides nutrition education in the outpatient department and she gave us a general overview of the information she teaches diabetes patients:

Limit daily calorie intake according to weight and BMI:
Normal weight BMI </=24: weight (kg) x 27 kcal
Overweight BMI >25: weight (kg) x 25 kcal

Limit carbohydrates to 4 portions per meal:
Each portion = 15g (same as what is taught in diabetes education classes in the US) but instead of emphasizing this, the nutritionist had many plates of plastic food to demonstrate portion sizes, which I thought was an effective way to help patients remember how many portions are in each type of food. For example, 1 bowl of rice = 4 portions of carbs, 1 bowl of noodles = 2 portions, 1 piece of toast = 2 portions. The nutritionist said that many Taiwanese patients eat too much rice and noodles, which causes high blood sugars.

Plastic food displayed on plates to demonstrate portions

Limit grains as well as rice:
Taiwanese people like to mix grains such as barley, oats, purple rice, brown rice and etc into their white rice to make mixed grain rice, and many think of these grains as healthy, so they tend to eat more of these, but the nutritionist advises them that these grains are also carbohydrates and should be included when considering the 4 portion limit of carbohydrates.

Limit fruits to 2 portions/day:
1 portion = 12 grapes, 1 small guava or mango,1 large kiwi, 1/2 banana. Many patients like eating fruit and eat lots of it without realizing its effect on their blood sugar, so the nutritionist has to teach patients about limiting sugar intake from fruit.

Limit milk to 1 cup per day
Commercially advertised milk meal supplement for diabetics is popular among diabetes patients in Taiwan. The milk contains sugar from lactose and maltodextrin but because of the high fat content, it does not cause a blood sugar spike after consumption. This is often used by elderly patients who can't chew as well as a meal replacement, but the nutritionist must teach them that 1 serving/can does not provide adequate calories for an entire meal (only provides 250kcal out of the recommended 500kcal/meal) so patients should eat rice or noodles with it if they are elderly and experience weight loss after using this as a meal replacement.

Encourage eating as many vegetables as they can, particularly steamed and boiled veggies. 2-3 portions/meal is recommended, with each portion being about the size of one's hand when laid flat on a plate.

Recommended protein intake = 1g protein for each kg of body weight. If the patient also has CKD, the recommended daily protein intake is 0.8g protein/kg body weight.
2-3 portions/meal is recommended, with each portion being about a 3 finger width piece of meat, fish or soybean product.
1 chicken drumstick = 2 servings

Encourage exercise 5 days/week: 30 min/day of walking for elderly patients, 1 hr/day running for younger patients

Encourage water intake 2L/day, limit alcohol and sweets as much as possible

In general, the information provided to patients is very similar to what is taught in diabetes education classes in the US, but tailored to the dietary conventions & habits of Taiwanese patients.

Today, we were with Director Liao as he examined patients using thyroid ultrasound and performed fine needle aspiration (FNA) on thyroid nodules. He explained that three things are looked at when evaluating the thyroid: size (normal, enlarged or atrophied), nodules (none, single or multiple) and function (euthyroid, hypothyroid or hyperthyroid). All the patients we saw today were ones referred for some type of nodular goiter, with or without abnormal thyroid lab results. When a patient presents with a nodule on ultrasound, a FNA is usually indicated. Dr. Liao explained to us that at this hospital they rarely do ultrasound-guided FNA, which is more often done at a larger medical center. An US-guided biopsy is indicated when a normal FNA result is nondiagnostic and malignant papillary thyroid cancer needs to be ruled out. I was surprised to discover that local anesthetic is not used for the FNA, which is done by palpating for the nodule, inserting the needle into the nodule and rotating the needle several times before pulling up on the syringe to extract enough cells. Performing the ultrasound and FNA procedure was extremely quick and patients were efficiently scheduled for follow-up appointments in the outpatient department to discuss the FNA findings.

One interesting patient we saw was a 49yo woman with a past history of thyroidectomy at age 13 but because she was so young at the time, she wasn't sure what her diagnosis was. Dr. Liao explained that it would be difficult to find this information since it occurred 36 years ago. The patient was referred for a recurrence of a nodule, which needed a FNA. She had a visible goiter on her neck and when asked to swallow, movement of the nodule could be seen. Dr. Liao told us that a thyroid nodule will move when the patient swallows while an enlarged lymph node will not. He also informed us that prior to the time of her thyroidectomy, iodine had not yet been introduced into table salt so it is likely that she had iodine deficiency thyroiditis. Iodine was incorporated into salt about 30 years ago and iodine deficiency thyroiditis has since become very rare.