Metabolic Syndrome and Dietary Guidelines for its prevention

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Metabolic Syndrome and Dietary Guidelines for its Prevention

Rekha Sharma, R.D. President , Indian Dietetic Association Director, Clinical Nutrition and Dietetics Diabetes Foundation (INDIA) Former Chief Dietician ,AIIMS, New Delhi

Ms. Rekha Sharma has more than 30 years of experience in the field of Nutrition and Dietetics. Worked at Boston hospital for women, USA and All India Institute of Medical sciences New Delhi as a Chief Dietician.

Written several books including “Diet Management” published 4th edition by Elsevier in 2011 and “Diabetes and its Dietary management” 3rd edition published by BI publications in 2011. Technical content for “Nutritional Therapy Guidelines in clinical practice” - Handbook for physicians , dieticians and Nurses- Published by Directorate General of Health Services , Ministry of Health and Family Welfare , Govt of India – 2008.

Have been a recipient of many awards namely WHO fellowship to Johns Hopkins Medical Institution, USA and Joslin Diabetic center, Boston USA. Distinguished service and Professional achievement award by Indian Medical Academy of Medical Specialties; lady Irwin College and Geriatric society of India.

Have been invited as a visiting scientist to many prestigious institutions in India and abroad including Mayo Clinic, USA.

Rekha SharmaNational President , Indian Dietetic AssociationDirector , Clinical Nutrition & Dietetics , Diabetes Foundation

AGENDA

SECTION I – Introduction

SECTION II – Metabolic Syndrome

SECTION III – Consensus Dietary Guidelines

SECTION IV - Conclusion

Questions and Answers

Introduction

In India, we are facing the dual burden of malnutrition, namely chronic energy deficiency (CED) and obesity.

Increasing urbanization and improvements in economic development has led to over-nutrition and sedentary life styles.

Obesity ,Hypertension ,Diabetes and coronary artery disease are like a rising inferno in India ,especially in urban areas leading to Metabolic syndrome.

Prevalence of Obesity

WHO: Incidence of obesity in India - 9%, concentrated in urban areas .Steady growth of the relatively affluent urban middle class is now estimated to be over 200million.100 million are upper middle class,50million over weight subjects.

World Health Report: Excess weight attributes globally to approximately 58% of diabetes, 21% of heart disorders and 8-42% of certain cancers.

World Health ReportExcess weight attributes globally to

Prevalence of CHD

WHO

Disease burden of CHD

Hypertension is16%

Prevalence of Diabetes

IDF-51 million in 2010 (urban - 7%-12%)

87 million by 2030(8.4% increase)

WHO data

Urban India 8/10 deaths are due to NCD’S

Rural India 6/10 deaths are due to NCD’S

Incidence of obesity & related disorders

Age Percentage SourceYoung Women (18 – 25 years)

13.2% Delhi, DST Trial 2000

Urban slum ( 35 years)

40.2% European Journal of Clinical Nutrition (2001)

Urban Slum (30-60 years) 28.2% Delhi, 2002 DST Trial

Post menopausal (52 years) 62 % Delhi, DBT trial 2006

Hyperlipidemia Cholesterol > 200 mg 47%

Diabetes Blood Sugar >126 mg 4 %

Osteoporosis (T-score < -2.5) 22%

4,621( >35 years) Overweight Urban Areas

64 % DST trial in 6 cities ,2009

Hypertension >140/90 mm Hg 50%

Hyperlipidemia Cholesterol > 200 mg 25%

Diabetes Blood Sugar >126 mg% 3 - 14 %

Incidence of obesity& related disorders Young Women (18 – 25 years)= 13.2% Delhi, DST Trial 2000 Urban slum ( 35 years) = 40.2% European Journal of Clinical Nutrition (2001) Urban Slum (30-60 years) = 28.2% Delhi, 2002 DST Trial

Post menopausal (52 years) = 62 % Delhi, DBT trial 2006

Hypertension >140/90 mm Hg = 43% Hyperlipidaemia Cholesterol > 200 mg = 47% Diabetes Blood sugar >126 mg% = 4 % Osteoporosis (T-score < -2.5) =22% 4,621( >35 years) overweight urban areas = 64 % DST trial in 6

cities ,2009

rural areas = 36 % Hypertension >140/90 mm Hg = 50% Hyperlipidaemia Cholesterol > 200 mg = 25% Diabetes Blood sugar >126 mg% = 3 - 14 %

AGENDA






Metabolic Syndrome

Metabolic syndrome (also known as syndrome X or insulin resistant syndrome) is a cluster of conditions that often occur together. It includes obesity, high blood pressure, high triglycerides and insulin resistance, which can lead to cardiovascular diseases.

Clustering of any of the above three factors is termed metabolic syndrome

Risk Factors WHO NCEP, ATP III Asian Indians*/IDF

1.Fasting plasma glucose --- ≥ 100 mg/ dL ≥ 100 mg/ dL

2.Abdominal obesity• Waist circumference

• Body mass index

• Waist hip ratio

> 102/94 cm - Men

> 88/80 cm -Women

> 25 kg/m2

> 0.90 -Men

> 0.85 -Women

> 102 cm -Men

> 88 cm -Women

---

> 90 cm -Men

> 80 cm -Women

> 23 kg/m2

> 0.9 -Men

> 0.8 -Women

3.Dyslipidemia• Triglyceride

4. High-density lipoprotein

cholesterol

> 150 mg/dL

< 35 mg/dL -Men

< 30 mg/dL -Women

≥ 150 mg/dL

< 40 mg/dL -Men

< 50 mg/dL -Women

≥ 150 mg/dL

< 40 mg/dL -Men

< 50 mg/dL -Women

5.Blood pressure

*Misra etal JAPI 2009

≥ 140/ ≥ 90 mmHg ≥ 130/ ≥ 85 mmHg > 130/ > 85 mmHg

Clinical diagnostic criteria for Metabolic Syndrome

Diet, Physical Activity & Risk FactorsDIET

Obesity

Physical activity

HyperlipidemiaDiabetes

Hypertension Coronary Artery Disease

Smoking

Stress

Transition in Dietary Habits Carbohydrates from whole grains are being

replaced by refined products Carbohydrates are also being replaced by

unhealthy fats specially by SFA and Trans Fats

Fiber, MUFA & N3 content of the diets is reducing.

Traditional foods are being replaced by modern refined foods

Increase in sedentary life styles and there is lack of physical activity

All leading to increased incidence of Obesity ,Metabolic syndrome, DM, & CHD

Scientific data shows

Lower intake of monounsaturated fatty acids (MUFA),

Low ratio of n-6/n-3 fatty acids, High ratio of polyunsaturated and saturated

fatty acids, a high intake of erucic acid, low consumption of fibre and vitamin E intake Even when mean body mass index (BMI) is in

a low range ,%BF is high and a high prevalence of abdominal obesity also in both males and females

High prevalence of hypercholesterolemia, hypertriglyceridemia and low levels of high-density lipoprotein cholesterol(HDL)

Components of Good Health and Lifestyle that We Can Control

Nutrition – Diet Physical activity - Exercise Behaviour modification / Stress

management

Dietary factors often over ride genetic factors in Asian Indians for

Obesity ,Insulin resistance, Metabolic Syndrome & Type II DM

The Problem

AGENDA






“Consensus Dietary Guidelines for Healthy Living and Prevention of Obesity,

Metabolic Syndrome, Diabetes, and Related Disorders in Asian Indians”

Diabetes Technology & Therapeutics , 2011

Energy Recommendation: Adequate to maintain ideal weight and health in

adults and growth in children. Type of activity profile (sedentary, moderate and

heavy) Age, gender and physiological status Ideal body weight should be aimed to maintain a

body mass index (BMI) between 18-23 kg/m2

Energy Recommendations

For example an Asian Indian man with medium frame, 165 cm tall

should weigh 62 kg (sedentary) would require 1850 K calories to maintain healthy weight. (62 x 30 =1860)

Energy Requirement (Kcal/Kg IBW/day)

Activity Obese Normal Underweight

Sedentary 20-25 30 35

Moderate 30 35 40

Heavy 35 40 45-50

Carbohydrates and fiber

The carbohydrate intake should be approximately 50-60% of total calorie intake. The quantity and quality of carbohydrate is important

Complex carbohydrates should be preferred over refined carbohydrates

Low Glycemic index (GI) carbohydrate foods should be preferred

Root vegetable should be consumed in moderation as they have a high glycemic index

Carbohydrates and fiber The total dietary fibre recommended is 25 to 40

g/day A minimum of five servings of vegetable and

fruit/day i.e. approximately 400-500 gms per day with at least 3 vegetable and 2 fruit portions.

Fruits should be eaten whole preferably with the skin whenever feasible instead of fruit juices.

The cereal, pulse, vegetable, salad and fruit group includes foods which are evidently higher in dietary fibre.

Simple sugars like direct sugar, sugarcane juice, sweetened carbonated beverages, fruit juices with added sugar and sugar syrups should be avoided.

Fiber and complex carbohydrates

Whole grains and pulses Vegetables & Fruits - All colours Nuts and seeds

Mediterranean diet :Good quality fat , low in energy and high in fiber, high in fruits ,vegetables, & whole grains gives

CHD reduction by 80 %Stroke reduction by 70 %T2DM reduction by 90 %

Willett 2006

Proteins

Protein intake is based on body weight. Normal adults, 1 g/kg/day, with mixed protein sources. OR

10–15% of the total calories/day for sedentary to moderately active individuals.

Recommended protein sources:

a. Non-vegetarian: egg white, fish, and lean chicken.

b. Vegetarian: soy, pulses, whole grams ,low fat milk, products like curds and cheese.

Fat Recommendations

Total fat not more than 30 % En SFA’s not more than 10% SFAs should be < 7% of total energy/day. If

LDL cholesterol of ≥ 100mg/dl, Essential PUFAs , LA (n6) should provide 5-

8% of total energy/day ALNA(n3)should be 1-2 % of total

energy/day. Optimal ratio of LA/ALNA(n6/n3) should be

5-10.

Fat Recommendations

Long chain n-3 PUFAs should be obtained from fish.

Cis MUFAs should provide 10-15% of total energy/day.

TFAs should be <1 % of total energy/day. Cholesterol intake should be limited to 200-

300 mg/day.

Fats

Saturated fatty acids (SFA) LDL, CholesterolMonounsaturated fatty acids (MUFA)(Oleic acid)When substituted for SFA LDL with no VLDL TG

Polyunsaturated fatty acids (PUFA)Linoleic acid (LA) n6 LDL (Upto 12 En %) > HDL

Alpha Linolenic acid (ALNA) n3 TG

LDLTrans fatty acids LDL and HDL(hydrogenation)

Recommended Oils

High MUFA:• Olive 76% Canola 61%• Rapeseed 53% Rice bran 41%• Til 42%

High n3:• Soyabean 5% Rapeseed 10%• Mustard 10%

High n6• Safflower, sunflower, corn, cottonseed 55-

70%

Moderate n6 & more n3 ratio (5-10) Mix one oil from each group to attain n6 n3 ratio

Food-Based Guidelines to Ensure Optimal Fat Quality in Asian Indian Diets:

The recommendation for oils should be as follows

Alternate or mix LA rich oils with ALNA rich oils to maintain n6/n3 ration between 5-10

Consumption of butter and ghee (clarified butter) should be kept to minimum.

Use of Poly Hydrogenated fat (Vanaspati) as cooking medium should be strictly avoided.

Other sources of trans fats to be strictly avoided


Regular consumption of foods with high n3 content (wheat, pearl millet, pulses, green leafy vegetables, fenugreek, flaxseed, mustard seeds)

Substitution of part of visible fat and invisible fats from animal foods- with whole nuts such as pistachios ,almonds.

Moderate use of animal foods (beef, pork, ham, eggs etc.)

For non-vegetarians, consumption of 100-200 g fish (4-6 pieces)/week.


Minimizing consumption of premixed, ready-to-eat, fast foods, bakery foods and processed foods prepared in vanaspati (hydrogenated fat) like savory (namkeen).

Choose low fat dairy foods such as double toned milk (fats < 1.5 %) or curd prepared from such milk – to keep SFA , TFA and cholesterol low.

Other Nutrients

Salt: 5 g/day or 2 g of Sodium Water : 1.5 – 2 liters/day should be

consumed,unless other wise advised by the physician

Free sugars < 10 % energy Small frequent meals at regular intervals Breakfast is essential Variety of foods should be included in the daily

diet for vitamins, minerals and phyto-Chemicals.

Healthy snacks should be opted Healthy cooking methods to minimize fat intake

Dietary Guidelines (Food Groups)1 .Variety of whole grains, millets and pulses

should be included in the daily diet2.Two glasses (1 glass = 240 ml) of low fat milk

or equivalent milk products should be included

3.Four to five servings of fruits and vegetables (all colors) to be included (1serving = 1 bowl = 125 g)

4.Encourage intake of salads.5. 15 – 20 g of healthy oil /day (low SFA and

TFA) is recommended. Promote alternate oils6.Substitute nuts and oilseeds in place of fats

and oils7.For non-vegetarians egg white, lean chicken

and fish is recommended.

Other Dietary Habits

1.5 -2 liters of water is recommended which includes other fluids like coconut water ,butter milk and vegetable juices and soups.

Small frequent meals at regular intervals should be taken. Gap between 2 meals should not be less than 3 hours.

Do not skip breakfast and have an early dinner.

Choose healthy snack options. Follow the healthy dietary guidelines while

eating out.


Boiled/steamed/roasted/grilled cooking methods should be preferred over frying.

Alcohol is not a recommendation. However, 1 small drink for women and 2 small drinks for men 4 times / week along with healthy eating could be beneficial for habitual takers.(one small drink = 30 ml of Gin , whisky ,vodka or 120 ml of wine or 240 ml of beer).

A Food labeling policy may need to be determined

Give healthy snack list.


Small frequent meals are not practical for everyone, specially office-goers.

Option should be provided to have either 3 meals a day or small-frequent meals, according to convenience.

Take time to chew your food. Avoid stress while eating. Avoid eating

while working or driving. Starting your day with a healthy breakfast

can jump start your metabolism and eating the majority of your daily calorie requirement early in the day gives your body time to work those calories off.

Look in to our future

Prevention is the key to our current rise in obesity

Nutritionists, Physicians, parents, teachers, fitness experts, media and all caretakers must demonstrate healthy food choices and exercise patterns.

Moderation is the key Physical activity should be regular Parents can participate in this including

modifying school canteen food. Govt. should help in organizing safe play areas

in the community

Realistic approach to diet prescription

Carbohydrates: Both quality and quantity- wholesome with fiber

Fats: * Omega-3 fatty acids: Deficiency may lead to

insulin resistance, high triglycerides and CAD

* Monounsaturated fatty acids (MUFA): deficiency may lead to adverse effects on lipids, blood pressure and heart

Fiber: Deficiency may lead to increase in blood glucose, heart disease and certain type of cancers

Proteins: Adequate and low fat

Realistic approach to diet prescription

Carbohydrates: Both quality and quantity- wholesome with fiber

Fats: * Omega-3 fatty acids: Deficiency may lead to

insulin resistance, high triglycerides and CAD

* Monounsaturated fatty acids (MUFA): deficiency may lead to adverse effects on lipids, blood pressure and heart

Fiber: Deficiency may lead to increase in blood glucose, heart disease and certain type of cancers

Proteins: Adequate and low fat

Exercises

Moderate intensityVigorous intensity

Type of physical activity

Modality Duration Frequency/ days per week

Modality Duration/ repetitions

Frequency/week

Aerobic physical activity

Brisk walking, stair climbing, jogging(4-7m/sec), cycling, treadmill and swimming

30 min 5 Football, badminton, basketball, running, rope jumping, dancing

20 min 3 days

Musclestrengthening

activity

Resistance weight training, curls, presses, anti-gravity exercise, isometric exercise

Children-Body weight activity (Pull ups)

1-3 sets of 8-12 repetitions targeting major muscle groups

2-3 Resistance training, curls, presses, anti gravity exercise, isometric exercise

Children- Body weight activity (Pull ups)

>3 sets of >12 repetitions targeting major muscle groups

2-3 days

Physical Activity Prescription for Aerobic and Muscle Strengthening Exercises Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management

JAPI • VOL. 57 • FEBRUARY 2009 www.japi.org

AGENDA






Conclusion

1. Life style management is the main stay

2. Maintain an ideal body weight

3. Follow a healthy balanced diet

4. Diet should contain whole grains, legumes, fruits & vegetables (fiber)

5. Take fat in moderation

Conclusion

6. MUFA is beneficial 7 . Mixed oils should be used to achieve N6/N3 fatty acid ratio (5-10)

8 . Avoid SFA and TFA

9 . Omega 3 should be encouraged

10 . Increased physical activity and Regular exercise is essential

Exercise Regularly

AGENDA






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Metabolic Syndrome and Dietary Guidelines for its prevention