Nutritional Management of Diabetes And Heart Diseases

Shilpa Joshi RD

Mumbai Diet And Health Center

Bandra (west)shlpjoshi@yahoo.com

Burden of Major NCD’s in India

35 million cases of Cardiovascular Diseases

45 million cases of Diabetes 2.4 million cases of cancer 22 million Obesity 1 million cases of Cerebrovascular

Disease/stroke Every 5th Diabetic is an Indian Every 5th to 10th Asian Indian Native

Urbanite is a Diabetic

Body fat9.1% 21.2%

BMI 22.3 22.3

Glucose is the currency of body & every cell needs it

Type 2 DM

Oxidative Stress Damages Here

Endothelial lining Smooth muscleCollagen

Food

Any substance that can be metabolized by an organism to give energy and build tissue

Any solid substance (as opposed to liquid) that is used as a source of nourishment; "food and drink"

Anything that provides mental stimulus for thinking

Traditional Diets

Traditional Diet

Food Pyramid

Fruits

2-3 Units

Cereals & Pulses

8-12 Units 10-14

units (veg)

Meat & Fish

1-2 Units

Fats, Oils & Nuts

2-3 Units

Vegetables

3-4 Units

Milk & Milk Products

2-3 Units

Food Components

MACRONUTRIENTCarbohydratesProteinsFats

MICRONUTRIENTSVitaminsMinerals

Carbohydrates

Primary source of energySources:cereals, fruits, vegetables,milkCarbs are of two types

simple carbs: sugars, honey, colas, fruits juices, jaggery,maida,bakery products

Complex carbs: cereals, vegetables, pulses

How to choose carbohydrates.

Complex carbohydrates are good for our health.

Simple carbohydrate easily increase our blood sugar, so decrease their consumption.

Eat carbohydrates only in recommended amounts.

Choose complex carbohydrates high in fibre e.g unpolished rice, ragi ,whole wheat

Fruits Exchanges ( to be eaten in prescribed amount)

AppleGuavaOrangePapayaPineapplePearsSweetlimeWater melonPomegranateCoconut waterJambun

1 small/½ medium1 medium1 medium1/3 medium or 3 slices2-3 slices1 medium1 medium2-3 slices1/3rd medium150 ml100 gm

FIBRE: Boon of nature

Fibre is non digestible carbohydrate.It forms a bulk and hence makes us feel

full.Soluble – oats, barley, psyllium, fruits

( guava, apple ), gumInsoluble-whole grains, pulses,

vegetables, fruit ( oranges, sweetlime )

Fruits Exchanges: (to be avoided)

High Calories Fruits

BananaChickooMangoSitaphalGrapes

½ big1 small½ medium (75 gm)½ big size (50 gm)12-15 pieces

Properties of Dietary FibreType Major Food

SourcesKnown Effects

Cellulose Bran, whole wheat four, cabbage, peas & beans, root vegetables, apples

Affect food texture, increase fecal bulk, shorten transit time

Hemicelluloses Bran, cereals, whole grains

Same as cellulose

Soluble noncellulosic pectin's

Polysaccharides

Apples, citrus, fruits, various berries, apricot, banana, carrots, sweet potato

Alter consistency of gastric & intestinal contents, reduce absorption of cholesterol, reduce serum cholesterol, water holding

Properties of Dietary Fibre

Type Major Food Sources

Known Effects

Gums & Mucilage's Oat meal, dried beans, other legumes

Binding of ions & other substances, water holding cholesterol-lowering

Lignin Old (tough) vegetables, wheat

Indigestible by fecal bacteria

Quantity of Soluble Fibre to Produce Lipid Lowering Effect

Source Quantity

Pectins

Gums

Dried beans

Dry oat bran

Oat meal

Psyllium

6 to 40

8 to 36

100 to 150

25 to 100

57 to 140

10 to 30

Fibre Content of FoodsLow Fibre Moderate Fibre High Fibre

Milled rice

Refined wheat flour

Bread white

Whole gram (bengal)

Lentil

Green gram dal

Bottle gourd

Ash gourd

Cucumber

Tomato

Spinach

Lettuce

Banana

Whole wheat flour

Wheat germ

Brown bread

Field beans

Red gram dal

Brinjal

Cauliflower

Radish leaves

Fenugreek

Cabbage

Apple

Rice bran

Bengal gram

Whole

Rajmah

Peas

Red gram

Green gram whole

drumstick

Fibre Content of Foods

Low Fibre Moderate Fibre High Fibre

Sweet lime

Lichi

Water melon

Prunes

Peaches

Pears

Orange

Parwar

Double beans

Colocasia

Amaranth

Amla/Dates/Grapes/

Guava/Pomegranate/

Sapota/Papaya

Proteins

Repair of tissues, immunitySources: pulses, nuts, milk and milk

products, meat, egg, fish, poultry.Egg ,poultry and red meat have saturated

fats in themGood source of proteins are dals, sprouts,

fish, egg whites,chicken breast.

Advantages of proteins

Is not converted into sugar as fast as carbohydrates.

It keeps us full for a long period of time.It takes a lot of energy to burn proteins,

therefore you store less energy.

FATS

Source of stored energySource: oil, butter, ghee, nuts, non-veg,

cheese, bakery products

A consumer is a confused

lot as far as choosing the

right kind of cooking

medium is concerned.

Every supplier of any type

of cooking oil claims the

same to be best for health

A common man is not

aware of the yardstick by

which any cooking oil could

be rated as the best one

.

.

CHOICE OF A HEALTHY COOKING MEDIUM:

a controversial subject

Recommended fats (heart friendly oils )are MUFA eg. ground nut oil, rice bran oil, olive oil

CHOLESTEROL BALANCING

OXIDATION STABILITY

Invisible Fats

Coconut Peanuts, Almonds, Cashewnuts etc.Condiments like pappad, pickles,

chutney’s etc.Garnishes like cheese, cream, white

sauce, etc.Bakery items like biscuits, kharis, puffs,

etc.Farsans and sweetsNon-Vegetarian foodMilk & milk products

Total Fat

Total fat intake is most importantInvisible sources of fat should be

included in the total fat intakeTotal fat intake is closely related to

serum lipidsRecommended intake is 20 gms per

person per dayDiets should not provide more than

30% calories from fat

Effect of heating on oils

Depends on saturation of oilsTemperature of heatingPUFA > MUFA > SFAChange in saturated:unsaturated ratioFormation of peroxidesLoss of antioxidants

Dietary cholesterol

Associated with animal fatSources of dietary cholesterol : ghee,

cream butter, non-vegetarian foods.Excess consumption of fat leads to

production of fat in our bodyPrudent fat intake : 3-4 tsp/day/personGood oils :ground nut oil, olive oil, rice

bran oil

Alternatives1 cereals exchange gives 100 kcals

1 chapatti (30 g) 1 thepla or1 khakra (dry) or1 medium vati porridge or2 medium size bread slice or1 pav (30 gm) or1 vati (medium) cooked rice or1 medium vati onion poha (no potato)½ Thalipith or1 Ghavan or1 bowl of spaghetti or¼ bhakri or1 bowl of corn flakes or1 idli with sambhar or1 dosa (home made – medium sized – on nonstick) with sambhar4-5 pieces of dhokla or muthia (steamed)4-5 pieces of Khandvi

Meal Patterns

Breakfast:Meal consumed within one hour of risingMost important meal of the dayShould be rich in complex carbs and protein

eg: cereal, porridge, roti, dosa, idli, upma, daliya,

paratha, eggs, milk, fruits.

Avoid :bakery products

Lunch

Eat balanced meal

Make right food choices

Do not skip lunch

Include protein as a important part of meal

eg thali, roti-subzi , dal rice, curd rice

Meal Patterns

DinnerMeal should be as light as possibleLow in carbohydrates especially simple

carbsMake clear soups as integral part of

dinner

Meal Patterns

Eating Out (Make Right Choices)Meal timeCuisineMeal selectionHygiene

A la carte

Either starter, main course or dessert never all together

Clear soup should be an integral part of menu

Choose grilled, tandoori, broiled, stir fryDo not order for deep fried, makhani,

white sauces, mayonnaiseSalad(?)

Buffet

Choose wiselyDo not have to eat it allSelect hot, steaming foodsSelect a live counter so dish can be made

as per your choiceAvoid greasy foods

Mid Meals/Snacks

Avoid high calorie snacks- split it into twoAvoid super sized snacks Fruits, channa, unbuttered pop corn, sukha bhel

with less sev, cooked channa chat are ideal snacks

Avoid bakery products, colas, juices, chaat etcThe best drink with and between meals is water

Mid-Meal Options

Skimmed milk ChaasKurmuraChannaFruit (permitted quantity only)

AlcoholCauses hypoglycemia if consumed without foodFoods consumed with alcohol are usually fried

foods/junk food empty calories)Alcohol is high in calories 7 kcals/gm and is

metabolized in a manner to fat. give up alcohol, if not then fix the quantity, frequency

and exchange it with fat. consume salads with alcohol.

AlcoholRaises HDLLowers insulin concentration and improves insulin sensitivity

ButRaises blood pressureThese findings are true for whites. Blacks (Afro American ) and

Hispanics do not show this relationshipStudies on Indian populations have not been done

Ref : Freiberg MS, Cabral HJ, Heeren TC, et al. Alcohol Consumption and the Prevalence of the Metabolic Syndrome in the U.S.A cross-sectional analysis of data from the Third National Health and Nutrition Examination Survey. Diabetes Care 2004; 27:2954-2959.

Alcohol & Sugar Content of Alcoholic Drink

Alcoholic Drink Carbohydrate/Sugar Content

(g/L)

Alcohol Content

(g/l)

Distilled Spirit (Whisky, Cognac, Vodka)

- 400-500

Dry White Wine & Red Wine

2-10 120

Beer & Dry Sherry 30 40-50

Sweetened White Wine & Poat Wine

120

An average drink namely 5 oz of wine, 12 oz of beer or 1.5 oz of distilled spirit contains 12-14 gms of alcohol. Thus they give approximately 100 kcal.Lieber CS. Alcohol Research & Health, Fall, 2003

Unit of Alcohol

One Unit of Alcohol Calories

Half a pint of beer, lager or cider

Pub measure of spirits (whisky, vodka, rum, gin)

Glass of wine

Glass of sherry

90

50

75

55

One unit of alcohol is 10 ml by volume, or 8 g by weight, of pure alcohol. For e.g. Half a pint of ordinary strength beer, 25 ml of spirits, 50 ml of fortified wine such as sherry or port

How Should be the Calories from Alcohol Calculated?When calories from alcohol need to be

calculated as part of the total caloric intake, alcohol is best substituted for fat exchanges (1 alcoholic beverage = 2 fat exchanges or fat calories.

ADA Guidelines

Fountain PEPSI

WATERFOUNTAINS

Fast Food Joints

Order wiselyFind a low fat option and orderDo not over indulgeEg: just a burger no fries ,one unbuttered

pav instead of two buttered pav, bhel puri instead of sev puri, ragada pattice instead of panipuri, samosa ,kachori

DO NOT UPSIZE !!!

We Need To Minimize Not

Maximize

Maharaja Mac ?Jumbo Vadapav?DoubleCheese Pizza?

Sweeteners

Sweeteners are of two kind: Nutritive Sweeteners (which have calories) and Non-Nutritive Sweeteners (which have no calories)

Nutritive and Non Nutritive Sweeteners should be used sparingly in prescribed amounts

Education on appropriate use of sweetenersImpact of nutritive sweeteners on the

individual’s blood glucose levels & lipid profile should be assessed on a regular basis

ADI of various sweeteners

Sweetener Acceptable daily intake(mg/kg body weight)

Acesulfame potassium 15

Aspartame 40

Cyclamate 11

Saccharin 5

Sucralose 9

Sodium

Sources: salt, bakery productsBlood pressure is significantly related to sodium

intake(inter salt study)High salt intake has been implicated in hypertensive

target organ diseasesStrategies to limit salt intakeReduce salted foods bakery, processed food, pickle, ketchupAvoid :salt shakers, salt on salads, fruits, atta, rice, sherbetUse of lime, tamarind, pudina to bring flavour to foods

Integrating Therapies

Physical Activity Benefits

Physical activity is it necessary?Prevents obesity( weight gain)Improves heart conditioningImproves blood pressureStabilizes blood sugarImproves muscle mass and bone healthSecretes feel good hormones

Physical Activity and Its Benefit

Reduces body weightReduces blood pressureKeeps blood sugars under controlIncreases HDL levels

Ref: Thompson PD, Buchner D, Piña IL, et al. AHA Scientific Statement - Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity. Circulation. 2003; 107: 3109

Diet Issues

Hypocaloric DietsLow Carb DietsMeal Replacement DietsEat less, Eat on TimeConcentrate on SatietySatiety Index

Killer Diet

Fast Foods kill fastFried,Calorie DenseOils and ButtersLack of FibreCola Culture

Traditional DietLess oilFibre rich

Designer Foods

Low cal mithai’sDiet cola’sLow calorie or diet farsan’sDiabetics adjunct’s – jam, jelly, pickles

Healthy Eating

Eating Out

Weight Control

Flexible Lifestyle

Good Nutrition

Prevention of Heart Diseases

Give up one, reduce two, and increase three

give up smoking reduce food and alcohol intake increase exercise

Ref: Wada T, Fujishiro K, Fukumoto T, Joki M. Inf Med. 2005; 44(2):319-22.

Aham Annam….

Atharva veda (2500 BC)

We Are ,What We Eat ….

Practical Activity Interventions to Prevent CVD

Education and knowledge Compulsory sport and physical activities in schools

and colleges as wellGyms at work placesSport culture to be developedPhysical activity intervention : elevators and escalators

to be used by only old and sick,walking for short distances, walking at home and in compounds of building

Less use of gadgets: cordless phones, remote controls Concept of ‘NEAT’ : do it your self

Diataal Powder

Faulty Nutrition via chronic diseases has the potential

to bankrupt SE Asia

We will lose migrant,affluent,Asian Indians

to CAD, DM, Cancer etcKiller lifestyle and Bad Genes

Predispose us“Load the Gun with Bad Genes and Pull

the Trigger by Bad environment”Its time to wake up

Soya Protein

Soya bean apart from being rich source protein also has other phytochemicals which are unique

Soya fibers reduces insulin requirement in diabetesDecrease cholesterol synthesis in humans.

Use only processed soya : atta, nuggets, drinks

LYCOPENE

Major carotenoids

Imparts colour to vegetables and fruits

Recent studies reveal a unique preventive role;Cancer &Cardiovascular complications

LYCOPENE

Are found in:Tomato & tomato productsApricots, papayaGrapefruit, guava etc

Shows enhanced absorption when consumed along with fats

Deposited in liver, lung, prostate glands, colon & skin

Fat soluble

LYCOPENE: HEALTH BENEFITS

Potent antioxidant

Major scavenger of harmful free radicals

Prevents/delays cardiovascular complications

Prevents oxidation of LDL

Reduces risk of atherosclerosis & CAD

L-ARGININE

Protein amino acid

Classified as semi-essential / conditionally essential

Essential for young children

Precursor of nitric oxide

Shown to play a critical role in:Hypertension

Heart dysfunction

Inflammation

• It is an herb and a spice• Fenugreek contains

an active ingredient of blood glucose control an active ingredient for blood cholesterol

control

• The typical range of intake for diabetes or cholesterol-lowering is 5–30 grams with each meal or 15–90 grams all at once with one meal.

• Use of more than 100 grams of fenugreek seeds daily can cause intestinal upset and nausea. Individuals with peanut allergies use with caution or avoid.  Otherwise, fenugreek is extremely safe.

Some Indian remedies : methi seed

Effect of nuts

Rich in MUFA and PUFARich in plant protein,fibre,micronutrients

like Cu and MgPlant sterolsVitamin E,thiamin,riboflavinPeanuts are good source of folate and

fibreWalnuts are good source of omega 3 oils

Effect of garlic

Bioactive compound allicinOrganosulfur compound inhibits

hepatocyte cholesterol synthesisAntiplatelet propertiesS alkenyl cysteine results in decreased

HMG coA reductase

Effect of green tea

Bioactive principle CATECHINEnhances fat oxidationImproves PP glucose responseStimulates insulin secretion