MEDICAL NUTRITION THERAPY (MNT)

Mrs. Sarah JacobMrs. Sarah Jacob

Rtd. Head, Department of DieteticsRtd. Head, Department of Dietetics

Christian Medical CollegeChristian Medical College

Vellore .Vellore .

Medical Nutrition Therapy (MNT) Replaces The earlier term of “Diet Therapy” and stresses aThe earlier term of “Diet Therapy” and stresses a

four pronged approach that includes….four pronged approach that includes….

Assessment of the individual’s metabolic and life Assessment of the individual’s metabolic and life style parametersstyle parameters

Identification of nutrition goalsIdentification of nutrition goals Intervention designed to achieve these goals.Intervention designed to achieve these goals. Evaluation of therapeutic outcome.Evaluation of therapeutic outcome.

Assessment

Involves assessment of habitual dietary pattern inInvolves assessment of habitual dietary pattern in

terms of nutrient content and eating behaviourterms of nutrient content and eating behaviour

HelpsHelps

- To identify goals- To identify goals

- To determine the type of intervention needed - To determine the type of intervention needed calorie intake, food pattern modification calorie intake, food pattern modification

of eating behaviour etc.of eating behaviour etc.

- Rapport building- Rapport building

- Gives information on clinical data. - Gives information on clinical data.

Goals

Treatment goals should be individualised, realisticTreatment goals should be individualised, realistic

and achievableand achievable

- Weight loss if necessary- Weight loss if necessary

- Blood glucose levels to be maintained as close to- Blood glucose levels to be maintained as close to

normal as possiblenormal as possible

- Blood lipid levels within desirable limits- Blood lipid levels within desirable limits

- Consistent and appropriate food intake- Consistent and appropriate food intake

- Regular meal timings- Regular meal timings

- Blood glucose monitoring- Blood glucose monitoring

Intervention - Education

- Appropriate meal plan suggested- Appropriate meal plan suggested

- Strategies for eating behaviour change- Strategies for eating behaviour change

- Food exchanges- Food exchanges

- Importance, source of dietary fibre- Importance, source of dietary fibre

- Adequate nutrient intake by including - Adequate nutrient intake by including varietyvariety

- Importance of exercise.- Importance of exercise.

Steps to individualised diet planning Step:1 - Determine past diet history, food habits,Step:1 - Determine past diet history, food habits, activity socio economic status, cultural andactivity socio economic status, cultural and religious practices etc. religious practices etc. e.g. Sex – male Age – 50 yrs e.g. Sex – male Age – 50 yrs Height – 170 cms or 5’ 7” Height – 170 cms or 5’ 7” Food habits - Non vegetarian Food habits - Non vegetarian Income – Middle IncomeIncome – Middle Income Activity – Sedentary Activity – Sedentary Type of Diabetes – Type 2 DiabetesType of Diabetes – Type 2 Diabetes

Step: 2 Determine ideal or desirable bodyStep: 2 Determine ideal or desirable body

weightweight

(a) Hamwi method (a) Hamwi method

IBW = 106+(7x6) = 148 lbsIBW = 106+(7x6) = 148 lbs

(b) Broca’s Index (b) Broca’s Index

IBW = 170-100 = 70 kgsIBW = 170-100 = 70 kgs

5 – 10% less for diabetics5 – 10% less for diabetics

= 63 – 67 kgs.= 63 – 67 kgs.

Step: 3 Calculate Energy RequirementStep: 3 Calculate Energy Requirement

Basal + activityBasal + activity

= (148 x 10) = (1480 x 20 / 100)= (148 x 10) = (1480 x 20 / 100)

= 1776 Kcal= 1776 Kcal

= Rounded off to 1800 Kcal.= Rounded off to 1800 Kcal.

Step: 4 Determine gm of carbohydrate,Step: 4 Determine gm of carbohydrate,

protein and fatprotein and fat

CHO = 60-65% of total calories = 270g- 292gCHO = 60-65% of total calories = 270g- 292g

Protein = 10-15% of total calories = 45g – 68gProtein = 10-15% of total calories = 45g – 68g

Fat = 20-25% of total calories = 40g – 50gFat = 20-25% of total calories = 40g – 50g

Step : 5 Carbohydrate – 60-65%Step : 5 Carbohydrate – 60-65%

Complex CHO is better than simple sugars Complex CHO is better than simple sugars as absorption is slower as absorption is slower

Amount of CHO in each meal to be Amount of CHO in each meal to be adjusted for each individual.adjusted for each individual.

Step: 6 Step: 6

Dietary fibre present in whole grain cereals, Dietary fibre present in whole grain cereals,

vegetables pulses and fruits delay digestionvegetables pulses and fruits delay digestion

and absorption may help in reducing bloodand absorption may help in reducing blood

sugars and lipids. Recommended intake –sugars and lipids. Recommended intake –

25 - 28g / 1000 Kcal.25 - 28g / 1000 Kcal.

Step: 7 Step: 7 Foods with high fibre content have lower Foods with high fibre content have lower glycemic indexglycemic index

Physical form of foodPhysical form of food Nature of cookingNature of cooking Nature of fibreNature of fibre Amount and composition of meal affect the Amount and composition of meal affect the

glycemic index of food.glycemic index of food.

(8) Protein – 15%(8) Protein – 15%

RDA of protein for adults – 1g/kg body weight.RDA of protein for adults – 1g/kg body weight.

Cereals, pulses, nuts, milk and its products, non-Cereals, pulses, nuts, milk and its products, non-

vegetarian items contribute to the protein contentvegetarian items contribute to the protein content

in the diet.in the diet.

(9) Fat – 20-25%(9) Fat – 20-25%

Type of fat – 7 – 10% SFAType of fat – 7 – 10% SFA

- < 10% PUFA- < 10% PUFA

- 10-15% MUFA- 10-15% MUFA

Step: 10 Step: 10

Translate in terms of food.Translate in terms of food.

Use of exchange listsUse of exchange lists

- gives information on nutrient content- gives information on nutrient content

- provides variety in diet by giving- provides variety in diet by giving

alternativesalternatives

(11) Sample meal plan:(11) Sample meal plan:

Breakfast – Milk – 100 mlBreakfast – Milk – 100 ml

Cereal preparation – from 75g cereal Cereal preparation – from 75g cereal

e.g: 3 iddlies / chappathiese.g: 3 iddlies / chappathies

Mid morning – Fruit + Lime juice withoutMid morning – Fruit + Lime juice without

sugars.sugars.

Lunch – 250 g cooked rice or chappathies – 3Lunch – 250 g cooked rice or chappathies – 3

meat / fish / paneermeat / fish / paneer

vegetablesvegetables

curdscurds

Dhal as sambarDhal as sambar

Tea time: Milk – 100 mlTea time: Milk – 100 ml

Whole gram or pulse – 15gWhole gram or pulse – 15g

Dinner: 250g cooked rice or 3 chappathiesDinner: 250g cooked rice or 3 chappathies

Meat / Fish / DhalMeat / Fish / Dhal

VegetablesVegetables

CurdsCurds

Bedtime: Mild – 200 mlBedtime: Mild – 200 ml

Oil for cooking – 3-4 teaspoonsOil for cooking – 3-4 teaspoons To be adjusted to suit individual needs.To be adjusted to suit individual needs.

Eating modifications

Reduce cereal intakeReduce cereal intakeAvoid simple sugars – Honey, Sucrose etc.Avoid simple sugars – Honey, Sucrose etc.Avoid fried foods – chips, nuts etcAvoid fried foods – chips, nuts etcIncrease use of vegetables – ensure adequate fibre Increase use of vegetables – ensure adequate fibre intakeintakeEat regular mealsEat regular mealsRegular food and exerciseRegular food and exerciseBalanced meal to ensure adequate Vitamins andBalanced meal to ensure adequate Vitamins and Minerals.Minerals.

Type I Diabetes – in children

(a)(a) Energy: 1000 kcal for the 1Energy: 1000 kcal for the 1stst year year

+ 100 Kcal for every year upto 10yrs /+ 100 Kcal for every year upto 10yrs /

upto 200kcalupto 200kcal

2000 + 50-100 kcal for girls between 12-15 yrs2000 + 50-100 kcal for girls between 12-15 yrs

2000 + 200 kcal for boys between 12-15 yrs2000 + 200 kcal for boys between 12-15 yrs

Above 15 yrs – 30-35 kcal / kg – sedentaryAbove 15 yrs – 30-35 kcal / kg – sedentary

40 kcal / kg – moderation40 kcal / kg – moderation

50 kcal / kg – very active50 kcal / kg – very active

(b) Distribution of CHO, Protein, Fat(b) Distribution of CHO, Protein, Fat

CHO – 50 – 55%CHO – 50 – 55%

Protein – 20 – 25%Protein – 20 – 25%

Fat – 20 – 25%Fat – 20 – 25%

Gestational Diabetes

Pregnant women need extra 300 kcal and 15gPregnant women need extra 300 kcal and 15g

protein during the 2protein during the 2ndnd or 3 or 3rdrd trimester. trimester.

Frequent small meals to be given.Frequent small meals to be given.

Diabetic Nephropathy

Depending on the function of the kidney.Depending on the function of the kidney. Energy – as for others with diabetesEnergy – as for others with diabetes Protein – 0.6 – 0.8 g / kg IBWProtein – 0.6 – 0.8 g / kg IBW Fat – less than 30% of total Kcal preferably Fat – less than 30% of total Kcal preferably

20-25%20-25% CHO – to make up the rest of the calories CHO – to make up the rest of the calories

preferably from complex carbohydrates.preferably from complex carbohydrates.

Evaluation…..,

- Monitoring medical and clinical outcomesMonitoring medical and clinical outcomes

- Effectiveness of nutrition care plan etcEffectiveness of nutrition care plan etc

- Re-assess and review nutrition care planRe-assess and review nutrition care plan

““Nutrition is a challenging aspect of diabetesNutrition is a challenging aspect of diabetes

management. Attention to nutrition and mealmanagement. Attention to nutrition and meal

planning principles is essential for glycemicplanning principles is essential for glycemic

control and over all good health”.control and over all good health”.