Nutritional Management of Diabetes And Heart DiseasesShilpa Joshi RDMumbai Diet And Health Center Bandra (west)shlpjoshi@yahoo.com

Burden of Major NCDs in India35 million cases of Cardiovascular Diseases45 million cases of Diabetes2.4 million cases of cancer22 million Obesity1 million cases of Cerebrovascular Disease/strokeEvery 5th Diabetic is an IndianEvery 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 HereEndothelial liningSmooth 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 Fruits2-3 UnitsCereals & Pulses 8-12 Units 10-14 units (veg)Meat & Fish 1-2 UnitsFats, Oils & Nuts 2-3 Units

Vegetables 3-4 UnitsMilk & Milk Products 2-3 Units

Food Components

MACRONUTRIENTCarbohydratesProteinsFatsMICRONUTRIENTSVitaminsMinerals

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 waterJambun1 small/ 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 FruitsBananaChickooMangoSitaphalGrapes big1 small medium (75 gm) big size (50 gm)12-15 pieces

Properties of Dietary Fibre

TypeMajor Food SourcesKnown EffectsCelluloseBran, whole wheat four, cabbage, peas & beans, root vegetables, applesAffect food texture, increase fecal bulk, shorten transit timeHemicellulosesBran, cereals, whole grainsSame as celluloseSoluble noncellulosic pectin'sPolysaccharidesApples, citrus, fruits, various berries, apricot, banana, carrots, sweet potatoAlter consistency of gastric & intestinal contents, reduce absorption of cholesterol, reduce serum cholesterol, water holding

Properties of Dietary Fibre

TypeMajor Food SourcesKnown EffectsGums & Mucilage'sOat meal, dried beans, other legumesBinding of ions & other substances, water holding cholesterol-loweringLigninOld (tough) vegetables, wheatIndigestible by fecal bacteria

Quantity of Soluble Fibre to Produce Lipid Lowering Effect

SourceQuantityPectinsGumsDried beansDry oat branOat mealPsyllium6 to 408 to 36100 to 15025 to 10057 to 14010 to 30

Fibre Content of Foods

Low FibreModerate FibreHigh FibreMilled riceRefined wheat flourBread whiteWhole gram (bengal)LentilGreen gram dalBottle gourdAsh gourdCucumberTomatoSpinachLettuceBananaWhole wheat flourWheat germBrown breadField beansRed gram dal

BrinjalCauliflowerRadish leavesFenugreekCabbage

AppleRice bran

Bengal gramWhole RajmahPeasRed gramGreen gram whole

drumstick

Fibre Content of Foods

Low FibreModerate FibreHigh FibreSweet limeLichiWater melonPrunesPeachesPearsOrangeParwarDouble beans

ColocasiaAmaranthAmla/Dates/Grapes/Guava/Pomegranate/Sapota/Papaya

ProteinsRepair 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 proteinsIs 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 oilCHOLESTEROL BALANCINGOXIDATION STABILITY

Invisible FatsCoconut Peanuts, Almonds, Cashewnuts etc.Condiments like pappad, pickles, chutneys 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 oilsDepends on saturation of oilsTemperature of heatingPUFA > MUFA > SFAChange in saturated:unsaturated ratioFormation of peroxidesLoss of antioxidants

Dietary cholesterolAssociated 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

Alternatives

1 cereals exchange gives 100 kcals1 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) Thalipith or1 Ghavan or1 bowl of spaghetti or 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 PatternsBreakfast:Meal consumed within one hour of risingMost important meal of the dayShould be rich in complex carbs and proteineg: cereal, porridge, roti, dosa, idli, upma, daliya, paratha, eggs, milk, fruits.Avoid :bakery products

LunchEat balanced mealMake right food choicesDo not skip lunchInclude protein as a important part of mealeg 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 carteEither starter, main course or dessert never all togetherClear soup should be an integral part of menuChoose grilled, tandoori, broiled, stir fryDo not order for deep fried, makhani, white sauces, mayonnaiseSalad(?)

BuffetChoose 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/SnacksAvoid 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 snacksAvoid bakery products, colas, juices, chaat etcThe best drink with and between meals is water

Mid-Meal OptionsSkimmed 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 DrinkLieber CS. Alcohol Research & Health, Fall, 2003

Alcoholic DrinkCarbohydrate/Sugar Content (g/L)Alcohol Content(g/l)Distilled Spirit (Whisky, Cognac, Vodka)-400-500Dry White Wine & Red Wine2-10 120Beer & Dry Sherry3040-50Sweetened White Wine & Poat Wine 120An 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.

Unit of Alcohol

One Unit of AlcoholCaloriesHalf a pint of beer, lager or cider Pub measure of spirits (whisky, vodka, rum, gin) Glass of wine Glass of sherry 90507555One 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 PEPSIWATERFOUNTAINS

Fast Food JointsOrder 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 MaximizeMaharaja Mac ?Jumbo Vadapav?DoubleCheese Pizza?

SweetenersSweeteners 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 amountsEducation on appropriate use of sweetenersImpact of nutritive sweeteners on the individuals blood glucose levels & lipid profile should be assessed on a regular basis

ADI of various sweeteners

SodiumSources: 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 BenefitReduces body weightReduces blood pressureKeeps blood sugars under controlIncreases HDL levels

Ref: Thompson PD, Buchner D, Pia 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 IssuesHypocaloric DietsLow Carb DietsMeal Replacement DietsEat less, Eat on TimeConcentrate on SatietySatiety Index

Killer DietFast Foods kill fastFried,Calorie DenseOils and ButtersLack of FibreCola Culture

Traditional DietLess oilFibre rich

Designer FoodsLow cal mithaisDiet colasLow calorie or diet farsansDiabetics adjuncts jam, jelly, pickles

Healthy EatingEating OutWeight ControlFlexible LifestyleGood Nutrition

Prevention of Heart DiseasesGive 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 CVDEducation 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 buildingLess 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 GenesPredispose usLoad the Gun with Bad Genes and Pull the Trigger by Bad environmentIts time to wake up

Soya ProteinSoya bean apart from being rich source protein also has other phytochemicals which are uniqueSoya fibers reduces insulin requirement in diabetesDecrease cholesterol synthesis in humans.Use only processed soya : atta, nuggets, drinks

LYCOPENEMajor carotenoids

Imparts colour to vegetables and fruits

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

LYCOPENEAre found in:Tomato & tomato productsApricots, papayaGrapefruit, guava etcShows enhanced absorption when consumed along with fatsDeposited in liver, lung, prostate glands, colon & skinFat soluble

LYCOPENE: HEALTH BENEFITSPotent antioxidant

Major scavenger of harmful free radicals

Prevents/delays cardiovascular complications

Prevents oxidation of LDL

Reduces risk of atherosclerosis & CAD

L-ARGININEProtein amino acidClassified as semi-essential / conditionally essentialEssential for young childrenPrecursor of nitric oxideShown to play a critical role in:HypertensionHeart dysfunctionInflammation

It is an herb and a spiceFenugreek containsan active ingredient of blood glucose control an active ingredient for blood cholesterol control

The typical range of intake for diabetes or cholesterol-lowering is 530 grams with each meal or 1590 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 nutsRich 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 garlicBioactive compound allicinOrganosulfur compound inhibits hepatocyte cholesterol synthesisAntiplatelet propertiesS alkenyl cysteine results in decreased HMG coA reductase

Effect of green teaBioactive principle CATECHINEnhances fat oxidationImproves PP glucose responseStimulates insulin secretion

****Without carb counting, some of you may remember or currently be on a regimen that requires you to eat a certain amount of food to match your insulin. If you eat more or less you pay the price by having high or low blood sugars. Once you learn how to carb count, all that is required is to give yourself a bolus of insulin to cover the carbs in your meal that you want to eat. This really opens up the possibilities of what you can eat (provided you do a little math).Many restaurants provide the nutrient information for their menu items as well with the advent of the internet, you can usually check out the larger chain restaurants on-line and they typically post it there. There is also this great book called the Calorie King: Calorie Fat and Carbohydrate Counter that lists many of the larger franchises and brands of food.There is an important caution though. Notice as we went through the nutrition labels, I did not have you check the calorie content. For carb counting, the calories or sodium content of what you are eating is irrelevant. But please remember, there is no substitute for healthy food choices. If your physician has asked you to follow a particular diet or meal plan, such as low sodium, then you would need to incorporate that into your food choices. The purpose of the counting carbohydrates is so you can have control of what you eat and match insulin to it, not have to match food for the insulin you take. It has nothing to do with other restrictions. With the freedom of carb counting, there is the temptation to eat extra food then adjust your insulin to cover extra calories; however, the calories add up and weight-gain is likely. As you become a carbohydrate counting expert and enjoy more flexibility in food selection, remember to include at least 5 servings of fruit and vegetables per day.We should ALL be eating healthy, whether we have diabetes or not. Just because you have diabetes shouldnt make you have to eat differently than anyone else. You just have to match insulin to what you eat. Again, we should all be eating healthy.*