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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
SECTION I – Introduction
SECTION II – Metabolic Syndrome
SECTION III – Consensus Dietary Guidelines
SECTION IV - Conclusion
Questions and Answers
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
SECTION I – Introduction
SECTION II – Metabolic Syndrome
SECTION III – Consensus Dietary Guidelines
SECTION IV - Conclusion
Questions and Answers
“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
Food-Based Guidelines to Ensure Optimal Fat Quality in Asian Indian Diets:
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.
Food-Based Guidelines to Ensure Optimal Fat Quality in Asian Indian Diets:
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.
Other Dietary Habits
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.
Other Dietary Habits
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
SECTION I – Introduction
SECTION II – Metabolic Syndrome
SECTION III – Consensus Dietary Guidelines
SECTION IV - Conclusion
Questions and Answers
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
SECTION I – Introduction
SECTION II – Metabolic Syndrome
SECTION III – Consensus Dietary Guidelines
SECTION IV - Conclusion
Questions and Answers
Questions & Answers
To submit a question for Dr Rekha Sharma,please message today’s moderator Akash Srivastavavia the chat
Closing Remarks