Guidapraca& all’elaborazionediun pianoditraamento...
Transcript of Guidapraca& all’elaborazionediun pianoditraamento...
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Guida pra)ca all’elaborazione di un piano di tra3amento
dietoterapico
Lorenzo M Donini
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Obesità Ipertensione Arteriosa T2DM Dislipidemie
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Obesità
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1/3 Kcal n.p.
0.8-‐1 g/kg PC di rif
2/3 Kcal n.p.
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ENERGETIC EQUIVALENT OF BODY TISSUES in “Biochemical, physiological, molecular aspects of human nutri6on” MH S'panuk ed – Saunders, 2006
Control of Energy Balance – chap 22 by JC Peters
• Perdita di un kg di peso: • 1 kg di tessuto adiposo(85% ac.grassi) = 7905 kcal (850g * 9.3 kcal/g)
• TuQa l’E contenuta nel grasso depositato contribuisce al bilancio E
• 1 kg di muscolo (20% proteine) = 1120 kcal (200g * 5.6 kcal/g)
• 800 kcal = E disponibile quale “carburante” • 320 kcal = necessarie per metabolizare l’N derivato dal catabolismo degli AA (⇒ urea)
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• Se voglio aumentare di 1 kg di massa magra ho bisogno di sinte'zzare ~250 g di proteine (40 g N) e ho bisogno di almeno 4.000 kcal n.p. (100 kcal n.p per g di N)
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Alimentazione ⇒ Nutrien) Deposi)
Acidi Grassi Alcuni AA Glucosio
Ace)l CoA
β-‐ossidazione
Glicolisi
Piruvato
Ossalacetato
Sir Hans Adolf Krebs 1900-‐1981
Piruvato carbossilasi
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• metabolic efficiency plays a key role in diet-induced obesity and its reversal by ketogenic diets
• ketogenic diets produce a less metabolically efficient state than high-fat non-ketogenic diets (enhanced conversion of lipids to ketones increases metabolic rate per calorie) (Davis, Wirtshafter, Asin, & Brief, 1981)
... assuming an average caloric value of 4.5 kcal/g for ketone-‐body oxida'on
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Ipertensione arteriosa
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• A livello del singolo paziente, l’effe`va restrizione sodica è senza dubbio non facile da aQuare.
• Si dovrebbe informare il paziente di evitare di aggiungere sale a cibi con elevato contenuto sodico.
• Una riduzione dell’introito salino su scala globale rimane una priorità della salute pubblica, ma richiede il contributo dell’industria alimentare, dei governi e della popolazione in generale, essendo l’80% del consumo di sale coinvolto nel “sale nascosto”.
• È stato calcolato che una riduzione di sale nel processo lavora'vo di pane, carne e formaggio, margarina e cereali, porterà ad un aumento degli anni di vita aggiusta' per qualità
Restrizione sodica: sale discrezionale e sale nascosto
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• Le modificazioni nella dieta devono essere accompagnate da altri cambiamen) dello s)le di vita.
• Nei pazien' con eleva' valori di BP del Dietary Approaches to Stop Hypertension (DASH), l’associazione di dieta, esercizio fisico e calo ponderale confrontata con la sola dieta è risultata determinare una maggiore riduzione della BP e della LVM.
• In merito all’assunzione di caffè una recente revisione sistema'ca ha mostrato che la maggior parte degli studi disponibili (10 RCT e 5 studi di coorte) sono di qualità insufficiente per permeQere di avanzare delle raccomandazioni a favore o contro l’assunzione del caffè in relazione all’ipertensione
Altre modifiche diete)che
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T2DM
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Abitudini alimentari
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Glycemic index is defined as the incremental area under the 2hrs glucose response curve aeer consump)on of 50 g CHO from a test food divided by the area under the curve aeer consump)on of 50 g CHO from a control food, either white bread or glucose (first defini)on D.Jenkins et al., 1981).
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Limi) del GI • CHO e Glucosio non sono la stessa cosa
• nelle tabelle di composizione degli alimen) è riportato il contenuto in CHO disponibili degli alimen):
• amido (espresso come polisaccaride) • zuccheri solubili (espressi come monosaccaridi: glucosio, fru3osio, gala3osio)
• glicemia = glucosio nel sangue
• il saccarosio ha un GI più basso del pane
• E’ da verificare quale contributo danno altri fa3ori nutrizionali (fibra, micronutrien), an)ossidan)) a determinare gli effem posi)vi a3ribui) ad un’alimentazione a basso GI
• Nella pra)ca quo)diana si u)lizzano piam/pas) complessi • il GI dei singoli alimen) è “mediato” dal GI degli altri alimen), dall’apporto di
altri nutrien), dai procedimen) di co3ura, dalla presenza di fibra, dalla stru4ura del cibo, dal 6po di amido, dalla digeribilità e dall’accessibilità dell’amido
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glycemic load
• The glycaemic load (GL) of a food is calculated as the carbohydrate content (g) mul)plied by the glycaemic index value of the food and divided by 100:
GL = CHO(g) x GI /100
• The total glycaemic load of a menu is the sum of all the individual glycaemic load values for the foods in the menu (Ebbeling 2003).
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Dislipidemie
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• The recommended total fat intake is between 25 and 35% of calories for adults. • A low intake of fats and oils increases the risk of inadequate intakes of
vitamin E and of essen6al fa=y acids, and may contribute to unfavourable changes in HDL.
• The type of fat intake should predominantly come from sources of MUFAs and both n-‐6 and n-‐3 PUFAs.
• Saturated fat intake should be lower than 10% of the total caloric intake. • The op'mal intake of SFAs should be further reduced (<7% of energy) in
the presence of hypercholesterolaemia. • Stearic acid, in contrast to other SFAs (lauric, myris'c, and palmi'c), does
not increase TC levels.
• n-‐6 PUFAs should be limited to <10% of the energy intake, both to minimize the risk of lipid peroxida)on of plasma lipoproteins and to avoid any clinically relevant HDL-‐C decrease.
• The cholesterol intake in the diet should ideally be <300 mg/day. • Limited consump'on of foods made with processed sources of trans fats
provides the most effec've means of reducing intake of trans fats below 1% of energy.
Dietary fat
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• Observa'onal evidence supports the recommenda'on that intake of fish and n-‐3 fa3y acids from plant sources (a-‐linolenic acid) may reduce the risk of CV death and stroke but has no major effects on plasma lipoprotein metabolism.
• At least two or three por)ons of fish (especially oily) per week are recommended to the general popula'on for the preven'on of CVD, together with regular consump)on of other food sources of n-‐3 PUFAs (nuts, soy, and flaxseed oil);
• Supplementa6on with pharmacological doses of n-‐3 fa4y acids (>2–3 g/day) reduces TG levels, but a higher dosage may increase LDL-‐C; not enough data are available to make a recommenda6on regarding the op6mal n-‐3/n-‐6 fa=y acid ra6o.
• For SECONDARY PREVENTION of CVD, the recommended amount of n-‐3 unsaturated fat should be 1 g/day, which is not easy to derive exclusively from natural food sources, and use of nutriceu6cals and/or pharmacological supplements may be considered
Dietary fat
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• Moderate alcohol consump)on (up to 20–30 g/day for men and 10–20 g/day for women) is acceptable for those who drink alcoholic beverages, provided that TG levels are not elevated. Pa)ents with HTG should abstain.
• Salt intake should be limited to <5 g/day, not only by reducing the amount of salt used for food seasoning but also by reducing the consump'on of foods preserved by the addi'on of salt (more stringent in people with hypertension or MetS).
• Smoking cessa)on has clear benefits on the overall CV risk and specifically on HDL-‐C.
• Weight reduc)on has a beneficial influence in par'cular on HDL-‐C and TG levels.
• Aerobic physical ac)vity corresponding to a total energy expenditure of between 1500 and 2200 kcal/week, such as 25–30 km of brisk walking per week (or any equivalent ac'vity) may increase HDL-‐C levels by 0.08–0.15 mmol/L (3.1–6 mg/dL)
Lifestyle recommenda)ons Lifestyle
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• Many func'onal foods and dietary supplements that are currently promoted as beneficial for people with dyslipidaemia or for reducing the risk of CVD.
• Some of these products have been shown to have poten6ally relevant func6onal effects but have not been tested in long-‐term clinical trials, and should therefore be u6lized only when the available evidence clearly supports their beneficial effects on plasma lipid values and their safety.
• Phytosterols compete with cholesterol for intes)nal absorp)on. • Based on the available evidence, foods enriched with phytosterols (1–2 g/day) may
be considered for individuals with elevated TC and LDL-‐C values in whom the total CV risk assessment does not jus)fy the use of cholesterol-‐lowering drugs.
• Soy protein has a modest LDL-‐C-‐lowering effect. Soy foods can be used as a plant protein subs'tute for animal protein foods high in SFAs, but expected LDL-‐C lowering may be modest (3–5%).
• Policosanol is a natural mixture of long chain alipha'c alcohols extracted primarily from sugarcane , rice, or wheat germ. It has no significant effect on LDL-‐C, HDL-‐C, TG, apo B, Lp(a), homocysteine, hs-‐CRP, fibrinogen, or blood coagula'on factors.
• ‘Red yeast rice’ (RYR): Possible bioac've effects of RYR (monacolins) are related to a sta)n-‐like mechanism [inhibi)on of hydroxymethylglutaryl-‐coenzyme A (HMG-‐CoA) reductase]. Monacolins lower TC and LDL-‐C, but the long-‐term safety of these products is not fully documented.
• The diet should be varied and rich in fruit and vegetables of different types to obtain a sufficient amount and variety of an'oxidants.
Lifestyle recommenda)ons Dietary supplements and func)onal foods
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Prescrizione diete)ca
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Definizioni di dieta La dieta (dal greco δίαιτα, ”modo di vivere”) è l'insieme degli alimen' che gli esseri umani assumono. Per estensione “s)le di vita” considerando anche l’a`vità fisica.
“Alimen) ed esercizi hanno in effem virtù reciprocamente opposte, ma che contribuiscono insieme a fare la salute. Per loro natura gli esercizi disperdono le energie disponibili, mentre i cibi e le bevande compensano le perdite” (Ippocrate di Coo o Kos -‐ Ιπποκράτης, 460 a.C. – 377 a.C.; De dieta, II, 1-‐2)
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Definizioni di dieta • La dieta (dal greco δίαιτα, ”modo di vivere”) è l'insieme degli alimen' che
gli esseri umani assumono. Per estensione “s)le di vita” considerando anche l’a`vità fisica.
• Dieta come Regime alimentare: metodo per modificare lo stato di nutrizione nei casi di malnutrizione (per eccesso o per difeQo), in patologie che lo influenzano (insufficienza renale, insufficienza epa'ca, …) o che, a loro volta, possono giovarsi di un diverso comportamento alimentare (diabete mellito, dilsipidemie, allergie o intolleranza alimentari).
• Dieta come “manipolazione”, spesso fantasiosa ed incongrua, del comportamento alimentare, che mira ad oQenere risulta' strabilian' (sia per la loro en'tà, che per la loro brevità). In genere presuppone la reiterazione di “falsi mi' e credenze”, la “riscoperta” in altra forma di proposte già dimostratesi inefficaci, l’uso del “la'norum”, assenza quasi totale di evidenze scien'fiche, una grande capacità istrionico/stregonesca unita ad una noncuranza scien'fica del proponente.
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Dieta come regime alimentare
Presuppone • Valutazione dello stato di nutrizione (bilancio di energia e
nutrien', composizione corporea, funzione corporea)
• Diagnosi (che consideri anche aspe` socio-‐culturali e psicologici)
• Prescrizione (apporto di energia e proteine, bilanciamento delle kcal n.p., appor' di nutrien' “cri'ci”, …)
• Elaborazione (che consideri abitudini, possibilità, gus', … del paziente)
• Professionis), di ambito sanitario, opportunamen' forma' (medici specialis' in scienza dell’alimentazione o con competenze specifiche in nutrizione clinica, die's')
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STIMA del MB
Equazioni (…)
Antropometria → FFM
BIA → FFM (BIAVECTOR)
MISURA del MB Calorimetria Indiretta
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LIVELLO DI ATTIVITA’ FISICA
QUESTIONARIO IEI → LAF
DIARIO AF
IPAQ
HOLTER METABOLICO, ACCELEROMETRI, CONTAPASSI
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kcal/h kcal/mMETABOLISMO BASALE kcal/24 h
IEI - ATTIVITA' DISCREZIONALI per adolescenti, adulti, anzianiCURE PERSONALI
Dormire + riposoIgiene personalePasti
ATTIVITA' PRODUTTIVE ORE kcalIstruzioneCura della casaCura dei figliAcquisti - spesa
TEMPO LIBERO ORE kcalAttività sportiveAtt. relig., civiel, polit.CamminateLetturaTV, RadioFreq. Luoghi pubbliciHobbies"Non specificato"Spostamenti
M FCasalinghe 1,6 1,6Impiegati 1,6 1,6Personale amministrativo e dirigenziale 1,6 1,6Liberi professionisti, tecnici e simili 1,6 1,6Collaboratori domestici 2,25 1,9Personale di vendita 2,25 1,9Lavoratori del terziario 2,25 1,9Lavoratori in agricoltura, allevamento, sivicoltura e pesca 3 2,3Manovali 3 2,3Operatori di produzione e di attrezzature di trasporto 3 2,3mansioni come nel gruppo/moderata/pesante ma in condizioni di scarsa meccanicizzazione 3,8 2,8
IEI ORE kcal1
2,51,5IEI1,52,53
2,5IEI6
1,84
1,1
kcalIEI
1,11,51,81,4
IEI - ATTIVITA' PROFESSIONALI per l'adulto medio
totale
2
ORE
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STIMA DEL FABBISOGNO PROTEICO: QUANTI GR DI PROTEINE?
Peso Ideale + 0,25 * (P attuale - P ideale)
A partire dal PESO DESIDERABILE
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Kcal Proteiche e Kcal Non Proteiche
1) Kcal proteiche Proteine g x 4
2) Kcal NP Kcal tot – kcal proteiche
3) Rapporto N/kcal NP 1:100 – 1:150 (NB: N = Pr g/6,25)
4) Kcal NP
a) Kcal CHO 65 – 75% → g CHO (3,75)
b) g CHO/g prot ≥ 2,5 c) Kcal LIP 30 – 35% → g LIP (9)
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h3p://alimentazione.fimmg.org/dieta_online.html
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6.10.1914 Larvik, Norvegia 18.04.2002 Andora (SV), Italia