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Nutritional Management of Diabetes And Heart Diseases
Shilpa Joshi RD
Mumbai Diet And Health Center
Bandra (west)[email protected]
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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
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Body fat9.1% 21.2%
BMI 22.3 22.3
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Glucose is the currency of body & every cell needs it
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Type 2 DM
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Oxidative Stress Damages Here
Endothelial lining Smooth muscleCollagen
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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
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Traditional Diets
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Traditional Diet
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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
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Food Components
MACRONUTRIENTCarbohydratesProteinsFats
MICRONUTRIENTSVitaminsMinerals
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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
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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
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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
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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 )
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Fruits Exchanges: (to be avoided)
High Calories Fruits
BananaChickooMangoSitaphalGrapes
½ big1 small½ medium (75 gm)½ big size (50 gm)12-15 pieces
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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
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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
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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
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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
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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
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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.
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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.
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FATS
Source of stored energySource: oil, butter, ghee, nuts, non-veg,
cheese, bakery products
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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
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Recommended fats (heart friendly oils )are MUFA eg. ground nut oil, rice bran oil, olive oil
CHOLESTEROL BALANCING
OXIDATION STABILITY
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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
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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
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Effect of heating on oils
Depends on saturation of oilsTemperature of heatingPUFA > MUFA > SFAChange in saturated:unsaturated ratioFormation of peroxidesLoss of antioxidants
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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
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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
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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
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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
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DinnerMeal should be as light as possibleLow in carbohydrates especially simple
carbsMake clear soups as integral part of
dinner
Meal Patterns
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Eating Out (Make Right Choices)Meal timeCuisineMeal selectionHygiene
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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(?)
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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
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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
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Mid-Meal Options
Skimmed milk ChaasKurmuraChannaFruit (permitted quantity only)
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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.
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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.
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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
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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
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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
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Fountain PEPSI
WATERFOUNTAINS
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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
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DO NOT UPSIZE !!!
We Need To Minimize Not
Maximize
Maharaja Mac ?Jumbo Vadapav?DoubleCheese Pizza?
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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
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ADI of various sweeteners
Sweetener Acceptable daily intake(mg/kg body weight)
Acesulfame potassium 15
Aspartame 40
Cyclamate 11
Saccharin 5
Sucralose 9
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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
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Integrating Therapies
Physical Activity Benefits
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Physical activity is it necessary?Prevents obesity( weight gain)Improves heart conditioningImproves blood pressureStabilizes blood sugarImproves muscle mass and bone healthSecretes feel good hormones
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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
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Diet Issues
Hypocaloric DietsLow Carb DietsMeal Replacement DietsEat less, Eat on TimeConcentrate on SatietySatiety Index
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Killer Diet
Fast Foods kill fastFried,Calorie DenseOils and ButtersLack of FibreCola Culture
Traditional DietLess oilFibre rich
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Designer Foods
Low cal mithai’sDiet cola’sLow calorie or diet farsan’sDiabetics adjunct’s – jam, jelly, pickles
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Healthy Eating
Eating Out
Weight Control
Flexible Lifestyle
Good Nutrition
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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.
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Aham Annam….
Atharva veda (2500 BC)
We Are ,What We Eat ….
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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
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Diataal Powder
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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
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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
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LYCOPENE
Major carotenoids
Imparts colour to vegetables and fruits
Recent studies reveal a unique preventive role;Cancer &Cardiovascular complications
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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
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LYCOPENE: HEALTH BENEFITS
Potent antioxidant
Major scavenger of harmful free radicals
Prevents/delays cardiovascular complications
Prevents oxidation of LDL
Reduces risk of atherosclerosis & CAD
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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
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• 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
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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
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Effect of garlic
Bioactive compound allicinOrganosulfur compound inhibits
hepatocyte cholesterol synthesisAntiplatelet propertiesS alkenyl cysteine results in decreased
HMG coA reductase
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Effect of green tea
Bioactive principle CATECHINEnhances fat oxidationImproves PP glucose responseStimulates insulin secretion