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Medical Nutrition Therapy inDiabetes
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Diet in diabetes is like religion
Everybody talks about it
Everybody interprets it
Everybody claims to understand it
Nobody truly practices it
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Primary goals of Medical NutritionTherapy for all persons with
Diabetes
Attain & maintain recommended metabolicoutcomes (glucose, HbA1c, cholesterol,triglycerides, blood pressure & body weight)
Prevent & treat the chronic complications & co-morbidities of diabetes
Improve health thro healthy food choices &physical activity
Address individual needs
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Goals of Medical Nutrition Therapythat apply to specific situations
Youth with type I diabetes : adequate energy &integrating insulin with eating regimen
Youth with type II diabetes: to facilitate change in
eating habits & encourage physical activity
Pregnant & Lactating women : adequate energy &other nutrients for optimum outcomes
Older adults : Provide nutritional & psychosocialneeds of aging
For individuals at risk : encourage good foodhabits & encourage physical activity
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Medical Nutrition therapyinvolves the following
Nutrition assessment to evaluate the patientsintake
Assessment of metabolic status
Lifestyle & readiness to make changes
Goal setting
Dietary instructions
Evaluation
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Assessment criteria
Dietary factors
Socioeconomic details
Lifestyle
Anthropometry
Physical examination
Biochemical Parameters
Clinical parameters
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Diabetes and Energy
The amount of energy provided to a diabetic dependson his/her weight
Weight loss in obese diabetics is an imp therapeuticobjective for persons with type 2 diabetes
Wt loss is associated with decreased insulin resistance,improved measures of glycemia & dyslipedemia &reduced blood pressure
Along with a reduced caloried diet, exercise andbehaviour modification are most useful for long termweight loss
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Diabetes and CHO
CHO can be divided into Sugars, Starches & Fibre
50 60% of energy should come from CHO
Different CHO have differing glycemic responses & they aredependent on a no of factors
Recent studies indicate that sucrose does not increase glycemiathan iso caloric amounts of starch.
Sucrose containing food need not be restricted, but substitutedfor other CHO sources or covered by medication
Fibre intake is encouraged as they confer metabolic benefits onglycemic control & plasma lipids (20g/1000cal)
The contribution of CHO should therefore be individualized basedon nut assessment, metabolic profile & treatment goals
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Diabetes and Protein
For persons with diabetes, 15- 20 % of the totalenergy should come from proteins
Prudent to avoid consuming > 20 % as the long
terms effects of high protein consumption on thedevelopment of nephropathy has not beendetermined
Food proteins can come from both veg andanimal sources and with the onset ofnephropathy, lower protein intakes arerecommended ( 0.8 gm / kg body weight)
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Diabetes and fat
For persons with diabetes, < 10 -15 % of the energyshould come from fats and < 7 % when LDL is above100mg
The primary dietary fat goal for persons withdiabetes is to limit saturated fat & dietary cholesterol
intake
Since sat fat is the primary determinant of plasmaLDL, < 10 % of the energy should come fromsaturated fat
Dietary cholesterol should not exceed 300 mg / dayand < 200 mg /day when LDL levels are above 100mg
N3 polyunsaturated fats may be most beneficial forthe treatment of hypertriglyceridemia and havecardioprotective effects
Intake of transfatty acids should be limited as it
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Diabetes and micronutrients
Persons with diabetes should be educated about theimportance of consuming adequate amounts of vitsand minerals from natural food sources
There is no clear evidence of benefit from vit &mineral supplementation in diabetics who have nounderlying deficiency
Exception to the above include folate for prevention ofbirth defects and calcium for prevention of bonedisease
Supplementation of vit and minerals in selectpopulation may be beneficial, but the patient shouldbe educated about the toxicity
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Diabetes and alcohol
Precautions for alcohol use is the same for diabetics andthe general population
Abstention is advised for * women during pregnancy *Pancreatitis * Advanced neuropathy * Severe
hypertriglyceredemia *Alcohol abuse
Alcohol limit : one drink for an adult woman and 2 for aman ( one drink is equal to 12 oz of beer, 5 oz of wine, 1.5oz of distilled spirits)
Cardio protective effects of alcohol appear not to bedetermined by the type of alc beverage consumed
To reduce risk of hypoglycemia, alcohol should always beconsumed with food
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Food Groups
Cereals
Pulses
Milk & milk products Vegetables
Fruits
Fats & oils
Meat & meat products
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Cereals
Cereals are the staple food in our country
They are rich in CHO & a fair source of minerals &B-group vitamins
All cereals have the same amount of CHO. Hencethe quantity of cereal consumption should bestressed upon, rather than the quality
A mixture of cereals should provide the fullcomplement of vitamins
A diet rich in whole grains should be advocatedrather than refined grains
The consumption of processed cereal food itemsshould be discouraged
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Pulses
Pulses (dhals & whole grams) are animportant source of protein forvegetarians
Inclusion of sprouted whole grams shouldbe encourged as they provide thenecessary fibre
Pulses should be restricted for patientswith nephropathy
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Vegetables
Vegetables are important for their mineral, vitamins& fibre content
Consumption of vegetables (both raw & cooked)should be encouraged as they provide the necessaryfibre
Some root veg which have more CHO like potato,sweet potato, yam, tapioca & sweet pumpkin are bestavoided
In nephropathy, the intake of raw veg should be
avoided and veg should be consumed after leachingthem of potassium
Leaching is a process in which cut veg and dhals areboiled in water for a few mins. The water is thendrained and the veg cooked with fresh water
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Fruits
Fruits are rich sources of vitamins, CHO & fibre
Fruits can be taken in limited quantities only whenthe blood sugar is below 200mg/dl
Some intensly sweet fruits like Mango,Seethaphal, Sapota, Jackfruit & Banana are bestavoided
Fruit juices in all forms should be completely
restricted
Excessive consumption of fruits can alter theglycemic control and lipid profile
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Milk and Milk Products
Milk & milk products contain good quality ofprotein for vegetarians
The cream of milk is also a rich source of saturated
fat. Therefore milk should always be skimmed ofcream before consumption
Milk can also be consumed in the form of yoghurt,curd and cheese. They should also be fat free
before consumption
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Fats and oils
Fats and oils are rich sources ofconcentrated energy
Consumption of saturated fats (butter,ghee Cream etc) should be kept to aminimum
The intake of transfatty acids should be
completely avoided
A mixture of oils (both saturated &unsaturated) is advocated
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Meat, fish and eggs
Rich sources of protein, vits, iron & phosphorous
Egg yolk is a rich source of cholesterol & should beavoided by people with dyslipedemia
Meat should be skimmed of all fat beforeconsumption
Method of cooking should preferably not involvedeep frying
Fish is a rich source of omega 3 fats and is hearthealthy
The consumption of meat & meat products isrestricted in patients with diabetic nephropathy
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Dietary modifications for co-morbidconditions
Protein, potassium, Sodium & fluid restrictions forpatients with diabetic nephropathy
Sodium restriction for patients with hypertension &
heart disease
Saturated fat restrictions for patients withdyslipedemia
Protein & fat restriction for patients with hepaticdiseases
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Sweeteners
A variety of sweeteners are used and aresafe for consumption in the amountsprescribed even for pregnancy and children
Some of the sweetners available in theIndian market are aspartame & saccharin
Fructose as a sweetening agent is not
recommended as it may adversely affectplasma lipids
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General Principles of Meal Planning
A diabetic should be motivated to adhere to his/her
diet throught life
Discourage fasting or feasting
Help the diabetic plan his meals into 3 major meals
and 2 minor meals or snacks
Stress upon restricting all direct sugars and refinedfoods
Educate the patient on the misconceptions that he orshe may have
Encourage the use of fibre rich foods
Stress on reducing total fat intake
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Strategies consider to affectadherence
Tailor the diet to the clients lifestyle
Involve client in decision making
Promote exercise
Promote self blood glucose monitoring
Identify areas where client is willing tochange
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Role of a diet counselor
Inform about the expected change
Use different appeals
Suggest alternatives for adopting newpractices
Use appropriate counselling skills empathy, reflective listening, praise etc
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Thankyou
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