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8/8/2019 Geeta Final
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MANAGEMENT OF DIET INMANAGEMENT OF DIET IN
CORONARY ARTERY DISEASECORONARY ARTERY DISEASE
WITH DIABETES MELLITUSWITH DIABETES MELLITUS
GeetaGeeta AroraArora, Diabetes Educator, Diabetes Educator
Endocrine DepartmentEndocrine DepartmentA.I.I.M.S., New DelhiA.I.I.M.S., New Delhi
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CAD is a condition in which the coronary CAD is a condition in which the coronary artetriesartetries
become narrowed due tobecome narrowed due to artherosclerosisartherosclerosis, coronary , coronary
artery spasm & the blood supply to the heart isartery spasm & the blood supply to the heart isobstructed & can damage the heart muscle .obstructed & can damage the heart muscle .
DM is a disease characterized by high blood glucoseDM is a disease characterized by high blood glucose
concentration resulting from defects in insulinconcentration resulting from defects in insulin
secretion, insulin action or both.secretion, insulin action or both.
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Common Modifiable Risk FactorsCommon Modifiable Risk FactorsHypertensionHypertension
DyslipidemiaDyslipidemia
Being Being OverwieghtOverwieght B.M.I.>25Kg/mB.M.I.>25Kg/m22
Sedentary LifestyleSedentary Lifestyle
Smoking Smoking
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Dietary Goals For CAD With DMDietary Goals For CAD With DM
To attain and maintain normal blood glucose, blood lipidsTo attain and maintain normal blood glucose, blood lipids
& blood pressure levels& blood pressure levels
To prevent degenerative complications (Macro and Micro)To prevent degenerative complications (Macro and Micro)
Improve health through healthy food choices & physicalImprove health through healthy food choices & physicalactivityactivity
To maintain appropriate weight and optimum nutrition.To maintain appropriate weight and optimum nutrition.
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Targets for diet management in CAD Targets for diet management in CAD
with DM with DM ABC ABC
A A 11CC <6.5%<6.5%
Blood PressureBlood Pressure 130/90mmhg130/90mmhg
CholestrolCholestrol <200mg%<200mg%
LDLLDL <130mg%<130mg%
HDLHDL >50mg%>50mg%
TG TG <150mg%<150mg%
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Recommended Kcal/kg of the Ideal body weight Recommended Kcal/kg of the Ideal body weight
for height or BMI for height or BMI
SedentarySedentary
activityactivity
ModerateModerate
activityactivity
StrenuousStrenuous
activityactivity
Normal weightNormal weight
Over weightOver weight
Under weightUnder weight
25 Kcals25 Kcals
20 Kcals20 Kcals
30 Kcals30 Kcals
30 Kcals30 Kcals
25 Kcals25 Kcals
35 Kcals35 Kcals
3535 KcalsKcals
3030 KcalsKcals
4040 KcalsKcals
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Distribution of Macronutrient in NormalDistribution of Macronutrient in Normal
DiabeticDiabeticNutrientNutrient % of Total Calories% of Total Calories
CarbohydratesCarbohydrates 6060--6565
ProteinsProteins 1515
FatsFats 2525--3030
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CarbohydratesCarbohydrates :: Individualized based on eating habits of Individualized based on eating habits of
patients patients
T ypes T ypes
Simple ComplexSimple Complex FiberFiber
MonosaccharidesMonosaccharides Whole wheat Whole wheat daliadalia,, Fruits,G
reen Leaf Fruits,G
reen Leaf DisaccharidesDisaccharides Flour,Bread,OatsFlour,Bread,Oats,, vegetables, vegetables, SoyabeanSoyabean
Pulses with HusksPulses with Husks Legumes, Beans, BarleyLegumes, Beans, Barley
GramsGrams
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FiberFiber
Fiber Fiber :: 2525-- 40 g / day40 g / day
14 g TDF/ 1000 Kcal14 g TDF/ 1000 Kcal
Benefits of fiber
Reduces gastric emptyingReduces gastric emptying
Slow digestion, slow absorptionSlow digestion, slow absorption
Prolonged intestinal transitionProlonged intestinal transition
Reduction in the following:Reduction in the following:Blood glucoseBlood glucose
Triglycerides Triglycerides
Total Cholesterol Total Cholesterol
LDLLDL
Body weightBody weight
Colon cancerColon cancer
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Glycemic Index (GI)Glycemic Index (GI)
Blood Glucose Response of FoodsBlood Glucose Response of Foods
Low G.I. Foods :Low G.I. Foods : Reduce insulin resistance Reduce insulin resistance
Prevent & control DM Prevent & control DM
Prevent cardiovascular disease Prevent cardiovascular disease
Factors affecting GIFactors affecting GI
Source of Starch (whole grains low G.I.)Source of Starch (whole grains low G.I.)
FiberFiber --Sources :Oats, legumes , rice bran, apples ,dried peas , beans, barley,Sources :Oats, legumes , rice bran, apples ,dried peas , beans, barley,fruits & vegetables are most effective.fruits & vegetables are most effective.
Fat , LimeFat , Lime
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Nutritive sweetenersNutritive sweeteners
**Fructose, honey, molasses, fruit juice, dextrose, maltose,Fructose, honey, molasses, fruit juice, dextrose, maltose, sorbitolsorbitol,, xylitolxylitol
* Fructose* Fructose(Fruits, vegetables & honey) 4 cal/g(Fruits, vegetables & honey) 4 cal/g ± ± slower bloodslower blood
glucose responseglucose response
** SorbitolSorbitol,, mannitolmannitol && xylitolxylitol 22--3 cal / g3 cal / g
* Tolerance level = 10 g / day* Tolerance level = 10 g / day
* Excess : Abdominal gas, discomfort, osmotic* Excess : Abdominal gas, discomfort, osmoticdiarrhoeadiarrhoea
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Non Nutritive SweetenersNon Nutritive Sweeteners
Sweetener Safe marginSweetener Safe margin
**SucraloseSucralose -- ( (Splenda Splenda, Su gar Free , Su gar Free Nat ura Nat ura, , Kaltame Kaltame) ) -- 5 mg / kg B.W5 mg / kg B.W
*Aspartame*Aspartame -- (( N utra N utra sweet, Equal, Su gar Freesweet, Equal, Su gar Free )) -- 50 mg / kg B.W50 mg / kg B.W
*Saccharin*Saccharin -- (( S weet'N S weet'N Low, Su gar Twin Low, Su gar Twin))-- 5 mg /kg B.W5 mg /kg B.W
Do not use for children , pregnancy , lactation ,liverDo not use for children , pregnancy , lactation ,liver
& kidney disorders.& kidney disorders.
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Individualized ,based on the nutrition assessment & treatment goalsIndividualized ,based on the nutrition assessment & treatment goals
Total Cholesterol < 300mg/day Total Cholesterol < 300mg/day
Fat
SourcesSources Function
Saturated fatSaturated fat
7%7%
Red Meat, butter, cheese, ghee,Red Meat, butter, cheese, ghee, whole milk cream whole milk cream
CholestrolCholestrol levellevel
and LDLand LDL
PU FAPU FA
10%10%
Sunflower Oil , Corn Oil, safflowerSunflower Oil , Corn Oil, safflowerOilOil
HDLHDL
& LDL& LDL
MUFAMUFA
1010--15 %15 %
Olive Oil, Canola Oil, Ground Nut Oil,Olive Oil, Canola Oil, Ground Nut Oil,Mustard Oil, Seasame Oil FishMustard Oil, Seasame Oil Fish
HDLHDL
LDLLDL
Trans fat Trans fat
<1%<1%
Baked Products , Biscuits cakesBaked Products , Biscuits cakes
processed cheeseprocessed cheese
HDL &HDL &
LDLLDL
Essential Fatty AcidsEssential Fatty Acids
OMEGA3OMEGA3
OMEGA 6OMEGA 6
Cold water, Fish, Nuts, Seeds,Cold water, Fish, Nuts, Seeds,
Fenugreek, Mustard, Corn Oil,Fenugreek, Mustard, Corn Oil,
SoyabeanSoyabean Oil, Cotton Seed,Oil, Cotton Seed,
Sunflower,Sunflower,
Makes cell membrane more flexibleMakes cell membrane more flexible
Blood Pressure and Cholesterol, TG LevelBlood Pressure and Cholesterol, TG Level
Mortality rate from heart diseaseMortality rate from heart disease
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Recommended fats
* Cooking oil
* Moderate N6, more N3
Mixed Oil: Soya bean/ mustard + sunflower/ safflower,
Sesame /groundnut/corn/rice bran oil
* High MUFA :Olive ,canola , rice bran ,mustard oil
*Trans fats ± To be avoided
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SodiumSodium : :
2.5 g/day2.5 g/day -- mild to moderate hypertensionmild to moderate hypertension
< 2 g/day< 2 g/day -- nephropathy, hypertension &nephropathy, hypertension &edemaedema
Salt: Less than 5 gm/daySalt: Less than 5 gm/day
Vitamins & MineralsVitamins & Minerals: : Normal populationNormal population
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ALCOHOL ALCOHOL
Alcohol is not a recommendation.Alcohol is not a recommendation.
Alcohol has calories. (Beer & Wine)Alcohol has calories. (Beer & Wine)
Alcohol interacts with certain drugs.Alcohol interacts with certain drugs.
To be avoided when Triglycerides are high.To be avoided when Triglycerides are high.
However if allowedHowever if allowed
Moderate amountsModerate amounts ± ± 2 drinks per day, 42 drinks per day, 4--5 times a week for a man &5 times a week for a man &
1 drink per day for a woman1 drink per day for a woman
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In addition to strengthening
& toning up the muscles
Consumes more energy
Sensitize the tissue
To the action of insulin
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ExerciseExercise
Reverses insulin resistance & increases insulinReverses insulin resistance & increases insulin
receptorsreceptors
Reduces weightReduces weight
Lowers LDLLowers LDLIncreases HDLIncreases HDL
Reduces total cholesterolReduces total cholesterol
Psychological benefitsPsychological benefits
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Guidelines for ExerciseGuidelines for Exercise
Test the blood sugar before and after exerciseTest the blood sugar before and after exercise
Maintain gap of at least 1 and half Maintain gap of at least 1 and half ± ± 2 hrs after meal2 hrs after meal
Snacks (10Snacks (10--15 g carbohydrate for < one hour of 15 g carbohydrate for < one hour of moderate exercise (fruit 100moderate exercise (fruit 100--150 g or 1 stuffed roti)150 g or 1 stuffed roti)
Extra snack for peak periods of insulinExtra snack for peak periods of insulin
Add 7Add 7--8 g protein for 1 or > 1 hour of exercise8 g protein for 1 or > 1 hour of exercise
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Conclusion
1. Education to maintain healthy lifestyle
2. Maintain ideal body weight
3. Maintain normal blood lipid levels
4. Food should contain whole grains,legumes and green
vegetables (fiber)
5. Use low GI foods
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Conclusion
6. Mixed oils should be used to achieve N6/N3 fatty acid ratio
7. MUFA is beneficial
8. Reduce SFA and avoid TFA
9. Small sized, frequently spaced meals
10. Regular exercise is essential