Managing Disease and Avoiding Complications Through Diet Diversification.pptx 31.10.14

8/9/2019 Managing Disease and Avoiding Complications Through Diet Diversification.pptx 31.10.14

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H N D - 4 0 3 D I E T E T I C S – I I I 3 ( 3 - 0 )

Managing disease and avoidingcomplications through diet

diversification

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Diet diversification

Food diversification; Make wider selection of foods with a high vitamin & mineral

content available for purchase More varied meals and have a more balanced diet Reduce under-nutrition and malnutrition Integrate food security

Diversification can be delivered through health services, along with food supplementation and fortification;

Play a major part in reducing malnutrition

Hence, dietary diversification/modification are the strategies toenhance micronutrients and bioavailability of varied diets forhealth promotion and disease prevention

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Adequate human nutrition involves regular intake of a wide rangeof nutrients, some of which must be consumed on a frequent basis,even if in small quantities

Micronutrient deficiencies are prevalent in areas where the diet

lacks variety, as in developing countries

When people cannot afford to diversify their diets with adequateamounts of fruits, vegetables or animal-source foods that containlarge amounts of micronutrients, deficiencies are inevitable

In addition, minimum amount of fat or vegetable oil is alsorequired in the diet for adequate absorption of fat-soluble vitamins A, D, E and K

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In treating the problem of micronutrient deficiencies, food-basedapproaches focus on improving overall dietary quality, rather thanmerely delivering a single nutrient

Complex nutrient-nutrient interactions increases bioavailability when nutrients consumed simultaneously

According to FAO, iron absorption is increased when it iscombined with vitamin C

Protective chemicals are easily obtained by consuming a wide variety of fruits and vegetables

Scientific knowledge linking nutrition and disease associate widerange of nutrients in health maintenance

Rickets; associated with vitamin D deficiency is now connected todiets low in calcium

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Dependent relationships heightens the importance of promotingfood-based approaches that focus on achieving sustainedimprovements in overall diet

Several low-cost, food-based measures that can be promoted atcommunity level to improve micronutrient status

Culturally appropriate dietary modifications should be developedto help people identify concrete actions that can improve both

dietary supply and micronutrients absorption

This information needs to be disseminated to the public throughtraditional information channels

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Dietary Diversity (DD); Typically measured in the form of count of food groups or food

group frequency Suggested as a proxy indicator for nutrient adequacy

Augmented by expanding production, processing, marketingand consumption of a wide variety of foods

Dietary diversity score (DDS) is an indicator of; Overall diet i.e. associated with nutrient adequacy ratios after

adjusting energy intake Nutritional adequacy of diet to assess the relationship between

DDS and disease risk factors

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Diverse diets protect against chronic diseases such as cancerhence associated with prolonged longevity and improved healthstatus

To protect from CVD, higher variety score are associated withincreased intakes of fibre, vitamin C and calcium

Nutritional epidemiology focuses on the affect of overall dietquality on diet-disease relationship instead of single nutrient

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Dietary Diversity (DD)

Defined as the number of individual food items or food groupsconsumed over a given period of time

It can be measured at household or individual level through the use of questionnaire

Most often it is measured by counting the number of food groups rather

than food items consumed

Type and number of food groups included in the questionnaire andsubsequent analysis vary, depending on the intended purpose and levelof measurement

At household level, dietary diversity is considered as a measure of foodaccess (e.g. households’ capacity to access costly food groups)

At individual level it reflects dietary quality, mainly micronutrientadequacy of the diet

Reference period can vary but is most often the previous day or week

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Dietary diversity is measured to monitor the impact of food based approaches; Monotonous diets mainly on energy dense but micronutrient

poor starchy staples are common in food insecure areas andcontribute to malnutrition

Food-based strategies are recommended as the first priority tomeet micronutrient needs

Inclusion of essential elements to food-based approaches

involves dietary diversification or consumption of a wide variety of foods across nutritionally distinct food groups

Increased dietary diversity is associated with increasedhousehold food access as well as individual probability of

adequate micronutrient intake

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Measurement of dietary diversity

Dietary diversity is measured as the number of individual food itemsor food groups consumed over a given reference period

FAO has developed a standardized tool for measuring dietary diversity that can be administered at either the household or individual level

The tool uses an open recall method to gather information on all thefoods and drinks consumed by the household or individual over theprevious 24 hr

Food and drinks mentioned by the respondent are then recorded intoone of 16 standardized food groups

Information from dietary diversity tool can then be analyzed in many different ways to provide a picture of dietary patterns within the

community as well as among vulnerable groups

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Conventional quantitative dietary assessment surveys arecostly and cumbersome to conduct and analyze

Resultantly, interest is found in using simple proxies of intake

that can be measured quickly and easily, reflecting validnutrient intake

Hence, rationale for developing dietary diversity measurementtools as proxies of quantitative dietary intake

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FAO’s dietary diversity guidelines

FAO has published operational guidelines for measuringdietary diversity in a standardized way

FAO data collection tool uses an open recall method to gatherinformation on all food and drinks consumed by household or

individual level over the previous 24 hours

Foods and drinks recalled by the respondent are then recordedinto one of 16 standardized food groups

Also inquire to capture information on consumption of any food groups not mentioned in the open recall

FAO guidelines describe how to adapt the tool to local foodsystems

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FAO guidelines recommend the following ways of reporting informationcollected on dietary diversity;

Dietary diversity scores are simple counts of number of food groupsconsumed at individual or household level

Two dietary diversity scores recommended by FAO; Household Dietary Diversity Score (HDDS) based on twelve food groups Women’s Dietary Diversity Score (WDDS) based on nine food groups

Mean scores can be compared across population sub-groups and overtime

Dietary profiles based on food groups consumed by a majority of

individuals/households can be compared; To provide insights on consumption patterns across population sub-groups

Percentage of individuals or households consuming food groups orcombinations of nutrient dense food groups (such as food groups rich in Vitamin A) can be analyzed

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Dietary diversity scores limits the ability to detect changes ordifferences in the mean score, particularly when the samplesize is small

Another limitation is that there is no universally recognizedcut point above or below which households or individuals can be classified as having adequate or inadequate dietary diversity

Additionally, at household level, the tool underestimate

household dietary diversity in urban areas and amongpopulations where out of home food consumption is common

Given these limitations, it is strongly recommended not to usethe dietary diversity measure as a standalone tool

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Thus, DD measurement should be integrated into broadersurvey instruments and results triangulated with othercharacteristics of interest such as wealth or food security status To obtain a holistic picture of the food and nutrition security situation

in a community

Collecting information on dietary diversity should be of interest where primary or secondary objective is to improvethe diet of the beneficiary population

Dietary diversity data are useful to evaluate the impact of foodand nutrition security program

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Role of nutrients in diet diversification

with respect to disease management

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Fiber

Recent recommendations suggest that fiber proportion should befulfilled from fiber rich foods rather than from dietary supplements

Healthy diet should provide a mixture of both soluble and insolublefibers

Different sources of fiber include; fruits (apple and citrus), leafy green vegetables, oats, wheat bran, whole grains, legumes, etc.

Good source should contain fiber upto 3 g while 5 g in high fiber diet

Healthy adult should consume 30-40 g of fiber/day

Children between the age of 3-18 need less fiber than adults and needdifferent amounts at different ages

To calculate a child’s daily fiber requirements, add the child’s age tonumber five (for five grams) For example: four year old child need nine grams of fiber/day

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Carbohydrates

Carbohydrates require less water to digest than protein or fats Carbohydrates are not necessary for human nutrition because

protein can be converted to carbohydrates

Carbohydrate is present in number of food items thus its deficiency

is very rare Excess carbohydrate is the raw material for liver to manufacture

triglyceride and cholesterol

Exercise causes the body to utilize energy from glycogen followed

by fat reserve One should not eliminate carbohydrates completely from the diet

because body then start using protein as energy source

Low carbohydrate diets slow down brain and neural function

Because nervous system especially relies on glucose (brain’spreferred fuel)

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Carbohydrate and glycemic index

Glycemic Index (GI) is a number associated with a particular type of food that indicates the food's effect on a person's blood glucose level

High fiber (contains less digestible carbohydrate), more fat (causes theliver to become resistant to insulin) or acid content (inactivates

amylase) in food or coarsely ground grains possess slower carbohydrateconversion to sugar

Starches in potatoes and ripened fruits and vegetables possess higherglycemic index

Glycemic index was originally invented to help diabetes patients tomanage their blood sugar levels, obesity, cravings and appetite swings

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Complex carbohydrates

Take longer to convert glucose, result in few insulin surges and lessnutrient depletion Digested in small intestine and more steady source of energy for a longer

period of time

Oat bran (soluble fiber); rich source of β-D-glucan thus used for cholesterolreduction

If attempting to lose weight and diabetes run in families, totally avoid simplecarbohydrates and be cautious with fruit and fruit juices

Fruits are best consumed one half hour before any other foods for quick entry into small intestine

Fruits in the midst of a large meal will keep the fruits in stomach for a longertime to ferment

Most effective approach to lose weight is to keep complex carbohydrates to aminimum, stop all simple carbohydrates and do not eat any food after your

evening meal

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Protein

One should eat a variety of protein foods to obtain full range of essential amino acids

Combination of plant and animal proteins is recommended for a balanced diet

Protein choices for vegetarians include legumes, nuts and dairy products

Weight loss strategies require protein consumption, away from any

carbohydrates

If dietary Ca is inadequate, excess protein increases calcium lossesin the bones

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Protein and fat are vital building components for body tissuesand cells hence not advisable to deplete

Protein in food is broken down into amino acids, forming a variety of proteins like collagen, myosin and hemoglobin asrequired by the body

Body has a finite need for protein, if one has fulfilled his dietary needs, additional proteins are deaminated and stored as fat

Kidney have to work overtime to get rid the body from excessnitrogen

Protein in the blood help to hold salt and water inside the blood vessels so fluid does not leak out into the tissues

For example; too low albumin (most abundant blood protein)causes oedema

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Fat

Average person makes up 75% of blood cholesterol in liver whileonly 25% get absorbed from food

About 10% of fat is converted to sugars in process called“gluconeogenesis”

Without fat in the diet, fat soluble vitamins would not able tofunction, resulting in severe problems

Fat protects internal organs, necessary for proper developmentof child

Dietary fat stimulates bile flow and emptying of gallbladderotherwise leads to gallstones

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Type of fat really matters in the diet; Bad fat means saturated or trans fat that increases disease risk Good fat means monounsaturated or polyunsaturated fat that lowers the disease risk

Fish contain polyunsaturated fat known as omega-3 fatty acids thatprotects against cardiac rhythm disturbances

Avoid commercial shortening and deep fat frying that leads to theformation of trans fatty acids

Trans fats are even worse than saturated fat because they raise bad LDLand lower good HDL

Trans fats lead to inflammation and over-activity of immune systemresulting in heart diseases and diabetes

Replacing only 30 calories (7 grams) of carbohydrates every day with 30calories (4 grams) of trans fat nearly double the risk for heart diseases

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Minerals and vitamins

Minerals are vital in absorption, function and effectiveness of certain vitamins

Vitamins are not sufficiently absorbed, if minerals are notpresent in proper proportion

Deficiency of one mineral may disrupt the entire chain of life,rendering other nutrients either useless or inefficient

Vitamins are required for every biochemical activity of the body but vitamins cannot function unless minerals are present

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Dietary diversification to

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Dietary management of CVD

Without cholesterol, body cannotfunction properly

Too much cholesterol causes

deposition in arteries leading toheart diseases

Triglyceride and trans fatty acidsare more atherogenic raising LDLand lowering HDL

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Dietary management of hypertensive subjects

Energy; About 20 kcal/kg b.w. are prescribed for

sedentary workers and 25 kcal/kg b.w. formoderately active worker

Increased calorie intake especially in theform of carbohydrate and fat significantly increases Sympathetic Nervous System(SNS) activity ultimately increasing blood

pressure

In case of obese hypertensive, a hypocaloricdiet is recommended

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Protein; Intake of 60 g protein daily is necessary to maintain proper

nutritional status

Excess amount of animal protein should be avoided

Protein foods are rich in sodium as well thus in severehypertension, reduction of 20 g proteins is advised astemporary measure

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Fats; Low fat diet i.e. about 20% of energy should come from fats

More of unsaturated fats should be used

About 20 g vegetable oil is permitted

High intake of animal or hydrogenated fats is avoided as thesepatients are more prone to atherosclerosis or other coronary

heart diseases

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Carbohydrate; About 60-65% of energy should come from carbohydrate

sources

Complex carbohydrates like starches and dietary fibers should be included to manage high blood pressure

Dietary fiber in the form of wheat, wheat bran, pectin and oat bran have hypotensive influence

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Sodium; Mild to moderate sodium restriction (1-2 g salt/day) along

with weight reduction is effective in controlling hypertension

Increased intake of sodium in diet leads to increased cardiacoutput, elevating blood pressure

Moderate sodium restriction up to 2-3 g salt/day reducesdiastolic pressure by 6-10 mm Hg, lowering blood pressure

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Low sodium and sodium/potassium ratio is preferred inthe diet

Average sodium intake is about 3000 mg/day

500 mg of sodium causes loss of about 10 mg of calcium

Sodium intake of < 50-80 mEq/day; No hypertension No increase in blood pressure with age

Sodium restriction up to 70-100 mEq/day (4-5 g of salt)is recommended for all hypertensive patients

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Potassium and calcium;

Sufficient amounts of foods rich in potassium and calciumshould be included in the diet

Role of potassium in hypertension is actually important as ithas complex interplay with sodium

For example; low levels of potassium cause the body to

retain sodium and water, elevating blood pressure

Reduction of sodium to potassium ratio by 3.1:1 is associated with 3.4 mm Hg decrease in the average level of systolic blood pressure

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Potassium rich foods such as fruits and vegetables should beincluded in the diet to fulfill 3500 mg of required potassium ondaily basis

800 mg/day of dietary Ca reduces hypertension significantly

Oral supplementation of Mg lowers both systolic and diastolic blood pressure (-0.2 and -0.1 mm Hg, respectively)

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Tips to reduce salt intake

Consume foods that are labeled “low sodium”, “no salt added” or“unsalted”

Check the total sodium content on food labels

Partially replace salt with pepper, garlic, lemon or other spicesfor flavor

Foods to be avoided; Naturally high in sodium; cured meat, hot dogs, bacons, sausages,

ham, nuts, olives, pickles, soy and worcestershire sauces, tomato& vegetable juices and cheese

Salt preserved foods like pickles, highly salt processed foods anduse of monosodium glutamate, baking powder, sodium

bicarbonate and sodium benzoate

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Dietary management of atherosclerotic subjects

In the initial phase of heart diseases, the basic objective iscardiac rest and strict dietary management

Diet modifications for heart to prevent cardiac disordersinclude; Adequate nourishment Maximum rest for heart Prevent further heart damage Restore the damaged heart to normal functioning Maintenance of good nutrition Relieve strain to heart Prevent and eliminate edema

To achieve above objectives, the diet is further modified inenergy value

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Normal diet with some modifications is suggested; Low calories, cholesterol and saturated fat High PUFA and MUFA along with omega -6 and omega-3 fatty

acids Low in simple carbohydrates and high fiber Normal protein and minerals & vitamins

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Energy; Total calories should be restricted to reduce weight according to what

is expected normal for height, age and sex

Mild degree of weight loss for the cardiac patients of normal weight isalso recommended

Obese or overweight patients experience symptomatic relief after weight reduction

Loss of weight by obese leads to considerable reduction in heart load Because decreased BMR lowers heart rate and blood pressure, improving

cardiac efficiency

During initial recovery period, 800-1000 kcal/day is recommendedthat progresses to 1200-1500 kcal/day while the patient is still at bedrest

Usually, 1000-2000 kcal/day is suitable for obese patients in bed

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After heart attack, it is advisable to under nourish thepatient for first two days;

High food intake increases cardiac burden to meet the

metabolic demands for digestion

Hypocaloric diet is recommended to reduces metabolic activity and accommodate heart activity without extra strain

In rehabilitative stage, calories adjustment is required tonormalize the weight

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Fat; Both type and amount of fat have to be modified

Fats > 20% of total calories can be tolerated without any side-effects

Low fat, cholesterol and monounsaturated fatty acids arerecommended

Monounsaturated fatty acids lowers LDL i.e. present in vegetablesources such as olive oil, canola oil, almond oil and groundnut oil

It is not desirable to restrict all forms of fat as severe restriction resultsin mental and physical depression

Choose soft margarines being lower in trans fatty acids than stick margarines

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Cholesterol; Manufactured in liver (about 2 g/day) in the amounts required

by the body to perform various functions

Hence, cholesterol level in the diet should not exceed 300 mg

Because serum cholesterol > 260 mg/dL cannot be reducedthrough diet

Saturated Fatty Acids (SFA) increases total cholesterol whileomega-6 decreases it; 1% increase in SFA increases total cholesterol by 2.7 mg/dL

1% increases in omega-6 fatty acids results in 1.4 mg/dLreduction in total cholesterol

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Vegetable oil; Trans Fatty Acids (TFA) High levels of TFA resemble saturated fatty acids as both raise

LDL while suppress HDL Consuming twice the average level of TFA, reduces HDL by 2.8%

Trans Fatty Acids (TFA) are produced during hydrogenation of vegetable oils

Commercially prepared, partially hydrogenated margarines and

solid cooking oils are high in trans fatty acids

In US, main sources of trans fatty acids include stick margarine(contain more TFA than soft, tub margarines), shortening,commercial frying fats and high-fat baked goods

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Consumer trend is now diverting towards unsaturated vegetableoil that contain no cholesterol but possess essential fatty acids,linoleic acids and antioxidants like vitamin E

Partially hydrogenated vegetable oils are required to maintain

the quality of commercially baked goods and decreasesSaturated Fatty Acid (SFA) intake as wellBecause totally liquid vegetable oils are unsuitable for fried

and baked products

Monounsaturated fatty acids (MUFAs) in olive oil and peanut oilare substituted for SFA; 12-15% of calories from MUFAs is recommended to lower

plasma total cholesterol and LDL without lowering HDL

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Polyunsaturated fatty acids (PUFA); Important PUFA are linoleic acid and α-linolenic acid

Omega-6 (linoleic acid) lowers total cholesterol and LDL while lowers HDL if consumed in larger amounts

Sources; Safflower and corn oil

Omega-3 (linolenic acid) lowers LDL, triacylglycerols andtotal serum cholesterol but not HDL levels (dose dependantaffect) Sources; mustard oil and soybean oil

Eicosapentanoic acid (i.e. omega-3) have an inverseassociation with coronary artery diseases (CAD) for men

Docosapentanoic acid have an inverse association with CADfor women

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Fish or fish oil prevent two important aspects of Coronary HeartDiseases (CHDs);

Lipid rich atherosclerotic plaque

Thrombosis

Antithrombic action of omega-3 fatty acids; decreasesthromoboxane A2 and increases prostacyclins

Example; salmons (rich in omega-3) reduce heart attacks, assistin brain development, prevent Alzheimer’s disease & breastcancer

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Role of fish oil; Reduces hypercholesterolemia

Stops formation of atherosclerotic plaque, platelet aggregatesand blood clots

Reduces platelet adhesiveness and increases bleeding time upto 4 min by prostaglandins levels due to essential fatty acids

Suppresses inflammation

Decreases blood viscosity by improving oxygen supply totissues and narrow blood vessels

Reduces fat level in the blood after a fatty meal

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Vegetarianism; Lower rate of LDL production plus low in calories, fat and

cholesterol

Higher linoleic acid and lower arachidonic acid concentrations

in platelets

Adequate fiber intake as it helps in binding cholesterol

Vegetable oil diminishes plasma cholesterol with the help of

PUFA Plant sterol inhibits cholesterol absorption and increases fecal

excretionConsumption of about 1.6 g of plant sterols/day beneficially

lowers serum cholesterol level

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Carbohydrates;

Adequate intake of complex carbohydrates and water solublefiber (whole pulses, legumes, beans, oats, fruits and vegetables) is recommended

Easily digestible carbohydrates should be included to reducethe work load on heart to minimum

As total calories are restricted resultantly carbohydrate intakecan also be reduced

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Fiber; Soluble fiber effects on plasma lipids by;

Binding cholesterol, steroid and bile acids in the smallintestine, carrying them to colon for elimination

Decreasing lipid and sterol absorption

Pectin in 2-8 apples/day have hypocholesterolemic effect

Pectin and guar gum reduces total cholesterol by 10% or more

Small amounts of legumes especially beans reduce totalcholesterol and triacylglycerols better than large consumption of fruits and vegetables

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Fiber in citrus pectin (28 g) reduces cholesterol up to 13mg/dL

One cup of hot oat bran cereal or five oat bran muffins/day reduces lipid response significantly

Oat contain compounds called avenanthramides thathinders the ability of blood cells to stick to artery walls

Water soluble fiber in oat reduces LDL circulation in blood vessels due to the antiinflammatory activity of avenanthramides

Dietary fiber is also inversely associated with high bloodpressure, LDL, HDL and triacylglycerols

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Protein; Sufficient intake of vegetable protein is suggested

Normal intake of protein @ 1 g/kg b.w. is advised for themaintenance of body tissue protein

Animal proteins are not suggested for atherosclerotic patients

Total fat, animal fat, organ meats, eggs and seafood are restricted

Choose chicken, fish or beans instead of red meat and cheese

Skim milk should be advisable due to its cholesterol loweringeffect

Eggs should be eaten in restricted amount only

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Mineral and vitamins; Normal allowances of vitamins and minerals are

recommended especially from fruits and vegetables

Get at least 5 serving of fruits and vegetables/day to avoid

constipation

Folate fortified breakfast or folate multivitamin @ 400 µg/day is suggested as it is good for heart

Deficiency of vitamin A may occur hence its supplementationis essential

Beverages containing caffeine are omitted because of theirstimulating effect on heart rate

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Folate; High homocysteine levels damages arterial walls

Conversion of homocysteine to methionine require folic acidand vitamin B12

High homocysteine and low folate levels double the risk of heart attacks

Homocysteine elevation are reversible if folic acid intake isincreased

In US studies, 9% male and 5.4% female prevented CVDthrough flour fortification @ 350 mcg folic acid/100 g food

Iron; Iron neither increases nor decreases infarct and CHD risk in

male as well as female

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Antioxidants; Garlic consumption (1/2 to 1 clove);

Reduces cholesterol by 9% when > 200 mg/dL

Vitamin E intake reverses CHD risk

Vitamin K;Stops vascular calcificationSuppress hardening of arteries

Activate a protein in artery walls that keeps calcifiedhardened sections of blood vessels from expanding orprevent further damage

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Sodium restricted diet;

Diet prescription to remove cardiac oedema; low in sodium(only 2-3 g/day) and energy

In severe oedema, fluid intake should be restricted

Egg and green leafy vegetables i.e. high in sodium arerestricted thus other sources of iodine should be prescribed

Because severe restriction of iodine also reduces vitamin-A

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Mild sodium restriction (2-3 g); Less salt use in cooking Fresh foods should be used Restrict salt processed foods

Moderate sodium restriction (1000 mg); No salt is used in cooking Use fresh foods and avoid salt processed foods Salt free baked products should be used

Strict sodium restriction; Natural sodium food sources; milk (two cups only), meat and

egg could be used in small proportions Vegetables containing higher sodium contents are not allowed

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Other recommendations in high blood pressureand heart diseases

Grapes and grape juice is particularly valuable when one isactually suffering from heart attack

Use of boiled vegetables, avoiding oil/ghee, doing yogicexercises and living tension free life reverse the heart problems

Vitamin C protects against heart attacks and high bloodpressure

Stress, anger, fear, disappointment and similar emotions canraise blood fat and cholesterol level immediately

Stress can do little harm if the diet is adequate in vitamin Cand pantothenic acid

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Daily consumption of lemon and bottle gourd keeps the heartstrong and reduces blood pressure

Daily intake of sprouted grams and moong makes the heartmuscles strong

Indian gooseberry or amla is considered an effective homeremedy for heart diseases

Patients suffering from a weak heart are benefitted by makingliberal use of apples

Onions are valuable in heart diseases, maintain bloodcholesterol by oxidizing excess cholesterol

Honey improves blood circulation, effective in cardiac pain

and prevent all sorts of heart troubles

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Safflower oil proved beneficial in lowering blood cholesterol

Patients with heart disease should increase their intake of foods rich in vitamin EOuter leaves of cabbage is a good source of vitamin E;

Promotes heart function by improving oxygenation of thecells

Improves circulation and muscle strength

Daily consume papaya on an empty stomach for a month

For higher efficiency, do not eat anything after for about 2 hr

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prevent diabetes62


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Dietary management of diabetics

Dietary control is an integral part of management fordiabetics

Diet provide essentials of good nutrition and adjustmentsmust be made from time to time for changing metabolic

needs

Mainstays of treatment include; Working to obtain ideal body weight

Following a diabetic diet

Regular exercise

Diabetic medication if needed

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Calories; Patients with type 1 diabetes should consume approx. 35

calories/kg b.w./day

Patients with type 2 diabetes should put on 1500-1800

kcal/day; Promote weight loss Maintain ideal body weight

Variation in calorie adjustment is found on the basis of person’s age, sex, activity level and current weight

Men require more calories due to more muscle mass Muscle burns more calories per hour than fat

People with low activity level need less calories on daily basis

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Proteins; Generally, diabetic are in negative nitrogen balance as large

quantities of nitrogen are excreted in the urine They should receive about twice as much protein as normal

subjects

Proteins should be of high biological value, providing about20-25% calories in the diet

Diet high in protein is good for diabetics because; It supplies essential amino acids needed for tissue repair Protein does not raise blood sugar during absorption as do

carbohydrates It does not supply more of calories

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Carbohydrates; Simple carbohydrates (mono and disaccharide) like sweets,

chocolates, etc. should be avoided

Despite of high carbohydrate, high fiber improves insulin

functioning

If total calories are not increased, raising carbohydrate intakedoes not adversely affect blood glucose or insulin requirements

Generally, low carbohydrate intake is associated with lowersugar levels in the blood

Daily intake of carbohydrate should provide about 40% of thecalories to prevent ketosis

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Fiber; Soluble fiber in oat bran, legumes (dried beans, peas and

lentils), pectin (from apples) and root vegetables (such ascarrot) manages diabetes by;

Controlling blood sugar by delaying gastric (stomach)emptying

Retarding glucose entry into the bloodstream

Decreasing postprandial (post-meal) rise in blood sugar

Reducing insulin requirements in type 1 diabetes

Slowing food digestion, suppressing sudden rise in bloodglucose that may occur after a low-fiber meal

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Fats; Fat allowance makes up the remaining calories for most diets

after protein and carbohydrate intakes

In case of adult diabetics or obese, fat intake is lowered to 20%or less/day energy intake

Foods high in saturated fat and cholesterol should be limited

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Pl i di f di b i bj


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Planning diet for diabetic subjects

Avoid simple sugar and high blood glucose level;

Roots and tubers e.g. potato, sweet potato, colocasia (taroplant or “arvi"), yam, tapioca (starch extracted from cassavaroot) except carrot and radish

Sugar, glucose, jams, honey, sweets, fried foods and alcohol

Fruits such as mango, banana, chickoo, custard apple, etc.

Include high fiber foods as these restrict excess fats & oils;Green leafy vegetablesSalad without salad dressing

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Oth d ti f di b ti


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Other recommendations for diabetics

Soak fenugreek seeds in water and drink that water in themorning on an empty stomach

Eat one teaspoon of cinnamon daily

Bitter gourd juice

Boil mango leaves in water, saturate and drink in the morning

Consume garlic daily

Put peels of green plantain in water and drink this water thricea day

Drink water boiled with leaves of basil, neem, jamun along with seeds of pepper (exception for high blood pressure)

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correct liver diseases71

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Dietary modifications in hepatic subjects

Basis of treatment; Adequate rest Requires dietary modifications

Objective of diet therapy; Relieve symptoms Aid in regeneration of liver cells Prevent further liver damage

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Energy; Initially, patient is not capable of eating large quantity of food

due to illness

Only 1500-2000 kcal is acceptable;Patient is advised to take bed rest thus reducing daily actual

energy expenditure

Gradual increase in energy intake up to 20-30% isrecommended;To promote weight gainTo ensure maximum protein utilization

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Protein; Protein of high biological value for maximum utilization,

preferably supplemented with protein of vegetable origin

In mild to moderate cases, high protein intake of 1.5-2 g/kg b.w. is suggested

In acute cases, with excessive liver damage, protein intakedecreases even below normalBecause damaged liver is unable to tolerate a high protein

load as it converts ammonia to urea, leading to hepatic coma

Protein intake is necessary;To overcome a negative nitrogen balanceTo promote regeneration of liver cellsTo prevent fatty infiltration of liver

Thus, protein intake depends on extent of liver damage

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Cont…

Carbohydrates;

High carbohydrate is recommended;To provide more energy

To build up glycogen stores in the liver as protection againstfatty infiltration for their protein sparing action

Daily intake of 300-400 g of simple carbohydrate should be

given

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Cont…

Fat; In liver disorder, digestion of fat is affected due to impaired

bile action

In mild to moderate cases, 35-45 g of total fat/day could begiven

In severe cases, accompanied by liver damage, total fat must berestricted by 20-30 g/day

More important is to modify the quality of fat;Emulsified fats such as milk fat should be givenMedium chain triglyceride present in coconut are better

tolerated

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Cont…

Minerals and vitamins; Judicious intake is recommended

Diet should provide all minerals particularly Ca and iron;To compensate increased tissue catabolism

Availability of fat-soluble vitamins is low;Because of decreased intake and impaired fat absorption

Care should be taken to include carotene rich foods like greenleafy vegetables, deep yellow or orange fruits and vegetables inthe diet

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Foods to be included Foods to be restricted

Sugar, glucose, honey,

Cereals & pulses

Milk & milk products

Eggs

Fruits & vegetables

Fats, oils, nuts, oil seeds

Strongly flavored fruits &

vegetables and meat

Intake of alcohol duringthe attack

Cont…78

Dietary modifications in cirrhotic subjects


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Dietary modifications in cirrhotic subjects

Objectives of dietary modifications are; To promote regeneration of liver cells

To correct fluid and electrolyte balance

To rectify the nutritional deficiencies

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Cont…

Energy; During the disease, patient become malnourished so their

energy requirement increases

Energy is required to promote regeneration of liver cells

Normal energy intakes are enough to meet bodily needsBecause actual energy expenditure for the patient on bed

rest is less

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Cont…

Protein; About 1-1.5 g protein/kg b.w. is suggested in the absence of hepatic coma (occur in severe cases of liver diseases)

If signs of impending coma appear, protein intake is decreasedto 0.3-0.5 g/kg of b.w. depending on individual tolerance;

To overcome malnutritionTo regenerate liver cellsTo replenish plasma proteins

Damaged hepatic cells may not be able to efficiently convert allammonia into urea

More vegetable protein should be included in the diet;Because animal proteins contain more aromatic amino acids

and their catabolism causes more ammonia production,leading to hepatic encephalopathy

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Cont…

Carbohydrates; Daily intakes of 300 g of carbohydrates

Mainly simple carbohydrates; glucose, sugar, fruits and fruit juices, starch (cereals and root vegetables) are advised

Foods containing irritating fibers should be eliminated due tothe presence of esophageal varices;

Thus, dehusked pulses, refined cereals and low fiber vegetables and fruits should be selected

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Cont…

Fats; Many cirrhotic patients suffer from malabsorption of fat due to

impaired bile secretion in liver diseases

Restriction in fat intake should be suggested for such patients

Moderate amount of fat can be included in the diet to increasepalatability and promote recovery

Emulsified fats and fat containing medium chain triglycerideare better tolerated

Amount of fat to be included in the diet varies according to theindividual's tolerance

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Cont…

Vitamins; Availability of fat-soluble vitamins is affected due to the

decreased intake and impaired fat absorption

Diet should include β-carotene rich foods

Supplements of vitamin B-group should be provided toreplenish liver stores and repair tissue damage

Minerals; Serum Ca and Mg levels are low in cirrhotic patients hence

need supplementation

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Cont…

Sodium; Sodium should be restricted

Because of the presence of ascites and oedema

In severe cases, 500 mg of sodium is recommended

During recovery period, restriction is somewhat relaxed

One should be very cautious about cooking salt, baking powderand preserved food products

In case of patients on diuretic therapy, liberal sodium intake isadvised

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Dietary modifications in cholecystitis andh l l h


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cholelithiasis

Usually low fat, high carbohydrate and moderate protein diet isrecommended

Large meals should be avoided and plenty of fluids should betaken early in the morning, late at night and in between the

meals

Nutritional therapy for gall bladder (involve in fat metabolism)include; Relief from discomfort of gall bladder Keep gall bladder at rest by minimizing the contractions

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Cont…

Modification in the diet include; Fat should be restricted in the diet to about 10-20 g

Causes contraction of gall bladder and consequent pain

Absorption of all fat-soluble vitamins is reduced hence their

intake should be increased

Carbohydrates sources like cereals, starches, simple sugar,pulses, fruits, etc. should be incorporated to fulfill energy requirements

Protein intake is kept normal, preferably from vegetariansources as they contain lesser fat than protein of animal origin

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Foods recommended Foods to be avoided

Skim milk, beverages liketea, coffee & fruit juices

Cereals like wheat, rice &pulses

Fruits & vegetables

Egg white, poultry and sea

food

Fatty, fried foods, butter,ghee, cheese and

margarine Red meat, cream soups,

whole milk

Fatty desserts like cake,

pastries and ice creams,chocolates

Nuts and dry fruits

Cont…88

Dietary management of jaundice


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Dietary management of jaundice

Fresh tomatoes or green leaves of radish; valuable remedy for jaundice

Juice of green leaves of pigeon pea isuseful in jaundice

Paste of almonds, dried dates andcardamoms is effective remedy for jaundice

Lemon is beneficial to treat jaundice andliver damage

Barley water is an effective remedy

Basil and reddish juice is also preventiveagainst this disease

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manage renal diseases90

Dietary modifications in renal disorders


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Dietary modifications in renal disorders

Diet modifications are not strict or rigid

Main objectives of dietary modifications include;To maintain adequate and optimum nutritionTo prevent oedema and uraemia

Adequate protein is given unless oliguria or anuria develops

Salt is restricted as oedema and hypertension are common inthis disease

Bed rest and antibiotic therapy are mainly important

Fluid intake is adjusted according to the fluid output

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Cont…

Energy; Energy requirements are usually the same as in good health

Sufficient calories are given

Calories need to be reduced up to 10-20%, if the patient is notsuffering from any kind of malnutrition and at bed rest sincelong time

Cereals in all forms is allowed

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Cont…

Carbohydrates; Intake is liberal to provide sufficient kilocalories for energy

needs

Carbohydrate help in protein sparing action, reducing protein

catabolism and preventing ketosis

Both simple carbohydrates such as sugars as well as complexforms such as starches can be included in the diet

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Cont…

Fat;Reduce bulk of dietMake diet more palatable

Fat is not restricted

Emulsified and easily digestible fats are included

Give non-protein calories for energy needs

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Cont…

Proteins; Intake of 20-40 g/day or 0.5-0.6 g of /kg b.w. is recommended

Dietary protein must be restricted because;Blood urea nitrogen is elevatedOliguria and anuria is present

Fruit and vegetables can be given being lower in protein, sodiumand potassium

Pulses and groundnuts increase the urea levels in blood so these

should be restricted

Sago (sabo dana) also contributes protein so need to avoid

Rice is good than wheat due to high quality protein

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Cont…

Sodium; Usually sodium is restricted to 500-1000 mg/day

Restriction varies with oliguria, oedema and hypertension

With recovery, sodium intake can be increased

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Cont…

Fluids; Fluid intake is adjusted according to urine output

During early stages of treatment, fluid intake is decreased toallow fluid dispersal i.e. accumulated in the body

In later stages, fluid intake is based on volume of fluid excreted Allowance of 500 mL/day is given for insensible water loss

Daily fluid replacement should be 500 mL plus daily amount

exceeded in the urine

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Dietary modifications in nephrotic syndrome


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Dietary modifications in nephrotic syndrome

High energy, low to moderate protein & fat and low sodiumdiet is prescribed

Energy;

High energy diet must be provided for the efficient utilizationof protein for tissue synthesis

High daily intakes of 50-60 kcal/kg b.w. are recommended

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Cont…

Protein; Restriction of protein is usually done;

Because increased protein intake adversely affects on kidney functioning

Plasma albumin level reduces as the major cause of oedemadevelopmentHence, moderate to high protein intake is suggested

according to the condition of the patient

Daily protein intake of 0.6-2 g/kg b.w. is recommended;To replenish the depleted storesTo enhance the synthesis of albumin

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Cont…

Sodium; Sodium level in the diet must be sufficiently reduced to combat

massive oedema

Diuretics are used to prevent further accumulation of fluids insome patients

For these patients, extreme degree of salt restriction is notrequired

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Dietary modifications in Acute Renal Failure (ARF)


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Dietary modifications in Acute Renal Failure (ARF)

Energy; Minimum intake of 800-

1200 kcal of energy isrequired depending on the

patient’s condition

Non-protein sources of energy should be included

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Protein; In the initial stages, no protein is given to the patients

As the condition improves, only 15-25 g/day protein should begiven to overcome endogenous losses

Complete proteins of high biological value should be included

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Fluid; Fluid intake is adjusted to compensate water losses during

urination, vomiting or diarrhea

Fluid intake is usually restricted to 500 mL/day for an average

adult with additions made for losses via other routes

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Dietary management of chronic renal failure


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y g

Objectives of dietary management in chronic renal failureinclude; Maintain electrolyte balance

Prevent protein catabolism

Control fluid and electrolyte losses during vomiting or diarrhea

Maintain optimal nutritional status

Maintain appetite

Control hypertension

Retard progression of renal failure

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Energy; Adequate kilocalories are mandatory

Carbohydrates and fat must supply sufficient non-proteinkilocalories;Spare proteins for tissue protein synthesisSupply energy

About 350-450 g of carbohydrates should be provided topatient everyday

If kilocalories intake is inadequate, protein catabolismincreases to supply energy, aggravating uremia

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Protein; Protein intake can be reduced to 0.5 g/kg b.w./day

To reduce azotemia and hyperkalemia

If blood urea nitrogen increases, restrict protein intake up to

15-20 g/day

In the absence of symptoms, protein restriction is not necessary

As renal failure progresses, patient develop symptoms of

uraemia hence can be treated through;Regular haemodialysisPeritoneal dialysisRenal transplantation

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Fluid; Fluid intake should be monitored carefully to avoid water

intoxication from overloading or dehydrationBecause capacity of failing kidneys to handle water is limited

Fluid intake should be decided, depending on the condition of patients

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Sodium and potassium; Sodium intake varies between 1500-2000 mg/day

Hypokalemia can occur at any time in chronic renal failure

In such cases, small dose of potassium should be given withproper checking of serum levels

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Dietary diversification in cancer109

Dietary management of cancer patients


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y g p

Plant phytoestrogen prevent binding of endogenous estrogen toestrogen receptor

Phytoestrogen includes isoflavones, daidzein and genisteinSoybeans and legumes are primary sources of daidzein and

genistein

Lignins in flaxseeds, in the form of glycoside is converted intomammalian lignins (enterodiol and enterolactone)Enterolactone possesses antiestrogenic, anticarcinogenic and

antiproliferative properties

Lignin; also associated with high fiber intake hence protectsagainst colon cancer

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Fiber from fruits and vegetables reduce cancer risks, whichmay also vary by gender

Calcium decreases the risk of colorectal cancer becauseincreased Ca in bile salts decreases cancer promotion

Likewise, vitamin D supplementation reduces colorectalcancer

Wheat bran fiber have protective effects against adenomasleading to carcinomas

Dietary fiber @ 30 g/day reduces circulating estrogen hencemodifies breast cancer

Lycopene protects human cells from free radicals ultimately oxidative stress, aging heart diseases and cancer

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Consumption of heat processed tomatoes increases lycopenelevels up to 5 times (by increasing bioavailability) as comparedto fresh tomatoes

Resveratrol starves cancer cells by stopping the action of key proteins (nuclear factor-kappa B) responsible for survival

Resveratrol initiates a reaction in NF-kB molecule, causingcancer cells to self-destruct in a process called apoptosis

Conjugated Linoleic Acids (CLA) inhibits uncontrolled cell

growth or neoplasia

Phytosterols (β-sitosterol) inhibit cell proliferation andstimulate apoptosis of human colon cancer

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Di t di ifi ti t


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prevent obesity 113

Dietary management of obesity (negative calorie balance)


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(negative calorie balance)

If calorie expenditure exceeds the calorie intake, negative calorie

balance occurs resulting in weight loss

Small frequent meals

Eat a low calorie or carbohydrate diet

High fiber and low fat diet

Regular exercise improves fitness and feeling of well-beingamong obese

Some foods get stored as fat more easily than others but toomuch of anything even “healthy food” get stored as fat

One can lose one pound weight by reducing 3500-calorie in a week through diet, exercise or preferably a combination of both

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Cutting calories in excess slows down metabolic rate, decreasingthyroid output hence causing loss of lean muscle mass

Calorie deficit for fat loss; reduce calories by at least 500 but not> 1000 i.e. below the maintenance level

Especially for lighter people, 1000 calories is a big deficit

Reducing calories by 15-20% below Total Daily Energy Expenditure (TDEE) is good place to start

Large deficit is necessary in some cases but best approach is to;Keep the calories deficit through diet Increase physical activity

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Other recommendations for obesity (fatness)


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Chew food efficiently

Do not take meals in tension

Bread/chapatti should contain a mixture of whole grams flour

and soybeans

Take half lemon in hot water daily in the morning

Increase in Ca reduces overweight and obesity by 60-80%

Drinking sodas (regular or diet) is linked with overweight

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Dietary diversification to manage

gout, arthritis and osteoarthritis117

Dietary management of gout complications


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Objectives; Control uric acid levels in

the blood Control and maintain IBW

(Ideal Body Weight) Provide relief from

symptoms Maintain optimal nutrition

status

Follow protein and calorie

restricted diet to reduce uricacid levels in the blood

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Following modifications in the diet arerequired;

Energy; Curtail energy requirement in case of

overweight individuals as losing weight lowersthe uric acid levels in the blood

Protein; Reduce protein content in the diet as uric acid

is a breakdown product of protein

Fat; Restrict fat content in the diet especially oils i.e.

subjected to heat as in fried foods

Fluids; Consume plenty of water as fluid intake

promotes uric acid excretion

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Other preventive measures include; Drink at least 6-8 glasses of water/day, fresh juices or herbal

tea, especially at the first signs of goutTo keep urine dilutedTo excrete uric acid

To prevent crystal formation

Eat generous amounts of other fruits and vegetables especially foods high in potassium;To keep uric acid crystals in solution form

Flavonoid containing foods should be the part of permanentgout-preventive diet

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After each meal, drink freshly squeezed lemon juice in lukewarm waterTo prevents gout attacks by stimulating the formation of

calcium carbonate in the body Calcium carbonate neutralizes acids in the body, including

uric acid responsible for gout attacks

Taking ½ teaspoon of baking soda with meals will prevent goutattacks by alkalizing the body

High fiber diet helps to eliminate uric acid by absorbing bile acidsformed in the liverBile acids act as a precursor to uric acid

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Dietary management to prevent arthritis


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Potato juice therapy in the morning

One teaspoon of black sesame seeds

3-4 walnuts or 1 fresh coconut on an empty stomach

Garlic or lime juice, effective remedies for arthritis

Deficiency of 1,25-dihydroxyvitamin D reduces Ca absorption

Oral supplementation of Ca and vitamin D decreases glucocorticoid-associated bone loss

Relief from arthritic symptoms; Garlic and wheat germ oil Apple cider vinegar and honey Vitamin A, D, E,C and choline Ca, Zn, Cu, Fe and Se

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Dietary management of osteoporosis


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Get adequate vitamin D, K and Ca along with muscle

strengthening exercises

Drink four or more cups of coffee increases the risk of fractures Because caffeine tends to promote Ca excretion in urine

Getting too much protein can leach Ca from bones Because as body digests protein, it releases acid into the blood whichthe body neutralizes by drawing Ca from the bones

Animal protein cause more Ca leaching than vegetable protein

Do not take more of vitamin A, preformed vitamin A canpromote fractures

While, vitamin A in the form of β-carotene does not increasesone’s fracture risk

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Dietary diversification to manageh th idi h th idi


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hypothyroidism, hyperthyroidism,

constipation and diarrhea124

Dietary management of hypothyroidism


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Avoid rapeseeds, brassica vegetables, maize, millets, sorghum,sweet potatoes and soy products As they contain natural goitrogens ; Causes thyroid glands to enlarge by interfering thyroid hormone

synthesis

Do not consume > 25-30 g of fat/day Fat intake should come mainly from vegetable oil i.e. rich in

essential fatty acids

Vitamin and mineral intakes should meet the daily requirement

Use very little sodium chloride (common salt) Avoid salted confectioneries, chips and pickles

Limit smoking, alcohol and caffeine (found in tea, coffee, colaand chocolate) as these raises the metabolic rate

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Diet should be low in calories

Adequate protein, fat and minerals & vitamins

Increase iodine consumption by eating;

Only iodized table salt

Seafood; fish (three times a week), fresh & canned oysters,prawns, shrimps, mussels and seaweed

Food commodities cultivated along the coastline, containingmore iodine than food grown at inland farms Iodine content depends on iodine level in soil and water

where cultivated

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Dietary management of hyperthyroidism


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Diet should include;Combination of pulses & wheat sprouts and carotene rich

foods like papaya, mango, fenugreek leaves and spinach

Intake of vitamin A, B and C should be increased twice the

daily requirement

Limit smoking, alcohol and caffeine containing beverages liketea, coffee and chocolate

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During hyperthyroidism, calcium and phosphorous excretionincreases;Hence, calcium and phosphorous rich foods like milk & milk

products and dark green leafy vegetables must be consumed

Ragi prepared with milk is an excellent source of calciumand phosphorous

Diets for hyperthyroidism consists of high calories, proteins, vitamins & minerals

Hence, the diet should consists of egg, meat, poultry andcombination of cereal & pulses

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Dietary management of constipation


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No special diet for constipation, modification in fiber andfluid intakes should be made in regular diet

Fiber; High fiber intake relives constipation

Increases the motility of small intestine and colon Amount of fiber required for this effect varies considerably

from individual to individual

Fluid Around 12-14 glasses of water are suggested Along with water, soups and broths should also be given

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Dietary management of diarrhea


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Objectives of dietary treatment in chronic diarrhea; To meet nutritional requirement To correct electrolyte and water losses

Increase energy intake by 10-20%, especially through

carbohydrates sources

Improve protein intake by 40-45%

Restrict fat intake by 15-20%

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Drink at least 8 to 10 glasses of fluid everyday to replace lost

fluid

Good fluid sources include; water, juices (except prune juicedue to laxative effects as rich in sorbitol), broth, ginger ale and weak tea

Treatment of diarrhea is different for each individual

Limit foods containing caffeine such as coffee, strong tea andaerated beverages

In some cases, milk and milk based products made diarrhea

worse Lactose free milk or soy based beverages are better tolerated

Limit high fatty foods such as fried foods, fatty meats, high fatdeserts, excess butter, margarine, higher fat milk products andgreasy snack foods

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Try eating small meals throughout the day

Reduce the amount of fiber in the diet

Fiber is found mostly in fruits & vegetables, whole grain breads & cereals and nuts & seeds

Avoid foods high sugar, lactose, high protein diet, fats & oilsand processed foods like all-purpose flour

Avoid dried peas, beans, broccoli, cabbage, cauliflower andonion to avoid cramping

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Diverse diets solve nutritional deficiencies; Balance and variety of meal especially rich in fruits and vegetables, is

the best insurance against deficiencies

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Documents

Managing Disease and Avoiding Complications Through Diet Diversification.pptx 31.10.14