Lec 4 nutrition therapy that apply to specific situations

Dr. Siham Mohamed Osman Gritly 1

Postgraduate Diploma in Diabetes Education (PDDE(

Nutrition therapy: Dietary advice in case of complications

Lec 4 nutrition therapy that apply to specific situations

Prepared by;

Dr. Siham M.O. Gritly


Heart and blood vesselsAdapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning

• atherosclerosis tends to develop early, progress rapidly, and be more severe in people with diabetes.

• The interrelationships among insulin resistance, obesity, hypertension, and atherosclerosis help explain why about 75 percent of people with diabetes die as a consequence of cardiovascular diseases, especially heart attacks.

• Intensive diabetes treatment that keeps blood glucose levels tightly controlled can reduce the risk of cardiovascular disease among those with type 1 diabetes


Atherosclerosis : a type of artery disease characterized by plaques (accumulations of lipid-containing material)

on the inner walls of the arteries

As atherosclerosis progresses, plaque thickens over time, causing arteries to harden, narrow, and become less elastic


Diabetes and Hypertension

• Advise overweight persons to lose weight.• Reduce salt consumption to less than 6 g daily. • Replace processed foods, which are mostly high

in salt, with fruits and vegetables, which are rich in potassium and aid in reducing blood pressure.

• Avoid sustained excessive alcohol consumption, as it has a deleterious effect on blood pressure.


• Physical Activity• Physical activity helps with weight control to

reduce hypertension, • moderate aerobic activity, such as 30 to 60

minutes of brisk walking most days, also helps to lower blood pressure directly.

• Or Regular exercise (30-45 minutes) on 4-5 days/week is beneficial


Dietary Strategies;- Hypertension

• The following dietary plans based on;-

• USDA (United States Department of Agriculture)

• the American Heart Association Dietary Strategies to Stop Hypertension (DASH) ,


• The Dietary Strategies to Stop Hypertension (DASH) recommended that;-

• diet rich in fruits, vegetables, nuts, and low-fat milk products and low in total fat and saturated fat have positive effect on blood pressure.


The DASH Eating Plan and the USDA Food Guide

These diet plans are based on 2000 kcalories per day

Food Group DASH USDA

Grains 6–8 oz 6 ozVegetables 2–2 c 2 cFruits 2–2 c 3 cMilk (fat-free/low-fat

2–3 c 2 c

Lean meats, poultry, fish

6 oz or less 5. oz

Nuts, seeds, legumes

4–5 oz per week combines nuts, seeds, and legumes with meat, poultry, and fish.


Diabetic Dyslipidemia

• is an abnormal amount of lipids (e.g. cholesterol and/or fat) in the blood.

• Dyslipidemia is one of the major risk factors for cardiovascular disease in diabetes mellitus.

• In many persons with type 2, and overweight persons with type 1 diabetes, dyslipidaemia is associated with insulin resistance.

• This is characterised by raised triglycerides and small dense LDL cholesterol.


The characteristic features of diabetic dyslipidemia

• a high plasma triglyceride concentration,• low HDL cholesterol concentration• increased concentration of small dense LDL-

cholesterol particles. • The lipid changes associated with diabetes

mellitus are attributed to increased free fatty acid flux secondary to insulin resistance.


• As suggested by some researchers that the abnormal lipid profile, Lifestyle changes, including increased physical activity and dietary modifications, are the cornerstones of management


Major lipoproteins in the blood


The body makes four main types of lipoproteins, distinguished by their size and density. Each type contains different kinds and amounts of lipids and proteins


• VLDL; in the liver the most active site of lipid synthesis—cells are making;-

• cholesterol,• fatty acids, • and other lipid compounds.

• the lipids made in the liver and those collected from chylomicron remnants are packaged with proteins as VLDL (very-low-density lipoproteins) and shipped to other parts of the body


• As the VLDL travel through the body, cells remove triglycerides, causing the VLDL to shrink.

• As VLDL lose triglycerides, Cholesterol becomes the predominant lipid, and the lipoprotein density increases. The VLDL becomes LDL (low-density lipoprotein).

• * This transformation explains why LDL contain few triglycerides but are loaded with cholesterol


• The LDL circulate throughout the body, making their contents available to the cells of all tissues—muscles (including the heart muscle), fat stores, the mammary glands, and others.

• The cells take triglycerides, cholesterol, and phospholipids to build new membranes, make hormones or other compounds, or store for later use.

• Special LDL receptors on the liver cells play a crucial role in the control of blood cholesterol concentrations by removing LDL from circulation.


• The liver makes HDL to remove cholesterol from the cells and carry it back to the liver for recycling or disposal.

• In addition, HDL have anti-inflammatory properties that seem to keep atherosclerotic plaque from breaking apart and causing heart attacks.


Dietary Management of dyslipidemia in people with diabetes mellitus

• The primary goal in individuals with diabetes is to limit saturated fatty acids, trans fatty acids, and cholesterol intakes so as to reduce risk for CVD.

• Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol


recommendations

Energy: Balance energy intake and physical activity to prevent weight gain and to achieve or maintain a healthy body weight.

Saturated fat, trans fat, and cholesterol: Choose lean meats, vegetables, and low-fat milk products; minimize intake of hydrogenated fats. Limit saturated fats to less than 7 percent of total kcalories, trans fat to less than 1 percent of total kcalories, and cholesterol to less than <200 mg/day

Two or more servings of fish per week (with the exception of commercially fried fish filets) provide n-3 polyunsaturated fatty acids and are recommended


• Plant sterols and stanols have been shown to lower LDL cholesterol:

• An intake of 2 g/day – LDL reduction of 10-15%. • fat-derived products, e.g. yoghurt, semi-skimmed

milk, cereal bars, soft cheese, to other dietary methods for reducing LDL cholesterol.

• Hypertriglyceridaemia is also associated with alcohol consumption.


Soluble fibers:

a diet rich in vegetables, fruits, whole grains, and other foods high in soluble fibers.

Potassium and sodium:

a diet high in potassium-rich fruits and vegetables, low-fat milk products, nuts, and whole grains.

• with little or no salt (limit sodium intake to 2300 milligrams per day).


Added sugars: Minimize intake of beverages and foods with added sugars.

Fish and omega-3 fatty acids: Consume fatty fish rich in omega-3 fatty acids (salmon, tuna, sardines) at least twice a week.

Soy: Consume soy foods to replace animal and dairy products that contain saturated fat and cholesterol.

Alcohol: If alcohol is consumed, limit it to one drink daily for women and two drinks daily for men


Dietary advice in case of complications children and adolescents

• Nutritional or energy requirements change throughout childhood and adolescence, e.g.:

• < 5 years – need a relatively energy-dense diet.

• 6-12 years – energy intake doubles, protein intake per kg body weight decreases.


• Recommendations• Regular dietetic review every 3-4 months

during growth and puberty.

• Monitor height and weight.

• Review changes in lifestyle and physical activity.


• Motivated adolescents benefit from a more flexible approach to diet and insulin.

• Use and intensive management approach in order to permit variability inherent in normal

• Nutrient requirements for children and adolescents with type 1 or 2 diabetes are similar to other children/adults of similar age


PregnancyPregnancy in pre-gestational diabetes

• Good control of diabetes before/during pregnancy is vital to reduce risks to the mother and the child.

• Folate supplementation (5 mg daily) should be taken to prevent neural tube defects in the baby.


• Vitamin/mineral supplements should be given if deemed necessary.

• Women whose body weight exceeds 120% of the ideal should be advised to lose weight before pregnancy


• During pregnancy• Regular dietary follow up is necessary to maintain near-

normal glycaemia and provide nutritional demands for pregnancy.

• A stable meal pattern that is composed of smaller frequent meals is vital.

• Food choices should focus on the need for micronutrient-rich foods (fruits, vegetables, low fat dairy products, lean meat, fish or alternatives) rather than energy-dense fat rich foods.

• Greater consumption of low glycaemic index foods is advisable.


• Alcohol should be avoided. • Tight glycaemic control increases hypoglycaemic risk and people

with diabetes need to be advised on symptoms and measures to take.

• Measures to cope with nausea and vomiting should be given. • Weight gain must be monitored. For a pre-pregnancy BMI of 20-26

kg/m2, recommended total gain is 11.5-16 kg. • If weight is gained too rapidly, try to replace energy-dense food with

nutrient-rich, lower energy alternatives. The aim is to stabilise weight/reduce the rate of weight gain. Active weight reduction is not advisable as it may compromise nutritional intake/foetal development.

• Energy consumption should be sufficient to prevent ketonaemia.


• If weight is gained too rapidly, try to replace energy-dense food with nutrient-rich, lower energy alternatives. The aim is to stabilise weight/reduce the rate of weight gain. Active weight reduction is not advisable as it may compromise nutritional intake/foetal development.

• Energy consumption should be sufficient to prevent ketonaemia.


• Pregnancy– Adequate caloric intake and nutrients needed to provide

appropriate weight gain for mother and fetus

– Focus on food choices for a healthy and steady weight gain, glycemic control, and absence of ketones

– Aim to develop healthy habits and lifestyle modifications (diet and exercise) for after delivery


• Lactation• Breast feeding should be encouraged unless the

infant requires specialist care in a neonatal unit.• The high energy costs of lactation means the

mother may require an additional 40-50 g of carbohydrates/day compared with her pregnancy state.

• Extra carbohydrates may be required before going to bed while the infant is still having nocturnal feeds.


• Gestational diabetes• Provide advice on healthy food choices. • Emphasise low glycaemic index foods and

carbohydrate distribution throughout the day.


• Modest dietary restriction 24-30 kcal/kg in obese women may be advised.

• • Postpartum advice on healthy eating and

weight management is vital as these women are prone to type 2 diabetes.

•


The elderly person

• nutrient-dense foods needs to be encouraged.

• • Overweight persons: weight reduction is

beneficial as long as micronutrient intake is not compromised.

•


• Zinc deficiency is more common in elderly, hence, a need for supplements or zinc-rich diet.

• • Calcium intake: at least 1200 mg; multivitamin

supplementation is advisable especially if low appetite.

•


• Dietary guidelines:• Meals should be balanced to meet clinical

needs of diabetes without diminishing older person’s ability to enjoy meals.

• Avoid hypoglycaemia (relax targets): to reduce falls with associated fractures.

• Physical activity/exercise is beneficial and should be encouraged.


• Institutional care• • In Africa, this is an emerging concept, i.e. homes for the

elderly. However, we have children in boarding schools, residential homes, and juveniles or adults in prison.

• • Residents have no control over the time of their meals and medications, or type and amount of food provided; as well as no access to facilities for food preparation and storage.

• • Undernutrition is common in elderly people in residential care.

• • It is recommended that such elderly residents be given regular meals, with less restrictive

• diets for better nutritional status and quality of life


• In prisons, problems include inappropriate foods and or meal times, and limited

• opportunities to exercise. Diabetes management must thus be provided by a multidisciplinary

• team, who are fully aware of the realities of prison life.


• Ethnic considerations• The dietician must be familiar with customs,

food habits and cooking practices of various ethnic groups,

• Language barriers are also obstacles, but a translator or a relative may help.


Eating disorders

• Eating disorders, such as anorexia and bulimia, are very common in adolescent females.

• This is because of their concern about body weight/shape since they (type 1 females) tend to be heavier than their non-diabetic peers.

• It may involve omission of insulin, reduced food consumption, or outright starvation.

• Success rates for treating eating disorders are lower in persons with diabetes than in those without diabetes.

• The following events should arouse suspicion regarding possible eating disorders:


• The three most common eating disorders found in athletes are:

• 1-Anorexia Nervosa, • 2-Bulimia, • 3-Compulsive Exercise


Anorexia nervosa lose 15 to 60 percent of their normal body weight by severely restricting their

food intake or exercising excessively.

Signs and Symptoms of Anorexia Excessive weight loss Always thinking about food, calories, and body weight Wearing layered clothing Mood swings or depression Inappropriate use of laxatives, or diuretics in order to lose weight Avoiding activities that involve food


Bulimia

Bulimia is one such eating disorder that describes a cycle of binging and purging. Bulimia can begin when restrictive diets fail, or the feeling of hunger associated with reduced calorie intake leads to reduce eating.Like the person with anorexia nervosa, the person with bulimia nervosa spends much time thinking about body weight and food


References

• American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34 Suppl 1:S11-61

• American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31:S61-S78.

• American Diabetes Association. Carbohydrate counting. Available at http://www.diabetes.org/food-and-fitness/food/planning-meals/carb-counting. Accessed December 8, 2012.


• American Diabetes Association (2002). Clinical Practice Recommendations:2002. Diabetes Care 25 (suppl. 1):S64-S68.

• Sareen Gropper, Jack Smith and James Groff, Advanced Nutrition and Human Metabolism, fifth ed. WADSWORTH

• Melvin H Williams 2010; Nutrition for Health, Fitness and Sport. 9th ed, McGraw Hill

• Heymsfield, SB.; Baumgartner N.; Richard and Sheau-Fang P. 1999.

Modern Nutrition in Health and Disease; Shils E Maurice, Olson A. James, Shike Moshe and Ross A. Catharine eds. 9th edition

• Guyton, C. Arthur. 1985. Textbook of Medical Physiology. 6th edition, W.B. Company

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Lec 4 nutrition therapy that apply to specific situations