1. By Hellen C Baliach Consultant Clinical Nutritionist
Role of Medical Nutrition Therapy in Prevention and Treatment Of Diabetes By
Hellen C Baliach
Consultant Clinical Nutritionist

2. Objectives Definition of terms
Outline of objectives of Medical Nutrition Therapy
Outline of nutritional assessment
Nutritional data from diabetes clinic andDiet Advicory Clinic (DAC)
What is the ideal diet
Challenges
Recomendations
Conclusion

3. What is on your Plate?

4. Definitions of Terms ‘Diabetic diet’-A normal diet
is simply a healthy eating plan
Aim-is to control the blood sugar level
Diet forms one of the three cornerstones of good health-1. Exercise/diabetes education 2.medication 3. meal planning

5. Definitions of Terms
BMI-for-Age: is a growth indicator that relates BMI to age. BMI for age is determined using gender-specific growth charts that place a child in a percentile relative to weight and height (WHO, 2006).
Obesity: A condition of malnutrition where there is deposition of excess fats around the body
particularly in subcutaneous tissues that arises from intake of food in excess of the body energy requirements(WHO, 2004)

6. Terms
Stunting: Growth failure that occurs over a slow cumulative process caused by inadequate nutrition or repeated infections in a child. It is defined as Weight-for-Height Z-scores < -2
Stunted-overweight/obesity-co-existence of stunting and overweight/obesity(WFH Z-scores <-2 and BMI for age z-scores <-2)

7. Aim of Medical Nutrition Therapy (MNT)
MNT is important in preventing diabetes
managing existing diabetes
Preventing and slowing the rate of development of diabetes complications
Achieving nutrition-related goals requires involvement of the person with diabetes in the decision-making process

8. Objectives of Medical Nutrition Therapy
Attain and maintain blood glucose level as close as normal
Prevent Hypo and Hyperglycemia
Obtain optimum blood lipids and blood pressure control and reduce the risk of macro vascular disease.
Assess energy intake to achieve optimum body weight
Promote physical, social and physiological wellbeing.

9. Objectives of Medical Nutrition Therapy
Prevent, delay or minimize the onset of chronic degenerative complications such as hypertension and renal disease.
Achieve and maintaining optimal metabolic and physiological outcome.
Provide relief from symptoms
Individualize meal plan according to a person’s lifestyle and based on usual dietary intake

10. Prevalence of Diabetes by sex in the clinic

11. Disease Prevalence in Diabetes Clinic

12. Anthropometrical Assessments
Physical measurements- involves measurements of the physical dimensions and gross composition of the body (WHO 1995)
Provide information on the past nutritional history and degree of chronic protein Energy Imbalance
The measurements vary with age,sex,race and degree of nutrition.

13. Body Mass Index Classification Wt(kg)/Ht(m)2(WHO,2006)
Underweight
Normal range
Overweight
Preobese
Obese class 1
Obese class 11
Obese class 111
BMI
< 18.5
18.5 – 24.99
>25
25 – 29.99
30 – 34.99
35 – 39
> 40
DISEASE RISK
Low (but risk of other clinical problems is increased
Average
Increased
Moderate
Severe
Very severe

14. Classification by BMI(DAC)

15. Prevalence of Stunted-Overweight
In children BMI> 75th percentile have increased risk of coronary heart disease, atherosclerosis and cerebrovascular diseases (Ellis, 2001)
Stunted-overweight puts the child at high risk of developing diabetes in adulthood
Prevalence of stunted-overweight was 3% at well Baby Clinic at KNH (CH. Hellen,AM Mwangi,2010)
19% children aged 3 years were both stunted and overweight SA (Mamabolo , et al 2007).

16. Waist–hip ratio
Measurement of waist hip ratio: In a lean person (left), the waist can be measured at its narrowest point, while for a person with convex waist (right), it may be measured at about one inch above the navel. The hip is measured at its widest portion of the buttocks at left, and at the great trochanters at right.
Waist–hip ratio or waist-to-hip ratio (WHR) is the ratio of the circumference of the waist to that of the hips.

17. Waist-Hip Ratio

18. Waist to Hip Ratio Chart
Waist and Hip Ratio
Waist to Hip Ratio Chart
Male
Female
Health Risk Based Solely on WHR
0.95 or below
0.80 or below
Low Risk
0.96 to 1.0
0.81 to 0.85
Moderate Risk
1.0+
0.85+
High Risk

19. Clinical
Observations – those who use raw carrot juice and raw beet root has elevated Blood Glucose.
Sweeterners, diet coke and ‘sugar free juices’

20. Biochemical assessments
Lipid profile
HBA1C
Blood sugar
Kidney and Hearth functions

21. Ecological factors
Are known to influence the nutritional status of individuals.
Variables include; household composition, education, literacy
ethinicity, religion, income, employment, material resources, water supply and household sanitation, access to health, and agricultural services as well as land ownership.

22. More cases have Diabetes(DAC)

23. Prevalence by Sex in DAC Clinic

24. Which diet? Current choices 1. low fat diet 2. low carbohydrates
3. Mediterranean diet

25. Standard modern diet consist of:
55-60% carbohydrates
20-30% fat
15-20% protein

26. Why low carbohydrates -metabolic consequences
Rapid reduction in body weight due to increased lipolysis
Increased water loss at the beginning
Mild metabolic ketoacidosis
Decrease in appetite and eventually food intake
Improvement in insulin resistance, plasma lipids and plasma glucose- caveats hypokalemia (cramps, weak legs) and bowel obstructions

27. A low carbohydrate Diet?
Improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus
(a 1- year prospective randomized intervention study Abel V.S et al, 2010)
Long-term following of any low calorie diet is beneficial for patients with type 2 diabetes
But only as a part of a structured permanent lifestyle modification

28. Major Challenges
Majority of the clients do not access the nutrition services.
Less than 5% of the total clients attending DC receive the Nutrition services
Clients have varied nutrition information/knowledge from other health workers,herbalists, relatives, bussinesmen/women
Undoing the information is a challenge.

29. Reccomendations Refer healthy clients – Hospital protocol
Refer all clients to Dietician/ Nutritionist
Nutrition guidelines on management of diabetes to be improved.
Provision of optimal Nutrition should start before, after and during pregnancy
Proper feeding practices and growth monitering should start from birth

30. Conclusion
Glycemic control is achieved when Drugs and Nutritional Therapy are combined
Diabetes management involves multidisplinary approach.
Prevention is better than cure- through
Intensifications of campaigns/education-Breastf eeding and HBV-proteins

31. How much food on your Plate