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Role of Medical Nutrition Therapy in the Management of Non-communicable Diseases Dr. N. Sudheera Kalupahana MBBS (SL), MPhil (SL), Ph.D. (USA) Senior Lecturer,

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Presentation on theme: "Role of Medical Nutrition Therapy in the Management of Non-communicable Diseases Dr. N. Sudheera Kalupahana MBBS (SL), MPhil (SL), Ph.D. (USA) Senior Lecturer,"— Presentation transcript:

1 Role of Medical Nutrition Therapy in the Management of Non-communicable Diseases Dr. N. Sudheera Kalupahana MBBS (SL), MPhil (SL), Ph.D. (USA) Senior Lecturer, Department of Physiology, Faculty of Medicine, University of Peradeniya

2 Why Medical Nutrition Therapy (MNT) is important Components of MNT Burden of NCDs Principles of MNT in Diabetes, NAFLD, CKD NCD preventive strategies Outline

3 History of Medical Nutrition Therapy “Let food be thy medicine and medicine be thy food” Hippocrates,400 B.C.

4 History of Medical Nutrition Therapy Treatment of night blindness in Ancient Egypt by squeezing the juice of a lamb liver onto the eye – Eber’s Papyrus, 1550 B.C.

5 History of Medical Nutrition Therapy Dr. James Lind (18 th Century) tested several scurvy treatments on crew members of the British naval ship Salisbury lemons and oranges were most effective

6 History of Medical Nutrition Therapy Richard Smith, Editorial, BMJ, 2004 “Although many patients are convinced of the importance of food in both causing and relieving their problems, many doctors' knowledge of nutrition is rudimentary. Most feel much more comfortable with drugs than foods, and the “food as medicine” philosophy of Hippocrates has been largely neglected.”

7 What are the Components of Medical Nutrition Therapy? American Academy of Nutrition and Dietetics 1. Performing a comprehensive nutrition assessment determining the nutrition diagnosis 2. Planning and implementing a nutrition intervention using evidence-based nutrition practice guidelines 3. Monitoring and evaluating an individual’s progress over subsequent visits

8 Medical Nutrition Therapy is Provided in the Following Conditions: Cardiovascular Diseases: hypertension, dyslipidemia, congestive heart failure Diabetes: Type 1, Type 2, Gestational Disease Prevention: general wellness GI Disorders: celiac disease, cirrhosis, Crohn’s disease Immunocompromise: food allergy, HIV/AIDS Nutritional Support: oral, enteral, parenteral Oncology Pediatrics: infant/child feeding, failure-to-thrive, inborn errors of metabolism Pulmonary Disease: COPD Renal Disease: insufficiency, chronic failure, transplantation Weight Management: overweight/obesity, bariatric surgery, eating disorders Women’s Health: pregnancy, osteoporosis, anemia

9 Irina A. Nikolic, Anderson E. Stanciole, and Mikhail Zaydman, "Chronic Emergency: Why NCDs Matter," World Bank Health, Nutrition and Population Discussion Paper (2011). Burden of Non-communicable Diseases

10 Diabetes is an emerging problem in SL 1.5 million adults 2.1 million by 2030 Somasundaram et al., Endocrine Society of Sri Lanka, Clinical Guidelines – Diabetes Mellitus – Glucose control, 2013 Medical Nutrition Therapy in Diabetes Mellitus

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12 “For forty-eight hours after admission to the hospital the patient is kept on an ordinary diet, to determine the severity of his diabetes. Then he is starved, and no food allowed save whiskey and black coffee. The whiskey is given in the coffee: 1 ounce of whiskey every two hours, from 7am until 7pm. The whiskey is not an essential part of treatment; it merely furnishes a few calories and keeps the patient more comfortable while he is being starved.” “This is very important: reduce the weight of a fat diabetic, and keep it reduced.” Hill LW, Eckman RS. Starvation Treatment of Diabetes. Boston: W. M. Leonard; 1915 Medical Nutrition Therapy in Diabetes Mellitus

13 Brown et al., Diabetes Care, 1996

14 What are carbohydrates? Carbohydrate is a word for foods that contain starch, sugar and fiber. Most carbohydrates turn into sugar in the body, which will then raise the blood sugar level Therefore it is important to limit the carbohydrates in your meals

15 What foods contain carbohydrates? Rice Foods made with flour (bread, rotti, string hoppers, hoppers, thosai, noodles) Dhal, Cowpea, Chickpeas, Green gram Starchy vegetables (Jack fruit, Bread fruit, potatoes, yams) Fruits and fruit juice Milk, yogurt, curd Sugar, honey, cake, biscuits, sweets

16 Food Groups Fruits Vegetables Grains Protein foods Dairy

17 Eat fruits for snacks Don’t eat fruits with the main meal Limit fruits to the size of one tea-cup per serving (e.g. one small banana) Fruits

18 Vegetables Eat lots of vegetables Limit starchy vegetables like jack fruit, bread fruit, potatoes and sweet potatoes Have vegetables cooked (without coconut milk), boiled, steamed or raw

19 Grains Limit rice to 1-2 tea-cups per meal Limit bread to 2-3 slices per meal Try to have whole grains (e.g. unpolished rice)

20 Protein foods Meat, poultry, seafood, beans and peas, eggs, processed soy products, nuts, and seeds Include protein foods in each main meal Limit red meats (beef and pork) to two servings per week

21 Changing your lifestyle Step 1 – Follow the “Health Plate” Non-starchy Vegetables Protein Food Grains (rice)

22 Step 2 Don’t eat fruits with the main meal Instead, eat fruits at least 2 hours after the breakfast, lunch or dinner Changing your lifestyle

23 Step 3 – Avoid / limit the following Deep fried food (short-eats, mixture, chips) Sweets (biscuits, cake, pudding, ice-cream, chocolate) Changing your lifestyle

24 Step 4 – Be physically active and limit inactivity Adults 30 minutes of moderate intensity exercise (e.g. brisk walking) 5 days / week (can be done in minute bouts) 1 hour/day for weight loss Children and teens: 60 minutes / day Changing your lifestyle

25 Step 5 - Weight Management Food Intake Physical Activity Fat Stores Food intake and physical activity determines your body weight. If your doctor wants you to lose weight, you have to reduced food intake and increase physical activity Changing your lifestyle

26 Medical Nutrition Therapy for NAFLD

27 Case Report Non-alcoholic 40 year-old male, BMI of 28.3 Incidental finding of fatty liver by USS Managed with lifestyle modification (low-fat energy –restricted diet, exercise) Lost 4 kg in 1 month ParameterBeforeAfter SGPT (U/L)19217 SGOT (U/L)13816 FBS (mg/dl)10988 Total Cholesterol (mg/dl) Triglycerides (mg/dl)10089 HDL (mg/dl)6054 LDL (mg/dl)115120

28 Lifestyle modification improves NASH Promrat et al., Hepatology, 2010

29 Lifestyle modification improves NASH

30 Lifestyle Modification Low- Calorie Diet Increased Physical Activity BehaviorTherapy

31 Medical Nutrition Therapy in Chronic Kidney Diseases – on Dialysis Step 1: Choose and prepare foods with less salt and sodium –Buy fresh food –Use spices instead of salt for flavor –Rinse canned vegetables, beans, meat and fish before eating –Avoid high-salt items like soy sauce, salt crackers, dried fish, pickles, chicken cubes

32 Step 2: Eat the right amount and right type of protein –Try to get high-quality protein with a low phosphorous / protein index Meat, Fish, egg whites (avoid pulses) Vegetarians – dhal, chick peas, green gram ?phosphate binders Summary of recommendations for dialysis patients

33 Step 3: Choose foods with less phosphorous –Avoid foods with “PHOS” on food labels –Avoid colas and sports drinks –Replace milk with non-dairy creamers – Use white rice and bread instead of whole- wheat –Avoid nuts (cashews, peanuts) Summary of recommendations for dialysis patients

34 Step 4: Choose foods with the right amount of potassium –Consume low-potassium fruits and vegetables (limit - 2 fruits and 5 tea-cups of vegetables) –Consume green leaves raw (salads) instead of cooking –Chop, boil and drain vegetables to reduce potassium –Reduce coconut milk, coconut water –Use lime instead of tamarind Summary of recommendations for dialysis patients

35 Fruits and Vegetables low in potassium and can be eaten Cabbage Carrots Cauliflower Onion Cucumber Eggplant Green beans Okra Lettuce Apples Papaya Pineapple Berries Grapes Lemons Lime

36 Fruits and Vegetables high in potassium and to avoid Beet greens Broccoli Potatoes Sweet potatoes Pumpkin Spinach Green leaves Tomatoes Bananas Dates Oranges Kiwi Raisins Butter fruit Mango King-coconut water Fruit juices

37 Prevention of Non-communicable Diseases (NCD) Nearly 80% of NCD deaths occur in low- and middle-income countries They share four risk factors: –tobacco use –physical inactivity –alcohol –unhealthy diets

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40 Obesity is an emerging problem in SL % 26% Katulanda et al., 2010 Jayatissa et al., 2012 Katulanda et al., 2010

41 Assessment - Body Mass Index (BMI) BMI = Weight (kg) / Height 2 (m) 2 Normal: Overweight ≥ 23 Obese ≥ 25 WHO, 2004 Consensus statement, 2009

42 Measuring Waist /Hip Circumferences Waist: At the midpoint between the lower margin of the lowest palpable rib and the top of the iliac crest At the end of normal expiration Hip: Around the widest portion of the buttocks, with the tape parallel to the floor Source: Waist Circumference and Waist-Hip Ratio Report of a WHO Expert Consultation, 2008

43 Waist Circumference : ≥ 90cm for men (35.4”) ≥ 80cm for women (31.5”) (Source: WHO, 2008) Waist-Hip ratio : ≥ 0.9 for men ≥ 0.85 for women (Source: WHO, 2008) Abdominal Obesity Cut-offs (for South Asians)

44 Lifestyle Modification Low- Calorie Diet Increased Physical Activity BehaviorTherapy

45 Diabetes Prevention Program: Incidence of Diabetes Cumulative Incidence of Diabetes (%) Year Placebo Metformin Lifestyle 31% 58% Reprinted from Diabetes Prevention Program Research Group. N Engl J Med. 2002; 346: Copyright © 2002 Massachusetts Medical Society. All rights reserved.

46 Curious power of modest weight loss (~7%) Hamman et al., Diabetes Care, 2006

47 Tips to Achieve a Healthy Weight

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49 Nutritional Math How many calories are in 1 gram of each macronutrient? –Carbohydrate: 4 kcal/g –Protein: 4 kcal/g –Fat: 9 kcal/g Although not a macronutrient, alcohol also provides energy in our diet. - Alcohol: 7 kcal/g

50 Choose a variety of colorful fruits and vegetables daily (4-5 cups / day) *cooked without coconut milk Tips to Achieve a Healthy Weight

51 Select whole-grain cereals and bread Tips to Achieve a Healthy Weight

52 Drink water instead of sugar-sweetened beverages Tips to Achieve a Healthy Weight

53 Grill or broil instead of deep-frying food Tips to Achieve a Healthy Weight

54 Replace Full-cream milk with non-fat milk Tips to Achieve a Healthy Weight

55 Reduce portion sizes Tips to Achieve a Healthy Weight

56 High-calorie foods

57 Coconut milk ( 1 medium coconut – 1500 kcal) Chocolate cake (3”X3”X2”): 550 kcal Beer 750ml – 320 kcal Liquor 100ml – 280 kcal High-calorie foods (compare with calorie requirement of 1800 / day)

58 Structured Meal Plans Enhance Weight Control Wing RR, et al. Int J Obes Relat Metab Disord. 1996;20: Weight Change (kg) Months Lifestyle modification + meal plans Weekly Treatment Follow-up Lifestyle modification + food provision Standard lifestyle modification

59 Meal Replacements Enhance Initial and Long-Term Weight Loss *1200 – 1500 kcal/d diet prescription CF = conventional foods; MR = replacements for 2 meals, 2 snacks daily; Reproduced with permission from Ditschuneit HH, et al. Am J Clin Nutr. 1999; 69: and from Fletchner-Mors M, et al. Obes Res. 2000;8: Weight Change (%) Time (mo) Phase 2 Phase 1* MRMR CF

60 Behavior Therapy Goal-setting - Weight-loss goal - Physical activity goal Self monitoring - Body weight - Food diary Stimulus control, stress management, coping strategies

61 How long would you have to walk briskly to burn about 550 calories*? 1 hour and 40 minutes Can you “burn it off”?

62 Physical activity recommended Adults 30 minutes of moderate intensity – 5 days / week 1 hour for weight loss Children and teens: 60 minutes / day

63 Heart-healthy Diets The Mediterranean Diet:

64 Thank You!


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