Presentation is loading. Please wait.

Presentation is loading. Please wait.

Faculty of Medicine, University of Peradeniya

Similar presentations


Presentation on theme: "Faculty of Medicine, University of Peradeniya"— Presentation transcript:

1 Faculty of Medicine, University of Peradeniya
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 Outline Why Medical Nutrition Therapy (MNT) is important
Components of MNT Burden of NCDs Principles of MNT in Diabetes, NAFLD, CKD NCD preventive strategies

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 (18th 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
“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.” Richard Smith, Editorial, BMJ, 2004

7 What are the Components of Medical Nutrition Therapy?
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 American Academy of Nutrition and Dietetics

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

10 1.5 million adults 2.1 million by 2030
Medical Nutrition Therapy in Diabetes Mellitus 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

11 Medical Nutrition Therapy in Diabetes Mellitus

12 Medical Nutrition Therapy in Diabetes Mellitus
“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

13 Medical Nutrition Therapy in Diabetes Mellitus
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 Fruits 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)

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” Protein Food Non-starchy Vegetables Grains (rice)

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

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

24 Changing your lifestyle
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 3 10-minute bouts) 1 hour/day for weight loss Children and teens: 60 minutes / day

25 Step 5 - Weight Management
Changing your lifestyle 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

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 Parameter Before After SGPT (U/L) 192 17 SGOT (U/L) 138 16 FBS (mg/dl) 109 88 Total Cholesterol (mg/dl) 193 Triglycerides (mg/dl) 100 89 HDL (mg/dl) 60 54 LDL (mg/dl) 115 120

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

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

30 Lifestyle Modification
Low- Calorie Diet Increased Physical Activity Lifestyle modification The three components of lifestyle modification are diet, exercise, and behavior therapy. Several reviews have found that standard lifestyle modification programs conducted in academic medical centers induce a mean weight reduction of approximately 8–10% of initial weight in 16–26 weeks of treatment. Many commercial weight loss programs also incorporate the principles of lifestyle modification. Such programs, however, produce more modest results than those achieved in clinical settings. The largest randomized controlled investigation of a commercial weight loss program, for example, found mean weight losses of 5.3% and 3.2% at 1 and 2 years, respectively, compared with 1.5% and 0%, respectively, for participants assigned to a control condition. Efforts to improve the results of lifestyle modification programs have typically involved modifying the diet and exercise prescriptions. The following slides will present typical diet and physical activity recommendations, as well as summarize the results of modifications. Components of behavior therapy also will be described. References: Wadden TA, Butryn ML, Byrne KJ. Efficacy of lifestyle modification for long-term weight control. Obes Res. 2004;12:151S-162S. Fabricatore AN, Wadden TA. Obesity. Annu Rev Clin Psychol. 2006;2: Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 2005;142:56-66. Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program. JAMA. 2003;289: Behavior Therapy

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 Summary of recommendations for dialysis patients
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

33 Summary of recommendations for dialysis patients
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)

34 Summary of recommendations for dialysis patients
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

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

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

38

39

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

41 Assessment - Body Mass Index (BMI)
BMI = Weight (kg) / Height2 (m)2 Normal: Overweight ≥ 23 Obese ≥ 25 WHO, 2004 Consensus statement, 2009

42 Measuring Waist /Hip Circumferences
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 Abdominal Obesity Cut-offs (for South Asians)
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

44 Lifestyle Modification
Low- Calorie Diet Increased Physical Activity Lifestyle modification The three components of lifestyle modification are diet, exercise, and behavior therapy. Several reviews have found that standard lifestyle modification programs conducted in academic medical centers induce a mean weight reduction of approximately 8–10% of initial weight in 16–26 weeks of treatment. Many commercial weight loss programs also incorporate the principles of lifestyle modification. Such programs, however, produce more modest results than those achieved in clinical settings. The largest randomized controlled investigation of a commercial weight loss program, for example, found mean weight losses of 5.3% and 3.2% at 1 and 2 years, respectively, compared with 1.5% and 0%, respectively, for participants assigned to a control condition. Efforts to improve the results of lifestyle modification programs have typically involved modifying the diet and exercise prescriptions. The following slides will present typical diet and physical activity recommendations, as well as summarize the results of modifications. Components of behavior therapy also will be described. References: Wadden TA, Butryn ML, Byrne KJ. Efficacy of lifestyle modification for long-term weight control. Obes Res. 2004;12:151S-162S. Fabricatore AN, Wadden TA. Obesity. Annu Rev Clin Psychol. 2006;2: Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 2005;142:56-66. Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program. JAMA. 2003;289: Behavior Therapy

45 Diabetes Prevention Program: Incidence of Diabetes
Placebo Metformin Lifestyle 58% 31% Cumulative Incidence of Diabetes (%) Diabetes Prevention Program: incidence of diabetes Even more impressive than the weight loss outcomes from the DPP are the findings regarding the incidence of type 2 diabetes in this at-risk population. The program of diet, exercise, and behavior therapy was associated with 58% and 31% reductions in the incidence of type 2 diabetes compared with placebo and metformin, respectively. The lifestyle modification intervention was also associated with a 41% reduction in the incidence of the metabolic syndrome, as compared with placebo. The metabolic syndrome is defined as the presence of three or more of the following risk factors: 1) waist circumference >102 cm in men and >88 cm in women; 2) serum triglycerides ≥150 mg/dL; 3) HDL cholesterol <40 mg/dL in men and <50 mg/dL in women; 4) blood pressure ≥130/85 mm Hg; and 5) fasting plasma glucose ≥110 mg/dL. References: Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346: Orchard TJ, Temprosa M, Goldberg R, et al, for the Diabetes Prevention Program Research Group. The effect of metformin and intensive lifestyle modification on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Ann Intern Med. 2005;142: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285: 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Year 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

48 Tips to Achieve a Healthy Weight

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

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

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

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

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

55 Tips to Achieve a Healthy Weight
Reduce portion sizes

56 High-calorie foods

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

58 Structured Meal Plans Enhance Weight Control
Weekly Treatment Follow-up -14 -12 -10 -8 -6 -4 -2 Standard lifestyle modification Lifestyle modification + food provision Structured meal plans enhance weight control Regardless of the macronutrient composition of the diet, dietary adherence is a strong predictor of weight loss. Adherence is facilitated by increasing the structure of the diet, such that unplanned overeating and the potential for measurement errors (i.e., when calculating calorie intake) are minimized. In this study, Wing and colleagues randomized overweight and obese women to a standard lifestyle modification program alone, with food provision, or with meal plans. The food provision group received the most structure; participants received 5 breakfasts and 5 dinners per week from the investigators. Participants in the meal plan group did not receive food, but were given menus, grocery lists, and recipes for the same meals that those in the food provision group received. Both structured groups achieved and maintained greater weight losses than the lifestyle modification alone condition, and there were no differences between the food provision and meal plan groups. Registered dietitians are able to help dieters develop structured meal plans. References: Wing RR, Jeffery RW, Burton LR, Thorson C, Nissinoff KS, Baxter JE. Food provision vs structured meal plans in the behavioral treatment of obesity. Int J Obes Relat Metab Disord. 1996;20:56-62. Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005;293:43-53. Weight Change (kg) Lifestyle modification + meal plans 6 12 18 Months Wing RR, et al. Int J Obes Relat Metab Disord. 1996;20:56-62.

59 Meal Replacements Enhance Initial and Long-Term Weight Loss
Phase 1* Phase 2 CF -15 -10 -5 Meal replacements enhance initial and long-term weight loss Meal replacement products (e.g., portion-controlled shakes or bars with a known energy content) provide another means of increasing the structure of a low-calorie diet. A meta-analysis of 6 randomized controlled trials found that participants who replaced 1 or 2 meals per day with shakes or bars lost an average of 6.2 kg at 3 months, compared with 3.6 kg for those who consumed a low-calorie diet of self-selected foods (p <.001). At 1 year, participants in the meal replacement and self-selected groups had lost 7.0 kg and 3.8 kg, respectively. This difference, however, was no longer statistically significant. The slide shows the strongest evidence for the long-term use of meal replacements. In the first phase of this study, participants were randomized to a low-calorie diet of self-selected foods or a partial meal replacement plan (i.e., meal replacement products were used for 2 meals and 2 snacks per day) for 3 months. Weight loss in the meal replacement group was nearly 5 times as great as that in the conventional food group during that time. All participants, regardless of original group assignment, were then instructed to replace 1 meal and 1 snack each day with formulated products for the ensuing 4 years. Results indicated that meal replacements were both safe and effective for long-term weight control. References: Heymsfield SB, van Mierlo CAJ, van der Knapp HCM, Heo M, Frier HI. Weight management using a meal replacement strategy: meta and pooling analysis from six studies. Int J Obes Relat Metab Disord. 2003;27: Ditschuneit HH, Flechtner-Mors M, Johnson TD, Adler G. Metabolic and weight-loss effects of a long-term dietary intervention in obese patients. Am J Clin Nutr. 1999;69: Flechtner-Mors M, Ditschuneit HH, Johnson TD, Suchard MA, Adler G. Metabolic and weight loss effects of long-term dietary intervention in obese patients: four-year results. Obes Res. 2000;8: Rothacker DQ, Staniszewski BA, Ellis PK. Liquid meal replacement vs traditional food: a potential change for women who cannot maintain eating habit change. J Am Diet Assoc. 2001;101: Yip I, Go VL, DeShields S, et al. Liquid meal replacements and glycemic control in obese type 2 diabetes patients. Obes Res. 2001;9:341S-347S. Hensrud DD. Dietary treatment and long-term weight loss and maintenance in type 2 diabetes. Obes Res. 2001;9:348S-353S. Ashley JM, St Jeor ST, Schrage JP, et al. Weight control in the physician's office. Arch Intern Med. 2001;161: Ahrens R, Hower M. Evaluation of the effectiveness of an OTC weight loss product versus traditional diet methods in a rural community pharmacy setting [abstract]. J Am Pharm Assoc. 2000;40:275. Weight Change (%) MR 2 4 6 8 10 18 12 24 30 36 45 51 Time (mo) *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:

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

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

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!


Download ppt "Faculty of Medicine, University of Peradeniya"

Similar presentations


Ads by Google