ROLE OF NUTRITION IN THE ROLE OF NUTRITION IN THE PREVENTION AND TREATMENT OF DIABETES Ex-Dean and Visiting Professor Department of Human Nutrition Agricultural University Peshawar

WHO 2011

Relationship between economic and health status

SUPPORTIVE ENVIRONMENT FOOD NUTRITION HEALTH SOCIAL DEVELOPMENT & PERFORMANCE RELATIONSHIP BETWEEN NUTRITION & HEALTH

NUTRITION CENTRAL TO HEALTH & ECONOMIC DEVELOPMENT NUTRITION HEALTH IMMUNE FUNCTIONS MENTAL DEVELOPMENT BEHAVIORAL SCHOLASTIC PHYSICAL PERFORMANCE SOCIAL & ECONOMIC DEVELOPMENT

IMBALANCE BETWEEN NUTRIENTS INTAKE AND REQUIREMENTS UNDERNUTRITION & OVERNUTRITION

MALNUTRITION TRENDS IN PAKISTAN Source: NNS (2011)

Hattersley (1999) Lancet 353:1789

Poor Nutritional Status During Pregnancy Adverse Pregnancy Outcome NCDs Later in Life “Brain Sparing” Impaired Liver, Kidney, Pancreas Functions Hormonal Resetting Insulin IGF GH & Corticosteroid ids

 Dietary Management is essential for:  Maintaining healthy weight and to prevent overweight and obesity  Maintaining blood glucose levels in the normal range  Maintaining lipid and lipoprotein profile in the normal range  Preventing or reducing the risk of diabetes  Managing existing diabetes  Preventing and reducing risk of micro and macro vascular complications such as retinopathy, neuropathy, nephropathy, amputation of lower limbs and premature deaths

 Meta-analysis of 70 randomized controlled trials shows correlation between fall in LDL-C and amount of weight loss  Weight loss reduces triglycerides, increases HDL-C, and lowers LDL-C  Weight loss reduces insulin resistance and improves glycemic control and reduces the risk of cardiovascular abnormalities  7% weight loss in pre-diabetic patients resulted in a 58% reduction in the risk of diabetes  Combined programs of weight loss and exercise are associated with greater increases in HDL-C and more significant loss of weight and fat.

 Macronutrients  Carbohydrates---Plants & Dairy --Simple & Complex -- - Low and High Glycemic Index--- Source of Energy --- cals---Essential role in Weight and Diabetes Management  Protein—Plants and Animals— Body Building, Enzymes, Hormones, Immune System  Fat---Plants and Animals-Rich Source of Energy— saturated vs unsaturated fatty acids, omega 3 and omega 6 fatty acids, cis and trans fatty acids  Micronutrients Vitamins ----Plants and Animals–- physiological and metabolic functions Minerals-----Plants and Animals—physiological and metabolic functions  All Macro and Micronutrients are required but need modifications during illness

 The total amount of carbohydrates consumed is the primary predictor of glycemic response and has a direct effect on postprandial glucose levels  The primary macronutrient of concern in glycemic management  Quantity and type of carbohydrates in a food influence blood glucose level  Carbohydrates a potential source of energy  Monitoring carbohydrate portions is a useful tool for improving postprandial glucose control 

History dates back to 18 th and 19 th centuries-Era of dietary restriction and fasting by clinicians  J. Rollo (1797) emphasized increased consumption of fat and protein for diabetic treatment  Bouchardat (1871): Noticed disappearance of glycosuria during food rationing and suggested individualized diets to treat diabetes  Joslin (1916): 20% reduction in case fatality rate by fasting and physical activity  Allen (1919): suggested strict dietary restriction or “starvation treatment” for hyperglycemia

 Mediterranean, vegetarian, low CHO, high protein and high fat diets have been tried on diabetic individuals over a period of time  Conflicting results on postprandial glucose levels, lipid profile and weight loss  Insufficient evidence to recommend any specific diet or amount of CHO, protein and fat for all diabetic people  Weight loss has been associated with reduction in insulin resistance, improved glycemic control and lipid profile  Dietary management in combination with physical activity has proven to be most effective in improving glycemic control and reducing the risk of cardiovascular abnormalities

 Irregular Meals  Small Frequency  Energy Dense  Small CHO  Refined/Processed  Animal Protein  Animal Fat  Saturated Fat  Regular Meals  Large Frequency  Nutrient Dense  Complex CHO  Whole Grain  Meat Protein  Meat Fat  Unsaturated Fat

FOOD PYRAMID FOR PAKISTANI POPULATION 5-9 Servings 2-4 Servings 2-3 Servings 3-5 Servings 2-3 Servings Eat in moderation or minimum

 Appropriate meal planning is critical for the prevention and treatment of diabetes  Nutrition education, counseling and meal planning is a prerequisite for effective management of diabetes  There is NO standard meal plan or eating pattern that works universally for all people with diabetes  There are NO standard recommended dietary allowances as well as the recommended amount or percentage of each macro and micro nutrient for diabetics  Individualized dietary approaches are needed in the light of nutritional status, cultural, economic, religious, dietary preferences and metabolic goals

 Consultation of Dietitian is must for developing an individualized meal plan that focuses on weight, glycemic and metabolic controls  Comprehensive diabetes management and awareness programmes that includes nutrition education, counseling, seminars, workshops at the community levels shall be started  Diploma Courses in Nutrition/Dietetics focusing on NCDs shall be started to produce technically skilled human resource who may work at community level for screening, prevention and treatment of NCDS  Periodic monitoring of metabolic parameters (e.g., glucose, lipids, blood pressure, body weight, renal function) is recommended to ensure successful health outcomes