MEDICAL NUTRITION THERAPY (MNT) Mrs. Sarah Jacob Rtd. Head, Department of Dietetics Christian Medical College Vellore.

Medical Nutrition Therapy (MNT) Replaces The earlier term of “Diet Therapy” and stresses a four pronged approach that includes…. Assessment of the individual’s metabolic and life style parameters Assessment of the individual’s metabolic and life style parameters Identification of nutrition goals Identification of nutrition goals Intervention designed to achieve these goals. Intervention designed to achieve these goals. Evaluation of therapeutic outcome. Evaluation of therapeutic outcome.

Assessment Involves assessment of habitual dietary pattern in terms of nutrient content and eating behaviour Helps Helps - To identify goals - To identify goals - To determine the type of intervention needed - To determine the type of intervention needed  calorie intake, food pattern modification of eating behaviour etc. - Rapport building - Rapport building - Gives information on clinical data. - Gives information on clinical data.

Goals Treatment goals should be individualised, realistic and achievable - Weight loss if necessary - Weight loss if necessary - Blood glucose levels to be maintained as close to - Blood glucose levels to be maintained as close to normal as possible normal as possible - Blood lipid levels within desirable limits - Blood lipid levels within desirable limits - Consistent and appropriate food intake - Consistent and appropriate food intake - Regular meal timings - Regular meal timings - Blood glucose monitoring - Blood glucose monitoring

Intervention - Education - Appropriate meal plan suggested - Appropriate meal plan suggested - Strategies for eating behaviour change - Strategies for eating behaviour change - Food exchanges - Food exchanges - Importance, source of dietary fibre - Importance, source of dietary fibre - Adequate nutrient intake by including variety - Adequate nutrient intake by including variety - Importance of exercise. - Importance of exercise.

Steps to individualised diet planning Step:1 - Determine past diet history, food habits, activity socio economic status, cultural and activity socio economic status, cultural and religious practices etc. religious practices etc. e.g. Sex – male Age – 50 yrs e.g. Sex – male Age – 50 yrs Height – 170 cms or 5’ 7” Height – 170 cms or 5’ 7” Food habits - Non vegetarian Food habits - Non vegetarian Income – Middle Income Income – Middle Income Activity – Sedentary Activity – Sedentary Type of Diabetes – Type 2 Diabetes Type of Diabetes – Type 2 Diabetes

Step: 2 Determine ideal or desirable body weight weight (a) Hamwi method IBW = 106+(7x6) = 148 lbs IBW = 106+(7x6) = 148 lbs (b) Broca’s Index IBW = = 70 kgs IBW = = 70 kgs 5 – 10% less for diabetics 5 – 10% less for diabetics = 63 – 67 kgs. = 63 – 67 kgs.

Step: 3 Calculate Energy Requirement Basal + activity = (148 x 10) = (1480 x 20 / 100) = (148 x 10) = (1480 x 20 / 100) = 1776 Kcal = 1776 Kcal = Rounded off to 1800 Kcal. = Rounded off to 1800 Kcal.

Step: 4 Determine gm of carbohydrate, protein and fat protein and fat CHO = 60-65% of total calories = 270g- 292g CHO = 60-65% of total calories = 270g- 292g Protein = 10-15% of total calories = 45g – 68g Protein = 10-15% of total calories = 45g – 68g Fat = 20-25% of total calories = 40g – 50g Fat = 20-25% of total calories = 40g – 50g

Step : 5 Carbohydrate – 60-65% Complex CHO is better than simple sugars as absorption is slower Complex CHO is better than simple sugars as absorption is slower Amount of CHO in each meal to be adjusted for each individual. Amount of CHO in each meal to be adjusted for each individual.

Step: 6 Dietary fibre present in whole grain cereals, vegetables pulses and fruits delay digestion and absorption may help in reducing blood and absorption may help in reducing blood sugars and lipids. Recommended intake – sugars and lipids. Recommended intake – g / 1000 Kcal g / 1000 Kcal.

Step: 7 Foods with high fibre content have lower glycemic index Physical form of food Physical form of food Nature of cooking Nature of cooking Nature of fibre Nature of fibre Amount and composition of meal affect the glycemic index of food. Amount and composition of meal affect the glycemic index of food.

(8) Protein – 15% RDA of protein for adults – 1g/kg body weight. RDA of protein for adults – 1g/kg body weight. Cereals, pulses, nuts, milk and its products, non- Cereals, pulses, nuts, milk and its products, non- vegetarian items contribute to the protein content vegetarian items contribute to the protein content in the diet. in the diet. (9) Fat – 20-25% Type of fat – 7 – 10% SFA Type of fat – 7 – 10% SFA - < 10% PUFA - < 10% PUFA % MUFA % MUFA

Step: 10 Translate in terms of food. Translate in terms of food. Use of exchange lists Use of exchange lists - gives information on nutrient content - provides variety in diet by giving alternatives alternatives

(11) Sample meal plan: Breakfast – Milk – 100 ml Cereal preparation – from 75g cereal Cereal preparation – from 75g cereal e.g: 3 iddlies / chappathies e.g: 3 iddlies / chappathies Mid morning – Fruit + Lime juice without sugars. sugars. Lunch – 250 g cooked rice or chappathies – 3 meat / fish / paneer meat / fish / paneer vegetables vegetables curds curds Dhal as sambar Dhal as sambar

Tea time: Milk – 100 ml Whole gram or pulse – 15g Whole gram or pulse – 15g Dinner: 250g cooked rice or 3 chappathies Meat / Fish / Dhal Meat / Fish / Dhal Vegetables Vegetables Curds Curds Bedtime: Mild – 200 ml Oil for cooking – 3-4 teaspoons Oil for cooking – 3-4 teaspoons To be adjusted to suit individual needs. To be adjusted to suit individual needs.

Eating modifications Reduce cereal intake Avoid simple sugars – Honey, Sucrose etc. Avoid fried foods – chips, nuts etc Increase use of vegetables – ensure adequate fibre intake intake Eat regular meals Regular food and exercise Balanced meal to ensure adequate Vitamins and Minerals. Minerals.

Type I Diabetes – in children (a) Energy: 1000 kcal for the 1 st year Kcal for every year upto 10yrs / Kcal for every year upto 10yrs / upto 200kcal upto 200kcal kcal for girls between yrs kcal for boys between yrs Above 15 yrs – kcal / kg – sedentary 40 kcal / kg – moderation 40 kcal / kg – moderation 50 kcal / kg – very active 50 kcal / kg – very active

(b) Distribution of CHO, Protein, Fat CHO – 50 – 55% CHO – 50 – 55% Protein – 20 – 25% Protein – 20 – 25% Fat – 20 – 25% Fat – 20 – 25%

Gestational Diabetes Pregnant women need extra 300 kcal and 15g protein during the 2 nd or 3 rd trimester. Frequent small meals to be given. Frequent small meals to be given.

Diabetic Nephropathy Depending on the function of the kidney. Energy – as for others with diabetes Energy – as for others with diabetes Protein – 0.6 – 0.8 g / kg IBW Protein – 0.6 – 0.8 g / kg IBW Fat – less than 30% of total Kcal preferably 20-25% Fat – less than 30% of total Kcal preferably 20-25% CHO – to make up the rest of the calories preferably from complex carbohydrates. CHO – to make up the rest of the calories preferably from complex carbohydrates.

Evaluation….., - Monitoring medical and clinical outcomes - Effectiveness of nutrition care plan etc - Re-assess and review nutrition care plan

“Nutrition is a challenging aspect of diabetes management. Attention to nutrition and meal planning principles is essential for glycemic control and over all good health”.