1. Nutritional Management of Diabetes And Heart Diseases
Shilpa Joshi RD
Mumbai Diet And Health Center
Bandra (west)

2. Burden of Major NCD’s in India
35 million cases of Cardiovascular Diseases
45 million cases of Diabetes
2.4 million cases of cancer
22 million Obesity
1 million cases of Cerebrovascular Disease/stroke
Every 5th Diabetic is an Indian
Every 5th to 10th Asian Indian Native Urbanite is a Diabetic

3. BMI
Body fat
9.1% %

4. Glucose is the currency of body & every cell needs it

5. Type 2 DM

8. Oxidative Stress Damages Here
Endothelial lining
Smooth muscle
Collagen

9. Food
Any substance that can be metabolized by an organism to give energy and build tissue
Any solid substance (as opposed to liquid) that is used as a source of nourishment; "food and drink"
Anything that provides mental stimulus for thinking

10. Traditional Diets

11. Traditional Diet

12. Food Pyramid Fats, Oils & Nuts 2-3 Units Milk & Milk Products
Meat & Fish
1-2 Units
Vegetables
3-4 Units
Fruits
2-3 Units
Cereals & Pulses
8-12 Units 10-14
units (veg)

13. Food Components MACRONUTRIENT Carbohydrates Proteins Fats
MICRONUTRIENTS
Vitamins
Minerals

14. Carbohydrates Primary source of energy
Sources:cereals, fruits, vegetables,milk
Carbs are of two types
simple carbs: sugars, honey, colas, fruits juices, jaggery,maida,bakery products
Complex carbs: cereals, vegetables, pulses

15. How to choose carbohydrates.
Complex carbohydrates are good for our health.
Simple carbohydrate easily increase our blood sugar, so decrease their consumption.
Eat carbohydrates only in recommended amounts.
Choose complex carbohydrates high in fibre e.g unpolished rice, ragi ,whole wheat

16. Fruits Exchanges ( to be eaten in prescribed amount)
Apple
Guava
Orange
Papaya
Pineapple
Pears
Sweetlime
Water melon
Pomegranate
Coconut water
Jambun
1 small/½ medium
1 medium
1/3 medium or 3 slices
2-3 slices
1/3rd medium
150 ml
100 gm

17. FIBRE: Boon of nature Fibre is non digestible carbohydrate.
It forms a bulk and hence makes us feel full.
Soluble – oats, barley, psyllium, fruits ( guava, apple ), gum
Insoluble-whole grains, pulses, vegetables, fruit ( oranges, sweetlime )

18. Fruits Exchanges: (to be avoided)
High Calories Fruits
Banana
Chickoo
Mango
Sitaphal
Grapes
½ big
1 small
½ medium (75 gm)
½ big size (50 gm)
12-15 pieces

19. Properties of Dietary Fibre
Type
Major Food Sources
Known Effects
Cellulose
Bran, whole wheat four, cabbage, peas & beans, root vegetables, apples
Affect food texture, increase fecal bulk, shorten transit time
Hemicelluloses
Bran, cereals, whole grains
Same as cellulose
Soluble noncellulosic pectin's
Polysaccharides
Apples, citrus, fruits, various berries, apricot, banana, carrots, sweet potato
Alter consistency of gastric & intestinal contents, reduce absorption of cholesterol, reduce serum cholesterol, water holding

20. Properties of Dietary Fibre
Type
Major Food Sources
Known Effects
Gums & Mucilage's
Oat meal, dried beans, other legumes
Binding of ions & other substances, water holding cholesterol-lowering
Lignin
Old (tough) vegetables, wheat
Indigestible by fecal bacteria

21. Quantity of Soluble Fibre to Produce Lipid Lowering Effect
Source
Quantity
Pectins
Gums
Dried beans
Dry oat bran
Oat meal
Psyllium
6 to 40
8 to 36
100 to 150
25 to 100
57 to 140
10 to 30

22. Fibre Content of Foods Low Fibre Moderate Fibre High Fibre Milled rice
Refined wheat flour
Bread white
Whole gram (bengal)
Lentil
Green gram dal
Bottle gourd
Ash gourd
Cucumber
Tomato
Spinach
Lettuce
Banana
Whole wheat flour
Wheat germ
Brown bread
Field beans
Red gram dal
Brinjal
Cauliflower
Radish leaves
Fenugreek
Cabbage
Apple
Rice bran
Bengal gram
Whole
Rajmah
Peas
Red gram
Green gram whole
drumstick

23. Fibre Content of Foods Low Fibre Moderate Fibre High Fibre Sweet lime
Lichi
Water melon
Prunes
Peaches
Pears
Orange
Parwar
Double beans
Colocasia
Amaranth
Amla/Dates/Grapes/
Guava/Pomegranate/
Sapota/Papaya

24. Proteins Repair of tissues, immunity
Sources: pulses, nuts, milk and milk products, meat, egg, fish, poultry.
Egg ,poultry and red meat have saturated fats in them
Good source of proteins are dals, sprouts, fish, egg whites,chicken breast.

25. Advantages of proteins
Is not converted into sugar as fast as carbohydrates.
It keeps us full for a long period of time.
It takes a lot of energy to burn proteins, therefore you store less energy.

26. FATS Source of stored energy
Source: oil, butter, ghee, nuts, non-veg, cheese, bakery products

27. CHOICE OF A HEALTHY COOKING MEDIUM:
a controversial subject
A consumer is a confused
lot as far as choosing the
right kind of cooking
medium is concerned.
Every supplier of any type
of cooking oil claims the
same to be best for health
A common man is not
aware of the yardstick by
which any cooking oil could
be rated as the best one .

28. CHOLESTEROL BALANCING
OXIDATION STABILITY
Recommended fats (heart friendly oils )are MUFA eg. ground nut oil, rice bran oil, olive oil

29. Invisible Fats Coconut Peanuts, Almonds, Cashewnuts etc.
Condiments like pappad, pickles, chutney’s etc.
Garnishes like cheese, cream, white sauce, etc.
Bakery items like biscuits, kharis, puffs, etc.
Farsans and sweets
Non-Vegetarian food
Milk & milk products

30. Total Fat Total fat intake is most important
Invisible sources of fat should be included in the total fat intake
Total fat intake is closely related to serum lipids
Recommended intake is 20 gms per person per day
Diets should not provide more than 30% calories from fat

31. Effect of heating on oils
Depends on saturation of oils
Temperature of heating
PUFA > MUFA > SFA
Change in saturated:unsaturated ratio
Formation of peroxides
Loss of antioxidants

32. Dietary cholesterol Associated with animal fat
Sources of dietary cholesterol : ghee, cream butter, non-vegetarian foods.
Excess consumption of fat leads to production of fat in our body
Prudent fat intake : 3-4 tsp/day/person
Good oils :ground nut oil, olive oil, rice bran oil

33. Alternatives 1 cereals exchange gives 100 kcals 1 chapatti (30 g)
1 thepla or
1 khakra (dry) or
1 medium vati porridge or
2 medium size bread slice or
1 pav (30 gm) or
1 vati (medium) cooked rice or
1 medium vati onion poha (no potato)
½ Thalipith or
1 Ghavan or
1 bowl of spaghetti or
¼ bhakri or
1 bowl of corn flakes or
1 idli with sambhar or
1 dosa (home made – medium sized – on nonstick) with sambhar
4-5 pieces of dhokla or muthia (steamed)
4-5 pieces of Khandvi

34. Meal Patterns Breakfast: Meal consumed within one hour of rising
Most important meal of the day
Should be rich in complex carbs and protein
eg: cereal, porridge, roti, dosa, idli, upma, daliya,
paratha, eggs, milk, fruits.
Avoid :bakery products

35. Meal Patterns Lunch Eat balanced meal Make right food choices
Do not skip lunch
Include protein as a important part of meal
eg thali, roti-subzi , dal rice, curd rice

36. Meal Patterns Dinner Meal should be as light as possible
Low in carbohydrates especially simple carbs
Make clear soups as integral part of dinner

37. Eating Out (Make Right Choices)
Meal time
Cuisine
Meal selection
Hygiene

38. A la carte Either starter, main course or dessert never all together
Clear soup should be an integral part of menu
Choose grilled, tandoori, broiled, stir fry
Do not order for deep fried, makhani, white sauces, mayonnaise
Salad(?)

39. Buffet Choose wisely Do not have to eat it all
Select hot, steaming foods
Select a live counter so dish can be made as per your choice
Avoid greasy foods

40. Mid Meals/Snacks Avoid high calorie snacks- split it into two
Avoid super sized snacks
Fruits, channa, unbuttered pop corn, sukha bhel with less sev, cooked channa chat are ideal snacks
Avoid bakery products, colas, juices, chaat etc
The best drink with and between meals is water

41. Mid-Meal Options Skimmed milk Chaas Kurmura Channa
Fruit (permitted quantity only)

42. Alcohol Causes hypoglycemia if consumed without food
Foods consumed with alcohol are usually fried foods/junk food empty calories)
Alcohol is high in calories 7 kcals/gm and is metabolized in a manner to fat.
give up alcohol, if not then fix the quantity, frequency and exchange it with fat.
consume salads with alcohol.

43. Alcohol
Raises HDL
Lowers insulin concentration and improves insulin sensitivity
But
Raises blood pressure
These findings are true for whites. Blacks (Afro American ) and Hispanics do not show this relationship
Studies on Indian populations have not been done
Ref : Freiberg MS, Cabral HJ, Heeren TC, et al. Alcohol Consumption and the Prevalence of the Metabolic Syndrome in the U.S.A cross-sectional analysis of data from the Third National Health and Nutrition Examination Survey. Diabetes Care 2004; 27:

44. Alcohol & Sugar Content of Alcoholic Drink
Carbohydrate/Sugar Content (g/L)
Alcohol Content
(g/l)
Distilled Spirit (Whisky, Cognac, Vodka) -
Dry White Wine & Red Wine
2-10
120
Beer & Dry Sherry 30
40-50
Sweetened White Wine & Poat Wine
An average drink namely 5 oz of wine, 12 oz of beer or 1.5 oz of distilled spirit contains gms of alcohol. Thus they give approximately 100 kcal.
Lieber CS. Alcohol Research & Health, Fall, 2003

45. Unit of Alcohol One Unit of Alcohol Calories
Half a pint of beer, lager or cider
Pub measure of spirits (whisky, vodka, rum, gin)
Glass of wine
Glass of sherry 90 50 75 55
One unit of alcohol is 10 ml by volume, or 8 g by weight, of pure alcohol. For e.g. Half a pint of ordinary strength beer, 25 ml of spirits, 50 ml of fortified wine such as sherry or port

46. How Should be the Calories from Alcohol Calculated?
When calories from alcohol need to be calculated as part of the total caloric intake, alcohol is best substituted for fat exchanges (1 alcoholic beverage = 2 fat exchanges or fat calories.
ADA Guidelines

47. Fountain
PEPSI
WATERFOUNTAINS

48. Fast Food Joints Order wisely Find a low fat option and order
Do not over indulge
Eg: just a burger no fries ,one unbuttered pav instead of two buttered pav, bhel puri instead of sev puri, ragada pattice instead of panipuri, samosa ,kachori

49. We Need To Minimize Not Maximize
Maharaja Mac ?
Jumbo Vadapav?
Double
Cheese Pizza?
DO NOT UPSIZE !!!
We Need To Minimize Not Maximize

50. Sweeteners
Sweeteners are of two kind: Nutritive Sweeteners (which have calories) and Non-Nutritive Sweeteners (which have no calories)
Nutritive and Non Nutritive Sweeteners should be used sparingly in prescribed amounts
Education on appropriate use of sweeteners
Impact of nutritive sweeteners on the individual’s blood glucose levels & lipid profile should be assessed on a regular basis

51. ADI of various sweeteners
Acceptable daily intake
(mg/kg body weight)
Acesulfame potassium 15
Aspartame 40
Cyclamate 11
Saccharin 5
Sucralose 9

52. Sodium Sources: salt, bakery products
Blood pressure is significantly related to sodium intake(inter salt study)
High salt intake has been implicated in hypertensive target organ diseases
Strategies to limit salt intake
Reduce salted foods bakery, processed food, pickle, ketchup
Avoid :salt shakers, salt on salads, fruits, atta, rice, sherbet
Use of lime, tamarind, pudina to bring flavour to foods

53. Integrating Therapies
Physical Activity
Benefits

54. Physical activity is it necessary?
Prevents obesity( weight gain)
Improves heart conditioning
Improves blood pressure
Stabilizes blood sugar
Improves muscle mass and bone health
Secretes feel good hormones

55. Physical Activity and Its Benefit
Reduces body weight
Reduces blood pressure
Keeps blood sugars under control
Increases HDL levels
Ref: Thompson PD, Buchner D, Piña IL, et al. AHA Scientific Statement - Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease A Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity. Circulation. 2003; 107: 3109

56. Diet Issues Hypocaloric Diets Low Carb Diets Meal Replacement Diets
Eat less, Eat on Time
Concentrate on Satiety
Satiety Index

57. Killer Diet Fast Foods kill fast Fried,Calorie Dense Oils and Butters
Lack of Fibre
Cola Culture
Traditional Diet
Less oil
Fibre rich

58. Designer Foods Low cal mithai’s Diet cola’s
Low calorie or diet farsan’s
Diabetics adjunct’s – jam, jelly, pickles

59. Healthy Eating Eating Out Weight Control Flexible Lifestyle
Without carb counting, some of you may remember or currently be on a regimen that requires you to eat a certain amount of food to match your insulin. If you eat more or less you pay the price by having high or low blood sugars.
Once you learn how to carb count, all that is required is to give yourself a bolus of insulin to cover the carbs in your meal that you want to eat. This really opens up the possibilities of what you can eat (provided you do a little math).
Many restaurants provide the nutrient information for their menu items as well – with the advent of the internet, you can usually check out the larger chain restaurants on-line and they typically post it there. There is also this great book called the “Calorie King: Calorie Fat and Carbohydrate Counter” that lists many of the larger franchises and brands of food.
There is an important caution though. Notice as we went through the nutrition labels, I did not have you check the calorie content. For carb counting, the calories or sodium content of what you are eating is irrelevant. But please remember, there is no substitute for healthy food choices.
If your physician has asked you to follow a particular diet or meal plan, such as low sodium, then you would need to incorporate that into your food choices. The purpose of the counting carbohydrates is so you can have control of what you eat and match insulin to it, not have to match food for the insulin you take. It has nothing to do with other restrictions.
With the freedom of carb counting, there is the temptation to eat extra food then adjust your insulin to cover extra calories; however, the calories add up and weight-gain is likely. As you become a carbohydrate counting expert and enjoy more flexibility in food selection, remember to include at least 5 servings of fruit and vegetables per day.
We should ALL be eating healthy, whether we have diabetes or not. Just because you have diabetes shouldn’t make you have to eat differently than anyone else. You just have to match insulin to what you eat. Again, we should all be eating healthy.
Good Nutrition
Weight Control
Flexible Lifestyle

60. Prevention of Heart Diseases
Give up one, reduce two, and increase three
give up smoking
reduce food and alcohol intake
increase exercise
Ref: Wada T, Fujishiro K, Fukumoto T, Joki M. Inf Med. 2005; 44(2):

61. Aham Annam…. Atharva veda (2500 BC) We Are ,What We Eat ….

62. Practical Activity Interventions to Prevent CVD
Education and knowledge
Compulsory sport and physical activities in schools and colleges as well
Gyms at work places
Sport culture to be developed
Physical activity intervention : elevators and escalators to be used by only old and sick,walking for short distances, walking at home and in compounds of building
Less use of gadgets: cordless phones, remote controls
Concept of ‘NEAT’ : do it your self

63. Diataal Powder

64. Kyonki TV se Obesity Hoti Hai ! !

65. Faulty Nutrition via chronic diseases has the potential
to bankrupt SE Asia
We will lose migrant,affluent,Asian Indians
to CAD, DM, Cancer etc
Killer lifestyle and Bad Genes
Predispose us
“Load the Gun with Bad Genes and Pull the Trigger by Bad environment”
Its time to wake up

66. Soya Protein
Soya bean apart from being rich source protein also has other phytochemicals which are unique
Soya fibers reduces insulin requirement in diabetes
Decrease cholesterol synthesis in humans.
Use only processed soya : atta, nuggets, drinks

67. LYCOPENE Major carotenoids Imparts colour to vegetables and fruits
Recent studies reveal a unique preventive role;
Cancer &
Cardiovascular complications

68. LYCOPENE
Are found in:
Tomato & tomato products
Apricots, papaya
Grapefruit, guava etc
Shows enhanced absorption when consumed along with fats
Deposited in liver, lung, prostate glands, colon & skin
Fat soluble

69. LYCOPENE: HEALTH BENEFITS
Potent antioxidant
Major scavenger of harmful free radicals
Prevents/delays cardiovascular complications
Prevents oxidation of LDL
Reduces risk of atherosclerosis & CAD

70. L-ARGININE Protein amino acid
Classified as semi-essential / conditionally essential
Essential for young children
Precursor of nitric oxide
Shown to play a critical role in:
Hypertension
Heart dysfunction
Inflammation

71. Some Indian remedies : methi seed
It is an herb and a spice
Fenugreek contains
an active ingredient of blood glucose control
an active ingredient for blood cholesterol control
The typical range of intake for diabetes or cholesterol-lowering is 5–30 grams with each meal or 15–90 grams all at once with one meal.
Use of more than 100 grams of fenugreek seeds daily can cause intestinal upset and nausea. Individuals with peanut allergies use with caution or avoid.  Otherwise, fenugreek is extremely safe.

72. Effect of nuts Rich in MUFA and PUFA
Rich in plant protein,fibre,micronutrients like Cu and Mg
Plant sterols
Vitamin E,thiamin,riboflavin
Peanuts are good source of folate and fibre
Walnuts are good source of omega 3 oils

73. Effect of garlic Bioactive compound allicin
Organosulfur compound inhibits hepatocyte cholesterol synthesis
Antiplatelet properties
S alkenyl cysteine results in decreased HMG coA reductase

74. Effect of green tea Bioactive principle CATECHIN
Enhances fat oxidation
Improves PP glucose response
Stimulates insulin secretion