role of medical nutrition therapy in the management of non-communicable diseases dr. n. sudheera...

Role of Medical Nutrition Therapy in the Management of

Non-communicable Diseases

Dr. N. Sudheera KalupahanaMBBS (SL), MPhil (SL), Ph.D. (USA)

Senior Lecturer, Department of Physiology, Faculty of Medicine, University of Peradeniya

skalupahana@pdn.ac.lk

• Why Medical Nutrition Therapy (MNT) is important

• Components of MNT• Burden of NCDs• Principles of MNT in Diabetes, NAFLD,

CKD• NCD preventive strategies

Outline

History of Medical Nutrition Therapy

“Let food be thy medicine and medicine be thy food”

Hippocrates,400 B.C.

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.

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

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.”

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

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

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

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

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

Medical Nutrition Therapy in Diabetes Mellitus

Medical Nutrition Therapy in Diabetes Mellitus

Brown et al., Diabetes Care, 1996

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

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

Food Groups

Fruits

Vegetables

Grains

Protein foods

Dairy

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

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

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)

Protein foodsMeat, 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

Changing your lifestyleStep 1 – Follow the “Health Plate”

Non-starchy Vegetables

Protein Food

Grains (rice)

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

Step 3 – Avoid / limit the following

• Deep fried food (short-eats, mixture, chips)

• Sweets (biscuits, cake, pudding, ice-cream, chocolate)

Changing your lifestyle

Step 4 – Be physically active and limit inactivity

• Adults30 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

Changing your lifestyle

Step 5 - Weight Management

Food IntakePhysical Activity

FatStores

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

Medical Nutrition Therapy for NAFLD

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) 193 192

Triglycerides (mg/dl) 100 89

HDL (mg/dl) 60 54

LDL (mg/dl) 115 120

Lifestyle modification improves NASH

Promrat et al., Hepatology, 2010

Promrat et al., Hepatology, 2010

Lifestyle modification improves NASH

Lifestyle Modification

Low-Calorie

Diet

IncreasedPhysicalActivity

BehaviorTherapy

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

• 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

• 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

• 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

Fruits and Vegetables low in potassium and can be eaten

CabbageCarrotsCauliflowerOnionCucumberEggplantGreen beansOkraLettuce

ApplesPapayaPineappleBerriesGrapesLemonsLime

Fruits and Vegetables high in potassium and to avoid

Beet greensBroccoliPotatoesSweet potatoesPumpkinSpinachGreen leavesTomatoes

BananasDatesOrangesKiwiRaisinsButter fruitMangoKing-coconut waterFruit juices

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

Obesity is an emerging problem in SL

34 - 43%

26%

Katulanda et al., 2010Jayatissa et al., 2012

Katulanda et al., 2010

Assessment - Body Mass Index (BMI)

BMI = Weight (kg) / Height2 (m)2

Normal: 18.5 - 23 Overweight ≥ 23Obese ≥ 25

WHO, 2004

Consensus statement, 2009

Measuring Waist /Hip Circumferences

Waist: At the midpoint between the lower margin of the lowest palpable rib and the top of the iliac crestAt 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

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)

Lifestyle Modification

Low-Calorie

Diet

IncreasedPhysicalActivity

BehaviorTherapy

0

10

20

30

40

Diabetes Prevention Program:Incidence of DiabetesC

um

ula

tive Inci

den

ce

of

Dia

bete

s (%

)

Year

Placebo

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Metformin

Lifestyle31%

58%

Reprinted from Diabetes Prevention Program Research Group. N Engl J Med. 2002;346: 393-403. Copyright © 2002 Massachusetts Medical Society. All rights reserved.

Curious power of modest weight loss (~7%)

Hamman et al., Diabetes Care, 2006

Tips to Achieve a Healthy Weight

Tips to Achieve a Healthy Weight

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

Choose a variety of colorful fruits and

vegetables daily (4-5 cups / day)

*cooked without coconut milk

Tips to Achieve a Healthy Weight

Select whole-grain cereals and bread

Tips to Achieve a Healthy Weight

Drink water instead of sugar-sweetened beverages

Tips to Achieve a Healthy Weight

Grill or broil instead of deep-frying food

Tips to Achieve a Healthy Weight

Replace Full-cream milk with non-fat milk

Tips to Achieve a Healthy Weight

Reduce portion sizes

Tips to Achieve a Healthy Weight

High-calorie foods

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)

Structured Meal Plans Enhance Weight Control

Wing RR, et al. Int J Obes Relat Metab Disord. 1996;20:56-62.

Weig

ht

Ch

an

ge (

kg)

Months0 6 12 18

Lifestyle modification + meal plans

Weekly Treatment

Follow-up

-14

-12

-10

-8

-6

-4

-2

0

Lifestylemodification + food provision

Standard lifestyle modification

0 2 4 6 8 10 1812 24 30 36 45 51

Meal Replacements EnhanceInitial and Long-Term Weight Loss

*1200–1500 kcal/d diet prescriptionCF = conventional foods; MR = replacements for 2 meals, 2 snacks daily;

Reproduced with permission from Ditschuneit HH, et al. Am J Clin Nutr. 1999; 69:198-204 and from Fletchner-Mors M, et al. Obes Res. 2000;8:399-402.

Weig

ht

Ch

an

ge (

%)

Time (mo)

Phase 2

Phase 1*

-15

-10

-5

0

MRMR

CF

Behavior Therapy

Goal-setting- Weight-loss goal- Physical activity goal

Self monitoring- Body weight- Food diary

Stimulus control, stress management, coping strategies

How long would you have to walk briskly to burn about 550 calories*?

1 hour and 40 minutes

Can you “burn it off”?

Physical activity recommended

• Adults30 minutes of moderate intensity – 5 days / week

• 1 hour for weight loss

• Children and teens:

60 minutes / day

Heart-healthy

Diets

The Mediterranean Diet:

Thank You!