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
• 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!