Role of Medical Nutrition Therapy in Prevention and Treatment Of Diabetes

ByHellen C Baliach

Consultant Clinical Nutritionist

Objectives

• Definition of terms• Outline of objectives of Medical Nutrition Therapy• Outline of nutritional assessment• Nutritional data from diabetes clinic andDiet

Advicory Clinic (DAC)• What is the ideal diet• Challenges• Recomendations• Conclusion

What is on your Plate?

Definitions of Terms

• ‘Diabetic diet’-A normal diet• is simply a healthy eating plan• Aim-is to control the blood sugar level• Diet forms one of the three cornerstones of

good health-1. Exercise/diabetes education 2.medication 3. meal planning

Definitions of Terms

• BMI-for-Age: is a growth indicator that relates BMI to age. BMI for age is determined using gender-specific growth charts that place a child in a percentile relative to weight and height (WHO, 2006).

• Obesity: A condition of malnutrition where there is deposition of excess fats around the body

• particularly in subcutaneous tissues that arises from intake of food in excess of the body energy requirements(WHO, 2004)

Terms

• Stunting: Growth failure that occurs over a slow cumulative process caused by inadequate nutrition or repeated infections in a child. It is defined as Weight-for-Height Z-scores < -2

• Stunted-overweight/obesity-co-existence of stunting and overweight/obesity(WFH Z-scores <-2 and BMI for age z-scores <-2)

Aim of Medical Nutrition Therapy (MNT)

• MNT is important in preventing diabetes• managing existing diabetes • Preventing and slowing the rate of

development of diabetes complications • Achieving nutrition-related goals requires

involvement of the person with diabetes in the decision-making process

Objectives of Medical Nutrition Therapy

• Attain and maintain blood glucose level as close as normal

• Prevent Hypo and Hyperglycemia• Obtain optimum blood lipids and blood pressure

control and reduce the risk of macro vascular disease.• Assess energy intake to achieve optimum body

weight

• Promote physical, social and physiological wellbeing.

Objectives of Medical Nutrition Therapy

• Prevent, delay or minimize the onset of chronic degenerative complications such as hypertension and renal disease.

• Achieve and maintaining optimal metabolic and physiological outcome.

• Provide relief from symptoms• Individualize meal plan according to a

person’s lifestyle and based on usual dietary intake

Prevalence of Diabetes by sex in the clinic

43%

57%MaleFemale

Disease Prevalence in Diabetes Clinic

Diabetes Hypertension/Diabetes

Hypertension Obese/Overweight

Diabetes/Nephropathy

0

10

20

30

40

50

60

70

80

Anthropometrical Assessments

• Physical measurements- involves measurements of the physical dimensions and gross composition of the body (WHO 1995)

• Provide information on the past nutritional history and degree of chronic protein Energy Imbalance

• The measurements vary with age,sex,race and degree of nutrition.

Body Mass Index Classification Wt(kg)/Ht(m)2(WHO,2006)

CLASSIFICATIONUnderweight

Normal range

Overweight Preobese Obese class 1 Obese class 11 Obese class 111

BMI< 18.5

18.5 – 24.99

>25 25 – 29.99 30 – 34.99 35 – 39 > 40

DISEASE RISKLow (but risk of other clinical problems is increasedAverage

IncreasedModerateSevereVery severe

Classification by BMI(DAC)

Obese Overweight Health/Normal Underweight0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

39.70%

35.40%

15.30%

3.30%

Prevalence of Stunted-Overweight

• In children BMI> 75th percentile have increased risk of coronary heart disease, atherosclerosis and cerebrovascular diseases (Ellis, 2001)

• Stunted-overweight puts the child at high risk of developing diabetes in adulthood

• Prevalence of stunted-overweight was 3% at well Baby Clinic at KNH (CH. Hellen,AM Mwangi,2010)

• 19% children aged 3 years were both stunted and overweight SA (Mamabolo , et al 2007).

Waist–hip ratio

• Measurement of waist hip ratio: In a lean person (left), the waist can be measured at its narrowest point, while for a person with convex waist (right), it may be measured at about one inch above the navel. The hip is measured at its widest portion of the buttocks at left, and at the great trochanters at right.

• Waist–hip ratio or waist-to-hip ratio (WHR) is the ratio of the circumference of the waist to that of the hips.

Waist-Hip Ratio

Waist and Hip RatioWaist to Hip Ratio Chart

Male Female Health Risk Based Solely on WHR

0.95 or below 0.80 or below Low Risk

0.96 to 1.0 0.81 to 0.85 Moderate Risk

1.0+ 0.85+ High Risk

Clinical

• Observations – those who use raw carrot juice and raw beet root has elevated Blood Glucose.

• Sweeterners, diet coke and ‘sugar free juices’

Biochemical assessments

• Lipid profile• HBA1C• Blood sugar • Kidney and Hearth functions

Ecological factors

• Are known to influence the nutritional status of individuals.

• Variables include; household composition, education, literacy

• ethinicity, religion, income, employment, material resources, water supply and household sanitation, access to health, and agricultural services as well as land ownership.

More cases have Diabetes(DAC)

D/M HTN

CCF/CHF

Hyperc

holester

olemia

Hyperc

alcem

ia

Cancer

s

Constipati

on

Hypert

hyrodism Gout

Athritis TB RVD

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00% 55.20%

34.50%

1.40%

5.40%

0.50% 1.80% 0.50% 0.50% 0.50% 0.50% 0.50% 1.40%

Prevalence by Sex in DAC Clinic

38%

62%

Gender

MaleFemale

Which diet?

• Current choices• 1. low fat diet• 2. low carbohydrates• 3. Mediterranean diet

Standard modern diet consist of:

• 55-60% carbohydrates• 20-30% fat• 15-20% protein

Why low carbohydrates -metabolic consequences

• Rapid reduction in body weight due to increased lipolysis

• Increased water loss at the beginning • Mild metabolic ketoacidosis• Decrease in appetite and eventually food intake• Improvement in insulin resistance, plasma

lipids and plasma glucose- caveats hypokalemia (cramps, weak legs) and bowel obstructions

A low carbohydrate Diet?

• Improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus

(a 1- year prospective randomized intervention study Abel V.S et al, 2010)

• Long-term following of any low calorie diet is beneficial for patients with type 2 diabetes

• But only as a part of a structured permanent lifestyle modification

Major Challenges

• Majority of the clients do not access the nutrition services.

• Less than 5% of the total clients attending DC receive the Nutrition services

• Clients have varied nutrition information/knowledge from other health workers,herbalists, relatives, bussinesmen/women

• Undoing the information is a challenge.

Reccomendations

• Refer healthy clients – Hospital protocol• Refer all clients to Dietician/ Nutritionist• Nutrition guidelines on management of

diabetes to be improved. • Provision of optimal Nutrition should start

before, after and during pregnancy• Proper feeding practices and growth

monitering should start from birth

Conclusion

• Glycemic control is achieved when Drugs and Nutritional Therapy are combined

• Diabetes management involves multidisplinary approach.

• Prevention is better than cure- through Intensifications of campaigns/education-

Breastf eeding and HBV-proteins

How much food on your Plate