Transcript Medical Nutrition Therapy in Chronic Kidney Diseases – on

Role of Medical Nutrition Therapy
in the Management of
Non-communicable Diseases
Dr. N. Sudheera Kalupahana
MBBS (SL), MPhil (SL), Ph.D. (USA)
Senior Lecturer, Department of Physiology,
Faculty of Medicine, University of Peradeniya
[email protected]
Outline
• Why Medical Nutrition Therapy (MNT) is
important
• Components of MNT
• Burden of NCDs
• Principles of MNT in Diabetes, NAFLD,
CKD
• NCD preventive strategies
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
“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.”
Richard Smith, Editorial, BMJ, 2004
What are the Components of Medical
Nutrition Therapy?
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
American Academy of Nutrition and Dietetics
Medical Nutrition Therapy is Provided in the
Following Conditions:
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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
Burden of Non-communicable Diseases
Irina A. Nikolic, Anderson E. Stanciole, and Mikhail Zaydman, "Chronic Emergency: Why
NCDs Matter," World Bank Health, Nutrition and Population Discussion Paper (2011).
Medical Nutrition Therapy in Diabetes Mellitus
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
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
Fruits
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)
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 foods
Meat, 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 lifestyle
Step 1 – Follow the “Health Plate”
Protein Food
Grains (rice)
Non-starchy
Vegetables
Changing your lifestyle
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
• Adults
30 minutes of moderate intensity exercise (e.g.
brisk walking) 5 days / week (can be done in 3 10minute bouts)
• 1 hour/day for weight loss
• Children and teens:
60 minutes / day
Changing your lifestyle
Step 5 - Weight Management
Fat
Stores
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
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
Lifestyle modification improves NASH
Promrat et al., Hepatology, 2010
Lifestyle Modification
LowCalorie
Diet
Increased
Physical
Activity
Behavior
Therapy
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
Summary of recommendations for dialysis
patients
• 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 wholewheat
– 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
Fruits and Vegetables low in potassium
and can be eaten
Apples
Papaya
Pineapple
Berries
Grapes
Lemons
Lime
Cabbage
Carrots
Cauliflower
Onion
Cucumber
Eggplant
Green beans
Okra
Lettuce
Fruits and Vegetables high in potassium
and to avoid
Bananas
Dates
Oranges
Kiwi
Raisins
Butter fruit
Mango
King-coconut water
Fruit juices
Beet greens
Broccoli
Potatoes
Sweet potatoes
Pumpkin
Spinach
Green leaves
Tomatoes
Prevention of Non-communicable
Diseases (NCD)
• Nearly 80% of NCD deaths occur in lowand middle-income countries
• They share four risk factors:
– tobacco use
– physical inactivity
– alcohol
– unhealthy diets
Obesity is an emerging problem in SL
34 - 43%
Katulanda et al., 2010
Jayatissa et al., 2012
26%
Katulanda et al., 2010
Assessment - Body Mass Index (BMI)
BMI = Weight (kg) / Height2 (m)2
Normal: 18.5 - 23
Overweight ≥ 23
Obese ≥ 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 crest
At 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
Abdominal Obesity Cut-offs (for South
Asians)
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)
Lifestyle Modification
LowCalorie
Diet
Increased
Physical
Activity
Behavior
Therapy
Diabetes Prevention Program:
Incidence of Diabetes
Cumulative Incidence
of Diabetes (%)
40
Placebo
Metformin
30
58%
Lifestyle
31%
20
10
0
0
0.5
1.0
1.5
2.0 2.5
Year
3.0
3.5
4.0
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
Tips to Achieve a Healthy Weight
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
High-calorie foods
High-calorie foods (compare with calorie
requirement of 1800 / day)
Coconut milk ( 1 medium coconut – 1500 kcal)
Chocolate cake (3”X3”X2”): 550 kcal
Beer 750ml – 320 kcal
Liquor 100ml – 280 kcal
Structured Meal Plans
Enhance Weight Control
Weekly
Treatment
Weight Change (kg)
0
Follow-up
Standard
lifestyle
modification
-2
-4
Lifestyle
modification
+ food
provision
-6
-8
-10
Lifestyle modification +
meal plans
-12
-14
0
6
Months
12
18
Wing RR, et al. Int J Obes Relat Metab Disord. 1996;20:56-62.
Meal Replacements Enhance
Initial and Long-Term Weight Loss
Weight Change (%)
Phase 1*
Phase 2
CF
0
-5
MR
-10
-15
0
2
4
6
8
10 12 18
Time (mo)
24
30
36
45
*1200–1500 kcal/d diet prescription
CF = 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.
51
Behavior Therapy
Goal-setting
- Weight-loss goal
- Physical activity goal
Self monitoring
- Body weight
- Food diary
Stimulus control, stress management,
coping strategies
Can you “burn it off”?
How long would you have to walk briskly to burn
about 550 calories*?
1 hour and 40 minutes
Physical activity recommended
• Adults
30 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!