By Hellen C Baliach Consultant Clinical Nutritionist Role of Medical Nutrition Therapy in Prevention and Treatment Of Diabetes By Hellen 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

Disease Prevalence in Diabetes Clinic

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) Underweight 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 RISK Low (but risk of other clinical problems is increased Average Increased Moderate Severe Very severe

Classification by BMI(DAC)

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 to Hip Ratio Chart Waist and Hip Ratio Waist 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)

Prevalence by Sex in DAC Clinic

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