Nutritional Management of
Diabetes And Heart Diseases
Shilpa Joshi RD
Mumbai Diet And Health Center
Bandra (west)
shlpjoshi@yahoo.com
Burden of Major NCD’s in India
 35 million cases of Cardiovascular
Diseases
 45 million cases of Diabetes
 2.4 million cases of cancer
 22 million Obesity
 1 million cases of Cerebrovascular
Disease/stroke
 Every 5th Diabetic is an Indian
 Every 5th to 10th Asian Indian Native
Urbanite is a Diabetic
BMI
22.3
22.3
Body fat
9.1%
21.2%
Glucose is the currency of body &
every cell needs it
Type 2 DM
Oxidative Stress Damages Here
Endothelial lining
Smooth muscle Collagen
Food
Any substance that can be metabolized by
an organism to give energy and build
tissue
Any solid substance (as opposed to liquid)
that is used as a source of nourishment;
"food and drink"
Anything that provides mental stimulus for
thinking
Traditional Diets
Traditional Diet
Food Pyramid
Fats, Oils & Nuts
2-3 Units
Milk & Milk Products
Meat & Fish
2-3 Units
1-2 Units
Vegetables
Fruits
3-4 Units
2-3 Units
Cereals & Pulses
8-12 Units 10-14
units (veg)
Food Components
MACRONUTRIENT
 Carbohydrates
 Proteins
 Fats
MICRONUTRIENTS
 Vitamins
 Minerals
Carbohydrates
Primary source of energy
Sources:cereals, fruits, vegetables,milk
Carbs are of two types
simple carbs: sugars, honey, colas, fruits
juices, jaggery,maida,bakery products
Complex carbs: cereals, vegetables,
pulses
How to choose carbohydrates.
Complex carbohydrates are good for our
health.
Simple carbohydrate easily increase our
blood sugar, so decrease their
consumption.
Eat carbohydrates only in recommended
amounts.
Choose complex carbohydrates high in
fibre e.g unpolished rice, ragi ,whole wheat
Fruits Exchanges ( to be eaten in
prescribed amount)
Apple
Guava
Orange
Papaya
Pineapple
Pears
Sweetlime
Water melon
Pomegranate
Coconut water
Jambun
1 small/½ medium
1 medium
1 medium
1/3 medium or 3 slices
2-3 slices
1 medium
1 medium
2-3 slices
1/3rd medium
150 ml
100 gm
FIBRE: Boon of nature
Fibre is non digestible carbohydrate.
It forms a bulk and hence makes us feel
full.
Soluble – oats, barley, psyllium, fruits
( guava, apple ), gum
Insoluble-whole grains, pulses,
vegetables, fruit ( oranges, sweetlime )
Fruits Exchanges: (to be
avoided)
High Calories Fruits
Banana
Chickoo
Mango
Sitaphal
Grapes
½ big
1 small
½ medium (75 gm)
½ big size (50 gm)
12-15 pieces
Properties of Dietary Fibre
Type
Cellulose
Hemicelluloses
Major Food
Sources
Bran, whole wheat
four, cabbage, peas
& beans, root
vegetables, apples
Bran, cereals, whole
grains
Soluble noncellulosic Polysaccharides
pectin's
Apples, citrus, fruits,
various berries,
apricot, banana,
carrots, sweet potato
Known Effects
Affect food texture,
increase fecal bulk,
shorten transit time
Same as cellulose
Alter consistency of
gastric & intestinal
contents, reduce
absorption of
cholesterol, reduce
serum cholesterol,
water holding
Properties of Dietary Fibre
Type
Gums & Mucilage's
Lignin
Major Food
Sources
Oat meal, dried
beans, other
legumes
Old (tough)
vegetables, wheat
Known Effects
Binding of ions &
other substances,
water holding
cholesterollowering
Indigestible by fecal
bacteria
Quantity of Soluble Fibre to Produce Lipid
Lowering Effect
Source
Pectins
Gums
Dried beans
Dry oat bran
Oat meal
Psyllium
Quantity
6 to 40
8 to 36
100 to 150
25 to 100
57 to 140
10 to 30
Fibre Content of Foods
Low Fibre
Milled rice
Refined wheat flour
Bread white
Whole gram (bengal)
Lentil
Green gram dal
Bottle gourd
Ash gourd
Cucumber
Tomato
Spinach
Lettuce
Banana
Moderate Fibre
Whole wheat flour
Wheat germ
Brown bread
Field beans
Red gram dal
High Fibre
Rice bran
Brinjal
Cauliflower
Radish leaves
Fenugreek
Cabbage
Bengal gram
Whole
Rajmah
Peas
Red gram
Green gram whole
Apple
drumstick
Fibre Content of Foods
Low Fibre
Sweet lime
Lichi
Water melon
Prunes
Moderate Fibre
Peaches
Pears
Orange
High Fibre
Parwar
Double beans
Colocasia
Amaranth
Amla/Dates/Grapes/
Guava/Pomegranate
/
Sapota/Papaya
Proteins
Repair of tissues, immunity
Sources: pulses, nuts, milk and milk
products, meat, egg, fish, poultry.
Egg ,poultry and red meat have saturated
fats in them
Good source of proteins are dals, sprouts,
fish, egg whites,chicken breast.
Advantages of proteins
Is not converted into sugar as fast as
carbohydrates.
It keeps us full for a long period of time.
It takes a lot of energy to burn proteins,
therefore you store less energy.
FATS
Source of stored energy
Source: oil, butter, ghee, nuts, non-veg,
cheese, bakery products
CHOICE OF A HEALTHY COOKING MEDIUM:
a controversial subject
A consumer is a confused
lot as far as choosing the
right kind of cooking
medium is concerned.
Every supplier of any type
of cooking oil claims the
same to be best for health
A common man is not
aware of the yardstick by
which any cooking oil could
be rated as the best one
CHOLESTEROL
BALANCING
OXIDATION
STABILITY
Recommended fats (heart friendly oils )are MUFA eg.
ground nut oil, rice bran oil, olive oil
Invisible Fats
Coconut
Peanuts, Almonds, Cashewnuts etc.
Condiments like pappad, pickles,
chutney’s etc.
Garnishes like cheese, cream, white
sauce, etc.
Bakery items like biscuits, kharis, puffs,
etc.
Farsans and sweets
Non-Vegetarian food
Milk & milk products
Total Fat
Total fat intake is most important
Invisible sources of fat should be
included in the total fat intake
Total fat intake is closely related to
serum lipids
Recommended intake is 20 gms per
person per day
Diets should not provide more than 30%
calories from fat
Effect of heating on oils
Depends on saturation of oils
Temperature of heating
PUFA > MUFA > SFA
Change in saturated:unsaturated ratio
Formation of peroxides
Loss of antioxidants
Dietary cholesterol
Associated with animal fat
Sources of dietary cholesterol : ghee,
cream
butter, non-vegetarian foods.
Excess consumption of fat leads to
production of fat in our body
Prudent fat intake : 3-4 tsp/day/person
Good oils :ground nut oil, olive oil, rice
bran oil
Alternatives
1 cereals exchange gives 100 kcals
1 chapatti (30 g) 1 thepla or
1 khakra (dry) or
1 medium vati porridge or
2 medium size bread slice or
1 pav (30 gm) or
1 vati (medium) cooked rice or
1 medium vati onion poha (no potato)
½ Thalipith or
1 Ghavan or
1 bowl of spaghetti or
¼ bhakri or
1 bowl of corn flakes or
1 idli with sambhar or
1 dosa (home made – medium sized – on nonstick) with
sambhar
4-5 pieces of dhokla or muthia (steamed)
4-5 pieces of Khandvi
Meal Patterns
Breakfast:
 Meal consumed within one hour of rising
 Most important meal of the day
 Should be rich in complex carbs and protein
eg: cereal, porridge, roti, dosa, idli, upma, daliya,
paratha, eggs, milk, fruits.
Avoid :bakery products
Meal Patterns
Lunch
Eat balanced meal
Make right food choices
Do not skip lunch
Include protein as a important part of meal
eg thali, roti-subzi , dal rice, curd rice
Meal Patterns
Dinner
Meal should be as light as possible
Low in carbohydrates especially simple
carbs
Make clear soups as integral part of dinner
Eating Out
(Make Right Choices)
Meal time
Cuisine
Meal selection
Hygiene
A la carte
Either starter, main course or dessert
never all together
Clear soup should be an integral part of
menu
Choose grilled, tandoori, broiled, stir fry
Do not order for deep fried, makhani, white
sauces, mayonnaise
Salad(?)
Buffet
Choose wisely
Do not have to eat it all
Select hot, steaming foods
Select a live counter so dish can be made
as per your choice
Avoid greasy foods
Mid Meals/Snacks
 Avoid high calorie snacks- split it into two
 Avoid super sized snacks
 Fruits, channa, unbuttered pop corn, sukha bhel
with less sev, cooked channa chat are ideal
snacks
 Avoid bakery products, colas, juices, chaat etc
 The best drink with and between meals is water
Mid-Meal Options
Skimmed milk
Chaas
Kurmura
Channa
Fruit (permitted quantity only)
Alcohol
 Causes hypoglycemia if consumed without food
 Foods consumed with alcohol are usually fried
foods/junk food empty calories)
 Alcohol is high in calories 7 kcals/gm and is
metabolized in a manner to fat.
 give up alcohol, if not then fix the quantity, frequency
and exchange it with fat.
 consume salads with alcohol.
Alcohol
 Raises HDL
 Lowers insulin concentration and improves insulin
sensitivity
But
 Raises blood pressure
 These findings are true for whites. Blacks (Afro
American ) and Hispanics do not show this
relationship
 Studies on Indian populations have not been done
Ref : Freiberg MS, Cabral HJ, Heeren TC, et al. Alcohol Consumption
and the Prevalence of the Metabolic Syndrome in the U.S.A crosssectional analysis of data from the Third National Health and Nutrition
Examination Survey. Diabetes Care 2004; 27:2954-2959.
Alcohol & Sugar Content of Alcoholic Drink
Alcoholic Drink
Carbohydrate/Sug
ar Content (g/L)
Distilled Spirit (Whisky,
Cognac, Vodka)
-
Alcohol Content
(g/l)
400-500
Dry White Wine & Red
Wine
2-10
120
Beer & Dry Sherry
30
40-50
Sweetened White Wine
& Poat Wine
120
An average drink namely 5 oz of wine, 12 oz of beer or 1.5 oz of distilled
spirit contains 12-14 gms of alcohol. Thus they give approximately 100
kcal.
Lieber CS. Alcohol Research & Health, Fall, 2003
Unit of Alcohol
One Unit of Alcohol
Half a pint of beer, lager or cider
Pub measure of spirits (whisky, vodka,
rum, gin)
Glass of wine
Glass of sherry
Calories
90
50
75
55
One unit of alcohol is 10 ml by volume, or 8 g by weight, of
pure alcohol. For e.g. Half a pint of ordinary strength beer, 25
ml of spirits, 50 ml of fortified wine such as sherry or port
How Should be the Calories from
Alcohol Calculated?
When calories from alcohol need to be
calculated as part of the total caloric
intake, alcohol is best substituted for fat
exchanges (1 alcoholic beverage = 2 fat
exchanges or fat calories.
ADA Guidelines
Fountain
PEPSI
WATERFOUNTAINS
Fast Food Joints
Order wisely
Find a low fat option and order
Do not over indulge
Eg: just a burger no fries ,one unbuttered
pav instead of two buttered pav, bhel puri
instead of sev puri, ragada pattice instead
of panipuri, samosa ,kachori
Maharaja Mac ?
Jumbo Vadapav?
Double
Cheese Pizza?
DO NOT UPSIZE !!!
We Need To Minimize
Not Maximize
Sweeteners
 Sweeteners are of two kind: Nutritive
Sweeteners (which have calories) and NonNutritive Sweeteners (which have no calories)
 Nutritive and Non Nutritive Sweeteners should
be used sparingly in prescribed amounts
 Education on appropriate use of sweeteners
 Impact of nutritive sweeteners on the
individual’s blood glucose levels & lipid profile
should be assessed on a regular basis
ADI of various sweeteners
Sweetener
Acceptable daily intake
(mg/kg body weight)
Acesulfame potassium
15
Aspartame
40
Cyclamate
11
Saccharin
5
Sucralose
9
Sodium
 Sources: salt, bakery products
 Blood pressure is significantly related to
sodium intake(inter salt study)
 High salt intake has been implicated in
hypertensive target organ diseases
Strategies to limit salt intake
Reduce salted foods bakery, processed food,
pickle, ketchup
Avoid :salt shakers, salt on salads, fruits, atta,
rice, sherbet
Use of lime, tamarind, pudina to bring flavour
to foods
Integrating Therapies
Physical Activity

Benefits
Physical activity
is it necessary?
Prevents obesity( weight gain)
Improves heart conditioning
Improves blood pressure
Stabilizes blood sugar
Improves muscle mass and bone health
Secretes feel good hormones
Physical Activity and Its Benefit
 Reduces body weight
 Reduces blood pressure
 Keeps blood sugars under control
 Increases HDL levels
Ref: Thompson PD, Buchner D, Piña IL, et al. AHA Scientific Statement Exercise and Physical Activity in the Prevention and Treatment of
Atherosclerotic Cardiovascular Disease A Statement From the Council on
Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and
Prevention) and the Council on Nutrition, Physical Activity, and Metabolism
(Subcommittee on Physical Activity. Circulation. 2003; 107: 3109
Diet Issues
Hypocaloric Diets
Low Carb Diets
Meal Replacement Diets
Eat less, Eat on Time
Concentrate on Satiety
Satiety Index
Killer Diet
Fast Foods kill fast
Fried,Calorie Dense
Oils and Butters
Lack of Fibre
Cola Culture
Traditional Diet
Less oil
Fibre rich
Designer Foods
Low cal mithai’s
Diet cola’s
Low calorie or diet farsan’s
Diabetics adjunct’s – jam, jelly, pickles
Healthy Eating
Eating Out
Good Nutrition
Weight
Control
Flexible
Lifestyle
Prevention of Heart Diseases
Give up one, reduce two, and increase
three
 give up smoking
 reduce food and alcohol intake
 increase exercise
Ref: Wada T, Fujishiro K, Fukumoto T, Joki M. Inf Med. 2005;
44(2):319-22.
Aham Annam….
Atharva veda (2500 BC)
We Are ,What We Eat ….
Practical Activity Interventions to
Prevent CVD
 Education and knowledge
 Compulsory sport and physical activities in
schools and colleges as well
 Gyms at work places
 Sport culture to be developed
 Physical activity intervention : elevators and
escalators to be used by only old and
sick,walking for short distances, walking at
home and in compounds of building
 Less use of gadgets: cordless phones,
remote controls
 Concept of ‘NEAT’ : do it your self
Diataal Powder
Faulty Nutrition via chronic diseases has the
potential
to bankrupt SE Asia
We will lose migrant,affluent,Asian Indians
to CAD, DM, Cancer etc
Killer lifestyle and Bad Genes
Predispose us
“Load the Gun with Bad Genes and Pull the Trigger
by Bad environment”
Its time to wake up
Soya Protein
Soya bean apart from being rich source
protein also has other phytochemicals
which are unique
 Soya fibers reduces insulin requirement in diabetes
 Decrease cholesterol synthesis in humans.
Use only processed soya : atta, nuggets,
drinks
LYCOPENE
Major carotenoids
Imparts colour to vegetables and fruits
Recent studies reveal a unique preventive
role;
Cancer &
Cardiovascular complications
LYCOPENE
 Are found in:
Tomato & tomato products
Apricots, papaya
Grapefruit, guava etc
 Shows enhanced absorption when consumed
along with fats
 Deposited in liver, lung, prostate glands, colon &
skin
 Fat soluble
LYCOPENE: HEALTH BENEFITS
 Potent antioxidant
 Major scavenger of harmful free radicals
 Prevents/delays cardiovascular complications
 Prevents oxidation of LDL
 Reduces risk of atherosclerosis & CAD
L-ARGININE
 Protein amino acid
 Classified as semi-essential / conditionally
essential
 Essential for young children
 Precursor of nitric oxide
 Shown to play a critical role in:
Hypertension
Heart dysfunction
Inflammation
Some Indian remedies : methi seed
• It is an herb and a spice
• Fenugreek contains
an active ingredient of blood glucose control
an active ingredient for blood cholesterol control
• The typical range of intake for diabetes or cholesterol-lowering is
5–30 grams with each meal or 15–90 grams all at once with one
meal.
• Use of more than 100 grams of fenugreek seeds daily can cause
intestinal upset and nausea. Individuals with peanut allergies use
with caution or avoid. Otherwise, fenugreek is extremely safe.
Effect of nuts
Rich in MUFA and PUFA
Rich in plant protein,fibre,micronutrients
like Cu and Mg
Plant sterols
Vitamin E,thiamin,riboflavin
Peanuts are good source of folate and
fibre
Walnuts are good source of omega 3 oils
Effect of garlic
Bioactive compound allicin
Organosulfur compound inhibits
hepatocyte cholesterol synthesis
Antiplatelet properties
S alkenyl cysteine results in decreased
HMG coA reductase
Effect of green tea
Bioactive principle CATECHIN
Enhances fat oxidation
Improves PP glucose response
Stimulates insulin secretion