Nutritional Management of

Diabetes And Heart Diseases

Shilpa Joshi RD
Mumbai Diet And Health Center
Bandra (west)
shlpjoshi@yahoo.com

Burden of Major NCDs 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/ 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

big
1 small
medium (75 gm)
big size (50 gm)
12-15 pieces

Properties of Dietary Fibre

Type

Major Food
Sources

Known Effects

Cellulose

Bran, whole wheat

four, cabbage, peas
& beans, root
vegetables, apples

Hemicelluloses

Bran, cereals, whole Same as cellulose

grains

Soluble noncellulosic Polysaccharides

pectin's
Apples, citrus, fruits,
various berries,
apricot, banana,
carrots, sweet potato

Affect food texture,

increase fecal bulk,
shorten transit time

Alter consistency of
gastric & intestinal
contents, reduce
absorption of
cholesterol, reduce
serum cholesterol,
water holding

Properties of Dietary
Fibre
Type

Major Food
Sources

Known Effects

Gums & Mucilage's

Oat meal, dried

beans, other
legumes

Binding of ions &

other substances,
water holding
cholesterollowering

Lignin

Old (tough)
vegetables, wheat

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 consumer is a
a controversial subject
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

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, chutneys
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)
Thalipith or
1 Ghavan or
1 bowl of spaghetti or
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 cross-sectional 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)

Alcohol Content
(g/l)

Distilled Spirit (Whisky,

Cognac, Vodka)

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

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
individuals 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

Sucralose

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, Pia 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 mithais
Diet colas
Low calorie or diet farsans
Diabetics adjuncts 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

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 530 grams with each meal
or 1590 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

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