Assoc

Institutul

prof. Cristian Serafinceanu

de Diabet, Nutriie i Boli metabolice

N. Paulescu
Bucharest

Diet and physical activity are linked to more deaths

each year than any single factor other than cigarette
smoking.

As health care providers, we can do more for our

patients by helping them eat healthy and exercise
regularly than any other intervention.
B Brenner, 2007

Nutritional care algorithm (nutritional medical

therapy) for renal patients
1
2
3.
4.
5.

nutritional screening
nutritional antecedents
nutritional behavior
clinical examination
biologic parameters

Periodic evaluation:
1. results monitoring - redefining goals
1. solving current problems

Identification of therapeutic goals:

1. Reasonable
acceptable
2. Negotiable
for own
lifestyle
3. Adjustable

Nutritional medical intervention:

1. Diet
2. Nutritional supplements

Significant antecedents:

1.

Physiologic
Pathologic
Therapeutic

Known nutritional problems or deficits

Chronic use of drugs with nutritional effects (i.e. chimiotherapy)
Psycho-social antecedents:

Alcohol or drug abuse

Smoking
Financial and social status
Marital status

Specific signs and symptoms for nutritional deficiencies

Subjective global assessment:

1.
2.

Evaluation of muscular waste

Evaluation of subcutaneous tissue
Presence of oedemas
Dialysis related items

Basal (level I): detection of

nutritional risk factors

-body mass index

-eating habits
-living environment
-functional status

Complete (level II): for

patients at nutritional risk

-history of weight changes (6

mo)
-mid-arm circumference
-triceps skinfold
-mid-arm muscle area
-serum albumin
-total plasma cholesterol
-clinical features
-drug prescriptions
-mental/cognitive status

Age

BMI

Malnutrition

>= 18 years

<16
16 16,9
17 18,5
>= 18,6

Severe
Moderate
Mild
Normal

14 17 years

<16,5

Present

11 13 years

<15

Present

Eating habits (topics)

-not have to eat enough (each day)

-usually eats alone
-poor appetite
-special (restrictive) diets
-does not eat vegetables, fruit or milk at least once
daily
-difficulties in chewing or swallowing
-more than two alcoholic drinks per day (one for
women)
-has pain in mouth , teeth or gums

Living environment

-poor income
-lives alone
-housebound
-is unable (or prefers not) to spend money on food

Functional status - needs assistance

(usually or always) with:

-bathing
-dressing
-toileting (grooming)
-eating (preparing food)
-walking (traveling)
-shopping (for food)

Target
population

Mid-arm
circumference
(MAC)

Triceps
skinfold
(TS)

Mid-arm
muscle area
(MAMA)

Females 3040y

28.6

24.2

32.4

Females 6070y

31.7

14.5

35.4

Males 30-40y

31.9

13

55.8

Males 60-70y

32.8

14.2

51

Clinical features and mental/cognitive status:

-evident problems with mouth, teeth, gums

-difficulties with chewing
-angular stomatitis
-glossitis
-skin lesions (dry, loose, wounds, etc.)
-history of bone fractures
-clinical evidence of mental status impairment
-depressive illness (Geriatric Depression Scale, etc.)

Mechanism

Inadequate intake

Inadequate
absorption

History of

Suspected
deficiency

Alcohol abuse

Protein, vitamins B

Avoidance of fruits,
vegetables

Vitamin C, folates,
vitamins B

Avoidance of meat ,
Protein, vitamin B12
eggs

Habitual
constipation

Dietary fibre

Poverty, isolation

Energy, protein

Drugs (antacids,
laxatives,
anticonvulsivants)

Various nutrients

Mechanism

History of
Malabsorption (diarrhea,
weight loss, steatorrhea)

Inadequate
absorption

Suspected
deficiency
Liposoluble
vitamins
(A,D,E,K),
energy, protein

Parasites
Pernicious anemia

Iron, vitamin, B12

Gastro-intestinal surgery

Decreased
utilization

Drugs
(anticonvulsivants,
antimetabolites,
isoniazide)
Inborn errors of
metabolism

Various

Mechanism

Increased losses

History of

Suspected
deficiency

Alcohol abuse

Magnesium, zinc

Blood loss

Iron

Centesis (ascitic,
pleural)
Uncontrolled
diabetes mellitus

Protein
Energy, protein

Diarrhea

Protein,
electrolytes

Nephrotic
syndrome

Protein

Dialysis

Protein, vitamins
(water soluble)

Mechanism

Increased
requirements

History of

Suspected
deficiency

Fever,
hyperthyroidism
Physiologic
demands
(adolescence,
pregnancy,
lactation)
Surgery, burns,
trauma

Energy, protein,
vitamin C

Infection, hypoxia

Energy

Smoking

Vitamin C, folates

Energy

Energy, various
nutrients

Organ
/syste
m

Nutritional deficiency

Non-nutritional
association

essential fats, vit.A

environmental

niacin or tryptophan

chemical burns,
Addisons disease

pallor

iron, vit B12

hemorrhage,
pigmentation
disorders

Petechiae,
ecchymoses

Vit K, C

Liver disease, aspirin

overdose

nails

spoon-shaped

iron

pulmonary or heart
chronic disease

hair

lack of shine, easy

pluckable

proteins, Zn, linoleic

acid

hypothyroidism,
chemotherapy,
psoriasis

Abnormal finding
dry, scaly

Skin

hyperpigmentation of
sunlight exposed
areas

Organ/system

Abnormal finding

Nutritional
deficiency

Non-nutritional
association

eyes

dry, grayish, night

blindness

Vit A

Gauchers disease

lips

bilateral (angular
stomatitis) or
vertical cracks
(cheilosis)

Vit B2, B6, niacin

dentures problems,
herpes, syphilis,
AIDS

tongue

magenta, loss of
papillae, swollen

Vit B2

Crohndisease,
bacterial or fungal
infections

Vit. C

Drugs (dilantin),
lymphoma,
thrombocytopenia,
aging, poor dental
hygiene

Protein deficiency

Tumors,
hyperparathyroidis
m

gums

spongy, bleeding,
receding

parotid glands

Bilateral
enlargement

Methods to assess protein and energy status

Protein stores

visceral

somatic

Salb
Sprealb
Stransf
Ret. bind. prot.
IGF-1

Other methods

SGA

Anthropometry
BIA
Nitrogen balance
Densitometry
Creat. Kinetics
Isotope studies
DEXA
NMR
others

Energy balance

expenditure

balance

Parameter Norma Plasmatic

l range
life (d)
(g/l)

Normal
function

Nutritional
significance

Albumin

35-45

18-20

Coloid-osmotic
pressure

late malnutrition
marker

Transferrin

2.6-4.3

8-9

plasma iron
carrier

malnutrition (more
early) marker; negative
inflammation marker

Prealbumin
(transthyreti
n)

0.2-0.4

2-3

Thyroid
hormones
transporter

Malnutrition (early
marker); acute
hypercatabolic states

Rhetynol
binding
protein
(RBP)

0.37

0.5 (12h)

Pro-vitamin A
transporter

Proteic intake
markerhypercatabolic
states

Insulin-like
growth
factor 1 (IGF
1)

0.55-1.4
UI/ml

2-6 h

Anabolic growth
factor

Immediate proteic
intake marker

1. Weight Change
Maximum body weight _______________
Weight 6 months ago _______________
Current weight

_______________

Overall weight loss in past 6 months _______________

Percent weight loss in past 6 months _______________
Change in past weeks: _______increase

_______no change

________decrease

2. Dietary Intake (relative to normal)

_________ No change

Duration: __________ Weeks

_________Change

Type: __________ Increased intake

__________ Suboptimal solid diet
__________ Full liquid diet
__________ IV or hypocaloric liquids
__________ Starvation

3. Gastrointestinal Symptoms (lasting >2 weeks)

__________ None
__________ Nausea

__________ Vomiting

____________ Diarrhea

___________ Anorexia

4. Functional Capacity
___________ NO dysfunction
___________ Dysfunction

Duration: ____________ weeks

Type: ____________ Works suboptimally
____________ Ambulatory
____________ Bedridden

PHYSICAL EXAMINATION
(For each trait specify: 0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe)
__________ Loss of subcutaneous fat (shoulders, triceps, chest, hands)
__________ Muscle wasting (quadriceps, deltoids)
__________ Ankle edema
__________ Ascites

SUBJECTIVE GLOBAL ASSESSMENT RATING (select one)

__________ A = well nourished
__________ B = moderately (or suspected of being) malnourished
__________ C = severely malnourished

ROSPEN, Poiana Braov, 2004

Parameter
/score

Weight
changes/6
mo

no

5%

5-10%

10-15%

15%

Dietary
intake
changes/ 6
mo

no

Suboptimal
solid food

Moderate
global
decrease

Liquid/hypocalo
ric diet

starvation

Digestive
symptoms

no

nausea

Vomiting/othe
r moderate

Frequent
diarrhea/vomiti
ng

Anorexia

Functional
status

Good/norm
al for age

Walking
difficulty

Usual efforts
difficulty
(housekeeping
)

Minimal efforts
difficulty
(toileting)

Bedriding

Comorbidities

No

mild

moderate

1 severe

Multiple,
severe

Dialysis
duration**

Less than 12
mo, RRF

Less than 12
mo, no RRF

12-24 mo, RRF

24-48 mo, RRF

More than 48
mo

Malnutrition:

-absent: 0 4
-mild:
58
-moderate: 9 14
-severe: 15 -24

1.

Classifying nutritional deficits in weight - for - height:

reference values (Torm B, Chen F, 1994)

Weight - for - height ratio = actual body

weight/reference weight for height (RWH)
RWH = 50+0,75(H-150)+(Age-20)/4

Normal: 90-110%
Mild deficit: 80-89%
Moderate deficit: 70-79%
Severe deficit: <70% (or with oedemas)

2. Body mass index (BMI, Quetelet index)

3. Tricipital skinfold (TS)
4. Mid-arm circumference (MAC)
5.Mid-arm muscular area (MAMA)
(MAC - TS)2/12.56

All anthropometric measurements must be interpreted for age, sex, race

Indication = patients with significant risk of malnutrition after

nutritional history and physical examination (SGA).

Aim = to detect specific nutritional deficiencies before onset of

clinic or anthropometric manifestations.

Protein status: central for the prevention, diagnosis and treatment of

malnutrition:

Bi - compartmental pattern (of evaluation):

Metabolic active proteins (30 50%)

Muscle (somatic) proteins (75%)

Visceral proteins (25%)

Metabolic inactive proteins (50 70%):

Bones, joints

Iron status.
Calcium and phosphorus status.
Vitamins status.

Nitrogen balance = ratio between the amount of

nitrogen consumed as proteins and the amount
excreted by the body.

The expected value for healthy adults is 1 the rate of

proteins synthesis (anabolism) equals the rate of protein
degradation (catabolism)
Formula: PRO(g)/6,25 = UUN(g) 4(g), where:

PRO: protein ingestion/24h(g)

6,25: protein nitrogen index
UUN: urinary urea nitrogen/24h (g)
4(g): constant for non urea nitrogen + non urinary
nitrogen (stool, sweat)

Disequilibrium of nitrogen balance need dietary and/or

non dietary correction (i.e.: increased losses in critically
ill patients).
ROSPEN, Poiana Braov, 2004

a.

Somatic protein status

Lean body mass assessment (muscle mass) can

be estimated by the 24h urinary creatinine excretion
comparing with a standard (expected) excretion
based on height

Urinary creatinin excretion:

Is a constant on ideal weight:

23 mg/Kgc/day in men

18 mg/Kgc/day in women

Its variation is exclusively determined by height (see

standards in table)
ROSPEN, Poiana Braov, 2004

Males

Females

Height (cm)

Urinary
creatinine /24h
(mg)

Height (cm)

Urinary
creatinine /24h
(mg)

160

1325

150

851

165

1386

155

900

170

1467

160

950

180

1642

165

1001

185

1739

170

1076

190

1831

175

1141

1)

2)

Include questions about diet and exercise in all your

routine patient histories.
Assess all patients height, weight and BMI.
Measure waist circumference when appropriate.

3)

Help patients understand the association between

their diet and exercise habits and their risk for
chronic diseases.

4)

Begin to negotiate realistic lifestyle changes that can

be achieved and maintained over time.

Increased total calories (and

portion sizes)-energy density
Increased fast food consumption
Increased saturated fat and salt
intake
Low fruit and vegetable intake
Inadequate calcium intake

USDA Food Guide Pyramid

2001 ATP III Guidelines target LDL

Diabetes is a CHD risk equivalent

Metabolic syndrome should be treated with

intensified lifestyle changes.

BMI >30 considered a major risk factor for CVD

Therapeutic Lifestyle Diet (TLC) developed

Fat intake 25 - 35% of total calories
Limit saturated fat
Increase monounsaturated fat

Nutrient

Recommended Intake

Saturated

fat
Polyunsaturated fat
Monounsaturated fat
Total fat
Carbohydrate
Fiber
Protein
Cholesterol
Total calories (energy)
Stanol esters
Soy protein
Soluble fiber
Fish

at least 2 times a week

Less than 7% of total calories

Up to 10% of total calories
Up to 20% of total calories
2535% of total calories
5060% of total calories
2030 grams per day
Approximately 15% of total calories
Less than 200 mg/day
Maintain healthy weight/prevent weight
2 grams/day
25-40 grams/day
5-10 grams/day

Sources of Dietary Fat

More Atherogenic

Less Atherogenic
Unsaturated Fatty Acids

Saturated Fatty Acids

Beef, Pork Veal,
Lamb, Butter,
Cheese

Hydrogenated
Vegetable Oils

Trans
Fatty Acids

Cocoa Butter
Coconut Oil
Palm Oil

Polyunsaturated
Fatty Acids

Omega-6
Fatty Acids

Omega-3
Fatty Acids

Corn, Safflower,
Sunflower,
Soybean

Fish, Flaxseed,
Soybean,
Marine Vegetation

Shortening
Margarine

Source: ATP III Guidelines. NCEP 2001 Report

Monounsaturated
Fatty Acids

Olive Oil,
Canola Oil,
Nuts, Avocado

According to the JNC VII 2003 Report, individuals

with a systolic BP of 120-139 mm Hg or a diastolic
of 80-89 mm Hg should be considered as
prehypertensive and require health promoting
lifestyle modifications to prevent CVD.

Lifestyle issues:

weight, diet, physical activity, alcohol and smoking

Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNC VII. JAMA. 2003;289:2560-2572.

459 adults enrolled with mean base-line BP of 131.3/84.7 mm Hg.

3 week control diet run-in period

Subjects randomized to 3 groups for 8 weeks

Control diet
Diet rich in fruits (5 servings/d) and vegetables (3 servings/d)
Combination diet: fruits/veggies, low fat dairy (2 servings/d),
low saturated fat (<7%).
Average sodium intake ~ 3000 mg/day in all groups

5.5 mm Hg in systolic pressure and 3.0 mm Hg in diastolic pressure

with combination vs. control diet. No change in BMI.

Reduction in BP began within 2 weeks and maintained for duration of study.

Source: Appel, LJ,et.al. NEJM 336:1117-24, 1997.

412 adults enrolled with mean BP of 135/86 mm Hg. Mean BMI=30

90 day trial. Subjects randomized to 2 groups:
Control diet
DASH diet: fruits (5 servings/d), vegetables (3 servings/d),
low fat dairy (2 servings/d), low saturated fat.

Each group spent 30 days on each 1150, 2300, and 3450 mg Na/day

DASH and low sodium resulted in a 7.1 mm Hg in systolic pressure

in patients with normal blood pressure.

11.5 mm Hg in systolic pressure in those with HTN.

Effects of reduced sodium seen in both patients with normal and high
blood pressure regardless of race or gender.

Source: Sachs FM,et.al. NEJM 344:3-10, 2001.

Do you taste your food before you add salt?

How often do you eat salty foods, such as chips, pretzels,

salted nuts, canned and smoked foods?

Do you read labels for sodium content?

How many servings of fruits and vegetables do you eat everyday?

How often do you eat or drink dairy products? What kind?

How often do you eat out? What kinds of restaurants

Modification

Recommendations

Approximate Systolic
Blood Pressure
Reduction

Weight Reduction

Maintain normal body

weight (BMI 18.5-24.9)

5-20 mm Hg for each

10 kg weight loss

Adapt DASH eating plan

Consume diets rich in fruits,

vegetables, low fat dairy

8-14 mm Hg

Dietary sodium reduction

Reduce sodium to no more

than 2.4 g/day sodium or 6
g/day NaCl

2-8 mm Hg

Increase physical activity

Engage in regular aerobic

activity such as walking

4-9 mm Hg

Moderate alcohol consumption Limit alcohol to no more

than2 drinks/d for men and

1 drinks/day for women.
2.

2-4 mm Hg

USDA Food Guide Pyramid

DASH PYRAMID

Achieve normal or near-normal blood glucose levels

Achieve optimal lipid levels
Appropriate calorie recommendations
Maintain reasonable weight for adults
Growth and development for children and teens
Improve health through optimal nutrition and physical activity
Prevent, delay, or treat nutrition-related complications
Individualized based on usual lifestyle habits and
need/willingness to change
Source: American Diabetes Association. Nutritional Recommendations and Principles for
People with Diabetes Mellitus. (Position Statement). Diabetes Care. 1998;21(Suppl 1):S32-35.

Diabetes Prevention Program (DPP) Research Group

27 Centers following patients from 1996 to 1999

Recruited 3234 people over 2.8 years

>25 years old

Fasting glucose 95 - 125 mg/dL
140 - 199 mg/dL 2 hours post 75 oral glucose load
BMI >24

Source: Diabetes Prevention Program II. NEJM. 2002:346;393-403

Year

Incidence of type 2 diabetes

was reduced by 58% with
lifestyle intervention and by
31% with Metformin, as
compared to placebo.
Lifestyle intervention group
significantly better outcome
compared to medication or
placebo groups.

8.4
8.2

8.0

HgbA1C

7.8
7.6
7.4
7.2
No Education

7.0

1 RD visit

6.8

3 RD visits

6.6
Initial

6 Week

3 Month

6 Month

Source: Franz et al., J Am Diet Assoc 95:1009-17, 1995

In diabetics, there is a strong correlation between

metabolic syndrome and CVD.

Metabolic syndrome patients with type 2 diabetes have

a higher prevalence of microalbuminuria or
macroalbuminuria.

Patients with metabolic syndrome have a small LDL

particle size pattern and preclinical atherosclerosis.