به نام خدا

1. به نام خدا

2. تغذیه در پیشگیری و کنترل دیابت امین صالحی ابرقوئی گروه تغذیه دانشکده بهداشت دانشگاه علوم پزشکی شهید صدوقی یزد

3. Chronic Respiratory Disease Cardiovascular Type 2 Diabetes Cancer Chronic Diseases result in percent of deaths 4 52

4. Diabetes definition Metabolic disorder of multiple etiology (causes) characterized by hyperglycemia with carbohydrates, fat, and protein metabolic alterations that result in defects in the secretion of insulin, its action or both.

6. Fasting Blood Glucose • > 8 hr fast • DM if FBG ≥ 126 mg/dl • Random blood sugar > 200 mg/dl • OGTT: after two hour, BG>200 mg/dl • on 2 occasions • Pre-Diabetes • Impaired fasting glucose (IFG) • if : 100 - 125 mg/dl • OGTT: after two hour, BG: 140-199 mg/dl

7. Classification • Diabetes Mellitus and Other Categories of Glucose Intolerance • DM (with four subclasses) • Impaired Glucose Tolerance • Gestational DM

8. Four Types of DM • Type I DM (Insulin Dependent) • Type II DM (Non-Insulin Dependent) • Secondary/other types of diabetes associated with certain conditions • Malnutrition related DM

9. Impaired Glucose Tolerance • Higher than normal plasma glucose but lower than the diagnostic values for DM • Precursor for Type II • about 25% develop into type II and rest go back to normal • Patients are more susceptible to macro-vascular diseases.

10. Gestational DM • fasting plasma glucose 5.1-6.9 mmol/l (92 -125 mg/dl) • - 1-hour plasma glucose ≥ 10.0 mmol/l (180 mg/dl) following a 75g oral glucose load* • - 2-hour plasma glucose 8.5-11.0 mmol/l (153 -199 mg/dl) following a 75g oral glucose load • More common in older women with family history of DM • Higher chance of developing NIDDM and IGT

11. Diabetes symptoms • Polydipsia – Increased thirst • Polyuria – Increased frequency of urination • Fatigue • Polyphagia • Increased Fatigue • Weight Loss • Abnormal Healing • Blurred Vision • Increased occurrence of infections

12. Global Prevalence of Diabetes

13. Global Prevalence Estimates, 2000 and 2030 4.4 % 2.8 % Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

14. 31.7 20.8 Indonesia 17.7 Japan China 8.4 6.8 India USA Diabetes in the World Year2000 millions Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

15. 79.4 42.3 Indonesia 30.3 Japan China 21.3 8.9 India USA Diabetes in the World Year2010 millions Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

16. Nutrition

17. کنترل وزن • کالري متناسب با وزن بدن • توصيه به فعاليت بدني

18. غلات سبوس دار

19. ارتباط مصرف غلات كامل با سندرم متابوليك در افراد تهراني غلات تصفيه شده غلات كامل يافته هاي اين مطالعه نشان داد كه مصرف غلات كامل با سندرم متابوليك ارتباط معكوس و مصرف غلات تصفيه شده با آن رابطه مستقيم دارد.

20. ارتباط مصرف غلات كامل با فنوتيپ دور كمرهيپرتري گليسريدميك در افراد تهراني غلات تصفيه شده غلات كامل يافته هاي اين مطالعه نشان داد كه مصرف غلات كامل از بروز دوركمر هيپرتري گليسريدميك پيشگيري كرده و مصرف غلات تصفيه شده خطر آن را افزايش ميدهد.

21. ميوه و سبزي • هر روز از گروه ميوه و سبزي مجزا استفاده شود

22. ارتباط مصرف ميوه و سبزي با سندروم متابوليک Esmaillzadeh et al. Am J Clin Nutr 2007

23. ارتباط مصرف ميوه و سبزي با سندروم متابوليک Esmaillzadeh et al. Am J Clin Nutr 2007

24. استفاده از خشکبار به همراه چاي بجاي قند و شکر

25. مصرف قند هاي ساده تنها در فرم ميوه ها نه در فرم قند و شکر و فرآورده هاي تهيه شده با آنها • عدم مصرف نوشابه هاي گاز دار

26. چربي ها • اسيد هاي چرب ترانس • اسيد هاي چرب اشباع • روغن زيتون (موثر در کاهش مقاومت انسولینی) • روغن مايع گياهي

27. 10th Iranian Nutrition Congress, Oct 2008

28. 10th Iranian Nutrition Congress, Oct 2008

29. مصرف بيشتر ماهي ها و ماکيان بجاي گوشت قرمز Azadbakht and Esmaillzadeh. J Nutr 2009

30. Prevention and Treatment of CVD and Diabetes • Omega-3 Food Sources • Preferably from both marine and plant sources, should be included in a cardio protective diet. • Consuming dietary sources of omega-3 fatty acids from fish [two 4oz servings of fish per week (preferably fatty fish such as mackerel, salmon, herring, trout, sardines, or tuna)] • Plant-based foods of 1.5g alpha-linolenic acids (1 Tbs canola or walnut oil, 0.5 Tbs ground flax seed, <1 tsp flaxseed oil) are recommended.

31. Prevention and Treatment of CVD and Diabetes • Omega-3 Supplements • If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention.

32. مغز ها و آجيل ها • ارتباط با کاهش مقاومت انسوليني • انتخاب انواع کم نمک • جايگزين گروه چربي دريافتي • توجه به مقدار مصرفي

33. SoyMilk SoyMilk سويا

34. مصرف وعده هاي غذايي منظم • مصرف سه وعده و 3 ميان وعده • مصرف صبحانه

35. لبنيات • توصيه به مصرف لبنيات کم چرب Azadbakht et al. Am J Clin Nutr 2005

36. شيرين کننده مصنوعي • در مقادير متعادل توصيه مي شود.

37. توجه به انديس گليسمي غذاها • انتخاب غذاهاي پر فيبر • صرف نظر از غذاهاي حاوي مقادير بالاي قند ساده و غلات تصفيه نشده

38. Nutrition • Nutrition Therapy – The Most Fundamental Component of the Diabetes Treatment Plan • Goals: • Near Normal Glucose Levels • Normal Blood Pressure • Normal Serum Lipid Levels • Reasonable Body Weight • Promotion of Overall Health

39. Weight Loss • Improves Glucose Control • Increases Sensitivity to insulin • Lower lipid levels and blood pressure • Corresponding lowering of the dosage of pharmacologic agents

40. For a Successful Outcome • Modest Caloric Restrictions • Spreading caloric intake throughout the day • Increased Physical Activity • Behavior Modification • Psychosocial Support

41. Caloric Intake and weight management The Most Important Key • If overweight or obese: • Calculate Adjusted Ideal Body Weight (AIBW) • Normal weight: • Use his/her current weight • Underweight: • Use his current weight to calculate energy and then add an extra 500 calorie

42. How to calculate energy? • 1) BEE: weight * (0.95 for females, 1 for males) • 2) Energy for Physical activity: BEE * 0.3 • 3) TEF: (BEE + Energy for physical activity) *0.1 • TEE=1+2+3

43. Nutrient Components • Protein • Fat • CHO • Sucrose and Fructose • Nutritive Sweeteners • Vitamins and Minerals

44. Protein Intake • Small to medium portion of protein once daily • 12-20% of daily calories (17-18% seems to be reasonable) • From both animal and vegetable sources • Vegetable source less nephrotoxic than animal protein • 3-5oz of meat, fish or poultry daily • Patient with nephropathy should limit to less than 12% daily

45. Fat Intake • <35% of total calories (about 30% is good) • Saturated fat <10% of total calories • Polyunsaturated fats 10% of total calories • Cholesterol consumption < 300 mg • Moderate increase in monounsaturated fats such as canola oil and olive oil (up to 20% of total calories)

46. CHO Intake • CHO intake determined after protein and fat intake have been calculated (lower than 60 percent, 50-55 percent is Ideal). • At least 4g CHO per unit of short or rapid acting insulin. • Restrict carbohydrate in breakfast meal for GDM patients. • Emphasize on whole grains, starches, fruits, and vegetables • Fiber same as for nondiabetics (20g to 35g) • Rate of digestion related to the presence of fat, degree of ripeness, cooking method, and preparation

47. دارو های خوراکی کنترل قند خون: