DIET PRESCRIPTION GENERATOR MANUAL

1. INTRODUCTION

BALANCED DIET
1) A diet which meets the calorie requirements
2) A diet which meets the nutrient requirements
3) A diet which contains a variety of foods
4) A diet in which the calorie requirement is equal to the daily energy requirement

BMI CLASSIFICATION
< 18.5 - underweight
18.5 - 24.9 - normal weight
25.0 - 29.9 - overweight
30.0 - 34.9 - obesity class 1
35.0 - 39.9 - obesity class 2
=> 40.0 - obesity class 3

GLYCEMIC INDEX
1) Measures the relative rise of blood sugar with a given carbohydrate
2) Low GI cause a small rise high GI cause high rise of blood sugar
3) GI => 70 high, 56-69 medium, =< 55 low

GLYCEMIC LOAD
1) Measures the relative rise of blood sugar with a given food item
2) GL => 20 high, 11-19 medium, =< 10 low
3) Foods with low GL will always have low GI
4) Medium and high GL may have a GI varying from very low to very high

2. PHYSICIAN AND DIETING

OBESITY AND FAMILY PHYSICIAN OFFICIAL STATUS - AFP
1) Consider waist circumference and BMI as vital sIgns in family medicine
2) Family physician should implement a systematic and practical approach to manage overweight and obese patients
3) Family physician Should undertake 5 A's approach to improve nutritional and exercise habits
4) Family physician should act as a role model for healthy lifestyle
5) Influence the community commitment for above ideals

WEIGHT FRIENDLY FAMILY PRACTICE
1) Discuss weight issues even when obesity nor overweight is evident
2) Check weight, BMI and WC in every visit
3) Discuss the eating habits and activity habits in every visit
4) If weight problems identified institute 5 A's behavioral counselling
5) If problems of weight seen apply the transtheoretical approach for behavior change (PCT)
6) 5 A's include Ask, Advise, Assess, Assist, Arrange

CHRONIC DISEASES RELEVANT TO MEDICAL NUTRITION
1) Obesity, overweight
2) Diabetes
3) Ischemic heart disease
4) Hypertension
5) Hyperlipidemia
6) Cancer
7) Osteoporosis
8) Dental hygiene

CLINICAL SIGNIFICANCE OF CHRONIC DISEASES
1) Chronic diseases are a heavy burden to the society
2) Chronic diseases are no more confined only to the adults and elderly,
even younger persons are too affected now
3) Chronic diseases are no more confined to the developed countries, but also
seen in developing countries
4) Developing countries have a double burden of nutritional of morbidity - overnutrition
and undernutrition
5) The rate of increase in chronic diseases in the developing world is higher
6) Most of the chronic diseases are preventable and modifiable
7) The best, most effective, most economically feasible solution to the pandemic of
chronic diseases is the primary prevention
8) Changes in meal patterns world over - increasing consumption of animal based
products, increasing consumption of oils/fats, increasing consumption of calories,
increasing consumption of sugars and simple carbohydrates in preference to complex
carbohydrates, decreasing consumption of fibers, decreasing consumption of fruits and
vegetables

SOME IMPORTANT NUTRITIONAL TARGETS IN THE COURSE OF LIFE-CYCLE
1) Newborns - achieve the optimal weight and height
2) Infants - achieve optimal nutrition to prevent heart attacks hypertension,
strokes, diabetes and obesity in later life.
3) Youth - achieve optimal nutrition to prevent middle aged cancers, heart attacks,
hypertension, hyperlipidemias, strokes and diabetes
4) Adults - achieve optimal nutrition to prevent many chronic diseases
5) Elderly - achieve optimal nutrition to give maximum impact for nutritional interventions for chronic diseases

REASONS FOR ABOVE NUTRITIONAL TARGETS
1) Every attempt should be made to achieve the optimal weight and height for the new born
2) Suboptimal infant nutrition can cause heart attacks, blood pressure, strokes, diabetes and obesity
3) Suboptimal youth nutrition is the best, most effective and most economical solution to the middle aged cancers, heart attacks, hypertension, hyperlipidemias, strokes, diabetes.
4) The 6 commonest risk factors for chronic diseases in adults are smoking, alcohol, obesity, inactivity, hyperlipidemias and hypertension. Out of this 3 are directly linked to nutrition. Thus adult nutrition is playing a significant role in the management of chronic diseases.
5) In the elderly the chronic diseases make their maximum impact. While elder nutrition took back stage a decade back, now it is known that the maximum benefit of nutritional interventions are seen only in this age.

3. NUTRITIONAL COUNSELING

NUTRITIONAL ADVICE TO INFANTS TO PREVENT LATER OBESITY
1) Promote breast milk only
2) When milk powder started no sugar added
3) Dont let meals become headaches for children
4) Educate the mother that the child is the best guide for child's
energy requirement
5) Ensure that th child gets minor nutrients adequately for correct height achievements
6) Stop force feeding children whose weight is proportionate for the height

NUTRITIONAL ADVICE TO YOUTH TO PREVENT LATER OBESITY
1) Encourage children for an active life
2) Increase the vegetables and fruits in the diet
3) Stop calorie-dense snacks in-between regular meals
4) Reduce fast foods and other foods which do not contain minor nutrients
5) Reduce sweet drinks consumed
6) Stop force feeding youth whose weight is proportionate for the height

4. MEDICAL NUTRITION THERAPY

MEDICAL NUTRITION THERAPY SUITABLE FOR PRIMARY CARE PHYSICIANS
1) Identification of nutritional problems
2) Evaluation of nutritional problems
3) Educate patients on nutritional topics
4) Providing correct solution for the relevant nutritional problem
5) Motivating the clients to implement the solutions provided
6) Helping the clients to tide over the barriers encountered in the course of
the nutritional therapy
7) Educating the clients to get the money's value for a given food item by analyzing
the nutrient content of the food item
8) Educating the client about the nutritional myths

BENEFITS OF WEIGHT LOSS
1) Improve glycemic control (1.67% reduction of HbA1 and 59 mg/dL reduction in FBS)
2) Improve BP control
3) Reduce cardiovascular risk burden
4) Reduce obesity and overweight
5) Prevention of development of diabetes (Finnish DPS, US DPP)

PREVENTION OF DM IN FINNISH DPS
1) Overweight subjects with mean BMI 31, mean age 55, IGT +
2) Losing 5% of initial body weight
3) Exercise 30 min/day moderate intensity, resisted training exercises
4) Fat consumption < 30% of total calories
5) Saturated fat < 10% of total calories
6) Fiber 15 g/1000 kcals
7) More the goals achieved higher the chance that DM will not develop
8) There is a dose-response curve for number of goals and the end point titration
9) Weight loss was the most important predictor of prevention of diabetes 3 yrs later

PREVENTION OF DM IN US DPP
1) Overweight subjects with mean BMI 34, mean age 51, IGT +
2) Losing 7% of initial body weight (rate od loss - 0.5-1 kg/wk)
3) Exercise 150 min/wk moderate intensity (basically like brisk walking)
4) Fat less than 25% of total calories
5) One to one contact every 2 weeks for counselling and motivation
6) Weekly supervised exercise classes
7) Prevented (58%) incident Dm more than in placebo and even metformin
8) Metformin also reduced incident DM by 31%
9) weight loss was the most important predictor of prevention of diabetes 3 yrs later
10) Even in the absence of weight loss exercise also prevented diabetes although not to the extent of weight loss

DPP and DPS BASED FINDINGS TO PREVENT DEVELOPMENT OF DIABETES
1) Lifestyle modifications are extremely effective to prevent Dm
2) Reduction of risk for DM development is 58%
3) Most important factor the lifestyles is the weight loss
4) Effect of Weight loss is dose dependent
5) Effects of lifestyles changes are also dose dependent (more the changes more the reduction of DM)
6) Moderate exercise can also reduce the chance of development of DM in the absence of weight loss

LOOK AHEAD - INTENSIVE LIFESTYLE INTERVENTIONS' IMPACT
1) 7% reduction in body weight minimum but encouraged to lose > 10%
2) Contact frequency - weekly group sessions and monthly individual session
3) Dietary advice - calorie restriction, liquid meal replacements
4) Moderate intensity exercise at home - 175 min/week
5) 1 yr interim results are as follows :
6) Weight loss of 8.6%
7) Improved sense of fitness
8) Use of diabetes and hypertensive medication reduction
9) Increased use of lipid lowering
10)Better glycemic control
11)Better BP control
12)Increased HDL-C
13)Reduction in metabolic syndrome

WHO RECOMMENDED NUTRIENT COMPOSITION OF A WELL BALANCED DIET
FOOD => NUTRIENT PER CENTAGE FROM TOTAL CALORIES
Carbohydrates => 55-75%
Sugar and sweets => < 10%
Proteins => 10-15%
Oils/Fats => 15-30%
Saturated fatty acids => < 10%
Unsaturated fatty acids => 6-10%
Trans fatty acids => < 1%
Monounsaturated fatty acids => balance
Cholesterols => < 300 mg/day
Salt => < 5 G/day
Vegetables and fruits => > 400 G/day
Fibers
Non-carbohydrate polysaccharides

5. DIETS IN SPECIFIC DISEASES

NUTRITIONAL ADVICE FOR HEALTHY ADULTS
1) Take a variety of foods - food variety is important because no single food can
give all the nutrients which are necessary for a healthy life
2) Maintain a healthy weight
3) Take a meal which is less in cholesterol less in saturated fats and oils and fats
4) Take a meal which is rich in vegetables, fruits and legumes
5) Consume less sugar
6) Consume less salt
7) Consume less alcohol

CANCER PREVENTION DIET
1) Maintain a weight which is proportional to the height
2) Calorie and protein requirements must be met by cereals and pulses
3) Oils and fats should provide only about 20-25% of the total energy requirement
4) Consume fresh vegetables and fruits which are particularly yellow more
5) Consume preserved and Tinned foods less
6) Limit frying, burnt, smoked, salted food
7) Do not consume foods with fungi and

HYPERTENSION DIET
1) Maintain normal body weight
2) Consume a diet less in salts (1500, 2300, 3300 mg/day)
3) Consume vegetables and fruits more
4) Reduce oils/fats and milk and milk products
5) Calcium supplements
6) Potassium and magnesium supplements
7) DASH diet - Dietary Approaches to Stop Hypertension

DASH DIET
1) Macronutrient composition - Carbos 55%, Proteins 18%, Total fat 27%, Saturated fat 6%,
2) Micronutrient composition - cholesterol 150 mg, sodium 1500-2300 mg, potassium 4700 mg,
calcium 1250 mg, magnesium 500 mg, fiber 30 g
3) High in fruits and vegetables
4) High in nuts and whole grains
5) High fish intake
6) High poultry intake
7) Low fat dairy products
8) Low in sugar, sweets, fat and cholesterol and red meat
9) Rich in potassium, magnesium, calcium, fibers
10) Obese hypertensives needs a hypocaloric DASH

TECHNICAL DETAILS OF DASH EATING PATTERNS
1) Reduces blood pressure in hypertensives
2) Pressure reduction occurs within 2 weeks
3) Reducing dietary sodium enhances the effects of pressure reduction of DASH patterns
4) Sodium reduction has a dose-dependent response for blood pressure reduction
5) Prevents development of hypertension in normotensive and prehypertensives

DIABETIC DIET
1) Fibre-rich low-glycaemic diets

TECHNICAL DETAILS
1) Fibre-rich low-glycaemic diet reduces HbA1c by 0.5%
2)

HYPERLIPIDEMIAS - HYPERTRIGLYCERIDEMIA
1) Reduce weight if overweight or obese
2) Reduce simple carbohydrates
3) Stop alcohol
4) Consume omega-3-fatty acids more - fresh fish at least twice per week
5) Reduce cereals
6) Reduce saturated oils/fats

HYPERLIPIDEMIAS - LOW HDL-C
1) Lose weight if overweight or obese
2) Substitute carbohydrates with monounstaturated fats
(almonds, walnuts, peanuts)

HYPERLIPIDEMIAS - HYPERCHOLESTEROLEMIA
STEP 1 DIET

TOTAL FAT < 30%
SATURATED < 10%
MONOUNSATURATED < 10%
POLYUNSATURATED < 10%
CARBOHYDRATE 50-70%
PROTEINS 10-20%
CHOLESTEROL < 300 MG

HYPERLIPIDEMIAS - HYPERCHOLESTEROLEMIA
STEP 2 DIET
TOTAL FAT < 30%
SATURATED < 7%
MONOUNSATURATED < 10%
POLYUNSATURATED < 10%
CARBOHYDRATE 50-70%

PROTEINS 10-20 %
CHOLESTEROL < 200 MG

MANAGEMENT OF METABOLIC SYNDROME

Abdominal obesity
1) Weight loss is managed by reducing daily calories by 250, year.
2) Physical activity of 30 min of moderate activity at least every other day of the week

Elevated blood pressure
3) Weight loss - see above
4) Modest salt restriction 
5) Fruits and vegetables intake to be increased to at least 5 servings each day
6) Low-fat dairy 3 servings skim milk or low-fat yogurt or cheese each day

LOW high-density lipoprotein (HDL) cholesterol
7) Stop smoking
8) Weight loss - see above and aim for a total loss of 20-lb for 1 year

9) Physical activity for 30 min every other day of a week
10) Substitute carbohydrates with modest amounts of monounsaturated fats and small mounts of unsalted almonds, walnuts and peanuts to substitute cookies, candy, cake and other snacks

Elevated fasting triglyceride level

11) Weight loss - See above and target an annual weight of loss of 20-lb
12) Reduce simple carbohydrates. Reduce regular soft drinks and juices, cordials as much as possible. Switch to seltzer, water or diet soda.13) Alcohol amount limited to to 1 alcoholic beverage per day for women; 2 drinks per day for men
14) Increase omega-3 fatty acids - Eat fresh or canned fish at least twice per week to increase omega 3 fatty acid intake

Impaired fasting glucose level
15) Annual weight loss of 20-lb - see above
16) Soluble fiber intake with more whole grains and cereals and also switching white to brown grains