Management of Noncommunicable Diseases

with Nutrition

DR ZAFAR EJAZ KHAN

PHD in faculty of Community Medicine
Epidemiology of Infectious diseases,
Malaysia
[email protected]
Noncommunicable diseases
Noncommunicable diseases (NCDs), also known as chronic diseases, tend to be of
long duration and are the result of a combination of genetic, physiological,
environmental and behavioral factors.

These diseases are a diverse group of chronic diseases that are not communicable, meaning
you can't catch them from another person. They are defined as diseases of long duration,
generally slow progression and they are the major cause of adult mortality and morbidity
worldwide.
The spread of non-communicable diseases
Non-communicable diseases (NCDs) have emerged as the leading cause of
human mortality and morbidity in low-, middle- and high-income countries.
NCDs are not considered only as social burden; the economic costs of NCDs
are also accelerating worldwide. By the year 2030, when the Sustainable
Development Goals (SDGs) should have attained their targets, cardiovascular
disease (CVD) will be the leading cause of death across the planet,
exceeding mortality from HIV, TB, malaria, and maternal & child
undernutrition combined. Despite these “costs,” not to mention personal
disabilities and social ailments, however, little progress has been made to
date in limiting or diminishing the NCD epidemic.
The main NCDs include diabetes, cardiovascular disease (CVD), chronic
respiratory disease, cancer, and mental health conditions. Obesity and
overweight are frequently associated with the presence of one of more of
these NCDs . The text is presented as key themes that need to be
considered in developing new model to diminish the burden of NCDs. An
overview of the basic epidemiology of these diseases will be considered,
and this will be followed by recognized and underappreciated drivers for
NCDs. The economic cost of NCDs will be considered, along with
interventions and challenges to the new model presented for successful
control of this major burden to human health and productivity.
Types of NCDs

Hypertension
Atherosclerosis
Angina Pectoris
Arrhythmias
Heart Attack
Stroke
Diabetes
Cancer
Hypertension (high blood pressure)
can be lowered with medication, weight management, physical activity, and
proper nutrition ,most common among people over the age of 35
normal range: 120/80
often called the “silent killer”- having no symptoms in early stages
 Atherosclerosis

A build up of fatty materials in your arteries

narrows the arteries, making the heart work harder.
Cardiovascular Diseases:
Angina- chest pains caused by lack of
oxygen
Arrhythmias- irregular heartbeat
Heart attack-
caused by blockages of arteries, damage
to the heart muscle.
Stroke-
arterial blockage that disrupts the flow of blood in the brain.

Congestive Heart Failure-

heart no longer pumps efficiently.
 Cholesterol:

HDL: high density lipoprotein (good)

HDL cholesterol levels range from 40 to 50 mg.
In the average woman, they range from 50 to 60 mg.
LDL: low density lipoprotein (bad) causes atherosclerosis
Less than 100 mg Optimal
Diabetes
Diabetes is a chronic health condition in which the body cannot use the
glucose (sugar) found in food.

Type 1 (T1D): The pancreas does NOT produce insulin.

Type 2: The pancreas does not produce ENOUGH insulin and/or the body
RESISTS the action of insulin.
RISK FACTORS FOR CVD’S

CONTROLLABLE UNCONTROLLABLE

 Tobacco Use Heredity

 High Blood Pressure- have it checked periodically Gender
 High Cholesterol- eat less high-fat foods Age
 Physical Inactivity
 Excess Weight The health behaviors that you practice
 Stress now are affective your cardiovascular system
 Drug and Alcohol Use
Role of functional foods in addressing non-communicable diseases

The emergence of dietary compounds with health benefits offers an excellent

opportunity to improve public health and thus, this category of compounds has
received much attention in recent years from the scientific community, consumers
and food manufacturers. The list of dietary active compounds (vitamins, probiotics,
bioactive peptides, antioxidants.) is endless, and scientific evidence to support the
concept of health promoting food ingredients is growing steadily.

The following factors have been associated with lower risks of NCDs:
•High intakes of fresh fruits and vegetables
•Frequent intake of fish
•Diets which are rich in whole grains, legumes, fresh fruits and vegetables and fish, and
low in refined grains, processed meats, sweets, desserts, sweetened drinks.
What are Functional foods

The Food and Nutrition Board of the National Academy of Sciences has suggested that a
functional food is “any modified food or food ingredient that may provide a health benefit beyond
the traditional nutrients it contains.” Others state that a functional food is any food promoted or
consumed for a specific health effect, regardless of whether the food has been modified in some
fashion. Foods qualify as functional foods because they contain non-essential substances with
potential health benefits. A considerable array of food has been described as “functional” in one
or more respects, including calcium-fortified orange juice, whole grains, fruits and vegetables,
soyabeans, omega-3 fatty acids, phytosterols and cocoa. While there is increased awareness of
the links between diet and disease such as certain fats and CVD, calcium and osteoporosis, fiber
and gastrointestinal (GI) health, it is important, for a functional food, to identify the specific food
constituents that could promote health and well-being as well as the exact conditions where they
can have this beneficial effect.
Practical examples of a functional food
•A natural food such as fruit or grain which may or may not be modified by plant breeding or
other technologies (e.g. lycopene-enhanced tomatoes, vitamin E-enriched vegetable oils,
vitamin A- enriched rice)
•A food to which a component has been added (e.g. a spread with added phytosterols)
•A food from which a component has been removed or reduced (e.g. a yogurt with reduced
fat)
•A food in which one, or several components, have been modified, replaced or enhanced to
improve its health properties (e.g. a juice drink with enhanced antioxidant content, a yogurt
with added prebiotic or probiotic).
Probiotics
The most recent definition says that probiotics are live microorganisms administered in amounts that
positively affect the health of the host. The health advantages of probiotics may include resistance
to pathogenic microorganisms, gut and systemic immunity, as well as colonocyte nutrition from the
lumen. Probiotic products present an opportunity for dairy companies to present their products as
part of a healthy diet, not by removing fat but by adding health promoting ingredients – live
microorganisms (probiotics), or substrates for them like oligosaccharides (prebiotics)
Probiotics represent one of the largest functional food markets. Most of the available products are
some form of dairy, such as milk, ice cream, yogurt, cheese, and frozen desserts, despite the
continuously growth of the nondairy sector, with products like soy-based drinks, fruit-based foods,
and other cereal-based products. Among the nondairy probiotic products, those made with soy
stand out because of the inherently health benefits of soy, linked to the presence of isoflavones, and
the beneficial changes in bacterial populations in the gastrointestinal tract, caused by the presence
of probiotic microorganisms. Both nondairy (in general) and soy-based probiotic products represent
a huge growth potential for the food industry, and may be widely explored through the development
of new ingredients, processes, and products.
Phytochemical rich Foods
In recent decades, a considerable number of epidemiological studies suggest that
the high consumption of “fruit and vegetables” as a collective term, or in some
studies, of specific vegetables, is associated with low morbidity and mortality from
CVDs and certain cancers. Compounds found in fruit and vegetables, such as
polyphenols in fruit, isoflavones in the legume soy and β-carotene in vegetables,
have been considered to be the responsible active compounds. However, several
intervention studies have shown that ingestion of some of these isolated
compounds, in tablet or capsule form, cannot confer similar health benefits to those
observed with the intact food from which they come. Studies of intact foods on
health outcomes, like those with whole grains on CVDs and diabetes support these
findings. This understanding should stimulate a more food ingredient and recipe
approach than the isolated phytonutrient approach to Functional Foods.
The Role of Nutrients in Reducing the Risk for Noncommunicable
Diseases
Vitamin D in Musculoskeletal Health

Vitamin D is involved in bone homeostasis by enhancing calcium and phosphorus

absorption from the intestine and maintaining adequate levels in blood. Low vitamin D
levels have been mainly implicated in musculoskeletal disorders including bone and
muscle health . Serum levels of 25(OH)D have been associated with bone turnover
markers levels .
Vitamin D comprises a group of secosteroids (calciferols), and in humans the two most
important compounds in this group are vitamin D3 (cholecalciferol) and vitamin
D2 (ergocalciferol) . A major part of vitamin D comes from UV-B induced production
in the skin and only about 20% from dietary intake. Dietary sources are limited to
mainly oily fish and foods fortified with the vitamin . Lack of vitamin D from the diet
and increased awareness of the harmful skin effects of excessive sunlight exposure
have contributed to low vitamin D status and even deficiency globally.
Current research investigating the effect of vitamin D alone or in
combination with other nutrients on fractures, cardiovascular
disease, diabetes, cognitive function, immunity, and other benefits is
ongoing in two large scale studies in older adults (DO-HEALTH in
Europe, FIND in Finland). In addition, many research groups
engage in basic science to study the combined action of vitamin K2,
vitamin D, and calcium, and their function on the molecular level.
More studies are required that target vitamin D supplementation in
combination with other nutrients such as calcium and vitamin K
where it is needed, in people with vitamin D deficiency or older
people, who are more likely to be frail in institutionalized residents.
 Vitamin K in Musculoskeletal Health

Two forms of vitamin K exist: vitamin K1 (phylloquinone, mainly found in green leafy
vegetables) and vitamin K2 (menaquinone, mainly found in fermented dairy and produced
by lactic acid bacteria in the intestine). Vitamin K is required for promoting osteoblast
differentiation, upregulating transcription of specific genes in osteoblasts, and activating
bone-associated vitamin K dependent proteins, which play critical roles in extracellular
bone matrix mineralization. Less is known about vitamin K and health, but there is
growing evidence suggesting a synergistic effect between vitamins K and D in bone . A
number of studies reported that vitamin K is essential for optimization of bone health
with benefits in preventing bone loss .Vitamin K2 supplementation combined with
vitamin D and calcium for 2 years in a randomized placebo-controlled trial resulted in a
significant increase in bone-mineral density and content in older women .In another
recent RCT it was found that combined vitamin K2, vitamin D and calcium
supplementation for 6 months increased the bone mineral density of lumbar 3 spine
vertebra compared to vitamin D and calcium alone in postmenopausal women.
 Cognitive Disorders
Dementia is a term that describes a decline in cognitive abilities
including memory, and reduction in a person’s ability to perform
everyday .Dementia prevalence is forecast to increase
dramatically in future years .At present about 50 million people
have dementia worldwide, and this is projected to reach 80
million by 2030 and 150 million by 2050 Alzheimer’s disease
(AD) is the most common form of dementia in people aged >60
years, accounting for 60–70% of the total number of cases and is
the major focus of this section .Vascular dementia is the second
most common cause of dementia with at least 20% of dementia
cases.
Alzheimer’s disease is a complex, progressive, multifactorial,
neurodegenerative disease .The presentation generally involves
progressive memory loss, impaired thinking, disorientation, and
changes in personality and mood. As the disease advances there is a
marked reduction in cognitive and physical functioning .Genetic factors
account for about 70% of the risk contributing to AD, while modifiable
factors related to general health and lifestyle may also be involved .Risk
factors for vascular dementia are predominantly modifiable and of
vascular origin (including hypertension, diabetes mellitus, dyslipidemia,
and the metabolic syndrome). Managing non-genetic risk factors
effectively may provide opportunity to prevent and treat the progressive
cognitive decline associated with AD . The focus of this section of the
review is on nutritional status and its potential role in AD
 The Role of Nutrition in Dementia

In terms of a link between nutrient status in older adults and cognition,

evidence exists for B-vitamins, and vitamin C, D, and E, as well as the
omega-3 long chain polyunsaturated fatty acids (LCPUFAs)
docosahexaenoic acid (DHA) and eicosatetraenoic acid (EPA).
Folic acid and vitamin B6 and B12 are important in the nervous system at
all ages, but particularly in elderly people, deficiency contributes to aging
brain processes. Low status of folic acid and vitamins B6 and B12 are
among the risk factors for elevated homocysteine. With respect to
dementia, there is reasonable evidence linking lower levels of folic acid,
vitamin B6, vitamin B12, and higher concentrations of homocysteine with
age-related cognitive decline
One of the mechanisms involved may the impaired methylation processes due
to folic acid and vitamin B12 deficiency that lead to accumulation of
homocysteine affecting mood and some cognitive functions . In several RCTs
supplementation with folic acid, vitamin B12, and vitamin B6 for at least 2 years
has been investigated . However, the findings of a recent meta-analysis
reported that B vitamins had little to no effect with respect to preventing
cognitive decline. Notably, individuals with high homocysteine levels had
significant cognitive decline and B-vitamins were found to improve memory
only in this subgroup.
Dehydroascorbic acid, a metabolite of vitamin C, is a potent
antioxidant, an essential cofactor in many enzymatic reactions, and
has a role in metabolizing cholesterol. Large dietary surveys
undertaken in Germany, the Netherlands, the UK, and the US
indicated inadequate vitamin C intake in up to half of respective
populations . As with vitamin E, however, studies of vitamin C in
patients with AD have been equivocal. The overall conclusion of
the Team of Alzheimer Drug Discovery Foundation is that
maintaining adequate levels of vitamin C through diet may offer
more benefit than supplementation
Cardiovascular Disease
Despite the global decline in cardiovascular mortality, cardiovascular diseases
remain the leading cause of morbidity and mortality, contributing to escalating
health care cost. Cardiovascular aging progresses over decades, influenced by
risk factors such as tobacco use, poor physical activity and diet, resulting in
hypertension, dyslipidemia (high triglycerides and lower HDL), elevated
fasting blood glucose, and central obesity . Cardiovascular disease is the major
clinical problem in the older population, with 68% of adults 60–79 years
having cardiovascular disease and this increases to 85% after the age of 80
years. Good nutrition plays an important role in delaying the progression of
cardiovascular disease. The adverse effects of excess intakes of saturated and
trans fats, cholesterol, added sugars, and salt in relation to cardiovascular
disease progression has been relatively well-established whereas the effect of
addressing inadequate essential nutrients is less well-known
 Older adults are highly susceptible to undernutrition due to the various
physiological and socioeconomic factors. In contrast to overnutrition, the
potential of addressing undernutrition to optimize cardiovascular health in
older adults has received inadequate attention. Evidence for nutrition in
reducing the risk for cardiovascular aging mostly derives from
epidemiological studies, whereas fewer interventions studies have been
performed. The RCTs addressing cardiovascular disease generally have
included, but not exclusively, older adults, not allowing generalizability of
results to typical older adults. The authors have therefore focused on nutrition
interventions addressing cardiovascular aging progress, not restricted to
elderly.
MANAGEMENT OF CARDIOVASCULAR DISEASE
WITH DIETS

Lifestyle changes, including dietary modifications, are

recommended as part of the management strategy to improve lipid
profiles and reduce the risk of cardiovascular disease. The primary
emphasis of dietary interventions has been on changing dietary
macronutrient and salt composition. The effect of improving
micronutrient-richness of the diet in cardiovascular disease control
has been less-well studied. A diet rich in fruits, vegetables,
wholegrains, legumes, nuts, fish, poultry, and low-fat dairy
products, and limited consumption of red meat, saturated fat, and
added sugar is advocated, mostly based on positive associations
with cardiovascular health
Dietary patterns that follow these principles include the Dietary
Approaches to Stop Hypertension (DASH) diet, a diet rich in fiber,
protein, magnesium, calcium, and potassium, and low in total and
saturated fats, which has been shown to reduce low-density
lipoprotein (LDL)-cholesterol levels and the Mediterranean diet,
which has been shown to reduce the risk for cardiovascular disease in
both primary and secondary settings. Regression of coronary artery
atherosclerosis has been demonstrated with a program of intensive
lifestyle changes that included a vegetarian diet, exercise, and
smoking cessation. In addition to dietary interventions, there has been
research into the effects of individual nutrients. While the evidence for
some of these is limited, several interesting findings have been
published.
 Vitamin D
Low vitamin D has been associated with cardiovascular disease in a
number of studies .Few studies have been targeting low vitamin D
specifically in the older population. In one study with post-menopausal
women randomized to Vitamin D3 2500 IU or placebo, daily for 4
months, vitamin D supplementation had no effect on endothelial
function, arterial stiffness, or inflammation. Results of a meta-analysis
of RCT with older adult participants suggested that vitamin D
supplementation might protect against cardiac failure but not against
MI or stroke .The recent results of the VITAL trial indicate that daily
supplementation of 2000 IU vitamin D did not reduce the occurrence
of cardiovascular events.
B-Vitamins
B-vitamins have been the subject of substantial research
because of their established effects on normalizing
homocysteine levels, an important risk factor for
cardiovascular disease. Risk factors including B-vitamin
shortages and pathogenetic mechanisms for the effect of
high homocysteine on cardiovascular disease.
Particularly the B-vitamins have been investigated for their potential
cardiovascular benefits due to their established lowering effect on
homocysteine levels, a marker for cardiovascular disease risk,
including ischemic stroke. A meta-analysis of 19 RCTs of B vitamins
(including folic acid, vitamin B6, vitamin B12, and B-complex
vitamins) found significant reductions in homocysteine levels,
however, no significant effect of vitamin B supplementation on rates
of cardiovascular disease, coronary heart disease, myocardial
infarction, cardiovascular death, or all-cause mortality whereas
vitamin B reduced the risk of stroke by 12% . Another meta-analysis
of 26 RCTs found that folic acid supplementation significantly
reduced the risk of stroke 7%.
 Vitamin K

Vitamin K plays an important role in anticoagulation and may

overcome the detrimental side effects associated with vitamin K
antagonists such as warfarin. Vitamin K may also help to
prevent vascular calcifications, especially in patients on
warfarin
 Omega-3
Supplementation of omega-3 increased high-density lipoprotein (HDL)
cholesterol concentration, improved vascular function, and lowered heart rate and
blood pressure with DHA having a greater effect than EPA while both EPA and
DHA inhibited platelet activity. Dietary supplementation with omega-3 can
reduce plasma triglyceride levels by up to 45% with the greatest effect seen in
those with the highest baseline levels.Omega-3 also cause a modest increase in
HDL-C levels, and although they also increase LDL-C levels, this is primarily an
increase in large, less atherogenic, particles .In addition to improving lipid
profiles, omega-3 reduce inflammation, lower blood pressure (blood pressure),
and have beneficial effects on endothelial function and platelet aggregation, all of
which could contribute to cardioprotective effects . However, despite positive
effects on intermediate markers, RCTs with omega-3 have produced mixed results
on cardiovascular morbidity and mortality.
 Antioxidants

Inflammation and oxidative stress appear to be key drivers for a

number of cardiovascular diseases and the metabolic syndrome.
Where as observations studies suggest that antioxidant nutrient
such as β-carotene and vitamin E are associated with lower
cardiovascular disease, the data of RCTs on antioxidant
supplements failed to confirm a significant benefit of
antioxidants on atherosclerotic cardiovascular disease. For
instance, supplementation with the antioxidant nutrients vitamin
E, β-carotene, and vitamin C, had no significant effects on
cardiovascular outcomes.
 Vitamin E
A key attribute of vitamin E (a combination of 8 distinct tocopherol/tocotrienol
isoforms) is its antioxidant activity and, as a consequence, its ability to protect poly-
unsaturated fatty acids (PUFAs), lipoproteins, and cell membranes from oxidative
damage. Vitamin E has been extensively investigated for its potential to prevent
cardiovascular disease events. Nevertheless, RCTs with vitamin E had mixed results
on various cardiovascular disease endpoints. In the Women’s Health Study, intake of
600 IU of vitamin E on alternate days in apparently healthy women non-significantly
reduced the risk for cardiovascular events by 7% and significantly reduced the risk
for cardiovascular death by 24%.
 And among women ages 65 and older, vitamin E supplementation
reduced the risk of major cardiac events by 26%.Data from the same
Women’s Health Study suggested that supplementation with vitamin
E may reduce the risk of venous thromboembolism in women,
particularly in those with a prior history or genetic
predisposition .RCTs that retrospectively analyzed the data for the
effect of vitamin in E in subgroups of patients with this these
genotypes sometimes showed that these patients are more responsive
to vitamin E supplementation.
 Hypertension
Hypertension is a major public health concern given its link to serious
cardiovascular events such as stroke and ischemic heart disease, the leading
causes of worldwide mortality. It has been estimated that hypertension is
responsible for approximately 40% of cardiovascular deaths. By the year
2025 almost 30% of the global population will be diagnosed with high blood
pressure, with 25% of these cases occurring in developing countries.
Hypertension rises dramatically with aging due to longer exposure to age-
associated alterations in vascular function and structure and cardiovascular
risk factors
Diets
In the current healthcare environment, lifestyle changes involving a
healthy diet and increased physical activity are considered pivotal in the
management of hypertension. Diets with a high nutritional value, such as
the traditional Mediterranean diet, DASH and the Omni Heart (a
variation of DASH with increased levels of protein) diets, can be
important steps on the path to weight loss, lowering blood pressure, and
prevention of hypertension. The benefits of the DASH diet on blood
pressure were reported in a RCT with all participants receiving graded
amounts of sodium (high, intermediate, low). There were dose-response
decreases in systolic and diastolic blood pressures, and age-related
increases in blood pressure were blunted.
Both the DASH diet and low sodium markedly decreased blood pressure, and
the combined effect was even greater. Findings of the DASH study also
provided additional support that the sodium-to-potassium ratio is stronger
associated with blood pressure outcomes than either nutrient alone among
prehypertensive and hypertensive adults combined. These findings were later
confirmed by a systematic review showing that the sodium-to-potassium ratio
appears to be more strongly associated with blood pressure outcomes than either
nutrient alone in hypertensive adults.
In addition to dietary control there has been research into the effects of other
nutrients, including vitamins, on blood pressure and hypertension
Milk peptides
A meta-analysis of 14 RCTs involving 1306 European subjects
found that the milk-derived Lactotripeptides isoleucine-proline-
proline and valine-proline-proline produced small and statistically
significant reductions in mean systolic blood pressure and diastolic
blood pressure. The authors noted that a similar effect had been
seen in Asian populations.
Omega-3
The omega-3 LCPUFAs EPA and DHA found in oily fish and fish oils (including capsule
preparations) have been associated with lower blood pressure levels. In a meta-analysis
of 70 RCTs, EPA, and DHA reduced mean systolic blood pressure and mean diastolic
blood pressure compared with placebo. The largest effect was in untreated hypertensive
patients .Likewise, in an earlier meta-analysis (36 trials), intake of fish oil (median dose
3.7 g/d) reduced both mean systolic and diastolic blood pressure. The antihypertensive
effects of doses <0.5 g/d remains to be established
Vitamin C
In short-term studies, vitamin C supplementation
reduced systolic and diastolic blood pressure. Long-
term trials on the effects of vitamin C
supplementation on BP and clinical events are
needed longer-term trials assessing the effects of
vitamin C supplementation on blood pressure and
clinical events in patients with hypertension would
seem to be worthwhile.
Vitamin D
In a study involving 283 hypertensive patients,
vitamin D3 (cholecalciferol) produced a modest but
statistically significant reduction in systolic blood
pressure compared with placebo after 3 months
There was no significant effect on diastolic blood
pressure.
Flavanols
Flavanols have also been found to lower blood pressure, and there
is some evidence suggesting that they improve endothelial function
in patients with ischemic heart disease, but additional studies are
needed.
The evidence for nutrients and blood pressure is convincing for
lowering sodium and sodium-to-potassium ratio. Flavanols vitamin
C and D may have modest significant effects on blood pressure
lowering.
Diabetes
Type 2 diabetes has become a global health-related pandemic
which is forecast to rise from 425 to almost 630 million by
2045. In developing countries, the forecasted increase is more
alarming, particularly in regions which are more rapidly
adopting a Western lifestyle. The direct financial burden on
healthcare systems and society is huge, as are the indirect costs
from loss of work attendance. Intensive lifestyle modification,
e.g., personalized nutrition and physical activity programs, with
the goal of improving glycaemia and losing excess body weight
should be the mainstay of initial management in individuals
with prediabetes
Vitamin D
Observational studies have highlighted a link between vitamin D
deficiency and type 2 diabetes, as well as possible future cardiovascular
events, whereas results from interventional studies have not been so
conclusive . A recent meta-analysis including a total of 20 RCTs and 2703
participants, found that vitamin D supplementation was associated with
elevated serum vitamin D levels and significantly decreased insulin
resistance. Changes in other parameters such as fasting blood glucose and
hemoglobin A1c (HbA1c) were relatively small and did not achieve
statistical significance. In a pilot study in 60 patients with co-existing type
2 diabetes and hypovitaminosis D, vitamin D improved vitamin D status
and several parameters associated with glycemic control such as HbA1c,
mean fasting plasma glucose, and mean post-prandial plasma glucose . In
addition, vitamin D in the study lowered LDL cholesterol levels, systolic
blood pressure and diastolic blood pressure.
Vitamin E
Diabetes patients with the haptoglobin 2-2 genotype have elevated risk
of cardiovascular disease events. The haptoglobin 2-2 genotype has
inferior antioxidant properties as compared with other haptoglobin types
resulting in elevated levels of oxidative stress, an atherogenic profile and
an increased risk of cardiovascular disease events compared with other
Hp genotypes . The RCTs in diabetes patients that retrospectively
analyzed the data for the effect of vitamin in E found that administration
of vitamin E lowered the risk of cardiovascular disease events by 34%
and cardiovascular-related mortality by 53% among patients with the
haptoglobin 2-2 genotype.
Omega-3
Cohort studies have shown that in countries where fish consumption is high the
prevalence of type 2 diabetes tends to be lower and this has been attributed to
the presence of omega-3 . However, the findings have not been conclusive with
respect to providing dietary guidance and a recent systematic meta-analysis
sought to provide more definitive evidence by analyzing different
dosage/compositions of omega-3 supplementation . In total, 20 RCTs recruited
1209 patients with type 2 diabetes. Overall, omega-3 supplementation resulted
in a reduction in triglycerides with the best response with high doses for a
longer duration; however, no significant changes in total cholesterol, fasting
plasma glucose, post-prandial plasma glucose, HbA1c, insulin, or body mass
was noted with this regimen. Interestingly, products with a relatively high ratio
of EPA to DHA exhibited an increasing tendency to decrease HbA1c, insulin,
total cholesterol, total triglycerides, and body mass. These findings will be
helpful for clinicians and nutritionists who manage patients with diabetes to
provide dietary guidance.
Vitamin K
To assess whether vitamin K is a risk factor for the
development of type 2 diabetes mellitus, Beulens and
colleagues analyzed a cohort of 38,094 Dutch men and
women over a 10-year period. The study showed that both
vitamin K1 and vitamin K2 intake were associated with a
reduced risk of type 2 diabetes mellitus. For vitamin K 1 the
risk reduction occurred at the higher levels of intake,
whereas for vitamin K2 a linear inverse association was
established. In older men with diabetes receiving vitamin
K1 supplementation for 36 months, vitamin K1 significantly
improved insulin sensitivity
Chromium
Chromium plays a role in insulin metabolism by activating oligopeptide low-
molecular-weight chromium (LMWCr)-binding substance and activating insulin-
dependent kinase activity. A meta-analysis of the efficacy of chromium
supplementation suggest that there is available evidence for chromium on
glycemic control in patients with diabetes.
Studies in diabetes patients showed that vitamin D supplementation can improve
serum vitamin D levels and significantly decrease insulin resistance. Currently, a
large multicenter RCT is ongoing in the US (Vitamin D and Type 2 Diabetes
Study; D2d), hypothesizing that vitamin D will enhance insulin production,
glucose processing and glycemic profiles. Subgroup analyses show that vitamin E
may be promising in reducing the rate of cardiovascular events among diabetes
patients with haptoglobin 2-2 genotype who are at increased risk of cardiovascular
events. The evidence for omega3 LCPUFA supplementation on fasting plasma
glucose or HbA1C is less conclusive but omega-3 have promising effects for
reduction of triglycerides. The evidence for chromium in glycemic control is
emerging.
OBESITY
Obesity is a complex disease involving an excessive amount of
body fat. Obesity isn't just a cosmetic concern. It is a medical
problem that increases your risk of other diseases and health
problems, such as heart disease, diabetes, high blood pressure
and certain cancers.
It frequently begins in childhood . Obese parents likely have overweight children
Body mass index (BMI) is a calculation that takes a person’s weight and height into
account to measure body size..
CAUSE OF OBESITY
 Overeating and Other Factors
 Factors that cause human obesity:
genetics, environmental, metabolic, behavioral, social
 Factors that predispose a person to gain excessive weight
gain.
 Eating patterns Eating environment
 Food packaging Food availability
 Body image Physical inactivity
 Basal body temp Dietary thermogenesis
 Fidgeting Biochemical differences
 Quantity & sensitivity to satiety hormones
 Management of Obesity through Diet control
Emphasizes fruits, vegetables, whole grains, fat-free or low-fat milk,
& milk products;
• Includes lean meats, poultry, fish, beans, eggs, and nuts
• Is low in saturated fats, trans fats, cholesterol, salt (sodium), and
added sugars.

• Limit intake of fats and oils high in saturated and/or trans fatty
acids, and choose products low in such fats and oils.
• Consume less than 10 percent of calories from saturated fatty
acids
• Consume less than 300 mg/day of cholesterol
• Keep trans fatty acid consumption as low as possible
• When selecting and preparing meat, poultry, dry beans, and milk
or milk products, make choices that are lean, low-fat, or fat-free.
 Diet Plus Exercise
 One pound of fat contains 3,500 kcal
Unbalance the Energy Equation (First Law
Thermodynamics)
1. Reduce kcal intake
2. Increase kcal output
3. Reduce intake and increase output

 Combining exercise and diet offers more

flexibility for weight loss.
Exercise facilitates fat mobilization from
adipose depots and fat catabolism.
Preserves fat free body mass, blunts
decrease in RMR, improves insulin
sensitivity
Risk Factor
“An aspect of personal behavior or lifestyle, an
environmental exposure, or a hereditary
characteristic that is associated with an
increase in the occurrence of a particular
disease, injury, or other health condition.”
Modifiable Risk Factor
A risk factor that can be reduced or controlled by intervention,
thereby reducing the probability of disease.
The WHO has prioritized the following four:
• Physical inactivity
• Tobacco use
• Alcohol use
• Unhealthy diets
Non-Modifiable Risk Factor
A risk factor that cannot be reduced or controlled by
intervention,
for example
• Age
•Gender
• Race
• Family history (genetics)
THANKYOU