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Cursul de nutriţie clinică pentru rezidenţi şi tineri medici, ediţia a 5-a, cu titlul

“Nutriţia în sindromul metabolic” a avut loc la Iaşi sub egida :


Universitatea de Medicină și Farmacie “Grigore T. Popa” Iaşi
Societatea de Nutriţie din România
Societatea Româna de Diabet, Nutriţie şi Boli Metabolice
Federaţia Româna de Diabet, Nutriţie şi Boli Metabolice

Descrierea CIP a Bibliotecii Naţionale a României


Nutriţia în sindromul metabolic : curs de nutriţie clinică
pentru rezidenţi şi tineri medici / sub red.: Graur Mariana. –
Iaşi : Editura Gr.T. Popa, 2014
Bibliogr.
ISBN 978-606-544-200-9

I. Graur, Mariana (coord.)

613.2(075.8)

Referenţi ştiinţifici:
Prof. dr. GABRIELA RADULIAN – Universitatea de Medicină şi Farmacie ”Carol Davila”
Bucureşti, Vicepreşedinte Societatea de Nutriţie din România
Conf. dr. FLORIN MITU – Universitatea de Medicină şi Farmacie ”Gr. T. Popa” Iaşi

Editura „Gr. T. Popa”


Universitatea de Medicină şi Farmacie Iaşi
Str. Universităţii nr. 16

Editura „Gr. T. Popa”este acreditată de CNCSIS - Consiliul Naţional al Cercetării


Ştiinţifice din Învăţământul Superior

Toate drepturile asupra acestei lucrări aparţin autorilor şi Editurii „Gr. T. Popa" Iaşi. Nici o
parte din acest volum nu poate fi copiată sau transmisă prin nici un mijloc, electronic sau
mecanic, inclusiv fotocopiere, fără permisiunea scrisă din partea autorilor sau a editurii.

Tiparul executat la Tipografia Universităţii de Medicină şi Farmacie "Gr. T. Popa" Iaşi


str. Universităţii nr. 16, cod. 700115, Tel. 0232 301678
Autori

Cornelia BALA – ef de lucrri, Universitatea de Medicin i Farmacie ”Iuliu Haieganu”


Cluj Napoca, medic primar Diabet, nutriie, boli metabolice, Centrul Clinic de Diabet,
Nutriie, Boli Metabolice, Cluj Napoca

Gina Eosefina BOTNARIU – ef de lucrri, Universitatea de Medicin i Farmacie


”Grigore T. Popa” Iai, medic primar Diabet, nutriie, boli metabolice, medic primar
Medicin intern, Centrul Clinic de Diabet, Nutriie, Boli Metabolice, Iai

Mariana GRAUR – profesor, Universitatea de Medicin i Farmacie ”Grigore T. Popa” Iai,


medic primar Diabet, nutriie, boli metabolice, medic primar Medicin intern, Centrul Clinic
de Diabet, Nutriie, Boli Metabolice, Iai - coordonator curs

Cristian GUJA – confereniar, Universitatea de Medicin i Farmacie ”Carol Davila”


Bucureti, medic primar Diabet, nutriie, boli metabolice, Institutul Naional de Diabet,
Nutriie, Boli Metabolice ”Prof. N.C. Paulescu”, Bucureti

Nicolae HÂNCU – profesor, Universitatea de Medicin i Farmacie ”Iuliu Haieganu” Cluj


Napoca, medic primar Diabet, nutriie, boli metabolice, Centrul Medical Regina Maria, Cluj
Napoca

Cristina Mihaela LCTUU – ef de lucrri, Universitatea de Medicin i Farmacie


”Grigore T. Popa” Iai, medic primar Diabet, nutriie, boli metabolice, Centrul Clinic de
Diabet, Nutriie, Boli Metabolice, Iai

Bogdan Mircea MIHAI – ef de lucrri, Universitatea de Medicin i Farmacie ”Grigore T.


Popa” Iai, medic primar Diabet, nutriie, boli metabolice, medic primar Medicin intern,
Centrul Clinic de Diabet, Nutriie, Boli Metabolice, Iai

Laura MIHALACHE – ef de lucrri, Universitatea de Medicin i Farmacie ”Grigore T.


Popa” Iai, medic primar Diabet, nutriie, boli metabolice, Centrul Clinic de Diabet, Nutriie,
Boli Metabolice, Iai

Maria MOA – profesor, Universitatea de Medicin i Farmacie Craiova, medic primar


Diabet, nutriie, boli metabolice, medic primar Medicin intern, Centrul Clinic de Diabet,
Nutriie i Boli Metabolice, Craiova

Amorin Remus POPA – profesor, Universitatea de Medicin i Farmacie Oradea, medic


primar Diabet, nutriie, boli metabolice, medic primar Medicin intern, Centrul Clinic de
Diabet, Nutriie, Boli Metabolice, Oradea

Alina Delia POPA – asistent universitar, Universitatea de Medicin i Farmacie ”Grigore T.


Popa” Iai, medic primar Diabet, nutriie, boli metabolice, Centrul Clinic de Diabet, Nutriie,
Boli Metabolice, Iai
Raluca Maria POPESCU – ef de lucrri, Universitatea de Medicin i Farmacie ”Grigore
T. Popa” Iai, medic primar Diabet, nutriie, boli metabolice, Centrul Clinic de Diabet,
Nutriie, Boli Metabolice, Iai

Gabriela RADULIAN – profesor, Universitatea de Medicin i Farmacie ”Carol Davila”


Bucureti, medic primar Diabet, nutriie, boli metabolice, Institutul Naional de Diabet,
Nutriie, Boli Metabolice ”Prof. N.C. Paulescu”, Bucureti

Gabriela ROMAN – confereniar, Universitatea de Medicin i Farmacie ”Iuliu Haieganu”


Cluj Napoca, medic primar Diabet, nutriie, boli metabolice, Centrul Clinic de Diabet,
Nutriie, Boli Metabolice, Cluj Napoca

Romulus TIMAR – confereniar, Universitatea de Medicin i Farmacie ”Victor Babe”


Timioara, medic primar Diabet, nutriie, boli metabolice, medic primar medicin intern,
Centrul Clinic de Diabet, Nutriie, Boli Metabolice, Timioara

Andrei Ioan VEREIU – confereniar, Universitatea de Medicin i Farmacie ”Iuliu


Haieganu” Cluj Napoca, medic primar Diabet, nutriie, boli metabolice, medic primar
Medicin intern, medic specialist Cardiologie, Centrul Clinic de Diabet, Nutriie, Boli
Metabolice, Cluj Napoca
Cuprins

Alimentaia proaterogen versus alimentaia antiaterogen ...................................7


Nicolae HÂNCU

Rolul alimentaiei sntoase în prevenirea diabetului zaharat..............................12


Amorin Remus POPA

Noul ghid de alimentaie în diabetul zaharat...........................................................16


Maria MO

Noiuni de nutrigenetic i nutrigenomic...............................................................20


Cristian GUJA

Nutriia în ficatul gras non-alcoolic..........................................................................24


Gabriela RADULIAN

Rolul alimentaiei în prevenia cardiovascular.....................................................26


Romulus TIMAR

Dieta mediteranean i sindromul metabolic..........................................................30


Gabriela ROMAN

Intervenii nutriionale în management-ul piciorului diabetic..............................34


Andrei Ioan VEREIU

Educaia terapeutic în sindromul metabolic…………………………..…………38


Cornelia BALA

Nutriia în dislipidemii………………………………….………………………..…42
Mariana GRAUR

De la ”sarea în bucate” la dietele hiposodate…………………………..….….…...46


Bogdan Mircea MIHAI

Incretinele în reglarea ponderal..............................................................................49


Gina Eosefina BOTNARIU

Nutriia în chirurgia metabolic..............................................................................51


Laura MIHALACHE

Alcoolul i sindromul metabolic..............................................................................55


Raluca Maria POPESCU

Fructoza – gustul dulce al... pericolului..................................................................58


Cristina Mihaela LCTU

Programarea nutriional a insulinorezistenei…….............................................61


Alina POPA
NUTRIIA ÎN SINDROMUL METABOLIC
Curs de nutriie clinic pentru rezideni i tineri medici

Sindromul cardio-metabolic este o grupare de anomalii metabolice care cresc riscul de


a dezvolta boli cardiovasculare aterosclerotice i diabet zaharat de tip 2. Etiologia
rmâne înc neclar dar se tie c este o interaciune complex între factori genetici,
metabolici i de mediu. Obezitatea i sedentarismul sunt factori de risc, prin urmare
intervenii asupra lor vor duce la scderea rezistenei la insulin, a hiperglicemiei, a
dislipidemiei aterogene i a hipertensiunii arteriale. Cu toate acestea, în prezent nu
exist un consens în prevenirea i tratarea acestui sindrom. Dieta i exerciiile fizice
sunt cheile strategiei de reducere non-farmacologic a riscului cardio-vascular.
Recomandri generale care vizeaz componentele de risc modificabile ale stilului de
via, includ scderea ponderal, creterea activitii fizice i implementarea dietelor
antiaterogene. Istoric, prima indicaie a fost scderea cantitii de lipide (“low fat-
diets”) dar, s-a constatat c i dietele bogate în carbohidrai pot contribui la creterea
trigliceridelor i scderea HDL-colesterolului. Dietele cu scderea carbohidrailor
(“low carb diets”) au fost la mod în ultimii ani dar, s-a constatat c astfel se consum
mai puin cereale integrale, fructe i mai ales legume decât recomandrile pentru o
nutriie sntoas. O alt tendin a fost suplimentarea cu calciu, vitamina D, potasiu
i magneziu. Scderea cantitii de sodiu este unanim recomandat. Dietele DASH i
mediteranean sunt benefice în reducerea dislipidemiei aterogene i a hipertensiunii
arteriale. Accelerarea cercetrilor privind interaciunea dintre gene i alimente este de
natur s dea informaii interesante care ar putea duce la o orientare particularizat a
dietelor în viitor.
S-a conchis c dietele cuprinse într-un stil de via sntos sunt cele mai apropiate de
ceea ce se recomand în sindromul metabolic, adic o diet echilibrat, cu o reducere
a lipidelor saturate i trans mai degrab decât reducerea grsimilor în total, dieta
bogat în fibre alimentare, cu glucide cu index glicemic mic, decât reducerea cantitii
totale de glucide, cu proteine de bun calitate, care includ aminoacizii eseniali (se
discut rolul benefic al lactatelor degresate sau parial degresate i a petelui).
Dietele sunt compuse dintr-o mare varietate de substane nutritive care pot lucra
sinergic pentru a preveni sau pentru a promova boala. Evaluarea profesional a dozei
zilnice de nutrieni este necesar. O anumit flexibilitate în macronutrienii alimentari
este permis în funcie de profilul metabolic al pacientului i de reacia la tratament.
De aceia o informare continu asupra dovezilor tiinifice privind nutriia este nu
numai de dorit dar i obligatorie mai ales pentru tinerii medici. S-a ajuns la a 5-a
ediie a Cursului de nutriie clinic adresat rezidenilor i tinerilor medici. Prelegerile
inute la ediiile anterioare de ctre cadre didactice din toate centrele universitare
medicale ale rii, in format electronic, au fost disponibile pentru medicii care au
audiat cursul. Pentru prima oar, la aceast a 5-a ediie s-a tiprit acest syllabus al
cursului pentru a maximiza invarea i a permite diseminarea informaiei. Mulumim
tuturor vorbitorilor care au ales cele mai reprezentative slide-uri pentru publicare i
editurii Gr. T. Popa pentru calitatea crii.

Coordonator curs,
Prof.dr. Mariana Graur
CURS DE NUTRIIE CLINIC

Alimentaia proaterogen (APA)


versus
Alimentaia Antiaterogen (ATA)

N.HÂNCU
CRISTINAN/f
UNIVERSITATEA“IULIUHAIEGANU”,CLUJNAPOCA

2013

Proatherogenic nutrition

7
CURS DE NUTRIIE CLINIC

LifestyleInfluenceonLipoproteins
andASCVDRisk
Dietarylipids
¾ Dietaryfatsinparticularaffectlipoproteinlevels

¾ DietsrichinsaturatedfattyacidsandtransfattyacidsraiseLDLClevels,as
doesahighcholesterolintake
¾Inpopulationsinwhichdietarysaturatedfattyacidsandcholesterolare
high,serumcholesterollevelsare1025%higherthanwhereintakesarelow

¾Unsaturatedfattyacids(monounsaturatedandpolyunsaturated)donotraise
LDL Clevelsandrepresentanalternativetosaturatedfattyacids

IASI,2013

LifestyleInfluenceonLipoproteins
andASCVDRisk
Dietarylipids
¾DietshighincarbohydrateswillcausemildtomoderateincreasesinVLDLand
oftenreduceHDLlevels

¾ Replacementofcarbohydrateswithmonounsaturatedfattyacidshasthe
advantagethatitdoesnotlowerHDLC

¾ ButthereislittleevidencethatahigherVLDLandlowerHDL Conhigh
carbohydratedietsareatherogenic;populationsconsuminglowfat,high
carbohydratedietsoftenhavelowratesofASCVD,especiallyCHD

IASI,2013

Antiatherogenic nutrition

8
CURS DE NUTRIIE CLINIC

n3unsaturatedfattyacids
™ Supplementationwith2–3g/dayoffishoil(richinlongchainn3fattyacids)can
reduceTGlevelsby25–30% inbothnormolipidaemic andhyperlipidaemic individuals

™ a Linolenic acid(amediumchainn 3fattyacidpresentinchestnuts,some


vegetables,andsomeseedoils)islesseffectiveonTGlevels

™ Longchainn 3PUFAs alsoreducethepostprandiallipaemic response

™ Alowdosesupplementationofamargarinewithn 3PUFAs (400mg/day)ora


linolenic acid(2g/day)didnotsignificantlyreduceTGlevelsinanRCT involving4837
post MIpatients;neitherdidthissupplementationreducetherateof majorCVevents

ESC/EAS. Eur Heart J (2011) 32 (14): 1769-1818

Lifestylerecommendations
¾ Therecommendedtotalfatintakeisbetween25and35%ofcalories foradults
‰ Fatintakesthatexceed35%ofcaloriesaregenerallyassociatedwithincreased
intakesofbothsaturatedfatandcalories
‰ Alowintakeoffatsandoilsincreasestheriskofinadequateintakesof
vitaminEandofessentialfattyacids,andmaycontributetounfavourable
changesinHDL.

¾ ThetypeoffatintakeshouldpredominantlycomefromsourcesofMUFAs and
bothn6andn3PUFAs
¾ Toimproveplasmalipidlevels,saturatedfatintakeshouldbelowerthan10%of
thetotalcaloricintake
‰ TheToptimal intakeofSFAs shouldbefurtherreduced(,7%ofenergy)inthe
presenceofhypercholesterolaemia

‰ Theintakeofn6PUFAs shouldbelimitedto<10%oftheenergyintake,bothto
minimizetheriskoflipidperoxidation ofplasmalipoproteinsandtoavoidany
clinicallyrelevantHDL Cdecrease
ESC/EAS. Eur Heart J (2011) 32 (14): 1769-1818

Lifestylerecommendations
¾ intake of fish and n-3 fatty acids from plant sources may reduce the risk of
CV death and stroke but has no major effects on plasma lipoprotein metabolism

¾ Supplementation with pharmacological doses of n-3 fatty acids (>2–3 g/day)


reduces TG levels, but a higher dosage may increase LDL-C;

¾ not enough data are available to make a recommendation regarding the optimal n-
3/n-6 fatty acid ratio

¾The cholesterol intake in the diet should ideally be <300 mg/day

¾ Limited consumption of foods made with processed sources of trans fats


provides the most effective means of reducing intake of trans fats below 1% of
energy

¾ Because the trans fatty acids produced in the partial hydrogenation of


vegetable oils account for >80% of total intake, the food industry has an
important role in decreasing the trans fatty acid content of the food supply

ESC/EAS. Eur Heart J (2011) 32 (14): 1769-1818

9
CURS DE NUTRIIE CLINIC

Dietarycarbohydrateandfibre
¾ Carbohydrate intake may range between 45 and 55% of total energy

¾ Consumption of vegetables, legumes, fruits, nuts, and wholegrain cereals


should be particularly encouraged, together with all the other foods rich in
dietary fibre with a low glycaemic index

¾ A fat-modified diet that provides 25–40 g of total dietary fibre, including at


least 7–13 g of soluble fibre, is well tolerated, effective, and recommended for
plasma lipid control; conversely, there is no justification for the recommendation of
a very low carbohydrate diet.

¾Intake of sugars should not exceed 10% of total energy (in addition to the
amount present in natural foods such as fruit and dairy products); more restrictive
advice concerning sugars may be useful for those needing to lose weight or with high
plasma TG values

¾Soft drinks should be used with moderation by the general population and
should be drastically limited in those individuals with elevated TG values

ESC/EAS. Eur Heart J (2011) 32 (14): 1769-1818

Summaryoflifestylemeasuresandhealthy
foodchoicesformanagingtotalcardiovascularrisk(1)

ESC/EAS. Eur Heart J (2011) 32 (14): 1769-1818

Summaryoflifestylemeasuresandhealthy
foodchoicesformanagingtotalcardiovascularrisk(2)

ESC/EAS. Eur Heart J (2011) 32 (14): 1769-1818

10
CURS DE NUTRIIE CLINIC

Nutrition
Keymessages

Fifth Joint Task Force of the European Society of Cardiology and Other Societies .
Eur Heart J (2012) doi: 10.1093/eurheartj/ehs092

Nutrition
Keymessages

• Energy intake should be limited to the amount of energy needed


to maintain (or obtain) a healthy weight, i.e. a BMI <25 kg/m2

• In general, when following the rules for a healthy diet, no dietary


supplements are needed

Fifth Joint Task Force of the European Society of Cardiology and Other Societies .
Eur Heart J (2012) doi: 10.1093/eurheartj/ehs092

Conclusion

• It is clear that dietary modifications should form the basis for CVD
prevention

• Some changes in the diet will be reflected in favourable changes in


measurable risk factors, such as BP and cholesterol levels

• However, it should be kept in mind that dietary habits that do not show their
effect on levels of BP or blood lipids can also make an important contribution to the
prevention of CVD

• The requirements for a healthy diet are summarized in the key messages at the
beginning of this section.

Fifth Joint Task Force of the European Society of Cardiology and Other Societies .
Eur Heart J (2012) doi: 10.1093/eurheartj/ehs092

11
CURS DE NUTRIIE CLINIC

Rolul Alimentatiei Sanatoase in


Prevenirea Diabetului Zaharat

Prof.Dr.Popa Amorin
Remus

TheRoleofDietandLifestyle
Nutritiontherapy isgenerallyrecommendedfor:
primary
secondary prevention
tertiary
Primary interventionbeforethedevelopmentofdiabetes
Secondary– interventionafterdiagnosisofdiabetes
Tertiary whensignificantnumbersofbeta cellsremainafterdiagnosis

Thereisstillnouniversaldietaryapproachfordiabetespreventionand
management.

TheRoleofDietandLifestyleinPrimary,Secondary,andTertiaryDiabetesPrevention:A
ReviewofMetaAnalyses:TheodoraPsaltopoulou,Ioannis Ilias andMariaAlevizaki  TheReview
ofDIABETICSTUDIESVol.7· No.1· 2010

ActiveCommutingCutsDiabetesRisk
Author:LisaNainggolan
AmericanJournalofPreventiveMedicine. September2013

12
CURS DE NUTRIIE CLINIC

TheRoleofDietandLifestyle
Meta analysesondietary 2000– 2009– 40studies

1.Wholegrainproducts&cerealfibers arebeneficialtohealth
protectagainstchronicdiseases(mainlycancer&CVD)
two serving per day wholegrainintake >
riskforDM– 21%(10,944
casemeta analysis)
highercerealfiberintake >
risk
Fibers soluble
insoluble
risk

TheRoleofDietandLifestyleinPrimary,Secondary,andTertiaryDiabetesPrevention:A
ReviewofMetaAnalyses:TheodoraPsaltopoulou,Ioannis Ilias andMariaAlevizaki  TheReview
ofDIABETICSTUDIESVol.7· No.1· 2010

WholeGrain,Bran,andGermIntake
andRiskofType2Diabetes
WholegrainintakeisinverselyassociatedwithriskofDM2,strongerfor
branthanforgerm(
21%)
partlymediatedbyeffectsonbodyweight
degintake
highercerealsfiberintake
intakeoflignans

ConsumptionofwholegrainsinmanypopulationsisverylowUSA>GB >
increasedconsumptionhasthepotentialtocontributesubstantiallyto
reducingriskoftype2diabetes

WholeGrain,Bran,andGermIntakeandRiskofType2Diabetes:AProspectiveCohortStudy
andSystematicReview:Jeroen S.L.deMunter,FrankB.Hu,DonnaSpiegelman,MaryFranz,RobM.van
Dam  PLoS Medicine,August2007|Volume4|Issue8|e261

ConsumptionofCertainFruitsLinked
toLowerDiabetesRisk
2.Fruits&Vegetables
intakeof fruits
vegetablefibers Æ notsignificantlyreducetheriskfortype2
diabetes
4,858casesDM2– 13years fruitsandvegetables noprotectionDM2

3.Combinedprospectivelongitudinalcohortstudies(theNurses' HealthStudy
(n=66,105),Nurses'HealthStudyII(n=85,104),andHealth
ProfessionalsFollow upStudy(n=36,173).
Juiceconsumptionmayuptheriskfordiabetes(IsaoMuraki,PhD,MD,from
theDepartmentofNutrition,HarvardSchoolofPublicHealth,
Boston,Massachusetts,andcolleaguesreportinanarticlepublished
onlineAugust29inBMJ.)
Primarypreventionofmanychronicdiseases increasingfruitconsumption
(blueberries,grapes,apples,grapefruits)
Risk cantaloupe,fruitjuice.

Joe Barber Jr, PhD, Aug 29, 2013 http://www.medscape.com/viewarticle/810244

13
CURS DE NUTRIIE CLINIC

TheRoleofDietandLifestyle
4.Leguminoase nonuleioase – naut,fasole,mazare,linte
goodproteinsource
(41trials)– goodeffectsondiabeticcontrol

TheRoleofDietandLifestyleinPrimary,Secondary,andTertiaryDiabetesPrevention:A
ReviewofMetaAnalyses:TheodoraPsaltopoulou,Ioannis Ilias andMariaAlevizaki  TheReview
ofDIABETICSTUDIESVol.7· No.1· 2010

CVDBenefitsinFishOil

5.Fish fishoil 3to18g/day– noeffectinDM


(NEJMStudyontheUseofFishOilforPreventionofCardiovascularEvents)
thereisnocardiovascularprotectivebenefitfromfishoilsupplementsin
highriskpatients(thosewithmultiplecardiovascularriskfactorsor
atheroscleroticvasculardiseasebutnotmyocardialinfarction)

20%to50%reductionsintotalmortalityandsuddendeathusingdosesof
0.85to4.0g/day,withtreatmentdurationsfrom12to42months

Carol Peckham, Howard S. Weintraub, MD June 05, 2013 - http://www.medscape.com/viewarticle/805344

TheRoleofDietandLifestyle
6.Coffee maindrip filteredcoffee protectiveeffect(4 6cupsperday)
(?antioxidantcomponents)

7.Tea – noreducedriskinDM(9studies 11,440cases)


teaconsumptionof 4cupsperdaymaylowertheriskofdevelopingDM2

8.Alcoholicbeverages U shaped(32studies,37years 1966to2003)


1to3drinks/day 33%to56%lowerincidenceofDMand34%to55%
lowerincidenceofdiabetes relatedCHD
heavyconsumption(>3drinks/day) 43% DM

TheRoleofDietandLifestyleinPrimary,Secondary,andTertiaryDiabetesPrevention:A
ReviewofMetaAnalyses:TheodoraPsaltopoulou,Ioannis Ilias andMariaAlevizaki  TheReview
ofDIABETICSTUDIESVol.7· No.1· 2010

14
CURS DE NUTRIIE CLINIC

TheRoleofDietandLifestyle
9.Nuts richinmono andpolyunsaturatedfats
noprotectiveeffectinDM
!!!nutsreducepostprandialoxidativestress
10.Chromium – US notaffectglucoseconcentration(15reports)
11.Magnesium functionattheinsulinreceptorlevel
Hypomagnesemia DMrisk
12.Antioxidantx – 9studies intakevitaminE
carotenoids protectiveeffectonDM
VIT.Cintake– noonDM
13.Cinnamon insulinsensitizer mainlyactivatinginsulinreceptorkinase
(5trials)
14.Chineseherbalmedicine
prediabetes 16trials herbals/lifestylecombinationwasmoreeffective
thanlifestylealone
Æ
progressioninDM

TheRoleofDietandLifestyleinPrimary,Secondary,andTertiaryDiabetesPrevention:AReview
ofMetaAnalyses:TheodoraPsaltopoulou,Ioannis Ilias andMariaAlevizaki  TheReviewof
DIABETICSTUDIESVol.7· No.1· 2010

TheRoleofDietandLifestyle
15.TheexactproportionofCH inclusionindiabeticadults’ diets

CHdiet?
19studies alow fat,high carbohydrate HbA1c similar
ahigh fat,low carbohydrate fastingbloodglucose
replacingfatwithCHÆ I.R.Æ gl.
lowCHdietÆ
HbA1c,gl.
TG(<45%ofcaloriesfromCH)
highCH,highfatsdietÆ
pre&postprandial gl.,HbA1c,LDL,TG, HDL
Æ > 55%CH,25 50g/dayfibers,proteinintakeof12 16%,fatintakeof<30%
(monounsaturatedfat12 15%)

TheRoleofDietandLifestyleinPrimary,Secondary,andTertiaryDiabetesPrevention:A
ReviewofMetaAnalyses:TheodoraPsaltopoulou,Ioannis Ilias andMariaAlevizaki  TheReview
ofDIABETICSTUDIESVol.7· No.1· 2010

TheRoleofDietandLifestyle
16.Polyunsaturatedfattyacids (PUFA)
omega 3 PUFA
TG,VLDLcholesterol
noLDL,gl.,fastinginsulin

17.Transfattyacids (TFA)– harmful


promoteI.R.,D.M.2

TheRoleofDietandLifestyleinPrimary,Secondary,andTertiaryDiabetesPrevention:A
ReviewofMetaAnalyses:TheodoraPsaltopoulou,Ioannis Ilias andMariaAlevizaki  TheReview
ofDIABETICSTUDIESVol.7· No.1· 2010

15
CURS DE NUTRIIE CLINIC

ADA POSITION STATEMENT 2013

Nutrition Therapy Recommendations


for the Management of Adults
With Diabetes

Prof. univ. dr. Maria Moa


UMF Craiova

Iai
9 noiembrie 2013

Goals of nutrition therapy that apply to


adults withdiabetes
• Topromoteandsupporthealthfuleating patterns,emphasizinga
varietyof nutrient dense foodsinappropriateportionsizes inorder
toimproveoverallhealthandspecifically to:
individualizedglycemic,bloodpressure,andlipidgoals;
achieve andmaintainbodyweight goals;
delay orpreventcomplicationsof diabetes.

•To address individual nutrition needs based on personal and


cultural preferences, health literacy and numeracy, access to
healthful food choices, willingness and ability to make behavioral
changes,aswellasbarrierstochange.

Goals of nutrition therapy that apply to


adults withdiabetes
• Tomaintainthepleasureofeatingby providingpositive messages
aboutfoodchoiceswhilelimitingfoodchoicesonly whenindicated
byscientificevidence.

• To provide the individual


with DM with practical
tools for day-to-day meal
planning rather than
focusing on individual
macro, micronutrients, or
single foods.

16
CURS DE NUTRIIE CLINIC

Effectivenessofnutritiontherapy
• MNT:for allpeoplewithtype1andtype2DM asaneffective
componentofthe overalltreatmentplan.
• Inividualized MNT toachievetreatmentgoals:
`  intensiveflexibleinsulintherapy:theCHcountingmeal
planningapproachcanresult inimprovedglycemic control.
fixeddaily insulindoses:consistentCH intakewithrespect
totime andamountcanresultinimproved glycemic controland
reducethe riskforhypoglycemia.
mealplanning:bettersuitedtoindividualswith type2DM
identifiedwith healthandnumeracyliteracyconcerns,aswellasfor
olderadults.

Energy balance

• For overweight or obese adults with type 2 DM,


reducing energy intake while maintaining a healthful
eating patternisrecommendedtopromote weightloss.
• Modest weight loss may provide clinical benefits
(improved glycemia, blood pressure, and/or lipids) in
someindividualswithDM.
• To achieve modest weight loss, intensive lifestyle
interventionswithongoingsupportarerecommended.

Carbohydrates
• Evidence is inconclusive for an ideal amount of CH intake for
people withDM.

• TheamountofCHandavailable insulinmaybethemostimportant
factor influencing glycemic response after eating and should be
consideredwhen developingtheeatingplan.

• Monitoring CH intake, whether by CH counting or experience


based estimation,remainsakeystrategyin glycemiccontrol.

• For good health, CH intake from vegetables, fruits, whole grains,
legumes, and dairy products should be advised over intake from
other CHsources,especiallythosethatcontainaddedfats,sugars, or
sodium.

17
CURS DE NUTRIIE CLINIC

Qualityofcarbohydrates
• Glycemic indexandglycemic load:
Substituting low–glycemic load foods for higher–
glycemic loadfoodsmay modestlyimproveglycemic
control

Dietaryfiberandwholegrains:
Peoplewithdiabetesshould consume
atleasttheamountoffiberandwhole
grainsrecommendedforthegeneral
public.

Summaryofprioritytopics
Strategiesforallpeoplewithdiabetes:

• Portioncontrol:forweightlossandmaintenance.
• WhenchoosingCH containingfoods,choosenutrient
dense, highfiber foods whenever possible instead of
processedfoodswith addedsodium,fat,andsugars.
• Substitutefoodshigherinunsaturatedfat(liquidoils)
forfoodshigherintransorsaturatedfat.
• Selectleanerproteinsourcesandmeatalternatives.

Summaryofprioritytopics
Strategiesforallpeoplewithdiabetes:

• Vitaminandmineralsupplements,herbalproducts,or
cinnamontomanageDMarenotrecommendeddueto
lackofevidence.
• Moderatealcoholconsumption(onedrink/dayorless
foradultwomenandtwodrinksorlessforadultmen)
has minimal acute or long term effects on blood
glucoseinpeople withDM.
•To reduce risk of hypoglycemia for individuals using
insulinorSU,alcohol shouldbeconsumedwithfood.
• Limitsodiumintaketo2,300mg/day.

18
CURS DE NUTRIIE CLINIC

Futureresearch directions

ƒ Therelationshipsbetweeneatingpatternsanddisease
indiversepopulations.
ƒThedevelopmentofstandardizeddefinitionsforhigh–
andlow–glycemic indexdietsandimplementationof
thesedefinitionsinlong termstudiestofurtherevaluate
theirimpactonglycemiccontrol.
ƒThedevelopmentofstandardizeddefinitionsforlow to
moderate CHdietsanddetermininglong term
sustainability.

Takehomemessages
There is no standard meal plan or eating pattern that works
universallyforallpeoplewithDM.
Nutritiontherapyshouldbeindividualized:
individualhealthgoals;
personalandculturalpreferences;
healthliteracy andnumeracy;
accesstohealthfulchoices;
willingnessandabilitytochange.
Minimally processed nutrient dense foods in appropriate portion
sizesaspartofahealthfuleatingpatternandprovidetheindividual
withDMwithpracticaltools for day to day food plan andbehavior
change,maintainedoverthelongterm.

19
CURS DE NUTRIIE CLINIC

Noiuni de nutrigenetic i
nutrigenomic

Conf. Dr. Cristian Guja MD, PhD


Institutul de Diabet, Nutriie i Boli Metabolice
“Prof. NC Paulescu”, Bucureti, România

Iai
9 Noiembrie 2013

Obiective
Ce este nutrigenomica

Ce este nutrigenetica

Interrelaia dintre factorii nutriionali


i cei genetici

Care sunt posibilele aplicaii practice

Ipoteze nutrigenomic/nutrigenetic

Factorii dietetici îi exercit efectul asupra sntii


alterând direct expresia unor gene critice pentru diferitele
ci metabolice i/sau determinând apariia unor mutaii genice

Efectul nutrienilor asupra sntii depinde de prezena unor


variante genice care influeneaz absorbia i metabolismul
acestor nutrieni i/sau interaciunea unor cofactori nutriional
cu enzimele respective i, în final, activitatea biologic a
acestora

Rezultate pozitive asupra sntii vor fi obinute dac


aportul de nutrieni este individualizat la fiecare subiect
inând cont de caracteristicile sale genetice în funcie de
vîrst, preferine dietetice i stare de sntate

Fenech et al. J Nutrigen et Nutrigenomics 2011;4:69–89

20
CURS DE NUTRIIE CLINIC

Nutrigenomic

Studiaz mai ales efectele alimentelor/nutrienilor


asupra genomului (expresiei genice)

Efectul PUFA

21
CURS DE NUTRIIE CLINIC

Nutrigenetic

Impactul diferitelor variante genice pe efectelor


unor nutrieni asupra corpului uman

Gena MTHFR pe cromozomul 1

Exist 2 variante genice (SNP) frecvente:

¾ 677 C>T în exon 4 (Ala / Val)

¾ 1298 A>C în exon 7 (Glu / Ala)

Heterozigoii alel mutant au 35%  activitate


enzimatic

Homozigoii alel mutant au 70%  activitate


enzimatic

Aplicaii practice

Subieci Diet srac


MTHFR Wild Type acid folic Normal

Subieci Diet srac


MTHFR Mutant Cancer, CVD
acid folic

Subieci Diet bogat


MTHFR Mutant Normal
acid folic

22
CURS DE NUTRIIE CLINIC

Gena NAT2 pe cromozomul 8

Exist 4 variante genice (SNP) frecvente:

¾ 341 T>C (114 Thr / Ile)


¾ 590 G>A (197 Arg / Gln)
¾ 803 A>G (268 Lys / Arg)
¾ 857 G>A (286 Glu / Gly)

În funcie de variantele genice exist acetilatori rapizi


i acetilatori leni

Aplicaii practice

NAT2 Diet bogat


Acetilatori rapizi Cancer
carne roie

NAT2 Diet bogat


Acetilatori rapizi DZ tip 1
nitrai/nitrii

Purtorii variantelor de risc NAT2 pot scdea riscul de


cancer prin evitarea crnii roii i pe cel de DZ tip 1
evitând alimentele conservate

Aplicaii comerciale

Salugen
HAVEOS - Supliment nutritiv pentru sevrare
narcotice
GenoTrim - Supliment nutritiv pentru control
ponderal
SpaGen - Supliment nutritiv pentru declin cognitiv

Suracell
Core Nutrition - Supliment pentru sistemele de
“DNA repair”

23
CURS DE NUTRIIE CLINIC

Medical nutrition therapy in


nonalcoholic steatohepatitis

Prof. Univ. Dr. Gabriela Radulian


Asist. Univ. Dr. Emilia Rusu

Definition of NASH
• A subset of Nonalcoholic Fatty Liver Disease (NAFLD)
- 20% (range 17-33%) of Americans may have NAFLD with
1/3 of these diagnosed with NASH
- NAFLD is an accumulation of fat on the liver. Once it
progresses to inflammation it becomes NASH

• Inflammation and accumulation of fat and fibrous tissue in


the liver

• Little to no alcohol use by patient

• Minimal symptoms

“Nutritional Management of Insulin Resistance in


Nonalcoholic
Fatty Liver Disease (NAFLD)”
Beth A. Conlon, Jeannette M. Beasley , Karin Aebersold , Sunil S. Jhangiani and Judith Wylie-Rose Nutrients oct 2013, 5,
4093-4114; doi:10.3390/nu510409 3nutrients

24
CURS DE NUTRIIE CLINIC

Treatment
• No cure for NASH

• Need to control the conditions that are


associated with NASH
- Excellent blood sugar control
- Weight loss (10% weight loss)
- Lipid lowering diet
- Lower sodium intake
• Lifestyle modifications

“Nutritional Management of Insulin Resistance in


Nonalcoholic
Fatty Liver Disease (NAFLD)”
Beth A. Conlon, Jeannette M. Beasley , Karin Aebersold , Sunil S. Jhangiani and Judith Wylie-Rose
Nutrients oct 2013, 5, 4093-4114; doi:10.3390/nu510409 3nutrients

NAFLD is regarded as the hepatic manifestation of the metabolic syndrome


and shares common comorbidities with insulin resistance and CVD.

It is important for clinicians to recognize this patient population and deliver


effective therapeutic lifestyle interventions.

In addition, patients may benefit from referral to MNT to optimize dietary


intake and promote behavioral changes.

Future research is needed to evaluate low-carbohydrate/high MUFA and


low-fat/low-GI diets for NAFLD.

Conclusions

• Increase in fruits, vegetables and whole grains


• Lower intake of meat and poultry
• Less fat in your diet
• Less processed or packaged foods
• Minimize alcohol and other liver toxins
• Improve blood sugar control if diabetic
• Exercise

25
CURS DE NUTRIIE CLINIC

Nutrition in Cardiovascular
Disease Prevention
Dr. Romulus Timar

Smoking cessation
“A te lsa de fumat este cel mai uor lucru; eu m las în fiecare zi!”

Mark Twain

• Advise all persons not to smoke


• Include smoking cessation counseling and
other forms of treatment as a routine
component of lifestyle modification

Physical activity
•Participation in regular physical activity and/or aerobic
exercise training is associated with a decrease in
cardiovascular mortality.
•A sedentary lifestyle is one of the major risk factors for CVD.

Sedentary behaviors increase risk of cardiovascular disease mortality


mortality in men.
Med Sci Sports Exerc 2010; 42: 879-
879-885
US Department of Health and Human Services. 2008 Physical Activity
Activity Guidelines for Americans

26
CURS DE NUTRIIE CLINIC

Body weight
• Both overweight and obesity are associated with a risk of
death in CVD.
• There is a positive linear association of BMI with all-
all-cause
mortality.
• All-
All-cause mortality is lowest with a BMI of 20–
20–25 kg/m2
• Further weight reduction cannot be considered protective
against CVD.

Zheng W, et al. Association between body-mass index and risk of death in more than 1 million
Asians. N Engl J Med 2011;364:719–729

Life Style Modification


• Healthy eating habits.

Nutrition
- trebuie s asigure un aport optim de nutrien
nutrieni, din
punct de vedere cantitativ i calitativ
- s previn sau amelioreze afec
afeciunile

27
CURS DE NUTRIIE CLINIC

Nutrition
A healthy diet: Carbohydrates

• 55-65% of the daily energy intake

• Choose:
– Carbohydrates with low glycemic index

• Att
Attention
ention!!
• Sugars should not exceed 10%
of the daily energy intake

Nutrition
A healthy diet: Proteins
•10-
10-15% of the daily energy intake
•0,8-
0,8-1 g/kg bw/day
– 40-50% from animal – 50-60% from
products vegetable products

Nutrition
• A healthy diet: Lipids

– Saturated fatty acids (SFA) to account for <10% of total


energy intake, through replacement by PUFA.

– Trans-
Trans-unsaturated fatty acids: as little as possible, preferably
no intake from processed food, and <1% of total energy
intake from natural origin.

– <5 g NaCl per day.

– 30–
30–45 g of bre/day,
bre/day, from whole grain products, fruits, and
vegetables.
European Guidelines on cardiovascular disease prevention in clinical practice
European Journal of Preventive Cardiology 2012 19: 585-667

28
CURS DE NUTRIIE CLINIC

Nutrition
• A healthy diet:
– 200 g of fruit per day (2–
(2–3 servings).
– 200 g of vegetables per day (2–
(2–3 servings).
– Fish at least twice a week, one of which to be oily sh.
sh.
– Alcoholic beverages should be limited to 2 glasses/day (20
g/day) for M and 1 glass/day (10 g/day of alcohol) for W.

• Energy intake should be limited to the amount of energy


needed to maintain (or obtain) a healthy weight, i.e. a BMI<25
kg/m2

• In general, when following the rules for a healthy diet, no


dietary supplements are needed.
European Guidelines on cardiovascular disease prevention in clinical practice
European Journal of Preventive Cardiology 2012 19: 585-667

Na+

Fibre
• Consumption of dietary fibre reduces the risk of CVD.
• The mechanism is not elucidated completely:
– reduces postprandial glucose responses after carbohydrate-
carbohydrate-rich meals
– lowers TC and LDLc.
LDLc.
• Sources of fibre are whole grain products, legumes, fruits, and
vegetables.
• The American Institute of Medicine recommends an intake of
3.4 g/MegaJoule,
g/MegaJoule, equivalent to an intake of 30-
30-45 g/day
Cereale integrale
Tarate de ovaz, orz, nuci, Trâe de grâu
Oleaginoase, seminte, fasole, Legume
Linte, legune, fructe

Weickert MO, Pfeiffer AF.Metabolic effects of


dietary fiber consumption and prevention of
diabetes. J Nutr 2008; 138: 439-442.

29
CURS DE NUTRIIE CLINIC

Dieta Mediteranean si
Sindromul metabolic

Conf Dr. G. Roman


Centrul Clinic de
Diabet, Nutriie,
Boli metabolice
Cluj-Napoca

PREDIMED TRIAL: DESIGN


‰ Men: 55-80 yr 1. Smoking
2. Hypertension
‰ Women: 60-80 yr 3. n LDL
‰ High CV risk w ithout CVD 4. p HDL
type 2 diabetics 5. Overweight/obes
6. Family history
3+ risk factors

Random

Provision of nuts
Provision of Olive oil 30 kg/wk walnuts
~2 000 l/wk 15 kg/wk almonds

• < 1 serving/wk of nuts vs > 3 servings/wk


• lower adjusted odds ratios (OR) for:
– obesity (0.61, P-trend ,0.001),
– MetS (0.74, Ptrend, 0.001),
– diabetes (0.87, P-trend = 0.043)
– MetS criterion (OR 0.68, P-trend,0.001

30
CURS DE NUTRIIE CLINIC

Farfuria Mediteraneana

Dieta mediteranean – Caracteristici

• Nu exist o diet unitar în rile aflate în zona Mediteranean -


elementele comune, specifice zonei
• DMed tradi
tradiional - opt componente caracteristice:
– Consumul crescut de
• fructe i legume
• vegetale proaspete
• cereale (inclusiv pâine), nuci i semin
semine
• ulei de msline,
msline, msline
– Consum moderat de produse lactate (î
(în principal brânz i iaurt)
– Consum moderat de ou (0-
(0-4 / sptmân)
sptmân)
– Consum redus de carne (se prefer
prefer pe
pete, pui i mai rar carnea
ro
roie)
– Vin în cantit
cantiti moderate.

31
CURS DE NUTRIIE CLINIC

Dieta mediteranean – Componen


Componen
nutri
nutriional

Aport crescut Aport sczut


acizi gra
grai mono-
mono- i poli-
poli- acizi gra
grai satura
saturai  7-8%
nesatura
nesaturai din totalul caloric
Antioxidan
Antioxidani - flavonoidele raport sczut între acizi gra
grai
existente în fructe, legume i omega-
omega-6 i omega-
omega-3
verde
verdeuri, precum i în uleiul
de msline.
msline.
fibre alimentare

Dieta mediteranean – Componen


Componen nutri
nutriional
Alimente Con
Coninut

Pe
Petele i produsele marine proteine, vitamin
vitamin A i D, calciu (oasele pe
petilor mici).

Fructele (ro
(roii i galbene) vitamina C, B i vitamina A,
Mazrea,
Mazrea, lintea, boabele de glucide complexe, fier i fibre
fasole
Nucile, alunele i semin
seminele • minerale, uleiuri esen
eseniale, vitamin
vitamin E,
E, fibre.
fibre.
(mai ales cele de susan) • Profil lipidic favorabil
• Surs bogat de -fitosteroli, acidul folic,
antioxidean
antioxideanii, ce influen
influeneaz în mod pozitiv riscul
cardiovascular
• con
coninut mare de acizi gra grai polinesatura
polinesaturai, în
principal acid alfa-
alfa-linoleic i omega-
omega-3, ce confer
propriet
proprieti antiaterogene adi adi ionale
Vegetalele proaspete vitamine B i C, minerale, fibre.
Verde
Verdeurile i ierburile • minerale,
aromatice, usturoiul • au efect antiseptic,
• antiinfec
antiinfecios
• asigur gustul plcut,
plcut, specific DMed.

Dieta mediteranean – Componen


Componen nutri
nutriional

Alimente Con
Coninut

Uleiul de msline - unul din -toate substan


substanele din mslin sunt transferate în ulei,
elementele centrale ale - con
coninutul crescut de acid oleic,
DMed, datorit
datorit propriet
proprietilor - antioxidan
antioxidani
sale specifice, diferite de
- acizi gra
grai mononesatura
mononesaturai,
cele ale celorlalte uleiuri
- men
menine componentele lipofilice din fructe, alfa-
alfa-
vegetale.
tocoferolul, compu
compuii fenolici, to
toi cu propriet
proprieti
- singurul tip de ulei ob
obinut
antioxidante i antiinflamatorii puternice.
din fructul întreg, fr
utilizarea de solven
solven
Vin, ceai negru, i
verde efecte antioxidante

32
CURS DE NUTRIIE CLINIC

Dieta mediteranean – Beneficii

• Posibilele mecanisme implicate sunt:


– reducerea LDL-
LDL-colesterolului i a oxidrii acestuia,
acestuia,
– cre
creterea HDL-
HDL-colesterolului,
– ameliorarea func
funciei endoteliale,
– reducerea tensiunii arteriale,
– Reducerea markerilor inflamatori i a stresului oxidativ,
Efectele benefice
•Preven
Prevenia bolilor coronariene
•Preven
Prevenia episoadelor coronariene acute
•Preven
Prevenia i controlul sindromului metabolic
•Preven
Prevenia diabetului zaharat tip 2
•Controlul lipidic
•Reducerea riscului cardiovascular
•Cre
Creterea speran via i a longevit
speranei de via longevitii

Scorul Dietei Mediteraneene


Grupa alimentar Alimente incluse Criterii pentru 1 punct
Vegetale Toate cu excep
excepia cartofilor
Legume Tofu, mazre
mazre,, fasole boabe
Mai mult decât aportul
Fructe Toate fructele i sucurile de mediu (por
(porii/zi)
fructe
Nuci, alune Alune, unt de arahide,
arahide, semin
semine, fistic
Cereale integrale Cereale, pâine neagr,
neagr, orez
brun
Carne ro hamburger, carne Mai pu
roie i produse de Hot dog, hamburger, puin decât aportul
carne de vit mediu (por
(porii/zi)
Pe
Pete Pe
Pete, creve
crevei Mai mult decât aportul
mediu (por
(porii/zi)
Raportul lipide
mononesaturate / saturate
Alcool Vin, bere, lichior 5-25 grame / zi

O puncte dac nu este îndeplinit criteriul

Scorul Dietei Mediteraneene


• Punctaj de 7-
7-9 - aderen
aderen crescut.
crescut.
• Pentru cei care ader la acest tip de alimenta
alimentaie,
o cre
cretere cu 2 puncte a scorului este asociat
cu ameliorri semnificative ale strii generale de
sntate,
sntate, prin
– reducerea cu 9% a mortalit
mortalitii de orice cauz
i de cauz cardiovascular
– cu 6% a mortalit
mortalitii prin cancer.

33
CURS DE NUTRIIE CLINIC

Conf. dr. IOAN ANDREI VERESIU


Univ de Med si Farm “Iuliu Hatieganu”
Centrul Clinic de Diabet, Nutritie si Boli Metabolice
Cluj-Napoca

Fapte...
(Bakker K, Riley P. The year of the diabetic foot. Diabetes Voice; 2005; 50:11-14)

 Undeva în lume se pierde un picior la fiecare 30 de sec din


cauza diabetului;
 Problemele picioarelor sunt cel mai frecvent motiv de internare
pentru pacienii cu diabet;
 Se estimeaz c, în rile în curs de dezvoltare, problemele
picioarelor “consum” pân la 40% din bugetele pentru
îngrijirea sntii;
 Majoritatea amputaiilor sunt precedate de ulceraii ale
picioarelor;
 Fiecare al 6-lea pacient cu diabet va avea o ulceraie a
picioarelor pe parcursul vieii;
 S-a demonstrat faptul c pân la 85% dintre amputaii pot fi
prevenite.

Bakker K, Riley P. The year of the diabetic foot. Diabetes Voice; 2005; 50:11-14

Diabetic Foot Disorders. A Clinical Practice Guideline. The Journal of Foot&Ankle Surgery. september/october ,
volume 45, number 5, 2006

34
CURS DE NUTRIIE CLINIC

Interventii nutritionale

• adresate factorilor de risc (neuropatia,


arteriopatia)

• leziunilor constituite

”Abordarea in echipa”

• Diabetologul – pacientul nostru !

• Chirurgul vascular – boala noastra !

• Cardiologul interventionist – procedura noastra!

• Patientul – piciorul meu !

• Nutritionistul ?

35
CURS DE NUTRIIE CLINIC

Nutrienti evaluati in
tratamentul neuropatiei
diabetice

Head AK. Altern Med Rev


2006;11(4):294-329

• one vitamin B complex capsule (50 mg of B1, 50 mg of B2, 50


mg of Niacin, 50 mg of B6, 400 mcg of folic acid, 50 mcg of
B12, 50 mcg of biotin and 50 mg of pantothenic acid).
• 1000 mg of vitamin C;
• 400 IU of vitamin E;
• 100 mcg of B12;
• 6o mg of alpha lipoic acid;
• 1000 mg of evening primrose oil;
• 50 mg zinc;
• 50 mg of selenium;
• one multivitamin/multimineral supplement mainly for trace
minerals ( 2 mg cooper, 2 mg manganese, 150 mcg chromium, 75
mcg of molybdenum).

Indicatori biochimici ai deficitului de proteine

Indicatorul Usor Moderat Sever

Albumina 2.8-3.5 2.1-2.7 <2.1


g/dL
Prealbumina 10-15 5-10 <5
mg/dL
Retinol 4-6 2-4 <2
Binding
Protein
mg/dL

36
CURS DE NUTRIIE CLINIC

Indicatori biochimici pentru anemiile nutritionale


Indicatorul Anemii Anemia Deficitul Deficitul
feriprive din bolile de ac folic de vit B12
cronice

Hb/Ht scazut scazut scazut scazut

VEM scazut normal crescut crescut

FOLATE _ _ scazut Normal sau


crescut

B12 _ _ normal scazut

FERRTIN scazut scazut crescut crescut

Interventii nutritionale la pacientii cu ulceratii ale


picioarelor

Necesarul caloric precis pentru optimizarea procesului de vindecare nu este


stabilit.

• La pacientii cu malnutritie s-a constatat diminuarea acumularii de


hidroxiprolina (un indicator al colagenogenezei) in microtuburi de
polytetrafluoroethylen implantate subcutan, conparativ cu pacientii cu
stare normala de nutritie.
• Malnutritia se coreleaza clinic cu frecventa complicatiilor ulceraiilor si
intarzierea vindecarii.
• Deficitul de arginina reduce sinteza si rezistenta fibrelor de colagen
• Aport proteic zilnic de min 1,5g proteine si 17-24g arginina (si 10-20g
glutamina ?)

Vitaminele si micronutrientele

• Nu exista argumente clare privind beneficiul administrarii de vitamine


si minerale la pacientii cu DZ care nu au deficite de alte cauze;
(A)
• Adminitrarea de rutina de antioxidanti, vit C, E si caroten, nu este
recomandata datorita lipsei evidentelor privind beneficiul si datorita
retinerilor privind siguranta pe termen lung;
(A)
• Beneficiile suplimentelor cu crom in tratamentul DZ si al obezitatii nu
au fost demonstrate si deci nu sunt recomandate.
(E)

Nutrition Recommendations and Interventions for Diabetes–2006, A position statement of the American Diabetes
Association. Cinical Practice Recommendations. Diabetes Care, 2008

37
CURS DE NUTRIIE CLINIC

Curs Nutriie, Iai, 10 nov. 2013

Educaia terapeutic în
sindromul metabolic

Cornelia Bala, MD, PhD


cbala@umfcluj.ro

Conceptul de educaie terapeutic

• ET este un proces de educaie gestionat


de personalul medical instruit în educarea
pacienilor i care d posibilitatea
pacientului (sau unui grup de pacieni i
familiilor lor) de a fi implicai în
managementul propriei boli i de a preveni
complicaiile acesteia, concomitent cu
meninerea sau îmbuntirea calitii vieii

WHO. Regional Office for Europe, Copenhagen. (1998). Report of a WHO


Working Group. Therapeutic Patient Education. Continuing education
programmes for healthcare providers in the field of prevention of chronic
diseases.

Conceptul de educaie terapeutic


• Scopul principal al ET este de a produce
un efect terapeutic adiional celui produs
de alte intervenii (farmacologice, de
reabilitare, etc).

Bala C. Educaia terapeutic în bolile metabolice populaionale. În Hancu N, Roman


G, Vereiu IA. Diabetul zaharat, Nutriia i Bolile metabolice- Tratat, vol 1, 2010

38
CURS DE NUTRIIE CLINIC

Conceptul de educaie terapeutic


• Scopurile specifice ale ET sunt:
– Însuirea de ctre pacient a deprinderilor legate
de adaptarea tratamentului la condiiile sale
specifice
– Însuirea deprinderilor i proceselor prin care
poate face fa provocrilor bolii
– Oferirea de ajutor specializat pentru ca pacientul
i familia sa s îneleag boala i tratamentul
acesteia, s coopereze cu echipa de îngrijire

Bala C. Educaia terapeutic în bolile metabolice populaionale. În Hancu N, Roman


G, Vereiu IA. Diabetul zaharat, Nutriia i Bolile metabolice- Tratat, vol 1, 2010

Conceptul de educaie
terapeutic
Educaia terapeutic are trei obiective principale:

A. transmiterea de cunotine

Bala C. Educaia terapeutic în bolile metabolice populaionale. În Hancu N, Roman


G, Vereiu IA. Diabetul zaharat, Nutriia i Bolile metabolice- Tratat, vol 1, 2010

Curricula de cunotine în SMet


• Ce este sindromul metabolic/ definiie
• Care sunt factorii de risc pentru apariia sindromului
metabolic
• Riscurile asociate sindromului metabolic - BCV i
diabet zaharat tip 2
• Cum se poate controla sindromul metabolic:
– Dieta i activitatea fizic pentru reducerea greutii i
efectele antiaterogene
– Medicamente adresate unora din componentele SMet

39
CURS DE NUTRIIE CLINIC

Conceptul de educaie
terapeutic
Educaia terapeutic are trei obiective principale:

B. deprinderea de abiliti

Bala C. Educaia terapeutic în bolile metabolice populaionale. În Hancu N, Roman


G, Vereiu IA. Diabetul zaharat, Nutriia i Bolile metabolice- Tratat, vol 1, 2010

Conceptul de educaie
terapeutic
Educaia terapeutic are trei obiective principale:

C. modificarea comportamentelor (de exemplu cele


legate de modul de alimentaie, practicarea
exerciiului fizic, administrarea corect a
tratamentului, etc).

Bala C. Educaia terapeutic în bolile metabolice populaionale. În Hancu N, Roman


G, Vereiu IA. Diabetul zaharat, Nutriia i Bolile metabolice- Tratat, vol 1, 2010

Modelul proceselor din ET

Golay A, Lagger G, Chambouleyron M. Therapeutic education of diabetic patients. Diabetes


Metab Res Rev 2008; 24: 192–196

40
CURS DE NUTRIIE CLINIC

ET în SMet-
evidene

A total of seventy-one adults who met diagnostic criteria for the


metabolic syndrome were randomly assigned to either the single-
visit group or the in-depth nutrition education group during a 3-
month intervention study period.
The in-depth telephone-delivered nutrition education group had an
initial visit with a dietitian and additional two telephone counseling
during the first 4 weeks of the study periods.

At the end of the trial, the in-depth nutrition education group showed
significantly higher reduction in weight, body fat and abdominal
circumference compared with the other group (p < 0.05). In the in-
depth nutrition groups, the prevalence of metabolic syndrome was
decreased to 45.5%, while 69.7% of the subjects were metabolic
syndrome patients in the single-visit group (p < 0.05).

Thérapie 2013 Mai-Juin; 68 (3): 163–167 Observation of the Long-term


Effects of Lifestyle Intervention during Balneotherapy in Metabolic
Syndrome

Methods. Observational pilot cohort study with 12-month


follow-up after multidimensional lifestyle training
(physical, dietary, educational) during 3-week standard
stay in the spa town of Eugénie-les-Bains.
Results. Of 145 eligible patients, 97 were included; 63
were followed and analysable. At inclusion all had 3
National cholesterol education program-Adult
treatment panel III (NCEP-ATPIII) criteria defining
metabolic syndrome, 76.2% were female, mean age
was 61.2 years.
At the end of follow-up (median:10.4 months, Inter-
Quartile Range: [6.7;11.4]), 48 of these 63 patients
(76.2%) no longer had metabolic syndrome (95%CI
[65.7;86.7]). These 48 patients without metabolic
syndrome at the end of follow-up represented 49.5% of
the 97 included (95%CI [39.5;59.4]).

Conclusions. Future studies of lifestyle interventions


taking advantage of the spa environment can be
expected to find least one third of patients free of
metabolic syndrome at the end of 12-month follow-up
in the intervention group.

41
CURS DE NUTRIIE CLINIC

Nutri ia în dislipidemii

Prof.univ.dr. Mariana GRAUR


UMF ”Grigore T. Popa”
Iai, 2013

Factori care contribuie la riscul cardio-metabolic

Brunzell, J. D. et al. J Am Coll Cardiol 2008;51:1512-1524

Disfuncia esutului adipos i contribuia sa


la sindromul cardio-metabolic

• Adiposity and TGs


• Lipoprotein disorders, hypertriglyceridemia, and adiposity
• Associations with CVD risk
• Adiposity and HDLs
HDL as regulator of islet cell insulin secretion
• Adiposity and LDLs
• Bariatric endocrinology and the management of
adiposopathy

Harold E. Bays et al. Journal of Clinical Lipidology 2013; 7, 304–383

42
CURS DE NUTRIIE CLINIC

Biomarkerii adiposopatiei

• Hyperinsulinemia/hyperglycemia
• High TG/low HDL-C
• Elevated free fatty acids
• Elevated leptin
• Decreased adiponectin
• Increasing leptin to adiponectin ratio over time
• Increased TNF-a
• Activation of renin-angiotensin-aldosterone
• Hypoandrogenemia in men
• Hyperandrogenemia in women

Harold E. Bays et al. Journal of Clinical Lipidology 2013; 7, 304–383

Adiposopathy: simplified relationship between pathogenic


adipose tissue and cardiovascular disease

Harold E. Bays et al. Journal of Clinical Lipidology 2013; 7, 304–383

LDL- i Non-HDL-colesterol:
inte terapeutice
• LDL: lipoproteina aterogenic major
• VLDL : lipoproteina aterogenic suplimentar
• Non-HDL: LDL + VLDL
• LDL-C: obiectivul primar tradiional al interveniilor
clinice
• Non-HDL-C: int adecvat pentru intervenii clinice

2013 International Atherosclerosis Society (www.athero.org)

43
CURS DE NUTRIIE CLINIC

Avantajele Non-HDL-C ca int pentru


intervenii clinice:

- Suma tuturor lipoproteinelor aterogene


- Nu are nevoie de recoltare pe nemâncate pentru o msurare
precis
- Subsumeaz cele mai multe cazuri de hipertrigliceridemie
- Are dovezi pentru o mai mare putere predictiv decât LDL-C
- Este echivalentul apolipoproteinei B ca putere de predicie

2013 International Atherosclerosis Society (www.athero.org)

Nivelurile optime ale LDL-C i ale


non-HDL-C în prevenia primar

--LDL-C < 100 mg/dl (2,6 mmol/L)


- Non-HDL-C < 130 mg/dl (3,4 mmol/L)

• Nivelul optim nu înseamn int a terapiei


• Obiectivele reducerii nivelului de colesterol sunt determinate de
judecata clinic
• Se acord prioritate categoriilor de risc pe termen lung asupra
riscului pe termen scurt
• Accent primar pe interveniile asupra stilului de via, accent
secundar pe terapia medicamentoas

2013 International Atherosclerosis Society (www.athero.org)

Nivel optim de colesterol aterogen vs inta


terapeutic:
• Nivelul optim este acela care produce o reducere maxim a
riscului prin terapiile disponibile
• Obiectivele tratamentului depind de judecata clinic si sunt
bazate pe eficacitatea scontat, pe cost-eficien, i sigurana
tratamentelor disponibile
• Când terapiile medicamentoase sunt deja incepute, nivelele
optime reprezint, de obicei, un obiectiv rezonabil de terapie

2013 International Atherosclerosis Society (www.athero.org)

44
CURS DE NUTRIIE CLINIC

Terapii nutriionale având ca int lipidele totale

- Se recomand flexibilitate, inând cont de preferinele


culturale: 20-25% din totalul caloriilor în zona Pacificului i
30-35% în dieta mediteranean
- Orice plus fa de recomandare trebuie s fie grsime
nesaturat
- Indiferent de coninutul total în grsimi a dietei, ea trebuie s
fie adecvat pentru a menine greutatea corporal recomandat

Recomandri nutriionale
• Terapii nutriionale având ca int scderea LDL-C
- Reducerea lipidelor saturate la < 7% din totalul caloriilor i cel puin la < 10%
- Scderea lipidelor trans la < 1% din totalul caloriilor
- Reducerea colesterolului alimentar la < 200 mg/zi
Alte recomandri nutriionale:
- Consum crescut de legume i fructe bogate în fibre alimentare
- Înlocuirea excesului de grsimi saturate cu carbohidrai cu index glicemic mic
sau MUFA/PUFA
- Consum de pete bogat în acizi -3
- Consum de alimente srace în sodiu i bogate în potasiu
- Alte alimente cardioprotective cum sunt nucile i seminele, steroli/stanoli
(din plante) 2g/zi
- Consum de alcool în limitele permise

Factori implicai în dezvoltarea aterosclerozei

Mariarita Dess et al, Hindawi Publishing Corporation. ISRN Inflammation 2013

45
CURS DE NUTRIIE CLINIC

De la “sarea în bucate”
la dietele hiposodate
ef lucrri Dr. Bogdan Mihai
Universitatea de Medicin i Farmacie “Gr.T.Popa” Iai
Centrul Clinic de Diabet, Nutri
Nutriie i Boli Metabolice Ia
Iai

Rolurile sodiului în organism

• Reglarea tensiunii arteriale, a volumului sanguin i a


fluidului extracelular
• Transmiterea impulsurilor nervoase
• Metabolizarea glucidelor i a proteinelor
• Reglarea echilibrului acido-bazic
• Interacioneaz cu ali ioni (potasiu, calciu, clor) pentru
meninerea echilibrului hidroelectrolitic

Excesul de sodiu

• În preistorie aportul zilnic de sodiu era de aprox. 690 mg


(148 mg din vegetale i 542 mg din carne)
• Astzi FDA recomand un aport zilnic de sodiu de 2400
mg (= 6 g clorur de sodiu = o linguri de sare)
• Astzi o diet considerat hiposodat conine de 3,5 ori
mai mult sare decât era consumat în paleolitic
• Aportul mediu de sare în lumea industrializat – 10 g/zi
(3900 mg sodiu)

46
CURS DE NUTRIIE CLINIC

Surse de sodiu în diet

Sarea
natural din
Sarea alimente 10%
adugat
de productor Sarea
75% adugat de
consumator
15%

Mattes and Donnelly. JACN 1991; 10: 383

Recomandri pentru aportul de sodiu


SUA i OMS (mg/zi)

“US 2005 Dietary Guidelines”

Populaia general < 2300

Hipertensivi, negri, aduli peste 45 ani < 1500

Organizaia Mondial a Sntii < 2000

Sodiul i hipertensiunea arterial


• Secolul II î.Chr. – China antic: “dac se pune mult sare în
mâncare, pulsul se întrete”
• 1836 – Richard Bright – studii morfopatologice pe 100
pacieni care au decedat de boal renal: “când rinichii sunt
mici, cordul este, de obicei, crescut” (indicator al HTA)
• 1904 – L. Ambard & E. Beaujard: “TA scade dac se
reduce aportul de sare i crete odat cu creterea
aportului de sare”
• 1944 – W. Kempner – “o diet hiposodat scade TA i
volumul cardiac chiar i în cazurile de HT malign”
• Sfâritul anilor ’50 – diureticele scad TA prin creterea
excreiei de sodiu i de ap
• Sensibilitatea la sare variaz de la o persoan la alta

47
CURS DE NUTRIIE CLINIC

Factori asociai cu creterea sensibilitii la sare

• Factori nemodificabili
– Afro-Americani
– Persoane vârstnice
– Factori genetici
– Persoane cu: HTA
Diabet zaharat
Insuficien renal cronic

• Factori modificabili
– Aport redus de potasiu
– Diete dezechilibrate

Factorii genetici implicai în creterea


sensibilitii la sare

• Sensibilitatea la sare a TA este legat de o regiune


specific din cromozomul 18
• Rspunsul la sare al TA are caracter familial
• Marker al sensibilitii la sare – un anumit fenotip al
haptoglobinei
• Afro-Americanii sunt mai sensibili la sare decât albii
– excreia de sodiu este mai puin eficient
– activitatea reninei plasmatice este diminuat

Renina plasmatic redus ar putea fi un marker al
sensibilitii la sare

Schimbarea obiceiurilor alimentare


legate de sodiu

• Adaptarea treptat la o diet cu mai puin sare


introducând treptat în alimentaie produse cu un coninut
sczut de sodiu

• La început, alimentele vor prea fr gust, ulterior


persoana respectiv va ajunge s prefere acele alimente
cu mai puin sodiu

• În timp, alimentele procesate industrial i mâncarea de


restaurant vor prea prea srate

48
CURS DE NUTRIIE CLINIC

Incretinele în reglarea
ponderal
ef lucr.dr. Gina BOTNARIU
UMF ”Grigore T. Popa”
Iai, noiembrie 2013

The Incretin Effect in Healthy Subjects (1964)


Oral Glucose
Intravenous (IV) Glucose

*
200 2.0
*
*
Plasma Glucose (mg/dL)

C-peptide (nmol/L)

1.5 * Incretin Effect


*
*
100 1.0

*
0.5

0 0.0
0 60 120 180 0 60 120 180
Time (min) Time (min)

N = 6; Mean ± SE; *Pd0.05


Adapted from Nauck MA, et al. J Clin Endocrinol Metab. 1986;63:492-498.

Incretin Secretion and DPP-4-Mediated Metabolism

DPP-4
Dipeptidyl peptidase-4
GLP-1
t/2 1-2min
GIP
t/2 7 min

DPP-4
Dipeptidyl peptidase-4

49
CURS DE NUTRIIE CLINIC

Semnale periferice care mediaza reglarea


centrala a aportului alimentar
• Glucagon-like peptides (GLP-1 and GLP-2)
- secretate ca raspuns la nutrienti
- reduce glicemia si apetitul prin multiplele efecte
asupra golirii gastrice
• Cholecystokinin
• Bombesin
• Gastric Inhibitory Peptide
• Enterostatin
• PYY

A diagrammatic representation of the complex interrelationship between peripheral and central
(hypothalamic) neuropeptides for regulation of feeding. Stimulation by orexigenic pathways results in food
intake;stimulationofanorexigenic pathwaysleadstosatiety.Continuouslinesrepresentstimulatingpathways,
broken lines indicate suppressive actions. NPY, neuropeptide Y; AgRP, argouti related peptide; POMC, pro
opiomelanocortin; PYY, peptide YY; Y21, Y2R, postsynaptic NPY receptors; Cart, cocaine amphetamine
regulatedtranscript;MC3R,MC4R,melanocortin receptor3and4;MCH,melaninconcentratinghormone;GLP
1,glucagonlikepeptide.

Kopelman,PGetal.Gut2004;53:10441053

Copyright©2004BMJPublishingGroupLtd.

50
CURS DE NUTRIIE CLINIC

UNIVERSITATEADEMEDICINIFARMACIE
”GrigoreT.Popa” – IAI

Nutriia în chirurgia metabolic

ef lucrri dr. Laura MIHALACHE

Al 5-lea curs de nutriie clinic pentru rezideni i tineri medici


Iai, 2013

“To Cut or Not To Cut”

• Terapia nutriional - 5-10% pierdere exces ponderal

• Tratament farmacologic ??? - 8-10% pierdere exces


ponderal

• Chirurgie metabolic - 60-80% pierdere exces ponderal

Posibiliti terapeutice în bolile


cardiovasculare

Stildevia Cardiologie Chirurgie


Tratamentfarmacologic intervenional  (bypassaorto coronarian)
(angioplastie,stent)

Posibilititerapeuticeîndiabetzaharattip2

Stildevia Diabetologie Chirurgie


Tratamentfarmacologic intervenional (dispozitive (procedurigastro
gastro intestinale intestinale)
endoluminale)

51
CURS DE NUTRIIE CLINIC

Chirurgia bariatric
25000

20000

15000
1998
2002
10000

5000

0
12-17 18-34 35-44 45-54 55-64 >65

grup de vârst

Health Affairs, July/Aug 2005

Proceduri
chirurgicale
practicate

Beneficiile
chirurgiei
bariatrice

BrethauerSAetal.2006

52
CURS DE NUTRIIE CLINIC

Beneficiile scderii ponderale vs risc


nutriional

70
60
50
40

30

20
10

0
Band Gastroplasty GBP DS

pierdere exces ponderal mortalitate deficit de B12

Poteniali candidai pentru chirurgie


bariatric
• IMC  40 kg/m2 sau IMC  35 kg/m2 cu patologie important
asociat obezitii
• Risc operator acceptabil
• Demonstrarea ineficienei programelor ”nechirurgicale” de scdere
ponderal
• Pacient stabil din punct de vedere psihologic, cu ateptri realiste
• Pacient bine informat i motivat
• Suport familial i social adecvat
• Absena afeciunilor psihotice sau depresive
• Absena consumului excesiv de alcool sau a consumului de droguri

53
CURS DE NUTRIIE CLINIC

Riscul de deficite nutriionale

Parametru RYGBP DS
nutriional
Proteine 4.7% 3-5%
Calciu 15-43% 15-57% 1 an
63% 4 ani
Fier 33-50% 1 ani 35-74% 3 ani
49-52% 3 ani
Feritina 44-50% 44-50%
Albumina 2% 2%
Anemie 35-74% 5 ani 35-74% 5 ani

Riscul de deficite nutriionale

Parametru RYGBP DS
nutriional
B12 12-33% 33%
Tiamina “frecvent” “frecvent”
Folat 12% 12%
Vitaminele A, E, K “frecvent” A - 69%, E - 4%, K -
Vitamina D >30% 68%
30 -63%
Zinc “frecvent” “frecvent”

Alte complicaii nutriionale

• Hipoglicemia

• Deficit de vitamina C

• Deficit de seleniu, cupru

• Malnutriia protein-caloric sever

• Scderea ponderal accelerat

• Deshidratare

54
CURS DE NUTRIIE CLINIC

Alcoolul si sindromul
metabolic
Raluca Maria Popescu

WHO Global Status Report 2011

Efectele alcoolului asupra


organismului

• Alcoolul afecteaz
toate organele
organismului uman,
având efecte nocive
asupra sntii
umane.

• “Alcoolul îi face s
triasc pe cei ce-l
vând, dar i s moar
pe cei ce-l beau”
» Anatole France

55
CURS DE NUTRIIE CLINIC

Patternuri ale
consumului de
alcool

Kauhanen et al, BMJ, 1997

Relatia Concentratie-Efect

Alcoolemie Efecte
[%]
0.02-0.03 Usoara relaxare musculara; buna dispozitie
0.05-0.06 Relaxare,incalzire; timp de reactie crescut; scaderea
coordonarii musculaturii fine
0.08-0.09 Tulburari de echilibru, vorbire, vedere,auz, coordonare
musculara; euforie
0.14-0.15 Afectare importanta a controlului mental si fizic
0.20-0.30 Intoxicatie severa; control minim asupra corpului
0.40-0.50 Pierderea starii de constienta; coma adanca; moarte prin
deprimarea centrilor respiratori

Beneficiile alcoolului

Ifadultswithdiabeteschoosetousealcohol,theyshouldlimit intaketoamoderateamount
(onedrinkperdayorlessforadultwomenandtwodrinksperdayorlessforadultmen)

DiabetesCare,Vol 36,Supplement1,Jan2013

56
CURS DE NUTRIIE CLINIC

“It has long been recognized that the problems


with alcohol relate not to be use of a bad
thing, but to the abuse of a good thing”
AbrahamLincoln

• “ Sabie cu doua taisuri”


– Consum moderat reduce riscul de CHD si
mortalitatea de toate cauzele
– Consumul excesiv – a treia cauza de moarte
prematura

+ =

Motivul:Vinul rosu reduceBoala coronariana


•Paradoxul francez
•Etanol,resveratrol,flavonoide

Curba J
• Consumul moderat de vin si boala cardiovasculara – curba J

J
Cresterea BCV

1 4(4oz)
pahare devin
Cresterea consumului

57
CURS DE NUTRIIE CLINIC

FRUCTOZA:
GUSTUL DULCE AL... PERICOLULUI

ef lucrri dr. Cristina Lctuu


Universitatea de Medicin i Farmacie ”Gr.T. Popa” – Iai

Iai, 9 noiembrie 2013

Metabolismul fructozei (1)

• Celulele nu utilizeaz fructoza ca surs de energie


• Dirijat imediat ctre ficat  metabolizat cu ajutorul
fructokinazei  consum de ATP i generare de acid
lactic i acid uric
• unteaz conversia G-6-P la F-1,6-P2 controlat de
fosfofructokinaz  producie necontrolat de
glucoz, glicogen, lactat i piruvat
• Determin up-reglarea Glut-5 i fructokinazei

Metabolismul fructozei (2)

• Conversie hepatic la AG  transport (ca AGL sau


TG) i stocare
• Stimuleaz sinteza hepatic de TG
• Suprim activitatea acil-CoA i acil-carnitinei i sti-
muleaz piruvatdehidrogenaza  celulele utilizeaz
glucoza ca substrat energetic i stocheaz AG
• Nu activeaz LPL adipocitar

58
CURS DE NUTRIIE CLINIC

Metabolismul fructozei (3)

• Determin formarea AGE (10 x glucoza) – rezisteni


la degradare
• Crete oxidarea LDL-colesterolului
• Nu stimuleaz / inhib eliberarea de insulin i
leptin
• Induce creterea rezistenei la insulin i leptin
• Nu inhib eliberarea de ghrelin
• Reduce senzaia de saietate i crete apetitul

Metabolismulfructozei

Consumulcronicdefructozihiperuricemia

Johnson RJet al. EndocrineRev2009;30(1): 96 116

59
CURS DE NUTRIIE CLINIC

Efecte experimentale ale încrcrii cu


fructoz
Fructoza induce modificri compatibile cu SM:
• Obezitate abdominal
• Insulinorezisten
• Creterea TG
• Creterea TA Efectedistinctede
• Inflamaie celealeglucozei!
• Stress oxidativ
• Disfuncie endotelial
• Boal microvascular
• Hiperuricemie / gut
• Hipertensiune glomerular
• Steatoz hepatic
Sanchez-Lozada L. Am J Clin Nutr 2008; 88: 1189-1190

Efecteleclinicealeconsumuluicronicde
fructoz
Adaptarea metabolic la expunerea cronic la
fructoz:
• Creterea cantitativ a Glut-5
• Creterea cantitativ a fructokinazei

Rezultanta:
• Cantiti reduse de fructoz  perpetuarea
anomaliilor metabolice (insulinorezisten, creterea
TG, hiperuricemie etc.)

Efecteclinicealeconsumuluicronicdefructoz

JohnsonRJ.EndocrineRev2009;30(1): 96 116

60
CURS DE NUTRIIE CLINIC

Programarea nutritionala a
insulinorezistentei
Asist. Univ. Alina Delia Popa
UMF “ Gr. T. Popa “ – Iasi
Centrul Clinic Diabet, Nutritie si Boli Metabolice
Iasi

Programarea fetala
• Programarea -
procesul prin care un
stimul sau un factor
nociv, care acioneaz
într-o perioad critic a
dezvoltrii, determin
efecte pe întreaga
durat a vieii.

RASPUNSUL ADAPTATIV

MEDIU MEDIU ADULT


INTRAUTERIN POSTNATAL

Nutritie adecvata Nutritie adecvata ADULT


SANATOS

Nutritie deficitara MALNUTRITIE

SINDROM
Nutritie adecvata
METABOLIC

Nutritie deficitara Nutritie deficitara MALNUTRITIE

61
CURS DE NUTRIIE CLINIC

Studii epidemiologice
• identifica grupele de aduli • Hertfordshire Study
a cror greutate a fost • Dutch Hunger Winter Study
precis determinat la • Chinese Famine study
natere • Leningrad Siege Study
• Permit corelaii cu
afeciunile cronice, au
relevat asocieri între
greutatea la natere i
afeciuni cu debut dup
câteva decade de via

Modificari ale aportului alimentar

Dieta Hipoproteica Hiperglucidica Hiperlipidica

Aminoacizi Zahar, Acizi grasi


Thyr, Met, gli Glucoza, fructoza SAT, MUFA, PUFA
Tau etc.. TFA

sarcina
Hipoproteica/ izocalorica hiperlipidica/izocalorica

izocalorica
alaptare Hipoproteica/ hiperglucidica hiperlipidica/izocalorica

izocalorica
intarcare hiperglucidica hiperlipidica/izocalorica
hiperlipidica

HTA Hiperinsulinism Hiperinsulinism


Insulinorezistenta Obezitate HTA
VARSTA Steatoza Obezitate
Pancreas – disfunctie
ADULTA cel.
(Armitage et al, J. Physiol 2004)

62
CURS DE NUTRIIE CLINIC

Epigenetica: Cheia Mecanismelor


Programarii Fetale?

• Epigenetica studiaz fenomenele biochimice care


permit acidului dezoxiribonucleic s se exprime într-o
manier diferit, graie activrii sau reprimrii
anumitor gene, dar fr a provoca schimbri la nivelul
secvenei genice.

• Mecanisme ale proceselor epigenetice: metilarea


acidului dezoxiribonucleic (ADN), modificarea
histogenetic, repoziionarea nucleosom,
remodelarea cromatinei, non-codarea acidului
ribonucleinic (ARN)

Epigenetica si obezitatea:
Waterland Mouse Studies

oareciiobeziproducurmasiobezi, darsuplimentarea cu donatori


demetilîmpiedicacestefect
Greutatea materna

alimente +donori metil

alimente

Greutatea urmasilor (a3ageneratie)

Waterland RAetal.Int JObes 2008

63