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1

.

I-Introduction

• Main risk factors associated

with chronic diseases in Brazil

*VIGITEL Brazil 2006 - www.saude.gov.br / bvs # Hearts of Brazil Atlas / SBC; 2005

Prevalence of risk factors

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2

%

+76,5

-36,6

MONTEIRO C & CONDE WL. Brazilian Archives Endocrinology Metabolism 1999; 43: 1586-196.

NUTRITION TRANSITION

ENDEF (N=89.772), 1975 VERSUS PNSN (N=14.602), 1989

malnutrition

0

2

4

6

8

10

12

14

16

18

20

Men Women

1975

1989

2003

2009

Source: Instituto Brasileiro de Geografia e Estatística. National Household Budget Survey 2008-2009:

Nutritional Status in Brazil. Rio de Janeiro, Brazil: IBGE, 2010

Secular trends of obesity %

In the young population:

Prevalence of overweight: 63%

Frequent presence of subclinical atherosclerosis,

Risk for obesity in the long term, statistically verified by the

increase in abdominal circumference and a positive correlation

with BMI.

CASSANI, R. S.L. et al. Arq Bras Cardiol 2009; 92:16-22.

INGELSSON, E. et al. Circulation 2007; 116: 375-384.

Overweight and obesity:

Epidemiologic study in Brazil

50

60

70

80

90

100

110

120

130

140

3 4 5 6 7 8 9 10 11 12

Abdominal Waist (cm)

Fasting - Dinner (Hours)

p =0,021

r= 0,230

Malerbi D et al. Diabetes Care, 1992;15:1509

Distribuição por grupo etário

2,7

5,5

12,6

17,4

7,5

%

Distribution by age group

30-39 40-49 50-59 60-69 70-79

GI and DM: Epidemiologic study in Brazil

High prevalence of subjects with GI: 40%.

• Overweight and GI:

Greater possibility of future occurrence of diabetes by maintaining lifestyle

habits inadequate.

American Diabetes Association. Diabetes Care 2007; 30: S42-S47.

CASSANI, R. S.L. et al. Arquivos Brasileiros de Cardiologia 2009; 92:16-22.

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3

0

5

10

15

20

25

30

35

55 65 75 85 95 105 115 125

Fatt

y ac

id n

-3 (

g)

Glycemia (mg/dl)

32,1

14,5 15,3

11,0

5,5

21,7

Cardiovascular Disease

External causes

Cancer

Respiratory Disease

Infectious and parasitic

Diseases

Other+ Perinatal

%

• Mortality Brazil – 2001

Adapted data from MS / Funasa / CENEPI - Information System (SIM) - published in Jan 2004

0,00

0,10

0,20

0,30

0,40

0,50

0,60

0,70

0,80

0,90

50 100 150 200 250 300

Fatt

y ac

id n

-6 (

% k

cal V

CT)

Triglycerides (mg/dl)

• Household Budget Surveys (Programa de Orçamento Familiar- POF):

Sources of food consumption indicators,

Increasing use in developing countries.

• POF – 2003:

Evaluation of national availability of food.

• POF-2008/2009:

Evaluation of the individual consumption.

LEVY-COSTA, R. B. et al. Journal of Public Health 2005; 39: 530-540.

Alteration of food consumption

• The average per capita consumption (g / day) in rural areas was higher for traditional Brazilian foods, such as rice, beans, sweet potates, cassava flour, fresh and salted fish and salted meat

• In urban areas it is highlighted the consumption of ready-to-eat and processed: salt bread, sandwiches, deep-fried snacks, stuffed biscuits, pizzas, sodas, juices and beers.

Rice, Beans,

Corn and preparations,

Lettuce, Cabbage, Raw

salad , Pumpkin, Carrot,

Cucumber, Tomato

Potato, Cassava

Other tubers,

Pineapple, Banana,

Orange

Apple, Papaya,

Watermelon, Grapes

Other fruits

POF: Brazil 2008-2009

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Juices

23%

40%

83% reported using sugar

to sweeten juices

and coffee

Data source: National Dietary Survey 2008-2009, Brazil, day 1, weighted

Per capita consumption of beverages in the diet of selected adolescents, adults

and the elderly - Brazil-period 2008-2009

Source: IBGE, Research, Coordination of Work and Income, Household Budget Survey 2008-2009

adolescents adults elderly

soda Juice and

refreshments Yogurt Milk integral Milk drink

0

2

4

6

8

10

12

14

16

18

4 4,5 5 5,5 6 6,5 7

Fructose (mg)

Glycated Hemoglobin (%)

p= 0,033

r =0,346

Consumption of food items selected in adolescents, adults and elderly

Source: IBGE, Research, Coordination of Work and Income, Household Budget Survey 2008-2009.

adolescents adults elderly

Stuffed biscuit cheese Salada raw Sandwiches

g/day

Data source: National Dietary Survey 2008-2009, Brazil, day 1, weighted

Mean intake of specific foods/food groups according to quartiles of income Average intake of sodium

Data source: National Dietary Survey 2008-2009, Brazil

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Food groups most consumed away from home

Data source: National Dietary Survey 2008-2009, Brazilian urban areas, day 1, weighted

Changes in diet POF 2003

• CH: the kind of it is worrying !

1/5 of CH diet (12% to 56%): rapid absorption CH

Sugar and derivatives: maximum 10% of the VCT.

• FAT:

Maximum limit was exceeded!

Saturated fat: increase between the surveys (maximum 7% of the VCT)

• POF 2003: 9.6%.

• PTN:

Percentage of calories suitable for the VCT.

YOKOO, E. M. et al. Journal of Nutrition 2008; 21: 767-776

Changes in diet

Increasing the quality and decreasing the amount.

• Food problem was basically deficient and quantitative.

ENDEF 1974-1975

• Excessive caloric intake

• Lack of Fe, Ca and Vit A and other micronutrients

35 years later

Very common

Uncommon

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Evaluations Time 1 Time 2 Time 3 Time 4 Time 5

Weight (kg) 96,4 85,4 80,4 76,1 75,2

Abdominal

circumference (cm) 110 99 94 90 88

Waist circumference

(cm) 110 104 99 99 97

Midarm circumference

(cm) 35 30 28 28 28

Biceps skinfold

thickness (mm) 09 09 05 04 04

Triceps skinfold

thickness (mm) 11 10 10 06 06

Subscapular skinfold

thickness (mm) 32 21 17 14 14

Abdominal skinfold

thickness (mm)

≥ 67 25 20 15 15

Interval time: 30 days

Time Glycemia

(mg/dL)

CT

(mg/dL)

HDL -c

(mg/dL)

LDL-c

(mg/dL)

TG

(mg/dL) Uric acid

(mg/dL)

1 163 231 41 155 173 7,6

5 97 160 44 104 62 5,2

Time 1: pre-intervention

Time 5: post-intervention

CT: Total cholesterol ; LDL-c: Low density lipoprotein cholesterol; HDL-c: High denisty lipoprotein cholesterol;

TG: triglycerides; mg/dL: miligrams/decilitres.

ELETRIC BIOIMPEDANCE

Percentage (%) Time 1 Time 5

Fat 24 15

Lean Mass 76 85

Water 54 63

Goal

Variation (kg) 85 - 91 76 - 80

Time 1: pre-intervention

Time 5: post-intervention

INDIRECT CALORIMETRY

Results Time 1 Time 5

BMR Prediction (Kcal) 1704 1941

BMR ( Kcal) 2304 1152

VO 2 333 167

% TMB variation 26 ↓ 68 ↑

Time 1: pre-intervention

Time 5: post-intervention

cal: calories;TMB: Basal Metabolic Rate; vo2: Oxygen volume

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Nutritional Survey

• Detection of proper and inadequate eating habits,

• Identifying of certain eating behaviors,

• Verification of sizes and types of food used,

• Times and places where meals are taken,

• Establishing an emotional bond between professional and patient:

“ The dietary behavior is not always completely negative, often small

changes can lead to large positive differences.”

Meal Time Food Households measure Quantity

Breakfast 1

French bread

Salami

Yellow cheese

Fat milk

Coffee

Sugar

Fresh Fruit Juice:

(2 oranges and half a papaya)

Unit

Medium slice

Medium slice

Medium glass

Cup

Table spoon

Medium glass

-

1

4

2

200ml

1

1

1

-

Morning Snack 1 - - -

Lunch 1

White rice

Beans

Lettuce

Cooked chayote

Carrots

Red Meat

Olive oil

Soy oil

Fresh orange juice

Table spoon

Table spoon

Table plate

Table spoon

Table spoon

Medium Steak

Tea spoon

Table spoon

Large glass

10

4

1

2

2

240g

1

2

200ml

Afternoon Snack 1 Sweet cake Medium slice 2

Dinner

1

White rice

Red meat

Cooked potato

Mussarela

Soy oil

Olive oil

Cream Ice- cream

Table spoon

Medium Steak

Medium unit

Medium slice

Table spoon

Tea spoon

Scoop

10

240g

2

2

1

1

2

Supper 1 - - -

Lipids 29%

Protein 20%

Carbohydrate 51%

lipídios Proteína HC carbohydrate lipids protein

Percentage of energy

Men Women

Data source: National Dietary Survey 2008-2009, Brazil, day 1, weighted

• Carbohydrates,

• Lipids and

• Proteins

Balance between the proportions of macronutrients

However, with excessive

caloric intake

Increasing the quality and decreasing the amount.

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Nutritional Intervention: preparing the dietary plan

• Meet the individual nutritional needs,

• Prevent or treat possible risk factors associated with chronic

metabolic disease,

• Promote interactive participation with other family members:

modification of lifestyle in the environment,

• Observe possible preferences and dietary restrictions.

STIMULUS AND MOTIVATION: professional patient

Meal Time Food Household measures Quantity

Breakfast 2 Oat flakes

Coffee

Sweetener

Non-fat milk

Vegetable margarine

Papaya

Light bread

Table spoon

Cup

Coffee spoon

Small glass

Table spoon

Half

Slice

1

1

1

1

1

1

1

Morning snack 2 Guava Medium unit 1

Lunch 2 White rice

Beetroot

Chicken steak

Watercress

Tomato

Olive oil

Soy oil

Light Juice

Table spoon

Tea cup

Medium steak

Dessert plate

Medium unit

Tea spoon

Table spoon

Medium glass

1

1

120g

1

1

1

1

1

Afternoon snack 2 Plum

Tea

Light white Cheese

Unit

Cup

Medium slice

1

1

1

Dinner

2 Lettuce

Smoked lean ham

Sliced Cucumber

Light bread

Mayonnaise

Olive oil

Light white cheese

Table plate

Medium slice

Tea saucer

Medium slice

Dessert spoon

Tea spoon

Medium slice

1

2

1

2

1

1

2

Supper 2 Non-fat milk

Oat flakes

Medium glass

Table spoon

240ml

1

Lipids 27%

Protein

23%

Carbohydrate 53%

lipídios Proteína HC lipids protein carbohydrate

Increasing the quality and decreasing the amount.

No significant difference in the percentage distribution

of macronutrients between the periods pre and post

intervention.

Nutritional information Time 1 Time 5

Energetic value (Kcal) 3917 1502

Lipids (g) 124,17 36,04

Monounsaturated fat (g) 38,26 11,62

Polyunsaturated fat (g) 13,34 13,10

Linoleic fatty acids (n-6) (g) 4,03 8,10

Alfa linolenic fatty acids (n-3) (g) 0,56 1,09

Saturated fat (g) 54,24 8,81

Trans fat (g) 0,22 0,71

Carbohydrates (g) 504,34 159,16

Proteins (g) 195,30 68,08

Calcium (mg) 1249,28 1194,06

Zinc (mg) 47,22 28,04

Cholesterol (mg) 500,90 73,15

Food Fiber (g) 30,00 28,47

(%) Time 1 Time 5

Lipids 28 26

Monounsaturated fat 8,79 8,28

Polyunsaturated fat 3,06 9,80

Saturated fat 12,46 6,59

Trans fat 0,05 0,53

Linoleic fatty acids (n-6) 0,92 6,06

Alfa linolenic fatty acids

(n-3) 0,12 0,81

Time 1: pre-intervention

Time 5: post-intervention

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RECOMMENDATIONS

Total fat 30 – 35% E

Maximum saturated 10%E

Essential fatty acids PUFA (w-6 e w-3) 6 – 10% E

Trans fatty acids ↓ 1% E

Remainder of calories from fats: monounsaturated.

Nutritional counseling

• Practical guidance on sizes and household measures,

• Assimilation of food groups present in the list of substitution,

• Provision of practical and viable food recipes, which may be

included in the patient's routine,

• Knowledge of the patient`s daily life and his structure:

Family, employees, workplace, times and numbers of meals.

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Theme courses and Groups

• Target Audience:

Practical sessions with client / patient (adults or children)

Staff who work at home:

Training for active participation in the process of changing lifestyle of

the individual and / or family,

Organization, presentation of dishes, meal preparation time.

• Objective: Dietary Technique

Elaborate preparations differentiated, tasty, nutritious that visually

stimulate adherence to dietary proposed new concepts.

Awareness and bond (professionals and clients / patients),

Relaxation,

Involvement ,

Sensorial stimulation: taste, smell.

Greater compliance for lifestyle modification.

Gourmet Space

Colocar aqui uma foto do treiamento de funcionaria Weder ou Ana Rosa !

Monitoring the patient

Beginning of the plan:

• The goal is: set the menu with the necessary adaptations.

• Home visits: defined with the patient.

Termination of the plan:

• Objective: Adherence to treatment

• Tip: Maintenance plans

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• THE DIET CAN BE MODIFIED !

A single nutrient: different metabolic responses.

The response in post-prandial:

Type and amount of nutrients

"Calorie is a calorie“: concept can be misleading.

EBBELING, C.B. et al. American Journal Clinical Nutrition. 2005; 81(5): 976-982.

RADULIAN, G. et al. Nutrition Journal. 2009; 8(5): 1-8. 2009.

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CASSANI, R. S.L. et al. Arquivos Brasileiros de Cardiologia 2009; 92:16-22.

CASSANI, R. S. L. et al. American Journal of Hypertension2009; 22: 980-984.

• Diet: modifiable risk factor

• Educational programs, on nutrition, for prevention

and control of complications from a unhealthy

lifestyle identified.

Conceptual, Motivators, sensitizers, possible and

frequent !