Actividad Dietética最新文献

First of all, and as an introduction, this review of scientific literature offers information on therapeutic education for the person with diabetes and his/her family members, as well as the concept of nutritional dietary education. Secondly, it reviews the current approach to treating diabetes mellitus type 1 either with therapy with multiple doses of insulin (MDI) or with continuous subcutaneous insulin infusion (CSII), their relation with the most liberalized food plan since they allow the dosage of pre-prandial insulin to be better adapted to the intake of carbohydrates (CH), and also offering aspects related with adhesion to dietetic monitoring. Lastly, in the third place, the bases and characteristics of the CSII therapy and specific learning that people with diabetes and their family members have to do basically focusing on the differential aspects in relation with the food plan with respect to the MDIs are explained. CSII therapy can offer more dietary flexibility than any other form of treatment, although in order to optimize the infuser's benefits, the patient not only has to learn to estimate the amount of CHs, but also other nutrients like the amount of fat or fibre that can interfere in their absorption.

Nutritional handling of the diabetic patient goes beyond being the mere provision of nutrients, but rather it is the basis of his/her general treatment to such an extent that the international scientific societies have decided to call it “nutritional medical treatment” (NMT) to give it the emphasis it deserves. However, a consensus has still not quite been reached and established on NMT, in such a way that the scientific societies’ recommendations have been changing in these last few years in light of the application of the evidence-based medicine revision methodology. In this article, the main dietary recommendations based on evidence from different international societies are reviewed and compared. In this sense, most societies recommend the provision of carbohydrates to be personalized, without indicating a specific amount. The fat content is well-established, and a maximum intake of 7% of the total calorie count in the form of saturated fats and less than 200 mg/day of cholesterol are recommended. The recommended protein intake is what has changed least over the years and is established at 15%-20% of the total calorie count. The effectiveness of the action of fibre on the improvement of the lipid and glycide metabolism is controversial, and even more so considering the low consumption of fibre in the Spanish population.

Although it is obvious that educating the boy/girl with diabetes has to be a personalized and sustained process, summer holiday camps are considered a very appropriate instrument (as suggested by the World Health Organization, the WHO, in the St. Vincent Declaration of 1989) for taking educational action both in what concerns self-control techniques and as psychological help for accepting the disease. The fact of being away from the family unit and also from the hospital environment, in a relaxed atmosphere, living with other boys/girls with diabetes, makes these summer activities a very favourable experience for learning to control glycaemias, modify the dosages, deal with acute situations and intercurrent conditions (often related with the coordination between sports activities, meals and the insulin dosage), choose the most appropriate food, all in all, to manage to get the treatment better adapted to everyday activity, always in a way that is integrated in daily activities. On the other hand, it is also enriching for the health personnel participating. For the 10 days a holiday camp tends to last, the health professionals (medical and nursing staff and dieticians-nutritionists) have the opportunity to live with the child or adolescent with diabetes in a situation which is not one that tends to occur in a hospital visit or consultation. In the educational process that these co-existences represent, the process of education in food both from the point of view of the appropriate healthy diet in childhood and adolescence, and from the aspect of the treatment of the disease itself stands out significantly.

Treatment of diabetes mellitus type 1 is built on three main pillars: treatment with subcutaneous insulin, a healthy and balanced diet ensuring control of the intake of carbohydrates and practicing a physical activity. Considering its condition as a chronic pathology, it is essential to build the bases of treatment through therapeutic education in diabetes (TED).

Handling diabetes is complex and requires full information and training. TED is a process through which the patient and the family acquire knowledge, skills and proper attitudes for managing to properly control their diabetes. The aims of the education are defined depending on the age of the boy/girl and on the family's degree of acceptance of the disease.

An educational programme has to be drawn up which must contemplate multiple aspects and which requires a structured planning in order to prevent the learning process from being complex. Furthermore, having the appropriate educational material significantly contributes to helping his/her new situation to adapt to everyday family life. It is essential to progressively convey these aspects which are personalized according to the patient and his/her family's learning capacity. Transmitting an excess of teaching contents could hinder the learning of the most relevant concepts. Therefore, we could say that it is not necessary for the patients to know everything about their disease, but only that which is useful for their self-care, all in all, to achieve a proper metabolic control.

The diet of the child and the adolescent with diabetes must be balanced and similar to that of those of the same age group, gender and family and social environment. During adolescence, changes occur in life style and in dietary habits. Adolescents are consuming high-calorie diets with a clear excess of fats and a lack of fibre and vitamins. Nutritional needs have to be personalized and they vary depending on the subject's stage of growth, gender and weight-height percentile. While the female gender grows from the beginning of puberty in parallel with breast development, reaching her maximum peak when she reaches menarche, boys chronologically start later and they do not do so with the beginning of testicular development, which marks the beginning of puberty, but they grow later. The examples of two adolescents are given: on the one hand, a 14 year-old school adolescent who is administered a slow analogue as basal insulin in the morning and one at night, and a rapid-acting analogue bolus in the doses that do not need either as much food or as much insulin. On the other hand, an adolescent of a similar age who goes to the surgery with poorly controlled glycaemia (HbA_1c, 10.5%) and a low weight velocity in relation to his growth velocity, undoubtedly due to an insufficiently insulinised intake. Adolescence is a risky time from the nutritional point of view, for, due to the pubertal spurt, a tendency to acquire wrong eating habits is added to the nutrient needs.

The EARNEST project is a collaborative investigation to study the effect that certain nutrients taken during the first stages of life have on the individual's health on a long term basis. This is a concept known as metabolic programming. The project brings together 44 multi-disciplinary scientific teams from 17 countries working on 6 significant issues, which carry out different clinical and epidemiological investigations, as well as in animals and in vitro. Other research included in the project covers aspects on the consumers’ communication and understanding of the programming concept. As a result of these investigations, it is hoped to provide to the following questions: a quantification of the effects of programming on adult health, a definition of the critical periods in the foetal and postnatal stages in relation with the development of illnesses, understanding the role of specific nutrients and the programming mechanisms, the development of strategies for treating and preventing the adverse effects of programming, the examination of its impact on public health and the consumer's behaviour, the study of the economic burden of ill health in adults and, finally, proving the viability of new technologies and ingredients. The project began in the year 2005 and ends in 2010. During these years, scientific meetings are arranged for presenting the partial results of the studies which, at the same time, are published in scientific journals. This project's conclusions, which will be presented at the International Conference to be held in Munich from May 6th to 8th, 2010, will allow more knowledge to be available for developing appropriate mother and child food policies. This project's importance makes it highly interesting for the dietician-nutritionist profession.

Background

Malnutrition among the elderly population in institutions leads to an increase in morbidity and mortality. One of the possible risk factors could be the poor planning and adaptation of the menus offered, which do not manage to cover the recommended energy, macronutrient and micronutrient consumptions.

Objective

The objective of this study was to analyse the planned menus of five geriatric homes to assess whether they are adapted to the recommended intakes for this age group.

Design

The study was carried out on five geriatric homes, 4 in Spain (Barcelona, Santa Coloma de Gramanet, Madrid and Bilbao) and one in Belgium (Leuven). A complete cycle of menus (21 days) was assessed in each of the homes. The method used for recording food was the double weighing method, taking into account the inedible part of each food product offered on the menu. In order to convert the menus to nutrients, the food composition database from the Nutrition and Dietetics Higher Education Centre (CESNID) and Belgium's food composition database were used.

Subjects

The menus of five geriatric homes were assessed during a full three-week cycle (21 days). The food products offered in the main meals, i.e. breakfast, lunch, afternoon snack and dinner, were assessed from each menu day. The food offered apart from the hours established by each centre was not taken into account.

Main resulting measures

The total amounts of energy, proteins (%), available carbohydrates (%), lipids (%), saturated fatty acids (%), monounsaturated fatty acids (%), polyunsaturated fatty acids (%), calcium, iron, phosphorus, folates, carotenes, vitamin C, vitamin D, vitamin E, retinol, thiamine, riboflavin, vitamin B₆ and vitamin B₁₂ were analysed. The values obtained were compared with the reference values of the recommended intakes (RI).

Results

Among the menus studied, it was found that the recommended intakes for energy, carbohydrates, calcium, zinc, vitamin C, folates and, especially, vitamin D were not being covered. On the other hand, an excess of lipids, saturated fatty acids and, above all, rapidly absorbed sugars was found.

Conclusions

According to the results obtained, it would be advisable for dietitians to carry out a periodic revision of the menus offered in geriatric homes to improve their planning and nutritional quality and to plan enrichment and/or menu supplement policies in those cases that required them.

Pica is an eating disorder characterized by the compulsive eating of substances that are inappropriate for consumption such as earth, chalk, plaster, paper, ice and other non-nutritious substances. Pagophagia (the consumption of ice) and geophagia (the consumption of soil compounds) are the most common forms of pica, which have often been associated with cases of iron deficiency and ferropenic anaemia. In this article, a description is given of the case of a woman submitted to a gastric bypass (GBP) with ferropenic anaemia who has an uncontrollable desire to eat ice (pagophagia) and an urge to smell and eat damp earth, which are secondary to the iron deficiency. After the anaemia is correctly treated (intravenous iron), the patient's eating disorders are resolved. This clinical case illustrates the importance of the early detection of pica in this type of patients to prevent irreversible dental and intestinal lesions.