About 347 million people worldwide have diabetes

There is an emerging global epidemic of diabetes that can be traced back to rapid increases in overweight, obesity and physical inactivity

Diabetes is predicted to become the seventh leading cause of death in the world by the year 2030 Total deaths from diabetes are projected to rise by more than 50% in the next 10 years

DIABETES – GLOBAL SCENARIO

An estimated 57 million Indians will have diabetes by 2025

An important factor contributing to increased prevalence of T2DM in

Asian Indians is excessive insulin resistance

Insulin resistance is highly prevalent in Asian Indians which results in

decreased glucose transport in muscle resulting in

hyperglycemia

Indians seem to have a genetic predisposition towards insulin resistance with a low BMI and high central adiposity

DIABETES – INDIAN SCENARIO

Approaches for Diabetes

management are:

Diet management

Exercise Drug

therapy.

Objectives for the management of

Diabetes are:

To provide relief from symptoms.

Prevention of complications.

MANAGEMENT OF DIABETES

There is not eating pattern

& supports its implementation

MEDICAL NUTRITION THERAPY IN

DIABETES

Medical Nutrition Therapy is a therapeutic approach to treating medical conditions and their associated symptoms via the use of a specifically tailored diet devised and monitored by a registered Dietitian.

BENEFITS OF MNT

MNT provided by Registered Dieticians (RDs) is a nutrition centered care plan that focuses on the assessment, nutrition diagnosis, treatment plan, evaluation and continued monitoring of a patient.

MNT has been shown to be effective in wellness, disease prevention and disease management.

MNT improves the health and quality of life for individuals with certain disease conditions and can reduce hospitalization

EMPHASIS ON NUTRITION – ADA GUIDELINES

GOALS OF MEDICAL NUTRITION THERAPY

1. Attain individualized glycemic, Blood pressure & Lipid goals.

HbA1C < 7%

Blood Pressure < 140/80mmHg

LDL Cholesterol < 100 mg/dL

Triglycerides < 150 mg/dL

HDL cholesterol > 40 mg/dL for Men

HDL cholesterol > 50 mg/dL for Women

2. Achieve & maintain body weight goals

3. Delay or prevent complications of Diabetes

4. Improve health through healthy food choices & physical activity

5. Address individual nutritional needs taking into considerations personal

& cultural preferences and lifestyle

6. For the young with type 2 diabetes, to facilitate changes in eating and

physical activity habits that reduces insulin resistance & improve metabolic

status

7. To provide self management education for treatment of hypoglycemia

8. To decrease risk by encouraging physical activity & promoting food choices that facilitate moderate weight loss or at least prevent weight gain

Diabetes

Glycemic Variations

CVDs

Obese & Poor QOL

Nutritional Imbalance

Weakness

Diet Restrictions

WHY MEDICAL NUTRITION THERAPY ???

Nutrition is a critical part of diabetes care. Balancing the right amount of carbohydrates, fat, protein along with fibre, vitamins and minerals helps us to maintain health and a healthy lifestyle. Major concern of Nutrition Therapy is Metabolic normalization and reduction of cardiovascular risk factors

Objective of Diabetic Nutrition

Calorie intake needs to be restricted to decrease weight & risks of vascular complications

SIGNIFICANCE OF NUTRITION IN DIABETES

MNT is recommended for all people with diabetes as an effective component of overall treatment plan Diabetic Individuals should receive individualized MNT as needed to achieve treatment goals, preferably provided by an RD

Gradual provides complete nutritional treatment plan to achieve treatment goals by providing an effective supplementation.

MEDICAL NUTRITION THERAPY & GRADUAL

Medical Nutrition Therapy for people with Diabetes

PRESENTING…

GRADUAL…

• Gradual is an Medical Nutrition Therapy for people with Diabetes

• Gradual follows ADA recommendations on MNT and its

Gradual Release Energy System (GRES) helps manage

glucose levels effectively thus minimising Hyper / Hypo glycemic

responses

• Fortified with micronutrients which further helps in attaining diabetes

management goals

WHAT?

- Follows ADA guidelines on Medical Nutrition Therapy - Helps in stabilizing high glycemic variance - Releases energy gradually through GDF – Gradually

Digestive Fibres (Proprietary Ingredient) - Helps in giving instant energy & weight loss through MCT - Helps achieve proper nutritional balance - Improves Quality of Life

WHY?

What Gradual Offers…

Features Benefits

GREAT TASTE EASY ACCEPTANCE AMONGST PEOPLE WITH

DIABETES

GREADUAL RELEASE ENERGY SYSTEM IMPROVED GLYCEMIC RESPONSE - FREEDOM

FROM HYPO/HYPER GLYCEMIA

LOW SFA, HIFH MUFA, SUGAR FREE,

TRANS FAT FREE GOOD FOR DIABETES MANAGEMNT & CVD

ADVANTAGE OF MCTs, FIBRES OMEGA 3

FATTY ACIDS

GOOD FOR WT. MANAGEMENT, DIABETES

MANAGEMNT & CVD

COMPLETE, BALANCED, LOW CALORIE

NUTRITION GOOD FOR DIABETES MANAGEMNT & CVD

CONVENIENT PRESENTATION COMPLIANCE WITH ADA DIETARY

RECOMMENDATIONS, EASY ACCEPTANCE

SPRAY DRIED POWDER BETTER MISCIBILITY, TASTE & STABILITY

GRADUAL

• Role of individual components of Gradual

GDF are short chain polymers of glucose that are resistant to digestion in

the human digestive system

GDF are not digested or absorbed in the human small intestine, and thus pass to the large intestine.

There the undigested GDF are fermented by the colonic bacteria where they yield short chain fatty acids, lower the pH, and gaseous by products.

Research studies have shown improved laxation with the consumption of GDF

GRES – Gradual Release Energy System

GDF is patented soluble dietary fibre and evidence indicates that it may help control postprandial glycemia. GDF consumption does not lead to an enhanced insulin response; rather, it gets attenuated GDF also attenuates the triacylglycerol response to ingested fat, which being structurally different, suggests a mechanism other than enzyme inhibition Foods with a low glycemic index or load can help to normalize the fasting blood glucose concentration, improve glycated protein concentrations, and elevate insulin sensitivity in diabetic and non diabetic subjects

GRES – Gradual Release Energy System

GRES – Gradual Release Energy System

Glycated albumin & glycosylated hemoglobin which are indicators of intermediate & long-term glycemic control, improved over time and in relation to placebo treated subjects

Glycosylated hemoglobin change over 12 weeks in Test and Control groups. Values are expressed as means ± SE

Glycated albumin change over 12 weeks in Test and Control groups. Values are expressed as means ± SE

Medium-chain triglycerides (MCTs) are fats with an unusual chemical structure that allows the body to digest them easily. Most fats are broken down in the intestine and remade into a special form that can be transported in the blood. But MCTs are absorbed intact and taken to the liver, where they are used directly for energy.

MCT – MEDIUM CHAIN TRIGLYCERIDES

MCT – MEDIUM CHAIN TRIGLYCERIDES

MCT – MEDIUM CHAIN TRIGLYCERIDES

MCT – MEDIUM CHAIN TRIGLYCERIDES

These are polyunsaturated fatty acids (PUFAs) with a double bond (C=C) at the third carbon atom from the end of the carbon chain. The three types of omega-3 fatty acids are 1. ALA - Alpha linolenic acid (found in plant oils) 2. EPA - Eicosapentaenoic acid (found in marine oils) 3. DHA - Docosahexaenoic acid (found in marine oils)

• Omega 3 fatty acids has anti-inflammatory, inflammation-resolving, anti arrhythmic & anti thrombotic effects as well as a regulation of transcription factors, gene expression & membrane fluidity

Alpha-linolenic acid (ALA): A large amount of ALA is sometimes used strictly for energy purposes. Our bodies can take ALA and use it to produce energy for our cells. In some situations, most of the ALA that we consume will get used in this way.

Eicosapentaenoic acid (EPA): Proper function of our inflammatory system depends on the presence of messaging molecules called prostaglandins. Many of these prostaglandins are made directly from EPA. Equally important, most of the prostaglandins made from EPA tend to be anti-inflammatory in their effect.

Docosahexaenoic acid (DHA): Proper function of our nervous system—including our brain—depends on the presence of DHA. DHA is particularly important to brain function

Inositol : Inositol can enhance the sensitivity of insulin in human body, which

is a favorable aspect for the control of diabetes. Another good aspect is that it can reduce the resulting factors for diabetes, including hyperinsulinemia and insulin resistance

Vitamin D: Vitamin D insufficiency & deficiency in obese and diabetic

individuals ranges from 80-90%. Given the high rates of vitamin D insufficiency in obese population & the observed benefits, clinicians may consider vitamin D supplementation in this population

Vitamin C : Diabetic patients have lower dietary intake & lower plasma

levels of vitamin C than healthy controls & its levels correlate inversely with BMI and deficiency of vitamin C is reported in 35-45% of obese individuals

Biotin: Increases hepatic glucose uptake & it also regulates transcription of

the insulin receptor & improves pancreatic B-cell function

Thiamine : Reduces reactive oxidative species in endothelial cells

Selenium : Decreases hyperglycemia by increasing insulin production &

Secretion

Chromium Picolinate : Chromium picolinate being most bioavailable

form of chromium enhances the biological action of Insulin. Chromium also helps insulin to binds with its receptors that line cell membranes and allow glucose to enter the cell to be converted into energy

Zinc : Uncontrolled diabetes results in prolonged glycosuria, which leads to

zinc deficiency

NUTRITION FOR DIABETES GRADUAL GLUCERNA D PROTEIN FRESUBIN

DM SUPPLEMENT

D

1 ENERGY Kcal 419 435 416 450 458

2 PROTEIN g 20.3 20.1 28 20.2 20

3 CARBOHYDRATES g 59.4 59.79 58 43.8 54

4 ADDED SUGAR g 0 0

5 DIETARY FIBER g 13 5.19 7 7.2

6 FAT g 15.1 14.61 8 20 18

7 SATURATED FAT g 2.8 1.17 0.4 3.5 1.2

8 MUFA g 9 12.02 5 9.3 11.2

9 PUFA g 1.3 1.92 2.6 7.2 4.8

10 O3FA mg 633 150

11 O6FA mg 523

12 TRANS FAT g 0 0 0 0 0

13 CHOLESTEROL mg 15 <10 0 0

14 FOS g 4 3 3.2 3.07

15 MCT g 1.2

16 TAURINE mg 40 30.6 39 53

17 CARNITINE mg 40 26.2 90 30

18 INOSITOL mg 330 305.7 360 320

MAJOR INGREDIENTS

NUTRITION FOR DIABETES

GRADUAL GLUCERNA D PROTEIN FRESUBIN

DM SUPPLEMENT

D

1 VIT-A IU 1170 255 mcg RE 2500 479 mcg 1962

2 FOLIC ACID mcg 250 127 200 120 135

3 VIT-B1 mcg 700 582 2000 600 221mcg

4 VIT-B2 mg 0.7mg 0.65mg 2 0.78 0.2mg

5 VIT-B6 mg 1.5 1.52 1 0.72 0.75mg

6 VIT-B12 mcg 4 1.48 3 1.2 0.43

7 NIACIN mg 10 5.11 10 7.2 7

8 PANTOTHENIC

ACID mg 5 2.91 mg 5 2.1 0.92

9 BIOTIN mcg 20 13.8 100 22 5.5

10 Vit D mcg 600 IU Vit D2 4 250 IU 4.5 180

11 Vit E mg 7.5 10 50 18 12.4

12 Vit K mcg 20 30.6 50 36 20.1

13 Vit C mg 40 33.1 100 75 36

VITAMINS

NUTRITION FOR DIABETES

GRADUAL GLUCERNA D PROTEIN FRESUBIN

DM SUPPLEMENT

D

1 SODIUM mg 294 324 350 360 424

2 POTASSIUM mg 552 568 700 599 523

3 CHLORIDE mg 112 480 250 539 664

4 CALCIUM mg 477 258 800 360 200

5 PHOSPHORUS mg 190 258 600 300 180

6 MAGNESIUM mg 123 91 200 112 73

7 IRON mg 8.5 4.73 5 9 4.1

8 ZINC mg 16 2.5 15 4.5 2.8

9 MANGANESE mcg 1.5 1.16mg 2 mg 1.5 mg 0.45

10 COPPER mcg 662 764 2 mg 0.6 mg 160

11 IODINE mcg 98 58.2 100 60 27.6

12 SELENIUM mcg 29 16.4 70 30 10.1

13 CHROMIUM mcg 100 25.5 120 120 40

14 MOLYBDENUM mcg 33 35.3 35 45 35.1

MINERALS

AS PER ADA GUIDELINES GRADUAL

Protein (between 10-20%) 19.68%

SFA (<7%) 5.83%

MUFA+PUFA (13-28%) 24.62%

TFA (< 2mg/day) 0

PUFA (<10%) 6.05%

Carbohydrate intake (<130gm per day) 28.7 g/day

Cholesterol (<200mg per day) 7.5 mg/day

MUFA + Carbohydrate (between 60-70%) 66.50%

Sodium (<2300mg per day) 190.5 mg/day

GRADUAL ADHEARANCE TO ADA

GRADUAL - TECHNOLOGY

Gradual has been prepared with special SPRAY DRIED TECHNOLOGY. This technology offers the following advantages.

– Gradual is very tasty and has vanilla flavour

– Gradual is easily SOLUBLE/MISCIBLE in water and milk

– Gradual formulation is more stable and has lesser chances of

developing rancidity, lumps and /or water absorption.

When to take Gradual?

- As a snack in the morning or in the evening

- As a meal replacement in the afternoon or night

- As a Enteral supplement for patients admitted in ICU/ITU

Dosage

- Gradual 25 gm (3 level scoops) should be taken atleast 2 times in a day

Direction for use

To prepare 122 ml feed, put 100 ml normal water/milk in a glass. Slowly add 25 gm (approximately 3 level scoop) of Gradual powder and mix until dissolved.

Storage

Once opened, store under cool & dry conditions. Keep the lid tightly closed and use the contents within 10 days of opening the container

Gradual as an Enteral Feeding

Indications

Long term diabetes

Weakness

Obese Diabetic patients

IPD, ICCU & ITU patients