Restricted Diet

Dr Leong Lai Peng

S14-06-03
Food Science and Technology Programme

1
Restricted Diets
What are Restricted Diets?
Diet that require a component in the food to be
kept within certain limits

2
Calorie Restriction (CR)
A diet that restrict Calorie intake (most are
about 30% less than unrestricted Calorie level)
but adequate essential nutrients.
Subjects are normal and without any medical
conditions.
Found to increase median and maximum
lifespan in rodents, fish, dogs and yeast.
1

3

1
Toxicologic Pathology (2009) 37 (1): 4751
http://www.pnas.org/content/106/47.cover-expansion
Calorie Restriction for longevity,
anyone?
SMS your answer to 77577,

Chmgek10 Message

Replace Message with y or n.

4
Calorie restriction in primates
1
did not increase
longevity. Genetic and healthy diet may matter
more.
No human studies have shown CR to increase
life span. Average weight highest life
expectancy.
Care should be taken when extrapolating results
from animal studies.
5
1
Nature 488, 569 (30 August 2012)
Diet Restriction
Diet
Eating habits
Health
Reduce risk of
disease
Disease management
6
Purpose of Diet Restriction:
The Need for Restricted Diet
Medical Condition
Obesity Weight management diet
Cardiovascular Diseases Healthy Fat Diet
Diabetes
High blood pressure
Phenylketonuria (PKU)

7
*Information given in this lecture cannot replace the need to seek
professional medical advise if you have a medical condition.
8
Overweight and Obesity
Abdominal fatness can be defined using waist to
hip ratio (WHR). >1.0 for men; >0.85 for
women.
BMI is normally used to indicate the weight
status of an individual. For Singapore:


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http://viweightloss.com/find-safe-and-effective-products-from-evolution-slimming/
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WHO Consultant, The Lancet, 363, 157-163

BMI cut off (kg/m
2
) Risk Level
1
18.5 to 22.9

Acceptable risk
23 to 27.4 Increased risk
27.5 High risk
Obesity in Singapore
For population between 18 to 69 years
1
,
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1
National Health Survey 2010, Ministry of Health
10.8% are obese (BMI > 30 kg/m
2
)
- 12.1%; - 9.5%
Malays 24.0%, Indians 16.9%, Chinese
7.9%
23.0% are high risk (BMI > 27.5 kg/m
2
)
Obesity and Health Risk
Obesity is associated with:
Cardiovascular Disease
Diabetes
Atherosclerosis
Inflammation
Some cancers

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Causes of Obesity
12
Increase
Calories
Reduced
Physical
Activity
Genetic Susceptibility
Within ones control
Within ones control
Not within ones control
Weight Loss Strategies
To maintain weight loss, one should:
Exercise regularly
Make small changes to diet and physical activity
(300 to 500 kcal reduction from usual intake).
13
Increase energy
expenditure
Reduce intake
= Weight Loss
Weight Loss Strategies
To maintain weight loss, one should:
Ensure nutrient adequacy by taking foods with
high nutrient density but low energy density.
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Weight Loss Strategies
Comparing energy density:
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Weight Loss Strategies
To maintain weight loss, one should:
Consume lower fat foods (30% of total kcalories)
Use less cooking oil.
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Low
Fat
Intake
Low
Energy
=
High
Fat
Intake
High
Energy
=
http://www.dreamstime.com/stock-image-raw-meat-image17630391
http://wildchildurbancity.blogspot.sg/2012/03/red-meat-
consumption-and-mortality.html
100 g
164 kcal
100 g
272 kcal
Food Label
% Daily Value is based on 30% energy intake for
fat and 10% for saturated fat based on 2000 kcal
a day.
For a person consuming 2000 kcal a day,
30% = 600 kcal
600 kcal 600/9 = 66.6 g 65 g

To comply to recommended proportion of fat in
diet, total quantity of fat in a day should add up to
about 65 g or 100% daily value.
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Weight Loss Strategy
Normal Diet
Lipid:Protein:CHO
= 35:20:45
Weight Loss Diet
Lipid:Protein:CHO =
30:15:55
Energy from fat is replaced by
protein and carbohydrate.
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Reducing % protein helps reduce fat intake and
high energy density foods.
Increasing % carbohydrate helps increase fibre
and low energy density foods.
Weight Control
To maintain weight loss, one should:
Increase high fiber food.
To promote satiety.
Lower energy density.
High in nutrient density.
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http://www.fruitsinfo.com/uses_of_fruits.htm
http://crazy-frankenstein.com/vegetables-wallpapers-3.html
Weight Loss Strategy
To maintain weight loss, one should:
Increase water intake.
Increase fullness without adding calories.
Help in coping with high fiber diet.
Avoid empty calories e.g. sweetened drinks and
alcohol.
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http://success-fitness.blogspot.sg/2011/02/carbonated-drinks-affect-health.html
http://www.scientificamerican.com/article.cfm?id=beer-batter-is-better
Weight Loss Strategy - Precautions
Reducing calories without compromising on
nutrient adequacy.
Diet should also be well balanced.
Nutrient supplements may be required.
Lower calories should not lead to feelings of
starvation which may lead to irresistible urge.
Beware of fad diets normally focus on extreme
changes and sudden weight loss.
Beware of weight loss products. E.g. consume
something to loose weight without change in diet.
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Weight Management
Weight loss Weight Management
Weight loss is not useful if weight is regained.
Weight loss products and services thrive
because:
Success rate is low in retaining weight loss
Social pressure to maintain normal weight
People are willing to try quick-fix solution
People believe that if a product sells, it must be
effective.
Some evidence in animal models.
Explanation sounds good.
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Low Fat or Low Carbohydrate?
Low Fat Low Carb
Total Calorie intake less than total expenditure
Adequate and balance?
Within recommended range of energy ratio?
Undesirable effect?
Possible to maintain healthy weight? ? ?
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Low Fat Low Carb
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Cardiovascular Diseases
Diseases of heart and blood vessels.
Includes:
Coronary heart disease (CHD)
Blood flow to the heart is affected.
Leads to heart attack
Stroke
Blood supply to brain is affected.
>30% of total deaths in Singapore is due to
Cardiovascular Diseases
1
.
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1
http://www.myheart.org.sg/heart-facts/statistics/
Risk Assessment of CHD
Blood lipid profile analysis.
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Functions of LDL and HDL
LDL transport TG,
cholesterol and
phospholipid to cells
of all tissues.
HDL transport
cholesterol back to the
liver for disposal.

27

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Healthy Fat Diet
Purpose:
Weight loss or maintenance
Reduce LDL level and obtain blood lipid balance.
Recommendation:
Total Fat 2035% of energy
Limit saturated fat to 7% of total energy. This can be done by
Taking lower fat food.
Cut off fats from meat.
Reduce cream and butter.
Replace with carbohydrate (but maintaining between 50-60% total
energy).

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How to Reduce Saturated Fats

30
Healthy Fat Diet
Recommendation:
Limit cholesterol to 200 mg.

Sources of cholesterol:
Animal fats
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http://www.mrbigben.com/food/dairy.html
http://faith-resources.blogspot.sg/2011/08/meat-shops-for-home-delivery.html
http://www.foodsubs.com/Eggs.html
Cholesterol
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Cholesterol is not essential.
When absorbed, the body will reduce the synthesis.
Some evidence shows that dietary cholesterol has little effect on blood
cholesterol.
Healthy Fat Diet
Recommendation:
Avoid trans fatty acid
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NUTRITION INFORMATION
SERVINGS PER PACK 50 SERVING SIZE 10g
QTY^ PER
SERVING
% DAILY
INTAKE*
QTY^PER
100g
ENERGY 242 kJ 3 2420 kJ
PROTEIN <1 g 0 <1 g
FAT TOTAL 6.5 g 9 65 g
SATURATED 1.7 g max 7 17 g max
TRANS** 0.06 g max 0.59 g max
POLYUNSATURATED 2.7 g min 27 g min
OMEGA-6 2.6 g min 26 g min
MONOUNSATURATED 1.6 g min 16 g min
CHOLESTEROL <0.3 mg <3 mg

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Trans fatty acid vs cis fatty acid
Oleic acid (cis 18:1)



Elaidic acid (trans 18:1)


Saturated fatty acid
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Small quantities
are found
naturally in
meat and milk.
Healthy Fat Diet
Recommendation:
n-6 Polyunsaturated fatty acids (linoleic acid)* 510% energy
n-3 Polyunsaturated fatty acids (-linolenic acid)* 0.61.2%
energy
* Approximately 10% of total can come from longer chain n-6 or n-3
fatty acids
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http://foodiesunite.com/2011/05/grilled-fish-101-mango-salsa-for-memorial-day/
Replace meat with fish:
Low in saturated fat.
Suppress inflammation reducing
blood clotting, lowering TG levels.
Omega-3 (n-3) and Omega-6 (n-6)
Fatty Acids
Linoleic Acid (n-6)


Linolenic Acid (n-3)
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all-cis-7,10,13,16,19-docosapentaenoic acid (22:5, n-3)




all-cis-4,7,10,13,16-docosapentaenoic acid (22:5, n-6)
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Healthy Fat Diet
Fat replacers
Replace the function of fats in foods (taste, texture
and/or cooking properties) with zero or lower
calories.
Do not contribute to hyperlipidemia.
Can be carbohydrate, protein or fat based.
Precaution
Fat based fat replacers is able to reduce the
absorption of fat soluble vitamin.

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Healthy Fat Diet
Examples of fat replacers:
Fat replacers obtained from food components are
GRAS. E.g.:
Avicel microcrystalline cellulose
Splendid derived from pectin
Simplese microcapsules of milk protein or egg white protein.
Benefat triacylglycerides with mixture of short chain fatty
acids and stearic acid.
Fat replacers which are not natural occurring are tested
vigorously for its safety before it is approved for use.
E.g.
Olean hexa-, hepta-, and octa-esters of sucrose; can cause
diarrhea and oily stools if consumed in large quantities.
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Precaution
Avoid deficiency of essential fatty acid e.g.
omega 3 (linolenic acid (18:3, -3),
eicosapentaenoic acid (20:5, -3) ,
docosapentaenoic acid(22:5, -3) and omega 6
(linoleic acid (18:2, -6), arachidonic acid (20:4,
-6)) fatty acids
Supply and absorption of vitamin A, D, E and K
may be affected.
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Healthy Fat Diet
Dos and donts of healthy fat diet. What is your
say?
Bread, cereal, rice and pasta group
Dairy products
Fats, oils and sweets
Protein
Vegetables and fruits
Snacks and desserts
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Healthy Fat Diet
Food labels
Regulation in Singapore is published by AVA Food regulations
and, HPB Handbook of nutrient claims has guidelines on:
Energy lite/light/low energy/calorie, less/lower/reduced
energy/calorie, more/fortified/added/enriched energy
Total fat fat free, no fat, low/light/lite in fat, reduced/lower/less in
fat, lean meat, extra lean meat
Fatty acids Saturated fat free, low saturated fat, reduced saturated
fat, contains PUFA, high in PUFA, more/increased PUFA, contains
MUFA, high in MUFA, more/increased MUFA
Cholesterol cholesterol free, low/light/lite in cholesterol,
lower/reduced cholesterol

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Diabetes
Diabetes is a disease in which the body does not
produce or properly use insulin.
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Muscle Cell
or
Fat Cell
Glycogen G-6-P Glucose
FA
Synthesis
Energy
VLDL
Blood Glucose
Starch, sugar
Digestion
Insulin
Liver
pancreas
Muscle
and fat
cell
Diabetes - Type 1 (Insulin dependent
diabetes mellitus)

Due to damage of pancreatic cells unable to
produce insulin.
5-10% of cases.
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Muscle Cell
or
Fat Cell
Glycogen G-6-P Glucose
FA
Synthesis
Energy
VLDL
Blood Glucose
Starch, sugar
Digestion




Insulin

Diabetes Type 2 (Insulin resistance)

Not responding to insulin.
90-95% of cases.
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Muscle Cell
or
Fat Cell
Glycogen G-6-P Glucose
FA
Synthesis
Energy
VLDL
Blood Glucose
Starch, sugar
Digestion


Insulin
Pancreas become exhausted/damage

Not responding to insulin
Diabetes
Problems:
Cells suffer from lack of sugar (starvation).
Fat is used for energy instead, resulting ketoacidosis in
type 1 diabetes.
Insulin in type 2 diabetes inhibit fat breakdown.
Ketoacidosis is less severe. Glucagon dominate and
gluconeogenesis result in hyperosmolar hyperglycemic
state (dehydration).
High blood sugar (hyperglycemic) may affect vision,
delay wound healing, heart disease, kidney failure,
stroke, loss of limbs etc.
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Body Weight of Diabetics
Type 1
Normally not
overweight.
Weight gain
may be side
effect of insulin
treatment.
Type 2
Normally
overweight.
Overweight can
worsen insulin
resistance.
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Diabetes
Principles of diet management;
Balance diet with essential nutrients
Maintenance of ideal weight
Meeting energy needs
Prevention of blood sugar variation and keeping it
as close to normal level
Decrease of blood lipid levels, if elevated
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Diabetes Nutrition Management
How is it achieved?
Consistent carbohydrate content in meals at timed
intervals to maintain blood sugar level.
Overall calories eaten must be controlled to
manage weight over long term.
Consumption of carbohydrate must not be lower
than 130 g/day.


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Diabetes Nutrition Management
Carbohydrate sources:
Different foods has different glycemic effect*
E.g.
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*Glycemic Effect rate of change in glucose in blood after
consumption of food
Food Glycemic Index
Rice 76
Brown Rice 48
Diabetes Glycemic Index
Glycemic index (GI): An index given to food base on its
ability to increase blood sugar level compared to glucose
(sometimes white bread is used instead of glucose).
Glycemic index = area under blue curve/area under red
curve x 100
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50g glucose
50g carbohydrate
containing food
Glycemic index is affected by
Cook or raw, cooking time, how the food is cut etc.
Level of ripeness of fruits and vegetables
Variations in digestion and absorption
Possibly of other components in foods e.g. fibre.
For people with diabetes, low GI foods should be
consumed.
GI does not give the extent to which blood
glucose is raised by a consumption of a
particular amount of a food.

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Classification GI range Examples
Low 55 or less most fruit and vegetables (except
potatoes), wholegrains, basmati rice,
pasta
Medium 56 - 69 sucrose, candy bar, croissant, some
brown rices
High 70 or
more
corn flakes, baked potato, some
white rices (eg. jasmine), white
bread
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Glycemic Load
Glycemic load (GL) represents blood-glucose-raising
potential of specific amount of food consumed.
GL = GI x mass of carbohydrate in food consumed/100
E.g. 1 baked potato has 34 g of carbohydrate. GI of
baked potato is 85. Therefore GL = 34 x 85/100 = 28.9
GL is a better indicator of the effect of a certain amount
food on blood glucose level.
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Comparing GI and GL of Foods
Long Grain Rice Brown Rice
Quantity per serve (g) 150 150
Total carbohydrate (g) 40 42
Glycemic Index 76 48
Glycemic Load 30 20
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Long Grain Rice Brown Rice
Quantity per serve (g) 100 150
Total carbohydrate (g) 27 42
Glycemic Index 76 48
Glycemic Load 20 20
Is there a need to avoid sugar?

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Diabetes
Use of sweeteners:
Nutritive sweeteners
E.g. fructose, sorbitol, xylitol.
Contain calories. May be labelled as sugar free!
Less elevation of blood sugar
Used in sugar free foods
May have laxative effects
Non-nutritive sweeteners.
E.g. Aspartame, Acesulfame K, Saccharin
Minimum or no calories
Minimal or no elevation of blood sugar
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Diabetes Nutrition Management
Fiber
Recommendation same as general population
i.e. 21 to 38 g per day.
Fiber rich foods are encouraged and may improve
glycemic control.

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Diabetes Nutrition Management
Fat intake
Due to high risk of cardiovascular disease, healthy
fat diet is recommended.
Protein
15 to 20 % of total kcalories. (within
recommended range for general population).
Alcohol
Minimise.
Consume with food to avoid hypoglycemia.
Alcohol interfere with glucose production in liver.
May increase triglyceride level.
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Diabetes Exchange Lists
Separation of foods into food groups:
Bread/starch
Vegetable
Milk
Meat
Fruit
Fat
Foods in the same group should have approximately
similar number of calories, composition (carbohydrate,
fats and protein) and effects on blood glucose levels.
Exchange list can be set up for each group.
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Diabetes Exchange List
Example of exchange list:

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Sample Exchange List
Food group You can have..... Or exchange it for...
Fruit (Each serving contains about 15
grams carbohydrates)
1 small or medium piece
of fresh fruit
1/2 cup fruit juice,or
canned or chopped fruit
Vegetable (Each serving contains about 5
grams carbohydrates)
1 cup raw vegetables 1/2 cup cooked vegetables
or vegetable juice
Starch (Each serving contains about 15
grams carbohydrates)
cup of rice 1/2 cup noodles
Sugar, honey, molasses 1 teaspoon 4 grams carbohydrates
Milk 1 cup low fat milk 1 cup of low-fat yogurt
Meat 1 ounce meat 1 ounce of fish or poultry
Fat (includes nuts, seeds and small
amounts of bacon & peanut butter)
1 teaspoon oil, butter or
margarine
5 grams fat
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Hypertension
Blood Pressure Systolic Pressure (when the
heart beats)/Diastolic Pressure (when the
heart relaxes between beats)
Blood Pressure levels for Adults:

Category Systolic (mm Hg) Diastolic (mm Hg)
Normal < 120 < 80
Prehypertension 120-139 80-89
Hypertension 140 90
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Hypertension
Salt contain 400mg of sodium in 1000mg of salt!
Na+ causes dehydration of cell and increase in blood
pressure.
Na+ can be reduced by reducing intake of food
containing sodium as well as salt.
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Water
Blood vessel
Na+
Cell
DASH Diet
Dietary Approaches to Stop Hypertension
Purpose of diet:
People with cardiovascular disease and high blood
pressure
Reduce asthma symptoms
Help with migraine, gastritis and ulcers.
Reduce intake of sodium which is related to
chronic diseases
Sodium can be found in table salt, MSG, baking
soda, soy sauce and some antiacids.
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DASH Diet
Daily nutrient goals (for 2100 kcal eating plan)

Total Fat 27% kcal Sodium* 2300 mg
Saturated Fat 6% kcal Potassium 4700 mg
Protein 18% kcal Calcium 1250 mg
Carbohydrate 55% kcal Magnesium 500 mg
Cholesterol 150 mg Fiber 30 g
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*1500 mg lower goal is better for lowering blood
pressure

DASH Diet
Food Groups
Servings/Day*
1600 kcal/d 2000 kcal/d 2600 kcal/d 3100 kcal/d
Grains (preferably whole grain) 6 6-8 10-11 12-13
Vegetables** 3-4 4-5 5-6 6
Fruits** 4 4-5 5-6 6
Fat-free or low fat milk and milk
products
2-3 2-3 3 3-4
Lean meats, poultry and fish 3-6 6 6 6-9
Nuts, seeds and legumes 3/wk 4-5/wk 1 1
Fats and oils 2 2-3 3 4
Sweets and added sugar 0 2 2 2
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*To lose weight, aim for lower caloric intake level
**Larger servings of vegetables and fruits are recommended
DASH Diet
Tips to reduce Salt and Sodium
Choose low- or reduced-sodium or no salt alternatives.
Choose fresh or frozen food. If canned, no salt added. And if
possible, rinse the salt from the food before using.
Choose processed food carefully some processes involves
the addition of salt. E.g. cured (bacon, ham), preserved with
brine (tuna, salted vegetables), condiments (tomato sauce,
BBQ sauce, steak sauce)
Soy sauce, teriyaki sauce also contains sodium. Choose low
salt versions. Use condiments and table salt sparingly.
Other words that may show the addition of salt: Smoked,
corned, pickled.
Cooked food normally has salt added.
Many snack foods also contain added salt.
Check nutrition labels for information on sodium content.
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vs
DASH Diet
Change gradually. For example:
Reduce sodium intake by reducing the use of table salt
and salt during cooking.
Increase intake of fruits and vegetables at one meal.
Choose the easiest change. E.g. drinking fruit juice.
Introduce high potassium vegetables or fruits slowly.
Cut down on saturated fat and trans fat.

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Other Examples
Gluten Restricted Diet
Who is affected: Celiac sprue
Foods to avoid: all wheat, rye, oats, barley and
buckwheat products.
Watch out for hidden gluten: e.g. sausage soy sauce,
sauce and gravy mixes etc.
Assignment: Prepare an exchange list for bread
and cereal, fat, fruit, meat and meat substitute
suitable for a celiac. State in each category what
foods they should avoid.
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Other Examples
Lactose Restricted Diet
Who is affected: Lactose intolerant
Foods to avoid: Foods with lactose, casein, caseinate,
whey, whey products, or non-fat dry milk solids.
Foods containing very low level of lactose is possible
for the less sensitive. E.g. yoghurt, aged-cheese,
buttermilk
Caution: lack of Ca
2+
Can consider adding lactase in milk
Assignment: What foods with hidden lactose
should be avoided? What is the best food to
replace milk?
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