Nutrition Management of Gestational Diabetes Mellitus.

Medical nutrition therapy (MNT) is the bedrock for the management of gestational diabetes mellitus (GDM). Several different types of dietary approaches are used globally, and there is no consensus among the various professional groups as to what constitutes an ideal approach. The conventional approach of limiting carbohydrates at the cost of increasing energy from the fat source may not be most optimal. Instead, allowing higher levels of complex, low-to-medium glycaemic index carbohydrates and adequate fibre through higher consumption of vegetables and fruits seems more beneficial. No particular diet or dietary protocol is superior to another as shown in several comparative studies. However, in each of these studies, one thing was common - the intervention arm included more intensive diet counselling and more frequent visits to the dieticians. For MNT to work, it is imperative that diet advice and nutrition counselling is provided by a dietician, which is easy to understand and use and includes healthy food options, cooking methods, and practical guidance that empower and motivate to make changes towards a healthy eating pattern. Various simple tools to achieve these objectives are available, and in the absence of qualified dieticians, they can be used to train other health care professionals to provide nutrition counselling to women with GDM. Given the impact of GDM on the future health of the mother and offspring, dietary and lifestyle behaviour changes during pregnancy in women with GDM are not only relevant for immediate pregnancy outcomes, but continued adherence is also important for future health.

Lean Mass Improvement from Nutrition Education and Protein Supplementation among Rural Indian Women Living with HIV/AIDS: Results from Cluster Randomized Factorial Trial at 18-Month Follow-Up.

Loss of lean muscle mass impairs immunity and increases mortality risk among individuals with HIV/AIDS. We evaluated the relative contributions of protein supplementation and nutrition education on body composition among 600 women living with HIV/AIDS in rural Andhra Pradesh, India. We conducted a cluster randomized controlled 2 × 2 factorial trial lasting six months with follow up at twelve and eighteen months. Interventions occurred in the Nellore and Prakasam regions of Andhra Pradesh by trained village women, ASHA (Accredited Social Health Activists), and included: (1) the usual supportive care from ASHA (UC); (2) UC plus nutrition education (NE); (3) UC plus nutritional protein supplementation (NS); (4) combined UC plus NE plus NS. A Bioimpedance Analyzer Model 310e measured body composition. SAS 9.4 analyzed all data. Mixed models using repeated measures evaluated lean mass change from baseline as primary and fat weight and total weight as secondary outcomes. Lean mass change was significantly associated with NS (p = 0.0001), NE (p = 0.0001), and combined NS plus NE (p = 0.0001), with similar associations for secondary outcomes. Stronger associations for total weight were observed with greater ART adherence. Nutritional interventions may improve physiologic response to HIV. Significant increases in lean mass resulted from independent and combined protein supplementation and nutrition education.

Development of a field-friendly automated dietary assessment tool and nutrient database for India.

Studies of diet and disease risk in India and among other Asian-Indian populations are hindered by the need for a comprehensive dietary assessment tool to capture data on the wide variety of food and nutrient intakes across different regions and ethnic groups. The nutritional component of the India Health Study, a multicentre pilot cohort study, included 3908 men and women, aged 35-69 years, residing in three regions of India (New Delhi in the north, Mumbai in the west and Trivandrum in the south). We developed a computer-based, interviewer-administered dietary assessment software known as the 'NINA-DISH (New Interactive Nutrition Assistant - Diet in India Study of Health)', which consisted of four sections: (1) a diet history questionnaire with defined questions on frequency and portion size; (2) an open-ended section for each mealtime; (3) a food-preparer questionnaire; (4) a 24 h dietary recall. Using the preferred meal-based approach, frequency of intake and portion size were recorded and linked to a nutrient database that we developed and modified from a set of existing international databases containing data on Indian foods and recipes. The NINA-DISH software was designed to be easily adaptable and was well accepted by the interviewers and participants in the field. A predominant three-meal eating pattern emerged; however, patterns in the number of foods reported and the primary contributors to macro- and micronutrient intakes differed by region and demographic factors. The newly developed NINA-DISH software provides a much-needed tool for measuring diet and nutrient profiles across the diverse populations of India with the potential for application in other South Asian populations living throughout the world.

Multi-center feasibility study evaluating recruitment, variability in risk factors and biomarkers for a diet and cancer cohort in India.

BACKGROUND: India's population exhibits diverse dietary habits and chronic disease patterns. Nutritional epidemiologic studies in India are primarily of cross-sectional or case-control design and subject to biases, including differential recall of past diet. The aim of this feasibility study was to evaluate whether a diet-focused cohort study of cancer could be established in India, providing insight into potentially unique diet and lifestyle exposures. METHODS: Field staff contacted 7,064 households within three regions of India (New Delhi, Mumbai, and Trivandrum) and found 4,671 eligible adults aged 35-69 years. Participants completed interviewer-administered questionnaires (demographic, diet history, physical activity, medical/reproductive history, tobacco/alcohol use, and occupational history), and staff collected biological samples (blood, urine, and toenail clippings), anthropometric measurements (weight, standing and sitting height; waist, hip, and thigh circumference; triceps, sub-scapula and supra-patella skin fold), and blood pressure measurements. RESULTS: Eighty-eight percent of eligible subjects completed all questionnaires and 67% provided biological samples. Unique protein sources by region were fish in Trivandrum, dairy in New Delhi, and pulses (legumes) in Mumbai. Consumption of meat, alcohol, fast food, and soft drinks was scarce in all three regions. A large percentage of the participants were centrally obese and had elevated blood glucose levels. New Delhi participants were also the least physically active and had elevated lipids levels, suggesting a high prevalence of metabolic syndrome. CONCLUSIONS: A high percentage of participants complied with study procedures including biological sample collection. Epidemiologic expertise and sufficient infrastructure exists at these three sites in India to successfully carry out a modest sized population-based study; however, we identified some potential problems in conducting a cohort study, such as limited number of facilities to handle biological samples.

A cross-sectional investigation of regional patterns of diet and cardio-metabolic risk in India.

BACKGROUND: The role of diet in India's rapidly progressing chronic disease epidemic is unclear; moreover, diet may vary considerably across North-South regions. METHODS: The India Health Study was a multicenter study of men and women aged 35-69, who provided diet, lifestyle, and medical histories, as well as blood pressure, fasting blood, urine, and anthropometric measurements. In each region (Delhi, n=824; Mumbai, n=743; Trivandrum, n=2,247), we identified two dietary patterns with factor analysis. In multiple logistic regression models adjusted for age, gender, education, income, marital status, religion, physical activity, tobacco, alcohol, and total energy intake, we investigated associations between regional dietary patterns and abdominal adiposity, hypertension, diabetes, and dyslipidemia. RESULTS: Across the regions, more than 80% of the participants met the criteria for abdominal adiposity and 10 to 28% of participants were considered diabetic. In Delhi, the "fruit and dairy" dietary pattern was positively associated with abdominal adiposity [highest versus lowest tertile, multivariate-adjusted OR and 95% CI: 2.32 (1.03-5.23); Ptrend=0.008] and hypertension [2.20 (1.47-3.31); Ptrend<0.0001]. In Trivandrum, the "pulses and rice" pattern was inversely related to diabetes [0.70 (0.51-0.95); Ptrend=0.03] and the "snacks and sweets" pattern was positively associated with abdominal adiposity [2.05 (1.34-3.14); Ptrend=0.03]. In Mumbai, the "fruit and vegetable" pattern was inversely associated with hypertension [0.63 (0.40-0.99); Ptrend=0.05] and the "snack and meat" pattern appeared to be positively associated with abdominal adiposity. CONCLUSIONS: Cardio-metabolic risk factors were highly prevalent in this population. Across all regions, we found little evidence of a Westernized diet; however, dietary patterns characterized by animal products, fried snacks, or sweets appeared to be positively associated with abdominal adiposity. Conversely, more traditional diets in the Southern regions were inversely related to diabetes and hypertension. Continued investigation of diet, as well as other environmental and biological factors, will be needed to better understand the risk profile in this population and potential means of prevention.

Measurement of spices and seasonings in India: opportunities for cancer epidemiology and prevention.

Bioactive components of many foods added during cooking have potential antioxidant, anti-inflammatory, antimicrobial, antibacterial and chemopreventive properties. However, epidemiologic studies generally do not collect detailed information on these items, which include spices, chilies, coconuts, garlic, onions, and oils. Since India has some of the highest spice consumption in the world, we developed a computer-based food preparer questionnaire to estimate per capita consumption of 19 spices, chilies, coconuts, garlic, onions, and 13 cooking oils among 3,625 participants in the India Health Study, a multicenter pilot study in three regions of India. We observed notable regional differences in consumption of spices, chilies, coconut, garlic, and onions. In Trivandrum, over 95 percent of the participants consumed 12 different spices, while in New Delhi and Mumbai, 95 percent of participants consumed only four and five spices, respectively. Cooking oil use also varied, as ghee was most common in New Delhi (96.8%) followed by mustard seed oil (78.0%), while in Trivandrum the primary oil was coconut (88.5%) and in Mumbai it was peanut (68.5%). There was some variation in consumption by education, income, and religion. Using a novel method for assessing food items primarly added during cooking, we successfully estimated per capita consumption within an epidemiologic study. Based on basic science research and suggestive ecologic level data on cancer incidence and spice consumption, improving epidemiologic assessment of these potentially chemopreventive food items may enhance our understanding of diet and cancer risk.

Barriers to changing dietary behavior.

Dietary change requires giving up long established patterns of eating behavior and acquiring new habits. 'Non-compliance' to diet advice may be a result of inability to provide diet self-management training and getting the right messages across to change eating behavior. Using a pre-tested questionnaire based interview, we carried out a study amongst 350 adults (> 20 years) with type 2 diabetes from two metro cities in South India, who had previously received diet advice with the objective to understand perceptions, attitudes and practices, as well as study factors that enhance or reduce compliance to diet advice. Ninety six patients (28%) followed diet for the full duration of diabetes (Group1), 131 (38%) followed diet for a partial duration varying between more than a quarter to three quarters of the total diabetes duration (Group 2) and 115 (34%) did not follow diet advice (Group 3) - followed for a duration less than a quarter of their diabetes duration. Study results show that many factors both patient and health care provider related influence outcomes of dietary advice. Factors that have a positive impact on compliance are - older age, shorter duration, nuclear family, good family support, less busy work life, higher health consciousness, advice given by dietician, more frequent visits to dietician, advice that includes elements to promote overall health not merely control of blood sugar, diet counseling that is easy to understand and use and includes healthy food options, cooking methods, practical guidance to deal with lifestyle issues. We conclude that patient barriers related to life circumstance are mostly non-modifiable, most modifiable barriers are related to behavioural aspect and the inability of the health care provider to provide individualized diet advice and self management training. Efforts must be made to improve counseling skills.