RAMADAN NUTRITION PLAN (RNP) - blood sugar control during Ramadan - Nestlé Health Science ...
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UTRITION
AD AN N
RAM )
N (RN P
PLA
it ion g u id e f or optimum
utr
An effective n l d u rin g Ramadan
on t r o
blood sugar c
WHAT IS RNP?
RAMADAN NUTRITION PLAN (RNP)
An effective nutrition guide during Ramadan developed specifically
for diabetic individuals who take oral anti-diabetic medication
without taking insulin injections.
RNP
RNP EFFICACY IN DIABETIC INDIVIDUALS
Change in HbA1c value from
Change in blood sugar profile
baseline at week 8
RNP Usual care
RNP Usual care
0 Before *p < 0.05
6.9*
-0.35% pre-dawn
meal 7.8
2 hours
Change in HbA1c
after 8.2
-0.72%* pre-dawn
meal
8.5
*p < 0.001 Before 7.6*
sleep 8.6
6.5 Mean blood glucose level (mmol/L)
Self-measured by subjects using a glucometer.
Adapted from Barakatun Nisak MY, et al. Nutrients 2020.
Adapted from Barakatun Nisak MY, et al. International Diabetes Federation
Congress 2019.
References
1. Barakatun Nisak MY, Wan Zul Haikal Hafiz WZ, Zalina AZ, et al. Comparison of structured nutrition therapy for Ramadan with standard care in type 2 diabetes patients. Nutrients 2020;12(813): doi:10.3390/nu12030813. 2. Barakatun Nisak
MY, Wan Zul Haikal Hafiz WZ, Zalina AZ, et al. Effects of structured nutrition therapy during Ramadan fasting on glycaemic control parameters in patients with type 2 diabetes. Presented at: International Diabetes Federation Congress 2019; 2-6
December 2019.
3 GOALS OF RNP
1 2 3
To ensure sufficient calorie To distribute carbohydrate To ensure other co-morbidities
intake and balanced portions uniformly across such as hypertension and
macronutrient proportions each meal to control blood dyslipidaemia are controlled.
to avoid hypoglycaemia, sugar level, especially after
hyperglycaemia, and to breaking fast.
control body weight.
Reference
1. Hamdy O, Mohd Yusof BN, Reda WH, Slim I, Jamoussi H, Omar MAK. Chapter 7: The Ramadan Nutrition Plan (RNP) for patients with diabetes. Diabetes and Ramadan: Practical Guidelines. 2016;
International Diabetes Federations; Belgium.
10 PRINCIPLES OF RNP
1 2 3 4 5
Get a doctor or a Take adequate Make sure the Use ‘Ramadan Plate’ Choose
dietitian’s advice amounts of calories macronutrient as a guide to ensure carbohydrates
before deciding to and carbohydrates. proportions are pre-dawn and breaking that are low in GI
fast. Distribute uniformly balanced (suggested fast meals are complete and high in fibre
between the carbohydrate 45-50%, with vegetables, (wholegrain is
pre-dawn meal, protein 20-30% and fat protein, a little fat and preferred).
breaking fast meal no more than 35% of carbohydrate. Eat
and (if needed) 1-2 total calorie intake). vegetables first.
snack times (before
breaking fast meal or
late suppertime).
References
1. Hamdy O, Mohd Yusof BN, Reda WH, Slim I, Jamoussi H, Omar MAK. Chapter 7: The Ramadan Nutrition Plan (RNP) for patients with diabetes. Diabetes and Ramadan: Practical Guidelines. 2016; International Diabetes Federations; Belgium.
2. Hui E, Bravis V, Hassanein M, et al. Management of people with diabetes wanting to fast during Ramadan. BMJ. 2010;340:c3053.
10 PRINCIPLES OF RNP
6 7 8 9 10
Delay pre-dawn Break fast with Drink sufficient Diabetes-specific If needed, take
mealtime. Snack 1 (mini break water (limit sugary formula (DSF) can be healthy snacks
fast) followed by or caffeinated taken as a part of pre- such as a cut
prayers. Then, take drinks) between dawn meal or snack, of fruit, boiled
a healthy breaking breaking fast time to ensure nutritional chickpeas or
fast meal. and pre-dawn adequacy and to savoury fresh
mealtime. control blood sugar spring roll.
level and body weight.
References
1. Hamdy O, Mohd Yusof BN, Reda WH, Slim I, Jamoussi H, Omar MAK. Chapter 7: The Ramadan Nutrition Plan (RNP) for patients with diabetes. Diabetes and Ramadan: Practical Guidelines. 2016; International Diabetes Federations; Belgium.
2. Chee WS, Singh HK, Hamdy O, et al. Structured lifestyle intervention based on a trans-cultural diabetes-specific nutrition algorithm (tDNA) in individuals with type 2 diabetes: a randomized controlled trial. BMJ Open Diabetes Res Care.
2017;5(1):e000384.
RNP RAMADAN PLATE
Fruits
Choose fresh fruits or dates
Soup or gravy
Choose a low-fat
cooking style
Plain water
Drink plain water habitually
Reduce intake of caffeinated
drinks
1/2 Vegetables
Eat vegetables first 1/4 Protein
Fish, chicken, meat
or legumes
Choose lean meat
1/4 Carbohydrate Choose a low-fat
cooking style
Rice, noodles, bread, cereal,
cereal products or tubers
Choose wholemeal
RAMADAN
PLATE
CARBOHYDRATE MANAGEMENT
P
ortion T ype T ime
45-50%
of calories
Take carbohydrates based on Choose low GI, Distribute equally
45-50% of total daily calorie wholegrain and high fibre throughout the day for
intake. carbohydrates. each meal (pre-dawn meal,
snack 1 [mini break fast],
breaking fast meal and
snack 2 [late suppertime]).
CARB
MANAGEMENT
CARBOHYDRATE MANAGEMENT
- PORTION
Protein
1 carbohydrate exchange* Fat
2 carbohydrate exchanges
Balanced meal = Carbohydrate + Protein + Fat + Vegetables (eat vegetables first)
F
ood intake becomes imbalanced if only
taking carbohydrates
*1 exchange = 15 g carbohydrates
PORTION
CARBOHYDRATE MANAGEMENT
- PORTION
Examples of foods containing 1 carbohydrate exchange
1 piece ½ cup wholemeal 1 medium ½ cup ½ cup ¼ cup 3 pieces
wholemeal bread spaghetti potato brown rice pasta muesli cream crackers
4 tablespoons 3 tablespoons ½ cup 1 small 3 small 1 red
skimmed milk powder oat dhal banana dates apple
4 small 1 green ½ cup ¼ cup /8 cup
1
½ cup ½ cup green soy
dried apricots apple baked beans kidney beans* red beans* green beans* beans (edamame)**
*Uncooked. **Without pod.
References
1. Suzana S, Nik Shanita S, Zahara AM, Hasnah H. Atlas of food exchanges & portion sizes. Third edition. Kuala Lumpur, KL: MDC Publishers Sdn. Bhd.; 2015. 2. Ministry of Health Malaysia. Clinical practice guidelines—management of type 2 diabetes
mellitus. Fifth edition, 2015. Available at http://www.moh.gov.my/moh/resources/Penerbitan/CPG/Endocrine/3a.pdf. Diakses pada 20 Februari 2020. 3. Diabetes Education Online—University of California, San Francisco. Food exchange lists.
Diperoleh dari https://dtc.ucsf.edu/pdfs/FoodLists.pdf. Accessed on 21 Februari 2020.CARBOHYDRATE MANAGEMENT
- TYPE
Low GI
Rendah
GI GI is a measure of how quickly a carbohydrate-containing food increases
blood sugar level.
Low GI foods will not increase blood sugar level as quickly as high GI foods.1
Rendah
GI
Rendah
GI Low GI foods are usually of the wholegrain and high-fibre variety.1
What is wholegrain? What is high-fibre?
Minimally processed grains Bran Fibre is the roughage resistant to digestion.3
which still contain germ,
endosperm and bran layers. High-fibre foods such as whole grains helps
Processed cereal usually Endosperma
one get full quicker and aids in digestion.3
contains only the endosperm.2 Germa
Examples of high-fibre foods include
It is high in fibre.2 vegetables, fruits, whole grains (such as
brown rice), legumes and oat.3
Examples of wholegrain foods are brown rice,
oat, barley, quinoa, rye and more.2
GI: glycaemic index.
References
1. Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low–glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials. Diabetes Care. 2003;26(8):2261-7. 2. de Munter JS, Hu FB, Spiegelman D, Franz M, van Dam
RM. Whole grain, bran, and germ intake and risk of type 2 diabetes: a prospective cohort study and systematic review. PLoS Med. 2007;4(8):e261. 3. Anderson JW, Baird P, Davis RH, et al. Health benefits of dietary fiber. Nutr Rev. 2009;67(4):188-205.
4. The University of Sydney. GI database. Available at http://www.glycemicindex.com/foodSearch.php. Diakses pada 20 Februari 2020.CARBOHYDRATE MANAGEMENT
- TIME
T
ime Estimated time RNP guide
Pre-dawn meal 4.30-5.30 am* Delay pre-dawn mealtime.
Mealtime before commencement Refer to the 10 principles of RNP,
of fasting during the day Carbohydrate Management (Portion,
Type, Time) and Ramadan Plate.
Snack 1 (mini break fast) 7.20-7.30 pm** Break fast with a mini break fast snack
Mealtime after sundown but before taking the main meal.
before prayers
Breaking fast meal 7.45-8.00 pm Refer to the 10 principles of RNP,
Main mealtime (after prayers) Carbohydrate Management (Portion,
Type, Time) and Ramadan Plate.
Snack 2 (late suppertime) 10.00-11.00 pm Refer to the 10 principles of RNP and
Mealtime after late night prayers Carbohydrate Management (Portion,
Type, Time).
*Depending on time to commence fasting. **Depending on sundown time.SUGGESTED DISTRIBUTION OF
CARBOHYDRATE EXCHANGES
Suggestion for carbohydrate exchange distribution according to
total daily calorie intake (50% from carbohydrate)
Daily calorie (kcal/day) 1200 1500 1800
Suggestion Women < 150 cm in •W
omen < 150 cm in height Men who wish to
height who wish to who wish to maintain weight maintain or lose
lose weight •W
omen > 150 cm in height weight
who wish to lose weight
150 cm 150 cm
Carbohydrate amount* 10 exchanges 12 exchanges 14 exchanges
Distribution Pre-dawn 3 4 5
according to meal
mealtimes Snack 1 2 2 2
Breaking 3 4 5
fast meal
Snack 2 2 2 2
*1 exchange = 15 g carbohydrates
CARBOHYDRATE
EXCHANGESSUGGESTED PORTION AND
DISTRIBUTION OF CARBOHYDRATES
(1200 kcal 10 EXCHANGES)
Pre-dawn meal Snack 1 Breaking fast meal Snack 2
3 carbohydrate exchanges 2 carbohydrate exchanges 3 carbohydrate exchanges 2 carbohydrate exchanges
1 piece stuffed tofu with
1 cup fried vegetables
brown rice 3 ½ scoops DSF* with 3
vermicelli small dates (21 g) 1 cup
+ + +
brown rice
1 apple
3½
scoops
DSF*
Fried brown rice vermicelli with Brown rice with grilled fish and
Date milk shake with DSF Stuffed tofu
egg and salad vegetables
DSF: diabetes-specific formula.
*One scoop is equivalent to 7.9 g.
For other menu options, refer to 14-day Ramadan menu plan for 1200 kcal.
1200 KCALSUGGESTED PORTION AND
DISTRIBUTION OF CARBOHYDRATES
(1500 kcal 12 EXCHANGES)
Pre-dawn meal Snack 1 Breaking fast meal Snack 2
4 carbohydrate exchanges 2 carbohydrate exchanges 4 carbohydrate exchanges 2 carbohydrate exchanges
½ cup
dhal gravy
½a
flatbread
2 slices (6 cm)
wholemeal 3 ½ scoops DSF* with 3
bread small dates (21 g)
+ + +
1 ½ cup
brown rice
1 medium
cut melon
7 scoops
DSF*
Brown rice with grilled fish and ½ a flatbread with dhal gravy,
Toast with egg and salad Date milk shake with DSF
vegetables fried tofu and salad
DSF: diabetes-specific formula.
*One scoop is equivalent to 7.9 g.
For other menu options, refer to 14-day Ramadan menu plan for 1500 kcal.
1500 KCALSUGGESTED PORTION AND
DISTRIBUTION OF CARBOHYDRATES
(1800 kcal 14 EXCHANGES)
Pre-dawn meal Snack 1 Breaking fast meal Snack 2
5 carbohydrate exchanges 2 carbohydrate exchanges 5 carbohydrate exchanges 2 carbohydrate exchanges
1 piece
Vietnamese
3 ½ scoops DSF* with 3 roll (40 g)
small dates (21 g) 2 cups
1 ½ cup
+ + +
spaghetti
brown rice
1 orange 1 green pear
7 scoops
DSF*
Brown rice with grilled chicken Spaghetti aglio e olio Vietnamese rolls with prawn,
Date milk shake with DSF
and salad with prawn and salad cucumber and carrot
DSF: diabetes-specific formula.
*One scoop is equivalent to 7.9 g.
For other menu options, refer to 14-day Ramadan menu plan for 1800 kcal.
1800 KCALEAT VEGETABLES FIRST
R
NP suggests eating vegetables first before carbohydrates
Change in HbA1c level within 24 months
Routine method Eat vegetables first
0
-0.4
Change in HbA1c
Research has shown that
0.9% those who eat vegetables
-0.8 first before carbohydrates
have a high intake of
vegetables and fibre, and
-1.1 choose lower GI foods.1
1.5%
This pattern of eating helps
-1.5 reduce postprandial glucose
level, and contributes to the
lowering of HbA1c level.1
-1.9
This method allows attainment of optimum
sugar level within 24 months1
Reference
1. Imai S, Matsuda M, Hasegawa G, et al. A simple meal plan of ‘eating vegetables before carbohydrate’ was more effective for achieving glycemic control than an exchange-based meal plan in Japanese patients with type 2 diabetes. Asia Pac J Clin Nutr.
2011;20(2):161-8.
VEGETABLES
FIRSTDIABETES-SPECIFIC FORMULA (DSF)
INTAKE
D
SF is a formula containing specific nutrients to aid in body weight
control and achieving optimum blood sugar control1,2
Nutrients in DSF
Low GI carbohydrates*
Soluble fibre and prebiotics
Unsaturated fat
High quality protein
DSF is a source of low GI carbohydrate and
contains high-quality protein.
*Low GI starches do not raise blood sugar level abruptly.
GI: glycaemic index.
References
1. Gulati S, Misra A, Nanda K, et al. Efficacy and tolerance of a diabetes specific formula in patients with type 2 diabetes mellitus: an open label,
randomized, crossover study. Diabetes Metab Syndr Clin Res Rev. 2015;9(4):252-7. 2. Mottalib A, Abrahamson MJ, Pober DM, et al. Effect of diabetes-
specific nutrition formulas on satiety and hunger hormones in patients with type 2 diabetes. Nutr Diabetes. 2019;9(1):1-6.
DSFEMOTIONAL ASPECT WHEN FASTING AND
CELEBRATING EID
D
iabetic individuals may face emotional stress when fasting and
celebrating Eid, such as:
• Confusion in choosing the right foods
• Anxiousness about blood sugar levels
• Boredom due to dietary restrictions
• Sadness due to limited freedom in selecting foods
The following steps Strive to maintain
Practice a healthy
may help diabetic Manage emotional mindful
stress with relaxation emotional state
individuals remain eating4,5
techniques, light and diet after the
healthy and happy: fasting month and
exercise and a
healthy diet1-3 Eid celebrations
References
1. Healthline. Stress—how it affects diabetes and how to decrease it. Available at https://www.healthline.com/health/diabetes-and-stress. Accessed on 24 January 2020. 2. Medscape. Diet and mental health—the evidence to date. Available at
https://www.medscape.com/viewarticle/923817#vp_1. Accessed on 24 January 2020. 3. Surwit RS, Van Tilburg MA, Zucker N, et al. Stress management improves long-term glycemic control in type 2 diabetes. Diabetes Care 2002;25(1):30-4.
4. University of Michigan Comprehensive Diabetes Center. Diabetes: mindful eating. Available at http://www.med.umich.edu/1libr/MEND/Diabetes-mindfulEatingTips.pdf. Accessed on 24 January 2020. 5. Miller CK. Mindful eating with diabetes.
Diabetes Spectr. 2017;30(2):89-94.
EMOTIONAL
ASPECTDeveloped by:
Malaysian Diabetes Ramadan Nutrition Plan
(My-Dia RNP) Research Group
Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia
With the cooperation of:
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