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Nutr Hosp. 2015;31(3):1147-1153
ISSN 0212-1611 • CODEN NUHOEQ
S.V.R. 318
Original / Síndrome metabólico
Nutritional adequacy in subjects with metabolic syndrome
1,5 1,5 2,5
Cláudia Mesquita de Carvalho , Dayana Dias Mendonça , Carla Haas Piovesan , Fabrício Edler
3,6 4,6
Macagnan and Ana Maria Pandolfo Feoli
1 2
Nutritionist, Pontifícia Universidade Católica do Rio Grande do Sul. Nutritionist, Master in Medicine and Health Sciences,
3
Professor of the Nutrition of the Pontifícia Universidade Católica do Rio Grande do Sul. Physiotherapist, PhD in Medicine
and Health Sciences, Professor at the Physiotherapy Department of the Universidade Federal de Ciências da Saúde de Porto
4
Alegre, Rio Grande do Sul, Brazil. Nutritionist, PhD in Biological Sciences - Biochemistry, Professor and Coordinator of the
5
Nutrition of the Pontifícia Universidade Católica do Rio Grande do Sul. Participated in conception and design of the study,
6
generation, data collection, analysis and interpretation of data, drafting and revision of the manuscript. Participated in the
overall coordination of the study, conception and design of the study, analysis and interpretation of data, drafting, revision and
orientation of the manuscript.
Abstract LA ADECUACIÓN NUTRICIONAL EN SUJETOS
Introduction: The nutritional approach in the treat- CON SÍNDROME METABÓLICO
ment of metabolic syndrome is a fundamental factor. It is Resumen
important to raise awareness to patients about the bene-
fits of following the treatments when you want to promo- Introducción: La terapia nutricional en el tratamiento
te changes in lifestyle. del síndrome metabólico es un factor clave. Es importan-
Objective: The aim of this study was to assess nutritio- te educar los pacientes sobre los beneficios de seguir el
nal adequacy in subjects with metabolic syndrome accor- tratamiento cuando se quiere promover cambios nel es-
ding to the dietary recommendations prescribed. tilo de vida.
Methods: Quasi-experimental research with 72 sub- Objetivo: El objetivo fue evaluar la adecuación nutri-
jects with metabolic syndrome, held in southern Brazil. cional en individuos con síndrome metabólico de acuerdo
A nutritional orientation was conducted, related or not con las recomendaciones dietéticas prescritas.
with physical exercise for three months. A 24-hour recall Métodos: Un ensayo clínico con 72 sujetos con síndro-
and two-day food record, were the reference method of me metabólico, llevados a cabo en el sur de Brasil. Aseso-
dietary intake assessment. Nutritional adequacy was de- ramiento nutricional se llevó a cabo, asociada o no con el
termined by the energy and nutrient intakes as defined ejercicio físico durante tres meses. Un retiro de alimentos
by the Brazilian Food Guide Pyramid groups. de 24 horas, y un registro de alimentos de dos días fueron
Results: Volunteers reached on average 80% of the los métodos de referencia para el consumo de alimentos.
energy consumption recommended. Protein and lipid La adecuación nutricional se determinó mediante la in-
intake was higher, and carbohydrate consumption was gesta de energía y nutrientes, grupos de alimentos defini-
lower than recommended levels. There was a low intake dos por la Pirámide de Alimentos del Brasil.
of cereals, vegetables, dairy product and beans (p<0.001) Results: Los voluntarios alcanzado un promedio del
as compared with the recommended servings. A high 80% del consumo de energía se recomienda. La inges-
consumption of meat (p<0.001) and an adequate intake tión de proteínas y lípidos fue mayor de lo esperado, y la
of fruit (p=0.149) were observed. ingesta de hidratos de carbono fue inferior a los niveles
Conclusion: The dietary intake was insufficient to recomendados. Hubo una baja ingesta de cereales, ver-
meet the recommendation of energy, although the goal duras, productos lácteos y frijoles (p <0,001) en compa-
for weight loss was achieved. Still, the results show the ración con las porciones recomendadas. Se observaron
need for a balance in food intake and quality of the diet un alto consumo de carne (p <0,001) y la ingesta de fruta
to achieve nutritional adequacy. adecuada (p = 0,149).
(Nutr Hosp. 2015;31:1147-1153) Conclusión: El consumo dietético fue insuficiente para
DOI:10.3305/nh.2015.31.3.8086 cumplir con las recomendaciones de la energía, aunque
se logró la meta de pérdida de peso. Aún así, los resulta-
Key words: Metabolic syndrome X. Nutrition therapy. dos muestran la necesidad de un equilibrio de la ingesta
Diet therapy. Risk factors. Nutritional requirements. de alimentos y calidad de la dieta para lograr la adecua-
ción nutricional.
(Nutr Hosp. 2015;31:1147-1153)
Correspondence: Ana Maria Feoli. DOI:10.3305/nh.2015.31.3.8086
Faculdade de Enfermagem, Nutrição e Fisioterapia/PUCRS; Avenida
Ipiranga 6681, prédio 12, 90619-900; Porto Alegre, RS, Brazil. Palabras clave: Síndrome metabólico X. Terapia nutricio-
E-mail: anamariafeoli@hotmail.com nal. Terapia de dieta. Factores de riesgo. Necesidades nu-
Recibido: 17-IX-2014. tricionales.
Aceptado: 16-XI-2014.
1147
021_8086 La adecuación nutricional en sujetos con síndrome metabólico.indd 1147 17/02/15 10:01
Abbreviations sources like plant oils and nuts as well as polyunsa-
turated fats found in fish (salmon, sardines and tuna)
NCD; Non-communicable chronic diseases and vegetable oils should be more consistently consu-
5, 7
AHA/NHLBI; American Heart Association/Natio- med . To assist in the alimentary recommendations
nal Heart, Lung, and Blood Institute Scientific State- are used dietary guidelines that should favoring nutri-
ment tion education using terms which are reasonable, sim-
HDL; HDL-cholesterol ple and clear for most consumers, indicating the ne-
8
PUCRS; Pontifícia Universidade Católica do Rio cessary modifications in food patterns . The Brazilian
Grande do Sul Food Guide Pyramid is an example of these guides.
IMC; Body mass index Studies have found that awareness of unhealthy lifes-
SPSS; Statistical Package for Social Sciences tyle and perceptions of susceptibility to chronic diseases
ANOVA; One-way analysis of variance lead individuals to have greater participation in pro-
9, 10, 11
grams to change eating habits and physical activity .
It is important to raise awareness to patients with chronic
Introduction diseases about the benefits of following the treatments
11
when you want to promote changes in lifestyle .
In the western world, shifts in lifestyle observed over Therefore, the objective of this study was to as-
the years include changes in eating habits and intensity sess nutritional adequacy in subjects with metabolic
of physical activity in the population. These changes syndrome according to the dietary recommendations
have contributed to the increase in non-communicable prescribed.
chronic diseases (NCD) such as obesity, diabetes melli-
tus, hypertension, dyslipidemia and cardiovascular di-
1, 2
seases . It is estimated that there are currently at least Methods
3
400 million obese people in the world . In this scena-
rio, in Brazil about 49% of adults are overweight and A quasi-experimental research was performed at Re-
4
approximately 14,8% of the population has obesity . habilitation Center of Hospital São Lucas of the Ponti-
The excess weight associated with other chronic di- fícia Universidade Católica do Rio Grande do Sul (PU-
seases or NCD gives rise to a clinical condition known CRS), Porto Alegre, Brazil. Including criteria were age
as metabolic syndrome, which is represented by a set between 30 and 59 years and diagnosis of metabolic sy-
5
of cardiovascular risk factors present in a single indivi- ndrome according to criteria defined by AHA/NHLBI ,
5
dual and can raise mortality due to cardiovascular di- which is determined by the presence of at least three
6
sease . Around 17 million deaths are caused by cardio- of the following factors: waist circumference ≥102 cm
1
vascular diseases, especially heart attack and stroke . for men and ≥88 cm for women, systolic and diastolic
Specifically concerning the Brazilian population, blood pressure ≥130 mmHg ≥85 mmHg, respectively,
there is a lack of data representative on the prevalen- fasting glucose ≥100 mg/dL, triglycerides ≥150 mg/dL,
ce of metabolic syndrome. According to the American HDL <40 mg/dL for men and <50 mg/dL for women.
Heart Association/National Heart, Lung, and Blood We considered the following exclusion criteria: use of
5
Institute Scientific Statement (AHA/NHLBI) , the medications for weight reduction and/or lipid-lowering
diagnosis of metabolic syndrome is determined by drugs, history of cardiovascular event, body mass index
12
the presence of three or more of the following factors: >40 kg/m² (BMI calculated as kg/height²) . Data were
increased waist circumference, high blood pressure, collected between May 2006 and July 2009. Initially
impaired glucose tolerance, hypertriglyceridemia and this study included 98 adult volunteers. Throughout the
low blood concentrations of HDL-cholesterol (HDL). study, 26 subjects dropped out, with 72 participants (48
The nutritional approach used in the treatment of females) remaining until the end.
metabolic syndrome is a fundamental factor whose The nutritional intervention was performed by the
main goals are weight loss and, consequently, the miti- nutrition team, and physical exercise sessions were su-
gation of associated risk factors such as blood pressu- pervised by the team of physiotherapists, all properly
re, glucose, cholesterol, and triglycerides. The nutritio- trained. Monitoring occurred individually and lasted
nal treatment must be individual and must be adjusted three months. The initial assessment comprised food
according to each subject, and provides a 7% to 10% record, a 24-hour recall, and measurement of weight,
reduction in the current body weight during a period of height and waist circumference. Also, subjects were
5
6 to 12 months . To achieve these goals, the individual asked to record their food intake for two days (one
should be directed towards adopting a balanced diet week day and one weekend day) to be brought in the
avoiding simple carbohydrates and choosing foods initial of study. After the evaluation, individualized
that are high in fiber like fruits, vegetables, legumes diet plans were presented to each patient. Follow-up
and whole grains, since these are sources of minerals visits occurred every two weeks to discuss changes in
and vitamins. Also, a balanced diet includes the de- eating habits, nutrition guidelines, and the importan-
creased intakes of saturated fatty acids. At the same ce of compliance with the diet to promote weight loss
time, monosaturated fatty acids present in vegetable and to improve the quality of health. The dietary in-
1148 Nutr Hosp. 2015;31(3):1147-1153 Cláudia Mesquita de Carvalho et al.
021_8086 La adecuación nutricional en sujetos con síndrome metabólico.indd 1148 17/02/15 10:01
tervention included written and oral instructions given The research protocol was started after approval by
as a lecture, visually aided using a series of posters. the Ethics in Research Committee of PUCRS (process
The achievement of goals and mainly difficulties to of number 159/06) and written informed consent was
adhere to diet were verified in all consultations. The obtained from all the volunteers.
physical exercise sessions included walking on a tre-
admill uninterruptedly for 30 min, three times a week,
totaling 36 sessions. Allowing speed and incline to Results
maintain a range of 65 to 75% of maximum heart rate
predicted for age. The mean age of the subjects was 50±6 years, BMI
2
The body weight of individuals was measured using of 33,3±4 kg/m classified as obese level I and average
a mechanical balance (Cauduro™) with maximum ca- criteria of metabolic syndrome are presented of table I.
pacity of 160 kg. Participants were required to wear The table II show the percentage of food intake in rela-
the minimum possible clothing and no shoes. Height tion to the calorie level recommended. We observed the
was obtained using a stadiometer, with two meters of following number of volunteers: 18, 30, 17 and seven
height and a half centimeters accuracy level. Waist for groups of calorie level 1.600, 1.900, 2.200 and 2.500
circumference was measured two centimeters over the kcal, respectively. The groups were not quantitatively
umbilical scar13 , using a common tape measure inex- homogeneous because the volunteers were allocated in
tensible and inelastic with 150 cm in length.
The recommended diet plan was based on calorie
equivalents. The food groups and serving sizes of each Table I
food group were established in accordance with the Characteristics of individuals. Porto Alegre (RS), 2009
Brazilian Food Guide Pyramid14. Four groups of ca-
lorie levels were established, in accordance with the Variable Value
15, 16
recommendation of 20 to 25 kcal/kg , aiming at the Age (years) 50.9±6.6
weight loss of 5% of initial weight within three mon- Weight (kg) 88.1±13.9
5
ths . The four groups of calorie levels established were:
1.600, 1.900, 2.200 and 2.500 kcal per day, distributed Height (m) 1.6±0.1
as 50-60% carbohydrates (predominantly from foods BMI (kg/m²) 33.3±4.2
rich in complex carbohydrates, especially whole gra- Waist circumference (cm) 106.6±9.2
ins), 20-30% of lipids (preferably polyunsaturated and
monounsaturated fats) and 10-15% protein (animal Total cholesterol (mg/dL) 228.7±51.0
sources and dairy products provide smaller amounts of Fasting glucose (mg/dL) 107.2±37.6
fat). Adherence to diet was analyzed by assessing the Triglycerides (mg/dL) 212.4±112.2
nutritional recommendations through the caloric levels
and servings of the food groups of the Brazilian Food HDL cholesterol (mg/dL) 44.4±10.2
Guide Pyramid prescribed and ingested, for every ca- LDL cholesterol (mg/dL) 139.7±43.1
lorie level. The 24-hour recall and two-day food record Systolic blood pressure (mmHg) 131.1±15.5
(obtained at the end of three months) were used to cal-
culate nutritional adequacy. The energy consumption Diastolic blood pressure (mmHg) 82.8±11.0
of macronutrients and servings of food groups were Fasting insulin (µUI/mL) 18.9±10.5
classified as below the recommended value, adequate
and above the recommended value. The results represent mean ± SD.
The Brazilian Food Composition Table was used in
the nutritional analysis of dietary surveys17. The data
were tabulated and submitted to statistical analysis with Table II
the aid of software Excel® 2007 and Statistical Packa- Percentage of food consumption in relation to the
ge for Social Sciences (SPSS®) version 17.0. To com- calorie level recommended. Porto Alegre (RS), 2009
pare food consumption in each group of energy level Groups of calorie level Energy consumption
the one-way analysis of variance (ANOVA) was used, (kcal) (%)
supplemented by the Scheffe post-test. The chi-square a
test was used to measure the association between cate- 1.600 (n=18) 93±16
gorical variables, and the Student’s t-test was employed a,b
1.900 (n=30) 82± 16
to verify differences between the recommended and 2.200 (n=17) 69 ±14b
ingested values of energy and food servings in each 2.500 (n=07) 68±21b
group of calorie level. For the purpose of analysis we
used a significance level of 5% (p<0.05). The groups All (n=72) 80±18
of calorie level 2.200 and 2.500 kcal were pooled for a The results represent mean ± SD. Different letters indicate means
proper statistical analysis, because of the limited num- statistically different between the groups of calorie level (ANOVA
ber of volunteers in the 2.500 kcal group (n = seven). p <0.05 Scheffe post-test).
Nutritional adequacy in subjects with Nutr Hosp. 2015;31(3):1147-1153 1149
metabolic syndrome
021_8086 La adecuación nutricional en sujetos con síndrome metabólico.indd 1149 17/02/15 10:01
groups according to initial body weight in the study. It
was possible to observe that the 72 volunteers managed
to ingest, on average, 80% of the calories in the diet 1.2 1.0 0.9 1.0
prescribed. On average, 93, 82, 69 and 68% of the re- otein/kg
commended calorie level was reached in groups 1.600, g prbody weight ke (p <0.05).
1.900, 2.200 and 2.500 kcal, respectively. No statisti- nta
cally significant difference was observed in average
consumption between groups of 1.900, 2.200 and 2.500 ended i
kcal and between groups of 1.600 kcal and 1.900 kcal. otein m
Table III presents the energy consumption and ma- Pr intake(%) om
cronutrients. The overall sample and groups of 1.900 21.6±3.3 21.3±3.6 22.5±4.4 21.8±3.8
kcal and 2.200/2.500 kcal had a significant reduction es and rec
in caloric intake (p <0.001) when compared to the va- lori
lues that were recommended in the diet. The average a
calorie intake of 1.600 kcal group was not statistically otein n c
different (p=0.076); however, there was a reduction of Pr (%) 10-15 10-15 10-15 10-15 twee
7% over the recommended calorie level. In the analy- ecommended
sis of the consumption of macronutrients, the overall r
rison be
sample and the four groups of calorie levels had mean
carbohydrate intake below the recommended range. ompa
The average intake of lipids and protein was shown to (%)
be higher than the values prescribed in the diet for the oups of calorie level32.1±5.332.9±6.330.9±4.632±5.6d for c
overall sample and all groups. Lipids intake use
Table IV shows the adequacy of macronutrient intake st
-te
in groups of calorie level in relation to the recommen- s t
’
ded range. Considering carbohydrates intake, most of espective gr
the volunteers (70.8%) had an intake below the requi- Lipids(%) 20-30 20-30 20-30 20-30
red values in food. For lipids was found that 66.7% of ecommended he Student
the volunteers ate more than the recommended range. r
In the analysis of protein intake, 95.8% of participants able III fers to t
had an intake above the recommended values. The re- T ue re
sults of the intra-group analysis of the adequacy of the onutrients in the r
macronutrients were similar to those of the total sample intake(%) 46.2±8
analysis. The chi-square test indicated no statistically 46.1±5.2 46.4±6.7 46.2±6.9he p val
significant difference between groups of calorie level Carbohydrate s. *T
1.600, 1.900 and 2.200/2.500 kcal for the adequacy of nt
macronutrients (p=0.299, p=0.733 and p=0.781 for car- gy and macr e
bohydrates, lipids and proteins, respectively). cronutri
The recommended values and intake of servings from (%) 50-60 50-60 50-60 50-60
the pyramid food groups are shown in table V. For most ecommended
volunteers, inadequacies were observed in main food Carbohydrater
groups, except the fruit group, in which appropriate es and ma
lori
levels were consumed (mean intake: 3.7 servings/day; a
p=0.149). Each group consumed on average 3.1, 3.6 Consumption of ener
and 4.2 servings of fruit a day, when 3 servings were re- p* 0.076 on of c
commended for groups 1.600 and 1.900 kcal and 4 ser- <0.001 <0.001 <0.001 pti
vings were indicated for groups 2.200 and 2.500 kcal.
No significant difference was observed between the re-
commendations of this food group (p=0.765, p=0.089,
p=0.704). A significantly lower intake was observed gy
for the group of cereals, vegetables and dairy groups, (kcal) an ± SD of consum
as compared to the recommended values (p<0.001). Ener 1.551±323e
consumption1.490.2±255.11.566.5±314.61.579.6±382.7 m
In the meat group, a significantly increased consump- nt the
tion was observed in the three groups at intake: the
volunteers ingested 1.9 servings of meat a day, when
prese
the recommended serving is one for 1.600 and 1.900 s re
kcal groups (p<0.001), and two servings per day in the oups of(kcal)1.600 1.900 All t
group of 2.200/2.500 kcal (recommended value: 1.5 Gr calorie level 2.200/2.500 resul
servings per day; p=0.024). In the beans group the daily The
1150 Nutr Hosp. 2015;31(3):1147-1153 Cláudia Mesquita de Carvalho et al.
021_8086 La adecuación nutricional en sujetos con síndrome metabólico.indd 1150 17/02/15 10:01
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