AT

VIVEKANAND POLYCLINIC & INSTITUTE OF MEDICAL SCIENCES LUCKNOW

Duration : 15th Feb. to 2nd April, 2013

Submitted by : Nidhi Dixit

Under the Guidance of : Anshu Bhardwaj

Reg. No.: (010/2010) Consultant Dietician

Anjali Sharma
Reg. No. : (009/2010) Consultant Dietician

INTRODUCTION
The Vivekananda Polyclinic is one of the novel medical centers in the state, providing extensive medical diagnostic facilities & specialized treatments for various to not only local people but also those hailing from different parts of Uttar Pradesh as well as far off places like Nepal. The polyclinic adopts various &acupressure are available too. Patients may use any system that suits them. For a developing country like India, with this limited resources & teeming population, it is hardly possible to provide indoor treatment for all the patients. The polyclinic has setup precedent by emphasizing domiciliary (at home) treatment in the Out-patient department, which is suited to Indian economy. In a changing situation where healthy competition, privatization & productivity are given prominence, eminent consultancy & a few super specialists have been including to the existing staff to keep a quality of service rendered. The polyclinic has been recognized by the government of India as a hospital for the treatment of Central govt. employees (CGE) & members of their family. It has also been recognized for the treatment of patient under the central govt. Health scheme (CGHS). Besides there are corporate clients from other public & private sector enterprises. The govt. of India has started the Directly Observed Treatment(DOT) of T.B cases under the aegis of the World Health Organization(WHO) & the Vivekananda Polyclinic has been chosen as a center for its implementation in the trans Gomati area. And ultra-modern complex consisting of 5 Operation Theatres with adequate pre-operative facilities in functioning to cover, various, cases under general surgery, urology, neurology, E.N.T, as well as Ophthalmology. there is separate minor O.T complex attached to the emergency Ward. A bio-medical waste management complex has been inaugurated for proper bio-medical waste management.

DEPARTMENT: ASTHAMA CLINIC:An Asthma clinic is functional every Tuesday from 1pm
to 3pm. Where patients are treated by expert clinicians & paramedics. Necessary investigation as pulse oximeter, pulmonary function test & peak flow meter are done economically under one roof. The polyclinic has a round the clock Blood bank with equipment for component separation.

C.T. SCAN FACILITY:C.T Scan facility is available for common man at rates
significantly lower than market rates through a state-of-the art. C.T scanner machine with most advance laser camera installed for the purpose.

DENTAL CLINIC:The dental clinic has been given a new looking & is
equipped with ultra modern nodular accessories in a very congenial environment to carry out necessary clinical procedures. Orthodontics is also performed.

EMERGENCY UNIT:The emergency unit with full staff of doctors & nurses
has 18 beds on the ground floor of the VPC, with special wards for clinical observation cases. This unit is open during the times & days that the outpatients departments are closed, thus enabling the VPC to offer 24hr daily services to the patients.

THE E.N.T CLINIC: The E.N.T clinic provides facilities of internal ear surgery.
For this, modern sophisticated equipments have been installed at the clinic. Also modern scientific methods like speech therapy, audiometry techniques & functional endoscopic procedure are carried out for treating patients.

GENERAL MEDICINE & GASTROENTROLOGY CLINICS:These are fully

functional & treat cases from far & wide. Gastro medicine includes video endoscopy, colonoscopy & sigmoidoscopy, sclerotherapy, foreign body removal etc. The radiology clinic has spiral C.T scan, angiography, X-ray, ultrasound facilities. Cardiology is equipped with Echo Cardiography Color Doppler, TMT, ECG. There is also electrophysiology with ECG, lung function Test & Allergy Tests.

GYNECOLOGY CLINIC:The Gynecology Clinic carries out Ultrasonography &

TVS investigations along with normal tests. Besides the Maternity Clinic, the infertility Clinic is fully functional with intrauterine insemination being performed successfully on infertile females, thus fulfilling their cherished dreams for motherhood. Along with this the family planning clinic carries out Tubectomy, MTP & Vasectomy cases.
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HOMEOPATHY & AYURVEDIC CLINICS:These are renowned for their

specialty treatments. To ensure benefits to villagers to the traditional system of medicine, the Ayurvedacharya visits.

NEPHROLOGY CLINIC & Dialysis UNIT:These are well equipped with

ultra modern equipment to treat impairments.

NEURO MEDICINE CLINIC:These have supporting facilities of Electro

Encephalogram & Spiral CT scan to treat neurological ailments.

NEURO SURGERY CLINIC:These are conducted on all working days from

11am to 1pm by a team of expert yoga teachers through yoga counseling & exercise. This facility goes a long way to tackle the age old problem of obesity in a short time and without drug induced adverse effects.

OPTHALMOLOGY CLINIC:these carry out major & minor eye operation in

its dedicated and fully equipped OT as well as one minor OT. Besides, there are various eye testing facilities with the necessary equipment likes synotophore and slit lamp. The clinic carries out Intra Ocular Lens Implementation.

ORTHOPEDIC CLINIC:In this, hip replacement, knee replacement, spinal

surgery is being done.

PATHOLOGY SECTION: The Pathology Section has hematology,

bacteriology, histopathology & biochemistry sub-section. State-of-the-art modern day equipments like Random Access Analyzer is available for biochemistry tests. The section also has AIDS HIV unit.

PEDIATRIC CLINIC: Pediatric Clinic has a neonatology section where special

care is provided to new born babies. Besides treating indoor patients at Vivekananda Polyclinic, this department has a 12 bed NICU, Special Baby Care Unit & Special Child Care Units for specialized & neonatal intensive care & step down neonatal care for patients. The Pediatric Clinic also participates in vaccination Programmers against TB, Polio, Diphtheria, Kurtosis, and Tetanus & Measles.

PHYSIOTHERAPY CLINIC:The efficient physiotherapy Clinic has made its

mark such that patients from Calcutta have begun to visit. There are 3 Ultrasound Therapy units, 4 diathermia Units, 3 Lumbar Traction Units & 3 Cervical Traction Units. Besides, there are facilities like Nerve Stimulator & Wax Bath & Limb exercise facilities like Rowing, Cycling etc.

PLASTIC, CRANIOFACIAL & MICRO SURGERY: The department of

Plastic, Craniofacial & Micro Surgery has been started with a team of well
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trained surgeons to give world class super specialty services in the institution. Today, Plastic Surgery is one off the most demanding & discussed branch of surgery & has been rightly named as "Surgery of Millennium". The department has been adequately equipped to do all specialized work & has been under the guidance of Dr.Vaibhav Khanna, who has done his specialized fellowship in micro vascular, Craniofacial & Cosmetic surgery. He & Dr.Adarsh Kumar are trying to give his specialized service to the masses. due to the team experience the department has been awarded to run the project-Smile Train project from USA for free treatment of Cleft Lip & Cleft Palate patients. VPC & Institute of Medical Science serves as a smile train cleft treatment centers as a partner Hospital of smile train India.

TUBERCULOSIS CLINIC:these aims at both treatment as well as control of

the disease to its fullest extent. The clinic continues to draw a large no. of patients from all across the state. Patients from the poorer strata of the society are treated free of cost. Anti T.B.drugs are provided. The govt. of India has started the Direct Observed Treatment of T.B. cases under the aegis of the World Health Organization & the VPC has been chosen as a center for its implementation in the Trans Gomti area & Lucknow.

ULTRAMODERN OT COMPLEX:This has 5 world class modern equipped

operation theatres with monitors, C-arm image intensifiers, operation microscopes etc.

UROLOGY & RADIOLOGY:These are an integral part of the Polyclinic. The

non-surgical process of treating the problem of kidney stones by Lithotripsy is now done at VPC at affordable cost for the common people in & around Lucknow.

THERAPEUTIC DIET
Therapeutic diet are based on normal adequate diet, modify a necessary to provide for individual requirement such as digestive & absorptive capacity alleviation of disease & psychological factors. The normal diet may be modified to provide change in consistency as in fluid & soft diet; to increase or decrease the energy value, to include greater or lesser amount of one or more nutrients, for example, high protein, low sodium etc; to increase or decrease bulk-high & low fiber diet; to provide foods bland in
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favour. Therapeutic diet may be qualitative & quantitative modification of the normal diet. The planning of the therapeutic diet implies the ability to adapt the principles of the normal nutrition to the various regimens for adequacy, correctness, economy & palatability. The quantitative diet is calculated with an increase or decrease amount of the food constituent. Example, diet is used in managing diabetes are usually quantitative. The qualitative diet is an adequate diet adjusts according to the type of foods allowed. Diet for management for gastrointestinal disease is quantitative.

OBJECTIVE OF THE THERAPEUTIC DIET:

To maintain a good nutritional status. To correct nutritional deficiencies which may have occured due to the disease? To afford rest to the whole body or to the specific organ affected by the disease. To adjust food intake to the body's ability to metabolize the nutrients during the disease. To bring about the changes in the body weight whenever necessary.

THERAPEUTIC MODIFICATION OF THE NORMAL DIET:

Change in consistency of food (liquid diet, soft diet low fiber diet) decrease or increase.

STANDARD NORMAL DIET:All hospital & institutional have some specific

diets designed for uniformity & convenience of service. These standard diets are based on foundational of an adequate diet pattern.

TYPES OF DIET IN THE HOSPITAL:

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CLEAR LIQUID DIET: This diet is used when the patient is very week,
no appetite, and foreign disease of throat & esophagus which makes swallowing difficult & painful for jaws when chewing is impossible or when the intestine is inflamed & the patient cannot digest solid food. The liquid diet is made up of clearly liquid that leave no residue, & it is non gas forming, non-irritating & non-stimulating. This amount of fluid is usually restricted to 30-60 ml/hr. The diet gives 300 kcal & no protein. This diet can meet the requirements of fluid & some minerals & can be given in 1-2hr intervals.

FULL FLUID DIET:The diet bridges the gap between the clear fluid &
the soft diet.. This diet is also suggested when milk is permitted & for patients are not requiring specific diet but to ill to eat solid or semi solid foods. This diet gives 1200 kcal & 35 gm protein.

SOFT DIET:This is one of the most frequently used in routine diets. It

may be used in acute infection surgery & for patients who are unable to chew.. This diet gives 1500 kcal & 40 gm protein. Light diet is given before regular diet.

NORMAL DIET: There is no particular food restriction. The diet is

generally low in fat especially saturated fat, cholesterol & in accordance with the dietary recommendation for the general population.

DISEASES
Protein Energy Malnutrition
Protein energy malnutrition is defined as a range of pathological conditions arising from coincident lack of varying proportions of protein and calorie, occurring most frequently in infants and young children and often associated with infection (WHO 1973).

Symptoms of different types of PEM:

Kwashiorkor:
Odema of the face and lower limbs, failure to thrive, anorexia, diarrhea, apathy, dermatosis flaky paint appearance, sparse, soft and thin hair, angular stomatitis, cheilosis and anemia.

Marasmic Kwashiorkor:
These children exhibit a mixture of some of the features of both marasmus and kwashiorkor.

Marasmus:
Failure to thrive_ means children whose weight or rate, irritability, fretfulness and apathy are common. Diarrhea is frequent. Many are hungry but some may be anorexic. The child is shrunk and there is little or no subcutaneous fat. The is often dehydration.

Dietary Management:
The diet should be rich in proteins of good quality and high in calories. The other nutritional requirements also must be met.

Energy:
The child should be given 150 to 200 kcal/kg/body weight/day for the existing weight. For children les than 2 years 200 kcal/kg body weight should be given and for older children 150 to 175 kcal/kg body weight.

Protein:
5gm of protein/kg body weight/day should be given for the existing weight.

Fats:
40 percent of total calories can be from fat which can be tolerated by children. Saturated fats such as butter, milk and coconut oil are preferred because unsaturated fatty acids worsen diarrhoea.

Diarrhoea
Diarrhoea is the passage of stools with increased frequency, fluidity or volume compared to the usual for a given individual. Acute diarrhea is a major cause of morbidity and mortality in infants and young children all over the world, more so in the developing countries.

Symptoms of different types of diarrhea:

Acute watery diarrhea:
It refers to diarrhea that begins acutely with passage of loose or watery stools without visible blood. Vomiting may occur and fever may be present. If diarrhoea occurs more than 14 days, it is called persistent diarrhoea.

Dysentery:
It is the term used for diarrhoea with visible blood. Dysentery may also be associated with fever and tenesmus.

Chronic diarrhea:
It is recurrent or long lasting diarrhoea due to non infectious causes such as sensitivity to gluten or inherited metabolic disorders.

Dietary Management:
Diet in weanling diarrhea:
Encouragement of breast feeding, better food hygiene, improvement of nutritional status of children and food environmental sanitation are important strategies for lowering the incidence of diarrhea.

Fluid Management:
The key to effective fluid management in childhood diarrhea is early replacement of fluid losses, starting with the first sign of liquid stool. Plenty of fluid should be given to the child early in the illness to prevent dehydration.

Weaning
The term weaning comes from the word wemian which means to accustom. Weaning begins from the moment supplementary food is started and continues till the child is taken off the breast completely. Solid food added to an infants diet is called beikost. There is an increase in activities of the enzymes at the time of weaning. 10

Need for weaning:

Infants in our country thrive on breast milk alone up to six months of life and their growth rate during this period is satisfactory. Breast milk alone is not able to provide sufficient amounts of all the nutrients needed to maintain growth after the first sin months. Bulky adult diet, when given to infants, usually does not meet the nutritional requirement, particularly calories. Nutrient density of weaning foods of western diet is 1.0 kcal/g of food whereas in Asia, the nutrient density is 0.25 kcal to 0.4 kcal/g. Calorie dense foods like malted food should be given to infants. Weaning food should provide atleast 10% of the energy as protein.

Thoracic Emphysema
Emphysema is a long term, progressive disease of the lungs that primarily causes shortness of breath. Subcutaneous emphysema is a condition when gas or air is present in the subcutaneous layer of the skin. In people with emphysema, the tissues necessary to support the physical shape and function of the lungs are destroyed. It is included in a group of diseases called CHRONIC OBSTUCTIVE PULMONARY DISEASE or COPD (pulmonary refers to lungs). Emphysema is called an obstructive lung disease because the destruction of lung tissue around smaller sacs, called alveoli, makes these air sacs unable to hold their functional shape upon exhalation. Emphysema is most often caused by tobacco smoking and long-term exposure to air pollution.

Dietary Management :
A high protein/ high calorie is necessary to correct malnutrition. Use 1.2-1.5 gm protein/kg and sufficient kcals for anabolism (starts with 30-35 kcal/kg depending on current weight). Promote weight loss through calorie controlled diet for obese persons. Diet should be 40-45% carbohydrates, 30-40% fat and 15-20% protein. A diet without tough and stingy foods and an antireflux regimen are useful. Gas forming vegetables may cause discomfort for some patients. Increase use of omega 3 fatty acids in foods such as salmon, haddock, mackerel, tuna and other fish sources are beneficial. To enrich the diet with antioxidants, use more citrus fruits whole grains and nuts. There is protective of fruits and possibly vitamin E intake, vitamin c, beta carotene, vegetables, fishes are general nutritional value. Fluid intake should be high if the patient is fibrile. 11

Piles

Hemorrhoids, are vascular structure in the canal which help with stool contro. They become pathological or piles when swollen or inflamed. In their physiological state, the act as a cushion composed of arterio-venous channels and connective tissue that aid the passage of stool. The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal bleeding while external hemorrhoids present with pain in the area of the anus. The primary cause of pile is chronic constipation and other bowel disorders. The pressure applied to pass a stool to evacuate constipated bowels and the congestion caused by constipation ultimately lead to piles. The use of purgatives to relieve constipation, by their irritating and weakening effect on the lining of the rectum, also result in enlargement and inflammation of veins and bleeding of mucus lining of the rectum, also result in enlargement and inflammation of veins and bleeding of mucus lining. Piles are more common during pregnancy and in conditions affecting the liver and upper bowel. Prolonged periods of standing or sitting, strenuous work, obesity and general weakness of the tissues of the baby are the other contributory causes of piles. Recommended treatment consists of increasing fiber intake, oral fluids to maintain hydration, NS AID analgesics, sitz baths and rest. Surgery is reserved for those who fail to improve following these measures.

Dietary Management:
A normal calorie, protein and protein and fat are given as per RDA. Recommended diet to help prevent hemorrhoids from developing is first of all a diet that helps keep a soft stool. Fiber rich diets rich in fruits, vegetables and whole grains (or fiber supplement). Fiber adds bulk and moisture to the stool, and it speeds movement through intestinal tract. Fiber rich diet can prevent constipation and thus also hemorrhoids from developing.

Fluids:
Drink lots of fluids at least 8 glass each day. Drinking results in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.

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Avoid:
Avoid highly refined foods like wheat, rice, white bread, pastries, cake, pies. Alcohol should also be avoided as I can contribute to small, dry stools. Avoid acid forming foods such as sugar, animal protein, dairy and caffeine. Containing food and beverages, as well as all beverages with soda.

Polycystic Ovarian Disease (PCOD)

Polycystic ovary syndrome is a condition in which a woman has an imbalance of female sex hormones. This may lead to menstrual cycle changes, cysts in the ovaries, trouble getting pregnant and other health changes.

Causes, Incidence and Risk Factors:

PCOD IS LINKED TO CHANGES IN THE LEVEL OF CERTAIN HORMONES-

Estrogen and progesterone, the female hormones that help a womans ovaries release eggs. Androgen. A male hormone found in small amts in women.

It is not completely understood why or how the changes in the hormone levels occur. The changes make it harder for a womans ovaries to release fully grown (mature) eggs. Normally, one or more eggs are released during a womans period. This is called ovulation. In PCOD, mature eggs are not released from the ovaries. Instead, they can form very small cysts in the ovary. These changes can contribute to infertility. The other symptoms of this disorder are due to the hormone imbalances. Most of the time, PCOD is diagnosed in women in their 20s or 30s. However, it may also affect teenage girls. The symptoms often begin when a girls periods start. Women with this disorder often have a mother or sister who has symptoms similar to those of polycystic ovary syndrome.

Dietary Management:
Here are some dietary tips that can be followed to tackle the problem naturally. Eat small meals at regular intervals of time. Avoid maintaining long gaps between meals and then eating large amounts at one time.

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Energy:
Diet plays a very important role in the treatment of PCOD and its symptoms. PCOD patients who are not overweight can take 50 to 55% of calories from complex carbohydrates but patients who are already obese and insulin resistant, should restrict to their intake to 40% or less, depending upon their condition.

Carbohydrates :
Simple carbohydrates are strictly to be avoided as they tend to increase the blood sugar level. These patients should follow a low glycemic index diet to get the best results. Simple carbohydrates like refined sugar, sweets, chocolates and candies can trigger more cravings and hunger pangs, therefore, complex carbohydrates that have a low glycemic index. Such as whole wheat flour, whole grains and green vegetables should be incorporated in the daily diet instead.

Protein:
A normal protein diet according to recommended dietary allowances is given.

Fats:
When it comes to fats, select monounsaturated fats (found in olive oil and canola oil) and omega 3 fats, which are found in flaxseeds and fishes like sardines (tarli), mackerel (bangda), and king fish (surmai). Restrict intake of saturated and trans fatty acids. Include fresh fruits and vegetables to boost bodys immunity.

Fiber and Fluid:

At least 10 to 20 glasses of water should be taken and consume a high fiber diet to prevent constipation. A healthy diet combined with regular exercise can help a PCOD patient to achieve her targe more effectively.

guillain Barres syndrome

Guillain barres syndrome also known an acute inflammatory denyelinating polyneuropathy is a neurological syndrome of rapid and increasing weakness, numbness, pain, paralysis of legs, arms, respiratory muscles. It often cause after a recent surgery, viral infection from under cooked meat, poultry, contaminated milk, immunization, bloody diarrhea, fever, cramping.

symptoms of guillain Barres syndrome:

Muscular weakness, respiratory failure, paralysis of lower extremities, difficulty in chewing, muscular pain, low grade fever, weight loss, anorexia. 14

DIETARY MANAGEMENT:
ACUTE Intravenous fluids will be required. Tube feeding or TPN may be necessary while patient is acutely ill over a period of time. Increased energy intake & protein may be necessary. After fat intake if necessary to reduce production of carbon dioxide, especially on ventilator. PROGRESSION- A thick, pureed diet may be beneficial with dysphegia. When tolerated, the individual can use a soft or general diet. Supplement oral intake with frequent snacks, such as shakes or eggnog, if unintentional weight loss has occurred. A vitamin-mineral supplement may be beneficial if intake has been poor.

HYSTECTOMY
A hystectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hystectomy may be total (removing the body, fundus & cervix of the uterus, often called complete) or partial (removal of the uterine body while leaving the cervix intact, also called supracervical). It is the most commonly performed gynecological surgical procedure. Removal of the uterus renders the patient unable to bear children (as does removal of ovaries & fallopian tubes) & has surgical risks as well as long term effects, so the surgery is normally recommended when other treatment options are not available. It is expected that the frequency of hysterectomies for non-malignant indications will fall as there are good alternatives in many cases.

DIETARY MANAGEMENT:
IMMEDIATELY FOLLOWING SURGERY:

Some restrictions in diet are required right after a hysterectomy. Medical provider will uses stethoscope to listen to stomach for bowel sounds. Post hysterectomy diet starts with ice chips. After that, if patients is feeling well, she can have liquids such as water, juice, broth and soda. When her hasnt had any problems drinking liquids, she can graduate to soft foods such as applesauce, ice cream or yogurt.

REGULAR FOODS:

One can return to a normal diet after having a normal bowel movement. Generally, after a hysterectomy, there are no food or drink restrictions and one can eat the same as before the operation. Assure that patient eats enough protein to acid in healing & recovery time. 15

PRECAUTIONS:

Some women who have been through the procedure recommend avoiding foods that cause gas, such as broccoli or beans. Avoid extra-spicy foods until patient recovers completely. Advise plenty of fiber, water & rest to help body heal.

INTRAUTERINE GROWTH RETARDATION (IUGR)

Intrauterine growth retardation (IUGR) refers to poor growth of a baby while in te mothers womb during pregnancy. The causes can be many, but most often involve poor maternal nutrition or lack of adequate oxygen supply to the fetus. At least 60% of the 4 million neonatal deaths that occur worldwide every year are associated with low birth rate (LBW), caused by intrauterine growth retardation (IUGR), preterm delivery & genetic/ chromosomal abnormalities demonstrating that under- nutrition is already a leading health problem at birth.

THERE ARE 2 MAJOR CATEGORIES OF IUGR:

SYMMETRICAL AND ASYMMETRICAL

ASYMMETRICAL IUGR : It is more common. In asymmetrical IUGR, there is restriction of weight followed by length. The head continues to grow at normal or near- normal rates (head sparing). This is a protective mechanism that may have evolved to promote brain fluid development. This type of IUGR is most commonly caused by extrinsic factors that affect the foetus at later gestational ages.

SYMMETRICAL IUGR :

It is less common & is more worrisome. This type of IUGR usually begins early in gestation. Since most neurons are developed by the by the 18th week of gestation, the foetus with symmetrical IUGR is likely to have permanent neurological sequela.

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DIETARY MANAGEMENT:
CALORIES AND PROTEINS:

Protein & caloric requirement of mothers gets increased due to increased nutritional requirement of the baby. In order to meet this requirement the value RDAs prescribed for pregnant woman, should be given.

FLUID:
High fluid diet is recommended for IUGR patients.

Oral ulcer
A mouth or oral ulcer is an open sore in the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. The types of mouth ulcers are diverse, with a multitude of associated causes including, physical abrasion, acidic fruit, infection, other medical conditions and cancerous & nonspecific processes. Once formed, the ulcer may be maintained by inflammation &/ or secondary infection. Two common types are apthous ulcers (canker sores) and cold sores (fever blisters, oral herpes). Cold sores around the lip are caused by viruses.

DIETARY MANAGEMENT :
Mouth ulcer diets focus primarily on avoiding irritants that can make symptoms worse and delay healing. Common irritants also vary from person to person. A good rule of thumb is that if a food or drink causes discomfort, it should be avoided until the mouth ulcer heals. Since oral hygiene also plays a role in mouth ulcer healing, it also helps to brush or at least rinse with antiseptic mouthwash after every meal or snack.

FOOD TO TAKE:

Cold foods & beverages actually soothe painful mouth ulcers, though room temperature. Choices do no harm. Cooking foods- especially fruits & vegetables- reduces their abrasive qualities. Fresh or frozen foods are good choices because they contain less acid than canned food & less salt than processed foods. Grain dishes and plain, unseasoned meat & also help because both meat & grains contain little acid & hover around a neutral pH. Sipping ice water, iced tea or cold milk during meals washes away debris and irritants from other foods, especially if the person does not have time to brush.

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FOOD TO LIMIT:

Fruits & vegetables are rich in nutrients that support the immune system, but many of them contain acids that can make mouth ulcers worse & contribute to discomfort. Fruits & vegetables that should be enjoyed in moderation until symptoms subside include apple, apricots, mangoes, nectarines, oranges, peaches, pears, plums, berries & tomatoes. Juices sauces & preserves are often more irritating than the whole fruit. Although the dietary guidelines for Americans encourage people to eat fewer sweets in general, its particularly important for people with mouth ulcers to limit sweets because bacteria in the mouth ferment them to acids that delay mouth ulcer healing and contribute to tooth decay.

FOOD TO AVOID:

Salty foods like pretzels & heavily spiced foods like curries make mouth sores sting. Highly acidic fruits such as lime, lemon, pineapples, grape fruit and pomegranates have the same effect. Pickled foods &foods like salad dressing that feature vinegar as a main ingredient should also be avoided because of their acid content. Nuts & seeds are abrasive, scratching & scraping mouth ulcers and often leaving small hard particles behind.

TONSILLITIS
It is inflammation of the tonsils most commonly caused by a viral or bacterial infection. Symptoms of tonsillitis include sore throat & fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes such as streptococcal pharyngites are treatable with antibiotics. It usually takes one to three weeks to recover. The most common causes of tonsillitis are adenovirus, rhinovirus, influenza, coronavirus & respiratory syncytial virus. It can also be caused by Epstein- Barr virus, herpes simplex virus, cytomegalovirus or HIV. The second most common causes are bacterial. The most common bacterial cause is group A Beta- hemolytic streptococcus (GABHS), which causes strep throat. Less common bacterial causes: Straphylococcus aureus (including methicillin resistant staphylococcus aureus or MRSA), Streptococcus pneumniae, Mycoplasma pneumonial, Chlamydiapneumoniae, pertussus, Fusobacterium, diphtheria, syphilis and gonorrhea. Common symptoms of tonsillitis include: red and/ or swollen tonsils, tender, stiff and/ or swollen neck, swollen lymph nodes, sore throat, cough, headache, sore eyes, body aches, earache, fever, chills, nasal congestions, ulceration.

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DIETARY MANAGEMENT:
BEVERAGES:

Drinking fluids is one of the most important dietary factors when suffering from tonsillitis, advises the University of Maryland medical center. Choose water, juice or sports drinks. You should avoid milk as it may increase the thickness of mucus in the back of the throat. Consume drinks at cold, lukewarm or warm temperatures. Avoid extremely hot liquids when suffering from a tonsil infection. Soothing warm drinks include apple cider, warm water flavored with honey and lemon asa well as chicken and vegetable broth.

FOOD INCLUDE:

Soft creamy foods are easy to swallow when tonsillitis is present. Choose foods such as sherbet, oatmeal, grits or steamed fruits. As infection begins to clear, often 2 to 3 days after beginning antibiotic treatment, add additional soft foods. These foods can include plain pastas, mashed potatoes, baked sweet potatoes & scrambled eggs. Fruit- based smoothies are ideal as a snack. Add extra protein to your shakes for more nutrition.

FOOD TO AVOID:

When suffering from tonsillitis, avoid hard or crisp foods, such as crackers, cookies hard breads or croutons, should be avoided, until the infection is gone. Crunchy foods can scratch & irritate infected throat even more acidic drinks should also be avoided, such as colas & other sodas, as well as citrus fruit juices. The acidic drinks can cause an irritable burning sensation I the back of the throat.

NEPHROTIC SYNDROME
It is a disorder where the kidneys have been damaged, causing them to leak protein from the blood into the urine. It is a fairly benign disease when it occurs in childhood, it is most common between age 2 & 6 but lead on to chronic renal failure, especially in adults occur slightly more often in males than females. Kidneys affected by nephritic syndrome have small pore in the podocytes, large enough to permit proteinuria (because some of the protein albumin has gone from the blood to the urine) but no large enough to allow cells through (hence no hematuria). By contrast, in nephritic syndrome, RBCs pass through the pores, causing hematuria. Nephritic syndrome causes massive proteinuria, with 3.5g or more of protein lost within 24 hours. As much as 30g can be lost as a result. Albumin is especially affected. Nephritic syndrome is also termed as 19

nephrosis. This disorder is characterized by massive oedema and proteinuria resulting from degenerative lesions of the tubules, mesangium (central part of the rental glomerulus) or basement membrane of the glomeruli.

DIETARY MANAGEMENT:
The major objectives of dietary management are To control & correct protein deficiency and Correct & prevent oedema and Maintain adequate nutrition to afford better resistance to infection.

CALORIES:
In most adults, energy requirement amounts to 30-40 kcal/kg body weight with upto 40-45 kcal/kg for hypercatabolic cases.

PROTEIN:
The intake may range from 0.5 to 0.6g/kg IBW, subsequently, increased to 0.8-1.2g/kg IBW/day. Depending on the degree of protein catabolism 0.5-1g/kg/day protein may be given.

SODIUM:
During the oliguric phase, sodium may need to be restricted to 500-1000mg (20-40 mEq) daily. It can be liberalized with onset of diuresis.

POTASSIUM:
Potassium intake is restricted to 1000-2000mg (25 to 50 mEq) and should be monitored strictly and regularly.

FLUID:
Intake is based on fluid balance but is usually restricted to a basic allowance of 500ml/day for an average adult with addition made for losses via other routes.

ASTHMA
Bronchial asthma involves paroxysmal dyspnea accompanied by wheezing and is caused by spam of bronchial tubes or swelling of their mucous membranes. Bronchial asthma differs from wheerzing caused by cardiac failure (cardiac asthma), in which an X-ray shows fluid in the lungs. Asthma involves inflammation of the airways.

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SIGNS AND SYMPTOMS:

Asthma include respiratory distress, audible wheezing, decreased breath sounds, tachycardia, cyanosis, hypotension, anxiety, pulmonary edema, dehydration, hard and dry cough & distended neck veins. Two types of bronchial asthma are recognized: ALLERGIC (entrinsic) and NON ALLERGIC (intrinsic or infections). Children who are exposed to second hand smoke may have chronic cough or symptoms of asthma. Chronic poor control can lead to a serious condition, status asthmaticus, which generally requires hospitalization & can be life threatening. Brittle asthma is a rare form of asthma with repeated attacks, either with wide variation from predicted daily peak expiratory flow or with apparent good control of asthma.

DIETARY MANAGEMENT:
Infants should be breastfed to reduce the risk of asthma in susceptible families. Provide balanced, small meals that are nutrient dense (ie. high-quality protein, vitamins and minerals), especially to reduce risk of infections and poor state of health. Encourage extra fluids unless contraindicated. Theobromine in cocoa tends to increase blood flow to the brain & to reduce coughing. Use less sodium. Highlight foods rich in vitamin A & C, magnesium, & zinc. Use more broccoli, grapefruit, oranges, sweet peppers, kiwi, tomato juice & cauliflower for vitamin C. Saturated & monounsaturated fats may have different effects on airway inflammation, saturated fatty acids may aggravate inflammation & monounsaturated fatty acids may be inversely related. Omega 3 fatty acids may be useful for those persons without fish allergy, walnuts & flaxseed may be used if tolerated. Oleic acid may contribute to clinical onset of asthma and use should be low.

DOWN SYNDROME
Down syndrome is a congenital defect in which patients carry altered chromosomes. Trisomy 21 patients are those with an extra chromosome 21. There is a direct correlation between the incidence of the syndrome & maternal age. Children with this condition have short stature, decreased muscle tone, constipation, intestinal defects, weight changes & mental retardation. There is a higher risk for congenital heart disease, gum disease, celiac disease, Hirschsprung diease, hypothyroidism, a rare form of Leutemia, respiratory problems, gatroesophageal reflux, & Alzheimers disease.

21

DIETARY MANAGEMENT:
Tube feed if the patient is unable to eat orally. Gradually wean to olids when possible. Supply adequate amounts of energy for age, for children ages 5-11 years, use 14.4 kcal/cm for girls and 16.1 kcal/cm for boys. Use protein according to RDA. Use a gluten-free diet if celiac disease is present. Monitor for pica overeating & idiosyncrases. Provide supplemental sources of folate, vitamin A, vitamin E, zinc, iron & calcium it intake of fruits, vegetables, meats dairy products or whole grains is limited. Provide feeding assistance for losses in drooling, diarrhea or spillage. Encourage complex carbohydrates, prune juice, etc, if constipation is a problem.

BURNS
Burns are injuries to tissues tat result from heat, electricity, radiation or chemicals. They are usually caused by heat (thermal burns), such as fire, steam, tar or hot liquids. While burns caused by chemicals are similar to thermal burns those caused by radiation, sunlight and electricity tend to be different. Thermal and chemical burns usually occur because heat or chemicals come in contact with part of the bodys surface, most often the skin. Thus, the skin usually sustains most of the damage. Severe surface burns may penetrate to deeper body structures, such as fat, muscle, or bone. When tissues are burned, fluid leaks into them from the blood vessels, causing swelling and pain.

Classification of Burns:

Burns can be classified in the basis of the extent, depth, patient age and associated illness or injury. On the basis of depth, burns are usually classified by degree. FIRST DEGREE BURNS or ERYTHEMA i.e, redness of the skin produced by coagulation of the capillaries with cell destruction above the basal layer of epidermis. SECOND DEGREE BURNS is erythema and is characterized by blistering with necros within the dermis. THIRD DEGREE BURNS lead to total loss of skin including the fat layer, hair follicles and sweat glands.

DIETARY MANAGEMENT:
ENERGY:
The Energy needs of the burned patient vary according to the depth and size of the burn. The requirements of course would be highest in third degree burns. Although several formulas have been developed to determine the energy needs. 22

BASAL ENERGY EXPENDITURE: MEN: BEE =66.47+13.75 W+5.00 H-6.76 A

= 66.47+13.75*60+5.00*170-6.76*35 = 66.47+825+850-236.6 = 1741.47-236.6 = 1504.87 Estimating 24 hours energy expenditure in burn patients (kcal/day) Harris_benedict equation_BEE =BEE*1.1-1.4 (for <40% TBSA) =BEE*2 (for >40%TBSA) =1504.87*2

CARBOHYDRATES:
Liberal amounts of carbohydrates should be given i.e around 60% to 65% of the total energy. Care must be taken regarding the maximum rate of administration feasible keeping in mind the fact that the maximum tolerance level is about 7mg/kg/min above which glucose is not oxidized to release energy but is converted to fat.

FAT :
A careful monitoring of immune function, feeding tolerance and serum triglycerides is required during lipid administration. Most of the patients are able to tolerate around 12-15% of the total calories in the form of lipids.

PROTEIN :
It is one of the most crucial nutrient which determines the ultimate outcome of burns. Amino acid requirements are high due to increased losses through wounds and urine, increased requirement for promoting synthesis of blood proteins and wounds. Adult patients should be given 20-25% of the increased energy from protein. Among children the requirements are still higher i.e 2.5 t 3.0g per kg usual body weight per day.

VITAMINS and MINERALS:

When the patient is on tube feeds it is suggested to provide around 500mg (twice daily) vitamin C and 5000 I.U of vitamin A per 1000 kcals of energy being provided.

23

HEPATITIS
Hepatisis is a condition of inflammation of liver, which can result in damage of the liver cells. A virus causes viral hepatisis, as liver celss are particularly susceptible to such infections. It causes damage to the liver cells and interferes with the uptake of bilirubin by the cells, and its conjugation and excretion. It can be either in form of an acute or chronic condition and is caused due to different strains of viruses such as A,B,C.D and E.

DIETARY MANAGEMENT:
ENERGY:
The caloric intake advised for adults is 35-40 cal/kg IBW or as per the requirement to maintain a desirable body weight.

CARBOHYDRATES:
Liberal intake of CHO is advised (300-400g). This is to prevent endogenous breakdown of protein thus having a protein sparing effect, increase the (intra hepatic) glycogen stores to improve the functioning and protect the liver against infectious agents.

PROTEIN:
Moderate protein intake in the diet is required for the following reasons: To prevent negative nitrogen balance, which may lead to hypoproteinemia, For adequate tissue regeneration especially of parenchymal cells and Prevent fatty infiltration of liver cells Thus, 1.5 to 2.0g/kg IBW protein is recommended. Supplements f high protein beverages are recommended in between the meals.

FATS:
Fats should not be severely restricted as they can make the food unpalatable. About 20% of the total calories should b from fat.

VITAMINS:
Supplementation of B complex vitamin and C should be given.

MINERALS:
Sodium restriction is required only if there is fluid retention. Potassium supplements are necessary with diuretic therapy. Iron supplementation is needed only if there is anaemia.

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parKinsons disease
Parkinsons disease is a degenerative central nervous system (CNS) condition characterized by progressive loss of cells with substain nigra. Substania nigra is a portio of the midbrain which is thought to be involved in certain aspects of movement and attention. It consists of two subdivisions, the PARS COMPACTA and the PARS RETICULATA. The cells within the substania nigra release the neurotransmitter dopamine and it is the loss of dopamine that is primarily responsible for the motor defects.

DIETARY MANAGEMENT:
These problems have to be taken into consideration while planning meals. Foods rich in fiber and which can be cut into pieces and made into cohesive bites could be given. Liquid foods may be difficult to handle, but care should be taken to ensure fluid intake is adequate to prevent constipation and hypertension (low blood pressure). Small frequent meals with more carbohydrates and less fat may be better tolerated, in view of the gastric side effects and delayed gastric emptying. Diets given should be balanced and nutritionally adequate. Frequent intake of high-protein snacks has deleterious effects upon Parkinsons disease control. Hence this should be avoided. Supplementation of vitamin B6 (pyridoxine) should be avoided as this vitamin can facilitate the premature conversion of levodopa to dopamine thus reducing the potency of the drug.

PRESCHOOL CHILDREN
The years between 1 and 6, growth is generally slower than in the first year of life but continues gradually. Activity also increase markedly during the second year of life as the child becomes increasingly mobile. Development of a full dentition by about the age of 2 years also increases the range of foods that can safely be eaten. There is an increased need for all nutrients, but the pattern f increase varies for different nutrients in relation to their role in growth of specific tissues.

DIETARY MANAGEMENT: ENERGY:

Energy is required for growth and activity. Insufficient food will not only result in undernutrition in terms of inadequate weight gain but will also hinder growth. The rate of growth fluctuates from one age to another. Upto 10 years of age there is no difference in sex for RDA. 25

PROTEINS:
The increase in the muscle mass that must accompany bone growth requires positive nitrogen balance that is met by protein intake of 1.5 to 2g/kg body weight.

FATS:
Fat energy including invisible fat for children should be 25 percent of total energy and essential fatty acid energy is 5-6 percent.

MINERALS:
Calcium requirements of children is calculated on the basis of the amount of calcium accretion in the body. All dietary calcium is not absorbed 400mg/day is prescribed though the actual requirement may be less. Milk is the best source of calcium. Hence the diet of preschool child should include 1-2 glasses of milk per day. During growth for an increase in each kilogram in body weight 30mg of iron is required and since the increase in body weight during childhood is 2kg/year on an average, the daily requirement of iron for growth will be 0.2mg.

VITAMINS:
The incidence of vitamin A deficiency signs are high and serum vitamin A levels are generally low among Indian children whose dietary intake is less than 100mcg.

26

DIABETES MELLITUS

Diabetes mellitus is a metabolic disorder characterized by decreased ability or total inability of the tissues to utilize carbohydrates (glucose).The disorder is due to absence of insulin, its deficiency or ineffectiveness- the hormone is produced by the beta cells of islet of langerhans in the pancreas.

CLASSIFICATION OF DIABETES:
Type 1-Insulin Dependent Diabetes Mellitus(IDDM) Type 2-Non Insulin Dependent Diabetes Mellitus(NIDDM) Type 3-Malnutrition Related Diabetes mellitus(MRDM) Impaired Glucose tolerance(IGT) Gestational Diabetes Mellitus(GDM)

DIETARY MANAGEMENT: ENERGY:The energy requirements of adult patients are governed by their
present body weight & the need to maintain a desirable or ideal body weight.

Calories requirements according to weight and activity Weight Activity levels Calories required/kg ideal body weight

27

1. 2. 3. 4. 5.

Ideal body wt. Ideal body wt. Overweight Underweight Underweight

Sedentary activity Moderate activity Sedentary activity Sedentary activity Moderate activity

25 30 15-20 30 35

PROTEIN:protein should be provided in adequate amounts to maintain

a normal body composition & prevent depletion of lean tissue mass. Adult diabetics without any complications are able to maintain good health when 1.0 g protein/ kg IBW/day. During childhood, adolescence, pregnancy & lactation the requirements are higher than the RDI & patients usually benefit by increasing the protein by 10 to 15%.

FATS:The total fat recommended is less than 30% of the total calories.
Low fat diet increases insulin binding & also reduces LDL & VLDL levels & reduces the incidence of atherosclerosis which is more common in diabetics. The dietary cholesterol intake should be kept below 300 mg/day for diabetics.

CARBOHYDRATES: Complex carbohydrates with more fiber are

recommended to simple carbohydrates like sugars. The amount should provide 55-65% of the days caloric intake.

DIETARY FIBER:Dietary fiber & complex carbohydrates benefit Type 1

& type 2 diabetics. Such diets lower Insulin requirements Increase peripheral tissue insulin sensitivity Decrease serum cholesterol & triglyceride value Aid in weight control & Lower B.P. Soluble fibers such as pectin, gums, and hemicelluloses increase intestinal transit time, delay gastric emptying slow glucose absorption & lower serum cholesterol. Insoluble fiber such as cellulose & lignin decrease intestinal transit time, increase fecal bulk, delay glucose absorption & slow starch hydrolysis.
28

Fenugreek seeds which contain high fiber are useful to diabetics. It contains mucilaginous fiber & total fiber to the extent of 20% & 50% respectively.

VITAMINS & MINERALS:Vitamin supplementation may be helpful to

overcome oxidative stress & deficiency. Diets rich in all vitamins particularly in vitamin C & E antioxidants in fruit & vegetables & in minerals, especially magnesium & zinc are encouraged.

NUTRITION FOR PREGANCY

Adequate nutrition before and during pregnancy has greater potential for a long term health impact than it does at any other time. Maternal health is a complex, influenced by various genetic, social and economic factors, infections and environmental conditions, many of which may affect the foetal growth. A woman who has been well nourished before conception begins her pregnancy with reserves of several nutrients so that the needs of the growing foetus can be met without affecting her health. Infants, who are well nourished in the womb, have an enhanced chance of entering life in good physical and mental health. The effects of undernutrition during reproduction will vary depending upon the nutrients involved, the length of time it is lacking and the stage of gestation at which it occurs. A woman whose diet is adequate before pregnancy is usually able to bear a full term viable infant, without extensive modifications of her diet. Mothers diet should produce adequate nutrients so that maternal stores do not get depleted and produce sufficient milk to nourish her child after birth. The nutritional demands are highly increased in an adolescent mother.

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NUTRITIONAL REQUIREMENTS:Increase in nutritional

requirements depends on the nature of metabolic changes of pregnancy and the nutrition reserves of the mother. The RDA of the expectant mother is given in below table: Recommended dietary allowances of the expectant mother Nutrient woman Energy kcals Sedentary Moderate Heavy Protein g Fat g Calcium mg Iron mg Retinol mcg Beta carotene mcg Thiamine mg Sedentary Moderate Heavy Niacin mg Sedentary Moderate Heavy Pyridoxine mg 12 14 16 2.0
30

Normal adult woman

Pregnant

1875 2225 2925 50 20 400 30 600 2400

+300 +300 +300 +15 30 1000 38 600 2400

0.9 1.1 1.2

+0.2 +0.2 +0.2

+2 +2 +2 2.5

Ascorbic acid mg Folic acid mcg Vitamin B12 mcg

40 100 1

40 400 1

DIETARY MODIFICATION:For a pregnant woman whose diet has

conformed to the BASIC FIVE FOOD pattern, it is merely a matter of emphasizing the more nutrient dense foods within each of the five food groups. Nutrient dense foods are those that give the most effective time to attempt nutrition education. Usually a daily diet containing 3 cups of milk or its equivalent, 2 servings of meat, fish, poultry eggs, or a source of complete protein, a dark green or yellow vegetables and a generous serving of citrus fruits will provide a foundation for a nutritionally adequate diet. Plenty of water at least four to six glasses in addition to what is contained in the form of milk and other beverages should be taken daily throughout pregnancy. This will help keep the bowels regular. It has been found that infection of the tube connecting the kidney and gladder is less common among pregnant woman who drink a lot of water. It is recommended that pregnancy women limit their intake to 2 cups of caffeine containing beverages per day.

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GESTATIONAL DIABETES
When a pregnant woman develops diabetes, it is known as gestational diabetes. It occurs in only 1% of the pregnant woman who have a risk of diabetes because of family history or bad obstetrics history should be screened for diabetes. In addition to ketoacidosis, pregnant women with diabetes are more prone to preeclampsia, toxaemia, urinary tract infections and hydromnios. Uncontrolled diabetes during the first three months of pregnancy increases the risk of abortions and congenital malformations in the foetus. Elevated blood sugar should therefore be adequately controlled by dietary means and treatment with insulin even before conception.

DIETARY PRINCIPLE:During pregnancy, the diabetic should be given

30-35 kcal/kg of the desirable body weight. The diet should provide 1.52.5 g of protein /kg body weight. The total gain in body weight during pregnancy should ideally not exceed 12 kg.

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GOUT
Gout is a chronic disease due to an inherited abnormality of purine metabolism. Purine is a nitrogenous base found in the nucleotides for the synthesis of DNA and RNA. Gout is caused when there is over production of uric acid in normal purine metabolism in the body.

DIETARY MANAGEMENT:Treatment of gout often includes a diet of

lower purine intake. Indeed, about one third of the bodys uric acid can be attributed to diet. Changing the diet to foods with lower purines can help relieve the symptoms, as well as, address the actual problem of hyperuricemia (elevated levels of uric acid in the blood). The thumb rule for dietary management is to advice the patient to try to cut down or avoid: Red meats Organ meats such as brains, kidneys, liver & heart Shellfish such as mussels, oysters, sea eggs etc. Peas and beans Alcohol, especially beer and wine.

Dietary recommendations for gout

33

Avoid foods highest in purines (150825 mg / 100 gm) Brain Kidney Liver Gravies Herring Sardines Broth Meat extracts Minced meat Sweet breads

Limit foods containing moderate amount of purines (50-150 mg / 100gm) Whole grain bread or cereals Cauliflower Spinach Fresh saltwater fish Legumes (beans, peas & lentils) Meat soups & broth Mushrooms Asparagus Oatmeal Chicken Wheat germ and bran

Consume foods lowest in purines (050 mg /100gm)

Beverages (coffee, tea and soda) Refined cereals Cheese Eggs Fat Fruits and fruit juices Milk Nuts Sugar syrup Vegetable Creamed soups Macaroni/nood le

Food items for a patient with gout

34

Permitted Refined cereals & cereal products-cornflakes, white bread, pasta, flour, arrowroot, sago and cakes. Milk, milk products and eggs. Lettuce, tomatoes and green vegetables. Vegetables and cream soups.

Excluded Beans, peas, lentils, spinach, oatmeal, cauliflower, mushrooms Fish, seafood Meats, poultry or other flesh; meat extract, gravies, marmite Liver, kidney Yeast and beer products, beer

Nutritional care: summary

Advice the patient to: Maintain ideal body weight. Avoid high purine contents foods. Take moderate protein, use low fat dairy products, eggs and cheese. Take liberal carbohydrates, refined cereals, beverages, fruits and fruit juices, vegetables. Take a low fat diet. Restrict/eliminate alcohol. Take liberal amounts of fluid.

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HYPERTENSION
Hypertension is elevated blood pressure. WHO defines hypertension is a condition in which systolic pressure exceeds 160 mm Hg and diastolic pressure exceeds 95 mm Hg. With diastolic pressures of 100 or more therapy should be initiated with drugs as well as diet. High blood pressure is not a disease but only a symptom indicating that some underlying disease is progressing. Hypertension impairs the pumping function of the heart and if untreated damages the heart, brain and kidneys. A stroke occurs more often in patients with high blood pressure.

PRINCIPLES OF DIET: Low calorie, low fat, low sodium diet with
normal protein intake is prescribed.

DIETARY MANAGEMENT: ENERGY:An obese patient must be reduced to normal body weight with
low calorie diet. About 20 kcal/kg of ideal body weight are prescribed for a sedentary worker and 25 kcal/kg of body weight for moderately active worker. Alcohol consumption should be reduced.

PROTEIN:A diet of 60 g protein is necessary to maintain proper

nutrition. In severe hypertension, protein restriction to 20 g may be necessary as a temporary measure since protein foods are rich in sodium.

FATS:As they are prone to atherosclerosis it is advisable to avoid a high

intake of animal or hydrogenated fat. About 20 g vegetable oil is permitted.

CARBOHYDRATE:Easily available carbohydrate is of great help in the

management of high B.P.

36

SODIUM:Increased intake of sodium in diet leads to increased

intravascular volume and thus increases cardiac output, elevating blood pressure. Also at the cellular level, increased intracellular sodium is exchanged for increased intracellular calcium with its potent effects of augmented vascular tone and vascular hypertrophy with resulting persistent hypertension. Restricted sodium and a decrease in the sodium/potassium ratio in the diet is preferred. Moderate sodium restriction 2-3 g/day reduces diastolic pressure 6-10 mm of Hg and enhances the blood pressure lowering effect of diuretic therapy.

POTASSIUM:Potassium role in hypertension is actually the result of a

complex interplay with sodium, calcium and magnesium found in all living cells and in blood. Foe example, low levels of potassium cause the body to retain sodium and water and this can elevate blood pressure. Research suggests that the risk of stroke, a common consequence of high blood pressure, relates inversely with the amount of potassium in the diet and the lowest risk is among the high potassium low sodium group. 3500 mg of potassium is required daily.

Do not use:
Salt in cooking or at the table. Monosodium glutamate (ajinomoto). Baking powder, sodium bicarbonate and sodium benzoate. Salt preserved foods-pickles, canned foods. Highly salted foods such as potato chips. Spices and condiments such as ketchups and sauce. Cheese, peanut butter, salted butter. Frozen peas. Shell fish and dry fish. Prepared mixes. Biscuits, cakes, breads, pastries.

For restricting sodium less than 500 mg low sodium vegetables should be chosen apart from the above restrictions.

DASH DIET:Dash diet is the dietary approaches to stop hypertension.

It is a dietary pattern promoted by the U.S based National heart, lung & blood institute to prevent and control hypertension.
37

Dash Diet and Food Guide Pyramid Compared

Food group (servings) Grains Vegetables Fruits Milk (low fat) Meat (lean) Dash (servings) 7-8 4-5 4-5 2-3 2 or less Pyramid 6-11 3-5 2-4 2-3 2-3

According to DASH DIET the following diet may bring about a healthy reduction in blood pressure High amount of fruits and vegetables Inclusion of fish inclusion of low fat milk reducing the fat intake reducing sodium

38

Protein Energy Malnutrition

Protein energy malnutrition is defined as a range of pathological conditions arising from coincident lack of varying proportions of protein and calorie, occurring most frequently in infants and young children and often associated with infection (WHO 1973).

Symptoms of different types of PEM:

Kwashiorkor:
Odema of the face and lower limbs, failure to thrive, anorexia, diarrhea, apathy, dermatosis flaky paint appearance, sparse, soft and thin hair, angular stomatitis, cheilosis and anemia.

Marasmic Kwashiorkor:
These children exhibit a mixture of some of the features of both marasmus and kwashiorkor.

Marasmus:
Failure to thrive_ means children whose weight or rate, irritability, fretfulness and apathy are common. Diarrhea is frequent. Many are hungry but some may be anorexic. The child is shrunk and there is little or no subcutaneous fat. The is often dehydration.

39

Dietary Management:
The diet should be rich in proteins of good quality and high in calories. The other nutritional requirements also must be met.

Energy:
The child should be given 150 to 200 kcal/kg/body weight/day for the existing weight. For children les than 2 years 200 kcal/kg body weight should be given and for older children 150 to 175 kcal/kg body weight.

Protein:
5gm of protein/kg body weight/day should be given for the existing weight.

Fats:
40 percent of total calories can be from fat which can be tolerated by children. Saturated fats such as butter, milk and coconut oil are preferred because unsaturated fatty acids worsen diarrhoea.

40

Thoracic Emphysema
Emphysema is a long term, progressive disease of the lungs that primarily causes shortness of breath. Subcutaneous emphysema is a condition when gas or air is present in the subcutaneous layer of the skin. In people with emphysema, the tissues necessary to support the physical shape and function of the lungs are destroyed. It is included in a group of diseases called CHRONIC OBSTUCTIVE PULMONARY DISEASE or COPD (pulmonary refers to lungs). Emphysema is called an obstructive lung disease because the destruction of lung tissue around smaller sacs, called alveoli, makes these air sacs unable to hold their functional shape upon exhalation. Emphysema is most often caused by tobacco smoking and long-term exposure to air pollution.

Dietary Management :
A high protein/ high calorie is necessary to correct malnutrition. Use 1.2-1.5 gm protein/kg and sufficient kcals for anabolism (starts with 30-35 kcal/kg depending on current weight). Promote weight loss through calorie controlled diet for obese persons. Diet should be 40-45% carbohydrates, 30-40% fat and 15-20% protein. A diet without tough and stingy foods and an antireflux regimen are useful. Gas forming vegetables may cause discomfort for some patients. Increase use of omega 3 fatty acids in foods such as salmon, haddock, mackerel, tuna and other fish sources are beneficial. To enrich the diet with antioxidants, use more citrus fruits whole grains and nuts. There is protective of fruits and possibly vitamin E intake, vitamin c, beta carotene, vegetables, fishes are general nutritional value. Fluid intake should be high if the patient is fibrile.
41

Piles

Hemorrhoids, are vascular structure in the canal which help with stool contro. They become pathological or piles when swollen or inflamed. In their physiological state, they act as a cushion composed of arterio-venous channels and connective tissue that aid the passage of stool. The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal bleeding while external hemorrhoids present with pain in the area of the anus. The primary cause of pile is chronic constipation and other bowel disorders. The pressure applied to pass a stool to evacuate constipated bowels and the congestion caused by constipation ultimately lead to piles. The use of purgatives to relieve constipation, by their irritating and weakening effect on the lining of the rectum, also result in enlargement and inflammation of veins and bleeding of mucus lining of the rectum, also result in enlargement and inflammation of veins and bleeding of mucus lining. Piles are more common during pregnancy and in conditions affecting the liver and upper bowel. Prolonged periods of standing or sitting, strenuous work, obesity and general weakness of the tissues of the baby are the other contributory causes of piles. Recommended treatment consists of increasing fiber intake, oral fluids to maintain hydration, NS AID analgesics, sitz baths and rest. Surgery is reserved for those who fail to improve following these measures.

Dietary Management:
A normal calorie, protein and protein and fat are given as per RDA. Recommended diet to help prevent hemorrhoids from developing is first of all a diet that helps keep a soft stool. Fiber rich diets rich in fruits, vegetables and whole grains (or fiber supplement). Fiber adds bulk and moisture to the stool, and it speeds movement through intestinal tract. Fiber rich diet can prevent constipation and thus also hemorrhoids from developing.

42

Fluids:
Drink lots of fluids at least 8 glass each day. Drinking results in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.

Avoid:
Avoid highly refined foods like wheat, rice, white bread, pastries, cake, pies. Alcohol should also be avoided as I can contribute to small, dry stools. Avoid acid forming foods such as sugar, animal protein, dairy and caffeine. Containing food and beverages, as well as all beverages with soda.

43

INTRAUTERINE GROWTH RETARDATION (IUGR)

Intrauterine growth retardation (IUGR) refers to poor growth of a baby while in te mothers womb during pregnancy. The causes can be many, but most often involve poor maternal nutrition or lack of adequate oxygen supply to the fetus. At least 60% of the 4 million neonatal deaths that occur worldwide every year are associated with low birth rate (LBW), caused by intrauterine growth retardation (IUGR), preterm delivery & genetic/ chromosomal abnormalities demonstrating that under- nutrition is already a leading health problem at birth.

THERE ARE 2 MAJOR CATEGORIES OF IUGR: SYMMETRICAL AND ASYMMETRICAL

It is more common. In asymmetrical IUGR, there is restriction of weight followed by length. The head continues to grow at normal or near- normal rates (head sparing). This is a protective mechanism that may have evolved to promote brain fluid development. This type of IUGR ismost commonly caused by
extrinsic factors that affect the foetus at later gestational ages.

ASYMMETRICAL IUGR :

SYMMETRICAL IUGR :
It is less common & is more worrisome. This type of IUGR usually begins early in gestation. Since most neurons are developed by the by the 18th week of gestation, the foetus with symmetrical IUGR is likely to have permanent neurological sequela.

44

DIETARY MANAGEMENT: CALORIES AND PROTEINS:

Protein & caloric requirement of mothers gets increased due to increased nutritional requirement of the baby. In order to meet this requirement the value RDAs prescribed for pregnant woman, should be given.

FLUID:
High fluid diet is recommended for IUGR patients.

Oral ulcer
A mouth or oral ulcer is an open sore in the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. The types of mouth ulcers are diverse, with a multitude of associated causes including, physical abrasion, acidic fruit, infection, other medical conditions and cancerous & nonspecific processes. Once formed, the ulcer may be maintained by inflammation &/ or secondary infection. Two common types are apthous ulcers (canker sores) and cold sores (fever blisters, oral herpes). Cold sores around the lip are caused by viruses.

DIETARY MANAGEMENT :
Mouth ulcer diets focus primarily on avoiding irritants that can make symptoms worse and delay healing. Common irritants also vary from person to person. A good rule of thumb is that if a food or drink causes discomfort, it should be avoided until the mouth ulcer heals. Since oral hygiene also plays a
45

role in mouth ulcer healing, it also helps to brush or at least rinse with antiseptic mouthwash after every meal or snack.

FOOD TO TAKE:
Cold foods & beverages actually soothe painful mouth ulcers, though room temperature. Choices do no harm. Cooking foods- especially fruits & vegetables- reduces their abrasive qualities. Fresh or frozen foods are good choices because they contain less acid than canned food & less salt than processed foods. Grain dishes and plain, unseasoned meat & also help because both meat & grains contain little acid & hover around a neutral pH. Sipping ice water, iced tea or cold milk during meals washes away debris and irritants from other foods, especially if the person does not have time to brush.

FOOD TO LIMIT:
Fruits & vegetables are rich in nutrients that support the immune system, but many of them contain acids that can make mouth ulcers worse & contribute to discomfort. Fruits & vegetables that should be enjoyed in moderation until symptoms subside include apple, apricots, mangoes, nectarines, oranges, peaches, pears, plums, berries & tomatoes. Juices sauces & preserves are often more irritating than the whole fruit. Although the dietary guidelines for Americans encourage people to eat fewer sweets in general, its particularly important for people with mouth ulcers to limit sweets because bacteria in the mouth ferment them to acids that delay mouth ulcer healing and contribute to tooth decay.

FOOD TO AVOID:
Salty foods like pretzels & heavily spiced foods like curries make mouth sores sting. Highly acidic fruits such as lime, lemon, pineapples, grape fruit and pomegranates have the same effect. Pickled foods & foods like salad dressing that feature vinegar as a main ingredient should also be avoided because of their acid content. Nuts & seeds are abrasive, scratching & scraping mouth ulcers and often leaving small hard particles behind.

46

TONSILLITIS
It is inflammation of the tonsils most commonly caused by a viral or bacterial infection. Symptoms of tonsillitis include sore throat & fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes such as streptococcal pharyngites are treatable with antibiotics. It usually takes one to three weeks to recover. The most common causes of tonsillitis are adenovirus, rhinovirus, influenza, coronavirus & respiratory syncytial virus. It can also be caused by Epstein- Barr virus, herpes simplex virus, cytomegalovirus or HIV. The second most common causes are bacterial. The most common bacterial cause is group A Beta- hemolytic streptococcus (GABHS), which causes strep throat. Less common bacterial causes: Straphylococcus aureus (including methicillin resistant staphylococcus aureus or MRSA), Streptococcus pneumniae, Mycoplasma pneumonial, Chlamydiapneumoniae, pertussus, Fusobacterium, diphtheria, syphilis and gonorrhea. Common symptoms of tonsillitis include: red and/ or swollen tonsils, tender, stiff and/ or swollen neck, swollen lymph nodes, sore throat, cough, headache, sore eyes, body aches, earache, fever, chills, nasal congestions, ulceration.

DIETARY MANAGEMENT: BEVERAGES:

47

Drinking fluids is one of the most important dietary factors when suffering from tonsillitis, advises the University of Maryland medical center. Choose water, juice or sports drinks. You should avoid milk as it may increase the thickness of mucus in the back of the throat. Consume drinks at cold, lukewarm or warm temperatures. Avoid extremely hot liquids when suffering from a tonsil infection. Soothing warm drinks include apple cider, warm water flavored with honey and lemon asa well as chicken and vegetable broth.

FOOD INCLUDE:
Soft creamy foods are easy to swallow when tonsillitis is present. Choose foods such as sherbet, oatmeal, grits or steamed fruits. As infection begins to clear, often 2 to 3 days after beginning antibiotic treatment, add additional soft foods. These foods can include plain pastas, mashed potatoes, baked sweet potatoes & scrambled eggs. Fruit- based smoothies are ideal as a snack. Add extra protein to your shakes for more nutrition.

FOOD TO AVOID:
When suffering from tonsillitis, avoid hard or crisp foods, such as crackers, cookies hard breads or croutons, should be avoided, until the infection is gone. Crunchy foods can scratch & irritate infected throat even more acidic drinks should also be avoided, such as colas & other sodas, as well as citrus fruit juices. The acidic drinks can cause an irritable burning sensation I the back of the throat.

NEPHROTIC SYNDROME
It is a disorder where the kidneys have been damaged, causing them to leak protein from the blood into the urine. It is a fairly benign disease when it
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occurs in childhood, it is most common between age 2 & 6 but lead on to chronic renal failure, especially in adults occur slightly more often in males than females. Kidneys affected by nephritic syndrome have small pore in the podocytes, large enough to permit proteinuria (because some of the protein albumin has gone from the blood to the urine) but no large enough to allow cells through (hence no hematuria). By contrast, in nephritic syndrome, RBCs pass through the pores, causing hematuria. Nephritic syndrome causes massive proteinuria, with 3.5g or more of protein lost within 24 hours. As much as 30g can be lost as a result. Albumin is especially affected. Nephritic syndrome is also termed as nephrosis. This disorder is characterized by massive oedema and proteinuria resulting from degenerative lesions of the tubules, mesangium (central part of the rental glomerulus) or basement membrane of the glomeruli.

DIETARY MANAGEMENT:
The major objectives of dietary management are To control & correct protein deficiency and Correct & prevent oedema and Maintain adequate nutrition to afford better resistance to infection.

CALORIES:
In most adults, energy requirement amounts to 30-40 kcal/kg body weight with upto 40-45 kcal/kg for hypercatabolic cases.

PROTEIN:
The intake may range from 0.5 to 0.6g/kg IBW, subsequently, increased to 0.81.2g/kg IBW/day. Depending on the degree of protein catabolism 0.51g/kg/day protein may be given.

SODIUM:
During the oliguric phase, sodium may need to be restricted to 500-1000mg (20-40 mEq) daily. It can be liberalized with onset of diuresis.

49

POTASSIUM:
Potassium intake is restricted to 1000-2000mg (25 to 50 mEq) and should be monitored strictly and regularly.

FLUID:
Intake is based on fluid balance but is usually restricted to a basic allowance of 500ml/day for an average adult with addition made for losses via other routes.

DOWN SYNDROME
Down syndrome is a congenital defect in which patients carry altered chromosomes. Trisomy 21 patients are those with an extra chromosome 21. There is a direct correlation between the incidence of the syndrome & maternal age. Children with this condition have short stature, decreased muscle tone, constipation, intestinal defects, weight changes & mental retardation. There is a higher risk for congenital heart disease, gum disease, celiac disease, Hirschsprung diease, hypothyroidism, a rare form of Leutemia, respiratory problems, gatroesophageal reflux, & Alzheimers disease.

DIETARY MANAGEMENT:
Tube feed if the patient is unable to eat orally. Gradually wean to olids when possible. Supply adequate amounts of energy for age, for children ages 5-11 years, use 14.4 kcal/cm for girls and 16.1 kcal/cm for boys. Use protein according to RDA. Use a gluten-free diet if celiac disease is present. Monitor for pica overeating & idiosyncrases.
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Provide supplemental sources of folate, vitamin A, vitamin E, zinc, iron & calcium it intake of fruits, vegetables, meats dairy products or whole grains is limited. Provide feeding assistance for losses in drooling, diarrhea or spillage. Encourage complex carbohydrates, prune juice, etc, if constipation is a problem.

BURNS
Burns are injuries to tissues tat result from heat, electricity, radiation or chemicals. They are usually caused by heat (thermal burns), such as fire, steam, tar or hot liquids. While burns caused by chemicals are similar to thermal burns those caused by radiation, sunlight and electricity tend to be different. Thermal and chemical burns usually occur because heat or chemicals come in contact with part of the bodys surface, most often the skin. Thus, the skin usually sustains most of the damage. Severe surface burns may penetrate to deeper body structures, such as fat, muscle, or bone. When tissues are burned, fluid leaks into them from the blood vessels, causing swelling and pain.

Classification of Burns:
Burns can be classified in the basis of the extent, depth, patient age and associated illness or injury. On the basis of depth, burns are usually classified by degree. FIRST DEGREE BURNS or ERYTHEMA i.e, redness of the skin produced by coagulation of the capillaries with cell destruction above the basal
51

layer of epidermis. SECOND DEGREE BURNS is erythema and is characterized by blistering with necros within the dermis. THIRD DEGREE BURNS lead to total loss of skin including the fat layer, hair follicles and sweat glands.

DIETARY MANAGEMENT: ENERGY:

The Energy needs of the burned patient vary according to the depth and size of the burn. The requirements of course would be highest in third degree burns. Although several formulas have been developed to determine the energy needs.

BASAL ENERGY EXPENDITURE: MEN: BEE =66.47+13.75 W+5.00 H-6.76 A

= 66.47+13.75*60+5.00*170-6.76*35 = 66.47+825+850-236.6 = 1741.47-236.6 = 1504.87 Estimating 24 hours energy expenditure in burn patients (kcal/day) Harris_benedict equation_BEE =BEE*1.1-1.4 (for <40% TBSA) =BEE*2 (for >40%TBSA) =1504.87*2

CARBOHYDRATES:
Liberal amounts of carbohydrates should be given i.e around 60% to 65% of the total energy. Care must be taken regarding the maximum rate of administration feasible keeping in mind the fact that the maximum tolerance level is about 7mg/kg/min above which glucose is not oxidized to release energy but is converted to fat.

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FAT :
A careful monitoring of immune function, feeding tolerance and serum triglycerides is required during lipid administration. Most of the patients are able to tolerate around 12-15% of the total calories in the form of lipids.

PROTEIN :
It is one of the most crucial nutrient which determines the ultimate outcome of burns. Amino acid requirements are high due to increased losses through wounds and urine, increased requirement for promoting synthesis of blood proteins and wounds. Adult patients should be given 20-25% of the increased energy from protein. Among children the requirements are still higher i.e 2.5 t 3.0g per kg usual body weight per day.

VITAMINS and MINERALS:

When the patient is on tube feeds it is suggested to provide around 500mg (twice daily) vitamin C and 5000 I.U of vitamin A per 1000 kcals of energy being provided.

HEPATITIS
Hepatisis is a condition of inflammation of liver, which can result in damage of the liver cells. A virus causes viral hepatisis, as liver celss are particularly susceptible to such infections. It causes damage to the liver cells and interferes with the uptake of bilirubin by the cells, and its conjugation and excretion. It can be either in form of an acute or chronic condition and is caused due to different strains of viruses such as A,B,C.D and E.

53

DIETARY MANAGEMENT: ENERGY:

The caloric intake advised for adults is 35-40 cal/kg IBW or as per the requirement to maintain a desirable body weight.

CARBOHYDRATES:
Liberal intake of CHO is advised (300-400g). This is to prevent endogenous breakdown of protein thus having a protein sparing effect, increase the (intra hepatic) glycogen stores to improve the functioning and protect the liver against infectious agents.

PROTEIN:
Moderate protein intake in the diet is required for the following reasons: To prevent negative nitrogen balance, which may lead to hypoproteinemia, For adequate tissue regeneration especially of parenchymal cells and Prevent fatty infiltration of liver cells Thus, 1.5 to 2.0g/kg IBW protein is recommended. Supplements f high protein beverages are recommended in between the meals.

FATS:
Fats should not be severely restricted as they can make the food unpalatable. About 20% of the total calories should b from fat.

VITAMINS:
Supplementation of B complex vitamin and C should be given.

MINERALS:
Sodium restriction is required only if there is fluid retention. Potassium supplements are necessary with diuretic therapy. Iron supplementation is needed only if there is anaemia.

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parKinsons disease
Parkinsons disease is a degenerative central nervous system (CNS) condition characterized by progressive loss of cells with substain nigra. Substania nigra is a portio of the midbrain which is thoughtto be involved in certain aspects of movement and attention. It consists of two subdivisions, the PARS COMPACTA and the PARS RETICULATA. The cells within the substania nigra release the neurotransmitter dopamine and it is the loss of dopamine that is primarily responsible for the motor defects.

DIETARY MANAGEMENT:
These problems have to be taken into consideration while planning meals. Foods rich in fiber and which can be cut into pieces and made into cohesive bites could be given. Liquid foods may be difficult to handle, but care should be taken to ensure fluid intake is adequate to prevent constipation and hypertension (low blood pressure). Small frequent meals with more carbohydrates and less fat may be better tolerated, in view of the gastric side effects and delayed gastric emptying. Diets given should be balanced and nutritionally adequate. Frequent intake of high-protein snacks has deleterious effects upon Parkinsons disease control. Hence this should be avoided. Supplementation of vitamin B6 (pyridoxine) should be avoided as this vitamin can facilitate the premature conversion of levodopa to dopamine thus reducing the potency of the drug.

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PRESCHOOL CHILDREN
The years between 1 and 6, growth is generally slower than in the first year of life but continues gradually. Activity also increase markedly during the second year of life as the child becomes increasingly mobile. Development of a full dentition by about the age of 2 years also increases the range of foods that can safely be eaten. There is an increased need for all nutrients, but the pattern f increase varies for different nutrients in relation to their role in growth of specific tissues.

DIETARY MANAGEMENT: ENERGY:

Energy is required for growth and activity. Insufficient food will not only result in undernutrition in terms of inadequate weight gain but will also hinder growth. The rate of growth fluctuates from one age to another. Upto 10 years of age there is no difference in sex for RDA.

PROTEINS:
The increase in the muscle mass that must accompany bone growth requires positive nitrogen balance that is met by protein intake of 1.5 to 2g/kg body weight.

FATS:
Fat energy including invisible fat for children should be 25 percent of total energy and essential fatty acid energy is 5-6 percent.

MINERALS:
Calcium requirements of children is calculated on the basis of the amount of calcium accretion in the body. All dietary calcium is not absorbed 400mg/day is prescribed though the actual requirement may be less. Milk is the best source of calcium. Hence the diet of preschool child should include 1-2 glasses of milk per day. During growth for an increase in each kilogram in body weight 30mg of iron is required and since the increase in body weight during childhood is 2kg/year on an average, the daily requirement of iron for growth will be 0.2mg.
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VITAMINS:
The incidence of vitamin A deficiency signs are high and serum vitamin A levels are generally low among Indian children whose dietary intake is less than 100mcg.

ULCERATIVE COLITIS
Ulcerative colitis is a diffuse inflammatory & ulcerative disease of unknown etiology involving the mucosa & sub-mucosa of the large intestine. It occurs at any age but predominates in adults. Onset is insidious in the majority of cases.

SYMPTOMS:
1. Mild abdominal discomfort, an urgent need to defecate several times a day. 2. Diarrhea accompanied by rectal bleeding. 3. Weight loss, dehydration, fever, anemia & general debility. 4. Edematous & hyperemic mucosa seen in early stages.
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DIETARY MANAGEMENT:The dietary management & nutrient

recommendations need individual attention depending on the extent of disease & problems of malnutrition exhibited.

ENERGY:The calories requirements must be increased to:

1) Restore weight status & maintain ideal weight. 2) Compensate for the elevated BMR. 3) Support growth especially if the age group is adolescents. A caloric intake of 40-50kcal/kg IBW/day is recommended.

PROTEINS:Patients with ulcerative colitis lose about 4-8g fecal nitrogen as

compared to the normal excretion of 2g. In severe case, 20g nitrogen may be lost daily. The serum albumin is low. Proteins are necessary for tissue synthesis, tissue healing & to compensate for the increased losses in stools. Thus, Liberal amounts of high quality protein i.e.1.5g/IBW are needed to make up for the losses. Emphasis should be on tender meats, fish, poultry & eggs for those patients who are allergic to milk.

FATS:Usual foods, which contain fats are permitted but not fried foods, as
they are not easily digested due to liver dysfunction. Thus fats rich in medium chain triglycerides should be consumed as steatorrhoea is predominant in ulcerative colitis. Total fat intake can be kept close to 55-60g with visible fat intake less than 25-30g/day.

CARBOHYDRATES:They form the easily absorbable source of energy. Bulkproducing vegetables are restricted so as to allow better intake of nourishing foods. Sugars & starches can make the increased caloric intake.

FIBRE:Eliminating roughage seems to have a better effect on preventing

relapses of the disease. A low residue diet may be given during an acute attack to prevent severe bleeding during diarrhea. Thereafter some degree of fiber restriction is generally needed as many ulcerative colitis patients do not tolerate raw vegetables.

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FLUIDS:A liberal intake of fluid should be given to prevent dehydration. The

passage of at least 1200ml of urine indicates that a patient is well hydrated.

HEPATIC ENCEPHALOPATHY (he) OR HEPATIC COMA

Hepatic encephalopathy is brain & nervous system damage that occurs as a complication of liver disorders that reduce liver functioning. It is a complex syndrome characterized by neurological disturbances. The symptoms associated with it are: changes in mental state, consciousness, personality & behavior changes characterized by the following signs-mild confusion, depression, decreased attention, slowing activity, irritability & disorder of sleep pattern, drowsiness, lethargy, speech disorientation & finally coma.

DIETARY MANAGEMENT: The nutritional management goals for hepatic

coma include: Reduction in protein intake to a minimum in order to decrease amount of ammonia produced, Correcting plasma amino acid profile, & Prevention of catabolism of tissue protein.

The dietary recommendations include:

CALORIES:A 1500 to 2000 kcal diet is recommended to prevent breakdown of

tissue protein for energy.

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PROTEINS:The protein intake may begin with 0.2 g/kg IBW/day. If the
patient remains asymptomatic for a week it may gradually be increased by 1015 g/week, & then 20-40 g & gradually to 0.5 g/kg IBW.

CARBOHYDRATES: An increase in carbohydrates in the diet is

recommended because it is the main source of energy & thus spares the protein.

FATS:Fats require restriction, as diseased liver cannot metabolize fats.

Substitution with MCT is recommended.

VITAMINS:Increase in intake of B-complex vitamins such as folate , thiamin

& vitamin C is recommended.

SODIUM:A restriction of 2 g/day along with use of diuretics is recommended. FLUID:There is a evident fluid retention. Thus, depending on the patients
state of hydration, urine output, presence of oedema & diuretic therapy, the fluid intake should be decided & recommended.

TYPHOID
Typhoid is an enteric fever, which relates to acute infection of short duration. It is caused by bacteria called SALMONELLA TYPHOSA. The mode of spread of this infection is through the fecal-oral route. The source of infection is the drinking water, milk & food contaminated by intestinal contents (through feces & urine)

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of the patients or carriers or by flies which transmit the disease. It may affect all age groups but is commonly observed in children.

PRINCIPLES OF DIET:High calorie, high protein, high carbohydrate,

moderate fat, high fluid, low fiber & soft diet is suggested for typhoid patients.

DIETARY MANAGEMENT:The golden rule in the dietary management of

any fever is feed the fever. Feeding several times a day improves tolerance. The texture of foods given would depend on the severity of infection. Bland, low fiber & soft foods are beneficial. The nutrient requirements are:

ENERGY:Fever is characterized by elevation of BMR, thus caloric

requirements are increased i.e. 10-20% above the normal recommended requirements.

PROTEIN:The protein intake should be increased above the normal of

1g/kg/day to 1.5-2g of protein /kg/day.

DIETARY FIBER:Typhoid patient has an inflamed intestinal mucosa, which

can be easily perforated & ulcerated leading to internal haemorrhage. Thus foods high in fiber such as certain green leafy vegetables, whole cereals or pulses, thick skins or fruits or vegetables must be avoided. Soluble fibers can be given.

FATS:Use of dairy fats like butter, cream, fats in milk products, egg yolk etc.
help in easy digestion as they contain medium chain triglycerides. Excessive use of fat in cooking, eating fried foods can aggravate nausea, impair digestion & lead to severe diarrhea. These should be avoided.

MINERALS:Loss of electrolytes & water is observed due to diarrhea. Thus

liberalizing on sodium intake through salty soups, beverages are desired. Food preparations in forms like juices, stews, soups & dal water are beneficial.

FLUIDS:Liberal fluid intake is desired to compensate for the fluid losses from
the body. A daily intake of 2.5 to 3.5 litres may be recommended.

Foods to be included:
Juices, soups, dal water, broths.
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Refined cereals & their products (e.g. maida, rava, bread, rice, noodles, washed dals, pureed vegetables, stewed fruits). Eggs, cottage cheese, steamed fish. Honey, sugar & dairy products.

Foods to be avoided:
High fiber foods like whole grains cereals & their products(e.g. whole wheat flour, cracked wheat, whole pulses) Raw vegetables & fruits Fried fatty foods Chemical irritants like spices, pickles, papad, ketchups etc.

TUBERCULOSIS

Tuberculosis is a chronic infectious disease which is caused by a bacterium MYCOBACTERIUM TUBERCULOSIS. It affects the lungs most commonly but can get localized in other organs also, like lymph nodes, kidney, bone etc. The most commonly observed form of tuberculosis in India is pulmonary tuberculosis.

Principles of diet:A high calorie, high protein, high vitamin & minerals,
high fluid soft diet is recommended.

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DIETARY MANAGEMENT:The recommended nutrients are: ENERGY:Since the metabolic rate is not as high as in other fevers,
satisfactory weight can be maintained with 2500 to 3000 calories. It is not desirable to gain more than 10% above the ideal weight for the body frame. High calorie diet is prescribed.

PROTEIN:A protein intake somewhat in excess of normal requirements is

necessary in tuberculosis, since the serum albumin value especially in advanced tuberculosis & in cases of long standing, may be low. The daily requirement may be from 80 to 120g.

MINERALS:The drug isoniazid interferes with vitamin D metabolism. This in

turn can decrease absorption of calcium & phosphorus. Calcium especially should be provided liberally since it is also essential for healing tuberculosis lesions. At least one litre of milk should be taken daily. The iron needs may also be increased if there has been haemorrhage.

VITAMINS:The metabolism of vitamin A is adversely affected in tuberculosis.

Carotene appears to be poorly converted to vitamin a so that the diet should be planned to provide vitamin a as such. Vitamin C is essential for many regenerative purposes.

OBESITY
Obesity is a state in which there is a generalized accumulation of excess adipose tissue in the body leading to more than 20% of the desirable weight. Obesity invites disability, disease & premature death. Excess body weight is a hindrance, leading to breathlessness on moderate exertion & predisposes a person to disease like atherosclerosis, high blood pressure, stroke, diabetes,

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gall bladder diseases & osteoarthritis of weight bearing joints & varicose veins. Obesity is a chronic disease. Usually obesity is due to positive energy balance. That is, the intake of calories is more than the expenditure of calories.

Principles of dietetic management:Low calorie, normal protein

vitamin & mineral (except sodium), restricted carbohydrate, restricted fat & liberal fluid, high fiber diet are given in such cases.

ENERGY:About 20 kcal/kg IBW is prescribed for a sedentary worker 7 25

kcal for moderately active worker.

PROTEINS:About 0.8-1g of protein/kg body weight is prescribed for tissue

repair 7 for specific dynamic action.

CARBOHYDRATES:High carbohydrates content foods like potatoes 7 rice

are restricted. Sugar which gives empty calories should be totally avoided. Fruits rich in carbohydrates like banana should be avoided.

FAT: Low fat or no fat diet should be given as calories are reduced. Foods rich
in fat-like nuts & oilseeds avoided. Skim milk should be the choice.

VITAMINS:With prolonged restriction of fats, there is likely to be a restriction

of fat soluble vitamins A & D which may be supplemented.

MINERALS:Restriction of sodium as common salt is helpful in weight

reducing diet as excess sodium predisposes to retention of fluid.

FLUID:Fluids can be taken liberally as extra fluids are excreted by healthy

kidneys. Also a glass of water before meals helps to cut down food intake.

HIGH FIBER:High fiber low calorie foods like green leafy vegetables, fruits,
vegetables salads, whole grain cereals & pulses can be included in the diet.

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UNDERWEIGHT
Just as overweight is the positive energy balance irrespective of the etiology, underweight results when the energy balance is negative. Failure to consume sufficient calories to meet the energy requirement of the body for whatever reasons is responsible for not maintaining optimum weight.

There are a number of factors causing underweight. These are:

Poor selection of food Physical activity Mothers health status Pathological condition Genetic predisposition

DIETARY MANAGEMENT: ENERGY:The calorie intake should be 500 to 1000 kcal in excess of the daily
needs in order to result a gain in weight by half to one kilogram in a week. Thus, if you need 2000 kcal for your normal activity, you require 2500-3000 kcal /day for weight gain. The patient may be given 30-35 kcal/kg IBW/day. The calories should be increased gradually over a period of one or two weeks to avoid digestive disturbances.

PROTEINS:Proteins are required for tissue building, as well as, to take care of
the daily wear & tear. Thus, the patient may benefit by consuming around 1.2g/kg body weight of proteins per day. Both animal & plant proteins should be emphasized.

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FATS:add extra fat gradually, a sudden increase in fatty foods like butter,
cream & oil may produce diarrhea. About 30% of calories should come from unsaturated sources of fat.

CARBOHYDRATES:All cereals provide high calories at low cost & should

provide about 55-65% of total kilocalories.

VITAMINS & MINERALS:If the diet provides good amounts of fresh fruits &
vegetables, vitamin or mineral supplements are usually not required.

FLUIDS:Take fluid only after meal instead of with or before meals so that food
intake is not reduced. High calorie nourishing beverages such as milk shakes, egg nog should be preferred over low nutrient beverages such as cold-drinks, barley water, plain soda etc.

CONSTIPATION
Constipation may be defined as less than 3 motions per week or as difficult or painful defecation. In this condition, hypermotility of the sigmoid colon increases resistance to movement of intestine al contents; consequently, there is distension & infrequent or difficult evacuation of feces from the intestine. An accurate definition is related to personal habits since the frequency of bowel movements varies greatly among individuals.
66

Infrequent or insufficient emptying of the bowel may lead to malaise, headache, coated tongue, foul breath & lack of appetite.

DIETARY MANAGEMENT:
The intake of dietary fiber should be increased by eating whole cereals & increasing consumption of fruits n vegetables. The most important factor is the water holding capacity of the fiber. Coarse bran has a capacity of 6g water/g of fibre, but fine bran holds only 2-3g water/g. patients should be encouraged to take coarse bran as a breakfast cereal. One tablespoon of bran may be taken in the first week & two thereafter. The bran may be more palatable by adding cooked fruits. Fruits n vegetables whose fiber holds waters effectively are oranges, apples, cabbage family. The diet should contain a helping of vegetables particularly in raw form n two such fruits each day preferably with skin and seed. Whole grain breads and cereals should be substituted for refined ones. Fat-cont6aining foods as bacon, butter, cream and oils are useful for some because o the stimulating effect of the fatty acids on the mucous membranes. A fluid intake of 8 to 10 glasses a day is useful in keeping the intestinal contents in a semisolid state for easier passage along the tract.

FOODS TO BE GIVEN FREELY IN CONSTIPATION

Whole-wheat, maize, millets Whole-pulses such as rajma, chole, whole green gram etc. Green leafy vegetables, knoll-khol, lotus stem, peas, beans Guavas, pomegranate, apples with skin, cherries, pear, peaches and plums

FOODS TO BE AVOIDED IN CONSTIPATION

Refined foods; pasta, refined cereals like maida, suji, baked products, pizza, biscuits Deep fried foods Pureed fruits and vegetables, banana, mango etc.

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CELIAC DISEASE
Celiac disease, often called gluten-sensitive enteropathy or non-tropical sprue is caused by a reaction to gliadin. The resulting damage to the villi of the intestinal mucosa results in potential or actual malabsorption of virtually all nutrients. The most common symptoms in children 6 months to 3 years of age are diarrhea, growth failure, vomiting, a bloated abdomen and stools that are abnormal in appearance, odour and quantity. Adults may experience weight loss despite increased appetite, weakness and fatigue. They may also suffer from anaemia and osteopenic bone disease.

DIETARY RECOMMENDATIONS:The only dietary treatment for celiac

disease is to follow a gluten-free diet. For most such a diet improves symptoms, heals intestinal damage, and prevents further damage.

GLUTEN and NON-GLUTEN SOURCES

Gluten sources
Beverages: cereal beverages, ovaltine, beer n ale Milk beverages that contain malt Meat and meat products: breaded meats Fats and oils: commercial gravies, white sauce and cream sauces Cereal and cereal products: bread, wheat, oats, rye, malt, pastry etc. Fruits; any fillings e.g. pies etc. Snacks: pastries, patties, pizzas, samosas, mathries etc.

Non-gluten sources
Coffee, tea, chocolate drinks Whole, toned, skim milk n buttermilk Pure meats, fish, poultry, eggs Butter fats and oils Rice, potato flour and soya flour, pure corn, popcorn All fresh fruits Milk base sweets without addition of any cereal products.

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JAUNDICE
Damage to liver cells leads to increase in bilirubin resulting in jaundice. It is a symptom common to many diseases of the liver & biliary tract & consists of a yellow pigmentation of conjunctiva, skin & body tissues because of the accumulation of bile pigments in the blood. After 120 days of life, RBC are broken & through a complex chemical reaction, bilirubin is produced. This is excreted in stools & urine along with bile. Problems like increased destruction of red blood cells decreased functioning of the liver or obstruction to the flow of bile from the liver can result in jaundice.

DIETARY MANAGEMENT:A high protein, high carbohydrate, moderate fat

is recommended. Small attractive meals at regular intervals are better tolerated. Overfeeding should be avoided.

ENERGY:In nasogastric feeding stage 1000 kcals are supplied. In severe

1,600 kcals to 2,000 are suggested.

PROTEINS:For the liver cells to regenerate an adequate supply of proteins is

needed. With severe jaundice, 40 g while in mild jaundice 60-80 g of protein is permitted.

FATS:In severe jaundice 20 g & in moderate jaundice 20-30 g of fat are

recommended. In other case of jaundice, fat needs to be restricted only if there is obstruction to bile flow that does not permit fat digestion & produces fatty diarrhoea.

CARBOHYDRATES:High carbohydrate content in the diet is essential to

supply enough calories so that tissue proteins are not broken down for energy purpose. When fever, nausea & vomiting are present, intravenous glucose is suggested. As soon as the patient can take oral feeds, intravenous feeding

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should be stopped & fruit juices, sugar, jaggery & honey are given not only to provide carbohydrate but also to supply adequate electrolytes.

VITAMINS:They are essential to regenerate liver cells. 500 mg of vitamin c, 10

mg of vitamin k & supplements of B complex are essential to meet the daily needs.

FOODS INCLUDED:Cereal porridge, soft chapattis, bread, rice, skimmed

milk, potato, fruit, fruit juices, jiggery, honey, biscuits, soft custards without butter cream & non-stimulant beverages.

FOODS AVOIDED:Pulses, beans, meat, fish, chicken, egg, meat soups, sweet
preparations where ghee, butter or oil are used, bakery products, dried fruits, nuts, spices, papads, chutney, alcoholic beverages, fried preparations, wholemilk, cream.

LIVER CIRRHOSIS
Cirrhosis is a condition in which there is destruction of the liver cell due to necrosis, fatty infiltration, fibrosis & nodular regeneration. It is a serious & irreversible disease. Vitamin A deficiency favours the formation of cirrhosis.

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The cirrhotic process may commence many years before it becomes clinically obvious & usually the patient when first seen is at a very late stage with complications, such as ascites, ruptured esophageal varices or hepatic coma. Almost 85-90% of liver damage also do not produce symptoms. The initial change in cirrhosis is widespread liver cell necrosis due to viral hepatitis, alcohol etc. this necrosis results in collapse of the liver cells & intrahepatic shunts, due to the proximity of the hepatic artery & portal vein to the central vein. The necrosis & collapse also stimulate nodular regeneration & fibrosis. Cirrhosis of liver is the structural & functional end result of nutritional, infective or toxic changes in the liver.

PRINCIPLES OF DIET: A high calorie, high protein, high carbohydrate,

moderate or restricted fat, high vitamin diet helps in regeneration of liver & helps to prevent the formation of ascites. Low fat with supplementation of fat soluble vitamins & minerals should be given. Sodium should be restricted only when there is ascites.

DIETARY TREATMENT: ENERGY: Consumption of food is difficult because of anorexia & ascites. The
patients are usually emaciated by the time cirrhosis of the liver is diagnosed. The patient required highly nutritious food i.e. high calorie diet is necessary because of prolonged undernourishment. The calorie requirement should be between 2000-2500 kcals.

PROTEINS:The serum albumin which is exclusively synthesized in the liver

cells is low in cirrhosis & aggravated by the loss of a considerable amount of albumin into ascite fluid. In the absence of hepatic coma a high intake of proteins about 1.2 g/kg of body weight can be given.

FATS:About 20 g of fat is given. Even if fatty changes are present in the liver,
fats should be provided in adequate amounts. Medium chain triglycerides containing C8 to C10 fatty acids can be given as these are digested & absorbed in the absence of bile salts. Coconut oil contains medium chain fatty acids.

CARBOHYDRATES:Should be liberally so that the liver may store glycogen.

Liver function improves when an adequate store of glycogen is present in liver
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cells. 60% of the calories should come from carbohydrate so that liver damage is minimized.

VITAMINS & MINERALS:The liver is the major site of storage & conversion
of vitamins into their metabolically active form. In cirrhosis, the liver concentration of folate, riboflavin, nicotinamide, vitamins A are decreased. Decreased vitamin A may be due to the decreased synthesis of retinol binding protein. Since vitamin D is converted to calcidiol in the liver, oral administration or injection of vitamin d in biliary cirrhosis is not successful in raising the serum level of calcidiol. In all patients with cirrhotic ascites dietary sodium intake may initially be restricted to 400-800 mg/day.

ACUTE PANCREATITIS
Acute pancreatitis is a rapid inflammation of the pancreas which results from escape of pancreatic enzymes from acinar cells into the surrounding tissues. The clinical feature of pancreatitis results from auto digestion of tissue & toxic effects of digestion products. Elevated serum & urinary amylase concentration due to enzyme released by necrosed pancreatic cells remain one of the main diagnostic criteria in acute pancreatitis.

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NUTRITIONAL MANAGEMENT:the nutritional management goals of acute

pancreatitis include; 1. Conservative management involves resting pancreas & maintaining fluid balance. 2. Nil by mouth till the pain & fever subsidies, as the oral intake further aggravates the symptoms caused by the increased secretory mechanism of pancreatic enzyme & bile. 3. The patient needs to be supported by early enteral nutrition with the formulation of nutrient in predigested forms & supplementation with low fat intake to prevent further precipitation of malnutrition. Sometimes TPN is required. 4. When oral feeding is resorted it should be a clear liquid diet with a waiting period to see the response of the patient in terms of undesirable symptoms. 5. A low fat diet with an intake of total fat as 30 g/day, which may gradually be increased as per the patients tolerance. MCT may be incorporated for better digestibility & assimilation, as they do not require the pancreatic enzyme system for the same. They also help in increasing the total caloric intake of the patient.

The dietary guidelines include:

A caloric intake of 35 kcal/kg IBW is ascertained keeping in mind the moderate stressful state. The patient needs to be kept on a low fat diet (40 to 60 g/day), the levels are ascertained with the tolerance of the patient. Calcium & vitamin B12 are important as deficiency of pancreatic protease may prevent cleaving of vitamin B12 from its carrier protein there by leading to vitamin B12 deficiency. Fat-soluble vitamin malabsorption may occur. Thus, parenteral administration of fat-soluble vitamin is necessary.

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ANOREXIA NERVOSA
Anorexia nervosa is a physcological eating disorder characterized by somatic delusions that one is too fat despite being emaciated, and refusal to maintain a minimally normal weight for height and age. The condition includes weight loss leading to maintenance of body weight 15% below normal; an intense fear of weight gain or becoming fat, despite the individuals underweight status; a disturbance in the selfawareness of ones own body weight or shape; and in females, the absence of at least three consecutive menstrual cycles that would otherwise be expected to occur. Individuals with anorexia nervosa are unwilling or refuse to eat enough food to maintain a body weight that is normal or expectable for their age and height. Such individuals typically display a pronounced fear of weight gain and dread of becoming fat although they are dramatically underweight.

DIETARY MANAGEMENT:The guideline for nutrient/diet therapy

and nutrient intake for anorexia nervosa patients include:

A.CALORIE INTAKE Initial intake:For refeeding and for all but the most severely ill
patients intake levels should start at 30-40 kcal/kg/day. This level of intake should be continued until it can be confirmed that gut function is normal and that water overload, if present, is beginning to resolve. The latter is indicated by weight stabilization and normally occurs within 7-10 days. Thereafter, food intake should be increased as discussed below:

Weight gain phase:during the weight gain phase the intake

may have to be increased to as high as 70-100 kcal/kg/day for some patients. A weekly weight gain of 0.5-1.0 kg is generally regarded as optimum. The rate of gain will slow down as weight increases, owing to an increase in metabolic rate and physical activity. It may be appropriate to increase energy intake to compensate for this or to allow a slower rate of weight gain in order to facilitate stopping at the agreed maintenance figure. This is followed by the weight maintenance phase.

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Weight maintenance phase:The intake level during weight

maintenance for adults and as needed in children and adolescents for further growth and maintenance should be set at 40-60 kcal/kg/day.

B.PROTEINS:A protein intake in the range of 15-20% of total

calories is recommended. Protein sources of high biological value need to be included in the diet of the patient.

C.CHARBOHYDRATE:Carbohydrate intake in the range of 50-55%

of calories is well tolerated. It is important to include sources of insoluble fiber for optimal health and for relief from constipation.

d. FATS:A dietary fat intake in the range of 25-30% of calories is

recommended. Patients may have an aversion to fat, which makes weight gain difficult. Fat may therefore be included in the diet in a disguised form.

E.MICRONUTRIENTS:It is advisable to include one 100% RDA

multivitamin tablet with minerals. The use of prophylactic thiamine supplements in oral form is recommended for in-patients and those undergoing rapid weight gains. Riboflavin deficiency may cause angular stomatitis and iron deficiency causes anemia. Vitamin C deficiency can cause bleeding gums. These problems may need specific nutritional supplementation. Vitamin D requirements are higher than average in anorexia nervosa, owing to the risk of osteoporosis, and there is an argument for giving vitamin D supplements as part of refeeding.

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GERIATRIC NUTRITION
Aging has been defined as a series of time related processes that ultimatelybring life to a close. Persons of 60 years of age and older are defined as elderly by WHO. Successful aging is said to be multidimensional and has been defined as encompassing the avoidance of disease and disability,maintenance of cognitive and physical function and sustained social and productive activity.

NUTRTIONAL CHANGES AND REQUIREMENT: ENERGY & PROTEIN:Decreased physical activity and changes in
body composition and decreased basal metabolic rate affects the macronutrient energy, protein requirements. It has been established that 0.8 gm protein /kg body weight/day in universally recommended providing about 15-20%of energy. The protein intake may be increased or decreased depending on illness/convalescence. The estimated energy requirements decrease by 0.5-1.0% per year and are based on physical activity level, weight, height and age of the individual -25-30 kcal/kg/day. With aging loss of muscle mass and strength (sarcopenia) is observed. It has been seen that decrease in physical activity causes these body composition changes. These process leads to a lower energy requirement. Due to the decrease in lean body mass, physical activity is most important. It is also important to emphasize the elderly to maintain adequate energy intake to prevent either underweight or overweight. Underweight may be observed in persons who have anorexia aging and depression. They may have gait instability, falls, and fractures, delayed wound healing etc.

CARBOHYDRATE:It is usually recommended that approximately

55% be provided from carbohydrate foods with emphasis on complex carbohydrates. Aging has been associated with decreased glucose tolerance and it can be corrected to an extent with increased dietary fiber and exercise.

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FATS:In elderly fat intake is recommended to be limited to 20% with

emphasis on quality of fats used. Emphasis is on right proportion of PUFA, MUFA and SFA for prevention of coronary artery disease.

VITAMIN AND MINERALS:Decreased gastric secretion &

intestinal motility affect the absorption & intake of nutrients especially calcium, iron, vitamin B12& fiber in the diet. The dietary fiber intake is also reduced with age.

WATER & ELECTROLYTES: Intake for individuals are said to be

consistent throughout adulthood. For adults 30 ml/kg body weight /day is recommended.

alZheimers disease
Named after the German neurologist who first described it, Alzheimers disease is the most common cause of progressive dementia, due to the degeneration of nerve cells in the brain & shrinkage of brain matter. Extra cellular deposits of amyloid forming protein or amyloid plaques are reported in the cerebral vessels.

ETIOLOGY & CLINICAL FEATURES:

The probable risk factors include a genetic basis, head injury, low education level, Down syndrome & mothers age at birth. However, no single factor has been proven to be responsible for this disease. The clinical manifestations of Alzheimers disease along with the nutrition related changes may be divided into three stages.

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Impairment of a wide range of neurological functions is involved, being a disease of the cortical neurons. The three stages are:

Stage 1- There is an increased forgetfulness, anxiety &

depression. Associated nutrition related changes include difficulty in food preparation, forgetting to eat, taste & smell changes, altered food choices & impaired appetite regulation.

Stage 2- There is memory loss, especially for the recent

events. There is disorientation & personality changes occur. Dietary manifestations include an increase in energy requirements as a result of agitation, holding food in the mouth, forgetting to eat & swallow, forgetting the use of eating equipment except perhaps a spoon & eating with hand.

Stage 3- This is characterized by severe mental confusion,

psychosis, memory loss, personal neglect & distinct feeding problems. There may be no recognition of food with refusal to open the mouth for eating.

FEEDING & NUTRITIONAL MANAGEMENT:

The main objectives of nutritional management are to; Provide adequate nutrition, Prevent malnutrition, & Devise methods to tackle feeding problems.

Several strategies may have to be used to achieve these objectives, keeping the functional impairments in mind. Some of these, based on the stage of the disease & individual needs are: Supervising meal times with minimal distractions, Assessing chewing & swallowing ability & providing foods of appropriate consistency, Initiating the activity of eating, by making the person touch or taste the food, Giving one food at a time in small bowls so as to avoid stress of food choices, Supervising to avoid eating of spilt food or inedible items, Giving only a spoon or finger foods, in case of inability to use other eating equipment,
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Encouraging individual appropriate feeding techniques, Permitting adequate feeding time to increase intake, Use of nutrient dense foods, frequent snacks & nutritional supplements to avid malnutrition, Avoiding finger foods & using only a small spoon in case of tendency to take a large bolus.

ACUTE GASTROENTERITIS
Gastroenteritis is an inflammation of the stomach & intestinal lining. Eating chemical toxins in food (such as seafood, mushrooms, arsenic & lead), drinking excessive alcohol, food allergies, food borne illness, intestinal viruses & other drugs can cause gastroenteritis. Gastroenteritis causes malaise, nausea, vomiting, intestinal rumbles, diarrhea with or without blood & mucus & sometimes fever & prostration.

DIETARY MANAGEMENT:
The nutritional treatment must follow general principles of soft diet. The diet should be adequate in calories & nutrients. There must be small feedings at regular intervals. Avoid gastric irritants & highly seasoned foods (onion garlic, chilly, caffeine, cola & alcohol). Excess water or other liquids with meals may cause distention.

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ENERGY:Give adequate calories through frequent feedings or else

proteins would be utilized for energy of repair work.

PROTEIN:Give adequate proteins (1 g/kg body weight) through

skimmed milk, egg, steamed fish, chicken, minced meat etc.

CARBOHYDRATES:Simple easy to digest carbohydrates should be

included in soft well cooked form. Thus, semolina, rice, arrowroot etc.may be included whereas whole cereals & millets should particularly be avoided if gastritis has caused damage to the mucosa.

FIBER: Eating a diet high in fiber reduces the risk of developing the
ulcers & also speeds up the healing process. However, care must be taken that fiber rich foods are always included in a soft cooked form. Raw foods, seeds etc should be completely avoided in the diet. While soluble fiber is safer for the patient as compared to insoluble fiber (husk/bran of cereals & pulses, peels of fruits & vegetables).

VITAMIN B12 Supplementation with vitamin B12 helps to treat

:

pernicious anemia & H.pylori infection. Its sources include fish, dairy products, organ meats, eggs, beef & pork.

VITAMIN A:A combination of vitamin A & antacids is helpful in

healing ulcers.

VITAMIN C:A high dose of vitamin C treatment is effective in

treating H. pylori infection.

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CHRONIC KIDNEY DISEASE

Chronic kidney disease (CKD) is characterized by the inability of kidney function to return to normal after acute kidney failure or progressive renal decline from disease. CKD causes permanent reduction in function, eventually leading to end-stage renal disease. Excess urea & nitrogenous wastes accumulate in the blood stream. Almost 80% of all persons with CKD have hypertension. Other risk factors include diabetes, autoimmune disease, systemic infections, urinary tract infections, kidney stones, cancer, family history of CKD, exposure to certain drugs & low birth weight.

DIETARY MANAGEMENT: ENERGY:30-40 kcal/kg/day body weight for adults & about 100150 kcal/kg/day for children is recommended.

PROTEIN:Protein needs to be restricted. However, enough as to be

provided to minimize tissue catabolism. About 0.8 g /kg/day is recommended but as to be regulated depending on declining renal function. A protein intake of 35-40 g/day. If BUN rises, the protein intake may need to be restricted to 20 g/day.

FAT:The serum triglyceride is raised partly due to excessive CHO

feeding or two large amount of glucose administered of haemdialysis for energy fats along with CHO are recommended.

CARBOHYDRATE:CHO should provide the main source of energy

to reduce body protein breakdown. Sugars & cereals from which protein are removed & liberally permitted as wheat starch.

FLUID:Fluid intake is dependent on urine output & water balance.

Fluid intake should be adequate to stimulate urine output for excretion of wastes but should avoid excess fluid retention at the same time.

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SODIUM:sodium intake will vary between 500 mg to 2.0 gm/day

weight loss & decreasing urine volume indicates a need for additional sodium, where if hypertension & oedema are present the sodium intake needs to be restricted.

POTASSIUM:The failing kidney cannot excrete potassium

adequately & therefore intake is kept at about 1500 mg/day.

CALCIUM & PHOSPHORUS:to maintain Ca & phosphorus balance

& prevent or delay renal bone diseases. Ca supplement (1-2 gm/day) is recommended & phosphate is restricted to 800-1200 mg/day.

VITAMIN:multivitamin supplement are recommended for a diet with

less than 40 gm/day of protein.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

COPD results from a history of emphysema, asthma or chronic bronchitis with lower airway obstruction. Smoking is most common cause. Signs & symptoms-:1- Dysponea on exertion 2- Frequent hyponemia 3- Forced expiratory volume in 1second 4- Destruction of alveolar capillary bed.

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The chronic bronchitis patient has inflammed bronchial tubes, excess mucus production, and chronic cough, shortness of breath & weight loss. Cardiac enlargement with failure is common. COPD is associated with muscular impairment nutritional depletion & systemic inflammation.

DIETARY MANAGEMENT:
A high protein/high calorie is necessary to correct malnutrition. Use 1.2-1.5 gm protein/kg & sufficient kcals for anabolism (starts with 30-35 kcal/kg, depending on current weight). Promote weight loss through caloric controlled diet for obese persons. Diet should be 40-55% CHO, 30-40% Fat & 15-20% protein. A diet without tough & stingy food & an antireflux regimen are useful. Gas forming vegetables may cause discomfort for some patients. Increase use of omega 3 fatty acids in foods such as salmon, tuna & other fish sources are beneficial. To enrich the diet with antioxidants, use more citrus fruits whole grains & nuts. There is protective effect of fruits & possibly vitamin E intake; vitamin C, beta carotene, vegetable, fishes are not as protective but are still encouraged for general nutritional value. Fluid intake should be high if the patient is febrile.

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MENOPAUSE

The term menopause is applied to women who have not experienced a menstrual bleed for a minimum of 12 months, assuming that they do still have a uterus, & are not pregnant or lactating. In women without a uterus, menopause or post menopause is identified by a very high FSH level. thus post menopause is all of the time in a womans life that take place after her last period, more accurately, all of the time that follows the point when her ovaries become inactive. A woman who still has her uterus can be declared to be in post menopause once she has gone 12 full months with no flow at all, not even any spotting. When she reaches that point, she is one year into post menopause. At this point a woman is considered infertile, & no longer needs to factor in the possibility of becoming pregnant. However the possibility of becoming pregnant has usually been very low for a number of years before this point is reached.

DIETARY MANAGEMENT:For most women a menopause diet is considered

healthy if it follows these guidelines: Soya & soy products should be given because of its phytoestrogen component.
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Increase calcium. The recommended daily allowance for calcium is 1200 mg/day for woman over 50 years. Eating & drinking 2 to 4 servings of dairy products & calcium rich foods a day will help ensure that a woman is getting enough calcium in the daily diet. Calcium is found in dairy products, clams, sardines, broccoli & legumes. Increase iron intake. Eating at least 3 servings of iron rich foods a day will help ensure that an adequate amount of iron is present in the daily diet. Iron is found in lean red meat, poultry, fish, eggs, green leafy vegetables, nuts & enriched grain products. High fiber food is recommended. Foods high in fiber are whole-grain breads, cereals, pasta, rice, fresh fruits & vegetables. At least 2 to 4 servings of fruits & 3 to 5 servings of vegetables should be Include essential fatty acids in the diet. EFAs are found in nuts, seeds & fish oily. The best EFAs are those from the omega-3 & omega-6 families, which are found in pumpkin seeds, walnuts, dark green leafy vegetables etc. High fat foods should be avoided. Moderate use of sugars & salt.

ACUTE LIVER DISEASE

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Acute liver failure is the appearance of severe complications rapidly after the first signs of liver disease (such as jaundice), & indicates that the liver has sustained severe damage (loss of function 80-90% of liver cells). The complications are hepatic encephalopathy & impaired protein synthesis. Acute liver failure is defined as "the rapid development of hepatocellular dysfunction, specifically coagulopathy & mental status changes in a patient without known prior liver disease."

DIETARY MANAGEMENT:The dietary recommendations include: CALORIES:1500-2000 kcal/day diet is recommended to prevent breakdown
of tissue protein for energy. It is provided chiefly in the form of carbohydrate it can be given by parenteral or tube feeding if needed.

CARBOHYDRATE:An increase in carbohydrate is recommended in the diet

because it is the main source of energy & thus spares the protein. It promotes glycogen repletion.

PROTEIN:The protein intake may begin with 0.2 gm /kg IBW/day. The
patient remains asymptomatic for a week it may gradually be increased by 1015 gm /week & then 20 to 40 gm & gradually to 0.5 gm /kg IBW /day.

FATS:Fat is restricted, as liver cannot metabolize fats. Substitution with

MCT's is recommended as they do not require bile salts & micelle formation for absorption & are readily taken up by the portal route.

VITAMIN:Increased intake of the B-complex vitamin such as folate, thiamine,

B12& vitamin C is recommended.

SODIUM:Depending on the state of patient a restriction of 2 gm/day along

with the use of diuretics is recommended.

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PRSSURE ULCER
Patient with severe malnutrition are at risk for many type of complication including the incidence progression & severity of pressure ulcer. Pressure friction or shear & a lack of oxygen & nutrition to an affected area have often been associated with the development of pressure ulcers. They can occur over bony or cartilaginous prominences (e.g. hip, sacrum, elbow, heels, back of the head). Risks include unintentional weight loss, incontinence, immobility, poor circulation (as in diabetes, peripheral vascular disease or anemia), infection, poor nutrition status, prolonged pressure, drugs & serum albumin below 5.4 g/dl.

DIETARY MANAGEMENT:
Provide a high quality protein diet. Recommended 1.0-1.5 gm protein/kg body weight. A deep ulcer may require 1.5-2.0 gm/kg. Recommended calorie levels for wound healing vary from 25-35 kcal. Provide small, frequent feedings if oral intake is poor, 4-5 times daily. Supplement diet with n general multivitamin-mineral supplement to supply adequate beta vitamins, vitamin A, vitamin C, zinc & copper; excesses are wasteful & do not necessarily speed the healing process &may harm the immune system.

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CLEFT LIP & CLEFT PALATE

Cleft lip & cleft palate are congenital malformations occuring during the embryonic period of development. They result in a fissure in the lip & roof of the mouth, which may be unilateral or bilateral. Infants with cleft palate are often smaller in size & weight than other infants.

DIETATY MANAGEMENT:
Provide a normal diet in accordance with the patients age & dietary recommendations. Monitor diet carefully because mother may have had a poor diet during preconceptual period & pregnancy.

For infant feeding, use a medicine dropper or plastic bottle with a soft nipple & enlarged hole. The use of a squeezable, collapsible bottle with a longer nipple & a large cross cut opening, which allows parents to control the flow of milk, canhelp release formula or milk a little at a time, in coordination with the infants chewing movements. Burp infant frequently to release swallowed air. Feed the infants in an upright position to prevent aspiration. When the infant is 4-6 months of age, begin to add solids in the diet. Pureed baby foods can be used, or the infant can be spoon fed with milk used to dilute the baby foods. Feed solids from a spoon & avoid use of a bottle or commercial syringe feeder, unless prescribed for unique circumstances. Avoid fruit peelings, nuts, peanut butter, leafy vegetables, heavy cream dishes, popcorn, grapes, biscuits, cookies & chewing gum as they may get lodged in the palate. Avoid spicy, acidic foods if they cause irritation.

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CYSTIC FIBROSIS
Cystic fibrosis [also known as CF] is an autosomal gentic disease affecting most critically the lungs, and also the pancreas, liver and intestine. It is characterized by abnormal transport of chloride and sodium across epithilium, leading to thick, viscous secetion. the name cystic fibrosis refers to the charactistic scarring and cyst formation within the pancreas. Difficulty in berathing is the most serious symptom and results from frequent lung infection that is treated with, though not cured by, antibiotics and other medications. Other symptoms include sinus infections; poor growth, dirrhoea and infertility affect other parts of the body. CF is caused by a mutation in the gene for the protein cystic fibrosis transmembrane conductance regulator. This gene is required to regulate the componce of sweat, digestive juices and mucous. Although most people without CF have two working copies of the CFTR gene only one is needed to prevent cystic fibrosis. CF developes when neither gene works normaly & therefore has autosomal recessive in herritance. Individual with CF can be diagnosed before birth by genetic testing or by a sweat test in early childhood. Ultimatiely lung transplantation is often necessary as CF worsens.
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DIETARY INTERVENTIONS:
A high calorie, high fat, high protein diet is recommended for CF patients. Energy may be as high as 199% of predicted in CF patients. CF patients may need to be given 120% -150%. Protein 10%-35% of total calories. 4 gm/kg for infants, 3 gm/kg for children, 2 gm/kg for teens 1.5 gm/kg for adults. High fat diet is encouraged. Provide essential fatty acids in tolrated form. High amount of sodium should be used to replace perspiration loss. Parenteral nutrition is not recommended due to high risk of infection. Use of turmeric & cumin in foods may be beneficial for CF is thepatients.

PREECLAMPSIA
Preeclampsia is often called as pregnancy induced hypertension, is a syndrome of edema, proteinuria & hyper tension that occurs during second half of the pregnancy. It is more common in first pregnancy & with the patient with multiple gestations, malnutrition & positive family history of PIH or undrelying vascular diseases. PIH occurs in approximately 6-10% of all pregnancy. The condition is often founded in woman with high BMI, chronic hypertension, diabetes or chronic renal diseases. Women with type1 diabetes have PIH rate 2-4% times higher than others. Delivery of the fetus is the only cure. Preeclampsia may be mild or severe. Criteria for mild preeclampsia include hypertension as defined as 140/92 to 159/109 mm Hg; proteinuria more than 300 Criteria for severe preeclampsia include blood pressure greater than 166/110 mm Hg on two occasions with patient on bed rest, systolic blood pressure rise more than 60 mm Hg over baseline, diastolic blood pressure increase of more
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than 30 mm Hg over baseline. protein urea more than 5 gm/24hr or 3+ or 4+ on a urine dip stick, massive edema & oliguria less than 400 ml/24 hr.

DIETARY MANAGEMENT: ENERGY:Energy needs during pregnancy increases because of additional

energy required for the foolowing: The growth & physical activity for the fetus. The growth of the placenta. The normal increase in maternal body size. The additional work involved in carrying the weight of the fetus & extra maternal tissues.

ICMR recommended energy requirement of pregnant woman as follows: Sedentary worker-1900+350=2250 kcal Moderate worker-2230+350=2580 kcal Heavy worker-2850+350=3200 kcal

PROTEIN:A pregnant woman needs 82.2 gm of protein a day. Additional

protein is needed for: Rapid growth of the fetus. The enlargement of uterus, mammary glands & placenta. Increase in maternal circulating blood volume & subsequent demand of increase plasma protein to maintain colloidal osmotic pressure & circulation of tissue fluids. Formation of amniotic fluid & storage reserve for labour, delivery & lactation.

Milk, meat, egg & cheese are complete proteins & of high biological value. Additional protein may be obtained from legumes & whole grains, nuts & oilseeds.

CALCIUM: Pregnant woman needs 1,200 mg of calcium a day. Dairy products

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are rich in calcium consume pasteurized low fat or non fat milk & yogurt to keep an adequate calcium & vitamin D intake.

SALT: Limit your salt intake to control blood pressure. Avoid using sauces,
dressings & seasoning made with salt. Use cilantro, basil, onions, garlic & pepper to add flavour to your food. Select low sodium versions of broths & soups.

IRON: Normal iron requirement of an adult woman is 30 mg/day. ICMR

requirement during pregnancy is 35 mg/day.

SODIUM:Sodium is restricted due to odema & hypertension i.e. 2 gm/day. POTASSIUM:About 47 mg/day is recommended in pregnancy. MAGNESIUM:310 mg/day is recommended. FOLIC ACID: Folic acid is required because of increases haematopoises, i.e.
increased blood formation. About 400 micro gm /day.

CHEMOTHERAPY
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Chemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standarized treatment regimen. The most common chemotherapy agents act by killing cells that divide rapidly, one of the main properties of most cancer cells. This means that chemotherapy also harm cells that divide rapidly under normal circumstances; cells in the bone marrow, digestive tract & hair follicles. This results in the most common side effects of chemotherapy: myelosuppression(decreased production of blood cells, hence also immunosuppression), mucositis(infammation of the lining of the digestive tract), & alopecia(hair loss).

NUTRITIONAL REQUIREMENTS:
Objectives of nutritional therapy: To meet the increased metabolic demands of the disease & prevent catabolism as much as possible, and To alleviate symptoms resulting from the disease & its treatment through adaptation of food & the feeding process.

ENERGY: To prevent excessive weight loss & to meet increased metabolic

demands, the total energy value of the diet must be increased. For an adult patient with good nutritional status about 2000 kcal will provide for maintenance needs. A malnourished patient may require 3000 to 4000 kcal depending on the degree of malnutrition & body trauma.

PROTEIN:

Additional protein is required to provide essential amino acids & nitrgen necessary for tissue regeneration, healing & rehabiliation. An adult patient with good nutritional status will need about 80-100 gm to meet maintenance needs & to ensure anabolism.

VITAMINS & MINERALS:Optimal intake of vitamins & minerals atleast at

recommended dietary allowance levels & frequently augmented with supplements according to nutritional status is indicated.

FLUID:Fluids are increased to compensate losses from gastrointestinal

problems as well as any additional loss caused by infections & fever. Also sufficient intake is necessary to help the kidneys rid the body of the breakdown products from destroyed cancer cells & from the drugs & inflammation.

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DIALYSIS
The process of dialysis involves cleansing the blood of metabolic wastes, based on the principle of osmosis & diffusion. A semi permeable porous membrane is used in dialysis to separate the patient blood carrying excess fluid & metabolic waste & the hypotonic dialysis fluid" called dialysate. Through osmosis & diffusion, the metabolic waste & excess water move into the dialysate. The pores of the semi permeable membrane do not permit large particles like protein & RBC to pass through, but smaller water-soluble molecules can pass. There are two types of dialysis. These include:

a. haemodialysis, and b. peritoneal dialysis

Haemodialysis (HD) - In this patients blood circulates outside the body

through what is commonly referred to as an "artificial kidney machine". an opening is created to connect any artery & a vein. Blood leaves the body via the artery, into the dialyser & after cleansing, flow back to the body via the vein.

Peritoneal dialysis (PD): In this, the patients peritoneum is used as

a semi permeable membrane & excess water & metabolic wastes are removed by injecting the dialysis fluid into the peritoneal cavity, after some time, the
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fluid with the metabolic wasteis drained out from the peritoneum. For long term use, continuous ambulatory peritoneal dialysis (CAPD) may be used based on facilities available. In this the dialysis fluid is exchanged 4-5 times daily. It is also important to prevent/control infection. In some cases, continous cyclic peritoneal dialysis CCPD or Intermittent Peritoneal Dialysis (IPD).

DIETARY MANAGEMENT: ENERGY: Up to 35-40 kcal/kg/day for adults and 100 kcal or more/kg/day
for children is recommended to meet the body needs and minimise tissue prtein breakdown. Fats and carbohydrates are the main energy sources used.

PROTEIN:The reqiurement is increased due to losses in the dialysate. In

haemodailysis, 1.2-1.5g/kg/day is reqiured. At least 70% of the protein given should be of high biological value from eggs, fish, chicken and milk, through milk may need to be limited being a rich source of potassium.

SODIUM:A daily intake of 1500 to 2500mg may be permitted to control fluid

retention and hypertension.

POTASSIUM:A daily intake of 1500 to 2500mg is prescribed to prevent

hyperkalemia.

PHOSPHORUS:This may need some restriction. VITAMINS AND MINERALS: A daily supplement of water-soluble vitamins
and minerals are usually given, as these are lost in the dialysate. Fat-soluble vitamins may be retained.

FLUID:Usually 400-500ml (basal losses) plus the urine output is

recommended.

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ALCOHOLIC LIVER DISEASE

Alcoholic liver disease is a major cause of illness & death. Alcohol is a hepatotoxin & is also ulcergenic, especially to the esophagus. Alcohol may increase resting energy expenditure, nitrogen exretion & appetie & can lead to cirrhosis of the liver, it affects most organs. Alcohol cannot be stored & is used preferentially over other energy fuels. Alcoholics are more often malnourished than are individuals with non-alcoholic liver disease; this is because they eat poorly or because alcohol & its metabolism prevent the body from properly absorbing, digesting & using those nutrients, particularly vitamin A. Classic affects of malnutrition from alcoholism includes Wernickes encephalopathy, Korsakoffs psychosis muscle wasting, weight loss & liver disease. Alcoholic may replace as much as 30% of their daily energy requirements from alcohol, alcoholic beverages account for about 6% of total energy consumed. A balanced diet will be needed to prevent malnutrition.

SIGNS & SYMPTOMS: It include restlessness, agitation, spider angiomas

on the face or back or belly, insomnia, anorexia, weight loss, GI cramping, malnutrition, delirium tremens & hand tremors. In men, altered hair distribution & gynecomastia may occur.

DIETARY MANAGEMENT:
Malnourished alcoholics should be administerd a diet rich in CHO & Protein, Calories preferentially via the oral or enteral route. Diet should provide protein as 1.5 gm/kg body weight. In hypertensive patients, obesity is often of greater importance. A weight loss diet may be planned that provides a sufficient mixture of nutrients without aggravating liver disease, fasting 7 very low calorie diets should be avoided. The diet should include a mixture of fat from omega 3 & omega 6 fatty acids. Medium chain fatty acids may also be well tolerated.

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Supplement diet with B-complex vitamins, synthetic folacin is needed because the patient is less able to use what is provided by diet because of liver damage. Avoided vitamin A & D which may not be tolerated by the liver. Oral diet should rovide adequate amounts of vitamin e & K, as well as phosphorous, potassium, selenium, magnesium, zinc & calcium. Include fruits & vegetables or supplement with vitamin c if dietary intake is low.

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Tables

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COMMON ABBREVIATIONS DM HTN CAD CHD COPD IHD ILD LRTI RTA FUC RT P/R H/R CLD ESRD CKD SOB PCOD IFG GDM TIBC GBP EPA DHA GBS GERD IGT IPD MTN CAPD Diabetes Mellitus Hypertension Coronary disease Coronary Heart Disease Chronic Obstructive Pulmonary Disease Ischemic Heart Disease Intestinal Lung Disease Lower Respiratory Tract Infection Road Traffic Accident Follow Up Case Rylis Tube Pulse Rate Heart Rate Chronic Liver Disease End Stage Renal Disease Chronic Kidney Disease Short Of Breathe Ploycystic Ovarian Disease Impaired Fastung Glycemia Gestational Diabetes Mellitus Total Iron Biding Compound General Blood Picture Ecosa Pentonic Acid Docosa Hexaconic Acid Gullian Barre Syndrome Gastro Esophageal Reflux Disease Impaired Glucose Tolerance Impaired Peritoneal Dialysis Medical Nutrition Therapy Chronic Ambulatory Peritoneal Dialysis
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FOODS RICH IN POTASSIUM ITEMS PULSES

Bengal gram whole Bengal gram dal

Black gram dal Black gramwhole Green gram dal Green gramwhole Horse gram Moth beans Red gram dal Peas (dry & roasted) OTHER VEGETABLES Drum stick Jack fruits Brinjal Lotus stem Green papaya NUTS Coconut meal FRUITS Amla Lemon Mango Peach Cherry Mausambi Muskmelon Sapota Palm Bale GREEN LEAFY VEGETABLES
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POTASSIUM/above 200mg/serving (In 30 gm) 242.4 216 240 240 345 252.9 228.7 328.8 331.2 217.5 (In 100 gm) 259 328 200 200.3 216 (In 10 gm) 200.3 (In 100 gm) 225 370 205 453 320 490 305 269 247 600 (In 100 gm)

Amarnathus Corrinder leaves Drumstick leaves Spinach FOODS RICH IN IRON ITEMs CEREALS Bajra Rice bran Rice flakes PULSES Red gram roasted Moth beans Lentil dal Soyabean GREEN LEAFY VEGETABLEs Amarnath Colocassia leaves Cauliflower green OTHER VEGETABLEs Lotus stem Onion stalks NUTs Gingerlly seeds Ground nut Ground nut (roasted) FRUITS Phalsa Sapota Pineapple Dates
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341 256 259 -

IRON (above 2 mg/servings) (In 30 gm) 2.4 10.5 5 (In 30 gm) 2.8 2.8 2.4 3.1 (In 100 gm) 27 40 40 (In 100 gm) 60.6 7.43 (In 100 gm) 9.3 3.1 2.5 (In 100 gm) 3.1 4.31 2.42 7.3

BIOCHEMICAL PARAMETERS TEST NAME Blood sugar fasting random P.P hrs after gm glucose Blood urea Serum creatinine Serum uric acid Serum bilirubin total Serum bilirubin conjugate Alkaline phosphate (adult) Alkaline phosphate (baby) Acid phosphate S.G.P.T S.G.O.T Serum Protein total Serum Albumin Serum Globulin Serum Calcium Serum Inorganic phosphate Serum Sodium Serum potassium Serum chloride Plasma bicarbonate Serum cholestrol Serum triglyceride Serum H.D.L cholestrol Serum L.D.L cholestrol Serum V.L.D.L cholestrol Haemoglobin (male) Haemoglobin (female)
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NORMAL RANGE 60-110 mg/dl Upto 160 mg/dl 12-45 mg/dl 0.1-1.5 mg/dl 3.2-6.0 mg/dl 0.1-1.0 mg/dl 0.1-0.5 mg/dl 108-306 IU/lt 210-810 IU/lt 1-5 KA units/lt Upto 40 IU/lt Upto 40 IU/lt 5.5-8.0 gm/dl 2.8-5.5 gm/dl 2.0-3.55 gm/dl 8.7-11.0 mg/dl 2.5 mg/dl 130-145 meq/lt 3.5-5.0 meq/lt 100-106 meq/lt 24-31 meq/lt 130-250 mg/dl 65-170 mg/dl 30-65 mg/dl Upto 150 mg/dl 10-30 mg/dl 13-18 mg /dl 12-16 mg/dl

GLYCEMIC INDEX OF SOME COMMON FOOD ITEMS FOOD RICE WHEAT BREAD UPMA IDLI CHOLE SPROUTED GRAM MILK CURDS ICE CREAM TOMATO SOUP GROUND NUTS APPLE ORANGE BANANA POTATO SWEET POTATO BEETROOT SOYABEAN RAJMAH BENGAL GRAM GLUCOSE HONEY FRUCTOSE ITEMS 72 70 70 75 80 65 60 33 36 36 38 13 39 40 69 70 48 64 43 29 47 100 87 20

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