Medical Nutrition

Therapy (MNT)
In
Different diseases
Wards in hospital:
 Emergency ward (female)
 Male ward
 Other important wards
i. General Medicine ward
ii. Surgery ward
iii. Burn ward
iv. Urology ward
v. CCU ward
vi. Gyne and Obs ward
 vii. Oncology ward
General medicine ward:
General medicine ward provide acute hospital care for inpatient with drug therapy
other than surgical procedures.
Following diseases are observed in this ward:
 Diabetes
 Diabetes ketoacidosis
 Diabetic neuropathy
 Hypertension
 Obesity
 Renal disorder
 Liver disorder
 Inflammatory bowel syndrome
 Peptic ulcer
 Chronic obstructive pulmonary disease
 Tuberculosis
 Diarrhea
 Celiac disease
 Galactose intolerance
Chapter no

Diabetes Mellitus
Diabetes can be defined as systematic metabolic disease in which glucose intolerance occurs as
result of disturbances in glucose metabolism and homeostasis resulting in elevated blood glucose
levels (Jannat et al., 2018).

Types of Diabetes Mellitus:

Type 1 diabetes mellitus is caused by autoimmune destruction of insulin-producing cells (β
cells) in the pancreas, resulting in absolute insulin deficiency.
Type 2 diabetes mellitus is characterized by resistance to the action of insulin and an inability to
produce sufficient insulin to overcome this “insulin resistance”.

The diagnostic criteria for diabetes:

 A fasting plasma glucose > 7.0 mmol/L (126 mg/dL) OR
 Glucose 2 hours after an oral glucose challenge > 11.1 mmol/L ( 200 mg/dL)

Diabetes mellitus (DM) is ranked among top ten ailments which cause mortality worldwide
affecting almost 30 % of human population. The sources of blood glucose are:

 Carbohydrate (CHO): 100% of digestible CHO converted to glucose

 Protein: 58% converted to glucose.
 Fat: 10% converted to glucose.
 Glycogen (the liver’s emergency supply of carbohydrate): converted to glucose when
other sources are used up. Muscle tissue also contains glycogen that may be used in
emergencies.
Patients with type 2 diabetes often have associated disorders including:

 Hypertension
 Dyslipidemia (characterized by elevated levels of small dense low-density lipoprotein
(LDL) cholesterol and triglycerides, and a low level of high-density lipoprotein (HDL)
cholesterol),
 Nonalcoholic fatty liver
 In women, polycystic ovarian syndrome
 This cluster has been termed the ‘insulin resistance syndrome’ or ‘metabolic syndrome’, and
is much more common in patients who are obese.

Clinical Symptoms of Diabetes Mellitus

 Thirst, dry mouth
 Polyuria
 Tiredness, fatigue, lethargy
 Blurring of vision
 Nausea
 Headache
 Hyperphagia; abnormally great desire for sweet foods (excessive eating)
 Mood change, irritability, difficulty in concentrating,
 Change in weight (usually weight loss)

Dietary Management of Diabetes Mellitus

MNT of diabetes should be based upon individual needs while considering:

 lifestyle
 Medication
 Eating habits
 Food preferences
 Ethnic group
 Cultural background
 Physical activity
 Limit intake of foods with sucrose and other refined sugars such as deserts

Dietary Constituents and Recommended % of Energy Intake

 Carbohydrate: 45–60%
 Sucrose: up to 10%
 Fat (total): < 35%
a) n-6 Polyunsaturated: < 10%
b) n-3 Polyunsaturated: eat 1 portion (140 g) oily fish once or twice weekly
c) Monounsaturated: 10–20% Saturated: < 10%
d) Cholesterol: < 300mg per day
 Protein: 10–15% (do not exceed 1 g/kg body weight/day)
 Fruit/vegetables: 5 portions daily
 Fiber up to 40 g per day

Foods Allowed and Restricted in Diet

 FOOD GROUPS FOODS ALLOWED FOODS RESTRICTED
Milk and Milk Products Yogurt and Cheese Milk Cream
Vegetables All raw and cooked in moderate oil None
Fruits All fresh Fruit None
Lentils/Daals All Daals with lots of added fats
Fats and oils Polyunsaturated oil Banaspati and Desi ghee

Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a medical emergency and remains a serious cause of morbidity,
principally in people with type 1 diabetes. Diabetic ketoacidosis (DKA) is severe, uncontrolled
diabetes resulting from insufficient insulin, in which ketone bodies (acids) build up in the blood;
if left untreated (with immediate administration of insulin and fluids), DKA can lead to coma and
even death.
The cardinal biochemical features are:

 Hyperketonemia (≥ 3mmol/L) and ketonuria ( more than 2+ on standard urine sticks)

 Hyperglycemia (blood glucose ≥ 11 mmol/L (~ 200 mg/dL))
 Metabolic acidosis (venous bicarbonate <15 mmol/L and/or venous pH < 7.3)

Clinical Symptoms of Diabetic Ketoacidosis

 Polyuria, thirst
 Weight loss
 Weakness
  Nausea, vomiting
 Leg cramps
 Blurred vision
 Abdominal pain

Dietary Management of DKA

 During acute illness, oral ingestion of 150 to 200 g of carbohydrate per day should be
sufficient, along with medication adjustment, to keep glucose in goal range and prevent
starvation ketosis.
 Reduced added sugar diet (To reduce CHO load).
 High-fiber from whole-grain products, vegetables, fruits and pulses which have more
moderate effects on blood glucose (i.e. slow rate of absorption) than do highly processed
starchy foods are recommended.
 Reduced fats especially saturated fats should be limited to less than 10 percent of calories
and cholesterol intake to less than 300 milligrams daily (To correct lipid abnormalities
 Diabetic Nephropathy
Diabetic nephropathy (DN) is a serious complication of diabetes; it initially manifests with
microalbuminuria and progresses towards end-stage renal failure. It can induce renal
inflammation eventually leading to renal fibrosis. Microalbuminuria is a term to describe a
moderate increase in the level of urine albumin.

Natural history of Diabetic Nephropathy

Dietary Management of Diabetic Nephropathy

 Low sodium (Na) : 2,000 mg/day
 Low potassium (K) : 2000 mg/day
 Low phosphorous (P)
 Low protein:
a) 0.8 g/kg BW/day for those with microalbuminuria
b) 0.8 g/kg IBW/d for those with macro albuminuria
c) 0.6-0.8 g/kg IBW/d for those with end-stage renal disease
 Moderate Fat
Prevalence of diabetes:
Total number of patient: 30
Patient with diabetes mellitus: 5
Patient with DKA: 1
Patient with diabetic neuropathy: 2

pr evalance of diabetes
total patient patient with diabetes mallitus
patient with DKA Patient with diabetic neuropathy
Chapter no:

Hypertension
Hypertension may be often due to obesity, because the increased weight means increasing work
of the heart to supply blood to the extra tissue formed. For many overweight hypertensive
people, dietary changes which result in weight loss will lead to reduction in blood pressure. This
may be adequate therapy in mild cases. But there are normal and underweight persons who suffer
from hypertension. The second possibility is excessive sodium intake, which draws more water
into circulation, thus increasing blood volume, leading to increased blood pressure.
There are about 20 per cent people who are sensitive to sodium and may be affected by excess
sodium intake; other 80 per cent appear to be relatively free from the adverse effects of excessive
sodium intake. Research studies have shown that increase in potassium intake can lower blood
pressure. Increase in intake of alcohol in excess of 2 oz. daily has a hypertensive effect, which
increases with the amount consumed.

Diet therapy for hypertension:

In patients, whose only problem is mild hypertension (diastolic pressure of 90-94 mm Hg),
therapy without use of drugs is used to achieve control. This includes:
(a) Moderate sodium restriction (1000-1500 mg/day): No salt in cooking or at the table. No
processed foods (pickles, canned foods etc. containing salt). Four servings of regular bread can
be taken.
(b) Adequate potassium intake Plant foods are rich sources of potassium, especially fruits and
vegetables. Potassium is present in higher concentration than sodium in fruits and vegetables by
a factor of 5 to 50 fold. 3-4 servings of fruits, which need no preparation (hence no addition of
salt), can ensure adequate potassium intake.
(c) Regular exercise tailored to the individual is a must – walking 5 km daily has been found to
be an ideal way to keep fit. It needs no equipment and can be undertaken in all weather.
(d) Stress management is a very important aspect of therapy. It involves regular planning of
one’s activities allowing realistic scheduling of work, relaxation, physical activity, mealtimes,
prayer/meditation and rest

Sodium Content Vegetables

Less than 5 mg/100
5 to 11 mg/100 g EP
12 – 15 mg/100 g EP
Sodium Content
Less than 6 mg/100 g EP
7 to 13 mg/100 g EP
Bitter gourd (green), bottle gourd.
Eggplant, French beans, onion stalks,
ridge gourd, onions
Pumpkin, ladies finger (bhendi), peas,
cucumber, , potato, sweet
potato, tapioca (dried chips), yam,
Brussel sprouts
Cabbage, green plantain.
Fruits
Amla, guava, orange, papaya,
peaches, plums, chiku,
Pomegranates, tree tomato, phalsa.
Pears, ripe tomato

Prevalence of hypertension:
Total no. of patients: 30
Patient with hypertension: 10
 per valence of hyper tens ion
total patient patient with hypertension

Chapter no

Obesity

Body Mass Index (BMI):

 Body Mass Index (BMI) is a simple index of weight-for-height that is commonly used to
classify underweight, overweight & obesity in adults
 BMI was devised between 1830 and 1850 by the Belgian polymath (a person of great and
varied learning) Adolphe Quetelet during the course of developing "social physics"
 The interest in measuring body fat being due to obesity becoming discernible issue in
prosperous Western societies
 It is defined as the weight in kilograms divided by the square of the height in meters (kg/m2)
 BMI' provides a simple numeric measure of a person's thickness or thinness, allowing health
professionals to discuss overweight and underweight problems more objectively with their
patients
 Although BMI is often considered an indicator of body fatness, it is a surrogate measure of
body fat because it measures excess weight rather than excess fat.
 BMI of 18.5 to 25 may indicate optimal weight, a BMI lower than 18.5 suggests the person is
underweight, a number above 25 may indicate the person is overweight, a number above 30
suggests the person is obese.
Other Measures for Body Fat:
 Some research suggests that other measures of body fat, such as skinfold thicknesses,
bioelectrical impedance, underwater weighing, and dual energy x-ray absorption, may be
more accurate than BMI
 The waist circumference (sometimes divided by height) is also a simple measure of fat
distribution
 Although these measures may provide a better indication of an individual’s body fatness and
risk of obesity, they can be expensive, intrusive, not widely available, or difficult to
standardize across observers or machines

 Some of these measures are considered inappropriate for routine clinical practice because
they are technically demanding and rely on more complex technologies
 In addition, most of our knowledge concerning obesity-related health risks is based on the
association of BMI to various outcomes
 There are few reference standards for body fatness based on the above mentioned measures,
and without established risk categories, it is difficult to determine if the body fatness of an
individual is low, moderate, or high.
 Consequently, other measures of body fat are not recommended for routine practice.

Why BMI is used?

 BMI is a simple, inexpensive, and noninvasive surrogate measure of body fat
 In contrast to other methods, BMI relies solely on height and weight and with access to the
proper equipment, individuals can have their BMI routinely measured and calculated with
reasonable accuracy
 High BMI predicts future morbidity and death. Therefore, BMI is an appropriate measure for
screening for obesity and its health risks.
 Lastly, the widespread and longstanding application of BMI contributes to its utility at the
population level. Its use has resulted in an increased availability of published population data
allowing public health professionals to make comparisons of region and population
subgroup.
Issues to be considered while using BMI:
 The clinical limitations of BMI should be considered
 BMI is a surrogate measure of body fatness because it is a measure of excess weight rather
than excess body fat
 Factors such as age, sex, ethnicity, and muscle mass can influence the relationship between
BMI and body fat
 Also, BMI does not distinguish between excess fat, muscle, or bone mass, nor does it provide
any indication of the distribution of fat among individuals.
 The following are some examples of how certain variables can influence
 the interpretation of BMI:
 On average, older adults tend to have more body fat than younger adults for
 an equivalent BMI
 On average, women have greater amounts of total body fat than men with an
equivalent BMI
 Muscular individuals, or highly-trained athletes, may have a high BMI
 because of increased muscle mass
 Height and level of sexual maturation, influence the relationship between BMI and body fat
among the children

How to calculate BMI?

The body mass index is calculated based on the following formula:
Bodyweight in kilograms divided by height in meters squared
Or
BMI = x KG / (y M2)
Where:
x=bodyweight in KG
y=height in meters
The result is in kilograms by meters squared, or KG/M2.
Imperial BMI formula. BMI = [Weight (lbs.) / Height (inches) ²] x 703

BMI can be determined by using:

 BMI Charts
 Excel spread sheets
 Calculators
A graph of body mass index as a function of body mass and body height is shown above. The dashed lines represent subdivisions within a major
class. For instance the "Underweight" classification is further divided into "severe", "moderate", and "mild" subclasses

BMI for Children:

 BMI is used differently for children
 It is calculated the same way as for adults, but then compared to typical values for other
children of the same age
 Instead of set thresholds for underweight and overweight, then, the BMI percentile allows
comparison with children of the same sex and age
 The percentile indicates the relative position of the child's BMI number
 Among children of the same sex and age

 A BMI that is less than the 5th percentile is considered underweight and above the 95th
percentile is considered obese for people 20 and under
 People under 20 with a BMI between the 85th and 95th percentile are
 considered to be overweight
 American Academy of Pediatrics (AAP) recommend the use of BMI to screen for
overweight and obesity in children beginning at 2 years old, However, BMI is not a
diagnostic tool

Weight Status Category Percentile Range

Underweight Less than the 5th percentile

Healthy weight 5th percentile to less than the 85th

 percentile
Overweight 85th to less than the 95th percentile

Obese Equal to or greater than the 95th percentile

 BMI for age is an index that enables early detection of both under and over nutrition in
children because it takes into account the current age, gender, weight and height for
assessment of nutritional status
 BMI for age will pick up all children who are overweight for their height and appropriate
interventions initiated
 BMI is calculated the same way for adults and children, but the results are interpreted
differently.
 For adults, BMI classifications do not depend on age or sex.
 For children and adolescents between 2 and 20 years old, BMI is interpreted relative to a
child’s age and sex, because the amount of body fat changes with age and varies by sex

Measuring Height Accurately At Home:

• Remove the child's shoes, bulky clothing, and hair ornaments, and any other thing that interferes with
the measurement
• Take the height measurement on flooring that is not carpeted and against a flat surface such as a wall
with no molding
• Have the child stand with feet flat, together, and against the wall. Make sure legs are straight, arms are at
sides, and shoulders are level
• Make sure the child is looking straight ahead and that the line of sight is parallel with the
floor
• Take the measurement while the child stands with head, shoulders, buttocks, and heels
touching the flat surface (wall)
• Depending on the overall body shape of the child, all points may not touch the wall
• Use a flat headpiece to form a right angle with the wall and lower the headpiece until it
firmly touches the crown of the head Make sure the measurer's eyes are at the same level as
the headpiece
• Lightly mark where the bottom of the headpiece meets the wall
• Then, use a metal tape to measure from the base on the floor to the marked measurement on
the wall to get the height measurement
• Accurately record the height to the nearest 1/8th inch or 0.1 centimeter

Measuring Weight Accurately At Home

• Use a digital scale. Avoid using bathroom scales that are spring-loaded. Place the scale
on firm flooring (such as tile or wood) rather than carpet
• Have the child or teen remove shoes and heavy clothing, such as sweaters
• Have the child or teen stand with both feet in the center of the scale
• Record the weight to the nearest decimal fraction (for example, 55.5 pounds or 25.1
kilograms)

BMI: International Variation:

The Hospital Authority of Hong Kong recommends BMI as following:

Category BMI range – kg/m2

Underweight < 18.5
Normal Range 18.5 - 22.9
Overweight - At Risk 23.0 - 24.9
Overweight - Moderately Obese 25.0 - 29.9
Overweight - Severely Obese ≥ 30.0
Japan Society for the Study of Obesity (2000) recommends BMI as following:

Category BMI range – kg/m2

Low 18.5 and below
Normal from 18.5 to 25.0 (Standard weight is 22)
Obese (Level 1) from 25.0 to 30.0
Obese (Level 2) from 30.0 to 35.0
Obese (Level 3) from 35.0 to 40.0
Obese (Level 4) 40.0 and above

In Singapore, the BMI cut-off figures were revised in 2005, motivated by studies showing that
many Asian populations, including Singaporeans, have higher proportion of body fat and
increased risk for cardiovascular diseases and diabetes mellitus, compared with Caucasians
(white or light skinned) at the same BMI. The BMI cut- offs are presented with an emphasis on
health risk rather than weight

BMI range – kg/m2 Health Risk

27.5 and above High risk of developing heart disease, high

blood pressure, stroke, diabetes

23.0 to 27.4 Moderate risk of developing heart disease,

high blood pressure, stroke, diabetes
18.5 to 22.9 Low Risk (healthy range)

18.4 and below Risk of developing problems such as

nutritional deficiency and osteoporosis

The International Classification of adult underweight, overweight and obesity

according to BMI by WHO
BMI in Different Races:
BMI values are age-independent and the same for both sexes. However, BMI may not
correspond to the same degree of fatness in different populations due, in part, to different
body proportions. The health risks associated with increasing BMI are continuous and the
interpretation of BMI grading in relation to risk may differ for different populations. In
recent years, there was a growing debate on whether there are possible needs for developing
different BMI cut-off points for different ethnic groups due to the increasing evidence that
the associations between BMI, percentage of body fat, and body fat distribution differ across
populations and therefore, the health risks increase below the cut-off point of 25 kg/m2 that
defines overweight in the current WHO classification.

Health consequences of overweight and obesity in adults

 • Overweight and obese individuals are at increased risk for many diseases and health
conditions, including the following:
• Hypertension
• Dyslipidemia (for example, high LDL cholesterol, low HDL cholesterol, or
• high levels of triglycerides)
• Type 2 diabetes
• Coronary heart disease and stroke
• Gallbladder disease
• Osteoarthritis
• Sleep apnea (a temporary suspension of breathing) and respiratory problems
• Some cancers (breast and colon)

Problems associated with Obesity

• Joint disorders such as osteoarthritis, which is wear and tear on the cartilage of joints

Coronary heart disease

• This could be hardening of the artery walls
• This could also be narrowing of the space in arteries due to fatty deposits restricting
blood flow
• Angina and heart attacks

Diet Counseling for Reducing Risk of Obesity, Leanness, and

Underweight
Obesity
• Obesity is a condition where a person has accumulated so much fat that it might have
negative effect on their health. If a person’s body weight is at least 20 % higher than it should
be, he or she is considered obese. If your Body Mass Index (BMI) is between 25 and 29.9
you are considered overweight.
• Obesity is characterized by an excess of adipose tissue
• Obesity is usually caused by eating too much and moving too little
• Obesity does not happen overnight. It develops gradually over time, as result of poor diet and
lifestyle choices, such as:
• Eating large amount of processed or fast food (higher in fat and sugar)
• Eating out a lot ( you may be tempted to also have a starter or dessert in a restaurant )
• Eating larger portions than you need
• Drinking too many sugary drinks
• Comfort eating ( if you are feeling depressed you may eat to make yourself feel better)
• A homeostatic network maintains energy stores through a complex interplay between feeding
regulatory centers in central nervous system (CNS), particularly in the hypothalamus and the
regulated storage and mobilization of fat stores that maintains the body energy stores
• Thus, genes that encode the molecular components of this system may underlie obesity and
related disorders

Adipose tissue as endocrine organ

Adipose tissue is a major endocrine organ, producing various hormones that regulate the body
metabolism. An increase in the fat cell mass leads to imbalances in its release of hormones,
which can have various metabolic effects. Adipose tissue produce adipokines (hormones) like:
• Leptin
• Adiponectin
• Visfatin
• Resistin
• Apelin

Role of Leptin in body weight regulation

Leptin, the 167 amino acid protein, is a cytokine-like hormone secreted from white adipose
tissue. It is first adipocytokine identified, encoded by ob. gene. Leptin receptors are expressed in
a number of different tissues. Adipocytes have been identified as the primary site for leptin
expression. Leptin has several roles including growth control, immune regulation, insulin
sensitivity regulation and reproduction. However, its most important role is in body weight
regulation.

Leptin and insulin

• The rate of insulin-stimulated glucose utilization in adipocytes is a key factor linking leptin
secretion to body fat mass
• Leptin receptors and insulin receptors are expressed by brain neurons involved in energy
intake, and administration of either peptide ( receptors) in directly into the brain reduces food
intake whereas deficiency of either hormone does the opposite
• Leptin deficiency causes severe obesity, with hyperphagia (excessive eating) that persists
despite high insulin levels. In contrast, obesity is not induced by insulin deficiency.

Leptin and obesity

• Leptin is chief regulator of ‘brain gut axis’, which provides a satiety signal through its action
on CNS receptors within the hypothalamus
• Activation of hypothalamic leptin receptors suppresses food intake and promotes energy
expenditure pathways. These neuronal effector pathways play a key role in energy
homeostasis
• Failure of one or more of these pathways in response to leptin signaling will cause leptin
resistance
• Human obesity may be due to reduced leptin action in brain. Obese humans cerebrospinal
fluid have low leptin levels in comparison to plasma
• Leptin levels decrease with weight reduction
• There is elevated plasma levels in obese humans

Weight management strategies

• Increase your physical activity enough to spend more energy than you consume
from foods
• Consume low energy dense foods with high nutrient density
• Eat small portions
• Eat slowly
• Limit high-fat foods. Make legumes, whole grains, vegetables, and fruits central to
your diet plan
• Limit low fat treats and concentrated sweets
• Drink plenty of water throughout the day ( 8 glasses per day)
• Keep a record of diet and exercise habits

Food Allowed and Restricted

Food Group Foods Allowed Foods Restricted

Bread, cereals and All types of whole meal, All cereals grains with lots of
grains bread, roti and rice with added fats such paratha and
 added fat puree
Milk and milk Skimmed Milk and milk Milk and milk products with
products products full cream milk

Meat All lean meat preparations All meat cuts with visible fat
with small quantity of oil and meat dishes with lots of
added fat
Lentils/ Daal All except indicated in foods Fried daals
(with/without husk) avoided

Vegetables (green All raw, fresh seasonal Fried vegetables

leafy starchy) vegetable cooked in little oil

Fresh fruits All fresh fruits None

Dry fruits, nuts and Controlled consumption of None

seeds dry fruits, nuts and seeds

Fats and oils Polyunsaturated oils such as Limit the consumption of

canola oil, sunflower oil,
soybean oil and limit the
consumption of butter and
margarine
Desserts and sweets All types of sweet dishes and
dairy ice cream in reasonably
small quantity
Fluids and drinks Small quantity of soft drinks
and milk shakes
Banaspati ghee and desi ghee
All types of refined sugar
based products such as sweets
and confectionary items
Drinks with lots of added
cream

Leanness:
Leanness means a person without excess fat or without much flesh or fat. Can be defined also as
a person containing little fat or less fat as compared to a standard

DIET FOR LEAN PEOPLE

• Healthy diet
• Help yourself to nuts and dairy products
• Protein is the key for muscle building; this will help you gain weight
• You may take dietary supplement, but you need a balanced diet more
• Eat healthy fats
• Eat lots of healthy vegetables and meat
• Foods that will help you gain weight:
• Whole wheat bread
1. Pasta
2. Lean red meat
3. Dried fruits
4. Healthy oils
5. Nuts and seeds
6. Fresh juice
7. Whole fat milk
8. Cheese Potatoes
9. Yogurt

Underweight
Underweight is a term describing a person whose body weight is considered too low to be
healthy. The definition usually refers to people with a body mass index (BMI) of under 18.5 or a
weight 15% to 20% below that normal for their age and height group
Causes
• A person may be underweight due to:
• Genetics
• Metabolism
• Lack of food (frequently due to poverty)
• Certain medical conditions (hyperthyroidism, cancer, tuberculosis, liver problems, eating
disorders)

Diet for underweight

• Underweight individuals may be advised to gain weight by increasing calorie intake
• This can be done by consuming calorie-dense foods such as dried fruits, cheese and nuts
• Body weight may also be increased through the consumption of liquid nutritional
supplements, such as Ensure and Boost
• Eat lean protein sources like meat, fish, eggs, beans and pulses
• Include cheese and yogurt in milk group as they are good sources of protein and calcium
• Limit sugary and high fat foods in diet
• Cut down saturated fats found in processed meats, cakes and biscuits

LIST OF FOOD ITEMS

Foods that make you GAIN WEIGHT Foods that will help you LOSE
 WEIGHT
Milk shakes Green juices
Soda Green juices
Biscuit Grapefruit juice
Fried shrimps Superfoods soup
Potato salad Cucumber
Alferado pasta Water with lemon and honey
French fries

Prevalence of obesity:
Total number of patients: 30
No. of patients who’re obese or overweight: 3
No. of patient who are underweight: 2

pervalence of obesity

total patient obese overweight underweight

 Liver diseases
Major role of the liver is the regulation of solutes in the blood that affect the functions of
other organs for example: the brain, heart, muscle and kidneys. Strategically placed such that
all blood passing from the small intestine must travel through the liver. Storage and
metabolism of macronutrients such as protein, carbohydrates and lipids. Metabolism of
micronutrients – vitamins and minerals. Metabolism and excretion of drugs and toxins –
endogenous and exogenous
Early Stages of Liver Disease
Acute Hepatitis:
 High protein/high energy intake required to promote hepatocyte regeneration
 Fat restriction contraindicated
 Nausea/anorexia
 Consider oral supplementation such as glucose polymers, fruit based high protein drinks, or
high protein/ high energy drinks in the presence of nausea/anorexia
 Caution against herbal remedies as some may be harmful and most have no scientific basis
 No specific dietary management
 Healthy diet according to healthy eating guidelines
 Beware of miracle cures

Nutritional Features of End Stage Liver Disease

 Look malnourished
 Low serum protein levels
 (albumin, pre-albumin, transferrin, retinol binding protein, insulin like growth
factor-1)
 Vitamin deficiencies: Thiamine, Vitamin A, D, E
 Mineral deficiencies: Zn, Mg, Cu, Ca
 Weight and BMI do not reflect true nutritional status (ascites and/or edema)
 Oral intakes are not necessarily poor
 Exhibit features of protein energy malnutrition

Nutritional Assessment of patients with End Stage Liver Disease (ESLD)

 Anthropometry
 Food history
 Nausea
 Anorexia
 Taste changes
 Diarrhea
 Protein markers of nutritional status
  Descriptive history of wasting
 Grip strength
Nutritional Management of End Stage Liver Disease
Energy Requirements:
 Patients with compensated cirrhosis do not appear to need modification of their
energy intakes
 Patients with decompensated liver disease require 35 – 40 non protein kcals/kg/day*
 Reduced glycogen storage capacity
 Unable to tolerate periods of prolonged fasting – increased protein breakdown in
periods of prolonged fasting
 Altered fat metabolism/synthesis
 Lipids are oxidized as a preferential substrate
 Increased lipolysis
 Active mobilization of lipid stores
Fat:
 Fat restriction contraindicated in most patients
 Symptoms of fat intolerance such as steatorrhea, abdominal pain or nausea following a high
fat intake are rare. If present fat modification may be necessary
Protein:

 Protein turnover in cirrhotic patients is normal or increased

 Stable cirrhotic have increased protein requirements
 Stable cirrhotic patients are capable of achieving positive nitrogen balance during aggressive
nutritional support regime
 Recommended protein intake for cirrhotic is 1.0 – 1.5g protein/kg/day¹
 Dietary protein restriction does not appear to be of any benefit in episodic hepatic
encephalopathy
Does the timing or frequency of meals matter?
Due to Reduced glycogen storage capacity modified eating pattern should be recommended to all
patients with ESLD. This would include eating at regular intervals – perhaps 5-7 small High
Protein high energy meals/snacks per day. Include a pre-bedtime HP/HE snack to provide
substrate for the liver to work with during sleep (supplements).
 Patients with ascites

 usually have a high total body sodium but often have a low serum sodium
 Generally have a poor intake secondary Early Satiety due to abdominal distension
 Delayed gastric emptying
 Frequent snacking important to achieve high energy intake
  Sodium restricted diet.

o Most common restriction is a no added salt diet which can range between 50Mm
Na and 100Mm Na
o Diuretics. Most commonly used are Lasix and Aldactone.
o Salt substitutes contraindicated due to potassium sparing effect of aldactone

 Fluid restriction

o Moderate (1500ml )to severe (≤ 800ml)

o ≤800ml used to treat intractable ascites unresponsive to diuretic therapy or when

diuretic therapy no longer possible due to compromised renal function
o Don’t measure: custards, ice cream

Diabetes in Liver Disease

Patients with ESLD may present with impaired glucose tolerance. This may be due to a number
of factors:

 Depleted hepatic glycogen stores

 Impaired glucose tolerance
 Hyperinsulinemia
 Insulin resistance

Dietary Management involves:

 Diabetic education without restriction of energy intake

 Insulin therapy
 BCAA supplementation has been shown to facilitate control of blood sugar levels in patients
with ESLD
 Achieve and maintain high energy intake(35-40 non protein kcal/kg/day)
 Achieve and maintain a high protein intake(1.0-1.5g/kg/day)
 Avoid unnecessary fat restriction
 Encourage frequent snacking
 Restrict dietary sodium intake in the presence of ascites and/or edema
 Restrict fluid intake to assist in the management of ascites/edema associated with
hyponatremia
 Consider branched chain amino acid supplementation
 Significant pre-bedtime snack

Nutritional Management of NAFLD

 Treatment centers around reducing insulin resistance
 Dietary intervention
 Increased physical activity
 Metformin
 Weight loss strategies in presence of overweight/obesity. Weight loss results in improved
lipid and carbohydrate metabolism.
 Weight loss must be slow. Rapid weight loss results in worsening liver function tests and
hepatomegaly
 Rapid weight loss may promote or worsen NAFLD, NASH and may result in liver failure
 Normal weight subjects: dietary and pharmacological treatment of altered lipid and /or
carbohydrate metabolism
 In overweight individuals with elevated aminotransferase levels weight loss of 10% or more
corrects aminotransferase levels and decreases hepatomegaly

Prevalence of hepatic disease:

Total no. of patients: 30
Patient with hepatic disease: 2

pervalance of hepatic disease

total patient patient with hapetic disease

 Renal disease
The kidneys play a central role in excretion of many metabolic breakdown products, including:

 Ammonia, urea and creatinine from protein, and

 Uric acid from nucleic acids, drugs and toxins

They regulate fluid and electrolyte balance in body by continuous filtration of blood. The kidney
receives 20% of cardiac output, which allows the filtering of approximately 1600L/day of blood.
It produces 120 mL/min or 170 L/day ultra-filtrate of plasma at the glomerulus, and selectively
reabsorbs components of this ultra-filtrate at points along the nephron. Approximately, 1.5 L of
urine excreted in an average day. Also involved in regulation of blood pressure through renin-
angiotensin mechanism. It produces erythropoietin (EPO) hormone in body which plays a critical
role in maintenance of calcium-phosphorous homeostasis and thus production of active form of
vitamin D in body.

Acute renal failure

It is a sudden and often reversible loss of renal function, which develops over days or weeks and
is usually accompanied by a reduction in urine volume. Approximately 7% of all hospitalized
patients and 20% of acutely ill patients develop signs of acute renal failure
It is classified into three subtypes;

 “Pre-renal”, when perfusion to the kidney is reduced

 ‘Renal’, when the diseases within the renal parenchyma
 ‘Post-renal’, when there is obstruction to urine flow at any point from the tubule to the
urethra

Causes of Acute renal failure

Pre-renal: Impaired perfusion may occur due to:
 Cardiac failure
 Sepsis
  Blood loss
 Dehydration
 Vascular occlusion

Renal: Glomerulonephritis, small vessel vasculitis and acute tubular necrosis may occur due to:
 Drugs
 Toxins
 Prolonged hypotension

Interstitial nephritis may occur due to:

 Drugs
 Toxins
 Inflammatory disease
 Infection

POST-RENAL
Following complications may lead to acute renal failure:

 Urinary calculi
 Retroperitoneal fibrosis
 Benign prostatic enlargement
 Prostate cancer
 Cervical cancer

Clinical features of Acute Renal Failure

Signs and symptoms include:

 The urine output become less than 500 mL/day, at least 600 ml is required to eliminate
solute wastes
 Fluid retention causing swelling in legs, ankles and feet
 Fatigue,
 Itching
 Poor vision
 Weakness

Acute renal failure may leads to:

 Tissue destruction
 Acidosis
 Uremia
  Hyperkalemia

Medical nutrition therapy in Acute Renal Failure

 Fluid, electrolyte and mineral balances are being focused
 In the early stages of ARF the patient is often unable to eat so diet is switched to total
parenteral nutrition and early dialysis is preferred
 The preferred treatment is parenteral administration of glucose, lipids, and a mixture of
essential and nonessential amino acids
 Restrict fluid intake to patient’s output plus 500 ml for insensible losses. Fluid need increases
if the patient has fever
 The diet should contain 0.5 to 0.8 g/kg of protein for no dialysis patients to 1 to 2 g/kg of
protein for dialyzed patients
 Potassium and phosphorus are also restricted
 Energy requirement is increased to 30-40 kcal/kg body weight
 The recommended nutrient allowance of some nutrients are:
 Potassium must be 30-50 mEq/day in oliguric phase (depending on urinary output, dialysis
and serum potassium levels)
 Sodium must be 20-40 mEq/day in oliguric phase (depending on urinary output, edema,
dialysis and serum sodium levels)
 Fluid intake should balance previous day output along with additional 500 ml

Chronic Kidney Disease

Chronic kidney disease (CKD), previously termed chronic renal failure, refers to an irreversible
deterioration in renal function which usually develops over a period of years. The loss of the
excretory, metabolic and endocrine functions of the kidney leads to the clinical symptoms and
signs of renal failure, collectively referred to as uremia. Uremia is the condition of having high
levels of urea in the blood as it is not filtered out properly in urine.

Clinical Features of Chronic kidney disease

Signs and symptoms include:

 Tiredness or breathlessness
 Renal anemia
 Pruritus
 Weight loss
 Nausea
 Vomiting

In later stages, patients may experience muscular twitching, fits, drowsiness and coma
 The typical presentation is with a raised urea and creatinine found during routine blood tests,
frequently accompanied by hypertension, proteinuria or anemia.

Medical Nutrition Therapy in Chronic Kidney Disease

 Diet is based upon restriction of protein and phosphorous along with blood pressure control
in the progression of renal disease
 Recommendations for dietary protein intake in progressive renal failure are:
 0.8 g/kg/day with 60% HBV for patients whose GFR is greater than 55 ml/min, and
 0.6 g/kg/day with 60% HBV for patients whose GFR is 25 to 55 ml/min
 If patient has edema, restrict sodium intake to 1-3 g/day
 Restrict intake of phosphorous to 8-12 mg/kg of ideal body weight by decreasing intake of
dairy products

Renal transplant:
Transplantation involves the surgical implantation of a kidney from:
i. A living related donor,
ii. A living nonrelated donor, or
iii. A deceased(cadaveric) donor
Major complications of transplantation include:
 Rejection of foreign tissue
 Infection secondary to immunosuppressive therapy
The acute post transplantation phase last up to 2 months; the chronic phase start after two months

Medical Nutrition Therapy in Transplantation

 Corticosteroids prescribed after surgery are associated with accelerated protein catabolism
and sodium retention
 During the first month after transplantation, a high protein diet (1.3 to 1.5 g/kg body weight)
with an energy intake of 30 to 35 kcal/kg is recommended to prevent negative nitrogen
balance
 In case of fever and infection, higher amount of protein approximately 1.6 to 2 g/kg is given
 To minimize fluid retention in body sodium is restricted in diet i.e. 80 to 100 mEq/day. This
also helps to control blood pressure
 Increase intake of calcium by 1-1.5 times the RDA to offset poor absorption
 Corticosteroids prescribed after surgery are associated with accelerated protein catabolism
and sodium retention
 During the first month after transplantation, a high protein diet (1.3 to 1.5 g/kg body weight)
with an energy intake of 30 to 35 kcal/kg is recommended to prevent negative nitrogen
balance
 In case of fever and infection, higher amount of protein approximately 1.6 to 2 g/kg is given
 To minimize fluid retention in body sodium is restricted in diet i.e. 80 to 100 mEq/day. This
also helps to control blood pressure
 Increase intake of calcium by 1-1.5 times the RDA to offset poor absorption

Anemia in Chronic Kidney Disease

It is defined as hemoglobin less than 11 g/dL in blood in women while less than 12 g/dL in adult
males. The causes of anemia in CKD is:

 Reduced production of erythropoietin by the kidneys

 Iron deficiency
 Folate and B12 deficiency
 Lower red blood survival, caused mainly by uremia

TREATMENT

 Adequate folate and B12 intakes, through diet and supplements

 Folic acid 1 mg supplement, Cobalamin (B12) 2.4 mg supplement)
 Physical activity should be encouraged to both promote and maintain muscle mass and
general overall health

Prevalence of renal disease:

Total no. of patients: 30
Patients with renal disease: 2
 pr evalence of r enal dis eas e
total patients patient with renal disease

Gastritis and Peptic Ulcers

Gastritis
An inflammation of the stomach lining is referred to as gastritis. Gastritis may be accompanied
by nausea and vomiting or by a sense of fullness after eating a small meal. The inflammatory
lesion may be either an acute erosive gastritis or a chronic atrophic gastritis

Causes
 Ingestion of drugs, other chemical irritants
 Atrophic gastritis may be due to an auto immune reaction
 It may also be present in metabolic disorders such as uremia
 Among, the most common causes of gastritis is aspirin, which may cause stomach bleeding
 Viral, bacterial (Helicobacter pylori) and parasitic infections may also be involved

Signs and Symptoms of Gastritis

 Loss of appetite
 Mild nausea
 A feeling of fullness
 Abdominal pain
 Heat burn
 Vomiting

Acute gastritis
Gastritis is essentially an inflammation of gastric mucosa
Acute gastritis may follow the ingestion of toxic substances, such as alkalis, strong acids, alcohol
and certain drugs

Chronic Gastritis
 Chronic gastritis may accompany chronic disease lesions such as ulcer and cancer or it
may be a diseases entity on its own
 Although no specific lesion may be present, the gastric mucosa is engorged and friable,
and the patient complaints of continued gastric discomfort

CAUSES
 Causative factors include:
 Long-continued emotional stress
 Chronic alcoholism
 Hyperchlorhydria or
 Hypochlorhydria

TREATMENT
If no specific dietary regimen is indicated, a convalescent ulcer diet or a bland diet will meet the
need of these patients. It should be continued until the gastric mucosa has returned to its normal
condition

Medical Nutrition therapy in Gastritis

 Treatment consists of stopping alcohol or the drug, sometimes washing out the stomach
and giving alkalis
 Water and electrolyte losses can be replaced by an oral rehydration fluid or, if necessary,
intravenously
 A solution recommended by WHO as an oral rehydration fluid is:
 Sodium chloride(table salt) 3.5g
 Sodium bicarbonate 2.5g
 Or trisodium citrate, dihydrate 1.9g
 Potassium chloride 1.5g
 Glucose 20g
 Dissolve in 1 liter of potable water
 With improvement patient is given small feeds of milk and gradually returns to a normal
diet within 1 to 2 days
 A liquid diet should be given on first and second day following the fast
 Initially, 3 oz. of bland liquid such as homogenized milk, or buttermilk, or strained gruel
should be given and repeating the feed every half hour if patient does not feel ill after
first feed.
 Both the amount and the interval should be increased until from 6 to 8 oz., are given at 2
hours intervals.
 Solid foods should be added to diet slowly, crisp dry toast or crackers being the first
addition to liquid food.
 Toasted cereal flakes, well-cooked cereals, such as rice or cream of wheat, and a soft
cooked egg may be given on the third and fourth days of feeding
 A convalescent ulcer diet or a bland diet, may be given when an acute emergency is over
and should be continued until healing is complete.

Bland Diet
PRINCIPLES:

 Low or soft residue and connective tissue

 Little or no condiments, except salt in small amount
 Low in acid content

Group Foods Allowed Foods Avoided

Milk Milk, cream, buttermilk,
 yogurt
Cheese Cream, cottage and other soft,
mild cheeses
Fats Butter and margarine Fried or fatty foods
Eggs Boiled, poached scrambled
Meat, Fish Roast beef and lamb; broiled Smoked or preserved
steak; broiled, boiled or meat and fish
roasted chicken; liver; baked
or boiled fish
Soups With milk or cream sauce
foundation
Fruits Orange juice, ripe bananas, All except listed in
baked apple (without skin), foods allowed column
pears, apricots
Vegetables Potatoes, peas, squash, All raw; All cooked
carrots, tender string beans, except those
beets, spinach( in severe mentioned in foods
cases, these vegetables are allowed column
pureed)
Bread and White bread and rolls,
cereals crackers, all refined cereals,
spaghetti, noodles
Beverages Milk, buttermilk, cocoa, fruit Carbonated beverages,
juices alcoholic beverages
desserts Custards, ice cream, gelatin Pastries, preserves,
desserts, sponge cake candies

Typical Menu for Bland Diet

 Meal Time Food Items
Breakfast • Banana(ripe)
• 1 egg (poached)
• White-bread toast
• Butter or margarine
• Coffee on substitute
Lunch • Roast lamb
• Mashed potatoes
• Peas
• White bread
• Small glass tomato juice
Dinner • Creamy potato soup
• Scrambled eggs
• Fresh spinach
• Cookies
• Small glass orange juice

Peptic Ulcer
An ulcer is an erosion of the top layer of cells from an area, such as the wall of the stomach or
duodenum. Ulcer of the stomach is known as gastric ulcer and ulcer of duodenum is known as
duodenal ulcer, both of which are collectively known as peptic ulcer

 The term gastric ulcer denotes an eroded lesion in the stomach, usually occurring along
the lesser curvature or near the pylorus
 A duodenal ulcer is the same type of lesion, but is found in the duodenum. It is much
more common than a gastric ulcer
 The term peptic ulcer is used because it appears to develop from a loss of ability of
mucosa to withstand the digestive action of pepsin and HCL
 An ulcer is always troublesome and may endanger the life of the patient, as hemorrhage
and perforation of the gastric or the duodenal wall are not uncommon occurrences

Causes of Peptic Ulcer

 Caffeine, aspirin nicotine have been subject to claims that promote peptic ulcers
 Peptic ulcers occurs more frequently in persons with blood group O and HLA-B5
antigens
 Chronic inflammation by bacterium Helicobacter pylori

Symptoms of Peptic Ulcer

 Pain in upper central abdomen
  Loss of weight
 Vomiting
 Hemorrhages
 Melena (black stool)
 Anemia
 Dyspepsia (considered a symptom for general disease)

Medical Nutrition Therapy in Peptic Ulcer

The characteristics of the diet include the following:

 Foods that neutralize and inhibit acidity

 These are bland protein foods such as milk and eggs
 Meat and fish is not given in early stages as they tend to stimulate flow of gastric
juice
 Fats delay emptying of stomach and inhibit gastric secretion that’s why preferred
 Frequent small feedings
 Feedings are given every 2 hours, alternating with antacids

A mechanically nonirritating diet

This is low in residues and therefore free of substances likely to cause abrasion or irritation when
coming in contact with eroded surface of ulcer
Foods to be omitted are tough fibered meats, whole grain cereals and most fruits and vegetables
unless they are strained
A chemically nonirritating diet
This diet is free of all foods that tend to stimulate the flow of gastric juice, such as meat in form
of broths, soups, gravies; tea, coffee and cola beverages; and all other foods that might irritate
the inflamed and friable mucosa

Diet in Acute Peptic Ulcer

 For many years, the Sippy diet or modifications of it have been used successfully in
treatment
 The diet begins with frequent feedings of milk and milk cream, usually 3 oz. given every
hour
 This is altered on half hour with alkaline powders
 This is altered on half hour with alkaline powders
 The feedings may be given from 7 am to 7 pm or may be continued during night and evening
if pain persists
Diet in convalescent peptic ulcer
 As pain subsides, soft cooked eggs, refined cereals and custard are added one by one to
above regimen
 Gradually, other foods such as milk toast, strained cream soups and cottage or cream cheese
are added or substituted
 Meals should remain small and frequent
 If the patient continues to improve, he is placed on a 6-feeding convalescent ulcer diet

Group Foods Allowed Foods Avoided

Milk Milk, cream, buttermilk

Cheese Cottage cheese, Cheddar cheese added

later
Fats Butter, margarine All fried foods

Desserts Ice cream, custard, rice pudding, gelatin Pastries, nuts, raisins, candies
desserts
Group Foods Allowed Foods Avoided

Eggs Soft cooked, poached, scrambled

Meat, Fish Minced beef, boiled chicken, poached Smoked and preserved meat and
fish fish
Soup Cream soups only using vegetables All meat soups
listed below
Vegetables Pureed spinach, corn, peas, beets, All gas forming vegetables
tomatoes, mashed potatoes (without including cabbage, cauliflower,
skin) onion, cucumber
Fruits Baked apples, ripe or baked bananas,
fruit juices like pear, puree of all dried
fruits like figs
Bread, cereals Enriched white bread, refined cereals,
spaghetti, ready to eat cereal except
containing bran

Prevalence of gastritis and peptic ulcer:

Total no. of patients: 30
Patient with gastritis: 5
Patient with peptic ulcer: 2
 prevalence of gastritis and peptic ulcer

total patients patient with gastritis patient with peptic ulcer

Inflammatory bowel syndrome

Inflammatory bowel disease (IBD) is an umbrella term used to describe disorders that involve
chronic inflammation of your digestive tract. Types of IBD include:
Ulcerative colitis. This condition involves inflammation and sores (ulcers) along the superficial
lining of your large intestine (colon) and rectum.
Crohn's disease. This type of IBD is characterized by inflammation of the lining of your
digestive tract, which often can involve the deeper layers of the digestive tract.
Both ulcerative colitis and Crohn's disease usually are characterized by diarrhea, rectal bleeding,
abdominal pain, and fatigue and weight loss. IBD can be debilitating and sometimes leads to life-
threatening complications.
Symptoms
Inflammatory bowel disease symptoms vary, depending on the severity of inflammation and
where it occurs. Symptoms may range from mild to severe. You are likely to have periods of
active illness followed by periods of remission.

Symptoms:
Signs and symptoms that are common to both Crohn's disease and ulcerative colitis include:

 Diarrhea
 Fatigue
 Abdominal pain and cramping
 Blood in your stool
 Reduced appetite
 Unintended weight loss

What causes IBD?

The exact cause of IBD is unknown, but IBD is the result of a defective immune system. A
properly functioning immune system attacks foreign organisms, such as viruses and bacteria, to
protect the body. In IBD, the immune system responds incorrectly to environmental triggers,
which causes inflammation of the gastrointestinal tract. There also appears to be a genetic
component—someone with a family history of IBD is more likely to develop this inappropriate
immune response.

Inflammatory bowel syndrome vs. irritable bowel syndrome:

IBD should not be confused with irritable bowel syndrome or IBS. Although people with IBS
may experience some similar symptoms to IBD, IBD and IBS are very different. Irritable bowel
syndrome is not caused by inflammation and the tissues of the bowel are not damaged the way
they are in IBD. Treatment is also different.
IBD is not celiac disease
Celiac disease is another condition with similar symptoms to IBD. It is also characterized by
inflammation of the intestines. However, the cause of celiac disease is known and is very
specific. It is an inflammatory response to gluten (a group of proteins found in wheat and similar
grains). The symptoms of celiac disease will go away after starting a gluten-free diet, although it
usually will be months before the full effects of the new diet will be reached.

The Effect of IBD on Digestion

In people with IBD, inflammation in the organs of the digestive tract can affect the process of
digestion. Inflammation in the small intestine of a person with Crohn’s disease can interfere with
the digestion and absorption of nutrients. Incompletely digested food that travels through the
colon may cause diarrhea and abdominal pain. In a person with ulcerative colitis, the small
intestine works normally, but the inflamed colon does not absorb water properly.

Diet therapy for Ulcerative Colitis:

 Follow a low residue diet to relieve abdominal pain and diarrhea.
 Avoid foods that may increase stool output such as fresh fruits and vegetables, prunes and
caffeinated beverages.
 Decrease concentrated sweets in your diet, such as juices, candy and soda, to help decrease
amounts of water pulled into your intestine, which may contribute to watery stools.
 Try incorporating more omega-3 fatty acids in your diet. These fats may have an anti-
inflammatory effect. They are found in fish, including salmon, mackerel, herring and
sardines.
 Patients often find that smaller, more frequent meals are better tolerated. This eating pattern
can help increase the amount of nutrition you receive in a day.
 Consider taking nutritional supplements if appetite is poor and solid foods are not tolerated
well (see section on recommended liquid supplements).

Diet therapy for Crohn's Disease:

 Follow a low residue diet to relieve abdominal pain and diarrhea.
 If you have strictures, it is especially important to avoid nuts, seeds, beans and kernels.
 Avoid foods that may increase stool output such as fresh fruits and vegetables, prunes and
caffeinated beverages. Cold foods may help reduce diarrhea.
 If you have lactose intolerance, follow a lactose-free diet. Lactose intolerance causes gas,
bloating, cramping and diarrhea 30 to 90 minutes after eating milk, ice cream or large
amounts of dairy. A breath hydrogen test may confirm suspicions of lactose intolerance.

Prevalence of inflammatory bowel syndrome:

Total no. of patients: 30
Patients with IBD: 2

Prevalence of IBD

total patient patient with IBD

Chapter no

Surgery ward
Surgery ward deal with the acute hospital care of
inpatient treated through surgical procedures.
 Post-surgical dietary modification
 Therapeutic modification of diet
 Therapeutic modification of diet
A therapeutic diet is a diet that is formulated usually by nutritionists, dieticians, and medical
doctors to aid in the healing of the body from certain types of injuries and diseases. Therapeutic
treatments involving food are also prescribed for medical conditions that affect the psychological
state of the individual as well, such as weakness caused by anorexia, or a loss of appetite due to
depression, loneliness, and other mental states that can discourage healthy eating. More common
conditions that may require a therapeutic diet include the loss of teeth with age, which may
necessitate a diet of soft foods, or a calorie-, fat-, and sodium-controlled diet to treat such routine
conditions as being overweight, having high cholesterol levels, or being borderline diabetes.
Severe health conditions often require a therapeutic diet recommended for the short term. A good
example of this is the liquid diet that is often prescribed immediately after surgery or a heart
attack. Liquid diets are also recommended for a variety of acute digestive problems and to
reestablish the normal water content of the body that can be reduced due to chronic diarrhea or
vomiting. The main components of a liquid diet are often a combination of fruit juices, low-
sodium soups, and foods that can be pureed or brought to a semi-liquid state such as boiled
vegetables, yogurt, and ice cream. Soft diets for individuals with a limited ability to chew or
digest food are similar in nature and require forgoing foods such as tough meat, fibrous grains
and fruits, and nuts that are difficult for the body to break down if swallowed whole.
A therapeutic diet is usually a modification of a regular diet. It is modified or tailored to fit the
nutrition needs of a particular person. Therapeutic diets are modified for
(1) Nutrients
(2) Texture
(3) Food allergies or food intolerances.

Common reasons therapeutic diets may be ordered:

• To maintain nutritional status
• To restore nutritional status
• To correct nutritional status
• To decrease calories for weight control
• To provide extra calories for weight gain
• To balance amounts of carbohydrates, fat and protein for control of diabetes
• To provide a greater amount of a nutrient such as protein
• To decrease the amount of a nutrient such as sodium
• To exclude foods due to allergies or food intolerance
• To provide texture modifications due to problems with chewing and/or swallowing

Common therapeutic diets include:

1. Nutrient modifications
• No concentrated sweets diet
• Diabetic diets
• No added salt diet
• Low sodium diet
• Low fat diet and/or low cholesterol diet
• High fiber diet
• Renal diet
2. Texture modification
• Mechanical soft diet
• Puree diet
3. Food allergy or food intolerance modification
• Food allergy
• Food intolerance
4. Tube feedings
• Liquid tube feedings in place of meals
• Liquid tube feedings in addition to meals
5. Additional feedings – In addition to meal, extra nutrition may be ordered as:
• Supplements – usually ordered as liquid nutritional shakes once, twice or three times per day;
given either with meals or between meals
• Nourishments – ordered as a snack food or beverage items to be given between meals mid-
morning and/or mid-afternoon
• HS snack – ordered as a snack food or beverage items to be given at the hour of sleep
The following list includes brief descriptions of common therapeutic diets:

Clear liquid diet

• Includes minimum residue fluids that can be seen through.
• Examples are juices without pulp, broth, and Jell-O.
• Is often used as the first step to restarting oral feeding after surgery or an abdominal procedure.
• Can also be used for fluid and electrolyte replacement in people with severe diarrhea.
• Should not be used for an extended period as it does not provide enough calories and nutrients.

Full liquid diet

• Includes fluids that are creamy.
• Some examples of food allowed are ice cream, pudding, thinned hot cereal, custard, strained
cream soups, and juices with pulp.
• Used as the second step to restarting oral feeding once clear liquids are tolerated.
• Used for people who cannot tolerate a mechanical soft diet.
• Should not be used for extended periods.

No Concentrated Sweets (NCS) diet

• Is considered a liberalized diet for diabetics when their weight and blood sugar levels are under
control.
• It includes regular foods without the addition of sugar.
• Calories are not counted as in ADA calorie controlled diets.

Diabetic or calorie controlled diet (ADA)

• These diets control calories, carbohydrates, protein, and fat intake in balanced amounts to meet
nutritional needs, control blood sugar levels, and control weight.
• Portion control is used at mealtimes as outlined in the ADA “Exchange List for Meal
Planning.”
• Most commonly used calorie levels are: 1,200, 1,500, 1,800 and 2,000.
No Added Salt (NAS) diet
• It is a regular diet with no salt packet on the tray.
• Food is seasoned as regular food.

Low Sodium (LS) diet

• May also be called a 2 gram Sodium Diet.
• Limits salt and salty foods such as bacon, sausage, cured meats, canned soups, salty seasonings,
pickled foods, salted crackers, etc.
• Is used for people who may be “holding water” (edema) or who have high blood pressure, heart
disease, liver disease, or first stages of kidney disease.

Low fat/low cholesterol diet

• Is used to reduce fat levels and/or treat medical conditions that interfere with how the body uses
fat such as diseases of the liver, gallbladder, or pancreas.
• Limits fat to 50 grams or no more than 30% calories derived from fat.
• Is low in total fat and saturated fats and contains approximately 250-300 mg cholesterol.

High fiber diet

• Is prescribed in the prevention or treatment of a number of gastrointestinal, cardiovascular, and
metabolic diseases.
• Increased fiber should come from a variety of sources including fruits, legumes, vegetables,
whole breads, and cereals.

Renal diet
• Is for renal/kidney people.
• The diet plan is individualized depending on if the person is on dialysis.
• The diet restricts sodium, potassium, fluid, and protein specified levels.
• Lab work is followed closely.

Mechanically altered or soft diet

• Is used when there are problems with chewing and swallowing.
• Changes the consistency of the regular diet to a softer texture.
• Includes chopped or ground meats as well as chopped or ground raw fruits and vegetables.
• Is for people with poor dental conditions, missing teeth, no teeth, or a condition known as
dysphasia.

Pureed diet
• Changes the regular diet by pureeing it to a smooth liquid consistency.
• Indicated for those with wired jaws extremely poor dentition in which chewing is inadequate.
• Often thinned down so it can pass through a straw.
• Is for people with chewing or swallowing difficulties or with the condition of dysphasia.
• Foods should be pureed separately.
• Avoid nuts, seeds, raw vegetables, and raw fruits.
• Is nutritionally adequate when offering all food groups.

Food allergy modification

• Food allergies are due to an abnormal immune response to an otherwise harmless food.
• Foods implicated with allergies are strictly eliminated from the diet.
• Appropriate substitutions are made to ensure the meal is adequate.
• The most common food allergens are milk, egg, soy, wheat, peanuts, tree nuts, fish, and
shellfish.
• A gluten free diet would include the elimination of wheat, rye, and barley.
Replaced with potato, corn, and rice products.

Food intolerance modification

• The most common food intolerance is intolerance to lactose (milk sugar) because of a
decreased amount of an enzyme in the body.
• Other common types of food intolerance include adverse reactions to certain products added to
food to enhance taste, color, or protect against bacterial growth.
• Common symptoms involving food intolerances are vomiting, diarrhea, abdominal pain, and
headaches.

Tube feedings
• Tube feedings are used for people who cannot take adequate food or fluids by mouth.
• All or parts of nutritional needs are met through tube feedings.
• Some people may receive food by mouth if they can swallow safely and are working to be
weaned off the tube feeding.

Chapter no.

Burn ward
Burn ward deal with the patient with different burn
injuries. There are many type of burn injuries. Some of
them are followed:
 Home burn
 Hot liquid burn
 Electrical burn
 Boiler burn
 Chemical burn
 1

According to the American Burn Association, there are roughly 450,000 patients each year that
receive hospital and emergency room treatment for a burn-related injury. Of these injuries, 3,400
deaths occur each year. Back in 2010, a fire-related death occurred every 169 minutes and an
injury occurred every 30 minutes according to the Centers for Disease Control and Prevention
(CDC), making it the third leading cause of death in the home.

TYPES OF BURN INJURIES:

(1) Home burns: A mild burn injury of the outermost layer that make up the skin
(epidermis). Usually heals without scarring the skin.
(2) Thermal Burns: These burns are usually caused by a flame, any heat or contact with
a hot object.
(3) Chemical Burns: Common in industrial settings and in household cleaners and
swimming pools, these burns are a bit different than others. Many times, chemical burns
may appear to be harmless as they do not seem serious right away. However, they can
become worse as they continue to react to the exposed tissue.
(4) Electrical Burns: Not only is the actual burn painful and serious, electricity can also
cause internal injuries that are not immediately visible to healthcare providers. These are
 very serious burns as they can cause a heart attack, neurological damage, and even
ruptured eardrums. Be careful as electrocution burns are far more serious than they tend
to appear. Even a small burn can place a person at risk of losing a limb.
(5) Hot liquid burn: Hot water scalding can cause pain and damage to the skin from
moist heat or vapors. This type of burn can be dangerous because it destroys affected
tissues and cells. Your body may even go into shock from the heat. In more serious
cases, these burns can be life-threatening.
2

CLASSIFICATION OF BURN INJURIES:

First Degree Burn:
This particular burn is a superficial burn injury. More like a sunburn, a bit pink with the
potential to cause dehydration for the victim. The outer skin layer, the epidermis, is the only
layer damaged in these burns with the deeper skin structures still intact. Usually, these types of
burn heal over the course of a few days. Medical attention is normally not required, however, if
most of the body is affected and you’re dehydrated or having problems with pain, then, by all
means, please seek out medical attention.

Second Degree Burn:

Also called a partial thickness injury, in addition to the outer skin layer (epidermis), the inner
skin layer (dermis) is also damaged. These burns are bright red, moist and painful to the touch.
They also blister and appear to look like an open wound. It usually takes about two to three
weeks to completely heal.

Third Degree Burn:

Also called a full thickness burn injury. These burns are less painful due to the nerve endings
being damaged. The outer skin and full inner skin layer (both the dermis and subcutaneous
tissue) are damaged. They appear as an open wound and can appear as dark red, white, brown
and leathery or even charred.

Causes of burn injuries:

Workplace Accidents – A very common way in which people suffer burn injuries is through
their work environment. Many jobs have their workers exposed to high-temperature equipment
or heavy machinery with open flames.
Car Accidents – Another common cause of burn injuries, car accidents sometimes result in
some part catching on fire which can cause a burn injury if trapped inside.
Defective Products – Defective consumer goods are a leading cause of serious burns amongst
people. If ever you have suffered an injury due to a defective product, seek help right away.
Therapeutic diet in burn patients
 Thermal trauma results in marked hyper metabolism and hyper catabolism.
 Aggressive nutritional support is required to meet metabolic demands, prevent the depletion
of body energy and nitrogen stores, support wound healing, enhance immunity, and improve
survival.
 Energy requirements increase linearly in proportion to burn size to a maximum of
approximately twice the normal levels.
 Factors such as agitation, pain, and heat loss during dressing changes are associated with a
large increase in energy expenditure.

Energy requirements in adults:

 Many formulas available to determine energy requirements unfortunately have not been
validated yet for the burn population.
 The expert consensus is indirect calorimetry done at late night or early morning to evaluate
REE also referred on admission to the hospital and at least once weekly until the patient is
stabilized.
 In addition, indirect calorimetry is recommended when the patient’s condition is complicated
by infection, sepsis, poor wound healing, obesity, or ventilator dependency.
 The REE obtained from indirect calorimetry may need to be multiplied by a factor of 1.3 (or
20% to 30%) to account for activity, physical rehabilitation, wound care, and stress of
treatments.
 If indirect calorimetry is not available, evidence based guidelines recommend using
predictive equations considering age (< 60 years or age, or > 60 years of age) and whether
the patient is obese or non-obese.
 Mifflin St Jeor Equation x 1.5 to calculate energy requirements is usually adopted but
practice of adding injury and stress factors may lead to the over estimation of the patient’s
needs when patients are mechanically ventilated, sedated or paralyzed.
 The Curreri equation appears to be most accurate in assessing energy requirements during the
early post burn phase (7-to-10 days post burn), when energy expenditure is at its maximum.
 Curreri equation for patients aged 16 to 59 years (7):
TEE: 25 kcal x kg actual body weight + (40 kcal x % TBSAB)
If percent TBSAB > 50%, use a maximum value of 50%
 Curreri Example: 30 year male weighing 70 kg with burns involving 50% TBSA.
TEE: 25 kcal x 70 kg + (40 kcal x 50) = 1750 kcal + 2000 kcal= 3750 kcal as total energy
expenditure

Energy requirements in children

 Indirect calorimetry, if available, should be used on admission to the hospital and twice
weekly thereafter until the patient is healed.
 The RMR should be multiplied by a factor of 1.3 (or 20% to 30%) to provide total energy
needs.
 For less than 30% TBSAB, use the Dietary Reference Intakes (DRI) for energy, per age
group, as a starting point to provide adequate energy intake.
 For greater than 30% TBSAB, use the following formulas, where BSA = Body Surface Area
and BSAB = Body Surface Area Burned.
 Infant 0 to 12 months 2,100 kcal/m2 BSA + 1,000 kcal/m2 BSAB
 Child 1 to 11 years 1,800 kcal/m2 BSA + 1,300 kcal/m2 BSAB
 Adolescent 12 to 18 years 1,500 kcal/m2 BSA + 1,500 kcal/m2 BSAB
 The Curreri formula, which was proposed to calculate the energy needs of the burned adult,
has been modified for pediatric patients by using balance studies of weight in burned
children. The Curreri junior formula is designed for burns of less than 50% total body surface
area. It typically overestimates energy requirements in burns exceeding 50%.

Age 0 to 1 year: Basal kcal + 15 kcal x % Burn

3
Age 1 to 3 years: Basal kcal + 25 kcal x % Burn
4
Age 3 to 15 years: Basal kcal + 40 kcal x % Burn
5
6 Protein requirements
Protein needs of burn patients are directly related to the size and severity of the burn. The
increased protein demand is necessary to promote adequate wound healing and to replace
nitrogen losses through wound exudate and urine. Failure to meet heightened protein needs can
yield suboptimal clinical results in terms of wound healing and resistance to infection.
Adults
Most sources currently suggest the following for adult burn patients using actual weight, unless
otherwise specified:

 Adults with TBSA < 10% 1.2 g/kg/day

 Adults with TBSA > 10% 1. 5 g to 2.0 g/ kg/day
 Adults with large surface area burns may require higher protein intake of 3.0 to 4.0
g/kg/day
 Adults (with BMI > 30) 2.0g/kg/day
 Adults target 120 to 150 Non Protein Calorie:1 g nitrogen

In addition, the following has been suggested in the literature:

 <10% TBSAB 1.2 to 1.5 g/kg of actual or ideal body weight

  10% to 15% TBSAB 1.5 to 2.0 g/kg of actual or ideal body weight
 15% to 35% TBSAB 2.0 to 2.5 g/kg of actual or ideal body weight
 >35% TBSAB 23% to 25% of total energy

Consider using ideal body weight when an actual weight cannot be evaluated or measured, or in
cases of severe obesity in which protein requirements may be overestimated if the actual body
weight is used.
Children

 <1% TBSAB 3 to 4 g/kg

 1% to 10% TBSAB 15% of total energy
 >10% TBSAB 20% of total energy

Parenteral Nutrition
Carbohydrate:

 Adults 3 to 4 mg/kg per minute parenteral glucose infusion or approximately 50 to 60%

of total energy requirements in critically ill burn patients. Insulin should be used to
maintain normoglycemia.
 Children Initiate dextrose at 7 to 8 mg/kg per minute and advance as needed to maximum
of 20% dextrose solution.
 Infants Initiate dextrose infusion at 5 mg/kg per minute and advance to 15 mg/kg per
minute over a 2-day period.
Fat:

 Adults 10% to 30% of total energy in critical care with 2 % to 4% as essential fatty acids
to prevent deficiency.
 Children >1 year 30% to 40% of total energy.
 Children <1 year Up to 50% of total energy.

Enteral feeding
If feeding is to be given totally by nutrition support, the enteral route is preferred over total
parenteral nutrition. Starting an intragastric feeding immediately after the burn injury (6 to 24
hours) has been shown to be safe and effective. Total parenteral nutrition should be reserved for
only those patients with prolonged alimentary tract dysfunction

Prevalence of burn injuries

Total no. of patient: 30
Patient with burn injuries: 1

prevalence of burn injuries

total no. of patient burn patients

Chapter no.

Cardiac care unit (CCU)

Cardiac care unit provide acute hospital care to the
patient with severe cardiac problems
 Cardiovascular diseases
 Angina Pectoris
 Myocardial Infarction
 Hypertension

Cardiovascular diseases
Cardio means of heart and vascular means of blood vessels, thus cardiovascular diseases include
ailments of heart (CHD) and of blood vessels (atherosclerosis). The heart is the strongest and
toughest muscle in the body. As the arteries carry blood from the heart to the lungs and other
tissues, any damage to the artery results in a variety of heart diseases. Cardiovascular diseases
include hypertension, ischemic heart disease, leading to angina pectoris and lastly myocardial
infarction.

 Hypertension is increased blood pressure or high BP in short

 In ischemic heart disease, there is lack of blood to the heart muscle resulting in a heart attack
 In angina pectoris, there is reduction of blood supply to the heart muscle due to narrowing of
the artery wall
 Myocardial infarction is caused by thrombosis, which is coagulation of blood in blood vessel
or organ.

Structure of heart
CVD Development stages
(a) In the first stage, arterial damage begins due to fat oxidation products, hypertension and/or
smoking
(b) As it progresses, there is deposition of fatty material in the arterial wall, increasing its
thickness, making it narrow and rigid. The movement of oxygen and nutrients is made more
difficult as the arterial passage is narrowed
The heart must pump harder driving blood pressure up (high B.P. or hypertension)
(c) Lastly there is heart attack, which is also known as coronary occlusion, coronary thrombosis
or myocardial infarction
It is virtually like a traffic jam, causing insufficient supply of blood to the tissues of the body
beyond the point of blockage. If the blockage is in the artery connecting to the brain, it leads to
stroke. As blood supply is crucial to the sustenance of life, it is crucial that the patient gets
immediate medical aid to minimize the damage and save life
The major risk factors are:
i. Elevated serum cholesterol
ii. Emotional stress
iii. Hypertension
iv. Lack of activity leading to obesity and
v. Smoking
Heredity is an additional risk factor, for one inherits the food habits and often the life style of
one’s pare

Serum Level Desirable Borderline high High risk

mg/dl mg/dl mg/dl

Total Serum cholesterol 160 190 – 239 240 and above

LDL cholesterol Less than 130 130 – 159 160 and above

HDL cholesterol More than 35 less or equal to 35

Serum triglycerides 30 – 190 250 – 500 500 and above

Basic Nutritional Plan to Monitor Serum Lipid Levels
The diet changes which have proved to be effective in preventing or reversing heart disease have
the following nutritional goals:
• Reduce the total amount of fat, mainly the saturated fat in the diet
• Use polyunsaturated fat in place of saturated fat in the diet
• Decrease the intake of the amount of dietary cholesterol
• Increase physical activity to alter cholesterol components in the blood
• Attain ideal body weight and maintain it

Hypertension
Hypertension may be often due to obesity, because the increased weight means increasing work
of the heart to supply blood to the extra tissue formed. For many overweight hypertensive
people, dietary changes which result in weight loss will lead to reduction in blood pressure. This
may be adequate therapy in mild cases. But there are normal and underweight persons who suffer
from hypertension. The second possibility is excessive sodium intake, which draws more water
into circulation, thus increasing blood volume, leading to increased blood pressure.
There are about 20 per cent people who are sensitive to sodium and may be affected by excess
sodium intake; other 80 per cent appear to be relatively free from the adverse effects of excessive
sodium intake. Research studies have shown that increase in potassium intake can lower blood
pressure. Increase in intake of alcohol in excess of 2 oz. daily has a hypertensive effect, which
increases with the amount consumed.

Diet therapy for hypertension:

In patients, whose only problem is mild hypertension (diastolic pressure of 90-94 mm Hg),
therapy without use of drugs is used to achieve control. This includes:
(a) Moderate sodium restriction (1000-1500 mg/day): No salt in cooking or at the table. No
processed foods (pickles, canned foods etc. containing salt). Four servings of regular bread can
be taken.
(b) Adequate potassium intake Plant foods are rich sources of potassium, especially fruits and
vegetables. Potassium is present in higher concentration than sodium in fruits and vegetables by
a factor of 5 to 50 fold. 3-4 servings of fruits, which need no preparation (hence no addition of
salt), can ensure adequate potassium intake.
(c) Regular exercise tailored to the individual is a must – walking 5 km daily has been found to
be an ideal way to keep fit. It needs no equipment and can be undertaken in all weather.
(d) Stress management is a very important aspect of therapy. It involves regular planning of
one’s activities allowing realistic scheduling of work, relaxation, physical activity, mealtimes,
prayer/meditation and rest

Sodium Content Vegetables

Less than 5 mg/100
5 to 11 mg/100 g EP
12 – 15 mg/100 g EP
Sodium Content
Less than 6 mg/100 g EP
7 to 13 mg/100 g EP
Bitter gourd (green), bottle gourd.
Eggplant, French beans, onion stalks,
ridge gourd, onions
Pumpkin, ladies finger (bhendi), peas,
cucumber, , potato, sweet
potato, tapioca (dried chips), yam,
Brussel sprouts
Cabbage, green plantain.
Fruits
Amla, guava, orange, papaya,
peaches, plums, chiku,
Pomegranates, tree tomato, phalsa.
Pears, ripe tomato

Angina Pectoris
 Narrowing of arterial lumen and hence insufficient blood supply to the heart causes angina
pectoris
 It manifests by tight chest pain, often shooting pain in the shoulder, arm and hand. Physical
exertion, excitement, the pressure of digesting a heavy meal or sudden exposure to cold wind
may precipitate it
 Weight loss, if the patient is obese, is helpful
 Medication is used to relax heart muscle.
7

Myocardial Infarction
 An infarct is necrosis (dead) local area, due to lack or poor blood supply resulting in the
death of cells
 When such an infarct forms in the heart, it is known as myocardial infarction (or heart attack)
 If it is in the brain it is called a stroke
 Acute Stage: Care is highly individualized, suited to the condition of the patient
 Electrocardiogram is used to monitor the condition of the patient
 The work of the heart muscle can be minimized by letting the patient rest
 Medications are given to help the heart muscle relax.

Diet therapy for Myocardial Infarction

 For 24 to 48 hours the patient is only given parenteral dextrose and no food is given by
mouth, but sips of cool water are given
 After that low fat liquid diet (500 to 800 calories and 1000- 1500 ml fluid diet) is given in
very small feeds for 2 to 3 days.
 The patient progresses to a soft diet (about 1000-1200 calories), which may help establish
circulation needed for digestion and absorption of food
 The diet is given in five or six easily digestible meals
 The fat content of the diet is less than 30 % of total calories, with less than 300mg cholesterol
and less than 10 % from saturated fat
 The sodium is restricted to less than 1000 mg for a congestive heart failure patient, while it
may be mild for less serious condition
 Gas producing foods as per patient’s perception are avoided
 In edema cases fluid is restricted
 The patient is gradually helped to progress to maintenance diet, before leaving the hospital
 The patient is helped to get used to a low salt diet, low cholesterol diet so that the recurrence
of heart attack is prevented

Congestive Heart Failure

 In this condition, the heart is unable to maintain sufficient circulation to tissues
 Reduced pumping ability leads to congestion of lungs and systemic circulation
 Kidneys are unable to excrete sodium normally, resulting in accumulation of sodium in
extracellular fluid and water retention
 This results in at first of the extremities and later the abdomen and the chest retaining water
and swelling
 The gastrointestinal tract and hence, digestion slows down due to reduced blood supply
 There is loss of appetite, distention and at times vomiting

Diet therapy
 Patient must take bed rest
 Oxygen may be needed The workload of heart must be reduced
 The dietary progression is similar as for myocardial infarction
 In addition severe sodium restriction (500 – 1000 mg) and fluid restriction may be advisable
Prevalence
8 Total number of patients: 30
9 Patients suffering from CVD: 4
10 Patients suffering from hypertension: 8

11

pr evalance of cvd
Total patient CVD hypertension

12
Chapter no.

Urology
Urology ward deals with the patients experiencing
acute and chronic renal disorders. Following
diseases are commonly observed:
 Acute renal failure
 Chronic renal failure
 Kidney stones
 Hemodialysis
 Peritoneal dialysis
 Renal disease
The kidneys play a central role in excretion of many metabolic breakdown products, including:

 Ammonia, urea and creatinine from protein, and

 Uric acid from nucleic acids, drugs and toxins

They regulate fluid and electrolyte balance in body by continuous filtration of blood. The kidney
receives 20% of cardiac output, which allows the filtering of approximately 1600L/day of blood.
It produces 120 mL/min or 170 L/day ultra-filtrate of plasma at the glomerulus, and selectively
reabsorbs components of this ultra-filtrate at points along the nephron. Approximately, 1.5 L of
urine excreted in an average day. Also involved in regulation of blood pressure through renin-
angiotensin mechanism. It produces erythropoietin (EPO) hormone in body which plays a critical
role in maintenance of calcium-phosphorous homeostasis and thus production of active form of
vitamin D in body.

Acute renal failure

It is a sudden and often reversible loss of renal function, which develops over days or weeks and
is usually accompanied by a reduction in urine volume. Approximately 7% of all hospitalized
patients and 20% of acutely ill patients develop signs of acute renal failure
It is classified into three subtypes;

 “Pre-renal”, when perfusion to the kidney is reduced

 ‘Renal’, when the diseases within the renal parenchyma
 ‘Post-renal’, when there is obstruction to urine flow at any point from the tubule to the
urethra

Causes of Acute renal failure

Pre-renal: Impaired perfusion may occur due to:
 Cardiac failure
 Sepsis
  Blood loss
 Dehydration
 Vascular occlusion

Renal: Glomerulonephritis, small vessel vasculitis and acute tubular necrosis may occur due to:
 Drugs
 Toxins
 Prolonged hypotension

Interstitial nephritis may occur due to:

 Drugs
 Toxins
 Inflammatory disease
 Infection

POST-RENAL
Following complications may lead to acute renal failure:

 Urinary calculi
 Retroperitoneal fibrosis
 Benign prostatic enlargement
 Prostate cancer
 Cervical cancer

Clinical features of Acute Renal Failure

Signs and symptoms include:

 The urine output become less than 500 mL/day, at least 600 ml is required to eliminate
solute wastes
 Fluid retention causing swelling in legs, ankles and feet
 Fatigue,
 Itching
 Poor vision
 Weakness

Acute renal failure may leads to:

 Tissue destruction
 Acidosis
 Uremia
  Hyperkalemia

Medical nutrition therapy in Acute Renal Failure

 Fluid, electrolyte and mineral balances are being focused
 In the early stages of ARF the patient is often unable to eat so diet is switched to total
parenteral nutrition and early dialysis is preferred
 The preferred treatment is parenteral administration of glucose, lipids, and a mixture of
essential and nonessential amino acids
 Restrict fluid intake to patient’s output plus 500 ml for insensible losses. Fluid need increases
if the patient has fever
 The diet should contain 0.5 to 0.8 g/kg of protein for no dialysis patients to 1 to 2 g/kg of
protein for dialyzed patients
 Potassium and phosphorus are also restricted
 Energy requirement is increased to 30-40 kcal/kg body weight
 The recommended nutrient allowance of some nutrients are:
 Potassium must be 30-50 mEq/day in oliguric phase (depending on urinary output, dialysis
and serum potassium levels)
 Sodium must be 20-40 mEq/day in oliguric phase (depending on urinary output, edema,
dialysis and serum sodium levels)
 Fluid intake should balance previous day output along with additional 500 ml

Chronic Kidney Disease

Chronic kidney disease (CKD), previously termed chronic renal failure, refers to an irreversible
deterioration in renal function which usually develops over a period of years. The loss of the
excretory, metabolic and endocrine functions of the kidney leads to the clinical symptoms and
signs of renal failure, collectively referred to as uremia. Uremia is the condition of having high
levels of urea in the blood as it is not filtered out properly in urine.

Clinical Features of Chronic kidney disease

Signs and symptoms include:

 Tiredness or breathlessness
 Renal anemia
 Pruritus
 Weight loss
 Nausea
 Vomiting

In later stages, patients may experience muscular twitching, fits, drowsiness and coma
The typical presentation is with a raised urea and creatinine found during routine blood tests,
frequently accompanied by hypertension, proteinuria or anemia.

Medical Nutrition Therapy in Chronic Kidney Disease

 Diet is based upon restriction of protein and phosphorous along with blood pressure control
in the progression of renal disease
 Recommendations for dietary protein intake in progressive renal failure are:
 0.8 g/kg/day with 60% HBV for patients whose GFR is greater than 55 ml/min, and
 0.6 g/kg/day with 60% HBV for patients whose GFR is 25 to 55 ml/min
 If patient has edema, restrict sodium intake to 1-3 g/day
 Restrict intake of phosphorous to 8-12 mg/kg of ideal body weight by decreasing intake of
dairy products

Renal transplant:
Transplantation involves the surgical implantation of a kidney from:
(1) A living related donor,
(2) A living nonrelated donor, or
(3) A deceased(cadaveric) donor

13 Major complications of transplantation include:

 Rejection of foreign tissue
 Infection secondary to immunosuppressive therapy
14 The acute post transplantation phase last up to 2 months; the chronic phase start after two
months
15
16 Medical Nutrition Therapy in Transplantation
 Corticosteroids prescribed after surgery are associated with accelerated protein catabolism
and sodium retention
 During the first month after transplantation, a high protein diet (1.3 to 1.5 g/kg body weight)
with an energy intake of 30 to 35 kcal/kg is recommended to prevent negative nitrogen
balance
 In case of fever and infection, higher amount of protein approximately 1.6 to 2 g/kg is given
 To minimize fluid retention in body sodium is restricted in diet i.e. 80 to 100 mEq/day. This
also helps to control blood pressure
 Increase intake of calcium by 1-1.5 times the RDA to offset poor absorption
 Corticosteroids prescribed after surgery are associated with accelerated protein catabolism
and sodium retention
 During the first month after transplantation, a high protein diet (1.3 to 1.5 g/kg body weight)
with an energy intake of 30 to 35 kcal/kg is recommended to prevent negative nitrogen
balance
 In case of fever and infection, higher amount of protein approximately 1.6 to 2 g/kg is given
 To minimize fluid retention in body sodium is restricted in diet i.e. 80 to 100 mEq/day. This
also helps to control blood pressure
 Increase intake of calcium by 1-1.5 times the RDA to offset poor absorption

Dialysis
Dialysis can be done by two methods:

 Hemodialysis
 Peritoneal dialysis

HEMODIALYSIS

 It is artificial filtering of blood by machine (hemodialyiser) which is a catabolic process.

 This allows bidirectional diffusion of solutes between blood and the dialysate across a
semipermeable membrane down a concentration gradient
 The dialysis fluid is similar to that of normal plasma
 Chronic long-term dialysis can be aggravate bone problems, anemia and can lead to
malnutrition

Modification in Diet during Hemodialysis

 Intake of protein should be 1.1-1.4 g/kg of body weight per day, 70 % should be of high
biological value proteins
 Limit intake of sodium to 2-3 g per day unless there is large losses in dialysis or through
vomiting or diarrhea
 Limit potassium to 2 g only
 Calorie intake of patients should be calculated using 30-35 calories per kilogram of ideal
body weight
 Use dietary supplements containing vitamin C and Vitamin B-complex

Peritoneal Dialysis
It involves artificial filtering of blood by a hyper osmolar solution. There are three types of
peritoneal dialysis:
(1) IPD (intermittent)
(2) CCPD (continue cycling) and
(3) CAPD (continuous ambulatory
Modifications in Diet
 Protein intake should be 1.2-1.5 g/kg body weight
 Daily the calorie intake should be 25 to 35 calories/kg body weight, one third of which
should come from carbohydrates
 Sodium intake should be 2-3 g
 Adjust phosphorous intake according to serum levels. Limit it to 1 g/day

Anemia in Chronic Kidney Disease

It is defined as hemoglobin less than 11 g/dL in blood in women while less than 12 g/dL in adult
males. The causes of anemia in CKD is:

 Reduced production of erythropoietin by the kidneys

 Iron deficiency
 Folate and B12 deficiency
 Lower red blood survival, caused mainly by uremia

TREATMENT

 Adequate folate and B12 intakes, through diet and supplements

 Folic acid 1 mg supplement, Cobalamin (B12) 2.4 mg supplement)
 Physical activity should be encouraged to both promote and maintain muscle mass and
general overall health

Prevalence of renal disease:

Total no. of patients: 30
Patients with renal disease: 2
pr evalence of r enal dis eas e
total patients patient with renal disease