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Food, Nutrition and
Dietary M anagem ent of

HN Sarker
M BBS, FCPS (M e d ic in e ), MRCP (U K ), MRCP (N e u ro lo sy), FRCP (E d in ), FRCP (G la sg o w )

Professor and Head

Department of Medicine, Sheikh Sayera Khatun Medical Collese
Gopalganj, Bangladesh

CBS

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 Contents

Preface vii
Colour Plates between pages xii and 1
Introduction 1

Section I
Basic Knowledge about Food and Nutrition

1. Food and Nutrition 5

2. Nutrients 8
Macronutrients 9
Carbohydrates 9
Starch 9
Fiber 10
Protein 11
Fat 13
Water 17
Micronutrients 19
Vitamins 19
Fat-soluble vitamins 20
Vitamin A 20
Vitamin D 21
Vitamin E or tocopherol 22
Vitamin K 23
Water-soluble vitamins 24
Thiamine 25
Riboflavin 26
Niacin 26
Pyridoxine 27
Folate 28
Cyanocobalam in 29
Ascorbic a cid 29
11|x Food Nutrition and Dietary M anagem ent of Disease

Minerals 30
Major minerals 32
Calcium (Ca) 32
Phosphorus (P) 33
Sodium (Na) 34
Potassium (K) 36
Trace minerals 38
Iron (Fe) 38
Iodine (I) 40
3. Energy Requirement 43
Meal plans as per energy requirement and
proportion of nutrients 45
4. Diet 48
Balanced diet 50
Desirable diet for Bangladesh 50
Cooked or prepared food 50
Key massages about nutrition and health 58

Section II
Diet and Diseases

5. Malnutrition 63
Overnutrition (obesity) 63
Undernutrition 73
Marasmus 73
Kwashiorkor 73
Marasmic-Kwashiorkor 73
Vitamins 73
Fat-soluble vitamins 73
Vitamin A deficiency 74
Vitamin A excess 75
Vitamin D deficiency 75
Vitamin D excess 76
Vitamin E deficiency 77
Vitamin K deficiency 77
Water-soluble vitamins 77
Thiamine (vitamin B,) 77
Riboflavin (vitamin B2) 78
Niacin (vitamin B3) 78
Pyridoxine (vitamin B6) 79
Pyridoxine toxicity 79
Folate 79
Folate deficiency 79
 Contents xi

Cyanocobalam in (vitamin B)2) 80

Vitamin B12deficiency 80
Ascorbic acid (vitamin C) 80
Vitamin C deficiency 80
Vitamin C excess 80

Section III
Diet and Systemic Diseases

6. Diet in Cardiovascular Diseases 83

Diet in hypertension 83
What to avoid 84
What to take 85
Diet in coronary artery disease (CAD) 86
What to eim inate 89
What to a dd 90
Diet in peripheral arterial disease (PAD) 92
Diet in hyperlipidaemia 93
Diet in heart failure 96

7. Diet in Diabetes Mellitus 98

Diet 98
Eat at regularly set times 102
Keep a food diary 102

8. Diet in Kidney Disease 103

Diet in acute glomerulonephritis 103
Diet in nephrotic syndrome 104
Diet in acute kidney injury (AKI) 105
Diet in chronic kidney disease (CKD) 107
Haemodialysis (HD) and peritoneal analysis (PD)
patient 108
Diet in renal stone disease 108

9. Diet in Liver Disease 112

Diet in acute viral hepatitis 112
Diet in hepatic encephalopathy 113
Diet in cirrhosis of liver 114
Diet in cirrhotic ascites 115
Diet in fatty liver disease 116
Diet in cholecystitis and cholelithiasis 117
Diet in pancreatitis 118
Acute pancreatitis 118
Diet in pancreatic carcinom a 119
11 xii Food Nutrition and Dietary M anagem ent of Disease

10. Diet in Gastrointestinal Disease 121

Diet in gastroesophageal reflux disease 121
Diet in peptic ulcer disease (PUD) 123
Diet in coeliac disease 124
Diet in irritable bowel syndrome 125
Diet in diarrhoea 126
Diet in lactose intolerance 128
Diet in constipation 129
Diet in inflammatory bowel disease 130
Diet in diverticular disease 131
Diet in adverse food reaction 132

11. Diet in Respiratory System Disease 134

Diet in asthma 134
Diet in chronic obstructive pulm onaiy disease 136
Diet in bronchiectasis 136
Diet in tuberculosis (TB) 137

12. Diet in Blood Diseases 138

Diet in iron deficiency anaem ia 138
Diet in megaloblastic anaem ia 139
13. Diet in Rheumatology and Bone Diseases 141
Diet in osteoarthritis (OA) 141
Diet in gout 142
Diet in osteom alacia 143
Diet in osteoporosis 143

14. Diet in Endocrine Diseases 146

Diet in iodine deficiency diseases 146
15. Diet in Neurological Diseases 148
Diet in stroke/cerebrovascular accidents (CVA) 148
Diet in multiple sclerosis (MS) 154
Diet in motor neuron disease 156
Diet in Parkinson's disease (PD) 157

Appendix 159
Index 161
 Plate 1
GRAINS
Cereals

Wheat Rice Maize

Legumes

Beans Peas Lentils

Green beans Green peas Lima beans

Pulses
Chapter

Diet in Liver Disease

------------------- DIET IN ACUTE VIRAL HEPATITIS -------------------

Acute viral hepatitis (AVH) is an acute inflammation of the liver
caused by a virus, usually hepatitis A, B, D and E. Hepatitis A
and E virus spread by faeco-oral route and hepatitis B and D
are transmitted by parental, sexual and vertical route.
Patient initially suffers from prodromal features like malaise,
fever, headache, anorexia, nausea, distaste and vomiting. These
are followed by jaundice when nausea and vomiting improve.
M ost of the patients recover spontaneously.
As patients with acute viral hepatitis are very ill, have a poor
appetite, anorexia and vomiting, eat very little during illness
and there are several myths regarding diet; dietary measures
are very important for management of acute viral hepatitis.
Treatment focuses on bed rest and nutrition therapy to
support the healing and regeneration of the liver tissue.

^Dietary M anagem ent )

□ No dietary restriction should be imposed upon and patients
should be encouraged to eat what they can.
□ Consume a diet that is adequate in energy, macronutrients,
and micronutrients.
□ Consume 4 to 6 small meals per day.
□ Give importance on his or her likes and dislikes and plan
diet to encourage optimal food intake.

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 Diet in Liver Disease 113 ; j

□ Carbohydrates: Glucose restores protective glycogen

reserves in the liver and meet the energy demands of the
disease process and spares protein for tissue regeneration.
The diet should supply about half of the total kilocalories as
carbohydrates.
□ Protein: Protein is essential for regenerating new liver cells.
The diet should supply 1.0 to 1.2 g/kg of body weight of
high-quality protein daily if no complications are present.
□ Fat: Fat restriction is not necessary as was used in the past.
□ Sodium: Sodium is limited to 2000 mg per day to avoid
fluid retention.
□ Avoid substances that are hepatotoxic (e.g. alcohol, drugs,
toxins)
□ Most patients can tolerate oral feedings, but parenteral
feedings may be warranted if there is intractable vomiting.

— ------------ DIET IN HEPATIC ENCEPHALOPATHY ------------------

Hepatic encephalopathy is a neuropsychiatric syndrome

caused by liver disease. Hepatic encephalopathy is thought to be
due to a disturbance of brain function provoked by circulating
neurotoxins that are normally metabolised by the liver. Hepatic
encephalopathy usually occurs in decompensated cirrhosis
but also occurs in acute hepatic failure. This results in apathy,
confusion, inappropriate behaviour, altered consciousness,
and eventually coma. SELLULAR M e d ic in e
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Dietary protein restriction is rarely needed as was believed
previously that nitrogenous compounds of dietary protein
were implicated in the pathogenesis of hepatic encephalopathy
and is no longer recommended as first-line treatment because
it is unpalatable and can lead to a worsening nutritional state
in already malnourished patients.
The dietary recommendations are:
□ Sufficient protein to meet the estimated requirements
should be provided, i.e. 1.0-1.5 g/kg/d.
□ Vegetable and dairy protein are better tolerated than
protein from meat and fish.
 Diet in Neurological Diseases 157

♦ Life-expectancy >3 months

♦ Able to provide consent and manage feeds (or career
who can).
□ Suitably prepared fruits and vegetables should be
included in diet to provide adequate antioxidants.

Overweight: Moderate energy restriction that does not compro­

mise other nutrient intakes should be advised.

------------------ DIET IN PARKINSON’S DISEASE -------------------

Parkinson's disease (PD) is a chronic progressive neurodegene-
rative disease. The cause of PD is unknown. It occurs in elderly
patients, usually above age 65 years and progress relentlessly.
PD has an annual incidence of about 18/100 000 in the UK and
a prevalence of about 180/100 000.
PD develops due depletion of the pigmented dopaminergic
neurons in the substantia nigra and the presence of a-synuclein
in nigral cells (Lewy bodies).
PD is characterised by hypokinesia, rigidity, tremor and
loss of postural reflexes. Depression is a common psychiatric
symptom developed in PD.
All these symptoms can contribute to a poor food intake
and impair nutritional status, particularly in the later stages.
Other symptoms which may develop in PD patients due to
disease itself and its medication are constipation, dry mouth,
weight loss and swallowing difficulties.
Free radicals (antioxidants) are implicated in the neurological
damage of PD.
Amino acid in dietary proteins interferes with absorption
from GI tract and transfer to brain of PD medication
Levodopa and may be responsible for fluctuation of disease
symptoms.
Diet may play a role in the management of PD patients in
the following ways:
□ Help to manage symptoms
□ Help supply of levodopa by changing meal pattern
□ Supply adequate antioxidants.
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158 Food Nutrition and Dietary Management of Disease

^Dietary M anagem ent )

□ Management of symptoms
+ Constipation: Constipation may be alleviated by increased
fiber intake and drinking sufficient fluid, >2 L/d.
Fiber can be provided for patients requiring a soft/puree
diet as:
♦ Oat porridge
♦ Pureed or mashed fruits like bananas, prunes, and
dates
♦ Thickened lentil-type soups.
♦ Dry mouth (usually a side-effect of medication): M oist
meals served with appropriate sauce may help. Sharp
flavor, e.g. lemon and grapefruit, may stimulate saliva.
Non-sugar chewing gum may help.
♦ Weight loss: Nutritional assessment should be done and
advise to correct nutritional deficit by adequate diet.
+ Swallowing difficulties: Swallowing difficulties are rela­
tively mild and do not impair food intake until late
stage. Swallowing should be evaluated by a speech
and language therapist and dietitian and advise an
appropriately textured diet.
□ Change of meal pattern: Patients experiencing fluctuating
symptoms may benefit from changing the timing of their
protein intake by:
♦ Avoiding taking levodopa with high protein meals
♦ Eating a greater proportion of dietary protein in the
evening or night.
□ Antioxidants: Though no convincing evidence has emerged
from studies for dietary recommendations; however, a well-
balanced diet including 5 portions of fruit and vegetables
per day will help provide a good baseline intake of anti­
oxidants.

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 Plate 2
GRAINS

Nuts

Coconut Almond Pistachio

Oil seeds

Sunflower Rapeseed

Soya bean
 Plate 3
VEGETABLES

Green leafy vegetables

Cabbage Spinach Lettuce

Carrots Beetroots Turnip

Tubers
A

(
Potato Sweet potato Onion Garlic