DIET THEPY

TOPIC I: INTRODUCTION TO DIET THERAPY

a) Diet – A diet is a set of food eaten in order to achieve a desired goal. It is
provided via the oral route. Examples of desired goals(goals of diet therapy) are
 To maintain nutritional status
 To correct nutritional deficiencies e.g. high iron diet in anemia
 To relieve pain
 To give rest to the body or an affected organ by giving a soft diet, low
protein diet (to give rest to the liver) etc.
 To prevent or delay complications of a disorder
 To restore good health by managing and treating disease/disorders
 To help adjust the body’s ability to use one or more nutrients
b) Therapy-This refers to the treatment of a disease, injury or maintaining the
nutrition status with e.g. a diet, medicine etc.
c) Diet therapy-This is refers to the use of a diet to treat a disease or injury, relieve
pain, correct a condition or to maintain nutritional status of a patient. A
therapeutic diet is used. The therapeutic diet is planned on the basis of a normal
diet, and it is used to either supplement medical and surgical care, or as the
specific treatment for the disease.
d) Therapeutic diets-Therapeutic diet is a diet prescribed to a person with a disease or a
disorder such as injury, infection, nutritional deficiency e.g. Liver cirrhosis, burns,
diabetes etc to hasten recovery. A therapeutic diet controls the intake of certain foods or
nutrients. It is usually a modification of a regular diet (normal diet)
e) Normal diet-This is a regular diet either vegetarian or non-vegetarian well balanced and
adequate for nutrition. It is the foundation of all diets and is designed to provide adequate
nutrition for optimal nutrition and health status in persons who do not require medical
nutrition therapy. This diet is used when there is no required diet modification or
restrictions. Individual requirements for specific nutrients may vary based on age, sex,
height, weight, activity level and different physiological status.
f) Modified diet-This is a normal die qualitatively or quantitatively altered as per
patients/clients special needs
g) Disease- Caused by agent which transit the bacteria or virus to the host
h) Disorder-It is a dysfunction of some organs of the body or it is the absence of a
specific nutrients in the body/over or low presence of nutrients/nutrient
i) Food – A complex mixture of many different chemical components consumed to
provide nutritional support for the body or it refers to any liquid or solid substance
consumed for nourishment of the body.

pg. 1
 j) Nutrients-These are substances obtained from food and are used in the body to
provide energy and structural materials and to regulate growth, maintenance and
repair of body tissue. They include carbohydrates, protein, vitamins, minerals,
fats and water.
k) Balanced diet – It is a food that gives your body the nutrient to function correctly
and involves eating different amount of food in the right amount i.e. CHO,
proteins, minerals, fats, vitamins and H2O.
l) Care Plan: A Plan created by the health care team to design/developed,
implement and achieve treatment goals for a patient
m) Nutrition Care Plan: A formal statement of the nutrition goals and interventions
prescribed for an individual using the data obtained from a nutrition assessment.
The plan should include statements of nutrition goals and monitoring/evaluation
parameters, the most appropriate route of administration of nutrition therapy,
method of nutrition access, anticipated duration of therapy, and training and
counseling goals and methods.
n) Malnutrition: Refers to any condition caused by an excess or deficient of energy
or nutrient intake or by an imbalance of nutrients. It is as a result of an imbalance
between dietary intake and requirements. There are single nutrient deficiencies,
and imbalances of two or more required nutrients.
o) Nutrition Therapy: A component of medical treatment that includes oral, enteral,
and parenteral nutrition.
p) Nutrition Support Therapy: Parenteral and/or enteral nutrition.

P) Nutrition Screening: A process of identifying an individual who may be

malnourished or at risk for malnutrition. It determines if nutrition assessment is indicated.
q) Nutrition Assessment: It is a detailed investigation to identify and quantify
specific nutritional problems or it is a systematic process of obtaining, verifying,
and interpreting data in order to make decisions about the nature and cause of a
nutrition related problems. It uses a combination of the following: medical,
nutrition, and medication histories; physical examination; anthropometric
measurements; and laboratory data
r) Nutrition Support Process: The assessment, diagnosis, ordering, preparation,
distribution, administration, and monitoring of nutrition support therapy.
s) Nutritional status-This is the condition of the body as a result of the
food/nutrients we take, absorb and use. It is also influenced by disease-related
factors.

NUTRITION CARE

pg. 2
 It is a systematic approach of providing high quality nutrition care. It includes
nutrition assessment, nutrition diagnosis, Interventions, monitoring, and
evaluation designed to facilitate appropriate nutrient intake.
Nutritional Assessment
Elements of nutritional Assessment
The data for a nutritional assessment falls into four categories:-
1. Anthropometric e.g. weight, height, BMI, Waist/hip ratio, MUAC,
skinfold thickness, measurements of the head
2. Biochemical
3. Clinical observations e.g. Condition of the skin, hair, tongue, eyes, ,
neck(glands) ETC weight, posture, gums,
4. Dietary intake - Diet history( number of meals eaten per day, appetite,
food dislikes, food frequency, food record or diary, 24 hour recall)
Nutrition Diagnosis -It is identification and labeling an actual occurrence, risk of, or
potential for developing a nutrition problem OR It is the establishment of a problem, its
etiology, its signs and symptoms
Nutrition intervention-It is a specific set of activities used to address the problem
Nutrition monitoring and evaluation-Monitoring (Refers to the review and
measurement of the patient/ client status at preplanned follow up point with regard to the
nutrition diagnosis, intervention goals and outcomes. Evaluation (It is the systematic
comparison of current findings with previous status, intervention goals or reference
standards

TOPIC 11: MEDICAL TERMINOLOGIES USED IN DIET THERAPY

Most medical terms are derived from Greek or Latin. Very few are derived from modern
language.
Some terms are composed of elements combined from more than one language. By
learning to analyze the component parts of words i.e. the root words, prefixes and
suffixes, it is possible to simplify learning , promote understanding of reading materials
and increase the ability to communicate e. g the word tonsillitis refers to the
inflammation (-itis )of the tonsils
A vowel “a’” “i” or “o” may be inserted in combined forms for easier pronunciation,
cardio, Gastro intestinal, lipolysis
ROOT WORDS
The root word of a medical term indicate the organ or the body part that is modified by
the prefix and suffix. A vowel a, i or o may be inserted in combined form for easier
pronunciation

pg. 3
Examples of root words particularly used in nutrition care include
Cardi- Heart
Enter – Intestine
Gastr – Stomach
Hemo-Blood
Hepat-Liver
Nephr-kidney
Osteo- Bone
SUFFIX AND COMPOUNDING WORDS
These are prepositions and adverbs added to the root word to modify their meaning.
Alternatively, adjectives or nouns are used as suffix to form compound words. Suffix
(added in front of the root words) and suffix may indicate
(i) Procedure
(ii) Diagnosis
(iii) A symptom

(i) Suffix indicating symptoms

Suffix Definition Examples

-lysis Breakdown Lipolysis(breakdown of fats)
-penia Decrease Leukopenia(decrease of
white blood cells)
-algia Pain Myalgia(pain in the muscles)
-spasm Involuntary contraction Cardiospasm(painful and
involuntary contraction of
the muscles)
-oid Resembling Carcinoid(tumour)
-genic Originate Cardiogenic(originate from
the heart)
-osis Increase Leukocytosis(increase of
white blood cells due to
infections)

(ii) Procedure suffixes

Suffix Definition Examples

-tomy Incision Lithotomy(surgical removal of
of calculus-stone, from

pg. 4
 kidney, bladder)
-stomy Opening Ileostomy(Surgical procedure
in the ilium through the
abdominal wall to act as anus)
-ectomy Removal of Appendicectomy(surgical
removal of the aapendix)
-scopy Examination of Gastroscopy(examination of
the stomach by means of
gastroscope)

(iii) Diagnostic suffix

Suffix Definition Examples

-it is Inflammation of Appendicitis
-oma Tumour of Hepatoma(tumour of the liver)
-osis Condition Nephrosis(condition or
syndrome of the liver)
-pathy Disease Cardiopathy(diseases of the
heart)
-megaly Enlargement of Cadiomegaly(enlargement of
the heart)
-iasis Presence of Lithiasias(presence of stones in
the internal organs)
-ectasis Dilation of Bronchiectasis(dilation of the
bronchial tubes)

PREFIXES
They precede root words to modify their meaning
Prefix Definition Examples
Dys- Difficult, painful Dyspnea(pain in the GIT)
Endo- Within Endocardium(membrane that
lines the cavities of the heart)
Hemi, semi- Half Hemiplegic(paralysis on the
one side of the body)
Hyper- Above or excessive Hyperglycemia high blood
sugar in the blood, above the
normal), Hypertension
Hypo- Beneath, below, deficient Hypoglycemia(low blood
sugar in the blood, below the
normal)
Para- Beside, around, near , Parathyroid (the endocrine
abnormal glands-4 in number that are

pg. 5
 located around the neck,
behind the thyroid. They
regulate blood calcium levels
Peri- Around Perinatal(occurring during the
period around birth), 5 month
before and 1 month after

pg. 6
TOPIC: MEDICAL RECORDS

MEDICAL RECORDS
INTRODUCTION

 The terms medical record and health record are used somewhat interchangeably
to describe the systematic documentation of patient's medical history and care in
the hospital
 Doctors, nurses and other health care professionals write up medical/health
records so that previous medical information is available when the patient returns
to the health care facility. This is vital for their continuing care. The
medical/health record must therefore be available.
 This is the job of the medical record worker. They keep record of all the patients
who are in or have been in the hospital. They also ensure forms are available for
new patients.
 The medical record/ health record is a record or a chart that contains the patient’s
medical history, past and present illness, history of the illness, progress notes,
diagnoses, x-rays, therapies and treatments by a particular physician, nurse,
dentist, nutritionist etc. They are filled out on the first visit of the patient and
then updated as necessary
 They also include the “notes” that the patient moves with to specialists, labs,
pharmacies etc.
The main uses of the medical records/purpose/Importance of medical records

 To document the course of the patient's illness and treatment;

 To track the patient’s medical history and identify problems or patterns that may
help determine the course of health care
 To communicate between attending doctors and other health care professionals
providing care to the patient; for communication with external health care
providers, and statutory and regulatory bodies
 For the continuing care of the patient: It allows other health care providers to
access quickly and understand the patient’s past and current health status.
 To enable physicians (and other health care providers) to provide quality health
care to their patients; facilitating patient safety improvements
 For research ((subject to ethics committee approval, as required)) of specific
diseases and treatment;

pg. 7
  Investigation of complaints/ Evidence of care: The record may become an
important piece of evidence in protecting the legal interests of the patient / client,
health care personnel or other personnel.
 Medical records are also legal documents and may provide significant evidence in
regulatory, civil, criminal, or administrative matters when the patient care
provided by a physician is questioned.
 The collection of health statistics
 Financial reimbursement(compensation paid to somebody for damages or losses
money already spent

Types of medical records based on the type of storage

1. Paper-based medical records

2. Electronic medical records/ Computer-based medical records
3. Hybrid record (where health care record exist in both paper and computer records)
In Kenya many health care facilities use hybrid medical records (where health care record
exist in both paper and computer records. It is not fully electronical as the patient’s
information cannot be accessed in all the hospital in Kenya, a patient has to carry his
medical report from one hospital to another hospital e.g. when going for a referral, for
that referral hospital to see the progress of his treatment.

Most developed countries use electronic medical records (a patient can move from one
hospital to another and find all his medical information in that hospital. He does not need
to carry e.g. any x-ray report, a card showing his medical history, medications, or referral
note. The doctor in the new hospital will be able to log in and see the patients past
medical history, vital signs, progress notes, diagnoses, medications, immunization dates,
allergies, lab data and imaging reports. Electronic medical records is the digital version of
the patient’s chart/information.

Paper medical records is where paper is used to record the patients information and files
are used for each and every patient in the ward

Advantages of electronic medical records

 Better data tracking over time-it is fast and accurate

 Patient information is clearer, no more illegible scribbles
 Improved information access/delivery makes prescribing medication and
therapies safer and more reliable-ensures that the inform, results are not
duplicated nor tampered with
 Better health care as the information walks with patient to specialists, nursing
home e.tc.
 You can talk in cyberspace with your patient

pg. 8
  Patient support-allows you to engage your patients by allowing them to receive
educational materials and allows the patient to engage you
 More than one person can use the record at a time.
 Information can be accessed in a variety of physical locations.
 Records can often be accessed from another city or state.
 Complete patient information even in emergency situations.
Disadvantages

 They are more expensive to implement initially as the providers must invest in the
proper hardware, software, training and support
 Unless properly built, the system may malfunction and destroy all the information
Disadvantages of Paper-Based Medical Records

 Only one person can use the record at a time, unless multiple people are
crowding around the same record.`
 Items can be easily lost or misfiled or tear out or can slip out of the record if
not securely fastened.
 The record itself can be misplaced or be in a different area of the facility when
needed
 The medical condition of a patient/patient’s information cannot be accessed in
emergency cases/situations as the record may not be with the patient
 It cannot be used in several institutions(hospitals) at the same time

Types of medical records based on the organization/recording of the Medical

Record

1. Source-oriented medical records

2. Problem- oriented medical records
Source oriented medical records (SOMR).

 It is a method of recording the medical forms in which each health care team( a
doctor, a nurse, a pharmacist, a nutritionist, lab technologist, physiotherapist etc.)
has his/her separate part in the form where he records his/her daily assessment,
progress notes and treatment of the patient. OR
 It is a method of recording the medical forms in which each health care team( a
doctor, a nurse, a pharmacist, a nutritionist, lab technologist, physiotherapist etc.)
has his/her separate form where he records his/her daily assessment, progress
notes and treatment of the patient.
 The forms are then filed together and kept for future reference
 Separate sections are established for laboratory reports, x-ray films, radiology
reports and so on
 It is a traditional method of recording
Advantages

pg. 9
  It allows more room for use by more health care professionals including the
nutritionist in the health care
 Each department can easily find and chart pertinent data
 It is advantageous for filling a report from respective department in an orderly
fashion. It also saves time when filling these reports

Disadvantages
Fragmented-making it hard to track patients problems chronologically when one wants to
follow up on the treatment process of the patient

Problem oriented medical records (POMR)

 Organized around a patients problems rather than around sources of information

i.e. all the care team (a doctor, a nurse, a pharmacist, a nutritionist, lab
technologist, physiotherapist etc.) write their daily assessments or progress notes
and treatment of the patient on the same form (there is no separate forms for each
health care team.
 A number is a signed to each problem
 Most health care facilities currently use this format
Advantages of problem oriented medical records (POMR)

 Entire health care team works together in identifying a master list of patient
problems and contributes collaboratively to the plan of care
N/B. Formatting; Progress notes are written in paragraph form

Components of POMR/Major parts of the POMR

 Defined database
 Problem list
 Care plan/ treatment plan
 Progress notes
Example of POMR

pg. 10
.

Components/sections of the medical report

Data base.it includes

 Patient information form/ Personal identification/Demographics. It is filled

out on the first visit of the patient and it is then updated as necessary. It provides
data that relates to the patient e.g. name of the patient, gender, date of birth,
marital status, date of birth, place of birth, patient’s permanent address, and
medical record number;
 Medical history (Hx)-Document describing past and current history of all medial
conditions experienced by the patient e.g. diagnoses, medical care, family history,
surgical history, nutrition history and nutrition assessment. It tells the medical
personnel a great deal about your symptoms
 Clinical data on the patient whether admitted to the hospital or treated as an
outpatient or an emergency patient.
 Consultation reports. Documentation given by specialists whom the physician
has asked to evaluate the patient
 Laboratory reports. Provides the results of all diagnostic and laboratory tests
performed on the patient

pg. 11
  Consent form. Signed document or legal guardian giving permission for
treatment e.g. to perform surgery. It also includes a signed consent for treatment
by appointed doctors and authorization for the release of information; Consent for
treatment is often on the back of the Front Sheet and must be signed by the patient
at the time of admission. There are two parts to this form. The first half of the
form is a general consent for treatment and the bottom half is consent to release
information to authorized persons;
 Discharge summery. Outline summary of the patients care, including date of
admission, diagnosis, treatment, follow -ups plans and date of discharge
Problem list

 Based on the data base, a master problem list is established by the physician and
is kept at the front of the patient’s chart
Care plan/ treatment plan

 For each problem identified, an initial plan is developed. The plan may include
obtaining more information for diagnosis, management, patient education and
treatment (physical examination, assessment, plan and treatment. It is written by
the health care professionals
 The plans are written by the physician in standardized format containing the
following elements known by the acronym SOAP
Formatting (SOAP format)
o Progress notes/care plan for the treatment of the patients is written by the
physician in a standardized format known as the “SOAP
format”(S=subjective-chief complainant i.e. the information on present
illness, how he fills, and other symptoms are recorded; O=objective-
information on physical examination, lab tests, x-ray report and any other
reports from the health care team is recorded; A=assessment-
diagnosis(interpretation of the problem is done and recorded); P=plan-
treatment or information on how to manage the problem is recorded. e.g in
planning for nutritional care, goals and objectives must be established )

Some Important Points about Forms in the Medical Record

 Forms should all be the same size, usually A4.

 The patient's name and medical record number, and the name of the form should
be in the same place on EVERY form.
 Only official forms approved by the administration or Medical Record Committee
(if there is one) should be included in the medical record.
The following is a sample medical record form. Sections A, B, C, D and E of the sample
form (see below) remain the same on all forms. Section F is different for every form, as it
is where the content of each form is written

B Top margin 1 cm

pg. 12
A

C Name & logo of hospital Patient D Medical Record Number. U

Names Ward:
MAR Nam
GIN Other patient details e of

F form

Sections A, B, C, D and E remain the same for all forms. 2 cm

Content of each different form recorded in this section.

2cm

pg. 13
 i. Clip or Fastener
Forms should be held in the medical record either by a clip or fastener. Staples should
NOT be used as they tend to rust and additional forms cannot be easily added.

It is best to use plastic rather than metal clips. Metal clips can cut fingers or rust.

ii. Medical Record Folder

All medical record forms should be kept in a medical record folder. This should be a
manila folder and, if possible, stronger cardboard folders should be purchased. Patients
may obtain copies upon request
Sample medical record folder:

Number tab

12-34-56

MR Number

Patient’s full name

Year of last attendance

2004

2005

2006

Etc.

0 0

Spine

↑ 0---Clip hole---
0

pg. 14
The following should be written on the medical record folder:

 patient's name;
 patient's medical record number; and
 Year of last attendance.

Remember: MEDICAL INFORMATION SHOULD NOT BE

RECORDED ON THE FOLDER.

Privacy and confidentiality

All information in a patient / client’s health care record is confidential and subject to
prevailing privacy laws and policies. Health care records contain health information
which is protected under legislation.

Security and Storage

Medical records must be stored in a safe and secure environment to ensure physical and
logical integrity and confidentiality. Health care providers must develop records
management protocols to regulate who may gain access to records and what they may do
according to their role, responsibilities, and the authority they have.

TOPIC: DIET MODIFICATION

MODIFIED DIETS
MORDIFICATION OF DIETS
Introduction: Modified diets are diets that have been qualitatively or quantitatively
altered as per patient’s special needs and in line with general principals of meal planning.
i.e. normal diet may be modified and become a specific therapeutic diet

Factors that may determine dietary modification

a. Disease symptoms
b. Severity of the symptom or disease (Condition of the patient)
c. Nutritional status of the patient
d. Metabolic changes involved

pg. 15
 e. Physiological state
THERAPEUTIC MODIFICATION OF NORMAL DIET
Modification can be done in the following ways

 Modification in consistency (to provide change in consistency) e.g. fluid and soft
diets
 Modification in fibre content e.g. low fibre or high fibre
 Modification in energy e.g. high (increase) or low (decrease) calorie diet

 Modification in the content of one or more nutrients

 Modification in flavor (foods bland in flavor)

 Modification by including or excluding specific foods

 Modify the intervals of feeding e.g. frequent feeding

 Modify the mode of feeding e.g. Parenteral feeding and enteral feeding

1. MODIFICATION IN/BY CONSISTENCY

LIQUID DIETS
Liquid diets are commonly ordered for patients with conditions requiring nourishment
that is easily digested and consumed or that has minimal residue.
The two varieties of oral liquid diets are:
f. Clear liquid diet
g. Full liquid diet
CLEAR LIQUID DIET
Purpose
This is a diet modified to provide oral fluids to prevent dehydration, provide small
amount of electrolytes, relieve thirst and provide a small amount of energy in a form that
requires minimal digestion and stimulation of the gastrointestinal tract.

This diet is served at frequent intervals to supply the tissue with fluid and relieve thirst.

It is an inadequate diet composed chiefly of water and carbohydrates; therefore it should

be used for a very short time (It is indicated for short term use -24hrs to 48hrs).
Nutritionally depleted patients should receive additional nutritional support through use
of nutritionally complete minimal residue supplements or parenteral nutrition.

pg. 16
NB: Additional modifications may be necessary when used in some clinical
conditions such as cardiac disease or prior to some tests. Indication and
characteristics for clear liquid diet

Diet Indications Characteristics of the diet

 E.g. Black tea, broth,  Used in Pre- and  Composed of water and
apple juice, coffee, Post-operation, carbohydrates.
strained fruit/ vegetable  As a transition from  Clear liquid at room
juices, carbonated intravenous feeding temperature
beverages etc. to a full liquid diet,  Leaves minimal amount
 Foods to be avoided  When other liquids of residue in the
include milk and milk and solid foods are Gastrointestinal (GI)
products not tolerated, tract.
 During bowel  Provides approximately
preparation prior to 400-500kcals, 5-10g
diagnostic proteins, 100-120g CHO
visualization or and no fat.
surgery  Should be of low
 In the initial concentration
recovery phase after  Milk and milk drinks are
abdominal surgery omitted
 Following acute  Improve energy level by
vomiting or diarrhea addition of sugar
 Are nutritionally
inadequate in all nutrients

N/B. INDICATIONS -MEANS CONDITIONS THAT WILL ALLOW YOU TO ADVISE

SOMEONE TO USE THE DIET BECAUSE OF THE BENEFITS. INDICATIONS ALSO
MEANS THE OBJECTIVES OF GIVING THE DIET OR THE CONDITIONS WHERE
THE DIET IS USED
CONTRAINDICATIONS-MEANS CONDITIONS WHERE YOU WILL ADVISE A
PATIENT AGAISNT USING THE DIET

FULL LIQUID DIET

Purpose

pg. 17
The full liquid diet is an adequate diet designed to provide nourishment in liquid form
and facilitate digestion and optimal utilization of nutrients in acutely ill patients who are
unable to chew or swallow certain foods. The diet is often used as a transition between
the clear liquid diet and a soft regular diet. Patients with hypercholesterolemia full liquid
diet to be modified to have low fat by substituting high saturated fats with low fat dairy
products and polyunsaturated fats and oils. Increasing protein and caloric value of full
liquid diet becomes necessary when the diet is used for a period extending over 2-3
weeks. Table 24 below provides indications for and characteristics of full liquid diet.
Indications and characteristics of full liquid diet

Diet Indications Characteristics of the diet

 Soft desserts  For post-operative patients  Foods should be liquid at
from milk and  For acutely ill patients or room temperature
eggs, those with esophageal/GIT  Free from condiments and
 Pureed and disorders and cannot spices
strained soups, tolerate solid foods  Provides between 1500-
ice creams,  Following surgery of the 2000kcal/day
milk or yoghurt, face-neck area or dental or  Large percentage is milk
etc. jaw wiring based foods; lactose
intolerant individuals need
special consideration.
 The diet may be
inadequate in
micronutrients and fiber

Thick Liquid Diet (Blended or Semisolid Diet)

This diet is moderately low in cellulose and connective tissue to facilitate easy digestion.
Tender foods are used to prepare the diet. Most raw fruits and vegetables, coarse breads,
cereals, tough meats and nuts are eliminated. Fried and highly seasoned foods are
omitted.
Purpose of the diet
The blended liquid diet is designed to provide adequate calories, protein and fluid for the
patients who are unable to chew, swallow or digest solid foods. The diet prescription
should be individualized to meet medical condition and tolerance. Patients with wired
jaws may use a syringe, spoon, or straw to facilitate passage of liquid through openings in
the teeth, depending on the physician’s recommendation
Blended foods should be used immediately but can be refrigerated up to 48hrs or frozen
immediately after blending to prevent growth of harmful bacteria.

pg. 18
Indications and characteristics of thick liquid diet

Die Indications Characteristics of the diet

t
 After oral surgery or plastic  Fluids and food blended to a liquid form
surgery of the face or neck  Viscosity ranges from the thickness of
area with chewing or fruit juice to that of cream soup
swallowing dysfunctions  All liquids can be used to blend foods.
 For acutely ill patients and However, nutrient dense liquids with
those with oral, esophageal similar or little flavor are preferable. Use
or stomach disorders who are of broth, gravy, vegetable juices, cream
unable to tolerate solid foods soups, cheese and tomato sauces, milk
due to stricture or anatomical and fruit juices is recommended
irregularities  Multivitamin and mineral
 Those progressing from full supplementation is recommended
liquid to a general diet.
 Patients who are too weak to
tolerate a general diet.
 Those whose dentition is too
poor to handle foods in a
general diet.
 -Those for whom a light diet
has been indicated e.g. post
operative

SOFT OR LIGHT DIET

This is an adequate diet soft in consistency, easy to chew and is moderately low in
cellulose and connective tissue. This diet is designed to provide nutrients for patients
unable to physiologically tolerate a general diet in which mechanical ease in eating,
digestion or both are desired. The diet should be individualized based on the type of
illness or surgery and the patient’s appetite, chewing and swallowing ability and food
tolerance.
Indication and characteristics of soft diet

Diet Indications Characteristics of the diet

 Fruit juices or  Post operative patients  Moderately low in
cooked fruits,  Patients with mild gastro cellulose and
 Well-cooked intestinal problems connective tissues
cereals, strained if  Non-surgical patients  Tender foods
necessary; whose dentition is too  Fluids and solid foods
 Fresh spinach weak or whose dentition is may be lightly
 Amaranth inadequate to handle a seasoned
(Terere); general diet|(patients with  Food texture ranges
 Pumpkin leaves; few or no teeth) from smooth and

pg. 19
  Managu  For transition from thick creamy to moderately
 Strained peas; liquid to a general diet crispy
 Potatoes, baked,  Most raw fruits and
boiled, or mashed. vegetables, course
 Fats: butter, thin breads and cereals gas
cream. producing foods and
 Milk: plain, in tough meats are
scrambled egg, in eliminated
cream soups, in  Fried and highly
simple desserts. seasoned foods, strong
 Eggs: soft-cooked, smelling foods should
omelettes, custards. be omitted
Simple desserts;
custards, ice cream,
gelatine desserts,
 Cooked fruits or
cereal puddings
 Minced meat, soft
fish

2. MODIFICATION IN/BY FIBER CONTENT

Fiber is the portion of carbohydrates not capable of being digested by enzymes in the
human digestive tract, thus contributing to increased fecal output. There are two types of
fiber; soluble and insoluble fiber. Diseases affecting digestive system generally require
modification in fiber content. This can be high or low fiber diet.

FIBER RESTRICTED (LOW RESIDUE) DIET

This diet is composed of foods containing low amounts of fiber which leave relatively
little residue for formation of fecal matter. Residue is the dietary elements that are not
absorbed and the total post digestive luminal contents present following digestion. The
diet excludes certain raw fruits, raw vegetables, whole grains and nuts high in fiber and
meats high in connective tissue. The diet is modified to meet the clients caloric, protein,
fat as well as vitamins and minerals requirements.

Purpose of the diet

The fiber (low residue) restricted diet is designed to prevent blockage of an inflamed
gastrointestinal tract and reduce the frequency and volume of fecal output while
prolonging intestinal transit time.

pg. 20
Indications and characteristics for fiber restricted diet

Die Indications Characteristics of the diet

t
 Gastro-intestinal disorders colitis,  Low in complex
colostomy carbohydrates
 Inflammatory bowel disease, diarrhea,  Has refined cereals and
hemorrhoids, etc grains
 Acute phase of diverticulosis  Legumes, seeds and whole
 Ulcerative colitis in initial stage nuts should be omitted
 Partial intestinal obstruction
 Pre and post-operative periods of the large
bowels
 convalescents from surgery, trauma or
other illnesses before returning to the
regular diet
 post - perennial suturing

pg. 21
 HIGH FIBER DIET
This diet contains large amounts of fiber that cannot be digested. Fiber increases the
frequency and volume of stools while decreasing transit time through the gastro-intestinal
tract. This promotes frequent bowel movement and results in softer stools. The
recommended fiber intake for women aged 50 years and below is 21-25g/day and for
men aged 50 years and below is 30-38g/day. Men over 50 years should consume at least
30g/day while women above 50 years should consume 21g/day.

Purpose
The diet is designed to prevent constipation and slow development of hemorrhoids,
reduce colonic pressure and prevent segmentation. The diet also reduces serum
cholesterol levels by decreasing absorption of lipids, reduces transit time and can be used
to control- glucose absorption for diabetic patients and overweight clients. Dietary fiber
reduces the risk of cancer of the colon and rectum.
Indications and characteristics of high fiber diet

Die Indications Characteristics of the diet

t
 Gastro-intestinal disorders:  High in complex
 Diverticular disease: high carbohydrates
 Cardiovascular disease  Has less of refined cereals
(hypercholesterolemia):
 Cancer prevention:
 Diabetes mellitus:
 Weight reduction:

NB: Intake of excessive dietary fiber may bind and interfere with absorption of calcium,
copper, iron, magnesium, selenium and zinc. This results in their deficiency. Therefore,
excessive intake of dietary fiber is not recommended for children and malnourished
adults.
3. MODIFICATION IN ENERGY INTAKE

This may be high or low energy depending on the metabolic activity patterns and the
weight of a patient.

HIGH ENERGY DIET

High energy diet is recommended to provide an energy value above the total energy
requirement per day in order to provide for regeneration of glycogen stores and spare
protein for tissue regeneration. Energy dense foods are used to avoid complication of
bulky diet. For effective metabolism, an extra of 500kcal of the RDA is recommended
per day. If there is poor appetite small servings of highly reinforced foods should be

pg. 22
given. The diet may be modified in consistency and flavor according to specific needs.
Excessive amounts of low calorie foods, fried foods or others which may interfere with
appetite are avoided.

Indications and characteristics of high energy diet

Diet Indications Characteristics of the

diet
Energy dense foods  Hyperthyroidism  Increased kilocalorie
include butter, sugar,  wasting energy
honey and ghee which  Typhoid 35-40kcal/kg/day in
are added to the normal  Malaria adults
diet to increase energy  HIV/AIDS
content  All cases of prolonged
degenerative illnesses

CALORIE RESTRICTED DIET

These diets are prescribed for weight reduction. The recommended kilocalorie level is
20-25kcal/kg/day. The diet should comprise of complex carbohydrates and should
provide 50-60% of the total calories. Fats should provide <30% of the total calorie.
Purpose
To provide adequate nutrition, maintain desirable body weight, maintain normal glucose
and lipid levels and to prevent, delay and treat diabetic related complications.
Indications and characteristics of calorie restricted diets

Diet Indications Characteristics of the diet

 Vegetables,  Overweight and  The diet should provide20-
 Carbohydrates obesity 25kcal/kg Bodyweight/day
 Hypertension with  Complex carbohydrates
excess weight  High in dietary fiber
 Hyper lipidemia  Proteins should be within the
 Diabetes mellitus with DRI
excessive weight
 Gout
 Gall bladder diseases
preceding surgery

4. MODIFICATION IN THE CONTENT OF ONE OR MORE NUTRIENTS

There are four ways to modify the content of one or more nutrients as listed below:
 Moderate fat diet/fat restricted diet
 High protein, high calorie diet
 High or low protein diet

pg. 23
 Low sodium diet
 High carbohydrates

FAT RESTRICTED DIET

The diet is designed to restrict fat intake for patients who experience symptoms of
nutrient losses when high fat foods are eaten. A fat restricted diet limits the amount of fat
you can consume each day and may be prescribed conditions that make it difficult for the
body to digest fat. Provision of fat restricted diet will minimize the unpleasant side
effects of fat malabsorption such as diarrhea, gas and cramping.

Indications and characteristics of fat restricted diet

Die Indications Characteristics of the diet

t
 Gall bladder  The diet provides overall fat between
diseases 25-50g/kg/day
 Biliary tract and  This diet is tailored to provide <30% of total
lymphatic system calorie and < 10% saturated fat acids. Levels of
 Hepatic cirrhosis restriction are as follows:
(liver cirrhosis)  Mild restriction-25-30% of total calories
 Pancreatic  Moderate restriction-20-25% of total
insufficiency calories
 Malabsorption  Severe restriction-15-20% of total calories
syndromes  The base of the diet should be composed of
 Intestinal resections grains, vegetables and fruits
 Overweight and  Meat fish, poultry and eggs should be limited to
obesity 180g per day
 Cardiovascular
diseases (CVDs
 bloating, diarrhea,
steatorrhea

Adequacy
It is possible to meet nutrient requirements on this diet, but depending on how long you
follow it and how much fat you can digest a supplement may be recommended. Patients
with prolonged stearrhoea or diarrhea may develop vitamin or mineral deficiencies.
Vitamin A, D, E and K are fat soluble which means they need fats to be absorbed and this
requires advice from the nutritionist/dietitian or doctor.

HIGH PROTEIN-HIGH CALORIE DIET

This diet is tailored to provide higher amounts of calorie and protein than usual diet. It is
prescribed where tissue regeneration is required. Its purpose is to help heal wounds,

pg. 24
maintain or increase weight, promote growth, decrease respiratory complications, resist
or fight infections and support the immune system. For a high protein diet, adequate
energy from carbohydrates and fats must be supplied.
Purpose
The diet is designed to maintain a positive nitrogen balance, promote normal osmotic
pressure, promote body tissue repair, prevent excessive muscle atrophy in chronic disease
states and build or repair worn out tissues of severely malnourished individuals. This diet
can also be used to meet increased energy and protein demands during illness, during
certain periods like pregnancy and lactation. Table 32 below shows indication for and
characteristics of the diet.
Indications and characteristics of high protein-high calorie diet

Die Indications Characteristics of the diet

t
 Febrile conditions  The diet must provide adequate
 Cancer protein carbohydrates ratio of (2:1).
 Wounds  The diet should provide i.e.35-
 Burns 40kcal/kg body weight/day
 Tissue injuries and trauma 1.5-2.0g/kg body weight/day
 After surgery  Consist more of high biological value
 Acute and chronic fever e.g. TB, protein
Malaria and Typhoid.
 Certain physiological alteration
- pregnancy and
lactation/infancy

pg. 25
LOW PROTEIN DIET
A low protein diet is temporarily indicated/ prescribed to avoid breakdown of tissue
protein which can lead to undesirable levels of nitrogen constituents in the blood. It is
essential that the calorie intake from carbohydrates be sufficient to avoid excessive
breakdown of tissue protein. Low protein may range from (0.6g-0.8g/kg/day).
Indications and characteristics of low protein diet

Die Indications Characteristics of the diet

t
 Hepatic coma  Low biological value protein can be
 Acute and chronic renal used during this time.
failure  The amount can be reduced to 20-
 Liver cirrhosis 35gms per day.
 Acute and chronic
glomerulonephritis

pg. 26
pg. 27
pg. 28
pg. 29
pg. 30
pg. 31 by Osonga
LOW SODIUM DIET
Sodium is a mineral that naturally occurs in some foods. However it can also added to food in
form of salt to help preserve them and add flavor. Limit sodium intake to less than 3000mg per
day. RDI should be limited to 2400mg
3000mg (130mEq) -Eliminate or eat sparingly processed foods and beverages such as fast foods,
salad dressings, smoked and salted meats. Omit 2000mg (87mEq)-prepared foods high in sodium
do not allow salt in preparation of food or table.
1000 (45mEq) eliminate processed foods and prepared foods and beverages high in sodium.
Omit many frozen foods and fast foods. Limit milk and milk products to 16oz per day. Do not
allow any salt in food preparation or table use. This meal plan used in the inpatient setting for a
short term basis
500 (22mEq) omit processed or canned foods high in sodium. Omit vegetables containing high
amounts of natural sodium limit milk to 16 oz daily and meat to 5 oz daily and meat products.
Use low sodium bread and distilled water for cooking where available.
Allow up to ¼ tsp table salt in cooking or at the table
Purpose
The purpose of a low sodium diet is to aid control of blood pressure (BP) in salt sensitive people
and to promote the loss of excessive fluids in edema and assist and manage hypertension. Table
34 below shows the indications for and characteristics of low sodium diet
Indications and characteristics of low sodium diet

Diet Indications Characteristics of the diet

 Unprocessed  Impaired liver  A diet low in processed foods and beverages
foods and functions  Diet should be low in canned foods,
beverages  Cardiovascular margarine, cheeses, and salad dressings.
 Low sodium diseases
bread  Severe cardiac
failure
 Acute and chronic
renal diseases

5. MODIFICATION IN FLAVOR (FOODS BLAND IN FLAVOR)

BLAND DIET
This is a diet modified to avoid irritation of any kind to the alimentary tract. Such diets are
chemically, mechanically and thermally modified. In bland diet, strong spices, stimulants and
strongly flavored vegetables and fruits that irritates should be avoided. The food should be served
at room temperature.
6. MODIFICATION BY INCLUDING OR EXCLUDING SPECIFIC FOODS

pg. 32 by Osonga
EXCLUSION OF CERTAIN FOODS (ALLERGIES)
In allergic conditions certain specific foods to which the individual is extremely allergic should
be excluded from the diet. Some people are allergic to protein foods like milk, eggs, peanut, soya
and seafood e.g lactose free diet or gluten free diet in allergic conditions

Diet for renal conditions

The purpose of diet for renal cases is to control protein, potassium, sodium and fluid levels in the
body.
It is used in acute and chronic renal failure and in hemodialysis.
Foods allowed include high-biological proteins such as meat, fowl, fish, and cheese
Vegetable such as cabbage, cucumber, and peas are lowest in potassium and are so advocated.
Potassium is usually limited to 500 mg/day
Fluid intake is restricted to the daily volume plus 500 ml, which represents insensible water loss.
Foods avoided include bread, macaroni, noodles, spaghetti, avocados, kidney beans, potato chips,
raw fruit, yams, soybeans, nuts, gingerbread, apricots, bananas, grapefruit, oranges, coca-cola

7. MODIFY THE INTERVALS OF FEEDING E.G FREQUENT FEEDING

INCREASING FREQUENCY OF FEEDING

In some disease conditions patients may not be able to eat very large amounts of food at one
time. It may thus become essential to give smaller meals at frequent intervals as in the case of
fevers, diarrhea and ulcers. In such cases provide small but frequent meals at each interval.
8. MODIFY THE MODE OF FEEDING E.G. PARENTERAL FEEDING AND
ENTERAL FEEDING

TOPIC : DRUG – NUTRIENT INTERACTIONS

Definition of terms
a) Drug – A substance that is used as a medicine or narcotic.
b) Medicine – Something that treats, prevents or alleviates (provides relief from e.g. pain)
the symptom of a disease.
c) Narcotic – Drug taken for pleasure, numbness or reduce pain and extensive use can lead
to addiction.
d) Drug abuse – Excessive use of a drug.
e) Absorption - the process of movement of a drug from the site of administration into the
systemic circulation
f) Bioavailability - the degree to which a drug or other substance reaches the general
circulation and becomes available to the target organ or tissue
g) Drug-nutrient interaction - the result of the action between a drug and a nutrient that
would not happen with the nutrient or the drug alone or it refers to changes to a drug
caused by a nutrient, or changes to a nutrient as a result of the drug

pg. 33 by Osonga
Drug pathway in the body/Stages of how drugs pass into the body
 Drugs undergo five stages before it is excreted in the body; administration (Drugs can
be swallowed, inhaled, injected, applied through the skin, snorted or dunked. The drugs
taken orally then dissolves in the stomach), Absorption (the drug is absorbed by the
blood), distribution (it is carried through the blood stream to various body tissues and the
area that needs it. The body(the area that needs it) then reacts with the drug), metabolism
and detoxification(it is then broken down by the liver into harmless products after the
drug has had its effect), and excretion(the drug is primarily excreted through urine or
faces)

Functions of drugs
1. Prevents occurrence of a disease.
2. Treats a disease.
3. Alleviates or provides relief from pain.

Effects of food on drugs /Impacts of food on effectiveness of drugs

Just like foods, drugs or medicines also have ingredients. Some foods may interact with
ingredients of drugs preventing the drug from working properly by; Delaying or speeding up its
absorption into the body, Speeds up the absorption into the blood., Also speeds up the rate
of elimination in the body, thus, interfering with the effectiveness of the drug e.g. Acidic
foods can decrease the power of antibiotics such as penicillin. Alcohol also interferes with the
absorption of some drugs.

Examples of effects of food on drugs

i) Drug Aspirin is absorbed more slowly when taken with food. Vitamin C can alter
urinary PH and limit the excretion of aspirin.
ii) Foods that stimulate secretion of digestive juices increases absorption of some drugs
e.g. Griseofulvin. (an antibiotic)
iii) Some foods e.g. Candy can change the acidity of the GIT thereby causing the slow
acting asthma medication to dissolve too quickly.
iv) Alcohol produces prolonged hypoglycemic effects when taken with insulin and oral
hypoglycemic agents.
v) Foods rich in dopamine e.g. (Cheese, chicken, liver, red wine, bread etc) cause
hypertensive crisis when taken alongside certain anti-depressants and thus can result
into accidents.
vi) Pyridoxine in food, blocks the effects of levodopa used in the treatment of Parkinson
disease.

pg. 34 by Osonga
Effects of drugs on foods
Effect of drug on food intake:
1. Drugs that may stimulate one’s appetite;

Appetite may be stimulated by certain drugs resulting in an increase in nutrient intake due to
more food being taken/eaten. On the other hand, drugs may also cause a decrease in nutrient
intake thus drugs affect nutritional status.
The following drugs may stimulate appetite and result into weight gain;
a) Anti – histamines (antibiotics); treat cold or allergies.
b) Anti – anxiety drugs; Relieves tension.
c) Tricycle anti – depressants.
d) Insulin: Hypoglycemia that may lead to a coma or death can occur in a person with type 1
diabetes, if food is not taken immediately after an insulin injection. If excess food is consumed to
avoid or treat hypoglycemia, weight gain may occur.
d) Steroids.
2. Drugs that may depress one’s appetite;
a) Alcohol

It can lead to loss of appetite; reduce food intake and malnutrition due to effects of alcoholism
such as gastritis (inflammation of the lining of the stomach), cirrhosis etc.
b) Amphetamines (depress appetite)

Effects of drugs on change of smell and taste

Change of smell or taste may stop people from eating or overeating and this affects their
nutritional status e.g. Antibiotics such as ampicillin, tetracycline etc., flagyl that may cause
metallic taste in the mouth. Anesthetics such as cocaine. Anti-coagulants, Anti-histamines,
Anti-hypertensive agents, toothpaste ingredients – sodium laurym sulphate.
Drugs that may lead to Gastro Intestinal effects
Drugs such as non – steroidal anti-inflammatory drugs (NSAIDS) e.g. Aspirin, Ibuprofen,
Antihistamines. {They cause stomach irritation. Sometimes the irritation is so severe and can
result into serious gastric bleeding.
Effect of drugs on nutrient / food absorption
A number of drugs can increase nutrient absorption thus benefit nutritional status while others
can decrease nutrient absorption in the body e.g.

pg. 35 by Osonga
 Anti-acids can interfere with iron absorption in the body.
Alcohol abuse can result into malsabsorption of thiamine and folic acid causing anemia.
Some anti-acids bind phosphorus thus hindering its absorption.
Chemotherapy drugs can damage mucosal cells thereby affecting nutrient absorption.
Neomycin may reduce lipase activity hence interfering with fat digestion.
Some drugs may also interfere or result into mineral depletion e.g.
Diuretics – taken to increase amount of water and aslant secreted from the body through
urine. Alcohol – may result to loss of potassium, magnesium and zinc.
Anti-acids – may result to phosphate deficiency, muscle weakness, convulsions and
calcification.
Other may also result into vitamin deficiency e.g.
Oral contraceptives that may result into loss of foliate, riboflavin, vitamin C and B12.
Some cancer drugs may also result into foliate deficiency.
Effect of drugs on nutrient excretions e.g.
Diuretics may result into increased excretion of sodium and potassium.
Aspirin may result into increased excretion of plasma protein carrier hence affecting
excretion of the protein.

TOPIC: DIET PLANNING

THERAPEUTIC DIETS
Therapeutic diet is a diet prescribed to a person with a disease or a disorder such as
injury, infection, nutritional deficiency, liver cirrhosis, diabetes etc to hasten
recovery. A therapeutic diet controls the intake of certain foods or nutrients. It is
part of the treatment of a medical condition and are normally prescribed by a
physician and planned by a dietician. It is usually a modification of a regular diet.
It is modified or tailored to fit the nutrition needs of a particular person. .
Therapeutic diets can be grouped into two types namely:

a) Normal diet

b) Modified diet

NORMAL DIET

This is a regular diet either vegetarian or non-vegetarian well balanced and

pg. 36 by Osonga
adequate for nutrition. It is the foundation of all diets and is designed to provide
adequate nutrition for optimal nutrition and health status in persons who do not
require medical nutrition therapy. This diet is used when there is no required diet
modification or restrictions. Individual requirements for specific nutrients may vary
based on age, sex, height, weight, activity level and different physiological status.

A normal diet consists of three (3) main meals and may include various snacks
depending on individual needs. In planning the meal, there are six principles which
should be considered.

Principles in meal planning

Adequacy

An adequate diet should provide enough energy and enough nutrients to meet the
needs of healthy people. For example, a person whose diet fails to provide enough
iron-rich foods may develop the symptoms of iron deficiency anemia.

Balance of foods and nutrients in the diet

This means not over consuming any one food. The art of balance involves the use
of enough but not too much or too little of each type of the seven food groups for
example use some meat or meat alternatives for iron, use some milk or milk
products for calcium and save some space for other foods. The concept of balance
encompasses proportionality both between and among the groups.

Energy control/density

This is the amount of energy in kilocalories in a food compared with its weight.
Examples of energy dense foods are nuts, cookies, and fried foods. Low energy
density foods include fruits, vegetables and any food that incorporates a lot of
water during cooking. They contribute to satiety without giving much calories.
This principle involves the management of food energy intake.

Nutrient density

This means eating foods that deliver the most nutrients for the least energy.

pg. 37 by Osonga
Nutrient density is a relative ratio obtained by dividing a food's contribution to the
needs for a nutrient by its contribution to calorie needs. This is assessed by
comparing the nutrient content of a food with the amount of calories it provides. A
food is nutrient dense if it provides a large amount of nutrient for a relatively small
amount of calories.

Moderation.

This mainly refers to portion size. In planning the diets, the goal should be to
moderate rather than eliminate intake of some foods. Foods rich in fats and sugar
should also be eaten in moderation they provide few nutrients with excess energy

Variety

This means choosing a number of different foods within any given food group
rather than eating the same food daily. People should vary their choices of food
within each class of food from day to day. This makes meals more interesting,
helps to ensure a diet contains sufficient nutrients as different foods in the same
group contain different arrays of nutrients and gives one the advantage of added
bonus in fruits and vegetables as each contain different phytochemicals

NUTRITION GUIDE/TOOLS FOR A HEALTHY DIET

Knowledge of the nutritive content of a diet is meaningless unless it can be

compared to some standards. This lead to the development of nutrition tools which
serve as reference values for intakes of essential nutrients that will maintain health
in practically all healthy individuals. They assist individuals to meet their
nutritional needs, in prevention of under nutrition and over nutrition that results in
chronic disease.

Nutrition guides are of three types

1. Nutrition/Dietary standards

2. Dietary guidelines

pg. 38 by Osonga
3. Food guides

1. Nutrition/Dietary standards

Dietary standards are guidelines that help us understand how much of a

particular nutrient is needed by a healthy human being. These are amounts of
essential nutrients considered sufficient to meet the physiological needs of
practically all healthy persons in a specified group and food sources of energy
needed by members of the group. These figures are derived from compilation of
experimental studies designed to determine the nutrient requirements of human
beings. Quantitatively, dietary standards are not requirements but rather are
estimates of reasonable levels of nutrients intake that should support normal
function in most \healthy people. Dietary standards are obtained by:

 Survey of food intake of large numbers of apparently healthy individuals.

 Surveys that include both food intake and nutritional status.
 Controlled metabolic experiments (with limited number of individuals).
 Relevant studies on several species of animals.
Most developed countries have developed their own nutrient standards and these
differ slightly for individual nutrients partly because populations, environmental
conditions and available food supplies differ. The following are some of the
different dietary standards for some countries.

Recommended dietary allowances (RDA).

These standards were developed for use in America. They represent quantities of
nutrients to meet known nutritional needs of practically all healthy people.

pg. 39 by Osonga
Allowances refer to the amount of nutrients to be actually consumed.

Recommended nutrient intakes (RNI)

This is the Canadian own version of the RDA. It estimates nutrients needed to
support good health.

Safe intake of nutrients (SIN)

These dietary standards were developed by the FOOD and Agriculture

Organization (FAO) and the World Health Organization (WHO) for

pg. 40 by Osonga
underdeveloped countries where supply of protein and other sources may be
limited

Recommended intakes of nutrients (RIN)

These standards were developed for use in the United Kingdom (UK)

Uses of RDA

1. Evaluating the adequacy of the national food supply; setting goals for food
production

2. Setting standards for menu planning for publicly funded nutritional

programme e.g. school feeding programmes

3. Establishing nutrition policy for public assistance, nursing homes and

institutions

4. Interpreting the adequacy of diets in food consumption studies

5. Developing materials for nutrition education

6. Setting patterns for normal diets in hospital

7. Establishing labeling regulation

8. Setting guidelines for formulation of new products or the fortification of

specific foods

Limitations and misuse of RDA

1. They are complex for direct use by consumers.

2. They do not state ideal or optimal levels of intakes.
3. Allowances for some age categories e.g. adolescents and elderly are based
on limited data.
4. Data on food content of some nutrients especially the trace minerals are
limited.

pg. 41 by Osonga
 5. They do not evaluate nutritional status.
6. They may not apply to sick people.
Nb...In 1990, nutrition experts recommended the framework of the RDAs be
expanded to address the following three emerging issues
a. The growing population of older people
b. The dangers of inappropriately high intakes of specific nutrients
c. The health benefits that might be achieved with higher intakes of certain
nutrients even though research was limited
-The expanded set of standards that evolved was given the working title of dietary
reference intakes (DRIs)

The Dietary Reference Intakes (DRIs)

DRIs reference values that are quantity estimates of nutrient intakes to be used for
planning and assessing diets for healthy people. The DRIs consist of four reference
intakes:

 Recommended Daily Allowances (RDA)-it serves as a reference for all

healthy individuals

 Tolerable Upper Intake Level (UL)-It is the highest amount of nutrient that
can be safely consumed with no risk of toxicity/likely pose no danger to
most individuals in the group. It helps health care providers when advising
individuals on the use of dietary supplements

o Tolerable Lower Intake Level (LL)-It is the lowest amount of a

nutrient likely to pose no danger to most individuals in the group.

 Estimated Average Requirement (EAR)- It is the nutrient intake estimated to

meet the requirement of half of the healthy individuals in a particular life
stage and gender group

 Adequate Intake (AI) - It is the level thought to meet or exceed the

requirements of almost all members of a life stage/gender group. It is used
when there is not a sufficient amount of research to develop RDA

pg. 42 by Osonga
2. Dietary guidelines

They were 1st developed in 1980.It is developed from the RDIs and other research
evidence describing the types and amount of food to eat and the physical guidelines
for optimum health and growth e.g in weight management

3. Food Guide/Daily food guide

It helps individuals in day to day meal planning. They give a practical
interpretation of both dietary standards and dietary guidelines. Most food guides
group foods into a particular categories based on their nutrient content and
recommends a certain number of servings from each group. The mostly used food
guides are
a) Food pyramid
b).Food exchange list
c).Food composition table
d).Signal system(Healthy food choices)
e). Hand jive
f). Plate model
g). Glycemic index

a). Food composition tables

These are charts or tables showing the relative nutrient content found in a given
quantity of food. They were developed by FAO/WHO for developing countries.
The nutrient compositions of foods were obtained in laboratory after food analysis.
The food composition tables:

 Serve as a basis for comparing one food with another in terms of nutrient
content. For example, when you examine different foods for calcium
content, you will discover that that milk is the best source of calcium.

pg. 43 by Osonga
  Enable the calculation of the nutritive value of any diet and compare these
values with the standards.
 Are valuable in planning diets that meet requirements for specific needs such
as low sodium and high protein diets.
 They provide a ready reference to answer numerous questions concerning
the nutritive value of foods.

b). Food group plan (Food pyramid)

This is a diet planning tool that sort out food of similar origin and nutrient content
into groups and then specifies that people eat a certain number of servings from
each group every day. The number of servings to be consumed from group depends
on a person’s age and energy needs. In the six food group plan, foods are classified
into six groups in which the breath/base of the pyramid shows that grains deserve
most emphasis in the diet. The tip is smallest and so these foods-fat, oils and
sweets- should be used sparingly, Figure 1.1. Shows the six food group plan. In this
pyramid foods are classified into six groups.

Group 1: Breads, cereals, rice and pasta (6-11 servings per day)

Group 2: Vegetables (3-5 servings per day)

Group 3: Fruits (2-4 servings per day)

Group 4: Meat, poultry, fish, dry beans, eggs etc. (2-3 servings per day)

Group 5: Milk, yoghurt, cheese (2-3 servings)

Group 6: Fats, oils and sweets (use sparingly).

pg. 44 by Osonga
c). Food exchange system
This refers to a system of classifying foods into numerous lists based on their
macro-nutrient composition and establishing serving sizes so that one serving of
each food on a list contains the same amount of carbohydrates, protein, fat, and
energy (kilocalories). Any food on the list can be exchanged or traded for any
other food on that same list without affecting a plan’s balance or total kilocalories.
It was originally developed for planning diabetic diets.

The system organizes food into seven exchange lists.

1. Starch/Bread
2. Milk
3. Meat
4. Fruits
5. Vegetables

pg. 45 by Osonga
 6. Fats
7. Sugar

The six exchange list

All the foods listed together are approximately equal in proteins, carbohydrates and
fat value. Exchange lists provide additional help in achieving kilocalorie control
and moderation. Originally developed for people with diabetes, exchange systems
have proved so useful that they are now in general use for diet planning.
The number of kilocalories is calculated given the number of grams of
carbohydrates, fats and proteins in a food (1g of carbohydrate/ protein yields 4
kcal; 1g of fat yields 9 kcal). To apply the system successfully, users must become
familiar with portion sizes. The table below shows exchanges for carbohydrates,
proteins, fat and energy values that pertain to each list
List Portion size per serving Amount CHO Protein Fats Kcal/
(ml or g) serving
Starch  1/3 cup arrowroots 30 g  15  2  - 80
 1/3 cup ugali  15  2 Trace
 1 slice bread  15  2
 1/3 cup cassava  15  2
 ½ cup cooked bananas  15  2
 ½ cup dried cooked beans  15  7
 ½ cup cooked rice  15  2
 ½ cup cooked pasta  15  2
 ½ cup sweet potatoes  15  2
 ½ cup porridge  15  2
 ½ cup Irish potatoes  15  2
 ½ chapatti  15  2


Milk  ½ cup fresh milk  250  12  8  Trace  90

 Nonfat  ¼ cup ice cream ml  12  8  5  120
 Low 75 ml or one scoop  250  12  8  8  150
fat  1 cup yoghurt ml 
 Whole  250
ml

pg. 46 by Osonga
 Meat  Size of matchbox meat  30 g -  7  3  55
 Lean  Palm size of fish  30 g  7  5  75
 Mediu  A leg, thigh or breast  30 g  7  8  100
m fat chicken  30 g  7  3  75
 High  2 tbsp peanut
fat  ½ cup fresh bean
 Egg  ½ cup omena
Vegetable  ½ cup cooked vegetable 100-150 5 2 - 25
s  1 cup raw vegetable g
Fruits  1 small apple, peach, Varies 15 - - 60
orange, apple or grape
fruit juice (pure juice)
 ¾ cup diced fruits
Fats  1 tsp margarine or oil - - 5 45
 10 large peanuts
 1/8 medium avocado
 1 slice bacon
 1 tbsp shredded coconut
 1 tbsp cream cheese
 1 tbsp salad dressing
 5 large olives
Sugar 1 tsp 5 20

Procedure for calculating diets using exchange lists

Suppose that 1,200 – calorie diet is to be planned with the following levels, CHO
120g, protein 70g, and fat 40g.Estimate the amounts of milk, vegetables and fruits
to be included. The amounts are dictated somewhat be the preferences of the clients
but the following are minimum levels that should ordinarily be included: Milk 2
cups for adults, 3-4 cups for children and for pregnant/lactating mother; fruits – 2
exchanges; vegetables – 2 exchanges
1. Fill the carbohydrate, protein and fat values for the tentative amount of milk,
vegetables and fruit.
2. Determine the number of bread exchanges. Add up the CHO value of milk,
vegetables and fruit. Subtract this total from the total amount of CHO
prescribed. Then divide the remainder by 15 (the CHO value of one bread

pg. 47 by Osonga
 exchange). Use the nearest whole number of bread exchanges. Fill in the
bread.
3. Total the CHO column. If the total deviates more than 3-4 from the
prescribed amount, adjust the amounts of vegetable, fruit and bread. No diets
should be planned with fractions of an exchange, since awkward measures of
food would sometimes be encountered.
4. Determine the number of meat exchanges. Add up the protein value of all
food so far calculated. Subtract this total from the amount of proteins
prescribed. Divide remainder by 7 (the protein value of one meat exchange).
Fill in the protein and fat values
5. Determine the number of fat exchange. Add up the fat value from the milk
and meat. Subtract this total from the amount of fat prescribed. Divide the
remainder by 5 (the fat content of one fat exchange). Fill in the fat value.
6. Check the entire diet for the accuracy of the computations. Divide the day’s
food allowances into a meal pattern suitable for the client.

List Food Measure CHO (g) Protein Fat (g) Calories

(g) Kcal
1. Milk, low 2 24 16 10 250
fat exchanges
2. Vegetable 2 10 4 - 56
exchanges
3. Fruits 3 30 - - 120
exchanges 64
4. Bread 4 60 8 - 272
exchanges 124 24
5. Meat, Low 7 49 21 385
fat exchanges
6. Fat 2 - - 10 90
exchanges
TOTAL 124 70 40 1173

Advantages of food exchange list

 It is a valuable tool for quickly estimating the energy requirements for an
individual

pg. 48 by Osonga
  Does not affect the diet plan because any food can be traded or exchanged
on the same list
 Help in establishing a meal or diet plan/pattern for families or persons

Signal System: Principle of Healthy Food Choices and Cooking Methods

This system is based on traffic light concept of red for ‘stop’ which also denotes danger, yellow
for ‘go slow’ or cautious, and green for ‘go’ or safer road (see table 63 below). It uses
universally understood symbols which makes it simple and highly useful way for a person to
make an informed choice. Importantly it focuses attention on processing and cooking, lays stress
on the Glycemic Index (GI), fiber content of food, the amount and type of fat used and the mode
of cooking. It removes negative feelings about being on a diet and avoiding certain foods. It
empowers the person to make a behavior change towards healthy eating. Table 63: Principles of
Healthy Food Choices, Signal system
Principles Green(safe) Yellow(go slow) Red(danger/stop)
Refined cereals Low Moderate to high High
and sugars
Saturated fat Low Low High
Total fat Low Moderate High
Glycemic index low Moderate high High GI
Fiber High Low Negligible
Cooking method Steaming, boiling, Pan fried, sautéed, stir Deep fried, extra butter,
roasting, grilling, fry; moderate amount ghee added, rich
tandoor, dry heat, of fat in cooking sauce/dressing, rich in
less fat in cooking added sugar
Processing Rich fiber, parboiled, Low fiber, refined, Low fiber processed, ready
hand pounded. milled to eat
How much to Eat as permitted Moderation Restrict
eat

Hand Jive
The Zimbabwe hand jive shown in figure 14 below, suggested by Dr K Mawji, illustrates how to
measure the amount of food 'imaginatively', in a reasonably accurate manner, without scales etc.
Hand Jive Vegetables: Choose as much as you can hold
in both hands. Choose low carbohydrate
vegetables (e.g. green or yellow beans,
Carbohydrates ( starch and fruit): cabbage, lettuce).
Choose an amount the size of
your 2 fists.

pg. 49 by Osonga
Figure 14: The Zimbabwe Hand Jive

Plate model method

Protein: Choose an
amount the size of the
palm of your hand and
the thickness of your
little finger.

Fat: Limit fat to an

amount the size of the
tip of your thumb.
Drink no more than 250
mL of low-fat milk with
a meal.

pg. 50 by Osonga
The Plate Method is a simple method for teaching meal planning. A 9-inch dinner plate
serves as a pie chart to show proportions of the plate that should be covered by various
food groups. This meal planning approach is simple and versatile. Vegetables should
cover 50 percent of the plate for lunch and dinner. The remainder of the plate should be
divided between starchy foods, such as bread, grains, or potatoes, and a choice from the
meat group. A serving of fruit and milk are represented outside the plate. Figure 15
below shows how a sample basic meal should appear in the plate for a normal healthy
individual.

Sample Basic Meal

Planning Guide

Fruit Meat/ Milk

Protein
Starch/
bread
Vegetables

American
Diabetes 31
Association®

Figure 15: Simple Basic Meal Planning Guide for Healthy individual

Figure 16 shows a sample plate for a diabetic patient. Note the difference in the portion
sizes of vegetables.

Model Plate

pg. 51 by Osonga
 Fruit

Milk/ Yoghurt
Protein

Vegetable

Vegetable

Starch /cereal

Figure 16: Model Plate for a Diabetic Patient

Combined with the plate model the signal system is a practical and easy way to
implement diet advice for a newly diagnosed person with type 2 diabetes
Figure 17 shows plates usually seen for many people which are not in line with the
principles of meal planning

Plate Formats Usually Seen

Milk/yoghurt Milk / yoghurt

Vegetable Vegetable

Starch /cereal
Protein

Starch /cereal Protein

Rich in starch/cereals, low in vegetables Rich in proteins, low in vegetables and

cereals

Figure 17: Plate Formats usually seen not in Line with Meal Planning

TOPIC: NUTRITION SUPPORT

pg. 52 by Osonga
  Nutrition support refers to the provision of food and nutrients to the patient when
the conventional feeding methods are not adequate or cannot meet nutrition needs.
These include Enteral and parenteral nutrition.
 Selection of the mode of feeding is dependent upon several factors.

Figure: Choice of route of nutrition administration Adopted from JPEN 1993; 17 (4):
1SA.
Enteral Nutrition

 Enteral nutrition by definition means within or by the way of the gastro-

intestinal tract
 Enteral nutrition is a way of providing nutrition to the patients who are unable to
consume an adequate oral intake but have at least a partially functional GI tract.

pg. 53 by Osonga
  In practice, enteral nutrition is generally considered a tube feeding
 Enteral nutrition may augment the diet or may be the sole source of nutrition. It is
recommended for patients who have problems chewing, swallowing, prolonged
lack of appetite, an obstruction, a fistula or altered motility in the upper GIT; are
in coma or have very high nutrient needs but have at least a partially functional GI
tract

Types of Enteral Nutrition Formula

 There are various types of enteral feeds available as ready to use or powdered
mixes specifically designed to meet the needs of the patient.
 The formulas are commonly categorized by the complexity of the proteins they
contain. There are two major types of Enteral feeds namely: standard and
hydrolyzed.

Standard Formulas

 These are also known as polymeric or intact formula. They are made from whole
proteins as found in the diet (e.g. eggs, meat) or protein isolates [semi-purified
high biological value proteins that have been extracted from milk, soybean or
eggs].
 Because they contain whole complex molecules of protein, carbohydrate and fat,
standard formulas are used for patients who have normal digestive and absorptive
capacity. They come in variety such as standard, high protein, high calorie and
disease specific.

N/B Polymeric formulas can either be home-made or commercially prepared

foods. Home-made formulas can either be (1). Natural liquid foods(.g. Whole
milk, skim milk, eggs, some form of CHO such as cooked strained cereals, cream)
or (2). Blenderized feeds (Foods which cannot be swallowed are blended to
make thin liquid which can pass nasogastric tubes. e.g. a mixture of starch, milk,
pumpkin, bread, butter skim milk powder, eggs, soya flour, refined oil, salt.
Example rice-75g, milk-200g, spinach-50g, pumpkin-50g, carrots-50g, banana-
70g, sugar-60g, refined oil-20g).The foods are cooked first before putting in an
electric mixture. Water is added to make the volume 1500 ml

Hydrolyzed Formulas

 Partially hydrolyzed formulas contain proteins that are partially digested into
small peptides.

pg. 54 by Osonga
  Completely hydrolyzed formulas are commonly known as elemental formula and
they contain protein in its simplest form; free amino acids.

Disadvantages of elemental diets

o High costs
o Unpleasant tastes
o High osmolarity at times
 Hydrolyzed formulas also provide other nutrients in simpler forms that require
little or no digestion e.g. very low fat in form of medium-chain triglycerides
(MCT).
 Hydrolyzed formulas are meant for patients with impaired digestion or
absorption such as people with inflammatory bowel syndrome, short gut
syndrome and pancreatic disorders.

Indications for Enteral Nutrition

 During periods of decreased oral intake, anticipated less than 50% of required
nutrient intake orally for 7-10 days as seen in severe dysphagia (difficulty
swallowing), metabolic stress, major bowel resections, low-output fistulas and
coma. Neurological disorders and psychological conditions.
 Malnourished patients expected to be unable to eat > 5 days
 Normally nourished patients expected to be unable to eat >5 days
 Adaptive phase of short bowel syndrome
 Following severe trauma or burns
 After surgery
 Persistent anorexia
 Babies of low birth weight

Contraindications
 Intestinal obstruction that prohibits use of intestine
 Paralytic illus
 Intractable vomiting
 Peritonitis
 Severe diarrhea
 High output fistulas between the GI tract and the skin
 Severe acute pancreatitis

pg. 55 by Osonga
  Inability to gain access
 Aggressive therapy not warranted

Determining nutrient requirements

 The type of formula, volume and hence the total nutrient required are determined
by the patients physiological condition. Several equations are available for
estimating nutrient requirements of patients depending on their clinical condition.
 The calorie to nitrogen ratio should be >150:1 (1g nitrogen is equivalent to 6.25g
protein). If the C: N ratio is less than 200:1, then the protein supplied by such a
feed will be inadequate for critically ill patients.

Tube feeding/enteral nutrition

 This is the delivering of food by tube in to the stomach or intestine. It is

indicated/considered whenever oral feeding is impossible or not allowed.

Tube feeding routes

 The decision regarding the type of feeding route/tube depends on the patient’s
medical status and the anticipated length of time that the tube feeding will be
required.

Mechanically inserted tubes;

N/B. Mechanical routes are used for a short term
Nasogastric tubes where by a feeding tube is pushed through the nose into the stomach

 Orogastric tubes whereby a feeding tube is pushed through the mouth into the
stomach
 Nasoduodenal tubes – the tube is pushed through the nose past the pylorus into
the duodenum
 Naso-jejunal tube – the tube is passed during the endoscopy from the nose past
the pylorus into the jejunum

Surgically inserted tubes

N/B. Surgical routes are used for a long term

pg. 56 by Osonga
  Oesophagostomy: A surgical opening is made at the lower neck through which a
feeding tube is inserted to the stomach
 Gastrostomy: A surgical opening is made directly into the stomach
 Jejunostomy : A surgical opening is made into the jejunum

A figure illustrating different routes of enteral nutrition administration

Different route of enteral nutrition administration

Advantages of Enteral nutrition

 There is a stimulation of GI hormones and consequent regulated metabolism and

utilization of nutrients.
 It ensures adequate nutrient supply to the mucosal wall, and protection against
atrophy of intestinal Villi.
 It offers physiological protection against ulcers due to its buffering effect from
gastric acids.
 Cost effective compared to parenteral nutrition
 Reduced hospital length of stay
 Reduced rate of infectious complications in critically ill patients
 Improved wound healing

pg. 57 by Osonga
 Methods of administration
Method Administration Remarks
Bolus Initially – 50ml then increase gradually up to a maximum of 250 Most appropriate when feeding
feeding to 400ml over approximately 30 minutes, 3 to 4 hourly daily (in in to the stomach
24 hrs)
Check aspirate before each
In bolus feeding, there are break in the feedings, allowing the feeding
patient to be free form the TF apparatus for activities such as
Feeds may poorly tolerated
physical therapy. It is administered by a syringe, cup, pump, etc.
causing nausea, vomiting,
Bolus is always delivered 4-8 times per day lasting about 15-30
diarrhea, cramping or aspiration
minutes
-Disadvantage of bolus is that they are more aspirated than the
other methods, may cause bloating, cramping, nausea and
diarrhea.
-Advantages-less expensive when pump is not used, allows the
patient to be freeform the TF apparatus for activities such as
physical therapy
The feed is administered over 20-60 min every 4-6 hours

Intermittent 400 – 500ml infused by gravity over approximately 20 -30 Patient retains freedom of
slow minutes to 1 hr. 3 to 4 hourly daily (in 24 hrs) movements in between feeds
gravity
Improved tolerance of feeds
feeding.

Continuous Total volume of feed required is slowly administered; Most suitable when feeding in to
approximately 100ml/hour over 18 – 24hrs the duodenum or jejunum where
elemental diets are most
Can be by a pump or gravity. The feed runs for 24
appropriate
hours .There is hourly rate. It is better tolerated, does not result
into diarrhea, nausea etc. At times it can be combined with bolus May also be suitable for feeding
feeding. May be continuous at night then bolus at day time in to the stomach
Method may slow peristalsis
Feeds are better tolerated

pg. 58 by Osonga
Tube feeding instructions

 Tube feeding should be used at room temperatures, cold mixtures can cause
diarrhea
 Ensure proper placement of tube and feed at slow constant rate
 Prescribed intervals and volumes of feeding should be adhered to
 Care should be taken to ensure that the tube feeds meet the patient’s nutrient
requirements
 Prepared mixture should be well covered, properly labeled including time of
preparation and stored in a refrigerator for up to 24 hours
 In the absence of refrigeration, quantities lasting only six to twelve hours should
be prepared
 All feeding equipment should be cleaned before and after each feed
 Shake/stir well before use

Commonly used equipment in enteral feeding

 Feed preparation equipment for kitchen made feeds and powder feeds
include measuring jars and cups and spoons, mixing bowls, blender, flask, sterile
water
 Ready to hang (RTH) feeds: giving sets for gravity or giving sets for the pump
system, Enteral feeding pumps, dual port connector and a feeding bag where
applicable, pole or where to hung the feed
 Liquid diets in easy bags: giving sets (gravity or pump), feeding pump and/or
dual port connector where applicable
 Feed delivery equipment; funnel especially in gastrotomy and Jejunostomy for
controlling viscous flow, syringe for naso-gastric bolus or intermittent feeding
and the feeding tubes where applicable

NB: Feeding pump is recommended as it eases feeding workload because it flows

without constant supervision, enhances accuracy, hygiene and sanitation.
Methods of estimating daily fluid allowance
Basis of estimation Calculation

pg. 59 by Osonga
Body weight
Adults

 Young active :16 – 30 years 40 ml/kg

 Average: 25 – 55 years 32 ml/kg

 Older: 55 – 65 years 30 ml/kg

 Elderly:> 65 years 25 ml/kg

Children
100 ml/kg.
 1 – 10kg
An additional 50ml per each kg > 10kg.
 11 – 20kg
An additional 25ml per each kg > 20kg
 21kg or more
1 ml per Kcal.
 Energy intake

Enteral tube feeding complications

 Sometimes a client does not respond to a tube feeding as expected. If the client
continues to lose weight, for example health care professionals must find out why.
Perhaps they have underestimated energy and nutrient requirements.

Commonly seen complications can be classified into:

 Gastro-intestinal
 Mechanical
 Metabolic
 Pulmonary.

A summary of the complications alongside prevention/management strategies.

Gastrointestinal complications of tube feeding

pg. 60 by Osonga
Gastro intestinal Prevention/management
complications
Diarrhea Slow feeding rate
Supplemental fluid and electrolytes
Use lactose free formula
Prevent formula contamination
Consider different formula
Check antibiotic/drug therapy
Check flow rate of feed
Consider Enteral nutrition with added fiber
Use ant diarrheal agent
Check osmolarity of feeds (< 500mosl/l recommended
Constipation Give supplemental fluid.
Check if fiber inadequate or excessive
Check physical activity
Nausea or vomiting Reduce flow rate
Discontinue feeding until underlying condition is managed
Change to polymeric feeds if on elemental diet
Check gastric emptying and review narcotic medications,
initiate low fat diet, reduce flow rate
Malabsorption/Mal- Identify the cause (crohn’s disease, radiation enteritis, HIV,
digestion pancreatic insufficiency etc)
Select appropriate Enteral product
PN may be necessary in selected patients
Abdominal distension Assess the cause
Check feed temperature (give at room temperature)
Do not give rapid formula administration

pg. 61 by Osonga
 Mechanical complications of tube feeding
Mechanical Prevention/management
complications
Tube placement To be placed by trained personnel using defined protocol to
reduce complications

Feeding tube Use small bore feeding tube to minimize upper airway
problems
Tube clogging Select appropriate tube size
Flash with water
Dilute formula with water
Dislocation of tube Ascertain tube placement before each feed
Clearly mark tube at insertion
Nasopharyngeal Use small lumen tube.
irritation
Use pliable tube
Esophageal erosion Discontinue tube feeding
Recommend parenteral nutrition

Metabolic complications of tube feeding

Metabolic Prevention/management
complications
(Fluid and electrolyte Check adequacy of daily nutrient supply of macro and
imbalance, trace micronutrients during EN.
element, vitamin and
Check possibility of Malabsorption
mineral deficiencies,
essential fatty acid
deficiencies
Hyperglycemia Reduce flow rate.
Give oral hypoglycemic agents or insulin.
Change formula
Tube feeding syndrome Reduce protein intake or increase water intake.

pg. 62 by Osonga
 For conscious patients education and counseling is needed
Hypernatremia Increased water intake and reduce sodium
(dehydration)
Replace sodium loses
Hyponatremia (over- Replace sodium loses
hydration)
Re-asses nutrient requirement, check volume administration,
change to nutrient dense formula

Pulmonary complications of tube feeding

Pulmonary Prevention/management
complications
Pulmonary aspiration Incline head of bed 300 – 450 during feeding 1 hr after
feeding.
Check tube placement.
Monitor symptoms of gastric reflux.
Check abdominal distension.
Check residual volumes before feeds.
Change to jejunal feeding.
Reduce volume of feed.
Change from bolus to continuous feeding

When a patient has been put on enteral feed, it is important that the administration is
monitored regularly to avoid or identify any complications early and address them.

pg. 63 by Osonga
 Checklist for monitoring patients recently placed on tube feeding to make sure that
complications do not arise
Action Check
Before starting a new Complete a nutrition assessment
feeding
Check tube placement
Before each intermittent Check gastric residual
feeding:
Check gravity drip rate when applicable
Every half hour
Check pump drip rate, when applicable
Every hour
Check vital signs, including blood pressure, temperature,
Every 4 hours pulse, and respiration
Every 6 hours Check blood glucose, monitoring blood glucose can be
discontinued after 48hrs if test results are consistently
negative in a non-diabetic client
Every 4 to 6 hours of Check gastric residual
continuous feeding
Every 8 hours Check intake and output
Check specific gravity of urine
Check tube placement
Chart clients total intake of, acceptance of, and tolerance
to tube feeding
Every day Weigh clients where applicable
Check electrolytes and BUN when needed
Clean feeding equipment
Check all laboratory equipment
Every 7 to 10 days Check all laboratory Findings
Re-assess nutrition status
As needed Observe client for any undesirable responses to tube
feeding; for example delayed gastric emptying, nausea,
vomiting, and diarrhea
Check nitrogen balance

pg. 64 by Osonga
 Check laboratory data
Chart significant details

pg. 65 by Osonga
Enteral formula classifications based on different conditions
Enteral formula Sub-category Characteristics Indications
Polymeric Standard Similar to average diet. Normal digestion
High nitrogen Protein > 15% of total Catabolism Wound
Kcal. healing
Calorie dense 2 Kcal/ml Fluid restriction
Volume intolerance
Fiber containing Fiber 5 – 15/l Regulation of bowel
function
Monomer Partially One or more nutrients Impaired digestive
hydrolyzed are hydrolyzed, and absorptive
elemental peptide composition varies. capacity
based
Disease specific Renal Whole protein with Renal failure
modified electrolyte
content in a caloric
Hepatic High
denseBCAA,
formula.low AA, Hepatic
encephalopathy
Pulmonary High % of calories ARDS
from fat.
Diabetic Low carbohydrate Diabetes mellitus
Immune Critically ill Arginine*, glutamine, Critically ill.
enhancing omega-3 fatty acids,
Formulas anti-oxidants
* is contraindicated in critical illness

pg. 66 by Osonga
Examples of enteral feed formulations in the market (This is not a complete list of
all the formula’s currently available in the market)
Feed Composition – 100g powder Indications
Infant feeding CHO-55.9% mainly lactose and For low birth weight,
formulas maltodextrin. premature or light for
date babies when breast
PRO-14.4% mainly whey
milk is not available.
protein and casein.
FAT-24.0% MCT, milk, fat,
corn oil, soybean.
CHO-56.2% For infants of normal
birth weight (mature,
PRO-12.5%
normal for date) when
FAT-27.7% breast milk is not
available.
CHO-55.4% For infants and low birth
weight, light for date
PRO-11.4%
babies when breast milk
FAT-27.7% corn oil, soy oil, is not adequate or not
coconut oil. available

Lactose free infant CHO-55.4% mainly For infants

formulas maltodextrin
PRO-14.0%
Soy protein isolate.
FAT-25% palm, soya and
coconut oil.
CHO-52% For infants and adults
when lactose or cow’s
Corn syrup solids
milk should be avoided.
PRO-14%
Soy protein isolate
FAT-27%
Blend of vegetable oils.
CHO-50% corn syrup, sucrose. For infants and adults
when lactose or cow’s
PRO-15.6% soy protein isolate.
milk should be avoided.

pg. 67 by Osonga
 CHO-40% For infants and adults
when lactose or cow’s
Glucose polymer and corn
milk should be avoided.
syrup solids.
PRO-12% Soy isolate.
FAT-48% soy oil, coconut oil.

pg. 68 by Osonga
Feed Composition – 100g powder Indications
High protein CHO-37.4% A protein caloric
powder supplement that can be
PRO-25%
supplements incorporated in liquid or
solid diets
Full cream 2. CHO-54% A protein caloric
powdered milk supplement useful where
PRO-36.4%
CHO-68% low fat dietfat
Controlled is required
diets
Dried skimmed
milk powder
Corn syrup solids, glucose,
(DSM)
lactose.
PRO-24%
CHO-54% Glucose and tapioca For oral or tube feedings.
starch Useful in Malabsorption
and low fat modified diets
PRO-11% Hydrolyzed casein and
amino acids
FAT-35% corn oil, MCT oil
CHO-6.7% Useful in high protein, low
calorie low fat, fat residue
Lactose, sucrose
diets
PRO-17.1%
Calcium caseinate
FAT-0.6%
CH0-30% A protein, vitamin and
mineral supplement ideal
PRO-55%
for high protein diets, low
FAT-1% fat diets and cases of
malabsorption useful for
Calories per 100g – 366g patient allergic to
lactalbumins
Nutritionally CHO-13.8g = 55% of total Cal. Nutritionally complete
complete liquid liquid diet for total or
PRO-3.8g = 15% total Kcal.
diets supplemental feeding, tube
FAT – 3.4g = 30% of total Kcal l. feeding or oral feeding
CHO-17g = 54.6% of total Kcal. High caloric formula
suitable for tube or oral
PRO-7.5g = 15.1% of total Kcal.
feeding especially where
FAT-68g = 30.3% of total Kcal. energy intake is increased,
where fluid is restricted

pg. 69 by Osonga
 CHO-12g = 53% of total Kcal.
PRO-3.4g = 15% of total Kcal
FAT-3.2g
CHO-58%=of32%
totalofKcal.
total Kcal
PRO-15% of total Kcal.
CHO-61.5g = 54% of total Kcal.
PRO-15.8g = 14% of total Kcal.
FAT-15.8g = 32% of total Kcal.
ENERGY = 100 Kcal per 100ml.
Nutritionally complete feed
for oral or tube feeding in
diabetics.
Nutritionally complete feed
for oral or tube feeding as a
total diet or supplemental
diet. Lactose free
Nutritionally with fiber
complete feed
for oral or tube feeding as a
total or supplemental diet.
Lactose free feed, low in
cholesterol and sodium

Parenteral Nutrition

 This refers to nutrition directly into the systemic circulation, bypassing the gastro-
intestinal tract (GIT) and the first circulation through the liver.
 The primary objective of parenteral nutrition is to maintain or improve the
nutritional and metabolic status of patients who have temporary or permanent
intestinal failure.

Characteristics of parenteral nutrition

 Patients on TPN (Total Parenteral Nutrition) have similar requirements as

enterally fed patients
 The six major nutrients covered are: carbohydrates, proteins, fats, vitamins,
minerals and water
 Feeds must provide adequate calories

Indications for Parenteral Nutrition

 Patients who are candidates for parenteral nutrition cannot eat adequately to
maintain their nutrient stores.
 These patients are already, or have the potential of becoming malnourished.

Peripheral Parenteral Nutrition (PPN) may be used in selected patients to provide partial
or total nutrition support for up to 2 weeks in patients who cannot ingest or absorb oral or
enteral tube delivered nutrients or when central-vein parenteral nutrition is not feasible.

pg. 70 by Osonga
Parenteral nutrition (PN) support is necessary when parenteral feeding is indicated for
longer than 2 weeks, peripheral venous access is limited, nutrient needs are large, or fluid
restriction is required, and the benefits of PN support outweigh the risks. Patient has
failed Enteral Nutrition (EN) trial with appropriate tube placement (post-pyloric).

pg. 71 by Osonga
EN is contraindicated or the intestinal tract has severely diminished function due to
underlying disease or treatment. Specific applicable conditions are as follows
(Indications for parenteral nutrition):

 Paralytic ileus
 Mesenteric ischemia
 Small bowel obstruction
 GI fistula except when Enteral access may be placed distal to the fistula or
volume of output (<200 mL/d) supports a trial of EN
 Diseases of the small intestine
 Intractable vomiting/diarrhea
 Massive small bowel resection
 Trauma
 Inflammatory Bowel Disease
 Enterocolitis (AIDS, chemotherapy, radiotherapy)
 Pancreatitis
 Burns
 Cancer
 Immaturity (premature babies)

Contraindications

 Functional GIT

Examples of feeds for pediatrics

 Protein source: Amino venous

 CHO source: dextrose
 LIPIDS (Fat) source: Lipovenous 10%

Total parenteral nutrition

 Total parenteral nutrition is defined as provision of all nutrients essential for

normal homeostasis and growth in the required amounts through parenteral routes
 It consists of a glucose and amino acid solution with electrolytes, minerals, and
vitamins, plus fat as the principal non-protein energy source.

pg. 72 by Osonga
Routes of administration of parenteral nutrition
Intravenous solutions can be provided in different ways. The methods used depend on the
person’s immediate medical and nutrient needs, nutrition status and anticipated length of
time on IV nutrition support. They include:

 Peripheral Parenteral Nutrition (PPN)

 Central Parenteral Nutrition (TPN)

The general decisions to use PPN instead of CPN are based on comparative energy
demands and anticipated time of use and osmolarity/osmolality (concentration of the
solids in the solution).

Peripheral Parenteral Nutrition

 This refers to use of peripheral veins to provide a solution that meet nutrient needs
for infusion. It has lower dextrose (5% to 10% final concentration) and amino
acid (5% final concentration) concentration than CPN.
 It may provide full or partial nutritional requirements to patients.
 PPN can be administered in to peripheral veins if solutions used have osmolarity
below 800 - 900mosm/l for a brief period of less than 14 days. Short catheters
(cannulas) and mid-way catheters are normally used. However, PPN
administration is possible for several weeks with fine bore catheter.
 PPN may be used in patients with mild or moderate malnutrition to provide partial
or total nutrition support when they are not able to ingest adequate calories orally
or enterally or when central vein PN is not feasible.

Central Parenteral Nutrition (CPN)

 CPN is often referred to as “Total Parenteral Nutrition” since the entire nutrient
needs of the patient may be delivered by this route.
 It requires a central venous system for long term infusions.
 It is used for solutions with osmolarity above 800 - 900 mosm/l. The sites mainly
used are the Vena jugularis external, Vena jugularis internal, Vena subclavia,
Vena cephalica and Vena basilica
 TPN can last for years after implantation with catheters being changed every 5 -
10 years.
 Central Parenteral Nutrition is complete nutrition similar to physiological
nutrition and can be provided for unlimited period (weeks to years). PN can be

pg. 73 by Osonga
 used in hospitalized patients and those who have returned home or are in assisted
living, extended care facilities or nursing homes.

Access routes for parenteral nutrition include:

Peripheral Access Routes

 The indications for peripheral infusion are short-term access needs.

 These solutions are based on a decreased dextrose concentration and osmolarity
and have been reported to be used for short-term therapies (<-10–14 days) when
fluid restriction is not necessary.
 The leading complication associated with peripheral access is peripheral venous
thrombophlebitis. The hallmark symptoms of infusion phlebitis (an inflammation
of the cannulated vein) are pain, erythema, tenderness or a palpable cord.

pg. 74 by Osonga
  Central Venous Access

 Central venous access is defined as a catheter whose distal tip lies in the larger
veins (in the distal vena cava or right atrium.)
 The most common sites of venipuncture for central access include the subclavian,
jugular, femoral, cephalic, and basilic veins.

Administration of PN through the sub-clavian vein.

pg. 75 by Osonga
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Calculating the nutrient content of Intra Venous (IV) formulas

 Different formulas can be used e.g. Total energy (TE) requirements can also be
calculated from e.g. the Harris Benedict Equation (HBE) or any other equation
or formulas available.

a. Assess the patient

Assessment of patients entail measurements of weight and asking their ages. EN and PN
feeds administration are influenced by weight and age which helps determine fluid
allowances and caloric requirement. Caloric and protein needs for individuals are
outlined as per the tables below;

Caloric Needs (Adults)

Mild catabolic weight loss 20-25 kcal/kgBW/day
Maintenance 30-35 kcal/kgBW/day
Weight gain 40-60 kcal/kgBW/day

Protein Needs (Adults)

Low/Reduction 0.6g/kgBW/day
Normal/Maintenance 0.8g/kgBW/day
High/Increase 1.2-2.0g/kgBW/day

b. Formulation for the feeds

Formulation of the EN (NGT& GTT) and PN feeds entails determination of the Fluid
Allowances and Caloric Requirements as per the illustration below;

a. Fluid Requirements
 Preterm; 60-120 mls/kg/bw/dy
 0-12 months;150 mls/kg/bw/dy
 1-3 years; 125mls/kg/bw/dy

pg. 76 by Osonga
  4-6 years; 100mls/kg/bw/dy
 7-9 years; 75mls/kg/bw/dy
 10-12 years; 75mls/kg/bw/dy
 13-15 years; 50mls/kg/bw/dy
 16-19 years; 50mls/kg/bw/dy
 Adults ; 30-40mls/kg/bw/dy
 56-65 years; 30mls/kg/bw/dy
 ≥ 65 years; 25mls/kg/bw/dy

b. Calories
 Preterm; 110-150 kcal/kg/bw/dy
 0-1 years; 90-100 kcal/kg/bw/dy
 1-7 years; 75-90 kcal/kg/bw/dy
 7-12 years; 60-75 kcal/kg/bw/dy
 12-18 years; 30-60 kcal/kg/bw/dy
 Adults; 30-45 kcal/kg/bw/dy
40-50% of calories for parenteral should comprise of carbohydrates. This ensures that
amino acids are not used for energy but protein synthesis and other protein functions

c. Proteins

 Low birth weight; 3-4g/kg/bw/dy

 Full term; 2-3.5g/kg/bw/dy
 1-3 years; 2-3.5g/kg/bw/dy
 4-6 years; 3g/kg/bw/dy
 7-9 years; 2g/kg/bw/dy
 10-12 years; 2g/kg/bw/dy
 13-15 years; 1.7g/kg/bw/dy
 16-19 years; 1.5g/kg/bw/dy
 Adults; 0.8-1.2g/kw/bw/dy
 Critically ill; 1.5g/kg/bw/dy

Protein in EN and PN should comprise of 15-20% of total calories

d. Fats
 Neonates; 0.5g/kg/bw/dy. Maximum of 3-4g/kg/bw/dy
 Older children; 1g/kg/bw/dy. Maximum of 2-3g/kg/by/dy
 Adults; 0.5-1.5g/kg/bw/dy. Maximum of 2g/kg/bw/dy

pg. 77 by Osonga
Fats should comprise of 20-30% of total calories. Regulate fat in the event of sepsis.

 Once you have calculated the caloric requirement and fluid allowances then you
distribute them in a feeding chart.

For Enteral Nutrition involving the NGT feeding; then the feeding chart is distributed as
follows;

Time (hrs) Type of feeds Amount (ml) Remarks

6 am Warm Milk Vomited
10 am Enriched Uji Tolerated
2 pm Blenderised Feeds Did not consume
6 pm Warm Milk
3 am
6 am

N/B: Children are fed after three hours while adults after every four hours. Feed
tolerance is assessed by gastric aspirates, vomiting and diarrhea. If patient do not
tolerates the feeds administered in three consecutive feeding then EN is stopped and PN
initiated.

Parenteral feeds can be administered peripherally or centrally.

These depend on osmolarity of the feeds. Those below 600mols are administered
peripherally hence PPN. Those above 600mols are administered centrally hence TPN.

The feeds are as follow,

 Carbohydrates; Dextrose 5%, 10%, 12.5%, 20% & 50%. 1g of Dextrose (D)
provide 3.4 kcal
 Protein; Aminosteril 10% or 8%, Nephrosteril 7%, Benutrion (for children)
 Fats; Lipovenous 10% or 20%, Intralipid 20%

pg. 78 by Osonga
The table for the TPN feeds is distributed as follows

 First carbohydrates with electrolytes, second amino-acid with electrolytes, third

fat
 You can have confidence in IV solutions if you know what they contain. The basic
thing to remember is that the percentage of a substance in solution tells you how
many grams of that substance are present in 100mL e.g. a 5% dextrose solution
contains 5g of dextrose per 100 ml; a 3.5% amino acid solution contains 3.5g of
amino acids per 100ml. A 0.9% normal saline solution contains 0.9g of NaCl per
100mL. Table 45 shows examples of parenteral formula feeds

Time Type of Route Amount CHO Prot Fats Total Kcal

Feed (mls) (g) (g) (g)
6am- Dextrose Peripheral 500 100 - - 3.4 x100
8am 20%
=340
8am- Aminosteril Central 500 50 4 x 50=200
12pm 10%
12-2pm Dextrose Peripheral 500 100 340
20%
2-10pm Lipovenouse Peripherall 500 50 9 x 50=450
10% y
10pm- Dextrose Peripherall 500 100 340
12am 20% y
12-4am Aminosteril Centrally 500 50
10%

20 % dextrose, 10 % aminosteril, 10 % lipovenouse are compoundable

Others are 70 % dextrose, 20 % lipids, 10 or 15 % amino acids

N/B. Fluids column (Amount-ml). Capacity of the container is 500 ml, i.e. for dextrose,
aminosteril, lipovenouse, that is given for adults while for children is 250 ml.
CHO collum-100 ml contains 20g(from 20%, if you have used 70% then 100 ml=70g)

pg. 79 by Osonga
 100 ml=20g
500 ml ?
500 x 20/100
=100g
For protein column
100 ml=10gm
500 ml ?
500 x 10/100
50g
When balancing the table, the amount of fluids should not supers the fluid allowance
because too much fluid can result into heart failure, edema etc. which may result into
death. In sepsis, fat may be reduced or not given as too much fat affects the wound
healing process
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
x
Precautions in Parenteral Nutrition
Osmolarity
When hypertonic solution is introduced in a small vein with a low blood flow, fluid from
the surrounding tissue moves into the vein due to osmosis. The area can become inflamed
 Ensure appropriate osmolarity is infused via the appropriate veins to avoid
thrombosis and small blood vessel damage. E.g. osmolarity > 900 should be
administered centrally.

Calculation of the osmolarity of parenteral nutrition solutions

Multiply the grams of dextrose per liter by 5 mosm/g

 Example: 50g of dextrose x 5 = 250mOsm/L

Multiply the grams of protein per liter by 10 mosm/g

 Example: 30g of protein x 10 = 300mOsm/L

 Fat is isotonic and does not contribute to osmolarity

Electrolytes further add to osmolarity for example: 1 mosm/me of individual electrolyte

additive

pg. 80 by Osonga
Total osmolarity is then derived from the sum of the osmolarity of all nutrients infused
Infusion rate

 Always check label and package inserts. The maximum infusion rate
recommended for specific solutions should not be exceeded in order to avoid
complications

Vital signs

 Should be monitored daily

 Discontinuation should also be gradual to avoid hypoglycemia

pg. 81 by Osonga
Administration of parenteral nutrition
Parenteral Nutrition feeds can be administered in the following forms:
1). Single bottle system: These are single products/bottles providing either one of
amino acid solution, dextrose solution or lipid emulsions or vitamins or trace
elements or a combination of Amino acid and dextrose. The single bottle system
may also contain electrolytes.
2). All in One (AIO) admixtures: These formulations may be prepared as a
single product by the hospital pharmacist or industrial admixtures. The industrial
admixtures are mixed up at the factory and delivered to the hospital. Refrigeration
is required and they have a short shelf life.
3). Chamber bags: Two and three chamber bags. These AIO parenteral nutrition
feeds have a much longer shelf life and are mixed prior to administration.
Complications of Parenteral Nutrition

 Bloodstream infection is the most common important complication of parenteral

nutrition use. Delivery of the solution via a central venous catheter rather than a
peripheral catheter is not associated with a higher risk of infection.
 Extravasation injury (injury in veins that results in leakage of fluid from veins to
the surrounding tissues) is a major concern when parenteral nutrition is given via
a peripheral cannula (small veins). Subcutaneous infiltration of a hypertonic and
irritant solution can cause local skin ulceration, secondary infection, and scarring.

Other complications are divided into different categories as follows:

Catheter related complications which involve:

 Occlusion of the catheter

 Catheter blockage (check the type, diameter, period of use)
 Catheter related infections - these infections may come from the skin or systemic
circulation (gram negative organisms and fungi)
 Catheter related sepsis - there is need to use antiseptic techniques at all times

Metabolic Complications
Hepatibiliary or Gastrointestinal complications

 Abnormal liver function (caused by underlying diseases, i.e. sepsis, malignancy,

IBD, pre-existing liver disease) bacterial overgrowth in the intestines, biliary
sludge and gallstones.

pg. 82 by Osonga
Macronutrient Complications
These are risks associated with underfeeding or overfeeding. |:

 Hyperglycemia - several factors may cause hyperglycemia including overfeeding

 Hypoglycemia - this may occur mainly if weaning off parenteral nutrition is not
done appropriately or if there is excess insulin administration
 Azotemia can result from dehydration, excessive and/or inadequate non protein
calories. Omission of fat emulsions during PN may cause EFAD

N/B. Azotemia – accumulation in the blood of abnormal quantities of urea, uric acid,
creatinine, and other nitrogenous wastes

 Too much infusion may cause hyperlipidemia

pg. 83 by Osonga
Micronutrient Related Complications

 Fluid imbalance (Dehydration from osmotic diuresis, fluid overload)

 Electrolyte imbalance
 Vitamin, mineral and trace elements deficiency may only occur

The above complications can greatly be reduced and avoided if there is a multi-
disciplinary nutrition team with experienced clinicians available to insert the central
feeding catheters, designated nurses to care for the catheters, and an experienced
registered dietician to prescribe the right parenteral nutrition formulation and make the
necessary follow ups, monitoring and necessary adjustments. The table below shows
complications of total parenteral nutrition.
Complications of total parenteral nutrition
Catheter related complications Metabolic complications
Bacteraemia (staphylococcal) Cholestatic jaundice
Invasive fungal infection Hyperglycaemia or glycosuria
Thrombosis Vitamin deficiencies or excesses
Extravasation injuries Hyperammonaemia
Cardiac tamponade

Examples of parenteral nutritional formulations:

You can have confidence in IV solutions if you know what they contain. The basic thing
to remember is that the percentage of a substance in solution tells you how many grams
of that substance are present in 100mL e.g. a 5% dextrose solution contains 5g of
dextrose per 100 ml; a 3.5% amino acid solution contains 3.5g of amino acids per 100ml.
A 0.9% normal saline solution contains 0.9g of NaCl per 100mL. Table 1 shows
examples of parenteral formula feeds. Table 2 on the other hand, shows pediatric
parenteral nutrition formulations.

pg. 84 by Osonga
Table1: Examples of parenteral formula feeds
Amino acid solutions Features Presentation
These are standard Amino acids for 200ml,500ml and
parenteral nutrition which contain 1000ml bottles
Standard Amino
WHO recommended ratio for
Acids
essential and non-essential amino
5% (50g AA/L) acids and may contain electrolytes or
may be electrolyte free
10% (100g AA/L)
Essential nitrogen balance
15% (150g AA/L)
Special Amino Acids May be balanced AA solution 200ml, 500ml bottle
containing Glutamine and tyrosine ,
Arginine
Special Amino Acids Disease specific formulation 50ml, 100ml, 200ml
containing AA glutamine bottles
Special AA for These are disease specific 200ml, 500ml bottles
Hepatic insufficiency formulations.
8% (80g AA/L) Specially designed to compensate the
AA disorders in hepatic insufficiency,
rich in BCAA and quite low in AAA.
Special AA for renal Adapted to the metabolic AA disorder 200ml, 250ml and
insufficiency in renal failure and contains a 500ml bottles
balanced profile of EAA and NEAA
7% (70g AA/L)
and the dipeptide glycyl-tyrosine
10% (100g AA/l)
Well balanced AA pattern specifically
designed for infants (preterm, new
born, babies) and young children.
Contains EAA and NEAA similar to
human breast milk.
Contains taurine an EAA for neonates
Carbohydrates Features Presentation
solutions
5% (50g /L) These carbohydrate feeds mainly 50ml, 100ml, 500ml,
contain glucose but some may contain 1000mls bags or bottles
6% (60g/ L)
xylitol and or sorbital
10% (100g/L)

pg. 85 by Osonga
20% (200g/L)
25% (250g/L)
50% (500g/L)
Solutions with both These parenteral nutrition solutions 200ml, 500ml, 1000ml
Carbohydrate and contain both carbohydrate and amino bottle
Amino acids. acid including electrolytes and may be
administered peripherally. e.g.
3% AA and 6% carbohydrate plus
electrolytes.
5% AA and 5% sorbital.

pg. 86 by Osonga
Lipid Emulsions Features Presentation
10% These are lipid emulsions for 200ml, 250ml and
parenteral nutrition with different 500ml bottle or bag
20%
special functions
30%
different lipid formulations may
20% MCT-LCT contain the following:
contains soybean oil (LCT) rich in
EFA
contain EFA, MCFA & LCFA
contain mixture of MCT and LCT
Rapid clearance and energy
production preference fuel in
conditions like carnitine
Isotonic
Mean globule size similar to
chylomicrons
Lipid Emulsion Contain fish oil 50ml and 100ml bottles
(fish oil)
Rich in EPA and DHA
Has anti-inflammatory and
immunomodulatory effect
All in One Features Presentation
All in One Three (triple) chamber bags with 1000ml, 15000ml,
Parenteral Nutrition separate compartments for amino 2000ml, 25000ml. bags
formulations acids, fat and a combination of
glucose or sorbital and electrolytes for
central or peripheral parenteral
Nutrition, depending on the
osmolarity and specifications.
Vitamins and minerals are added into
the bag prior to infusion.
Two chamber bags Two chamber bags with separate 1000ml, 1500ml,
compartments for amino acid and 2000ml bags
glucose with or without electrolytes.

pg. 87 by Osonga
 Other nutrients may be added i.e. fat,
vitamins, trace elements as per the
specifications
Vitamins Contains all the water soluble and or 10ml vials
fat soluble vitamin based on
9 water soluble 10ml ampules.
international recommendations.
vitamins
These are added into the parenteral
4 fat soluble
nutrition product prior to infusion,
vitamins
once daily.
Water soluble vitamins to be added
into water base products e.g.
Dextrose, amino acids or the all in
One PN bags but NOT to be added
into the single bottle of fat emulsion.
The fat soluble vitamins can only be
added into the fat emulsion bottle or
the All in One PN bags
follow instructions as specified
Trace element in adults for parenteral 10ml ampoule
nutrition based on international
Trace elements 1ml, 3ml, 10ml vials
recommendations e.g. zinc, copper,
chromium, manganese, selenium.

pg. 88 by Osonga
Table 2: Pediatric Parenteral Nutritional Formulations
Feed Composition per 10 0mls Presentation
Special AA for Well balanced AA pattern 100ml, 250ml and 500ml
pediatrics specifically designed for infants bottles.
(preterm, new born, babies) and
6.5% (65g AA/l)
young children
7% (70g AA/L) Dosage: As per the child’s
Contains EAA and NEAA
age, weight and
10% (100g AA/L)
Similar to human breast milk recommendations
Contains taurine an EAA for
neonates
Special Amino acids As above for children above 6 As above
for hepatic and renal months of age
Dosage: As per the child’s
failure
age, weight and
recommendations
Carbohydrate The carbohydrate solutions 100ml, 500ml bottles
solutions mainly contain glucose
Dosage: As per the child’s
(presentations as age, weight and
Above for adults) recommendations
Lipid emulsions As Adults 100ml bottles
Dosage: As per the child’s age,
weight and recommendations
Vitamins: As Adults 10ml vial
Water soluble Dosage: As per the child’s age,
vitamins weight
Requirements will be calculated
as per the child’s weight
Fat soluble vitamins A multivitamin preparation of 10ml ampoule
for infants lipid soluble vitamins for
Dosage: As per the child’s
parenteral nutrition for infants
age, weight and
recommendations
Trace elements for Trace element additive for 10ml vial
children children in parenteral nutrition

pg. 89 by Osonga
 based on international Dosage: As per the child’s
recommendations, to meet the age, weight and
basal requirements of trace recommendations
elements during intravenous
nutrition in infants and children

pg. 90 by Osonga
Current formulations in the market have the three chamber bags for peripheral and central
parenteral infusion.
Vitamin requirements in Parenteral Nutrition

 It is recommended that all adult/pediatrics PN patients, be supplemented daily with a

standard multivitamin package.

Vitamin requirements in parenteral nutrition

Vitamins Daily Requirements
B1 3.0 mg
B2 3.6 mg
Niacin 40.0 mg
Pantothenic Acid 15.0 mg
B6 4.0 mg
Biotin 60,0 mg
Folacin Acid 400.0 mg
B12 5.0 mg
C 100.0 mg
A 3,300 IU
D 200 IU
E 10 IU
K 300-500 mg
* AMA Recommendation, JPEN 1979
** Nutritional advisory group, JPEN 1998
Note: Vitamin supplementations for pediatrics are calculated as per the child’s weight.

pg. 91 by Osonga
Determining trace element requirements

 The trace elements zinc, copper, chromium, manganese, iodine, iron, and selenium must
be provided in PN to prevent clinical deficiency. It is recommended that all adult PN
patients be supplemented daily with a standard trace element package

Table14: Recommendations for trace elements in parenteral nutrition

Adult patients mg/day µmol/day
Chromium (Cr) 0.010-0.015 0.19-0.29
Cobalt (Co)
Copper (Cu) 0.5-1.5 8-24
Fluorine (F) 1-3 53-158
Iron (Fe) 1-2 18-36
Iodine (I) 0.1-0.2 0.79-1.6
Manganese (Man) 0.15-0.8 2.7- 15
Molybdenum (Mo) 0.015-0.030 0.16-0.31
Selenium (Se) 0.03-0.06 0.38-0.76
Zinc (Zn) 2.5-4.0 38-61

Monitoring of Parenteral Nutrition

 This is necessary to assess whether the regimen is suitable for the patient and also to
confirm and, if necessary correct the prescribed regime. To prevent possible
complications, for example, catheter related complications and metabolic related
complications

Be careful to check:

 The general condition of the patient

 Patient’s daily body weight - bed weighing scales may be practical to check body weight
daily at the same time.
 Nitrogen balance
 Fat elimination - check fat tolerance test and plasma triglycerides
 Blood electrolytes - including phosphate

pg. 92 by Osonga
  Blood glucose
 Micronutrients in the long-term parenteral nutrition patients
Difference between enteral and parenteral feeding
Enteral
Feeding orally through nasogastric tube or
oragastric tube
The normal health of intestinal mucosa is well
maintained
Satisfaction of taking food is felt by the
patients
Less technical skills required
Calculation of food is less complicated
Chances of complications are less expensive
pg. 93 by Osonga
Parenteral
Feeding through peripheral or central vein
A trophy of the intestinal mucosa may take
place
Though the patients gets the nutrients,
satisfaction of taking is not felt by the patient
More technical skill is required
All nutrients in correct amounts must be
present
Chances of complications are expensive
TOPIC. INBORN ERRORS OF METABOLISM, ALLERGIES AND
INTOLERANCE:
Inborn errors of metabolism (Inborn genetic disorders of metabolism)

 Inborn errors of metabolism are a group of rare genetic disorders in which the body
cannot metabolize food components normally
 This is where a nutrient in the body e.g. amino acid cannot be metabolized normally
because a person is born with lack of an enzyme that is needed in the metabolic circle.
This results in other metabolites that are formed that in most instances are toxic in the
body e.g. phenylketonuria. These metabolites are found in the urine

MAPLE SYRUP URINE DISEASE (MSUD)-It is also called branched chain ketoaciduria

 MSUD is an inherited disorder affecting branched chain amino acids (Leucine isoleucine
and valine)
 The condition gets its name(maple syrup urine )from the distinctive sweet oduor of
affected infants urine (particularly prior to diagnosis and during times of acute illness)
 MSUD is caused by deficiency of the branch chain alpha keto acid dehydrogenase
complex (BCKDC) enzyme that is responsible for the breakdown of amino acids
(leucine, isoleucine and valine) leading to build up of the branched chain amino acids
(leucine isoleucine and valine) and their toxic by-products in the blood and urine i.e. the
amino acids (Leucine isoleucine and valine) do not get broken down because of the
deficiency of branch chain alpha keto acid dehydrogenase complex that is needed for
their breakdown

 Infants with this disease seem healthy at birth but if left untreated suffer severe brain
damage and eventually die within the first five months in severe cases of the diseases
(when left untreated)

SYMPTOMS

Beginning in early infancy this condition is characterized by

 poor feeding
 vomiting
 lack of energy (lethargy)
 developmental delay
 Presence of sweet smelling urine
If left untreated MSUD can lead to:

 seizures
 coma

pg. 94 by Osonga
  hypoglycemia
 keto acidosis
 opisthotonos(severe spasm in which the back arches and the head bends back)
 pancreatititis
 neurological decline
Diagnosis

 Presence of sweet smelling urine

 Blood test to determine the levels of leucine, isoleucine and valine
 Urine test for ketones
Management

 Low protein diet (leucine, isoleucine and valine).This is a must as all natural protein
contain these enzymes
 Adequate energy to prevent the body from breaking up muscle protein that may lead to
metabolic stress
 Supplementation of calcium
 MSUD patients with anorexia, diarrhea or vomiting must be hospitalizes for intravenous
infusion of sugars and for nasogastric drip formulae
 Liver transplantation at younger age as it completely and permanently normalize
metabolic function enabling discontinuation of nutritional supplements
 Close dietary monitoring of pregnant women with MSUD to prevent detrimental
abnormalities in development of the embryo or fetus

PHENYLKETONURIA (PKU)

 It is metabolic genetic disorder characterized by impaired activity of the liver (hepatic)

enzyme, phenylalanine hydrolase (PHA) which oxidizes phenylalanine to tyrosine
rendering it non- functional
 It is a genetic disorder in which the body cannot process part of a protein called
phenylalanine into tyrosine thus result into a buildup of phenylalanine in the body
(blood)
 Phenylalanine is almost in all foods(It is high in animal and plant protein) and in artificial
sweeteners
Complications of PKU

The disease is expressed at 3 to 6 months of age if not treated within 3 weeks of age and result
into accumulation of phenylalanine or deficiency of tyrosine. Accumulation of phenylalanine or
deficiency of tyrosine affects central nervous system and result into

 Mental retardation(lack of normal intellectual capacities)

pg. 95 by Osonga
  Brain function abnormalities
 Microcephaly(abnormally small head and underdeveloped brain)
 Mood disorders
 Eczema(inflammation of the skin-skin rushes)
 Hyperactivity
 Musty body oduor( smelling of mold)
 Irregular motor functioning
 Seizures/convulsions
Diagnosis

 Newborns with blood Phenylalanine concentration greater than 2 mg/dl on screening are
scheduled for confirmation test.
 Diagnosis can also be done in urine as phenyl pyruvate
Management

 The objective of nutrition therapy is to maintain blood phenylalanine concertation that

will allow optimum growth and brain development.
PKU in breastfeeding mother with a normal baby; PKU in both the mother and
breastfeeding child; PKU in a baby being breastfed by a normal mother

o In all these scenario, Infants may still be breastfeed to provide all of the benefits of breast
milk
o But in PKU baby’s, the quantity must also be monitored (e.g. breastfed twice a day if the
blood phenylalanine level of the child is high. This should be supplemented with low
phenylalanine milk substitute to prevent clinical manifestations
o Supplementation for missing nutrient will be required.
o PKU mothers should keep their phenylalanine level low through dietary control
Breast milk is low in phenylalanine than cow’s milk. Blood level of the baby’s phenylalanine
level must be monitored through lab tests

Diet for infants, older children and adults

Adequate energy

Provide foods low in phenylalanine that includes

o Restricting or eliminating foods high in protein e.g. meat, chicken, fish, eggs, nuts, dry
beans, cheese, legumes, milk and other dairy products
o Provide 20 to 70 mg/kg of phenylalanine of body weight and this requirement declines as
the child grows
o Provide 180-200 mg/kg/day of tyrosine (an essential amino acid) for infant and 120-150
mg/kg/day for children and adults

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 o More fruits and vegetables since they provide very low phenylalanine
o Jams, sweets, cooking oils
o Fruits and vegetables (should be taken freely) since they provide very low phenylalanine
o Low protein breads pastas and cereals
o Aspartame, artificial sweetener contains aspartic acid and phenylalanine. It should be
avoided because phenylalanine is released during its metabolism. Aspartame is present in
many diet foods, chewing gums and soft drinks
It’s important that they stay on the diet for the rest of their lives

N/B. If PKU is diagnosed early enough, an affected newborn can grow up with normal brain
development, but only by managing and controlling phenyl ketone levels through diet or a
combination of diet and medication

Proving a diet low in protein foods (low in phenylalanine) and supplementing tyrosine intake is
the best treatment for PKU. There are medical foods with low phenylalanine

GALACTOSEMIA

 This is a rare genetic metabolic disorder that affects an individual’s ability to metabolize
the sugar galactose properly thus resulting into accumulation of galactose in the blood
 Although the sugar lactose can metabolize the galactose, galactosemia is not related and
should not be confused with lactose intolerance
Cause

 Lactose in food (dairy products and milk) is broken down by the enzyme lactase into
glucose and galactose
 In individuals with galactosemia, the enzyme needed for further metabolism of
galactose are severely diminished or missing entirely leading to toxic levels of
galactose and phosphate
Management

The only treatment for this is eliminating lactose and galactose from the diet i.e

 All products containing milk

 Milk products
 Omelets
Symptoms

 Speech difficulties
 Learning disabilities
 Neurological impairments e.g. tremors

pg. 97 by Osonga
  Ovarian failure in females
Long term complications

 Speech difficulty
 Ataxia/staggering
 Diminished bone density
 Premature ovarian failure
 Cataract

FRUCTOSURIA

 It is a rare hereditary disorder in which about 10-20 % of the fructose taken is excreted in
the urine
 In normal individuals, about 80% of the ingested fructose is converted to glucose and
glycogen when the rest is broken down to form lactic acid. In fructosuria, there is lack of
fructokinase enzyme that is needed for conversion of fructose into glucose.
Symptoms

 In fructosuria, infants are free of symptoms unless sugar (sucrose) is given. Then there
may be vomiting and hypoglycemic fits and a series of episodes may lead to jaundice and
enlargement of the liver. It is potentially fatal as liver failure may develop if the condition
is not recognized and treated
Management

 Sucrose and fruit should be excluded from the diet.

 Vitamin C supplements

FOOD ALLERGY
 Food allergy is an immune system reaction that occurs soon after eating a certain food.
 Even a tiny amount of allergy – causing food can trigger signs and symptoms such as
digestive problems, hives (itchy skin rushes) or swollen airways. In some people, a food
allergy can cause severe symptoms or even a life threatening reaction known as
anaphylaxis (severe allergic reaction that can cause a coma or even death)
 Food allergy affects an estimated 6 to 8 percent of children under age 3 up to 3 percent of
adults. While there’s no cure, some children outgrow their food allergy as they get older.
Most food allergies start in childhood, but they can develop at any time of life time. It
isn’t clear why, but some adults develop an allergy to a food they used to eat with no
problem.

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  It’s easy to confuse a food allergy with a much more common reaction known as food
intolerance. While bothersome, food intolerance is a less serious condition that does not
involve the immune system.

Symptoms
 Food allergy symptoms usually develop within a few minutes to two hours after eating
the offending food.

The most common food allergy signs and symptoms include:

 Tingling or itching in the mouth, swollen airways, eczema(inflamed reddish itchy skin),
hives (itchy skin rushes), swelling of the lips, face , tongue and throat or other parts of the
body, dry throat, wheezing, nasal congestion or trouble breathing , Abdominal pain,
diarrhea , nausea or vomiting , dizziness , light headedness or fainting , rashes and even
anaphylactic shock

Causes of Food allergy

 When you have a food allergy, your immune system mistakenly identifies a specific food
or substance in food as something harmful. Your immune system triggers cells to release
antibodies known as immunoglobulin E (IgE) antibodies (an antibody specific to that
allergen) to neutralize the culprit food or food substance (the allergen). The next time you
eat even the smallest amount of that food, the IgE antibodies sense it and signal your
immune system to release chemical called histamine, as well as other chemicals, into
your blood stream.
 The majority of food allergies are triggered by certain proteins in: shellfish such as
lobster, crab, Peanuts, walnuts, fish and Eggs
 In children, food allergies are commonly triggered by proteins in:
o Eggs, milk, peanuts and wheat.
 Food allergies can also be triggered by meat but it is not as much as in eggs milk, peanuts
and wheat
 Food allergy may also be caused by pollen grains from vegetable and fruits e.g. in
carrots, pears, raw potatoes and bananas, melon coriander. Cooking fruits and vegetables
can help you avoid this reaction

Risk factors
Food allergy risk factors include:
 Family History – You are at increased risk of food allergies if asthma, eczema, or
allergies are common in your family
 A past food allergy: children may outgrow a food allergy, but in some cases it returns
later in life

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  Other allergies: if you are already allergic to one food, you may be at increased risk of
becoming allergic to another
 Age - Food allergies are most common in children, especially toddlers and infants. As
you grow older, your digestive system matures and your body is less likely to absorb food
or food from components that trigger allergies. Fortunately, children typically outgrow
allergies to milk, soy, wheat and eggs. Severe allergies to nuts and shellfish are more
likely to be lifelong
 Asthma - Asthma and food allergy commonly occur together. When they do, both food
and asthma symptoms are more likely to be severe

Test and diagnosis

There is no standard test used to confirm or rule out a food allergy. The following may help
determine if you are allergic to a food or if your symptoms are caused by something else
1. Description of your symptoms and family history of food allergies or other allergies
2. Food dairy.
3. Skin test. A skin test can determine your reaction to a particular food. In this test, a
small amount of the suspected food is placed on the skin of your forearm or back. Your
skin is then pricked with a needle to allow a tiny amount of the substance beneath your
skin surface
4. Elimination – You may be asked to eliminate suspect food for a week or two and then
add the food items back into your diet one at a time. This process can help link symptoms
to specific foods.
However, this isn’t a foolproof method
5. Blood test - A blood test can measure your immune system’s response to a particular
foods by checking the amount of allergy- type antibodies in your blood stream known as
immunoglobulin E (igE) antibodies

Treatment and drugs

 The only way to avoid an allergic reaction is to avoid foods that cause signs and
symptoms. However, despite your best efforts, you may come into contact with a
food that causes a reaction
 For a minor allergic reaction, over –the counter or prescribed antihistamines may help
to reduce symptoms.
 These drugs can be taken after exposure to an allergy causing food to help relieve
itching of hives, however antihistamines cannot treat a severe allergic reaction
 For severe allergic reaction, you may need an emergency injection of epinephrine

FOOD INTOLERANCE

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  It is much more common than food allergy and is not caused by the immune system.
The onset of symptoms is usually slower and may be delayed hours after eating
offending food. The symptoms may also last for several hours, even into the next day
and sometimes longer
 With food intolerance, some people can tolerate a reasonable amount of food, but if
they eat too much (or too often) they get symptoms because their body cannot tolerate
unlimited amounts
 The symptoms caused by food intolerance are varied. They usually cause
gastrointestinal symptoms such as bloating, diarrhea, nausea and vomiting, irritable
bowel and can include skin rashes and sometimes fatigue, joint pains, dark circles
under eyes, night sweats and other chronic conditions

Cause of food intolerance

Caused by enzyme defects or lack of enzyme
 Enzymes are required to help with the breakdown of natural substances found in
certain foods. If these enzymes are missing or in short supply, then eating the food
can cause symptoms because part of the content of the food cannot be properly dealt
with by the body
 In lactose intolerance( an example of a food intolerance) , for example , the body may
lack enzyme (lactase) that breaks down lactose (milk sugar) into smaller sugars ready
for absorption from the gut. Lactose is too large to be absorbed across the gut wall
undigested, and its presence in the gut causes gut spasm, pain and bloating, diarrhea
and ‘failure to thrive’. Incidentally these same symptoms can occur in milk allergy,
when the body has made antibodies to milk protein, which causes an immune reaction
when you drink milk. Hence, you cannot always distinguish allergy from intolerance
alone without expert help

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TOPIC: ENERGY AND WEIGHT MANAGEMENT
 Weight management for a healthy living depends on energy output and input.
 If energy input is more than energy output you get a positive energy balance thus an
increase in weight whereas if energy input is less than energy output you get a negative
energy balance thus decrease in energy.
 For proper weight gain you need a positive energy balance and a negative energy balance
for weight loss therefore
o Energy balance = Energy intake – energy output

Component of weight
 Body weight = Bone + muscle + Organs + body fluids + Adipose tissue.
 Water consistent 60 – 65% body weight whereas adipose tissues varies through weight
gain and weight loss.

Adipose (fat) tissue – The normal constituent of the human body that serves the
important stores energy in the form of fat. (Energy is stored in the form of glycogen-that
last only 12-36 hours; Excess energy is stored in the adipose (fat) tissue).Adipose tissue
fat is in form of triglycerides in the fat cells. Adult female require an appropriate body fat
of 20 – 25% body weight and 12% of this should be essential including that of breast,
thighs and pelvic region.
Adult male require 12 – 25% of body weight with 5 – 7% as essential fat.
Essential fat is stored both in bone marrow, lungs, kidney, intestines, muscles, brain,
heart and liver.

Storage fat – Fat that accumulates under the skin and internal organ and prevent them
from traumas.
Overweight and Obesity.
Types of obesity
 Obese (equals or more than 30)
 Obese class I (30.0-39.9
 Obese class II (35.0-39.9).
 Obese class III (equals or more than 40)

N/B 1. Central obesity-It is where someone is obese and most of the fat is located in the central
abdominal parts of the body.(Obesity where there is a visceral fat in the body mostly the
abdomen).

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N/B. Visceral fat (fat that collects deep within the central abdominal area of the body) may lead
to diabetes, stroke, hypertension and coronary artery disease. The risk from all causes may be
higher for those with central obesity than for those whose fat accumulates elsewhere in the body.

Classification of obesity
Obesity has been classified in various ways
1. Classification based on the number and size of the adipose fat cells

Hypertrophic obesity- It is where the number of adipose cells remains normal but the adipose
fat cells increases in size with large quantities of fat in the cells. It is common among people who
develop obesity during middle age
Hyperplastic obesity- It is where the number of adipose cells increases in number with the
quantity of fat in the fat cells remains normal. It is common among people who have a history of
obesity dating to early childhood (during infancy and adolescent when the child is still
developing)
Fat cell development
 Adipose tissues increases either by increase in the size of the cell (hypertrophy) or
increase in the number of fat cell (hyperplasia) or a combination of hypertrophy and
hyperplasia.
 Obesity is usually characterized by hypertrophy and fat deposits can expand up to 1000
times.
 Once fat cells are formed they are permanent and cannot be decreased in their numbers.
i.e. during weight reduction, the number of fat cells is not affected, but size of fat cells is
reduced. Thus an obese individual with too large fat cells (hypertrophic) can reduce the
size of each fat cell to normal size while an individual with many fat cells will have to
reduce the fat cells to below the normal size while the number remains the same.
 After weight loss, the reduced cell size is unhappy and seeks to restore normal volume
hence the risk of weight gain.
 The hyperplastic have difficult time maintaining the reduced body weight as the cells will
seek to restore to normal size
 Hyperplastic obesity is common among people who have a history of obesity dating to
early childhood (during infancy and adolescent when the child is still developing)
 Overfeeding during these critical period may lead to a permanent abnormality with wch a
person must struggle throughout life. Therefore preventive measures must be taken early
in life if hyperplastic obesity is to avoided

2. Classification based on Regional distribution of adipose tissue (Body types /Types of

fat deposits)

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Each one of us inherits a unique body type
i. Endomorphs - are generally shaped like apples or pears and carry more body fat.

a) Gynoid type (pear shape)/female type/lower body obesty

 Common in women. Characterized by pear shape with heavier deposits around the
buttocks, hips and thighs (heavier deposit below the waist than above the waist) and are
assumed to be energy reserve to support pregnancy and lactation.
 Fat below the waist is more difficult to lose than fat above the waist. A woman who is
obese over all her body might find that her upper body will be reduced dramatically by
dieting by dieting while the lower body will not be much affected

b) Android type (Apple shape)/male type/Upper body obesity

 Common in men. Characterized by apple shape with heavier fat deposits around the
waist, above the waist and around the abdomen and is associated with significance risk of
cardiovascular diseases and non-insulin dependent diabetes mellitus and heart attack.
 Their bodies resist losing weight and body fat no matter how restrictive they are with
their eating. In fact, the more they “diet,” the more their metabolisms slow down to resist
weight loss. These people are better able to handle long periods of starvation and famine
(which was a benefit to our ancestors). In sports they excel at are distance swimming,
field events, and weight lifting
 Waist hip ratio can be used to identify android and gynoid obesity. A ratio of about 0.7 is
considered normal. A ratio below the 0.7 indicates lower body obesity, while a ratio
above 0.7 indicates upper body obesity

ii. Ectomorphs - are generally tall and thin and have long arms and legs.

 These people have difficulty gaining weight and muscle no matter how much they eat or
how hard they weight train.
 They have the body type you tend to see in ballet dancers, runway models, long-distance
runners, and some basketball players.
 A very small proportion of the population has this type of body.

iii. Mesomorphs - are generally muscular, shorter, and have stocky arms and legs.

 These people are strong and tend to gain muscle mass when they do strength training.
They may find it difficult to lose weight.
 They excel in power sports like soccer, softball, vaulting in gymnastics, and sprinting
events in track and field.

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N/B. Weight gain in the area of and above the waist (apple type) is more harmful than weight
around the hips (pear type

Assessment of weight
Weight can be assessed by the following methods.
 BMI
 Waist Hip ratio Waist circumference: It is a good indicator of fat distribution and
the best tool for evaluating central obesity/abdominal fat. Women with a waist
circumference ≥35 inches (88.9 cm) and men with a waist circumference greater than
40 inches (101.6 cm) have a high risk of central obesity – related health problems.
 Ideal body weight
 Percentile Chart for children
 Skinfold measurement- Provide an accurate estimate of total body fat and a fair
assessment of the fat’s location. About half of the fat in the body lies directly beneath
the skin, so the thickness of this subcutaneous fat is assumed to reflect total body fat.
Measures taken from central body sites (around the abdomen) better reflect changes
in fatness than those taken from upper sites (arm and back).

Causes of predisposing/risk factors to obesity and overweight

 Overweight and obesity are consequences of energy imbalance due to diet high in
energy/diet high in fat.

Hereditary/Genetics
 Obesity tends to run in families the probability of becoming obese when you have a lean
parents is 9 – 14% and 41 – 50% when you have a lean and obese parent. When you have
obese parents 66 – 80%.

Physiological factors
 Inability to respond to hunger and satiety may lead to obesity and overweight.

Hormonal factors
 Play a role on how a person may eat e.g. during stress you may eat less.

Regulatory dysfunction
 Some people respond to external cues than internal cues e.g. if given appetizing food
some people are unable to resist over eating.

Inactivity

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  Poor physical activity is a risk factor to obesity and overweight.

Health Risks Associated with overweight and obesity

Health risks increase as BMI falls rise above 24.9. Independently, factors such as smoking habits
raise health risks, and physical fitness lowers them.
 Excess weight contributes to hypertension thereby increasing the risk of heart attack and
strokes. Obesity raises blood pressure in part by altering kidney function and promoting
fluid retention.
 Increased risk of type 2 diabetes. Most adults with type 2 diabetes are overweight or
obese, and these cause some degree of insulin resistance.
 High blood lipids
 Cardiovascular diseases
 Sleep apnea (abnormal ceasing of breathing during sleep)
 Osteoarthritis
 Abdominal hernias
 Some cancers
 Varicose veins
 Gout
 Gallbladder disease
 Kidney stones
 Respiratory problems
 Complications in pregnancy and surgery
Metabolic syndrome
 Metabolic syndrome involves the dysregulation of several measures of health (Or it is a
combination of several symptoms that presents itself in an individual).
 According to WHO(1998), It consists of glucose intolerance and / or insulin resistance
plus two or more of the following: Hypertension/high blood pressure, central
obesity/abdominal obesity, albuminuria, low HDL cholesterol, elevated fasting glucose,
hypertriglyceridemia, high total lipids. Overweight and obesity can therefore result into
metabolic syndrome

Management of obesity and overweight

There are ways of management – diet, regular physical activity, behavior modification and
surgery.
1. Diet
 Energy-Calorie restricted diet is needed to achieve negative energy balance. It should
be nutritionally adequate except for energy which should be low to a point where fat
stores are mobilized. Most adults will loose weight at intakes of 1200 – 1300kcal/day.

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 However diet less than 1500 kcals pauses a risk since it is likely to lead to excessive
loss of lean tissues.
 Protein: To preserve lean body mass, daily protein intake should be in the range of
0.8 to 1.2 g/kg of body weight
 Fat: Fat should account for 20% to 30% of total energy. Saturated fats should be
limited to less than 6% to 8% of total fat energy. Diets with low to moderate fat
intake (15% to 30% of total energy) tend be lower in total energy and highest in diet
quality when compared to low-carbohydrate diets.
 Carbohydrates: Carbohydrates should account for 50% to 60% of total energy.
Carbohydrates can help prevent the loss of lean tissue.
 Calcium: A review of evidence suggest calcium intake lower than the recommended
level is associated with increased body weight. The research suggests that a calcium
rich diet especially one that include dairy sources(with limit to total calories) not only
helps young women keep weight in check may reduce overall levels of body fat.
Calcium may depress certain hormones which consequently improves the body’s
ability to breakdown fat in cells and slow fat production
 High fiber diet. From complex CHO and vegetables

N/B. Benefits of high fiber-Low in calorie, High in minerals and vitamins especially greens, give
satiety, help in regulating bowel movements, reduce blood cholesterol, promote chewing and
decreases rate of ingestion/constipation
 Adequate water/fluids: in weight management, water is to satisfy thirst. Water helps
with weight management in several ways

o Food with high water content increase fullness, reduce hunger and
consequently reduce energy intake
o Drinking a large glass of water before a meal may ease hunger, fill the
stomach, and reduce energy intake/food intake. Water adds no kcalories, and
it helps the GI tract adapt to a high fiber diet.
Weight loss is often slow when diet is used as a weight management strategy. About 0.5-1 kg
weight loss is recommended in a week. To loose 0.5 kg, then a caloric deficit of 500 kcals per
day should be ensured. Water, fat, protein and glycogen are lost during dieting on a short term
basis while minerals are lost over a longer period of time. As the person looses weight, a state of
plateau is reached. This is a state in which the body no longer loses weight and even weight gain
may occur. The state comes about because water is retained by body as fat and protein are lost.
This may discourage the dieter. More physical exercise should be encouraged and the person
should adhere to the diet
2. Regular physical activity
 The burning of kcals is influenced by duration and frequency of physical activity.
Exercise can help increase BMR, manage stress and increase vascularity of blood vessels.

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 The time of doing the exercise is also important. It is advisable to do the exercise in the
morning when the level of blood glucose is low the fasting blood glucose level ) as the
body will start breaking the fats immediately

Benefits of regular physical activity

 Improve cardiovascular functions.
 Increases HDL and lower insulin resistance.
 Lead to weight loss.
 It regulates appetite and increases BMR.
 It decreases stress especially diet related.
 Increases bone mineralization thereby decreasing the risk of bone weakening.

3. Behavior Modification (e.g. watching TV, rate of chewing)

 It helps control energy intake and weight loss. It involves self-evaluation to identify the
behavior that is bringing the weight gain.

4. Bariatric surgery
 It advised for patients with a BMI of more than 40 or for diabetic obese patients with
BMI of 35-40. Bariatric surgery is where the volume of the stomach is reduced mostly
through gastric bypass

5. Drugs
 Many drugs have been developed to promote anorexia

7. Group therapy
 Weight management goals are always met when people are in groups as they encourage
one another

6. Fasting as a dietary measure to reduce weight

 Total fasting, only water, vitamins and minerals are allowed. Some people achieve this
by not eating on a given days
 Semi-starvation diets provide 300-600 kcals per day. Some people achieve this by
skipping meals.
 Lack of CHO in the diet causes the excretion of water, sodium, potassium, calcium,
magnesium and phosphate. Up to 30% of volume of plasma and extracellular fluid can
be lost during fasting. The decrease in circulatory blood volume decreases blood
pressure, if the individual stands up, he may faint. Decrease in blood volume also
diminishes the ability of the kidney to clear the blood wastes and also impairs the
liver’s function

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  During fasting, approximately 90% of Kcals (1800-2400) are supplied by the
breakdown of fats. Therefore, about 200-250g of fat would be lost per day. Fats are
hydrolyzed into fatty acids, and to ketone bodies when there is excessive breakdown of
fats. Presence of ketone in urine is a confirmation that a person is not ingesting food
 About 6 Kgs can be lost after 3-4 weeks of fasting

Why Doctors and Dieticians were against fasting as a strategy for weight loss
 Many Doctors and Dieticians have been advocating against fasting because of safety
issues, drop in metabolic rate( That the body will under-go slow metabolic rate thus
the dieter will not have energy to do other things, and thus he would be just resting),
and the effect on eating disorders( They argued that most people would binge the
next meal or next day resulting in weight gain as the body is also under low metabolic
rate. The body will save as much energy in the form of fats, knowing that it will be
starved when the person is fasting). They argued that all this could harm the dieter

Recent studies
 Recent studies are now advocating for fasting as a way of weight loss among other
benefits. They argue that most people do not eat much after breaking their fasts as they
know the goal why they are fasting. Fasting also lowers the LDL cholesterol and
triglyceride, lowering blood pressure thus lowered cardiovascular diseases, lowered
immune disorders, lowered incidences of cancer, improve the symptoms of individuals
with asthma, and inflammation ,improving insulin levels that protects the body against
heart attack and diabetes risk and thus fasting lengthen peoples life expectancy. For
better results a meal of 500 kcals should be eaten per day or by going without food in
given days( 1-3 days a week)

N/B 1. Do not fast if you have health issues e.g. binge eating and other eating disorders, if you
are pregnant, diabetic, suffer from low blood pressure
N/B 2. Drink 8-12 glasses of water per day

Rate and extent of weight loss

 It’s recommended to loss ½(0.5) kg/weight leading to a loss of approximately 10% of
weight reduction and this can be achieved by reducing kcals intake by 500kcals to
1000kcals/day.
 The final goal should be individualized and realistic e.g. for people with morbid obesity,
ideal body weight or BML may not be realistic.
 WHO recommends a weight loss of 0.5-1kg per week

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Advantages of weight loss
 Reduction in blood pressure
 Reduces total cholesterol and LDL cholesterol
 Increases in physical activity that comes with more benefits
 Lower blood glucose level
 Reduced risks of diabetes mellitus, heart diseases and cancer

Theories that explain weight gain

1. Lipostatic theory

It is a long term theory, it involves a feedback mechanism where a signal from the adipose mass
is released when normal body composition is disturbed.
It is higher in younger people than older people and mostly occurs when weight loss has been
experienced.
2. Set point theory

Each person has an ideal biological weight or set point weight. Once body weight reaches this
point, a whole set of signals/ regulation mechanism is produced that influences the persons food
intake to maintain this weight/ return to the set point weight.
It has been noted that many people who lose weight quickly regain all their lost weight,
suggesting that the body somehow chooses a preferred weight and defends that weight by
regulating eating behaviors and hormonal actions. Research confirms that the body adjusts its
metabolism whenever it gains or loses weight – in the direction that returns to the initial body
weight/set point weight.
If this theory is true some forms of obesity could be due to abnormally established set points.
3. Glucostatic theory
It is a short term mechanisms and involves factors governing hunger, appetite and satiety. In a
fed state blood glucose level can raise as high as 100mg/dl while during hunger it can be as low
as less than 70mg/dl.
4. Hormonal factors theory

Hormonal imbalances such as reduction in thyroxin hormone will result in decreased BMR and if
food intake remains the same, this may lead to weight gain.
5. Fat cell theory

Number of fat cells is determined early in life to provide space to store fat. Once they have been
formed, fat cells have a tendency to remain full of fat. A child onset obesity or overweight may

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be because of increased number of fat cells while an adult onset obesity or overweight may
because of an increase in size of fat cells

UNDERWEIGHT
This is when a patient, adult has BMI less than 18.5
Health risk factors of low body weight.
 Increase in morbidity and mortality due to lowered resistance and infection and injuries.
 Under functioning of some glands e.g. Pituitary, thyroid adrenal and gonads which could
lead to infertility and loss of menstruation.
 Chronic fatigue.
 Anemia
 Psychological problems e.g. Anorexia, bulimia, depression, anorexia nervosa.

 Underweight and significant weight loss are also associated with osteoporosis and bone
fractures

Causes of underweight
1. Inadequate intake of calories to meet activity needs.
2. Excess activities or compulsive athletic training.
3. Poor absorption and utilization of food.
4. Metabolic and pathological condition/diseases e.g. HIV, cancer, TB
5. Psychological or emotional stress e.g. nervosa and bulimia

Management of underweight
Assessment of the cause and extent of the underweight should be done before starting any
treatment. The diet should be high in energy and protein to build the muscles.
Strategies of weight gain
Energy. For increasing weight the total calorie intake should be in excess of the energy
requirement. An additional 500kcals per is recommended this will result into a weekly
gain of 1/2kg or
Limiting low calorie foods or by enriching the foods/giving energy dense foods e.g.
adding sugar, honey.
Protein: Instead of 1 g of protein, over 1.2 g per kg is recommended for tissue building
Fats: Increased fat is recommended. Easily digestible fats are recommended. Fried foods
and fatty foods are not recommended as they may cause diarrhea. Fatty foods should not

pg. 111 by Osonga

 be taken at the beginning of a meal as they reduce appetite. High calorie fatty foods such
as cream, butter, margarine and oils help to increase weight
Carbohydrates: High carbohydrate sources must form the basis of the diet.
Fluids: Fluids should not be taken before or with a meal but only after a meal so that
food intake is not reduced
Regular meals, no skipping of meals at least 3 meals daily and if possible 6 meals a day.
Regular moderate exercise to stimulate appetite and build up muscles.

TOPIC: GASTRO INTESTINAL DISEASES

Introduction
 The gastro intestinal tract also called the alimentary canal; is a long hollow tube that
begins at the mouth and ends at the anus.
 It’s made up of the mouth, esophagus, stomach, small intestine, large intestine (colon)
and rectum. Other organs that lie outside the tract but support its work by secretion of
important enzymes and digestive fluids are gall bladder and the liver.
1. Disorder of the mouth/mouth problems
 Tissues of the mouth often reflect a person nutritional status. In malnutrition, tissues of
the mouth deteriorate and become inflamed and are more vulnerable to infection, injury,
pain and difficulties with eating. The conditions of the mouth are:

Gingivitis
 This refers to inflammation of the gums and the affected gums bleed during tooth
brushing.

Stomatitis/Angular stomatitis
 This refers to the inflammation of the oral mucosa lining the mouth.

Glossitis

 Refers to inflammation of the tongue whereby there is wounds in the tongue. The
tongue becomes smooth and purple red in colour.

Cheilosis
 Refers to the cracking at the corner of the mouth affecting the lips and the corner
angers making opening of the mouth to receive food difficult OR
 It is a condition characterized by inflammation of the lips.

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N/B. Stomatitis, glossitis and cheilosis can occur due to riboflavin/Vitamin B2 deficiency

Nutrition implications
1. Reduced food intake and difficulty in swallowing (dysphagia).
2. Loss of blood.

Management
1. Nutrition therapy
 Give high protein diet for wound healing
 High caloric liquid and then soft food (diet)
 Give non acidic and without strong spices to avoid irritation.
 Do not give hot foods which may cause pain
 Give foods reach in vitamin C and iron
 Give small quantity of food but at a frequent interval
 Provide foods rich in vitamin B2 if it is due to riboflavin deficiency
2. Medical therapy
 Use of mouth washes before meals to relieve pain
 Use of antibiotics

2. Esophagus problem/disorders
 Esophagus is a long muscular tube lined with mucus membrane that extends from the
pharynx/throat to the stomach. It has 2 sphincters that control the movement of food into
the esophagus and into the stomach that is the upper and lower sphincter and it’s about
25cm long.

Lower esophageal sphincter problems

Achalasia
 This is where the lower esophageal sphincter (LES) does not relax normally when
presented with food during swallowing, thus resulting into obstruction at the gastro-
esophageal junction ie it’s a disorder in which the esophagus is less able to move food
towards the stomach.

Nutrition implications and signs

1. Dysphagia (difficulty in swallowing)
2. Regurgitation
3. Chest pain
4. Heart burn
5. Weight loss

pg. 113 by Osonga

Management
1. Give nutrient dense liquid and semi solid foods taken at moderate temperature.
2. Give small quantities of food but at frequent intervals.

Gastro esophageal reflux diseases (GERD)

 This refers to the backflow/regurgitation of gastric contents from the stomach into
esophagus.
 The regurgitation of the acid gastric contents into the lower part of the esophagus
causes irritation (burning sensation) of the walls of the esophagus as its wall do not
have linings to prevent it from the acid.

Signs and symptoms

 Heart burn
 Regurgitation
 Chronic bleeding and aspiration which may result into coughing and dyspnea
 Sour throat
 Excessive belching
 Frequent throat clearing
 Breathing problems (sinusitis)
 Dysphagia

Causes of GERD
1. Pregnancy (estrogen and progesterone) can reduce LES pressure thus causing the valve
separating the esophagus and stomach not to close properly.
2. Hiatal – hernia
3. Obesity
4. Nasogastric tubes can cause aspirations
5. Use of some drugs to treat certain conditions
6. Radiation such as for lung cancer treatment
7. Aging
8. Fungal infection
9. Stress

Aims of nutritional management

 Prevent irritation of the oesophageal mucosa in the acute phase
 Prevent oesophageal reflux
 Decrease the irritating capacity or acidity of gastric juice

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Management of GERD
1. Nutrition therapy – nutrition plays a major role in the management of GERD
 Provide low fat food and small frequent meals
 Avoid acidic foods such as citrus fruits, tomato products, coffee, carbonated drinks,
alcohol and spices.
 Iron supplements/iron rich foods for chronic bleeding
 Avoid large meals at night
 Reduce weight if overweight
 Avoid smoking as it triggers acid production
 Avoid eating within 2 hours before bedtime
 Eat slowly and chew your food well

N/B Symptoms are aggravated by lying down or by any increase of abdominal pressure e.g. tight
clothing
2. Medical therapy – Many people do use anti acids and other drugs e.g. omeprazole but
the use of antacids has a nutritional complications e.g.
 They have effects on the absorption of vitamin and iron and therefore it should be taken
at least 2 hours before/after iron supplementation.
 Effects of the aluminum containing anti acids may be decreased by high protein meals.
 Folate absorption/utilization may be impaired by anti-acids thus resulting into neural tube
defects as well as genital abnormalities of the heart, palate and urinary tract. Provide
folate supplementation to offset the increased risk.
 Prolonged anti acid used with excessive consumption of calcium may cause high calcium
levels that may result into serious metabolic diseases.
3. Mechanical management
 Reduce weight
 Avoid bending/leaning over or lying down immediately after meals
 Avoid tight clothing
 Elevate head of bed/use pillows

Lifestyle
 avoid smoking as it triggers acid production
 Avoid alcohol

N/B (LES- is a valve at the entrance of the stomach. LES closes as soon as food passes through
it. If LES does not close all the way or if it happens too often, acid produced by your stomach
can move up into the esophagus causing a burning chest pain called heartburn. If acid reflux
symptoms happens more than twice a week then you have acid reflux disease also known as
GERD

pg. 115 by Osonga

Esophagitis
The inflammation of the esophagus as a result of the reflux gastric juice
Causes
 Short esophagus
 Excessive vomiting
 Hiatus hernia
 Inability to empty stomach

Symptoms
 Anorexia
 Dysphagia
 Pain

Management
As in GERD

Hiatel – hernia
 This is where a portion of the upper part of the stomach protrudes through the hiatus
(diaphragm) into the chest.

Diagram

pg. 116 by Osonga

  Food is easily held in this herniated area of the stomach and mix with acid, then
regurgitated back up into the lower part of the esophagus. Gastritis (inflammation of the
lining of the stomach) may occur in the herniated portion of the stomach and cause
bleeding and anemia

Symptoms
 As in GERD, others are: Discomfort after heavy meals, difficulty breathing, lying down
and bending

Management
 As in GERD
 Large hiatal hernia may require surgical operation

3. Problems of the stomach (Gastric) and duodenum

 They include: indigestion, acute gastritis, chronic gastritis, dumping syndrome, duodenal
and gastric ulcers.

i) Peptic ulcer disease

Definition of terms
Mucosa – Mucus secreting membrane lining all body cavities
Mucosal membrane – a thin sheet of material that covers the organs or cavities
Sub mucosa – the connective tissue that lies below the mucosa membrane.
Ulcer – refers to the loss of tissue on the surface of the mucosa or ulcers are open sores or
lessons. They are found in the skin or mucus membrane of the body.
Peptic ulcer
 It is the general term for an eroded lining or sore of the lower portion of esophagus,
stomach and first portion of the duodenum (central portion of the GI tract) that is in
contact with gastric juice(pepsin and hydrochloric acid).

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  It occurs when these central GI tract is corroded by HCL and pepsin (pepsin is an enzyme
produced by the cells of the stomach that splits proteins into peptones. This enzyme is
acidic in nature).HCL and pepsin wears away the protective mucus layer of the central GI
tract.
 A peptic ulcer of the stomach (those that occur in the stomach) is called gastric ulcer; of
the duodenum (those that occur in the duodenum, a duodenal ulcer. And of esophagus,
an esophageal ulcer.

Although there is much overlap, symptoms of a gastric ulcer may differ from those of a duodenal
ulcer.
i. Duodenal ulcer
 Pain may occur or worsen when the stomach is empty, usually two to five hours after a
meal.
 Symptoms may occur at night between 11 PM and 2 AM, when acid secretion tends to be
greatest.
 Duodenal ulcers is the most common and normally occur at age 20-30
 It is more common in men than in women
 Patients with duodenal ulcers may gain weight from frequent eating to counteract pain.
ii. Gastric ulcer
 Symptoms of a gastric ulcer typically include pain soon after eating.
 Symptoms are sometimes not relieved by eating or taking antacids.
 Normally occur at age 45-60
 It is more common in men
 Weight loss is common
Cause of peptic ulcers
Helicobacter pylori
 80%-90% of peptic ulcers is caused by helicobacter pylori. The stomach is naturally
designed to protect itself against ulcers. A protective mucous protects the stomach lining
against powerful acids (Pepsin and hydrochloric acid; pepsin HCL are produce by the
body to aid in digestion process). H. pylori causes ulcers by damaging the protective
mucous layer that lines the stomach and duodenum.
 When H. Pylori attacks the lining of the stomach, the H. pylori produces urease (an
enzyme) which neutralizes the stomach acid –from HCL and pepsin and allows H pylori
to grow in acid free zone. This enzyme also injure the cells of the stomach or duodenum
(causing sores) leaving the linings vulnerable to the damage from digestive juices (pepsin
and HCL). This can eventually result into ulcers

Non-Steroidal Anti-Inflammatory Drug (NSAIDS)

pg. 118 by Osonga

  These drugs e.g. Aspirin, declophenac, Panadol, brufen are taken to decrease
inflammation.
 Inflammation is caused by natural chemical in the body called prostaglandins
 NSAIDS prohibits the body’s production of prostaglandins. However, certain
prostaglandins are important in protecting the stomach linings from HCL and pepsin. By
disrupting the production of prostaglandins in the stomach, an overdose of NSAIDS
leaves the stomach and duodenum linings unprotected making them vulnerable to the
damage from digestive juices (pepsin and HCL). This can eventually result into ulcers
and bleeding

Other risk factors include (They aggravate the existing ulcer)

 Stress which causes vasoconstriction or reduced blood supply to the gastric mucosa
leaving it unprotected.
 Hereditary factors; Family history of ulcers is often in ulcer patients. Some families have
more pepsinogen. People with more pepsinogen produces more gastric acid
 Eating habits; eating hurriedly, improper mastication of food and skipping of meals.
 Irritants e.g. alcohol, cigarettes, caffeine and spices. Smoke has nicotine that concentrate
the HCL and induce increased production

Symptoms of peptic ulcer

 Painful hunger (burning, gnawing, aching) contractions usually in the upper abdomen
 Anemia
 Blood in the stools
 Hemorrhage
 Bloating
 Low plasma protein levels
 Vomiting
 Low weight in gastric ulcer and gain weight in duodenal ulcer.

NB: The amount of concentration of hydrochloric acid is higher in duodenal ulcers while in
gastric ulcer the amount and concentration is normal.

Management
Medical therapy – take medicine regularly as prescribed e.g. Use of anti- acids, antibiotics and
omeprazoles one to three hours after meals or before bed times.
Aims of nutrition management
 Reducing and neutralizing stomach acid secretion
 Maintaining acid resistance of gastro-intestinal epithelial tissue

pg. 119 by Osonga

  Limiting patient’s discomfort and reliving their pain
 To provide continuous neutralization of gastric acid
 To promote healing and reduce irritation of GIT
 Restoring good nutrition status
 To reduce mechanical, thermal and chemical irritation to the gastric mucosa

Nutritional management –
1. Limit the foods and seasoning that increase acid secretions/inhibit healing.
a) Caffeine (including coffee and strong tea) and chocolate
b) Spices, and black pepper
c) Unripe citrus fruits like oranges
d) Sour foods
e) Alcohol
f) Fried foods
g) Fatty meat
h) Garlic
i) Seasonings such as pepper, garlic, pickles, ginger, chilies and strong spices.

2. Avoid foods that are high in fiber that are irritating

3. Eat slowly and chew your food well
4. Give foods high in iron/iron supplements may be provided
5. Fat: a moderate intake of fat is beneficial since fat delays the empting of the stomach but
fatty foods should be avoided e.g. fried foods and fatty foods
6. Give small quantity but frequent meals to ensure that the stomach is not empty, at least 3
regular meals daily.
7. Protein: a high protein intake to promote healing of the wounds and to provide buffering
action
8. Avoid eating within 2 hours before bedtime
9. Use of probiotics
10. Use of Probiotics.
 Probiotics (eg, Lactobacillus bulgaricus) interfere with H pylori adhesion to epithelial
cells, and inhibit growth of H pylori in humans, in addition to reducing the side effects of
eradication treatment.
 Combining probiotic treatment with omeprazole, amoxicillin, and clarithromycin in H
pylori–infected children significantly improves the treatment effectiveness, compared
with drug treatment alone.

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 Foods high in vitamin C, A, Protein, zinc enhance the healing of the gut wall

NB 1: Milk (a historical food for peptic ulcer diseases) does not aid in ulcer healing and
actually promote gastric acid secretion i.e. Milk is an alkaline that neutralizes the stomach
acid thus provides a temporary relief however, it increase acid secretion thus delays the
healing of the ulcers. Other foods that increase acid secretion are coffee, soft drinks and
alcohol.
N/B 2. Fermented milk is good in the prevention of ulcers as the probiotic (the live
bacteria-e.g. lactobacillus bulgaricus) in milk prevents the growth of ulcer causing bacteria,
H-Pylori. Combining probiotic treatment with omeprazole, amoxicillin, and clarithromycin
in H pylori–improves the treatment effectiveness, compared with drug treatment alone.

Some specific foods to be given are

 Cabbage-cabbage has anti-inflammatory effects.
 Spinach- has low fiber.
 Potatoes: nutritive and anti-acid
 Okra: contain mucilage capable of protecting gastric mucosa
 Other vegetables are carrots.
 Fruits: apples, ripe bananas, avocado, pawpaw, pears, guava, orange juice
 Cereals: oat meal, porridge with low fibre, chapatti, macaroni, spaghetti, rice, matoke
 Eggs e.g. scrambled
 However roast beef and lamp, stewed/ baked should be taken in moderation as they
contain pureness (that stimulate gastric mucosa)

Lifestyle habits:
 Avoid alcohol, cigarette smoking and NSAIDS
 Minimize stress as stress cause hyper secretion of gastric acid

N/B. Not everyone with “ulcer” symptoms has an ulcer. Symptoms similar to those of peptic
ulcers can be caused by a wide variety of conditions. The differential diagnoses of peptic ulcers
are:-
 Functional dyspepsia (i.e., the presence of ulcer-symptoms without a specific cause)
 Abnormal emptying of the stomach
 Acid reflux
 Gallbladder problems
 Much less commonly, stomach cancer.

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Probiotics and prebiotics
Probiotics
Probiotics are live microorganisms usually bacteria that have health benefits when consumed.
Getting probiotics from supplements is popular but you can also get them from foods that are
prepared by bacterial fermentation
1. Yoghurt and mala. It is one of the best sources of probiotics. It mainly has the lactic acid
bacteria e.g lactobacillus bulgaricus
2. Sauerkraut: Sauerkraut is finely shredded cabbage that has been fermented by lactic acid
bacteria. It is always used in top of sausages. It is also rich in fiber, vitamin C, B,K, and
also high in sodium, manganese and iron

3. Fermented soya beans .Fermented beans also produces B12 something that is not in soya
beans but reach in animal foods(meat, eggs, fish, dairy products)

4. Fermented tea leaves

5. Some types of fermented cheese e.g. cheddar, gouda, mozzarella and cottage. not all
cheeses have probiotics as some cultured microorganisms are destroyed during the
aging process

6. Traditional buttermilk. There are two types of butter milk: Traditional and cultured.
Traditional buttermilk is simply is simply the leftover liquid from making butter. Only
this vision contains probiotics. Buttermilk is low in fat and calories, but rich in calcium,
phosphorus,, B12 and riboflavin

7. Pickles: pickles are cumbers that have been pickled in a solution of salt and water. They
are left to ferment to ferment using their own naturally present lactic acid bacteria. It is
the process that makes them sour

8. Pickles made with vinegar do not contain live probiotics

9. Fermented black or green tea leaves

Benefits of yoghurt/ mala and other probiotics

 It helps in reducing and treating bacterial induced diarrhea
 Has nutraceutical effects including reduction of serum cholesterol, management
of diabetes and prevention of osteoporosis
 Improves peristalsis, improve colon health and remove toxins (good for digestive
system)

pg. 122 by Osonga

  Helps in the synthesis of vitamin K and B- vitamins
 Enhance immunity
 Deactivate carcinogenic activities
 Improvement of gut functions, normalizing microflora balance(good for people
with ulcers that comes as a result of H. pylori), reducing constipation (good for
digestive system)
 Relive irritable bowel syndrome
 good for people with lactose intolerance,
Prebiotics
 Prebiotics are non-digestible food ingredients (carbohydrate/fiber in nature) that act as
food for probiotics.
 They reach the large intestine unaffected by digestion, and feed the good bacteria in our
gut helping them to grow and flourish.
 Prebiotics such fructo-oligosaccharides(FOS) and galacto-oligosaccharides(GOS) are
naturally found in foods such as legumes whole wheat products, onions, cabbage, garlic
etc. Both probiotic and prebiotics enhance the growth of healthy bacteria in the body

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2. INDIGESTION (dyspepsia)
 This refers to any discomfort in the digestive tract or it refers to a feeling of fullness or
discomfort during or after meal. It is a condition of impaired digestion

 It can be accompanied by burning or pain in the upper stomach, bloating, belching,

nausea, or heartburn.
 Basically, Indigestion is often a sign of an underlying problem, such as gastroesophageal
reflux disease (GERD), ulcers, gastritis, or gallbladder disease, rather than a condition of
its own.
 It may also be the first symptom of peptic ulcer disease (an ulcer of the stomach or
duodenum) and occasionally cancer.
 Indigestion is common after a large meal at some time
 Causes: Indigestion is mainly caused by gall bladder disease, GERD, chronic
appendicitis, chronic pancreatitis, stomach infections, ulcers, stress, rapid eating, irritable
bowel syndrome, thyroid diseases, poor mastication, over indulgence, food allergies and
Gastroparesis (a condition where the stomach doesn't empty properly; this often occurs in
diabetics)

Symptoms

pg. 123 by Osonga

  Discomfort in the digestive tract
 Feeling of fullness(bloating) or discomfort during or after meal

 Belching and gas

 Nausea and vomiting
 Acidic taste
 Growling stomach
 Burning in the stomach or upper abdomen
 Abdominal pain

Nutritional implication
 Inadequate food and nutrient intake

Nutrition therapy/dietary management

 Provide a well-balanced diet
 Avoid rapid eating and poor mastication of food
 Give plenty of water

Medical therapy
 Aspirin and many other painkillers
 Estrogen and oral contraceptives
 Steroid medications
 Certain antibiotics
 Thyroid medicines

3. Gastritis
The inflammation of the mucosa of the stomach. It may be acute or chronic gastritis

Acute gastritis
 This is a temporary inflammation of the gastric mucosa (the lining of the stomach).
Unlike chronic gastritis that develop slowly, acute gastritis occurs suddenly

Causes
 Overeating
 Overuse of alcohol and tobacco
 Chronic and excessive uses of aspirin/non-steroidal anti-inflammatory drugs (NSAIDS),
trauma and shock, fever, renal failure, burns, food poisoning, H pylori and chronic
vomiting etc.

pg. 124 by Osonga

  Bacterial infections, toxins, viruses, chemical irritants

Symptoms
 Nausea
 Vomiting
 Feeling of fullness in the upper part of abdomen
 Burning pain in your upper abdomen
 Malaise
 Anorexia
 Headache
 Haemorrhage

Nutrition implications
 Anemia
 Loss of nutrients
 Increased metabolism

Aims of nutritional management

 Restore nutrient loss
 Maintain adequate food and nutrient intake
 Relieve pain
Dietary management
1. No food or liquid is allowed for 24 – 48 hours or longer depending on whether there is
bleeding or not or until acute pain and nausea have ceased. This is done to allow the
stomach time to rest and heal. During this time, parenteral feeding is needed/Give fluids
intravenously during this period.
2. A clear liquid diet is followed by soft diet and the amount of foods are increased
according to the patient’s tolerance until a full regular diet is achieved.
3. Avoid seasoned foods.

Chronic Gastritis
 This refers to a condition (gastritis) that occurs slowly overtime resulting into irreversible
atrophy of the gastric mucosa related to chronic inflammation.
 Loss of mucosal cell functions may lead to lack of HCL in the stomach, anemia and
malnutrition.

pg. 125 by Osonga

Cause
 Cause is unknown, but usually precedes the development of gastric lesions such as cancer
or ulcer
 It may be caused by an enteral infection with Helicobacter pylori
 It may also be indirectly due to diseases such TB, myocardial failure and nephritis
Symptoms
 Maybe vague or absent
 Loss of appetite, feeling of fullness, belching, vague epigastric pain, nausea and vomiting
Nutrition implication
 Altered food intake
 Loss of nutrients
Aims of nutritional management
 Restore nutrient loss
 Maintain adequate food and nutrient intake
 Relieve pain
Dietary management
 Nutrition care must follow general guidelines because the symptoms are vague
 Diet should be adequate in calories and soft in consistency
 Encourage patient to eat at regular intervals, chew food thoroughly and avoid foods
known to cause discomfort
 Bland diet is recommended
 Minimize drinking fluids with food; drinking lots of fluids with food tends to cause
discomfort because of stomach distension
 In atrophic gastritis there is loss of secretion of HCL and B 12 intrinsic factor, therefore
Vitamin B12 status should be assessed

4. Damping syndrome (rapid gastric emptying)

 Damping syndrome is a condition where the lower end of the small intestine (jejunum)
fills too quickly with undigested food from the stomach.
 It develops after a survey to remove part of the stomach usually pyloric sphincter/after
surgery to bypass the stomach to help you loose weight, bariatric surgery/weight loss
surgery.
 This causes partially digested food to rapidly enter jejunum too quickly (in an
uncontrolled, abnormal fast manner) causing hyperosmolar load.
 Fluids from the intestinal capillarities enter the jejunum thus resulting into low blood
pressure and also stimulates peristalisis thus resulting into diarrhea.

Causes of the Dumping Syndrome

 Gastric surgery – removal of part of the stomach/gastric bypass surgery

pg. 126 by Osonga

Symptoms
 Abdominal cramps
 Diarrhea
 Vomiting
 Bloating
 Sweating
 Rapid pulse rate
 Shortness of breath
 Weakness
 Dizziness and paleness

Types of dumping syndromes

 Early dumping syndrome-It is where people develop signs and symptoms (diarrhea,
nausea, vomiting, bloating, shortness of breath and abdominal cramps) during or right
after meal (10-30 minutes)
 Late dumping syndrome- It is where people develop signs and symptoms 1-3 hours
after eating
 While others have both early and late symptoms

Nutritional implications
 Loss of nutrients
 Weight loss

Aims of nutrition management

 Provide adequate calories and nutrients to support tissue healing
 Prevent weight loss
 Correct hypoglycaemia in the short term
Nutrition therapy
After surgery the following should be done
 All fluids and foods by mouth should be withheld for 3 – 5 days and the patients feed by
Nasogastric tube
 Give pectin, a dietary fibre found in fruits and vegetables as it helps in treating dumping
syndrome by delaying gastric empting and slow carbohydrate absorption.
 Vitamin and mineral supplementation may be necessary.
 Serve liquids between meals rather with meals to slow the passage of the food mass.
 Limit simple carbohydrates

pg. 127 by Osonga

  Lie down immediately after eating to help slow the transit of food to the intestine but
clients with reflux should not lie down after eating.

4. Disorders of the small intestine

1. Diarrhea and Malabsorption
 Diarrhea refers to an increase in frequency of bowel movements compared with the usual
pattern/excess water content of stools affecting consistency/volume/both.
 Diarrhea is not a disease but a symptom of a medical condition either in the small
intestine, large intestine, pancreas or other conditions such as lactose intolerance, HIV,
mal absorption and irritable bowel syndrome etc.

NB: General diarrhea may result from basic dietary excess e.g. excess fiber/sugar.
Categories of diarrhea
Acute diarrhea
 Characterized by sudden onset and frequent passage of watery stool. It lasts for 24 – 48
hours.

Symptoms:
 Abdominal pain
 Fever
 Vomiting.

Chronic diarrhea
 Persist for a longer period of time and may last for several weeks.

Management
Medical therapy
 Treat the underlying cause
 Ors may be given in severe acute diarrhea.

Dietary modification
 Give a low fiber diet, mostly simple carbohydrates
 Low fat diet (to avoid malabsorption)
 Bland diet: Spicy diet may cause irritation of the stomach.
 Plenty of fluids to provide for lost fluids and electrolytes
 Energy – increase energy if the diarrhea is accompanied by fever.

pg. 128 by Osonga

  Increased intake for vitamin for the loss of vitamins
 Increased mineral intake mostly sodium and potassium
 Small quantities of food at frequent intervals. Excess will cause pressure in the GIT

2. Malabsorption
 This is where there is interference with how nutrients are absorbed/digested

There are 4 malabsorption conditions

1. Celiac disease
2. Cystic fibrosis
3. IBD (inflammatory bowel diseases)
4. Short bowel syndrome

Celiac disease
 It is an inherited disorder that causes damage to the small intestine and interferes with the
absorption of the nutrients.
 People who have celiac diseases cannot tolerate gluten, a protein found in cereal grains
such as Wheat, barley etc.
 Gluten molecules combine with antibiotics in the small intestine causing the usually
brush like lining of the intestine to flatten thus affecting the digestion and absorption of
foods.

Management
 Avoid food with gluten

Cystic fibrosis
 It is an inherited disorder that mostly affects the white people and can be classified as
either gastro – intestinal disorder or respiratory disorder
 It is where there is a high mucus secretion that obstructs endocrine glands, the lungs and
ducts.

Symptoms
 Bulky, foul smelling, oily stool
 Malabsorption
 Excessive sweeting in hot weather
 Thick mucus that accumulates on the endocrine glands, lungs

Nutrition therapy

pg. 129 by Osonga

  High energy diet
 High protein diet

Inflammatory bowel disease

 The term inflammatory bowel is used to apply to two intestinal conditions that result into
inflammation of the bowel i.e. crohn’s disease and ulcerative colitis

Predisposing factors
 Hereditary
 Environment e.g. crohn’s disease is higher in industrialized areas
 Immune functions

Difference between crohn’s disease and ulcerative colitis

Difference
Definition Crohn’s disease( a chronic Ulcerative colitis( a chronic
inflammation of the intestine) inflammation of the large intestine
that begins in the rectum)
Cause Inadequate intake of food, zinc Unknown but it’s likely that intestinal
deficiency, malabsorption of fats and allergy caused by some food e.g. Milk
protein, fever may be responsible
Cite of Any part of the GIT (from mouth to Inflammation and ulceration of large
inflammation the anus) but mostly the small intestine(colon) that always begin in the
intestine. rectum .Rectal bleeding is common
The inflammation affects the GIT
from mouth to anus but may skip
certain areas
Symptoms: Symptoms
Weight loss : common Weight loss: Common
1.Diarrhea 1.Diarrhea: common (passage of Common (alternating periods of
loose stools with mucus and blood diarrhea and constipation)
accompanied by pain)
2.Steatorea Steatorrhea: sometimes it can result No steatorrhea
into loss of calcium, magnesium and
zinc.
3.Fever Fever: yes No

4.Other Other symptoms: anorexia, fatigue Loss of appetite, rectal bleeding,

symptoms cramping dehydration, electrolyte imbalance,
anorexia mal absorption

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Crohn’s disease
Definition
 Crohn’s disease is a chronic inflammatory bowel disease that affect any part of the GIT,
from mouth to the anus, but the inflammation mostly occurs in the small intestine.

Cause:
 Inadequate intake of food
 zinc deficiency,
 malabsorption of fats and protein
 fever
 Chronic intestinal obstruction

Symptoms of Crohn’s disease

 Fatigue,
 Anorexia
 variable weight loss
 right lower quadrant pain or cramping
 diarrhoea
 steatorrhea
 Fever.
Nutrition implications
 Inadequate food and nutrient intake
 Malabsorption and mal-digestion
 Increased nutrient needs
Aims of nutrition management
 Restoration of good nutritional status
 Relief of discomfort

Management

Dietary management
 During acute flare-ups bowel rest and parenteral nutrition is recommended
 Later in patients who cannot tolerate whole foods elemental oral formula maybe useful
 High energy diet 40 – 50Kcal/Kg body weight
 High protein for wound healing, 1 – 1.5g/Kg body weight
 Give a low fibber diet to minimize bowel stimulation
 Give small frequent meals that are better tolerated than three large meals, this may help
maximize intake
 Low fiber diet

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  Give iron because of bleeding
 Provision of vitamin A,C, E, B12, and Folate
 Provision of pro-biotic and pre-biotic to promote growth of flora in the colon and
intestine.
 Provision of calcium ,zinc and magnesium since steatorrhea promotes their loss

Medical therapy
 Drugs e.g. antibiotics
 Surgical operation mostly for people suffering from people suffering from ulcerative
colitis where the colon or rectum may be removed.

Ulcerative colitis

Definition
 Ulcerative colitis is a chronic inflammation of the large intestine (colon) that begins in
the rectum)

Cause: Unknown but it’s likely that intestinal allergy caused by some food e.g. Milk may be
responsible
Symptoms
 Passage of loose stool with mucus and blood accompanied by pain and spasms
 Loss of appetite
 Rectal bleeding
 Ulcerative lesions in the mucosa of the large intestines
 Dehydration
 Electrolyte imbalance
 Anorexia
 Malnutrition
Nutrition implications
 Anaemia due to rectal bleeding
 Increased nutrient needs
 Fluid imbalance
 Food mal-digestion and nutrient malabsorption
Aims of nutrition management
 To relieve pain and inflammation
 To restore and maintain optimal nutritional status

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Dietary management
 Same as in Crohn’ disease. However, no dietary interventions seem to lessen disease
activity. And unlike Crohn’s disease where intestinal surgery fails to cure the disorder,
removal of the colon and the rectum does cure ulcerative colitis

Gastroenteritis-This refers to the inflammation of the stomach and intestine

Short Bowel Syndrome
 It is a malabsorptive condition that results after surgical removal of the parts of the small
intestine (usually 2/3 of the ileum and the ileocecal valve) with extensive dysfunction
of the remaining portion of the organ or it refers to malabsorptive condition that results
after surgical removal of more than 50% of the small intestine
 Ileocecal valve is the valve between ileum and the caecum. It prevents the backflow of
materials from the large intestine to the small intestine.
 Removal of some parts of the ileum and the valve promotes a transit time too rapid for
sufficient absorption of nutrients such as water, electrolytes, proteins, fats, carbohydrates,
vitamins and minerals thus resulting into malnutrition. Resection (surgical removal of
about 50% of the small intestine) can be done to conditions such as crohn’s disease,
abdominal injury and traumas.

Management
 Enteral or parenteral nutrition as the small intestine adapts to its function( remaining
villi may enlarge and lengthen to increase the absorptive surface area of the
remaining intestine)
 Reduced fat intake as the remaining intestine adopts.
 Increased electrolyte intake, vitamin and mineral.

Disorders of the large intestine

1. Flatulence – refers to the condition of having excessive stomach/intestinal gas as a result
of swallowed air (when eating, swallowing and chewing gum) or production in the GIT.
Most swallowed air is expelled from the stomach by belching and is odorless. Some
travel into the large intestines and is mixed with the gas produced by the bacteria in the
large intestine and is expelled through the anus. Increased amount of rectal gas indicate
excessive bacterial fermentation and suggest malabsorption of a fermentable substance
The unpleasant odor of the flatulence is as a result of the gases that contain sulphur
produced by the bacteria that mix with the odorless CO2, O2, hydrogen, nitrogen and
sometimes methane that are produced in the intestine or swallowed

Management

pg. 133 by Osonga

Medical therapy
 Use of drugs

Nutrition therapy
 Reduction in the amount of gas swallowed(aerophogia)-aerophagia can be avoided by
eating slowly, chewing with mouth closed and refraining from drinking through straws
 Reduction in fiber intake and other foods that results into increased production of gases
eg beans, cabbage, broccoli, whole grains, milk and its products, onions, apples, pears,
potatoes and decrease in intake of food that contains artificial sweeteners e.g gums

NB: Rice is the only starch that does not produce a gas
2. Irritable Bowel Syndrome
 A disorder where there is a recurrent abdominal pain and diarrhea that often alternating
with periods of constipation
 It differs from one person to another. Some experience only diarrhea or constipation
whereas others experience and alternating patterns of both.
 It’s more common with females than men.
 It is also common in individuals who tend to eat irregular meals, overuse of laxatives and
people who don’t get adequate rest

Symptoms
 More than three bowel movements per day or fewer than three
 Lumpy/hard or loose/ watery stool
 Passage of mucus
 Bloating (swelling of the abdomen caused by excessive gas)

Management
 For constipation, give high fiber diet
 For diarrhea give low fiber diet

3. Diverticular Disease
 Diverticulum or diverticular is a small tubular sack that protrudes from the main canal or
cavity in the body (diverticular refers to a small out pouching in the GIT i.e. from the
esophagus to the colon)
 Or diverticular are small sacs that protrude through weak sports in the muscle of the
colon
 It is caused by increased pressure within the intestinal lumen which may be related to
chronic constipation and a low fiber diet

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It can either be
i. Diverticulosis – presence of multiple diverticular in the walls of the GIT mostly colon. It
mostly occurs in older adults.
ii. Diverticulitis – refers to the inflammation of the diverticular. It is where the sacs become
filled with food residues and bacterial actions leads to inflammation

The common term for the conditions is diverticular disease

Causes of diverticular disease
 Aging
 Low fiber diet
 Chronic constipation

Symptoms
 Gross bleeding
 Low Hb and albumin level
 Cramping of the stomach /lower abdominal pain
 Alternating periods of diarrhea and constipation
 Bad breath
 Regurgitation and fever
 Dysphagia
 Constipation

Nutritional implications
 Anaemia
 Increased nutrient needs
Aims of nutrition management
 To restore nutritional status
 To relieve pain and enhance healing

Management
 Provision of high fiber for the management of the diseases(for diverticulosis) and low
fiber diet for the diverticulitis
 High protein for repair of worn out tissues
 Low fat diets in acute cases, provide clear liquid diet with progression to a very low-
residue diet

5. Constipation

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  Refers to the retention of feces in the colon beyond normal empting time (or this is where
bowel movement become difficult or less frequent thus resulting into hard stool that is
more difficult to pass.
 A person is said to be constipated if he/she goes longer than three days without bowel
movement (without passing a stool) or when he passes dry or hard stool often or often
having difficulty pushing out stool
 It is more common in older adults.

Causes
 Low fiber diet
 Inadequate fluid/water intake
 Lack of exercise
 Changes in social settings
 Inadequate activity or exercise
 Stress/worries
 Overuse of laxatives (stool softeners) which overtime weaken the bowel muscles
 A disruption of regular diet or routine/change of diet
 Excessive/ prolong use of anti-acids containing calcium or aluminum
 Ignoring the urge to pass stool
 Some medications e.g. iron supplements

Management
To manage the problem, you need to make your stool softer by
 Increased fiber intake (both soluble and insoluble fiber), this is found in vegetables,
fruits and cereals
 Increased fluid intake
 Increased physical activities. Avoid sitting or lying down for long
 use of laxatives(medical therapy)

Other management strategies

 You also need to have a good toilet routine-go to the toilet at a regular time and place
where you feel comfortable
 Use the toilet when you feel the urge

Other conditions of large intestine are acute and chronic gastritis, indigestion and the
hemorrhoids

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 Hemorrhoids (piles)
Hemorrhoids are swollen (enlarged) and inflamed veins in the rectum and anus that cause
discomfort and bleeding (they occur when the veins in the anus are enlarged)
Types of hemorrhoids
 Internal hemorrhoids-located inside the rectum. They cannot be seen or felt
(Not visible from outside). They are normally painless and rarely cause
discomfort. Straining when passing stool can damage the surface of the
hemorrhoid and cause bleeding (The first sign is rectal bleeding)
Occasionally straining can push an internal hemorrhoid through the anal opening.
This is known as protruding or prolapsed hemorrhoid
 External hemorrhoid-develops under the skin around the anus and therefore not
visible. They are painful. Straining when passing stool cause them to bleed
Causes of hemorrhoids
 Straining during bowel movement
 Obesity
 Sitting for long period of time on the toilet
 Pregnancy-increases pressure on the anus veins during later period of pregnancy
(as the uterus enlarges, it presses on the vein in the colon, causing it to bulge)
 Chronic diarrhea
 Chronic constipation
 Anal intercourse- can cause or worsen existing ones
 Aging-It is most common among the adults aged 45-65 years. However the young
people and children can also get it
 Low fiber diet
 Lifting heavy objects repeatedly
 Genetics-Some people inherit tendency to develop hemorrhoids

Symptoms
 Discomfort during bowel movement or sitting
 Swelling around the anus
 Bleeding during bowel movement
 Itching in anal region
 A lump near the anus (protruding from the anal region)
 Feces may leak out unintentionally

Prevention
 Nutrition therapy-high fiber diet( more fruits, vegetables and whole grains) to
soften stool and increase its bulk thus avoiding the straining caused by
hemorrhoids

pg. 137 by Osonga

  Drink plenty of water
 Fiber supplementation
 Stool softeners
 Do not strain-Straining and holding your breath when trying to pass a stool
creates greater pressure in the veins of the lower rectum
 Go to the toilet as soon as you feel the urge. This prevents the stool from
becoming dry and harder to pass
 Exercise to prevent constipation and reduce pressure on veins
 Avoid long periods of sitting more so on the toilet. Long periods increases
pressure on the veins of the anus
 Sufficient rest
Treatment
 Nutrition therapy-High fiber diet, Increased protein, increased iron intake,
increased vitamin C, increased intake of water
 Use of cream and ointment containing hydrocortisone
 Ice parks and cold compress- applied to the affected areas may help with swelling
 Moist towelettes-dry toilet paper may aggravate the problem
 Analgesics-painkillers e.g. aspirin, ibuprofen to alleviate pain
 Surgical operation

TOPIC: NUTRITION THERAPY IN DISEASES OF INFANCY AND

CHILD HOOD:
 Infancy refers to a period between birth to one year of age. Definitions may vary and may
include children up to two years of age
 Childhood refers to a period between birth to adolescent.
 Disease of infancy and childhood therefore refers to diseases that affects children from
birth to adolescent

HOSPITALIZED CHILDREN.

Malnutrition is the common diseases that affects most of hospitalized children. Malnutrition is
common at the time of hospital admission and tend to increase during hospital stay. It also
increases among hospitalized adults as well but not as much as in children. It tends to increase
during hospital stay because of

 Highly restricted diets that remains on order for too long

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  Unserved meals due to interference of medical procedures and clinical tests
 Unmonitored patients appetite
 Increased physiological stress due to hospital stay and environment. Increased
physiological stress increases the metabolic rate thus increased energy needs
Malnutrition is also common at home because; many families lack enough resources to buy
nutritious foods for children, some families lack information on what should be given to children
during this period of growth, Low immune system thus increased rate of disease that may result
into malnutrition

Malnutrition therefore increases the incidences of complications of the disease, multiple organ
failure (can affect cardiovascular system, GIT system, immune system, liver function, circulatory
system and endocrine system) and motilities in children.

Types of malnutrition in children.

Nutritional deficiency has traditionally been defined in two ways:

 Caloric Malnutrition or Marasmus

 Protein malnutrition or Kwashiorkor.
 Marasmic kwashiorkor (Combination of the two)
Management

 Provision of breast milk(depending on the age)

 Encourage small frequent meals
 Intake of vitamins such vitamin C for increased immunity
 Well established routine for eating
 Intake of fluid to prevent dehydration, depending on the existence of edema
 High energy diet in marasmus, high protein diet in kwashiorkor and high energy, high
protein diet in marasmic kwashiorkor
 Intake of milk for provision of calcium
 Enteral and parenteral feeding in severe cases
Formulation for the feeds (EN and PN)

Formulation of the EN (enteral nutrition) and PN (parenteral nutrition) feeds entails

determination of the Fluid Allowances and Caloric Requirements

Fluid Requirements
 0-12 months;150 mls/kg/bw/day
 1-3 years; 125mls/kg/bw/day
 4-6 years; 100mls/kg/bw/day
 7-9 years; 75mls/kg/bw/day
 10-12 years; 75mls/kg/bw/day
 13-15 years; 50mls/kg/bw/day

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  16-19 years; 50mls/kg/bw/day
Calories
 0-1 years; 90-100 kcal/kg/bw/day
 1-7 years; 75-90 kcal/kg/bw/day
 7-12 years; 60-75 kcal/kg/bw/day
 12-18 years; 30-60 kcal/kg/bw/day
 Adults; 30-45 kcal/kg/bw/day
40-50% of calories for parenteral should comprise of carbohydrates. This ensures that amino
acids are not used for energy but protein synthesis and other protein functions

Proteins
 Full term; 2-3.5g/kg/bw/day
 1-3 years; 2-3.5g/kg/bw/day
 4-6 years; 3g/kg/bw/day
 7-9 years; 2g/kg/bw/day
 10-12 years; 2g/kg/bw/day
 13-15 years; 1.7g/kg/bw/day
 16-19 years; 1.5g/kg/bw/day
Protein in EN and PN should comprise of 15-20% of total calories

Fats
 Older children; 1g/kg/bw/dy. Maximum of 2-3g/kg/by/day

LOW BIRTH WEIGHT INFANTS.

 This is when a child is born with a weight less than 2.5 kgs( less than 1500g-very low
birth weight, less than 1000g-extreamly low birth weight)
 Low birth weight is either because of preterm birth or full term birth (small for
gestational age
 Pre-term babies refers to children born before 37 weeks of gestation.
 Full term but low birth weight babies are not considered as pre-term.
Low birth weight can occur with other conditions such as fetal alcohol disease syndrome,
congenital heart disease or failure to thrive, irritability, learning disabilities, poor vision,

Causes of low birth weight babies

Low birth weight is caused primarily by maternal factors such as

 Multiple pregnancy
 Chronic medical condition
 Complication of pregnancy e.g. pre-eclampsia and eclampsia
 Inadequate medical care

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  Improper diet or poor eating(malnutrition)
 A mothers past obstetrical history.
 Weak cervix
 Acute infections e.g. STIs and other general infections
 Vaginal bleeding and spontaneous abortion
 Illicit drugs
 Smoking
 Stress
 Problems with the placenta or uterus
 Too much intake of alcohol
Problems that comes with feeding of low birth weight

 Frequent coughing, gagging, and spitting up during or after feeding

 Failure to take enough formulae during feeding
 May fall asleep during feeding
 Easily upset during feeding
Management of low birth weight babies

 Provision of specialized formulas that is concentrated or high calorie diet

 Small frequent feeding to increase energy, every 2 hours and fed at the middle of the
night
 Decrease exposure to light, noise, and movement that may distract them
 Enteral and parenteral when necessary
 Provision of breast milk if the mother can hold the baby
Formulation for the feeds (EN and PN)
Formulation of the EN (enteral nutrition) and PN (parenteral nutrition) feeds entails
determination of the Fluid Allowances and Caloric Requirements

Fluid Requirements
 Preterm; 60-120 mls/kg/bw/day
Calories
 Preterm; 110-150 kcal/kg/bw/day
40-50% of calories for parenteral should comprise of carbohydrates. This ensures that amino
acids are not used for energy but protein synthesis and other protein functions

Proteins
 Low birth weight; 3-4g/kg/bw/day
Protein in EN and PN should comprise of 15-20% of total calories

Fats
 Neonates; 0.5g/kg/bw/dy. Maximum of 3-4g/kg/bw/day

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 FAILURE TO THRIVE

It is a term that refers to children whose growth is significantly lower than what is expected of
their age and gender or failure to thrive refers to lack of expected normal physical growth or
failure to gain weight

It is caused by malnutrition (inadequate nutrition) whether primary or secondary. It can also be

seen in severely neglected or abused children

Signs and symptoms of failure to thrive

 Irritability
 Excessive sleepiness
 Easy fatigued
 Lack of appropriate weight growth
 Delayed motor development/failure to develop cognitive skills
 Failure to grow/develop social skills
Management

 Adequate energy for growth, 120 kcals/kg of ideal body weight

 Special formulas for children who cannot ingest enough food
 Provision of adequate carbohydrate
 Provision of adequate proteins
 Provision of adequate lipids
 Provision of vitamins and minerals

COLIC

 This is when a healthy, well fed infant/baby cries more than 3 hours a day, more than 3
days a week, for more than 3 weeks i.e. it is an excessive crying by a baby
 Colic mostly occurs in the evenings and it occurs without any identifiable causes.
 It always start 2-6 weeks after birth in full term babies or later in premature babies
 It always goes away on its own by 3 or 4 months
Causes

Some theories behind colic

 Growing digestive system with muscles that often spasm

 Too much gas in the stomach
 Hormones in the body that causes stomach pain
 Oversensitivity to light, noise

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  Food allergy
 Moody baby
 Developing nervous system
A good diagnosis should be conducted to differentiate it from normal crying, medical conditions
that can cause baby cries e.g. infections, acid reflux, inflammation of the brain or nervous
system, irregular heartbeat, injury to the bones, muscles, fingers etc.

Management of colic

 Eliminate cow’s milk as some children are intolerant to protein in cow’s milk
 Diet low in dairy, soy, eggs, peanut and wheat may offer relief from excessive crying.
This is because of the protein found in them as children who are allergic to cow’s milk
tend to be allergic to these proteins as well
 Ensure that the child do not swallow much air while breastfeeding or from the bottle (the
nipple should have a smaller whole). Too much air can result into colic
Other management strategies

 Lay him across your lap and gently rub his back
 Use warm water in bathing the child
 Sit him/her up while being fed
 Burp him/her up during and after eating
 Lay him on his back in dark, quiet room

FUNCTIONAL INFANT VOMITING

 Commonly known as rumination/infant rumination syndrome/infant regurgitation/spitting

up or innocent vomiting. It is the effortless (unforceful) repetitive regurgitation of
recently ingested food (gastric content) into the mouth with subsequent re-mastication
and re-swallowing of and/ or spitting out/expelled.
 It is not accompanied by nausea or pain or food refusal. .
 It occurs during and between feedings several times per week or per hour.
 The vomitus contains no blood or bile and is not accompanied by weight loss or nor does
it impair growth provided the infant is consistently fed to satiety. But it can result into
weight loss, growth failure, electrolyte imbalance, dehydration and even death if the child
spit out too much and the child is not fed to satiety.
 It affects two thirds of well-fed babies and it begins as early as 2-3 months and does not
occur when the infant is a sleep or when the baby is actively interested in the
environment. Rumination also affects children and adults and it is also common in
mentally challenged persons
Self-stimulating behaviors that can cause rumination in infants are moving the head, sucking on
the hand and making sound. It can result into malnutrition, weight loss, growth failure,

pg. 143 by Osonga

electrolyte imbalance, dehydration and even death. Others believe that it is caused by hiatal
hernia and poor mother-child relationship

Management

 The infant should be feed until turns away regardless of how often or how much he spits
up(Feeding should not be limited as this may result in insufficient intake as well as
increased irritability)
 Small frequent meals
 Thickened feeding by thickening the milk with small amounts of baby cereals
 The infant should be put in upright position for at least thirty minutes following feeding
 Provision of temporary mother substitute/ or encourage the mother to have a good close
mother –infant relationship as some people believe that it is also caused as a result of
poor mother-infant relationship. The mother substitute must recognize when the baby
enters into the self-occupied state of withdrawal that fosters rumination and must respond
promptly by making social contact with baby
Other management strategies

 Medical therapy and surgery in case of hernia

N/B. Rumination differs with the real vomiting, that is forceful throwing up of stomach contents
through the mouth which might be caused by infections, chemicals in the blood(e.g. drugs),
psychological stimuli from disturbing sights or smells, nervousness in the stomach(nervousness
can be as a result of anxiety, excitement and stress. Nervousness also affects people travelling in
a vehicle and can be managed by chewing ginger root, or drinking ginger tea, lemon palm as
they ease nervousness. Avoid caffeine especially coffee as they fuel nervousness).

Real vomiting is accompanied by nausea, pain, weight loss, growth failure, electrolyte imbalance
and dehydration. Some people mostly children aged 2-16 years old repeated vomiting syndrome
(cyclic vomiting) where they have episodes of vomiting

CONSTIPATION

 Constipation has been defined as a delay or difficulty in defection present for two or
more weeks.
 Infant constipation is not common
Causes in infants

 More common in formula fed than breast fed infants

 It might be as a result of a serious health problem e.g. spinal cord abnormality,
hypothyroidism, diabetes insipidus, cystic fibrosis, rectal abnormality, or glucose
intolerance if it present constipation starts at an early age as it is not common in early age
and when children are breast feed. A doctor should be consulted

pg. 144 by Osonga

  Infant constipation often begins when a baby starts eating solid foods
 Some medications e.g. iron supplements and anti-acids
Causes among children on solid foods

 Low fiber diet

 Inadequate fluid/water intake
 Lack of exercise
 Changes in social settings
 Inadequate activity or exercise
 Ignoring the urge to pass stool
 Some medications e.g. iron supplements and anti-acids
Signs and symptoms

 Infrequent passage of hard stools(pellet like bowel movements)

 Abdominal distention
 Rectal bleeding
 Failure to thrive
 Decreased appetite, nausea and vomiting
 Frequent urination or bed wetting
Management

 Increased intake of water or fruit juice. These juice contains sorbitol that acts as a
laxative
 Increased vegetable and fruits(fiber) if the child is eating solid foods
 Provision of milk of magnesia
 Provision of mineral oil
 Provision of sorbitol
 Provision of lactulose
 Avoid giving constipating fruits to infants e.g. bananas, apple
 Increased physical activities. Avoid sitting or lying down for long
 Use of rectal medication
 Good toilet routine-the child should be encouraged to go to the toilet at a regular time and
place where he/she feels comfortable

DIARRHEA

 Diarrhea refers to an increase in frequency of bowel movements compared with the usual
pattern/excess water content of stools affecting consistency/volume/both.
Causes

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  Infection with virus, bacteria, or parasite
 Food allergy or sensitivity to medicines
 Drinking too much fruit juice
Nutrition implications

 Dehydration(loss of fluids)
 Loss of electrolytes
 Increased metabolic needs
 Increased protein and nutrient loss
 Decrease in micro-nutrient loss-e.g. zinc copper
Symptoms

 Dry mouth
 No tears when the baby is crying
 Irritable
 Sunken eyes
 Sunken soft sport on the top of the baby’s head
 Skin doesn’t spring back when pinched
 Peeing less often
 Blood may appear in the stool
 Vomiting

Management

 Increased breast feeding

 Increased fluid intake
 Small frequent meals. Excess will cause pressure in the GIT
 Bland diet: Spicy diet may cause irritation of the stomach.
 Plenty of fluids to provide for lost fluids and electrolytes
 Energy – increase energy if the diarrhea is accompanied by fever.
 Increased intake for vitamin for the loss of vitamins
 Avoid foods that can make it worse e.g
o Greasy foods
o Foods high in fiber
o Dairy products such as milk, cheese
o Sweets such as soda
Medical therapy

 Treat the underlying cause

 Ors may be given in severe acute diarrhea.

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 CLEFT LIP AND PALATE

 A cleft is a gap or split in the upper lip and/or roof of the mouth).It is present from birth
or this is a condition when a baby is born with an opening in the lip and or roof of the
mouth
 The gap is there because parts of the baby’s lips and or palate didn’t join together
properly during development in the womb. Both cleft lip and cleft palate are treatable
through surgery within the first year or two in life.
Types

 Cleft lips, where there is a gap in the lip-It is most common in boys
 Cleft palate, where there is a gap in the palate- It is most common in girls.
 Cleft lips and palate, where there is a gap in the lip together with the plate-It is most
common in boys
A cleft can be on one side of the mouth (unilateral cleft) or no both sides of the mouth (bilateral
cleft)

Sometimes the palate cleft can be hidden by the lining of the roof of the mouth

Causes

The exact cause is not known but it is associated with anything a mother did or didn’t do during
pregnancy

 Lack of folic acid during pregnancy

 Obesity during pregnancy
 Smoking or drinking alcohol during pregnancy
 Taking certain medicines in early pregnancy such as some anti-seizure medications and
steroids
 Genes a child inherit from their parents
Complications/problems related to cleft lip and palate in new born

 Difficulty in feeding-Nasal regurgitation and chocking are common because they lack the
bone and soft tissue separating the nose and the mouth. As a result, the baby may get
milk into the nose. This is called nasal regurgitation. Have a soft cloth readily available to
wipe the baby’s nose and mouth and allow the baby to rest a few moments before
resuming feeding. Cleft palate babies feed better when positioned upright so there is less
chance of milk getting into the nose. Difficulty in feeding into poor growth and failure to
gain weight
 Excessive air intake that results into choking, they requires frequent burping to remove
excess air. Excess air also interferes with the amount of feeds taken by the baby

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  Feeding time is significantly longer and fatigues both mother and baby
 Poor suction as they cannot hold the nipple of the breast or of the bottle well
 Frequent infections
Other problems

 Speech problems
 Hearing problems
Management

 Good nutrition to build resistance to infection, to be strong to surgery and to have the
nutrients needed to heal after surgery
 Frequent feeding
 Frequent burping to remove excess air, 10-15 minutes, six to eight times in 24 hours
following breast feeding attempts
 Buy bottle and nipple that are meant for them
 For children with poor weight gain breast milk can be fortified or high calorie formulas
can be used to meet nutrition requirement
 Early referral for dental care should be encouraged as they have higher dental problems
than normal children(Childs teeth do not develop correctly and they may be at higher risk
of tooth decay)

Strategies that can be used to encourage children to eat during illness

 Encourage the child to drink and eat with lots of patience

 Feed small amounts frequently
 Give foods that the child likes most
 Give a variety of nutrient rich foods which are well prepared and attractively served
 Continue to breastfeed(often ill children breastfed more frequently)
 Give extra breastfeeds
 Feed an extra meal
 Give an extra amount
 Use energy and nutrient dense foods
 Feed with extra patience and love
 Give a variety of nutrient-rich foods which are well prepared and attractively served to
stimulate appetite

TOPIC: LIVER DISEASES

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TOPIC: DISEASES OF THE LIVER AND THE GALLBLADDER
(A) DISEASES OF THE LIVER
Anatomy of the Liver:
 The Liver is the largest internal organ in the body and the second largest organ of the body
after the skin, located just below the diaphragm.
 The liver lies to the right of stomach and overlies the gallbladder and it weighs about 3.2-3.7
pounds (1.44-1.66 Kgs).It is also the largest gland in the human body.
 It is called a gland because it secretes chemicals that are used by other parts of the body
 The liver is part of the biliary system, which includes the gallbladder and the pancreas.

A diagram of the liver, gallbladder and pancreas in the body

Note:
1. The liver has an important bearing on ones nutritional status as the disease of this
organ has direct effects on metabolism of nutrients
2. The liver is connected to two large blood vessels. 1. The hepatic portal vein that
caries blood containing digested nutrients from the entre gastrointestinal tract,

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 blood from the spleen and blood from the pancreas. 2. The hepatic portal artery
carries blood from aorta

Functions of the liver:

The functions of the liver can be grouped into three main categories.

1. Manufacturing functions
1. Protein synthesis(Production of proteins that are secreted into the blood-plasma
proteins) e.g fibrinogen, globulin, albumin (protein for the blood stream that is
required to maintain fluid within the circulation system) and blood clotting factors
2. Synthesis of glycogen from glucose. Glucose is synthesized into glycogen when the
supply glucose is in excess and the glycogen can be stored both in the liver and in the
muscle cells.
3. Synthesis of cholesterol which is used for production of hormones, vitamin D and bile
4. Synthesis of triglycerides.
5. Production of bile that is essential for fat metabolism
6. Production of special proteins that carry lipids in circulation e.g chylomicrons, LDL,
HDL
7. Synthesis of hormones; thrombopoietin, hepcidin, betatrophin, angiotensinogen
2. Storage functions
1. Storage of vitamins ( Vitamin A-for vision and immunity, D-for absorption of
calcium, K-for clotting of blood, B12 and folic acid)
2. Storage of iron (For production of red blood cells)-Most of the iron is stored in the
liver
3. Storage of glycogen-It is released when the extra energy is needed by the body
4. Waste disposal/detoxification

Detoxification refers to the process in which in which liver converts harmful products
(e.g. drugs, toxins from foods, etc.) into harmless substances. Detoxification is done by
the enzymes found in the liver

1. The liver plays an important role in detoxifying the body by converting

ammonia, a toxic by-product of metabolism from dietary protein and muscle tissue into

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 urea that is excreted by the kidneys as urine. Ammonia is mixed with carbon dioxide
and synthesized into urea and then excreted in the urine

2. Drugs, medicines and alcohol are metabolized and detoxified by the liver.
Intake of some drugs for a longer period of time can affect the endoplasmic reticulum of the liver
and result into liver disease

3. Breaking down of insulin, hormones and red blood cells and helps in the
removal of waste products from the breakdown of these products e.g. bilirubin from the
breakdown of red blood cells

General causes of diseases of the liver

This may be due to;
i) Infectious agents (viruses, bacteria and parasites)
ii) Toxic chemicals e.g. carbon tetrachloride, drugs
iii) Excessive alcohol intake
iv) Poor nutrition and metabolic disorders
v) Biliary obstruction
vi) Cancer
General objectives of dietary management of liver diseases;
 Maintain or improve the patient’s nutritional status through provision of adequate energy and
nutrients
 To prevent further degeneration of the liver, enable regeneration of as much new tissues as
possible
 To enable the damaged liver to easily and efficiently perform its functions.
 To relieve disease symptoms
 To allow liver to rest as much as possible.
 To replenish glycogen stores.
 To prevent or alleviate hepatic coma.

Liver Diseases (Liver disease is any condition that affects liver

function.)

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 1. Hepatitis
2. Liver cirrhosis
3. Alcoholic liver disease
4. Liver cancer
5. Fatty liver disease
6. Hepatic failure/ liver failure
When the liver is diseased, the liver diseases can result into
 Atrophy (reduction in the cell size of the liver)
 Fatty infiltration
 Fibrosis (excessive fibrous tissue in the liver)
 Necrosis (dead of cells or tissue of the liver)
 Jaundice -is the yellow discoloration of the tissues that causes yellowing of the skin,
urine and the whites of the eyes. In jaundice the blood levels of bile pigments are high.

1. HEPATITIS
 Hepatitis is an infectious disease characterized by inflammation and degeneration of the
liver cells (causes injury to the liver cells) that affect the liver’s ability to function OR
hepatitis is an inflammation of the liver. Hepatitis viruses(A, B, C, D, E) are the most
common cause of hepatitis in the world but hepatitis can also be caused by toxic
substances (e.g. alcohol, certain drugs), herbal substances, other infections(bacteria,
parasites) and autoimmune diseases
Types of hepatitis
There are five types of hepatitis, hepatitis A, B, C, D and E but the most common hepatitis
are A, B and C.. Hepatitis B and C are serious infections
1. Hepatitis A.
It is caused by hepatitis A virus (HAV).
Sources of contamination: Drinking water and food contaminated with sewage/fecal
matter, eating raw or uncooked food or eating food handled by someone who is infected.
It is mild and do not always progress to chronic state/illnss or permanent liver damage.
Most people infected recover without being treated nor showing the signs. Vaccinations

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 against HAV are routinely provided to children and high risk individuals. Hepatitis E is
also transmitted as hepatitis A and both are acute infections that disappear on their own
2. Hepatitis B.
It is a serious liver infection caused by hepatitis B virus (HBV) and it can progress into
chronic stage and thus develop into liver failure, liver cancer and liver cirrhosis (a
condition that causes permanent scarring of the liver. It is a global health concern.
Vaccinations are currently recommended for newborn infants and children, health care
providers, recipients of blood products, dialysis patients and sexually active adults and
users of injected drugs.
Mode of transmission of hepatitis B:
1. Sexual contact with infected person, through blood, saliva, semen, or vaginal secretions,
blood transfusion and by sharing of infected needles
2. Mother to child during birth
3. Hepatitis C.
It is caused by hepatitis C virus (HCV). Most cases progress to chronic illness and it is the
most common cause of chronic liver disease .Most people infected with hepatitis C (HCV)
have no symptoms until liver damage shows up after a long period of time. Preventive
measures include; blood donor screening, viral inactivation of blood products and infection
control practices in health care settings. No vaccine is available against Hepatitis C
Mode of transmission of hepatitis C:
1. Sexual contact with infected person, through blood, saliva, semen, or vaginal secretions,
blood transfusion and by sharing of infected needles
2. Mother to child during birth
4. Hepatitis D.
Hepatitis D is also spread through contact with blood, but infections with this virus only occur
when someone is also infected with hepatitis B. Injection drug users are at risk for this type of
hepatitis

N/B. Hepatitis can manifest itself as acute or chronic. Most acute infections brought
on by the hepatitis A, B, C and E virus will resolve on their own over several weeks or
months. Chronic hepatitis B and C infections (which do not get better on their own

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 after a few months) may be treated with antiviral medications. Vaccinations are also
available for prevention of hepatitis except for hepatitis C

Symptoms of hepatitis
Anorexia, weakness and fatigue, joint pain, loss of appetite, jaundice (is the yellow
discoloration of the tissues that causes yellowing of the skin, urine and the whites of the
eyes{due to the accumulating of the bile pigment (bilirubin) in the blood}, vomiting, diarrhea,
fever, weight loss and abdominal pain in the liver area, Oedema, Ascites

N/B Types of jaundice;

 Obstructive jaundice; this is due to interference to the flow of bile by stones, tumours or
inflammation of the bile ducts.
 Hemolytic jaundice; this occurs due to abnormally large destruction of blood cells. This is
seen in yellow fever (not related to liver disease).
 Toxic jaundice; this is due to poison or drugs or viral infections.
N/B. Other conditions that can result into jaundice are malaria and sickle cell anemia. Pregnant
women can also have jaundice when they have liver problem such as hepatitis

Management of Hepatitis;
Aims of management include;
a. To promote liver tissue regeneration
b. To prevent further liver damage
c. To prevent weight loss
d. To prevent or alleviate hepatic coma
Management of Hepatitis;
1. Nutrition therapy-hepatic diet
 High energy diet because of the degeneration of the organ, fever and for weight gain. E.g.
glucose and honey can be added to food
 Protein intake: Protein intake depends on the extent of liver damage. High protein diet
for mild and moderate cases for repair and synthesis of new tissue. Give low protein

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 (High biological protein) in a cute cases and when the extent of damage is extensive as the
damage liver may not be able to convert all the ammonia into urea. We also give low
protein diet to minimize the production of ammonia
 Low fat diet because of impaired bile secretion. Emulsified fat like from whole milk,
butter and eggs can be given as less bile is required for their emulsification. Avoid fried
foods, fatty foods
 High vitamins especially A,D,E,K due to decrease and impaired absorption of fat as this
vitamins need fat for their absorption
 Increased vitamin C intake for tissue leaching
 Other diet modification to manage the symptoms such as vomiting, diarrhea
 Tube feeding and parenteral feeding in severe cases
 Avoid alcohol
 Fluids - Fluid intake should be high to help in the removal of ammonia and prevent
dehydration (at least 2000 ml/day) unless there is ascites or edema
2. Medical therapy. Use of drugs and medicines
3. Change of Lifestyle e.g. good hygiene, use of protection during sexual intercourse and by
not sharing needles

2.LIVER CIRRHOSIS/ SCARRING (FIBROSIS)

This is a chronic disease of the liver in which the healthy functioning cells of the liver are
gradually replaced by fibrous connective tissues and the liver looses its functions. It is
characterized by destruction of the cells thus resulting into an abnormal structure. It happens after
the healthy cells are damaged over a long period of time, usually many years. (Cirrhosis is the
advance stage of liver disease- it is the most serious form of liver disease)

There’s no cure for cirrhosis except a liver transplant, but you and your doctor can slow cirrhosis
down by treating whatever is causing it.

What Causes Cirrhosis?

Chronic alcoholism is the main cause of liver cirrhosis. This disease can also develop as a result
of other liver conditions or diseases you already have. They include:

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 Chronic Alcoholism is the main cause of liver cirrhosis. Alcohol and metabolic products
interfere with liver metabolism and damages liver cells directly. This results into fatty
liver, inflammation and replacement of liver cells by fibrous connective

 Viral hepatitis mostly Hepatitis C and B

 Obstruction/ blockage of the liver (by e.g. gall stones ) of the bile duct leading to
accumulation of bile in the liver

 Malnutrition resulting into development of fatty liver (fatty cirrhosis) –Malnutrition

conditions that can result into fatty liver .are- overweight, diabetes, high cholesterol levels,
and high blood pressure. Continuous fat infiltration causes cellular destruction and fibrotic
tissues changes

 Metabolic conditions e.g. copper and iron overload

 Autoimmune inflammatory conditions. .

 Medications. Some drugs can cause cirrhosis if they’re taken for a very long time.
 Poisons
 Atherosclerosis and congestive heart failure

Symptoms
 The onset of the disease is gradual with initial symptoms of gastro-intestinal disturbances
like nausea, vomiting, anorexia and abdominal distention and pain. This is then followed
by:
 Bleeding in the GIT leading to anemia
 Ascites (Fluid accumulation in the abdomen/ belly) and edema
 Accumulation of waste products in the body blood leading mental confusion
(encephalopathy).
 Loss of weight
 Jaundice, due to excess bilirubin in the body. Bilirubin is a yellow compound that arise from
the destruction of aged red blood cells or excess bilirubin may also occur when the liver is
not clearing the bilirubin properly. Major symptom of jaundice is the yellowing of the skin
and the yellowing of the whites of the eyes. Jaundice can also be a sign of hemolytic anemia

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  As the diseases progresses, blood circulation through the liver is impaired and blood clotting
mechanism is also impaired as factors such as prothrombin and fibrinogen are not adequately
produced by the damaged liver thus you bleed easily from a small bruise.
 You can also develop gallstones that may block the bile duct
N/B Ascites is the buildup of fluid in the space between the lining of the abdomen and the
abdominal organs (the peritoneal cavity)
Edema is fluid built up in the tissues, usually the feet, legs or back.
Both conditions result from abnormal accumulation of sodium associated with portal
hypertension (High blood pressure) and liver disease.
Liver cirrhosis is characterized by:-
 Extensive loss of liver cells
 Formation of inactive or functionless scar tissue (fibrous connective tissues) which impair
blood circulation through the liver. They are as result of repeated episodes of liver necrosis
followed by regeneration
 Fatty infiltration of the liver

1MAGE OF A NORMAL LIVER AND ONE WITH CIRRHOSIS

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Management of liver cirrhosis
1. Nutrition therapy-Hepatic diet
 High energy diet because of the degeneration of the organ, fever and for weight
gain. E.g. glucose and honey can be added to food.35 to 35 Kcal/kg body weight
 Low Protein diet to minimize the production of ammonia and not to over work the
liver as the diseased liver may not convert all the ammonia into urea: 0.8 to 1.2g/kg
body weight of protein is recommended. The intake should be adequate to regenerate
the liver cells and prevent infections. Give low protein(High biological protein)
 Carbohydrate: Adequate intake of carbohydrate to prevent catabolism of the of
the body protein for energy, which would further increase blood ammonia. No
restriction of carbohydrates is required unless the patients has Diabetes mellitus (DM)
or insulin resistance. For patients with DM, monitor carbohydrate intake and provide a
diet that maintains blood glucose levels.
 Low fat diet because of impaired bile secretion. Emulsified fat like from whole
milk, butter and eggs can be given as less bile is required for their emulsification.
Avoid fried foods, fatty foods. The fat should be moderate enough as it increases
kcalorie content of food. Restriction should also be ensured when there is steatorrhea
 High vitamins and minerals: The central role of the liver is to metabolize and store
vitamins and minerals. High minerals and vitamins should be ensured as diseased liver
may not be able to metabolize and store enough minerals for the body. High intake of
vitamins especially A,D,E,K should also be ensured due to decrease and impaired
absorption of fat as this vitamins need fat for their absorption
 Increased vitamin C intake for tissue leaching.
 Decreased sodium intake to reduce and manage ascites and edema. Usually ‘no added
salt’ is recommended for patients with severe cirrhosis; however, sodium intake is often
restricted for patients who develop decompensated cirrhosis (cirrhosis nearing end stage)
with ascites. Limit sodium intake to 2000 mg/day or less or no salt at all in order to
prevent fluid buildup and swelling of the liver. The best salt substitute is lemon juice (it is
salt free).

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  Fluid: Fluids should be encouraged unless ascites or edema is present. Water is the
fluid of choice
 Alcohol: There should be abstinence from alcohol to protect the liver from further
injury
How to reduce salt intake?
 Choose low salt foods
 Do not add any salt at the table
 Check labels low salt or “no salt added”
 Try to avoid processed foods e.g canned meat, vegetables, bread, cheese, mayonnaise
because they have more salt than the unprocessed ones
3. Medical therapy:
Use of drugs and medicines e.g anti-viral drugs to treat viral infections, use of diuretics to
treat ascites, lactoluse to treat hepatic coma by reducing the level of ammonia, use of
antibiotics
4. Liver transplantation in advance liver cirrhosis
N/B: Patients with liver cirrhosis are at increased risk of developing liver cancer

IMAGE OF A PATIENT WITH LIVER CIRROSIS

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Consequences of liver cirrhosis
1. Anemia; Patients may develop anemia and be more susceptible to infection.
2. jaundice and fat malabsorption; If there is bile obstruction
3. Portal hypertension; a cirrhotic liver may interfere with blood flow from the hepatic
portal vein. This cause resistance to blood flow causing a rise in blood pressure in the
portal vein a condition called portal hypertension.
4. Oedema; Interference with blood flow causes accumulation of fluids in the blood vessels
and body tissues situation known as oedema.

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5. Varices: This refers to dilated or enlarged veins. Blood flow through the liver slows
down in people with liver diseases. This results into increased pressure in the portal vein
that supplies blood to the liver. This vein can dilate as a result of the increased pressure.
Cirrhosis can also result into dilation of the oesophagus and abdomen blood vessels as
they have thin vessels. Varices can break open and bleed. Bleeding is a medical
emergency
6. It also results in altered sex hormones leading to feminization of men and
hypogonadism(Failure of the gonads, testes in men and ovaries in women to function
properly-produce the sex hormones e.g failure of the men to produce sperm, testosterone
or both ). (N/B Liver regulates the balance of sex hormones)
7. Ascites; Within ten years of disease onset, 50% of cirrhosis patients develop ascites
which is the accumulation of fluids in the abdominal cavity. The development of ascites
indicates that liver damage has reached a critical stage as half of the patients with ascites
die within 2 years.
Ascites can be as a result of
o Portal hypertension which forces plasma from the vessels into the cavity causing
swelling known as ascites
o Sodium and water retention in the kidneys due to increased pressure within the
portal vein
o A fall in plasma osmotic pressure due to impaired albumin synthesis in the liver.
Albumin is a blood protein that helps to retain fluid in blood vessels
o Opening of oesophageal varices which occurs due to blockage of blood flow
through the liver
o Elevated pressure within the liver’s small blood vessels (sinusoids) causes leakage
of fluids into the lymphatic vessels and ultimately the abdominal cavity.
N/B. Ascites can cause abdominal discomfort and early satiety which contribute to malnutrition.
8. Hepatic encephalopathy; It is a brain disorder/ Loss/decline of brain functions when
damaged liver cannot remove/ detoxify toxins in the blood that eventually reaches the blood and
affects the brain. It can occur due to liver cirrhosis or liver failure
Causes

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 Elevated blood ammonia levels which causes ammonia neurotoxicity because the liver
cannot detoxify ammonia to urea.
 Entrance of ammonia into the cerebral circulation i.e. nervous system intoxication.
 Accumulation of other substances in the brain e.g sulfur compounds, short-chain fatty
acids and manganese.
General symptoms of hepatic encephalopathy;
It is in four stages;
Stage Symptoms
I  Mild confusion
 Gitation
 Irritability
 Sleep disturbance
 Decreased attention
II  Lethargy
 Disorientation
 Inappropriate behavior
 Drowsiness
III  Somnolent/excess sleep
 Incomprehensible speech
 Confused
 Aggressive behavior when awake
IV  Coma

Manifestation of hepatic encephalopathy;

 Asterixis (flapping tremor) - this is the uncontrolled movement of the hands and legs,
confusion, restlessness and irritability
 Fetor hepaticus- fecal odour breath
 Convulsions- leads to coma which can result to death.
 Elevated blood ammonia levels; In advanced liver disease, the liver is unable to
convert ammonia to urea

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  Malnutrition and wasting; most patients with cirrhosis develop PEM and experience
some degree of wasting. Malnutrition is caused by a combination of factors such as;
a) Reduced nutrient intake due;
o To abdominal discomfort
o Altered mental status
o Anorexia
o Early satiety due to ascites
o effects of medication
o Fatigue
o Nausea and vomiting
o Restrictive diets e.g. sodium restriction which may make food less
palatable
b) Malabsorption or nutrient losses; due to diarrhoea, effects of medication,
malabsorption (fat malabsorption due to reduced bile flow this can lead to fat soluble
vitamin deficiencies and some minerals)
c) Altered metabolism or increased nutrient needs due hypermetabolism, impaired
protein synthesis, infection or inflammation, muscle catabolism
d) If the cirrhosis is due to alcohol abuse, multiple nutrient deficiencies may be present.
9. Hepatic coma; it is unconsciousness caused by severe liver disease. It occurs when the liver
fails to break down toxins in the body. It is a syndrome caused by high blood levels of ammonia
due to;
 Use of a high protein diet in severe liver disease
 Ammonia produced in the GIT by bacterial action
 GIT hemorrhage
 Surgery of the GIT.
Symptoms of hepatic coma
i) Severe mental confusion (loss of consciousness)
ii) Restlessness
iii) Hyperactivity
iv) Drowsiness

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 v) Breath that has feacal odour
vi) The person goes into coma and may have convulsions
vii) Poor coordination of arms and legs (asterixis)
Management of hepatic coma;
 Use of medicines/drugs.

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Dietary management of hepatic coma
 Low protein diet i.e. 20-30g/day) but as the condition improves the protein intake is
gradually improved to supply 1g/kgbwt/day.
 Sufficient calories from carbohydrates and fats should be given to prevent tissue breakdown
about 1500-2000kcals/day.
 It is necessary to restrict fluid intake to 1000-1500ml/day
 Vitamin supplements especially of vitamin C and B complex which are important for
regeneration of the liver tissues.

3. ALCOHOLIC LIVER DISEASE (ALD)

 Alcoholic liver disease refers to liver diseases/ liver damage that occurs due to
overconsumption of alcohol. Alcoholic liver diseases include, alcoholic fatty liver
(steatosis/ steatohepatitis) disease, alcoholic hepatitis, chronic hepatitis (alcoholic liver
cirrhosis/ fibrosis) which are brought about by consumption of alcohol. They occur in
people who consume large amount of alcohol over a long period of time and alcoholic liver
disease does not occur in all heavy drinkers. Alcoholic liver disease can also occur in in
moderate drinkers
 Alcoholic fatty liver disease: Alcoholic fatty liver disease is a condition in which fat builds
up in the liver. Alcoholic fatty liver disease is due to heavy consumption of alcohol. This can
result into inflammation which can eventually results into alcoholic hepatitis and cirrhosis
N/B. Fat can also build up in nonalcoholic individuals. In nonalcoholic individuals, the fatty
liver disease can be categorized as Simple fatty liver; in which the liver becomes fat with little
or no inflammation, or liver cell damage. Simple fatty liver rarely causes liver damage or
complications. Non-alcoholic steatohepatitis; in which there is fat in the liver, liver is inflamed
and the liver cells are damaged. The inflammation can cause liver scarring/fibrosis

 Fatty liver is more common in type 2 diabetes, obese, middle or older people(children can
also get it), hypertensive people, people with high levels of cholesterol, , those who are on
some cancer drugs, and those with infections such as hepatitis C, people who suffer from
rapid weight loss (starvation), nutritional deficiencies e.g. kwashiorkor, TB

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 Alcoholic hepatitis: This refers to the inflammation of the liver caused by drinking alcohol.
Not all heavy drinkers develop alcoholic hepatitis, and the disease can occur in people who
drink only moderately.
Symptoms of alcoholic liver diseases
jaundice, Loss of appetite Nausea and vomiting, abdominal pain and tenderness, Retention of
large amounts of fluid in the abdominal cavity (ascites),Confusion and behavior changes due
to brain damage from buildup of toxins

(encephalopathy) Kidney and liver failure

N/B. Fatty liver is reversible.

Management
As in liver cirrhosis, and hepatitis

4. LIVER CANCER

 Liver cancer is a cancer that begins in the cells of the liver. Cancer is where there is a
development of abnormal cells that divide uncontrollably and have the ability to destroy
normal body tissue. The most common form of liver cancer is hepatocellular carcinoma,
which begins in the main type of liver cell (hepatocyte).
Risk factors to liver disease
 Certain inherited liver diseases e.g Wilsons disease , exposure to aflatoxins(poisons produced
by molds that grow on poorly stored crops), Cirrhosis, Chronic infection with hepatitis B and
C viruses, obesity, fatty liver, diabetes, excessive alcohol consumption
Early cancers can be treated by chemotherapy surgery or a liver transplantation.

5. LIVER/HEPATIC FAILURE
 Liver failure can be grouped as either acute or chronic liver failure
 Acute liver failure is loss of liver function (when liver cells are damaged) that occurs rapidly-
in days or weeks in a person who has no pre-existing liver disease. It is less common than
chronic liver failure which develops slowly

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Causes: Acetaminophen overdose (This drug is the main cause of liver in U.S.A),
Use of herbal medicines, Hepatitis, Autoimmune disease that attacks liver cells, cancer,
Metabolic diseases e.g. Wilson’s disease, acute fatty liver of pregnancy
Symptoms
Jaundice, abdominal pain, abdominal swelling, vomiting, weight loss, confusion and
sleepiness

6. Cholestasis
This is a condition in which bile cannot flow into the small intestines to aid the digestion of fats
as a result, fat is not absorbed. It results in the backup of bile in the liver. In this condition, fat is
not absorbed and is excreted in large amounts in feaces, giving feaces a pale-coloured and foul
smell a condition known as steatorrhea.
The loss of fat calories may result in weight loss. To alleviate this condition, special fat
substitutes need to be used which are less dependent on bile for intestinal absorption.

Functional Foods to incorporate into the weekly diet for people with liver
diseases
1. Garlic – Activates liver enzymes that help your body flush out the toxins.
2. Grapefruit, citrus fruits e.g lemon and oranges–They are high in both Vitamin C and
antioxidants, have cleansing abilities for the liver and boost production of the liver
detoxification enzymes that help flush out carcinogens and other toxins.
3. Beets and Carrots – Both are extremely high in plant flavonoids and betacarotene, that
stimulate and support overall liver function.
4. Green Tea- This liver loving beverage is full of plant based antioxidants known as
catechins compounds known to assist liver function.
5. Green Leafy Vegetables – Extremely high in chlorophyll, greens soak up
environmental toxins from the blood stream. With their distinct ability to neutralize
chemicals and pesticides these cleansing foods offer a powerful protective mechanism
for the liver.

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 6. Avocados – this nutrient dense superfood help the body produce glutathione, a
compound that is necessary for the lives to cleanse harmful toxins.
7. Apples – High in pectin apples hold the chemical constituents necessary for the body to
cleanse and release toxins from the digestive tract. This in turn, makes it easier for the
liver to handle the toxic load during the cleansing process.
8. Alternative Grains – e.g Millet can help filter toxins from the liver.
9. Cruciferous Vegetables- Broccoli and cauliflower are good sources of glucosinalate
which supports enzyme production in the liver. These natural enzymes flush carcinogens
and other toxins from the body and may significantly lower risks associated with cancer.
10. Lemons and Lime – these citrus fruits are high in vitamin C. Drinking freshly squeezed
lemon or lime juice in the morning can help stimulate the liver.
11. Cabbage – Stimulates liver detoxifying enzymes (that help the liver to flush out toxins

(B) GALLBLADDER DISEASES

GALLBLADDER DISEASE
Introduction
 The gallbladder is a small pouch (sac) that is located under the liver.
 The main function of the gallbladder is to store the bile produced in the liver and pass it
along to the intestine. After meals, the gallbladder is empty and flat, like a deflated
balloon. Before a meal, the gallbladder may be full of bile and about the size of a small
pear.
 In response to signals, the gallbladder squeezes stored bile into the small intestine
through a duct.
 Bile helps digest fats but the gallbladder is not absolutely necessary for human survival,
as bile can reach the small intestine in other ways and therefore removing the gallbladder
in an otherwise healthy individual typically causes no observable problems with health or
digestion yet there may be a small risk of diarrhea and fat malabsorption
 The release of bile into the intestine is signaled by a hormone called cholecystokinin,
which is released when food enters the small intestine. It causes the gallbladder to

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 contract and deliver bile into the intestine where it emulsifies (breaks down) fatty
molecules. It also enables fat-soluble nutrients (such as vitamins A, D, E, and K), to pass
through the intestinal lining and enter the bloodstream.

Disease of the Gall Bladder

1. Gallstones(cholelithiasis)
2. Choledocholithiasis disease
3. Acalculous Gallbladder Disease
4. cholecystitis disease

1. Gallstones(Cholelithiasis)

 The process of gallstone formation is referred to as cholelithiasis.

 Gallstones are solidified particles (hard deposits) of substances in the bile. They are made of
a “combination of bile salts, cholesterol, calcium, lecithin(a phospholipid) and bilirubin,”
 The majority of gallbladder diseases are caused by
inflammation due to irritation to the gallbladder
wall (cholecystitis). This occurs when gallstones
obstruct the ducts leading to the small intestine
and may eventually lead to necrosis or gangrene.
 Gallstones can be any size from tiny as a grain of
sand to large as a golf ball.
TYPES OF GALLSTONES
a) Cholesterol Stones.
Although cholesterol makes up only 5% of bile, about three-fourths of the gallstones are
formed when there is too much cholesterol in the bile.
b) Pigment Stones.
 Pigment stones form when there is excess bilirubin in the bile.
 Pigment stones can be black or brown.
c) Mixed stones: Mixed stones are a mixture of cholesterol and pigment stones.

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 Although it is common to have many smaller stones, a single larger stone or any combination
of sizes is possible.
N/B
 Gallstones are most common among overweight, middle-aged women, but the elderly
and men are more likely to experience more serious complications from gallstones.
 Women who have been pregnant are more likely to develop gallstones. The same is true
for women taking birth control pills or on hormone/estrogen therapy as this can mimic
pregnancy in terms of hormone levels.
Conditions that may lead to cholelithiasis(formation of gall stones):
 When the liver secretes too much cholesterol into the bile.
 When the gallbladder is not be able to empty normally, so bile becomes stagnant.
 When the cells lining the gallbladder is not able to efficiently absorb cholesterol and fat
from bile.
 There are high levels of bilirubin. Bilirubin is a substance normally formed by the
breakdown of hemoglobin in the red blood cells. It is removed from the body in bile.

2. Choledocholithiasis (Common Bile Duct Stones)

This is when gallstones are present in the common bile duct, rather than the gallbladder. This
condition is called choledocholithiasis.

Symptoms of Stones in the Common Bile Duct (Choledocholithiasis)

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 Stones lodged in the common bile duct can cause symptoms that are similar to those
produced by stones that lodge in the gallbladder, but they may also cause the following
symptoms:
 Jaundice (yellowish skin)
 Dark urine, lighter stools, or both
 Rapid heartbeat and abrupt blood pressure drop
Fever, chills, nausea and vomiting, and severe pain in the upper right abdomen.

3. Acalculous Gallbladder Disease

 This is when gallbladder disease occurs without stones, a condition called acalculous
gallbladder disease.
 It is where a person has symptoms of gallbladder stones, yet there is no evidence of
stones in the gallbladder or biliary tract. It can be acute (arising suddenly)

4. Cholecystitis disease
 This is the inflammation of the gallbladder.
 It occurs when gallstones blocks the tube leading the gallbladder. Other causes of
cholecystitis include bile duct problems and
tumors.
Symptoms of cholecystiti

Severe pain in the right abdomen., Pain that radiates from the right shoulder or back.,
Tenderness over your abdomen when it's touched., Nausea., Flatulence, Vomiting and Fever

Cholecystitis signs and symptoms often occur after a meal, particularly a large or fatty meal.

RISK FACTORS FOR GALL BLADDER DISEASE

Risk Factors in Women
1) Women are much more likely than men to develop gallstones. In general, women are
probably at increased risk because estrogen stimulates the liver to remove more
cholesterol from blood and divert it into the bile.
2) Pregnancy increases the risk for gallstones, and pregnant women with stones are more
likely to develop symptoms than women who are not pregnant. Surgery should be
delayed until after delivery if possible. In fact, gallstones may disappear after delivery

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 3) Hormone replacement therapy (HRT) doubles or triples the risk for gallstones,
hospitalization for gallbladder disease, or gallbladder surgery. Estrogen raises
triglycerides, a fatty substance that increases the risk for cholesterol stones.
4) Risk Factors in Men
1. Advance in age- About 20% of men have gallstones by the time they reach age 75.
Because most cases do not have symptoms, however, the rates may be underestimated
in elderly men.
Risks in Children
Gallstone disease is relatively rare in children. When gallstones do occur in this age group,
they are more likely to be pigment stones. Girls do not seem to be more at risk than boys.
The following conditions may put children at higher risk: Spinal injury, History of abdominal
surgery, Sickle-cell anemia, impaired immune system, receiving nutrition through a vein
(intravenous)
GENERAL RISK FACTORS
1. Ethnicity
e.g Hispanics and Northern Europeans have a higher risk for gallstones than do people of
Asian and African descent.
2. Genetics
Having a family member or close relative with gallstones may increase the risk.
3. Diabetes
People with diabetes are at higher risk for gallstones and have a higher-than-average risk
for acalculous gallbladder disease (without stones).
4. Obesity
Obesity. Being overweight is a significant risk factor for gallstones. In such cases, the
liver over-produces cholesterol, which is delivered into the bile and causes it to become
supersaturated.
Complications of gall stones;
 It can result result into inflammation of the gall bladder( cholecystitis ). Cholecystitis can
lead to infection or to more severe complications including perforation of the gall bladder.
 If the gall stones obstruct the common bile duct, they can block bile from the liver and lead
to jaundice or damage to the liver tissues.

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 A gall stone within the bile ducts may lead to infection and the condition known as bacterial
cholangitis which causes severe pain, sepsis and fever which is often a medical emergency.
 Gall stones can also block the pancreatic duct as well cause primary acute pancreatitis.
Management gallbladder diseases
Surgery; It involves the removal of the gall bladder is known as cholecystectomy is the
primary treatment for patients with recurring gallstones.
Nutrition therapy
Diet may play a role in gallstones. Specific dietary factors may include: -
1. Fats: e.g lean meat and low dairy fats. Dietary fat is the principal cause of contraction of
the diseased organ and subsequent pain. Energy should come primarily from
carbohydrate foods especially during acute phases. Fats also contributes to weight loss , a
primary goal because obesity and excess food intake is associated with the development
of gallstones
2. Fiber: High intake of fiber has been associated with a lower risk for gallstones It also
helps in weight management e. g whole grains
3. Fruits and vegetable: People who eat a lot of fruits and vegetables may have a lower risk
of developing symptomatic gallstones that require gallbladder removal. Some great ones
are avocados, berries, grapes, cucumbers and beets. Broccoli, bell peppers and oranges
are high in fiber and vitamin C, which if lacking can contribute to gallstones. Pectin-rich
fruits — such as apples, strawberries and citrus — can also help
4. Kcalories: Reduced kcals if one is overweight
5. Sugar: High intake of sugar has been associated with an increased risk for gallstones.
Diets that are high in carbohydrates (such as pasta and bread, chips, cakes, sodas Crips,
pastry and biscuits) can also increase risk, because carbohydrates are converted to sugar
in the body
6. Drink plenty of water
7. Alcohol: A few studies have reported a lower risk for gallstones with alcohol
consumption. Even small amounts (1 ounce per day) have been found to reduce the risk
of gallstones in women by 20%. Moderate intake (defined as 1 - 2 drinks a day) also
appears to protect the heart. It should be noted, however, that even moderate alcohol

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 intake increases the risk for breast cancer in women. Pregnant women, people who are
unable to drink in moderation, and those with liver disease should not drink at all.
8. Coffee: Research suggests that drinking coffee every day can lower the risk of gallstones.
The caffeine in coffee is thought to stimulate gallbladder contractions and lower the
cholesterol concentrations in bile. However, drinking other caffeinated beverages, such as
soda and tea, does not seem to have the same benefit.

TOPIC: PANCREATIC DISORDERS

PANCREATIC DISORDERS
Unit Objectives
By the end of the unit the learner should be able to:
a) Describe the functions of the pancreas
b) Describe the various types, causes and management of pancreatic disorders
c) Plan and prepare meals for management of pancreatic disorders

ANATOMY OF THE PANCREAS

The pancreas is about 6 inches long and sits across the back of the abdomen, behind the stomach.
The head of the pancreas is on the right side of the abdomen and is connected to the duodenum
(the first section of the small intestine) through a small tube called the pancreatic duct. The
narrow end of the pancreas, called the tail, extends to the left side of the body (Towards spleen)

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Functions of the pancreas

 The pancreas has two main functions: an exocrine function that helps in digestion and an
endocrine function that regulates blood sugar.
 Almost all of the pancreas (95%) consists of exocrine tissue that produces pancreatic
enzymes for digestion. The remaining tissue consists of endocrine cells called islets of
Langerhans that produces hormones that regulate blood sugar and regulate pancreatic
secretions. The pancreas is therefore two glands that are intimately mixed together into
one organ.
Exocrine functions (digestion)
 The exocrine portion of the pancreas plays a major role in the digestion of food( that the
stomach releases slowly into the duodenum as a thick, acidic liquid called chime)
Pancreatic juice is a mixture of
1. Digestive enzymes. The digestive enzymes digest food (carbohydrates, fats, and
proteins) that the stomach realises slowly into the duodenum as a thick, acidic liquid
called chime. These enzymes include
 trypsin , chymotrypsin and carboxypeptidase to digest proteins;
 pancreatic amylase for the digestion of carbohydrates;

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  lipase to break down fats
2. The bicarbonate ions that neutralize the acid in the chime to protect the intestinal wall
and create a proper environment for the functioning of pancreatic enzymes

N/B. The pancreatic juice eventually mixes with the bile in the common duct where they act on
the food in the duodenum. Bile is produced by the liver and stored by the gallbladder until need
arises

Endocrine Function (Blood Glucose Homeostasis)

 The endocrine component of the pancreas consists of islet cells (islets of Langerhans) that
create and release important hormones directly into the bloodstream.
 Blood glucose levels must be maintained within certain limits so that there is a constant
supply of glucose to feed the cells of the body but not so much that glucose can damage
the kidneys and other organs.
 The pancreas produces 2 antagonistic hormones to control blood sugar: glucagon and
insulin.

1. Glucagon (produced by the alpha cells) that raises blood glucose levels by stimulating the
liver to metabolize glycogen into glucose molecules and to release glucose into the blood.
Glucagon also stimulates adipose tissue to metabolize triglycerides into glucose and to
release glucose into the blood.
2. Insulin is produced by the beta cells of the pancreas. This hormone lowers blood glucose
levels after a meal by stimulating the absorption of glucose by liver, muscle, and adipose
tissues. Insulin triggers the formation of glycogen in the muscles and liver and
triglycerides in adipose to store the absorbed glucose.

 Regulation of Pancreatic Function

The function of the pancreas is controlled by both the nervous system and the endocrine
system.
 The endocrine system uses 2 hormones to regulate the digestive function of the pancreas:
secretin and cholecystokinin (CCK).

COMMON DISORDERS OF THE PANCREAS

1. Pancreatitis
2. Cystic Fibrosis
3. Pancreatic cancer

PANCREATITIS

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 Pancreatitis refers to the inflammation of the pancreas. The inflammation is caused by
digestion of the organ tissues by enzymes it produces, principally trypsin. (i.e. It is a disease
where the pancreatic tissues are damaged by its own enzymes-auto digestion). Normally
enzymes remain in inactive form in the pancreas until pancreatic secretions reach the
duodenum through the pancreatic duct. The damage happens when these digestive enzymes
are activated before they are released into the duodenum and begin attacking the pancreas
tissues causing a cute pain it is characterized by edema, cellular exudate, and fat necrosis.

Causes

The main cause is the activation of the inactive enzyme trypsinogen to active form trypsin. This may
occur as a result of gallbladder disease that may cause gallstones to enter the common bile duct and
obstruct flow from the pancreas or cause a reflux of these secretions and bile from the common duct back
into the pancreatic duct

Other causes include

 Heavy alcohol use which can lead to blockage of the pancreatic duct.
 Medications/ Indigestion of certain drugs
 infections e.g bacterial infections
 Mumps
 Hep A/B or salmonella
 Abdominal trauma
 Metabolic disorders
 Cystic fibrosis
 Lupus and surgery.
 Presence of tumour/pancreatic cancer
 Triglycerides in the very high range
 Hypocalcaemia
 A venomous sting of a scorpion.
Forms of pancreatitis: acute and chronic.

Acute pancreatitis

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  Acute pancreatitis is a sudden inflammation that lasts for a short time. It may range from
mild discomfort to a severe, life-threatening illness.
 Most people with acute pancreatitis recover completely after getting the right treatment.
 In severe cases, acute pancreatitis can result in bleeding into the gland, serious tissue damage,
infection, and cyst formation. Severe pancreatitis can also harm other vital organs such as
the heart, lungs, and kidneys.
Symptoms of Acute Pancreatitis

 Upper abdominal pain that radiates to your back;

 Abdominal pain that feels worse after eating, especially foods high in fat.
 Swollen and tender abdomen( when touched)
 Nausea and vomiting
 Fever
 Increased heart rate

The primary goals of nutritional management in acute pancreatitis are:

 Maintain a healthy body weight: Obesity appears to be a risk factor for the development
of pancreatitis and for an increased severity when it occurs. Gallstones is also a risk factor
for acute pancreatitis
 Minimise pain
 Reduce steatorrhea

Management of acute pancreatitis

 All oral feeding is withheld-The patient is kept NPO( nil per os-that is nothing by mouth)
until condition improves because food intake will stimulate pancreatic enzyme release in
already inflamed/ injured pancreas. Intravenous feedings are given in order to rest the G.I
tract.
 Intravenous fluid hydration is provided. This is to prevent dehydration. Dehydration often
accompanies pancreatitis and it can worsen the symptoms and complications.
 Nasogastric tube is inserted to remove gastric contents, which will reduce any stimulation of
the pancreas.

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 Enteral nutrition is introduced within 24-48 hours. Clear liquid diet is introduced while
tolerance is assessed
 Since proteins and fats stimulate pancreatic secretion, high carbohydrates liquids are the best
initial oral source of energy.
 Later as the patient improves, small meals consisting of easily digested carbohydrates and
proteins with limited fats (25-30gms.) are given.
 Fats are restricted due to absence of the pancreatic enzyme necessary for their digestion.
 As the patient improves, a bland, low fat diet with six small feedings in a day is instituted.
 Small frequent meals may be better tolerated initially because they help to reduce the amount
of pancreatic stimulation at each meal.

N/B .Parenteral nutrition used to be the preferred option for the treatment of acute pancreatitis
but it placed patients on strict bowel rest. Enteral nutrition is now recommended (introduced
within 24-48 hours) as Parenteral nutrition results into gastro intestinal atrophy (death of the cells
of the intestine) which leads to bacterial translocation across the gut barrier, sepsis (infection)
and organ failure. Prolonged Parenteral nutrition should only be recommended when enteral
nutrition is impossible. It may fail due to pseudocytes, intestinal and pancreatitis fistulas,
pancreatitis abscesses, and pancreatitis ascites

Some foods to be avoid:

 Saturated fats found in shortening, margarine, certain oils, chips, cookies, cakes,
pastries and crackers
 Fried food and junk food
 Refined carbs present in white bread, pasta, snacks and certain cereals
 Sugar and sweets
 Caffeine, present in coffee, tea and chocolate

Chronic pancreatitis

 Chronic pancreatitis is long-lasting inflammation of the pancreas.

Causes:
1. It most often happens after an episode of acute pancreatitis.
2. Heavy alcohol drinking is another big cause. Damage to the pancreas from heavy
alcohol use may not cause symptoms for many years, but then the person may
suddenly develop severe pancreatitis symptoms.
3. Autoimmune conditions(when the body’s immune system attacks its own body)
4. Blocked pancreatic duct due to gall stones

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 5. Penetration of chronic duodenal ulcers to the pancreas
6. Hyperparathyroidism-increases calcium levels in blood causing it to be deposited
in soft tissues.
7. Hyperlipidemia - This condition causes the digestion of fat and other nutrients to
be permanently impaired.
Symptoms of chronic pancreatitis

 The symptoms of chronic pancreatitis are similar to those of acute pancreatitis.

Other symptoms are:
 Weight loss due to poor absorption (malabsorption) of food. This malabsorption happens
because the gland is not releasing enough enzymes to break down food.
 Hyperglycaemia-diabetes may develop if the insulin-producing cells of the pancreas are
damaged.
 Jaundice
 Oily, smelly stools (Steatorrhea)
The primary goals of nutritional management for chronic pancreatitis are:

 Prevent malnutrition and nutritional deficiencies

 Maintain normal blood sugar levels (avoid both hypoglycaemia and hyperglycaemia)
 Prevent or optimally manage diabetes, kidney problems, and other conditions associated
with chronic pancreatitis
 To reduce steatorrhea
 To reduce pain

Management of chronic pancreatitis

Nutrition therapy
 Small frequent meals should be given to ensure that the nutrient requirements are met
 A low-fat diet: Limit fat to the maximum that can be tolerated by the patient without
causing steatorrhea or pain. Usually 50g/day or less (give medium chain triglycerides
(MCTs)).
 Protein: Provide liberal/moderate quantities of protein. A protein diet of 1.0-1.5 g/kg
body weight/d is generally sufficient and well tolerated.

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  Calories: High energy diet. High carbohydrate diet to replenish calorie and nutrient
losses.
 Fibre: In general, a low fibre diet is recommended, because fibre may absorb enzymes
and delay the absorption of nutrients.
 Eliminate individual intolerances and gastric stimulants e.g. coffee, black pepper, tea,
chili powder, cloves and garlic.
 Provide supplements of vitamin C and B-complex vitamins as well as water-miscible
forms of the fat-soluble vitamins.
 Alcohol: Avoid alcohol if pancreatitis was caused by alcohol use. Alcohol should be
taken in moderation even if it was not the main cause of acute pancreatitis

 Smoking: People with pancreatitis should avoid smoking, as it increases the risk for
pancreatic cancer.

 A soft diet, high in carbohydrates, moderate in proteins, and low in fat is given.

 If possible, allow the patient to take what he prefers and can tolerate.
 Foods are given in six small feeds as they are better tolerated.

Complications associated with Pancreatitis

 Kidney failure: Acute pancreatitis may cause kidney failure.

 Diabetes: Damage to insulin-producing cells in your pancreas from chronic pancreatitis

can lead to diabetes, a disease that affects the way your body uses blood sugar.

 Malnutrition: Both acute and chronic pancreatitis can cause your pancreas to produce
fewer of the enzymes that are needed to break down and process nutrients from the food
you eat. This may lead to weight loss, even though you may be eating the same foods or the
same amount of food

 Pancreatic cancer: Long-standing inflammation in your pancreas caused by chronic

pancreatitis is a risk factor for developing pancreatic cancer.

 Pseudocyst(Pancreatic cyst): These are sack like pockets of fluid on or within the
pancreas. Most of them are not cancerous but some can be cancerous. A large pseudocyst

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 can ruptures and cause complications such as internal bleeding and infection. Signs and
symptoms of pseudocyst are:

o Persistent abdominal pain which may radiate to your back.

o A mass you can feel in your upper abdomen.
o Nausea and vomiting

N/B. A ruptured pseudocyst is a medical emergency. Fluid released by the pseudocycts can
damage nearby blood vessels and cause massive bleeding

Signs and symptoms of a ruptured pseudocyst are: vomming of blood, fainting, severe abdominal
pain, weak heat beat, and decreased consciousness

CYSTIC FIBROSIS (CF)

Cystic fibrosis is an inherited disorder that mostly affects the white population. It is where an
organ e.g pancreas, lungs, GIT, liver over secretes sticky, thick mucus (by cells that produce
mucus).This causes severe damage to the lungs, sweat glands digestive system and in males it
causes infertility

SYMPTOMS

 Secretion of thick mucus that accumulates and clogs air passages in the lungs and
intestines. This may result into frequent respiratory infections, breathing difficulties, and
chronic lung disease.
 Loss of salt that accompanies the mucus. A loss of salt may cause an upset in the balance
of minerals in the blood, abnormal heart rhythms, and, possibly, low blood pressure and
shock.
 Liver disease
 Diabetes
 Pancreatitis. Inflammation of the pancreas that causes severe abdominal pain.
 Gallstones
 Fatty/oily stool,
 Infertility in males.
 Sinusitis( inflammation and swelling of the nasal passage)
 Nasal polyps(soft painless noncancerous growth on the lining of the nasal cavity)
 Clubbing of fingers and toes. A condition marked by extremely thickened fingertips and
toes due to decreased oxygen in the blood

ORGANS AFFECTED BY CYSTIC FIBROSIS

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 Management

Nutrition therapy
Enzymes, vitamins, and salt:

 High energy, high protein with no fat restriction

 Increase intake of vitamin A, D, E, K, and extra calcium. There are special formulas for
people with CF.

 People who live in hot climates may need a small amount of extra table salt.

 Give small and frequent meals

 Most people with CF must take pancreatic enzymes to help in the digestion of
carbohydrates, proteins, fats.
o These enzymes help your body absorb fat and protein. Taking them all the time
will decrease or get rid of foul-smelling stools, gas, and bloating. They are taken
with all meals
PANCREATIC CANCER
Two types of cancer can affect the pancreas:

1. The most common is cancer of the exocrine pancreas that originates in the pancreatic
ducts.

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 This type of pancreatic cancer, called "pancreatic ductal adenocarcinoma. It is the most
common
2. Another type of cancer consists of a group of tumours that originate from the cells that
make hormones such as insulin. These tumours are called "pancreatic endocrine tumours.

A diagram of pancreatic ductal adenocarcinoma.

Causes of Pancreatic cancer

It's not clear what causes pancreatic cancer in most cases. Doctors have identified factors, such
as smoking, that increase your risk of developing the disease.

How pancreatic cancer forms

Pancreatic cancer occurs when cells in your pancreas develop mutations in their DNA. These
mutations cause cells to grow uncontrollably and to continue living after normal cells would die.
These accumulating cells can form a tumour. Untreated pancreatic cancer spreads to nearby
organs and blood vessels.

Pancreatic cancer symptoms

Pancreatic cancer is often referred to as a “silent cancer” because it is thought that the early
symptoms can be vague and unrecognised. Most people with pancreatic cancer have pain and
weight loss, with or without jaundice (yellowing of the skin):

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  Pain – Pain is a common symptom. It usually develops in the upper abdomen as a dull
ache that wraps around to the back. The pain can come and go, and it might get worse
after eating.
 Weight loss – Most people with pancreatic cancer lose weight because of a lack of
appetite, feeling full after eating only a small amount of food, or having diarrhoea. The
bowel movements might look greasy tract where and float in the toilet bowl because they
contain undigested fat.
 Jaundice – This causes yellow coloured skin and whites of the eyes. Jaundice is caused
by a block in the flow of bile from the gallbladder, where it is stored, to the intestinal the
bile assists in digestion of food. The block is caused by the cancer.
 Dark urine, nausea, vomiting, and enlarged lymph nodes in the neck.
 Loss of appetite and changes the taste.
 An enlarged gall bladder due to blockage of the bile ducts.
 Elevated blood sugars. Some people with pancreatic cancer develop diabetes as the cancer
impairs the pancreas' ability to produce insulin.
 Itching: Itchy skin, palms, and soles of feet. People with pancreatic cancer sometimes
report itching all over. Blockage of the bile ducts is often responsible.

N/B Understanding that the tube (duct) carrying bile from the liver passes through the pancreas
on its way to the intestine, helps us understand why some people with pancreatic cancer develop
jaundice (an abnormal yellowing of the skin and eyes).

Risk factors of pancreatic cancer

The following factors may raise a person's risk of developing pancreatic cancer:
 Age. The risk of developing pancreatic cancer increases with age.
 Gender.
 Race/ethnicity.

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  Smoking.
 Obesity and diet.
 Diabetes.
 Family history.
 Rare inherited conditions.

Pancreatic cancer staging

The stages of pancreatic cancer are:

 Stage I: Cancer is confined to the pancreas and can be removed using surgery.

 Stage II: Cancer has spread beyond the pancreas to nearby tissues and organs and may
have spread to the lymph nodes. At this stage, surgery may be possible to remove the
cancer.

 Stage III: Cancer has spread beyond the pancreas to the major blood vessels around the
pancreas and may have spread to the lymph nodes. Surgery may or may not be possible
to remove the cancer at this stage.

 Stage IV: Cancer has spread to distant sites beyond the pancreas, such as the liver, lungs
and the lining that surrounds your abdominal organs (peritoneum). Surgery isn't an option
at this stage.

Dietary problems that come with cancer

The dietary problems can be brought about by
1. Cancer infection

 The main functions of the pancreas are to provide digestive enzymes to help break
down food and hormones such as insulin and glucagon to control blood sugars.

 Cancer of the pancreas can interfere with this, which can lead to digestive problems
and prevent you from absorbing all the nutrients from your food.

2. Treatment methods

 Treatment options such as surgery, to remove all or part of the pancreas and/or radio
and chemotherapy, can also cause dietary problems leading to poor appetite, nausea
and vomiting, diarrhoea and changes in taste and smell.

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The dietary problems may include:

 Poor digestion and malabsorption of fats, carbohydrates and proteins due lack of digestive
enzymes which help us break down our food and absorb the nutrients from food. Symptom of
malabsorption are: pale, floaty stools which can be oily, foul smelling and difficult to flush
away. Other symptoms include bloating, flatulence and weight loss.
 Poor appetite and weight loss. Due to poor digestion, malabsorption, poor appetite and
diarrhoea
 Nausea and vomiting
 Jaundice can cause loss of appetite, taste changes, nausea, vomiting, and steatorrhea. These
symptoms usually resolve once the jaundice is treated
 Change in taste and smell.
 Mouth sores
 Diabetes that occurs because your pancreas may not be making enough insulin

Management
Medical therapy
 Surgery
 Chemotherapy
 Radiation

Nutrition therapy
 High energy diet: Because of increased metabolic rate
 Sufficient carbohydrate to spare protein for synthesis of tissues and healing process,
production of hormones and enzymes
 High intake of protein
 Sufficient intake of vitamins and minerals especially vitamin A, C,E and B
complex(They are coenzyme agents for protein and energy metabolism

 Nutrition therapy for change in taste and smell

o If your food tastes too sweet, try adding lemon juice or salt – starting with a few
sprinkles/drops and increase until you find the taste acceptable.
o If food tastes metallic or too salty, try adding sugar or honey.
o If you are affected by cooking odours, try to stay out of the kitchen while food is
being cooked if possible.
o Choose foods without a strong smell – sometimes the smell of a food can put you off
eating. Cold foods tend not to smell as much as hot foods.
o Marinate meat or vegetables to add more flavour.
o To add more flavour to your food, add herbs, spices e.tc
 Nutrition therapy Nausea
o Eat little and often especially before your treatment (e.g. soup and dry biscuits or
toast), and drink as much fluid as possible.

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 o Instead of drinking a lot at once, try sipping small amounts of liquid often.
Sucking on ice cubes can also help to increase your fluid intake.
o If you wake up feeling sick, eat a dry biscuit (ginger biscuits may help with
nausea) or a slice of toast. If you are diabetic, consult your medical team.
o Fizzy drinks such as ginger ale or soda water can often help relieve an upset
stomach.
o It is important to keep up your fluid intake to prevent you from becoming
dehydrated if you have been vomiting a lot. You should contact your medical
team if you are unable to keep fluids down.
o Avoid strong odours and cooking smells, which can trigger nausea and vomiting

TOPIC: CARDIOVASCULAR DISEASE

CARDIOVASCULAR AND LUNG DISEASES
By the end of the unit the learner should be able to:
a) Define terms used in the topic
b) Explain the functions of the cardiovascular system
c) Describe the types, causes and management of cardiovascular diseases
d) Plan and prepare meals for managing various types of cardiovascular diseases

Introduction
CARDIOVASCULAR SYSTEM
The cardiovascular system consists of the heart and blood vessels (arteries, veins, and capillaries).
 The Heart is a pumping organ, weighing about between 250 and 350 grams (It is about
the size of a large fist) located slightly to the left of the middle of the chest. The heart is
made of strong muscle tissue and is protected by the rib cage. It is enclosed in a
protective sac, pericardium which also contain a lubricating fluid. The outer wall is made
up of three layers, the epicardium, the myocardium which is the muscle of the heart, and
the endocardium.
All blood vessels are lined with a thin layer, endothelium that keeps blood cells inside of the
blood vessels and prevents clots from forming. The endothelium lines the entire circulatory
system, all the way to the interior of the heart, where it is called the endocardium.

o Arteries and Arterioles: Arteries are blood vessels that carry blood away from the heart.
They carry oxygenated blood except pulmonary artery. Arteries face high levels of blood
pressure as they carry blood being pushed from the heart under great force. To withstand
this pressure, the walls of the arteries are thicker, more elastic, and more muscular than
those of other vessels

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 o Capillaries: Capillaries are the smallest and thinnest of the blood vessels in the body and
also the most common
o Veins and Venules: They carry blood to the heart. They carry deoxygenated blood
except pulmonary vein. Because the arteries, arterioles, and capillaries absorb most of the
force of the heart’s contractions, veins and venules are subjected to very low blood
pressures. This lack of pressure allows the walls of veins to be much thinner, less elastic,
and less muscular than the walls of arteries.

Veins rely on gravity, inertia, and the force of skeletal muscle contractions to help push
blood back to the heart. To facilitate the movement of blood, some veins contain many
o one-way valves that prevent blood from flowing away from the heart.

Definition of terms
Arteriosclerosis: Blood vessel disease characterized by thickening and hardening of artery walls,
with loss of functional elasticity, mainly affecting the intima (inner lining) of the arteries
Atherosclerosis: Common form of arteriosclerosis, characterized by the gradual formation of
yellow cheese like streaks of cholesterol and fatty materials that develop into hardened plagues
in the intima or inner lining of the major blood vessels. Thickened blood vessel or blood clot as a
result of atherosclerosis may eventually cut off blood supply to the tissues e.g. tissues of the
heart and this may result into heart attack if it affects major coronary vessel
N/B.1 The term atherosclerosis originated from the Greek word “ athera ”( gruel-meaning
porridge like) and “sclerosis” (hardening).
N/B.2 There are two major coronary arteries, the left and the right coronary artery, that branched
from the aorta to the muscles of the heart(myocardium), that branched further into the muscles of
the heart
Intima: inner layer of the blood vessel wall

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Plague: Thickened deposits of fatty material, largely cholesterol, within the blood vessel wall
that eventually may fill the lumen and cut off blood supply to the tissue served by the damaged
vessel
Ischemia: Deficiency of blood (oxygen and nutrients) to a particular tissue, resulting from
functional blood vessel constriction or actual obstruction wall as in atherosclerosis
Infarct: An area of tissue necrosis caused by local ischemia, resulting from obstruction of blood
circulation to the area or infarct refers to an area of dead tissues as a result of ischemia e.g. acute
myocardium infarction
Atheroma: A mass of fatty plague formed in inner arterial walls in atherosclerosis
Cachexia-a wasting condition marked or metabolic syndrome marked by weakness, extreme
weight loss (loss of muscle), and malnutrition e.g cardiac cachexia

CARDIOVASCULAR DISEASES

Cardiovascular disease (CVD) is a general term for conditions/diseases affecting the heart or
blood vessels.

Common/General symptoms of cardiovascular diseases

Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or
stroke may be the first warning of underlying disease. Symptoms of a heart attack include:
o pain or discomfort in the centre of the chest;
o Pain or discomfort in the arms, the left shoulder, elbows, jaw, or back.
o In addition the person may experience difficulty in breathing or shortness of breath;
feeling sick or vomiting; feeling light-headed or faint; breaking into a cold sweat; and
becoming pale. Women are more likely to have shortness of breath, nausea, vomiting,
and back or jaw pain.
o The most common symptom of a stroke is sudden weakness of the face, arm, or leg,
most often on one side of the body. Other symptoms include sudden onset of:
o Numbness of the face, arm, or leg, especially on one side of the body;
o Confusion, difficulty speaking or understanding speech;
o Difficulty seeing with one or both eyes;
o Difficulty walking, dizziness, loss of balance or coordination;
o Severe headache with no known cause; and
o Fainting or unconsciousness.

Risk factors of CVD /Causes of CVD

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  The exact cause of CVD isn't clear, but there are lots of things that can increase your risk
of getting it. These are called "risk factors".

The risk factors can damage the blood vessels (arterial wall) and or can result into development
of plague.

1. High total cholesterol > 200 mg/dl

2. High triglycerides > 150 mg/dl
3. High LDL(harmful) cholesterol > 130 mg/dl
4. Low HDL cholesterol < 40 mg/dl
5. High blood pressure (> 140/90 mm Hg)
6. Smoking/Tobacco use/exposure to tobacco smoke
7. Diabetes mellitus
8. Physical inactivity
9. Overweight and obesity
10. Unhealthy diet
11. Alcohol
12. Drugs
13. Stress
14. Gender
15. Age
16. Ethnicity/ Race
17. Family history of CVD

The risk factors can be divided into two

1. Lipid risk factors

2. Non-lipid risk factors

Lipid risk factors

1. High total cholesterol > 200 mg/dl

Cholesterol is soft, fatlike (a fatty substance) substance found in all the cell membranes and the
blood. High cholesterol in the blood can cause blood vessels to narrow and increase the risk of
developing a blood clot as well as damage the blood vessels thus resulting into increased risk of
heart attack (myocardial infraction) and stroke (thrombosis)

There are two types of cholesterol that is dietary cholesterol contained in food and blood or
plasma cholesterol that is essential from body metabolism.

Animal based foods and products (milk and its derivatives, eggs, fish, shellfish and all types of
meat), variety of meats especially offal (particularly liver and brain), shrimps and eggs have the

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highest cholesterol content. Plant based foods do not contain cholesterol. However, there are
minute amounts of cholesterol in vegetable oils that are considered incidental.

2. High triglycerides > 150 mg/ dl

Too much fat, saturated fatty acid, Trans -unsaturated fatty acids increases harmful cholesterol
(LDL) levels in the blood and reduces the good cholesterol. The major dietary sources of
saturated fatty acids include animal based foods and products such as butter, cured cheeses,
margarine, bacon, sausages and pork, fresh eggs, cream, hydrogenated vegetable fats, lard, palm
oil and whole cow’s milk. Plant based foods are low in saturated fatty acids with some exception
such as coconut and palm oil.

3. High LDL(harmful) cholesterol > 130 mg/dl

4. Low HDL cholesterol < 40 mg/dl

Non- lipid risk factors

Non-lipid risk factors can be divided into two,

1. Modifiable
2. Non-modifiable

Modifiable non lipid risk factors

High blood pressure (> 140/90 mm Hg)

 High blood pressure (hypertension) is one of the most important risk factors for CVD. If
the blood pressure is too high, it can damage the blood vessel(arterial walls)

Smoking/Tobacco use/exposure to tobacco smoke

 Smoking and other tobacco use is a significant risk factor for CVD. The harmful
substances in tobacco can damage and narrow your blood vessels.

Diabetes mellitus

 Diabetes is a lifelong condition that causes blood sugar level to become too high. High
blood sugar levels can damage the blood vessels, making them more likely to become
narrowed.

N/B. Many people with type 2 diabetes are also overweight or obese, which is also a risk factor
for CVD.

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Physical Inactivity

 People who do not exercise regularly are more likely to have high blood pressure, high
cholesterol levels and be overweight. All of these are risk factors for CVD.
 Exercising regularly will help keep the heart healthy. When combined with a healthy diet,
exercise can also help you maintain a healthy weight.

Overweight and obesity

 Being overweight (BMI > 25-29.9 kg/m2or obese (BMI > 30 kg/m2) and having a waist of
94cm (about 37 inches) or more for men , or a woman with a waist measurement of 80cm
(about 31.5 inches) or more for women

 Being overweight or obese increases the risk of developing diabetes and high blood
pressure, both of which are risk factors for CVD. The risk is more if one has an
abdominal/central obesity

Unhealthy Diet

An unhealthy diet can lead to high cholesterol and high blood pressure. This can be as a result
of
o High salt (sodium chloride) intake: when sodium is taken in excess more
water is drawn into the circulation, increasing the volume of blood to be
pumped. In addition, excess salt makes the arterial walls to be more rigid
leading to arteriosclerosis. Much of the salt we eat is added to the table during
eating (20%), fifteen percent comes from salt naturally found in foods and
60% comes from salt added to processed foods (hidden salt).
o High fat intake

Alcohol

 Excessive alcohol consumption can also increase the cholesterol and blood pressure
levels, and contribute to weight gain. Alcohol(> 1 drink per day for women and > 2
drinks per day for men)
Drugs -such as cocaine
Stress
 While stress can affect all the body organs and functions of the body, its effect tends to
be concentrated on the heart and the cardiovascular system which is obliged to work
hard.

Non-modifiable non lipid risk factors

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Family history of CVD

 If you have a family history of CVD, your risk of developing it is also increased.
 You're considered to have a family history of CVD if either:
o Your father or brother were diagnosed with CVD before they were 55
o Your mother or sister were diagnosed with CVD before they were 65

Ethnic background/race

 CVD is more common in people of South Asian and African (blacks) or Caribbean
background.
 This is because people from these backgrounds are more likely to have other risk factors
for CVD, such as high blood pressure or type 2 diabetes

Age

 CVD is most common in people over 50 and the risk of developing it increases as you get
older. Age (males > 45 years, females > 55 years)

Male gender

 Men are more likely to develop CVD at an earlier age than women

Toxins and viruses can also damage (cause injury) the endothelium tissue of the blood vessel

Prevention and nutrition management of CVD

 Energy: An obese patient must be reduced to normal body weight with low calorie diet
 Protein: A diet of 60g protein is necessary to maintain proper nutrition. In severe
hypertension, protein restriction to 20 g may be necessary as temporary measure since
protein foods are rich in sodium
 Fats: Avoid high intake of animal or hydrogenated fats as they are prone to
atherosclerosis. Instead provide omega 3 fatty acids as they help in regulation of high
blood pressure
 Carbohydrates: Provide complex carbohydrates
 Diet high in fibre (Fibre): Fibre is found exclusively in plant based foods. Provide both
soluble and insoluble fibre. Animal foods such as milk, eggs, fish, meat and their
derivatives contain no fibre. Insoluble fibres are found in higher concentration in
vegetables such as carrots, green leafy vegetables, cereals such as wheat, brown rice, rice
bran, wheat bran, corn bran, whole grain bread and cereals, cabbage family, cauliflower,
green beans, green peas, legumes, mature vegetables, root vegetables, tomatoes, nuts,
fruits such as pears, peaches, plums, seeds, strawberries, apples and bananas. High

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 concentration of soluble fibre occurs in fruits, oats, barley and legumes such as peas,
beans and lentils
 Sodium: Increased intake of sodium in diet leads to increased intravascular volume and
thus increases cardiac output by elevating blood pressure
 Potassium: Potassium role in hypertension is its interplay with sodium, calcium and
magnesium in all living cells and in blood. 1. Potassium causes increased excretion of
sodium by the kidney (low levels of potassium cause the body to retain sodium and water
and this can elevate high blood pressure).2. Potassium relaxes the vascular tissues and
the arterial muscle. 3. Potassium reduces secretion of rennin which operates to conserve
sodium and blood fluids. Provide about 3500 mg of potassium daily and this can be
provided by high amounts of fruits and vegetables. Dietary sources of potassium include
foods such as blackstrap molasses, soybeans, wheat germ, pumpkins, bananas, almond,
avocado, spinach, potatoes, sweat potatoes, carrot juice, tomatoes, whole grain bread,
melon, cucumber, prune juice, beans, oranges, mangoes. Others from animal sources
include salmon, cod, beef steak, cheese, cow’s milk and fresh eggs.
 Calcium: Increased calcium intake as calcium is involved in the control of strength with
which blood is pumped by the heart
 Magnesium: High consumption of magnesium reduces the production of prostacyclin
which is vasodilating and increases the release of thromboxane which is vasoconstricting
(Prostacyclins and thromboxanes are hormone like the one compounds referred to as
eicosanoids that regulate BP, clotting and other body functions). Magnesium also
stabilizes calcium channels. Low blood magnesium lowers potassium level and leads to
hypokalemia. The food sources of magnesium ranked by milligram of magnesium per
standard amount include bran, pumpkin and squash seeds kernel roasted, sesame, nuts,
wheat germ, whole wheat flour, soybeans, molasses, spinach, white bean, green leafy
vegetables, potatoes and oranges.
 Physical activity: Physical activity has measurable biological effects affecting
cholesterol levels, insulin sensitivity and vascular reactivity

Classification of cardiovascular Diseases;

Diseases of the cardiovascular system include;
1. Atherosclerosis
2. Coronary heart disease
3. Myocardial ischemia/cardiac ischemia/ischemic heart disease
4. Cardiac arrhythmia
5. Cerebrovascular disease-Stroke
6. Peripheral vascular disease
7. Congestive heart disease

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 8. Rheumatic heat disease
9. Aneurysm
10. Heart attack/Myocardial infarction/Cardiac arrest
11. Hypertension
12. Hyperlipidemia
13. Hyperlipoproteinemia

 ATHEROSCLEROSIS

 Atherosclerosis is a condition in which plaque builds up inside the arteries.

 Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood.
 Over time, plaque hardens and narrows and weakens the arteries.
 Atherosclerosis limits the flow of oxygen-rich blood to your organs and other parts of the
body.

Symptoms that may be develop

o Angina(Chest pain or pressure)- If you have atherosclerosis in your heart you may
develop
o Carotid artery disease and transient ischemic attack (TIA if left untreated, may progress
to a stroke) - If you have atherosclerosis in the arteries leading to your brain and neck.
Carotid artery refers to the two major arteries supplying the brain and the neck with blood
o Peripheral artery disease e.g. Intermittent claudication (leg pain when walking)-If you
have atherosclerosis in the arteries in your arms and legs. Peripheral arteries are the
arteries that supply other parts of the body other than the brain, neck and spinal cord with
blood
o High blood pressure or kidney failure-If you have atherosclerosis in the arteries leading
to your kidneys
o Erectile dysfunction in men -If you have atherosclerosis in the arteries leading to your
genitals. You may have difficulties having sex.
o In women, high blood pressure can reduce blood flow to the vagina, making sex less
pleasurable.
o Aneurysms- Aneurysms is a serious complication that can occur anywhere in your body.
An aneurysm is a bulge in the wall of your artery. If an aneurysm bursts, you may face
life-threatening internal bleeding

Causes and risk factors

 High cholesterol, often from getting too much cholesterol or saturated fats in your diet

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  High triglycerides, a type of fat (lipid) in your blood
 Smoking and other sources of tobacco
 Diabetes
 Inflammation from diseases, such as arthritis, lupus or infections, or inflammation of
unknown cause
 High blood pressure
 High cholesterol
 Obesity
 Smoking and other tobacco use
 A family history of early heart disease and Lack of exercise

Angina/Angina Pectoris-It is a symptom or a manifestation of many heart diseases and arteries

that supply the heart with blood e.g. coronary heart disease

 Angina is a term used to refer to chest pain caused by reduced blood flow to the heart
muscle.
 Angina is a symptom of e.g. coronary artery disease. Angina can be a recurring problem
or a sudden, acute health concern.
 Angina is relatively common but can be hard to distinguish from other types of chest
pain, such as the pain or discomfort of indigestion. If you have unexplained chest pain,
seek medical attention right away.

Symptoms associated with angina include:

o Pressure
o Squeezing (feeling like a heavy weight has been placed on their chest)
o Heaviness, tightness or pain in the center of your chest
o Nausea, dizziness and Fatigue
o Shortness of breath
o Sweating

N/B. Types of anginas. Stable angina and unstable anginas.

 Stable angina is the most common form of angina, and it typically occurs with exertion
and goes away with rest. It develops when your heart works harder, such as when you
exercise or climb stairs
 Unstable angina (a medical emergency)
Occurs even at rest. It is usually more severe and lasts longer than stable angina, maybe

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 as long as 30 minutes. May not disappear with rest or use of angina medication. Might
signal a heart attack

 CORONARY HEART DISEASE

 Coronary heart/artery disease (CHD) is a disease in which the coronary arteries (the
major blood vessels that supply the heat with blood, oxygen and nutrients) become
damaged or diseased by a waxy substance called plaque (a cholesterol containing
substance) that builds up inside the coronary arteries i.e It is a disease caused by
atherosclerosis and it is the most common form of CVD
 When plaque builds up in the arteries, the condition is called Atherosclerosis.
Note: This fatty degeneration and thickening (atherosclerosis) narrow the vessel lumen and may
allow a blood to clot. Eventually the clot may cut off blood flow in the involved artery. If the
artery is a critical, such as a major coronary vessel, a heart attack occurs. Tissue area serviced
by the involved artery is deprived of its oxygen and nutrients supply, a condition called
ischemia, and the cells die. The localized area of dying or dead tissue is called an infarct.
Because the artery involved supplies cardiac muscle, the myocardium, the result is called
myocardium infarction

Symptoms of coronary artery disease

 When plaques build up, they narrow your coronary arteries, decreasing blood flow to
your heart. Eventually, the decreased blood flow may cause
o Chest pain due to restricted blood flow to the heart muscle (angina)
o Cardiac/myocardial Ischemia
o Shortness of breath
o Arrhythmias
o Heart failure (where the heart is unable to pump blood around the body properly)
or other coronary artery disease signs and symptoms.
A complete blockage can cause a heart attack.
The buildup of plaque occurs over many years and therefore can go unnoticed until you have
a heart attac
 CARDIAC ARRHYTHMIA
 This refers to uneven heat rhythm(beats)
 Heart rhythm problems (heart arrhythmias) occur when the electrical impulses that
coordinate the heartbeats don't work properly, causing the heart to beat too fast, too slow
or irregularly.
 Worse heart arrhythmias may be caused by a weak or damaged heart

Symptoms

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Arrhythmias may not cause any signs or symptoms. Noticeable arrhythmia symptoms may
include:

o A racing heartbeat (tachycardia)-an abnormal rapid heat beat, over 100 beats per minute
o A slow heartbeat (bradycardia)
o Chest pain
o Shortness of breath
o Lightheadedness
o Dizziness
o Fainting (syncope) or near fainting

Causes/risk factors

Many things can lead to, or cause, an arrhythmia, including:

 Cardiomyopathy( a condition where the heart muscle is abnormal making it harder for the
heart to pump and deliver blood to the rest of the body)
 Blocked/narrowed arteries in your heart (coronary artery disease)
 High blood pressure
 Diabetes
 Overactive thyroid gland (hyperthyroidism) and Underactive thyroid gland
(hypothyroidism)
 Smoking
 Drinking too much alcohol or caffeine
 Drug abuse
 Stress
 Certain prescription medications
 Certain dietary supplements and herbal treatments
 Electrical shock
 Heart attack
 Abnormal heart valves
 Prior heart surgery
 Heart failure
 Congenital heart disease (Being born with a heart abnormality may affect your heart's
rhythm)
 Drugs and supplements.
Complications
 Certain arrhythmias may increase your risk of developing conditions such as Stroke.
Heart failure

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  MYOCARDIAL ISCHEMIA/CARDIAC ISCHEMIA/ISCHEMIC HEART
DISEASE
 Myocardial ischemia is a condition in which the blood flow to the heart muscle is
decreased by a partial or complete blockage of the heart's arteries (coronary arteries). The
blood vessels are narrowed or blocked due to the deposition of cholesterol on their walls.
 This result into reduced supply of oxygen and nutrients to the heart, which is essential for
proper functioning of the heart.
 This may eventually result in a portion of the heart being suddenly deprived of its blood
supply leading to the death of that area of heart tissue, resulting in a heart attack.
 Myocardial ischemia may also cause serious abnormal heart rhythms.
o Treatment for myocardial ischemia is directed at improving blood flow to the heart
muscle and may include medications, a procedure to open blocked arteries or coronary
artery bypass surgery and Making heart-healthy lifestyle

Symptoms
Some people who have myocardial ischemia don't experience any signs or symptoms (silent
ischemia). When myocardial ischemia does cause signs and symptoms, they may include:
o Chest pressure or pain typically on the left side of the body (angina pectoris)
o Neck or jaw pain
o Shoulder or arm pain
o A fast heartbeat
o Shortness of breath(dyspnea)
o Nausea and
o Vomiting
o Heart failure
o Difficulty in breathing or swelling of the extremities due to weakness of the heart
muscle

Causes
Conditions that may cause myocardial ischemia include:
 Coronary artery disease (atherosclerosis) is the most common cause of myocardial
ischemia.
Risk factors: Factors that may increase your risk of developing myocardial ischemia
include:
 Tobacco, smoking and long-term exposure to secondhand smoke can damage the interior
walls of arteries — including arteries of the heart.
 Smoking also increases the risk of blood clots forming in the arteries that can cause
myocardial ischemia

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  High cholesterol level that can result into high blood pressure
 Diabetes. Diabetes is linked to high blood pressure. High blood pressure can damage
arteries that feed your heart by accelerating atherosclerosis.
 High blood pressure/ hypertension
 High blood pressure is common in those who are obese.
 High salt intake that may result into high blood pressure
 Stress
Complications
 The condition can result into heart attack (myocardial infarction) and Irregular heart
rhythm (arrhythmia)

 CEREBROVASCULAR DISEASE

 Cerebrovascular disease refers to cardiovascular disease that affects the blood vessels of
the brain or cerebrovascular disease refers to a problem with the circulation of blood in
the blood vessels of the brain.)
 It occurs when the blood flow in the blood vessel to the brain is cut off or is temporarily
disrupted resulting in the death of nerve cells
 Sometimes, a blood vessel in the brain can burst resulting in long term effects.
Types of Cerebrovascular disease
 Stroke – A stroke is a "brain attack". It is where the blood supply to part of the brain is
cut off, which can cause brain damage and possibly death. Brain damage occurs and cells
die because they are deprived of oxygen and nutrients. The blood supply can be blocked
or interrupted/disrupted by a blood clot, where the blood thickens and becomes solid.
Blood clot is the most common cause of stroke. Blood clot form of stokes account for
approximately 70% and 80% of all strokes. Stroke can also occur when the blood vessel
ruptures

o Cerebral thrombosis, the most common stroke, occurs when a thrombus ( a

blood clot formed within a blood vessel and remaining attached to its place of
origin)) forms and blocks blood flow in an artery bringing blood to part of the
brain. They usually occur at night or first thing in the morning when blood
pressure is low. They are often preceded by transient ischemic attach (TIA or mini
stroke)
o Cerebral embolism occurs when an embolus (a loos blood clot) forms away from
the brain, usually in the heart. The clot is carried in the bloodstream until it lodges
in an artery leading to or in the brain and blocks the flow of blood
o A subarachnoid hemorrhage/hemorrhagic stroke/bleeds. occurs when a blood
vessel on the brain’s surface ruptures and bleeds into the space between the brain
and skull

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 o A cerebral hemorrhage occurs when defective artery in the brain busts, flooding
the surrounding tissue with blood

 Transient ischemic attack (TIA) – It is also known as a mini stroke, it is similar to

stroke but here the blood flow to the brain is only temporarily disrupted, a blockage with
effects lasting less than 24 hours

Complications

A stroke can sometimes cause temporary or permanent disabilities, depending on how long the
brain lacks blood flow and which part was affected. Complications may include:

 Paralysis or loss of muscle movement. You may become paralyzed on one side of your
body, or lose control of certain muscles, such as those on one side of your face or one arm.
Patients who experience left-sided stroke most commonly experience sight and hearing
losses e.g. inability to see where food is on the plate. Right hemisphere, bilateral, or
brainstem stroke causes significant problems with feeding and swallowing in addition to
speech problems

Symptoms of paralysis can be remembered with the word FAS, which stands for:

o Face (usually on one side of the body) – the face may have drooped on one
side, the person may be unable to smile, or their mouth or eye may have
dropped.
o Arms or legs– the person may not be able to lift both arms or legs and keep
them there because of arm weakness or numbness in one arm (usually on one
side of the body)
o Speech – their speech may be slurred or garbled, or they may not be able to
talk at all.

 Difficulty talking or swallowing.

 Memory loss or thinking difficulties. Many people who have had strokes experience
some memory loss. Others may have difficulty thinking, making judgments, reasoning and
understanding concepts.

 Emotional problems. People who have had strokes may have more difficulty controlling
their emotions, or they may develop depression.

 Pain. People also may be sensitive to temperature changes, especially extreme cold after a
stroke. This condition generally develops several weeks after a stroke, and it may improve
over time.

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  Changes in behaviour and self-care ability. People who have had strokes may become
more withdrawn and less social or more impulsive. They may need help with grooming and
daily chores.

Other symptoms include:

 Sudden vision problems in one or both eyes.

 Dizziness.
 Sudden, severe headache.
 Dysphagia
 Sleepiness
 Loss of balance or coordination

Management

Nutrition therapy
o Limit the amount of salt in the daily diet. Recommended: 2400 mg per
day .Sodium may be restricted to 2 to 4 g if there is hypertension or to control edema
o Carbohydrates. Use of complex carbohydrates to replace saturated fats as this
lowers LDL cholesterol levels. Recommended: 50-60%.
o Protein. Plant based proteins e.g legumes, dry beans, nuts, whole grains and
vegetables are the best as they lower LDL cholesterol. Fat free and low- fat dairy
products e.g. egg white, fish, skinless poultry and lean cuts of beef and pork are also
low in saturated fats and cholesterol
o High fiber diet. Recommended: 20-30 g/day, soluble fiber 10-25 g/day. Adding 5 to
10 g of soluble fiber( oats, barley, pectin reach fruits and beans ) per day is associated
with approximately a 5 % reduction in LDL cholesterol
o Reduce the total fat to no more than 20%, and trans fatty acids in your diet
particularly saturated fat. Saturated fats raises the LDL cholesterol level.
o Saturated fats, less than 7% of the total energy intake
o Use of monounsaturated (up to 20% of the total energy intake) and
polyunsaturated fats (up to 10% of the total energy intake). Monounsaturated fats
e.g. plant oils and nuts lowers LDL cholesterol levels without decreasing HDL
cholesterol or triglycerides while polyunsaturated fats e.g. linoleic acid and omega -3-
fatty acids reduce LDL cholesterol when used instead of saturated fats.
o Intake of Omega-3 fatty acids improve the health of the blood vessels, as well as
reducing Hypertension, blood clotting, inflammation and decrease the synthesis
of VLDL. They are found in fish oil, flaxseed oil and walnuts or fish oil
supplementation

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 o Dietary cholesterol, less than 200 mg/day/. Flax seeds are one the richest source of
omega 3
o Antioxidants such as vitamin C and vitamin E protect the arteries from damage.
o Garlic may help reduce the level of fats in the blood, improve blood flow and
reduce blood clotting.
o Potassium, magnesium and calcium are minerals that help reduce blood pressure
(maintain cell fluid balance) and blood clotting. Magnesium and potassium also helps
in muscle contraction. Low potassium level is associated with high blood pressure.
Low magnesium level is also associated high blood pressure and angina while
magnesium intake is associated with decreased incidence of CHD
o Control diabetes
o Nutritional supplements may only be effective if dietary intake is inadequate.
o Avoid foods that cause choking or that are hard to manage e.g. peanut butter, raw
vegetables, dry or crisp foods
o If the patient has problem with saliva production , foods can be moistened with small
amount of liquid e.g. gravy
o Exercise – regular daily walks of about 1 hour (to expend at least 200 kcal/day) –
Exercise has been shown to increase the level of HDLs, the so called “good cholesterol”
with no notable changes in or plasma triglycerides. Thus it helps maintain the health of
the vessels leading to the heart.
o Weight reduction using diet low in saturated fats and cholesterol. Weight reduction
reduces LDL cholesterol levels
o Stop smoking -smoking oxidizes cholesterol, causing it to deposit in your blood vessels
and contribute to atherosclerosis.
o Avoid Sedentary lifestyle and stress - being physically active
o Reduced alcohol intake

Surgery
o Arterial reconstruction surgery to bypass them- to redirect the blood flow in the artery
o Removal of fatty deposits in inner lungs (endarterectomy)
o Balloon angioplasty to widen the vessels(using balloon –tipped catheter inserted
through the artery at the groin or wrist)
Drug Therapy
o Drug therapy aims – to prevent blood clotting

 PERIPHERAL VASCULAR DISEASE

Peripheral vascular disease is characterized by narrowing blood vessels in the legs and
sometimes the arms. Blood flow is restricted and causes pain in the affected areas. Risk factors

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include hypertension and diabetes mellitus. Major risk factor is cigarette smoking which
constrict blood vessels.
Symptoms
Aching of the leg muscles when walking. Resting the leg for few minutes relives pain, but it
recurs shortly when walking is resumed. The symptom is called intermittent claudication
Intermittent claudication-A symptomatic pattern of peripheral vascular disease, characterized by
the absence of pain or discomfort in a limb, usually the legs, when at rest, which is followed by
pain and weakness when walking, intensifying until walking becomes impossible, and then
disappearing again after a rest period

Management
 Stop smoking
 Surgery
o Arterial reconstruction surgery to bypass them- to redirect the flow blood flow in the
artery
o Removal of fatty deposits in inner linings (endarterectomy)
o Balloon angioplasty to widen the vessels(using balloon –tipped catheter inserted
through the artery at the groin or wrist)
 Drug therapy-e.g. antiplatelet or anticoagulant agents to prevent blood clotting
 Nutrition therapy as described for cerebrovascular diseases
 Exercise-The person should walk every day gradually increasing to about 1 hour and
stopping whenever intermittent pain occurs and resuming when it stops.
 Lifestyle-Regular inspection of feet, daily washing of feet and stocking change, good
fitting shoes to avoid pressure

 CONGESTIVE HEART FAILURE

 Congestive Heart Failure (CHF) or severe heart disease is when the heart can no longer
provide or pump enough blood to the rest of the body as it is needed.
 CHF can happen as a result of damage to the heart muscle, including coronary artery
disease (CAD), heart attack, cardiomyopathy, valve disease, heart defects present at birth,
diabetes mellitus and chronic renal disease. Patients with heart failure usually suffer from
shortness of breath and swelling of the legs.
 Because of the reduced circulation, tissues retain fluid that would normally be carries off
by the blood. Sodium builds up, and more fluid is retained, resulting in edema. In an
attempt to compensate for this pumping deficit, the heart beats faster and enlarges, this
adds to the heart’s burden. In advanced cases when edema affects the lungs, death occurs.

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  With the inadequate circulation, body tissues do not receive sufficient amounts of
nutrients. This insufficiency can cause malnutrition ad underweight, although the edema
can mask these problems.
Increased cellular free potassium
As reduced blood circulation depresses cell metabolism, cell protein is broken down and
releases its bound potassium in the cell. As a result, the amount of free potassium inside
the cell is increased, which increases intracellular osmotic pressure. Sodium ions in fluid
surrounding the cell then also increase in number to balance increased osmotic pressure
within the cell and to prevent cell dehydration. In time, the increased sodium outside the
cell causes still more water retention
Symptoms
o Shortness of breath (dyspnea) when you lie down
o Fatigue and weakness
o Swelling (edema) in your legs, ankles and feet
o Rapid or irregular heartbeat
o Reduced ability to exercise
o Fainting and severe weakness.
o Persistent cough or wheezing with white or pink blood-tinged phlegm
o Increased need to urinate at night
o Swelling of your abdomen (ascites)
o Sudden weight gain from fluid retention
o Lack of appetite and nausea
o Difficulty concentrating or decreased alertness

Drug Therapy
o Diuretics(Any substance that tends to increase the flow of urine, which causes the
body to get rid of excess water)to be used to aid in the excretion of water
o Digitalis to strengthen contraction of the heart muscles.
o Because diuretics can cause loss of potassium the client’s potassium should be
carefully monitored to prevent hypokalemia, which can upset the heartbeat.
o When necessary prescribe supplementary potassium.

Diet Therapy
o Reduce fluid intake to 11/2-2 liters per day.
o Sodium restricted diet 1 – 2 g/day.
o Salt should not be used in cooking or at table
o Fresh unprocessed foods such as meat, fish, eggs, milk and are moderate sources – use
in small units.

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 o Fruits especially oranges, bananas, kiwifruit, avocados, green beans, pumpkin,
pineapple, strawberries, spinach, tomatoes, broccoli, potatoes, sweet potatoes, yams
and prunes can be useful to restore potassium levels and unprocessed cereals contains
little sodium.
o Processed foods and cereals products are rich in sodium and should be avoided.
o Moderation of alcohol

N/B Two hormones are involved in fluid balance in normal circulation i.e Aldosterone and
Antidiuretic hormone (ADH) also known as vasopressin. There mechanisms can result into
increased cardiac edema.
Aldosterone hormone-As the heart fails to propel blood flow circulation forward, deficient
cardiac output effectively reduces blood flow through kidney nephrons. Decreased renal blood
flow pressure triggers the liver to produce a hormone to stimulate adrenal glands to produce
aldosterone that in turn effects a reabsorption of sodium in an ion exchange with potassium and
water reabsorption follows
Antidiuretic hormone-Cardiac stress and reduced renal flow cause the release of antidiuretic
hormone from the pituitary gland. ADH then stimulates more water reabsorption in nephrons of
the kidney thus increasing the problem of edema

 RHEUMATIC HEART DISEASE

 Rheumatic heart disease is caused by damage to the heart valves and heart muscle
from the inflammation and scarring caused by rheumatic fever.
 Rheumatic fever is an inflammatory disorder caused by a Group A streptococcus
bacteria that normally affects the throat. It affects the connective tissue of the body,
causing temporary, painful arthritis and other symptoms. In some cases, rheumatic
fever causes long-term damage to the heart and its valves. This is called rheumatic
heart disease.
 Rheumatic fever usually begins as a sore throat or tonsillitis in children.
 Rheumatic fever mostly affects children between 5-15 years in developing countries,
especially where poverty is widespread.
Symptoms of Rheumatic Heart Disease
o Shortness of breath
o Fatigue
o Irregular heart beat
o Chest pain and fainting

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  MYOCARDIAL INFARCTION

 This is sudden tissue death caused by blockage of vessels that feed the heart muscle, also
called heart attack or cardiac arrest
 A heart attack occurs when the flow of blood to the heart is blocked, most often by a
build-up of fat, cholesterol (Atherosclerosis-it is the primary cause) which form a plaque
in the arteries that feed the heart (coronary arteries).Other contributing factors are
abnormal blood clotting, hypertension and infections caused by rheumatic fever(which
damages heart valves)
 The heart tissue is denied blood because of this blockage and dies

Symptoms.
o Pain, or a squeezing or aching sensation in your chest or arms that may spread to your
neck, jaw or back
o Nausea
o Pressure and tightness
o Indigestion
o Heartburn or abdominal pain
o Shortness of breath
o Cold sweat
o Fatigue
o Lightheadedness or sudden dizziness

Heart attack symptoms vary. Not all people who have heart attacks have the same symptoms or
have the same severity of symptoms. Some people have mild pain; others have more severe pain.
Some people have no symptoms, while for others, the first sign may be sudden cardiac arrest
(sudden, unexpected loss of heart function, breathing and consciousness. Cardiac arrest usually
results from an electrical disturbance "short circuits" in the heart that disrupts its pumping action,
stopping flow to the rest of the body. It differs with heart attack which occurs when blood flow
to a portion of the heat is blocked. Heart attack can result into cardiac arrest) However, the more
signs and symptoms you have, the greater the likelihood you're having a heart attack.

Some heart attacks strike suddenly, but many people have warning signs and symptoms hours,
days or weeks in advance. The earliest warning may be recurrent chest pain (angina) that's
triggered by exertion and relieved by rest. Angina is caused by a temporary decrease in blood
flow to the heart.

Taking aspirin during a heart attack could reduce heart damage by helping to keep your blood
from clotting. Aspirin can interact with other medications, however, so don't take an aspirin
unless your doctor or emergency medical personnel recommend it.

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If you encounter someone who is unconscious, first call for emergency medical help. Then begin
CPR to keep blood flowing. Push hard and fast on the person's chest — about 100 compressions
a minute. It's not necessary to check the person's airway or deliver rescue breaths unless you've
been trained in CPR.
Use of tobacco and of illicit drugs, such as cocaine, can cause a life-threatening spasm. A heart
attack can also occur due to a tear in the heart artery (spontaneous coronary artery dissection).

Risk Factors
 Certain factors contribute to the unwanted buildup of fatty deposits (atherosclerosis) that
narrows arteries throughout your body.
Heart attack risk factors include:
 Age. Men age 45 or older and women age 55 or older are more likely to have a heart
attack than are younger men and women.
 Tobacco. Smoking and long-term exposure to secondhand smoke increase the risk of a
heart attack.
 High blood pressure. Over time, high blood pressure can damage arteries that feed your
heart by accelerating atherosclerosis.
 High blood pressure that occurs with obesity, smoking, high cholesterol or diabetes
increases your risk even more.
 High blood cholesterol or triglyceride levels. A high level of low-density lipoprotein
(LDL) cholesterol (the "bad" cholesterol) is most likely to narrow arteries.
 However, a high level of high-density lipoprotein (HDL) cholesterol (the "good"
cholesterol) lowers your risk of heart attack.
 Diabetes. Insulin, a hormone secreted by your pancreas, allows your body to use glucose,
a form of sugar. Having diabetes — not producing enough insulin or not responding to
insulin properly — causes your body's blood sugar levels to rise. Diabetes, especially
uncontrolled, increases your risk of a heart attack.
 Family history of heart attack. If your siblings, parents or grandparents have had early
heart attacks (by age 55 for male relatives and by age 65 for female relatives), you may
be at increased risk.
 Lack of physical activity. An inactive lifestyle contributes to high blood cholesterol
levels and obesity. Exercise is also beneficial in lowering high blood pressure.
 Obesity. Obesity is associated with high blood cholesterol levels, high triglyceride levels,
high blood pressure and diabetes. Losing just 10 percent of your body weight can lower
this risk, however.
 Stress. You may respond to stress in ways that can increase your risk of a heart attack.
 Using stimulant drugs, such as cocaine or amphetamines
 A history of preeclampsia. This condition causes high blood pressure during pregnancy
and increases the lifetime risk of heart disease.

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  A history of an autoimmune condition, such as rheumatoid arthritis or lupus. Conditions
such as rheumatoid arthritis, lupus and other autoimmune conditions can increase your
risk of having a heart attack.
Complications
Abnormal heart rhythms (arrhythmias), Heart failure, Heart and valve rupture

Dietary Management
o The dual goal is to allow the heart to rest and its tissue to heal.
o After the attack, the client is in shock. This causes a fluid shift and the client may feel
thirsty. The client should be given nothing by mouth (NPO), however until after
evaluation/ if nausea remains after the period of shock, IV infusions are given to prevent
dehydration.
o After several hours, the client may begin to eat. A liquid diet may be recommended for
the first 24 hours.
o A low cholesterol diet – low sodium diet is usually given, regulating the amount eaten.
o Foods should not be extremely hot or extremely cold.
o Food should be easy to chew and digest and contain little roughage so that the work of
the heart is minimal. Both chewing and increased activity of the gastro intestinal tract that
follow ingestion of high fiber foods cause extra work for the heart.
o Limit types and amounts of fats.
o Sodium is limited to prevent fluid accumulation

 ANEURSYM
 Aneurysm occurs when part of a blood vessel (arteries) e.g. aorta or brain blood vessel or
cardiac arteries becomes weakened (thinning of the artery wall), swells and bulges
outwards (like a balloon).
 The swelling can be quite small or very large. The most common aneurysm affects the
brain. A brain aneurysm can leak or rupture, causing bleeding into the brain (hemorrhagic
stroke). This type of hemorrhagic stroke is called a subarachnoid hemorrhage.
 Most brain aneurysms, however, don't rupture, create health problems or cause
symptoms.

Symptoms

Ruptured aneurysm
A sudden, severe headache is the key symptom of a ruptured aneurysm. This headache is often
described as the "worst headache" ever experienced.
Common signs and symptoms of a ruptured aneurysm include:
 Sudden, extremely severe headache
 Nausea and vomiting

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  Stiff neck
 Blurred or double vision
 Sensitivity to light
 Seizure
 A drooping eyelid
 Loss of consciousness
 Confusion
Unruptured aneurysm
An unruptured brain aneurysm may produce no symptoms, particularly if it's small. However, a
large unruptured aneurysm may press on brain tissues and nerves, possibly causing:
 Pain above and behind an eye
 A dilated pupil
 Change in vision or double vision
 Numbness, weakness or paralysis of one side of the face
 A drooping eyelid
Risk Factors
A number of factors can contribute to weakness in an artery wall and increase the risk of a brain
aneurysm. Brain aneurysms are more common in adults than in children and more common in
women than in men.
Some of these risk factors develop over time; others are present at birth.
Risk factors that develop over time
These include:
 Older age
 Smoking
 High blood pressure (hypertension)
 Hardening of the arteries (arteriosclerosis),
 High cholesterol level,
 Drug abuse, particularly the use of cocaine
 Head injury
 Heavy alcohol consumption
 Lower estrogen levels after menopause
Risk factors present at birth
These include:
 kidney disease
 Abnormally narrow aorta the large blood vessel
 Cerebral arteriovenous malformation (brain AVM)
 An abnormal connection between arteries and veins in the brain
 Family history of brain aneurysm, particularly a first-degree relative, such as a parent,
brother or sister

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Complications
 When a brain aneurysm ruptures, the bleeding usually lasts only a few seconds. The
blood can cause direct damage to surrounding cells, and the bleeding can damage or kill
other cells.
 It also increases pressure inside the skull.
 If the pressure becomes too elevated, the blood and oxygen supply to the brain may be
disrupted to the point that loss of consciousness or even death may occur.

Management
 Keep your hypertension in check
 Maintain a healthy lifestyle
 Keep your blood cholesterol levels under control
 Stay away from stress
 Get some exercise
 Maintain a good diet
 Avoid excessive alcohol drinking
 Quit smoking

 HYPERTENSION

 Hypertension is also referred to as high blood pressure/elevated blood pressure.

 According to WHO, hypertension is defined as a condition in which the blood pressure is
greater than 160/95 mm Hg i.e. when systolic pressure exceeds 160 mm Hg and diastolic
pressure exceeds 95 mm Hg
 It is a condition in which the arteries have persistently elevated blood pressure(i.e. it is
where. the force of the blood against your artery walls is high enough that it may
eventually cause health problems, such as heart disease )
 Blood pressure is determined by the amount of blood your heart pumps and the amount
of resistance to blood flow in your arteries. The more blood your heart pumps and the
narrower your arteries, the higher your blood pressure
Tests and Diagnosis
 A sphygmomanometer( a pressure-measuring gauge) is usually placed around the arm to
measure the blood pressure
 A blood pressure reading, given in millimeters of mercury (mm Hg), has two numbers.
 The first, or upper, number measures the pressure in your arteries when your heart beats
(systolic pressure).

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  The second, or lower, number measures the pressure in your arteries between beats
(diastolic pressure).
 Blood pressure measurements fall into four general categories:
 Normal blood pressure. Your blood pressure is normal if it's between 90/60mmHg and
120/80 mm Hg.
 High blood pressure is considered to be 140/90mmHg or higher
 Low blood pressure is considered to be 90/60mmHg or lower
 Once blood pressure reaches 120/80mm Hg, the risk of cardiovascular disease begins to
increase.-Prehypertension.
 Prehypertension is a systolic pressure ranging from 120 to 139 mm Hg or a diastolic
pressure ranging from 80 to 89 mm Hg.
 Prehypertension tends to get worse over time.
 Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 140 to
159 mm Hg or a diastolic pressure ranging from 90 to 99 mm Hg.
 Stage 2 hypertension. More severe hypertension, stage 2 hypertension is a systolic
pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher.
 Both numbers in a blood pressure reading are important. But after age 60, the systolic
reading is even more significant.
 Isolated systolic hypertension — when diastolic pressure is normal but systolic pressure
is high — is a common type of high blood pressure among people older than 60.
Summery
Blood Systolic(mm Hg) Diastolic(mm Hg)
pressure(BP)
Classification
Normal < 120 And <80
Prehypertension 120-139 80-89
Stage 1 140-159 90-99
hypertension
Stage 2 More or equals More or equals
hypertension 160 100

Symptoms
 Many people with hypertension have no symptoms.
 Headache, dizziness, impaired vision, failing memory, shortness of breath, pain over the
heart, gastrointestinal disturbances and unexplained tiredness are some of the symptoms
Causes
There are two types of high blood pressure.
 Primary (essential) hypertension

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 o For most adults, there's no identifiable cause of high blood pressure (the cause is
unknown). This type of high blood pressure, called essential hypertension or
primary hypertension, tends to develop gradually over many years.90% of
hypertension fall under this category
 Secondary hypertension
o Some people have high blood pressure caused by an underlying condition. This
type of high blood pressure, called secondary hypertension, tends to appear
suddenly and cause higher blood pressure than does primary hypertension.
o Various conditions and medications can lead to secondary hypertension,
including:
Kidney problems e.g glomerulonephritis, Adrenal gland tumors, Diseases of the
ovary, Thyroid problems, Certain defects in blood vessels you're born with
(congenital), Certain medications, such as birth control pills, decongestants, over-
the-counter pain relievers and some prescription drugs, , Illegal drugs, such as
cocaine and amphetamines, Alcohol abuse or chronic alcohol use, Obstructive
sleep apnea

Risk Factors
 High blood pressure has many risk factors, including:
 Age. The risk of high blood pressure increases as you age. Through in early middle age,
or about age 45, high blood pressure is more common in men.
 Women are more likely to develop high blood pressure after age 65
 Race. High blood pressure is particularly common among blacks, often developing at an
earlier age than it does in whites. Serious complications, such as stroke, heart attack, and
kidney failure, also are more common in blacks.
 Family history. High blood pressure tends to run in families.
 Being overweight or obese. The more you weigh the more blood you need to supply
oxygen and nutrients to your tissues. As the volume of blood circulated through your
blood vessels increases, so does the pressure on your artery walls.
 Not being physically active. People who are inactive tend to have higher heart rates. The
higher your heart rate, the harder your heart must work with each contraction and the
stronger the force on your arteries. Lack of physical activity also increases the risk of
being overweight.
 Using tobacco. Not only does smoking or chewing tobacco immediately raise your
blood pressure temporarily, but the chemicals in tobacco can damage the lining of your
artery walls. This can cause your arteries to narrow, increasing your blood pressure.
Secondhand smoke also can increase your blood pressure.
 Too much salt (sodium) in your diet. Too much sodium in your diet can cause your
body to retain fluid, which increases blood pressure.

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  Too little potassium in your diet. Potassium helps balance the amount of sodium in
your cells. If you don't get enough potassium in your diet or retain enough potassium, you
may accumulate too much sodium in your blood.
 Too little vitamin D in your diet. It's uncertain if having too little vitamin D in your diet
can lead to high blood pressure. Vitamin D may affect an enzyme produced by your
kidneys that affects your blood pressure.
 Drinking too much alcohol. Over time, heavy drinking can damage your heart. Having
more than two drinks a day for men and more than one drink a day for women may affect
your blood pressure. If you drink alcohol, do so in moderation.
 Stress. High levels of stress can lead to a temporary increase in blood pressure. Certain
chronic conditions. Certain chronic conditions also may increase your risk of high blood
pressure, such as kidney disease and sleep apnea.
 Sometimes pregnancy contributes to high blood pressure, as well.
 Although high blood pressure is most common in adults, children may be at risk, too.
For some children, high blood pressure is caused by problems with the kidneys or heart.
But for a growing number of kids, poor lifestyle habits, such as an unhealthy diet, obesity
and lack of exercise, contribute to high blood pressure.

Other risks factors of high blood pressure

Complications

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  Excessive pressure on your artery walls caused by high blood pressure can damage your
blood vessels, as well as organs in your body.
 The higher your blood pressure and the longer it goes uncontrolled, the greater the
damage
Uncontrolled high blood pressure can result into
 Heart attack or stroke. High blood pressure can cause hardening and thickening of the
arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
 Aneurysm. Increased blood pressure can cause your blood vessels to weaken and bulge,
forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
 Heart failure. To pump blood against the higher pressure in your vessels, your heart
muscle thickens. Eventually, the thickened muscle may have a hard time pumping
enough blood to meet your body's needs, which can lead to heart failure.
 Weakened and narrowed blood vessels in your kidneys. This can prevent these organs
from functioning normally.
 Thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
 Metabolic syndrome. This syndrome is a cluster of disorders of your body's metabolism,
including increased waist circumference; high triglycerides; low high-density lipoprotein
(HDL); or "good," cholesterol; high blood pressure; and high insulin levels.
 Trouble with memory or understanding. Uncontrolled high blood pressure may also
affect your ability to think, remember and learn. Trouble with memory or understanding
concepts is more common in people with high blood pressure
 Hypertension can lead to damaged organs, as well as several illnesses, such as renal
failure (kidney failure), aneurysm, heart failure, stroke, or heart attack

DASH DIET AND HIGH BLOOD PRESSURE

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  DASH stands for -Dietary Approaches to Stop Hypertension (DASH Diet)
 This a dietary pattern promoted to prevent and control hypertension.
 It is a diet rich in fruits, vegetables, and low-fat dairy foods/fat free dairy foods
 It also emphasizes on moderate amount of whole grains, fish, poultry and nuts
 But the diet should be low/limited in sodium, sweets, sugary or sugar sweetened
foods, red meat and fats
 The DASH diet is also recommended to prevent osteoporosis, cancer, heart diseases,
stroke and diabetes
DASH diet suggests
 Fruits: 4-5 daily servings. Fruits are rich in potassium, magnesium, and fibre
 Vegetables: 4-5 daily servings e.g. tomatoes, broccoli, carrots, sweet potatoes, greens.
They are high in fibre
N/B. Increased intake of vegetables and fruits must be ensured for increase intake of potassium
i.e. 4.7grams or 4700mg per day.
 Whole grains: 6-8 daily servings e.g. brown bread, brown rice, cereals. They are reach
in fibre
 Low fat or fat free dairy products: 2-3 daily servings e.g. yought, fresh milk. They are
rich in calcium, vitamin D, and proteins. Choose low fat dairy of fat free because dairy
products are reach in saturated fats
 Lean meat, poultry and fish: 6 servings or fever daily. They are rich in protein, B
vitamins, iron and zinc. Remove the skin from poultry. Grill, bake, or boil your meat
 Fats and oils: 2-3 daily servings. Fats helps your body absorb essential vitamins and
helps the immune system. Too much fat increases the risk of heart diseases, diabetes and
obesity more so the saturated fats
 Nuts, seeds and legumes: 4-5 servings per week e.g. beans, kidney beans, peas,
sunflower seeds
 Sodium: Reduce the sodium intake to 1500 mg (2/3 teaspoon) daily. Begin by
reducing the amount of salt/sodium you eat to not more than 2 to 3g sodium or 6 g of
sodium chloride. Other measures to reduce sodium intake: never put salt at the table and
no salt should be used in severe hypertension, do not use salted foods such as biscuits,
cakes, pastries, bread, dry fish, salted butter, peanut butter, cheese, salted potato chips,
baking powder, sodium bicarbonate, sodium benzoate, salt preserved foods such as
pickles and canned foods
 Increased intake of potassium to 4.7grams or 4700mg per day. This is ensured by
increased intake of fruits and vegetables
You can achieve this by ensuring that you add servings of vegetables at lunch and dinner; and
servings of fruits to your meals or s snacks
Other lifestyle changes can help prevent and lower high blood pressure:

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  Cut back on alcohol if you drink too much
 Lose weight if you're overweight
 Exercise regularly
 Cut down on caffeine
 Stop smoking
 Try to get at least six hours of sleep a night
 Increase intake of foods rich in Omega 3 fatty acids
 Physical activity at least 30 minutes’ walk daily.
 Drug therapies for reducing blood pressure
 Fluid may be restricted to 1000ml- 1500 ml per day if needed
N/B Nutrients that have effect on blood pressure are calcium, potassium and sodium

 HYPERLIPIDEMIA

 Hyperlipidemia refers to an elevation of the blood lipids i.e. cholesterol and triglycerides
or an elevation of the lipoproteins due to their overproduction or inadequate removal.
 Hyperlipidemia is characterized by elevated concentrations of circulating lipids,
increasing the risk of atherosclerosis and other serious conditions. Specific classes of
hyperlipidemia include hyperlipoproteinemia, elevated very low-density lipoprotein
(VLDL) and low-density lipoprotein (LDL) levels, hypercholesterolemia (elevated
cholesterol levels), and hypertriglyceridemia (elevated triglyceride levels).

 Hyperlipidemia is typically asymptomatic and is frequently detected during routine

screening.

Nutritional Considerations
 Elevated concentrations of blood lipids, particularly LDL cholesterol, are a significant
risk factor for atherosclerosis and coronary heart disease.
 Reducing saturated fat and cholesterol intake decreases these concentrations. Cholesterol
is present only in foods of animal origin, and these products are often the primary source
of saturated fat in a person’s diet. Thus, a diet that reduces or eliminates these products
lowers total and LDL cholesterol and triglycerides.

The key nutritional interventions are as follows:

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Reduced Dietary Fat and Cholesterol

 Following a diet low in saturated fat and total fat and replacing saturated with
unsaturated fat lower cholesterol production and blood lipids. A diet deriving ≤ 7% of
calories from saturated fat and ≤ 200 mg/day of cholesterol.
 Vegetarian (especially vegan) diets that are free of cholesterol and very low in
saturated fat reduce LDL cholesterol by 17% to 40%, with the strongest effects seen
when the diet is combined with exercise.
 Reducing total fat, saturated fat, and cholesterol intake also lowers triglyceride levels
by approximately 20%.
 Proteins should make up 12-20% of the diet.
 Consuming small amounts of fats in their naturally occurring form (eg, nuts) may be
preferable to using oils because of their potentially cardio-protective nutrients:
magnesium, fiber, vitamin E, and flavonoids.
 Soluble fiber (mostly from oats, barley, pectin reach fruits and beans) reduces
cholesterol concentrations chiefly through binding of bile acids, leading to increased
cholesterol excretion.
 Soluble fiber appears to be most effective in the context of a diet low in saturated fats.
Soluble fiber lowers total cholesterol and lowers the LDL: HDL cholesterol ratio.
Common sources include oats, barley, legumes, and many fruits and vegetables.
 While diets high in refined carbohydrates (e.g. white flour) can increase plasma
triglyceride concentrations, the opposite is typically seen with diets high in unrefined,
low–glycemic–index carbohydrate sources, such as legumes and most whole grains.
Carbohydrates should make up 50-55% of the calories.
 Soy protein reduces hepatic cholesterol synthesis and may increase the hepatic LDL
receptor uptake of cholesterol. In clinical tests, soy protein decreased total cholesterol
by 9%, LDL by 13%, and triglycerides by 10%.
 Nuts (almonds, peanuts, pecans, and walnuts) appear to have hypolipidemic effects,
apparently due to their fiber, plant sterol, and unsaturated fat content. Walnuts, for
example, lowered total cholesterol by 12% and LDL cholesterol by 16%, and lowered
the LDL: HDL ratio by 12%.
 Plant sterols (often in the form of margarine) reduce LDL cholesterol concentrations
by roughly 10% by inhibiting cholesterol absorption.
 Avoiding alcohol may help reduce triglycerides. Alcohol appears to raise
triglycerides by 5 to 10 mg/dL. Restricting its consumption joins diet, exercise, and
weight loss as cornerstones of treatment for patients with elevated triglyceride levels.
 Use Fat free or low fat milk
 Nutrition consultation to advise patient in above diet and arrange follow–up.
 Smoking cessation.
 Alcohol restriction for hypertriglyceridemia.

pg. 219 by Osonga

Weight reduction

o Exercise prescription (patient–specific). Obese patients should be instructed to attain

ideal body weight by appropriate reduction in caloric intake and regular exercise.

N/B 1.Fats are divided into two categories.1. Saturated. 2. Unsaturated

Saturated fats raise LDL cholesterol level. Unsaturated fats are divided into two.
Monounsaturated and polyunsaturated fats. Both monounsaturated and polyunsaturated
lowers LDL cholesterol levels. Good sources of unsaturated fats are plant/vegetable oils and
nuts. Therefore to reduce cholesterol in the body: 1. Increase intake of polyunsaturated fats
2.Increase intake of plant proteins as compared to animal proteins e.g. legumes, dry beans, nuts,
whole grains, and vegetables 3. Increase intake of soluble fiber (mostly from oats, barley,
pectin reach fruits and beans)

N/B 2.Cholesteral, Lipoproteins and Lipids

Cholesterol and triglycerides (TG)-Cholesterol is a fatlike substance in all cell membranes and
blood that helps in cell membrane support; hormone production (such as estrogen,
testosterone, progesterone, aldosterone and cortisone); vitamin D and bile production.
Cholesterol and triglycerides (TG) cannot dissolve in blood and must be transported to and from
cells by individual components containing both lipids and proteins (lipoproteins).There are five
types of lipoproteins, classified according to the fat contentment and thus their density. Those
with highest fat content possesses the lowest density

Chylomicrons. They accumulate in portal blood after meal and transport dietary triglycerides
from the intestinal cells into the blood. They are synthesized in the intestinal wall

Intermediate density lipoprotein. They continue the delivery of endogenous triglycerides to the
cells (they transport dietary triglycerides from the blood to the cells) and carry about 40%
cholesterol. They are synthesized in the liver

Very Low Density Lipoprotein (VLDL)

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They are synthesized in the liver. They transport triglycerides that are produced within/in the
body mainly in the liver and intestinal mucosa to various tissues in the body.

Low Density Lipoprotein (LDL)

They are synthesized in the liver as they are derived from VLDL. They transport cholesterol
from liver to the body thus increasing the amount of cholesterol in the body tissues. They are
therefore called the bad cholesterol as they increase the amount of cholesterol in the body.

High Density Lipoprotein (HDL)

They are synthesized in the liver. They transport cholesterol back to the liver from peripheral
cells for catabolism or disposal (excretion).i.e. they transport cholesterol from the body to the
liver for destruction. They are therefore called the good cholesterol as they reduce the amount of
cholesterol in the body

 HYPERLIPOPROTEINEMIA
 Hyperlipoproteinemia is a common disorder. It results from an inability to break down
lipids or fats in your body, specifically cholesterol and triglycerides. There are several
types of hyperlipoproteinemia. The type depends on the concentration of lipids and which
are affected.
 High levels of cholesterol or triglycerides are serious because they’re associated with
heart problems.
Causes
Hyperlipoproteinemia can be a primary or secondary condition.
 Primary hyperlipoproteinemia is often genetic. It’s a result of a defect or mutation in
lipoproteins. These changes result in problems with accumulation of lipids in your body.

 Secondary hyperlipoproteinemia is the result of other health conditions that lead to high
levels of lipids in your body. These include:
o diabetes
o hypothyroidism
o pancreatitis
o use of certain drugs, such as contraceptives and steroids
o certain lifestyle choices

pg. 221 by Osonga

  It is important to recognize that hyperlipoproteinemia may be secondary to diet, drugs,
disorders of metabolism and diseases. It is difficult to correct a secondary dyslipidemia
unless the primary problem is addressed. Thus, the first step in analysis is always a
detailed history including evaluation of diet, medications (prescription or over-the-
counter), family history, and personal history of thyroid disease, diabetes, or kidney
disease.

There are five types of primary hyperlipoproteinemia:

 Type 1 is an inherited condition. It causes the normal breakdown of fats in your body to
be disrupted. A large amount of fat builds up in your blood as a result.
 Type 2 runs in families. It’s characterized by an increase of circulating cholesterol, either
low-density lipoproteins (LDL) alone or with very-low-density lipoproteins (VLDL).
These are considered the “bad cholesterols.”
 Type 3 is a recessively inherited disorder in which intermediate-density lipoproteins
(IDL) accumulate in your blood. IDL has a cholesterol-to-triglycerides ratio that’s higher
than that for VLDL. This disorder results in high plasma levels of both cholesterol and
triglycerides.
 Type 4 is a dominantly inherited disorder. It’s characterized by high triglycerides
contained in VLDL. The levels of cholesterol and phospholipids in your blood usually
remain within normal limits.
 Type 5 runs in families. It involves high levels of LDL alone or together with VLDL.

Symptoms of hyperlipoproteinemia
 Lipid deposits are the main symptom of hyperlipoproteinemia. The location of lipid
deposits can help to determine the type. Some lipid deposits, called xanthomas, are
yellow and crusty. They occur on your skin.
 Many people with this condition experience no symptoms. They may become aware of it
when they develop a heart condition.
Other signs and symptoms of hyperlipoproteinemia include:
o pancreatitis (type 1)
o abdominal pain (types 1 and 5)
o enlarged liver or spleen (type 1)
o lipid deposits or xanthomas (type 1)
o family history of heart disease (types 2 and 4)
o family history of diabetes (types 4 and 5)
o heart attack
o stroke

pg. 222 by Osonga

  Physical examination should include careful inspection of the skin, tendons, and eyes
looking for xanthoma, xanthelasma, corneal arcus, and lipemia retinalis, which directly
suggest a lipid disorder.
 In addition, evaluation of the blood pressure and peripheral pulses may provide evidence
for existing atherosclerosis, raising the probability of finding a lipid disorder upon
laboratory testing.
Dietary and Lifestyle changes

 Restrict total calories to maintain a desirable weight.

 Consume less than 200mg/day of cholesterol.
 Total fat consumption should be 25% to 30% of total calories.
 Saturated fat should be less than 7% of total calories.
 Polyunsaturated fat should be 10% or less of total calories.
 Monounsaturated fat should be 20% or less of total calories.
 Carbohydrate should be predominantly of the complex variety and provide 50%
to 60% of total calories
 Fibre should be 20 to 30g/day
 Protein should account for approximately 15% of total calories
 In addition to dietary modification, a therapeutic lifestyle change must include
regular exercise

TOPIC: RENAL DISORDERS

RENAL DISEASES

Physiology and function of kidneys

 The kidneys are two bean-shaped organs, each about the size of a fist, each weighing
about 150g. They are located just below the rib cage, one on each side of the spine.

 Every day, the two kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2
quarts of urine, composed of wastes and extra fluid. The urine flows from the kidneys to
the bladder through two thin tubes of muscle called ureters, one on each side of the
bladder. The bladder stores urine.

pg. 223 by Osonga

  In men the urethra is long, while in women it is short.

Functions of the Kidney

The kidneys are essential to life through three functions: excretory, endocrine, and regulatory
1. Excretory function: Excretory functions serve to remove potentially toxic metabolic
substances such as urea (major end products of protein metabolism), uric acid, keto acid
creatinine, as well as hydrogen ions which arise from sulphur containing amino acids.
They also excrete surplus quantity of water, sodium, potassium, calcium, phosphate
and magnesium from the blood.
2. Regulatory functions- Regulatory functions control electrolytes, acid- base and fluid
balance. The regulatory functions helps in the maintenance of serum concentrations of
sodium, potassium, chloride, bicarbonate and hydrogen ions
 Acid-base balance is maintained through a buffer system, which maintains blood at pH of
7.4
 Bicarbonate carries hydrogen ions to the kidneys where they are removed from extracellular
fluid in the tubules, returned to the bloodstream as needed
 Phosphate buffers intracellular fluid

pg. 224 by Osonga

  When fluid volume is low, anti-diuretic hormone (ADH) or vasopressin is released from the
anterior pituitary; increases absorption of water in the collecting duct. When extracellular
volume (ECV) decreases, the renin-angiotensin-aldosterone system is activated  excretes
less sodium chloride

3. Endocrine functions. Endocrine functions include conversion of the inactive form of

vitamin D (25-hydroxy-cholecaliciferol) to active vitamin D (1, 25
dihydroxycholecalciferol), synthesis of erythropoietin hormone (needed for the
production of red blood cells in the bone marrow), and for the synthesis and release of
renin, which regulates the blood pressure.
 Deficiency of erythropoietin is a factor in the severe anaemia present in chronic
renal disease.
 Active vitamin D promotes efficient absorption of calcium by the gut and is one
of the substances necessary for bone remodelling and maintenance; and also
promotes the metabolism of calcium and phosphorus

How do the kidneys work?

• These functions are accomplished by a filtering units called the nephron. Each kidney is
made up of about a million nephrons (The basic functional unit of the kidney). Each
nephron consists of a glomerulus (a filter) and a long tubule (the collecting duct)

• Each nephron filters a small amount of blood. The nephrons work through a two-step
process. The glomerulus lets fluid and waste products pass through it; however, it
prevents blood cells and large molecules, mostly proteins, from passing. The filtered
fluid then passes through the tubule, which sends needed minerals back to the
bloodstream and removes wastes. The final product becomes urine. The tubule helps in
the reabsorption of water, sodium, potassium, chloride.

• Kidney receives 20% of cardiac output, which allows the filtering of approximately 1600
litres/day of blood. As the filtrate passes through the nephrons, it is concentrated or diluted
to meet the body’s needs. In this way, the kidneys help maintain both the composition and
the volume of body fluids and, consequently, they maintain fluid balance, acid-base balance,
and electrolyte balance.

• The liquid waste is sent via two tubes called ureters from the kidneys to the urinary bladder,
from which they are excreted in approximately 1.5 liters of urine per day. These waste
materials include end products of protein metabolism (urea, uric acid, creatinine,
ammonia, and sulfates), excess water and nutrients, dead renal cells, and toxic

pg. 225 by Osonga

 substances. When the urinary output is less than 500 ml/day, it is impossible for all the
daily wastes to be eliminated. This condition is called oliguria. When the kidneys are
unable to adequately eliminate nitrogenous waste (end products of protein metabolism),
renal failure can result. The recycled materials are reabsorbed (taken back) by the blood.
They include amino acids, glucose, minerals, vitamins, and water.

Key terms
 Azotemia – accumulation in the blood of abnormal quantities of urea, uric acid, creatinine,
and other nitrogenous wastes
 Oliguria –Abnormally small production of urine(A condition of having urinary volumes of
less than 500ml/day)
 Anuria-Inability to urinate
 Uremia – Presence of an unacceptable level of nitrogenous wastes in blood. Also known as
azotemia
 Haematuria-Presence of blood in the urine
 Proteinuria-Presence of excessive protein, mostly albumin but also globulin in the urine
 Glomerular filtration rate (GFR) – the quantity of glomerular filtrate formed per unit in
all nephrons of both kidneys
 Nephritic syndrome – the syndrome of hematuria (presence of blood in urine),
hypertension, and mild loss of function that results from acute inflammation of the capillary
of the glomerulus
 Nephritisis- a general term referring to the inflammatory diseases of the kidneys. Nephritis
can be caused by infection, degenerative processes, or vascular disease.
 Nephrolithiasis- is a condition in which stones develop in the kidneys. The size
of the stones varies from that of a grain of sand to much larger
 Nephrotic syndrome – a condition resulting from loss of the glomerular barrier to protein
and characterized by massive edema and proteinuria, hypoalbuminemia,
hypercholestrolemia, hypercoagulability, and abnormal bone metabolism
 Nephrosclerosisis the hardening of renal arteries. It is caused by arte-riosclerosis and
hypertension. Although it usually occurs in older people, it sometimes develops in young
diabetic clients.
 Hemodialysis – a method of clearing waste products from the blood in which blood passes
by the semipermeable membrane of the artificial kidney and waste products are removed by
diffusion

pg. 226 by Osonga

  Renal failure – the inability of a kidney to excrete the daily load of end-stage renal disease
 End stage renal disease – a disease characterized by the kidney’s inability to excrete waste
products, maintain fluid and electrolyte balance, and produce hormones

 DISEASES OF THE KIDNEY

 Nephritic syndrome / Glomerulonephritis / Nephritis
 Nephrotic syndrome
 Acute renal failure (ARF)
 Chronic renal failure
 End-stage renal disease (ESRD)

Other Kidney diseases are

 Diabetic Nephropathy damage to the nephrons in the kidneys from unused sugar in
the blood, usually due to Diabetes.
 Glomerulosclerosis; It is the scarring or hardening of the tiny blood vessels within
the kidney
 Polycystic Kidney Disease (PKD) is a hereditary kidney disease in which many
cysts grow in the kidneys. These cysts may lead to kidney failure.
 Acute Kidney Injury - Sudden kidney failure caused by blood loss, drugs or
poisons. If the kidneys are not seriously damaged, acute renal failure may be
reversed.
 Chronic Kidney Disease - Gradual loss of kidney function is called Chronic Renal
Failure or Chronic Renal Disease. It results from progressive and irreversible
destruction of nephrons, regardless of the cause It is also called chronic kidney
disease
 End-Stage Kidney Disease - The condition of total or nearly total and permanent
kidney failure.

N/B. The most common kidney diseases are acute renal failure, chronic renal failure, end stage
renal disease, polycystic kidney diseases and diabetic nephropathy

N/B 2. Glomerular diseases fall into the following major categories

 Glomerulonephritis; It is the inflammation of the membrane tissue in the kidney that

serves as a filter, separating wastes and extra fluid from the blood.
 Glomerulosclerosis; It is the scarring or hardening of the tiny blood vessels within the
kidney. They damage the glomeruli letting protein and sometimes red blood cells leak into
the urine. They can both lead to kidney failure
 Nephrotic syndrome

pg. 227 by Osonga

  NEPHRITIC SYNDROME /GLOMERULONEPHRITIS/NEPHRITIS

 Glomerulonephritis refers to the inflammation of the glomerulus, a membrane tissue in

the kidney that serves as a filter, separating wastes and extra fluid from the blood.
 It is mostly common in its acute form in children 3 to 10 years of age although it can
occur in adults past age 50.
 The onset is sudden and lasts a short time and proceeds to either complete recovery or
development of chronic nephrotic syndrome.

There are two types of glomerulonephritis—acute and chronic.

a) Acute glomerulonephritis - It develops suddenly. it results in damage of glomerular barrier
allowing large molecules of RBCs and proteins to be filtered out of blood. It occurs mostly in
children and young adults.
b) Chronic glomerulonephritis
This occurs after repeated episodes of acute phase leading to increased loss of nephrons and kidney
function. The chronic form may develop silently (without symptoms) over several years. It often leads to
complete kidney failure.
Causes
It is mostly caused by

 streptococcal infection

Other causes are

 shock((hypovolemia) e.g. accident, injury

 scarlet fever,
 respiratory infections
 pneumonia,
 surgery on other parts of the body
 are metallic poisoning
 drugs
 lupus and hereditary nephritis

Symptoms

Classical symptoms

pg. 228 by Osonga

  Haematuria(blood in the urine)-It is present mostly when nephritis is caused by an
infection or as result of accident or injury resulting into blood lost. Haematuria results
into low level of blood that results into low GFR
 Mild Proteinuria-loss of proteins in the urine (albumin and globulin are lost in the urine)
 Edema. Low albumin levels in the blood leads to oedema as blood osmotic pressure is
lost
 Hypoalbuminia-it refers to low level of albumin in the blood as albumin is lost in the
urine
 Tea coloured urine
 Hypertension due to fluid retention that result into reduced blood flow

*******HHAD STREP*************
Other symptoms

 Edema(fluid retention) -swelling of your ankles or face (edema) that results into
weight gain
 Shortness of breath and cough because of extra fluid in your lungs.
 Anorexia
 Anaemia- May be present mostly when nephritis is caused by an infection or as result of
accident or injury resulting into blood loss
 Nausea and vomiting
 Increased blood urea nitrogen(BUN), due to the diminished out put
 There may be oliguria (decreased output of urine about <400 mls/day) Or anuria (lack
of urine) and uremia which may signal development of acute renal failure

Implications
 PEM due to protein loss
 Impaired protein and fat metabolism and excretion.
 Infections due to loss of immunoglobin- immune system proteins that help fight disease
and infection—this leads to an increased risk of infections. These infections include
pneumonia, a lung infection; a skin infection; peritonitis, an abdominal infection; and
meningitis, a brain and spine infection.
 Blood coagulation disorders - blood clots can form when fibrinogen( proteins) that normally
prevent the clotting are lost through the urine. Blood clots can block the flow of blood and
oxygen through a blood vessel.
 Anemia— low blood volume may occur when nephrotis is caused by an infection or as
result of accident or injury resulting into blood loss

pg. 229 by Osonga

  Hypertension/High blood pressure—a condition in which blood flows through the blood
vessels with a force greater than normal
 Low urine due to low glomerulus filtration rate (GFT). Low GFT is due to low blood volume
 Fluid imbalance
 Edema

Aim of nutritional management

 to spare the diseased kidneys
 To increase blood volume
 to prevent uremia (presence of urea or other nitrogenous waste in the blood also called
uraemic syndrome)
 To prevent oedema
 To maintain adequate nutrition.
 To control and correct protein deficiency.
 To afford better resistance to infection/to improve the immunity.
 Replacement of albumin and other protein lost from the plasma into the urine.

Treatment of nephritic syndrome

 Drugs; e.g. Diuretics to reduce oedema, antibiotics and anti-inflammatory drugs.

Diet therapy

Energy

 Provide high carbohydrate diet (60% of total kilocalorie) to cater for the increased
energy demand and protein sparing effect, prevent/reduce catabolism of protein, ketosis,
as well prevent starvation. For adults, provide (35 – 50Kcal/Kg/bwt).

For children 80kcal/kg body weight and 10% for infection.

 Sufficient calories is given without increasing the protein intake by means of e.g
sugar, honey, glucose, and starchy foods (cereals in all forms are
recommended).Sufficient carbohydrate helps in preventing protein catabolism
(reduce catabolism of protein), starvation and ketosis. Above mentioned foods are not
only rich in calories but also poor in sodium and potassium

Protein

 Adequate protein should be given unless there is oliguria, uremia(elevated blood urea
in the blood-i.e with normal BUN levels) or anuria.

pg. 230 by Osonga

  Limit protein at 0.6-0.8g/kg bwt/day for adults if there is uremia (when BUN levels
are high), oliguria and uremia. Animal proteins should be provided
 Usually, provide 0.5g of protein/ kg of ideal body weight for older children and 1-1.5
g/kg per day for younger children. Provide proteins from the animal sources.
 A low protein is recommended so as to give rest to the kidney
 High-protein diets(high quantity) are not recommended as they may encourage damage
to the nephrons, leading to a progression of renal insufficiency
 The patients should consume a high quality of protein foods from animal
souces, such as fish, milk, lean meat, egg white, and so on.

Fluid

 Fluid should be restricted if there is oedema, hypertension, or oliguria. The fluid is

restricted for disposal of oedema fluid.
 Adjust fluid intake to fluid output, which occurs through urine, vomiting and diarrhoea.
Volume of fluid intake is calculated from volume of urine passed in previous 24hrs.
 If urine output is above 1000ml in 24 hours do not restrict, if output is below 1000ml in
24 hours restrict by giving output equivalent plus 500ml(in adults), if no urine output
give 500ml to 700ml.
 The equivalent plus 500ml is based on the volume of fluid excreted and allowance, 500
ml/day, is given for insensible water loss (urine, vomiting, diarrhoea and perspiration). It
should be calculated based on the amount of water consumed with drugs, fluid from milk,
soups, tea etc.
 The equivalent plus 500ml normally happens in the later stage of the disease and this plus
500 is for adults

Sodium

 Sodium (Na) should be restricted to control hypertension and edema. Restriction depends
on the extent of symptoms present. Restriction varies with the degree of symptoms
present (oliguria, oedema and hypertension).
 If renal function is impaired, sodium is restricted to 500 to 1000 mg/day.
Calcium

 About 1g/day should be given

Potassium

pg. 231 by Osonga

  Monitor potassium intake as renal clearance of potassium is impaired when severe
oliguria is a complication, and this may lead to potassium intoxication and even require
dialysis as hyperkalemia can result in cardiac arrest.
 Should be restricted to 1mmol/kg /day. Too much potassium in the body results into
uneven heat beat and thus the heart may stop suddenly(cardiac arrest)

Phosphorus

 This is a mineral found in almost all foods. High phosphors in blood can cause calcium to
be pulled from the bones and thus make bones weak and break easily
 Restrict phosphorus intake to 8-12 mg /kg/day
Others

 Provide small frequent meals as there is poor appetite

 Provide iron rich foods in case anaemia results from haematuria, iron supplement may be
necessary
 Ensure that the diet is of low fat(less than 30%). Include emulsified and easily digestible
fat to provide non-protein calories for energy needs.

Example

Patients particulars: Age- 5 yrs., wt-15kgs, B.P-130/90, urine output-300 ml

Requirements: Energy 15 x 80=1200 + 120(10%) =1320 kcals

Protein: 1.25 x 15=20 to 25 g/day

Sodium: 500 mg

Fluid: 300 + 25 ml/kg body weight=300 + (25 x 15) =675 ml

 NEPHROTIC SYNDROME
Nephrotic syndrome is where glomerular capillary wall has failed to act as an impermeable
barrier to proteins, resulting in the loss of albumin and other plasma proteins in the urine. It is
called a syndrome because it comes with a cluster of symptoms which include oedema due to
low albumin (due to proteinuria) , hypoalbuminemia (low serum albumin), elevated
blood lipids (cholesterol and triglycerides), poor bleeding times and alterations in bone
metabolism.

pg. 232 by Osonga

Causes
This can be caused by:
 progressive glomerulonephritis (glomerular disorders)
 Glomerulosclerosis
 Kidney damage from infection
 Blood clots in the renal veins
 Some medications(drugs), illicit drugs and toxins which increase permeability
 Metabolic disorders e.g lupus, diabetes nephropathy as a result of diabetes mellitus
 Preeclampsia
 Reaction to toxic venom.
 immunological and hereditary diseases
 chemical damage (from some medications or illicit drugs) which increase permeability
 heavy metals
 Some cancers.
Clinical symptoms

 Heavy proteinuria (large quantities of protein in the urine-at least 3.0g per day),
 Hypoalbuminemia (low albumin level in the blood/low serum albumin-due to large
protein losses in the urine)
 High cholesterol in the blood/Hyperlipidemia (Low albumin levels in the blood
triggers production of cholesterol)

 Peripheral oedema.That results in weight gain

 Ascites with fluid collecting in the peritoneal cavity causing distension of abdomen.

Unlike in nephritis, haematuria, anaemia are always absent. At times anaemia may be
present mostly when nephrotis is caused by an infection or as result of accident or injury
resulting into blood loss

Implications
 PEM due to protein loss
 Impaired protein and fat metabolism and excretion.
 Infections due to loss of immunoglobin- immune system proteins that help fight disease
and infection—this leads to an increased risk of infections. These infections include
pneumonia, a lung infection; a skin infection; peritonitis, an abdominal infection; and
meningitis, a brain and spine infection.

pg. 233 by Osonga

  Blood coagulation disorders - blood clots can form when fibrinogen( proteins) that normally
prevent the clotting are lost through the urine. Blood clots can block the flow of blood and
oxygen through a blood vessel.
 Accelerated atherosclerosis due to elevated, cholesterol, LDL and low HDL.
 Anemia— low blood volume may occur when nephrotis is caused by an infection or as
result of accident or injury resulting into blood loss
 Hypertension/High blood pressure—a condition in which blood flows through the blood
vessels with a force greater than normal
 Acute kidney injury—sudden and temporary loss of kidney function
 Low urine due to low glomerulus filtration rate(GFT). Low GFT is due to low blood volume

Aim of nutritional management

 To control and correct protein deficiency.
 To correct and prevent edema.
 To maintain adequate nutrition.
 To afford better resistance to infection/to improve the immunity.
 To avoid unnecessarily harm to the kidney.
 Replacement of albumin and other protein lost from the plasma into the urine.
 To increase blood volume
 to prevent uremia (presence of urea or other nitrogenous waste in the blood also called
uraemic syndrome)

Treatment of nephritic syndrome

 Drugs; e.g. Diuretics to reduce oedema, antibiotics and anti-inflammatory drugs.

Diet therapy/Nutrition care in nephrotic syndrome

 The diet should provide sufficient protein and energy to maintain a positive nitrogen
balance and to produce an increase in plasma albumin concentration, prevent PEM,
alleviate oedema and hyperlipedemia.
Protein
 Provide 0.8 to 1.0 g/kg of ideal body weight. 75% of the protein should be of high biological
value
 Although there is protein lose (heavy proteinuria) through the kidney, high protein
provision will cause deterioration of the renal function/high protein could cause further
renal damage in patients who have nephrotic syndrome.
 Some studies suggest 0.8 - 1g per kg of body weight/day

pg. 234 by Osonga

  The recommended protein intake for children who have nephrotic syndrome is the
Dietary Reference Intake for age plus the amount of urinary protein loss. Children who
have persistent proteinuria may require 2.0 to 2.5 g/kg of protein per day
 Some studies suggest that a low or very-low protein diet with essential amino acid
supplementation reduces proteinuria.
Energy
 Provide high energy intake of 35-50 kcal/kgbwt/day for adults. For obese give
25kcals/kgbwt/day to help reduce weight. Restricted energy intake also helps
in control of lipids. Children should be given 100-150 kcal/kgbwt/day

 An adequate energy intake sustains weight and spares protein for tissue synthesis. Complex
carbohydrates should be the primary source of energy intake.
 Weight loss may be recommended for obese patients, because they have an increased risk of
comorbid diseases and complications.
 Calculate according to individual needs. If the patient is obese, formulate a weight. reduction diet
regime
 Weight loss may be recommended for obese patients, because they have an increased risk of
comorbid diseases and complications.

Fats
 The diet should be of low fats to control the elevated blood lipids (hypercholesterolemia
and hyperlipidemia i.e. to provide 20-25% of the total calories. Restrict intake of
saturated fats/animal fats

 The diet should be low in saturated fats/animal fats (saturated fat <7% of total fat), and
cholesterol <200 mg/dL per day.
 A diet low in saturated fat, trans-fats, cholesterol, and refined sugars helps to control
elevated LDL and VLDL. Dietary measures are usually inadequate for controlling blood
lipids, thus a combination of statin therapy (drugs that can lower cholesterol) and the
Therapeutic Lifestyle Changes diet lowers serum lipid levels. Fish oil supplementation
(12 g/day) may be beneficial for patients who have IgA nephropathy, which is a caused
by the deposition of immunoglobin A in the kidneys
Sodium
 The level of sodium prescribed is based on the severity of edema and hypertension.
Controlling sodium intake helps to control edema (since the body has tendency to retain
water), therefore, sodium is usually restricted to 1 to 2 g/day, depending on the severity
of the patient’s signs and symptoms.
Fluid

 Fluid should be restricted if there is oedema, hypertension, or oliguria. The fluid is

restricted for disposal of oedema fluid.
 Adjust fluid intake to fluid output, which occurs through urine, vomiting and diarrhoea.
Volume of fluid intake is calculated from volume of urine passed in previous 24hrs.

pg. 235 by Osonga

  If urine output is above 1000ml in 24 hours do not restrict, if output is below 1000ml in
24 hours restrict by giving output equivalent plus 500ml(in adults), if no urine output
give 500ml to 700ml.
 The equivalent plus 500ml is based on the volume of fluid excreted and allowance, 500
ml/day, is given for insensible water loss (urine, vomiting, diarrhoea and perspiration). It
should be calculated based on the amount of water consumed with drugs, fluid from milk,
soups, tea etc.
 The equivalent plus 500ml normally happens in the later stage of the disease and this plus
500 is for adults

Fluid restriction is often necessary and should be based on the patient’s symptoms. Diuretics can
help maintain fluid and sodium balance. If the diuretics prescribed for the edema cause
potassium losses, patients are encouraged to select food rich in potassium
Vitamins and minerals:

 Provide iron, based on the individual patient’s need

 Ensure patient is meeting Dietary Reference Intakes for B-complex vitamins (niacin,
riboflavin, and thiamin) and vitamin C. Supplement as needed
 Supplement 1 to 1.5 g of calcium, not to exceed 2,000 mg
Limit phosphorus to <12 mg/kg per day

 In case of poor appetite provide small frequent meals.

N/B. Abnormalities in iron, copper, zinc, and calcium levels are directly related to the urinary
loss of proteins that are involved in their metabolism. Supplemental zinc may be needed, as zinc
is bound to albumin. In addition, decreased levels of calcium and serum 1,25-
dihydroxycholecalciferol may occur as a result of being bound to albumin. Supplemental
calcium (about 1000 to 1500 milligrams per day), vitamin D and iron may be needed to
normalize serum levels, and to help prevent bone loss and rickets

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  RENAL FAILURE
Classification of kidney failure
1. Acute kidney Injury (AKI)
2. Chronic kidney disease (CKD)

Acute kidney injury has replaced acute kidney failure while chronic kidney disease has
replaced chronic renal failure

 ACUTE KIDNEY INJURY (AKI)-formaly acute renal failure

 This refers to an abrupt/sudden decline of kidney function over a period of hours or
days OR
 This refers to an abrupt/sudden loss of kidney ability to excrete the waste products
and maintain normal composition of blood over a period of hours or days
 It is characterized by a sudden reduction in glomerular filtration rate (Normal
filtration rate is –above 90 ml/1 min to 130 ml/min)
 There is high mortality and the condition needs a medical emergency in which and
nutrition support
 AKI has replaced the term acute renal failure, as the condition (AKI) does not
always result in chronic kidney disease (AKI can be reversed)

Diagnosis

 AKI is diagnosed by increase in serum/blood creatinine level (a 50% increase in

the serum creatinine level) because the kidney cannot clear the creatinine. Creatinine
should be cleared completely by glomeruli. There is increased creatinine level,
other nitrogenous waste and electrolytes in the blood due to decreased GFR rate.
Normal filtration rate- above 90 ml/min to 130 ml/1 min

N/B. The loss of kidney function reduces urine output and allows nitrogenous waste to build
up in the blood e.g creatinine. With prompt treatment, acute kidney injury is often reversible.

Causes of Acute Kidney Injury (AKI)

Causes of acute kidney injury [AKI]) fall into one of the following categories: Pre-renal, post-
renal and renal factors

 Pre-renal: Factors that cause sudden reduction in blood flow to the kidneys
 Sudden loss of blood supply to the kidneys can be as result of the following.

pg. 237 by Osonga

  Low blood volume or pressure: haemorrhage, burns, sepsis, or shock, anaphylactic
reactions, ulcers, sickle cell anemia, aneurysm, blood loose e.g at the time of delivery,
shock e.g. as a result of injury and accidents nephritic syndrome, diuretics,
antihypertensive medications, acute haemolytic disorders (RBC are destroyed due to
some diseases)
 Renal artery disorders: blood clots or emboli, stenosis, aneurysm, trauma
 Heart disorders: heart failure, arrhythmias

Post-renal: Factors/Problems affecting the movement of urine out of the kidneys/ factors that
prevent excretion of urine e.g.
 Renal blood clots/renal vein thrombosis
 Trauma affecting the bladder
 Obstruction of ureter/bladder
 transfusion reactions
 kidney inflammation, stones and tumours;
 loss of fluid from the gut as in severe diarrhoea or vomiting, acute intestinal obstruction
 diabetic coma( excessive urination and excessive sweating)
 cervical and prostate cancer surgical complications
 Exposure to a nephrotoxic chemical or drug (e.g., radiologic dyes, cleaning solvents,
pesticides, and gentamicin). In haling tetra-chloromethane (CCl4) or mercury (Hg)
 general anaesthesia and streptococcal infection e.g. E.coli food poisoning

Renal factors: Problems with the kidney itself that prevent proper filtration of blood or
production of urine
 glomerular disease(nephritis)
 tubular necrosis ,
 nephrotoxins like paracetamol and some varieties of mushrooms
 Vascular disorders: sickle cell disease, diabetes mellitus, transfusion reactions
 Obstructions within kidney: inflammation, tumors, stones, scar tissue
 Renal injury: infections, environmental contaminants, drugs, medications E. coli food
poisoning
Symptoms
Oliguric phase
Follows precipitating event and may last for a few days to five weeks.

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  Volume of urine may be as little as 20ml to 200ml a day (oliguria). Most patient
produces less than 400 ml of urine per day. This is because of decline in renal functions.
Oliguria leads to fluid retention. Anuria may be present
 Excretion of sodium, water, potassium and nitrogenous waste are all reduced due to
decreased GFR rate

 There is danger of hyperkalemia(elevated potassium) due to increased breakdown of

damaged tissues leading to increased release of intracellular potassium. Elevated
potassium (hyperkalemia) can alter heart rhythm and lead to heart failure.
 Nausea and vomiting
 Blood pressure elevated
 Signs of uremia may be present (Accumulation of waste product of protein metabolism
in blood. Serum urea nitrogen and creatinine levels are increased)

 Elevated serum phosphate levels (hyperphosphatemia) promote excessive secretion of

parathyroid hormone, leading to losses of bone calcium
 Oral intake is usually difficult during this phase because of anorexia, vomiting and
nausea
 Neuromuscular disturbances: symptoms may include altered thought processes, sleep
disorders, muscle cramping, sensory deficits, tremor and seizures.
 Other effects: defects in platelet function and clotting factors prolong bleeding time
and contribute to bruising and gastrointestinal bleeding.
 Skin changes include increased pigmentation and severe pruritus (itchiness). Patients
with uremia typically have suppressed immune responses.
 Death is caused not because of rise in blood urea but potassium intoxication or water
intoxication due to over treatment with fluids to stimulate urine excretion.

Diuretic phase. The stage indicates a return of renal function to normal

 The patient may start passing moderate amount of urine

 In the following day larger than normal amount of urine may be passed
 The urine volume may increase gradually to between 2 to 5litres per day and excretion
of sodium, potassium and other solutes also increases
 Blood urea falls to normal in 7 to10 days indicating that gromerula filtration has
effectively improved.

Consequences/implications of acute renal failure

 Electrolyte imbalances: The reduced excretion of fluids results in sodium retention and
elevated levels of potassium, phosphate, and magnesium in the blood. Elevated potassium

pg. 239 by Osonga

 (hyperkalemia) can alter heart rhythm and lead to heart failure. Elevated serum phosphate
levels (hyperphosphatemia) promote excessive secretion of parathyroid hormone, leading to
losses of bone calcium.
 Fluid imbalance.
 Uremia – as a result of impaired kidney function, nitrogen- containing compounds and
various other waste products may accumulate in the blood.
 Hormonal imbalance: - diseased kidneys are unable to produce erythropoietin, causing
anemia. Reduced production of active vitamin D contributes to bone disease
 Altered heart function/increased heart disease risk. Fluid and electrolyte imbalances
result in hypertension, arrhythmias, and heart muscle enlargement. Excessive parathyroid
hormone secretion leads to calcification of arteries and heart tissues.
 Neuromuscular disturbances: symptoms may include altered thought processes, sleep
disorders, muscle cramping, tremor and seizures.
 Sudden reduction in urine output (oliguria or anuria).
 Edema due to fluid and sodium retention
 Accumulation of wastes of metabolism e.g. BUN, creatinine etc.
 Decrease oral intake due to anorexia, vomiting and nausea
 Acidosis may occur since hydrogen is not excreted.

Aims of nutritional management

 To support overall medical management
 Maintain adequate nutrition status in order to minimize endogenous protein catabolism
 Provide an optimal environment for wound healing
 Preventing infections
 Minimize uremia.
 Control edema
 Control electrolyte imbalance
 Control fluid imbalance
 Increase intake of food
 Minimize vomiting and nausea

Treatment of Acute Kidney Injury

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Treatment is done to restore fluid and electrolyte balances and minimize blood concentrations of
toxic waste products. Treatment involves a combination of
 drug therapy
 dialysis
 nutrition therapy
Nutrition therapy/Dietary management
 In the early stages, the patients are usually unable to eat as they are very sick. There
may also be vomiting and diarrhoea, therefore, total parenteral nutrition plus dialysis
is normally used.
Proteins
 During oliguric phase reduce proteins to a minimum amount required to compensate for
endogenous process
 If not on dialysis allow 0.6 - 1g/kg bwt/day. If on dialysis allow a more liberal amount of
protein of 1.1 - 1.5g/kg bwt/day. A 40gm protein diet may be used where the weight of
an adult patient is unknown
 60-75% of dietary protein should be of high biological value e.g. eggs, meat, fish,
poultry, milk
N/B. Protein should be restricted or stopped if the patient is under conservative treatment and
blood urea is rising and the patient is not on dialysis

Calories
 Sufficient calories from carbohydrates and fats are used to increase the caloric content of
the diet and spare the breakdown of body proteins
o 35KCal/kg/body weight (patients with normal weight).
o 20-30KCal/kg/body weight (obese patients)
o 40-50KCal/kg/body weight (underweight/catabolic patients)

Carbohydrate.

 55-60% of energy should be provided by carbohydrate, a minimum of 100g/day

should be provided to minimise tissue protein breakdown e.g two litters of 5%
glucose meets this
Fluid intake
 Adjust fluid intake to fluid output, which occurs through urine, vomiting and diarrhoea.
Volume of fluid intake is calculated from volume of urine passed in previous 24hrs. If
urine output is above 1000ml in 24 hours do not restrict, if output is below 1000ml in 24

pg. 241 by Osonga

 hours restrict by giving output equivalent plus 500ml, if no urine output give 500ml to
700ml. An individual with fever, vomiting or diarrhea requires additional fluid. Patients
undergoing dialysis can ingest fluids more freely.

Sodium
 Sodium is restricted to avoid fluid retention
 Control hypertension and prevent congestive cardiac failure
 Restriction of total sodium to 1000 - 2000mg daily is necessary during the oliguric phase.
Do not give salt if there is anuria, elevated high blood pressure and when the level of
urine produced is too little
Other electrolytes
 Serum electrolyte levels are monitored closely to determine appropriate electrolyte
intakes. Depending on the results of laboratory tests and the clinical assessment,
restrictions may be necessary for potassium (2000-3000 mg/day) Potassium is controlled
to avoid hyperkalemia and hypokalemia, phosphorus (8-12 mg/day)
N/B. Potassium intoxication (hyperkalemia) has deleterious effect on heart. Potassium sources
like tomatoe juice, coffee, tea, cocoa and potassium rich vegetables can be avoided

Haemodialysis or peritoneal dialysis may be considered when blood urea level is over 200
mg/100ml.The energy and protein content of the diet may then be increased

Diuretic phase
In oliguric patients, recovery from kidney injury sometimes begins with period of diuresis in
which large amounts of fluid (up to 3 liters daily) are excreted.

 The stage indicates a return of renal function to normal

 The patient is passing a large amount of urine and so is at risk from excessive loss of
water, sodium, bicarbonate, phosphate and magnesium
 Prescribe a normal diet with free fluid intake
 May need to be supplemented with electrolytes
 Proteins intake restriction continues until BUN and serum creatinine returns back to
normal.
 The fluid and electrolyte status need to be monitored by daily weighing and blood and
urine analysis

N/B 30% of ICU patients develop acute renal injury

 CHRONIC KIDNEY DISEASE

 This is an irreversible destruction of kidney tissues by disease leading to insufficiency of
renal excretory and regulatory functions

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  It is called chronic kidney disease (CKD) when the kidney can no longer excrete waste
products and maintain normal composition of blood for longer than 3 months.
 This is as a result of the progressive deterioration of kidney tissue during several months
or years as scar tissue is substituted for viable kidney tissue.
N/B. It is also known as uraemia as the level of urea in blood is very high.

Causes of chronic Kidney disease

 Chronic Kidney disease can be attributed to several underlying causes, some of the most
common being nephrotic syndrome, glomerularnephritis, acute renal failure,
diabetes, hypertension, and HIV
1. Nephrotic syndrome: This is a loss of protein through the glomerular lumen, which can
lead to proteinuria, hypoalbuminemia, edema, increased cholesterol, poor bleeding times,
and alterations in bone metabolism
2. Glomerularnephritis (nephritic syndrome): This is inflammatory response in the
glomerulus capillary loop. It normally occurs after streptococcal infections, and can cause
hypertension and blood in the urine along with decreased renal function. The main side
effect of this disease is hematuria.
3. Acute kidney injury: This develops when filtration rate and urea production suddenly
drop, a process that can be reversed if caught in time
4. Diabetic nephropathy: As blood sugars continue to rise, the damage to the small blood
vessels in the kidney increase with time. Diabetes mellitus especially type II
5. Atherosclerosis and hypertension: Poor blood pressure control places continued high
pressure on the kidneys’ arteries and weakens them.
6. HIV:The HIV infection can affect the cells in the kidney and also can attack the nephrons
within the kidneys that help filter the by-products.
7. Abdominal surgical emergency, Gout, exposure toxic substances and polycystic kidneys

N/B. CKD is a risk factor of cardiovascular disease as more lipids are produced when there is
low calcium in the blood

Who is at risk of CKD

Adults are at increased risk of developing CKD if they:
 are 60 years or older
 have diabetes
 have a family history of kidney disease
 have established cardiovascular disease
 have high blood pressure
 are obese (body mass index ≥30)

pg. 243 by Osonga

  are a smoker

Symptoms
 Decrease in renal blood flow leading to low glomerular filtration rate/GFR because
of damaged nephrons
 Increased creatinine or urea in the blood, blood and/or protein in the urine
 Dehydration( Increased thirst at night leading to dehydration ) or water intoxication,
sodium depletion, high serum potassium,
 Calcium reabsorption from the bones leading to osteomalacia)
 Increased susceptibility to infection as a result of impaired of immune function
 Oedema
 high blood pressure (hypertension)
 Irregular heartbeats, muscle cramps due to increased potassium in the blood
 Gastrointestinal problems due to increased waste products-Loss of appetite, changes
in taste, nausea, vomiting and hiccups. Gastrointestinal problems can result into weight
loss
 Weakness, poor sleeping habits, fatigue caused by an increased amount of waste
products in the blood
 Neurological problems-twitching, convulsions, and coma may occur
 Anaemia(due to impaired erythropoietin and loss of blood through nose bleeding,
haematuria and gastrointestinal bleeding) leading to tiredness, breathlessness and
tendency to bleed due to abnormal platelet function
 Uremic symptoms of anorexia and vomiting resulting from accumulation of urea and
creatinine.
 Hyperlipidemia
 Skin changes pigmentation, muscle cramping and itching, restless leg
 Osteodystrophy, dwarfism and ricket growth failure may occur
 Shortness of breath, if fluid builds up in the lungs
 Weight loss

Stages of CKD

 It can be categorized as stage 1, 2, 3, 4 and 5(End Stage Renal Disease) based on the
GFR and symptoms. This can be achieved through laboratory tests.
 Glomerular Filtration Rate (GFR) is the measurement used to determine kidney function.
Specifically, it estimates how much blood passes through the glomeruli each minute.
Glomeruli are the tiny filters in the kidneys that filter waste from the blood. Knowing
your GFR score enables the physician to figure out the stage of your kidney disease and
plan the best possible treatment.

pg. 244 by Osonga

 CKD Stage GFR Level/score
Stage 1 (Normal Glomerula Filtration Rate) 90-130 ml/minute.
Stage 2 (mild decrease/reduction in kidney function) 60-89 ml/minute.
Stage 3 (moderate decrease/reduction in kidney function) 30-59ml/minute.
Stage 4 (Severe decrease/reduction in kidney function) 15-29ml/minute.
Stage 5 (End stage renal disease)-kidney failure <15 ml/minute.

N/B : Kidney failure is defined by a GFR below 15 ml/minute.

Five stages of chronic kidney disease

There is no cure for CKD.

 Stages 1: GFR is 90-130 ml/minute (The GFR rate is normal).

Kidney disease is relatively unrecognized because there are typically no or very few
symptoms at this stage of early chronic kidney disease(CKD)
 Stage 2: GFR is 60-89ml/minute.
There is mild reduction in kidney function. Creatinine clearance is 40mls/minute. The
creatinine levels may be 120-250mmols/litre in blood. Usually few symptoms are present at this
stage.
 Stage 3: GFR is 30-59 ml/minute.
There is moderate reduction of kidney function. Creatinine clearance is 20 mls/minute.
Creatinine levels in the blood are more than 300 mmols/litre. Patient will experience uremia,
anemia, high blood pressure, and slight bone disorders. These disturbances will lead to
fatigue, fluid accumulation, decreased urine output, sleep disturbances, and kidney pain. They
may want to see a nephrologist.
 Stage 4: GFR is 15-29ml/minute.
A patient at stage 4 has severe reduction in kidney function. Uremia, anemia, nausea,
changes in taste, decreased appetite, weight loss, impaired immune function, high blood
pressure, and bone disorders become more prominent.Later, patients develop
osteodystrophy(bone disorders due to renal disease as a result of calcium and phosphorus
imbalances-the kidney can no longer convert inactive vitamin D to active vitamin D. The active
vitamin D is needed for absorption of calcium from intestine to the blood. Bone disorder
develops as the body starts absorbing calcium from the bones thus the bones become porous and

pg. 245 by Osonga

can therefore break easily).Patients at this stage will be referred to a nephrologist. It is at this
point that they start receiving information about dialysis or kidney transplant.
 Stage 5: GFR is < 15 mls/minute.
It is also called End Stage Renal Disease (ESRD). GFR is less than15 mls/minute. There is
more than 90% of the kidney tissue damage. In stage 5, the patient has reached full kidney
failure. The patient will have little to no urine output among other symptoms seen in stage 4. At
this stage, the kidneys cannot keep up with waste and fluid clearance on its own. At this
point, dialysis or a kidney transplant is needed for the patient to live.

This is summarized in the figure below.

pg. 246 by Osonga

The following clinical values should be monitored during CKD: Serum albumin and total
protein, Urinary protein, Glomerular filtration rate, Dietary protein, fat, and cholesterol, Daily
weights, Serum lipids)

Nutrition implications /Consequences of CKD

 Gastro-intestinal disturbances such as diarrhorea and vomiting

 Hypocalcemia; low blood calcium levels
 Hyperphosphatemia; elevated phosphorus levels in blood
 Hyperkalemia; elevated potassium levels in blood
 Sodium and fluid retention
 Elevated lipids
 Anemia due to lack of erythropoietin
 Nitrogen retention; the creatinine and blood urea nitrogen would be high because the
kidney is unable to excrete.
 Growth failure in children and wasting in children and adults.
 Congestive heart failure due to retention of water and sodium
 Kidney stones
 Urinary tract infection
 Urinary tract obstruction
 Uremia – a condition where nitrogen-containing compounds and various other waste
products may accumulate in the blood
 Protein energy malnutrition – patients with CKD often develop PEM and wasting.
Anorexia is a contributor to poor food intake that may result from hormonal
disturbances, nausea & vomiting, restrictive diet, uremia and medications. Nutrient
losses also contribute to malnutrition and may result from vomiting, diarrhea,
gastrointestinal bleeding, and dialysis.
 Bone disease i.e. renal oesteodystrophy; this is a combination of bone diseases
e.g. oesteoporosis and oesteomalacia. This is malfunction of bones because the
kidney is unable to excrete phosphorus therefore its levels in blood rises, excess

pg. 247 by Osonga

 phosphorus forms salts with calcium which are deposited in soft tissues especially the
lungs, the heart, blood vessels and the eyes and therefore levels in the blood falls. It is
also due to the inability of the diseased kidneys to effectively activate vitamin d
which increases calcium absorption from the GIT. It is also due to low calcium diet.

Diagnosis of CKD
CKD can be diagnosed by GFR and the symptoms .This can be achieved through laboratory
tests

Laboratory Tests used to investigate CKD-urine test (albuminuria, heamaturia), blood test
1. Urine tests - Albuminuria
• Excessive amounts of proteins in the urine are a key marker of kidney damage.
Factors Other than CKD known to Increase Urine Albumin Excretion
• Urinary tract infection
• High dietary protein intake
• Congestive cardiac failure
• Acute febrile illness
• Heavy exercise within 24 hours
• Menstruation or vaginal discharge
• Drugs (especially NSAIDs)
2. Urine tests - Haematuria
• In many people, haematuria is related to menstruation or urinary tract infection (UTI).
• Persistent haematuria, or haematuria found in conjunction with other indicators of kidney
damage necessitates investigation.
• Glomerular haematuria is due to kidney disease.
3. Blood tests – glomerular filtration rate (GFR)*
• GFR is accepted as the best measure of kidney function.
• GFR can be estimated (GFR) from serum creatinine. Creatinine is a chemical waste
product of creatine. Creatine is a chemical the body makes to supply energy, mainly
to muscles.
Clinical situations where GFR results may be unreliable and/ or misleading include:
• people on dialysis
• exceptional dietary intake (e.g. vegetarian diet, high protein diet, recent consumption of
cooked meat, creatine supplements)
• extremes of body size
• diseases of skeletal muscle, paraplegia, or amputees (may overestimate GFR) or high
muscle mass (may underestimate GFR)
• Infants, children under the age of 18 years and the elderly. For patients under this age, a
GFR between 60-89 mL/min may be normal if no kidney damage is present.

pg. 248 by Osonga

 • severe liver disease present
• GFR values above 90 mL/min
• acute changes in kidney function (e.g. acute kidney injury)

Management/treatment of CKD
 Drug therapy/medical therapy
 dialysis
 Nutrition therapy- Conservative dietary management
 Kidney transplantation
 Lifestyle modification

Lifestyle modification
 Lifestyle modification: cessation of smoking, weight reduction, low-salt diet, physical
activity, and moderate alcohol consumption are successful in reducing overall CVD risk.
Carbonated beverages; Soft-drink (especially cola) consumption has been associated with
diabetes, hypertension and kidney stones.

Drug therapy:
 Hypertension can contribute to the progression of CKD. Reducing blood pressure to
below threshold levels is one of the most important goals in management of CKD
 Antihypertensive drugs are usually prescribed, which can also reduce proteinuria and
help prevent additional kidney damage.
 Erythropoietin administration (to treat anemia)
 Glycaemic control: For people with diabetes, blood glucose control significantly reduces
the risk of developing CKD, and in those with CKD reduces the rate of progression
Dietary management-conservative dietary management
Aims/objectives of dietary management in CDK
 To retard the progression of renal failure
 To reduce and control the amount of waste products which accumulate in the
body e.g. hyperkalemia which is life threatening
 To prevent protein metabolism and minimize toxicity due uremia
 To avoid dehydration or over hydration
 To correct acidosis
 To correct electrolyte imbalances, from depletion, vomiting and diarrhoea
 To obtain optimal nutritional status by preventing PEM and weight loss
 To slow disease progression
 To prevent or alleviate symptoms

pg. 249 by Osonga

Dietary management
Dietary management can be divided as pre-dialysis dietary management and dialysis dietary
management

PRE-ESRD (PRE-DIALYSIS) DIETARY MANAGEMENT

Proteins
 A low protein diet of 0.6gm/kg/bwt (0.5 – 0.8g/kg/bwt) body weight helps to reduce
azotemia (uremia) and hyperkalemia and control acidosis
 60-75% of dietary protein should be of high biological value e.g. eggs, meat, fish,
poultry, milk
N/B 1. When BUN rises protein intake need to be restricted to 20gms per day.
N/B 2. A 40gm protein diet may be used where the weight of an adult patient is unknown
N/B 3. Protein should be restricted or stopped if the patient is under conservative treatment and
blood urea is rising and the patient is not on dialysis

Energy
 Recommended Allowance

o 30-35KCal/kg/body weight (patients with normal weight)-wt maintenance

o 20-30KCal/kg/body weight (obese patients)-wt reduction
o 40-50KCal/kg/body weight (underweight/catabolic patients)-wt gain

Fluid
 Volume of fluid intake is calculated from volume of urine passed in previous 24hrs. If
urine output is above 1000ml in 24 hours do not restrict, if output is below 1000ml in 24
hours restrict by giving output equivalent plus 500ml, if no urine output give 500ml to
700ml.
 Intake to be increased in the event of fever, vomiting or diarrhea.
Sodium
 The need for sodium varies and both severe and excesses have to be avoided
 The restriction varies between 1000 – 2000 grams per day.
 Do not give salt if there is anuria, elevated high blood pressure and when the level of
urine produced is too little
All renal patients advised on a No Added Salt (NAS) diet:
o Avoid adding salt at the table
o Use small amount in cooking or none at all
o Reduce intake of salty foods (e.g., cheese, smoked food, savoury snacks)

pg. 250 by Osonga

 o Limit intake of packet, processed & convenience foods
o Encourage use of pepper, herbs and spices as alternative flavourings

Potassium
 The potassium level has to be adjusted to maintain normal levels in the blood. In severe
vomiting significant losses of potassium may occur and these may need careful potassium
supplementation
 The dietary intake is kept at about 1500mg/day.
 If overnight urine output is above 1000ml do not restrict potassium intake.

Calcium iron, and phosphorus

 Chronic renal failure with uremia causes secondary hyperthyroidism which in turn results
in hyperphosphatemia and hypocalcemia leading to osteodystrophy
 Phosphate intakes need to be restricted to 8-12 mg/day Start restriction early before
symptoms of bone deformity develops
 Calcium supplementation helps to prevent hypocalcemia. Recommended Calcium
supplementation is1000-1500mg/day
 Parenteral supplementation of iron is essential because of deficient production of
erythropoietin.
 Vitamin supplementation to help correct osteodystrophy or activated form of vitamin D
and water soluble vitamins.

DIET PLAN

Pre-ESRD (pre-dialysis) dietary management

Example 1

John is a 50 year old man weighing 70 kgs. He is on a conservative dietary management. He

needs to maintain his body weight
Calculate
 Calorie requirements
 Protein requirement, also show the amount of protein from High
biological value(HBV)
 CHO requirements
 Fat requirements
 Show the prescribed diet
Calculations
a) Calories=35 x 70=2450 kcals/day
b) Protein=0.6 x 70=42gm/day
42 x 4=168 kcals

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 HBV=65 + 75=140/2
70/100 X 42
=29.4 gm
HBV Protein=29gm
Diet=1 egg 7gm
1 cup of milk 8gm
2 oz(60g) meat 14gm
TOTAL= 29gm
42-29=23gm
Therefore 13gm should be from plants sources (Bread, starchy foods, vegetables and
fruits)
NB…Grains and legumes are not used as source of proteins because they are low
biological value proteins and also high in potassium
c) Carbohydrates= 50 + 60=110/2
=55%
=55/100 x2450=336.86
=337gm/day
d) Fat: Should come from the remaining calories after protein and CHO
=Total kcals-(kcals from protein + Kcals CHO)
=2450-(168 +1347.57)
=2450-1515.5=934.5 Kcals
=943.5 Kcals
=943.5/9
=104gm/day
e) Diet prescribed
Calories=2450/day
Protein=42gm/day
CHO=337gm/day
Fat=104 gm/day

Example 2
A 70kg patient will take 42gms of protein per day. (70x0.6=42), HBV-65-75%. Thus 70/100
x42=29.4%. His diet could include
1egg -7gms
1cup milk -8gms
2oz (60gms) meat-14gms
=29gms protein
This allows only 13gms of protein to be obtained from other protein containing foods in the diet
e.g. bread, starch foods cereals and vegetables.
Example 3

pg. 252 by Osonga

If the patient passed 700mls, urine his fluid allowance will be 1200mls in 24hrs
The fluid intake will be 700 ml Urine +500 ml= 1200mls/24hrs. Patients should weigh
themselves daily and measure urine output, each 1000ml of retained fluid will add a kg of Bwt.

DIALYSIS
 This is the removal of wastes products from blood using the principles of simple
diffusion, osmosis and ultra-filtration through a semi-permeable membrane of an
artificial kidney. There is use of dialysate which is a solution used in dialysis to remove
waste products and fluids from blood. Dialysis is done to slow down progression to End
Stage Renal Disease (ESRD) and also used during ESRD.
 There are two types of dialysis i.e. haemodialysis and peritoneal dialysis. The most
common is hemodialysis.

a) Haemodialysis;

This is where a person’s arterial blood rich in nitrogenous wastes is circulated from the dialyzer
(machine-artificial kidney) where blood passes through a semi permeable membrane (dialyzing
membrane) that are bulk in a dialisate fluid. The dialysate is similar to plasma in composition. As
blood circulates in the dialysate, waste products, electrolytes and water are exchanged into the
dialysate by osmosis and diffusion. The purified blood is returned into veins.
The process requires a permanent access to blood stream therefore a fistula (opening) is created
surgically connecting an artery and a vein. The entire process requires 4-6hours 3 times a week.

pg. 253 by Osonga

pg. 254 by Osonga
Types of hemodialysis

i. Intermittent hemodialysis
ii. Continuous hemodialysis. The difference between the two is the speed.
Continuous is the slow method

Disadvantages of haemodialysis;
i) There is loss of proteins (amino acids) about 9-12g/6hours of treatment i.e some protein
is lost from the body to the machine
ii) Very costly
iii) Risk of infection
iv) Altered taste, anorexia, fatigue and nausea after haemodialysis.

b) Peritoneal dialysis;

pg. 255 by Osonga

  Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen
or belly, (peritoneum or peritoneal cavity) to filter your blood inside your body.
 The process uses the peritoneal cavity as a semi permeable membrane. A catheter or tube
is surgically inserted into the peritoneal cavity.
 Dialysate solution/fluid flows from a bag through the catheter/tube into the peritoneal
cavity. When the bag is empty, you can disconnect your catheter from the bag and go on
with the normal activities.
 While the dialysis solution is inside your cavity, it soaks up wastes (nitrogenous products,
electrolytes and extra fluid) from your body by osmosis. After a few hours, you drain out
the used fluid from the peritoneal cavity into a drain bag and fresh dialysate is instilled.
 Patients with peritoneal dialysis have higher protein needs (about 1.2-1.5g/kg of protein)
because of greater protein losses.
Peritoneal dialysis

Types of peritoneal dialysis

1) Continuous ambulatory peritoneal dialysis (CAPD)
2) Continuous cyclic peritoneal dialysis (CCPD)/Automated peritoneal dialysis (APD)

Continuous ambulatory peritoneal dialysis (CAPD)

 The advantage of peritoneal dialysis is that it is usually performed in the home(it is
mostly performed by patients themselves)

pg. 256 by Osonga

  It does not require a machine. The dialysis solution in plastic pouch is drained via gravity
each day (24 hours), 5 times at 4 hour intervals.
 The dialysate stays in the peritoneum for about 20-30minutes to allow for the solution to
exchange. The bag is then lowered to allow the wastes to flow into the bag by force of
gravity.
Advantages of CAPD;
i) Clients on CAPD have a more normal lifestyle because they are mobile than do
clients on either hemodialysis or other peritoneal dialysis as they can read, watch
television, or sleep.
ii) There is more liberal allowance for fluids, Na and K since the therapy is
continuous.
Disadvantages of CAPD;
i) Inflammation of the peritoneal cavity (peritonitis) due to infections
ii) It is associated with hypotension because sodium and potassium are removed during
this process. The loss of sodium can be as much as 6g/day, thus these patients may
need higher sodium intakes.

iii) Weight gain (dialysate contains glucose or dextrose and 600-800 kcals/day
from the glucose dialysate is absorbed to the body). This may be desirable in
patients who are underweight but undesirable in patients who are overweight or
patients with normal nutrition status
iv) Greater loss of proteins than haemodialysis and other peritoneal dialysis. Higher
protein losses than any other peritoneal dialysis/hemodialysis. Patients with peritoneal
dialysis have higher protein needs (about 1.2-1.5g/kg of protein) because of greater
protein losses.
v) It is less efficient than hemodialysis
Continuous cyclic peritoneal dialysis (CCPD)
In which 3-4 machine delivered exchanges are given at night, about 3 hours each, leaving about
2L of dialysate solution in the peritoneal cavity for 12 to 15 hours during the day
Dietary management in dialysis

Aim of nutritional management in dialysis

The purpose of diet in dialysis is to:

pg. 257 by Osonga

  Maintain optimal nutrition to preserve normal body weight.
 Control abnormal body biochemistry and symptoms of uremia.
 Provide sufficient protein for tissue building.
 Allow adequate [moderate] amount of calories for energy and protein sparing.
 Prevent or retard the development of bone disease.
 Slow down disease progression.

Hemodialysis-dietary management

Protein

 Dialysis is a drain on body protein, and the daily intake should be increased to
compensate for the loses but the amount must be carefully controlled to prevent the
accumulation of protein waste between treatments
Proteins
Recommended allowance

1.0-1.2 gm/kg Bwt – weight maintenance

1.5 kg Bwt /day – weight increase
1.2 kg Bwt /day – weight reduction

65-75% to be of HBV

Calories
Recommended allowance
 30-35 kcals /kg Bwt /day –for wt maintance(patient with normal weight)
 40-50 kcals /kg Bwt /day-wt increase(for underweight/wt gain)
 25-30 kcals /kg Bwt/day-wt reduction(obese patients)

Potassium:

 1.5-3g/day
No restriction with urine output of 1000ml/day.

 Potassium is restricted to prevent hyperkalemia.

 Hypokalemia may lead to cardiac arrest.
 In case of Hypokalemia, potassium supplementation is required.
Sodium:
 2-3g/day
 Dietary sodium is restricted to help control fluid retention and hypertension.

pg. 258 by Osonga

  The state of blood pressure and the amount of fluid gained between dialysis determine
sodium needs on hemodialysis.
 Hypotension due to salt depletion require increased sodium intake.
All renal patients advised on a No Added Salt (NAS) diet:
o Avoid adding salt at the table
o Use small amount in cooking or none at all
o Reduce intake of salty foods (e.g., cheese, smoked food, savoury snacks)
o Limit intake of packet, processed & convenience foods
o Encourage use of pepper, herbs and spices as alternative flavourings

Phosphorus:
 1200 mg/day.
 Dietary phosphates are restricted in the Hemodialysis as they may cause constipation.
Calcium:
 500-1000mg/day.
 Supplementation of calcium and vitamin D is necessary due to reduced intestinal
absorption of calcium resulting from lack of active form of vitimin. D [1,25 dihydroxy-
D3]
Fluids:
 24hrs urine output + 500 mls / day.
 Calculated fluid intake prevents severe fluid overloading.
 Fluid intake should be increased in the event of hot weather or severe and persistent
pyrexia [fever], diarrhoea or vomiting
Iron:
 10 mg men/ women
 18 mg women of reproductive age.
 Although the main cause of anaemia is deficient production of erythropoietin due to
kidney failure:
 Iron depletion is common in uremic patients due to bleeding tendency.
 Some is also lost in hemodialysis and blood tests.
 Iron supplementation is therefore necessary parenterally.

B-vitamins

B -vitamins:  Water-soluble vitamins are dialyzable.

 Require supplementation.

pg. 259 by Osonga

 Thiamine 1.5mg/day
Riboflavin 1.8 mg/day
Niacin 20 mg/day
Pyridoxine 5-10 mg/ day
Folic Acid 1 mg/day
Vitamin C 100 mg/day
Vit. B12 , pantothenic Acid
5mg/day

Peritoneal dialysis-dietary management

 Ensure increased protein intake due to higher albumin protein losses during peritoneal
dialysis (1.3-1.4g/kg/day). .Losses of 20-30 g protein can occur during a 24 hour
peritoneal dialysis, with an average of 1 g/hour.
 Calorie intake is decreased because of the glucose absorbed from the dialysate (25-30
Kcal/kg/day).
 Account for calories absorbed from dialysis fluid.
 The dialyser used in peritoneal dialysis contains glucose, in order to draw fluid from
blood to the peritoneal cavity by osmosis; about 60% of this glucose is absorbed. The
kcals from glucose (as many as 800 kcal /day) must be included in estimates of energy
intake.
 Weight gain is sometimes a problem when peritoneal dialysis continues for a long period.

 Restriction of sodium and potassium is not necessary as they are filtered from the blood
daily. Sodium intake therefore should be 3-4g daily (Individualize to blood pressure).
 Potassium intake at 2-3g daily.
 Vitamins and iron supplements are still required.
 Allow adequate intake of fluids as excess fluid can easily be removed.

DIET PLAN

Hemodialysis-dietary management

Example 1 - A 60-kg female receiving hemodialysis three times per week should be eating
60g/day of protein. If 75% of this protein is to be HBV protein, then 46grams of protein should
be in the form of eggs, meat, fish, poultry, milk or cheese. A possible combination of these foods
that would contribute 46gms of HBV protein would be:
Food Protein

pg. 260 by Osonga

1 egg 7
2oz chicken 14
3oz beef 21
1/2cup milk 4
Total 46

The remaining 14gms is obtained from LBV protein. Sources: breads and cereals, vegetables,
potatoes, pasta, and milk-free desserts. A combination of foods that would provide 14gms of
LBV protein is:
Food Protein (g)
3 slices bread 6
3/4cup cereal 3
1/2cup mashed potato 2
½ cup carrots 1
1/2 cup peas 1
1/2cup orange juice 0.5
1 small apple 0.5
Total 14

Example 2- A 30 yrs old Female on hemodialysis IBW- 60 kgs, Ht 162.5 cm (5’5), Light
worker. To calculate her dietary requirements;

Protein should be high, hence allow 1gm per kg of body weight.

60kgs x1 gm =60 gms, 70% should be HBV. 70/100 x 60 = 42gms

Calories Allowance- 30-35 kcals /kg, Allow 35cals= 35x60=2100cals

CHO allowance is normal 50-60 % of total calories, Allow 60%= 60/100x2100 =1260cals divide
by 4 =315gms
Fat allowance is normal 20 -30% of total calories, allow 30%= 30/100 x2100 =630/9 =70gms

The diet prescription

Calories -2100
Protein - 60gms
CHO - 315gms
Fat - 70gms
Meal patterns
Breakfast
Milk ½exchange
Fruit 1 exchange
Bread 3 exchange
Meat 1 exchange
Fat 3 exchange
Lunch

pg. 261 by Osonga

Meat 1 exchange
Bread 1 ½ exchange
Veggies 1 exchange
Fruit 2 exchanges
Fat 3 exchange
Sugar 2 exchanges
Supper
Meat 2 exchanges
Bread 1 ½ exchanges
Veggies 1 exchange
Fruit 1 exchange
Fat 2 exchange
Snacks
10.00 am
Fruit 1 exchange
Bread 2 exchange
Milk ¼ exchange
Fat 1 exchange
Sugar 4 exchanges
4.00 pm
Fruit 1 exchange
Bread 2 exchange
Milk ¼ exchange
Fat 1 exchange
Sugar 4 exchanges

Sample Menu
1 boiled egg
1 cup uji ½ cup milk +3 tsps sugar
1 small fruit
2 slices bread 2 tsps margarine +2 tsps jam
Lunch
1 ½ cup Ugali/rice/potatoes or equivalent
1 oz (30gms) meat/fish/poultry
½ cup veggies
1 cup fruit salad 2 tsps sugar
3 tsps cooking fat
Supper
1 ½ cup Ugali/Rice/potatoes or other equivalent
2 oz (60gms) meat
½ cup veggies
1 small fruit
2 tsps cooking fat

pg. 262 by Osonga

Snacks
10.00am
A fruit
Tea ¼ cup milk +2 tsps sugar
2 slices bread 1 tsps margarine +2 tsps jam
4.00 pm
1 fruit
2 slices bread 1 tsp margarine + 2 tsps jam
1 cup Tea (¼ cup milk) + 2 tsp sugar

Kidney transplant.

 A kidney transplant involves surgically placing a healthy kidney from a donor into a a
patient with end-stage renal disease. Transplanted kidneys can come from deceased or
living donors. You'll need to take medications for the rest of your life to keep your body
from rejecting the new organ.
Aim of nutritional management
 Promoting nutritional repletion during the early post-operative period.
 Maintaining good nutrition in the ensuing period.
 Maintaining normal body weight.
 Counteracting the side effects caused by immuno-suppressive therapy.

Dietary management in renal transplant

 The diet prescription is based on the kidney functions as indicated by: urine output,
serum creatinine, blood urea nitrogen (BUN), potassium and phosphorus.
 Initially clear liquids are given to the patient during the early post- operative period, and
then progresses to solid foods as tolerated. Finally the patient is placed on an essentially
normal diet.
Protein
 Initially a low protein diet.
 Once graft function is established give 1 to 2g /KgBWT. This is because immuno-
suppressive therapy used increases the body’s protein requirements. After first month the
requirements drop to 1g/KgBWT.

pg. 263 by Osonga

Calories
 Calorie requirements are such that; first month following transplant and during treatment
of acute rejection, 30 – 35KCal/kg bwt. After the first month sufficient calories to
achieve optimal weight for height. At all times, no more than 50% of calories while
encouraging complex carbohydrates and avoiding simple sugars.
 A low carbohydrates diet is prescribed due to excessive weight gain after transplant,
which is partly due to increased appetite and steroid therapy.

Fats
 Increase intake of polyunsaturated fats and reduce intake of saturated fats.
Sodium
 Ensure low intake as steroids cause sodium retention (250 – 2000mg/day).
Potassium
 Potassium is usually not restricted. May be restricted if hyperkalemia occurs.
Phosphorus
 Serum phosphorus levels decrease after transplant, and patients may require
supplementation (1,200mg/day).
 Encourage intake of high phosphorus foods e.g. dairy products, eggs and meat.
Calcium
 Give 1,200 mg/day.
Iron
 May require supplementation after the operation.
Fluids
 Add liberal amounts unless fluid retention and hypertension worsens.

 KIDNEY STONES(NEPHROLITHIASIS/ RENAL CALCULI)

pg. 264 by Osonga

  Kidney stones (renal lithiasis, nephrolithiasis, renal calculi) are hard deposits/clumps
made of minerals and salt that form inside the kidney. Stones can also form in the
bladder, the urinary track, ureter and nephrones, Their passage can cause severe pain or
block the urinary tract.
 Kidney stones are generally composed of calcium salts (calcium oxalate and calcium
phosphate)-95%, uric acid-3%, cysteine-1%, or struvite (triple salt of ammonium,
magnesium, and phosphate) 1%.

Types of kidney stones

They are classified according to chemical constituents;

 Calcium salts (calcium oxalate and calcium phosphate)- 95%
 Uric acid-3%
 Cysteine-1%
 Struvite( ammonium phosphate, magnesium, and phosphate) 1%.. It is associated with
infections

1. Calcium Oxalate Stones

 There are calcium oxalate stones and calcium phosphate stones. About 70-80% of the
renal stones formed contains calcium oxalate, and are most common in middle-aged
men. Oxalate is a natural chemical of metabolism in the body, and it's also found in
certain types of food. Oxalate bind to calcium in the GIT during digestion in the
stomach and intestines and leave the body in stool. Oxalate that is not bound to calcium
in the GIT is absorbed into the blood and eliminated as a waste product in the urine
through the kidney. Having too much oxalate in the urine and too little liquid in the
urine can cause calcium and oxalate to crystalize and clump together
Health concerns about oxalates
 It can bind to minerals in the gut and prevent the body from absorbing them thus resulting
into mineral deficiency. For example, spinach is high in calcium and oxalate, which
prevents a lot of the calcium from being absorbed into the body. Small percentage of
oxalate can also bind with iron to form iron oxalate

pg. 265 by Osonga

  Oxalate can also bind with calcium and form stones in the kidney, bladder, ureter and in
nephrones resulting into kidney disorders
Causes of calcium stones in the kidney;
Calcium stones are caused by
i. Hyperoxaluria
Hyperoxaluria refers to condition where there is too much oxalate in the urine (Hyperoxaluria
refers to an excessive urinary excretion of oxalate).
Hyperoxaluria occurs due to;

 Overproduction of oxalate (primary hyperoxaluria)- due to rare inherited (genetic)

condition present at birth in which there is overproduction of oxalate by body because of the
livers failure to create enough of a certain protein (enzyme) that prevents overproduction of
oxalate, or the enzyme doesn't work properly
 Enteric hyperoxaluria- This is where there is an overabsoption/ increase in the absorption
of oxalate from foods, which can then increase the amount of oxalate excreted in the urine.
This is due to several intestinal diseases, including short bowel syndrome as a result of
surgical procedures; Crohn's disease ; celiac disease and in pancreatic insufficiency
 Excessive vitamin C intake. Vitamin C can also be converted into oxalate when it's
metabolized
 Eating high-oxalate foods. Eating large amounts of foods high in oxalate can increase your
risk of hyperoxaluria or kidney stones.

Examples of foods that contain oxalates:

Vegetables Fruits Others

- Beets - Oranges, orange peel - Barley
- Collard greens and green - Strawberries*** - Cocoa
leafy vegetables - Kiwi - Nuts and peanuts
- Okra - Grapes - Tea***
- Green beans - Figs - Soybean products
- Eggplant - Lemmon peels - Wheat bran***
- Parsley - Whole wheat flour

pg. 266 by Osonga

 - Spinach**** - Soy products
- Sweet potatoes - Margarine

N/B. ***Foods high in oxalates

Treatment/management;

 Reducing dietary oxalate e.g. margarine, spinach, strawberry, chocolates, wheat bran,
tea, peanuts etc.
 Increased fluid intake (4 liters). Crystals form when there is too much oxalate in too
little liquid in the urine. Having too much oxalate or too little urine can cause the oxalate
to crystalize and clump together. Dilution of urine through fluid intake of over 4 litres
per day; including drinking at night to form about 3 litres of urine per day. The goal of
rigorous hydration is to keep the urine dilute, preventing the crystallization of stone-
forming minerals.
 Limit the salt in your diet. A high-sodium diet can increase the amount of calcium in
your urine, which can help stones form. High sodium diet can also triggers a mechanism
that increases water reabsorption in the body and, thus, produces more concentrated
urine(little urine)
 Increased calcium intake-800-1200mg/day (more than normal. When you do eat
oxalate-rich foods, have them with something containing high calcium, like a glass
of milk, yoghurt, salmon fish or omena to bind oxalates in the GIT during digestion
before reaching the kidney so that those that are excreted through urine is not so high to
trigger crystallize in the urine..
 Limit the salt in your diet. A high-sodium diet can increase the amount of calcium in
your

ii. Hypercalcuria
This refers to excessive excretion of calcium in urine. It is where over 200mg of calcium is
excreted in 24hrs.It is the most common identifiable cause of calcium kidney stone disease.

Causes;

pg. 267 by Osonga

 Increased calcium absorption from the GIT
 Impaired renal calcium reabsorption
 Excessive reabsorption of calcium from the bones due to primary hyperthyroidism
Treatment;
 A high protein diet increases calcium excretion thus the requirements should be the RDA and
not more than that
 Increase fluid intake to over 4 litres per day; including drinking at night to form about 3 litres
of urine per day.
 Use thiazide diuretics which decreases urinary calcium
N/B-mild salt restriction 4-5gm/day improves thiazide effectiveness
iii. Hyperuricosuria
This is elevated uric acid in urine/it refers to the presence of excess uric acid in the urine, this
leads to formation of calcium oxalates stones rather than uric acid stones by binding calcium
oxalate inhibitors.
Causes
 Increase intake of diet high in purines (animal proteins). Uric acid is the major end-
product of purine metabolism
 Rapid breakdown of bodily tissues containing large quantities of DNA and RNA
Treatment;
 Protein intake should be as per the RDA.
 Potassium supplementation which decreases calcium excretion therefore reduces the
incidence of stones.

Risk factors of calcium oxalate stones

You’re more likely to get calcium oxalate stones if you have:

 Hyperparathyroidism, or too much parathyroid hormone

 inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn’s disease
 Gastric bypass surgery for weight loss
 Diabetes

pg. 268 by Osonga

  Obesity

2. Uric acid stones.

 Uric acid stones can form in those who eat a high-protein ( Diet high in purines)
 Purines are the end products of nucleoprotein metabolism and are found in all meats,
fish, and poultry. Organ meats, sardines, meat extracts, and broths are especially rich
sources of them. Uric acid stones are usually associated with gout
 If too much uric acid builds up in the bloodstream it is called hyperuricemia. In some
people, hyperuricemia can cause kidney stones or lead to an inflammatory joint
condition called gout.

Treatment;
 Increase fluid intake to dilute urine through fluid intake of over 4 litres per day; including
drinking at night to form about 3 litres of urine per day.
 Increase urine pH to 6-6.5 using alkalis e.g. sodium or potassium bicarbonate or citrate
 A reduction of animal proteins may be useful as their consumption leads to acid urine.
 Avoid alcohol. Alcoholic drinks can inhibit the body's ability to eliminate uric acid, so
people with gout are advised to avoid alcohol or drink in moderation. Beer is notorious for
bringing on gout attacks because it contains both alcohol and brewer’s yeast, which is high in
purines.

3. Cystine stones.
Causes;

 It is a hereditary disorder of amino acids transport leading to excess cysteine in urine

(cystinuria).

Treatment;
 Dilution of urine through fluid intake of over 4 litres per day; including drinking at
night to form about 3 litres of urine per day.
 Alkalinization of urine e.g. using sodium bicarbonate to increase pH to 7-7.4.

pg. 269 by Osonga

4. Struvite Stones.

 Struvite stones are composed of magnesium, ammonium and phosphate, are usually
common in women.
 They are sometimes called infection stones because they develop following urinary
tract infections caused by certain microorganisms that break down urea to ammonia
leading to alkaline urine. The stones (MgNHPo4) are extremely insoluble in alkaline
conditions and will crystallize spontaneously.
Treatment;
 Surgery to remove stones
 Eradication of infections using antibiotics
 Acidification of urine i.e. by use of ascorbic acid and ammonia chloride
 A low-phosphorus diet is often prescribed.
N/B: Diet has very little role in this stones.

 POLYCYSTIC KIDNEY DISEASE

 Polycystic kidney disease (PKD) is an inherited disorder in which clusters of cysts

develop primarily within your kidneys.
 Cysts are noncancerous round sacs containing water-like fluid. The cysts vary in size
and, as they accumulate more fluid, they can grow very large.

Symptoms

pg. 270 by Osonga

Polycystic kidney disease symptoms may include: High blood pressure, Back or side pain,
Headache, Increase in the size of your abdomen, Blood in your urine, frequent urination, Kidney
stones, Kidney failure, Urinary tract or kidney infections

Causes
 Abnormal genes cause polycystic kidney disease, and the genetic defects mean the
disease runs in families. Rarely, a genetic mutation can be the cause of polycystic kidney
disease.

Dietary Management
 Eliminate toxins, especially kidney toxins, Exercise and rest sufficiently.
 A low sodium, 1200 mg sodium diet helps to keep blood pressure low which in turn can
help keep cystic organs smaller.
 A neutral protein is neither low protein nor high protein. It is neutral. What goes in,
comes out. A neutral plant based protein diet that is individually calculated to 0.6 grams
of protein per kilogram of body weight is something to try for maintaining healthy cystic
kidneys.
 Drinking enough water to shut down vasopressin or about 3 litres of water per day, might
help assure the health of polycystic kidneys.
 An alkaline vegan diet that avoids all animal proteins (ground meats, dairy, egg whites,
milk, cheese, beef, pork, chicken), soy proteins, yeast, alcohol, concentrated sugars seems
to make us feel better.

 KIMMELSTIEL SYNDROME
Kimmelstiel-Wilson syndrome is a kidney condition associated with long-standing diabetes. It is
also known as Diabetic nephropathy (kidney disease).
It affects the network of tiny blood vessels (the microvasculature) in the glomerulus, a key
structure in the kidney that is composed of capillary blood vessels and which is critically
necessary for the filtration of the blood.
Its features include:
 Nephrotic syndrome with excessive filtration of protein into the urine (proteinuria),
 high blood pressure (hypertension), and
 Progressively impaired kidney function.
 When severe, it leads to kidney failure, end-stage renal disease, and the need for chronic
kidney dialysis or a kidney transplant.
Causes

pg. 271 by Osonga

The cause of diabetic nephropathy is not well understood, but it is thought that high blood
sugar, advanced glycation end product formation, and cytokines may be involved in the
development of diabetic nephropathy.
Kidney damage is likely if one or more of the following is present:
 Poor control of blood glucose
 High blood pressure
 Type 2 diabetes mellitus (after age 30)
 History of cigarette smoking
 A family history of kidney problems
Signs and symptoms
 Albumin or protein in the urine
 High blood pressure
 Ankle and leg swelling, leg cramps
 Going to the bathroom more often at night
 High levels of blood urea nitrogen (BUN) and serum creatinine
 Less need for insulin or antidiabetic medications
 Morning sickness, nausea, and vomiting
 Weakness, paleness, and anemia
 Itching
Dietary Management
Common principles in dietary management:
 Salt - In order to protect kidney and reduce its work load, diabetic patients should take in less
salt within 7g/day. If patients have symptoms of vomiting and diarrhea, they should ingest
some salt rather than limit it.
 Potassium - If the daily urine volume is over 1000 ml and potassium volume is at normal
level, patients don′t have to limit their intake of potassium and they can generally choose
food vegetables and fruits freely. Patients with Diabetic Nephropathy are easier to have
acidosis and hyperkalemia which can lead to cardiac arrhythmia and hepatic coma, so
patients should limit the intake of drinks and fruits containing potassium.

pg. 272 by Osonga

 Protein - Protein intake should be controlled within 0.6-0.8g/d/kg of body weight. It is better
to take fish and lean meat for vegetable protein is difficult to be absorbed. But milk protein is
the best choice, and egg protein takes the second place.
 Vitamins and trace elements - Patients should take in enough vitamins and trace elements,
especially VB, VC, zinc, calcium, and iron, which can protect kidney.
Patients should also concern the intake of calcium and phosphorus. When kidney is damaged,
phosphorus in blood will increase. And reduction of their ability to synthesise Vitamin D3
affects the calcium absorption. The concentration of calcium in the blood reduces which lead
to osteoporosis. So the ideal diet is to take foods containing high calcium but low phosphorus
 Calories - When taking low protein diet, calories must be supplied sufficiently to meet the
basic need of living. Patients should take in 30-35kj/kg of body weight to keep the balance.
Some staple food containing high calories and low protein can be the choice for patients.
 Water - Keep the in and out liquid balance of patients is also very important. At the uremic
stage in end-stage of renal disease may appear the symptom of less urine or even no urine,
then water intake is very important. Drinking too much water will add the burden to the
kidney, leading to deterioration of his condition, so daily intake of the fluid amount equals to
urine output amount of the day before plus 500 ml. When patients have symptoms of fever,
vomiting and diarrhea, they should be take in more liquid so the patient still need to know the
water content of the food and make ends meet.

TOPIC: METABOLIC AND ENDOCRINE DISORDERS

METABOLIC DISORDERS

 These are conditions as a result of defective gene (inherited or a dysfunction of an organ).

They include diabetes mellitus, gout, hyper/hypothyroidism etc.
 Metabolism is a chemical process which the body uses to transform the food eaten into
fuel.
 A metabolic disorder occurs when the metabolism process fails or abnormal chemical
reaction in the body disrupts this process. When it happens then you might have too much
or too little of a nutrient

 Endocrine disorders are conditions associated with lack, low or excessive hormone
secretion.

pg. 273 by Osonga

Definition of terms:
 Hyperglycemia- high blood glucose levels
 Ketonuria or acetonuria is the excretion of ketones through urine
 Hyperinsulinemia elevated levels of insulin in plasma due to the pancreas increase the
secretion of insulin causing insulin to rise to abnormally high levels.
 Nocturia-night time urination
 Macrosomia- a large baby
 Glycosuria-presence of glucose in urine
 Insulin shock- This is a condition that occurs when blood sugar levels are <70mg/dl
(<3.9mmol/l).
 Gangrene-death of lower tissues of the extremities e.g. legs contributing to diabetic foot.
 Microangiopathies. Microvascular complications of DM
 Hypothyroidism is decreased secretion of thyroid hormones (thyroxine) by the thyroid
gland which leads to lowered metabolic rate.
 Myxoederma- non-pitting oedema caused by reduced levels of thyroid hormones
 Hyperthyroidism-an excessive secretion of thyroid hormone that is also known as
thyrotoxicosis due to exposure of body tissues to excessive levels of thyroid hormones

DIABETES MELLITUS

 The name comes from Latin word diabetes -meaning passing through or excessive urination
and mellitus meaning sweet or honey like
 It is a chronic disorder characterized by elevated blood glucose and altered metabolism of
carbohydrates(CHO), Proteins, fats and other substances
 It is a leading cause of blindness, amputation, renal failure and it is also a major cause of
heart attack and stoke
 The abnormality of high blood sugar is due to
(i) Lack of secretion of insulin
(ii) Lack of formation of insulin

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 (iii) Ineffective insulin in that there is circulating insulin in the blood but it doesn’t
produce the expected metabolic function

 Insulin is a hormone produced by the beta Cells of Islet of langerhans in the pancreas.
This hormone regulates the movement of glucose in the blood into the cells. After eating
a meal containing carbohydrates, blood glucose level normally rises to 130-140 mg/dl in
1 hour, but returns to fasting blood glucose level of 80-100mg/dl in 2 hours after the
meal. Absence of insulin or inadequate amounts or if in effective in the blood causes
glucose to rise leading to hyperglycemia.
 Diabetes is a lifestyle disease which is associated with changing diet from the traditional
diets to western diets. The prevalence of diabetes mellitus is high in developed countries
than developing counties but it is increasing in developing counties due to increasing life
style in developing counties. In Kenya the prevalence is estimated at 5 %

Classification of diabetes;
1. Classic diabetes mellitus;
2. Impaired glucose tolerance diabetes mellitus
3. Gestational diabetes mellitus(Pre diabetes)

1. Classic Diabetes Mellitus

 This is a DM characterized by fasting hyperglycemia/hyperglycemia or elevated plasma

glucose level during an oral glucose tolerance test (OGTT)
 It is of three types namely;
a) Type 1 diabetes mellitus
b) Type 2 diabetes mellitus
c) Secondary diabetes mellitus
a) Diabetes type I
 Formally called juvenile-onset diabetes, it usually occurs before age 30 even though it
can occur at any age (Some people can be diagnosed of the diabetes type I between 30-74

pg. 275 by Osonga

 years of age). The individuals are usually lean and have abrupt (acute) onset of
symptoms. They depend on exogenous insulin and ketoacidosis may occur
 It constitutes about 5 % of all cases of diabetes
Predisposing factors to DM/etiology-causes;
 Genetic predisposition
 Autoimmunity- antibodies produced by the body mistakenly attack and destroy insulin
producing cells.
 Lack of insulin ( Born with pancreas but not producing insulin)
 Viral conditions e.g. mumps and measles which have been implicated to trigger
autoimmunity.
 Environmental toxins and certain drugs e.g. alloxan and pyrinuros that can destroy beta cells
of the pancreas
 Inadequate protein intake and nitrosamines in food e.g. smoked and cured mutton which
damage the beta cells.
Symptoms of type I diabetes mellitus

1. Polydipsia- (increased thirst) because of loss of fluids

2. Polyuria – frequent and excessive urination.
3. Polyphagia – increased appetite or excessive hunger (The abrupt appearance of polyuria,
polydipsia, polyphagia are accompanied by the following symptoms)
4. Weight loss- because you loose too much blood sugar in urine, taking calories and fluids
with it. Type I DM patients are usually lean or underweight
5. Ketosis/Ketonemia- Ketosis refers to accumulation of excess ketones in the blood.
Ketosis results into ketoacidosis- low blood PH due to ketoacidosis. Ketosis can also
result into Ketonuria (presence of ketones in the urine).
6. Ketoacidosis- the lowering of blood PH due to ketosis. The ketones are acid products
which when they accumulate in blood they lower the PH. Severe ketoacidosis leads to a
diabetic comma
7. Ketonuria -presence of ketone in the urine. The loss of ketones through urine results in
loss of sodium and potassium that can cause death.
8. Glycosuria-presence of glucose in urine
9. Blurred Vision – due to destruction of Cells of eyes

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 10. Skin irritation
11. Infections e.g. skin infections, pneumonia, urinary tract infections and yeast infections in
women
12. Poor wound healing
13. Fatigue, weakness and loss of strength because the cells are starving
14. Numbness/tingling of hands/ feet because of peripheral neuropathy
15. Gastroparesis-Stomach problems as diabetes damages the nerves of the stomach thus the
stomach will not empty as normally, a condition known as gastroparesis. This may result
into constipation and diarrhea
16. Swelling hands and feet because of high blood pressure and diabetes. A sign that the
kidney is failing

N/B- ketones are intermediate products of fat metabolism that come when fats are oxidized to
supply energy. During uncontrolled diabetes, starvation or extreme conditions when
available carbohydrates are inadequate to meet energy needs, fat is oxidized at excessive rates.
The liver breaks down fatty acids to ketone bodies such as acetone, beta hydroxyl butyric acid
and acetoacetic acid.
In diabetes the breakdown of fatty acids is more rapid than the body can handle i.e. break down
to carbon dioxide and water to release energy thus some ketones are excreted in urine a condition
known as ketonuria or acetonuria. The loss of ketones through urine results in loss of sodium
and potassium that can cause death.
N/B. It is important to note that there is a honey moon phase when endogenous insulin secretion
recovers after diagnosis and correction of hyperglycemia and acidosis. During this time
exogenous requirements decreases for up to 1 year. However the need for insulin increases after
that, and within 8-9 years, beta cells loss is complete and insulin deficiency is absolute

b) Diabetes Type II
 This is DM in which majority of the patients are obese or have a history of obesity (80%-
90%). but can also occur in none obese persons.
 Formally called maturity-onset or adult type diabetes. Age of onset is usually over 30 years
of age but can occur at any age

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 It is a progressive disease that is characterized by circulating ineffective insulin, insufficient
insulin or there is insulin resistance (insulin responsiveness).
 Insulin ineffectiveness and resistance by muscle, adipose and liver cells is may be due to to-
abnormalities in cell membrane leading to decrease number of insulin receptors or abnormal
receptors or decreased binding insulin receptors
 To compensate for the insulin resistance, the pancreas increase the secretion of insulin and
plasma insulin may rise to abnormally high levels a condition known as hyperinsulinemia.
 Overtime, the pancreas become less liable to compensate for reduced insulin sensitivity and
hyperglycemia worsens.
 Individuals who have type 2 and are thin are known as type 2a while those who are obese are
known as type 2b.
 Type 2 DM patients do not require insulin but in severe cases about 40% may require insulin
to control hyperglycemia

Causes/etiology;
 Its cause remains unknown but both genetic and environmental factors e.g. aging and
physical inactivity are implicated.
 Overweight and obesity especially intra-abdominal fat is powerful risk factor that can result
into ineffective insulin, insufficient insulin or insulin resistance
N/b-In type 2 DM there is circulating insulin though it is ineffective, insufficient or there insulin
resistance

Symptoms of type II diabetes mellitus

1. The individuals are usually obese or overweight

2. One may or may not experience the classic symptoms of uncontrolled diabetes mellitus
(polydipsia, polyuria, Polyphagia)
3. Night time urination (nocturia)

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 4. They are not prone to ketoacidosis unless in time of severe stress because they have
circulating insulin though ineffective or insufficient. Insulin resistance may be due to-
abnormalities in cell membrane leading to decrease number of insulin receptors or
abnormal receptors or decreased binding insulin receptors
N/B. Uncontrolled type 2 diabetes can result into other symptoms as in type I diabetes

Comparison between diabetic type I and diabetic type II

Type I Type II

Age of onset Usually before the age of 30 Over 30 years

Nutritional status prior to diagnosis Generally malnourished Mostly obese

Genetic predisposition Moderate Strong

Prevalence About 6% About 95%

Ketosis Common in unmanaged patients Rare

Insulin Necessary Usually not required

Hyperosmolar Rare Common in

unmanaged patients

c) Secondary Diabetes
 This is a diabetes mellitus that comes as a result of a disease condition or is associated with;
i) Certain diseases e.g. pancreatitis, cystic fibrosis where there is a disorder of the
endocrine glands in the pancreas which may lead to suppression in insulin production.
ii) Malnutrition related conditions commonly found in developing countries especially in
the age between 10-12 years. These individuals require insulin but they have insulin
inhibitors.
iii) Exposure to certain drugs
2. Gestational diabetes mellitus (Pre diabetes)

pg. 279 by Osonga

  This is DM in which glucose intolerance occur during pregnancy due to the hormones
produced during pregnancy by e.g. the placenta that works against the insulin. OR
 It is where the body is unable to regulate blood glucose levels normally because of
hormonal changes as a result of pregnancy
 Fasting blood glucose levels are elevated to 100-125 mg/dl or 5.6-6.9 mmol/L) but not
yet within classic diabetic range (126 mg/dl or 7 mmol/Land above)
 It occurs in approximately 2- 4 % of all pregnant women in the 2nd or 3rd trimester
 Insulin resistance normally occurs but glucose tolerance returns in 90 % of the women
after delivery. It may be a risk factor in developing type diabetes in future. 40-60% of
women with GDM develop NIDDM within 5-15 years.
Consequences of gestational diabetes;
Uncontrolled gestational diabetes results in;
 Severe hypo or hyperglycemia
 Spontaneous abortion
 Pregnancy induced hypertension
 Macrosomia (a large baby)
 Hypoglycemia in the foetus
 Congenital malformation.
 Respiratory distress which increases morbidity and mortality in the infant.

3. Impaired Glucose Tolerance diabetes mellitus/impaired fasting glucose

 It is where the body is unable to regulate blood glucose levels normally

 It is a pre-diabetic state of hyperglycemia that is associated with insulin resistance
 Fasting blood glucose levels are elevated/high (100-125 mg/dl or 5.6-6.9 mmol/L)) but
not yet within classic diabetic range (126 mg/dl or 7 mmol/L and above)
 .Approximately ¼ or 25 % of individuals with impaired glucose tolerance (IGT)
eventually develops DM. Mostly occurs among the elderly
N/B 1. Gestational diabetes mellitus and impaired glucose tolerance are pre diabetic conditions
in which blood glucose levels are elevated(100-125 mg/dl or 5.6-6.9 mmol/L) but not yet within
classic diabetic range (126 mg/dl or 7 mmol/Land above)

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N/B 2. Normal glucose level is 3.5 – 6.7 mmol/l or 70-120 mg/dl while fasting blood should be
between 3.8 – 5.0 mmol/l (70-90mg/dl)

General symptoms of DM;

 Polydipsia- increased thirst
 Polyuria- frequent urination
 Polyphagia- excessive hunger or increased appetite
 Weight loss (even in type 2 DM)
 Blurred vision
 Skin irritation or infection
 Fatigue/weakness/no strength or energy to work.
 Glycosuria-presence of glucose in urine
 Ketoacidosis- this is a condition that occurs due to excess ketones in the blood leading to a
lowering of blood pH or acidosis and ketonuria.
 Skin irritation
 Infections e.g. skin infections, pneumonia, urinary tract infections and yeast infections in
women
 Poor wound healing
 Fatigue, weakness and loss of strength because the cells are starving
 Numbness/tingling of hands/ feet because of peripheral neuropathy
 Gastroparesis-Stomach problems as diabetes damages the nerves of the stomach thus the
stomach will not empty as normally, a condition known as gastroparesis. This may result into
constipation and diarrhea
 Swelling hands and feet because of high blood pressure and diabetes. A sign that the
kidney is failing

DIAGNOSIS OF DIABETES MELLITUS

Test should be done on individual at risk of DM which include

i. Those with family history of diabetes mellitus, overweight and obese individuals

pg. 281 by Osonga

 ii. Female with a history of giving birth to babies weighing greater than 9 pounds
iii. Pregnant women in 24th – 28th week of pregnancy
iv. People with obvious signs of diabetes mellitus
Types of tests

(I) Random glucose test-for hyperglycemia

 High random plasma glucose ≥ 11.1 mmol/l (200mg/dl) + a classic symptoms e.g.
polyuria, polydipsia, polyphagia
(II) Fasting plasma glucose test-for hypergycemia
 Fasting plasma glucose ≥ 7.8 mmol/l (140mg/dl) on at least 2 occasions
(III) Glucosuria test
 Presence of abnormal amount of sugar in urine. It occurs when urine glucose level
exceeds 180mg/100ml.
(iv) Oral glucose tolerance test (OGTT)

 This measures the body’s ability to utilize a known amount of glucose

The procedure is as follows

(i) 3 days prior to the test an individual consumes a diet with at least 150g of CHO per
day
(ii) After an overnight fast of 10-16 hours, a fasting blood sample is drawn. A glucose
load of 75 g is given in 300 ml of flavored beverage
(iii) Additional blood sample is taken every 30 minutes (½ an hour) and at 2-5 hours after
ingestion of glucose.
Diabetes mellitus is said to be in adults if 2 results are abnormal (i.e. Fasting plasma glucose
level is initially higher (greater than 125 mg/dl) in diabetic person and rises to concentrations
greater than 200 mg/dl 2 hours following administration of glucose). Normal individuals has
a fasting glucose level of (63-90 mg/dl) and rise to about 140 mg/dl following glucose
administration
N/B. Normal glucose level is 3.5 – 6.7 mmol/l or 70-120 mg/dl while fasting blood should be
between 3.5 – 5.0 mmol/l (63-90mg/dl)

Complications of Diabetes

pg. 282 by Osonga

 1. Metabolic acidosis/ketoacidosis
 If type I diabetes goes uncontrolled, excessive level of ketones persists in the blood
(ketosis)
 The presence of acetone, which is a ketone can be detected by a fruity oduor in the
breath of uncontrolled diabetes with the buildup of ketones
 This results into ketonuria, and sodium and potassium becomes depleted because they
are secreted along with ketones
 The loss of sodium, potassium ions, both of with are base formers worsen the
acidosis.
 When acidosis become severe the diabetic can lapse into a fatal coma- (A fatal coma
as a result of ketosis and ketonuria
Risk factors/causes
 Uncontrolled diabetes; Metabolic acidosis can also occur in renal failure, prolonged
fasting and heavily meat based diet
Implications/complications of metabolic acidocis/ketoacidisis
 Acetone breath; dehydration; severe acidosis can result to fatal coma
Aim of management in ketocidosis
 To control acidosis by increasing the blood PH
Management ketoacidosis
 Treat underlying cause
 Withhold acidic foods especially meat
 Use of plant based foods that are alkaline in nature .e.g. potatoes is recommend
 Take safe drinking water based on tolerance
 Provide supplemental insulin and fluid and electrolyte replacement
2. Hyperosmolar, hyperglycemic non-ketonic comma.
 People with type 2 diabetes generally are not prone to ketosis since they have some
insulin to prevent the excessive buildup of ketosis. However they can develop another
type of comma called hyperosmolar, hyperglycemic non-ketonic comma.
 As the name implies this occurs when blood glucose level becomes excessive
resulting into osmotic diuresis & dehydration-. Acidosis is not present

pg. 283 by Osonga

 3. Infections e.g. Urinary tract infections and pruritus vulvae
 The diabetic is more likely to develop infections because of the high level of sugar in
the blood and urine.
 Urinary tract infections and pruritus vulvae (severe itching of the external female
genitalia) are fairly common. For these reasons diabetic must pay a close attention to
hygiene( e.g. wear cotton pants instead of polyester)
4. The vascular problems- are common in the long term.
 The vascular diseases are of two types
I. Macro vascular-Those that affect the large vessels
II. Micro vascular-Those that affect the small vessels
a) Macrovascular complications;
 These are diseases of the large vessels. They are usually due to type II diabetes. They
include;
i. Coronary heart disease (CHD)
ii. Peripheral vascular disease (PVD)
iii. Cerebrovascular disease (CVD)
 Patients with diabetes have an increased prevalence of lipid abnormalities that contribute
to higher risk of cardiovascular diseases and this is due to the elevated levels of LDL
cholesterol and lower levels of HDL cholesterol that increases arterogenicity.
N/B. Development of arteriosclerosis is more common in diabetes due to large amounts of
circulating fats. The arteries become blocked by the formation of the plague so that when blood
flow to the limb is blocked, the cells die and thus the limb must be amputated

N/B. Reduced supply of blood to organs leads to cardiovascular diseases e.g. gangrene (death
of lower tissues) of the extremities e.g. legs contributing to diabetic foot.

b) Microvascular complications/microangiopathy;
These are also known as microangiopathies. These are the diseases of small blood vessels
(capillaries) due to high circulating glucose that results into high bold pressure and fats that
accumulates and thickens the capillaries of smaller vessels which lead to;
i. Retinopathy (due to the retinal blood vessels); the capillaries of the retina(eyes) are
affected. This may lead to blindness in adults.ss

pg. 284 by Osonga

ii. Nephropathy; this is due to the damage of the capillaries to the kidneys due to high
circulating glucose-high blood pressure and fats in the capillaries which thicken and thus
lead to renal failure
iii. Neuropathy; this is the nerve damage due to chronic high blood glucose levels which is
usually expressed as painful pricking/tingling sensation in the arms and the legs. Damage
to the nerves results into loss of sensation in the feet and the hands. Because of loss of
sensation, the diabetic may not feel that his hands or feet are being injured by e.g a nail
and infection once started can progress rapidly leading to amputation because bacteria
thrive on the high blood glucose levels and this chain of events can lead to amputation of
the limb and again points to the need of hygiene especially care of the feet
N/B- loss of both blood circulation and nerve function can lead to undetected injury and
infection which may lead to death of tissues (i.e gangrene) which may necessitate amputation.
High hygiene practices must be maintained in diabetes to avoid this condition i.e. cleaning
between the toes and fingers and thorough drying is necessary.

5. Hypoglycemia/insulin shock

 This is a metabolic disorder caused by a drop in the blood glucose level to below the
normal minimum i.e. it is where the blood glucose level falls below 3.9 mmol/l
(70mg/dl) in diabetic people.
 It occurs when there is too much insulin and there is no enough glucose in the blood
because of;
Causes of Hypoglycemia

a) Skipping a meal or delayed meals

b) Eating less than usual( Inadequate food intake)
c) Exercising more than usual
d) Excessive insulin administration
e) Drinking alcohol especially when one has not eaten
f) Severe vomiting or diarrhea
Hypoglycemia can also be experienced in the following conditions

a) Weight loss surgery

pg. 285 by Osonga

 b) Severe infections
c) Thyroid deficiency
Symptoms of hypoglycemia

During hypoglycemia, the brain is deprived of its source of energy and the person experience
symptoms like

 Nervousness
 Weakness
 Sweating
 Rapid heartbeat
 Shallow breathing
 Double vision
 Dizziness
 Slurred speech
 Headache
 Shakiness
If untreated (If the level become lower) the symptoms can become more severe and can include:
difficulty walking, confusion, weakness, difficulty in seeing, seizures and coma and death

Management of Hypoglycemia

Aim of management
 Increase the glucose level to normal
Management

 In mild symptoms the diabetic should eat a fast digestive CHO, rapidly absorbed glucose
or a snack that contains about 15 g glucose e. g honey , glucose , lucosade, gel , soda,
fruit juice , candies , milk , glucose tablets , sweets and sugar. Glucose is preferred
 In severe cases or when the patient is unable to swallow food – glucose is administered
intravenously.
 Sometimes glucagon is given to counteract the insulin action. Epinephrine can also be
injected

pg. 286 by Osonga

  Follow with complex carbohydrates to prevent the BGLs from dropping again.
6. Hyperglycemia

 This is a condition that is characterized by elevated blood glucose

Causes
 Include insufficient insulin, ineffective insulin and untreated diabetes
Symptoms
1. Glycosuria
2. Confusion
3. Nausea
4. Laboured breath
5. Acetone breath
6. Vomiting
7. Polydipsia
8. Polyuria
9. Blurred vision
10. Weight loss
11. Fatigue
12. Drawing of water from tissues into the blood leading to severe dehydration
Management
 Adjust dosage of regular insulin
 Enhance physical activity
 Reduce amount of CHO
 Space meals based on insulin activity time span
N/B Most diabetics suffer from metabolic syndrome. (A cluster of syndromes-high blood
glucose level, high blood pressure, overweight, neuropathy etc.)

How nutrients are affected in diabetes mellitus

PROTEIN Decreased Increased Urinary increase in nitrogen Increased

synthesis catabolism and potassium gluconeogenesis

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 CARBOHYDRARE Glucose Decrease Hyperglycemia,glucosuria,
availability in glycogenesis, increased volume of urine,
muscles and increased dehydration
fat cells is glycogenolysis,
decreased increased
gluconeogenesi
s

FAT Decreased Increased Increased blood lipid Ketonuria,

synthesis lipolysis ketonemia, loss
of urinary
sodium because
of loss of
ketones, acidosis

Metabolic syndrome

 Metabolic syndrome involves the dysregulation of several measures of health (Or it is a

combination of several symptoms that presents itself in an individual).
 According to WHO(1998), It consists of glucose intolerance and / or insulin resistance
plus two or more of the following: Hypertension/high blood pressure, central
obesity/abdominal obesity, albuminuria, low HDL cholesterol, elevated fasting glucose,
hypertriglyceridemia, high total lipids. Diabetes can therefore result into metabolic
syndrome

Management of Diabetes mellitus

Diabetes requires changes that last a lifetime.
The goals of therapy in diabetes include

1. To maintain blood glucose levels in acceptable range

2. To prevent or delay the onset or progression of associated complications

pg. 288 by Osonga

 3. To encourage people to resume normal life activities
4. To relief symptoms and improve health through optimum nutrition
5. To attain or maintain weight within the acceptable range
Guidelines/rules of diabetes management;
i) Maintenance of normal weight
ii) Regular spacing of meals
iii) Normal nutrition requirements with normal proportions of carbohydrates, proteins and
fats.
iv) Restriction of cholesterol and modification of the types of fats
v) Use of oral compounds or insulin if diabetes cannot be controlled by diet alone
vi) Regulation of physical activity and behavioural modification
vii) Attention to body hygiene
viii) Maintenance of normal rate of growth and emotional being in children
The management of diabetes mellitus

1. Diet therapy
2. Treatment using Medications

a. Insulin therapy
b. Oral hypoglycemic agents

3. Exercise
Goals of dietary management of DM;
i) To attain or maintain weight within the acceptable range
ii) To maintain blood glucose levels in acceptable range
iii) To prevent or delay the onset or progression of short term complications
iv) To prevent or delay the onset or progression of long term complications
v) To relief symptoms and improve health through optimum nutrition

Dietary management of diabetes mellitus

 A diabetic diet has the same nutrition requirements as non-diabetic of the same age, sex,
stature and height

pg. 289 by Osonga

 The first step is to provide kcals adequate to achieve or maintain adequate weight in diabetes

 Fundamental principle of dietary management of diabetes is to give the individual only the
necessary calories according to the body’s daily requirements. For those patients who are
underweight, they require adjustments for weight gain whereas those patients who are
overweight and obese, they require adjustment for weight loss through taking lower calorie
diet because this promotes insulin sensitivity.

Nutrition recommendations

Energy

 An overweight or obese patient should be placed on a diet that permit weight loss of atleast
0.5-1kg/week
 Children with type I diabetes do not require caloric restriction for normal growth but they
should not gain excess weight. Children with good control of sugar will gain weight rapidly
if they over-eat beyond their energy needs
Carbohydrates

 They should provide approximately 50-55% of the total kcals. There is no need for severe
restriction. Complex unrefined carbohydrates e.g. whole grains, legumes, fruits, vegetables,
and low fat milk should tubers and green bananas should for a larger percentage of these
because they are hydrolysed slowly thus glucose will be released slowly over a period of
time and no rapid increase in blood glucose levels. Cane sugar and refined carbohydrates
should be limited unless very little is taken with meals e.g. sweets, honey, ice cream, etc.
because they are hydrolysed quickly and cause rapid increase in blood glucose levels.
 Individuals receiving intensive insulin therapy should adjust their pre-meal insulin doses
based on the carbohydrate content
 Individuals receiving fixed daily insulin doses should try to be consistent in day to day
carbohydrate intake
 Fructose is metabolized without insulin, and produces less hyperglycemia.
 Fructose is present in fruits, honey and in some vegetables and should be taken in limited
quantities and with meals. Consumption of fructose in large amounts may have adverse

pg. 290 by Osonga

 effects on plasma lipids and can raise blood glucose level as the body may convert fructose
into glucose if fructose concentration in the body is high.
 Fructose in commercially produced foods and beverages known as fructose corn syrup
should be avoided as they have a high glycemic index. Fructose has low glycemic index
compared to glucose, galactose and sucrose

Comparison between glucose and fructose

GLUCOSE FRUCTOSE

Glucose is metabolized in both the liver
and the muscles i.e. after it has been
absorbed by the blood, it can be
channeled to the cells of muscles or
different organs or the liver for energy
or for storage in case it is in excess
It is metabolized only in the liver where
majority of fructose is metabolized into
fatty acids and stored in the liver and
other body parts, and some are
metabolized into glucose(through
gluconeogenesis) and glycogen and
stored in the liver

-Highly absorbed from the digestive
system. Thus high glycemic index.
-Proceed sugar or table sugar has a
glycemic index of 80
-Poorly absorbed from the digestive
system. Thus low glycemic index
. Has low glycemic index compaired to
glucose and galctose. It has a glycemic
index of about 17 while natural honey
has a glycemic index of 30.
-Artificial sweeteners made from
fructose such as high fructose corn syrup
has glycemic index of corn syrup is 87

Needs insulin for it to channeled into Do not need insulin

the cells

The main problem with too much

fructose is that it can result into fatty
liver that that can result into insulin

pg. 291 by Osonga

 resistance in the long term.
Too much fructose may also be
converted into glucose
Alcohol also behaves like fructose as
excess results into fatty liver`

Dietary fiber

 Foods high in soluble fiber such as dry legumes, oats, oranges, apples, vegetables etc. should
be encouraged as they are effective in reducing blood glucose levels and serum cholesterol.
 Insoluble fiber promotes satiety and thus weight loss. It should be introduced little by little to
avoid abdominal discomfort.
 They also delay absorption of glucose and result into less hyperglycemia.
 Increased fiber is also associated with reduced insulin resistance.
 Bulk your meal with fiber from whole grains, legumes and vegetables
Protein
 The amount of protein required by the diabetic is similar to that of normal person.
 Protein intake of 10-15 %( 0.8g/kg desirable body weight) should be ensured if renal
function is normal. Excessive intake should be avoided since it is linked with diabetic
nephropathy. Low fat proteins e.g. flesh foods and milk be encouraged e.g. fish, lean meat,
poultry
 In neuropathy, a lower protein intake of 0.6g/kg/day is considered sufficient
 Low fat proteins of high quality that provide all the amino acids should be provided e.g low
fat milk, fish. lean meat and poultry instead of fatty red meat

Fat
 Fats in the diet should be restricted to less than 30%
 High fat diet has metabolic disadvantages. They cause insulin resistance, decrease glucose
transport into muscle and increases atherosclerosis. Atherosclerosis tend to develop at an
early age than in non-diabetic patients. Vegetable fats are preferred over animal origin.
Avoid fried foods and high fat dairy foods

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 Less than 10 % of energy intake should be derived from saturated fats
 Omega 3 fatty acids should be supplied to maintain cholesterol at minimum and to avoid the
onset of cardiovascular diseases.

Water

 Drink adequate amount of water. Do not wait till you are thirsty to drink. Fill your water
bottle and carry it with you. The goal should be at least 8 glasses of water.
 You should also keep yourself cool. When you diabetic, you feel hotter faster than other
people. A hot body does not deal with blood glucose well. Wear loose fitting cloths
Vitamins

 They do not require vitamin and mineral supplementation. Vitamins and minerals should be
provided at the recommended dietary allowance( RDA)

Alcohol

 The metabolism of alcohol does not require insulin and it would appear to offer some
theoretical advantages. However. Alcohol is high in calories, is of no nutritive valve, inhibit
gluconeogenesis and produces distressing symptoms which are not good for diabetic patients
(when stress is high, so is a hormone in your body called cortisol. Too much of it messes
with how well your body manages sugar in the blood)
Alternative sweetness

 Non-nutritive sweeteners such as saccharin and aspartate are recommended for diabetics.
They can be used in pregnancy except saccharin which can be passed to the foetus through
the placenta.
 Saccharine (300 times sweeter than sugar), Aspartame (200 times sweeter than sugar) are
also used when one can afford to replace sugar. They are none nutritive (do not raise glucose
level and provide lesser energy). it is important to differentiate them from nutritive sweetness
such as fructose , sorbitol, xylitol

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N/B. Glycemic index is one of the tools used to manage diet for diabetics. It is a measure of how
quickly a given food causes blood sugar to rise, comparing it to the effect of pure glucose

N/B. Always pay attention to portions even when you eating healthy foods. Some of the tools
that are used to achieve this or the tools used in diabetic diet plan are diabetes plate model, hand
jive and food exchange system

Dietary prescription;
i) There should be regularity of meals. No skipping or delay of meals, no binging (overeating
than normal) and there should be a consistency in the amounts.
ii) Timing and distribution of meals is important especially for individuals on insulin and oral
hypoglycemic agents. This helps to avoid great swings in hypo and hyperglycemia.
iii) If the patient is using oral hypoglycemic agents, it is necessary to know if the tablet is short
acting or long acting so as to allow the distribution of kcals during the day.
iv) The meal pattern of a diabetic on insulin alone is determined according to the time of which
the insulin is administered.
v) Each of the meals and snacks should contain some form of fibre or complex carbohydrates.
vi) Adjustment for exercise during illness is necessary.
vii) There is also need to give advice to the patient on the portion sizes using the household
measures and in general meal planning sizes. E.g. The diabetic plate model.

Physical exercise in diabetes mellitus

 All patients should have individualized exercise and physical activity plan. However,
physical activity must be regular to be effective. Walk, swim, do yoga, dance etc.
Benefits of exercise to diabetic mellitus patient:
 Improve insulin sensitivity and therefore reduces insulin resistance-this helps in
increasing glucose uptake by the cells
 Increases insulin efficiency. Exercise increases the number of insulin receptors on
muscle cells, thus increasing insulin efficiency.
 Lowers blood pressure and reduces lipid profile thus reduces the risk of
cardiovascular diseases
 Prevents development of Type II diabetes in high risk individuals

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  Maintain appropriate body weight/weight loss. Exercise is an integral component of
diabetes care more so in type II diabetes because of obesity
 It maintains good circulation and tones up muscles
 It increases fitness
 It helps with relaxation and reduces stress
 It prevents type 2 DM in high risk individuals
Despite the benefits of exercise, exercise presents severe challenges for individuals with diabetes
because they lack glucose regulatory mechanisms. Intense exercise can result into hypoglycemia.
During periods of intense exercise the diabetic will need more carbohydrate since exercise has
insulin like effects. The diabetic should also ingest carbohydrates before taking exercise and/or
reduce insulin dosage.
 The following can serve as a general guideline
1. No extra food is required for exercise of short duration and slow mode intensity/durarion
2. 10-15 g of CHO are allowed per hour of moderate exercise
3. 20-30 g of CHO are allowed per hour for vigorous exercise
N/B. Diabetic should also pay attention on the shoes they wear. They should put on flat closed
shoes
N/B- patients with type 1 DM and on insulin should avoid injecting insulin on limbs involved in
exercise such as the thighs because it increases insulin absorption and can lead to hypoglycemia.
Medications used in the treatment of DM

1. Insulin therapy
 Insulin was the first successfully used by banting and best in 1922 at the University of
Toronto.
 Insulin must be used for diabetic type 2(insulin dependent diabetics) but type 2 may
be put on this therapy.
 Since insulin is polypeptide, it must be injected subcutaneously to avoid the action of
digestive enzymes
 In type I diabetes, since no insulin is made in the body , it must be obtained from
another source

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  Commercially made insulin is commonly extracted from pancreases of pigs and
cattle.
 Insulin need changes as growth occur/it changes with age.
 Physical activity reduces insulin needs since exercise has an insulin like effects in
lowering blood glucose levels
 Insulin need increases during stress such as pregnancy, surgery, infections and illness
Insulin is classified based on;
i. The mode of action
ii. They type of insulin
iii. The dosage given
iv. The administration schedule
The dosage and administration schedule is based on stage of growth, physical activity, and other
factors such as stress, pregnancy, infections/ illness etc
Types of insulin and their action;
There are three major types;
 The short acting insulin e.g. Anirapia which has a rapid action (onset is 30minutes-1hour,
peak action is 2-3hours). Effective duration is 3-6hours.The total duration of action is 4-
6hours.
 Intermediate acting insulin e.g. NPH, Lente and Mixtard which has an intermediate
action and duration (onset is 2-4hours, peak action is 4-10hours). Effective duration is 10-
16hours.The total duration of action is 14-18hours.
 Long acting insulin e.g. ultralente which has a delayed action and long duration (its onset
is 6-8hours and has no peak action). Effective duration is 18-20hours.The total duration of
action is 20-30hours.
N/B- insulin must be given by injection because it will be digested and made inactive by mouth.

Administration of insulin;
The three types of insulin are mostly used in combination and are administered as follows;
i) Conventional insulin therapy;
This involves the use of an injection of a single morning dose or twice. Usually a combination of
short and intermediate acting insulin is used. The short acting controls the rise in blood sugar

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levels (BGLs) after breakfast and evening meals while intermediate acting control the rise after
lunch and maintenance of a normal blood glucose levels during the night.
The administration is done 30minutes before breakfast and evening meals.
ii) Intensive conventional therapy;
This is where there is multiple daily injections. It involves where there is an injection of regular
or short acting insulin before meals and a dose of long acting or intermediate acting at bed time
to provide a continuous background supply of insulin. This allows for greater flexibility with
timing of meals. It is suitable for shift workers and those who travel a lot and for those with poor
eye sight.
iii) Continuous subcutaneous therapy;
This involves the use of insulin diffusion pump. A small infusion pump is worn on the belt or
under clothing and it delivers insulin through a small tube or catheter and a tiny needle that is
inserted subcutaneously into the abdomen or thigh. Regular insulin/short acting tickles through
the day and night
It is a more expensive method.

2. Oral hypoglycemic agents and drugs (OHAs)

 They are also known as oral glucose lowering medication. They are used in type 2 DM
when diet alone cannot control the condition.
N/B- Oral hypoglycemic agents are not insulin i.e. when control is inadequate because of
stress, failure to loose weight or other factors hypoglycemic agents are always prescribed.

Oral hypoglycemic agents include;

There are two types of oral Glycemic agents
(i) Biguanides
(ii) Sulfonylurea/ Sulphonylureas;

i. Sulphonylureas;
These are the most commonly used OHAs and their mode of action is that;
 They stimulate the pancreas to produce insulin (1st generation).

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 It stimulates the body to increase sensitivity to insulin probably through increasing the
number and activity of insulin receptors in the peripheral tissues (2nd generation).
N/B- There is a tendency of weight gain and hypoglycemia when used. Examples are; Diabenese
and Glipizides.
ii. Biguanides;
Their mode of action is;
 Decreasing absorption of glucose from the GIT,
 Increasing uptake of glucose by tissues
Example include; Metformin

3. Combination of insulin and Oral hypoglycemic agents;

This is normally used by type 2 DM with poor control of blood sugar with oral hypoglycemic
agents. It is required to lower the insulin requirements, improve glycemic control through
increased sensitivity to insulin by oral hypoglycemic agents. It also assists in overcoming
secondary failure of oral hypoglycemic agents.
4. Use of insulin in type 2 DM;
Insulin therapy in type II supplements their own endogenous supply.

GOUT

 A gout is a disorder of purine metabolism in which abnormal levels of uric acid

accumulate in the blood and result to deposition and crystallization of uric acid, usually
in one joint, that begins suddenly
 The deposition and crystallization of uric acid results in inflammation and sharp joint
pain.

Purines

 The name "purines" refers to a specific type of molecule made up of carbon and nitrogen
atoms, and these molecules are found in cells' DNA and RNA.

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  They are typically found in the nucleus of any plant or animal cell and therefore purines
are part of normal diet as they are found in food and drinks from plants and
animals. .Essentially, purines are the building blocks of all living things. In the human
body, purines can be divided into two categories:

o Endogenous purines that are manufactured by the body

o Exogenous purines that enter the body via food

Exogenous purines-the purines that a person eats, are metabolized by the body. Specifically, the
liver breaks down the purines and produces a waste product called uric acid. The uric acid is
released into the bloodstream and is eventually filtered by the kidneys and excreted in the urine.

If too much uric acid builds up in the bloodstream it is called hyperuricemia. In some people,
hyperuricemia can cause kidney stones or lead to an inflammatory joint condition called gout.

Main Risk factors/causes of elevated blood uric level (hyperuricemia) include

 Excessive intake of red meat and fish which result to elevated uric acid in the blood
 Excessive intake of alcohol, as it blocks the elimination of uric acid from the body
 Excessive consumption of stimulant beverages as caffeine if part of the chemical
family of purine. It transforms into uric acid in the body
 Genetic factors
 Kidney diseases
 Hormonal factor
 Obesity

Symptoms
 Inflammation and pain of the joints especially the meta tarsal pharyngeal ( the base of
big toe)
 Joint redness
 Swollen joints
 Joint pain

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  Warmth of the joint/heat in the joint
 Nodules under the skin called tophi
 A risk factor to chronic arthritis

Aim of nutritional management

 Prevent excessive accumulation of uric acid

Management
 Use of low purine diet by restricting consumption red meat, fish, alcohol, stimulants,
and high protein foods to avoid exogenous addition of purines to the existing high
uric acid load is recommended
 Encourage consumption of alkalizing foods e.g. lemons, tomatoes, green beans, fruits
milk and milk products
 Intake of fluids about 3lts/day to enhance excretion of uric acid based on assessment
is recommended
 Moderate protein intake ( 0.8g/kg/day)
 Maintain adequate CHO intake to prevent ketosis
 Limit fat intake
 Avoid large and heavy meals late in the evening
 Encourage consumption of whole grains
N/B. People with hyperuricemia are encouraged to eat foods with low purine concentrations and
avoid foods with high purine concentrations. In addition, foods and drinks that inhibits the body's
ability to metabolize purines, such as alcohol and saturated fats, should be limited or avoided
altogether

A summary of the risk factors/ foods that have relatively high concentrations of purines
with other foods with moderate and low concentrations of purines.

High Purine Foods/risk factors/causes Moderate Purine Foods: Eat Low Purine Foods
Limited Quantities

Meats, especially organ meats or Certain vegetables, including Any vegetables that

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 are not listed as
"sweetmeats," such as liver, brains, and asparagus, spinach, mushrooms, moderately high in
beef kidneys, as well game meats, such as green peas and cauliflower (no purines, such as leafy
venison, which are typically fatty more than ½ cup per day) greens, carrots and
tomatoes

Condiments that
Foods containing saturated fats: these tend
Beef, pork, lamb, fish and poultry contain oils, spices,
to inhibit the body's ability to metabolize
(no more than 4-6 oz daily) and vinegars are
purines
generally acceptable

Seafood, particularly scallops and other Rice, enriched pastas

Wine* (1-2 glasses, when gout
shellfish, anchovies, sardines, herring, and and breads, potatoes,
symptoms are absent)
mackerel and popcorn

Foods and drinks made with high fructose Wheat bran and wheat germ (1/4 Nuts and nut products,
corn syrup, such as sodas1 cup dry daily) such as peanut butter

Dairy products
Supplements containing yeast or yeast Dried beans, lentils and peas (1 cup
(preferably low- or no-
extract cooked)
fat)

Eggs, particularly egg

Gravy Oatmeal (2/3 cup dry daily)
whites

Alcoholic beverages, especially -Beer* Fruit juice (no corn syrup) Coffee and tea

Meat-based soup stocks Fruits

Meat-based soup stocks Fruits

*Alcoholic drinks can inhibit the body's ability to eliminate uric acid, so people with gout are
advised to avoid alcohol or drink in moderation. Beer is notorious for bringing on gout attacks
because it contains both alcohol and brewer’s yeast, which is high in purines.

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People on a low-purine diet should drink plenty of water to aid with digestion and lower uric
acid concentrations in the blood.

Difference between gout and arthritis

 Gout and arthritis can be grouped as musculoskeletal disorders that result into the injuries
of the joints (inflammation, redness, swelling and pain of the joints) but gout can also be
grouped as a metabolic disorder because of poor purine metabolism in which abnormal
levels of uric acid accumulate in the blood that results into deposition and crystallization
of uric acid.
 Even though gout and arthritis cause inflammation, redness, swelling and pain in the
joints, there are some tendencies that differentiate the two such as

GOUT ARTHRITIS

Gout is a disorder of metabolism(poor Arthritis is a disorder of wear and tear of the

metabolism of purines, a form of protein protective cartilage/layer/cushion of the bones

Usually affects one joint. Severe gout can Can affect any joint on either side of the body
sometimes affect many joints at once. This is but most commonly occurs in the small joints
known as polyarticular gout of the hands, wrist and feet

Begins suddenly Gradually

Caused by the deposition of crystals of uric Caused by wear and tear of the protective
acid in a joint cartilage/layer/cushion of the bones

Usually occurs in the foot, most commonly at Can affect any joint on either side of the body
the base of the big toe but most commonly occurs in the small joints
of the hands, wrist and feet

Always accompanied by redness, swelling -The joint affected may become painful, but
and intense pain won’t always be red or swollen

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 -Pain varies in quality and
intensity(sometimes it is mild and sometimes
it is severe)

HYPERTHYROIDISM

 This is a condition due to excessive secretion of thyroid hormone that is also known as
thyrotoxicosis(It is where the thyroid gland overproduces the thyroxine hormone).
 Thyroxine hormone controls the rate of energy metabolism in the cells. Iodine is needed
for the production of thyroxine hormone. The body contains about 15 to 20 mg of iodine,
and most of this (70% to 80%) is in the thyroid gland.
 Increased secretion of thyroid hormone results in increased metabolic rate more than
50%. As a result of increased metabolic rate, the appetite is increased resulting in
hyperactivity, nervousness, rapid heart rate and cardiac failure because the heart must
work harder to deliver more blood and nutrients to the hyperactive body cells. There is
also loss of weight.
 Liver glycogen is rapidly lost due to increased metabolism and there is tissue wasting.
Increased excretion of calcium and phosphorus may cause osteoporosis.

Causes
 Hormonal imbalances
 Tumors-due to cancer of the thyroid gland)
 Grave’s disease(autoimmune disease)

Symptoms and implications of hyperthyroidism

 Increased metabolic rate
 Increased basal metabolic rate(BMR)by increasing oxygen uptake
 Good appetite
 Excessive production of the thyroid hormones

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  weight loss due to increased energy expenditure
 Nervousness
 Palpitation
 Hair loss
 Anxiety
 Tachycardia ( high heart rate)
 Increased perspiration and heat sensitivity
 Diarrhoea

Aims of management
 To prevent/control weight loss-through provision of high calorie diet.
 Reduce workload

Management
 Treat the underlying cause
 A high calorie (4000-5000kcals for adults) and high protein diet (100-125g) diet is
required for extra energy needs, to reverse the weight loss and tissue wastage until
normal nutritional status is attained.

 Intake of snacks in between meals helps to increase calorie intake and satisfy hunger.
Multivitamin-mineral supplements are often given.
 Foods containing caffeine are avoided due to their stimulating effect.
 To reduce metabolic rate to normal, antithyroid drugs are used in most cases.
Tranquilisers are given to control cardiac and hyperactivity effects.

HYPOTHYROIDISM
 Hypo is decreased secretion of thyroid hormones (thyroxine) by the thyroid gland
which leads to lowered metabolic rate.
 Mild form of this disorder is common and affects women more than men, it’s more
common in older adults. Overweight is common due to lowered metabolic rate. Screening
of newborns helps to detect it and start treatment early.

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  Severe hypothyroidism in adults is known as myxoederma (non-pitting oedema) because
reduced levels of thyroid hormones results in accumulation of mucopolysaccharides in
the subcutaneous tissues causing swelling especially of the face, hands, feet and eyelids.

Causes
 Inadequate iodine intake and selenium deficiency
 The commonest cause is autoimmune thyroiditis
 Severe iodine/sekenium deficiency or Inadequate iodine intake and selenium
deficiency

Implications
 Enlargement of thyroid gland as the cells enlarge to trap as much iodine as possible
 Weight gain due to severe reduction in metabolic rate
 In pregnancy it can result to impaired fetal development
 Flabby muscles
 Lethargy
 constipation
 High blood lipids.
 Severe lowering of metabolic rate in fetal life is known as cretinism with symptoms
such as short limbs, a large protruding tongue, coarse dry skin, poor abdominal
muscle tone resulting in umbilical hernia.
Symptoms;
 Decreased BMR  Bradycardia
 Weight gain  Dry cold skin
 Anorexia  Prone to hypothermia
 Depression  Constipation
 Psychosis
 Mental slowness
 Lethargy
 Dry skin
 Brittle hair

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Aim of management
 To control iodine deficiency

Treatment management;
 A synthetic hormone is given to make up for the missing thyroid hormone.
 Recommend iodine rich foods e.g. sea foods or iodine fortified foods
 Dietary fibre is increased to prevent constipation.
 A calorie restricted diet helps to maintain normal weight in overweight patients.
 Surgical removal of the thyroid tissue or ionizing radiation.
 Recommend suitable exercise program

TOPIC: RESPIRATORY DISEASES

Unit Objectives
By the end of the unit the learner should be able to:
a) Describe types, causes and management of respiratory diseases
b) Plan and prepare meals for respiratory diseases
c) Visit a health facility to learn more about management of respiratory diseases
Functions of the respiratory system
i) Gaseous exchange - The lungs enable the body to obtain the oxygen needed to meet its
cellular metabolic demands and to remove the carbon dioxide (CO 2) produced. Healthy
nerves, blood, and lymph are needed to supply oxygen and nutrients to all tissues.
ii) The lungs also filter, warm, and humidify inspired air.
iii) Defense against air borne pathogens e.g. the epithelial surface of the alveoli contains
macrophages. By the process of phagocytosis, these alveolar macrophages engulf inhaled
inert materials and microorganisms and digest them.
iv) Other metabolic functions e.g. they help regulate the body’s acid-base balance.
The body’s pH is maintained partially by the proper balance of CO2 and O2.
The lungs also synthesize arachidonic acid that ultimately may be converted to
prostaglandins or leukotrienes. These appear to play a role in bronchoconstriction seen in

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 asthma. The lungs convert angiotension I to angiotensin II by the angiotension-converting
enzyme (ACE) found mainly in the numerous capillary beds of the lungs. Angiotensin II
increases blood pressure. Because of the ultrastructure and the fact that they receive the
total cardiac output, lungs are well suited to function as a chemical filter.

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 THE RESPIRATORY SYSTEM

The respiratory conducting passages are divided into the upper respiratory tract and the lower
respiratory tract. The upper respiratory tract includes the nose, pharynx, and larynx. The
lower respiratory tract consists of the trachea, bronchial tree, and lungs. These tracts open to
the outside and are lined with mucous membranes. In some regions, the membrane has hairs that
help filter the air. Other regions may have cilia to propel mucus.

INFECTIONS OF THE RESPIRATORY SYSTEM

The respiratory tract infections are dived into upper and lower respiratory tract infections.

 Respiratory tract infections (Upper and lower tract infections) are communicable, in the
sense that they are spread from one person to another, the contraction occurs basically
when exposed to an infected person. By inhaling the air which contains the germs, by
contact with an infected person's body fluids (when one touches the eyes, mouth, or nose
with the infected body fluids).
 Increased amount of oxygen, fluid intake, and humidified air can help fight the symptoms
of a mild to moderate infections.

Upper respiratory tract infections

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Upper respiratory tract infection is any infection of any of the components of the upper airway. It
includes
 Common cold (most common URT
infection)
 Sinusitis
 Tonsillitis
 Otitis media
 Pharyngitis
 Laryngitis
 Epiglottitis
 Laryngotracheitis

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 COMMON COLD AND FLU

 A cold is a mild viral infection of the nose, throat, sinuses and upper airways
 Cold and flu (or Influenza) are both respiratory illnesses and the terms are used
interchangeably. However, they are both caused by different viruses. The cold (also
known as nasopharyngitis, acute viral rhinopharyngitis, acute coryza, or a common
cold) is a viral infectious disease of the upper respiratory system. Cold is caused
primarily by rhinoviruses and corona viruses.
 Influenza is a contagious respiratory tract infection caused by one of three influenza
viruses: A, B and C. Influenza C causes mild infections in infants and young children, in
adult cases are rare and usually asymptomatic. Influenza A & B viruses cause seasonal
epidemics in people of all ages. Influenza B & C viruses are virtually restricted to
humans and both have been isolated from other mammals, there are no natural animal
reservoir of infection. Although, both A & B viruses can be responsible for the annual
winter epidemics (widespread) of influenza (‘seasonal flu’) that occur around the world,
only influenza A has the potential to give rise to global pandemic/outbreak disease.
Transmission

 Person to person (When one is in contact with an infected person's body fluids e.g.
through coughs and sneeze.)
Risk Factors
Exposure to any of these makes people to be suspetable
 Cold weather
 Damp
 Wind
 Rapid temperature change
 Low resistance due to fatigue, exhaustion, loss of sleep, stress, depression.
 Unhygienic family practices.
How it happens
 During cold, virus particles penetrate the mucous layer of the nose and throat and attach
themselves to cells there. The viruses punch holes in the cell membranes, allowing viral
genetic material to enter the cells. Within a short time, the virus takes over and forces the
cells to produce thousands of new virus particles.
 In response to this viral invasion, the body marshals its defenses. The nose and throat
release chemicals that spark the immune system; injured cells produce chemicals called

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 prostaglandins, which trigger inflammation and attract infection-fighting white blood
cells; tiny blood vessels stretch, opening up space to allow blood fluid (plasma) and
specialized white cells to enter the infected area; the body temperature rises, enhancing
the immune response; and histamine is released, increasing the production of nasal mucus
in an effort to trap viral particles and remove them from the body. As the battle against
the cold virus rages on, the body counterattacks with its specialized white blood cells
called monocytes and lymphocytes.
Symptoms of a cold

Cold manifest slowly with

 a sore throat
 a runny nose/nasal congestion/blocked nose (An increase in mucus production)
 Sneezing (from the irritation in the nose).
 Cough (from the increased mucus dripping down the throat)
 a hoarse voice

 Fatigue
 generally feeling unwell
 Usually without fever
Mucus production is an act to wash viruses out of cells and coughing clears the mucus and
viruses out of the body.
Colds tend to last longer in younger children who are under five, typically lasting around 10 to
14 days.
Flu comes on more suddenly with
 Fever
 Sore muscles
 Fatigue
 Cough.
Fever causes the body to heat up and destroy infection

Complications of colds and flu

These ailments can last from a few days to about a week, colds usually clear up without causing
any further problems but can progress into bronchitis, strep throat or asthma if not properly
treated.
MANAGEMENT

Medical management
1. Vaccination -influenza vaccines are used worldwide according to WHO
recommendations.

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2. Antibiotics- they do not kill viruses and they should not be used for colds or flu. They
can however treat bacterial complications such as sinus or ear infections. The overuse of
antibiotics has become a very serious problem, which leads to a resistance in disease-
causing bacteria that may decrease the effectiveness of antibiotics when really needed.
3. Antivirals - There are several antiviral medications that can limit the course and duration
of these infections and are specific to the viruses. They work by inhibiting viral
replication rather than directly killing the viruses. They are generally avoided because of
resistance problem.
4. Anti-histamines - Antihistamines can be used for symptoms such as runny nose,
sneezing and itching. Precautions are necessary as most of these drugs cause drowsiness.

Diet management/therapy
 Increased vitamin C because of low immunity- Vitamin C stimulates antibody response.
Regular use can prevent colds before they happen. Consume fruits and vegetables that are
loaded with vitamin C such as citrus, lemon, berries, bell peppers, orange fruits etc. as
they are have high vitamin C. Vitamin C acts as a mild natural antihistamine and
supporting the function of white blood cells. Antihistamines reduce mucus secretion and
inflammation in airways and sinuses, making it easier to breathe.
 Increase intake of vitamin A and/or beta carotene in your diet - Vitamin A and/or beta
carotene strengthen the mucus membranes making them more resistant to infection. All
yellow fruits and vegetables contain Vitamin A. Meat, fish, kidney and liver, liver oils of
fish like cod are richest source of vitamin A. If you are a vegetarian you can have fish
liver oil supplements but over dose can be toxic.
 Zinc especially in the form of lozenges helps prevent viral replication in the throat by
stimulating T-cell response. The lozenges should not be used for more than one week.
Zinc can suppress the immune system if used for an extended period of time.
 Energy: High energy diets because of increased metabolic needs as flu comes with fever,
thus increased BMR.
Fluid: In case of profuse nasal discharge, fluid intake (water) should be increased.Drink
plenty of water, can add a pinch of turmeric and ginger powder to it.
 .Food and soups should be served hot.
 Small frequent meals because of loss of appetite and smell
 Avoid milk and milk products - cottage cheese as they result into increased production
of mucus
Functional foods
 Include garlic, ginger and onions in your food.

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  Drink boiled mixture of - half cup water, little ginger, 2-3 leaves of sweet basil (tulsi) and
mint leaves, or you can eat the raw leaves, this will boost up your immunity and control
your cough and cold.
 Gargle with warm water, a pinch of salt and turmeric to sooth your throat.
 Take raw fruits and vegetables. Apple is good for cold, should consume at least one apple
a day.
 Avoid milk and milk products - cottage cheese as they result into increased production of
mucus
 Avoid spicy food, eggs, sweets and cold refrigerated drinks.
 Avoid cold drinks, cold water, ice creams and aerated drinks.
 Encourage intake of lemon juice with honey which is a traditional
remedy for coughs

SINUSITIS
Sinusitis is an infection/inflammation of the small air-filled cavities inside the cheekbones and
forehead. It develops in up to 1 in every 50 adults and older children who have a cold.

The sinuses are small, air-filled cavities behind your cheekbones and forehead.
The mucus produced by your sinuses usually drains into your nose through small channels. In
sinusitis, these channels become blocked because the sinus linings are inflamed (swollen).

Causes
Conditions that can cause sinus blockage include:

 The common cold

 Allergic rhinitis, which is swelling of the lining of the nose
 Small growths in the lining of the nose called nasal polyps
 A deviated septum, which is a shift in the nasal cavity
 A weakened immune system

Types

 Acute sinusitis usually starts with cold like symptoms such as a runny, stuffy nose and facial
pain. It may start suddenly and last 2-4 weeks.
 Sub-acute sinus inflammation usually lasts 4 to 12 weeks.
 Chronic inflammation symptoms last 12 weeks or longer.
 Recurrent sinusitis happens several times a year.

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Signs and symptoms
Sinusitis usually occurs after an upper respiratory tract infection, such as a cold. If you have
a persistent cold and develop the symptoms below, you may have sinusitis.
Symptoms of sinusitis include:
 a green or yellow discharge from your nose

 a blocked and runny nose

 pain and tenderness around your cheeks, eyes or forehead
 a sinus headache
 a high temperature (fever) of 38C (100.4F) or more
 toothache
 a reduced sense of smell
 bad breath (halitosis)
Children with sinusitis may be irritable, breathe through their mouth, and have difficulty feeding.
Their speech may also sound nasal (as though they have a stuffy cold).
The symptoms of sinusitis often clear up without treatment within a few weeks (acute sinusitis),
although occasionally they can last three months or more (chronic sinusitis).

Dietary Management

As in common cold

Functional foods
Foods that reduce and prevent inflammation
 Fish such as wild salmon, cod, and sardines are high in omega 3 fatty acids.
 Turmeric spice, contains curcumin, which actively reduces inflammation.
 Avocados are high in omega 3 fatty acids and can reduce immune dysfunction.
 Beans, such as mung, pinto, and kidney, are also high in omega 3 fatty acids.
 Red bell peppers are rich in Vitamin C and acts as an antioxidant.
 Green vegetables such as broccoli, asparagus, leafy greens, and bean sprouts contain
high levels of vitamin C and calcium, helping to counteract histamine, “the substance that
can contribute to inflammation, runny nose, sneezing, and other related symptoms.”
 Vitamin A is considered a ‘membrane conditioner’ that helps build healthy mucus
membranes in the head, chest, and throat and is great for skin and eye health. Vitamin A
is plentiful in sweet potato, carrots, dark leafy greens, squash, apricots, rockmelon, paw
paw, and red and yellow capsicum. Infact paw paw is rich in vitamins A, C and E.
 Citrus fruits such as oranges, grapefruit, and berries are also high in vitamin C.
 Other fruits such as tomatoes, apples and pears are rich in Quercetin, a natural
antihistamine.

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  Green tea and drinking more fluids can help to alleviate any headaches that can result
from dehydration caused by constant sneezing and blowing your nose.
 Spices like ginger

PHARYNGITIS (SORE THROAT)

 Pharyngitis (sore throat) is an inflammation of the pharynx or throat – the area between
the tonsils and the larynx (voice box). A sore throat is characterised by redness, swelling
and pain in this area, which can make swallowing or speech difficult.
 The pharynx is connected to the mouth, nose, oesophagus, larynx and ears. It is also close
to the tonsils (at the back of the pharynx) and the adenoids (higher up in the nasal portion
of the pharynx).
 A sore throat is usually the first symptom of a mild illness such as a cold or the flu.
However, it can also be an indication of a more serious condition, such as strep throat or
scarlet fever.

Causes

Sore throat can be caused by viruses or bacteria.

Viral causes

Viruses cause most sore throats:

 Most commonly, the viruses that cause the common cold are responsible for viral
pharyngitis.

o In young children, the condition is usually mild, and can be mistaken for a
common cold or flu.

 Other viral infections that can result in pharyngitis include influenza (flu), measles,
chickenpox and herpes.

Bacterial causes

Bacteria can also cause a sore throat:

 The most common bacterial cause of a sore throat is the streptococcus bacterium, which
causes the serious condition strep throat.

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Other causes

 Smoking cigarettes, consuming excessive alcohol, breathing in chemical fumes or air

pollution, or swallowing substances that irritate or damage the lining of the throat can
also cause pharyngitis.

Symptoms

Inflammation of the pharynx causes it to redden and swell. The condition is characterised by a
raw, scratchy or burning sensation in the back of the throat, and pain, especially when
swallowing.

Other symptoms may include:

 Tenderness or swollen glands at the front of the neck

 Sneezing and coughing
 Hoarseness
 Runny nose
 Mild fever
 General fatigue
 Painful breathing and speaking
 Pus in the throat
 Ear infection
 Sinusitis
 Abscess near the tonsils

Treatment
 Usually no specific treatment is required if you have viral pharyngitis (such as mono),
which usually clears up within a week.
 Bacterial infections such as strep throat can be effectively treated with antibiotics.
Antibiotics do not help with viral infections.
 For chronic pharyngitis (persistent pain due to a respiratory, sinus, or mouth infection
spreading to the throat), your doctor should treat the primary source of infection.
Home remedies

Most sore throats will go away by themselves after a few days and can be effectively treated at
home.

To relieve the pain and discomfort of a sore throat, you could try the following:

 Get a lot of rest.

 Drink plenty of fluids.

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  Gargle with warm salt water or some other home-made gargle to wash away mucus and
irritants.
 Avoid smoking cigarettes.
 Eat largely soft foods for a couple of days to avoid irritating your throat.
 Suck non-prescription lozenges containing a mild anaesthetic. Zinc lozenges can relieve
sore throats and other cold symptoms. Mildly anaesthetic sprays and mouthwashes are
also available over the counter.
 If mouth breathing or dry air causes your sore throat, try using a humidifier in your home.
 If your nose is blocked, use a nasal spray to prevent mouth breathing. (Caution: using
these products for more than a couple of days may result in dependency. If you have
heart disease or high blood pressure, check with a doctor before using any decongestant
products.)
 Apply a warm heating pad, compress or salt plaster to your throat.
 Try steam inhalations.

Management

Nutrition therapy: As in common cold

Functional foods

 Lemon and water - Mix 1 teaspoon lemon juice in 1 cup water for this home remedy for
sore throats; the astringent juice will help shrink swollen throat tissue and create a hostile
(acidic) environment for viruses and bacteria
 Ginger, lemon and honey - This sore throat home remedy mixes 1 teaspoon each of
powdered ginger and honey, 1⁄2 cup of hot water, and the juice of 1⁄2 squeezed lemon. Pour
the water over the ginger, then add the lemon juice and honey, and gargle. Honey coats the
throat and also has mild antibacterial properties.
 Hot sauce and water - The capsicum in hot peppers helps alleviate pain and fights
inflammation. Add five shakes of ground cayenne pepper (or a few shakes of hot sauce) to a
cup of hot water for sore throat relief. It'll burn, but try this gargle every 15 minutes and see
if it helps.
 Turmeric and water - This yellow spice is a powerful antioxidant, and scientists think it has
the strength to fight many serious diseases. For a sore throat remedy, mix 1/2 teaspoon of
turmeric and 1/2 teaspoon of salt into 1 cup of hot water and gargle.
 Clove tea - Add 1 to 3 teaspoons of powdered or ground cloves to water, then mix and
gargle. Cloves have antibacterial and anti-inflammatory properties that can help soothe and
heal a sore throat.
 Tomato juice - For temporary relief of sore throat symptoms, gargle with a mixture of 1/2
cup tomato juice and 1/2 cup hot water, plus about 10 drops hot pepper sauce. The
antioxidant properties of lycopene may help remedy a sore throat faster.

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Prevention

 If you are prone to sore throats, try changing your toothbrush every month – the bristles
can harbour bacteria. Also throw away your old toothbrush after recovery from a sore
throat so as not to re-infect yourself.
 Try not to share eating and drinking utensils with other people.
 When you use public telephones or water faucets, try to avoid touching them with your
nose or mouth.
 Do not have close contact with someone who has a sore throat.
 If you live in a polluted environment, try to stay indoors as much as possible on days
when the pollution is very bad.
 Don't consume large amounts of alcohol.
 Avoid areas where there is a lot of cigarette smoke.
 If the air is very dry, try humidifying your home.
 Build up your body's natural defences: reduce stress levels and get plenty of rest. This
can help you to avoid infections such as strep throat.

EPIGLOTTITIS

 Epiglottitis is a medical emergency that may result in death if not treated quickly. The
epiglottis is a flap of tissue at the base of the tongue that keeps food from going into
the trachea, or windpipe, during swallowing.
 When it gets infected and inflamed, it can obstruct, or close off, the windpipe, which may
be fatal unless promptly treated.
 Respiratory infection, environmental exposure, or trauma may result in inflammation and
infection of other structures around the throat. This infection and inflammation may
spread to the epiglottis as well as other upper airway structures.
 With continued inflammation and swelling of the epiglottis, complete blockage of the
airway may occur, leading to suffocation and death. Even a little narrowing of the
windpipe can dramatically increase the resistance of an airway, making breathing much
more difficult.

Causes

Causes of epiglottitis include bacteria, viruses, and fungi, especially among adults.

 Various organisms that can cause epiglottitis e.g Streptococcus pneumoniae, herpes simplex
virus type 1, and Staphylococcus aureus,
 Other types of epiglottitis are caused by heat damage. Thermal epiglottitis occurs from
drinking hot liquids; eating very hot solid foods; or using illicit drugs

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Symptoms
When epiglottitis strikes, it usually occurs quickly, from just a few hours to a few days. The most
common symptoms include sore throat, muffling or changes in the voice, difficulty speaking, fever,
difficulty swallowing, fast heart rate, and difficulties in breathing.
Fever is usually high in children but may be lower in adults or in cases of thermal epiglottitis.

CAUTION:

Epiglottitis is a medical emergency. Someone who is suspected of having epiglottitis should be taken
to the hospital immediately. Try to keep the person as calm and comfortable as possible. Make no
attempt at home to inspect the throat of a person suspected of having epiglottitis. This can cause the
windpipe and surrounding tissues to close and an irregular heartbeat, which can lead to respiratory
and/or cardiac arrest (stopping of breathing and/or heart) and death.

Complications
Epiglottitis can cause a number of complications, including:

 Respiratory failure. This is when the airway narrows and become completely
blocked. This can lead to respiratory failure — a life-threatening condition in which
the level of oxygen in the blood drops dangerously low or the level of carbon dioxide
becomes excessively high.

Prevention
Epiglottitis can often be prevented with proper vaccination against H influenza type b (Hib). Adult
vaccination is not routinely recommended, except for people with immune problems such as sickle
cell anaemia, splenectomy (removal of the spleen), cancers, or other diseases affecting the immune
system.
Common sense precautions
Of course, the Hib vaccine doesn't offer guarantees. Immunized children have been known to
develop epiglottitis — and other germs can cause epiglottitis, too. That's where common sense
precautions come in:

 Don't share personal items.

 Wash your hands frequently.
 Use an alcohol-based hand sanitizer if soap and water aren't available.

LARYNGOTRACHEITIS (CROUP)

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  Croup is the common name for laryngotracheitis. This is when the voice box (larynx),
trachea (windpipe) and airways from the lungs (bronchi) become infected. It's a common
condition and only rarely has serious consequences.

 Croup mainly affects children under the age of six. Croup is a condition in which parts of
your child's respiratory (breathing) system become infected, leading to inflammation.
Thick mucus is also produced. The airways from the lungs are likely to be swollen and
this makes it difficult for air to move into and out of the lungs.

Symptoms
Acute laryngotracheitis in children and adults
 sore throat that triggers a cough;
 Changed and rough voice.
 headaches;
 a feeling of a lump in the throat;
 Coughing fits that occur mostly at night. They are accompanied by wheezing, dyspnea.
 The child is very restless and scared, crying constantly. He sits or stands. This is due to
the fact that he just cannot take a horizontal position, as the cough in this position is
reinforced (due to edema).
Causes
It is caused by a virus. Very occasionally croup may be caused by bacteria or an allergic
reaction.

Prevention
Croup is spread by droplets in the air which are released when someone with the infection
coughs or sneezes. The disease can also be passed on by touching a surface that has been
contaminated. You can reduce the risk of croup by making sure your child washes his/her hands
regularly. If possible, keep your child away from people who have a respiratory infection.

Treatment
.Drug therapy:
Nutrition therapy: As in common cold

Middle ear infection (otitis media)

A middle ear infection (otitis media) develops in an estimated one in every five children under
the age of five with a cold.
Symptoms of a middle ear infection include:
 severe earache
 a high temperature of 38C (100.4F) or above
 flu-like symptoms, such as vomiting and a lack of energy
 some loss of hearing

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Most middle ear infections will resolve without treatment within a few days. Treatment is
usually only required if your child has repeated middle ear infections.

Chest infection
A chest infection such as bronchitis and pneumonia can occur after a cold, as your immune
system is temporarily weakened.
Symptoms of a chest infection include a persistent cough, bringing up phlegm (mucus),
and shortness of breath.
Minor chest infections will resolve in a few weeks without specific treatmen

LOWER TRACT INFECTIONS

 The lower respiratory tract begins from the trachea and ends in the lungs. The tract enters
the lungs and divides into the bronchi. Then each of the bronchi divides further into
smaller air pipes that are bronchioles.
 These bronchioles end in small air sacs which are known as alveoli. Many alveoli bunch
up together and form the alveolar sac. From these alveoli the blood capillaries go out.
 The common illnesses are bronchiolitis, pneumonia, bronchitis and flu.
 Lower respiratory tract infection cause greater harm to the human body than the upper
respiratory infections.

LOWER RESPIRATORY TRACT INFECTIONS

BRONCHITIS

 Bronchitis or Bronchial Infection refers to the swelling and inflammation of the

membranes lining the bronchial tubes. The swelling of the tubes reduces the airway
passage resulting in coughing spells. These coughing spells are usually accompanied
by breathlessness. At times phlegm is also there.

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  It is mostly caused by a virus one gets from the flu or the common cold but can also
be caused by bacteria and fungi

Risk factors
 Heavy smoking as long-term cigarette smoking affects the bronchial tubes and
this leads to excess mucus production that eventually leads to the inflammation of
the tubes.
 The inflammation is also high among those who work in quarries, mining field
and also grain handlers. They are continually exposed to dust particles and
poisonous fumes.

Symptoms

 Shortness of breath
 Rapid breathing
 Chest constriction
 Coughing and wheezing
 Blood in cough at times
 Nose block
 Fever

Types of Bronchitis or Bronchial Infection

Bronchitis or Bronchial Infection generally affects people in two forms–Acute Bronchitis (which
lasts for one to three weeks) and chronic Bronchitis (which lasts for minimum 3 months to two
years in a continuum).

o Acute Bronchitis or Acute Bronchial Infection: In acute bronchitis, there are symptoms of
hacking cough and it also produces phlegm that at times is accompanied by an upper
respiratory tract infection. In most cases, it is a viral infection, but sometimes bacterial
infection is also found. Acute bronchitis goes away with good hygiene.

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  Chronic Bronchitis or Chronic Bronchial Infection: Chronic bronchitis, however, is a
serious ailment and a long term disorder which requires medical attention

Management and prevention:

Aims of treatment of bronchitis;

i. To aid in expulsion of mucus
ii. To relieve cough

Medical intervention

Antibiotics: Since bronchitis usually results from a viral infection, hence antibiotics aren't
usually effective in treating bronchial infection. However, a doctor might still prescribe an
antibiotic if he or she suspects that the infection is caused by a bacterial invasion.

Cough Medicine: It is always considered best not to suppress a cough that brings up the mucus,
since coughing also helps in removing the irritants from your lungs and clears the air passages.
Still, if your cough keeps you miles away from sleeping, one might also try using cough
suppressants or cough medicines at bedtime.

Avoid Cigarette and Smoke: Cigarette smoke usually increases the risk of chronic bronchitis.
Hence it has to be avoided at all cost. People who smoke, particularly long-time smokers, and
also those who experience second-hand smoking, have an increased risk of not just bronchial
infection but also lung cancer.

Get Vaccinated: Many cases of acute bronchitis might result from influenza, which again
caused by an influenza virus. Thus, getting a yearly flu vaccine can help and protect you from
getting flu.

Wash Your Hands: To avoid and cure communicable diseases and also to reduce the risk of
catching a viral or bacterial infection, consider washing your hands frequently and also get in the
habit of using hand sanitizers.

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Wear a Surgical Mask: If anyone you know is suffering from bronchitis or COPD, considering
the idea of wearing a face mask at work and in crowds is worth giving a thought and at times it
becomes a necessity since prevention is better than a cure.

Dietary management:

Diet management/therapy
 Increased vitamin C because of low immunity- Vitamin C stimulates antibody response.
Regular use can prevent colds before they happen. Consume fruits and vegetables that are
loaded with vitamin C such as citrus, lemon, berries, bell peppers, orange fruits etc. as
they are have high vitamin C. Vitamin C acts as a mild natural antihistamine and
supporting the function of white blood cells. Antihistamines reduce mucus secretion and
inflammation in airways and sinuses, making it easier to breathe.
 Increase intake of vitamin A and/or beta carotene in your diet - Vitamin A and/or beta
carotene strengthen the mucus membranes making them more resistant to infection. All
yellow fruits and vegetables contain Vitamin A. Meat, fish, kidney and liver, liver oils of
fish like cod are richest source of vitamin A. If you are a vegetarian you can have fish
liver oil supplements but over dose can be toxic.
 Zinc especially in the form of lozenges helps prevent viral replication in the throat by
stimulating T-cell response. The lozenges should not be used for more than one week.
Zinc can suppress the immune system if used for an extended period of time.
 Energy: High energy diets because of increased metabolic needs as flu comes with fever,
thus increased BMR.
 Fluid: In case of profuse nasal discharge, fluid intake (water) should be increased.Drink
plenty of water, can add a pinch of turmeric and ginger powder to it.
 .Food and soups should be served hot.
 Small frequent meals because of loss of appetite and smell
 Avoid milk and milk products - cottage cheese as they result into increased production
of mucus
Functional foods
 Include garlic, ginger and onions in your food.
 Drink boiled mixture of - half cup water, little ginger, 2-3 leaves of sweet basil (tulsi) and
mint leaves, or you can eat the raw leaves, this will boost up your immunity and control
your cough and cold.
 Gargle with warm water, a pinch of salt and turmeric to sooth your throat.
 Take raw fruits and vegetables. Apple is good for cold, should consume at least one apple
a day.
 Avoid milk and milk products - cottage cheese as they result into increased production of
mucus
 Avoid spicy food, eggs, sweets and cold refrigerated drinks.

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  Avoid cold drinks, cold water, ice creams and aerated drinks.
 Encourage intake of lemon juice with honey which is a traditional remedy for coughs

Other remedies

 If you do suffer from shortness of breath or tightness in the chest, rubbing turpentine over
the chest can offer some much needed relief.
 Warm salt water gargles can also help to loosen the phlegm and reduce constriction that
you may feel in your chest.
 The best way to treat bronchitis is by getting adequate rest.
Asthma;
This is a chronic condition that manifest with attacks of dyspnea (difficulty in breathing)
accompanied by wheezing, cough, expectoration and chest pain. Asthma is caused by allergic
reactions. It is the result of a complex interaction between environmental exposures and genetics.
When people are genetically susceptible, environmental factors exacerbate airway hyper-
responsiveness, airway inflammation, and atopy (tendency to develop allergic reaction) that
eventually leads to asthma.

Environmental risk factors for the development of asthma

 Indoor allergies (dust mites, animal allergies)
 Outdoor allergies (pollen and fungi)
 Air pollution
 Tobacco smoke exposure
 Small size at birth
 Respiratory infection
 Lower socioeconomic status.
 A higher than desirable BMI during childhood

Symptoms of asthma;
 Increased response of trachea and  Swelling of airway
bronchi stimuli  chest tightness
 Breathlessness  Excess mucus
 Reduced airway  Coughing

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  Wheezing
 Chest pressure
 Expectoration
 Difficulty in breathing

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Medical management
 Routine monitoring of symptoms and lung functions
 Patient education
 Control of environmental triggers
 Pharmacotherapy – stepwise and tailored to meet individual patient needs. Quick relief
(short-acting beta agonists – bronchodilators and steroids) and long term controller
medication (inhaled long acting beta agonists and leukotriene modifiers) are used as
therapy for asthma.
Medical nutrition therapy
Goals of nutrition therapy
 Correct energy and nutrient deficiencies and excesses in the diet.
 Address dietary triggers. GERD (Gastroesophageal reflux disease), food allergens and
some specific food additives are the two most common dietary triggers.
 Monitoring food-drug interactions.

The nutrition care involves;

i. Provide antioxidants e.g. vitamin A, C and E because they enhance bronchial tubes’
ability to withstand free radicals coming from the environment
ii. Provide honey as it contains some pollen which can desensitize the body against
environmental pollens.
iii. Encourage the consumption of onions as it is a bronchial dilator and antispasmodic
which can relieve and prevent asthma attack.
iv. Reduce intake of food additives e.g. salt, wine, beer and fish. Fish contains histamines
which provoke all allergic reactions. N/B- asthma and bronchitis are conditions that
are collectively called chronic obstructive pulmonary disease (COPD)
v. Provide omega-3 polyunsaturated fatty acid (PUFA) fish oil supplements throughout
childhood to reduce wheezing.
vi. Supplementation of zinc to improve asthma symptoms and lung function
vii. Provide diet free of known irritants such as spicy foods, caffeine, chocolate, and
acidic foods.

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 viii. Limit the intake of high fat foods and control portions to prevent gastric secretions,
which exacerbate GERD.
ix. Food allergens e.g. an immunoglobulin E-mediated reaction to a food protein can lead
to bronchoconstriction. Completely avoiding the allergenic food protein is the only
dietary treatment currently available for food allergies.
x. Some food additives used in the processing of foods such as potassium metasulfite
and sodium sulfide, have been found to be a trigger for asthmatics. Therefore they
should be avoided.
xi. Some asthma patients need maintenance oral steroids, and these patients are prone to
develop drug-nutrient interaction problems and should be managed as appropriate.

Chronic obstructive pulmonary disease (COPD)

This refers to a group of conditions characterized by the persistent obstruction of airflow through
the lungs particularly in the main airways (bronchi and bronchioles) and air sacs (alveoli) of the
normal respiratory system and reduced expiratory flow.
As COPD progresses, the work of breathing increases to 10 to 20 times that of a person with
normal lung function. The two main types of COPD are chronic bronchitis and emphysema,
and in many patients, these conditions may co-exist in varying degrees and are generally
irreversible.
Chronic bronchitis is characterized by persistent inflammation and excessive secretions of
mucus in the airways of the lungs, which may ultimately thicken and become too narrow for
adequate mucus clearance. Chronic bronchitis is diagnosed when a chronic, productive cough
persists for at least 3 months of the year for 2consecutive years.
Emphysema is characterized by the breakdown of the lungs’ elastic structure and destruction of
the walls of the bronchioles and alveoli, changes that significantly reduce the surface area
available for respiration. Emphysema is diagnosed on the basis of clinical signs and the results of
lung function tests.
Both chronic bronchitis and emphysema are associated with:
 Abnormal levels of oxygen and carbon dioxide in the blood
 Shortness of breath (dyspnea)
 COPD may eventually lead to respiratory or heart failure

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  Dramatic reductions in physical activity
 Reduced quality of life
 Weight loss and wasting are common in the advanced stages of disease resulting from
hypermetabolism, poor food intake, and the actions of various inflammatory proteins
Causes of COPD
 Smoke from cigarettes is a major risk factor, along with that from biomass fuel used for
cooking and heating in rural areas, occupational exposure as well as other forms of air
pollution may also predispose an individual to COPD.
 Genetic factors - Alpha-1-antitrypsin deficiency. Individuals with this defect have inadequate
blood levels of a plasma protein (alpha-1-antitrypsin) that normally inhibits the enzymatic
breakdown of lung tissue.
Medical treatment of COPD
The primary objectives of COPD treatment are
 To prevent the disease from progressing and relieve major symptoms (dyspnea and
coughing).
 Individuals with COPD are also encouraged to quit smoking to prevent disease progression
and to get vaccinated against influenza and pneumonia to avoid complications
 For people with severe COPD, supplemental oxygen therapy (12 hours daily) can maintain
normal oxygen levels in the blood and reduce mortality risk.
 Improve the quality of life

Nutrition therapy for COPD

Goals of MNT
 To correct malnutrition (which affects up to 60% of COPD patients) resulting from poor
food intake and poor appetite.
 To promote the maintenance of a healthy body weight
 To prevent muscle wasting resulting from hyper-metabolism.
General nutrition care plan
Energy needs of COPD patients are usually raised due to hyper-metabolism (about 20 percent
above normal), which results from chronic inflammation and the increased workload of

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respiratory muscles. The energy requirements of most adult COPD patients range from 25 to
35kcal/kg body weight.
In addition, it has been proposed that patients with COPD may benefit from a high fat, moderate
carbohydrate diet distributed as protein (15% to 20% of total calories), fat (30% to 45% of total
calories) and carbohydrate (40% to 55% of total calories) so as to preserve a satisfactory
respiratory quotient (volume of CO2 expired/volume of O2 consumed) from substrate
metabolism use.
Weight management – for underweight COPD patients a high-kcalorie, high-protein diet may
be helpful, but excessive energy intakes increase the amount of carbon dioxide produced and can
increase respiratory stress.
Excess body weight places an additional strain on the respiratory system, and so overweight or
obese COPD patients may benefit from energy restriction and gradual weight reduction.
Decreased food intake - Food intake often declines as COPD progresses.
Causes of decreased food intake in COPD patients
 Dyspnea may interfere with chewing or swallowing.
 Physical changes in the lungs and diaphragm which may reduce abdominal volume,
leading to early satiety.
 Medications which may reduce appetite
 Depression
 Altered taste perception (which may be due to the use of bronchodilators or the mouth
dryness caused by chronic mouth breathing)
 Disability in some patients hence they are unable to shop or prepare food or may lack
adequate support at home.
Provide small, energy dense and frequent meals spaced throughout the day rather than two or
three large ones. The lower energy content of small meals reduces the carbon dioxide load, and
the smaller meals may produce less abdominal discomfort and dyspnea.
Some individuals may eat better if they receive supplemental oxygen at mealtimes.
Fluids - Consuming adequate fluids should be encouraged to help prevent the secretion of overly
thick mucus; however, some patients should consume liquids between meals so as not to
interfere with food intake.

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Cigarette smoking – a combination of nutritional counselling and nicotine replacement may
optimize success.
Oral supplements may be recommended as between-meal snacks to improve weight gain or
endurance, but patients should be cautioned not to consume amounts that reduce energy intake at
mealtime.
Pulmonary Formulas- Enteral formulas designed for use in COPD provide more kcalories from
fat and fewer from carbohydrate than standard formulas. The ratio of carbon dioxide production
to oxygen consumption is lower when fat is consumed.
Incorporating an exercise Program - Loss of muscle can be more readily prevented or reversed
if the treatment plan includes an effective exercise program. With exercise, patients are likely to
see improvements in their strength, endurance, and ability to perform activities of daily living.
Both aerobic training and resistance exercise can be beneficial.
Protein - Sufficient protein of 1.2 to 1.5 g/kg of dry body weight is necessary to maintain or
restore lung and muscle strength, as well as to promote immune function.
Vitamins and Minerals - the requirements for individuals with stable COPD depend on the
underlying pathologic conditions of the lung, other concurrent diseases, medical treatments,
weight status, and bone mineral density. For people continuing to smoke tobacco, additional
vitamin C is necessary. The role of minerals such as magnesium and calcium in muscle
contraction and relaxation may be important for people with COPD. Other minerals of
importance include vitamin D and K depending on the comorbidities and the drugs administered.

PNEUMONIA

 The term pneumonia comes from the Greek word pneuma meaning “ breath”

 Pneumonia refers to an acute inflammation of the lung caused by an infectious agent that
primarily affects the microscopic air sacs known as alveoli.
 The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or
pus, fever, chills, and difficulty breathing.
Causes/Infectious agents
 Infection by organisms. A variety of organisms, including bacteria, viruses and fungi, can
cause pneumonia but is mostly caused by
viruses and bacteria. The organisms (bacteria and fungi) can be as a result of aspiration of
normal bacterial flora and/ or gastric contents secretions and through inhalation of the virus

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 and bacteria. Pneumococcus (Streptococcus pneumoniae) is the most common cause of
bacterial pneumonia. Aspiration and gastric secretion delivers bacteria straight to the lungs
 Medications
 Conditions such as autoimmune diseases
It is most serious for infants and young children, people older than age 65, and people with
health problems or weakened immune systems.

Symptoms

The signs and symptoms of pneumonia are nonspecific and vary from mild to severe, depending
on factors such as the type of germ causing the infection, and your age and overall health. Mild
signs and symptoms often are similar to those of a cold or flu, but they last longer
 Fever
 Sweating and shaking chills
 Cough, with or without phlegm (sputum). The sputum may be rusty or green or tinged
with blood. Coughing is the immune response by the body
 Sneezing(pulmonary defense mechanism to guard against pneumonia)
 Chest pain when you breathe or cough
 Fast breathing and feeling short of breath.
 Fast heartbeat.
 Shaking and "teeth-chattering" chills.
 Fatigue
 Nausea, vomiting or diarrhea
 Purulent sputum( containing pus)
Newborns and infants may not show any sign of the infection. Or they may vomit, have a fever
(and cough, appear restless or tired and without energy, or have difficulty breathing and eating.

People older than age 65 and people in poor health or with a weakened immune system may
have a lower than normal body temperature. Older people who have pneumonia sometimes have
sudden changes in mental awareneness

For some older adults and people with heart failure or chronic lung problems, pneumonia can
quickly become a life-threatening condition.

Classification of pneumonia

Pneumonia is classified according to the types of germs that cause it and where you got the
infection.

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1. Community-acquired pneumonia
Community-acquired pneumonia is the most common type of pneumonia. It occurs outside of
hospitals or other health care facilities. It may be caused by:

Bacteria. The most common cause of bacterial pneumonia in the Streptococcus pneumonia This
type of pneumonia can occur on its own or after you've had a cold or the flu.
Mycoplasma pneumoniae also can cause pneumonia. It typically produces milder symptoms than
do other types of pneumonia.
Walking pneumonia, a term used to describe pneumonia that isn't severe enough to require bed
rest, may be caused by M. pneumoniae.

Viruses. Some of the viruses that cause colds and the flu can cause pneumonia. Viruses are the
most common cause of pneumonia in children younger than 5 years. Viral pneumonia is usually
mild. But in some cases it can become very serious.

Fungi. This type of pneumonia is most common in people with chronic health problems or
weakened immune systems, and in people who have inhaled large doses of the organisms. The
fungi that cause it can be found in soil or bird droppings.

2. Hospital-acquired pneumonia. Some people catch pneumonia during a hospital stay for
another illness. This type of pneumonia can be serious because the bacteria causing it may be
more resistant to antibiotics. People who are on breathing machines (ventilators), often used in
intensive care units, are at higher risk of this type of pneumonia.

3. Health care-acquired pneumonia. Health care-acquired pneumonia is a bacterial infection

that occurs in people who are living in long-term care facilities or have been treated in outpatient
clinics, including kidney dialysis centers. Like hospital-acquired pneumonia, health care-
acquired pneumonia can be caused by bacteria that are more resistant to antibiotics.

3. Aspiration pneumonia. Aspiration pneumonia occurs when food, drink or vomit passes into
your lungs causing infection.

Other types of pneumonia

 Pneumonia in an immune compromised host
 Ventilator associated pneumonia(VAP)

Risk Factors.

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Pneumonia can affect anyone. But the two age groups at highest risk are:
 Children who are 2 years old or younger
 People who are age 65 or older
Other risk factors include:
 Chronic disease. You're more likely to get pneumonia if you have asthma, lung diseases
such as cystic fibrosis, diabetes, heart failure, stroke
 Malnutrition-Weakened or suppressed immune system.
 People who have HIV/AIDS, who've had an organ transplant, or who receive
chemotherapy or long-term steroids are at risk.
 Smoking. Smoking damages your body's natural defenses against the bacteria and viruses
that cause pneumonia.
 Being hospitalized. You're at greater risk of pneumonia if you're in a hospital intensive
care unit, especially if you're on a machine that helps you breathe (a ventilator).
 Those with swallowing disorders
 Chest or upper abdominal surgery
 Preexisting lung disease
Complications
Pneumonia can be treated successfully with medication. However, some people, especially those
in high-risk groups, may experience complications, including:
 Bacteria in the bloodstream (bacteremia). Bacteria that enter the bloodstream from
your lungs can spread the infection to other organs, potentially causing organ failure.
 Lung abscess. An abscess occurs if pus forms in a cavity in the lung. An abscess is
usually treated with antibiotics. Sometimes, surgery or drainage with a long needle or
tube placed into the abscess is needed to remove the pus.
 Fluid accumulation around your lungs (pleural effusion). Pneumonia may cause fluid
to build up in the thin space between layers of tissue that line the lungs and chest cavity
(pleura). If the fluid becomes infected, you may need to have it drained through a chest
tube or removed with surgery.
 Difficulty breathing. If your pneumonia is severe or you have chronic underlying lung
diseases, you may have trouble breathing in enough oxygen. You may need to be
hospitalized and use a breathing machine (ventilator) while your lung heals.

Management
Medical therapy
 Use of antibiotics
Aims of nutrition therapy

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 i) To preserve lean body mass and immune function
ii) Prevent unintentional weight loss
iii) Maintain nutrition status

Dietary management
 Sufficient fluids (3 to 3.5 liters) if not contraindicated as much water is lost through sweat,
vomiting and diarrhea
 High energy diets because of increased metabolic needs as pneumonia comes with fever,
thus increased BMR. Eat high dense energy diet.You can also try to drink beverages that
are calorie-rich, such juices. Adding peanut butter or ice-cream to your fruits and cream
cheese, butter or olive oil to your vegetables adds calories.
 Small frequent meals because of nausea, vomiting and diarrhea
 Adequate proteins for building new tissues and fixing damaged tissues. Protein-rich
foods can come from both animal and plant sources. Animal sources of protein include
red meat, pork, poultry or fish. Plant-based protein comes from nuts and seeds, and
beans, soybeans
 Specific nutrients and the immune system: several nutrients have been linked to the
preservation and maintenance of immune function. Nutrients that have been identified
include vitamins A, E, and B6, zinc, copper, selenium, the amino acids glutamine and
arginine, and omega-3 fatty acids. These nutrients may play a key role in the immune
function, leading to less of a risk of developing pneumonia. Supplementation is not
warranted since there are no studies demonstrating a direct cause and effect relationship
with the incidence of pneumonia. However, it is recommended to increase consumption
of foods that are rich in these nutrients.
N/B. Tuberculosis is an important cause of pneumonia. There are clinical studies that have linked
pneumonia with poor oral health. Additionally, dental treatment and improvements in oral health
have been associated with significant reductions in respiratory diseases in institutionalized
elderly adults.

TOPIC: FEBRILE DISEASES

Unit Objectives
By the end of the unit the learner should be able to:
a) Explain the nutrition and metabolic implications of febrile conditions

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 b) Describe types, causes and management of febrile conditions
c) Plan and prepare meals for various hypothetical febrile condition patients
d) Visit a health facility to learn more about management of febrile conditions.

FEBRIBLE CONDITIONS

Febrile (fever) refers to conditions that results into high body temperature (fever). During fever, the
body temperature rise above the normal of 37oc.
Definition of terms

Hyperpyrexia

Hyperpyrexia is an extreme elevation of body temperature greater than or equal to 40.0 or

41.5 °C (104.0 or 106.7 °F). Such a high temperature is considered a medical emergency, as it
may indicate a serious underlying condition or lead to problems including permanent brain
damage, or death. Infections commonly associated with hyperpyrexia include roseola, measles

Hyperthermia

Hyperthermia is an example of a high temperature that is not a fever. It occurs from a number of
causes including heatstroke, cocaine and drug reactions

Fever

Fever also known as pyrexia is an increase of more than 1 degree Celsius or any rise above the
maximal normal temperature.

Temperature classification

Core (rectal, esophageal, etc.)

Hypothermia <35.0 °C (95.0 °F)

Normal 36.5–37.5 °C (97.7–99.5 °F)
Fever >37.5 or 38.3 °C (99.5 or 100.9 °F)
Hyperthermia >37.5 or 38.3 °C (99.5 or 100.9 °F)
Hyperpyrexia >40.0 or 41.0 °C (104.0 or 105.8 °F)

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Measurement of temperature can be done

 In the anus (rectum/rectal).It is the most accurate

 In the mouth (oral)
 Under the arm (axillary) or in the ear

FEVER

 It is an elevation of temperature above the normal and results from an imbalance

(difference) between the heat produce in the body and the heat eliminated from the body.

 The heat is produced as a natural response of the body, to destroy virus or pathogens in
the blood, by raising the body’s natural metabolic.
 Fever is a common symptom of many infections and chronic conditions(diseases)
 The normal body temperature varies from 36.5 degree Celsius – 37.5 degree Celsius
(average 37°C) and is regulated by hypothalamus
 There is normally a diurnal variation of 1 degree Celsius, the lowest temperature being
between 2-4 am and highest in the afternoon.

Therefore fever also known as pyrexia is an increase of more than 1 degree Celsius or any rise
above the maximal normal temperature.

N/B: all fevers are not as a result of infection, and elevation in body temperature is not fever e.g.
elevation in body temperature in heat stroke as the body is unable to eliminate heat.

Fever increases BMR approximately 7% for each 0.83°C(1°F)

Causes of fever

 Infections(Exogenous factors): Any infection whether bacterial, viral, fungal or parasitic

can give rise to fever-a fever is a symptom of a disease
 All fevers are not as a result of infection
Other causes
 Certain inflammatory conditions such as rheumatoid arthritis— inflammation of the
lining of your joints (synovium)
 Some medications, such as antibiotics and drugs used to treat high blood pressure or
seizures.
 Some immunizations, such as the diphtheria ,tetanus
 Endogenous factors: Antigen-antibody reaction can also result into fever
 Trauma; A massive crush injury may lead to pyrexia.

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Types of fevers: Typhoid Fever, Rheumatic Fever, Meningitis, Small pox, viral hepatitis
Influenza, Malaria, Measles, Chicken Pox, etc.

Classification of fever

It must be noted that following types of fever association are generally noted as classic
associations and overlap might occur.

Acute fever (short fever)

 They are of short duration but the temperature may rise very high to even 39.5.°C.Fevers
accompanying infections like chicken pox, Cold, tonsillitis, typhoid, influenza,
pneumonia, malaria, Chicken pox, scarlet fever
Chronic fever(Long fever)- last from several days to months
 This is a fever of long duration. Temperatures may remain low but fever continues for a
long period of time. It can take several months as in tuberculosis.even several
months e.g. T.B. The fever has a gradual start and is also low in severity

Continuous Fever

 The temperature remains above normal throughout the day and does not fluctuate more
than 1 degree Celsius in 24 hours. This type of fever occurs in pneumonia, typhoid,
urinary tract infection, brucellosis, etc.

Remittent Fever

 The temperature remains above normal throughout the day and fluctuates more than 2
degree Celsius in 24 hours. This type of fever is usually seen patients of typhoid
infection. This type of fever is most common in practice.

Intermittent Fever

 There is alternation of temperature. There is high temperature for a few some hours in a
day and then remains normal for the remaining hours e.g. malaria

Septic Fever

 The temperature variation between the highest temperature and lowest temperature is
very large and exceeds 5 degree Celsius. This type of fever occur in septicemia.

Symptoms of fever

 Rise in temperature of body heat

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  Sweating, Perspiration or Shivering. Sweating results into loss of fluids and electrolytes

 Restlessness and agitated temper

 Pain and soreness all over the body but some limbs may be extra painful and sore

 Thirst

 Loss of Appetite

 Catabolism

Benefits of Fever

Fever is associated with release of endogenous pyrogens, which activate the T cells and thus
enhance the host defense mechanism.

Complications of Fever

It induces a state of catabolism which is detrimental to body. It may also lead to fluid and
electrolyte imbalance-due to sweating and loss of minerals. High grade fevers can lead to
convulsions, brain damage, circulatory overload and arrhythmia.

Some of the metabolic changes that occur in fever include

 Increased BMR leading to increased metabolic rate .Increased BMR (13% increase in
Basal Metabolic rate) is due to the fever. Increased BMR results into increased demand
for nutrients
 Anorexia- leading to reduced nutrient intake
 Nausea and vomiting-leading to reduced nutrient intake
 Glycogen breakdown due to increase in energy expenditure- leading to weakness, fatigue
 Red cell destruction-leading to anemia
 Tissue protein catabolism-leading to wasting , muscle wasting
 Increased loss of water/fluids through perspiration/sweating and urination
 Increase in urine volume so as to remove excess nitrogenous wastes
 Loss of electrolytes such sodium, chloride and potassium through sweat, urine and
sometimes vomiting

N/B. These metabolic changes above takes place in all conditions leading to fever such as
tuberculosis, malaria, measles, chicken pox, small pox , typhoid, meningitis, rheumatic
fever etc.

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 Management

Medical: Medications such as ibuprofen or paracetamol (acetaminophen) to lower the

temperature

Dietary modification in fevers

Energy: Increased by 50% if the temperature is high and tissue damage is high can be able to
ingest 600-1200 kcal daily.
Carbohydrates: Glycogen stores are replenished by readily absorbable glucose
Protein: A high protein diet supplying 1.25-1.5g protein/kg body wt. should be fed. Protein
supplements can be incorporated in the beverages. A high protein is required because of
increased protein catabolism. Protein catabolism is especially marked in fevers such as typhoid,
malaria and TB. This depends on the severity and duration of the infection. Increased protein
catabolism leads to increased nitrogen wastes and places an additional burden on the kidneys.
Fats: Avoid fried foods. These foods are difficult to digest and also they may be associated with
excessive strain on the already poor gastro-intestinal system
Vitamins: All vitamins may be given as supplements to the patient. More so vitamin C which
helps enhance immunity and natural ability of the body to fight infection. Orange juice is a great
source of energy and is also loaded with Vitamin C. Avoid tinned or canned fruit juices as they
are loaded with preservatives and can delay the recovery process.

Increase intake of vitamin E

Minerals: Sufficient intake Of: Sodium, potassium should be given liberally.

Fluids: Since loss of body fluids through sweat, vomiting & excretory wastes is high (urine),
plenty of water and other fluids is important especially during fever. Water also helps to flush the
toxins out of the body system and hastens recovery.
Frequency. These feeding should be small & as frequent as possible. Generally, 6-8 feedings
should be sufficient
Foods to avoid: There are various foods to avoid when affected by fever.

 Do not consume red meat, as it is difficult to digest.

 Junk foods should be strictly avoided.
 You should also stay away from oily and high cholesterol foods
 Avoid cold foods like ice-creams.
 Carbonated drinks are a no-no.
 Alcohol and smoking should be completely avoided.

Conservative measures

 Some limited evidence supports sponging or bathing feverish children with tepid water
The use of a fan or air conditioning may somewhat reduce the temperature and increase

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 comfort.
 If the temperature reaches the extremely high level of hyperpyrexia, aggressive cooling is
required (generally produced mechanically via conduction by applying numerous ice
packs across most of the body or direct submersion in ice water)

CONDITIONS LEADING TO FEVER

Malaria

Malaria is a vector- borne disease specifically caused by a parasite known as plasmodium

malarie from an infected Anopheles mosquito(i.e the parasite is carried by female
anopheles mosquito). Malaria is the most significant parasitic disease of human beings and
remains a major cause of morbidity and mortality worldwide

It can cause growth failure, particularly young children and is a contributory factor to
malnutrition

Common symptoms of malaria

 Fever
 Chills
 Sweats
 Fatigue
 Nausea and vomiting
 Dry cough
 Muscle and/or back pain
 Enlarged spleen

Metabolic changes that occur/compilications/Nutritional implication of malaria

 Increased BMR leading to increased metabolic rate .Increased BMR (13% increase in
Basal Metabolic rate) is due to the fever. Increased BMR results into increased demand
for nutrients
 Anorexia- leading to reduced nutrient intake/malnutrition
 Nausea and vomiting-leading to reduced nutrient intake
 Glycogen breakdown due to increase in energy expenditure- leading to weakness, fatigue
 Red cell destruction-leading to anemia
 Tissue protein catabolism-leading to wasting , muscle wasting
 Increased loss of water/fluids through perspiration/sweating and urination
 Increase in urine volume so as to remove excess nitrogenous wastes
 Loss of electrolytes such sodium, chloride and potassium through sweat, urine and

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 sometimes vomiting
N/B. Among pregnant mothers, malaria can lead to low birth weight

N/B These metabolic changes above takes place in all conditions leading to fever such as
tuberculosis, malaria, measles, chicken pox, small pox , typhoid, meningitis, rheumatic
fever etc.

Nutritional Management

 High energy diet-Energy may be increased up to 50% based on the extent of fever, its
duration and associated weight loss
 High protein diet-Protein requirement increases by 25-505 above normal based on
weight loss. The protein should of high biological value. High protein beverages are
preferred to the regular solid meals
 Fat-Fat is needed to meet the increased energy needs. However, fat intake should be
cautiously planned considering palatability of diet and the patient’s tolerance. Fats in the
form of fried food should food should be avoided during malaria fever
 Increased B-complex vitamins in relation to increased energy needs.
 Increased iron due to malaria induced anemia and
 Increased vitamin A and C for immunity. Incorporate vitamin A rich foods such as
liver, milk, fruits (mangoes, papaya) and vegetables (carrots, tomatoes,
drumstick, amaranth, spinach, pumpkin
 Fluid-Adequate amount to maintain good hydration status, to compensate for the loss of
fluid through sweating and to help bring down the body temperature. Also, frequent
vomiting in malarial fever causes dehydration.
 Zinc: Zinc deficient individuals are also more likely to get malarial infection. Foods rich
in zinc are oysters, meat, poultry, beans, nuts, certain types of seafood (such as crab and
lobster), whole grains, fortified breakfast cereals, and dairy products.
 Frequency- small frequent meals at an interval of about 2 hours (initially)

Medical therapy to kill the microorganism

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Rheumatic Fever

 Rheumatic fever is caused by a reaction to the bacteria that causes strep throat, group
A streptococcus (a bacteria that causes strep throat). Although not all cases of strep throat
result in rheumatic fever, this serious complication may be prevented with diagnosis and
treatment of strep throat.
 Rheumatic fever causes your body to attack its own tissues after it’s been infected with
the bacteria that causes strep throat. It is an inflammatory disorder as this reaction causes
widespread inflammation throughout your body, which is the basis for all of the
symptoms of rheumatic fever.
 The condition usually appears in children between the ages of 5 and 15, even though
older children and adults have been known to contract the fever as well. It’s still common
in places like sub-Saharan Africa, south central Asia, and certain populations in Australia
and New Zealand.

Symptoms

Symptoms usually appear two to four weeks after your child has been diagnosed with strep
throat. If your child has any of the following symptoms, they should get a strep test: Common
symptoms of strep throat include:

 a sore throat
 a sore throat with tender and swollen lymph nodes
 a red rash
 difficulty swallowing
 thick, bloody discharge from nose
 a temperature of 101°F or above
 tonsils that are red and swollen
 tonsils with white patches or pus
 small, red spots on the roof of their mouth
 a headache/fever
 nausea
 vomiting
 sweating
 nosebleeds outbursts of crying or inappropriate laughter
 chest pain
 rapid fluttering or pounding chest palpitations

If your child has a fever, they might require immediate care. You should seek immediate medical
care for your child in the following situations:

 a temperature over 100°F in newborns to 6-week-old infants

 a temperature of 102°F or higher in babies 6 weeks to 2 years old
 a temperature of 103°F or higher in children age 2 years or older

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  a fever that lasts more than three days in a child of any age

Risk Factors for Rheumatic Fever

Factors that increase your child’s chances of developing rheumatic fever include:

 a family history because certain genes make you more likely to develop rheumatic fever
 the type of strep bacteria present because certain strains are more likely to lead to
rheumatic fever than others
 environmental factors present in developing countries, such as poor sanitation,
overcrowding, and a lack of clean water

How to Prevent Rheumatic Fever

The most effective way to make sure that your child doesn’t develop rheumatic fever is to treat
their strep throat infection quickly and thoroughly. This means making sure your child completes
all prescribed doses of medication.

Practicing proper hygiene methods can help prevent strep throat. These include:

 covering your mouth when coughing or sneezing

 washing your hands
 avoiding contact with people who are sick
 avoiding sharing personal items with people who are sick

Effective Treatments for Rheumatic Fever

Treatment will involve getting rid of all of the residual group A strep bacteria and treating and
controlling the symptoms. This can include any of the following:

 Antibiotics
 Anti-Inflammatory Treatment
 Bed Rest

Complications Associated with Rheumatic Fever

Rheumatic fever is relatively a serious illness that can cause long term complications such as
stroke, permanent damage to the heart and death if it is left untreated. One of the most prevalent
complications is rheumatic heart disease. Other heart conditions include:

 valve stenosis, which is a narrowing of a valve

 valve regurgitation, which is a leak in the valve that causes blood to flow in the wrong
direction
 heart muscle damage, which is an inflammation that can weaken the heart muscle and
decrease the heart’s ability to pump blood effectively
 atrial fibrillation, which is an irregular heart beat in the upper chambers of the heart

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  heart failure, which happens when the heart can no longer pump blood to all parts of the
body

Tuberculosis
 Etiology (cause)-It is an infection of the lungs caused by mycobacterium tuberculosis
(bacillus mycobacterium). It is an air bone disease characterized by the growth of nodules
(tubercles) and spread mostly in overcrowded area. It is one of the world’s more wide spread
and deadly diseases
 It mostly occurs in the lungs, however it may occur in other organs like bones, kidney, spine,
brain etc. When it primarily affects the lungs, it is referred to as pulmonary tuberculosis.
Pulmonary tuberculosis is the most common form of tuberculosis in Kenya
 Tuberculosis is an infectious disease and it is more contagious than pneumonia and is spread
from one person to another through tiny droplets released into air via coughs, spits, laughs,
sings and sneeze( It is an airborne disease)
 It occurs mostly among the disadvantaged populations such as the malnourished and those
living in overcrowded area and substandard housing
 It is on the increase in developing countries partly because of the HIV, the virus that causes
AIDS.HIV weakens a person’s immune system so it cannot fight the TB germs. As a result,
people with HIV are many times more likely to get TB and to progress from latent to active
disease than are people who are not HIV positive.
 Another reason why TB remains a major killer is the increase in drug resistant strains of the
bacterium. Some germs have developed the ability to survive and that ability is passed to
their descendants.
 Drug resistant strains of tuberculosis emerge when antibiotic e.g rifampin, isoniazid and
injectable medications including amikacin, kanamycin, and capreomyacin fails to kill all of
the bacteria it targets

Stages of TB.
There are two stages of TB
1. Latent TB/Inactive TB: In this condition, you have a TB, but the bacteria remain in your
body in an inactive state and cause no symptoms. It is not contagious in this stage. It can turn
into active TB if untreated. An estimated 2 billion people have latent TB
2. Active TB: This condition makes you sick and can spread to others. It can occur in the first
few weeks after infection with TB bacteria or it might occur years later. The acute phase
resembles pneumonia with high fever and increased circulation and respiration

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Symptoms
Symptoms differs depending on the stage of TB infection
o Anorexia
o Fever and night sweat which increases calorie requirement(10% extra calorie per every 10
rise in body temperature)- i.e. if febrile, patients will be hypermetabolic
o Malaise( a feeling of weakness , illness, pain , uneasiness or simply not feeling well)
o Night sweats
o Weight loss( patients appear chronically ill and malnourished)
o Chronic cough lasting 2 weeks or more (Chronic cough is the most universal pulmonary
symptom). It may be dry at first but becomes productive of sputum as the disease progresses.
More often than not , the sputum is blood steaked
o Chest pain
o Fatigue
o Enlarged lymph nodes which increases protein and micronutrients requirements for tissue
repair
o Blood in the urine as a result of TB of the kidney or blood in the sputum resulting into loss of
blood that may predispose clients to anemia
Risk factors
 A healthy immune system often successfully fights TB bacteria. A number of diseases and
medications can weaken your immune system , including
 HIV/AIDS
 Diabetes
 Certain cancers
 Cancer treatment such as chemotherapy
 Malnutrition
 Very young or advanced age
 Tobacco use
Complications: Without treatment, tuberculosis can be fatal. Untreated active disease
typically affects your lungs, but it can spread to other parts of the body through the blood stream.
Examples of complications are
 Spinal injury

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  Joint damage (Tuberculosis arthritis that usually affects the hips and the knees)
 Meningitis (Swelling of the membranes that cover your brain)-this my result into mental
impairment
 Kidney/ liver problems
 Heart disorders
Tests and diagnosis
 Physical exam test using stethoscope to check for the swelling of lymph nodes
 Skin test-It is not very accurate
 Blood test-.Requires sophisticated technology
 Imaging test-chest x-ray or a CT scan that may show white sports in your lungs where
immune system has walled off TB bacteria. CT scan is more accurate
 Sputum test( mucus that comes with the cough).Sputum test is also used to test for drug
resistant strains of bacteria
Nutrition implications of TB

 Reduced protein synthesis and metabolism

 Reduced immunity
 Reduced food and nutrient intake
 Increased nutrient requirements
Objectives of Nutrition care and management of TB

 Achieve and maintain good nutrition status i.e. Maintain weight and prevent weight loss
 Prevent and control body wasting and weakness
 Correct nutritional deficiencies
 Accelerate healing process
 Control symptoms and prevent associated complications
Management
Dietary management
 Energy. Most patients with chronic tuberculosis are undernourished and underweight. Energy
needs are increased to minimize weight loss and achieve a desirable weight, to facilitate
tissue regeneration and to spare the protein. An additional 300-500kcals (35-40kcals/kg of

pg. 42 by Osonga
 ideal body weight above normal intake) is recommended. High energy diet is also needed
when the patient is hypermetabollic to meet high metabolic demands and to minimize weight
loos
 Adequate protein (2-3.5 kg per body weight) of high biological value to regenerate serum
albumin levels. serum albumin level is often very low due to tissue wasting and repair of
worn out tissues

 Adequate amounts of calcium e.g. from milk and milk products (to promote healing of
tuberculin lesions), iron, and B-complex. Patients on isoniazid should be supplemented with
B6 since the drug inhibit its absorption complex are obtained mostly from whole grain
cereals, pulses, nuts, seeds, eggs, fish and chicken
 Vitamin A. Patient should be supplemented with vitamin A as conversion of beta carotene to
retinal is affected in the intestinal mucosa of TB patients
 Vitamin C for wound healing
 Antioxidants( vitamin A, C, E, folic acid, zinc and selenium) to neutralize free radicals
(ROS) and prevent the production of peroxides from lipids
 A liberal amount of Ca should be included in the diet to promote the healing of TB lesions.
Some amount of milk should be included in the diet daily.
 Iron supplement may be necessary if the patient suffers from hemorrhages
 Carbohydrates-60 to 65% energy requirements should be from the carbohydrates
 Fats-25 to 30% energy requirements should be from fats
 Water. At least 8 glasses of water( 250 ml) or more of safe drinking water per day to reduce
dehydration rate
N/B Patients who have TB have low circulating concentrations of micronutrients such as
vitamin A, E, and D and the minerals iron, zinc and selenium

N/B 2. Undernutrition in TB patients lowers the immunity

Medical therapy
 Use of drugs
 Medication side effects. Nausea, vomiting, loss of appetite, a yellow colour to your
skin(jaundice), abdominal discomfort, interferes with B6 utilization, dark urine and fever,
taste changes
 Most of the drugs used interact with some nutrients
Vaccination

pg. 43 by Osonga
Vaccinating children with BCG (Bacille Calmette –Guerin) vaccine. It is not effective in adults
Other remedies
 Adequate ventilation,
 Cover your mouth when sneezing o coughing when infected with the disease
 Wear a mask when attending to TB patients

Typhoid

 Typhoid fever is an infectious diseases caused by Salmonella typhi

 Most cases of typhoid fever are seen in those aged 3–19 years but it can affect all age
groups and humans are the only natural host and reservoir.
 The infection is transmitted by ingestion of faecally contaminated food milk or water.
The highest incidence occurs where water supplies serving a large population are faecally
contaminated.
 The incubation period is usually 8–14 days, but may range from 3 days up to 2 months.
 Some 2–5% of infected people become chronic carriers who harbour S.typhi in the gall
bladder.
 Patients infected with HIV are at a significantly increased risk of severe disease due to S.
typhi and S. paratyphi.

Susceptibility is general.
 Susceptibility is increased in individuals with gastric achlorhydia (deficiency of HCL in
the stomach e.g. patient with anemia and cancer of the stomach) and HIV positive people.

Mode(s) of Transmission
 Mode of transmission is person-to-person, usually via the faecal-oral route. Faecally
contaminated drinking water is a commonly identified vehicle.
 S. typhi may also be found in urine and vomitus and, in some situations, these could
contaminate food or water.
 Flies can mechanically transfer the organism to food, where the bacteria then multiply to
achieve an infective dose.
Symptoms;
 Nausea  Headache
 Vomiting  Weight loss
 Anorexia
 Diarrhoea
 Sweating

pg. 44 by Osonga
DIET THERAPY OSONGA

Body changes in typhoid

 Loss of tissue protein which may amount to as much as 250-500g of muscle tissue a day
 Body stores of glycogen are quickly depleted and the water and electrolyte balance is
disturbed
 Inflammation and irritation of the intestinal tract. Diarrhoea is therefore a frequent
complication which interferes with absorption of nutrients
 Ulceration in the intestine may be so severe that hemorrhage and eve perforation of the
intestine may occur

Management
Objectives of nutrition management;
 To maintain adequate nutrition
 To restore positive nitrogen balance
 To provide relief from symptoms
 To correct and maintain water and electrolyte balance
 To avoid irritation of the intestinal tract.
Management
 Medical therapy-Antibiotics
 Keeping the patient warm
 Rest in bed
 A modified diet
A modified diet:
Objective of nutrition therapy
 To maintain adequate nutrition
 To restore positive nitrogen balance
 To provide positive relief from symptoms
 To correct and maintain water and electrolyte balance
 To avoid irritation of intestinal tract

Nutrition therapy
 High energy diet-the BMR may increase as high as 50% due to increase in body
temperature and also restlessness which increase energy expenditure.
Increase energy by 10%-20%. Initially during the acute stage, 600-1200kcals may be
consumed per day, this energy intake should be increased gradually with recovery and
improved tolerance.

 High protein diet-requirements of proteins are related the severity and duration of
infection rather than on the height of the fever.

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There is an excessive destruction of tissues, protein intake should be increased to between

1.5 to2g/ideal body weight/day. Proteins of high biological value should be used e.g. soya
beans, milk, fish, meat and chicken to minimize tissue loss. Meals should be
supplemented with high protein beverages e.g. milk shakes.
 Carbohydrate-A provide liberal carbohydrates to replenish glycogen stores. Well
cooked, easily digestible carbohydrate like simple starches, glucose, honey, sugar cane
etc. should be included because they require less digestion and well assimilated

 Dietary fiber- as the symptoms of fever include diarrhoea and lesions in the
intestinal tract, all hash irritating fiber and other forms of irritants should be eliminated
 Fats-Fats are needed mainly to increase the energy intake.
 However due to diarrhea, fats only in the emulsified form like cream, butter,
whole milk, egg, yolk should be included in the diet because they are easily
digested and well tolerated by patients.
 Limit fats as they may aggravate nausea; avoid fried foods.
 Fried foods which are difficult to digest should be avoided

 Minerals-There is excessive loos of electrolytes like sodium ion, potassium and chloride
due to increased perspiration. Salty soups, broths, fruit juices, milk etc. should be
included to compensate for the loss of electrolytes
 Vitamins
 Increased vitamin A and C for immunity and formation of collagen
 Increase vitamin B complex because of increased need for energy. The use of
antibiotics and drugs interfere with intestinal bacteria synthesis of some B
vitamins so vitamins B supplementation may have to be given for sometime.

 Fluid-increased fluid for rehydration of the body. A daily intake of 2.5 -5 liters is
desirable. They may be included in the form of beverages, soups, juices, plain etc.

Smallpox

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 Smallpox was an infectious/contagious deadly disease caused by either of two virus ,

Variola major and Variola minor. There is no cure for small pox and the last naturally
occurring case of smallpox (Variola minor) was diagnosed on 26 October 1977 in
Somalia and in 1949 in United States. Due to worldwide vaccination programs, this
disease has been completely eradicated.
 By 1980, the WHO declared that smallpox had been completely eradicated, although
government and health agencies still have stashes of smallpox virus for research
purposes.
 People no longer receive routine smallpox vaccinations. The smallpox vaccine can have
potentially fatal side effects, so only the people who are at high risk of exposure get the
vaccine.

Signs and symptoms

Historical accounts show that when someone was infected with the smallpox virus (inhale the
virus), they had no symptoms for between seven and 17 days. However, once the incubation
period (or virus development phase) was over, the following flu-like symptoms occurred:

 high fever
 chills
 headache
 severe back pain
 abdominal pain
 vomiting

These symptoms would go away within two to three days. Then the patient would feel better.
However, just as the patient started to feel better, a rash/characteristic pimples would appear. The
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rash started on the face and then spread to the hands, forearms, and the main part of the body.
The person would be highly contagious until the rash disappeared.

Within two days of appearance, the rash would develop into abscesses that filled with fluid and
pus (blisters will develop). The abscesses would break open and scab over. The scabs would
eventually fall off, leaving pit mark scars. Until the scabs fell off, the person remained
contagious.

Transmission

 Coughing, sneezing, or direct contact with any bodily fluids could spread the smallpox
virus,
 Sharing of contaminated clothing or bedding
 It is also transmitted from one person to another primarily through prolonged face-to-face
contact with an infected person, usually within a distance of 6 feet (1.8 m),
 The virus can cross the placenta, but the incidence of congenital smallpox is relatively
low.

Treatment and prevention for Smallpox

 There is no cure for the smallpox virus. As a result of worldwide, repeated vaccination
programs, the variola virus (smallpox) has been completely eradicated. The only people
considered to be at risk for smallpox are researchers who work with it in a laboratory
setting.

Chickenpox

 Chickenpox, also called varicella, is a viral disease characterized by itchy red blisters that
appear all over the body. It often affects children, and was so common it was considered
a childhood rite of passage.
 It’s very rare to have the chickenpox infection more than once. And since the chickenpox
vaccine was introduced in the mid-1990s, cases have declined.

Causes

 It is caused by varicella-zoster virus (VZV).

Symptoms

It begins with the non-rash symptoms that may last a few days and include:

 fever
 headache
 loss of appetite

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One or two days after you experience these symptoms, an itchy rush will begin to develop. The
rash goes through three phases before you recover. These include:

 You develop red or pink bumps all over your body.

 The bumps become blisters filled with fluid that leaks.
 The bumps become crusty, scab over, and begin to heal.

-The bumps on your body will not all be in the same phase at the same time. New bumps will
continuously appear throughout your infection. The rash may be very itchy, especially before it
scabs over with a crust.

N/B. You are still contagious until all the blisters on your body have scabbed over. The crusty
scabbed areas eventually fall off. It takes seven to 14 days to disappear completely.

An itchy rash is the most common symptom of chickenpox.

Transmission

Most cases occur through contact with an infected person. The virus is very contagious and can
spread through:

 Direct contact with saliva

 Through air by coughing and sneezing.
 Direct contact with fluid from the blisters

Prevention

 Vaccination
 A child with chickenpox should stay home and rest until the rash is gone and all blisters
have dried, usually about 1 week.
 Pregnant women, newborns, or anyone with a weakened immune system (for instance,
from cancer treatments like chemotherapy or steroids) who gets chickenpox should see a
doctor right away.

Difference between small pox and chicken pox

Chickenpox was commonly confused with smallpox in the immediate post-eradication era.

 Unlike smallpox, chickenpox does not usually affect the palms and soles.
 Additionally, chickenpox pustules are of varying size due to variations in the timing of
pustule eruption: smallpox pustules are all very nearly the same size since the viral effect
progresses more uniformly.
 In contrast to the rash in smallpox, the rash in chickenpox occurs mostly on the torso,
spreading less to the limbs.
 A variety of laboratory methods are available for detecting chickenpox in evaluation of
suspected smallpox cases
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Meningitis

 Meningitis is an acute inflammation (swelling) of the protective membranes (meninges)

covering the brain and spinal cord. A bacterial or viral infection of the fluid surrounding
the brain and spinal cord usually causes the swelling.

Cause

 The infection by viruses, bacteria, or other microorganisms, and less commonly by

certain drugs. However, injuries and cancer can also cause meningitis.

Symptoms

The most common symptoms are

 Sudden high fever

 headache
 Inability to tolerate light or loud noises.
 Stiff neck
 Severe headache that seems different than normal
 Headache with nausea or vomiting
 Confusion or difficulty concentrating
 Seizure
 Sleepiness or difficulty waking
 No appetite or thirst

Signs in newborns

Newborns and infants may show these signs:

 High fever
 Constant crying
 Excessive sleepiness or irritability
 Inactivity or sluggishness
 Poor feeding
 A bulge in the soft spot on top of a baby's head (fontanel)
 Stiffness in a baby's body and neck

Infants with meningitis may be difficult to comfort, and may even cry harder when held

Meningitis can be life-threatening because of the inflammation's proximity to the brain and
spinal cord; therefore, the condition is classified as a medical emergency.
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Prevention and treatment

 Immunization-Some forms of meningitis are preventable by immunization

 Giving antibiotics to people with significant exposure to certain types of meningitis may
also be useful
 The first treatment in acute meningitis consists of promptly giving antibiotics and
sometimes antiviral drugs

Complications

 Meningitis can lead to serious long-term consequences such as deafness, inflammation or

swelling of brain which may result into seizures/epilepsy, internal bleeding of the blood
vessels, hydrocephalus, or cognitive deficits, especially if not treated quickly.

Measles

 Measles, also called rubeola, is a highly contagious respiratory infection that is caused
by a measles virus.
 It causes a total-body skin rash and flu-like symptoms, including a fever, cough, and
runny nose.
 Since measles is caused by a virus, there is no specific medical treatment for it and the
virus has to run its course. But a child who is sick should drink plenty of fluids, get lots
of rest, and be kept from spreading the infection to others.

Signs and Symptoms

 Fever
 Cough
 Runny nose
 Conjunctivitis (pink eye)
 Children who get the disease may develop tiny white spots inside the mouth or small red
sports with blue-white centers in the mouth
 Eventually full body rash

The measles rash breaks out 3-5 days after symptoms start, and can coincide with high fevers up
to 104°F (40°C). The red or reddish-brown rash usually first shows up as flat red spots on the
forehead. It spreads to the rest of the face, then down the neck and torso to the arms, legs, and
feet. The fever and rash gradually go away after a few days.

Contagiousness

 Measles is highly contagious — 90% of people who haven't been vaccinated for measles
will get it if they are near an infected person.

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 Measles spreads when people breathe in or have direct contact with virus-infected fluid,
such as the droplets sprayed into the air when someone with measles sneezes or coughs.
A person who is exposed to the virus might not show symptoms until 8-10 days later.
 Those with weakened immune systems due to other conditions (like HIV and AIDS) may
be contagious until they recover from measles.

Prevention

There is no treatment for measles, but the measles-mumps-rubella (MMR) vaccine can prevent
it.

TOPIC: CONDITIONS LEADING TO SEVERE STRESS-STARVATION, BURNS,

SURGERY, LOW BIRTH WEIGHT AND ICU

CONDITIONS LEADING TO METABOLIC STRESS: SEPSIS, STARVATION,

TRAUMA, BURNS AND SURGERY

INTRODUCTION

Conditions that can cause stress and result in hyper metabolic state are

 Sepsis
 Trauma e.g. wound, motor vehicle accidents, gunshots
 Burns
 Surgery
 Cancer
 Hypoxic injuries such as acute renal failure, necrosis of tissue such as gangrene
 Severe inflammation such as pancreatitis

Conditions that can cause stress and result in hypo metabolic state are
 Starvation
 Fasting

Definition of terms

Glutamine – A major fuel source for rapidly dividing cells such as lymphocytes. It is the
preferential fuel in the gut mucosa (for gut metabaolism), especially during stress;

Growth hormone –Realized from the anterior pituitary gland. It is thought to accelerate growth
in children and improve protein synthesis in injured patients. Oppose the actions of insulin

Cytokines – pro-inflammatory proteins released by cells of the immune system that serves to
regulate the immune system e.g. macrophages that act as mediators of shock and in sepsis;
examples include tumor necrosis factor, interleukin- 1, and interleukin-6
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Multiple organ dysfunction syndrome (MODS) - organ dysfunction that results from direct
injury trauma, or disease or as a response to inflammation;

Sepsis(infection) – the systemic response to an infectious agent. Sepsis occurs when chemicals
released into the blood stream to fight the infection trigger inflammatory responses throughout
the body. This changes can damage multiple organ systems, causing them to fail. If sepsis
progress to septic shock, blood pressure drops dramatically which may lead to death. It is more
common in older people and or those with week immunity

Shock – sudden disturbance of mental equilibrium; characterized by failure of the circulatory

system to maintain adequate perfusion of vital organs. It is critical (life threatening) condition as
the circulatory system fails to maintain the adequate blood flow to vital organs, sharply curtailing
the delivery of oxygen and nutrients to vital organs

Stress

 Stress refers to a reaction or a response by an organism to stimulus events that disturb its
equilibrium (homeostasis). Normally, the human body operates in a state of homeostasis
(metabolic equilibrium) and the balance is upset when the body is under stress.
 Some of the stimulus events (stress factors) that upset homeostasis are critical illness,
traumatic injury, sepsis, burns, starvation, accidents, gunshots or major surgery. The
metabolic response to stress is complex and involves most metabolic pathways. This state
is characterized by an accelerated catabolism of lean body or skeletal mass that clinically
results in negative nitrogen balance and muscle wasting. Starvation also results into
increased catabolism of lean body tissues
 The body constantly responds to these changes to maintain homeostasis
Trauma- trauma refers to a massive crush, injury or damage to the body e.g. accident, burns,
sepsis, surgery, starvation, critical illness etc. These conditions (traumas) can lead to mild or
severe metabolic stress

Types of stress
Physical or physiological

They normally originate from disease or physical injury

Physiological stress Occurs in many hospitalized patients as a consequence of infection, fever,

surgery, burns or other trauma. Many patients are unable to meet the increased needs imposed by
stress. Compromised nutritional status has been shown increase susceptibility to infections,
prolonged hospital stay and increased mortality rate.

Psychological or sociological stress

 Normally represented by emotional threshold or economic burden

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 The metabolism effects during stress differs with that during starvation or fasting.

N/B. Some stress result into hypometabolisn e.g starvation while others result into
hypermetabolism e.g. surgery, burns, accidents, gunshots, critical illness, sepsis e.tc

METABOLIC RESPONSE TO SEVERE STRESS THAT RESULTS INTO

HYPO METABOLISM- STARVATION
Starvation- Starvation is the period one involuntarily goes without food or the period when the
nutrients in the body are below the metabolic needs while fasting or dieting is where people
withhold food from themselves, such as when they try to lose weight.

Whatever the cause of inadequate food intake and nourishment (starvation or fasting), results are
the same.

The body extracts stored carbohydrate, fat, and protein (from muscles and organs) to meet
energy demands.

 Liver glycogen is used to maintain normal blood glucose levels to provide energy for
cells. Although readily available, this source of energy is limited, and glycogen stores are
usually depleted after 8 to 12 hours of fasting.
 As the glucose stores (glycogen) decreases, lipid (triglyceride) stores may be substantial,
and the body begins to mobilize free fatty acids from adipose tissue to provide needed
energy to the body. After approximately 24 hours without energy intake (especially
carbohydrates), the prime source of glucose is from gluconeogenesis substrates.
Gluconeogenesis - is a metabolic pathway that results in the generation of glucose
from certain non-carbohydrate carbon).Energy from fat > 90%, energy from protein <
10 %

 Some body cells, brain cells in particular, use mainly glucose for energy. During early
starvation (about 2 to 3 days of starvation), the brain uses glucose produced from muscle
protein. As muscle protein is broken down for energy, the level of branched-chain
amino acids (BCAA -. leucine, isoleucine, and valine) in circulation increases although
they are primarily metabolized directly inside muscle.
The body does not store any amino acids as it does glucose and triglycerides; therefore,
the only sources of amino acids are lean body mass (muscle tissue), vital organs
including heart muscle, or other protein-based body constituents such as enzymes,
hormones, immune system components, or blood proteins. By the second or third day of
starvation, approximately 75 g of muscle protein can be catabolized daily, a level
inadequate to supply full energy needs of the brain.

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At this point, other sources of energy become more available. Fatty acids are hydrolyzed
from the glycerol backbone and both free fatty acids and glycerol are released into the
bloodstream. Free fatty acids are used, while glycerol can be used by the liver to generate
glucose via the process of gluconeogenesis.
 As starvation is prolonged, the body preserves proteins by mobilizing more and more fat
for energy. Ketone body production from fatty acids is accelerated, and the body’s
requirement for glucose decreases. Although some glucose is still vital for brain cells and
red blood corpuscles, these and other body tissues obtain the major proportion of their
energy from ketone bodies. Muscle protein is still being catabolized but at a much lower
rate, which prolongs survival. During this period of starvation, approximately 60% of the
body’s energy is provided by metabolism of fat to carbon dioxide, 10% from metabolism
of free fatty acids to ketone bodies, and 25% from metabolism of ketone bodies
 An additional defense mechanism of the body to conserve energy is to slow its metabolic
rate (metabolic rate decreases by 20-25kcals/kg/day) thereby decreasing energy needs.
As a result of declining metabolic rate, body temperature drops, activity level
decreases, and sleep periods increase—all to allow the body to preserve energy
sources.
If starvation continues, intercostal muscles necessary for respiration are lost, which may
lead to pneumonia and respiratory failure. Starvation will continue until adipose stores
are exhausted

N/B 1: The response therefore in chronic starvation is conservatory aimed at adopting to preserve
the lean body mass.
N/B 2. During starvation there is decrease in metabolic rate while in severe stress e.g. in burns,
gunshot, surgery, critical illness and sepsis there is increase in metabolic rate

METABOLIC RESPONSE TO SERVERE STRESS THAT RESULT

INTO HYPER METABOLIC STATE (BURNS, SURGERY, CRITICAL
ILLNESS, ACCIDENTS, SEPSIS)
 Whether stress is accidental (e.g., from broken bones or burns) or necessary (e.g., from
surgery), or as a result of an infection(sepsis) or due to critical illness, the body reacts to
these stresses much as it does to the stress of starvation— with a major difference.
 During starvation, the body’s metabolic rate slows, becoming hypometabolic. During
burns, surgery, sepsis, cancer, trauma and accidents, the body’s metabolic rate rises
profoundly, thus becoming hypermetabolic.
The response to critical illness, injury (burns), major surgery and sepsis characteristically
involves:

i. Ebb

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ii. Flow phases

Ebb phase

The ebb phase, or early phase begins immediately after the injury. The aim of the ebb phase is to
conserve energy. Characteristics of the ebb phase/early phase.

 Decreased Oxygen Consumption

 Hypothermia (Lowered Body Temperature)
 Hypovolemia (A Decreased Volume Of Circulating Blood In The Body)
 Shock (Low Blood Perfusion To Tissues)
 Decreased Cardiac Output
 Vascular constriction
 Decrease in production of digestive enzyme
 Decrease urine production
 Insulin levels drop because glucagon is elevated (increased), most likely as a signal to
increase hepatic glucose production.
 Decrease in metabolic needs

The major medical concern during this time is to maintain cardiovascular effectiveness and
tissue perfusion

Flow phase: “It brings hyper-metabolism”

Characteristics of the flow phase

 Increased cardiac output- Increased cardiac work immediately after a burn, because of
low amount of blood in the body
 Increase myocardial oxygen consumption,
 Increase body temperature (hyperthermia),
 Increase energy expenditure(increased metabolic rate)
 Increase protein breakdown- Muscle protein degradation (breakdown) becomes a
necessary and large source of energy-(protein is degraded much faster than it is
synthesized).This leads to loss of lean body mass and increased immune dysfunction
(Increased risk for infection)
 Increase nitrogen excretion/loss
 Liver dysfunction (the liver increases in size to help in removing the increased nitrogen
rates)
 Increased catabolism- causing the rapid breakdown of energy reserves to provide glucose.
This is because of increased energy need due to hypermetabolism and increased catabolic
hormones(glucagon and cortisol)

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 Changes in glucose metabolism-Elevated circulating levels of catecholamine, glucagon,

cortisol and gluconeogenic hormones in response to severe thermal injury propagate
(results into) inefficient glucose production in the liver.
 Sex hormones and growth levels decrease around 3 weeks post burn. This results in
growth retardation
 Decrease in protein synthesis
 Increase in gluconeogesis-increase in glucose production
 Increase in cytokines
 Increase in basal metabolic rate(increase in energy expenditure)
The flow stage lasts for days, weeks, or months until the injury is healed

Hormonal changes and Cell Mediated Response towards stress

 Metabolic stress is associated with an altered hormonal state that results in an increased
flow of substrate but poor use of carbohydrate, protein, fat, and oxygen
 Counter-regulatory hormones, which are elevated after injury and sepsis, play a role in
the accelerated proteolysis that characteristically is seen.
Glucagon promotes gluconeogenesis, amino acid uptake, ureagenesis and protein catabolism.
Cortisol, which is released from the adrenal cortex in response to stimulation by
adrenocorticotropic hormone secreted by the anterior pituitary gland, enhances skeletal muscle
catabolism and promotes hepatic use of amino acids for gluconeogenesis, glycogenolysis, and
acute-phase protein synthesis.

 After injury or sepsis, energy production becomes increasingly protein-dependent.

Branched-chain amino acids (leucine, isoleucine, and valine) are oxidized from skeletal
muscle as a source of nitrogen, energy for the muscle, and carbon skeletons for the
glucose-alanine cycle and muscle glutamine synthesis.
 Lipid metabolism is also altered in stress and sepsis. Increased circulation of free fatty
acids is thought to result from increased lipolysis caused by elevated catecholamines and
cortisol, as well as a marked elevation in the ratio of glucagon to insulin. The free fatty
acids can be oxidized and used to form ketones, which provide energy to non-glucose
dependent tissues, or to resynthesize triglycerides.
 There is notable hyperglycemia observed during stress. This initially results from a
marked increase in glucose production and uptake secondary to gluconeogenesis and
elevated levels of hormones, including epinephrine, that diminish insulin release. Stress
also initiates the release of aldosterone, a corticosteroid that causes renal sodium
retention, and vasopressin (antidiuretic hormone), which stimulates renal tubular water
resorption. The action of these hormones results in conservation of water and salt and
support of the circulating blood volume (See table below)
N/B. During starvation we burn more fat and during severe stress, we burn more protein

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Summary of the affected organ and the metabolic Response

Organ Response

Liver ↑Glucose production

↑Amino acid uptake

↑Acute-phase protein synthesis

↑Trace metal sequestration

Central Nervous System Anorexia

Fever

↑Glucose

↑Triglycerides

↑Amino acids

↑Urea

↓Iron

↓Zinc

Skeletal muscle ↑amino acid uptake from both luminal and circulating sources,
leading to gut mucosal atrophy (wasted away-degeneration of
cells)

Endocrine ↑Adrenocorticotropic hormone

↑Corticosol

↑Growth hormone

↑Epinephrine

↑Norepinephrine

↑Glucagon

↑Insulin

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Effects of the hormones during Stress*

Target Organ Hormonal Physiologic Response Signs/Symptoms

Response
Sympathetic Norepinephri Vasoconstriction Pallor, decreased glomerular
nervous system ne filtration rate, nausea,
and adrenal elevated blood pressure
medulla
Adrenal medulla Epinephrine Vasoconstriction Pallor, decreased glomerular
filtration rate, nausea,
elevated blood pressure
Increased heart rate Elevated blood pressure

Vasodilation Increased skeletal muscle

function
Central nervous system More alert, increased muscle
(CNS) stimulation tone
Bronchodilation Increased O2
Glycogenolysis, Increased blood glucose
lipolysis,
gluconeogenesis
Adrenal pituitary Cortisol CNS stimulation Increased blood glucose,
and cortex (glucocorticoi increased serum
ds)
Protein catabolism, amino acids, delayed wound
gluconeogenesis healing
Stabilize cardiovascular Enhance catecholamine action
system
Gastric secretion Ulcers

Inflammatory response Decreased white blood cells

decreased (WBCs)
Allergic response
decreased
Immune response
decreased
Aldosterone Retain sodium and water,
(mineralocor increased blood volume,
ticoid) increased blood pressure
Posterior Antidiuretic Water reabsorbed,
pituitary hormone increased blood volume,
increased blood pressure
*Possible complications include hypertension, tension headaches, insomnia, diabetes mellitus,
infection, heart failure, peptic ulcer, and fatigue

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Effects of Stress on Nutrient Metabolism

i. Protein Metabolism
Even if adequate carbohydrate and fat are available, protein (skeletal muscle) is mobilized for
energy (amino acids are converted to glucose in the liver). There is decreased uptake of amino
acids by muscle tissue, and increased urinary excretion of nitrogen.

Some non- essential amino acids may become conditionally essential during episodes of
metabolic stress. During stress, glutamine is mobilized in large quantities from skeletal muscle
and lung to be used directly as a fuel source by intestinal cells. Glutamine also plays a significant
role in maintaining intestinal immune function and enhancing wound repair by supporting
lymphocyte and macrophage proliferation, hepatic gluconeogenesis, and fibroblast function

ii. Carbohydrate Metabolism

Hepatic glucose production is increased and disseminated to peripheral tissues although proteins
and fats are being used for energy. Insulin levels and glucose use are in fact increased, but
hyperglycemia that is not necessarily resolved by the use of exogenous insulin is present. This
appears, to some extent, to be driven by an elevated glucagon-to- insulin ratio.

iii. Fat metabolism

To support hypermetabolism and increased gluconeogenesis, fat is mobilized from adipose stores
to provide energy (lipolysis) as the result of elevated levels of catecholamines along with
concurrent decrease in insulin production.

If hypermetabolic patients are not fed during this period, fat stores and proteins are rapidly
depleted. This malnutrition increases susceptibility to infection and may contribute to multiple
organ dysfunction syndrome (MODS), sepsis, and death.

iv. Hydration/Fluid Status

Increased fluid losses can result from fever (increased perspiration), increased urine output,
diarrhea, draining wounds, or diuretic therapy.

v. Vitamins and Minerals

Just as kcal needs increase during hypermetabolic conditions, so, too, do needs for most vitamins
and minerals. And if kcal needs are met, the patient will most likely receive adequate amounts of
most vitamins and minerals.

Special attention, however, should be given to vitamin C (ascorbic acid), vitamin A or beta-
carotene, and zinc.

 Vitamin C is crucial for the collagen formation necessary for optimal wound healing.
Supplements of 500 to 1000 mg/day are recommended.
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 Vitamin A and beta- carotene (vitamin A’s precursor) play an important role in the
healing process in addition to their role as anti- oxidants.
 Zinc increases the tensile strength (force required to separate the edges) of a healing
wound. Supplements of 220 mg/day zinc sulfate (orally) when stable are commonly used.
Additional zinc may be necessary if there are unusually large intestinal losses (small
bowel drainage or ileostomy drainage).
These metabolic changes can result into malnutrition that eventually affects the immune system
and thus prolong the healing process

Immune System

 One of the first body functions affected by impaired nutritional status is the immune
system. When metabolic stress develops, hormonal and metabolic changes subdue the
immune system’s ability to protect the body. This activity is further depressed if impaired
nutritional status accompanies the metabolic stress. A deadly cycle often develops:
 Impaired immunity leads to increased risk of disease,
 Disease impairs nutritional status, and
 Compromised nutritional status further impairs immunity.
Recovery requires that this cycle be broken by good nutrition

Role of Nutrition

 For the immune system to function optimally, adequate nutrients must be available. A
well-nourished body will not be ravaged by infections the way a poorly nourished body.
Immune system components affected by malnutrition include:

 Mucous membrane- microvilli flattened which reduces nutrient absorption and decreases
antibody secretions
 Skin – thinned with less connective tissue. Integrity of the skin may be compromised as it
loses density and wound healing is slowed
 Gastrointestinal tract - Injury to the gastrointestinal tract because of malnutrition may
increase risk of infection-causing bacteria spreading from inside the tract to outside the
intestinal system.
 T-lymphocytes - are affected as the distribution of T cells is depressed
 Macrophages, granulocytes - the effect on macrophages and granulocytes requires that
more time be needed for phagocytosis kill time and lymphocyte activation to occur
 and antibodies – may be less available because of damage to the antibody response
Role of Nutrients and Nutritional Status on Immune System Components

Immune System Effects of Malnutrition Vital Nutrients

Component

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Mucus Decreased antibody Vitamin B12, biotin, vitamins

secretions B6 and C

Gastrointestinal tract Flat microvilli, increased risk Arginine, omega-3 fatty acids
of bacterial spread to outside
GI tract

Skin Integrity compromised, Protein, vitamins A and C,

density reduced, wound niacin, zinc, copper, linoleic
healing slowed acid, vitamin B12

T-lymphocytes Depressed T-cell distribution Protein, arginine, omega-3

fatty acids, vitamins A, B12,
B6, folic acid, thiamine,
riboflavin, niacin,
pantothenic acid, zinc, iron

Macrophages and Longer time for phagocytosis Protein, vitamins A, C, B12,

Granulocytes kill time and lymphocyte B6, folic acid, thiamine,
activation riboflavin, niacin, zinc, iron

Antibodies Reduced antibody response Protein, vitamins A, C, B12,

B6, folic acid, thiamine,
biotin, riboflavin, niacin

Medical Nutrition Therapy for Metabolically Stressed Patients

Energy requirements are highly individual and may vary widely from person to person. Total kcal
requirements are dependent on the basal energy expenditure (BEE) plus the presence of trauma, surgery,
infection, sepsis, and other factors. Additionally, age, height, and weight are often taken into consideration.

B. Harris-Benedict Formula
The Harris-Benedict formula is one of the most useful and accurate for calculating basal energy
requirements, although it generally overestimates BEE by 5% to 15%. It is important to remember this
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formula uses current (actual) weight in the calculation.

Wt in pounds ÷ 2.2 kg = Wt in kg

Ht in inches ÷ 2.54 cm = Ht in cm

Men = 66.5 + (13.8 × Wt in kg) + (5 × Ht in cm) - (6.8×Age)

Women = 655.1 + (9.6×Wt in kg) + (1.8×Ht in cm)-(4.7×Age)

Once BEE has been calculated, additional kcal for activity and injury are added:

BEE × Activity factor (AF) × Injury factor (IF)

C. Protein Requirements
Additional protein is required to synthesize the proteins necessary for defense and recovery, to spare lean
body mass, and to reduce the amount of endogenous protein catabolism for gluconeogenesis.

D. Vitamin/Mineral Needs
Needs for most vitamins and minerals increase in metabolic stress; however, no specific guidelines exist
for provision of vitamins, minerals, and trace elements. It is usually believed that if the increased kcal
requirements are met, adequate amounts of most vitamins and minerals are usually provided. In spite of
this, vitamin C, vitamin A or beta carotene, and zinc may need special attention.

E. Fluid Needs
Fluid status can affect interpretation of biochemical measurements as well as anthropometry and physical
examination. Fluid requirements can be estimated using several different methods

Micronutrient Supplementation
Vitamin C: 500 to 1000 mg/daily in divided dose

Vitamin A: one multivitamin tablet containing vitamin A, one to four times daily

Zinc sulfate: 220 mg, one to three times daily

Activity Activity Factors Clinical Energy G,

status stress protein/kg
factor BW/day

Bed rest 1.2 Elective surgery 1 – 1.2 1 – 1.5

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Ambulatory- 1.3 Multiple trauma 1.2 – 1.6 1.3 – 1.7

able to walk

Severe infection 1.2 – 1.6

Peritonitis 1.05 – 1.25

Multiple/long 1.1 – 1.3

bone fracture

Infection with 1.3 – 1.5

trauma

Sepsis 1.2 – 1.4 1.2 – 1.5

Closed head 1.3

injury

Cancer 1.1 – 1.45

Burns (% BSA) 1.8- 2.5

0-20% 1 – 1.5

20-40% 1.5 – 1.85

40-100% 1.85 – 2.05

Fever 1.2 per 10C

>370C

Fluid requirement based on: Water (ml)

Weight 100ml/kg/day for first 10 kg

50 ml/kg/day for the next 10 kg

20 ml/kg/ day for each kg above 20

kg

Age & weight 16-30 yrs (active) 40 ml/kg/day

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20-55 35 ml/kg/day

55-75 30 ml/kg/day

>75 25 ml/kg/day

Energy 1ml/kcal

Fluid balance Urine output + 500 ml/day

Hydration/Fluid Status

Increased fluid losses can result from fever (increased perspiration), increased urine output,
diarrhea, draining wounds, or diuretic therapy.10

Vitamins and Minerals

Just as kcal needs increase during hypermetabolic conditions, so, too, do needs for most vitamins
and minerals. And if kcal needs are met, the patient will most likely receive adequate amounts of
most vitamins and minerals. Special attention, however, should be given to vitamin C (ascorbic
acid), vitamin A or beta-carotene, and zinc. Vitamin C is crucial for the collagen formation
necessary for optimal wound healing. Supplements of 500 to 1000 mg/day are recommended.12
Vitamin A and beta- carotene (vitamin A’s precursor) play an important role in the healing
process in addition to their role as anti- oxidants. Zinc increases the tensile strength (force
required to separate the edges) of a healing wound. Supplements of 220 mg/day zinc sulfate
(orally) when stable are commonly used. Additional zinc may be necessary if there are unusually
large intestinal losses (small bowel drainage or ileostomy drainage).

NUTRITION IN BURNS
- A burn is defined as an injury to the skin or other organic tissue caused by thermal
trauma.
- Trauma refers to a massive crush injury or damage to the body
- A burn occurs when some or all of the cells in the skin or other tissues are destroyed by
hot liquids (scalds), hot solids (contact burns), or flames (flame burns), radiation,
radioactivity, electricity, friction or contact with chemicals e.tc.
- Major burns result in severe trauma. When a patient suffer from burn injuries the energy
requirements can sometimes increase to as much as 100% above resting energy
expenditure, depending on the extent of the burn (Total Burnt Surface Area - TBSA) and
depth of the injury (degree of burns).
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-
Most burns heal without any problems but complete healing in terms of cosmetic
outcome is often dependent on appropriate care, especially within the first few days after
the burn. Most simple burns can be managed in primary care but complex burns and all
major burns warrant a specialist and skilled multidisciplinary approach for a successful
clinical outcome.
- Burns(burn wounds) may be distinguished and classified by their:
o Mechanism or cause
o The degree or depth of the burn
o The area of body surface that is burned,
o The region or part of the body affected
o The extent
I. Classification by mechanism or cause
Causally, burns may be classified as thermal or inhalational.

a) Thermal burns involve the skin and may present as:

- scalds – caused by hot liquid or steam;
- contact burns – caused by hot solids or items such as hot pressing irons and cooking
utensils, as well as lighted cigarettes;
- flame burns – caused by flames or incandescent fi res, such as those started by lighted
cigarettes, candles, lamps or stoves;
- flash burns of short duration but intense heat
- chemical burns – caused by exposure to reactive chemical substances such as strong acids
or alkalis;
- Electrical burns – caused by an electrical current passing from an electrical outlet, cord or
appliance through the body.
Mechanisms of thermal injury

 Scalds—spilling hot drinks or liquids or being exposed to hot bathing water. Cause
superficial to superficial dermal burns.
 Flame—they are often associated with inhalational injury and other concomitant trauma.
Flame burns tend to be deep dermal or full thickness.
 Contact—the object touched must either have been extremely hot or the contact was
abnormally long. Burns from brief contact with very hot substances are usually due to
industrial accidents. Contact burns tend to be deep dermal or full thickness.
b) Inhalational burns are the result of breathing in superheated gases, steam, hot liquids or
noxious products of incomplete combustion. They cause thermal or chemical injury to the
airways and lungs and accompany a skin burn in approximately 20% to 35% of cases.
Inhalational burns are the most common cause of death among people suffering fire-related burn
as they cause injury to the internal organs, upper highway edema and difficulty in breathing

II. Classification by the degree and depth of a burn

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Burns may also be classified by depth or thickness.

• It is important to estimate the depth of the burn to assess its severity and to plan future wound
care. Burns can be divided into three types, as shown below.

Depth of burn Characteristics Cause

First degree burn • Erythema Sunburn

• Pain •

Absence of blisters

Second degree (Partial • Red or mottled • Contact with hot liquids

thickness)
Flash burns

Third degree (Full • Dark and leathery • Fire

Thickness)
• Dry • Electricity or lightning

• Prolonged exposure to hot

liquids/ objects

a) First-degree or superficial burns are defined as burns to the epidermis that result in a
simple inflammatory response.
Characteristics
 They affect only the outer/top layer of the skin (epidermis)
 They are caused by ultraviolet light e.g. solar radiation (sun burn), short heat
exposure/ brief contact with hot substances, liquids, short flames or flash flames
(scalds) on an unprotected skin
 They are painful
 Characterized by redness.
 They heal within a week (5-10 days)
 They heal with no permanent changes in skin colour, texture, or thickness(No
scaring)
 No blisters

b) Second-degree or partial-thickness burns result when damage to the skin extends

beneath the epidermis into the dermis. The damage does not, however, lead to the
destruction of all elements of the skin.
Characteristics

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 They affect both the epidermis and the layer below it (the dermis).
 They are characterized by blisters, pain and redness
 They heal within 10–14 days (for milder burns) or 25–35 days (when the depth of burn is
greater).
 Scaring not very common
 They require hospitalization
o Superficial second-degree burns are those that take less than three weeks to
heal.
o Deep second-degree burns take more than three weeks to close and are likely to
form hypertrophic scars.
c) Third-degree or full-thickness burns are those where there is damage to all epidermal
elements – including epidermis, dermis, subcutaneous tissue layer and deep hair follicles.
Characteristics
 Epidermis, dermis, subcutaneous tissue(fat) and deep hair follicle are affected
 Third-degree burn wounds cannot regenerate themselves without grafting. i.e.
they require surgery This because of extensive destruction of the skin layers
 They are wet or waxy
 Risk of scaring
 Require more than 21 days to heal
 They are characterized by a white burn site
 Lack of sensation due to the destruction of the nerve endings, disturbed
temperature control and a higher danger of infections.
 They require immediate hospitalization
 Can be caused by flame, oil, hot water etc.
In adults, a full-thickness burn will occur within 60 seconds if the skin is exposed to hot
water at a temperature of 53° C. If, though, the temperature is increased to 61° C, then
only 5 seconds are needed for such a burn.

Third-degree burns: They may also destroy the underlying bones, muscles and
tendons.

 Fourth degree burns.

Characteristics
 They destroy all layers of the skin
 They damage the underlying bones, muscles, and tendons.
 There is no sensation in the area since the nerve endings are destroyed.
 Definite scaring

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 Waxy and coloured ( gray to charred and black)

 They are caused by e.g. high voltage electricity, grease, oil, steam, chemicals
In children, burns occur in around a quarter to a half of the time needed for an adult to burn.

 It is common to find all three types within the same burn wound and the depth may change
with time, especially if infection occurs. Any full thickness burn is considered serious.

III. Classification by extent of burn

The extent of burn, clinically referred to as the total body surface area burned (TBSA), is
defined as the proportion of the body burned.
Several methods are used to determine this measurement, the most common being the so-
called “rule of nines”. This method assigns:
 9% to the head and neck region
 9% to each arm (including the hand)
 18% to each leg (including the foot) and
 18% to each side of the trunk (back, chest and abdomen).
The body is divided into anatomical regions that represent 9% (or multiples of 9%) of the total
body surface (Figure below). The outstretched palm and fingers approximates to 1% of the body
surface area.

NB: The “rule of nines” is used for adults and children older than 10 years, while the Lund and
Browder Chart is used for children younger than 10 years. The calculation assumes that the size
of a child’s palm is roughly 1% of the total body surface area

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Summary: estimating the (TBSA) in relation to the Body surface area: Rule of Nines:
1. The adult body is divided into anatomical regions that represent 9%, or multiples
of 9%, of the total body surface. Therefore 9% each for the head and each upper
limb. 18% each for each lower limb, front of trunk and back of trunk.
2. The palmar surface of the patient's hand, including the fingers, represents
approximately 1% of the patient's body surface.
3. Children:
 For children <1 year: head = 18%, leg = 14%
 For children >1 year: add 0.5% to leg, subtract 1% from head, for each
additional year until adult values are attained
Depth of burns
 Depth of burn (described as first-degree, second-degree and third-degree burns). Burn
wounds are dynamic and need reassessment in the first 24-72 hours because depth can
increase as a result of inadequate treatment or superadded infection.
 Burns can be superficial in some areas but deeper in other areas:
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1. Epidermal (superficial partial-thickness): red, glistening, pain, absence of blisters

and brisk capillary refill. Not life-threatening and normally heal within a week
without scarring.
2. Superficial dermal: pale pink or mottled appearance with associated swelling and
small blisters. The surface may have a weeping, wet appearance and is extremely
hypersensitive. Brisk capillary refill. Heal in 2-3 weeks with minimal scarring and
full functional recovery.
3. Deep dermal: blistering, dry, blotchy cherry red, doesn't blanch no capillary refill
and reduced or absent sensation. 3-8 weeks to heal with scarring, may require
surgical treatment for best functional recovery.
4. Full-thickness (third-degree): dry, white or black, no blisters, absent capillary
refill and absent sensation. Requires surgical repair and grafting.
5. Fourth-degree: includes subcutaneous fat, muscle, and perhaps bone. Requires
reconstruction and, often, amputation.
 Circumferential extremity burns: assess status of distal circulation, checking for cyanosis,
impaired capillary refilling or progressive neurological signs. Assessment of peripheral
pulses in burn patients is best performed with a Doppler ultrasound.
Burn care in the first 24 hours
 Assessment of patient airway and ventilation status
 Fluid /electrolyte resuscitation of major importance
 Maintain vital organ function
 Restoration of blood flow to the heart, injured tissues and vessels

Serious burn requiring hospitalization

 Greater than 15% burns in an adult

 Greater than 10% burns in a child
 Any burn in the very young, the elderly or the infirm
 Any full thickness burn
 Burns of special regions: face, hands, feet, perineum
 Circumferential burns
 Inhalation injury
 Associated trauma or significant pre-burn illness: e.g. diabetes
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The body’s metabolic response to burn

 The body’s metabolic response to burn is divided into 2 phases

1. The ebb phase/early phase
2. The flow phase.
 The ebb phase occurs immediately after a burn. If the patient survives, the ebb phase
evolves into the flow phase. The ebb phase is focused in maintaining heart action and
blood circulation and this is the major medical concern.
Characteristics of the ebb phase/early phase

 Decreased Oxygen Consumption

 Hypothermia (Lowered Body Temperature)
 Hypovolemia (A Decreased Volume Of Circulating Blood In The Body)
 Shock ((Low Blood Perfusion To Tissues)
 Decreased Cardiac Output
 Vascular constriction
 Decrease in production of digestive enzyme
 Decrease urine production
 Insulin levels drop because glucagon is elevated (increased), most likely as a signal to
increase hepatic glucose production.
 Decrease in metabolic needs
Flow phase:

“It brings hyper-metabolism”

Characteristics of the flow phase

 Increased cardiac output- Increased cardiac work immediately after a burn, because of
low amount of blood in the body
 Increase myocardial oxygen consumption,
 Increase body temperature (hyperthermia),
 Increase energy expenditure(increased metabolic rate)
 Increase protein breakdown- Muscle protein degradation (breakdown) becomes a
necessary and large source of energy-(protein is degraded much faster than it is
synthesized).This leads to loss of lean body mass and increased immune dysfunction
(Increased risk for infection)
 Increase nitrogen excretion/loss
 Liver dysfunction (the liver increases in size to help in removing the increased nitrogen
rates)

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 Increased catabolism- causing the rapid breakdown of energy reserves to provide glucose.
This is because of increased energy need due to hypermetabolism and increased catabolic
hormones(glucagon and cortisol)
 Changes in glucose metabolism-Elevated circulating levels of catecholamine, glucagon,
cortisol and gluconeogenic hormones in response to severe thermal injury propagate
(results into) inefficient glucose production in the liver.
 Sex hormones and growth levels decrease around 3 weeks post burn. This results in
growth retardation
 Decrease in protein synthesis
 Increase in gluconeogesis- increase in glucose production
 Increase in cytokines
 Increase in basal metabolic rate-increase in energy expenditure
The flow stage lasts for days, weeks, or months until the injury is healed

N/B.The hypermetabolic response is believed to be as a result of increased oxygen consumption,

increased production of catecholamine, increased production of catabolic hormones (cortisol,
epinephrine and glucagon, leading to inhibition of protein synthesis and lipogenesis) and
inflammatory cells (cytokines). Glucagon promotes gluconeogenesis, amino acid uptake,
ureagenesis and protein catabolism while Cortisol, which is released from the adrenal cortex
enhances skeletal muscle catabolism and promotes hepatic use of amino acids for
gluconeogenesis, glycogenolysis, and acute-phase protein synthesis.

Nutrition challenge of burn patients/ Special concerns for burn patients/Effects of burn

Adequate and prompt nutrition is extremely important for preventing numerous complications
that comes with burn

 Increased nitrogen losses that exceed any other type of stress or trauma. There is
increased nitrogen loss in the urine because of increased movement of amino acids from
skeleton muscle to the liver where amino acid (protein) serve as source of glucose.
Nitrogen is a by-product of protein synthesis
Nitrogen is also lost from wound exudate and blood loss during surgery, leading to an
extraordinarily negative nitrogen balance.

 Increased energy needs due to hyper metabolism that increase with size of the burnt area
peaking up to 2 to 2.5 times above the normal metabolic rate for burns involving as much
as 40% of the body surface.
 Severe protein catabolism

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 Susceptible to infection due to destruction of the skin surface. Skin is the body’s first line
of defense against infection
 Loss of skin also results in increased water and heat loss. The larger the burnt area the
greater the loss of water vapor and heat. Approximately 2.5-4l/day of water vapor may be
lost from a major burnt wound
 More protein loss as burnt surface allows leakage of a protein rich fluid containing
approximately two thirds as much proteins as plasma.
 Malnutrition. Many are anorexic and unable to consume a sufficient amount of
kilocalories to satisfy energy requirements. Also, burn patients do not feed well because
of pain, generalized discomfort and depression
 Increased need for water. Large amounts of waste products (such as nitrogen and
potassium) must be excreted by the kidney- fluids are required to keep these in solutions
 Curling ulcer or acute ulceration of the stomach or duodenum is frequently observed in
burn patients-large amount of vitamin A can reduce incidence of stress ulcer
 Edema.-Capillary permeability increases and plasma protein fluids and electrolytes
escape into the burn area and intestinal space
 Anemia
 Heat loss
 Loss of electrolytes
 Burn patients may develop an ileus( blockage of the intestine especially the ileum) as a
result of shock that results into lack of peristalsis
Other challenges in patients (Systemic Effects following a Burn)

 Toxic gases -Causes upper airway edema and difficulty in breathing

 Edema
 Airway obstruction
 Gastric effects
o Acute gastroduodenal mucosal lesions
o Prolonged gastroduodenal mucosal lesions
o Duodenal ulcer induced by surgery
o Stomach dilatation.
Nutritional care of the burn patient
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Goals/Aims

 To offer energy, fluids and nutrients in adequate quantities to maintain vital functions and
homeostasis, recover the activity immune system, reduce the risks of overfeeding, to
provide protein and energy necessary to minimize the protein catabolism and nitrogen
loss.
N/B. Burn patients require specialized nutritional support because over-nutrition predisposes the
patient to hyperglycemia, overload of the respiratory system, and hyperosmolarity. When dealing
with under-nutrition, the patient could suffer from malnutrition and subsequent reduction of
immunocompetence, prolonged dependency on mechanical ventilation and delay in the healing
processes, increased risk of infection, morbidity and mortality

Nutrition therapy

 Monitor nutritional status and provide specialized nutrition. Provide enteral nutrition (within
24 hours) if the patient cannot consume enough food orally.
Why enteral nutrition is important.
It stimulates the production of specific hormones beneficial for the proliferation of gut
mucosal cell33s
Maintains gut integrity and prevention of bacterial translocation
Parenteral nutrition is not recommended but only for patients with non-functioning GI tract

 Vitamin A (As much as 5000 units/1000 calories for increased immunity. Supplementation
may be done
 Vitamin C (As much as 1000-2000mg/day or 1-2g/day). For collagen synthesis. Vitamin C is
also an antioxidant Supplementation may be done
 Adequate copper-copper assists in the formation of red blood cells and work with vitamin C
to form the connective tissues.2-4 mg/day is recommended during the first few weeks of
injury repair
 Zinc-Zinc is required for over 300 enzymes in the body and plays a role in DNA synthesis-all
necessary for tissue regeneration and repair
Zinc deficiency has been associated with poor wound healing and, as Zinc deficiencies is one
of the most common micronutrient deficiencies.15-30 mg/day is recommended especially
during the initial stages of healing(Balancing of copper and zinc should be ensured as excess
of can create deficiency of the other)
 Mineral supplementation or adequate minerals e.g. calcium (it is affected during burns) and
vitamin. Calcium is needed for fracture repair/healing
 Adequate iron to compensate for the lost iron(to prevent anemia) and increase the volume of
oxygen for the organs and tissues
 Adequate energy to prevent weight loss of greater than 10% usual body weight.

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 Provide adequate protein to promote wound healing, for positive nitrogen balance and
maintenance or repletion of circulating proteins. Protein degradation in burn patients
proceeds despite adequate protein supplementation.
 Protein requirements are also increased in burn patients because of the increased catabolism
of skeletal muscle, more protein is also lost as the burnt surface allows leakage of a protein
rich fluid leading to average losses of 260 mg protein/kg/hr. Protein intake should vary
between 1.5–2.0 g/kg of ideal body weight on a daily basis. The extra protein is needed
for:
o Wound healing,
o Tissue building
o Blood regeneration.
o Optimize the immunize system

 Adequate fluids to prevent dehydration and for the removal of the nitrogenous wastes
Estimation of nutritional requirements in burn patients (Energy and protein)

 The most common formulas utilized in these patients are the Curreri, Pennisi, Schofield,
IretonJones, Harris-Benedict and the ASPEN recommendations.
 For children is the Mayes,Harris-Benedict. pennisi and World Health Organization
formula. The majority of mathematical formulas overestimate the nutritional needs.
 Between 1970 and 1980 the most frequently used formula for estimating the nutritional
needs of burn patients was developed by William Curreri.
 In 1976, Pennisi created a more comprehensive formula, designed for adults and
children, estimating both the energetic needs in calories and protein needs in grams.
 Other formulas developed for critically ill and burn patients include Toronto, Schofield,
Ireton Jones, Harris-Benedict, and the American Society for Parenteral and Enteral
Nutrition (ASPEN) recommendations.
Formulas for calculating approximate nutritional needs in burn cases. Electronic archive study,
2010

Author Gender Formula

Harris & Estimated Energy Requirements: BMR x Activity factor x Injury

Benedict factor
Male
66 + (13.7 x weight in kg) + (5 x height in cm) - (6.8 x age)
Female
665 + (9.6 x weight in kg) + (1.8 x height in cm) - (4.7 x age)

Activity factor:

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Confined to bed: 1.2

Minimal ambulation: 1.3

Injury factor:

< 20% TBSA: 1.5

20-40% TBSA: 1.6

> 40% TBSA: 1.7

Curreri For all patients Estimated Energy Requirements: (25 kcal x w) + (40 x %TBSA)

Curreri equation

for patients aged 16 to 59 years:

TEE: 25 kcal x kg actual body weight + (40 kcal x % TBSABa)

a
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

Pennisi Adults Estimated Energy Requirements:

Calories (20 x w) + (70 x %TBSA)

Protein (1 g x w) + (3g x %TBSA)

Children

Calories (60 kcal x w) + (35 Kcal x %TBSA)

Protein (3 g x w) + (1 g x %TBSA)

WHO For Children

Male < 3 years (60.9 x weight in kg) – 54

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Male 3 to 10 (22.7 x weight in kg) + 495

years

Female < 3
years (61 x weight in kg) – 51

3 to 10 years (22.5 x weight in kg) + 499

NUTRITION IN SURGERY

INTRODUCTION

Definition of terms

Surgery-This is a branch of medicine that involves the cutting, removal or closing of a body
tissue or organ with an aim of treating an injury, a disease or a disorder e.g. vasectomy, tooth
extraction and feeling, bariatric surgery, gastrectomy,

Elective surgery-It refers to surgery that is scheduled in advance because it does not involve
medical emergency. They can be delayed e.g. hernia, vasectomy etc. Most surgeries are elective

Emergency surgery-It is one that must be performed immediately without delay

Surgery like any other injury to the body elicits a series of reactions including release of stress
hormones and inflammatory mediators i.e. cytokines. This release of mediators to the
circulation has a major impact on body metabolism. They cause catabolism of glycogen, fat
and proteins with release of glucose, free fatty acids and amino acids into the circulation so that
substrate are diverted from their normal purposes e.g. physical activities to the task of healing
and immune response.
For optimal recovery and wound healing all patients undergoing surgery should be at optimal
nutritional status to help them tolerate the physiologic stress of the surgery and temporary
starvation that follows. But all too often, surgical patients may be malnourished secondary to the
medical condition causing the need for surgery. Additionally, they may experience anorexia,
nausea, or vomiting, which decrease their ability to eat.
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Fever may increase their metabolic rate. Or nutritional needs may not be met because of
malabsorption.

For surgery to be successful, patients who are malnourished or in danger of malnutrition must be
identified so corrective action may be arranged.

Measures to reduce stress of surgery can minimize catabolism and support anabolism
throughout surgical treatment and allow patients to recover substantially better and faster even
after major surgical operation.
The body metabolic responses like release of stress hormones and inflammatory mediators i.e.
cytokines and catabolism of glycogen, fat and proteins can result into malnutrition

Goal of nutritional management

To enhance recovery of patients after surgery
Objectives
 To avoid long periods of preoperative fasting
 To improve or maintain nutritional status of preoperative patients as this will prevent
postoperative complications and malnutrition as well as improve the healing process
 To control metabolic processes
Preoperative/pre-surgery nutrition care
Surgery stresses the client regardless of whether it is elective (schedule in advance, not
emergency. One that can be postponed for 24 hours) or not. If the surgery is elective, the client’s
nutritional status should be evaluated before surgery; and if improvement is needed, it should be
undertaken immediately.

 High energy diet: Extra carbohydrates will be converted to glycogen and stored to help
provide energy after surgery, when needs are high and when clients may be unable to eat
normally. Encourage patients who do not meet their energy needs from normal foods to
take oral nutrition supplements during the preoperative periods
 High protein diet: Protein body stores should be assessed. The extra protein is needed
for:
o Wound healing,
o Tissue building
o Blood regeneration.
o Optimize the immune system
 Administer preoperative enteral nutrition preferably before admission to the hospital

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 Vitamins and minerals: Any deficiency state such as anemia should corrected.
Electrolytes and fluids should be normalized
o Vitamins A and C and zinc for wound healing,
o Vitamin D for the absorption of calcium,
o Vitamin K for proper clotting of the blood.
o Iron is necessary for blood building
o Calcium and phosphorus for bones
o The other minerals are needed for maintenance of acid-base, electrolyte,
and fluid balance in the body.
o The B vitamins are needed for the increased metabolism
In cases of overweight, improved nutritional status includes weight reduction before surgery
whenever possible. Excess fat is a surgical hazard because the extra tissue increases the chances
of infection, and fatty tissue tends to retain the anesthetic longer than other tissue.

 Immediate preoperative period- nutrition care

Many physicians order their clients to be NPO (nothing by mouth) after midnight the night
before surgery, i.e. in elective cases no food is allowed by mouth for at least 6 hours before
surgery. In emergency cases gastric lavage or suction is used to remove stomach contents before
anesthesia is started. This is done prevent to cases where food is regurgitated/vomiting then
aspirated into the lungs during surgery(Aspiration-a condition in which food, liquids, saliva or
vomit is breathed/inhaled through airways), upon awakening or to prevent vomiting or aspiration
that may be induced by anesthesia
 If there is to be gastrointestinal surgery, the colon should be free of residue to prevent
postoperative infection, fecal matter may interfere with the procedure itself and cause
contamination as colonic bacteria are reduced when less food residue is present.
Therefore a low-residue diet may be ordered for a few days before surgery (2-3 days).
This is intended to reduce intestinal residue.
The Low-Residue Diet

Low-fiber or residue-restricted diets may be used in cases of severe diarrhea, diverticulitis,

ulcerative colitis, and intestinal blockage and in preparation for and immediately after intestinal
surgery.

In some facilities, these diets consist of foods that provide no more than 3 grams of fiber a day
and that do not increase fecal residue (Tables 20-5 and 20-6). Some foods that do not actually
leave residue in the colon are considered “low-residue” foods because they increase stool volume
or provide a laxative effect. Milk and prune juice are examples. Milk increases stool volume, and
prune juice acts as a laxative.
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Foods to Allow and to Avoid on Low-Residue Dietsod

Foods to Allow Foods to Avoid

 Milk, buttermilk (limited to 2 cups daily) if  Fresh or dried fruits and vegetables
physician allows  Whole-grain breads and cereals
 Cottage cheese and some mild cheeses as  Legumes, coconut, and marmalade
flavorings in small amounts  Tough meats
 Butter and margarine  Milk, unless physician allows
 Eggs, except fried Rich pastries  Meats and fish with tough connective
 Tender chicken, fish, ground beef, and ground tissue
lamb (meats must be baked, boiled, or broiled)  Potato skin
 Soup broth
 Cooked, mild-flavored vegetables without
coarse fibers; strained fruit juices (except for
prune); applesauce; canned fruits including
white cherries, peaches, and pears; pureed
apricots; ripe bananas
 Refined breads and cereals, white crackers,
macaroni, spaghetti, and noodles
 Custard, sherbet, vanilla ice cream; plain
gelatin; angel food cake; sponge cake; plain
cookies
 Coffee, tea, cocoa, carbonated beverage
 Salt, sugar, small amount of spices as
permitted
 by physician

An example of low residue meal plan

Breakfast Dinner Lunch/supper

Strained orange Chicken broth Tomato juice

Cream of rice with milk and
sugar
White toast with margarine
and jelly
Ground beef patty Macaroni and cheese
Boiled potato, no skin Green beans
Baked squash White bread and butter

Coffee with cream and sugar Gelatin dessert Lemon sherbet

Milk Tea with milk and sugar

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Examples of common surgeries

 Neck and head surgery-It is usually performed to remove a tumor due to neck and brain
cancer that inhibit a patient ability to chew and swallow normally.
 Esophageal surgery- e.g. due to esophageal cancer. It can prevent swallowing
 Gastric /stomach surgery –e.g. partial gastrectomy/vagotomy(partial removal of the
stomach), total gastrectomy (removal of the entire stomach. A storage reservoir may be
created using a section of jejunum), gastroduodenostomy(removal of part of the stomach
and joining it directly to the duodenum), gastrojejunostomy(bypass the duodenum).They
are performed to remove a tumor, ulcer disease, hemorrhage, or to loss weight due to
morbid obesity) e.tc. Another surgical operation, bariatric surgery is often performed for
the treatment of obesity. Bariatric surgery(if it is passed with the purpose of losing
weight) limits the amount of food intake
Consequences of gastrectomy
 Weight loss-gastrectomy leads to early satiety
 Absence of gastric juice pepsin and HCL acid-the entire digestion of protein must
occur in the small intestine
 Impaired fat utilization because of inadequate mixing of with food with digestive
enzymes
 intestinal surgery-It is where part of small or large intestine is removed e.g. colostomy
or ileostomy (These procedures involve creation of an artificial anus on the abdominal
wall by incision into the colon or ilium and bring it out to the surface, forming a stoma to
collect fecal matter).They are performed in cases of intestinal obstruction, inflammatory
bowel disease, diverticulosis etc. If more than 50% of the small intestine is removed ,
short-bowel syndrome may occur
Consequences

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 Weight loos
 Diarrhea
 Protein and fat metabolism

Post-surgery Nutritional Care

The post-surgery diet is intended to provide calories and nutrients in amounts sufficient to fulfill
the client’s increased metabolic needs and to promote healing and subsequent recovery.

The introduction of solid food depends on the condition of the gastrointestinal tract. Oral feeding
is often delayed for the first 24 to 48 hours after surgery to await the return of bowel sounds or
passage of flatus (flatus - gas in or from the stomach or intestines, produced by swallowing air
or by bacterial fermentation).
To some patients, oral intake including clear liquids can be initiated within hours after surgery if
bowel sound s back
In general, during the 24 hours immediately following major surgery, most clients will be given
intravenous solutions only. These solutions will contain water, 5% to 10% dextrose, electrolytes,
vitamins, and medications as needed. The maximum calories supplied by them is about 400 to
500 calories per 24-hour period. The estimated daily calorie requirement for adults after surgery
is 35 to 45 calories per kilogram of body weight. A 110-pound (50 kgs) individual would require
at least 2,000 calories a day. Obviously, until the client can take food, there will be a
considerable calorie deficit each day. Body fat will be used to provide energy and to spare body
protein, but the calorie intake must be increased to meet energy demands as soon as possible.

Because protein losses following surgery can be significant and because protein is especially
needed then to rebuild tissue, control edema, avoid shock, resist infection, and transport fats, a
high-protein diet of 80 to 100 grams a day may be recommended. In addition, extra minerals and
vitamins are needed. When peristalsis returns, ice chips may be given; and if they are tolerated, a
clear liquid diet can follow. (Peristalsis is evidenced by the presence of bowel sounds.)

Normally in postoperative cases, clients proceed from the clear-liquid diet to the regular diet.
Sometimes this change is done directly and sometimes by way of the full-liquid diet, depending
on the client and the type of surgery. The average client will be able to take food within 1 to 4
days after surgery. If the client cannot take food then, parenteral or enteral feeding may be
necessary.

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Sometimes following gastric surgery, dumping syndrome occurs within 15 to 30 minutes after
eating. This is characterized by dizziness, weakness, cramps, vomiting, and diarrhea. It is caused
by food moving too quickly from the stomach into the small intestine. It occurs secondary to an
increase in insulin, in anticipation of the increase in food, which never comes.

Dumping syndrome: nausea and diarrhea caused by food moving too quickly from the
stomach to the small intestine

To prevent dumping syndrome, the diet should be high in protein and fat, and carbohydrates
should be restricted. Foods should contain little fiber or concentrated sugars and only limited
amounts of starch. Complex carbohydrates are gradually reintroduced. Gradual reintroduction is
recommended because carbohydrates leave the stomach faster than do proteins and fats.

Fluids should be limited to 4 ounces (appr. 120 ml) at meals, or restricted completely, so as not
to fill up the stomach with fluids instead of nutrients. They can be taken 30 minutes after meals.
The total daily food intake may be divided and served as several small meals rather than the
usual three meals in an attempt to avoid overloading the stomach. Some clients do not tolerate
milk well after gastric surgery, so its inclusion in the diet will depend on the client’s tolerance.

The food habits of the postoperative client should be closely observed because they will affect
recovery. When the client’s appetite fails to improve, efforts should be made to offer nutritious
foods and supplements (either in liquid or solid form) that the client will ingest. The client
should be encouraged to eat and to eat slowly to avoid swallowing air, which can cause
abdominal distension and pain.

Severe trauma (surgery)

For patients with obvious under-nutrition at the time of surgery and for whom oral intake will be
inadequate (<60%) for more than 10 days;
 Initiate tube feeding for patients in need within 24 hours after surgery
 Start tube feeding with a low flow rate ( e.g. 10ml/hr to maximum of 20ml/hr) due to
limited intestinal tolerance
 It may take 5-7 days to reach the target intake and this is not considered harmful

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 Reassess nutritional status regularly during the stay in the hospital and if necessary
continue nutritional support after discharge in patients who have received nutritional
support preoperatively
 Progress over a period of several meals from clear liquids, and finally to solid foods

N/B. The postoperative nutrition care should be planned to address the nutrition challenges that
comes with surgery especially for patients who undergo alimentary canal surgery

Some of the nutrition challenges are:

 Weight loss due to inadequate intake of intake of food after surgery

 Increased protein loss due to catabolism
 Malabsorption of fats and fat soluble vitamins, simple sugars e.g. as a result of gastric
surgeries
 Malabsorption of vitamins e.g. fluids and electrolyte e.g. sodium, potassium and chloride
ions e.g. colon surgery
 Early satiety due to reduced storage capacity
 Rapid gastric emptying that may result into diarrhea, vomiting etc.
These nutrition challenges together with surgical metabolic responses if not checked can result
into malnutrition. Malnutrition is associated with low immune function, poor wound healing,
morbidity and mortality

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NUTRITION CARE AND SUPPORT IN THE INTENSIVE CARE

 Intensive care is a therapy unit concerned with the management of patients with acute life
threatening disorders. The severe or critical disease relates to a wide variety of clinical or
surgical conditions.
 Changes in most patients in the ICU include hyper metabolism, hyperglycemia with
insulin resistance, accentuated lipolysis and increased protein catabolism.
 The impact of the combination of these metabolic changes and absence of nutritional
support may lead to rapid and severe depletion of lean body mass. The implications are;
 Multiple organ failure
 Increased risk of infection
 Hyper metabolism
 Decreased immunity
 Increased nutritional requirements
NB: The goal of nutrition management is to preserve lean body mass
Nutrition care and feeding

 Enteral nutrition (EN) via tube feeding is the preferred way of feeding the critically ill
patients and an important means of counteracting for the catabolic state induced by
severe diseases.
Indications for and implementation of enteral nutrition (EN) in the ICU
 All patients who are not expected to be on full oral diet within 3 days should receive
enteral nutrition (EN)
 Haemodynamically stable critically ill patients who have a functioning GI tract should be
fed early (<24hours) using an appropriate amount of feed
 With an inadequate oral intake, undernutrition is likely to develop within 8-12 days
following surgery
 No general amount can be recommended as EN therapy has to be adjusted to the
progression/ course of the disease and gut tolerance
 During the acute and initial phase of critical illness: an exogenous energy supply in
excess of 20-25kcal/kg/day may be associated with a less favorable outcome and thus

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should be avoided whereas during the recovery (anabolic flow phase) the aim should be
to provide 25-35kcal/kg/day to support the anabolic reconstitution
 Patients with severe under nutrition should receive EN up to 25-35 total kcal/kg/day. If
these target values are not reached supplementary parenteral nutrition should be given
Route of administration
 In patients who tolerate EN and can be fed approximately to the target values no
additional parenteral nutrition should be given. In patients who cannot be fed sufficiently
enterally, the deficit should be supplemented parenterally
 Carefully consider parenteral nutrition in patients intolerant to EN at a level equal to but
not exceeding the nutritional needs of the patients thus overfeeding should be avoided
 There is no significant difference in the efficacy of jejuna versus gastric feeding in
critically ill patients
Types of formula
 Whole protein formulas are appropriate in most patients because no clinical advantage of
peptide based formula has been shown
 Immune-modulating formulae (formulae enriched with Arginine, nucleotides and α -3
fatty acids) are superior to standard enteral formulae (these acts as energy substrate for
immune cells, reduce inflammatory stimuli and cell mediated immunity as well as
scavenge free radicals)
In elective upper GI surgical patients:-
 In patients with mild and severe sepsis immune modulating formulae may be harmful and
therefore are not recommended
In patients with trauma
 In patients with ARDS (formula containing omega 3 fatty acids and antioxidants are
recommended)
 For burn patients trace elements (Cu, Se and Zn) should be supplemented in a higher than
standard dose

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 ICU patients with very severe illness who do not tolerate more than 700ml enteral
formulae per day should not receive an immune modulating formulae enriched with
Arginine, nucleotide and omega 3 fatty acids
 Glutamine should be added to standard enteral formula in burn and trauma patients
 Glutamine decreases infection complications, strengthens immune defense, improves
protein synthesis and nitrogen balance, improves metabolic homeostasis (glucose) and
improves gut functions
 There are no sufficient data to support enteral glutamine supplementation in surgical or
heterogeneous critically ill patients
FEEDING OF LOW BIRTH WEIGHT AND PRETERM INFANTS
 Low birth weights are defined as babies having less than 2500g at birth.
 Very low birth weights are those born with less than 1500g.
 About a third of low birth weight infants are small for gestational age and show intra
uterine growth retardation.
Pre-term babies are subdivided into three categories depending on the degree of maturity i.e.
 Less than 30 weeks( extremely premature)
 31-32 weeks
 35-36 weeks (borderline)
 The clinical management and nutritional requirement of the immature or preterm infants
is different from a mature infant born after 37 weeks.
 Preterm infants experience renal, hepatic, gastrointestinal and respiratory problems due to
immaturity of organ systems. They are more likely to need assistance with breathing and
are less likely to tolerate oral feeds.
Factors that cause variation in weight at birth
 Mother’s health
 Mother’s nutritional status
 Mother’s diet during pregnancy

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Factors affecting women’s nutritional status which might predispose the infant born
prematurely or of low birth weights are
 Nutritional intake
 Drug abuse
 Maternal under nutrition-is the major factor causing LBW (Low Birth weight) in
developing countries
 Mothers pre-pregnancy weight i.e. preconception weight of 40kg and a height 150 cm
 Low pregnancy weight gain
 Anemia
 Malaria
 Acute and chronic infections e.g. tuberculosis
Challenges to optimal nutrition for preterm infants

 Providing adequate nutrition to preterm infant is complicated by immature organ systems,

particularly the GI system and metabolic processes.

GI immaturities in the preterm infant include:

 Face and oral musculature
 Inability to coordinate sucking and swallowing, breathing (synchronization)
 Poor pastoral control
 Low esophageal sphincter pressure
 Pharyngeal swallow
 Delayed gastric emptying and stool passage
 Slower upper and lower intestinal motility
 Immature digestion and absorption of carbohydrates, protein and lipids

Renal (kidney) functions

 Concentrating controlling ability
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 Sodium excretion
 Ability to maintain acid base balance
 Glucose re-absorption
 Energy glycogen and fat
 Proteins hardly any muscles
 Minerals and micronutrients – low level of Ca, Zn, Iron and others most of which are
accumulated in the last ten weeks

In addition, prior to birth the GI tract is sterile and therefore immunologically immature. Normal
gut colonization, acquired through contact with the mother and feeding, may be delayed or
absent following birth due to isolation of the infant and residence in the new inborn care unit
(NICU) setting. Preterm infants may therefore be at risk of acquiring abnormal bacterial flora
and developing nosocomial infections.

Key issues in preterm infants

 Preterm infants, especially those who have been growth restricted in uterus have fewer
nutrient reserves at birth than term infants
 Additionally, preterm infants are subject to physiological and metabolic stresses that can
affect their nutritional needs, such as respiratory distress or infection
Feeding Premature Infants

 The premature infant’s nutritional requirements are substantially different from those of
the term infant, and meeting their unique needs can be challenging.

 The aim of feeding the premature is to provide optimal nutrition early in life, in order to
improve survival as well as promote growth and development. This is the cornerstone of
the care of preterm infants.

 Avoiding early malnutrition can have both short- and long-term benefits for the infant.
Early care in the new inborn care unit (NICU) is therefore focused on vital organ
development

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Objectives of nutrition management

 To promote feeding tolerance
 To improve digestibility
 To promote progress to full feeds
 To promote weight gain
 To enhance neurodevelopment, organ maturity and functioning
 To prevent infections and promote development of immune system

Recommendations for nutritional requirements for pre-terms is based on data from intrauterine
growth and nutrient balance studies and assume that optimal rate of postnatal growth for preterm
infants should be similar to that of normal fetuses of the same post conception age. In practice,
however, target levels for nutrient input are not always achieved and this may result in important
nutritional deficits.

Nutritional requirements for preterm

The recommended nutritional requirements for preterm are as shown in table 67 below:

Table 1: Recommended Nutritional requirements for Pre term Infants

Nutritional Requirements Recommended amounts
Fluid 150 – 200 Mmol
Energy 110 – 130 kcal/kg/day
Protein 3 -4 g/kg/day
Fat 4.5 – 6.8 g/kg/day
Calcium 120 – 230 mg/kg/day (2 – 4.5 Mmol)
Phosphorus 60 – 140 mg/kg/day (Ca: P 1.4 – 2.0: 1)
Sodium 1.3 Mmol
Iron 35 – 45 μmol
Vitamin K 2 – 3 μg

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Feeding options;
There are a number of feeding options available for pre-term babies. These are
 Mother’s own unmodified breast milk
 Mother’s own breast milk fortified
 Preterm formula
 Parenteral nutrition
Feeding Pre-terms
 Enteral feeds: should be given as soon as possible to prevent gut atrophy. If the baby’s
condition is unfavorable give minimal feeds to keep the gut functional i.e. 10-20ml
/kg/day
 Parenteral feeds: if the baby is unable to take enteral feeds, parenteral feeds should be
started as soon as possible to prevent severe malnutrition

Choice of feeding methods

The choice of feeding method is determined by several factors. Nonetheless;
 The methods outlined above can be used singularly or in combination depending on the
baby’s ability
 For small babies (L1500g) breast can be used in combination with kangaroo care
 Babies in kangaroo care gain weight faster and infection rate is reduced
Well infants of gestational age > 34 weeks are usually able to coordinate sucking, swallowing,
and breathing, and so establish breast or cup feeding. In less mature infants, oral feeding may not
be safe or possible because of neurological immaturity or respiratory compromise. In these
infants milk can be given as a continuous infusion or as an intermittent bolus through a fine
feeding catheter passed via the nose or the mouth to the stomach.
Note: A major concern with the introduction of enteral feeds (especially to preterm, IUGR infant
or sick infants) is the additional physiological strain on the immature gastrointestinal tract
which predisposes them to development of necrotizing Enterocolitis whose risk is inversely
related to gestational age and birth weight. The incidence of necrotizing Enterocolitis in very
low birth weight infants is 5-10%. The conditions long term morbidity may include substantial

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neuro-developmental problems, undernutrition and associated infection during a vulnerable

period of growth and development.
Clinical features of necrotising enterocolitis include
 Abdominal distension, tenderness or rigidity
 Lethargy, hypotonia, or apnoea
 Hepatic portal gas on abdominal x ray
 Intramural gas (pneumatosis intestinalis) on abdominal x ray
 Intestinal perforations
 Blood or mucus in stool
Modes of feeding
 Enteral feeding/oral
 Breastfeeding
 Cup feeding
Enteral nutrition
Most preterm infants who develop necrotizing enterocolitis receive enteral feeds. Start minimal
enteral nutrition within the first days of life of preterm infants, particularly those who are
clinically stable. Initiate using extremely small volumes to “prime” the digestive system and
increase the volume as the infant becomes more stable and tolerance is confirmed.
 Feeds nutritionally insignificant volumes of enteral milk (0.5-1.0 ml/hour)
 Aims to stimulate postnatal development of gastrointestinal system
 Use in parallel with total parenteral nutrition
 Increase enteral feeds' volume after pre specified interval, typically 7-14 days
 Calculate feeds based on weight
 Consider starting volume for either expressed breast milk or formula milk
 Babies who weigh less than 2.5kg (low birth weight) start with 60ml/kg/day
 Increase the total volume by 20ml/kg/day until the baby is taking a total of 200ml/kg/day
 Provide breast milk up to 240ml/kg/day but no other types of milk
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 Feed 2-3 hourly including night feeds

 Continue until the baby weighs 1800g or more and is fully breastfeeding
 Check the baby’s 24 hr intake
 The size of individual feed may vary

NOTE: When feeding pre-term infants strictly use preterm formulas. Cow’s milk or any other
form of milk is contra indicated

Breast milk
 Breast milk provides same advantages to preterm infants as to the full term infant and it is
the recommended form of enteral nutrition for preterm infants
 Early immune system development is particularly important for preterm infant to help
protect against infection, including NEC. Contributions of breast milk to immune
development are well confirmed
 Human breast milk may not consistently provide all the nutrient requirements of
preterm infants and may vary depending on the stage of lactation at which it is
collected. Micronutrient fortifiers should therefore be added to breast milk to achieve
desired targets. Fortification of human milk with calcium and phosphate may improve
bone mineral content
 Monitoring of the infant’s nutritional status is important to ensure that breast milk is
meeting the infant’s needs
 Breast milk has non-nutrient advantages for preterm infants including immuno-protective
properties and growth factors to the immature gut mucosa
 Some evidence show that preterm infants who receive human breast milk rather than
formula milk have a lower incidence of feed intolerance and gastrointestinal upset, as
well as lower incidence of necrotising enterocolitis

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Supporting mothers to express breast milk

Mothers may be very anxious after preterm delivery, especially if their infant needs intensive
care. Although feeding might not be seen as an immediate concern, mothers should be aware that
providing breast milk is one of the most important parts of their infant's care. Supporting mothers
to provide expressed breast milk may be the most important intervention available for preterm
infants. Feeding with expressed human milk reduces the risk of serious infection, which is a
major cause of neonatal morbidity and mortality in preterm infants in developing countries.
Several initiatives may help mothers to express breast milk successfully:
 Supporting the mother on how to correctly position and attach their infants to the breast
 Stimulation of oxytocin reflex
 Early discussion of the importance of breast feeding
 Provision of relevant written information, education and communication (IEC)materials
 Encouraging frequent breast milk expression to empty the breast
 Simultaneous expression of both breasts
 Breast massage
 Skin to skin contact (Kangaroo method)
How to express breast milk
 Place finger and thumb each side of the areola and press inwards towards the chest wall.
 Press behind the nipple and areola between your finger and thumb
 Press from the sides to empty all segments
Formula milks
Despite optimal maternal support, expressed breast milk may not always be available. As an
alternative, preterm infants may be fed with a variety of artificial formula milks. Broadly, these
may be "term" formulae (based on the composition of mature breast milk), or calorie, protein,
and mineral enriched "preterm" formulae (tailored to support intrauterine nutrient accretion
rates). Concerns about feeding tolerance with cow’s milk formula – characterized by vomiting,
larger gastric residuals, gas and constipation – have prompted studies on the implications of
protein source and type. In term formulas, improved digestibility has been observed with

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hydrolyzed formulas as compared to formulas with intact protein, and whey protein-based
formula has been shown to promote a faster gastric emptying rate than casein. Therefore cow’s
milk should be discouraged. It is difficult to develop optimal recommendations for minimal
effective volumes and quantity of volume increases considering that preterm infants differ
widely with respect to developmental stage, particularly GI maturity.

Very preterm infants often have relatively delayed gastric emptying and intestinal peristalsis
and may be slow to tolerate the introduction of gastric tube feeds. In such circumstances give
intravenous nutrition (e.g. Amino venous, dextrose or Lipovenous 10% formulations) while
enteral nutrition is being established or when enteral nutrition is not possible (e.g. because of
respiratory instability, feed intolerance, or serious gastrointestinal disease).
Total parenteral nutrition should consist of glucose and amino acid solution with electrolytes,
minerals, and vitamins, plus fat as the principal non-protein energy source. Bloodstream
infection is the most common important complication of parenteral nutrition use. Delivery of the
solution via a central venous catheter rather than a peripheral catheter is not associated with a
higher risk of infection. Extravasation injury is a major concern when parenteral nutrition is
given via a peripheral cannula. Subcutaneous infiltration of a hypertonic and irritant solution can
cause local skin ulceration, secondary infection, and scarring.
Routes of administration of parenteral nutrition
Intravenous solutions can be provided in different ways. The methods used depend on the
person’s immediate medical and nutrient needs, nutrition status and anticipated length of time on
IV nutrition support. They include:
 Peripheral Parenteral Nutrition (PPN)
 Central Parenteral Nutrition (TPN)

TOPIC: NUTRITION THERAPY IN CANCER

MEDICAL NUTRITION THERAPY FOR CANCER
Content
 Cancer disease overview
 Relationship between cancer and nutrition

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 Effect of cancer on nutrient intake

 Nutrition care

Definition of terms
 Cancer:
Refers to abnormal division and reproduction of cells that can spread throughout the
body, crowding out normal cells and tissues OR
Refers to diseases characterized by the uncontrolled growth of a group of cells, which can
destroy adjacent tissues and spread to other areas of the body via lymph or blood
 Malignant – describes a cancerous cell or tumor which can injure healthy tissues and
spread cancer to other regions of the body.
 Malignant neoplasm - a mass of cancer cells that invades surrounding tissues or spreads
to distant areas of the body; if left untreated, it will likely worsen and become possibly
fatal
 Carcinogen – an agent (physical, chemical, or viral) that induces cancer in humans and
animals OR It refers to substances that can cause cancer
 Carcinogenesis – the process of cancer development
 Cancer cachexia -a specific form of malnutrition characterized by loss of lean body
mass, muscle wasting, and impaired immune, physical, and mental function that
accompany advanced cancer, even with adequate nutrition. It may be related to elevated
levels of tumor necrosis factor
 It is a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with
or without loss of fat mass) that cannot be fully reversed by conventional nutritional
support and leads to progressive functional impairment.
 Tumor (neoplasm) – an abnormal tissue mass that has no physiological functions, a solid
cancer that causes a swelling or a lump; commonly defined as a malignant neoplasm
-Tumors can be benign or malignant (cancerous). Malignant tumor cells invade nearby
tissues and spread to other parts of the body. Benign tumor cells do not invade nearby
tissues or spread.
 Metastasize – to spread by cancer cells from one part of the body to another
 metastasis - growth of malignant tissue that spreads to surrounding tissues or organs
 Palliative care – to provide support and comfort when cure or control is not possible; to
improve quality of life; to reduce tumor burden and help relieve cancer-related symptoms
 Control – to extend the length of life when a cure is not possible; to obscure
microscopic metastases after tumors are surgically removed; to shrink tumors before
surgery or radiation therapy
 Cure - to obtain a complete response to treatment of a specific cancer

How cancer develops

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It is caused by mutations (changes) to the DNA within the cell. DNA is in the genes of the cell.
Cells are the smallest units of the body and they make up the body’s tissues. The DNA inside a
cell contains a set of instructions telling the cell what functions to perform, as well as how to
grow, repairs itself and divide. Errors in the instructions can cause the cell to stop its normal
function and may allow a cell to become cancerous.

Changes (mutations) in genes occur during carcinogenesis.

Changes (mutations) in genes can cause normal controls in cells to break down. When this
happens, cells do not die when they should and new cells are produced when the body does not
need them. The buildup of extra cells may cause a mass (tumor) to form.

Tumors can be benign or malignant (cancerous). Malignant tumor cells invade nearby tissues and
spread to other parts of the body. Benign tumor cells do not invade nearby tissues or spread.

What causes gene mutations/factors that increase the risk of cancer?

Gene mutations can occur for several reasons:
1. Gene mutations you're born with. You may be born with a genetic mutation that you
inherited from your parents. This type of mutation accounts for a small percentage of
cancers.

2. Gene mutations that occur after birth. Most gene mutations occur after you're born and
aren't inherited. The mutations are caused by e.g. as smoking, radiation, viruses, cancer-
causing chemicals, diet, obesity, hormones, chronic inflammation and a lack of exercise.

 Cigarette Smoking and Tobacco Use

Tobacco use is strongly linked to an increased risk for many kinds of cancer. Smoking
cigarettes is the leading cause of the following types of cancer:
 Acute myelogenous leukemia (AML), Bladder cancer., Esophageal cancer, Renal
cancer, Pelvis cancer, Rectum cancer, Liver cancer, Mouth cancer, Kidney cancer,
Lung cancer, Colon cancer, Oral cavity/nasal cavity cancer., Pancreatic cancer,
Stomach cancer.

 Infections

Certain viruses and bacteria are able to cause cancer. Viruses and other infection -causing
agents cause more cases of cancer in the developing world (about 1 in 4 cases of cancer)

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than in developed nations (less than 1 in 10 cases of cancer). Examples of cancer-causing

viruses and bacteria include:
 Human papillomavirus (HPV) increases the risk for cancers of
the cervix, penis, vagina, anus
 Hepatitis B and hepatitis C viruses increase the risk for liver cancer.
 Helicobacter pylori increases the risk for gastric cancer.
 Aflatoxins(toxins in moldy peanuts or grain)-liver cancer

Two vaccines to prevent infection by cancer-causing agents have already been developed
and approved by theU.S. Food and Drug Administration (FDA). One is a vaccine to
prevent infection with hepatitis B virus. The other protects against infection with strains
of human papillomavirus (HPV) that cause cervical cancer.

 Radiation

Being exposed to radiation is a known cause of cancer. There are two main types of
radiation linked with an increased risk for cancer:
Ultraviolet radiation from sunlight: This is the main cause of nonmelanoma skin cancers.
Ionizing radiation including:
o Medical radiation from tests to diagnose cancer such as x-rays, CT
scans, fluoroscopy, and nuclear medicine scans.
o Radon gas in our homes.

Ionizing radiation causes leukemia, thyroid cancer, and breast cancer in women. Ionizing
radiation also causes cancers of the lung, stomach, colon, esophagus, bladder, andovary.
Being exposed to radiation from diagnostic x-rays increases the risk of cancer in patients
and x-raytechnicians.

The growing use of CT scans over the last 20 years has increased exposure to ionizing
radiation. The risk of cancer also increases with the number of CT scans a patient has and
the radiation dose used each time.

 Immunosuppressive Medicines
Immunosuppressive medicines are linked to an increased risk of cancer. These medicines lower
the body’s ability to stop cancer from forming. For example, immunosuppressive medicines may
be used to keep a patient from rejecting an organ transplant.

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 Alcohol

Studies have shown that drinking alcohol is linked to an increased risk of the following
types of cancers: Oral, Esophageal cancer., Breast cancer, Colorectal cancer (in men),
Drinking alcohol may also increase the risk of liver cancer and female colorectal cancer.

 Physical Activity

Studies show that people who are physically active have a lower risk of certain cancers
than those who are not

Studies show a strong link between physical activity and a lower risk of colorectal
cancer. Some studies show that physical activity protects against postmenopausal breast
cancer and endometrial cancer.

 Obesity

Studies show that obesity is linked to a higher risk of the following types of cancer:
Postmenopausal breast cancer, Colorectal cancer, Endometrial cancer, Esophageal
cancer, Kidney cancer, Pancreatic cancer. Some studies show that obesity is also a risk
factor for cancer of the gallbladder.

 Environmental Risk Factors

Being exposed to chemicals and other substances in the environment has been linked to
some cancers:
Links between air pollution and cancer risk have been found. These include links
between lung cancer and secondhand tobacco smoke, outdoor air pollution, chromium
and asbestos.
Drinking water that contains a large amount of arsenic has been linked to skin, bladder,
and lung cancers.

 Diet -
Diets contain both inhibitors and enhancers of carcinogenesis. Examples of dietary
carcinogen inhibitors include: antioxidants (e.g. vitamin C, vitamin E, selenium, and
carotenoids) and phytochemicals. Dietary enhancers of carcinogenesis may be the fat in
red meat or the polycyclic aromatic hydrocarbons that form with the grilling of meat at
high heat
Some studies have shown that a diet high in fat, proteins, calories, and red meat increases
the risk of colorectal cancer. Some studies show that fruits and non-starchy
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vegetables may protect against cancers of the mouth, esophagus, and stomach. Fruits may
also protect against lung cancer.

Dietary factors that contribute to increased risk of cancer

Over Consumption of Energy (Calories)
Eating too much food is one of the main risk factors for cancer. This can be shown two ways:
i. By the additional risks of malignancies caused by obesity,
ii. By the protective effect of eating less food.

Overweight and obesity account for 14 percent of all cancer deaths (esophagus, colon and
rectum, liver, gallbladder, pancreas, kidney, stomach (in men), prostate, breast, uterus, cervix,
and ovary) in men and 20 percent of those in women
Glucose Metabolism
Refined sugar is a high energy, low nutrient food – junk food. "Unrefined" sugar (honey,
evaporated cane juice, etc) is also very concentrated and is likely to contribute to the same
problems as refined sugar. Refined wheat flour products are lacking the wheat germ and bran, so
they have 78 percent less fiber, an average of 74 percent less of the B vitamins and vitamin E,
and 69 percent less of the minerals.
Some case control studies have found consistent increased risk of a high glycemic load (index)
with gastric, upper aero digestive tract, endometrial, ovarian, colon or colorectal cancers
Low Fiber
Unrefined plant foods typically have an abundance of fiber. Dairy products, eggs, and meat all
have this in common – they contain no fiber. Refined grain products also have most of the
dietary fiber removed from them. So, a diet high in animal products and refined is low in fiber.
Refined grains have been found to be associated with increased risk of rectal cancer.
Red Meat
Red meat has been implicated in colon and rectal cancer. In some studies, meat and the
heterocyclic amines formed in cooking have been correlated to breast cancer.
Omega 3:6 Ratio Imbalance
In animal studies, omega 3 fats (alpha-linolenic acid, EPA, DHA) have been shown to be
protective from cancer, while omega 6 fats (linoleic acid, arachidonic acid) have been found to
be cancer promoting fats.
Flax seed
Flax seed is an excellent source of dietary fiber, omega 3 fat (as alpha-linolenic acid), and
lignans. The lignans in flax seed are metabolized in the digestive tract to enterodiol and

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enterolactone, which have estrogenic activity. In fact, flax seed is a more potent source of
phytoestrogens than soy products, as flax seed intake caused a bigger change in the excretion of
2-hydroxyestrone compared to soy protein.
Studies have found flax seed to be protective against cancer
Fruits and vegetables
The consumption of fruits and vegetables may provide some benefits in protecting against the
development of cancer. Fruits and vegetables contain both nutrients and phytochemicals with
antioxidant activity, and these substances may prevent or reduce the oxidative reactions that
cause DNA damage.
Phytochemicals may also help to inhibit carcinogen production in the body, enhance immune
functions that protect against cancer development or promote enzyme reactions that inactivate
carcinogens.
The B vitamin folate, which is provided by certain fruits and vegetables plays roles in DNA
synthesis and repair, thus inadequate folate intakes may allow DNA damage to accumulate.
Fruits and vegetables also contribute dietary fiber, which may help to protect against colon and
rectal cancers by diluting potential carcinogens in fecal matter and accelerating their removal
form the GI tract.
Summary: Nutrition-related factors that influence cancer risk
Nutrition-related factors Cancer sites
Factors that may increase cancer risk
Obesity Esophagus, colon, rectum, pacrease,
gallbladder, kidney, breast (postmenopausal),
endometrium
Red meat, processed meats Colon, rectum
Salted and salt-preserved foods Stomach
Beta-carotene supplements Lung
High calcium diets (over 1500 mg daily) Prostate
Alcohol Mouth, pharynx, larynx, esophagus, colon,
rectum, liver, breast (postmenopausal)
Low level of physical activity Colon, breast (postmenopausal), endometrium
Factors that may decrease cancer risk
Fruits and nonstarchy vegetables Lung, mouth, pharynx, larynx, esophagus,
stomach
Carotenoid-containing foods Lung, mouth, pharynx, larynx, esophagus
Tomato products Prostate
Allium vegetables (onion, garlic) Stomach, colon, rectum
Vitamin C – containing foods Esophagus
Folate – containing foods Esophagus
Fiber- containing foods Colon, rectum
Milk an calcium supplements Colon, rectum

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High level of physical activity Colon, breast (postmenopausal), endometrium

N/B. Food preparation methods are responsible for producing certain types of carcinogens.
Cooking meat, poultry, and fish at high temperatures (frying, broiling) causes the amino acids
and creatine in these foods to react together and form carcinogens. Carcinogens also accompany
the smoke that adheres to foods during grilling and are present in the charred surfaces of grilled
meat and fish.

N/B. Gene mutations occur frequently during normal cell growth. However, cells contain a
mechanism that recognizes when a mistake occurs and repairs the mistake. Occasionally, a
mistake is missed. This could cause a cell to become cancerous. Carcinogenesis often proceeds
slowly and continues for several decades.

Classification of cancers
Cancers are classified by the tissues or cells from which they develop
 Adenocarcinomas – arise from glandular tissues
 Carcinomas – arise from epithelial tissues
 Leukemias – arise from white blood cell precursors
 Lymphomas – arise from lymphoid tissues
 Melanomas – arise from pigmented skin cells
 Myelomas – arise from plasma cells in the bone marrow
 Sarcomas – arise from connective tissues, such as muscle or bone

All this has resulted into e.g. Cancer of the ureter, leukemia (Cancer of the blood and bone
marrow), Anal cancer, Basal cell carcinoma(Cancer of the skin), Gallbladder cancer, Breast
cancer, Carcinoid tumors, Cervical cancer, Colon cancer, Esophageal cancer, Eye melanoma,
Stomach cancer, Vaginal cancer, Tonsil cancer, Tongue cancer, Thyroid cancer, Throat cancer,
Testicular cancer, Prostrate cancer, Small bowel cancer, Skin cancer, Kidney cancer, Rectal
cancer, Osteosarcoma, Ovarian cancer, Pancreatic cancer, Oral/ Mouth cancer, Male breast
cancer, Lip cancer, Liver cancer. Lung cancer, Head and neck cancer e.t.c

Consequences of cancer
Nonspecific effects of cancer include:
 Anorexia
 Lethargy
 weight loss/wasting
 night sweats
 fever

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NB: During the early stages, many cancers produce no symptoms, and the person may be
unaware of the threat to health.
 Wasting associated with cancer
 Anorexia, muscle wasting, weight loss, anemia and fatigue typify cancer cachexia.

Cancer cachexia – Is a multifactorial syndrome defined by an ongoing loss of skeletal muscle

mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional
support and leads to progressive functional impairment
 In addition to weight loss, cancer patients often experience loss of lean body mass, or
muscle mass. Loss of muscle mass can result in decreased immunity, increased
infections, increased skin breakdown, decreased healing, and increased mortality.

How is wasting is brought about?

 Metabolic changes
Cancer patients exhibit an increased rate of protein turnover but reduced muscle protein
synthesis. Muscle contributes amino acids for glucose production, further depleting the
body’s supply of protein. Triglyceride breakdown increases, elevating serum lipids. Many
patients also develop insulin resistance.
 Anorexia and reduced food intake
Anorexia is a major contributor to the wasting associated with cancer. Some factors that
contribute to anorexia or otherwise reduce food intake include:
 Chronic nausea and early satiety
 Fatigue
 Pain
 Mental stress
 Gastrointestinal obstructions e.g. a tumor obstructing a portion of the GI tract
 Effects of cancer therapies – chemotherapy and radiation treatments for cancer
frequently have side effects that make food consumption difficult, such as nausea,
vomiting, altered taste perceptions, mouth sores, inflammation of mucosal tissue,
abdominal pain or discomfort, and diarrhea

Treatments for cancer

Treatment for cancer include: surgery, chemotherapy, radiation therapy, or any combination
of the three; with the aim to:
- Remove cancer cells
- Prevent further tumor growth
- Alleviate symptoms

(i) Surgery – is performed to remove tumors, determine the extent of cancer, and protect nearby
tissues
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The acute metabolic stress caused by surgery raises protein and energy needs and can
exacerbate wasting. Surgery also contributes to pain, fatigue, and anorexia.
(ii) Chemotherapy – relies on use of drugs to treat cancer, and is used to inhibit tumor growth,
shrink/localized tumors before surgery, and prevent or eradicate metastasis. Some cancer
drugs interfere with the process of cell division; others sterilize cells that are in a resting
phase and not actively dividing.
(iii) Radiation therapy – treats cancer by bombarding cancer cells with X-rays, gamma rays, or
various atomic particles. These treatments damage cellular DNA and cause cell death.
It can cause damage of healthy tissues and sometimes has long term detrimental effects on
nutrition status. Radiation to the head and neck area can damage the salivary glands and taste
buds, causing inflammation, dry mouth, and reduced sense of taste.
(iv) Hematopoietic stem cell transplantation – replaces the blood-forming stem cells that have
been destroyed by high-dose chemotherapy or radiation therapy. These procedures may be
used to treat leukemia, lymphomas and multiple myeloma.
(v) Biologic Therapies – Use of biological molecules that stimulate immune responses against
cancer cells (also called immunotherapy). These substances include antibodies, cytokines,
and other proteins that strengthen the body’s immune defenses, enable the destruction of
cancer cells, or interfere with cancer development in some way. Many of these treatments
can cause anorexia, GI symptoms, and general discomfort, reducing a person’s ability or
desire to consume adequate amounts of food.
(vi) Nutrition Therapy –Use of diet to improve patients’ nutritional status and help patients to
maintain body weight, maintain lean body mass, better tolerate treatment, and improve
quality of life. Cancer patients face many challenges, including poor nutritional status,
weight loss, and malnutrition For some patients, the nutritional deficits can proceed to cancer
cachexia, a specific form of malnutrition characterized by loss of lean body mass, muscle
wasting, and impaired immune, physical, and mental function

The objective of nutrition therapy for cancer patients are:

 To minimize loss of weight and muscle tissue
 Correct deficiencies
 Provide a diet that patients can tolerate and enjoy despite the complications of illness

Proper nutrition helps patients maintain weight, tolerate treatment, maximize outcomes,
and improve quality of life

 Protein and energy

 For maintenance of body weight and lean tissue, suggest 1.0 to 1.5 g protein/kg body
weight; and 25-35 kcal/kg body weight daily.

 For weight regain and repletion of muscle tissue, suggest 1.5 to 2.0 g protein/kg body
weight; and 35 to 45 kcal/kg body weight daily.
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 Increase calories e.g. by frying foods and using gravies, mayonnaise, and salad dressings.
Supplements high in calories and protein can also be used.

 Choose high-protein and high-calorie foods to increase energy and help wounds heal.
Good choices include: eggs, cheese, whole milk, ice cream, nuts, peanut butter, meat,
poultry, and fish.

Although weight loss is a problem for many cancer patients, breast cancer patients often gain
weight. The weight gain occurs during the first two years after breast cancer diagnosis and is
associated with an increase in total body fat. Thus, there is need to help these patients avoid
unnecessary weight gain.
 Enteral and parenteral nutrition support

Nutrition support is used in limited situations during cancer treatment. Generally, tube feeding
and parenteral nutrition are provided to patients who have long-term or permanent
gastrointestinal impairment or are experiencing complications that interfere with food intake.
 Enteral nutrition (feeding liquid through a tube into the stomach or intestines), parenteral
nutrition (feeding through a catheter into the bloodstream).

 Nutrition therapy for side effects of cancer treatments and the caner itself

Loss of appetite :May be due to the cancer itself, treatment and psychological factors
 Eat small, frequent, high-calorie meals and snacks such as juices, soups, milk, shakes, and fruit
smoothies at regular times each day(every 2hours)
 Add extra protein and calories to food.
 Eat the largest meal at the time of day when you feel the best
 Include nutrient dense foods in meals, and consume them before other foods
 Indulge in favorite foods throughout the day. Serve foods attractively
 Avoid drinking large amounts of liquids before or with meals
 Eat in relaxed and pleasant environment. Eat with family members and friends when
possible
 Listen to your favourite music or enjoy a TV or radio program while eating
 Ask your doctor about appetite enhancing medications

Types of foods are usually recommended

 Cheese and crackers (a baked food typically made from flour. Flavorings or seasonings,
such as herbs, seeds, and/or cheese, may be added to the dough or sprinkled on top before
baking), Muffins, Puddings, Nutritional supplements, Milkshakes, Yogurt, Ice cream,
Powdered milk added to foods such as pudding, milkshakes, or any recipe using milk,
Finger foods (handy for snacking) such as deviled eggs, cream cheese or peanut butter on
crackers or celery, or deviled ham on crackers, Chocolate.

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When food don’t just taste right/ Alterations of taste and smell: May be due to the cancer
itself, radiation, dental problems, chemotherapy infections (thrush) and medications
Taste dysfunction can result in food avoidance and dislike that may result into weight loss
 Brush teeth or use mouthwash, or rinse the mouth before eating
 Eat small, frequent meals and healthy snacks.
 Be flexible. Eat meals when hungry rather than at set mealtimes.
 Try favorite foods.
 Plan to eat with family and friends.
 Have others prepare the meal.
 Try new foods when feeling best.
 Use sugar-free lemon drops, gum, or mints when experiencing a metallic or bitter taste in
the mouth.
 Add spices and sauces to foods.
 Consume foods chilled or at room temperature.
 Use plastic utensils rather than metal eating utensils if foods taste metallic
 Choose eggs, fish, poultry and milk products instead of meats
 Add spices or flavorings to foods. Citrus may be tolerated well if no mouth sores or
mucositis/stomatitis is present.
 Experiment with sauces, seasonings, herbs, spices, and sweeteners to improve food taste
and flavor
 Save your favorite foods for times when you are not feeling nauseated
Nauseated a lot of the time and sometimes need to vomit

Nausea can affect the amount and types of food eaten during treatment. Eating before
treatment is important, as well as finding foods that do not trigger nausea.

Frequent triggers for nausea include spicy foods, greasy foods, or foods that have strong odors.
 If nausea comes from chemotherapy treatment, then avoid eating for at least hours before
treatment
 Consume your largest meal at a time when you are least likely to feel nauseous
 Try consuming meals, and eat slowly. Experiment with foods to see if some foods cause
nausea more than others
 Frequent eating, and slowly sipping on fluids throughout the day may help.
 Eat dry foods such as crackers, breadsticks, or toast, throughout the day.
 Sit up or recline with a raised head for 1 hour after eating.
 Eat bland, soft, easy-to-digest foods rather than heavy meals.
 Avoid eating in a room that has cooking odors or is overly warm; keep the living space
comfortable but well ventilated.
 Avoid foods and meals that have strong odors or are fatty, greasy or gas forming
Problems with chewing and swallowing food
 Experiment with food consistencies to find the ones you can manage best. Thin liquids, dry
foods, and sticky foods (such as peanut butter) are often difficult to swallow
 Add sauces and gravies to dry foods
 Drink fluids during meals to ease chewing and swallowing

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 Try using a straw to drink liquids. Experiment with beverage thickness if you cannot
tolerate thin beverages
 Tilt head forward and backward to see if you can swallow more easily when your head is
positioned differently
Dry mouth/xerostomia: May be due radiation directed at the head and neck, and
medications
Dry mouth may affect speech, taste sensation, ability to swallow, and use of oral
prostheses (is an artificial device that replaces a missing body part, which may be lost
through trauma, disease, or congenital conditions). There is also an increased risk of
cavities and periodontal disease because less saliva is produced to cleanse the teeth and
gums
 Try eating chilled or frozen foods, they are often smoothening
 Try soft foods such as ice cream, milk shakes, bananas, mashed potatoes, macaroni etc.
mix dry foods with sauces or gravies
 Cut foods into smaller pieces, so they are less likely to irritate the mouth
 Avoid foods irritate mouth sores, such as citrus fruits and juices, tomatoes & products,
spicy foods, foods that are salty, foods with seeds that can scrape the sores and coarse
foods such as raw vegetables, crackers, corn chips and toast
 Use straw for drinking liquids in order to bypass the sores
Dry mouth(continuation)
 Rinse mouth with warm salt water or mouthwash frequently. Avoid using mouthwash/rises
that contains alcohol
 Drink small amounts of liquid frequently between meals-plenty of liquids (25-30 mL/kg
per day) Perform oral hygiene at least 4 times per day (after each meal and before
bedtime).
 Brush and rinse dentures (mouth) after each meal.
 Keep water handy at all times to moisten the mouth.
 Consume very sweet or tart foods and beverages, which may stimulate saliva.
 Contact your doctor/pharmacist about medications or saliva substitute that can help a dry
mouth condition
 Use sour candy or chewing gum to stimulate the flow of saliva
 Slip fluids frequently while eating. Add broth, sauces, gravies, butter/margarine to foods
 Make sure to brush teeth and floss regularly to prevent tooth decay and oral infections
Constipation
Constipation is defined as fewer than three bowel movements per week. It is a very common
problem among individuals with cancer and may result from lack of adequate fluids or
dehydration, lack of fiber in the diet, physical inactivity or immobility, anticancer therapies
such as chemotherapy, and medications used in the treatment of side effects of anticancer
therapy such as antiemetics and opioids (medications that relieve pain).

 Drink plenty of fluids. Try warm fluids, especially in the morning

 Eat more fiber: whole-grain breads and cereals, nuts, fresh fruits and vegetables, prunes,
and prune juices. Avoid refined carbohydrate foods such as white bread, oatmeal, corn,
pears, popcorn, broccoli, carrots, cabbage, cauliflower, beans, oranges, popcorn, onions,
white rice and pasta. The recommended fiber intake is 25 to 35 grams per day. Fiber

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should be gradually added to the diet, and adequate fluids must be consumed at the same
time.
 Engage in physical activity regularly

[Note: *These food items may cause gas; products containing alpha-galactosidase enzyme may be
helpful.]

Diarrhea: May be due radiation, chemotherapy, gastrointestinal surgery, or emotional

distress
 To avoid dehydration and hypokalemia, drink plenty of fluids throughout the day. Salty
broths and soups, bananas, diluted fruit juices, and sports drinks are good choices.
 Avoid hot or cold liquids, caffeine and alcohol containing beverages. For severe diarrhea
try oral rehydration formulas that are commercially prepared
 Avoid foods and beverages that increase gas, such as legumes e.g. beans, onions,
vegetables of the cabbage family, foods that contain sorbitol or mannitol(gum made with
alcohol), chewing gum and carbonated beverages
 Drink plenty of fluids through the day; room-temperature fluids may be better tolerated, at
least 1 cup of liquid after each loose bowel movement.
 Limit milk to 2 cups or eliminate milk and milk products until the source of the problem is
determined.
 Try using lactase enzyme replacements when you use milk products in case you are
experiencing lactose intolerance. E.g. yogurt may be easier to tolerate than milk
 Avoid fatty foods if you are fat intolerant
 Eat small, frequent meals instead of large ones. Try consuming cool or lukewarm foods
instead of very cold or hot foods
 Ask your doctor about using bulk-forming agent or antidiarrheal medication
Hydration and dehydration
 Drink 8 to 12 cups of liquids a day; take a water bottle whenever leaving home. It is
important to drink even if not thirsty, as the thirst sensation is not a good indicator of fluid
needs.
 Limit consumption of caffeine-containing products, including colas and other caffeinated
sodas, coffee, and tea (both hot and cold).
 Drink most liquids after and/or between meals to increase overall consumption of both
liquids and solids
 Use antiemetics (a drug that is effective against vomiting and nausea) for relief from
nausea and vomiting

Mucositis/stomatitis
 Stomatitis, or a sore mouth, can occur when cells inside the mouth, which grow and divide
rapidly, are damaged by treatment such as bone marrow transplantation, chemotherapy,
and radiation therapy. These treatments may also affect rapidly dividing cells in the bone
marrow, which may make patients more susceptible to infection and bleeding in their
mouth
 Eat soft foods that are easy to chew and swallow such as soft fruits; bananas, pear,
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watermelon; cottage cheese; mashed potatoes; macaroni and cheese; custards; puddings;
gelatin; milkshakes; scrambled eggs; oatmeal or other cooked cereals; pureed or mashed
vegetables such as peas and carrots; and pureed meats.
 Avoid foods that irritate the mouth, including citrus fruits and juices such as orange,
grapefruit, or tangerine; spicy or salty foods;
 Cook foods until soft and tender.
 Cut foods into small pieces.
 Use a straw to drink liquids. Eat foods cold or at room temperature; hot and warm foods
can irritate a tender mouth.
 Practice good mouth care, which is very important because of the absence of the
antimicrobial effects of saliva.
 Increase the fluid content of foods by adding gravy, broth, or sauces.
 Supplement meals with high-calorie, high-protein drinks.
 Numb the mouth with ice chips or flavored ice pops.

Neutropenia
 People with cancer may have a low white blood cell count for a variety of reasons, some
of which include radiation therapy, chemotherapy, or the cancer itself. Patients who have a
low white blood cell count are at an increased risk for developing an infection.
 Suggestions for helping people prevent infections related to neutropenia include the
following:
 Check expiration dates on food and do not buy or use if the food is out of date.
 Do not buy or use food in cans that are swollen, dented, or damaged.
 Thaw foods in the refrigerator or microwave—never thaw foods at room temperature.
 Cook foods immediately after thawing.
 Refrigerate all leftovers within 2 hours of cooking and eat them within 24 hours.
 Keep hot foods hot and cold foods cold.
 Avoid old, moldy, or damaged fruits and vegetables.
 Cook all meat, poultry, and fish thoroughly; avoid raw eggs or raw fish.
 Buy individually packaged foods, which are better than larger portions that result in
leftovers.
 Limit exposure to large groups of people and people who have infections.
 Wash hands frequently to prevent the spread of bacteria.
 This list may be modified after chemotherapy or when blood count returns to norm

Effects of Cancer Treatment on Nutrition

Surgery and Nutrition (Surgery increases the body's need for nutrients and energy)

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Surgery increases the body's need for nutrients and energy for wound healing,
o
fight infection, and recover from surgery. If the patient is malnourished before
surgery, it may cause problems during recovery, such as poor healing or infection.
For these patients, nutrition care may begin before surgery.
o Surgery to the head, neck, esophagus, stomach, or intestines may affect nutrition
as they cause problems with Chewing, Swallowing, Tasting or smelling food,
Making saliva, Seeing. Stay away from carbonated drinks (such as sodas) and
foods that cause gas, such as: Beans, peas, broccoli, cabbage, Brussels sprouts,
green peppers, radishes and cucumbers. .
Nutrition therapy may include the following:
 Nutritional supplement drinks.
 Enteral nutrition (feeding liquid through a tube into the stomach or intestines).
 Parenteral nutrition (feeding through a catheter into the bloodstream).
 Medicines to increase appetite.

Chemotherapy and Nutrition

Chemotherapy may cause side effects that cause problems with eating
o
and digestion. When more than one anticancer drug is given, more side effects
may occur or they may be more severe.
o The following side effects are common: Loss of appetite; inflammation, and sores
in the mouth; changes in the way food tastes; feeling full after only a small
amount of food; nausea; vomiting; diarrhea; constipation.
Nutrition therapy may include the following:
 Nutrition supplement drinks between meals.
 Enteral nutrition (tube feedings).
 Changes in the diet, such as eating small meals throughout the day.

Radiation Therapy and Nutrition

Radiation therapy can affect cancer cells and healthy cells in the treatment area.
Radiation therapy can kill cancer cells and healthy cells in the treatment area. The
amount of damage depends on the part of the body that is treated; and the
total dose of radiation and how it is given.
Radiation therapy may affect nutrition.
Radiation therapy to any part of the digestive system often has side effects that cause nutrition
problems. Most of the side effects begin a few weeks after radiation therapy begins and go away
a few weeks after it is finished. Some side effects can continue for months or years after
treatment ends. The following are some of the more common side effects:
 For radiation therapy to the head and neck
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oLoss of appetite.
o Changes in the way food tastes.
o Pain when swallowing.
o Dry mouth or thick saliva.
o Sore mouth and gums.
o Narrowing of the upper esophagus, which can cause choking, breathing, and
swallowing problems.
 For radiation therapy to the chest

Infection of the esophagus.

o
o Trouble swallowing.
o Esophageal reflux (a backward flow of the stomach contents into the esophagus).
 For radiation therapy to the abdomen or pelvis
o Diarrhea.
o Nausea.
o Vomiting.
o Inflamed intestines or rectum
o A decrease in the amount of nutrients absorbed by the intestines.
Radiation therapy may also cause tiredness, which can lead to a decrease in appetite.
Nutrition therapy can help relieve the nutrition problems caused by radiation therapy.
Nutrition therapy during radiation treatment can help the patient get enough protein and calories
to get through treatment, prevent weight loss, help wound and skin healing, and maintain general
health. Nutrition therapy may include the following:
 Nutritional supplement drinks between meals.
 Enteral nutrition (tube feedings).
 Changes in the diet, such as eating small meals throughout the day.
Patients who receive high-dose radiation therapy to prepare for a bone marrow transplant may
have many nutrition problems and should see a dietitian for nutrition support.
Biologic Therapy and Nutrition
Biologic therapy may affect nutrition.
The side effects of biologic therapy are different for each patient and each type of biologic agent
The following nutrition problems are common:
 Fever.
 Nausea.
 Vomiting.
 Diarrhea.
 Loss of appetite.
 Tiredness.

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 Weight loss

Stem Cell Transplant and Nutrition

Stem cell transplant patients have special nutrition needs.

Chemotherapy, radiation therapy, and medicines used for a stem cell transplant may cause side
effects that keep a patient from eating and digesting food as usual. Common side effects include
the following:
 Changes in the way food tastes.
 Dry mouth or thick saliva.
 Mouth and throat sores.
 Nausea.
 Vomiting.
 Diarrhea.
 Constipation.
 Weight loss and loss of appetite.
 Weight gain.

Nutrition therapy is very important for patients who have a stem cell transplant.
Transplant patients have a very high risk of infection. High doses of chemotherapy or radiation
therapy decrease the number of white blood cells, which fight infection. It is especially important
that transplant patients avoid getting infections.
Patients who have a transplant need plenty of protein and calories to get through and recover
from the treatment, prevent weight loss, fight infection, and maintain general health. It is also
important to avoid infection from bacteria in food. Nutrition therapy during transplant treatment
may include the following:
 A diet of cooked and processed foods only, because raw vegetables and fresh fruit may
carry harmful bacteria.
 Guidelines on safe food handling.
 A specific diet based on the type of transplant and the part of the body affected by cancer.
 Parenteral nutrition (feeding through the bloodstream) during the first few weeks after the
transplant, to give the patient the calories, protein, vitamins, minerals, and fluids they
need to recover.

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Nutrition in Advanced Cancer

Advanced cancer is often associated with cachexia. Individuals diagnosed with cancer may
develop new, or worsening, nutrition-related side effects as cancer becomes more advanced. The
most prevalent symptoms in this population are the following:
 Weight loss.
 Early satiety.
 Bloating.
 Anorexia.
 Constipation.
 Xerostomia.
 Taste changes.
 Nausea.
 Vomiting.
 Dysphagia.

As defined by the WHO, palliative care is an approach that improves the quality of life of
patients and their families facing the problems associated with life-threatening illness, through
treatment of pain and other problems, physical, psychosocial, and spiritual.

The goal of palliative care is to give relief of symptoms that are bothersome to the patient.
Although some of the symptoms listed above can be effectively treated, anorexia, though
common, is a symptom that is often not noted as problematic for most terminally ill patients but
is distressing to most family members; this distress may vary according to cultural factors.
Terminally ill patients lack hunger, and of those who do experience hunger, the symptom is
relieved with small amounts of oral intake.

Decreased intake, especially of solid foods, is common as death becomes imminent. Individuals
usually prefer and tolerate soft-moist foods and refreshing liquids (full and clear liquids). Those
who have increased difficulty swallowing have less incidence of aspiration with thick liquids
than with thin liquids.

Dietary restriction is not usually necessary, as intake of prohibited foods (e.g., sweets in the
diabetic patient) is insufficient to be of concern. As always, food should continue to be treated
and viewed as a source of enjoyment and pleasure. Eating should not just be about calories,
protein, and other macronutrient and micronutrient needs.

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TOPIC: MUSCULOSKELETOL DISORDERS

MUSCULOSKELETAL DISORDER

 Musculoskeletal disorders are injuries and disorders that affect the human body’s
movement or musculoskeletal system (i.e. muscles, tendons, ligaments, nerves, discs,
blood vessels, etc.).
 Musculoskeletal disorders include arthritis, gout, lupus, fibromyalgia, osteoporosis,
osteomalacia e.tc
 There are over 100 types of arthritis. The most common forms are osteoarthritis
(degenerative joint disease) and rheumatoid arthritis.

 Musculoskeletal disorders are one of the most common work-related ailments.

 Musculoskeletal disorders usually affect the back, neck, shoulders and upper limbs, but
lower limbs can also be affected. In more chronic cases, they can even lead to disability
and the need to give up work.

Causes of musculoskeletal disorders

There is usually no single cause of MSDs; various factors often work in combination. Physical
causes and risk factors include:

 Handling loads, especially when bending and twisting

 Repetitive or forceful movements
 Awkward and static postures
 Vibration, poor lighting or cold working environments
 Fast-paced work
 Prolonged sitting or standing in the same position

Types of musculoskeletal disorders

Arthritis.

Arthritis comes from the Greek word arthron meaning “joint”

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Arthritis therefore refers to an inflammation of one or more joints. Symptoms include Pain,
stiffness, swelling, redness, and decreased range of motion

The most common forms are osteoarthritis (degenerative joint disease) and rheumatoid arthritis

Rheumatoid arthritis

 Rheumatoid arthritis is an autoimmune chronic inflammatory disorder that mostly affects

the joints of the hips, hands, wrists, elbows, knees, ankles, arms, and feet, causing them
to become extremely painful, stiff, and even deformed but in some people, the condition
also can damage a wide variety of body systems, including the skin, eyes, lungs, heart
and blood vessels. Severe damage of the joint can result into disability.

Cause

It is an autoimmune disorder that occurs when your immune system mistakenly attacks your own
body's tissues. This creates inflammation that causes the tissue that lines the inside of joints (the
synovium) to thicken (inflamed) and secretes more fluid, resulting in swelling of the joints, and
pain in and around the joints.

The synovium makes a fluid that lubricates joints and helps them move smoothly.

If inflammation goes unchecked, it can damage cartilage, the elastic tissue that covers the ends of
bones in a joint, as well as the bones themselves. Over time, there is loss of cartilage, and the
joint spacing between bones can become smaller. Joints can become loose, unstable, painful and
lose their mobility. Joint deformity also can occur.

The joint effect is usually symmetrical. That means if one knee or hand if affected, usually the
other one is, too. Because RA also can affect body systems, such as the cardiovascular or
respiratory systems, it is called a systemic disease. Systemic means “entire body.”

Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of your
joints, causing a painful swelling that can eventually result in bone erosion and joint deformity.

The inflammation associated with rheumatoid arthritis is what can damage other parts of the
body as well.

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 Rheumatoid arthritis symptoms and signs include

 joint pain, such as in the joints of the feet, hands, and knees,
 swollen joints,
 afever,
 limping,
 polyarthritis,
 Non joint effects such as anemia due to chronic disease, decrease in saliva secretions and
dysphagia that can result into malnutrition

Medications

The types of medications recommended depend on the severity of the symptoms and how long
you've had rheumatoid arthritis.

 NSAIDs (Nonsteroidal anti-inflammatory drugs).They relieve pain and reduce

inflammation. Over-the-counter NSAIDs include ibuprofen and naproxen sodium
(Aleve). Stronger NSAIDs are available by prescription. Side effects may include ringing
in your ears, stomach irritation, heart problems, and liver and kidney damage.
 Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain
and slow joint damage. Side effects may include thinning of bones, weight gain and
diabetes.
 Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the
progression of rheumatoid arthritis and save the joints and other tissues from permanent
damage. Common DMARDs include methotrexate (Trexall, Otrexup, Rasuvo),
leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).
 Drugs that target cytokines-cytokines are substances produced in tissues, that can cause
inflammatory changes in tissue cells( e.g. tumor necrosis factor and interleukin-1)

Side effects vary but may include liver damage, bone marrow suppression and severe
lung infections.
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Therapy

Your doctor may send you to a physical or occupational therapist who can teach you exercises to
help keep your joints flexible. The therapist may also suggest new ways to do daily tasks, which
will be easier on your joints. For example, if your fingers are sore, you may want to pick up an
object using your forearms.

Surgery

If medications fail to prevent or slow joint damage, surgery may be done to repair damaged
joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct
deformities.

Rheumatoid arthritis surgery may involve one or more of the following procedures:

 Synovectomy. Surgery to remove the inflamed synovium (lining of the joint).

Synovectomy can be performed on knees, elbows, wrists, fingers and hips.
 Tendon repair. Inflammation and joint damage may cause tendons around your joint to
loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
 Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint
and for pain relief when a joint replacement isn't an option.
 Total joint replacement. During joint replacement surgery, your surgeon removes the
damaged parts of your joint and inserts a prosthesis made of metal and plastic.

Surgery carries a risk of bleeding, infection and pain.

Nutrition therapy

Energy: Energy needs vary depending on individual needs. A high energy diet is needed
because of increased fever, sepsis, stressed of the disease skeleton injury or surgery

A high energy diet is also required if the patient is on physical therapy

Protein: Protein needs vary with protein status, surgical therapy, proteinuria, and nitrogen
balance. A well-nourished adult patient needs about 0.5 to 1 g of protein/kg/day during quit
disease periods. An increase to 1.5 to 2 g/kg/day is needed during active inflammatory disease
periods.

Vitamin minerals. Adequate minerals and vitamins are required. Calcium and vitamin D may be
supplemented if the patient is undergoing steroid therapy or the disease is severe

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Alternative medicine

Some common complementary and alternative treatments that have shown promise for
rheumatoid arthritis include:

 Fish oil. Some preliminary studies have found that fish oil supplements may reduce
rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a
fishy taste in the mouth. Fish oil can interfere with medications.
 Plant oils. The seeds of evening primrose, borage and black currant contain a type of
fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects
may include nausea, diarrhea and gas.
 Tai chi. This movement therapy involves gentle exercises and stretches combined with
deep breathing. Many people also use tai chi to relieve stress in their lives. But don't do
any moves that cause pain.

Osteoarthritis

 This is the milder and most common form of arthritis affecting millions of people
worldwide. It accounts for 60% to 70% of the joint diseases. It is sometimes called
degenerative joint disease or “wear and tear” because there is no inflammation involved.
 Osteoarthritis is a chronic condition that mostly affects older adults (over 40 years).
 It occurs when the protective cartilage of the bones wears down over time or when
cushion between joints breaks down leading to pain, stiffness and swelling.
 Although osteoarthritis can damage any joint in your body, the disorder most commonly
affects joints in your hands, wrist, knees, neck, hips and spine (back).
 Unlike many other forms of arthritis, such as rheumatoid arthritis and systemic lupus,
osteoarthritis does not affect other organs of the body.

Symptoms

 The main symptoms of osteoarthritis are joint pain and stiffness, particularly first thing
in the morning or after resting
 Some people also experience swelling, tenderness and a grating or crackling sound
when moving the affected joints. Affected joints may get swollen after extended activity.
 Other symptoms of osteoarthritis include bone spurs(feeling of hard lumps around the
affected joints)

The severity of osteoarthritis symptoms can vary greatly from person to person, and between
different affected joints.

For some people, the symptoms can be mild and may come and go. Other people can experience
more continuous and severe problems which make it difficult to carry out everyday activities.

Almost any joint can be affected by osteoarthritis, but the condition most often causes problems
in the knees, hips and small joints of the hands.

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In severe osteoarthritis, complete loss of cartilage causes friction between bones, causing pain at
rest or pain with limited motion.

Causes

Osteoarthritis has no specific cause. Several factors lead to the development of osteoarthritis
including:

 Joint injury – overusing your joint when it hasn't had enough time to heal after an injury
or operation
 Other conditions (secondary arthritis) – osteoarthritis can occur in joints severely
damaged by a previous or existing condition, such as rheumatoid arthritis or gout
 Age – your risk of developing the condition increases as you get older. It mostly occurs
in people aged 50 years or older
 Family history – osteoarthritis may run in families, although studies haven't identified a
single gene responsible
 Obesity/overweight – being obese puts excess strain on your joints, particularly those
that bear most of your weight, such as your knees and hips

In osteoarthritis, the protective cartilage on the ends of your bones breaks down, causing pain,
swelling and problems moving the joint. Bony growths can develop, and the area can become
inflamed (red and swollen).

Diagnosis

The diagnosis of osteoarthritis includes a medical history and a physical examination. These may
be followed by laboratory tests, X-rays, and a magnetic resonance imaging (MRI) scan.
Osteoarthritis may suspect if:

 you're aged 50 or older

 you have joint pain that gets worse the more you use your joints
 you have stiffness in your joints in the morning that lasts less than 30 minutes, or no
stiffness at all

If your symptoms are slightly different from those listed above, this may indicate another joint
condition. For example, prolonged joint stiffness in the morning can be a sign of rheumatoid
arthritis.

Treatment

Osteoarthritis is a long-term condition and can't be cured, but it doesn't necessarily get any worse
over time and it can sometimes gradually improve. A number of treatments are also available to
reduce the symptoms.

Regular exercise/ physical activity e.g. swimming, walking around the neighborhood

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 One of the most beneficial ways to manage osteoarthritis is to get moving. While it may
be hard to think of exercise when the joints hurt, moving is considered an important part
of the treatment plan.
 Strengthening exercises build muscles around the affected joints, easing the burden on
those joints and reducing pain. Improve joint flexibility and reduce stiffness. Exercise
also help to reduce excess weight.

Losing weight if you're overweight.

 Excess weight adds additional stress to weight-bearing joints, such as the hips, knees,
feet and back.
 Losing weight can help people with osteoarthritis reduce pain and limit further joint
damage.
 The basic rule for losing weight is to eat fewer calories and increase physical activity

Wearing suitable footwear

Medicines (Painkilling medications)

They are available as pills, syrups, creams or lotions, or they are injected into a joint. They
include:

 Analgesics. These are pain relievers e.g. acetaminophen, opioids (narcotics).They are
available over-the-counter or by prescription.
 Nonsteroidal anti-inflammatory drugs (NSAIDs). These are the most commonly used
drugs to ease inflammation and related pain. NSAIDs include aspirin, ibuprofen and
naproxen. They are available over-the-counter or by prescription. NSAIDs can cause
stomach upset, cardiovascular problems, bleeding problems, and liver and kidney damage
 Corticosteroids. Corticosteroids are powerful anti-inflammatory medicines. They are
taken by mouth or injected directly into a joint
 Hyaluronic acid. Hyaluronic acid occurs naturally in joint fluid, acting as a shock
absorber and lubricant. However, the acid appears to break down in people with
osteoarthritis. The injections are done in the hospital.

Occupational Therapy

 An occupational therapist can help you discover ways to do everyday tasks or do your job
without putting extra stress on your already painful joint. For instance, a toothbrush with
a large grip could make brushing your teeth easier if you have finger osteoarthritis. A
bench in your shower could help relieve the pain of standing if you have knee
osteoarthritis.

Tai chi and yoga.

 These movement therapies involve gentle exercises and stretches combined with deep
breathing.

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 Many people use these therapies to reduce stress in their lives, and research suggests that
tai chi and yoga may reduce osteoarthritis pain and improve movement.
 When led by a knowledgeable instructor, these therapies are safe. Avoid moves that
cause pain in your joints.
 Massage and relaxation techniques can also help in reducing the pain

Surgery (joint replacement surgery)

 In a small number of cases, where the above treatments haven't helped or the damage to
the joints is particularly severe, surgery may be carried out to repair, strengthen or replace
a damaged joint, especially hips or knees.
 In joint replacement surgery (arthroplasty), your surgeon removes your damaged joint
surfaces and replaces them with plastic and metal parts. Surgical risks include infections
and blood clots. Artificial joints can wear out or come loose and may need to eventually
be replaced.

Surgical and other procedures

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Knee osteotomy

Artificial hip




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Preventing osteoarthritis

It's not possible to prevent osteoarthritis altogether. However, you may be able to minimize your
risk of developing the condition by avoiding injury and staying as healthy as possible.

 Exercise
-Avoid exercise that puts strain on your joints and forces them to bear an excessive load,
such as running and weight training. Instead, try exercises such as swimming and cycling,
where your joints are better supported and the strain on your joints is more controlled.
-Try to do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic
activity (such as cycling or fast walking) every week to build up your muscle strength
and keep yourself generally healthy.
 Posture
-It can also help to maintain good posture at all times and avoid staying in the same
position for too long.

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-If you work at a desk, make sure your chair is at the correct height, and take regular
breaks to move around.
 Losing weight
-Being overweight or obese can increase the strain on your joints and increase your risk
of developing osteoarthritis. If you're overweight, losing weight may help lower your
chances of developing the condition.

Alternative medicine

Various complementary and alternative medicine may help with osteoarthritis symptoms.
Treatments that have shown promise for osteoarthritis include:

 Acupuncture. Some studies indicate that acupuncture can relieve pain and improve
function in people who have knee osteoarthritis. During acupuncture, hair-thin needles
are inserted into your skin at precise spots on your body.
 Glucosamine and chondroitin. Studies have been mixed on these nutritional
supplements. A few have found benefits for people with osteoarthritis, while most
indicate that these supplements work no better than a placebo.

Don't use glucosamine if you're allergic to shellfish. Glucosamine and chondroitin may
interact with blood thinners such as warfarin and cause bleeding problems.

 Avocado-soybean unsaponifiables. This nutritional supplement — a mixture of avocado

and soybean oils — is widely used in Europe to treat knee and hip osteoarthritis. It acts as
an anti-inflammatory, and some studies have shown it may slow down or even prevent

Osteoporosis

Osteoporosis is a bone disease as result of the body not forming new bone or of the body
reabsorbing too much bone, or both. It is characterized by low bone mass and deterioration of
bone tissue. This leads to increased bone fragility and risk of fracture (broken bones) as bones
become weak, particularly of the hip, spine, wrist and shoulder. So brittle that a fall or even mild
stresses like bending over or coughing can cause a fracture
 Osteoporosis literally leads to abnormally porous bone that is compressible, like a
sponge. This disorder of the skeleton weakens the bone and results in frequent fractures
(breaks)
 Osteoporosis is often known as “the silent thief” or “silent disease” because bone loss
occurs without symptoms.

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 Osteoporosis is sometimes confused with osteoarthritis, because the names are similar.
Osteoporosis is a bone disease; osteoarthritis is a disease of the joints and surrounding
tissue.
 Bone mass (bone density) decreases after 35 years of age, and bone loss occurs more
rapidly in women after menopause. In old age, osteoporosis is as a result of the body
reabsorbing too much bone
N/B. Calcium and phosphate are two minerals responsible for normal bone formation

Key risk factors for osteoporosis

 Genetics,
 Lack of exercise,
 Lack of calcium and vitamin D,
 Personal history of fracture as an adult,
 Cigarette smoking and excessive alcohol consumption
 Family history of rheumatoid arthritis,
 Low body weight and family history of osteoporosis.
 Age: The older you get, the greater the risk of osteoporosis
 Sex. Women are much more likely to develop osteoporosis than men. Older women who
are past menopause are at greater risk than young women/This is because of lowered sex
hormone, estrogen
 Body frame size. Men and women who have small body frames tend to have a higher risk
because they may have a higher less bone mass to draw from as they age
 Those who are on drugs for cancer, seizers, gastric reflux
 Thyroid hormone: Too much thyroid hormone can cause bone loss(hyperthyroidism)

Symptoms

There are typically no symptoms in the early stages of bone loss . But once bones have been
weakened by osteoporosis, you may have the following symptoms that include the following

 Back pain, caused by fracture or collapsed vertebra

 Loss of height over time
 A stopped posture
 A bone fracture that occurs much more easily than expected

Diagnosis

 Osteoporosis can be suggested by X-rays and confirmed by tests to measure bone density.

Treatments

 Medications
 Stopping use of alcohol and cigarettes
 Adequate exercise
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 Sufficient calcium, and vitamin D. This depends on age, sex and condition( pregnancy
and lactation) e.g. for adults aged 19 to 50 years, at least 1000 mg/day of calcium and 5
ug/day of vitamin D

Osteomalacia

 Osteomalacia refers to the softening of the bones, often caused by vitamin D deficiency.
Soft bones are more likely to bow and fracture than are harder, healthy ones
 Osteomalacia is not the same as osteoporosis, another bone disorder that also can lead to
borne fractures. Osteomalacia results from a defect in the bone-building process due to
vitamin D deficiency, while osteoporosis develops due to a weakening of previously
constructed bone. .
 Osteomalacia is most likely to occur in people with kidney, stomach, gallbladder or
intestinal disease and in those with cirrhosis of the liver.
 Osteomalacia is also known as the rickets for adults

Symptoms

 There are typically no symptoms in the early stages of osteomalacia. As osteomalacia

worsens, you may experience bone/aching pain that commonly affects the lower back,
pelvis, hips, legs and ribs. The pain may get worse at night , or when you are putting
weight on affected bones

Cause

Vitamin D deficiency

Diet Therapy for Musculoskeletal

Energy: Energy needs vary widely and must be determined on individual basis and will depend
on increased metabolic activity factors such as stress of disease activity, sepsis, fever, skeletal
injury or surgery. If the client is receiving physical therapy, an additional physical activity factor
is used

Protein: Protein needs vary with protein status, surgical therapy, proteinuria and nitrogen
balance well-nourished adult patient needs about 0.5 to 1 g of protein/kg/day during quit disease
periods. An increase to 1.5 to 2g/kg/day

Vitamins and minerals: Standard recommendations for vitamins and minerals are used.
Specific supplementation may be used if needed, such as calcium and vitamin D if borne disease
is involved

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Fat: A diet high in fat, especially saturated fat, may speed up the progression of knee
osteoarthritis

TOPIC: NEUROMASCULAR DISEASES

Introduction
 The neuromuscular system includes all the muscles in the body and the nerves serving
them.
How the neuromuscular system work
 The contraction and the relaxation of the muscles requires communication between the brain and
the muscles. This is done by the nervous system
 Nerves have cells called neurons. Neurons carry messages from the brain via the spinal
cord. The neurons that carry these messages to the muscles are called motor neurons.

Diseases of the neuromuscular system

 Neuromuscular diseases/disorders are the diseases that impairs the functions of the
muscles and are majorly characterised by weakness and wasting of muscle tissues.
 In some neuromuscular diseases, the nerves are damaged, and don’t carry messages
from the brain as they should. In others, the muscles are damaged, and they either
can’t receive messages from motor neurons, or they can’t respond as they should.
 There is no cure for most neuromuscular disorders, but some can be effectively managed
and treated.
Note: Some common interventions for neuro-muscular include
1. Drug therapy/ medicine
a. Immunosuppressive drugs -can treat certain muscle and nerve diseases and
diseases of the nerve-muscle junctions.
b. Anticonvulsants and antidepressants may be used to treat the pain of neuropathy)
2. Nutrition therapy
3. Patient and family education and counselling

Neuromuscular diseases

 TRAUMATIC BRAIN INJURY (TBI)

 Traumatic brain injury occurs when an external mechanical force causes brain damage
resulting into brain dysfunction i.e. when an object penetrates the skull, such e.g. a bullet.

Complications

 Brain damage can result into infection of the brain; Fluid build-up(Cerebrospinal
fluid )may build up in the spaces in the brain causing increased pressure and swelling
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in the brain(The blood vessels getting squeezed, undermining their ability to supply the
brain cells with oxygen and essential nutrients); Blood vessel damage that lead to a
stroke, blood clots; nerve damage that may lead damage of the nerves of the eyes
resulting into blurred/double vision; damage of the nerves that provide sense of smell;
paralysis. Brain injury can at times also result into a drop in blood pressure thus
reducing blood supply to the brain
 Mild traumatic brain injury may cause temporary dysfunction of brain cells.

 More serious traumatic brain injury can result in long-term complications or death.

Causes: Falls, Violence, vehicle related accidents, sports injuries, Explosive blasts, bullets etc.

Symptoms:
 Blurred vision, A bad taste in the mouth or changes in the ability to smell, Sensitivity to
light or sound, Difficulty sleeping/insomnia or sleeping more than usual, Dizziness, Loss
of balance, Loss of facial sensation, Swallowing problems, Paralysis of facial muscles,
Memory loss, Mood changes or mood swings,, Feeling depressed or anxious, confusion,
Agitation/irritability, Slurred speech-communication problem, Coma, Brain death,
Seizures

Note: Some signs or symptoms may appear immediately after the traumatic event, while others
may appear days, weeks or years later.

Children's symptoms

Infants and young children with brain injuries may lack the communication skills to
report headaches, sensory problems, confusion and similar symptoms.
Symptoms:

 Change in eating or nursing habits, Persistent crying and inability to be consoled,

Unusual or easy irritability, Change in ability to pay attention, Change in sleep habit, Sad
or depressed mood, Loss of interest in favourite toys or activities, Seizures: Some
children with traumatic brain injury will have seizures within the first week. Some
serious injuries may result in recurring seizures, called post-traumatic epilepsy.
Treatment/management for brain injury
 Medications: e.g. anti- seizures, Diuretics (encourages the formation of urine by the
kidneys thus reduce the amount of fluid retained in the kidney e.g. in cases of fluid build-
up in the bran
 Surgery: Where localized blood is removed, open fractures are closed, pressing veins are
repaired etc.

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 Family and individual counselling to help you cope with the pain and stress of life with
a spinal cord injury.
 Rehabilitation: Serious cases need rehabilitation where they learn how to walk, talk and
carry other important tasks.

 Nutrition therapy.
Note. Most people with brain injury are well nourished before the injury, however they are
susceptible to develop nutritional deficiencies because of stress that comes with initial injuries.
Stress result into hyper-catabolic state and hyper-metabolic state may persist for 4 - 6 weeks or
be sustained throughout the injury.

The importance of immediate nutrition care will decrease the change of rapid loss of nutritional
stores, in particular protein, resulting in weight loss and suppressed immune function.

 Energy: complex carbohydrates for energy

 High Proteins- diet for wound healing

 Low fat diet -to maintain ideal body weight range. Lean meat, low fat dairy products
and legumes should be chosen.

 Vitamins: Each vitamin is found in different foods and has a different purpose for our
brains.

o Vitamin B-1- Helps metabolize glucose (blood sugar)

Sources: Grain products, pork, legumes, nuts, seeds and organ meats.
o Vitamin B-12- Protects nerve cells by maintain a myelin sheath (outer
coating) - B-12 deficiency can result in nerve damage and impaired brain
function.
Sources: Milk, meat and eggs.
o Folic Acid- Prevents a build-up of blood reducing the risk of heart disease
and stroke also can lower levels of serotonin in the brain (neurotransmitter
and functions the brain).
Sources: liver, yeast, asparagus, fried beans, peas, wheat, broccoli, and
some nuts.
o Vitamin A- Helps provide protection against infection, bone and teeth
formation, smooth skin and promotes growth and repair of body tissue.
Sources: meats, fish, eggs, carrots, yellow squash and spinach.
o Vitamin E- plant oils, green leafy vegetables (e.g. Spinach) and some
breakfast cereals. Supplies oxygen to the brain, slows down ageing
process, nutrition for cells and prevents blood from clotting
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Sources: plant oils, green leafy vegetables (e.g. Spinach) and some
breakfast cereals.
o Vitamin B-6- Helps with metabolism of carbohydrates and fats, supports
nervous system and maintains healthy skin.
Sources: chicken, fish, pork, whole wheat products, brown rice and
some fruit and vegetables.
 Minerals:
o Iron- Iron helps the formation of haemoglobin (which carries oxygen to
cells throughout our bodies).
Sources: meat, poultry and fish.
o Magnesium- Assists with bone structure and aids in the transmission of
nerve impulses.
Sources: Green leafy vegetables (e.g. spinach), whole grains, nuts, seeds
and bananas.
o Manganese- Helps metabolize carbohydrates and assists in the brain
functioning.
Sources: Whole grains and nut, also some fruits and vegetables.
o Copper- Deficiency can cause anaemia and impairs brain function and
immune system response.
Sources: organ meats, seafood, nuts, seeds, whole grain bread and
cereals and chocolate.
o Zinc- Maintains cell membranes and protects our cells from any damage.
Sources: red meats, liver, eggs, dairy products, vegetables and some
seafood's.
o Selenium- Provides synthesis for some hormones and protects cell
membranes from damage.
Sources: Seafood, liver and eggs also some grains and seeds.
 Alcohol should be avoided as it promotes seizure.

 Small, frequent meals and snacks for poor appetite and serving food with stronger
natural flavours to improve the appetite

 Increased iron, zinc, vitamin C, calcium and vitamin B12 are essential for wound
healing, prevention of abnormal red blood cells, and osteoporosis or brittle bones.

 Enteral(if he/she cannot swallow enough) and parenteral nutrition if the patient
cannot eat enough

 SPINAL CORD INJURY

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Introduction
 The spinal column provides the main support to the body, allowing you to stand upright,
bend, and twist, while protecting the spinal cord from injury.

 Spinal cord constitutes about 2% of the central nervous system and is about 18 inches
long.

 The spinal cord serves as an information super-highway, relaying messages between the
brain and the body.

 The brain sends motor messages to the limbs and other body parts through the spinal cord
allowing for movement. The limbs and other body parts send sensory messages to the
brain through the spinal cord about what we feel and touch.
NB: Spinal cord injuries affect more men than women. The majority of people who sustain a
spinal cord injury are young adults between the ages of 16 and 30 because of riskier behaviours.
Symptoms of spinal cord injuries
The effects of spinal cord injury may include the following:

 Loss of movement
 Loss of sensation
 Loss of bowel and/or bladder control
 Exaggerated reflex actions or spasms
 Changes in sexual function, sexual sensitivity and fertility
 Pain or intense stinging sensation

Prevention of spinal cord injuries

Some risk-reducing measures include:

 Always wearing a seatbelt while in a car

 wearing proper protective gear while playing sports
 Never diving into water unless you’ve examined it is deep enough and free of rocks
Treatment/Management

 Physical therapy to help retrain your brain and body; many spinal cord injury survivors
are able to regain significant mobility with physical therapy.
 Family and individual counselling to help you cope with the pain and stress of life with
a spinal cord injury.

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 Surgery as needed to correct injury-related health problems.

Nutrition therapy

Note

1. Spinal cord injury often results into paralysis. After a spinal cord injury, the body’s
systems – such as bowel, bladder and skin – function are altered due to paralysis. You
need to pay attention to your bowel and bladder function.
2. Because you are less active, your muscles and bones may become weaker.
3. Your circulatory and respiratory systems that pump blood and oxygen to your heart,
lungs and throughout your body may not work as effectively.
4. With less physical activity, you burn off fewer calories and may gain weight or possibly
maintain weight but replace muscle with fat.
5. Excess weight adds stress on your heart and may make weight shifts and transfers more
difficult. This can contribute to skin breakdown or pressure ulcers. One thing that you can
do to reduce some of these risks is to maintain a healthy diet.

Special nutritional needs when you have a spinal cord injury

 Adequate energy: For weight Maintenance

o People with SCI have a higher risk for diabetes, metabolic syndrome, and
cardiovascular disease when they become overweight. They are prone to overweight
because they less active and have a lower metabolic rate.
o Because of this, people with SCI will have lower energy/calorie needs and should
engage in physical activates.
 Physical activity-No matter what your level of injury, it remains critical that you
exercise on a daily basis to maintain a healthy weight. For patients with paraplegia, the
use of a manual wheelchair can increase your metabolic rate and energy use to help you
maintain a healthy weight.
 Increased protein, vitamins A, C, iron and zinc for wound prevention and more protein
for skin health. Those with a spinal cord injury are at risk for pressure wounds. People
with a spinal cord injury need to prevent skin breakdown and pressure sores
 High fibre diet: For bowel health/movement
o Fibre helps move the stool through the bowel. Drink a minimum of 1.5 L of liquid
each day Fluid keeps the stool soft, making it easier to pass.
 Fluid: A change in how much you drink for bowel and bladder health
o Get enough fluids (drink plenty of fluids), preferably water, to help flush your bladder
and keep your urine light in colour. This also helps prevent kidney and bladder
stones.

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o Some drinks, such as alcohol and drinks with caffeine - coffee, tea and colas, are not
good sources of fluids. This means that they take water out of the body.
 High calcium and vitamin D diet - for bone health/sending signals/lower blood pressure
Calcium
o Calcium is important in maintaining the structure and hardness in your teeth and
bones.
o Calcium is also important in sending the appropriate signals through your body
o Lowering blood pressure levels.
Sources: low-fat dairy products, green leafy vegetables, fish with soft bones that
you can eat, grains, and fortified foods (such as cereals, juice, and soy products).
Vitamin D
o The best form of vitamin D available to SCI patients is the sun. By sitting outside
in the sun for 10-15 minutes per day with shorts and a sleeveless shirt, patients
can achieve optimal vitamin D intake.
o Patients with dark skin or older age may need more time in the sun. The skin
creates vitamin D from the sun’s rays. This is important as vitamin D helps to
absorb calcium in your gut.
Sources: cod liver oil, fatty fish (salmon, tuna, and mackerel), low-fat dairy
products, fortified orange juice, egg yolks, and fortified margarine.
o Vitamin D supplement if you a deficiency of vitamin D
 An increase in heart healthy fats for heart health-Decrease your intake of fried foods and
high fat snack foods, Try different cooking methods such as baking, boiling, broiling,
grilling, poaching, and sautéing to decrease your intake of fried foods.

N/B. Diabetes, Heart Disease, & Metabolic Syndrome

 Patients with SCI have an increased risk of developing Diabetes, Heart Disease, and
Metabolic Syndrome due to increase in body weight as a result of decreased physical
activity, decreased muscle mass, increased fat mass, and altered body metabolism.

 STROKE
 Stroke – A stroke is a "brain attack". It is where the blood supply to part of the brain is
cut off, which can cause brain damage and possibly death.
 Brain damage occurs and cells die because they are deprived of oxygen and nutrients.
 The blood supply can be blocked or interrupted/disrupted by a blood clot, where the
blood thickens and becomes solid.
 Blood clot is the most common cause of stroke. Blood clot form of stokes account for
approximately 70% and 80% of all strokes. Stroke can also occur when the blood vessel
ruptures

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o Cerebral thrombosis, the most common stroke, occurs when a thrombus ( a

blood clot formed within a blood vessel and remaining attached to its place of
origin)) forms and blocks blood flow in an artery bringing blood to part of the
brain. They usually occur at night or first thing in the morning when blood
pressure is low. They are often preceded by transient ischemic attach (TIA or mini
stroke)
o Cerebral embolism occurs when an embolus (a loos blood clot) forms away from
the brain, usually in the heart. The clot is carried in the bloodstream until it lodges
in an artery leading to or in the brain and blocks the flow of blood
o A subarachnoid hemorrhage/hemorrhagic stroke/bleeds. occurs when a blood
vessel on the brain’s surface ruptures and bleeds into the space between the brain
and skull
o A cerebral hemorrhage occurs when defective artery in the brain busts, flooding
the surrounding tissue with blood
 Transient ischemic attack (TIA) – It is also known as a mini stroke, it is similar to
stroke but here the blood flow to the brain is only temporarily disrupted, a blockage with
effects lasting less than 24 hours

Complications

A stroke can sometimes cause temporary or permanent disabilities, depending on how long the
brain lacks blood flow and which part was affected. Complications may include:

 Paralysis or loss of muscle movement. You may become paralyzed on one side of your
body, or lose control of certain muscles, such as those on one side of your face or one arm.
Patients who experience left-sided stroke most commonly experience sight and hearing
losses e.g. inability to see where food is on the plate. Right hemisphere, bilateral, or
brainstem stroke causes significant problems with feeding and swallowing in addition to
speech problems

Symptoms of paralysis can be remembered with the word FAS, which stands for:

o Face (usually on one side of the body) – the face may have drooped on one
side, the person may be unable to smile, or their mouth or eye may have
dropped.
o Arms or legs– the person may not be able to lift both arms or legs and keep
them there because of arm weakness or numbness in one arm (usually on one
side of the body)
o Speech – their speech may be slurred or garbled, or they may not be able to
talk at all.

 Difficulty talking or swallowing.

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 Memory loss or thinking difficulties. Many people who have had strokes experience
some memory loss. Others may have difficulty thinking, making judgments, reasoning and
understanding concepts.

 Emotional problems. People who have had strokes may have more difficulty controlling
their emotions, or they may develop depression.

 Pain. People also may be sensitive to temperature changes, especially extreme cold after a
stroke. This condition generally develops several weeks after a stroke, and it may improve
over time.

 Changes in behaviour and self-care ability. People who have had strokes may become
more withdrawn and less social or more impulsive. They may need help with grooming and
daily chores.

Other symptoms include:

 Sudden vision problems in one or both eyes.

 Dizziness.
 Sudden, severe headache.
 Dysphagia
 Sleepiness
 Loss of balance or coordination

Management

Nutrition therapy
 Limit the amount of salt in the daily diet. Recommended: 2400 mg per day .Sodium may
be restricted to 2 to 4 g if there is hypertension or to control edema
 Carbohydrates. Use of complex carbohydrates to replace saturated fats as this lowers
LDL cholesterol levels. Recommended: 50-60%.
 Protein. Plant based proteins e.g legumes, dry beans, nuts, whole grains and vegetables
are the best as they lower LDL cholesterol. Fat free and low- fat dairy products e.g. egg
white, fish, skinless poultry and lean cuts of beef and pork are also low in saturated fats
and cholesterol
 High fiber diet. Recommended: 20-30 g/day, soluble fiber 10-25 g/day. Adding 5 to 10
g of soluble fiber( oats, barley, pectin reach fruits and beans ) per day is associated with
approximately a 5 % reduction in LDL cholesterol
 Reduce the total fat to no more than 20%, and trans fatty acids in your diet particularly
saturated fat. Saturated fats raises the LDL cholesterol level.
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 Saturated fats, less than 7% of the total energy intake

 Use of monounsaturated (up to 20% of the total energy intake) and polyunsaturated fats
(up to 10% of the total energy intake). Monounsaturated fats e.g. plant oils and nuts
lowers LDL cholesterol levels without decreasing HDL cholesterol or triglycerides while
polyunsaturated fats e.g. linoleic acid and omega -3-fatty acids reduce LDL cholesterol
when used instead of saturated fats.
 Intake of Omega-3 fatty acids improve the health of the blood vessels, as well as reducing
Hypertension, blood clotting, inflammation and decrease the synthesis of VLDL. They
are found in fish oil, flaxseed oil and walnuts or fish oil supplementation
 Dietary cholesterol, less than 200 mg/day/. Flax seeds are one the richest source of
omega 3
 Antioxidants such as vitamin C and vitamin E protect the arteries from damage.
 Garlic may help reduce the level of fats in the blood, improve blood flow and reduce
blood clotting.
 Potassium, magnesium and calcium are minerals that help reduce blood pressure
(maintain cell fluid balance) and blood clotting. Magnesium and potassium also helps in
muscle contraction. Low potassium level is associated with high blood pressure. Low
magnesium level is also associated high blood pressure and angina while magnesium
intake is associated with decreased incidence of CHD
 Control diabetes
 Nutritional supplements may only be effective if dietary intake is inadequate.
 Avoid foods that cause choking or that are hard to manage e.g. peanut butter, raw
vegetables, dry or crisp foods
 If the patient has problem with saliva production , foods can be moistened with small
amount of liquid e.g. gravy
 Exercise – regular daily walks of about 1 hour (to expend at least 200 kcal/day) –
Exercise has been shown to increase the level of HDLs, the so called “good cholesterol”
with no notable changes in or plasma triglycerides. Thus it helps maintain the health of
the vessels leading to the heart.
 Weight reduction using diet low in saturated fats and cholesterol. Weight reduction
reduces LDL cholesterol levels
 Stop smoking -smoking oxidizes cholesterol, causing it to deposit in your blood vessels
and contribute to atherosclerosis.
 Avoid Sedentary lifestyle and stress - being physically active
 Reduced alcohol intake

Surgery
 Arterial reconstruction surgery to bypass them- to redirect the flow blood flow in the
artery

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 Removal of fatty deposits in inner lungs (endarterectomy)

 Balloon angioplasty to widen the vessels(using balloon –tipped catheter inserted through
the artery at the groin or wrist)
Drug Therapy
 Drug therapy aims – to prevent blood clotting

 CEREBRAL PALSY
 Cerebral palsy is a disorder that affects body movement, muscle tone or posture
 Cerebral palsy's effects varies greatly. Some affected people can walk while others can't.
Some people show normal or near-normal intellectual capacity, but others may have
intellectual disabilities, seizures, epilepsy, vision problems,(blindness) or
hearing(deafness) also may be present.

Causes of Cerebral Palsy

Cerebral palsy is caused by a brain injury or problem that occurs to immature brain
during pregnancy or birth or within the first 2 to 3 years of a child's life or It can also occurs to the
immature, developing brain(after birth) . It can be caused by:

 Lack of or not getting enough blood, oxygen (asphyxia-lack of oxygen to the brain), or
other nutrients before or during birth.
 Problems from being born too early (premature birth

 A serious head injury to an infant e.g. a fall or motor vehicle accident

 A serious infant infection that can affect the brain, such as meningitis.
 Mutations in genes that lead to abnormal brain development
 Maternal infections that affect the developing fetus
 Fatal stroke, a disruption of blood supply to the developing brain
 Some problems passed from parent to child (genetic conditions) that affect brain
development.
 In many cases, the exact cause of cerebral palsy is not known.

Risk factors

A number of factors are associated with an increased risk of cerebral palsy.

Maternal health

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Certain infections or health problems during pregnancy can significantly increase cerebral palsy
risk to the baby. Infections of particular concern include:

 German measles (rubella). Rubella is a viral infection that can cause serious birth
defects. It can be prevented with a vaccine.
 Chickenpox (varicella). Chickenpox is a contagious viral infection that causes itching
and rashes, and it can cause pregnancy complications. It too can be prevented with a
vaccine.
 Herpes. Herpes infection can be passed from mother to child during pregnancy, affecting
the womb and placenta. Inflammation triggered by infection may then damage the unborn
baby's developing nervous system.
 Syphilis. Syphilis is a sexually transmitted bacterial infection.
 Exposure to toxins. Exposure to toxins, such as methyl mercury, can increase the risk of
birth defects.
 Other conditions. Other conditions may increase the risk of cerebral palsy, such as
thyroid problems, intellectual disabilities or seizures.

Other factors of pregnancy and birth

While the potential contribution from each is limited, additional pregnancy or birth factors
associated with increased cerebral palsy risk include:

 Breech births. Babies with cerebral palsy are more likely to be in a feet-first position
(breech presentation) at the beginning of labour rather than headfirst.
 Complicated labour and delivery. Babies who exhibit vascular or respiratory problems
during labour and delivery may have existing brain damage or abnormalities.
 Low birth weight. Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher
risk of developing cerebral palsy. This risk increases as birth weight drops.
 Multiple babies. Cerebral palsy risk increases with the number of babies sharing the
uterus. If one or more of the babies die, the chance that the survivors may have cerebral
palsy increases.
 Premature birth. A normal pregnancy lasts 40 weeks. Babies born fewer than 37 weeks
into the pregnancy are at higher risk of cerebral palsy. The earlier a baby is born, the
greater the cerebral palsy risk.
 Rh blood type incompatibility between mother and child. If a mother's Rh blood type
doesn't match her baby's, her immune system may not tolerate the developing baby's
blood type and her body may begin to produce antibodies to attack and kill her baby's
blood cells, which can cause brain damage.

Infant illness

Illnesses in a new-born baby that can greatly increase the risk of cerebral palsy include:

 Bacterial meningitis. This bacterial infection causes inflammation in the membranes

surrounding the brain and spinal cord.

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 Viral encephalitis. This viral infection similarly causes inflammation in the membranes
surrounding the brain and spinal cord.

Symptoms

 Problems with body movement and posture. Cerebral palsy affects muscle control and
coordination. Even simple movements like standing still may become difficult. Motor
skills such as breathing, bladder and bowel control, eating, and talking, eye muscle
imbalance (in which the eyes don't focus on the same object) may also be affected when a
child has CP. Movement. Motor skills and coordination problems associated with
cerebral palsy may include:

o Variations in muscle tone, such as being either too stiff muscles or too floppy
o Lack of muscle coordination (ataxia)
o Tremors or involuntary movements
o Delays in reaching motor skills milestones, such as pushing up on arms,
sitting up alone or crawling
o Favouring one side of the body, such as reaching with only one hand or
dragging a leg while crawling
o Difficulty walking, such as walking on toes
o Excessive drooling or problems with swallowing or eating
o Difficulty with sucking or eating
o Delays in speech development or difficulty speaking
o Eye muscle imbalance (in which the eyes don't focus on the same object)
o Difficulty with precise motions, such as picking up spoon
o osteoporosis (weak, brittle bones)
o Seizures

 Brain abnormalities. Brain abnormalities associated with cerebral palsy also may
contribute to other neurological problems (more so babies with severe cerebral
palsy).People with cerebral palsy may also have:

o Difficulty with vision and hearing

o Intellectual disabilities
o Seizures
o Abnormal touch or pain perceptions
o Oral diseases
o Mental health (psychiatric) conditions
o Behaviour problems
o Urinary incontinence/ problem with bladder and bowel control

Signs and symptoms can vary greatly. (The physical problems are worse for some people than for
others). Some people who have cerebral palsy have a slight limp or a hard time walking.

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Other people have little or no control over their arms and legs, the entire body or other parts of the
body, such as the mouth and tongue, which can cause problems with eating and speaking.

This depends on the extent of brain damage or the part of brain damaged .For example, brain
damage can be very limited, affecting only the part of the brain that controls walking, or it can be
much more extensive, affecting muscle control of the entire body.

N/B. Seizures, speech and communication problems, and intellectual disabilities are more
common among kids with CP.

Treatment/Management

Even though cerebral palsy can't be cured, you and your child can do things to help deal with
symptoms, prevent problems, and make the most of your child's abilities.

Physical therapy is one of the most important treatments.

Medical therapy

Surgery

Special equipment such as a walker

Nutrition and Diet therapy in Cerebral Palsy

 Calcium, to support bone functions. Best sources of this include milk, yogurt, and
cheese.
 Protein : Provide adequate amount
 Fluids: Higher needs due to constipation, drooling & excessive sweating.
 Vitamin D, to help the body absorb calcium from food and supplements
 Phosphorus, plays a role in the formation of bones and teeth.
 Vitamin C Many children with cerebral palsy suffer from mood swings, depression, and
anxiety. It’s possible that they may lack enough vitamin C to synthesize
the norepinephrine neurotransmitter in the brain. Adequate amounts of vitamin C also
helps children battle common illnesses.
 Copper is an important trace mineral found in the brain, heart, kidneys, skeletal muscles,
and liver. It helps increase iron absorption, maintain collagen, and ward off infections.
Children with cerebral palsy are often low in copper, as well as manganese, a chemical
often found in minerals with iron. Low copper and manganese levels can cause weak
bones, neurological function issues, growth problems, and a greater chance of infection.

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 Other important minerals for bone health include magnesium, zinc, and manganese.
These are needed in small amounts and are readily available in beans, vegetables, and
other foods.
 Other minerals and vitamins need are: iron, folate and vitamin A
 Children and adolescents with CP have decreased energy requirements in comparison
with normal children and adolescents. This is partly because of decreased basal
metabolic rate (related to reduce lean body mass and largely because of reductions in
physical activity levels)

 EPILEPSY
 Epilepsy is a central nervous (neurological) system disorder in which brain activity
becomes abnormal (nerve activities become abnormal), causing seizures or periods of
unusual behaviour, se and sometimes loss of awareness.
There are two main types of seizures.
 Generalized/complex seizures affect the whole brain.
 Focal, or partial seizures, affect just one part of the brain.
Note:
 A mild seizure may be difficult to recognize. It can last a few seconds during which you
lack awareness.

 Stronger seizures can last a few seconds to several minutes.

 There’s no cure for epilepsy, but the disorder can be managed with medications and other
strategies.

Symptoms
 Seizures characterized by

o Stiffening of the body

o Shaking
o Repeated, jerky muscle movements of the face, neck, and arms.
o Muscle stiffness
o Tingling and twitching of limbs
o Blank stare
o Loss of bladder or bowel control
o Biting of the tongue
o Loss of consciousness/loss of awareness

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Triggers
You need to identify your trigger. A few of the most commonly reported triggers are:

 lack of sleep
 illness or fever
 stress
 bright lights, flashing lights, or patterns
 caffeine, alcohol, medicines, or drugs
 skipping meals, overeating, or specific food ingredients

Causes of epilepsy
Possible causes include:

 traumatic brain injury

 scarring on the brain after a brain injury (post-traumatic epilepsy)
 serious illness or very high fever
 stroke, which is a leading cause of epilepsy in people over age 35
 other vascular diseases
 lack of oxygen to the brain
 brain tumour or cyst
 dementia or Alzheimer’s disease
 maternal drug use, prenatal injury, brain malformation, or lack of oxygen at birth
 infectious diseases such as AIDS and meningitis
 genetic or developmental disorders or neurological diseases
 Heredity plays a role in some types of epilepsy
Other conditions other than epilepsy that may result into a seizure.

 high fever
 head trauma
 very low blood sugar 1
 alcohol withdrawal

First Aid for an Epileptic seizure

Here are things you can do to help someone who is having this type of seizure:

o Ease the person to the floor.

o Turn the person gently onto one side. This will help the person breathe.
o Clear the area around the person of anything hard or sharp. This can prevent
injury.
o Put something soft and flat, like a folded jacket, under his or her head.
o Remove eyeglasses.
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o Loosen ties or anything around the neck that may make it hard to breathe.

Never do any of the following things

o Do not hold the person down or try to stop his or her movements.
o Do not put anything in the person’s mouth. This can injure teeth or the jaw. A
person having a seizure cannot swallow his or her tongue.
o Do not try to give mouth-to-mouth breaths (like CPR). People usually start
breathing again on their one.

Treatment/Management

Medical therapy-anti seizure drugs

Nutrition therapy

Ketogenic Diet for Epilepsy

 The ketogenic diet is a high fat diet, low in carbohydrate and minimal protein diet
designed to mimic the fasting state. It is used most commonly to treat epilepsy. The diet
increases the body’s reliance on fatty acids rather than on glucose for energy

Basis of ketogenic diet

 The basis of the ketogenic diet is apparently the brains ability to obtain 30% to 60% or
more of its energy during fasting from serum ketone bodies derived from beta oxidation
of fatty acids
 Fasting lowers serum glucose concentration resulting in low ratio of insulin to glucagon.
This stimulates lipolysis resulting in the production of fatty acids.
 The free fatty acids released into the blood cannot cross blood brain barrier and therefore
cannot be used directly to sustain brain metabolism. Instead fatty acids are converted by
liver to ketone bodies that cross the blood brain barrier and serve as a major energy
source for brain

Side Effects of ketogenic diet

 Constipation
 Kidney stones
 Slow growth and low weight
 Weak bones (which may be more likely to break)
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 High cholesterol

 DOWN’S SYNDROME

 Down's syndrome, also known as trisomy 21 and formally known as mongolism is a

genetic disorder/condition in which a baby is born with an extra chromosome 21(when an
error in cell division or when abnormal cell division results in an extra full or partial copy
of chromosome 21), the extra chromosome causes some level of learning disability and
certain abnormal physical characteristics.

Note. In every cell in the human being there is nuclear, where genetic material is stored. Genes
carry the codes responsible for all of our inherited traits and are grouped in rod lie structures
called chromosomes, half of which are inherited from each paren. The nucleus of each cell
contains 23 pairs of chromosomes half of which is inherited from each parent. Down syndrome
occurs when an individual has a full or partial extra copy of chromosome 21.

Characteristics of Down's syndrome

1. Physical abnormalities/Signs
Most babies born with Down's syndrome are diagnosed soon after birth and may have:
 Floppiness (hypotonia)-decrease in muscle tone i.e. no stiffness or no resistance to stretch
in muscles(i.e. their muscles are fully relaxed)
 Relatively small head
 Eyes that slant upwards and outwards
 A small mouth with a tongue that may stick out
 A flat back of the head/Broad facial appearance/flat face
 Below-average weight and length at birth
 Their palm may have only one palmer crease across it
 Short broad hands
 Wide gap between first and second toes
 Short height
 Broad hands with short fingers
 Flattened nasal bridge
 Protruding/large tongue
 Short neck
 Small ears

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2. Developmental delays/intellectual disabilities/learning disabilities

Children with Down syndrome often reach developmental milestones later than their peers.
 There may be a delay in acquiring speech. A child may need speech therapy to help them
gain expressive language.
 Fine motor skills may also be delayed.
On average, a child with Down syndrome will:
o sit at 11 months
o crawl at 17 months
o walk at 26 months
 There may also be problems with attention, a tendency to make poor judgments, and
impulsive behaviour.

Causes of Down's syndrome

 Down's syndrome is usually caused by an extra chromosome in a baby's cells. In most
cases, this isn't inherited – it's simply the result of a one-off genetic change in the sperm
or egg.
Risk factors

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 Advancing maternal age: A woman’s chances of giving birth to a child with Down
syndrome increase with age because older eggs have greater risk of improper
chromosome division. A woman’s risk of conceiving a child with Down syndrome
increases after 35 years of age

 There's no evidence that anything done before or during pregnancy increases or decreases
the chance of having a child with Down's syndrome.

Down’s syndromes complications

People with Down's syndrome are more likely to have certain health problems, including:
 Heart disorders, such as congenital heart disease (half of all people with Down syndrome
have a congenital heart defect.)
Other problems

 Hearing and vision problems

 Thyroid problems, such as an underactive thyroid gland (hypothyroidism)
 Recurrent infections, especially chest, ear, nose, throat, eye infections and pneumonia
 Respiratory problems
 Alzheimer's disease
 Childhood leukaemia
 Epilepsy
 Food intolerance and allergies
 Diabetes

Treatment/Management
 There is no specific treatment for Down syndrome.
 People with the syndrome will receive care for health problems, just as other people do.
However, additional health screening for common problems may be recommended.
 Keeping active and early intervention can help in managing the condition
Nutrition concerns in Down syndrome
 Infants and children with Down syndrome can have swallowing, feeding and drinking
difficulties that results into poor weight gain. This is because of
o They have a smaller oral cavity and low muscle tone that affects the
sucking and swallowing of milk and food. This also affects the way they
breath
o Protruding and larger tongue that affects sucking and swallowing of milk
and food
o Many are mouth breathers due to smaller nasal passage this affects their
sacking and swallowing capabilities
o Teeth tend to appear at a later stage. This affects chewing of food
o Poor development of oral motor skills, that affects their feeding skills
Other than swallowing, feeding and drinking difficulties, other nutrition concern is:
 Overweight

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Overweight is common among the older children and adolescents because they have
a lower metabolic rate of 10-15% than the general population, they also tend to be
inactive than the general population. This predisposes them to weight gain

Nutrition management
The Mediterranean diet
 The Mediterranean diet has been associated with a reduced risk of Alzheimer's disease
and reduced heart problems as well as other cardiovascular diseases such as stroke. It is
also good in weight management
 Mediterranean diet refers to a healthy diet (or a way of eating healthy diet) that
emphasizes eating foods high in vegetables, fruits, legumes, nuts, beans, cereals, grains,
fish and unsaturated fats. It usually include a low intake of meat and dairy foods
Nutrition management should be provided based on the common complications that comes with
Down syndrome
 Thyroid disorder: Hypothyroidism occurs more frequently in people with Down
syndrome resulting into overweight. Provide a low energy diet to reduce the excess
weight
 Celiac disease: Where there is celiac disease, provide a gluten free diet
 Constipation: High fluid intake and high fibre diet
 Food intolerance and allergies: This may result into runny nose, wheezing colic and
crying. Exclude the food the baby/ child is allergic too
 Infections: They are vulnerable to infections especially chest, ear, nose, throat and eye
infections. Provision of vitamin A, mala, yoghurt to boost immunity.
 Diabetes: Provision of low glycaemic diet to manage sugar levels
 Heart defects: 40 -50 % of babies with Down syndrome have a heart defects requiring
surgery. Provide a nutrition support prior and post corrective cardiac surgery
 Overweight: Lowering portion size, low energy diet, physical exercise

o
 SPINA BIFIDA
Spina bifida is a condition in which a developing baby’s spinal cord fails to develop properly
(i.e. the vertebral column do not fully cover the spinal cord, leaving it exposed.)
Or
It is a congenital problem, present before birth, and it is caused by the incomplete closing of the
embryonic neural tube. It is a neural tube defect.
Note

 Spina bifida is a congenital condition in which the spinal column is exposed.

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 Myelomeningocele is the most serious type and it is present around 60 births in every in
100,000.
 Exposure means the spinal column is more at risk of infection.
 Excess cerebrospinal fluid can build up and result in hydrocephalus, and this increases
the chances of learning difficulties.
 A low intake of folic acid before and during pregnancy has been linked to spina bifida.
 Treatment options include surgery, physical therapy, and assistive devices.

Diagrams of spina bifida

Types
Occulta: Occulta means hidden and the defect is not visible. This is the mildest form of spina
bifada and rarely linked/comes with complications or symptoms. It is usually discovered
accidentally when a person has an x-ray or MRI.
Meningocele: The spinal cord develops normally, but the meninges, or protective membranes
around the spinal cord May enlarge creating a lump. The membranes are surgically removed,
usually with little or no damage to nerve pathways.
Myelomeningocele: Myelomeningocele is the most severe form of spina bifida. In this
condition, the spinal cord is exposed, causing partial or complete paralysis of the body below the
opening. It is the form that comes with symptoms.
Symptoms

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An infant who is born with spina bifida may have or develop:

 Weakness or paralysis in the leg

 Lack of sensation in the skin
 Hydrocephalus (accumulation of fluid in the brain) that may lead to brain damage or
mental retardation. . If hydrocephalus is present, it increases the chance of learning
problems. However, this individuals are of normal intelligence if their hydrocephalus is
treated. Hydrocephalus often recurs gradually after treatment
 The nervous system will also be more prone to infections, some of which can be life-
threatening.
 Psychological, social and sexual problems occur more often in people with spina bifida
than in general population
 Growth hormone deficiency resulting into short height
 Urinary tract disorders and bowel problems thus inability to hold urine in the bladder a d
stool in the rectum
 Obesity due to inactivity
 There is a higher risk of meningitis among people with spina bifida. This can be life-
threatening.
 Allergy to latex (a natural rubber used in medical gloves and some types of balloons).
This is thought to be as a result of intense exposure to latex in early years of life because
of frequent surgeries and other medical procedures. An allergic reaction to latex can be
life threatening.
Causes and risk factors

 Folic acid: Spina bifida is more likely if a mother does not have enough folic acid during
the pregnancy
 Family history: If one infant is born with spina bifida, there is a 4 percent chance that a
future sibling will have the same condition.
 Medications: Drugs such as valproate, used to treat epilepsy or bipolar disorder, have
been associated with a higher risk of giving birth to babies with congenital defects, such
as spina bifida.
 Diabetes: A woman who has diabetes is more likely to have a baby with spina bifida,
than one who does not.
 Obesity: A woman whose body mass index (BMI) is 30 or above has a higher risk of
having a baby with spina bifida.

Treatment/Management
Treatment depends on several factors, mainly how severe the signs and symptoms are.

 Surgical options
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o Surgery to repair the spine: This can be done within 2 days of birth. The
surgeon replaces the spinal cord and any exposed tissues or nerves back into the
new-born’s body.
o Prenatal surgery: The surgeon opens the uterus and repairs the spinal cord of the
foetus, usually during week 19 to 25 of pregnancy. This type of surgery may be
recommended to reduce the risk of spina bifida worsening after delivery.
o Caesarean-section birth: If spina bifida is present in the foetus, delivery should
be by caesarean section. This is safer for the exposed nerves.
o Hydrocephalus: Surgery can treat a build-up of cerebrospinal fluid in the brain.
 Physical and occupational therapy
o Physical therapy: This is vital, as it helps the individual become more
independent and prevents the lower limb muscles from weakening.
o Occupational therapy: This can help the child perform everyday activities more
effectively, such as getting dressed. It can encourage self-esteem and
independence.
 Nutritional complications with spina bifida : obesity, bowel health, Pressure sores)
Obesity

 Most of the spina bifida people are obese. The problem increase as the child gets older
and moves into teenage years and adulthood. This is because lower metabolic rate and
less activities. Increased weight have negative implications on them such high blood
sugars(diabetes), as breathing problems(For those in wheel chairs, the weight gain is
concentrated on the chest area which will affect breathing and affect the lungs ability to
expand properly
 Increase weight gain also results into increase pressure on the skin for those in
wheelchairs. Increase weight gain will put increasing pressure on skin in contact with the
seats. Sustained pressure on skin is a risk for pressure sore, a break in the skin which can
become infected
Bowel health/constipation
Pressure sores

 Nutrition management for obesity

o Healthy eating to prevent obesity
 Nutrition management for bowel incontinence
o Diet: A healthy, balanced diet with plenty of fibre is essential to
avoid constipation, but too much fibre can cause diarrhoea. A food diary will
help keep a record of suitable foods.

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o Colostomy or ileostomy: A colostomy involves diverting a section of the

colon so that it connects to a stoma, which is attached to a pouch. The pouch
collects stools. If the diversion is at the end of the small intestine, the
procedure is called an ileostomy.
 Nutrition management for pressure sore
o High protein, vitamin C and zinc diet for wound healing and vitamin A to
prevent infections

Diet in pregnancy (Spina Bifida Prevention)

o The best means of preventing spina bifida in new-borns is by having the mother fortified
with folic acid. However, folic acid will only help in the prevention of spina bifida if used
for at least a month before pregnancy begins. Taking supplements of folic acid before
conception reduces the risk of the disease as well as other neural tube defects.
o Enough folic acid should also be ensured especially during the early weeks of pregnancy
to prevent spina bifida.
o Pregnancies should therefore be planned to ensure that mothers have enough stores of
folic acid before they become pregnant

 HUNTINGTON’S CHOREA
 Huntington's disease is an inherited/genetic disorder that results in death of brain cells or
neurons of the brain. It is an inherited disease that happens due to faulty genes.
 The faulty defective genes can be passed from a parent to a child

Note
o Huntington's disease (HD) attacks nerve cells gradually over time. It happens when a
faulty gene causes toxic proteins to collect in the brain leading to neurological symptoms.
o Early symptoms comes as parts of the brain deteriorate, this affects movement, mood
swings, emotional problems, and cognition (thinking ability). It becomes harder to walk,
think, reason, swallow, and talk. Eventually, the person will need full-time care. The
complications are usually fatal.
o During the later stages of the disease, choking becomes a major concern.
o There is currently no cure, but medications may help relieve symptoms.
o The first signs normally appear between the ages of 30 and 50 years. By the time of
onset, the individual may have already passed the genetic abnormality on to their
children

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Causes
 HD is caused by inherited faulty gene
 Normal gene provide instructions for making of protein called huntingtin. Huntingtin
protein play an important role in nerve cells (neurons).
 The faulty gene affects the production of the huntingtin(results in larger form of
huntingtin) which eventually results into the death of nerve cells(brain cells)

Symptoms
The key symptoms include:
 Personality changes, mood swings, unusual behaviour and depression are common early
signs
 Problems with memory and judgment
 Unsteady walk and uncontrollable movements
 Difficulty speaking and swallowing(eating), and weight loss
 Irritability
 Excessive restlessness
 Risk of choking, especially in the later stages

 Eventually in the later stage, the person will no longer be able to walk or talk, and they
will need full nursing care. However, they will usually understand most of what is being
said and will be aware of friends and family members.

Management
 HD is currently incurable. There is no treatment that can reverse its progression or slow it
down.
Nutrition complications
Weight loss
o Weight loss can make the symptoms worse and weaken the patient's immune system,
making them more vulnerable to infections (such as pneumonia) and other complications.
Choking
o HD itself is not usually fatal, but choking can worsen the disorder.
o Throughout all stages, it is important to adjust the patient's diet to ensure adequate food
intake.
Nutrition therapy to those with Huntington’s disease

 Most of the people with huntingtin disorders have a low weight compared to the general
population. Research has proven that a desirable weight is beneficial in managing the
condition.
 A diet that promotes weight gain, minimise choking, reduce infections and for brain
health should be provided
Diet therapy
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o Provide frequent small diet for increased energy; and provide soft, moist easy-to-chew
and easy-to-swallow foods to reduce chocking, e.g.

 Add plenty of custards, ice-cream and cream to desserts.

 Avoid hard foods such as nuts and lollies.
 Try to choose foods high in nutritional and calorific value. For example, have a
protein-supplemented milkshake rather than a cup of black tea, and eat iced cake
instead of water crackers.
 Avoid non-fat or low-fat products – always choose full-fat varieties.
 Drink fortified beverages such as protein milkshakes or nutritional supplement
drinks.
o Provide brain healthy diets(e.g. B12, essential fatty acids, omega 3)
o Provide adequate protein and vitamin A to boost immunity
o Provision of supplements for added extra energy, protein, vitamins and minerals.
o Tube feeding: Feeding tubes are usually recommended when a person ca no longer take
in adequate amounts of nutrients by mouth to maintain their weight at a healthy point
o The person with Huntington’s disease should be sitting upright while eating, never in a
reclining position to reduce choking
o The person should also angle their head down towards the plate to reduce choking.
o The person should never try to drink while they have a mouthful of food – this can
prompt choking.
o The person should remain sitting upright for about half an hour following a meal. Lying
down too soon after eating increases the risk of reflux and possible choking.
o Suggest they breathe out before taking a forkful. Remind them to stop breathing when it
comes time to swallow.
o A gentle massage of the face and throat may help the person to swallow.

Other management strategies

Speech therapy
 Speech therapy can help patients find ways to express words and phrases and
communicate in a more effective way.
Physical and occupational therapy
 A physical therapist can help improve muscle strength and flexibility, leading to better
balance and a reduced the risk of falling.

 MULTIPLE SCLEROSIS
 This a disease in which the immune system attacks the protective layer that covers the
nerves of the brain and the spinal cord. It is where the immune system attacks the myelin
(the fatty substance that coats and protects nerve fibres in the brain and spinal cord).

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 This causes communication problems between the brain and the rest of the body.
Eventually, the disease can cause the nerves themselves to deteriorate or become
permanently damaged.
Symptoms
Multiple sclerosis signs and symptoms may differ greatly from person to person depending on
the location of affected nerve fibres, amount of nerve damage and which nerves are affected.
Some people with severe MS may lose the ability to walk independently. The symptoms may
include:

 Numbness or weakness in one or more limbs that typically occurs on one side of the body
at a time, or the legs and trunk
 Paralysis
 Pregnancy problems
 Partial or complete loss of vision, usually in one eye at a time, often with pain during eye
movement
 Prolonged double vision
 Tingling or pain in parts of the body
 Tremor, lack of coordination
 Slurred speech
 Fatigue
 Dizziness
 Problems with bowel and bladder function
 Mental changes, such as forgetfulness or mood swings
 Depression

Causes
 The cause of multiple sclerosis is unknown. It's considered an autoimmune disease in
which the body's immune system attacks its own tissues.
 In the case of MS, this immune system destroys myelin (the fatty substance that coats
and protects nerve fibres in the brain and spinal cord).

Note. Myelin can be compared to the insulation coating on electrical wires. When the protective
myelin is damaged and nerve fibre is exposed, the messages that travel along that nerve may be
slowed or blocked. The nerve may also become damaged itself.

Risk factors
The factors may increase the risk of developing multiple sclerosis:
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 Age. MS can occur at any age, but most commonly affects people between the ages of 15
and 60.
 Sex. Women are more likely to develop MS than men
 Family history. If one of your parents or siblings has had MS, you are at higher risk of
developing the disease.
 Certain infections. A variety of viruses have been linked to MS, including infections such
as herpes, influenza, mosquito Epstein-Barr, the virus that causes infectious
mononucleosis;
 Race. White people, particularly those of Northern European descent, are at highest risk of
developing MS. People of Asian, African or Native American descent have the lowest risk.
 Climate. MS is far more common in countries with temperate climates, including Canada,
the northern United States, New Zealand, south-eastern Australia and Europe.
 Certain autoimmune diseases. You have a slightly higher risk of developing MS if you
have thyroid disease, type 1 diabetes or inflammatory bowel disease.
 Smoking. Smokers who experience an initial event of symptoms that may signal MS are
more likely than non-smokers to develop a second event that confirms relapsing-remitting
MS.

Dietary recommendations

There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks,
modify the course of the disease and manage symptoms.

 Adequate complex carbohydrate/less refined starch

o High blood glucose and insulin levels are pro-inflammatory, provide foods high in
fibre/ low glycaemic foods
 Lower saturated fats/low total fats
o A diet low in saturated fat is ideal for an MS patient. This ensures the body doesn’t
deteriorate rapidly. Avoid the animal rich fats. Provide a diet from poly unsaturated
fats e.g. from coconut oil, cod liver oil, flaxseed, sunflower oil etc.
 Eat more omega-3 fats
o Omega-3s are important for brain functions and have also been shown to be helpful
in treating several inflammatory diseases(they are precursors for anti-inflammatory
factors in the body) and may well help to reduce the progression and symptoms of
MS. Omega-3 fats can be obtained from oily fish, in some plant foods including
flaxseed (also called linseed, walnuts etc.
 Increased vitamin D
o A low exposure to sunlight and vitamin D are risk factors to MS as vitamin D has
effects on the immune system and also helps in cell growth
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 Increased anti-oxidants
o Increased anti-oxidants to reduce inflammation caused by the immune system.
Increased inflammation can affect the protective layer
 Probiotics
o Commonly known as the good bacteria, probiotics are similar to the
microorganisms found in the human body. Probiotics are believed to help avoid
malabsorption of nutrients in people with MS and also influences the immune
system
 Gluten
o Avoidance of gluten in gluten intolerance individuals. The anti-body’s directed
towards the gluten can affect the protective layer of the nerves

 PARKINSON’S DISEASE
 Parkinson's disease is a progressive/gradual neurological condition/disorder caused by
damage to nerve cells in the brain (brain cells die off) because of less production of a
chemical messenger, the dopamine
Note: Similarities/difference between Parkinson’s disease and multiple sclerosis
 They both affect the central nervous system (the brain)
 Multiple sclerosis often affects people between ages 20 -50 but children get it too.
Parkinson’s usually starts at age 60 or older, but some younger adults get it as well
 Multiple sclerosis is autoimmune while Parkinson’s disease is not autoimmune but
here, brain cells die off gradually because the brain makes less and less of a
chemical called dopamine. A chemical messenger which is required by the brain

Symptoms of Parkinson's disease

 Tremors and shaking of hand, lips, limbs and fingers
 Numbness
 slurred speech
 Loss of bladder or bowel control
 Headache
 Fatigue
 Dizziness
 Double vision
 Pain or tingling

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 Itching
 Seizures
 Hearing loss
Other Parkinson’s symptoms that people with multiple sclerosis may not have
 Feet dragging
 Stiff rigid muscles
 Slowed movement
 Poor balance posture
 Speaking changes
Causes

 Drug induced Parkinson’s disease - A small number (around 7%) of people diagnosed
with Parkinson’s develop symptoms following treatment with particular medication.
Neuroleptic drugs (used to treat schizophrenia and other psychotic disorders) which block
the action of dopamine are thought to be the biggest cause of drug-induced Parkinson’s
disease

 Old age is another risk factor

Nutrition therapy
Note: No single diet can treat Parkinson’s disease or its symptoms but a healthy and a balanced
diet can improve the wellbeing of a person suffering from Parkinson’s disease

o Eat a well-balanced diet with a variety of different foods, including lean protein, wholegrains
and at least 5 portions of fruit and vegetables a day. Ask your doctor if you should take a
daily vitamin supplement.
o Maintain your weight through a correct balance of exercise and food.
o Eat plenty of high-fibre foods such as vegetables, peas, beans, pulses (lentils and chick peas),
wholegrain breakfast cereals, granary or wholemeal bread, pasta, rice and fresh fruit.
o Don't eat too many foods that contain a lot of saturated fat.
o Limit sugary foods like sweets and chocolate or sugary soft drinks.
o Ask your doctor if you should reduce the amount of salt in your diet.
o Drink about 8-10 cups or 6-8 mugs (2 litres) of liquid per day. Water, cordial (squash), tea,
coffee, and lower sugar yoghurt drinks are all suitable. One small (150ml) glass of fruit juice
a day is also fine.
o Sufficient fibre and fluids are especially important if you are struggling with constipation.
o Alcohol may interfere with some of your medications.

 GUILLAIN BARRE SYNDROME

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 Guillain-Barré syndrome (GBS) is a rare acute disorder in which the body's immune
system attacks the peripheral nervous system
 The peripheral nervous system help the central nervous system to communicate with the
rest of the body including the skin, heart and muscles
 The degradation of the peripheral nervous system affects the transmission of the nerves
and that is why the muscles begin to lose their ability to respond to the brain's commands
 Guillain-Barré syndrome can affect anybody. It can strike at any age and both sexes are
equally prone to the disorder.

Note. Similarities and differences between Guillain-Barré syndrome and multiple syndrome
 Both multiple syndrome and Guillain-Barré syndrome (GBS) are auto immune diseases
that attack the myelin sheath of the nervous system
 The only difference is that multiple syndrome damages (attacks) the central nervous
system (attacks the myelin of the brain and the spinal cord) while Guillain-
Barré syndrome (GBS) damages the peripheral nervous system (attacks the myelin
sheath of the nerves outside the brain and the spinal cord).
 They almost have the same symptoms with MS symptoms lasting longer than GBS
symptoms
 The GBS patients normally get better after a few weeks but the MS might result into
disability
Causes
 GBS is caused by bacteria or virus infections that changes cells of the nervous system in
a way that makes the immune system think that the cells of the nervous system are
attackers.
 The following infections have also been associated with Guillain-Barré: influenza, herpes
virus, Epstein infection, or mononucleosis, Mosquito borne virus, HIV and AIDS virus
Symptoms

 tingling in the fingers, legs and toes

 muscle weakness in the legs that gets worse over time
 difficulty walking steadily
 difficulty moving your eyes or face, talking, chewing, or swallowing
 severe lower back pain
 loss of bladder control
 fast heart rate
 difficulty breathing
 paralysis

Treatment/Management
 Plasma exchange. Blood is removed from the body. Plasma, (the liquid part of blood), is
separated from the white and red blood cells then the cells are returned to your body.

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Getting rid of plasma takes out antibodies. They are part of the immune system
responsible nerve damage
Nutrition therapy

 Mytrophic Sclerosis /Amyotrophic lateral sclerosis (ALS)

 Amyotrophic lateral sclerosis or ALS, is a rare progressive (gradual) nervous system
disease in which nerve cells gradually break down and die. (It is a type of motor neuron
disease in which nerve cells gradually break down and die). The disease destroys nerve
cells and causes disability.
 There is high risk of malnutrition in ALS as the disease destroys the muscles that controls
swallowing

Symptoms
Early signs and symptoms of ALS include:

Difficulty walking or doing your normal daily activities

 Tripping and falling
 Weakness in your leg, feet or ankles
 Hand weakness or clumsiness
 Slurred speech or trouble swallowing
 Muscle cramps and twitching in your arms, shoulders and tongue
 Difficulty holding your head up or keeping good posture
NOTE
 ALS often starts in the hands, feet or limbs, and then spreads to other parts of the body.
As the disease advances and nerve cells are destroyed, the muscles gradually weakens.
This eventually affects chewing, swallowing, speaking and breathing.
 ALS doesn't usually affect the bowel or bladder control
 There is no cure for ALS, and eventually the disease is fatal.

Causes
 ALS is inherited in 5 to 10 percent of cases, while the rest have no known cause.

Risk factors
Established risk factors for ALS include:

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 Heredity. Five to 10 percent of the people with ALS inherited it (familial ALS). In most
people with familial ALS, their children have a 50-50 chance of developing the disease.
 Age. ALS risk increases with age, and is most common between the ages of 40 and 60.
 Sex. Before the age of 65, slightly more men than women develop ALS. This sex
difference disappears after age 70.
Environmental factors may trigger ALS. Some that may affect ALS risk include:

 Smoking. Smoking is the only likely environmental risk factor for ALS. The risk seems to
be greatest for women, particularly after menopause.
 Environmental toxin exposure/heavy metal toxicity. Some evidence suggests that
exposure to lead and mercury or other substances in the workplace or at home may be
linked to ALS. Exposure to pesticides is also a risk factor
 Military service. Recent studies indicate that people who have served in the military are at
higher risk of ALS. It's unclear exactly what about military service may trigger the
development of ALS. It may include exposure to certain metals or chemicals, traumatic
injuries, viral infections, and intense exertion.

ALS Complications
The complications come as the disease progresses, the complications may include:
 Breathing problems: The most common cause of death for people with ALS is
respiratory failure. On average, death occurs within three to five years after symptoms
begin.
 Speaking problems: Most people with ALS will develop trouble speaking over time.
People with ALS often rely on other communication technologies to communicate for
others to understand them
 Eating problems: People with ALS can develop malnutrition and dehydration from
damage to the muscles that control swallowing. They are also at higher risk of getting
food, liquids or saliva into the lungs, which can cause pneumonia. A feeding tube can
reduce these risks and ensure proper hydration and nutrition.
 Dementia: Some people with ALS experience problems with memory and making
decisions
Nutrition therapy


Remove all toxins and processed food from the diet- Remove all sugars (including
artificial sweeteners and grains), hydrogenated oils and any preservatives from the diet as
they contain radicals that attack the motor neurons
 Antioxidants-Provide foods rich in antioxidants to fight the radicals
 Provide nutrient dense foods to prevent malnutrition and to manage malnutrition if
present
Some specific foods/nutrients for the management of ALS conditions are:

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 Quality Protein sources: Organic sources are important. Choose grass-fed beef, free-
range chicken, cage-free eggs, lamb, lentils, pecans, cashews, pumpkin/squash seeds.
 Healthy Fats: coconut oil, cold-pressed olive oil, cultured butter or ghee, avocado.
 Coconut oil specifically is extremely healing to the body and works on several levels to
boost the body’s natural defences to disease.
 Food high in vitamin E and C – help in supporting the immune functions
 Foods high B-complex / vitamin B12 – Vitamin B in all its forms is an important
support to muscles, energy levels, and nerve function.
 Provide calcium, magnesium, and vitamin D
Replenishing calcium and magnesium levels in the body, helps to process the heavy
metals and remove toxins. Both minerals works together to activate each other. Also
adding Vitamin D assists in calcium absorption, helps maintain bone mass, and improves
mitochondrial function.
 Selenium – Selenium is a known beneficial mineral that reduces mercury concentrations
and counteracts heavy metal effects in the body.
 Fish Oil – Rich in Omega-3’s, and essential fatty acid, fish oil is one of the best ways to
reduce inflammation in the body. It restores brain health and helps boost your immune
system.
The vitamins and minerals can be supplemented as well

 ALZEIHMERS & DEMENTIA

 Alzheimer's disease is a progressive disease that is caused by gradual death of brain cells.
 Actually, it occurs when there is abnormal build-up of proteins in and around the brain
cell resulting into the death of brain cells
 This destroys memory and other important mental functions.
 It is well characterised by memory loss (dementia).
 At first, someone with Alzheimer's disease may notice mild confusion and difficulty
remembering. Eventually, people with the disease may even forget important people in
their lives (their children and spouse)
N/B. Dementia is a general term for the symptoms of memory loss

Symptoms

 Memory loss; People with Alzheimer's may:

o Repeat statements and questions over and over, not realizing that they've asked
the question before
o Forget conversations, appointments or events, and not remember them later
o Get lost in familiar places

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Have trouble finding the right words to identify objects, express thoughts or take
o
part in conversations
o Eventually forget the names of family members and everyday objects
 Changes in personality and behaviour
o People with Alzheimer's may experience:

o Depression
o Social withdrawal
o Mood swings
o Distrust in others
o Irritability and aggressiveness
o Changes in sleeping habits
o Delusions, such as believing something has been stolen
Causes
 Scientists believe that for most people, Alzheimer's disease is caused by a combination of
genetic, lifestyle and environmental factors that result into death of brain cells over
time (It actually occurs when there is abnormal build-up of proteins in and around the
brain cell resulting into the death of brain cells)

Risk factors
 Age: Age is the single most significant factor. The likelihood of developing Alzheimer’s
disease doubles every 5 years after you reach 65. People with rare genetic changes linked
to early-onset Alzheimer's begin experiencing symptoms as early as their 30s.
 Family history and genetics: Although the actual risk is small. There is risk of
developing Alzheimer’s disease if your parent or sibling has/had the disease.

 MYASTHENIA GRAVIS
 Myasthenia gravis is a rare autoimmune disorder in which the antibodies (formed
antibodies) block the neuromuscular transmission (communication) resulting in skeletal
weakness.
Symptoms
 Weakness of arm, leg, or neck muscles(It worsens as the affected muscle is used
repeatedly), Drooping of one or both eyelids (ptosis), Double vision (diplopia) and
difficulties with speech, chewing, swallowing and breathing.
 The symptoms worsens with warm weather, immunization, stress, menstruation, viral
infections, pregnancy and postpartum periods
Note: There is no cure for myasthenia gravis, but treatment can help relieve signs and symptoms
Though myasthenia gravis can affect people of any age, it's more common in women younger
than 40 and in men older than 60.
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Causes

 It is caused by the antibodies that the immune system produces that blocks
neuromuscular transmission/communication. The antibodies eventually destroys the
muscle receptors resulting into weakness of the muscles

Other causes
 Genetic factors may also be associated with myasthenia gravis.
Note: Rarely, mothers with myasthenia gravis have children who are born with myasthenia
gravis (neonatal myasthenia gravis).
If treated promptly, children generally recover within two months after birth.

Nutrition therapy

 Provision of B vitamins for nerve health. Specific B vitamins that can help
with myasthenia gravis include:
o B1 and B2: can help with the healthy functioning of the muscles, nerves and
heart.

o B3: can help regulate the nervous and digestive systems. It helps convert food
to energy as well.

o B6: can help support the immune system.

o B12: can help support the nervous system, alongside vitamins B3 and B6.

 Protein: Reduce protein intake to 10 percent of total calories; replace animal protein
as much as possible with plant protein.
 Eliminate milk and milk products (substitute other calcium sources).
 Eat more fruits and vegetables (make sure that they are organically grown).
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 Fats: Avoid intake of trans-fatty acids

 Increase your intake of omega-3 fatty acids.
 Avoid foods that causes Inflammation: Since inflammation might trigger the
autoimmune response, eat foods that ease inflammation Provide omega-3 fatty acids
such as fatty fish, walnuts and flaxseed to ease inflammation
 Provide foods rich in anti-oxidants: Eat lots of fresh fruits and vegetables as they
are rich in antioxidants—nutrients that prevent cell damage, ease inflammation and
promote a healthy immune system.
 Increased Potassium: For muscle functions. Potassium-rich foods include bananas,
low-fat dairy, lean meats like chicken and turkey, fish and a wide range of fruits and
vegetables.
 Increased vitamin D: It is good I slowing down symptoms of autoimmune diseases
 Soft diet: Do not eat foods that require a lot of chewing. Moisten solid foods with
gravy, sauce, broth, butter, mayonnaise, or yoghurt. This is to avoid solid hard foods
getting stuck in the throat and increase the risk of choking.

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