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Chapter-01 Basic concept of diet therapy: one question this chapter Q. What is diet therapy? Describe the basic Objective------------------------------------------------- Diet Therapy is the use of food in the treatment of a disease. This is accomplished by changing the patient’s normal diet in order to meet the altered requirements resulting from diseases or injury. Objectives/ Purposes of diet therapy are as follows------------------------------------------------------

To increase or decrease body weight To maintain a state of positive health and good nutritional status To ensure adequate nutrition for all age groups and physiological conditions To correct nutrient deficiency that may occur To prevent chronic degenerative processes and diseases To adjust food intake to the body’s ability to metabolize the nutrient e.g. carbohydrate

modifications in diabetes mellitus. Q. Principle of diet therapy ---------------------------------------------------------------------------------------- There are certain principles of diet therapy are-------------- One important aspect is that all therapeutic diets are adaptations of the normal diet and

skeleton structure of the therapeutic diet must be based the requirements of a healthy person.

The dietitian also must consider the patient as a person and also given to the---economic status, dietary pattern, likes and dislikes, family environment, preferences and religious status of the patient

As a rule therapeutic diet must be easily digestible, soft, liquid, clear fluid or bland based on the condition

Best sources must be selected to ensure maximum utilization from the food consumed as a whole a patient has poor appetite

Confidence and cooperation from the patient are essential success of diet therapy The dietetic history of the patient must be collected to know of any intolerance of food or

allergic manifestation in the patient Working condition and dietary habits of work place also must be considered before dietetic

instructions. Q. Classification of Therapeutic Diet According to function, therapeutic diet is classified into four groups: 1. Primary Therapy: Here diet is the only way to treat the diseases. In case of non insulin

dependent diabetes mellitus (NIDDM), the macronutrients mainly carbohydrate modification is needed. Primary diet therapy is also used in non-complicated obesity, inherent metabolic diseases (Galactosemia, Lactose intolerance), Vitamin A deficiency, Iron deficiency anemia, IDD and other nutritional deficiencies.

2. Integral Therapy: It is used in conjunction with therapeutic agents. i.e. here both diet and medicine is required , e.g. atherosclerosis, insulin dependent diabetes mellitus (IDDM).

3. Adjunct Therapy: Here diet helps but not an integral part, e.g. in case of hypertension, sodium may be restricted, but medicine is must. In the ulcer patients, irritating foods should be avoids but medicine is essential.

4. Supportive Therapy: Medical treatment is the only way to treat the disease, but a good diet helps to recovery fast, e.g. bone fracture, surgery diet

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Q. Important of therapeutic diet --------------------------------------------------------------------- Therapeutic foods are usually made of a mixture of protein, carbohydrate, lipid and vitamins and

minerals. Therapeutic foods are usually produced by grinding all ingredients together and

mixing them. “The mixing process allows for the protein and carbohydrate components of the

food to be embedded in the lipid matrix.

Importances are bellows----------------------------------------------------------------------------------

i. To maintain nutritional status

ii. To restore nutritional status

iii. To correct nutritional status

iv. To improve clinical or subclinical nutritional deficiencies

v. To decrease calories for weight control

vi. To provide extra calories for weight gain

vii. To balance amounts of carbohydrates, fat and protein for control of diabetes

viii. To provide a greater amount of a nutrient such as protein

ix. To decrease the amount of a nutrient such as sodium

x. To exclude foods due to allergies or food intolerance

xi. To provide texture modifications due to problems with chewing and/or swallowing

xii. To maintain, decrease, or increase body weight.

xiii. To rest certain organs of the body.

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Chapter-02 Nutritional deficiency Disorders Q. What is Malnutrition and classification---------------------------------------------------------------- Malnutrition means more than feeling hungry or not having enough food to eat. It is a condition that develops when the body does not get the proper amount of protein, calories, vitamins and other nutrients it needs to maintain healthy tissues and organ function. It occurs in children who are either undernourished or over nourished. Children who are over nourished may become overweight or obese and those who are under nourished are more likely to have severe long term consequences. Malnutrition includes: under nutrition and over nutrition. Under nutrition: is a consequence of consuming little energy and other essential nutrients or using or excreting them more. Malnutrition: is a term referring to poor or inadequate nutrition. The cause of malnutrition may be due to:- Poor food availability &preparation Recurrent infections (GE) Lack of nutritional education Lack of sanitation Erratic health care provision Chronic diarrhea Hook worm & malaria Chronic infection by (T.B, otitis media) Congenital mal formations as (pyloric stenosis)

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1. What is PEM/PCM? Classification of PEM--------------------------------------------------- Definitions of PEM: Protein energy malnutrition (PEM) is the term given to a group of clinical conditions which occur due to inadequate protein and calorie intake, especially in children. The combined form of Kwashiorkor and Marasmus is called protein calorie malnutrition (PEM/PCM) Classification of protein energy malnutrition (PEM)------------------------------------------- Protein energy malnutrition has been classified in many ways, two of the important types are mentioned below. Clinical classification:

Kwashiorkar Marasmus Marasmic Kwashiorkar

Gomez classification Grade 1- 90-75% of expected weight Grade 2 – 75-60% of expected weight Grade 3 – <60% of expected weight 2. Q. General causes/ etiology of PEM=================================== There are many causes which contribute to PEM: -

1) Diet – A diet which is deficit in protein and energy or calories results in PEM. Through prolonged breastfeeding of children should be the rule, the amount of breast milk

secreted in poor Indian mothers is lower. 2) Social and Economic factors –

Poverty is one of the major causes of PEM, which leads to low food availability and unsanitary living condition which is the root cause infections and other diseases. Improper distribution of food among the family members.

Improper child care, neglect etc may also lead to PEM. Misconceptions, food and fallacies, poor child rearing practices and lack of knowledge, lack of adequate feeding during illness may all lead to PEM. 3) Environmental Factors –

Overcrowding of living space along with unsanitary living conditions lead to frequent infections like diarrhoea.

Respiratory infection and diarrhoea are the common diseases that cause severe PEM and death. 4) Biological factors

Maternal malnutrition before and during pregnancy may already make the child vulnerable to under nutrition and proper care and nutrition if not provided post birth may cause PEM.

3. Q. Important Risk factors of PEM====================================== Socioeconomic factors - poverty, lack of parental awareness and education Feeding practices – introduction of formula, easy cessation of breast feeding, non- exclusive

breastfeeding, insufficient complementary feeding practices Infections – water contamination and diarrhea are associated with PEM, malnutrition

adversely affects the immune status and makes the malnourished child more vulnerable to infections, and during infections the child’s appetite is impaired. Moreover, wrong practices of withholding food, reducing feeding or diluting infant formula during the episodes of diarrhea may lead to PEM.

Maternal factors – short maternal stature, anemia, low pre-pregnancy weight appear to be major factors in producing LBW babies who are more likely to develop PEM. Less birth space and large family size may also contribute to the poor nutritional status of mother

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Q. Complications of Protein-Energy Malnutrition================================= Acute • Electrolyte imbalance • Diarrhea, dehydration and shock • Hypoglycemia • Hypothermia • Sepsis Chronic • Insult to the brain development leading to low school performance • Stunting and ending up in short adult with low fitness for physical activity Q. Specific cause of PEM/PCM============================================= The combined form of Kwashiorkor and Marasmus is called protein calorie malnutrition-PCM Low protein intake Low Carbohydrate intake Low calorie intake Infection (Diarrhoea, measles, tuberculosis etc) Micronutrient deficiency by certain vitamins and minerals Impaired digestion and absorption (anorexia) Q. What are the biochemical and Metabolic changes during PEM?================

The following changes occur during PEM – Alteration in hormone levels can also lead to fluid retention.

Plasma levels of Aldosterone are elevated in kwashiorkor but not in marasmus.

Increased levels of ADH are seen in kwashiorkor.

There are raised levels of plasma cortical in PEM. The levels are higher in marasmus than kwashiorkor.

Somatomedins activity is also reduced on kwashiorkor but not in marasmus.

Plasma growth hormone levels are raised in kwashiorkor. Q. What are the hematological changes during PEM?============================

The following changes occur during PEM – There is moderate anaemia, which is a common feature.

Protein deficiency leads to a reduction in haemoglobin synthesis and total red cell mass.

Associated iron deficiency leads to microcytic anaemia.

Serum Vitamin B 12 levels are actually increased in PEM.

The red cell life is shortened in PEM along with various abnormalities of the red cell membrane, cell metabolism and composition.

The neutrophil leucocyte response to infection is often impaired.

Purpura and bleeding manifestations are seen in PEM. Q. How can you treat infections in PEM?=======================================

Infections may be fatal if not treated during PEM. It is difficult to detect infections clinically as symptoms of PEM may mask the symptoms of fever and rapid pulse rate. Antibiotic therapy can be administered after the infectious agent is detected.

Q. How can anemia be treated during PEM?================================= A. Severe anemia may be fatal if not corrected. The hemoglobin should not fall below 5 g/dl, blood transfusion should be provided in such a case. A diet rich in iron sources like jiggery, rice flakes, spinach, raw banana, kamal kadkadi (lotus stem), liver etc should be provided to the child. Inclusion of vitamin C food sources like citrus fruits, Amla (Indian gooseberry) etc with iron rich foods should be given to increase the absorption of iron in the body.

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Q. Prevention and treatment of PEM========================================== According to the FAO/WHO expert group suggest for the prevention of PEM in the community are as follows___ Health promotion: Exclusive breast feeding during the first 4-6 months Avoidance of bottle feeding and use of cup and spoon instead Giving supplementary foods after 6 months and continue breast feeding up to 2 years Importance of continued feeding during diarrhoeal attack Weaning of children gradually and step by step with liquid through semisolid diet to solid diet Understand the importance of continued feeding during diarrhoeal attack Get your child weighed in the nearby health institution/health post (PHCU) at least every month in the first one years, every two months in the second year and

every 3 months thereafter for proper growth monitoring Home economics and family environment Specific protection: Understand the importance of small frequent feeds for young children Avoid unhygienic practices contributing to development of PEM (food and water Hygiene,

personal hygiene, environment hygiene & proper waste and excreta disposal) Understand the importance of immunization on prevention of PEM Food fortifications Early diagnosis & Treatment: Periodic surveillance Early diagnosis and treatment of infection and Diarrhoea Early diagnosis any loss in growths Rehabilitation: Follow-up care Hospital treatment Nutrition rehabilitation service Q. How can PEM be treated with dietary management/ principle of treatment?========== Severe malnutrition or PEM require intensive care and should be referred to a hospital for

initial treatment. Nutrition intervention is the primary consideration. The child should be given a diet providing sufficient quantities of calories and proteins, with an increase in amounts gradually without provoking vomiting or diarrhoea. 170 – 200 kcal per kg of body weight and 3-4 g/ kg of body weight should be provided to the child.

It is suitable to initiate the feeding with a liquid formula gradually changing the consistency. The child may refuse the feed due to lack of appetite. Both proteins and calories are needed in large quantities. Sugar and vegetable oil should be added to increase the energy content.

Milk intolerance may be seen in severely malnourished children. In such cases, formulation should change to include buttermilk or dal based formulas. A mixed cereal based diet can be given with added oil to increase the energy.

Vitamin and mineral supplementation should be done to meet the increased requirements. These can be added to the diet or can be provided separately to the child. Vitamin A deficiency is quite common in children with severe PEM. Daily supplement of 60 mg/day of iron and 100 microgram/day of folic acid should be introduced in the diet.

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Differences between Kwashiorkor and Marasmus are given below:=================

Traits Marasmus Kwashiorkor

Cause Mainly due to Calorie deficiency

Mainly due to protein deficiency

Time of onset Onset is earlier, usually in first year of life

Onset is later, usually after breast feeding is stopped

Growth failure More marked Not very prominent

Edema No edema Edema present

Blood protein concentration

Reduced less noticeably Reduced very much

Skin changes Less frequent Red boils and patches are typical symptoms

Liver infiltration with fat

Not infiltrated Infiltrated

Recovery period Prolonged in marasmus Small in kwashiorkor

1- Marasmus Definition========================================= It is a clinical syndrome and a form of under nutrition characterized by failure to gain weight due to inadequate caloric intake. Incidence: Commonly in infants between the age of 6mo. - 2years (Infantile atrophy). Q. What are the symptoms of Marasmus?============================== The symptoms of Marasmus include the following - 1) The child has very less subcutaneous fat and muscle however there is no oedema.

2) The head of the child seems larger than the body, and has very little hair.

3) The child is below 60% of her weight for age, and the height of the baby is also affected.

4) The skin has some pigmentation or peeling skin lesions.

5) The abdomen of the child appears extended and protruding due to the weakness of abdominal walls and wasting.

6) The child suffers and is more prone to infections.

7) The child is irritable and whines a lot.

8) The child loses interest in her/his environment and is inactive.

9) Moderate degree of anemia and other deficiencies are also there in the child.

Q. Causes 0r etiology of Marasmus======================================== 1- Dietary errors 2 – Infection: Acute or chronic as T.B, otitis media pyelo nephritis 3- Gastroenteritis: (acute or chronic ) 4- Parasitic inf estuations as: Ascaris, ankylostoma ,giardia 5-Congenital anomalies as: Cardiac (P.D.A,V.S.D,F4) ,Renal (renal agenesis) 6-Metabolic diseases: Galactosemia, Fructose intolerance, Idiopathic hypocalcaemia 7- Prematurity 8- Some cases of mental retardation 9- Low socio economic status 10-Endocrine causes ( DM.hyperthyroidism

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Q. Assessment of Marasmic Child/Infant failure a to thrive ,loss of weight (weight < 60%of expected) loss of subcutaneous fat : measured at many parts of the body according to the degress:- 1 st degree: s.c fat in the abd. wall 2 nd degree: s.c fat in the abd. wall and limbs 3 rd degree: s.c fat in the abd. wall and limbs and face Muscle wasting ( thin muscles and prominence of bony surfaces ) G.I.T disturbances as anorexia in advanced cases, hungry, constipation or diarrhea or

starvation diarrhea liability to infection Hypovolemia Weak feeble pulse, subnormal temp, pulse rate Senile face and pallor Q. Complications of Marasmus 1. Intercurrent infection : Broncho pneumonia . is the cause of death 2. Gastro enteritis 3. Hemorrhagic tendency, purpura 4. Hypothermia 5. Hypoglycemia 6. Edema(marasmic kwashiorkor ) Q. Treatment of Marasmus 1- Prevention:- – proper diet ( balanced nutritional diet ) – encourage breast feeding up to weaning – proper weaning – proper vaccination as measles , T.B. whooping cough – Education regarding the cheap sources of balanced diet, family planning. – Proper follow up of the growth rate – Early treatment of defects or associated diseases

2 – Curative treatment:- A- Proper dietary management:- Adequate balanced feeding. Teaching about nutritional needs. Preparation of diet,

technique of administration of food B – Treatment of the cause C- Emergency treatment for complications D – Blood transfusion E – Vitamins and minerals supplementation

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Definition of Kwashiorkor?============================== It is a clinical syndrome and a form of malnutrition characterized by slow rate of growth due to deficient of protein intake, high CHO diet and vitamins & minerals deficiency (adequate supply of calories). Incidence Q. What are the symptoms of Kwashiorkor?====================== The symptoms of kwashiorkor include the following - 1) The three essential features of kwashiorkor are growth failure, oedema and mental changes. 2) The weight of the child depends upon the extent of oedema in the body and it is usually less

than 60% of the expected weight for age of the child. 3) The height of the child is affected more and the retardation is more pronounced than

marasmus. 4) Pitting edema appears first on the feet and legs and later spreads to the whole body. 5) The face looks puffy with sagging cheeks and swollen eye lids. 6) Abdomen is distended but as cites is rare. 7) The liver is enlarged due to fatty infiltration. 8) The symptoms include apathy (laziness), a moon face appearance due to edema, un- lustrous

and less hair. 9) Loss of hair results in patchy alopecia. The texture of the hair is dull and can be pulled out

easily. 10) Anorexia is common. 11) Diarrhoea may occur due to defective digestion and absorption as a result of secondary

infection. 12) Associated iron and foliate deficiencies may lead to anaemia. Q. Etiology or Cause Kwashirkor ===================================== 1. Balanced diet (of protein, CHO.) 2. improper weaning (during and post weaning period ) 3. faulty management of marasmic baby 4. Ignorance poverty due to lack of basic health education 5. precipitating factors as(acute infection with measles, diarrhea and malaria, parasitic

infestations) Q. Complication of kwashiorkor=========================================== 1. Secondary infection ,fungal and bacterial infection 2. Hemorrhagic tendency, purpura 3. Gastroenteritis 4. Hypoglycemia 5. Hypothermia 6. Heart failure due to anemia and infection. Common Nursing Diagnoses of Marasmus and KWO========================= 1. Altered nutrition :less than body requirements related to knowledge deficit, infection,

emotional problems, physical deficit 2. Body temperature alteration (hypothermia) related to low subcutaneous fat and deficiency of

food intake 3. Impaired skin integrity related to vitamins deficiency 4. Fluid volume deficit related to diarrhea 5. High risk for infection related to low body resistance.

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Nursing care of Marasmus=========================================== Support the infant and parents

1. provide nutrition rich in essential nutrients 2. Give small amounts of foods limited in proteins, carbohydrates and fats 3. Maintain body temperature 4. Provide periods of rest and appropriate activity and stimulation 5. Record intake and output 6. Weight daily 7. Change position frequently 8. Proper treatment is given for infection 9. Protection from infected persons and injuries 10. Refer family to social worker for financial support 11. Education for parents about proper nutrition

Nursing care of Kwashiorkor=========================================== Support the infant and parents

1. Proper diet intake proteins and CHO vitamins 2. Nursing care for vomiting, diarrhea or dehydration 3. Skin care for child for edema , injuries 4. Avoid any infection and follow hygienic measures for child 5. Frequent assessment of growth and development 6. Safety measures to avoid injuries 7. Nutritional counseling 8. Record intake and out put 9. Health education about medications and follow up 10. Frequent monitoring for any complications

Definition Marasmic Kwashiorkor============================ It’s a combination of caloric deficiency (marasmus ) and protein deficiency (KWO) . Clinical picture The clinical picture of this disease represents manifestations from both diseases as: loss of subcutaneous fat as in marasmus Edema, hair and skin changes as in KWO but there are no moon face.

Q. Contributing factors of Marasmic Kwashiorkor ======================= 1. Age common in infants (6 months -2years) 2. Preterm babies and twins 3. season more in winter than in summer 4. Diet inadequate intake of vitamin D and calcium and vitamin C in diet. 5. Heredity factor 6. Atmospheric condition 7. Race; more common in dark races

COMPLICATIONS Bone fractures, limbs deformities as the following: Tetany due to hypocalcaemia Anemia G.I.T disturbances as: G.E, constipation. Respiratory complications as pneumonia, bronchi –pneumonia low resistance , liability to infection as urinary tract infections

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What Is Iron-Deficiency Anemia? Anemia occurs when a person has lower-than-normal levels of red blood cells (RBCs) in the blood. According to the American Society of Hematology, there are many factors that can contribute to lower-than-normal RBC counts, including age, viral infections, and certain chronic diseases (ASH-American Society of Hematology, 2010). Iron-deficiency anemia is the most common type of anemia, which occurs when your body does not have enough of the mineral iron. Your body needs iron to produce a protein called hemoglobin, which is responsible for carrying oxygen to your body’s tissues. Your tissues and muscles need oxygen to function effectively. In women of child-bearing age, the most common cause of iron-deficiency anemia is loss of iron in blood due to heavy menstruation or pregnancy. Iron-deficiency anemia can also be caused by a poor diet or by certain intestinal diseases that affect how the body absorbs iron. The condition is normally treated with iron supplements Q. What Causes Iron-Deficiency Anemia? According to the Centers for Disease Control and Prevention (CDC), iron deficiency is the most common nutritional deficiency in the United States. It is also the most common cause of anemia (CDC, 2011). There are many reasons why a person might become deficient in iron. These include:

a) Inadequate Iron Intake Eating too little iron over an extended amount of time can cause a shortage in your body. Iron can be found in foods such as meat, eggs, and some green vegetables. Pregnant women and young children may need even more iron in their diet, as it is essential during times of rapid growth and development.

b) Pregnancy or Blood Loss Due to Menstruation In women of child-bearing age, the most common causes of iron-deficiency anemia are heavy menstrual bleeding or blood loss during childbirth. The CDC found that about nine percent of women ages 12 to 49 years are deficient in iron (CDC, 2012).

c) Internal Bleeding Certain medical conditions can cause internal bleeding, which can lead to iron-deficient anemia. Examples include an ulcer in your stomach, polyps (tissue growths) in the colon or intestines, or colon cancer. Regular use of pain relievers, such as aspirin, can also cause bleeding in the stomach.

d) Inability to Absorb Iron Certain disorders or surgeries that affect the intestines can also interfere with how your body absorbs iron. Even if you get enough iron in your diet, Celiac disease or an intestinal surgery such as gastric bypass may limit the amount of iron your body can absorb. Q. What Are the Symptoms of Iron-Deficiency Anemia?--------------------------------------- Symptoms of moderate to severe iron-deficiency anemia include:

general fatigue weakness pale skin shortness of breath dizziness strange cravings for non-food items, such as dirt, ice, and clay tingling or a crawling feeling in the legs swelling or soreness in the tongue cold hands and feet fast or irregular heartbeat brittle nails headaches

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Q. Who Is at Risk for Iron-Deficiency Anemia? Anemia is a common condition and can occur in both men and women, in all ages and ethnic groups. The risk for iron-deficiency anemia is higher in the following groups:

women of child-bearing age pregnant women people with poor diets frequent blood donors infants and children, especially those born prematurely or experiencing a growth spurt vegetarians who do not replace meat with another iron-rich food

Q. How Is Iron-Deficiency Anemia Treated? i. Iron Supplements Iron tablets can help restore iron levels in your body. If possible, you should take the iron tablets on an empty stomach to improve absorption. If they upset your stomach, they can be taken with meals. You may need to take the supplements for several months. Iron supplements may cause constipation or stools that are black in color. ii. Diet Diets high in red meat, dark leafy vegetables, dried fruits and nuts, and iron-fortified cereals can help treat or prevent iron deficiency. Additionally, vitamin C helps your body absorb iron. If you are taking iron tablets, a doctor might suggest taking the tablets along with a source of vitamin C, like a glass of orange juice or citrus fruit. iii. Treating the Underlying Cause of Bleeding Iron supplements will not help if the deficiency is caused by excess bleeding. Oral contraceptives (birth control pills) might be prescribed to women who experience heavy periods to reduce the amount of menstrual bleeding each month. In the most severe cases, a blood transfusion can replace iron and blood loss quickly. Q. Can Iron-Deficiency Anemia Be Prevented? When caused by inadequate iron intake, iron-deficiency anemia can be prevented by eating a diet high in iron-rich foods and vitamin C. Mothers should make sure to feed their babies breast milk or iron-fortified infant formula. Foods high in iron include:

meat, such as lamb, pork, chicken, and beef beans pumpkin and squash seeds leafy greens, such as spinach raisins and other dried fruit eggs seafood, such as clams, sardines, shrimp, and oysters iron-fortified dry and instant cereals

Foods high in vitamin C include: citrus fruits, such as oranges, grapefruit, strawberries, kiwis, guava, papaya, pineapple, melons,

and mango broccoli red and green bell peppers Brussels sprouts cauliflower tomatoes leafy greens

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Q. What Are the Potential Health Complications of Iron-Deficiency Anemia?=========== Most cases of iron-deficiency anemia are mild and do not cause complications. However, if anemia or iron deficiency is not treated, it can lead to other health problems, including: a. Rapid or Irregular Heartbeat When you are anemic, your heart must pump more blood to compensate for the low amount of oxygen. This can lead to irregular heartbeat, or in severe cases, heart failure or an enlarged heart may occur. b. Pregnancy Complications In severe cases of iron deficiency, a child may be born prematurely or with a low birth weight. Most pregnant women take iron supplements as part of their prenatal care to prevent this from happening. c. Delayed Growth in Infants and Children Infants and children who are severely deficient in iron may experience a delay in their growth and development. They may also be more susceptible to infections. Q.How Is Iron-Deficiency Anemia Diagnosed?=================================== A doctor can diagnose anemia with blood tests. These include: Complete Blood Cell (CBC) Test A test called a complete blood cell (CBC) test is usually the first test a doctor will use. A CBC test measures the amount of all components in the blood, including:

RBCs white blood cells (WBCs) hemoglobin hematocrit platelets

The CBC test provides information about your blood that is helpful in diagnosing iron-deficiency anemia. This information includes:

hematocrit levels (percent of blood volume that is made up by RBCs) hemoglobin levels size of your RBCs

In iron-deficiency anemia, hematocrit and hemoglobin levels are low. RBCs are usually smaller in size than normal. A CBC test is often performed as part of a routine physical examination. It is a good indicator of a person’s overall health. It may also be performed routinely before a surgery. This test is useful to diagnose this type of anemia since most people do not realize they are iron-deficient. Other Tests Anemia can usually be confirmed with a CBC test. Your doctor might order additional blood tests to determine the severity of your anemia and how to treat it. They may also examine your blood by using a microscope. These tests will provide information including:

RBC size and color (RBCs are pale in color if they are deficient in iron) ferritin levels (this protein helps with iron storage in your body. Low levels indicate low iron

storage) iron level in your blood total iron-binding capacity: a test to determine the amount of a protein, named transferrin, that is

carrying iron. Causes of iron deficiency Chronic blood loss Increased demand Malabsorbtion of iron Inadequate iron intake Intravascular hemolysis and hemoglobinuria-hemosiderinuria Combinations

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1. Goiter/IDD ( sign, symptoms, prevention, starvation & anorexia)-1 What is Goiter? Goiter is an abnormal enlargement of your thyroid gland. Your thyroid is a butterfly-shaped gland located at the base of your neck just below your Adam's apple. Although goiters are usually painless, a large goiter can cause a cough and make it difficult for you to swallow or breathe Classification of Goiter: Toxic goiter: A goiter that is associated with hyperthyroidism is described as a toxic goiter. Examples of toxic goiters include diffuse toxic goiter (Graves disease), toxic multinodular goiter, and toxic adenoma Nontoxic goiter: A goiter without hyperthyroidism or hypothyroidism is described as a nontoxic goiter. It may be diffuse or multinodular Examples of nontoxic goiters including goiter identified in early Graves disease, congenital goiter, and physiologic goiter that occurs during puberty Other type of classification: I - palpation Struma - in normal posture of head it cannot be seen. Only found when palpating. II - Struma is palpative and can be easily seen. III - Struma is very big and is retrosternal. Pressure and compression marks Q. Sign & Symptoms / Effect of Goiter?==================================== Not all goiters cause signs and symptoms. When signs and symptoms do occur they may include:

A visible swelling at the base of your neck that may be particularly obvious when you shave or put on makeup

A tight feeling in your throat Coughing Hoarseness Difficulty swallowing Difficulty breathing Impair physical & mental growths

Q. SYMPTOMS OF IODINE OR THYROID DEFICIENCY============================ Do you have any of these symptoms? Brittle nails, cold hands and feet, cold intolerance, depression, difficulty swallowing, dry skin, dry hair or hair loss, fatigue, high cholesterol, hoarseness, infertility, lethargy, menstrual irregularities, early menopause, poor memory or concentration, slower heartbeat, throat pain, or weight gain. Or more serious diseases: thyroid dysfunction, fibrocystic breast disease, breast cancer, ovarian cancer, endometrial cancer, or prostate cancer? Does your child have any of these symptoms? Q. Risk factors of Goiter=============================================== Goiters can affect anyone. They may be present at birth and occur at any time throughout life, although they're more common after age 40. Some common risk factors for goiter include:

A lack of dietary iodine. People living in areas where iodine is in short supply and who don't have access to iodine supplements are at high risk of goiter.

Being female. Because women are more prone to thyroid disorders, they're also more likely to develop goiters.

Your age. Your chances of developing a goiter increase with age. Medical history. A personal or family history of autoimmune disease increases your risk. Pregnancy and menopause. For reasons that aren't entirely clear, thyroid problems are more

likely to occur during pregnancy and menopause. Certain medications. Some medical treatments, including immunosuppressant’s, antiretroviral,

the heart drug amiodarone (Cordarone, Pacerone, others Radiation exposure. Your risk increases if you've had radiation treatments to your neck or chest

area or you've been exposed to radiation in a nuclear facility, test or accident

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Q. A number of factors can cause your thyroid gland to enlarge.==================== Among the most common causes for thyroid gland enlarge are below

a) Iodine deficiency. Iodine, which is essential for the production of thyroid hormones, is found primarily in seawater and in the soil in coastal areas. In the developing world, people who live inland or at high elevations are often iodine deficient and can develop goiter when the thyroid enlarges in an effort to obtain more iodine. The initial iodine deficiency may be made even worse by a diet high in hormone-inhibiting foods, such as cabbage, broccoli and cauliflower. Although a lack of dietary iodine is the main cause of goiter in many parts of the world, this is not often the case in countries where iodine is routinely added to table salt and other foods.

b) Graves' disease. Goiter can sometimes occur when your thyroid gland produces too much thyroid hormone (hyperthyroidism). In Graves' disease, antibodies produced by your immune system mistakenly attack your thyroid gland, causing it to produce excess thyroxine. This overstimulation causes the thyroid to swell.

c) Hashimoto's disease. Goiter can also result from an underactive thyroid (hypothyroidism). Like Graves' disease, Hashimoto's disease is an autoimmune disorder. But instead of causing your thyroid to produce too much hormone, Hashimoto's damages your thyroid so that it produces too little. Sensing a low hormone level, your pituitary gland produces more TSH to stimulate the thyroid, which then causes the gland to enlarge.

d) Multinodular goiter. In this condition, several solid or fluid-filled lumps called nodules develop in both sides of your thyroid, resulting in overall enlargement of the gland.

e) Solitary thyroid nodules. In this case, a single nodule develops in one part of your thyroid gland. Most nodules are noncancerous (benign) and don't lead to cancer.

f) Thyroid cancer. Thyroid cancer is far less common than benign thyroid nodules. Cancer of the thyroid often appears as an enlargement on one side of the thyroid.

g) Pregnancy. A hormone produced during pregnancy, human chorionic gonadotropin (HCG), may cause your thyroid gland to enlarge slightly.

h) Inflammation. Thyroiditis is an inflammatory condition that can cause pain and swelling in the thyroid. It may also cause an over- or underproduction of thyroxin. Q. Treatments and drugs of Goiter======================================= Goiter treatment depends on the size of the goiter, your signs and symptoms, and the underlying cause. Your doctor may recommend:

a) Observation. If your goiter is small and doesn't cause problems, and your thyroid is functioning normally, your doctor may suggest a wait-and-see approach.

b) Medications. If you have hypothyroidism, thyroid hormone replacement with levothyroxine (Levothroid, Synthroid) will resolve the symptoms of hypothyroidism as well as slow the release of thyroid-stimulating hormone from your pituitary gland, often decreasing the size of the goiter. For inflammation of your thyroid gland, your doctor may suggest aspirin or a corticosteroid medication to treat the inflammation. For goiters associated with hyperthyroidism, you may need medications to normalize hormone levels.

c) Surgery. Removing all or part of your thyroid gland (total or partial thyroidectomy) is an option if you have a large goiter that is uncomfortable or causes difficulty breathing or swallowing, or in some cases, if you have nodular goiter causing hyperthyroidism. Surgery is also the treatment for thyroid cancer. You may need to take levothyroxine after surgery, depending on the amount of thyroid removed.

d) Radioactive iodine. In some cases, radioactive iodine is used to treat an overactive thyroid gland. The radioactive iodine is taken orally and reaches your thyroid gland through your bloodstream, destroying thyroid cells. The treatment results in diminished size of the goiter, but eventually may also cause an underactive thyroid gland. Hormone replacement with the synthetic thyroid hormone levothyroxine then often becomes necessary, usually for life.

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Q. Discuss the effect of IDD in community===================================== There are some effects of IDD in community as below__ 1) It is difficult to educate iodine deficiency children and when the children grow up, they do not

get good jobs 2) Severally young disable children, who survive can be a burden on their families and

communities 3) A large goiter may reduce a person changes of Marring or employment 4) Iodine deficiency delays economical development in the area, because There are more handicapped people who need care for the community Cattle, Goat, Poultry and others domestic animals are also iodine deficient__ they grow

more slowly and reproduce less Local people are mentally slower & less energetic than healthy people.

Q. Goiter Tests and diagnosis ============================================= Hormone test: If the thyroid is overactive, the level of thyroid hormone in the blood will be high and the level of thyroid stimulating hormone (TSH) will be low If the thyroid is underactive the level of thyroid hormone will be low while the level of TSH will be high Antibody test: auto-immune antibodies. Ultra-sonography: To show the size of the thyroid gland and the presence of any nodules

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Q. What is obesity/overweight? Assessment of obesity What is overweight? A person who is more than 10-15% above the normal ideal weight for his or her sex, age and height is called overweight. What is obesity? A person who is more than 20% above the normal ideal weight for his or her sex, age and height is called obesity. Assessment of obesity: Obesity can be assessed by-

Body weight

Estimation of total body fat

Skin fold thickness

Body Mass Index On a more scientific basis, Obesity is expressed in terms of BMI (Body Mass Index) BMI = Weight (kg) Height (m2) Normal range from 20 to 25 is the good nutritional status for men while 19-24 is good nutritional status for women. Obesity is the condition in which an excess of fat has accumulate. In most case it can be detected by visual inspection. Obesity is risk factor which increased risk of death from heart disease. Q. Cause of obesity:================================================ Several factors may contribute to the development of obesity. Some are discussed below______ 1) Genetic factor: A genetic base regulates difference in body fat and sexual difference in

weight. Within families if one parent is obese a child has a 40% change of becoming obese. This change is 80% if both parents are obese.

2) Psychological factor: Fat person are seen as having less control over their appetites and as being more responsive external than 10 internal ones. Therefore some people believe that obese person eats:

When it is meal time or when they are surrounded by food instead of when they are hungry. When they are unhappy Because as children they associate food with maternal love. Over eating may result boredom

loneliness. 3) Sociological factor: Class values of different social groups also influence obesity. As a

person move upward in social class, there is a tendency to be more highly motivated to maintain a moderate to normal body weight. In lower socio-economic status groups obesity is fairly common and considered

4) Physiological factor: The normal physiology of growth and development during the life cycle contribution to accumulates of fat tissue deposits. There are critical periods for the development of obesity Early child hood Early stage of puberty Adult hood

For women other times may be during pregnancy and after menopause 5) Hormones: Disinfection of the thyroid, pituitary or suprarenal’s may result in obesity. Insulin

plays a contributory role is obesity. The female sex hormone also plays an important in obesity.

6) Food habit: The food habits of obese people are variable. Some eat three large meals a day, while other eats frequently 5 or 6 times a day. In both the groups excessive food intake is the course of obesity.

7) Inadequate physical activity: If physical activity is inadequate may result in obesity.

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Q. Dietary treatment of obesity:=================================== Principles of the treatment: On the basis of careful interviewing, assesses nutritional status, food habit and situational factors. A sound food plan is developed with the client based on the following component.

1) Energy balance: The energy level is adjusted to meet individual weight reduction requirement. A decrease of 1000 kcal daily is the necessary adjusted to lose about 900 g a week, 500 kcal is need to lose 450g a week. An average sound diet prescription for energy balance for women is about 1200 kcal/day. For large women and men the prescription would be 1500 to 1800 kcal/day.

2) Nutrient balance: Basic energy nutrients are outline in the diet prescription to achieve the following nutrient balance Carbohydrate: About 50-55% of total kcal with emphasis on complex forms such as starch with fiber and limit on simple sugars Protein: Approximately 20% of the total kcal with emphasis on lean food and small protein Fats: About 25-30% of the total kcal with emphasis on low animal fats

3) Distribution balance: Spread food evenly through the day to meet energy needs consider any daily problem times and are simple planned snacks as needed for such periods.

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Chapter-05 Diet therapy and meal planning: (Shahinur Sir) Q. What is Nutrition? ======================================= According to Cronin H Robinson- “Nutrition is the science of foods, the nutrients and other substances, their action, interaction and balance in relationship to health and disease. The process by which the organism, ingests, digest, absorb, transport and utilizes nutrients and disposes of their end products. According to Sumati R Mudambi- “The study of various nutrients, their functions, food sources, their utilization by the human body and their effect on human wellbeing is called nutrition.” According to Bogart- “Nutrition may be defined as the science of foods and at relates to optimum health performance.” Dietetics:============================================= Dietetics is the subjects which deals with general diet menu designed for individual (infant, children, adolescent, adult, pregnant, lactation, old age) who require normal diet and who require extensive modified diet (therapeutic diet). Dietitian: ================================================= Dietitian is a person who plans and supervises the preparation of therapeutic or other diets for individuals or groups in hospitals, institutions, other establishments and for workers in particular sectors, gives instructions in selection and proper preparation of food according to dietetic principles, performs duties related to nutrition programmes and may be responsible for food purchasing on behalf of an organization or establishment. Registered dietitian:=============================================== A registered dietitian (RD) is a person who has been extensively trained and certified as an expert in all things dealing with dietetics, food and nutrition. They educate on proper nutrition as well as oversee diet programs and food preparation. Q. Describe the types of a dietitian? 4 type of dietitian below ================

1. General dietitian They promote healthy eating habits and dietary modifications that help prevent and treat certain illnesses. On a large scale dietitians work for hospitals, schools and other institutions, managing food services. They educate the community on the healthy eating habits and conduct research.

2. Clinical dietitian Clinical dietitian works in hospitals, nursing care facilities and institutions. They work with doctors and health workers to develop nutrition programs the patients needs. The Clinical dietitians evaluate the results for effectiveness. If a patient has high blood pressure a Clinical dietitian explains how to cut down Na from the diet, for example. Clinical dietitians can specialize in diabetes, weight management, renal diseases or critically ill patient care.

3. Consultant dietitian A consultant dietitians screen clients for their nutritional needs and advice necessary changes. People go to consultant dietitians with a goal, weight loss or lower blood pressure and get diet plans to achieve the goal. Consultant dietitians can work with health care facilities, in their own private practice, for wellness programs, sports team, or nutrition related organizations.

4. Community dietitian Community dietitians work with individuals or groups, promoting disease preventions and healthy eating. They often work public health clinics, health maintenance organizations and home health agencies. They evaluate individuals’ needs and create nutritional plans accordingly. They instruct children, the elderly, and pupil with special needs how to grocery shop and prepare food, as well.

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Q. Describe the major roles of a renowned dietitian are as follows-==============--

Dietitian has an important role to prepare modification diseases diet especially planning the diet of a convalescing patient.

He/ She plan a healthy diet chart as per the doctor’s diet prescription. Prepare the patient mentally to accept the modified diet. Plan the diet and make it more appetizing and appealing. Enlightens and motivates the patient as per the needs regarding the technical and scientific

aspects governing the diet. Q. Scope of nutrition and dietetics are as follows---------==================-----

Dieticians in hospitals, nursing homes and multispecialty clinics. Food service managers in food service institutions, airline, catering, star hotels and other

catering agencies. Nutritionist in community, companies and private organizations. Resource person to conduct nutrition programs in villages. Nutrition counselors in Non-Governmental Organizations (NGOs) Research Scientist/expert in research and development centers

Like National Institute of Nutrition (NIN), Indian Dietetic Association (IDA), Indian Council of Agricultural Research (I.C.A.R.) and Central Food Technological Research Institutes (C.F.T.R.I.)

Recruitment as Nutritionists and Quality Assurance Executives in multi-national companies. Recruitment as Academicians. Entrepreneurs in different sectors related to health, diet, and food. Food Writer and Critics

Q. Signs of good nutritional status are as bellows---------------------------------------------------- i. Shiny hair, smooth skin, clear eyes and alert expression and firm flesh on well-developed

structure. ii. Correct weight in relation to his height.

iii. Physical and mental responses should be normal. iv. Good stamina and resistance to diseases. v. Regular sleep and elimination habits.

Q. Signs of poor nutritional status are as bellows--------------------------------------------------------- i. Apathetic attitude in general towards life. ii. Poor physique, very little stamina, dull lifeless hair, dull eyes, slumped posture, fatigue and

depression. iii. Overweight or underweight. iv. Diet, sleep and elimination habits are irregular.

Clinical symptoms of nutritional deficiencies may be present but may not exhibit any symptoms. Q. Guidelines for good health are as follows ---------------------------------------------------------------

i. Maintain regularity in your routine. ii. Eat as much natural foods as you can.

iii. Consume seasonal foods as far as possible. iv. Eat well but do not ‘overeat’. v. Avoid excessive salt and spices.

vi. Avoid too much sweet, especially sugar. vii. Eat foods which contain carbohydrates, especially starch and fiber.

viii. Avoid foods that contain large amounts of cholesterol and saturated fats. ix. Watch your weight and maintain ideal weight. x. Avoid eating the same kind of foods all the time and eat a variety of foods.

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Q, Reference Man:------------------------------------------------------------------------------------------ Reference man is between 20-39 years of age and weighs 55 kg. He is free from diseases and physically fit for active work. On each working day he is employed for eight hours in occupation that usually involves moderate activity. While not at work he spends eight hours in bed, 4-6 hours sitting and moving around and two hours in walking and in active recreation or in house hold duties. Q. Reference Woman:-------------------------------------------------------------------------------- Reference woman is between 20-39 years of age, healthy and weighs 45 kg. She may be engaged for eight hours in general household work, in light industry or in other moderately active work. Apart from eight hours in bed, she spends 4-6 hours sitting or moving around only through light activity and two hours in walking or in active recreation or in household duties. MEAL PLANNING Balanced Diet----------------------------------------------------------------------------------------------------------

• A diet, which provides all the essential nutrients in sufficient quantities to meet our needs, is called an adequate or balanced diet. We need a plan to select a balanced diet so simple and attractive that everyone can understand and follow it.

• This practical plan, known as a food guide, helps to ensure good nutrition through proper food selection. What is meal planning?----------------------------------------------------------------------------------------------

• Meal planning involves deciding what to eat per day at each meal. It takes thought, effort and use of knowledge about nutrition.

• We need to plan the meals to ensure that the needs of each family member are met. The plan can be flexible to take advantage of lower prices of seasonal foods and to meet the needs and choices of the family.

• Meal planning should involve- Planning, Purchasing, Preparation and Serving. Objectives in meal planning---------------------------------------------------------------------------------------

i. To satisfy the nutritional needs of the family members, according to their age and occupation. ii. Keep expenditure within the family’s food budget.

iii. To decide amounts of foods to be purchased from each food group. iv. To consider family size and composition. v. To consider food storage space and conditions of storage, to decide how often we need to

purchase various foods. In order to translate the meal plan into meals that meet the family’s need, the following additional steps have to be taken------------------------------------------------------------------------------

i. Prepare a food purchases list, taking the food preferences of members into account. ii. Use methods of preparation, which retain nutrients, without sacrificing palatability.

iii. Serve meals, which are appetizing and attractive and fit in the schedule of the members. iv. Manage the time, energy and available materials efficiently, with the help of the family members. v. If we make a weekly plan for all meals, we can save time, energy and money. It will also help us

to avoid monotonous meals.

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Q. Which factors should be considered in diet prescription?-------------------------------------- a) Dietetic history: Economic status: The economic status of the patient is an important practical consideration in formulating a diet prescription. During an acute illness or convalescence a few expensive items may be permissible, but for more prolonged or chronic illnesses, foods must be within the means of the patient. Vegetarian or non-vegetarian: Whether the patient is a vegetarian or not must be known. If vegetarian, then the ‘degree’ of vegetarian should be assessed; for example, vegans do not eat even eggs or dairy products, ‘egg vegetarians’ eat eggs and fish but not animal flesh; and ‘home vegetarians’ are vegetarian at home, for family reasons, but relish meat or chicken at a restaurant or party. Food intolerance: The dietetic history should elicit whether a patient can tolerate all foods: especially milk, pulses, spices, egg, meat, fish and prawn. Milk may produce diarrhea in some and constipation in others; those with colonic disorders are likely to get flatulence with pulses. Such foods should be restricted or excluded as necessary. Depending on the diseases, certain foods may have to be excluded. In peptic ulcer and gastritis, spices and chilies are not permitted. For a patient confined to bed, fried foods and pulses are best avoided as they produce flatulence Allergy: Allergy to food manifests as urticaria, abdominal cramps, or bleeding. The common allergens are shellfish and egg, and these have to be excluded. Occupation and time of meals: The occupation of the patient and the time he takes his meals has to be noted. A mill-worker who works on different shifts requires more detailed instructions for a peptic ulcer diet than a clerk whose hours of work are fixed. b) Calorie Requirement:

A person confined to bed tends to consume fewer/less calories than a person undergoing physical exertion. Bed-rest also decreases appetite. For an average adult confined to bed, about 1400-1600 kcal may be adequate. Fever increases the calorie needs.

A diet high in calories is indicated for undernourished or convalescent patients. They are advised to take more cereals, butter and oils at the main meals and snacks of milk, sandwiches or biscuits at mid-morning, mid-evening and before retiring.

A low calorie diet is indicated for all obese patients. A diet consisting of raw and cooked vegetables, fruits, eggs, meat, fish, chicken and skimmed milk, with a low intake of cereals provides bulk, satiety, adequate proteins and relatively few calories. Avoiding fat reduces weight. c) Protein Requirement: Total intake of proteins is usually adequate in a standard non-vegetarian diet. For vegetarians, the important sources of proteins are milk, cereals and pulses. In diseases of the colon, whole milk usually produces diarrhea while pulses produce flatulence. The protein requirements of vegetarians with colonic diseases can only be met by providing commercial protein foods, or by supplying skimmed milk powder which is usually more easily digested than fresh milk. Cirrhosis, nephritic syndrome, pregnancy and lactation: A high protein diet is prescribed to patients with low serum albumin, as in liver cirrhosis without liver failure and in the nephritic syndrome. It is also advisable to increase the protein intake during pregnancy and lactation. For a non-vegetarian, this can be done by increasing the quantity of meat, chicken, fish or egg. For the vegetarian, extra skimmed milk, cottage cheese, and pulses are advised. All pulses, including gram (Bengal gram) and groundnut, are relatively inexpensive and palatable protein-rich foods. Liver and kidney failure: During hepatic coma or uremia, protein has to be withheld temporarily and carbohydrate rich foods like fruit juice, banana, sugar cane juice and lemonade with sugar, honey or jiggery are advised. d) Fat Requirement:

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Fats are a convenient source of calories. Fats are not as indispensable as proteins, though prolonged deficiency of essential fatty acids leads to skin changes. A high-calorie diet should contain fatty foods like cream, butter, ghee and oil and fats should be freely used in cooking. A low-calorie diet contains little fat. e) Carbohydrate Requirement: Carbohydrates provide bulk and together with fats, form the chief sources of calories. If a high-calorie diet is to be prescribed, carbohydrates in the form of chapattis, bread and biscuits provide comparatively inexpensive nourishing foods. For a low-calorie diet they are used sparingly f) Vitamin Requirement: The best sources of vitamins are liver, yeast, whole grain cereals and fruits. Vitamin A is derived from egg, milk and butter, while carrots and green vegetables provide the pro-vitamin A, carotene. Vitamin B-complex is derived from unrefined cereals and flesh foods. The best sources of vitamin-C are fresh fruits, vegetables and germinating cereals. Vitamin-D can be easily acquired by exposure of skin to the sun for about half an hour. g) Mineral Requirement: Calcium is available from milk. The usual diet is seldom deficient in phosphorus. Iron is available from cereals, liver, kidney and egg. Sodium is easily provided by common salt added to food. A low sodium diet may have to be prescribed during fluid retention, cardiac failure, or the nephritic syndrome. The potassium intake can be increased with vegetables and fruits. A low potassium intake is advisable for patients with kidney failure. h) Fluid Requirement:

• Inadequate fluid intake can lead to constipation. Fluid intake should be liberal enough to ensure the passage of 1500-2000 ml of light-colored urine per day.

• Fluids need to be restricted when excretion is impaired, as in acute nephritis and kidney failure. The water requirement per day is then calculated as: 1000 ml a day to replace the insensible loss in respiration and perspiration, plus the volume of urine passed during the previous 24 hours.

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Estimation of Desirable Body Weight (DBW)------------------------------------------------------------------ 1. Infant: DBW (kg) = (Age in months ÷ 2) + 3

6-months old infants DBW (kg)= (6÷2) + 3 =3+3= 6 kg

10-months old infants DBW (kg)= (10÷2)+3=5+3= 8 kg

7-months old infants DBW (kg)= (7÷2)+3 =3.5+3= 6.5 kg or 7 kg

• N.B: [Infant weight will be- Doubled at 5-6 months, Tripled at 12 months, Quadrupled at 24 months] (If birth wt is not know, use 3 kg or 3000 g)

Height or Length: Example

At birth : 50 cm 50 cm

At 1 year : (--) + 24 cm 50 + 24 = 74 cm

At 2 year : (--) + 12 cm 74 + 12 = 86 cm

At 3 year : (--) + 8 cm 86 + 8 = 94 cm

At 4-8 year : (--) + 6 cm 94 + 6 = 100 cm

2. Children: DBW (kg) = (Age in years x 2) + 8

6-years old child DBW (kg) = (6x2) + 8 =12+8 = 20 kg

8-years old child DBW (kg) = (8x2) + 8 =16 + 8 = 24 kg

10-years old child DBW (kg) = (10x2) + 8 =20+8 = 28 kg

2-years old child DBW (kg) = (2x2) + 8 =4 + 8 = 12 kg

N.B: [+2 for every year] 3. Adult: (Method-1) : Derived formula based on BMI (Body Mass Index) DBW (kg) = Desirable BMI x Height (m2) N. B. Desirable BMI for men= 22 Desirable BMI for women= 20.8 or 21

Male (5’6”): DBW (kg) = 22 x 1.68 m2 = 22 x 2.82 m2 =62kg

Female (5’3”): DBW (kg) = 21 x 1.6 m2 = 21 x 2.56 m2 = 53.76 or 54 kg

• (Method-2): Tannhauser’s Method DBW (kg) = (Height in cm – 100) – (10% off) ± 1 eg. Male (5’6”): DBW (kg) = (168-100) = 68 kg – 6.8 or 7 = 61 kg DBW for male = 61+1 = 62 kg DBW for female = 61-1 = 60 kg Estimation of Total Calorie Requirement (TCR) or TER/Day------------------------------------------------ Infant (1-12 months):TCR/Day = 120-110 kcal/ KDBW

4-months old child TCR/Day = 120 kcal x 5.4 kg (DBW) =648 or 650 kcal

6-months old child TCR/Day = 120 kcal x 6 kg =720 or 700 kcal

9-months old child TCR/Day = 110 kcal x 7.5 kg =825 or 850 kcal

Children (1-12 years): TCR/Day = 1000 + (100 x age in years)

4-years old child TCR/Day = 1000 + (100 x4) kcal/day =1400 kcal/day

7-years old child TCR/Day = 1000 + (100 x7) =1700 kcal/day

11-years old child TCR/Day = 1000 + (100 x11) =2100 kcal/day

Adolescents (13-18 years): TCR/Day = 45 kcal/ KDBW

13-15 years Boys 55 kcal

Average 45 kcal / KDBW Girls 45 kcal

16-18 years Boys 45 kcal

Girls 40 kcal

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Example-

13 years old Boys (5’4”) TCR /Day = 45 kcal x 56 kg (DBW) = 2520 or 2500 kcal

16 years old girls (5’2”) TCR /Day = 45 kcal x 50 kg (DBW) = 2250 kcal

18 years old boys (5’7”) TCR /Day = 45 kcal x 63 kg = 2835 kcal

Adult: TCR/Day = DBW (kg) x Activity level Ref: [Krause’s method]

Activity level Example of Activity

Bed rest 27.5

Sedentary 30 Secretary, Clerk, Typist, Cashier, Administrator, Bank Teller etc.

Light 35 Teacher, Student, Nurse, Housewife with maids, Lab technician

Moderate 40 Housewife without maids, Vendor, Mechanic, Driver etc.

Heavy 45 Farmer, Labor, Fisherman, Heavy equipment operator etc

Example-

For light activity, (DBW = 52 kg) TCR/Day = 52 x 35 = 1820 or 1800 kcal/day

For Sedentary activity, (DBW =62 kg) TCR/Day = 62 x 30 = 1860 or 1900 kcal/day

For Moderate activity, (DBW = 49 kg) TCR/Day = 49 x 40 = 1960 or 2000 kcal/day

N.B. Pregnant Women: TCR/Day = Normal requirement + 300 kcal N.B. Lactating Women: TCR/Day = Normal requirement + 500 kcal Q, Distribution of Total Calorie Requirement (TCR) Method-1: By Percentage distribution

% of TER

Carbohydrate 50-70 % or Average of 60%

Protein Infants , children, adolescent 10 %

Adult 10-12 %

Fat Normal adult, Moderately active adolescents, Children

20-25 %

Very active individuals 30-35 %

Example: 7-years old children • TER/day = 1700 kcal • CHO/day = 1700 x 0.60 = 1020 kcal ÷ 4 = 255 g • Protein /day = 1700 x 0.10 = 170 kcal ÷ 4 = 42.5 g or 45 g • Fat /day = 1700 x 0.30 = 510 kcal ÷ 9 = 56.6 g or 55 g

[C, P and F are rounded off to nearest 5] • Rx Diet: 1700 kcal, C255 g P45 g F55 g

Moderately active housewife; DBW of 52 kg • TER/day = 52 x 40 = 2080 or 2100 kcal • CHO/day = 2100 x 0.60 = 1260 kcal ÷ 4 = 315 g • Protein /day = 2100 x 0.10 = 210 kcal ÷ 4 = 52.5 g or 50 g • Fat /day = 2100 x 0.30 = 630 kcal ÷ 9 = 70 g

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Rx Diet: 2100 kcal, C315 g P50 g F70 g Calorie Distribution List---------------------------------------------------------------------------------------------

Exchange lists

Servings/ amount

CHO (g)

Protein (g)

Fat (g)

Na (mg)

Kcal Serving Size/ day

Rich Source

1. Skim Milk 1 glass (240 ml)

12 8 0 120 80 2 to 3 (5-10% of total calorie)

Protein, Ca, Vit-B2

Low fat milk “ 12 8 5 120

Whole milk “ 12 8 10 170

2. Vegetables ½ cup 5 2 small 9 28 3 to 8 Vit-A,C, Folic acid

3. Fruits Different 10 small small 2 40 2 to 6 Vit-A,C; K

4. Rice, Bread and more Starchy foods

½ cup = 25g parboiled rice/smashed potato, 1cup=20g (Muri),

15 2 small 5 70 6 to 16 (60% of total calorie)

CHO, Thiamin, Niacin Fe

5. Meat, fish (Low fat/lean meat)

30 small 7 3 12.5 70

55 2 to 4 (10-15% of total calorie)

Fe, Protein, niacin, thiamin

Meat, fish (Medium fat)

30 small 7 5 75

Meat, fish (High fat)

30 small 7 8 100

Egg 50 small 6.7 6.8 90

Pulses (Low conc.)

½ cup 3 1 small 16

Pulses (Medium conc.)

½ cup 6.4 2.7 small 36

Pulses (High conc.)

½ cup 13 5.4 small 72

6. Fats and Oils

1 tea spoon 0 0 5 45 4 to 8 (20-30% of total calorie)

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Diet Prescription----------------------------------------------------------------------------------------------- Sample-1: Rx Diet: 1000 kcal, C150 g P50 g F23 g

Food Items Servings CHO (g)

Proteins (g)

Fat (g)

Total kcal

Milk (skim) 1 12 8 - 80

Vegetables 5 25 10 - 140

Fruits 4 40 - - 160

Sugar 1 5 - - 20

Pulses (low conc.) 1 3 1 - 16

Bread/Cereal (150-85 = 65/15 = 5)

5 75 10 - 340

Egg ½ - 3.3 3.4 45

Meat/ Fish (50-32.3 = 17.7/7 = 2.5)

2.5=1(med)+ 1(low fat)

- 17.5 10 160

Fats and Oils (23-13.4 = 9.6/5 = 2)

2 tsp - - 10 90

Total= - 160 49.8 23.4 1051

Sample-2: Rx Diet: 1700 kcal, C255 g P45 g F55 g

Food Items Servings CHO (g)

Proteins (g)

Fat (g)

Total Kcal

Milk (whole) 1 12 8 10 170

Vegetables 5 25 10 - 140

Fruits 4 40 - - 160

Sugar 1 5 - - 20

Pulses (low conc.) 1 3 1 - 16

Bread/Cereal (255-85 = 170/15 = 11.3)

11.5 172.5 23 - 805

Egg ½ - 3.3 3.4 45

Meat/ Fish (45-45.3 = 0)

- - - - -

Fats and Oils (55-13.4 = 41.6/5 = 8.3)

8.5 tsp - - 42.5 382

Total= - 257.5 45.3 55.9 1738

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Example-1: • Nusrat (23) is a housewife and her weight is 63 kg. Recently she went to a dietitian and

complains about her hypertension and anemia. Calculate and prepare a diet menu for her. (She is 149 cm long). History: Name: Nusrat; Age: 23 years; Weight: 63kg; Height: 149cm; BMI: 28.38; Health condition: Overweight; Activity: light; Socio-economic status: Middle class. Health Problems: Hypertension, Anemia, over weight Estimation of Daily Calorie Requirement for Nusrat

• DBW (kg) = (149-100) – (10% off) ± 1 = (49 – 4.9) - 1 = 43 kg

• DCR = DBW (kg) x Activity level = 43 x 35 = 1505 kcal Since Nusrat is obese person, so-

• Expected loss of weight = 500g/week • Prescribed calories to be= (1500 – 500)= 1000 kcal

Distribution of Energy • Energy: 1000 kcal/day with control fat (decreased saturated fat) • Carbohydrate (60%): 150g; Protein (20%): 50g; Fat (20%) : 23g; Cholesterol: 230 mg/day

Diet Prescription: Rx Diet: 1000 kcal, C150 g P50 g F23 g Cholesterol 230 mg Rx Diet: 1000 kcal, C150 g P50 g F23 g

Food Items Servings CHO (g)

Proteins (g)

Fat (g)

Total kcal

Milk (skim) 1 12 8 - 80

Vegetables 5 25 10 - 140

Fruits 4 40 - - 160

Sugar 1 5 - - 20

Pulses (low conc.) 1 3 1 - 16

Bread/Cereal (150-85 = 65/15 = 5)

5 75 10 - 340

Egg ½ - 3.3 3.4 45

Meat/ Fish (50-32.3 = 17.7/7 = 2.5)

2.5=1(med)+ 1(low fat)

- 17.5 10 160

Fats and Oils (23-13.4 = 9.6/5 = 2)

2 tsp - - 10 90

Total= - 160 49.8 23.4 1051

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Q. Menu Plan or Meal Distribution----------------------------------------------------------------------------- 1. Breakfast:

Hotchpotch (Khichuri)/ Bread/Toast /Cereals

1Servings ½ cup vegetable mixed khichuri or 1 slice bread or 1 ps medium size atta ruti.

Egg ½ Svg 1 ps egg pouched or boiled

Milk 1 Svg 1 glass milk made with/ without sugar

2. Mid morning snacks:

Noodles/ Butter cookies 1 Svg 1 cup noodles with mixed vegetables or 2 ps biscuits

Fruit juice or Lasschi 1 Svg 1 glass fruit juice or fruit lasschi

3. Lunch:

Rice 2 Svg 1 ½ cup or full plate parboiled rice

Fish / meat 2 Svg 2 ps or 60g locally available fish or chicken

Leafy vegetables 2 Svg 2 cup dark green leafy vegetables

Pulses 1 Svg 1 cup medium concentration lentils or mung bean

Curd/ Puddings ½ Svg 1 cup (100) or 1 slice

Noodles/ butter cookies 1 Svg 1 cup noodles with mixed vegetables or 2 ps biscuits

Fruits juice or Lasschi 1 Svg 1 glass fruit juice or fruit lasschi

4. Afternoon snacks

Cornflakes/Muri/popcorn 1 Svg ½ cup cornflakes made with/without milk and sugar/ 1 cup muri/ popcorn

Fruit juice or Lasschi or Horlics

2 Svg 1 glass fruit juice or fruit lasschi or Horlicks

5. Dinner

Rice 2 Svg 1 cup or half plate parboiled rice or 2 lice bread

Fish / meat 2 Svg 1 ps or 30g locally available fish or chicken

Leafy vegetables 1 Svg 1 cup dark green leafy vegetables

Pulses ½ Svg ½ cup medium concentration lentils or mung bean

6. Bed Time

Milk 1 Svg 1 glass milk made with/ without sugar

N. B. Tea: not more than 2-3 cups in a day Cooking oil: 2-3 teaspoon vegetable oil for whole day cooking process Water: minimum 10-12 glasses of water should be taken daily to avoid constipation. Special Tips=====================================

1. Exercise should be continue for minimum 1 hour (running, swimming, dancing, yoga etc). 2. 1 or 2 glass water should be taken before meal. 3. Mixed salad should be eaten so much as possible. 4. Eat variety of native and seasonally available fruits and vegetables. 5. Among fruits and vegetables one servsings must be from citrus fruits and green leafy

vegetables. 6. Vegetable oil is preferable because it contains more unsaturated fatty acid which is beneficial for

atherosclerosis patient. 7.Try to eat more sea food such as sea fish, sea weeds because it contains more unsaturated fatty acid. 8. Try to avoid fatty meat or fatty fish (such as pungus fish). 9. Reduce alcoholic drinks intake and avoid smoking. 10. Don’t add extra salt during cooking and don’t take extra salt during eating.

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Chapter-04 Dietary management: Kidney disease A large number of waste products are produced in the body as a result of metabolic activities. The removal of these waste products from the body is must. Kidneys are most important for removing these waste products and to regulate the volume and composition of body fluids. The kidneys, a pair of bean-shaped reddish-brown organs, are behind the liver and stomach on either side of the spine just below the diaphragm. Partially protected by the 11th and 12th ribs. They measure about 4 ½ inches long, 2 ½ inches wide and 1 inch thick. Basic functions of Kidney---------------------------------------------------------------------------------- Kidney has two major functions: 1. Filtration of blood Removes metabolic wastes from the body, esp. those containing nitrogen 2. Regulation:

Blood volume and composition

Electrolytes

Blood pH

Blood pressure In addition to removing wastes, the kidneys release three important hormones:

Erythropoietin or EPO, which stimulates the bone marrow to make red blood cells Renin, which regulates blood pressure The active form of vitamin D, which helps maintain calcium for bones and for normal chemical

balance in the body Q. What is Kidney disease----------------------------------------------------------------------------------- Kidney diseases are disorders that affect the kidneys. Most kidney diseases attack the nephrons, causing them to lose their filtering capacity. This can occur quickly, as the result of injury or poisoning, but in the majority of cases nephrons die slowly and silently. Kidney diseases may be menifested as- Acute glomerulonephritis, Nephrotic syndrome, renal failure etc. Q. Stages of Kidney Disease---------------------------------------------------------------------------------- The National Kidney Foundation (NKF) has divided chronic kidney disease into five stages to create a guideline to identify and treat each level of kidney disease.

Stage-1: with normal or high GFR (GFR > 90 ml/min)- usually no symptoms, but > normal levels of creatinine or urea in the blood and/or blood or protein in the urine

Stage-2: Mild CKD (GFR = 60-89 ml/min) like above – no symptoms, but, >creatinine or urea and/or blood or protein in urine

Stage-3: Moderate CKD (GFR = 30-59 ml/min)- complications include elevated blood pressure, anemia, early bone disease, fluid retention etc.

Stage-4: Severe CKD (GFR = 15-29 ml/min), fatigue, sleep problems, fluid retention, dark colored urine, nausea, and/or loss of appetite. Preparing for dialysis, but not there yet.

Stage-5: End Stage CKD (GFR <15 ml/min), all symptoms above and more, and dialysis is needed.

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Q. What is GFR? How is it calculated?--------------------------------------------------------------------- The Glomerular Filtration Rate (GFR) is the volume of fluid filtered from glomerular capillaries into the Bowman’s capsule per unit time Normal GFR: Men: 130 mL/min./1.73m2 Women: 120 mL/min./1.73m2 Cannot be measured directly, So we use creatinine and creatinine clearance to estimate. Creatinine

A naturally occurring amino acid, predominately found in skeletal muscle Freely filtered in the glomerulus, excreted by the kidney and readily measured in the plasma As plasma creatinine increases, the GFR exponentially decreases.

Limitations to estimate GFR: • Patients with decrease in muscle mass, liver disease, malnutrition, advanced age, may have

low/normal creatinine despite underlying kidney disease • 15-20% of creatinine in the bloodstream is not filtered in glomerulus, but secreted by renal

tubules (giving overestimation of GFR) • Medications may artificially elevate creatinine: Trimethroprim (Bactrim) Cimetidine • Creatinine Clearance Best way to estimate GFR GFR = (creatinine clearance) x (body surface area in m2/1.73)

Creat. Cl =1.23 x weight x (140-age)/(s.creat) { in female 1.03} Q. What Factors Increase Kidney Damage?---------------------------------------------------------

• Uncontrolled hypertension, Uncontrolled diabetes, Smoking, Hypercholesterolemia • Excessive proteinuria • Autoimmune Diseases • Recovery from ARF • UTI or Urinary Tract Infection • Kidney Stones • Lower Urinary Tract Obstruction • Systemic Infection • Drug Toxicity

Q. Types of kidney diseases ------------------------------------------------------------------------------ Generally kidney diseases are obtains as kidney failure. There are basically two common forms of kidney failure:

• Acute kidney failure: This is sudden in onset and caused by damage to the kidneys by infection, dehydration, poisoning or hemorrhage.

• Chronic kidney failure: This is more common, with a progressive deterioration of kidney function. Q. Sign & Symptoms of Kidney failure----------------------------------------------------------------

Acute kidney failure Chronic kidney failure Other sign and symptoms

-Vomiting -Diarrhoea -Lethargy -Dehydration -Anorexia (not

eating) -Abdominal pain -Weight loss

-Increased thirst -Increased urination -Periodic vomiting -Picky appetite -Dehydration -Anemia -Weakening of the bones, due

to imbalances in the calcium/ phosphorus levels

-Swelling the face, hands and legs -Urine may be foamy or dark color -Burning or difficulty during urination -An increase in the frequency of

urination -Passage of blood in the urine -Pain in the small of the back just below

the ribs

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Dietary Management============================================ Dietary modifications for patients with impaired or absent renal function Aim to:

1. Maintain or improve nutritional status 2. Minimize uremic toxicity 3. Retard progression of renal failure 4. Promote patient’s well-being

NUTRITION FOR RENAL PATIENTS================================= • The formulation of the renal diet is relatively complex compared to planning of other modified

diets. 6 components must be regulated:

– Protein – Sodium – Potassium – Calcium – Phosphorus – Fluid

PROTEIN • The major end products of protein metabolism are non-protein nitrogen – urea, uric acid, organic acids, carbon dioxide and water • Normally eliminated through the kidneys. • When kidneys are not functioning normally, these waste products are not excreted properly – Thus, nitrogen accumulates in the blood and tissues • Causing anorexia, nausea and vomiting, drowsiness and a general feeling of ill health • Thus in renal patient: Protein intake must be restricted. • The level of protein intake is determined by the patient’s symptoms as well as the degree of

impairment of renal function as shown by creatinine clearance.

Creatinine Clearance (Ml/min)

Daily Protein Intake (g/Kg)

30 to 20 0.60

19 to 5 0.45

5 0.30

• The higher the creatinine clearance, the greater the level of protein allowed. • For children, protein intake should not be less than 1.0 to 1.3 g/kg per day to assure adequate

protein supply for growth. • If there is loss of protein in the urine, the diet should provide an equal quantity to replace this. • When the diet is restricted in protein, it is important that at least 2/3 is of high quality and

distributed evenly throughout the days meal to ensure an adequate supply of essential amino acid.

• Egg whites are best source of high quality protein. • Meat, fish, milk and whole eggs are other good sources. • The amount of rice and high protein vegetables need to be regulated as the proteins in these

foods are of lower biological value. • A patient can choose one of the following-

1 glass of milk (200 ml) = ½ cup small fish = 2 cup concentrated pulses (200 ml) = 2 egg (white portion)

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Minerals

• Excess and deficiencies of certain electrolytes as a consequence of kidney malfunction are common features of renal disease

• These can lead to disruption of other body processes. Sodium:

• When there is edema and HPN Na intake of 60 to 90 mEq (1380-2070mg)/day is indicated • In extremely edematous patients Intake of less than 60 mEq (1380mg)/day • If renal function is impaired, the sodium will be restricted to 500 to 1000 mg/day. • Greatest source of Na – table salt

In sodium restricted diets, the following foods are avoided- • Salt during cooking or on the table. • Baking powder and soda bicarbonate which are added to cakes and pastries. • Sodium benzoate, potassium metabisulphite which are added as preservatives in pickles,

squashes and canned foods. • Cheese, salted chips, nuts, popcorn and biscuits. • Commercial soft drinks and proprietary drinks where sodium or potassium is present. • Dried foods like fish, fruits and soup cubes.

Foods containing moderate amounts of sodium (should be taken in restricted quantities)- • Milk, curds, pulses, vegetables etc.

Potassium • The kidneys eliminate 90 percent of potassium in healthy individuals. Potassium accumulates in

the body if the kidneys are not functioning properly. • Too much potassium intake will cause headache, vomiting, irregular heart beat or a heart attack.

Too little potassium can also be dangerous. • Potassium intake should not exceed 70mEq (2370mg)/day • Potassium is present mostly in fruits and vegetables. Potassium content can be reduced in

vegetables by cooking in extra water and then discarding the water. Spices and condiments can be used in small quantities as they are rich in potassium. In general, fruit juices are not recommended because most of the potassium is present in fruit juices. Foods high in potassium:

• Nuts, potato, instant coffee, chocolate and cocoa powder • Carrots, cabbage, cauliflower, tomato, beans, lau, pumpkin, mula, palon shak etc. • Apple, banana, guava, orange, mango, coconut, plum, papaya etc.

Foods low in potassium: • Cucumber, lettuce, beetroot, radish pink, broad beans, green mango, peas etc. • Sugar, honey, sago, unsalted butter, vegetable shortenings, vegetable oils and ghee.

Potassium content of fruits mg/100 g

Fruits low in potassium

mg/100 g Fruits high in potassium

mg/100 g

Orange Pineapple Papaya Apple Banana Guava Watermelon

9 37 69 75 88 91 160

Mango Amla Plums Sapota Lemon Peaches Sweet lime

205 225 247 267 270 453 490

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Phosphorus and Calcium • Phosphate retention occurs with decline in renal function. • As a result serum Calcium goes down. • A lower serum Calcium conc. stimulates an increase in the secretion of PTH results to

withdrawal of calcium from the bones. • Thus, bones abnormalities may develop. • Unfortunately, dietary phosphorus and calcium are difficult to control • Increasing the calcium intake and at the same time reducing the phosphorus intake maybe

difficult since those nutrients usually occur together in foods. Ex. Meat and milk products are high in both minerals • Level of Phosphorus restriction may range from 45 to 65 mEq (700-1000mg) daily

Foods to be included: Rice, sugar, leached vegetables, sago, honey. Foods to be restricted: Milk, curd, pulses, fruits like apple, papaya, banana, guava, watermelon etc. Foods to be avoided: Salts, bakery products, pulses, fruits like mango, amla, plums, lemon, peaches, meat, chicken and egg. Fluids

• Reduced ability to conserve or eliminate excess fluid. • Advised to consume 500-600ml fluid more than their 24 hour urine output, this will provide for

the insensible daily lose of water • Excessive fluid intake – edema, HPN, & shortness of breath

Fluids supplied as liquid foods such as milk, tea and soups should be measured and taken into account in the estimation of total fluid allowance Calories

• Patient with renal disease must have an adequate calorie intake, to prevent breakdown of body protein.

• To maintain Desirable BW, an adult usually needs at least 35 kcal/kg desirable body weight per day.

• Children should be no less than 80% of their recommended allowance for age (60-80 kcal/kg) to prevent growth retardation.

• Since protein intake of patients with renal disease is restricted, an adequate supply of calories should come from the carbohydrates and Fats in the diet. Carbohydrates Whole grain cereals, sago, high fiber breakfast cereals from unrefined carbohydrates are best. Refined carbohydrates include: sweets, chocolates, cakes, biscuits, sugary drinks - these are best as taken as occasional treats, not frequently. Fats Fat should be given liberally, but high lipid levels in the bloodstream (hyperlipidemia) are common in kidney patients, so, the risks of stroke and heart disease are increased. Highly unsaturated fats, like corn oil, sunflower oil and olive oil are better than highly saturated fats such as butter, cream, ghee, suet, coconut and fats from meat and poultry.

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HEALTHY FATS Source: U.S. Department of Agriculture, Agricultural Research Service. 2008. USDA National Nutrient Database for Standard Reference, Release 21.

Omega 3 Fatty Acids (EAT MOSTLY)

Omega 6 Fatty Acids (EAT MODERATE)

Omega 9 Fatty Acids (EAT MODERATE)

Flax seeds, china seeds, hemp seeds, walnuts

Sesame seeds, pumpkin seeds

Almonds, peanuts, cashews, pecans, pistachios, avocado

Flax, and fish oils Corn, soy, mixed vegetable oils and soft margarine

Olive, canola, sunflower, peanut oils

Daily Diet Menu Q. Dietary Prescription for Kidney patient===================================

• Generally, a low protein, high carbohydrate, low sodium, potassium and purine diet with restricted fluids is prescribed.

• 50% protein should be first class protein eg. Fish, meat, milk and egg and second class protein like rice, wheat, suji and sabu.

• Low potassium rich foods should be taken eg. Lau, pumpkin, jhinga, chichinga, mula, cucumber, bean (without seeds), dhundol etc.

• High potassium rich foods should be cooked in extra water and then discarding the water eg. Potato, banana (green), papaya (green), carrot, data shak, noteshak, puishak, sojne, kolar mocha, tomato, corolla etc.

• Low potassium fruits can be taken daily (1pc or 50-100g) eg. Apple, guava, papaya, naspati, jamrul, bel, pineapple etc.

• High potassium fruits should be restricted eg. Mango, jam (berry), lichu, anar, banana, amra, kamrangga, amla, coconut, orange, grape, jackfruit, boroi, lemon etc.

• Low purine rich foods should be taken eg. Sugar, honey, sweet, milk product, egg (white), oil, rich, bread, wheat, suji, sago etc.

• High purine rich foods should be restricted eg. Meat (beef, duck), liver, brain, egg (fish), dried fish, prawn, cabbage, cauliflower, palongshak, puishak, brinjal, kachu and its derivatives etc.

• Avoid salted foods like baking powder, bottle foods, chips, popcorn, nut, soft drinks, jam, sos, dried fruits and vegetables, chanachur, and table salt.

• Fluid intake should be controlled including tea, coffee and liquid foods. • Avoid nuts and seeds like pulses, seeds of been, jackfruit, puishak etc. • Pulses and milk can be taken twice in a week instead of fish/meat.

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Sample-1: 30 g Protein Diet

Meal Ingredient Amount

Breakfast (7.00-8.00 am)

Bread/ Ruti (small) Egg / Milk Vegetable / Dal

3-4 p 1 (white portion)/ 1 cup (100ml) 1 cup

Mid-morning (11.00 am)

Biscuit / Muri/Chira

2-4 1 cup

Lunch (1.00-2.00 pm)

Rice / Ruti (small) Fish/Meat Vegetables/ Dal

1 ½-2 cup 2-3 p 2 servings (60 g) 1 cup (60 g)

Afternoon (4.00-5.00 am)

Biscuit / Nooduls/ Muri Tea

2-4 1 cup 1 cup

Dinner (8.00-9.00 pm)

Rice / Ruti Fish/Meat Vegetables/ Dal

1 ½-2 cup 2-3 p 2 servings (60 g) 1 cup (60 g)

Bed time Juice/ Milk 1 cup (100 ml)

Q. Avoid for kidney patient: • Extra milk or milk products • Extra fish, chicken and eggs • Dry fruits: almonds, peanuts, cashewnuts, walnuts etc. • Pulses, legumes, peas, beans • Fruit juices

DIALYSIS--------------------------------------------------------------------------------------------------------- • Dialysis is a procedure that replaces some of the kidney’s normal functions. It is performed

when a person experiences kidney failure, usually when more than 95% of normal kidneys. • ½ of patients with CRF eventually require dialysis • keeps the body in balance by removing waste products including salt and excess fluids • Control BP • maintaining a safe level of blood chemicals such as potassium, sodium and chloride in the body • In general, dialysis becomes necessary at a creatinine clearance of 4 to 8 ml/min or a serum

creatinine of about 10 mg/dl.

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2 types of Dialysis kidney: a. Hemo dialysis b. peritoneal dialysis b. Hemo dialysis

• Most common type of dialysis which separates toxins and excess water artificially from the patient's blood.

• Hemodialysis usually takes place in clinics or hospitals, though some units have been adapted for home use.

• An artificial kidney, haemodialyser is used to remove the waste products from the blood and restore the body’s chemical balance.

• A rapid flow of blood is needed for haemodialysis. So, an access is made through a short surgery. Hemodialysis process

• In this type of dialysis, blood is taken from patient via vascular access and pumped into a dialyzer; blood is separated from the dialysate (dialysis solution) by semipermeable membrane

• Processes of diffusion and ultrafiltration remove waste products, electrolytes, excess water • Glucose, electrolytes, water can pass through, but larger molecules (protein, red blood cells) are

blocked Substances can be added to dialysate to diffuse into the blood of the patient Hemodialysis

• Haemodialysis is done approximately 3-4 hours and is usually 3-4 times a week. • Blood flow rates of 200 to 300 ml/min are usual. • Heparin is given intermittently or infused continuously to prevent clotting of blood in the dialyser

Haemodialysis patients unable to take oral supplements. So, needed substances like calcium or dextrose can be added to dialysate Dialysis Related Problems

• Lightheaded –give fluids • Hypotension • Dysrhythmias • Disequilibration Syndrome At end of early sessions Confusion, tremor, seizure Due to decrease concentration of blood versus brain leading to cerebral edema

Q. The Vitamin A deficiency disorder (VADD) cycle

Vitamin A deficiency disorder

Fig: VADD cycle

Adults Reliance on leaves and fruits Low performed vitamin A Low fat Low vit E Parasites Low vit A statues

Pregnancy Increased needs Food taboos

Low fetal stores

Young child Increased needs for growth

Breast protective Bottle hazardous Immunization Infection Mother care Neglect

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Peritoneal Dialysis • In this type, the patient’s blood is cleaned within the body • Catheter is surgically placed to create an access. The dialysate is slowly filled through the

catheter. • The exchange of waste products and chemical balancing takes place. Once exchange is

completed the used dialysis is drained from the peritoneal cavity. • Peritoneal dialysis is mostly performed by the patients themselves.

3 types Continuous ambulatory Continuous cyclical Intermittent

Q. Characteristics of haemodialysis and peritoneal dialysis------------------------------------------

Haemodialysis Peritoneal dialysis

Take only 3 to 5 hours per treatment Can be performed immediately

Requires only three treatments weekly Requires less complex equipment and less specialized personnel

Requires large doses of heparin Requires small amount of heparin or none at all

Requires complex water treatment, expensive dialysis equipment and highly trained personnel

Can be performed by patient anywhere without assistance

Requires surgical creation of vascular access between circulation and dialysis machine

Allows patient independence without long interruption in daily activities

Confines patient to special treatment unit Allows for more liberal diet

Risk of complications more Costs less

Q. Disadvantages of peritoneal dialysis--------------------------------------------------------------------- • Less effective metabolite elimination • Risk for infection (peritonitis: dialysate returns cloudy; should be straw colored) • Serum triglyceride levels increase • Altered body image with peritoneal catheter

Portable Dialysis • Portable Dialysis is a home dialysis process that introduces dialysis directly into the peritoneal

cavity, where it can be exchanged for fluids that contain metabolic waste products. Five years ago, the Food and Drug Administration approved a portable hemo dialysis system called NxStage that allows patients, with a partner, to undergo dialysis at home.

• The size of dialysis machine about 13-inch television. It comes with a disposable daily cartridge and high-purity fluid. Advantage:

• The main advantage of portable machine use is it is more easier then other dialysis machine. • It is not expensive. • It has carrying opportunity. • For use require less time in compare other dialysis machine.

Drawbacks of Dialysis • Dialysis can only control the kidney failure and does not cure the diseased kidneys • Patients with chronic kidney failure need to continue dialysis throughout their lives or until they

receive a kidney transplant. • Discomfort is seen when needles are inserted for haemodialysis.. • Dialysis is very expensive.

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Q. Slowing & Preventing Kidney Disease----------------------------------------------------------------- Using blood pressure medications if needed. Decrease of progression of diabetic kidney disease. Diet Modifications. Avoid too many pain medications Drink plenty of water Prevention urinary tract infections

Correlated with Prevention Kidney Disease:-------------------------------------------------------------- Healthy body weight Exercise (30 min/day: improve diabetic control, BP control, and heart function). Normal blood lipid levels

DIARRHOEA

Diarrhoea is the passage of 3 or more (more than 300g in 24 hours) loose or liquid stools per day, or more frequently than is normal for the individual. It is usually a symptom of gastrointestinal infection, which can be caused by a variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated food or drinking-water, or from person to person as a result of poor hygiene.

Severe diarrhoea leads to fluid loss, and may be life-threatening, particularly in young children and people who are malnourished or have impaired immunity. Q. Causes of Diarrhea--------------------------------------------------------------------------------------------- The most common cause of diarrhea is a virus that infects the gut. The infection usually lasts for two days and is sometimes called "intestinal flu" or "stomach flu.“ Diarrhea may also be caused by:

Infection by bacteria (the cause of most types of food poisoning) Infections by other organisms Eating foods that upset the digestive system Allergies to certain foods Medications Radiation therapy Diseases of the intestines (Crohn's disease, ulcerative colitis) Malabsorption (where the body is unable to adequately absorb certain nutrients from the diet) Hyperthyroidism Some cancers Alcohol abuse Digestive tract surgery Diabetes Competitive running Food poisoning Certain bacteria (usually staphylococci) irritate the digestive tract by producing toxins. These

toxins affect the mucous membrane much sooner, a few hours after consumption, compared with bacterial infection.

For this reason, people with inflammation or sores on their hands should not prepare food for others. Other causes---------------------------------------------------------------------------------------

When taking antibiotics, many people suffer diarrhoea, which may continue after the antibiotic course has finished.

The diarrhoea occurs because the antibiotic alters the intestinal bacterial environment. It is not an allergic reaction. In rare cases, such as diarrhoea caused by pseudomembranous colitis due to Clostridium difficile, it may require hospital admission.

This is an infection that can occur within two months of taking antibiotics or within a short time of being admitted to hospital.

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Q. Signs and Symptoms of diarrhea---------------------------------------------------------------------------- The signs and symptoms of diarrhoea include:

Passage of frequent, loose and watery stools. Abdominal cramps or pain. Fever-Particularly if there is an infectious cause. Bleeding- Bacteria and parasites often can produce bloody diarrhoea (dysentery). In addition

inflammatory bowel disease, polyps and colorectal cancer cause blood and mucus in the stools. Nausea and vomiting may also be present in the case of infection. Loss of appetite. Dehydration.

Q.What are the warning signs of Diarrhoea?---------------------------------------------------------- Blood in the motions. Pus in the motions (yellow mucus). Inability to drink liquids because of vomiting. Dehydration - symptoms include excreting small amounts of dark urine, drowsiness, dry mucous

membranes and thirst. Dehydration as a result of diarrhoea is a particular risk for young children and the elderly.

Pronounced drowsiness due to dehydration or intoxication. Acute diarrhoea in infants and very old people.

Q.Types of Diarrhoea There are mainly 2 types of diarrhoea -------------------------------------- 1. Acute diarrhoea

Last less than two weeks. Mostly infective type. Cause due to bacteria, virus, toxin, food poising, parasite and antibiotics. Causes due to contaminated food consumption.

2. Chronic diarrhoea Last more than three weeks. Mostly non-infective and cause due to different types of bowel disease. Chronic diarrhoea cause mainly due to bacteria, parasite and due to some irritable bowel

diseases. Others Types of Diarrhoea

Secretory diarrhea Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a Cholera toxin that stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a charge balance in the lumen, sodium is carried with it, along with water. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting. It continues even when there is no oral food intake.

Osmotic diarrhea Osmotic diarrhea occurs when too much water is drawn into the bowels. This can be the result

of maldigestion (e.g., pancreatic disease or Coeliac disease), in which the nutrients are left in the lumen to pull in water.

Osmotic diarrhea can also be caused by osmotic laxatives (which work to alleviate constipation by drawing water into the bowels).

In healthy individuals, too much magnesium or vitamin C or undigested lactose can produce osmotic diarrhea and distention of the bowel.

Travellers diarrhoea It occurs when tourists visiting foreign countries with warm climates and poor sanitation can acquire (ETEC enterotoxigenic E. coli) by eating contaminated foods such as fruits, vegetables, seafood, raw meat, water, and ice cubes, cause diarrhoea.

Motility-related diarrhea It is caused by the rapid movement of food through the intestines (hypermotility). This can be due to diabetic neuropathy, or a complication of menstruation and hyperthyroidism

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Exudative diarrhea

It occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections such as E. coli or other forms of food poisoning.

Inflammatory Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis. NB: [ Generally, if there is blood visible in the stools, it is not diarrhea, but dysentery. The blood is trace of an invasion of bowel tissue. Dysentery is a symptom of, among others, Shigella, Entamoeba histolytica, and Salmonella.] Q. Risk factors of Diarrhoea---------------------------------------------------------------------------------------

Age Diarrhoea occurred most frequently during the first year of life when, rates of growth and weight gain are most rapid.

Malnutrition Diarrhoea causes more malnutrition than acute attacks. The mean duration of episodes of diarrhoea in malnourished infants was also longer than in adequately nourished children.

Impaired immune defences The risk of persistent diarrhoea was also increased by impaired immunity (as measured by skin testing). Presumably a healthy immune system is required to fight off gut infections. Measles and malnutrition, which can damage immunity.

Previous diarrhoea Children who had recently had an episode of acute diarrhoea or who had ever experienced persistent diarrhoea were more likely to have persistent diarrhoea in future. This may be because of damage caused to the gut by the previous episode, or some other change in the child's defences against infection.

Specific gut infections Infection with certain micro-organisms (especially Shigella, enteropathogenic E coli and, in malnourished children, cryptosporidium) appears to increase the risk of persistent diarrhoea. Q. Management of Diarrhoea------------------------------------------------------------------------------

Oral Rehydration Therapy ( ORT) Diet Intravenous feeding Drug (ORT is an increase in administered fluids and continued feeding. Oral rehydration therapy

(ORT) is a simple, cheap, and effective treatment for dehydration associated with diarrhea. Concentrations of ingredients in Reduced Osmolarity ORS

Ingredient g/L Molecule mmol/L

Sodium chloride (NaCl) 2.6 Sodium 75

Glucose, anhydrous (C6H12O6)

13.5 Glucose 75

potassium chloride (KCl) 1.5 Potassium 20

Chloride 65

trisodium citrate, dihydrate (Na3C6H5O7•2H2O)

2.9 Citrate 10

Total Osmolarity 245

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Q. Homemade oral rehydration solutions for children Rice kanji: Boil water and add 30 gms of rice powder to make solution into a thin liquid. Add one

level teaspoon of salt and water to this liquid to make it up to 1 litre. Water, sugar and salt solution: This solution is essential medicine for diarrhoea. It is necessary

for adults as well as children. This solution should not taste too salty. Keep this solution in a cool place. Make fresh solution after 24 hrs.

-For 1 liter of boiled water, add ¾ teaspoon of salt and 8 teaspoons of sugar. Mix and taste. Q. Approximate amount of ORS solution to be given in the first 4 hours

Age Less than 4 months

4-11 months

12-23 months

2-4 years 5-14 years 15 years or older

Weight Less than 5 kg

5-7.9 kg 8-10.9 kg

11-15.9 kg

16-29.9 kg 30 kg or more

In ml 200-400 400-600 600-800

800-1200 1200-2200 2200-4000

Q. Type diet for children according to age group

Age Group Therapy Types

0 to 6 months Breast feeding and ORT

6 months to 1 year Breast feeding, ORT and liquid to semisolid type diet.

1 year to older ORT and pediatrics' food

Q. ***Developed by ICDDR’B

Composition of diets used in chronic diarrhoea ( g/ Liter )* (6 months to 4 years)

Half strength rice suji Half strength chicken

Rice powder 30g Chicken, minced 90g

Egg albumin 15g

Oil (Soya) 20ml Oil (coconut, Soya) 20ml

Glucose 25g Glucose 30g

Potassium chloride 1g Potassium chloride 1g

Sodium chloride 1g Sodium chloride 1g

Magnesium chloride 0.5g Magnesium chloride 0.5g

Calcium chloride 1g Calcium chloride 1g

Water up to 1 L Water up to 1 L

Energy 400 kcal Energy 380 kcal

Osmolality 280 mosmol/ kg Osmolality 218 mosmol/ kg

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Diet therapy of Diarrhoea Q. Principle of dietary modifications in diarrhoea are------------------------------------------------------

Energy: Energy requirements are increased by 10 to 20 % to meet the losses during diarrhoea as well as overcome weakness and loss of weight.

Protein: A high protein intake is essential to build up body tissue and replace the tissue breakdown which has occurred. It is advisable to increase the protein intake by as much as 50% . complementary protein sources should be used.

Carbohydrate: The intake of carbohydrate should be increased to meet the high energy requirements. However, the fiber intake is kept to a minimum (1 to 2 grams per day) to give rest to the intestines.

Fats: Due to the increased motility of the intestines, fats are not completely digested and therefore there intake needs to be restricted. Emulsified fats like butter and whole milk are given as they are easy to digest.

Vitamins: Greater amount of B group vitamin have to be provided to compensate for the losses that occur due to diarrhoea. Fat soluble vitamin like vitamin A is impaired and therefore sufficient amount should be provided in the diet.

Minerals: The absorption of calcium and iron in the intestines is lowered as they form insoluble salts with free fatty acids. Therefore calcium and iron rich foods should be included in the diets. Q. Sample menu for a adult patient with diarrhea

Time Meal Menu

8.00 AM Breakfast Toast

Jam

Barley water with skimmed milk

Tea or coffee

10.00 AM Mid morning Sago or arrowroot

Sweet lime juice

12.00 PM Lunch Rice gruel or Soft chapati

Thin dal

Clear soup

Mashed potato

4.00 PM Mid Afternoon Tea or coffee

Plain Biscuit

6.00 PM Evening Strained vegetable soup

8.00 PM Dinner Rice gruel or Soft chapati

9.00 PM – 11 Pm

Bed time Mashed potato

Apple slice

Sago porridge

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Q. BRAT Diet The BRAT diet is a treatment historically prescribed for patients with gastrointestinal distress such as diarrhea, dyspepsia, and/or gastroenteritis. The BRAT diet consists of foods that are relatively bland and low in fiber. Low-fiber foods were recommended as it was thought that foods high in fiber cause gas and possibly worsen gastrointestinal upset. An acronym, BRAT is a mnemonic for bananas, rice, apple sauce and toast, the staples of the diet. Extensions to the BRAT diet include BRATT (with tea) and BRATTY (with tea and yogurt). Benefit of BRAT diet

Reduce stool volume Reduce water and electrolytes losses Reduce gastrointestinal symptom

Q. Key notes in the management of diarrhoea Don’t stop breastfeeding of infant. Ensure adequate fluids. This is the most appropriate treatment in most cases of minor diarrhea. Try eating more but smaller portions. Eat frequently Don't eat or drink too quickly. Intravenous fluids: Sometimes, especially in children, dehydration can be life threatening and

intravenous fluid may be required. Dietary manipulation: especially avoid wheat products with celiac disease and lactose free milk

or other product. It is claimed that some fruit, such as bananas, mangoes and papaya may have positive effects on

this condition. Hygiene and sometime isolation: Hygiene is important in limiting spread of the disease.

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Diabetes =============================================

Diabetes is a group of diseases or chronic disease that occurs either when the pancreas does

not produce enough insulin which marked by high levels of blood glucose resulting from defects

in insulin production, insulin action, or both. Insulin is a hormone that regulates blood sugar

History: Diabetes is the fastest-growing disease in the country. Diabetes is the fifth leading

cause of death by disease. Each day, approximately 4,110 people are diagnosed with diabetes,

and 613 people die from the disease. Since 1987, the death rate due to diabetes has increased by

45%. Each year more than 80,000 people with diabetes undergo amputation. More than 80% of

diabetes deaths occur in low- and middle-income countries.

Q. Symptoms of diabetes:---------------------------------------------------------- -----------

High blood levels of sugar

Blurry vision

Fatigue

Painful urination

Frequent urination

Sores that do not heal

Nausea

Vomiting

Weight loss

Hunger

In some case there are no symptoms at all.

Q. Diabetes Transmitted:-------------------------------------------------------------------------------

Genetically (Type 1 diabetes, pre-diabetes & gestational )

Can develop due to poor diet & inadequate exercise (Type 2 diabetes, pre-diabetes &

gestational )

Developed due to following ways:

Over weight

High blood pressure

High cholesterol

Family history of diabetes

Family history of gestational diabetes

Testing for Diabetes:

FPG (Fasting Plasma Glucose Test)

OGTT (Oral Glucose Tolerance Test)

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Q. Types of Diabetes ---------------------------------------------------------------------------------------------------Four

types of diabetes exist which are given below

Type 1 diabetes Type1 diabetes is previously known as insulin-dependent/juvenile or childhood-onset. Type 1 diabetes develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose. The cause of type 1 diabetes is not known and it is not preventable with current knowledge. Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly. There is no known way to prevent type 1 diabetes. To survive, people with type 1 diabetes must have insulin delivered by injection or a pump. Type 1 usually strikes children and young adults, although disease onset can occur at any age. Risk factors for type 1 diabetes may be autoimmune, genetic or environmental. People at greater risk for type 1 diabetes: siblings of people with type 1diabetes and children of parents with type 1 diabetes. Type 2 diabetes Type 2 diabetes is formerly called non-insulin-dependent or adult-onset that results from the bodies in effective use of insulin. Type 2 diabetes usually begins as insulin resistance, a disorder in which the cells do not use insulin properly and as the need for insulin rises, the pancreas gradually losses its ability to produce it. Type 2 diabetes comprises 90% of people with diabetes around the world and is largely the result of excess body weight and physical inactivity. Symptoms may be similar to those of Type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, once complications have already arisen. Until recently, this type of diabetes was seen only in adults but it is now also occurring in children. The warning signs for type 2 diabetes are: any of the type 1 symptoms, frequent infections, blurred vision, cuts/bruises that are slow to heal; tingling/numbness in the hands/feet; recurring skin, gum, or bladder infections. Often people with type 2 diabetes have no symptoms. Type 2 Diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity and race/ethnicity. 3. Gestational diabetes Gestational diabetes is hyper glycaemia with onset or first recognition during pregnancy or form of glucose intolerance diagnosed in women during pregnancy. During pregnancy, gestational diabetes requires treatment to normalize maternal blood glucose levels to avoid complications in the infant. After pregnancy, 5-10% of women with gestational diabetes are found to have type 2 diabetes. Women who have had gestational diabetes have a 20-50% chance of developing diabetes in the next 5-10 years. 70% of women who have had gestational diabetes will develop type 2 diabetes at some point during their lifetime. Symptoms of gestational diabetes are similar to Type 2 diabetes. Gestational diabetes is most often diagnosed through prenatal screening, rather than reported symptoms. Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes, although this is not inevitable.

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Q. Common consequences of diabetes--------------------------------------------------------------------- Over time, diabetes can damage

Heart, blood vessels, eyes, kidneys (direct result from large amount of protein being deposit in urine), and nerves system.

Diabetes increases the risk of heart disease and stroke. 50-65% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).

Combined with reduced blood flow, neuropathy (nerve damage) in the feet increases the chance of foot ulcers, infection and eventual need for limb amputation.

Diabetic retinopathy is an important cause of blindness, and occurs as a result of long-term accumulated damage to the small blood vessels in the retina. One percent of global blindness can be attributed to diabetes

Diabetes is among the leading causes of kidney failure. The overall risk of dying among people with diabetes is at least double the risk of their peers

without diabetes.

Daily Meal Plan of Diabetes:=========================================

Time Grams of Carbohydrate Menus

8.00AM __Carbohydrate choices __Meat exchanges ___Fat exchanges

_Bread _Mutton/chicken _Vegetables

10.00AM __ Carbohydrate Choices _Rice

12:30 PM ___Carbohydrate choices ___Meat exchanges ___ Fat exchanges

_Rice _Mutton/chicken _Vegetables/Fruit

6:30 PM ___Carbohydrate choices ___Meat exchanges ___ Fat exchanges

_Bread _Mutton/chicken _Vegetables/Fruit

8.00 PM __Carbohydrate Choices _Rice

Q. Diabetes Management:------------------------------------------------------------------------------------- Routine Care:

Will be able to handle all or almost all routine diabetes care by themselves Because of age, developmental level, or inexperience, will need help from school staff.

Urgent Care: Diabetes may need help with emergency medical care.

Prevention / Control of diabetes ----------------------------------------------------------------------------- Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. To help prevent type 2 diabetes and its complications, people should:

Achieve and maintain healthy body weight; Be physically active – at least 30 minutes of regular, moderate-intensity activity on most days.

More activity is required for weight control; Eat a healthy diet of between three and five servings of fruit and vegetables a day and reduce

sugar and saturated fats intake; Avoid tobacco use – smoking increases the risk of cardiovascular diseases. Taking care of body.

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Q. Treating diabetes---------------------------------------------------------------------------------------- Diet, insulin, and oral medication to lower blood glucose levels are the foundation of diabetes treatment and management. Patient education and self-care practices are also important aspects of disease management that help people with diabetes lead normal lives.

To survive, people with type 1 diabetes must have insulin delivered by injection or a pump. Many people with type 2 diabetes can control their blood glucose by following a healthy meal

plan and exercise program, losing excess weight, and taking oral medication. Medications for each individual with diabetes will often change during the course of the disease. Some people with type 2 diabetes may also need insulin to control their blood glucose.

Self-management education or training is a key step in improving health outcomes and quality of life. It focuses on self-care behaviors, such as healthy eating, being active, and monitoring blood sugar. It is a collaborative process in which diabetes educators help people with or at risk for diabetes gain the knowledge and problem-solving and coping skills needed to successfully self-manage the disease and its related conditions.

Many people with diabetes also need to take medications to control their cholesterol and blood pressure. Blood pressure control

Blood pressure control reduces the risk of cardiovascular disease (heart disease or stroke) among people with diabetes by 33% to 50%, and the risk of micro vascular complications (eye, kidney, and nerve diseases) by approximately 33%.

In general, for every 10 mmHg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12%.

No benefit of reducing systolic blood pressure below 140 mmHg has been demonstrated in randomized clinical trials.

Reducing diastolic blood pressure from 90 mmHg to 80 mmHg in people with diabetes reduces the risk of major cardiovascular events by 50%. Control of blood lipids

Improved control of LDL cholesterol can reduce cardiovascular complications by 20% to 50%. Q. Preventive care practices for eyes, feet, and kidneys----------------------------------------------

Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50% to 60%.

About 65% of adults with diabetes and poor vision can be helped by appropriate eyeglasses. Comprehensive foot care programs, i.e., that include risk assessment, foot-care education and

preventive therapy, treatment of foot problems, and referral to specialists, can reduce amputation rates by 45% to 85%.

Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by 30% to 70%.