Professional Documents
Culture Documents
INTRODUCTION:
Diabetes mellitus is one of the most common metabolic disorders affecting
humankind.
Type 2 diabetes is a lifelong (chronic) disease in which there are high levels of sugar
in the blood.
Type 2 diabetes is the most common form of diabetes.
DEFINITION:
Diabetes Mellitus is a metabolic disorder characterised by decreased ability of the
tissues to utilize carbohydrates (glucose). This results in shifts and disturbances in the
fat and protein metabolism and in water and electrolyte balance.
CLASSIFICATION:
The classification of diabetes includes four clinical classes: (ADA 2003)
Type 1 diabetes (results from -cell destruction, usually leading to absolute insulin
deficiency).
Type 2 diabetes (results from a progressive insulin secretory defect on the background
of insulin resistance).
Other specific types of diabetes (due to other causes, e.g., genetic defects in -cell
function, genetic defects in insulin action, diseases of the exocrine pancreas, and drug
or chemical induced).
Gestational diabetes mellitus (GDM) (diagnosed during pregnancy).
PREVALENCE:
Prevalence is rapidly rising all over the globe at an alarming rate.
Although there is an increase in the prevalence of type 1 diabetes also, the major
driver of the epidemic is the more common form - type 2- more than 90% of the
diabetic cases.
India earns the dubious distinction- Diabetes capital of the world
WHO (2000) 32 million people had diabetes in the year 2000.
Diabetes atlas (2006) diabetic people in India in the year 2006 were 40.9 and expected
to rise to 69.9 million by 2025.
CAUSES AND RISK FACTORS:
Weight being overweight is a primary risk factor.
Fat distribution- more prevalent in people with fat stored primarily in the abdomen
CLINICAL SYMPTOMS:
Symptoms may develop very slowly
DIAGNOSIS:
A person is said to be diabetic if his/her blood sugar levels are above 100 mg/dL. To confirm
the diagnosis, one or more of the following tests must be done.
100 /<126
Height
Weight
BMI CLASSIFICATION:
BMI (kg/m2)
RISK OF
CO-MORBIDITIES
Underweight
18.5
Low
18.5 24.9
Average
Overweight (Pre-Obese)
25 29.9
Increased
Moderate (Class I)
30 34.9
Moderate
35 39.9
Severe
40
Very severe
Obesity
Waist circumference
Waist Circumference
Men
High Risk
94 102
>102
Women
High Risk
80 88
>88
HbA1c
Non-fasting lipid profile - total cholesterol, HDL cholesterol, LDL cholesterol and
triglycerides
Urinalysis for ketones, protein and nitrite (evidence of infection).
Clinical:
Blood pressure has to be recorded since diabetics are prone to hypertension and vice
versa.
Evaluation of clinical symptoms
Polyuria
Polyphagia
Polydipsia
Giddiness
Tiredness
Itching
Nocturia
Blurring of vision
Weight loss
Decreased healing capacity
Diet history of the patient can be assessed using
3- day dietary recall and
Food frequency questionnaire.
The nutritional needs of the patient should then be determined and based on the nutritional
assessment according to the patients requirements.
COMPLICATIONS OF DIABETES:
Control of diabetes by ensuring normal blood levels is important for preventing the
complications to develop.
A. ACUTE COMPLICATIONS:
Hypoglycemia:
Because of poor timings of meals and snacks or exercising more than usual without
adding an extra meal or snack in the diet.
Symptoms- shakiness, nervousness, sweating, dizziness, weakness, irritability and
hunger.
Hyperglycemia :
Abnormally high levels of sugar in the blood leading to diabetic ketoacidosis.
Ketoacidosis is an extremely serious condition leading to coma or even death.
To prevent ketoacidosis, one should for ketones under the following conditions:
Blood glucose levels- >240mg/dL
Fever is present
Nausea and vomiting
Stress
If insulin dosage is being adjusted
B.CHRONIC COMPLICATIONS:
The chronic complications arising due to uncontrolled diabetes are
ATHEROSCLEROSIS
Degeneration of walls of the arteries due to fatty plaques deposition.
The risk of stroke is two to four times higher for people with diabetes, and the death
rate from heart disease is two to four times higher for people with diabetes than for
people without the disease (ADA).
NEPHROPATHY
Changes occur in nephrons of the kidney due to thickening of capillary basement
membrane.
RETINOPATHY
Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially
leading to blindness.
It also increases the risk of other serious vision conditions, such as cataracts and
glaucoma.
NEUROPATHY
Lesions of peripheral nervous system could cause tingling, burning, or numbness in
the sensation of upper and lower limbs.
FOOT DAMAGE
Nerve damage in the feet or poor blood flow to the feet increases the risk of various
foot complications.
SKIN AND MOUTH CONDITIONS
Diabetes makes a person more susceptible to skin problems, including bacterial and
fungal infections.
OSTEOPOROSIS
Diabetes may lead to lower than normal bone mineral density, increasing the risk of
osteoporosis.
ALZHEIMER'S DISEASE
Type 2 diabetes may increase the risk of Alzheimer's disease and vascular dementia.
The poorer the blood sugar control, the greater the risk appears to be.
HEARING PROBLEMS
Diabetes can also lead to hearing impairment.
Before
Post
Age
Meal
Meal
(Years)
Adolescent
s 13-19
90-130
Random
Bedtime/
Hba1c
Rationale
Overnight
-
< 7.5
Risk of severe
Hypoglycemia.
Developmental
& Psychological
Adults
70-130
<7
Issues.
Goals should be
indivudualised
based on
duration, age,
comorbid
conditions.
Pre-
60-99
Existing
GDM
Elderly
100-
<180
60-99
<6
7-8
129
70-130
<130/80 mmHg
110-129/65-79
Cholesterol
<170 mg/ dl
LDL
Triglyceride
<150 mg/dl
HDL
NUTRITION THERAPY:
Nutrition therapy is essential for the treatment of Diabetes and is well recognised as a
keystone of management in diabetic patients.
Main dietary objectives are:
To supply optimum nutrition to maintain good health.
To provide adequate calories for maintaining ideal body weight and allowing for
normal growth and development in children.
To maintain glycemic control
To achieve optimum blood lipid levels
WEIGHT
ACTIVITY LEVELS
CALORIES REQUIRED/KG
BODY WEIGHT
25
30
20
30
35
Carbohydrates:
Diabetics need not restrict the CHO intake but have to alter the type of carbohydrate.
Emphasis is on complex CHO than simple carbohydrates present in jams, jellies etc.
CHO should provide 55-60% of calories with low glycemic index along with high
fibre foods.
CHO distribution in the diet:
One third (33%) during lunch
One third (33%) during dinner
Remaining for breakfast (25%) and evening (9%).
Proteins:
0.8-1g/kg bodyweight providing 15-20% of the total calories.
In diabetics with renal problems, protein is restricted to 0.5g/kg IBW.
Fats:
Fats should provide 15-25% of the calories.
High fat diets adversely affect glucose tolerance and may increase the risk of CHD.
Vitamins and Minerals:
Uncontrolled diabetes may produce deficiencies of zinc, chromium and magnesium
and vitamins C and D.
Low calorie diets prescribed for obese diabetics may not provide enough
micronutrients and individuals may need micronutrient supplements
Dietary Fibre:
Soluble fibre pectins, gums, mucilages, present in vegetables, fruits and legumes id
more effective in controlling glucose than insoluble fiber (cellulose, lignin) present in
cereals and millets.
40g dietary fibre/day or 25g/1000 calories is recommended.
High fibre foods also have low glycemic index and caloric value.
ADA, 2011
Carbohydrates
Soluble Fibre
Proteins
10-35% TEI
Fats
25-35% TEI
Less than 7%
Acids Greater than or equal to 10%
(MUFA)
Poly Unsaturated Fatty Acids (PUFA)
Trans fats
PUFA:MUFA:SFA
Reduction of protein intake to 0.8-1.0g per Kg body weight in diabetics with renal
complications.
Balanced diet does not require vitamin and mineral supplementation.
NIN, 2000
Carbohydrates
60-65% TEI
Distribution 25% breakfast, 33 % lunch,
Fat
Protein
Cereals
Wt/Vol.
Calories
Rice
30 gms uncooked
100
Wheat flour
30 gms uncooked
100
Dalia
30 gms uncooked
100
Sago
30 gms uncooked
100
White flour
30 gms uncooked
100
Bread
40 gms
100
Chapati
44 gms
100
Jowar roti
Ragi
55 gms
30 gms uncooked
100
100
Rice flakes
30 gms uncooked
100
Oat meal
30 gms uncooked
100
Vermicelli
30 gms uncooked
100
Corn flakes
30 gms uncooked
100
Maize dry
30 gms uncooked
100
Marie biscuit
100
Monaco biscuit
100
Idlis
Poha
Upma
Dosa ordinary
100
100
100
LIST
FAT
EXCHANGE
50 gm Calories; Fat 5.5 gm
Fats
Weight [gm]
Calories
Butter
7.5
50
Ghee
5.5
50
5.5
50
5.5
50
Cashew nuts
10
50
Groundnuts, roasted
10
50
Walnuts
Pistachio
Almonds
7.5
7.5
7.5
50
50
50
Wt./Vol.
Calories
Curd
105 gm
50
Butter Milk
375 ml
50
Cheese
15 gm
50
Milk [Buffalo]
45 ml
50
Milk [Cow]
90 ml
50
Milk, Skimmed*
130 ml
50
15 gm
50
50
[ without sugar]
Tea + 75 ml milk
Khoya
1 medium glass 150 ml
*provides 5 gm protein
LIST 4 - VEGETABLE EXCHANGE
50 Calories; Carbohydrate 10 gm
50
15 gm
50
Vegetables
Wt. (gm)
Calories
Beetroot [Chukander]
75
50
Carrot
105
50
Colocasia [arbi]
45
50
Onion [big]
90
50
Onion [small]
75
50
Potato
45
50
Sweet potato
30
50
Tapioca
30
50
Yam [Zimikand]
45
50
Broad beans
90
50
Cluster beans
90
50
Double beans
50
50
Jack, Tender
105
50
Jackfruit seeds
30
50
Leeks
60
50
Peas
45
50
Singhara
45
50
Sambar
35 ml
50
50
Cooked vegetable
Size/No.
Wt. (ml)
Calories
Apple
1 small
75
50
Amla
20 medium
90
50
Banana
1/4 medium
30
50
Cashew fruit
2 medium
90
50
Custard apple
1/4
50
50
Dates
30
50
Figs
6 medium
135
50
Grapes
20
105
50
Grape fruit
1/2 big
150
50
Jack fruit
3 medium pieces
60
50
Mango
1 small
90
50
Melon
1/4 medium
270
50
Orange
1 small
90
50
Lemon
1 medium
90
50
Papaya
2 medium
120
50
Peach
Pear
Plums
1 medium
1 medium
4 medium
135
90
120
50
50
50
Pineapple
Strawberry
90
105
50
50
Sweetlime
1 medium
150
50
Tomato
4 medium
240
50
Water melon
1/4 small
175
50
Wt. (gm)
Calories
Bengal gram
30
100
30
100
30
100
Cow gram
30
100
Horse gram
30
100
30
100
Lentils
30
100
Moth beans
30
100
Peas, dried
30
100
60
100
Red gram
30
100
Wt. (gm)
Calories
2 No.
100
Fish
60
70
Liver, sheep
60
70
Mutton, muscle
60
100
Pork
60
70
Prawn
60
70
Chicken
60
70
Egg Hen
Crab
70
Beef
60
70
Bittergourd
Curry leaves
Amaranth
Fenugreek leaves
Brussels sprouts
Mint
Cabbage
Other Vegetables
Spinach
Coriander leaves
Cauliflower
Pumpkin
Brinjal
Onion stalks
Drumstick
French beans
Tomato, Green
Mango, green
GLYCEMIC INDEX:
Glycemic index is the numerical index given to a carbohydrate rich food that is based on the
average increase in blood glucose level occurring in blood after the food is eaten.
Glycemic Index = Area under 2 hours blood response curve to the test food
Area under 2 hours response for equivalent Glucose
Low GI
55 Or less
Medium GI
High GI
56-69
70 or more
rice
Corn flakes, baked potato,
some white rice varieties,
white bread, candy bar and
syrupy foods.
Starch
Fruit
Milk
Vegetable
Meat
Fat
15
15
12
5
0
0
Types vary in how quickly it starts working, how it works and its peak activity.
Short acting works quickly 2 to 3 hours after injection Regular insulin Semilente
Intermediate acting works slowly 8-12 hours after injection- Lente
Long acting- peak activity 18 to 24 hours after injection.
Carbohydrate distribution varies with the type of insulin prescribed.
Regular insulin- 1/3rd each CHO in 3 meals.
Intermediate 1/7th breakfast, 2/7th for noon, 1/7th for mid noon, 2/7th for evening &
1/7th for bed time.
Long acting 1/5th for breakfast, 2/5th for noon & 2/5th for evening.
SICK DAY GUIDELINES:
Never omit the insulin or drug dose, even if the person is unable to eat.
Test the blood glucose level before each mealtime and at the bedtime.
Take liquids every hour.
Rest or keep warm, do not exercise.
25-35 kcal
Carbohydrates
Lipids
30% TEI
Protein
1.0-1.5 g
DIETARY GUIDELINES:
Eat at regular times and maintain healthy eating habits.
Eat regular small mealsup to 6 per day
Eat a lot of non-starchy vegetables, beans, and fruits such as apples, pears, peaches,
and berries.
Eat grains in the least-processed state possible: unbroken, such as whole-kernel
bread, brown rice, and whole barley, millet, and wheat berries; or traditionally
processed, such as stone-ground bread, steel-cut oats, and natural granola or muesli
breakfast cereals.
Limit potatoes and refined grain products
Limit concentrated sweetsincluding high-calorie foods with a low glycemic index,
such as ice cream to occasional treats. Reduce fruit juice to no more than one cup a
day. Completely eliminate sugar-sweetened drinks.
Choose low fat foods such as lean meats, seafood, chicken breast, tofu, and egg white.
Remove all visible fats and skins from meat.
Eat a healthful type of protein at most meals, such as beans, fish, or skinless chicken.
Limit high cholesterol foods such as organ meats (liver, gizzard, kidney, brain,
tongue), egg yolk, shrimp, and squid.
Limit animal fats (lard, chicken fat, butter), fried foods, dim sum, margarine,
Foods to be used in
Foods to be avoided
moderation
Flesh food especially red Sugar
meats
Sweets
Fats
Honey
Nuts
Jams
Cereals/roots/tubers
Jellies
Pulses
Milk products
Pizzas
Eggs
SAMPLE MENU
Meal timings
Food items
Quantity
Morning 6.00-6.30 AM
Breakfast 8.00-8.30AM
cup (100ml)
2 nos (50g)
Mid morning10.00-10.30AM
Lunch 12.30-1.00PM
Sambhar
Custard without sugar
Rice
cup (25g)
1 cup
1 cup (50g)
Phulka
1 nos (25g)
Vegetables
1 cup (100g)
Sambhar
1 cup (50g)
cup (50g)
Steamed fish
1 slice (65g)
Evening 4.00-4.30PM
Curd
Milk without sugar
cup
cup (100ml)
Sundal
Buttermilk
Phulkas
Dhal
cup (25g)
Vegetable curry
Milk without sugar
cup (100g)
cup (100ml)
Bedtime
10.00PM
The above sample menu provides approximately:
2000 kilocalories
300g of carbohydrates: 61% of total calories
84 g of protein: 17% of total calories
48 g of fat: 22% of total calories.
FOOD ITEMS
Daily
Once
In
Two
Twice
A
Week
Once
A
Week
Once
In 15
Days
Once A
Month
Occasionally
Never
Days
CEREALS
Rice
Wheat
Ragi
Rava
Rice flakes
Broken wheat
PULSES
Red gram
Black gram
Green gram
Bengal gram
Cow pea
Soya
GREEN LEAFY
VEGETABLES
Amaranth
Spinach
Agathi
Drumstick leaves
Cabbage
ROOTS AND TUBERS
Beetroot
Carrot
Radish
Potato
Colacasia
Tapioca
Yam
Tapioca
Colacasia
OTHER VEGETABLES
Ladies finger
Drumstick
Brinjal
Cauliflower
Plantain
Tomato
FRUITS
Apple
Banana
Orange
Guava
Papaya
Mango
Gooseberry
MILK AND MILK
PRODUCTS
Milk
Curd
Butter
Paneer
Cheese
Ice cream
MEAT AND MEAT
PRODUCTS
Chicken
Mutton
Beef
Pork
SEA FOOD
Fish
Prawns
Crab
NUTS AND OILSEEDS
Cashewnut
Coconut
Ground nut
Gingelly seeds
EDIBLE OIL
Sunflower oil
Gingelly oil
Coconut oil
Palmolein
Vanaspathi
Ghee
Butter
SPICES AND
CONDIMENTS:
Asafoetida
Cardomom
Chillies
Cloves
Coriander
Cinnamon
Cumin seeds
Fenugreek seeds
Ginger
Garlic
Pepper
Fennel seeds
Turmeric
Tamarind pulp
BEVERAGES
Tea
Coffee
Cocoa
Carbonated beverages
Any other
SNACKS
Chocolate
Chips
Cakes
Biscuits
Samosa
Pizzas
Burgers
MISCELLANEOUS
Sweets
Jam
Jaggery
Pappad
Pickle
Sugar
Honey
PREVENTION:
It is possible to Prevent or delay the onset of type 2 diabetes through a healthy
lifestyle.
The most important rule in the prevention strategy maintain ideal body weight.
Changing the diet, increasing the level of physical activity, and maintaining a healthy
weight are the positive steps to stay healthier longer and reducing the risk of diabetes.
Eat healthy foods. Choose foods low in fat and calories. Focus on fruits, vegetables
Bibliography
1) Leslie & Robbins. C (1995). Diabetes: clinical science in practice. New
York: Press syndicate. pp. 375-392.
2)
DEFINITION:
Coronary Heart Disease can be defined as disease of the blood vessels supplying the
heart muscle.
It is a type of heart disease caused by narrowing of the coronary arteries that feed the
heart. When the coronary artery becomes narrowed or clogged by fat and cholesterol
deposits and cannot supply enough blood to the heart CHD results.
PREVALENCE:
According to WHO (2003), 16.7 million people around the world die of Cardio
Vascular Diseases each year, which is 29% of the deaths globally.
CVD alone kills five times as many people as HIV/AIDS in the middle income
countries (WHO, 2005).
According to NCMH (2005), in India, cases of CVD may increase from about 2.9
crore in 2000 to as many as 6.4 crore in 2015. Deaths from CVD may also more than
double.
NUTRITIONAL RISK FACTORS IN THE CAUSATION OF CORONARY HEART
DISEASE:
The most significant degree of risk association is seen with cholesterol and
atherosclerosis and coronary heart disease.
Nutritional risk factors is CHD
Disease
Nutritional factor
LDL cholesterol
Low HDL cholesterol
High triglyceride
Obesity
Elevated homocysteine
Oxidative stress
Lipoprotein (a)
Atherosclerosis is a process that refers to the thickening of the inner lining of arteries,
due to accumulation of lipid (athere gruel). The typical lesion is called an
atheroma.
SYMPTOMS:
Various arteries affected by atherosclerosis and
Their clinical manifestations
Artery affected
Coronary arteries
Carotid arteries, Cerebral arteries
Peripheral limb circulation
Splanchnic circulation
Renal arteries
Aorta
Other symptoms include
Shortness of breath and
Fatigue with activity (exertion).
Clinical manifestations
Angina pectoris, myocardial infarction
Transient ischemic attack, Stroke
Intermittent claudication, gangrene
Mesentric ischemia, bowel gangrene
Renal artery stenosis, hypertension.
Aortic dissection, embolic disease
Lack of
antioxida
nts
Oxidised LDL
Cytokines
Endothelial cell
Leucocyt
e
adhesins
Monocytes,
lymphocytes
Formation of foam cells by endocytosis of
LDL
If lipid entry > lipid exit in
intima
Atheroma
Intra plaque new vessel
formation, bleeding
Migration of
smooth muscle
cells
Platelet
derived
growth factor
Microthrombin formation
(fibrinogen, high Lp(a),
homocystine)
Superimposed vascular
system
Blockage of
blood vessels
Mechanism of action
Favours lipid accumulation in intima
Excess LDL
Low HDL level
Triglyceride level
High lipoprotein (a)
Hypertension
Male gender
Family history of premature coronary disease
Diabetes mellitus
Cigarette smoking
Post menopausal state
Increased fibrinogen
Increased homocystine
Physical inactivity
HDL,
Myocardial
efficiency
Insulin resistance, increased TG, low HDL,
Oxidative stress
Excessive alcohol consumption
hypertension
Prevents LDL
Decreased HDL
Increased thrombosis
Increased stress
Increased stress hormones
Comment
Male more than or equal to 45, Female
Family history
instability
Low HDL cholesterol
levels an overall healthy
Less
Consume
dietthan 40mg/dl is a risk factor
Aim for a healthy body weight
Aim for recommended levels of low density lipoprotein,
American Heart Association (2006) Diet and Lifestyle Goals for Risk Reduction
cholesterol, high density- lipoprotein cholesterol, and
triglycerides
Aim for a normal blood pressure
Aim for a normal blood glucose level
Be physically active
Avoid use of and exposure to tobacco products
Steps must be taken to detect and treat hypercholesterolemia in any prevention and treatment
programme for cardio vascular diseases.
DIAGNOSIS:
Many tests can diagnose possible heart disease. The choice of which tests to perform depends
on the patient's risk factors, history of heart problems, and current symptoms.
Blood pressure and cholesterol levels are measured.
Specific tests are also important in people who may have risk factors or symptoms of
diabetes.
Electrocardiograms
Echocardiograms
Angiography
Computed Tomography
Calcium Scoring CT Scans of the Heart to detect calcium deposits on the
arterial walls.
CT Angiography to visualize the coronary arteries.
NUTRITIONAL ASSESSMENT:
Anthropometric measurements
Height
Weight
BMI
Waist circumference
Waist hip ratio
HDL CHOLESTEROL
CATEGORY
VLDL (calculated)
TRIGLYCERIDES
LIPO A
The commonly used nutritional assessment tool to reveal diet history is the 24-hour dietary
recall or 3 day dietary recall.
MEDICAL NUTRITION THERAPY:
MNT (3-6 month), which includes physical activity, is the primary intervention for
patients with elevated LDL cholesterol.
With diet, exercise, and weight reduction patients can often reach serum lipid goals.
The third Adult Treatment Panel (ATPIII) of the National Cholesterol Education
Programme (NCEP) provides specific guidelines for the assessment and treatment of
hyperlipidemia in adults aged 20 and over.
NCEP guidelines for the nutritional management of risk factors include:
Lowering of lipid levels
Weight reduction
Cessation of cigarette smoking
Alcohol consumption
Dietary fibre
Reduction of oxidative stress
Reduction of Homocystine levels
Control of diabetes mellitus
PRINCIPLES OF DIETARY MANAGEMENT:
Low calorie, low fat, high fibre and sodium restricted diet is prescribed.
NUTRITIONAL CONSIDERATIONS:
Calories:
Based on the BMI, calories needs should be calculated.
Obese patient must reduce to normal body weight with a low calorie diet as
recommended for obesity.
20 Kcal/Kg IBW/d (sedentary)
25 Kcal/Kg IBW/d (active)
Protein:
Provide 15% of the total calories.
Substitute organ meat and red meat (mutton, beef and pork) with fish and fowl.
Include sprouted gram and other pulses as they are all low glycemic index foods.
Carbohydrates:
To supply 55-65% of the total calories.
Promote complex carbohydrates as it is a natural source of fibre
Fats:
Around 20% of the total calories.
Visit I
Begin
Lifestyl
First e
Visit
Therapi
Visit 2
Evaluate
LDL
Response.
If LDL goal
not
achieved,
intensify
Visit 3
Evaluate
LDL
response
If LDL goal
not
achieved,
consider
F/U
Visit
Monitor
adhere
nce to
First visit
Second Visit
Evaluate LDL response
Intensify LDL-lowering therapy (if goal not achieved)
Reinforce reduction in saturated fat and cholesterol
Consider plant stanols/sterols
Increase viscous (soluble) fiber
Consider referral for medical nutrition therapy
Return visit in about 6 weeks
Third Visit
Step 1
500 to 1,000 kcal/day
Step 2
500 to 1,000 kcal/day
Total Fat
reduction
30 percent or less of total
reduction
20 percent or less of total
SFA
calories
8 to 10 percent of total
calories
7% percent of total calories
MUFA
calories
Up to 15 percent of total
Up to 15 percent of total
PUFA
calories
Up to 10 percent of total
calories
Up to 10 percent of total
Cholesterol
calories
< 300 mg/day
calories
< 200 mg/day
Protein
Carbohydrate
Sodium Chloride
calories
No more than 100 mmol/day
calories
No more than 100 mmol/day
(2.4 g
( 2.4 g
of sodium or 6 g of sodium
of sodium or ~6 g of sodium
chloride)
1,000 to 1,500 mg
20 to 30 g
chloride)
1,000 to 1,500 mg
20 to 30 g
Calcium
Fiber
Cereals millets
Pulses legumes
Source
Food
Wheat, bajra
Black gram, cow pea, rajma
Soybean
Vegetables
Spices
Oil
Animal foods
Transfatty acids:
They raise LDL cholesterol levels and increase the risk of CVD. Less than 1gram per
day is the allowance.
Food Sources of Types of Dietary Fats
Type of fat
Saturated fats
Mono Unsaturated Fatty Acids
Poly Unsaturated Fatty Acids
Food source
Dairy products, beef, lamb and pork
Olive oil, canola oil and nuts
Vegetable oils (corn, sunflower, soy)
Cholesterol
Dietary fibre:
Total dietary fibre intake of 20-35 g per day is recommended for adults. Soluble fibre
helps in reduction in serum cholesterol.
Lentils, pulses, oats, fruits and vegetables are rich in fibre.
Soy protein:
May decrease LDL cholesterol by a few percent.
Soy foods such as tofu, soy nuts or soy butter may have cardio protective benefits
because of their PUFA and fibre content.
Plant stanols and sterols:
Isolated from soybean oil or pine tree oil can also lower cholesterol.
The mechanism for cholesterol lowering is by inhibiting absorption of dietary
cholesterol.
Alcohol:
For those who do drink, consumption should not exceed 1-2 oz of ethanol per day.
Weight reduction:
Obese patients should attain ideal body weight by appropriate reduction in caloric
intake and regular exercise.
Weight loss is associated with an increase in HDL cholesterol and decrease in LDL
cholesterol.
Sodium Restriction:
Restriction of 2-3 grams of sodium is usually advised for heart patients. Avoiding
processed food itself will cut down on a lot of sodium.
Cessation of cigarette smoking
Reduction of oxidative stress:
Oxidative stress is thought to play an important role in the development of
atherosclerosis.
Diet rich in fruits & vegetables and hence antioxidants should be encouraged. While
beta carotene appears to be of little use, supplementation with 200-400 mg of Vitamin
E may benefit in reducing risk for Ischemic heart disease.
SAMPLE MENU
Meal timings
Food items
Quantity
Morning
Tea (skimmed)
1 cup
6.00-7.00 AM
Breakfast
1 cup
8.00-9.00 AM
Mid morning
Orange
Vegetable sandwich (wheat
I nos
2 slices
10.00-11.00 AM
bread)
Lunch
1 cup
2 nos
12.00-1.00PM
Rice
cup
Dal
1 cup
1 cup
1 cup
Tomato soup
1 cup
cup
Apple
1 cup
Evening
1 cup
4.00-5.00PM
Dinner
Marie biscuits
Vegetable macroni
3 nos
2 cups
8.00-9.00PM
Grilled fish
1 nos
1 cup
Guava
Bed time
Milk (skimmed)
1 cup
1 cup
10.00PM
1800 calories
300g carbohydrate: 65% of the total calories
70g proteins: 15% of total calories
40g fat: 20% of total calories
FOOD ITEMS
QUANTITY
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
DAY 2
MEAL TIMINGS
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
DAY 3
FOOD ITEMS
QUANTITY
MEAL TIMINGS
FOOD ITEMS
QUANTITY
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
PREVENTION:
Healthy diet, regular exercise, and quitting smoking (if you smoke) may prevent heart
disease.
Heart disease prevention is considered important before and after someone is diagnosed with
the condition:
Primary prevention refers to measures that should be done to reduce the risk of heart
disease in everyone.
Maintain cholesterol levels at appropriate levels using a heart healthy diet, exercise,
and medications
Maintain an appropriate low blood pressure level
Maintain an active lifestyle
Use an antiplatelet drug, such as aspirin, if appropriate
Manage diabetes and kidney disease when present
Smoking Cessation
Cholesterol and Other Lipid Disorders
All patients should start following a heart-healthy diet and exercise regularly.
Follow a Heart-Healthy Diet
Current American Heart Association (AHA) guidelines recommend:
Balance calorie intake and physical activity to achieve or maintain a healthy body
weight.
Consume a diet rich in a variety of vegetables and fruits.
Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes
(beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley,
brown rice, buckwheat, bulgur, millet, and quinoa.
Consume fish, especially oily fish, at least twice a week. Oily fish such as salmon,
mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid
(EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to
reduced risk of sudden death and death from coronary artery disease.
Limit daily intake of saturated fat, trans fat and cholesterol. Choose lean meats and
vegetable alternatives (such as soy). Select fat-free and low-fat dairy products.
Use little or no salt in your foods. Reducing salt can lower blood pressure and
decrease the risk of heart disease and heart failure.
Cut down on beverages and foods that contains added sugars (corn syrups, sucrose,
glucose, fructose, maltose, dextrose, concentrated fruit juice, and honey.)
If you drink alcohol, do so in moderation. The AHA recommends limiting alcohol to
no more than 2 drinks per day for men and 1 drink per day for women.
Manage High Blood Pressure
Keep Blood Pressure Low. People in normal health should have a blood pressure
reading of 120/80 mm Hg or less.
Diabetes
All patients with diabetes should have their blood sugar (glucose) levels well
managed.
Weight Reduction
People should aim for a BMI index of 18.5 - 24.9. Weight reduction is recommended
for obese patients who have high blood pressure, high cholesterol levels, metabolic
syndrome, or diabetes.
Exercise and Cardiac Rehabilitation
Everyone in normal health should do at least moderate physical activity for a
minimum of 30 - 60 minutes on most, if not all, days of the week.
Even low amounts of moderate or high intensity exercise (walking or jogging 12
miles a week) can help produce beneficial changes in cholesterol and lipid levels.
However, more prolonged exercise is required to significantly change cholesterol
levels, notably by increasing HDL ("good cholesterol"). Resistance (weight) training
has also been associated with heart protection.
It is important that along with management of nutritional risk factors, other risk factors are
also dealt with simultaneously.
Only a comprehensive risk reduction programme with appropriate changes in lifestyle will
result in the successful treatment and prevention of cardiovascular disease.
OBESITY
INTRODUCTION:
Overweight and obesity are defined as abnormal or excessive fat accumulation that
may impair health.
Obesity is a state in which there is a generalised accumulation of excess adipose tissue
in the body leading to more than 20% of the desirable body weight.
Overweight is a condition where the body weight is 10-20% greater than the mean
where the body weight is 10-20% greater than the mean standard weight for age,
height and sex.
The WHO definition is:
A BMI greater than or equal to 25 is overweight
A BMI greater than or equal to 30 is obesity.
PREVALENCE:
Greatly varies from country to country from <0.1% in South Asia to >75% in urban Samoa.
WHO global estimates (2008)
1.5 billion Adults, 20 and older, were overweight.
Of these 1.5 billion overweight adults, over 200 million men and nearly 300 million
women were obese.
Overall, more than one in ten of the worlds adult population was obese.
In 2010, around 43 million children under five were overweight.
Close to 35 million overweight children are living in developing countries and 8
million in developed countries.
Overweight and obesity are linked to more deaths worldwide than underweight.
65% of the world's population live in countries where overweight and obesity kill
more people than underweight (this includes all high-income and most middle-income
countries).
CAUSES OF OBESITY:
The fundamental cause of obesity and overweight is an energy imbalance between calories
consumed and calories expended.
Increased intake of energy- dense foods that are high in fat, salt and sugars but low in
vitamins, minerals and other micronutrients.
Ideal weight = energy intake is equal to energy expended
Weight gain = Energy intake is more than energy expended
Weight loss = energy intake is less than energy expended
Genetic factors: Obesity tends to run in families. Genetic inheritance influences 50
70% a persons chance of becoming fat more than any other factor. Within families,
the chance is 50% if one parent is obese and 80% if both the parents are obese.
Metabolic factors: Endocrine disorders such as Cushings syndrome and
hypothyroidism, Prader- willi syndrome and congenital leptin deficiency can cause
obesity.
Physical inactivity: A decrease in physical activity due to the increasingly sedentary
nature of many forms of work, changing modes of transportation, and increasing
urbanization.
Other factors leading to obesity are
Stress- sometimes can lead to excessive calorie intake.
Trauma head injury causing damage to the hypothalamus leading to improper
regulation of appetite or satiety.
Improper eating habits
P
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Y
S
I C
A
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G
Y
I N
TS
A
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E
T
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Neurologic system
Endocrine
Gastointestinal
Genitourinary
Integument
Cholelithiasis
Hernias
Colon cancer
Urinary stress incontinence
Obesity-related glomerulopathy
Hypogonadism(male)
Breast and uterine cancer
Pregnancy complications
Striae distensae (stretch marks)
Status pigmentation of legs
Lymphedema
Cellulitis
Intertrigo, carbuncles
Acanthosis nigricans/skin tags
Musculoskeletal
Psychological
Respiratory
E x c e s s S u b c u ta n e o u s F a t
C
A
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A
o m
n d
ig
p p
m
ro
h ly
le
E x c e s s G lu t e o fe m o r a l F a t
P e a r S h a p e
G y n o id
In c r e a s e s r is k fo r b lo o d g lu c o s e , lip id a n d p r e s s u r e a b n o r m a lit ie s .
o n in M e n
id
c o r r e la t e d W it h In s u lin r e s is t a n c e , S m o k e r s , A lc o h o lic s .
s h a p e
Weight history
Weight-loss efforts
Exercise habits
Eating patterns
Other associated conditions such as diabetes and hypertension.
Medications
Stress levels and
Familys health history to see predisposed to certain conditions.
Adult weighing 10% more than the standard weight is overweight and 20% more is obese.
% Body weight excess of normal
25%
50%
75%
100%
Degree of obesity
Mild
Moderate
Severe
Morbid (very severe)
18.5
18.5 24.9
25 29.9
RISK OF
CO-MORBIDITIES
Low
Average
Increased
Moderate (Class I)
30 34.9
Moderate
35 39.9
Severe
While BMI is simple and quick to use, it has limitations because it is based simply on
ratio of weight to height and does not take account of body composition.
Waist circumference:
The most practical tool to evaluate a patients abdominal fat. It can be used to identify
patients at high risk.
Classification of Risk of Obesity Based On Waist Circumference (WHO, 1998)
Waist Circumference
Men
High Risk
94 102
>102
Women
High Risk
80 88
>88
Male
Unacceptable
Excellent
Good
Average
High
< 0.85
0.85 -
0.90 - 0.95
0.95 -
0.90
Female
< 0.75
0.75 -
Extreme
> 1.00
1.00
0.80 - 0.85
0.80
0.85 -
> 0.90
0.90
Ponderal Index:
Ratio of height to the cube root of weight.
PI = Height (inches)
Weight (lbs)
The subject is measured in air and under water to determine volume and therefore
body density.
The densities of FM (Fat mass) and FFM (Fat free mass) are assumed and the
percentage of body weight is derived by substituting into appropriate equations.
Density of FM = 0.901 g/ml
Density of FFM = 1.10 g/ml
%Body fat= (495/body density) 450
Air displacement plethsymography equipment is commercial available as Bod Pod.
BIOELECTRICAL IMPEDANCE ANALYSIS (BIA)
A small electric current is passed through the body and voltage drop is measured by
electrodes.
The drop in voltage reflects the bodys impedance or resistance.
Resistance will be greater in individuals with greater body fat and lower in individuals
with more FFM and Total Body Water (TBW).
DUAL ENERGY X RAY ABSORPTIOMETRY (DEXA)
The body is scanned with X-rays of 2 energy levels and the chemical composition of
tissues will determine the attenuation of the radiation.
Software calculates bone mineral content ,bone mineral density, and FM
Brokas Index:
Height (cm)-100 = Ideal Body Weight (kg)
This measurement is easy to calculate and quite accurate.
MANAGEMENT OF OBESITY:
Multifactorial approach embracing a number of different strategies which should be
individualised.
Goals:
To develop realistic goals for weight reduction.
To Plan for weight maintenance after 6 month weight loss period.
The strategies for weight loss and weight maintenance are:
Diet therapy
Life style modification Physical Activity & Behavioural Therapy
Stress management
Pharmacotherapy
Surgery
PRINCIPLES OF DIETETIC MANAGEMENT:
Low calorie, restricted carbohydrate, restricted fat, normal protein, high fibre, normal
vitamin & mineral and liberal fluid diet.
NUTRITIONAL CONSIDERATIONS:
Energy:
20 kcal /kg IBW for sedentary worker
25 kcal /kg IBW for moderately active workers.
Protein:
0.8-1 g of protein for tissue repair and for specific dynamic action.
Carbohydrates:
Bulk producing carbohydrates like green leafy vegetables and fruits to be taken in
liberal amounts to produce a feeling of satiety and regular bowel movements.
Starches with high CHO content like potato and rice to be restricted.
Fats:
Fats to be restricted and emphasis should be on vegetable oils (except coconut and
palm) to provide essential fatty acids.
Vitamins:
Prolonged restriction of fats can lead to restriction of fat soluble vitamins A and D
which may be supplemented.
Minerals:
Restriction of sodium is helpful in weight reducing diets as excess sodium predisposes
to retention of fluid.
Fluids:
To be taken liberally. A glass of water before meals may help to cut down fluid intake.
High fibre:
High fibre low calorie foods like green leafy vegetables, fruits, vegetable salads,
whole grain cereals and pulses to be included in the diet.
Foods low in Glycemic Index should be included as they may benefit weight control in 2
ways:
By promoting satiety
By promoting fat oxidation at the expense of carbohydrate oxidation.
DIET THERAPY:
Very low calorie diet (VLCD):
Provide <800 kcal per day leading to rapid weight reduction.
Should be used only for extremely obese individuals.
VLCD s can be in two forms:
PSFM- Protein Sparing Modified Fast Diets.
1.5g of protein/ kg IBW in the form of lean meat and no CHO fat from only
protein sources.
Commercial liquid diets (based on milk/ egg protein)
33.70 g protein; 30-45g CHO and small amount of fat.
Risks of such diet- cardiac complications leading to sudden death
Loss of potassium and body protein
Disturbances in serum electrolytes
Increased urinary ketones
Increased uric acid levels
Reducing diet:
Ideal reduction of to 1 kg per week is ideal.
A calorie deficit of 1000 kcal is required to lose 2 pounds of body fat per week.
Another way of doing it is to calculate the calorie needs using Harris- Benedict
equation and subtracting 500-1000 kcal from the requirement for a 2 lb loss per week.
Harris- Benedict equation
WOMEN:
BMR = 655 + (9.6 X weight in kilos) + (1.8 X height in cm) - (4.7 X age in years).
MEN:
BMR = 66 + (13.7 X weight in kilos) + (5 X height in cm) - (6.8 X age in years)
LEVEL OF PHYSICAL ACTIVITY
CALORIE CALCULATION
BMR X 1.2
BMR X 1.375
days/week)
Moderately Active (moderate exercise/sports
BMR X 1.55
3-5 days/week)
Very Active (hard exercise/sports 6-7
1.725
days/week)
Extra Active (very hard daily exercise/sports
BMR X 1.9
Yet another way is to determine the ideal body weight and adjusted body weight and
prescribing 20 kcal/kg IBW.
Reducing diet should provide adequate amount of proteins, vitamins and minerals.
Effective menus include teaching patients to plan menus and exercise sessions to
record their actual behaviour.
They can also be taught to recognise eating cues such as emotional, situational etc
and how to avoid or control them.
Stress management:
One of the major reasons for overeating and relapse.
Stress related overeating can be reduced by learning to implement methods other than
eating such as
Breathing exercises
Deep muscle relaxation
Meditation
Yoga
Physical activity
PHARMACOTHERAPY:
Can be used as part of a comprehensive weight loss programme including dietary
therapy and physical exercise for patients with BMI of 30 or more.
Drugs cause an energy deficit through various mechanisms.
Act on the brain to suppress appetite.
Producing bulk to fill the stomach
Increase thermogenesis, metabolism and interfere with fat absorption.
Drugs are Classified as
CNS- acting agents Eg: Orlistat
Non CNS- acting agents Eg: Sibutramine
Not all individuals respond to these drugs and may have side effects.
BARIATRIC SURGERY:
Advised only for patients with BMI of 40 kg/m2.
The average weight loss at 5 years is about 65% of excess weight and most
complications resolve in about 50% of cases.
Most common surgical procedures practiced are
Gastric bypass surgery
Gastric stapling
Gastric balloon
Jaw wiring
Foods to be used in
Foods to be avoided
Fruits
moderation
Flesh food especially red Refined starch and sugar
meats
White bread
Pulses
Fats
Nuts
Pizzas
Cereals/roots/tubers
High
fiber
foods-
sweetened juices
Eggs (white)
Sweetened yoghurt
Sugar
Fatty meats
Fish
Sweets
Egg yolk
Chocolates
Alcohol
SAMPLE MENU
MEAL TIMINGS
Morning
FOOD ITEMS
QUANTITY
Tea(skim milk)
1 cup
Breakfast
Oats upma
1 cup
8.00-8.30AM
Mint chutney
1 tbsp
Mid morning
Vegetable soup
1 cup
Lunch
Phulkas
2 nos
12.00-1.00pm
Rice
cup
Sambhar
cup
Vegetable curry
1 cup
Buttermillk
1 cup
Any fruit
1 nos
Evening
Green tea
1 cup
4.00-5.00PM
3 nos
Dinner
Phulkas
2 nos
8.00-9.00 PM
Tomato chutney
2 tbsp
Apple
1 nos
Milk (skimmed)
1 cup
6.00-6.30AM
10.00-10.30 AM
Bed time
10.00-10.30
MEAL TIMINGS
FOOD ITEMS
QUANTITY
FOOD ITEMS
QUANTITY
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
DAY 2
MEAL TIMINGS
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
DAY 3
MEAL TIMINGS
FOOD ITEMS
QUANTITY
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
PREVENTION:
There are possible steps to prevent unhealthy weight gain and related health problems. Daily
exercise, a healthy diet, and a long-term commitment to watch what we eat and drink.
Exercise regularly: 150 to 250 minutes of moderate-intensity activity a week is
recommended to prevent weight gain. Moderately intense physical activities include
fast walking and swimming.
Eat healthy meals and snacks: Focus on low-calorie, nutrient-dense foods, such as
fruits, vegetables and whole grains. Avoid saturated fat and limit sweets and alcohol
Know and avoid the food traps that cause to eat: Identify situations that trigger outof-control eating. Keeping a journal and writing down what we eat, how much we eat,
when we eat, may be a useful strategy.
Monitor weight regularly: People who weigh themselves at least once a week are
more successful in keeping off excess pounds
Be consistent: Sticking to our healthy-weight plan during the week, on the weekends,
and amidst vacation and holidays as much as possible increases our chances of longterm success.
BIBLIOGRAPHY
1) Louis J. Aronne (2002). Classification of Obesity and Assessment of Obesity-Related
Health Risks. Journal of Obesity research, vol.10.
HYPERTENSION
INTRODUCTION:
Hypertension is a common public health problem in developed countries and is one of
the most common vascular diseases.
It is often called silent killer because hypertensives can be asymptomatic for years
and then have a fatal stroke or heart attack.
DEFINITION
A general definition is persistently high arterial blood pressure, the force exerted per
unit area on the walls of arteries.
To be defined as Hypertension, the systolic blood pressure has to be 140 mmHg or
higher and the diastolic blood pressure has to be 90 mmHg or higher.
CLASSIFICATION OF BLOOD PRESSURE AND DIAGNOSIS:
Category
Systolic
Blood
Pressure
Diastolic
Blood
Optimal
Normal
High normal
(SBP) mmHg
<120
120 129
130 139
(DBP) mmHg
<80
80 84
85 89
Stage 1
140 150
90 99
Stage 2
160 179
100 109
Stage 3
180 209
110 119
Stage 4
210
120
Pressure
Pre hypertension
Hypertension
Persistent headache
Dizziness
Blurred vision
Nausea and vomiting, and
Chest pain and shortness of breath.
Heredity
Gender BP is higher in men than women and in women post menopause
Race- most severely affects the Afro Americans
Age- BP increases with age
Obesity, especially central obesity
Manifestations
Clinical, electrocardiogram or radiologic
evidence of coronary artery disease; left
Cerebrovascular
Peripheral
Renal
aneurysm.
Serum creatinine >1.5 mg/ dl, proteinuria;
Retinopathy
microalbuminuria
Haemorrhages or exudates, with or without
papilledema.
MANAGEMENT OF HYPERTENSION:
Managing hypertension efficiently is important in achieving maximum reduction in the total
health risk of cardiovascular morbidity and mortality.
Objectives
Control blood pressure at a safe level to prevent damage to target organs e.g. heart,
kidneys, brain, thereby reducing the likelihood of congestive heart failure, renal
NUTRITIONAL CONSIDERATIONS:
Calories:
Obese patient must reduce to normal body weight with a low calorie diet as
recommended for obesity.
20 Kcal/Kg IBW/d (sedentary)
25 Kcal/Kg IBW/d (active)
Protein:
10 14% of calories should come from protein
A diet of 50 g of protein to maintain nutrition is necessary.
Fats:
Hypertensives are prone to atherosclerosis, it is advisable to keep the fat calories at
20% level.
Advisable to avoid high intake of animal fats or hydrogenated oils.
About 40 50 g of fats, partly as vegetable oil, is permitted.
Carbohydrates:
Emphasis is on high fibre complex carbohydrate diet providing 55-60% of total
calories.
Minerals:
Minerals affecting blood pressure are Sodium, Potassium, and Calcium &
Magnesium.
Sodium:
Moderate salt restriction 2300mg sodium (6g of salt) is recommended (NIH, 2004).
2.3g sodium
1.2g sodium
0.6g sodium
Adequate intake of sodium has been set at 1.5g/day (Institute of medicine, 2004).
Most dietary salt comes from processed foods and eating out. Changes in food
preparation and processing can help patients reach the sodium goal.
First step is to determine the appropriate energy level based on desired body weight
and activity level.
The appropriate number of servings per day of each group should then be based on
the diet and serving size.
Daily
Serving Sizes
Grains
Servings
68
1 slice bread
1 oz dry cereal
1/2 cup cooked rice, pasta, or
Vegetables
45
cereal
1 cup raw leafy vegetable
1/2 cup cut-up raw or cooked
vegetable
Fruits
45
Fat-free or low-fat
23
products
Lean meats,
poultry, and fish
6 or less
45 per week
Legumes
23
5 or less
1 Tbsp sugar
Sugars
per week
Servings/Day
1,600
2,600
3,100
Grains
calories/day
6
calories/day
1011
calories/day
1213
Vegetables
34
56
Fruits
56
Fat-free or low-fat
23
34
Lean meats,
36
69
3/week
Legumes
Fats and oils
Sugars
Weight reduction
5- 20mmHg/10kg
8-14 mmHg
2-8 mmHg
/day)
Physical activity
4-9 mmHg
2-4 mmHg
DIETARY GUIDELINES:
Reduction of excess body weight.
Limit alcohol intake to maximum of 21 or 14 units per week for men and women,
respectively.
Eat more fruits and vegetables. 5 portions per day should be the target.
Limit salt intake to <6g/day (2.4g)
Avoid salt at the table
As salt in the diet is less try to use herbs and spices like parsley, coriander, ginger,
garlic etc to liven up the diet. Most of the herbs do not contain sodium.
If non vegetarian, eat fish regularly.
If vegetarian, take living foods like sprouted gram, fermented foods.
Include green leafy vegetables to increase the n-3 fatty acids.
Try to meet the RDAs for calcium, magnesium and potassium.
Calcium, potassium, and magnesium supplements are not recommended at present.
The use of salt substitutes is not recommended. Salt which contains lysine and
SAMPLE MENU
Meal timings
Food items
Quantity
Morning
Milk
1 cup (200ml)
6.00-7.00 AM
Breakfast
Oats idli
3 nos (75g)
8.00-9.00 AM
Vegetable kurma
cup
Mint chutney
1tbsp
Mid morning
Buttermilk
1 cup (200ml)
10.00-11.00 AM
Lunch
Phulka
1 nos (25g)
12.00-1.00PM
Sambhar
cup (25g)
Vegetable porial
cup (100g)
White rice
1 cup (50g)
Curd rice
cup (25g)
Palak paneer
cup (100g)
Water melon
1 cup (100g)
Evening
Milk (skimmed)
1 cup (200ml)
4.00-5.00PM
Sundal
cup (25g)
Dinner
Phulkas
2 nos(50g)
8.00-9.00PM
Channa masala
1 cup(50g)
Bed time
Milk (skimmed)
1 cup
10.00PM
*Meals to be cooked without adding salt.
*Salt allowance for the entire day is 5g= 1 tsp
The above given sample menu provides approximately,
1900 calories
295g carbohydrate: 61% of the total calories
79g proteins: 16% of total calories and 48g fat: 23% of total calories
FOOD FREQUENCY QUESTIONNAIRE
Food Items
CEREALS
Rice
Wheat
Ragi
Rava
Rice flakes
Broken wheat
PULSES
Red gram
Black gram
Green gram
Bengal gram
Cow pea
Soya
GREEN LEAFY
VEGETABLES
Amaranth
Spinach
Agathi
Drumstick leaves
Cabbage
ROOTS AND TUBERS
Daily
Once
In
Two
Days
Twice
A
Week
Once
A
Week
Once
In 15
Days
Once A
Month
Occasionally
Never
Beetroot
Carrot
Radish
Potato
Colacasia
Tapioca
Yam
Tapioca
Colacasia
OTHER VEGETABLES
Ladies finger
Drumstick
Brinjal
Cauliflower
Plantain
Tomato
FRUITS
Apple
Banana
Orange
Guava
Papaya
Mango
Gooseberry
MILK AND MILK
PRODUCTS
Milk
Curd
Butter
Paneer
Cheese
Ice cream
MEAT AND MEAT
PRODUCTS
Chicken
Mutton
Beef
Pork
SEA FOOD
Fish
Prawns
Crab
NUTS AND OILSEEDS
Cashewnut
Coconut
Ground nut
Gingelly seeds
EDIBLE OIL
Sunflower oil
Gingelly oil
Coconut oil
Palmolein
Vanaspathi
Ghee
Butter
SPICES AND
CONDIMENTS:
Asafoetida
Cardomom
Chillies
Cloves
Coriander
Cinnamon
Cumin seeds
Fenugreek seeds
Ginger
Garlic
Pepper
Fennel seeds
Turmeric
Tamarind pulp
BEVERAGES
Tea
Coffee
Cocoa
Carbonated beverages
Any other
SNACKS
Chocolate
Chips
Cakes
Biscuits
Samosa
Pizzas
Burgers
MISCELLANEOUS
Sweets
Jam
Jaggery
Pappad
Pickle
Sugar
Honey
PREVENTION:
NEPHRITIS
DEFINITION:
Nephritis also known as acute glomerulonephritis is characterised by acute
inflammation of the glomeruli, with congestion, cellular proliferation and infiltration
of leucocytes and others cells associated with inflammation.
ETIOLOGY:
The most common cause is probably an allergic reaction in the kidneys to
streptococcal infection.
Other less common causes are:
Goodpasturess syndrome:
Antibodies directed against the basement membrane of the glomeruli resulting in
rapidly progressive glomerulonephritis and acute renal failure.
Crescent glomerulonephritis:
Proliferation of the epithelial cells of Bowmans capsule, leading to destruction of
Bowmans space.
Disease process
SYMPTOMS:
Gross hematuria
Proteinuria
Edema
Shortness of breath due to sodium and water retention and circulatory congestion
Anorexia
If there is progression to renal insufficiency, oliguria and anuria develops
COMPLICATIONS:
DIAGNOSIS:
Diagnosis of nephritis is based on:
The patient's symptoms and medical history
Physical examination
Laboratory tests
Kidney function tests
Blood tests - levels of waste products, such as creatinine and blood urea nitrogen.
Imaging studies such as ultrasound or x rays to determine blockage and inflammation
Urinalysis can reveal the presence of:
Albumin and other proteins
Red and white blood cells
Pus, blood, or bacteria in the urine
Renal biopsy is the only definitive method of establishing the diagnosis; this step
usually is undertaken when the diagnosis is unclear or when the patient does not
improve clinically.
NUTRITIONAL ASSESSMENT:
Nutritional assessment is designed to evaluate three aspects of overall nutritionenergy, protein and micronutrients balance.
It has 3 components:
The nutritional history
Appropriate physical examination with simple anthropometric measurements
Laboratory studies.
BMI is assessed.
Caliper measurements of skinfold (triceps) thickness- index of fat mass to identify
individuals with depleted fat stores.
Mid arm circumference- muscle mass assessment.
Patients with values below 25th percentile for either mid upper arm circumference or
triceps skin fold thickness are likely to be malnourished.
Laboratory assessment Renal profile constituting the various parameters should be assessed.
Elevation of these parameters indicate accumulation of waste products in the blood
due to renal impairment.
Parameters
Normal range
Serum Sodium
134-146 mmol/L
Serum Potassium
Blood urea
10-50mg/dL
Creatinine
0.1-1.3 mg/dL
MEDICAL TREATMENT:
Treatment can vary depending on
Cause of the disorder
Type & severity of symptoms.
Drugs used:
Antimicrobials to clear the infection
Blood pressure medications to control high blood pressure.
GFR
>75ml/minute
25- 75 ml/minute
<20 ml/minute
Protein intake
0.8-1.0 g / kg IBW/day
0.55- 0.6/kg IBW/day
0.5 g/kg IBW/day
Phosphorus:
Excess phosphorus in the diet can have a deleterious effect on serum calcium, which
is already low in renal patients.
It is better to restrict phosphorus.
GFR
25-70 ml/min
<20 ml/min
Fluids:
First stage of treatment- fluid restriction- to allow for dispersal of edematous fluid.
SAMPLE MENU
MEAL TIMINGS
FOOD ITEMS
QUANTITY
Breakfast 8.00-8.30AM
2 nos
Honey
2 tbsp
Apple pudding
cup
Lunch 12.30-1.00PM
Rice
1 cup
Aaloo palak
2 cup
cup
cup
Fish fry
1 nos
Kesari
Vegetable cutlet
cup
1 nos
Badam milk
cup
Idiappam
1 nos
Coconut milk
cup
cup
Evening 4.00-5.00PM
Dinner 8.00-9.00PM
Bed time 10.00-10.30PM
1700 kilocalories
280 g of CHO: 67% of total calories
42 g of protein: 10% of total calories
45 g of fats: 23% of total calories
MEAL TIMINGS
FOOD ITEMS
QUANTITY
FOOD ITEMS
QUANTITY
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
DAY2
MEAL TIMINGS
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
DAY 3
MEAL TIMINGS
FOOD ITEMS
QUANTITY
Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM
DIETARY GUIDELINES:
PREVENTION:
There is no way to prevent most forms of glomerulonephritis. However, there are some steps
that may be beneficial:
Seek prompt treatment of a streptococcal infection causing a sore throat or impetigo.
To prevent infections that can lead to some forms of glomerulonephritis, such as HIV
and hepatitis, follow safe-sex guidelines and avoid intravenous drug use.
Control blood pressure, which lessens the likelihood of damage to your kidneys from
hypertension.
Control blood sugar to help prevent diabetic nephropathy.