Nutrition and Prevention of
disease
Supriya Bhattarai
MSc Nutrition and Dietetics/ Sports Nutrition
28/04/2019
1
• You are what you eat
• Nutrition is the science that interprets the interaction of nutrients and other substances in food in relation to
maintenance, growth, reproduction, health and disease of an organism. It includes food intake, assimilation,
biosynthesis, catabolism and excretion .
• Food and food products have become commodities produced and traded in a market that has expanded from a
local base to an increasingly global one. Changes in the world food economy is one of the major reason in
bringing change in the dietary pattern and thereby increasing the risk of many chronic diseases.
• Hence Nutrition is coming forth as a major modifiable determinant of chronic disease, with scientific
evidence increasingly supporting the view that alterations in diet affects the health throughout life in both
positive and negative ways.
• Likewise dietary adjustments may not only influence present health, but may determine whether or not an
individual will develop such diseases as cancer, cardiovascular disease , diabetes later in their life time.
• However, these concepts has not led to change in policies or in practice. In many developing countries, food
policies remain focused only on under nutrition and are not addressing the prevention of chronic disease.
• Hence it becomes important to understand the role nutrition plays in various chronic diseases so as to prevent
and reduce the progression of non communicable diseases.
2
The immune system
• The human body has an intricate system of
defence mechanisms, which protects it against
potentially harmful foreign agents.
• this complex system of molecules and cells and
tissues is widely dispersed throughout the body .
• Any organism that breaks through this surface
barrier encounters two further levels of defence,
the innate and the acquired immune responses.
• Innate: also known as non-specific immune
system or in-born immunity system is the first
and immediate line of defense against infection.
Example: skin, mucus, saliva, gut flora etc
• Acquired: this system is acquired after birth, is
specific and requires continuous adaptations to
foreign agents.
3
Cells in immune system
4
The immune system of the gut
• Also called as the gut-associated lymphoid tissue (GALT) prevents the passage of
bacteria and food antigens.
• This system develops two strategies
• It secrets antibodies to inhibit the colonization of disease causing bacteria and
to prevent mucosal infections.
• The GALT also possesses mechanisms to avoid overreaction to non harmful
substances presented on the epithelial surfaces. This phenomenon is called oral
tolerance and it largely explains why most people show no adverse immune
reactions to foods.
• However, in some individuals the immune system initiates an inappropriate and
exaggerated immune response towards food constituents, which is known as “food
allergy”. Examples: allergies to egg, soy products , peanuts …
5
Nutrition and immunity
6
Dietary factors which alter the immune responses
• High and low energy intakes: Malnutrition in children, leads to impairments in
immune function.
• Protein energy malnutrition is often accompanied by deficiencies of
micronutrients such as vitamin A, vitamin E, vitamin B6 , vitamin C, folate, zinc,
iron, copper and selenium.
• The rapidly proliferating T cells responding to pathogens are especially affected,
resulting in a decrease in their numbers.
• Severe and chronic malnutrition leads to atrophy of the thymus and other
lymphoid organs.
• The relationship of obesity and immunity has not yet been experimentally proven.
However various observational studies have shown higher risk of inflammatory
diseases.
7
• The quantity and type of fat consumed: Fatty acids have several functions in immune cells and changes in
total fat intake can influence the immune response in humans.
• Provide energy for immune cells.
• Components of cell membrane
• Regulate gene expression
• Precursors of eicosanoids.
• the parent n-3 and n-6 PUFA, α-linolenic acid and linoleic acid, respectively, cannot be synthesised by man
and they must be supplied by the diet. These are, therefore, regarded as essential fatty acids.
• linoleic acid, is found primarily in plant oils such as maize or sunflower oil, while α-linolenic acid, is found in
linseed (flax), canola or soy oils.
• To influence the immune system, these have to be converted into their long chain derivatives (LCPUFA):
arachidonic acid (AA) of the n-6 family, and eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)
of the n-3 family.
• Depending on the type of PUFA in the diet, especially the amount of n-3 LCPUFA, immune cells produce
different quantities and kinds of eicosanoids with very different effects on the immune response.
• diets rich in n-3 PUFA tend to inhibit excessive immune responses, which are associated with chronic
inflammatory diseases such as rheumatoid arthritis. Diets rich in n-6 PUFA have a diverse effect on immune
responses, including pro- and anti-inflammatory responses.
8
Deficiencies in vitamins and trace elements can
impair the immune response
9
Probiotic , prebiotic and dietary fibre
• A probiotic is a live microorganism that, when administered in adequate amounts,
confers a health benefit on the host.
• A prebiotic is a non-digestible selectively fermentable food constituent that
beneficially affects the host by selectively stimulating the growth and/or activity
of one or a limited number of bacteria in the large intestine that confer benefits
upon host well-being and health.
• A synbiotic is a mixture of a probiotic combined with a prebiotic whose aim is the
establishment and increased survival of health-promoting bacteria.
• Dietary fiber is the indigestible portion of food derived from plants. It has two
main components: Soluble fiber, which dissolves in water, is readily fermented in
the colon into gases This delays gastric emptying which, in humans, can result in
an extended feeling of fullness.
• Insoluble fiber, which does not dissolve in water, is metabolically inert and
provides bulking, or it can be fermented in the colon. Bulking fibers absorb water
as they move through the digestive system, easing defecation.
10
• There are several ways in which probiotics affect the host defence system.
• The first is by contributing to the “barrier effect” of the intestinal bacteria, which creates
an environment hostile to some pathogenic bacteria.
• Another way relates to the metabolic products produced by lactic acid bacteria, such as
bacteriocins and lactic acid itself, which inhibit the growth of pathogenic organisms.
• Some probiotic strains also adhere to the epithelial wall of the intestine, thus preventing
pathogenic bacteria from adhering to the same receptors, or they compete with pathogens
for nutrients that are in limited supply.
• Hence Probiotics may be of value in the prevention and treatment of various clinical
conditions Examples: acute diarrhoea caused by rotavirus, inflammatory bowel diseases
or allergic diseases.
• Prebiotics are present in the normal diet at intakes of 2–10 g/day. They include inulin,
fructooligosaccharides, galactooligosaccharides and lactulose.
• Prebiotics and dietary fibres have in common that they are not hydrolyzed in the small
intestine and reach the colon. There, they serve as energy and carbon sources for the
colonic microbiota and thus increase the bacterial mass in the intestine.
• Shortchain fatty acids, including butyrate, are by-products of bacterial fermentation in the
gut. These short-chain fatty acids have a beneficial effect on intestinal cells. High
concentrations improve symptoms of inflammatory bowel disease
11
Breathe in your biome ( Zach Bush, MD)
Gut diversity is important
12
The food evolution
https://i2.wp.com/darwinian-medicine.com/wp-content/uploads/2017/02/theevolution-of-the-human-diet.jpg
13
14
Lifestyle choices and risk of non- communicable
diseases
• Industrialization
• Urbanization
• Market globalization
Shift in dietary patterns
eg: increased
consumption of energydense diets high in fat,
particularly saturated fat,
and low in unrefined
carbohydrates.
Non- communicable
diseases : obesity,
diabetes mellitus,
cardiovascular
disease (CVD),
Sedentary lifestyle hypertension and
stroke, and some
types of cancer
15
Nutrition and Hypertension
• Blood pressure is the force exerted by the blood against the
walls of the blood vessels. High blood pressure or
Hypertension is a condition when the same blood pressure
in the arteries are persistently elevated.
• Risk factors:
• Age:
The AHA 2017 guidelines define the following ranges of
blood pressure:
Systolic
(mmHg)
Normal blood
Less than 120
pressure
• Ethnicity:
• Obesity
• Alcohol and tobacco use
• Sex:
• Existing health conditions
• A salt-rich diet associated with processed and fatty foods
• Low potassium in the diet
Diastolic
(mmHg)
Less than 80
Elevated
Between 120
and 129
Less than 80
Stage 1
hypertension
Between 130
and 139
Between 80
and 89
Stage 2
hypertension
At least 140
At least 90
Over 180
Over 120
Hypertensive
crisis
16
• Lose weight - The most effective non-drug method of lowering blood pressure.
• Exercise - Even 30 to 45 minutes of mild to moderate aerobic exercise (brisk
walking or cycling four times a week) can nudge your blood pressure down a few
points.
• Limit your alcohol intake to one to two drinks per day.
• Eat a low-fat, high-fruit and -vegetable diet.
• Limit your salt intake to no more than 2.4g per day – about 1 teaspoon of salt.
• Don't smoke.
• Dietary approach: DASH Diet (Dietary Approaches to Stop Hypertension): It is a
plant-focused diet, rich in fruits and vegetables, nuts, with low-fat and non-fat
dairy, lean meats, fish, and poultry, mostly whole grains, and heart healthy fats
17
Nutrition and Cardiovascular diseases
• Heart and blood vessel disease — also called heart disease/ cardiovascular
diseases includes numerous problems, many of which are related to a process
called atherosclerosis.
• Atherosclerosis is a condition that develops when a substance called plaque builds
up in the walls of the arteries. This buildup narrows the arteries, making it harder
for blood to flow through. If a blood clot forms, it can stop the blood flow. This
can cause a heart attack or stroke.
18
• Risk factors.
• Unhealthy blood cholesterol levels.
• High blood pressure.
• Smoking.
• Diabetes.
• Overweight or obesity.
• Lack of physical activity
• Unhealthy diet. An unhealthy diet can raise
your risk for atherosclerosis. Foods that are
high in saturated and trans fats, cholesterol,
sodium (salt), and sugar can worsen other
atherosclerosis risk factors.
• Older age.
• Family history of early heart disease.
• Dietary factors influence the
immunological processes underlying the
pathogenesis of Atherosclerosis.
• Dietary approach:
• Choose plant-based foods: vegetables,
beans, whole grains, and fruit.
• Minimize refined grains, added salt,
and sweeteners.
• Include some nuts and seeds; avoid
oils.
• Avoid foods containing saturated and
trans fats.
• Have a reliable source of vitamin
B12.
19
Nutrition and cancer
• An abnormal growth of cells which tend to proliferate in an
uncontrolled way and, in some cases, to metastasize (spread).
• The abnormal mass of cells can be of two types : benign ( non
cancerous) and malignant ( cancer causing) .
• Skin cancer is the most common type of malignancy for both men and
women, the second most common type in men is prostate cancer and
in women, breast cancer.
20
•
•
•
•
•
•
•
•
•
•
•
•
•
Risk factors:
Age
Alcohol
Cancer-Causing Substances
Chronic Inflammation
Diet
Hormones
Immunosuppression
Infectious Agents
Obesity
Radiation
Sunlight
Tobacco
• Scientists have studied many
additives, nutrients, and other dietary
components which have possible
cancer risk such as acrylamide and
charred meat .
• Dietary approach :
• Limit or avoid alcohol to reduce
the risk of cancers of the mouth,
pharynx, larynx, esophagus, colon,
rectum, and breast.
• Avoid red and processed meats to
reduce the risk of cancers of the
colon and rectum.
• Emphasize fruits and vegetables to
reduce risk of several common
forms of cancer.
21
Summary
• Nutritional factors can influence immune functioning in many ways and at many
levels.
• Dietary factors that influence immune responses include total energy intake (both
as it pertains to malnutrition and to obesity and dieting), total fat intake, the types
of fatty acids ingested (especially n-3 LCPUFA), several vitamins (especially
vitamins A, D, E, B6 and C), carotenoids, flavonoids, trace minerals (especially
zinc and selenium), prebiotics and probiotics.
• Dietary transition has been major factor for the risk of non communicable diseases
in the urban population . Hence nutrition and dietary management plays an
significant role in prevention and reducing the progression of these communicable
diseases.
22
Thank you !!!!
• Expert Consultation on Diet, Nutrition, and the Prevention of Chronic Diseases,
Weltgesundheitsorganisation, & FAO (Eds.). (2003). Diet, nutrition, and the prevention of chronic
diseases: report of a WHO-FAO Expert Consultation ; [Joint WHO-FAO Expert Consultation on
Diet, Nutrition, and the Prevention of Chronic Diseases, 2002, Geneva, Switzerland]. Geneva:
World Health Organization
• Gredel, S. (2011). Nutrition and immunity in man. Brussels: ILSI Europe.
23
Principles of diet therapy
Supriya Bhattarai
MSc Nutrition and Dietetics\ Sports Nutrition
30/04/2020
• Dietetics
Dietetics is concerned with planning of diets in maintaining
health and in prevention and treatment of disease. It is a combination of
both nutrition and food science.
• Diet therapy
Diet therapy means use of diet (food and drink) not only in the
care of the sick, but also in the prevention of disease and maintenance of
health. It is concerned with the use of food as an agent in effecting
recovery from illness.
2
PRINCIPLES OF THERAPEUTIC DIET
• A well planned diet providing all the specific nutrients to the body helps to
achieve nutritional homeostasis in a normal, healthy individual.
• However, in disease conditions, the body tissues either do not receive
proper nutrients in sufficient amounts or cannot utilize the available
nutrients owing to faulty digestion, absorption or transportation of food
elements, thus affecting the nutritional homeostasis of the sick person.
• the diet, therefore needs to be suitably modified. However, it is required that
the basis for planning such modified diets should be the normal diet.
• Therefore diet therapy is concerned with the modification of normal diet to
meet the requirements of the sick individual.
• The general objectives of diet therapy are
1. To maintain a good nutritional status.
2. To correct nutrient deficiencies which may have occurred due to the
disease.
3. To afford rest to the whole body or to the specific organ affected by
the disease.
4.To adjust the food intake to the body's ability to metabolize the
nutrients during the disease.
5. To bring about changes in body weight whenever necessary.
Factors to be considered while planning the
diet and attributes
1. The underlying diseased
condition which requires a change
in the diet.
• 2. The possible duration of the
disease.
• 3. The factors in the diet which
must be altered to overcome
these conditions.
• 4. The patients tolerance for food
by mouth.
• 5. The preference of the patients
• The four attributes of a
therapeutic diet are;
1.
2.
3.
4.
Adequacy
Accuracy
Economy
Palatability
Modification of therapeutic diet
• therapeutic diets can be modified in terms of quality and quantity.
• Qualitative• - Restriction of a Nutrient eg.; Sodium in hypertension
• - Excess of a nutrient eg.; Tuberculosis where increased protein and
energy are required
• Quantitative
• - Change in consistency eg.;clear liquid diet
• - Rearrangement of meals eg: Increasing frequency of meals
• - Omission of foods eg: Allergy, which demands complete exclusion
of the allergic food.
Routine hospitals diet
• Clear liquid Diet
• Clear liquid diet is a temporary diet of
clear liquids without residue and is non stimulating, non-irritating and non-gas
forming.
• Small amounts of fluids (usually 30-60
ml) are served at frequent intervals (2 hrs)
to replace fluid and electrolytes and also
to relieve thirst. Being composed mainly
of water, carbohydrates and some
electrolytes, a clear fluid diet can
normally provide only 400-500 k.cal, 5 g
protein, negligible fat and 100-120 g of
carbohydrates.
• It is nutritionally inadequate and therefore
used for a very short period of time (24-48
hrs).
• Disease conditions for its use
• 1. Preoperative patients eg: preparation for
bowel surgery.
• 2. Prior to colonoscopic examination.
• 3. Post operative patients eg: in the initial
recovery phase after abdominal surgery or
after a period of intravenous feeding.
• 4. Acute illness and infections as in acute
Gastro Intestinal (GI) disturbances such as
acute gastroenteritis, when fluid and
electrolyte replacement is desired to
compensate for losses from diarrhoea.
• 5. Temporary food intolerance.
• 6. To relieve thirst.
• 7. To reduce colonic fecal matter.
full fluid diet
• A full fluid diet includes all foods which are
liquid or can be liquefied at room and body
temperature. It is free from cellulose and
irritating condiments and spices.
• This diet can be properly planned and made
nutritionally adequate for maintenance
requirements. If used for more than two days,
then a high protein, high calorie supplement
may be necessary.
• This diet is given in between a clear liquid diet
and soft diet. The average nutritional
composition of this diet is 1200 k.cal and 35 g
protein. This should be given at 2-4 hr
interval.
• Disease condition for its use
• 1. Most often used post operatively by
patients progressing from clear liquids to
solid foods.
• 2. Acute gastritis and infections.
• 3.
Following oral surgery or plastic
surgery of face or neck area.
• 4.
In presence of chewing and
swallowing dysfunction for acutely ill
patients.
• 5. Patients with oesophagal or stomach
disorder who cannot tolerate solid foods
owing to anatomical irregularity.
• Soft Diet
• A soft diet is used as a transitional diet
between full fluid and normal diet. It is
nutritionally adequate. It is soft in consistency,
easy to chew, made up of simple, easily
digested foods, containing limited fibre and
connecting tissues and does not contain rich or
highly flavoured foods.
• The average soft diet supplies around 1800
k.cal and 50 g protein. However the energy,
protein and other nutrients are adjustable
according to the individual's need, based on
activity, height, weight, sex, age and disease
condition.
• It can be given as three meals a day with or
without in between meal feedings.
• Disease condition for its use
• 1.
Patients progressing from full fluid diet
to general diet.
• 2.
Post operative patients unable to tolerate
general diet.
• 3. Patients with mild GI problems.
• 4. Weak patients or patients with inadequate
dentition to handle all foods in a general diet.
• 5. Diarrhoea convalescence
• 6. Between acute illness and convalescence.
• 7. Acute infections.
• Mechanical soft diet
• Many people require a soft diet simply
because they have no teeth and such a diet is
known as mechanical or a dental soft diet. It is
not desirable to restrict the patient to the food
selection of the customary soft diet and the
following modifications to the normal diet
may suffice.
• 1. Vegetables may be chopped or diced
before cooking
• 2. Hard raw fruits and vegetables are to be
avoided; tough skins and seeds to be removed.
• 3. Nuts and dried fruits may be used in
chopped or powdered forms.
• 4.
Meat to be finely minced or ground.
• 5.
Soft breads and chapattis can be given.
• Disease condition for its use
• 1. In cases of limited chewing or
swallowing.
• 2. Patients who have undergone
head and neck surgery.
• 3. Dental problems.
• 4. Anatomical oesophagal strictures.
• Normal diet
• A normal diet is defined as one which
consists of any and all foods eaten by
a person in health. It is planned
keeping the basic food groups in mind
so that optimum amounts of all
nutrients are provided. As there is no
restriction of any kind of food, this
diet is well balanced and nutritionally
adequate.
• Since the patient is hospitalized or is at
bed rest, a reduction of 10% in energy
intake should be made and too many
fatty foods and fried foods be avoided
as they are difficult to digest. The
proteins are slightly increased (+10%)
to counteract a negative nitrogen
balance. All other nutrients are
supplied in normal amounts.
• Cold semi liquid diets
• This diet is given following
tonsillectomy or throat surgery until a
soft or general diet may be swallowed
without difficulty. It contains more of
cold beverages and luke warm
preparations.
• Blenderized liquid diet
• This is adopted in conditions of
1. inadequate oral control
2. oral surgery with dysphagia
3. wired jaws (blenderized foods can be consumed through small openings).
4. Patients with reduced pharyngeal peristalisis.
• Routine food is made into liquid pulp and can be prepared using a kitchen blender.
Special Feeding method
• The special feeding methods depend on the type of disease, the patient's
conditions and his tolerance to food. The different modes of feeding patients are
1.Enteral
• By definition enteral means 'within or by the way of the gastrointestinal tract.' As
for as possible, the patient should be encouraged to ingest food through the oral
route. Supplements may be added whenever necessary. The foods are administered
via a tube and hence enteral feeding in also called tube feeding.
• Tube feeding
• Tube feeding may be advised where the
patient is unable to eat but the digestive
system is functioning normally. Full fluid
diets or commercial formulas may be
administered through this route.
• The tube may be passed through the nose
into the stomach (nasogastric), duodenum
(nasoduodenal) or jejunum (nasojejunal).
• When there is an obstruction in the
oesphagus, enteral feeding is done by
passing a tube surgically through an
incision in the abdominal wall into the
stomach (gastrostomy), duodenum
(duodenostomy) or jejunum
(jejunostomy).
• Indications for tube feeding
1. Inability to swallow due to paralysis of
muscles of swallowing (diptheria,
poliomyelites)
2. Unwillingness to eat.
3. Persistent anorexia requiring forced
feeding.
4. Semiconcious or unconscious patients.
5. Severe malabsorption requiring
administration of unpalatable formula.
6. Short bowel syndrome.
7. Babies of low birth weight.
• For enteral feeding for a short period of time locally available thin bore
nasogastric tubes are usually adequate. For prolonged use, specially prepared thin
bore, soft, flexible tubes are desirable.
• Procedure: The preparations to be administered are kept in bottles marked 'For
intragastric use'. They are connected to the tube and allowed to drip into the
stomach by gravity. Feeding is started as a continuous drip of 50 ml per hour,
increased by 20 ml every 24 hours until the required rate is achieved (usually 100
to 120 ml per hour).
• The types of feeds that can be administered though a tube include:
• Blenderized foods
• Polymeric mixtures: Polymeric mixtures contain intact protein, fat and
carbohydrate of high molecular weight and are thus lower in osmolarity and
require normal digestive juices.
• Elemental diets : Elemental diets are commercially predigested mixtures of
amino acids, dextrins, sugars, electrolytes, vitamins and minerals with small
amounts of fat. They are free of lactose and can be easily administered.
• The main indication for elemental diets is short bowel syndrome, till
functional regeneration occurs in the residual bowel. These diets are used as
alternatives to intravenous feeding. The disadvantages of this diet are high
cost and unpleasant taste and sometimes high osmolarity. Therefore, easily
digestible and more palatable preparations of casein and egg albumin are
preferred.
Method of administration
1. Continuous drip
2. Intermittent drip
3. Bolus
• Continous drip
• This is the most common form of
administration. The drip rate is adjusted in
increments to prevent cramping, nausea,
diarrhoea or distention. Feedings are
started at 30 to 50 ml/hr every 8 or 12 hrs
until the final rate is attained
• Intermittent drip
• In this 4-6 feeds are given with regular
periods of interruption example : 4 hours
on and 4 hours off.
• Bolus method
• In this method large volumes are given in
a short time. For example, 200 ml is
administered in a minimum time of ten
minutes.
• Parenteral Nutrition
• The delivery of nutrients directly
into the circulation through the
peripheral or central vein is termed
as parenteral nutrition. This can be
total or supplemental.
• Intravenous feeding is best used in
conditions when the patient cannot
eat, will not eat, should not eat,
cannot eat enough or cannot be fed
adequately by tube feeding.
• Conditions which necessitate
parenteral feeding includes
1.
Cancer
2.
Inflammatory bowel disease
3.
Short-bowel syndrome
4.
Preoperative patients
5.
Gastrointestinal fistulae.
• Parenteral feed solutions
The parenteral feed solutions contain
1 glucose
2 fat
3. amino acids
4. vitamins
5. electrolyes - Sodium, chlorine,
phosphorus, potassium, calcium and
magnesium
6. trace elements - zinc, copper,
chromium, manganese and iodine
7. water
• Advantages of enteral feeding over
intravenous feeding
1. Convenient to administer.
2. Inexpensive.
3. No hospitalization.
4.No sterilization of tubes or nutrient.
5. Expert supervision not necessary.
6. Easily tolerated.
7. Avoids catheter related sepsis and
infections.
8. Avoids metabolic disturbances.
Thank you
Dietary management of
diseases
Supriya Bhattarai
MSc Nutrition and Dietetics / Sports nutrition
07/05/2020
1
Fever
• Fever, also known as pyrexia and febrile response, is defined as having
a temperature above the normal range due to an increase in the body's
temperature set-point (37.5 and 38.3 °C (99.5 and 100.9 °F)
• The increase in set-point triggers increased muscle contractions and causes
a feeling of cold. This results in greater heat production and efforts to
conserve heat. When the set-point temperature returns to normal, a person
feels hot, becomes flushed and may begin to sweat. Rarely a fever may
trigger a febrile seizure. This is more common in young children. Fevers do
not typically go higher than 41 to 42 °C (105.8 to 107.6 °F).
• A fever can be caused by many medical conditions ranging from non
serious to life threatening. This includes viral, bacterial and parasitic
infections
such
as
the
common
cold,
urinary
tract
infections, meningitis, malaria and appendicitis among others. Noninfectious causes include vasculitis, deep vein thrombosis, side effects of
medication, and cancer among others.
2
Metabolism during fever
• With a rise in body temperature above normal (98.4° F or 37° C), the following metabolic changes
occur inside the body. These changes are in proportion to the elevation of body temperature above
normal and the duration of fever.
• There is a 7% increase in BMR with every 1° F increase in body temperature or 13% increase with
every 1° C rise in body temperature true. This change is more significant in patients suffering from
acute fever.
• Glycogen and adipose tissue stores decrease significantly because of increased energy expenditure.
Thus more energy is required.
• The rate of protein catabolism increases depending upon severity of infection and duration of fever.
There are increased losses in long continuous fever than in short duration fevers. Protein
breakdown is especially marked in fevers such as typhoid, malaria, poliomyelitis and tuberculosis.
This leads to increased nitrogen wastes and places an additional burden on the kidneys.
• There is loss of body fluid in the form of excessive sweat and urine formation.
• There is increased loss of minerals like sodium, potassium, chloride etc. through sweat, urine and
vomiting leading to electrolyte imbalance.
• The absorption of nutrients like protein, minerals and vitamins decreases.
• The above changes are accompanied by a loss of appetite resulting in low intake of food which
3
leads to loss of weight.
Symptoms
• Rise in temperature of body heat
• Perspiration or Shivering
• Restlessness and agitated temper
• Pain and soreness all over the body but some limbs may be extra
painful and sore
• Thirst
• Loss of Appetite
4
Dietary modification
• ENERGY: Increased by 50% if the temperature is high and tissue damage is
high can be able to ingest 600-1200 kcal daily.
• CARBOHYDRATES: Glycogen stores are replenished. around 60 % of total
energy
• PROTEIN: A high protein diet supplying 1.25-1.5g protein/kg body wt
should be fed. Protein supplements can be incorporated in the beverages
• FATS: Judiciously increased. Avoid fried foods
• VITAMINS: All vitamins may be given as supplements to the patient .
• MINERALS: Sufficient intake of Sodium, potassium should be given
liberally.
• FLUIDS: Since loss of body fluids through perspiration & excretory wastes
is high, plenty of water, coconut water, fruit & vegetable juices & soups are
advised.
• TEXTURE & CONSISTENCY OF THE DIET: Soft texture & fluid to semi
solid consistency are desirable to promote appetite & help the patient to
consume a diet which is nutritionally adequate These feeding should be small
& as frequent as possible. Generally, 6-8 feedings should be sufficient
5
HIV- AIDS
•
•
•
•
•
•
•
•
•
•
•
•
H = Human (who is affected)
I = Immunodeficiency (the result)
V = Virus (the causal agent)
A = Acquired (from bodily fluids
through a behavior or action,
including from the mother during
pregnancy, during delivery or
through breastmilk)
I = Immune (where the virus attacks)
D = Deficiency (resulting effect of virus)
S = Syndrome (series of illnesses; not
just one)
6
• Acquired Immune Deficiency Syndrome, or AIDS, is a disease caused by a
retrovirus known as the Human Immunodeficiency Virus (HIV), which attacks and
impairs the body’s natural defense system against disease and infection.
• HIV is a slow-acting virus that may take years to produce illness in a person. During
this period, an HIV-infected person’s defense system is impaired, and other viruses,
bacteria and parasites take advantage of this “opportunity” to further weaken the
body and cause various illnesses, such as pneumonia, tuberculosis and oral thrush.
• When a person starts having opportunistic infections, he/she has AIDS. The amount
of time it takes from HIV infection to become full-blown AIDS depends on the
general health and nutritional status before and during the time of HIV infection.
The average time for an adult is approximately ten years.
• There is no cure for HIV/AIDS as of now officially, many genetic engineering
methods have been formulated but not approved by FDA. N6 antibody is the
potential cure in experimental phase.
7
• HIV is transmitted through three
primary routes:
● Having unprotected sex with a person
already carrying the HIV virus;
● Transfusions of contaminated blood
and its by-products; or use of nonsterilized instruments such as sharing
non-sterilized needles, razors and other
instruments for surgical procedures;
● From infected mother to her child
(mother-to-child transmission, MTCT)
during
pregnancy,
childbirth
or
breastfeeding
•
•
•
•
HIV is not transmitted through:
● Handshakes,
● Hugging,
● Eating from the plate of an HIV
infected person,
• ● Mosquitoes or other insects,
• ● Kissing,
• ● Latrines.
8
9
10
11
Treatment: Anti- retro viral
therapy
12
Nutrition and HIV
13
14
• Consuming micronutrients (especially Vitamins A, B6 and B12, iron
and zinc) is important for building a strong immune system and
fighting infections. For example, Vitamin A deficiency is associated
with higher maternal-child transmission rates, faster progression from
HIV to AIDS, higher infant mortality and child growth failure. The Bgroup vitamins play important roles in immune regulations, and
deficiencies play a role in disease progression.
• Likewise supplements of Vitamin B6 (niacin) and B12
supplementation have been shown to improve survival and reduce
disease progression.
15
16
17
• The patients are more vulnerable to infection because their immune systems
have already been weakened. Properly handling food and water is especially
important.
Guidelines: Water
● Be sure water is clean. Boil water for at least 5 - 10 minutes to kill germs.
● Keep water stored in a container with a lid.
● Always wash your hands with soap before and after touching foods.
Animal Products
● Cook all animal products (meat, chicken, pork, fish and eggs) at high
temperatures until thoroughly cooked.
● Do not eat soft-boiled eggs or meat that still has red juice.
● Thoroughly wash utensils and surfaces where you placed uncooked foods,
particularly meats, before you handle other foods.
● Cover meat, poultry or fish with a clear cover or cloth and keep separate
from other foods to avoid contamination.
18
Fruits and Vegetables
● Use clean water to thoroughly wash all fruits and vegetables that are to be
eaten raw to avoid contamination.
● If it is not possible to wash fruits and vegetables properly, remove the skin
to avoid contamination.
● Remove the bruised parts of fruits and vegetables to remove any molds and
bacteria that are growing.
General Foods Storage and Handling
● Make sure that the areas where you prepare and eat food are free of flies.
● Cover food that is not eaten to avoid contamination.
● Keep hot foods hot and cold foods cold.
● If food products have expiration labels, do not eat after the “best before”
date has expired.
● Store cooked food at most for one day and re-heat before eating.
● If you have a refrigerator, put all leftover foods in refrigerator.
19
Sexual education
• Having protected sex will lead to healthier and more productive lives by:
1) Reducing further spread of the virus;
2) Reducing the risk of repeated exposure to HIV infection, (repeated
exposure can speed up the disease process in the body of an HIV-infected
person);
3) Avoiding pregnancy, (pregnancy puts greater strain on a woman’s health
and risks possible infection of the baby);
4) Preventing exposure to other sexually transmitted diseases, (exposure to
sexually transmitted diseases can lead to severe morbidity or premature
mortality);
5) Avoiding infection in women and therefore the possibility of transferring
it to their infants.
20
Physical activity and immediate attention to
illness.
• being active plays a very important role in maintaining health. Activity
improves appetite, develops muscle, reduces stress, increases energy
and helps maintain overall physical and emotional health.
• Social and everyday activities such as walking, cleaning and collecting
firewood or water are important.
• Illnesses and infections are signs that the body is weak. If left
untreated, they can lead to further deterioration. When the signs of
illness – such as cough, sore throat or fever – begin, an HIV-infected
person should seek treatment if available. Quick attention to early
signs of illness can prevent further damage to the body.
21
• Psychosocial support
• Community involvement.
22
Peptic ulcer
• Peptic ulcers are open sores that
develop on the inside lining of
your stomach and the upper
portion of your small intestine.
• Peptic ulcers include:
• Gastric ulcers that occur on the
inside of the stomach
• Duodenal ulcers that occur on
the inside of the upper portion of
your small intestine (duodenum)
23
Causes and symptoms
• The most common causes of peptic ulcers are infection with the
bacterium Helicobacter pylori (H. pylori) and long-term use of aspirin
and certain other painkillers, such as ibuprofen (Advil, Motrin, others)
and naproxen sodium (Aleve, Anaprox, others). Stress and spicy foods
do not cause peptic ulcers. However, they can make your symptoms
worse.
• Symptoms
• Burning stomach pain
• Feeling of fullness, bloating or belching
• Fatty food intolerance
• Heartburn
• Nausea
24
25
Diagnosis
• Test for H. pylori
• Endoscopy
• Antibiotics against H. pylori
• Proton pump inhibitors
• H2 inbitiors
• Medications that neutralize the
acids
• Medications that protect the
lining of the stomach
26
Nutrition management
• Eat mostly fruits, vegetables, whole grains, and fat-free or lowfat
• milk and milk products.
• • Eat lean meats, poultry (such as chicken and turkey), fish,
• beans, eggs, and nuts.
• • Choose fats that are better for your health such as olive oil and
• canola oil.
• • Eat fewer foods that have added salt.
• • Eat fewer foods that have added sugar
27
28
29
Food allergies
30
• Food allergy is an adverse immune mediated reaction to a food,
usually a food protein or hapten . The symptoms are individual
response to the food.
• Food intolerance is an adverse reaction to a food that does not involve
the immune system and occurs because of the way the body processes
the food or components in the food.
31
32
• Causes : hereditary
• Maternal diet and early infant
feeding
• Gastrointestinal microbiota
• Skin – prick test
• Antibody test
33
Nutrition therapy
• Food and symptom diary is a 7- 14 day diary , which is used to
identify possible nutrient insufficiencies and deficiencies and its
associated symptoms.
• Food elimination diet : suspected foods are eliminated from the diet
for a specified period , usually 4- 12 weeks followed by
reintroduction.
34
Prevention
• Breast feeding
• Antioxidants
• Pre- probiotics
• Vitamin D
• Solid food introduction
35
Thank you
36
Nutrition in cardiovascular
diseases
Supriya Bhattarai
MSc Nutrition and
Dietetics/ Sports
14/05/2020
• Arteriosclerosis is the general term for vascular disease in which arteries harden (become
thickened), making the passage of blood difficult and some- times impossible.
• It is believed to begin in childhood and is considered one of the major causes of heart
attack.
• Atherosclerosis affects the inner lining of arteries (the intima), where deposits of
cholesterol, fats, and other substances accumulate over time, thickening and weakening
artery walls. These deposits are called plaque .
• Plaque deposits gradually reduce the size of the lumen of the artery and, consequently,
the amount of blood flow. The reduced blood flow causes an inadequate supply of
nutrients and oxygen delivery to and waste removal from the tissues. This condition is
called ischemia.
• The reduced oxygen supply causes pain. When the pain occurs in the chest and radiates
down the left arm, it is called angina pectoris and should be considered a warning.
• When the lumen narrows so that a blood clot (thrombus) occurs in a coronary artery and
blood flow is cut off, a heart attack occurs. The dead tissue that results is called an
infarct. The heart muscle that should have received the blood is the myocardium. Thus,
such an attack is commonly called an acute myocardial infarction (MI)
• When blood flow to the brain is blocked in this way or blood vessels burst and blood
flows into the brain, a stroke, or cerebrovascular accident (CVA), results. When it occurs
in tissue some distance from the heart, it is called peripheral vascular disease (PVD).
Risk factors
• Hyperlipidemia, hypertension (high blood pressure), and smoking are
major risk factors for the development of atherosclerosis. Other
contributory factors are believed to include obesity, diabetes mellitus,
male sex, heredity, personality type (ability to handle stress), age (risk
increases with years), and sedentary lifestyle.
• Lipoproteins carry cholesterol and fats in the blood to body tissues.
Low-density lipoprotein (LDL) carries most of the cholesterol to the
cells, and elevated blood levels of LDL are believed to contribute to
atherosclerosis. High- density lipoprotein (HDL) carries cholesterol
from the tissues to the liver for eventual excretion. It is believed that
low serum levels of HDL can contribute to atherosclerosis.
Medical nutrition therapy for Hyperlipidemia
• The American Heart Association categorizes blood cholesterol levels
of 200 mg/dl or less to be desirable, 200 to 239 mg/dl to be
borderline high, and 240 mg/dl and greater to be high.
• In an effort to prevent heart disease, the American Heart Association
has developed guidelines in which it is recommended that adult diets
contain less than 200 mg of cholesterol per day and that fats provide
no more than 20% to 35% of calories, with a maximum of 7% from
saturated fats and trans fat, a maximum of 8% from polyunsaturated
fats, and a maximum of 15% to 20% of monounsaturated fats.
Carbohydrates should make up 50% to 55% of the calories and
proteins from 12% to 20% of them.
• Studies indicate that water-soluble fiber, such as that found in oat bran,
legumes, and fruits, bind with cholesterol-containing substances and
prevent their reabsorption by the blood. It is thought that 20 to 25 grams
of soluble fiber a day will effectively reduce serum cholesterol by as much
as 15%.
• Omega 3 fatty- acids: EPA and DHA are high in fish oils and fatty fishes. For
patients who have CVD 1 g of EPA and DHA is recommended from fish or
supplements. Patients who have hyper triglyceridemia need 2 to 4 g .
• Antioxidants: vitamin E and catechins are very potent with CVD.
• Stanols and sterols. 2- 3 gram / day, the dosage still remains controversial.
Myocardial infarction
• After the attack, the client is in shock. This causes a fluid shift, and the
client may feel thirsty. The client should be given nothing by mouth (NPO),
however, until the physician evaluates the condition. If the client remains
nauseated after the period of shock, IV infusions are given to prevent
dehydration.
• After several hours, the client may begin to eat. A liquid diet may be
recom- mended for the first 24 hours. Following that, a low-cholesterol–
low-sodium diet is usually given, with the client regulating the amount
eaten.
• Foods should not be extremely hot or extremely cold. They should be easy
to chew and digest and contain little roughage so that the work of the
heart will be minimal. Both chewing and the increased activity of the
gastrointestinal tract that follow ingestion of high-fiber foods cause extra
work for the heart.
Congestive heart failure
• The heart cannot provide adequate blood flow to the rest of the body
causing symptoms of fatigue, shortness of breath ( dyspnea) and fluid
retention.
• Caused due to damage or stress to the heart muscle .
• Stages :
• Class I : no undue symptoms associated with ordinary activity and no
limitation of physical activity.
• Class II: slight limitation of physical activity, patient comfortable at rest.
• Class III: marked limitation of physical activity, patient comfortable at rest.
• Class IV: inability to carry out physical activity without discomfort,
symptoms of cardiac insufficiency or chest pain at rest.
Medical management
• Ace inhibitors
• Angiotensin receptor blockers
• Aldosterone blockers
• Vasodilators
• And many more
Nutrition Management
• Diet low in saturated fat, trans fat, cholesterol
• Restricted sodium diet – less than 2 G/day
• Increased use of whole grains, fruits, vegetables.
• Limit fluid to 2 L per day
• Lose or maintain appropriate weight.
• Magnesium supplementation
• Thiamin supplementation
• Increased physical activity as tolerated
• Avoid tobacco
• Avoid alcohol
Hypertension
high blood pressure
• Hypertension contributes to heart attack, stroke, heart failure, and kidney failure.
It is sometimes called the silent disease because sufferers can be asymptomatic
(without symptoms).
• Hypertension causes damage to the walls of blood vessels, making them weaker.
This leads to a number of pathologies
including atherosclerosis, thromboembolism (progressing to MI or stroke) and
aneurysms.
• Hypertension also damages the heart itself by increasing the afterload of the
heart. The heart is pumping against greater resistance, leading to left ventricular
hypertrophy. This increases the risk of heart failure in the future. Hypertrophy of
the cardiac muscle also increases the heart’s oxygen demand, predisposing to
myocardial ischemia and ultimately angina.
Blood pressure regulation in the body
• Short-term regulation of blood pressure is controlled by the autonomic nervous system.
• Changes in blood pressure are detected by baroreceptors. These are located in the arch of the
aorta and the carotid sinus.
• Increased arterial pressure stretches the wall of the blood vessel, triggering the baroreceptors.
These baroreceptors then feedback to the autonomic nervous system. The ANS then acts to
reduce the heart rate and cardiac contractility via the efferent parasympathetic fibres (vagus
nerve) thus reducing blood pressure.
• Decreased arterial pressure is detected by baroreceptors, which then trigger a sympathetic
response. This stimulates an increase in heart rate and cardiac contractility leading to an increased
blood pressure.
• Baroreceptors cannot regulate blood pressure long-term. This is because the mechanism of
triggering baroreceptors resets itself once a more adequate blood pressure is restored.
Renin angiotensin aldosterone system
Dietary approaches
• Salt restricted diet: A sodium-restricted diet is a regular diet in which
the amount of sodium is limited.
• Such a diet is used to alleviate edema and hypertension. Most people
obtain far too much sodium from their diets.
• It is estimated that the average adult consumes 7 grams of sodium a
day. A committee of the Food and Nutrition Board recommends that
the daily intake of sodium be limited to no more than 2,300 mg (2.3
grams.
• Dash diet: used for preventing and controlling high blood pressure.
(https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthyeating/in-depth/dash-diet/art-20048456) / Ornish diet / atkins
• Potassium calcium and magnesium:
• Consuming a diet rich in potassium has been shown to lower blood
pressure and blunt the effect of salt on blood pressure.
• Increased intakes of calcium and magnesium may have blood
pressure benefits.
Thank you
Nutritional management of
cancer
Supriya bhattarai
MSc Nutrition and dietetics
15/05/2020
Pathophysiology
• Oncogenes are altered genes that promote tumor growth and change
programmed cell death.
• Tumor suppressor genes are the opposite of oncogenes, these genes
become deactivated in cancer cells. This loss of function leads to
unregulated cell growth and ultimately cancer.
• Phases : initiation involves transformation of cells produced by the
interaction of chemicals, radiation ,or viruses with cellular deoxyribonucleic
acids.
• Transformation
• Promotion: initiated cells multiply and escape the mechanisms set in place
to protect the body from the growth and spread of such cells.
• Progression: tumor cells aggregate and grow into a fully malignant
neoplasm or a tumor.
Nutrition and carcinogenesis
• Alcohol
• Body weight
• Fat
• Smoked , grilled and preserved foods
• Bisphenol A
Diagnosis and staging
• CAUTION
• Tumor suppressor marker
• Body fluids, sputum, urine and tissue
• Histopathologic examination
• 8- OHdG
• Staging – I-IV
• Classification : benign and malignant
• Chemotherapy
• Radiation
• Surgery
• Biotherapy
Medical Nutrition therapy
• Energy
Condition
Energy needs
Cancer, nutritional repletion , weight gain 30-40 kcal /kg/day
Cancer normometabolic
25-30 kcal/kg/day
Cancer hypermetabolic
35 kcal/kg/day
Sepsis
25-30 kcal/kg/day
Obese
21-25 kcal/kg/day
• Protein: 1.5-2g/kg/day
• Fluid: 1ml / 1 kcal
• Vitamins and minerals
Nutrients for cancer prevention
• Calcium and vitamin D
• Coffee and tea
• Fruits and vegetables
• Soy and phytoestrogens
Importance of nutrition during treatment
• Maintenance of adequate nutrient stores and muscle mass
• Improved strength and energy
• Management of side effects
• Improved quality of life
• Fewer complications, infections, hospitalizations, treatment breaks
• Improved survival and outcome
Malnutrition in cancer
Nausea and vomiting
• Ginger
• Suck on tart hard candies
• Cold/room temp foods to avoid strong smells
• Bland/dry foods
• Small frequent meals
• Sip on calorie containing liquids between meals
Poor Appetite
• Small, frequent meals
• Choose calorie rich foods
• Choose liquids with calories
• Nutritional supplements
Fatigue
• Light physical activity
• Prepare frozen meals on goods days
• Ask friends and family for help
• Nutritional Supplements
Sore Mouth or Throat
•
•
•
•
Drink through a straw
Avoid mouthwash containing alcohol
Rinse your mouth with water/salt/baking soda solution
Soft foods
•
•
•
•
•
•
•
•
Pureed fruits/veggies
Cream soups
Cooked cereal
Mashed potatoes
Scrambled eggs
Mac and Cheese
Yogurt/applesauce/puddings
Ice cream/milk shakes
Taste Changes
• Rinse mouth before meals with water/baking
soda/salt
• Try sucking on hard candies
• Experiment with herbs/spices
Diarrhea
• Drink at least 1 cup (150ml) of liquid after each loose
bowel movement
• Eat small frequent meals throughout the day
• Avoid greasy, fried, spicy, sweet foods
• Avoid caffeine and alcohol
• Limit drinks and foods that cause gas
•
•
•
•
Vegetables in the cabbage family
Peas
Dried beans
Carbonated beverages
• Stir or pour it into a glass to lessen the bubbles
Constipation
• Eat at about the same times each day
• Drink a hot beverage or eat hot cereal to stimulate a bowel movement
•
•
•
•
Warm fruit or vegetable juices
Decaffeinated teas
Hot Cocoa
Hot water with added lemon juice and honey
• Drink at least 1.5-2 L of liquid each day
• Water
• juices
• Foods that are liquid at room temp: popsicles, Jell-O, Ice cream
• Eat more fiber
•
•
•
•
Whole grain breads and cereals
Fruits and vegetables
Popcorn
Dried beans
• Move!
Thank You
Nutrition and liver diseases
Introduction
• Liver
– Most metabolically active organ in the body
•
•
•
•
Produces most of the proteins circulating in plasma
Produces bile to emulsify fat during digestion
Detoxifies drugs and alcohol
Processes excess nitrogen for excretion as urea
Fatty Liver and Hepatitis
• Fatty liver
– Accumulation of fat in liver tissue
• Amount of fat produced in the liver or picked up
from the blood exceeds the amount the liver can
use or export to the blood.
– Causes
• Metabolism defects, excessive alcohol intake,
exposure to drugs and toxins
• Insulin resistance in nonalcoholic fatty liver disease
Fatty Liver and Hepatitis: Fatty Liver
(cont’d.)
• Consequences of fatty liver
– Asymptomatic for many
– Steatohepatitis: liver inflammation
– Hepatomegaly: liver enlargement
– Fatigue
– May progress to more serious conditions
• Cirrhosis, liver failure, or liver cancer
Fatty Liver and Hepatitis: Fatty Liver
(cont’d.)
• Treatment of fatty liver
– Eliminate causative factors
• Discontinue alcohol or drug use
• Lower blood lipid levels
• Weight reduction, increased activity, medications to
improve insulin sensitivity
Fatty Liver and Hepatitis (cont’d.)
• Hepatitis: liver inflammation
– Causes
•
•
•
•
•
Specific viral infections (A, B, C, D, and E)
Excessive alcohol intake
Exposure to drugs or toxic chemicals
Fatty liver disease
Autoimmune disease
Fatty Liver and Hepatitis: Hepatitis
(cont’d.)
• Viral hepatitis
– Hepatitis A virus (HAV)
• Primarily spread via fecal-oral transmission
– Hepatitis B virus (HBV)
• Transmission: infected blood or needles, sexual
contact with an infected person, or mother to infant
during childbirth
Fatty Liver and Hepatitis: Hepatitis
(cont’d.)
• Viral hepatitis
– Hepatitis C virus (HCV)
• Spread via infected blood or needles
• Not readily spread by sexual contact or childbirth
• Symptoms and signs of hepatitis
– Onset of acute hepatitis
• Fatigue, malaise, nausea, vomiting, anorexia, and
pain in the liver area
Fatty Liver and Hepatitis: Hepatitis
(cont’d.)
• Symptoms and signs of hepatitis
– Slightly enlarged, tender liver
– Jaundice
– Elevated ALT and AST serum levels
• Treatment of hepatitis
– Supportive care: bed rest and diet
– Antiviral agents for HBV or HCV
Fatty Liver and Hepatitis: Hepatitis
(cont’d.)
• Nutrition therapy for hepatitis
– Most individuals: no dietary changes required
– Nutritional support as needed
• Small, frequent meals (for anorexia, abdominal
discomfort)
• Electrolyte replacement (persistent vomiting)
• Adequate protein (1.5-2 g/kg/day) and energy to
replenish nutrient stores (malnourished)
• Oral supplements
Cirrhosis
• Late stage of chronic liver disease
– Extensive scarring replaces healthy liver
tissue
– Impaired liver function and liver failure
Cirrhosis (cont’d.)
• Consequences of cirrhosis
– Metabolic disturbances
• Anemia; bruise easily; susceptible to infections
– Bile obstruction
• Jaundice, fat malabsorption, and pruritis (itchy
skin)
– Fluid accumulation in blood vessels and body
tissues
Cirrhosis (cont’d.)
• Portal hypertension
– Rise in blood pressure due to increased portal
blood coupled with obstructed blood flow
through the liver
– Varices: abnormally dilated blood vessels
– Esophageal and gastric varices
• Vulnerable to rupture
• Bleeding may be fatal
Cirrhosis (cont’d.)
• Ascites
– Large accumulation of fluid in the abdominal
cavity
– Indicates a critical stage of liver damage
– Causes:
• Portal hypertension
• Sodium and water retention in kidneys
• Reduced albumin synthesis in liver
Oncotic Pressure through Albumin
Throughout the body, dissolved compounds have an osmotic pressure. Because
large plasma proteins cannot easily cross through the capillary walls, their effect on the
osmotic pressure of the capillary interiors will, to some extent, balance out the tendency
for fluid to leak out of the capillaries. In other words, the oncotic pressure tends to pull
fluid into the capillaries. In conditions where plasma proteins are reduced, e.g. from being
lost in the urine (proteinuria), there will be a reduction in oncotic pressure and an increase
in filtration across the capillary, resulting in excess fluid buildup in the tissues (edema).
Cirrhosis (cont’d.)
• Hepatic encephalopathy
– Abnormal neurological functioning
– Signs: adverse changes in personality,
behavior, mood, mental ability, and motor
functions
– Fully reversible with treatment
– Exact etiology unknown
Copyright © 2017 Cengage Learning. All Rights Reserved.
Cirrhosis (cont’d.)
• Elevated ammonia levels
– Healthy liver converts blood ammonia to urea
– In advanced disease, liver is unable to
process the ammonia sufficiently
– Ammonia-laden blood bypasses the liver via
collateral vessels
• Reaches the general blood circulation and thereby,
brain tissue
Cirrhosis (cont’d.)
• Malnutrition and wasting
– Some degree of wasting in most patients with
advanced cirrhosis
– Possible causes of malnutrition Reduced
nutrient intake
• Malabsorption or nutrient losses
• Altered metabolism or increased nutrient needs
Cirrhosis (cont’d.)
• Treatment of cirrhosis
– Objectives: correct the underlying cause of
disease; prevent or treat complications
– Supportive care
• Appropriate diet
• Avoidance of liver toxins
– Medications to treat complications
• Be aware of diet-drug interactions.
Cirrhosis (cont’d.)
• Nutrition therapy for cirrhosis Customized
to each patient’s needs
– Energy
• 25 to 40 kcal/kg dry body weight per day
• Four to six small meals
• Oral supplements
Cirrhosis: Nutrition Therapy for Cirrhosis
(cont’d.)
• Protein
– 1.0 to 1.5 g/kg dry body weight/day
– Branched-chain amino acids (BCAA)
• Carbohydrate and fat
– Medications or insulin to treat insulin
resistance
– Carbohydrate and glucose control
– Fat may be restricted to <30% of kcal with
steatorrhea
Cirrhosis: Nutrition Therapy for Cirrhosis
(cont’d.)
• Vitamins and minerals
– Deficiencies common; nutrient
supplementation often necessary
Cirrhosis: Nutrition Therapy for Cirrhosis
(cont’d.)
• Food safety: to avoid foodborne illness
• Enteral and parenteral nutrition support
– Tube feedings
• Supplement or replace oral intakes
• Standard formula; or energy-dense formula for
patients with ascites
– Parenteral nutrition support for patients
unable to tolerate enteral feedings
Liver Transplantation
• Overview
– Most transplants preceded by chronic
hepatitis C or alcoholic liver disease
– Five-year survival rate of 54% to 81%
Liver Transplantation (cont’d.)
• Posttransplantation concerns
– Immediate concerns
• Organ rejection
• Infection
– Immunosuppressive drugs raise infection risk
– Antibiotics and antiviral medications reduce risk
Liver Transplantation (cont’d.)
• Post transplantation concerns
– Stress of surgery increases protein and
energy requirements
• High-kcal, high-protein snacks and oral
supplements
– Vitamin and mineral supplementation
– Food safety measures
Nutrition and Diabetes Mellitus
Overview of Diabetes Mellitus
• Elevated blood glucose concentrations
and disordered insulin metabolism
– Inability to produce sufficient insulin and/or
inability to use insulin effectively
• Effects
– Defective glucose uptake and utilization in
muscle and adipose cells
Overview of Diabetes Mellitus (cont’d.)
• Hyperglycemia
– Marked elevation in blood glucose levels
– Can ultimately cause damage to blood
vessels, nerves, and tissues
• Symptoms of diabetes mellitus
– Related to the degree of hyperglycemia
present
• Above 200 mg/dL: exceeds renal threshold
Overview of Diabetes Mellitus (cont’d.)
• Diagnosis of diabetes mellitus
– Based primarily on plasma glucose levels
• Measured under fasting conditions or at random
times during the day
– Oral glucose tolerance test
– Indirect measure: glycated hemoglobin
(HbA1c)
Overview of Diabetes Mellitus:
Diagnosis of Diabetes Mellitus (cont’d.)
• Current diagnosis criteria
– After a fast of at least eight hours
• Plasma glucose concentration: 126 mg/dL or
higher
– Random sample during the day
• Plasma glucose concentration: 200 mg/dL or
higher
• Classic symptoms of hyperglycemia present
Overview of Diabetes Mellitus:
Diagnosis of Diabetes Mellitus (cont’d.)
• Current diagnosis criteria
– Two hours after a 75-gram glucose load
• Plasma glucose concentration: 200 mg/dL or
higher
– HbA1c level: 6.5% or higher
Overview of Diabetes Mellitus (cont’d.)
• Types of diabetes mellitus
– Main types
• Type 1 diabetes
• Type 2 diabetes
– Gestational diabetes: during pregnancy
– Can also result from medical conditions that
damage the pancreas or interfere with insulin
function
Overview of Diabetes Mellitus:
Types of Diabetes Mellitus (cont’d.)
• Type 1 diabetes
– Caused by autoimmune destruction of the
pancreatic beta cells
– Insulin must be supplied exogenously
– Usually develops in children or teens
– Classic symptoms: polyuria, polydipsia,
weight loss, and weakness or fatigue
Overview of Diabetes Mellitus:
Types of Diabetes Mellitus (cont’d.)
• Type 2 diabetes
– Most prevalent form of diabetes (90-95%)
– Insulin resistance coupled with relative insulin
deficiency
– Hyperinsulinemia: abnormally high blood
insulin
– Obesity substantially increases type 2
diabetes risk (80% of cases obese)
Overview of Diabetes Mellitus:
Types of Diabetes Mellitus (cont’d.)
• Type 2 diabetes in children and
adolescents
– Risk factors
• Overweight/obesity
• Family history of diabetes
– Types 1 and 2 may be difficult to distinguish in
children
Overview of Diabetes Mellitus (cont’d.)
• Prevention of type 2 diabetes mellitus
– Weight management
• Sustained weight loss of ~7% of body weight
recommended for overweight and obese
individuals
– Dietary modifications
• Increase intake of whole grains and dietary fiber
• Limit intake of sugar-sweetened beverages
• Decrease dietary fat if overweight/obese
Overview of Diabetes Mellitus (cont’d.)
• Prevention of type 2 diabetes mellitus
– Active lifestyle
• At least 150 minutes of moderate physical activity
weekly
– Regular monitoring
• Annual monitoring for individuals at risk
Effects of Insulin Insufficiency
Overview of Diabetes Mellitus (cont’d.)
• Acute complications of diabetes mellitus
– Diabetic ketoacidosis in type 1 diabetes
• Caused by severe lack of insulin
• Severe ketosis (abnormally high levels of ketone
bodies)
• Acidosis (pH <7.30)
• Hyperglycemia (usually >250 mg/dL)
• Symptoms: acetone breath, marked fatigue,
lethargy, nausea, and vomiting
Overview of Diabetes Mellitus:
Acute Complications (cont’d.)
• Diabetic ketoacidosis in type 1 diabetes
– Mental state: alert to diabetic coma
– Treatment:
• Insulin therapy
• Intravenous fluid and electrolyte replacement
• In some cases, bicarbonate therapy
Overview of Diabetes Mellitus:
Acute Complications (cont’d.)
• Hypoglycemia: low blood glucose
– Due to inappropriate management of diabetes
– Caused by excessive dosages of insulin or
antidiabetic drugs, prolonged exercise,
skipped or delayed meals, etc.
– Symptoms: sweating, heart palpitations,
shakiness, hunger, weakness, etc.
– Treatment: glucose tablets, juice, or candy
Overview of Diabetes Mellitus:
Chronic Complications (cont’d.)
• Macrovascular complications: damage to
large blood vessels
– Accelerates the development of
atherosclerosis in the arteries of the heart,
brain, and limbs
– Peripheral vascular disease: claudication, foot
ulcers, gangrene
Overview of Diabetes Mellitus:
Chronic Complications (cont’d.)
• Microvascular complications: damage to
small blood vessels (capillaries)
– Diabetic retinopathy: weakened retinal
capillaries leak fluid, lipids, or blood, causing
local edema or hemorrhaging
– Diabetic nephropathy
• Causes microalbuminuria
• Decreased urine production with accumulation of
nitrogenous wastes
Overview of Diabetes Mellitus:
Chronic Complications (cont’d.)
• Diabetic neuropathy: nerve damage
– Extent determined by severity and duration of
hyperglycemia
– Symptoms: deep pain or burning in the legs
and feet, weakness of the arms and legs,
numbness and tingling in hands and feet
– Occurs in about 50% of diabetes cases
Treatment of Diabetes Mellitus
• Requires lifelong treatment
– Balancing meals, medications, exercise
– Frequent adjustments necessary to establish
good glycemic control
• Treatment goals
– Maintain blood glucose levels within a
desirable range
• Prevent or reduce the risk of complications
Treatment of Diabetes Mellitus (cont’d.)
• Treatment goals
– Maintain healthy blood lipid concentrations,
control blood pressure, and manage weight
– Diabetes education
• Certified Diabetes Educator (CDE)
• Patients learn: meal planning, medication
administration, blood glucose monitoring, weight
management, appropriate physical activity,
prevention and treatment of complications
Treatment of Diabetes Mellitus (cont’d.)
• Evaluating diabetes treatment
– Monitor glycemic status
• Self-monitoring of blood glucose
• Continuous glucose monitoring
– Long-term glycemic control
Treatment of Diabetes Mellitus (cont’d.)
• Evaluating diabetes treatment
– Monitoring for long-term complications
• Blood pressure at each checkup; annual lipid
screening; routine checks for urinary protein, etc.
– Ketone testing
• Checks for ketoacidosis
• Most useful for type 1 diabetes or gestational
diabetes patients
Treatment of Diabetes Mellitus (cont’d.)
• Nutrition therapy: dietary
recommendations
– Improves glycemic control
– Slows the progression of diabetic
complications
– Macronutrient intakes
• % of kcal distribution depends on food preferences
and metabolic factors
• Maintain consistent day-to-day carbohydrate intake
(unless using intensive insulin therapy)
Treatment of Diabetes Mellitus:
Dietary Recommendations (cont’d.)
• Total carbohydrate intake
– Based on metabolic needs, type of insulin or
other medications, and individual preferences
– Recommended sources: vegetables, fruits,
whole grains, legumes, milk products
• Glycemic index (GI)
– Choosing low- over high-GI foods may
modestly improve glycemic control
Treatment of Diabetes Mellitus:
Dietary Recommendations (cont’d.)
• Sugars
– Minimize added sugars
– Sugary foods counted in the daily
carbohydrate allowance
– Fructose as an added sweetener not advised
– Artificial sweeteners can be used safely
• Whole grains and fiber
– Recommendations similar to those for general
public: include fiber-rich foods
Treatment of Diabetes Mellitus:
Dietary Recommendations (cont’d.)
• Dietary fat
– Increase omega-3s from fatty fish or plants
– Saturated fat: <10% of total kcalories
– Trans fat: minimized
– Cholesterol: <300 milligrams daily
• Protein: similar to general population
– High intakes may harm kidney function in
patients with nephropathy
Treatment of Diabetes Mellitus:
Dietary Recommendations (cont’d.)
• Alcohol use in diabetes
– 1 drink/day for women; 2 drinks/day for men
– Which groups should avoid alcohol?
• Micronutrients
– Same recommendations as general
population
– Supplements not currently recommended for
managing diabetes
Treatment of Diabetes Mellitus (cont’d.)
• Nutrition therapy: meal-planning strategies
– Carbohydrate counting
• Widely used for planning diabetes diets
• Dietician:
– Learns about patient’s usual food intake
– Calculates nutrient and energy needs
– Provides patient with daily carbohydrate allowance
divided into a pattern of meals and snacks.
Treatment of Diabetes Mellitus:
Meal-Planning Strategies (cont’d.)
• Carbohydrate counting
• Food lists for diabetes
• Meal plan created by choosing foods with
specified portions from the lists
Treatment of Diabetes Mellitus (cont’d.)
• Insulin therapy
– Required by people with:
• Type 1 diabetes
• Type 2 diabetes who are unable to maintain
glycemic control with medications, diet, and
exercise
– Ideally, insulin treatment should reproduce the
natural pattern of insulin secretion as closely
as possible
Treatment of Diabetes Mellitus:
Insulin Therapy (cont’d.)
• Insulin preparations
• Forms: rapid acting, short acting, intermediate
acting, long acting, and insulin mixtures
• Insulin delivery
– Administered by subcutaneous injection
• Using syringes, insulin pens, or insulin pump
Treatment of Diabetes Mellitus:
Insulin Therapy (cont’d.)
• Insulin regimen for type 1 diabetes
– Best managed with intensive insulin therapy
• Multiple daily injections of several types of insulin
or use of an insulin pump
– To learn amounts required for meals:
• Patient keeps records of food intake, insulin doses,
and blood glucose levels
• Carbohydrate-to-insulin ratio calculated
Treatment of Diabetes Mellitus:
Insulin Therapy (cont’d.)
• Insulin regimen for type 2 diabetes
– ~30% of patients can benefit from insulin
therapy
– Different regimens
• Insulin alone or combined with antidiabetic drugs
• One or two daily injections
– Single injection of long-acting insulin at bedtime
– Two or more injections of mixed insulin
Treatment of Diabetes Mellitus:
Insulin Therapy (cont’d.)
• Insulin therapy and hypoglycemia
– Hypoglycemia is the most common
complication of insulin treatment
– Corrected by immediate intake of glucose or
glucose-containing food (15-20 g CHO)
• Insulin therapy and weight gain
– Unintentional side effect
• Particularly with intensive insulin treatment
Treatment of Diabetes Mellitus:
Insulin Therapy (cont’d.)
• Fasting hyperglycemia
– Typically develops in the early morning after
an overnight fast of at least 8 hours
• Insufficient insulin during the night
• Dawn phenomenon
• Rebound hyperglycemia (Somogyi effect)
– Treatment: adjust the dosage or formulation of
insulin administered in the evening
Treatment of Diabetes Mellitus (cont’d.)
• Antidiabetic drugs
• For type 2 treatment
– Oral medications and injectable drugs other
than insulin
Treatment of Diabetes Mellitus (cont’d.)
• Physical activity and diabetes
management
– Improves glycemic control considerably
– At least 150 minutes of moderate-intensity
aerobic activity per week over at least 3 days
– Both aerobic and resistance exercise can
improve insulin sensitivity
Treatment of Diabetes Mellitus: Physical
Activity & Diabetes Management (cont’d.)
• Medical evaluation before exercise
– Screen for potential problems
• Aggravated by certain activities
– Exercise safety considerations
• Maintaining glycemic control
– Adjust insulin and/or medication doses
– Check glucose before and after exercise
– Avoid vigorous activity during ketosis
Kidney Diseases
The Kidney
 The kidney are two bean shaped organs that
filter the extra water and wastes out of blood.
2
The Nephron
 The Nephron are the
filtration units in the
kidneys
3
Functions of the Kidney
Functions:
• Waste excretion
• Water level balancing
• Blood pressure
regulation
• Red blood cell
regulation
• Salt Balance
5
Kidney Diseases
 There are various complications that
are associated with kidneys:




Kidney Stones (Nephrolithiasis)
Chronic kidney disease
Acute Renal Failure
Nephrotic syndrome
6
Kidney Stones (Nephrolithiasis)
7
Kidney Stones (Nephrolithiasis)

Nephrolithiasis, or kidney stone, is the
presence of renal calculi caused by a disruption
in the balance between solubility and
precipitation of salts in the urinary tract and
in the kidneys.

The incidence is at peak among males age 20
and 30 years old.

Kidney stones develop when urine becomes
“supersaturated” with insoluble compounds
containing calcium, oxalate, and phosphate
(Han, 2015).
8
Kidney stone formation

The levels of urinary supersaturation of the different
solutes
determine
the
specific types of stones:



Calcium oxalate
Calcium phosphate
Uric acid


Struvite
Cystine
8
Conditions favoring
development of kidney stones

Increased urinary crystalloids

Dehydration

Urine pH

Diet

Medication
10
Medical and nutrition
evaluation of kidney stones

The dietitian should evaluate dietary intakes of
calcium, oxalates, sodium, protein (both
animal and plant), dietary supplements
and fluid intake

Several dietary factors can increase risk of the
stone formation, including sodium, protein,
potassium, calcium, magnesium.

These constituents can be modified depending
on the types of different stone risks.
11
Dietary recommendations to
prevent kidney stones
(Han et al., 2015)
12
Medical Treatment & Prevention
 To reduce the recurrence rate of urinary
stones, dietary modification is important.
 Of greatest importance in reducing stone
recurrence is an increased fluid intake.
Absolute volumes are not established, but
increasing fluid intake to ensure a voided
volume of 1.5-2.0 L/day is recommended.
 Surgical Treatment - In the acute setting,
forced intravenous fluids will not push stones
down the ureter.
13
Acute Renal Failure
14
Acute Renal Failure
 Acute kidney injury (AKI) is defined as a sudden
decrease in kidney function that
compromises the normal regulation of fluid,
electrolyte, and acid-base homeostasis (National
Kidney Foundation Primer on Kidney Diseases
(Sixth Edition), 2014)
 It is characterized by a rapid (hours to weeks)
decline in the glomerular filtration rate (GFR)
and retention of nitrogenous waste products
such as blood urea nitrogen and creatinine.
15
Acute Renal Failure
 It is considered as an acute condition,
potentially reversible with full restitution if
patient survives the acute phase of the disease
(Lombardi et al., 2014)
 Recent epidemiologic and observational studies
underscore the association of an episode of
AKI with long-term adverse outcomes such
as chronic kidney disease, end-stage renal
disease, cardiovascular events, and
premature death (Finlay & Jones, 2017)
16
Acute Renal Failure
 Acute kidney failure can occur as a result
of many complications:
 acute tubular necrosis (ATN)
 severe or sudden dehydration
 toxic kidney injury from poisons or
certain medications
 autoimmune kidney diseases.
17
Treatment of AKI
 Potential opportunities to improve care include
 closer monitoring of kidney function,
 management of CKD complications,
 blood pressure control, (Silver & Siew, 2017).
18
https://nephcure.org/livingwithkidneydiseas
e/diet-and-nutrition/renal-diet/
Nephrotic syndrome
20
Nephrotic syndrome
 In nephrotic syndrome the glomerular
filtration barrier fails to retain
protein leading to proteinuria,
hypoalbuminaemia, hyperlipidemia
and oedema (Liebeskind, 2014;
Zolotas & Krishnan, 2016)
 The majority of the patients are younger
than 6 years of age (80%) and there is
a male predisposition (2:1).
21
Clinical features
 Oedema is the major presenting feature
of NS. It becomes evident when the fluid
retention exceeds 3% of the body
weight.
 Abdominal pain is a frequent symptom
and is suggestive of hypovolaemia
due to visceral vasoconstriction.
22
Causes Nephrotic syndrome
 nephrotic syndrome may develop due to
diabetes, amyloidosis, viral infections,
malaria, pre-eclampsia, systemic lupus
erythematosus, or other disorders that
affect the kidneys.
 Immune complex injury of the glomerulus by
cancer antigens may cause membranous
nephropathy.
 It has also been associated with nonsteroidal
anti-inflammatory drugs, gold, lithium,
mercury, interferon-b-1a, pamidronate,
penicillamine, or heroin use.
23
Management Nephrotic syndrome
 The approach to management of
the nephrotic syndrome is 2-fold:
 Management of proteinuria, edema,
dyslipidemia, and other complications
of the syndrome
 Therapy targeting the individual
patient’s underlying disease process
24
Therapies for the nephrotic syndrome
 Angiotensin-converting enzyme (ACE)
inhibitors and angiotensin-II receptor
blockers (ARBs) for reducing proteinuria and
controlling blood pressure.
 A low-sodium (<2 g/24 hours) diet and
diuretic therapy for control of edema.
 The use of 3-hydroxy-3-methyl-glutaryl
coenzyme A reductase inhibitors (ie,
statins) may be effective in treating the
dyslipidemia.
25
https://nephcure.org/livingwithkidneydisease/
diet-and-nutrition/
Chronic kidney disease (CKD)
27
Chronic kidney disease (CKD)

CKD is defined as a reduced glomerular
filtration rate, increased urinary albumin
excretion, or both, (Jha, 2013)

It’s a condition of decreased kidney function
shown by glomerular filtration rate (GFR) of
less than 60 mL/min per 1·73 m², or markers
of kidney damage, or both, of at least 3 months
duration, (Webster, 2016; McManus & WynterMinnot, 2017).

Prevalence is estimated to be 8–16% worldwide.
28
Chronic kidney disease
stages
(Chawla, et al., 2014)
29
Causes of CKD

CKD may be caused by
 Diabetes,
 Hypertension, Or
 Glomerulonephritis
 CKD is leading cause of hypertension
30
Causes of CKD
 Other problems that can cause kidney
failure include:
 Autoimmune diseases, such as lupus and
IgA nephropathy
 Genetic diseases (diseases you are born
with), such as polycystic kidney disease
 Nephrotic syndrome
Urinary tract problems
(Beto et al., 2014).
31
Chronic kidney disease Symptoms
 Most patients are asymptomatic.
 Some may present with symptoms of
fatigue due to underlying anemia.
 Others may present with nonspecific
nausea, vomiting, and decreased
appetite due to uremia.
 Urine output typically does not change
until kidney failure (stage 5/G5).
32
Diagnosis for CKD
 Diagnoses done using a physical
examination and tests to check kidney
function:




Urinalysis
Serum creatinine test
Blood urea nitrogen test
Estimated glomerular filtration rate
(GFR)
33
Slowing Progression
 Control of diabetes should be aggressive
in early CKD;
 Blood pressure control (Sign, 2013).
 Several studies suggest a possible
benefit of oral bicarbonate therapy in
slowing CKD progression
 Obese patients should lose weight.
 Management of traditional cardiovascular
risk factors
34
Dietary Management
(Beto et al.,2014)
35
Dietary Management
(Beto et al.,2014)
36
Dietary Management
(Beto et al., 2014)
37
Treatment
 Dialysis
 Hemodialysis, which uses a machine to process
your blood.
 peritoneal dialysis, involves using the lining of the
abdomen to filter blood inside the body using a
catheter.
 Kidney transplant: removing your affected
kidneys (if removal is needed) and placing a
functioning donated organ.
38
Conclusion
 Many kidney diseases result in
reduced or loss of kidney function –
affected glomerulus
 Prevention is possible with
administration of specific diet choices
- Lifestyle changes
 Treatment may range from drug use
to minor surgeries, to renal
replacement therapies
39
Foods high and low in sodium
Foods high and low in potassium
Foods high and low in phosphorous
- Inborn errors of metabolism comprise a large class of
genetic diseases involving disorders of metabolism.
- The majority are due to defects of single genes that
code for enzymes that facilitate conversion of various
substances (substrates) into others(products).
- In most of the disorders, problems arise due to
accumulation of substances which are toxic or
interfere with normal function, or to the effects of
reduced ability to synthesize essential compounds.
2
Inborn errors of metabolism are
now often referred to as
congenital metabolic diseases
or inherited metabolic diseases
3
Garrod’s hypothesis
A
B
Cproductdeficiency
substrateexcess
Dtoxic metabolite
4
5
Glycogen storage disease
• Glycogen storage disease (GSD, also glycogenosis
and dextrinosis) is the result of defects in the
processing of glycogen synthesis or breakdown within
muscles, liver, and other cell types. GSD has two classes
of cause:genetic and acquired.
• Genetic GSD is caused by any inborn error of
metabolism (genetically defective enzymes) involved in
these processes.
6
7
• Symptoms:
Hypoglycemia, Hyperlipidemia, Hepatomegaly, Lactic
acidosis, andHyperuricemia.
• Progression: Growthfailure
• Enzyme deficiency: (glucose-6-phosphatase) which is an
enzymethat hydrolyzesglucose-6-phosphate
This deficiency impairs the ability of the liver to produce free
glucose from glycogen and from gluconeogenesis. Since these
are the two principal metabolic mechanisms by which the
liver supplies glucose to the rest of the body during periods of
fasting, it causessevere hypoglycemia.
8
Treatment:
• The essential treatment goal is prevention of hypoglycemia and the
secondary metabolic derangements by frequent feedings of foods
high in glucose or starch (which is readily digested to glucose). To
compensate for the inability of the liver to provide sugar, the total
amount of dietary carbohydrate should approximate the 24-hour
glucose production rate. The diet should contain approximately 6570% carbohydrate, 10-15% protein, and 20-25% fat. At least a
third of the carbohydrates should be supplied through the night, so that
a young child goes no more than 3–4 hours without carbohydrate
intake
• Two methods have been used to achieve this goal in young children:
(1) continuous nocturnal gastric infusion of glucose or starch; and (2)
night-time feedings of uncooked cornstarch.
9
11
• (PKU) is an autosomal recessive metabolic genetic disorder
characterized by a deficiency in the hepatic enzyme
phenylalanine hydroxylase (PAH). This enzyme is necessary to
metabolize the phenylalanine (Phe) to the tyrosine. When PAH is
deficient, phenylalanine accumulates and is converted into
phenylpyruvate, which is detected in the urine.
• It can cause problems with brain development, leading to
progressive mental retardation, brain damage, and seizures.
• Optimal treatment involves lowering blood (Phe) levels to a safe
range and monitoring diet and cognitive development.
• PKUis normally detected using the HPLCtest after birth.
12
Signs and Symptoms:
• the disease may present clinically with seizures, albinism (excessively
fair hair and skin), and a "musty odor" to the baby's sweat and urine
(due to phenylacetate, one of the ketones produced).
• Treatment: by managing and controlling (Phe) levels through diet, or
a combination of diet and medication.
• All PKU patients must adhere to a special diet low in phenylalanine for
at least the first 16 years of their lives. This requires severely
restricting or eliminating foods high in phenylalanine, such as meat,
chicken, fish, eggs, nuts, cheese, legumes, cow milk and other dairy
products. Starchy foods such as potatoes, bread, pasta, and corn must
be monitored.
• Infants require a commercial formula of milk that free from (Phe).
14
• Tyrosine, which is normally derived from phenylalanine, must be
supplemented.
• The sweetener of aspartame must be avoided, as aspartame
consistsof two amino acids: phenylalanine and aspartic acid.
• The oral administration of tetrahydrobiopterin (or BH4) (a
cofactor for the oxidation of phenylalanine) can reduce blood
levels of this amino acid in certain patients.
• For childhood, we can add some fruits and vegetables the low in
(Phe)which provide essential vitamins and minerals.
15
16
• Also called branched-chain ketoaciduria, is an autosomal recessive
metabolic disorder affecting branched-chain amino acids. It is one
type of organic acidemia.
• MSUD is caused by a deficiency of the branched-chain alpha-keto
acid dehydrogenase complex (BCKDH), leading to a buildup of the
branched-chain amino acids (leucine, isoleucine, and valine) and their
toxic by-products in the blood and urine.
• The disease is characterized in an infant by the presence of sweetsmelling urine, with an odor similar to that of maple syrup. Infants with
this disease seem healthy at birth but if left untreated suffer severe
brain damage and eventually die.
• From early infancy, symptoms of the condition include poor feeding,
vomiting,
dehydration, lethargy, seizures, hypoglycaemia,
ketoacidosis, pancreatitis, coma and neurological decline.
17
Management:
• Keeping MSUD under control requires careful monitoring of
blood chemistry and involves both a special diet and frequent
testing.
• A diet with minimal levels of the amino acids leucine, isoleucine,
and valine must be maintained in order to prevent neurological
damage. As these three amino acids are required for proper
metabolic function in all people, specialized protein
preparations containing substitutes and adjusted levels of the
amino acids have been synthesized and tested, allowing MSUD
patients to meet normal nutritional requirements without causing
harm.
18
Leucine (Food)
Soybeans
Lentils
Cowpea ‫ايبولال‬
Beef (lean and trimmed)
Peanuts
Salmon fish
Shrimp
Nuts
Eggs
Isoleucine (Food)
Eggs
Soy protein
Seeweed
Milk
Cheese
Sesame seeds
Sunflower seeds
Cod liver
Valine (Food)
Closed to Isoleucine sources
19
20
• Medium-chain acyl-coenzyme A dehydrogenase deficiency
(MCADD) is a fatty acid oxidation disorder associated with
inborn errors of metabolism. It is due to defects in the enzyme
complex known as medium-chain acyl dehydrogenase (MCAD) and
reduced activity of this complex. This complex oxidizes medium
chain fatty acids (Fatty acids having 6-12 carbons) while
reducing FADto FADH2.
• It is recognized as one of the more rare causes of suddeninfant
death syndrome (SIDS).
21
Treatment:
• There is no cure for MCADD, but once diagnosed, adverse effects can
be prevented by proper management.
• The most important part of treatment is to ensure that patients never
go without food for longer than 10–12 hours(overnight fast).
• Patients with an illness causing loss of appetite or severe vomiting may
need IV glucose to make sure that the body is not dependent on fatty
acids for energy. Patients also usually adhere to a low-fat diet.
• Patients may also take daily doses of carnitine, which helps reduce
toxic accumulation of fatty acids by forming acyl carnitines, which are
excreted in the urine.
• Severity of symptoms seems to decrease after puberty.
22
Part-II
• Galactosemia is an inherited disorder characterized by
an inability of the body to utilize galactose.
• Galactosemia means "galactose in the blood".
• The main source of galactose in the diet is milk products.
• The deficient enzyme that is responsible of galactosemia
is called galactose-1-phosphate uridyl transferase
(GALT). The GALT enzyme enables the body to break
down galactose into glucose for energy.
• Galactosemia is treated by removing foods that contain
galactose from the diet. Untreated galactosemia will
result in a harmful build-up of galactose and galactose-1phosphate in the bloodstream and body tissues.
24
• Infants with unrecognized galactosemia usually have
problems with feeding and do not grow as they should.
• If galactosemia is not treated, infants can develop
cataracts, liver disease, kidney problems, brain damage,
and in some cases, can lead to death.
Diet:
• The diet should allow most protein-containing foods other
than milk and milk products.
• Lactose is often used as a filler or inactive ingredient in
medicines, and might not be listed on the package.
25
Some foods contain galactose and are unacceptable:
Butter
Calcium caseinate
Nonfat milk
Dry milk and milk protein
Hydrolyzed protein made from casein
Lactalbumin (milk albuminate)
Milk and milk solids
Nonfat dry milk & solids
Organ meats (liver, heart, etc.)
Sodium caseinate
Whey ‫نبلاللصم‬and whey solids
Buttermilk and solids
Casein
Cream
beans
Ice cream
Lactose
Milk chocolate
Cheese
Sherbet
Sour cream
Yogurt
• Sherbet: Traditional cold drink prepared of species of cherries,
rose, licorice or Hibiscus with diary products.
26
• Foods with more than 10 mg Galactose/100 gram of food:
Tomato
Date
Papaya
Bell Pepper
Watermelon
23
11
29
10
15
• Foods with 5-10 mg Galactose/100 gram of food:
• Apricot, Avocado, Cabbage, Cantaloupe, Cauliflower, Celery, Sweet corn,
Cucumber, Eggplant, Green grapes, Grapefruit, Kale, Lettuce, Oranges,
Peas, White potato, Radish Spinach, Turnip ,Apple ,Banana ,Broccoli Carrot,
Kiwi, Green onion, Yellow onion, Pears, Sweet potato, Pumpkin.
27
Nutrition in fitness
Supriya Bhattarai
MSc Nutrition and Dietetics
19/06/2020
1
Energy production
• The human body must be supplied continuously with energy to perform its
many complex functions.
• So is the case with exercise, where the energy demands increase with
exercise.
• Two metabolic system supply energy for the body: aerobic metabolism
• Anaerobic metabolism
• Aerobic metabolism
• The body obtains its energy in the form of ATP. The energy produced from
the breakdown of ATP provides fuel that activates muscle contraction.
• Stored in limited amounts hence has to be resynthesized for constant energy
during exercise.
2
Resynthesizing ATP
• When ATP loses a phosphate, thus releasing energy the resulting adenosine
di phosphate is enzymatically combined with another high energy
phosphate from creatine phosphate to resynthesize ATP.
• The total amount of CP and ATP stored in muscles is small, so there is
limited energy available for muscular contraction. It is, however,
instantaneously available and is essential at the onset of activity, as well as
during short-term high-intensity activities lasting about 1 to 30 seconds in
duration, such as sprinting, weight-lifting or throwing a ball.
• Anaerobic glycolysis : Anaerobic glycolysis does not require oxygen and
uses the energy contained in glucose for the formation of ATP. This pathway
occurs within the cytoplasm and breaks glucose down into a simpler
component called pyruvate. As an intermediate pathway between the
phosphagen and aerobic system, anaerobic glycolysis can produce ATP
quite rapidly for use during activities requiring large bursts of energy over
somewhat longer periods of time.
3
• Aerobic glycolysis: This pathway requires oxygen to produce ATP,
because carbohydrates and fats are only burned in the presence of
oxygen. This pathway occurs in the mitochondria of the cell and is
used for activities requiring sustained energy production. Aerobic
glycolysis has a slow rate of ATP production and is predominantly
utilized during longer-duration, lower-intensity activities after the
phosphagen and anaerobic systems have fatigued.
4
5
Relationship between diet and exercise
Diet
Exercise
6
Fuels for contracting muscles
• Protein , fat and carbohydrate are all possible sources of fuel for muscle
contraction.
• However the intensity and duration of the exercise determine the relative
rates of substrate ion.
• Intensity : high energy short duration exercise has to rely on anaerobic
production of ATP. As oxygen is not available for anaerobic pathways, only
glucose and glycogen can be broken down anaerobically.
• Moderate to low intensity exercise as casual walk, a stretch session, a
beginners' yoga class or tai chi, bike riding etc approximately half the
energy comes from aerobic breakdown of muscle glycogen and the other
half comes from circulating blood glucose and fatty acids.
7
• Duration : the longer the exercise gets the greater the contribution of
fat as the fuel. Fat can supply upto 60- 70% of the energy needed for
ultra – endurance events lasting 6- 10 hours. Because as the duration
of exercise increases , the reliance on aerobic metabolism becomes
greater and a greater amount of ATP can be produced from fatty acids.
8
9
10
Dietary guidelines for athletes
• The primary goal of the training diet is to provide nutritional support
to allow the athlete to stay healthy and injury-free while maximizing
the functional and metabolic adaptations to a periodized exercise
program that prepares him or her to better achieve the performance
demands of their event. While some nutrition strategies allow the
athlete to train hard and recover quickly, others may target an
enhanced training stimulus or adaptation.
• Body carbohydrate stores provide an important fuel source for the
brain and muscle during exercise, and are manipulated by exercise and
dietary intake. Recommendations for carbohydrate intake typically
range from 3–10 g/kg BW/d (and up to 12 g/kg BW/d for extreme and
prolonged activities), depending on the fuel demands of training or
competition, the balance between performance and training adaptation
goals, the athletes total energy requirements and body composition
goals.
11
• Recommendations for protein intake typically range from 1.2–2.0 g/kg BW/d, but
have more recently been ex- pressed in terms of the regular spacing of intakes of
modest amounts of high quality protein (0.3 g/kg body weight) after exercise and
throughout the day. Such in- takes can generally be met from food sources.
Adequate energy is needed to optimize protein metabolism, and when energy
availability is reduced (eg, to reduce body weight/fat), higher protein intakes are
needed to support the retention of fat-free mass.
• For most athletes, fat intakes associated with eating styles that accommodate
dietary goals typically range from 20%– 35% of total energy intake. Consuming
20% of energy intake from fat does not benefit performance and extreme
restriction of fat intake may limit the food range needed to meet overall health and
performance goals. Claims that extremely high-fat, carbohydrate-restricted diets
provide a benefit to the performance of competitive athletes are not supported by
current literature.
• Athletes should consume diets that provide at least the Recommended Dietary
Allowance (RDA)/Adequate Intake (AI) for all micronutrients. Athletes who
restrict energy intake or use severe weight-loss practices, eliminate com- plete
food groups from their diet, or follow other extreme dietary philosophies are at
greatest risk of micronutrient deficiencies.
12
• A primary goal of competition nutrition is to address nutrition-related factors that may limit performance by
causing fatigue and a deterioration in skill or concentration over the course of the event. For example, in
events that are dependent on muscle carbohydrate availability, meals eaten in the day(s) leading up to an event
should provide sufficient carbohydrate to achieve glycogen stores that are commensurate with the fuel needs
of the event. a carbohydrate-rich diet (7–12 g/kg BW/d) can normalize muscle glycogen levels within ~ 24
hours, while extending this to 48 hours can achieve glycogen super-compensation.
• Foods and fluids consumed in the 1–4 hours prior to an event should contribute to body carbohydrate stores
(particularly, in the case of early morning events to re- store liver glycogen after the overnight fast), ensure appropriate hydration status and maintain gastrointestinal comfort throughout the event. The type, timing and
amount of foods and fluids included in this pre-event meal and/or snack should be well trialed and
individualized according to the preferences, tolerance, and experiences of each athlete.
• Dehydration/hypohydration can increase the perception of effort and impair exercise performance; thus,
appropriate fluid intake before, during, and after exercise is important for health and optimal performance.
The goal of drinking during exercise is to address sweat losses which occur to assist thermoregulation.
Individualized fluid plans should be developed to use the opportunities to drink during a workout or
competitive event to replace as much of the sweat loss as is practical; neither drinking in excess of sweat rate
nor allowing dehydration to reach problematic levels. After exercise, the athlete should restore fluid balance
by drinking a volume of fluid that is equivalent to ~125–150% of the remaining fluid deficit (eg, 1.25–1.5 L
fluid for every 1 kg BW lost).
13
• In general, vitamin and mineral supplements are unnecessary for the athlete who
consumes a diet providing high- energy availability from a variety of nutrientdense foods. A multivitamin/mineral supplement may be appropriate in some cases
when these conditions do not exist; for example, if an athlete is following an
energy-restricted diet or is unwilling or unable to consume sufficient dietary
variety. Supple- mentation recommendations should be individualized, realizing
that targeted supplementation may be indicated to treat or prevent deficiency (eg,
iron, vitamin D, etc.).
• Athletes should be counseled regarding the appropriate use of sports foods and
nutritional ergogenic aids. Such products should only be used after careful
evaluation for safety, efficacy, potency and compliance with relevant anti-doping
codes and legal requirements.
• Vegetarian athletes may be at risk for low intakes of energy, protein, fat, creatine,
carnosine, n-3 fatty acids, and key micronutrients such as iron, calcium, riboflavin,
zinc, and vitamin B-12.
14
Thank you
15
Eating disorders
Supriya Bhattarai
MSc Nutrition and Dietetics/ Sports
01/07/2018
1
Eating disorders
• Eating disorders are debilitating psychiatric illnesses characterized by
a persistent disturbance of eating habits or weight control behaviors
that result in significantly impaired physical health and psychosocial
functioning.
• Types : Anorexia Nervosa ◦ Restriction of energy intake leading to
low body weight that is expected for age. Body Image Disturbance .
• Bulimia Nervosa ◦ Recurrent binge episodes and compensatory
behaviors that are meant to prevent weight gain.
• Binge Eating Disorder ◦ Recurring episodes of eating large amounts
of food, with feelings of loss of control.
Anorexia Nervosa
• The diagnostic and statistical manual of mental disorders defines AN as
“refusal to maintain body weight at or above a minimally normal
weight for age and height”.
• Patients with AN have body image distortion causing them to feel fat
despite their often cachectic state. Some feel over weight all over while
others are overly concerned about the fatness of a specific part of the body.
• Amenorrhoea defines as the absence of at least three consecutive cycles in
postmenarcheal women is a diagnostic feature.
• Psychologial features associated are compulsivity, perfectionism, feeling of
ineffectiveness, restrained emotions. Other psychological state associated
are depression, Obsessive compulsive disorder, substance abuse , anxiety
etc.
• Two types: Restricting: restricting food without episode of binge eating or
purging.
• Binge eating and purging: regular episode of binge eating and purging .
• According to the DSM-5 criteria, to be diagnosed as having Anorexia
Nervosa a person must display:
• Persistent restriction of energy intake leading to significantly low body
weight (in context of what is minimally expected for age, sex,
developmental trajectory, and physical health) .
• Either an intense fear of gaining weight or of becoming fat, or
persistent behavior that interferes with weight gain (even though
significantly low weight).
• Disturbance in the way one's body weight or shape is experienced,
undue influence of body shape and weight on self-evaluation, or
persistent lack of recognition of the seriousness of the current low
body weight.
• Amenorrhoea
Nutritional rehabilitation
•
•
•
•
Nutritional assessment
Medical nutrition therapy
Counselling
Education
• Diet history
• Patients with restricting subtype of AN
consume less than 1000 kcal/ day .
• Tendency to restrict carbohydrate and fat
containing foods.
• Chaotic diet patterns of purging and binging
types.
• Vegetarianism
• Do not meet the requirement of vitamins and
minerals especially fat soluble vitamins and
minerals such as calcium, magnesium, copper
and zinc.
• Abnormalities in fluid intake
• Consumption of excessive amounts of
artificial sweeteners and beverages.
Eating behaviors
• Food aversions
• Unusual and ritualistic behaviors
• Meal spacing and self allotted food
ration
• Time limits on eating
Important biochemical and
nutritional characterstics
• Cachexia
• High cholesterol levels
• Low t3 syndrome
• Hypercarotenemia
• Riboflavin, vitamin B6, thiamin,
niacin, folate and Vitamin E along
with Vitamin B12.
• Decreased iron requirements
• Zinc deficiency
• Deficiency of calcium, magnesium
and vitamin D.
• Dehydration, hypokalemia,
hyponatremia.
• Reduced REE.
Medical nutrition therapy
• Calorie prescription : initial weight gain
• Assess risk of refeeding syndrome
• Controlled weight gain phase
• Weight maintainence phase
• Protein: 15- 20 % of Total energy ( high biological sources)
• Carbohydrate: 50- 55 % of total energy ( insoluble fibers)
• Fat : 30 % of total energy
• Micronutrients: supplements
• Do not supplement iron
• Determine the need of thiamin supplement during weight restoration.
Bulimia Nervosa
• Bulimia nervosa is a disorder characterized by recurrent episodes of binge
eating followed by one or more inappropriate compensatory behaviors to
prevent weight gain. The compensatory behaviors are self- induced
vomiting, laxative use, diuretic misuse, compulsive exercise or fasting.
• They are typically within normal weight.
• Binge is a characteristics feature which is defined as consumption of large
amount of food in a discrete period.
• Types : purging: engage into self induced vomiting after binges
• Non – purging : rather fast or exercise excessively than indulge into
purging behavior.
• Emotional states: labile mood, frustration, anxiety, depression, substance
abuse, self injurious behaviors.
• Unlike AN the patients with bulimia are aware about their habit and
condition and its easier for them to change it through assistance.
• According to the DSM-5 criteria, to be diagnosed as having Bulimia
Nervosa a person must display:
• Recurrent episodes of binge eating. An episode of binge eating is
characterised by both of the following:
• Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food
that is definitely larger than most people would eat during a similar period of time and
under similar circumstances.
• A sense of lack of control over eating during the episode (e.g. a feeling that one
cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behaviour in order to prevent weight
gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other
medications, fasting, or excessive exercise.
• The binge eating and inappropriate compensatory behaviours both occur, on
average, at least once a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
Clinical features
Nutritional rehabilitation
• Nutritional assessment
• Medical nutrition therapy
• Counselling
• Education
• Diet history : chaotic eating
• Daily food intake determination
is required.
• Eating behaviors: eating quickly
• Fear of food that trigger the
binge.
• Avoidance of food
Important biochemical and nutritional
characteristics
• Abnormal lipid levels
• Hypokalemia, dehydration, hyponatremia
• Unpredictable metabolic rates.
Medical nutrition therapy
• Calorie prescription : check whether the patient is hypo or
hypermetabolic state.
• Avoid weight reduction diets until eating patterns are stabilized.
• Protein: 15- 20 % of Total energy ( high biological value proteins)
• Carbohydrate: 50- 55 % of total energy (insoluble fiber for
constipation)
• Fat : 30 % of total energy
• Micronutrients: supplements
Nutrition counselling
• Pre contemplation
• Contemplation
• Preparation
• Action
• Maintenance and relapse
Nutrition education
• Topics : healthy and balanced eating
• Impact of malnourishment on adolescent growth and development
• Body image perception
• Cause of binging and its triggers
• Exercise and energy balance
• Hunger cues
• Ineffectiveness of use of laxative
• Portion control
• reading food labels
Other similar disorders: Binge eating disorder
• According to the DSM-5 criteria, to be diagnosed as having Binge Eating
Disorder a person must display:
• Recurrent episodes of binge eating.
• Binge eating occurs, on average, at least once a week for three months
• Binge eating not associated with the recurrent use of inappropriate
compensatory behaviours as in Bulimia Nervosa and does not occur
exclusively during the course of Bulimia Nervosa, or Anorexia Nervosa
methods to compensate for overeating, such as self-induced vomiting.
• Note: Binge Eating Disorder is less common but much more severe than
overeating. Binge Eating Disorder is associated with more subjective
distress regarding the eating behaviour, and commonly other co-occurring
psychological problems.
Pica
• According to the DSM-5 criteria, to be diagnosed with Pica a person must
display:
• Persistent eating of non-nutritive substances for a period of at least one
month.
• The eating of non-nutritive substances is inappropriate to the developmental
level of the individual.
• The eating behaviour is not part of a culturally supported or socially
normative practice.
• If occurring in the presence of another mental disorder (e.g. autistic
spectrum disorder), or during a medical condition (e.g. pregnancy), it is
severe enough to warrant independent clinical attention.
• Note: Pica often occurs with other mental health disorders associated with
impaired functioning.
Other condition
• Female athletic triad: is a syndrome in which eating disorders (or low
energy availability),amenorrhoea /oligomenorrhoea, and decreased bone
mineral density (osteoporosis and osteopenia) are present.
• this condition is seen in females participating in sports that emphasize
leanness or low body weight.
• Gymnastics, figure skating, ballet, diving, swimming, and long distance
running are examples of sports which emphasize low body weight.
• Baryphobia :
The unreasonable fear that one's child will become obese. The allowed diet
may be insufficient to support the child's growth and development needs.
Thank you
Nutrition in weight
management
Supriya Bhattarai
MSc Nutrition and Dietetics
08/05/2020
Body weight components
• Body weight is the sum of bone, muscle, organ, body fluids and
adipose tissue.
• It is divided into components: fat mass- the fat from all the body
sources including the brain, skeleton, and adipose tissue.
• Fat free mass- includes water , protein, and mineral components.
• Lean body mass is muscle.
• Body fat: essential fat- fat necessary for normal physiological
conditions and is stored in small amounts in the bone marrow, heart,
lungs, liver, spleen kidneys, muscles and the nervous system.
• Storage fat: it is the energy reserve primarily as TG.
• Adipose tissue: located primarily under the skin, in the mesentries, and
omentum and behind the peritoneum.
• White adipose tissue: stores energy as a repository for TGs , serves as
a cushion to protect the abdominal organ and insulates the body to
preserve the heat.
• Brown adipose tissue: rapid source of energy for infants, usually found
in scapular and sub scapular region.
• By adulthood BAT decreases in amount although its prevalence is still
there in the upper chest and neck area.
• adipocyte consists of large central lipid droplet surrounded by a thin
rim of cytoplasm which contains nucleus and the mitochondria. Gains
in weight occurs by increasing the number of cells, the size of cells or
both.
Regulation of body weight
Obesity
• Overweight occurs as a result of an imbalance between food consumed and
physical activity.
• Obesity is a complex issue related to lifestyle, environment, and genes.
• United states has the highest prevalence of obesity among the developed nations.
• However It has been observed throughout the world. The trend being called as
“globesity”.
• Overweight and obesity are defined as abnormal or excessive fat accumulation
that presents a risk to health. A crude population measure of obesity is the body
mass index (BMI). A person with a BMI of 30 or more is generally considered
obese. A person with a BMI equal to or more than 25 is considered overweight.
• Overweight and obesity are major risk factors for a number of chronic diseases,
including diabetes, cardiovascular diseases and cancer. Once considered a problem
only in high income countries, overweight and obesity are now dramatically on the
rise in low- and middle-income countries, particularly in urban settings.
Causes ( Nature VS nurture)
• Genetics
• The number and size of fat cells, regional distribution of body fat, and
RMR are influenced by genes.
• Ob gene, the adiponectin gene, FTO gene, and β3 – adrenoreceptor
gene.
• Mutations in Ob gene and adiponectin gene result in obesity or
metabolic syndrome if the diet is rich in saturated fat.
• β3 – adrenoreceptor regulates RMR and fat oxidation in humans.
• Nutritional and lifestyle choices can activate or deactivate those
obesity triggering genes.
• Taste , satiety and portion sizes
• Food and its taste elements evoke pleasure responses. The endless
variety of food available at any time at a reasonable cost can
contribute to a higher calorie intake.
• Overriding Sensory – specific satiety.
• Excessive portion sizes
• Inadequate physical activity: sedentary lifestyle along with chronic
overeating causes weight gain.
• Fewer people are exercising, more time is being spent in low- energy screen
involving activities .
• Sleep stress and circadian rhythms
• Shortened sleep alters the endocrine regulation of hunger and appetite.
Hormones that alter appetite take over and may promote excessive energy
intake.
• Work shift, exposure to bright light at night disrupts the circadian rhythm
hence enhancing adiposity.
• Stress releases cortisol, that stimulates insulin release to maintain glucose
level.
Obesogenes
• They are chemical compounds foreign to the body that act to disrupt
the normal metabolism of lipids, ultimately resulting in over fatness
and obesity.
• Example: bisphenol A and Phthalates which are found in many plastics
used in food packaging that migrate into foods processed or stored in
them .
• glyphosphate ( potent herbicide)
Assessment
• Body Mass Index: weight in KG divided by height in meter square.
• Waist circumference and waist to hip ratio .
Medical complications of obesity
Management of obesity in adults
•
•
•
•
•
•
•
•
•
Pharmaceutical management
Sibutramine
Orlistat
Bupropin
Others
• Surgical therapy: bariatric surgeries
Gastric bypass
Gastroplasty
Gastric banding
Liposuction
Dietary management of obesity
• A drastic reduction in calories results in high rate of loss of both
protein and fat.
• Steady weight loss over a longer period favors the reduction of fat and
limits the loss of vital proteins .
• Hence the weight reduction goals must be slow and individualized.
• Likewise the weight loss program must combine nutritionally balanced
dietary regimen with exercise and lifestyle modification.
• Restricted energy diets
• Nutritionally adequate except for energy which is decreased to the
point that fat gets mobilized to meet the energy needs.
• Normal proportions of the macronutrients along with fiber .
• Formula diets: commercially made meal replacers.
• Extreme energy restriction and fasting: provide diet fewer than
800kcals.
• Others: commercial programs, famous diet practices such as atkins
diet, detox diets and many more ( Assignment)
Physical activity
• 60- 90 minutes daily , at least 30 minutes of moderate intensity
exercise.
• Both aerobic and resistance training should be recommended.
Weight management in children
• Childhood obesity is a very commonly seen in urban set-up. It
increases the risk of being an obese adult.
• Goals: achieve healthy and balanced eating practices
• Nutrition education programs should be incorporated in schools
• Motivation from friends and parents
• Involving children in daily chores so that they are physically active
Excessive leanness and unintentional weight
loss
Causes
• Inadequate oral and beverage intake
• Excessive physical activity
• Inadequate capacity for absorption and metabolism of foods
consumed.
• A diseased condition
• Excessive energy expenditure during psychological or emotional
stress.
Dietary management
• High energy diets:
• Appetite enhancers: corticosteroids , cyproheptadine, loxiglumide.
Mirtazapime and many more.
10 marks assignment
• Write a pager about different types of diet that has been in the market .
• Its benefits and consequences
• Why is it famous
• What is your take on the very specific diet
•
•
•
•
•
•
•
eg: intermittent fasting
ornish diet
atkins diet
eggeterian diet
meditterrean diet
paleo diet
detox diet .................... and many more
Thank you
Introduction
A functional food is a food given an
additional function.
"Functional Food is a Natural or processed food
that contains known biologically-active
compounds which when in defined quantitative
and qualitative amounts provides a clinically
proven and documented health benefit.
Functional foods includes processed food or foods
fortified with health-promoting additives, like
"vitamin-enriched" products.
Functional foods as
nutraceuticals
 Nutraceuticals are functional foods which d0nt only
provide mere health benefits but helps in effective
prevention and treatment of different diseases.
 Nutraceuticals have been claimed to have a
physiological benefit or provide protection against the
following diseases:Cardiovascular agents
Antiobese agents
Antidiabetics
Anticancer agents
Immune boosters
Chronic inflammatory disorders
Degenerative diseases
Concept of functional foods
The “functional food” concept was developed in
Japan at the early 1980s and as “food for
specified health use (FOSHU)” was established in
1991.
Defined as “any food or ingredient that has a
positive impact on an individual’s health, physical
performance, or state of mind, in addition to its
nutritive value”.
Should be naturally occurring, can be consumed
as part of the daily diet, and when ingested
should enhance or regulate a particular biological
process or mechanism to prevent or control
specific diseases.
Concept of Nutraceutical foods
Dr Stephen DeFelice, founder and chairman of the
Foundation for Innovation in Medicine located in
Cranford, New Jersey, coined the term
"Nutraceutical“ from "Nutrition" and
"Pharmaceutical" in 1989,
defined as ‘a food or part of food, that provides
medical or health benefits, including the
prevention and treatment of disease.
Nutraceuticals are natural bioactive, chemical
compounds that have health promoting, disease
preventing or medicinal properties.
components that not only maintain, support,
and normalize any physiological or metabolic
function, but can also potentiate, antagonize, or
otherwise modify physiological or metabolic
functions.
non-specific biological therapies, used to promote
wellness, prevent malignant processes and
control symptoms.
Cereals as functional food
In recent years, cereals and
their ingredients are accepted
as functional foods as they
provide dietary fibre, proteins,
energy, vitamins, minerals,
antioxidants etc.
Most common cereal based
functional foods and
nutraceuticals: wheat, barley,
buckwheat, oat, brown rice
The outer bran layer of cereals is rich in B
vitamins and phytonutrients such as flavonoids
and indoles, along with a small amount of protein.
The endosperm is predominantly carbohydrate,
and the germ layer is concentrated with minerals
such as iron and zinc, along with the antioxidant
vitamin E.
Preventing cancer and CVDs, reducing tumour
incidence, reducing blood pressure, risk of heart
disease, cholesterol and fat absorption rate,
delaying gastric emptying, providing
gastrointestinal health- protective effects of
cereals.
Buckwheat
Cholesterol reducing effects, antihypertension
effects, improve constipation and obesity
conditions
Approved as antihaemorrhagic and
hypotensive drug
Used against circulatory disorders, and as
vasculoprotector, known to have antiinflammatory properties
Antioxidative properties
Legumes as functional foods
Pulses and legumes have been
recognized as part of functional
foods.
Pulses are the main source of
protein and besides these, it is
also good sources of vitamins,
minerals, omega-3 fatty acids
and dietary fibre or non-starch
polysaccharides (NSP).
contain non-nutrient bioactive
phytochemicals that have
health-promoting and diseasepreventing properties.
Non nutritive compounds
in legumes are non-starch
polysaccharides (NSP),
phytosterols, saponins,
isoflavones, a class of
phytoestrogens, phenolic
compounds and
antioxidants such as
tocopherols and
flavonoids.
demand for bean products is growing because of
the
presence of several health-promoting
compounds in edible
bean products
known as saponins which are naturally occurring
compounds widely distributed in all cells of
legume plants
saponins have the ability to:
 Help protect the human body against cancers
 Lower cholesterol
 Lower blood glucose responses
Soybeans
In 1999, FDA approved a health claim for the
cholesterol-lowering properties of soy protein.
American Heart Association (AHA) recommended
that patients with elevated cholesterol should
include soy protein foods in their diets.
Soy has phytoestrogens called isoflavones.
Soy isoflavones are believed to play a role in
prostate cancer, where supplementation with
isoflavones has shown a reduction in prostate
cancer risk in studies.
Soy isoflavones, and possibly soy proteins as well,
are believed to play a role in bone health.
There is also the biologically active non-isoflavone
component of soy that has received much
attention in past years– soy protein.
The protein part is believed to be responsible for
the additional benefits seen from soy
consumption, which are:
 Cholesterol-lowering effects
 Blood pressure-lowering effects
 Reduction of cancer risks
 Favorable effects on kidney function
Vegetables as functional food
Vegetables are rich in fiber, vitamins,
minerals, carotene, pigments, flavonoids, all
of which are important for maintaining our
health and prevention and/or treatment of
various diseases.
Low in calorific value, yet rich in vital
components
Tomatoes
Lycopene is the pigment principally responsible for
the deep-red color of ripe tomato fruits and tomato
products.
Consumption of tomatoes and tomato products
containing lycopene have been shown to be
associated with decreased risk of chronic diseases
like cancer and cardiovascular diseases in several
studies.
Tomato paste and other processed tomato products
are even more effective than fresh tomatoes in
preventing prostate cancer.
This is because processing converts much of the
trans-form of lycopene found in fresh tomatoes into
the cis-form, which is much more readily taken up
The evidence suggests that the anti-proliferative
properties of lycopene may extend it’s effects to
other types of cancer, beyond just that of prostate
cancer, preventing heart disease, inhibits
cholesterol synthesis and enhances the
breakdown of the bad cholesterol, low-density
lipoprotein (LDL).
Fruits as functional foods
Fruits are nature’s wonderful gift to mankind;
indeed, medicines packed with vitamins, minerals,
anti-oxidants and many phyto-nutrients.
Fruits are low in calories and fat and provide
plenty of soluble dietary fibers which
consequently helps in prevention of chronic
diseases like obesity, diabetes, CVDs,hypertension
etc.
Fruits contain many anti-oxidants like polyphenolic flavonoids, vitamin-C, and
anthocyanin offer protection against aging,
infections and some diseases like Alzheimer's
disease, colon cancers, weak bones
Mango
Mango fruit is rich in pre-biotic dietary fiber, vitamins,
minerals, and poly-phenolic flavonoid antioxidant
compounds.
Mango fruit is an excellent source of VitaminA,vitamin-B6 (pyridoxine), vitamin-C and vitaminE and flavonoids like beta-carotene, alphacarotene, andbeta-cryptoxanthin.
Consumption of mango is essential for maintenance of
healthy skin, healthy vision, prevention of CVDs and
cancer.
Fresh mango is a rich source of potassium which is an
important component of cell and body fluids that helps
controlling heart rate and blood pressure.
Probiotics as functional
food
Probiotics which means for life in Greek, is one of the
approach to inhibit harmful m/os in our body and is
widely used as functional foods.
Probiotic approach involves the consumption of live
bacterial cells mainly lactic acid producing
bacteria(Lactobacillus or Bifidobacterium genera ) in
foods or dietary supplements.
Probiotic yoghurt are known to exert +ve response
towards lactose-intolerant people.
Probiotics are known to exerts many health benefits
beyond inherent general nutrition. Some of them are
: lowering of blood pressure
Lowering
weringof
ofblood
bloodlipid(obesity
lipid(obesity,, CVDs
CVDs etc).
etc).
Lo
 Lowering of blood lipid(obesity , CVDs etc).
Increases calcium
calcium absorption
absorption from
from the
the intestine.
Increases
 Increases calcium absorption from the intestine.
Lowering of
of harmful
harmful enzyme
enzyme activities
activities of
of colonic
colonic bacteria.
Lowering
 Lowering of harmful enzyme activities of colonic bacteria.
bacteria.
Decreases carcinogenecity.
 Decreases carcinogenicity.
 Decreases carcinogenicity.
Functional food and
fortification
Foods are fortified and enriched with different
essential ingredients to make it functionally
bioactive for promoting health status of
consumer
Products considered functional generally do
not include products where fortification has
been done to meet government regulations
and the change is not recorded on the label as
a significant addition ("invisible fortification").
Some of the fortified food used as functional
food and their health benefits :-
Juices with calcium reduces risk of osteoporosis and
reduces hypertension
 Grains with folic acid reduces risk of heart disease and
neural tube birth defects.
 Infant formulas with iron reduces risk of iron deficiency.
 Grains with added fiber reduces risk of certain cancers
and heart disease; reduces cholesterol and constipation;
increases blood-glucose control
 Juices with added fiber reduces risk of certain cancers
and heart disease; reduces cholesterol, hypertension,
and constipation.
 Foods containing sugar alcohols in place of sugar reduces
risk of tooth decay.

Conclusion
Functional food offers great potential to improve
health and/or help prevent certain diseases when
taken as part of balanced diet and healthy
lifestyle.
Thus, a functional food for one consumer can act
as a nutraceutical for another consumer.
Many food pdts containing components with
health benefits are being incorporated with many
other beneficial components for desirable
physiological change.
Functional foods are on peak demands due to
increasing consumer awareness for healthy
living, ageing population, increasing health
care cost, advancing scientific evidence that
diet can affect on prevalence and progression
of disease.
Although the dangerous effects of many foods
like soy, honey mustn’t be overlooked;
nutraceuticals and functional foods should be
taken under proper supervision of nutritionist
or other medical assistant if possible.
Anti-nutritional factors and toxins in
food
Anti-nutritional factors
 Compounds or substances which act to reduce
nutrient intake, digestion, absorption and utilization
and may produce other adverse effects are referred
to as anti-nutrients or anti-nutritional factors.

Secondary plant metabolites, also referred to as
anti-nutritional factors (ANFs), cause depressions in
growth performance and animal health due to a
variety of mechanisms including reducing protein
digestibility, binding to various nutrients or damaging
the intestinal wall, thereby lowering digestive
efficiency
Anti-nutritives can also cause
toxic effects by
 causing nutritional deficiencies.

interference with the functioning and
utilization of nutrients.
Antinutritives can interfere with food
components before intake, during digestion in
the gastrointestinal tract, and after absorption
in the body
Type of Antinutritives
1.type A: substances primarily interfering with the
digestion of proteins or the absorption and utilization of
amino acids antiproteins
2.type B: substances interfering with the absorption or
metabolic utilization of minerals  antiminerals
3.type C: substances that inactivate or destroy vitamins or
otherwise increase the need for vitamins  antivitamins
Antiproteins
 Protease inhibitor 
proteins which inhibit proteolytic
enzymes by binding to the active sites of the enzymes.
 Source: many plants (soybean, potatoes), and in a few animal
tissues, eggs
 Stability:
heat labile : Autoclaving soybeans for 20 min at 115°C or 40
min at 107 to 108°C
Prior soaking in water for 12 to 24 h makes the heat treatment
more effective.
Example: Boiling at 100°C for 15 to 30 min is sufficient to
improve the nutritional value of soaked soybeans.
Continued….
heat resistant:
Pasteurization for 40 sec at 72°C destroys only 3 to 4%,
heating at 85°C for 3 sec destroy 44 to 55%,
heating at 95°C for 1 hr destroy 73% of the inhibitor.
Ex: trypsin inhibitor in milk, chymotrypsin inhibitor in
potatoes
Lectins

Lectins is proteins that have highly specific binding sites
for carbohydrates.The majority of the lectins are
glycoproteins.
 Source: plants (legumes such as peanut, soybean, etc),
potato, banana, mango, and wheat germ.
 Mechanism: disrupt small intestinal metabolism and
damage small intestinal villi via the ability of lectins to
bind with brush border surfaces in the distal part of small
intestine.
 Reduction: Heat processing can reduce the toxicity of
lectins, low temperature or insufficient cooking may not
completely eliminate their toxicity, as some plant lectins
are resistant to heat.
Antiminerals
 Substances interfering with the utilization of
essential minerals.
Source: vegetables, fruits, and cereal grains.
 It includes; phytic acid, oxalic acid, dietary
fiber and gossypol
Phytic acid
 Phytic acid, the hexphosphoric ester of myo-inositol, is a strong
acid.
 Phytic acid has been shown to have a negative effect on iron
absorption in humans.
 Mechanism: Phytic acid prevents the complexation between iron
and gastroferrium, and iron-binding protein secreted in the stomach.
 Reduction:
 phytase activity can reduce the phytic acid level.
 vit D consumption Calcium absorption is influenced
not only by dietary phytate but also by vitamin D and
lipids. If vitamin D is limiting in the diet, calcium
absorption will be less efficient and the phytate effect will
become more pronounced.
 food processing: the activity of phytase drastically
reduces the phytate content of dough during breadmaking.
 Source Phytase: plants (soybeans, cereal grain)
 Phytase is an enzyme which catalyzes
dephosphorylation of phytic acid.
the
Oxalic acid
 Oxalic acid (HOOC–COOH) is a strong acid, it can
induce toxic as well as antinutritive effects. To humans, it
can be acutely toxic (4 to 5 g to induce any toxic effect)
 Interference on calcium absorption
 Negative effects  oxalate/calcium ratio of foods
higher than 1 may decrease the calcium availability
Reduction: Consumption of foods rich in calcium, such
as dairy products and seafood, and enhanced vitamin D
intake
Antivitamins
 Mechanism: a group of naturally occurring
substances which :
- can decompose vitamins,
- form unabsorbable complexes with them,
-interfere with their digestive or metabolic
utilization.
 ascorbic acid oxidase, antithiamine factors,
and antipyridoxine factors
Ascorbic acid oxidase
 is a copper-containing enzyme that mediates :
1.oxidation of free ascorbic acid  dehydroascorbic
acid
2.dehydroascorbic acid  diketogulonic acid, oxalic
acid, and other oxidation products

Source: fruits and vegetables such as cucumbers,
pumpkins, lettuce, bananas, tomatoes, potatoes, carrots,
and green beans.
 The enzyme is active between pH 4, about 38°C.
 Being an enzyme, ascorbic acid oxidase can be inhibited
effectively by blanching of fruits and vegetables.
Antithiamine factors
 Antithiamine factors can be distinguished as thiaminases,
tannins, and catechols.

The interaction with vitamin B1 can lead to serious
neurotoxic effects as a result of vitamin B1 deficiency

Source: Thiaminases are found in many fish species,
freshwater, saltwater species, and in certain species of
crab.

Mechanism: interact with vitamin B1 (thiamine),
antithiamine factors are enzymes that split thiamine at the
methylene linkage
• Reduction: cooking destroys thiaminases in fish and
other sources.
• Antithiamine factors can also be of plant origin. Tannins,
occurring in a variety of plants, including tea  inhibition
of growth in animals and for inhibition of digestive
enzymes.
• Tannins are a complex of esters and ethers of various
carbohydrates. A component of tannins is gallic acid.
Tannins

Tannins are a heterogeneous group of broadly
distributed substances of plant origin.
 Two types of tannins can be distinguished on the basis
of degradation behavior and botanical distribution,
namely hydrolyzable tannins and condensed tannins.
 The hydrolyzable tannins are gallic, digallic, and ellagic
acid esters of glucose or quinic acid.
 An example of this group is tannic acid, also known as
gallotannic acid, gallotannin. Tannic acid has been
reported to cause acute liver injury, i.e., liver necrosis
and fatty liver.
Tannins
 The condensed
tannins are flavonoids. They are
polymers of leukoanthocyanidins.
 The contribution of the tannins in tea, coffee, and cocoa
to the total tannin intake by humans is of particular
importance. Tea has the highest tannin content.
 Other important sources of tannins are grapes, grape
juice, and wines.
 A person may easily ingest 1–5g tannins per day.
Antipyridoxine factors
 A variety of plants and mushrooms contain pyridoxine (a form
of vitamin B6) antagonists
 The antipyridoxine factors have been identified as hydrazine
derivatives
 Source: mushroom
 Reduction: Immediate blanching after cleaning and cutting
can reduce the substance
 Mechanism: condensation of the hydrazines with the
carbonyl compounds pyridoxal and pyridoxal phosphate —
the active form of the vitamin — resulting in the formation of
inactive hydrazones
Other antinutrional compounds
Saponins
 Saponins are a heterogeneous group of naturally occurring
foam-producing triterpene or steroidal glycosides that occur
in a wide range of plants, including pulses and oil seeds
such as kidney bean, chickpea, soybean, groundnut, and
sunflower.
 saponins can affect metabolism in a number of ways as
follows: erythrocyte haemolysis, reduction of blood and liver
cholesterol, depression of growth rate.
 Reduction; Saponins from beans can reduced by Sprouting
& roasting.
Cyanogenic glycosides

Some legumes like linseed, lima bean, kidney bean
and the red gram contain cyanogenic glycosides from
which Hydrogen Cyanide may be released by
hydrolysis.
 Hydrolysis occurs rapidly when the ground meal is
cooked in water and most of the liberated HCN is lost
by volatilization.
 HCN is very toxic at low concentration to animals. it
can cause dysfunction of the central nervous system,
respiratory failure and cardiac arrest.
Goitrogens
 Goitrogenic substances, which cause enlargement


of
the thyroid gland, have been found in legumes such
as soybean and groundnut.
They have been reported to inhibit the synthesis and
secretion of the thyroid hormones.
Goitrogenic
effect
have
been
effectively
counteracted by iodine supplementation rather heat
treatment.
Chlorogenic acid
 Sunflower
meal contains high levels of chlorogenic acid, a
tannin like compound that inhibits activity of digestive
enzymes including trypsin, chymotrypsin, amylase and
lipase.
 chlorogenic acid is a precursor of ortho- Quinone that occur
through the action of the plant enzyme polyphenol oxidase.
 These compounds then react with the polymerize lysine
during processing or in the gut.
 it can be controlled by dietary supplementation with methyl
donors such as choline and methionine. And readily
removed from sunflower seeds using aqueous extraction
methods
Main non-nutrient compounds and their main
beneficial and adverse effects
compounds
Beneficial effects
Adverse effects
Main source
Protease
inhibitors
Anticarcinogenic.
growth inhibition.
Soya, cereals.
Amylase
inhibitors
Potentially therapeutic in
diabetes.
- Starch digestion.
Cereals
Lectins
help in obesity treatment.
-nutrient absorption.
Beans
Phytates
Hypocholesterolaemic
effect.
- Bioavailability of
minerals.
Wheat bran, soya
Oxalates
Anticarcinogenic.
Same as for phytates
Spinach,rhubarb.
tannins
-risk of hormone related
cancer.
Astringent taste,
-food intake.
Tea, sorghum,
Rapeseed.
Lignans
- Risk factors for
Menopause.
growth inhibition.
Linseed
Saponins
Hypocholesterolaemic
effect.
Bitter taste,
intake.
soybean,
groundnut.
-food
Elimination of anti-nutritional substances by
technological treatments
 A number of treatments of food material are able to
eliminate some bioactive substances partially
including soaking, dry and moist heat treatment,
filtration, germination, fermentation and enzymatic
treatments.
 chemical and physical characteristics determine the
choice of appropriate treatment used to eliminate an
undesirable compound from food
Heat treatment
 Heat
processing is widely accepted as an effective
means of inactivating the thermo-labile anti-nutritional
factors in food material.
 This improves protein quality by inactivating antiphysiological factors, particularly trypsin inhibitor and
haemagglutinins and by unfolding the protein
structure.
 Heat treatment process includes boiling, autoclaving,
pressure cooking, extrusion cooking, toasting
Cooking (boiling)


Cooking generally inactivates heatsensitive antinutritive factors such as trypsin and chymotrypsin
inhibitors and volatile compounds.
Cooking for 60 minutes at 1000C was sufficient to
inactivate over 90% of the trypsin inhibitor activity in
food materials.
Autoclaving

Autoclaving cooking under pressure includes the
food materials are autoclaved for 30 minutes at
125oC and 15 Ib pressure, thermo-labile inhibitory
substances such as cyanogenic glycosides,
saponins, terpenoids and alkaloids could be
eliminated from the food materials.
Pressure cooking
 the food material is cooked under pressure for 30
minutes to remove trypsin inhibitors in food.
microwave treatment

microwave treatment is the heats food by passing
microwave radiation through it. Microwave ovens use
frequencies
2.45 (GHz)
a wavelength is
12.2
and
centimetres for 10 minutes to eliminates the trypsin inhibitor
and haemagglutinating activity in food.
Extrusion cooking
 The cooking process takes place within the extruder where
the product produces its own friction and heat due to the
pressure generated (10–20 bar). The process can induce
both protein denaturation and starch gelatinization, complete
inactivation of haemagglutinins in food materials
Soaking
 Soaking could be one of the processes to remove soluble
antinutritional factors, seeds were soaked in water at 22oC
for 18 h to decreases in trypsin inhibitor activity in the food.
Germination (sprouting)

Germination has been documented to be an effective
treatment to remove some anti-nutritional factors in legumes
by mobilizing secondary metabolic compounds which are
thought to function as reserve nutrients.
 Germination can lower the phytate content in legume seeds
depending upon the type of bean and germinating conditions
Main anti-nutritional factor are eliminated
by particular process are
Bioactive substance
Commonly used elimination processes
Enzyme inhibitors
Heat treatment
Phytic acid
Enzymatic degradation, germination, and
fermentation
Oxalate
Cooking, dehulling
Phenolic compounds
Dehulling
Saponins
Sprouting
Lectins
Heat treatment
Eating disorders
Supriya Bhattarai
MSc Nutrition and Dietetics/ Sports
01/07/2018
1
Eating disorders
• Eating disorders are debilitating psychiatric illnesses characterized by
a persistent disturbance of eating habits or weight control behaviors
that result in significantly impaired physical health and psychosocial
functioning.
• Types : Anorexia Nervosa ◦ Restriction of energy intake leading to
low body weight that is expected for age. Body Image Disturbance .
• Bulimia Nervosa ◦ Recurrent binge episodes and compensatory
behaviors that are meant to prevent weight gain.
• Binge Eating Disorder ◦ Recurring episodes of eating large amounts
of food, with feelings of loss of control.
Anorexia Nervosa
• The diagnostic and statistical manual of mental disorders defines AN as
“refusal to maintain body weight at or above a minimally normal
weight for age and height”.
• Patients with AN have body image distortion causing them to feel fat
despite their often cachectic state. Some feel over weight all over while
others are overly concerned about the fatness of a specific part of the body.
• Amenorrhoea defines as the absence of at least three consecutive cycles in
postmenarcheal women is a diagnostic feature.
• Psychologial features associated are compulsivity, perfectionism, feeling of
ineffectiveness, restrained emotions. Other psychological state associated
are depression, Obsessive compulsive disorder, substance abuse , anxiety
etc.
• Two types: Restricting: restricting food without episode of binge eating or
purging.
• Binge eating and purging: regular episode of binge eating and purging .
• According to the DSM-5 criteria, to be diagnosed as having Anorexia
Nervosa a person must display:
• Persistent restriction of energy intake leading to significantly low body
weight (in context of what is minimally expected for age, sex,
developmental trajectory, and physical health) .
• Either an intense fear of gaining weight or of becoming fat, or
persistent behavior that interferes with weight gain (even though
significantly low weight).
• Disturbance in the way one's body weight or shape is experienced,
undue influence of body shape and weight on self-evaluation, or
persistent lack of recognition of the seriousness of the current low
body weight.
• Amenorrhoea
Nutritional rehabilitation
•
•
•
•
Nutritional assessment
Medical nutrition therapy
Counselling
Education
• Diet history
• Patients with restricting subtype of AN
consume less than 1000 kcal/ day .
• Tendency to restrict carbohydrate and fat
containing foods.
• Chaotic diet patterns of purging and binging
types.
• Vegetarianism
• Do not meet the requirement of vitamins and
minerals especially fat soluble vitamins and
minerals such as calcium, magnesium, copper
and zinc.
• Abnormalities in fluid intake
• Consumption of excessive amounts of
artificial sweeteners and beverages.
Eating behaviors
• Food aversions
• Unusual and ritualistic behaviors
• Meal spacing and self allotted food
ration
• Time limits on eating
Important biochemical and
nutritional characterstics
• Cachexia
• High cholesterol levels
• Low t3 syndrome
• Hypercarotenemia
• Riboflavin, vitamin B6, thiamin,
niacin, folate and Vitamin E along
with Vitamin B12.
• Decreased iron requirements
• Zinc deficiency
• Deficiency of calcium, magnesium
and vitamin D.
• Dehydration, hypokalemia,
hyponatremia.
• Reduced REE.
Medical nutrition therapy
• Calorie prescription : initial weight gain
• Assess risk of refeeding syndrome
• Controlled weight gain phase
• Weight maintainence phase
• Protein: 15- 20 % of Total energy ( high biological sources)
• Carbohydrate: 50- 55 % of total energy ( insoluble fibers)
• Fat : 30 % of total energy
• Micronutrients: supplements
• Do not supplement iron
• Determine the need of thiamin supplement during weight restoration.
Bulimia Nervosa
• Bulimia nervosa is a disorder characterized by recurrent episodes of binge
eating followed by one or more inappropriate compensatory behaviors to
prevent weight gain. The compensatory behaviors are self- induced
vomiting, laxative use, diuretic misuse, compulsive exercise or fasting.
• They are typically within normal weight.
• Binge is a characteristics feature which is defined as consumption of large
amount of food in a discrete period.
• Types : purging: engage into self induced vomiting after binges
• Non – purging : rather fast or exercise excessively than indulge into
purging behavior.
• Emotional states: labile mood, frustration, anxiety, depression, substance
abuse, self injurious behaviors.
• Unlike AN the patients with bulimia are aware about their habit and
condition and its easier for them to change it through assistance.
• According to the DSM-5 criteria, to be diagnosed as having Bulimia
Nervosa a person must display:
• Recurrent episodes of binge eating. An episode of binge eating is
characterised by both of the following:
• Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food
that is definitely larger than most people would eat during a similar period of time and
under similar circumstances.
• A sense of lack of control over eating during the episode (e.g. a feeling that one
cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behaviour in order to prevent weight
gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other
medications, fasting, or excessive exercise.
• The binge eating and inappropriate compensatory behaviours both occur, on
average, at least once a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
Clinical features
Nutritional rehabilitation
• Nutritional assessment
• Medical nutrition therapy
• Counselling
• Education
• Diet history : chaotic eating
• Daily food intake determination
is required.
• Eating behaviors: eating quickly
• Fear of food that trigger the
binge.
• Avoidance of food
Important biochemical and nutritional
characteristics
• Abnormal lipid levels
• Hypokalemia, dehydration, hyponatremia
• Unpredictable metabolic rates.
Medical nutrition therapy
• Calorie prescription : check whether the patient is hypo or
hypermetabolic state.
• Avoid weight reduction diets until eating patterns are stabilized.
• Protein: 15- 20 % of Total energy ( high biological value proteins)
• Carbohydrate: 50- 55 % of total energy (insoluble fiber for
constipation)
• Fat : 30 % of total energy
• Micronutrients: supplements
Nutrition counselling
• Pre contemplation
• Contemplation
• Preparation
• Action
• Maintenance and relapse
Nutrition education
• Topics : healthy and balanced eating
• Impact of malnourishment on adolescent growth and development
• Body image perception
• Cause of binging and its triggers
• Exercise and energy balance
• Hunger cues
• Ineffectiveness of use of laxative
• Portion control
• reading food labels
Other similar disorders: Binge eating disorder
• According to the DSM-5 criteria, to be diagnosed as having Binge Eating
Disorder a person must display:
• Recurrent episodes of binge eating.
• Binge eating occurs, on average, at least once a week for three months
• Binge eating not associated with the recurrent use of inappropriate
compensatory behaviours as in Bulimia Nervosa and does not occur
exclusively during the course of Bulimia Nervosa, or Anorexia Nervosa
methods to compensate for overeating, such as self-induced vomiting.
• Note: Binge Eating Disorder is less common but much more severe than
overeating. Binge Eating Disorder is associated with more subjective
distress regarding the eating behaviour, and commonly other co-occurring
psychological problems.
Pica
• According to the DSM-5 criteria, to be diagnosed with Pica a person must
display:
• Persistent eating of non-nutritive substances for a period of at least one
month.
• The eating of non-nutritive substances is inappropriate to the developmental
level of the individual.
• The eating behaviour is not part of a culturally supported or socially
normative practice.
• If occurring in the presence of another mental disorder (e.g. autistic
spectrum disorder), or during a medical condition (e.g. pregnancy), it is
severe enough to warrant independent clinical attention.
• Note: Pica often occurs with other mental health disorders associated with
impaired functioning.
Other condition
• Female athletic triad: is a syndrome in which eating disorders (or low
energy availability),amenorrhoea /oligomenorrhoea, and decreased bone
mineral density (osteoporosis and osteopenia) are present.
• this condition is seen in females participating in sports that emphasize
leanness or low body weight.
• Gymnastics, figure skating, ballet, diving, swimming, and long distance
running are examples of sports which emphasize low body weight.
• Baryphobia :
The unreasonable fear that one's child will become obese. The allowed diet
may be insufficient to support the child's growth and development needs.
Thank you