Food Nutrition and Dietetics Class XII PDF

CBSE Study Material for Students FOOD NUTRITION AND DIETETICS Class XII Prepared by - Prof. Deeksha Kapur, Discipline of Nutritional Sciences, SOCE, IGNOU, New Delhi Mrs Anita Khosla , Principal,G D Goenka Public School ,New Delhi Mrs Deepti Sharma , PGT Biology G D Goenka Public School ,New Delhi Unit 1 Chapter 1: THERAPEUTIC NUTRITION Learning Objectives: After reading this unit, the students will be able to: 1. Define the terms dietetics, clinical nutrition & therapeutic diet, 2.Enumerate the scope of dietetics and the role of dietitian in health care, Welcome to the study of clinical and therapeutic nutrition. Clinical nutrition, as a study focuses on the nutritional management of individuals or group of individuals with established disease condition. Clinical nutrition deals with issues such as altered nutritional requirements associated with the disease, disease severity and malnutrition and many such issues. Nutrition is an integral part of the medical therapy as adequate nutrition support can go a long way in improving quality of care and improving patient's medical outcome. The importance of nutrition in the prevention of illness and disease has been long recognized. So let us get to know more about clinical and therapeutic nutrition. DIETETICS AND ROLE OF DIETITIAN IN HEALTH CARE As a student of nutrition it must be evident to you by now that the diet and the food we eat have a direct and significant impact on our health. Eating a healthy balanced diet improves the quality of our life, whereas a poor diet may lead to morbidity and disease. The branch of medicine concerned with how food and nutrition affects human health comprising the rules to be followed for preventing, relieving or curing disease by diet is called Dietetics. Dietetics deals with feeding individuals based on the principles of nutrition. In fact, dietetics is the science and art of human nutritional care. Clinical Dietetics is the application of dietetics in a hospital or health care institutional setting. Clinical dietetics focuses on individual nutrition support and symptom management. You may come across the terms diet therapy, therapeutic diets while studying about clinical dietetics. Let us get to understand these terminologies used in the context of dietetics. Diet therapy is a branch of dietetics concerned with the use of food for therapeutic purpose. Diet therapy is a broad term used for the practical application of nutrition as a preventive or corrective treatment of a disease. It concerns with recovery from illness by giving good diet and prevention of disease. It may involve the modification of the existing dietary lifestyle to promote optimum health. The principles of diet therapy are to: maintain good nutritional status, correct deficiencies or disease, if any, provide rest to the body, help metabolize the nutrients, and make changes in body weight, when necessary. Diet therapy may include prescribing specialized dietary regimes or meal plans. These specialized diet regimens or meal plans are called therapeutic diets. Therapeutic diet refers to a meal plan that controls the intake of certain foods or nutrients. They are adaptation of the normal, regular diet. Some common examples of therapeutic diets include clear liquid diet, diabetic diet, renal diet, gluten free diet, low fat diet, high fibre diet etc. Therapeutic diets are usually prescribed by dietitians, nutritionists or physicians. Role of Dietitian in Nutrition Care Dietitian you know is an expert in dietetics, dealing with human nutritional care. A dietitian applies the science and principals of human nutrition to help people understand the relationship between food and health and make appropriate dietary choices to attain and maintain health and to prevent and treat illness and disease. Dietitians work in a wide variety of roles in, for example, a clinical, public health or community, food service, administrative, freelance/consultancy, research or teaching capacity. However, you will find that majority of dietitians are clinical dietitians working in hospitals, nursing homes and other health care facilities or specialized institutes/units to provide nutritional care to patients with a variety of health conditions, and provide dietary consultations to patients and their families. The activities most likely to be undertaken by the clinical dietitians would include:  Collecting, organizing and assessing data relating to health and nutritional status of individuals, groups and  communities,  Review and analyze patients’ nutritional needs and goals to  make appropriate dietary recommendations,  Develop and implement nutrition care plans and monitor, follow up and evaluate these plans and take corrective measures wherever  required,  Calculate nutritional value of food/meals planned,  Prescribe therapeutic diets and special nutrition support and feeding  regimens,  Oversee the preparation of special diets, special nutrition formulas for patients who are critically or terminally and require special feeding  through oral, enteral or parenteral routes,  Plan and prepare basic menus and assist in supervising food service personnel in  preparing menus and serving of meals,  Schedule work assignments in the dietary unit to facilitate the effective operation of the CHAPTER 2: THERAPEUTIC DIETS Learning Objectives: After reading this chapter, the students will be able to: 1. Enumerate the scope of dietetics and the role of dietitian in health care, 2. Explain the diets of altered consistencies, 3. Discuss the adaptation of normal diet to therapeutic diets, and Therapeutic diet is a qualitative/quantitative modified version of a normal regular diet which has been tailored to suit the changing nutritional needs of patient/individual and are used to improve specific health/disease condition. It is a planned diet used to supplement the medical or surgical treatment. Balanced diet is defined as one which contains a variety of foods in such quantities and proportions that the need for energy, proteins, vitamins, minerals, fats and other nutrients is adequately met for maintaining health and well being Refer to Figure 1.1 which illustrates routine hospital diets. Figure 1.1: Routine hospital diets Normal or general diet in a hospital setting is a balanced diet which meets the nutritional needs of an individual/patient. It is given when the individual's medical condition does not warrant any specific modification. Most hospitals follow simple dietary recommendations (given by ICMR(Indian council for Medical Research) for Indian population) while planning the general diet. It is planned keeping the basic food groups in mind so that optimum amount of all nutrients is provided. Further, since the patient is hospitalized or on bed rest, reduction of 10% in energy intake should be made. The diet provides approximately 1600 to 2200Kcal, and contain around 180 to 300g carbohydrates, 60 to 80g of fat and 40 to 70 g of protein. Figure 1.1 also illustrates the soft diet and the liquid diets which are examples of therapeutic diet. In addition to these there may be other modified diets which individuals may require as part of their therapeutic needs. The reasons for modifying the diets may include: For essential or lifesaving treatment: For example in celiac disease, providing gluten free diet, To replete patients who are malnourished because of disease such as cancer and intestinal diseases by providing a greater amount of a nutrient such as protein, To correct deficiencies and maintain or restore optimum nutritional status, To provide rest or relieve an affected organ such as in gastritis, To adjust to the body's ability to digest, absorb, metabolize or excrete: For example, a low fat diet provided in fat malabsorption, To adjust to tolerance of food intake. For example, in case of patients with cancer of esophagus tube feeding is recommended when patients cannot tolerate food by mouth, To exclude foods due to food allergies or food intolerance, To adjust to mechanical difficulties, for example for elderly patients with denture problems, changing the texture/consistency of food recommended due to problems with chewing and/or swallowing, To increase or decrease body weight/body composition when required, for example as in the case of obesity or underweight, As helpful treatment, alternative or complementary to drugs, as in diabetes or in hypertension Types of Dietary Adaptations for Therapeutic Needs A diet may need to be altered and adjusted in many ways before it meets the therapeutic needs of an individual patient. These adaptations may include: Change in consistency of foods, such as liquid diet, soft diet, low fibre diet, high fibre diet. Increase or decrease in energy value of the diet such as low calorie diet for weight reduction, high calorie diet for burns. Increase or decrease in specific nutrients or type of food consumed, such as sodium restricted diet, lactose restricted diet, high fibre diet, high potassium diet. Elimination of spices and condiments, such as bland diets. Omission of specific foods such as allergy diets, gluten free diet. Adjustment in the ratio and balance of proteins, fats and carbohydrate such as diabetic diet, renal diet and cholesterol-lowering diets. Test diets: These are single meals or diets lasting one or few days that are given to patients in connection with certain tests e.g. the fat absorption test used to determine if steatorrhea is present. Change in frequency of meals, feeding intervals, re-arrangement of the number and frequency of the meals such as diabetic diet, diet for peptic ulcer disease. Remember, normal nutrition is the foundation upon which the therapeutic modifications are made. The various dietary adaptations for therapeutic needs are briefly highlighted here. A. Diets of Altered Consistency Therapeutic diets are modified for consistency, texture to fit the nutritional needs. Some individuals may require a clear liquid diet, while others a fully liquid diet or soft diet based on their medical condition. Figure 1.2 illustrates the modified diets based on consistency. Figure 1.2: Modifications in consistency a) Liquid Diet consists of foods that can be served in liquid or strained form in room temperature. They are usually prescribed in febrile states, postoperatively i.e. after surgery when the patient is unable to tolerate solid foods. It is also used for individuals with acute infections or digestive problems, to replace fluids lost by vomiting, diarrhoea. The two major types of liquid diets include - Clear liquid diet and full liquid/fluid diet. i) Clear liquid diet provides foods and fluids that are clear and liquid at room temperature. The purpose of the clear liquid diet is to provide fluids and electrolytes to prevent dehydration. It provides some amount of energy but very little amount of other nutrients. It is also deficient in fibre. Hence it is nutritionally inadequate and should be used only for short periods i.e. 1-2 days. Examples of clear liquid diet: Water, strained fruit juices, coconut water, lime juice (nimbu pani), whey water, barley/arrowroot water, rice kanji, clear dal soup, strained vegetable or meat soup, tea or coffee without milk or cream, carbonated beverages, ice pops, plain gelatin are some examples of clear liquid diet. ii) Full liquid diet provides food and fluids that are liquid or semi liquid at room temperature. It is used as a step between a clear liquid diet and a regular diet. The purpose of the full liquid diet is to provide an oral (by mouth) source of fluid for individuals who are incapable of chewing, swallowing or digesting solid food. It provides more calories than the clear liquid diet and gives adequate nourishment, except that it is deficient in fibre. It is indicated for post-operative patients and for gastrointestinal illness. The nutritive content of the full liquid diet can be increased by using protein, vitamin and fibre supplements. Examples of full liquid diet: Foods allowed or included in a full liquid diet include beverages, cream soups, vegetable soups, daal soups, strained food juices, lassi/butter milk, yogurt, hot cocoa, coffee/tea with milk, carbonated beverages, cereal porridges (refined cereals) custard, sherbet, gelatin, puddings, ice cream, eggnog, margarine, butter, cream (added to foods), poached, half boiled egg etc. b) Soft diet as the name suggests provides soft whole food that is lightly seasoned and are similar to the regular diet. The term 'soft' refers to the fact that foods included in this type of diet are soft in consistency, easy to chew and made of simple, easily digestible foods. It does not contain harsh fibre or strong flavors. It is given during acute infections, certain gastrointestinal disorders and at the post-operative stage to individuals who are in the early phase of recovery following a surgery. The soft diet provides a transition between a liquid and a normal diet i.e. during the period when a patient has to give up a full liquid diet but is yet not able to tolerate a normal diet. Soft diet can be nutritionally adequate (providing approximately 1800-2000 calories, 55-65g protein) provided the patient is able to consume adequate amount of food. Examples of soft diet: A soft diet freely permits the use of cooked vegetables, soft raw fruits without seeds, broths and all soups, washed pulses in the form of soups and in combination of cereals and vegetables (like khichri, dalia), breads and ready-to-eat cereals (most preferable refined such as poha, upma, pasta, noodles etc.), milk and milk beverages, yogurt, light desserts (including kheer, halwa, custard, jelly, ice cream), Egg and tender and minced, ground, stewed meat and meat products, fat like butter, cream, vegetable oil and salt and sugar in moderation. Foods to be best avoided in the soft diet include coarse cereals, spicy highly seasoned and fried foods, dry fruits and nuts, rich desserts. c) Bland Diet: A bland diet is made of foods that are soft, not very spicy and low in fiber. It consists of foods which are mechanically, chemically and thermally non-irritating i.e. are least likely to irritate the gastrointestinal tract. Individuals suffering from gastric or duodenal ulcers, gastritis or ulcerative colitis are prescribed this diet. Foods Included: Milk and milk products low in fat or fat free; Bread, pasta made from refined cereals, rice; cooked fruits and vegetables without peel and seeds; Eggs and lean tender meat such as fish, poultry that are steamed, baked or grilled; Cream, butter; Puddings and custards, clear soups. Foods Avoided: Fried, fatty foods; Strong flavored foods; Strong tea, coffee, alcoholic beverages, condiments and spices; High fiber foods; hot soups and beverages; whole grains rich in fiber; strong cheeses. B. Modification in Quantity Depending on the clinical condition some individuals may require a restriction diet such as sodium restricted diet (as in high blood pressure), purine restricted diet (as in gout) or low residue diet (prescribed and/or before abdominal surgery) designed to reduce the frequency and volume of fecal output. Sometimes a complete elimination diet may be recommended when there is food intolerances or complete insensitivity to a particular food such as a gluten free diet or a dairy free diet or nut free diet etc. Occasionally an increase in the amount of a specific dietary constituent may be prescribed such as a high potassium diet or a high fibre diet (as in constipation) or an iron-rich diet (as in anemia) when the clinical condition demands. C. Modification in Nutrient (Proteins, Fat, Carbohydrate) Content The nutrient content of the diet is modified to treat deficiencies, change body weight or control diseases such as hypertension or diabetes. You may have come across patients with high blood sugar levels, being prescribed a diabetic diet which requires changes in the quantity and type of carbohydrates included in each meal. Refined carbohydrates (such as sugar, honey, refined flour, semolina etc.) are best avoided and use of complex carbohydrates (whole wheat flour, coarse cereals etc.) recommended. Patients with heart diseases require a fat controlled low cholesterol diet while patients with renal (kidney) failure and advanced liver diseases a low protein diet, patients with HIV disease, cancer or malnourished a high protein, high calorie diet. Others as in the case of overweight, obesity a weight reduction diet, low in fat and calories. D. Changes in Meal Frequency Individuals suffering with gastro-esophageal reflux disease (GERD) stand to benefit by consuming small but frequent meals. 5 to 6 small meals instead of three regular meals are recommended. E. Changes in Method of Cooking Leaching is indicated for cooking vegetables for people with chronic kidney diseases because the kidney's no longer maintains the ideal level of potassium necessary for optimum health. Leaching (soaking in water) drains out excessive potassium and phosphorous from the vegetables. In elderly people food may be modified by mechanical processing such as mashing, blending or chopping. For patients on bland diet foods steamed, baked or grilled are recommended. A review on the methods of cooking is presented for your understanding at the end of the book. F. Modification in the Method of Feeding To provide adequate nutrition, normally oral feeding (by mouth) is recommended. Sometimes oral feeding is not possible, under such circumstances special feeding methods such as enteral feeding (provision of liquid formula diet delivered via nasogastric feeding tube) and parenteral feeding (fluids containing water, glucose, amino acids, minerals, vitamins given through the peripheral and central veins) is recommended. _____________________________________________________________________ Chapter 3: NUTRITION AND INFECTION Learning Objectives: After reading this chapter, the students will be able to: 1. Discuss the interaction between nutrition and infection, 2. Describe the effect of infection on nutritional status, 3. Discuss how malnutrition can lead to infection, The role of nutrition in disease prevention and health management is well established. Also you are aware that poor nutrition can lead to ill health, disease and infections. Infections are caused by microorganisms which in turn can lead to malnutrition. Is there a link between these two conditions? In this section we shall discuss the interaction of infection and nutrition. Infection and malnutrition have always been intricately linked. Evidence suggests that common childhood infections exert their influence in precipitating malnutrition. The relationship between malnutrition, impaired immunity and infection can be described as a vicious cycle. We will learn about this vicious cycle in this chapter. THE CYCLE OF MALNUTRITION AND INFECTION Malnutrition, as you already know, is an impairment of health resulting from a deficiency or lack of food/nutrients or imbalance of nutrients in the diet. Almost any nutrient deficiency, if sufficiently severe, will impair resistance to infection. Let us understand this interaction between malnutrition and infection with the help of a case study. Raju, a 4-year-old boy, is suffering from infectious diarrhoea, caused by the invasion of the body by harmful microorganisms. The infection caused loose motion, fever, dehydration and impaired absorption. On further investigation he was also found to be suffering from protein energy malnutrition reflecting as loss of weight. Now, when these two diseases exist in the same person (here Raju) concurrently, the interaction between the two diseases usually alters the nature, behavior of the diseases. The overall clinical status of the child worsens often resulting in increased complications or increased duration of the disease and in some cases results in death. In case of Raju, infection is a common precipitating factor for malnutrition. Ironically, malnutrition is also a major factor in the occurrence of infection and the two interact, making each other worse. Figure 2.1 illustrates this interaction. Figure 3.1: Interaction between infection and malnutrition An inadequate dietary intake, in case of Raju, led to weight loss, lowered immunity, mucosal injury, invasion by pathogens, and impaired growth and development as highlighted in Figure 3.1. Raju's nutrition was further aggravated by diarrhea, malabsorption, loss of appetite, diversion of nutrients for the immune response, and urinary nitrogen loss, all of which lead to nutrient losses and further damage to defense mechanisms making him more susceptible to infections. This in turn led to further reduced dietary intake causing a vicious cycle of malnutrition and infection as highlighted in Figure 3.2. Figure 3.2: The vicious cycle of malnutrition and infection So when infection aggravates malnutrition or malnutrition lowers resistance to infection, the relationship between the two can be described as Synergism i.e. the simultaneous presence of malnutrition and infection results in an interaction that is more serious for the individual than would be expected from the combined effect of the two working independently. The synergistic effect of malnutrition and infection often leads to a high rate of child deaths in poor households/communities in India. What generally happens is that in a poor rural/slum household a child is as such born with low birth weight (that is less than 2.5kg) because of inadequate dietary intake of the mother during pregnancy. Subsequently the child is solely breast fed for long periods (2 or more years). Complementary feeding (i.e. introduction of additional foods other than breastmilk) is delayed beyond 6 months of age. This triggers growth faltering that is the child's growth and development slows down resulting in weight loss. In other terms malnutrition sets in. Moreover, in view of the poor environment and lack of hygiene so common in rural/slum areas, the children are further exposed to infections like diarrhoea and respiratory tract infections. There is reduction in food intake by the child due to loss of appetite due to these infections. As a result, there is further slowing down of growth. The cumulative effect of dietary deficit and infection produces retardation of physical growth leading to stunting (short stature or low height/length for age as compared to normal child) in children. It is important to highlight here that the effects of stunting are long lasting. Children who are stunted grow up to be adults with reduced capacity to do physical work and are less economically productive. Effect of Malnutrition on Infection With reference to Figure 3.1 and 3.2, it must be evident to you that inadequate nutrient intake lowers immunity. Also it leads to mucosal damage. Let us get to know more on this aspect. a) Lowered Immunity: Immunity, in simple terms can be described as the state of being unsusceptible or being protected against a particular disease or illness by the presence of particular substance in the blood. These particular disease fighting substances are called antibodies. A healthy well-nourished child/individual is at a lower risk of infection. They can fight the infection because of the ability of these well-nourished individuals to produce these disease fighting substances called antibodies. But in case of malnourished individuals there is reduction in antibody production and therefore the disease fighting capacity is lowered making the individual more prone to infections. b) Effect on the integrity of skin and mucous membrane: Dietary inadequacy diminishes resistance to infection by reducing the integrity of various tissues. In a healthy well fed individual the skin, mucosal membrane and other tissues are healthy and prevent the entry of infectious agents. They act as a barrier and prevent the infection from entering the body. In an individual suffering from malnutrition, the protective mechanism is absent. The mucous membrane becomes readily permeable and provides a favorable environment for the growth of the infectious agent. Consequently, the individual will catch infection easily. Infection and Nutritional Status Infection, no matter how mild, has adverse effects on nutritional status. Nutritional status, as you may recall, refers to the condition of health of an individual as influenced by the utilization of the nutrients. So how does infection influence the utilization of the nutrients which in turn influences nutritional status? Let us understand. There can be multiple ways but the first and foremost effect of infection is on loss of appetite. a) Loss of Appetite: Do you recall the last time you were sick or down with some infection? What did you experience? Yes, you may not have been eager to consume food or were not able to tolerate food leading to loss of appetite. Further with use of medicines such as antibiotics to treat the infection your appetite may have been further affected leading to reduced food intake. Now if this condition would have been prolonged it would have led to consistent decrease in food intake leading to nutrient deficiency. b) Unfavorable cultural practices: One of the common practices in our country is to restrict or withdraw food from individuals when suffering from infection, particularly diarrhoea or respiratory infections. It is believed that solid foods, milk etc. be best avoided instead bland, starchy gruels low in nutritive value be provided to rest the digestive system. Such a practice is deleterious; particularly when the individual due to infection is already having low food intake and further reduction in the quality of diet contributes to nutrient deficiencies and thus leading to poor nutritional status. c) Decreased intestinal absorption: The main function of intestine is to digest, absorb and propel food along its length. During infection all these functions are affected. Infections cause's changes to the epithelial membrane leading to malabsorption. Any decrease in the absorption of nutrients can lead to deficiency. For example, in children suffering from infectious diarrhoea, protein absorption from intestine may reduce as much as 40%. Other evidence suggests that in children with acute diarrhoea and respiratory infections only 30 -70 per cent of ingested vitamin A is absorbed. Poor absorption thus leads to nutrient deficiency disorders influencing nutritional status. d) Worm/parasite infection: Also there are documented reports implicating intestinal worm/parasitic infections with poor nutritional status. Hookworm, round worm infection, amoebiasis, giardiasis is among the most common intestinal parasitic infections worldwide. These infections are associated with decreased child growth, loss of weight, chronic blood loss, iron deficiency anaemia, diarrhoea and stunted growth. e) Protein loss: In some infections and fevers, few nutrients, particularly proteins are excreted and lost from the body thus causing poor nutritional status. For example, diseases associated with diarrhoea, dysentery produce an average loss of 0.9g protein per kg body weight per day. Higher losses are observed with typhoid fever and other acute infections, reaching 1.2g protein/kg body weight/day. Such losses therefore contribute to increased requirement of protein during infection and fevers. From the discussion above it must be evident to you that the overall effect of the infections on the nutritional status is substantial. In the context of developing country like India, where large number of children, are already on a deficient diet and malnourished, the coexistence of infection in the same child is producing the effect that is beyond the summed effect expected from the two conditions acting alone. ______________________________________________________________ CHAPTER 4: METHODS OF COOKING Learning Objectives: After reading this chapter, the students will be able to: 1. Describe different methods of cooking , 2. Explain and ensure the nutritive values in various methods of cooking. Many foods are consumed as such in the raw state while some are cooked to make them edible. Food is being cooked as it tastes better Even vegetable and fruits are cooked to add variety to the diet and make them easily palatable, attractive and colorful. Cooking also kills many microorganism and makes the food safe to be consumed. Several raw foods have anti-nutritional factors which are destroyed by cooking. It also enhance the availability of some nutrients. Figure 4.1 Different methods of cooking Principles of cooking food 1. Foods must be cooked in a way that it retains the original flavours. 2. Sometimes the flavor of the food is drawn out into the gravy or broth. 3. The preservation of the maximum nutritive value can be ensured by using the correct method of cooking. Cooking methods During cooking, heat may be transferred to the food by conduction, convection, radiation or by the energy of microwave-electronic heat transfer. Table 4.1: Classification of Cooking Methods Moist Method Dry heat Combination Method Boiling Roasting Braising Simmering Griling/ Broiling Poaching Toasting Stewing Baking Blenching Suffering Steaming Frying Pressure Cooking i) Moist Methods: These are the methods in which we use the heat generated by water in some form or the other. Some of the important ones are explained as follows: a) Boiling 0 Foods are cooked by placing them in boiling water at 100 C and maintain this temperature till the desired stage of cooking has been reached. Rice, pulses, potatoes are cooked this way. Advantages 1. Simplest Method of cookery 2. Boiling of food brings about uniform cooking of food 3. At high temperatures protein content of food get denatured and embedded in food 4. Starch gets gelatinized and collagen gets hydrolyzed. 5. Boiling of foods aids in proper digestion Disadvantages 1. The process of boiling takes time. 2. When excess of water is used the water soluble nutrients are lost. 3. Loss of minerals is also a big disadvantage with boiling. 4. Boiling of food brings about its decoloration b) Pressure Cooking In this method the food is cooked under pressure and with increase in pressure the temperature also correspondingly increases. Thus the food is cooked very fast. Actually it is a type of steaming only, in which water is boiled under high pressure, thus raising the temperature and reducing the cooking time. Advantages 1. Reduces cooking time. 2. Fuel efficiency increased. 3. Nutrient loss is less. 4. Food is cooked properly and is made tender. 5. The flavor and aroma of the food is trapped inside the cooker and is not lost. Disadvantages 1. Long hours of pressure cooking make food soggy and too soft. 2. Flavors of foods may make and individuality be lost. c) Steaming This method uses steam as the medium of cooking. The food is surrounded by steam and is cooked by the heat supplied from steam. Types of steaming are: Dry steaming: The steam generated from double boiler is used for cooking food. Sauces and custards are made by this method. Wet Steaming: Steam comes in direct contact with the food and cooks it. Dhokla and idli are made by this method. Advantages 1. Constant stirring is not required. 2. Nutritive value of food remains intact. 3. Cooking time is less. 4. No external is added which makes the food easily digestible. 5. The flavor of the steamed food is good. Disadvantages 1. Dhokla cooker and Idli makers are required. 2. Special vessels are essential for steaming food. 3. Limitation of the type of foods that can be cooked by this method. d) Poaching This method is generally used for eggs. This involves cooking in the minimum amount of liquid at a temperature of 80-85℃. Fish and fruits are also poached. Advantages 1. Cooks food quickly. 2. There is no addition of fat. 3. The foods that are poached are better digestible. Disadvantages 1. Water soluble nutrients leach into the water. 2. The foods are generally bland in taste. e) Toasting Generally applied for bread slices which are browned from both sides by keeping them between two grilles. Advantages 1. Improves color, flavor and texture of food. 2. Roasted seeds are easy to grind. 3. Roasting reduces the amount of moisture of foods Disadvantages 1. A continuous vigil is required to prevent burning. 2. Amino acids are lost while toasting. f) Baking The medium of cooking is hot air. A dry method of cooking, it combines steam which is generated while food is cooked. Cakes, custard, baked vegetables, bread, biscuit, pizzas are all baked food. Advantages 1. Texture and flavor of foods are improved. 2. Baking give rise to a variety of combination of dishes. 3. Foods are cooked uniformly in an oven. Disadvantages 1. An oven is required for baking. 2. Over cooking results in the burning and scorching of food. g) Blanching Blanching is a cooking process wherein a food, usually a vegetable or fruit, is scalded in boiling water or oil, removed after a brief, timed interval, and finally plunged into iced water or placed under cold running water (shocking or refreshing) to halt the cooking process. Advantages 1. Blanched dishes are healthy as there is minimal loss of nutrients because of the short cooking time. 2. Blanching also enhances the color of green vegetables, and the time taken is also lesser than other moist heat cooking methods. Disadvantages 1. Blanching cannot be used for every type of food item. 2. Blanching often needs to be coupled with another cooking process so as to provide more flavor to the final dish. ___________________________________________________________________________ UNIT 2: DIET IN HEALTH AND DISEASE (CAUSES, PHYSIOLOGICAL CONDITIONS, CLINICAL SYMPTOMS AND DIETARY MANAGEMENT) CHAPTER 5: FEVER (ACUTE & CHRONIC) CHAPTER 6: DIARRHOEA CHAPTER 7: EATING DISORDERS (ANOREXIA NERVOSA, BULIMIA, BINGE EATING) CHAPTER 8: OVERWEIGHT/OBESSITY CHAPTER -5: FEVERS (ACUTE&CHRONIC) (TYPES, CAUSES, CLINICAL SYMPTOMS AND DIETARY MANAGEMENT) Learning Objectives: After reading this chapter, the students will be able to: 1. Define the term fever and present the classification of fevers 2. Differentiate between acute and chronic fevers 3. Explain the causes, clinical symptoms and the metabolic changes during infection and fevers, and 4. Describe diet therapy during fevers. In the previous Unit we looked at the interrelationship between nutrition and infections. You would realize that infection and fevers are coexistent. Fever is an outcome of infection. In this section we will also look at the basic concepts and inter-relationship between fever, infection and nutrition. A detail review on dietary management of fevers will be presented. FEVER: DEFINITION, CAUSES & SYMPTOMS Fever is classically defined as the abnormal condition of the body, characterized by undue rise in temperature, quickening of the pulse, and disturbance of various body functions. Surely, you must be aware of the normal body temperature. Yes, the normal human body temperature may o o range from 36 C to 37 C (98.6F). So, technically any body temperature above the normal temperature may be considered fever. What do you think? Well, in practice an individual is usually not considered to have a significant fever until the temperature is above 100.4 (38° C). It is important to understand that fever is not an illness but it is a symptom or an adaptive response of our body to a variety of conditions, such as infection, inflammation or unknown causes. Fever may be caused by a bacterial infection or by a virus or certain inflammatory conditions such as rheumatoid arthritis (inflammation of the lining of the joints) or a malignant tumor etc. As a child you may recall suffering from cold/cough and/or chest infection or diarrhoea, and very often these infections were accompanied by fever. The clinical and behavioral manifestations of fever besides elevated temperature you might have experienced included headache, muscle ache, chills and shivering, sweating, loss of appetite, irritability, general weakness, dehydration etc. Fever is, therefore, a sign that something out of the ordinary is going on in the body. Fever, in fact, is part of the body's own disease-fighting mechanism. A rise in body temperature is one of the ways our immune system attempts to combat an infection Fever helps defend against microbial (bacterial/viral) invasions and apparently is capable of killing or inhibiting the growth of some bacteria/viruses that can tolerate only a narrow temperature range. From our review so far we may then conclude that usually a rise in temperature helps the individual resolve an infection. So a mild fever i.e. above the normal body temperature but below 100.4F (38° C) is probably helping to neutralize the bacteria or virus that is causing the infection. There is no need to worry. But sometimes fever may rise too high and can be severe and serious and lead to complications. Therefore it is important to learn about the classification, type and pattern of fever for appropriate management. FEVER: CLASSIFICATION AND TYPES Fevers are primarily classified into three categories: Acute, Sub-acute and Chronic fevers based on duration as highlighted in Figure 5.1. Figure 5.1 Classification of fevers Acute fevers are those which are for less than 7 days in duration and are characteristics of infectious diseases such as malaria and viral-related upper respiratory tract infections. Sub-acute fevers are usually not more than 2 weeks in duration as can be seen in cases of typhoid fever. Chronic fever on the other hand are persistent, usually more than 2 week in duration 2 Basal Metabolic Rate is defined as the rate at which our body uses energy when we are resting in order to keep the vital body functions (such as breathing, heart beating etc.) going and are typical of chronic bacterial infections such as tuberculosis, viral infections like HIV, cancers etc. Further, based on the height of the body temperature, fevers can also be classified as low grade, moderate grade or high grade fever. You would notice that a low grade fever does not exceed 0 37.8 C and is present daily especially in the evening. Tuberculosis causes low grade fever. Similarly you may come across fever types described as continuous or sustained fever, intermittent fever and remittent fever. Continuous/sustained fever is defined as a fever that does o not fluctuate more than about 1 C (1.5F) during 24h, but at no time touched normal. Continuous fevers are seen in pneumonia, typhoid, and urinary tract infection among others. Such fevers are characterized by slow step-wise temperature rise. Intermittent fever is defined as fever present only for several hours during the day. This pattern you may notice in malaria, tuberculosis or pyrogenic infections. Remittent fever, on the other hand, is defined as fever with daily o fluctuations exceeding 2 C but at no time touched normal. This kind of fever is always associated with infectious diseases such as infective endocarditis, rickettsiae Infection. Having looked at the different types and classification of fever, we shall focus next on management of fevers, with special reference to dietary management. Diet, you would notice plays an important role in the management of fevers. With the rise in body temperature, (above normal), several metabolic changes occur in the body that increases the nutritional needs. A brief review on these changes is presented next. METABOLIC CHANGES DURING FEVER Fever is usually characterized by certain metabolic changes. Higher the temperature, longer the duration of the fever, more is the ill effect. The common effects include:  Increase in the basal metabolic rate (BMR). Note, there is a 13% increase in BMR with every 1°C rise in body temperature.(or 7% increase with every 1°C increase in temperature).   Decreased glycogen stores and decreased stores of adipose (fat) tissue.   Increased catabolism (breakdown) of proteins, especially in case of typhoid, malaria, tuberculosis fevers. This results in production of excess amount of nitrogenous wastes, which places an additional burden on the kidneys.   Increased excretion of sodium, potassium, chloride etc. thought sweat, urine, vomiting leading to electrolyte imbalance.   Accelerated loss of body fluid in the form of excessive sweat and urine formation.   Loss of appetite which limits the food intake thus leading to weight loss.  Decrease in the absorption of nutrients like proteins, vitamins, minerals. The above changes accompanied by headache, muscle ache, chills and shivering, sweating, loss of appetite, irritability, general weakness, dehydration experienced during fever may have a significant effect on the nutritional status of the individual. Thus management of fever becomes critical. In the next section we shall look at the diet therapy for management of Fevers. We shall first consider the dietary management in sub-acute fever, followed by dietary therapy for chronic fever. DIETARY MANAGEMENT OF SUB-ACUTE FEVER Typhoid is a serious health threat in the developing world such as India, especially for children. We have already learnt that typhoid is a sub-acute continuous fever which can last for about two week’s duration. What is the cause of typhoid? Typhoid is caused by the Salmonella typhi bacteria, and is also called enteric fever because the bacteria or infection is found in the intestines. Typhoid fever spreads through contaminated food and water or occasionally through direct contact with someone who is infected. The mode of spread of this infection is, through fecal-oral route. Let us understand the concept of fecal-oral route here. Note, Salmonella typhi is passed in the feces and sometimes in the urine of infected people. The source of infection can be the drinking water or milk or any other food contaminated by intestinal contents (through faeces, urine) of the patient or by flies which transmit the disease. We can also contact the infection if we eat food handled by someone with typhoid fever who has not washed their hands carefully after using the toilet. A patient with typhoid will usually present with:   high fever, headache, loss of appetite, nausea and vomiting  gastrointestinal problems like abdominal pain and either diarrhoea or constipation.   increased BMR  massive loss of lean body mass (muscle) due to tissue (protein) breakdown leading  to excessive nitrogen loss.  significant decrease in glycogen and adipose tissue stores because of increased  energy expenditure.  excessive diarrhoea, vomiting leading to fluid and electrolyte losses. Dietary management in Sub-acute fever The main objective of dietary management during sub acute fever is to: i) provide a nutritious diet to prevent malnutrition. ii) restore positive nitrogen balance and reduce the burden on kidneys iii) provide relief to symptoms as and when present. iv) correct and maintain water and electrolyte balance, and v) avoid irritation of intestinal tract as may occur in typhoid. Thus the dietary management will focus on providing a diet that contains high calories, proteins, carbohydrates and moderate fat. But very often the fever is accompanied by anorexia, vomiting, nausea. You would notice the patient has poor appetite moreover is unable to tolerate food. So, the diet has to be modified as per the patients’ tolerance. The texture of foods given would depend on the patient’s tolerance. Initially a liquid or full fluid diet may be provided for few days. As the person’s appetite improves a bland diet, low fibre soft diet may be given which is soothing and easy to digest. Slowly the person may be put on a normal diet. The idea is to encourage the patient to eat so as to meet the increased nutrient requirements. Feedings several times a day need to be encouraged. The nutrient needs during typhoid and how to meet them is the focus of discussion next. The information is summarized in Table 5.1. Table 5.1: Dietary considerations and nutritional needs during sub-acute fever. 1600 Kcal Diet Chart Meal Menu Amount Early Morning Coconut water (Liquid and 1 glass (250ml) electrolytes) Glucose biscuit 2 No. Breakfast Potato sandwich with butter 1 portion (2 slices) (high calorie) Banana 1 No. (100-150gms) Apple Juice 1 glass (250ml) 10.00am Buttermilk (salty) 1 glass (250ml) Suji upma 1 katorie cooked Mid Morning (12:00noon) Clear dal soup 1 big bowl (200ml) Lunch Khichri 1 big bowl Soft Vegetable (Lauki/ 1 katorie cooked Tinda/ Pumpkin/potato) Washed dal 1 katorie cooked Curd 1 katorie Cooking oil 1 - 1½ tsp Evening tea Tea with sugar 1 cup with 2 tsp Glucose Biscuit 2 No. Evening Snack Lemon Water (sugar and 1 glass salt) 1 katorie cooked Stewed apple Dinner Boiled Rice 1 big bowl Soft Vegetable (Lauki/ 1 katorie cooked Tinda/ pumpkin/ potato) Washed dal 1 katorie cooked Curd 1 katorie Cooking Oil 1 1 ½ tsp Bed time Apple Juice 1 glass (250 ml) Following the dietary considerations highlighted in Table 5.1, we hope you should be in a position to plan a diet for a typhoid patient.. Do’s and Don’ts, and a list of what foods to give and what foods to avoid are highlighted herewith. You may consult the list while planning the diet. Table 5.2: Foods to include and foods to avoid in the diet of the typhoid patient Foods to include Foods to avoid 1. Plenty of fluids like juices, soups, 1. High fibre foods like whole grain coconut water, electrolyte, barley cereals and their products e.g. whole water, soups. wheat flour, whole wheat bread, oats 2. Milk and milk based beverages. and cracked wheat, whole pulses and 3. Bland, well cooked, well mashed, pulses with husk. sieved, soft, semisolid foods like 2. All raw vegetables and fruits with khichdi, rice with curd, suji hard skin or fibre such as green leafy kheer, custard etc. vegetables. 4. Low fibre foods such as refined 3. Strongly flavoured vegetable like s cereals and their products (e.g. cabbage, capsicum, turnip, raddish, maida, rava, bread, rice, noodles etc.) onion and garlic as they cause gas, dehusked pulses (washed dals), well bloating. cooked/stewed fruits, vegetables in 4. Thick creamy soups soft and puree form and potatoes. 5. Fried fatty foods such as samosas, 5. Foods providing proteins of high pakoras, puri, paratha etc. biologic value e.g. eggs, soft 6. Sweet concentrated foods using cheeses, tender meats, fish, poultry etc. excessive whole milk and dairy fat 6. Plain gelatin based desserts, sugars, including halwas, ladoos, pasteries, honey,candy and jam. desserts etc. 7. Acidic and spicy food such as pickles, relishes, chutneys, sauces, vinegar as they may irritate the intestine. 8. Spices condiments and seasonings , like pepper, cayenne and chilli powder to ensure that the digestive tract does not inflame all the more In addition to the list provided in Table 5.2, some do’s and don’ts basic tips are presented in Table 5.3: Do’s and Don’ts Do’s Don’ts 1. Always wash vegetables, fruits with 1. Avoid places that do not maintain clean water before eating. hygiene, avoid foods from street 2. wash hands frequently, particularly vendors before eating or preparing food and 2. Don’t buy open and cut fruits and after using the toilet vegetable from street vendors 3. Drink water that has been boiled, 3. Do not eat unwashed or unpeeled filtered and treated fruits and vegetables 4. Consume 3-5 liters of fluids in day in 4. Avoid eating large meals to prevent the form of water, fruit juices, tender discomfort coconut water and soup 5. Avoid excessive use of fats in 5. Eat small frequent meals cooking 6. Make sure the food is thoroughly 6. Avoid eating food at room cooked and served steaming hot temperature 7. Avoid unpasteurised dairy products 8. Avoid using ice made from tap or well water 9. Avoid close contact or sharing eating utensils, cups with people who are infected DIETARY MANAGEMENT OF CHRONIC FEVER Tuberculosis (TB), you may be aware, is an example of chronic fever caused by bacteria - Mycobacterium tuberculosis. The disease spreads from person to person through microscopic droplets released into the air by cough or spit or sneeze from a person with tuberculosis. Tuberculosis mainly affects the lungs but can get localized in other organs also, like lymph nodes, kidney, bone etc The most commonly observed form of tuberculosis in India is pulmonary tuberculosis. It is worthy to note that tuberculosis remains a major global health problem and is one of the top 10 causes of death and the leading cause from a single infectious agent. It is linked to poverty, under nutrition and poor immune function. When a person is infected with pulmonary tuberculosis, in a normal healthy individual, the immune system help fights the infection and the bacteria in the body are in an inactive state and the person shows no symptom. This is called latent tuberculosis. However, if the body's immune system is unable to fight the bacteria the disease becomes active and is contagious and can spread in the body and to other people. The association between TB and undernutrition has long been known. TB makes undernutrition worse and undernutrition weakens immunity, thereby increasing the likelihood that latent TB will develop into active disease. The common symptom with active TB in individuals is that they:  are in a catabolic (breakdown of protein/body tissue) state leading to muscle wasting,   experience weight loss,   have fever, fatigue, exhaustion and persistent coughing,   show signs of vitamin and mineral deficiencies, and   have low body mass index (BMI) (lower than 18.5 kg/m2). Why do you think weight loss occurs among those with TB? Weight loss can be caused by several factors, including:  reduced food intake due to loss of appetite, nausea and abdominal pain;   loss of protein and other nutritional reserves due to fever ,   malabsorption due to diarrhoea,   loss of fluids, electrolytes   metabolic alterations caused by the disease, and   an increase in the energy expenditure of the patient in an attempt to fight infection The progression of the disease may be slow gradual but can lead to serious consequences. The key to treatment, therefore, is early detection, followed by antibiotic therapy, adequate rest and diet management. Children with TB, in particular, need special attention since the child has increased requirements as a result of both growth and TB. Tuberculosis is completely curable through short-course chemotherapy. Treating TB cases who are sputum-smear positive (and who can therefore spread the disease to others) at the source, it is the most effective means of eliminating TB from a population.DOTS or Directly Observed Treatment Short course is the internationally recommended strategy for TB control that has been recognized as a highly efficient and cost-effective strategy. Let us study the dietary management next. Dietary Management of tuberculosis As undernutrition is highly prevalent among people with TB, the dietary recommendations for TB patients are based on the nutrient and energy requirements for hyper catabolic and undernourished patients. The main objective of diet therapy is to prevent weight loss, strengthen the immune system and accelerate recovery. An adequate diet containing all essential nutrients namely carbohydrates, fats, proteins, minerals and vitamins is necessary for the well being and health of the TB patient. Dietary considerations for tuberculosis Here are some recommendations on how to monitor weight gain in TB patients, particularly in children:  Encourage the individual to eat healthy, nourishing balanced diet.   TB often adversely affects nutritional intake due to poor appetite, making patients at risk for malnutrition. Encourage patients to consume six smaller meals per day instead of three.   Make the meals appetizing in appearance and taste and provide enough energy and protein.   Commercially-available high energy and protein drinks (balanced in terms of micro- and macronutrients) may be used effectively to meet the increased requirements.   Household ingredients such as sugar, vegetable oil, peanut butter, eggs and non-fat dry milk powder can be used in porridge, soups, gravies, milk based-drinks to increase the protein and energy content without adding to the bulk of the meal.   At least 500ml to 1litre milk (or milk product like yoghurt t, soft cheese) should be consumed daily to ensure adequate intakes of vitamin D and calcium.  Ensure consumption of at least five to six portions of fruit and vegetables per day. Pure fruit juice can be used to decrease the bulk of the diet.   Provide adequate fluid intake (at least 10 to 12 glasses per day) to compensate for increased losses   Provide a good multivitamin and mineral supplement.   Ensure safe food handling and personal hygiene. Now, can you now summarize the dietary recommendation for a TB patient. Prepare a list of foods you may include liberally or restrict/avoid in the diet of a TB patient. Table 5.4: Foods to include and to be restricted/ avoided in the diet of tuberculosis patient Foods to include Foods to avoid 1. Cereals and millets (wheat, rice, ragi, 1. Red meat and organ meats jowar) 2. Limit refined foods 2. Pulses (rajma, black chana, soyabean) 3. Strongly flavored vegetables 3. High energy, protein drinks and 4. Excess fat beverages 5. Fried fatty food 4. Foods providing proteins of high 6. Sweets concentrated food biologic values ex.- eggs, soft cheese, 7. Acidic and spicy food such as pickles tender meat, fish etc. 8. Spices, condiments and seasoning 5. Cereals pulse combination with some animal protein ex. Khichri with curd etc. 6. Nuts and oil seeds like pea nuts 7. Seasonal fruits and vegetables 8. Green leafy vegetables like maithi, mint, spinach, cabbage etc. 9. Citrus fruits 10. Milk and milk products 11. Vegetables oils and dairy fat like ghee 12. Jaggary and sugar We end the dietary management of TB patients with some Do\s and Don’ts. Table 5.5: Do’s and Don’ts Do’s Don’ts 1. Always washed vegetables and fruits 1. Do not serve large meals to prevent with clean water before serving discomfort 2. Wash hands frequently particularly 2. Do not excessive fat in cooking before eating or preparing food 3. Consumption of tobacco and alcohol 3. Give plenty of fluids and electrolytes to should be avoided compensate for loses 4. Caffeine tea consumption should be 4. Provide 6 frequent meal per day avoided 5. Include 5-6 portion of fruits and 5. Avoid close contact or sharing utensils, vegetable in the diet each day cups with people who are infected 6. Include meals which are easy to digest well tolerated 7. provide a good multivitamin and mineral supplements ______________________________________________________________________________ CHAPTER 6: DIARRHOEA (TYPES, CAUSES, CLINICAL SYMPTOMS AND DIETARY MANAGEMENT) Learning Objectives: After reading this chapter, the students will be able to: 1. Define diarrhoea and review the different terminologies used in the context of diarrhoea, 2. Differentiate between different types of diarrhoea, 3. Explain the causes, clinical symptoms and the metabolic changes during diarrhoea and 4. Describe the diet therapy during diarrhoea. We have looked at the basic concepts and inter-relationship between fever, infection and nutrition in our study so far. Diarrhoea, an infection, is an important public health problem among under-five children in developing countries. Recent evidence suggests that diarrhoea is the third leading cause of childhood mortality in India, and is responsible for 13% of all deaths/year in children under five years of age. This chapter will focus on the classification/terminologies, determinants, preventive and control strategies of diarrhoea and dietary principles for management of diarrhoea at home or in a community setting. DIARRHOEA: DEFINITION, CAUSES & SYMPTOMS As per the World Health Organization (WHO), diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than normal for the individual). Now consider the following cases. Case 1: Rani is a 2-year-old girl. She has a history of frequent passing of stools but they are well formed. As a baby who was breast fed, even then, Rani use to pass loose “pasty” (semi formed) stools. Her mother is worried. Case 2: Ramu is a 2-year-old boy. He has a 2-day history of watery diarrhoea. His mother informs that he has had several episodes of loose motions with 4-5 loose liquid stools passed per day. In your opinion are the two children suffering from Diarrhoea? Before you jump to any conclusion, please read the definition of diarrhoea once again more carefully. Then comment on each case. Diarrhoea is the passage of three or more liquid or watery stools in a day. Here the consistency and character of stools rather than the number of stools alone is critical. Figure 6.1: Types of diarrhoea Now, considering the two cases mentioned above, Ramu is more likely to be suffering from diarrhoea as his stools are liquid, watery and off course frequent. Rani, though was passing frequent stools but the stools were well formed. Hence, she is not likely to be suffering from diarrhoea. Remember, Diarrhoea is characterized by the frequent passage of liquid stools, which is accompanied by excessive loss of fluids and electrolytes, especially sodium and potassium. Diarrhoea, is a symptom and not a disease. This must be clear to you. SYMPTOMS OF DIARRHOEA Diarrhoea is associated with symptoms depending on the cause and who is affected. Common symptom, however, include:   Watery, thin or loose stools   Abdominal cramps   Sense of urgency to have a bowel movement  Nausea and vomiting In addition to the symptoms described above, the symptoms of severe persistent diarrhea include:   Dehydration   Blood, mucus, or undigested food in the stool   Weight loss  Fever Diarrhoea can be life-threatening! During diarrhoea, the stools have high water content – an indicator that water is being lost in higher than normal amounts. The stools also contain a high amount of electrolytes (sodium, potassium). This results in the deficiency of water and electrolytes in the body which is referred to as dehydration. By now, you must have understood the consequences of diarrhea/dehydration and can appreciate that it is the highest cause of illness and death especially in children. So an understanding on what causes diarrhoea needs urgent attention. Causes of diarrhea  Diarrhoea, is usually a symptom of bowel infection. The infection may be caused by a  wide range of pathogens, including bacteria, viruses and protozoa. These include:  Bacteria, such as Campylobacter, Clostridium difficile (C. difficile), Vibrio cholerae (causing cholera) (Escherichia coli (E. coli), Salmonella and Shigella: they all may cause  food poisoning  Virus, such as a Norovirus or Rotavirus  Parasites, such as the Giardia intestinalis, that causes Giardiasis Infection is spread through contaminated food or drinking-water or from person to person as a result of poor hygiene. Poverty, ignorance, poor sanitation is often the underlying risk factors Diarrhoea caused by contaminated food or water while travelling is often known as traveller’s diarrhoea. Recognizing the ill-effects, management of diarrhoea, particularly in the context of management of dehydration and malnutrition is crucial which is discussed next. TREATMENT AND MANAGEMENT OF DIARRHOEA Diarrhea/dehydration should not be neglected and must receive prompt medical care to minimize the frequency of morbidity and mortalities. In light of the complications discussed above let us now examine what should be the objectives in the management of diarrhoea and more specifically dehydration. The major objectives in the management of diarrhoea include: 1. Fluid and electrolyte replacement 2. Removal of cause (especially if infection) 3. Nutrition concerns 4. Determining the status of dehydration 5. Fluid management(ORT-Oral rehydration therapy) 6. Nutritional management The first step in diarrhea management is to determine the status of dehydration. Let us consider this Determining the status of Dehydration Table 6.1: Recognizing dehydration Dehydration status Sign/Symptoms Some dehydration Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back Slowly Severe dehydration Two of the following signs: Lethargy or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly Figure 6.2a: Sunken eyes - a sign of dehydration Figure 6.2b: Skin pinch - goes back slowly A review on the use of ORT and the fluid therapy in the management of dehydration is presented next. The key to diarrhoea management is the early replacement of fluid lost in the stools through intravenous or oral route (by mouth). Oral Rehydration Therapy (ORT) is at the core of management of diarrhoea. A review on the use of ORT and the fluid therapy in the management of dehydration is presented in this section. First let us understand what is ORT? Oral rehydration therapy is a simple treatment for dehydration associated with diarrhoea. The term ORT includes:   Complete oral rehydration salts (ORS) solution,  Solutions made from sugar and salt,  Food based solutions, and  Home fluids without insisting on specified amounts of glucose and salt.. The term ORS refers to the complete oral rehydration salt mixture. ORS is potentially the most important medical advance of this century. It is safe, effective and cost saving. ORS can alone successfully rehydrate 95-97% individuals with diarrhoea. A single universal ORS solution containing: sodium - 75 mmol/l and glucose - 75 mmol/l, osmolarity 245 mosmol/l is recommended for all ages and all types of diarrhoea. How much of ORS to give for replacement of ongoing stool losses to maintain hydration. Refer to Table 6.2 for easy reference. Table 6.2: ORS guidelines for replacement of ongoing losses to maintain hydration Age After each liquid stool, offer < 6 months Quarter glass or cup * (50 ml) 7 months to less than 2 years Quarter to half glass or cup * (50-100 ml) 2 up to 10 years Half to one glass or cup* (100-200 ml) Older children and adults As much as desired * Large tea cup Besides ORS, other oral rehydration therapies can also be used and recommended, when ORS is not available. These other oral rehydration therapies are presented in Table 6.3. Table 6.3: Other oral rehydration therapies* Composition per litre Appropriate use Home made fluids Sugar (Sucrose) 40g Prevention of dehydration Sugar and salt solution Salt (NaCl) 4g Food based solutions -Rice approximately 50g Prevention of dehydration -Rice water* with salt (precise measurement not required -Dal or dal water with salt -Salt 4g -Butter milk (Lassi) with salt -Soups with salt _________________________________________________________________________________ CHAPTER 7-EATING DISORDERS (DEFINITION, CAUSES, PHYSIOLOGICAL CONDITIONS,CLINICALSYMPTOMSAND DIETARY MANAGEMENT) Learning Objectives: After reading this chapter, the students will be able to: 1. Define the term eating disorder, 2. Define and differentiate between different types of eating disorders, 3. Explain the causes, clinical symptoms, metabolic changes and consequences of eating disorders, and 4. Discuss the management of eating disorders with special reference to nutritional management. Disordered eating behavior includes a wide range of eating related problems such as inadequate eating pattern, including binge eating, purging and restrictive diet to lose or control weight, unhealthy dieting practices, maladaptive behavior related to dissatisfaction with body shape or size. Adolescents, young adulthood is a period of increased awareness of one’s body appearance and having a distorted body image or negative perception about one’s body weight and shape during this phase of life can be a potent cause of several unhealthy body- related behaviors and disordered eating patterns. In this chapter we will focus on these issues. We will learn about eating disorders - the types, causes, consequences and what dietary measures to adopt to manage the disordered eating condition. WHAT ARE EATING DISORDERS? Eating disorders are illnesses in which the people experience severe disturbances in their eating pattern/behaviors and related thoughts and emotions. People with eating disorders typically become pre- occupied with food and their body weight. These disorders can affect a person's physical and mental health. Eating disorders are serious and sometimes fatal and life- threatening. Disorders include binge eating disorder, bulimia nervosa, and, less common but very serious, anorexia nervosa. These conditions are defined herewith. Binge eating disorder Binge eating disorder is characterized by recurrent binge (excessive indulgence in eating) episode during which a person feels a loss of control and marked distress over his or her eating. Three particular features are characteristic of binge eating. These include: i) the amount of food eaten is larger than most persons would eat under similar circumstances, ii) the excessive eating occurs in a discreet period, usually less than 2 hours, and iii) the eating is accompanied by a subjective sense of loss of control. Bulimia Nervosa Bulimia nervosa is an disorder characterized by binge eating (eating large amount of food in a short time, along with the sense of loss of control) followed by a type of behavior that compensates for the binge, such as purging (including self-induced vomiting), excessive use of laxatives or diuretics, fasting and/or engaging in excessive exercise. People with bulimia can fall within normal range for their weight. But, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Anorexia Nervosa Anorexia refers to loss of appetite. Anorexia nervosa, therefore, is a disease characterized by a significant and persistent reduction in food intake leading to extremely low body weight in the context of age, sex, and physical health. Features characteristic of anorexia nervosa include: i) a relentless pursuit of thinness, ii) a distortion of body image and intense fear of gaining weight, and iii) extremely disturbed eating behavior. CLINICAL CHARACTERISTICS, SIGN, SYMPTOMS OF EATING DISORDERS Having looked at the different types of eating disorders surely you may be able to distinguish between these specific conditions. To help you recall, you studied that:  Unlike bulimia nervosa, in binge eating disorder, binge eating episodes are not followed by purging, fasting or excessive exercise. People with binge eating disorder are often overweight or obese,   Unlike anorexia nervosa, people with bulimia can fall within the normal range for their weight.   People with anorexia see themselves as overweight, even when they are starved or severely malnourished. Some common clinical characteristics and sign, symptoms associated with these disorders are highlighted in Table 7.1. Surely they will help you in diagnosis or further identification of an eating disorder. Table 7.1: Clinical features, signs and symptoms of eating disorders Bulimia Nervosa Binge Eating Disorder Anorexia Nervosa - Profound Weight loss - Frequent fluctuations in - Food seeking in the leading to weight. Individual is usually absence of hunger (such maintenance of body normal weight to overweight as after a full meal), weight 15 percent below - Excessive eating, amount - Eating large amount of normal, of food eaten is large at food in a short time, along with - Dieting, deny hunger, even one time, the sense of loss of control, when one is thin or - A sense of lack of control emaciated, - Purging (self-induces over eating, - An intense fear of weight vomiting) after meals - Absence of purging (self- gain or becoming fat - Inability to voluntarily induced vomiting), fasting despite the individual's stop eating/feeling guilty or or excessive exercise underweight status; ashamed about eating, - Excessive or - Overeating in reaction to compulsive exercising, emotional stress. - Delayed puberty (if early onset) and in females, - Irregular periods in women amenorrhoea - Swollen glands , tooth i.e. absence of atleast decay three consecutive - Depressive moods menstrual cycles, - Persistent over concern - Strange eating habits such with body shape and weight as avoiding meals, eating in secret, monitoring -Exercising or dieting every bite of food excessively - Sensitivity to cold -Using laxatives, diuretics or other pills after eating when - In severe cases, the bones they are not needed protrude through the skin, as there is hardly any - Dehydration, Electrolyte body fat. imbalance which can lead to - The skin may be dry and kidney and heart failure scaly. - Body hair is increased (excessive growth of coarse hair in women), People with eating disorders may struggle with one or more of the following psychological problems: distress, anxiety, feeling of helplessness, low self esteem, inability to concentrate, unable to engage in conversation and withdrawn. The reality behind these conditions is that the brain is literally unable to function properly due to the lack of nutrition available to the body. Thus knowledge of these signs/symptoms is critical. Understanding the signs, symptoms will help in identifying target symptoms and behaviors that will be addressed in the treatment plan. We will learn about the management of eating disorders later in this chapter. Next let us look at the causative factors. WHAT CAUSES EATING DISORDERS The exact cause of eating disorders is not known. But, it is thought to be multi-factorial in origin. The multidimensional causative factors may include: vulnerable personality; psychological conflicts – individual and family relationship; socio-cultural environmental factors - cult of thinness, hazardous dieting, social class and race and finally genetic and constitutional factors. The best-known environmental contributor to the development of eating disorders is the socio-cultural idealization of thinness. Young children start to express concern about their own weight or shape or about becoming too fat. Beauty and appearance anxiety are critical global issues and media and advertizing are key factor driving this concern. Pictures, television, magazines influence children’s/adolescents concept of the ideal body shape, influencing them to want to lose weight and promoting unrealistic standard of beauty. This concern endures through life. Bullying, weight stigma has been identified as yet another factor. Overweight girls and boys are teased about their weight by peers or family members. Individuals report coping with weight stigma by eating more food. Weight teasing or weight-based victimization among youth thus predicts weight gain, frequent binge eating, are at increased risk for eating disorder symptoms, and are more likely to have a diagnosis of binge eating disorder. Weight stigma is also a significant risk factor for depression, low self esteem and body dissatisfaction among individuals. Occupation/profession may also play a role. Athletes are at-risk, especially those competing in sports that tend to emphasize diet, appearance, size and weight, such as weight-class sports (wrestling, rowing, horseracing etc.) and aesthetic sports (bodybuilding, gymnastics, swimming etc.). Though most athletes with eating disorders are females, but male athletes also are at-risk. Similarly dancers have a prevalence of anorexia 10 times that of general population MANAGEMENT OF EATING DISORDERS The management of eating disorders should be a multidisciplinary approach. A multidisciplinary team comprising of a physician, nutritionist and psycho-therapists is usually involved in their management. The treatment of eating disorders can be said to have three components. A) Medical and Biochemical Management B) Nutritional Management, and C) Psychological Management Our focus in this unit will be only on nutritional management as psychological and medical management are not within our preview. Nutritional Management of Eating Disorders Here in this section we will consider the components of the management of anorexia nervosa and bulimia nervosa together, since the nutritional consequences and nutritional management for both these conditions are on similar lines. Malnutrition due to low or poor consumption of energy-giving macronutrients, such as carbohydrates, fats, proteins and/or micronutrients relative to individual needs is a concern with both anorexia nervosa and bulimia nervosa. In both the cases, consideration needs to be given to symptoms of the starvation syndrome. Starvation syndrome here refers to starvation caused either by food restriction/dieting as in anorexia nervosa or problems related to food absorption as in purging or excessive exercise may mean that insufficient energy is consumed for weight maintenance in bulimia nervosa. An illustrative 3000Kcal diet plan/menu is presented in Table 7.2 for reference. Table 7.2: Menu for a 3000 kcal diet for an eating disorder (anorexic) patient Early Breakfast Mid- Lunch Mid Evening Dinner Morning Morning Afternoon Tea (Snack) (Snack) (Snack) Milk shake (1 Paushtik Veg. Soup Chapati Veggie pasta Fruity Chapati (4) glass) OR Methi roti with cream (2)+ or Vegetable Muffin Dal (1 Fried Rice katori) Aloo Milk with any (2) OR Veg. and croutons Upma OR (1 katori) Gobhi supplement yogurt (1 bowl) (1 bowl) Cup Cake + Soya Sabji (1 like Ensure sandwich chunks (1) Milk(1 Nuts (8-10 (2) + Cup) katori) Mint curry (1 chutney pieces) Milk (1 cup) katori) Cuatard or + Sewiya (1 Vegetable bowl) (1 katori) + Raita(1 Katori) The menu involves 3 meals per day and some snacks as appropriate with foods incorporated from all food groups to promote optimal nutrition. Based on the likes, dislikes of the patient the meals may be altered provided they are balanced. Some do’s and don’ts related to management of eating disorders are highlighted herewith. Remember eating disorders are long term illnesses and people recover slowly. Be patient and encourage the patient not to give up. Do’s Don’ts - Educate yourself about the eating disorder. - People with eating disorder are extremely This will equip you to help those around self-conscious about their eating habits. Do you suffering from the problem not nag them about eating or not eating. - Family support is extremely important, This will reinforce the behavior. especially in helping the recovering patient - Do not blame or shame the person. with everyday tasks. Educate the family, - Do not hide food to keep the person from friends regarding the disorder and binge eating. This will create resentment Encourage them to attend family - Do not force the person to eat. This will counseling sessions. make them feel out of control or childish. - Encourage the patient to seek medical help. This will reinforce the behavior But, don’t be too forceful. This will make - Don’t comment positively or negatively on them more anxious appearance, shape or weight. - Encourage the person not to blame herself/himself or feel guilty or dwell on causes - Encourage the patient to attend support groups and read current literature - Encourage the patient not to skip meals or talk about dieting ------------------------------------------------------------------------------------------------------------------------------ CHAPTER: 8 OVER WEIGHT/ OBESITY (DEFINITION, CAUSES, CLINICAL SYMPTOMS AND DIETARY MANAGEMENT) Learning Objectives: After reading this chapter, the students will be able to: 1. Define the term overweight and obesity 2. Explain the causes, clinical symptoms, metabolic changes and consequences of obesity, 3. Discuss the general strategies for obesity prevention, and 4. Describe the dietary management of obesity. World Health Organization (WHO) defines Overweight and Obesity as a condition of abnormal or excessive fat accumulation that presents a risk to health. So any individual with more than 120% of ideal body weight may be considered as overweight. The ideal body weight (IBW) can be calculated by the formula: IBW = (height in cm -100) × 0.9 A simple measure, however, commonly used to classify overweight and obesity across all ages is BMI (Body Mass Index). BMI is defined as person's weight in kilograms divided by the square of his/her height in meters (kg/m2). [BMI = Weight (kg)/Height (m) 2] Overweight, Obesity among Adults BMI is considered to be the most useful population-level measure of obesity, as it is the same for both sexes and all ages of adults. The BMI based classification for adults (both International and for Asian population) is given in Table 8.1. As you may have noticed that WHO defines overweight and obesity as follows: overweight is a BMI greater than or equal to 25; and obesity is a BMI greater than or equal to 30. But, for Indian population, BMI between 18.5 and 23 is considered normal, since they tend to have higher percentage body fat even at lower BMI as compared to the European population. BMI greater than or equal to 23 is considered overweight/obese for Indian adult as indicated in Table.1. Table 8.1: BMI categories for adults (WHO) Body Mass Index (BMI) International Asian population Class 2 2 25 kg/ m Obese Note, the BMI classification presented in Table 8.1 is specific to adult population only. You can use this classification to categorize adults into different grades of malnutrition. First calculate the BMI (based on weight and height) and then check in which class the individual's BMI falls. To illustrate, an Indian female 2 (30 years of age) who weighs 70kg and height is 1.6 meters, BMI calculated is: 70/1.6 ×1.6 = 27.34kg/m. As per BMI classification (Asian population in Table 8.1), the individual is obese. BMI cut-off levels for categorizing overweight and obesity among children and adolescent are different. The BMI classification presented in Table 8.1 is not applicable to children and adolescent. WHO has given the ideal ranges of weight for a given height for children 5-19 years of age. These Tables are useful for categorizing children as normal, under-nourished and overweight or obese. Obesity is defined based on the degree of excess fat. More than a general accumulation, the distribution of fat around the abdomen is now considered more harmful than fat around the hips. Accumulation of fat around the abdomen indicated by higher waist circumference is classified as central obesity. Waist circumference of 90cm for men and 80 cm for women classified as central obesity is associated with increased risk of several chronic diseases. Figure 8.1 Fat around abdomen Table 8.2: Indirect measures of body fatness (other than BMI) Measurements Descriptions Skinfold thickness Skin fold thickness is being used for estimating the body fat content. This (SFT) requires special instruments called 'calipers'. Skin folds at different parts of the body (triceps, biceps, sub-scapular, supra-iliac, front thigh and calf) have been used for estimating body fat. Specific equations are used to convert the skin fold thickness into the body fat content. Advantage: Relatively simpler, non invasive and apart from the total body fat content, it can also indicate about the body fat distribution. Waist circumference WC is highly sensitive and specific measure of central obesity. Cut off values (WC) for adults available as highlighted earlier. Advantage: Simple technique Disadvantage: For children no Indian data available and not widely used. Waist hip ratio WHR= Waist circumference / Hip circumference. (WHR) WHR cut offs available for adult males and females but not for children. WHR of more than 0.9 among men and 0.85 in women are associated with increased risk of several chronic diseases. WHY SHOULD WE AVOID OBESITY? Maintaining an ideal body weight is crucial for good health. There is no clear definition of ideal body weight, but body weight for a given height of a person with good health and long lifespan is considered as ideal body weight. Excessive body weight increases the risk of chronic diseases such as heart disease, hypertension, diabetes, certain types of cancers, osteoarthritis etc. Excess body fat broadly affects every organ in the body with multi-organ consequences. Major health consequences have been illustrated in Figure 8.2. Figure 8.2: Major health consequences of overweight and obesity Obese children are not only at risk to become obese adults, and consequently suffer from ill health and premature death, but serious complications can also emerge during their childhood. Children with obesity have more risk factors for heart disease like high blood pressure and high cholesterol than their normal weight peers. Children with obesity are also at higher risk for having other chronic health conditions and diseases, such as asthma, sleep apnea, bone and joint problems. Type 2 diabetes is increasingly being reported among children who are overweight. Onset of diabetes in children can lead to heart disease and kidney failure. Overweight and obese adolescents may also suffer from: - depression, low self-esteem, and behavioral problems, - stigmatization (teasing, harassment, and rejection) and bullying behavior by their peers, - psychological distress manifested by poor self-image, aggressive and negative behavior, depression, suicide, and - drug abuse, alcohol and tobacco addiction. In view of the rising obesity prevalence, many of the young children and adolescents have developed ‘fear of fatness’ and are adopting various dietary and behavioral practices to lose weight and remain thin, even if they have normal BMI. It is more seen in urban areas at this moment. These individuals are at higher risk of developing eating disorders. Apart from health consequences which we discussed above, body fatness has other implications also. These are economic and academic burden. It has been estimated that obesity accounts for 2% to 7% of total healthcare costs in developed countries. There are also other costs to consider such as reduced quality of life and productivity loss attributed to decreased work efficiency and medical issues. With regards to academic consequences, among obese adolescents, higher school absenteeism, dropout and lower academic achievement have been seen. But, drawing definite conclusion on this issue is difficult. Considering the ill effects of obesity it is important that we look at the causes of obesity. The next section focuses on etiology of obesity. WHAT CAUSES OBESITY? Figure 8.3: The causes and risk factors of obesity Overweight and obesity, are broadly the result of an imbalance between energy intake (food) and energy expenditure (physical activity and some other metabolic activity). The imbalance might be due to excess energy intake (overeating) or reduced energy expenditure (sedentary lifestyle). The excess of energy consumed is stored in the body in the form of adipose tissue. When food availability is less, it could be seen as a survival mechanism, but when food is abundant and the physical activity level decreases, this results in fat deposition. Table 8.3 lists the key factors that might promote weight gain and obesity. Table 8.3: Summary of factors that promote weight gain and obesity - High intake of energy-dense, micronutrient poor foods - Heavy marketing of energy-dense foods and fast food outlets - High intake of sugar-sweetened soft drinks and fruit juices - Sedentary lifestyle - Adverse socio-economic conditions - Large portion sizes - High proportion of food prepared and eaten outside the home - Rigid restraint/periodic disinhibition eating patterns - Alcohol Source: Joint FAO/WHO Expert Consultation. WHO Technical Report Series 916: Diet, Nutrition and the Prevention of Chronic Diseases. World Health Organization; Geneva, Switzerland: 2003 As highlighted in Table 8.3, increased risk factors include a higher energy density diet with increased intake of fat and added sugars, salt in foods. Eating junk or unhealthy foods coupled with low physical activity (sedentary lifestyle) promotes weight gain. Saturated fat intake (mostly from animal sources), marked increases in animal food consumption, reduced intakes of complex carbohydrates and dietary fiber, and reduced fruit and vegetable intake are other contributing factors. Over-feeding during infancy, childhood and adolescence predisposes to overweight/obesity in adulthood. Further, lack of access to healthy foods as determined by adverse socioeconomic conditions influences the diet and health of a population. Energy-dense and nutrient-poor foods provide daily calories at an affordable cost to the poor groups hence consumed in large portions. On the other hand, the commercial driven food market environment is other probable causes of obesity. The traditional micronutrient-rich foods consumed by children/families are replaced by heavily marketed, sugars-sweetened beverages (i.e. soft drinks) and energy dense fatty, salty and sugar foods (HFSS snacks), contributing to obesity. The dietary changes highlighted above are compounded by lifestyle changes that reflect reduced physical activity at work/school and during leisure time. Evidence suggests that insufficient physical activity is one of the important risk factors of obesity, and work-related activity has declined over recent decades, whereas, leisure time dominated by television viewing and other physically inactive pastimes has increased, particularly among children. Considering the multifaceted causes of obesity it is important that appropriate strategies based on improved dietary practices and physical activity for prevention of obesity are considered. The next section focuses on prevention strategies followed by dietary management of obesity. GENERAL STRATEGIES FOR OBESITY PREVENTION The prevention of obesity in infants, young children, adolescents and adults should be considered of high priority. There can be no single or simple solution to the in

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