834_food nutrition - xii (1).pdf

CBSE Study Material for Students FOOD NUTRITION AND DIETETICS Class XII Central Board of Secondary Education  FOOD NUT RIT ION AN D DI E TE TI C S CBSE STUDY MATERIAL FOR STUDENTS...

CBSE Study Material for Students FOOD NUTRITION AND DIETETICS Class XII Central Board of Secondary Education  FOOD NUT RIT ION AN D DI E TE TI C S CBSE STUDY MATERIAL FOR STUDENTS FOOD NUTRITION AND DIETETICS Class XII CENTRAL BOARD OF SECONDARY EDUCATION (A Constituent Unit of NCERT, Under Ministry of Human Resource Development) CE NT RAL BOAR D OF SECONDARY EDUCATION i FO O D N U TR ITI O N AND D I E TE T ICS FOOD NUTRITION AND DIETETICS Class - XII Price : ` 00.00 CBSE, Delhi-110092 1st Edition : December 2021 Paper used : 100 GSM Art Paper © Central Board of Secondary Education Copyright protects this publication. Except for purposes permitted by the Copyright Act, reproduction, adaptation, electronic storage and communication to the public are prohibited without prior written permission. Published by : The Secretary, Central Board of Secondary Education, Shiksha Kendra, 2, Community Centre, Preet Vihar, Delhi-110092 Design, Layout & Printed by : Vijaylakshmi Printing Works Pvt. Ltd., B-117, Sector-5, Noida, Ph.: 0120-2421977, 2422312 ii CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S CE NT RAL BOAR D OF SECONDARY EDUCATION iii FO O D N U TR ITI O N AND D I E TE T ICS iv CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S PREFACE The development of students’ hand book for the skill subject under the National Skill Qualification Framework (NSQF), has been undertaken under the esteemed leadership & guidance of the Ministry of India. The NSQF sets common principles and guidelines for a nationally recognized qualification system for Schools, Vocational education & Training institutions, Technical education institutions, Colleges and Universities. It is envisioned that NSQF will foster transparency of qualification, cross – sectoral as well as student-centric learning and aid learner’s mobility amid different qualifications, which consequently will promote lifelong learning. The National Education Policy (NEP) 2020 recommends that children’s learning exposure at school must be not be confined to four walls of the classroom. This perception makes a departure from the legacy of bookish learning which continues to shape our system and causes a gap between the schools, home, community and the workplace. This student workbook, which has been developed keeping in view the set by the Healthcare Sector Skill Council (HSSC) for the Role of Dietetic Assistant/Dietary Assistant is meant for students who have passed class XI. The success of education in schools depends on the steps that principals and teachers will take to encourage children to reflect on their own learning and to pursue imaginative and on-the-job training activities. The students’ handbook has been conceptualized, developed and reviewed by Dietetics experts of AIIMS, IGNOU and MoHFW and their contributions are deeply acknowledged. The utility of the handbook will be decided by the qualitative improvements it will bring in the journey of teaching and learning. The feedback and suggestions on the content by the teachers and other stakeholders will be of enormous importance to us in reflecting, reviewing and refining our work. Chairperson, CBSE CE NT RAL BOAR D OF SECONDARY EDUCATION v FO O D N U TR ITI O N AND D I E TE T ICS ACKNOWLEDGEMENTS Advisory, Editorial and Creative Inputs: Sh. Manoj Ahuja, IAS, Chairman, Central Board of Secondary Education Guidance and Support: Dr. Biswajit Saha, Director (Skill Education & Training), Central Board of Secondary Education Dr. Joseph Emmanuel, Director (Academics), Central Board of Secondary Education Content Reviewed by: Dr. Sushma Sharma, Lady Irwin College, Delhi Dr. P.R. Janci Rani, Assistance Professor, Food & Nutrition & Health Education Center Dr. Anupama Saxena, (Ph.D.Litt), Principal, Gargi Girls School, Merrut Content Developed by: Dr. Parmeet Kaur, Chief Dietician, All India Institute of Medical Sciences, New Delhi Prof. Deeksha Kapur, Discipline of Nutritional Sciences, SOCE, IGNOU, New Delhi Ms. Aparna Pareek, Assistant Dietician, AIIMS, New Delhi Mrs. Anita Khosla, Principal, GD Goenka Public School, Dwarka, New Delhi Mrs. Deepti Sharma, PGT Biology, GD Goenka Public School, Dwarka, New Delhi Curator and Co-ordinator: Sh. Ravinder Pal Singh, Joint Secretary, Department of Skill Education, Central Board of Secondary Education Ms. Moushumi Sarkar, Deputy Secretary, Department of Skill Education, Central Board of Secondary Education Cover & Back Page by: Navya Kataria and Dewangi Bhaumik, Class-VIII, GD Goenka Public School, Dwarka, New Delhi Illustrations by: Dew Mondal, Class-XII, GD Goenka Public School, Dwarka, New Delhi vi CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S CONTENTS PREFACE (v) ACKNOWLEDGEMENTS (vi) CONTENTS (vii) UNIT 1 CLINICAL AND THERAPEUTIC NUTRITION 1 Chapter 1 Therapeutic Nutrition 3 Chapter 2 Therapeutic Diets 7 Chapter 3 Nutrition and Infection 15 Chapter 4 Methods of Cooking 21 UNIT 2 DIET IN HEALTH AND DISEASE-I 27 (Causes, Physiological Conditions, Clinical Symptoms and Dietary Management) Chapter 5 Fever (Acute & Chronic) 29 Chapter 6 Diarrhoea 41 Chapter 7 Eating Disorders 47 (Anorexia Nervosa, Bulimia, Binge Eating) Chapter 8 Overweight/Obessity 55 UNIT 3 DIET IN HEALTH AND DISEASE-II 69 (Causes, Physiological Conditions, Clinical Symptoms and Dietary Management) Chapter 9 Hypertension 71 Chapter 10 Diabetes 81 Chapter 11 Jaundice/ Hepatitis 95 Chapter 12 Celiac disease, Lactose Intolerance & Peptic ulcer 105 CE NT RAL BOAR D OF SECONDARY EDUCATION v ii FO O D N U TR ITI O N AND D I E TE T ICS UNIT 4 FOOD SAFETY AND QUALITY CONTROL 117 Chapter 13 FOOD HAZARDS 119 Chapter 14 PERSONAL HYGIENE & FOOD HYGIENE 129 Chapter 15 FOOD ADULTERATION 135 Chapter 16 READING AND UNDERSTANDING FOOD LABELS 143 Chapter 17 HFSS FOODS AND THEIR IMPLICATIONS 153 viii CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Unit-1 CLINICAL AND THERAPEUTIC NUTRITION CE NT RAL BOAR D OF SECONDARY EDUCATION 1 FO O D N U TR ITI O N AND D I E TE T ICS CONTENTS UNIT-1 CHAPTER 1 THERAPEUTIC NUTRITION 3 CHAPTER 2 THERAPEUTIC DIETS 7 CHAPTER 3 NUTRITION AND INFECTION 15 CHAPTER 4 METHODS OF COOKING 21 2 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S UNIT - 01 Chapter 01 THERAPEUTIC NUTRITION Learning Objectives: After reading this chapter, the students will be able to: 1. Define the terms dietetics, clinical nutrition & therapeutic diet. 2. Explain and specify the role of dietitian in health care. Welcome to the Study of Clinical and Therapeutic Nutrition Clinical nutrition, may be defined as the nutritional management of individuals or a group of individuals with established disease conditions. It deals with issues such as altered nutritional requirements associated with the disease, its severity, malnutrition and many such issues. Nutrition is a vital part of medical therapy as adequate nutrition support can go a long way in improving patient’s medical outcomes. The importance of nutrition in the prevention of illness and disease has long been established. Let us know more about clinical and therapeutic nutrition. Role of Dietitian in Health Care As a student of nutrition and dietetics, 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. Dietetics is defined as the application of the science of nutrition to the human being in health and disease. In fact, dietetics deals with feeding individuals based on the principles of nutrition. Therefore, dietetics is the science and art of human nutritional care. Clinical Dietetics is the application of dietetics in a health care institutional setting. Clinical nutrition deals with the prevention, diagnosis and management of nutritional and metabolic changes related to acute and chronic diseased and conditions caused by a lack of excess of energy and nutrients. You will come across the terms like diet therapy, therapeutic diets while studying clinical dietetics. Let us understand these terminologies as used in the context of dietetics. CE NT RAL BOAR D OF SECONDARY EDUCATION 3 FO O D N U TR ITI O N AND D I E TE T ICS 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 deals with the recovery from illness by giving a nutritious diet and prevention of disease. It also involves the modification of the existing dietary lifestyle to promote good health. The principles of diet therapy are to: maintain good nutritional condition, improve deficiencies or disease, if any, provide adequate rest to the body, help metabolize the nutrients, and make changes in body weight, when necessary. Diet therapy may include following specialized dietary regimes or meal plans. These specialized diet regimens or meal plans are called therapeutic diets. A therapeutic diet may be defined as a meal plan that controls the intake of certain foods or nutrients. They are an adaptation of the normal/ regular diet. Some common examples of therapeutic diets include a clear liquid diet, diabetic diet, renal diet, gluten-free diet, low-fat diet, high fibre diet etc. Therapeutic diets are usually prescribed by a trained dietitian, nutritionist or physician. Role of Dietitian in Nutrition Care Dietitian is an expert in dietetics, dealing with human nutritional care. A dietitian applies the science and principles of human nutrition to help people understand the relationship between food and health. She makes appropriate dietary choices to attain and maintain health and to prevent and treat illness and disease. Dietitians work in a wide variety of roles. For example, 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. They also provide dietary consultations to patients and their families. The roles most likely to be played by the clinical dietitian include: collecting, organizing and assessing the data related to health and nutritional status of individuals, groups and communities, 4 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S review and analyze patients’ nutritional requirements and goals to make appropriate dietary recommendations, develop and execute nutrition care plans and monitor, follow up and evaluate these plans and take necessary measures wherever required, calculate the 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 ill and require special feeding through oral, enteral or parenteral routes, plan and prepare basic menus and assist in supervising food service personnel in the preparation and serving of meals, schedule work assignments in the dietary unit to facilitate effective operation. EXERCISES Q-1 Define the term ‘Dietetics’. Q-2 What is clinical dietetics? Q-3 List the principles of diet therapy. Q-4 Write any five roles played by a clinical dietitian. Q-5 Explain a therapeutic diet with the help of an example/ examples. CE NT RAL BOAR D OF SECONDARY EDUCATION 5 FO O D N U TR ITI O N AND D I E TE T ICS NOTES............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 6 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S UNIT - 01 Chapter 02 THERAPEUTIC DIETS Learning Objectives: After reading this chapter, the students will be able to: 1. Explain the diets of altered consistencies. 2. Discuss the adaptation of normal diet to therapeutic diets. A therapeutic diet is a qualitative/quantitative modification of a normal regular diet that has been tailored to suit the changing nutritional needs of patient/individual. It is used to improve specific health/disease conditions. It is a planned diet to supplement the medical or surgical treatment. Balanced diet 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 2.1 which illustrates routine hospital diets. Figure 2.1: Routine hospital diets CE NT RAL BOAR D OF SECONDARY EDUCATION 7 FO O D N U TR ITI O N AND D I E TE T ICS A normal or general diet in a hospital setting is a balanced diet that meets the nutritional requirement of an individual/patient. It is given when the individual’s medical condition does not permit any specific modification. Most hospitals follow simple dietary recommendations [given by ICMR (Indian Council for Medical Research) for the Indian population] while planning the general diet. It is planned keeping the ICMR five food groups in mind so that the optimum amount of all nutrients are provided. Further, since the patient is hospitalized or on bed rest, a reduction of 10% in energy intake should be made. The diet provides approximately 1600 to 2200Kcal and contains around 180 to 300g carbohydrates, 60 to 80g of fat and 40 to 70 g of protein. Figure 2.1 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 are given to individuals/patients as a part of their therapeutic needs. The reasons for altering the diets may include: for essential or lifesaving treatment: For example, people diagnosed with celiac disease, are put on a gluten free diet, to replenish patients who are malnourished because of diseases such as cancer and intestinal diseases by providing a greater amount of a nutrient such as protein, to correct deficiencies and maintain optimum nutritional status, to provide rest or relieve an affected organ such as in gastritis, to adapt to the body’s ability to digest, absorb, metabolize or excrete: For example, a low-fat diet provided in fat malabsorption, to adjust the body to the mode of food intake. For example, in case of patients with cancer of esophagus, tube feeding is recommended when patients cannot swallow food by mouth, to exclude certain foods due to food allergies or food intolerance, to adjust to the body’s 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 a helpful treatment, alternative or complementary to drugs. For example in diabetes or in hypertension. 8 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Types of Dietary Adaptations for Therapeutic Needs A diet may need to be modified and adjusted in many ways before it meets the therapeutic needs of an individual patient. These adaptations may include: change in the consistency of foods, such as liquid diet, bland 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 weight gain, 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, exclusion of spices and condiments, such as bland diets, avoiding specific foods such as allergy diets, gluten-free diets, adjustment in the ratio and balance of proteins, fats and carbohydrates such as diabetic diet, renal diet and cholesterol-lowering diets, test diets: These are single meals or diets lasting for one or a 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 the frequency of meals, feeding intervals, re-arrangement of the number such as diabetic diet, diet for peptic ulcer disease. CE NT RAL BOAR D OF SECONDARY EDUCATION 9 FO O D N U TR ITI O N AND D I E TE T ICS A. Diets of Altered Consistency Therapeutic diets are modified for their consistency and 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 health and medical condition. Figure 2.2 represents the modified diets based on consistency. Figure 2.2: Modifications in consistency a) Liquid Diet consists of foods that can be served in liquid or strained form at room temperature. They are usually prescribed in febrile states, postoperatively i.e. after surgery when the patient is unable to digest solid foods. It is also used for individuals with acute infections or digestive problems, to replace fluids lost by vomiting and diarrhea. The two major types of liquid diets include - Clear liquid diet and full liquid or fluid diet. i) A clear liquid diet includes foods and fluids that are clear and liquid at room temperature. The main purpose of the clear liquid diet is to provide fluids and electrolytes to prevent dehydration. It provides a considerable amount of energy but very little amount of other nutrients. It is also deficient in roughage and fibre. Hence it is nutritionally inadequate and should only be used 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, 10 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S clear dal soup, strained vegetable or meat soup, tea or coffee without milk or cream are some examples of a clear liquid diet. ii) A full liquid diet includes food and fluids that are liquid or semi-liquid at room temperature. It is a step between a clear liquid diet and a regular diet. The purpose of the full liquid diet is to provide an oral 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 also gives adequate nourishment, except that it is deficient in fibre. It is prescribed for post-operative patients and 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: Cream soups, vegetable soups, daal soups, strained food juices, lassi/butter milk, yogurt, hot cocoa, coffee/tea with milk,cereal porridges (refined cereals) custard, sherbet, gelatin, puddings, ice cream, cream (added to foods), poached, half boiled egg etc. b) Soft diet as the name suggests includes soft whole food that is lightly seasoned and is 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 and easily digestible foods. It does not contain any 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 phases of recovery following 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 digest a normal diet. Soft diet can be nutritionally balanced (providing approximately 1800-2000 calories, 55-65g protein) provided the patient can consume adequate amount of food. Examples of soft diet: A soft diet freely permits the use of boiled vegetables, soft raw fruits without seeds, broths and all soups, cooked pulses in the form of soups and the combination of cereals and vegetables (like khichri, dalia), bread and ready-to-eat cereals (such as poha, upma, pasta, 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 fried foods, dry fruits and nuts, rich desserts. CE NT RAL BOAR D OF SECONDARY EDUCATION 11 FO O D N U TR ITI O N AND D I E TE T ICS c) Bland Diet: A bland diet is made of foods that are soft, not very spicy and low in fiber. It consists of foods that are mechanically, chemically and thermally non-irritating i.e. are least likely to inflame the gastrointestinal tract. Individuals suffering from gastric or duodenal ulcers, gastritis, or ulcerative colitis are prescribed this diet. Foods Included: Milk and milk products that are 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-flavore foods; 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 restricted 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 an individual experiences 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 roughage and fibre diet (as in constipation) or an iron-rich diet (as in anemia) according to the clinical condition. C. Modification in Nutrient (Protein, Fat, Carbohydrate) Content: The nutrient content of the diet is modified to treat deficiencies, change body weight or control certain 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 amount and type of carbohydrates included in each meal. Refined carbohydrates (such as sugar, honey, refined flour, semolina etc.) are avoided and the use of complex carbohydrates (whole wheat flour, coarse cereals etc.) is recommended. Patients with heart diseases require a fat controlled low cholesterol diet while patients with renal (kidney) failure and advanced liver diseases require a low protein 12 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S diet, patients with HIV disease, cancer or malnourished a high protein and high calorie diet. Others as in the case of overweight, obesity a weight reduction diet, low in fat and calories is recommended. D. Changes in Meal Frequency Individuals suffering from gastro-esophageal reflux disease (GERD) are benefitted from 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 recommended for cooking vegetables for people with chronic kidney diseases because the kidney 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. 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. CE NT RAL BOAR D OF SECONDARY EDUCATION 13 FO O D N U TR ITI O N AND D I E TE T ICS EXERCISES Q-1 Define the following: a) Test diet b) Balanced diet c) Liquid diet d) Soft diet e) Bland diet Q-2 Draw a flow chart to depict the classification of hospital diet. Q-3 What is a test diet? Q-4 Write the full form of GERD, ICMR and HIV. Q-5 List the adaptations required to meet the therapeutic needs of a patient. 14 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S UNIT - 01 Chapter 03 NUTRITION AND INFECTION Learning Objectives: After reading this chapter, the students will be able to: 1. Understand the interaction between nutrition and infection. 2. Explain 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 very well established. Also, you are aware that poor nutrition can directly 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 chapter, we shall discuss the interaction of infection and nutrition. Infection and malnutrition have always been closely linked. Evidence suggests that common childhood infections impose their influence in precipitating malnutrition. The relationship between malnutrition, impaired immunity and infection can be described as a vicious cycle. 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 an imbalance of nutrients in the diet. Almost any nutrient deficiency, if sufficiently severe, will diminish 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 diarrhea, caused by the invasion of harmful microorganisms in the body. The infection caused loose motion, fever, dehydration and impaired absorption. On further investigation, he was also diagnosed 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 and 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 severe cases results in death. In case of Raju, infection is a common precipitating factor for malnutrition. Ironically, CE NT RAL BOAR D OF SECONDARY EDUCATION 15 FO O D N U TR ITI O N AND D I E TE T ICS malnutrition is also one of the major factor in the occurrence of infection and the two interact, making each other worse. Figure 3.1 illustrates this interaction. Figure 3.1: Interaction between infection and malnutrition An inadequate dietary intake, in the case of Raju, led to weight loss, lowered immunity, mucosal injury, invasion by pathogens, and impaired growth and development as illustrated in Figure 3.1. Raju’s nutrition was further aggravated by diarrhea, malabsorption, loss of appetite, deprivation 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 vulnerable 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. So, 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. 16 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Figure 3.2: The Vicious Cycle of Malnutrition and Infection The synergistic effect of malnutrition and infection often leads to a high rate of child deaths in poor 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 exclusively breastfed 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 , the children are further exposed to infections like diarrhea and respiratory tract infections. There is reduction in food intake by the child due to loss of appetite as a result of these infections. 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 any physical work and are less economically productive. CE NT RAL BOAR D OF SECONDARY EDUCATION 17 FO O D N U TR ITI O N AND D I E TE T ICS Effect of Malnutrition on Infection With reference to Figures 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 can be described as the state of being unsusceptible or being protected against a disease or illness by the presence of a 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 the case of malnourished individuals there is a reduction in antibody production and therefore the disease fighting capacity is lowered making the individual more vulnerable to infections. b) Effect on the integrity of skin and mucous membrane: Dietary inadequacy diminishes resistance towards infection by reducing the integrity of various tissues. In a healthy well nourished individual the skin, mucosal membrane and other tissues are healthy and prevent the entry of infectious agents. They act as a barrier and prevent infections 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 catches infection easily. Infection and Nutritional Status Infection, no matter how mild, has adverse effects on nutritional status. Nutritional status 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 the 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 the use of medicines such as antibiotics to treat the infection your appetite may have been affected leading to reduced food intake. Now if this condition would have been prolonged it would have led to consistent decrease in the amount of food intake leading to nutrient deficiency. 18 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S b) Unfavorable cultural practices: One of the most common practices in our country is to restrict or withdraw food from individuals while suffering from infection, particularly diarrhea or respiratory infections. It is believed that solid foods, milk etc. be best avoided instead of bland, starchy gruels low in nutritive value being provided to rest the digestive system. Such a practice is deleterious and harmful; particularly when the individual due to infection is already having low food intake. Further reduction in the quality of diet contributes to nutrient deficiencies and thus leads to poor nutritional status. Decreased intestinal absorption: The main function of intestine is to digest, absorb and propel food along its length. During the course of infection all these functions are affected. Infections cause changes to the epithelial membrane leading to malabsorption. Any decrease in the absorption of nutrients can further lead to deficiency. For example, in children suffering from infectious diarrhea, protein absorption from the intestine may reduce as much as 40%. Other evidence suggests that in children with acute diarrhea and respiratory infections only 30 -70 percent of ingested vitamin A is absorbed. Poor absorption thus leads to nutrient deficiency disorders influencing nutritional status. c) 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 leading to anemia, diarrhea and stunted growth. d) Protein loss: In some infections and fevers, few nutrients, particularly proteins are excreted and lost from the body thus causing its deficiency. For example, diseases associated with diarrhea, 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 the increased requirement of protein-rich food 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 a developing countries like India, where a large number of children, are already on a deficient diet and malnourished, the coexistence of infection in the same child is producing an effect that is beyond the summed effect expected from the two conditions acting alone. CE NT RAL BOAR D OF SECONDARY EDUCATION 19 FO O D N U TR ITI O N AND D I E TE T ICS EXERCISES Q-1 Differentiate between malnutrition and nutrition. Q-2 Draw a flowchart to show the interaction between nutrition and malnutrition. Q-3 ‘The synergistic effect of malnutrition and infection often leads to high rate of child deaths in poor communities.’ Comment on this statement. Q-4 List the effects of malnutrition on infection. Q-5 What are the consequences of worm/parasite infection on children? 20 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S UNIT - 01 Chapter 04 METHODS OF COOKING Learning Objectives: After reading this chapter, the students will be able to: 1. Describe various methods of cooking. 2. Explain and ensure the nutritive values in different methods of cooking. Many food items are consumed as such in the raw state while few are cooked to make them edible. Food is being cooked as it tastes better. Even vegetables and fruits are cooked to add variety to the diet and make them easily palatable, attractive and colorful. Cooking also kills many microorganisms and makes the food safe to be consumed. Several raw food items also have anti-nutritional factors which are destroyed by cooking. It also enhances the availability of some nutrients. Figure 4.1: Different Methods of Cooking CE NT RAL BOAR D OF SECONDARY EDUCATION 21 FO O D N U TR ITI O N AND D I E TE T ICS Principles of cooking food 1. Food must be cooked in a manner that retains the original flavors. 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 process 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. Moist Method Dry heat Combination Method Boiling Roasting Braising Simmering Grilling/ Broiling Poaching Toasting Stewing Baking Blenching Suffering Steaming Frying Pressure Cooking Table 4.2: Classification of Cooking Methods Moist Methods: In this method, the heat generated by water in some form or the other is used for cooking. Some of the important ones are explained below: a) Boiling Food items are cooked by placing them in boiling water at 100°C and this temperature is maintained till the desired stage of cooking has been reached. Rice, pulses, potatoes are cooked this way. Advantages 1. It is the simplest method of cooking. 2. Boiling of food brings about uniform cooking. 3. At high temperatures, protein content of food get denatured and embedded in food 22 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S 4. Starch gets gelatinized and collagen gets hydrolyzed. 5. Boiling of food also aids in proper digestion Disadvantages 1. The process of boiling takes more time. 2. When an excess water is used the water-soluble nutrients are lost. 3. Loss of minerals is also a big disadvantage with the boiling method. 4. Boiling of food brings about its decoloration. b) Pressure Cooking In this method, the food is cooked under pressure and with the increase in pressure the temperature also correspondingly increases. Thus the food is cooked relatively fast. Pressure cooking 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 increases. 3. Nutrient loss is relatively less. 4. Food is cooked properly and is made tender. 5. The flavor and aroma of the food are retained inside the cooker and is not lost. Disadvantages 1. Long hours of pressure cooking make food soggy and too soft. 2. Flavors of food may blend and individuality is lost. c) Steaming This method uses steam as the mode 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 a 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. CE NT RAL BOAR D OF SECONDARY EDUCATION 23 FO O D N U TR ITI O N AND D I E TE T ICS Advantages 1. Constant stirring is not required. 2. Nutritive value of the food remains intact. 3. Cooking time is less. 4. 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. Only a few food items can be cooked by this method. d) Poaching This method is generally used for cooking eggs. This involves cooking in the minimum amount of liquid at a temperature of 80-85°C. 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 easily digestible. Disadvantages 1. Water-soluble nutrients leach into the water. 2. The food items are generally bland in taste. e) Toasting Generally used 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 24 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S 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 food are improved. 2. Baking gives rise to a variety of combinations of dishes. 3. Food items 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, and removed after a brief, timed interval. 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 enhances the color of green vegetables, and the time taken is also lesser than other moist heat cooking methods. Disadvantages 1. Blanching can be used only for limited food items. 2. Blanching often needs to be coupled with another cooking process so as to provide more flavor to the final dish. CE NT RAL BOAR D OF SECONDARY EDUCATION 25 FO O D N U TR ITI O N AND D I E TE T ICS EXERCISES Q-1 Why is it important to cook the food before eating? Q-2 Classify the cooking methods based on a) Moist method b) Dry heat method Q-3 What are the two types of steaming methods of cooking? Q-4 List the advantages and disadvantages of the baking method of cooking. Q-5 Why blanched dishes are termed as ‘Healthy’? 26 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Unit-2 DIET IN HEALTH AND DISEASE-I (CAUSES, PHYSIOLOGICAL CONDITIONS, CLINICAL SYMPTOMS AND DIETARY MANAGEMENT) CE NT RAL BOAR D OF SECONDARY EDUCATION 27 FO O D N U TR ITI O N AND D I E TE T ICS CONTENTS UNIT-2 CHAPTER 5 FEVER (ACUTE & CHRONIC) 29 CHAPTER 6 DIARRHEA 41 CHAPTER 7 EATING DISORDERS 47 (ANOREXIA NERVOSA, BULIMIA, BINGE EATING) CHAPTER 8 OVERWEIGHT/OBESITY 55 28 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S UNIT - 02 Chapter 05 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. 4. Describe diet therapy during fevers. In the last unit, we looked at the correlation between nutrition and infections. You would realize that infection and fever coexist. Fever is a result of infection. In this section, we will also look at the basic concepts and correlation between fever, infection and nutrition. A detailed review on dietary management of fevers will be discussed. Fever: Definition, Causes & Symptoms Fever is classically described as the abnormal condition of the body, characterized by an excessive rise in body temperature, quickening of the pulse, and disturbance of various body functions. Surely, you must be aware of the normal body temperature. The normal human body temperature may 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 a disease but is a symptom or an adaptive response of our body to a variety of conditions, such as inflammation, infection or any unknown cause. Fever may be caused due to any bacterial infection or by a virus or certain inflammatory conditions such as rheumatoid arthritis – inflammation of the lining of your joints or heat exhaustion etc. As a child, you may recall suffering from cough/cold or diarrhea and/or chest infection, and very often these infections were accompanied by fever. The clinical and behavioral manifestations of fever besides raised temperature you might have CE NT RAL BOAR D OF SECONDARY EDUCATION 29 FO O D N U TR ITI O N AND D I E TE T ICS experienced included headache, chills and shivering, muscle ache, sweating, loss of appetite, irritability, dehydration, general weakness 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. One of the ways our immune system attempts to combat infection is, rise in body temperature. Fever helps to 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 slender temperature range. From our review so far, we may then conclude that usually, a rise in temperature helps the individual overcome an infection. So, a mild fever i.e., above the normal body temperature but below 100.4°F (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 type, classification 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. Figure 5: Classification of Fevers 30 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Acute fevers are those which stay in the body for less than 1 week and are characteristics of infectious diseases such as malaria and viral-related upper respiratory tract infections. Sub-acute fevers usually stay in the body for not more than 2 weeks as can be seen in cases of typhoid fever. Chronic fever on the other hand is persistent, it usually stays in the body for more than 2 weeks. Basal Metabolic Rate is described as the rate at which our body uses energy when we are resting in order to keep the vital body functions (such as heart beating, breathing etc.) going and are typical of chronic bacterial infections such as viral infections like HIV, cancers tuberculosis, etc. Based on the height of the body temperature, fevers can be further classified as low- grade, moderate- grade or high-grade fever. You would observe that a low-grade fever does not go beyond 37.8°C and is present daily, especially during the evening. Tuberculosis leads to low-grade fever. Similarly, you may come across fever types described as sustained or continuous fever, intermittent fever and remittent fever. Sustained/continuous fever is described as a fever that does not vary more than about 1°C (1.5°F) during 24 hours but at no time touched normal. Continuous fevers are seen in typhoid, pneumonia 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 tuberculosis, malaria or pyrogenic infections. Remittent fever, on the other hand, is defined as fever with daily fluctuations exceeding 2°C but at no time touched normal. This kind of fever is always associated with infectious diseases such as rickettsia infection, infective endocarditis. Looking at the different types and classifications of fever, we shall focus next on fever management, with special reference to dietary management. Diet, you would observe plays an important role in fever management. As the body temperature rises above normal, several metabolic changes occur in the body that increases the nutritional needs. A brief review of these changes is discussed further. Metabolic Changes during Fever Usually, fever is 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). CE NT RAL BOAR D OF SECONDARY EDUCATION 31 FO O D N U TR ITI O N AND D I E TE T ICS Decreased stores of adipose (fat) tissue and decreased glycogen stores. Increased catabolism (breakdown) of proteins, especially in case of malaria, typhoid, tuberculosis fevers. This leads to the production of an excess amount of nitrogenous wastes, which lays additional stress on the kidneys. Increased excretion of potassium, sodium, chloride etc. through sweat, urine, vomiting leads to electrolyte imbalance. Accelerated loss of fluid from the body in the form of excessive sweat and urine formation. Loss of appetite limits the food intake thus leading to weight loss. Decrease in the absorption of nutrients like vitamins, minerals, proteins. The above changes accompanied by muscle ache, headache, chills and shivering, sweating, loss of appetite, general weakness, irritability, dehydration experienced during fever may have a serious effect on the nutritional status of the individual. Thus, fever management becomes critical. In the next section, we shall look at diet therapy for fever management. We shall first consider the dietary management in sub-acute fever, followed by dietary management for chronic fever. Dietary Management of Sub-Acute Fever Typhoid is a serious health threat in the developing countries such as India, especially for children. We have already learnt that typhoid is a sub-acute continuous fever that can last for about 14 days. Typhoid is caused by the Salmonella typhi bacteria and is also called enteric fever as 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 the faecal-oral route. Let us understand the concept of the faecal-oral route here. Note, Salmonella typhi is passed in the faeces 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 that 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. 32 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S A patient with typhoid will usually suffer: High fever, headache, loss of appetite, nausea and vomiting. Gastrointestinal problems like abdominal pain and either diarrhea or constipation. Increased BMR. Massive loss of lean body mass (muscle) due to tissue (protein) breakdown leads to excessive nitrogen loss. Significant decrease in adipose and glycogen tissue stores because of increased energy expenditure. Excessive diarrhea, vomiting leads 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, v) avoid irritation of intestinal tract as may occur in typhoid. Thus, the dietary management will focus on providing a diet that contains proteins, high calories, carbohydrates and moderate fat. But, very often the fever is accompanied by vomiting, anorexia, nausea. You would observe that the patient has poor appetite and moreover is unable to intake food. So, the diet has to be modified as per the patients’ tolerance. The food textures 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 easy to digest and soothing. Slowly the person may be asked to take normal diet. The main idea is to encourage the patient to eat properly so as to meet the increased nutrient requirements. Feeding several times a day needs to be encouraged. The nutrient needs during typhoid and how to meet them is the focus of the discussion next. The information is summarized in Table 5.1. CE NT RAL BOAR D OF SECONDARY EDUCATION 33 FO O D N U TR ITI O N AND D I E TE T ICS 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) Pasteurized skin milk 1 glass (250ml) 10.00am Buttermilk 1 glass (250ml) Suji upma 1 bowl cooked Mid Morning (12:00 noon) Clear dal soup 1 big bowl (200ml) Lunch Khichri 1 big bowl Soft Vegetable (Lauki/ Tinda/ 1 bowl cooked Pumpkin/potato) Washed dal 1 bowl cooked Curd 1 bowl 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 salt) 1 glass Stewed apple 1 bowl cooked Dinner Boiled Rice 1 big bowl Soft Vegetable (Lauki/ Tinda/ 1 bowl cooked pumpkin/ potato) Washed dal 1 bowl cooked Curd 1 bowl Cooking Oil 1 1½ tsp Bed time Apple Juice 1 glass (250 ml) Table 5.1: Dietary Considerations and Nutritional Needs During Sub-acute Fever. 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. 34 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Do’s and Don’ts, and a list of what food items to give and which type of food to avoid are highlighted herewith. You may consult the list while planning the diet. Food Itmes to Include Food Items 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 and cracked wheat, whole pulses and pulses with husk. 2. Milk and milk based beverages. 2. All raw vegetables and fruits with hard skin or fibre such as green leafy vegetables. 3. Bland, well cooked, well mashed, 3. Strongly flavoured vegetables like sieved, soft, semisolid food like cabbage, capsicum, turnip, raddish, khichdi, rice with curd, suji kheer, onion and garlic as they cause gas, custard etc. bloating. 4. Low fibre food such as refined 4. Thick creamy soups cereals and their products (e.g. maida, rava, bread, rice, noodles etc.) dehusked pulses (washed dals), well cooked/stewed fruits, vegetables in soft and puree form and potatoes. 5. Food providing proteins of high 5. Fried fatty food such as samosas, biologic value e.g. eggs, soft cheeses, pakoras, puri, paratha etc. tender meats, fish, poultry etc. 6. Plain gelatin-based desserts, sugars, 6. Sweet concentrated food using honey,candy and jam. excessive whole milk and dairy fat including halwas, ladoos, pastries, 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. Table 5.2: Food Items to Include and Food Items to Avoid in the Diet of the Typhoid Patient In addition to the list provided in Table 5.2, some do’s and don’ts basic tips are presented in Table 5.3. CE NT RAL BOAR D OF SECONDARY EDUCATION 35 FO O D N U TR ITI O N AND D I E TE T ICS 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 vendors. 2. Wash hands frequently, particularly 2. Don’t buy open and cut fruits and before eating or preparing food and vegetables from street vendors. after using the toilet. 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 a day 4. Avoid eating large meals to prevent in the form of water, fruit juices, discomfort. tender coconut water and soup. 5. Eat small frequent meals. 5. Avoid excessive use of fats in cooking. 6. Make sure the food is thoroughly 6. Avoid eating food at room temperature. cooked and served steaming hot. 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. Table 5.3: Do’s and Don’ts Dietary Management of Chronic Fever Tuberculosis (TB), is an example of chronic fever which is caused by the bacteria- Mycobacterium tuberculosis. The disease is spread from person to person through microscopic droplets which are released into the air by cough or spit or sneeze from a person suffering from tuberculosis. Tuberculosis mainly affects the lungs but can spread to other organs also, like lymph nodes, kidneys, bones etc. In India, it is observed that pulmonary tuberculosis occurs most commonly. It is worthy to note that tuberculosis remains a major global health problem and is one of 36 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S the top 10 causes of death and the leading cause from a single infectious agent. It is linked to poverty, undernutrition, and poor immune function. Latent tuberculosis is when a person is infected with pulmonary tuberculosis. In a normal healthy individual, the immune system helps fight the infection and the bacteria in the body are in an inactive state and the person shows no symptom. 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. There is a long-term association between tuberculosis and undernutrition. 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 body/protein tissue) state leading to muscle wasting, experience loss of appetite leading to weight loss, fever, fatigue, exhaustion and persistent coughing, show signs of vitamin and mineral deficiencies, and low body mass index (BMI) (lower than 18.5 kg/m2). Why do you think weight loss occurs among those suffering from 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 diarrhea, 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 and gradual but it can have serious consequences. The key to treatment, therefore, is early detection, followed by antibiotic therapy, adequate rest and dietary management. Children suffering from TB, in particular, need special attention since the child has increased requirements as a result of both growth and TB. Tuberculosis can be completely cured through CE NT RAL BOAR D OF SECONDARY EDUCATION 37 FO O D N U TR ITI O N AND D I E TE T ICS short-course chemotherapy. Treating TB cases who are sputum-smear positive (and who can therefore spread the disease to others) at the source, 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 about the dietary management next. Dietary Management of Tuberculosis As undernutrition is highly prevalent among people suffering from TB, the dietary recommendations for TB patients are based on the nutrient and energy requirements for hyper-catabolic and malnourished patients. The main objective of diet therapy is to avoid weight loss, strengthen the immune system and accelerate recovery. A suitable diet containing all the vital nutrients namely carbohydrates, fats, proteins, minerals and vitamins is required for the well-being and health of a person suffering from TB. Dietary Considerations for Tuberculosis Here are some dietary recommendations on how to monitor weight gain in TB patients, particularly in children: Encourage the individual to take a healthy, nourishing balanced diet. TB often harmfully affects the 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 vegetable oil, sugar, peanut butter, eggs and non- fat dry milk powder can be used in porridge, soups, milk based-drinks and gravies to increase the protein and energy content without adding to the bulk of the meal. At least 500ml to 1litre milk (or milk products like yoghurt, soft cheese) should be consumed daily to ensure suitable 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. 38 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S 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, you can summarize the dietary recommendation for a TB patient. Prepare a list of food items you may include liberally or restrict/avoid in the diet of a TB patient. Do’s Don’ts 1. Cereals and millets 1. Red meat and organ meats (wheat, rice, ragi, jowar) 2. Pulses 2. Limit refined foods (rajma, black chana, soyabean) 3. High energy, protein drinks and 3. Strongly flavored vegetables beverages 4. Foods providing proteins of high 4. Excess fat biologic values ex.- eggs, soft cheese, tender meat, fish etc. 5. Cereals pulse combination with 5. Fried fatty food some animal protein ex. Khichri with curd etc. 6. Nuts and oil seeds like pea nuts 6. Sweets concentrated food 7. Seasonal fruits and vegetables 7. Acidic and spicy food such as pickles 8. Green leafy vegetables like maithi, 8. Spices, condiments and seasoning mint, spinach, cabbage etc. 9. Citrus fruits 10. Milk and milk products 11. Vegetable 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. CE NT RAL BOAR D OF SECONDARY EDUCATION 39 FO O D N U TR ITI O N AND D I E TE T ICS Do’s Don’ts 1. Always wash 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 use excessive fat in cooking. before eating or preparing food. 3. Give plenty of fluids and electrolytes 3. Consumption of tobacco and alcohol to compensate for losses. should be avoided. 4. Provide 6 frequent meals per day. 4. Caffeine tea consumption should be avoided. 5. Include 5-6 portions of fruits and 5. Avoid close contact or sharing utensils, vegetables in the diet each day. cups with people who are infected. 6. Include meals that are easy to digest, well-tolerated. 7. Provide good multivitamin and mineral supplements. Table 5.5: Do’s and Don’ts EXERCISES Q-1 Define the terms: a) Acute fever b) Chronic fever c) Intermittent fever Q-2 Write the causative agents of a) Typhoid fever b) Tuberculosis Q-3 What are the main objectives of dietary management in sub-acute fever? Q-4 Plan a sample menu (1600kcal) for a patient with sub-acute fever. (Refer Table 5.1) Q-5 List the food items to be included /restricted /avoided in the diet of a TB patient. 40 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S UNIT - 02 Chapter 06 Diarrhea (TYPES, CAUSES, CLINICAL SYMPTOMS AND DIETARY MANAGEMENT) Learning Objectives: After reading this chapter, the students will be able to: 1. Explain the term Diarrhea and review the different terminologies used in the context of Diarrhea. 2. Discuss and differentiate between different types of Diarrhea. 3. Explain the causes, clinical symptoms and the metabolic changes during Diarrhea. 4. Describe the dietary recommendations during Diarrhea. We have looked at the basic concepts and correlation between fever, infection and nutrition in our study so far. Diarrhea is an infection and an important public health problem among children under the age of 5 years in most developing countries. Recent studies suggest that diarrhea is the third leading cause of childhood mortality in India, and is responsible for 13% of all deaths/among children under the age of five years. This chapter will focus on the classification/ terminologies, determinants, strategies to prevent and control of diarrhea and dietary recommendations for the management of diarrhea at home or in a community setting. Diarrhea: Definition, Causes & Symptoms As per the World Health Organization (WHO), diarrhea 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 breastfed, 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 Diarrhea. His mother informs that he has had several episodes of loose motions with 4-5 loose liquid stools passed per day. CE NT RAL BOAR D OF SECONDARY EDUCATION 41 FO O D N U TR ITI O N AND D I E TE T ICS In your opinion are the two children suffering from Diarrhea? Before you draw any conclusion, please go through the definition of diarrhea once again more carefully. Then comment on each case. Diarrhea 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: Types of Diarrhea Now, considering the two cases mentioned above, Ramu is more likely to be suffering from Diarrhea as he is having frequent watery stools. Rani, though was passing frequent stools but the stools were well-formed. Hence, she is not likely to be suffering from Diarrhea. Remember, Diarrhea is characterized by the frequent passage of watery stools, which is accompanied by excessive loss of fluids and electrolytes, especially sodium and potassium. Diarrhea, is a symptom and not a disease. This must be clear to you. SYMPTOMS OF DIARRHEA Diarrhea is associated with symptoms depending on the cause and who is affected. Common symptoms, 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 42 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Weight loss Fever Diarrhea can be life-threatening! If a person is suffering from diarrhea, the stools will 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 termed as dehydration. By now, you must have understood the consequences of diarrhea/dehydration and can observe that it is the highest cause of illness and death especially, in children. So, an understanding of what causes diarrhea needs urgent attention. CAUSES OF DIARRHEA Diarrhea, is usually considered 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: all may cause food poisoning. Viruses, such as a Norovirus or Rotavirus. Parasites, such as the Giardia intestinalis, that cause Giardiasis. Infection is spread through contaminated food or water or from person to person as a result of poor hygiene. Poverty, unawareness, poor sanitation is often the underlying risk factors. Diarrhea is caused by the consumption of contaminated food or water while travelling and is often known as the traveller’s diarrhea. Recognizing the ill-effects, management of diarrhea, particularly in the context of management of dehydration and malnutrition is crucial which is discussed next. TREATMENT AND MANAGEMENT OF DIARRHEA Diarrhea/dehydration should not be ignored and must receive rapid 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 Diarrhea and more specifically dehydration. The major objectives in the management of diarrhea include: 1. Fluid and electrolyte replacement. 2. Removal of cause (especially if infection). 3. Nutritional concerns. CE NT RAL BOAR D OF SECONDARY EDUCATION 43 FO O D N U TR ITI O N AND D I E TE T ICS 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 Dehydration status Sign/Symptoms Two of the following signs: Restless, irritable Some dehydration Sunken eyes Drinks eagerly, thirsty Skin pinch goes back Slowly Two of the following signs: Lethargy or unconscious Severe dehydration Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly Table 6.1: Recognizing dehydration Figure 6.2a: Sunken eyes - a sign of dehydration 44 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S Figure 6.2b: Skin pinch - goes back slowly A review on the use of ORT and fluid therapy in dehydration management is presented next. The key to the management of Diarrhea is the early replacement of fluid lost in the stools through intravenous or oral route (by mouth). Oral Rehydration Therapy (ORT) is the most essential and effective way for the management of diarrhea. A review on the use of ORT and the fluid therapy in the management of dehydration is presented further. First, we need to understand what is ORT? Oral rehydration therapy is a simple treatment for dehydration that is associated with Diarrhea. The term ORT includes: Complete Oral Rehydration Salts (ORS) solution. Solutions made from sugar and salt. Food based solutions. 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 effective, safe and cost saving. It can alone successfully rehydrate 95-97% of individuals suffering from diarrhea. 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 diarrhea. How much of ORS is to be given for the replacement of ongoing stool losses to maintain hydration. Refer to Table 6.2 for easy reference. CE NT RAL BOAR D OF SECONDARY EDUCATION 45 FO O D N U TR ITI O N AND D I E TE T ICS 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 Table 6.2: ORS Guidelines for Replacement of Ongoing Losses to Maintain Hydration 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. 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 - Dal or dal water with salt required) - Butter milk (Lassi) with salt -Salt 4g - Soups with salt Table 6.3: Other oral rehydration therapies EXERCISES Q-1 Define the terms: a) Diarrhea b) Dysentery Q-2 List the causes of diarrhea. Q-3 Draw a flowchart to depict the types of diarrheas. Q-4 What are the objectives in the management of Diarrhea? Q-5 How will you determine the status of dehydration? Q-6 List the home-made and food base oral rehydration therapies. 46 CENT RAL BOARD OF SECON DARY EDU C A TI O N  FOOD NUT RIT ION AN D DI E TE TI C S UNIT - 02 Chapter 07 EATING DISORDERS (DEFINITION, CAUSES, PHYSIOLOGICAL CONDITIONS, DIETARY MANAGEMENT) Learning Objectives: After reading this chapter, the students will be able to: 1. Explain the term eating disorder. 2. Explain and differentiate between different types of eating disorders. 3. Discuss the causes, clinical symptoms, metabolic changes and consequences of eating disorders. 4. Discuss the management of eating disorders with special reference to nutritional management. Inappropriate eating behavior includes a wide range of problems related to eating such as inadequate eating patterns, 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 the illnesses in which the people experience severe disturbances in their eating pattern/behaviors and related thoughts and emotions. People suffering from 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 can be life- threatening. Eating disorders include binge eating disorder, bulimia nervosa, and, less common but very serious, anorexia nervosa. These conditions are defined herewith. CE NT RAL BOAR D OF SECONDARY EDUCATION 47 FO O D N U TR ITI O N AND D I E TE T ICS Binge Eating Disorder Binge eating disorder is characterized by recurring binge (excessive indulgence in eating) episodes during which a person feels a loss of control and marked distress over his or her eating patterns. Three particular features are characteristic of the binge eating disorder. 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 eating disorder characterized by binge eating (eating large amount of food in a short time span, along with the sense of loss of control) followed by a type of behavior that recompenses 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 the normal range for their weight. But they often fear gaining weight, want to lose weight desperately, and are intensely unhappy with their body shape and size. Anorexia Nervosa Anorexia Nervosa refers to loss of appetite. Anorexia nervosa, therefore, is a disease that is 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. Feature characteristics of anorexia nervosa include: i) relentless pursuit of thinness, ii) a distortion of body image and a great fear of gaining weight, and iii) extremely disturbed eating behavior. Clinical Characteristics, Sign, Symptoms of Eating Disorders After looking at the different types of eating disorders surely you may be able to differentiate 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 suffering from binge eating disorders are often overweight or obese.