﷽

INTERNSHIP REPORT (2016)

AT

SHAUKAT KHANUM MEMORIAL CANCER HOSPITAL & RESEARCH CENTRE

Hafiz Syed Muhammad Umar Kazmi

(2012-ag-3901)

B.Sc. (Hons.) Human Nutrition & Dietetics

Faculty of Food, Nutrition & Home Sciences

University of Agriculture Faisalabad

INTERNSHIP REPORT (2016)

AT

SHAUKAT KHANUM MEMORIAL CANCER HOSPITAL & RESEARCH CENTRE

Hafiz Syed Muhammad Umar Kazmi

(2012-ag-3901)

B.Sc. (Hons.) Human Nutrition & Dietetics

Faculty of Food, Nutrition & Home Sciences University of Agriculture Faisalabad

_________________ Rashidah Javid, RD

(Supervisor)

________________ Dr. Allah Rakha

(Advisor)

CONTENTS

1 Acknowledgement

2 Introduction to Hospital

3 Electiveship Programme

4 First Week Plan

5 Second Week Plan

6 Third Week Plan

7 Fourth Week Plan

8 Fifth Week Plan

9 Sixth Week Plan

10 Seventh Week Plan

11 Eighth Week Plan

12 Conclusion

13 References

ACKNOWLEDGMENT

All admirations and thanks are for Stupendous ALLAH, the Omnipotent, the

Sublime, the only Creator of universe and the source of knowledge and ingenuity who

benedicts me with health, thought, talented teachers, helping friends and opportunity to

complete this study. I offer my meekly thanks to The Holy Prophet Hazrat MUHAMMAD

Peace Be Upon Him ( ملسو هيلع هللا ىلصدمحم الرّسول ہللا ) the nimbus, the beacon, whose moral and spiritual

teachings illuminate my heart, mind and thrived my thoughts towards achieving high ideas of

life. My special praises are also for Aal-e-Muhammad A.S.

I feel highly privileged to express heartiest gratitude to my honorable Supervisor

Miss. Rashidah Javaid (Clinical Nutritionist) Shaukat Khanum Memorial Cancer Hospital

& Research Center, honorable advisor Dr. Allah Rakha (Assistant Professor) University of

Agriculture Faisalabad, and all other members of SKMCH&RC and NIFSAT – UAF for their

keen interest, full help, valuable suggestions, timely advised and sympathetic attitude

throughout the internship programme.

With deep sense of honor, I wish to extend my sincere gratitude to Prof. Dr. Masood

Sadiq Butt (Dean – Faculty of Food, Nutrition & Home Sciences at University of

Agriculture Faisalabad) for his insuring help and sympathetic guidance throughout the

internship programme.

No acknowledgment could ever adequately express my obligation to my loving and

affectionate father, mother, sisters and brother. Sincere thanks are also extended to my

teachers Dr. Amir Shehzad & Dr. Sarfraz Ahmed for their sympathetic attitude and moral

support during internship.

HAFIZ SYED MUHAMMAD UMAR KAZMI

INTRODUCTION TO SKMCH&RC

Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) is a

state-of-the-art cancer centre located in Lahore, Pakistan. It is a charitable organization .The

institution is the brain child of Pakistani cricket superstar and famous politician, IMRAN

KHAN. Inspiration came after the death of his mother, Mrs. Shaukat Khanum, from cancer,

said Imran.

SOME FAST FACTS

Inaugurated December 29, 1994

Founder Imran Khan (Chairman, Board of Governors)

Annual budget Rs. 8.7 billion (Year 2016)

Financially supported patients 75% (since 1994)

Philanthropic spending to date Rs. 22.18 billion (US$ 270 Million)

Area/Location 20 acres (in Lahore, Pakistan)

Beds 195

New registrations 10,253 (Year 2015)

Outpatient visits 205,313 (Year 2015)

Admissions 11,352 (Year 2015)

Staff 2,458

INTERNSHIP SCHEDULE/ PLACEMENT

Duration of Internship February 8th – April 8th, 2016

Post Elective (Clinical Nutrition)

Supervisor Rashidah Javid, RD (Clinical Nutritionist)

Timings 9:00 am – 5:00 pm (Monday-to-Friday)

INSTITUTIONS

)From Which Students/ Physicians Have Completed Elective Rotations At SKMCH&RC(

USA

Medical Education & Research

Center Grand Rapid / MSU General

Surgery Programme

Washington University School of

Medicine, St. Louis , MO

Cedars Sinai Medical Center , Los

Angele

UNITED KINGDOM

Medical College of London

North Eastern Ohio University College

of Medicine

Queen Mary's School of Medicine and

Dentistry

Royal Free Hospital School of Medicine

Kings College School of Medicine

University of Oxford

University of Cambridge

United Medical and Dental Schools of

Guy's and St. Thomas's Hospitals

St. George's Hospital Medical School

St. Mary's Hospital Medical School

University of Edinburgh

University of Glasgow

University of Leicester

University of Birmingham

University of Southampton

AUSTRALIA & CANADA

University of Queensland Medical School

University of British Columbia

PAKISTAN

Aga Khan Medical University

Agricultural University, Faisalabad

Allama Iqbal Medical College, Lahore

Baqai Medical University

Dow Medical College, Karachi

Fatima Jinnah Medical College, Lahore

Hamdard College of Medicine and

Dentistry, Karachi

King Edward Medical College, Lahore

Lahore Medical and Dental College

Nishtar Medical College, Multan

Oncology and Radiotherapy Institute,

Islamabad

Post Graduate Medical Institute, Lahore

Quaid-e-Azam University, Islamabad

Sindh Medical College

INTERNSHIP PROGRAM

WEEK TOPICS

1 & 2

What is cancer, its treatment

Cancer cachexia and nutritional requirements

Nutritional assessment (tools/ parameters) guidelines

Exchange list (count caloric intake, food groups, and diet consistencies

3

Diabetes mellitus

Cardiac diseases, hypertension

Obesity

Eating disorders (Anorexia nervosa, bulimia nervosa)

GI tract & celiac disease

4

Renal diseases (pre-dialysis, dialysis, post-dialysis)

Renal calculi & Uric acid

Liver diseases (jaundice, hepatitis, cirrhosis, hepatic encephalopathy)

5

Surgery (modifications for buckle surgery, esophagectomy, gastrostomy)

Intestinal cancers and stoma formation

Assignment

6

Enteral feeding (types, indication, supplement reconstitution)

PEG/ NG (problems & solutions)

Pediatric assessment (ideal height & weight for age)

7 & 8

PG-SGA rating form/ Caloric recommendations for different people

Counseling & preparing a diet chart

Assessment of assigned patients

Assignment

What is cancer, its treatment

Cancer cachexia and nutritional requirements

Nutritional assessment (tools/ parameters) guidelines

Exchange list (count caloric intake, food groups, and diet

consistencies

WEEK (1&2)

CANCER

A disease caused by an uncontrolled division of abnormal cells in a part of body. A

malignant growth or tumor resulted from an uncontrolled cell division. It is not just one

diseases rather its inter-related set of diseases.

Types of Tumors:

- Malignant/ Metastasized Tumor

Cancerous cells which can injure healthy tissue and spread to the other region of the body.

- Benign Tumor

These are not cancerous and often they can remove. In most cases they do not come back

and do not spread to the other body parts.

How cancers develop?

Cancer arises from the mutation in the genes that control the cell division in a single

cell. These mutations may promote cellular growth, interfere with growth resistant or prevent

cellular death. The development often proceed slowly and continuous for several decades.

Stages of cancer development:

Stage 1 Involve location of tumor

Stage 2 In which cancer spread to some extent

Stage 3 Involve metastasis

Stage 4 It is advanced stage

Types of cancer:

There are 150 different types of cancer depend upon location on part of body. Some major

types of cancer are as follow:

- Carcinoma

It is a solid type and form in epithelial cell that cover surface of skin, mouth, nose, throat,

lung, and GIT or line glands such as breast or thyroid. Lung, breast, prostate, stomach and colon

cancer are called carcinoma.

- Sarcoma

This solid type of cancer occurs in bone, connective and supportive tissues that surrounding

organs and tissues such as cartilage, muscle, tendon, fat outer lining of lung, abdomen, heart,

CNS and blood vessels. This found rarely in malignant tumor.

- Leukemia

This is not solid. It can occur in blood and bone marrow and involve over production of

abnormal WBCs that causes in spleen and other tissues.

- Lymphoma

This is a solid. It is a cancer of lymph glands. Lymph glands act as a filter for body

impurities and are concentrated mostly in neck, groin, armpit, spleen, center of chest, and

around of intestine. It involve in abnormal lymphocytes that congregate in lymph gland to

produce solid masses.

- Myeloma

It is a cancer of antibodies producing plasma cells or haemopoitic cells.

Causes:

Mutation occur by genetically defect that alter the DNA structure, function or repair.

Certain metabolic may initiate the carcinogenesis as when phagocytes (immune cells) produce

oxidants that cause DNA damage, or when chronic inflammation increase the rate of cell

division and increase the risks of damaging mutation. Environmental factors, diet, life style and

family history strongly influence the cancer risk. Having an inherited genetic mutation does not

necessarily means you will get cancer. About 10% of cancers are due to the inherited condition

90% has their roots in the environment and lifestyle.

- Environmental Factors that increase Cancer Risk

Environmental Factors Cancer Sites Environmental Factors Cancer Sites

Aflatoxins (Toxins in

mouldy peanuts and

grains)

Liver Immunosuppressant medications

Lymphoid tissue, Liver

Alcohal Mouth, Pharynx, Larynx, Colon Esophagus, Liver, Rectum ,Breast

Infection with Helicobacter Pylori

Stomach

Asbestos Lung, Pleura, Peritoneum Infection with Hepatitis B & C viruses

Liver

Ionizing Agents(X-ry,

Radioactive isotopes

and other source)

Leukemia, Breast, Esophagus, Bladder, Stomach , lung , Thyroid and Colon

Infection with human Papillomavirus (HPV)

Cervix

Tobacco Nasal cavity, lung, mouth, Pharynx, Larynx, Colon Esophagus, Liver, Rectum ,Breast, Stomach, Kidney, Pancreas, Renal pelvis, Bladder

UV Rays Skin

- Nutrition-Related Factors that influence Cancer Risk

Factors that increase cancer risk

Cancer Sites Factors that decrease cancer risk Cancer Sites

Obesity Liver Fruits and non-starchy

vegetables

Lymphoid tissue, Liver

Red meat, Processed

meat

Mouth, Pharynx, Larynx, Colon Esophagus, Liver, Rectum ,Breast

Carotenoid containg

foods

Stomach

Salt and salt preserved

foods

Lung, Pleura, Peritoneum Tomato products Prostate

Beta-carotene

Supplements

Lung Allium vegetables

(Onion garlic)

Stomach, Colon, Rectum

High calcium diets

(over1500 mg daily)

Prostate Vit.C containing foods Esophagus

Low level of physical

activity

Colon, Breast, Endometrium

Milk and calcium

supplements and fiber

containing foods

Colon , Rectum

Folate containing foods Pancreas

High level of physical

activity

Colon, breast (postmenopausal), endometrium

SOURCE: World Cancer Research Fund/American Institute for Cancer Research, Food,

Nutrition, Physical Activity & Prevention of Cancer: A Global Perspective (Washington, D.C.:

American Institute for Cancer Research, 2007).

Consequences/ Co – Morbidities of Cancer:

Once cancer develops, its consequences depend on the location of the tumor, its severity

and the treatment. The complications that develop are often due to the tumors impingement on

surrounding tissues. Nonspecific effects of cancer include anorexia, lethargy, weight loss, night

sweats, and fever. During the early stages, many cancers produce no symptoms, and the person

may be unaware of the threat to health.

- Wasting Associated with Cancer

Anorexia, muscle wasting, weight loss, and fatigue typify cancer cachexia, which

eventually affects over 80 percent of people with terminal cancer. Weight loss is often evident

at the time that cancer is diagnosed, and an involuntary weight loss of more than 10 percent,

which indicates significant severe malnutrition, is the ultimate cause of death in many cases.

Without adequate energy and nutrients, the body is poorly equipped to maintain organ function,

support immune defenses, and restore damaged tissues.

Many Factors play a role in the wasting associated with cancer. Cytokines released by both

tumor cells and immune cells, induce a catabolic state. The combined effects of a poor appetite,

accelerated and abnormal metabolism and the diversion of nutrients to support tumor growth

result in a lower supply of energy and nutrients at a time when demands are high. Appetite and

food intake are further disturbed by the effects of treatments and medications prescribed for

cancer patients.

- Metabolic Changes

Cancer patients exhibit an increased rate of protein turnover, but reduced muscle protein

synthesis. Gluconeogenesis increases, further straining the body’s supply of protein (recall that

muscle supplies the amino acids used in glucose production). Triglyceride breakdown increases,

elevating serum lipids. Many patients develop insulin resistance. Due to these metabolic

abnormalities many people with cancer fail to regain lean tissue or maintain healthy body

weights even when they are consuming adequate energy and nutrients.

- Anorexia and Reduced Food Intake

Anorexia is a major contributor to the wasting associated with cancer. Some factors that

contribute to anorexia or otherwise reduce food intake include:

Chronic nausea and early satiety Fatigue Pain Mental stress

- Gastrointestinal obstruction

A tumor may partially or completely obstruct a portion of the GI tract, causing

complications such as nausea and vomiting, early satiety, delayed gastric emptying, and

bacterial overgrowth. Some patients with obstructions are unable to tolerate oral diets.

Treatment:

Treatment of cancer depends upon its stages and its types. Some treatments follow as:

- Chemotherapy

It is the use of chemical agents or medications to systematically treat cancer.

- Biotherapy

It is the use of biologic agents to produce anticancer effects indirectly by inducing,

enhancing, or suppressing an individual’s own immune response. Anti– angiogenic agents are

used to inhibit the development of new blood vessels needed by cancers (tumor vasculature) and

thus prevent their growth, invasion, and spread.

- Hormonal therapy

It is systemic therapy used for the treatment of hormone-sensitive cancers (e.g., breast,

ovarian, prostate) by blocking or reducing the source of a hormone or its receptor site.

- Radiation

Oncologists work in the area of therapeutic radiation therapy, which uses high-energy

(ionizing radiation) in multiple fractionated doses, or radioactive chemicals to treat cancer.

- Surgery

It involves the surgical removal of cancerous tissue.

All have their side effects and may be risky. Each type of treatment is recommended by

oncologist. The time of treatment is also planned by oncologist.

Medical Nutrition Therapy for Cancer:

The objectives of medical nutrition therapy for cancer patients are to minimize loss of

weight and muscle tissue, correct nutrient deficiencies, and provide a diet that patients can

tolerate and enjoy despite the complications of illness. Appropriate nutrition care helps patients

preserve their strength and improves recovery after stressful cancer treatments. Moreover,

malnourished cancer patients develop more complications and have shorter survival times than

patients who maintain good nutrition status.

Because there are many forms of cancer and a variety of potential treatments, nutritional

needs among cancer patients vary considerably. Furthermore, a person’s needs may change at

different stages of illness. Patients should be screened for malnutrition when cancer is

diagnosed and be reassessed during the treatment and recovery periods.

- Nutritional Intervention Strategies

Side effects or Symptoms Strategies Weight Loss • Eat small, more frequent, nutrient dense meals and snacks.

• Add protein and calories to favourite foods. • Use protein and calorie-containing supplements (e.g., whey or soy powder, nutritional supplements). • Keep nutrient dense foods close at hand and snack frequently.

Poor Appetite/Anorexia • Capitalize on times when feeling best. • Eat meals and snacks in a pleasant atmosphere. • Keep nutrient dense foods close at hand and snack frequently.

Nausea/Vomiting • Sip on cool or room temperature clear liquids in small amounts. • Avoid high fat, greasy, spicy, or overly sweet foods. • Avoid foods with strong odours. • Eat bland, soft, easy-to-digest foods on scheduled treatment days.

Diarrhea • Consume plenty of clear liquids such as water, clear juices, broth, gelatine, popsicles, and sports drinks. • Decrease intake of high fibre foods such as nuts, raw fruits and vegetables, and whole-grain breads and cereals. • Avoid sugar alcohol–containing foods such as sugar-free candies and gums

Constipation • Increase intake of high fiber foods such as whole grains, fresh or cooked fruits and vegetables, especially those with skins and seeds, dried fruits, beans, and nuts. • Drink plenty of healthy fluids to keep the digestive system moving. Try to eat and snack at the same time each day. • Try to increase physical activity as able.

Sore Throat

• Eat soft, moist foods with extra sauces, dressings, or gravies. • Avoid dry, coarse, or rough foods. • Avoid alcohol, citrus, caffeine, tomatoes, vinegar, and hot peppers. Experiment with food temperatures (e.g. warm, cool, or icy) to find which temperature is the most soothing

Stomatits

(Sore Mouth)

• Maintain good oral hygiene (e.g., rinse mouth frequently, keep mouth clean). • Eat soft, moist foods with extra sauces, dressings, and gravies. • Avoid alcohol, citrus, caffeine, tomatoes, vinegar and hot peppers; and dry, coarse, or rough foods. • Try foods at room temperature or chilled.

Fatigue • Consume easy-to-prepare, easy-to-eat foods. • Keep nutrient dense snacks close at hand and snack frequently. • Drink plenty of healthy fluids to keep the digestive system moving. • Be as physically active as possible

Neutropenia • Wash hands frequently, keep kitchen surfaces and utensils clean. • Do not eat raw or undercooked animal products, including meat, pork, game, poultry, eggs, and fish. • Wash all fresh fruits and vegetables. • “When in doubt, throw out” and “No oldy or moldy.”

Altered Test Or Smell • Maintain good oral hygiene (e.g., rinse mouth frequently, keep mouth clean). • Try marinades and spices to mask strange tastes. • Use plastic utensils if metallic tastes are a problem. • Try cooler foods, rather than warmer foods.

Thickened Saliva • Sip on liquids throughout the day to keep the oral cavity moist. • Thin oral secretions with club soda, seltzer water, or papaya nectar. • Try guaifenesin to help thin oral secretions. • Try using a cool mist humidifier while sleeping

Xerostomia

(dry mouth)

• Sip on liquids throughout the day to keep the oral cavity moist. • Try tart foods to stimulate saliva, if open sores are not present. • Eat soft, moist foods with extra sauces, dressings, or gravies. • Maintain good oral hygiene

American cancer society guideline for cancer prevention should be followed during and

after cancer treatment:

- Avoidance of foods that contain unsafe levels of bacteria (raw meats, spoiled or moldy

foods, and unpasteurized beverages)

- Proper hand washing

- Special handling of raw meats, game, poultry, and eggs, utensils and cutting boards

- Avoidance of untested well water

- Storage of foods at appropriate temperatures (below 40° F and above 140° F).

- Eat a healthy diet, with an emphasis of plant sources.

- Choose foods and beverages which help to maintain in healthy weight.

- Eat five or more serving of a Varity of fruits and vegetables.

- Eat whole grain.

- Limit consumption of processed and red meat.

Energy:

Individual energy needs to maintain their weight and prevent weight loss associated with

cancer are different for the individual’s diagnosis, presence of other diseases, intent of treatment

(e.g., curative, control, or palliation), anticancer therapies (e.g., surgery, chemotherapy,

biotherapy, or radiation therapy), presence of fever or infection, and other metabolic

complications need consideration.

Conditions Energy Needs Cancer, nutritional repletion, weight gain 30-40 kcal/kg/day Cancer, norm metabolic 25-30 kcal/kg/day Cancer, hyper metabolic, stressed 35 kcal/kg/day Hematopoietic cell transplant 30-35 kcal/kg/day Sepsis 25-30 kcal/kg/day Obese 21-25 kcal/kg/day

Protein:

It is also important but the amount of protein also varies to the patient conditions e.g.

Conditions Energy Needs Non-stressed patients (undergoing treatment) 1.0 to 1.2 g/kg

patients with substantial protein losses or

cachexia

1.2 to 1.5 g/kg

Cancer, hyper metabolic, stressed 35 kcal/kg/day

Hematopoietic cell transplant 30-35 kcal/kg/day

Sepsis 25-30 kcal/kg/day

Obese 21-25 kcal/kg/day

Carbohydrates, Fluids and Fats:

Normally, 45% to 65% of energy intake should be come from carbohydrates. The food

selected should be rich in essential nutrients, photochemical and fibers.

Patients having difficulty tolerating whole foods may need some modifications. Patient

with nausea, vomiting, diarrhea, or partial bowel obstructions may feel better consuming less

fiber.

Fat intake during chemotherapy may vary from patient to patient as well. In general, a

low- fat diet is recommended overall health. Side effects such as nausea and diarrhea can make

fat less tolerable. Fats can contribute needed calories to patient with weight loss that are able to

tolerate them.

Fluid is important for health maintenance, and side effects such which alter hydration

status and electrolyte balance. So patient should consume about 64oz of fluids/day, with more

or less needed at certain times depending upon a patient condition. Altered fluid balance may

occur with fever, ascites, edema, fistulas, vomiting or diarrhea, multiple concurrent intravenous

(IV) therapies, impaired renal function, or medications such as diuretics.

Vitamins and Minerals:

Individuals diagnosed with cancer often take large amounts of vitamin and mineral

supplements because they believe that these products can enhance their immune system or even

reverse the course of their disease and also a way to make up for existing nutritional

deficiencies at the time of diagnosis caused by poor diet and lifestyle choices. Vitamins A, C,

and E and mineral selenium could inadvertently repair cancer cells that have been intentionally

damaged by chemotherapy.

Some antioxidants such as melatonin may protect the body from side effects of

chemotherapy. Some instances during and after a cancer diagnosis, supplementation or

restriction of specific micronutrients may be required as DRI levels, depending on medical

diagnosis and laboratory analysis (e.g., iron supplementation for iron-deficiency anemia).

Enteral and Parenteral Nutrition Support:

Nutrition support is used in limited situations during cancer treatment. Generally, tube

feedings and parenteral nutrition are provided to patients who have long-term or permanent

gastrointestinal impairment or are experiencing complications that interfere with food intake.

For example, many patients undergoing radiation therapy for head and neck cancers require

long-term tube feeding and may need to continue tube feedings at home.

Medical Treatment Side effects:

- Chemotherapy

Short term side effects:

Pain

Mucositis

Stomatitis (Mouth and throat sores)

Fatigue

Hair loss (alopecia)

Finger nail and toenail weakness

Constipation

Diarrhea

Amenorrhea (Temporary loss of

menstrual periods)

Menopausal symptoms (such as hot

flashes)

Infection

Weight gain

Insomnia (Sleep disorders)

Anemia

Leukopenia/neutropenia

- Long term side effects:

Early menopause

Fatigue

Mental fatigue

Long term health risks

- Radiation therapy

Nausea & vomiting Changes in menstruation, vaginal

itching, burning Rectal bleeding May damage healthy cells Skin problems ( dryness, iching,

blistering or peeling) Bone marrow transplant Low platelets and low red blood cells Pain Respiratory distress Organ damage

- Surgery

Fatigue Pain and anorexia Blood loss leads to malnutrition Acute metabolic distress which raises

the protein and energy needs Cancer Cachexia:

Cancer cachaxia is the multi-factorial syndrome defined by an ongoing loss of skeleton

muscle mass that can nutritional support and leads to functional impairment.

- A syndrome characterized by;

Anorexia, early satiety, weight loss, muscle wasting, anemia, edema, severe body weight,

fat and muscle loss, increases protein catabolism

- Diagnosis

By Involuntary weight loss >5% over last six months

- Clinical manifestations

Anorexia Asthenia Hypo-albuminaria Glucose Intolerance Skeletal muscle atrophy

Hypoglycemia Hyperlipidemias Lactic acidosis Increased Gluconeogenesis Visceral organ atrophy

NEUTROPENIA

The presence of abnormally few neutrophils in blood, leading to increased susceptibility

to infection is called Neutropenia (deficiency of neutrophils which form in bone marrow.

Patients have unusually low number of neutrophils. Neutrophils formed in bone marrow, travel

to the infected area via blood to combat bacteria and other invading organisms.

Causes:

- Some level of neutropenia occurs in about half of the people with cancer who receiving

Chemo and Radiation therapy or in Leukemia, Lymphoma, Myeloma and bone marrow

cancer.

- High risk of neutropenia leads to high risk of serious infection.

Signs & Symptoms:

- Fatigue

- Fever (100.5 F or higher)

- Chills or sweating

- Sore throat in mouth and tooth decay

- Pain in abdomen and near anus or during urinating

- Burning in urination

- Diarrhea

- Cough and Shortening of breath

- Any redness, swallowing, pain particularly around wound

- Unusual vaginal discharge or itching

Neutropenia Diet:

This diet is for the people with weakened immune system. This diet help to protect them

from bacteria and other harmful organism found in food and drinks. Cooking food (like beef

chicken, fish and eggs) completely sure that all bacteria’s are destroyed. When ANC (Absolute

Neutrophils Count) less than 500 cells/ mm3 than patient is often introduce to follow

Neutropenic Diet

Food Groups Foods Allowed Foods Avoided

Bread and cereals All other breakfast cereal for

example porridge, bread,

chapatti, cornflakes.

Cereal containing nuts and

dried fruits

Milk and yogurt Pasteurized milk and yogurt Unpasteurized milk and

yogurt and others products

with live and active culture

Meat and Meat Products

(Eggs)

Well cooked meat

Fresh, frozen and canned

fish and meat

Well cooked egg as boiled,

scrambled, omelet.

Raw or rare cooked meat

Raw and cracked eggs

Fruits and vegetables Washed fruits and vegetable

Fruits with thick peel,

canned and remove damaged

area

Cooked vegetables, canned

fruit & juices

Unwashed fruits or

deteriorate fruits and veggies

Fruits with thin peels

Dried fruits unless cooked

Unwashed/uncooked

Vegetables/salad

Cheese and cream Hard cheese

Pasteurized cream

Soft and ripened

Fresh/frozen cheese

Unpasteurized cream

Sweets, ice-cream and snacks Wrapped cream and

chocolate

Soft ice cream

Avoid sweets or chocolate

containing dried fruits and

nuts

Drinks Canned drinks

Tea, Coffee, Hot chocolate

Bottled still water

Bottle beer

Miscellaneous Cooked spices

Undercooked spices

Nuts, Ice

NUTRITIONAL ASSESSMENT GUIDELINES

Calculations of Caloric Requirement:

- Total caloric requirement = BEE x Activity factor x Stress/ Injury factor

- Basal Energy Expenditure (BEE) OR Harris-Benedict Equation

BEE for Male = 66.5 + (13.7 ×wt) + (5 × height) – (6.8 × age)

(Female) = 655.1 + (9.6 × wt) + (1.85 × height) – (4.7 × age)

(Wt = kg, ht = cm, age = yrs)

Activity Factor

- No activity = 1.0-1.1 - Slightly active = 1.2- 1.3 - Moderate Active = 1.3- 1.5 - Athletes heavy = 1.5- 1.7

Injury Factors

- Surgery - Minor = 1.0-1.1 - Major = 1.3-1.9

Injury Factors

Infection

- Mild= 1.0-1.2 - Moderate = 1.2-1.5 - Severe = 1.4=1.8

Trauma

- Skeletal = 1.2-1.35 - Blunt = 1.15- 1.35

Burns

- Up to 40% body surface - Area= 1.0- 1.5 - Over 100% BSA= 1.95

Quick Methods of Caloric Calculation:

- Estimation of Energy Needs Based On Stress

Normal: 30-35Kcal/kg body wt

Elective Surgery: 35-40Kcal/kg body wt

Severe Injury: 30-40Kcal/kg body wt

Extensive Burn or trauma 44-55Kcal/kg body wt

- Energy Needs Based on Weight & activity

Weight Sedentary Moderate Active Over weight 20-25Kcal/kg 30Kcal/kg 35Kcal/kg Normal 30Kcal/kg 35Kcal/kg 40Kcal/kg Under weight 30Kcal/kg 40Kcal/kg 45-50Kcal/kg

Types of Activity:

- Sedentary Activity

Eating, Writing, Watching television, working on computer, typing and table work in office.

- Light Activity

Preparation of food, washing the utensils, dusting, ironing, light walk, fast computer typing.

- Moderate Activity

Mopping, booming/ brisk walking.

- Vigorous Exercise

Washing clothes with hands, white washing, and very brisk walk, playing golf and

gardening.

- Strenuous Exercise

Swimming, jogging, bicycling, playing cricket and other games.

Estimating Protein Needs:

- Normal Health -------------------- 0.8-1.0gm/kg body wt

- Fever, Fracture, Infection ------- 1.5-2gm/kg body wt

- Protein depleted ------------------ 1.8-2gm/kg body wt

- Extensive burns ------------------ 1.5-3.0gm/kg body wt

Estimating Fluids Needs:

1- Based on age

Adult ----------------- 30-50ml/kg body wt

Infant ----------------- 100-150ml/kg body wt

Children ----------------- 70-110ml/kg body wt

Adolescent ----------------- 40-60ml/kg body wt

2- Based on weight (First 20 kg 1500 ml, then for each additional kg, 25ml added)

3- Based on energy intake (1ml/ Kcal)

4- Fluid calculation for renal patients

In oligo-uria restricted to the daily urine output plus 500 ml. this includes the water

present in foods and drink.

(1 cup) 1 glass = 250 ml e.g. if one’s fluid requirement is 1800ml to calculate 1800 ml

in glasses then 1800÷250 = 7.2 which means 7 glasses.

Calculation of Ideal Body Weight:

IBW for Men = 106 lb for first 5 feet & 6 lb for each additional inch IBW for Women = 100 lb for first 5 feet & 5 lb for each additional inch

Calculation of Body Mass Index:

Standard BMI Women Men

Under weight <18.5 <18.5

Desirable weight 18.5-24 20-25

Over weight 25-30 25-30

Obese grade I 30-35 30-35

Obese grade II 35-40 35-40

Obese grade III 40-45 45-50

Obesity Adjustment: (Actual BW – IBW) x 0.25 + IBW

Wrist Circumference:

r = Height (cm) ÷ Wrist Circumference (cm)

Male Female Frame

r> 10.4 r > 11.0 Small

r 9.6 – 10.4 r 10.1 – 11.0 Medium

r < 9.6 r < 10.1 Large

Total Exchanges for Per Day:

Total Calories 1000 1200 1400 1600 1800 2200 Milk 1 2 2 3 4 4 Fruits 2 3 3 3 3 3 Vegetable 2 2 3 3 3 3 Bread & Cereal 4 4 5 6 8 10 Meat 3 3 4 4 5 5 Fat 2 2 3 3 3 4

Serving Sizes:

Food Groups Serving Sizes Milk & Milk Products 1 exchange = 1 cup/glass or 8 ounces of milk or ¾ cup of yogurt Meat & meat

Substitutes

1 exchange = 1 egg or 1 ounces of cooked meat (1 inch cube) or 2 tbsp of cheese

Bread or Cereal 1 exchange = 1 slice of bread or ½ chapatti or ½ cup of cereal, pasta or starchy vegetables

Vegetables 1 exchange = ½ cup cooked vegetables or 1 cup raw

Fruits 1 exchange = 1 small fruit or ½ cup of juice or ½ cup plums or 3 oz grapes

Fats 1 exchange = 1 tsp or 6 nuts

Nutrition Formulas (For oral/ enteral nutrition):

Formula Dilution Calories Administration conditions

(For Adults)

Ensure Powder 6 scoops in 190 ml

water 230 kcal/servings Weakness, fatigue,

anorexia, old age, in weight loss, fever

Ensure Plus 250 ml 1.5 kcal/ml 375kcal/can

Surgery, chronic infection, cancer, sepsis, burn, multiple fracture, trauma, high fever

Glucerna SR 6 scoops in 200 ml water

220 kcal/serving Diabetes, weight reduction

Glucerana RTF 250 ml 1 kcal/ml 250 kcal/can

Enteral nutrition for diabetics, COPD

Suplena 237 ml 2kcal/ml 475 kcal/serving

Chronic renal failure, liver disorders

Osomolite 500 ml 1 kcal/ml 50kcal/500 ml

Isotonic general nutrition for problem free tube feeding, paralysis & CV

(For Infant and Children)

Isomel 1 leveled scope 20kcal/erving From birth to 2 year of

age, Vomiting, diarrhea

Semilac Advance 1 leveled scoop in 1 ounce of water

20 kcal/oz From birth to 6 months of age

Semilac gain 5 leveled scoops 1 ounce of water

22 kcal/oz 6 month to 2 years of age

Pediasure 5 leveled scoops in 190 ml water

225kcal/serving 2 to 12 years of age

Formance 4 leveled scoops in 205 ml water

178 kcal/serving For pregnant ladies.

Food Exchange list:

Food Exchange US Unit Metric Unit Comments Starches 80 calories 15 g carb., 3 g protein, 1 g fat Bread

Breads, other

Tortilla

Crackers

Cooked cereals

Dry cereals, unsweetened

Dry cereals, sweetened

Dry flour or grain

Pasta

Rice

Corn

Popcorn

Potato (small)

Potato, mashed

Sweet potato

Squash, winter

Cooked beans, peas, lentils

(add 1 meat exchange)

1 slice 1 oz 1 (6") 4-6 (3/4 oz) 1/2 cup 3/4 cup 1/2 cup 3 tbsp 1/2 cup 1/3 cup 1/2 cup 3 cups 1 (3 oz) 1/2 cup 1/3 cup 1 cup 1/2 cup

1 slice 30 g 1 (15 cm) 4-6 (20 g) 125 ml 175 ml 125 ml 45 ml 125 ml 80 ml 125 ml 720 ml 1 (85 g) 125 ml 80 ml 250 ml 125 ml

Most starches are a good source of b vitamins Choose whole grain foods such as 'all natural, 100% whole wheat' bread, pasta, tortillas, and brown rice, etc. For nutrients and fiber. Combine beans (starch & meat) with grains (starch) for their complimentary proteins and fiber Combine grains (starch) with milk (milk) or cheese (meat) to compliment proteins. Add additional fat exchanges for starchy foods prepared with fat.

vegetables 25 calories 5 g carb., 2 g protein

Raw vegetables

Cooked vegetables

Tomato or vegetable juice

1 cup 1/2 cup 1/2 cup

250 ml 125 ml 125 ml

Choose more dark green leafy and deep yellow vegetables such as spinach, broccoli, carrots, and peppers.

fruit 60 calories 15 g carb. Fresh fruit

Melon (cubes)

Canned fruit

Dried fruit

1 small 12 oz (1 cup) 1/2 cup 1/4 cup

1 small 360 g (250 ml) 125 ml 60 ml

Choose whole fruits for fiber Choose citrus fruits such as oranges, grapefruits, or tangerines

Fruit juice 1/2 cup 125 ml

meat & substitutes 35-145 calories 7 g protein, 0-13 g fat

Meat, poultry, fish

Cheese

Cottage cheese

Egg

Peanut butter

Tofu

Cooked beans, peas, lentils

(add 1 starch)

1 oz 1 oz 1/4 cup 1 1.5 tbsp 4 oz (1/2 cup) 1/2 cup

30 g 30 g 60 ml 1 22 ml 115 g (125 ml) 125 ml

Choose leaner meats such as chicken, fish, and lean cuts of meat; add fat exchange for higher fat meats and substitutes. Remove skin from poultry. Limit frying or adding fat. Have 2 servings of fish per week for omega 3 fatty acid.

milk

80-150 calories 12 g carb., 8 g protein, 0-8 g fat

Milk

Yogurt

1 cup 1 cup

250 ml 250 ml

Choose lower fat milks; add fat exchange for higher fat milk.

fat

45 calories

5 g fat

Oil

Mayonnaise

Cream cheese

Salad dressing

Peanuts

Avocado

Butter or margarine

Higher fat exchange

(additional)

1 tsp 1 tsp 1 tbsp 1 tbsp 10 1/8 1 tsp 1 exchange

5 ml 5 ml 15 ml 15 ml 10 1/8 5 ml 1 exchange

Eat less saturated fat such as animal fat found in fatter meat, cheeses, butter, and tropical oils (eg: palm). Also eat less hydrogenated fat, or trans-fats. Consume mono-unsaturated fat and moderate poly-unsaturated fat. Check nutrition facts on food labels; 5 g fat = 1 fat exchange.

sweets

Calories vary 15 g carb., protein & fat varies

Ice cream

Cookies

Syrup

Jam or jelly

Sugar

Pudding

Muffin or cupcake

1/2 cup 2 small 1 tbsp 1 tbsp 2 tbsp 1/4 cup 1/2 small

125 ml 2 small 15 ml 15 ml 30 ml 60 ml 1/2 small

Choose sweets sparingly because they are high in sugar, saturated fats or trans fats. Can be substituted for a 1 starch, fruit, or milk exchange. Add 1 or 2 fat exchanges for sweets containing fat.

Sample: ______________ Date: ______________ H. Syed M. Umar Kazmi

PATIENT’S PROFILE NAME: BED NO:

AGE: WARD / UNIT:

GANDER: ADM. DATE:

ANTHROPOMETRIC MEASUREMENT

Weight: Height:

BMI: IBW:

Activity factor: Stress factor:

ENERGY CALCULATIONS (Kcal COUNT)

BEE (M) = 66.47 + (13.75 x _____kg) + (5.003 x _____cm) – (6.755 x _____years) = ________Kcal.

BEE (F) = 655.1 + (9.563 x _____kg) + (1.850 x _____cm) – (4.676 x _____years) = ________Kcal.

TEE = ___________ (BEE) x ___________ (AF) x ___________ (SF) = _________Kcal.

BIOCHEMICAL ASSESSMENT HISTORY PROVISIONAL DIAGNOSIS

HBs Ag Anti – HCV HTN / HBP D.M, (Type) GFR, Stage Fever, (0F)

ELECTROLYTE VALUE R. RANGE STATUS

Sodium (Na)

133 – 145

Potassium (K)

3.3 – 5.0

Chloride (Cl)

95 – 108

Phosphate (HPO4

2-)

3.0 – 5.5

Calcium (Ca)

8.8 – 10.5

CBC VALUE R. RANGE STATUS

HBG 11.5 – 17.5

WBC 4 – 11

RBC 4 – 6

PLT 150 – 400

MCV 76 – 96

MCH 27 – 33

MCHC 33 – 35

MPV 7.2 – 11

HCT 36 – 54

ESR 0 – 22 (M) 0 – 29 (F)

BIOCHEM. VALUE R. RANGE STATUS

Bilirubin 0.0 – 1.0

Albumin 2.0 – 3.5

Globulin 3.5 – 5.5

ALT < 50

AST < 50

ALP 50 – 136

BUN 7 – 16

Creatinin 0.8 – 1.3

Uric Acid 3.5 – 7.2 Cholesterol Triglycerides HDL LDL Vitamin D

CLINICAL ASSESSMENT CLINICAL SIGNS

SKIN Dry, Rough, White Spots,

Pale, Normal LIPS

Cracks Erosion at angle of Mouth,

Swollen, Normal

FACE Pale, Scaling Around Nose,

Swollen, Normal TONGUE

Coated, Wavy Edges, Pale,

Scarlet Red, Normal

HAIR Thin, Dry, Easily Pluck able,

Brown Streaks, Normal GUMS Swollen, Bleeding, Normal

EYES Pale, Dry and –

Scaly at Corner, Normal NAILS

White Spots, Brittle, Ridges,

Spoon Shaped, Pale

G.I. FUNCTIONS Problem Duration Problem Duration

Appetite Loss Vomiting

Nausea Diarrhea

Anorexia Constipation

DIETARY ASSESSMENT

TYPE OF FLOUR

TYPE OF FAT TOTAL WATER

INTAKE

TOTAL (SNACKS & MEALS)

HOW MANY TIMES A WEEK DOES YOU EAT THE FOLLOWING MEALS?

Breakfast

7 6 5 4 3 2 1 0 Morning/ Eve. Tea

7 6 5 4 3 2 1 0

Lunch Dinner DIETARY QUESTIONNAIRE

Have you been on a special diet? Fluid / Solid Low residual High fiber DASH

Did you follow the diet? Strictly Mostly Occasionally Never

Taking any traditional remedies?

Taking any nutrition supplement?

Taking any anti-nutritional food?

Do you smoke? How many a day? DIET INTARACTIONS HISTORY

Foods that you like (favorite)

Foods that you dislike (aversion)

Foods from that you are allergic

Foods from that you are intolerant

24 HOURS RECALL Meal & Time Food Item Amount

Breakfast

Time

Morning Snack

Time

Lunch

Time

Evening Snack

Time

Dinner

Time

Bed Snack

Time

FOOD FREQUENCY CHECK LIST Foods 7 6 5 4 3 2 1 0

Egg Meat (Mutton, Beef) Poultry Fish Green leafy Vegetables

Vegetables Potatoes Pulses & Legumes Wheat Rice Milk Yogurt Lassi Milk based Desserts Cheese Butter / cream Carbonated Drinks Fruit Juices Fruits Tea / Coffee Fried foods Fast foods Sweets/Toffee / Chocolates

Cake/pastries / Biscuits

DIETARY RECOMMENDATIONS

Total Kcal / day (TEE): Total water intake / day: CALORIC DISTRIBUTION

Food component Percentage Kilo Calories Grams / day Carbohydrates

Proteins

Total fat DAILY DIETARY MANU (DIET CHART)

Breakfast

Time

Morning Snack

Time

Lunch

Time

Evening Snack

Time

Dinner

Time

Bed Snack

Time

DIETARY MODIFICATIONS

Rx.

EXERCISE RECOMMENDATIONS

SIGNATURE ___________________

Diabetes mellitus

Cardiac diseases, hypertension

Obesity

Eating disorders (Anorexia nervosa, bulimia nervosa)

GI tract & celiac disease

WEEK (3)

DIABETES

Main objective of diabetic diet is to maintain ideal body weight, by providing adequate

nutrition along with normal blood sugar levels in blood. Diabetes is a chronic degenerative

disease. It is caused by the disturbance of metabolism of the body and of its harmonic

imbalance.

Patients with high blood sugar will typically experience (frequent urination) polyuria

they will become increasingly thirsty (polydipsia) and hungry (polyphagia), weight gain,

unusual weight loss, fatigue, cuts and bruises that do not heal, male sexual dysfunction,

numbness and tingling in hands and feet.

Types of Diabetes:

- Type 1 diabetes (insulin dependent diabetes)

Diabetes mellitus type 1 is a form of diabetes mellitus that results from

autoimmune destruction of insulin producing beta cells of the pancreas. The subsequent lack of

insulin leads to increased blood and urine glucose. The classical symptoms are polyuria

(frequent urination), polydipsia (increased thirst), polyphagia (increased hunger), and weight

loss.

- Type-II diabetes (non-insulin-Depended)

It seldom develops before the age of 40 or above. Most people who develop type-2 diabetes

tend to be overweight. Diabetes may affect blood vessels, eyes, kidneys and nerves.

- Gestational Diabetes

It is a temporary form of diabetes (insulin resistance that usually occurs half way through a

pregnancy (at 4th-5th month). It results from excessive hormone production in the body or

inability of the pancreas to make the additional insulin that is needed during pregnancy.

However women who experience gestational diabetes are at an increased risk of developing

type-II DM later. Untreated gestational diabetes can lead to problems for both the mother and

the child.

Symptoms:

- Frequently urination - Increased thirst - Extreme hunger - Loss of weight - Slow healing of wounds, sores - Weakness fatigue - Itching/ Depression - Body pain

- Ketosis (small in urine) - Blurred vision (excessive sugar in

blood polls the fluid out of lenses of the eye, causing them to thin out and affecting their ability to focus).

- Oral disorders (dryness and burning sensations saliva also contains glucose in diabetic patients).

Causes:

- Inherited/ genetically transferred

- Smoking: It decreases insulin absorption

- Self-inflicted (eating too much sugar, refined carbohydrates) but high protein and fats

which are transformer dint sugar.

- Age: The risk of type 2 DM above the age of 45 years become increases.

- Obesity: Excess fat prevents insulin from working properly, the more fatty tissues in the

body, the more resistant the muscle and tissue cell become to body insulin.

- Lifestyle Risk: A sedentary lifestyle, physical activity and exercise helps control weight

uses up a lot of glucose present in the blood.

- Stress and Tension: Pancreatic insufficiency caused by stress can lead DM. Grief, worry

and anxiety resulting from examination, death of close relative, loss of job, business

failure and strained martial relationship all have a deep influence on the metabolism and

may cause glucose to appear in the urine.

Normal caloric Requirements for Diabetic:

- 45 - 60 % calories from CHO. Emphasis should be on grains, starches, fruits and

vegetables

- 12-15 % of daily calories from protein (1-1.5g/kg body weight). Type-2 diabetic patients

with evidence of nephropathy should limit protein intake to 12%

- 25-30 % calories from fat. 30-50 g fat/day preferably 30 g unsaturated)

- Fiber inake from fruits, vegetables and cereals 25-30 g/day

- You can consume alcohol 20-30 g per day.

- Physical activity of 20 minutes per day

- Medicines (Oral hypoglycemic agents) hinder the absorption of Vit.B12. So B-complex

supplement also recommend as required

Meal planning should adhere to certain factors, as follows:

Fiber should be at least 1.4 oz / day

Instead of 3 heavy meals, we should go for 4-5 small mid intervals

Replace bakery products and fast foods by simple whole cooked cereals, and don't eat

carbohydrates 2 hours before bedtime

Consume fresh fruit and vegetables at least 5 exchange/ day

Some anti-diabetic foods

Apple: It is rich in Pectin content. It aids in detoxification of body by supplying galacturonic

acid needed for the elimination of harmful substances. Pectin is a natural therapeutic ingredient

found in rind and pulps. This food reduces the body’s insulin requirement by approximately

35%. Apple is also considered valuable in depression. The various chemical substances present

in this fruit such as vitamin B1, phosphorus and potassium help the synthesis of glutamic acid

which controls the wear and tear of nerve cells.

Chana (Bengal Gram): Chickpea is anti-diabetic food.

Bitter Gourd: It contains insulin like principle designated as plant insulin. Seeds of bitter gourd

can be powdered and added to regular meals. It is Good source of Vitamin A, B, B2, C and iron.

Broccoli: It is a rich source of chromium, trace minerals that seems to lower blood sugar.

Yogurt: It washes the pancreas of its acids and wastes. Yoghurt injects friendly bacteria in

digestive system that stimulates the pancreas.

Garlic: This vegetable is rich in potassium, which effectively replaces the large quantities of

potassium lost in the urine of diabetes. It also contains zinc and sulphur which are constitutes of

insulin. Garlic also contain manganese.

Grape Fruit: The gape fruit has great appetizing properties and its refreshing qualities. Two

weeks of grapefruit rich diet bring down sugar level in individuals not taking insulin.

Jambul Fruit (Jamun): It possess anti diabetic properties. If the seeds are dried and powdered.

This powder mixed with water, taken 3 to 11 times daily reduces sugar in urine and lessen

thirst. These seeds are considered beneficial in the treatment of excessive urination. (Doses of 1

gram)

Kidney Beans: Are high in CHO and fiber. They should be eaten liberally to keep diabetes

under control.

Onion: It has hypoglycemic substances. Onions are source of allyl, propyl, disulphide and

allicin. It affects the livers metabolism of glucose, or release of insulin.

Soybean: It is one of the most nutritious food of great value in the treatment of DM. It contains

very little starch and good quality of fats and proteins.

Buttermilk: Lactic acid contained in it stimulates the secretion of the pancrease.

Flour: Soybean, black gram, jowar, bajra, Bengal gram, barley, wheat bran for making

chappati.

Legumes: Valuable because of slow energy release.

Cinnamon: It stimulates insulin activity.

Fenugreek: The seeds of the plant are the best cleaners of the body as they are the highly

mucus solvents and soothing agents. Seeds contain alkaloid known to reduce sugar levels. The

soaked seeds can also be dried and powdered, and powder taken with milk.

Mango leaves: The tender leaves of the mango tree are an anti-diabetic food.

- Foods to Avoid

Its best to avoid dairy products, caffeine, spice foods, fried foods, oils or any type, sugary

foods or high fiber vegetables and fruits.

Dietary Guidelines for Diabetic Patients:

Walk about 15-30 minutes daily

Before taking each meal drink 1 glass of water

Avoid cold drinks bakery products, oily and fast foods

Raw fruits are better than juices. (Only 2-3 fruits consume daily)

Take all fresh vegetables

Take low fat dairy products. Avoid tetra pack milk, yogurt, mayonnaise, ice cream.

Consume chicken, fish and egg. Avoid beef, mutton and frozen meat.

Avoid foods that contain high glycemic index or sugar like canned foods, sweet

potatoes, turnip etc.

Use canola, mustard or olive oil. Avoid butter ghee and margarine but only 1 tsp. of

homemade Dasi ghee or butter can be used daily

Divide the meals in to small portions and almost (4-5 meals)

Check your Blood glucose level daily and note on diary.

Counseling Points:

To wear cotton clothes.

Take care much care of hygiene.

Take care of your feet.

Do not use the towel of other people.

Diet plan for a diabetic is based on:

Height

Weight

Age

Sex

Physical activity

Nature of diabetes.

Diet plan for Diabetic (1500kcal.):

Time Meal Kcal.

Breakfast

8:00 am.

2 slice brown bread +1tbsp butter.

1 egg boiled.

1 cup tea(without sugar).

130+45.

90.

30.

Snack

10:30pm.

1 Apple.

1 glass milk(without sugar).

60.

150.

Lunch

1:30pm.

1 chapatti.

½ plate curry(chicken).

1 small plate salad.

210.

112.

30.

Snack

4:30 pm.

1 chicken sandwich.

1 cup tea (without sugar).

150.

30.

Dinner

8:00 pm.

1 chapatti.

½ plate lentil.

1 small plate salad.

1 small cup fruit yogurt.

210.

100.

30.

70.

Snack

9:30 pm.

6 almonds(soaked & pealed) 45.

CARDIOVASCULAR DISEASES

Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood

vessels. Cardiovascular disease includes coronary artery diseases (CAD) such

as angina and myocardial infarction (commonly known as a heart attack). Other CVDs are

stroke, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, heart

arrhythmia, congenital heart disease, valvular heart disease, carditis, aortic

aneurysms, peripheral artery disease, and venous thrombosis.

Causes:

High Blood Pressure

Smoking

Diabetes

Lack of exercise

Obesity

High Blood Cholesterol,

Poor diet

Excessive alcohol consumption

Atherosclerosis

Risks Factors:

Age, gender, tobacco use, life style, physical inactivity, excessive alcohol consumption,

unhealthy diet, obesity, family history of cardiovascular disease, raised blood pressure

(hypertension), raised blood sugar (diabetes mellitus), raised blood cholesterol

(hyperlipidemias), psychosocial factors, poverty and low educational status, and air pollution.

Ischemic Heart Disease (IHD):

Ischemic Heart Disease or myocardial Ischemia is a disease characterized by Ischemia

(reduce the blood supply of the heart muscles). It may be manifested as sudden death

myocardial infraction (IM) and Angina (chest pain).

Congestive Heart Failure (CHF):

It is the condition in which the heart cannot pump the enough blood to organs of the

body. This result from

Coronary artery disease (Narrowed that supply blood to the heart muscle

High blood pressure

Cardio-myopathy (Primary disease of heart muscle itself

Congenital heart defects (defect present at birth)

Endocarditis or Myocarditis (infection of the heart value or muscle itself)

Medical Nutrition Therapy: Eggs don’t raise blood cholesterol. Eggs are very rich in lecithin. Lecithin is a fat and

cholesterol emulsifier and mobilizer. They are rich in HDL (heart friendly cholesterol). Egg

lecithin improves HDL/LDL ratio.

CHO 50-60% Protein 15% Total Fat 27 – 30% SFA 7%

MUFA 10% PUFA 10% Cholesterol <300mg Fiber 25- 30 gm.

Dietary Guidelines:

Choose whole grains/ high fibers Consume fish at least twice a

week Diet rich in fruits/ veggies Consume eggs 2/3 per week

Choose lean meats Cook foods in cold pressed

vegetable oil Choose low-fat milk and milk

products

The low fat food choices are for patient with Hyperlipidemias and Hypertriglycerdaemia:

FOOD GROUPS FOODS ALLOWED FOODS RESTRICTED

Bread, cereals and grains

All types of bread, naan, roti, rusk (paapay), khitchri, rice, pasta, noodles

All types of cereal and grain products prepared ing ghee, butter and lots of oil.

Milk and milk products

Milk and milk products without balai. Malai and cream

Milk and milk products with malai/ balai and cream, or added fat.

Meat (red. White meat and

egg)

All lean meat preparation in little quantity of oil, Egg preparation in little oil

Meat dishes with moderate to high cooking fat such as qorma, biryani, pulao

Lentils/ daals (with. Without

rusk) All cooked in little oil Fired daals dishes

Vegetables (green leafy/

starchy)

All seasonal fresh, boil and cooked in little oil

Deep fried vegetables

Fresh fruits All fresh fruits None

Dry fruits, nuts and seeds All dry fruits, nuts and seeds in small quantity

All kinds of fried and salted nuts and seeds

Fats and oils

Polyunsaturated oil such as olive oil, corn oil, sunflower, canola oil, and soybean oil, limit to 2 teaspoon (10g) per day

Butter, ghee and hydrogenated fat

Desserts and sweets

All types of desserts and sweets with little fat and cream

Ghee and butter based sweets such as kheer, halva, khoya, gajraila

Fluids and drinks

All types of beverages, juices, tea, coffee, lassi, sherbets, and cold drinks

Sweetened milk, canned salted fruit juices, milk shakes

(DIET MANUAL FOR PAKISTAN, MINISTRY OF HEALTH – PK)

HYPERTENSION

Blood pressure is the force per unit area exerted by the blood against the walls of blood vessels,

and the magnitude of this force depends on the cardiac output and the resistance of the blood

vessels.

Persistently elevated high blood pressure is called hypertension. Hypertension (HTN)

or high blood pressure, sometimes called arterial hypertension is a chronic medical condition

in which the blood pressure in the arteries is elevated. This requires the heart to work harder

than normal to circulate blood through the blood vessels.

Classification Systolic BP Diastolic BP

Normal < & = 120 < & = 80

Pre-hypertension 120-129 80-89

Hypertension 1 130-139 90-99

Hypertension 2 140-149 100-110

Hypertension 3 > & = 150 > & = 110

Signs and Symptoms:

A proportion of people with high blood pressure reports headaches (particularly at

the back of the head and in the morning), as well as light headedness, vertigo

(dizziness), tinnitus (buzzing or hissing in the ears), altered vision or fainting episodes.

Diet for Hypertension: (DASH diet):

One step to lower high blood pressure is incorporating the DASH diet into your lifestyle.

The DASH diet which stands for Dietary Approaches to Stop Hypertension is an example of

such an eating plan. In studies, patients who were on the DASH diet reduced their blood

pressure within two weeks. Another diet (DASH-Sodium) calls for reducing sodium (salt) to

1,500 mg a day (about 2/3 teaspoon). Studies of patients on the DASH-Sodium plan

significantly lowered their blood pressure.

Recommendations – Eat more fruits, vegetables, and low-fat dairy foods. Cut back on

foods high in saturated fat, cholesterol, and total fat. Eat more whole grain products, fish,

poultry, and nuts. Eat less red meat and sweets. Eat foods that are rich in magnesium,

potassium, and calcium.

The number of servings you require may vary, depending on your caloric need. When beginning the diet, start slowly and make gradual changes. Consider adopting a diet plan that allows 2,400 milligrams of salt per day (about 1 teaspoon) and then once your body has adjusted to the diet further lower your salt intake to 1,500 mg per day (about 2/3 teaspoon). These amounts include all salt consumed including that in food products, used in cooking, and added at the table.

Tips to get started on the DASH diet:

Add a serving of vegetables at lunch and at dinner. Add a serving of fruit to your meals

or as a snack. Use only half the butter, margarine, or salad dressing, and use low-fat or fat-

free condiments. Drink low-fat or skim dairy products three times a day. Limit meat to six

ounces a day. Try eating some vegetarian meals. Add more vegetables, rice, pasta, and dry

beans to your diet.

Instead of typical snacks (chips, etc.), eat unsalted pretzels or nuts, raisins, crackers,

low-fat and fat-free yogurt and frozen yogurt, unsalted plain popcorn with no butter, and

raw vegetables. Read food labels carefully to choose products that are lower in sodium.

Food groups and suggested serving amounts for the DASH diet:

Grains: 7-8 daily servings

Vegetables: 4-5 daily servings

Fruits: 4-5 daily servings

Low-fat or fat-free dairy

products: 2-3 daily servings

Meat, poultry and fish: 2 or less

daily servings

Nuts, seeds, and dry beans: 4-5

servings per week

Fats and oils: 2-3 daily servings

Sweets: try to limit to less than 5

servings per week

Other possible diet treatments are increasing potassium and calcium intake, and

ingestion of a vegetarian diet or fish oil supplements or losing weight in case of obese.

Foods for hypertension patients include lean meat, whole grain cereals, fruits and

vegetables, low sodium and salts foods (This can be achieved by using less salt in food

preparations, avoiding prepared or frozen meals or other foods that use salt as a

preservative, and to increase low-sodium foods in their diets).

OBESITY

Accumulation of fat in the fat cells is called obesity. Adults gain an average of half

pound an excess accumulation of fat in the body. Adults gain an average of half pound per year

between the ages of 25-55.

Types of Obesity:

- Hyperplasic obesity

This type of obesity is due to increase in the number of fat cells.

- Hypertrophic obesity

It is due to increase in size of fat cells.

- Obesity in Women

In women there is pear shaped obesity which is also called lower body obesity.

- Obesity in Men

In men there is upper body obesity which is apple shaped obesity.

Fat Cells Development:

When more energy is utilized then expenditure then excess energy stored in the fat cells

of the adipose tissues. The amount of fats in person’s body reflects both number and size of the

fat cells. The numbers of fat cells increase more rapidly in the growing age of the childhood and

early. When the numbers of cells reaches to their maximum growth then they divide and cause

obesity. As the fat loses then size of fat cells decrease but does not remove. So the people can

shrink the fat cells but they cannot make the cells disappear. So the proper management of

obesity is necessary.

Causes:

- Excess food intake

- Lack of physical activity

- Life style

- Genetics

- Other illness

- Social determinants

- Drugs, infection agents

- Inadequate sleep (Ghrelin hormone

low and increase the feel of hunger

and decrease the Leptin enzyme

which give the satiety

Ob gene:

There is an obesity gene called ob gene that is expressed in fat cells and holds for protein leptin. Leptin acts primarily as a hormone in hypothalamus.

Health Risks Associated to Obesity:

- Hyperlipidemia

- Hypertension

- High Triglycerides

- Diabetes Militias

- High blood cholesterol

- Metabolic syndrome

- Reproductive problems

- Sleep apnea

- Bone Degeneration

- Treatment

- Change your life style

- Drugs

- Weight loss surgery

- Combination of 2 hormones into 1

molecule

Dietary Guidelines for Obese People:

Use DASH diet and drink plenty of water

Low of CHO & fats

Very low caloric diet (800-1000 calories) per day)

Plenty of vegetables, including different types and colors, and legumes/beans

Fresh Fruit as compared to juices

Wholegrain cereals and/or high fiber varieties, such as bread, cereals, rice, pasta,

noodles, oats and barley

Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans

Milk, yoghurt, cheese and/or their alternatives, mostly reduced fat (reduced fat milks are

not suitable for children under 2 years)

Limit intake of foods containing saturated fat, added salt, added sugars and alcohol.

Some restaurants, cafes and fast-food outlets provide kilojoule information per portion,

but providing this information is not compulsory. Be careful - some foods can quickly

take you over the limit, such as burgers and fried chicken.

Avoid Fad Diets:

Avoid fad diets that recommend unsafe practices such as fasting (going without food for

long periods of time) or cutting out entire food groups such as meat, fish, and wheat or dairy

products.These are not sustainable, can make you feel ill, and may cause unpleasant side effects

such as bad breath, diarrhea and headaches.

Choose A Responsible Diet Programme that:

Education about issues such as portion sizes, make changes to long-term behaviors/

healthy eating patterns. It is not overly restrictive in terms of the type of food you can eat. It is

based on achieving gradual sustainable weight loss rather short-term rapid weight loss, which is

unlikely to last.

EATING DISORDERS (ANOREXIA NERVOSA)

Anorexia nervosa is a complex eating disorder with three key features:

1. Refusal to maintain a healthy body weight

2. An intense fear of gaining weight

3. A distorted body image

Because of your dream of becoming fat or disgusted with how your body looks, eating and

mealtimes may be very stressful. And yet, what you can and can’t eat is practically all you can

think about. Thoughts about dieting food and your body may take up most of your day leaving

little time for friends, family, and other activities you used to enjoy. Life becomes a relentless

pursuit of thinness and going to extremes to lose weight. But no matter how skinny you become,

it’s never enough. Fortunately, recovery is possible. With proper treatment and support, you or

someone you care about can break anorexia’s self-destructive pattern and regain health and self-

confidence.

Types:

1. Restricting type

In which weight loss occurs by restricting calories (following drastic diet, fasting or

excess of exercise).

2. Purging type

It includes weight loss by vomiting or using laxative and diuretics.

Sign and Symptoms:

- Dramatic weight loss

- Denial you are thin

- Feeling fat

- Deny using pills

- Eat low calorie food

- Harshly critical feeling of appearance in

front of mirror

Causes:

- Develop later as a result of mal

nutrition.

- Fear of gaining weight

- Psychologically

- Family and social depression

- Biological cause

- Body dissatisfaction

- Low self esteem

- Family history of eating disorder

- Strict diet

- Difficulty expressing feeling

Treatment:

1. Medical

2. Nutritional

3. Counseling and psychotherapy.

Dietary Recommendations:

o Macronutrients

Protein

- Minimum intake = RDA in g/kg ideal body weight

- 15% to 20% kcal

- High biologic value sources

Carbohydrate

- 50% to 55% kcal

- Provide sources of insoluble fiber for treatment of constipation

Fat

- 30% kcal, including sources of essential fatty acids Encourage small increases in fat

intake until goal can be attained

o Macronutrients

- 100% RDA multivitamin with minerals supplement with the exception of iron

- Avoid supplemental iron during initial phase of weight restoration; reassess need during

late treatment

- Determine need for supplemental thiamin during course of weight restoration

Nutritional Support:

- Protein drinks (powdered protein)

- Milk

- Eggs

- Meat

- Sauces or gravies

- Oil

- Before treatment the parenteral nutrition or enteral nutrition should be provided.

EATING DISORDERS – BULIMIA NERVOSA

It is eating disorder in process eat a large amount of food and then want to get rid of that by

including vomiting or diarrhea by different measurements.

Causes:

o Poor body image

o Low self esteem

o Psychological

o Appearance-oriented professional or activities

Sign and Symptoms:

o Lack of control of over

eating

o Malnutrition

o Weight may be normal or

loss

o Mouth injuries

o Dehydration

o Constipation

o Tooth decay

Treatment:

o Same as anorexia nervosa

Effects on Body:

o Cheeks(swallowing)

o Stomach(empty delayed)

o Heart(irregular)

o Hormones (irregular)

Nutritional Care:

1. Caloric prescription for weight maintenance

- If there is evidence of a hypo metabolic rate provide 1500 to 1600 kcal/day diet if patient is

hypo metabolic.

- If metabolic rate appears to be normal, provide DRI for energy if metabolic rate is normal.

- Monitor body weight and adjust caloric prescription for weight maintenance.

- Avoid weight reduction diets until eating patterns and body weight are stabilized.

2. Macronutrients

Protein

- Minimum intake is RDA in g/kg of ideal body weight.

- Provide 15% to 20% kcal.

- Provide high biologic–value sources.

Carbohydrate

- Provide 50% to 55% kcal.

- Encourage insoluble fiber for treatment of constipation.

Fat

- Provide approximately 30% kcal.

- Provide source of essential fatty acids.

3. Micronutrients

- Provide 100% RDA multivitamin with minerals supplement.

- Note that iron-containing preparation may aggravate constipation.

GASTROINTESTINAL DISEASES

1. UPPER GIT DISORDERS

Gastritis: (Inflammation of the stomach)

Causes:

Chronic use of aspirin/ alcohol

Food allergies, food poisoning, infections, radiations exposure or stress

Symptoms:

Anorexia, nausea, feeling of fullness and Epigastria pain are symptoms of gastritis.

Recommendations:

Bland diet if tolerated.

Intravenous fluids to be given if this stage prolonged

Use mechanically soft diet.

Avoid excessive intake of fluids with meals to avoid stomach distension.

When intrinsic factor is lacking Vitamin B12 is given by injection.

Gas: (Flatulence)

Recommendations:

Do not overtax you digestive system.

Chew well. Drink as much as water.

Walking is an excellent way to alleviate gas.

Keep a food diary to help you determine which foods seem to be causing gas.

Avoid Carbonated drink, cabbage, cauliflower and broccoli, producing gas tract disorder

2. Lower GI tract disorders:

Constipation:

It is characterized by delayed passage of soft stool. A person is constipated when bowel

movement are infrequent. Colonic constipation is stood that is hard and dry with small round

pieces like marbles. An average healthy adult should consume at least 26 grams of fiber (ideally

26 to 35 grams daily)

Causes:

Lack of water in diet

Lack of fibre in diet

Lack of exercise.

Some other reasons can include

taking specific medications and

other medical conditions.

Oral rehydration

formula ORF

a) 1/3 to 2/3 tbsp of salt b) ¾ tsp sodium

bicarbonate c) 1/3 tsp potassium

bicarbonate d) 1/3 tbsp of sugar e) 1 liter boiled water

Recommendations:

Eat high fiber foods

Eat 5 to 7 almonds before breakfast or 3 soaked figs or prunes

Use olive oil.

Drink 8-12 glasses of water

Drink several cups of warm-to-hot liquid in the morning. Herbal teas/ water work well.

Eat oatmeal, apple sauce, legumes (dried beans) and barley, to soften the stool.

Consume plenty of food that is high in pectin such as apples, carrots, beets, cabbage,

citrus fruits, and okra.

Get exercise, physical activity speeds the movement of waste through the intestine.

20- 30 minute walk can often relieve constipation.

Sit quietly for 15 minutes after eating a meal to aid in digestion.

Diarrhea:

Diarrhea is the condition of having three or more loose or liquid bowel movements per

day. The loss of fluids through diarrhea can cause dehydration and electrolyte

disturbances such as potassium deficiency or other salt imbalances. Oral rehydration solutions

(ORS) with modest amounts of salts and zinc tablets are the treatment of choice; ORS should be

begun at early as possible. Vomiting does often occurs during the first hour or two of treatment

with ORS, but this seldom prevents successful rehydration as most of the fluid is still absorbed.

Homemade solutions recommended by WHO include salted drinks (e.g. salted rice water or a

salted yoghurt drink) and vegetable or chicken soup with salt.

Diarrhea diet:

A diarrhea diet accordingly includes drinking plenty of water. However, broths and

soups that contain sodium, and fruit juices, mineral water, soft fruits, or vegetables that contain

potassium, are also extremely important to restore the

electrolyte levels and correct nutritional deficiencies.

Until the diarrhea stops it is also recommended to

avoid caffeine, milk products, and foods that are high

in fiber, or very high in simple sugars, as they tend to

aggravate diarrhea. For example, soft drinks,

undiluted fruit juices, and presweetened cereals

should be avoided. Also fried or fatty foods should be

avoided because of their tendency to delay stomach

emptying.

Carbonated drinks can also affect intestinal contractions and make diarrhea worse. A

heath care practitioner may also recommend the BRAT diet that includes bananas, plain rice,

apple sauce, and toast.

Some specific diarrheas have their own dietary requirements. For instance, avoiding

dairy products in cases of lactose intolerance, or gluten in cases of mal absorption, diarrhea

caused by antibiotics can also be reduced by taking probiotic yogurt with live active cultures.

As the diarrhea improves, soft, bland foods can usually be added to the diet,

supplementing bananas, plain rice, and toast with boiled potatoes, crackers, cooked carrots, and

baked chicken without the skin or fat. Other recommended foods include cereals (rice, wheat,

and oat cereals) and yogurt. Once the diarrhea has stopped, a person can usually return to a

normal and balanced diet.

Gastric Ulcer:

It is painful sore that can be found in stomach lining or small intestine.

Causes

- Helicobacter pylori infection

- Hyperacidity in stomach

- Hyper-calemia

- Genetically

- Alcohol

Sign and Symptoms

- Tummy pain

- Heart burn

- Loss of appetite

- Feeling and being sick

- Weight loss

Diagnoses

- Breath test

- Endoscopy

- Endoscopy biopsy

- Barium X-rays

Treatment

- H2 blockers

- Proton pump inhibitor

- Over counter antacid

- Surgically

Nutritional Care

- Avoid fatty foods

- Avoid spicy foods (black peeper, chili , garlic powder)

- Avoid acidic foods (beverages, citrus fruits, caffeinated products, alcohol)

- Avoid High fiber foods

Celiac Disease:

Celiac disease is an immune disorder characterized by an abnormal immune response to

a protein fraction in wheat gluten and to related proteins in barley and rye. The reaction to

gluten causes severe damage to the intestinal mucosa and subsequent malabsorption.

Consequences

The immune reaction to gluten can cause striking changes in intestinal tissue. In affected

areas, the absorptive surface appears flattened due to the shortening or absence of villi and

overdeveloped crypts.

Individuals with severe disease may malabsorb all nutrients to some degree, especially the

macronutrients, fat-soluble vitamins, electrolytes, calcium, magnesium, zinc, iron, folate, and

vitamin B12.

Symptoms

- Weight loss

- Diarrhea

- Anemia

- low bone mineral density.

- Mal absorption

- 20% people face constipation

Nutrition Therapy for Celiac Disease

- Remove gluten sources (wheat, rye, barley) from diet. Vitamin and mineral

supplementation.

- Substitute with corn, potato, Calcium and vitamin D administration.

- Read food labels carefully for hidden gluten containing ingredients.

Gluten-Free Diet

Meat and meat alternates Breads, cereals, rice, and pasta

Recommended: Fresh, frozen, salted, and

smoked meats (unless processed meats contain

any prohibited grains); products made with

hydrolyzed vegetable protein (HVP) or

hydrolyzed plant protein (HPP); eggs; dried

beans and peas

Questionable: sandwich spreads, meat loaf,

frozen burgers, sausage, imitation meat

products,

Meat products: egg substitutes, dried egg

products, dry-roasted nuts, peanut butter.

Recommended: Breads, baked products, and

cereals made with corn, rice, soy, potato

starch, potato flour, sorghum, pasta and

noodles made with grains

Questionable: Oatmeal and oat bran; rice

crackers, rice cakes, and corn cakes.

Avoid: Breads, baked products, cereals, , rye,

barley, wheat bran, wheat starch, wheat;

commercially prepared mixes for biscuits,

cornbread, muffins, pancakes, or waffles; malt

and malt

Avoid: Products that are breaded or prepared

in cream sauces, gravies.

Milk and milk products Fruits and vegetables

Recommended: Milk, buttermilk, plain yogurt,

cheese.

Questionable: Milk shakes, cheese spreads,

flavored yogurt, frozen yogurt, chocolate milk.

Avoid: Malted milk and malted milk powders.

Recommended: Any unprocessed fruits or

vegetables.

Questionable: French fries, especially in fast-

food restaurants; commercial salad dressings;

fruit pie fillings;dried fruits.

Avoid: Scalloped potatoes (with wheat flour),

creamed vegetables, vegetables dipped in

batters.

Beverages Desserts

Recommended: Coffee; tea; cocoa; soft drinks;

distilled alcoholic beverages such as rum, gin,

whisky, and vodka; wine.

Questionable: Instant tea or coffee, coffee

substitutes, chocolate drinks, hot cocoa mixes.

Avoid: Beer, ale, lager, malted beverages,

cereal beverages (Postum), beverages that

contain nondairy cream

Recommended: Ice cream, sherbet, egg

custards, or gelatin desserts that do not

contain gluten; pure baking, chocolate;

chocolate chips; hard candy.

Questionable: Icing, powdered sugar,

candies, chocolate bars, marshmallows.

Avoid: Puddings thickened with wheat flour;

ice cream or sherbets that contain gluten

stabilizers; baked products or doughnuts made

with wheat, rye, or barley; ice cream cones;

SOURCE: Adapted from American Dietetic Association, Manual of Clinical Dietetics

(Chicago: American Dietetic Association, 2000), pp. 181–191.

Renal diseases (pre-dialysis, dialysis, post-dialysis)

Renal calculi & Uric acid

Liver diseases (jaundice, hepatitis, cirrhosis, hepatic encephalopathy)

WEEK (4)

RENAL DISEASE

(Pre-Dialysis, Dialysis/ Post Dialysis Diets)

Kidneys are two beans shaped organs each about your size of fists. Inside each kidney

about millions of tiny structures called the Nephron which filter the blood and remove the

toxins or wastes products. Damage to the nephrons results in the kidney disease and kidney

unable to filter the blood. Kidney failure occurs when kidney partially or completely lost their

ability to filter the water and wastes products.

Symptoms of Kidney Failure:

Reduced amount of urine

Unexplained shortness of breath

Excessive drowsiness or fatigue

Persistent nausea

Confusion

Pain or pressure in your chest

Seizures

Coma

Swelling of your legs, ankles, and

feet from retention of fluids

Causes of Kidney Failure:

Loss of Blood Flow to the Kidneys (due to heart disease, liver failure, a severe burn, an

allergic reaction, a severe infection, such as sepsis, Bp and anti-inflammatory medications)

Urine Elimination Problems (Some cancers include: prostate, colon, cervical, and bladder,

kidney stones, an enlarged prostate, blood clots in urinary tract, damage to the nerves that

control your bladder)

Other Causes (a blood clot in or around your kidneys, infection, an overload of toxins from

heavy metals, drugs and alcohol, autoimmune disease, chemotherapy drugs, certain

antibiotics

Types of Kidney Failure:

1. Acute Pre-renal Kidney Failure

Insufficient blood flow to the kidneys can cause acute prerenal kidney failure. The kidneys

can’t filter toxins from the blood without enough blood flow. This type of kidney failure can

usually be cured once the cause of the decreased blood flow is determined.

2. Acute Intrinsic Kidney Failure

Acute intrinsic kidney failure can be caused by direct trauma to the kidneys, such as

physical impact or an accident. Causes also include toxin overload and ischemia, which is a lack

of oxygen to the kidneys. Ischemia may be caused by severe bleeding, shock, renal blood vessel

obstruction, glomerulo-nephritis, which is an inflammation of the tiny filters in your kidneys

3. Chronic Pre-renal Kidney Failure

When there isn’t enough blood flowing to the kidneys for an extended period of time, the

kidneys begin to shrink and lose the ability to function.

4. Chronic Intrinsic Kidney Failure

This happens when there is long-term damage to the kidneys due to intrinsic kidney disease.

Intrinsic kidney disease is caused by a direct trauma to the kidneys, such as severe bleeding or a

lack of oxygen.

5. Chronic Post-Renal Kidney Failure

A long-term blockage of the urinary tract prevents urination, which causes pressure and

eventual kidney damage.

Nutritional Guideline:

Acute Renal Failure

Chronic Renal Failure

Haemodialysis Peritoneal Dialysis

Calories (kcal)

25-30 35<60 yrs 30-35>60 yrs

35<60 yrs 30-35>60 yrs

35<60 yrs 30-35>60 yrs

Protein (gm/kg/d)

1-1.5 0.6-0.75 50%HBV

1.2 50%HBV

1.2-1.3 50%HBV

Fat (g/kg of bw/d)

0.8-1.5 - (if patient not consider to CND disease)

- -

Crab (g/kg bw/d)

3.5-5.0 Max:7

- - -

Sodium (mg/d)

1000-3000 2000 2000 2000

Potassium (mg/d)

Not restricted unless serum potassium is elevated and urine output is less than 1 L/d

Co-related to laboratory values

2,000-3,000 (8-17 mg/kg/d)

3,000-4,000 (8-17 mg/kg/d)

Calcium (mg/d)

1200-1600 1200 <2000 from diet and medication

<2000 from diet and medication

Phosphorus (mg/d)

800-1200 Co-related to laboratory values

800-1000 800-1000

Fluid (mg/d)

Fluid generally unrestricted balance fluid intake with urine output in patients with oedema and & congestive heart failure

Unrestricted with normal urine output

1,000+urine output

1,500-2,000

General Instructions:

Avoid high potassium, low sodium and low phosphorous.

Protein amount varies according to stage of renal and its treatments.

Avoid fruits as banana, orange juice, pear dates and fig.

Take vegetables as green beans, raw cabbage, raw carrot, cauliflower.

Avoid spinach, potato, tomato and broccoli.

Take fruits as apple juice, lemon, blueberries, grapes, apricot, canned pear and peaches.

RENAL CALCULI

Renal calculi or Kidney stones are solid masses made of crystals. These are usually

originate in kidneys but can develop anywhere along your urinary tract. And these are known to

be one of the most painful medical conditions. Kidney stones are most likely to occur between

the ages of 20 and 40.

Types of Kidney Stones:

Calcium

Calcium stones can be made of calcium oxalate (most common), phosphate, or maleate.

Eating fewer oxalate-rich foods can reduce your risk of developing this type of stone. High-

oxalate foods include potato chips, peanuts, chocolate, beets, and spinach.

Uric Acid

This type of kidney stone is more common in men than in women. They can occur in people

with gout or those going through chemotherapy. This type of stone develops when urine is too

acidic. A diet rich in purines can increase urine’s acidic level. Purine is a colorless substance in

animal proteins, such as fish, shellfish, and meats.

Struvite

This type of stone is found mostly in women with urinary tract infections. These stones can

be large and cause urinary obstruction. These stones are caused by a kidney infection.

Cystine

Cystine stones are rare. They occur in both men and women who have the genetic disorder

cystinuria. With this type of stone, cystine ( an acid that occurs naturally in the body leaks from

the kidneys into the urine).

Risk Factors for Kidney Stones:

Dehydration Obesity High-protein, salt, or glucose diet Hyper parathyroid condition Gastric bypass surgery

Inflammatory bowel diseases that increase calcium absorption

Taking medications such as diuretics, anti-seizure drugs, and calcium-based antacids

Dietary Prevention for Kidney Stones:

People can help prevent kidney stones by making changes in fluid intake and, depending

on the type of kidney stone, changes in consumption of sodium, animal protein, calcium, and

oxalate.

Fluid

Drinking enough fluids each day is the best way to help prevent most types of kidney

stones. Health care providers recommend that a person drink 2 liters of fluid a day. People with

cystine stones may need to drink even more. Though water is best, other fluids may also help

prevent kidney stones, such as citrus drinks.

Calcium Oxalate Stones

o Reducing sodium

o (low purine diet) reducing animal protein, such as meat, eggs, and fish

o Getting enough calcium from food or taking calcium supplements with food

o Avoiding foods high in oxalate, e.g. spinach, rhubarb, nuts, and wheat bran

Calcium Phosphate Stones

o Low purine diet/ or reducing animal protein

o Reducing sodium

o Getting enough calcium from food or taking calcium supplements with food

o Take foods high in citrate such as lemon, lime, pine apple, orange juice etc.

Uric Acid Stones

o (Low purine diet) limiting red meat and organ meats (liver, tongue and

sweetbreads)

o Refined carbohydrates (white bread, white rice, pasta, sugar)

o Processed foods (chips, snack foods, frozen dinners)

o Sugary beverages

o Alcohol (If you drink, limit it to no more than one alcoholic drink for women

and two for men within 24 hours.)

Struvite Stones

o Low sodium/ sugar intake

o Take fruits and vegetables juices and 50% fluid from water

o Consume food high in citrate

o High fiber foods (green leafy vegetables, peas, beans, potato, raw

vegetables/fruits, bran, whole grain)

o Take Supplement of Vit.B-complex (because this deficiency cause stones)

Systine Stones

o Fluid intake (2-3 liters)

o Low salt intake 6g/day

o High fruits and vegetables

o Low animal protein

o Foods that contains methionine like eggs, cheese, yogurt because these

breakdown the cysteine

URIC ACID

The final oxidation (breakdown) product of purine metabolism and is excreted in urine.

Uric acid concentrations in blood plasma above and below the normal range are known,

respectively, as hyperuricemia and hypouricemia. Likewise, uric acid concentrations in urine

above and below normal are known as hyperuricosuria and hypouricosuria. Such abnormal

concentrations of uric acid are not medical conditions, but are associated with a variety of

medical conditions.

Normal Ranges: (in blood plasma)

Men Women 3.4-7.2 mg/dL 2.4-6.1 mg/dL

High Uric Acid:

Hyperuricemia and can lead to gout (a type of arthritis ). This painful condition is the

result of needle-like crystals of uric acid precipitating in joints, capillaries, skin, and other

tissues. Kidney stones can also form through the process of formation and deposition of

Sodium– urate Microcrystals.

Causes

Diet may be a factor. High intake of dietary purine, high-fructose corn syrup, and table

sugar can cause increased levels of uric acid.

Serum uric acid can be elevated due to reduced excretion by the kidneys.

Fasting or rapid weight loss can temporarily elevate uric acid levels.

Certain drugs, such as thiazide diuretics, can increase uric acid levels in the blood by

interfering with renal clearance.

Co-Morbidities

Cardiovascular disease

Type 2 Diabetes

Obesity

Dyslipidemia

Uric acid stone formation

Lesch-Nyhan syndrome (an inherited

disorder, is also associated with very

high serum uric acid levels.

Dietary Recommendations:

A diet to lower uric acid levels makes gout one of the most controllable forms of arthritis.

- Foods Allowed

Skim milk

Low-fat dairy products (yogurt, cheese, cottage cheese)

Whole-grain products

Plant oils (olive, canola, sunflower)

Vegetables

Cherries

Vitamin C supplements (One study showed that 500 mg or more per day decreased gout

incidence in men.)

Coffee (if you drink it)

Water bottles (good for always having water handy, but tap water is fine, too)

- Foods to Avoid

Red meat and organ meats (liver, tongue and sweetbreads)

Shellfish such as shrimp and lobster

Refined carbohydrates (white bread, white rice, pasta, sugar)

Processed foods (chips, snack foods, frozen dinners)

Sugary beverages

Alcohol (If you drink, limit it to no more than one alcoholic drink for women and two for

men within 24 hours.)

JAUNDICE

The word Jaundice is derived from French word “Jaune” (Yellow.) It is the yellowish

discoloration of the skin, mucus membranes and white of the eyes caused by the levels of

chemicals Bilirubin in the blood (Hyper-bilirubinemia).

Types:

- Hepatocellular Jaundice

It occur as a result of liver disease or injury

- Hemolytic Jaundice

It occur as a result of hemolysis (an accelerated break down of erythrocytes-RBCs)

leading to high bilirubin.

- Obstructive Jaundice

It occurs as a result of an obstruction in bile duct (carries bile from liver to gall bladder

& S.I) which prevent the bilirubin from leaving liver.

Cause:

- Inflammation of the liver

- Inflammation of the bile duct

- Obstruction of the bile duct

- Hemolytic Anemia

Dietary Recommendations:

Food Groups Food Allowed Foods Avoided

Cereals Rice, rice flakes, puffed rice,

wheat, bread

Bajra, millet, brown bread,

ragi

Pulses All green dhal, red & Bengal

dhal

All grams, green, whole

black, channa, peas (dry), cow

pea

Root Vegetables Potato, carrot, beet root,

sweet potato

Yam, radish, tapioca

Green leafy Vegetables All leaves Stalk of the green leafy

vegetables, cabbage

Others vegetables All Cauliflower, capsicum

Milk & their products Skim butter, milk and curd Whole milk and products,

cheese, condensed milk

Fruits Allow without skin With skin

Non vegetarian Items Egg white, fish , chicken Egg yolk, organ meat, bee,

mutton

Fats & oils All

Nuts & oil seeds Tender coconut, water All ground & cashew nuts,

coconut

Sugar Glucose, honey

Spices Turmeric powder Mustard seeds, Jeera, chilies,

ginger, peeper, Coriander seed

Commercial Foods Marie biscuits, health drink Gram masala, pickle, chip,

chutney

HEPATITIS

It is an inflammation of liver. This condition can be self-limiting or can be progress to

fibrosis (Scaring), cirrhosis or liver cancer. Virus, other substances (Alcohol, drugs) and

autoimmune disease are responsible for hepatitis.

Types:

- Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, Hepatitis E

Dietary Recommendations:

Food Allowed Foods Avoided

Fatty fish, fried meats, poultry skin, gravies, fish canned oil

Fat free milk, energy drinks, fruit juices, shakes, smoothes

Chocolate, biscuit, cakes Jelly low fat ice cream, fat free custard

Mayonnaise, fatty salad sour cream

Clear soups, dry crackers and nuts

3 eggs per week Sugar to boost energy intake and bland porridge with fat free

Butter, nut spreads, peanuts Potato chips Spicy or fatty snacks

CIRRHOSIS

It is a complication of liver disease which involves loss of liver cells and irreversible

scarring of liver. Liver damage by cirrhosis can be undone. But if disease is in earlier stage then

treated further damage. It progresses more & more scar tissues forms, making it difficult to liver

function.

Symptoms:

- Fatigue

- Bleeding easily

- Brusing &Itchy skin

- Loss of Appitite & Weight loss

- Nausea

- Swelling in your lungs

- Yellow discoloration in skin

- Fluid accumulation in the blood

- Confusion, drowsiness and slurred

speech (Hepatic encephalopathy)

Causes:

- Alcohol

- Inherited

- Hepatitis B & C

- Infection of pancreas

- Fatty liver disease

- Destruction of bile & bile duct

- Scar tissues formed in the liver

Dietary Recommendations:

- Patient needs more extra calories due to nausea, vomiting, sewer weight loss

- Do not drink alcohol, avoid fast/ sea foods

- Eat healthy diet (freash fruits and vegetables) due to malnutrition

- Eat small & frequent meals

- Use herbs for seasoning food instead of salt

- Choose lean protein (legumes, poultery, fish)

- Eat low sodium diet (excessive salt retain fluid in the body)

HEPATIC ENCEPHALOPATHY

It is a condition in which decline in brain functioning occur as a result of sewer liver

disease because toxins build up in blood stream and brain damage.

Signs and Symptoms:

Difficulty in thinking

Confusion

Anxiety

Swerve personality damage

Fatigue

Shaky hands

Poor concentration

Forgetfulness

Poor judgment

Causes:

Acute viral hepatitis

Toxic hepatitis

Supplements

Kidney problem

Low oxygen level

Recent Surgery and trauma

Electrolyte imbalance

Acute and chronic Cirrhosis

Reye,s syndrome (swelling &

inflammation of liver or brain of the

children)

Dietary Recommendations:

Food Allowed Foods Avoided Low protein foods About 1g of protein per kg of body weight

Contaminated foods Fruits and vegetables

Alcohol Fiber rich foods

Preservatives, chemicals

Canned foods

Packed foods

Surgery (modifications for buckle surgery, esophagectomy,

gastrostomy)

Intestinal cancers and stoma formation

Assignment

WEEK (5)

SURGERY (DIETARY MODIFICATIONS)

Types of Surgery:

Buccal surgery

Esophagectomy

Gastrostomy

Pancreas surgery

Liver surgery

Intestinal surgery

- General dietary guidelines

Easily digested able foods

High caloric diet

Bed rest after 30 minutes of eating

Take a small bite

Take a frequent meal

Modifications for Buccle Surgery:

- For first two days of surgery

Liquid and soft diet e.g. milk shake, yogurt, cooked cereals, cheese, smoothies, mashed

potato, fried beans, ice cream, pudding, fruits, protein shakes etc. having good quality protein.

- Third day of the surgery

Soft food, don’t require more chewing.

- Food Choices – as following:

Foods Groups Foods Allowed Foods Avoided

Fruits Canned or cooked fruits,

Apple sauce, juices, jelly,

soft fruits or without skin

Dried fruits, coconuts,

apple, pine apple and

orange

Vegetables Soup, Canned or well

cooked, mashed potato

Raw and stringy cooked,

Spinach

Milk Products Yogurt, pudding, custard,

ice cream, milk shake,

smoothies

Grains Oatmeal, pasta, rice, hot

cereals,

Popcorn & chips or any

grain contains nuts &

seeds, Crusty bread,

cookies

Beverages Herbal tea Alcoholic, Carbonated,

Meat & their alternatives Tender minced, moist fish,

gravy sauces, soft cooked,

Egg (Scrambled, soft or

boiled)

Dry, rough or stringy, nuts

seeds, crunchy peanut

butter, stringy cooked,

mozzarella cheese

Esophagectomy:

It is a surgery in which remove all or a part of esophagus. When esophagus is removed

then stomach is pulled up in the chest.

- Signs and Symptoms

Nausea

Vomiting

Acid reflux

Dumping Syndrome (undigested food is

dumped quickly from stomach to

intestine)

- Dietary Recommendations – as following:

Foods Allowed Foods Avoided

Water with lemon orange slice Salty, sugary and fast foods Low fat yogurt Cold cuts of processed meat Broccoli Grape fruit juice Kale Potato, yams Banana More than 500mg of calcium, 2000IU of

Vit. D & 500mg supplements of Vit. C/ day

Raw red & yellow peeper Black tea, wheat, bran

Gastrectomy:

It is a surgical removal of all or a part of stomach.

- Types

1. Partial: Removal of the part of the stomach usually lower half

2. Full: Removal of the entire stomach

3. Sleeve Gastrectomy: Removal of the left side of the stomach usually for weight loss (up

to 3 quarter removed).

- Causes

Benign

Bleeding

Perforation in the stomach wall

Polyps (growth inside your stomach)

Stomach cancer

To treat the obesity

Severe peptic and duodenal cancer

- Side Effects

Acid reflux

Diarrhea

Gastric dumping syndrome

Vomiting

Intestinal bleeding

Leakage from the stomach at the

operation site

Blockage of the small bowel

Vitamins deficiencies

- Dietary Recommendations – as following:

Foods Groups Foods Allowed Foods Avoided

Fruits (1fesh or ½ cup

canned)

Fresh fruits (banana),

melon, canned packed in

its own juice

All raw fruits except melon &

banana, Dried & frozen fruits,

juices, canned fruits in sugar

Vegetables (½ cup cooked

or 1 cup raw)

All well-cooked without

seeds or skin, lettuce

(salad), strained veg. juice

All raw veg. except lettuce,

beats, broccoli, brusel, sprouts,

cabbage. Cauliflower, mustard,

turnip, potato kin

Milk Products

(1 cup)

Skim (1%) milk, Yogurt,

pudding, custard, ice

cream, milk shake,

smoothies, cheese &

cottage cheese, butter milk

Chocolate milk, milk foods

with added sugar, mozzarella

cheese

Grains (1 slice or ½ cup) Oatmeal, pasta, rice, hot

cereals, white flour,

crackers, cold & hot

cereals

High fiber, whole grain, (2 g

fibers per serving), Popcorn &

chips or any grain contains nuts

& seeds, Crusty bread, cookies

Beverages Herbal tea, decaffeinated

coffee, caffeine free tea,

sugar free soft drink

Alcoholic, Carbonated, ,

caffeinated tea or coffee,

beverages with sugar, corn

syrup or honey, fruit juices

Meat & their alternatives

(2-3 oz)

Any meat, fish , Tender

minced, Peanut butter

smoothe, gravy sauces,

soft cooked, Egg,

(Scrambled, soft or boiled)

Dry, rough or stringy, nuts

seeds, crunchy peanut butter,

stringy cooked, Fried meat,

High fat Luncheon meat ,

sausages

Fats & oils Oil, butter, salad dressing,

mayonnaise, cream, cream

cheese

Others Diet gelatin, herbs and

spices, sugar substitute,

boulion (shorba)

Sugar, honey, sorbitol

INTESTINAL CANCERS

Tumor in intestine (small intestine) may block the flow of food and effect digestion.

Types:

- Adenocarcinomas

The most common type of small intestine cancer, usually develop in the cells that line the

walls of the small intestine. Often, this type of cancer will develop out of small benign

(noncancerous) growths called polyps.

- Sarcoma

It is a type of intestinal cancer that develops in the connective tissue of the small intestine.

- Gastrointestinal stromal tumors

These are variants of soft tissue sarcoma.

- Carcinoid

These tumors form in the lining of the intestines and are often are slow growing.

- Lymphomas

These are an immune system disease that may originate within the intestines.

Symptoms:

- Abdominal pain

- Weight loss for no reason

- Blood in the stool

- Weakness or fatigue

- Bloody or tarry stools (from

bleeding tumors)

- A lump in the abdomen

Treatment:

- Surgery (most common)

- Chemotherapy therapy

- Radiation therapy

- A combination of chemo/ radiation

therapies

Risk factors:

- Older age

- Personal history of colorectal cancer

or polyps

- Family history of colon cancer

- Low-fiber, high-fat diet

- A sedentary life style or Obesity

- Diabetes

- Smoking &Alcohol

- Radiation therapy for cancer

- Ulcerative colitis and Crohn's

disease

- Celiac disease

- Inherited syndromes that increase

colon cancer risk

Dietary Recommendations:

- High protein diet

- Plenty of fluid

- Chewable foods

- Do not eat spicy foods

- Small & frequents meals

STOMA FORMATION

Stoma is a Greek word meaning ‘mouth’ or ‘opening’. Stoma surgery results in small

opening on the surface of abdomen being surgically created in order to divert the flow of fesses

or urine. It is estimated that 13500 people undergo stoma surgery each year. It is deep pink in

color.

Conditions for Stoma Formation:

- Colorectal cancer

- Ulcerative colitis

- Crohn,s disease

Stomach Bag:

Waste material comes out of the stoma is collected in stoma bag, depends on the stoma type.

Types of Stomas Stoma Bags

Colostomy: Coming from the colon

(Larger bowl)

Can be permanent or temporary

Closed bag or Drainable bag

Ileostomy: Coming from the Ileum

(Small bowl)

Can be permanent or temporary

Drainable bag

Urostomy: Coming from the kidney

and drainage urine

Permanent

Urostomy bag

Dietary Recommendations:

The foods that are poorly or temporarily digested or may block a narrow stoma are:

Cabbage Lettuce Corn Olives

Cerley Mushroom Cucumber Peas

Coconut Nuts Dried fruits Pickles

Green chilies Pineapple Cucumber Peas

- Foods that cause excessive swallowed air and gas

- Smoking pipes or cigarettes, chewing gum or tobacco, poorly fitting

dentures can caused increase salivation and swallowing.

- Eating fast and swallowing large chunk of food/ beverages

- Using straw or drinking from a bottle or can

- Inactivity and lying down after eating

Foods forming the Gas:

Legumes Most beans especially dried beans and peas, backed beans, soy

beans, limba beans

Vegetables Cabbage, Radish , Onion, Broccoli, Brussels sprouts,

cauliflower, cucumber, sauerkraut, kohlrabi, turnip, rutabaga,

onions

Fruits Prunes, apples, raisins, bananas, excessive amount of fruits

Cereals &

Bread

Excessive wheat products including bread and Cereals, check

labels for specific grains

Milk & their

products

Excessive milk , ice cream, cheese,

Fatty foods Excessive pan fried or deep fried food , fatty meals, rich cream,

assuages and gravies, pastries,

Liquids Carbonated beverages,

Foods thickening the Stool:

Foods causing the Diarrhea:

Odour producing Foods:

Asparagus Garlic & onion

Eggs Fish

Odour Reducing Foods:

Butter milk Yogurt

Cranberry juice Parsley

Apple sauce Pasta and cheese

Bananas Creamy peanut butter

Breads Starchy foods (potato)

Apple & Grape juice Prune juice

Hot peeper Highly seasoned foods

Enteral feeding (types, indication, supplement reconstitution)

PEG/ NG (problems & solutions)

Pediatric assessment (ideal height & weight for age)

WEEK (6)

ENTERAL FEEINGS

It is refers to delivery of nutritionally complete foods containing protein, carbohydrates,

fat, water, minerals and vitamins directly to the stomach, deudenum or jejunum. It is also called

tube feeding. It plays a major role in the management of patients with poor voluntary intake,

chronic neurological or mechanical dysphagia (difficulty in swallowing) or gut dysfunction or

critically ill patients.

Types:

- Nasogastric

In this small tube (NG) is inserted (without surgery) through the persons nose, throat and down

in to stomach short terms less than months but in infants & children may by longer)

- Nasojejunal

NJ tube is similar to the NG except threaded through the stomach and in to the jejunum and in

same case ND (Nasodedunal)

- Percutaneous endoscopic gastrostomy or jejunostomy

In this tube is placed through the endoscopically or surgically. Position can be visualized on

outside the patient abdomen due to the powerful light source.

Enteral Feedings Formulas: (depend upon the patients’ needs and requirements)

Formulas Examples

Polymeric / Standard or

Intact Formula

(best for the people who can

easily digest and absorb)

These are nutritionally complete. They are made with intact protein, carbohydrates, long chain triglycerides, vitamins and minerals. They may also include fiber and are administered through an enteral feeding tube.

Complain, Horlicks, Insure, Isocal, Pediasure, Insure plus

Disease Specific Formula

Specialized / disease-specific products are nutritionally complete and are designed to meet the needs of individuals with specific disease states, such as diabetes, renal dysfunction, liver dysfunction, respiratory dysfunction, acute illness or wound healing. Formulas may contain biologically active substances/ nutrients such as glutamine, arginine, nucleotides or essential FAs

Glucema, Nova source Renal, Resource Diabetes, Elemental028, Elemental(captamin),

Modular Formula

Modular/ Incomplete products are used to deliver an additional source of a specific nutrient. They are not designed to meet 100% of estimated nutritional needs, but can provide additional calories, or protein or fat. They may be taken alone or in combination with other products.

Bene protein, MCT oil

Advantages:

- For better function of GI Tract

- Less complication then parental feeding

- Less costly

SUPPLEMENTS RECONSTITUTION

Steps:

- Total Enteral Tube Feeding (ETF) products are prepared following specialize procedure

which assure that they are:

- Therapeutically and pharmaceutically appropriate the patient (suggested by the nutritionist/

physician)

- Free from microbial and pyrogenic contaminants (boiled water, clean utensils, hygiene

precautions like gloves and aprons etc.)

- Correctly prepared (as per standard dilutions).

- Properly labels (to place tag).

Supplements Uses Supplements Uses Isocal For tube feeding Sustagen For adult

malnourished Pediasure Lactose free formula

for children (1-10years)

O-lac Infant formula

Ensure For adult malnourished, lactose & gluten free

Elemental028 Crohn,s disease, short bowl syndrome

Elemental(captamin) Semi digested adult formula

Beneprotein Lactose free instant protein powder

Ensure plus (250ml) High protein & energy formula

Nutren Diabetes Lactose free Diabetes formula

Nova source Renal

(273ml)

Renal failure Moringa NL-33 Infants

- Properly stored (opened can should be covered & stored in cool and dry place but not in

refrigerated. Once open use contents within 3 weeks. Reconstitution Supplements should be

used promptly or covered, refrigerated)

- Properly distributed to patients.

Hang Time:

- Minimizing the ‘Hang-time’ (i.e. the amount of time and formula is at room temperature in

the feeding bag and accompanying lines during enteral tube feeding), with no hang-time

exceeding 4 hours.

- Longer time should be avoided because of the potential for significant microbial growth in

the reconstituted infant formula.

Labeling of Formula: (Use within 24 hours after preparation)

Patient Name: ----------------------------

Mr Number: ----------------------------

Formula: ----------------------------

Concentration: ---------------------------

Volume: ----------------------------

Time: ----------------------------

Standard Dilution:

Formula Water (ml) Powder (g) Volume (ml) Kcal/ ml

Isocal 211.25 53.25 250 1

Sustagen

211.25 66.25 250 1

Ensure 190 52.3 230 1

Pediasure

190 45.7 225 1

O-lac 224 34.4 240 0.68

Elemental028 422 100 500 0.78

Captamin 210 55 250 1

Calculating Volume: (for 24 hours)

Volume to be given in single dose x how many times a day

e.g. 250ml bid means 250x 2= 500ml per day

Different Concentrations:

Full strength According to the standard dilution

Double strength Double calories

Half strength Half calories

2/3 strength 2/3 calories

1/3 strength 1/3 calories

Important:

Increase strengths means Increase scoops & decrease water

Decrease strengths means decrease scoops & decrease water

Different Abbreviations:

Abbreviations Full Form Abbreviations Full Form

f/s Full strength Q2h Every 2 hours

h/s Half strength Ml Milliliter

Od Once a day Tid Thrice a day

Bid Twice a day Qid Four times a day

PEG/NG (PROBLEMS & SOLUTIONS)

Problems Causes Solutions Necrotizing fasciitis (dangerous

infections cause by EColi. An

clostridium bacteria of the soft

tissues that start in subcutaneous

tissue just below the skin) & spread

along the different layers of tissues

Necrosis (death of the body tissue due to low supply of the blood) of lower most skin layer of all body regions

Broad spectrum antibiotics Surgical debrement

Bleeding from the puncture site

A surrounding vessel injury

Producing compressive hemostasis by increasing the traction from tube If does not remove than remove the tube an undergo endoscopy

Aspiration Aspiration of reflux content from stomach

Prevent it with postural treatment

Irritation or infection in skin

around stoma

Excessive pressure on stoma Lack of peristomal hygiene Output gastric fluid

Adjust the distance between external retention ring and stoma. Clean stoma Put the gauze below the

retention ring and clean it daily

Obstruction from PEG Tube

Dried food or drug products clogging inside the probe. Lack of flushing water after and between administrating food or medication

Always flesh water after and between administrating food or drug Flushing with warm water & carbonated beverages with syringe Not to place object through lumen (space b/w tubular structure) in attempt to disclodge a clog (prevent from repture). Using pancreatic enzymes mixed with bicarbonate soln. if not enough then change tube.

Tube extraction

PEG tubes comes out of accidental or voluntry

Immediately replace the tube. If not available then place Foley Catheter (Flexible tube pass through urethra and bladder to drain the urine.)

Tube cannot be retarded

Burial (dead body) of the tube in the abdominal wall.

Rotate and push the probe (surgical instrument) gently inward. If not turn then remove the substitute the tube

Nausea/Vomiting

High osmolarity of formula Infusion excessively fast Lactose Intolerance Excessive fat in diet. Diet Cold

Use dilute formula Return to previous infusion rate Manage lactose free diet Use low fat diets

Diarrhea

Hyperosmolar solution Deficit lactose Poor absorption of fat Diet cold

Use isotonic diet and or dilute hypertonic ones. Suppress lactose Use low fat formula

Constipation Low fluid administration Insufficient fiber intake

Administrate fluid in adequate amount

Peristomal Grnuloma (Mass of

granulation tissue produced in

response to infection, inflammation

or foreign substance)

Prolifiration of granulation tissue (during healing process new connective tissues form on the surface of wound) through stoma

Resection and / or cauterization of tissue.

Pediatric Assessment Form

Child's Name: Child’s date of birth:

Caregiver’s Name: Relationship to Child:

Child’s most recent Height/Weight and approximate date of measurements:

Child’s Birth Weight and Length

Answer the following questions about your child's dietary habits. Only answer those that apply!

1. What are your concerns about your baby’s/child’s nutrition?

2. Does your child have any chronic illness or medical condition? YES NO

If yes, please list:

3. Was your baby/child premature? YES NO If yes, how many weeks?

4. Has your baby/child seen a registered dietitian before? YES NO If yes, where?

5. Does your baby/child have any food allergies? YES NO

If yes, please list:

6. What reaction does your child have when these foods are eaten?

How would you categorize it? mild moderate severe life threatening

7. Was your child ever on a special diet? YES NO If yes, who recommended this?

8. Is there any food practices related to cultural/ethnic/religious beliefs? YES NO

9. Does your baby/child drink: (indicate by a checkmark all that apply and estimate amount per 24 hours)

Breast milk whole cow’s milk

Infant formula 2% milk

Pediasure or similar product skim milk _______________________

Instant breakfast goat’s milk

Water soft drinks

Tea juice

Other:

10. Was your baby/child ever breastfed? YES NO

11. If you are currently breastfeeding, do you have any concerns?

If yes, please specify:

12. If your baby/child is on formula, list all formulas used:

13. If your baby/child is on formula, how is it prepared? Are other supplements added?

Follow directions on can cereal sodium

Add more water than directions call for polycose potassium

Add less water than directions call for oil/microlipid other

14. If your baby/child is on formula, is the formula iron fortified? YES NO

If no, why not?

15. If your baby/child is on formula, how many cans of formula do you use each week?

_____ powdered _____ liquid concentrate _____ ready to feed liquid

16. Is your child enrolled on the WIC Program? YES NO If yes, where?

If yes, do you ever have to buy formula? YES NO If yes, how/ month?

17. Does your baby/child take vitamin or mineral supplements?

Vitamins multivitamin with minerals iron fluoride herbal products other

18. Does your baby/child take a bottle to bed? YES NO if yes, what is in the bottle?

19. Do you add solid foods to the bottle? YES NO

20. Sleep/wake cycle: (circle hours when your baby/child is usually awake)

12mid

1 2 3 4 5 6 7 8 9 10 11 12noon

1 2 3 4 5 6 7 8 9 10 11

21. At what times does your baby/child eat?

12mid

1 2 3 4 5 6 7 8 9 10 11 12noon

1 2 3 4 5 6 7 8 9 10 11

22. Does your child eat at approximately the same time every day? YES NO

23. In what position is your baby/child during feedings? lap/cradles in arms infant seat walker

Lying flat on back high chair regular chair other:

24. How does your baby/child eat? (circle all that apply)

Breast bottle spout cup open cup spoon fork

infant feeder fingers straw special feeding equipment feeding tube

25. How does your baby/child act during the feeding? happy/eager concentrates on eating fussy

Easily distracted tires easily sleepy/tired trouble breathing while eating must be

burped frequently frequently gags/coughs/chokes

26. Do any of the following apply to your child at his/her present age? (check all that apply)

7 mo of age or older and has not started using a cup yet

9 mo of age or older and does not finger feed yet

12 mo of age or older and drinks liquids primarily from the bottle

19 mo of age or older and does not use a spoon yet

27. If your child is older than 12 mo of age, does he/she avoid or reject any of the following food groups?

(mark all that apply) grains (cereal, bread, rice, pasta) fruits vegetables dairy (milk,

cheese, yogurt) protein sources (meat, eggs, dried beans and peas) fats (butter, salad dressings,

oils)

28. Does your baby/child prefer foods at a certain temperature? YES NO

29. Does your baby/child regularly eat: (check all that apply)

Strained/pureed/baby foods: cereal juice fruit vegetable meat dinners egg yolk

Table foods: cereal bread pasta juice fruit vegetables meat

poultry fish beans/peas peanut butter cheese

30. How often does your baby/child eat? Every hours; times per day; meals_____

31. How long does it take your baby/child to finish a meal? < 30 minutes 30-45 minutes >45

32. At what age did you begin solid foods? What was the first food?

33. Describe your child’s appetite: good fair poor

34. How do you know your baby/child is hungry? (check all that apply) awakens sucks on

hand/fingers fussy cries screams says words that mean food points

35. How do you know your baby/child is full? (check all that apply) stops eating falls asleep

Spits out food or nipple turns away from food plays with food or is easily distracted

36. Does your baby/child do anything that upsets you at mealtimes such as refusing to eat, excessive

throwing of food or utensils or other?

Please explain:

37. What describes your baby’s/child’s usual feeding behavior?

Seems to enjoy eating, takes feedings easily, good appetite

Happy at beginning of feeding, then often gets fussy or distressed during feedings

Frequently has trouble breathing while eating

Often does not wake for feeding, tires easily with feedings, or often has difficulty finishing feedings

Eats slowly, usually takes more than 30 minutes (infants)/45 minutes (toddler) to eat -

(excluding time for diaper changes, play, etc.)

Usually has difficulty sucking, swallowing or chewing

Frequently gags, coughs, or chokes during feedings

Refuses to eat, is difficult to feed, fussy throughout most of feeding, arches backward, or doesn’t

seem to enjoy eating

Picky eater, seems to eat very little, not interested in food or eating, or has poor appetite

38. Does your baby/child experience any of the following? difficulty with sucking difficulty with

swallowing

Difficulty with chewing spit up or vomiting gagging diarrhea constipation

39. Usual stool frequency:

40. Does your baby/child take any medicines other than vitamin or mineral supplements? YES NO

If yes, please list:

41. How many meals does your child skip?

5-10 meals per week Less than 5 meals per week 1-2 meals per week none

42. What meal(s) does your child usually skip?

43. What are some of your child’s favorite foods?

44. Does your child eat clay, paint chips, or anything not usually considered food? YES NO

If yes, what? How often?

45. Where does your child eat most of their meals? high chair kitchen table living room

On the run in front of the TV school/daycare other:

46. Please list any additional concerns or questions you would like addressed

______________________________________________________________________________

Signature _________________ Dated _______________

2 to 20 years: Boys

Stature Weight-for-age percentiles-for-age and

NAME

RECORD #

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Published May 30, 2000 (modified 11/21/00).

W

E

I

G

H

T

W

E

I

G

H

T

S

T

A

T

U

R

E

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

S

T

A

T

U

R

E

74

76

72

70

68

66

64

62

60

in

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

lb

30

40

50

60

70

80

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

150

155

cm

150

155

160

165

170

175

180

185

190

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

12 13 14 15 16 17 18 19 20

AGE (YEARS)

AGE (YEARS)

40

95

90

75

50

25

10

5

95

90

75

50

25

10

5

160

cm 113 4 5 6 7 8 9 10

145

Date

Mother’s Stature Father’s Stature

Age Weight Stature BMI*

50

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

2 to 20 years: Girls

Stature Weight-for-age percentiles-for-age and

NAME

RECORD #

Published May 30, 2000 (modified 11/21/00).

W

E

I

G

H

T

W

E

I

G

H

T

cm

150

155

160

165

170

175

180

185

190

lb

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

190

200

210

220

230

kg10

15

20

25

30

35

105

45

50

55

60

65

70

75

80

85

90

95

100

20

20

S

T

A

T

U

R

E

40

lb

30

40

50

60

70

80

S

T

A

T

U

R

E

62

42

44

46

48

60

58

52

54

56

in

30

32

34

36

38

40

50

74

76

72

70

68

66

64

62

60

in

kg10

15

20

25

30

35

80

85

90

95

100

105

110

115

120

125

130

135

140

145

150

155

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

12 13 14 15 16 17 18 19

AGE (YEARS)

AGE (YEARS)

160

cm 113 4 5 6 7 8 9 10

95

90

75

50

25

105

95

90

75

50

25

105

Date

Mother’s Stature Father’s Stature

Age Weight Stature BMI*

PG-SGA rating form/ Caloric recommendations for different people

Counseling & preparing a diet chart

Assessment of assigned patients

Assignment

WEEK (7&8)

“PG-SGA” RATING FORM

A nutrition assessment tool in patients with cancer

OR

An easy to use nutrition assessment tool that allows quick identification and prioritisation of

malnutrition in hospitalised patients with cancer

CALORIC REQUIREMENTS

Total caloric requirement = BEE x Activity factor x Stress/ Injury factor

Basal Energy Expenditure (BEE) OR Harris-Benedict Equation

BEE for Male = 66.5 + (13.7 ×wt) + (5 × height) – (6.8 × age)

(Female) = 655.1 + (9.6 × wt) + (1.85 × height) – (4.7 × age)

(Wt = kg, ht = cm, age = yrs)

Activity Factor

No activity = 1.0-1.1

Slightly active = 1.2- 1.3

Moderate Active = 1.3- 1.5

Athletes heavy = 1.5- 1.7

Injury Factors (Surgery)

- Minor = 1.0-1.1

- Major = 1.3-1.9

- Infection, Trauma or Burns as below;

(Infection)

- Mild= 1.0-1.2

- Moderate = 1.2-1.5

- Severe = 1.4=1.8

(Trauma)

- Skeletal = 1.2-1.35

- Blunt = 1.15- 1.35

(Burns)

- Up to 40% body surface

- Area= 1.0- 1.5

- Over 100% BSA= 1.95

Quick Methods:

- Estimation of Energy Needs Based On Stress

Normal: 30-35Kcal/kg body wt

Elective Surgery: 35-40Kcal/kg body wt

Severe Injury: 30-40Kcal/kg body wt

Extensive Burn or trauma 44-55Kcal/kg body wt

- Energy Needs Based on Weight & activity

Weight Sedentary Moderate Active

Over weight 20-25Kcal/kg 30Kcal/kg 35Kcal/kg

Normal 30Kcal/kg 35Kcal/kg 40Kcal/kg

Under weight 30Kcal/kg 40Kcal/kg 45-50Kcal/kg

MAIN DIETS AGAINST MAJOR DISEASES

Diseases Diet Modifications

Hypercholeterolemia Low cholesterol

Hyperlipidemia Low triglycerdie cholesterol

Hypertension 2 gm or 4gm sodium diet + DAS Diet

Diabetes mellitus Sugar free

Obesity Low Calori, high fiber

Gout Purine restricted

Surgical Condition High protein, high fat and low carbohydrate

Fever High protein, + soft diet or fluid liquid

Tuberculosis High protein, low CHO high fat diet

For patients With Renal Failure Low protein, low phosphorus, low potassium, low sodium

Dialysis High protein, low phosphorus, low potassium, low sodium

Hypokalemia High potassium

Janudice High quality protein, High CHO and Moderate fat

Hepatitis High protein, Moderate, Fat, High CHO

Liver Cirrhosis High CHO, Moderate fat, 30-50gm/day protein, fiber

retricted (in advanced cirrhosis) & liquid or soft diet.

Hepatic coma 20 gm/day or omitted protein, High CHO and Moderate

fat

Later stage of cirrhosis (Acities) Sodium restricted and low fluid intake

Wilson’s disease Low copper diet

Peptic Ulcer and GIT disease Bland Diet

Lactose intolerance Lactose free Diet

Gluten Enteropathy Gluten Restricted Diet

Consitpation High Fiber Diet

Gallbladder and pancreatic

disease Fat Modified Diet

Dental problem Mechanical Soft Diet or Liquid Diet or Semi Solid Diet

COPD High energy, high protein diet

PATIENT ASSESSMENTS At Shaukat Khanum Hospital, OPD / outdoor patient department engaged with those

patients having appointment with their respective consultants (physicians, clinical nutritionists, psychologists, speech therapists/). Patients have hypertension, diabetes, obesity, renal, hepatic, gastrointestinal issues or other metabolic problems etc. along with the cancer treatments. Those feeding via tube through NG/ PEG are further guided side by side. As a clinical nutritionist, main objective was to take their daily intake, interpret changes where urged and counsel them to obtain the optimal nutritional.

PEG Patients: (1800 Kcal)

Time Feed Volume

6:00 am. 2/3rd cup milk+2tbsp.sugar/honey+ 1apple/banana/mango. 240cc

9:00 am. 2tbsp. sagoodana+ 2/3rd cup milk+2tbsp.sugar. 240cc

12’o clock. 2/3rd cup ch.stock +2tbsp.cooked lentil +1tbsp.cooking oil. 240cc

3:00 pm. 1cup juice + 1 slice bread. 240cc

6:00 pm. 2tbsp. semolina + 1tbsp.oil + 2/3rd cup milk. 240cc

9:oo pm. 2/3rd cup stock +1tbsp.oil + 2tbsp boiled vegetables. 240cc

Midnight. 3 scoops Isocal supplement + 1cup water. 240cc

- Preparation Techniques

Thoroughly blend all ingredients in

blender.

Make it like thick paste.

Strain the feed before pouring,

Pour 1 syringe of clean/boiled

water before & after pouring feed.

Feed should be at room temp.

Avoid street foods.

Diabetic Patient: (1500 Kcal)

Time Meal Kcal Breakfast 8:00 am.

2 slice brown bread +1tbsp butter. 1 egg boiled. 1 cup tea(without sugar).

130+45. 90. 30.

Snack 10:30pm.

1 Apple. 1 glass milk(without sugar).

60. 150.

Lunch 1:30pm.

1 chapatti. ½ plate curry(chicken). 1 small plate salad.

210. 112. 30.

Snack 4:30 pm.

1 chicken sandwich. 1 cup tea (without sugar).

150. 30.

Dinner 8:00 pm.

1 chapatti. ½ plate lentil. 1 small plate salad. 1 small cup fruit yogurt.

210. 100. 30. 70.

Snack 9:30 pm.

6 almonds(soaked & pealed) 45.

Hepatic Patient: (1500 Kcal)

Time Meal Kcal Breakfast 1 bowl porridge.

1 small apple. 165. 60.

Snack 1 glass skimmed milk. 90. Lunch 1 chapatti.

1 plate mix vegetable curry. 1 small plate custard.

210. 150. 150.

Snack Fruit salad + yogurt dressing. 270. Dinner 1 plate khichri.

2oz. chicken. 1 small plate salad.

170. 150. 30.

Snack 1 cup tea 50.

Patient of Breast Cancer, CKD, HTN, Acidic Stomach, Anorexia, Obesity: (1266 Kcal)

Time Meal Kcal BREAKFAST

Milk 1cup 100 kcl Dates 3 60 kcl

AT 10:00 AM Milk Porridge/sorghum/ corn flex

1cup 360 kcl

BRUNCH Apple and Watermelon 1 and 1cups 120 kcl

LUNCH Chicken polao 1cup 100 kcl Salad 1 cup 25 kcl Yogurt ¾ cup 100 kcl

SNACK Tea 1cup 100 kcl

DINNER Chicken vegetable 1 cup 70 kcl Chapatti ½ 80 kcl

POST DINNER Banana shake 1cup 100 kcl Total 1285 kcl

- Dietary Guideline

Three time 5-10 minute walk daily.

Eat vegetables three time per week and do not eat saag or spinach.

Eat meat or chicken two time per week

At least drink 8 glass of water daily

(0)

(2)

(3)

(3)

(3)

Scored Patient-Generated Subjective Global Assessment (PG-SGA)

History Boxes 1-4 are designed to be completed by the patient. [Boxes 1-4 are referred to as the PG-SGA Short Form (SF)]

1. Weight (See Worksheet 1)

In summary of my current and recent weight:

Patient ID Information

2. Food Intake: As compared to my normal intake, I would rate my food intake during the past month as:

unchanged more than usual

I currently weigh about pounds less than usual (1)

(0)

I am about feet tall

One month ago I weighed about pounds Six months ago I weighed about pounds

I am now taking: normal food but less than normal amount little solid food only liquids only nutritional supplements (3)

(1)

During the past two weeks my weight has: very little of anything (4)

decreased (1) not changed (0) increased (0) Box 1 only tube feedings or only nutrition by vein (0) Box 2

3. Symptoms: I have had the following problems that have kept me from eating enough during the past two weeks (check all that apply):

no problems eating (0)

4. Activities and Function: Over the past month, I would generally rate my activity as:

no appetite, just did not feel like eating normal with no limitations (0)

nausea (1)

constipation

(3) vomiting diarrhea

(3)

not my normal self, but able to be up and about with fairly normal activities

(1)

(1) (3) not feeling up to most things, but in bed or chair less than half the mouth sores (2) dry mouth (1) day things taste funny or have no taste (1) smells bother me (1)

(2)

problems swallowing pain; where?

(2)

feel full quickly fatigue

(1)

able to do little activity and spend most of the day in bed or chair pretty much bedridden, rarely out of bed

other** (3)

(1)

(1)

** Examples: depression, money, or dental problems Box 3 Box 4

©FD Ottery, 2001, 2005, 2006, 2014 Email: faithotterymdphd@aol.com or info@pt-global.org

Additive Score of the Boxes 1-4 A

While height is not essential for scoring, the app calculates BMI

Complete both 1 & 6 months; for scoring, use 1 mo if available. Use 6 mos only if 1 mo is not available

Box 1 max score = 5 points: up to 4 pts from wt loss + up to 1 point for past 2 wks Box 2 not additive; max = 4; use the highest score checked, no matter how many checked

Pt should complete if possible; not professional or family unless needs help (sight, literacy, etc.)

Score how the patient self-rates his/her intake during the past month; this helps to address recent deficit / current risk

Box 3 Any symptoms that patient reports (checks off) that has kept them from eating enough during the past 2 weeks gets scored. Add all points for Box 3 total score

This is the WHO or ECOG performance status in patient terms, Patient rates his/her activity level over the past month regardless of the cause – inadequate intake, metabolic stress (corticosteroids, fever, inflammation, trauma) or significant inactivity. Remember, 1 week of complete bed rest is associated with up to 4% loss in lean tissue/muscle mass

Worksheet 1 - Scoring Weight (Wt) Loss To determine score, use 1 month weight data if available. Use 6 month data only if there is no 1 month weight data. Use points below to score weight change and add one extra point if patient has lost weight during the past 2 weeks. Enter total point

Wt loss in 1 month Points Wt loss in 6 months 10% or greater 4 20% or greater 5-9.9% 3 10 -19.9% 3-4.9% 2 6 - 9.9% 2-2.9% 1 2 - 5.9% 0-1.9% 0 0 - 1.9%

Numerical score from Worksheet 1

Additive Score of the Boxes 1-4 (See Side 1) 5. Worksheet 2 - Disease and its relation to nutritional requirements

A

All relevant diagnoses (specify) Primary disease stage (circle if known or appropriate) I II III IV Other

One point each: Cancer AIDS Pulmonary or cardiac cachexia Presence of decubitus, open wound, or fistula Presence of trauma Age greater than 65 years Chronic renal insufficiency

Numerical score from Worksheet 2 B 6. Work Sheet 3 - Metabolic Demand Score for metabolic stress is determined by a number of variables known to increase protein & calorie needs. The score is additive so that a patient who has a fever of > degrees (3 points) and is on 10 mg of prednisone chronically (2 points) would have an additive score for this section of 5 points. Stress none (0) low (1) moderate (2) high (3) Fever no fever >99 and <101 >101 and <102 >102 Numerical score from Worksheet 3 Fever duration no fever <72 hrs 72 hrs > 72 hrs Corticosteroids no corticosteroids low dose moderate dose high dose steroid

(<10mg prednisone (>10 and <30mg prednisone (> 30mg prednisone equivalents/day) equivalents/day) equivalents/day)

102

C

7. Worksheet 4 - Physical Exam Physical exam includes a subjective evaluation of 3 aspects of body composition: fat, muscle, & fluid status. Since this is subjective, each aspect of the exam is rated for degree of deficit. Muscle deficit impacts point score more than fat deficit. Definition of categories: 0 = no deficit, 1+ = mild deficit, 2+ = moderate 3+ = severe Muscle Status: Fluid Status:

clavicles (pectoralis & deltoids) 0 1+ 2+ 3+ sacral edema 0 1+ 2+ 3+

interosseous muscles 0 1+ 2+ 3+ Global fluid status rating 0 1+ 2+ 3+

thigh (quadriceps) 0 1+ 2+ 3+ Numerical score from Worksheet 4 D Global muscle status rating 0 1+ 2+ 3+ Total PG-SGA score

orbital fat pads 0 1+ 2+ 3+ (Total numerical score of A+B+C+D above) triceps skin fold 0 1+ 2+ 3+ (See triage recommendations below)

Global fat deficit rating 0 1+ 2 3+ Global PG-SGA rating (A, B, or C) = Clinician Signature RD RN PA MD DO Other Date

Worksheet 5 - PG-SGA Global Assessment Categories Stage A Stage B Stage C

Category Well nourished Moderately malnourished Severely malnourished Weight No wt loss < 5% wt loss in 1 month > 5% wt loss in 1 month

OR Recent wt gain (or 10% in 6 mos) (or >10% in 6 mos) OR Progressive wt loss OR Progressive wt loss

Nutrient intake No deficit OR Significant recent Definite decrease in intake Severe deficit in intake improvement

Nutrition Impact None Present of nutrition impact Present of nutrition impact Symptoms OR Significant recent symptoms (PG-SGA Box 3) symptoms (PG-SGA Box 3)

improvement allowing adequate intake

Functioning No deficit OR Moderate functional deficit Severe functional deficit Recent improvement OR Recent deterioration OR recent significant deterioration

Physical Exam No deficit OR Evidence of mild to moderate Obvious signs of malnutrition Chronic deficient but loss of muscle mass / SQ fat / (e.g., severe loss muscle, SQ tissue, recent improvement muscle tone on palpation possible edema)

Nutritional Triage Recommendations: Additive score is used to define specific nutritional interventions including patient & family education, symptom management including pharmacologic intervention, and appropriate nutrient intervention (food, nutritional supplements, enteral, or parenteral triage). First line nutrition intervention includes optimal symptom management.

Triage based on PG-SGA point score 0-1 No intervention required at this time. Re-assessment on routine and regular basis during treatment. 2-3 Patient & family education by dietitian, nurse, or other clinician with pharmacologic intervention as

indicated by symptom survey (Box 3) and lab values as appropriate. 4-8 Requires intervention by dietitian, in conjunction with nurse or physician as indicated by symptoms (Box 3). > 9 Indicates a critical need for improved symptom management and/or nutrient intervention options.

©FD Ottery, 2001, 2005, 2006, 2014 email: faithotterymdphd@aol.com or info@pt-global.org

The remainder of this form is to be completed by your doctor, nurse, dietitian, or therapist. Thank you. Scored Patient-Generated Subjective Global Assessment (PG-SGA)

See www.pt-global.org for prednisone equivalents chart and metric and additional language version (as available) Even short term use of corticosteroids can

adversely impact protein status and muscle mass

These are examples of areas that can/should be considered in determining loss/deficit (or excess fluid). RELAX… One does NOT have to assess all of these to have a global sense for loss or deficit of muscle or fat. Remember the maximum point score for physical exam is only 3 points and you are not likely to be off by more than 1 point…

Worksheet 5 May be helpful to circle relevant statement for each PG-SGA category to visually help identify the overall global assessment

Fever: Score fever intensity or duration, whichever is greater. (99°F= 37.2°C 101°=38.3° and 102° = 38.9°)

CONCLUSION

During my Electiveship I have learnt counseling and assessment skills. First of all I have learnt

the basic nutritional calculations and then about different diseases’ physiology and their medical

nutrition therapy. Then I started to visit Clinics. I took case studies from there and then made

diet plans according to diseases assigned. I interacted with some patients directly and inform

them about the importance of clinical interventions of nutrition and dietetics in the medical

therapy. In last my Electiveship experience is a good practical approach. My focus of study is

all types of patients (along with cancer patients) and to counsel them about dietary management

for achieving and maintaining optimal nutrition through healthy body weight and life style.

REFERENCES

MEDICAL LIBRARY, SKMCH&RC, LAHORE

Titled: Manual of Clinical Nutrition of Adults

Titled: Pediatric Manual of Clinical Dietetics

Titled: Krause’s Food & Nutrition Therapy

e-BOOKS LIBRARY, SKMCH&RC, LAHORE

Titled: Clinical Nutrition in Practice (By: Nikolaos Katsilambros)

Title: Manual of Dietetic Practice (By: Joan Gandy)

Title: Cancer Prevention and Management (By: Anne McTiernan)

OTHER/ ONLINE SOURCES

Understanding Normal & Clinical Nutrition (By: Whitney, Cataldo & Rolfes)

Understanding Nutrition (By: Whitney & Rolfes)

http://www.choosemyplate.gov/search

http://www.nutrition-and-you.com/search

http://www.freedieting.com/tools/nutrient_calculator