TYPE 2 DIABETES MELLITUS

INTRODUCTION:
Diabetes mellitus is one of the most common metabolic disorders affecting
humankind.
Type 2 diabetes is a lifelong (chronic) disease in which there are high levels of sugar
in the blood.
Type 2 diabetes is the most common form of diabetes.
DEFINITION:
Diabetes Mellitus is a metabolic disorder characterised by decreased ability of the
tissues to utilize carbohydrates (glucose). This results in shifts and disturbances in the
fat and protein metabolism and in water and electrolyte balance.
CLASSIFICATION:
The classification of diabetes includes four clinical classes: (ADA 2003)
Type 1 diabetes (results from -cell destruction, usually leading to absolute insulin
deficiency).
Type 2 diabetes (results from a progressive insulin secretory defect on the background
of insulin resistance).
Other specific types of diabetes (due to other causes, e.g., genetic defects in -cell
function, genetic defects in insulin action, diseases of the exocrine pancreas, and drug
or chemical induced).
Gestational diabetes mellitus (GDM) (diagnosed during pregnancy).
PREVALENCE:
Prevalence is rapidly rising all over the globe at an alarming rate.
Although there is an increase in the prevalence of type 1 diabetes also, the major
driver of the epidemic is the more common form - type 2- more than 90% of the
diabetic cases.
India earns the dubious distinction- Diabetes capital of the world
WHO (2000) 32 million people had diabetes in the year 2000.

 Diabetes atlas (2006) diabetic people in India in the year 2006 were 40.9 and expected
to rise to 69.9 million by 2025.
CAUSES AND RISK FACTORS:
Weight being overweight is a primary risk factor.
Fat distribution- more prevalent in people with fat stored primarily in the abdomen

than elsewhere such as hips and thighs.

Physical inactivity
Family history
Race Blacks, Hispanics, American Indians and Asian Americans are more likely
Age - risk increases with age especially after the age 45.
Pre diabetes- blood sugar levels higher than normal.
Gestational diabetes during pregnancy

CLINICAL SYMPTOMS:
Symptoms may develop very slowly

Polyuria- excessive urination

Polydipsia- excessive thirst
Polyphagia- excessive hunger
Weight loss
Lassitude and lack of energy
Pruritus vulvae- irritation in the genitalia
Paraesthesia- tingling sensation in the hands and feet
Blurring of vision
Delay in wound healing and minor infections

DIAGNOSIS:
A person is said to be diabetic if his/her blood sugar levels are above 100 mg/dL. To confirm
the diagnosis, one or more of the following tests must be done.

Diabetes Blood Tests

Fasting blood glucose level - 126 mg/dL
Post Prandial level -- higher than 200 mg/dL during a 75 g oral glucose tolerance test
(OGTT)

 Random plasma glucose concentration- 200mg/Dl

CATEGORY
Normal
Impaired fasting glucose

GLUCOSE LEVELS (mg/dL)

Fasting
2 hr post load
<140
<100
<140

100 /<126

Impaired glucose tolerance

<126
Diabetes
>126
Source: American Diabetes Association 2004 Guidelines of Care

140 and <200

200

Hemoglobin A1c test - Normal: Less than 5.7%

Pre-diabetes: 5.7% - 6.4%
Diabetes: 6.5% or higher
DIABETES SCREENING:
There is a major distinction between diagnostic testing and screening. The purpose of
screening is to identify asymptomatic individuals who are likely to have diabetes.
Individuals at high risk should be screened for diabetes and pre-diabetes.
Diabetes screening is recommended for:
Overweight children who have other risk factors for diabetes, starting at age 10 and
repeated every 2 years
Overweight adults (BMI greater than 25) who have other risk factors
Adults over age 45 every 3 years
Either an FPG test or 2-h OGTT (75-g glucose load) is appropriate.
The 2-h OGTT identifies people with IGT, and thus more people who at increased risk
for the development of diabetes and CVD.
The FPG is the preferred test to screen for pre-diabetes and diabetes. The OGTT may
also be used to screen for pre-diabetes or diabetes in high-risk adults.
NUTRITIONAL ASSESSMENT:
Anthropometric measurements to be assessed include:

 Height
Weight
BMI CLASSIFICATION:
BMI (kg/m2)

RISK OF
CO-MORBIDITIES

Underweight

18.5

Low

Healthy/ Ideal Weight

18.5 24.9

Average

Overweight (Pre-Obese)

25 29.9

Increased

Moderate (Class I)

30 34.9

Moderate

Severe (Class II)

35 39.9

Severe

Morbid (Class III)

40

Very severe

Obesity

Waist circumference
Waist Circumference
Men
High Risk

94 102

Substantially High Risk

>102

Women
High Risk

80 88

Substantially High Risk

>88

Waist Hip ratio to assess the risk of co morbidities like obesity

WHR of more than 0.8 in women and 1.0 in men is associated with high risk.
Biochemical:
Blood glucose levels: Fasting and post prandial.

 HbA1c
Non-fasting lipid profile - total cholesterol, HDL cholesterol, LDL cholesterol and
triglycerides
Urinalysis for ketones, protein and nitrite (evidence of infection).
Clinical:
Blood pressure has to be recorded since diabetics are prone to hypertension and vice
versa.
Evaluation of clinical symptoms
Polyuria
Polyphagia
Polydipsia
Giddiness
Tiredness
Itching
Nocturia
Blurring of vision
Weight loss
Decreased healing capacity
Diet history of the patient can be assessed using
3- day dietary recall and
Food frequency questionnaire.
The nutritional needs of the patient should then be determined and based on the nutritional
assessment according to the patients requirements.
COMPLICATIONS OF DIABETES:
Control of diabetes by ensuring normal blood levels is important for preventing the
complications to develop.
A. ACUTE COMPLICATIONS:
Hypoglycemia:
Because of poor timings of meals and snacks or exercising more than usual without
adding an extra meal or snack in the diet.
Symptoms- shakiness, nervousness, sweating, dizziness, weakness, irritability and
hunger.

Hyperglycemia :
Abnormally high levels of sugar in the blood leading to diabetic ketoacidosis.
Ketoacidosis is an extremely serious condition leading to coma or even death.
To prevent ketoacidosis, one should for ketones under the following conditions:
Blood glucose levels- >240mg/dL
Fever is present
Nausea and vomiting
Stress
If insulin dosage is being adjusted
B.CHRONIC COMPLICATIONS:
The chronic complications arising due to uncontrolled diabetes are
ATHEROSCLEROSIS
Degeneration of walls of the arteries due to fatty plaques deposition.
The risk of stroke is two to four times higher for people with diabetes, and the death
rate from heart disease is two to four times higher for people with diabetes than for
people without the disease (ADA).

NEPHROPATHY
Changes occur in nephrons of the kidney due to thickening of capillary basement
membrane.
RETINOPATHY
Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially
leading to blindness.
It also increases the risk of other serious vision conditions, such as cataracts and
glaucoma.
NEUROPATHY
Lesions of peripheral nervous system could cause tingling, burning, or numbness in
the sensation of upper and lower limbs.
FOOT DAMAGE

 Nerve damage in the feet or poor blood flow to the feet increases the risk of various
foot complications.
SKIN AND MOUTH CONDITIONS
Diabetes makes a person more susceptible to skin problems, including bacterial and
fungal infections.
OSTEOPOROSIS
Diabetes may lead to lower than normal bone mineral density, increasing the risk of
osteoporosis.
ALZHEIMER'S DISEASE
Type 2 diabetes may increase the risk of Alzheimer's disease and vascular dementia.
The poorer the blood sugar control, the greater the risk appears to be.
HEARING PROBLEMS
Diabetes can also lead to hearing impairment.

MANAGEMENT OF TYPE 2 DIABETES:

A good synchronisation between diet, lifestyle, and drugs can help in preventing /
delaying the onset of complications.
Successful management of diabetes involves a holistic approach with coordination
between diet, lifestyle and hypoglycaemic drugs/insulin.
PLASMA BLOOD GLUCOSE AND HbA1c FOR DIABETES BY AGE
Values By

Before

Post

Age

Meal

Meal

(Years)
Adolescent
s 13-19

90-130

Random

Bedtime/

Hba1c

Rationale

Overnight
-

< 7.5

Risk of severe
Hypoglycemia.
Developmental
& Psychological

Adults

70-130

<7

Issues.
Goals should be
indivudualised
based on
duration, age,
comorbid
conditions.

Pre-

60-99

Existing
GDM
Elderly

100-

<180

60-99

<6

7-8

129
70-130

LIPIDS AND BLOOD PRESSURE GOALS FOR DIABETES MELLITUS

Blood pressure

<130/80 mmHg
110-129/65-79

Cholesterol

<170 mg/ dl

LDL

< 100 mg/dl

Triglyceride

<150 mg/dl

HDL

>4O mg/dl- female

>50 mg/dl- male

NUTRITION THERAPY:
Nutrition therapy is essential for the treatment of Diabetes and is well recognised as a
keystone of management in diabetic patients.
Main dietary objectives are:
To supply optimum nutrition to maintain good health.
To provide adequate calories for maintaining ideal body weight and allowing for
normal growth and development in children.
To maintain glycemic control
To achieve optimum blood lipid levels

 To prevent or minimize acute and chronic complications of diabetes

PRINCIPLES OF DIETARY MANAGEMENT:
Restricted calories, low fat, high fiber and normal protein diet is prescribed.
NUTRITIONAL CONSIDERATIONS:
Macronutrients in diabetes management:
Individualisation based on treatment goals, physiologic parameters, and medications
used.
Individualisation will depend on the metabolic status of the patient and/ or food
preferences, insulin dosage & action.
CALORIES:
Governed by present body weight and the need to maintain a desirable body weight.
Total daily requirement is computed considering the age, sex, weight, height, nature
of physical activity and physiological needs.
INDIVIDUALIZED DIETARY REGIMEN:
SL.NO
1.
2.
3.
4.
5.

WEIGHT

ACTIVITY LEVELS

Ideal Body Weight Sedentary

Ideal body weight
Moderate
Overweight
Sedentary
Underweight
Moderate
Underweight
Moderate
Not less than 1200 Kcal for female
Not less than 1400-1600 for male

CALORIES REQUIRED/KG
BODY WEIGHT
25
30
20
30
35

Carbohydrates:
Diabetics need not restrict the CHO intake but have to alter the type of carbohydrate.
Emphasis is on complex CHO than simple carbohydrates present in jams, jellies etc.
CHO should provide 55-60% of calories with low glycemic index along with high
fibre foods.
CHO distribution in the diet:
One third (33%) during lunch
One third (33%) during dinner
Remaining for breakfast (25%) and evening (9%).

Proteins:
0.8-1g/kg bodyweight providing 15-20% of the total calories.
In diabetics with renal problems, protein is restricted to 0.5g/kg IBW.
Fats:
Fats should provide 15-25% of the calories.
High fat diets adversely affect glucose tolerance and may increase the risk of CHD.
Vitamins and Minerals:
Uncontrolled diabetes may produce deficiencies of zinc, chromium and magnesium
and vitamins C and D.
Low calorie diets prescribed for obese diabetics may not provide enough
micronutrients and individuals may need micronutrient supplements
Dietary Fibre:
Soluble fibre pectins, gums, mucilages, present in vegetables, fruits and legumes id
more effective in controlling glucose than insoluble fiber (cellulose, lignin) present in
cereals and millets.
40g dietary fibre/day or 25g/1000 calories is recommended.
High fibre foods also have low glycemic index and caloric value.
ADA, 2011

Carbohydrates

45-65% of Total Energy Intake (TEI)

Sugar can be <10% of TEI

Dietary Fibre

14g per 1000 calories, maximum 50g daily

10-25g daily

Soluble Fibre

Proteins

10-35% TEI

Fats

25-35% TEI

Saturated Fatty Acids (SFA)

Mono Unsaturated Fatty

Less than 7%
Acids Greater than or equal to 10%

(MUFA)
Poly Unsaturated Fatty Acids (PUFA)
Trans fats
PUFA:MUFA:SFA

Less than 10%

Nil
1:1.8:0.8

Reduction of protein intake to 0.8-1.0g per Kg body weight in diabetics with renal

complications.
Balanced diet does not require vitamin and mineral supplementation.

NIN, 2000
Carbohydrates

60-65% TEI
Distribution 25% breakfast, 33 % lunch,

Fat

33% dinner, 9% evening and bedtime

15-25% TEI, 20g visible fat, 1 g per kg IBW

Protein

15-20% TEI, 1-1.5 g per kg IBW

FOOD EXCHANGE SYSTEM:

Food exchange system provides almost the same amount of calories, carbohydrates,
proteins and fats grouped together.
By this we keep the total intake of nutrients constant but at the same time provide
variety in foods.
Exchange for fruits, vegetables, cereals, pulses, meat, milk and fats have been worked
out.
LIST 1: CEREAL EXCHANGE
30 gm provide: Carbohydrate 20 gm, Protein 2 gm

Cereals

Wt/Vol.

Calories

Rice

30 gms uncooked

100

Wheat flour

30 gms uncooked

100

Dalia

30 gms uncooked

100

Sago

30 gms uncooked

100

White flour

30 gms uncooked

100

Bread

40 gms

100

Chapati

44 gms

100

Jowar roti
Ragi

55 gms
30 gms uncooked

100
100

Rice flakes

30 gms uncooked

100

Oat meal

30 gms uncooked

100

Vermicelli

30 gms uncooked

100

Corn flakes

30 gms uncooked

100

Maize dry

30 gms uncooked

100

Marie biscuit

100

Monaco biscuit

100

Idlis
Poha
Upma
Dosa ordinary

100
100
100

LIST

FAT

EXCHANGE
50 gm Calories; Fat 5.5 gm
Fats

Weight [gm]

Calories

Butter

7.5

50

Ghee

5.5

50

Hydrogenated fat [Vanaspati]

5.5

50

Oil [Coconut, Mustard

5.5

50

Cashew nuts

10

50

Groundnuts, roasted

10

50

Walnuts
Pistachio
Almonds

7.5
7.5
7.5

50
50
50

Wt./Vol.

Calories

Curd

105 gm

50

Butter Milk

375 ml

50

Cheese

15 gm

50

Milk [Buffalo]

45 ml

50

Milk [Cow]

90 ml

50

Milk, Skimmed*

130 ml

50

Milk, Skimmed, powder*

15 gm

50

Sunflower, Corn, Groundnut,

Cotton seed, Til, Palm]

LIST 3 - MILK & MILK PRODUCTS

50 Calories; Protein 2.5 gm
Milk & Milk Products

Coffee +75 ml milk

50

[ without sugar]
Tea + 75 ml milk
Khoya
1 medium glass 150 ml
*provides 5 gm protein
LIST 4 - VEGETABLE EXCHANGE
50 Calories; Carbohydrate 10 gm

50
15 gm

50

Vegetables

Wt. (gm)

Calories

Beetroot [Chukander]

75

50

Carrot

105

50

Colocasia [arbi]

45

50

Onion [big]

90

50

Onion [small]

75

50

Potato

45

50

Sweet potato

30

50

Tapioca

30

50

Yam [Zimikand]

45

50

Broad beans

90

50

Cluster beans

90

50

Double beans

50

50

Jack, Tender

105

50

Jackfruit seeds

30

50

Leeks

60

50

Peas

45

50

Singhara

45

50

Sambar

35 ml

50

50

Cooked vegetable

LIST 5 - FRUIT EXCHANGE

50 Calories; Carbohydrate 10 gm
Fruits

Size/No.

Wt. (ml)

Calories

Apple

1 small

75

50

Amla

20 medium

90

50

Banana

1/4 medium

30

50

Cashew fruit

2 medium

90

50

Custard apple

1/4

50

50

Dates

30

50

Figs

6 medium

135

50

Grapes

20

105

50

Grape fruit

1/2 big

150

50

Jack fruit

3 medium pieces

60

50

Mango

1 small

90

50

Melon

1/4 medium

270

50

Orange

1 small

90

50

Lemon

1 medium

90

50

Papaya

2 medium

120

50

Peach
Pear
Plums

1 medium
1 medium
4 medium

135
90
120

50
50
50

Pineapple
Strawberry

1 1/2 slices (round)

40

90
105

50
50

Sweetlime

1 medium

150

50

Tomato

4 medium

240

50

Water melon

1/4 small

175

50

LIST 6 - LEGUME AND PULSE EXCHANGE

30 gm provide: Carbohydrate 15 gm, Protein 6 gm
Pulse [uncooked]

Wt. (gm)

Calories

Bengal gram

30

100

Bengal gram, roasted

30

100

Bengal gram-flour [Besan]

30

100

Cow gram

30

100

Horse gram

30

100

Kabuli Channa [white gram]

30

100

Lentils

30

100

Moth beans

30

100

Peas, dried

30

100

Rajmah [kidney beans]

60

100

Red gram

30

100

LIST 7 - FLESH FOOD EXCHANGE

70 Calories; Protein 10 gm
Flesh Foods

Wt. (gm)

Calories

2 No.

100

Fish

60

70

Liver, sheep

60

70

Mutton, muscle

60

100

Pork

60

70

Prawn

60

70

Chicken

60

70

Egg Hen

Crab

70

Beef

60

70

LIST 8 - VEGETABLE EXCHANGE

These vegetables may be used as desired. Carbohydrates and calories are negligible
Leafy Vegetables

Bittergourd
Curry leaves
Amaranth
Fenugreek leaves
Brussels sprouts
Mint
Cabbage

Other Vegetables

Spinach
Coriander leaves
Cauliflower
Pumpkin
Brinjal
Onion stalks
Drumstick

 French beans
Tomato, Green

Mango, green

GLYCEMIC INDEX:
Glycemic index is the numerical index given to a carbohydrate rich food that is based on the
average increase in blood glucose level occurring in blood after the food is eaten.

Glycemic Index = Area under 2 hours blood response curve to the test food
Area under 2 hours response for equivalent Glucose

Low GI

55 Or less

More fruit & vegetables,

whole grains, pasta foods,
beans (pulses), lentils,
(except potatoes, watermelon

Medium GI
High GI

56-69

& sweet corn)

Sucrose, basmati rice, brown

70 or more

rice
Corn flakes, baked potato,
some white rice varieties,
white bread, candy bar and
syrupy foods.

GLYCEMIC LOAD (GL):

The product of the GI value of a food and its Carbohydrate content. Diabetics should
choose foods low in GI and low in GL.
1 CHO count = 10-15 g approximately.
Counting Carbohydrates allows flexibility in the meal plan.
This list shows the average amount of carbohydrates in each food group per serving:
Carbohydrates Grams

Starch
Fruit
Milk
Vegetable
Meat
Fat

15
15
12
5
0
0

SUPPORTIVE THERAPY: BENEFICIAL EFFECTS OF SOME FOODS

Certain foods, part of food or food components have been found to be beneficial in
managing hyperglycemia due to the presence of fibre.
FENUGREEK SEEDS
Rich in mucilaginous fibre and contains an alkaloid Trigonelline, known to reduce
blood sugar levels.
It is also known to lower triglycerides and cholesterol.
Other foods/ isolated fibre
Diabetics should substitute whole wheat flour with soya flours, whole Bengal flour or
stalks of green leafy vegetables is it n the ratio of 3:1 preventing peak rise post
prandially.
ARTIFICIAL SWEETENERS:
Aspartame
Saccharin
Both have been recommended to be safe (NIN, 2008)
NUTRITIVE SWEETENERS:
Sugar alcohols Erythritol, Mannitol, Sorbitol, Xylitol
Can cause osmotic diarrhoea
Provides 1.5-2.0 kcals per gram
Recommended intake is < 10g per day
Tagatose, Hydrogenated starch
Fructose not more than 60 gram per day for 2000 kcals
Long term intake can lead to Dyslipidemia
NON NUTRITIVE SWEETENERS:

Acesulfame K- safe limit is 15 mg/ kg body weight per day (ADA)

Aspartame- safe limit 50mg/kg body weight per day (FDA)
Saccharin
Neotame
Sucralose

Artificial sweeteners should be avoided during pregnancy and lactation.

NON DIETARY MANAGEMENT:

EXERCISE:
Regular controlled exercise helps to increase glucose utilisation.
Aerobic exercise 20 to 30 minutes for 4 or more times a week.
Benefits:

Lowers or eliminates the need for drugs

Decreases insulin resistance
Helps in weight loss & maintenance of decreased weight.
Lowers TG and increases HDL levels
Improves circulation
Reduces stress

Few precautions to be taken by a diabetic patient:

Initiate the exercise programme gently and then build it up gradually
Be particular about the intensity, timing and type of exercise.
DRUGS AND INSULIN:
Oral Hypoglycemia drugs are generally recommended to NIDDM patients. Several
drugs are available.
They work by stimulating the pancreas to release additional insulin or help the cells to
utilise the insulin properly.
Drugs used
Sulphonylureas- Eg Tolbutamide, Chlorpropamide: 2 to 3 doses per day
Biguanides- Eg Metformin
INSULIN:
Three types of insulin are available.

Types vary in how quickly it starts working, how it works and its peak activity.
Short acting works quickly 2 to 3 hours after injection Regular insulin Semilente
Intermediate acting works slowly 8-12 hours after injection- Lente
Long acting- peak activity 18 to 24 hours after injection.
Carbohydrate distribution varies with the type of insulin prescribed.
Regular insulin- 1/3rd each CHO in 3 meals.
Intermediate 1/7th breakfast, 2/7th for noon, 1/7th for mid noon, 2/7th for evening &
1/7th for bed time.
Long acting 1/5th for breakfast, 2/5th for noon & 2/5th for evening.
SICK DAY GUIDELINES:

Never omit the insulin or drug dose, even if the person is unable to eat.
Test the blood glucose level before each mealtime and at the bedtime.
Take liquids every hour.
Rest or keep warm, do not exercise.

Sick day diabetic diet / Enteral diet:

ADA, 2011
Calories

25-35 kcal

Carbohydrates

50% / 33-40% TEI

Lipids

30% TEI

Protein

1.0-1.5 g

DIETARY GUIDELINES:
Eat at regular times and maintain healthy eating habits.
Eat regular small mealsup to 6 per day
Eat a lot of non-starchy vegetables, beans, and fruits such as apples, pears, peaches,
and berries.
Eat grains in the least-processed state possible: unbroken, such as whole-kernel
bread, brown rice, and whole barley, millet, and wheat berries; or traditionally

processed, such as stone-ground bread, steel-cut oats, and natural granola or muesli
breakfast cereals.
Limit potatoes and refined grain products
Limit concentrated sweetsincluding high-calorie foods with a low glycemic index,
such as ice cream to occasional treats. Reduce fruit juice to no more than one cup a
day. Completely eliminate sugar-sweetened drinks.
Choose low fat foods such as lean meats, seafood, chicken breast, tofu, and egg white.
Remove all visible fats and skins from meat.
Eat a healthful type of protein at most meals, such as beans, fish, or skinless chicken.
Limit high cholesterol foods such as organ meats (liver, gizzard, kidney, brain,
tongue), egg yolk, shrimp, and squid.
Limit animal fats (lard, chicken fat, butter), fried foods, dim sum, margarine,

mayonnaise, and salad dressing. Avoid coconut milk.

Use a small amount of vegetable oil in cooking.
Limit salty (high sodium) foods and condiments
Prepare foods by steaming, braising, boiling, or baking.
Have three meals and one or two snacks each day, and dont skip breakfast.
Eat slowly and stop when full.
Dont skip breakfast
Keep calorie intake the same. Get more physical activity
Get plenty of fiber
Lose extra weight
Skip fad diets and make healthier choices

Foods to be used freely

Foods to be used in

Foods to be avoided

Vegetables- low starch

moderation
Flesh food especially red Sugar

Green leafy vegetables

meats

Sweets

Spices and condiments

Fats

Honey

High fiber foods

Nuts

Jams

Coffee/tea without sugar

Cereals/roots/tubers

Jellies

Pulses

Cakes and pastries

Milk products

Pizzas

Eggs

Aerated drinks and

sweetened juices
Sweetened yoghurt

SAMPLE MENU
Meal timings

Food items

Quantity

Morning 6.00-6.30 AM
Breakfast 8.00-8.30AM

Milk without sugar

Idli

cup (100ml)
2 nos (50g)

Mid morning10.00-10.30AM
Lunch 12.30-1.00PM

Sambhar
Custard without sugar
Rice

cup (25g)
1 cup
1 cup (50g)

Phulka

1 nos (25g)

Vegetables

1 cup (100g)

Sambhar

1 cup (50g)

Plantain stem porial

cup (50g)

Steamed fish

1 slice (65g)

Evening 4.00-4.30PM

Curd
Milk without sugar

cup
cup (100ml)

Late evening 5.30-6.00PM

Dinner 8.00-8.30PM

Sundal
Buttermilk
Phulkas

1.2 cup (25g)

1 cup (200ml)
2 nos (50g)

Dhal

cup (25g)

Vegetable curry
Milk without sugar

cup (100g)
cup (100ml)

Bedtime

10.00PM
The above sample menu provides approximately:

2000 kilocalories
300g of carbohydrates: 61% of total calories
84 g of protein: 17% of total calories
48 g of fat: 22% of total calories.

FOOD FREQUENCY QUESTIONNAIRE

FOOD ITEMS

Daily

Once
In
Two

Twice
A
Week

Once
A
Week

Once
In 15
Days

Once A
Month

Occasionally

Never

Days
CEREALS
Rice
Wheat
Ragi
Rava
Rice flakes
Broken wheat
PULSES
Red gram
Black gram
Green gram
Bengal gram
Cow pea
Soya
GREEN LEAFY
VEGETABLES
Amaranth
Spinach
Agathi
Drumstick leaves
Cabbage
ROOTS AND TUBERS
Beetroot
Carrot
Radish
Potato
Colacasia
Tapioca
Yam
Tapioca
Colacasia
OTHER VEGETABLES
Ladies finger
Drumstick
Brinjal
Cauliflower
Plantain
Tomato
FRUITS
Apple
Banana
Orange
Guava
Papaya
Mango
Gooseberry
MILK AND MILK

PRODUCTS
Milk
Curd
Butter
Paneer
Cheese
Ice cream
MEAT AND MEAT
PRODUCTS
Chicken
Mutton
Beef
Pork
SEA FOOD
Fish
Prawns
Crab
NUTS AND OILSEEDS
Cashewnut
Coconut
Ground nut
Gingelly seeds
EDIBLE OIL
Sunflower oil
Gingelly oil
Coconut oil
Palmolein
Vanaspathi
Ghee
Butter
SPICES AND
CONDIMENTS:
Asafoetida
Cardomom
Chillies
Cloves
Coriander
Cinnamon
Cumin seeds
Fenugreek seeds
Ginger
Garlic
Pepper
Fennel seeds
Turmeric
Tamarind pulp
BEVERAGES
Tea

Coffee
Cocoa
Carbonated beverages
Any other
SNACKS
Chocolate
Chips
Cakes
Biscuits
Samosa
Pizzas
Burgers
MISCELLANEOUS
Sweets
Jam
Jaggery
Pappad
Pickle
Sugar
Honey

PREVENTION:
It is possible to Prevent or delay the onset of type 2 diabetes through a healthy
lifestyle.
The most important rule in the prevention strategy maintain ideal body weight.
Changing the diet, increasing the level of physical activity, and maintaining a healthy
weight are the positive steps to stay healthier longer and reducing the risk of diabetes.
Eat healthy foods. Choose foods low in fat and calories. Focus on fruits, vegetables

and whole grains.

Get more physical activity. Aim for 30 minutes of moderate physical activity a day.
Lose excess pounds and Maintain ideal body weight
Do physical activity
Minimise use of tobacco and other harmful drugs
Read and educate yourself on various aspects of diabetes.
Avoid stress, enjoy good music, meditate and have a positive attitude towards life.

Diabetes Mellitus cannot be completely cured, but can be controlled by adopting

healthy eating and lifestyle habits coupled with hypoglycemic drugs / insulin

Bibliography
1) Leslie & Robbins. C (1995). Diabetes: clinical science in practice. New
York: Press syndicate. pp. 375-392.
2)

CORONARY HEART DISEASE (CHD)

DEFINITION:
Coronary Heart Disease can be defined as disease of the blood vessels supplying the
heart muscle.
It is a type of heart disease caused by narrowing of the coronary arteries that feed the
heart. When the coronary artery becomes narrowed or clogged by fat and cholesterol
deposits and cannot supply enough blood to the heart CHD results.
PREVALENCE:
According to WHO (2003), 16.7 million people around the world die of Cardio
Vascular Diseases each year, which is 29% of the deaths globally.
CVD alone kills five times as many people as HIV/AIDS in the middle income
countries (WHO, 2005).
According to NCMH (2005), in India, cases of CVD may increase from about 2.9
crore in 2000 to as many as 6.4 crore in 2015. Deaths from CVD may also more than
double.
NUTRITIONAL RISK FACTORS IN THE CAUSATION OF CORONARY HEART
DISEASE:
The most significant degree of risk association is seen with cholesterol and
atherosclerosis and coronary heart disease.
Nutritional risk factors is CHD
Disease

Atherosclerosis and Coronary Heart

Disease

Atherosclerosis and Coronary Heart disease:

Nutritional factor
LDL cholesterol
Low HDL cholesterol
High triglyceride
Obesity
Elevated homocysteine
Oxidative stress
Lipoprotein (a)

 Atherosclerosis is a process that refers to the thickening of the inner lining of arteries,
due to accumulation of lipid (athere gruel). The typical lesion is called an
atheroma.
SYMPTOMS:
Various arteries affected by atherosclerosis and
Their clinical manifestations
Artery affected
Coronary arteries
Carotid arteries, Cerebral arteries
Peripheral limb circulation
Splanchnic circulation
Renal arteries
Aorta
Other symptoms include
Shortness of breath and
Fatigue with activity (exertion).

Clinical manifestations
Angina pectoris, myocardial infarction
Transient ischemic attack, Stroke
Intermittent claudication, gangrene
Mesentric ischemia, bowel gangrene
Renal artery stenosis, hypertension.
Aortic dissection, embolic disease

Outline of steps in the formation of fatty streak and atheroma evolution

High LDL Cholesterol

Glycation
LDL accumulation in the
intima

Lack of
antioxida
nts

Oxidised LDL
Cytokines
Endothelial cell

Leucocyt
e
adhesins

Monocytes,
lymphocytes
Formation of foam cells by endocytosis of
LDL
If lipid entry > lipid exit in
intima
Atheroma
Intra plaque new vessel
formation, bleeding
Migration of
smooth muscle
cells

Platelet
derived
growth factor

Microthrombin formation
(fibrinogen, high Lp(a),
homocystine)
Superimposed vascular
system
Blockage of
blood vessels

Risk factors and the process of atherosclerosis

Risk factor
Hypercholesterolemia

Mechanism of action
Favours lipid accumulation in intima

Excess LDL
Low HDL level
Triglyceride level
High lipoprotein (a)
Hypertension
Male gender
Family history of premature coronary disease
Diabetes mellitus
Cigarette smoking
Post menopausal state
Increased fibrinogen
Increased homocystine
Physical inactivity

Reverse cholesterol transport

Inhibits fibrinolysis
Cause vascular injury
Glycation of LDL
Favours thrombosis
Lack of estrogen
Favours thrombosis
Favours thrombosis
Exercise increases

HDL,

Myocardial

Central obesity, abnormal waist hip ratio

efficiency
Insulin resistance, increased TG, low HDL,

Oxidative stress
Excessive alcohol consumption

hypertension
Prevents LDL
Decreased HDL

Low socio economic status

Psychosocial factors

Increased thrombosis
Increased stress
Increased stress hormones

Non- lipid risk factors

Risk factor
Age

Comment
Male more than or equal to 45, Female

Family history

greater than or equal to 55.

Definite myocardial infarction in first degree

Cigarette smoking, hypertension

male relative (55) or female relative (65)

Influence thrombus formation & plaque

instability
Low HDL cholesterol
levels an overall healthy
Less
Consume
dietthan 40mg/dl is a risk factor
Aim for a healthy body weight
Aim for recommended levels of low density lipoprotein,
American Heart Association (2006) Diet and Lifestyle Goals for Risk Reduction
cholesterol, high density- lipoprotein cholesterol, and

triglycerides
Aim for a normal blood pressure
Aim for a normal blood glucose level
Be physically active
Avoid use of and exposure to tobacco products

Steps must be taken to detect and treat hypercholesterolemia in any prevention and treatment
programme for cardio vascular diseases.

DIAGNOSIS:
Many tests can diagnose possible heart disease. The choice of which tests to perform depends
on the patient's risk factors, history of heart problems, and current symptoms.
Blood pressure and cholesterol levels are measured.
Specific tests are also important in people who may have risk factors or symptoms of
diabetes.

Electrocardiograms
Echocardiograms
Angiography
Computed Tomography
Calcium Scoring CT Scans of the Heart to detect calcium deposits on the
arterial walls.
CT Angiography to visualize the coronary arteries.

NUTRITIONAL ASSESSMENT:
Anthropometric measurements

Height
Weight
BMI
Waist circumference
Waist hip ratio

SERUM LIPID PROFILE should be assessed:

NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP)

ADULT TREATMENT PANEL III
LIPID RISK CATEGORIES REVISED MAY 2001
LDL CHOLESTEROL
Optimal: <100 mg/dl
Near Optimal To Above Optimal: 100-129
mg/dl
Borderline High: 130-159 mg/dl
High: 160-189 mg/dl
TOTAL CHOLESTEROL

Very High: >189 mg/dl

Desirable: <200 mg/dl
Borderline High: 200-239 mg/dl

HDL CHOLESTEROL

High: >239 mg/dl

Low: <40 mg/dl

LDL TREATMENT GOALS BY RISK

Desirable: >59 mg/dl

RISK : LDL GOAL

CATEGORY

With CHD Or CHD Equivalents: <100 mg/dl

Multiple (2+) Risk Factors: <130 mg/dl

VLDL (calculated)
TRIGLYCERIDES

Zero To One Risk Factor: <160 mg/dl

<30 mg/dl
Normal: <150 mg/dl
Borderline High: 150-199 mg/dl
High: 200-499 mg/dl

LIPO A

Very High: >500 mg/dl

<5.0 mg/dl

The commonly used nutritional assessment tool to reveal diet history is the 24-hour dietary
recall or 3 day dietary recall.
MEDICAL NUTRITION THERAPY:
MNT (3-6 month), which includes physical activity, is the primary intervention for
patients with elevated LDL cholesterol.
With diet, exercise, and weight reduction patients can often reach serum lipid goals.

 The third Adult Treatment Panel (ATPIII) of the National Cholesterol Education
Programme (NCEP) provides specific guidelines for the assessment and treatment of
hyperlipidemia in adults aged 20 and over.
NCEP guidelines for the nutritional management of risk factors include:
Lowering of lipid levels
Weight reduction
Cessation of cigarette smoking
Alcohol consumption
Dietary fibre
Reduction of oxidative stress
Reduction of Homocystine levels
Control of diabetes mellitus
PRINCIPLES OF DIETARY MANAGEMENT:
Low calorie, low fat, high fibre and sodium restricted diet is prescribed.
NUTRITIONAL CONSIDERATIONS:
Calories:
Based on the BMI, calories needs should be calculated.
Obese patient must reduce to normal body weight with a low calorie diet as
recommended for obesity.
20 Kcal/Kg IBW/d (sedentary)
25 Kcal/Kg IBW/d (active)
Protein:
Provide 15% of the total calories.
Substitute organ meat and red meat (mutton, beef and pork) with fish and fowl.
Include sprouted gram and other pulses as they are all low glycemic index foods.
Carbohydrates:
To supply 55-65% of the total calories.
Promote complex carbohydrates as it is a natural source of fibre
Fats:
Around 20% of the total calories.

Cholesterol intake to be less than 200 mg per day.

10% of calories from MUFA
8% OF SFA
10% from PUFA.
Ratio of n-6 to n-3 = 4:1
Saturated fats to be avoided like butter, ghee, ice cream etc.

Lowering of lipid levels

The ATP (III) suggest a comprehensive lifestyle approach to reducing risk for CHD
called Therapeutic Life Style Changes (TLC) and includes the following components
Reduced intake of Saturated fats and cholesterol
Therapeutic dietary options for enhancing LDL lowering (plant sterols/stanols
& soluble fibre)
Weight reduction
Increased regular physical activity

Nutrient composition of TLC dietary pattern

Saturated fat
PUFA
MUFA
Total fat
CHO
Fibre
Protein
Cholesterol
Total calories

< 7% of total calories

upto 10% of total calories
upto 20% of total calories
25-35%
50-60%
25-30g/day
15% of the total energy intake.
Less than 200 mg/day
Balance energy intake and expenditure to
maintain desirable weight/prevent weight
loss.

A Model of Steps in Therapeutic Lifestyle Changes (TLC)

Visit I
Begin
Lifestyl
First e
Visit
Therapi

Visit 2
Evaluate
LDL
Response.
If LDL goal
not
achieved,
intensify

Visit 3
Evaluate
LDL
response
If LDL goal
not
achieved,
consider

F/U
Visit
Monitor
adhere
nce to

First visit

Begin Therapeutic Lifestyle Changes

Emphasize reduction in saturated fats and cholesterol
Initiate moderate physical activity
Consider referral to a dietitian (medical nutrition therapy)
Return visit in about 6 weeks

Second Visit
Evaluate LDL response
Intensify LDL-lowering therapy (if goal not achieved)
Reinforce reduction in saturated fat and cholesterol
Consider plant stanols/sterols
Increase viscous (soluble) fiber
Consider referral for medical nutrition therapy
Return visit in about 6 weeks
Third Visit

Evaluate LDL response

Continue lifestyle therapy (if LDL goal is achieved)
Consider LDL-lowering drug (if LDL goal not achieved)
Initiate management of metabolic syndrome (if necessary)
Intensify weight management and physical activity
Consider referral to a dietician

NCEP RECOMMENDATIONS FOR REDUCTION IN FAT INTAKE

Dietary component
Calories

Step 1
500 to 1,000 kcal/day

Step 2
500 to 1,000 kcal/day

Total Fat

reduction
30 percent or less of total

reduction
20 percent or less of total

SFA

calories
8 to 10 percent of total

calories
7% percent of total calories

MUFA

calories
Up to 15 percent of total

Up to 15 percent of total

PUFA

calories
Up to 10 percent of total

calories
Up to 10 percent of total

Cholesterol

calories
< 300 mg/day

calories
< 200 mg/day

Protein
Carbohydrate

15percent of total calories

55percent or more of total

15percent of total calories

55percent or more of total

Sodium Chloride

calories
No more than 100 mmol/day

calories
No more than 100 mmol/day

(2.4 g

( 2.4 g

of sodium or 6 g of sodium

of sodium or ~6 g of sodium

chloride)
1,000 to 1,500 mg
20 to 30 g

chloride)
1,000 to 1,500 mg
20 to 30 g

Calcium
Fiber

Omega 3 fatty acids:

Consumption of 1-2 servings of fish per week is associated with lower rates of CHD.
Rich sources of omega 3 fatty acids

Cereals millets
Pulses legumes

Source

Food
Wheat, bajra
Black gram, cow pea, rajma

Soybean
Vegetables
Spices
Oil
Animal foods

Green leafy vegetables

Fenugreek mustard
Mustard, soya bean
Fish (long chain fatty acids)

Transfatty acids:
They raise LDL cholesterol levels and increase the risk of CVD. Less than 1gram per
day is the allowance.
Food Sources of Types of Dietary Fats
Type of fat
Saturated fats
Mono Unsaturated Fatty Acids
Poly Unsaturated Fatty Acids

Food source
Dairy products, beef, lamb and pork
Olive oil, canola oil and nuts
Vegetable oils (corn, sunflower, soy)

Cholesterol

Fatty fish and fish oils

Egg yolk, Meats, Dairy products

Dietary fibre:

 Total dietary fibre intake of 20-35 g per day is recommended for adults. Soluble fibre
helps in reduction in serum cholesterol.
Lentils, pulses, oats, fruits and vegetables are rich in fibre.
Soy protein:
May decrease LDL cholesterol by a few percent.
Soy foods such as tofu, soy nuts or soy butter may have cardio protective benefits
because of their PUFA and fibre content.
Plant stanols and sterols:
Isolated from soybean oil or pine tree oil can also lower cholesterol.
The mechanism for cholesterol lowering is by inhibiting absorption of dietary
cholesterol.
Alcohol:
For those who do drink, consumption should not exceed 1-2 oz of ethanol per day.
Weight reduction:
Obese patients should attain ideal body weight by appropriate reduction in caloric
intake and regular exercise.
Weight loss is associated with an increase in HDL cholesterol and decrease in LDL
cholesterol.
Sodium Restriction:
Restriction of 2-3 grams of sodium is usually advised for heart patients. Avoiding
processed food itself will cut down on a lot of sodium.
Cessation of cigarette smoking
Reduction of oxidative stress:
Oxidative stress is thought to play an important role in the development of
atherosclerosis.
Diet rich in fruits & vegetables and hence antioxidants should be encouraged. While
beta carotene appears to be of little use, supplementation with 200-400 mg of Vitamin
E may benefit in reducing risk for Ischemic heart disease.

Reduction of homocysteine levels:

Elevated homocysteine level is an independent risk factor for coronary heart disease.
Reduction can be achieved by daily supplementation with 1 to 2 mg of folic acid.
Control of Diabetes Mellitus:
Strict control of diabetes mellitus has now been shown to reduce the risk of coronary
heart disease.
DIETARY GUIDELINES:
Eat plenty of fruits and vegetables. They are not only rich in antioxidants and fibre but
also contain fewer calories.
Keep away from all kinds of fizzy drinks as they contain empty calories.
Have a combination of oils to maintain balance between n-3 and n6 fatty acids.
Include whole foods which are rich in MUFA like nuts. But they should be substituted
within the energy intake prescribed as they are calorie dense.
Include sprouted gram, fermented foods, and green leafy vegetables as they contain n3 long chain fatty acids and fibre.
Include 100-200 grams of oily fish at least 2-3 times a week.
Animal foods like meat, pork and beef (red meat) can be substituted by white meat
like fish and fowl.
Reduce the intake of egg yolk
Avoid sweets, desserts etc on a regular basis.
Limit usage of convenience foods and processed foods.

SAMPLE MENU
Meal timings

Food items

Quantity

Morning

Tea (skimmed)

1 cup

6.00-7.00 AM
Breakfast

Corn flakes with milk

1 cup

8.00-9.00 AM
Mid morning

Orange
Vegetable sandwich (wheat

I nos
2 slices

10.00-11.00 AM

bread)

Lunch

Tender coconut water

Phulkas (medium size)

1 cup
2 nos

12.00-1.00PM

Rice

cup

Dal

1 cup

Green leafy porial

1 cup

Boiled vegetable salad

1 cup

Tomato soup

1 cup

Curd (from skim milk)

cup

Apple

1 cup

Evening

Green tea with lime

1 cup

4.00-5.00PM
Dinner

Marie biscuits
Vegetable macroni

3 nos
2 cups

8.00-9.00PM

Grilled fish

1 nos

Sprouted green gram salad

1 cup

Guava
Bed time

Milk (skimmed)

1 cup
1 cup

10.00PM

The above given sample menu provides approximately,

1800 calories
300g carbohydrate: 65% of the total calories
70g proteins: 15% of total calories
40g fat: 20% of total calories

3- DAY DIETARY RECALL:

DAY 1
MEAL TIMINGS

FOOD ITEMS

QUANTITY

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

DAY 2
MEAL TIMINGS

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

DAY 3

FOOD ITEMS

QUANTITY

MEAL TIMINGS

FOOD ITEMS

QUANTITY

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

PREVENTION:
Healthy diet, regular exercise, and quitting smoking (if you smoke) may prevent heart
disease.
Heart disease prevention is considered important before and after someone is diagnosed with
the condition:

Primary prevention refers to measures that should be done to reduce the risk of heart
disease in everyone.

Secondary prevention refers to measures to reduce the risk of progression of heart

disease in a patient who has already been diagnosed. Many of these measures are
similar or the same as those recommended for primary prevention.

Key prevention measures include:

All patients should stop smoking

 Maintain cholesterol levels at appropriate levels using a heart healthy diet, exercise,

and medications
Maintain an appropriate low blood pressure level
Maintain an active lifestyle
Use an antiplatelet drug, such as aspirin, if appropriate
Manage diabetes and kidney disease when present

Smoking Cessation
Cholesterol and Other Lipid Disorders
All patients should start following a heart-healthy diet and exercise regularly.
Follow a Heart-Healthy Diet
Current American Heart Association (AHA) guidelines recommend:
Balance calorie intake and physical activity to achieve or maintain a healthy body
weight.
Consume a diet rich in a variety of vegetables and fruits.
Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes
(beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley,
brown rice, buckwheat, bulgur, millet, and quinoa.
Consume fish, especially oily fish, at least twice a week. Oily fish such as salmon,
mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid
(EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to
reduced risk of sudden death and death from coronary artery disease.
Limit daily intake of saturated fat, trans fat and cholesterol. Choose lean meats and
vegetable alternatives (such as soy). Select fat-free and low-fat dairy products.
Use little or no salt in your foods. Reducing salt can lower blood pressure and
decrease the risk of heart disease and heart failure.
Cut down on beverages and foods that contains added sugars (corn syrups, sucrose,
glucose, fructose, maltose, dextrose, concentrated fruit juice, and honey.)
If you drink alcohol, do so in moderation. The AHA recommends limiting alcohol to
no more than 2 drinks per day for men and 1 drink per day for women.
Manage High Blood Pressure
Keep Blood Pressure Low. People in normal health should have a blood pressure
reading of 120/80 mm Hg or less.

Diabetes
All patients with diabetes should have their blood sugar (glucose) levels well
managed.
Weight Reduction
People should aim for a BMI index of 18.5 - 24.9. Weight reduction is recommended
for obese patients who have high blood pressure, high cholesterol levels, metabolic
syndrome, or diabetes.
Exercise and Cardiac Rehabilitation
Everyone in normal health should do at least moderate physical activity for a
minimum of 30 - 60 minutes on most, if not all, days of the week.
Even low amounts of moderate or high intensity exercise (walking or jogging 12
miles a week) can help produce beneficial changes in cholesterol and lipid levels.
However, more prolonged exercise is required to significantly change cholesterol
levels, notably by increasing HDL ("good cholesterol"). Resistance (weight) training
has also been associated with heart protection.

It is important that along with management of nutritional risk factors, other risk factors are
also dealt with simultaneously.
Only a comprehensive risk reduction programme with appropriate changes in lifestyle will
result in the successful treatment and prevention of cardiovascular disease.

OBESITY

INTRODUCTION:
Overweight and obesity are defined as abnormal or excessive fat accumulation that
may impair health.
Obesity is a state in which there is a generalised accumulation of excess adipose tissue
in the body leading to more than 20% of the desirable body weight.
Overweight is a condition where the body weight is 10-20% greater than the mean
where the body weight is 10-20% greater than the mean standard weight for age,
height and sex.
The WHO definition is:
A BMI greater than or equal to 25 is overweight
A BMI greater than or equal to 30 is obesity.
PREVALENCE:
Greatly varies from country to country from <0.1% in South Asia to >75% in urban Samoa.
WHO global estimates (2008)
1.5 billion Adults, 20 and older, were overweight.
Of these 1.5 billion overweight adults, over 200 million men and nearly 300 million
women were obese.
Overall, more than one in ten of the worlds adult population was obese.
In 2010, around 43 million children under five were overweight.
Close to 35 million overweight children are living in developing countries and 8
million in developed countries.
Overweight and obesity are linked to more deaths worldwide than underweight.
65% of the world's population live in countries where overweight and obesity kill
more people than underweight (this includes all high-income and most middle-income
countries).

CAUSES OF OBESITY:

The fundamental cause of obesity and overweight is an energy imbalance between calories
consumed and calories expended.
Increased intake of energy- dense foods that are high in fat, salt and sugars but low in
vitamins, minerals and other micronutrients.
Ideal weight = energy intake is equal to energy expended
Weight gain = Energy intake is more than energy expended
Weight loss = energy intake is less than energy expended
Genetic factors: Obesity tends to run in families. Genetic inheritance influences 50
70% a persons chance of becoming fat more than any other factor. Within families,
the chance is 50% if one parent is obese and 80% if both the parents are obese.
Metabolic factors: Endocrine disorders such as Cushings syndrome and
hypothyroidism, Prader- willi syndrome and congenital leptin deficiency can cause
obesity.
Physical inactivity: A decrease in physical activity due to the increasingly sedentary
nature of many forms of work, changing modes of transportation, and increasing
urbanization.
Other factors leading to obesity are
Stress- sometimes can lead to excessive calorie intake.
Trauma head injury causing damage to the hypothalamus leading to improper
regulation of appetite or satiety.
Improper eating habits

P
H
Y
S
I C
A
L
I N
A
C
T
I
V
I
T
Y

A
S
S
O
C
I
A
T
E
D
G
C
H
R
E
O
N
I
N
C
E
D
I S
T
I
E
A
S
C
E
F A
C
T
O
R
S

E
X
C
E
O
S
S
E
N B
E
R
E
G
Y
I N
TS
A
K I
E

T
Y

SYMPTOMS, DISEASES, AND SPECIAL PROBLEMS ASSOCIATED WITH

OBESITY:
Obesity is associated with higher risk of death and morbidity. The life expectancy of
men and women with BMI of >45 kg/m2 aged 20-30 years is 13 and 8 years lower,
respectively than that of those with a BMI of 24 kg/m2.
Cardiovascular system

Coronary heart disease

Hypertension
Pulmonary embolism
Varicose veins

Neurologic system

Idiopathic intracranial hypertension

Meralgia paresthetica
Stroke
The metabolic syndrome
Type 2 diabetes
Dyslipidemia

Endocrine

Gastointestinal

Polycystic ovarian syndrome/

angrogenicity
Amenorrhea/infertility/
menstrual disorders
Gastroesophageal reflux disease
(GERD)
Non-alcoholic fatty liver
disease (NAFLD)

Genitourinary

Integument

Cholelithiasis
Hernias
Colon cancer
Urinary stress incontinence
Obesity-related glomerulopathy

Hypogonadism(male)
Breast and uterine cancer
Pregnancy complications
Striae distensae (stretch marks)
Status pigmentation of legs

Lymphedema
Cellulitis
Intertrigo, carbuncles
Acanthosis nigricans/skin tags
Musculoskeletal

Psychological

Respiratory

Source: Kushner RF and Roth JL, 2003.

REGIONAL DISTRIBUTION OF FAT:

There are 2 major types of fat deposition.

Hyperuricemia and gout

Immobility
Osteoarthritis (knees, hips)
Low back pain
Depression/low self esteem
Body image disturbance
Social stigmatization
Dyspnia
Obstructive sleep apnea
Hypoventilation syndrome
Pickwickian syndrome
Asthma

E x c e s s S u b c u ta n e o u s F a t

C
A
H
A

o m
n d
ig
p p

m
ro
h ly
le

E x c e s s G lu t e o fe m o r a l F a t

P e a r S h a p e
G y n o id
In c r e a s e s r is k fo r b lo o d g lu c o s e , lip id a n d p r e s s u r e a b n o r m a lit ie s .

o n in M e n
id
c o r r e la t e d W it h In s u lin r e s is t a n c e , S m o k e r s , A lc o h o lic s .
s h a p e

TESTS AND DIAGNOSIS:

Include reviewing health history of the subject in detail, physical examination and some tests.
Health history:

Weight history
Weight-loss efforts
Exercise habits
Eating patterns
Other associated conditions such as diabetes and hypertension.
Medications
Stress levels and
Familys health history to see predisposed to certain conditions.

Calculating the BMI to determine the level of obesity.

Measuring waist circumference.
A general physical examination including Blood pressure measurement.
Blood tests: Tests taken depend on the health and risk factors. They may include a cholesterol
test, liver function tests, fasting glucose, a thyroid test and others, depending on your health
situation.
ASSESSMENT OF OBESITY:
Body weight:

Adult weighing 10% more than the standard weight is overweight and 20% more is obese.
% Body weight excess of normal
25%
50%
75%
100%

Degree of obesity
Mild
Moderate
Severe
Morbid (very severe)

Body Mass Index: Also known as Quetlet Index.

The simplest and most widely used classification for obesity in adults is based on the BMI,
Body Mass Index.
Classification of obesity in adults based on BMI (WHO, 1998)
BMI (kg/m2)
Underweight
Healthy/ Ideal Weight
Overweight (Pre-Obese)
Obesity

18.5
18.5 24.9
25 29.9

RISK OF
CO-MORBIDITIES
Low
Average
Increased

Moderate (Class I)

30 34.9

Moderate

Severe (Class II)

35 39.9

Severe

Morbid (Class III)

40
Very severe
Source: Obesity: preventing and managing the global epidemic: report of a WHO
consultation. WHO technical report series; 89, Geneva 2000

While BMI is simple and quick to use, it has limitations because it is based simply on
ratio of weight to height and does not take account of body composition.
Waist circumference:
The most practical tool to evaluate a patients abdominal fat. It can be used to identify
patients at high risk.
Classification of Risk of Obesity Based On Waist Circumference (WHO, 1998)
Waist Circumference
Men
High Risk

94 102

Substantially High Risk

>102

Women
High Risk

80 88

Substantially High Risk

>88

Waist to Hip Ratio (WHR):

Adults with Waist Hip Ratio values in excess of 1.0 in men and 0.85 in women are
classified as obese and at high risk.
Acceptable

Male

Unacceptable

Excellent

Good

Average

High

< 0.85

0.85 -

0.90 - 0.95

0.95 -

0.90
Female

< 0.75

0.75 -

Extreme
> 1.00

1.00
0.80 - 0.85

0.80

0.85 -

> 0.90

0.90

Ponderal Index:
Ratio of height to the cube root of weight.
PI = Height (inches)
Weight (lbs)

Ponderal index of less than 13 is associated with obesity.

MEASUREMENT OF BODY FAT:
Skin fold calipers are used to measure body fat at the triceps, abdomen, subscapular
and subcostal sites.
Measurement of triceps should be less than 80-90 percentile for the age.
DENSITOMETRY

 The subject is measured in air and under water to determine volume and therefore
body density.
The densities of FM (Fat mass) and FFM (Fat free mass) are assumed and the
percentage of body weight is derived by substituting into appropriate equations.
Density of FM = 0.901 g/ml
Density of FFM = 1.10 g/ml
%Body fat= (495/body density) 450
Air displacement plethsymography equipment is commercial available as Bod Pod.
BIOELECTRICAL IMPEDANCE ANALYSIS (BIA)
A small electric current is passed through the body and voltage drop is measured by
electrodes.
The drop in voltage reflects the bodys impedance or resistance.
Resistance will be greater in individuals with greater body fat and lower in individuals
with more FFM and Total Body Water (TBW).
DUAL ENERGY X RAY ABSORPTIOMETRY (DEXA)
The body is scanned with X-rays of 2 energy levels and the chemical composition of
tissues will determine the attenuation of the radiation.
Software calculates bone mineral content ,bone mineral density, and FM
Brokas Index:
Height (cm)-100 = Ideal Body Weight (kg)
This measurement is easy to calculate and quite accurate.
MANAGEMENT OF OBESITY:
Multifactorial approach embracing a number of different strategies which should be
individualised.
Goals:
To develop realistic goals for weight reduction.
To Plan for weight maintenance after 6 month weight loss period.
The strategies for weight loss and weight maintenance are:
Diet therapy
Life style modification Physical Activity & Behavioural Therapy
Stress management

 Pharmacotherapy
Surgery
PRINCIPLES OF DIETETIC MANAGEMENT:
Low calorie, restricted carbohydrate, restricted fat, normal protein, high fibre, normal
vitamin & mineral and liberal fluid diet.
NUTRITIONAL CONSIDERATIONS:
Energy:
20 kcal /kg IBW for sedentary worker
25 kcal /kg IBW for moderately active workers.
Protein:
0.8-1 g of protein for tissue repair and for specific dynamic action.
Carbohydrates:
Bulk producing carbohydrates like green leafy vegetables and fruits to be taken in
liberal amounts to produce a feeling of satiety and regular bowel movements.
Starches with high CHO content like potato and rice to be restricted.
Fats:
Fats to be restricted and emphasis should be on vegetable oils (except coconut and
palm) to provide essential fatty acids.
Vitamins:
Prolonged restriction of fats can lead to restriction of fat soluble vitamins A and D
which may be supplemented.
Minerals:
Restriction of sodium is helpful in weight reducing diets as excess sodium predisposes
to retention of fluid.
Fluids:
To be taken liberally. A glass of water before meals may help to cut down fluid intake.

High fibre:
High fibre low calorie foods like green leafy vegetables, fruits, vegetable salads,
whole grain cereals and pulses to be included in the diet.
Foods low in Glycemic Index should be included as they may benefit weight control in 2
ways:
By promoting satiety
By promoting fat oxidation at the expense of carbohydrate oxidation.

DIET THERAPY:
Very low calorie diet (VLCD):
Provide <800 kcal per day leading to rapid weight reduction.
Should be used only for extremely obese individuals.
VLCD s can be in two forms:
PSFM- Protein Sparing Modified Fast Diets.
1.5g of protein/ kg IBW in the form of lean meat and no CHO fat from only
protein sources.
Commercial liquid diets (based on milk/ egg protein)
33.70 g protein; 30-45g CHO and small amount of fat.
Risks of such diet- cardiac complications leading to sudden death
Loss of potassium and body protein
Disturbances in serum electrolytes
Increased urinary ketones
Increased uric acid levels
Reducing diet:
Ideal reduction of to 1 kg per week is ideal.
A calorie deficit of 1000 kcal is required to lose 2 pounds of body fat per week.

 Calorie recommendation to be determined from actual food intake. A detailed 24 hour

dietary recall or 3 day dietary recall can be used to assess the intake and then the
desired deficit to be incorporated into the diet plan.
E.g:

Intake= 3100 kcal

Deficit for 2 lbs loss/week = 100 kcal
Therefore, daily diet recommendation = 2100 kcal

Another way of doing it is to calculate the calorie needs using Harris- Benedict
equation and subtracting 500-1000 kcal from the requirement for a 2 lb loss per week.
Harris- Benedict equation
WOMEN:
BMR = 655 + (9.6 X weight in kilos) + (1.8 X height in cm) - (4.7 X age in years).
MEN:
BMR = 66 + (13.7 X weight in kilos) + (5 X height in cm) - (6.8 X age in years)
LEVEL OF PHYSICAL ACTIVITY

CALORIE CALCULATION

Sedentary (little or no exercise)

BMR X 1.2

Lightly Active (light exercise/sports 1-3

BMR X 1.375

days/week)
Moderately Active (moderate exercise/sports

BMR X 1.55

3-5 days/week)
Very Active (hard exercise/sports 6-7

1.725

days/week)
Extra Active (very hard daily exercise/sports

BMR X 1.9

& physical job or 2X day training)

Yet another way is to determine the ideal body weight and adjusted body weight and
prescribing 20 kcal/kg IBW.
Reducing diet should provide adequate amount of proteins, vitamins and minerals.

Weight maintenance diets:

Provide 1500-1800 kcal per day.
When the body weights are reduced to optimal level on reducing diets, theses diets
are used to maintain weight at this level.
Atkins diet:
Extremely high in protein and low in carbohydrates.
Such a diet helps to regulate insulin production and decrease circulating insulin,
less insulin may result in less fat storage and fewer food cravings.
Not advised as it is a ketogenic diet.
FORMULA DIETS AND MEAL REPLACEMENT:
Meal replacement programmes provide a range of food items that contribute an intake
limited in energy but supplemented with micronutrients.
The food items may vary but include milk shakes, soups, cereal type snack bars and
pre prepared meals.
The total calories may range from 100-1600 kcal daily with the meal replacement
drink or bars replacing 2 calorie counted meals.
Adherence to these diets is difficult.
PHYSICAL ACTIVITY:
A low calorie diet accompanied by moderate exercise is the most effective way of
reducing weight and preventing weight gain.
Regular physical activity regulates appetite, increases the BMR, and reduces the fat
deposit.
Reduced risk of ill health including diabetes mellitus, CVD and some cancers.
Significant weight loss can be observed after 6-12 months following 2-4 episodes per
week of aerobic activity each lasting for 20-45 minutes.
Also reduces stress and gives an increased sense of well being.
Physical exercise alone is less effective than dietary modification but ideally both
should be together
BEHAVIOUR THERAPY:
Behaviour modifications rely on analyzing behaviours to identify events that are
associated with inappropriate eating, exercise or thinking habits.
Long term changes in eating behaviour are required to maintain weight loss.

 Effective menus include teaching patients to plan menus and exercise sessions to
record their actual behaviour.
They can also be taught to recognise eating cues such as emotional, situational etc
and how to avoid or control them.
Stress management:
One of the major reasons for overeating and relapse.
Stress related overeating can be reduced by learning to implement methods other than
eating such as
Breathing exercises
Deep muscle relaxation
Meditation
Yoga
Physical activity
PHARMACOTHERAPY:
Can be used as part of a comprehensive weight loss programme including dietary
therapy and physical exercise for patients with BMI of 30 or more.
Drugs cause an energy deficit through various mechanisms.
Act on the brain to suppress appetite.
Producing bulk to fill the stomach
Increase thermogenesis, metabolism and interfere with fat absorption.
Drugs are Classified as
CNS- acting agents Eg: Orlistat
Non CNS- acting agents Eg: Sibutramine
Not all individuals respond to these drugs and may have side effects.

BARIATRIC SURGERY:
Advised only for patients with BMI of 40 kg/m2.
The average weight loss at 5 years is about 65% of excess weight and most
complications resolve in about 50% of cases.
Most common surgical procedures practiced are
Gastric bypass surgery
Gastric stapling
Gastric balloon
Jaw wiring

Benefits of weight loss:

Losing 10kg is associated with a reduction of

>20% of total mortality
Blood pressure 10mmHg systolic and 20mmHg diastolic BP
50% Fasting glucose
10% total cholesterol and rise 0f 8% HDL cholesterol
WEIGHT MANAGEMENT TIPS:

Eating out everyday should be restricted

Eat small portions
Serve food on a smaller plate
Chew eat mouthful thoroughly
Do nothing else while eating
Differentiate between hunger and the urge to eat
Make legumes, whole grains, vegetables and fruits central to the diet plan.
Limit high fat foods
Drink plenty of water especially before and during while eating.
Identify situations that might lead to a lapse; plan how to cope with these.
Participate in some form of physical activity
Set realistic goals for improved eating and weight loss.
Plan rewards for goals achieved.

Foods to be used freely

Foods to be used in

Foods to be avoided

Fruits

moderation
Flesh food especially red Refined starch and sugar

Vegetables- low starch

meats

White bread

Pulses

Fats

Cakes and pastries

Green leafy vegetables

Nuts

Pizzas

Spices and condiments

Cereals/roots/tubers

Aerated drinks and

High

fiber

foods-

whole Milk products

sweetened juices

grains & legumes

Eggs (white)

Sweetened yoghurt

Low calorie foods

Sugar

Fatty meats

Fish

Sweets

Egg yolk
Chocolates
Alcohol

SAMPLE MENU

MEAL TIMINGS
Morning

FOOD ITEMS

QUANTITY

Tea(skim milk)

1 cup

Breakfast

Oats upma

1 cup

8.00-8.30AM

Mint chutney

1 tbsp

Mid morning

Vegetable soup

1 cup

Lunch

Phulkas

2 nos

12.00-1.00pm

Rice

cup

Sambhar

cup

Vegetable curry

1 cup

Buttermillk

1 cup

Any fruit

1 nos

Evening

Green tea

1 cup

4.00-5.00PM

Whole grain biscuits

3 nos

Dinner

Phulkas

2 nos

8.00-9.00 PM

Tomato chutney

2 tbsp

Apple

1 nos

Milk (skimmed)

1 cup

6.00-6.30AM

10.00-10.30 AM

Bed time
10.00-10.30

3 DAY DIETARY RECALL:

DAY 1

MEAL TIMINGS

FOOD ITEMS

QUANTITY

FOOD ITEMS

QUANTITY

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

DAY 2
MEAL TIMINGS

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

DAY 3
MEAL TIMINGS

FOOD ITEMS

QUANTITY

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

PREVENTION:
There are possible steps to prevent unhealthy weight gain and related health problems. Daily
exercise, a healthy diet, and a long-term commitment to watch what we eat and drink.
Exercise regularly: 150 to 250 minutes of moderate-intensity activity a week is
recommended to prevent weight gain. Moderately intense physical activities include
fast walking and swimming.
Eat healthy meals and snacks: Focus on low-calorie, nutrient-dense foods, such as
fruits, vegetables and whole grains. Avoid saturated fat and limit sweets and alcohol
Know and avoid the food traps that cause to eat: Identify situations that trigger outof-control eating. Keeping a journal and writing down what we eat, how much we eat,
when we eat, may be a useful strategy.
Monitor weight regularly: People who weigh themselves at least once a week are
more successful in keeping off excess pounds
Be consistent: Sticking to our healthy-weight plan during the week, on the weekends,
and amidst vacation and holidays as much as possible increases our chances of longterm success.

BIBLIOGRAPHY
1) Louis J. Aronne (2002). Classification of Obesity and Assessment of Obesity-Related
Health Risks. Journal of Obesity research, vol.10.

HYPERTENSION

INTRODUCTION:
Hypertension is a common public health problem in developed countries and is one of
the most common vascular diseases.
It is often called silent killer because hypertensives can be asymptomatic for years
and then have a fatal stroke or heart attack.
DEFINITION
A general definition is persistently high arterial blood pressure, the force exerted per
unit area on the walls of arteries.
To be defined as Hypertension, the systolic blood pressure has to be 140 mmHg or
higher and the diastolic blood pressure has to be 90 mmHg or higher.
CLASSIFICATION OF BLOOD PRESSURE AND DIAGNOSIS:
Category

Systolic

Blood

Pressure

Diastolic

Blood

Optimal
Normal
High normal

(SBP) mmHg
<120
120 129
130 139

(DBP) mmHg
<80
80 84
85 89

Stage 1

140 150

90 99

Stage 2

160 179

100 109

Stage 3

180 209

110 119

Stage 4

210

120

Pressure

Pre hypertension
Hypertension

90 95% of the hypertensive patients have essential or primary hypertension for

which the cause cannot be determined.
Just 5% hypertension arises as the result of another disease usually endocrine, and
referred to as secondary hypertension.
NUTRITIONAL ASSESSMENT:

 A comprehensive nutrition assessment and review of historical and laboratory data

will provide a good indication of need for nutrition intervention.
A detailed family history can reveal cardio vascular risk factors and disease.
Past and current medical history review of medications, substances and dietary
supplements.
Anthropometric measurements to be assessed include:
Height
BMI
Weight
Waist Hip ratio to assess the risk of co morbidities.
Laboratory data
Urinalysis - to assess kidney function
Hematocrit to evaluate the ratio of fluid to solids in the blood
BUN (Blood Urea Nitrogen) and/or Creatinine to detect and monitor kidney
dysfunction or to monitor the effect of medications on the kidneys
Serum Sodium & Potassium to evaluate and monitor the balance of the bodys
electrolytes; some high blood pressure medications can upset the balance by causing
excessive sodium and potassium loss
Fasting Glucose to determine if blood glucose levels are within healthy ranges
Serum Calcium to determine how much total calcium or ionized calcium is
circulating in the blood; increased activity of the parathyroid glands, which produces
an increase in serum calcium, is associated with hypertension
Lipid Profile may be ordered to evaluate levels of total cholesterol, HDL
cholesterol, LDL cholesterol and triglycerides
Non-Laboratory Tests:
Blood pressure measurement using sphygmomanometer or modern electronic devices.
Evaluation of clinical symptoms such as

Persistent headache
Dizziness
Blurred vision
Nausea and vomiting, and
Chest pain and shortness of breath.

Diet history of the patient can be assessed using

3- day dietary recall and
Food frequency questionnaire.
The nutritional needs of the patient should then be determined based on the nutritional
assessment according to the patients requirements.
PREDISPOSING FACTORS:
Although the cause for essential hypertension is not known, certain factors are known to
predispose it.
Physiological risk factors:

Heredity
Gender BP is higher in men than women and in women post menopause
Race- most severely affects the Afro Americans
Age- BP increases with age
Obesity, especially central obesity

Environmental risk factors:

Sophisticated society - Low levels of physical activity
Psychosocial stress
Dietary risk factors:
High salt intake
Potassium inversely related to BP
Magnesium- inversely related to BP because Mg is found to regulate blood pressure
by acting as a vasodilator.
Lipids High ratio of PUFA to SFA
High alcohol intake, especially if regular heavy or binge drinking.
Other risk factors:
Diabetes Insulin resistance
Smoking increases the hearts overload raising the BP
CONSEQUENCES:

 Congestive heart failure due to narrowing of arterioles leading to increased effort in

pumping blood through the system.
Encourages the development of atherosclerosis by weakening the arterial wall.
Aneurysms due to constantly elevated BP
Aneurysm in large arteries of brain Stroke
Infarct in small vessels of brain Transient Ischemic attack
Bleeding in the artery of the eye leads to blindness.
Damage to the kidneys.
Organ system
Cardiac

Manifestations
Clinical, electrocardiogram or radiologic
evidence of coronary artery disease; left

Cerebrovascular
Peripheral

ventricular malfunction or cardiac failure.

Transient ischemic attack or stroke
Absence of one or more pulses in extremities
with or without intermittent claudication,

Renal

aneurysm.
Serum creatinine >1.5 mg/ dl, proteinuria;

Retinopathy

microalbuminuria
Haemorrhages or exudates, with or without
papilledema.

MANAGEMENT OF HYPERTENSION:
Managing hypertension efficiently is important in achieving maximum reduction in the total
health risk of cardiovascular morbidity and mortality.

Objectives
Control blood pressure at a safe level to prevent damage to target organs e.g. heart,
kidneys, brain, thereby reducing the likelihood of congestive heart failure, renal

failure and stroke

Achieve weight loss in the overweight or obese client.
Reduce excessive intake of sodium, alcohol and caffeine.
Increase in take of potassium and calcium.
Provide a nutritionally adequate diet, balancing food intake with physical activity to
achieve optimum results.

 Address risk factors present e.g. cigarette smoking.

Pharmacologic treatment (Drug therapy)
Antihypertensive drugs are numerous and each lowers blood pressure by differing
actions on the cardio vascular system.
Diuretics are given along with antihypertensive agents and act by increasing sodium
output in the urine.
Non- pharmacologic treatment:
Life style modifications are definitive therapy for some and adjunctive therapy for all
persons with hypertension.
Lifestyle advice include
Promotion of a healthy diet
Regular exercise
Smoking cessation and
Relaxation therapies.
Even if lifestyle modifications cannot completely correct the blood pressure, they will
help increase the efficacy of pharmacologic agents and improve other CVD risk
factors.
Weight management:
Weight reduction to within 15% of desirable body weight.
Weight loss is an effective means of lowering blood pressure in hypertensive
individuals.
For each Kg of weight lost, reductions in SBP and DBP of approximately 1 mmHg are
expected (Neter et al., 2003).
Patients weighing more than 115% of ideal body weight should be placed on an
individualised weight reduction programme focussing on both hypo caloric dietary
intake and exercise.
Weight loss also has a synergistic effect with drug therapy.
Physical activity- 30-45 minutes for 3 or more days a week.
DIETETIC MANAGEMENT:
PRINCIPLES OF DIET:
Low calorie, low fat, low sodium diet with normal protein and high fiber is
prescribed.

NUTRITIONAL CONSIDERATIONS:
Calories:
Obese patient must reduce to normal body weight with a low calorie diet as
recommended for obesity.
20 Kcal/Kg IBW/d (sedentary)
25 Kcal/Kg IBW/d (active)
Protein:
10 14% of calories should come from protein
A diet of 50 g of protein to maintain nutrition is necessary.
Fats:
Hypertensives are prone to atherosclerosis, it is advisable to keep the fat calories at
20% level.
Advisable to avoid high intake of animal fats or hydrogenated oils.
About 40 50 g of fats, partly as vegetable oil, is permitted.
Carbohydrates:
Emphasis is on high fibre complex carbohydrate diet providing 55-60% of total
calories.
Minerals:

Minerals affecting blood pressure are Sodium, Potassium, and Calcium &
Magnesium.
Sodium:
Moderate salt restriction 2300mg sodium (6g of salt) is recommended (NIH, 2004).
2.3g sodium
1.2g sodium
0.6g sodium

Mild low sodium diet

Moderately low sodium diet
Restricted low- sodium diet

Adequate intake of sodium has been set at 1.5g/day (Institute of medicine, 2004).
Most dietary salt comes from processed foods and eating out. Changes in food
preparation and processing can help patients reach the sodium goal.

 Sodium restricted diet recommendation:

No salt served at meals.
Avoid salt- preserved foods such as salted or smoked meat, fish, sauerkraut
and olives, pickles etc.
Avoid highly salted foods such as crackers, potato chips, corn chips, salted
nuts etc.
Limit processed foods such as cheese and peanut butter.
Other minerals:
Increased calcium, potassium, and magnesium intake is beneficial for hypertensives.
Increase in potassium intake is claimed to reduce blood pressure in patients with
hypertension.
American Heart Association encourages a diet with a variety of fruits, vegetable, and
low fat dairy products for adequate intake for these mineral.
Vitamins: To meet the RDAs.
Alcohol:
Three or more drinks per day are a risk factor in high blood pressure.
Alcohol may also interfere with drug therapy.
Smoking:
Has a deleterious effect in high blood pressure.
THE DASH DIET: Dietary Approaches to Stop Hypertension
Recommended for individuals with
Hypertension
Blood pressure in pre hypertension stage
Family history of hypertension
Patients trying to eliminate the use of hypertensive drugs.
The DASH eating plan follows heart healthy guidelines to limit saturated fat and
cholesterol.
It focuses on increasing intake of foods rich in nutrients that are expected to lower
blood pressure, mainly minerals (like potassium, calcium, and magnesium), protein,
and fibre.
It includes nutrient-rich foods so that it meets other nutrient requirements.
Average decrease in SBP of 6-11 mmHg has been recorded in patients following
DASH diet plan.

 First step is to determine the appropriate energy level based on desired body weight
and activity level.
The appropriate number of servings per day of each group should then be based on
the diet and serving size.

Following the DASH Eating Plan

Food Group

Daily

Serving Sizes

Grains

Servings
68

1 slice bread
1 oz dry cereal
1/2 cup cooked rice, pasta, or

Vegetables

45

cereal
1 cup raw leafy vegetable
1/2 cup cut-up raw or cooked
vegetable

Fruits

45

1/2 cup vegetable juice

1 medium fruit
1/4 cup dried fruit
1/2 cup fresh, frozen, or
canned fruit
1/2 cup fruit juice

Fat-free or low-fat

23

milk and milk

1 cup milk or yogurt

1 &1/2 oz cheese

products
Lean meats,
poultry, and fish

6 or less

1 oz cooked meats, poultry,

or fish 1 egg

Nuts, seeds, and

45 per week

1/3 cup or 1 & 1/2 oz nuts

Legumes

2 Tbsp peanut butter

2 Tbsp or 1/2 oz seeds
1/2 cup cooked legumes (dry
beans
and peas)

Fats and oils

23

1 tsp soft margarine

1 tsp vegetable oil
1 Tbsp mayonnaise
2 Tbsp salad dressing

Sweets and added

5 or less

1 Tbsp sugar

Sugars

per week

1 Tbsp jelly or jam

1/2 cup sorbet, gelatin
1 cup lemonade

DASH Eating Plan

Food Group

Servings/Day
1,600

2,600

3,100

Grains

calories/day
6

calories/day
1011

calories/day
1213

Vegetables

34

56

Fruits

56

Fat-free or low-fat

23

34

milk and milk

products

Lean meats,

36

69

poultry, and fish

Nuts, seeds, and

3/week

Legumes
Fats and oils

Sweets and added

Sugars

PRINCIPLES OF LIFESTYLE MODIFICATION

Encourage healthy lifestyles for all individuals.
Prescribe lifestyle modifications for all patients with pre hypertension and
hypertension.
Components of lifestyle modifications include weight reduction, DASH eating plan,
dietary sodium reduction, aerobic physical activity, and moderation of alcohol
consumption.

Lifestyle modification to prevent and manage hypertension

Modification

Approximate SBP reduction

Weight reduction

5- 20mmHg/10kg

Adopt DASH eating plan

8-14 mmHg

Dietary sodium restriction (2.4g of sodium

2-8 mmHg

/day)
Physical activity

4-9 mmHg

(at least 30 minutes/day)

Moderation of alcohol consumption (not

2-4 mmHg

more than 2 drinks per day in men and not

more than 1 drink per day in women)

DIETARY GUIDELINES:
Reduction of excess body weight.

 Limit alcohol intake to maximum of 21 or 14 units per week for men and women,

respectively.
Eat more fruits and vegetables. 5 portions per day should be the target.
Limit salt intake to <6g/day (2.4g)
Avoid salt at the table
As salt in the diet is less try to use herbs and spices like parsley, coriander, ginger,

garlic etc to liven up the diet. Most of the herbs do not contain sodium.
If non vegetarian, eat fish regularly.
If vegetarian, take living foods like sprouted gram, fermented foods.
Include green leafy vegetables to increase the n-3 fatty acids.
Try to meet the RDAs for calcium, magnesium and potassium.
Calcium, potassium, and magnesium supplements are not recommended at present.
The use of salt substitutes is not recommended. Salt which contains lysine and

potassium may cause a potassium overload.

Limit consumption of caffeine and alcoholic beverages. Decaffeinated Beverages may
be substituted for caffeinated ones.

SAMPLE MENU
Meal timings

Food items

Quantity

Morning

Milk

1 cup (200ml)

6.00-7.00 AM
Breakfast

Oats idli

3 nos (75g)

8.00-9.00 AM

Vegetable kurma

cup

Mint chutney

1tbsp

Mid morning

Buttermilk

1 cup (200ml)

10.00-11.00 AM
Lunch

Phulka

1 nos (25g)

12.00-1.00PM

Sambhar

cup (25g)

Vegetable porial

cup (100g)

White rice

1 cup (50g)

Curd rice

cup (25g)

Palak paneer

cup (100g)

Water melon

1 cup (100g)

Evening

Milk (skimmed)

1 cup (200ml)

4.00-5.00PM

Sundal

cup (25g)

Dinner

Phulkas

2 nos(50g)

8.00-9.00PM

Channa masala

1 cup(50g)

Bed time

Milk (skimmed)

1 cup

10.00PM
*Meals to be cooked without adding salt.
*Salt allowance for the entire day is 5g= 1 tsp
The above given sample menu provides approximately,
1900 calories
295g carbohydrate: 61% of the total calories
79g proteins: 16% of total calories and 48g fat: 23% of total calories
FOOD FREQUENCY QUESTIONNAIRE
Food Items

CEREALS
Rice
Wheat
Ragi
Rava
Rice flakes
Broken wheat
PULSES
Red gram
Black gram
Green gram
Bengal gram
Cow pea
Soya
GREEN LEAFY
VEGETABLES
Amaranth
Spinach
Agathi
Drumstick leaves
Cabbage
ROOTS AND TUBERS

Daily

Once
In
Two
Days

Twice
A
Week

Once
A
Week

Once
In 15
Days

Once A
Month

Occasionally

Never

Beetroot
Carrot
Radish
Potato
Colacasia
Tapioca
Yam
Tapioca
Colacasia
OTHER VEGETABLES
Ladies finger
Drumstick
Brinjal
Cauliflower
Plantain
Tomato
FRUITS
Apple
Banana
Orange
Guava
Papaya
Mango
Gooseberry
MILK AND MILK
PRODUCTS
Milk
Curd
Butter
Paneer
Cheese
Ice cream
MEAT AND MEAT
PRODUCTS
Chicken
Mutton
Beef
Pork
SEA FOOD
Fish
Prawns
Crab
NUTS AND OILSEEDS
Cashewnut
Coconut
Ground nut
Gingelly seeds
EDIBLE OIL

Sunflower oil
Gingelly oil
Coconut oil
Palmolein
Vanaspathi
Ghee
Butter
SPICES AND
CONDIMENTS:
Asafoetida
Cardomom
Chillies
Cloves
Coriander
Cinnamon
Cumin seeds
Fenugreek seeds
Ginger
Garlic
Pepper
Fennel seeds
Turmeric
Tamarind pulp
BEVERAGES
Tea
Coffee
Cocoa
Carbonated beverages
Any other
SNACKS
Chocolate
Chips
Cakes
Biscuits
Samosa
Pizzas
Burgers
MISCELLANEOUS
Sweets
Jam
Jaggery
Pappad
Pickle
Sugar
Honey

PREVENTION:

 Food planning & purchasing labels (nutrition labels)

Food preparation healthier options
Special needs individual adaptation of diet principles is important in all nutrition
teaching & counseling, considering personal desires, ethnic diets, food habits etc.
EDUCATION PRINCIPLES:
Starting early
Focusing on high-risk groups
Using a variety of resources.
Some practical suggestions:

Reducing time spent watching TV or being online;

Increasing time spent walking increasing the heart rate;
Limiting fat intake.
Reducing portion sizes for meals & snacks;
Reducing size & frequency of calorie-containing drinks;

Hypertension, or high Blood Pressure, contributes to the etiology of a number of

degenerative diseases, many of them associated with the development of atherosclerosis.
Although no cure is available, hypertension is easily detected and usually controllable.
Increasing interest in non pharmacologic therapy has suggested an expanding role for diet in
the prevention and treatment of hypertension and related diseases.

NEPHRITIS

DEFINITION:
Nephritis also known as acute glomerulonephritis is characterised by acute
inflammation of the glomeruli, with congestion, cellular proliferation and infiltration
of leucocytes and others cells associated with inflammation.
ETIOLOGY:
The most common cause is probably an allergic reaction in the kidneys to
streptococcal infection.
Other less common causes are:
Goodpasturess syndrome:
Antibodies directed against the basement membrane of the glomeruli resulting in
rapidly progressive glomerulonephritis and acute renal failure.
Crescent glomerulonephritis:
Proliferation of the epithelial cells of Bowmans capsule, leading to destruction of
Bowmans space.
Disease process

Antibody response to bacteria,

viruses, chemicals
Excess antigen antibody complex in
circulation
Antigen antibody complex trapped in
glomeruli
Antigen antibody complex binds components
of complement
Activated complement provides chemical
factors that attract leucocytes

Lysosomal enzymes of leucocytes cause

injury to the glomerulus
Lumps deposit between the epithelial cells
of the nephron capsule and the basement
membrane of glomeruli
Lesions develop, fibrinogen leaks into
bowmans capsule
Scar tissue forms obstructing circulation to
glomerulus
Fatty degeneration, necrosis & destruction
of nephron
Reduction in the number of functioning
nephrons
NEPHRITIS

SYMPTOMS:

Gross hematuria
Proteinuria
Edema
Shortness of breath due to sodium and water retention and circulatory congestion
Anorexia
If there is progression to renal insufficiency, oliguria and anuria develops

COMPLICATIONS:

Nephrotic syndrome (type2 nephritis)

Acute renal failure
End stage renal disease
Hypertension

Fluid overload- congestive heart failure, pulmonary edema.

Chronic or recurrent urinary tract infection
Increased susceptibility to other infections
Hyperkalemia

DIAGNOSIS:
Diagnosis of nephritis is based on:
The patient's symptoms and medical history
Physical examination
Laboratory tests
Kidney function tests
Blood tests - levels of waste products, such as creatinine and blood urea nitrogen.
Imaging studies such as ultrasound or x rays to determine blockage and inflammation
Urinalysis can reveal the presence of:
Albumin and other proteins
Red and white blood cells
Pus, blood, or bacteria in the urine
Renal biopsy is the only definitive method of establishing the diagnosis; this step

usually is undertaken when the diagnosis is unclear or when the patient does not
improve clinically.
NUTRITIONAL ASSESSMENT:
Nutritional assessment is designed to evaluate three aspects of overall nutritionenergy, protein and micronutrients balance.
It has 3 components:
The nutritional history
Appropriate physical examination with simple anthropometric measurements
Laboratory studies.

Nutritional history Chronological record of body weight.

24 hour dietary recall.
Physical examination Presence and severity of edema or ascites.

 BMI is assessed.
Caliper measurements of skinfold (triceps) thickness- index of fat mass to identify
individuals with depleted fat stores.
Mid arm circumference- muscle mass assessment.
Patients with values below 25th percentile for either mid upper arm circumference or
triceps skin fold thickness are likely to be malnourished.
Laboratory assessment Renal profile constituting the various parameters should be assessed.
Elevation of these parameters indicate accumulation of waste products in the blood
due to renal impairment.
Parameters

Normal range

Serum Sodium

134-146 mmol/L

Serum Potassium

3.5- 5.0 mmol/l

Blood urea

10-50mg/dL

Creatinine

0.1-1.3 mg/dL

Serum albumin, transferrin, prealbumin are markers of nutritional status.

Hypoalbuminemia predicts mortality and risk rising as levels decline below 4g/dl.
Dietary recall is done for the assessing energy intake
Three day food diaries can be utilised to monitor nutritional intake.

MEDICAL TREATMENT:
Treatment can vary depending on
Cause of the disorder
Type & severity of symptoms.
Drugs used:
Antimicrobials to clear the infection
Blood pressure medications to control high blood pressure.

 Angiotensin converting enzyme inhibitors

Angiotensin receptor blockers
Cortisols
Immunosupressive drugs
DIETARY MANAGEMENT:
PRINCIPLE S OF DIETARY MANAGEMENT:
A low protein, high carbohydrate, low sodium and low potassium diet with restricted
fluids is prescribed.
NUTRITIONAL CONSIDERATIONS:
Energy: Around 30-35 Kcal/Kg IBW per day.
Protein :
If blood urea is elevated and oliguria is present, protein must be restricted.
In acute phase, if urine flow stops, protein containing foods to be completely avoided
and then slowly progressed to 20-30 g(0.5g/kg IBW) per day as urine flow
commences.
Once acute phase resolves, normal RDA can be given
Complete high biological value proteins are advised. But depending upon the
tolerance.
Protein needs should be calculated according to the Glomerular Filtration Rate (GFR)

GFR
>75ml/minute
25- 75 ml/minute
<20 ml/minute

Protein intake
0.8-1.0 g / kg IBW/day
0.55- 0.6/kg IBW/day
0.5 g/kg IBW/day

Fats: 20% of the total calories.

Carbohydrates :
60-70% of the calories from carbohydrates like rice, corn, wheat, sago, honey etc.
Liberal intake- combat catabolism of tissue protein & prevent starvation ketosis.
Sodium:
Restriction varies with the degree of oliguria and hypertension.

 In case of impaired renal function: 500 1000mg per day.

Following foods to be avoided:
Salt at the table
Baking powder, soda bicarbonate added to cakes, pastries, bread & other
bakery items.
Papads, popcorn, cheese
Soft drinks and beverages like horlicks, boost etc.
Dried foods like fish, fruits and soup cubes.
Potassium:
Potassium build up the body due to impaired kidney function can cause the heart to
beat unevenly and stop suddenly.
Too little potassium is also dangerous.
Fruits and vegetable should be cooked in excess water and then consumed (leaching).
Potassium rich foods

Instant coffee, cocoa, nuts, jaggery, mango,

sapota, citrus fruits, soups, tender coconut
water, banana etc.

Low potassium foods

Sugar, unsalted butter, vegetable oils, ghee

Phosphorus:
Excess phosphorus in the diet can have a deleterious effect on serum calcium, which
is already low in renal patients.
It is better to restrict phosphorus.
GFR
25-70 ml/min
<20 ml/min

Amount of phosphorus recommended

8-12mg/kg IBW/day
5-10 mg/kg IBW/day

Phosphorus rich foods

Brinjal, bakery products, pulses, mango,

Moderate phosphorus sources

Phosphorus free foods

plums, amla, meat, egg, chicken & lemon.

Milk, curd, jaggery, guava etc
Rice, sugar, sago, honey

Fluids:
First stage of treatment- fluid restriction- to allow for dispersal of edematous fluid.

 Daily weighing is needed to monitor overall fluid balance.

Later stages, fluid intake can be as follows:
Fluid intake per day = Previous days urine output + 500ml
Vitamins: B complex and Vitamin C supplement is advocated.

SAMPLE MENU
MEAL TIMINGS

FOOD ITEMS

QUANTITY

Breakfast 8.00-8.30AM

Idli stuffed with carrots

2 nos

Honey

2 tbsp

Mid morning 10.30-11.00AM

Apple pudding

cup

Lunch 12.30-1.00PM

Rice

1 cup

Aaloo palak

2 cup

Ladies finger porial

cup

Plantain stem porial

cup

Fish fry

1 nos

Kesari
Vegetable cutlet

cup
1 nos

Badam milk

cup

Idiappam

1 nos

Coconut milk

cup

Sago porridge (thin)

cup

Evening 4.00-5.00PM
Dinner 8.00-9.00PM
Bed time 10.00-10.30PM

*Meals should be cooked without salt.

*Salt allowance per day is 5g.
The above sample menu provides approximately

1700 kilocalories
280 g of CHO: 67% of total calories
42 g of protein: 10% of total calories
45 g of fats: 23% of total calories

3- DAY DIETARY RECALL:

DAY 1

MEAL TIMINGS

FOOD ITEMS

QUANTITY

FOOD ITEMS

QUANTITY

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

DAY2
MEAL TIMINGS

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

DAY 3
MEAL TIMINGS

FOOD ITEMS

QUANTITY

Morning
6.00-6.30AM
Breakfast
8.00-8.30AM
Mid morning
10.30-11.00AM
Lunch
12.30-1.00PM
Evening
4.00-5.00PM
Dinner
8.00-8.30PM
Bed time
10.00-10.30PM

DIETARY GUIDELINES:

All foods should be cooked without salt.

Only prescribed amount of salt should be taken.
All vegetables should be cooked well or leached before consumption
Intake of fluids should be restricted to the prescribed quantity.
Foods high in sodium and potassium to be avoided.
Tender coconut water, raw vegetables and vegetable soups should be avoided
Maintain a healthy weight
Only one fruit (100g) can be taken per day. Fruits allowed are sweet lime, orange,

papaya, guava, pineapple, pears.

Cut back on protein consumption to slow the buildup of wastes in the blood.
Refrain from eating vegetables like spinach which contain large quantities of oxalic
acid.
Juicy fruits such as apple, grapes, orange, pear, peach and pineapple should be taken
during this period.
Smoking and drinking, where habitual, must be completely given up.
Avoid tea, coffee, all flesh foods, condiments, pickles and sauces.

PREVENTION:
There is no way to prevent most forms of glomerulonephritis. However, there are some steps
that may be beneficial:
Seek prompt treatment of a streptococcal infection causing a sore throat or impetigo.
To prevent infections that can lead to some forms of glomerulonephritis, such as HIV
and hepatitis, follow safe-sex guidelines and avoid intravenous drug use.
Control blood pressure, which lessens the likelihood of damage to your kidneys from
hypertension.
Control blood sugar to help prevent diabetic nephropathy.