NUTRITIONAL STATUS AND DIETARY GUIDELINES OF PREDIALYTIC AND HEMODIALYTIC PATIENTS

Thesis submitted to the University of Agricultural Sciences, Dharwad in partial fulfilment of the requirements for the Degree of

MASTER OF HOME SCIENCE In

FOOD SCIENCE AND NUTRITION

By

SWETA SUMAN

DEPARTMENT OF FOOD SCIENCE AND NUTIRTION COLLEGE OF RURAL HOME SCIENCE, UNIVERSITY OF AGRICULTURAL SCIENCES, DHARWAD - 580 005 JULY, 2006

ADVISORY COMMITTEE

DHARWAD JULY, 2006

(USHA MALAGI) MAJOR ADVISOR

Approved by : Chairman : ___________________________ (USHA MALAGI) Members : 1. _________________________ (RAMA K. NAIK) 2.__________________________ (P. W. BASARKAR) 3. _________________________ (KASTURIBA B.) 4.__________________________ (I. S. HASABI)

C ON TE N TS

Chapter No.

Title

INTRODUCTION

II

REVIEW OF LITERATURE

III

MATERIAL AND METHODS

IV

EXPERIMENTAL RESULTS

V.

DISCUSSION

VI.

SUMMARY

VII.

REFERENCES

VIII.

APPENDICES

IX.

ABSTRACT

LIST OF TABLES

Table No. 1 2 3 4 5 6

Title

Demographic profile of selected chronic renal failure patients Clinical and health status of subjects at the time of investigation Etiology of chronic renal failure in the subjects Symptoms of kidney disease at the time of onset Prevailing clinical signs of the subjects at the time of investigation Stage of kidney disease based on Glomerular Filtration Rate (GFR) (ml/min) Prevailing complications of selected chronic renal failure subjects Prevalent vices in the subjects Exercise behaviour of the subjects Mean anthropometric measurements of the subjects Classification of the subjects based on Body Mass Index (BMI) and Waist to Hip Ratio (WHR) Age-wise classification of the subjects based on Triceps Skinfold Thickness (TSF) Age-wise classification of the subjects based on Mid Upper Arm Circumference (MUAC) Age-wise classification of the subjects based on Mid Arm Muscle Circumference (MAMC) Mean food intake of the subjects Mean nutrient and electrolyte intake of the subjects

7 8 9 10 11

12

13

14

15 16

Contd..

Table No. 17 18 19 20 21 22 23

Title Mean vitamin intake of the subjects Mean food intake of the subjects according to gender Classification of the subjects based on adequacy of nutrients Dietary modification followed by the subjects Biochemical profile of selected subjects Biochemical profile of dialytic patients before and after dialysis Classification of selected subjects based on protein and hemoglobin status Classification of selected subjects based on lipid profile Classification of subjects based on associated conditions for planning individual diets

24 25

LIST OF FIGURES

Figure No.

Title

Etiology of chronic renal failure in the selected subjects

Classification of selected subjects based on protein and hemoglobin status

LIST OF PLATES

Plate No.

Title

Dietary survey

Weight measurement

Edema

Hemodialytic patient

Model diet plan for a predialytic non-diabetic patient with GFR 25 ml/min

Model diet plan for a predialytic non-diabetic patient with GFR 2670 ml/min

Model diet plan for a hemodialytic patient

Model diet plan for a hemodialytic diabetic patient

LIST OF APPENDICES

Appendix No.

Title

Questionnaire

II

Diet plans

III

Dietary tips for kidney disease

I. INTRODUCTION
The prevalence of chronic renal disease is rising worldwide. The global patient population with an end stage renal disease continues to grow at the rate of 7 per cent per annum due to demographic transition, increase in disease leading to chronic renal disease and increased availability of diagnostic and therapeutic facilities (Shyam and Sreenivas, 2005). Renal disease may be part of a systemic, inherited, drug induced disease or a result of an infection, affecting glomeruli or blood vessels supplying blood to the kidney, renal tubules, interstitium, epithelial lining and urinary tract. The world wide prevalence of etiology of chronic kidney disease was given by Anonymous et al. (2002). Diabetes mellitus 34 per cent, hypertension 29 per cent, glomerulonephritis 14 per cent, obstructive nephropathy 9 per cent, pyelonephritis and interstitial kidney disease 3 per cent, polycystic kidney disease 3 per cent, drug induced nephropathy 1 per cent, unknown (not detected) 7 per cent. Chronic renal disease is defined by the level of kidney function and the evidence of kidney damage. The National Kidney Foundation (Kidney Disease Outcomes Quality Initiatives) (NKF-K/DOQI), Clinical Practice Guidelines for Chronic Renal Disease (2002), identified five stages of renal disease defined by the glomerular filtration rate (Anon., 2005b). Community based prevalence figures are not available in India for chronic renal disease. However, it is estimated that approximately one lakh new patients develop end stage renal disease in India annually. This number is likely to be an underestimate, as it is based on data only from a few tertiary care centres. The progression of the renal disease is though slow initially, becomes exponential in the later phases and requires renal replacement therapy. Estimates reveal that renal units in India are offering treatment to 80 to 100 new patients, with end stage renal disease (serum creatinine =10mg/dl), per million population each year. To add to this burden, there is an unknown number whose creatinine concentrations are approaching this arbitrary threshold. End stage renal disease population has exceeded 7,00,000 by turn of the century. Therapeutic options for such patients are limited, the choice is between two forms of replacement therapy i.e., maintenance dialysis and renal transplantation. The latter is the most desirable treatment, nevertheless the major limiting factor is the lack of available organs, hence, majority have to remain on long term/life long dialysis (Gulati, 2001). The patients with renal disease are often present with nonspecific signs and symptoms, including nausea, anorexia, lethargy, edema, dyspnea, diminished urine output and hematuria. Complications of chronic renal failure include fluid and electrolyte disorders causing hyponatremia or hypernatremia and hypokalemia or hyperkalemia. Secondary hyperparathyroidism are associated with symptoms of bone disease, persistent hyperphosphatemia and / or soft tissue calcification. Vitamin D is usually required to replace decreased renal production of calcitriol, but vitamin D compounds can cause hypercalcemia and hyperphosphatemia. Few other complications associated with chronic renal disease are anaemia and hyperlipidemia leading to a many fold increased risk for cardiovascular disease (Anon., 2005). Other than these complications patients with end stage renal disease undergoing renal replacement therapy are prone to develop several types of malnutrition, including protein energy and deficiencies of certain minerals (eg, iron and possibly zinc and selenium) and vitamins (eg, vitamin B-6 and vitamin C, folic acid and 1,25 dihydroxy cholecalciferol) and possibly impaired bioactivity of other essential nutrients (eg, carnitine). Depression, low socioeconomic status and multiple medications are associated with malnutrition which leads to morbidity and mortality. Hence, there is a need for assessing nutritional status in chronic renal patients so that appropriate therapy can be prescribed and the effect of such treatments monitored and provide nutritional support followed by drug therapy.

Assessment of nutritional status can provide valuable information concerning nutrient intake and requirement and can identify patients who are at risk for various nutritional disorders. Among the disorders which are common in uremic patients are protein and calorie deficiency and excessive salt and water intake (Kopple, 1974). Thus dietary therapy which is an integral component of medical care is required for the patient with progressive or end stage renal disease and its goal is to minimize uremic toxicity and other metabolic disorders of renal failure, possibly slowing the rate of progression of chronic renal failure while maintaining body protein store. Ironically, there is a paucity of data on nutritional profile of renal patients in India and no research efforts are insight, except for a few limited studies. Hence, the present study has been planned to throw light in this direction with the following objectives : 1. 2. 3. To assess the nutritional status of renal patients in terms of anthropometry, dietary and biochemical methods To document the related complications of renal patients, and To plan suitable dietary guidelines for renal patients

II. REVIEW OF LITERATURE

Wasting and malnutrition occur commonly in patients with renal failure. The causes are multifactorial and include inadequate intake of nutrients, loss of nutrients in dialysate, intercurrent illnesses, uremic toxins, and endocrine abnormalities such as insulin resistance, hyperglucagonemia and hyperparathyroidism. Malnutrition and wasting may contribute to many aspects of the uremic syndrome, including increased susceptibility to infection, impaired wound healing, decreased strength and vigor and poor rehabilitation and quality of life. These above facts stress the need for assessing nutritional status in uremic patients, for prescription of appropriate therapy and effective treatment monitoring. Conversely anthropometric parameters, dietary history and biochemical value such as serum protein measurements provide valuable data concerning the nutritional status of the patient. The interaction between nutrients and biochemical parameters in terms of serum urea nitrogen to serum creatinine ratio and urea nitrogen appearance are useful for selecting optimal protein intake. The dietary therapy which aims towards preserving the body cell mass and function, fluid electrolytes and acid-base homeostasis, mineral balance and with early use of dialysis, the avoidance of uremic toxicity is of paramount importance. Disturbances in these components superimpose the patients to develop life threatening complicatons. Dietary therapy can be interms of dietary modifications including dietary prescription and supplementations as per the need of the patient. The literature related to predisposing factors to chronic renal disease, nutritional assessment, complications prevailing in nephrotic patients and the related dietary therapy are reviewed in this.

2.1 PREDISPOSING FACTORS TO CHRONIC RENAL FAILURE

Renal disease can occur due to various causes, which appear either limited to the kidney or may be part of a systemic process, called as predisposing factors. These factors can lead to the complete failure of the organ termed as chronic renal failure. Rao and co workers (1988) found 2.6 per cent of the NIDDM subjects had persistent proteinuria. Lazzari and Brunelli (1991) found 7.7 per cent nephropathy in 514 type 2 diabetics. It was more frequent when average daily glycemia was greater than 150 than when 150mg/dl. Yassine et al. (1991) conducted a retrospective cohort study to define the risk factors for nephropathy in NIDDM in 704 patients who were admitted between 1978 and 1987 to Michigan hospital. The results showed that incidence of complication increased with duration of diabetes (1% at 5 years, 5% at 10 years, 11% at 15 years, 33% at 20 years and 45% at 25 years). Older age at diagnosis of diabetes and obesity were significantly associated with risk of nephropathy. Risk factors related to subsequent renal mortality have been studied in seven years follow up of 4740 middle aged diabetic subjects participating in multinational study at Arizona, Hong Kong and Tokyo (Fuller and Stevens, 1991). The presence of proteinuria at the baseline examination was the strongest predictor of renal mortality in both type 1 and type 2 diabetes mellitus. Age adjusted renal mortality increased significantly with diabetes duration in both types of diabetes mellitus. Mattack et al. (1992) conducted the retrospective studies of patients with NIDDM (n=141) from 1985-89 to know whether the predictive power of microalbuminuria is independent of other cardio-vascular risk factors. The authors concluded that micro-

albuminuria is a significant risk marker for mortality in diabetes, independent of other risk factors. Its presence can be regarded as an index of increased cardiovascular vulnerability. In India, majority of End Stage Renal Disease patients (ESRD) are Non-Insulin Dependent Diabetes Mellitus (NIDDM). About 30-40 per cent of Insulin Dependent Diabetes Mellitus (IDDM) and five per cent NIDDM patients die due to ESRD. Hyperglycemia can lead to diabetic nephropathy by non enzymatic glycation of proteins, abnormal and metabolism, abnormal lipid metabolism (Maji, 1998). Tanaka et al. (1998) investigated the rate of glycemic control and blood pressure in development and progression of nephropathy in 123, age and diabetes duration matched elderly Japanese NIDDM patients (60-75 years) for six years. Results showed that the group that developed micro-albuminuria from normoalbuminuria, showed a higher six year mean HbA1c than the group that remained narrow albuminuric (n=50, 9 Vs 8.1%). On the other hand, the group that progressed from microalbuminuria to overt proteinuria showed a higher six year mean blood pressure than the group that remained micro-albuminuric (n=23, 106 vs95). Thus the authors concluded that glycemic control is more potent factor than blood pressure level on development of microalbuminuria. Nevertheless, in development of overt proteinuria from micro albuminuria, hypertension is the most crucial factor in elderly NIDDM patients.

2.2

NUTRITIONAL ASSESSMENT FAILURE PATIENTS

OF

CHRONIC

RENAL

Malnutrition is relatively common problem among chronic renal failure patients. It can be secondary to poor nutrient intake, increased losses in body composition and increased protein catabolic rate. For all these reasons nutritional assessment is of paramount importance which can be done by various methods which are interlinked to each other.

2.2.1 Anthropometry
Blumenkrantz et al (1978) assessed the nutritional status of predialytic (n=79) and dialytic patients (n=26) through anthropometric measurements and compared the values with the normal subjects (n=51). Relative body weight, triceps skin fold thickness, the percentage body fat and mid upper arm muscle circumference were significantly lower in predialytic subjects compared to normal and dialytic subjects. The mid upper arm muscle circumference and fat free mass each correlated with creatinine appearance (r=0.73, p<0.001 and r=0.50, P<0.001; respectively), reflecting reduced protein mass in predialytic subjects. For each measurement dialytic patients were having significantly lower value than normal subjects, showing the poor nutritional status of the dialytic subjects compared to normal. Guarnieri et al. (1980) assessed the nutritional status of dialysis patients (n=18) by anthropometric measurements. The body weight of the patients tended to be lower than the reference standard. Triceps skinfold thickness was more frequently abnormal than the subscapular one and arm muscle circumference was generally decreased, showing a mixed, Kwashiorkar-marasmus like protein calorie malnutrition in these patients. Cano et al. (1990) evaluated the nutritional status of 26 malnourished adults receiving hemodialysis using body composition and compared with ideal values. The patients were having decreased body weight of >10 per cent, a loss in mid arm muscle circumference of 15 per cent and a reduction in triceps skin fold of 35 per cent, showing a poor nutrition status in this group. Schneeweiss et al. (1990) evaluated the nutritional status of predialytic (n=17) and dialytic subjects (n=25) by anthropometric methods and compared with control subjects. Both the groups of patients were having significantly lower body weight compared to controls. Mid upper arm circumference was significantly lower in predialytic and the female dialytic patients. Triceps skinfold thickness was significantly lower in dialytic patients (P<0.05). Females belonging to dialysis group were more malnourished compared to their male counterparts as

they had significantly lower subscapular skin fold thickness, mid thoracic skin fold thickness and estimated body fat when compared to females of control subjects (P<0.050). Thus anthropometric measurements indicated signs of malnutrition in chronic renal failure undergoing conservative treatment or hemodialysis. Axelsson et al. (2004) related the inflammatory biomarkers (Median IL-6) concentration with truncal fatmass in 197 patients with end stage renal disease, before the beginning of dialysis and found a significant positive association (P<0.01) suggesting truncal fat mass as a contributor to inflammation in end stage renal disease.

2.2.2 Dietary Assessment

Blumenkrantz et al. (1978) compared the dietary intake of predialytic (n=76) with dialytic patients (n=26) by using dietary history method. It was found that predialytic patients were ingesting an average of 70.43.3 g of protein per day and 2032115 kcal/day of energy whereas the average daily protein and energy intake, determined from dietary interviews, was 8821 g/day and 2128413 kcal/day, respectively in dialytic patients showing improved nutrient intake in the patients undergoing dialysis. Gokal et al (1978) assessed the nutritional status based on dietary intake in 131 chronic hemodialysis patients and found their mean calories intake as 2600 kcal/day, out of which 50 per cent was from fat, 40 per cent from carbohydrate and rest from protein. Cholesterol intake was 675 mg and saturated to polyunsaturated ratio was 4:1. The diet revealed a high fat content, which was predominantly saturated imposing patients to develop hyperlipidemia. Guarnieri et al. (1980) assessed the dietary intake of 18 chronically uremic patients undergoing hemodialysis over a period of one week using dietary diaries maintained by subjects. The intake of energy (31.216.31/kcal/kg/day), proteins (1.230.19 g/kg/day), carbohydrates (27183g/day), fats (7522g/day), cholesterol (209105 mg/day), polyunsaturated to saturated fatty acid ratio (0.210.18) and phosphorus intake (1.076295 mg/day) were documented. A significant correlation was present between protein intake and the predialysis serum urea nitrogen, a mean to indicate the nutritional status in these patients. Cano et al. (1990) assessed the nutritional status of 26 malnourished hemodialysis patients through nutrient intake survey over a one week period by use of standard food tables. Carbohydrate, fat, protein and total calorie intakes were computed. The mean energy and protein intake in these patients were 308.4 kcal/kg body wt/d and 1g protein/kg body wt/day, respectively against 40 kcal/kg body wt/d and 1.2 g protein / kg body wt/d as the usual recommendation. Schneeweiss et al. (1990) assessed the nutritional status of predialytic and dialytic patients based on dietary survey and compared the nutrient intake with control subjects. Energy and protein intake in predialytic and dialytic patients were significantly low (1381157 kcal/d, 476 g/d, P<0.05 and 127994 kcal/d, 423 g/d, P<0.05, respectively) compared to normal subjects (217055 kcal/d, 792 g/d), thus showing a poor nutrient intake in chronic renal failure patients.

2.2.3 Biochemical parameters

Kopple et al. (1974) interpreted the factors affecting serum urea nitrogen to creatinine ratio in 6 chronically uremic non dialyzed patients consuming 1g/kg protein/day living in a metabolic unit. Authors concluded that it requires measurements of the glomerular filtration rate and the rate of urinary nitrogen appearance. A high ratio may occur in a patient with only moderate impairment of the glomerular filtration rate due to catabolic stress resulting in increased net protein breakdown and increased urinary nitrogen appearance. Blumenkrantz et al. (1978) assessed the nutritional status of predialytic (n=79) and dialytic patients (n=26) through biochemcial parameters and compared the values with the

normal subjects (n=51). Serum total protein, albumin, trnasferrin and C3 were also significantly decreased in predialytic patients compared to normal, with the greatest decrease observed for serum albumin and transferrin. In dialytic subjects these parameters were less than the normal, showing wasting and malnutrition in chronic renal failure and even in populations of dialytic patients who are considered to be particularly robust and healthy. Guarnieri et al. (1980) studied the serum protein contents of patients undergoing hermodialysis (n=18) and showed decreased serum total protein, albumin, transferrin, C3 and pseudo cholinesterase whereas serum IgM content tended to be increased, compared to normal values, showing the signs of malnutrition in these patients. Harvey et al. (1980) monitored the dietary adherence in clinically stable, chronically, uremic men (n=6), with a protein intake of 60, 40, 20g/day for whom serum urea nitrogen to creatinine ratio was supposed to be 8.6:1, 6.0:1 and 3.4:1 respectively. An increase in this ratio, in a patient who was ingesting known protein intake indicated catabolic stress. Rubin et al. (1981) studied the effective method of assessing nutritional status of 14 patients undergoing peritoneal dialysis, by serial simultaneous measurements (3 to 6 months) of total body potassium, which correlated negatively with episodes of peritonitis per month and fell in 46 per cent of patients (2225185 mEq from the start to 2063126 mEq at the end of study), reflecting long term clinical consequences of peritonitis. Thus, it was concluded that estimating total body potassium is an effective method of assessing nutritional status in patients on peritoneal dialysis, as its an indicator of lean body mass and thus indirectly of nitrogen balance. Goldstein et al. (1989) studied the relationship between the blood levels of 25 hydroxy vitamin D and the concentration of serum albumin in 26 patients with nephrotic syndrome and 26 patients with renal failure but without proteinuria. The blood levels of 25 (OH) D3 ranged 1.0 to 18.6 (8.61.0) ng/ml in patients with nephrotic syndrome and 11.6 to 41.3 (24.83.2) ng/ml in patients with a comparable degree of renal failure but without proteinuria. The blood levels of 25 (OH) D3 in patients with nephrotic syndrome showed a direct and significant (P<0.01) relationship with the levels of serum albumin and an inverse and significant (P<0.01) relationship with the magnitude of the protein. Thus, author concluded that 25 (OH) D3 was lost in the urine of these patients, as the protein binding this vitamin is lost in proteinuria. Cano et al. (1990) studied the effect of supplementing malnourished hemodialysis patients through perdialytic parenteral nutrition with lipids and amino acids for 84 days on serum protein contents and showed a significant increase (P<0.05)in albumin and transthyretin (P<0.05) from the control values, showing improved nutritional status, in these patients. Bhimo et al. (2003) found out the pattern of lipid profile in chronic renal failure patients (n=50) and compared with equal number of controls. The subjects showed increased levels of serum cholesterol (P<0.01), triglyceride (P<0.01), increased ratio of total cholesterol to high density lipoprotein, high low density lipoprotein cholesterol (P<0.01), low HDLcholesterol and high VLDL cholesterol (P<0.01) accordingly. Thus it was concluded that in chronic renal failure, lipid profile gets altered contributing to development of various cardiovascular diseases. They further studied the relation between serum creatinine and iron status of chronic renal failure patients (n=50) and observed a negative correlation with the value of serum creatinine and hemoglobin value (P<0.01), indicating a decline in protein status of chronic renal failure patients with the progression of catabolic stress. Axelsson et al. (2004) studied about the contributors to inflammation in end stage renal disease patients (n=197) and showed inverse correlations between inflammatory biomarker concentration (Median IL-6) and total cholesterol, HDL-C and apo A concentrations, which supports the link between cholesterol metabolism and chronic inflammation and inturn malnutrition. The same authors further showed a relation between protein malunutrition and elevated concentrations of inflammatory biomarker (Medium IL-6) in end stage renal disease patients (n=197). Surrogate markers of muscle protein stores

(Handgrip strength and serum creatinine) were correlated with plasma IL-6, which indicates an important role for this cytokine in the development of protein malnutrition and muscle catabolism in end stage renal disease.

2.3 DIETARY MODIFICATION IN CHRONIC RENAL FAILURE

Patients with renal disease are prone to develop several types of malnutrition. It occurs due to deficiency or over consumption of certain macro and micro nutrients. So dietary modification is very important, which can either be done by counseling for prescribing the required dietary intake or giving supplements to come on par with the recommended dietary intakes.

2.3.1 Dietary prescription

Giordano et al. (1973) studied the effect of at least 1 g/kg of protein intake primarily of high biological value on 40 dialysis patients. Patients were on liberal diet having at least 1 g/kg of protein primarily of high biological value. The nutrient intake was measured over a period of seven days. On statistical analysis, high biological value protein intake was correlated to total amino acid levels, the essential amino acid levels and the non-essential amino acid level in blood. Interestingly, there was a correlation between methionine intake and the level of transferrin. Thus it was concluded that there was a higher need of protein, primarily of high biological value for dialytic patients to prevent protein malnutrition. Heidland (1978) prescribed the nutrient requirements for 12 chronically uremic, predialytic patients whose Glomerular Filtration Rate (GFR) was less than 4 to 5 ml/min. It was suggested that diets providing 16 to 22 g of miscellaneous protein with either the nine essential amino acids (EAAs) or a combination of four EAAs and ketoacid or hydroxyacid analogues of the other five EAAs may be used. Recommended vitamin intake refers to the quantities of supplemental vitamins to be administered. Vitamin A levels are elevated in uremia and supplements should not be administered. Phosphate binders are usually also necessary. Thus dietary intake may have to be supplemented to attain the desired levels. Fiaschi et al. (1978) evaluated the effect of restricted protein and phosphorus diet on 45 chronic renal failure patients (CRF) with plasma creatinine values of 2.9 to 3.5 mg/dl and GFR of 35 to 15 ml/min, consuming a dietary regimen containing about 40 Kcal/kg, 0.6 g/kg of protein with 75 per cent as high biological value, 600-750 mg of phosphorus and 1500 to 2000 mg of calcium (with oral supplementation in all cases). An additional, usually intermittent treatment with vitamin D (3 lakh to 6 lakh IU twice a week) or its analogs (dihydrotachisterol, 0.250 to 0.375 mg/day) was prescribed in order to keep plasma calcium normal. It was concluded that a reliable follow-up of 5 years showed this regimen to be effective in maintaining normal mean values of plasma calcium and phosphate and in preventing the progression of secondary hyperparathyroidism. Malluche et al. (1978) compared the effect of early intervention of protein and phosphorus restricted and calcium and vitamin D supplemented diet on two groups of chronic renal failure subjects having plasma creatinine levels of 16.-2.8 mg/dl (n=20) and 2.8-3.5 mg/dl n=28). After an 18-months follow up, plasma parathyroid hormone values (P<0.01) and fractional excretion of phosphate (P<0.01) were significantly greater in patients who started the diet at plasma creatinine level of 2.8 to 3.5 mg/dl than in those who started an early treatment. No progression of osteodystrophy and some improvement of bone lesions (decrease of both osteomalacia and bone resorption) were shown in patients who started an earlier treatment. Thus, it was concluded that early protein and phosphorus restriction, calcium supplementation and vitamin D administration are effective means to prevent the development of both hyperparathyroidism and osteomalacia in these patients. Gokal et al. (1978) examined the effect of dietary advice in dialytic patients (n=131), suffering from type IV and type IIB hyperlipoproteinemia and concluded that a dietary modification in fat diets made by reducing the total fat by 10 per cent from the earlier diet, while increasing the carbohydrate intake by 10 per cent to maintain total calorie intake and

limiting the cholesterol to less than 300 mg daily and altering the saturated to polyunsaturated ratio from 4:1 to 1:1 may be an effective treatment in reducing the high mortality from cardiovascular and cerebrovascular disease in patients as hyperlipidemia contributes to the high mortality in dialysis patients from these diseases. Giordano et al. (1980) studied the effect of a diet based on modulated nitrogen intake to overcome malnutrition associated with long lasting low-protein intakes, and supplying energy of at least 188 kJ/kg/day, in six chronic renal patients. Each patient underwent three different regimens (A, B, C) of protein intake. In period A the protein intake was 0.33 g/kg a day. In period B, the patients were given 0.33 g/kg a day during day 1, 2, 3, 5, 6 and 1.0 g/kg during days 4 and 7 of the week. In period C, the daily protein intake was the mean of the weekly value from day 1 to 7 of period B. Data obtained showed that in period A the urea nitrogen appearance rate (2.990 g/day) was equal to that in period B (2.700 g/day) and lower than that in period C (3.160 g/day). Thus it was concluded that modulating the low-protein intake with a periodic increase or booster intake of dietary protein in uremic patients will remain effective to overcome malnutrition. Maschio et al. (1980) evaluated the effect of protein and phosphorus restricted diet on 24 patients in chronic renal failure (CRF) with plasma creatinine values of 1.6 to 2.8 mg/dl and Glomerular Filtration Rate (GFR) of 60 to 30 ml/min, consuming a dietary regimen containing about 40 Kcal/kg, 0.8 g/kg of protein, 800 to 900 mg of phosphorus and 1500 to 2000 mg of calcium (with oral supplementation). An additional, usually intermittent treatment with vitamin D (3 lakh to 6 lakh IU once or twice a week) or dihydrotachisterol (0.250 to 0.375 mg/day) was also prescribed in order to keep plasma calcium in the normal range. Thus, it was concluded that after 2 years of follow-up, this regimen was shown to be very effective in maintaining normal values of plasma calcium and phosphate and in preventing the progression of secondary hyperparathyroidism. Kopple et al. (1986) examined the dietary requirements of six hemodialysis patients who underwent nitrogen balance studies for 21 days. These individuals ingested a constant protein intake but in which dietary energy intake varied every 3 week, in random order to about 25, 35 and 45 Kcal/kg/d. Mean (SEM) nitrogen balance after equilibration and adjustment for changes in body urea nitrogen was 0.570.42 g/d. If one adjusts for unmeasured nitrogen losses, which was estimated to be about 0.5-1.0 g/d, balance was neutral in these patients, but there was a rather large variance in nitrogen balances and some patients were in negative nitrogen balance with this intake. So taking into account the prevalence of protein malnutrition in these patients, about 1.2 g protein/kg/d as a safe intake was recommended that may fulfill the requirement of protein during frequent occurrence of mild intercurrent illnesses. Kopple et al. (1986) examined dietary protein requirement in eight patients undergoing peritoneal dialysis who were fed low or high protein diets of 0.98 or 1.44 g/kg. Total energy intake were from both dietary intake and uptake of D-glucose from the peritoneal dialysate averaged (41.31.9 and 42.11.2 Kcal)/kg/d with the low and high protein diets, respectively). The low and high-protein diets were fed for about 16-35 d and balance data were collected for 14-33 d. There was a curvilinear relation between dietary protein intake and nitrogen balance. Nitrogen balance increased as protein intake rose until the protein intake was 1.90 g/kg/d. At this intake, nitrogen balance was significantly positive. As dietary protein increased above this amount, there was no further increment in nitrogen balance. Thus, the safe intake of protein, recommended for CAPD and requirement during illness for patients was 1.2-1.3 g/kg/d. Kopple et al. (1986) examined the effects of different energy intakes on nitrogen balance and body composition in six predialytics with chronic renal failure (CRF); mean (SD) creatinine and urea clearances were 10.83.5 and 4.72.2 ml/min, respectively. Patients were studied while they ingested a constant protein diet of about 0.55-0.60 g protein/kg/d and were given diets that provided 45, 35, 25 or 15 Kcal/kg/d. About 16 nitrogen-balance studies were conducted while the patients ingested these different energy diets. The order in which the different energy diets were fed to individual was determined randomly after equilibration and after adjustment for change in body urea nitrogen and unmeasured losses correlated directly

with dietary energy intake. When the estimated unmeasured nitrogen lossess of about 0.58 g/d were adjusted for nitrogen balance was negative in one of four patients for, 45 Kcal, in one of five patients fed 35 Kcal, in 3 of 5 patients fed 25 Kcal and in both patients fed 15 Kcal/kg/d. Urinary nitrogen appearance (UNA), UNA divided by nitrogen intake and several plasma amino acid concentrations, measured after an overnight fast, each correlated inversely with dietary energy intake. These observations suggested that, though in some CRF who are ingesting about 0.55-0.60 g protein/kg/d may maintain neutral or positive nitrogen balance with an energy intake of less than 30 Kcal/kg/day, a dietary intake providing about 35 Kcal/kg/day is more likely to maintain neutral or positive nitrogen balance, maintain or increase body mass and reduce net urea generation. Slomowitz et al. (1989) examined dietary energy requirements in six maintenance hemodialysis (MH) patients who were given diets of 45, 35 and 25 Kcal/kg/d. Each dietary energy intake was ingested for 21-23 days with a constant protein intake of 1.13 0.02 g/kg/day for each patient. Body weights rose with energy intakes of 45 and 35 Kcal (P<0.05) and fell with 25 Kcal/kg/d (P<0.05). From regression equation, the energy intake to maintain neutral nitrogen balance was 38.5 Kcal, to maintain an unchanging mid upper arm circumference and muscle mass was 34.1 and 33 Kcal, respectively and to maintain unchanging body weight or per cent body fat, the projected energy intake was 32.4 and 32 Kcal/kg/day respectively. Thus, it was suggested that MH patient require 38 Kcal to maintain nitrogen balance and about 32-34 Kcal/kg/d, to maintain body weight, muscle mass and muscle fat is required when they ingest an average of 1.13 protein/kg/day. Walker et al. (1989) examined the effect of a low protein diet of 40 g/day given for 3 months on the rate of progression of renal disease in cohort of 19 IDDM patients with persistent proteinuria of >0.5 g/day and renal function ranging from normal Glomerular Filtration Rate (GFR) (125 ml/min) to moderately impaired (23 ml/min) and concluded that a low-protein diet may help to retard deterioration of renal function in insulin-dependent patients with diabetic nephropathy by reducing the rate of decline of GFR and reducing albumin excretion and bringing a significant fall in urinary excretion of urea and creatinine indicating compliance with the diet. Zeller et al. (1991) compared the effect of study diet involving restricted dietary protein of 0.6 g/kg/d and phosphorus of 500 to 1000 mg/day and a control diet providing at least 1 g of protein/kg/d and 1000 mg of phosphorus on the progression of renal failure in predialytic patients (n=35), having similar Glomerular Filtration Rate (GFR), suffering from of Type I diabetes mellitus, for a mean of 34.7 months and concluded that dietary restriction of protein and phosphorus can slow the progression of chronic renal failure substantially in patients with diabetic nephropathy, by reducing the rate of decline of GFR and thus maintaining renal function. Dobell et al. (1993) studied the food preferences and food habits of patients with chronic renal failure (CRF) undergoing dialysis at Royal Prince Alfred Hospital, Australia, including 33 patients on hemodialysis, 17 on peritoneal dialysis and 30 control subjects. The 88 foods were grouped into 14 food classes to compare preferences. Taste aversions, food preparation details and psychological and social determinants of food intake were also compared. Sweet foods (P=0.002), vegetables (P=0.003), red meat (P=-0.010) and fish and poultry (P=0.015) were less pleasant for patients on hemodialysis than for control subjects and patients on peritonial dialysis. Red meat was the most unpopular food item for all dialytic patients. The most common factor, reducing dietary intake was a loss of interest in food and/or eating. Thus it was concluded that CRF influences patients food preferences and food habits. Klahr et al. (1994) tested the hypotheses that a reduction in dietary protein intake (0.58 g/kg/day) and the maintenance of arterial blood pressure at a level below that usually recommended (125 mm Hg) retards the progression of renal disease and concluded that among patients (n=585) with moderate renal insufficiency (GFR-25 to 55 ml/min) the slower decline in renal function that started 4 months after the introduction of a low-protein diet suggested a benefit of this dietary intervention. Patients with a higher degree of proteinuria (3 g/day) had a more rapid decline in the glomerular filtration rate and a significant benefit of

low blood pressure was apparent at three years in reducing the rate of decline of glomerular filtration rate.

2.3.2 Supplementation
Healy et al. (1977) studied the effect of 0.5 g/day of 1, 25 (OH)2 D3 supplementation on 20 chronic renal failure with glomerular filtration rates (GFR) of 30 to 50 ml/min for six months and found that this therapy raised serum calcium, reversed the defect in intestinal calcium absorption, normalised the serum levels of parathyroid hormone and healed bone diseases. GFR remained stable during the six months of therapy. Thus, it was concluded that initiation of therapy with 1, 25 (OH)2 D3 at the early course of renal failure could be beneficial for the prevention of the progression of renal osteodystrophy. Ell et al. (1978), investigated the metabolic effects of keto-acid supplements in five chronic renal failure with particular reference to nitrogen balance, and urea metabolism at Harrow, England. Patients taking a diet containing approximately 5g N throughout were st studied during two periods of 1 month each. During weeks 3 and 4 of the 1 month, the patients were given a supplementary keto acid/essential amino acid mixture of 0.46g and in all other weeks of both months, they received an isonitrogenous glycine supplement. Ketoacids produced a reduction of plasma urea, urea synthesis and urea excretion and an improvement in nitrogen balance compared to glycine supplemented diet, thus ketodiet supplement improved nitrogen balance. Wathen et al. (1978) compared some of the metabolic effects of hemodialysis on 10 non-diabetic fasting patients with (200 mg/dl) and without glucose in the dialysate bath when carried out in succession on the first and second dialysis, respectively, of a thrice weekly schedule. Unlike glucose dialysis, glucose free dialysis caused marked decrease in blood levels of glucose, insulin, lactate and pyruvate along with profound increase in acetoacetate and -hydroxybutyrate to meet energy demands causing glycogenolysis and gluconeogenesis to prevent critical hypoglycemia during glucose free dialysis. Thus glucose dialysis was effective in preventing protein and lipid catabolism. Alvestrand et al. (1980) studied a dietary treatment with an 18g protein diet supplemented with essential amino-acid providing 1.8 to 2.7 g N/day or ketoanalogs (0.3 g N/day) as a long term alternative to dialysis in patients with severe renal insufficiency (n=68). After institution of the dietary regimen, for an average of 215 days, serum urea and serum urea/creatinine ratio decreased from 104 to 94 mg/dl and 9.45 to 7.90 respectively while serum creatinine increased slowly from 11.0 to 11.9 mg/dl due to progression of the underlying renal disease. Serum albumin and transferrin were unchanged. The patients were treated for 30 to 840 days before they were dialyzed. The three years cumulative survival in all 68 patients was 68 per cent, which is well at level with the survival rates of patients treated with dialysis. Thus treatment with an 18g protein diet plus essential amino acids or ketoacids can considerably extend the period of conservative treatment and postpone the start of regular dialysis without endangering life expectancy of the patients. Maschio et al. (1980), studied the effect of early dietary phosphorus restriction and calcium supplementation in the prevention of renal osteodystrophy in two groups of patients with chronic renal failure. 45 patients with plasma creatinine values of 2.9 to 3.5 mg/dl were kept for 1 to 4 years on a diet containing 40 kcal/kg energy, about 0.6g/kg of protein, 600 to 750 mg of phosphorus and 1500 to 2000 mg of calcium (with oral supplementation). Vitamin D or its analogs were prescribed for the patients. Since elevation of serum parathyroid hormone in early renal failure impaired homeostasis of plasma phosphate after a phosphate load, 24 patients with plasma creatinine values of 1.6 to 2.8 mg/dl were kept for six to 18 months on a diet containing 40 kcal/kg energy, about 0.8g/kg of protein, 800 to 900 mg of phosphorus and 1500 to 2000 mg of calcium (with oral supplementation). An additional treatment with vitamin D or its analogs was performed. After 18 months of follow up, this regimen resulted in a fall of serum parathyroid hormone values with no progression or amelioration of bone lesions (defective mineralization and increased bone resorption) in the affected patient. Thus early phosphorus restriction, calcium supplementation and vitamin D

administration are effective means to prevent the development of both hyperparathyroidism and osteomalacia in patients with chronic renal failure. Frohling et al. (1980) studied the conservative treatment in patients (n-26) with advanced renal failure (glomerular filtration rate (<6 ml/min) when given a mixed quality low protein diet providing 0.4 g of protein /kg normal body weight /day and ketoacid analogues in the form of tablets providing 0.5g of nitrogen /day. An improvement in nitrogen balance, serum transferrin and phosphate and base excess was observed after 2 weeks of treatment. Thus, nutritional treatment with ketoanalogues and a mixed Low Protein Diet (LPD) is beneficial for uremic patients in the final stage of conservative therapy. Allman et al. (1990) studied the effect of energy supplementation for six months on the indices of nutritional status of patients on maintenance hemodialysis (n=21) and concluded that addition of glucose polymer of 100 or 150 gm providing 200 kcal to the usual diet of patients on maintenance hemodialysis increased their energy intakes. This was accompanied by an increase in body weight and this weight was maintained even after six months when taking glucose polymer was ceased. Cano et al. (1990) assessed the efficacy and tolerance of a perdialytic parenteral supply of fat and amino acids, given as 16ml/kg body weight and providing an energy supply of 16 kcal/kg body wt of fat and 0.08gN/kg body weight for a period of 12 weeks in malnourished hemodialysis patients and concluded that perdialytic parenteral nutrition appeared to be effective and safe with respect to plasma lipids and improved the nutritional status of malnourished hemodialysis patients. Chazot et al. (1995) evaluated the effect of supplementation of amino acid through hemodialysate, in concentrations that were three times the typical post absorptive plasma amino acid concentrations of normal adults, on the nutritional status of maintenance hemodialysis patients. The patients lost 9.3 2.7 g amino acids when they were dialyzed with no amino acids in the dialysate and plasma total amino acid concentrations decreased by 52 per cent by the end of the dialysis procedure. With these a net aminoacid uptake of 39.114.8 g and plasma total amino acids increased by 50 per cent. Thus, supplementing amino acids was effective in improving the nutritional status of malnourished hemodialysis patients. Kopple et al. (1995), studied the effect of supplementation through dialysate containing a 1.1 per cent mixture of essential and non-essential amino acids substituted each day for one or two of the standard glucose-containing dialysates, for 35 days. The total intake of dietary protein plus dialysate amino acids was between 1.1 and 1.3 g/kg/day. This regimen showed a shift in nitrogen balance from neutral to strongly positive. Total-body protein anabolism increased and there was a rise in serum transferrin and total protein concentrations and several postabsorptive plasma essential and non-essential aminoacids and serum albumin. Thus supplementation with amino acids through dialysate was effective in improving the nutritional status of malnourished continuous ambulatory peritoneal dialysis patients. Boaz et al. (2000) investigated the effect of high dose vitamin E supplementation for 2 years for preventing cardiovascular disease outcomes in 97 haemodialysis patients with 800 IU of vitamin E/day and concluded that supplementation reduced composite cardiovascular disease end points and myocardial infarction. Prakash et al. (2004) assessed the effectiveness of a keto diet, a combination of keto analogs of essential amino acids (KAS) and a very low protein diet, in retarding progression of chronic renal failure and maintaining nutritional status. Author concluded that over a nine months period, very low protein diet containing 0.3g/kg/day supplemented with keto analogues (at a dose of 1 tablet per 5 kg body wt/day) helped chronic renal failure patients (n=34) to preserve glomerular filtration rate and maintain body mass index. Ketoanalogs were efficacious in retarding the progression of renal failure and preserving the nutritional status of CRF patients.

2.4 COMPLICATIONS
Complications due to renal diseases are common, silent and potentially lethal which may result from dietary or normal imbalance, pharmacologic effects or abnormalities of renal or gastrointestinal function. Stein et al. (1969) studied the causes for elevated levels of uremic toxin, Guanidino Succinic Acid (GSA) in six predialytic uremic patients. A linear relationship was observed between urinary excretion of urea and GSA in normal patients, but for any level of urea excretion, urinary GSA was greater in the uremic subjects. Since serum GSA was also elevated in uremia, these findings suggested that in renal failure either degradation of GSA is reduced, or more likely production of GSA is increased. Increased serum GSA levels have been implicated in abnormal coagulation and altered lymphocyte function in renal failure. Norbeck et al. (1978) undertook the study to give more detailed information on the concentrations of triglycerides and cholesterol in the three lipoprotein classes, very low (VLDL), low (LDL) and high density lipoproteins (HDL) in 39 fasting patients suffering from chronic uremia. The dietary calories were 33, 56 and 11 per cent from fat, carbohydrate and protein respectively and the daily intake of protein was restricted to approximately 1g/kg/day. The findings consisted of raised concentrations of triglycerides in Very Low Density Lipoprotein (VLDL) and Low Density Lipoprotein (LDL) above the median of the controls. But very low concentrations of cholesterol in low density lipoproteins and still lower in high density lipoproteins. With the conventional typing system for hyperlipidaemia, type IIA, III and IV were present in 6, 9 and 30 per cent of patients respectively. The ratio between cholesterol and triglycerides (0.67) was higher than in the controls (0.51) in VLDL but lower in LDL. Thus, it was concluded that above mentioned abnormalities could be particularly malignant and a major contributing factor to the rapid development of atherosclerotic manifestations in chronic renal failure. Phillips et al. (1980) studied the relationship between aminoaciduria in chronic renal failure (CRF) patients (n=24) with vitamin D and parathyroid status. Sequential measurements of fractional clearance of aminoacids, plasma 25 hydroxy-vitamin D and serum parathyroid hormone were made. All patients initially had hyperaminoaciduria, secondary hyperparathyroidism and osteomalacia. Treatment with 1, 25dihydroxy cholecalciferol or 1 -hydroxycholecalciferol significantly improved amino acid reabsorption irrespective of the initial degree of aminoaciduria. Cholecalciferol or 25hydroxycholecalciferol improved amino acid transport in patients with hyperaminoaciduria. Reduction in aminoaciduria during treatment with 25(OH) D3 may have depended on a variable ability to synthesize 1, 25 (OH)2 D3. Changes in amino acid transport did not correlate with changes in serum parathyroid hormone. It was suggested that defective amino acid reabsorption in patients with CRF is due at least in part to deficiency of 1, 25 (OH)2 D3. Goldstein et al (1989) studied the effect of vitamin D deficient state in 7 patients with nephrotic syndrome (creatinine clearance 30 ml/min). The blood levels of the amino-terminal fragment of parathyroid hormone in these seven patients displayed an inverse relationship with the concentration of ionized calcium. The concentrations of ionized calcium (3.690.10 mg/dl) in blood were significantly lower (P<0.01) in patients with nephrotic syndrome and renal failure than in patients with comparable degree of renal insufficiency but without proteinuria (4.020.08 mg/100 ml). These observations underscored the importance of the low blood levels of 25(OH)D3 in the etiology of the hypocalcemia of the nephrotic patients and demonstrate that secondary hyperparathyroidism may develop in patients with nephrotic syndrome and normal renal function. Bhimo et al. (2003) found out the pattern of lipid profile in 50 chronic renal failure (CRF) patients with other associated risk factors, like hypertension, diabetes mellitus, cerebrovascular accident and ischaemic heart disease. CRF cases showed significantly increased level of serum cholesterol (186.60468.34mg/dl), triglyceride (190.1192 mg/dl) and significantly lower high density lipoprotein cholesterol (36.01610.54 mg/dl) than normal values. When lipid profile in CRF with different associated risk factors were seen,

hypertensive CRF had the highest degree of dyslipidemia. CRF with diabetes mellitus had the highest triglyceride value (207.340.29 mg/dl) and the lowest high density lipoprotein cholesterol value (37.26.5 mg/dl). It was also observed that as the value of serum creatinine increased, the hemoglobin value decreased accordingly. Thus it was concluded that the high degree of cardiovascular complications were due to association of hypertension, diabetes, dyslipidemia and anaemia in this group of patients. Influence of co-morbid disease with malnutrition on mortality in peritoneal dialysis patients from that of only malnutrition was dissociated by Chung et al. (2003). A total of 153 consecutive peritoneal patients were included. Nutritional status was assessed by subjective global assessment. Comorbid survey was done and graded by Davies index (Davies et al., 2002). There was a high prevalence of malnutrition and co-morbid disease at the start of pertioneal dialysis and that the combined presence of co-morbid disease and malnutrition was associated with high mortality. Malnutrition alone was associated with statistically insignificant increase in mortality. Thus it was concluded that malnutrition without co-morbid diseases may not be associated with significant mortality.

III. MATERIAL AND METHODS

Chronic renal failure patients are often catabolic and malnourished. To treat malnutrition effectively, the nutritional profile of the patient and assessment is of paramount importance. Hence, study was conducted to assess the nutritional status and dietary guidelines of predialytic and hemodialytic patients. The details of material used and the methodology employed has been described in this chapter.

3.1 LOCALE OF THE STUDY

The study was conducted at Dialysis unit, In and Out-patient wards of Karnataka Institute of Medical Sciences (KIMS), Hubli, Karnataka.

3.1.1 Selection of sample

Twenty-five chronic kidney failure patients undergoing maintenance hemodialysis were selected from dialysis unit and 20 pre dialytic patients were taken from In and Outpatient wards of KIMS, Hubli.

3.2 DEVELOPING TOOLS

A detailed questionnaire was developed, to elicit information on various aspects related to renal patients including demographic profile, clinical and health status, symptoms at the onset of disease, existing signs, etiology of renal disease, medications and supplementations being used, stage of renal diseases, complications seen, life style factors and nutritional profile with respect to anthropometry, dietary intake and biochemical parameters. The questionnaire was structured and modified based on the suggestions of the experts. Further, the developed questionnaire was pre-tested on renal patients at KIMS and required changes were made (Appendix I).

3.2.1 General information

Data generation on general information of chronic renal failure patients included, age, gender, education, occupation, monthly income of family, family size, number of earning members, activity pattern of respondent and marital status.

3.2.2 Clinical and health status

Information on onset of kidney disease, date of commencement of maintenance hemodialysis, other diseases/disorders present before the onset of kidney disease, symptoms at the onset of kidney disease, physical examination of patients for signs, type of kidney disease, etiology, medication and supplementation were included in this section. The Glomerular Filtration Rate (GFR) of patients was computed based on the hospital records. The serum creatinine levels, age and actual body weight of the subjects were considered for computation of GFR. Cockcroft-Gault formula was used for calculating GFR (Anon., 2005e) and the subjects were classified based on their GFR (Anon., 2005b). GFR = [(140-age) x body weight (kg)] / (Serum creatinine x72) for men] x 0.85 in women Complications observed in chronic renal failure (CRF) patients, were noted from hospital records.

3.3 LIFE STYLE FACTORS

Present prevalent vices in subjects such as smoking, alcohol intake, and tobacco chewing were recorded. An information on exercise habits with special reference to type, regularity, benefits observed and who advised alike were collected.

Plate 1. Dietary survey

Plate 2. Weight measurement

3.4 ANTHROPOMETRIC ASSESSMENT

Anthropometric measurements viz., height (cm), weight (kg), waist (cm), hip (cm) and mid upper arm circumferences (cm) and triceps skinfold thickness (mm) were recorded as per the guidelines suggested by Jelliffe (1966). The height was measured using height chart to nearest 0.1 cm. The subjects were weighed using portable platform weighing balance to nearest 0.5 kg with causal clothes and barefoot. A narrow flexible, non-elastic tape was used to measure the mid upper arm circumference (MUAC), waist and hip circumferences. The measurements were made to nearest 0.1 cm. Triceps skinfold thickness was measured with Harpenden calipers to the nearest 0.1 mm. Body Mass Index (BMI) was computed using the formula given by Garrow (1987) to classify the individual as normal, obese or under weight.

Weight (kg) Body mass index = (Height) (m) BMI Classifications BMI Class < 18.5 18.5-22.9 >23 >25 >30 WHO classification Underweight Normal Overweight Obese I Obese II (Anon., 2006) The abdominal obesity was assessed by waist/hip ratio (Lean et al., 1995). Male 0.95 obese < 0.95 normal Female 0.80 obese < 0.80 normal Mid arm muscle circumference (MAMC) was calculated by using formula given below (Jelliffe, 1966). MAMC (cm) = Mid upper arm circumference (cm) 0.314 x triceps skinfold thickness (mm).

3.5 DIETARY SURVEY

Data regarding the frequency of food consumption, choices of foods after the onset of disease and after dialysis were documented. The foods specially included, restricted and avoided for the present condition, reasons and who advised were recorded. Food consumption pattern was assessed on consecutive 3 days by 24 hours dietary recall method. A set of standardized vessels were used to obtain estimates of the amount of raw and cooked food consumed by the subjects. The ingredients used in preparing the food and method of preparation was carefully recorded.

3.5.1 Nutrient intake and adequacy

The nutrient intake of patients was computed based on the diet survey data. For this purpose the amount of cooked food consumed by the patients were converted into raw ingredients. Food items consumed by patients were prepared in the laboratory to get approximate amount of raw ingredients. The nutritive value of the raw ingredients such as energy, carbohydrates, protein, fat, minerals such as calcium, sodium, copper, phosphorus, potassium, zinc, iron, magnesium and vitamins like -carotene, thiamine, riboflavin, niacin and folate was computed. Ascorbic acid was computed for foods consumed raw. Nutrient computation was done by using Annapurna VAR 3, software developed by M.R. Chandrashekhar of Bangalore. The requirement of energy, fuel nutrients and electrolytes were computed based on the ideal body weight, range of energy prescribed for the patient, associated conditions and age of the patients. The fuel nutrients such as proteins, fats, carbohydrates and electrolytes like sodium and potassium consumed by each group of patients viz., dialytic and predialytic were compared with the requirements for each patient. Further, the subjects were classified as high, adequate and low based on the nutrient adequacy.

3.6 BIOCHEMICAL PARAMETERS

Biochemical parameters were documented from the case files of each patient maintained in the hospital. For dialysis patients, biochemical profile recorded at the time of first dialysis and the present status were documented. Biochemical profile included serum albumin, total protein, creatinine, urea, sodium, potassium, calcium, phosphorus and lipid profile including total cholesterol, triglycerides, High Density Lipoprotein Cholesterol (HDL-C) and Low Density Lipoprotein Cholesterol (LDL-C) was computed using the following formula (Anonymous, 2005c).

Triglyceride VLDL-C = 5

LDL-C =

Total cholesterol (HDL-C + VLDL-C)

3.7 FORMULATING SUITABLE DIETARY GUIDELINES

Suitable dietary guidelines for chronic renal failure patients were formulated based on the ideal body weight, associated conditions, age and basal energy expenditure. Ideal body weight was calculated using Brocas Index. Ideal body weight = Height 100 Basal Energy Expenditure (BEE) for calculating energy requirement was done using Harris-Benedict equation. BEE for male = [66+(13.7 x body weight (kg)) + (5 x height (cm)) (6.8 x age)] BEE for female = [655+(9.6 x body weight (kg)) + (1.8 x height (cm)) (4.7 x age)] The figure got from BEE is multiplied by 1.2 for sedentary activity and 1.3 for moderate activity to get the value of BEE (Anon., 2005d). For diabetic patients energy requirement was based on 10 per cent less weight than ideal body weight (Raghuram et al., 1998).

Carbohydrate requirement was computed by taking 50-60 per cent of total energy. Protein requirement for dialytics was 1.2 g/kg/day having 50 per cent of protein of high biological value and for predialytics it was 0.6 g/kg/ day or 0.3 g/kg/day with essential amino acid supplementation. For 0.6 g/kg of protein, 2/3 was from high biological value and 0.3 g/kg of protein was containing vegetable proteins only based on Glomerular Filtration Rate (GFR) ml/min (Anon., 1995). For hepatitis protein prescribed was 1.5 g/kg/day. Rest of the total energy for all subjects was from fat. For diabetic patients, energy distribution was done as follows (Raghuram et al., 1998). Non-Insulin Dependent Diabetes Mellitus (NIDDM) Breakfast Lunch Snacks Dinner 25 per cent

33 per cent 9 per cent 33 per cent

Insulin Dependent Diabetes Mellitus (IDDM) Breakfast Lunch Snacks Dinner Bed time 20 per cent

33 per cent 10 per cent 33 per cent 4 per cent

Sodium and potassium requirement for dialysis were 1-1.5 g/d and 1.5-2.7 g/d, respectively and that for predialytics, 1-3 g/d and 2 g/day respectively. Recommendation of water intake for dialytics was 750-1500 ml/day and that of predialytics was 2000 ml/day, depending on urine output (Anon., 1995).

3.8 STATISTICAL ANALYSIS

The responses of subjects were expressed in frequency and percentage. The student t test was used as per the statisticians suggestions to test the significance of mean difference between the dialytic and predialytic patients, with respect to dietary intake and biochemical parameters, and biochemical parameters of dialytics before and after dialysis.

IV. EXPERIMENTAL RESULTS

The occurrence of poor nutritional status in patients with chronic renal failure has been well documented. The reasons for malnutrition are complex and related to loss of nutrients during dialysis, decreased food intakes and altered metabolic requirements. So chronic kidney disease deserves attention and examination as it is a major cause of morbidity and mortality. The results of the present study on nutritional status and dietary guidelines of predialytic and hemodialytic patients conducted during the year 2005-06 are presented in this section.

4.1 GENERAL INFORMATION OF RENAL PATIENTS

4.1.1 Demographic profile of chronic renal failure patients
The demographic profile of chronic renal failure patients is presented in Table 1. Among 45 patients interviewed, 20 were predialytic and 25 were dialytic patients. Among predialytic patients 65 per cent were males and 35 per cent were females. Likewise among dialytic patients 84 per cent were males and rest were females. Among the two categories of patients, majority were falling in the age group of 41-60 years (45% and 56% in predialytic and dialytic group, respectively) followed by 20-40 years (40 and 32%) and very few were more than 60 years in both the groups (15 and 12%). Most of the predialytic patients had primary school level education (45%) followed by almost equal number in college level (25%) and illiterate category (20%). But in dialytic group, majority had college level education (32%) followed by high school level education (28%) and primary school level education (20%). Very few subjects were illiterates (4%). In both the groups, majority of patients belonged to the Hindu religion (80% and 72% in predialytic and dialytic groups, respectively) followed by muslim religion (20 and 24%) and only one belonged to Christian in dialytic group. Among predialytic patients 85 per cent were non-vegetarians and almost similar number were seen in dialytic patients (88%). Majority of the patients in both groups were married (85 and 88% in pre-dialytic and dialytic groups, respectively). Among chronic renal failure patients higher percentage had a medium sized family (75 and 68% in predialytic and dialytic groups, respectively) followed by small (15 and 20%) and large sized family (10 and 12%).

4.2 CLINICAL AND HEALTH STATUS

4.2.1 Clinical and health status of chronic renal patients
The majority of predialytics and dialytics had the onset of kidney disease for the last 24 months (80 Vs 60%). About 15 per cent of predialytics were suffering from kidney disease for the last 48-72 months and very few (15%) had it for more than 72 months. On the other hand, 32 per cent of dialytics were diagnosed for the renal disease between 24 and had been suffering from this disease from 48 to 72 months and for more than 72 months (Table 2). Most of the renal patients in both the groups had presence of disorders prior to the onset of kidney disease (85% and 92% in predialytic and dialytic group, respectively). Majority of the predialytic and dialytic subjects suffered from hypertension alone (47.00 Vs 60.80%), followed by both hypertension and diabetes (47.00 Vs 30.40%) and diabetes alone (5.80 Vs 8.70%) prior to the onset of kidney disease.

Table 1. Demographic profile of chronic renal failure patients (N=45) Characteristics Gender Male Female Age (years) 20-40 41-60 >60 Education Illiterate Primary school High school Pre-university College Religion Hindu Muslim Christian Food habit Vegetarian Non-vegetarian Marital status Married Unmarried Widow(er) Family size Small (<4) Medium (4-8) Large (>8) 3 15 2 15.00 75.00 10.00 5 17 3 20.00 68.00 12.00 17 2 1 85.00 10.00 5.00 22 3 88.00 12.00 3 17 15.00 85.00 3 22 12.00 88.00 16 4 80.00 20.00 18 6 1 72.00 24.00 4.00 5 25.00 4 9 2 20.00 45.00 10.00 1 5 7 4 8 4.00 20.00 28.00 16.00 32.00 8 9 3 40.00 45.00 15.00 8 14 3 32.00 56.00 12.00 13 7 65.00 35.00 21 4 84.00 16.00 Predialytics (n=20) Frequency % Dialytics (n=25) Frequency %

Table 2. Clinical and health status of subjects at the time of investigation (N=45) Variables Onset of kidney disease* (months) 1-24 24-48 48-72 >72 Commencement of dialysis* (months) 1-24 24-48 48-72 >72 Disorder before the onset of kidney disease None Presence of disease/ disorder Diabetes Hypertension Both NA Not applicable * At the time of study 3 17 1 8 8 15.00 85.00 5.80 47.00 47.00 2 23 2 14 7 8.00 92.00 8.70 60.80 30.40 1 4 NA NA 21 3 84.00 12.00 16 1 3 80.00 5.00 15.00 15 8 1 1 60.00 32.00 4.00 4.00 Predialytics (n=20) Frequency % Dialytics (n=25) Frequency %

4.2.2 Etiology of chronic renal failure in the selected subjects

Table 3 is presented with the etiology of chronic renal failure in the selected subjects. It was observed that the most common cause of chronic renal failure in predialytic group was chronic glomerulonephritis (40%) followed by diabetes mellitus (30%) and chronic pyelonephritis (25%) and only one patient was suffering from chronic tubulointerstitial nephritis. Similar trend was observed in dialytic group with chronic glomerulonephritis (40%) as the most common cause followed by diabetes mellitus (32%) and chronic pyelonephritis (12%). About eight per cent had hypertension as the cause of chronic renal failure followed by equal number of patients who had polycystic renal disease and chronic obstructive nephropathy (4% in each). The common medications for both the groups of subjects were amlodipin, lasix, metaloz, minipres, acromin, dytor, ranitidine, methyldopa, aldactone, ramiprin and atenolol as prescribed by the physicians. The common supplements found among the two groups were calcium, folic acid, Bcomplex, vitamin D3, erythropoietin, iron and phostat.

Table 3. Etiology of chronic renal failure in the subjects (N=45) Predialytics (n=20) Etiology Frequency Diabetes mellitus Hypertension Chronic glomerulonephritis Chronic tubulointerstitial nephritis Chronic pyelonephritis Familial and cystic renal disease Chronic obstructive nephropathy 6 8 1 5 % 30.00 40.00 5.00 25.00 Frequency 8 2 10 3 1 1 % 32.00 8.00 40.00 12.00 4.00 4.00 Amlodipin Minipress Atenolol Lasix Dytor Metlaoz Amlong Vitamin B-complex Vitamin D3 Erythropoietin Iron tablets Calcium tablet Folic acid Phostat Dialytics (n=25) Medications Supplements

4.2.3 Symptoms of kidney disease at the time of onset

Table 4 shows the symptoms of kidney disease at the time of onset. Among the 45 patients studied, edema and breathlessness were the most common symptoms (84.44% and 82.22%, respectively) followed by oliguria and anorexia (73.33% and 66.66%, respectively). Headache, nausea, nocturia and vomiting were prevailing in almost 50 per cent of the subjects. Very few subjects suffered from hematuria (11.11%) followed by loss of consciousness (22.22%) and convulsions (26.66%).

4.2.4 Prevailing clinical signs of the subjects

Prevailing clinical signs of the subjects at the time of investigation is presented in Table 5. It was observed that clinical signs such as pallor of eyes and nails were common in all the subjects undergoing dialysis (100%) followed by edema (92%), swollen joints and excoriation due to pruritus (52% and 48%, respectively). Similar signs were observed in predialytics with maximum subjects having pallor of eyes (95%) followed by edema (75%). Pallor of nails was present in 55 per cent patients, followed by swollen joints and excoriation due to pruritus. Very few subjects from both the groups had restless leg syndrome and poor wound healing. Table 4. Symptoms of kidney disease at the time of onset (N=45) Subjects Symptoms Frequency Anorexia Breathlessness Convulsions Frequent urination Headache Hematuria Loss of consciousness Nausea Nocturia Oliguria Edema Vomiting Any other* 30 37 12 19 25 5 10 27 22 33 38 26 17 % 66.66 82.22 26.66 42.22 55.55 11.11 22.22 60.00 48.88 73.33 84.44 57.78 37.77

* Symptoms: Fever, acidity, abdominal pain, giddiness, sleep disturbances, dark coloured urine, pain in right side of chest, blood in cough, burning micturation, pain while breathing

Table 5. Prevailing clinical signs of the subjects at the time of investigation (N=45) Predialytics (n=20) Symptoms Frequency % Frequency % Dialysis (n=25)

Pallor of eyes

19

95.00

25

100.00

Excoriation due to pruritus

40.00

12

48.00

Pallor of nails

11

55.00

25

100.00

Restless leg syndrome

10.00

12.00

Swollen joints

10

50.00

13

52.00

Edema

15

75.00

23

92.00

Poor wound healing

5.00

16.00

4.2.5 Stage of kidney disease based on Glomerular Filtration Rate (ml/min GFR)
Table 6 shows the stage of kidney disease based on glomerular filtration rate. It was depicted that 80 per cent of the patients had GFR between 15-29 ml/min and were falling in the fourth stage of kidney disease and the rest were falling in stage three (20%) of kidney disease with GFR in between 30-59 ml/min.

4.2.6 Complications of the chronic renal failure subjects

Complications of the selected chronic renal failure subjects have been given in the Table 7. The complications of the selected subjects were based on biochemical parameters of dialytics. All the subjects suffered from anaemia (100%) followed by hyperphosphatemia (66.66%) and hypocalcemia (54.54%). Majority revealed hyperkalemia (53.33%) compared to hypokalemia (13.33%) and only a few had hyponatremia (12.5%).

Table 6. Stage of kidney disease based on Glomerular Filtration Rate (GFR) (ml/min)

Predialytics (n=20) Glomerular Filtration Rate (ml/min) Stage Frequency %

90 or higher

60-89

30-59

20.00

15-29

16

80.00

<15 Note: <15 is denoted for dialytic subjects

Table 7. Prevailing complications* of selected chronic renal failure subjects

Subjects Complications F Frequency %

Hyponatremia

16

12.50

Hypokalemia

15

13.33

Hyperkalemia

53.33

Hypocalcemia

11

54.54

Hyperphosphatemia

66.66

Anaemia

23

23

100.00

*Based on biochemical parameters of dialytics prior to dialysis

4.3 LIFE STYLE PATTERN

4.3.1 Prevalence of vices in renal patients
About 65 per cent of predialytics and 64 per cent of dialytics had no vices at the time of investigation. Tobacco chewing was the most common vice found in predialytic and dialytic patients (35 Vs 28%) followed by alcohol consumption (10 Vs 4%). These vices were also present prior to the onset of disease, but were still prevailing after the onset of disease (Table 8).

4.3.2 Exercise behaviour of selected patients

Exercise behaviour of the predialytic and dialytic subjects has been presented here in Table 9. Higher percentage of dialytics exercised compared to predialytic patients (52 Vs 35%). Most common exercise followed was walking (20% in predialytic and 36% in dialytic patients respectively) in both the groups followed by formal exercise (15% in predialytic and 12% in dialytic patients, respectively). In addition, one dialytic subject also followed yoga (4%). All the dialytic subjects exercised regularly, whereas 25 per cent of predialytics were regular exercisers and rest of them (10%) were not regular in the exercise. The reason quoted for doing exercise were relief from pain in the leg and improvement in appetite. The reasons for not exercising were-not effective and lack of interest. Table 8. Prevalence of vices in the subjects (N=45) Predialytics (n=20) Vices present Frequency % Frequency % Dialytics (n=25)

No vices

13

65.00

17

68.00

Alcohol consumption

10.00

4.00

Tobacco chewing Multiple answers

35.00

28.00

Table 9. Exercise behaviour of the subjects (N=45) Particulars Exercising habit Yes No Predialytics (n=20) Frequency 7 13 % 35.00 65.00 Dialytics (n=25) Frequency 13 12 % 52.00 48.00 Doing exercise Feeling good Relief from leg pain *Improvement in appetite Not doing exercise Not effective Not interested Who suggested Doctor Own decision Reason

Type of exercise Walking 4 Formal exercise 3 Yoga Regularity Regular 5 Irregular 2 *Only in dialytic patients

20.00 15.00

9 3 1 13 -

36.00 12.00 4.00 52.00

25.00 10.00

4.4 ANTHROPOMETRIC MEASUREMENT

4.4.1 Mean anthropometric measurements of the subjects
Table 10 reveals the mean anthropometric measurements of the subjects. The mean height, weight, waist and hip circumference of predialytic males were found to be lower compared to dialytic males (1636.26 Vs 166.288.03 cm for height, 53.519.17 Vs 57.746.52 kg for weight, 76.3813.62 Vs 86.4210.8 cm for waist circumference and 87.157.98 Vs 90.76 7.25 cm, for hip circumference in predialytics and dialytics, respectively). Mid upper arm circumference and triceps skin fold thickness were found to be almost similar in both the male groups. However, a reverse trend was observed in the anthropometric measurements of predialytics compared to dialytic females. Predialytic females showed higher mean values for height, weight, waist and hip circumference, mid upper arm circumference and triceps skin fold thickness (156.577.44 Vs 1545.47 cm for height, 50.5711.91 Vs 42.95 7.35 kg for weight, 78.424.64 Vs 69.5 7.93 cm for waist circumference, 917.28 Vs 83.75 11.58 cm for hip circumference, 11.51 4.02 Vs 8.854.79 mm for TSF and 24.713.14 Vs 232.94 cm for MUAC in predialytic and dialytic females, respectively).

4.4.2 Classification of chronic renal failure subjects based on Body Mass Index (BMI) and Waist to Hip Ratio (WHR)
Majority of the patients in both predialytics and dialytics were grouped under normal BMI followed by underweight category (Table 11). Majority of predialytic males were normal (61.53%) followed by underweight (23.07%). Maximum percentage of predialytic females were normal (42.85%) and there was an equal distribution of females, falling in underweight and overweight categories (28.57% in each). In dialytic subjects, majority of males were normal (42.85%) and equal number were grouped under underweight and overweight categories (28.57%). Equal number of dialytic females were falling in normal and underweight categories (50% each) and none was observed to be overweight. Higher percentage of predialytic males were normal compared to dialytic males (61.53 Vs 42.85%) but there was a higher percentage of dialytic males compared to predialytic males with respect to those falling in underweight and overweight categories (28.57 Vs 23.07% in underweight and 28.57 Vs 15.40% in overweight categories for dialytic and predialytic males, respectively). However, higher percentage of dialytic females were normal as well as underweight compared to predialytic females (50 Vs 42.85% in normal and 50 Vs 28.57% in underweight categories, respectively). With respect to waist to hip ratio, majority of the patients were normal in both the groups. Most of the predialytic males were normal (84.61%) with very few in the obese category (15.39%). But the trend was vice-versa in case of predialytic females. About 71.43 per cent belonged to obese category and had abdominal obesity. The same trend was followed in dialytic males and females. More number of predialytic males as well as females were normal compared to dialytics and had normal WHR (84.61 Vs 61.91% for males and 28.57 Vs 25% for females, respectively).

4.4.3 Age wise classification of the subjects based on mean value of Triceps Skinfold Thickness
The Table 12 shows the age wise classification of subjects based on Triceps Skinfold Thickness (TSF). The mean TSF of all the males and females of dialytics and prediaytics of different age groups were lower than the NCHS standard values. The dialytic males of age group 35-44.9 years and 65-74.9 years had higher mean values for TSF compared to predialytic counterparts (9.523.05 Vs 6.81.41 cm in between 35-44.9 years and 10.623.36 Vs 8.462.38 cm in between 65-74.9 years) except for the age group of 25-34.9 year (4.660.83 Vs 3.842.26 cm for predialytic and dialytic subjects, respectively). Dialytic females falling in the age group of 25-34.9 years had higher mean value of TSF compared to predialytic females (16 Vs 9.062.72 cm).

Table 10. Mean anthropometric measurements of the subjects

Subjects

Height (cm)

Weight (kg)

Waist circumference (cm)

Hip circumference (cm)

Mid upper arm circumference (cm)

Triceps skinfold thickness (mm)

Predialytics

Male (n=13)

163.536.26

53.519.17

76.3813.62

87.157.98

24.842.27

8.303.38

Female (n=7)

156.577.44

50.5711.91

78.424.64

917.28

24.713.14

11.514.02

Dialytics

Male (n=21)

166.288.03

57.746.52

86.4210.81

90.767.25

24.542.17

8.873.17

Female (n=4)

1545.47

42.957.35

69.57.93

83.7511.58

232.94

8.854.79

Table 11. Classification of the subjects based on Body Mass Index (BMI) and Waist to Hip Ratio (WHR) Subjects Frequency Underweight (<18.5) Predialytics Male Female Dialytics Male Female 21 4 6 (28.57) 2 (50.00) 9 (42.85) 2 (50.00) 6 (28.57) 13 (61.91) 1 (25.00) 8 (38.09) 3 (75.00) 13 7 3 (23.07) 2 (28.57) 8 (61.53) 3 (42.85) 2 (15.40) 2 (28.57) 11 (84.61) 2 (28.57) 2 (15.39) 5 (71.43) Body Mass Index Normal (18.5-22.9) Overweight (>23) Waist to Hip Ratio* Normal Obese

Note: Figures in parenthesis indicate percentage *Waist to hip ratio For male For female Normal <0.95 <0.80 Obese 0.95 0.80

4.4.4 Agewise classification of the subjects based on mean value of Mid Upper Arm Circumference (MUAC)
The Table 13 is presented with the age wise classification of subjects based on MUAC. The mean MUAC of all the subjects belonging to different age groups were lower than the standard values with respect to gender. The dialytic males, falling in the age-groups of 35-44.9 years, 45-54.9 years and 65-74.9 years had higher mean value for MUAC compared to predialytic males (24.821.78 Vs 232.82 cm for 35-44.9 years, 25.431.51 Vs 24.751.76 cm for 45-54.9 years and 262.64 Vs 25.662.08 cm for 65-74.9 years) except for the age group of 55-64.9 years where predialytic males had higher mean value of MUAC compared to dialytic males (25.66 2.08 Vs 23.522.12 cm). The dialytic females of age group 25-34.9 years had higher mean value of MUAC compared to predialytic females (26.00 Vs 23.33 3.51 cm).

4.4.5 Age-wise classification of the subjects based on mean value of Mid Arm Muscle Circumference (MAMC)
The mean MAMC of all the males of dialytics and prediaytics of different age groups were lower than the standard values (Table 14). However, in case of females all the MAMC values were lower in comparison with the standards except in the predialytic group of 35-44.9 years who had higher MAMC in comparison with the standards (23.30 Vs 21.80 cm). The dialytic males in the age-group of 25-34.9 years, 55.00-64.90 years and 65.00-74.90 years had higher mean values of MAMC compared to predialytic males (20.492.66 Vs 20.95 cm for 25-34.90 years, 23.001.34 Vs 20.83 2.03 cm for 55-64.9 years and 23 1.34 Vs 22.61 1.72 cm for 65-74.9 years) except for the age-group of 35-44.9 years and 45-54.9 years where predialytic males had higher mean value of MAMC (21.821.48 Vs 20.862.38 cm for 35-44.9 years, and 22.170.74 Vs 21.52 0.56 cm for 45-54.9 years).

Table 12. Age-wise classification of the subjects based on Triceps Skinfold Thickness (TSF) N=45 Age (years) Predialytics (n=20) Male Female 25-34.9 Male Female 35-44.9 Male Female 45-54.9 Male Female 55-64.9 Male Female 65-74.9* Male Frequency Mean Dialytics (n=25) Frequency Mean Standard (cm)

19-24.9

0 0 3 3 2 1 2 0 3 3 3

4.660.83 9.062.72 6.801.41 14.80 10.133.81 8.462.38 12.824.91 8.462.38

Male Female Male Female Male Female Male Female Male Female Male

1 1 2 1 5 0 5 2 5 0 3

5.40 5.80 3.842.26 16.00 9.523.05 10.283.13 6.820.28 8.521.75 10.623.36

10.00 18.00 12.00 21.00 12.00 23.00 12.00 25.00 11.00 25.00 11.00

* No female was there in age-group 65-74.9 years

Table 13. Age-wise classification of the subjects based on Mid Upper Arm Circumference (MUAC) N=45 Age (years) Predialytics (n=20) Male Female 25-34.9 Male Female 35-44.9 Male Female 45-54.9 Male Female 55-64.9 Male Female 65-74.9* Male Frequency Mean Dialytics (n=25) Frequency Mean Standard (cm)

19-24.9

0 0 3 3 2 1 2 0 3 3 3

24.163.32 23.333.51 23.002.82 28.00 24.751.76 25.662.08 25.003.28 25.662.08

Male Female Male Female Male Female Male Female Male Female Male

1 1 2 1 5 0 5 2 5 0 3

23.00 19.00 23.004.24 26.00 24.821.78 25.431.51 23.500.70 23.522.12 26.002.64

30.80 26.50 31.90 27.70 32.60 29.00 32.20 29.90 31.70 30.30 30.70

* No female was there in age-group 65-74.9 years

Table 14. Age-wise classification of the subjects based on Mid Arm Muscle Circumference (MAMC) N=45 Age (years) Predialytics (n=20) Male Female 25-34.9 Male Female 35-44.9 Male Female 45-54.9 Male Female 55-64.9 Male Female 65-74.9* Male Frequency Mean Dialytics (n=25) Frequency Mean Standard (cm)

19-24.9

0 0 3 3 2 1 2 0 3 3 3

21.83.53 20.492.66 20.862.38 23.30 21.520.56 20.832.03 20.901.46 22.611.72

Male Female Male Female Male Female Male Female Male Female Male

1 1 2 1 5 0 5 2 5 0 3

21.32 17.17 22.723.50 20.95 21.821.48 22.170.74 21.360.79 23.001.34 23.001.34

27.30 20.70 27.90 21.20 28.60 21.80 28.10 22.00 27.8 22.50 26.80

* No female was there in the age-group of 65-74.9 years

4.5 DIETARY INTAKE

4.5.1 Mean food intake of the subjects
The mean food intake of dialytics were higher compared to predialytic subjects for cereals (200.0796.34 Vs 122.6982.53 g), pulses (34.6428.22 Vs 20.7022.97 g), other vegetables (27.5649.74 Vs 15.3532.03 g), roots and tubers (43.4443.81 Vs 23.9022.61 g), nuts and seeds (10.4916.40 Vs 4.076.30 g), fruits (17.0925.11 Vs 4.786.27 g), fats and oils (13.0711.05 Vs 5.447.26 g) and sugar (18.0617.23 Vs 11.1014.06 g) except for green leafy vegetables and milk and milk products whose intakes were higher in predialytics (15.6530.00 Vs 8.4817.67 g for green leafy vegetables and 197.88171.31 Vs 176.41131.19 g for milk and milk products) but the difference in mean intakes of two groups was significant only for cereals (P<0.01), fruits (P<0.05), fats and oils (P<0.01). However, the mean intakes of green leafy vegetables and milk and milk products was higher in case of predialytics compared to dialytics, but the difference in means was not significant. None of the predialytic subjects consumed non-vegetarian food items including egg (Table 15).

4.5.2 Mean nutrient intake of the subjects

Table 16 reveals the mean nutrients intake of subjects. The mean intake of all the nutrients were significantly higher in dialytics compared to predialytics with respect to energy (1304533.22 Vs 764493.11 Kcal, P<0.01), protein (38.2617.71 Vs 23.5015.57 g, P<0.01), fat (39.0226.04 Vs 19.22 13.67 g, P<0.01), carbohydrate (204.9683.13 Vs 124.6280.29g, P<0.01) and fibre (16.536.11 Vs 10.5469.05 g, P<0.05). The mean intake of all the minerals and electrolytes were significantly higher in case of dialytics compared to predialytic subjects (876.24427.17 Vs 511.77360.33 mg, for phosphorus, 12.327.44 Vs 6.295.98 mg, for iron, 3.381.49 Vs 2.001.70 mg, P<0.01, for zinc, 1079.92515.29 Vs 702.13509.53 mg, P<0.05, for potassium and 314.33131.07 Vs 190.09157.98 P<0.01, for magnesium), except for calcium and sodium.

4.5.3 Mean vitamin intake of the subjects

Table 17 depicts the mean vitamin take of selected subjects. It was observed that the mean intake of thiamin, riboflavin, folic acid, vitamin B12 and ascorbic acid were higher in dialytic group with a significantly higher intake of niacin (P<0.01), compared to predialytics (1.461.34 Vs 1.220.91 mg for thiamine, 0.820.66 Vs 0.560.43 mg, for riboflavin, 8.853.76 Vs 4.983.93 mg for niacin, 100.3952.42 Vs 75.18 70.37 mg for folic acid, 0.701.68 Vs 0.270.23 mg for vitamin B12 and 27.0820.56 Vs 21.6630.62 mg for ascorbic acid). However, there was a higher mean intake of carotene, vitamin A and pyridoxine among predialytics compared to their counterparts, but the difference in means was not significant (756.761395.74 Vs 584.28695.92 g, for total carotene, 192.07350.38 Vs 157.26 175.46 g, for vitamin A, and 1.606.45 Vs 0.240.12 mg for pyridoxine).

4.5.4 Mean food intake of the subjects according to gender

Table 18 depicts mean food intake of the subjects according to the gender. The dialytic males had higher mean intake of cereals, pulses, other vegetables, roots and tubers, nuts and oil seeds, fruits, fats and oils and sugar compared to predialytic males (211.7597.10 Vs 134.7689.27 g for cereals, 34.5230.88 Vs 19.7521.71 g for pulses, 29.3847.06 Vs 11.3027.99 g for other vegetables, 46.1053.73 Vs 24.0722.99 g for roots and tubers, 11.1117.50 Vs 4.806.52 g for nuts and oils, 13.7815.55 Vs 5.177.20 g for fruits, 14.2611.34 Vs 6.598.50 g for fats and oils and 19.5518.14 Vs 9.608.89 g for sugar for dialytics and predialytics, respectively) except for green leafy vegetables and milk and milk products, which were higher in predialytic males (24.0734.72 Vs 6.1415.67 g for green leafy vegetables and 202.97160.84 Vs 74.19127.52 g for milk and milk products). The difference in mean intake was significant for cereals (P<0.05), fruits (P<0.05), fats and oils (P<0.05) and sugar (p<0.05). Non-vegetarian food items were not eaten by predialytic males. On the other hand, dialytic females had the higher mean intake compared to predialytics for cereals (138.7473.78 Vs 100.2768.78 g), pulses (35.254.36 Vs 22.4626.88 g), roots and tubers (29.515.69 Vs 23.5724.42 g), nuts and oil seeds (7.259.67 Vs 2.716.10 g), fruits (34.5054.34 Vs 4.074.45 g) and fats and oil (6.893.86 Vs 3.303.74 g).

Table 15. Mean food intake of the subjects (N=45) Foods (g) Cereals Pulses Green leafy vegetables Other vegetables Roots and tubers Nuts and oil seeds Milk and milk products Meat/fish/poultry/egg Fruits Fats and oil Sugar 3 day recall * - Significant at 5 per cent level ** - Significant at 1 per cent level Predialytics (n=20) 122.6982.53 20.7022.97 15.6530.00 15.3532.03 23.9022.61 4.076.30 197.88171.31 4.786.27 5.447.26 11.1014.06 Dialytics (n=25) 200.0796.34 34.6428.22 8.4817.67 27.5649.74 43.4443.81 10.4916.40 176.41131.19 65.72268.05 17.0925.11 13.0711.05 18.0617.23 t value 2.89** 1.82 0.95
NS

NS

1.07

NS

1.75NS 1.79 0.46

NS

NS

1.22

NS

2.36* 2.78** 1.49NS

Table 16. Mean nutrient and electrolyte intake of the subjects (N=45) Nutrients (g) Energy (Kcal) Protein Fat Carbohydrate Fibre Electrolytes (mg) Calcium Phosphorus Iron Zinc Magnesium Sodium Potassium * Significant at 5 per cent level ** Significant at 1 per cent level Table 17. Mean vitamin intake of the subjects (N=45) Vitamin (mg) Total carotene (g) Vitamin A (g) Thiamin Riboflavin Niacin Pyridoxine Folic acid Vitamin B12 Ascorbic acid * Significant at 5 per cent level ** Significant at 1 per cent level NS-Non-significant Predialytics (n=20) 756.751395.74 192.07350.38 1.220.91 0.560.43 4.983.93 1.606.45 75.1870.37 0.270.23 21.6630.62 Dialytics (n=25) 584.28695.92 157.26175.46 1.461.34 0.820.66 8.853.76 0.240.12 100.3952.42 0.701.68 27.0820.56 t value 0.50
NS

Predialytics (n=20) 764493.11 23.5015.57 19.2213.67 124.6280.29 10.5469.05

Dialytics (n=25) 1304533.22 38.2617.71 39.0226.04 204.9683.13 16.536.11

t value 3.52** 2.97** 3.28** 3.28** 2.70*

341.57260.59 511.77360.33 6.295.98 2.001.70 190.09157.98 969.56753.46 702.13509.53

519.60513.71 876.24427.17 12.327.44 3.381.49 314.33131.07 1308.061203.11 1079.92515.29

1.51

NS

3.10** 3.02** 2.83** 2.82** 1.15

NS

2.46*

0.41 NS 0.73 NS 1.61

NS

3.35** 0.94
NS

1.33 NS 1.26 0.68

NS

NS

Table 18. Mean food intake of the subjects according to gender (N=45) Male Food (g) Predialytics (n=13) Cereals Pulses Green leafy vegetables Other vegetables Roots and tubers Nuts and oil seeds Milk and milk products Meat/fish/poultry/egg Fruits Fats and oil Sugar * Significant at 5% level ** Significant at 1% level 134.7689.27 19.7521.71 24.0734.72 11.3027.99 24.0722.99 4.806.52 202.97160.84 5.177.20 6.598.50 9.608.89 Dialytics (n=21) 211.7597.10 34.5230.88 6.1415.67 29.3847.06 46.1053.73 11.1117.50 174.19127.52 78.25291.88 13.7815.55 14.2611.34 19.5518.14 t value 2.36* 1.63
NS

Female Predialytics (n=7) 100.2768.78 22.4626.88 22.8539.75 23.5724.42 2.716.10 188.42202.57 4.074.45 3.303.74 13.9021.3 Dialytics (n=4) 138.7473.78 35.254.36 20.7524.94 18.0021.18 29.5015.69 7.259.67 188.10170.48 34.5054.34 6.893.86 10.259.32 t value 0.85NS 1.23 1.66
NS

1.75

NS

NS

1.40NS 1.66
NS

0.26NS 0.49
NS

1.49NS 0.55
NS

0.85NS 0.002 1.12 0.87

NS NS

1.23NS 2.19* 2.24* 2.13*

NS

0.39NS

Table 19. Classification of the subjects based on adequacy of nutrients (N=45) Predialytic Nutrients Energy (Kcal) Adequacy Low Adequate High Low Adequate High Low Adequate High Low Adequate High Low Adequate High Low Adequate High Male (n=13) F 12 1 10 2 1 7 1 5 12 1 8 4 1 13 % 92.30 7.69 76.92 15.38 7.69 53.84 7.69 38.46 92.30 7.69 61.53 30.76 7.69 100 Female (n=7) F 7 6 1 4 2 1 7 4 3 7 % 100.00 85.71 14.28 57.14 28.57 14.28 100.00 57.14 42.85 100.00 Combined (n=20) F % 19 95.00 1 5.00 16 80.00 3 15.00 1 5.00 11 55.00 3 15.00 6 30.00 19 95.00 12 5.00 12 60.00 7 35.00 1 5.00 100 Male (n=21) F 17 2 2 10 9 2 19 2 13 5 3 9 9 3 16 5 % 80.95 9.52 9.52 47.61 42.85 9.52 90.47 9.52 61.90 23.80 14.28 42.85 42.85 14.28 76.19 23.80 Dialytic Female (n=4) F 4 4 4 3 1 3 1 4 % 100.00 100.00 100.00 7.00 25.00 75.00 25.00 100.00 Combined (n=25) F % 21 84.00 2 8.00 2 8.00 14 56.00 9 36.00 2 8.00 23 92.00 2 8.00 16 64.00 6 24.00 3 12.00 12 48.00 9 36.00 4 16.00 20 80.00 5 20.00 -

Carbohydrate (g)

Protein (g)

Fat (g)

Sodium (mg)

Potassium (mg)

F=Frequency

Whereas, predialytic females had higher mean intake of other vegetables and sugar compared to dialytic females (22.8539.75 Vs 1821.18 g for other vegetables and 13.9021.3 Vs 10.259.32 g for sugar). The mean intake of milk and milk products were similar for females of both the groups. Predialytic females did not eat green leafy vegetables and none of the females in either groups had non-vegetarian food items. The differences between the means were not significant for all the food consumed.

4.5.5 Classification of the subjects based on adequacy of nutrients

Majority of the predialytics had low adequacy for energy (95%), carbohydrate (80%), protein (55%), fat (95%), sodium (60%) and all the subject had adequacy for potassium. Similar trend was seen for dialytics since majority were having low adequacy for energy (84%), carbohydrate (56%), protein 929%), fat (64%), sodium (48%) and potassium (80%) (Table 19). When the both groups were compared, higher percentage of dialytics were having adequate intake of nutrients compared to predialytics with respect to energy (8 Vs 0%), carbohydrate (36 Vs 15.38%), fat (24 Vs 0%) and potassium (20 Vs 0%) except for protein and sodium. Higher percentage of predialytics had adequate intake of protein and sodium compared to dialytics (55 Vs 92% for protein and 60 Vs 48% for sodium predialytic and dialytics, respectively). However, higher percentage of dialytics had more than adequate intake compared to predialytics for energy (8 Vs 5%), carbohydrate (8 Vs 5%), fat (12 Vs 5%) and sodium (16 Vs 7.69%), except for protein whose intake was higher than adequacy in case of predialytics compared to dialytics (30 Vs 50%).

4.6 DIETARY MODIFICATION

4.6.1 Dietary modification followed by the subjects
Table 20 depicts the dietary modification followed by the subjects. It was observed that 10 per cent in the predialytic and 12 per cent in dialytic group did not include any special foods. Higher percentage of dialytics included fruits like apple, guava and pineapple compared to predialytics (32 Vs 10%) and the same trend was seen for inclusion of leached vegetables (8 Vs 5% for dialytic and predialytic subjects, respectively). About 20 per cent of dialytic subjects included chicken and fish as a special foods but none of the predialytics included these foods in the diet. However, the reasons quoted for including the special foods was due to the doctors advice. Inclusion of fruits was due to the low potassium content. The vegetables were leached by boiling in water and discarding the water to reduce the potassium content. Chicken and fish were eaten to increase the protein content of the diet. Under foods restricted, 90 per cent among predialytics and 60 per cent among dialytic groups did not practice any restriction for food items. The remaining patients, restricted water intake (10 and 40 per cent in predialytics and dialytics, respectively) and salty food items (5 and 24%, respectively). The reasons given for restricting water and salty food items were to protect kidney and to decrease the sodium level. Forty per cent of predialytics and 20 per cent of dialytics did not avoid any food items. The food avoided by the kidney patients were coconut water (60 and 80% by predialytics and dialytics, respectively), sweet items (30 and 32%, respectively) and banana (10 and 28%, respectively). Sweet items were avoided as they raised blood sugar in diabetic renal patients and coconut water and banana were avoided as they raised the potassium levels in the blood.

Table 20. Dietary modification followed by the subjects (N=45) Dietary modification Predialytic (n=20) F Foods specially included No special food Fruit like apple, guava and pineapple Leached vegetables* Chicken and fish Foods restricted No restriction Water Salty food items Foods avoided No avoidance Coconut water Fruits like banana Sweets 8 12 2 6 40.00 60.00 10.00 30.00 5 20 7 8 20.00 80.00 Raises potassium level 28.00 72.00 Raises blood sugar level 18 2 1 90.00 10.00 5.00 15 10 6 60.00 40.00 24.00 To protect kidney in body Raises serum sodium level 2 2 10.00 10.00 3 8 12.00 32.00 Doctors advice and they were low potassium fruits To reduce potassium content To raise protein level % Dialytic (n=25) Reasons for inclusion and restriction

1 -

5.00 -

2 5

8.00 20.00

* Boiling vegetables and discarding the cooked water F=Frequency

4.7 BIOCHEMICAL PARAMETERS

Biochemical profile of the chronic renal failure have been recorded in Table 21. Mean biochemical parameters of dialytic patients were significantly higher compared to predialytic subjects for serum albumin (3.670.58 Vs 2.900.73 g/dl), serum total protein (6.781.60 Vs 5.531.41 g/dl), serum creatinine (7.143.57 Vs 3.041.04 mg/dl) and serum urea (113.2064.12 Vs 111.1048.83 mg/dl). The mean lipids were in normal range for predialytics and dialytics (total cholesterol 145.23 Vs 160.75 mg/dl, TG 121.14 Vs 60.08 mg/dl, HDL-C 34 Vs 32 mg/dl and LDL-C 103 Vs 116.73 mg/dl for predialytics and dialytics, respectively).

Table 21. Biochemical profile of selected subjects Parameters Serum protein status (g/dl) Albumin Total protein Hemoglobin Creatinine (mg/d) Urea (mg/d) Lipids (mg/dl) Total cholesterol Triglycerides HDL-cholesterol LDL-cholesterol **Significant at 1 per cent level *Significant at 5 per cent level 12 12 12 12 145.2350.82 121.14118 34.597.48 103.5822.31 24 24 24 24 160.7560.67 60.0820.35 32.006.13 116.7359.36 0.83NS 1.78* 1.04
NS

Frequency

Predialytics

Frequency

Dialytics

t value

Normal range

15 10 20 20 20

2.900.73 5.531.14 8.612.49 3.041.04 111.1048.83

23 6 16 19 20

3.670.58 6.781.60 8.601.76 7.143.57 113.2064.12

3.44** 1.58
NS

3.5-5 6.5-8

0.01NS 4.81** 0.11NS 0.5-1.5 10-45

130-250 50-170 30-75 100-150

0.96NS

4.7.1 Biochemical profile of dialytic patients before and after dialysis

Table 22 presents the biochemical profile of dialytic patients before and after initiation of dialysis. After dialysis there was a significant lowering in the mean serum creatinine (10.665.43 Vs 7.143.57 mg/dl) and urea (153.0766.19 Vs 113.2064.12 mg/dl) levels. Even after lowering these levels did not reach in the normal range. The mean total cholesterol, LDL-cholesterol and serum calcium levels increased after dialysis (150.7131.75 Vs 160.7560.67 mg/dl, 96.1935.58 Vs 116.7359.36 mg/dl and 7.851.21 Vs 8.190.78 mg/dl, respectively) but there was a decline in the serum level of triglycerides, HDL-cholesterol and phosphorus (80.6733.44 Vs 60.0820.35 mg/dl for triglycerides, 38.3926.4 Vs 326.13 mg/dl for HDL-C and 6.173.42 Vs 5.341.33 mg/dl for phosphorus, respectively). However, the differences in the means were not significant. The mean values of serum albumin, total protein and hemoglobin were almost similar even after dialysis.

4.7.2 Classification of selected subjects based on protein and hemoglobin status

Classification of chronic renal failure subjects based on protein and hemoglobin status has been documented in Table 23. Majority of the subjects in predialytic groups were deficient for serum albumin (46%), serum total protein (40%) and hemoglobin level (92.4% of males and 57.1% of females). Whereas, equal number of patients had low and acceptable levels of serum albumin (26.6% each) and total protein (30% each). None of the males had acceptable hemoglobin level whereas only one female recorded acceptable level. On the other hand, majority of the dialytic subjects had acceptable levels of serum albumin (73.9%) and total protein (50%) but none had acceptable hemoglobin level. None had deficient serum albumin status and 33.3 per cent had deficient serum total protein. All the males were deficient for hemoglobin and there was an equal number of female falling in deficient and low categories for the same (50% each). Higher percentage of dialytics had acceptable serum albumin and total protein compared to predialytics (73.90 Vs 26.60% and 50 Vs 30% for serum albumin and total protein, respectively) but none of the dialytic patients had acceptable hemoglobin status when compared with predialytics.

4.7.3 Classification of selected subjects based on lipid profile

Table 24 reflects the classification of chronic renal failure subjects based on lipid profile. Majority of the subjects in the both groups were having desired levels of cholesterol, LDL-cholesterol and triglycerides (91.66 and 87.5% for total cholesterol, 91.66 and 75% for LDL-cholesterol and 83.33 and 100% for triglycerides for predialytics and dialytics, respectively). Among predialytics, half the subjects belonged to risk group for HDL-cholesterol (50%) followed by the borderline category (41.66%) and the rest belonged to the desirable group (8.33%). None of the predialytics were in the risk group for total cholesterol, LDLcholesterol and triglycerides. On the other hand, majority of the dialytics were classified in the risk group for HDLcholesterol (70.83%) and rest were falling in borderline category. Equal number of dialytics belonged to the borderline and risk categories for LDL-cholesterol and only 12.5 per cent were classified in the risk category for total cholesterol. Higher percentage of predialytics had desirable status for total cholesterol and LDL-cholesterol when compared to the dialytics (91.66 Vs 87.5% for total cholesterol and 91.66 Vs 75% for LDL-cholesterol respectively). However, triglycerides level was desirable in all the dialytics but only 83.33 per cent had desirable level of triglycerides in predialytics.

Table 22. Biochemical profile of dialytic patients before and after dialysis Parameters Serum protein status (g/dl) Albumin Total protein Hemoglobin Creatinine (mg/dl) Urea (mg/dl) Lipids (mg/dl) Total cholesterol Triglycerides HDL-cholesterol LDL-cholesterol Serum electrolytes (mg/dl) Calcium Phosphorus 11 9 7.851.21 6.173.42 7 7 8.190.78 5.341.33 0.73 0.66
NS NS

Frequency

Prior to dialysis

Frequency

After dialysis

t value

Normal range

9 8 23 25 22

3.560.25 6.031.73 8.191.86 10.665.43 153.0766.19

23 6 16 19 20

3.630.58 6.781.00 8.601.73 7.143.57 113.2064.12

0.75

NS

3.5-5 6.5-8

0.85 NS 0.70
NS

2.59** 2.08*

0.5-1.5 10-45

7 7 7 7

150.7131.75 80.6733.44 96.1935.58 38.3926.49

24 24 24 24

160.7560.67 60.0820.35 116.7359.36 32.006.13

0.58 1.55 0.63 1.13

NS NS NS NS

130-250 50-170 100-150 30-75

8.5-10.5 2.5-4.5

NS-Non-significant, **-Significant at 1 per cent level, *-Significant at 5 per cent level

Table 23. Classification of selected subjects based on protein and hemoglobin status Predialytics Parameters (g/dl) n Deficient F Serum albumin Serum total protein Hemoglobin Male Female F=Frequency (g/dl) Serum protein Serum albumin Hemoglobin Deficient <6 <2.8 Low 6-6.4 2.8 to 3.4 12 to 13.9 10 to 11.9 Acceptable 6.5 3.5 14.0 12.0 15 10 20 13 7 12 4 92.40 57.10 1 2 7.60 28.57 1 14.28 7 4 % 46.00 40.00 F 4 3 Low % 26.60 30.00 Acceptable F 4 3 % 26.60 30.00 23 6 16 14 2 14 1 100.00 50.00 1 50 n F 2 Deficient % 33.33 F 6 1 Dialytics Low % 26.00 16.66 Acceptable F 17 3 % 73.90 50.00

<12.0 Male <10 Female Gopaldas and Seshadri (1987)

Table 24. Classification of selected subjects based on lipid profile

Predialytics (n=12)

Dialytics (n=24)

Parameters (mg/dl)

Desirable

Borderline

Risk

Desirable

Borderline

Risk

Total cholesterol

11

91.66

8.33

21

87.50

12.50

LDL-C

11

91.66

8.33

18

75.00

12.5

12.50

HDL-C

8.33

41.66

50

26.16

17

70.83

TG F Frequency (Anon., 1996) Lipids Total cholesterol LDL-C HDL-C TG

10

83.33

16.66

24

100

Desirable <200 <130 >45 <150

Borderline 200-240 130-159 35-45 150-200

Risk >240 >160 <35 >200

4.8

CLASSIFICATION OF THE SUBJECTS BASED ON ASSOCIATED CONDITIONS FOR PLANNING INDIVIDUAL DIETS

Classification of predialytics was based on Glomerular Filtration Rate (GFR) and associated disorders for the purpose of planning the diets. The patients were classified based on low and high GFR and the associated conditions. All the patients of predialysis with the GFR ( 25 ml/min) were hypertensive (35%). In the GFR range of 26-70 ml/min, equal number of subjects had kidney disease alone, hypertension alone and IDDM with hypertension (15% each). Two renal patients were suffering from NIDDM with hypertension and one patient each was categorized as NIDDM alone and proteinuria with hypertension (Table 25). Majority of the dialytics were classified as hypertensive (56%) followed by IDDM with hypertension (16%). Other associated disease conditions had equal percentage of subjects (4% for each) which included kidney disease alone, hypertension with hepatitis, NIDDM with hypertension, NIDDM with hepatitis and hypertension, IDDM alone and hepatitis alone.

4.9 DIETARY GUIDELINES FOR CRF PATIENTS

Diet guidelines for five CRF patients have been presented here, the remaining have been presented in Appendix II. The exchanges for diet plans have been presented Appendix III. Case I: Hemodialytic with hypertension Age Height Actual weight Ideal weight Food habit Activity pattern Energy : : : : : : : 45 years 157 cm 40 kg 57 kg Non-vegetarian Sedentary worker (655 + 9.6 x body weight + 1.8 x height 4.7 x age) x 1.2 1528-1995 Kcal/day 1.2 g/kg ideal body weight/day=68g/day (18% of 1528 Kcal/day) 50-60 per cent of 1528 Kcal 191-229 g/day 22-32 per cent of 1528 Kcal 37-54 g/day 1-1.5 g/day 1.5-2.7 g/day

Range of energy Protein

: :

Carbohydrate

Fat

Sodium (g/d) Potassium (g/d)

: :

50 per cent of protein should be of high biological value Fluid intake : 750-1500 ml/day

Meals Breakfast

Recipes Wheat roti Egg omlet

Amount 1 no 1 no

Ingredients Wheat flour 30 g Egg white of 2 eggs, onion 25g, oil tsp Sago 15 g, potato 50 g, oil tsp Milk 100 ml, sugar 1 tsp Sorghum roti 30 g Redgram dhal 30 g, onion 50 g, oil tsp Amaranthus 100 g, onion 50 g, Oil tsp Apple 50 g, Papaya 25 g, guava 25 g, milk 100 ml, sugar 2 tsp Sago 15 g, milk 100 ml, sugar 2 tsp, oil tsp Oil tsp, apple 100 g Wheat flour 30 g Redgram dhal 30 g, oil tsp Fish 50 g, oil tsp Green papaya 100 g, sugar 1 tsp, oil tsp Milk cup

Sago cutlet Tea Lunch Roti Sambhar

1 no cup 1 no k

Leached amaranthus bhaji Fruit salad

1k

Snacks

Sago paysa

Fruit Dinner Wheat roti Sambhar Fish curry Green papaya halwa Milk 1 katori (k)/1 cup: 200 ml

1 1 k k k

cup

Case II: Hemodialytic with insulin dependent diabetes mellitus and hypertension Age Height Actual weight Ideal weight Food habit Activity pattern Energy : : : : : : : 47 yrs 173 cm 70 kg 73 kg Non-vegetarian Sedentary worker (66 + 13.7 x body weight + 5 x height 6.8 x age) x 1.2 1818-1934 Kcal/day 1.2 g/kg ideal body weight/day =79g/day (17% of 1818 Kcal/day) 50-60 per cent of 1818 Kcal 227-273 g/day Fat : 23-33 per cent of 1528 Kcal 39-56 g/day 1-1.5 g/day 1.5-2.7 g/day

Range of energy Protein

: :

Carbohydrate

Sodium (g/d) Potassium (g/d)

: :

50 per cent of protein should be of high biological value Fluid intake Distribution of energy Breakfast 20 per cent = 364 Kcal/day Lunch 33 per cent = 600 Kcal/day Snacks 10% = 182 Kcal/day Dinner - 33 per cent = 600 Kcal/day Bed time 4 per cent = 73 Kcal/day : 750-1500 ml/day

Meals Breakfast

Recipes Wheat roti Sambhar Egg bhurji Tea Fruits

Amount 1 no k k cup 1 no

Ingredients Wheat flour 40 g Red gram dhal 15 g, oil 1/8 tsp Egg white of an egg, oil tsp Milk 100 ml Apple 100 g Guava 50 g Sorghum flour 60 g Rice 45 g Fish 50 g, onion 25 g, oil tsp Red gram dhal, oil tsp Fenugreek 25 g, oil tsp

Lunch

Roti Cooked rice Fish curry Sambhar Leached fenugreek bhaji Brinjal bhaji Curd

2 no k k k 1/8 k

Brinjal 50 g, oil tsp, onion-20g Curd 50 ml k cup 2 no k k Rice flakes 30 g, oil 1/8 tsp Milk 150 ml Sorghum flour 60 g Rice 45 g Chicken 75 g, onion 25 g, coriander 25 g, oil tsp Cucumber 50 g, oil 1 tsp Curd 50 ml Milk 100 ml

Snacks

Rice flake Tea

Dinner

Roti Cooked rice Chicken curry

Cucumber Curd Bed time Milk

k k cup

1 katori (k)/1 cup: 200 ml

Case III: Predialytic with hypertension (GFR 21 ml/min) Age Height Actual weight Ideal weight Food habit Activity pattern Energy : : : : : : : 30 yrs 162 cm 57 kg 62 kg Non-vegetarian Moderate worker (66 + 13.7 x body weight + 5 x height 6.8 x age) x 1.2 1892-1981 Kcal/day (Actual body weight-ideal body weight) 0.3 g/kg/day (18 g/day = 3.75% of 1981 Kcal) 50-60 per cent 248 297 g/day 36 per cent (1892-1981 Kcal) 76 79 g/day Sodium (g/d) Potassium (g/d) : : 1-3 g/day 2 g/day

Range of energy

Protein Carbohydrate

: :

Fat

Note: Protein should be from vegetable sources, 18-20 g of renal resource powder as essential amino acid supplement and 3 g of medium chain triglycerides tablets can be given.

Meals Breakfast

Recipes Sorghum roti Knol khol bhaji Potato bhaji Carrot halwa Tea 1

Amount

Ingredients Sorghum flour 30 g Knol khol 50 g, oil 2 tsp, Potato 50 g, onion 50 g, oil 1 tsp Carrot 100 g, sugar 2 tsp, oil 2 tsp Milk 25 ml, sugar 1 tsp Rice 40 g Red gram dhal 15 g, radish 25 g, onion 25 g, oil 2 tsp Potato 100 g, fenugreek 25 g, onion 50 g, oil 4 tsp Guava-50 g, grapes-50 g, sugar 2 tsp Rice flakes 30 g, oil 1 tsp Banana 100 g, Milk 25 ml, sugar 1 tsp

k k k cup k k

Lunch

Cooked rice Sambhar

Potato fenugreek bhaji Fruit salad Snacks Rice flakes Banana milk shake Dinner Fried rice Sago cutlet Onion bhaji Fruit salad 1 katori (k)/1 cup: 200 ml

k k

K 2

Rice 50 g, oil 1 tsp Sago 30 g, potato 100 g, oil 4 tsp Onion 100 g, oil 1 tsp

Apple 50 g, papaya 50 g, sugar 2 tsp

Case IV: Predialytic (GFR 41 ml/min) Age Height Actual weight Ideal weight Food habit Activity pattern Energy : : : : : : : 28 150 cm 35 kg 50 kg Non-vegetarian Sedentary worker (655 + 9.6 x body weight + 1.8 x height 4.7 x age) x 1.2 1528-1750 Kcal/day 0.6 g/kg ideal body weight/day = 30 g/day 50-60 per cent of 1528 Kcal 191-229 g/day 32 per cent of 1528 Kcal = 54 g/day 1-3 g/day 2 g/day

Range of energy Protein Carbohydrate

: : :

Fat Sodium (g/d) Potassium (g/d)

: : :

2/3 of total protein should be of high biological value Fluid intake Meals Breakfast Recipes Sago upma Omlet Fruit Tea Lunch Fried rice Ridge gourd chutney Snacks Sago cutlet Fruit Tea Dinner Chapati Fish curry Butter ball 1 katori (k)/1 cup: 200 ml : Depending upon urine output (2000 ml/day) Amount k cup 1k 2 tsp 2 k cup 1 1k 1 Ingredients Sago 30g, onion 50 g, oil 1 tsp Egg white of egg, onion 50 g, oil 1 tsp Apple 50 g Milk 100 g, glucose 2 tsp Rice 60 g, onion 100 g, oil 1 tsp Ridge gourd 25 g, oil- tsp Sago 30 g, onion 100 g, oil 1 tsp Papaya 100 g Milk 100 ml, glucose 2 tsp Refined wheat flour 30 g, oil tsp Fish 50 g, coriander leaves 25 g, oil 1 tsp Butter 8 g (without salt), glucose 2 tsp

Case V: Predialytic with hypertension (GFR 38 ml/min) Age Height Actual weight Ideal weight Food habit Activity pattern Energy : : : : : : : 45 yrs 155 cm 52 kg 55 kg Non-vegetarian Moderate worker (66 + 13.7 x body weight + 5 x height 6.8 x age) x 1.2 1464-1546 Kcal/day 0.6 g/kg/day = 33 g/day =9 per cent of 1464 Kcal 50-60 per cent of 1464 Kcal/d 183 220 g/day 31 per cent of 1464 Kcal/d = 50 g/day 1-3 g/day 2 g/day

Range of energy Protein Carbohydrate

: : :

Fat Sodium (g/d) Potassium (g/d)

: : :

2/3 of total protein should be of high biological value Fluid intake : Upto 2000 ml/day depending on urine output

Meals Breakfast

Recipes Onion paratha Fruit Tea

Amount 1 cup 2 k k cup k cup 2 k k cup cup

Ingredients Wheat flour 45 g, onion 25 g, oil 1 tsp Apple 25 g Milk 100 ml Sorghum flour 70 g egg white of energy, onion 50 g, oil 1 tsp Fenugreek leaves 25 g, onion 50 g, oil 2 tsp Milk 100 ml Rice flakes 30 g, oil 1 tsp Milk 50 ml Sorghum flour 70 g egg white of energy, onion 50 g, oil 1 tsp Fenugreek leaves 25 g, onion 50 g, oil 2 tsp Curd 50 ml Ragi flour 10g, milk 100 ml

Lunch

Roti Egg bhurji Leached fenugreek bhaji Milk

Snacks

Rice flakes Tea

Dinner

Roti Egg bhurji Leached fenugreek bhaji Curd Ragi ganji

1 katori (k)/1 cup: 200 ml

V. DISCUSSION
Chronic renal disease, a component of non-communicable disease is gaining ground throughout the world, in both developed and developing countries. The incidence of chronic renal disease is increasing at an alarming rate in India. Malnutrition is a relatively common problem in chronic renal failure patients which can be secondary to poor nutrient intake, to increased losses and/or to an increase in protein catabolism. The sequelae of malnutrition are numerous and include increased mortality and hospitalization rates, impaired wound healing, increased susceptibility to infection, malaise, fatigue and poor rehabilitation. Thus nutrition therapy for kidney disease is required as it is another side of medical care for the patients with progressive as well as end stage renal disease. Nutritional management is multifaceted and includes not only diet education but also nutritional assessment in terms of patients interview to know the symptoms of onset of disease, with a view to ascertaining their causes, assessment of food intake, physical examination including anthropometry and laboratory tests. Conversely, the nutritional assessment has started gaining importance all over the world. Hence, the present study on nutritional status of renal patients was conducted and suitable dietary guidelines were prescribed. The salient results of the study have been discussed in this chapter.

5.1 HEALTH AND CLINICAL STATUS OF CHRONIC RENAL FAILURE PATIENTS

Chronic Renal Failure (CRF) is irreversible loss of renal function. The etiologies of CRF are many. Diabetes mellitus is the foremost cause for the CRF, affecting the glomeruli, vasculature and tubulointerstitial compartment. The pathogenesis of diabetic nephropathy is undoubtedly multifactorial and includes hemodynamic alterations, level of glycemic control, genetic predisposition and race. One of the most important factors in the management of diabetic renal disease is the control of hypertension, which may be a cause in itself causing intraglomerular destruction. Another cause is glomerular disease which may present clinically as acute glomerulonephritis, nephrotic syndrome, or asymptomatic proteinuria or hematuria or both, which in long run can cause chronic glomerulonephritis. Chronic tubulointerstitial nephritis is another major cause refers to a group of disorders characterized by inflammation, cellular infiltration and fibrosis of the renal tubules and interstitium. Urinary tract infection known as chronic pyelonephritis and polycystic kidney disease that occurs due to genetic disorder have also been seen as reasons of chronic renal disease. In the present study, chronic glomerulonephritis was the major etiology for CRF in 40 per cent subjects in each group followed by diabetes mellitus (30% in each group) and chronic pyelonephritis (25% in dialytics and 12% in predialytics) (Fig. 1). Prakash et al. (2004) also reported diabetes mellitus as the main cause of chronic renal failure followed by chronic glomerulonephritis. In another study, Schneeweins et al. (1990) found chronic glomerulonephritis, chronic pyelonephritis, polycystic kidney disease and hemolytic uremic syndrome as the etiologies of CRF in 15 patients. Rao and Coworker (1988) found 26 per cent of the NIDDM subjects with persistent proteinuria. As the disease progresses there is lowering in the Glomerular Filtration Rate (GFR) which is matched by a proportionate decline in tubular function and leads to often nonspecific initial symptoms like edema, anorexia, oliguria, frequent urination and nausea with vomiting. In the present study, edema (84.44%), followed by breathlessness (82.22%), anorexia (66.66%) and oliguria (73%) were the classic symptoms at the time of onset of the disease, as reported by the CRF subjects (Table 4). The cause for edema and oliguria may be due to impaired ability to excrete because of defective tubular function resulting in an overt expansion of the plasma and extracellular fluid volumes and edema. Shortness of breath may indicate congestive heart failure, anaemia or metabolic acidosis. Anorexia points to advanced uremia.

40

Predialytics patients Dialytics patients

35

30

25

20

15

10

0 Di bet es mel us a t i l Hyper t en si n o Chr on i c gl mer ul n ephr i i o o ts Chr on i c t ubul i t er st i i l on ta n ephr i i ts Chr on i pyel n ephr i i Fami l an d cyst i r en al Chr on i obst r uct i e c o ts l i a c c v di ease s n ephr opat hy

E t i ol ogy

Fi g. 1 . E t i ol ogy of c hr oni c r e na l f a i l ur e i n t he s e l e c t e d s ubj e c t s

Fig. 1. Etiology of chronic renal failure in the selected subjects

Plate 3. Edema

Plate 4. Hemodialytic patient

Further progression of disease, characterized by sharp decline in the GFR leads to appearance of clinical signs in the patients. In the present study, pallor of eyes and nails were seen in all the dialytics and in few predialytics characterized by yellow colouration of the eyes and nails is due to accumulation of urochrome pigment. Excoriation due to pruritus was also a striking feature, found among half of the patients in both the groups, causing abrasion of the skin due to itching. The above symptom observed is due to inability of the kidney to excrete some unknown substances that accumulate in the body and cause abrasion of the skin due to pruritus. Restless leg syndrome was also reported by few CRF patients marked by an intolerable creeping and internal itching sensation occurring in the lower extremities. It is attributed to carnitine deficiency. A further decline in GFR leads to diminished ability of the kidney to concentrate or dilute the urine or to conserve or eliminate acid, sodium, potassium and other electrolytes leading to complications of CRF in advanced renal disease. In the present study, majority were found, having hyperphosphatemia (66.66%) and hypocalcemia (54.54%) (Table 7). This occurs due to losses of vitamin D and vitamin D binding protein and when there is an impaired production of 1,25 dihydroxy cholecalciferol, hyperphosphatemia and chronic metabolic acidosis occurs. Hyperphosphatemia also occurs due to decreased renal excretion of phosphorus in renal insufficiency or when tubular reabsorption of phosphorus is increased in hypoparathyroidism. Similar findings have been reported by Goldstein et al. (1989) who observed the importance of the low blood levels of 25(OH)D3 in the etiology of the hypocalcemia of the nephrotic patients. According to our observations, hyperkalemia was present in 53.33 per cent of the patients and only a few had hypokalemia (13.33%). This is due to imbalance in acid-base balance that affects the serum potassium primarily by altering the renal potassium excretion. Metabolic acidosis promotes hyperkalemia whereas alkalosis leads to hypokalemia. Hyponatremia was seen in 12.5 per cent of the cases in the study. It occurs by excessive water with normal renal function or by normal solute free water with decreased renal diluting capacity. Inspite of existing malnutrition, based on the anthropometric measurements (Table 11) waist to hip ratio showed that 11 dialytics and seven predialytics were having abdominal obesity in this present study. Nevertheless the lipid profile, also warned that 12.5 per cent of dialytics had high risk level of total cholesterol and HDLcholesterol (70.83%) whereas 50 per cent of predialytics were in risk category for HDLcholesterol (Table 24). These abnormalities could be a major contributing factor for the development of cardiovascular disease. Bhimo et al. (2003) found that high degree of cardiovascular complications was due to dyslipidemia in CRF patients i.e. high cholesterol, high triglyceride and low HDLcholesterol. But our findings showed normal levels of triglycerides in predialytic patients and significantly lower value of triglycerides in dialytic patients. However, HDL levels were touching the lower limit of normal range. The reason for this significantly low value of triglycerides may be due to dialysis process. Similar result was found by Parija et al. (1997) wherein triglyceride levels of renal patients decreased with increase in the years of dialysis. Quality of life can be improved and renal disease can be prevented with certain modifications in the life style such as in food intake, regular exercise and regular intake of prescribed medicine. In the present study predialytics and dialytics avoided certain foods such as coconut water and banana and restricted water intake, salty foods and included low potassium foods and high biological value protein (Table 20). The observed modifications in diet was due to the advice of physicians and patients acquired knowledge regarding certain food items or due to exposure to literature or discussions. These modification in the diet are highly useful in the management of the renal disease and further prevention of complications. Among the subjects in this study, majority had no vices and alcoholism and tobacco chewing was seen in few cases (Table 8). The less number of subjects with vices observed in the present investigation may be due to medical advise or awareness regarding the ill effect of vices and cultivating good habits. Shyam and Sreenivas (2005) have reported that old age

together with unhealthy diets, tobacco usage, alcoholism, obesity and sedentary life styles is contributing to the increase in chronic diseases. Exercise improves the general well being. Five predialytics and 13 dialytics were doing regular exercise (Table 9). Exercise improves the glycemic control in diabetic renal patients, reduces the cardiovascular risk and relieve the pain from muscle cramps, during the dialysis process.

5.2 NUTRITIONAL STATUS OF CHRONIC RENAL FAILURE

In the present study the triceps skin fold thickness (TSF), Mid Arm Muscle Circumference (MAMC) and Mid Upper Arm Circumference (MUAC) were lower in predialytics compared to the dialytics and NCHS standard (Tables 12, 13, 14). However, for each measurement, the dialytic subjects had lower mean values compared to the NCHS standards. Higher number of dialytics were underweight compared to the predialytic subjects (Table 11). From the documented biochemical parameters it was evident that serum albumin and total protein levels were lower in predialytics compared to the dialytics. But in the dialytic subjects these values were touching the lower limits of normal reference (Table 21). The mean values of hemoglobin were low in both the groups (8.61 Vs 8.60 mg/dl) (Table 21). All the subjects in dialytics and majority of subjects in predialytics belonged to the deficient group with respect to hemoglobin status (Fig. 2). The reasons for higher mean anthropometric measurements and biochemical parameters in dialytic subjects compared to the predialytics in the present study may be due to the liberal food intake (Table 15) and higher intake of nutrients such as energy, protein, carbohydrates and fats (Table 16). Adequate dialysis improves appetite with subsequent increase of protein and calorie intake leading to better nutritional status of dialytics. Similar results have been observed by Schneeweiss et al. (1990) who found significantly lower MUAC in predialytics compared to the dialytics. Guarnieri et al. (1980) have noted lower values of MAMC, serum total protein and albumin in dialytic patients compared to reference standards. Cano et al. (1990) postulated a decrease in body weight of 10 per cent, a loss in MUAC of 15 per cent and reduction in TSF of 35 per cent in patients receiving hemodialysis. Further, schneeweiss et al. (1990) reported that anthropometric measurements of both dialytics and predialytic were lower than the controls with respect to the body weight. MUAC was significantly lower in predialytics, whereas TSF was lower in dialytics. The lower anthropometric and biochemical values in dialytic subjects compared to the NCHS standards in the present study may be due to lower intake of food because of anorexia which is caused by uremic toxicity, medicinal intake, emotional depression, intercurrent illness and the dialysis process. Patients are often starved in preparation for diagnostic procedures or because of gastrointestinal disorder. The low serum albumin and total protein levels in the predialytics compared to the dialytics in the present study may be due to insufficient intake of high biological value protein and calories by this group (Table 15). But in our study the dialytics consumed high biological value proteins. This may be the reason for better protein status in terms of serum albumin and total protein. But still the values of dialytic patients were not comparable to the normal values, this may be due to the loss of amino acids in the dialysis process. The results are in agreement with that of Giordano et al. (1973) who have concluded that there is a need for protein, primarily of high biological value for the CRF patients to prevent protein malnutrition. The low values for the hemoglobin in both the groups in the present study may be due to the progress in the kidney disease leading to decreased production of erythropoietin hormone. Iron deficiency also occur when intestinal iron absorption is impaired and substantial blood loss occurs in CRF patients. Frequent blood collections for laboratory measurements in case of CRF patients, the residual blood volume in the dialyzer may be the causes for this. Similar results have been reported by Kluthe et al. (1978).

Fig. 2. Classification of selected subjects based on protein and hemoglobin status

Both dialytic and predialytics (32 Vs 25%) belonged to underweight group indicating malnutrition in the present study; this may be due to the constant restriction of food due to monotony of diets, low food intake in terms of energy and proteins, mental depression and anorexia. The reasons for malnutrition may be complex and related to loss of nutrients during dialysis, altered metabolic requirement. Guarnieri et al. (1980) have reported similar reasons for the cause of malnutrition in CRF. Bhimo et al. (2003) have reported that with the increase in the serum creatinine, the hemoglobin levels decreases in the CRF patients. In the present study the mean serum creatinine levels were found to be higher in dialytics compared to predialytic (7.143.57 Vs 3.04 0.04 mg/dl). However, these values were found to be higher than the normal range. So this may have led to the low hemoglobin status.

5.3 DIETARY THERAPY IN CHRONIC RENAL FAILURE (CRF)

There have been rapid advances in the therapy of CRF along two lines. The development of regular dialysis and transplantation on one hand and nutritional support therapy on the other. The optimal dietary management of dialytic patient is very different from optimal nutritional regimen in predialysis phase. It is also clear that it is not possible to revert the dietary therapy after chronic dialysis is constituted, because renal function has generally fallen to such a level that it is no longer effective. The diet therapy offers a substantial prospect of arresting the disease in the predialysis phase of renal disease in a large fraction of patients when the serum creatinine levels range from 2 to 6 mg/dl. Nutritional therapy when properly applied reduce progressive protein depletion and malnutrition and these patients are better off nutritionally when compared to their counterparts of comparable severity on dialysis. Thus conservative management can extend the dialysis in CRF patients. In the present study the dietary guidelines were formulated for 20 predialytics (Table 25). Model diet plans have been presented in Plates 5 and 6. Majority of the predialytics i.e. 13 per cent belonged to higher GFR category (26-70 ml/min) and were prescribed 0.6 g protein/kg/d. The patients who were having low (GFR 25 ml/min) were asked to consume 0.3 g protein/kg/d along with 18-20 g of essential amino acids supplements (EAA) renal resource. A similar prescription for protein was reported by Frohling et al. (1980) who substituted ketoanalogues in place of EAA with low protein diet is due to the inability of the kidney to eliminate nitrogenous wastes. Patients with renal failure accumulate nitrogenous wastes and inorganic ions, resulting in clinical and metabolic disturbances characteristic of uremia. Limiting dietary proteins can ameliorate many uremic symptoms and metabolic complications of CRF (eg. Secondary hyperparathyroidism and metabolic acidosis). The protein prescribed for the patient suffering from proteinuria was on gram to gram basis (0.6 g/kg/d + protein lost in the urine). The energy prescription for CRF patients ranged from 25-35 Kcal/kg/d and was based on ideal body weight, age and activity pattern, since this level of energy is needed to maintain neutral or positive nitrogen balance and to spare the proteins. The carbohydrates given constituted 50-60 per cent of the total energy and the rest was given through fat (40%). The simple carbohydrates such as sugar, sweets like halwas prepared from papaya, carrot, bottlegourd was included to increase the intake of sugar and glucose in the diet. In diabetic patients the complex carbohydrates in the form of rotis, chapaties, pulses and fiber in the form of salad and admissible fruits were included. The quantities of fats and oils included were higher since higher energy was coming from non-protein sources. So the medium chain triglycerides were prescribed to these subjects to improve the palatability and assimilation.

Plate 5. Model diet plan for a predialytic non-diabetic patient with GFR ml/min

Plate 6. Model diet plan for a predialytic non-diabetic patient with GFR 26-70 ml/min

Plate 7. Model diet plan for a hemodialytic patient

Plate 8. Model diet plan for a hemodialytic diabetic patient

As renal insufficiency progresses, both glomerular filration rate and fractional reabsorption of sodium fall progressively. However, in advanced renal failure the ability to excrete sodium is reduced hence sodium and water intake are restricted. Unrestricted sodium intake accentuates hypertension and precipitate congestive heart failure. So in the present study 1-3 g sodium and upto 2000 ml water was suggested depending on urine output. Major route for potassium excretion is kidney. In renal failure, potassium retention occurs leading to hyperkalemia, so potassium intake was restricted to 2 g/d in the predialytics. The low potassium fruits were selected and leaching of vegetable (by boiling in water and discarding the water) was suggested. In the CRF patients on hemodialysis, there is a high prevalence of protein energy malnutrition. The subjects lose aminoacids, water soluble vitamins and essential nutrients in the dialysate, contributing to impaired nutritional status. Therefore, in the present study about 30-35 Kcal of energy of ideal body weight and 1.2 grams of protein were prescribed to the dialytics. The model diet plans have been presented in Plates 7 and 8. High biological value foods such as egg, chicken and fish in non-vegetarians and soybeans and milk in vegetarian were prescribed. The sodium requirement prescribed to the dialytic patients was 1-1.5 g. The subjects were asked not to eat salt on table. The low potassium fruits and leaching of vegetable was suggested. The carbohydrate intake prescribed was 50-60 per cent of the total energy and 25-35 per cent was coming from fats and oils. In general the diets of the dialytic subjects were more flexible compared to predialytics due to the higher amount of proteins. Food high in fiber were prescribed with more caution in case of diabetic renal patients, because food higher in fibre are often high in potassium and phosphorus.

In conclusion
The nutritional status of predialytics and dialytics in terms of anthropometric measurements and protein status was lower compared to the standards. However, predialytics were having lower values of anthropometric measurements and protein status compared to dialytics. The dietary intakes and the nutrient intake of predialytics were lower than the dialytics and majority of predialytics and dialytics had low adequacy for energy, protein, carbohydrates and fat. The foremost cause of renal disease among CRF patients was glomerulonephritis followed by diabetes mellitus and chronic pyelonephritis. The prevailing complications of CRF were anaemia followed by hyperphosphatemia, hypocalcemia, hyperkalemia, hypokalemia and hyponatremia. Serum creatinine and urea levels were higher in dialytics than in predialytics but were beyond the normal limits in both the groups. Suitable diet guidelines were formed for all the predialytics and dialytics.

Future line of research

1. To study the progression of cardiovascular disease in chronic renal failure 2. Formulation of designer foods for different levels of Glomerular Filtration Rate 3. To study the impact of dietary modification on progression of chronic renal failure

VI. SUMMARY
An investigation on nutritional status and dietary guidelines of predialytic and hemodialytic patients was undertaken during 2005-06. The patients were from Dialysis unit, in and out patient wards of Karnataka Institute of Medical Sciences (KIMS), Hubli, Karnataka. The general information, dietary and life style pattern including prevalent vices and exercise behavior, clinical and health status of the subjects including symptoms and signs were recorded by using pre-tested questionnaire. Etiology of the chronic renal disease, complications and biochemical parameters were documented from the case files of the patients. Anthropometric measurements such as height, weight, waist and Hip circumference, MUAC and TSF and dietary intakes were assessed by 3 days 24 hours recall. The salient findings of the study are summarized below : Among 20 predialytic patients 65 per cent were males and 35 per cent were females. Like wise in 25 dialytic subjects 84 per cent were males and rest were females. Most of the subjects in both the groups belonged to the age group of 41-60 years. Majority of the predialytic patients had primary school level education followed by almost equal number in college level and illiterate category. In dialytic group most of them had college level education followed by high school level education. In both the groups maximum were Hindus. Eighty-five per cent of predialytic and 88 per cent of dialytic subjects were non vegetarians. Majority were married in both the groups and had medium size family. In majority of the subjects among two groups kidney disease started within two years (80% and 60% in predialytics and dialytics, respectively). Majority of the dialytic patients started undergoing dialysis between 1-24 months (84%) at the time of investigation and mostly had hypertension in both the groups (47.00% and 60.80% in predialytics and dialytics, respectively) followed by hypertension and diabetes both. The most prevailing etiology for chronic renal failure was chronic glomerulonephritis (40% in each group) followed by diabetes mellitus and chronic pyelonephritis. All the CRF patients were using medications and supplements of iron, calcium and B-complex. Majority of the patients had edema (84.44%) followed by breathlessness (82.22%) oliguria, anorexia, headache, vomiting, nocturia, and frequent urination were other prevailing symptoms. Hematuria and convulsions were seen in few subjects. Physical examination of subjects showed pallor of eyes followed by edema as the most prevailing signs among the subjects. However all the dialytic patients had pallor of nails (100%) swollen joints and excoriation due to pruritus were other signs found commonly among both the groups. Majority of the predialytic patients were in stage 4 of kidney disease (80%) followed by stage 3 (20%) when classified according to GFR. However, Glomerular filtration rate in all the dialytic subjects was less than 15ml/min indicating stage 5 of the kidney disease. Majority of the subjects were suffering from anaemia (100%) as the most common complication of chronic renal failure, followed by hyperphosphatemia (66.66%) hypocalcemia (54.54%) and hyperkalemia (53.33%). Prevalent vices among both the groups were tobacco chewing (35 and 28%), followed by alcohol consumption (10% and 4%) in predialytics and dialytics, respectively. Higher percentage (52%) of dialytics were doing exercise in comparison with predialytics (35%). Walking was the most common exercise followed by formal physical exercise and yoga. Most of the subjects were regular in doing exercise.

The dialytics had higher mean values for all the anthropometric measurements compared to predialytic. Most of the subjects in both the groups had normal body mass index. Majority of males in both the groups had normal waist to hip ratio however majority of females in both the groups had abdominal obesity (71.43% and 75% in predialytic and dialytic females respectively). The mean triceps skinfold thickness in both the groups of subjects were lower than the NCHS standards. When the predialytics and dialytics were classified age wise the mean triceps skin fold thickness was higher in most of the dialytics compared to predialytics. The mean mid upper arm circumference in both the groups of subjects were lower than the NCHS standards. When the predialytics and dialytics were classified age-wise, the mean mid upper arm circumference was higher in dialytics compared to predialytics. The mean mid arm muscle circumference in both the groups of subjects were less than the standard values for each age group except in one female falling in the age group of 35-44 years, who had higher value. In most of the age groups MAMC was higher for dialytics compared to predialytics. The mean intake of cereals, pulses, other vegetables, roots and tubers, nuts and oil seeds, fruits, fats and oils and sugar were higher in dialytics except for green leafy vegetables and milk and milk products. The difference in mean intake reached significant level for cereals, fruits and fats and oils. Only dialytics consumed nonvegetarian food items. The mean intake of all the nutrients viz., energy, protein, fat, carbohydrate and fiber were significantly higher in dialytics compared to predialytics. The mean intake of all the minerals and electrolytes viz., phosphorus, iron, zinc, magnesium and potassium were significantly higher in dialytics compared to predialytics. The mean intake of all the vitamins, viz., thiamin, riboflavin, niacin, folic acid and ascorbic acid were higher in dialytics compared to predialytics except for total carotene, vitamin A and pyridoxine which were higher in predialytics. Only the difference in mean intake of niacin was significantly higher. Dialytic males had higher mean intake of the food items except for green leafy vegetables and milk and milk products which were higher in predialytic males. The difference in mean intake of cereals, fruits, fats and oils and sugar reached the level of significance. The similar trend was seen in dialytic females except for the mean intakes of other vegetables and sugar which were higher in predialytic females. The intake of green leafy vegetables was seen only in dialytic females whereas none of the females had non-vegetarian food items in either of the group. Majority of the subjects in both the groups had low adequacy for all the nutrients. Higher percentage of predialytic had low adequacy compared to dialytics for energy, carbohydrate, fat, sodium and potassium except for protein. Few predialytics had adequate intake for carbohydrate and protein (15% each) and 35 per cent for sodium but none had adequate intake for energy and potassium. In dialytics, higher percentage had low per cent adequacy for most of the nutrients, followed by adequate and high. When compared according to gender between two groups, higher percentage of predialytic males had low adequacy compared to dialytics for energy, carbohydrate, fat, sodium and potassium except for protein and higher percent of dialytics were having adequate intake for all the nutrients.

Higher percentage of dialytic females were in low adequacy group for carbohydrate, protein and sodium, except fat and all the females in both the groups had low adequacy of energy and potassium. The mean serum creatinine and urea decreased significantly after dialysis but still remained higher than the normal range. The dietary habit revealed that majority of the subjects in both the groups included fruits like apple, guava and pineapple, chicken and fish and leached vegetables as special foods. The foods restricted were water and salty food items. Foods avoided were banana, coconut water and sweet items in case of diabetic renal patients, for management of disease. Majority in predialytics belonged to deficient group with respect to albumin, total protein and hemoglobin but majority of dialytic subjects had acceptable levels for all the proteins except hemoglobin as all had deficient hemoglobin level. The mean serum albumin and creatinine were significantly higher in dialytics compared to predialytics. The mean HDL- cholesterol and triglycerides were higher in predialytics compared to dialytics but the total cholesterol and LDL-cholesterol were higher in dialytics. Higher percentage of dialytics had acceptable serum albumin and total protein (73.9 Vs 26.6% and 50 Vs 30% for serum albumin and total protein, respectively). Maximum number of subjects in both the groups had desirable levels for total cholesterol, LDL cholesterol and triglyeerides. Among predialytic, none were in risk category status for total cholesterol, LDLcholesterol and triglycerides. On the other hand, majority of the dialytic patients were in risk group for HDL cholesterol status (50% and 70.83% in predialytics and dialytics respectively). Higher percentage of predialytics had desirable status for all the lipid profile compared to dialytics except for triglyceride which was good in majority of the dialytics compared to predialytics (100%m 83.33% for triglycerides). All the predialytics having GFR 25 ml/min were hypertensive (35%). In the GFR range of 26-70 ml/min, equal number of subjects had kidney disease alone, hypertension alone and IDDM with hypertension (50% each). Majority of the dialytics were classified as hypertensive (56%) followed by IDDM with hypertension (16%).

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KOPPLE, J.D., 1974, Protein-energy malnutrition in maintenance dialysis patients. The American Journal of Clinical Nutrition, 31: 1544-1557. KOPPLE, J.D., CIANEIARUSO, B. AND BRUNORI, G., 1995, Cross-sectional vision of malnutrition in continuous ambulatory peritoneal dialysis and hemodialysis patients. American Journal of Kidney Disease, 26: 475-486. KOPPLE, J.D., MONTEON, F.J. SHAIB, J.K., 1986, Effect of energy intake on nitrogen metabolism in non-dialyzed patients with chronic renal failure. Kidney International, 29: 734-742. LAZZARI, G. AND BRUNELLI, L.B., 1991, Glycemic control and diabetic complications in patients with type 2 diabetes. International Journal of Diabetes in Developing Countries, 11: 36. LEAN, M.E., HAN, T.S. AND MORRISON, C.E., 1995, Waist circumference as a measurement for indicating need for weight management. British medical Journal, 11: 638-642. MAJI, D., 1998, Diabetic nephropathy. Nidus Diabetology Proceedings, 3: 45. MALLUCHE, H.H., WERNER, E. AND RITZ, E., 1978, Intestinal absorption of calcium and whole-body calcium retention in incipient and advanced renal failure mineral electrolyte. Metabolism, 1: 263-271. MASCHIO, G., TESSITORE, N., ANGELO, A.D., BONUCCI, E., LUPO ANTONIO, VALVO, E., LOSCHIAVA, C., FABRIS, A. AND FIASCHI, E., 1980, Early dietary phosphorous restriction and calcium supplementation in the prevention of renal osteodystrophy. The American Journal of Clinical Nutrition, 33: 1546-1554. MATTACK, M.B., MORRISH, N.J., IBERTI, G., KEEN, H., FITZGERLAND, A.P. AND JACKSON, G., 1992, Microalbuminuria, a risk marker for mortality in diabetes. Diabetes, 4: 736-741. NORBECK, H.E., ORO, L. AND CARLSON, L.A., 1978, Serum lipoprotein concentration in chronic uremia. The American Journal of Clinical Nutrition, 31: 1881-1885. PARIJA, K., GIUNTINI, D., RAIMONDI,A. AND LEVINE, S.E., 1997, Annual Internal Medicine, 87: 659-661. PHILLIPS, M.E., HAVARD, J. AND OTTERUD, B., 1980, Amino-aciduria in chronic renal failure to relationship to vitamin D and parathyroid status. The American Journal of Clinical Nutrition, 33: 1541-1545. PRAKASH, S., PANDE, D.P., SHARMA, S., SHARMA, D., BAL, C.S. AND KULKARNI, H., 2004, Randomized, double-blind, placebo-controlled trial to evaluate efficacy of ketodiet in predialytic chronic renal failure. Journal of Renal Nutrition, 14: 89-96. RAGHURAM, T.C., PASRICHA, S. AND SHARMA, R.D., 1998, Diet and Diabetes, National Institute of Nutrition. RAO, K.V.R., SESHAIAH, V., SEHRAYAN, P., 1988, Observations on compositions in NIDDM. Indian Journal of Public Health, 32(3): 142-147. RUBIN, J., FLYNNN, M.A. AND NALPH, K.D., 1981, Total body potassium a guide to nutritional health in patients undergoing continuous ambulatory peritoneal dialysis. The American Journal of Clinical Nutrition, 34: 94-98. SCHNEEWEISS, B., GRANINGER, W., STOCKENHUBER, F., DRUML, W., FERENCI, P., EICHINGER, S., GRIMM, G., LAGGNER, A.N. AND LENZ, K., 1990, Energy metabolism in acute and chronic renal failue. The American Journal of Clinical Nutrition, 52: 596-601. SHYAM, C. AND SREENIVAS, V., 2005, Chronic kidney disease : a missing component of integrated control of non-communicable disease. Indian Journal of Medical Research, 122: 451-453. SLOMOWITZ, L.A., MONTEAN, F.J. AND GROSVENOR, M., 1989, Effect of energy intake on nutritional status in maintenance of hemodialysis patients. Kidney International, 35: 704-711. STEIN, J., LINDEMAN, R., BARTER, D. AND PEDERSON, J., 1969, Cell metabolism in uremia. The American Journal of Clinical Nutrition, 30: 1627-1634.

TANAKA, Y., YOSHIHITO, A., KENPEI, M., TOMSO, O., TOSHIO, T. AND TYUZO, K., 1998, Role of glycemic control and blood pressure in the development and progression of nephropathy in elderly Japanese NIDDM patients. International Journal of Diabetes in Developing Conditions, 18: 89. WALKER, J.D., BENDING, J.J., DODDS, R.A., MATTOCK, M.B., MURRELLS, T.J., KEEN, H. AND VIBERTI, G.C., 1989, Restriction of dietary protein and progression of renal failure in diabetic nephropathy. The Lancet, 86: 1411-1415. WATHEN, R.L., KESHAVIAH, P., HOMMEYER, P., CADWELL, K., AND COMTY, C.M., 1978, The metabolic effects of hemodialysis with and without glucose in the dialysate. The American Journal of Clinical Nutrition, 31: 1870-1875. YASSINE, P.D.E., HAWTHORNE, V.M. AND HERMAN, W.H., 1991, Natural history and risk factors for rephropathy in NIDDM. International Journal of Diabetes in Developing Countries, 11: 31. ZELLER, K., WHILTKAER, E., SULLIVAN, L., RASKIN, P. AND JACOBSON, H.R., 1991, Effect of restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes mellitus. The New England Journal of Medicine, 324: 78-84.

APPENDIX I
QUESTIONNAIRE
Sl. No. Date of interview Contact address : :

Telephone No. : Dialytic/pre dialytic : Residential status : Rural / Urban Religion : A) I. Basic data 1. Name 2. Age (yrs) 3. Gender Male/Female 4. Education completed 5. Occupation 6. Monthly income of family (per capita) 7. Family size 8. No. of earning members in the family 9. Activity pattern Sedentary worker/Moderate worker/Heavy worker 10. Marital status Married/unmarried/widow(er) II. Clinical and health status 1. Onset of kidney disease: _________ days/month/year 2. First consultation with doctor 3. Was the patient suffering from any other disease/disorder before the onset of kidney disease. Disease/disorder Present/Absent Medication a) Diabetes b) Hypertension c) Any other (specify) 4. What were the symptoms of onset of kidney disease? ( ) Swelling Palpitation Breathlessness Oliguria Hematuria Headache Anorexia Nausea Vomiting Convulsions Loss of consciousness Frequent urination Nocturia Allergy to food (which food) Any other

5. Physical examination of patient Sl. No. 1 2 3 4 5 6 7 Area of examination Eyes Lung Hair Mouth Skin Nails Muscle and skeletal system Signs Pallor Increased rate of respiration Thinning hair Cheilosis Bruising Excoriation due to pruritus Pallor Muscle wasting Restless leg syndrome Carpal tunnel syndrome Inflamed and swollen joint Edema Poor wound healing Present/Absent

Subcutaneous tissue

6. Which type of kidney disease the patient is suffering from* Disease - Glomerular disease including Glomerulonephritis - Autoimmune disease Systemic lupus erythematosus Good pastures syndrome IgA nephropathy - Hereditary nephritis Alport syndrome - Infection related glomerular disease Acute poststreptococcal glomerulonephritis Bacterial endocarditis - Sclerotic disease Glomerulosclerosis Focal segmental glomerulosclerosis - Other glomerular disease Membranous nephropathy *(Anon., 2005a) Cause Diabetes Medication Supplement (mineral/vitamin /herbal)

Autoantibodies

Heredity Infection

Bacterial

Bacterial infection Diabetic nephropathy Systemic disorder or idiopathy Immunoglobulin G and complement C3

7. At which stage of kidney disease the patient is based on GFR ( ) Sl. GFR ml/min Complication in each stage Medications for complication No. 1. 90 or higher 2. 60-89 Osteodystrophy 3. 30-59 Hypocalcemia Malnutrition Anaemia Ventricular hypertrophy Hyper triglyceridemia Hyperphosphatemia Metabolic acidosis Hyperkalemia Uremia

4.

15-29

5.

<15

8. Complications of chronic renal failure Complications Hyponatremia Hypernatremia Hypokalemia Hyperkalemia Anamia Hyper phosphatemia Hypocalcemia Any other III. Life style factors 1. Vices a. Alcohol consumption Yes/No If yes, Sl. Type of alcohol No. 1. Whisky 2. Brandy 3. Beer 4. Wine 5. Country liquor 6. Any other b. Smoking Yes/No If yes, Number c. Chewing habit Sl. No. 1. Tobacco 2. Pan masala 3. Beetle nut 4. Gutakha 5. Any other

Present/absent

Medication

Quantity (ml) or no. of glasses

Frequency

Frequency

Type

Quantity/No.

Frequency

2. Exercise: Does patient do exercise ? Yes/No When initiated Sl. Types of Duration Frequency Regulatory Benefits No. exercise 1 Yoga 2 Meditation 3 Physical exercise 4 Walking 5 Any other B) I. Anthropometric assessment a) Height : ___________ cm b) Weight : ___________ kg c) BMI : ___________ weight in (kgs)/height (m) d) Waist circumference : ___________ cm e) Hip circumference : ___________ cm f) Waist/hip ratio : f) Mid upper arm circumference: ___________ cm g) Triceps skinfold thickness: ___________ cm h) Mid arm muscle circumference: ___________ cm C) Dietary survey 1. Food frequency questionnaire
Food groups Name of the food stuff Type of preparation Rice Dosa Idli Roti Puri Parotha Upma Rot Balls Qty/ mea sure No. of times per day 1 2 3 4 5 AD 1 2 3 4

Who suggested

In one week 5 Once in 15 days O S

Cereals

Rice Wheat flour (sifted/ whole) Sorghum flour (sifted/ whole) Any other Redgram dhal Bengalgram dhal Blackgram dhal Greengram dhal

Pulses & legumes

Green leafy vegetable

Peas Any other Palak

Dhal cooked Sambar Chutney Mixed with vegetable Idli Dosa Wada Sprouted greengram vegetable Any other Bhaji Palak curry Palak dhal bhaji Bhaji Curry Curry Bhaji Bhaji Bhaji Salad Bhaji Bhaji Bhaji Bartha

Methi Amaranthus Cabbage Any other Cauliflower Cucumber Pumpkin Brinjal

Other vegetable

Food groups

Name of the food stuff Any other Potato

Type of preparation

Qty/ mea sure

No. of times per day 1 2 3 4 5 AD 1 2

In one week 3 4 5 Once in 15 days O S

Roots and tubers

Radish

Onion Spring onion Beetroot

Boiled, peeled & prepared Cut and prepared Salad Sambar Curry Salad Bhaji Bhaji Boiled, cooked and prepared Peeled, cut and prepared Cooked on fire Boiled

Sweet potato Any other Apple Grapes Raisins Lemon Tomato

Fruit

With food Salad Curry Bhaji

Pineapple Watermelon Banana Mango

Pulp with sugar or jaggery

Nuts

Orange Papaya Any other Cashewnuts Coconut dry Coconut fresh Groundnut

Chutney Chutney Added in vegetable Chutney Roasted Boiled Fried

Milk and milk products Meat and poultry

Any other Whole milk Low fat milk Curd Chicken Whole egg Curry Bhaji Omlet Curry Fried

Egg white Fish Pork Beef Canned meat Butter Groundnut oil

Fats and Edible oil

Salted Unsalted

Food groups

Name of the food stuff Safflower oil Sunflower oil Soybean oil Ghee Any other Honey Sugar Jaggery Water/day Fruit juices Rice ganji Soup Butter milk Tea Coffee Milkshakes Chocolate shakes Any other Sauce

Type of preparation

Qty/ mea sure

No. of times per day 1 2 3 4 5 AD 1 2

In one week 3 4 5 Once in 15 days O S

Pure CHO

Beverages

Miscellaneous

Soya Tomato Chilli

Jam Pickle Biscuits Bakery products Papad Salted nuts Any other

Cake Puff Biscuits

2. Choices of foods after onset of disease Foods specially included Sl.No. 1. 2. 3. 4. Any other Foods restricted 1. 2. 3. 4.

Reasons

Who suggested

Any other Foods avoided

1. 2. 3. 4.

Any other

3. Choices of food after dialysis Foods specially included Sl.No. 1. 2. 3. 4. Any other Foods restricted 1. 2. 3. 4.

Reasons

Who suggested

Any other Foods avoided

1. 2. 3. 4.

Any other

4. Dietary survey by 3 days recall method For pre-dialytic patient/dialytic patients before dialysis Volu me of Serving the size Reci Ingredien Total raw total katori/sp Meals pe ts amount (g) cooke oons/gla d sses food (ml) One day before dialysis Breakfast Lunch Snacks Dinner Any other On the day of dialysis Breakfast Lunch Snacks Dinner Any other After dialysis Breakfast Lunch Snacks Dinner Any other Salt is added to rice, butter milk or other food on table (Yes/No) If Yes, How much ?

Volume of cooked food consume d (ml)

Raw equivalent of food consume d by responde nt (g)

D) Documentation of biochemical parameters 1. Blood level A. Prior to dialysis 1. Albumin level 2. Creatinine level 3. Triglyceride level 4. Potassium level 5. Sodium level 6. Phosphorus level 7. Glucose level 8. Any other B. After dialysis 1. Albumin level 2. Creatinine level 3. Triglyceride level 4. Potassium level 5. Glucose level 6. Sodium level 7. Phosphorus level 8. Any other

APPENDIX II
Diet plans
Predialytic with GFR-25 ml/min
Case 6 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Bread omlet Sago upuma Tea Fruit Fried rice Fruit salad Sago upuma Fruit salad Tea Sago chapatti Chicken curry Bottle gourd halwa : : : : : : : : : : : 31 yrs 165 cm 54 kg 65 kg Non-vegetarian Sedentary worker 29-35 kcal/kg/day = 1885-2275 kcal/day 0.6g/kg/day = 39g/day = (8% of 1885 kcal/day) 50-60% of 1885 kcal/day (236-283 g/day) 32% of 1885 kcal/day = 67g/day Amount 1 k cup 1 k k k k cup 1 k 1/8 k Ingredients Bread slice 1, egg white of an egg, oil2 tsp, onion-100g Sago-15g, onion-100g, oil-1tsp Milk 100ml, glucose 2-tsp Apple-100 g Rice-30 g, onion-100g, coriander leaves-25 g, oil 2 tsp Guava-50g, pineapple-50g, sugar-1tsp Sago-30g, onion-100g, rice flakes-20 g, oil 2tsp Pineapple-50g, guava-25g, papaya-25 g, sugar-1tsp Milk-100ml, sugar 1tsp Sago-15g, refined wheat flour-30 g, oil 1 tsp Chicken-50g, onion-100g, oil 3 tsp Bottle gourd-25g, sugar-1tsp, oil-1tsp

Lunch

Snacks

Dinner

Predialytic with (GFR-36 ml/min)

Case 7 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

67 yrs 167 cm 64 kg 67 kg Vegetarian Sedentary worker 1472-1636 kcal/day 0.6g/kg/day = 40g/day (11% of 1472 kcal) 56-60% of 1472 kcal/day = 188-221g/day 29-39% of 1472 kcal/day = 47-63 g/day

Meals Breakfast

Recipes Upma Carrot halwa Tea Fruit Mixed chapati Potato fenugreek bhaji Curd rice Sago upma Banana milk shake Tea Mixed chapati Ragi ganji Potato bhaji Green papaya halwa Milk

Amount k k cup 1 k k k cup 1 k k cup

Lunch

Ingredients Samolina-15g, oil tsp Carrot-50g, milk-100 ml, sugar-1tsp, oil-1tsp, oil-1tsp Milk-50 ml, sugar-1tsp Guava-25 g Wheat flour-30 g, soybean flour-15g, oil-1tsp Potato-100g, fenugreek-25g, oil-1tsp Rice-15 g, curd-50ml Sago-15g, oil tsp Banana-25g, milk-50ml, sugar-1tsp Milk-50ml, sugar-1tsp Wheat flour-30g, soybean flour-15g, oil 1tsp Ragi flour-15 g, sugar tsp Potato-75g, onion-25 g, oil 1 tsp Green papaya-50 g, milk-100 ml, sugar-1 tsp, oil/4 tsp Milk 50 ml

Snacks

Dinner

Predialytic with non-insulin dependent diabetes mellitus (GFR-51 ml/min) Case 8 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat : : : : : : : : : : : 68 hrs 170 cm 56 kg 170-100 = 70 kg Vegetarian Sedentary worker 1580 kcal/day 1695 kcal/day 0.6g/kg/day = 38g/day (10% of 1580 Kcal/day) 50-60% of 1580 kcal/day = 197-237 g/day 30-40% of 1580 Kcal/day = 52-70 g/day

Meals Breakfast

Recipes Dosa Rice flakes Onion bhaji Sambar Tea Fruit Milk Mixed chapati Cooked rice Fenugreek dhal curry Carrot bhaji Raita Milk Upma Tea Mixed chapati Ragi ganji Sambar Fenugreek bhaji Curd salad Milk

Amount 1 k 1/8 k 1/8 k cup cup 2 1/8 k 1/8 k k cup k cup 2 1/8 k 1/8 k k k cup

Lunch

Snacks Dinner

Ingredients Rice-22g, blackgramdhal-10g, oil tsp Rice flakes-20 g, onion-25g, oil tsp Onion-25g, oil tsp Redgram dhal 10, oil tsp Milk-100 ml Jamun-25 g Milk-100 ml Wheat flour-60 g, soybean-10 g, oil 1 tsp Rice 10 g Redgram dhal 7g, Fenugreek-25g, oil 1 tsp Carrot-50g, onion-25g, oil 1tsp, curd-50 ml, onion-25g Milk-50 ml Samolina-30g, oil tsp Milk-50 ml Wheat flour-60 g, soybean-10 g, oil 1tsp Ragi 10 g Redgram dhal 10g, oil tsp Fenugreek-25 g, onion-50g, oil 1 tsp Curd-50 ml, carrot-50g Milk-50 ml

Predialytic with hypertension (GFR-58 ml/min)

Case 9 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

Ashok Gourappa 40 yrs 166 cm 40 kg 66 kg Non-vegetarian Sedentary 1834-2310 kcal/day 0.6g/kg/day = 40g/day (9% of 1834 kcal/day) 50-60% of 1834 kcal=229-275 g/day 31% of 1834 kcal= 63g/day

Meals Breakfast

Recipes Egg Paratha Sago upuma Fruit Tea Roti Beetroot bhaji Fenugreek bhaji Fruit Curd Sago upuma Fruit Tea Chicken rice Green papaya halwa

Amount 1 k 1 cup 1 k k 1 cup k 1 cup 1k 1/8 k

Lunch

Snacks

Dinner

Ingredients Refined wheat flour-30g, egg white of an egg, oil 2 tsp Sago-30g, onion-50g, oil-1tsp Apple-100g Milk-100 ml, glucose-2tsp Sorghum flour-30 g, Beetroot-75g, onion-25 g, oil 2tsp Fenugreek-25g, oil-2tsp Orange 100g Curd-50ml, sugar-1tsp Sago-30 g, rice flakes 7 g, onion-100 g, oil 1 tsp Pear 100 g Milk-100 ml, sugar-1 tsp Rice-30g, chicken-50g, onion-100g, oil-3tsp Green papaya-25g, sugar 1 tsp, oil 1tsp

Predialytic with insulin dependent diabetes mellitus with hypertension (GFR-38 ml/min)

Case 10 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Onion paratha Fruit Tea Mixed chapati Carrot bhaji Milk Samolina upuma Tea Mixed chapati Onion bhaji Milk

: : : : : : : : : : :

30 yrs 162 cm 39 kg 162-100 = 62 kg Vegetarian Sedentary 1612-1680 kcal/day 0.6g/kg/day = 34g/day (8% of 1612 kcal) 50-60% of 1612 kcal/day = 201-242 g/day 32% of 1612 kcal = 57 g/day Amount 1 1 cup 1 1k cup k cup 1 1k cup Ingredients Wheat flour-40g, onion-50g, oil 1 tsp Apple-100g Milk-100 ml Wheat flour-37 g, soybean flour 10 g, oil 1 tsp Carrot-100g, onion-150g, oil 2 tsp Milk-100ml Samolina-30g, oil tsp Milk-50 ml Wheat flour-40g, soybean, flour-10 g, oil 1 tsp Onion-250 g, oil 2 tsp Milk-100 ml

Lunch

Snacks Dinner

Bedtime

Predialytic with Hypertension GFR-27 ml/min

Case 11 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Wheat roti Egg bhurji Carrot halwa Tea Sorghum roti Cooked rice Sambar Chicken curry Bottle gourd bhaji Curd Salad Banana milk Tea Fruit Sorghum roti Cooked rice Cabbage bhaji Fish curry Sago paysa Salad Butter milk

: : : : : : : : : : :

52 yrs 169 cm 58.5 kg 69 kg Non-vegetarian Sedentary worker 1503-2415 Kcal/day 0.6 g/kg/day = 41 g/day (11% of 1503 Kcal/day) 50-60%=187-225 g/day 29%-39% = 48 g/day-65 g/day Amount 1 k 2/3 k cup 1 k k k 1/8 k k 1/8 k k k 1 1 k 1/8 k k k 1/8 k k Ingredients Wheat flour 30g Egg white of an egg of 50 g, onion-25 g, oil-1tsp Carrot-75 g, milk-50 ml, sugar-2 tsp, oil-1 tsp Milk 25 ml, sugar 1tsp Sorghum flour-30g Rice 40 g Redgram dhal 15 g, oil tsp Chicken-25g, onion-75g, oil-2tsp Bottle gourd 25g, oil tsp Curd 25 ml Onion 25g Banana 50 g, milk-50 ml, sugar 1 tsp Milk-25 ml, sugar 1tsp Apple 100 g Sorghum flour 30 g Rice 40 g Cabbage 25 g, oil 1 tsp Fish-25g, onion-50g, oil-2tsp Sago-5g, milk-50 ml, sugar-1tsp, oil1tsp Onion 25g, Curd 25 ml, onion 25 g

Lunch

Snacks

Dinner

Predialytic with GFR-29 ml/min Case 12 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Chapati Omlet Sago cutlet Sago paysa Lunch Fried rice Coriander chutney Fruit salad Snacks Sago Upuma Fruit Tea Roti Fish curry Green papaya halwa : : : : : : : : : : :

35 yrs 160 cm 56 kg 60 kg Non-vegetarian Sedentary worker 1740-2100 kcal/day 0.6 g/kg/day = 36 g/day (8% of 1740 Kcal/day) 50-60% of 1740 Kcal/day = 217 g 261 g/day 32% = 61 g/day Amount 1 2 k k 1/8 k 1k k 1 cup 1 k 1/8 k Ingredients Refined wheat flour 15 g, oil tsp Egg white of an egg, onion-100 g, oil-2 tsp Sago-15g, Potato-100g, oil 2 tsp Sago-15g, milk 100ml, glucose-3tsp, oil-1tsp Rice-30g, onion-50g, carrot-50g, oil2tsp Coriander leaves-25 g Apple-100g, guava-50, grapes-50g, milk-50ml, sugar-1tsp Sago-30g, onion-100g, oil-2tsp Orange-100g Milk-100ml, sugar 1tsp Sorghum flour-30g Fish-50g, onion-100g, oil-2tsp Green papaya-25g, sugar-1 tsp, oil- tsp

Dinner

Predialytic with non-insulin dependent diabetes mellitus and hypertension (GRF-32 ml/min) Case 13 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Roti Onion bhaji Fruit Tea Milk Roti Egg bhurji Leached amaranthus bhaji Fruit salad Snacks Dinner Rice flakes Tea Roti Egg bhurji Cabbage bhaji Fruit salad Tea : : : : : : : : : : :

59 yrs 166 cm 50 kg 66 kg Non-vegetarian Sedentary worker 1580-1679 Kcal/day 0.6 g/kg/day = 36g/day = 9% of 1580 kcal/day 50-60% of 1580 kcal/day = 197g-237g/day 31% of 1580 kcal/day = 54g/day Amount 1 no k cup cup 1 no k k 1k k cup 1 no k k 1k Ingredients Wheat flour 50 g Onion-50g, oil 1 tsp Apple 25 g Milk 100 ml Milk 100 ml Sorghum flour 40 g Egg white of an egg, onion-100g, oil 2tsp Amaranthus 25 g, onion-100g, 2 tsp Apple-100g, guava-50 g, milk-50 ml, milk-50 ml Rice flakes 30 g, oil tsp Milk 25 ml Sorghum flour 40 g Egg white of an egg, onion-100g, oil 2tsp Cabbage-25g, onion-100g, oil 2 tsp Apple-100g, guava-50 g, milk-50 ml Milk-50 ml

Lunch

Predialytic with proteinuria (GRF-55 ml/min) Case 14 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat : : : : : : : : : : :

30 yrs 169 cm 58 kg 169-100 = 69 kg Vegetarian Sedentary worker 1776-2415 kcal/day 0.6g/kg/day = 41.4+1.1g = 42.5g/day (10% of 1776 Kcal/day) 50-60% of 1176 Kcal/day=222-266 g/day 30-40% of 1776 = 59g/day -79 g/day

Meals Breakfast

Recipes Mixed chapati Potato bhaji Carrot halwa Fruit Tea Mixed chapatti Sambar Carrot halwa Curd Leached fenugreek bhaji Fruit Sago upuma Fried soybean Fruit salad Tea Mixed chapatti Potato bhaji Green papaya Halwa Milk

Amount 1/8 k k 1 cup 1 1/8 k k 1/8 k k k

Lunch

Ingredients Refined wheat flour-15 g, soybean 10, oil-1 tsp Potato-25 g, oil-2 tsp Carrot-75 g, oil 1tsp, sugar-1tsp Apple-100g Milk-50 ml, sugar-1 tsp Refined wheat flour-30 g, soybean flour-10 g, oil 1 tsp Redgram dhal 10 g, oil 1 tsp Carrot-100g, sugar 1tsp, oil-1 tsp, milk-25 ml Curd 25 ml Fenugreek 100g, oil 1 tsp Papaya-100 g Sago-30g, onion-100g, oil-1tsp Soybean-10g, oil-1tsp Apple 50g, guava-25g, pineapple-25g, sugar-1tsp Milk-50 ml, sugar 1tsp Refined wheat flour 30 g, soybean flour 10 g, oil tsp Potato-50g, Onion-100g, Oil-1tsp Green papaya 25 g, milk-50 ml, sugar1 tsp, oil tsp Milk 50ml

Snack

k cup 1 k 1/8 k cup

Dinner

Predialytic with insulin dependent diabetes mellitus and hypertension (GFR-26 ml/min) Case 15 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Onion paratha Fruit salad Egg rice Carrot bhaji Curd Rice flakes Tea Roti Egg bhurji Carrot bhaji Curd Milk : : : : : : : : : : :

42 yrs 148 cm 56 kg 148-100 = 48 kg Non-vegetarian Sedentary worker 1364-1422 kcal/day 0.6g/kg/day ) = 26g (8% of 1364 kcal) 50-60% of 1364 kcal/day = 170-205g /day 32% of 1364 kcal/day = 48g/day Amount no 1 k k k k cup 1 k k cup cup Ingredients Wheat flour-15 g, onion-50g, oil 1 tsp Apple-100g, guava-75g, Milk-100ml Rice-30 g, egg white of egg, onion100g, oil-1 tsp Carrot-150g, oil 2 tsp, curd 50 ml Curd 50 ml Rice flakes-20 g, oil-3/4 tsp Milk-50 ml Sorghum flour-30g Egg white of egg, onion-100g, oil 1 tsp Carrot-50g, onion-100g, oil-2 tsp Curd-50 ml Milk 75ml

Lunch

Snacks Dinner

Bed time

Predialytic with non-insulin dependent diabetes mellitus and hypertension (GFR-58 ml/min) Case 16 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Roti Onion bhaji Fruit Tea Milk Roti Egg bhurji Leached amaranthus bhaji Fruit salad Snacks Dinner Rice flakes Tea Roti Egg bhurji Cabbage bhaji Fruit salad Tea : : : : : : : : : : :

59 yrs 166 cm 63 66 kg Non-vegetarian Sedentary worker 1580-1679 kcal/day 0.6g/kg/day = 36g/day (9% of 1580 kcal/day) 50-60% of 1580 kcal/day = 197 g-237 g/day 31% of 1580 kcal/day = 54 g/day Amount 1 no k cup cup 1 no k k 1k k cup 1 no k k 1k Ingredients Wheat flour 52 g Onion-50g, oil 1 tsp Apple 25 g Milk 100 ml Milk 100 ml Sorghum flour 40 g Egg white of an egg, onion-100g, oil 2tsp Amaranthus 25 g, onion-100g, 2 tsp Apple-100g, guava-50 g, milk-50 ml, milk-50 ml Rice flakes 30 g, oil tsp Milk 25 ml Sorghum flour 40 g Egg white of an egg, onion-100g, oil 2tsp Cabbage-25g, onion-100g, oil 2 tsp Apple-100g, guava-50 g, milk-50 ml Milk-50 ml

Lunch

Predialytic with hypertension (GFR- 22 ml/min) Case 17 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Sago upuma Tea Fruit Cooked rice Sambar Carrot halwa Fruit Sago cutlet Tea Fruit Roti Beetroot bhaji Bottle gourd halwa Butter balls : : : : : : : : : : :

55 yrs 152 cm 70 kg 52 kg Non-vegetarian Sedentary worker 1403-1820 kcal/day 0.3g/kg/day = 16 g/day (5% of 1403 kcal/day) 50% -60% of 1403 kcal/day = 175g-210g/day 35% = 54g/day Amount k cup 1 k k k 2 no cup k 1 k k 1 Ingredients Sago-15g, onion-100g, coriander leaves-25g, oil-2 tsp Milk-25 ml, glucose-1tsp, Apple-100g Rice-30 g Redgram dhal-15g, oil 1tsp Carrot-100g, sugar-2tsp, oil 2 tsp Pineapple-100g Sago-15g, potato-50g, onion-50g, oil2tsp Milk-25 ml, glucose-1 tsp Papaya Sorghum flour-30 g Beetroot-50g, onion-50g, oil-1tsp Bottlegourd-50g, sugar-2 tsp, oil-1tsp Butter-18 g, sugar-2tsp

Lunch

Snacks

Dinner

Predialytic with hypertension GRF-16 ml/min Case 18 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat : : : : : : : : : : :

58 yrs 157 cm 48 kg 57 kg Non-vegetarian Sedentary worker 1350-1454 Kcal/day 0.3 g/kg/day = 17 g/day = (5% of 1454 kcal) 50-60 % of 1454 kcal = 182-218 g/day 35% of actual to ideal weight = 52 g-56 g/day

Meals Breakfast

Recipes Sago upuma Maida halwa Fruit Roti Sambhar Carrot bhaji Coriander chutney Fruit Butter balls Sago cutlet Tea Fruit Onion Paratha Bottlegourd halwa

Amount k k 1 1 k k tsp 1 2 cup 1 1 k

Lunch

Ingredients Sago 15 g, Onion-100g, oil-1tsp Maida-15g, Milk 25 ml, Oil-1tsp, Glucose 2tsp, Apple 100g Sorghum flour 30 g Redgram dhal 15 g Onion-50g, oil 1tsp, carrot- 50 g Coriander leaves 25 g Guava 100 g 18 g glucose 2tsp Sage 15, potato-50g, onion 50g, oil2tsp Milk 25 ml, glucose 2 tsp Apple 100 g Refined wheat flour-30 g, onion-100 g, oil-1tsp Bottlegourd-50 g, sugar-2 tsp, oil 1tsp

Snacks

Dinner

Note: 4 g of fat can be given through medium chain triglycerides.

Predialytic with GRF-21 ml/min

Case 19 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Sago Upuma Fruit Tea Cooked rice Sambhar Fruit salad Tea Fried sago Fruit Tea Fried rice Mungdhal paysa Ridge gourd bhaji

: : : : : : : : : : :

60 yrs 157 cm 48 cm 57 kg Non-vegetarian Sedentary 0.3 g/kg/day = 17 g (5% of 1299) 50-60% of 1299 = 162-195 g/day 35% of 1299 = 50 g Amount 2 1 cup k k k cup k 1k cup k 1/8 k k Ingredients Sago-15g, onion-100g, coriander leaves-25g, oil 1tsp Apple 100g Milk 25 ml, glucose 2 tsp Rice-30g, Redgram dhal 15g Apple 50 g, grapes 25g, papaya-25g, Glucose 2 tsp Milk 25 ml, sugar-1tsp Sago-15g, oil-1tsp Papaya 50g, Orange-50g, sugar-1tsp Milk-25, sugar-1 tsp Rice-15g, onion-100g, oil 2tsp Greengram dhal 10 g, jaggery-10g, oil 1tsp Ridge gourd-50g, oil 2tsp

Lunch

Snacks

Dinner

Predialytic with GFR-20 ml/min

Case 20 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

60 yrs 162 cm 50 kg 62 kg Non-vegetarian Sedentary worker 1154-1422 Kcal/day 0.3g/kg/day = 19 g/day (5% of 1422 kcal) 50-60% of 1422 Kcal/day = 177-213 g/day 35% of (1154 to 1422 kcal) = 45-50 g/day

Ingredients Refined wheat flour 22 g, Sago 15 g, oil 1 tsp Carrot halwa k Carrot 100g, Sugar low, oil 1 tsp Milk cup Milk 25 ml, sugar 1 tsp Lunch Butter roti 1 Refined wheat flour-30 g, butter 7 g (without salt) Dhal curry k Redgram dhal, onion-50 g, oil 1tsp Bittergourd bhaji k Bittergourd-50g, onion 50g, oil 2 tsp Fruit 1 Apple-50g, orange-25 g, pineapple-25 g, glucose 2 tsp Snack Sago cutlet 2 Sago-15g, Potato-50g, Onion 50g, Oil 2 tsp Fruit k Pineapple 100g Tea cup Milk 25 ml, Glucose 2 tsp Dinner Chapati 1 Refined wheat four 30 g, oil 1 tsp Potato palak k Potato-25g, Fenugreek-25g, oil 2 tsp, Butter balls 1 Butter-8g, glucose-2tsp Note: 10 g of fats can be given through medium chain triglycerides

Meals Breakfast

Recipes Sago chapati

Amount 1

Predialytic with hypertension GFR=22 ml/min

Case 21 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

30 yrs 148 cm 32 48 kg Non-vegetarian Sedentary worker 1248-1511 kcal/day 0.3 g/kg/day = 15g (4% of 1511 kcal/day) 50-60% = 189-226g/day 36% of (Actual and ideal energy) = 50-60g/day

Meals Breakfast

Recipes Onion paratha Sago upuma Tea Fruit Chapati Onion bhaji Fruit salad Sago upuma Tea Fruit Chapati Onion bhaji Butter balls

Amount 1 k cup 1 1 k k cup 1 1 k

Lunch

Snack

Dinner

Ingredients Refined wheat flour-30g, onion-50g, oil 1 tsp Sago-15g, onion-50g, oil 1-tsp Milk 25 ml Apple-100g Refined wheat flour 30g, oil 1tsp Onion 100g, oil 1 tsp Pineapple-50 g, orange-50g, glucose 2 tsp Sago-15g, rice flakes, 25 g, onion100g, oil-2tsp Milk-25 ml Apple 100-g Refined wheat flour-30g, oil 1 tsp Onion-100g, oil 1tsp Glucose 2 tsp, butter 22g

Note: 10 g of medium chain triglyceride can be given

Predialytic with hypertension (GFR-16 ml/min)

Case 22 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Sago upuma Tea Fruit Cooked rice Spinch dhal Carrot halwa Fruit Sago cutlet Tea Fruit Chapati Beetroot bhaji Ridge gourd chutney Butter balls

: : : : : : : : : : :

68 yrs 170 cm 63 kg 70 kg Non-vegetarian Sedentary 1525-1580 kcal 0.3 g/kg/day = 21 g/day = 5% 1525 Kcal/day 50-6% of 1525 Kcal/day 35% of 1525 Kcal/day = 59 g/day Amount k cup 1 k k k k 2 cup 1 1 k k Ingredients Sago 15 g, rice flakes-15 g, onion-100 mg, oil 2 tsp Milk 50 ml, Glucose 2 tsp Apple 100g Rice 30g Redgram dhal-15 g, spinach-25 g, oil 1 tsp Carrot-100g, sugar-2tsp, oil 1 tsp Pineapple-100g Sago-15g, potato-50g,onion-50 g, oil 2 tsp Milk 50 ml Pear 100g Refined flour-30 g, oil 1 tsp Beetroot-100g, oil 1tsp Ridgegourd 50g, oil 1tsp Butter 24 g, glucose 3 tsp

Lunch

Snacks

Dinner

Hemodialytic with hypertension

Case 23 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Wheat roti Greengram bhaji Omlet Tea Fruit salad Cooked rice Sambhar Chicken Curd Spinach bhaji Salad Rice flakes Tea Roti Sambar Fish Carrot halwa Milk

: : : : : : : : : : :

76 yrs 170 cm 62 kg 70 kg Non-vegetarian Sedentary worker 1467-1630 Kcal/day 1.2 g/kg/day = 84 g/day (23% of 1467) 50-60% of 1467 Kcal/day=183-220 g/day 17-27% of 1467 = 28g 44 g/day Amount 1 no k 1 no cup k k k k k k k k cup 2 no k k k cup Ingredients Wheat flour 30 g Greengram-30g, oil tsp Egg white from 2 eggs each to 50 g Milk-100 ml, sugar 1tsp Apple 100g, milk-100 ml, Rice 30 g Redgramdhal 30g, oil tsp Chicken-50g, onion-50g, oil tsp Curd-50g Spinach 100g, oil tsp Cucumber 100g Rice flakes 50 g, oil tsp Milk 100 ml, sugar-1tsp Sorghum flour 60 g Redgram dhal 30 g Fish 50 g, oil tsp Carrot-100g, sugar-1 tsp, oil tsp, milk-50 ml 100 ml

Lunch

Snacks Dinner

Hemodialytic with insulin dependent diabetes mellitus and hypertension

Case 24 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Wheat roti Greengram bhaji Egg bhurji Tea Fruit Roti Cooked rice Fish Fenugreek bhaji Curd Rice flakes Tea Fruit Wheat roti Cooked rice Chicken Cabbage bhaji Curd Wheat roti Cooked rice Chicken Cabbage bhaji Curd Ragi gangi

: : : : : : : : : : :

58 yrs 160 cm 47 kg 60 kg Non-vegetarian Sedentary worker 1454-1552 kcal/day 1.2 g/kg/day = 65 g = 18% of 1454 Kcal/day 50-60% of 1454 kcal = 182-218 g/day 22-32% of 1454 kcal = 36 - 52 g/day Amount 1 k k cup 1 no 1 no k k 1/8 k k k cup 1 1 no k k 1/8 k k 1 no k k 1/8 k k cup Ingredients Wheat flour-30g Whole greengram-15g, oil tsp Half of egg white of an egg of 50g, oil tsp Milk 100 ml Apple 100 g Sorghum flour 30 g Rice 49 g Fish 50 g, oil tsp, onion 25 g Fenugreek 25 g, oil tsp Curd 50 g Rice flakes 50g, oil tsp Milk 100 ml Guava 50 g Wheat flour 30 g Rice 48 g Chicken 50g, oil tsp, onion-25 g Cabbage-25 g, oil tsp Curd 50g Wheat flour-30g Rice 48g Chicken-50g Oil tsp, onion 25 g Cabbage-25 g, oil tsp Curd 50 g Ragi 10 g, milk 50 ml

Lunch

Snacks

Dinner

Bed time

Hemodialytic with hypertension, Hepatitis and non-insulin dependent diabetes mellitus Case 25 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Wheat Roti Rice flakes Egg bhurji Fruit salad Roti Cooked rice Egg bhurji Sambar Cauliflower bhaji Fenugreek bhaji Curd Rice flakes Fruit salad Tea Roti Cooked rice Egg bhurji Sambhar Bean bhaji Fenugreek bhaji Curd Milk : : : : : : : : : : :

48 yrs 160 cm 60 kg 60 kg Non-vegetarian Sedentary worker 1535-1634 kcal/d 1.5x60 = 90 kcal/day (23% of 1535 kcal/day) 50-60% of 1535 Kcal/day = 191-230 g/day 17-27% of 1535 Kcal/day = 29-46 g/day Amount 1 no k k cup 1 no k k k k 1/8 k K k k cup 1 no k k k k 1/8 k k cup Ingredients Wheat flour 30 g Rice flakes 20 g, oil tsp Egg white of an egg of-50g, oil tsp Apple-25 g, guava-25g, Milk-100 ml Sorghum flour-30 g Rice 50 g Egg white of two eggs each of 50 g, oil 1 tsp, onionRedgram dhal 20 g, oil tsp, oil-1 tsp, onion-25 g Cauliflower 50 g Fenugreek 25 g, Oil tsp, Curd 50 g Rice flakes-50g, oil tsp Apple 25 g, guava, 25 g, milk 100 ml Milk 75 ml Sorghum flour 30 g Rice 50 g Egg white of 2 eggs, each of 50 g, oil tsp Red gram dhal-30 g, oil tsp Beans 50g, onion 25 g, oil tsp Fenugreek 25 g oil tsp Curd 50 g Milk 100 ml

Lunch

Snacks

Dinner

Hemodialytic with hypertension

Case 26 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Wheat roti Egg omlet Carrot halwa Tea Cooked rice Sambar Chicken curry Leached fenugreek bhaji Fruit salad Sago paysa Tea Cooked rice Sambar Fish curry Beans bhaji Fruit salad Curd

: : : : : : : : : : :

52 yrs 162 cm 62 kg 62 kg Non-vegetarian Sedentary worker 1646-2170 kcal/day 74 g/day = 1.2 g/kg/day = 18% of 1646 kcal/day 50-60% of 1646 Kcal/day = 2051-247 g/day 22-32% of 1646 kcal/day = 40-58 g/day Amount 1 k cup k k k k k Ingredients Wheat-15g Egg white of 2 eggs each of 50 g, onion-25g, oil tsp Carrot-75 g, milk-50 ml, oil tsp, sugar 1 tsp Milk-50 ml, sugar 1 tsp Rice 30g Redgram dhal 30g Chicken 50 g, onion-50 g, oil tsp Fenugreek 100 g, oil tsp Guava 100g Sago 30 g, milk 150 ml, sugar 2 tsp, oil tsp Milk, sugar-1tsp Rice 30 g Redgram dhal 15 g, oil tsp Fish 50g, onion-25g, oil tsp Bean 100g, onion-25 g, oil tsp Apple-50g, guava-50g, milk-50 ml, sugar-1tsp Curd 50 ml

Lunch

Snacks

Dinner

k k k k k

Hemodialytic with hypertension

Case 27 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Rice flakes Egg omlet Lunch Roti Sambar Chicken curry Leached fenugreek bhaji Raita Upuma Fruit salad Tea Roti Cooked rice Sambar Fish curry Carrot halwa Cauliflower bhaji Milk

: : : : : : : : : : :

60 yrs 173 cm 64 kg 73 kg Non-vegetarian Sedentary worker 1828-2555 kcal/day 1.2g/kg/day = 8g/day (19% of 1828 kcal/day) 50-60% of 1828 Kcal=228-274 g/day 21-31% of 1828 = 43-63g/day Amount k 1 no k 1 k k k Ingredients Rice flake-30g, oil tsp, Onion 50g Egg white of 2 eggs, onion-50 g, oil tsp Sorghum flour 30 g, rice-30g, Redgram dhal 30g, oil tsp Chicken-50g, oil tsp, onion-75 g Fenugreek 100g, oil tsp, Curd 100 ml, onion 50 g Samolina-30 g, Oil tsp Apple-100g, milk-50 ml, sugar-1tsp Milk 50 ml, sugar 1tsp Sorghum flour-30 g Rice-30g Redgram dhal 15 g, oil 1/8 tsp Fish-50 g, onion 25g, oil tsp Carrot-75 g, sugar 1 tsp, oil 1/8 tsp, milk 50 ml Cauliflower-50g, oil tsp Milk-50 ml

Snack

k k 1 no k k k k k cup

Dinner

Hemodialytic with hypertension

Case 28 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Wheat chapatti Egg bhurji Tea Fruit Roti Cooked rice Chicken curry Carrot halwa Fenugreek bhaji Rice flakes Fruit Tea Roti Cooked rice Sambar Fish curry Green papaya halwa Onion bhaji Milk

: : : : : : : : : : :

28 yrs 173 cm 55 kg 73 kg Non-vegetarian Sedentary worker 29-35 kcal/kg/day = 2088-2555 kcal/day 88g/day = 17% of 2088 kcal/day 50-60% of 2088 kcal = 261 g-313g/day 23% -33% of 2088 kcal = 53g-76g/day Amount 1 k cup 1 2 k k k k k 1 cup 2 k k k k k cup Ingredients Wheat flour 30g, oil tsp Egg white of 2 eggs, onion-100g, oil tsp Milk 100 ml, sugar 1tsp Apple 100g Sorghum flour 60 g Rice-30g, Redgram dhal 30g, oil tsp Chicken 50g, onion, 25 g, oil tsp Carrot 75g, sugar tsp Fenugreek 100g, oil tsp Rice flakes-30g, oil tsp, onion 25g Apple-100g Milk-100 ml, sugar 1 tsp Sorghum flour 60g Rice 30 g Redgram dhal 15 g, oil tsp Fish-50 g, oil tsp Green papaya-100g, oil tsp, sugar 1 tsp Onion 10 g, oil tsp Milk 100 ml

Lunch

Snack

Dinner

Hemodialytic with non-insulin dependent diabetes mellitus Case 29 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Mixed chapatti Dhal curry Fruit salad Tea Sorghum roti Cooked rice Mixed dhal curry Cucumber bhaji Raita Milk Rice flakes rice flake Fruit salad Tea Chapati Ragi gangi Mixed dhal curry Bittergourd bhaji Methi bhaji Salad Curd Milk : : : : : : : : : : : 56 yrs 170 cm 59 kg 70 kg Vegetarian Sedentary worker 1678 kcal/day 1793 kcal/day 1.2g/kg/day = 76g/day (18% of 16.78 kcal/day) 50-60% of 1678 kcal = 252g/day 22-32% of 1678 kcal = 41g/day-60/day Amount 2 k k cup 2 Ingredients Wheat flour-50 g, soybean flour 10 g, oil tsp Redgram dhal-15 g, oil tsp Milk-100 ml, apple-30g, guava-20g Milk 100 ml Sorghum flour 60 g Rice 30 g Redgram dhal 20 g, soybean-10 g, onion-25 g, oil tsp Cucumber 50g, Oil 1tsp Curd 50 ml Milk 50 ml Rice flakes 15g, oil tsp Milk-100 ml, apple-30g, pear-20g, Milk-25 ml Wheat flour-60g, Ragi flour-30 g Redgram dhal-20 g, soybean-10g, oil tsp Bitter gourd 50g, oil tsp Fenugreek 25 g, oil tsp Onion-25 g Curd 50 ml Milk 50 ml

Lunch

Snack

k k cup k k cup 2 k k k 1/8 k k k cup

Dinner

Hemodialytic with hypertension

Case 30 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

35 yrs 176 cm 59 kg 76 kg Non-vegetarian Sedentary worker 28-35 kcal/kg/day = 2100-2660 kcal/day 1.2g/kg/day = 2100 kcal = 262-316 g/day 50-60% of 2100 kcal/day= 262-315 g/day 23-33% of 2100 kcal/day = 54g-7g/day

Meals Breakfast

Recipes Wheat roti Greengram bhaji Egg omlet Tea Fruit Roti Cooked rice Sambar Chicken curry Amaranthus bhaji Fruit salad Rice flakes Tea Roti Cooked rice Sambar Fish curry Raita Green papaya halwa

Amount 1 no k k cup 1 no 2 no k k k k 1k k cup 1 no k k k

Lunch

Snack Dinner

Ingredients Wheat flour 30g Whole greengram, oil tsp, onion 50 g Egg while of 2 eggs, onion-50g, oil tsp Milk-100 ml, sugar 1 tsp Apple-100 g Sorghum flour 60 g Rice-30g Redgramdhal 30g, oil tsp Chicken 50 g, onion, 50g, oil tsp Amaranthus-100g, onion-50g, oil tsp Apple, 25 g, Grapes-25g, Guava-50g, Milk-100ml, Sugar 1 tsp Rice flakes 30g, oil tsp Milk-100 ml, sugar 1 tsp Sorghum flour 30 g Rice 40 g Redgram dhal 30g, oil tsp Fish-50g, onion-100g, oil-1tsp Curd-100 ml, onion-25g Green papaya 100g, sugar 1 tsp, oil 1 tsp

Hemodialytic with hypertension

Case 31 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

42 yrs 173 cm 53 kg 73 cm Non-vegetarian Sedentary worker 1975-2555 kcal/day 1.2g/kg/day=88g/day (18% of 1795 kcal/day) 50-60% of 1975 kcal/day = 247g -296 g/day 22-32% of 1975 kcal/day = 48-70g/day

Meals Breakfast

Recipes Wheat roti Egg bhurji Tea Fruit Roti Cooked rice Sambar Fish curry Amaranthus bhaji Carrot halwa Rice flakes Tea Fruit Roti Cooked rice Sambar Fish curry Carrot halwa Salad

Amount 1 k cup 1 1 k k k k k k cup 1 no 1 no k k k k k

Lunch

Ingredients Wheat flour 30 g Egg white of 2 eggs, onion-100g, oil tsp Milk-100ml, Sugar-1tsp Apple-100g Sorghum flour-30g Rice 45 g Redgram dhal 30g, oil tsp Fish-50 g, oil tsp Amaranthus 100g, oil tsp Carrot-100g, milk-100, sugar-1 tsp, oil tsp Rice flakes-30g, onion-25g, oil tsp Milk-100ml, sugar 1 tsp Apple 100g Sorghum flour-30g Rice 45g Redgram dhal-15g, oil tsp Fish-50g, oil 1tsp Carrot-100g, milk-100ml, sugar 1 tsp, oil tsp Cucumber

Snacks

Dinner

Hemodialytic with hypertension

Case 32 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

30 yrs 160 48 kg 60 kg Non-vegetarian Sedentary 1653-2100 kcal/day 1.2 g/kg/day=72 day (18% of 1653 kcal/day) 50-60% of 1653 Kcal/day = 206-247 g/day 22-32% of 1653 kcal/day = 40-59g/day

Meals Breakfast

Lunch

Recipes Dosa Sambar Egg omlet Potato bhaji Tea Fruit Cooked rice Sambar Brinjal bhaji

Amount 1 no k 1 no 1/8 k cup 1 no k k k

Snacks

Dinner

Fried sago Fruit Tea Wheat roti Cooked rice Sambar Chicken curry Amaranthus bhaji Milk

k 1 no 1 cup 1 no k k k k cup

Ingredients Rice-30g, blackgram dhal 10g Redgram dhal 22 g, oil tsp Egg white of an egg oil tsp Potato 5g, oil tsp Milk-100 ml, sugar 1 tsp Apple-100g Rice-30 g Redgramdhal-30g, onion-50g, oil tsp Brinjal-100g, onion-50g, oil- tsp, sago-15 g, milk-100 ml, sugar 2 tsp, oil tsp Sago-15 g, oil tsp Apple-100g, Milk-100 ml, sugar 1 tsp Wheat flour-30 g Rice 20 g Redgram dhal-30g, oil tsp Chicken tsp Amaranthus 10g, oil tsp Milk-100, sugar-1 tsp

Hemodialytic with hypertension

Case 33 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

69 yrs 160 cm 69 kg 60 kg Non-vegetarian Sedentary worker 1316-1462 kcal/day 1.2g/kg/day = 72g/day (22% of 1316 kcal/day) 50-60% of 1316 kcal/day = 165-197g/day 18-28% of 1316 kcal/day = 26-40g/day

Meals Breakfast

Lunch

Snacks Dinner

Recipes Wheat roti Sambar Egg bhurji Cucumber Tea Roti Rice Sambar Chicken curry Raita Fruit Tea Wheat roti Sambhar Egg bhurji Leached fenugreek bhaji Curd Milk

Amount 1 k k 1 no cup 1 no k k k k 1 cup 1 no k k k k cup

Ingredients Wheat roti-30 g Redgram dhal 30 g, oil tsp Egg white of an egg, oil tsp Cucumber 100 g Milk-100 ml, sugar 1tsp Sorghum flour-30 g Rice 30g Red gram dhal-30g, oil tsp Chicken-50g, onion-50, oil-1 tsp Curd 100 g, onion 50 g Apple-100g Milk 100 ml, sugar 1 tsp Wheat flour-30g Redgram dhal-30 g, oil tsp Egg white of an egg oil tsp Fenugreek 100 g, oil 1 tsp Curd 50 ml Milk 150 ml

Hemodialytic patient Case 34 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast : : : : : : : : : : : Recipes Fenugreek Chapati Omlet Raita Tea Apple Sorghum roti Cooked rice Sambar Clusterbean bhaji Chicken curry Sago paysa Curd Salad Rice flakes cutlet Tea Apple Sorghum roti Rice Sambar 24 yrs 178 cm 53 kg 78 kg Non-vegetarian Sedentary worker 2244-2753 Kcal/day 1.2 g/kg/day = 17% of 2244 Kcal/day 50-60% of 2240 Kcal/day = 325-337 g/day 23-33% of 2240 Kcal/day 57-82 g/day Amount 1 1 k 1 cup 1 1 k k Ingredients Wheat flour 30 g, Fenugreek leaves 25 g oil tsp Egg white of 2 eggs, Onion-75 g, Oil-1 tsp Curd 50 ml, onion 25 g, carrot 50 g Milk 100 ml, sugar 1 tsp, Apple 10 g Sorghum flour 45 g Rice 30 g Red gramdhal 30 g, oil tsp Clusterbeans-50g, onion-25 g, oil-3/4 tsp Chicken 75 g, onion-50 g, oil 1 tsp Sago-25 g, milk-100 ml, sugar-1 tsp, oil-3/4 tsp Curd 50 ml Carrot-50 g Rice flakes-30 g, potato-50 g, onion50 g, oil tsp Milk-100 ml, sugar 1 tsp, Apple-100g Sorghum flour 45 g Rice 30 g Redgram dhal-30 g, potato-50 g, onion-50 g, oil tsp, fish-50 g, onion50 g, onion-50 g, oil 1 tsp Cucumber 50 g, curd 50 ml Carrot 50 g

Lunch

k k k k 2 cup 1 1 k k

Snacks

Dinner

Cucumber raita Salad

Hemodialytic with hypertension

Case 35 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Bread omlet Tea Roti Cooked rice Sambar Chicken curry Potato palak Fruit salad Rice flakes cutlet Tea Roti Cooked rice Sambar Fish curry Green papaya halwa Milk

: : : : : : : : : : :

38 yrs 176 cm 64 kg 76 kg Non-vegetarian Sedentary worker 2074-2660 Kcal/day 1.2g/kg/day = 91 g/day (17% of 2074 kcal) 50-60% of 2074 kcal/day = 259-311 g/day 23-33% of 2074 kcal /day = 53g-76g/day Amount 1 no cup 1 no k 2/3 k k 1k 2 no cup 2 no k 1k k k cup Ingredients Bread slice 2, omlet of egg white of 2 eggs, oil 1 tsp, onion 100 g Milk 100 ml, sugar 1 tsp Sorghum flour 30 g Rice 30 g Redgram dhal 22, oil tsp Chicken 50 g, oil tsp, Potato 100 g, spinach 100 g, oil 1 tsp Apple-50 g, guava-25g, papaya-15g, grapes-10g sugar 1 tsp, milk 100 ml Rice flakes 30g, potato-100g, oil tsp Milk 100 ml, sugar 1 tsp Sorghum flour 60 g Rice 30 g Redgramdhal 30 g, oil tsp Fish-50g, oil-1tsp, onion-25g Green papaya-100g, sugar-1 tsp, oil tsp 100 ml

Lunch

Snacks Dinner

Hemodialytic with hypertension Case 36 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Mixed flour chapatti Potato bhaji Fruit salad Tea Mixed roti Rice Sambar Beetroot bhaji Raita Salad Rice kheer Tea Fruit Mixed chapatti Dhal curry Potato fenugreek Curd Milk : : : : : : : : : : :

26 yrs 170 cm 54 kg 170-100 = 70 kg Vegetarian Sedentary worker 2038-2450 kcal/day 1.2g/kg/day = 84 g/day (16% of 2038 kcal/day) 50-60% of 2038 Kcal/day = 255-305 g/day 24-34% of 2038 Kcal/day = 54g-76g/day Amount 1 k 1k cup 1 k k k k k cup 1 3 1k 1k k cup Ingredients Wheat flour-30g, soybean flour-15g, oil tsp Potato-100g, oil tsp Apple-50g, guava-50g, sugar-1tsp, milk 100 ml Milk-100 ml, sugar-1tsp Sorghum flour-30 g, soybean flour15g, Rice-30g Redgramdhal 30 g, oil tsp Beetroot-100g, oil tsp Curd-50 ml, cucumber-50 g, onion-25 g Cucumber-50 g Rice-30g, milk-100 ml, sugar-1tsp Milk-50ml, sugar-1tsp Guava 100g Wheat flour-50 g, oil-2tsp Redgramdhal-30g, oil tsp Potato-100g, fenugreek-100g, oil tsp Curd-50 ml, sugar- tsp Milk-50 ml

Lunch

Snacks

Dinner

Hemodialytic with insulin dependent diabetes mellitus and hypertension Case 37 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat : : : : : : : : : : :

53 yrs 162 cm 53 kg 62 kg Non vegetarian Sedentary worker 1539-1638 kcal/day 1.2g/kg/day = 67g/day (17% of 1539 kcal) 50-60% of 1539 kcal/day = 192-231g/day 23-33% of 1539 kcal/day = 39-56g/day

Meals Breakfast

Recipes Idli Sambar Egg omlet Tea Fruit Roti Rice Sambar Fish curry Curd French beans bhaji Rice flakes Fruit Tea Roti Rice Sambar Chicken curry Brinjal bhaji Milk

Amount 2 k 1/8 k cup 1 1 2/3 k k k k k k cup 1 2/3 k k k k cup

Lunch

Ingredients Rice-30g, blackgram 10 g Redgram dhal-15g, oil tsp Half of the egg white of an egg, oil- tsp Milk-100ml Apple -100g Sorghum flour-30g Rice 50 g Redgramdhal-15g, oil tsp Fish-25 g, onion-25g, coriander leaves-25 g, oil tsp Curd-50 ml French beans-50g, oil tsp Rice flakes 20 g, oil tsp Guava-50g Milk-100 ml Sorghum flour-30g Rice 50 g Redgram dhal 20 g, oil tsp Chicken-25g, onion-25g, coriander leaves-25 g, oil tsp Brinjal-50g, oil tsp Milk-50 ml

Snacks

Dinner

Bed time

Hemodialytic with non-insulin dependent diabetes mellitus and hypertension GFR-29 ml/min Case 38 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Mixed flour chapati Raita Tea Mixed flour roti Sambar Brinjal bhaji Curd Milk Ragi ganji Fruit Mixed flour roti Sambar Cauliflower bhaji Curd Milk : : : : : : : : : : :

65 yrs 150 cm 51 kg 50 kg Vegetarian Sedentary worker 1188-1270 kcal/day 1.2x45 = 54g/day = 18% of 188 kcal 50-60% of 1188 kcal= 148-178g/day 22-32% of 1188 kcal= 29-42g/day Amount 1 no k cup 2 no 1/8 k k k k 1 no 2 no 1/8 k k k k Ingredients Wheat flour-30g, soybean flour-10 g, oil tsp Curd-100ml, onion-50g Milk-100 ml Sorghum flour-60 g, soybean flour 10 g Redgram dhal 10g, onion-25 g, coriander leaves-25 g, oil tsp Brinjal-50 g, oil tsp, onion-25 g Curd 50 ml Milk 50 ml Ragi flour tsp, milk-125 ml Guava 50g Sorghum flour 60g, soybean flour-10 g, Redgrandhal 10g, onion-25g, coriander leaves-25g, oil tsp Cauliflower-50g, oil tsp Curd 50 ml Milk-50 ml

Lunch

Snacks Dinner

Hemodialytic with hypertension

Case 39 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Sago paysa Cucumber Tea Mixed flour chapati Sambar Fenugreek bhaji Curd Sago paysa Tea Fruit Fixed flour chapati Sambar Amaranthus bhaji Milk

: : : : : : : : : : :

50 yrs 151 cm 50 kg 51 kg Vegetarian Sedentary worker 1181-1785 kcal/day 1.2x5 = 61 g/day (20% of 1181 kcal/day) 50-60% of 1181 kcal/day= 148g-177g/day 20-30% of 1181 kcal/day = 26g-39g/day Amount k 1 cup 1 no 1k k k k cup 1 1 no k k cup Ingredients Sago-15g, milk-50 ml, sugar tsp Cucumber-100 g Milk-50 ml, sugar tsp Wheat flour-30g, soybean flour 20g, oil 1/8 tsp Redgramdhal-30g Fenugreek 100g, oil tsp Curd 100 ml Sago-15 g, milk-50 ml, sugar- tsp Milk-50 ml, sugar- tsp Guava-50g Wheat flour-15g, soybean flour-20 g, oil 1/8 tsp Redgram dhal-30 g Amaranthus-100g, oil tsp Milk-100 ml

Lunch

Snacks

Dinner

Hemodialytic with insulin independent diabetes mellitus

Case 40 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat Meals Breakfast Recipes Dosa Egg omlet Raita Tea Fruit Roti Rice Sambar Fish curry Raita Ragi ganji Fruit Wheat roti Rice Sambar Chicken curry Raita Ragi ganji

: : : : : : : : : : :

58 yrs 153 cm 56 kg 53 kg Non-vegetarian Sedentary worker 1313-1395 kcal/day 1.2g/kg/day = 58g/day (18% of 1313 kcal/day) 50-60% of 1313 Kcal=164-197 g/day 22-32% of 1313 kcal=32-46g/day Amount 1 1 no k cup 2 no 1/8 k k k k k 4-5 2 no 1/8 k k k k k Ingredients Rice-30g, blackgram-10g Egg white of an egg, oil tsp Curd-50 ml Milk-50 ml Guava-50g, jamun-25 g Sorghum flour-60g Rice-10 g Redgramdhal 20 g, oil tsp Fish-25g, onion-10g, coriander leaves25 g, oil tsp Curd-50 ml, cucumber-50g Ragi-15g, milk-100ml Jamun-25 g Wheat flour-60g Rice-10 g Redgram dhal 20 g, oil tsp Chicken-25g, onion-10g, coriander leaves 25 g, oil tsp Curd-50ml, cucumber-50 g Ragi-10g, milk-50ml

Lunch

Snacks Dinner

Hemodialytic with Hepatitis

Case 41 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

38 yrs 160 cm 46 kg 60 kg Non-vegetarian Sedentary worker 1715-2100 kcal/day 1.5g/kg/day =90g/day (21% of 1715 kcal/day) 50-60% of 1715 = 214-257g/day 19-29% of 1715 = 36-55g/day

Meals Breakfast

Lunch

Snacks

Recipes Dosa Egg omlet Potato bhaji Tea Fruit Cooked rice, Sambar Chicken curry Bread omlet Carrot halwa Apple Tea Cooked rice Sambar Fish curry Green papaya halwa Milk

Amount 1 1 cup 1 k k 1 no k 1 cup k k k k cup

Dinner

Ingredients Rice-30g, blackgram dhal-15g Egg white of two eggs oil tsp Potato-100g, oil tsp Milk-100 ml, sugar-1tsp Apple-100g Rice 30g Redgram dhal-30 g, oil tsp Chicken-50g, onion-100g, oil cup Bread slice 1, egg white of 2 eggs oil tsp Carrot-100g, milk-50ml, sugar-2tsp, oil-1/4 Apple-100g Milk-50 ml, sugar-1tsp Rice-30g, Redgraml dhal-30g, oil tsp Fish -25 g, onion-25g, oil tsp Green papaya-100g, sugar 1 tsp Milk-100 ml

Hemodialytic with hypertension Case 42 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat : : : : : : : : : : :

43 yrs 165 cm 60 kg 65 kg Non-vegetarian Sedentary worker 1787-2275 kcal/day 1.2g/kg/day = 78g (17% of 1787 kcal/day) 50-60% of 1787 kcal = 223g-268g/day 23-33% of 1787 kcal = 46g-65g/day

Meals Breakfast

Recipes Bread omlet Tea Fruit Roti Cooked rice Sambar Chicken curry Beans bhaji Curd Rice flakes Tea Roti Cooked rice Sambar Fish curry Carrot halwa Leached fenugreek bhaji

Amount 1 cup 1 1 k k k k

Lunch

Snacks Dinner

k cup 1 k k k k k

Ingredients Bread 1, egg white of 2 eggs, onion100 g, oil tsp Milk-100, sugar-1 tsp Apple-100g Sorghum flour-30g Rice-30 g Redgram dhal-30g, oil tsp Chicken-50g, onion-25g, oil tsp French beans 100g, onion-75g, oil tsp Curd-100 ml, sugar-1tsp Rice flakes-30g, onion-25g, oil tsp Milk-100 ml, sugar-1tsp Sorghum flour-30g Rice-15 g Redgram dhal-15g Fish-50 g, oil tsp Carrot-100g, milk-100ml, sugar-1 tsp, oil tsp Fenugreek 100g, oil tsp

Hemodiatytic with insulin dependent diabetes mellitus and hypertension

Case 43 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

58 yrs 170 cm 52kg 70 kg Non-vegetarian Sedentary 1662 kcal/day 1777 kcal/day 1.2g/kg/day = 76 g/day (18% of 1662 kcal) 50-60% of 1662 kcal = 208-250g/day 22-32% of 1662 kcal = 59g/day

Meals Breakfast

Lunch

Recipes Wheat roti Dhal curry Egg bhurji Tea Fruit Sorghum roti Cooked rice Sambar Fish curry Salad Curd Rice flakes Tea Fruit Wheat roti Cooked rice Sambar Chicken curry Cucumber raita

Amount 1 k k 1 cup 1 2 2/3 k 2/3 k k k k k cup 1 2 2/3 k 2/3 2 pieces k

Snacks

Dinner

Ingredients Wheat flour 40 g Redgram dhal-15g, oil tsp Egg white of an egg, oil tsp Milk-100 ml Apple-100g Sorghum flour-60 g Rice-20 g Redgramdhal 20 g, oil tsp Fish-50g, onion-25g, coriander leaves25g, oil 1 tsp Cucumber-50g Curd-50 ml Rice flakes-15g, oil tsp Milk-100 ml Guava-50g Wheat flour-60g Rice 20 g Redgram dhal-20 g, oil tsp Chicken-50g, onion-25g, coriander leaves-25g, oil 1 tsp Curd-50ml, cucumber-50g

Hemodialytic with hypertension and hepatitis Case 44 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat : : : : : : : : : : :

51 yrs 162 cm 61 kg 62 kg Non-vegetarian Sedentary worker 1654-2170 kcal/day 1.5g/kg/day = 93g = 22% of 1654 50-60% of 1654 = 207-248 g/day 18-28% = 33-51g/day

Meals Breakfast

Recipes Dosa Sambhar Omlet Leached potato bhaji Fruit Tea Cooked rice Sambar Chicken curry Carrot halwa Sago paysa Carrot Fruit Egg rice Sambar Bittergourd bhaji Milk

Amount 1 k 1 k 1 cup k k k k k 1 1 k k k cup

Ingredients Rice-30g, blackgram dhal-10 g, oil tsp Redgram dhal-20 g, oil tsp Egg white of 2 eggs, oil tsp Potato-100g, oil tsp Apple-100g Milk-100 ml, sugar-1tsp Rice-30 g Redgram dhal-30 g, oil tsp Chicken-75g, onion-25g, oil 1tsp Carrot-75g, milk-100 ml, sugar-1tsp, oil tsp Sago-15g, milk-100ml, 1 tsp, oil tsp Carrot-100g Apple-100g Rice-30g, egg white of 2 eggs, oil tsp Redgram dhal 45g, onion-25g, oil Bittergourd-100g Milk 100 ml, tsp sugar

Lunch

Snacks

Dinner

Hemodialytic with Hypertension

Case 45 Age Height Actual weight Ideal weight Food habit Activity pattern Energy Protein Carbohydrate Fat

: : : : : : : : : : :

21 yrs 148 yrs 34 kg 48 kg Non-vegetarian Sedentary worker 1540-1680 kcal/day 1.2g/kg/day = 58g/day (15% of 1540 kcal/day) 50-60% of 1540 kcal/day = 192-231g/day 25-35% of 1540 kcal/day = 43-60g/day

Meals Breakfast

Lunch

Snacks

Recipes Rice flakes Sago cutlet Tea Fruit Wheat roti Sambar Egg bhurji Fenugreek bhaji Tea Sago cutlet Fruit salad Tea Roti Greengram paysa Chicken curry Milk

Amount k 2 no cup 1 no 1 no k k 1/8 k cup 2 no 1k

Dinner

1no k k cup

Ingredients Rice flake-30g, oil tsp Potato 100g, sago-15g, oil 1 tsp Milk-100 ml, sugar-1 tsp Apple-100g Wheat flour 30g, Redgram dhal-30g, oil tsp Egg white of 1 egg, oil 1 tsp Fenugreek 25 g, oil 1 tsp Milk-100ml, sugar-1tsp Sago-15 g, potato-100g, oil 1 tsp Apple-50, guava-25 g, papaya-25g, sugar-1 tsp Milk-100 ml, sugar-1tsp Sorghum flour-30g Whole green gram-30 g, sugar-2 tsp, oil tsp Chicken-50g, oil-1tsp Milk-100 ml

APPENDIX III
Dietary tips for kidney disease
Common Instruction to the subjects
Calculate ideal body weight using the formula Ideal body weight = Height (cm) 100 Calculate energy requirement using the formula

BEE for male = [66+(13.7 x body weight (kg)) + (5 x height (cm)) (6.8 x age)] BEE for female = [655+(9.6 x body weight (kg)) + (1.8 x height (cm)) (4.7 x age)] Based on ideal body weight energy prescription is 30-35 Kcal/day come in the range of 28-35 Kcal/kg/day. For predialytics Calculate Glomerular filtration Rate (GFR) using the formula

GFR = [(140-age) x body weight (kg)] / (Serum creatinine x72) for men] x 0.85 in women If GFR is 25 ml/min, eat 18-20 g of protein from vegetable sources only and include 18-20 g of essential amino acid powder that is available in the market as renal resource. Patients whose GFR comes in between 26-70 ml/min, should eat 38-40 g of protein per day. Use 2/3 of protein from egg/chicken/fish/soybean. Eat only egg white if cholesterol level is high or suffering from hypertension or diabetes mellitus. Take 1-3 g of sodium per day A tea spoon of salt contains 2 g of sodium. Include 2 g/day of potassium in your diet. Restrict fluid and water intake upto 2000 ml/day depending on urine output. Fluid intake can be in the form of water, butter milk, tea, coffee, fruits like watermelon, milks, curd etc. Use groundnut oil for cooking food.

For dialysis Consume 1.2 g/kg/day of protein i.e. around 60-80 g. Half of protein should be from high biological value, including egg, fish, chicken, soybean, milk. Eat only egg white if cholesterol level is high and suffering from hypertension or diabetes mellitus. Eat 1-1.5 g of sodium per day A tea spoon of salt contains 2 g of sodium Include 1.5-2.7 g of potassium in your diet your diet plan will give 1.5-2 g of potassium Restrict fluid intake upto 750-1500 ml/day. Fluid intake can be in the form of water, butter milk, tea, coffee, fruits like water melon, milk, curd etc. Use groundnut oil for cooking food.

Biological value (BV) of selected foods Item Superior BV Egg, milk, milk powder Commercially available protein powders Excellent BV Satisfactory BV Meat, fish Rice, groundnut, soybean cooked, wheat and ginglly

High protein foods Non-vegetarian food items Egg

Low protein foods Roots and tubers Carrot

Fish Meat Chicken Milk Milk Curd Cheese Skimmed milk powder Other vegetables

Potato Beetroot Onion Ash gourd Bitter gourd Bottle gourd Brinjal Clusterbeans Cucumber Frenchbeans Knokhol Ladies finger Papaya, green

Pulses

Greengram Redgram Blackgram Bengalgram Lentil Soybean

Green leaf vegetables

Cauliflower Cabbage Amaranthus Gogu

Peas Rajmah Nuts and oil seeds Cashewnuts Ginglly seeds Groundnut Almond Potassium and chronic kidney disease Potassium is mineral that controls muscle function. One important muscle the heart beats at a normal rhythm because of potassium. The kidneys help keep potassium at a normal level. Potassium levels that are too high or too low can be dangerous. How to prevent potassium levels from getting high ? Limit fruits and vegetables. Limit milk and milk products. Avoid salt substitutes and other seasoning that contain potassium. Read labels on low salt or low sodium packaged foods to be sure potassium ingredients like potassium chloride are not added. Keep an eye on serving size. Almost all foods have same potassium, so even a low potassium food can turn into a high potassium food when eaten in large amounts. Leach high potassium vegetables, if including them in your diet. Leaching removes some of the potassium. Fruits All fruits

How to leach vegetables to lower potassium Peel the vegetable, cut into small pieces and place in a very large pot of water for half an hour Rinse the vegetables in water and drain Fill the pot with water and let the vegetables soak for at least four hours at room temperature (or you can let them soak over night in the refrigerator) for excess of leaching. After soaking, rinse the vegetables with clean water. Cook vegetables as desired limit portion to one serving, usually cup.

To keep your potassium levels normal try suggestions Food type Fruit Tip Choose apples, berries, or grapes, instead of banana select a small piece of water melon Eat pineapple instead of mango. Vegetables Choose green beans instead of dried beans or peas. Prepare mashed potatoes from leached potatoes instead of eating baked potato or French fries.

Cool with onion, mushrooms or garlic, instead of tomatoes, tomato sauce or chillie sauce. Drink ice water with sliced lemon and cucumber instead of drinking vegetable juices. Dairy Miscellaneous Use rice milk instead of milk Choose vanilla or lemon flavoured deserts, instead of chocolate deserts Eat unsalted popcorn instead of nuts or seeds. Season with lemon or low sodium herb and spice blends instead of salt substitutes. Food type Fruits High potassium food Banana, sapota Dried nuts , sitaphal Muskmelon Mangoes, lemon Vegetables Sweet potatoes Dried beans and peas Pumpkin Potatoes, French fries Spinach (cooked) Tomatoes, tomato sauce Vegetable juices Dairy Miscellaneous Milk Chocolate Salt substitute Seeds and nuts Note : Portion size plays a role in the amount of potassium got from the foods.

Food type Fruits

Low potassium foods Apple, peaches Berries, pineapple Grapes, plums Lemon Jamun, guava

Vegetables

Carrot, green beans Cabbage, onion Cauliflower, lettuce Cucumber Brinjal

Dairy substitute Snacks

Rice milk Popcorn (unsalted)

Note : Portion size also plays a role in the amount of potassium you get from the foods you eat. Low, moderate and high potassium foods Low Grains Fruits Refined Diluted fruit drinks Moderate Whole grain Canned fruit juices High Bran and germ Dried and raw, frozen, whole Dried, raw, baked fried

Vegetables

Soaked and cooked in large volume of water canned and drained Butter, heavy cream, cream, cheese, instant

Frozen, steamed and cooked in very little water

Dairy

Hard, processed and cottage cheere

Dried evaporated, condensed and fluid milk coconut, coconut water, chocolate, raisin, nuts, brewed and strong coffee

Sodium and chronic kidney disease Although sodium is essential for the body functions but having renal disease means your kidneys cannot eliminate excess sodum and fluid from your body. As sodium and fluid build up in your tissues and blood stream, your blood pressure increases and you feel uncomfortable. The recommended intake of sodium for most healthy people is 2,400mg or less. This equals the amount of one teaspoon of salt.

Tips for managing sodium intake read food labels It will provide important nutritional facts about the contents of your food. Be sure to check the serving size and compare it to the amount you eat. Some of the sodium ingredients used in food processing include, salt, sodium, monosodium glutamate, baking, powder, baking soda, disodium phosphate, sodium benzoate, sodium hydroxide, sodium nitrite, sodium propionate and sodium sulfite. Limit the amount of processed canned foods in your diet. Another option is to use fresh or frozen foods. Watch your beverage intake canned or bottled drinks may not taste salty, but some beverages have added sodium. Avoid sports beverages that contain added sodium. Try substituting fresh herbs and other spices to flavor foods. Be cautions when eating in restaurant. Report any changes to your weight or any swelling to your doctor.

Sodium and potassium content of fruits Fruits (100 g) Apple Amla Banana Guava Jackfruit Jamun Lemon Mosambi Mango Muskmelon Watermelon Orange Papaya Pineapple Sapota Sitaphal Tomato Sodium (mg) 28.00 5.00 36.60 5.50 41.10 26.20 26.00 104.60 27.30 4.50 6.00 34.70 5.90 12.90 Potassium (mg) 75.00 225.00 88.00 91.00 191.00 55.00 270.00 490.00 205.00 341.00 160.00 9.30 69.00 37.00 269.00 340.00 146.00

Phosphorus and chronic kidney disease Unhealthy kidneys are no longer able to remove phosphorus from the blood and get rid of the excess in urine, high levels of phosphorus is a problem for people with severe kidney disease. Almost every food has phosphorus. Knowing what to eat and how much is the key to keep phosphorus levels in a good range. Lower phorphorus food tips Instead of milk, use substitutes like, rice milk, or soy milk. Instead of chocolate biscuits have sugar biscuits. Instead of whole cereal flour use cereals made form corn, refined wheat or rice. Instead of dried beans or peas have green peas. Instead of processed meats, fish and poultry, use fresh or fresh frozen items. Some high phosphorus foods Milk Cheese Ice crme Beer, cola, milk based coffee and chocolate drinks Chocolate Whole grain cereals Nuts, seeds Some low phosphorus food Rice milk, soy milk `unsalted popcorn Sugar biscuits Jam, jelly, honey

Butter Corn or rice cereals refined wheat cereats Fresh or fresh frozen meat, fish and poultry (compared to processed) Fruits like, apples, berries, grapes, plums, pineapple, peaches, Vegetables like green beans, cabbage, carrot, cauliflower, brinjal, cucumber, onion, radish

Dried beans and peas

Processed meat

Organ meat Note : Even if food is considered low in phosphorus, portion size also play a role in the amount of phosphorus you get from foods. Fluid control for kidney disease patients For people in the later stages of chronic kidney disease, normal amount of fluid may cause problems. Too much fluid can build up in the body and may be dangerous. Fluid control for those on hemodialysis Even though dialysis gets rid of excess fluid and waste in the body, it is not as effective as healthy kidneys because healthy kidney work all the time 24 hrs a day, 7 days a week fluid buildup causes swelling and increases blood pressure which makes heart work harder. Too much fluid can build up in the lungs, making it difficult to breathe. Fluid restriction may very for each individual patient. Factors such as weight gain between treatments, urine output and swelling are considered. Fluid control for progressive chronic kidney disease patient

It is based on urine output plus 500ml extra for other fluid losses. Tips for managing your thirst Salty and spicy foods make one thirsty. So limit the amount of sodium and spicy foods in your diet. Be aware of hidden fluids in foods. Fluid is not what you drink, it is also in what you eat. Limit foods with high water content such as water melon, soup, gravy, ice-cream etc. Stay cool, keeping cool will helps to reduce thirst, especially in warmer weather. Try drinking cold liquids instead of had beverages. And if you are thirsty between meals, try snacking an approved vegetables and fruits that are ice cold. Sip your beverages siping will let you savor the liquid longer. Use small cups or glasses for your beverages. Try ice, try freezing your allotted amount of water into an ice tray. You can also try freezing approved fruit juices in ice trays for a special treat. Take your medicines with your meal, if possible. Try swallowing pills with food instead of liquids. (check with your doctor before changing the times you take medications). Battle dry mouth. Dry mouth can be uncomfortable. Instead of drinking fluid to refresh your mouth, try using mouth wash or brushing your teeth. If you have diabetes, maintain good blood glucose levels. High blood glucose levels will increase your thirst. Exchanges for menu planning
Cereals Energy100 Kcal, Protein-3 g Energy100 Kcal, protein-6 g Energy100 Kcal, protein-9 g Energy85 Kcal, protein 7 g Energy80 Kcal, protein 1.3 g Energy45 Kcal, protein 3.6 g Energy30 Kcal, protein 1.7 g 100 g Raw around (30 g) 1 roti/1 chapati/1 dosa/2 idli/1 k rice flakes, 1 k semolina/1 k vermicelli/2 slices of bread

Pulses

30 g

K sambar k dhal curry/ K green gram dhal

Non-vegetarian food items

50 g

6-8 pieces meat/1 slice fish/2 pieces of chicken

Egg:

1 egg

Roots and tubers

k carrot/ k onion/ k beet root/ k potato

Green leafy vegetable

100 g

K spinach (bhaji), K Amaranthus bhaji, K methi bhaji/ k cabbage

Other vegetable

100 g

k bitter gourd/ k bottle gourd/ k brinjal/ k cauliflower/ k clusterbeans/ k cucumber/ k french beans / k green papaya/ k knol-khol / k ladies finger/ k ridge gourd/ k snake gourd 1 apple/2 guava/1 orange/100 g papaya/ 100g pineapple/100 g jamun/2/3 banana

Fruits

Energy40 Kcal

100 g

NUTRITIONAL STATUS AND DIETARY GUIDELINES OF PREDIALYTIC AND HEMODIALYTIC PATIENTS

SWETA SUMAN 2006
ABSTRACT
An investigation was undertaken with an objective to assess the nutritional status of renal patients and document the related complications and suggest suitable dietary guidelines. Predialytic (n=20) and hemodialytic (n=25) patients were selected from Karnataka Institute of Medical Sciences, Hubli, Karnataka. The personal information, prevalent vices, exercise behaviour, dietary modifications and clinical and health status of the subjects were recorded by using pre-tested questionnaire. Etiology of the chronic renal disease, complications and biochemical parameters were documented from the case files. The nutritional status of the patients was assessed by dietary, anthropometric and biochemical methods. Chronic glomerulonephritis (40% in each) followed by diabetes mellitus (30% in predialytics and 32% in dialytics) were the most common etiology for chronic renal failure. Pallor of eyes was the most prevailing sign and the most common complication was anaemia (100%). The dialytics had higher mean values for all the anthropometric measurements compared to predialytics however, both groups had mean values lower than NCHS standards. The mean nutrient intake viz., energy, protein, fats, carbohydrates, fiber, minerals, electrolytes and vitamins were significantly higher in dialytics compared to predialytics. When the subjects were divided based on adequacy of nutrients, higher percentage of predialytics had low adequacy compared to dialytics for energy, carbohydrates, fats, sodium and potassium except for protein. When the biochemical parameters were considered, higher percentage of dialytics had acceptable levels for serum albumin and serum total protein compared to predialytics except for hemoglobin. Suitable dietary guidelines were formulated for dialytics and predialytics based on associated conditions such as hypertension and diabetes mellitus and patients glomerular filtration rate. Low protein, sodium and potassium and high carbohydrate diets were formulated for predialytics and high protein, low sodium and potassium for dialytics, making variations according to individual requirements.

Dr. USHA MALAGI MAJOR ADVISOR