GASTROINTESTINAL DISEASE

Digestive disorders are among the most common problems in health care. Approximately 30percent -40percent of adults claim to have frequent indigestion. Dietary habits specific food types can play a significant role in the onset, treatment of many gastrointestinal disorders.

1. INDIGESTION-

   Indigestion or dyspepsia is a general term that is frequently used to describe discomfort in the upper digestive tract. Symptoms of dyspepsia may include vague abdominal pain, bloating, nausea, belching. Prolonged dyspepsia may be related to gastroesophageal reflux, gastritis, peptic ulcer disease, delayed gastric emptying, gall bladder disease, or cancer. The dietary indulgences-excessive volume of food of high intake of fat, sugar, caffeine, spices, or alcohol or both or commonly implicated in dyspepsia. Management of uncomplicated dyspepsia is by eating slowly, chewing, thoroughly not eating drinking excessively.Indigestion is commonly called ‘heartburn’. Change in hormone during pregnancy slow digestion & also enlarged uterus pressing on your stomach contribute to indigestion.

   Tips to prevent or relieve indigestion:

   • Eat 5 or 6 small meals a day instead of 2 or 3 large ones.
   • A glass of fluid may be equal in volume to a small meal, so avoid drinking a large amount of fluid with your meals.
   • Avoid foods that cause gas, such as spicy or greasy foods.
   • Avoid smoking, caffeine, chocolate, & alcohol.
   • Do not eat or drink several hours before exercising.
   • An antacid may be helpful – ask your health care provider for a suggestion.



2. DIARRHOEA-

   Diarrhea is the frequent passage of loose, watery unformed stools which may also contain blood or mucous. This may prove fatal, particularly, in ‘infants’ and young children. Diarrhea is generally not a disease by itself but a symptom of an underlying functional or organic disease. Diarrhea may be either acute or chronic. Acute diarrhea is characterized by a sudden onset and frequent passage of watery and unformed stools. Acute diarrhea lasts for only 24-48 hours. This can be easily prevented if timely steps are taken to rehydrate the child by giving oral dehydration therapy. Chronic diarrhea persists for a longer time even several weeks and the patient may pass 4-5 unformed stools in a day. Symptoms included abdominal pain, cramps, weakness, and sometimes fever and vomiting.
   
   

   DIETARY MANAGEMENT

   • Energy requirements are increased by 10-20percent to meet the losses during diarrhea as well as overcome weakness and loss of weight.
   • Protein:A high protein intake an essential to building up body tissue. Advisable increase in protein up to 50percent.
   • Carbohydrate: Intake of carbohydrates should be increased to meet the high energy requirement. But fiber intake is kept to a minimum (1-2g/day). Patients should be encouraged to avoid caffeine because it increases cyclic adenosine monophosphate levels, promoting the secretion of fluid.
   • Fat: Due to increased motility of the intestines, fat is not completely digested, and therefore their intake needs to be restricted.
   • Minerals: During diarrhea, care should be taken to include calcium and iron-rich foods in the diet.
   • Vitamins: Greater amounts of B group vitamins must be provided to compensate for the losses that occur due to diarrhea.
   • Fiber: Low residue foods should be given to patients with diarrhea.
   • Diet and feeding pattern: The diet should be easily digestible. A soft, bland diet, low in fiber, residue, and fat is recommended. Well-cooked, soft, semisolid foods may be included. The patient should drink fluids and eat food at frequent intervals.
   • Foods included: Washed Pulses and Refined Cereals, Well Cooked Vegetables, and Soft Low Fiber Foods Like Banana, Papaya, Milk Product Such as Curd and Paneer, Egg, Chicken, Fish, bananas, plain rice, toast, broth, or soups (which contain sodium) certain fruit juices, soft fruits, or vegetables (which contain potassium).
   • Foods avoided: Whole cereals, pulses, raw vegetables fried foods and milk-based beverages, most dairy products, fried foods.




SAMPLE MENU

Time	Menu	Portion
Early morning	Milk	1 glass
Breakfast	Bread Toast	2
	Papaya shake - milk or curd	1
Lunch	Spinach Khichari	1 plate
	Curd	1 bowl
Mid-afternoon	Banana shake	1 glass
Evening tea	Sandwich	1 piece
Dinner	Chapatti	2
	Fried Potatoes	1 bowl
	Plain custard	1 bowl
Bedtime	Milk	1 glass

3. CONSTIPATION

   Constipation may be defined as the retention of the feces in the colon beyond the normal length of emptying time. It is the irregular, infrequent, or difficult passage of feces. It is a condition of stasis in the large intestine. Constipation may be defined as less than 3 motions per week or as difficult or painful defecations. Loss of muscle tone in the colon or rectum may cause difficulty in the evacuation of stools and results in atonic constipation. On the other hand, Spastic constipation occurs due to an increase in the muscle tone which narrows the cavity and the forward movement of feces is retarded. Symptoms generally seen are general malaise, headache, coated tongue, foul breath, and lack of appetite. These symptoms disappear with the passage of stools.

   DIETARY MANAGEMENT

   The requirement of various nutrients is not altered in constipation. It is essentially a normal diet with modifications in fiber and fluid intake. The intake of dietary fiber should be increased by eating whole cereals and increasing the consumption of fruits and vegetables. A fluid intake of 8-10 glasses a day is useful in keeping the intestinal contents in a semisolid state for easier passage along the tract. Many laxatives are available like hydrophilic colloids i.e., isabgol and agar-agar. It is used in the case of chronic constipation, but continued use is not recommended because they lead to excessive sodium, potassium, and water in the feces.

   FOODS TO TREAT CONSTIPATION

   • Water: The first to understand is that constipation is often due to a lack of water. If you just increase your water intake, then this can be enough. Well, if you do not have enough water following through your colon then your stools can become hard, dry, and difficult to pass.
   • Fiber: In Addition to too little water, most people also eat too little fiber. Fiber is important because it adds bulk to stools this makes it easier for the body to pass the waste through the system. However, one must make sure that he is eating the right type of fiber – white bread, breakfast cereals covered in sugar are not going to help. Instead, one should look to increase fiber intake via whole-grain pieces of bread, whole grain pasta, brown rice, fruit including the skins, vegetables (these also contain a lot of water).
   • Avoid processed foods: Other foodstuffs to avoid or consume in moderation when first tackling your constipation include fried food, cheese, ice cream, cakes, soda etc. One can reintroduce these foods once they have made some progress seen some positive results.
   • Dietary modification in terms of consistency the diet should be normal, rich in fibrous foodstuffs.



SAMPLE MENU

Time	Menu	Portion
Early morning	Lemon water	1 glass
Breakfast	Poha	1 bowl
	Milk	1 cup
Mid-morning	Fruit chat	1/2 plate
Lunch	Chapatti	2
	Rice	1 bowl
	Rajma	1 bowl
	Green salad	1/2 plate
Evening time	Tea	1 cup
	Vegitable Sandwich	2 pieces
Dinner	Chapatti	2
	Palak dhal	1 bowl
	Bottle grourd vegitable	1 bowl
	Vegitable Raita	1 bowl
Bedtime	Warm milk + 1 spoon isabgol	1 glass




HIGH FIBRE DIET

• Cereals- Whole wheat Bread, Whole wheat flour, Wheat bran, Brown Rice, Multigrain bread, Wheat pasta, Oats, broken wheat Daliya
• Pulses- Whole & skinned, Sprouts.
• Vegetables- Raw Vegetables, Salads, High fiber vegetables Like lettuce, cabbage, beans, cauliflower, peas, lotus stem, radish
• Fruits- with skin especially fruits like papaya, guava.
• Seed-Flax seeds, Fenugreek seeds
• Dry fruits like Almonds, figs

A peptic ulcer is any localized erosion of the mucosal lining of those portions of the alimentary tract that meet acidic gastric juice. This disintegration of tissues can also result in necrosis. Most ulcers are found in the stomach, jejunum (gastric ulcer) in the duodenum (duodenal ulcer) above the point of entry of alkaline pancreatic juices. The most common symptom is pain or discomfort in the upper central abdomen. It appears as burning or pressing pain when the stomach is empty in the case of duodenal ulcers and after a meal is gastric ulcers. This may be accompanied with appearance of black stools or vomiting of blood. Thus, bleeding ulcers also cause anemia.

Dietary Management

It was customary to suggest diet for an ulcer patient. A bland diet is a diet that is mechanically, chemically, and thermally non-irritating. There must be optimal overall nutritional intake to support recovery maintain healthy tissue, based on individual needs and food tolerance.

• Protein is included because of its good buffering action. They may be increased by about a 50percent.
• FatsModerate amounts help to suppress gastric secretion motility through the enterogastrone mechanism. Fats are included to meet the energy needs. Foods containing harsh, irritating fiber should be avoided.
• Vitamins adequate amount of vitamin C should be provided for the healing of ulcers and better iron absorption.
• Mineral care should be taken to include good sources of iron and calcium in the diet.

DIET and FEEDING PATTERN

1. Bland diets are recommended for patients suffering from peptic ulcers.
2. The quantity of food eaten should be small to avoid overfilling.
3. The cooking methods most suitable for the preparation of foods and diets and moist heat methods such as boiling, steaming, simmering, stewing, pressure cooking, etc.
4. Eat smaller meals more often, eat slowly savor your food in a calm environment.
5. Moderate uses of seasoning are permitted.
6. Cut down on or stop smoking cigarettes.
7. Avoid excessive spices or concentrated meat broths and extractives.
8. Avoid caffeine beverages such as coffee, cola, and tea. Also, avoid alcohol.

Foods to be included.

Dairy products like Milk, Cream, Butter, Milk, Cheese Eggs (not Fried), Steamed Fish, Rice, Rice Flakes Puffed Rice, Well Cooked Cereal, Semolina, Cooked Green Leafy Vegetables, Custards, Malted Drinks, Cooked Pulses (if they are not causing gas formation)

Foods to be avoided.

Alcohol Strong Tea, Coffee, Cola Beverages, Pickles, Spices, Chilies, Curries, Condiments, All Fried Foods, Pastries, Cakes, Heavy Sweets Like Halwa, Barfi, Raw Unripe Fruits, Raw Vegetables Like Cucumber, Onions, Radish, Tomatoes.

SAMPLE MENU

Time	Menu	Portion
Early morning	Milk	1 glass
Breakfast	Upma	1/2 plate
Mid-morning	Shrikhand	1/2 bowl
Lunch	Plain Khichari	1 plate
	Curd	1 bowl
Mid-afternoon	Fruit chat	1 plate
Evening tea	Bread and flavored Milk	1 piece
Dinner	Chapatti	3
	Light vegitable (tinda)	1 bowl
	Kadhi dal will be better	1 bowl
Bedtime	Kheer	1 bowl

Intestinal gases include nitrogen, oxygen, carbon dioxide in some individual’s methane gases takes in or produced in the GI tract may be absorbed into the circulation lost in respiration, expelled through eructation (bleaching), or passed rectally, the patient may complain of abdominal distention or cramping pain associated with the accumulation of gases in the upper or lower GI. Gas in the upper intestinal tract primarily from aerophobia (swallowing air).

• Dietary modification in terms of nutrients- Energy-according to RDA, Protein-1g/ideal body weight, Fat-15-20percent of total calories, -50-60percent of total calories.
• Dietary modification in terms of consistency- Bland Diet

Foods to be included:

Consumption of a large amount of dietary fiber (especially soluble fiber) resistant starch, meat fish, chicken, potato, sweet potato, vegetable cooked thick soups, rice, desserts, pastry, biscuits, etc.

Food to be avoided:

Papad, Chutney, pickle, cabbage, radish, cauliflower.

SAMPLE MENU

Time	Menu	Portion
Early morning	Lukewarm water	1 glass
Breakfast	Sago kheer	1 bowl
	Mixed juice	1 glass
Mid-morning	Sprouted chat	1 bowl
Lunch	Chapatti	2
	Green gram dhal	1 bowl
	Parwal Vegitable	1 bowl
	Rice	1/2 plate
	Green salad	1/2 plate
Evening tea	Tomato soup	1 bowl
Dinner	Chapatti	3
	Soybean vegetable	1 bowl
	Curd	1 bowl
Bedtime	Milk	1 glass

A high prevalence of cancer in ulcerative colitis has been reported from tertiary referral centers. This frequency has not been reported in the general population with ulcerative colitis. Periodic surveillance with colonoscopy for cancer in ulcerative colitis is thus not cost-effective.

DIETARY MANAGEMENT

• Calories: An adequate supply of about 2000-2500 kcal should be aimed at.
• Proteins: Patients with ulcerative colitis lose about 4.8g. Fecal nitrogen daily, Compared to the normal excretion of 2g. In severe disease, up to 20g nitrogen (equivalent to 125g protein) may be lost daily. The serum albumin level is low. 100g protein/per day should be supplied. This can be achieved easily in a person taking a mixed diet. In vegetarians, it is a difficult task, particularly when the exclusion of milk is also tried in the hope of producing remissio.
• 1. Usual foods that contain fats are permitted. Fried foods are not easily digested.
  2. Bulk-producing vegetables are restricted to allow a better intake of more nourishing foods.
  3. Commercial multivitamin preparation should be administered orally or by injections as required.
  4. Mineral’s loss may be marked, unless replaced may contribute to a fatal outcome. A patient with moderately advanced ulcerative colitis passes a large volume of feces (over 400ml/day) may lose considerable sodium, potassium, sodium loss is approximately 100mEq or mmol (6g when expressed as sodium chloride) per liter of stools.
  5. All forms of irritant stale foods should be strictly avoided. Fish oil contains eicosapentaenoic acid n-3 fatty acids which have been found useful in some patients. Supplementary feeding of preparation made commercially from protein concentrate may help.
  6. Eight level tablespoons of Complan are mixed with 500ml of water or milk. The powder is rigorously stirred then strained to remove lumps. About 20g of elemental iron must be given daily. If anemia is marked, Blood transfusions or intramuscular injection of 100 mg each of iron dextrin complex may be given. Iron given injection is stored in the body and utilized when necessary.
  7. A liberal intake of fluids should be ensured to prevent dehydration. The passage of at least 1200 ml of urine indicates that a patient is well hydrated. It is worth trying a regime consisting of a milk-free diet for all patients.
• Foods permitted: Bread, Chapatti of Wheat, Rice, Maize, Jawar, Bajra or Ragi, Breakfast cereals of Wheat, Rice, Oatmeal, or Maize. Rice’s Cooked, Pulses Beans, As Dal Water Vegetables, Cooked Tender. Potato, Sweet Potato or Yam, Soups. Meat, Fish or Chicken, Egg. Milk Product. (Restricted If Diarrhoea) Fat for Cooking Butter (Fried Food Not Permitted) Sugar, Jaggery Honey. Jam Or Murrabba Biscuits, Desserts Fresh Fruits, Beverage, Water Liberal.
• Foods Excluded: Vegetable Salad, Condiments Spices, Papad, Chutney or Pickles, Nuts, Fruits.
• Alcohol: There appears to be an individual’s susceptibility to an attack of gout after ingestion of alcohol. Stopping may prevent an attack of gout in such people otherwise, gouty patients usually tolerate a couple of ounces of while wine or whisky, but not beer, stout, or red wines.
• Beverages: Tea coffee contains methyl purines which are not converted by the body into uric acid. About 2 or 3 cups a day are permitted.

Esophagus is a muscular tube 25cm in length that helps in transporting food from the mouth to the stomach. As the bolus of food is moved voluntarily from the mouth to the pharynx, the upper esophageal sphincter relaxes, the food enters the esophagus, and subsequently the lower esophageal sphincter relaxes to receive the food bolus. There are two types of esophagitis conditions: acute oesophagitis chronic or reflux esophagitis.

Nutrition management goals

1. Prevention of irritation of the inflamed esophageal mucosa.
2. Prevention of esophageal reflux.
3. To decrease the acidity of the gastric juice.

Dietary management

In Acute Phase, the dietary factors to be kept in mind is the Liquid diet: small frequent meals, less abrasion to the esophagus thus avoide orange juice other citrus, tomato products because of their acidity. Spices like chili powder, black pepper to be avoided.
In the chronic phase, the following factors must be considered as well: Avoiding food that is known to cause heartburn, decrease pressure like alcohol, caffeine-containing beverages, coffee, cold drinks, fatty food, increased fat intake, Timing of the meals is especially important especially before the afternoon nap, evening. Reduce weight so that abdominal pressure is decreased. Avoid tight-fitting clothes. Avoid smoking.

Gastritis is an inflammatory lesion of the gastric mucosa, (the inner of the stomach) the problem is seen in two forms: Acute gastritis, Chronic gastritis. It is a sudden inflammation of the lining of the stomach. It occurs mainly due to overeating, overuse of alcohol, tobacco, chronic or excessive dose of aspirin, anti-inflammatory drugs, surgery, shock, fever, jaundice, renal failure, burns, and radiation therapy.

• Symptoms: Anorexia, epigastric discomfort, heartburn, severe vomiting, pain in the upper abdomen, Headache, Bleeding.
• Etiology: Faulty dietary habits like overeating taking highly seasoned foods. Excessive use of alcohol, drugs. Exposure of gastric mucosa to irradiation. Increased production of the bile salts. Burns, renal failure.

Dietary guidelines

• Energy: give adequate calories through frequent feeding or else proteins would be utilized for the energy of repair work.
• Protein: give adequate proteins through skimmed milk, egg, steamed fish, chicken, minced meat, etc.
• Carbohydrate: simple easy to digest foods should be included in soft well-cooked from. Thus semolina, rice, Maida, sago, arrowroot, etc. can be given.
• Fiber: Eating a diet high in fiber reduces the risk of developing ulcers, also speeds up the healing process.
• Vitamins: Supplementation with vitamin B helps to treat pernicious anemia and H. Pylori infection. Its sources include fish, dairy products, organ meats, eggs, beef, and pork. A high dose of vitamin C treatment is effective in H. Pylori infection.

A common disorder of the large bowel, diverticulitis, is an early stage of the disease. An increased intracolonic pressure, straining to pass hard feces rupturing of the bowel well at weak points to form small pockets, which are called diverticulitis.

• Symptoms Depending on the site of diverticula the symptoms may appear. It occurs most often in the sigmoid colon, frequency increases with age.
• Etiology Aging, The movement of waste through the colon, a low fiber diet, and anatomic defects.

Dietary management

• High fiber diet: high fiber diet prevents diverticular disease and other gastrointestinal disorders, A review of such studies reports that vegetarians are less likely to have diverticular disease, most likely because they tend to eat more fiber.
• Glutamine: while specific nutrients that have an impact on diverticular disease have not been studied as thoroughly as the high-fiber diet.
• Omega-3 essential fatty acids: omega-3 essential fatty acids found in flax cold water fish help fight inflammation.
• Lifestyle modification: obesity may be health-associated with increased severity of diverticular disease. Hence, maintaining the ideal weight for age is beneficial from all health aspects.
• Prevention strategy: Eat a high-fiber diet. If diverticulitis is present avoid food such as seeds that may block the opening of a diverticular lead to inflammation infection. Exercise regularly to decrease the occurrence of symptoms.

The most common symptoms are alternating diarrhea and constipation, abdominal pain, and bloating but the perception of excessive flatulence, the sensation of incomplete evacuation, rectal pain, and mucus in the stool may also occur. In patients with a strong family history of allergy, hypersensitivity to certain foods may be the cause of IBS.

The reason for IBS are

1. excess use of laxatives
2. antibiotics
3. caffeine
4. previous gastrointestinal illness
5. lack of regularity in sleep, rest, and fluid intake.

DIETARY MANAGEMENT

A normal diet is recommended, with emphasis on High fiber foods that will add bulk to the stool, thus relieving the constricting pressure and promoting normal bowel motility. A daily fiber intake of 20-30g is recommended.

• Foods to be included Whole cereals like whole wheat, Dalia, etc. whole pulses, vegetables like peas, beans, lotus stem, etc. fruits like apple, cherries, pear, peaches, plums, etc.
• Foods to be avoidedExcesses in dietary fat, caffeine, sugar, and alcoholic beverages should be avoided.

SAMPLE MENU

Time	Menu	Portion
Early morning	Milk	1 glass
Breakfast	Palak Parantha	2
	Amla Chutney	1/2 bowl
Mid-morning	Fruit custard	1 bowl
Lunch	Chapatti	2
	Rice	1 bowl
	Green gram dhal	1 bowl
	Spinach Vegitable	1/2 bowl
	Curd	1 bowl
Evening tea	Banana shake	1 glass
Dinner	Chapatti	3
	Pumpkin vegetable	1 bowl
	Lentil dhal	1 bowl
	Vegitable Raita	1 bowl
Bedtime	Milk	1 glass

Tropical sprue causes malabsorption, a condition that can prevent the body from taking in important to cause symptoms that should be avoided. Otherwise, a generally healthy diet should be followed.

Strategies for a healthy diet include:

1. Limit your intake of fat to 30percent of your total calories.
2. 10 percent to 15 percent of your total calories should be in the form of monounsaturated fats, such as olive oil, canola oil peanut oil.
3. Consume only unsaturated fats that are low in cholesterol a day.
4. Consume less than 300 milligrams of cholesterol a day.
5. Eat dietary fiber: whole grains are best. Avoid fad diets.
6. Check with your doctor about B vitamin Supplements. Some people may benefit from B vitamins.

Celiac disease is characterized by sensitivity to gluten, the protein fraction of wheat. The resulting damage to the villi of the intestinal mucosa resulting in potential or actual malabsorption of virtually all nutrients. Celiac disease usually develops within the first three years of life. The child fails to thrive, loses appetite, and is pot-bellied. Stools are large, pale, and offensive due to the presence of free fatty acids. When gluten is derived from wheat, oat rye and barley are excluded. Giving soft diet and progressing to normal incomplete

• Foods to be included: Product made Corn, Potato, Rice, Soybean, Tapioca, Arrowroot, Amaranth Seeds, and Millets can be included in the diet.
• Foods to be avoided Wheat, Oat, Rye, Barley, and Its Product like Breakfast Cereal, Poories, Parantha, Chapattis, Macaroni, Noodles, and Pasta, etc.

SAMPLE MENU

Time	Menu	Portion
Early morning	Sweet corn	1 bowl
Breakfast	Poha	1 bowl
	Milk	1 glass
Mid-morning	Besan cheela	2 pieces
Lunch	Rice	1 plate
	Dhal red gram	1 bowl
	Soyabean Vegetable	1 bowl
	Curd	1 bowl
	Salad	1/2 plate
Evening tea	Fruit chat	1 bowl
Dinner	Idli	4 pieces
	Sambhar	1 bowl
Bedtime	Milk	1 glass

SAMPLE MENU

Time	Menu	Portion
Early morning	TEA/COFFEE	1 cup
Breakfast	SAGO PORRIDGE/SAGO KHICHRI/UTTAPAM/ IDLI/POHA	2 serv.
	Milk	1 cup
	SPROUTS/EGG	50 g
Mid-morning	FRUIT/FRUITJUICE/CLEARSOUP	1 cup
	ROASTED CHANNA/STEAMED CORN	20 g
Lunch	SALAD RICE/ IDLI/ DOSA/ UTTAPAM/ BESAN CHEELA/ MAKKI KI ROTI	1 plate
	DAL/ N.VEG	30 gm
	VEGETABLE	100 gm
	CURD/ RAITA	1 cup
	TEA/ COFFEE/ MILK SHAKE	1 cup
Evening tea	MURMURA CHAAT/BHELPURI/POTATO CHAAT/PAKORA/ DAL VADA/ SPROUTS CHAAT/ CUTLET/ DHOKLA	1 piece
Dinner	DAL/ N.VEG.	30 g
	RICE/ IDLI/ DOSA/ UTTAPAM/ BESAN CHEELA/ MAKKI KI ROTI	2-3
	VEGETABLE	100 gm
	CURD/ RAITA/ SALAD	1 cup
Bedtime	Milk	1 cup

• FOODS ALLOWED: Amaranth, Arrowroot, Buckwheat (Kuttu), Corn, Flax, Legumes/Besan, Millet (Bajra+Ragi), Nuts Potatoes, Rice/Rice Flakes, Sago, Soybean, Sorghum (Jowar).
• FOODS AVOIDED: Wheat & Wheat Product Like Atta, Maida, Bread, Cakes, Chapatti, Noodles, Pasta, Seviyan, Suji, Wheat Starch, Wheat Bran, Cracked Wheat, Barley (Jave), Oats, Rye.
• Processed Foods That May Contain Wheat, Barley, or Rye*: Brown Rice Syrup, Chips/Potato Chips, Hot Dogs, French Fries, Gravy, Rice Mixes, Sauces, Soups, Soy Sauce, Vegetable in Sauce.
• * Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer.

Hepatitis is an infectious disease characterized by inflammation and degeneration of the liver cells and is of two types-viral and drug. Hepatitis can be due to type A and E or due to B, C, D, and G virus. The symptoms of infective hepatitis are anorexia, fever, headache, rapid weight loss, loss of muscle tone, nausea and vomiting, and abdominal discomfort. The urine color changes from dark yellow to red, the feces become whitish.

VIRAL HEPATITIS

Hepatitis means inflammation of the liver. Many illness conditions can lead to inflammation of the liver. For example drug, chemical, and autoimmune disease.
Hepatitis is defining as liver inflammation resulting from alcohol use, toxic material (carbon tetrachloride), or viral infection (transmitted in foods liquids, or blood transfusion).

The liver is in the upper right side of the abdomen, mostly behind the rib following vital function-

1. The liver helps purify the blood by changing harmful chemicals into harmless ones.
2. The liver produces many important substances especially proteins that are necessary for good health.
3. The liver stores many sugars, fats, vitamins until they are needed elsewhere in the body.
4. The liver build smaller chemicals into large, more complicated chemicals that are needed elsewhere in the body.

Stages of Viral Hepatitis:

• The first stage of viral hepatitis is preicteric/prodromal (with flu-like symptoms).
• The second stage is posticteric jaundice, dark urine, light stools.
• The third stage is posticteric/convalescent.

Symptoms of Viral Hepatitis

Hepatitis A has an incubation period of about 15-45 days, Hepatitis B from 46-160 days, Hepatitis C from 2 weeks to 6 months. Many patients infected with Hepatitis A, B, and C have few or no symptoms of illness. For those who do develop symptoms of viral hepatitis, the most common are flu-like symptoms including loss of appetite, Nausea, Vomiting, Fever, Weakness, Tiredness, Ache in the abdomen. Less common symptoms include-Dark urine, Light-colored stools, fever; Jaundice (a yellow appearance to the skin and white portion of the eyes.).

Dietetic management:

• Calories: In a 60 kg patient with hepatic precoma or coma, 1500-2000 kcal (6.3-8.4ml) should be supplied, if necessary, by nasogastric tube feeding during moderate or severe jaundice.
• Protein: The liver metabolizes products of intestinal protein decomposition with marked deterioration of liver function products of protein break. In severe jaundice (serum bilirubin over 16mg/100ml), an average intake of 30-40g protein daily, helps in the regeneration of the liver cells, a higher intake may precipitate coma.
• Fat: The observation in animals that a high fat low protein diet produces fatty liver, has led to the wrong assumption that fats should be prohibited in viral hepatitis. In severe jaundice about 30g of fats daily is permissible. In moderate to mild jaundice, about 50-60g fat daily may be permitted. In patients taking fat in moderate quantities, not only is weight loss prevented, but weight increase and quicker recovery may result.
• Minerals: During intravenous feeding, a careful watch should be kept on the resume sodium-potassium levels.
• Food items for a patient with severe jaundice: Viral hepatitis or obstructive in which total serum bilirubin is over 15mg/100ml, 256micromal/l.
• Foods Permitted: Bread or Chapatti of Wheat, Rice, Maize Jowar, Breakfast Cereal of Wheat, Rice Oatmeal or Maize. Milk Or Its Product, Cooked Vegetables Salad, Fresh Fruit or Dried Fruits. Sugar, Jaggery, or Honey. Jam Or Murabba. Dessert As Light Custard or Ice-Cream. Water, Liberal. Cereal Porridge, Soft Chapattis, Bread, Rice, Skimmed Milk, Tapioca, Potato, Yam, Fruits Juices, Sugar, Jaggery, Honey, Biscuit, Soft Custards Without Cream and Non-Stimulant Beverages.
• Foods Excluded: Pulses or Beans, Meat and Fish or Chicken, Eggs, Oils and Butter, Nuts, Spices, Chutney or Pickles, Pulses, Beans, Meat, Fish, Chicken, Meat Soups, Sweet Preparation where Ghee, Butter or Oil are used, Bakery Products, Dried Fruits, Nuts, Spices, Papads, Chutneys, Alcohol Beverages, Fried Preparation, Whole Milk, Cream.
• In term of nutrients- Energy-1600-1700kcal; Protein-40-45g; Carbohydrate-300-340g ;Fat-25-30g.
• In terms of consistency, the diet should be given in liquid consistency.
• Diet and feeding pattern: soft consistency.

A high protein, high moderate fat is recommended, Small attractive meals at regular intervals are better tolerated. Overfeeding should be avoided.

SAMPLE MENU

Time	Menu	Portion
Early morning	Milk	1 glass
Breakfast	Milk-based Dalia	1 bowl
Mid-morning	Sprouted chat	1 bowl
Lunch	Vegetable khichari	1 plate
	Curd	1 bowl
Mid-afternoon	Rasgulla	2
Evening tea	Orange juice	1 glass
Dinner	Sandwich	2
	Boiled egg	2
	Custard	1 bowl
Bedtime	Milk	1 glass

HEPATIC DIET

Time	Menu	Portion
Breakfast	DALIYA PORRIDGE/ SUJI PORRIDGE/ SAGO KHEER/ VERMICELLI KHEER/ CORNFLAKES WITH MILK/ TOAST WITH JAM.	1 bowl
Mid-morning	FRUIT CHAT	1 bowl
Lunch	CHAPATTI/ RICE	2/ 1 bowl
	VEGETABLE	1 Katori
	KATORI DAL	1 Katori
	KATORI CURD	1 Katori
	FRUIT	1
Teatime	JUICE/COCONUT WATER/ROOHAFZA/KHUS/SHIKANJI/1KATORI UPMA/ POHA/ VEG/ALOO TOAST/IDLI/MURMURA CHAT
Snacks	Fruit	1
	VEGETABLE SOUP/ JUICE	1 bowl
Dinner	CHAPATTI	2
	VEGETABLE	1 Katori
	DAL (WASHED)	1 Katori
	CURD/ KHEER/ JELLY/ CUSTARD	1 Katori
Bedtime	Milk	1 glass

• FOODS ALLOWED: Fruits, Potato Based Products Like Aloo Tikki (Baked), Aloo Toast, Sweet Dishes Like Custard, Rice Kheer, Sago Kheer, Snacks Like Murmura chat, Idli, Upma, Poha, Steam Corns.
• FOODS AVOIDED: Ghee, butter, cream, excess oil, fried foods, Meat & meat products, Full cream milk & its products.
• DIET INSTRUCTIONS: Small frequent meals, plenty of fluids, eat a balanced diet, do not miss meals; a High carbohydrate diet should be encouraged.

The two types of hepatitis that one comes across are viral and drug- usually mild and rarely progress to chronic hepatitis. Type B may be transmitted chiefly through improperly sterilized surgical needles etc. It is more severe and may potentially progress to a serious disorder. Type C may be transmitted by blood transfusion. It is also frequently seen in male homosexuals.

• DIETARY MANAGEMENT: A high protein, high, moderate fat diet is recommended. Small attractive meals at regular intervals are better tolerated. Overfeeding should be avoided.
• Energy: In the nasogastric feeding stage about 1000kcal are supplied. In severe cases 1600kcal to 2000kcal are suggested.
• Protein: For the liver cells to regenerate, an adequate supply of protein is needed. Protein requirements vary according to the severity of the disease. With severe jaundice, 40g while in mild jaundice 60-80g of protein is permitted. With hepatic precoma and coma, protein-containing foods are withheld as the liver cannot metabolize protein and only high protein-containing foods are given.
• Fats: Fats make the food more palatable and increase calorie intake. During hepatitis precoma and coma, due to severe liver failure, fats are not metabolized by the liver and so fats are restricted. In severe jaundice, 20g and moderate jaundice 20-30g fats are recommended. In other cases of jaundice, fat digestion and produce fatty diarrhea.
• Carbohydrate: High containment in the diet is essential to supply enough calories so that tissue protein is not broken down for energy purposes. When fever, nausea, and vomiting are present, intravenous glucose is suggested. As soon as the patient can take oral feeds, intravenous feeding should be stopped and fruit juice, sugar, jaggery, and honey are given not only to provide but also to supply adequate electrolytes.
• Vitamins: They are essential to regenerate liver cells. 500mg of vitamin C, 10mg of vitamin K and supplements of B-complex are essential to meet the daily needs. In anorexia, nausea, or vomiting, the vitamins may be given by injection,
• Minerals: If the food is not taken orally then a careful watch should be kept on the serum sodium, potassium level. An oral feed of fruit juice, vegetable, and meat soup with added salt, given orally or through a nasogastric tube helps in maintaining the electrolyte balance. Normal serum levels of Na and K must be maintained through supplements.
• Intravenous feeding: With severe nausea and vomiting it may not be possible to take oral feeds. Intravenous administration of 10percent glucose solution is required.
• Food included: Cereal Porridge, Soft Chapattis, Bread, Rice, Potato, Yam, And Fruit, Jaggery.
• Foods avoided: Pulses, Meat, Beans, Egg, Sweet Preparation Where Ghee, Oil Are Used, Papads and Chutney Cream, etc.

Cirrhosis is not merely fibrosis, but a chain of events initiated by necrosis of hepatic cells, and resulting in collapse, liver fibrosis alone without cirrhosis is observed in conditions like non-cirrhosis and congenital hepatic fibrosis, after trauma or liver abscess. Cirrhosis is a chronic disease of the liver. It is a condition in which there is the destruction of the liver cells due to necrosis, fatty infiltration, and fibrosis nodular regeneration. It is a serious irreversible disease. Vitamin A deficiency favors the formation of cirrhosis. Almost 85-90 percent of liver damage also does not produce symptoms.

• Etiology: Viral infection, chronic alcoholism, Malnutrition of vitamin A, B-carotene and vitamins E and C. Toxins of foods
• Symptoms: The onset of the disease is gradual with symptoms of gastrointestinal disturbances. Such as nausea, vomiting, anorexia, distension epigastric pain. Jaundice appears with increasing weakness, edema, ascites, and tendencies of gastrointestinal bleeding, esophageal varices, and iron deficiency anemia. Steatorrhea is a common symptom.

Dietary management

The energy requirements are increased to correct malnutrition and to promote the regeneration of liver cells. The calorie requirement should be between 2000-2500k.cals. In the absence of impending hepatic coma, the protein intake should be continued at the levels suggested for hepatitis, i.e., 1.0-1.5g/kg actual body weight. However, if signs of impending coma appear, the protein intake is decreased to 0.3g/kg body weight; depending on the individual’s tolerance. Fat about 20g is given. Even if fatty changes are present in the liver, fat should be given, provided adequate amounts of protein are supplied; it should be supplied liberally so that the liver may store glycogen. Intake of 300g mainly in the form of simple sugars like sugar, glucose, fruits, and fruits juices, starch, cereals, root vegetables, is advised. 60percent of calories should come from so that liver damage is minimized. Irritating fibers should be eliminated due to the presence of esophageal varices. Thus, dehusked pulses, refined cereals, low fiber vegetables fruits should be selected. In cirrhosis, the liver concentration of folate, riboflavin, nicotinamide, vitamin B 12, and vitamin A is decreased. These minerals and vitamins should be provided in adequate amounts. The presence of ascites, edema necessitates the restriction of sodium in the diet. In severe cases, a 500mg sodium diet is recommended.

1. A nutritive high protein (1-1.2/kg body weight) diet is the most essential part of therapy for liver cirrhosis.
2. A high protein diet may be adequate in most cases. Generally, a protein intake of 35-40g/day is considered.
3. The fiber in the diet may be increased in the diet as much as can be tolerated. Adequate calories should be supplied, about 30-60kcal/kg body weight is sufficient.
4. Vitamins may be supplemented in the diet to replenish liver stores and repair tissues damage, especially if there is anorexia.
5. If swelling and ascites are seen, then sodium in the diet may be restricted. Generally, a 500-800mg sodium diet is prescribed.
6. The consistency of the diet should be liquid too soft with small and frequent meals, accompanied by a reduction in the fiber content of the diet.

• Food allowed: Bread or Chapattis of Wheat, Rice, Maize, Ragi, Sweet Potato, Yam, Sugar Honey, Fruits, etc. Cereals, Pulses, Dried Beans, Fish (Steam Fish), Jowar, Bajra, Chicken, Egg White, Fruit Juice, Glucose, Sugar.
• Food avoided: Papads, Chutney, Pickles, Paper Chutney, Pickle, Uncle Chips, Kurkure, Salt Some Amount, High Fiber Foods Like Husked with Pulses, Salads, Green Leafy Vegetables, etc.

A high calorie, high, moderate, or restricted fat, high vitamin diet, low fiber diet helps in regeneration of the liver and helps to prevent the formation of ascites. Low fat with supplementation of fat-soluble vitamins and minerals should be given. Sodium should be restricted only when there are ascites. Acutely ill patients may require a fluid diet with 6-8 feeds in a day while patients on the path to recovery may be given a soft diet, with small frequent meals. Since sodium restriction is also advised care should be taken to avoid cooking salt, baking powder preserved foods, and foods containing salt.

SAMPLE MENU

Time	Menu	Portion
Early morning	Tea	1 cup
Breakfast	Sago porridge	1 bowl
	Papaya	1 bowl
Mid-morning	milk	1 glass
Lunch	Vegetable pulao	1 plate
	Curd	1 bowl
Mid-afternoon	Custard	1 bowl
Evening tea	Sweet vermicelli	1 bowl
Dinner	Macaroni with Tomato Sauce	1 bowl
	Bread Pugging	1 bowl

Obesity is a state in which there is a generalized accumulation of excess adipose tissue in the body leading to more than 20percent of the desirable body weight. Overweight is a condition where t6he body weight is 10-20 percent greater than the mean standard weight for age, height sex, Obesity invites disability, disease, and premature death. Excess body weight is a hindrance, leading to breathlessness on moderate exertion and diseases osteoarthritis of weight-bearing joints, varicose veins. Obesity is a chronic disease.

Etiology:

Obesity is a complex multifactorial chronic disease developing from the interactive influence of numerous factors like social, behavioral, psychological, metabolic, and cellular molecular. Genetic inheritance probably influences 50-70 percent of a person’s chance of becoming fat more than any other factor, within families, the chance is 80 percent if both parents are obsessed 50 percent of one parent is obese. It can occur at any age in either sex if the people under positive energy balance. Studies conducted at The Nutrition Foundation of India have shown more females than males to be overweight in all age groups. Certain types of eating habits may lead to obesity. Nibbling between meals is common among housewives is a potential cause of obesity. Some may eat faster taking less time chewing, therefore and they tend to consume more food. People who eat outside their homes more frequently are prone to obesity. People who eat more junk food (high fat) may become obese.

Types of Obesity:

• Grade I obesity- These people have a body mass index of more than 25 but less than 29.9 overweight does not affect their health and they lead normal healthy lives, life expectancy is above normal.
• Grade II obesity- The body mass index is between 30-39.9.
• Grade III obesity- The BMI is above 40 these patients are in pathetic condition. And need immediate expert help.

Metabolic changes commonly present in obese patients -

• Assessment: An adult weighing 10 percent more than the standard is overweight.
  

  Percent Body weight excess of normal	Degree of obesity
  25	Mild
  50	Moderate
  75	Severe
  100	Very severe

  BMI=	Weight (kg)
  	_________________
  	Height2(m)

• Waist circumference: - It is the most practiced tool a clinician can use to evaluate a patient’s abdominal fat before and during weight loss treatment, high risk of waist circumference- Men->40 inches (>102cm), Women- >35 inches (>88cm).

Dietary management

Energy about 20k.cal/kg ideal body weight is prescribed for a sedentary worker and 25 kcal for a moderately active worker. Exceptionally low calories diets (400-800k.cal/day) can be used safely in extremely obese individuals (greater than 50percent overweight).
Proteins about 0.8-1g/kg body weight are prescribed for tissue repair.
High carbohydrate content foods like potatoes, rice, banana, and sugar are avoided. Low fat or no-fat diet should be given as calories are reduced.
Prolonged restriction of fats, there may be deficiency of fat-soluble vitamins A and D, which may have to be supplemented.
Fluids can be taken liberally as extra fluids are excreted to healthy kidneys.
Dietary fiber is important to provide bulk and satiety. Low Glycaemic index foods may benefit weight control.
A low calories diet accompanied by moderate exercise will be effective in causing weight loss.
Patients can reduce stress-related overeating.
Some methods help to reduce stress such as deep muscle relaxation, meditation, yoga, and physical activity. Obese patients should be encouraged to eat “unprocessed” foods and foods in their natural forms. They should limit fat, sucrose, and alcohol.

• Diet and feeding pattern: The satiety value of the diet is extremely important to give a feeling of satisfaction and wellbeing. Adequate amount of protein foods, fibrous fruit and vegetables, whole grain cereals and provide satiety.
• Principal of dietetic management: Low caloric, normal protein, vitamins, minerals (except sodium) restricted fat, liberal fluid, and high fiber diet, is given in such cases.
• Energy: - About 20kcal/kg ideal body weight is prescribed for sedentary worker 25 kcal for the moderately active worker.
• Protein: - About 0.8-1g protein/kg boy weight is prescribed for tissue repair for specific dynamic action.
• Carbohydrate: - High carbohydrate content foods like potatoes, rice are restricted. Sugar which gives empty calories should be avoided fruits rich in cleansing like banana, should be avoided.
• Fat: - Low fat or no-fat diet should be given as calories are reduced. Foods rich in fat-like nuts oil seeds are avoided.
• Vitamins: - With a prolonged restriction of fat there is likely to be a restriction of fat-soluble vitamins A and D.
• Minerals: - Restriction of sodium as common salt is helpful in a weight-reducing diet as excess sodium predisposes to the retention of fluids. Research suggests that a calcium-rich diet especially one that includes dairy sources (with the limit in total calories) not only helps young women keep weight in check but may reduce the overall level of body fat.
• Fluid: - Fluids can be taken liberally as extra fluids are excreted by healthy kidneys. Also, a glass of water before meals helps to cut down food intake.
• High Fiber: - High fiber low calories foods like green leafy vegetables, fruits, vegetable salad, and whole-grain cereals, pulses can be included in the diet.
  Inclusion of high fiber foods in the diet for obese has many advantages: They are (1) Low in calories density (2) foods like green provides many vitamins and minerals (which are difficult to meet with restricted food) (3) Give satiety (4) Helps in regulating bowel movements (5) Reduce blood cholesterol (6) Promote chewing, decrease the rate of ingestion. A higher intake of fiber automatically cuts down fat calories.
• FOOD ALLOWED: High Fiber Calorie Foods Like Green Leafy Vegetables Like Amaranth, Cabbage, Lettuce, Celery Spinach, Fruits with Skin, Vegetable Salads, Whole Grain Cereals and Pulses, Germinated Fenugreek Seeds, Whole Grain, Fluids.
• FOODS AVOIDED: High-fat foods like; Butter, Processed Cheese, Chocolate, Cream, Ice-Cream, Fatty Meats, Fried Foods Like Samosa, Mathris, Paranthas, Poories, Karies, and Potato Chips, Nuts, Pastries, Salad Dressing Etc. High Foods Such as Bread, Cakes, Cookies, Dried Fruits, Rich Pulaos, Potatoes, Honey, Syrups, Jams, Rich Puddings, Etc. Carbonated And Malted Beverages, Alcoholic Drinks and Sweetened Fruits Juices.

Suggested Recipes:

Foods	Reason
Vegetable salads	Low calories high fiber.
Chapathis without oil	More proteins high fiber give satiety
Thin dals, steamed foods like idlis	To limit calories, increase protein content
Thin soups	Provide fluids, low calories value
Poached fish	Low in calories high in protein
Greens porial	High in fiber
Coffee, tea without sugar	Low calories

SAMPLE MENU

Time	Menu	Portion
Early morning	Lemon water	1 glass
Breakfast	Tea	1 cup
	Poha	1 plate
Mid-morning	Fruit Salad	1 bowl
Lunch	Chapatti	3
	Mixed Vegetable	1 bowl
	Red Gram Dhal	1 bowl
	Green salad	1 bowl
	Curd	1 bowl
Evening tea	Sprouted chaat	1/2 plate
Dinner	Chapatti	2
	Green gram dhal	1 bowl
Zeera Rice	1/2 plate
Cauliflower vegetable	1 bowl
Salad	1/2 plate
Bedtime	Skimmed milk	1 glass

SAMPLE MENU

Time	Menu	Portion
BED TEA:	TEA	1 cup
Breakfast	MILK	125ML (1 cup)
	CEREAL	20gms (1 chap/1small slice)
	PROTEIN	30gms paneer/6tsp besan/1 kat sprouts
Mid-morning	FRUIT	100 gms
	SALAD	150gms
Lunch	CEREAL	40gms (2 chap/)
	DAL	30gms (1 kat)
	VEGETABLES	150gms (1 kat)
	OIL	5gms(1tsp)
Evening tea	TEA	1 cup
	SNACK	20 gms
Dinner	SOUP	1 cup
	CEREAL	40gms (2 chapati)
	DAL	30gms (1 kat)
	VEGETABLES	150gms (1 kat)
	OIL	5gms (1 tsp)
Bedtime	MILK	100mls (1 small cup)
Non-Veg	Paneer 30, Egg 1, dal 30gms, Chicken 100gms, Fish 120gms, mutton 80gms

• FOODS ALLOWED LIBERALLY: Raw & boiled vegetable, juices like fresh lemon, coconut water, soda, Vegetable juices like tomato juices, veg soups, cucumber juice, Skimmed or toned milk & milk products, Refined vegetable oil for cooking, Egg white, Lean meat, chicken, fish.
• FOODS TO BE AVOIDED: Excess of cream, butter, oil, cheese, mayonnaise, ghee, Excess of fried foods- potato chips, puri, parantha, pakora, Excess of dried nuts, Whole milk & its products Pork, Ham, Sausages, Red meat, organ meat, Egg yolk, Fruit Juices, Banana, Cheeku, Mango, Grapes.

SAMPLE MENU

Time	Menu	Portion
BED TEA:	TEA	1 cup
Breakfast	MILK	125ML (1 cup)
	CEREAL	30gms (1 slice/1 chapatti)
	PROTEIN	30gms paneer/6tsp besan/1 kat sprouts
	OIL	½ tsp
Mid-morning	FRUIT	100 gms
Lunch	SALAD	150gm
	CEREAL	40gms (2 chap/2 kat rice)
	WHOLE DAL	30gm (1 kat)
	VEGETABLE	150gms (1 kat)
	DAHI	100gms (1 kat)
	OIL	5gms (1 tsp)
Evening tea	TEA	1 cup
	SNACK (PRT)	20 gms
Dinner	SOUP	1 cup
	CEREAL	40gms (2 chapati)
	DAL	30gms (1 kat)
	VEGETABLES	150gms (1 kat)
	OIL	5gms (1 tsp)
Bedtime	MILK	125mls (1 kat)
Non-Veg	Paneer 30gms, Egg, Dal 30Gms, Chicken 100gms, Fish 120gms

• FOODS ALLOWED LIBERALLY: Raw & boiled vegetable, juices like fresh lemon, coconut water, soda, Vegetable juices like tomato juices, veg soups, cucumber juice, Skimmed or tones milk & milk products, Refined vegetable oil for cooking, Egg white, Lean meat, chicken, fish.
• FOODS TO BE AVOIDED: Excess of cream, butter, oil, cheese, mayonnaise, ghee, Excess of fried foods- potato chips, puri, parantha, pakora, Excess of dried nuts, Whole milk & its products Pork, Ham, Sausages, Red meat, organ meat, Egg yolk, Fruit Juices, Banana, Cheeku, Mango, Grapes

Underweight is a condition when the bodyweight is 10-20percent less than average expected for one’s height, age, and sex. If the bodyweight is less by 20percent or than IBW, the individual is grossly underweight, and it is a matter of concern. Underweight is a common problem most often associated with poverty, poor living conditions, or long-term diseases. However, in some people, underweight is because of a physiological difficulty in gaining and maintaining weight. Such persons eat less and feel full of less food than normal-weight persons.

• Etiology: Inadequate food intake increased physical activity, malabsorption of nutrients, pathological conditions, hormonal imbalance, eating disorders.
• Health Hazards of underweight: It result in growth retardation and failure to thrive in growing children. Resistance to infection is lowered and general health is poor in underweight individuals. Work efficiency is affected, and the person feels fatigued and restless. Underweight increases the chances of complications during pregnancy leading to preterm delivery and smaller babies. Underweight is most often associated with deficiency diseases like marasmus and kwashiorkor.

Dietary Management

1. The calorie requirements vary depending upon the activities, for increasing the weight the total calories intake should be more than the requirement. An additional 500kcal/day is recommended.
2. Instead of 1g of protein, over 1.2g/kg is recommended for tissue building. Good quality protein is completely utilized by the body.
3. Fat content is increased easily digestible fats are to be included. Fried and fatty foods are not recommended. High calories fatty foods such as cream, butter, margarine, and oils help to increase weight.
4. The diet must be liberal in minerals and vitamins to help to regain health.
5. Fluids should not be taken before or with a meal but only after a meal so that food intake is not reduced. Enough fluids must be taken to avoid constipation.
6. Regular outdoor exercise helps to stimulate appetite.
7. As it is difficult to adjust at once to a higher energy intake, it is better, to begin with the normal intake and gradually increase the food intake quantitatively and qualitatively. Small frequent feeding helps to increase the food intake in some individuals. A variety of foods, well prepared and attractively served promote appetite and the desire to eat.

• Foods to be included: A regular diet with Added Sugar, Cream, Butter, Eggs, Jam Jelly, Jam, Sweets, Dried Fruits, Desserts, Cereals, Cereals Products, Non-Vegetarian Foods, Porridge, Cutlets, And Potato Chips, High Proteins Drinks, Like Milk, Malted Milk, and Badam Kheer.
• Foods to be avoided: Fried foods or foods tending to interfere with the appetite and digestion Leafy vegetables should be restricted and preference to be given to potato and yam. Excessive quantities of bulky, low calories foods.

SAMPLE MENU

Time	Menu	Portion
Early morning	Milk	1 glass
	Glucose biscuit	4
Breakfast	Aloo parantha with butter	2
	Curd	1 bowl
Mid-morning	Boiled egg	2
Lunch	Chapatti	2
	Palak dhal	1 bowl
	Rice	1 bowl
	Mixed vegetable	1 bowl
	Salad	1/2 plate
Mid-afternoon	Whole fruit (apple, guava, orange, etc.)	1
Evening tea	Paneer sandwich	2
	Tea	1 cup
Dinner	Vegetable, pulao	1 plate
	Raita	1 bowl
	Mutton Curry	1 bowl
Bedtime	Kheer	1 bowl

Diabetes Mellitus is a chronic metabolic disorder that prevents the body to utilize glucose completely or partially. It is characterized by raised glucose concentration in the blood alteration in, protein fat metabolism. This can be due to failure in the formation of insulin. Since insulin is produced by the β cells of the Islets of Langerhans, any reduction in the number of functioning cells will decrease the amount of insulin that can be synthesized. The hormones of the anterior pituitary, adrenal, thyroid α cells of the Islets of Langerhans are glycogenic, that is, they increase the supply of glucose.

Diabetes Insipidus

Diabetes Insipidus is a condition that shares some of the symptoms of diabetes mellitus, large urine output, great thirst sometimes a large appetite but in diabetes insipidus, these are symptoms of a specific injury, not a collection of metabolic disorders.

Classification

• IDDM (Insulin Dependent Diabetes Mellitus) also known as juvenile-onset, in the younger age diabetes patients depend on insulin.
• NIDDM (Non-Insulin Dependent Diabetes Mellitus) is non-insulin-dependent and develops slowly. Insulin may be produced by the pancreas, but action is impaired. This occurs mainly in adults and the person is usually overweight.
• MRDM (Malnutrition Related Diabetes Mellitus) this type of diabetes is mainly seen in some tropical countries like India and it occurs in young people between 15-30 years of age. In this diabetes, the pancreas fails to produce adequate insulin.
• Symptoms: Increased thirst (polydipsia), Increased urination (polyuria), Increased hunger (polyphagia), Glycosuria (sugar in the urine), Hyperglycemia, Abnormal glucose tolerance test, Weakness.

Test	Normal level	Impaired Glucose Tolerance	Diabetes
Fasting Plasma Glucose	< 110mg/dl(6.1mmol/l)	≥110 (6.1mmol/l) < 126mg/dl (7.0mmol/l)	≥126mg/dl (7.0mmol)
Oral Glucose Tolerance Test	< 140mg/dl (7.8mmol/l)	≥ 140(7.8mmol/l) 200mg/dl (11.1mmol/l)	≥ 200mg/dl (11.1mmol/l)
Casual Plasma Glucose			≥ 200mg/dl (11.1mmol/l) in the presence of symptoms

Foods to be avoided	Eaten in moderation	Foods permitted
Simple Sugar (Glucose Honey, Syrup, Sweets, Dried Fruits, Cake, Cry Fried Foods, Alcohol, Nuts, Jaggery, Sweetened Juices	Fats, Cereals, Meat, Egg, Nuts, Roots, Fruits, Artificial Sweetener.	Green Leafy Vegetable. Fruits Except, Banana, Lemon, Clears Soup, Onion, Mint, Salads Plain Coffee or Tea, Spiced, Skimmed Butter Milk Spices.

DIETARY MODIFICATION

High fiber diet improves insulin receptor binding. Restriction impairs insulin sensitivity reversed by a high fiber diet. High fiber improves insulin binding which results in increase in monocyte insulin receptor binding. Hence is maintained to about 60-65percent of total calories. Most carbohydrate should be in the form of polysaccharides such as bread, cereals, beans, etc. Rapidly absorbed mono disaccharides such as sweets, the sweetened drink should be avoided. The whole apple is better than apple juice because of its high fiber content and low glycemic index.

• Proteins: A diet high on protein is good for the health of diabetes because it supplies the essential amino acids needed needs for tissue repair. In patients with NIDDM, the consumption of protein will lower the blood glucose concentration due to amino acid stimulation of insulin.
• Fat: Low-fat diet increase insulin binding, also reduces LDL, VLDL levels which reduce the incidence of atherosclerosis which is more common in diabetics. Fat content in the diet should be 15-25percent of total calories.
• Vitamin and minerals: Vitamin supplements may be helpful to overcome oxidative stress deficiency. Diet rich in all vitamins particularly in vitamin C and E antioxidants in fruits vegetables. Dietary sodium may have a role in the development of insulin resistance is beneficial.
• Dietary fiber: Soluble fiber such as pectin, gums, hemicellulose (in fruits) Insoluble fiber such as cellulose lignin (vegetables, grains) High fiber diets promote weight loss. Fenugreek seeds which contain high fiber are useful to diabetics. Dietary fiber complex benefit type I (IDDM) type II (NIDDM) diabetics:
  1. Insulin requirements
  2. Increased peripheral tissue insulin sensitivity
  3. Decreased serum cholesterol triglyceride values and in weight control
  4. Lower blood pressure
  Diets high in fiber improve glucose metabolism without increasing insulin recreation.
• Glycaemic index: The ability of the food item to raise the blood sugar is measured in terms of the Incremental area the 2 hours plasma glucose curve after eating 50g. of from test food X.
  http://www.youtube.com/watch?v=P4MjNX0TQ_A
  

  Glycaemic index=	Incremental area under the 2 hrs. Plasma glucose curve
  	______________________________________________________
  	After taking 50g glucose in water.

• Artificial calorie sweeteners: on caloric high intense sweeteners are available as sugar substitutes.
• Low-calorie sweeteners:
  • Polyols: They are less than sweet 50percent of energy of polyols is available to the human body average caloric value is 2.4 Kcal/g
• Non-calorie sweeteners:
  • Cyclamate: It is thirty times sweeter than sucrose. It tastes much like sugar is heat stable.
  • Alitame: It is a dipeptide-based amide, has a sweet taste similar to sugar. It is more than 2000 times sweeter than sucrose.
  • Aspartame: It is a white, odorless, crystalline powder that has a sugar-like taste, sweetness potency 180 to 200 times that of sucrose without any bitter after taste.
  • Saccharin: It is 300 times sweeter than sucrose.
  • Sucralose: It is 600 times sweeter than sugar no bitter after taste. It is very soluble in water-stable at high temperatures.

Points to be considered in planning a diet for a diabetic patient

1. Daily energy intake must be estimated after considering such factors as age, sex, actual weight with desirable weight, activity occupation.
2. Distribution of calories for each meal if no insulin is given is 20percent. Breakfast, 10percent Mid Morning. 30percent Lunch, 10percent Tea, 20percent Dinner
3. Simple sugar should be restricted since they are easily absorbed and have a high glycaemic index
4. Fats with high polyunsaturated fatty acids like vegetable oil is preferred (sunflower oil, corn oil, gingelly oil) than animal fat, hydrogenated fat which contain more saturated fatty acids
5. High protein intake helps to increase insulin production, promote satiety.
6. Vitamins minerals are supplemented to meet the daily requirement (fat-soluble vitamins).
7. Complex fiber should be included in the feasting.
8. Patients should avoid fasting and feasting.
9. Sodium intake is to be no more than 6g daily. Sodium is restricted to 3g in hypertensive diabetics’ patients.

Some tips for a healthy diet

1. Avoid foodstuffs high in saturated fat, cholesterol.
2. Avoid sweet foods, jams, cola, cakes, sweet cream, which increase triglyceride levels.
3. Bake, roast, boil or steam instead of frying food.
4. It is better to avoid alcohol; Too much alcohol may cause low blood sugar by potentiating the effecting of insulin or drugs, blocking glucose production in the liver while adding to calories.
5. Artificial sweeteners like aspartame saccharine tables are available.
6. Diabetics can control blood sugar by doing exercise physical activity.