Wilson’s disease is a hereditary disorder in which the body retains too much copper. Copper is a trace mineral in the body. This means it is essential for good health, but only a tiny amount is needed. When excess copper accumulates, it is stored in the eyes, brain, kidneys, liver. Excess copper collecting in the liver causes cirrhosis of the liver, which is a serious life-threatening condition. However, Wilson’s disease is treatable. Copper is found in different amounts in a wide variety of foods. Therefore, dietary restriction alone is usually not enough to control Wilson’s disease. Medicines such as Cuprime Depen (generic name: D-penicillamine) Syprine (generic name: trientine) as used to help excess copper with the urine. It is helpful to avoid.

• Copper- rich foods as much as possible. The dietary intake of copper should be less than 1.0mg per day.
• Nutrition facts Allow copper diet is generally adequate in all the nutrition necessary for good health. However, patients taking D-penicillamine may develop a deficiency of vitamin B-6 (pyridoxine), the physician may prescribe a supplement of 25mg daily.

Special Considerations

1. The copper content in a specific food can vary depending on a number of factors. The copper content the location of the soil in which the food was grown or the method used to process the food. In general the low copper diet is meant to restrict foods that are usually high in copper, especially organ meats, shellfish, dried beans, peas, whole wheat, collate.
2. Drinking water should be analyzed because it may contain too much copper. If the water contains more than 100 micrograms per liter, then bottled demineralized water should be used. This water should contain only 1 microgram of copper per liter. Demineralized water distilled water are processed differently may not contain the same amount of copper. Check with the physician or registered dietitian for more information.
3. Avoid drinking alcohol. It can be harmful to the liver; the liver may already be damaged from Wilson’s disease.
4. Read food labels; some prepared foods list the cooper content. Always check the labels of vitamin/mineral supplements to see if they contain copper.
5. For better control of copper intake, use only average portions or serving sizes of foods. Examples of average portions are 3 to 4oz, of meat, fish, or poultry; ½ cup of vegetables; one slice of bread.
6. Do not use copper cooking utensils.
7. Patients with Wilson’s disease should have initial periodic consultations with a registered dietitian to make sure copper in the diet is being adequately controlled.

Low Copper Diet

Food items	Eat as Desired Foods low in copper – less than 0.1mg/portion.	6 Portions/Day	Avoid
Meat and meat substitute	Beef; eggs; white meat turkey chicken; cold cuts, dark chicken, or organ meats, all other not listed on high or Moderate list.	All fish except shellfish 3 oz, dark meat turkey chicken 3 oz, peanut butter 2 tbsp	Lamb; pork; pheasant duck; goose; squid; salmon; organ meats including liver. Heart, kidney, brain; shellfish including oysters, scallops, shrimp, lobster, clams Crab; meat gelatin; soy protein meat substitutes; tofu; nuts seeds
Vegetables	Most vegetables including fresh tomatoes	Beans sprouts 1 cup; beets 1/2 cup; spinach 1/2 cup cooked, 1 cup raw; tomato juice other tomato products 1/2 cup; broccoli 1/2 cup; asparagus 1/2 cup	Vegetable juice cocktail, mushrooms
Fruits	Most fruits except as listed to right fruits dried at home are permitted	Mango 1/2 cup, papaya 1/4 average, pear 1 medium, pineapple 1/2 cup	Commercially dried fruits including raising dated prunes; avocado
Starches breads and grains	Breads and pasta form refined flour, rice, regular oatmeal, cereals with < 0.1mg of copper serving	Whole wheat bread 1 slice, Melba toast 4, whole wheat crackers 6, instant oatmeal 1/2 cup, instant RalstonTm 1/2 cup, cereal with 0.1 to 0.2mg of copper per serving, dehydrated canned soups 1 cup, potatoes in any form 1/2 cup or small pumpkin 3/4 cup, parsnips 2/3 cup, winter summer squash 1/2 cup, green peas 1/2 cup	Dried beans including soybeans, lima beans baked beans, garbanzo beans, pinto beans; dried peas; lentils; millet; barley; wheat germ; bran breads cereals; cereals with >0.2mg of copper per serving (check label); soy flour, soy grits; fresh sweet potatoes
Fats, oils	Butter, cream, margarine, mayonnaise, non-dairy creamer, sour cream, oils salad dressings	Olives 2
Milk and milk products	Most milk products milk flavored with crab, cheeses, cottage cheese	All others	Collate milk, soy milk coca
Sweets and desserts	Most sweets; jams, jellies, pies made with allowed ingredients; crab; Flavoring extracts	Licorice 1 oz, syrups 1 oz	Desserts that contain high amounts of ingredients rich in copper; with nuts, collate or cocoa
Beverages, liquids, misc.	coffee, tea, fruits juices, fruit-flavored beverages, lemonade, soups, made with allowed ingredients	Cereal beverages 1 cup, carbonated beverages 12 oz, ketchup 2 tbsp, dehydrated canned soups	Instant breakfast beverages, minerals water, soy-based beverages, copper fortified formulas, brewer’s yeast, multiple vitamins with copper or minerals

SAMPLE MENU

Breakfast	Lunch	Dinner
Grape fruit 1/2 cup, Scrambled egg 1, White toast 1 slice, Margarine 1 tsp, Skim milk 1/2 cup, Coffee 1 cup, Salt/pepper	White bread 2 slices, Roast beef 2 oz lettuce, tomatoes, mayonnaise 1 tbsp, Carrot sticks 6, Fresh orange 1, Skim milk 1/2 cup	Chicken breast 3 oz Rice 1/.2 cup Green beans 1/2 cup Margarine 1 tsp, White bread 1 slice, Jelly 1 tsp, Apple 1, Lemonade 1 cup, Salt/pepper	PROVIDES: Calories 1520Kcal, Protein 69g, Fat 54g, Sodium 1500mg, Potassium 2150mg, Copper 0.68mg

Foods to include in the plan

1. Fruit- your plan can include any fruit including fresh, frozen, dried or canned in natural fruit juice. This includes apples, bananas, pears, oranges, grapefruit, raisins, pineapple, mango, kiwi fruit, strawberries, raspberries, blackcurrants, peaches, melons, papaya etc.
2. Vegetables- eat any vegetables fresh. This includes carrots, onion, turnip, Sprouts, cabbage, peppers, mushrooms, sweet corn peppers,, broccoli, cauliflower, salad, tomatoes, cucumber, spring onions etc.
3. Beans lentils- eat any beans, including those that have been dried or canned in water. This includes red kidney, red lentils, green lentils brown lentils
4. Tofu / Oatssprinkle oats over fresh fruit or use to make porridge, sweetened with honey fresh fruit
5. Potatoes- all types
6. Brown rice noodles
7. Fresh fish- eat any fresh fish including cod, mackerel, salmon, lobster, crab, trout, haddock, tuna, prawns, Dover sole, red mullet, halibut, lemon sole, monkfish, swordfish etc.
8. Unsalted nuts- eat any including peanuts, almonds, cashew, hazelnuts, pecans, pine nuts, pistachio, walnuts etc
9. Unsalted seeds- eat any including sunflower pumpkin, Plain popcorn- without sugar or salt, live natural yoghurt, extra virgin olive oil balsamic vinegar, Garlic, ginger fresh herbs, Ground black pepper, Honey, Water- at least 2 liters a day. Herbal teas

Our body detoxifies itself beautifully via all its organs. One can only support his/her body by ingesting less foods which can turn toxic in nature and by consuming anti-inflammatory and healing foods.

FOODS ALLOWED:

• Fruits- your plan can include any fruit including fresh, frozen, dried, canned. This includes apples, bananas, pears, oranges, grapefruit, raisins, pineapple, mango, kiwi fruit, strawberries, raspberries, blackcurrants, peaches, melons, papaya etc.
• Vegetables- Eat any vegetables but fresh. This includes carrots, onion, turnip, Sprouts, cabbage, peppers, mushrooms, sweet corn peppers, broccoli, cauliflower, salad, tomatoes, cucumber, spring onions etc.
• Beans & lentils- eat any beans, including those that have been dried or canned in water. This includes red kidney, red lentils, green lentils & brown lentils.
• Tofu, Oats- use to make porridge sweetened with honey & and add fresh fruit, Potatoes- all types, Brown rice noodles,
• Fresh fish- eat any fresh fish including cod, mackerel, salmon, lobster, crab, trout, haddock, tuna, prawns, Dover sole, red mullet, halibut, lemon sole, monkfish, swordfish etc.,Unsalted nuts- eat any including Brazil, peanuts, almonds, cashew, hazel nuts, pecans, pine nuts, pistachio, walnuts etc.
• Unsalted seeds- eat any including sunflower & pumpkin.
• Plain popcorn- with sugar or salt, Live natural yoghurt, Extra virgin olive oil & balsamic vinegar, Garlic, ginger & fresh herbs, Ground black pepper, Honey ,Water- at least 2 liters a day, Herbal teas.

FOODS ALLOWED:

Red Meat, Chicken, Turkey & Any Meat Products Like Sausages, Burgers, Milk, Cheese, Eggs, Cream, Butter & Margarine, Any Food That Contains Wheat Including Bread, Croissants, Cereals, Cakes, Biscuits, Pies, Pastry, Quiche, Battered Or Bread Crumbed Foods, Etc., Crisps & Savory Snacks Including Salted Nuts, Chocolate, Sweets, Jam & Sugar, Processed Foods, Ready Meals, Ready-Made Sauces & Takeaways, Alcohol, Coffee & Tea, Sauces, Pickles, Shop Bought Salad Dressing, Mayonnaise, Salt Fizzy Drinks & Squashes, Including Diet Versions.

DETOX DIET PLAN

Breakfast

1. Banana porridge: Porridge made with water & topped with natural yoghurt, banana, raisins & sweetened with honey
2. Fruit salad with yoghurt & oats Fresh fruit salad with natural yoghurt
3. Fresh fruit smoothie: Fruit smoothie made from fresh fruit, natural yoghurt & honey to sweeten if needed.
4. Muesli & yoghurt: Homemade muesli made from oats, seeds, nuts & dried fruit served with natural yoghurt.
5. Fresh fruit & yoghurt: Fresh fruit & a pot of natural yoghurt sweetened with honey.

Lunches

1. Vegetable soup & Oats/rice: Large bowl of vegetable or lentil soup with oat/brown rice.
2. Mediterranean salad with Rice: Brown Rice served with, avocado, tomatoes, fresh basil & black pepper plus a handful of unsalted nuts (Almonds/groundnuts).
3. potato with grilled cod: Grilled cod fillet served with jacket potatoes & lightly steamed vegetables.

Dinners

1. Chinese vegetable stir fry: Stir fry a selection of vegetable such as spring onions, mushrooms, & beansprouts in a little olive oil with garlic & ginger. Serve with brown rice.
2. Baked salmon with jacket potato: Bake a salmon fillet & serve with steamed vegetables.
3. Sweet & sour stir fry with rice: Gently fry a selection of chopped vegetables such as onions, peppers, baby corn & mushrooms. Add pineapple, tomatoes, tomato puree, white wine vinegar & honey. Bring to the boil & simmer until the sauce has thickened. Serve with brown rice.
4. Potato & bean casserole: Gently fry a selection of typical casserole vegetables such as onion, carrot & green veggies in a little olive oil with garlic. When browned, add diced potato & fry for a few minutes. Add fresh vegetable stock, black pepper & your favorite beans. Bring to the boil & simmer until the casserole thickens.

Snacks

1. Fresh fruit or fish fruit salad.
2. Natural yoghurt mixed with honey.
3. Plain popcorn.
4. Unsalted nuts or seeds.

When you are pregnant, eating a healthy diet is more important than ever. Everything that you eat or drink will affect your baby’s development. Also, a healthy diet will help you maintain your health as well as develop your uterus & prepare your breasts for breast feeding.

The diet during pregnancy should be adequate for

1. Maintenance of mother’s health.
2. Need of the growing fetus.
3. Successful lactation.

Dietary Guidelines During Pregnancy

1. A healthy diet for pregnant women should be nutrient dense & requires more calories, iron calcium & folate.
2. Maximum a steady rate of weight gain. Aim for 1-2Kg gain in the first trimester & then about 2Kg each month during the second & third trimester. A total weight gain of around 10-13Kg for healthy women is considered normal.
3. Excessive use of salt should be restricted.
4. Wash all fruits & vegetables thoroughly before use.
5. Excessive caffeine should be avoided.

PROBLEMS DURING PREGNANCY

CONSTIPATION

A common problem during pregnancy due to hormonal changes, iron supplements or pressure on the rectum from the enlarged uterus. Tips to help relive constipation:

1. Drinking plenty of fluids—at least 6-8 glasses of water each day, including 1-2 glasses of fruit juices such as prune juice.
2. Eat foods high in fiber, such as raw fruits & vegetables & bran cereals.
3. Exercise regularly.

INDIGESTION

Indigestion is commonly called ‘heartburn’ Changes in hormone during pregnancy slowS digestion & also enlarged uterus pressing on your stomach contribute to indigestion. Tips to prevent or relieve indigestion:

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

MORNING SICKNESS

Morning sickness is nausea or vomiting that occurs during the first trimester of pregnancy. Women with high levels of pregnancy hormones tend to develop this condition. Mild morning sickness can be relieved by:

1. Eating snacks that are high in protein.
2. Eating foods with no fiber that are high in carbohydrates & low in fat.
3. Having frequent small snacks instead of full meals.
4. Eating foods that taste good to you.
5. Eating before you can get out of bed, as movement often makes morning sickness worse.
6. Drinking salty fluids, such as broth.

What specific requirements do you need during pregnancy?

The table below displays what your requirements are & why they are necessary

Daily Pregnancy Requirement	Why You & Your Baby Need this Nutrient/Food	Food Sources for this Requirement
1600calories (+300)	Provides Energy For The Fetus To Develop	All Foods & Drinks (Except Water), Whole Grain Cereals, Pulses, Milk & Milk Products
46 grams of protein + 9.5(2nd trimester) + 22 (3rd trimester)	Helps Fetal Tissue To Grow Helps Develop Your Breasts & Uterus Increases Blood Supply Aids The Growth & Development Of The Placenta Maximizes Fetal Brain Development	Milk, Cheese, Eggs, Meat, Fish, & Poultry, Beans & Dals, Nuts
1000mg of calcium	Helps The Development & Formation Of The Fetal Skeleton Aids The Development Of The Baby’s Tooth Buds	Milk, Yogurt, Cheese, Whole Grains Leafy Vegetables, Egg Yolk"
2 servings of vitamins C rich foods	Heals Wounds Repairs Tissues Develops Teeth & Bones Assists Various Other Maternal & Fetal Metabolic Processes"	Citrus Fruits & Juices, Tomatoes, Strawberries, Melons, Peppers Potatoes
570micro gram of folic acid	Significantly Decreases The Risk Of Your Baby Being Born With Neural Tube Defects	Dark Green Leafy Vegetables, Citrus Fruits & Juices, Fortified Breads & Cereals, Whole Grains, Liver, Dried Beans & Peas
8 glasses of fluids	Helps Build The Fetus’s Cells Develops The Circulatory System Helps Deliver Nutrients To The Fetus Assists With The Excretion Of Wastes Helps Prevent Dry Skin Reduces Risk Of Urinary Tract Infection	Water, Fruit Juice, Vegetable Juice & Soups, Roohafza, Fresh Lime, Coconut Water
27mg of iron	Increases Maternal Blood Volume Prevents Anemia	Green Leafy Vegetables, Fortified Breads & Cereals, Meat, Fish, & Poultry, Beans & Dals, Nuts & Jaggery, Food Rich in Vitamin C

DIETARY GUIDELINES TO BE FOLLOWED AFTER TONSILECTOMY

When on a Liquid Diet:

1. Give only cold liquids. Do not give any hot liquids like soups or hot milk.
2. Foods items like custard, ice creams can also be given.
3. Do not give any citrus liquids like apple juices, lassi, lemon water etc.
4. Full liquids such as milkshakes, roohafza milk, flavored milk can be included.

When on A semi Solid diet:

1. Semi solid foods like khichri, rice, suji upma, poha, bread etc. can be given.
2. Any food to be given must be soft.
3. In fruits, soft fruits such as banana, papaya, stewed apple etc can be given.
4. Avoid giving roti or paranthas.

When on a Normal Diet:

1. A person who has undergone tonsillectomy can have a normal diet after about 4-5 days after the wound has healed.
2. Foods like chapatti & other foods can be given as in normal routine.

Vitamin K is a fat-soluble vitamin used in the body to control blood clotting, Green leafy vegetables are among the best sources of vitamin K rich foods decrease the effects of warfarin (acitrom), so vitamin K intake should be consistent, so the dose of warfarin is right.

Vitamin K rich foods (to be avoided):

Green leafy vegetables: Kale, Broccoli, Parsley, Spinach, Cabbage, Lettuce, And Vegetable oil: Soybean oil, Canola oil, Mayonnaise, Olice, Soyabeans, Wheat bran, Wheat germ, Cauliflower, Liver (beef).

Do’s & Don’t

• Take warfarin exactly as prescribed by your doctor.
• Always take warfarin at the same time of the day.
• Do not make sudden changes to your diet.
• Exercise regularly.
• Have your pro-time (INR) checked regularly.
• Never take a double dose.
• Take each dose with a full glass of water.
• Do not stop taking warfarin without your doctor’s advice.

DIET IN MEGALOBLASTIC ANEMIA

FOODS RICH IN FOLIC ACID

• Meat: liver (best source), chicken giblets, kidney, egg yolk.
• Legumes: dried beans, lentils, split peas (dals), soya products, almonds, nuts
• Starches: wholegrain breads, wheat flour, potato, sweet potato
• Fruit & Vegetables: spinach, Beetroot, Brussel sprouts, broccoli, asparagus, banana, oranges, peaches

Foods rich in Vitamin B12

• Meat: liver (best source); beef/chicken; pork/ham; fish; whole egg
• Dairy products: milk; cheese; yoghurt

IMPORTANT GUIDELINES

Fruit & vegetables should be eaten raw whenever possible as cooking destroys Folic Acid. Avoid alcohol in the diet as it leads to Folic Acid deficiency. Increase the use of wheat flour & soya flour in baking & food preparation. Liver should be included more often in the diet as it is an excellent source of Vitamin B12 Folic, iron & other important nutrients.

Encourage the patient to eat small, frequent meals a day improve tolerance. Increase the intake of juices, stews, soups, fresh lime, coconut water, buttermilk to maintain the electrolyte balance. A daily fluid intake of 2.5 to 3.5 liter is recommended. Well cooked, easily, digestible carbohydrates like simple starches, glucose, honey, jam should be included. Refined cereals & their products (e.g., maida, rava, bread, idli, poha, upma, rice, vermicelli) should be consumed. Calorie & protein rich dishes could be prepared. Excessive use of fat in cooking, eating fried foods can aggravate nausea, impair digestion & lead to severe diarrhea. Foods which help in binding the stool are banana, stewed apple, and curd.

Weaning is the process of expanding the diet to include solid foods other than breast milk & infant formula.

WHEN TO START:

In term, infant 4-6 months of age

STARTING OF SOLID FOOD:

1. Breast milk or formula along with baby rice (1-2teaspoons) having smooth thin consistency.
2. Before & after breast/bottle, one feed can be given in alert condition.
3. Place only a small quantity of food on the spoon.
4. Feeding should be done in sitting position.
5. Frequency may be increased by 1 or 2 or times daily.
6. Food quantity should be increased gradually.
7. Using various fruits introduced child with new tastes.
8. Add gluten containing food after 6 months.
9. Gradual increase in food thickness can be done by assign less fluid to purees.
10. After 5-7 months, food variety can be increased to encourage good acceptances of foods.

PRECAUTIONS FOR FOOD BEFORE 6 MONTHS:

1. Wheat & gluten containing food.
2. Less of salt & sugar.
3. Honey till 1 years (to avoid botulism).
4. Nuts & seeds.
5. Eggs.
6. Fish & shell fish.
7. Fruit juices.

FOOD FOR 7-12 MONTHS INFANTS:

1. Introduce finger food to develop acceptance of different textures.
2. Consistency can be increased gradually.
3. Provide variety to food.
4. Prefer to provide meal in family meal time.

Time	Menu
7:00am	Sooji Porridge/Daliya Porridge in water (Blended)
9:30am	Mashed aloo (without Milk) with butter
11:30am	Blend Khichri (No Tadka) + butter
1:30pm	Sabudana porridge in water
3:30pm	Biscuit
5:30pm	Dal pani
7:30pm	Blend khichri ( No Tadka)
9:30pm	Milk

MEALS	WEANING FOOD 6-12 months	INFANT 1-2 years	CHILDREN >2 years
Early Morning	Lactogen/ Milk	Milk+ Bis	Milk+ Bis
Breakfast	Suji Porridge/Bread Porridge/Egg Yolk	Suji Porridge /Bread Porridge/ Dalia Porridge / South Indian Snack/ Egg Breakfast/ Sandwich / Parantha/ Real Fruit Juice/ Seasonal Fresh Fruit	"Suji Porridge/Bread Porridge/ Dalia Porridge/ Cornflakes Milk/South Indian Snack/ Egg/ Sandwich / Parantha/Real Fruit Juice/ Seasonal Fresh Fruit
Mid-Morning	Soft Fruit	Snack/ Fruit/Soup	Snack/ Fruit/ Soup
Lunch	Blend Khichri, Blend Dal, Soft Veg, Curd/Sweet/Custard	Salad, Roti, Rice, Dal, Seasonal Veg/ Non Veg, Curd, Sweet	Salad, Roti, Rice, Dal, Seasonal Veg/ Non Veg, Curd, Sweet
Evening Tea	Lactogen/ Milk	Milk+ Biscuits	Milk+ Biscuits
Evening Soup	Clear Veg Soup	Veg Soup/ Tomato Soup	Veg Soup/ Tomato Soup/ Snack
Dinner	Blend Khichri, Blend Dal, Soft Veg, Curd/ Sweet/ Custard	Salad, Roti, Rice, Dal, Seasonal Veg/ Non Veg, Curd, Fruit	Salad, Roti, Rice, Dal, Seasonal Veg/ Non Veg, Curd, Fruit
Bed Time	Milk	Milk	Milk

TIPS FOR INFANT FEEDING:

1. Introduce only one food at a time, giving only small amounts at first.
2. Increase variety slowly.
3. Introduce all food groups.
4. Give an extra dash of fat in one or two items.
5. Do not use excessive fat, salt & sugar.
6. Prepare bland & non flavored items.
7. Consistency should be gradually built from liquid to semi solid & then to solid.
8. Particle size of gruels should be built gradually from homogenized khichri, to well mash to a thick khichri.
9. Quantity should be gradually increased.
10. If child dislike or is disinterested, discontinue the food for some time & re-introduce later. Do not force-feed.
11. Parents should avoid personal prejudices, likes & dislikes in front of children. Rather they should eat a variety of foods & encourage children to do the same.
12. Identify intolerance & immediately discontinue. Cow’s milk, egg white, soybean, etc. are known to cause allergies. Cereals which cause least allergy are rice & the pulse which causes best tolerance is moong dal.
13. Avoid fiber. Whole legumes & raw vegetables with their high fiber content are not recommended for infants.
14. Due care should be given in handling & sanitation while feeding.

Foods that may be hard to chew or swallow	Foods allowed
Rough or Crunchy Foods: Dry Cereals, Dry Toast, Popcorn, Nuts, Plain Rice, Fried Foods, Raw Vegetables & Hard Fruits	Cooked Cereals Or Dry Cereals Soaked In Milk, Pancakes, French Toast, Pasta Dishes, Foods Cooked Or Simmered In Sauces Or Liquids, Soft Fruits, Mashed Or Cut Up Such As Bananas, Canned Peaches, Pears & Fruit Cocktail, Baby Foods E.G. Vegetable & Fruits, Add Butter, Margarine Or Sauces To Vegetables.
Dry Foods: Baked Or Fried Meats, Chicken Or Fish Cookies, Crackers, Bread & Buns, Dry Cakes.	Foods Cooked or Simmered in Liquid (E.G. Stews with Ground or Finely Chopped Meats, Hearty Soup), Soft Casseroles Egg Macaroni & Cheese, Egg Dishes, Meats, That Have Been Chopped, Ground or Blenderized, Meats Served with Gravy, Sauces or Soups, Baby Foods E.G. Meats, Cookies Dipped in Drinks, Crackers or Bread Soaked in Soup, Add Butter Margarine, Mayonnaise or Salad Dressing to Moisten Foods, Pour Cream or Custard Sauce Over Cakes, Puddings, Jell-O, Custards
Beverages: Beer, Wine, Hard Liquor	Milk, Milkshakes & Food Supplements, Juices (Except Orange, Grapefruit & Lemonade), Fruit Nectars, Flat Soft Drinks & Non-Alcoholic Beer, Add Water Or Milk To Drinks If You Find Them Too Strong.
Tart Or Acidic Foods: Foods Made With Citrus Fruit Such As Oranges, Grapefruits, Lemons Foods Made With Tomatoes ( E.G. Juices & Sauces).	Canned Peaches, Pears, Fruit Cocktail, Applesauce, Fruit Flavored Drinks Sauces Made with Milk, Cream or Cheese
Foods That Are Too Hot Or Too Cold: Very Hot Beverages Or Soups, Very Cold Beverages Or Food.	Warm Beverages Or Soup (Let Hot Foods Cool Off To A Temperature That Is Best For You), Puddings, Milkshakes Or Melted Ice Cream
Highly Seasoned Foods: Pepper, Curry, Chili Seasoned Dishes, Or Salty Snack Foods.	Garlic, Onion Or Herb Seasonings, Cream Or Cheese Sauces

Cancer is a term used to refer to malignant neoplasm or tumors. Neoplasia the cell in a tissue proliferates without the normal control on growth. In Malignant neoplasm the cells spread to adjacent tissue interfere with the function often have undesirable systemic effects. Benign tumors represent accumulation of cells which has been transformed to reproduce in abnormal numbers but under circumstances where they remain within the tissue of origin.
Cancer is caused by mutation or abnormal activation of cellular genes that control cell growth cell mitosis. The abnormal genes are called on cogenesis is now recognized that there exist regulatory genes known as tumor suppressor genes whose normal function is to prevent malignant transformation. The latter might be triggered by exposure to a carcinogen (e.g. tobacco) or by a spontaneous mutation.

DIETARY MANAGEMENT

• Energy- The total energy value of the diet must be increased to prevent excessive weight loss to meet increased metabolic demands. For an adult patient with good nutritional status about 2000kcal will provide for maintenance needs. A malnourished patient may require 3000 to 4000kcal depending on the degree of malnutrition body trauma. Of the total dietary kilocalorie value, there must be sufficient carbohydrate to spare for vital tissue synthesis.
• Protein- Additional protein is required to provide essential amino acids nitrogen necessary for tissue regeneration, healing rehabilitation. An adult patient with good nutritional status will need about 80-100g to meet maintenance needs to ensure anabolism. A malnourished patient will need more to replenish tissue ensure positive nitrogen balance.
• Vitamin and Minerals- Optimal intake of vitamins minerals at least at recommended dietary allowance levels frequently augmented with supplements according to nutritional status is indicated.
• Fluids- are increased to compensate losses from gastrointestinal problems as any additional loss caused by infections or fever, also sufficient fluid intake is necessary to help the kidney rid the body of the breakdown products from destroyed cancer cells from the drugs themselves Increased fluid also helps to protect the urinary tract from irritation and inflammation.

DIET FEEDING PATTERN

Oral enteral feeding modes pose fewer problems than alternative means.
Oral diet amplified with nutrient supplement for increased protein, kilocalories, vitamins, minerals.
Enteral feeding with several routes of entry. Parental Nutrition through enteral peripheral veins.
Enteral: Oral diet nutrient supplementation. Food should be nutrient dense. Texture is varied as tolerated with appeal to sensory perceptions of cooler aroma ,taste to enhance the desire to eat. Mini meals using a wide variety of foods item are better tolerated than regular large meals.

• Foods included: Dry Foods Such As Crackers. Dry Toast, Cereals, Pulses, Milk, Vegetables, Egg, Fish, Cold Foods, Soft To Liquid In Texture Can Be Given.
• Foods avoided: Foods that are Hot, Sweet, Fatty, And Spicy.

AIDS (acquired immune deficiency syndrome) is a condition caused by a virus called HIV. The virus attacks the immune system, the body’s “security force” that fights off infections. When the immune system breaks down you lose this protection which can develop many serious, often deadly infection, these are called “opportunistic infections. Without living cell, a virus can’t do anything- it’s like a brain with no body. For Viruses to reproduce they must infect a cell. HIV mostly infect T-cells are also known as cd4 +cells or t-helper cells. HIV starts producing millions of little viruses which eventually kill the cell and go out to infect other cells.

CLASSIFICATION

Species	Virulence	Infectivity	Prevalence	Inferred origin
HIV-1	High	High	Global	Common Chimpanzee
HIV-2	Lower	Low	West Africa	Sooty Mangabey

DIETARY MANAGEMENT

The role of good nutrition in the management of HIV/AIDS has assumed increasing importance over the past decade. In fact, medical research has shown that nutrition food is one of the most powerful weapons available for fighting the often-calamitous effects of AIDS. Furthermore, it has been clinically confirmed that malnutrition is the fatal manifestation of AIDS for many of the people who succumb to the disease. People living with AIDS may require up to twice the normal daily caloric intake to protect themselves from the dangers of HIV-related malnutrition: heightened immunosuppressant, muscle wasting, outright starvation due to malabsorption, abnormal metabolism of nutrients. In addition, Appropriate dietary modification can significantly reduce both the side effects of medications, the symptoms of opportunistic infections.

1. Maintain normal body weight. Be aware of the calorie you need to achieve and maintain normal weight.
2. Build muscles/maintain lean body mass (avoid wasting). Use strength training, if necessary.
3. Optimize digestion. The digestive tract is your center of health- simple steps like chewing your food carefully can make its job much easier! Eating 4-6 small meals is more efficient than eating 1-3 large meals. Eating more ‘healing foods’, fewer processed foods. Drinks 6-10 cups of non-caffeinated fluids daily. Use supplements rationally and consistently.
4. Address social and emotional isolation, as these factors can negatively influence your food choices.
5. Dietary supplements are commonly used in an effort to boost the immune system. Foods or substances derived from foods (garlic, turmeric) are used as well. In nonfood dietary supplements such as shark cartilage or blue-green algae (spirulina). Vitamins, minerals, amino acids are also used in an attempt to boost the immune system. Supplements can be beneficial as just that: supplements to a well balanced healing foods diet. Supplements are not substitute for the vitamins in food. If you’d like to start taking supplements, consult with an HIV nutrition specialist to help you develop a supplement regimen that meets your needs.
6. Use supplements consistently for 6-8 weeks in order to see result. Never take supplements on an empty stomach: they will be absorbed more effectively if you take them with food. Tell your primary care provider about the supplements that you are taking.

Why Do I Need A “Clean Diet” ?

Due to your treatment you are at increased risk of infection. This is because your body is unable to produce white blood cells, which fight infection. To minimize this risk you need to follow a ‘neutropenic’ diet. This involves avoiding foods which contain higher levels of bacteria which are known to increase the risk of infection.
The diet involves high standards of food hygiene. There are suitable alternatives to most of the foods you need to avoid most people manage the diet very well.

Nine Tips on Food Safety

1. Wash your hand thoroughly; keep the kitchen clean, and wear worktops prior to food preparation.
2. Once hot foods are prepared keep them hot. Do not reheat any food.
3. Prepare and store raw cooked foods separately. After preparing raw meat or fish clean work surface well.
4. Use foods well within their use-by date follow the cooking instructions carefully. Preheat the oven before cooking. Do not reheat leftovers.
5. Tins of food should be damaged/dented. Wipe the tops of cans before opening, including fizzy drinks cans. Do not drink directly from cans or bottles.
6. Avoid those foods which have a higher risk of carrying infection e.g., soft cheese, uncooked eggs.
7. Be extra cautious when using a microwave. Follow the cooking instructions precisely, do not reheat leftovers.
8. Avoid take-away meals.
9. Check the temperature of your fridge freezer. A fridge should be kept at 0 to 5oC a freezer at Minus 18^o C.

Nutritional Supplements

There is a wide range of nutritional supplements, extra-nutritious drinks, that can be taken if you are unable to manage your meals.
Cartons of supplements should be used within 2 hours of opening and are best served chilled e.g., Ensure Plus/Clinitren 1.5/Fortisip/Forti juice.
Supplements made up from powder should be poured into a glass and used within 2 hours of preparation. A variety of other supplements is available that can be added to foods. Your dietitian will be able to advise you which ones to use.

Following A “Clean Diet” Whilst You Are In Hospital.

Generally, food prepared in the hospital kitchen is suitable, there is however a few foods you need to avoid. Please ask for help if you are unsure.

Foods allowed:

1. MILK: Pasteurized/sterilized. Tinned milks (pour into a clean container, store for 24hours only). Wipe the top of the carton/bottle before opening. Use a fresh supply each day.
2. EGGS: Hard-boiled or well-cooked in dishes such as omelet/scrambled egg. In baked products e.g. cakes
3. MEAT, POULTRY, FISH: Hot, fresh, well-cooked products. Vacuum-packed meats/ poultry (use within 24hours of opening) Refrigerated/frozen prepared meals must be stored correctly and used within the use-by-date.
4. FRUIT, VEGETABLE: Well-washed, peeled Fresh fruit, vegetables. Any frozen/tinned fruit, vegetables. Cook Pulses well e.g. lentils.
5. Jam/Marmalade/honey: Buy small jars, keep in the fridge. Pickles: small jars keep in the fridge once opened. Sauces, tomato ketchup: Small bottles or individual packets stored in the fridge.
6. BREAD, CEREALS, BAKED PRODUCTS: Fresh bread that has come from a sealed packet.
7. DRINK WATER: Preferably sterilized water ONLY should be used for drinking and brushing of teeth. If not available then ideally run the tap water for a few minutes. Drink only if labeled ‘drinking water’. Carbonated bottled water (use within 24hours of opening) freshly made ice. Fruit squashes, Fizzy drinks (Ideally buy small bottles or cans. Wipe the top before opening pour into a glass).
8. HOT DRINKS: Tea, Coffee, Hot chocolate, Malted milk drinks, packet soups.

Foods Avoided:

1. MILK: Unpasteurized milk
2. EGGS: Raw/partially cooked eggs e.g. poached/soft-boiled. Products containing raw eggs e.g. homemade mayonnaise, soft meringue, soufflé, mousse.
3. MEAT, POULTRY, FISH: Under-cooked products e.g. meat that is still pink after cooking. Loose meats such as ham, salami (use vacuum-packed varieties) Raw beef, sushi or smoked salmon- No shellfish.
4. FRUIT, VEGETABLES: Raw salad ,vegetables that cannot be peeled. e.g., lettuce, cress. Fruit that cannot be washed easily e.g. strawberries, blackberries.
5. BREAD, CEREALS, BAKED PRODUCTS: Unwrapped bread, stale/out-of-date bread.
6. ICE CREAM: Ice creams from ice cream vans, etc. Ice lollies, Ice pops.
7. DRINKS: Non-carbonated bottles of water. Unpasteurized, freshly squeezed fruit juices.

TIPS FOR BETTER NUTRITION DURING THERAPY

Why it is important to eat well during treatment ?

• Research has found that patient who eat well including diets high in proteins, calories are able to tolerate chemotherapy, radiation, surgery better.
• Inclusion of a balanced diet helps maintain the patient strength. It prevents the breakdown of body tissue, helps in rebuilding the normal tissue.
• Patients with good eating habits have fewer infections can recoup faster.
• When there is decrease in food intake the body uses its own stored reserve leading to progressive weight loss and malnutrition. This makes the person more prone to infections.

What is a well-balanced diet ?

A Balanced Diet is a diet which includes all food group in specified amount i.e. Carbohydrates, Proteins, Fats, Minerals, Vitamins. Also include plenty of water and fibers in your diet.

Include:

1. Vegetables- 4-5 serving a day, salads. Fruit: juices, cooked or skewed fruits. Fruit, vegetables have an alkaline ash which helps in neutralizing the effect of treatment.
2. Dals/Non vegetable foods- At least 3 serving of dals, or meat, eggs, nuts to ensure adequate protein intake.
3. Cereals- At least 8-10 serving from porridge, rice, flour, bread etc.
4. Milk- One litre of milk or milk products in the form of milk, curd, paneer, or desserts should be consumed.

General Instructions

1. Eat food in a relaxed environment.
2. Include foods you like.
3. Eat small frequent meals.
4. Eat snacks in-between the meals like idli with chutney, paneer hot toast, upma, besan cheela etc.
5. Drinks plenty of liquid in between meals, flavor with different things like lemon, roohafza, squashes, coconut water, and badam sherbet. Limit intake of fluids with meals.
6. Eat slowly and chew the food well so that it can be digested easily.

SAMPLE MENU

Meal	Menu	Portion
Early morning	Milk	1 glass
Breakfast	Porridge	1 bowl
	Cheese sandwich	2
Mid morning	Orange juice	1 glass
Lunch	Chapatti	2
	Rice	1 bowl
	Dhal	1 bowl
	Mix Vegetable	1 bowl
	Raita	1 bowl
Evening tea	Poha	1 bowl
	Orange juice	1 glass
Dinner	Egg curry	1 bowl
	Vegetable Pulao	1 bowl
	Cucumber raita	1 bowl
Bed time	Milk shake	1 glass

Fresh vegetables are important components of a healthy diet. A healthy diet is one that helps maintain or improve health. It is important for lowering many chronic health risks, such as obesity, heart disease, diabetes, hypertension, cancer. A healthy diet involves consuming appropriate amounts of all essential nutrients, an adequate amount of water.
Since no single food group can nourish the body with all the vital ingredients it requires, it is important that we consume a variety of health foods to derive the nutrition our body needs.

There are five main foods groups, they are:

1. Fruits
2. Vegetables
3. Cereals Pulses
4. Dairy
5. Poultry, Fish Meat Products

Dietary recommendations

There are a number of diet recommendations by numerous medical governmental institutions that are designed to promote certain aspects of health.

World Health Organization

The World Health Organization (WHO) makes the following 5 recommendations with respect to both populations and individuals:

1. Achieve an energy balance and healthy weight
2. Limit energy intake from total fats, shift fat consumption away from saturated fats to unsaturated fats towards the elimination of trans-fatty acids.
3. Increase consumption of fruits vegetables, legumes, whole grains, and nuts.
4. Limit the intake of simple sugar.
5. Limit salt/sodium consumption from all sources, ensure that salt is iodized.

Other recommendations include:

Sufficient essential amino acids (“complete protein”) to provide cellular replenishment, transport proteins. All essential amino acids are present in animals. Some plants (such as quinoa, soy hemp) give all the essential acids. A combination of other plants in a diet may also provide all essential amino acids. Fruits such as vitamins certain minerals. Avoiding directly poisonous (e.g. heavy metals) carcinogenic (e.g. benzene) substances; Avoid foods contaminated by human pathogens (e.g. E. coli, tapeworm eggs).

• American Heart Association: The American Heart Association recommends a diet rich in fruits, vegetables, healthful fatty acids limited saturated fat.
• For specific condition: In addition to dietary recommendation for the general population, there are many specific diets that have primarily been developed to promote better health in specific population groups, such as people with high blood pressure (as in low sodium diet or the more specific DASH diet), or people who are overweight or obese (in weight control diets). However, some of them may have more or less evidence for beneficial effects in normal people as well.
• Hypertension: A low sodium diet is beneficial for people with high blood pressure.

The DASH diet

(Dietary Approaches to Stop Hypertension) is a diet promoted by the National Heart, Lung, Blood Institution (part of the NIH, a United States government organization) to control hypertension. A major feature of the plan is limiting intake of sodium, it also generally encourages the consumption of nuts, whole grains, fish, poultry, fruits vegetables while lowering the consumption of red meats, sweets, sugar. It is also “rich in potassium, magnesium, calcium, as well as protein”. Evidence shows that the Mediterranean diet improves cardiovascular outcomes.

Weight control diet aim to maintain a controlled weight. In most cases dieting is used in combination with physical exercise to lose weight in those who are overweight or obese. Diets to promote weight loss are generally divided into four categories: low-fat, low-calorie, very low calorie.

AVOIDING DIRECTLY POISONOUS CARCINOGENIC SUBSTANCES

Grains	Legumes	Vegetables	Fruits	Spices
Best options Wheat Basmati Rice	Best options Black gram Aduki beans	Best options Asparagus Avocado Grated coconut Raw Banana Sweet Potatoes	Eat Banana Cantaloupes Cooked Apples Fleshy dates Papaya Water melon Tender coconut	Eat Cumin Curry leaves Fennel Poppy seeds Saffron Turmeric
Other Spices Oats	Other Spices Spices (Spiced with Asafetida/Garlic) Whole Green gram Whole Red lentils	Other Spices Ash gourd Bottle gourd Pointed Gourd Pumpkin Ridged gourd Sponge gourd Other Spices (winter) Flat beans French beans Stalks Parsnips Pea leaves Water cress	Avoid Country pears Lemon Pomegranate Pears Sour Fruits	Occasionally Caraway Cardamom Cinnamon leaves Fenugreek Parsley
Avoid Corn Millets	Avoid Garbanzo (Chick peas) Red Kidney beans	Occasionally Beetroot Bitter gourd Carrots Brinjals Okra Avoid Broccoli Cauliflower Raw Vegetables	Dry Fruits preferably stewed or soaked Figs Raisins	Avoid Ajwain Anise Black pepper. Raw garlic

Some foods to consider eating more often

1. Green leafy vegetables, sweet potato
2. Carrots, Broccoli Greens (lightly cooked to keep the carotenoids)
3. Pumpkin, canned or cooked
4. Squash
5. 97percent or greater fat free chicken or turkey breast.
6. Low fat tomato sauces pasta.
7. Onion, Garlic or crush to release the phyto nutrients.
8. Homemade pizza with 99percent fat free chicken as meat sauce.
9. Foods with low/no salt for those who have high blood pressure
10. Peanuts, walnuts, almonds in moderation (be careful not to gain weight).
11. Olive oil, canola oil substituted for other oils, (the key is to monounsaturated fats vs. trans-fatty acids or partially hydrogenated fat).
12. Salmon, other fish (mackerel, sardines, herring), including the skin fat.

Research suggested that omega 3 fat (EPA fat) has the ability to raise HDLs.

1. 1-5 serving per week recommended
2. Defatted soy flour (at least 1/3 of a cup per day recommended)
3. Fat free milk (skim)
4. Oatmeal, shredded wheat, low-no sugar added cereals
5. Whole wheat bread
6. Fresh fruits
7. Apples (with skin for flavonoids)
8. Oranges (Eat pulpy parts for flavonoids)
9. Red or black grapes
10. Grape juice (1 cup per day recommended)
11. Grape fruit, especially pink which has 40percent more beta carotene than white
12. Dried fruits, especially apricots, dates, prunes
13. Cantaloupes
14. Fat free yogurt with extra dry milk to increase the magnesium calcium content
15. Tupelo honey as a substance for sugar in cakes, cookies, breads, etc.

Foods to be avoid

1. 1percent, 2percent whole milk
2. Meats with 96percent or less fat.
3. Red meats
4. Hydrogenated oils such as stick margarine, when listed as an ingredient in foods
5. Food with high butter fat, other animal fats, e.g., cheese, full fat yogurt, sauces
6. Hot dogs, hamburgers
7. Deep-fried foods
8. Sugar
9. Ice cream
10. Salt (if you have high blood pressure)
11. Baked goods ice cream made with fats
12. High fat snacks, chips
13. Pies, pastry’s cookies made with fat and sugar.

TIPS FOR BETTER NUTRITION DURING THERAPY

Why it is important to eat well during treatment ?

Research has found that patients who eat well, including diets high in proteins, calories are able to tolerate chemotherapy, radiation, surgery better. Inclusion of a balanced diet helps maintain the patient strength. It prevents the breakdown of body tissue helps in rebuilding the normal tissue that too gets affected by treatment. Patients with good eating habits have fewer infections are able to recoup faster. When there is decrease in food intake the body uses its own stored reserve leading to progressive weight loss and malnutrition. This makes the person more prone to infections.

What is a well balanced diet?

A Balanced Diet is a diet which includes all food groups in specified amounts i.e. s, Proteins, Fats, Minerals Vitamins. Also include plenty of water and fiber in your diet.

Include:

• Fruits Vegetables- 4-5 serving a day as fruits juices, cooked or skewed fruits, salads Fruits vegetables have an alkaline ash which helps in neutralizing the effect of treatment.
• Dals/Non vegetable foods- At least 3 serving of dals, or meat, eggs, nuts to ensure adequate protein intake.
• Cereals- At least 8-10 serving from porridge, rice, flour, bread etc.
• Milk- One litre of milk or milk products in the form of milk, curd, paneer or desserts should be consumed.

General Instructions:

1. Eat food in a relaxed environment.
2. Include foods which interest you.
3. Eat small frequent meals.
4. Eat snacks in-between the meals like idli with chutney, paneer hot toast, upma, besan cheela etc.
5. Drink plenty of liquids in between meals, flavor with different things like lemon, roohafza, squashes, coconut water almond sherbet.
6. Limit intake of fluids with meals.
7. Eat slowly and chew the food well so that it can be digested easily.

In case of nausea vomiting:

1. Take small/frequent meals
2. Include cold foods i.e. ice-cream, ice cubes, coconut water, fresh lime, cold custard, cold puddings, and jelly. It helps to relieve nausea.
3. Greasy fried foods are worst tolerated.
4. Do not lie flat after eating for at-least an hour after meals.
5. Eat slowly; chew your food well so it can be digested easily.

In case of dry mouth, mucositis, stomatitis (mouth sores):

1. Try a semisolid diet.
2. Use butter, cream to make the food more calorie concentrate.
3. Do not use hot spices i.e., pepper chili powder.
4. Eat lukewarm or cool rather than hot foods.
5. Use nutritional formulas to supplement food intake.

In case of diarrhea:

1. Stay away from foods that causes gas or cramps such as cabbage, soybeans, or highly spiced foods.
2. Avoid milk.
3. Do not skip meals.
4. Eat soft bland foods like khichri, rice, washed dals and banana.
Take more of fluids like clear soups, lassi, fresh lime, coconut water, roohafza, apple juice to replenish the potassium loses add salt to these to prevent sodium depletion.

In case of constipation:

1. Constipation can be a problem due to some drugs or if you have been eating mostly soft or liquid foods.
2. Add fiber to your food- Eat variety of fruits vegetables, whole grain cereals dals-dry fruits/raisins, prunes nuts.
3. Drinks plenty of liquids, at least eight to ten glasses every day.
4. Hot lemon water in the morning helps to stimulate bowel activity.
5. Honey papayas are known to be good laxatives.
6. Try taking 1-2 Tbsp of bran or isabgol.

Depressed Immune Function:

1. This includes WBC/TLC only. If either is lower than their ranges avoid fruits vegetables.
2. As a precaution avoid raw fruit, salad, fresh juices.
3. Eat freshly prepared food.
4. Include Milk (boiled), dahi from pasteurized milk bread, cooked paneer in your diet.

Protein supplement:

1. Protinex, Resources High Protein, Ensure Kabiproshake Acti base

PROTECTIVE FOODS

1. FENUGREEK SEEDS ¼ - 1tsp/day . Help in reducing blood glucose, inhibits cholesterol, triglycerides dur to its high fiber content.
2. ALMONDS/WALNUTS- 5/day. High in omega 3 fatty acid Vitamin E that reduces LDL cholesterol.
3. Garlic 2-3 cloves/day. The active ingredient ALLICIN reduces blood lipids plaque formation.
4. SOYABEAN 25g/day. Helps to reduce the risk of heart disease due to its antioxidant anti-angiogenesis activity. Soyabean also has a low glycemic index.
5. OATS 30g/day. Reduces cholesterol, prevents plaque formation because of high content of soluble fiber
6. HONEY 1tsp/day. Blocks cholesterol synthesis
7. ISABGOL/WHEAT BRAN 1tsp /2-3Tbsp./day. Lowers bad cholesterol (LDL), blood glucose, triglycerides.
8. AMLA 2/day. Rich in Vitamin C, an antioxidant that inflammation.