9th Part
Q A relationship between nutritional status & infection exists 5
Q Infection can influence nutritional status. 5
A Effect of Infection on Nutritional Status -
Nutritional status is the condition of the health of an individual as influenced by the utilization of nutrients.
a) Reduced food intake: When a child is suffering from infections like diarrhea or respiratory infection, one of the first changes noted by the mother is the loss of appetite. Quite often, the child may not like or tolerate food. As a result of this, the child consumes less food or there is reduced dietary intake. Furthermore, the antibiotics used in the treatment of infection may also reduce the appetite in the child leading to reduced food intake.
b) Effect on the absorption of nutrients - during digestion various nutrients are absorbed and they enter the bloodstream. Any decrease in the absorption of nutrients can lead to a deficiency of the particular nutrient. It is observed that in the case of infections
like diarrhea, measles, and respiratory disease there is a reduction in the absorption of nutrients. Only 60-70 percent of the nutrients consumed are available to the body. Even worm diseases like roundworm disease usually reduce the absorption of nutrients, thus, leading to ill-health.
c) Loss of protein: In some of the infections and fevers, few nutrients, particularly proteins are excreted i.e. lost from the body. This naturally increases the requirement of protein during infections and fevers. The overall effect of the infections on the dietary intake of the child is substantial. In a poor rural child, who is already on a deficient diet, the effect of the infections can, therefore, be devastating.
Q Enumerate the effect of infection such as diarrhea on the nutritional status of an individual. It also gives the dietary management of diarrhea. 4+4
A Diarrhoea and Nutritional Status
Diarrhoea is a symptom that is characterized by the sudden frequent onset of stools of a watery consistency, abdominal pain, cramping, weakness, and sometimes fever and vomiting. Diarrhoea is very common among children and it can reduce the appetite of the child considerably. As a result, the child does not eat properly.
Further in diarrhoea fluids are lost from the body. Along with the fluids, important minerals such as sodium and potassium (usually known as electrolytes) are also lost. This loss of fluids and electrolytes during diarrhoea leads to dehydration. It is this dehydration that is responsible for the high death rate in children with diarrhoea. In the villages and slum areas in the cities, the children generally suffer from frequent and repeated attacks of diarrhoea. Repeated attacks of diarrhoea lead to significant weight loss in children. If we examine the nutritional status of children affected with diarrhoea we notice that the bodyweight of these children is much lower than the normal children. Similarly, diarrhoea are also associated with kwashiorkor and marasmus, the clinical features of PEM.
Q Enumerate the clinical features and measures for the control of Obesity 5
Q Dietary management of Obesity 5
A We can call a person obese if he or she weighs 20 percent above the ideal body weight (if a person's ideal body weight is 45 kg and he weighs 55 kg i.e. higher than 20 percent of his ideal body weight, he is obese). However, the term overweight is applied only to persons who weigh 10 percent to 20 percent more than the ideal body weight. Ideal body weight refers to the average or desirable weight of a healthy individual according to height and body frame.
The different measures to control obesity are dietary modifications, physical exercise, and psychological support.
Dietary management of Obesity -
i) Food restrictions: For dietary modification, firstly make a note of foods(no of meals) one (obese individual) eats throughout the day. Don't forget to count the foods one eats in between meals like biscuits, namkin, a piece of sweet, toffee, or chocolates. Calculate the total energy intake. Energy restriction has to be slow and gradual. Start reducing 200-300 Kcal per day and slowly more restrictions can be placed. Do not start energy restriction with main meals. First cut down on the extra titbits one tends to eat in between. Give smaller meals at regular intervals. Don't let the person miss a meal. In general, a restriction of 500 Kcal per day results in a loss of about 450 g a week and 1000 Kcal leads to a loss of about 900 g a week.
ii) Cut down the intake of fat and fat-rich foods: Restrict the intake of visible fat. Give visible fats in the form of vegetable oils. Avoid giving ghee, butter, or hydrogenated fats as they contain saturated fats and cholesterol.
iii) Give more protein-rich foods: Add enough of protein-rich food in the diet. Around 1 g protein/kg body weight can be given. Milk (toned milk or whole milk from which cream has been removed), pulses, lean meats, chicken, fish.
iv) Give more of leafy vegetables and yellow and orange fruits: They provide the basic protective and regulatory nutrients.
v) Give more fiber-rich foods: Add more fibrous foods in the diet as they have more satiety value. They not only satisfy hunger but also provide less energy (calories). Whole cereals, whole pulses, fibrous fruits, and vegetables.
Q Enumerate the risk factors for obesity. 5
A Over-eating: Eating too much-is a habit with many people. If one has the habit of eating more food in general or consuming energy-rich foods like butter, cakes, pastries, jam, jellies, wafers and other rich snacks and desserts, one is likely to gain weight. Some people prefer to eat less during mealtime, but keep on munching snacks throughout the day in between meals which also adds to the weight.
Sedentary lifestyle: Besides food intake, another factor that is responsible for gaining bodyweight is lesser physical activity. In urban areas, especially the affluent or rich class people lead a sedentary lifestyle. Most of the time they are involved in some kind of mental work and do very little of running or walking around. Today housewives are equipped with electric gadgets like a vacuum cleaner, mixer, washing machine, etc. to make work simpler for them. Such people tend to spend or use very little calories they have consumed as part of the food. As a result of it, they gain weight.
Psychological factors: Some people tend to eat more when they are tense or bored or lonely. These people use food as the outlet for the release of tension and boredom. Because of this, such people gain weight and become obese.
Genetic influence: Obese parents do tend to have obese children. This fact has been proved by medical research investigations. If both the parents are obese, the chances that children will be obese goes up to 80 percent.
Q Discuss the factors which favor the development of obesity and list the dietary measures you would adopt to prevent this condition. 8
A above 2 questions
Q Principles of treatment of obesity 5
A I) PRINCIPLES OF TREATMENT OF OBESITY: The main principles are -
# slow and gradual reduction of body weight till it is closer to ideal body weight
# maintenance of weight loss achieved
# prevention of complications like heart disease or diabetes mellitus.
2) THE MODIFIED NUTRITIONAL NEEDS: The modifications needed for obese individuals are-
Energy - In general, a restriction of 500 Kcal per day results in a loss of about 450 g (1 pound) a week and 1000 Kcal leads to a loss of about 900 g (or 2 pounds) a week. In many studies, it has been found that a daily intake of 1400-1600 Kcal results in satisfactory weight reduction. However, it is not the same for every individual. Start reducing 200-300 Kcal per day and slowly more restriction can be placed, one can go up to 1000 to 1200 Kcal depending upon requirements of an individual.
Protein: Add enough protein-rich foods in the diet. Around 1 g protein/kg body weight can be given.
Fat: Restrict the intake of visible fat. Give visible fats in the form of cooking oils. Avoid giving ghee, butter or hydrogenated fats-they contain saturated fats and cholesterol
Vitamins and minerals: Diet should provide vitamins and minerals in adequate amounts according to recommended dietary intakes.
DIETARY MODIFICATIONS above
Q Explain briefly the modifications needed in the amount of energy, protein, carbohydrate, and fat in the diet of an : (i) Obese individual 6
A above
Q List the clinical features & measures you would adopt to prevent Diabetes mellitus 5
A Clinical features - If an individual has increased thirst, increased urination, increased hunger, or weight loss all of a sudden, it can be due to diabetes. Other symptoms that indicate the presence of diabetes are blurred vision, weakness or loss of strength, pain in legs.
However, in order to confirm the presence of diabetes in an individual, one has to depend on blood and urine tests. A test called the glucose tolerance test (GTT) is performed to confirm the presence of diabetes in an individual.The three measures commonly adopted for control of the disease are:
a) dietary management alone
b) dietary management and oral drugs
c) dietary management and insulin doses.
I) MAIN PRINCIPLES OF TREATMENT: The principles for the treatment of diabetes mellitus are -
a) maintain ideal body weight and general well-being
b) keep the person relatively free of symptoms
c) prevent further complications.
2) MODIFICATIONS IN NUTRITIONAL NEEDS: The following modifications are needed in RDIs for various nutrients.
Energy: Control of energy intake in order to maintain ideal body weight is essential. If the individual is underweight, then an increase in total energy intake is recommended. However, if an individual is overweight energy restriction is essential. The main aim of treatment is to maintain the ideal body weight.
Protein: For diabetic individuals, the protein intake considered is 1 g/kg body weight.
Carbohydrates - Around 80-100g carbohydrates should be given to prevent too much breakdown of fat and accumulation of its by-products (ketosis). However, most of the carbohydrates taken should be in the form of complex carbohydrates (having more fiber). Refined or simple carbohydrates need to be avoided. Fibre reduces the fasting blood sugar level and insulin requirements. On the other hand, simple carbohydrates tend to increase fasting blood glucose levels. They are readily absorbed and immediately raise blood sugar.
Fat: The diabetic individual should not be allowed to take more than 15 to 20-g fat per day. This is because he/she is more at risk of developing heart disease. Foods high in saturated fat and cholesterol should be limited. Effort should be made to give fats having unsaturated fatty acids.
Q Indicate two risk factors- of diabetes. 2
A Age: Although diabetes can begin at any age, middle-aged people are prone to it.
Malnutrition: Undernutrition and overnutrition both play a role in the development of the diseases. Thus, both underweight and obese (overweight) individuals are more at risk.
Heredity: People whose parents, grandparents, or siblings are suffering from the disease are at higher risk.
Gestation: Some women develop diabetes during pregnancy (gestation). In most of the cases, it gets cured after delivery. Such women who had diabetes during pregnancy are at risk of developing the disease later.
Stress: Some of the studies have indicated that some factors like emotional stress, anxiety, etc. can lead to the development of the disease in the body.
Q Dietary modifications for diabetic individuals 5
A Dietary modifications are -
Energy-Giving croup
Cereals- Use of whole-grain cereals like whole wheat flour is recommended. The use of refined cereal products like maida, suji, etc. should be restricted or avoided.
Roots.and tubers- Use of roots and tubers like yam, colocasia, potato, sweet potato should be in moderation as they contain more refined or simple carbohydrates.
Sugar- Sweeteners like table sugar, jaggery, honey, glucose, and others like jams, jellies, marmalade, and concentrated sweets (like toffees, chocolates, burfi, gulab jamuns, and other such sweets) should be avoided.
Fat- Not more than 15 to 20 g of visible fat should be allowed. Unsaturated fats like groundnut oil, soya oil, corn oil, etc. Should be used in moderation. Saturated fats and cholesterol-rich foods should be avoided.
Body-Building Group
Milk- Milk should be taken literally. The use of milk products like paneer, curd, khoya, etc. should be encouraged. However, the use of full-fat milk or buffalo's milk should be restricted.
Pulses- Use of pulses (especially the whole pulses) should be encouraged. This is because whole pulses are not only rich in protein but also fiber. {In order to ensure adequate intake of protein and fiber in the diet, one could mix the flour of Bengal gram (whole) in atta (whole wheat flour) used for making chapatis for a diabetic individual in the proportion of 1:2 (1 part of Bengal gram (whole) flour and 2 parts of atta (whole wheat flour).}
Egg- Eggs (especially egg yolk) should be consumed in moderation. If one is fond of taking eggs, one can take the egg white and discard the yolk portion (as it is a rich source of cholesterol).
Flesh foods- Avoid Organ meats like liver, kidney, etc. As they are rich sources of cholesterol. Consume lean meat for diabetic individuals or preferably use chicken or fish.
Protective/regulatory Group
Vegetables: Increase the intake of vegetables especially fibrous vegetables (like leafy vegetables, lotus stem, brinjal, beans, etc.).
Fruits: Fruits, as they are sweet, need to be taken with caution. One should take very sweet fruits like mango, grapes, sapota, watermelon, sugarcane juice, all canned foods, banana, and apple, etc. with caution. If one wants one can just have a piece of it occasionally. Others like guava, apples, oranges, mausmbi etc. can be taken in moderation (just one or two a day).
Q Explain the dietary management of the following disorders: Diabetes mellitus 8
A 1) Regulation of the meals consumed is essential. Diabetic individuals should be encouraged to have meals at regular intervals. It is advisable for him/her not to skip meals or keep a fast.
2) AII the main meals consumed should provide a fairly even amount of calories.
3) Care should be taken to include foods from all three basic food groups.
However, suitable modifications are needed within each group to ensure control. Let us see what these modifications are:
above answer
Q What is IDDM & NIDDM.
A Insulin-dependent diabetes mellitus (IDDM)- In this type of diabetes mellitus (in order to function normally) body is dependent on insulin doses from an exogenous source (outside source). It occurs more frequently in young children and adolescents.
Non-Insulin dependent diabetes mellitus (NIDDM)- In this type of diabetes mellitus, there is a lack or insufficiency of insulin in the body which can be brought under control by either diet alone or a combination of diet and certain drugs. The body is not dependent on insulin from an outside source. This is frequently observed in adults (especially those who are overweight).
Q Risk factors for Coronary Heart Disease 4
A There are various factors responsible for the disease can be clubbed in three categories:
# personal characteristics
# learned behavior
# background conditions
Personal characteristics- These include factors like sex, age, a family history that are not in control of a person. These factors are -
Age - The incidence of CHD rises with aging particularly after middle age.
Sex - Men are more prone to CHD than women.
Family history- Those persons who have a family history of CHD (i.e. their parents or grandparents are suffering from it) are more prone to CHD.
Learned Behaviour- The factors that have a definite influence on coronary heart disease.
Sedentary lifestyle- Sedentary individuals (who are engaged in light physical activity and remain sitting most of the time in a day) are more prone to CHD.
Stress- Anxiety and emotional stress increase, the chances of CHD.
Smoking- Many research investigations have proved the definite influence of smoking on CHD. Heavy smokers are more prone to CHD than non-smokers.
Diet- Consumption of diets rich in saturated fat and cholesterol increases the chances of CHD.
Obesity- Obese individuals. are more prone to CHD, than those having a normal weight.
Background Conditions- These include other disease conditions like diabetes mellitus, hypertension, higher levels of cholesterol in the blood, etc. by which one might have been suffering. The persons suffering from these diseases are at increased risk of developing CHD.
Q Discuss the dietary management of coronary heart disease. 8
A The main objective of dietary management is to provide a fat controlled and energy-restricted diet to the patient. Some points are
Energy restriction: You need to make the following modifications:
# Cut down the intake of total food.
# Avoid consumption of fat-rich foods.
# Give cereals in moderation. Cut down the intake of refined cereals, encourage the use of whole-grain cereals.
# Give more of pulses especially the whole pulses. Other body-building foods like milk and milk products and flesh foods have to be given by taking their fat content into consideration.
# Increase the intake of fruits and vegetables (especially fibrous ones).
# Cut down the intake of sugar and other sweeteners.
Fat restriction: i) Reduce the intake of fats and oils.
ii) Replace saturated fats like ghee, hydrogenated fats, butter with unsaturated fats like groundnut oil, soya oil, safflower oil.
iii) Oils like mustard oil and coconut oil have more saturated fatty acids than unsaturated fatty acids. Their use should be limited.
iv) Use low-fat milk or toned milk instead of whole milk. Whole milk can be given after removing the fat or cream (which comes on top after boiling).
v) Give eggs in moderation. If possible not more than one egg should be given to the patient (or otherwise, 'it should be given after removing the yolk portion of it).
vi) Avoid giving fat-rich flesh foods. Select lean cuts of meat. Fish can be given.
vii) Use roasting, baking, boiling, and steaming as methods of cooking instead of frying (both shallow and deep-frying).
viii) Don't give nuts like groundnuts, cashew nuts, walnuts, etc. They are rich in fat.
ix) Avoid giving other fat-rich desserts and fried snacks like cakes, pastries, samosas, etc.
Sodium restriction- Since hypertension or high blood pressure can lead to CHD. Sodium intake should be in moderation as it increases the risk of CHD also.
Q List the clinical features and measures you would adopt to prevent Hypertension 5
A Hypertension' is a condition of the body in which blood pressure is higher than normal. Normal blood pressure is 120/80 mmHg. The upper figure is called systolic pressure and the lower figure is called diastolic pressure. Hypertension is classified into mild, moderate, and severe hypertension depending upon the range of increase in diastolic pressure.
Mild Hypertension-If diastolic pressure is 90 to 104 mm Hg, it is termed as mild hypertension.
Moderate Hypertension- If diastolic pressure is 105 to 119 mm Hg, the condition is known as moderate hypertension.
Severe hypertension- If diastolic pressure is 120 to 130 mm Hg and above, the condition is known as severe hypertension.
The diet for hypertension patients like any other heart disease involves a check on the intake of fat and total energy. The fat controlled and energy-restricted diet as prescribed for CHD patients is applicable here also. In addition, you need to carefully monitor the intake of sodium by these patients. It has also been found that restriction of sodium intake accompanied by fat restriction can effectively control mild or moderate hypertension.
Q What dietary modifications would you advocate for a hypertensive patient? 7
A Dietary management and modifications are similar to CHD Above
The only addition is -
In mild hypertension, just restriction of intake of common salt can be helpful. However, for moderate and severe hypertension patients, no salt is recommended to be used for cooking. In addition, patients have to give up foodstuffs that are rich in sodium.
Q Consequences of Maternal Malnutrition 5
A # Maternal malnutrition also affects the health and well-being of the foetus, the infant, and the young child. It often results in the death of the child. Even if the child survives, it can condemn the child to a lifetime of poor health.
# Poor maternal nutrition and low birth weight are related. The frequency of births with weights below 2.5 kg among poor income groups is more because of extensive malnutrition among the women.
# Children with low birth weights are at a higher risk of death as compared to those with normal weights. This is one of the reasons for high death rate among infants (referred to as infant mortality rate). The lower the birth weight, the higher will be the risk of death in the case of the child. Besides high mortality rates, low birth weight babies also tend to have:
- greater incidence of infections
- fewer brain cells
- lower growth rates and
- greater incidence of mental retardation
# the prevalence of anemia is very high in pregnant women . Severe anaemia leads to premature births (birth before. 37 weeks of pregnancy) and low birth weights. There are risks for the mother as well. In anaemic pregnant women, the deaths during delivery are also more. Anaemic women will not be able to do normal physical work.
Q What is maternal malnutrition? What are its causes and consequences? 3+3+4
A "Maternal malnutrition" therefore means malnutrition of mothers. It can be extended to include women in the reproductive age. The physiological stress of added nutrient demands makes pregnancy and lactation high-risk periods in the life of a woman.
Causes - less food and not enough food of the right kind. This accounts for the lower heights and weights of women particularly in rural areas and urban slums. It also explains why so many Indian women suffer from anaemia and vitamin B-complex deficiencies. The diets of these women are inadequate largely because they are poor and do not have the money to purchase enough food. Ignorance adds to their problems. They do not have the knowledge to make wise food choices for themselves or their families. In fact, we do not often realize that maternal malnutrition begins with poor nutrition during the years of adolescence. Our health and nutrition programs should also be targeted at adolescent girls so that they can be better equipped for safe motherhood.
