1

Managing disease and avoiding

complications through diet
diversification
2
HND-403 DIETETICS III 3(3-0)

Diet diversification
3

Food diversification;

Make wider selection of foods with a high vitamin & mineral

content available for purchase
More varied meals and have a more balanced diet
Reduce under-nutrition and malnutrition
Integrate food security

Diversification can be delivered through health services, along

with food supplementation and fortification;

Play a major part in reducing malnutrition
Hence, dietary diversification/modification are the strategies to

enhance micronutrients and bioavailability of varied diets for

health promotion and disease prevention

Cont
4

Adequate human nutrition involves regular intake of a wide range

of nutrients, some of which must be consumed on a frequent basis,

even if in small quantities
Micronutrient deficiencies are prevalent in areas where the diet

lacks variety, as in developing countries

When people cannot afford to diversify their diets with adequate

amounts of fruits, vegetables or animal-source foods that contain

large amounts of micronutrients, deficiencies are inevitable
In addition, minimum amount of fat or vegetable oil is also

required in the diet for adequate absorption of fat-soluble vitamins

A, D, E and K

Cont
5

In treating the problem of micronutrient deficiencies, food-based

approaches focus on improving overall dietary quality, rather than

merely delivering a single nutrient

Complex nutrient-nutrient interactions increases bioavailability

when nutrients consumed simultaneously

According to FAO, iron absorption is increased when it is

combined with vitamin C

Protective chemicals are easily obtained by consuming a wide

variety of fruits and vegetables

Scientific knowledge linking nutrition and disease associate wide

range of nutrients in health maintenance

Rickets; associated with vitamin D deficiency is now connected to

diets low in calcium

Cont
6

Dependent relationships heightens the importance of promoting

food-based approaches that focus on achieving sustained

improvements in overall diet
Several low-cost, food-based measures that can be promoted at

community level to improve micronutrient status

Culturally appropriate dietary modifications should be developed

to help people identify concrete actions that can improve both

dietary supply and micronutrients absorption
This information needs to be disseminated to the public through

traditional information channels

Cont
7

Dietary Diversity (DD);

Typically measured in the form of count of food groups or food

group frequency
Suggested as a proxy indicator for nutrient adequacy
Augmented by expanding production, processing, marketing
and consumption of a wide variety of foods

Dietary diversity score (DDS) is an indicator of;

Overall diet i.e. associated with nutrient adequacy ratios after

adjusting energy intake
Nutritional adequacy of diet to assess the relationship between
DDS and disease risk factors

Cont
8

Diverse diets protect against chronic diseases such as cancer

hence associated with prolonged longevity and improved health

status
To protect from CVD, higher variety score are associated with

increased intakes of fibre, vitamin C and calcium

Nutritional epidemiology focuses on the affect of overall diet

quality on diet-disease relationship instead of single nutrient

Dietary Diversity (DD)

9

Defined as the number of individual food items or food groups

consumed over a given period of time

It can be measured at household or individual level through the use of

questionnaire

Most often it is measured by counting the number of food groups rather

than food items consumed

Type and number of food groups included in the questionnaire and

subsequent analysis vary, depending on the intended purpose and level
of measurement

At household level, dietary diversity is considered as a measure of food

access (e.g. households capacity to access costly food groups)

At individual level it reflects dietary quality, mainly micronutrient

adequacy of the diet

Reference period can vary but is most often the previous day or week

Cont
10

Dietary diversity is measured to monitor the impact of food

based approaches;

Monotonous diets mainly on energy dense but micronutrient

poor starchy staples are common in food insecure areas and
contribute to malnutrition

Food-based strategies are recommended as the first priority to

meet micronutrient needs

Inclusion of essential elements to food-based approaches

involves dietary diversification or consumption of a wide
variety of foods across nutritionally distinct food groups

Increased dietary diversity is associated with increased

household food access as well as individual probability of
adequate micronutrient intake

Measurement of dietary diversity

11

Dietary diversity is measured as the number of individual food items

or food groups consumed over a given reference period

FAO has developed a standardized tool for measuring dietary diversity

that can be administered at either the household or individual level

The tool uses an open recall method to gather information on all the
foods and drinks consumed by the household or individual over the
previous 24 hr

Food and drinks mentioned by the respondent are then recorded into
one of 16 standardized food groups

Information from dietary diversity tool can then be analyzed in many

different ways to provide a picture of dietary patterns within the
community as well as among vulnerable groups

Cont
12

Conventional quantitative dietary assessment surveys are

costly and cumbersome to conduct and analyze

Resultantly, interest is found in using simple proxies of intake

that can be measured quickly and easily, reflecting valid
nutrient intake

Hence, rationale for developing dietary diversity measurement

tools as proxies of quantitative dietary intake

FAOs dietary diversity guidelines

13

FAO has published operational guidelines for measuring

dietary diversity in a standardized way

FAO data collection tool uses an open recall method to gather

information on all food and drinks consumed by household or
individual level over the previous 24 hours

Foods and drinks recalled by the respondent are then recorded

into one of 16 standardized food groups

Also inquire to capture information on consumption of any

food groups not mentioned in the open recall

FAO guidelines describe how to adapt the tool to local food

systems

Cont
14

FAO guidelines recommend the following ways of reporting information

collected on dietary diversity;

Dietary diversity scores are simple counts of number of food groups

consumed at individual or household level

Two dietary diversity scores recommended by FAO;

Household Dietary Diversity Score (HDDS) based on twelve food groups

Womens Dietary Diversity Score (WDDS) based on nine food groups

Mean scores can be compared across population sub-groups and over

time

Dietary profiles based on food groups consumed by a majority of

individuals/households can be compared;

To provide insights on consumption patterns across population sub-groups

Percentage of individuals or households consuming food groups or

combinations of nutrient dense food groups (such as food groups rich in
Vitamin A) can be analyzed

Cont
15

Dietary diversity scores limits the ability to detect changes or

differences in the mean score, particularly when the sample
size is small

Another limitation is that there is no universally recognized

cut point above or below which households or individuals can
be classified as having adequate or inadequate dietary diversity

Additionally, at household level, the tool underestimate

household dietary diversity in urban areas and among
populations where out of home food consumption is common

Given these limitations, it is strongly recommended not to use

the dietary diversity measure as a standalone tool

Cont
16

Thus, DD measurement should be integrated into broader

survey instruments and results triangulated with other
characteristics of interest such as wealth or food security status

To obtain a holistic picture of the food and nutrition security situation

in a community

Collecting information on dietary diversity should be of

interest where primary or secondary objective is to improve
the diet of the beneficiary population

Dietary diversity data are useful to evaluate the impact of food

and nutrition security program

Role of nutrients in diet diversification

with respect to disease management
17

Fiber
18

Recent recommendations suggest that fiber proportion should be

fulfilled from fiber rich foods rather than from dietary supplements

Healthy diet should provide a mixture of both soluble and insoluble

fibers

Different sources of fiber include; fruits (apple and citrus), leafy green

vegetables, oats, wheat bran, whole grains, legumes, etc.

Good source should contain fiber upto 3 g while 5 g in high fiber diet

Healthy adult should consume 30-40 g of fiber/day

Children between the age of 3-18 need less fiber than adults and need

different amounts at different ages

To calculate a childs daily fiber requirements, add the childs age to

number five (for five grams)

For example: four year old child need nine grams of fiber/day

Carbohydrates
19

Carbohydrates require less water to digest than protein or fats

Carbohydrates are not necessary for human nutrition because

protein can be converted to carbohydrates

Carbohydrate is present in number of food items thus its deficiency

is very rare

Excess carbohydrate is the raw material for liver to manufacture

triglyceride and cholesterol

Exercise causes the body to utilize energy from glycogen followed

by fat reserve

One should not eliminate carbohydrates completely from the diet

because body then start using protein as energy source

Low carbohydrate diets slow down brain and neural function

Because nervous system especially relies on glucose (brains

preferred fuel)

Carbohydrate and glycemic index

20

Glycemic Index (GI) is a number associated with a particular type of

food that indicates the food's effect on a person's blood glucose level
High fiber (contains less digestible carbohydrate), more fat (causes the

liver to become resistant to insulin) or acid content (inactivates

amylase) in food or coarsely ground grains possess slower carbohydrate
conversion to sugar
Starches in potatoes and ripened fruits and vegetables possess higher

glycemic index
Glycemic index was originally invented to help diabetes patients to

manage their blood sugar levels, obesity, cravings and appetite swings

Complex carbohydrates
21

Take longer to convert glucose, result in few insulin surges and less
nutrient depletion
Digested in small intestine and more steady source of energy for a longer
period of time

Oat bran (soluble fiber); rich source of -D-glucan thus used for cholesterol

reduction

If attempting to lose weight and diabetes run in families, totally avoid simple

carbohydrates and be cautious with fruit and fruit juices

Fruits are best consumed one half hour before any other foods for quick entry

into small intestine

Fruits in the midst of a large meal will keep the fruits in stomach for a longer

time to ferment

Most effective approach to lose weight is to keep complex carbohydrates to a

minimum, stop all simple carbohydrates and do not eat any food after your
evening meal

Protein
22

One should eat a variety of protein foods to obtain full range of

essential amino acids

Combination of plant and animal proteins is recommended for a

balanced diet
Protein choices for vegetarians include legumes, nuts and dairy

products
Weight loss strategies require protein consumption, away from any

carbohydrates
If dietary Ca is inadequate, excess protein increases calcium losses

in the bones

Cont
23

Protein and fat are vital building components for body tissues

and cells hence not advisable to deplete

Protein in food is broken down into amino acids, forming a

variety of proteins like collagen, myosin and hemoglobin as

required by the body

Body has a finite need for protein, if one has fulfilled his dietary

needs, additional proteins are deaminated and stored as fat

Kidney have to work overtime to get rid the body from excess

nitrogen

Protein in the blood help to hold salt and water inside the blood

vessels so fluid does not leak out into the tissues

For example; too low albumin (most abundant blood protein)

causes oedema

Fat
24

Average person makes up 75% of blood cholesterol in liver while

only 25% get absorbed from food

About 10% of fat is converted to sugars in process called

gluconeogenesis
Without fat in the diet, fat soluble vitamins would not able to

function, resulting in severe problems

Fat protects internal organs, necessary for proper development

of child
Dietary fat stimulates bile flow and emptying of gallbladder

otherwise leads to gallstones

Cont
25

Type of fat really matters in the diet;

Bad fat means saturated or trans fat that increases disease risk
Good fat means monounsaturated or polyunsaturated fat that lowers the disease risk
Fish contain polyunsaturated fat known as omega-3 fatty acids that

protects against cardiac rhythm disturbances

Avoid commercial shortening and deep fat frying that leads to the

formation of trans fatty acids

Trans fats are even worse than saturated fat because they raise bad LDL

and lower good HDL

Trans fats lead to inflammation and over-activity of immune system

resulting in heart diseases and diabetes

Replacing only 30 calories (7 grams) of carbohydrates every day with 30

calories (4 grams) of trans fat nearly double the risk for heart diseases

Minerals and vitamins

26

Minerals are vital in absorption, function and effectiveness of

certain vitamins
Vitamins are not sufficiently absorbed, if minerals are not

present in proper proportion

Deficiency of one mineral may disrupt the entire chain of life,

rendering other nutrients either useless or inefficient

Vitamins are required for every biochemical activity of the body

but vitamins cannot function unless minerals are present

Dietary diversification to
manage CVD
27

Dietary management of CVD

28

Without cholesterol, body cannot

function properly
Too

much cholesterol causes

deposition in arteries leading to
heart diseases

Triglyceride and trans fatty acids

are more atherogenic raising LDL

and lowering HDL

Dietary management of hypertensive subjects

29

Energy;
About 20 kcal/kg b.w. are prescribed for
sedentary workers and 25 kcal/kg b.w. for
moderately active worker

Increased calorie intake especially in the

form of carbohydrate and fat significantly
increases Sympathetic Nervous System
(SNS) activity ultimately increasing blood
pressure

In case of obese hypertensive, a hypocaloric

diet is recommended

Cont
30

Protein;
Intake of 60 g protein daily is necessary to maintain proper
nutritional status

Excess amount of animal protein should be avoided

Protein foods are rich in sodium as well thus in severe

hypertension, reduction of 20 g proteins is advised as
temporary measure

Cont
31

Fats;
Low fat diet i.e. about 20% of energy should come from fats

More of unsaturated fats should be used

About 20 g vegetable oil is permitted

High intake of animal or hydrogenated fats is avoided as these

patients are more prone to atherosclerosis or other coronary
heart diseases

Cont
32

Carbohydrate;
About 60-65% of energy should come from carbohydrate
sources

Complex carbohydrates like starches and dietary fibers should

be included to manage high blood pressure

Dietary fiber in the form of wheat, wheat bran, pectin and oat
bran have hypotensive influence

Cont
33

Sodium;
Mild to moderate sodium restriction (1-2 g salt/day) along
with weight reduction is effective in controlling hypertension

Increased intake of sodium in diet leads to increased cardiac

output, elevating blood pressure

Moderate sodium restriction up to 2-3 g salt/day reduces

diastolic pressure by 6-10 mm Hg, lowering blood pressure

Cont
34

Low sodium and sodium/potassium ratio is preferred in

the diet

Average sodium intake is about 3000 mg/day

500 mg of sodium causes loss of about 10 mg of calcium

Sodium intake of < 50-80 mEq/day;

No hypertension
No increase in blood pressure with age

Sodium restriction up to 70-100 mEq/day (4-5 g of salt)

is recommended for all hypertensive patients

Cont
35

Potassium and calcium;

Sufficient amounts of foods rich in potassium and calcium

should be included in the diet

Role of potassium in hypertension is actually important as it

has complex interplay with sodium
For

example; low levels of potassium cause the body to

retain sodium and water, elevating blood pressure

Reduction

of sodium to potassium ratio by 3.1:1 is associated

with 3.4 mm Hg decrease in the average level of systolic
blood pressure

Cont
36

Potassium rich foods such as fruits and vegetables should be

included in the diet to fulfill 3500 mg of required potassium on
daily basis

800 mg/day of dietary Ca reduces hypertension significantly

Oral supplementation of Mg lowers both systolic and diastolic

blood pressure (-0.2 and -0.1 mm Hg, respectively)

Tips to reduce salt intake

37

Consume foods that are labeled low sodium, no salt added or

unsalted

Check the total sodium content on food labels

Partially replace salt with pepper, garlic, lemon or other spices

for flavor

Foods to be avoided;

Naturally high in sodium; cured meat, hot dogs, bacons, sausages,

ham, nuts, olives, pickles, soy and worcestershire sauces, tomato
& vegetable juices and cheese

Salt preserved foods like pickles, highly salt processed foods and
use of monosodium glutamate, baking powder, sodium
bicarbonate and sodium benzoate

Dietary management of atherosclerotic subjects

38

In the initial phase of heart diseases, the basic objective is

cardiac rest and strict dietary management

Diet modifications for heart to prevent cardiac disorders

include;

Adequate nourishment
Maximum rest for heart
Prevent further heart damage
Restore the damaged heart to normal functioning
Maintenance of good nutrition
Relieve strain to heart
Prevent and eliminate edema

To achieve above objectives, the diet is further modified in

energy value

Cont
39

Normal diet with some modifications is suggested;

Low calories, cholesterol and saturated fat

High PUFA and MUFA along with omega -6 and omega-3 fatty
acids
Low in simple carbohydrates and high fiber
Normal protein and minerals & vitamins

Cont
40

Energy;

Total calories should be restricted to reduce weight according to what

is expected normal for height, age and sex

Mild degree of weight loss for the cardiac patients of normal weight is
also recommended

Obese or overweight patients experience symptomatic relief after

weight reduction

Loss of weight by obese leads to considerable reduction in heart load

Because decreased BMR lowers heart rate and blood pressure, improving
cardiac efficiency

During initial recovery period, 800-1000 kcal/day is recommended

that progresses to 1200-1500 kcal/day while the patient is still at bed
rest

Usually, 1000-2000 kcal/day is suitable for obese patients in bed

Cont
41

After heart attack, it is advisable to under nourish the

patient for first two days;

High food intake increases cardiac burden to meet the

metabolic demands for digestion

Hypocaloric diet is recommended to reduces metabolic activity

and accommodate heart activity without extra strain

In rehabilitative stage, calories adjustment is required to

normalize the weight

Cont
42

Fat;

Both type and amount of fat have to be modified

Fats > 20% of total calories can be tolerated without any side-effects

Low fat, cholesterol

recommended

Monounsaturated fatty acids lowers LDL i.e. present in vegetable

sources such as olive oil, canola oil, almond oil and groundnut oil

It is not desirable to restrict all forms of fat as severe restriction results

in mental and physical depression

Choose soft margarines being lower in trans fatty acids than stick
margarines

and

monounsaturated

fatty

acids

are

Cont
43

Cholesterol;

Manufactured in liver (about 2 g/day) in the amounts required

by the body to perform various functions

Hence, cholesterol level in the diet should not exceed 300 mg

Because serum cholesterol > 260 mg/dL cannot be reduced
through diet

Saturated Fatty Acids (SFA) increases total cholesterol while

omega-6 decreases it;

1% increase in SFA increases total cholesterol by 2.7 mg/dL

1% increases in omega-6 fatty acids results in 1.4 mg/dL

reduction in total cholesterol

Cont
44

Vegetable oil;
Trans Fatty Acids (TFA)

High levels of TFA resemble saturated fatty acids as both raise

LDL while suppress HDL

Consuming twice the average level of TFA, reduces HDL by 2.8%

Trans Fatty Acids (TFA) are produced during hydrogenation of

vegetable oils

Commercially prepared, partially hydrogenated margarines and

solid cooking oils are high in trans fatty acids

In US, main sources of trans fatty acids include stick margarine

(contain more TFA than soft, tub margarines), shortening,
commercial frying fats and high-fat baked goods

Cont
45

Consumer trend is now diverting towards unsaturated vegetable

oil that contain no cholesterol but possess essential fatty acids,
linoleic acids and antioxidants like vitamin E

Partially hydrogenated vegetable oils are required to maintain

the quality of commercially baked goods and decreases
Saturated Fatty Acid (SFA) intake as well
Because totally liquid vegetable oils are unsuitable for fried
and baked products

Monounsaturated fatty acids (MUFAs) in olive oil and peanut oil

are substituted for SFA;
12-15% of calories from MUFAs is recommended to lower
plasma total cholesterol and LDL without lowering HDL

Cont
46

Polyunsaturated fatty acids (PUFA);

Important PUFA are linoleic acid and -linolenic acid

Omega-6

(linoleic acid) lowers total cholesterol and LDL

while lowers HDL if consumed in larger amounts
Sources; Safflower and corn oil

Omega-3

(linolenic acid) lowers LDL, triacylglycerols and

total serum cholesterol but not HDL levels (dose dependant
affect)
Sources; mustard oil and soybean oil
Eicosapentanoic acid (i.e. omega-3) have an inverse
association with coronary artery diseases (CAD) for men
Docosapentanoic acid have an inverse association with CAD
for women

Cont
47

Fish or fish oil prevent two important aspects of Coronary Heart

Diseases (CHDs);

Lipid rich atherosclerotic plaque

Thrombosis

Antithrombic

action of omega-3 fatty

thromoboxane A2 and increases prostacyclins

acids;

decreases

Example; salmons (rich in omega-3) reduce heart attacks, assist

in brain development, prevent Alzheimers disease & breast
cancer

Cont
48

Role of fish oil;

Reduces hypercholesterolemia

Stops formation of atherosclerotic plaque, platelet aggregates

and blood clots

Reduces platelet adhesiveness and increases bleeding time up

to 4 min by prostaglandins levels due to essential fatty acids

Suppresses inflammation

Decreases blood viscosity by improving oxygen supply to

tissues and narrow blood vessels

Reduces fat level in the blood after a fatty meal

Cont
49

Vegetarianism;

Lower rate of LDL production plus low in calories, fat and

cholesterol

Higher linoleic acid and lower arachidonic acid concentrations

in platelets

Adequate fiber intake as it helps in binding cholesterol

Vegetable oil diminishes plasma cholesterol with the help of

PUFA

Plant sterol inhibits cholesterol absorption and increases fecal

excretion
Consumption of about 1.6 g of plant sterols/day beneficially
lowers serum cholesterol level

Cont
50

Carbohydrates;

Adequate intake of complex carbohydrates and water soluble

fiber (whole pulses, legumes, beans, oats, fruits and
vegetables) is recommended

Easily digestible carbohydrates should be included to reduce

the work load on heart to minimum

As total calories are restricted resultantly carbohydrate intake

can also be reduced

Cont
51

Fiber;

Soluble fiber effects on plasma lipids by;

Binding cholesterol, steroid and bile acids in the small
intestine, carrying them to colon for elimination
Decreasing lipid and sterol absorption

Pectin in 2-8 apples/day have hypocholesterolemic effect

Pectin and guar gum reduces total cholesterol by 10% or more

Small amounts of legumes especially beans reduce total

cholesterol and triacylglycerols better than large consumption of
fruits and vegetables

Cont
52

Fiber in citrus pectin (28 g) reduces cholesterol up to 13

mg/dL

One cup of hot oat bran cereal or five oat bran muffins/day
reduces lipid response significantly
Oat

contain compounds called avenanthramides that

hinders the ability of blood cells to stick to artery walls

Water

soluble fiber in oat reduces LDL circulation in blood

vessels due to the antiinflammatory activity of
avenanthramides

Dietary fiber is also inversely associated with high blood

pressure, LDL, HDL and triacylglycerols

Cont
53

Protein;
Sufficient intake of vegetable protein is suggested

Normal intake of protein @ 1 g/kg b.w. is advised for the

maintenance of body tissue protein

Animal proteins are not suggested for atherosclerotic patients

Total fat, animal fat, organ meats, eggs and seafood are restricted

Choose chicken, fish or beans instead of red meat and cheese

Skim milk should be advisable due to its cholesterol lowering

effect

Eggs should be eaten in restricted amount only

Cont
54

Mineral and vitamins;

Normal allowances of vitamins and minerals

recommended especially from fruits and vegetables

are

Get at least 5 serving of fruits and vegetables/day to avoid

constipation

Folate fortified breakfast or folate multivitamin @ 400 g/day

is suggested as it is good for heart

Deficiency of vitamin A may occur hence its supplementation

is essential

Beverages containing caffeine are omitted because of their

stimulating effect on heart rate

Cont
Folate;

55

High homocysteine levels damages arterial walls

Conversion of homocysteine to methionine require folic acid

and vitamin B12

High homocysteine and low folate levels double the risk of

heart attacks

Homocysteine elevation are reversible if folic acid intake is

increased

In US studies, 9% male and 5.4% female prevented CVD

through flour fortification @ 350 mcg folic acid/100 g food

Iron;

Iron neither increases nor decreases infarct and CHD risk in

male as well as female

Cont
56

Antioxidants;

Garlic consumption (1/2 to 1 clove);

Reduces cholesterol by 9% when > 200 mg/dL

Vitamin E intake reverses CHD risk

Vitamin K;
Stops vascular calcification
Suppress hardening of arteries
Activate a protein in artery walls that keeps calcified
hardened sections of blood vessels from expanding or
prevent further damage

Cont
57

Sodium restricted diet;

Diet prescription to remove cardiac oedema; low in sodium

(only 2-3 g/day) and energy

In severe oedema, fluid intake should be restricted

Egg and green leafy vegetables i.e. high in sodium are

restricted thus other sources of iodine should be prescribed
Because severe restriction of iodine also reduces vitamin-A

Cont
58

Mild sodium restriction (2-3 g);

Less salt use in cooking

Fresh foods should be used
Restrict salt processed foods

Moderate sodium restriction (1000 mg);

No salt is used in cooking

Use fresh foods and avoid salt processed foods
Salt free baked products should be used

Strict sodium restriction;

Natural sodium food sources; milk (two cups only), meat and
egg could be used in small proportions
Vegetables containing higher sodium contents are not allowed

Other recommendations in high blood pressure

and heart diseases
59

Grapes and grape juice is particularly valuable when one is

actually suffering from heart attack

Use of boiled vegetables, avoiding oil/ghee, doing yogic

exercises and living tension free life reverse the heart problems

Vitamin C protects against heart attacks and high blood

pressure

Stress, anger, fear, disappointment and similar emotions can

raise blood fat and cholesterol level immediately

Stress can do little harm if the diet is adequate in vitamin C

and pantothenic acid

Cont
60

Daily consumption of lemon and bottle gourd keeps the heart

strong and reduces blood pressure

Daily intake of sprouted grams and moong makes the heart

muscles strong

Indian gooseberry or amla is considered an effective home

remedy for heart diseases

Patients suffering from a weak heart are benefitted by making

liberal use of apples

Onions are valuable in heart diseases, maintain blood

cholesterol by oxidizing excess cholesterol

Honey improves blood circulation, effective in cardiac pain

and prevent all sorts of heart troubles

Cont
61

Safflower oil proved beneficial in lowering blood cholesterol

Patients with heart disease should increase their intake of

foods rich in vitamin E
Outer leaves of cabbage is a good source of vitamin E;
Promotes heart function by improving oxygenation of the
cells
Improves circulation and muscle strength

Daily consume papaya on an empty stomach for a month

For higher efficiency, do not eat anything after for about 2 hr

Dietary diversification to
prevent diabetes
62

Dietary management of diabetics

63

Dietary control is an integral part of management for

diabetics

Diet provide essentials of good nutrition and adjustments

must be made from time to time for changing metabolic

needs

Mainstays of treatment include;

Working to obtain ideal body weight

Following a diabetic diet

Regular exercise

Diabetic medication if needed

Cont
64

Calories;

Patients with type 1 diabetes should consume approx. 35

calories/kg b.w./day

Patients with type 2 diabetes should put on 1500-1800

kcal/day;

Promote weight loss

Maintain ideal body weight

Variation in calorie adjustment is found on the basis of

persons age, sex, activity level and current weight

Men require more calories due to more muscle mass

Muscle burns more calories per hour than fat

People with low activity level need less calories on daily basis

Cont
65

Proteins;

Generally, diabetic are in negative nitrogen balance as large

quantities of nitrogen are excreted in the urine

They should receive about twice as much protein as normal

subjects

Proteins should be of high biological value, providing about

20-25% calories in the diet

Diet high in protein is good for diabetics because;

It supplies essential amino acids needed for tissue repair
Protein does not raise blood sugar during absorption as
carbohydrates
It does not supply more of calories

do

Cont
66

Carbohydrates;

Simple carbohydrates (mono and disaccharide) like sweets,

chocolates, etc. should be avoided

Despite of high carbohydrate, high fiber improves insulin

functioning

If total calories are not increased, raising carbohydrate intake

does not adversely affect blood glucose or insulin requirements

Generally, low carbohydrate intake is associated with lower

sugar levels in the blood

Daily intake of carbohydrate should provide about 40% of the

calories to prevent ketosis

Cont
67

Fiber;

Soluble fiber in oat bran, legumes (dried beans, peas and

lentils), pectin (from apples) and root vegetables (such as
carrot) manages diabetes by;

Controlling blood sugar by delaying gastric (stomach)

emptying

Retarding glucose entry into the bloodstream

Decreasing postprandial (post-meal) rise in blood sugar

Reducing insulin requirements in type 1 diabetes

Slowing food digestion, suppressing sudden rise in blood

glucose that may occur after a low-fiber meal

Cont
68

Fats;

Fat allowance makes up the remaining calories for most diets

after protein and carbohydrate intakes

In case of adult diabetics or obese, fat intake is lowered to 20%

or less/day energy intake

Foods high in saturated fat and cholesterol should be limited

Planning diet for diabetic subjects

69

Avoid simple sugar and high blood glucose level;

Roots

and tubers e.g. potato, sweet potato, colocasia (taro

plant or arvi"), yam, tapioca (starch extracted from cassava
root) except carrot and radish

Sugar,

glucose, jams, honey, sweets, fried foods and alcohol

Fruits

such as mango, banana, chickoo, custard apple, etc.

Include high fiber foods as these restrict excess fats & oils;
Green leafy vegetables
Salad without salad dressing

Other recommendations for diabetics

70

Soak fenugreek seeds in water and drink that water in the

morning on an empty stomach

Eat one teaspoon of cinnamon daily

Bitter gourd juice

Boil mango leaves in water, saturate and drink in the morning

Consume garlic daily

Put peels of green plantain in water and drink this water thrice
a day

Drink water boiled with leaves of basil, neem, jamun along

with seeds of pepper (exception for high blood pressure)

Dietary diversification to
correct liver diseases
71

Dietary modifications in hepatic subjects

72

Basis of treatment;
Adequate rest
Requires dietary modifications
Objective of diet therapy;
Relieve symptoms
Aid in regeneration of liver cells
Prevent further liver damage

Cont
73

Energy;

Initially, patient is not capable of eating large quantity of food

due to illness

Only 1500-2000 kcal is acceptable;

Patient is advised to take bed rest thus reducing daily actual
energy expenditure

Gradual increase in energy intake up to 20-30% is

recommended;
To promote weight gain
To ensure maximum protein utilization

Cont
74

Protein;
Protein of high biological value for maximum utilization,
preferably supplemented with protein of vegetable origin

In mild to moderate cases, high protein intake of 1.5-2 g/kg

b.w. is suggested

In acute cases, with excessive liver damage, protein intake

decreases even below normal
Because damaged liver is unable to tolerate a high protein
load as it converts ammonia to urea, leading to hepatic coma

Protein intake is necessary;

To overcome a negative nitrogen balance
To promote regeneration of liver cells
To prevent fatty infiltration of liver

Thus, protein intake depends on extent of liver damage

Cont
75

Carbohydrates;

High carbohydrate is recommended;

To provide more energy
To

build up glycogen stores in the liver as protection against

fatty infiltration for their protein sparing action

Daily intake of 300-400 g of simple carbohydrate should be

given

Cont
76

Fat;
In liver disorder, digestion of fat is affected due to impaired
bile action

In mild to moderate cases, 35-45 g of total fat/day could be

given

In severe cases, accompanied by liver damage, total fat must be

restricted by 20-30 g/day

More important is to modify the quality of fat;

Emulsified fats such as milk fat should be given
Medium chain triglyceride present in coconut are better
tolerated

Cont
77

Minerals and vitamins;

Judicious intake is recommended

Diet should provide all minerals particularly Ca and iron;

To compensate increased tissue catabolism

Availability of fat-soluble vitamins is low;

Because of decreased intake and impaired fat absorption

Care should be taken to include carotene rich foods like green

leafy vegetables, deep yellow or orange fruits and vegetables in
the diet

Cont
78

Foods to be included

Sugar, glucose, honey,

Cereals & pulses
Milk & milk products
Eggs
Fruits & vegetables

Foods to be restricted

Fats, oils, nuts, oil seeds

Strongly flavored fruits &
vegetables and meat
Intake of alcohol during
the attack

Dietary modifications in cirrhotic subjects

79

Objectives of dietary modifications are;

To promote regeneration of liver cells

To correct fluid and electrolyte balance
To rectify the nutritional deficiencies

Cont
80

Energy;

During the disease, patient become malnourished so their

energy requirement increases
Energy

is required to promote regeneration of liver cells

Normal

energy intakes are enough to meet bodily needs

Because actual energy expenditure for the patient on bed
rest is less

Cont
81

Protein;

About 1-1.5 g protein/kg b.w. is suggested in the absence of

hepatic coma (occur in severe cases of liver diseases)

If signs of impending coma appear, protein intake is decreased

to 0.3-0.5 g/kg of b.w. depending on individual tolerance;
To overcome malnutrition
To regenerate liver cells
To replenish plasma proteins

Damaged hepatic cells may not be able to efficiently convert all

ammonia into urea

More vegetable protein should be included in the diet;

Because animal proteins contain more aromatic amino acids
and their catabolism causes more ammonia production,
leading to hepatic encephalopathy

Cont
82

Carbohydrates;

Daily intakes of 300 g of carbohydrates

Mainly simple carbohydrates; glucose, sugar, fruits and fruit
juices, starch (cereals and root vegetables) are advised

Foods containing irritating fibers should be eliminated due to

the presence of esophageal varices;
Thus, dehusked pulses, refined cereals and low fiber
vegetables and fruits should be selected

Cont
83

Fats;

Many cirrhotic patients suffer from malabsorption of fat due to

impaired bile secretion in liver diseases

Restriction in fat intake should be suggested for such patients

Moderate amount of fat can be included in the diet to increase

palatability and promote recovery

Emulsified fats and fat containing medium chain triglyceride

are better tolerated

Amount of fat to be included in the diet varies according to the

individual's tolerance

Cont
84

Vitamins;

Availability of fat-soluble vitamins is affected due to the

decreased intake and impaired fat absorption

Diet should include -carotene rich foods

Supplements of vitamin B-group should be provided to

replenish liver stores and repair tissue damage

Minerals;

Serum Ca and Mg levels are low in cirrhotic patients hence

need supplementation

Cont
85

Sodium;

Sodium should be restricted

Because of the presence of ascites and oedema

In severe cases, 500 mg of sodium is recommended

During recovery period, restriction is somewhat relaxed

One should be very cautious about cooking salt, baking powder

and preserved food products

In case of patients on diuretic therapy, liberal sodium intake is

advised

Dietary modifications in cholecystitis and

cholelithiasis
86

Usually low fat, high carbohydrate and moderate protein diet is

recommended
Large meals should be avoided and plenty of fluids should be

taken early in the morning, late at night and in between the

meals
Nutritional therapy for gall bladder (involve in fat metabolism)

include;
Relief from discomfort of gall bladder
Keep gall bladder at rest by minimizing the contractions

Cont
87

Modification in the diet include;

Fat should be restricted in the diet to about 10-20 g

Causes contraction of gall bladder and consequent pain

Absorption of all fat-soluble vitamins is reduced hence their

intake should be increased

Carbohydrates sources like cereals, starches, simple sugar,

pulses, fruits, etc. should be incorporated to fulfill energy
requirements

Protein intake is kept normal, preferably from vegetarian

sources as they contain lesser fat than protein of animal origin

Cont
88

Foods recommended

Skim milk, beverages like

tea, coffee & fruit juices
Cereals like wheat, rice &
pulses
Fruits & vegetables
Egg white, poultry and sea
food

Foods to be avoided

Fatty, fried foods, butter,

ghee,
cheese
and
margarine
Red meat, cream soups,
whole milk
Fatty desserts like cake,
pastries and ice creams,
chocolates
Nuts and dry fruits

Dietary management of jaundice

89

Fresh tomatoes or green leaves of radish;

valuable remedy for jaundice

Juice of green leaves of pigeon pea is

useful in jaundice

Paste of almonds, dried dates and

cardamoms is effective remedy for
jaundice

Lemon is beneficial to treat jaundice and

liver damage

Barley water is an effective remedy

Basil and reddish juice is also preventive

against this disease

Dietary diversification to
manage renal diseases
90

Dietary modifications in renal disorders

91

Diet modifications are not strict or rigid

Main objectives of dietary modifications include;

To maintain adequate and optimum nutrition
To prevent oedema and uraemia

Adequate protein is given unless oliguria or anuria develops

Salt is restricted as oedema and hypertension are common in

this disease

Bed rest and antibiotic therapy are mainly important

Fluid intake is adjusted according to the fluid output

Cont
92

Energy;

Energy requirements are usually the same as in good health

Sufficient calories are given

Calories need to be reduced up to 10-20%, if the patient is not

suffering from any kind of malnutrition and at bed rest since
long time

Cereals in all forms is allowed

Cont
93

Carbohydrates;

Intake is liberal to provide sufficient kilocalories for energy

needs

Carbohydrate help in protein sparing action, reducing protein

catabolism and preventing ketosis

Both simple carbohydrates such as sugars as well as complex

forms such as starches can be included in the diet

Cont
94

Fat;
Reduce bulk of diet
Make diet more palatable

Fat is not restricted

Emulsified and easily digestible fats are included

Give non-protein calories for energy needs

Cont
95

Proteins;

Intake of 20-40 g/day or 0.5-0.6 g of /kg b.w. is recommended

Dietary protein must be restricted because;

Blood urea nitrogen is elevated
Oliguria and anuria is present

Fruit and vegetables can be given being lower in protein, sodium

and potassium

Pulses and groundnuts increase the urea levels in blood so these

should be restricted

Sago (sabo dana) also contributes protein so need to avoid

Rice is good than wheat due to high quality protein

Cont
96

Sodium;

Usually sodium is restricted to 500-1000 mg/day

Restriction varies with oliguria, oedema and hypertension

With recovery, sodium intake can be increased

Cont
97

Fluids;

Fluid intake is adjusted according to urine output

During early stages of treatment, fluid intake is decreased to

allow fluid dispersal i.e. accumulated in the body

In later stages, fluid intake is based on volume of fluid excreted

Allowance of 500 mL/day is given for insensible water loss

Daily fluid replacement should be 500 mL plus daily amount

exceeded in the urine

Dietary modifications in nephrotic syndrome

98

High energy, low to moderate protein & fat and low sodium

diet is prescribed
Energy;

High energy diet must be provided for the efficient utilization

of protein for tissue synthesis

High daily intakes of 50-60 kcal/kg b.w. are recommended

Cont
99

Protein;

Restriction of protein is usually done;

Because increased protein intake adversely affects on kidney
functioning

Plasma albumin level reduces as the major cause of oedema

development
Hence, moderate to high protein intake is suggested
according to the condition of the patient

Daily protein intake of 0.6-2 g/kg b.w. is recommended;

To replenish the depleted stores
To enhance the synthesis of albumin

Cont
100

Sodium;

Sodium level in the diet must be sufficiently reduced to combat

massive oedema

Diuretics are used to prevent further accumulation of fluids in

some patients

For these patients, extreme degree of salt restriction is not

required

Dietary modifications in Acute Renal Failure (ARF)

101

Energy;

Minimum intake of 8001200 kcal of energy is

required depending on the
patients condition

Non-protein sources of
energy should be included

Cont
102

Protein;

In the initial stages, no protein is given to the patients

As the condition improves, only 15-25 g/day protein should be

given to overcome endogenous losses

Complete proteins of high biological value should be included

Cont
103

Fluid;

Fluid intake is adjusted to compensate water losses during

urination, vomiting or diarrhea

Fluid intake is usually restricted to 500 mL/day for an average

adult with additions made for losses via other routes

Dietary management of chronic renal failure

104

Objectives of dietary management in chronic renal failure

include;

Maintain electrolyte balance

Prevent protein catabolism

Control fluid and electrolyte losses during vomiting or diarrhea

Maintain optimal nutritional status

Maintain appetite

Control hypertension

Retard progression of renal failure

Cont
105

Energy;

Adequate kilocalories are mandatory

Carbohydrates and fat must supply sufficient non-protein

kilocalories;
Spare proteins for tissue protein synthesis
Supply energy

About 350-450 g of carbohydrates should be provided to

patient everyday

If kilocalories intake is inadequate, protein catabolism

increases to supply energy, aggravating uremia

Cont
106

Protein;

Protein intake can be reduced to 0.5 g/kg b.w./day

To reduce azotemia and hyperkalemia

If blood urea nitrogen increases, restrict protein intake up to

15-20 g/day

In the absence of symptoms, protein restriction is not necessary

As renal failure progresses, patient develop symptoms of

uraemia hence can be treated through;
Regular haemodialysis
Peritoneal dialysis
Renal transplantation

Cont
107

Fluid;

Fluid intake should be monitored carefully to avoid water

intoxication from overloading or dehydration
Because capacity of failing kidneys to handle water is limited

Fluid intake should be decided, depending on the condition of

patients

Cont
108

Sodium and potassium;

Sodium intake varies between 1500-2000 mg/day

Hypokalemia can occur at any time in chronic renal failure

In such cases, small dose of potassium should be given with
proper checking of serum levels

Dietary diversification in cancer

109

Dietary management of cancer patients

110

Plant phytoestrogen prevent binding of endogenous estrogen to

estrogen receptor

Phytoestrogen includes isoflavones, daidzein and genistein

Soybeans and legumes are primary sources of daidzein and
genistein

Lignins in flaxseeds, in the form of glycoside is converted into

mammalian lignins (enterodiol and enterolactone)
Enterolactone possesses antiestrogenic, anticarcinogenic and
antiproliferative properties

Lignin; also associated with high fiber intake hence protects

against colon cancer

Cont
111

Fiber from fruits and vegetables reduce cancer risks, which

may also vary by gender

Calcium decreases the risk of colorectal cancer because

increased Ca in bile salts decreases cancer promotion

Likewise, vitamin D supplementation reduces colorectal

cancer

Wheat bran fiber have protective effects against adenomas

leading to carcinomas

Dietary fiber @ 30 g/day reduces circulating estrogen hence

modifies breast cancer

Lycopene protects human cells from free radicals ultimately

oxidative stress, aging heart diseases and cancer

Cont
112

Consumption of heat processed tomatoes increases lycopene

levels up to 5 times (by increasing bioavailability) as compared
to fresh tomatoes

Resveratrol starves cancer cells by stopping the action of key

proteins (nuclear factor-kappa B) responsible for survival

Resveratrol initiates a reaction in NF-kB molecule, causing

cancer cells to self-destruct in a process called apoptosis

Conjugated Linoleic Acids (CLA) inhibits uncontrolled cell

growth or neoplasia

Phytosterols (-sitosterol) inhibit cell proliferation and

stimulate apoptosis of human colon cancer

Dietary diversification to
prevent obesity
113

Dietary management of obesity

(negative calorie balance)
114

If calorie expenditure exceeds the calorie intake, negative calorie

balance occurs resulting in weight loss

Small frequent meals

Eat a low calorie or carbohydrate diet

High fiber and low fat diet

Regular exercise improves fitness and feeling of well-being

among obese

Some foods get stored as fat more easily than others but too
much of anything even healthy food get stored as fat

One can lose one pound weight by reducing 3500-calorie in a

week through diet, exercise or preferably a combination of both

Cont
115

Cutting calories in excess slows down metabolic rate, decreasing

thyroid output hence causing loss of lean muscle mass

Calorie deficit for fat loss; reduce calories by at least 500 but not
> 1000 i.e. below the maintenance level
Especially for lighter people, 1000 calories is a big deficit

Reducing calories by 15-20% below Total Daily Energy

Expenditure (TDEE) is good place to start

Large deficit is necessary in some cases but best approach is to;

Keep the calories deficit through diet
Increase physical activity

Other recommendations for obesity (fatness)

116

Chew food efficiently

Do not take meals in tension

Bread/chapatti should contain a mixture of whole grams flour

and soybeans

Take half lemon in hot water daily in the morning

Increase in Ca reduces overweight and obesity by 60-80%

Drinking sodas (regular or diet) is linked with overweight

Dietary diversification to manage

gout, arthritis and osteoarthritis
117

Dietary management of gout complications

118

Objectives;

Control uric acid levels in

the blood
Control and maintain IBW
(Ideal Body Weight)
Provide
relief
from
symptoms
Maintain optimal nutrition
status

Follow protein and calorie

restricted diet to reduce uric

acid levels in the blood

Cont
119

Following

required;

modifications in the diet are

Energy;

Curtail energy requirement in case of

overweight individuals as losing weight lowers
the uric acid levels in the blood

Protein;

Reduce protein content in the diet as uric acid

is a breakdown product of protein

Fat;

Restrict fat content in the diet especially oils i.e.

subjected to heat as in fried foods

Fluids;

Consume plenty of water as fluid intake

promotes uric acid excretion

Cont
120

Other preventive measures include;

Drink at least 6-8 glasses of water/day, fresh juices or herbal

tea, especially at the first signs of gout
To keep urine diluted
To excrete uric acid
To prevent crystal formation

Eat generous amounts of other fruits and vegetables especially

foods high in potassium;
To keep uric acid crystals in solution form

Flavonoid containing foods should be the part of permanent

gout-preventive diet

Cont
121

After each meal, drink freshly squeezed lemon juice in lukewarm

water
To prevents gout attacks by stimulating the formation of
calcium carbonate in the body
Calcium carbonate neutralizes acids in the body, including
uric acid responsible for gout attacks

Taking teaspoon of baking soda with meals will prevent gout

attacks by alkalizing the body

High fiber diet helps to eliminate uric acid by absorbing bile acids
formed in the liver
Bile acids act as a precursor to uric acid

Dietary management to prevent arthritis

122

Potato juice therapy in the morning

One teaspoon of black sesame seeds

3-4 walnuts or 1 fresh coconut on an empty stomach

Garlic or lime juice, effective remedies for arthritis

Deficiency of 1,25-dihydroxyvitamin D reduces Ca absorption

Oral supplementation of Ca and vitamin D decreases glucocorticoidassociated bone loss

Relief from arthritic symptoms;

Garlic and wheat germ oil

Apple cider vinegar and honey
Vitamin A, D, E,C and choline
Ca, Zn, Cu, Fe and Se

Dietary management of osteoporosis

123

Get adequate vitamin D, K and Ca along with muscle

strengthening exercises

Drink four or more cups of coffee increases the risk of fractures

Because caffeine tends to promote Ca excretion in urine

Getting too much protein can leach Ca from bones

Because as body digests protein, it releases acid into the blood which
the body neutralizes by drawing Ca from the bones

Animal protein cause more Ca leaching than vegetable protein

Do not take more of vitamin A, preformed vitamin A can

promote fractures

While, vitamin A in the form of -carotene does not increases

ones fracture risk

Dietary diversification to manage

hypothyroidism, hyperthyroidism,
constipation and diarrhea
124

Dietary management of hypothyroidism

125

Avoid rapeseeds, brassica vegetables, maize, millets, sorghum,

sweet potatoes and soy products

As they contain natural goitrogens ;

Causes thyroid glands to enlarge by interfering thyroid hormone
synthesis

Do not consume > 25-30 g of fat/day

Fat intake should come mainly from vegetable oil i.e. rich in
essential fatty acids

Vitamin and
requirement

Use very little sodium chloride (common salt)

mineral

intakes

should

meet

the

daily

Avoid salted confectioneries, chips and pickles

Limit smoking, alcohol and caffeine (found in tea, coffee, cola

and chocolate) as these raises the metabolic rate

Cont
126

Diet should be low in calories

Adequate protein, fat and minerals & vitamins

Increase iodine consumption by eating;

Only iodized table salt
Seafood;

fish (three times a week), fresh & canned oysters,

prawns, shrimps, mussels and seaweed

Food

commodities cultivated along the coastline, containing

more iodine than food grown at inland farms
Iodine content depends on iodine level in soil and water
where cultivated

Dietary management of hyperthyroidism

127

Diet should include;

Combination of pulses & wheat sprouts and carotene rich
foods like papaya, mango, fenugreek leaves and spinach

Intake of vitamin A, B and C should be increased twice the

daily requirement

Limit smoking, alcohol and caffeine containing beverages like

tea, coffee and chocolate

Cont
128

During hyperthyroidism, calcium and phosphorous excretion

increases;
Hence, calcium and phosphorous rich foods like milk & milk
products and dark green leafy vegetables must be consumed
Ragi

prepared with milk is an excellent source of calcium

and phosphorous

Diets for hyperthyroidism consists of high calories, proteins,

vitamins & minerals
Hence, the diet should consists of egg, meat, poultry and
combination of cereal & pulses

Dietary management of constipation

129

No special diet for constipation, modification in fiber and

fluid intakes should be made in regular diet

Fiber;

High fiber intake relives constipation

Increases the motility of small intestine and colon
Amount of fiber required for this effect varies considerably
from individual to individual

Fluid

Around 12-14 glasses of water are suggested

Along with water, soups and broths should also be given

Dietary management of diarrhea

130

Objectives of dietary treatment in chronic diarrhea;

To meet nutritional requirement

To correct electrolyte and water losses

Increase energy intake by 10-20%, especially through

carbohydrates sources
Improve protein intake by 40-45%
Restrict fat intake by 15-20%

Cont
131

Drink at least 8 to 10 glasses of fluid everyday to replace lost

fluid

Good fluid sources include; water, juices (except prune juice

due to laxative effects as rich in sorbitol), broth, ginger ale and
weak tea

Treatment of diarrhea is different for each individual

Limit foods containing caffeine such as coffee, strong tea and

aerated beverages

In some cases, milk and milk based products made diarrhea

worse

Lactose free milk or soy based beverages are better tolerated

Limit high fatty foods such as fried foods, fatty meats, high fat
deserts, excess butter, margarine, higher fat milk products and
greasy snack foods

Cont
132

Try eating small meals throughout the day

Reduce the amount of fiber in the diet

Fiber is found mostly in fruits & vegetables, whole grain
breads & cereals and nuts & seeds

Avoid foods high sugar, lactose, high protein diet, fats & oils
and processed foods like all-purpose flour

Avoid dried peas, beans, broccoli, cabbage, cauliflower and

onion to avoid cramping

Wrap up
133

Diverse diets solve nutritional deficiencies;

Balance and variety of meal especially rich in fruits and vegetables, is

the best insurance against deficiencies

134