DIET THERAPY COURSE OUTLINE

INTRODUCTION TO DIET THERAPY Lesson 1

 Definition of terms
 Importance of die therapy
 Principles of diet therapy

DIET MODIFICATION Lesson 2

 Definition of terms
 Importance of diet modification
 Ways of modifying diet

THERAPEUTIC DIETS Lesson 3

 Definition of terms
 Importance of Therapeutic diets
 Types of Therapeutic diets

HOSPITALIZATION AND THE Lesson 4

NUTRITIONAL TEAM  Definition of term
 Members of nutritional team
 Roles of nutritional team members
 Causes of stress experienced by patients
in the hospital

SPECIAL FEEDING METHODS Lesson 5

 Definition of terms
 Importance of special feeding methods
 Types of special feeding methods

DRUG NUTRIENT INTERACTION Lesson 6

  Definition of terms
 Effects of food and its nutrients on drugs
in the body.
 Effects of drugs on appetite and nutrient
absorption.
Lesson 7
 Points along the GIT where food
consumed can affect the efficacy of drug
action.
 Side effects of drugs
 Route of drug administration.

DISORDERS OF DIGESTIVE SYSTEM Lesson 8

 Definition of terms
 Functions of the stomach
 Components of digestive system
Lesson9
 Types of digestive diseases
 Causes of digestive diseases
Lesson 10
 Symptoms of digestive diseases
 Dietary management of digestive
diseases
DISORDERS OF THE LIVER Lesson 11
 Definition of terms
 Functions of the liver
 Types of liver diseases
Lesson12
 Causes of liver diseases
 Symptoms of liver diseases
  Dietary management of liver diseases

DISORDERS OF THE PANCREAS Lesson13

 Definition of terms
 Functions of the pancreas
 Types of pancreatic diseases
 Causes of pancreatic diseases
Lesson14
 Symptoms of pancreatic diseases
 Dietary management of pancreatic
diseases

DISORDERS OF THE GALL BLADDER Lesson 15

 Definition of terms
 Functions of the gall bladder
 Types of gall bladder
 Causes gall bladder
Lesson 16
 Symptoms of gall bladder
 Dietary management of gall bladder

DISORDERS OF THE RENAL/KIDNEY Lesson17

 Definition of terms
 Functions of the kidney
 Types of kidney diseases
Lesson18
 Causes kidney diseases
 Symptoms of kidney diseases
 Dietary management of kidney diseases
Lesson 19
  Dialysis treatment

CARDIOVASCULAR DISORDERS Lesson 20

 Definition of terms
 Types of Cardiovascular Disorders
 Causes Cardiovascular Disorders
Lesson 21
 Symptoms of Cardiovascular Disorders
 Dietary management of Cardiovascular
Disorders

DIABETES Lesson 22
 Definition of terms
 Types of diabetes
 Causes of diabetes
Lesson 23
 Symptoms of diabetes
 Dietary management

NUTRITION IN BURNS Lesson 24

 Definition of terms
 Causes of burns
 Nutritional implication
 Dietary management
NUTRITION IN SURGERY Lesson 25
 Definition of terms
 Nutritional implication
 Dietary management

NUTRITION IN HIV/AIDS Lesson 25

  Definition of terms
 Causes of HIV/AIDS
Lesson 25
 Signs and symptoms of HIV/AIDS
 Dietary management of HIV/AIDS

EMERGING TRENDS Lesson 26

 Emerging trends in diet therapy

 Challenges posed by emerging trends.
 Management of challenges posed by
emerging trends in diet therapy

TOPIC ONE: INTRODUCTION TO DIET THERAPY

Definition of diet therapy

It refers the practical application of nutrition as a preventative or corrective treatment of

disease. This usually involves the modification of an existing dietary lifestyle to promote
optimum health.

Purpose of diet therapy

1. Maintain a healthy lifestyle or improve health

2. Maintain good nutritional status,
3. Correct deficiencies or disease, if any
4. Provide rest to the body
5. Help metabolize the nutrients,
6. Make changes in body weight, when necessary

Diet modification

Dietary modifications are changes made during food preparation, processing, and

consumption to increase the bioavailability of micronutrients—and reduce micronutrient
deficiencies—in food at the commercial or individual/household level.

A modified diet is also one that has been adjusted in regards to texture or content

Examples of Modified Diets

 Texture Modified: pureed, ground, finely chopped, Chopped

 Content Modified: Weight loss, Low fat/cholesterol, Low Sodium, Diabetic, High
Fiber

What are the Purposes of modification of diet during illness?

The reasons for modifying the diets may include:

1. For essential or lifesaving treatment: For example in celiac disease, providing gluten
free diet,
2. To replete patients who are malnourished because of disease such as cancer and
intestinal diseases by providing a greater amount of a nutrient such as protein,
3. To correct deficiencies and maintain or restore optimum nutritional status,
4. To provide rest or relieve an affected organ such as in gastritis,
5. To adjust to the body's ability to digest, absorb, metabolize or excrete: For example a
low fat diet provided in fat mal absorption,
6. To adjust to tolerance of food intake. For example in case of patients with cancer of
esophagus tube feeding is recommended when patients cannot tolerate food by mouth,
7. To exclude foods due to food allergies or food intolerance,
8. To adjust to mechanical difficulties, for example for elderly patients with denture
problems, changing the texture/consistency of food recommended due to problems
with chewing and/or swallowing,
9. To increase or decrease body weight/body composition when required, for example as
in the case of obesity or underweight,
10. As helpful treatment, alternative or complementary to drugs, as in diabetes or in
hypertension to change the liquidity of foods according to the requirements-liquid,
semi- liquid or soft foods.

The normal diet may be modified:

A diet may need to be altered and adjusted in many ways before it meets the therapeutic
needs of an individual patient. These adaptations may include:

1. Change in consistency of foods, such as liquid diet, soft diet, low fibre diet, high fibre
diet.
2. Increase or decrease in energy value of the diet such as low calorie diet for weight
reduction, high calorie diet for burns.
3. Increase or decrease in specific nutrients or type of food consumed, such as sodium
restricted diet, lactose restricted diet, high fibre diet, high potassium diet.
4. Elimination of spices and condiments, such as bland diets.
5. Omission of specific foods such as allergy diets, gluten free diet.
 6. Adjustment in the ratio and balance of proteins, fats and carbohydrate such as
diabetic diet, renal diet and cholesterol lowering diets.
7. Test diets: These are single meals or diets lasting one or few days that are given to
patients in connection with certain tests e.g. the fat absorption test used to
determine if steatorrhoea is present.
8. Change in frequency of meals, feeding intervals, re-arrangement of the number and
frequency of the meals such as diabetic diet, diet for peptic ulcer disease.

Remember, normal nutrition is the foundation upon which the therapeutic modifications
are made. The various dietary adaptations for therapeutic needs are briefly highlighted
here. To modify the intervals of feeds [like in tube feeds etc]

Disadvantages of modified diets

1. Their refusal to eat these meals could negatively affect their overall health.
2. Therapeutic diet restrictions and texture-modified diets raise concerns of risk for
dehydration and malnutrition

Factors to consider when modifying a diet

1. Type of disease. It is essential to determine the diet in accordance to it disease,

otherwise it may have adverse effects e.g., low carbohydrate diet in diabetes air fibrous
food in case of constipation.

2. Duration of disease. The diet should be planned after determining the duration the
disease whether it is long or shoe duration. In long duration diseases theft planning should
not be always same. Mackie changes from time to time is very important
3. Selection of food products cacti ding to the disease. The amount and t; of food should
be changed after analyzing the modification required in food products foil curing the
disease.

4. Case history of food of the patient The food habits, liking and disliking, meal timings,
economic conditions, availability a food, knowledge of cooking methods, etc., should be
obtained and diet should be planned accordingly.
5. Psychology of the patient. Diet cans should take care of the psychological factors of the
patient. His whole personality should be considered as one unit, i.e., emotional, economic
status, social status, etc,] should be kept in mind. The diet of a patient should be planned in
such a way that the patient should not feel different from the others.
6. Variety and attraction in meals.

TOPIC THREE: THERAPEUTIC DIETS

A therapeutic diet 

A therapeutic diet is a medically prescribed eating plan recommended as a mode of

treatment for a chronic disease. It usually requires you to eliminate or limit certain types of
foods, eat more of certain types of foods, change the consistency of your foods or alter your
eating pattern.

Therapeutic Lifestyle Changes

The Therapeutic Lifestyle Changes diet is a therapeutic diet prescribed by doctors to help
you lower your blood cholesterol levels and reduce your risk of heart disease. It is also
used to treat coronary artery disease and diabetes, the diet requires you to limit your
saturated fat intake to less than 7 percent of your total daily calories and to limit your
cholesterol intake to less than 200 mg a day. It also encourages you consume 10 to 25 g of
soluble fiber and 2 g of plant sterols a day to help lower blood cholesterol levels. Calories
on the TLC diet are also controlled to help with weight management.

Diabetic Diet

The diabetic diet is a therapeutic diet for treatment of diabetes. The principle behind the
eating plan is that people with diabetes have a difficult time managing the sugar their body
produces from the food they eat due to an inability to make enough insulin or properly use
the insulin they do make. The diabetic diet aims to control the amount of food you eat,
especially foods that dramatically affect blood sugar, to help manage the disease. The diet is
not overly restrictive, but encourages you to make wise food choices from each of the food
groups to maximize your nutritional intake. The diet also aims to promote a healthy weight
because this improves blood sugar management.

DASH Diet

The Dietary Approaches to Stop Hypertension, also known as the DASH diet, is a
therapeutic diet used to treat high blood pressure. The diet encourages you to eat foods
that contain high amounts of potassium, magnesium, calcium and fiber to help lower your
blood pressure. It also recommends you limit your intake of sodium to 1,500 mg a day if
you have high blood pressure. The DASH diet is considered an overall healthy diet and has
also been shown to be helpful for those wishing to lose weight and prevent the onset of
diabetes. The diet includes high amounts of fruits, vegetables and whole grains, along with
lean sources of protein, low-fat dairy foods, nuts, seeds and legumes

The main purposes of therapeutic diet are:

1. To maintain good nutritional status.
2. To correct the deficiencies which has occurred?
3. To provide rest to the body or to certain part of the body for the metabolism of
nutrients.
4. To bring about changes in weight where ever necessary.
5. Education of the patient regarding the need for adherence to prescribed diet.

Note: Therapeutic nutrition begins with the normal diet which are planned to restore good
nutrition a sick person.

1. Diets of Altered Consistency

Therapeutic diets are modified for consistency, texture to fit the nutritional needs. Some
individuals may require a clear liquid diet, while others a fully liquid diet or soft diet based
on their medical condition.

a) Liquid Diet

It consists of foods that can be served in liquid or strained form in room temperature. They
are usually prescribed in febrile states, postoperatively i.e. after surgery when the patient is
unable to tolerate solid foods. It is also used for individuals with acute infections or
digestive problems, to replace fluids lost by vomiting, diarrhea. The two major types of
liquid diets include - Clear liquid diet and full liquid/fluid diet.

i. Clear liquid

This diet provides foods and fluids that are clear and liquid at room temperature. The
purpose of the clear liquid diet is to provide fluids and electrolytes to prevent dehydration.

It provides some amount of energy but very little amount of other nutrients. It is also
deficient in fiber. Hence it is nutritionally inadequate and should be used only for short
periods i.e. 1-2 days. An average clear liquid diet contains 600 to 900Kcal, 120 to 200g
carbohydrate, minimal fat 5 to 10g protein and small amount of sodium and potassium
(electrolytes).

The clear liquid diet is usually useful in situations when the gastrointestinal tract has to be
kept functionally at rest. It is also prescribed before and after certain types of surgery
involving the mouth or gastrointestinal tract. Also may be used in acute vomiting or
diarrhea. Examples of clear liquid diet: Water, strained fruit juices, coconut water, lime
juice (nimbu pani), whey water, barley/arrowroot water, 9 rice kanji, clear dal soup,
strained vegetable or meat soup, tea or coffee without milk or cream, carbonated
beverages, ice pops, plain gelatin are some examples of clear liquid diet.

ii. Full liquid

This diet provides food and fluids that are liquid or semi liquid at room temperature. It is
used as a step between a clear liquid diet and a regular diet.
The purpose of the full liquid diet is to provide an oral (by mouth) source of fluid for
individuals who are incapable of chewing, swallowing or digesting solid food. It provides
more calories than the clear liquid diet and gives adequate nourishment, except that it is
deficient in fibre.

It is indicated for post-operative patients and for gastrointestinal illness. An average full
liquid diet can provide approximately 1000 to 1800 calories and 50 to 65g of protein and
adequate minerals and vitamins.

The nutritive content of the full liquid diet can be increased by using protein, vitamin and
fibre supplements. Examples of full liquid diet: Foods allowed or included in a full liquid
diet include beverages, cream soups, vegetable soups, daal soups, strained food juices,
lassi/butter milk, yogurt, hot cocoa, coffee/tea with milk, carbonated beverages, cereal
porridges (refined cereals) custard, sherbet, gelatin, puddings, ice cream, eggnog,
margarine, butter, cream (added to foods), poached, half boiled egg etc.

b. Soft diet

As the name suggests provides soft whole food that is lightly seasoned and are similar to
the regular diet. The term 'soft' refers to the fact that foods included in this type of diet are
soft in consistency, easy to chew and made of simple, easily digestible foods. It does not
contain harsh fiber or strong flavors.

It is given during acute infections, certain gastrointestinal disorders and at the post-
operative stage to individuals who are in the early phase of recovery following a surgery.

The soft diet provides a transition between a liquid and a normal diet i.e. during the period
when a patient has to give up a full liquid diet but is yet not able to tolerate a normal diet.
Soft diet can be nutritionally adequate (providing approximately 1800-2000 calories, 55-
65g protein) provided the patient is able to consume adequate amount of food.

Examples of soft diet: A soft diet freely permits the use of cooked vegetables, soft raw fruits
without seeds, broths and all soups, washed pulses in the form of soups and in combination
of cereals and vegetables), breads and ready-to-eat cereals (most preferable refined such
as poha, upma, pasta, noodles etc.), milk and milk beverages, yogurt, light desserts
(including kheer, halwa, custard, jelly, ice cream), Egg and tender and minced, ground,
stewed meat and meat products, fat like butter, cream, vegetable oil and salt and sugar in
moderation.

Foods to be best avoided in the soft diet include coarse cereals, spicy highly seasoned and
fried foods, dry fruits and nuts, rich desserts. Among the soft diet is also the mechanical soft
diet also known as the dental diet which is a normal diet that is modified only in texture for
ease of mastication i.e. chewing. When an individual cannot chew or use facial muscles for a
variety of dental, medical or surgical conditions mechanical soft diet is recommended.
Elderly persons who have dental problems are prescribed mechanical soft diets.

The food in mechanical soft diet is similar to the soft diet and may be full liquid, chopped,
pureed or regular food with soft consistency. Simple salads, fruit salads and cottage cheese
may be included. No food is restricted unlike in the case of the customary soft diet. Just
removing the skin and seeds, cutting or chopping the food into small fine pieces are
processes usually employed.

C. Bland Diet:

A bland diet is made of foods that are soft, not very spicy and low in fiber. It consists of
foods which are mechanically, chemically and thermally non-irritating i.e. are least likely to
irritate the gastrointestinal tract. Individuals suffering from gastric or duodenal ulcers,
gastritis or ulcerative colitis are prescribed this diet. Foods Included: Milk and milk
products low in fat or fat free; Bread, pasta made from refined cereals, rice; cooked fruits
and vegetables without peel and seeds; Eggs and lean tender meat such as fish, poultry that
are steamed, baked or grilled; Cream, butter; Puddings and custards, clear soups. Foods
Avoided: Fried, fatty foods; Strong flavored foods; Strong tea, coffee, alcoholic beverages,
condiments and spices; High fiber foods; hot soups and beverages; whole grains rich in
fiber; strong cheeses.

2. Modification in Quantity
Depending on the clinical condition some individuals may require a restriction diet such as
sodium restricted diet (as in high blood pressure), purine restricted diet (as in gout) or low
residue diet (prescribed and/or before abdominal surgery) designed to reduce the
frequency and volume of fecal output. Sometimes a complete elimination diet may be
recommended when there are food intolerances or complete insensitivity to a particular
food such as a gluten free diet or a dairy free diet or nut free diet etc. Occasionally an
increase in the amount of a specific dietary constituent may be prescribed such as a high
potassium diet or a high fiber diet (as in constipation) or an iron rich diet (as in anaemia)
when the clinical condition demands.

3. Modification in Nutrient content

(Proteins, Fat, Carbohydrate)

The nutrient content of the diet is modified to treat deficiencies, change body weight or
control diseases such as hypertension or diabetes. You may have come across patients with
high blood sugar levels, being prescribed a diabetic diet which requires changes in the
quantity and type of carbohydrates included in each meal. Refined carbohydrates (such as
sugar, honey, refined flour, semolina etc.) are best avoided and use of complex
carbohydrates (whole wheat flour, coarse cereals etc.) recommended. Patients with heart
diseases require a fat controlled low cholesterol diet while patients with renal (kidney)
failure and advanced liver diseases a low protein diet, patients with HIV disease, cancer or
malnourished a high protein, high calorie diet. Others as in the case of overweight, obesity a
weight reduction diet, low in fat and calories.

4. Changes in Meal Frequency

Individuals suffering with gastro-esophageal reflux disease (GERD) stand to benefit by

consuming small but frequent meals. 5 to 6 small meals instead of three regular meals are
recommended.

5. Changes in Method of Cooking

Leaching is indicated for cooking vegetables for people with chronic kidney diseases
because the kidney's no longer maintain the ideal 12 level of potassium necessary for
optimum health. Leaching (soaking in water) drains out excessive potassium and
phosphorous from the vegetables. In elderly people food may be modified by mechanical
processing such as mashing, blendrizing or chopping. For patients on bland diet foods
steamed, baked or grilled are recommended. A review on the methods of cooking is
presented for your understanding at the end of the book.

6. Modification in the Method of Feeding

To provide adequate nutrition, normally oral feeding (by mouth) is recommended.

Sometimes oral feeding is not possible, under such circumstances special feeding methods
such as enteral feeding (provision of liquid formula diet delivered via nasogastric feeding
tube) and parenteral feeding (fluids containing water, glucose, amino acids, minerals,
vitamins given through the peripheral and central veins) is recommended. Here we have
just introduced to you some common dietary modifications. A detail review on modified
therapeutic diets in different disease conditions will be presented later in the units.

TOPIC 4: HOSPITALIZATION AND THE NUTRITIONAL TEAM

To hospitalize is either to check a patient into a hospital, or to injure someone seriously

enough that they need to be treated in a hospital.

It also refers to place in a hospital for medical care or observation.

Causes of stress in hospital

Physical symptoms of stress:

o A pounding heart.
o Short, fast breathing.
o A dry mouth.
o Clammy hands.
o Tension headaches.
o Gritting or grinding of teeth.
o Tense muscles.
o Blushing.
o Panic attacks.
o Diarrhoea or constipation.
o Fatigue.

Mental symptoms of stress:

o Anxiety.
o Worry.
o Guilt or nervousness.
o Increased anger or frustration.
o Depression.
o Racing thoughts.
o Nightmares.
o Problems in concentrating or learning.
o Difficulty making decisions.
o A sense of being overloaded or over-burdened by problems.

Behavioural symptoms of stress:

o Nervous habits such as finger or foot tapping.

o Increased irritability or edginess.
o Increased use of alcohol or cigarettes.
o Defensiveness or suspiciousness.
o Withdrawal from social situations.
o Difficulty sleeping

How do I cope with stress in the hospital environment?

1. Bring in familiar objects such as family photographs, books or pillows.
2. Listen to relaxing music during procedures. Audiocassette players with headphones are
generally available in most procedure rooms.
3. Don’t be afraid to ask for what you need. If you are cold ask for another blanket. If you
are experiencing increased levels of pain inform the nurse. If you cannot sleep tell the
night nurse. If appropriate she can organize a sleeping tablet for you.
4. Ask not to be disturbed when you want to rest.
5. Be positive in the way you talk to yourself, e.g. ‘Many people have coped well with this
test and so will I’.
6. Try not to focus on the possibilities of what can go wrong.
7. Take your mind off the problem by using distraction — read a magazine, listen to the
radio or play an audiotape. Remember that laughter can be a very effective method of
relieving stress.
8. If you are unclear about the nature of the procedure you are about to undergo ask one of
the nurses for clarification.
9. If you are afraid say so to a member of the ward staff. Your fears may be groundless.
10. Many hospital patients derive great comfort from speaking to a chaplain. If you would
like to speak to the chaplain just ask.

Nutritional care team in hospital

The core members of a nutrition support team usually consist of a (senior) physician (e.g.

surgeon, intensivist, gastro-enterologist), dietitian, nurse and pharmacist.

Goals of nutrition care team

 1. Preventing and treating hospital malnutrition.

A NST can play a role in the early recognition of malnutrition by, for example, standardizing
the screening process, describing which patients need nutritional support, standardizing
referral of patients at risk of malnutrition to the dietetic department or the nutritional
support team respectively, monitoring the process of nutritional support, ensuring
adequate nutrition reaches each individual patient.
2. Reducing or avoiding metabolic complications.
Giving a patient artificial nutrition is not without risks. The patients may experience
metabolic disturbances, including hyperglycaemia or hypoglycaemia, micronutrient
disturbances, water and electrolyte disturbances (e.g. refeeding syndrome),
hypertriglyceridaemia, or parenteral nutrition-associated liver steatosis. Both nutrient
deficiencies and overfeeding represent a metabolic burden. Careful and regular
measurement of serum and sometimes urinary parameters are important for preventing
(acute) metabolic complications.

3. Reducing complications related to nutrition

Both parenteral and enteral nutrition may cause complications. These include not only
disturbances in carbohydrate or lipid metabolism (often associated with parenteral
nutrition), but also diarrhoea, constipation, vomiting or aspiration (often associated with
enteral nutrition). The NST discusses these nutrition-related complications from an
interdisciplinary perspective and provides the treating physician with solutions to solve
them.

4. Reducing mechanical complications

Standardisation of procedures for supplying artificial nutrition reduces complications.
These procedures include criteria for the choice of central venous catheters, nasogastric or
nasojejunal tubes, and protocols for the frequency of dressing and changing giving sets. In
addition the protocols describe how the different catheters and tubes can, or should, be
used. Reducing mechanical complications (e.g. catheter sepsis, catheter or tube occlusions,
drug interactions), standardisation of equipment and materials can result in significant
improvement in patient safety and to economic savings.

5. Developing clinical nutrition guidelines

Clinical practice guidelines can help reduce the risk of complications and provide clinicians
with consistent methods for carrying out patient care activities. Parenteral and enteral
nutrition are examples of high cost therapies from which benefit, set apart from the
treatment of the primary disease, is difficult to discern. Development and use of an
evidence-based clinical guideline is one way to ensure that a NST is using (par)enteral
nutrition safely (11). For example, short-term parenteral nutrition given to patients who
are not malnourished may even be harmful, and this should be avoided. The team provides
guidelines on which patients will benefit from parenteral nutrition (PN) and which not,
taking into account enteral (im)possibilities, contra-indications, nutritional status,
expected duration of PN, patient prognosis, etc. For any kind of nutritional support, the
team recommends the optimal amount and type of nutrition, based on individual
calculations, the means of delivery, and the most appropriate route of administration.
Computer assisted prescribing programs may be helpful to calculate a patient's individual
needs.

6. Monitoring and evaluation of nutrition therapy

Besides initiating and developing nutrition guidelines a NST can monitor and evaluate
nutritional therapy to ensure that it is optimal. This is critical to assuring and improving
nutritional care; it can then be determined whether a change in practice results in an
improvement. Improving the quality of nutritional support requires that the nutrition
support team measures performance after goals have been established. Team goals can
continually be evaluated to determine whether further changes better meet patients' needs
(11). Improved technology, electronic communication and computer assisted nutrition
programmes can contribute to this

7. Collecting data on the effectiveness (and side effects) of artificial nutrition reveals
that nurses and physicians often do not get the opportunity to build up experience with
patients on artificial nutrition, because they sometimes treat only a few patients per year.
One of the advantages of a nutrition support team is that they can monitor all patients on
artificial nutrition, thus creating a database of knowledge. Bed-side nutrition support teams
usually keep a database including the indication for nutrition, length of feeding,
complications, effectiveness of nutritional therapy, etc. This database may serve as a
starting point to improve clinical guidelines (e.g. in the case of a high percentage of
catheter-related sepsis) or to initiate research.

8. Being a centre of knowledge

Relatively few patients admitted to hospital are given enteral or parenteral nutrition.
Standardized procedures and the involvement of healthcare professionals who are
knowledgeable about this complex form of therapy improve the quality of nutritional
support. The nutrition support team acts as an 'oracle' for all kind of questions on
nutritional support, varying from questions on delivery sets, formulas, monitoring, drug-
nutrient interactions etc. One of the core jobs of the team is the dissemination of its
knowledge to the doctors and nurses who are responsible for the daily treatment of
patients. Preferably, they educate a nurse and a doctor in every clinical ward to be an
extended member of the team, to enhance implementation of the procedures and
guidelines at the bedside.

9. Sharing knowledge with others

NST members are front-runners in nutritional support. They have the responsibility to
create awareness of the problem of disease-related malnutrition, to teach nurses, dietitians
and doctors in training, to share their knowledge at symposia and congresses, and to
publish their knowledge in guidelines, handbooks, e-learning modules, etc. Only then does
adequate nutritional support becomes available to everybody.

Roles of nutritional care team

 TOPIC 5: SPECIAL FEEDING METHODS

The special feeding methods depend on the type of disease, the patient's conditions and his
tolerance to food.

The different modes of feeding patients are

1. Enteral nutrition

 2.  Parenteral nutrition

1. Enteral nutrition/tube feeding

 Tube feedings may become necessary when you can’t eat enough calories to meet your
nutritional needs. This may occur if you physically can’t eat, can’t eat safely, or if your
caloric requirements are increased beyond your ability to eat.

If you can’t eat enough, you’re at risk for malnourishment, weight loss, and very serious
health issues. This may happen for a variety of reasons.

Some of the more common underlying reasons for enteral feeding include:

1. a stroke, which may impair ability to swallow

2. cancer, which may cause fatigue, nausea, and vomiting that make it difficult to eat

3. critical illness or injury, which reduces energy or ability to eat i.e. burns

4. failure to thrive or inability to eat in young children or infants

5. serious illness, which places the body in a state of stress, making it difficult to take in
enough nutrients
 6. neurological or movement disorders that increase caloric requirements while
making it more difficult to eat

7. GI dysfunction or disease, although this may require intravenous (IV) nutrition

instead

8. After some types of operations on the face, neck, throat, gullet or stomach

9. Blockages of the gullet or stomach

10. After radiotherapy to the throat or gullet

11.  The main Prolonged anorexia

12. Severe protein-energy under nutrition

13. Coma or depressed sensorium

14. Liver failure

Types of enteral feeding tubes include:

1. Nasogastric tube (NGT) starts in the nose and ends in the stomach.

2. Orogastric tube (OGT) starts in the mouth and ends in the stomach.

3. Nasoenteric tube starts in the nose and ends in the intestines (subtypes include
nasojejunal and nasoduodenal tubes).

4. Oroenteric tube starts in the mouth and ends in the intestines.

5. Gastrostomy tube is placed through the skin of the abdomen straight to the stomach
(subtypes include PEG, PRG, and button tubes).

6. Jejunostomy tube is placed through the skin of the abdomen straight into the intestines
(subtypes include PEJ and PRJ tubes).

Compared with parenteral nutrition, enteral nutrition has the following

advantages:

Advantages of enteral feeding over intravenous feeding

1.     Convenient to administer.

2.     Inexpensive.

3.     No hospitalization.

4.     No sterilization of tubes or nutrient.

5.     Expert supervision not necessary.

6.     Easily tolerated.

7.     Avoids catheter related sepsis and infections.

8.     avoids metabolic disturbances.

Formulas

Liquid formulas for enteral tube feeding commonly used include feeding modules and
polymeric or other specialized formulas.

 Feeding modules are commercially available products that contain a single

nutrient, such as proteins, fats, or carbohydrates. Feeding modules may be used
individually to treat a specific deficiency or combined with other formulas to
completely satisfy nutritional requirements.
 Polymeric formulas (including blenderized food and milk-based or lactose-free
commercial formulas) are commercially available and generally provide a
complete, balanced diet. For oral or tube feedings, they are usually preferred to
feeding modules. In hospitalized patients, lactose-free formulas are the most
commonly used polymeric formulas. However, milk-based formulas tend to taste
better than lactose-free formulas. Patients with lactose intolerance may be able to
tolerate milk-based formulas given slowly by continuous infusion.
 Specialized formulas include hydrolyzed protein or sometimes amino acid
formulas, which are used for patients who have difficulty digesting complex
proteins. However, these formulas are expensive and usually unnecessary. Most
 patients with pancreatic insufficiency, if given enzymes, and most patients with
malabsorption can digest complex proteins. Other specialized formulas (eg,
calorie- and protein-dense formulas for patients whose fluids are restricted, fiber-
enriched formulas for constipated patients) may be helpful.

Complications Associated with Feeding Tube

1. Constipation.

2. Dehydration.

3. Diarrhea.

4. Skin Issues (around the site of your tube)

5. Unintentional tears in your intestines (perforation)

6. Infection in your abdomen (peritonitis)

7. Problems with the feeding tube such as blockages (obstruction) and involuntary

movement (displacement)

8. Babies of very low birth weight.

.
2. Parenteral Nutrition/intravenous feeding

 Parenteral nutrition (PN) is intravenous administration of nutrition, which may include

protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements for
patients who cannot eat or absorb enough food through tube feeding formula or by mouth
to maintain good nutrition status.

Parenteral nutrition is administered through

a) Total Parenteral nutrition 

b) Partial Parenteral nutrition 

TPN vs PPN

Total Parenteral Nutrition (TPN) and Peripheral Parenteral Nutrition (PPN) are provided
to patients who do not have any other source of nutrition. Both the TPN and the PPN are
provided by IV. Though the two are used to provide the required nutrition to a patient, they
are different in many aspects.

Total Parenteral Nutrition means total nutrition, which is provided when a patient does not
receive any other form of nutrition. When a patient is on Total Parenteral Nutrition, he
relies on it completely. On the other hand, Peripheral Parenteral Nutrition, or PPN, is only
partial. This means that the patient may be getting nutrition from other sources along with
the PPN.

Total Parenteral Nutrition is given to persons who are suffering from digestive disorders,
or who are having any extended consequences of surgery or accident. The Peripheral
Parenteral Nutrition is provided if a person’s digestive system has been blocked, or if the
patient is not getting enough nutrition during an extended stay in the hospital.

Another difference that can be seen is that Total Parenteral Nutrition comes in a higher
concentration, and can only be administered through a larger vein. On the contrary,
Peripheral Parenteral Nutrition comes in a lesser concentration, and can be delivered
through a peripheral vein. Generally, the TPN is administered in the larger vein in the chest
or neck.

Well, the TPN is caustic when compared to PPN. The TPN is caustic as it contains glucose
and minerals, as well as electrolytes.

PPN is not a preferred nutritional supplement for a long time. This is because it is not safe
to use hyperosmolar solutions in peripheral veins for a very long time. However, the TPN
can be used for a very long time as it is delivered through a central vein.

Indications

TPN may be the only feasible option for patients who do not have a functioning GI tract or
who have disorders requiring complete bowel rest, such as the following:

 Some stages of ulcerative colitis

 Bowel obstruction
  Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged diarrhea
regardless of its cause)
 Short bowel syndrome due to surgery
 Cancer
  Inflammatory bowel disease
 Short-bowel syndrome
 Preoperative patients
 Gastrointestinal fistulae.
 Active gastrointestinal bleeding
 Pseudo-obstruction with complete intolerance to food

Common side effects of parenteral nutrition

The most common side effects of parenteral nutrition are mouth sores, poor night vision,
and skin changes. You should speak with your doctor if these conditions don’t go away.

Other less common side effects include:

1. changes in heartbeat

2. confusion

3. convulsions or seizures

4. difficulty breathing

5. fast weight gain or weight loss

6. fatigue

7. fever or chills

8. increased urination

9. jumpy reflexes
 10. memory loss

11. muscle twitching, weakness, or cramps

12. stomach pain

13. swelling of your hands, feet, or legs

14. thirst

15. tingling in your hands or feet

16. vomiting

The most common risk of using parenteral nutrition is developing catheter infection. Other
risks include:

 blood clots

 liver disease

 bone disease

How is parenteral nutrition administered?

 Parenteral nutrition is administered from a bag containing the nutrients you need
through tubing attached to a needle or catheter.
 With TPN, your healthcare provider places the catheter in a large vein, called the
superior vena cava, that goes to your heart. Your healthcare provider may also place
a port, such as a needleless access port, which makes intravenous feeding easier.
 For temporary nutritional needs, your doctor may suggest PPN. This type of
intravenous feeding uses a regular peripheral intravenous line instead of a central
line threaded into your superior vena cava.
 You’ll most likely complete intravenous feedings yourself at home. It usually takes
10 to 12 hours, and you’ll repeat this procedure five to seven times a week.
 Your healthcare provider will provide detailed instructions for this procedure. In
general, you first need to check your nutrient bags for floating particles and
 discoloration. Then you insert tubing into the bag and attach the tubing to your
intravenous catheter or port as designated by your healthcare provider.
 You need to leave the bag and tubing in place for most or all of the day. Afterward,
you remove the nutrient bag and tubing.

Parenteral feed solutions

The peripheral vein solution should be of less than 600 mOsm, as higher osmolarity results
in thrombosis and inflammation of the vein. The parenteral feed solutions contain;
1.     Glucose

2.     Emulsified fat

3.     Crystalline amino acids

4.     Vitamins

5.     Electrolytes - Sodium, chlorine, phosphorus, potassium, calcium and magnesium

6.     Trace elements - zinc, copper, chromium, manganese and iodine

7.     Water

Parenteral nutrition should not be used routinely in patients with an intact GI tract.
Compared with enteral nutrition, it has the following disadvantages:

 It causes more complications.

 It does not preserve GI tract structure and function as well.

 It is more expensive.

 
 TOPIC 6: DRUG NUTRIENT INTERACTION

A drug-nutrient interaction

 Is a reaction between a medicine and one or more nutrients? Nutrients are the vitamins

and minerals that are in the food you eat. It can also decrease or increase the amount of
a nutrient in your body. Food can increase or decrease the amount of medicine your body
absorbs.

Food can increase or decrease the amount of medicine your body absorbs. If your body
cannot absorb as much of the medicine as it should, you will not get the full effect of the
medicine. If your body absorbs too much of the medicine, it can cause the medicine to have
an effect that is too strong. Food and nutrients can also affect the rate at which your body
processes or removes a medicine.

Drug-nutrient depletion

It occurs when long-term use of a medicine affects the body’s ability to create or maintain a
healthy nutrient level. This can cause low levels of nutrients in your body.

For example:

 Statins (cholesterol-lowering medicine) can cause coenzyme Q10 levels to be too low
in your body
 Diuretics (water pills) can cause potassium levels to be too low in your body
 Acid reducers can decrease your body’s levels of vitamin B12, calcium, magnesium,
and other minerals
 Anticonvulsants (seizure medicine) can cause low levels of vitamin D
Effects of Food on Drug Intake
 Drug Absorption: Food or nutrients in the stomach or intestine may act to reduce the
absorption of a drug by delaying digestion, binding to minerals found in the food, or
adhering to food particles. In other cases, the food may promote drug absorption.
 Drug Breakdown: Food may act to enhance or inhibit the metabolism of certain drugs
in the body.
 Drug Excretion: Food and nutrients may act to alter the reabsorption and excretion of
drugs from the kidney.
 Other Actions: Certain food components can lead to the enhancement or opposition of
the effects of some drugs. Some examples of food and constituents found in food
include: vitamins, minerals, fat, proteins, caffeine, or alcohol.

Effects of Drugs on Food and Nutrition

 Nutrient Absorption: Certain drugs may increase, decrease, or prevent nutrient
absorption in the gut.
 Nutrient Breakdown: Drugs may speed up the metabolism of certain nutrients,
resulting in higher dietary requirements of that particular nutrient.
 Nutrient Excretion: Drugs can increase or decrease the urinary excretion of
nutrients.

Side Effects of Drugs and Other Medications

 Taste and Smell Alterations: Some drugs may alter one’s ability to taste and smell
certain foods. Food intake may be affected due to alteration of taste sensation,
reduced acuity to taste, or undesirable aftertaste.
 Gastrointestinal (GI) Effects: Some drugs can cause irritation to the digestive tract
that includes stomach upset, nausea, vomiting, diarrhea, constipation, ulcers, and
gastric bleeding. Some drugs may alter gastric acidity and damage mucosal surfaces
leading to decreased nutrient absorption.
 Appetite Changes: Alterations in appetite may include suppression or stimulation
of hunger leading to weight loss or weight gain.
  Organ Toxicity: Since many drugs must pass through the liver and kidney upon
excretion, hepatotoxicity (liver damage) and nephrotoxicity (kidney damage) are of
primary concern.
 Metabolic Effects: Some drugs may affect blood glucose levels by stimulating the
production of glucose or inhibiting its uptake. Other drugs may inhibit insulin
secretion decrease insulin sensitivity, or increase insulin clearance from the blood.
This may lead to conditions known as hyperglycemia (high blood glucose),
hypoglycemia (low blood glucose), or diabetes. Other medications may lead to
abnormal lipid levels, causing elevated cholesterol or triglycerides.

Host Factors Affecting the Development of Adverse Interactions between Foods and
Drugs

The likelihood of adverse interactions between foods and drugs is affected by the following
factors:

1. Age- because older people have less metabolic reserve;

2. Medical conditions- such as diabetes mellitus, that leads to abnormalities in both
food and drug handling;
3. Conditions, such as arthritis-that increase the likelihood that the person will be
taking over-the-counter medications;
4. Sex
5. Size and fat mass-which are related to a person's diet and nutritional status;
6. Exclusionary diets- for example, diets from which all animal products are excluded
(vegan diets);
7. The use of substances of abuse, such as alcohol, which alter the handling of both
drugs and nutrients; and finally,
8. Medical conditions that require the care of different specialists and multiple
medications
 Effects of Foods and Food Components on Drug Absorption and Bioavailability

There are at least four ways in which foods and their components can affect the absorption
and bioavailability of a drug:

 Physicochemical binding: The food component and the drug can bind to each other
physicochemically, so that neither the drug nor the component can be absorbed. For
example, the antibiotic tetracycline binds with calcium, magnesium, iron, and zinc; once
bound, the antibiotic becomes unavailable—that is why this drug should not be taken with
dairy products, which contain high amounts of these minerals.
 Stability: The food can alter the stability of the drug preparation in the stomach, so that it
breaks down before it can be absorbed.
 Gastric emptying: The drug or food can change the rate at which the stomach empties, and
therefore the rate at which the drug arrives in the small intestine. Gastric emptying is
normally a three-phase process. When you begin to eat, a small amount of food mixed with
stomach juices enters the small intestine. The presence of this mixture makes the small
intestine send a signal to slow down gastric emptying. This slow-down allows the stomach
time to thoroughly mix the food with the stomach juices, and to break down the food into
small particles. Fatty foods are highly effective in slowing stomach emptying, while
erythromycin, an antibiotic, increases the speed of gastric emptying.
 Competition for absorption: Many drugs use the intestine's natural transport systems—
which normally transport food components—to cross the intestinal wall. They therefore
compete with food components for transport. For example, L-dopa and methyldopa (drugs
used to control Parkinson's disease) use the same transporter mechanism as aromatic
amino acids from proteins, so absorption of these drugs is decreased if you eat a high-
protein meal at the same time you take the drug.

Drugs are introduced into the body by several routes. They may be

1. Taken by mouth (orally)

2. Given by injection into a vein (intravenously, IV), into a muscle (intramuscularly,
IM), into the space around the spinal cord (intrathecally), or beneath the skin
(subcutaneously,)
 3. Placed under the tongue (sublingually) or between the gums and cheek (buccally)
4. Inserted in the rectum (rectally) or vagina (vaginally)
5. Placed in the eye (by the ocular route) or the ear (by the otic route)
6. Sprayed into the nose and absorbed through the nasal membranes (nasally)
7. Breathed into the lungs, usually through the mouth (by inhalation) or mouth and
nose (by nebulization)
8. Applied to the skin (cutaneously) for a local (topical) or bodywide (systemic)
effect
9. Delivered through the skin by a patch (transdermally) for a systemic effect

TOPIC 7: DISORDERS OF DIGESTIVE SYSTEM

A digestive disease is any health problem that occurs in the digestive tract. Conditions may
range from mild to serious.

Function of the Digestive System

The function of the digestive system is digestion and absorption. Digestion is the
breakdown of food into small molecules, which are then absorbed into the body.

The digestive system is divided into two major parts:

  The digestive tract (alimentary canal) is a continuous tube with two openings: the
mouth and the anus. It includes the mouth, pharynx, esophagus, stomach, small
intestine, and large intestine.

 Accessory organs - include the teeth and tongue, salivary glands, liver, gallbladder,
and pancreas.

The treatment of food in the digestive system involves the following seven processes:

1. Ingestion is the process of eating.

2. Propulsion is the movement of food along the digestive tract. The major means of
propulsion is peristalsis, a series of alternating contractions and relaxations of
smooth muscle that lines the walls of the digestive organs and that forces food to
move forward.

3. Secretion of digestive enzymes and other substances liquefies, adjusts the pH of, and
chemically breaks down the food.

4. Mechanical digestion is the process of physically breaking down food into smaller
pieces. This process begins with the chewing of food and continues with the
muscular churning of the stomach. Additional churning occurs in the small intestine
through muscular constriction of the intestinal wall. This process, called
segmentation, is similar to peristalsis, except that the rhythmic timing of the muscle
constrictions forces the food backward and forward rather than forward only.

5. Chemical digestion is the process of chemically breaking down food into simpler
molecules. The process is carried out by enzymes in the stomach and small
intestines.

6. Absorption is the movement of molecules (by passive diffusion or active transport)

from the digestive tract to adjacent blood and lymphatic vessels. Absorption is the
entrance of the digested food (now called nutrients) into the body.
 7. Defecation is the process of eliminating undigested material through the anus.

Digestive System components

Mouth

The anterior opening of the alimentary canal is the mouth. It leads to a oral cavity, where teeth
tongue and salivary glands are present. Here, ingestion, mastication, and swallowing of food
occur. In humans, there are a total of 32 permanent teeth. There are four different types of
teeth, namely, incisors, canines, premolars, and molars. These help in the chewing of food.

Salivary Glands

They are exocrine glands that produce saliva in the oral cavity. They secrete an enzyme called
amylase, which helps in the breakdown of starch into maltose. There are three types of
salivary glands, namely:

 Parotid gland

 Submandibular gland

 Sublingual gland

Stomach

The esophagus leads to a sac-like organ called the stomach. It is a muscular, hollow organ,
having a capacity of 1 litre. The stomach holds food and also is a mixer and grinder. It secretes
strong acids and powerful enzymes that help in the process of breaking down of food. Food is
generally in a liquid or pastes consistency when it leaves the stomach.

Small Intestine
The small intestine is a long tube, which loosely coils in the abdomen area. Here, enzymes
from the pancreas and liver further break down the food. Three segments make up the small
intestines, which are the duodenum, jejunum, and ileum. The contractions of the small
intestine help in the movement of food, along with its breakdown, after mixing with the
digestive secretions. The jejunum and ileum areas of the small intestine are responsible for
the absorption of food into the blood, though their villi.

Pancreas, Liver and Gall Bladder

These organs also play a significant role in the human digestive system. The pancreas secretes
enzymes which help in the breakdown protein, fat, and carbohydrate. The liver secretes bile
and cleanses and purifies the blood coming from the small intestine.  The gallbladder stores
the bile that the liver produces. It releases bile into the small intestine to aid in the digestion
process.

Large Intestine

The large intestine is a long muscular tube that has different parts, which are caecum, colon,
and rectum. The waste that is left over after digestion of food, reaches the rectum through the
peristaltic movements of the colon.

Digestive System Controls

Hormones and nerves control the human digestive system. The walls of the alimentary canal
have many sensors which regulate the digestive functions. Even hormones are involved in the
digestion process. The main digestive hormone, gastrin is secreted in response to the
presence of food. Gastrin again stimulates the gastric acid secretion. All these regulate the
digestion process.

TYPES OF DIGESTIVE DISEASES

 1. CONSTIPATION 

Refers to bowel movements that are infrequent or hard to pass. The stool is often hard and
dry

 Causes of constipation

1. low-fiber diet, particularly diets high in meat, milk, or cheese

2. dehydration

3. lack of exercise

4. delaying the impulse to have a bowel movement

5. travel or other changes in routine

6. certain medications, such as high calcium antacids and pain medications

7. pregnancy

Symptoms of constipation

1. Trouble having a bowel movement (straining to go)

2. fewer than three bowel movements a week

3. passing hard, dry stools

4. straining or pain during bowel movements

5. a feeling of fullness, even after having a bowel movement

6. experiencing a rectal blockage

Dietary management of constipation

1. Drink two to four extra glasses of water a day, unless the doctor told you to limit fluids
for another reason.
2. Try warm liquids, especially in the morning.
3. Add fruits and vegetables to in diet.
4. Exercise most days of the week. When you move your body, the muscles in the
intestines are more active, too.
5. Limit consumption of alcohol and caffeinated drinks, which cause dehydration.
 6. Add fiber-rich foods to your diet, such as raw fruits and vegetables, whole grains,
beans, prunes, or bran cereal. Cut down on low-fiber foods, such as meat, milk,
cheese, and processed foods.

If you feel the urge to have a bowel movement, don’t delay. The longer you wait, the
harder your stool can become.

7. Use laxatives sparingly. Never use laxatives for more than two weeks without
talking to your doctor. Your body can become dependent on them for proper colon
function.

2.  DIARRHEA

Diarrhea is loose, watery stools three or more times a day. Diarrhea may be acute,

persistent, or chronic:

Acute diarrhea is more common than persistent or chronic diarrhea.

 Acute diarrhea is a common problem that typically lasts 1 or 2 days and goes
away on its own.
 Persistent diarrhea lasts longer than 2 weeks and less than 4 weeks.
 Chronic diarrhea lasts at least 4 weeks. Chronic diarrhea symptoms may be
continual or may come and go.

Potential causes of diarrhea

1. Viruses. Viruses that can cause diarrhea include viral hepatitis. Rotavirus is a

common cause of acute childhood diarrhea.

2. Bacteria and parasites. Contaminated food or water can transmit bacteria and

parasites to the body..

3. Medications. Many medications, such as antibiotics, can cause diarrhea. Antibiotics

destroy both good and bad bacteria, which can disturb the natural balance of
bacteria in the intestines. Other drugs that cause diarrhea are cancer drugs and
antacids with magnesium.

4. Lactose intolerance. Lactose is a sugar found in milk and other dairy products.

People who have difficulty digesting lactose have diarrhea after eating dairy
 products. Lactose intolerance can increase with age because levels of the enzyme
that helps digest lactose drop after childhood.

5. Fructose. Fructose is a sugar found naturally in fruits and honey. It's sometimes

added as a sweetener to certain beverages. In people who have trouble digesting
fructose, it can lead to diarrhea.

6. Artificial sweeteners. Sorbitol and mannitol — artificial sweeteners found in

chewing gum and other sugar-free products — can cause diarrhea in some
otherwise healthy people.

7. Surgery. Abdominal or gallbladder removal surgeries can sometimes cause

diarrhea.

8. Other digestive disorders. Chronic diarrhea has a number of other causes, such as

Crohn's disease, ulcerative colitis, celiac disease and irritable bowel syndrome

Symptoms of diarrhea

1. nausea
2. abdominal pain
3. cramping
4. bloating
5. dehydration
6. a fever
7. bloody stools
8. a frequent urge to evacuate your bowels
9. a large volume of stools

Dietary management

1. Drink plenty of clear liquids, including water, broths and juices. Avoid caffeine and
alcohol.
2. Eat small frequent meals slowly during the day.
3. Limit fried or fatty foods since these can worsen diarrhea.
4. Foods with lots of sugar may worsen diarrhea, such as candy, large quantities of juice,
and chocolate milk.
5. Add semisolid and low-fiber foods gradually as the bowel movements return to
normal. Try soda crackers, toast, eggs, rice or chicken.
6. Avoid certain foods such as dairy products, fatty foods, high-fiber foods or highly
seasoned foods for a few days.
7. Ask about anti-diarrheal medications.  Anti-diarrheal medications might help reduce
the number of watery bowel movements and control severe symptoms.

Complications of diarrhea

Dehydration

Diarrhea may cause dehydration, which means the body lacks enough fluid
and electrolytes to work properly. The body loses more fluid and electrolytes in loose
stools than solid stools.

Mal-absorption

Diarrhea may cause mal-absorption. If the body doesn’t absorb enough nutrients from the
food, one may become malnourished. Certain conditions that cause chronic diarrhea—such
as infections, food allergies and intolerances, and certain digestive tract problems—may
also cause mal-absorption.

3. VOMITING

The act of emptying the contents of the stomach through the mouth

Vomiting itself is not a condition. It’s a symptom of other conditions.

Causes of vomiting

1. Food poisoning 5. Pregnancy-related morning

sickness
2. Indigestion

3. Infections (associated with

bacterial and viral illnesses)
6. Prescription medications
4. Motion sickness
7. Anesthesia

8. Chemotherapy
 9. Crohn’s disease 12. A reaction to certain smells or odors

10. Peptic Ulcers 13. Overeating

11. Ingestion of toxins or excessive 14. Intense pain

amounts of alcohol

Symptoms
 abdominal pain  decreased urination

 fever  chest pain

 lightheadedness  fainting

 rapid pulse  confusion

 excessive sweating  excessive sleepiness

 dry mouth  vomiting blood

Dietary management

1. Eat small meals throughout the day instead of three large meals.
2. Eat slowly.
3. Avoid hard-to-digest foods.
4. Consume foods that are cold or room temperature if you nauseated by the smell of
hot or warm foods.
5. Rest after eating with your head elevated about 12 inches above your feet.
6. Drink liquids between meals rather than during meals.
7. Try to eat when you feel less nauseated.
 4. PEPTIC ULCERS 

It refers to sores that develop in the lining of the stomach, lower esophagus, or small
intestine. They're usually formed as a result of inflammation caused by the bacteria H.
pylori, as well as from erosion from stomach acids. Peptic ulcers are a fairly common health
problem.

There are three types of peptic ulcers:

 Gastric ulcers: ulcers that develop inside the stomach

 Esophageal ulcers: ulcers that develop inside the esophagus

 Duodenal ulcers: ulcers that develop in the upper section of the small intestines,
called the duodenum

Causes of peptic ulcers

Different factors can cause the lining of the stomach, the esophagus, and the small intestine
to break down. These include:

 A bacterium. Helicobacter pylori bacteria commonly live in the mucous layer that

covers and protects tissues that line the stomach and small intestine. Often, the H.
pylori bacterium causes no problems, but it can cause inflammation of the stomach's
inner layer, producing an ulcer.

It's not clear how H. pylori infection spreads. It may be transmitted from person to
person by close contact, such as kissing. People may also contract H. pylori through
food and water

 An excessive production of stomach acid

  Other medications. Taking certain other medications along with NSAIDs, such as
steroids, anticoagulants, low-dose aspirin, can greatly increase the chance of
developing ulcers

 Regular use of certain pain relievers. Taking aspirin, as well as certain over-the-

counter and prescription pain medications called non - steroidal anti-inflammatory
drugs (NSAIDs) can irritate or inflame the lining of your stomach and small
intestine. These medications include ibuprofen, aspirin ketoprofen and others.

 Smoke. Smoking may increase the risk of peptic ulcers in people who are infected
with H. pylori.

 Drink alcohol. Drinking too much alcohol can irritate and erode the mucous lining
of your stomach, and it increases the amount of stomach acid that's produced.

 Have untreated stress.

Symptoms of peptic ulcers

1. Discomfort between meals or during the night (duodenal ulcer)

2. Discomfort when you eat or drink (gastric ulcer)

3. Stomach pain that wakes you up at night

4. Feel full fast

5. Bloating, burning or dull pain in your stomach

6. The discomfort lasts for minutes or hours

If your ulcer becomes perforated (torn), it becomes a bleeding ulcer. This can cause the

following symptoms:

1. Nausea

2. Vomiting blood

3. Unexpected weight loss

4. Blood in your stool

 5. Pain in your back

Complications of a peptic ulcer

Untreated ulcers can become worse over time. They can lead to other more serious health
complications such as:

 Perforation: A hole develops in the lining of the stomach or small intestine and

causes an infection. A sign of a perforated ulcer is sudden, severe abdominal pain.

 Internal bleeding: Bleeding ulcers can result in significant blood loss and thus

require hospitalization. Signs of a bleeding ulcer include lightheadedness, dizziness,
and black stools.

 Scar tissue: This is thick tissue that develops after an injury. This tissue makes it
difficult for food to pass through your digestive tract. Signs of scar tissue include
vomiting and weight loss.

All three complications are serious and may require surgery. Seek urgent medical attention
if you experience the following symptoms:

 sudden, sharp abdominal pain

 fainting, excessive sweating, or confusion, as these may be signs of shock

 blood in vomit or stool

 abdomen that’s hard to the touch

 abdominal pain that worsens with movement but improves with lying completely
still
Dietary management

 Choose a healthy diet. Choose a healthy diet full of fruits, especially with vitamins A
and C, vegetables, and whole grains. Not eating vitamin-rich foods may make it
difficult for the body to heal your ulcer.

 Consider foods containing probiotics. These include yogurt, aged cheeses, and

sauerkraut.

 Consider eliminating milk. Sometimes drinking milk will make ulcer pain better, but
then later cause excess acid, which increases pain.

 Control stress. Stress may worsen the signs and symptoms of a peptic ulcer. Consider
the sources of stress and do what can address the causes. Some stress is unavoidable,
but can learn to cope with stress with exercise, spending time with friends or writing
in a journal.

 Don't smoke. Smoking may interfere with the protective lining of the stomach,
making the stomach more susceptible to the development of an ulcer. Smoking also
increases stomach acid.

 Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous
lining in the stomach and intestines, causing inflammation and bleeding.

 Try to get enough sleep. Sleep can help the immune system, and therefore counter
stress. Also, avoid eating shortly before bedtime.

Foods to recommend

1. Apples
2. Grapes
3. Pomegranate
4. Green tea
5. Vegetables
6. yogurt
7. strawberries
8. kiwis
9. broccoli
Foods to Avoid

1. Meats with a high fat content.

2. Citrus fruits and juices.
3. Tomato products.
4. Alcoholic beverages.
5. Spicy foods.
6. Pepper, including black pepper and other types of peppers.
7. Caffeine, including caffeinated sodas.
8. Tea, including black and green varieties that contain tannins that can increase
production of stomach acid.

Complications may include:

 Bleeding. A broken blood vessel can cause bleeding into the stomach. This may
show up as dark or bloody stools.
 Obstruction. Obstructions or blockages can develop that prevent food from moving
through the digestive tract properly.
 Perforations. When the ulcer creates a hole in the stomach wall, this is called a
perforation and is a very serious condition that allows digestive juices and food to
leak into the abdominal cavity. This can lead to a potentially life-threatening
infection.
 Peritonitis. This infection of the lining of the abdominal cavity can also become a
serious issue.
 6. Gastro esophageal Reflux Disease (GERD)

Gastro esophageal reflux disease (GERD) occurs when stomach acid frequently flows back
into the tube connecting the mouth and stomach (esophagus). This backwash (acid reflux)
can irritate the lining of the esophagus.

Symptoms

1. A burning sensation in the chest (heartburn), usually after eating, which might be
worse at night

2. Chest pain

3. Difficulty swallowing

4. Regurgitation of food or sour liquid

5. Sensation of a lump in the throat

Causes of GERD

Conditions that can increase risk of GERD include:

1. Obesity

2. Bulging of the top of the stomach up into the diaphragm (hiatal hernia)

3. Pregnancy

4. Connective tissue disorders, such as scleroderma

5. Delayed stomach emptying

Factors that can aggravate acid reflux include:

1. Smoking

2. Eating large meals or eating late at night

 3. Eating certain foods (triggers) such as fatty or fried foods

4. Drinking certain beverages, such as alcohol or coffee

5. Taking certain medications, such as aspirin

Complications

Over time, chronic inflammation in the esophagus can cause:

 Narrowing of the esophagus (esophageal stricture). Damage to the lower esophagus

from stomach acid causes scar tissue to form. The scar tissue narrows the food
pathway, leading to problems with swallowing.

 An open sore in the esophagus (esophageal ulcer). Stomach acid can wear away tissue
in the esophagus, causing an open sore to form. An esophageal ulcer can bleed, cause
pain and make swallowing difficult.

 Precancerous changes to the esophagus (Barrett's esophagus). Damage from acid can

cause changes in the tissue lining the lower esophagus. These changes are associated
with an increased risk of esophageal cancer.

Dietary management

1. Limit high fat foods, e.g. fried foods, high fat baked goods, cream, ice cream, high fat
cheeses, sausages, bacon, potato chips, etc. Fatty foods have been found to delay
gastric emptying and decrease the LES pressure thereby prolonging the esophageal
exposure time to stomach acid and the volume available for reflux.

2. Ensure adequate protein intake. Early studies indicated that protein increased the
LES pressure thereby allowing the closure of the sphincter and reducing reflux.
Even though more recent studies do not support this belief, maintaining a diet with
adequate low-fat protein intake can still help in the healing of irritated mucosa or
ulcers.
3. Limit chocolate and coffee which causes muscles to relax and lowers the LES
pressure. In addition, coffee can stimulate gastric secretions, which can promote
reflux. If the esophageal mucosa is irritated, individual tolerance of coffee (regular
or decaffeinated) should be determined.

4. Limit or avoid alcohol, mint, citrus, tomatoes, and/or carbonated beverages

according to individual tolerance. These foods may cause further irritation to
damaged esophageal mucosa but have not been found to cause reflux themselves.

5. Maintain a healthy weight. Excess weight put pressure on the abdomen, pushing up

the stomach and causing acid to reflux into the esophagus.

6. Stop smoking. Smoking decreases the lower esophageal sphincter's ability to

function properly.

7. Don't lie down after a meal. Wait at least three hours after eating before lying down
or going to bed.

8. Eat food slowly and chew thoroughly. 

9. Avoid foods and drinks that trigger reflux. Common triggers include fatty or fried
foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.

10. Avoid tight-fitting clothing. Clothes that fit tightly around the waist put pressure on
the abdomen and the lower esophageal sphincter.

11. Maintain an upright posture during meals and for 45 to 60 minutes after eating (to
avoid backflow of stomach contents)

12. Elevate the head of the bed about 6 inches when sleeping

13. Avoid eating within 2 to 3 hours of bedtime

 6. Inflammatory bowel disease (IBD)

Inflammatory bowel disease (IBD) is a term for two conditions (Crohn’s disease and
ulcerative colitis) that are characterized by chronic inflammation of the gastrointestinal
(GI) tract.1

 Prolonged inflammation results in damage to the GI tract. Some of the differences between
Crohn’s disease and ulcerative colitis:

Crohn’s Disease Ulcerative Colitis

 Can affect any part of the GI tract (from the mouth to  Occurs in the large intestine (colon) and
the anus)—Most often it affects the portion of the the rectum
small intestine before the large intestine/colon.
Damaged areas appear in patches that are next to  Damaged areas are continuous (not
areas of healthy tissue patchy) – usually starting at the rectum
and spreading further into the colon
 Inflammation may reach through the multiple layers  Inflammation is present only in the
of the walls of the GI tract innermost layer of the lining of the colon

Symptoms

Inflammatory bowel disease symptoms vary, depending on the severity of inflammation

and where it occurs. Symptoms may range from mild to severe. You are likely to have
periods of active illness followed by periods of remission.

1. Diarrhea

2. Fever and fatigue

3. Abdominal pain and cramping

4. Reduced appetite
 5. Unintended weight loss

6. Persistent diarrhea
7. Abdominal pain
8. Rectal bleeding/bloody stools

Causes of IBD

The exact cause of inflammatory bowel disease remains unknown. Previously, diet and
stress were suspected, but now doctors know that these factors may aggravate but don't
cause IBD.

One possible cause is an immune system malfunction. When your immune system tries to
fight off an invading virus or bacterium, an abnormal immune response causes the immune
system to attack the cells in the digestive tract, too. Heredity also seems to play a role in
that IBD is more common in people who have family members with the disease. However,
most people with IBD don't have this family history.

Risk factors

 Age. Most people who develop IBD are diagnosed before they're 30 years old. But
some people don't develop the disease until their 50s or 60s.

 Race or ethnicity. Although whites have the highest risk of the disease, it can occur in
any race. If you're of Ashkenazi Jewish descent, your risk is even higher.

 Family history. You're at higher risk if you have a close relative — such as a parent,
sibling or child — with the disease.

 Cigarette smoking. Cigarette smoking is the most important controllable risk factor

for developing Crohn's disease. Although smoking may provide some protection
 against ulcerative colitis, the overall health benefits of not smoking make it important
to try to quit.

 Nonsteroidal anti-inflammatory medications. These include ibuprofen (Advil,

Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium (Voltaren) and
others. These medications may increase the risk of developing IBD or worsen disease
in people who have IBD.

 Where you live. If you live in an industrialized country, you're more likely to develop
IBD. Therefore, it may be that environmental factors, including a diet high in fat or
refined foods, play a role. People living in northern climates also seem to be at greater
risk.

Complications of Crohn's disease may include:

 Bowel obstruction. Crohn's disease affects the full thickness of the intestinal wall.
Over time, parts of the bowel can thicken and narrow, which may block the flow of
digestive contents. You may require surgery to remove the diseased portion of your
bowel.

 Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult for you to
eat or for your intestine to absorb enough nutrients to keep you nourished. It's also
common to develop anemia due to low iron or vitamin B12 caused by the disease.

 Ulcers. Chronic inflammation can lead to open sores (ulcers) anywhere in your

digestive tract, including your mouth and anus, and in the genital area (perineum).

 Fistulas. Sometimes ulcers can extend completely through the intestinal wall,

creating a fistula — an abnormal connection between different body parts. Fistulas
near or around the anal area (perianal) are the most common kind. In some cases, a
fistula may become infected and form an abscess.

 Anal fissure. This is a small tear in the tissue that lines the anus or in the skin around
the anus where infections can occur. It's often associated with painful bowel
movements and may lead to a perianal fistula.
Lifestyle and home remedies

 Limit dairy products. Many people with inflammatory bowel disease find that
problems such as diarrhea, abdominal pain and gas improve by limiting or eliminating
dairy products.

 Try low-fat foods. With Crohn’s disease of the small intestine, one may not be able to
digest or absorb fat normally. Instead, fat passes through the intestine, making
diarrhea worse. Try avoiding butter, margarine, cream sauces and fried foods.

 Take care with fiber. If you have inflammatory bowel disease, high-fiber foods, such
as fresh fruits and vegetables and whole grains, may make symptoms worse. If raw
fruits and vegetables bother you, try steaming, baking or stewing them.

 Avoid other problem foods. Spicy foods, alcohol and caffeine may make your signs
and symptoms worse.

 Eat small meals. Eating five or six small meals a day rather than two or three larger
ones makes one feel better.

 Drink plenty of liquids.  drink plenty of fluids daily. Water is best. Alcohol and
beverages that contain caffeine stimulate the intestines and can make diarrhea worse,
while carbonated drinks frequently produce gas.

 Consider multivitamins. Because Crohn's disease can interfere with the ability to

absorb nutrients and because diet may be limited, multivitamin and mineral
supplements are often helpful.

 Quit Smoking. Smoking increases the risk of developing Crohn's disease, and
smoking can make it worse. People with Crohn's disease who smoke are more likely
to have relapses and need medications and repeat surgeries.

 Cope with Stress. The association of stress with Crohn's disease is controversial, but
many people who have the disease report symptom flares during high-stress periods.
 9. DIVERTICULITIS 

Diverticulitis - is the infection or inflammation of pouches that can form in the intestines.
These pouches are called diverticula.

The pouches generally are not harmful. They can show up anywhere in the intestines. If have
them, its called diverticulosis. If they become infected or inflamed, you have diverticulitis.

Symptoms

Symptoms of diverticular disease include:

a) pain in the abdomen

b) bloating

c) diarrhea

d) constipation

If you develop diverticulitis, you might experience:

a) constant or severe pain in the abdomen

b) nausea and vomiting

c) fever and chills

d) blood in the stool

e) bleeding from the rectum

Causes

Diverticula usually develop when naturally weak places in the colon give way under
pressure. This causes marble-sized pouches to protrude through the colon wall.
Diverticulitis occurs when diverticula tear, resulting in inflammation or infection or both.

Risk factors

Several factors may increase risk of developing diverticulitis:

 Aging. The incidence of diverticulitis increases with age.

 Genetics: Like many chronic conditions, if one have a family history of diverticulitis,

may be more likely to develop it.

 Obesity. Being seriously overweight increases the risk of developing diverticulitis.

 Smoking. People who smoke cigarettes are more likely than nonsmokers to

experience diverticulitis.

 Red meat intake. Red meat consumption has been correlated with a higher risk for
diverticular disease, independent of fiber intake

 Lack of exercise. Vigorous exercise appears to increase the risk of diverticulitis.

 Diet high in animal fat and low in fiber. A low-fiber diet in combination with a high
intake of animal fat seems to increase risk, although the role of low fiber alone isn't
clear.

 Constipation: Ongoing constipation (straining while passing hard stool) can increase

pressure in the colon, which can create weak spots in the colon lining over time

 Certain medications several drugs are associated with an increased risk of

diverticulitis, including steroids and non-steroidal anti-inflammatory drugs, such as
ibuprofen.

Complications

 Peritonitis (a painful infection of the abdominal cavity)

 Abscesses (infections in the abdomen)
 Obstruction (blockages of the intestine)
Dietary management

 Exercise regularly. Exercise promotes normal bowel function and reduces pressure

inside the colon. Try to exercise at least 30 minutes on most days.

 Eat more fiber. A high-fiber diet decreases the risk of diverticulitis. Fiber-rich foods,
such as fresh fruits and vegetables and whole grains, soften waste material and help it
pass more quickly through the colon

 Drink plenty of fluids. Fiber works by absorbing water and increasing the soft, bulky
waste in your colon. But if you don't drink enough liquid to replace what's absorbed,
fiber can be constipating.

 Avoiding diet high in fat and sugar and low in fiber because they are linked with an
increased incidence of diverticulitis.

10. CELIAC DISEASE /CELIAC SPRUE GLUTEN-SENSITIVE ENTEROPATHY

It is an immune reaction to eating gluten, a protein found in wheat, barley and rye.

With celiac disease, eating gluten triggers an immune response in the small intestine. Over
time, this reaction damages the small intestine's lining and prevents it from absorbing
some nutrients (mal-absorption). The intestinal damage often causes diarrhea, fatigue,
weight loss, bloating and anemia, and can lead to serious complications.

Symptoms

The signs and symptoms of celiac disease can vary greatly and differ in children and adults.
Digestive signs and symptoms for adults include:

a) Diarrhea

b) Fatigue
 c) Weight loss

d) Bloating and gas

e) Abdominal pain

f) Nausea and vomiting

g) Constipation

However, more than half the adults with celiac disease have signs and symptoms unrelated
to the digestive system, including:

a) Anemia, usually from iron deficiency

b) Loss of bone density (osteoporosis) or softening of bone (osteomalacia)

c) Itchy, blistery skin rash

d) Mouth ulcers

e) Headaches and fatigue

f) Nervous system injury, including numbness and tingling in the feet and hands,
possible problems with balance, and cognitive impairment

g) Joint pain

h) Reduced functioning of the spleen

Digestive signs and symptoms for Children include:

a) Nausea and vomiting

b) Chronic diarrhea

c) Swollen belly

d) Constipation

e) Gas
 f) Pale, foul-smelling stools

The inability to absorb nutrients might result in:

1. Failure to thrive for infants

2. Damage to tooth enamel

3. Weight loss

4. Anemia

5. Irritability

6. Short stature

7. Delayed puberty

8. Neurological symptoms, including attention-deficit/hyperactivity disorder (ADHD),

learning disabilities, headaches, lack of muscle coordination and seizures

Causes

o Celiac disease is an autoimmune disease in which gluten in the diet triggers white blood
cells to attack the tiny, finger-like projections called villi that line the small intestine and
normally help digest food. The lining is eroded until it's worn smooth. Without villi, one
can't absorb vitamins, minerals, and other nutrients from food.
o Genes combined with eating foods with gluten and other factors can contribute to celiac
disease, but the precise cause isn't known. Infant-feeding practices, gastrointestinal
infections and gut bacteria might contribute, as well. Sometimes celiac disease becomes
active after surgery, pregnancy, childbirth, viral infection or severe emotional stress.

Risk factors

Celiac disease tends to be more common in people who have:

 a) A family member with celiac disease

b) Type 1 diabetes

c) Down syndrome

d) Autoimmune thyroid disease

Complications

Untreated, celiac disease can cause:

 Malnutrition. This occurs if small intestine can't absorb enough nutrients.

Malnutrition can lead to anemia and weight loss. In children, malnutrition can cause
slow growth and short stature.

 Bone weakening. Mal-absorption of calcium and vitamin D can lead to a softening of

the bone (osteomalacia or rickets) in children and a loss of bone density in adults.

 Infertility and miscarriage. Mal-absorption of calcium and vitamin D can contribute

to reproductive issues.

 Lactose intolerance. Damage to the small intestine might cause abdominal pain and
diarrhea after eating or drinking dairy products that contain lactose.

 Cancer. People with celiac disease who don't maintain a gluten-free diet have a
greater risk of developing several forms of cancer, including small bowel cancer.

 Nervous system problems. Some people with celiac disease can develop problems
such as seizures or a disease of the nerves to the hands and feet

Dietary management

a) If you've been diagnosed with celiac disease, you'll need to avoid all foods that
contain gluten.
b) Allowed foods - Many basic foods are allowed in a gluten-free diet, including:
  Eggs

 Fresh meats, fish and poultry that aren't breaded, batter-coated or marinated

 Fruits

 Lentils

 Most dairy products, unless they make your symptoms worse

 Nuts

 Potatoes

 Vegetables

 Wine and distilled liquors, ciders and spirits

Grains and starches allowed in a gluten-free diet include:

 Amaranth

 Buckwheat

 Corn

 Cornmeal

 Gluten-free flours (rice, soy, corn, potato, bean)

 Pure corn tortillas

 Rice

9. Galactosemia

Galactosemia is an inherited disease in which the body is unable to metabolize the simple
sugar galactose, which is found primarily in dairy products but is also produced by the
body. If left unaddressed, galactose can increase to toxic levels in the body and may lead to
damage of the liver, central nervous system, and various other body systems
Causes of Galactosemia

Galactosemia is an inherited disorder. People with the disease are unable to fully break
down galactose. If an infant with galactosemia is given milk, byproducts of galactose will
build up in the baby's body, causing damage to the liver, kidneys, brain, and eyes.
Characteristically, a newborn with galactosemia that is fed milk products will
have jaundice , vomiting, lethargy, irritability, and convulsions. Continued feeding of milk
products to the infant will lead to cirrhosis, cataracts, kidney failure, and mental
retardation .

Symptoms

Symptoms of galactosemia usually develop several days or weeks after birth. The most
common symptoms include:

 loss of appetite

 vomiting

 jaundice, which is yellowing of the skin and other parts of the body

 liver enlargement

 liver damage

 fluid building up in the abdomen and swelling

 abnormal bleeding

 diarrhea

 irritability

 fatigue or lethargy

 weight loss

 weakness
  higher risk of infection

Common complications of galactosemia include:

 liver damage or liver failure

 serious bacterial infections

 sepsis, which is a life-threatening problem caused by infections

 shock

 delayed development

 behavioral problems

 cataracts

 tremors

 speech problems and delays

 learning disabilities

 fine motor difficulties

 low bone mineral density

 reproductive problems

 premature ovarian insufficiency

Diet

The main goal of long-term treatment of classic galactosemia is to minimize dietary

galactose intake. Galactose should be excluded from the diet as soon as galactosemia is
suspected.

Free galactose also is present in some fruits and vegetables, such as tomatoes, Brussels
sprouts, bananas, and apples.
To follow a low-galactose diet, avoid foods with lactose, including:

1. milk

2. butter

3. cheese

4. ice cream

5. other dairy products

TOPIC EIGHT

DISORDERS OF THE LIVER

INTRODUCTION

 The liver is the largest solid organ in the body, weighing on average about 3.5
pounds.
  It sits just under your rib cage on the right side of your abdomen.
 The liver has two large sections, called the right and the left lobes.
 The liver and these organs work together to digest, absorb, and process food.

DEFINITION OF TERMS

Liver - is the second largest organ in the body. It processes what one eat and drink into
energy and nutrients the body can use. The liver also removes harmful substances from
the blood.

Liver disease- refers to any disorder of the liver

Liver biopsy - is a medical procedure used to remove a small piece of liver tissue that is
studied in the lab to determine the liver’s condition.
 Liver cancer - is the growth and spread of unhealthy cells in the liver.

Cirrhosis - is extensive scarring of the liver — hard scar tissue replaces soft healthy
tissue. Severe scarring of the liver can prevent the liver from functioning well.

Fibrosis - is the initial scarring of the liver.

Hepatitis - is a disease characterized by inflammation of the liver.

Ascites - is the buildup of fluid in the abdomen that can occur with liver failure

Autoimmune - is an immune response by the body against its own tissue, cells, or
molecules. In people with autoimmune disease, their immune system may attack the
same cells that it is supposed to protect

Jaundice - is the yellowing of the skin and white part of the eyes.

FUNCTIONS OF LIVER

1. Production of bile that is required in the digestion of food, in particular fats

2. Storing of the extra glucose or sugar as glycogen, and then converting it back into
glucose when the body needs it for energy
3. Production of blood clotting factors
4. Production of amino acids (the building blocks for making proteins), including those
used to help fight infection
5. The processing and storage of iron necessary for red blood cell production
6. The manufacture of cholesterol and other chemicals required for fat transport
7. The conversion of waste products of body metabolism into urea that is excreted in
the urine
8. Metabolizing medications into their active ingredient in the body
COMMON CAUSES OF LIVER DISEASE INCLUDE:

1. Infections - Parasites and viruses can infect the liver, causing inflammation that
reduces liver function. The viruses that cause liver damage can be spread through
blood or semen, contaminated food or water, or close contact with a person who is
infected. The most common types of liver infection are hepatitis viruses, including:
Hepatitis A, B& C
2. Immune system abnormality - Diseases in which the immune system attacks
certain parts of the body (autoimmune) can affect the liver. Examples of
autoimmune liver diseases include: Autoimmune hepatitis
3. Genetics - An abnormal gene inherited from one or both of the parents can cause
various substances to build up in the liver, resulting in liver damage.
4. Cancer and other growths Examples include: Liver cancer ,Bile duct cancer and
Liver adenoma
5. Chronic alcohol abuse - Years of alcohol abuse can cause the liver to become
inflamed and swollen. This damage can also cause scarring known as cirrhosis.
6. Fat accumulation in the liver - occurs when some of those fat molecules
accumulate inside liver cells. The presence of those fattened cells can then lead to
inflammation in the liver and damage to surrounding liver tissue.
7. Certain prescription or over-the-counter medications - Some drugs, such as
statins (used to treat high cholesterol levels), can increase the levels
of liver enzymes and cause liver damage.  Many other drugs can affect the way
the liver functions, damage it, or do both.

RISK FACTORS THAT MAY INCREASE THE RISK OF LIVER DISEASE INCLUDE:

a) Obesity

b) Type 2 diabetes

c) Tattoos or body piercings

 d) Injecting drugs using shared needles

e) Blood transfusion

f) Exposure to other people's blood and body fluids

g) Unprotected sex

h) Exposure to certain chemicals or toxins

LIVER SYMPTOMS

1. Skin and eyes that appear yellowish (jaundice)

2. Abdominal pain and swelling

3. Swelling in the legs and ankles

4. Itchy skin

5. Dark urine color

6. Pale stool color

7. Chronic fatigue

8. Nausea or vomiting

9. Loss of appetite

10. Tendency to bruise easily

TO PREVENT LIVER DISEASE

 Drink alcohol in moderation. For healthy adults, that means up to one drink a day
for women and up to two drinks a day for men. Heavy or high-risk drinking is defined
as more than eight drinks a week for women and more than 15 drinks a week for men.
  Avoid risky behavior. Use a condom during sex. If you choose to have tattoos or
body piercings, be picky about cleanliness and safety when selecting a shop. Seek help
if you use illicit intravenous drugs, and don't share needles to inject drugs.

 Get vaccinated. If you're at increased risk of contracting hepatitis or if you've already

been infected with any form of the hepatitis virus, talk to your doctor about getting
the hepatitis A and hepatitis B vaccines.

 Use medications wisely. Take prescription and nonprescription drugs only when

needed and only in recommended doses. Don't mix medications and alcohol. Talk to
your doctor before mixing herbal supplements or prescription or nonprescription
drugs.

 Avoid contact with other people's blood and body fluids. Hepatitis viruses can be
spread by accidental needle sticks or improper cleanup of blood or body fluids.

 Keep your food safe. Wash your hands thoroughly before eating or preparing foods.
If traveling in a developing country, use bottled water to drink, wash your hands and
brush your teeth.

 Take care with aerosol sprays. Make sure to use these products in a well-ventilated
area, and wear a mask when spraying insecticides, fungicides, paint and other toxic
chemicals. Always follow the manufacturer's instructions.

 Protect your skin. When using insecticides and other toxic chemicals, wear gloves,
long sleeves, a hat and a mask so that chemicals aren't absorbed through your skin.

 Maintain a healthy weight. Obesity can cause nonalcoholic fatty liver disease.

TYPES OF LIVER DISEASES

The most common liver diseases are various types of:

1. Acute (sudden) hepatitis (inflammation)

 2. Chronic (long duration) hepatitis
3. Fatty liver disease
4. Cirrhosis (scarring)

1. LIVER CIRRHOSIS

It is a disease in which healthy liver tissue is replaced with scar tissue. The scar tissue
blocks the flow of blood through the liver and slows the liver’s ability to process nutrients,
hormones, drugs, and natural toxins.

Symptoms

1. Loss of appetite
2. Lack of energy (fatigue)
3. Weight loss or sudden weight gain
4. Bruises
5. Yellowing of skin or the whites of eyes (jaundice)
6. Itchy skin
7. Fluid retention (edema) and swelling in the ankles, legs and abdomen
8. A brownish or orange color to the urine
9. Light-colored stools
10. Confusion, disorientation, personality changes
11. Blood in the stool
12. Fever

Causes include:

 Chronic alcohol abuse

 Chronic viral hepatitis (hepatitis B, C and D)

 Fat accumulating in the liver (nonalcoholic fatty liver disease)

 Iron buildup in the body (hemochromatosis)

  Cystic fibrosis

 Copper accumulated in the liver (Wilson's disease)

 Poorly formed bile ducts (biliary atresia)

 Alpha-1 antitrypsin deficiency

 Inherited disorders of sugar metabolism (galactosemia or glycogen storage disease)

 Genetic digestive disorder (Alagille syndrome)

 Liver disease caused by your body's immune system (autoimmune hepatitis)

 Destruction of the bile ducts (primary biliary cirrhosis)

 Hardening and scarring of the bile ducts (primary sclerosing cholangitis

 Infection, such as syphilis or brucellosis

 Medications, including methotrexate or isoniazid

Risk factors

 Drinking too much alcohol. Excessive alcohol consumption is a risk factor for

cirrhosis.

 Being overweight. Being obese increases your risk of conditions that may lead to
cirrhosis, such as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

 Having viral hepatitis. Not everyone with chronic hepatitis will develop cirrhosis,
but it's one of the world's leading causes of liver disease.

Complications of cirrhosis can include:

 High blood pressure in the veins that supply the liver (portal
hypertension). Cirrhosis slows the normal flow of blood through the liver, thus
increasing pressure in the vein that brings blood to the liver from the intestines and
spleen.
 Swelling in the legs and abdomen. The increased pressure in the portal vein can
cause fluid to accumulate in the legs (edema) and in the abdomen (ascites). Edema
and ascites also may result from the inability of the liver to make enough of certain
blood proteins, such as albumin.

 Enlargement of the spleen (splenomegaly). Portal hypertension can also cause

changes to and swelling of the spleen, and trapping of white blood cells and platelets.
Decreased white blood cells and platelets in your blood can be the first sign of
cirrhosis.

 Bleeding. Portal hypertension can cause blood to be redirected to smaller veins.

Strained by the extra pressure, these smaller veins can burst, causing serious
bleeding. Portal hypertension may cause enlarged veins (varices) in the esophagus
(esophageal varices) or the stomach (gastric varices) and lead to life-threatening
bleeding. If the liver can't make enough clotting factors, this also can contribute to
continued bleeding.

 Infections. If you have cirrhosis, your body may have difficulty fighting infections.
Ascites can lead to bacterial peritonitis, a serious infection.

 Malnutrition. Cirrhosis may make it more difficult for your body to process nutrients,
leading to weakness and weight loss.

 Buildup of toxins in the brain (hepatic encephalopathy). A liver damaged by

cirrhosis isn't able to clear toxins from the blood as well as a healthy liver can. These
toxins can then build up in the brain and cause mental confusion and difficulty
concentrating. With time, hepatic encephalopathy can progress to unresponsiveness
or coma.

 Jaundice. Jaundice occurs when the diseased liver doesn't remove enough bilirubin, a
blood waste product, from your blood. Jaundice causes yellowing of the skin and
whites of the eyes and darkening of urine.

 Bone disease. Some people with cirrhosis lose bone strength and are at greater risk
of fractures.
  Increased risk of liver cancer. A large proportion of people who develop liver
cancer have pre-existing cirrhosis.

 Acute-on-chronic cirrhosis. Some people end up experiencing multiorgan failure.

Researchers now believe this is a distinct complication in some people who have
cirrhosis, but they don't fully understand its causes.

Prevention

Reduce your risk of cirrhosis by taking these steps to care for your liver:

 Do not drink alcohol if you have cirrhosis. If you have liver disease, you should
avoid alcohol.

 Eat a healthy diet. Choose a plant-based diet that's full of fruits and vegetables. Select
whole grains and lean sources of protein. Reduce the amount of fatty and fried foods
you eat.

 Maintain a healthy weight. An excess amount of body fat can damage your liver.
Talk to your doctor about a weight-loss plan if you are obese or overweight.

 Reduce your risk of hepatitis. Sharing needles and having unprotected sex can
increase your risk of hepatitis B and C. Ask your doctor about hepatitis vaccinations.

Lifestyle and home remedies

If you have cirrhosis, be careful to limit additional liver damage:

 Don't drink alcohol. Whether your cirrhosis was caused by chronic alcohol use or
another disease, avoid alcohol. Drinking alcohol may cause further liver damage.

 Eat a low-sodium diet. Excess salt can cause your body to retain fluids, worsening
swelling in your abdomen and legs. Use herbs for seasoning your food, rather than
salt. Choose prepared foods that are low in sodium.
  Eat a healthy diet. People with cirrhosis can experience malnutrition. Combat this
with a healthy plant-based diet that includes a variety of fruits and vegetables. Choose
lean protein, such as legumes, poultry or fish. Avoid raw seafood.

 Avoid infections. Cirrhosis makes it more difficult for you to fight off infections.
Protect yourself by avoiding people who are sick and washing your hands frequently.
Get vaccinated for hepatitis A and B, influenza, and pneumonia.

 Use over-the-counter medications carefully. Cirrhosis makes it more difficult for

your liver to process drugs. For this reason, ask your doctor before taking any
medications, including nonprescription drugs. Avoid drugs such as aspirin and
ibuprofen (Advil, Motrin IB, others). If you have liver damage, your doctor may
recommend you avoid acetaminophen (Tylenol, others) or take it in low doses for
pain relief.

2. NONALCOHOLIC FATTY LIVER DISEASE (NAFLD)

Is an umbrella term for a range of liver conditions affecting people who drink little to no
alcohol. As the name implies, the main characteristic of NAFLD is too much fat stored in
liver cells.

NAFLD is increasingly common around the world, especially in Western nations. In the
United States, it is the most common form of chronic liver disease, affecting about one-
quarter of the population.

Some individuals with NAFLD can develop nonalcoholic steatohepatitis (NASH), an

aggressive form of fatty liver disease, which is marked by liver inflammation and may
progress to advanced scarring (cirrhosis) and liver failure. This damage is similar to the
damage caused by heavy alcohol use

Symptoms

NAFLD usually causes no signs and symptoms. When it does, they may include:
  Fatigue

 Pain or discomfort in the upper right abdomen

Possible signs and symptoms of NASH and advanced scarring (cirrhosis) include:

 Abdominal swelling (ascites)

 Enlarged blood vessels just beneath the skin's surface

 Enlarged spleen

 Red palms

 Yellowing of the skin and eyes (jaundice)

Causes

Experts don't know exactly why some people accumulate fat in the liver while others do
not. Similarly, there is limited understanding of why some fatty livers develop
inflammation that progresses to cirrhosis.

NAFLD and NASH are both linked to the following:

 Overweight or obesity

 Insulin resistance, in which your cells don't take up sugar in response to the hormone
insulin

 High blood sugar (hyperglycemia), indicating prediabetes or type 2 diabetes

 High levels of fats, particularly triglycerides, in the blood

These combined health problems appear to promote the deposit of fat in the liver. For
some people, this excess fat acts as a toxin to liver cells, causing liver inflammation
and NASH, which may lead to a buildup of scar tissue in the liver.

Risk factors
A wide range of diseases and conditions can increase your risk of NAFLD, including:

 High cholesterol

 High levels of triglycerides in the blood

 Metabolic syndrome

 Obesity, particularly when fat is concentrated in the abdomen

 Polycystic ovary syndrome

 Sleep apnea

 Type 2 diabetes

 Underactive thyroid (hypothyroidism)

 Underactive pituitary gland (hypopituitarism)

NASH is more likely in these groups:

 Older people

 People with diabetes

 People with body fat concentrated in the abdomen

It is difficult to distinguish NAFLD from NASH without further testing.

The main complication

The main complication of NAFLD and NASH is cirrhosis, which is late-stage scarring in the

liver. Cirrhosis occurs in response to liver injury, such as the inflammation in NASH. As the
liver tries to halt inflammation, it produces areas of scarring (fibrosis). With continued
inflammation, fibrosis spreads to take up more and more liver tissue.

If the process isn't interrupted, cirrhosis can lead to:

  Fluid buildup in the abdomen (ascites)

 Swelling of veins in your esophagus (esophageal varices), which can rupture and
bleed

 Confusion, drowsiness and slurred speech (hepatic encephalopathy)

 Liver cancer

 End-stage liver failure, which means the liver has stopped functioning

Between 5% and 12% of people with NASH will progress to cirrhosis.

Prevention

To reduce your risk of NAFLD:

 Choose a healthy diet. Choose a healthy plant-based diet that's rich in fruits,

vegetables, whole grains and healthy fats.

 Maintain a healthy weight. If you are overweight or obese, reduce the number of
calories you eat each day and get more exercise. If you have a healthy weight, work to
maintain it by choosing a healthy diet and exercising.

 Exercise. Exercise most days of the week. Get an OK from your doctor first if you
haven't been exercising regularly.

Lifestyle and home remedies

With your doctor's help, you can take steps to control your nonalcoholic fatty liver disease.
You can:

 Lose weight. If you're overweight or obese, reduce the number of calories you eat
each day and increase your physical activity in order to lose weight. Calorie reduction
is the key to losing weight and managing this disease. If you have tried to lose weight
in the past and have been unsuccessful, ask your doctor for help.
  Choose a healthy diet. Eat a healthy diet that's rich in fruits, vegetables and whole
grains, and keep track of all calories you take in.

 Exercise and be more active. Aim for at least 30 minutes of exercise most days of the
week. If you're trying to lose weight, you might find that more exercise is helpful. But
if you don't already exercise regularly, get your doctor's OK first and start slowly.

 Control your diabetes. Follow your doctor's instructions to stay in control of your

diabetes. Take your medications as directed and closely monitor your blood sugar.

 Lower your cholesterol. A healthy plant-based diet, exercise and medications can
help keep your cholesterol and your triglycerides at healthy levels.

 Protect your liver. Avoid things that will put extra stress on your liver. For instance,
don't drink alcohol. Follow the instructions on all medications and over-the-counter
drugs. Check with your doctor before using any herbal remedies, as not all herbal
products are safe.

3. HEPATITIS

It refers to an inflammatory condition of the liver.

Common causes of hepatitis include

1. Specific hepatitis viruses

2. Genetic liver disorders
3. Viral infections
4. Parasitic infections
5. Drugs and toxins
6. Excess alcohol consumption
7. An autoimmune reaction directed against the liver cells of the body.

The 5 types of viral hepatitis

Viral infections of the liver that are classified as hepatitis include hepatitis A, B, C, D, and E.
A different virus is responsible for each type of virally transmitted hepatitis.
Hepatitis A is always an acute, short-term disease, while hepatitis B, C, and D are most
likely to become ongoing and chronic. Hepatitis E is usually acute but can be particularly
dangerous in pregnant women.

Hepatitis A

Hepatitis A is caused by an infection with the hepatitis A virus (HAV). This type of hepatitis
is most commonly transmitted by consuming food or water contaminated by feces from a
person infected with hepatitis A.

Hepatitis B

Hepatitis B is transmitted through contact with infectious body fluids, such as blood,
vaginal secretions, or semen, containing the hepatitis B virus (HBV). Injection drug use,
having sex with an infected partner, or sharing razors with an infected person increase
your risk of getting hepatitis B.

It’s estimated by the CDCTrusted Source that 1.2 million people in the United States and
350 million people worldwide live with this chronic disease.

Hepatitis C

Hepatitis C comes from the hepatitis C virus (HCV). Hepatitis C is transmitted through
direct contact with infected body fluids, typically through injection drug use and sexual
contact. HCV is among the most common bloodborne viral infections in the United
States. Approximately 2.7 to 3.9 million AmericansTrusted Source are currently living with
a chronic form of this infection.

Hepatitis D
Also called delta hepatitis, hepatitis D is a serious liver disease caused by the hepatitis D
virus (HDV). HDV is contracted through direct contact with infected blood. Hepatitis D is a
rare form of hepatitis that only occurs in conjunction with hepatitis B infection. The
hepatitis D virus can’t multiply without the presence of hepatitis B. It’s very uncommon in
the United States.

Hepatitis E

Hepatitis E is a waterborne disease caused by the hepatitis E virus (HEV). Hepatitis E is
mainly found in areas with poor sanitation and typically results from ingesting fecal matter
that contaminates the water supply. This disease is uncommon in the United States.
However, cases of hepatitis E have been reported in the Middle East, Asia, Central America,
and Africa, according to the CDC

Common symptoms of hepatitis

If you have infectious forms of hepatitis that are chronic, like hepatitis B and C, you may not
have symptoms in the beginning. Symptoms may not occur until the damage affects liver
function.

Signs and symptoms of acute hepatitis appear quickly. They include:

 fatigue

 flu-like symptoms

 dark urine

 pale stool

 abdominal pain

 loss of appetite

 unexplained weight loss

  yellow skin and eyes, which may be signs of jaundice

Tips to prevent hepatitis

Hygiene

Practicing good hygiene is one key way to avoid contracting hepatitis A and E. If you’re
traveling to a developing country, you should avoid:

 local water

 ice

 raw or undercooked shellfish and oysters

 raw fruit and vegetables

Hepatitis B, C, and D contracted through contaminated blood can be prevented by:

 not sharing drug needles

 not sharing razors

 not using someone else’s toothbrush

 not touching spilled blood

Hepatitis B and C can also be contracted through sexual intercourse and intimate sexual
contact. Practicing safe sex by using condoms and dental dams can help decrease the risk of
infection. You can find many options available for purchase online.

Vaccines
The use of vaccines is an important key to preventing hepatitis. Vaccinations are available
to prevent the development of hepatitis A and B. Experts are currently developing vaccines
against hepatitis C.

 HEPATIC FAILURE/LIVER FAILURE

Liver failure is the inability of the liver to perform its normal synthetic and metabolic
function as part of normal physiology.

Two forms are recognized,

a) acute
b) chronic

Acute liver failure

Acute liver failure strikes fast. You’ll experience loss of liver function within weeks or even
days. It may happen suddenly, without showing any symptoms.

Common causes of acute liver failure include poisoning from mushrooms or drug overdose,
which can occur from taking too much acetaminophen (Tylenol).

Chronic liver failure

Chronic liver failure develops more slowly that acute liver failure. It can take months or
even years before you exhibit any symptoms. Chronic liver failure is often the result
of cirrhosis, which is usually caused by long-term alcohol use. Cirrhosis occurs when
healthy liver tissue is replaced with scar tissue.
During chronic liver failure, your liver becomes inflamed. This inflammation causes the
formation of scar tissue over time. As your body replaces healthy tissue with scar tissue,
your liver begins to fail.

There are three types of alcohol-related liver failure:

 Alcoholic fatty liver disease: Alcoholic fatty liver disease is the result of fat cells
deposited in the liver. It generally affects those who drink a lot of alcohol and those
who are obese.

 Alcoholic hepatitis: Alcoholic hepatitis is characterized by fat cells in the liver,

inflammation, and scarring. According to the American Liver Foundation, up to 35
percent of people who drink heavily will develop this condition.

 Alcoholic cirrhosis: Alcoholic cirrhosis is considered the most advanced out of the

three types. The American Liver Foundation says that some form of cirrhosis affects
10 to 20 percent of people who drink heavily.

Symptoms of hepatic failure

Symptoms of liver failure may include:

 nausea

 loss of appetite

 ·fatigue

 diarrhea

 jaundice, a yellowish color of the skin and eyes

 weight loss

 bruising or bleeding easily

 itching
  edema, or fluid buildup in the legs

 ascites, or fluid buildup in the abdomen

These symptoms can also be attributed to other problems or disorders, which can make
liver failure hard to diagnose. Some people don’t show any symptoms until their liver
failure has progressed to a fatal stage. You may be disoriented, drowsy, or even slip into
a coma by the time you reach this stage.

If you have alcohol-related liver disease (ARLD), you may develop jaundice. Toxins can
build up in your brain and cause sleeplessness, lack of concentration, and even decreased
mental function. You may also experience an enlarged spleen, stomach bleeding,
and kidney failure. Liver cancer can also develop.

Other preventive measures include:

 practicing safe sex

 not engaging in drug use or needle sharing

 getting vaccinated for hepatitis A and B

 protecting your skin from toxic chemicals

 using aerosol spray cans in ventilated areas so that you don’t inhale the fumes

Causes

Acute liver failure occurs when liver cells are damaged significantly and are no longer able
to function. Potential causes include:

 Acetaminophen overdose. Taking too much acetaminophen (Tylenol, others) is the

most common cause of acute liver failure in the United States. Acute liver failure can
occur after one very large dose of acetaminophen, or after higher than recommended
doses every day for several days.
 If you or someone you know has taken an overdose of acetaminophen, seek medical
attention as quickly as possible. Don't wait for the signs of liver failure.

 Prescription medications. Some prescription medications, including antibiotics,

nonsteroidal anti-inflammatory drugs and anticonvulsants, can cause acute liver
failure.

 Herbal supplements. Herbal drugs and supplements, including kava, ephedra,

skullcap and pennyroyal, have been linked to acute liver failure.

 Hepatitis and other viruses. Hepatitis A, hepatitis B and hepatitis E can cause acute
liver failure. Other viruses that can cause acute liver failure include Epstein-Barr
virus, cytomegalovirus and herpes simplex virus.

 Toxins. Toxins that can cause acute liver failure include the poisonous wild
mushroom Amanita phalloides, which is sometimes mistaken for one that is safe to
eat. Carbon tetrachloride is another toxin that can cause acute liver failure. It is an
industrial chemical found in refrigerants and solvents for waxes, varnishes and other
materials.

 Autoimmune disease. Liver failure can be caused by autoimmune hepatitis — a

disease in which your immune system attacks liver cells, causing inflammation and
injury.

 Diseases of the veins in the liver. Vascular diseases, such as Budd-Chiari syndrome,

can cause blockages in the veins of the liver and lead to acute liver failure.

 Metabolic disease. Rare metabolic diseases, such as Wilson's disease and acute fatty
liver of pregnancy, infrequently cause acute liver failure.

 Cancer. Cancer that either begins in or spreads to your liver can cause your liver to
fail.

 Shock. Overwhelming infection (sepsis) and shock can severely impair blood flow to
the liver, causing liver failure.
Many cases of acute liver failure have no apparent cause.

Complications

Acute liver failure often causes complications, including:

 Excessive fluid in the brain (cerebral edema). Too much fluid causes pressure to
build up in your brain.

 Bleeding and bleeding disorders. A failing liver cannot make enough clotting
factors, which help blood to clot. Bleeding in the gastrointestinal tract is common with
this condition. It may be difficult to control.

 Infections. People with acute liver failure are more likely to develop infections,
particularly in the blood and in the respiratory and urinary tracts.

 Kidney failure. Kidney failure often occurs after following liver failure, especially if
you had an acetaminophen overdose, which damages both your liver and your
kidneys.

Prevention

Reduce your risk of acute liver failure by taking care of your liver.

 Follow instructions on medications. If you take acetaminophen or other

medications, check the package insert for the recommended dosage, and don't take
more than that. If you already have liver disease, ask your doctor if it is safe to take
any amount of acetaminophen.

 Tell your doctor about all your medicines. Even over-the-counter and herbal
medicines can interfere with prescription drugs you're taking.

 Drink alcohol in moderation, if at all. Limit the amount of alcohol you drink to no

more than one drink a day for women of all ages and men older than 65 and no more
than two drinks a day for younger men.
  Avoid risky behavior. Get help if you use illicit intravenous drugs. Don't share
needles. Use condoms during sex. If you get tattoos or body piercings, make sure the
shop you choose is clean and safe. Don't smoke.

 Get vaccinated. If you have chronic liver disease, a history of any type of hepatitis
infection or an increased risk of hepatitis, talk to your doctor about getting the
hepatitis B vaccine. A vaccine also is available for hepatitis A.

 Avoid contact with other people's blood and body fluids. Accidental needle sticks
or improper cleanup of blood or body fluids can spread hepatitis viruses. Sharing
razor blades or toothbrushes also can spread infection.

 Don't eat wild mushrooms. It can be difficult to tell the difference between a
poisonous mushroom and one that is safe to eat.

 Take care with aerosol sprays. When you use an aerosol cleaner, make sure the
room is ventilated, or wear a mask. Take similar protective measures when spraying
insecticides, fungicides, paint and other toxic chemicals. Follow product instructions
carefully.

 Watch what gets on your skin. When using insecticides and other toxic chemicals,
cover your skin with gloves, long sleeves, a hat and a mask.

 Maintain a healthy weight. Obesity can cause a condition called nonalcoholic fatty

liver disease, which may include fatty liver, hepatitis and cirrhosis.

Topic 9: DISORDERS OF THE PANCREAS

Functions of the Pancreas

A healthy pancreas produces the correct chemicals in the proper quantities, at the right
times, to digest the foods we eat.
Exocrine Function:

The pancreas contains exocrine glands that produce enzymes important to digestion.

These enzymes include trypsin and chymotrypsin to digest proteins; amylase for the
digestion of carbohydrates; and lipase to break down fats. When food enters the stomach,
these pancreatic juices are released into a system of ducts that culminate in the
main pancreatic duct. The pancreatic duct joins the common bile duct to form
the ampulla of Vater which is located at the first portion of the small intestine, called
the duodenum. The common bile duct originates in the liver and the gallbladder and
produces another important digestive juice called bile. The pancreatic juices and bile that
are released into the duodenum help the body to digest fats, carbohydrates, and proteins.

Endocrine Function:

The endocrine component of the pancreas consists of islet cells (islets of Langerhans) that
create and release important hormones directly into the bloodstream. Two of the main
pancreatic hormones are insulin, which acts to lower blood sugar, and glucagon, which
acts to raise blood sugar. Maintaining proper blood sugar levels is crucial to the functioning
of key organs including the brain, liver, and kidneys.

Diseases of the Pancreas

1. Pancreatitis 

Is inflammation of the pancreas.  Pancreatitis occurs when the enzymes damage the

pancreas, which causes inflammation.

 Pancreatitis can be

a) acute
b) chronic.

Acute pancreatitis
Acute pancreatitis occurs suddenly and is a short-term condition. Most people with acute
pancreatitis get better, and it goes away in several days with treatment. Some people can
have a more severe form of acute pancreatitis, which requires a lengthy hospital stay.

Acute pancreatitis signs and symptoms include:

 Upper abdominal pain

 Abdominal pain that radiates to your back

 Abdominal pain that feels worse after eating

 Fever

 Rapid pulse

 Nausea

 Vomiting

 Tenderness when touching the abdomen

Chronic pancreatitis

Chronic pancreatitis is a long-lasting condition. The pancreas does not heal or improve.
Instead, it gets worse over time, which can lead to lasting damage to your pancreas.

Chronic pancreatitis signs and symptoms include:

 Upper abdominal pain

 Losing weight without trying

 Oily, smelly stools (steatorrhea)

Causes of Pancreatitis 
Pancreatitis occurs when digestive enzymes become activated while still in the pancreas,
irritating the cells of your pancreas and causing inflammation.

With repeated bouts of acute pancreatitis, damage to the pancreas can occur and lead to
chronic pancreatitis. Scar tissue may form in the pancreas, causing loss of function. A
poorly functioning pancreas can cause digestion problems and diabetes.

Conditions that can lead to pancreatitis include:

 Abdominal surgery

 Alcoholism

 Certain medications

 Cystic fibrosis

 Gallstones

 High calcium levels in the blood (hypercalcemia), which may be caused by an

overactive parathyroid gland (hyperparathyroidism)

 High triglyceride levels in the blood (hypertriglyceridemia)

 Infection

 Injury to the abdomen

 Obesity

 Pancreatic cancer.

Sometimes, a cause for pancreatitis is never found.

Risk factors
Factors that increase your risk of pancreatitis include:

 Excessive alcohol consumption. Research shows that heavy alcohol users (people

who consume four to five drinks a day) are at increased risk of pancreatitis.

 Cigarette smoking. Smokers are on average three times more likely to develop

chronic pancreatitis, compared with nonsmokers. The good news is quitting smoking
decreases your risk by about half

 Obesity. You're more likely to get pancreatitis if you're obese.

 Family history of pancreatitis. The role of genetics is becoming increasingly

recognized in chronic pancreatitis. If you have family members with the condition,
your odds increase — especially when combined with other risk factors.

Complications

Pancreatitis can cause serious complications, including:

 Pseudocyst. Acute pancreatitis can cause fluid and debris to collect in cystlike

pockets in your pancreas. A large pseudocyst that ruptures can cause complications
such as internal bleeding and infection.

 Infection. Acute pancreatitis can make your pancreas vulnerable to bacteria and

infection. Pancreatic infections are serious and require intensive treatment, such as
surgery to remove the infected tissue.

 Kidney failure. Acute pancreatitis may cause kidney failure, which can be treated
with dialysis if the kidney failure is severe and persistent.

 Breathing problems. Acute pancreatitis can cause chemical changes in your body

that affect your lung function, causing the level of oxygen in your blood to fall to
dangerously low levels.
  Diabetes. Damage to insulin-producing cells in your pancreas from chronic
pancreatitis can lead to diabetes, a disease that affects the way your body uses blood
sugar.

 Malnutrition. Both acute and chronic pancreatitis can cause your pancreas to

produce fewer of the enzymes that are needed to break down and process nutrients
from the food you eat. This can lead to malnutrition, diarrhea and weight loss, even
though you may be eating the same foods or the same amount of food.

 Pancreatic cancer. Long-standing inflammation in your pancreas caused by chronic

pancreatitis is a risk factor for developing pancreatic cancer

Lifestyle and home remedies

 Stop drinking alcohol. If you're unable to stop drinking alcohol on your own, ask
your doctor for help. Your doctor can refer you to local programs to help you stop
drinking.

 Stop smoking. If you smoke, quit. If you don't smoke, don't start. If you can't quit on
your own, ask your doctor for help. Medications and counseling can help you quit
smoking.

 Choose a low-fat diet. Choose a diet that limits fat and emphasizes fresh fruits and
vegetables, whole grains, and lean protein.

 Drink more fluids. Pancreatitis can cause dehydration, so drink more fluids

throughout the day. It may help to keep a water bottle or glass of water with you

TOPIC 10: DISORDERS OF THE GALL BLADDER

The gallbladder is a pear-shaped, hollow structure located under the liver and on the right
side of the abdomen. Its primary function is to store and concentrate bile, a yellow-brown
digestive enzyme produced by the liver. The gallbladder is part of the biliary tract

TYPES OF GALL BLADDER DISEASES

 1. Gallstones/ choledocholithiasis

Are hardened deposits of digestive fluid that can form in your gallbladder. Your
gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath
your liver. The gallbladder holds a digestive fluid called bile that's released into your small
intestine.

Gallstones range in size from as small as a grain of sand to as large as a golf ball. Some
people develop just one gallstone, while others develop many gallstones at the same time.

People who experience symptoms from their gallstones usually require gallbladder
removal surgery. Gallstones that don't cause any signs and symptoms typically don't need
treatment.

Symptoms

Gallstones may cause no signs or symptoms. If a gallstone lodges in a duct and causes a
blockage, the resulting signs and symptoms may include:

 Sudden and rapidly intensifying pain in the upper right portion of your abdomen

 Sudden and rapidly intensifying pain in the center of your abdomen, just below your
breastbone

 Back pain between your shoulder blades

 Pain in your right shoulder

 Nausea or vomiting

Gallstone pain may last several minutes to a few hours

Causes

It's not clear what causes gallstones to form. Doctors think gallstones may result when:
  Your bile contains too much cholesterol. Normally, your bile contains enough
chemicals to dissolve the cholesterol excreted by your liver. But if your liver excretes
more cholesterol than your bile can dissolve, the excess cholesterol may form into
crystals and eventually into stones.

 Your bile contains too much bilirubin. Bilirubin is a chemical that's produced when
your body breaks down red blood cells. Certain conditions cause your liver to make
too much bilirubin, including liver cirrhosis, biliary tract infections and certain blood
disorders. The excess bilirubin contributes to gallstone formation.

 Your gallbladder doesn't empty correctly. If your gallbladder doesn't empty

completely or often enough, bile may become very concentrated, contributing to the
formation of gallstones.

Types of gallstones

Types of gallstones that can form in the gallbladder include:

 Cholesterol gallstones. The most common type of gallstone, called a cholesterol

gallstone, often appears yellow in color. These gallstones are composed mainly of
undissolved cholesterol, but may contain other components.

 Pigment gallstones. These dark brown or black stones form when your bile contains
too much bilirubin.

Risk factors

Factors that may increase your risk of gallstones include:

 Being female

 Being age 40 or older

 Being a Native American

 Being a Mexican American

  Being overweight or obese

 Being sedentary

 Being pregnant

 Eating a high-fat diet

 Eating a high-cholesterol diet

 Eating a low-fiber diet

 Having a family history of gallstones

 Having diabetes

 Having certain blood disorders, such as sickle cell anemia or leukemia

 Losing weight very quickly

 Taking medications that contain estrogen, such as oral contraceptives or hormone

therapy drugs

 Having liver disease

Complications

Complications of gallstones may include:

 Inflammation of the gallbladder. A gallstone that becomes lodged in the neck of the
gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can
cause severe pain and fever.

 Blockage of the common bile duct. Gallstones can block the tubes (ducts) through
which bile flows from your gallbladder or liver to your small intestine. Severe pain,
jaundice and bile duct infection can result.
  Blockage of the pancreatic duct. The pancreatic duct is a tube that runs from the
pancreas and connects to the common bile duct just before entering the duodenum.
Pancreatic juices, which aid in digestion, flow through the pancreatic duct.

A gallstone can cause a blockage in the pancreatic duct, which can lead to
inflammation of the pancreas (pancreatitis). Pancreatitis causes intense, constant
abdominal pain and usually requires hospitalization.

 Gallbladder cancer. People with a history of gallstones have an increased risk of

gallbladder cancer. But gallbladder cancer is very rare, so even though the risk of
cancer is elevated, the likelihood of gallbladder cancer is still very small.

Prevention

You can reduce your risk of gallstones if you:

 Don't skip meals. Try to stick to your usual mealtimes each day. Skipping meals or
fasting can increase the risk of gallstones.

 Lose weight slowly. If you need to lose weight, go slow. Rapid weight loss can
increase the risk of gallstones. Aim to lose 1 or 2 pounds (about 0.5 to 1 kilogram) a
week.

 Eat more high-fiber foods. Include more fiber-rich foods in your diet, such as fruits,
vegetables and whole grains.

 Maintain a healthy weight. Obesity and being overweight increase the risk of

gallstones. Work to achieve a healthy weight by reducing the number of calories you
eat and increasing the amount of physical activity you get. Once you achieve a healthy
weight, work to maintain that weight by continuing your healthy diet and continuing
to exercise.

2. Cholecystitis
Is inflammation of the gall-bladder
 Gallbladder is a small, pear-shaped organ on the right side of your abdomen, beneath
your liver. The gallbladder holds a digestive fluid that's released into your small
intestine (bile).
In most cases, gallstones blocking the tube leading out of your gallbladder cause
cholecystitis. This results in a bile buildup that can cause inflammation. Other causes of
cholecystitis include bile duct problems, tumors, serious illness and certain infections.
If left untreated, cholecystitis can lead to serious, sometimes life-threatening
complications, such as a gallbladder rupture. Treatment for cholecystitis often involves
gallbladder removal.

Symptoms

Signs and symptoms of cholecystitis may include:

 Severe pain in your upper right or center abdomen

 Pain that spreads to your right shoulder or back

 Tenderness over your abdomen when it's touched

 Nausea

 Vomiting

 Fever

Cholecystitis signs and symptoms often occur after a meal, particularly a large or fatty one.

Causes

Cholecystitis occurs when your gallbladder becomes inflamed. Gallbladder inflammation

can be caused by:
  Gallstones. Most often, cholecystitis is the result of hard particles that develop in
your gallbladder (gallstones). Gallstones can block the tube (cystic duct) through
which bile flows when it leaves the gallbladder. Bile builds up, causing inflammation.

 Tumor. A tumor may prevent bile from draining out of your gallbladder properly,
causing bile buildup that can lead to cholecystitis.

 Bile duct blockage. Kinking or scarring of the bile ducts can cause blockages that
lead to cholecystitis.

 Infection. AIDS and certain viral infections can trigger gallbladder inflammation.

 Blood vessel problems. A very severe illness can damage blood vessels and decrease
blood flow to the gallbladder, leading to cholecystitis.

Risk factors

Having gallstones is the main risk factor for developing cholecystitis.

Complications

Cholecystitis can lead to a number of serious complications, including:

 Infection within the gallbladder. If bile builds up within your gallbladder, causing
cholecystitis, the bile may become infected.

 Death of gallbladder tissue. Untreated cholecystitis can cause tissue in the

gallbladder to die (gangrene). It's the most common complication, especially among
older people, those who wait to get treatment, and those with diabetes. This can lead
to a tear in the gallbladder, or it may cause your gallbladder to burst.

 Torn gallbladder. A tear (perforation) in your gallbladder may result from

gallbladder swelling, infection or death of tissue.
Prevention

You can reduce your risk of cholecystitis by taking the following steps to prevent
gallstones:

1. Lose weight slowly. Rapid weight loss can increase the risk of gallstones. If you need
to lose weight, aim to lose 1 or 2 pounds (0.5 to about 1 kilogram) a week.

2. Maintain a healthy weight. Being overweight makes you more likely to develop

gallstones. To achieve a healthy weight, reduce calories and increase your physical
activity. Maintain a healthy weight by continuing to eat well and exercise.

3. Choose a healthy diet. Diets high in fat and low in fiber may increase the risk of
gallstones. To lower your risk, choose a diet high in fruits, vegetables and whole
grains.

3. Acalculous gallbladder disease

Acalculous gallbladder disease is inflammation of the gallbladder that occurs without the
presence of gallstones. Having a significant chronic illness or serious medical condition has
been shown to trigger an episode.

Symptoms are similar to acute cholecystitis with gallstones. Some risk factors for the
condition include:

 severe physical trauma

 heart surgery

 abdominal surgery

 severe burns

 autoimmune conditions like lupus

 blood stream infections

  receiving nutrition intravenously (IV)

 significant bacterial or viral illnesses

4. Biliary dyskinesia

Biliary dyskinesia occurs when the gallbladder has a lower-than-normal function. This
condition may be related to ongoing gallbladder inflammation.

Symptoms can include upper abdominal pain after eating, nausea, bloating, and indigestion.
Eating a fatty meal may trigger symptoms. There are usually no gallstones in the
gallbladder with biliary dyskinesia.

Your doctor may need to use a test called a HIDA scan to help diagnosis this condition. This
test measures gallbladder function. If the gallbladder can only release 35 to 40 percent of
its contents or less, then biliary dyskinesia is usually diagnosed.

5. Sclerosing cholangitis

Ongoing inflammation and damage to the bile duct system can lead to scarring. This
condition is referred to as sclerosing cholangitis. However, it’s unknown what exactly
causes this disease.

Nearly half the people with this condition don’t have symptoms. If symptoms do occur, they
can include:

 fever

 jaundice

 itching

 upper abdominal discomfort.

Approximately 60 to 80 percentTrusted Source of people with this condition also
have ulcerative colitis. Having this condition does increase the risk of liver cancer as well.
Currently, the only known cure is a liver transplant.

Medications that suppress the immune system and those that help break down thickened
bile can help manage symptoms.

6. Gallbladder cancer

Cancer of the gallbladder is a relatively rare disease. There are different types of
gallbladder cancers. They can be difficult to treat because they’re not often diagnosed until
late in the disease’s progression. Gallstones are a common risk factor for gallbladder
cancer.

Gallbladder cancer can spread from the inner walls of the gallbladder to the outer layers
and then on to the liver, lymph nodes, and other organs. The symptoms of gallbladder
cancer may be similar to those of acute cholecystitis, but there may also be no symptoms at
all.

7. Gallbladder polyps

Gallbladder polyps are lesions or growths that occur within the gallbladder. They’re usually
benign and have no symptoms. However, it’s often recommended to have the gallbladder
removed for polyps larger than 1 centimeter. They have a greater chance of being
cancerous.

8. Gangrene of the gallbladder

Gangrene can occur when the gallbladder develops inadequate blood flow. This is one of
the most serious complications of acute cholecystitis. Factors that increase the risk of this
complication include:

 being male and over 45 years old

 having diabetes

The symptoms of gallbladder gangrene can include:

 dull pain in the gallbladder region

 fever

 nausea or vomiting

 disorientation

 low blood pressure

9. Abscess of the gallbladder

Abscess of the gallbladder results when the gallbladder becomes inflamed with pus. Pus is
the accumulation of white blood cells, dead tissue, and bacteria. Symptoms may include
upper right-sided pain in the abdomen along with fever and shaking chills.

This condition can occur during acute cholecystitis when a gallstone blocks the gallbladder
completely, allowing the gallbladder to fill with pus. It’s more common in people with
diabetes and heart disease

TOPIC 11: DISORDERS OF THE RENAL/KIDNEY

The kidneys are a pair of bean-shaped organs on either side of your spine, below your ribs
and behind your belly.

Functions of kidneys

 Controlling acid-base balance

The acids and bases in the human body are always in a state of delicate equilibrium
reflected by a parameter known as pH. The normal pH of the blood is 7.35 to 7.45.
To maintain this healthy range, the kidneys excrete acids and bases when there’s an
excess of them, or retain these compounds when the body is lacking them.

 Controlling water balance

The kidneys are one of the body’s main ways to maintain a stable water balance. By
regulating the volume of urine they produce, the kidneys adapt to one’s hydration
level. When you drink a lot, the kidneys produce more urine, and the opposite
happens when you are dehydrated.

 Maintaining electrolyte balance

The kidneys filter some electrolytes from the blood, return part of them back into
circulation, and excrete excess electrolytes into the urine. The levels of electrolytes
like sodium and phosphate are largely dependent on the health of one’s kidneys.

 Removing toxins and waste products from the body

The kidneys filter out water-soluble waste products and toxins, flushing them out of
the body with urine. That’s precisely why kidney failure quickly leads to severe
intoxication, as the body’s waste products build up and impair its functions.

 Controlling blood pressure

The kidneys produce an enzyme called renin. Renin converts the angiotensinogen
produced in the liver into angiotensin I, which is later converted in the lungs into
angiotensin II. Angiotensin II constricts the blood vessels and increases blood
 pressure as a result. On the other hand, when one’s blood pressure is too high, the
kidneys produce more urine to reduce the volume of liquid circulating in the body
and somewhat compensate the high blood pressure.

 Producing the hormone erythropoietin

The kidneys produce a hormone called erythropoietin. The main function of this
hormone is to help the body create more red blood cells (erythrocytes), which are
essential for the transport of oxygen throughout all the tissues and organs.

 Activating vitamin D

The kidneys transform calcifediol into calcitriol, the active form of vitamin D.
Calcitriol circulates in the blood and plays a vital role in regulating calcium and
phosphate balance in the body, which is essential for healthy bone growth.

Types of kidney diseases

1. Chronic kidney disease.

2. Kidney stones

3. Glomerulonephritis

4. Polycystic kidney disease

5. Urinary tract infections.

1. Chronic kidney disease/chronic kidney failure

It describes the gradual loss of kidney function. Your kidneys filter wastes and excess fluids
from your blood, which are then excreted in your urine. When chronic kidney disease
reaches an advanced stage, dangerous levels of fluid, electrolytes and wastes can build up
in your body.

Symptoms
Signs and symptoms of chronic kidney disease develop over time if kidney damage
progresses slowly. Signs and symptoms of kidney disease may include:

 Nausea

 Vomiting

 Loss of appetite

 Fatigue and weakness

 Sleep problems

 Changes in how much you urinate

 Decreased mental sharpness

 Muscle twitches and cramps

 Swelling of feet and ankles

 Persistent itching

 Chest pain, if fluid builds up around the lining of the heart

 Shortness of breath, if fluid builds up in the lungs

 High blood pressure (hypertension) that's difficult to control

Signs and symptoms of kidney disease are often nonspecific, meaning they can also be
caused by other illnesses. Because your kidneys are highly adaptable and able to
compensate for lost function, signs and symptoms may not appear until irreversible
damage has occurred.

Causes
Chronic kidney disease occurs when a disease or condition impairs kidney function,
causing kidney damage to worsen over several months or years.

Diseases and conditions that cause chronic kidney disease include:

 Type 1 or type 2 diabetes

 High blood pressure

 Glomerulonephritis an inflammation of the kidney's filtering units (glomeruli)

 Interstitial nephritis an inflammation of the kidney's tubules and surrounding

structures

 Polycystic kidney disease

 Prolonged obstruction of the urinary tract, from conditions such as enlarged prostate,
kidney stones and some cancers

 Vesicoureteral reflux, a condition that causes urine to back up into your kidneys

 Recurrent kidney infection, also called pyelonephritis

Risk factors

Factors that may increase your risk of chronic kidney disease include:

 Diabetes

 High blood pressure

 Heart and blood vessel (cardiovascular) disease

 Smoking

 Obesity

 Being African-American, Native American or Asian-American

  Family history of kidney disease

 Abnormal kidney structure

 Older age

Complications

Chronic kidney disease can affect almost every part of your body. Potential complications
may include:

 Fluid retention, which could lead to swelling in your arms and legs, high blood
pressure, or fluid in your lungs (pulmonary edema)

 A sudden rise in potassium levels in your blood (hyperkalemia), which could impair
your heart's ability to function and may be life-threatening

 Heart and blood vessel (cardiovascular) disease

 Weak bones and an increased risk of bone fractures

 Anemia

 Decreased sex drive, erectile dysfunction or reduced fertility

 Damage to your central nervous system, which can cause difficulty concentrating,
personality changes or seizures

 Decreased immune response, which makes you more vulnerable to infection

 Pericarditis, an inflammation of the saclike membrane that envelops your heart

(pericardium)

 Pregnancy complications that carry risks for the mother and the developing fetus

 Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring

either dialysis or a kidney transplant for survival

Prevention
To reduce your risk of developing kidney disease:

 Follow instructions on over-the-counter medications. When using

nonprescription pain relievers, such as aspirin, ibuprofen (Advil, Motrin IB, others)
and acetaminophen (Tylenol, others), follow the instructions on the package. Taking
too many pain relievers could lead to kidney damage and generally should be avoided
if you have kidney disease. Ask your doctor whether these drugs are safe for you.

 Maintain a healthy weight. If you're at a healthy weight, work to maintain it by being

physically active most days of the week. If you need to lose weight, talk with your
doctor about strategies for healthy weight loss. Often this involves increasing daily
physical activity and reducing calories.

 Don't smoke. Cigarette smoking can damage your kidneys and make existing kidney
damage worse. If you're a smoker, talk to your doctor about strategies for quitting
smoking. Support groups, counseling and medications can all help you to stop.

 Manage your medical conditions with your doctor's help. If you have diseases or
conditions that increase your risk of kidney disease, work with your doctor to control
them. Ask your doctor about tests to look for signs of kidney damage.

Lifestyle and home remedies

As part of your treatment for chronic kidney disease, your doctor may recommend a special
diet to help support your kidneys and limit the work they must do. Ask your doctor for a
referral to a dietitian who can analyze your current diet and suggest ways to make your
diet easier on your kidneys.

Depending on your situation, kidney function and overall health, your dietitian may
recommend that you:

 Avoid products with added salt. Lower the amount of sodium you eat each day by
avoiding products with added salt, including many convenience foods, such as frozen
 dinners, canned soups and fast foods. Other foods with added salt include salty snack
foods, canned vegetables, and processed meats and cheeses.

 Choose lower potassium foods. Your dietitian may recommend that you choose
lower potassium foods at each meal. High-potassium foods include bananas, oranges,
potatoes, spinach and tomatoes. Examples of low-potassium foods include apples,
cabbage, carrots, green beans, grapes and strawberries. Be aware that many salt
substitutes contain potassium, so you generally should avoid them if you have kidney
failure.

 Limit the amount of protein you eat. Your dietitian will estimate the appropriate
number of grams of protein you need each day and make recommendations based on
that amount. High-protein foods include lean meats, eggs, milk, cheese and beans.
Low-protein foods include vegetables, fruits, breads and cereals.

2. Kidney stones/ renal lithiasis/ nephrolithiasis

Kidney stones are hard deposits made of minerals and salts that form inside your kidneys.

Passing kidney stones can be quite painful, but the stones usually cause no permanent
damage if they're recognized in a timely fashion. Depending on your situation, you may
need nothing more than to take pain medication and drink lots of water to pass a kidney
stone. In other instances — for example, if stones become lodged in the urinary tract, are
associated with a urinary infection or cause complications — surgery may be needed.

Symptoms

A kidney stone may not cause symptoms until it moves around within your kidney or
passes into your ureter — the tube connecting the kidney and bladder. At that point, you
may experience these signs and symptoms:

 Severe pain in the side and back, below the ribs

 Pain that radiates to the lower abdomen and groin

  Pain that comes in waves and fluctuates in intensity

 Pain on urination

 Pink, red or brown urine

 Cloudy or foul-smelling urine

 Nausea and vomiting

 Persistent need to urinate

 Urinating more often than usual

 Fever and chills if an infection is present

 Urinating small amounts

Pain caused by a kidney stone may change — for instance, shifting to a different location or
increasing in intensity — as the stone moves through your urinary tract

Causes

Kidney stones often have no definite, single cause, although several factors may increase
your risk.

Kidney stones form when your urine contains more crystal-forming substances — such as
calcium, oxalate and uric acid — than the fluid in your urine can dilute. At the same time,
your urine may lack substances that prevent crystals from sticking together, creating an
ideal environment for kidney stones to form.

Types of kidney stones

Knowing the type of kidney stone helps determine the cause and may give clues on how to
reduce your risk of getting more kidney stones. If possible, try to save your kidney stone if
you pass one so that you can bring it to your doctor for analysis.
Types of kidney stones include:

 Calcium stones. Most kidney stones are calcium stones, usually in the form of calcium
oxalate. Oxalate is a naturally occurring substance found in food and is also made
daily by your liver. Some fruits and vegetables, as well as nuts and chocolate, have
high oxalate content.

Dietary factors, high doses of vitamin D, intestinal bypass surgery and several
metabolic disorders can increase the concentration of calcium or oxalate in urine.

Calcium stones may also occur in the form of calcium phosphate. This type of stone is
more common in metabolic conditions, such as renal tubular acidosis. It may also be
associated with certain migraine headaches or with taking certain seizure
medications, such as topiramate (Topamax).

 Struvite stones. Struvite stones form in response to an infection, such as a urinary

tract infection. These stones can grow quickly and become quite large, sometimes
with few symptoms or little warning.

 Uric acid stones. Uric acid stones can form in people who don't drink enough fluids
or who lose too much fluid, those who eat a high-protein diet, and those who have
gout. Certain genetic factors also may increase your risk of uric acid stones.

 Cystine stones. These stones form in people with a hereditary disorder that causes
the kidneys to excrete too much of certain amino acids (cystinuria).

Risk factors

Factors that increase your risk of developing kidney stones include:

 Family or personal history. If someone in your family has kidney stones, you're
more likely to develop stones, too. And if you've already had one or more kidney
 stones, you're at increased risk of developing another.

 Dehydration. Not drinking enough water each day can increase your risk of kidney
stones. People who live in warm climates and those who sweat a lot may be at higher
risk than others.

 Certain diets. Eating a diet that's high in protein, sodium (salt) and sugar may
increase your risk of some types of kidney stones. This is especially true with a high-
sodium diet. Too much salt in your diet increases the amount of calcium your kidneys
must filter and significantly increases your risk of kidney stones.

 Being obese. High body mass index (BMI), large waist size and weight gain have been
linked to an increased risk of kidney stones.

 Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease

or chronic diarrhea can cause changes in the digestive process that affect your
absorption of calcium and water, increasing the levels of stone-forming substances in
your urine.

 Other medical conditions. Diseases and conditions that may increase your risk of
kidney stones include renal tubular acidosis, cystinuria, hyperparathyroidism, certain
medications and some urinary tract infections.

Lifestyle changes

You may reduce your risk of kidney stones if you:

 Drink water throughout the day. For people with a history of kidney stones, doctors
usually recommend passing about 2.6 quarts (2.5 liters) of urine a day. Your doctor
may ask that you measure your urine output to make sure that you're drinking
enough water.

If you live in a hot, dry climate or you exercise frequently, you may need to drink even
more water to produce enough urine. If your urine is light and clear, you're likely
drinking enough water.
  Eat fewer oxalate-rich foods. If you tend to form calcium oxalate stones, your doctor
may recommend restricting foods rich in oxalates. These include rhubarb, beets, okra,
spinach, Swiss chard, sweet potatoes, nuts, and tea, chocolate and soy products.

 Choose a diet low in salt and animal protein. Reduce the amount of salt you eat and
choose nonanimal protein sources, such as legumes. Consider using a salt substitute,
such as Mrs. Dash.

 Continue eating calcium-rich foods, but use caution with calcium

supplements. Calcium in food doesn't have an effect on your risk of kidney stones.
Continue eating calcium-rich foods unless your doctor advises otherwise.

Ask your doctor before taking calcium supplements, as these have been linked to
increased risk of kidney stones. You may reduce the risk by taking supplements with
meals. Diets low in calcium can increase kidney stone formation in some people.

3. Glomerulonephritis

It is inflammation of the tiny filters in your kidneys (glomeruli). Glomeruli remove excess
fluid, electrolytes and waste from your bloodstream and pass them into your urine.
Glomerulonephritis can come on suddenly (acute) or gradually (chronic).

Glomerulonephritis occurs on its own or as part of another disease, such as lupus or

diabetes. Severe or prolonged inflammation associated with glomerulonephritis can
damage your kidneys. Treatment depends on the type of glomerulonephritis you have.

Symptoms

Signs and symptoms of glomerulonephritis depend on whether you have the acute or
chronic form and the cause. Your first indication that something is wrong might come from
symptoms or from the results of a routine urinalysis.

Glomerulonephritis signs and symptoms include:

  Pink or cola-colored urine from red blood cells in your urine (hematuria)

 Foamy urine due to excess protein (proteinuria)

 High blood pressure (hypertension)

 Fluid retention (edema) with swelling evident in your face, hands, feet and abdomen

Causes

Many conditions can cause glomerulonephritis. Sometimes the disease runs in families and
sometimes the cause is unknown. Conditions that can lead to inflammation of the kidneys'
glomeruli include:

Infections

 Post-streptococcal glomerulonephritis. Glomerulonephritis may develop a week or

two after recovery from a strep throat infection or, rarely, a skin infection (impetigo).
To fight the infection, your body produces extra antibodies that can eventually settle
in the glomeruli, causing inflammation.

Children are more likely to develop post-streptococcal glomerulonephritis than are

adults, and they're also more likely to recover quickly.

 Bacterial endocarditis. Bacteria occasionally can spread through your bloodstream

and lodge in your heart, causing an infection of one or more of your heart valves.
You're at greater risk of this condition if you have a heart defect, such as a damaged or
artificial heart valve. Bacterial endocarditis is associated with glomerular disease, but
the connection between the two is unclear.

 Viral infections. Viral infections, such as the human immunodeficiency virus (HIV),

hepatitis B and hepatitis C, can trigger glomerulonephritis.

Immune diseases
  Lupus. A chronic inflammatory disease, lupus can affect many parts of your body,
including your skin, joints, kidneys, blood cells, heart and lungs.

 Goodpasture's syndrome. A rare immunological lung disorder that can mimic

pneumonia, Goodpasture's syndrome causes bleeding in your lungs as well as
glomerulonephritis.

 IgA nephropathy. Characterized by recurrent episodes of blood in the urine, this

primary glomerular disease results from deposits of immunoglobulin A (IgA) in the
glomeruli. IgA nephropathy can progress for years with no noticeable symptoms.

Vasculitis

 Polyarteritis. This form of vasculitis affects small and medium blood vessels in many
parts of your body, such as your heart, kidneys and intestines.

 Granulomatosis with polyangiitis. This form of vasculitis, formerly known as

Wegener's granulomatosis, affects small and medium blood vessels in your lungs,
upper airways and kidneys.

Conditions likely to cause scarring of the glomeruli

 High blood pressure. This can damage your kidneys and impair their ability to
function normally. Glomerulonephritis can also lead to high blood pressure because it
reduces kidney function and can influence how your kidneys handle sodium.

 Diabetic kidney disease (diabetic nephropathy). This can affect anyone with

diabetes, usually taking years to develop. Good control of blood sugar levels and blood
pressure might prevent or slow kidney damage.

 Focal segmental glomerulosclerosis. Characterized by scattered scarring of some of

the glomeruli, this condition can result from another disease or occur for no known
reason.
Infrequently, chronic glomerulonephritis runs in families. One inherited form, Alport
syndrome, also might impair hearing or vision.

In addition to the causes listed above, glomerulonephritis is associated with certain

cancers, such as multiple myeloma, lung cancer and chronic lymphocytic leukemia.

Complications

Glomerulonephritis can damage your kidneys so that they lose their filtering ability. As a
result, dangerous levels of fluid, electrolytes and waste build up in your body.

Possible complications of glomerulonephritis include:

 Acute kidney failure. Loss of function in the filtering part of the nephron can result
in rapid accumulation of waste products. You might need emergency dialysis — an
artificial means of removing extra fluids and waste from your blood — typically by an
artificial kidney machine.

 Chronic kidney disease. Your kidneys gradually lose their filtering ability. Kidney
function that deteriorates to less than 10 percent of normal capacity results in end-
stage kidney disease, which requires dialysis or a kidney transplant to sustain life.

 High blood pressure. Damage to your kidneys and the resulting buildup of wastes in
the bloodstream can raise your blood pressure.

 Nephrotic syndrome. With this syndrome, too much protein in your urine results in
too little protein in your blood. Nephrotic syndrome can be associated with high blood
cholesterol and swelling (edema) of the eyelids, feet and abdomen.

Prevention

There may be no way to prevent most forms of glomerulonephritis. However, here are
some steps that might be beneficial:
  Seek prompt treatment of a strep infection with a sore throat or impetigo.

 To prevent infections that can lead to some forms of glomerulonephritis, such

as HIV and hepatitis, follow safe-sex guidelines and avoid intravenous drug use.

 Control high blood pressure, which lessens the likelihood of damage to your kidneys
from hypertension.

 Control your blood sugar to help prevent diabetic nephropathy.

Lifestyle and home remedies

If you have kidney disease, your doctor might recommend certain lifestyle changes:

 Restrict your salt intake to prevent or minimize fluid retention, swelling and
hypertension

 Consume less protein and potassium to slow the buildup of wastes in your blood

 Maintain a healthy weight

 Control your blood sugar level if you have diabetes

 Quit smoking

4. Polycystic kidney disease (PKD)

It is an inherited disorder in which clusters of cysts develop primarily within your kidneys,
causing your kidneys to enlarge and lose function over time. Cysts are noncancerous round
sacs containing fluid. The cysts vary in size, and they can grow very large. Having many
cysts or large cysts can damage your kidneys.

 Polycystic kidney disease also can cause cysts to develop in your liver and
elsewhere in your body. The disease can cause serious complications, including high
blood pressure and kidney failure.
  PKD varies greatly in its severity, and some complications are preventable. Lifestyle
changes and treatments might help reduce damage to your kidneys from
complications.

Symptoms

Polycystic kidney disease symptoms can include:

 High blood pressure

 Back or side pain

 Headache

 A feeling of fullness in your abdomen

 Increased size of your abdomen due to enlarged kidneys

 Blood in your urine

 Kidney stones

 Kidney failure

 Urinary tract or kidney infections

Causes

Abnormal genes cause polycystic kidney disease, which means that in most cases, the
disease runs in families. Rarely, a genetic mutation occurs on its own (spontaneous), so that
neither parent has a copy of the mutated gene.

The two main types of polycystic kidney disease, caused by different genetic flaws, are:

 Autosomal dominant polycystic kidney disease (ADPKD). Signs and symptoms of

ADPKD often develop between the ages of 30 and 40. In the past, this type was called
adult polycystic kidney disease, but children can develop the disorder.
 Only one parent needs to have the disease for it to pass to the children. If one parent
has ADPKD, each child has a 50 percent chance of getting the disease. This form
accounts for about 90 percent of cases of polycystic kidney disease.

 Autosomal recessive polycystic kidney disease (ARPKD). This type is far less

common than is ADPKD. The signs and symptoms often appear shortly after birth.
Sometimes, symptoms don't appear until later in childhood or during adolescence.

Both parents must have abnormal genes to pass on this form of the disease. If both
parents carry a gene for this disorder, each child has a 25 percent chance of getting
the disease.

Complications

Complications associated with polycystic kidney disease include:

 High blood pressure. Elevated blood pressure is a common complication of

polycystic kidney disease. Untreated, high blood pressure can cause further damage to
your kidneys and increase your risk of heart disease and stroke.

 Loss of kidney function. Progressive loss of kidney function is one of the most

serious complications of polycystic kidney disease. Nearly half of those with the
disease have kidney failure by age 60.

PKD can interfere with the ability of your kidneys to keep wastes from building to
toxic levels, a condition called uremia. As the disease worsens, end-stage kidney
(renal) failure may result, necessitating ongoing kidney dialysis or a transplant to
prolong your life.

 Pregnancy complications. Pregnancy is successful for most women with polycystic

kidney disease. In some cases, however, women may develop a life-threatening
disorder called preeclampsia. Those most at risk have high blood pressure before they
become pregnant.
  Growth of cysts in the liver. The likelihood of developing liver cysts for someone
with polycystic kidney disease increases with age. While both men and women
develop cysts, women often develop larger cysts. Female hormones might contribute
to cyst development.

 Development of an aneurysm in the brain. A balloonlike bulge in a blood vessel

(aneurysm) in your brain can cause bleeding (hemorrhage) if it ruptures. People with
polycystic kidney disease have a higher risk of aneurysm. People with a family history
of aneurysm seem to be at highest risk.

 Heart valve abnormalities. As many as 1 in 4 adults with polycystic kidney disease

develops mitral valve prolapse. When this happens, the valve no longer closes
properly, which allows blood to leak backward.

 Colon problems. Weaknesses and pouches or sacs in the wall of the colon

(diverticulosis) may develop in people with polycystic kidney disease.

 Chronic pain. Pain is a common symptom for people with polycystic kidney disease.
It often occurs in your side or back. The pain can also be associated with a urinary
tract infection, a kidney stone or a malignancy.

Prevention

If you have polycystic kidney disease and you're considering having children, a genetic
counselor can help you assess your risk of passing the disease to your offspring.

Keeping your kidneys as healthy as possible may help prevent some of the complications of
this disease. One of the most important ways you can protect your kidneys is by managing
your blood pressure.

Here are some tips for keeping your blood pressure in check:

 Take the blood pressure medications prescribed by your doctor as directed.

 Eat a low-salt diet containing plenty of fruits, vegetables and whole grains.
  Maintain a healthy weight. Ask your doctor what the right weight is for you.

 If you smoke, quit.

 Exercise regularly. Aim for at least 30 minutes of moderate physical activity most days
of the week.

 Limit alcohol use

5. A urinary tract infection (UTI)

It is an infection in any part of your urinary system — your kidneys, ureters, bladder and
urethra. Most infections involve the lower urinary tract — the bladder and the urethra.

Women are at greater risk of developing a UTI than are men. Infection limited to your
bladder can be painful and annoying. However, serious consequences can occur if a UTI
spreads to your kidneys.

Symptoms

Urinary tract infections don't always cause signs and symptoms, but when they do they
may include:

 A strong, persistent urge to urinate

 A burning sensation when urinating

 Passing frequent, small amounts of urine

 Urine that appears cloudy

 Urine that appears red, bright pink or cola-colored — a sign of blood in the urine

 Strong-smelling urine

 Pelvic pain, in women — especially in the center of the pelvis and around the area of
the pubic bone
Causes

Urinary tract infections typically occur when bacteria enter the urinary tract through the
urethra and begin to multiply in the bladder. Although the urinary system is designed to
keep out such microscopic invaders, these defenses sometimes fail. When that happens,
bacteria may take hold and grow into a full-blown infection in the urinary tract.

The most common UTIs occur mainly in women and affect the bladder and urethra.

 Infection of the bladder (cystitis). This type of UTI is usually caused by Escherichia

coli (E. coli), a type of bacteria commonly found in the gastrointestinal (GI) tract.
However, sometimes other bacteria are responsible.

Sexual intercourse may lead to cystitis, but you don't have to be sexually active to
develop it. All women are at risk of cystitis because of their anatomy — specifically,
the short distance from the urethra to the anus and the urethral opening to the
bladder.

 Infection of the urethra (urethritis). This type of UTI can occur when GI bacteria
spread from the anus to the urethra. Also, because the female urethra is close to the
vagina, sexually transmitted infections, such as herpes, gonorrhea, chlamydia and
mycoplasma, can cause urethritis.

Risk factors

Urinary tract infections are common in women, and many women experience more than
one infection during their lifetimes. Risk factors specific to women for UTIs include:

 Female anatomy. A woman has a shorter urethra than a man does, which shortens
the distance that bacteria must travel to reach the bladder.

 Sexual activity. Sexually active women tend to have more UTIs than do women who
aren't sexually active. Having a new sexual partner also increases your risk.
  Certain types of birth control. Women who use diaphragms for birth control may be
at higher risk, as well as women who use spermicidal agents.

 Menopause. After menopause, a decline in circulating estrogen causes changes in the

urinary tract that make you more vulnerable to infection.

Other risk factors for UTIs include:

 Urinary tract abnormalities. Babies born with urinary tract abnormalities that don't
allow urine to leave the body normally or cause urine to back up in the urethra have
an increased risk of UTIs.

 Blockages in the urinary tract. Kidney stones or an enlarged prostate can trap urine
in the bladder and increase the risk of UTIs.

 A suppressed immune system. Diabetes and other diseases that impair the immune
system — the body's defense against germs — can increase the risk of UTIs.

 Catheter use. People who can't urinate on their own and use a tube (catheter) to
urinate have an increased risk of UTIs. This may include people who are hospitalized,
people with neurological problems that make it difficult to control their ability to
urinate and people who are paralyzed.

 A recent urinary procedure. Urinary surgery or an exam of your urinary tract that

involves medical instruments can both increase your risk of developing a urinary tract
infection.

Complications

When treated promptly and properly, lower urinary tract infections rarely lead to
complications. But left untreated, a urinary tract infection can have serious consequences.

Complications of a UTI may include:

  Recurrent infections, especially in women who experience two or more UTIs in a six-
month period or four or more within a year.

 Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis)

due to an untreated UTI.

 Increased risk in pregnant women of delivering low birth weight or premature

infants.

 Urethral narrowing (stricture) in men from recurrent urethritis, previously seen with
gonococcal urethritis.

 Sepsis, a potentially life-threatening complication of an infection, especially if the

infection works its way up your urinary tract to your kidneys.

Prevention

You can take these steps to reduce your risk of urinary tract infections:

 Drink plenty of liquids, especially water. Drinking water helps dilute your urine
and ensures that you'll urinate more frequently — allowing bacteria to be flushed
from your urinary tract before an infection can begin.

 Drink cranberry juice. Although studies are not conclusive that cranberry juice
prevents UTIs, it is likely not harmful.

 Wipe from front to back. Doing so after urinating and after a bowel movement helps
prevent bacteria in the anal region from spreading to the vagina and urethra.

 Empty your bladder soon after intercourse. Also, drink a full glass of water to help
flush bacteria.

 Avoid potentially irritating feminine products. Using deodorant sprays or other

feminine products, such as douches and powders, in the genital area can irritate the
urethra.
  Change your birth control method. Diaphragms, or unlubricated or spermicide-
treated condoms, can all contribute to bacterial growth.

Lifestyle and home remedies

Urinary tract infections can be painful, but you can take steps to ease your discomfort until
antibiotics treat the infection. Follow these tips:

 Drink plenty of water. Water helps to dilute your urine and flush out bacteria.

 Avoid drinks that may irritate your bladder. Avoid coffee, alcohol, and soft drinks
containing citrus juices or caffeine until your infection has cleared. They can irritate
your bladder and tend to aggravate your frequent or urgent need to urinate.

 Use a heating pad. Apply a warm, but not hot, heating pad to your abdomen to
minimize bladder pressure or discomfort.

TOPIC 12: CARDIOVASCULAR DISEASE (CVD)

The cardiovascular system consists of the heart, blood vessels, and blood.

This system has three main functions:

 Transport of nutrients, oxygen, and hormones to cells throughout the body and
removal of metabolic wastes (carbon dioxide, nitrogenous wastes).
 Protection of the body by white blood cells, antibodies, and complement proteins
that circulate in the blood and defend the body against foreign microbes and toxins.
Clotting mechanisms are also present that protect the body from blood loss after
injuries.
 Regulation of body temperature, fluid pH, and water content of cells.
 CVD includes coronary artery diseases (CAD) such as angina and myocardial
infarction (commonly known as a heart attack).

Other CVDs include stroke, heart failure, hypertensive heart disease, rheumatic heart

disease, cardiomyopathy, abnormal heart rhythms, congenital heart disease, valvular heart
disease, carditis, aortic aneurysms, peripheral artery disease, thromboembolic disease,
and venous thrombosis

Types of cardiovascular diseases

1. Arteriosclerosis

It occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest
of body (arteries) become thick and stiff — sometimes restricting blood flow to organs and
tissues. Healthy arteries are flexible and elastic, but over time, the walls in your arteries can
harden, a condition commonly called hardening of the arteries.

Atherosclerosis is a specific type of arteriosclerosis, but the terms are sometimes used
interchangeably. Atherosclerosis refers to the buildup of fats, cholesterol and other
substances in and on artery walls (plaque), which can restrict blood flow.

The plaque can burst, triggering a blood clot. Although atherosclerosis is often considered a
heart problem, it can affect arteries anywhere in your body. Atherosclerosis may be
preventable and is treatable.

Symptoms

Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't have any

symptoms.

You usually won't have atherosclerosis symptoms until an artery is so narrowed or clogged
that it can't supply adequate blood to your organs and tissues. Sometimes a blood clot
completely blocks blood flow, or even breaks apart and can trigger a heart attack or stroke.
Symptoms of moderate to severe atherosclerosis depend on which arteries are affected.
For example:

 If you have atherosclerosis in your heart arteries, you may have symptoms, such
as chest pain or pressure (angina).

 If you have atherosclerosis in the arteries leading to your brain, you may have
signs and symptoms such as sudden numbness or weakness in your arms or legs,
difficulty speaking or slurred speech, temporary loss of vision in one eye, or drooping
muscles in your face. These signal a transient ischemic attack (TIA), which, if left
untreated, may progress to a stroke.

 If you have atherosclerosis in the arteries in your arms and legs, you may have
symptoms of peripheral artery disease, such as leg pain when walking (claudication).

 If you have atherosclerosis in the arteries leading to your kidneys, you develop

high blood pressure or kidney failure.

Causes

Atherosclerosis is a slow, progressive disease that may begin as early as childhood.

Although the exact cause is unknown, atherosclerosis may start with damage or injury to
the inner layer of an artery. The damage may be caused by:

 High blood pressure

 High cholesterol

 High triglycerides, a type of fat (lipid) in your blood

 Smoking and other sources of tobacco

 Insulin resistance, obesity or diabetes

 Inflammation from diseases, such as arthritis, lupus or infections, or inflammation of

unknown cause
Once the inner wall of an artery is damaged, blood cells and other substances often clump
at the injury site and build up in the inner lining of the artery.

Over time, fatty deposits (plaque) made of cholesterol and other cellular products also
build up at the injury site and harden, narrowing your arteries. The organs and tissues
connected to the blocked arteries then don't receive enough blood to function properly.

Eventually, pieces of the fatty deposits may break off and enter your bloodstream.

In addition, the smooth lining of the plaque may rupture, spilling cholesterol and other
substances into your bloodstream. This may because a blood clot, which can block the
blood flow to a specific part of your body, such as occurs when blocked blood flow to your
heart causes a heart attack. A blood clot can also travel to other parts of your body,
blocking flow to another organ.

Risk factors

Hardening of the arteries occurs over time. Besides aging, factors that increase the risk of
atherosclerosis include:

 High blood pressure

 High cholesterol

 Diabetes

 Obesity

 Smoking and other tobacco use

 A family history of early heart disease

 Lack of exercise

 An unhealthy diet
Complications

The complications of atherosclerosis depend on which arteries are blocked. For example:

 Coronary artery disease. When atherosclerosis narrows the arteries close to your

heart, you may develop coronary artery disease, which can cause chest pain (angina),
a heart attack or heart failure.

 Carotid artery disease. When atherosclerosis narrows the arteries close to your

brain, you may develop carotid artery disease, which can cause a transient ischemic
attack (TIA) or stroke.

 Peripheral artery disease. When atherosclerosis narrows the arteries in your arms

or legs, you may develop circulation problems in your arms and legs called peripheral
artery disease. This can make you less sensitive to heat and cold, increasing your risk
of burns or frostbite. In rare cases, poor circulation in your arms or legs can cause
tissue death (gangrene).

 Aneurysms. Atherosclerosis can also cause aneurysms, a serious complication that

can occur anywhere in your body. An aneurysm is a bulge in the wall of your artery.

Most people with aneurysms have no symptoms. Pain and throbbing in the area of an
aneurysm may occur and is a medical emergency.

If an aneurysm bursts, you may face life-threatening internal bleeding. Although this
is usually a sudden, catastrophic event, a slow leak is possible. If a blood clot within an
aneurysm dislodges, it may block an artery at some distant point.

 Chronic kidney disease. Atherosclerosis can cause the arteries leading to your

kidneys to narrow, preventing oxygenated blood from reaching them. Over time, this
can affect your kidney function, keeping waste from exiting your body.

Prevention
The same healthy lifestyle changes recommended to treat atherosclerosis also help prevent
it. These include:

 Quitting smoking

 Eating healthy foods

 Exercising regularly

 Maintaining a healthy weight

Just remember to make changes one step at a time, and keep in mind what lifestyle changes
are manageable for you in the long run.

Lifestyle and home remedies

Lifestyle changes can help you prevent or slow the progression of atherosclerosis.

 Stop smoking. Smoking damages your arteries. If you smoke or use tobacco in any
form, quitting is the best way to halt the progression of atherosclerosis and reduce
your risk of complications.

 Exercise most days of the week. Regular exercise can condition your muscles to use
oxygen more efficiently.

Physical activity can also improve circulation and promote development of new blood
vessels that form a natural bypass around obstructions (collateral vessels). Exercise
helps lower blood pressure and reduces your risk of diabetes.

Aim to exercise at least 30 minutes most days of the week. If you can't fit it all into one
session, try breaking it up into 10-minute intervals.

You can take the stairs instead of the elevator, walk around the block during your
lunch hour, or do some situps or pushups while watching television.
  Eat healthy foods. A heart-healthy diet based on fruits, vegetables and whole grains
— and low in refined carbohydrates, sugars, saturated fat and sodium — can help you
control your weight, blood pressure, cholesterol and blood sugar.

Try substituting whole-grain bread in place of white bread; grabbing an apple, a

banana or carrot sticks as a snack; and reading nutrition labels as a guide to
controlling the amount of salt and fat you eat. Use monounsaturated fats, such as olive
oil, and reduce or eliminate sugar and sugar substitutes.

 Lose extra pounds and maintain a healthy weight. If you're overweight, losing as
few as 5 to 10 pounds (about 2.3 to 4.5 kilograms) can help reduce your risk of high
blood pressure and high cholesterol, two of the major risk factors for developing
atherosclerosis.

Losing weight helps reduce your risk of diabetes or control your condition if you
already have diabetes.

 Manage stress. Reduce stress as much as possible. Practice healthy techniques for

managing stress, such as muscle relaxation and deep breathing.

2. Heart attack/ myocardial infarction

It occurs when the flow of blood to the heart is blocked. The blockage is most often a
buildup of fat, cholesterol and other substances, which form a plaque in the arteries that
feed the heart (coronary arteries).

 The plaque eventually breaks away and forms a clot. The interrupted blood flow can
damage or destroy part of the heart muscle.
 A heart attack, also called a myocardial infarction, can be fatal, but treatment has
improved dramatically over the years.
Symptoms

Common heart attack signs and symptoms include:

 Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms

that may spread to your neck, jaw or back

 Nausea, indigestion, heartburn or abdominal pain

 Shortness of breath

 Cold sweat

 Fatigue

 Lightheadedness or sudden dizziness

Causes

A heart attack occurs when one or more of your coronary arteries become blocked. Over
time, a coronary artery can narrow from the buildup of various substances, including
cholesterol (atherosclerosis). This condition, known as coronary artery disease, causes
most heart attacks.

During a heart attack, one of these plaques can rupture and spill cholesterol and other
substances into the bloodstream. A blood clot forms at the site of the rupture. If large
enough, the clot can block the flow of blood through the coronary artery, starving the heart
muscle of oxygen and nutrients (ischemia).

You might have a complete blockage or partial. A complete blockage means you've had an
ST elevation myocardial infarction (STEMI). A partial blockage means you've had a non-ST
elevation myocardial infarction (NSTEMI). Diagnostic steps and treatment might be
different depending on which you've had.
Another cause of a heart attack is a spasm of a coronary artery that shuts down blood flow
to part of the heart muscle. Using tobacco and illicit drugs, such as cocaine, can cause a life-
threatening spasm.

Risk factors

Certain factors contribute to the unwanted buildup of fatty deposits (atherosclerosis) that
narrows arteries throughout your body. You can improve or eliminate many of these risk
factors to reduce your chances of having a first or another heart attack.

Heart attack risk factors include:

 Age. Men age 45 or older and women age 55 or older are more likely to have a heart
attack than are younger men and women.

 Tobacco. This includes smoking and long-term exposure to secondhand smoke.

 High blood pressure. Over time, high blood pressure can damage arteries that feed
your heart. High blood pressure that occurs with other conditions, such as obesity,
high cholesterol or diabetes, increases your risk even more.

 High blood cholesterol or triglyceride levels. A high level of low-density

lipoprotein (LDL) cholesterol (the "bad" cholesterol) is most likely to narrow arteries.
A high level of triglycerides, a type of blood fat related to your diet, also ups your risk
of heart attack. However, a high level of high-density lipoprotein (HDL) cholesterol
(the "good" cholesterol) lowers your risk of heart attack.

 Obesity. Obesity is associated with high blood cholesterol levels, high triglyceride

levels, high blood pressure and diabetes. Losing just 10 percent of your body weight
can lower this risk, however.

 Diabetes. Not producing enough of a hormone secreted by your pancreas (insulin) or

not responding to insulin properly causes your body's blood sugar levels to rise,
increasing your risk of heart attack.
  Metabolic syndrome. This occurs when you have obesity, high blood pressure and
high blood sugar. Having metabolic syndrome makes you twice as likely to develop
heart disease than if you don't have it.

 Family history of heart attack. If your siblings, parents or grandparents have had
early heart attacks (by age 55 for male relatives and by age 65 for female relatives),
you might be at increased risk.

 Lack of physical activity. Being inactive contributes to high blood cholesterol levels

and obesity. People who exercise regularly have better cardiovascular fitness,
including lower high blood pressure.

 Stress. You might respond to stress in ways that can increase your risk of a heart
attack.

 Illicit drug use. Using stimulant drugs, such as cocaine or amphetamines, can trigger
a spasm of your coronary arteries that can cause a heart attack.

 A history of preeclampsia. This condition causes high blood pressure during

pregnancy and increases the lifetime risk of heart disease.

 An autoimmune condition. Having a condition such as rheumatoid arthritis or lupus

can increase your risk of heart attack.

Complications

Complications are often related to the damage done to your heart during an attack, which
can lead to:

 Abnormal heart rhythms (arrhythmias). Electrical "short circuits" can develop,

resulting in abnormal heart rhythms, some of which can be serious, even fatal.

 Heart failure. An attack might damage so much heart tissue that the remaining heart
muscle can't pump enough blood out of your heart. Heart failure can be temporary, or
 it can be a chronic condition resulting from extensive and permanent damage to your
heart.

 Sudden cardiac arrest. Without warning, your heart stops due to an electrical

disturbance that causes an arrhythmia. Heart attacks increase the risk of sudden
cardiac arrest, which can be fatal without immediate treatment.

Prevention

It's never too late to take steps to prevent a heart attack — even if you've already had one.
Here are ways to prevent a heart attack.

 Medications. Taking medications can reduce your risk of a subsequent heart attack

and help your damaged heart function better. Continue to take what your doctor
prescribes, and ask your doctor how often you need to be monitored.

 Lifestyle factors. You know the drill: Maintain a healthy weight with a heart-healthy
diet, don't smoke, exercise regularly, manage stress and control conditions that can
lead to heart attack, such as high blood pressure, high cholesterol and diabetes.

Lifestyle and home remedies

To improve your heart health, take the following steps:

 Avoid smoke. The most important thing you can do to improve your heart's health is
to not smoke. Also, avoid being around secondhand smoke. If you need to quit, ask
your doctor for help.

 Control your blood pressure and cholesterol levels. If one or both of these is high,
your doctor can prescribe changes to your diet and medications. Ask your doctor how
often you need to have your blood pressure and cholesterol levels monitored.
  Get regular medical checkups.. Some of the major risk factors for heart attack —
high blood cholesterol, high blood pressure and diabetes — cause no symptoms early
on. Your doctor can test for these conditions and can help you manage them, if
necessary.

 Exercise. Regular exercise helps improve heart muscle function after a heart attack
and helps prevent a heart attack. Walking 30 minutes a day, five days a week can
improve your health.

 Maintain a healthy weight. Excess weight strains your heart and can contribute to
high cholesterol, high blood pressure and diabetes.

 Eat a heart-healthy diet. Saturated fat, trans fats and cholesterol in your diet can
narrow arteries to your heart, and too much salt can raise blood pressure. Eat a heart-
healthy diet that includes lean proteins, such as fish and beans, and fruits and
vegetables and whole grains.

 Manage diabetes. Regular exercise, eating well and losing weight all help to keep
blood sugar levels at more-desirable levels. Many people also need medication to
manage their diabetes.

 Control stress. Reduce stress in your day-to-day activities. Rethink workaholic habits

and find healthy ways to minimize or deal with stressful events in your life.

 If you drink alcohol, do so in moderation. That means up to one drink a day for

women and men older than age 65, and up to two drinks a day for men age 65 and
younger.

4. Congenital heart disease (congenital heart defect)

It is one or more abnormalities in your heart's structure that you're born with. This most
common of birth defects can alter the way blood flows through your heart. Defects range
from simple, which might cause no problems, to complex, which can cause life-threatening
complications
Symptoms

Some congenital heart defects cause no signs or symptoms. For some people, signs or
symptoms occur later in life. They can recur years after you've had treatment for a heart
defect.

Common congenital heart disease symptoms you might have as an adult include:

 Abnormal heart rhythms (arrhythmias)

 A bluish tint to the skin, lips and fingernails (cyanosis)

 Shortness of breath

 Tiring quickly upon exertion

 Swelling of body tissue or organs (edema)

Causes

Researchers aren't sure what causes most congenital heart disease, which develops in the
womb. Heredity might play a role in some congenital heart disease.

How the heart works

The heart is divided into two chambers on the right and two on the left. To pump blood
through the body, the heart uses its left and right sides differently.

The right side of the heart moves blood to the lungs through certain blood vessels
(pulmonary arteries). In the lungs, blood picks up oxygen and then returns to the left side
through the pulmonary veins. The left side of the heart then pumps the blood through the
aorta and out to the rest of the body.

Congenital heart disease can affect any of the heart's structures, including valves,
chambers, the wall of tissue that separates the chambers (septum) and arteries.
Why congenital heart disease resurfaces in adulthood

For some adults, problems with their heart defects arise later in life, even if treated in
childhood. Repairing defects improves heart function, but might not make the heart
completely normal.

Even if the treatment you received in childhood was successful, a problem can occur or
worsen as you age. It's also possible that problems in your heart, which weren't serious
enough to repair when you were a child, have worsened and now require treatment.

Then there are complications of childhood surgeries to correct congenital heart disease
that can occur later, such as scar tissue in your heart that contributes to an abnormal heart
rhythm (arrhythmia).

Risk factors

Certain environmental and genetic risk factors might play a role in the development of your
heart defect, including:

 German measles (rubella). Your mother having had rubella while pregnant could
have affected your heart development.

 Diabetes. Your mother having type 1 or type 2 diabetes might have interfered with
the development of your heart. Gestational diabetes generally doesn't increase the
risk of developing a heart defect.

 Medications. Taking certain medications while pregnant can cause congenital heart

and other birth defects. They include isotretinoin (Amnesteem, Claravis, others), used
to treat acne; and lithium, used to treat bipolar disorder. Drinking alcohol while
pregnant also contributes to the risk of heart defects.

 Heredity. Congenital heart disease appears to run in families and is associated with

many genetic syndromes. For instance, children with Down syndrome often have
 heart defects. Genetic testing can detect Down syndrome and other disorders during a
baby's development.

 Smoking. A mother who smokes while pregnant increases her risk of having a child
with a congenital heart defect.

Complications

Congenital heart disease complications that might develop years after the initial treatment
include:

 Abnormal heart rhythms (arrhythmias). Arrhythmias occur when the electrical

impulses that coordinate heartbeats don't function properly, causing your heart to
beat too fast, too slowly or irregularly. In some people, severe arrhythmias can cause
sudden cardiac death if not treated.

 Heart infection (endocarditis). Your heart comprises four chambers and four

valves, which are lined by a thin membrane called the endocardium. Endocarditis is
an infection of this inner lining, which generally occurs when bacteria or other germs
enter your bloodstream and lodge in your heart. Untreated, endocarditis can damage
or destroy your heart valves or trigger a stroke.

If you have an artificial (prosthetic) heart valve or your heart was repaired with
prosthetic material, or if your heart defect wasn't completely repaired, your doctor
might prescribe ongoing antibiotics to lower your risk of developing endocarditis.

 Stroke. Stroke occurs when the blood supply to a part of your brain is interrupted or
severely reduced, depriving brain tissue of oxygen. A congenital heart defect can allow
a blood clot to pass through your heart and travel to your brain.

Certain heart arrhythmias also can increase your chance of blood clot formation
leading to a stroke.

 Heart failure. Heart failure, also known as congestive heart failure, means your heart
can't pump enough blood to meet your body's needs. Some types of congenital heart
 disease can lead to heart failure.

Over time, certain conditions such as coronary artery disease or high blood pressure
gradually sap your heart of its strength, leaving it too weak or too stiff to fill and pump
efficiently.

 Pulmonary hypertension. This is a type of high blood pressure that affects the

arteries in your lungs. Some congenital heart defects cause more blood to flow to the
lungs, causing pressure to build and making your heart work harder. This eventually
causes your heart muscle to weaken and sometimes to fail.

 Heart valve problems. In some types of congenital heart disease, the heart valves are
abnormal.

5. High blood pressure

It is a common condition in which the long-term force of the blood against your artery
walls is high enough that it may eventually cause health problems, such as heart disease.

Blood pressure is determined both by the amount of blood your heart pumps and the
amount of resistance to blood flow in your arteries. The more blood your heart pumps and
the narrower your arteries, the higher your blood pressure.

You can have high blood pressure (hypertension) for years without any symptoms. Even
without symptoms, damage to blood vessels and your heart continues and can be detected.
Uncontrolled high blood pressure increases your risk of serious health problems, including
heart attack and stroke.

High blood pressure generally develops over many years, and it affects nearly everyone
eventually. Fortunately, high blood pressure can be easily detected. And once you know
you have high blood pressure, you can work with your doctor to control it.
Causes

There are two types of high blood pressure.

Primary (essential) hypertension

For most adults, there's no identifiable cause of high blood pressure. This type of high
blood pressure, called primary (essential) hypertension, tends to develop gradually over
many years.

Secondary hypertension

Some people have high blood pressure caused by an underlying condition. This type of high
blood pressure, called secondary hypertension, tends to appear suddenly and cause higher
blood pressure than does primary hypertension. Various conditions and medications can
lead to secondary hypertension, including:

 Obstructive sleep apnea

 Kidney problems

 Adrenal gland tumors

 Thyroid problems

 Certain defects you're born with (congenital) in blood vessels

 Certain medications, such as birth control pills, cold remedies, decongestants, over-
the-counter pain relievers and some prescription drugs

 Illegal drugs, such as cocaine and amphetamines

Risk factors

High blood pressure has many risk factors, including:

 Age. The risk of high blood pressure increases as you age. Until about age 64, high
blood pressure is more common in men. Women are more likely to develop high
blood pressure after age 65.

 Race. High blood pressure is particularly common among people of African heritage,

often developing at an earlier age than it does in whites. Serious complications, such
as stroke, heart attack and kidney failure, also are more common in people of African
heritage.

 Family history. High blood pressure tends to run in families.

 Being overweight or obese. The more you weigh the more blood you need to supply
oxygen and nutrients to your tissues. As the volume of blood circulated through your
blood vessels increases, so does the pressure on your artery walls.

 Not being physically active. People who are inactive tend to have higher heart rates.
The higher your heart rate, the harder your heart must work with each contraction
and the stronger the force on your arteries. Lack of physical activity also increases the
risk of being overweight.

 Using tobacco. Not only does smoking or chewing tobacco immediately raise your
blood pressure temporarily, but the chemicals in tobacco can damage the lining of
your artery walls. This can cause your arteries to narrow and increase your risk of
heart disease. Secondhand smoke also can increase your heart disease risk.

 Too much salt (sodium) in your diet. Too much sodium in your diet can cause your
body to retain fluid, which increases blood pressure.

 Too little potassium in your diet. Potassium helps balance the amount of sodium in
your cells. If you don't get enough potassium in your diet or retain enough potassium,
you may accumulate too much sodium in your blood.

 Drinking too much alcohol. Over time, heavy drinking can damage your heart.
Having more than one drink a day for women and more than two drinks a day for men
may affect your blood pressure.
 If you drink alcohol, do so in moderation. For healthy adults, that means up to one
drink a day for women and two drinks a day for men. One drink equals 12 ounces of
beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.

 Stress. High levels of stress can lead to a temporary increase in blood pressure. If you
try to relax by eating more, using tobacco or drinking alcohol, you may only increase
problems with high blood pressure.

 Certain chronic conditions. Certain chronic conditions also may increase your risk
of high blood pressure, such as kidney disease, diabetes and sleep apnea.

Symptoms of High Blood Pressure

 Severe headache.

 Fatigue or confusion.

 Vision problems.

 Chest pain.

 Difficulty breathing.

 Irregular heartbeat.

 Blood in the urine.

 Pounding in your chest, neck, or ears.

Complications

The excessive pressure on your artery walls caused by high blood pressure can damage
your blood vessels, as well as organs in your body. The higher your blood pressure and the
longer it goes uncontrolled, the greater the damage.

Uncontrolled high blood pressure can lead to complications including:

 Heart attack or stroke. High blood pressure can cause hardening and thickening of
the arteries (atherosclerosis), which can lead to a heart attack, stroke or other
complications.
  Aneurysm. Increased blood pressure can cause your blood vessels to weaken and
bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.

 Heart failure. To pump blood against the higher pressure in your vessels, the heart
has to work harder. This causes the walls of the heart's pumping chamber to thicken
(left ventricular hypertrophy). Eventually, the thickened muscle may have a hard time
pumping enough blood to meet your body's needs, which can lead to heart failure.

 Weakened and narrowed blood vessels in your kidneys. This can prevent these
organs from functioning normally.

 Thickened, narrowed or torn blood vessels in the eyes. This can result in vision
loss.

 Metabolic syndrome. This syndrome is a cluster of disorders of your body's

metabolism, including increased waist circumference; high triglycerides; low high-
density lipoprotein (HDL) cholesterol, the "good" cholesterol; high blood pressure and
high insulin levels. These conditions make you more likely to develop diabetes, heart
disease and stroke.

 Trouble with memory or understanding. Uncontrolled high blood pressure may

also affect your ability to think, remember and learn. Trouble with memory or
understanding concepts is more common in people with high blood pressure.

 Dementia. Narrowed or blocked arteries can limit blood flow to the brain, leading to
a certain type of dementia (vascular dementia). A stroke that interrupts blood flow to
the brain also can cause vascular dementia.

Lifestyle and home remedies

Lifestyle changes can help you control and prevent high blood pressure, even if you're
taking blood pressure medication. Here's what you can do:

 Eat healthy foods. Eat a heart-healthy diet. Try the Dietary Approaches to Stop
Hypertension (DASH) diet, which emphasizes fruits, vegetables, whole grains, poultry,
 fish and low-fat dairy foods. Get plenty of potassium, which can help prevent and
control high blood pressure. Eat less saturated fat and trans fat.

 Decrease the salt in your diet. Aim to limit sodium to less than 2,300 milligrams
(mg) a day or less. However, a lower sodium intake — 1,500 mg a day or less — is
ideal for most adults.

While you can reduce the amount of salt you eat by putting down the saltshaker, you
generally should also pay attention to the amount of salt that's in the processed foods
you eat, such as canned soups or frozen dinners.

 Maintain a healthy weight. Keeping a healthy weight, or losing weight if you're

overweight or obese, can help you control your high blood pressure and lower your
risk of related health problems. In general, you may reduce your blood pressure by
about 1 mm Hg with each kilogram (about 2.2 pounds) of weight you lose.

 Increase physical activity. Regular physical activity can help lower your blood
pressure, manage stress, reduce your risk of several health problems and keep your
weight under control.

Aim for at least 150 minutes a week of moderate aerobic activity or 75 minutes a
week of vigorous aerobic activity, or a combination of moderate and vigorous activity.
For example, try brisk walking for about 30 minutes most days of the week. Or try
interval training, in which you alternate short bursts of intense activity with short
recovery periods of lighter activity. Aim to do muscle-strengthening exercises at least
two days a week.

 Limit alcohol. Even if you're healthy, alcohol can raise your blood pressure. If you
choose to drink alcohol, do so in moderation. For healthy adults, that means up to one
drink a day for women, and up to two drinks a day for men. One drink equals 12
ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.

 Don't smoke. Tobacco can injure blood vessel walls and speed up the process of
buildup of plaque in the arteries. If you smoke, ask your doctor to help you quit.
  Manage stress. Reduce stress as much as possible. Practice healthy coping
techniques, such as muscle relaxation, deep breathing or meditation. Getting regular
physical activity and plenty of sleep can help, too.

 Monitor your blood pressure at home. Home blood pressure monitoring can help
you keep closer tabs on your blood pressure, show if medication is working, and even
alert you and your doctor to potential complications. Home blood pressure
monitoring isn't a substitute for visits to your doctor, and home blood pressure
monitors may have some limitations. Even if you get normal readings, don't stop or
change your medications or alter your diet without talking to your doctor first.

If your blood pressure is under control, check with your doctor about how often you
need to check it.

 Practice relaxation or slow, deep breathing. Practice taking deep, slow breaths to

help relax. There are some devices available that promote slow, deep breathing.
According to the American Heart Association, device-guided breathing may be a
reasonable nondrug option for lowering blood pressure, especially when anxiety
accompanies high blood pressure or standard treatments aren't well-tolerated.

 Control blood pressure during pregnancy. If you're a woman with high blood
pressure, discuss with your doctor how to control your blood pressure during
pregnancy.

TOPIC 13: DIABETES MELLITUS

Diabetes is a disease that affects the body’s ability to produce or use insulin. Insulin is a
hormone. When your body turns the food you eat into energy (also called sugar or glucose),
insulin is released to help transport this energy to the cells. Insulin acts as a “key.” Its
chemical message tells the cell to open and receive glucose. If you produce little or no
insulin, or are insulin resistant, too much sugar remains in your blood. Blood glucose levels
are higher than normal for individuals with diabetes.

There are three main types of diabetes:

 Type 1 diabetes
 Type 2 diabetes
 gestational diabetes

Type 1 diabetes/ juvenile diabetes

When you are affected with Type 1 diabetes, your pancreas does not produce insulin. Type
1 diabetes once called juvenile diabetes, is often diagnosed in children or teens. However, it
can also occur in adults. This type accounts for 5-10 percent of people with diabetes.

Type 2 diabetes

Type 2 diabetes occurs when the body does not produce enough insulin, or when the cells
are unable to use insulin properly, which is called insulin resistance. Type 2 diabetes is
commonly called “adult-onset diabetes” since it is diagnosed later in life, generally after the
age of 45. It accounts for 90-95 percent of people with diabetes. In recent years, Type 2
diabetes has been diagnosed in younger people, including children, more frequently than in
the past.

Symptoms

Diabetes symptoms vary depending on how much your blood sugar is elevated. Some
people, especially those with prediabetes or type 2 diabetes, may not experience symptoms
initially. In type 1 diabetes, symptoms tend to come on quickly and be more severe.

Some of the signs and symptoms of type 1 and type 2 diabetes are:
  Increased thirst

 Frequent urination

 Extreme hunger

 Unexplained weight loss

 Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle
and fat that happens when there's not enough available insulin)

 Fatigue

 Irritability

 Blurred vision

 Slow-healing sores

 Frequent infections, such as gums or skin infections and vaginal infections

Type 1 diabetes can develop at any age, though it often appears during childhood or
adolescence. Type 2 diabetes, the more common type, can develop at any age, though it's
more common in people older than 40.

Causes

To understand diabetes, first you must understand how glucose is normally processed in
the body.

How insulin works

Insulin is a hormone that comes from a gland situated behind and below the stomach
(pancreas).

 The pancreas secretes insulin into the bloodstream.

 The insulin circulates, enabling sugar to enter your cells.

  Insulin lowers the amount of sugar in your bloodstream.

 As your blood sugar level drops, so does the secretion of insulin from your pancreas.

The role of glucose

Glucose — a sugar — is a source of energy for the cells that make up muscles and other
tissues.

 Glucose comes from two major sources: food and your liver.

 Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.

 Your liver stores and makes glucose.

 When your glucose levels are low, such as when you haven't eaten in a while, the liver
breaks down stored glycogen into glucose to keep your glucose level within a normal
range.

Causes of type 1 diabetes

The exact cause of type 1 diabetes is unknown. What is known is that your immune system
— which normally fights harmful bacteria or viruses — attacks and destroys your insulin-
producing cells in the pancreas. This leaves you with little or no insulin. Instead of being
transported into your cells, sugar builds up in your bloodstream.

Type 1 is thought to be caused by a combination of genetic susceptibility and

environmental factors, though exactly what those factors are is still unclear. Weight is not
believed to be a factor in type 1 diabetes.

Causes of pre-diabetes and type 2 diabetes

In pre-diabetes — which can lead to type 2 diabetes — and in type 2 diabetes, your cells
become resistant to the action of insulin, and your pancreas is unable to make enough
insulin to overcome this resistance. Instead of moving into your cells where it's needed for
energy, sugar builds up in your bloodstream.

Exactly why this happens is uncertain, although it's believed that genetic and
environmental factors play a role in the development of type 2 diabetes too. Being
overweight is strongly linked to the development of type 2 diabetes, but not everyone with
type 2 is overweight.

Causes of gestational diabetes

During pregnancy, the placenta produces hormones to sustain your pregnancy. These
hormones make your cells more resistant to insulin.

Normally, your pancreas responds by producing enough extra insulin to overcome this
resistance. But sometimes your pancreas can't keep up. When this happens, too little
glucose gets into your cells and too much stays in your blood, resulting in gestational
diabetes.

Risk factors

Risk factors for diabetes depend on the type of diabetes.

Risk factors for type 1 diabetes

Although the exact cause of type 1 diabetes is unknown, factors that may signal an
increased risk include:

 Family history. Your risk increases if a parent or sibling has type 1 diabetes.

 Environmental factors. Circumstances such as exposure to a viral illness likely play

some role in type 1 diabetes.
  The presence of damaging immune system cells (autoantibodies). Sometimes
family members of people with type 1 diabetes are tested for the presence of diabetes
autoantibodies. If you have these autoantibodies, you have an increased risk of
developing type 1 diabetes. But not everyone who has these autoantibodies develops
diabetes.

 Geography. Certain countries, such as Finland and Sweden, have higher rates of type
1 diabetes.

Risk factors for pre-diabetes and type 2 diabetes

Researchers don't fully understand why some people develop prediabetes and type 2
diabetes and others don't. It's clear that certain factors increase the risk, however,
including:

 Weight. The more fatty tissue you have, the more resistant your cells become to
insulin.

 Inactivity. The less active you are, the greater your risk. Physical activity helps you
control your weight, uses up glucose as energy and makes your cells more sensitive to
insulin.

 Family history. Your risk increases if a parent or sibling has type 2 diabetes.

 Race. Although it's unclear why, people of certain races — including black people,
Hispanics, American Indians and Asian-Americans — are at higher risk.

 Age. Your risk increases as you get older. This may be because you tend to exercise
less, lose muscle mass and gain weight as you age. But type 2 diabetes is also
increasing among children, adolescents and younger adults.

 Gestational diabetes. If you developed gestational diabetes when you were

pregnant, your risk of developing prediabetes and type 2 diabetes later increases. If
you gave birth to a baby weighing more than 9 pounds (4 kilograms), you're also at
risk of type 2 diabetes.
  Polycystic ovary syndrome. For women, having polycystic ovary syndrome — a
common condition characterized by irregular menstrual periods, excess hair growth
and obesity — increases the risk of diabetes.

 High blood pressure. Having blood pressure over 140/90 millimeters of mercury

(mm Hg) is linked to an increased risk of type 2 diabetes.

 Abnormal cholesterol and triglyceride levels. If you have low levels of high-density
lipoprotein (HDL), or "good," cholesterol, your risk of type 2 diabetes is higher.
Triglycerides are another type of fat carried in the blood. People with high levels of
triglycerides have an increased risk of type 2 diabetes. Your doctor can let you know
what your cholesterol and triglyceride levels are.

Risk factors for gestational diabetes

Any pregnant woman can develop gestational diabetes, but some women are at greater risk
than are others. Risk factors for gestational diabetes include:

 Age. Women older than age 25 are at increased risk.

 Family or personal history. Your risk increases if you have prediabetes — a

precursor to type 2 diabetes — or if a close family member, such as a parent or
sibling, has type 2 diabetes. You're also at greater risk if you had gestational diabetes
during a previous pregnancy, if you delivered a very large baby or if you had an
unexplained stillbirth.

 Weight. Being overweight before pregnancy increases your risk.

 Race. For reasons that aren't clear, women who are black, Hispanic, American Indian
or Asian are more likely to develop gestational diabetes.

Complications

Long-term complications of diabetes develop gradually. The longer you have diabetes —
and the less controlled your blood sugar — the higher the risk of complications. Eventually,
diabetes complications may be disabling or even life-threatening. Possible complications
include:

 Cardiovascular disease. Diabetes dramatically increases the risk of various

cardiovascular problems, including coronary artery disease with chest pain (angina),
heart attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes,
you're more likely to have heart disease or stroke.

 Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood
vessels (capillaries) that nourish your nerves, especially in your legs. This can cause
tingling, numbness, burning or pain that usually begins at the tips of the toes or
fingers and gradually spreads upward.

Left untreated, you could lose all sense of feeling in the affected limbs. Damage to the
nerves related to digestion can cause problems with nausea, vomiting, diarrhea or
constipation. For men, it may lead to erectile dysfunction.

 Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel

clusters (glomeruli) that filter waste from your blood. Diabetes can damage this
delicate filtering system. Severe damage can lead to kidney failure or irreversible end-
stage kidney disease, which may require dialysis or a kidney transplant.

 Eye damage (retinopathy). Diabetes can damage the blood vessels of the retina
(diabetic retinopathy), potentially leading to blindness. Diabetes also increases the
risk of other serious vision conditions, such as cataracts and glaucoma.

 Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the
risk of various foot complications. Left untreated, cuts and blisters can develop
serious infections, which often heal poorly. These infections may ultimately require
toe, foot or leg amputation.

 Skin conditions. Diabetes may leave you more susceptible to skin problems,

including bacterial and fungal infections.

 Hearing impairment. Hearing problems are more common in people with diabetes.

  Alzheimer's disease. Type 2 diabetes may increase the risk of dementia, such as
Alzheimer's disease. The poorer your blood sugar control, the greater the risk appears
to be. Although there are theories as to how these disorders might be connected, none
has yet been proved.

 Depression. Depression symptoms are common in people with type 1 and type 2

diabetes. Depression can affect diabetes management.

Complications of gestational diabetes

Most women who have gestational diabetes deliver healthy babies. However, untreated or
uncontrolled blood sugar levels can cause problems for you and your baby.

Complications in your baby can occur as a result of gestational diabetes, including:

 Excess growth. Extra glucose can cross the placenta, which triggers your baby's
pancreas to make extra insulin. This can cause your baby to grow too large
(macrosomia). Very large babies are more likely to require a C-section birth.

 Low blood sugar. Sometimes babies of mothers with gestational diabetes develop

low blood sugar (hypoglycemia) shortly after birth because their own insulin
production is high. Prompt feedings and sometimes an intravenous glucose solution
can return the baby's blood sugar level to normal.

 Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a
higher risk of developing obesity and type 2 diabetes later in life.

 Death. Untreated gestational diabetes can result in a baby's death either before or

shortly after birth.

Complications in the mother also can occur as a result of gestational diabetes, including:

 Preeclampsia. This condition is characterized by high blood pressure, excess protein

in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even
life-threatening complications for both mother and baby.
  Subsequent gestational diabetes. Once you've had gestational diabetes in one
pregnancy, you're more likely to have it again with the next pregnancy. You're also
more likely to develop diabetes — typically type 2 diabetes — as you get older.

Complications of pre-diabetes

Pre-diabetes may develop into type 2 diabetes.

Prevention

Type 1 diabetes can't be prevented. However, the same healthy lifestyle choices that help
treat pre-diabetes, type 2 diabetes and gestational diabetes can also help prevent them:

 Eat healthy foods. Choose foods lower in fat and calories and higher in fiber. Focus
on fruits, vegetables and whole grains. Strive for variety to prevent boredom.

 Get more physical activity. Aim for 30 minutes of moderate physical activity a day.
Take a brisk daily walk. Ride your bike. Swim laps. If you can't fit in a long workout,
break it up into smaller sessions spread throughout the day.

 Lose excess pounds. If you're overweight, losing even 7 percent of your body weight
— for example, 14 pounds (6.4 kilograms) if you weigh 200 pounds (90.7 kilograms)
— can reduce the risk of diabetes.

Don't try to lose weight during pregnancy, however. Talk to your doctor about how
much weight is healthy for you to gain during pregnancy.

To keep your weight in a healthy range, focus on permanent changes to your eating
and exercise habits. Motivate yourself by remembering the benefits of losing weight,
such as a healthier heart, more energy and improved self-esteem.

Sometimes medication is an option as well. Oral diabetes drugs such as metformin

(Glucophage, Glumetza, others) may reduce the risk of type 2 diabetes — but healthy
lifestyle choices remain essential. Have your blood sugar checked at least once a year to
check that you haven't developed type 2 diabetes.

Lifestyle and home remedies

Diabetes is a serious disease. Following your diabetes treatment plan takes round-the-clock
commitment. Careful management of diabetes can reduce your risk of serious — even life-
threatening — complications.

 Make a commitment to managing your diabetes. Learn all you can about diabetes.
Establish a relationship with a diabetes educator, and ask your diabetes treatment
team for help when you need it.

 Choose healthy foods and maintain a healthy weight. If you're overweight, losing
just 5 percent of your body weight can make a difference in your blood sugar control
if you have prediabetes or type 2 diabetes. A healthy diet is one with plenty of fruits,
vegetables, lean proteins, whole grains and legumes, with a limited amount of
saturated fat.

 Make physical activity part of your daily routine. Regular exercise can help
prevent prediabetes and type 2 diabetes, and it can help those who already have
diabetes to maintain better blood sugar control. A minimum of 30 minutes of
moderate exercise — such as brisk walking — most days of the week is
recommended.

A combination of exercises — aerobic exercises, such as walking or dancing on most

days, combined with resistance training, such as weightlifting or yoga twice a week —
often helps control blood sugar more effectively than does either type of exercise
alone.

It's also a good idea to spend less time sitting still. Try to get up and move around for
a few minutes at least every 30 minutes or so when you're awake.

Lifestyle for type 1 and type 2 diabetes

In addition, if you have type 1 or type 2 diabetes:

 Identify yourself. Wear a tag or bracelet that says you have diabetes. Keep a glucagon
kit nearby in case of a low blood sugar emergency — and make sure your friends and
loved ones know how to use it.

 Schedule a yearly physical and regular eye exams. Your regular diabetes checkups
aren't meant to replace yearly physicals or routine eye exams. During the physical,
your doctor will look for any diabetes-related complications and screen for other
medical problems. Your eye care specialist will check for signs of retinal damage,
cataracts and glaucoma.

 Keep your vaccinations up-to-date. High blood sugar can weaken your immune
system. Get a flu shot every year, and your doctor may recommend the pneumonia
vaccine, as well. The Centers for Disease Control and Prevention (CDC) also currently
recommends hepatitis B vaccination if you haven't previously been vaccinated against
hepatitis B and you're an adult ages 19 to 59 with type 1 or type 2 diabetes.

The most recent CDC guidelines advise vaccination as soon as possible after diagnosis
with type 1 or type 2 diabetes. If you are age 60 or older, have diabetes, and haven't
previously received the vaccine, talk to your doctor about whether it's right for you.

 Pay attention to your feet. Wash your feet daily in lukewarm water. Dry them gently,
especially between the toes. Moisturize with lotion, but not between the toes. Check
your feet every day for blisters, cuts, sores, redness or swelling. Consult your doctor if
you have a sore or other foot problem that doesn't heal promptly on its own.

 Keep your blood pressure and cholesterol under control. Eating healthy foods
and exercising regularly can go a long way toward controlling high blood pressure
and cholesterol. Medication may be needed, too.

 Take care of your teeth. Diabetes may leave you prone to more-serious gum
infections. Brush and floss your teeth at least twice a day. And if you have type 1 or
 type 2 diabetes, schedule regular dental exams. Consult your dentist right away if
your gums bleed or look red or swollen.

 If you smoke or use other types of tobacco, ask your doctor to help you
quit. Smoking increases your risk of various diabetes complications. Smokers who
have diabetes are more likely to die of cardiovascular disease than are nonsmokers
who have diabetes, according to the American Diabetes Association. Talk to your
doctor about ways to stop smoking or to stop using other types of tobacco.

 If you drink alcohol, do so responsibly. Alcohol can cause either high or low blood
sugar, depending on how much you drink and if you eat at the same time. If you
choose to drink, do so only in moderation — one drink a day for women and two
drinks a day for men — and always with food.

Remember to include the carbohydrates from any alcohol you drink in your daily
carbohydrate count. And check your blood sugar levels before going to bed.

 Take stress seriously. The hormones your body may produce in response to

prolonged stress may prevent insulin from working properly, which will raise your
blood sugar and stress you even more. Set limits for yourself and prioritize your tasks.
Learn relaxation techniques. And get plenty of sleep.

TOPIC 14: NUTRITION IN BURNS

Burn: Damage to the skin or other body parts caused by extreme heat, flame, contact with
heated objects, or chemicals. 

Burn depth is generally categorized as first, second, or third degree. The treatment

of burns depends on the depth, area, and location of the burn, as well as additional factors,
such as material that may be burned onto or into the skin.

Treatment options range from simply applying a cold pack to emergency treatment to skin
grafts.
Burn levels

There are three primary types of burns: first-, second-, and third-degree. Each degree is
based on the severity of damage to the skin, with first-degree being the most minor and
third-degree being the most severe. Damage includes:

 First-degree burns: red, non-blistered skin

 Second-degree burns: blisters and some thickening of the skin

 Third-degree burns: widespread thickness with a white, leathery appearance

 Fourth-degree burns. This type of burn includes all of the symptoms of a third-
degree burn and also extends beyond the skin into tendons and bones.

Burns have a variety of causes

1. Fire

2. Hot liquid or steam

3. Hot metal, glass or other objects

4. Electrical currents

5. Radiation, such as that from X-rays

6. Sunlight or other sources of ultraviolet radiation, such as a tanning bed

7. Chemicals such as strong acids, lye, paint thinner or gasoline

8. Abuse

Note:

The type of burn is not based on the cause of it. Scalding, for example, can cause all three
burns, depending on how hot the liquid is and how long it stays in contact with the skin.
Chemical and electrical burns warrant immediate medical attention because they can affect
the inside of the body, even if skin damage is minor.

First-degree burn

First-degree burns cause minimal skin damage. They are also called “superficial burns”
because they affect the outermost layer of skin. Signs of a first-degree burn include:

 redness

 minor inflammation, or swelling

 pain

 dry, peeling skin occurs as the burn heals

Since this burn affects the top layer of skin, the signs and symptoms disappear once the
skin cells shed. First-degree burns usually heal within 7 to 10 days without scarring.

You should still see your doctor if the burn affects a large area of skin, more than three
inches, and if it’s on your face or a major joint, which include:

 knee

 ankle

 foot

 spine

 shoulder

 elbow

 forearm
First-degree burns are usually treated with home care. Healing time may be quicker the
sooner you treat the burn. Treatments for a first-degree burn include:

 soaking the wound in cool water for five minutes or longer

 taking acetaminophen or ibuprofen for pain relief

 applying lidocaine (an anesthetic) with aloe vera gel or cream to soothe the skin

 using an antibiotic ointment and loose gauze to protect the affected area

Make sure you don’t use ice, as this may make the damage worse. Never apply cotton balls
to a burn because the small fibers can stick to the injury and increase the risk of infection.
Also, avoid home remedies like butter and eggs as these are not proven to be effective.

Second-degree burn

Second-degree burns are more serious because the damage extends beyond the top layer of
skin. This type burn causes the skin to blister and become extremely red and sore.

Some blisters pop open, giving the burn a wet or weeping appearance. Over time, thick,
soft, scab-like tissue called fibrinous exudate may develop over the wound.

Due to the delicate nature of these wounds, keeping the area clean and bandaging it
properly is required to prevent infection. This also helps the burn heal quicker.

Some second-degree burns take longer than three weeks to heal, but most heal within two
to three weeks without scarring, but often with pigment changes to the skin.

The worse the blisters are, the longer the burn will take to heal. In some severe cases, skin
grafting is required to fix the damage. Skin grafting takes healthy skin from another area of
the body and moves it to the site of the burned skin.
As with first-degree burns, avoid cotton balls and questionable home remedies. Treatments
for a mild second-degree burn generally include:

 running the skin under cool water for 15 minutes or longer

 taking over-the-counter pain medication (acetaminophen or ibuprofen)

 applying antibiotic cream to blisters

However, seek emergency medical treatment if the burn affects a widespread area, such as
any of the following:

 face

 hands

 buttocks

 groin

 feet

Third-degree burn

Excluding fourth-degree burns, third-degree burns are the most severe. They cause the
most damage, extending through every layer of skin.

There is a misconception that third-degree burns are the most painful. However, with this
type of burn the damage is so extensive that there may not be any pain because of nerve
damage.

Depending on the cause, the symptoms third-degree burns can exhibit include:

 waxy and white color

 char
  dark brown color

 raised and leathery texture

 blisters that do not develop

Without surgery, these wounds heal with severe scarring and contracture. There is no set
timeline for complete spontaneous healing for third-degree burns.

Complications

Complications of deep or widespread burns can include:

 Bacterial infection, which may lead to a bloodstream infection (sepsis)

 Fluid loss, including low blood volume (hypovolemia)

 Dangerously low body temperature (hypothermia)

 Breathing problems from the intake of hot air or smoke

 Scars or ridged areas caused by an overgrowth of scar tissue (keloids)

 Bone and joint problems, such as when scar tissue causes the shortening and
tightening of skin, muscles or tendons (contractures)

Preventing all degrees of burns

The obvious best way to fight burns is to prevent them from happening. Certain jobs put
you at a greater risk for burns, but the fact is that most burns happen at home. Infants and
young children are the most vulnerable to burns. Preventive measures you can take at
home include:
 1. Keep children out of the kitchen while cooking.

2. Turn pot handles toward the back of the stove.

3. Place a fire extinguisher in or near the kitchen.

4. Test smoke detectors once a month.

5. Replace smoke detectors every 10 years.

6. Keep water heater temperature under 120 degrees Fahrenheit.

7. Measure bath water temperature before use.

8. Lock up matches and lighters.

9. Install electrical outlet covers.

10. Check and discard electrical cords with exposed wires.

11. Keep chemicals out of reach, and wear gloves during chemical use.

12. Wear sunscreen every day, and avoid peak sunlight.

13. Ensure all smoking products are stubbed out completely.

14. Clean out dryer lint traps regularly.

It’s also important to have a fire escape plan and to practice it with your family once a
month. In the event of a fire, make sure to crawl underneath smoke. This will minimize the
risk of passing out and becoming trapped in a fire.

Outlook for burns

When properly and quickly treated, the outlook for first- and second-degree burns is good.
These burns rarely scar but can result in a change in pigment of the skin that was burned.
The key is to minimize further damage and infection. Extensive damage from severe
second-degree and third-degree burns can lead to problems in deep skin tissues, bones,
and organs. Patients may require:

 surgery

 physical therapy

 rehabilitation

 lifelong assisted care

Lifestyle and home remedies

To treat minor burns, follow these steps:

 Cool the burn. Hold the burned area under cool (not cold) running water or apply a
cool, wet compress until the pain eases. Don't use ice. Putting ice directly on a burn
can cause further damage to the tissue.

 Remove rings or other tight items. Try to do this quickly and gently, before the
burned area swells.

 Don't break blisters. Fluid-filled blisters protect against infection. If a blister breaks,

clean the area with water (mild soap is optional). Apply an antibiotic ointment. But if a
rash appears, stop using the ointment.

 Apply lotion. Once a burn is completely cooled, apply a lotion, such as one that
contains aloe vera or a moisturizer. This helps prevent drying and provides relief.

 Bandage the burn. Cover the burn with a sterile gauze bandage (not fluffy cotton).
Wrap it loosely to avoid putting pressure on burned skin. Bandaging keeps air off the
area, reduces pain and protects blistered skin.

 Take a pain reliever. Over-the-counter medications, such as ibuprofen (Advil, Motrin

IB, others), naproxen sodium (Aleve) or acetaminophen (Tylenol, others), can help
relieve pain.
  Consider a tetanus shot. Make sure that your tetanus booster is up to date. Doctors
recommend that people get a tetanus shot at least every 10 years.

TOPIC 15: NUTRITION IN SURGERY

A surgical operation or procedure, especially one involving the removal or replacement of

a diseased organ or tissue.

Surgery can involve cutting, abrading, suturing, or otherwise physically changing body

tissues and organs.

Importance of good nutrition before and after surgery

 Help your incisions heal

 Provide the raw materials your immune system needs to protect you against
infection
 Help to replace any blood loss
 Help to repair your skin, nerves, blood vessels, muscles and bones
 Increase your level of energy

Pre-Op Nutrition Guidelines

Your pre-surgery diet should include as many nutrients in your “bank account” as possible
before surgery:

 Eat enough protein. At least 1 – 2 weeks before surgery, make sure to eat enough
protein every day. Protein needs are based on the amount of muscle that you have,
but research has shown that 65 – 100 grams per day are proving to be optimal.
Protein provides building blocks for our muscles, bones, and our immune system.
You want to be as strong as possible going into surgery.
 Stock up on fruit and vegetables. Include fruit and vegetables at most meals and
snacks. More specifically, greens. Greens are great for your skin and repair muscles,
 bones, and cartilage because they contain loads of vitamins and minerals including
vitamins C, K and magnesium.
 Include whole grains. Be sure to include good sources of whole grains to give your
body all the B vitamins it needs to combat stress.
 Eat less of these. Consider reducing or eliminating additional sugars, caffeine, and
alcohol from your diet. These create more stress on the body and actually remove
nutrients from the body to metabolize properly.

Post-Op Nutrition Guidelines

Post-op nutrition goals make it possible for a speedier recovery and help you return to
doing the things you love as soon as possible. Maintaining a proper post-op diet is essential.

Some people lose their appetite after surgery and while taking pain medications. However,
surgery increases the body’s need for calories, and you need more calories to heal.

 Eat smaller meals more often if your appetite has decreased.

 Include fiber. Add fiber at each meal and snack from fruits, vegetables, cooked
beans, and whole grains. Fiber helps maintain normal bowel movements.
 Eat enough protein. Have protein at each meal for your muscles and bones. It is
found in meat, fish, eggs, poultry, nuts, dairy products, soy products, and cooked
dried beans.
 Calcium is an important component of bone. Drink milk or calcium-fortified
juices, and eat yogurt or cheese. Your doctor may recommend a calcium pill and
vitamin D if you don’t get enough from your food.
 Vitamin C helps the body heal wounds and form bone. Get vitamin C from citrus
fruits, green and red peppers, collard greens, broccoli, spinach, strawberries,
tomatoes, and potatoes.
 Remember to drink plenty of water. To avoid constipation, drink at least six to
eight cups of fluid a day.
 TOPIC 16: NUTRITION IN HIV/AIDS

 HIV and nutrition

HIV infection progressively destroys the immune system, leading to recurrent opportunist
infections (OIs), debilitation and death. OIs are infections that take advantage of a weak
immune system. Poor nutritional status is one of the major complications of HIV and a
significant factor that might lead people to develop full-blown AIDS. In places where there
are inadequate food supplies (resource-limited settings), many people who become
infected with HIV may already be undernourished. Their weakened immune systems
further increase their vulnerability to infection.

Poor nutrition and HIV: a vicious cycle

In this section you are going to look at the damaging cycle that can lead to a person with
HIV and under-nutrition developing a variety of health problems including weakness,
weight loss and loss of muscle tissue and fat. This cycle is represented in Figure 12.1.
Vitamin and mineral deficiencies may occur at a time when a person actually has increased
nutritional needs because of infections, viral replication and poor nutrient absorption. The
whole body develops reduced immune functioning and increased susceptibility to
opportunistic infections.
The effects of HIV on nutrition

People living with HIV infection have a higher chance of developing under nutrition than
those who are not infected. HIV affects the nutritional status of these people in different
ways. The effects of HIV may occur at different times during the course of their illness.

The following are typical adverse effects of HIV infection which may affect the person’s
nutritional status:
  Reducing food consumption because of appetite loss or anorexia

 Nausea

 Oral thrush

 Constipation

 Bloating or heartburn.

People with HIV also tend to have various oral conditions that can make it difficult for them
to eat. Impact on nutritional status includes:

 Impaired nutrient absorption

 Increased energy needs because of fever

 Possible increase in the need for other nutrients because of symptoms such as
anaemia

 HIV-associated wasting

 Changing body composition.

Why is nutrition important?

Nutrition is important for everyone because food gives our bodies the nutrients they need
to stay healthy, grow, and work properly. Foods are made up of 6 classes of nutrients, each
with its own special role in the body:

Protein builds muscles and a strong immune system.

Carbohydrates (including vegetables, fruits, grains) give you energy.

Fat gives you extra energy.

Vitamins regulate body processes.

 Minerals regulate body processes and also make up body tissues.

Water gives cells shape and acts as a medium where body processes can occur.

Do I need a special diet?

There are no special diets, or particular foods, that will directly boost your immune system.
But there are things you can do to keep your immunity up.

When you are infected with HIV, your immune system has to work very hard to fight off
infections--and this takes energy (measured in calories). For some people, this may mean
you need to eat more food than you used to.

If you are underweight--or you have advanced HIV disease, high viral loads, or
opportunistic infections--you should include more protein as well as extra calories (in the
form of carbohydrates and fats). You'll find tips for doing this in the next section.

If you are overweight, you should follow a well-balanced meal plan such as the ones
presented on the U.S. government's Choose My Plate website (www.choosemyplate.gov/).
Keep in mind; you may need to eat more nutritious foods to meet your body's needs.

How do I keep from losing weight?

Weight loss can be a common problem for people with relatively advanced stages of HIV
infection, and it should be taken very seriously. It usually improves with effective
antiretroviral therapy (ART). Losing weight can be dangerous because it makes it harder
for your body to fight infections and to get well after you're sick.
People with advanced HIV often do not eat enough because:

HIV may reduce your appetite, make food taste bad, and prevent the body from
absorbing food in the right way; some HIV medicines may also cause these symptoms (if
this is so, tell your HIV specialist--you may be able to change to medications that do not
have these side effects)

Symptoms like a sore mouth, nausea, and vomiting make it difficult to eat

Fatigue from HIV or the medicines may make it hard to prepare food and eat regularly

To keep your weight up, you will need to take in more protein and calories. What follows
are ways to do that.

To add protein to your diet

Protein-rich foods include meats, fish, beans, dairy products, and nuts. To boost the protein
in your meals:

Spread nut butter on toast, crackers, fruit, or vegetables.

Add cottage cheese to fruit and tomatoes.

Add canned tuna to casseroles and salads.

Add shredded cheese to sauces, soups, omelets, baked potatoes, and steamed vegetables.

Eat yogurt on your cereal or fruit.

Eat hard-boiled (hard-cooked) eggs. Use them in egg-salad sandwiches or slice and dice
 them for tossed salads.

Eat beans and legumes (pinto and other beans, lentils, etc), nuts, and seeds.

Add diced or chopped meats to soups, salads, and sauces.

Add dried milk powder or egg white powder to foods (such as scrambled eggs,
casseroles, and milkshakes).

To add calories to your diet

The best way to increase calories is to add extra fat and carbohydrates to your meals.

Fats are more concentrated sources of calories. Add moderate amounts of the following to
your meals:

Butter, margarine, peanut butter, gravy

Sour cream, cream cheese, grated cheese

Avocados, olives, salad dressing

Carbohydrates include both starches and simple sugars.

Starches are in:

Breads, muffins, biscuits, crackers

Oatmeal and cold cereals

 Pasta, potatoes, rice

Simple sugars are in:

Fresh or dried fruit (eg, raisins, dates, apricots, etc)

Jelly, honey, and maple syrup added to cereal, pancakes, and waffles

How can I maintain my appetite?

When you become ill, you often lose your appetite. This can lead to weight loss, which can
make it harder for your body to fight infection.

Here are some tips for increasing your appetite:

Try a little exercise, such as walking or doing yoga. This can often stimulate your
appetite and make you feel like eating more.

Eat smaller meals more often. For instance, try to snack between meals.

Eat whenever your appetite is good.

Do not drink too much right before or during meals. This can make you feel full.

Avoid carbonated (fizzy) drinks and foods such as cabbage, broccoli, and beans. These
foods and drinks can create gas in your stomach and make you feel full and bloated.

Eat with your family or friends.

How much water do I need?

Drinking enough liquids is very important when you have HIV. Fluids transport the
nutrients you need through your body.

Extra water can:

Reduce the side effects of medications

Help flush out the medicines that have already been used by your body

Help you avoid dehydration (fluid loss), dry mouth, and constipation

Make you feel less tired

Many of us don't drink enough water every day. You should be getting at least 8-10 glasses
of water (or other fluids, such as juices or soups) a day.

Here are some tips on getting the extra fluids you need:

Drink more water than usual. Try other fluids, too, like noncaffeinated teas, flavored
waters, or fruit juice mixed with water.

Avoid alcohol.

Begin and end each day by drinking a glass of water.

Suck on ice cubes and popsicles.

Note: If you have diarrhea or are vomiting, you will lose a lot of fluids and will need to
drink more than usual.

For more information, see the medication side effects and symptoms section.

Do I need supplements?

Our bodies need vitamins and minerals, in small amounts, to keep our cells working
properly. They are essential to our staying healthy. People with HIV need extra vitamins
and minerals to help repair and heal cells that have been damaged.

Even though vitamins and minerals are present in many foods, your health care provider
may recommend a vitamin and mineral supplement (a pill or other form of concentrated
vitamins and minerals). While vitamin and mineral supplements can be useful, they can't
replace eating a healthy diet.

If you are taking a supplement, here are some things to remember:

Always take vitamin pills on a full stomach. Take them regularly.

Some vitamins and minerals, if taken in high doses, can be harmful. Talk with your health
care provider before taking high doses of any supplement.

Below is a table of some vitamins and minerals that affect the immune system.

Vitamins and minerals that affect the immune system

Name What It Does Where to Get It About Supplements

Vitamin A Keeps skin, Liver, whole eggs; milk; It's best to get vitamin A from
and beta- lungs, and dark green, yellow, food. Vitamin A supplements
carotene stomach orange, and red are toxic in high doses.
 vegetables and fruit
(such as spinach, Supplements of beta-carotene
pumpkin, green peppers, (the form of vitamin A in fruits
healthy. squash, carrots, papaya, and vegetables) have been
and mangoes); also found shown to increase cancer risk
in orange and yellow in smokers.
sweet potatoes

Keeps the White beans, potatoes,

Vitamin B
immune and meat, fish, chicken,
group (B1,
nervous watermelon, grains, nuts,
B2, B6,
systems avocados, broccoli, and
B12, folate)
healthy. green leafy vegetables

Helps protect
Citrus fruits (such as
the body from
oranges, grapefruit, and
Vitamin C infection and
lemons), tomatoes, and
aids in
potatoes
recovery.

Important for
developing and
Fortified milk, fatty fish,
Vitamin D maintaining
sunlight
heathy bones
and teeth.

Protects cells Green leafy vegetables,

Vitamin E and helps fight vegetable oils, avocados, Limit to 400 IU per day.
off infection. almonds

Iron Not having Green leafy vegetables, Limit to 45 mg per day unless
enough iron whole grain breads and otherwise instructed by your
can cause pastas, dried fruit, beans, doctor. Iron may be a problem
 for people with HIV because it
can increase the activity of
What should I know about food safety?
some bacteria. Iron

Paying attention red safety

to food and water meat, chicken, liver,when
is important supplements canbecause
you have HIV, be your
anemia.
fish, and
immune system is already weakened andeggs constipating.
working hard to fight Supplements that
off infections.
do not contain iron may be
If food is not handled or prepared in a safe way, germs frombetter
the food can be Ask
tolerated. passed
youron to
you. These germs can make you sick. doctor.

Important
You need to handle for food
and cook Whole grains,
properly tomeat, fish, germs from getting to you.
keep those
Selenium the immune poultry, eggs, peanut Limit to 400 mcg per day.
Here are somesystem.
food safety guidelines:
butter, and nuts

Important
Keep everything clean!for
CleanMeat, fish, poultry,
your counters and beans,
utensils often.
Zinc the immune peanuts, and milk and Limit to 40 mg per day.
system. dairy products

Source: Adapted from the Food and Agriculture Organization of the United Nations
Wash your hands with soap and warm water before and after preparing and eating food.

Check expiration dates on food packaging. Do not eat foods that are past the expiration
date.

Rinse all fresh fruits and vegetables with clean water.

Thaw frozen meats and other frozen foods in the refrigerator or in a microwave. Never
thaw foods at room temperature. Germs that grow at room temperature can make you
very sick.

Clean all cutting boards and knives (especially those that touch chicken and meat) with
soap and hot water before using them again.

Make sure you cook all meat, fish, and poultry "well-done." You might want to buy a
meat thermometer to help you know for sure that the meat is fully cooked. Put the
thermometer in the thickest part of the meat, not touching a bone. Cook the meat until it
reaches 165-212 degrees F. on the thermometer.

Do not eat raw, soft-boiled, or "over easy" eggs, or Caesar salads with raw egg in the
dressing. This includes eating uncooked cookie dough or cake batter that contains
uncooked eggs.

Do not eat sushi, raw seafood, or raw meats, or unpasteurized milk or dairy products.

Keep your refrigerator cold, set no higher than 40 degrees F. Your freezer should be at 0
degrees.

Refrigerate leftovers at temperatures below 40 degrees F. Do not eat leftovers that have
 been sitting in the refrigerator for more than 3 days.

Keep hot items heated to over 140 degrees F, and completely reheat leftovers before
eating.

Throw away any foods (like fruit, vegetables, and cheese) that you think might be old. If
food has a moldy or rotten spot, throw it out. When in doubt, throw it out.

Some germs and parasites are spread through tap water. If your public water supply
isn't totally pure, drink bottled water.

Can diet help ease side effects and symptoms?

Many symptoms of HIV, as well as the side effects caused by HIV medicines, can be
alleviated by using (or avoiding) certain types of foods and drinks.

Below are some tips for dealing with common problems facing people living with HIV.

Nausea

Try the BRAT diet (bananas, rice, applesauce, and toast).

Try some ginger--in tea, ginger ale, or ginger snaps (these need to be made with real
ginger root).

Don't drink liquids at the same time you eat your meals.

Eat something small, such as crackers, before getting out of bed.

 Avoid foods such as the following:

Fatty, greasy, or fried foods

Very sweet foods (candy, cookies, or cake)

Spicy foods

Foods with strong odors

Mouth and swallowing problems

Avoid hard or crunchy foods such as raw vegetables.

Try eating cooked vegetables and soft fruits (such as bananas and pears).

Avoid very hot foods and beverages. Cold and room temperature foods will be more
comfortable to your mouth.

Do not eat spicy foods. They can sting your mouth.

Try soft foods such as mashed potatoes, yogurt, and oatmeal.

Also try scrambled eggs, cottage cheese, macaroni and cheese, and canned fruits.

Rinse your mouth with water. This can moisten your mouth, remove bits of food, and
make food taste better to you.
Diarrhea

Try the BRAT diet (bananas, rice, applesauce, and toast).

Keep your body's fluids up (hydrated) with water or other liquids (those that don't have
caffeine).

Limit sodas and other sugary drinks.

Avoid greasy and spicy foods. High-fat foods can make diarrhea worse in some
situations.

Avoid milk and other dairy products.

Eat small meals and snacks every hour or two.

Points to remember

You may feel that many things are out of your control if you have HIV. But you can control
what you eat and drink, and how much. Good nutrition is an important part of your plan to
stay well.

Eating right can make your body and your immune system stronger.

When you are HIV-positive, you may need to eat more. Be sure to eat a diet that is high in
proteins and calories.

Exercise can stimulate your appetite and make you feel like eating more.
Drink plenty of liquids to help your body deal with any medications you are taking. If you
are vomiting or have diarrhea, you will need to drink more than usual.

Practice food safety. Keep your kitchen clean, wash foods, and be careful about food
preparation and storage. If your tap water isn't pure, drink filtered or bottled water.

You can use certain foods and beverages to help you deal with symptoms and side
effects.

Before taking vitamin and mineral supplements, check with your health care provider