DIET

THERAPY II

LECTURE NOTES
 1. INTRODUCTION TO DIET THERAPY

Definition of terms

Diet

Is the sum of food consumed by a person or other organism. The word diet often implies the use of
specific intake of nutrition for health or weight-management reasons

Diet Therapy

Diet therapies are specially designed and prescribed for medical and/or general nutritional reasons.

Diet plan

A set of scheduled meals in order to achieve different metabolic and health goals, such as weight
loss, sugar control, muscle gain.

Food

Any substance, solid or liquid, usually of plant or animal origin that contains or consists of
essential body nutrients, such as carbohydrates, fats, proteins, vitamins, or minerals, and is
ingested and assimilated by an organism to produce energy, stimulate growth, and maintain life.

Nutrition
The process of nourishing or being nourished, especially the process by which a living organism
assimilates food and uses it for growth and for replacement of tissues.
The science or study that deals with food and nourishment, especially in humans.
Nutrients
Is a chemical that an organism needs to live and grow or a substance used in an
organism's metabolism which must be taken in from its environment. Calorie

It is how the energy content of food is measured.

Dietary assessment

An estimation of food and nutrients eaten over a particular time point. Some of the most common
dietary assessment methods are food records, dietary recalls, and food frequency. questionnaires,
and diet histories.

Dietitian

A dietitian is a health professional who has a bachelor's degree, specializing in foods and
nutrition, and in addition undergoes a period of practical training in a hospital or
community setting.

Electrolytes

Any of the various ions, such as sodium, potassium, or chloride, required by cells to
regulate the electric charge and flow of water molecules across the cell membrane.

Kilojoule

A unit of measure. Food energy values is frequently given in kilojoules (kJ), the metric
unit of energy. Using the metric system nomenclature, a calorie is converted into a
kilojoule (kJ), where 1 kcal=4.184 kJ and 1 megajoule (MJ)=1000 kJ. To convert
kilojoules to kcals, divide by 4.184.

Legumes

A pod, such as a pea or bean, that splits into two valves with the seeds attached to one
edge of the valves.

Nutrition

The branch of science that deals with nutrients and nutrition, particularly in humans

Nutritionist

A person who studies or is an expert in nutrition

Diet therapy is the branch of dietetics concerned with the use of foods for therapeutic purpose. It is
method of eating prescribed by a physician to improve health. Diet therapy usually involves the
modification of an existing dietary lifestyle to promote optimum health. Therapeutic diets are
modified for nutrients, texture and food allergies or food intolerances.

Diet therapy is a method of eating to improve health for prescribed by a physician. Diet therapy
involves the modification of an existing dietary lifestyle for good health. Some common
therapeutic diets are clear liquid diet, full liquid diet, high fiber diet, renal diet, pureed diet, food
allergy modification etc. It is branch of dietetics related with the use of food for therapeutic
purposes. It is ordered to maintain, restore and correct nutritional status, to decrease calorie for
weight control, provide extra calorie for weight gain. It also balances amount of carbohydrate, fat
and protein for control of diabetes.

Today's major health care problems are increasingly the result of acute and chronic conditions
related to poor nutrition and/or overconsumption. A large proportion of coronary disease and
cancer can be attributed to unhealthy eating habits and obesity. Chronic diseases continue to
increase due to such factors as the rise in obesity.

Diet therapy promotes a balanced selection of foods vital for good health. By combining foods
appropriate for each individual and drinking enough water, one can help maintain the best possible
health. Eating a proper diet is critical for the health of individuals, groups with special medical and
dietary needs, and entire populations afflicted with malnutrition.

Individualized diet therapy can provide the patient important insight into food-related illnesses and
education regarding how various nutrients (protein, carbohydrate, fat, alcohol) affect illness,
diseases, or obesity. Dietary therapy can be tailored to meet the treatment needs of patients on
diagnosis of specific illnesses, can help reduce complications and/or side effects, and can improve
general well-being.

Objectives of diet therapy

Vital for good health. The principles of diet therapy are to:
• maintain good nutritional status, correct deficiencies or disease, if any,
• provide rest to the body,
• help metabolize the nutrients, and
• make changes in body weight, when necessary.
Precautions

A particular modified diet is prescribed specifically for each individual. Those individuals who
have medical conditions or who are sensitive to certain foods need to be very compliant and
cautious about what they eat.

Individuals should not follow a "fad" diet without first consulting a registered dietitian or
physician. Popular (but sometimes dangerous) low-carbohydrate diets, for example, may deprive
the body of the glucose it needs for central nervous system and brain functions.

Description

Nutrition is the science concerned with the human body's use of nutrients and food substances.
Proper nutrition decisions are important for the optimal health of each individual. This is
especially true for those individuals with specific dietary needs and acute or chronic diseases. The
nutrients necessary to maintain normal growth and health include proteins, carbohydrates, fats,
vitamins, and minerals. Included in these nutrients are eight amino acids the body cannot produce
but that must be derived from proteins, four fat-soluble and 10 water-soluble vitamins, 10
minerals, and three electrolytes.

Nutrient classes

PROTEIN

Protein is important for building body tissue and synthesizing enzymes. Enzymes are specialized
organic substances that act to regulate the speed of chemical reactions in human metabolism.
Twenty amino acids of the 100 or more occurring in nature make up proteins. Animals and plants
are quick and available sources of what are termed "essential" amino acids; they are called
essential because the body cannot build them internally. Normal growth and health are dependent
upon these essential amino acids. Dietitians recommend that a healthy diet includes 10-20% of
daily calories from protein (poultry, fish, dairy, and vegetable sources).

CARBOHYDRATES

Carbohydrates provide most of the energy in the majority of human diets. Foods rich in
carbohydrates are usually the most abundant and cheapest. The carbohydrates containing the most
nutrients are the complex carbohydrates, such as unrefined grains, tubers, vegetables, and fruits.
Simple carbohydrates or sugars should be eaten in moderation, since they are high in calories but
low in nutrients.

Carbohydrates are needed in the form of glucose by the brain and central nervous system (CNS). A
minimum of 1.6 oz (50 g) of glucose is required daily for proper functioning of the CNS. If the
body is denied carbohydrates, it will use ketone bodies for energy, but this is not a good energy
source for the body, and may have unfavorable health effects.

FATS

Fats supply energy and essential fatty acids and promote absorption of the fat-soluble vitamins A,
D, E, and K. The accumulation of body fat has become a serious health concern; almost two-thirds
of Americans are considered overweight. Fats are compact fuels efficiently stored in the body for
later use when carbohydrates are in short supply. Fats produce more than twice as much energy as
carbohydrates, approximately 9 Kcals/gram versus about 4 Kcals/gram for carbohydrate and
protein. Dietary fats are broken down into fatty acids that pass into the blood. These fatty acids are
either saturated or unsaturated (monounsaturated, polyunsaturated, or trans unsaturated). Saturated
fats, derived mostly from animal sources, have been found to raise the level of total cholesterol in
the bloodstream, and certain unsaturated fats tend to lower the level of total cholesterol in the
blood stream. For example, monounsaturated fats like oleic acid in olive oil reduce low-density
lipoprotein cholesterol (LDL, what is considered bad cholesterol) and increase high-density
lipoprotein cholesterol (HDL, also known as good cholesterol), thus reducing the risk of heart
disease. Saturated and trans unsaturated fatty acids both raise serum cholesterol; in contrast,
neither monounsaturated nor polyunsaturated fats have this effect.

INORGANIC MINERAL NUTRIENTS

Inorganic mineral nutrients are required to build tissues. They are also important for muscle
contractions, nerve reactions, and blood clotting. All of these mineral nutrients must be supplied in
the diet. Minerals are categorized as major elements or trace elements. Major elements consist of
calcium, phosphorus, magnesium, iron, iodine, and potassium. Trace elements include copper,
cobalt, manganese, fluorine, and zinc.

Calcium, Ca2+, is a major constituent of bones and teeth and is required to keep bones strong.
It is required in blood clotting as an activator of various plasma proteins and is also involved
in muscle contraction. Calcium is used in synapses and also as an enzyme activator. A good
source of calcium is in dairy products, eggs and green vegetables, the RDA for calcium is
800mg.

Chlorine, Cl-, is required to maintain the osmotic anion / cation balance of the body and the
formation of HCl in the stomach. It is found in table salt and is rarely deficient in the diet as it is
used as a preservative to may foods. Sodium, Na+, is also found in table salt as well as dairy
foods, meat, eggs and vegetables. Sodium is used in conjunction with chlorine in the maintenance
of the osmotic anion / cation balance. It is also needed in nerve conduction and muscle action.
Potassium, K+, is yet another mineral required in nerve and muscle action, it also has a role in
protein synthesis. It is found in meat, fruit and vegetables.

Phosphorus, in the form of phosphate, PO43- is a constituent of nucleic acids, ATP,

phospholipids in cell membranes, bones and teeth. It is present in dairy foods, eggs, meat
and vegetables.

Magnesium, Mg2+, is an important component of bones and teeth and is also an enzyme
activator.
It is found in meats and green vegetables.

Micronutrients are minerals needed in trace quantities. Despite the small quantity required,
they are still essential to a healthy balanced diet.

Iron, in the forms of Fe2+ and Fe3+, are required in the formation of haemoglobin and
myoglobin. Iron is a constituent of many enzymes as a prosthetic group and also as an
electron carrier in mitochondria. Red meat, liver and green vegetables are all sources
of iron. Iron supplements are taken by people who suffer from anaemia.

Iodine, I-, is a component of the growth hormone thyroxine. A lack of iodine in the diet can
cause hypothyroidism which results in weight gain and in extreme cases a lack of physical and
mental development known as cretinism. A swelling of the neck can occur which is called
goitre if iodine is deficient in the diet. Iodine can be found in seafood such as shellfish, seaweed
and fish. Iodine has also been added to water supplies in areas where it is deficient in the main
water system.
Copper, Cu2+, manganese, Mn2+ and cobalt, Co2+, are all needed in the diet to form cofactors
for enzymes. Copper is also needed for bone and haemoglobin formation and cobalt is needed for
the production of red blood cells, manganese is also a growth factor in bone development. They
are found in meat and liver as well as some dairy products.
VITAMINS

Vitamins increase the breakdown and absorption of proteins, carbohydrates, and fats. Certain
vitamins help form blood cells, hormones, nervous system chemicals, and genetic materials.
Vitamins are classified into two groups: fat-soluble vitamins, such as A, D, E, and K; and
watersoluble vitamins, such as vitamin C and the B-vitamin complex. Fat-soluble vitamins are
usually found in foods that contain fat. Because excess amounts are stored in the body's fat and in
the liver and kidneys, fat-soluble vitamins do not have to be consumed every day. The
watersoluble vitamins, C and B complex, cannot be stored and must be consumed daily to
replenish the body's supply.

Fibre
Fibre is not digested by the body, but is involved in maintaining the health of the gut and is
therefore an essential part of a balanced diet. Fibre is mostly made up of cellulose from plant cell
walls and is indigestible as the stomach and gut do not contain the correct enzymes. Fibre aids
the formation of faeces, preventing constipation. It also aids the peristaltic movement in the
intestine and has been linked to the prevention of bowel cancer. Fibre also removes some
saturated fats and cholesterol therefore protecting the body a little from the build up of plaques in
blood vessels. Fruit, vegetables and cereals are a good source of dietary fibre.

Water
The diet must provide water which is required as a solvent, a transport medium, a substrate in
hydrolytic reactions and for lubrication. Water in fact makes up about 70% of the total body
weight of humans. Water is needed as it is lost constantly from our bodies in urine, sweat,
evaporation from lungs and in faeces. An average person requires 2-3 litres of water a day which
is supplied through drinks and liquid foods.
 Food types

Foods can be widely grouped into breads and cereals; legumes, tubers or starchy roots;
vegetables and fruits; meat, fish, and eggs; milk and milk products; fats and oils; and sugars.
Breads and cereals are high in starches (carbohydrates), but whole cereals also often supply
significant amounts of protein. However, these cereals should be eaten in conjunction with other
protein foods to supply all the essential amino acids. Meat, fish, and eggs supply all the essential
amino acids that the body needs to build its own proteins.

Milk and milk products also provide a plentiful amount of protein, phosphorus, calcium, and
vitamins. Legumes are rich in starch but also furnish more protein than cereals or tubers. Tubers
provide a variety of minerals and vitamins. Vegetables and fruits are a direct source of many
minerals and vitamins. Fats and oils are high in calories but usually contain few nutrients.
Sugars, which are heavily consumed in more affluent countries, contain few nutrients and can
cause tooth decay.

Dietary guidelines

A guide to the amount an average person needs to remain healthy has been determined for each
vitamin and mineral as well as macronutrients. This guide is called the Dietary Reference
Intakes (DRI). Dietary counselors may use the DRI as a guide when providing counseling. A
dietitian can advise the patient about any vitamin or mineral inadequacy concerns during the
dietary counseling session. The DRIs have replaced the Recommended Dietary Allowance
(RDA), but encompass both the RDAs and the upper intake limits for each nutrient.

They provide a broad overall view of good nutrition. They provide science-based guidance to
promote health and reduce risk for major chronic diseases through diet and physical activity.
These dietary guidelines include these basic recommendations:

• eat a variety of foods; let the food pyramid guide your food choices
• control weight
• be physically active each day
• eat a diet low in saturated fat (less than 10% of total calories) and cholesterol (less than 300
mg/day), and moderate in total fat (20-35% of total calories)
• limit intake of fats and oils high in saturated and trans-fatty acids
• eat a variety of vegetables and fruits, and whole grains
• eat a variety of whole-grains
• eat sugar in moderation
• use salt in moderation
• if you drink alcohol, do so in moderation; no more than two drinks per day of wine, beer, or
spirits
• keep food safe to eat; follow the government safety precautions as outlined on the food package

Energy requirements

Carbohydrates, proteins, and fats provide energy in the form of calories to fuel the body for
metabolic processes, growth, and activity. When an individual consumes as many calories each
day as the body uses, they are in a state of energy balance and will neither gain nor lose weight.
When more calories are eaten than the body uses, the excess calories are stored as fat and
weight increases. On the other hand, when fewer calories are consumed than the body needs,
stored fat and muscle is burned for fuel and weight decreases. The amount of energy required
depends on such factors as an individual's weight, gender, age, and activity level, so estimation
should be made based on these parameters. The DRIs provide energy (caloric) estimates based
on activity level (sedentary, low active, active, very active) and body mass index. An equation is
used to calculate energy needs based on these parameters in addition to age and gender. Using
the metric system nomenclature, a kilojoule (kJ) is used instead of a kilocalorie (kcal), where 1
kcal = 4.184 kJ and F1 mega joule (MJ) = 1000 kJ.

Calorie-modified diet

Calorie-modified diets are prescribed to correct weight problems with a healthy diet. Lowcalorie
diets are designed for weight reduction and are prescribed for people who are overweight or
obese. High-calorie diets are recommended for people with greatly increased energy needs such
as athletes in training or individuals fighting diseases such as cancer, AIDS, or cystic fibrosis.
High-calorie diets are also prescribed to treat anorexia nervosa.

Calorie-modified diets are planned by dietitians and should be prescribed following a complete
physical examination and dietary assessment or dietary history. A low-calorie diet provides
enough energy to meet the person's metabolic needs and activity level. It includes a balanced
variety of foods, but limits carbohydrates and alcohol. A low-calorie diet should not aim to
promote a weight loss of more than approximately 1-2 lb (500 grams to one kilogram) per week.
In general, for a slightly overweight person, it is not wise to lose more than 1 lb (about 500
grams) per week. A high-calorie diet usually provides an extra 500-1,000 calories, leading to a
weight gain of about 1 lb (500 grams) per week for most people. It has a high protein content,
normal fat content, and emphasizes foods that pack many calories into a small volume.
Snacking between meals is encouraged as a way to increase the calories consumed.

When caloric limits allow, have no more than two drinks of wine, beer or liquor per day.
 Fiber-modified diet

Fruits and vegetables are excellent sources of fiber. Fiber has important nutritional benefits such
as facilitating the movement of food through the digestive tract, helping to prevent constipation.
Research suggests low dietary fiber may be responsible for increasing the incidence of
diverticulosis and may also be associated with cancer of the colon.

High-fiber diets, including whole grains (especially bran), raw vegetables, unpeeled fresh fruits,
nuts, and seeds, are recommended to:

• increase fecal bulk

• increase intestinal movement
• prevent or treat constipation, diverticulosis, Crohn's disease, or irritable bowel syndrome
• help lower cholesterol
• assist with weight loss in people who are overweight and improve sugar tolerance in diabetics

Low-fiber diets exclude raw fruits and vegetables, whole grains, nuts, and seeds, while
emphasizing soft, mild foods. They are recommended to:

• decrease fecal bulk

• slow intestinal movement
• decrease stomach acid secretion
• treat a variety of disorders including indigestion, diarrhea, bowel inflammation, and heart
attack

Protein-modified diet

High-protein diets are designed to provide about 0.05 oz (1.5 g) of protein for each kilogram of
a person's body weight. Complex proteins, such as milk and meats, should make up one-half to
two-thirds of the daily protein requirement. High-protein diets are recommended for people
who:

• have an increased need for protein due to proteincalorie malnutrition, severe stress, or
conditions such as AIDS, cancer, or burns with high metabolic rates that lead to the loss of
large amounts of protein
• have malabsorption syndromes, celiac disease, or other disorders characterized by poor food
absorption

A low-protein diet excludes dairy products and meats, and requires that about three-fourths of
the daily food intake of protein come from high-value protein sources. Supplements may be
 prescribed to prevent amino acid deficiencies. Low-protein diets are used in treatment of
cirrhosis and kidney disease.

Low-cholesterol diet

Dietary modification is the first weapon in the fight against the high cholesterol levels that
contribute to heart disease and atherosclerosis. Low-cholesterol diets are prescribed to reduce
the risk of heart disease and to treat atherosclerosis, diabetes, high serum cholesterol (which
may be hereditary and might also require cholesterol-reducing drugs), and high blood pressure.
A low-cholesterol diet is not a cure for the conditions it is prescribed to treat, so most people
must stay on the diet for the rest of their lives.

The American Heart Association eating plan recommends that total cholesterol intake should be
less than 0.01 oz (300 mg) per day and total fat intake should be 30% or less of total calories.
Saturated fatty acid intake should be less than 10% of calories or for anyone with elevated blood
cholesterol levels or heart disease, saturated fat and cholesterol intake is limited even further to
7% of total calories per day.

The AHA eating plan also suggests:

• Polyunsaturated fatty acid intake should be 8-10% of calories.

• Monounsaturated fatty acids should make up the rest of the total fat intake, up to 15% of total
calories.

These guidelines apply to all healthy individuals over two years of age.

Low-fat diet

Most American diets contain too much fat. Fat often makes up about 40% of total calories
consumed each day. Dietary guidelines recommend limiting fat to 20%-35% or less of daily
calories, since consumption of too much fat has been linked to obesity, heart disease, and
several types of cancer. A low-fat diet usually limits daily fat intake to 1.76 oz (50 g), while an
extremely low-fat diet limits fat consumed each day to 0.88-1.05 oz (25-30 g). The grams of fat
in your diet will depend on the calories you need. Low-fat diets are recommended to:

• help prevent heart disease

• help prevent colon, prostate, and breast cancers
• help treat a variety of conditions including gout, AIDS, gallbladder disease, liver disease,
celiac disease, inflammatory bowel disease, and heartburn
• lose or control weight
Some fat is required in the diet to prevent essential fatty acid deficiencies, but most people
consume more than enough fat to meet these needs. Cutting back on fat will likely help
individuals eat fewer calories, thus reducing weight and helping to prevent coronary diseases.

Gluten-free diet

Gluten and gliadin are proteins found in certain grains and grain-containing products. These
proteins are toxic to cells within the intestinal tract of an individual who is "intolerant" and
cause difficulty in food absorption. Celiac disease is caused by intolerance to these proteins.
This intolerance causes patients with celiac disease to suffer weight loss, diarrhea, malnutrition,
and bloating. By eliminating foods containing gluten from the diet, further damage to the
intestines can be prevented, symptoms are relieved, and malabsorption of nutrients is corrected.
A gluten-free diet eliminates all foods containing wheat, rye, barley, and malt, and must be
followed for life.

Low-purine diet

This diet restricts food, such as sardines, liver, and eggs, that cause the body to produce uric
acid. It is usually prescribed as part of a treatment program for gout (a disease usually caused by
having too much uric acid in the body) and kidney stones, which also includes exercise and
medication. In addition to excluding organ meats (sweetbreads, liver, kidney) and certain types
of fish (anchovies, sardines, mackerel) and limiting the amount of other purine-containing foods
such as shrimp, meats, and dairy products, this diet emphasizes drinking about 2 qt (1.89 l) of
water and fruit juice daily, to promote the excretion of uric acid, and eating fruits and vegetables
that increase urine alkalinity and the solubility of uric acid.

Low-salt diet

On the average, Americans consume about 0.17 oz (5 g) of salt or sodium daily. Dietary
guidelines suggest that 0.08 oz (2.4 g) of sodium should be the upper limit, even if there are no
signs of heart disease. Most people with heart disease should limit their sodium intake to less
than 0.07 oz (2 g) a day, and some low-salt diets restrict sodium to as little as 0.008 oz (250 mg)
per day. The amount of salt in the diet is important for people who have high blood pressure or
congestive heart failure.

Some experts believe excessive intake of salt is a major reason for high blood pressure,
especially in Western countries. Excess sodium encourages the body to retain fluid, thereby
increasing fluid pumped by the heart and circulating in the bloodstream. Diets high in salt also
can be harmful to people with congestive heart failure because the excess fluid backs up into the
lungs, causing congestion.
 Potassium chloride is a common ingredient in salt substitutes. But too much potassium can be
harmful for people with kidney problems. One way to enhance the flavor of food while
eliminating salt is to add lemon juice, herbs, spices, or flavored vinegar.

Low-phenylalanine diet

A low-phenylalanine diet is normal treatment for phenylketonuria (PKU). PKU is a rare genetic
disorder in the degradation of dietary phenylalanine that if left untreated, can result in severe
progressive mental retardation. The diet is extremely restrictive, and rigorous dietary
compliance is necessary to reduce or prevent mental retardation. Close supervision by a
registered dietitian or physician is necessary.

A normal diet cannot be tolerated by people with PKU. Dietary treatment necessitates avoiding
foods containing high levels of protein. A prescribed diet contains only the amount of
phenylalanine that is essential for the body. Basic principles of the PKU diet state that:

• Meat, fish, cheese, eggs, milk, and nuts are not allowed because they are rich in protein and thus
phenylalanine.
• Other foods which contain moderate amounts of protein (e.g., potato and cereals) are given in
small measured quantities. These foods are spread out between the day's meals to keep the
phenylalanine levels steady.
• Most fruits, some vegetables, and salads can be taken in normal quantities but excessive use
should be avoided.
• Sugar, jam, syrups, and fats such as butter, lard, and cooking oil can be used fairly freely.
• There are many low-protein manufactured foods available on prescription. These can all be
taken freely to provide variety in the diet. Foods include pasta, low-protein bread, biscuits, flour,
spaghetti, etc.
• Infants can be fed phenylalanine-free formulas.

There is a high incidence of tooth decay among individuals affected by PKU because of the
increased amounts of carbohydrates consumed.

Diabetic diet

For the most part, dietary management is the key to keeping diabetes in check. There no single
diet that meets the needs of all diabetics. The general rules for healthy eating as discussed
previously apply to diabetics as well.

Several dietary methods are available for controlling blood sugar levels. The Dietary Guidelines
for Americans can be followed by everyone over 2 years old, including diabetics. Some experts
 believe these dietary guidelines may be sufficient for diabetics, although there are more detailed
dietary methods available for controlling blood sugar. These methods may be complex,
however, which deters many diabetics from using them. The American Diabetic Association
developed the Diabetic Exchange Lists, the most common system used for controlling blood
sugar. Other nutrition experts recommend adopting a Mediterranean diet because they point out
the food pyramid has some drawbacks; for example, there is little focus on meal planning.
Carbohydrate counting plans may assist but may also be complicated and require a committed
learner; the concepts of the Diabetic Exchange Lists may be difficult to understand for some
people.

Type 1 and type 2 diabetics on insulin or oral medication must focus on controlling blood
glucose levels by coordinating food intake with insulin administration or medication, or other
variables such as exercise.

Nutrition habits that assist in glucose control:

• Stick to a meal plan.

• Appropriately treat hypoglycemia (low blood sugar).
• Quickly respond to hyperglycemia (high blood sugar).
• Maintain consistent snacking habits.

The recommendation given by the American Diabetes Association is to eat more complex
carbohydrates. This is the opposite of what has been advised in past years. Current research
studies now show it is healthiest for everyone to eat more grains, beans, and starchy vegetables
to control fat and cholesterol. Total carbohydrate intake has greater impact on blood glucose
control than the source of carbohydrate. However, consumption of complex carbohydrates (e.g.,
whole grain bread, beans, etc.) are better than eating foods that are sucrose (simple sugar) based.

Both weight loss and blood sugar control are particularly important for overweight type 2
diabetics who are not taking medication. Health effects are most beneficial after initial weight
loss. A 10% decrease in body weight can control the progression of type 2 diabetes. Other
important issues are controlling lipid (cholesterol and triglyceride) levels, and blood pressure.
Controlling fat intake is important because diabetics are about twice as likely to get
cardiovascular disease compared to other people.

Research shows that diabetics have the same protein requirements as other people, but with
onset of nephropathy, protein should be limited to 0.8 grams/kg per day for adults, with 80%
coming from high biological value protein.
Traditional diets may offer some health advantages

Certain populations have dietary habits that are much healthier than the typical Western diet,
which is often too high in fat and cholesterol. Research has shown that the traditional
Mediterranean diet, Japanese diet, or "hunter-gatherer" diets have health advantages. The dietary
habits characteristic of Mediterranean countries with the consumption of olive oil
(monounsaturated fatty acid) as the main fat source appear to provide optimal health benefits
with a low incidence of coronary heart disease. The Mediterranean diet consists of large
amounts fruit, vegetables, pulses, nuts, cereal products, and fish, while generally only small
amounts of meat and dairy foods are consumed.

Preparation

Effective estimation of an individual's diet is required in order to provide dietary counseling

and guidance. If a dietary assessment is not conducted in preparation, using proper
methodologies, it will be difficult for the dietitian to draw any conclusions regarding the need
for diet therapy.

Despite the diet type, all foods should be prepared appropriately. This includes adequate cooking
time and proper storage. Some diets must be phased in gradually.

Aftercare

Regular follow-up with a dietician or physician is always important when an individual has been
placed on a special diet because of a health condition.

One cannot live on "a diet" permanently, because strict guidelines are difficult and painstaking
to follow. Therefore, dietary modifications have to be about lifestyle changes in food selections
and healthier attitudes regarding nutrition and wellness.

Risks

There is always the possible risk of non-compliance of any diet. However, when the individual
is placed on the appropriate diet and the primary physician is aware of any known allergies,
there are very few risks involved, if any.

Results

When special diets are followed as prescribed, better health is the expected outcome, with a
decreased risk of acquiring many diseases. However, it is up to an individual to implement the
necessary dietary modifications. If a patient does not follow the recommended dietary guidance,
then they will not benefit. Typically, modest effects are seen in weight loss or reduction in serum
lipids (cholesterol) often due to failure to fully comply with the dietary recommendations
provided by a dietitian or doctor.

The outcome of any diet therapy will be better when combined with exercise unless the patient
is unable to exercise for medical reasons.

If the appropriate diet is prescribed by medical professionals, abnormal results are very rare.

Health care team roles

A certified nutrition professional such as a registered dietician (R.D.) should be seen for a
dietary assessment and professional dietary counseling prior to commencing diet therapy.
Beware of individuals prescribing diets without an education in dietetics and nutrition. In
general, only registered dietitians have sufficient training and knowledge to accurately assess
the nutritional adequacy of a patient's diet, especially if chronic disease is present. Some
dietitians call themselves nutritionists, but the term "nutritionist" is not regulated by law;
therefore anyone can call themselves a nutritionist. A doctor may also have a nutrition
background or specialization and may thus be able to conduct a dietary assessment or to provide
general nutrition advice and/or diet therapy. However, many physicians do not have any
specialized knowledge in dietary therapy because they have not studied nutrition.

Importance of good nutrition

Nutrition keeps us healthy and free of diseases, psychological and behavioral issues.
Deals with the relationship between our diet and how our body functions. If we want our body
to maintain health then we must s apply the essential nutrient. Nothing can heal the body except
the body itself so it is vital that we properly nourish our cells.
When cells do not receive proper nutrition our health suffers and we become malnourished or
experience an imbalance. When the body is nourished and working properly it can fight off
toxins, bacteria and viruses.
Our bodies’ needs are simple, vitamins, minerals, water, carbohydrates, protein and fats. The
food we eat gets absorbed in our bloodstream and is broken down and carried to every cell in
our body. These cells all have jobs to do in order for us to function correctly, build and maintain
health

We need to get the optimum balance of these nutrients in order to thrive.

The importance of good nutrition plays a vital role in our well-being.
When we eat a diet rich in essential nutrients we can then sustaining health and reduce risks of
problems, disease and premature death.
Eating fruits and vegetables in their natural state provides unsurpassed nutrition. Removing
toxins in our food is also imperative to lessen the load our bodies have to deal with.
A raw vegan diet can provide all the nutrients we need. Why nutrition is important can best be
answered by knowing how our body works and responds to the substances it needs to maintain
health and then givingitjustthat.

BALANCED DIET
A balanced diet is one that provides an adequate intake of energy and nutrients for
maintenance of the body and therefore good health. A diet can easily be adequate for normal
bodily functioning, yet may not be a balanced diet. An ideal human diet contains fat, protein,
carbohydrates, vitamins, minerals, water and fibre all in correct proportions. These
proportions vary for each individual because everyone has different metabolic rates and levels
of activity.

Malnutrition results from an unbalanced diet, this can be due to an excess of some dietary
components and lack of other components, not just a complete lack of food. Too much of one
component can be as much harm to the body as too little. Deficiency diseases occur when
there is a lack of a specific nutrient, although some diet related disorders are a result of eating
an excess.

A balanced diet contains seven key nutrient groups that are required in appropriate amounts for
health.

Therapeutic Diet

Diets are not just meant for weight loss, but they serve other purposes too.
Therapeutic diet is a modification in regular diet as a part of the treatment plan for certain
medical conditions.
It is the type of diet which controls the consumption of certain foods or nutrients. This is done to
make sure that the individual's health condition does not get worsened. Therapeutic diet is
suggested to people who are getting treated for a medical condition. This meal plan is usually
suggested and created by a physician or dietician, and is planned by making a few moderations
in the patient's regular diet.

A lot of people are not aware about this diet as it is only prescribed by experts as a part of the
treatment plan for some health problem. It is a healing diet that can also help in preventing
several medical conditions. The most common factor in a lot of therapeutic diets is to avoid
processed foods at all cost. Another important thing to remember is that no matter which
therapeutic diet you are following, it should be under the guidance of a healthcare expert

Therapeutic diet types

The length of the diet depends on the individual’s response and any improvements in health
conditions. The diet is not permanent unless the restricted foods can cause allergies,
sensitivities, or any negative symptoms. Only an expert can give you a verified and balanced
meal plan for the betterment of your health. You should not try to customize your regular diet
with your own convenience and ways. There are many types of therapeutic diets that are
suggested to patients suffering from a specific health problem.

1. Clear liquid diet

There has to be clear liquid in this type of therapeutic diet. Mostly, when people are not able to
digest or swallow solid food or are facing digestion issues, then some modifications should be
made in the regular diet by an expert. Firstly, clear liquid diet will instruct you to avoid heavy or
solid foods and consume liquids including electrolytes and rice water instead.

2. Low cholesterol/low fat diet

This type of therapeutic diet plan has foods that and low in fat and cholesterol. It can be planned
for people fighting to manage their weight or have high cholesterol levels. The doctor will ask
you to have foods like low fat milk, yogurt and cottage cheese. In addition, to follow this diet,
an individual is advised to avoid cheese, processes foods and butter among others.

3. Intolerance diet

Intolerance diet is for people who cannot have certain foods due to allergies and intolerances. In
such cases, the regular diet is customized a little according to the requirement. The method is to
eliminate the allergic food items from your daily diet. After omitting those foods for some time,
a test can be done to see if the symptoms are coming back.

4. High fiber diet

People who have diabetes can manage their glucose levels by consuming soluble fiber. High
fiber diet can also be prescribed for individuals facing problems related to constipation and are
on a weight loss regime. High fiber foods include avocados, apples, whole grains, dry fruits, etc.

Who should follow therapeutic diet?

 Therapeutic diets basically tell all about the nutrients/compounds and food textures to be
included or avoided, considering all the food allergies, intolerances, or health conditions.
Therapeutic diets are helpful for a variety of purposes. Many conditions are treated or improved
with therapeutic diets.

• Diabetes

• Heart problems

• Chronic kidney disease

• Food allergy or intolerance

• Crohn's disease

• Hypertension

• Chronic health conditions

• Gastrointestinal issues

• Celiac disease

• Dysphagia

• Hyperthyroidism or hypothyroidism
 2. DISEASES OF THE LIVER AND THE GALL BLADDER

MANAGEMENT OF LIVER DISORDERS

The liver is an organ about the size of a football. It sits just under the rib cage on the
right side of the abdomen. The liver is essential for digesting food and ridding the body
of toxic substances.

Liver disease can be inherited (genetic). Liver problems can also be caused by a
variety of factors that damage the liver, such as viruses, alcohol use and obesity.

Over time, conditions that damage the liver can lead to scarring (cirrhosis), which can
lead to liver failure, a life-threatening condition. But early treatment may give the liver
time to heal.

Stages of liver disease

Stages of liver failure

• Inflammation. In this early stage, the liver is enlarged or inflamed.
• Fibrosis. Scar tissue begins to replace healthy tissue in the inflamed liver. 
Cirrhosis. Severe scarring has built up, making it difficult for the liver to
function properly.
• End-stage liver disease (ESLD). ...  Liver cancer.
Symptoms of Liver disease

Liver disease doesn't always cause noticeable signs and symptoms. If signs and
symptoms of liver disease do occur, the may include:

• Skin and eyes that appear yellowish (jaundice)

• Abdominal pain and swelling

• Swelling in the legs and ankles

 • Itchy skin

• Dark urine color

• Pale stool color

• Chronic fatigue

• Nausea or vomiting

• Loss of appetite

• Tendency to bruise easily

Causes of liver disease

Liver disease has many causes.

Infection

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:

i) Hepatitis A
Hepatitis A, is a viral infection that attacks the liver. The virus is spread by eating or drinking
food and water that is contaminated with the faeces of an infected person. It’s more common in
places with poor sanitation and hygiene conditions and a lack of clean water. But, it can also be
passed on through unprotected sex and via sharing needles.

Hepatitis A is not usually serious and clears up on its own after 10 to 14 days. However,
hepatitis A has many of the same symptoms as more serious types of hepatitis infections – such
as hepatitis B or C – so it’s important to get tested. Transmission

The hepatitis A virus needs to get from human faeces into the mouth to infect someone. You
only need to be in contact with small amounts of faeces to become infected.

Hepatitis A is most commonly passed on by:

 eating food prepared by someone with the virus who has not washed their hands
properly
 drinking dirty water (including ice cubes)
 eating raw or undercooked shellfish from dirty water
 injecting drugs using contaminated equipment
  being in close contact with someone who has hepatitis A
 Having sex with someone who has the infection without using a condom or dental dam.

You are more likely to get hepatitis A via anal sex, particularly if you touch the anus with your
fingers, mouth or tongue. Touching used condoms, sex toys and equipment that have been in
someone else’s anus can also spread the virus. Prevention of hepatitis A

You can stop the spread of the virus by washing your hands regularly, particularly after you go
to the toilet or before you prepare or eat food.

If tap water isn’t safe you should boil it before drinking or using it to brush your teeth. You
should also peel and wash all your fresh fruit and vegetables and avoid raw or undercooked
meat and fish.

Sharing contaminated needles and syringes during recreational drug use can also pass hepatitis
A on, so it’s important to use new injecting equipment every time.

You can practice safer sex by using a new external (or male) or internal (or female) condom
or dental dam each time you have vaginal, anal or oral sex. You should cover sex toys with a
new condom and wash them after use, as well as washing your hands after touching someone’s
anus or handling used condoms and sex toys.

NOTE: Taking pre-exposure prophylaxis (PrEP), the contraceptive pill or any other type of
contraception – apart from condoms – doesn’t prevent hepatitis A.

If you’re in close contact with someone with hepatitis A or you’re in a high-risk group then
having the hepatitis A vaccine (where available) is recommended. Symptoms of Hepatitis A

Many people with hepatitis A don’t have any symptoms. If symptoms do develop, you’ll usually
notice them around two to seven weeks after infection. These symptoms will usually pass
within two months, although some people can experience illness for up to 6 months.

If symptoms develop, they can include:

 flu-like symptoms, including tiredness, a fever and aches and pains
 loss of appetite

 feeling and/or being sick

 diarrhea
 pain in the upper right part of your tummy (abdomen)
  dark urine and pale faeces

 yellowing of the skin and eyes (jaundice)

Itchy skin.

You can spread the infection even if you have no symptoms, or up to 2 weeks before
symptoms appear.
How to treat Hepatitis A

There is currently no cure for hepatitis A. Your healthcare professional will usually
recommend rest, good nutrition and plenty of fluids. Painkillers and/or medication to help
with itchiness, nausea or vomiting may be prescribed. Most people will recover fully
within one to two months.

Whether you’ve got symptoms or not, don’t prepare food for others or have sex until a
healthcare professional tells you that you’re no longer infectious.

Once you’ve recovered from hepatitis A you’re immune – this means you can’t get it again.
But you can still get other types of hepatitis.

ii) What is hepatitis B?

Hepatitis B, part of a group of hepatitis viruses that attack the liver. For some people the
infection becomes chronic, meaning it lasts more than six months. People with chronic hepatitis
B have a higher chance of liver damage.

Most adults with hepatitis B make a full recovery, even if their symptoms are severe. Babies and
children are more likely to develop a long-lasting (chronic) hepatitis B infection.

Transmission of Hepatitis B

Hepatitis B spreads when the blood, semen or vaginal fluids of an infected person gets into
someone else’s body. The virus is highly infectious and can last outside the body for up to seven
days.

Hepatitis B is passed on by:

 having unprotected vaginal, anal and oral sex with someone who has hepatitis B*
  changing partners frequently and not using a condoms every time you have sex

 injecting drugs using contaminated equipment

 Using unsterilized tattoo, body-piercing or medical/dental equipment.

 Sharing towels, razor blades or toothbrushes with infected blood on them (this is rare).

Hepatitis B can also be passed on from a mother to her newborn baby, particularly in countries
where the infection is common.

Some sexual activities are riskier than others, such as anal sex or any type of sex where blood
may be present.

Prevention of Hepatitis B

You can stop the spread of the virus by using a new external (male) or internal (female)
condom or dental dam every time you have vaginal, anal or oral sex. You should cover sex toys
with a new condom and wash with soap and water after use. It’s also a good idea to use latex
gloves and wash your hands after touching someone’s anus (bottom) or handling used condoms
and sex toys.

NOTE: Taking pre-exposure prophylaxis (PrEP), the contraceptive pill or any other type of
contraception – apart from condoms – won’t protect you from hepatitis B and other STIs.

Having regular STI tests is one of the best ways to look after your sexual health. If you are
having sex with multiple partners, it’s even more important to use condoms and get tested
regularly, even if you don’t have any symptoms.

You should never share needles and syringes or other items that may be contaminated with
blood, such as razors. Only have tattoos, body piercings or acupuncture in a professional
setting, and make sure new, sterile needles are used.

Getting vaccinated is a good idea if you think you may be at risk.

Symptoms of Hepatitis B

Many people with hepatitis B don’t have any symptoms. If you do get symptoms you may not
notice them until two or three months after infection. You can pass the virus on to others even if
you don’t have symptoms.

There are two types of infection – acute and chronic.

Acute (or short-term) symptoms can include:

  flu-like symptoms, including tiredness, fever and aches and pains
 feeling and/or being sick
 loss of weight/appetite
 diarrhea

 tummy (abdominal) pain

 yellowing of the skin and eyes (jaundice)

 dark urine (pee)
 Pale, grey coloured faeces.

People who can’t fight off acute infection after six months can go on to develop chronic
hepatitis B. These include babies, young children and people with a weakened immune
system because of HIV. People with chronic hepatitis B are at higher risk of liver failure,
liver disease and cancer of the liver.
How Hepatitis B is treated

Treatment for hepatitis B depends on how long you have had the virus.

There is no specific treatment for acute (short-term) hepatitis B, and most people recover
within one to two months. Usually, you can manage symptoms at home with plenty of rest
and painkillers if necessary. Most people make a full recovery from acute hepatitis B.

If you develop chronic (long-term) hepatitis B, you will be given treatment to help some of
the symptoms. This will also reduce the risk of liver damage and liver cancer. Treatment
keeps the virus under control but cannot cure chronic hepatitis B. Some people will need
lifelong treatment.

iii) Hepatitis C

Hepatitis C is part of a group of hepatitis viruses that attack the liver.

Chronic hepatitis C can be serious and without appropriate treatment and care, can cause liver
disease and liver cancer. Treatment, where available, can cure hepatitis C in most cases.
Transmission of Hepatitis C

Hepatitis C is most commonly spread through blood-to-blood contact. It is very infectious and
the virus can stay alive outside the body for up to several weeks.

The infection can be spread by:

 sharing needles and syringes, particularly when injecting drugs

 medical and dental equipment that has not been properly sterilised
  the transfusion of unscreened blood and blood products.
 unsterilised tattoo and body piercing equipment
 sharing contaminated razors, toothbrushes or towels (this is rare).

It can be transmitted sexually, especially during anal sex or other types of sex that may
involve blood, although this is less common. Sharing uncovered or unwashed sex toys can
also pass it on.

The risk of hepatitis C infection is increased when you have another STI – especially one
that causes sores. People with HIV are also more likely to get hepatitis C.

The virus can also be passed on from a pregnant woman to her unborn baby
Prevention of Hepatitis C

There is no vaccine for hepatitis C but there are a number of ways to reduce the risk of
infection.

Never share needles and syringes or other items that may be contaminated with infected
blood, even old or dried blood can contain the virus.

Only have tattoos, body piercings or acupuncture in a professional setting, where new,
sterile needles are used

You can also stop the spread of the virus by practising safer sex. Use condoms, especially
during anal sex, rough sex or if you’re menstruating. Use dental dams and latex gloves for
rimming, fingering and fisting. Knowing the status of your sexual partner is another
important way to stay safe.

If you have HIV, taking your antiretroviral treatment keeps your immune system strong.

NOTE: Taking pre-exposure prophylaxis (PrEP), the contraceptive pill or any other type of
contraception – apart from condoms – doesn’t protect you from hepatitis C and other STIs.

Having regular STI tests is one of the best ways to look after your sexual health. If you are
having sex with multiple partners, it’s even more important to use condoms and get tested
regularly even if you don’t have any symptoms.

If you’ve been diagnosed with hepatitis C you should avoid sex until you have finished your
treatment and a health care professional says it’s safe. Symptoms of Hepatitis C

Many people with hepatitis C don't have any symptoms, especially during the first 6 months.
The hepatitis C infection can go through two stages: acute and chronic. In the early ‘acute’
stage, these symptoms can include:
 flu-like symptoms, tiredness, high temperature and aches and pains
 loss of appetite

 tummy (abdominal) pain

 Yellowing of the eyes and skin (known as jaundice).

For some people the infection will clear without treatment.

In most cases an acute infection will develop into long-term ‘chronic’ infection. Chronic
infection may not become apparent for a number of years until the liver displays signs of
damage.

Symptoms vary but some of the most common include:

 problems with short-term memory, concentration and completing complex mental
tasks
(often called ‘brain fog’)
 depression or anxiety

mood swings


 constantly feeling tired

 nausea, vomiting or tummy pain
 dark urine (pee)

 pale faeces
 jaundice
 itchy skin
 feeling bloated

 Joint and muscle pain.

How Hepatitis C is treated

Treatment for hepatitis C depends on how long you have had the virus.

People with acute (short-term) infection do not always need treatment because their immune
system may clear hepatitis C on its own. If you test positive during the acute stage, your doctor
may ask you to come back after a few months to re-test and to see if you need any treatment.

If you develop chronic (long-term) infection, you will need treatment to help clear the virus.
Treatment with drugs called direct-acting antivirals (DAAs) can cure hepatitis in most cases.
These are usually taken for 8-12 weeks. Your doctor will also check your liver for any damage.
 If you’ve had hepatitis C in the past, you’re not immune to future infections – which means you
can get it again. You can also still get other types of hepatitis and having hepatitis C together
with another type is more serious.

If you’ve already had hepatitis C, it’s advisable to have the vaccination against hepatitis A and
B to protect your liver from further damage.

Whether you have symptoms or not, don’t have sex until your healthcare professional says you
can.
Immune system abnormality

Diseases in which your immune system attacks certain parts of your body (autoimmune) can
affect your liver. Examples of autoimmune liver diseases include:

i) Autoimmune Hepatitis

Autoimmune Hepatitis, also known as AIH, is a chronic (condition that lasts longer than six
months), usually lifelong liver condition. It is an autoimmune disorder; this means your body’s
immune system (the body’s defence against illness) attacks your body’s own cells.

Causes of Autoimmune Hepatitis

The cause of most cases of Autoimmune Hepatitis is not clear but is thought to be a mixture of:

• autoimmunity – the process of your immune system making autoantibodies, which ‘attack’ and
damage your body’s own cells and organs
• environmental triggers – causes starting outside of the body; for example getting a virus,
taking certain medications, or coming into contact with other toxins
• Genetic predisposition – inheriting genes which may make it easier for a trigger to set off the
disease.

Symptoms of Autoimmune Hepatitis

• feeling more tired than normal or becoming tired easily

• feeling generally unwell

• mild joint or muscle pains, usually these are worse in the morning

• low appetite (not feeling hungry) and weight loss

• feeling sick (nausea)

• itching (pruritus)

• skin rash

• excessive hair growth (usually in women)

• passing loose or more frequent bowel movements (diarrhoea)

• absent periods/menstruation cycle (amenorrhoea)

• tummy pain or bloating

When symptoms do start to appear, they often start over weeks or months. The symptoms are
often nonspecific and have many possible causes so your doctor may not immediately attribute
your symptoms to liver disease.

• the build-up of fluid in the tummy (ascites)

• The build-up of fluid in the legs, feet and ankles (oedema)

• confusion

• jaundice – a condition in which the whites of the eyes go yellow and, in more severe cases, the
skin also turns yellow

• bruising

• abnormal blood vessels on the skin

• dark urine (wee)

• Pale and/or fatty floating stools.

For those who have symptoms, diagnosis is usually made though a mixture of taking a careful
medical history, performing a physical examination, a range of blood tests and a liver biopsy. A
diagnosis of Autoimmune Hepatitis is usually made by looking at your test results and ruling out
other causes of liver disease such as fatty liver disease or viral hepatitis.

Treatment for Autoimmune Hepatitis

Once you have been diagnosed with Autoimmune Hepatitis, treatment is almost always needed.
The type of treatment used is called immunosuppression (reducing how active your immune
system is).This is done by using a combination of medications.

The main goal of treatment is to stop the liver inflammation by suppressing your immune
system (make it less active) but this can also reduce the ability of your immune system to fight
infection. Reducing the liver inflammation will improve your symptoms, improve your liver
tests, reduce the degree of scarring and help prevent long term liver damage and liver failure.
Once treatment has started it is long-term, for at least two years and it is usually lifelong. It may
be possible to stop treatment in a few people with AIH, however this is not without risk as a
relapse (becoming ill again) can occur and you may need further treatment.

Prednisolone

Prednisolone is part of a group of medications called corticosteroids. Prednisolone is the main

steroid used to treat Autoimmune Hepatitis; it can also be used to treat a number of other
conditions that are linked to inflammation for example, ulcerative colitis (an inflammatory
bowel disease) and rheumatoid arthritis (a disease that affects your joints). Prednisolone works
by suppressing your immune system, helping to reduce the inflammation in the liver.

ii) Primary biliary cholangitis

Primary biliary cholangitis, previously called primary biliary cirrhosis, is a chronic disease in
which the bile ducts in your liver are slowly destroyed.

Bile is a fluid made in your liver. It aids with digestion and helps you absorb certain vitamins. It
also helps your body get rid of cholesterol, toxins and worn-out red blood cells. Chronic
inflammation in the liver can lead to bile duct damage, irreversible scarring of liver tissue
(cirrhosis) and eventually, liver failure.

Although it affects both sexes, primary biliary cholangitis mostly affects women. It's considered
an autoimmune disease, which means your body's immune system is mistakenly attacking
healthy cells and tissue. Researchers think a combination of genetic and environmental factors
triggers the disease. It usually develops slowly. At this time, there's no cure for primary biliary
cholangitis, but medication can slow liver damage, especially if treatment begins early.

Symptoms

Common early symptoms include:

• Fatigue

• Itchy skin

Later signs and symptoms may include:

• Dry eyes and mouth

 • Pain in the upper right abdomen

• Swelling of the spleen (splenomegaly)

• Bone, muscle or joint (musculoskeletal) pain

• Swollen feet and ankles (edema)

• Buildup of fluid in the abdomen due to liver failure (ascites)

• Fatty deposits (xanthomas) on the skin around the eyes, eyelids or in the creases of the
palms, soles, elbows or knees

• Yellowing of the skin and eyes (jaundice)

• Darkening of the skin that's not related to sun exposure (hyperpigmentation)

• Weak and brittle bones (osteoporosis), which can lead to fractures

• High cholesterol

• Diarrhea, which may include greasy stools (steatorrhea)

• Underactive thyroid (hypothyroidism)

• Weight loss

Causes

It's not clear what causes primary biliary cholangitis. Many experts consider it an autoimmune
disease in which the body turns against its own cells. Researchers believe this autoimmune
response may be triggered by environmental and genetic factors.

The liver inflammation seen in primary biliary cholangitis starts when certain types of white
blood cells called T cells (T lymphocytes) start to collect in the liver. Normally, these immune
cells detect and help defend against germs, such as bacteria and viruses. But in primary biliary
cholangitis, they mistakenly destroy the healthy cells lining the small bile ducts in the liver.

Inflammation in the smallest ducts spreads and eventually damages other cells in the liver. As
the cells die, they're replaced by scar tissue (fibrosis) that can lead to cirrhosis. Cirrhosis is
scarring of liver tissue that makes it difficult for your liver to work properly.

Risk factors

The following factors may increase your risk of primary biliary cholangitis:
 • Sex. Most people with primary biliary cholangitis are women.

• Age. It's most likely to occur in people 30 to 60 years old.

• Genetics. You're more likely to get the condition if you have a family member who has or
had it.

• Geography. It's most common in people of northern European descent, but primary biliary
cholangitis affects all races.

Researchers think that genetic factors combined with certain environmental factors trigger
primary biliary cholangitis. These environmental factors may include:

• Infections, such as a urinary tract infection

 

Smoking

• Toxic chemicals

Complications

As liver damage worsens, primary biliary cholangitis can cause serious health problems,
including:

• Liver scarring (cirrhosis). Cirrhosis makes it difficult for your liver to work and may
lead to liver failure. It indicates the later stage of primary biliary cholangitis. People with
primary biliary cholangitis and cirrhosis have a poor prognosis and higher risk of other
complications.

• Enlarged veins (varices). When blood flow through the portal vein is slowed or blocked,
blood may back up into other veins — usually those in your stomach and esophagus.
Increased pressure may cause delicate veins to break open and bleed. Bleeding in the
upper stomach or esophagus is a life-threatening emergency that requires immediate
medical care.

• Increased pressure in the portal vein (portal hypertension). Blood from your intestine,
spleen and pancreas enters your liver through a large blood vessel called the portal vein.
When scar tissue from cirrhosis blocks normal blood flow through your liver, blood backs
up. This causes increased pressure inside the vein. Also, because blood doesn't flow
normally through your liver, drugs and other toxins aren't filtered properly from your
bloodstream.

• Enlarged spleen (splenomegaly). Your spleen can become swollen with white blood cells
and platelets because your body no longer filters toxins out of the bloodstream as it
should.

• Gallstones and bile duct stones. If bile cannot flow through the bile ducts, it may harden
into stones, causing pain and infection.

• Liver cancer. Liver scarring (cirrhosis) increases your risk of liver cancer. If you have
liver scarring, you'll need regular cancer screening.

• Weak bones (osteoporosis). People with primary biliary cholangitis have an increased
risk of weak, brittle bones that may break more easily.

• Vitamin deficiencies. A lack of bile affects your digestive system's ability to absorb fats
and the fat-soluble vitamins, A, D, E and K. Because of this, some people with advanced
 primary biliary cholangitis may have low levels of these vitamins. These deficiencies can
result in a variety of health problems, including night blindness and bleeding disorders.

• High cholesterol (hyperlipidemia). Up to 80% of people with primary biliary cholangitis

have high cholesterol.

• Decreased mental function (hepatic encephalopathy). Some people with advanced

primary biliary cholangitis and cirrhosis have personality changes and problems with
memory and concentration.

• Increased risk of other disease. Primary biliary cholangitis is associated with metabolic
or immune system disorders, including thyroid problems, limited scleroderma (CREST
syndrome), rheumatoid arthritis, and dry eyes and mouth (Sjogren's syndrome).

iii) Primary sclerosing cholangitis

Primary sclerosing is a disease of the bile ducts. Bile ducts carry the digestive liquid bile from
your liver to your small intestine. In primary sclerosing cholangitis, inflammation causes scars
within the bile ducts. These scars make the ducts hard and narrow and gradually cause serious
liver damage. A majority of people with primary sclerosing cholangitis also have inflammatory
bowel disease, such as ulcerative colitis or Crohn's disease.

In most people with primary sclerosing cholangitis, the disease progresses slowly. It can
eventually lead to liver failure, repeated infections, and tumors of the bile duct or liver. A liver
transplant is the only known cure for advanced primary sclerosing cholangitis, but the disease
may recur in the transplanted liver in a small number of patients.

Care for primary sclerosing cholangitis focuses on monitoring liver function, managing
symptoms and, when possible, doing procedures that temporarily open blocked bile ducts.

Symptoms

Primary sclerosing cholangitis is often diagnosed before symptoms appear when a routine blood
test or an X-ray taken for an unrelated condition shows liver abnormalities.

Early signs and symptoms often include:

• Fatigue

• Itching
 

Yellow eyes and skin (jaundice)

• Abdominal pain

Many people diagnosed with primary sclerosing cholangitis before they have symptoms
continue to feel generally well for several years. But there's no reliable way to predict how
quickly or slowly the disease will progress for any individual.

Signs and symptoms that may appear as the disease progresses include:

• Fever

• Chills

• Night sweats

• Enlarged liver

• Enlarged spleen

• Weight loss

Causes

It's not clear what causes primary sclerosing cholangitis. An immune system reaction to an
infection or toxin may trigger the disease in people who are genetically predisposed to it.

A large proportion of people with primary sclerosing cholangitis also have inflammatory bowel
disease, an umbrella term that includes ulcerative colitis and Crohn's disease.

Primary sclerosing cholangitis and inflammatory bowel disease don't always appear at the same
time, though. In some cases, primary sclerosing cholangitis is present for years before
inflammatory bowel disease occurs. If primary sclerosing cholangitis is diagnosed, it's
important to look for inflammatory bowel disease because there is a greater risk of colon
cancer.

Somewhat less often, people being treated for inflammatory bowel disease turn out to have
primary sclerosing cholangitis as well. And rarely, people with primary sclerosing cholangitis
develop inflammatory bowel disease only after having a liver transplant.
Risk factors

Factors that may increase the risk of primary sclerosing cholangitis include:

• Age. Primary sclerosing cholangitis can occur at any age, but it's most often diagnosed
between the ages of 30 and 40.

• Sex. Primary sclerosing cholangitis occurs more often in men.

• Inflammatory bowel disease. A large proportion of people with primary sclerosing

cholangitis also have inflammatory bowel disease.

• Geographical location. People with Northern European heritage have a higher risk of
primary sclerosing cholangitis.

Complications

Complications of primary sclerosing cholangitis may include:

• Liver disease and failure. Chronic inflammation of the bile ducts throughout your liver
can lead to tissue scarring (cirrhosis), liver cell death and, eventually, loss of liver
function.

• Repeated infections. If scarring of the bile ducts slows or stops the flow of bile out of the
liver, you may experience frequent infections in the bile ducts. The risk of infection is
particularly high after you've had a surgical procedure to expand a badly scarred bile duct
or remove a stone blocking a bile duct.

• Portal hypertension. Your portal vein is the major route for blood flowing from your
digestive system into your liver. Portal hypertension refers to high blood pressure in this
vein.

Portal hypertension can cause fluid from the liver to leak into your abdominal cavity
(ascites). It can also divert blood from the portal vein to other veins, causing these veins to
become swollen (varices). Varices are weak veins and tend to bleed easily, which can be
life-threatening.

• Thinning bones. People with primary sclerosing cholangitis may experience thinning
bones (osteoporosis). Your doctor may recommend a bone density exam to test for
osteoporosis every few years. Calcium and vitamin D supplements may be prescribed to
help prevent bone loss.
 

Bile duct cancer. If you have primary sclerosing cholangitis, you have an increased risk
of developing cancer in the bile ducts or gallbladder.

• Colon cancer. People with primary sclerosing cholangitis associated with inflammatory
bowel disease have an increased risk of colon cancer. If you've been diagnosed with
primary sclerosing cholangitis, your doctor may recommend testing for inflammatory
bowel disease, even if you have no signs or symptoms, since the risk of colon cancer is
elevated if you have both diseases.

Genetics

An abnormal gene inherited from one or both of your parents can cause various substances to
build up in your liver, resulting in liver damage. Genetic liver diseases include:

i) Hemochromatosis

Hereditary hemochromatosis causes your body to absorb too much iron from the food you eat.
Excess iron is stored in your organs, especially your liver, heart and pancreas. Too much iron
can lead to life-threatening conditions, such as liver disease, heart problems and diabetes. The
genes that cause hemochromatosis are inherited, but only a minority of people who have the
genes ever develop serious problems. Signs and symptoms of hereditary hemochromatosis
usually appear in midlife.

Treatment includes regularly removing blood from your body. Because much of the body's iron
is contained in red blood cells, this treatment lowers iron levels.

Symptoms

Some people with hereditary hemochromatosis never have symptoms. Early signs and
symptoms often overlap with those of other common conditions.

Signs and symptoms may include:

• Joint pain

• Abdominal pain

• Fatigue
 

Weakness

• Diabetes

• Loss of sex drive

• Impotence

• Heart failure

• Liver failure

• Bronze or gray skin color

• Memory fog

When signs and symptoms typically appear

Hereditary hemochromatosis is present at birth. But most people don't experience signs and
symptoms until later in life — usually after the age of 40 in men and after age 60 in women.
Women are more likely to develop symptoms after menopause, when they no longer lose iron
with menstruation and pregnancy.

When to see a doctor

See your doctor if you experience any of the signs and symptoms of hereditary
hemochromatosis. If you have an immediate family member who has hemochromatosis, ask
your doctor about genetic tests that can determine if you have inherited the gene that increases
your risk of hemochromatosis.

Causes

Hereditary hemochromatosis is caused by a mutation in a gene that controls the amount of iron
your body absorbs from the food you eat. These mutations are passed from parents to children.
This type of hemochromatosis is by far the most common type.

Gene mutations that cause hemochromatosis

A gene called HFE is most often the cause of hereditary hemochromatosis. You inherit one HFE
gene from each of your parents. The HFE gene has two common mutations, C282Y and H63D.
Genetic testing can reveal whether you have these mutations in your HFE gene.
 

If you inherit 2 abnormal genes, you may develop hemochromatosis. You can also pass
the mutation on to your children. But not everyone who inherits two genes develops
problems linked to the iron overload of hemochromatosis.

 If you inherit 1 abnormal gene, you're unlikely to develop hemochromatosis. However,

you are considered a gene mutation carrier and can pass the mutation on to your children.
But your children wouldn't develop the disease unless they also inherited another
abnormal gene from the other parent.

How hemochromatosis affects your organs

Iron plays an essential role in several body functions, including helping in the formation of
blood. But too much iron is toxic.

A hormone called hepcidin, secreted by the liver, normally controls how iron is used and
absorbed in the body, as well as how excess iron is stored in various organs. In
hemochromatosis, the normal role of hepcidin is disrupted, causing your body to absorb more
iron than it needs.

This excess iron is stored in major organs, especially your liver. Over a period of years, the
stored iron can cause severe damage that may lead to organ failure and chronic diseases, such as
cirrhosis, diabetes and heart failure. Though many people have faulty genes that cause
hemochromatosis, not everyone develops iron overload to a degree that causes tissue and organ
damage.

Hereditary hemochromatosis isn't the only type of hemochromatosis. Other types include:

• Juvenile hemochromatosis. This causes the same problems in young people that
hereditary hemochromatosis causes in adults. But iron accumulation begins much earlier,
and symptoms usually appear between the ages of 15 and 30. This disorder is caused by
mutations in the hemojuvelin or hepcidin genes.

• Neonatal hemochromatosis. In this severe disorder, iron builds up rapidly in the liver of
the developing baby in the womb. It is thought to be an autoimmune disease, in which the
body attacks itself.

• Secondary hemochromatosis. This form of the disease is not inherited and is often
referred to as iron overload. People with certain types of anemia or chronic liver disease
may need multiple blood transfusions, which can lead to excess iron accumulation.
Risk factors

Factors that increase your risk of hereditary hemochromatosis include:

• Having 2 copies of a mutated HFE gene. This is the greatest risk factor for hereditary
hemochromatosis.

• Family history. If you have a first-degree relative — a parent or sibling — with

hemochromatosis, you're more likely to develop the disease.

• Ethnicity. People of Northern European descent are more prone to hereditary

hemochromatosis than are people of other ethnic backgrounds. Hemochromatosis is less
common in people of Black, Hispanic and Asian ancestry.

• Your sex. Men are more likely than women to develop signs and symptoms of
hemochromatosis at an earlier age. Because women lose iron through menstruation and
pregnancy, they tend to store less of the mineral than men do. After menopause or a
hysterectomy, the risk for women increases.

Complications

Untreated, hereditary hemochromatosis can lead to a number of complications, especially in

your joints and in organs where excess iron tends to be stored — your liver, pancreas and heart.
Complications can include:

• Liver problems. Cirrhosis — permanent scarring of the liver — is just one of the
problems that may occur. Cirrhosis increases your risk of liver cancer and other
lifethreatening complications.

• Diabetes. Damage to the pancreas can lead to diabetes.

• Heart problems. Excess iron in your heart affects the heart's ability to circulate enough
blood for your body's needs. This is called congestive heart failure. Hemochromatosis can
also cause abnormal heart rhythms (arrhythmias).

• Reproductive problems. Excess iron can lead to erectile dysfunction (impotence), and
loss of sex drive in men and absence of the menstrual cycle in women.

• Skin color changes. Deposits of iron in skin cells can make your skin appear bronze or
gray in color.
 ii) Wilson's disease
Wilson's disease is a rare inherited disorder that causes copper to accumulate in your liver, brain
and other vital organs. Most people with Wilson's disease are diagnosed between the ages of 5
and 35, but it can affect younger and older people, as well.

Copper plays a key role in the development of healthy nerves, bones, collagen and the skin
pigment melanin. Normally, copper is absorbed from your food, and excess is excreted through
a substance produced in your liver (bile).

But in people with Wilson's disease, copper isn't eliminated properly and instead accumulates,
possibly to a life-threatening level. When diagnosed early, Wilson's disease is treatable, and
many people with the disorder live normal lives.

Symptoms

Wilson's disease is present at birth, but signs and symptoms don't appear until the copper builds
up in the brain, liver or other organ. Signs and symptoms vary depending on the parts of your
body affected by the disease. They can include:

• Fatigue, lack of appetite or abdominal pain

• A yellowing of the skin and the whites of the eye (jaundice)

• Golden-brown eye discoloration (Kayser-Fleischer rings)

• Fluid buildup in the legs or abdomen

• Problems with speech, swallowing or physical coordination

• Uncontrolled movements or muscle stiffness

When to see a doctor

Make an appointment with your doctor if you have signs and symptoms that worry you,
especially if a family member has Wilson's disease.

Causes

Wilson's disease is inherited as an autosomal recessive trait, which means that to develop the
disease you must inherit one copy of the defective gene from each parent. If you receive only
one abnormal gene, you won't become ill yourself, but you're a carrier and can pass the gene to
your children. Risk factors

You can be at increased risk of Wilson's disease if your parents or siblings have the condition.
Ask your doctor whether you should undergo genetic testing to find out if you have Wilson's
disease. Diagnosing the condition as early as possible dramatically increases the chances of
successful treatment.

Complications

Untreated, Wilson's disease can be fatal. Serious complications include:

• Scarring of the liver (cirrhosis). As liver cells try to make repairs to damage done by
excess copper, scar tissue forms in the liver, making it more difficult for the liver to
function.

• Liver failure. This can occur suddenly (acute liver failure), or it can develop slowly over
years. A liver transplant might be a treatment option.

• Persistent neurological problems. Tremors, involuntary muscle movements, clumsy gait

and speech difficulties usually improve with treatment for Wilson's disease. However,
some people have persistent neurological difficulty despite treatment.

• Kidney problems. Wilson's disease can damage the kidneys, leading to problems such as
kidney stones and an abnormal number of amino acids excreted in the urine.

• Psychological problems. These might include personality changes,

depression, irritability, bipolar disorder or psychosis.

• Blood problems. These might include destruction of red blood cells (hemolysis) leading
to anemia and jaundice.

Cancer and other growths

Examples include:

I) Liver cancer

Liver cancer
 Liver cancer is cancer that begins in the cells of your liver. Your liver is a football-sized organ
that sits in the upper right portion of your abdomen, beneath your diaphragm and above your
stomach.

Several types of cancer can form in the liver. The most common type of liver cancer is
hepatocellular carcinoma, which begins in the main type of liver cell (hepatocyte). Other types
of liver cancer, such as intrahepatic cholangiocarcinoma and hepatoblastoma, are much less
common.

Cancer that spreads to the liver is more common than cancer that begins in the liver cells.
Cancer that begins in another area of the body — such as the colon, lung or breast — and then
spreads to the liver is called metastatic cancer rather than liver cancer. This type of cancer is
named after the organ in which it began — such as metastatic colon cancer to describe cancer
that begins in the colon and spreads to the liver.

Types

1. Hepatocellular carcinoma

Symptoms

Most people don't have signs and symptoms in the early stages of primary liver cancer. When
signs and symptoms do appear, they may include:

• Losing weight without trying

• Loss of appetite

• Upper abdominal pain

• Nausea and vomiting

• General weakness and fatigue

• Abdominal swelling

• Yellow discoloration of your skin and the whites of your eyes (jaundice)  White, chalky

stools
When to see a doctor

Make an appointment with your doctor if you experience any signs or symptoms that worry
you.

Causes

Liver cancer happens when liver cells develop changes (mutations) in their DNA. A cell's DNA
is the material that provides instructions for every chemical process in your body. DNA
mutations cause changes in these instructions. One result is that cells may begin to grow out of
control and eventually form a tumor — a mass of cancerous cells.

Sometimes the cause of liver cancer is known, such as with chronic hepatitis infections. But
sometimes liver cancer happens in people with no underlying diseases and it's not clear what
causes it.

Risk factors

Factors that increase the risk of primary liver cancer include:

• Chronic infection with HBV or HCV. Chronic infection with the hepatitis B virus
(HBV) or hepatitis C virus (HCV) increases your risk of liver cancer.

• Cirrhosis. This progressive and irreversible condition causes scar tissue to form in your
liver and increases your chances of developing liver cancer.

• Certain inherited liver diseases. Liver diseases that can increase the risk of liver cancer
include hemochromatosis and Wilson's disease.

• Diabetes. People with this blood sugar disorder have a greater risk of liver cancer than
those who don't have diabetes.

• Nonalcoholic fatty liver disease. An accumulation of fat in the liver increases the risk of
liver cancer.

• Exposure to aflatoxins. Aflatoxins are poisons produced by molds that grow on crops
that are stored poorly. Crops, such as grains and nuts, can become contaminated with
aflatoxins, which can end up in foods made of these products.
 
Excessive alcohol consumption. Consuming more than a moderate amount of alcohol
daily over many years can lead to irreversible liver damage and increase your risk of liver
cancer.

Prevention

Reduce your risk of cirrhosis

Cirrhosis is scarring of the liver, and it increases the risk of liver cancer. You can reduce your
risk of cirrhosis if you:

• Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit the amount
you drink. For women, this means no more than one drink a day. For men, this means no
more than two drinks a day.

• Maintain a healthy weight. If your current weight is healthy, work to maintain it by

choosing a healthy diet and exercising most days of the week. If you need to lose weight,
reduce the number of calories you eat each day and increase the amount of exercise you
do. Aim to lose weight slowly — 1 or 2 pounds (0.5 to 1 kilograms) each week.

Get vaccinated against hepatitis B

You can reduce your risk of hepatitis B by receiving the hepatitis B vaccine. The vaccine can be
given to almost anyone, including infants, older adults and those with compromised immune
systems.

Take measures to prevent hepatitis C

No vaccine for hepatitis C exists, but you can reduce your risk of infection.

• Know the health status of any sexual partner. Don't engage in unprotected sex unless
you're certain your partner isn't infected with HBV, HCV or any other sexually transmitted
infection. If you don't know the health status of your partner, use a condom every time
you have sexual intercourse.

• Don't use intravenous (IV) drugs, but if you do, use a clean needle. Reduce your risk
of HCV by not injecting illegal drugs. But if that isn't an option for you, make sure any
needle you use is sterile, and don't share it. Contaminated drug paraphernalia is a common
 
cause of hepatitis C infection. Take advantage of needle-exchange programs in your
community and consider seeking help for your drug use.

Seek safe, clean shops when getting a piercing or tattoo. Needles that may not be
properly sterilized can spread the hepatitis C virus. Before getting a piercing or tattoo,
check out the shops in your area and ask staff members about their safety practices. If
employees at a shop refuse to answer your questions or don't take your questions
seriously, take that as a sign that the facility isn't right for you.

ii) Cholangiocarcinoma (bile duct cancer)

Cholangiocarcinoma is a type of cancer that forms in the slender tubes (bile ducts) that carry the
digestive fluid bile. Bile ducts connect your liver to your gallbladder and to your small intestine.

Cholangiocarcinoma, also known as bile duct cancer, occurs mostly in people older than age 50,
though it can occur at any age.

Doctors divide cholangiocarcinoma into different types based on where the cancer occurs in the
bile ducts:

• Intrahepatic cholangiocarcinoma occurs in the parts of the bile ducts within the liver
and is sometimes classified as a type of liver cancer.

• Hilar cholangiocarcinoma occurs in the bile ducts just outside of the liver. This type is
also called perihilar cholangiocarcinoma.

• Distal cholangiocarcinoma occurs in the portion of the bile duct nearest the small
intestine. This type is also called extrahepatic cholangiocarcinoma.

Cholangiocarcinoma is often diagnosed when it's advanced, making successful treatment

difficult to achieve.

Types

1. Hilar cholangiocarcinoma

Symptoms

Signs and symptoms of cholangiocarcinoma include:

 
• Yellowing of your skin and the whites of your eyes (jaundice)

Intensely itchy skin

• White-colored stools

• Fatigue

• Abdominal pain on the right side, just below the ribs

• Losing weight without trying

• Fever

• Night sweats

• Dark urine

When to see a doctor

See your doctor if you have persistent fatigue, abdominal pain, jaundice, or other signs and
symptoms that bother you. He or she may refer you to a specialist in digestive diseases
(gastroenterologist).

Causes

Cholangiocarcinoma happens when cells in the bile ducts develop changes in their DNA. A
cell's DNA contains the instructions that tell a cell what to do. The changes tell the cells to
multiply out of control and form a mass of cells (tumor) that can invade and destroy healthy
body tissue. It's not clear what causes the changes that lead to cholangiocarcinoma.

Risk factors

Factors that may increase your risk of cholangiocarcinoma include:

• Primary sclerosing cholangitis. This disease causes hardening and scarring of the bile
ducts.

• Chronic liver disease. Scarring of the liver caused by a history of chronic liver disease
increases the risk of cholangiocarcinoma.

• Bile duct problems present at birth. People born with a choledochal cyst, which causes
dilated and irregular bile ducts, have an increased risk of cholangiocarcinoma.
 
• A liver parasite. In areas of Southeast Asia, cholangiocarcinoma is associated with liver
fluke infection, which can occur from eating raw or undercooked fish.

Older age. Cholangiocarcinoma occurs most often in adults over age 50.

• Smoking. Smoking is associated with an increased risk of cholangiocarcinoma.

• Diabetes. People who have type 1 or 2 diabetes may have an increased risk of
cholangiocarcinoma.

• Certain inherited conditions. Some DNA changes passed from parents to children cause
conditions that increase the risk of cholangiocarcinoma. Examples of these conditions
include cystic fibrosis and Lynch syndrome.

Prevention

To reduce your risk of cholangiocarcinoma, you can:

• Stop smoking. Smoking is linked to an increased risk of cholangiocarcinoma. If you

smoke, stop. If you have tried quitting in the past and haven't been successful, talk with
your doctor about strategies to help you quit.

• Reduce your risk of liver disease. Chronic liver disease is associated with an increased
risk of cholangiocarcinoma. Some causes of liver disease can't be prevented, but others
can. Do what you can to take care of your liver.

For instance, to reduce your risk of liver inflammation (cirrhosis), drink alcohol in
moderation, if you choose to drink. For healthy adults, that means up to one drink a day
for women and up to two drinks a day for men. Maintain a healthy weight. When working
with chemicals, follow the safety instructions.

iii) Liver adenoma/Hepatic Adenoma

It means having a liver tumor that is "benign." That's another way of saying that it isn't cancer. It
won't spread to other parts of your body.

Hepatic adenoma is very rare. It happens more often in women, because it's linked to the use of
birth control pills.
 
The tumor starts from liver cells called hepatocytes. You might also hear your doctor call it
hepatocellular adenoma.
Symptoms

About half of the time, hepatic adenomas don't cause any symptoms. You may not even know
that you have one. But some can cause pain or a lump in your stomach area. Or you may feel
bloated or full for no reason.

The tumor can also bleed heavily or burst, which can cause symptoms like:

• Severe belly pain

• Stomach bloating
• Vomiting
• A cold sweat
• A rapid pulse

If you have any of these symptoms, get medical help right away. It's a life-threatening emergency.

Causes

Anyone can get a hepatic adenoma. Changes in your genes, called mutations, may play a role.

There are certain things that can raise your chances of getting it. Medicines and conditions that
affect your sex hormones, such as estrogen and testosterone, may lead to a hepatic adenoma.

Birth control pills. Your odds of getting a hepatic adenoma go up when you take higher-dose
estrogen pills for longer periods of time.

Pregnancy. When you're expecting, your body releases higher levels of sex hormones.

Anabolic steroids. These drugs act like testosterone.

Clomiphene. This fertility drug has an effect similar to estrogen.

Recombinant human growth hormones. They're used to treat growth disorders.

Other things that raise your chances of getting hepatic adenoma include:

Obesity and metabolic syndrome. Doctors have seen a link between these problems and hepatic
adenoma, especially in men.

Type I and type III glycogen storage diseases. These genetic diseases can affect how your liver
works.

Barbiturates. These sedatives are linked with hepatic adenoma.

Diagnosis

If your doctor thinks you may have a liver tumor, you'll get an imaging test, such as an
ultrasound.

If the scans show that you have a tumor, you'll likely get another imaging test that can show more
detail, such as an MRI or a CT scan. This helps your doctor confirm that it's a hepatic adenoma.

In rare cases, your doctor may need more information about your tumor. You may need a
biopsy. That's a procedure where a doctor removes a sample of your tissue and checks it under a
microscope.

Types

There are four main kinds of hepatic adenoma. Each has different features, but they're usually
treated the same way.

Inflammatory. These make up 40%-50% of cases, and they're usually found in women.

HNF-1 inactivated. This type accounts for 35%-40% of all hepatic adenomas. Mostly seen in
women, HNF-1 inactivated adenomas usually don't have complications.

Beta-catenin activated. Men tend to get this kind of adenoma, which makes up 15%-20% of
cases.

Unclassified. These are 10% of hepatic adenomas.

Complications

If you don't get treatment, the tumor can bleed heavily or burst. This is more common in larger
tumors. Pregnant women, those who recently took hormones, and those with inflammatory
hepatic adenomas have higher chances of getting these complications.

About 5% of the time, hepatic adenomas turn into liver cancer. This happens more often in men,
as well as those with larger or beta-catenin activated tumors.

Treatment

If you're diagnosed with hepatic adenoma, your doctor will suggest that you stop taking any
medicines with estrogen, such as birth control pills. This may cause your tumor to shrink. Your
doctor will also encourage you to keep to a healthy weight.

Your doctor will also suggest treatment based on whether you're a man or a woman and the size of
your tumor.
Men. Hepatic adenomas are more likely to turn into cancer in men. Because of this, doctors
usually recommend that men have surgery to remove the tumor.

Women with small tumors and no symptoms. If your tumor is 5 centimeters or less, your
doctor will suggest watching the tumor over time instead of treating it. You'll get an MRI after 6
months and then once a year to make sure the tumor isn't getting bigger.

Women with small tumors and symptoms. Your doctor will likely suggest surgery.

Women with large tumors. If your tumor is more than 5 centimeters, your doctor will likely
recommend surgery. If you stopped taking birth control pills, you may wait 6 months to see if
the tumor shrinks.

If you can't or don't want to get surgery, your options include:

Trans arterial embolization. In this procedure, a doctor blocks blood flow to your tumor.

Radiofrequency ablation. This treatment may be useful for tumors less than 3 centimeters that
are causing pain. An electric current heats a small area of nerve tissue, which stops the pain.

Other

Additional, common causes of liver disease include:

• Chronic alcohol abuse

• Fat accumulation in the liver (nonalcoholic fatty liver disease)

• Certain prescription or over-the-counter medications

• Certain herbal compounds

Risk factors of liver disease

• Heavy alcohol use

• Obesity

• Type 2 diabetes

• Tattoos or body piercings

• Injecting drugs using shared needles

 • Blood transfusion before

• Exposure to other people's blood and body fluids

• Unprotected sex

• Exposure to certain chemicals or toxins

• Family history of liver disease

Complications of liver disease

Complications of liver disease vary, depending on the cause of your liver problems. Untreated
liver disease may progress to liver failure, a life-threatening condition.

Prevention

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.

Treatment

Treatment for liver disease depends on the diagnosis. Some liver problems can be treated with
lifestyle modifications, such as stopping alcohol use or losing weight, typically as part of a
medical program that includes careful monitoring of liver function. Other liver problems may
be treated with medications or may require surgery.

Treatment for liver disease that causes or has led to liver failure may ultimately require a liver
transplant.

Changing certain lifestyle habits can often help improve the health of the liver. If diagnosed
with liver disease, the following recommendations should apply:

• Reduce alcohol intake or stop completely.

• Avoid red meat, trans fats, processed carbohydrates and foods with high-fructose corn
syrup.

• Exercise 30 to 60 minutes around three to four times a week at a moderate intensity.

• Reduce calorie intake by 500 to 1,000 calories daily, if you're overweight.

Dietary management of liver disease

Some people with liver disease must eat a special diet. This diet helps the liver function and
protects it from working too hard.
Function
Proteins normally help the body repair tissue. They also prevent fatty buildup and damage to the
liver cells.
In people with badly damaged livers, proteins are not properly processed. Waste products may
build up and affect the brain.
 Dietary changes for liver disease may involve:

• Reducing the amount of animal protein you eat. This will help limit the buildup of toxic waste
products.

• Increasing your intake of carbohydrates to be in proportion with the amount of protein you eat.
• Eating fruits and vegetables and lean protein such as legumes, poultry, and fish. Avoid uncooked
shellfish.

• Taking vitamins and medicines prescribed by your health care provider for low blood count,
nerve problems, or nutritional problems from liver disease.
• Limiting your salt intake. Salt in the diet may worsen fluid buildup and swelling in the liver.

Preventing weight loss

Chronic liver disease, particularly liver cirrhosis (advanced liver disease) is often associated
with muscle and body fat loss. This may be difficult to see because of fluid gains around your
stomach or legs. For example, you may be losing muscle, but if you are carrying extra fluid
you may stay the same weight.

What to eat to prevent weight loss

To help prevent muscle and fat loss, you need to eat foods high in energy and protein
regularly throughout the day (e.g. every 2-3 hours). This is important for people with chronic
liver disease as the protein is used to maintain muscles and body tissues (including the liver)
and to keep the body working normally.

Role of exercise

Regular exercise can help to preserve your muscles. Speak to your doctor about a referral to an
exercise physiologist if you need help getting started or feel unsafe exercising.

Reducing fluid and/or salt

As liver disease progresses, excess fluid can build up around your stomach (ascites) and in
your feet and legs (oedema). If this occurs, it becomes very important to limit the amount of
salt (sodium) you eat. This is because salt acts like a sponge with fluid in your body.
Reducing the amount of salt you eat can limit the amount of fluid that stays in your body.
 Ideas to increase the protein and energy in your diet

Eat 6-8 smaller meals and snacks throughout the day, rather than 3 large meals, particularly if
you have a small appetite or feel full quickly.

• Always make sure each meal has some protein in it (meat, fish, eggs, legumes, nuts, seeds
yoghurt, low salt cheese)

• Use extra oil in cooking, frying and baking and on veggies and salads.

• Add eggs, legumes, yoghurt or low salt cheese to your meat dishes or salads.

• Have a small high-energy snack before going to bed.

• Replace tea, coffee or water with fluids that provide energy (such as milk based drinks).

• There are also several nutrition supplements available which are high in protein and energy.

Talk to your dietitian about these, if required.

Choosing foods that are high in protein and energy and lower in salt:
Include at least one food from the high energy and high protein columns from the table below at
each meal or snack.
The amount of energy and protein required over the day differs from person to person.
If you wish to know more about your energy or protein needs, please talk to your dietitian.

High energy foods lower in salt

Rolled oats, wheat or oat bran
• Pasta and rice, noodles
• Potato, sweet potato, corn, avocado
• Unsalted butter/margarine, olive oil, sunflower oil, canola oil
• Cream/mayonnaise
• Jam, honey, golden syrup, ice cream
• Fruit, dried fruit and fruit juice
• Sugar and sugary products including soft drinks

High protein foods lower in salt

Milk, milk powder and soy milk
• Cheese: Swiss, ricotta, bocconcini, cottage
• Yoghurt, custard
• Meat, chicken, pork, lamb, fresh fish
• Tinned fish in spring water/oil
• Eggs

• Unsalted nuts and seeds – (including pastes)

• Dried legumes – (lentils, chickpeas, kidney beans, soup mixes)
Note: Some of these high energy foods will not be appropriate for everyone, including those who
have diabetes.
If you are overweight, you should focus on having a high protein intake and limit fatty and
sweet foods. Sometimes people with liver disease require a low-fat diet. If your doctor
recommends a low-fat diet, see your dietitian for more information.

The following foods are good sources of protein and energy, however are high in salt so should be
avoided if you are carrying excess fluid.

High energy foods high in salt

Breakfast cereals
• Packet rice, pasta and instant noodles with flavouring
• Bread and bread products
• Pastries
• Cakes, biscuits and savoury crackers
• Potato chips
• Most takeaway and fast foods

High protein foods high in salt

Cheese – hard cheese, fetta, brie, camembert
• Cured or preserved meats e.g. ham, bacon, salami and other deli meats
• Prawns, oysters and other shellfish
• Tinned fish in brine or flavoured
• Tinned legumes – (baked beans, lentils, chickpeas)

Ideas to decrease salt in your diet

• Check nutrition labels:
- Aim for less than 2000mg salt (sodium) per day. There are a range of phone apps that can help
you count your salt intake – Easy Diet Diary, Calorie King Australia and FoodSwitch
(using the filter ‘SaltSwitch’).
- Select foods that have less salt (sodium), ideally less than 120mg per 100g serve.
- Avoid foods with more than 400mg per 100g serve.
• Avoid convenience/take-away foods.
• Avoid high salt foods such as processed meats (e.g. salami, ham, sausages, bacon), smoked
foods (e.g. salmon, ham), salty snacks (e.g. chips, olives, pretzels), pre-made sauces and soups.
• Don’t add salt to your meals or when cooking – use other herbs and spices to flavour your food
(e.g. pepper, garlic, herbs, spices, chilli, ginger, onions, chives, shallots, lemon, lime, vinegars,
salt reduced sauces (e.g. salt-reduced tomato paste, mango chutney, corn relish, balsamic glaze,
plum sauce, plain passata sauce)).

Ready-made meals
• Ready-to-eat meals can be found frozen or fresh and can be useful to have on hand if you are
too tired to cook or prefer not to cook for only one person.
• Aim for <600 mg of sodium per serve. There are also home meal delivery services available,
for example TLC Meals, Gourmet Meals or Meals on Wheels that offer low salt options. You can
check the service availability online or with your dietitian.
Nourishing drinks
Milk is a great base for nourishing drinks as it is high in protein and energy. It is better to use
full cream milk, as it contains more energy than low fat milks. Fortified soy milk (e.g. So
Good®) is also suitable. Almond / rice / oat / coconut milk contain little to no protein unless
they have extra added in. Increase the energy content of your milk by adding other ingredients
such as instant milk powder or ice cream and a variety of flavourings.
Supplying energy to the body overnight:
• The liver plays an essential role in supplying energy (in the form of glucose) to the body while
you are not eating overnight. • When you have liver disease this becomes harder to do - this
means the liver needs a regular supply of energy from our food, as it cannot rely on stored
energy. This means that as well as eating every 2-3 hours, you should also eat an energy-rich
snack before bed.
Some pre-bed snack ideas include:
• 2 thick slices of bread with swiss cheese or low salt nut paste
• 2 thick slices of raisin bread/ toast with low salt butter or nut paste
• Glass of milk with milo and slice of bread/toast
• 1 tub of yoghurt/ custard/ ice-cream with fruit
• 1 cup of Just Right or whole-grain cereal/ muesli with ¾ cup of milk
• Muesli bar and fruit smoothie/ glass of milk/ creamed rice/ rice pudding with fruit/ honey
• High energy supplement drink
Vitamins and minerals
The changes that occur in liver disease can lead to vitamin and/or mineral deficiencies. Eating a
variety of foods can help to avoid deficiencies. However, your doctor may still recommend a
vitamin/mineral supplement if required. Avoid taking any supplements or following diets not
recommended by your doctor or dietitian.

Suggested meal plan

BREAKFAST
½ cup rolled oats or Weet-Bix with full cream milk and honey, cream, nuts/seeds or fruit Or 2
slices salt reduced bread with 2 eggs, tomato, unsalted butter or avocado Plus Yoghurt or fruit

MORNING TEA

Raw, unsalted nuts

Or Milk based drink (e.g. milkshake/ smoothie, Up & Go, flavoured milk, supplement drink)

LUNCH
2 slices salt reduced bread
With salad, avocado and fresh meat
Or Tinned fish (in olive oil) with rice and vegetables or salad
Plus 1 yoghurt or dairy dessert or fruit

AFTERNOON TEA
Reduced salt rice crackers with ricotta cheese or cottage cheese

DINNER

100-120g lean meat, chicken or fish (fresh)

Plus 1 cup plain pasta or 2/3 cup rice or mashed potato (using unsalted butter/margarine)
Plus vegetables – roasted or stir fried with olive, canola, safflower or sunflower oil

SUPPER
Yoghurt / Custard OR supplement drink (e.g. Sustagen) Or
Just Right or whole-grain cereal/muesli with ¾ cup of milk
OR 2 slices of raisin toast with low salt butter.

MANAGEMENT OF GALLBLADDER DISORDERS

The term gallbladder disease is used for several types of conditions that
can affect your gallbladder.

The gallbladder is a small pear-shaped sac located underneath your liver. The gallbladder’s main
function is to store the bile produced by your liver and pass it along through a duct that empties
into the small intestine. Bile helps to digest fats in your small intestine.

Inflammation causes the majority of gallbladder diseases due to irritation of the gallbladder
walls, which is known as cholecystitis. This inflammation is often due to gallstones blocking
the ducts leading to the small intestine and causing bile to build up. It may eventually lead to
necrosis (tissue destruction) or gangrene.

Types of gallbladder diseases

There are many different types of gallbladder diseases.

i) Gallstones

Gallstones develop when substances in the bile (such as cholesterol, bile salts, and calcium) or
substances from the blood (like bilirubin) form hard particles that block the passageways to the
gallbladder and bile ducts.

Gallstones also tend to form when the gallbladder doesn’t empty completely or often enough.
They can be as small as a grain of sand or as large as a golf ball.

Numerous factors contribute to your risk of gallstones. These include:

 • being overweight or obese

• having diabetes

• being age 60 or older

• taking medications that contain estrogen

• having a family history of gallstones

• being female

• having Crohn’s disease and other conditions that affect how nutrients are absorbed

• having cirrhosis or other liver diseases

ii) Cholecystitis

Cholecystitis is the most common type of gallbladder disease. It presents itself as either an acute
or chronic inflammation of the gallbladder.

Acute cholecystitis

Acute cholecystitis is generally caused by gallstones. But it may also be the result of tumors or
various other illnesses.

It may present with pain in the upper right side or upper middle part of the abdomen. The pain
tends to occur right after a meal and ranges from sharp pangs to dull aches that can radiate to
your right shoulder. Acute cholecystitis can also cause:

• fever

• nausea

• vomiting

• jaundice

Chronic cholecystitis

After several attacks of acute cholecystitis, the gallbladder can shrink and lose its ability to store
and release bile. Abdominal pain, nausea, and vomiting may occur. Surgery is often the needed
treatment for chronic cholecystitis.
 iii) Choledocholithiasis

Gallstones may become lodged in the neck of the gallbladder or in the bile ducts. When the
gallbladder is plugged in this way, bile can’t exit. This may lead to the gallbladder becoming
inflamed or distended.

The plugged bile ducts will further prevent bile from traveling from the liver to the intestines.
Choledocholithiasis can cause:

• extreme pain in the middle of your upper abdomen

• fever

• chills

• nausea

• vomiting

• jaundice

• pale- or clay-colored stools

iv) 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

v) 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 diagnose 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.

vi) 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 percent 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.
 vii) 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.

viii) 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.

ix) 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

 x) 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.

How to diagnose gallbladder disease

To diagnose gallbladder disease, your doctor will ask you about your medical history and
perform an abdominal exam. This will include checking for pain in the abdomen. One or more
of the following tests and procedures may be used:

Detailed medical history

A list of symptoms you’re experiencing and any personal or family history of gallbladder
disease are important. A general health assessment may also be performed to determine if there
are any signs of a long-term gallbladder disease.

Physical exam

Your doctor may perform a special maneuver during the abdominal exam to look for what’s
referred to as “Murphy’s sign.”

During this maneuver, your doctor will put their hand on your abdomen over the area of the
gallbladder. They’ll then ask you to take a breath while examining and feeling the area. If you
feel significant pain, it suggests you may have gallbladder disease.

Chest and abdominal X-ray

Symptomatic cholecystitis will sometimes show stones on abdominal X-rays if the stones contain
calcium. An X-ray of the chest may show pleurisy or pneumonia.
However, X-rays aren’t the best test for identifying gallbladder disease. They’re often used to rule
out other potential causes of pain that’s not related to gallstones, the gallbladder, or the liver.

Ultrasound

An ultrasound uses sound waves to produce images inside your body. This test is one of the
main methods your doctor uses to make a diagnosis of gallbladder disease. An ultrasound can
evaluate the gallbladder for the presence of gallstones, thickened walls, polyps, or masses. It
can also identify any issues within your liver.

HIDA scan

A HIDA scan looks at the duct system within the gallbladder and liver. It’s often used when a
person has gallbladder symptoms but the ultrasound didn’t show a reason for the symptoms. A
HIDA scan can also be used for a more thorough evaluation of the bile duct system.

This test can evaluate the function of the gallbladder using a harmless radioactive substance.
The substance is injected into a vein and then watched as it moves through the gallbladder.
Another chemical may also be injected that causes the gallbladder to release bile.

A HIDA scan shows how the gallbladder moves bile through the bile duct system. It can also
measure the rate of bile moving out of the gallbladder. This is known as the ejection fraction. A
normal ejection fraction for the gallbladder is considered between 35 to 65 percent.

Other tests

Other imaging tests, such as a CT and MRI scan, can also be used. Blood tests are also done to
check for increased white blood cell counts and abnormal liver function.

Endoscopic retrograde cholangiopancreatography (ERCP) is a more invasive but useful test. A

flexible camera is inserted into the mouth and down past the stomach into the small intestine.
Contrast dye is injected to show the bile duct system with a specialized X-ray.

ERCP is an especially useful test if a blockage due to gallstones is suspected. Any gallstone that is
causing blockage can often be removed during this procedure.
How to treat gallbladder disease

Lifestyle changes

Since certain health conditions increase the risk of gallstone formation, changes in lifestyle may
help manage gallbladder disease in people without symptoms. Being overweight and having
diabetes increases the likelihood of gallstones. Losing weight and getting good control over
diabetes may help lower your risk.

However, rapid weight loss can also trigger gallstone formation. Talk to your doctor about safe
ways to lose weight.

Increasing physical activity also appears to decrease gallstone formation along with lowering
high triglycerides, a type of fat in the blood. It’s often recommended to quit smoking and limit
alcohol intake as well.

Medical treatment

The first episode of gallbladder inflammation is often treated with pain medications. Because
the pain is often severe, prescription medications are needed. Your doctor may prescribe
medications with codeine or hydrocodone. IV prescription anti-inflammatories may be
prescribed, or stronger pain medications like morphine.

Over-the-counter medications like ibuprofen (Advil) and naproxen (Aleve) may not be used as
often due to the increased risk of nausea and vomiting. If you’re dehydrated, anti-inflammatory
drugs may also cause severe kidney issues.

Most people have difficulty managing the pain and its accompanying symptoms at home. Talk
with your doctor to discuss the best treatment for you.

Ongoing research is looking into the use of the medication ezetimibe and its role in decreasing
the formation of cholesterol gallstones. This medication changes how the body absorbs
cholesterol from the intestinal tract.
Surgery

Surgery will be recommended to remove your gallbladder if you’ve experienced multiple

episodes of inflammation. Gallbladder surgery continues to be the most effective method for
treating active gallbladder disease.

The surgery can be done either by opening your abdomen with an incision, or laparoscopically.
This involves making several poke holes through the abdominal wall and inserting a camera.
Laparoscopic surgery allows for faster recovery. This method is preferred for people who don’t
have complications of significant gallbladder disease.

After gallbladder surgery by either method, it’s not uncommon for people to experience some
diarrhea. According to the Mayo Clinic, up to 3 out of 10 people can have diarrhea after
gallbladder surgery.

For most people, diarrhea will only last a few weeks. But in a few cases, it can last for years. If
diarrhea is continuing after surgery for more than two weeks, talk to your doctor. Depending on
other symptoms, you may require follow-up testing.

Complications of gallbladder disease

The gallbladder may form an abnormal passageway, or fistula, between the gallbladder and the

intestine to help process the liver’s bile. This is most often a complication of chronic

inflammation related to gallstones. Other complications can include:

• obstruction of the intestine

• inflammation and scarring

• perforation (a hole in the gallbladder)

• bacterial contamination of the abdomen, known as peritonitis

• malignant transformation (the change cells undergo to become a cancerous tumor)

Prevention of gallbladder disease

Certain risk factors for gallbladder disease, such as sex and age, can’t be changed. However,
your diet may play a role in developing gallstones. Foods high in fiber and healthy fats may
help prevent gallstones.

Refined grains (found in sugary cereals and white rice, bread, and pasta) and sugary sweets are
associated with a higher risk of gallbladder disease. Whole grains like brown rice and whole
wheat bread and fats from fish and olive oil are all recommended.

The earlier gallbladder problems are recognized and treated, the less likely significant
complications will occur.

Symptoms of a gallbladder problem

Gallbladder conditions share similar symptoms. These include:

Pain

The most common symptom of a gallbladder problem is pain. This pain usually occurs in the mid-
to upper-right section of your abdomen.

It can be mild and intermittent, or it can be quite severe and frequent. In some cases, the pain can
begin to radiate to other areas of the body, including the back and chest.

Nausea or vomiting

Nausea and vomiting are common symptoms of all types of gallbladder problems. However, only
chronic gallbladder disease may cause digestive problems, such as acid reflux and gas.

Fever or chills

Chills or an unexplained fever may signal that you have an infection. If you have an infection,
you need treatment before it worsens and becomes dangerous. The infection can become
lifethreatening if it spreads to other parts of the body.
Chronic diarrhea

Having more than four bowel movements per day for at least three months may be a sign of
chronic gallbladder disease.

Jaundice

Yellow-tinted skin, or jaundice, may be a sign of a block or stone in the common bile duct. The
common bile duct is the channel that leads from the gallbladder to the small intestine.

Unusual stools or urine

Lighter-colored stools and dark urine are possible signs of a common bile duct block.

Potential gallbladder problems

Any disease that affects your gallbladder is considered a gallbladder disease. The following
conditions are all gallbladder diseases.

Inflammation of the gallbladder

Inflammation of the gallbladder is called cholecystitis. It can be either acute (short-term), or

chronic (long-term).

Chronic inflammation is the result of several acute cholecystitis attacks. Inflammation may
eventually damage the gallbladder, making it lose its ability to function correctly.

Gallstones

Gallstones are small, hardened deposits that form in the gallbladder. These deposits can develop
and go undetected for years.

In fact, many people have gallstones and aren’t aware of them. They eventually cause problems,
including inflammation, infection, and pain. Gallstones typically cause acute cholecystitis.

Gallstones are usually very small, no more than a few millimeters wide. However, they can
grow to several centimeters. Some people develop only one gallstone, while others develop
several. As the gallstones grow in size, they can begin to block the channels that lead out of the
gallbladder.

Most gallstones are formed from cholesterol found in the gallbladder’s bile. Another type of
gallstone, a pigment stone, is formed from calcium bilirubinate. Calcium bilirubinate is a
chemical that’s produced when the body breaks down red blood cells. This type of stone is rarer.

Common bile duct stones (choledocholithiasis)

When gallstones occur in the common bile duct, it’s known as choledocholithiasis. Bile is ejected
from the gallbladder, passed through small tubes, and deposited in the common bile duct. It then
enters the small intestine.

In most cases, common bile duct stones are actually gallstones that developed in the gallbladder
and then passed into the bile duct. This type of stone is called a secondary common bile duct
stone, or secondary stone.

Sometimes stones form in the common bile duct itself. These stones are called primary common
bile duct stones, or primary stones. This rare type of stone is more likely to cause an infection
than a secondary stone.

Gallbladder disease without stones

Gallstones don’t cause every type of gallbladder problem. Gallbladder disease without stones,
also called acalculous gallbladder disease, can occur. In this case, you may experience
symptoms commonly associated with gallstones without actually having stones.

Common bile duct infection

An infection may develop if the common bile duct is obstructed. Treatment for this condition is
successful if the infection is found early. If it’s not, the infection may spread and become fatal.

Abscess of the gallbladder

A small percentage of people with gallstones may also develop pus in the gallbladder. This
condition is called empyema.
Pus is a combination of white blood cells, bacteria, and dead tissue. The development of pus,
also known as an abscess, leads to severe abdominal pain. If empyema isn’t diagnosed and
treated, it can become life-threatening as the infection spreads to other parts of the body.

Gallstone ileus

A gallstone may travel into the intestine and block it. This condition, known as gallstone ileus, is
rare but can be fatal. It’s most common among individuals who are older than 65 years old.

Perforated gallbladder

If you wait too long to seek treatment, gallstones can lead to a perforated gallbladder. This is a
life-threatening condition. If the tear isn’t detected, a dangerous, widespread abdominal
infection may develop.

Gallbladder polyps

Polyps are abnormal tissue growths. These growths are typically benign, or noncancerous.
Small gallbladder polyps may not need to be removed. In most cases, they don’t pose any risk to
you or your gallbladder.

However, larger polyps may need to be surgically removed before they develop into cancer or
cause other problems.

Porcelain gallbladder

A healthy gallbladder has very muscular walls. Over time, calcium deposits can stiffen the
gallbladder walls, making them rigid. This condition is called porcelain gallbladder.

If you have this condition, you have a high risk of developing gallbladder cancer.

Gallbladder cancer

Gallbladder cancer is rare. If it’s not detected and treated, it can spread beyond the gallbladder
quickly.
Treatment for a gallbladder problem

Treatment will depend on your specific gallbladder problem and may include:

• over-the-counter (OTC) pain medications, such as ibuprofen (Aleve, Motrin)

• prescription pain medications, such as hydrocodone and morphine

• lithotripsy, a procedure that uses shock waves to break apart gallstones and other masses

• surgery to remove gallstones

• surgery to remove the entire gallbladder

Not all cases will require medical treatment. You may also be able to find pain relief with natural
remedies, such as exercise and a heated compress.

The gallbladder diet

If you’re experiencing gallbladder problems, you may find it beneficial to adjust your diet. Foods
that may aggravate gallbladder disease include:

• foods high in trans fats and other unhealthy fats

• processed foods

• refined carbohydrates, such as white bread and sugar

Instead, try to build your diet around:

• fiber-rich fruits and vegetables

• calcium-rich foods, such as low-fat dairy and dark leafy greens

• foods containing vitamin C, such as berries

• plant-based protein, such as tofu, beans and lentils

• healthy fats, such as nuts and fish

• coffee, which reduces your risk of gallstones and other gallbladder diseases
When to see a doctor

Symptoms of a gallbladder problem may come and go. However, you’re more likely to develop a
gallbladder problem if you’ve had one before.

While gallbladder problems are rarely deadly, they should still be treated. You can prevent
gallbladder problems from worsening if you take action and see a doctor. Symptoms that should
prompt you to seek immediate medical attention include:

• abdominal pain that lasts at least 5 hours

• jaundice

• pale stools

• sweating, low-grade fever, or chills, if they’re accompanied by the above symptoms

How food affects the gallbladder

The gallbladder is a small organ located below the liver. It stores bile produced by the liver, and
releases the bile into the small intestine to help digest food.

The gallbladder is a sensitive organ, and maintaining a healthy diet full of nutrient-dense foods
helps keep it in perfect health. Certain foods can protect and promote a healthy gallbladder,
while others increase the likelihood of problems like inflammation or gallstones.

If your gallbladder isn’t kept in good health, it may need to be removed. So eating a gallbladder-
healthy diet is essential.

Gallbladder-friendly foods

For a healthy gallbladder, incorporate the following foods into your diet:

• bell peppers

• citrus fruits

• dark, leafy greens

• tomatoes

• milk
 • sardines

• fish and shellfish

• low-fat dairy

• beans

• nuts

• lentils

• tofu

• tempeh

Eating a healthy, well-balanced diet full of fruits and vegetables is the best way to improve and
protect your gallbladder’s health. Fruits and vegetables are full of nutrients and fiber, the latter
of which is essential to a healthy gallbladder.

Some of the listed foods are either high in vitamin C, calcium, or B vitamins, which are also good
for your gallbladder.

It’s thought that eating more plant-based protein could also help prevent gallbladder disease.
Foods like beans, nuts, lentils, tofu, and tempeh (as long as you aren’t allergic to soy) are
excellent alternatives for red meat.

Foods that aggravate your gallbladder

Avoid the following foods for a healthy gallbladder diet:

• vegetable oil

• peanut oil

• Refined white foods (breads, pastas, etc.)

• foods high in fat

• processed foods

You should avoid certain foods to help protect your gallbladder. The biggest problem foods are
high-fat and processed foods. Foods that are greasy or fried in oils like vegetable oil and peanut
oil are more difficult to break down and can cause gallbladder problems.
Foods with trans fats, like those in processed or commercially baked products, can also be
harmful to gallbladder health.

Avoiding refined white foods, like white pastas, breads, and sugars, can protect your gallbladder.
You should also avoid alcohol and tobacco.

Gallbladder diet after surgery

If you need to have your gallbladder removed, you’ll likely experience diarrhea and loose stools
in the weeks after surgery. This is due to the more continuous release of bile into your intestines.

To reduce these side effects, avoid these foods after gallbladder surgery:

• foods containing more than 3 grams of fat

• greasy, fried, or processed foods

• cream sauces or gravies

• full-fat dairy

Causes of gallbladder problems

There are two primary types of gallbladder problems: cholecystitis (inflammation of the
gallbladder) and cholestasis (gallstones). Some people with gallstones don’t experience any
symptoms. In those that do, symptoms of gallbladder problems can include:

• pain on the upper right side of the abdomen, especially following meals and eating fatty
foods

• loss of appetite

• nausea

• vomiting

• jaundice, if the gallbladder ducts are blocked

• low-grade fever

• tea-colored urine

• light-colored stools
Gallstones can be painful. If large enough, they can also block the duct that leads out of the
gallbladder. Over time, this can become life-threatening. In these cases, removal of the
gallbladder is often necessary.

Women are more likely to develop gallstones than men. Pregnant women, women using
hormonal birth control, and women who use hormone replacement therapy are at increased risk
for the formation of gallstones. Other risk factors include:

• a history of gallbladder problems, either personally or in your immediate family

• excess weight

• rapid weight loss followed by weight gain

• coronary artery disease

• diabetes

• diets high in refined carbohydrates and calories but low in fiber

• ignoring existing food allergies, like celiac disease

• lactose intolerance
3. MANAGEMENT OF PANCREATIC DISORDERS

The pancreas is a long, flat gland that sits tucked behind the stomach in the upper abdomen.
The pancreas produces enzymes that help digestion and hormones that help regulate the
way your body processes sugar (glucose).

Pancreatitis is inflammation of the pancreas. Pancreatitis can occur as acute pancreatitis —

meaning it appears suddenly and lasts for days. Some people develop chronic pancreatitis,
which is pancreatitis that occurs over many years.

Mild cases of pancreatitis improve with treatment, but severe cases can cause life-threatening
complications.
Common disorders of the pancreas

The evaluation of pancreatic diseases can be difficult due to the inaccessibility of the pancreas.
There are multiple methods to evaluate the pancreas. Initial tests of the pancreas include a
physical examination, which is difficult since the pancreas is deep in the abdomen near the
spine. Blood tests are often helpful in determining whether the pancreas is involved in a
specific symptom but may be misleading. The best radiographic tests to evaluate the structure
of the pancreas include CAT (computed tomography) scan, endoscopic ultrasound, and MRI
(magnetic resonance imaging). Tests to evaluate the pancreatic ducts include ERCP (endoscopic
retrograde cholangiopancreatography) and MRCP(magnetic resonance
cholangiopancreatography). There are also instances in which surgical exploration is the only
way to confirm the diagnosis of pancreatic disease.
Types of pancreatic disorders

There are a variety of disorders of the pancreas including; acute pancreatitis, chronic
pancreatitis, hereditary pancreatitis, and pancreatic cancer.

i) Acute Pancreatitis

Acute pancreatitis is a sudden attack causing inflammation of the pancreas and is usually
associated with severe upper abdominal pain. The pain may be severe and last several days.
Other symptoms of acute pancreatitis include nausea, vomiting, diarrhea, bloating, and fever.
Other causes include chronic alcohol consumption, hereditary conditions, trauma, medications,
infections, electrolyte abnormalities, high lipid levels, hormonal abnormalities, or other
unknown causes. The treatment is usually supportive with medications showing no benefit.
Most patients with acute pancreatitis recover completely.

ii) Chronic Pancreatitis

Chronic pancreatitis is the progressive disorder associated with the destruction of the pancreas.
The disease is more common in men and usually develops in persons between 30 and 40 years
of age. Initially, chronic pancreatitis may be confused with acute pancreatitis because the
symptoms are similar. The most common symptoms are upper abdominal pain and diarrhea. As
the disease becomes more chronic, patients can develop malnutrition and weight loss. If the
pancreas becomes destroyed in the latter stages of the disease, patients may develop diabetes
mellitus.

The treatment for chronic pancreatitis depends on the symptoms. Most therapies center on pain
management and nutritional support. Oral pancreatic enzyme supplements are used to aid in the
digestion of food. Patients who develop diabetes require insulin to control blood sugar. The
avoidance of alcohol is central to therapy.

iii) Hereditary Pancreatitis

In some cases, pancreatitis is related to inherited abnormalities of the pancreas or intestine.

Acute recurrent attacks of pancreatitis early in life (under age 30) can often progress to chronic
pancreatitis. The most common inherited disorder that leads to chronic pancreatitis is cystic
fibrosis. Recent research demonstrates genetic testing can be a valuable tool in identifying
patients predisposed to hereditary pancreatitis.
 As in chronic pancreatitis, hereditary pancreatitis is a progressive disease with a high risk of
permanent problems. Patients with these disorders may have chronic pain, diarrhea,
malnutrition, or diabetes. Treatment focuses on pain control and pancreatic enzyme
replacement.

iv) Pancreatic Cancer

Pancreatic cancer is the fourth most common cause of cancer death in men and the fifth in
women. Cancer of the pancreas is resistant to many standard treatments including
chemotherapy and radiation therapy. This cancer grows insidiously and initially does not cause
symptoms. The classic presentation of pancreatic cancer is referred to as painless jaundice, a
yellowish skin discoloration with no other symptoms. The diagnosis is usually made using
different radiographic imaging techniques.

If detected in the early stages, pancreatic cancer can be cured by surgical resection.
Unfortunately, early detection is more the exception than the rule. At later stages, treatment can
improve the quality of life by controlling symptoms and complications.

Symptoms of pancreatic disorders

The symptoms of the diseased pancreas include:

• Abdominal pain.
• Nausea.
• Vomiting.
• Bloating.
• Diarrhea or oily stools.
• Fever.
• Weight loss.
• Malnutrition.

Dietary management of Pancreatic disorders

Nutrition is a vitally important part of treatment for patients with pancreatitis. The primary goals
of nutritional management for chronic pancreatitis are:

• Prevent malnutrition and nutritional deficiencies

• Maintain normal blood sugar levels (avoid both hypoglycemia and hyperglycemia)
• Prevent or optimally manage diabetes, kidney problems, and other conditions associated with
chronic pancreatitis
• Avoid causing an acute episode of pancreatitis
To best achieve those goals, it is important for pancreatitis patients to eat high protein,
nutrientdense diets that include fruits, vegetables, whole grains, low fat dairy, and other lean
protein sources. Abstinence from alcohol and greasy or fried foods is important in helping to
prevent malnutrition and pain.

Nutritional assessments and dietary modifications are made on an individual basis because each
patient’s condition is unique and requires an individualized plan.

Vitamins & Minerals

Patients with chronic pancreatitis are at high risk for malnutrition due to malabsorption and
depletion of nutrients as well as due to increased metabolic activity. Malnutrition can be further
affected by ongoing alcohol abuse and pain after eating. Vitamin deficiency from malabsorption
can cause osteoporosis, digestive problems, abdominal pain, and other symptoms.

Therefore, patients with chronic pancreatitis must be tested regularly for nutritional deficiencies.
Vitamin therapies should be based on these annual blood tests. In general, multivitamins,
calcium, iron, folate, vitamin E, vitamin A, vitamin D, and vitamin B12 may be supplemented,
depending on the results of blood work.

If you have malnutrition, you may benefit from working with our Registered Dietitian who can
guide you towards a personalized diet plan.

Risk of diabetes in chronic pancreatitis

Chronic pancreatitis also causes the pancreas to gradually lose its ability to function properly, and
endocrine function will eventually be lost. This puts patients at risk for type 1 diabetes.
Patients should therefore avoid refined sugars and simple carbohydrates.

Enzyme Supplementation

If pancreatic enzymes are prescribed, it is important to take them regularly in order to prevent
flare-ups.
The healthy pancreas is stimulated to release pancreatic enzymes when undigested food reaches
the small intestine. These enzymes join with bile and begin breaking down food in the small
intestine.

Since your pancreas is not working optimally, you may not be getting the pancreatic enzymes
you need to digest your food properly. Taking enzymes can help to digest your food, thus
improving any signs or symptoms of steatorrhea (excess fat in the stool, or fat malabsorption).
In turn this will improve your ability to eat better, lowering your risk for malnutrition.

Alcohol

If pancreatitis was caused by alcohol use, you should abstain from alcohol. If other causes of
acute pancreatitis have been addressed and resolved (such as via gallbladder removal) and the
pancreas returned to normal, you should be able to lead a normal life, but alcohol should still be
taken only in moderation (maximum of 1 serving/day). In chronic pancreatitis, there is ongoing
inflammation and malabsorption — patients gradually lose digestive function and eventually
lose insulin function — so regular use of alcohol is unwise.

Smoking

People with pancreatitis should avoid smoking, as it increases the risk for pancreatic cancer.

4. MANAGEMENT OF CARDIOVASCULAR DISEASES

Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels.

Anatomy of the heart

The heart consists of four chambers:

• The atria: These are the two upper chambers, which receive blood.

• The ventricles: These are the two lower chambers, which discharge blood.

A wall of tissue called the septum separates the left and right atria and the left and right ventricle.
Valves separate the atria from the ventricles.
The heart’s walls consist of three layers of tissue:

• Myocardium: This is the muscular tissue of the heart.

• Endocardium: This tissue lines the inside of the heart and protects the valves and
chambers.

• Pericardium: This is a thin protective coating that surrounds the other parts.

• Epicardium: This protective layer consists mostly of connective tissue and forms the
innermost layer of the pericardium.

How the heart works

The rate at which the heart contracts depends on many factors, such as:

• activity and exercise

• emotional factors

• some medical conditions

• a fever

• some medications

• dehydration

At rest, the heart might beat around 60 times each minute. But this can increase to 100 beats per
minute (bpm) or more.

Left and right sides

The left and right sides of the heart work in unison. The atria and ventricles contract and relax in
turn, producing a rhythmic heartbeat.

Right side

The right side of the heart receives deoxygenated blood and sends it to the lungs.

• The right atrium receives deoxygenated blood from the body through veins called the
superior and inferior vena cava. These are the largest veins in the body.

• The right atrium contracts, and blood passes to the right ventricle.
 • Once the right ventricle is full, it contracts and pumps the blood to the lungs via the
pulmonary artery. In the lungs, the blood picks up oxygen and offloads carbon dioxide.

Left side

The left side of the heart receives blood from the lungs and pumps it to the rest of the body.

• Newly oxygenated blood returns to the left atrium via the pulmonary veins.

• The left atrium contracts, pushing the blood into the left ventricle.

• Once the left ventricle is full, it contracts and pushes the blood back out to the body via
the aorta.

Diastole, systole, and blood pressure Each

heartbeat has two parts:

Diastole: The ventricles relax and fill with blood as the atria contract, emptying all blood into the
ventricles.

Systole: The ventricles contract and pump blood out of the heart as the atria relax, filling with
blood again. lader

When a person takes their blood pressure, the machine will give a high and a low number. The
high number is the systolic blood pressure, and the lower number is the diastolic blood pressure.

Systolic pressure: This shows how much pressure the blood creates against the artery walls
during systole.

Diastolic pressure: This shows how much pressure is in the arteries during diastole.

Gas exchange

When blood travels through the pulmonary artery to the lungs, it passes through tiny capillaries
that connect on the surface of the lung’s air sacs, called the alveoli.
The body’s cells need oxygen to function, and they produce carbon dioxide as a waste product.
The heart enables the body to eliminate the unwanted carbon dioxide.

Oxygen enters the blood and carbon dioxide leaves it through the capillaries of the alveoli.

The coronary arteries on the surface of the heart supply oxygenated blood to the heart muscle.

Pulse

A person can feel their pulse at points where arteries pass close to the skin’s surface, such as on
the wrist or neck. The pulse is the same as the heart rate. When you feel your pulse, you feel the
rush of blood as the heart pumps it through the body.

A healthy pulse is usually 60–100 bpm, and what is normal can vary from person to person.

A very active person may have a pulse as low as 40 bpm. People with a larger body size tend to
have a faster pulse, but it is not usually over 100 bpm.

Valves

The heart has four valves to ensure that blood only flows in one direction:

• Aortic valve: This is between the left ventricle and the aorta.

• Mitral valve: This is between the left atrium and the left ventricle.

• Pulmonary valve: This is between the right ventricle and the pulmonary artery.

• Tricuspid valve: This is between the right atrium and right ventricle.

Most people are familiar with the sound of the heart. In fact, the heart makes many types of
sound, and doctors can distinguish these to monitor the health of the heart.

The opening and closing of the valves are key contributors to the sound of the heartbeat. If there
is leaking or a blockage of the heart valves, it can create sounds called “murmurs.”
The heart’s electrical system

To pump blood throughout the body, the muscles of the heart must work together to squeeze the
blood in the right direction, at the right time, and with the right force. Electrical impulses
coordinate this activity.

The electrical signal begins at the sino-atrial node, sometimes called the sinus, or SA, node.
This is the heart’s pacemaker, and it sits at the top of the right atrium. The signal causes the atria
to contract, pushing blood down into the ventricles.

The electrical impulse then travels to an area of cells at the bottom of the right atrium, between the
atria and ventricles, called the atrioventricular, or AV, node.

These cells act as a gatekeeper. They coordinate the signal so that the atria and ventricles do not
contract at the same time. There needs to be a slight delay.

From here, the signal travels along fibers, called Purkinje fibers, within the ventricle walls. The
fibers pass the impulse to the heart muscle, causing the ventricles to contract.

Blood vessels

There are three types of blood vessels:

Arteries: These carry oxygenated blood from the heart to the rest of the body. The arteries are
strong, muscular, and stretchy, which helps push blood through the circulatory system, and they
also help regulate blood pressure. The arteries branch into smaller vessels called arterioles.

Veins: These carry deoxygenated blood back to the heart, and they increase in size as they get
closer to the heart. Veins have thinner walls than arteries.

Capillaries: These connect the smallest arteries to the smallest veins. They have very thin walls,
which allow them to exchange compounds such as carbon dioxide, water, oxygen, waste, and
nutrients with surrounding tissues.

The heart, blood, and blood vessels make up the circulatory, or cardiovascular, system.
Cardiac arrest: When the heart stops

The heart is essential to life — if it stops beating, blood will not reach the brain and other organs,
and the person can die within minutes. This is called cardiac arrest.
If a person experiences cardiac arrest, they will be unable to speak or breathe, and they will have
no heartbeat.

Cardiovascular disease

Cardiovascular disease (CVD) is a general term for conditions affecting the heart or blood
vessels.

It's usually associated with a build-up of fatty deposits inside the arteries (atherosclerosis) and an
increased risk of blood clots.

It can also be associated with damage to arteries in organs such as the brain, heart, kidneys and
eyes.

CVD is one of the main causes of death and disability in the UK, but it can often largely be
prevented by leading a healthy lifestyle.

Types of CVD

There are. 4 of the main types of CVDs

ii) Coronary heart disease

Coronary heart disease occurs when the flow of oxygen-rich blood to the heart muscle is blocked
or reduced.This puts an increased strain on the heart, and can lead to:

• angina – chest pain caused by restricted blood flow to the heart muscle

• heart attacks – where the blood flow to the heart muscle is suddenly blocked

• heart failure – where the heart is unable to pump blood around the body properly iii) Strokes
and TIAs

A stroke is where the blood supply to part of the brain is cut off, which can cause brain damage
and possibly death.

A transient ischemic attack (also called a TIA or "mini-stroke") is similar, but the blood flow to
the brain is only temporarily disrupted.
The main symptoms of a stroke or TIA can be remembered with the word FAST, which stands
for:

• Face – the face may have drooped on one side, the person may be unable to smile, or their
mouth or eye may have dropped.

• Arms – the person may not be able to lift both arms and keep them there because of arm
weakness or numbness in one arm.

• Speech – their speech may be slurred or garbled, they may not be able to talk at all or they
may not be able to understand what you are saying to them.

• Time – it's time to seek medical attention immediately if you see any of these signs or
symptoms.
iv) Peripheral arterial disease

Peripheral arterial disease occurs when there's a blockage in the arteries to the limbs, usually the
legs.

This can cause:

• dull or cramping leg pain, which is worse when walking and gets better with rest

• hair loss on the legs and feet

• numbness or weakness in the legs

• persistent ulcers (open sores) on the feet and legs

v) Aortic disease

Aortic diseases are a group of conditions affecting the aorta. This is the largest blood vessel in the
body, which carries blood from the heart to the rest of the body.

One of most common aortic diseases is an aortic aneurysm, where the aorta becomes weakened
and bulges outwards.

This doesn't usually have any symptoms, but there's a chance it could burst and cause
lifethreatening bleeding.
High blood pressure

The heart is a muscle that pumps blood around the body. As it travels, the blood delivers oxygen
to the body’s vital organs.

Sometimes, a problem in the body makes it harder for the heart to pump the blood. This could
happen, for example, if an artery becomes too narrow.

Persistent high blood pressure can put a strain on the walls of the arteries. This can lead to a
variety of health problems, some of which can be life threatening.

High blood pressure chart

Doctors measure blood pressure in millimeters of mercury (mm Hg).

Systolic pressure measures the pressure in the arteries as the heart contracts and is the top
number on a blood pressure reading. Diastolic, which is the lower number, represents the blood
pressure when the heart is resting between beats.

Systolic (mm Hg) Diastolic (mm Hg)

Normal Below 120 Below 80

Elevated (hypertension) 120–129 Below 80

Stage 1 hypertension 130–139 80–90

Stage 2 hypertension 140 or above 90 or above

Hypertensive crisis Over 180 Over 120

Signs and symptoms

Most people with high blood pressure will not experience any symptoms, which is why people
often call hypertension the “silent killer.”

However, once blood pressure reaches about 180/120 mm Hg, it becomes a hypertensive crisis,
which is a medical emergency.

At this stage, a person may have:

 • a headache

• nausea

• vomiting

• dizziness

• blurred or double vision

• nosebleeds

• heart palpitations

• breathlessness

Anybody who experiences these symptoms should see their doctor immediately.

Causes

High blood pressure can occur when certain changes happen in the body or if a person is born
with specific genetic features that cause a health condition.

It can affect people with:

• obesity

• type 2 diabetes

• kidney disease

• obstructive sleep apnea

• lupus

• scleroderma

• underactive or overactive thyroid

• congenital conditions, such as Cushing’s syndrome, acromegaly, or pheochromocytoma

Sometimes, there is no apparent cause. In this case, a doctor will diagnose primary hypertension.

Consuming a high fat diet, carrying excess weight, drinking a lot of alcohol, smoking tobacco,
and the use of some medications also increase the risk.
How to lower blood pressure

Treatment will depend on several factors, including:

• how high the blood pressure is

• the risk of cardiovascular disease or a stroke

The doctor will recommend different treatments as blood pressure increases. For slightly high
blood pressure, they may suggest making lifestyle changes and monitoring the blood pressure.

If blood pressure is high, they will recommend medication. The options may change over time,
according to how severe the hypertension is and whether complications arise, such as kidney
disease. Some people may need a combination of several different medications.

Medications

Conventional drugs for treating high blood pressure include:

1) Angiotensin converting enzyme inhibitors

Angiotensin converting enzyme (ACE) inhibitors block the actions of some hormones that
regulate blood pressure, such as angiotensin II. Angiotensin II causes the arteries to constrict
and increases blood volume, resulting in increased blood pressure.

ACE inhibitors can reduce the blood supply to the kidneys, making them less effective. As a
result, it is necessary for people taking ACE inhibitors to have regular blood tests.

People should not use ACE inhibitors if they:

• are pregnant

• have a condition that affects the blood supply to the kidneys

ACE inhibitors may cause the following side effects, which usually resolve after a few days:

• dizziness

• fatigue

• weakness
 • headaches

• a persistent dry cough

If the side effects are persistent or too unpleasant to manage, a doctor may prescribe an
angiotensin II receptor antagonist instead.

These alternative medications often cause fewer side effects, but they may include dizziness,
headaches, and increased potassium levels in the blood.

2) Calcium channel blockers

Calcium channel blockers (CCBs) aim to decrease calcium levels in the blood vessels. This will
relax the vascular smooth muscle, causing the muscle to contract less forcefully, the arteries to
widen, and blood pressure to go down.

CCBs may not always be suitable for people with a history of heart disease, liver disease, or
circulation issues. A doctor can advise on taking CCBs and which type of CCB is safe to use.

The following side effects may occur, but they usually resolve after a few days:

• redness of the skin, generally on the cheeks or neck

• headaches

• swollen ankles and feet

• dizziness

• fatigue

• skin rash

• swollen abdomen, in rare cases

3) Thiazide diuretics

Thiazide diuretics help the kidneys get rid of sodium and water. This lowers blood volume and
pressure.

The following side effects can occur, and some of them may persist:

• low blood potassium, which can affect heart and kidney function
 • impaired glucose tolerance

• erectile dysfunction

People taking thiazide diuretics should have regular blood and urine tests to monitor their blood
sugar and potassium levels.

4) Beta-blockers

Beta-blockers were once popular for treating hypertension, but doctors only tend to prescribe
them now when other treatments have not been successful.

Beta-blockers slow the heart rate and reduce the force of the heartbeat, causing a drop in blood
pressure.

Side effects may include:

• fatigue

• cold hands and feet

• slow heartbeat

• nausea

• diarrhea

• Less common side effects are:

• disturbed sleep

• nightmares

• erectile dysfunction

Beta-blockers are often the standard medication for a person with very high blood pressure,
known as a hypertensive crisis.

5) Renin inhibitors

Aliskiren (Tekturna, Rasilez) reduces the production of renin, an enzyme that the kidneys
produce.
Renin helps produce a hormone that narrows blood vessels and raises blood pressure. Reducing
this hormone causes the blood vessels to widen and blood pressure to fall.

This drug is relatively new, and healthcare professionals are still determining its optimal use and
dosage.

Possible side effects include:

• diarrhea

• dizziness

• flu-like symptoms

• fatigue

• a cough

It is essential to read the packaging of any medication to check for interactions with other drugs.

Diet Management of high blood pressure

Managing the diet can be an effective way of both preventing and treating high blood pressure.

Plant-based foods

A healthful, balanced diet includes plenty of fruits and vegetables, vegetable and omega oils,
and good quality, unrefined carbohydrates, such as whole grains. People who include animal
products in their diet should trim all the fat off and avoid processed meats.

Lowering salt intake

Experts recommend reducing salt consumption and increasing potassium intake to manage or
prevent high blood pressure. Limiting salt intake to less than 5–6 grams per day could help
improve cardiovascular health and reduce systolic blood pressure by 5.6 mm Hg in people with
hypertension.
Healthful fats

In moderation, plant sources of fats, such as avocados, nuts, olive oil, and omega oils, can be
healthful. People should limit their intake of saturated fats and trans fats, common in
animalsourced and processed foods.

The DASH diet (Dietary Approaches to Stop Hypertension)

Health experts recommend the DASH diet for people with high blood pressure. The DASH diet
focuses on an eating plan that emphasizes whole grains, fruits, vegetables, nuts, seeds, beans,
and low-fat dairy products.

Food groups Number of weekly servings for Number of weekly servings

those eating 1,600–3,100 calories for those on a 2,000-calorie
a day diet

Grains and 6–12 7–8

grain products

Fruits 3–6 3–5

Vegetables 4–6 4–5

Mostly low-fat or 2–4 2–3

non-fat dairy foods

Lean meat, fish, or 1.5–2.5 2

poultry

Nuts, seeds, and 3–6 4–5

legumes

Fats and candy 2–4 Limited

Alcohol

Some studies indicate that consuming some alcohol may help lower blood pressure. However,
others report the opposite, noting that even drinking a moderate amount might increase blood
pressure levels.

People who regularly drink more than moderate amounts of alcohol will almost always
experience elevated blood pressure levels.
Caffeine

Studies into the relationship between caffeine and blood pressure have produced conflicting
results. A report published in 2017 concluded that a moderate intake of coffee appears to be safe
for people with high blood pressure.

Home remedies

A range of lifestyle adjustments that can help reduce blood pressure, such as:

• managing stress

• quitting smoking

• eating healthfully

• getting exercise

• following any treatment plan the doctor prescribes

Discuss any planned lifestyle changes with a healthcare professional before introducing them.

Regular exercise

This amount of exercise is also appropriate for people with high blood pressure.

However, a person who has not exercised for a while or who has a new diagnosis should talk to
their doctor before starting a new physical activity program to ensure the choices they make are
suitable for them.

Losing weight

Studies have revealed that losing as little as 5–10 pounds in weight can help reduce blood
pressure.

Weight loss will also improve the effectiveness of blood pressure medications.

Ways of achieving and maintaining a healthy weight include:

• getting regular exercise

 • following a diet that emphasizes plant-based foods and limits the intake of fat and added
sugars

Sleep

Increasing sleep alone cannot treat hypertension, but too little sleep and poor sleep quality may
make it worse.

A 2015 analysis of data from a Korean national health survey found that people who had less
than 5 hours of sleep per night were more likely to have hypertension.

Natural remedies

According to the National Center for Complementary and Integrative Health (NCCIH), the
following may help lower blood pressure:

• meditation, yoga, qi gong, and tai chi

• biofeedback and transcendental meditation

• supplements such as garlic, flaxseed, green or black tea, probiotics, cocoa, and roselle
(Hibiscus sabdariffa)

They also warn that:

Some supplements can have adverse effects. They may raise blood pressure or interact with
medications.

Meditation and exercise therapies are usually safe, but some poses may not be suitable for
people with high blood pressure.

Anyone who is considering an alternative therapy should speak to their doctor first.

Diastolic and systolic pressure

There are two parts to a blood pressure measurement:

Systolic pressure: This is the blood pressure when the heart contracts.
Diastolic pressure: This is the blood pressure between heartbeats.

If blood pressure is 120/80 mm Hg, it means that the systolic pressure is 120 mm Hg and the
diastolic pressure is 80 mm Hg.

Diagnosis

There are different devices for measuring blood pressure. A doctor will often use a manual
sphygmomanometer with a stethoscope. This has a pressure cuff that they put around the
person’s arm.

When a person gets a blood pressure reading, they will have one of the following:

Normal: Less than 120/80 mm Hg.

Elevated: 120–129/80 mm Hg. At this stage, a doctor will advise the individual to make lifestyle
changes to return their blood pressure to the normal range.

Stage 1 hypertension: 130–139/80–89 mm Hg.

Stage 2 hypertension: Over 140/90 mm Hg.

Hypertensive crisis: 180/120 mm Hg or above.

A person with a hypertensive crisis needs immediate medical attention.

A person will typically need more than one reading to confirm a diagnosis, as various factors can
affect the result.

Blood pressure can fluctuate:

• according to the time of day

• when a person feels anxiety or stress

• after eating

However, a doctor will take immediate action if a reading shows very high blood pressure or if
there are signs of organ damage or other complications.
Dangers and side effects of hypertension

A healthy blood pressure is essential for maintaining bodily functions.

High blood pressure can have a severe impact on:

The cardiovascular system: High blood pressure can cause the arteries to harden, increasing the
risk of a blockage.

The heart: A blockage can reduce blood flow to the heart, increasing the risk of angina, heart
failure, or a heart attack.

The brain: A blockage in the arteries can lower or prevent blood flow to the brain, leading to a
stroke.

The kidneys: High blood pressure can result in kidney damage and chronic kidney disease.

All of these effects can be life threatening.

Complications

Without treatment or taking measures to manage blood pressure, excessive pressure on the artery
walls can lead to damage of the blood vessels, which is a form of cardiovascular disease.
It can also damage some vital organs.

Possible complications of high blood pressure include:

• stroke

• heart attack and heart failure

• blood clots

• aneurysm

• kidney disease

• thickened, narrow, or torn blood vessels in the eyes

• metabolic syndrome

• brain function and memory problems

Seeking early treatment and managing blood pressure can help prevent many health
complications.

Risk factors

The risk factors for high blood pressure include the following:

Age: The risk increases with age because the blood vessels become less flexible.

Family history and genetic factors: People who have close family members with hypertension
are more likely to develop it.

Ethnic background: African Americans have a higher risk of developing hypertension than
other groups in the United States.

Obesity and being overweight: People with overweight or obesity are more likely to develop
high blood pressure.

Physical inactivity: A sedentary lifestyle increases the risk.

Smoking: When people smoke, the blood vessels narrow, and blood pressure rises. Smoking also
reduces the blood’s oxygen content, so the heart pumps faster to compensate. This, too, increases
blood pressure.

Alcohol intake: Drinking a lot of alcohol increases the risk of blood pressure and its
complications, such as heart disease.

Diet: A diet that is high in unsaturated fat and salt increases the risk of high blood pressure.

High cholesterol: Over 50% of people with high blood pressure have high cholesterol.
Consuming unhealthful fats can contribute to a buildup of cholesterol in the arteries.

Mental stress: Stress can have a severe impact on blood pressure, especially when it is chronic.
It can occur as a result of both socioeconomic and psychosocial factors.

Stress: Persistent stress can lead to high blood pressure, and it may increase the risk of
unhealthful choices, such as smoking.
Diabetes: High blood pressure often occurs alongside type 1 diabetes. Following a treatment plan
to manage diabetes can reduce the risk.

Pregnancy: High blood pressure is more likely during pregnancy due to hormonal changes.
Hypertension is also a symptom of preeclampsia, a potentially severe placental disorder.

Sleep apnea: People with sleep apnea momentarily stop breathing while they sleep. Experts say
there are links with hypertension.

Rheumatic heart disease

Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the
inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by an
abnormal response of the body to infection with streptococcal bacteria, which usually begins as
a sore throat or tonsillitis in children.

Rheumatic fever mostly affects children in developing countries, especially where poverty is
widespread. Globally, about 2% of deaths from cardiovascular diseases are related to rheumatic
heart disease.

Symptoms of rheumatic heart disease

Symptoms of rheumatic heart disease include: shortness of breath, fatigue, irregular heartbeats,
chest pain and fainting.

Symptoms of rheumatic fever include: fever, pain and swelling of the joints, nausea, stomach
cramps and vomiting.

CVD comprises many different types of condition. Some of these might develop at the same time
or lead to other conditions or diseases within the group.

Diseases and conditions that affect the heart include:

• angina, a type of chest pain that occurs due to decreased blood flow into the heart

• arrhythmia, or an irregular heartbeat or heart rhythm

• congenital heart disease, in which a problem with heart function or structure is present
from birth
 • coronary artery disease, which affects the arteries that feed the heart muscle

• heart attack, or a sudden blockage to the heart’s blood flow and oxygen supply

• heart failure, wherein the heart cannot contract or relax normally

• dilated cardiomyopathy, a type of heart failure, in which the heart gets larger and cannot
pump blood efficiently

• hypertrophic cardiomyopathy, in which the heart muscle walls thicken and problems with
relaxation of the muscle, blood flow, and electrical instability develop

• mitral regurgitation, in which blood leaks back through the mitral valve of the heart during
contractions

• mitral valve prolapse, in which part of the mitral valve bulges into the left atrium of the
heart while it contracts, causing mitral regurgitation

• pulmonary stenosis, in which a narrowing of the pulmonary artery reduces blood flow
from the right ventricle (pumping chamber to the lungs) to the pulmonary artery (blood
vessel that carries deoxygenated blood to the lungs)

• aortic stenosis, a narrowing of the heart valve that can cause blockage to blood flow
leaving the heart

• atrial fibrillation, an irregular rhythm that can increase the risk of stroke

• rheumatic heart disease, a complication of strep throat that causes inflammation in the
heart and which can affect the function of heart valves

• radiation heart disease, wherein radiation to the chest can lead to damage to the heart
valves and blood vessels

Vascular diseases affect the arteries, veins, or capillaries throughout the body and around the
heart.

They include:

• peripheral artery disease, which causes arteries to become narrow and reduces blood flow
to the limbs

• aneurysm, a bulge or enlargement in an artery that can rupture and bleed

• atherosclerosis, in which plaque forms along the walls of blood vessels, narrowing them
and restricting the flow of oxygen rich blood
 • renal artery disease, which affects the flow of blood to and from the kidneys and can lead
to high blood pressure

• Raynaud’s disease, which causes arteries to spasm and temporarily restrict blood flow

• peripheral venous disease, or general damage in the veins that transport blood from the
feet and arms back to the heart, which causes leg swelling and varicose veins  ischemic
stroke, in which a blood clot moves to the brain and causes damage

• venous blood clots, which can break loose and become dangerous if they travel to the
pulmonary artery

• blood clotting disorders, in which blood clots form too quickly or not quickly enough and
lead to excessive bleeding or clotting

• Buerger’s disease, which leads to blood clots and inflammation, often in the legs, and
which may result in gangrene.

Common symptoms of cardiovascular diseases

Symptoms of heart attacks and strokes

Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or
stroke may be the first sign of underlying disease. Symptoms of a heart attack include:

• pain or discomfort in the centre of the chest; and/or

• Pain or discomfort in the arms, the left shoulder, elbows, jaw, or back.

In addition the person may experience difficulty in breathing or shortness of breath; nausea or
vomiting; light-headedness or faintness; a cold sweat; and turning pale. Women are more likely
than men to have shortness of breath, nausea, vomiting, and back or jaw pain.

The most common symptom of a stroke is sudden weakness of the face, arm, or leg, most often
on one side of the body. Other symptoms include sudden onset of:

• numbness of the face, arm, or leg, especially on one side of the body;
• confusion, difficulty speaking or understanding speech;
• difficulty seeing with one or both eyes;
• difficulty walking, dizziness and/or loss of balance or coordination;
• severe headache with no known cause; and/or  Fainting or unconsciousness.

People experiencing these symptoms should seek medical care immediately

Causes of CVD

The exact cause of CVD isn't clear, but there are lots of things that can increase your risk of
getting it. These are called "risk factors".

The more risk factors you have, the greater your chances of developing CVD.

Risk factors of CVD

High blood pressure

High blood pressure (hypertension) is one of the most important risk factors for CVD. If your
blood pressure is too high, it can damage your blood vessels.

Smoking

Smoking and other tobacco use is also a significant risk factor for CVD. The harmful substances
in tobacco can damage and narrow your blood vessels.

High cholesterol

Cholesterol is a fatty substance found in the blood. If you have high cholesterol, it can cause your
blood vessels to narrow and increase your risk of developing a blood clot.

Diabetes

Diabetes is a lifelong condition that causes your blood sugar level to become too high.

High blood sugar levels can damage the blood vessels, making them more likely to become
narrowed.

Many people with type 2 diabetes are also overweight or obese, which is also a risk factor for
CVD.

Inactivity

If you don't exercise regularly, it's more likely that you'll have high blood pressure, high
cholesterol levels and be overweight. All of these are risk factors for CVD.
Exercising regularly will help keep your heart healthy. When combined with a healthy diet,
exercise can also help you maintain a healthy weight.

Being overweight or obese

Being overweight or obese increases your risk of developing diabetes and high blood pressure,
both of which are risk factors for CVD.

You're at an increased risk of CVD if:

• your body mass index (BMI) is 25 or above – use the BMI healthy weight calculator to work
out your BMI

• you're a man with a waist measurement of 94cm (about 37 inches) or more, or a woman with
a waist measurement of 80cm (about 31.5 inches) or more
Family history of CVD

If you have a family history of CVD, your risk of developing it is also increased.

You're considered to have a family history of CVD if either:

• your father or brother were diagnosed with CVD before they were 55

• your mother or sister were diagnosed with CVD before they were 65

Tell your doctor or nurse if you have a family history of CVD. They may suggest checking your
blood pressure and cholesterol level.

Ethnic background

In the UK people of south Asian and Black African or African Caribbean background have an
increased risk of getting CVD.

This is because people from these backgrounds are more likely to have other risk factors for
CVD, such as high blood pressure or type 2 diabetes.

Other risk factors

Other factors that affect your risk of developing CVD include:

 • age – CVD is most common in people over 50 and your risk of developing it increases as
you get older

• gender – men are more likely to develop CVD at an earlier age than women

• diet – an unhealthy diet can lead to high cholesterol and high blood pressure

• alcohol – excessive alcohol consumption can also increase your cholesterol and blood
pressure levels, and contribute to weight gain
Preventing CVD

A healthy lifestyle can lower your risk of CVD. If you already have CVD, staying as healthy as
possible can reduce the chances of it getting worse.

Stop smoking

If you smoke, you should try to give up as soon as possible.

Seek prescribed medication to help you quit.

Have a balanced diet

A healthy, balanced diet is recommended for a healthy heart.

A balanced diet includes:

• low levels of saturated fat – try to include healthier sources of fat, such as oily fish, nuts and
seeds, and olive oil, and avoid unhealthy fats such as fatty cuts of meat, lard, cream, cakes
and biscuits

• low levels of salt – aim for less than 6g (0.2oz or 1 teaspoon) a day

• low levels of sugar

• plenty of fibre and wholegrain foods

• plenty of fruit and vegetables – eat at least 5 portions of fruit and vegetables a day
Exercise regularly

Adults are advised to do at least 150 minutes of moderate activity a week, such as cycling or brisk
walking.
If you find it difficult to do this, start at a level you feel comfortable with and gradually increase
the duration and intensity of your activity as your fitness improves.

Maintain a healthy weight

If you're overweight or obese, a combination of regular exercise and a healthy diet can help you
lose weight.

If you're struggling to lose weight, your nutritionist or practice nurse can help you come up with a
weight loss plan.

Cut down on alcohol

If you drink alcohol, try not to exceed the recommended limit of 14 alcohol units a week for men
and women.

If you do drink this much, you should aim to spread your drinking over 3 days or more.

A unit of alcohol is roughly equivalent to half a pint of normal-strength lager or a single measure
(25ml) of spirits. A small glass of wine (125ml) is about 1.5 units.

Medicine

If you have a particularly high risk of developing CVD due to high blood cholesterol, your GP
may recommend taking medicines called statins to reduce your risk.
5. MANAGEMENT OF RENAL DISORDERS

The kidneys are a pair of fist-sized organs located at the bottom of the rib cage. There is one
kidney on each side of the spine.

Kidneys are essential to having a healthy body. They are mainly responsible for filtering waste
products, excess water, and other impurities out of the blood. These toxins are stored in the
bladder and then removed during urination. The kidneys also regulate pH, salt, and potassium
levels in the body. They produce hormones that regulate blood pressure and control the
production of red blood cells. The kidneys even activate a form of vitamin D that helps the body
absorb calcium.

Kidney disease occurs when your kidneys become damaged and can’t perform their function.
Damage may be caused by diabetes, high blood pressure, and various other chronic (long-term)
conditions. Kidney disease can lead to other health problems, including weak bones, nerve
damage, and malnutrition.

If the disease gets worse over time, your kidneys may stop working completely. This means that
dialysis will be required to perform the function of the kidneys. Dialysis is a treatment that
filters and purifies the blood using a machine. It can’t cure kidney disease, but it can prolong
your life.
Types and causes of kidney disease

i) Chronic kidney disease (CKD)

The most common form of kidney disease is chronic kidney disease. Chronic kidney disease is
a long-term condition that doesn’t improve over time. It’s commonly caused by high blood
pressure.

High blood pressure is dangerous for the kidneys because it can increase the pressure on the
glomeruli. Glomeruli are the tiny blood vessels in the kidneys where blood is cleaned. Over
time, the increased pressure damages these vessels and kidney function begins to decline.

Kidney function will eventually deteriorate to the point where the kidneys can no longer
perform their job properly. In this case, a person would need to go on dialysis. Dialysis filters
extra fluid and waste out of the blood. Dialysis can help treat kidney disease but it can’t cure it.
A kidney transplant may be another treatment option depending on your circumstances.

Diabetes is also a major cause of chronic kidney disease. Diabetes is a group of diseases that
causes high blood sugar. The increased level of sugar in the blood damages the blood vessels in
the kidneys over time. This means the kidneys can’t clean the blood properly. Kidney failure
can occur when your body becomes overloaded with toxins.

ii) Kidney stones

Kidney stones are another common kidney problem. They occur when minerals and other
substances in the blood crystallize in the kidneys, forming solid masses (stones). Kidney stones
usually come out of the body during urination. Passing kidney stones can be extremely painful,
but they rarely cause significant problems.

iii) Glomerulonephritis

Glomerulonephritis is an inflammation of the glomeruli. Glomeruli are extremely small

structures inside the kidneys that filter the blood. Glomerulonephritis can be caused by
infections, drugs, or congenital abnormalities (disorders that occur during or shortly after birth).
It often gets better on its own.

iv) Polycystic kidney disease

Polycystic kidney disease is a genetic disorder that causes numerous cysts (small sacs of fluid)
to grow in the kidneys. These cysts can interfere with kidney function and cause kidney failure.
(It’s important to note that individual kidney cysts are fairly common and almost always
harmless. Polycystic kidney disease is a separate, more serious condition.)
 v) Urinary tract infections

Urinary tract infections (UTIs) are bacterial infections of any part of the urinary system.
Infections in the bladder and urethra are the most common. They are easily treatable and rarely
lead to more health problems. However, if left untreated, these infections can spread to the
kidneys and cause kidney failure.

Symptoms of kidney disease

Kidney disease is a condition that can easily go unnoticed until the symptoms become severe. The
following symptoms are early warning signs that you might be developing kidney disease:

• fatigue
• difficulty concentrating
• trouble sleeping
• poor appetite
• muscle cramping
• swollen feet/ankles
• puffiness around the eyes in the morning
• dry, scaly skin
• frequent urination, especially late at night

Severe symptoms that could mean your kidney disease is progressing into kidney failure include:

• nausea

• vomiting
• loss of appetite
• changes in urine output
• fluid retention
• anemia (a decrease in red blood cells)
• decreased sex drive
• sudden rise in potassium levels (hyperkalemia)
• inflammation of the pericardium (fluid-filled sac that covers the heart)

Risk factors for developing kidney disease

People with diabetes have a higher risk of developing kidney disease.

 Diabetes is the leading cause of kidney disease; you may also be more likely to get kidney
disease if you:

• have high blood pressure

• have other family members with chronic kidney disease
• are elderly
• are of African, Hispanic, Asian, or American Indian descent

Diagnosis of kidney disease

Your doctor will first determine whether you belong in any of the high-risk groups. They will then
run some tests to see if your kidneys are functioning properly. These tests may include:

Glomerular filtration rate (GFR)

This test will measure how well your kidneys are working and determine the stage of kidney
disease.

Ultrasound or computed tomography (CT) Scan

Ultrasounds and CT scans produce clear images of your kidneys and urinary tract. The pictures
allow your doctor to see if your kidneys are too small or large. They can also show any tumors
or structural problems that may be present.

Kidney biopsy

During a kidney biopsy, your doctor will remove a small piece of tissue from your kidney while
you’re sedated. The tissue sample can help your doctor determine the type of kidney disease
you have and how much damage has occurred.

Urine test

Your doctor may request a urine sample to test for albumin. Albumin is a protein that can be
passed into your urine when your kidneys are damaged.

Blood creatinine test

Creatinine is a waste product. It’s released into the blood when creatine (a molecule stored in
muscle) is broken down. The levels of creatinine in your blood will increase if your kidneys
aren’t working properly.
How to prevent kidney disease

Some risk factors for kidney disease — such as age, race, or family history — are impossible to
control. However, there are measures you can take to help prevent kidney disease:

• drink plenty of water

• control blood sugar if you have diabetes
• control blood pressure
• reduce salt intake
• quit smoking

Be careful with over-the-counter drugs

You should always follow the dosage instructions for over-the-counter medications. Taking too
much aspirin (Bayer) or ibuprofen (Advil, Motrin) can cause kidney damage. Call your doctor
if the normal doses of these medications aren’t controlling your pain effectively.

Get tested

Ask your doctor about getting a blood test for kidney problems. Kidney problems generally
don’t cause symptoms until they’re more advanced. A basic metabolic panel (BMP) is a
standard blood test that can be done as part of a routine medical exam. It checks your blood for
creatinine or urea. These are chemicals that leak into the blood when the kidneys aren’t working
properly. A BMP can detect kidney problems early, when they’re easier to treat. You should be
tested annually if you have diabetes, heart disease, or high blood pressure.

Limit certain foods

Different chemicals in your food can contribute to certain types of kidney stones. These include:

• excessive sodium
• animal protein, such as beef and chicken

• citric acid, found in citrus fruits such as oranges, lemons, and grapefruits
• oxalate, a chemical found in beets, spinach, sweet potatoes, and chocolate

Ask about calcium

Talk to your doctor before taking a calcium supplement. Some calcium supplements have been
linked to an increased risk of kidney stones.
Treatment of kidney disease

Treatment for kidney disease usually focuses on controlling the underlying cause of the disease.
This means your doctor will help you better manage your blood pressure, blood sugar, and
cholesterol levels. They may use one or more of the following methods to treat kidney disease.

Drugs and medication

Your doctor will either prescribe angiotensin-converting enzyme (ACE) inhibitors, such as
lisinopril and ramipril, or angiotensin receptor blockers (ARBs), such as irbesartan and
olmesartan. These are blood pressure medications that can slow the progression of kidney
disease. Your doctor may prescribe these medications to preserve kidney function, even if you
don’t have high blood pressure.

You may also be treated with cholesterol drugs (such as simvastatin). These medications can
reduce blood cholesterol levels and help maintain kidney health. Depending on your symptoms,
your doctor may also prescribe drugs to relieve swelling and treat anemia (decrease in the
number of red blood cells).

Dietary and lifestyle changes

Making changes to your diet is just as important as taking medication. Adopting a healthy
lifestyle can help prevent many of the underlying causes of kidney disease. Your doctor may
recommend that you:

• control diabetes through insulin injections

• cut back on foods high in cholesterol
• cut back on salt
• start a heart-healthy diet that includes fresh fruits, veggies, whole grains, and low-fat dairy
products
• limit alcohol consumption
• quit smoking
• increase physical activity
• lose weight

Dialysis and kidney disease

Dialysis is an artificial method of filtering the blood. It’s used when someone’s kidneys have
failed or are close to failing. Many people with late-stage kidney disease must go on dialysis
permanently or until a donor kidney is found.

There are two types of dialysis: hemodialysis and peritoneal dialysis.

Hemodialysis

In hemodialysis, the blood is pumped through a special machine that filters out waste products
and fluid. Hemodialysis is done at your home or in a hospital or dialysis center. Most people
have three sessions per week, with each session lasting three to five hours. However,
hemodialysis can also be done in shorter, more frequent sessions.

Several weeks before starting hemodialysis, most people will have surgery to create an
arteriovenous (AV) fistula. An AV fistula is created by connecting an artery and a vein just
below the skin, typically in the forearm. The larger blood vessel allows an increased amount of
blood to flow continuously through the body during hemodialysis treatment. This means more
blood can be filtered and purified. An arteriovenous graft (a looped, plastic tube) may be
implanted and used for the same purpose if an artery and vein can’t be joined together.

The most common side effects of hemodialysis are low blood pressure, muscle cramping, and
itching.

Peritoneal dialysis

In peritoneal dialysis, the peritoneum (membrane that lines the abdominal wall) stands in for the
kidneys. A tube is implanted and used to fill the abdomen with a fluid called dialysate. Waste
products in the blood flow from the peritoneum into the dialysate. The dialysate is then drained
from the abdomen.

There are two forms of peritoneal dialysis:

continuous ambulatory peritoneal dialysis, where the abdomen is filled and drained several
times during the day, and

continuous cycler-assisted peritoneal dialysis, which uses a machine to cycle the fluid in and
out of the abdomen at night while the person sleeps.

The most common side effects of peritoneal dialysis are

infections in the abdominal cavity or in the area where the tube was implanted.

Other side effects may include weight gain and hernias.

A hernia is when the intestine pushes through a weak spot or tear in the lower abdominal wall.

Long-term outlook for someone with kidney disease

Kidney disease normally does not go away once it’s diagnosed. The best way to maintain
kidney health is to adopt a healthy lifestyle and follow your doctor’s advice. Kidney disease can
get worse over time. It may even lead to kidney failure. Kidney failure can be lifethreatening if
left untreated.
Kidney failure occurs when your kidneys are barely working or not working at all. This is
managed by dialysis. Dialysis involves the use of a machine to filter waste from your blood. In
some cases, your doctor may recommend a kidney transplant.

Dietary management of chronic kidney disease

You may need to make changes to your diet when you have chronic kidney disease (CKD).
These changes may include limiting fluids, eating a low-protein diet, limiting salt, potassium,
phosphorous, and other electrolytes, and getting enough calories if you are losing weight. You
may need to alter your diet more if your kidney disease gets worse, or if you need dialysis.

Chronic Kidney Disease (CKD):

o Progressive loss of kidney function over time.
o Requires dietary modifications to manage fluid and electrolyte balance.

Nutritional management;
o Control Protein Intake: Protein metabolism in the body produces waste products that need to
be eliminated by the kidneys. In the early stages of CKD, it's important to control protein intake
but not necessarily restrict it. However, in later stages, protein may need to be limited more.
o Manage Sodium (Salt) Intake: High sodium intake can lead to fluid retention and high blood
pressure, both of which can worsen kidney function. Limit your sodium intake by avoiding
processed foods, canned soups, and restaurant meals. Use herbs and spices to flavor food
instead of salt.
o Control Phosphorus Intake: As kidney function declines, the body may struggle to remove
excess phosphorus. High phosphorus levels can weaken bones and affect heart health. Limit
phosphorus-rich foods like dairy products, nuts, seeds, and processed foods. Take phosphate
binders as prescribed by your healthcare provider.
o Monitor Potassium Intake: Elevated potassium levels can be dangerous, especially in later
stages of CKD. Limit high-potassium foods like bananas, oranges, potatoes, and tomatoes.
Cooking certain high-potassium vegetables can reduce their potassium content.
o Limit High-Potassium and High-Phosphorus Beverages: Be cautious with beverages like
orange juice and colas, which are high in potassium and phosphorus. Opt for low-phosphorus
beverages like clear sodas and herbal teas.
o Monitor Fluid Intake: In advanced stages of CKD, you may need to limit fluid intake to
prevent fluid overload.
 For early-stage CKD (Stages 1-2): The fluid allowance is often close to normal (1,500-
2,000 mL/day) unless there are specific issues.
 For moderate-stage CKD (Stages 3-4): The fluid allowance may be more restricted,
typically around 1,000-1,500 mL/day.
 For advanced-stage CKD (Stage 5, on dialysis): Fluid intake is severely restricted, and the
specific amount will be determined by your healthcare provider based on your dialysis schedule
and individual needs
 The general rule is to match your fluid intake to your urine output plus an additional
allowance for insensible losses (sweating, breathing).
 The total fluid allowance is typically set as follows:
Urine Output + 500 mL (for insensible losses) = Total Fluid Allowance
o Balanced Diet: Focus on a well-balanced diet that includes adequate calories, vitamins, and
minerals.
o Supplemental Nutrition: If you are not meeting your nutritional needs through your diet,
your healthcare provider may recommend nutritional supplements.
o Medication and Medical Care: Take prescribed medications as directed and attend regular
follow-up appointments with your healthcare provider to monitor your kidney function and
adjust your treatment plan.
o Manage Blood Sugar and Blood Pressure: If you have diabetes or hypertension, it's crucial
to manage these conditions to protect kidney function.
o Limit Phosphorus Additives: Be aware of phosphorus-containing additives found in
processed and fast foods. These additives can significantly contribute to phosphorus intake.
o Regular Monitoring: Regularly monitor your laboratory values, such as serum creatinine,
potassium, phosphorus, and others, to assess your kidney function and nutritional status.
o Nutrition care for CKD is highly individualized, and it's essential to work with a healthcare
team that includes a registered dietitian. They will help you develop a dietary plan that
addresses your specific needs and stage of CKD while also helping to manage any related
health conditions.

Function
The purpose of this diet is to keep the levels of electrolytes, minerals, and fluid in your body
balanced when you have CKD or are on dialysis.

People on dialysis need this special diet to limit the buildup of waste products in the body.
Limiting fluids between dialysis treatments is very important because most people on dialysis
urinate very little. Without urination, fluid will build up in the body and cause too much fluid in
the heart and lungs.
6. EMERGING ISSUES AND TRENDS IN MANAGEMENT OF
CARDIOVASCULAR DISEASES

A workshop was held to address issues relating to national trends in mortality and morbidity
from cardiovascular diseases; the apparent slowing of declines in mortality from cardiovascular
diseases; levels and trends in risk factors for cardiovascular diseases; disparities in
cardiovascular diseases by race/ethnicity, socioeconomic status, and geography; trends in
cardiovascular disease preventive and treatment services; and strategies for efforts to reduce
cardiovascular diseases overall and to reduce disparities among subpopulations.

The conference concluded that coronary heart disease mortality is still declining in the United
States as a whole, although perhaps at a slower rate than in the 1980s; that stroke mortality rates
have declined little, if at all, since 1990; and that there are striking differences in cardiovascular
death rates by race/ethnicity, socioeconomic status, and geography.
Trends in risk factors are consistent with a slowing of the decline in mortality; there has been
little recent progress in risk factors such as smoking, physical inactivity, and hypertension
control. There are increasing levels of obesity and type 2 diabetes, with major differences
among subpopulations. There is considerable activity in population-wide prevention, primary
prevention for higher risk people, and secondary prevention, but wide disparities exist among
groups on the basis of socioeconomic status and geography, pointing to major gaps in efforts to
use available, proven approaches to control cardiovascular diseases. Recommendations for
strategies to attain the year 2010 health objectives were made.

The 20th century witnessed dynamic, worldwide changes in cardiovascular disease (CVD)
mortality, including death from coronary heart disease (CHD), stroke, and other CVDs. Many
Western countries documented a rise in mortality from CVD until the 1960s and 1970s, with
substantial declines since those peaks. Other parts of the world have shown different patterns,
including high rates of CVD mortality in Eastern Europe that continue to rise and an ominous
epidemic of CHD and stroke emerging in developing countries. In the United States, recent
evidence has suggested that the decline in CHD mortality since the late 1960s has slowed. This
may be especially true in specific subgroups (defined by socioeconomic status, race or ethnicity,
and region), whose declines have lagged. This has led to relatively higher CVD rates, which
constitute a major challenge to reaching the Healthy People 2010 Objectives set for the
American people. The causes of these disparities in CVD burden are primarily environmental
and likely include differences in CVD risk factors, lifestyle, and the availability and use of
primary and secondary preventive services.

The Conference had the following 5 objectives.

1. To examine trends in levels of CVD mortality (and morbidity, if possible) in the US

population as a whole and in selected subpopulations

2. To describe trends in levels of CVD risk factors by both behavior (eg, diet, exercise, and
tobacco use) and physiology (eg, serum lipids, blood pressure, obesity, and diabetes) in the US
population as a whole and in selected subpopulations in parallel to CVD mortality trends as a
way to better understand observed disparities in CVD mortality.

3. To estimate trends in levels of cardiovascular health services, including primary prevention,

secondary prevention, and rehabilitation, in parallel to CVD mortality trends as a way to
understand the influence of disparities in health care and disparities in CVD mortality trends.
4. To identify areas where new or better data are needed to attain the Year 2010 Health
Objectives for the Nation so as to target those areas as part of the strategic research agenda for
the 21st century.

5. To develop a more effective strategic agenda for CVD prevention programs and policies to
reduce disparities among subpopulations in CVD mortality, morbidity, risk factors, and
healthcare services as a means to reduce CVD mortality in the US population as a whole and to
meet 2010 Health Objectives.

The Conference had roots in 3 previous conferences that endeavored to describe and explain
changes in CVD mortality in the last quarter of the 20th century. The first, “The Conference on
the Decline in Coronary Heart Disease Mortality,”4 was convened in 1978 and verified the
newly described downward trend in CVD mortality but was unable to identify precisely the
causes for these declines. The second, “Trends and Determinants of Coronary Heart Disease
Mortality: The Influence of Medical Care,” 5 was held in 1986 to examine the contributions of
preventive and therapeutic patient management; it concluded that some of the decline in CVD
mortality could indeed be attributed to preventive and early medical care. The third, “Trends
and Determinants of Coronary Artery Disease Mortality: International Comparisons,” 6 was
convened in 1988 to make international comparisons of CHD mortality, morbidity, risk factors,
and medical care and to seek explanations for worldwide variations in CHD incidence,
prevalence, mortality, case fatality rates, and trends.

This report summarizes the findings of the Conference on CVD Prevention. It aims to provide a
better picture of the cardiovascular health of the United States and to propose a strategic agenda
for research to enhance the understanding of and to improve CVD indicators and to create
policies and programs that will more effectively prioritize and implement CVD control efforts
over the next decade.