Wafeera Report

INTERNSHIP REPORT
A report submitted in partial fulfillment for the award of degree of

B.S. (Hons.) Human Nutrition and Dietetics
Submitted by
Wafeera Moazzam
Session: 2019-2023
Supervisor: Ms. Safa Akram
DEPARTMENT OF HUMAN NUTRITION AND DIETETICS (HND)

AFRO ASIAN INSTITUE, LAHORE
AFFILIATED WITH GCUF, FAISLABAD
1
AFRO ASIAN INSTITUTE, LAHORE
DEPARTEMENT OF HUMAN NUTRITION AND DIETETICS (HND)
SUPERVISORY COMMITTEE
We, the Supervisory Committee, certify that the contents and the form of report submitted by
Wafeera Moazzam (2019-GCUF-059127) was, found satisfactory and we recommend it for
the evaluation from the examination committee for the award of the degree BS (Hons.)
Human Nutrition and Dietetics.
Ms. Safa Akram

Supervisor ____________________
Ms. Sania Khalid

Member ____________________
Ms. Maryam Ashraf

Member ____________________
2
AFRO ASIAN INSTITUTE, LAHORE
DEPARTEMENT OF HUMAN NUTRITION AND DIETETICS (HND)
UNDERTAKING
I, Wafeera Moazzam (2019-GCUF-059127), declare that the contents of this Internship

Report have not been, taken from any other work. I also undertake that I was responsible for
any plagiarism in this report.
_______________
3
DEDICATED TO
MY PARENTS
&
MY TEACHERS
4
ACKNOWLEDGEMENT
In the name of ALLAH, the Most Gracious and the Most Merciful. All praises to ALLAH
and his blessing for the completion of this report. I thank to ALLAH almighty for all the
opportunities, trials and strength that have been, showered on me to complete the report.
My humblest gratitude to the holy Prophet Hazrat Muhammad (Peace be upon him) whose
way of life has been a continuous guidance for me.
First, my deepest gratitude goes to my Parents and all of my Family Members. It would not
be possible to write this report without the support from them.
I would like to sincerely thank to my supervisor Miss Safa Akram and all members for their
guidance, understanding, patience and most importantly, they have provided positive
encouragement and a warm spirit to finish this report. It has been a great pleasure and honor
to have them as my supervisor.
I experienced so much during this process, not only from the academic aspect but also from
the clinical field. I am also grateful for those great people and professionals who guide me
through this internship period.
May Allah shower his countless blessings on the above-cited personalities?
5
TABLE OF CONTENTS
Chapter No. Topic Page No.

Introduction of Nutrition 09
01 Anthropometric measurements 10
Orthopedic Ward 11
Fracture
Rheumatoid arthritis 18
02 Osteoarthritis 25
Osteoporosis 31
03 Gastro Ward 38
Constipation
IBS 44
Celiac disease 51
GERD 57
Lactose intolerance 63
Diarrhea 69
04 Pulmonary Ward 75
Lung cancer
Cystic fibrosis 81
Tuberculosis 87
Asthma 93
Chronic obstructive pulmonary
99
disease
Pneumonia 105
05 Cardiac Ward
Hypertension 110
Coronary heart disease 117
Heart failure 123
06 Surgery Ward 129
Cholecystitis
Hernia 138
Appendectomy 146
07 Medical Unit
Diabetes 155
Hepatitis (A, B, C, Jaundice) 160
6
Cirrhosis 165
Non- alcoholic Fatty Liver
169
Disease
Cholelithiasis 171
08 Gynae Ward 173
Cesarean 176
Gestational Diabetes Mellitus 178
Anemia 179
09 Pediatrics Ward 182
Hypothyroidism 185
Typhoid Fever 186
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LIST OF ABREVATIONS
Sr. No. Abbreviation Full Form
01 RD Registered Dietitian
02 BMI Body Mass Index
03 IBW Ideal Body Weight
04 BMR Basal Metabolic Rate
05 SBP Systolic Blood Pressure
06 DBP Diastolic Blood Pressure
07 LDL Low Density Lipoprotein
08 HDL High Density Lipoprotein
09 VLDL Very Low-Density Lipoprotein
10 DASH Dietary Approaches to Stop Hypertension
11 CVD Cardio Vascular Disease
12 CHD Coronary Heart Disease
13 IHD Ischemic Heart Disease
14 PUFA Poly Unsaturated Fatty Acid
15 MUFA Mono Unsaturated Fatty Acid
16 HF Heart Failure
17 FPG Fasting Plasma Glucose
18 GTI Gastro Intestinal Track
19 CAP 4 Community Acquired Pneumonia
20 GERD Gastro Esophageal Reflex Disease
21 COPD7 Chronic Obstructive Pulmonary Disease
22 DHA Decosa Hexanoicnoic Acid
23 EPA Ecosa Pentatonic Acid
24 AKI Acute Kidney Injury
8
Chapter No.1
INTRODUCTION:
1.1 Nutrition
Nutrition is a process of obtaining and providing the food necessary for health &
growth.
1.2 Nutrients
Nutrients are the substances that provide the nourishment essential for the
maintenance of life and growth. There are two types of nutrients:
1.2.1 Macronutrient
 Carbohydrates
 Protein
 Fat
1.2.2 Micronutrients
 Vitamins
 Minerals
1.3 Food
Any nutritious substance that can eat or drink by animals and humans or absorbed by
plants to maintain life and growth.
1.4 Nutritional Status
The condition of the body that is, affected by the diet. The level of the nutrients in the
body and ability of nutrients to maintain normal metabolic integrity.
1.5 Nutritional Assessment
It is the detailed investigation to identify and quantify the nutritional problems. This
can be, performed by Registered Dietitian (RD).
1.6 Tools of Assessment

 Anthropometric assessment
 Biochemical assessment
 Clinical assessment
 Dietary assessment
1.6.1 Anthropometric measurement
 Height
 Weight
 Body mass index (BMI)
9
Formula for measuring BMI is:
Weight in kg/height in m2=BMI in kg/m2
Ideal body weight (IBW)

For males
106lbs for 5 feet +6lb for each inch
For females
100lb for 5 feet + 5lb for each inch
Waist to hip ratio

Use to identify adiposity, also known as gluteal ratio
W/H=0.7(normal ratio)
1.7 Harris Benedict Equation (energy calculation)

Equation for males
66.5+13.75× (weight in kg) +5 × (height in cm) – 6.78×age
Equation for female

655.1+ 9.6 × (weight in kg) + 1.9 × (height in cm) – 4.7 × age
10
Chapter No.2
CASE 1
ORTHOPEDIC WARD
During the Second week of internship, the rotation was, placed at orthopedic ward.
2.1 Case Study:
Mr. Faisal is, hospitalized due to fracture of Tibia bone, pain in his right leg, his
height is 5’5 inches, and current weight is 50 kg. His BMI is about 19 kg/m2 and TEE
is 1901 kcal/day.
2.1.1 Fracture:
A fracture is a partial or complete break in the bone. When a fracture happens, it is,
classified as either open or closed:
 Open fracture (also called compound fracture): The bone pokes through the skin and
can be, seen, or a deep wound exposes the bone through the skin.
 Closed fracture (also called simple fracture). The bone is broken, but the skin is
intact.
2.1.2 Medical Nutrition Therapy of Fracture:
For the treatment of fracture high protein and anti-inflammatory diet is,
recommended.
Objective:
High protein, anti-inflammatory and calcium rich diet is prepared to fasten the process
of healing, to prevent bone and tissue death and to reduce the inflammation.
Basic Principle:
High calorie, high protein, calcium rich, normal carbs and normal fat diet.
Dietary Guidelines:
Calcium:
 An adequate calcium dietary intake, the principal component of bone, can
significantly reduce the loss of bone and is necessary to replenish the compulsory
daily calcium losses.
 Adults should get between 1,000 and 1,200 milligrams of calcium each day for
bone fracture.
 Milk and other dairy products are the best source of calcium but also significant
amounts are contained in foods such as green leafy vegetables (e.g., spinach),
broccoli, almonds, legumes, and seafood.
11
Vitamin D:
 Calcium in combination with vitamin D in dietary supplements is, found to reduce
the incidence of fractures.
 It plays an important role in protecting your bones, both by helping your body
absorb calcium and by supporting muscles needed to avoid falls.
 Up to 5000u, Vitamin D3 daily during periods of bone healing is, recommended.
 Foods that can contain high amounts of vitamin D are eggs, liver, fish, and
breakfast cereals.
Smoking and Alcohol:
 Smoking and excessive alcohol consumption can adversely affect bone health.
 Therefore, cessation of smoking is, recommended, which contributes to the overall
health of the person.
 Regarding alcohol restriction, less than two servings of alcohol per day for men
and one for women may enhance bone health.
Fish:
 Fish with dark flesh, such as salmon, are a rich source of vitamin D and are,
recommended as a safe way to increase the intake of vitamin D and reduce the
risk of fracture up to 33%.
Protein:
 You should aim to eat 1 to 1.2 grams of protein per kilogram body weight.
 Protein is, needed to heal wounds, repair broken bones, build healthy blood cells,
keep your immune system strong, and support muscle protein growth and
strength.
Vitamin C and Zinc:
 Vitamin C is, needed to make a protein called collagen and for repairing tendons,
ligaments, bones and skin. Citrus fruits are high in vitamin C, but do not overlook
other sources of vitamin C such as strawberries, kiwifruit, baked potatoes,
broccoli, and bell peppers.
 We recommend 500mg of vitamin C daily in both phase 1 and phase 2 of healing.
 Zinc is a mineral found mostly in animal foods such as meat, fish, poultry, and
dairy foods.
 Zinc is also found in whole grain breads and cereals, legumes (dried beans and
peas), and nuts.
2.1.3 Table Food choices for Fracture:
Food Groups Foods Allowed Foods Restricted
Bread, Cereals and Grains Whole grain bread, brown White bread, white rice,
12
rice, oatmeal, Chapatti, Bakery items, white flour
whole grain flour
Milk and Milk products Milk, cheese, yogurt Milk, cheese and yogurt
without cream if tolerable with added cream and fats
Meat (red/ white and eggs) Fish, lean meat, red meat Processed meat and all
and eggs. meats that made in high
quantity of oil, fat cuts.
Lentils/daals All lentils cooked in low oil All fried lentils
Vegetables (green Spinach, Green leafy Tomatoes, potatoes and
leafy/starchy) vegetables, broccoli cooked deep-fried vegetables.
in low amount of oil
Fruits All fruits None
Dried fruits/ nuts and seeds All kind of fruits, nuts and Fried and salted nuts and
seeds seeds
Fats and oils Olive oil, sunflower oil, Butter, ghee, margarine,
canola oil cooking oil and fried foods
Desserts and Sweets All types of desserts and All types of desserts with
sweets high fats and added sugar
like kheer and halwa
Fluids and Drinks Water, fresh juices, tea, Coffee, Beverages with
green tea and lassi added sugar, soft drinks and
alcohol
Calculation:
 Patient name: Faisal Ahmed

 Age: 21 years
 Height: 5’5 inches
 Weight: 50 kg
Anthropometric Measurements:
Height: 5’5 multiply first 5 feet with12 and
BMI: then add additional inches.
Formula= Weight kg
Height m2  5x12= 60
 60+5=65
50kg
Multiply it with 2.54 for converting in cm
(1.6)(1.6)
= 50  65x2.54=165cm
Converting it into m
2.56
 165
= 19 100
=1.6m
 BMI= 19kg/m2 (patient
has normal weight)
13
IBW:
Height 5’5 for first 5 feet is 106 and multiply additional inches with +6
 106+6x5
 106+30
 136 Lbs.
Converting it into kg
=136
2.2
61kg
IBW= 61kg
IBW%:
Formula = Actual weight x 100  Actual weight= 50 kg

IBW  IBW= 61 kg
= 50 x 100
61
= 0.8 x 100
= 80%
IBW% = 80%
Energy Calculation:
BEE:
Formula for male BEE= 66.5+ (13.8x weight kg) + (5.0xheight cm) - (6.8xage years)
BEE= 66.5+ (13.8x 50 kg) + (5.0x 165 cm) – (6.8x 21 years)
BEE= 66.5+ 690+ 825- 142
BEE= 1582- 142  Weight: 50kg
BEE= 1440 kcal  Height: 165 cm
BEE= 1440 kcal  Age: 21 years
TEE:
Formula= BEE x Activity factor x Stress factor BEE= 1440 kcal
= 1440 x 1.1 x 1. 2 A.F= 1.1
= 1901kcal S.F= 1.2
TEE= 1901 kcal
AMDRS:
 Carbohydrates= 52% Calories=1901kcal
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
14
100
= 52 x 1901 kcal
100
= 0.52 x 1901 kcal
= 989 kcal
= 989 as 1 gram of carb= 4kcal
4
Carbohydrate= 247 grams
PROTIEN:
= % x calories
100
= 18 x 1901
100
= 0.18 x 1901
= 342 kcal
= 342 as1 gram of protein=4kcal
4
Protein = 86 grams
FAT:
= % x calories
100
= 30 x 1901
100
= 0.3 x 1901
= 570 kcal
= 570
9 as 1 gram of fat= 9kcal
Fats= 63 grams
1.4.4 EXCHANGES:
Food Exchange Carbohydrate Protein Fats
Milk 2 24g 16g 10g
Vegetable 3 15g 6g -
Fruit 3 45g - -
Total - 84g 22g 10g
Starch= Total- Consumed Carbs= 247g
= 247g- 84g
= 163g
 As 1 exchange of carbs = 15g
= 163
15
Carbohydrate= 11 exchanges
15
Starch 11 165g 22g 11g
Total - 165+84 = 249g 22+22= 44g 11+10= 21g
- -
Protein= Total- Consumed Protein= 86g
86g- 44g
42g
 As 1 exchange of protein= 7g
= 42
7
Protein= 6 exchanges
Lean Meat 6 - 42g 12g
Total - - 42+44= 86g 12+21g= 33g
- -
Fats= Total- Consumed Fat= 63g
63g-33g
30g
 As 1 exchange of fat= 5g
= 30
5
Fat= 6 exchanges
Food Exchange Carbohydrate Protein Fat
Fat 6 - - 30g
Total - - - 30+33= 63g
- -
16
2.1.4 DIET PLAN:
Breakfast:
 3 slices of brown bread
 2 fried Eggs
 EXCHANGES
 1 cup tea (1 cup reduced fat milk)
Milk= 2
 ½ tsp oil
Fruit= 3
Snack:
Vegetable= 3
 Strawberry shake (3 strawberries+1cup low fat milk)
Starch= 11
Lunch:
Protein= 6
 1 chapatti (12 inches of whole grain flour)
Fat= 6
 2-piece grilled chicken (3oz each)
 1 cup salad
 1tsp oil
Snack:
 1 cup whole grain pasta (½ cup mixed vegetable)
 1 tsp oil
Dinner:
 2-piece baked fish
 1 cup vegetable rice (1cup brown rice+ ½ cup vegetable)
 1.5 tbsp. oil
17
CASE 2
2.2 Case Study:
Mr. Salamat Ali, 60 years male is, hospitalized due to diagnosis of Rheumatoid
arthritis. MRI scan showed flexion of metacarpal phalangeal joints of hands while
thumbs are inclined towards deformity. Patient is also suffering from pain, stiffness
and inflammation within joints. His height is 5feet 8inches and his current weight is
75kg. His BMI is about 25kgm2 and his TEE is 2124kcal. Patient is also heavy
smoker from last 20 years.
2.2.1 Rheumatoid Arthritis:
Rheumatoid Arthritis is an autoimmune chronic disorder that affects the interstitial
tissues, blood vessels, cartilage, bones, tendons as well as synovial fluid membrane
that line joint surfaces. It causes inflammation in synovial membrane causing damage
in cartilage.
Symptoms:
 Pain
 Stiffness
 Swelling
 Loss of function
 Inflammation of synovial membrane
2.1.2 Medical Nutrition Therapy of RA:
For the treatment of RA gluten free, nutrient rich diet, anti-inflammatory diet and
calcium rich diet is, recommended.
Objective:
Anti-inflammatory diet, gluten free, calcium rich and nutrient rich diet is prepared for
maintaining or losing body weight, reducing inflammation and pain, and to attain
symptomatic relief.
Basic Principle:
High nutrient, anti-inflammatory, calcium rich diet.
Dietary recommendation of RA:
Weight Management:
 In overweight or obese patients RA mostly like to occur.
 Weight change is an important measure in severity of RA.
 Weight loses can bring improvement in RA disease activity.
Gluten-free diet:
 A vegan, gluten-free diet causes improvement in RA symptoms because of the
reduction of immune reactivity to food antigens.
 Whole grain bread, brown rice and unrefined grains are, recommended.
Fasting:
 Intermittent fasting during the acute phase of RA may provide some pain relief,
however after the normal diet is, resumed, inflammation returns unless the fasting
period is, followed by a vegetarian diet.
18
 Combination of fasting and vegetarian diet is beneficial for treatment of RA.
Anti-Inflammatory diet:
 Anti-inflammatory diet is, recommended to reduce inflammation within joints.
 Diet should be full of fruits and vegetables of all bright and dark colors, especially
berries, oranges and yellow fruits and dark green vegetables like broccoli but
should avoid vegetables like potato.
 Diet should be full of whole grain carbs and should avoid processed and white bread
and rice.
 Low in saturated and Tran’s fats.
 High in Mono-unsaturated fatty acids like olive oil and nuts, high in Omega 3.
 Low in Omega 6.
Energy:
 People with RA should consume nutrient-rich diets and incorporate physical activity
throughout the day to boost their total energy expenditure.
 This helps them improve their physical activity, quality and maintain a healthy life.
Protein:
 Protein requirement for individuals who are poorly nourished or who are in the
inflammatory process of disease are 1.2 to 1.5g protein/kg body weight.
 Well-nourished individuals have done not any increased requirements.
Fats:
 Fats should contribute less than 30% of the total energy intake for the purpose of
healthy eating and weight management.
Vitamins, Minerals and Antioxidants:
 Vitamin E along with Omega-3 fatty acids help in reduction of inflammation.
 Diet rich with calcium, vitamin D, vitamin E, zinc and vitamin B.
 Intake of folate, vitamin B6 and vitamin B12.
2.2.3 Table food choices for RA:

rice, oatmeal, Chapatti, Bakery items, white flour,
whole grain flour pasta, pastries, cookies,
energy bars.
Milk and Milk products Milk, yogurt without cream Milk, cheese and yogurt
if tolerable with added cream and fats
and full fat dairy products.
Meat (red/ white and eggs) Chicken, Fish Processed meat and all
meats that made in high
quantity of oil, fat cuts,
Eggs, red meat.
19
Vegetables (green Spinach, Green leafy Potatoes, eggplant, pepper
leafy/starchy) vegetables, broccoli, and tomatoes, onions and
cabbage, cauliflower and all deep-fried vegetables.
sweet potato
seeds seeds
canola oil, olive oil, cold cooking oil and fried foods
water fish oil, canola oil
sweets high fats, high dairy content
and added sugar like kheer
and halwa
green tea and. added sugar, soft drinks and
alcohol
Calculation:
 Patient name: Salamat Ali

 Age: 60 years
 Weight: 75 kg
1.4.1Anthropometric Measurements:
BMI:
Formula= Weight kg Height: 5’5 multiply first 5 feet with12 and
Height m2 then add additional inches.
75kg  5x12= 60
(1.7)(1.7)  60+8=68
= 75 Multiply it with 2.54 for converting in cm
2.89  68x2.54=172cm
= 25 Converting it into m
 172
 BMI= 25kg/m2 (patient is
overweight ) 100
=1.7m
IBW:
 106+6x8
20
 106+48
 154 Lbs.
=154
2.2
70kg
IBW=70kg
IBW%:
IBW  IBW= 70 kg
= 75 x 100
70
= 1.07 x 100
= 107%
IBW% = 107%
Energy Calculation:
BEE:
BEE= 66.5+ 966 + 860 - 408
BEE= 1893- 408  Weight: 70kg
BEE= 1485 kcal  Height: 172cm
TEE:
= 1485 x 1.1 x 1.3 A.F= 1.1
=1901 kcal S.F= 1.3
TEE= 2124 kcal
AMDRS:
 Protein=18%
 Fats= 28%
CARBOHYDRATE:
= % x calories
100
= 54 x 2124 kcal
100
= 0.54 x 2124 kcal
= 1147 kcal
= 1147
4 as 1 gram of carb= 4kcal
21
PROTIEN:
= % x calories
100
= 18 x 2124
100
= 0.18 x 2124
= 382 kcal
= 382 as 1 gram of protein= 4kcal
4
Protein = 96 grams
FAT:
= % x calories
100
= 28 x 2124
100
= 0.28 x 2124
= 595 kcal
= 595
Fats= 66 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 287g- 84g
= 203g
= 203
15
Total - 210+84 = 294g 28+22= 50g 14+10= 24g
- -
96g- 50g
46g
22
= 46
7
Total - - 49+50= 99g 14+24g= 38g
- -
66g-38g
28g
= 28
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+38= 68g
- -
23
2.2.4 DIET PLAN:
Breakfast:
 1 cup oatmeal (1 cup reduced fat milk +
2 bananas + 1 cup sweet potato)
 EXCHANGES
Snack:
Milk= 2
 ¾ cup berries
Fruit= 3
 12 almonds
Vegetable= 3
Lunch:
Starch= 14
 1 chapatti (12 inches of whole grain flour)
Protein= 7
 1 cup lentils
Fat= 6
 1 cup vegetable salad (spinach+ broccoli)
 1tsp oil
Snack:
 1 cup tea
 2 chicken kababs
 1 tsp oil
Dinner:
 2-piece baked fish
 1 cup brown vegetable rice (1cup brown rice+ 1cup vegetable)
 1.5 tbsp. oil
Snack:
 1 whole grain bread slice
 1 tbsp. peanut butter
24
CASE 3
2.3Case Study:
Mr. Azhar Ali 60 year’s male is, hospitalized due to osteoarthritis in both knees. X-rays
showed severe osteoarthritis in both knees followed by pain, stiffness of joints. Calcium
deficiency and lack of physical activity is, also observed. His height is 5 feet 8 inches
and his current weight is 75kg. His BMI is about 25kg/m2 and TEE is 2124kcal.
2.3.1Osteo-Arthritis:
 It is, commonly known as degenerative arthritis or degenerative joints disease that
involves the loss of habitually of weight bearing joints.
 This cartilage normally allows bones to smoothly glide over each other that cause
pain stiffness, swelling, inflammation, loss of motion and changes in joint shape.
 Thumb, knees, hip, ankles and spines joints are most likely to be, affected.
2.3.2 Medical Nutrition Therapy of OA:
For the treatment of OA, nutrient rich diet, anti-inflammatory diet and calcium rich
diet is, recommended.
Objective:
Anti-inflammatory diet, calcium rich and nutrient rich diet is prepared for,
maintenance, losing body weight, reducing inflammation, pain, and to attain
symptomatic relief.
Basic Principle:
High nutrient, anti-inflammatory, calcium rich diet
Dietary recommendation of OA:
Weight Management:
 In overweight or obese patients OA mostly like to occur.
 Weight change is an important measure in severity of OA.
 Weight loses can bring improvement in OA disease activity.
Anti-Inflammatory diet:
 Anti-inflammatory diet is, recommended to reduce inflammation within joints.
 Diet should be full of fruits and vegetables of all bright and dark colors, especially
berries, oranges and yellow fruits and dark green vegetables like broccoli but
should avoid vegetables like potato.
 Diet should be full of whole grain carbs and should avoid processed and white bread
and rice.
 Low in saturated and Tran’s fats.
 High in Mono-unsaturated fatty acids like olive oil and nuts, high in Omega 3.
 Low in Omega 6.
Protein:
 Protein requirement are normal.
 Well-nourished individuals have done not any increased requirements.
Vitamins, Minerals and Antioxidants:
25
 Vitamin E along with Omega-3 fatty acids help in reduction of inflammation.
 Diet rich with calcium, vitamin D, vitamin E, zinc and vitamin B.
 Intake of folate, vitamin B6 and vitamin B12.
Exercise:
 Normal exercise of 10-15 minutes is, recommended.
2.3.3 Table food choices for OA:

energy bars.
Eggs, red meat.
sweet potato
seeds seeds
and halwa
alcohol
Calculation:
 Patient name: Azhar Ali
26
 Age: 60 years
 Weight: 80 kg
BMI:
80kg  5x12= 60
(1.7)(1.7)  60+10=70
2.89  70x2.54=177cm
 177
overweight ) 100
=1.7m
IBW:
 106+6x10
 106+60
 166 Lbs.
=166
2.2
75kg
IBW=75kg
IBW%:
IBW  IBW= 75 kg
= 80 x 100
75
= 1.06 x 100
= 106%
IBW% = 106%
Energy Calculation:
BEE:
BEE= 66.5+ 1035 + 885 - 408
 Weight: 75kg
27  Height: 177cm
 Age: 60 years
BEE= 1986- 408
BEE= 1578 kcal
BEE= 1485 kcal
TEE:
= 1578 x 1.1 x 1.2 A.F= 1.1
= 2083 kcal S.F= 1.2
TEE= 2083 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2083 kcal
100
= 0.52 x 2083 kcal
= 1083 kcal
= 1083
PROTIEN:
= % x calories
100
= 18 x 2083
100
= 0.18 x 2083
= 375 kcal
4
Protein = 94 grams
FAT:
= % x calories
100
= 30 x 2083
100
= 0.3 x 2083
= 625 kcal
= 625
Fats= 70 grams
28
Total - - 42+52= 94g 12+27g= 39g
- -
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g
= 271g- 96g
= 175g
= 175
15
Total - 180+96 = 276g 24+30= 54g 12+15= 27g
- -
94g- 54g
40g
= 40
7
70g-39g
31g
= 31
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+39= 69g
- -
29
2.3.4 DIET PLAN:
Breakfast:
 1 cup oatmeal (1 cup reduced fat milk + 3 peaches)
Snack:  EXCHANGES
 1 cup green tea Milk= 3
 12 almonds
Fruit= 3
Lunch:
 2 slice of whole grain bread Vegetable= 3
 2-piece baked fish Starch= 12
 1 cup vegetable salad
 1tsp oil Protein= 6
Snack: Fat= 6
 1 cup tea
 ½ cup sweet potato
Dinner:
 1 cup brown rice
 3-piece grilled chicken (6oz)
 1.5 tbsp. oil
Snack:
 2 whole grain bread slices
 2 egg whites boiled
 2 tbsp. mayo
 1 cup reduced fat milk
30
Case.4
2.4 Case Study:
Miss Zainab Ahmed, 65 years old woman is, hospitalized due to incidence of
osteoporosis. She has family history of osteoporosis by her mother. X-rays scan showed
severe osteoporosis in her knees followed by pain and stiffness. Her height is 5 feet 6
inches and weight are 42kg. Her BMI is about 16kg/m2 and TEE is 1618kcal.
2.4.1Osteoporosis:
Osteoporosis is a bone disease that develops when bone mineral density and bone mass
decreases, or when the structure and strength of bone changes. It can occur both in old
age people and in young people but rarely.
Types of Osteoporosis:
There are 2 types of osteoporosis:
 Primary osteoporosis
 Secondary osteoporosis
Primary Osteoporosis:
 It occurs because of natural aging process.
 BMD declines both with age and with the loss of estrogen after menopause.
 For women, primary osteoporosis is more likely 10 to 15 years after menopause.
 In men around 65 to 80 years.
Secondary Osteoporosis:
 It occurs when an identifiable drug or disease process cause loss of bone tissue.
Risk factors:
 Age especially after 60.
 Amenorrhea in women because of excessive exercise.
 Androgen depletion with hypogonadism in men.
 Cigarette smoking
 Female gender
 Family history of osteoporosis
 Inadequate intake of calcium and vitamin D.
 Lack of exercise.
 Excessive Exercise.
 Underweight, low body max index.
2.4.2 Medical Nutrition Therapy of Osteoporosis:
For management of osteoporosis moderate intake of protein, carbohydrate. And
calcium, vitamin D rich and anti-inflammatory diet is, recommended.
Objective:
Moderate amount of protein, carbs and fat. And high intake of Vitamin D, calcium
In addition, Phosphate helps to stop and prevent osteoporosis.
31
Basic Principle:
Moderate amount of protein, carbs and fat, high intake of Vitamin D and calcium.
Dietary Modification:
Adequate calcium and vitamin D:

 Calcium (1000 mg/day) and vitamin D (800 to 1000 units/day) typically are,
recommended as supplements for patients, treated with one of the bone drugs.
 These amounts are, considered safe and sufficient for bone formation.
Sodium:
 A high sodium intake may contribute to osteoporosis because of increased calcium

excretion.
Energy:
 Energy intake does not have a direct effect on bone; rather, inadequate energy
intake leading to low body weight, or too many calories leading to overweight has
effects on bone.
 Being underweight is, considered a risk factor for osteoporosis, whereas being
overweight may be protective
Protein:
 Adequate protein intake, with adequate calcium intake, is, needed for optimal bone
health.
 Dietary protein may increase acid load and thereby increase urinary calcium
excretion, protein also may improve calcium absorption and increase growth
factors, which also could improve bone health.
2.4.3 Table food choices for OP:

energy bars.
32
Eggs, red meat.
sweet potato
seeds seeds
and halwa
alcohol
Calculation:
 Patient name: Zainab Ahmed

 Age: 65 years
 Weight: 42 kg
1.4.1Anthropometric Measurements:
BMI: Height: 5’5 multiply first 5 feet with12 and

Formula= Weight kg then add additional inches.
42kg  60+6=66
(1.6)(1.6) Multiply it with 2.54 for converting in cm
= 42  66x2.54=167cm
2.56 Converting it into m
= 16  167
100
 BMI= 16kg/m2 (patient is =1.6m
underweight )
33
IBW:
 100+5x6
 100+30
 130 Lbs.
=130
2.2
59kg
IBW=59kg
IBW%:
IBW  IBW= 59 kg
= 42 x 100
59
= 0.71 x 100
= 71%
IBW% = 71%
Energy Calculation:
BEE:
Formula for female BEE= 665+ (9.6x weight kg) + (1.8xheight cm) - (4.7xage years)
BEE= 665+ (9.6x 59 kg) + (1.8x 167 cm) – (4.7x 65 years)
BEE= 665+ 566 + 301 - 306
BEE= 1532- 306  Weight: 59kg
TEE:
= 1226 x 1.1 x 1.2 A.F= 1.1
= 1618 kcal S.F= 1.2
TEE= 1618 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1618 kcal
100
34
= 0.52 x 1618 kcal
= 841 kcal
= 841
4 as 1 gram of carb4kcal
PROTIEN:
= % x calories
100
= 18 x 1618
100
= 0.18 x 1618
= 291 kcal
= 291 as 1-gramprotein=4kcal
4
Protein = 72 grams
FAT:
= % x calories
100
= 30 x 1618
100
= 0.3 x 1618
= 485 kcal
= 485
Fats= 53 grams
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g
= 210g- 96g
= 114g
= 114
15
Total - 120+96 = 216g 16+30= 46g 8+15= 23g
- -
35
72g- 46g
26g
= 26
7
Total - - 28+46= 74g 8+23g= 31g
- -
53g-31g
22g
= 22
5
Fat= 4 exchanges
Fat 4 - - 20g
Total - - - 20+31= 51g
- -
36
2.4.4 DIET PLAN:
Breakfast:
 1 whole egg
 1 whole wheat flour chapatti  EXCHANGES
Snack: Milk= 3
 2 peaches Fruit= 3
 1 apple Vegetable= 3
Lunch: Starch= 8
 1 whole wheat flour chapatti Protein= 4
 1-piece baked fish Fat= 4
 1 cup cooked vegetable
 1tsp oil
Snack:
 2-3 whole wheat biscuits
Dinner:
 2-piece grilled chicken (6oz)
 1.5 tbsp. oil
 1 cup raita
Snack:
37
Chapter No.3
GASTRO WARD
During the third week of internship, the rotation was, placed at gastro ward.
CASE 1
3.1CASE STUDY:
Mr. Gurlzar, age 21 years is, hospitalized due to constipation from a long time. He is
facing too much pain while passing stool. His height is 5, 3 inches and his weight are
52kg. His BMI is about 20kg/m2 and TEE is 1904kcal.
3.1.1Constipation:
 Constipation is, defined as difficulty with defecation characterized by frequency
dyschezia (painful, hard, or incomplete evacuations).
 Normal bowel movement frequency can range from three times per day to three times
per week.
 A volume of as little as 200 g daily is, considered normal in healthy children and adults.
Causes of constipation:
 Lifestyle and Diet
 Lack of fiber in diet
 Low total calorie and fluid intake
 Iron and calcium supplements
 Lack of exercise
 Immobility
 Laxative abuse
3.1.2 Medical nutrition therapy:
Whole grains, such as whole wheat bread and pasta, oatmeal, and bran flake cereals.
Legumes, such as lentils, black beans, kidney beans, soybeans, and chickpeas.
Fruits, such as berries, apples with the skin on, oranges, and pears.
Objective:
Dietary Reference Intakes (DRI) recommend consumption of 14 g dietary fiber per
1000 kcal, or 25 g for adult women and 38 g for adult men.
Dietary guidelines:
• Appropriate kinds and amounts of dietary fiber for children, the critically ill, and the
very old are unknown.
• Primary therapy for healthy people is consumption of adequate amounts of fluids
and dietary fiber, soluble and insoluble.
• Fiber increases colonic fecal fluid, microbial mass (which accounts for 60% to 70%
of stool weight), stool weight and frequency, and the rate of colonic transit.
• Usual intake of dietary fiber in the United States is only about 16.2 g/day.
38
• Fiber can be, provided in the form of whole grains, fruits, vegetables, legumes,
seeds, and nets’ high-fiber therapeutic diet may have to exceed 25 to 38 g/day.
• Amounts greater than 50g/day are not necessary and may increase abdominal
distention.
• Gastric obstruction may occur when bran is not consumed with fluid.
3.1.3 Table Food choices for Constipation:

whole grain flour
Lentils/daals All lentils cooked in low All fried lentils
oil
leafy/starchy) vegetables, broccoli deep-fried vegetables.
cooked in low amount of Cabbage cauliflower.
oil
seeds seeds
green tea and lassi added sugar, soft drinks
and alcohol
Calculation:
 Patient name: Gulzar Ahmed
 Age: 21 years
39
 Weight: 52 kg
BMI:
52kg  5x12= 60
(1.6)(1.6)  60+3=63
2.56  63x2.54=160cm
 160
 BMI= 20kg/m2 (patient
has normal weight ) 100
=1.6m
IBW:
 106+6x3
 106+18
 124 Lbs.
=124
2.2
56kg
IBW=56kg
IBW%:
IBW  IBW= 56 kg
= 52 x 100
56
= 0.9 x 100
= 90%
IBW% = 90%
Energy Calculation:
BEE:
BEE= 66.5+ 718 + 800 - 143
BEE= 1585- 143  Weight: 52kg
40
TEE:
= 1442 x 1.1 x 1.2 A.F= 1.1
= 1904 kcal S.F= 1.2
TEE= 1904 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1904 kcal
100
= 0.52 x 1904 kcal
= 990 kcal
= 990
PROTIEN:
= % x calories
100
= 18 x 1904
100
= 0.18 x 1904
= 343 kcal
= 343 as 1 gram of
protein=4kcal
4
Protein = 86 grams
FAT:
= % x calories
100
= 30 x 1904
100
= 0.3 x 1904
= 571 kcal
= 571
Fats= 63 grams
41
EXCHANGES:
Milk 3 36g 24g 15g
Vegetable 4 45g - -
Fruit 3 20g 8g -
Total - 101g 32g 15g
= 247g- 101g
= 146g
= 146
15
Total - 150+101 = 251g 20+32= 52g 10+15= 25g
- -
86g- 52g
34g
= 34
7
Total - - 35+52= 87g 20+25g= 45g
- -
= 63-45g
= 18g
= 18
5
Fat= 4 exchanges
Fat 4 - - 20g
Total - - - 20+45= 65g
- -
42
3.1.4 Diet plan
Breakfast:
 1 cup oatmeal with fruits (1 cup cooked oats+ 1 cup milk +1 apple)
Snack: Exchanges
 2 slice watermelon Milk: 3
Lunch: Fruit: 3
 1 chapatti Vegetable: 4
 1 cup lentils
Starch: 10
 1 cup raita
Protein: 5
 1 cup salad
Fat: 4
Snack:
 Pasta (1 piece chicken+ 1 cup vegetable+ 1/3 cup pasta)
Dinner:
 1 cup vegetable rice (1 cup brown rice+ ½ cup vegetable)
 2-piece steamed chicken (6oz)
Snack:
 1 cup Milk with espaghol
43
CASE 2
3.2 Case Study:
Mr. Basit aged 62 is, hospitalized due to IBS. He is facing continuous abdominal pain
followed by irregular bowel movements. His height is 5’11 inches and current weight
is 66 kg. His BMI is about 20 kg/m2 and TEE is 1923 kcal/day.
3.2.1 Inflammatory bowel disease:
 The two major forms of IBD are Crohn’s disease and UC. Crohn’s disease and UC are
relatively rare disorders, but they result in frequent use of health care resources.
 The prevalence and incidence are increasing as it emerges as a global disease.
 It is also becoming more prevalent in the elderly.
Crohn’s disease Crohn’s Disease:
 Ulcerative Colitis and Crohn’s disease may involve any part of the GIT, but
approximately 50% to 60% of cases involve the distal ileum and the colon.
 Only the small intestine or only the colon is involved in 15% to 25% of cases Disease
activity in UC is limited to the large intestine and rectum.
 In Crohn’s disease, healthy segments may separate segments of inflamed bowel,
whereas in UC the disease process is continuous.
 Mucosal involvement in Crohn’s disease is transmural in that it affects all layers of
the mucosa; in UC, the ddisease normally is limited to the mucosa.
 Abscesses, fistulas, fibrosis, submucosal thickening, localized strictures, narrowed
Types Symptoms of IBS

IBS with constipation ,3 bowel movements per week
(IBS-C) Hard or lumpy stools
Straining during bowel movements
IBS with diarrhea (IBS-D) 3 bowel movements per day

Fecal urgency
Loose watery stool
Mixed IBS (IBS-M) A mix of hard and loose stools over
periods of hours to day
Unsub typed IBS Insufficient abnormality of stool
patterns to meet criteria for IBS-C,
D, or M
segments of bowel, and partial or complete obstruction of the intestinal characterize

Crohn’s disease.
44
3.2.2 Medical nutrition therapy for IBS:
Persons with IBD are at increased risk of nutrition problems for a host of reasons
related to the disease and its treatment.
Objective:
 Thus, the primary goal is to restore and maintain the nutrition status of the individual.
Foods, dietary and micronutrient supplements, and enteral and parenteral nutrition
may be, used to accomplish that mission.
 Oral diet and the other means of nutrition support may change during remissions and
exacerbations of the disease.
Dietary guidelines:
 The goals of nutrition therapy for IBS are to ensure adequate nutrient intake, tailor the
diet for the specific GI pattern of IBS and explain the potential roles of foods in the
management of symptoms.
 Implementation of nutrition interventions for IBS should take a stepwise approach
from simple to complex.
 Initial steps during nutrition counseling should include
1. Review of current medications for IBS and other medications;
2. Review of GI symptoms (duration, severity, frequency);
3. Assessment of nutritional status and food intake;
4. Review of supplement intake (vitamins, minerals, fats, pre- and probiotics,
herbals); and
5. Review of use of mind-body therapies and the results achieve.
6. Initiate smoking cessation (lower LES pressure)
7. Improve clearing of materials from esophagus
8. Remain upright after eating
9. Avoid eating within 3 hours of bedtime
10. Wear loose-fitting clothing
11. Raise the head of bed for sleeping
3.2.3 Table content for IBS:

whole grain flour
45
seeds seeds
alcohol
Calculation:
 Patient name: Basit Ali
 Age: 62 years
 Weight: 66 kg
then add additional inches.
Formula= Weight kg
66kg  60+11=71
(1.6)(1.6) Multiply it with 2.54 for converting in cm
= 66  71x2.54=180cm
 180
= 20
100
 BMI= 20kg/m2 (patient =1.8m
has normal weight )
IBW:
 106+6x11
 106+66
 172 Lbs.
46
=172
2.2
78kg
IBW=78kg
IBW%:
IBW  IBW= 78 kg
= 66 x 100
78
= 0.8 x 100
= 80%
IBW% = 80%
Energy Calculation:
BEE:
BEE= 66.5+ 911 + 900 - 422
BEE= 1878- 422  Weight: 66 kg
TEE:
= 1457 x 1.1 x 1.2 A.F= 1.1
= 1923 kcal S.F= 1.2
TEE= 1923 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1923 kcal
100
= 0.52 x 1923 kcal
= 1000 kcal
= 1000
PROTIEN:
47
= % x calories
100
= 18 x 1923
100
= 0.18 x 1923
= 346 kcal
4
Protein = 87 grams
FAT:
= % x calories
100
= 30 x 1923
100
= 0.3 x 1923
= 577 kcal
= 577
Fats= 64 grams
EXCHANGES:
Food Exchange Carbohydra Protein Fats
te
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 250g- 84g
= 166g
= 166
15
Total - 165+84=249g 22+22=44g 10+11=21g
- -

87g- 44g
48
43g
= 43
7
Total - - 42+44= 86g 12+21g= 33g
- -
= 64-33g
31g
= 31
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+33= 63g
- -
49
3.2.4 Diet plan:
Breakfast:
 1 cup oatmeal with fruits (1 cup cooked oats+ 1 cup fat free milk +1 banana sliced)
Snack:
 2 apple+ 1 tbsp. almond butter.
 1 boiled egg.
Lunch: Exchanges
 1 cup brown rice Milk: 2
 2-piece baked Fish Fruit: 3
 1 cup vegetable salad Vegetable: 3
 1 cup raita Starch: 11
Snack: Protein: 6
 Pasta (1 cup vegetable+ 1 cup cooked brown pasta) Fat: 6

Dinner:
 1 whole grain chapatti
 1 cup lentils
Snack:
 2-3 digestive biscuits.
50
CASE 3
3.3 Case Study:
Mr. Sarmad aged 21 is, hospitalized due to incidence of celiac disease. He ate the
food that contain gluten. He is also facing digestive problems like bloating and loose
bowl movement. Severe abdominal pain and allergic reaction on mouth and face of
patient is, observed. His height is 5,5inches and weight is 50kg. His BMI is about
18.3kg/m2 and TEE is 2100kcal.
3.3.1 Celiac disease:
Celiac disease is a chronic digestive and immune disorder that damages the small
intestine. The disease is, triggered by eating foods containing gluten. The disease can
cause long-lasting digestive problems and keep your body from getting all the
nutrients it needs.
Symptoms:
 Anemia (iron or folate, rarely B12)
 Osteomalacia, osteopenia, fractures (vitamin D deficiency, inadequate
 Calcium absorption)
 Coagulopathies (vitamin K deficiency)
 Dental enamel hypoplasia
 Delayed growth, delayed puberty, underweight
 Lactase deficiency
3.3.2 Medical Nutrition Therapy of celiac disease:

 Elimination of gluten peptides from the diet is the only treatment for CD presently.
 The diet omits all dietary wheat, rye, and Barley, which are the major sources of the
protamine fractions.
 Nutrition management includes restoration and maintenance of fluids, electrolytes,
macronutrients, and micronutrients, and introduction of a diet that is appropriate for
the extent of malabsorption.
 Along with other nutrients, B12 and folate supplementation may be, needed if
deficiency is, identified.
 Nutritional deficiency increases susceptibility to infectious agents, further
aggravating the condition.
Objective:
 Electrolyte and fluid replacement
 Management of other co-morbid conditions
Dietary guidelines:
 Delete gluten sources (wheat, rye, barley) from diet
 Vitamin and mineral supplementation
 Substitute with corn, potato, rice, soybean, tapioca, and other non-gluten flours
 Calcium and vitamin D administration
51
 Read food labels carefully for hidden gluten containing ingredients
 Supplementation with ω-3 fatty acid
3.3.3 Table Food choices for celiac disease:

Grains and flours Amaranth, bean flour, White bread, white rice,
cornstarch, millet, potato, Bakery items, white flour
rice, soybean.
Lentils All lentils cooked in low All fried lentils
oil
leafy/starchy) vegetables, broccoli deep-fried vegetables.
cooked in low amount of
oil
seeds seeds
green tea and lassi added sugar, soft drinks
and alcohol
Calculation:
•Patient name: Sarmad Shehbaz
•Age: 21 years
•Height: 5’5 inches
•Weight: 50 kg
52
BMI:
50kg  5x12= 60
(1.65)(1.65)  60+5=65
2.72  65x2.54=165cm
= 18.3 Converting it into m
 165
 BMI= 18.3kg/m2 (patient
is underweight ) 100
=1.65m
IBW:
 106+6x5
 106+30
 136 Lbs.
=136
2.2
61kg
IBW=61kg
IBW%:
Formula = Actual weight x 100
IBW
 Actual weight= 50 kg
= 50 x 100
 IBW= 61 kg
61
= 0.8 x 100
= 80%
IBW% = 80%
Energy Calculation:
BEE:
Formula for male BEE= 66.5+ (13.8 x weight kg) + (5.0 x height cm) - (6.8 x age years)
BEE= 66.5+ (13.8 x 61kg) + (5.0 x 165 cm) – (6.8 x 21 years)
BEE= 66.5+ 842+ 825- 143
BEE= 1734- 143
BEE= 1591 kcal
BEE= 1591 kcal
53
TEE:
= 1591 x 1.1 x 1.2 A.F= 1.1
=2100 kcal S.F= 1.2
TEE= 2100 kcal
AMDRS:
• Carbohydrates= 52% Calories=2100kcal
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2100 kcal
100
= 0.52 x 2100 kcal
= 1092 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2100
100
= 0.18 x 2100
= 378 kcal
= 378 as1 gram of protein= 4kcal
4
Protein = 95 grams
FAT:
= % x calories
100
= 30 x 2100
100
= 0.3 x 2100
= 630 kcal
= 630
Fats= 70 grams
EXCHANGES:
Milk 2 24g 16g 10g
54
Fruit 3 45g - -
Total - 84g 22g 10g
= 273g- 84g
= 189g
•As 1 exchange of carbs = 15g
= 189
15
Total - 180+84 = 264g 36+22= 58g 12+10= 22g
- -
95g- 58g
37g
•As 1 exchange of protein= 7g
= 37
7
Total - - 35+58= 93g 22+21g= 43g
- -
70g-43g
27g
• As 1 exchange of fat= 5g
= 27
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 25+43= 68g
- -
55
3.3.4 DIET PLAN:
Breakfast:
 1 cup gluten free oatmeal (1 cup cooked + 1 cup low fat milk)
 1 boiled egg
 1 cup herbal tea
Snack:
 1 bowl of fruit chaat (non-citrus fruits like apple, papaya, guava)
 Hand full of almonds Exchanges
Lunch:
Milk: 2
 2-piece grilled chicken breast Fruit: 3
 1 cup salted vegetable salad Vegetable: 3
Snack:
Starch: 12
 Sandwich (2 slices of maize flour bread + 1-piece boiled chicken
+ 1 cucumber + 1tbsp mayo). Protein: 5
Dinner: Fat: 5
 1 cup moong daal
 1 small whole grain chapatti.
 1 cup vegetable salad.
Snack:
 2-3 gluten free biscuits
 1 cup tea
56
CASE 4
3.4 Case Study:
Mr. Waseem, aged 22 years is, hospitalized due to a disease name GERD
(gastroesophageal reflux disease); he had a history of stomach issue from last 5 years,
and a heavy smoker from last 7 years. He is suffering from severe gastroesophageal
reflux followed by abdominal pain and burning sensation.
Esophagogastroduodenoscopy diagnosed destruction of esophageal walls. Continues
episodes of blood vomiting is, also observed. His height is 5’6 inches and current
weight is 48 kg. His BMI is about 17kg/m2 and TEE is 2279 kcal/day.
3.4.1 GERD:
GERD occurs when stomach acid repeatedly flows back into a tube connecting to
your mouth and stomach. This acid reflux can irritate the lining of your esophagus.
Many people experience acid reflux from time to time.
3.4.2 Medical Nutrition Therapy of GERD:

Fibrous foods make patient feel full so you are less likely to overeat which may
contribute to heart burn.so, load up on healthy fiber from these foods: Whole grains
such as oatmeal and brown rice. Root vegetables such as sweet potatoes, carrots and
beets.
Objective:
The goals of managing GERD are to address the resolution of symptoms and prevent
complications such as esophagitis, BE and esophageal adenocarcinoma.
Basic Principle:
High protein, low carbs and low-fat diet.
Dietary Guidelines:
 Limit high fat foods, e.g., fried foods, high fat baked goods, cream, ice cream, high
fat cheeses, sausages, bacon, potato chips etc. Fatty foods have been, found to delay
gastric emptying and decrease the LES pressure thereby prolonging the esophageal
exposure time to stomach acid and the volume available for reflux.
 Ensure adequate protein intake. Early studies indicated that protein increased the
LES pressure thereby allowing the closure of the sphincter and reducing reflux.
Even though studies that are more recent do not support this belief, maintaining a
diet with adequate low-fat protein intake can still help in the healing of irritated
mucosa or ulcers.
 Limit chocolate and coffee. Both contain methyl xanthine, which causes muscles
to relax and lowers the LES pressure. In addition, coffee can stimulate gastric
secretions, which can promote reflux. If the esophageal mucosa is irritated,
individual tolerance of coffee, (regular or decaffeinated) should be determined.
 Limit or avoid mint, citrus, tomatoes, and/or carbonated beverages according to
individual tolerance. These foods may cause further irritation to damaged
esophageal mucosa but not have been, found to cause reflux themselves.
57
 Thickened feedings for children under 2 years of age reduce regurgitation severity
and emesis frequency, although this does not lower the reflux index.
 To minimize risk of secondary complications, such as bone fractures when taking
PPIs, it is helpful to note potential drug-nutrient interactions.
 A vegetarian diet may be protective against gastric reflux. A cross-sectional
analysis of a group of Buddhist priests following a vegetarian diet were, compared
to a group of non-vegetarians matched for age and weight found that the non-
vegetarian group had a significantly higher risk of esophageal reflux.
 Antioxidants in plant-based foods may play a role in reducing free radicals that
play a role in the pathogenesis of GERD. The combination of reducing animal
products while consuming vegetables, fruits, legumes, and whole grains may help
reduce symptoms of GERD.
 Symptoms of GERD may be, alleviated by avoiding late night eating. Patients
should avoid going to bed less than 2 to 4 hours after consuming their last meal.
Smoking and Alcohol:
 Smoking and excessive alcohol consumption can adversely affect health.
 Therefore, cessation of smoking is, recommended, which contributes to the overall
health of the person.
3.4.3 Table Food choices for GERD:
whole grain flour
Spices
Lentils/daals All lentils cooked in low All fried lentils
oil
Vegetables (green Broccoli, Green beans, Tomatoes
vegetables/Root sweet potatoes, carrot,
vegetables) beets
Fruits Melon, Bananas, Apples, Citrus fruits
Pears
Dried fruits/ nuts and seeds Raisins and Almonds Fried and salted nuts and
seeds
canola oil
58
cooking oil and fried foods
Desserts and Sweets None None
green tea added sugar, soft drinks
and alcohol
Calculation:
•Patient name: Waseem Zaid
•Age: 22 years
•Weight: 48 kg
BMI:

48kg  5x12= 60
(1.67)(1.67)  60+6=66
2.7  66x2.54=167cm
 167
 BMI= 18.3kg/m2 (patient
=1.67m
IBW:
 106+6x6
 106+36
 142 Lbs.
=142
2.2
64kg
IBW=64 kg
59
IBW%:
IBW
= 48 x 100
 IBW= 64 kg
64
= 0.75 x 100
= 75%
IBW% = 75%
Energy Calculation:
BEE:
BEE= 66.5+ (13.8 x 64 kg) + (5.0 x 165 cm) – (6.8 x 21 years)
BEE= 66.5+ 883+ 825- 143
BEE= 1775- 143
BEE= 1632 kcal
BEE= 1632 kcal
TEE:
= 1632 x 1.1 x 1.2 A.F= 1.1
=2154 kcal S.F= 1.2
TEE= 2154 kcal
AMDRS:
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2154 kcal
100
= 0.52 x 2154 kcal
= 1120 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2154
100
= 0.18 x 2154
60
= 388 kcal

4
Protein = 97 grams
FAT:
= % x calories
100
= 30 x 2154
100
= 0.3 x 2154
= 646 kcal
= 646
Fats= 71 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 280g- 84g
= 196g
= 196
15
Total - 195+84 = 279g 26+22= 48g 13+10= 23g
- -
97g- 48g
49g
= 49
7
Total - - 49+48= 97g 21+23g= 44g
61
- -
71g-44g
27g
= 27
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 25+44= 69g
- -
3.4.4 DIET PLAN:

8:00 AM:
 Beet root + carrot juice (2 carrots)
10:00 AM:
Exchanges
 1 cup cooked oatmeal + ½ cup milk
Milk: 2
12:00 PM:
Fruit: 3
 Yogurt and banana in blended form (2 bananas + ½ cup yogurt)
Vegetable: 3
2:00 PM:
Starch: 13
 1 egg boiled mashed + 2 slices of whole grain bread.
Protein: 7
4:00 PM:
Fat: 5
 1 cup boiled potato
 1 cup apple juice
6:00 PM:
 3 slices of brown bread blended with chicken broth. (3 pieces
Of chicken added).
8:00 PM:
 Chicken soup (½ cup vegetable + 3-piece chicken)
10:00 PM:
 1-cup milk with 1-cup brown boiled rice in blended form.
62
CASE 5
3.5 Case Study:
Mr, Zain aged 23 is, hospitalized due to incidence of disease named lactose
intolerance. He is having abdominal pain after consumption of any lactose-containing
product. Patient is also experiencing bloating and diarrhea. His height is 5’10 inches
and current weight is 67 kg. His BMI is about 21kg/m2 and TEE is 2277kcal/day.
3.5.1 Lactose intolerance:
 Lactose intolerance, also called lactase deficiency or hypolactasia, is

the inability to digest and metabolize lactose, a sugar found in milk.
 Lactose intolerance is not an allergy because it
is not an immune response but caused by lactase deficiency.
Symptoms:
 Abdominal bloating and cramps

 Flatulence
 Diarrhea
 Nausea
 Borborygmi (rumbling stomach)
 Vomiting (particularly in adolescents
3.5.2 Medical nutrition therapy for lactose intolerance:
 Avoiding lactose-containing products

 Alternative products such as Plant- based milks and derivatives are
inherently lactose free: soymilk, rice milk, almond milk, hazelnut milk, oat milk,
hemp milk, peanut milk.
Objective:
 Objective is to avoid lactose, containing food.
Basic principle:
 Limiting those foods that contain lactose.
3.5.3 Table content for lactose intolerance:

whole grain flour
63
Spices
Milk and Milk products Lactose free milk cheese, Milk, cheese and yogurt
yogurt without cream if with added cream and fats,
tolerable plain milk.
Lentils All lentils cooked in low oil All fried lentils
Vegetables (green Broccoli, Green beans, Tomatoes
vegetables/Root vegetables) sweet potatoes, carrot, beets
Fruits Melon, Bananas, Apples, Citrus fruits
Pears
Dried fruits/ nuts and seeds Raisins and Almonds Fried and salted nuts and
seeds
Desserts and Sweets None None
green tea added sugar, soft drinks and
alcohol
Calculation:
•Patient name: Zain khawar
•Age: 23 years
•Weight: 67 kg
Formula= Weight kg
 60+10=70
67kg
(1.8)(1.8)
= 67  70x2.54=178cm
3.24
 178
= 21 100
=1.8m
normal weight )
64
IBW:
 106+6x10
 106+60
 166 Lbs.
=166
2.2
75kg
IBW=75 kg
IBW%:
IBW
= 67 x 100
 IBW= 75 kg
75
= 0.89 x 100
= 89%
IBW% = 89%
Energy Calculation:
BEE:
BEE= 66.5+ 925+ 890- 156
BEE= 1882- 156
BEE= 1726 kcal
BEE= 1726 kcal
TEE:
= 1726 x 1.1 x 1.2 A.F= 1.1
=2278 kcal S.F= 1.2
TEE= 2278 kcal
AMDRS:
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
65
= 52 x 2278 kcal
100
= 0.52 x 2278 kcal
= 1184 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2278
100
= 0.18 x 2278
= 410 kcal
4
Protein = 103 grams
FAT:
= % x calories
100
= 30 x 2278
100
= 0.3 x 2278
= 683 kcal
= 683
Fats= 75 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 296g- 84g
= 212g
= 212
15
66
Total - 210+84 = 294g 28+22= 50g 14+10= 24g
- -
= 103g- 50g
53g
= 53
7
Total - - 56+50= 106g 16+24g= 40g
- -
75g-40g
35g
= 35
5
Fat= 7 exchanges
Fat 7 - - 35g
Total - - - 35+40= 75g
- -
67
3.5.4 DIET PLAN:
Breakfast:
 1-cup oatmeal (1 cup cooked + 1-cup lactose free milk + 1 apple peeled).
 1 boiled egg
Snack:
Exchanges
 1 cup brown pasta (1 cup mixed vegetable + 2-piece chicken boiled)
Milk: 2
 Hand full of almonds
Fruit: 3
Lunch:
Vegetable: 3
 1 whole grain flour chapatti
Starch: 14
 1 cup kidney beans
Protein: 8
 1 cup salted vegetable salad
Fat: 7
Snack:
 Mango smoothie (1 cup mango + 1 cup lactose free milk)
Dinner:
 1 cup lentils
 1-cup vegetable salad.
Snack:
 1 sandwich (2 brown bread slices + 1 boiled chicken piece + 1 tbsp. mayo).
68
CASE 6
3.6 Case Study:
Mr., Nawaz aged 25 years old is, hospitalized due to complain of diarrhea. Patient is
suffering from abdominal pain and experiencing 3 or more than 3 watery stools from
more than a week. Bloating and abdominal pain in constant. His height is 5’5 inches
and current weight is 61 kg. His BMI is about 18kg/m2 and TEE is 1864 kcal/day.
3.6.1 Diarrhea:
Diarrhea is, defined by world health organization as the passage of three or more
loose or liquid stools per day.
Causes of diarrhea:
Diarrhea occurs when there is accelerated transit of intestinal contents through the
small intestine, decreased enzymatic digestion of foodstuffs, decreased absorption of
fluids and nutrients increased secretion of fluids into the GIT, or exudative losses.
3.6.2 Medical nutrition therapy for diarrhea:
For the treatment of diarrhea, replacement of necessary fluids and electrolytes is the
first step, using oral rehydration solutions.
Objectives:
BRAT diet is used a diet made up of banana, rice, applesauce, and toast as they are
necessary for acute diarrheal illness.
Dietary guidelines:
 All nutrition interventions related to diarrhea must be, viewed within the context of
the underlying pathologic condition responsible for the diarrhea.
 Carbohydrates such as cereals, breads, and low-fat meats, followed by small
amounts of vegetables and fruits, followed by fats.
 The goal with this progression is to limit large amounts of hyperosmotic
carbohydrates that may be mal digested or mal absorbed foods that stimulate
secretion of fluids, and foods that speed the rate of GI transit.
 Modest intake of prebiotic components and soluble fibers such as pectin or gum slows
transit through the GI tract.
 Supplementation with probiotics
 Sugars, alcohols, lactose, fructose and large amount of sucrose may worsen osmotic
diarrhea.
3.6.3 Table Food choices for diarrhea:

69
whole grain flour
seeds seeds
Calculation:
•Patient name: Nawaz
•Age: 25 years
•Weight: 25 kg
Formula= Weight kg
 60+5=65
50kg
(1.65)(1.65)
= 50  65x2.54=165cm
2.7
 165
= 18 100
=1.65m
normal weight )
70
IBW:
 106+6x5
 106+30
 136 Lbs.
=136
2.2
61kg
IBW=61 kg
IBW%:
IBW
= 50 x 100
 IBW= 61 kg
61
= 0.82 x 100
= 82%
IBW% = 82%
Energy Calculation:
BEE:
BEE= 66.5+ 690+ 825- 170
BEE= 1582- 170
BEE= 1412 kcal
BEE= 1412 kcal
TEE:
= 1412 x 1.1 x 1.2 A.F= 1.1
=1864 kcal S.F= 1.2
TEE= 1864 kcal
AMDRS:
• Carbohydrates= 52% Calories= 1864kcal
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
71
= 52 x 1864 kcal
100
= 0.52 x 1864 kcal
= 969 kcal
4
PROTIEN:
= % x calories
100
= 18 x 1864
100
= 0.18 x 1864
= 336 kcal
4
Protein = 84 grams
FAT:
= % x calories
100
= 30 x 1864
100
= 0.3 x 1864
= 559 kcal
= 559
Fats= 62 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 242g- 84g
= 158g
• As 1 exchange of carbs = 15g
= 158
15
72
Total - 165+84 = 249g 22+22= 44g 11+10= 21g
- -
84g- 44g
40g
= 40
7
Total - - 42+44= 86g 12+21g= 33g
- -
62g-33g
29g
= 29
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+33= 63g
- -
73
3.6.4 DIET PLAN:
Breakfast:
 2 brown bread slices Exchanges
 1 cup yogurt Milk: 2
 2 boiled eggs Fruit: 3
Snack: Vegetable: 3
 1 mashed potato Starch: 11

 1 cup carrot juice (2 carrots) Protein: 6
Lunch: Fat: 6
 1 cup uncooked oatmeal + 2 apples pealed + 1 banana + ½ cup milk
Snack:
 1 cup chicken broth (2-piece chicken boiled 6oz)
Dinner:
 1 piece chicken boiled
 1-cup vegetable salad.
Snack:
 ½ cup milk
74
Chapter No.4
PULMONARY WARD
During the fourth week of internship, the rotation placed at pulmonary ward.
CASE 1
4.1 Case Study:
Mr. Fareed aged 40, hospitalized due to onset of lung cancer. Chest radiograph
detected the presence of tumor within lungs. Patient is a consistent smoker. Patient is
suffering from anorexia and weakness. Shortness of breath, chest tightness, and pain,
chronic and persistent cough also observed. His weight is 58 kg and height are 5 feet
6 inches. His BMI is about 20kg/m2 and TEE is 2045kcal.
4.1.1 Lung Cancer:

 Lung cancer is the uncontrolled growth of abnormal cells that starts in one or both
lungs.
 These abnormal cells do not carry out the functions of normal lung cells and do not
develop into healthy lung tissue.
 With time, the abnormal cells start to form tumors that interfere with the
functioning of the lung.
Symptoms:
 Chronic cough
 Chest tightness
 Chest pain
 Shortness of breath
 Anorexia
 Weight loss
4.1.2 Medical Nutrition Therapy of lung cancer:
 Moderate protein, carbs and fats, induced to manage weight.
Objective:
 Management of weight and providing nutritional support and reversible cause of
anorexia should be, treated.
Basic Principle:
 Moderate amount of carbs, protein and fats are included in diet to manage weight,
aiding the nutritional status of patients.
Dietary Guidelines:
 Treat the reversible cause of anorexia such as early satiety.
 Evaluate the rate and severity of weight loss.
75
 Treat the symptoms interfering with food intake: nausea and vomiting, dyspnea,
constipation and pain.
 Providing nutritional support.
 Reversible causes of anorexia should be, treated.
 Small frequent meals that are calorie and protein dense.
 Provide caloric level that meets or exceeds the resting energy expenditure.
 Rest before meals.
 Meals that require minimal preparation.
 Oral nutritional supplements.
 Prokinetic agents for delayed gastric emptying.
 Megestrol acetate, an appetite stimulant, may result in increasing appetite and
caloric intake.
 Moderate amount of carbs, protein and fat.
 Branched chain amino acid (BCAA) supplementation.
4.1.3 Table Food choices for Lung cancer:

whole grain flour
seeds, avocado, olive oil seeds
76
Calculation:
•Patient name: Fareed
•Age: 40 years
•Weight: 58 kg
BMI:
50kg  5x12= 60
(1.67)(1.67)  60+6=66
2.78  66x2.54=167cm
 167
 BMI= 20 kg/m2 (patient is
normal weight ) 100
=1.67m
IBW:
 106+6x6
 106+36
 142 Lbs.
=142
2.2
64 kg
IBW=64 kg
IBW %:
IBW
= 58 x 100
 IBW= 64 kg
64
= 0.90 x 100
= 90%
IBW% = 90%
77
Energy Calculation:
BEE:
BEE= 66.5+ 800 + 835 - 272
BEE= 1702- 272
BEE= 1430 kcal
BEE= 1430 kcal
TEE:
= 1430 x 1.1 x 1.3 A.F= 1.1
=2045 kcal S.F= 1.3
TEE= 2045 kcal
AMDRS:
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2045 kcal
100
= 0.52 x 2045 kcal
= 1068 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2054
100
= 0.18 x 2054
= 370 kcal
= 370 a 1 gram of protein= 4kcal
4
Protein = 93 grams
FAT:
= % x calories
100
= 30 x 2054
100
= 0.3 x 2054
78
= 616 kcal
= 616
Fats= 68 grams
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g
= 267g- 96g
= 171g
= 171
15
Total - 165+96 = 261g 22+30= 52g 11+15= 26g
- -
93g - 52g
41g
= 40
7
Total - - 42+41= 83g 12+26g= 38g
- -
68g-38g
30g
= 30
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+30= 60g
79
- -
4.1.4 DIET PLAN:

8:00 AM:
 1 cup tea Exchanges
 2 slice brown bread Milk: 3
 1 boiled egg Fruit: 3
10:00 AM: Vegetable: 3
 Apple smoothie (3 apples+ 1 cup low fat milk) Starch: 12
12:00 PM: Protein: 6
 Vegetable soup (1 cup boiled vegetables + 1 piece chicken boiled and Fat: 6
Shredded).
2:00 PM:
 Corn vegetable salad (1 cup raw vegetables + 1 cup corn + 1 piece
Chicken boiled)
4:00 PM:
 2 brown bread slices + 1tbsp peanut butter.
6:00 PM:
 1 cup chicken broth (1-piece boiled chicken)
8:00 PM:
 Sandwich (2-piece brown bread slices+ 1-piece boiled chicken)
10:00 PM:
 1-cup tea+ 2-3 digestive biscuits.
80
CASE: 2
4.2 Case study:
Mr. Javed aged 18 years is, hospitalized due to disease named cystic fibrosis. Chest
radiograph and CT scan showed the formation of cyst and inflammation of
bronchioles. Patient is suffering from thick mucus production in lungs along with
chronic persistent cough, wheezing and chest pain. Condition of Steatorrhea is, also
observed. His weight is 67kg and height is 5 feet 3 inches. His BMI is about 26 kg/m 2
and TEE is 2171 kcal.
4.2.1Cystic Fibrosis:
 Cystic fibrosis is a life threatening autosomal recessive inherited disorder.
 It is, caused by mutation in the cystic fibrosis transmembrane conductace regulator
(CFTR) protein.
 Mutation in CFTR protein cause thick viscous secretion in the lungs, pancreas,
liver, intestines and reproductive organs.
Symptoms:
 Chronic persistent cough
 Wheezing
 Chest pain
 Fat Malabsorption
 Steatorrhea
 Thick viscous production in lungs, pancreas.
 Recurrent lungs infection
 Diabetes
 Malnutrition
4.2.2 Medical Nutrition Therapy of CF:

 Management of nutritional status of CF patients.
Objective:
 Evaluating nutritional status of patients, treating malnutrition, managing weight,
muscle strength, promoting optimal growth and enhancing quality of life.
Basic Principle:
 Limiting the fat to 27%, as fat malabsorption is very common.
 Carb and fat should be normal.
Dietary Guidelines:
 Evaluation of nutritional status of patient.
 Increased energy needs.
 Growth rate should be, monitored.
 Healthy balanced diet with good exercise habits.
81
 Increasing muscle strength
 Promoting optimal growth.
 Enhancing quality of life
 Treat malabsorption and mal digestion.
Energy:
 Newborn to 24 months: weight/length >50th percentile, using centers for
disease control.
 2 to 20 years: BMI 50th to 85th percentile, using CDC growth charts.
 Adult Females: BMI 22 to 27 kg/m2
 Adult Males: BMI 23 to 27 kg/m2
 120% to 150% energy requirements.
 Energy dense diet.
 Oral energy dense food who can eat from mouth and those who cannot eat
should induce their diet through tube feeding.
Vitamins and Minerals:
 In CF patients, liver disease and pancreatic dysfunction can lead to the
deficiency of fat-soluble vitamins like A, D, E and K.
 Patients should be, given fat-soluble vitamin supplements.
 Daily dosage of vitamin D is 1500 to 2000IU daily.
 Patients should be, supplemented with vitamin K. Taking up to 10,000 IU.
Salt:
 Supplementation of sodium chloride is necessary.
Zinc:
 Additional zinc is, recommended with the supplementation of zinc.
4.2.3 Table Food choices for CF:

whole grain flour
Milk and Milk products Milk, cheese, yogurtMilk, cheese and yogurt
82
seeds seeds
alcohol
Calculation:
 Patient name: Javed Ashraf

 Age: 18 years
 Weight: 67 kg
BMI:
67 kg  5x12= 60
(1.6)(1.6)  60+3=63
2.56  63x2.54=160cm
 160
over-weight) 100
=1.6m
IBW:
 106+6x3
 106+18
 124 Lbs.
=124
2.2
56kg
IBW= 56kg
83
IBW %:
IBW  IBW= 56 kg
= 67 x 100
56
= 1.19 x 100
= 119%
IBW% = 119%
Energy Calculation:
BEE:
BEE= 66.5+ 773+ 800- 122
BEE= 1640- 122  Weight: 56kg
TEE:
= 1518 x 1.1 x 1.3 A.F= 1.1
= 2171kcal S.F= 1.3
TEE= 2171 kcal
AMDRS:
 Protein=18%
 Fats= 27%
CARBOHYDRATE:
= % x calories
100
= 55 x 2171 kcal
100
= 0.55 x 2171 kcal
= 1194 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2171
100
= 0.18 x 2171
= 391 kcal
84
4
Protein = 98 grams
FAT:
= % x calories
100
= 27 x 2171
100
= 0.27 x 2171
= 586 kcal
= 586
Fats= 65 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 299g- 84g
= 215g
= 215
15
Total - 210+84 = 294g 28+22= 50g 14+10= 24g
- -
98g- 50g
48g
= 48
7
Total - - 49+50= 99g 14+24g= 38g
- -
85
65g-38g
27g
= 27
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 38+25= 63g
- -
4.2.4 Diet Plan:

8:00 AM: Exchanges
 1 cup cooked oatmeal Milk: 2
 1 cup low fat milk
Fruit: 3
 1 banana
Vegetable: 3
10:00 AM:
Starch: 14
 peach juice (2 peaches)
Protein: 7
12:00 PM:
Fat: 5
 Vegetable soup (1 cup vegetable + 1 piece chicken boiled and
Shredded).
2:00 PM:
 2 brown bread slices + 2-piece boiled fish
4:00 PM:
 1 cup yakhni pulao (1 cup brown rice + 1 cup chicken broth (1
Piece chicken) + 1 cup salad.
6:00 PM:
 2 brown bread slices soaked in 1-cup lentil soup.
8:00 PM:
 1 cup low fat milk
 2-3 digestive biscuits (soaked in milk)
10:00 PM:
 2 brown bread slices + 1tbsp peanut butter.
86
CASE: 3
4.3 Case Study:
Miss Sarah, aged 25 years is, hospitalized due to incidence of TB. Chest radiograph
diagnosed tuberculosis. Patient is suffering from persistent cough, prolonged fever,
and anorexia and weight loss. Malnutrition is also observed.
Patient height is 5 feet 6 inches and weight are 47kg. Her BMI is about 17kg/m2 and
TEE is 2022kcal.
4.3.1 Tuberculosis:
 Tuberculosis (TB) is a contagious infectious disease caused by the bacterium
Mycobacterium tuberculosis.
 It primarily affects the lungs but can also affect other parts of the body, such as the
kidneys, spine, and brain.
 TB transmit, through the air when an infected individual coughs, sneezes, or speaks,
releasing tiny droplets containing the bacteria into the air.
4.3.2 Medical Nutrition Therapy of Tuberculosis:
 Weight management
 Protein is vital in preventing muscle tissue wastage and an in-Take of 15% of
energy needs or 1.2 to 1.5 g/kg ideal body Weight, approximately 75 to 100 g per
day, is recommended
 Low carbohydrate diet.
Objective:
 Weight management
 Low carbs, high protein diet.
Dietary guidelines:
Energy
 Current energy recommendations are those for under-nourished and catabolic
patients, 35 to 40 kcal/kg of ideal body Weight.
 For patients with any concomitant infections such as HIV, energy requirements
increase by 20% to 30% to maintain Body weight.
Protein
 Protein is vital in preventing muscle tissue wastage and an in-Take of 15% of
energy needs or 1.2 to 1.5 g/kg ideal body Weight, approximately 75 to 100 g per
day, recommended.
87
Micronutrients:
 Certain micronutrients play a crucial role in supporting the immune system and
combating the infection.
 These include vitamin A, vitamin C, vitamin E, zinc, selenium, and iron.
Encourage the consumption of foods rich in these nutrients, such as fruits,
vegetables, whole grains, nuts, seeds, and lean meats.
Hydration:
 Adequate hydration is essential to prevent dehydration and promote overall health.
Encourage individuals with TB to drink plenty of fluids, such as water, herbal teas,
and soups, throughout the day.
Avoid Alcohol and Smoking:

 Alcohol and smoking can weaken the immune system and hinder the body’s ability
to fight off TB infection.
 Encourage individuals to avoid alcohol and quit smoking for better treatment
outcomes.
4.3.3 Table Food choices for TB:

whole grain flour
Milk and Milk products Milk, cheese, yogurtMilk, cheese and yogurt
seeds seeds
88
alcohol
Calculation:
 Patient name: Sarah Zubair

 Age: 25 years
 Weight: 47 kg
BMI:
47kg  5x12= 60
(1.67)(1.67)  60+6=66
2.56  66x2.54=167cm
 167
underweight ) 100
=1.67m
IBW:
 100+5x6
 100+30
 130 Lbs.
=130
2.2
59kg
IBW=59kg
IBW%:
IBW  IBW= 59 kg
= 47 x 100
59
89
= 0.7 x 100
= 70%
IBW% = 70%
Energy Calculation:
BEE:
BEE= 665+ 566 + 301 - 118
BEE= 1532- 118  Weight: 59kg
TEE:
= 1518 x 1.1 x 1.3 A.F= 1.1
= 2022 kcal S.F= 1.3
TEE= 2022 kcal
AMDRS:
 Carbohydrates= 54%
 Protein= 16% Calories= 2022kcal
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 54 x 2022 kcal
100
= 0.54 x 2022 kcal
= 1092 kcal
= 1092
4 as 1-gram carb=4kcal
PROTIEN:
1.2-1.5/kg ideal body weight for protein.
Taking mid value
1.4x 59 = 83g
83x4
332 kcal
Dividing calories
332 x 100
2022
Protein = 16%
As 1 gram of protein = 4kcal
90
FAT:
= % x calories
100
= 30 x 2022
100
= 0.3 x 2022
= 607 kcal
= 607
Fats= 67 grams
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g
= 273g- 96g
= 177g
= 177
15
Total - 180+96 = 276g 24+30= 54g 12+15= 27g
- -
83g- 54g
29g
= 29
7
Total - - 28+54= 82g 8+27g= 35g
- -
67g-35g
32g
91
= 32
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+35= 65g
- -
4.3.4 DIET PLAN:

Breakfast:
 Cottage cheese vegetable salad (¼ cup cottage cheese + 1 cup raw vegetables)
Snack:
 Banana smoothie (2 bananas + 1 cup low fat milk) Exchanges
Lunch:
Milk: 3
 Vegetable pulao (1 cup brown rice + 1 cup cooked vegetable)
Fruit: 3
 1 cup raita
Vegetable: 3
Snack:
Starch: 12
 1 cup cooked barley + 1 cup low fat milk + 3 dates
Protein: 4
Dinner:
Fat: 6
 1 chapatti
 1 cup lentils
Snack:
 Fish Sandwich (2 brown bread slices + 1-piece baked fish).
92
CASE: 4
4.4 Case Study:
Miss, Saima aged 40 hospitalized due to asthma. She has a history of smoking.
Patient is suffering from severe chest pain, chest tightness followed by shortage of breath
and wheezing. Her height is 5’7 inches and weight are 52kg. Her BMI is about 17kg/m2
and TEE is 1823kcal.
4.4.1 Asthma:
Asthma is a chronic disorder that affects the airways and characterized by bronchial
hyper-reactivity, reversible airflow obstruction, and airway remodeling.
Symptoms:
Asthmatic symptoms include:
 Periodic episodes of chest tightness

 Breathlessness
 Wheezing
Increased risk of asthma:
Increased risk of asthma development also has, been linked to air pollution, tobacco
smoke exposure, and small size at birth, respiratory infection, and lower
socioeconomic status.
4.4.2 Medical Nutrition Therapy of Asthma:
For treatment of asthma moderate intake of protein, calcium, vitamin C and anti-
inflammatory diet is, recommended
Objective:
A diet rich in antioxidants and monounsaturated fats and Supplementation of vitamin C and
zinc also have been, reported to improve asthma symptoms and lung function.
Basic Principle:
Moderate amount of protein, carbs and fat, good intake of Vitamin C and calcium.
Dietary Guidelines:
 Modulation of antioxidant intake with nutritional supplementation has a beneficial

effect on the severity and progression of asthma.
 A diet rich in antioxidants and monounsaturated fats seems to have a protective effect
on childhood asthma by counteracting oxidative stress.
 Omega-3 polyunsaturated fatty acid (PUFA) fish oil was, supplemented throughout
childhood and wheezing was reduce.
 Supplementation of vitamin C and zinc also have been reported to improve asthma
symptoms and lung function
 High doses of vitamin D supplementation were not shown to have any protective effect
93
Gastro-esophageal reflux disease (GERD) and food allergens:
 Gastro-esophageal reflux disease (GERD) and food allergens are the two most
common dietary triggers for asthma.
 A critical component of medical nutrition therapy for asthmatic patients is a diet free
of known irritants such as spicy foods, caffeine, chocolate, and acidic foods
 Limiting the intake of high fat foods and portion control can prevent gastric
secretions, which exacerbate GERD.
4.4.3 Table Food choices for Asthma:

whole grain flour
seeds seeds
alcohol
Calculation:
 Patient name: Saima fazal

 Age: 40 years
 Weight: 52 kg
94
BMI:
52kg  5x12= 60
(1.7)(1.7)  60+7=67
2.89  67x2.54=170cm
 170
underweight ) 100
=1.7m
IBW:
 100+5x7
 100+35
 135 Lbs.
=135
2.2
61kg
IBW=61kg
IBW%:
IBW  IBW= 61 kg
= 52 x 100
61
= 0.8 x 100
= 80%
IBW% = 80%
Energy Calculation:
BEE:
BEE= 665+ 598 + 306 - 188
BEE= 1569- 188  Weight: 61kg
 Age: 40 years
95
BEE= 1381 kcal
TEE:
= 1381 x 1.1 x 1.2 A.F= 1.1
= 1823 kcal S.F= 1.2
TEE= 1823kcal
AMDRS:
 Carbohydrates= 52% Calories= 182kcal
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1823 kcal
100
= 0.52 x 1823 kcal
= 912 kcal
4
PROTIEN:
= % x calories
100
= 18 x 1823
100
= 0.18 x 1823
= 328 kcal
4
Protein = 82 grams
FAT:
= % x calories
100
= 30 x 1823
100
= 0.3 x 1823
= 547
= 547
Fats= 61 grams
96
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 228g- 84g
= 144g
= 144
15
Total - 150+84 = 234g 20+22= 42g 10+10= 20g
- -
82g- 42g
40g
= 40
6
Total - - 42+42= 84g 12+20g= 32g
- -
61g-32g
29g
= 29
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+32= 62g
- -
97
4.4.4 DIET PLAN:
Breakfast:
 Beet root + carrot juice (1 beet root + 2 carrots)
Snack:
 1-cup sweet potato + 1 cup vegetable and beans salad. Exchanges
Lunch: Milk: 2
 Pulao (1 cup brown rice + 2 chicken pieces)
Fruit: 3
 1 cup raita
Vegetable: 3
Snack:
Starch: 10
 Banana smoothie (2 bananas + 1 cup low fat milk)
Protein: 6
 12 cherries
Fat: 6
Dinner:
 1 whole grain chapatti
 1 cup chicken curry (2 pieces of chicken)
Snack:
 6 almonds.
98
CASE: 5
4.5Case Study:
Mr. Mansoor aged 60 years hospitalized due to chronic obstructive pulmonary
disease. He was a heavy smoker from past 30 years and had family history of COPD.
Patient is suffering from shortness of breath, heavy chronic cough and mucous
production along with chest tightness, wheezing and chest pain. His height is 5, 10
inches and weight are 58kg. His BMI is about 18.3kg/m2 and TEE is 2265kcal.
4.5.1 COPD:
 COPD is a term that encompasses chronic bronchitis (a long-term condition of

COPD in which inflamed bronchi lead to mucus, cough and difficulty breathing)
and emphysema (a form of long-term lung disease characterized by the destruction
of lung parenchyma with lack of elastic recoil).
 COPD overlap between these three conditions, asthma, chronic bronchitis and
emphysema.
 Patients with primary emphysema suffer from greater dyspnea and cachexia. On the
other hand, patients with bronchitis have hypoxia, hypercapnia (increased amount of
carbon dioxide), and complications such as pulmonary hypertension and right heart
failure.
COPD exacerbations can be, caused by:
 Haemophilus influenza
 Moraxella catarrhalis
 S. pneumonia
 Rhinovirus
 Coronavirus
4.5.2 Medical Nutrition Therapy of COPD:
 For treatment of COPD must meet the nutritional needs of patient and decrease the
depletion of protein and vital minerals such as calcium, magnesium, potassium, and
phosphorus.
Objective:
 Small frequent meals that are dense.

 The patient eats the main meal when energy level is at its highest
 Adequate calories, protein, vitamins and minerals to maintain a desire weight.
 Availability of foods that require less preparation and can heated easily.
 Patients can cook their or heat up their meals on their own.
99
 Limitation of alcohol.
 A period of rest before mealtime.
Basic Principle:
 Moderate Carbs, protein and fats are required.
Dietary Guidelines:
There are two main goals in managing the hyperactive metabolism seen in stable COPD:
1. The prevention of weight loss.

2. The prevention of the loss of lean body mass (LBM).
These goals can be, achieved by ensuring the following:
 Small frequent meals that are nutritionally dense

 The patient eats the main meal when energy level is at its highest
 Adequate calories, protein, vitamins, and minerals to maintain a desirable weight - a
BMI of 20 to 24 kg/m2
 Availability of foods that require less preparation and can be heated easily in a
microwave oven
 Limitation of alcohol to fewer than 2 drinks/day (30 g alcohol)
 A period of rest before mealtimes.
 Management of weight
 Evaluation of nutritional Status
 Healthy and Balanced diet
 Correcting Anemia improves dyspnea.
 Vitamin D Supplementation.
 Maintaining appropriate ratio of LBM to adipose tissues.
4.5.3 Table Food choices for COPD:

whole grain flour
100
seeds, avocado, olive oil seeds
Calculation:
•Patient name: Mansoor
•Age: 60 years
•Weight: 58 kg
BMI:
58kg  5x12= 60
(1.78)(1.78)  60+10=70
3.16  70x2.54=178cm
= 18.3 Converting it into m
 178
 BMI= 18.3 kg/m2 (patient
=1.78m
IBW:
 106+6x10
 106+60
 166 Lbs.
=166
2.2
75 kg
101
IBW=75 kg
IBW %:
IBW
= 58 x 100
 IBW= 75 kg
75
= 0.77 x 100
= 77%
IBW% = 77%
Energy Calculation:
BEE:
BEE= 66.5+ 1035 + 890 - 408
BEE= 1992- 408
BEE= 1584 kcal
BEE= 1584 kcal
TEE:
= 1584 x 1.1 x 1.3 A.F= 1.1
=2265 kcal S.F= 1.3
TEE= 2265 kcal
AMDRS:
• Carbohydrates= 52% Calories= 226kcal
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2265 kcal
100
= 0.52 x 2265 kcal
= 1178 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2265
100
= 0.18 x 2265
102
= 408 kcal
4
Protein = 102 grams
FAT:
= % x calories
100
= 30 x 2265
100
= 0.3 x 2265
= 680 kcal
= 680
Fats= 76 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 295g- 84g
= 211g
• As 1 exchange of carbs = 15g
= 211
15
Total - 210+84 = 294g 28+22= 50g 14+10= 24g
- -
102g - 50g
52g
= 52
7
Total - - 49+50= 99g 14+24g= 38g
- -
103
76g-38g
38g
= 38
5
Fat= 8 exchanges
Fat 8 - - 40g
Total - - - 40+38= 78g
- -
4.5.4 DIET PLAN:

8:00 AM:
 Cooked oat meal (1 cup oats + 1 cup low fat milk + 1 banana)
10:00 AM:
 Banana smoothie (2 banana + 1 cup low fat milk)
12:00 PM:
 Vegetable soup (1 cup boiled vegetables + 2-piece chicken boiled and
Shredded).
2:00 PM:
Exchanges
 2 brown bread slices
Milk: 2
 1 boiled egg
Fruit: 3
4:00 PM:
Vegetable: 3
Starch: 14
 1cup lentils soup
Protein: 7
6:00 PM:
Fat: 8
 1 cup chicken broth (2-piece boiled chicken)
8:00 PM:
 Vegetable Salad
10:00 PM:
 2-3 digestive biscuits.
104
CASE: 6
4.6 Case Study:
Miss Bushra aged 60 years old woman is, hospitalized due to pneumonia. Her height
is 5’3 inches and current weight is 68kg. Her BMI is about 17 kg/m2 and TEE is 1620
kcal/day
4.6.1 PNEUMONIA:
An inflammatory condition of the lungs that causes chest pain, fever, cough, and
dyspnea is called pneumonia
In the clinical setting, there are various kinds of pneumonias, such as:
 Community-acquired pneumonia, which may be viral or bacterial; hospital-

acquired pneumonia;
 Pneumonia in an immune compromised host;
 Ventilator-associated pneumonia (VAP);
 Aspiration pneumonia.
 Three clinical syndromes exist within the category of aspiration pneumonia:
 Chemical pneumonitis resulting from aspiration of acid
 Bacterial infection
 Airway obstruction.
4.6.2 Medical Nutrition Therapy of Pneumonia:
Parenteral and Enteral Nutrition (SCCM/ASPEN) guidelines, nutritional interventions

for preventing aspiration pneumonia and managing it when it exists in the patient in
the acute care setting are the following:
 Direct tube feedings into the small bowel rather than the stomach
 Implement continuous feedings rather than bolus feedings recommended
 Elevate the head of the patient’s bed to 45 degrees
 Use prokinetic agents
 Minimize use of sedatives
 Optimize oral hygiene
 Use naloxone to improve gut motility
Calculation:
 Patient name: Bushra Bibi
 Age: 68 years
 Weight: 44 kg
105
BMI:
44kg  5x12= 60
(1.6)(1.6)  60+3=63
2.56  63x2.54=160cm
 160
underweight ) 100
=1.6m
IBW:
 100+5x3
 100+15
 115 Lbs.
=115
2.2
52 kg
IBW=52 kg
IBW%:
IBW  IBW= 52 kg
= 44 x 100
52
= 0.84 x 100
= 84%
IBW% = 84%
Energy Calculation:
BEE:
BEE= 665+ 499 + 288 - 320
BEE= 1452- 320  Weight: 52kg
106
TEE:
= 1132 x 1.1 x 1.3 A.F= 1.1
= 1619 kcal S.F= 1.3
TEE= 1619 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1619 kcal
100
= 0.52 x 1619 kcal
= 842 kcal
4
PROTIEN:
= % x calories
100
= 18 x 1619
100
= 0.18 x 1619
= 291 kcal
4
Protein = 73 grams
FAT:
= % x calories
100
= 30 x 1619
100
= 0.3 x 1619
= 486
= 486
Fats= 54 grams
EXCHANGES:
Milk 2 24g 16g 10g
107
Fruit 4 60g - -
Total - 99g 22g 10g
= 210g- 99g
= 111g
= 111
15
Total - 105+99 = 204g 21+22= 43g 7+10= 17g
- -
73g- 43g
30g
= 30
7
Total - - 28+43= 71g 12+17g= 29g
- -
54 g-29g
25g
= 25
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 25+29= 54g
- -
108
4.6.4 DIET Plan: (2hrs for Pneumonia patient)
8:00:
 Shake (1 cup milk+ 2 Banana Blended)
10:00 EXCHANGES:
 1-cup lentils soup.
Milk: 2
12:00
Fruit: 4
 Juice (1 beet root + 2 carrot blended)
2:00 Vegetable: 3
Starch: 7
 1 cup rice drink
Meat: 4
4:00
Fat: 5
 1 cup corn soup
6:00
 1 cup chicken soup (2oz)
8:00
 1 cup pineapple juice
10:00
 1 cup milk+ 3 almonds (blended)
109
Chapter no 5:
Cardiovascular Ward:
During the fifth week of internship, the rotation was, placed at cardio ward.
CASE: 1
5.1Case Study:
42 years old MR is, hospitalized due to hypertension, Heart attack. His current weight
is 57kg and height is 5 feet 3 inches. His BMI is 22kg/m2 and her TEE is 1806 kcal.
Diagnosis:
The Patient blood pressure reading for several weeks had consistently shown a
reading of 160/100mmHg, which is in the high range.
5.1.1 Hypertension:
 Hypertension is persistently high arterial blood pressure, the force exerted per unit
area on the walls of arteries.
 It is, often called silent killer.
Types:
 Systolic Blood Pressure:

The systolic blood pressure, the upper reading in a blood pressure measurement, is the
force exerted on the walls of blood vessels as the heart contracts and pushes blood out
of its chambers.
 Diastolic Blood Pressure:
The lower reading known as diastolic blood pressure, measures the force as the heart
relaxes between contractions.
5.1.2 Medical Nutrition Therapy:
 Use protein in normal range.
 Less than 50% carbs.
 Sodium less than 2300mg if patient has issue with sodium.
 Use food without salt and sugar.
 Avoid High glycemic foods in hypertension because they increase blood glucose
level.
 Use complex carbs such as bread, chapatti, fruits and veggies.
Objective:
Use low sodium, moderate protein, omega 3 and omega 6 fatty acids potassium,
magnesium, calcium diet.
110
Basic Principles:
DASH (dietary Approaches to control hypertension) is, used to treat hypertension.
Dietary guidelines:
 Sodium Intake:
Consume less than 2300mg sodium per day, because it is associated with even greater
reduction in blood pressure.
 Weight Management:
 Optimal body weight should be, achieved and maintained to reduce blood
pressure.
 Increase the amount of aerobic or dynamic resistance physical activity to a
minimum of 90 to 150 minutes per week is, recommended as an adjunct therapy
of hypertension management.
 Alcohol:
Alcohol consumption should be limited to no more than two drinks daily in men.
Excessive alcohol consumption is associated with left ventricular function.
 Dash Diet:
The Dash diet is, used for preventing and controlling high blood pressure.
 Potassium:
 Consume a diet rich in potassium may lower blood pressure.
 The recommended intake of potassium for adults is 4.7g/day.
 Potassium rich fruits and vegetables include green leafy vegetables, fruits, and
roots vegetables.
 Calcium and magnesium:
Increase intake of calcium and magnesium may have blood pressure benefits.
5.1.3 Table of food choices:

energy bars.
Eggs, red meat.
111
sweet potato
seeds seeds
and halwa
alcohol
Calculation:
•Patient name: Ibrahim
•Age: 42 years
•Weight: 57 kg
BMI:
57kg  5x12= 60
(1.6)(1.6)  60+3=63
3.16  63x2.54=160cm
 160
 BMI= 22 kg/m2 (patient
has normal weight ) 100
=1.6m
IBW:
 106+6x3
 106+18
112
 124 Lbs.
=124
2.2
56 kg
IBW=56 kg
IBW %:
IBW
= 57 x 100
 IBW= 56 kg
56
= 1.0 x 100
= 100%
IBW% = 100%
Energy Calculation:
BEE:
BEE= 66.5+ 787 + 800 - 286
BEE= 1654- 286
BEE= 1368 kcal
BEE= 1368 kcal
TEE:
= 1368 x 1.1 x 1.2 A.F= 1.1
=1806 kcal S.F= 1.2
TEE= 1806 kcal
AMDRS:
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1806 kcal
100
= 0.52 x 1806 kcal
= 939 kcal
4
113
PROTIEN:
= % x calories
100
= 18 x 1806
100
= 0.18 x 1806
= 325 kcal
4
Protein = 81 grams
FAT:
= % x calories
100
= 30 x 1806
100
= 0.3 x 1806
= 542 kcal
= 542
Fats= 60 grams
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g
= 235g- 96g
= 139g
= 139
15
Total - 135+96 = 231g 18+30= 48g 9+15= 24g
- -
81g - 48g
33g
114
= 33
7
Total - - 35+48= 83g 10+24g= 34g
- -
60g-34g
26g
= 26
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 25+34= 59g
- -
115
5.1.4 DIET PLAN:
Breakfast:
 Mix fruit meal (1 cup yogurt + 1 banana mashed + 3 blackberries
+ 4 strawberries + 3 almonds).
Exchanges
Snack:
Milk: 3
 1-cup beet root juice (1 beet root)
Fruit: 3
Lunch:
Vegetable: 3
 1 chapatti
Starch: 9
 1 cup lentils
Protein: 5
Fat: 5
 1 cup raita
Snack:
 Steamed vegetable chicken roll in Air fryer (2-piece chicken boiled
+ 1 cup mixed vegetables + olive oil).
Dinner:
 ½ brown rice
 1 cup chicken curry (1 pieces of chicken)
Snack:
 1 cup warm milk
116
CASE: 2
5.2 Case Study:
21 years old Mr. Zohaib is, hospitalized due to coronary heart disease, shortness of
breath, and radiation in left arm. His current weight is 55 kg and height are 5 feet 9
inches. His BMI is 17.9kg/m2, TEE is 2367 kcal.
5.2.1 Coronary heart disease:

Coronary heart disease refers to a condition where is a significant narrowing or
blockage in the coronary arteries that supply blood to the heart.
5.2.2 Medical Nutrition therapy:

 Consume a dietary pattern that emphasize intake of vegetables, fruits, and whole
grains.
 Low fat dairy products, poultry, fish, legumes, oils and nuts recommended.
 Limit the intake of sweets, sugar-sweetened beverages and red meats.
 Reduce percent of calories from saturated fat.
 Reduce percent of calories from trans-fat.
 Physical activity for 40 minutes per day.
 (Mediterranean diet) serving of fruits and vegetables (mostly fish) root vegetables
and greens, whole grains, fatty fish (rich in omega-3 fatty acids).
Objective:
Healthy protein, calcium, vitamin D, potassium, recommended.
Basic principles:
Mediterranean diet and vegan diet are, recommended.
Dietary guidelines:
 Mediterranean diet pattern
 Weight reduction if needed
 Increase dietary fiber to 25-30g/day or more.
 Add omega-3 fatty acids from food sources.
 Add fruits and vegetables.

117
energy bars.
Eggs, red meat.
sweet potato
seeds seeds
and halwa
alcohol
Calculation:
 Patient name: Mr. Zohaib
 Age: 21 years
 Weight: 55
118
Formula= Weight kg then add additional inches.
Height m2
 5x12= 60
55kg
 60+9=69
(1.75)(1.75)
= 55
 69x2.54=175cm
= 18  175
100
 BMI= 18 kg/m2 (patient has
underweight) =1.75m
IBW:
 106+6x9
 106+54
 160 Lbs.
=160
2.2
72kg
IBW= 72kg
IBW%:
IBW  IBW= 72 kg
= 55 x 100
72
= 76%
IBW% = 76%
Energy Calculation:
BEE:
BEE= 66.5+ 993.6+ 875- 142
BEE= 1793 kcal  Weight: 72kg
TEE:  Age: 21 years
= 1783.6 x 1.1 x 1.2 A.F= 1.1
119
= 2367kcal S.F= 1.2
TEE= 2367 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2367 kcal
100
= 0.52 x 2367 kcal
= 1230 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2367
100
= 0.18 x 2367
= 426 kcal
4
Protein = 106 grams
FAT:
= % x calories
100
= 30 x 2367
100
= 0.3 x 2367
= 710 kcal
= 710
Fats= 79 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
120
= 307g- 84g
= 223g
= 223
15
Total - 210+84 = 294g 22+42= 64g 10+14= 24g
- -
= 106g- 64g
42g
= 42
7
Total - - 42+64= 106g 18+24g= 42g
- -
79g-42g
37g
= 37
5
Fat= 8 exchanges
Fat 7 - - 35g
Total - - - 35+42= 77g
- -
121
5.2.4 Diet Plan:
8:00 AM:
Exchanges
 1 egg white
 1 cup milk low fat Milk: 2
10:00 AM: Fruit: 3
 fruit chaat (2 apples + 8 strawberries) Vegetable: 3
12:00 PM: Starch: 14
 1 piece fish baked Protein: 6
 1 brown bread slice Fat: 7
2:00 PM:
 1 cup vegetable salad (carrot, cucumber, cabbage, onion)
4:00 PM:
 6-7 almonds
 2-piece chicken steamed
6:00 PM:
 1 cup lentils (yellow)
8:00 PM:
 1 chapatti
 1 cup cooked carrots + 1 cup potatoes
10:00 PM:
 1 cup tea + 1tbsp of sugar
 2-3 digestive biscuits
122
CASE: 3
5.3 Case Study:
18 years old female Sakeena is, hospitalized due to heart failure, chest pain. Her
current weight is 49kg and height is 5 feet 2 inches. Her BMI is 20kg/m2 and TEE is
1906 kcal.
5.3.1 Heart Failure:
Heart failure formerly called congestive HF; the heart cannot provide adequate blood
flow to the rest of the body.
Symptoms:
 Fatigue
 Dyspnea (SOB)
 Fluid Retention
5.3.2 Medical Nutrition therapy:
 Consume a diet low in saturated and trans-fat.

 Restrict sodium diet.
 Increase use of whole grains, fruits, vegetables.
 Lose or maintain appropriate weight.
 Use magnesium supplementation.
 Use thiamine supplementation.
 Increase physical activity.
 Avoid Alcohol and tobacco.
Objective:
Diet low in saturated and Trans – fat, magnesium, thiamine, recommended.
Basic Principles:
Complex carbs, moderate protein is, recommended.
Dietary Guidelines:
 Diet low in saturated fat and trans-fat

 Restrict sodium diet
 Increase use of whole grains, fruits vegetables.
 Magnesium supplementation
 Thiamine supplementation.
123
 Increase physical activity

energy bars.
Eggs, red meat.
sweet potato
seeds seeds
and halwa
alcohol
Calculation:
 Patient name: Sakeena

 Age: 18 years
 Weight: 49 kg
124
BMI:
49kg  5x12= 60
(1.57)(1.57)  60+2=62
2.4  63x2.54=157cm
 157
having normal weight ) 100
=1.57m
IBW:
 100+5x2
 100+10
 110 Lbs.
=110
2.2
50 kg
IBW=50 kg
IBW%:
IBW  IBW= 50 kg
= 49 x 100
50
= 0.98 x 100
= 98%
IBW% = 98%
Energy Calculation:
BEE:
BEE= 665+ 470 + 283 - 85
BEE= 1418- 85  Weight: 49kg
 Age: 18 years
125
BEE= 1333 kcal
TEE:
= 1333 x 1.1 x 1.3 A.F= 1.1
= 1906 kcal S.F= 1.3
TEE= 1906 kcal
AMDRS:
 Protein=18%
 Fats= 27%
CARBOHYDRATE:
= % x calories
100
= 55 x 1906 kcal
100
= 0.55 x 1906 kcal
= 1048 kcal
4
PROTIEN:
= % x calories
100
= 18 x 1906
100
= 0.18 x 1906
= 343 kcal
4
Protein = 86 grams
FAT:
= % x calories
100
= 27 x 1906
100
= 0.27 x 1906
= 515
= 515
Fats= 57 grams
126
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Vegetable 3 15g 6 -
Total - 84g 22g 10g
= 262g- 84g
= 178g
= 178
15
Total - 180+84 = 264g 24+22= 46g 12+10= 22g
- -
86g- 46g
40g
= 40
7
Total - - 42+46= 88g 12+22g= 34g
- -
57 g-34g
23g
= 23
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 25+34= 59g
- -
127
5.3.4 DIET Plan:
8:00
 1 cup pudding without sugar (1 cup fat free milk)
10:00
 2 egg whites EXCHANGES:
12:00
 Apple and banana smoothie (1 banana + 2 apples) Milk: 2
 1 cup fat free milk
Fruit: 4
2:00
 1 cup vegetable soup Vegetable: 3
4:00 Starch: 12
 2-piece chicken steamed.
Protein: 6
6:00
Fat: 5
 Sandwich (2 brown bread slices + 1 piece chicken boiled)
8:00
 1 cup lentils
10:00
 2-3 digestive biscuits
128
Chapter no 6:
Surgery Ward:
During the Sixth week of internship, the rotation was, placed at Surgery ward.
CASE: 1
6.1Case Study:
40 years old MR is, hospitalized due to cholecystitis. He had a history of gallstones

and acute cholecystitis. His gallbladder was inflamed and surgery was, advised. Later
on, after surgery patient’s GCS factor is 9. Patient is on EN and PCT tube is, placed.
His current weight is 85kg and height is 5 feet 5 inches. His BMI is 31kg/m2 and her
TEE is 2229 kcal.
6.1.1Cholecystitis:
Cholecystitis is a redness and swelling (inflammation) of the gallbladder. It happens

when bile become, trapped and builds up in the gallbladder. In most cases, this
happens when solid lumps (gallstones) block the tube that drains bile from the
gallbladder.
Symptoms:
 Intense, sudden pain in the upper right part of your belly.

 Pain (often worse with deep breaths) that spreads to your back or below the right
shoulder blade.
 Nausea.
 Vomiting.
 Fever.
 Yellowing of the skin and eyes (jaundice)
 Loose, light-colored bowel movements.
 Belly bloating.
EN Nutrition:
Enteral nutrition, also known as tube feeding, is a way of delivering nutrition directly
to your stomach or small intestine.
Tube feedings may become necessary when you cannot eat enough calories to meet
your nutritional needs.
This may occur if you physically cannot eat, cannot eat safely, or if your caloric
requirements are increased beyond your ability to eat.
129
Types of Tubes:
The main types of enteral feeding tubes include:

 Nasogastric tube (NGT) starts in the nose and ends in the stomach.
 Orogastric tube (OGT) starts in the mouth and ends in the stomach.
 Nasoenteric tube starts in the nose and ends in the intestines (subtypes
include nasojejunal and nasoduodenal tubes).

 Gallstones are more prevalent in low fiber, high fat diets.
 Consumption of large amounts of animal protein and animal fat
especially saturated fat and a lack of dietary fiber promote the
gallstones development.
 There are also some benefits in replacing simple sugars and refined
starches with high fiber carbohydrates.
 Individual consuming refined carbohydrates have a 60% greater risk of
developing gallstones.
 Plant based diet may reduce the risk of cholelithiasis.
 Vegetarian diet is high in fiber and low in fat primarily of unsaturated
fat.
 Weight cycling, fasting and very low caloric diet increase the
likelihood of cholelithiasis.
Objective:
To treat cholecystectomy MNT includes a high fiber, low fat, plant-based diet
to prevent gallbladder contractions.
Basic Principle:
Consumed high fiber diet, eat plant-based food, low fat diet.
Dietary guidelines:
 Eat high fiber diet.

 Consume low fat diet and avoid the intake of saturated fats or trans-fat.
 Consume plant-based diets to reduce the risk of cholelithiasis.
 Vitamin c, which is generally present in vegetarian diet, may affect the
rate-limiting step in catabolism of cholesterol.
Food Groups Food Allowed Food Restricted
Milk and Milk products Skim ,1% or 2% low fat Whole milk (4%),
milk, low fat and fat free chocolate milk
130
yogurt
Vegetables All other vegetables Fried or creamy style
vegetables, tomatoes
Fruits Apples, berries, melons, Citrus such as oranges,
bananas, peaches, pears grapefruits, pineapple
Breads and Grains All those made with low fat Any prepared with low
content milk and high fat
Meat and meat products Low fat meat, chicken, fish, Cold cuts, sausage, bacon,
turkey, fatty meat, chicken fat/skin
Fats and oils None or small amount All animals and vegetables
oils
Beverages Decaffeinated, non-mint Alcohol, coffee (regular or
herbal tea, juices (except decaf), carbonated
citrus), water beverages, tea, mint tea
Calculation:
 Patient name: Zaheer

 Age: 40 years
 Weight: 85 kg
BMI:
85kg  5x12= 60
(1.65)(1.65)  60+5=65
2.72  65x2.54=165cm
 165
obese ) 100
=1.65m
IBW:
 106+6x5
 106+30
 136 Lbs.
=136
2.2
131
62kg
IBW= 62kg
IBW%:
IBW  IBW= 62 kg
= 85 x 100
62
= 137%
IBW% = 137%
Adjusted Body Weight:

IBW+ (ABW-IBW) x 0.25  IBW= 62 kg
= 62 + (85-62) x 0.25
= 62 + 23 x 0.25
= 62+ 6
68kg
Energy Calculation:
BEE:
Formula for Male BEE= 66.5+ (13.8x weight kg) + (5.0xheight cm) - (6.8xage years)
BEE= 66.5+ 938 + 825 - 272
BEE= 1829- 272  Weight: 68kg
TEE:
= 1559 x 1.1 x 1.3 A.F= 1.1
= 2389 kcal S.F= 1.3
TEE= 2229 kcal
AMDRS:
 Protein=20%
 Fats= 23%
CARBOHYDRATE:
= % x calories
100
132
= 57 x 2229 kcal
100
= 0.57 x 2229 kcal
= 1270 kcal
4
PROTIEN:
= % x calories
100
= 20 x 2229
100
= 0.2 x 2229
= 446 kcal
4
Protein = 111 grams
FAT:
= % x calories
100
= 23 x 2229
100
= 0.23 x 2229
= 513
= 513
Fats= 57 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Vegetable 3 15g 6 -
Total - 84g 22g 10g
= 317g- 84g
= 233g
= 233
15
133
Total - 225+84 = 309g 30+22= 52g 15+10= 25g
- -
111g- 52g
59g
= 59
7
Total - - 56+52= 108g 16+25g= 41g
- -
57 g-41g
16g
= 16
5
Fat= 3 exchanges
Fat 3 - - 15g
Total - - - 15+41= 56g
- -
Fluid Requirement:
= 1500+25 x65  Weight = 85kg

 1500ml for first 20 kg and 25ml
= 1500 + 1625 for additional kg
= 85-20
= 3125ml
65kg
As 1 glass = 250ml
3125
250
Fluid requirement = 12 glasses
134
6.1.4 DIET Plan:
Total Ml = 3125ml
1. Clear Liquid: (1 hourly diet plan)
Timing Feed ML
8:00 AM Water 30ml
9:00 AM Water 70ml
10:00 AM Water with honey 180ml
11:00 AM ORS 200ml
12:00 PM Water with lemon 250ml
1:00 PM ORS 250ml
2:00 PM Water with glucose 250ml
3:00 PM Water 250ml
4:00 PM Green tea 250ml
5:00 PM ORS 250ml
7:00 PM Water with honey 250ml
8:00 PM ORS 250ml
9:00 PM Water 250ml
- Total ml= 2980ml
135
2. Liquid diet: (2 hourly diet plan)
FEED SERVING TIME

Milk Shake (1 cup milk + 1 1 cup 6:00 AM
mango)
Corn soup 1 cup 8:00 AM
Chicken broth (1 piece 1 cup 10:00 AM
chicken)
Lentils soup 1.5 cup 12:00 AM
Carrot juice (3 carrots) 1 cup 2:00 PM
Rice drink 1 cup 4:00 PM
Corn soup 1 cup 6:00 PM
Lentils Soup 1 cup 8:00 PM
Lentils soup 1 cup 12:00 PM
Milk shake (1 cup milk + 2 1 cup 2:00 AM
bananas)
136
3. Semi Solid:
6:00
 2 beet root + 1 carrot juice
8:00 EXCHANGES:
 Smoothie (½ cup milk + 2 bananas + 1 apple) Milk: 2
10:00
Fruit: 3
 1 cup broth (3-piece chicken used)
12:00 Vegetable: 3
Starch: 15
 ½ cup yogurt + 2tbsp honey
Protein: 8
2:00
Fat: 3
 1.5 cup lentils
4:00
 2 boiled eggs mashed+ 2 brown bread slices mashed
6:00
 1 cup kheer (½ cup milk + ½ cup rice + 1tbsp sugar)
8:00
 1 cup rice blended with ½ cup milk

10:00
 1 cup mashed potato
137
CASE: 2
6.2 Case Study:

75 years old MR is, hospitalized due to hernia. He had a history of abdomen muscle
weakness. His hernia surgery was, advised. Later on, after surgery patient’s GCS
factor is 9. Patient is on EN and NG tube is, placed. His current weight is 78kg and
height is 5 feet 3 inches. His BMI is 30kg/m2 and her TEE is 1714 kcal.
6.2.1 Hernia:
A hernia of the abdominal wall is a protrusion of the abdominal contents through an
acquired or congenital area of weakness or defect in the wall.
Symptoms:
 A painful bulge that does not reduce in size when you lay down and rest.
 Worsening pain.
 Nausea and/or vomiting.
 Difficulty having a bowel movement.
 Bloating.
 Racing heart rate.
 Fever.
EN Nutrition:
Types of Tubes:
 Nasoenteric tube starts in the nose and ends in the intestines (subtypes include
nasojejunal and nasoduodenal tubes).
 It is necessary to add a small and frequent meal to your diet after your surgery
because one large meal can develop postoperative pain.
 If you take a small six to eight meals in a day that will not put extra pressure on
your stomach.
 Eat slowly and chew your food properly.
138
 After your meal, take a small walk or remain upright for about 20-30 minutes to
let your digestive system function smoothly.
 Avoid carbonated beverages for about six weeks after the hernia surgery to reduce
the complications such as gas. Avoid chewing gums and drinking through a straw,
this can increase the intake of air in the stomach further leading to gas.
 Do not consume alcohol, citrus juices, and tomato-based drinks, as these can
result in an increased stomach acid level.
 Eating sugary products such as deserts after meals are, suggested as it moves
quickly from the stomach to the intestines.
 Avoid taking them on an empty stomach it can create a few complications such as
diarrhea, nausea, dizziness, cramping, and weakness.
 You will receive diet instruction about foods that are soft and easy to swallow that
forestall any risk of complications such as choking because of the swollen
esophagus. After hernia surgery, this soft diet is, generally recommended for at
least six weeks.
Dietary Guidelines:
Clear Liquid Diet Post – Surgery
 Patients may feel some discomfort from flatulence or indigestion right after
surgery.
 Thus, doctors may recommend clear liquid diet, such as clear soup, non-acidic
juices (apple juice or tea), or jelly in the initial stages of recovery.
 Although they may have less nutrition and calories, but they will prevent
dehydration during this phase.
Nutrition to Prevent Constipation
 Lack of physical activities after surgery in combination with painkillers are the
main causes of constipation in recovering hernia patients.
 Fluid consumption will alleviate these symptoms, though the amount is
dependent on physical activities as well as the climate.
 On average, patients should drink at least 8 glasses of water per day.
 Alternatives may include 100% fruit juice, tea, decaffeinated coffee (with
minimal sugar content), or low-salt clear soup.
 Also, choose meals composed of high fiber diet, such as fruits, vegetables, and
whole grains (brown rice, whole wheat bread, oats, etc.).
Balanced Meals for Recovery
 Well-balanced meals will help the body recover.
 Consider fruits, vegetables, and whole grains together with healthy proteins from
fish, meat, eggs, tofu, nuts, milk and dairy products, such as yogurt and cheese.
 Avoid high fat and high caloric foods with low nutritional values, such as syrup
drinks, French fries, desserts, etc.
139
Proteins to Repair Muscles
 Consuming enough protein post-surgery is necessary to support the immune
system, help decrease inflammation, and promote muscle repair.
 Patients should eat 1 – 1.2 grams of protein per kilogram of body weight.
 For example, a 70-kg person should eat 70 – 84 grams of healthy protein, from
sources such as fish, pork, duck, chicken, eggs, seafood, roasted nuts, tofu, milk
and other low-fat source.
Constipation:
After hernia surgery, you may experience constipation, even if you are not prone to
it.
The following are foods you can add to your diet:
 Vegetables in the diet such as broccoli, carrots, sweet potatoes
 Beans and pulses such as green peas, lentils split peas
 Nuts, Grains, and seeds like almonds, oats, sunflower seeds, chia
seeds, walnuts
 Fresh Fruits such as apples, oranges, mangoes, watermelon, berries
Calculation:
 Patient name: Mahmood

 Age: 75 years
 Weight: 78 kg
BMI:
78kg  5x12= 60
(1.6)(1.6)  60+3=63
2.56  63x2.54=160cm
 160
obese ) 100
=1.6m
IBW:
 106+6x3
140
 106+18
 124 Lbs.
=124
2.2
56kg
IBW= 56kg
IBW%:
IBW  IBW= 56 kg
= 78 x 100
56
= 139%
IBW% = 139%
Adjusted Body Weight:

IBW+ (ABW-IBW) x 0.25  IBW= 56 kg
= 56 + (78-56) x 0.25
= 56 + 22 x 0.25
= 56+ 5
61kg
Energy Calculation:
BEE:
BEE= 66.5+ 842 + 800 - 510
BEE= 1708- 510  Weight: 61kg
TEE:
= 1199 x 1.1 x 1.3 A.F= 1.1
= 1714 kcal S.F= 1.3
TEE= 1714 kcal
141
AMDRS:
 Protein=18%
 Fats= 27%
CARBOHYDRATE:
= % x calories
100
= 55 x 1714 kcal
100
= 0.55 x 1714 kcal
= 943 kcal
= 943 as1 gram of carb= 4kcal
4
PROTIEN:
= % x calories
100
= 18 x 1714
100
= 0.18 x 1714
= 308 kcal
4
Protein = 77 grams
FAT:
= % x calories
100
= 27 x 1714
100
= 0.27 x 1714
= 463
= 463
Fats= 51 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Vegetable 3 15g 6 -
Total - 84g 22g 10g
= 236g- 84g
= 152g
142
= 152
15
Total - 150+84 = 234g 20+22= 42g 10+10= 20g
- -
77g- 42g
35g
= 35
7
Total - - 35+42= 77g 10+20g= 30g
- -
51 g-30g
21g
= 21
5
Fat= 4 exchanges
Fat 4 - - 20g
Total - - - 20+30= 50g
- -
Fluid Requirement:
= 1500+25 x58
 Weight = 78kg
= 1500 + 1450  1500ml for first 20 kg and 25ml
for additional kg
= 2950ml
= 78-20
As 1 glass = 250ml
58kg
143
2950
250
6.2.4 DIET Plan:

Total Ml = 2950ml
Timing Feed ML
8:00 AM Water 30ml
9:00 AM Water with glucose 50ml
10:00 AM Water 100ml
12:00 PM ORS 170ml
1:00 PM Water with lemon 200ml
2:00 PM Water 250ml
3:00 PM ORS 250ml
6:00 PM ORS 250ml
7:00 PM Water 250ml
9:00 PM ORS 250ml
10:00 PM Water 250ml
- Total ml= 2920ml
144
FEED SERVING TIME
Apple + carrot juice (3 1 cup 8:00 AM
apples + 1 carrot)
Corn soup 1 cup 10:00 AM
Chicken broth (2-piece 1 cup 12:00 PM
chicken)
Milk with 1tbsp honey 1 cup 2:00 PM
1 cup vegetable soup 1 cup 8:00 PM
(without solid) + 1 piece
chicken
Milk with 1tbsp honey 1 cup 12:00 PM
145
3. Semi Solid:
8:00
 1 cup water with 1tbsp honey
10:00
 1 cup cooked oatmeal (1 cup milk + 1 banana blended)
12:00
 2 beet root + 2 carrot juice EXCHANGES:
2:00 Milk: 2
 1 cup broth (2-piece chicken) with 2 slices of bread blended Fruit: 3
4:00
Vegetable: 3
 Milk shake (1 cup milk + 2 medium sized banana)
Starch: 10
6:00 Protein: 5
Fat: 4
 2 eggs boiled and mashed + 1 brown bread slice mashed
8:00
 1 cup vegetable soup (½ cup vegetable + 1 piece chicken)
10:00
 1 cup mashed potato.
146
CASE: 3
6.3 Case Study:

25 years old MR is, hospitalized due to Appendectomy. He had a history of acute
appendicitis. His appendix was, burst and surgery was, advised. Later on, after
surgery patient’s GCS factor is 9. Patient is on EN and NG tube is, placed. His current
weight is 75kg and height is 5 feet 7 inches. His BMI is 26kg/m2 and her TEE is 2389
kcal.
6.3.1 Appendicitis:
Appendicitis is inflammation of your appendix, a finger-like pouch attached to your
large intestine. The appendix is in the lower-right area of your abdomen, or belly.
Your appendix is in the lower-right area of your abdomen, near where the small
intestine attaches to the large intestine.
Symptoms:
 Sudden pain that begins on the right side of the lower abdomen.
 Sudden pain that begins around your navel and often shifts to your lower right
abdomen.
 Pain that worsens if you cough, walk or make other jarring movements.
 Nausea and vomiting.
 Loss of appetite.
EN Nutrition:
Types of Tubes:
 Nasoenteric tube starts in the nose and ends in the intestines (subtypes include
nasojejunal and nasoduodenal tubes).
 For management after surgery start with the clear liquids. Drink plenty of
water.
 Eat a lot of whole grains fruits and vegetables.
147
 Avoid foods that cause constipation such as dairy products, red meat,
processed foods such as pizza, pasta sugary products etc.
 Rest for the next 24 hours after the surgery.
 Drink plenty of fluids.
 If your stomach is upset, try bland low-fat foods like plain rice boiled chicken
and yoghurt.
Objective:
Moderate amount of protein, carbs and fat. Drink plenty of fluids. Eat a lot of whole
grains, fruits and vegetables.
Basic Principle:
Moderate amount of protein, carbs and fat, and plenty of fruits and vegetables.
Dietary Modification:
 Eat only easy to digest foods for the few days.
 Include lighter foods such as fruits, vegetables, items made with rice.
 Soup, milk light breakfast type of foods can be, easily digest and can give
energy to the body.
6.2.3 Table food choices for Appendectomy:

whole grain flour
seeds seeds
148
alcohol
Calculation:
 Patient name: Haris

 Age: 25 years
 Weight: 75 kg
BMI:
78kg  5x12= 60
(1.7)(1.7)  60+7=67
2.89  63x2.54=170cm
 170
overweight ) 100
=1.7m
IBW:
 106+6x7
 106+42
 148 Lbs.
=148
2.2
67kg
IBW= 67kg
IBW%:
IBW  IBW= 67 kg
= 75 x 100
67
= 111%
IBW% = 111%
149
Energy Calculation:
BEE:
BEE= 66.5+ 925 + 850 - 170
BEE= 1841- 170  Weight: 67kg
TEE:
= 1671 x 1.1 x 1.3 A.F= 1.1
= 2389 kcal S.F= 1.3
TEE= 2389 kcal
AMDRS:
 Protein=18%
 Fats= 27%
CARBOHYDRATE:
= % x calories
100
= 55 x 2389 kcal
100
= 0.55 x 2389 kcal
= 1314 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2389
100
= 0.18 x 2389
= 430 kcal
4
Protein = 107 grams
FAT:
150
= % x calories
100
= 27 x 2389
100
= 0.27 x 2389
= 645
= 645
Fats= 72 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Vegetable 3 15g 6 -
Total - 84g 22g 10g
= 328g- 84g
= 244g
= 244
15
Total - 240+84 = 324g 32+22= 54g 10+16= 26g
- -
107g- 54g
53g
= 53
7
Total - - 49+54= 103g 14+26g= 40g
- -
72 g-40g
32g
151
= 32
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 40+30= 70g
- -
Fluid Requirement:
= 1500+25 x55
 Weight = 75kg
= 1500 + 1375
 1500ml for first 20 kg and 25ml
for additional kg
= 2875ml
= 75-20
As 1 glass = 250ml
55kg
2875
250
152
6.2.4DIET Plan:
Total Ml = 2875ml
Timing Feed ML
8:00 AM Water 30ml
9:00 AM ORS 50ml
10:00 AM Green tea 100ml
1:00 PM Water 200ml
3:00 PM Water 220ml
4:00 PM ORS 230ml
9:00 PM ORS 250ml
10:00 PM Water 250ml
- Total ml= 2830ml
FEED SERVING TIME

Beet root + carrot juice (2 1 cup 6:00 AM
beet roots + 2 carrot)
Milk shake (1 cup milk+2 1 cup 8:00 AM
bananas+ 1 apple)
Chicken broth (3-piece 1 cup 10:00 AM
chicken)
Yogurt with 2 tbsp. honey 1 cup 12:00 PM
Corn soup 2 cups 4:00 PM
½ cup vegetable soup 1 cup 6:00 PM
(without solid)
Rice soup 1 cup 8:00 PM
Corn soup ½ cup 12:00 PM
153
3. Semi Solid:
8:00
 2 beet root + 2 carrot juice
10:00 EXCHANGES:
 1 cup kheer (1 cup milk + 1 cup rice + 1tbsp sugar)
Milk: 2
12:00
Fruit: 3
 2 eggs boiled and mashed + 2 brown bread slices mashed
Vegetable: 3
2:00 Starch: 16
 1.5 cup lentils soup
Protein: 7
4:00
Fat: 6
 1 cup vegetable soup (½ cup vegetable + 2-piece chicken)
6:00
 1 cup blended rice + 1 cup milk
8:00
 1 cup boiled mashed potato
10:00
 1 cup fruit puree (2 peaches + 1 apple blended in water)
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Chapter no 7:
Medical Unit:
During the Seventh week of internship, the rotation was, placed at Medical Unit.
CASE: 1
7.1 Diabetes:
A disease in which the body’s ability to produce or respond to the hormone insulin is
impaired, resulting in abnormal metabolism of carbohydrates and elevated levels
of glucose in the blood. This disease occurs when the body does not make enough
insulin or does not use it the way it should.
Types:
 Prediabetes
 Types 1 Diabetes
 Type 2 Diabetes
 Gestational Diabetes
1. Prediabetes:
Individuals with a stage of impaired glucose homeostasis that includes impaired
fasting glucose (IFG) and impaired glucose tolerance (IGT) ae referred to as having
prediabetes. IFG (100-125mg/dl) and IGT (140-199 mg/dl) are, diagnosed as
prediabetes.
2. Diabetes-Type 1
 Type 1 diabetes mellitus (T1D) is an autoimmune disease that leads to the
destruction of insulin-producing pancreatic beta cells.
 Individuals with T1D require life-long insulin replacement with multiple daily
insulin injections daily, insulin pump therapy, or the use of an automated
insulin delivery system.
 It accounts for 5% of all diagnosed cases of diabetes.
3. Diabetes-Type 2
 If you have type 2 diabetes, cells do not respond normally to insulin; this is,
called insulin resistance.
 Your pancreas makes more insulin to try to get cells to respond.
 Eventually your pancreas cannot keep up, and your blood sugar rises, setting the
stage for prediabetes and type 2 diabetes.
 Type 2 diabetes is also, called type 2 diabetes mellitus and adult-onset diabetes.
 T2DM accounts for 90% to 95% of all diagnosed cases of diabetes.
4. Gestational Diabetes:
 Gestational diabetes mellitus (GDM) is a condition in which a hormone made by
the placenta prevents the body from using insulin effectively.
155
 Glucose builds up in the blood instead of being absorbed by the cells.
 Unlike type 1 diabetes, gestational diabetes is, not, caused by, a lack of insulin,
but, by, other hormones produced during pregnancy that can make insulin less
effective, a condition referred to as insulin resistance.
 Gestational diabetic symptoms disappear following delivery.
 Approximately 3 to 8 percent of all pregnant women in the United States are,
diagnosed with gestational diabetes.
Symptoms:
 Urinate (pee) a lot, often at night.
 Are very thirsty.
 Lose weight without trying.
 Are very hungry.
 Have blurry vision.
 Have numb or tingling hands or feet.
 Feel very tired.
 Have very dry skin.
For pre diabetes:

 MNT should be, individualized for each patient take into account a patient health
status, food preference, food security and house situation.
 Healthy eating Pattern.
 Regular Physical Activity.
 Healthy body weight.
 Moderate Alcohol intake.
 No smoking
 Mediterranean diet
 MUFAS (olive oil)
 Plant based diet.
 Moderate intake of fish and wine.
 High intake of fruits and vegetables.
 Low intake of red meat and whole fat dairy products.
 High intake of whole grain and dietary fibers.
 Low intake of carbonated drinks and fatty acids.
For Diabetes:
 Individualized approach and effective nutrition, self-management, education,
counselling and support.
 Monitoring glucose, A1C and lipids levels, and blood pressure, weight, and
quality of life issues.
 Physical activity.
156
 Planned Carbohydrate intake.
Objective:
 To promote and support healthful eating patterns, emphasizing a variety of
nutrient dense foods in appropriate portion sizes, to improve overall diet and
specifically to
1. Attain individualized glucose, blood pressure and lipid
goals.
2. Achieve and maintain body weight goals.
3. Delay or prevent complications of Diabetes
 To address individual nutrition needs based on personal and cultural
preference’s, health literacy and numeracy, access to healthful food choices,
willingness and ability to make behavioral changes.
 To maintain the pleasure of eating by providing positive messages about food
choices while limiting food choices only when indicated by scientific evidence.
 To provide the individual with diabetes with practical tools for day-to-day meal
planning rather than focusing on individual macronutrients, micronutrients or
single foods.
Dietary Guidelines:
Energy balance and weight:
For Children and Adolescents:
 Height and weight should be, monitored via appropriate height and weight growth
charts.
 Prevention of excessive weight gain while encouraging normal linear growth.
 Prevention of obesity.
 Healthy life styles.
For Adults:
 Reduced calorie intake can lead to reduction in A1C of 0.3% to 2.0% in adults
with T2DM.
 Weight loses interventions.
 Mediterranean-style diet.
Carbohydrate Intake:
 Approach of consuming low carbohydrate diet.
 Insulin to Carbohydrate ratios to adjust insulin doses for variable carbohydrate
intake.
157
 Carbohydrate counting plan.
 Natural sources of carbohydrate than processed forms.
 Restriction of table sugar containing foods.
Fiber and Whole grain:
 Intervention involving fiber supplementation for T2DM can reduce fasting blood
glucose.
 40g/day of fiber is, recommended for the population with diabetes.
Nonnutritive Sweeteners:
 Reduced calorie sweeteners approved by the FDA include sugar alcohols
(erythritol, isomalt) when consumed within established dietary intake levels,
facilitate in the reduction of added sugar intake.
 It causes decrease in total energy intake.
 They reduced total calorie intake.
Protein intake:
 Protein should be 1 to 1.5g/kg body weight/day or 15% to 20% to total calories.
Fat intake:
 Monounsaturated fatty acids (MUFA) - rich foods as a component of the
Mediterranean-style eating patterns are associated with improved glycemic
control.
 Poly unsaturated fatty acids.
 Omega 3 fatty acids.
7.1.3 Table food choices for Diabetes:

whole grain flour
158
seeds seeds
alcohol
159
CASE: 2
7.2 Hepatitis:
Hepatitis means inflammation of the liver. The liver is a vital organ that processes
nutrients, filters the blood, and fights infections. When the liver is inflamed or
damaged, its function can be, affected.
Symptoms:
 Yellow skin or eyes.
 Not wanting to eat.
 Upset stomach.
 Throwing up.
 Stomach pain.
 Fever.
 Dark urine or light- colored stools.
 Diarrhea.
 Fever,
 Malaise,
 Loss of appetite
 diarrhea,
 Nausea,
 Abdominal discomfort
 Jaundice
 Chills
 Fever
Types:
 Hepatitis A
 Hepatitis B
 Hepatitis C
 Jaundice
1. Hepatitis A:
Overview. Hepatitis A is an inflammation of the liver caused by the hepatitis A virus
(HAV). The virus is, primarily spread when an uninfected (and unvaccinated) person
ingests food or water that is, contaminated with the feces of an infected person.
Hepatitis A is a contagious liver infection caused by the hepatitis A virus.
2. Hepatitis B:
Hepatitis B is a vaccine-preventable liver infection caused by the hepatitis B virus
(HBV). Hepatitis B is, spread when blood, semen, or other body fluids from a person
infected with the virus enters the body of someone who is not infected.
3. Hepatitis C:
160
Hepatitis C is a liver infection caused by the hepatitis C virus (HCV). Hepatitis C is,
spread through contact with blood from an infected person. Today, most people
become, infected with the hepatitis C virus by sharing needles or other equipment
used to prepare and inject drugs.
4. Jaundice:
A condition in which the skin and the whites of the eyes become yellow, urine
darkens, and the color of stool becomes lighter than normal. Jaundice occurs when the
liver is not working properly or when a bile duct is blocked.
Causes of hepatitis
Type of
Common route of transmission
hepatitis
hepatitis A exposure to HAV in food or water
contact with HBV in body fluids, such as blood, vaginal secretions, or

hepatitis B
semen
contact with HCV in body fluids, such as blood, vaginal secretions, or

hepatitis C
semen
hepatitis D contact with blood containing HDV
hepatitis E exposure to HEV in food or water
7.2.2 Medical Nutrition Therapy of Hepatitis:

 For a patient with Hepatitis food choices are not limited to a few bland dishes.
There are plenty of healthy, tasty food options, which are both beneficial for the
liver and for the recovery process.
 Avoid alcohol and cigarettes for a healthy liver.
 Avoid taking vitamin supplements or over-the-counter drugs without consulting
your doctor.
 Do not skip meals when recovering from Hepatitis.
 Eat small meals.
 Drink lots of water.
 Take adequate rest.
Objective:
Dietary changes, Small frequent meals with adequate protein and energy to treat
malnourishment and for speeding up the recovery process.
161
Basic Principle:
1.0 to 1.2 grams of protein per kilograms of body weight. Low Sodium and low-fat
diet. Less than 30% fat.
Dietary Guidelines for Hepatitis:
Whole grain:
 Whole grains are very beneficial to consume as part of a healthy Hepatitis diet.
 These can be in the form of bran, whole wheat bread or cereal, brown rice, whole
grain pasta or porridge.
 Include other whole grains such as whole oats, wild rice, rye, oatmeal and corn.
Fruits and Vegetables
 Fruits and vegetables should be a significant part of any diet to help in recovering
from a liver disease.
 They are full of essential nutrients and are easy to digest. As a bonus, they also
contain antioxidants, which can protect the liver cells from damage.
 However, it is, recommended that one go easy on starchy vegetables such as
potatoes when on a Hepatitis recovery diet.
 While canned or frozen fruits are fine, it is always a good idea to try to eat fresh and
seasonal produce when possible.
Fats and Oils:
 Olive oil, canola oil and flaxseed oil are all healthy fats that are, recommended as
part of a diet for patients with Hepatitis.
 Fat should be less than 30% for the patients with steatorrhea.
Protein:
 Healthy proteins in the form of low-fat milk and dairy products along with lean
meats, beans, eggs and soy products can also be a part of a healthy liver diet.
 1.0 to 1.2 grams of protein per kilograms of body weight.
Processed food items
 Processed food items are, best, avoided, when recovering from Hepatitis.
 Processed food items include processed ingredients that are harder on the liver and
relatively devoid of nutrients.
 Processed breads, cheese and almost all fast -food items also best avoided during
Hepatitis, as they can worsen recovery times.
Sugar intake
 Sugar intake should be limited for a healthy liver.
 This includes all artificial sweeteners as well as fruits juices.
162
 Juices have high concentrations of sugar in them, which can be difficult for the liver
to digest when the body is under attack from the Hepatitis virus.
Hepatitis A
 Hepatitis A is a short-term illness and may not require treatment. However, if
symptoms cause a great deal of discomfort, bed rest may be necessary. In addition,
if you experience vomiting or diarrhea, your doctor may recommend a dietary
program to maintain your hydration and nutrition.
Vaccine for Hepatitis B:

 The Centers for Disease Control and Prevention (CDC) Trusted
Source recommends that all children and adults up to age 59 should receive the
hepatitis B vaccine.
 Infants should get their first hepatitis B vaccine within 24 hours of birth and
complete their doses by age 6 to 18 months.
 All unvaccinated children and adults through age 59 should receive the vaccine. In
addition, unvaccinated adults over the age 60 who are at risk of hepatitis B should
get the vaccine.
 Adults over age 60 who are not at risk of hepatitis B may also choose to get the
shot.
 Several types of the HBV vaccine are also safe to administer to pregnant women.
Jaundice:
There is no cure for yellow fever. Treatment involves managing symptoms and assisting your
immune system in fighting off the infection by:
 getting enough fluids, possibly through your veins

 getting oxygen
 maintaining a healthy blood pressure
 getting blood transfusions
 having dialysis if you experience kidney failure
 getting treatment for other infections that may develop
Hepatitis C:
 Antiviral medications can treat both acute and chronic forms of hepatitis C.
 Typically, people who develop chronic hepatitis C will use a combination of
antiviral drug therapies. They may also need further testing to determine the best
form of treatment.
 People who develop cirrhosis or liver disease due to chronic hepatitis C may be
candidates for a liver transplant.
163
Hepatitis D
 The WHO Trusted Source lists PEGylated interferon alpha as a treatment for
hepatitis D. However, this medication can have severe side effects. As a result, it is,
not recommended for people with cirrhosis liver damage, those with psychiatric
conditions, and people with autoimmune diseases.
7.2.3 Table food choices for Hepatitis:

whole grain flour
seeds seeds
alcohol
164
CASE: 3
7.3 Cirrhosis:
An advanced stage of liver disease in which extensive scarring replaces healthy liver
tissue, causing impaired liver function and liver failure. A cirrhotic liver is often
shrunken and has an irregular, nodular appearance. The physical changes in liver
tissue may interfere with blood flow, causing fluid to accumulate in blood vessels and
body tissues. Advanced cirrhosis can disrupt kidney and lung function.
Causes of Cirrhosis:
 Alcoholic liver disease
 Autoimmune hepatitis Bile duct obstructions
 Complications of gallbladder surgery
 Cystic fibrosis
 Diseases that cause bile duct injury
 Wilson’s disease (causes excessive liver copper)
 Steatohepatitis (fatty liver disease)
 Viral hepatitis
 Hepatitis B
 Hepatitis C
Symptoms:
 Tiredness and weakness.
 Loss of appetite.
 Weight loss and muscle wasting.
 Feeling sick (nausea) and vomiting.
 Tenderness or pain around the liver area.
 Yellowing of the skin and the whites of the eyes (jaundice).
Complications
It includes portal hypertension, gastroesophageal varices, ascites, and hepatic
encephalopathy.
 Portal hypertension:
Elevated blood pressure in the portal vein due to obstructed blood flow through the
liver
 Hepatic encephalopathy:
A condition in advanced liver disease characterized by altered neurological
functioning, including personality changes, reduced mental abilities, and
disturbances in motor function.
165
 Ascites:
An abnormal accumulation of fluid in the abdominal cavity.
 Gastroesophageal varices:
When blood flow through the portal vein is, impeded, the blood is, diverted to the
smaller blood vessels surrounding the liver.
These collaterals develop throughout the gastrointestinal (GI) tract and in regions
near the abdominal wall. As pressure builds, the collateral vessels become enlarged
and engorged, forming abnormally dilated vessels called varices.
7.3.1 Medical Nutrition Therapy for Liver Cirrhosis:

Energy:
 Energy needs may be approximately 20% above resting metabolic rate
(RMR); calculate or measure RMR and apply the stress factor 1.2.
 Energy requirements may be higher in patients with infection or
malnutrition. Energy requirements may be lower in patients who would
benefit from weight loss.
Meal frequency:
 To improve food intake, patients should consume small meals 4 to 6 times
daily
Protein:
 Provide 0.8 to 1.2 g protein per kilogram of dry body weight per day to
maintain nitrogen balance and prevent wasting.
Carbohydrate:
 No carbohydrate restrictions unless patient has insulin resistance or
diabetes.
 For persons with insulin resistance or diabetes, provide up to 50% to 60%
of kilocalories from carbohydrates (mainly complex carbohydrates);
carbohydrate intake should be consistent from day to day and at each meal
and snack.
Fat:
 No, fat restrictions unless fat malabsorption is present.
 If fat is malabsorbed, restrict fat to 30% of total kilocalories or as
necessary to control steatorrhea; use medium-chain triglycerides (MCT) to
increase kilocalories.
Sodium and fluid:
 Restrict sodium as necessary to control ascites; 2000 mg sodium per day is
adequate restriction in most cases.
166
 If ascites is, accompanied by low serum sodium levels (less than 128
mEq/L), restrict fluids to 1200 to 1500 mL per day. In severe cases (serum
sodium less than 125 mEq/L), restrict fluids to 1000 to 1200 mL per day.
Vitamins and minerals:
 Ensure adequate intake from diet or supplements based on individual
needs.
Enteral and Parenteral Nutrition Support:

 In patients who are unable to consume enough food, tube feedings may be
infused overnight as a supplement to oral intakes or may replace oral
feedings entirely
 Although standard formulas are often appropriate, an energy-dense,
moderate-protein, low-electrolyte formula may be necessary for patients
with ascites or fluid restrictions.
 To avoid excessive fluid delivery, patients with ascites typically require
concentrated parenteral solutions, which are, infused into central veins.
167
7.3.2 Table food choices for Cirrhosis:

whole grain flour
seeds seeds
alcohol
168
CASE: 4
7.4 NON-ALCOHOLIC FATTY LIVER DISEASE:
 Non-alcoholic fatty liver disease is a spectrum of liver disease ranging from

steatosis to steatohepatitis and cirrhosis. It involves the accumulation of fat
droplets in the hepatocytes and can lead to fibrosis, cirrhosis and even
hepatocellular carcinoma.
 The initial stage of NAFLD is, characterized by the accumulation of fat in the
liver.
 Non-alcoholic steatohepatitis is associated with the hepatocyte injury with or
without fibrous tissue in the liver.
 NASH is developed into chronic liver disease and NASH cirrhosis.
Causes of non-alcoholic fatty liver disease:
 It includes drugs inborn errors of metabolism and, acquired metabolic disorders.

 It is directly associated with obesity, type 2 diabetes mellitus, dyslipidemia, and
the metabolic syndrome.
For the treatment of NAFLD, weight reduction, insulin sensitizing drugs such as
thiazolidinedione’s and vitamin E.
Objective:
Eating lower glycemic index foods such as most fruits vegetables and whole
grains. High fiber plants like legumes and whole grains. Reduce intake of sugars
or beverages, refined carbohydrates and saturated fat.
Basic Principle:
Fruits, vegetables and whole grains or low fiber diet. Weight cycling, fasting very
low-calorie diets may increase the risk of gallstones.
Dietary Guidelines:
 Weight loss:
The treatment recommendations for NAFLD from the American Association for
the study of liver disease (AASLD) is first weight loss for obese. Rapid and
uncontrolled weight loss can be detrimental for patients. It is, recommended to
avoid a very low caloric diet.
 Saturated fat:
169
Saturated fat should be, avoided because they increase the risk of liver fat and
insulin resistant.
 Regular exercise:
A good diet and a regular exercise can reverse it. Losing 10% of your current
weight can dramatically decrease the amount of fat in the liver as well as reduce
the inflammation.
 Mediterranean diet:
The Mediterranean diet has a beneficial effect on NAFLD. This die is, based on
the high intake of extra virgin olive oil, fruits, vegetables, nuts and cereals
moderate intake of fish and other meats, dairy products and low intake of eggs and
sweets.
7.4.2 Table Food choices for NAFLD:
whole grain flour
seeds seeds
alcohol
170
CASE: 5
7.5 Cholelithiasis:
 The formation of gallstones is, called cholelithiasis. Virtually all gallstones from
within the gallbladder. In most cases, gallstones are asymptomatic. Gallstones that
pass from the gallbladder into the common bile duct may remain there indefinitely
without causing symptoms or they may pass to the duodenum with or without
symptoms.
 Choledocholithiasis develops when the stones slip into the bile ducts producing
the obstruction pain and cramps.
 If passage of bile into the duodenum is, interrupted, Cholecystitis can develop.
 In the absence of bile in the intestines, lipid absorption is impaired and without
bile pigments stools become light in the color (alcoholic).
 Most of the gallstones are un-pigmented cholesterol stones composed of
cholesterol bilirubin and calcium salts.
For the treatment of cholelithiasis low fiber and high fat diet is prevalent. Eat healthy
fats like olive oil, fish oil to help your gallbladder contract and empty on a regular
basis. Lean meat, poultry and fish are good sources also. Use low fat dairy products.
Objective:
Eat high fat low fiber diet. Consumption of animal protein animal fat and a lack of
dietary fiber may promote the gallstones development. Refined carbohydrates have a
60% of greater risk of gallstones.
Basic Principle:
Fruits, vegetables and whole grains or low fiber diet. Weight cycling, fasting very
low-calorie diets may increase the risk of gallstones.
Dietary Guidelines:
 Weight loss:
The treatment recommendations for NAFLD from the American Association for
the study of liver disease (AASLD) is first weight loss for obese. Rapid and
uncontrolled weight loss can be detrimental for patients. It is, recommended to
avoid a very low caloric diet.
 Saturated fat:
Saturated fat should be, avoided because they increase the risk of liver fat and
insulin resistant.
 Regular exercise:
A good diet and a regular exercise can reverse it. Losing 10% of your current
weight can dramatically decrease the amount of fat in the liver as well as reduce
the inflammation.
 Mediterranean diet:
171
The Mediterranean diet has a beneficial effect on NAFLD. This die is, based on
the high intake of extra virgin olive oil, fruits, vegetables, nuts and cereals
moderate intake
Of fish and other meats, dairy products and low intake of eggs and sweets.
7.5.2 Table Food choices for Cholelithiasis:
whole grain flour
seeds seeds
alcohol
172
Chapter No.8
GYNAE WARD:
During the Eight week of internship, the rotation placed at Gynae ward.
8.1 Nutrients Requirements during Pregnancy:
Nutrients Recommendations
RDI is slightly high during pregnancy to maintain the
Carbohydrates blood glucose level and choose complex
carbohydrates more preferably than simple.
RDA is 0.8 g/kg current weight/day for first half
Protein
RDA is 1.1 g/kg/day for second half of the pregnancy
There are no specific recommendations for fat. Its
amount depends on
Fat total caloric intake for proper weight gain.
Recommendations of omega-6
and omega-3 are slightly increased
Fiber DRI is 14 g/day/1000 kcals
DRI increases about 340 kcal/day for second
Energy trimester, and 452 kcal/day
for third trimester
Vitamin
Standard dose is about 25 mg three times a day which
Vitamin B6
is not dangerous
According to the centers for disease control and
Folic acid prevention the recommendations are 400 mcg/day for
all women of childbearing age expecting pregnancy
Vitamin B12 is found in high amount in animal food
Vitamin B12 sources, their sufficient intake can easily meet the
vitamin B12 requirements
DRI of vitamin C is increased during pregnancy and
Vitamin C its good sources like 7FM citrus fruits should be
encouraged
Supplementation is not necessary and is often limited
Vitamin A
to 5000 IU/day
The requirements are not increased during pregnancy
Vitamin D
and 600 IU/day is sufficient
Vitamin E The requirements are not increased during pregnancy
Vitamin K The requirements are not increased during pregnancy
Minerals
Calcium The requirements are not increased but some women
173
having low calcium status when entering into the
pregnancy so require encouraged calcium- rich-foods
intake
Copper Requirements are increased slightly during pregnancy
Fluoride The requirements are not increased during pregnancy
Women should receive 150 mcg/day during
Iodine pregnancy and lactation in the form of potassium
iodide
Iron RDA of iron nearly doubles during pregnancy
Magnesium Recommendation slightly increases during pregnancy
Phosphorus The requirements are not increased during pregnancy
Selenium DRA slightly increases during pregnancy
Sodium intake should not be restricted below 2300
Sodium
mg/day
Zinc Requirement slightly increase during pregnancy
At least 30 minutes of moderate intensity exercise
Exercise
most days of week
1.2 Nutrients Requirements during Lactation:
Nutrients Recommendations
The RDA of carbohydrates is based on to provide
Carbohydrates sufficient energy by diet for the production of milk
and to maintain the energy level
Protein RDA is 1.1 g/kg/day of woman's body weight
There are no specific recommendations for fat. Its
amount depends on the amount of energy required by
the mother for the production of milk.
Fat
Recommendations of specific omega-6 and omega-3
are low than
pregnancy
DRI of energy is about 330 kcal greater per day for
Energy first six month of lactation, and 400 kcal greater per
day for second six month of lactation
Vitamin
The requirements are not increased during lactation
Vitamin D
and 600 IU/day is sufficient
Minerals
The lactating women are encouraged to intake
Calcium calcium-rich-foods to meet
their DRA
174
The requirements are nearly double to non-pregnant
Iodine
values
There is no specific recommendations and restrictions
Sodium
for breastfeeding mothers
Requirements during lactation are more than the
Zinc
pregnancy
Fluids Drink to thirst but not in excess
175
CASE: 1
8.1 Cesarean:
Cesarean section, C-section, or Cesarean birth is the surgical delivery of a baby
through a cut (incision) made in the mother's abdomen and uterus. Health care
providers use it when they believe it is safer for the mother, the baby, or both. The
incision made in the skin may be up-and-down (vertical).
8.1.1 Medical Nutrition Therapy for Cesarean:

Objective:
The main purpose of the diet design for mother after the C-section delivery is to
provide food that helps the mother to digest food easily and aid the bowel movements
without straining the wound on abdomen and meets the nutritional requirements.
Basic Principle:
High in protein, high energy, high in major vitamins and minerals especially vitamin
C and iron respectively and plenty of fluids.
Dietary Guidelines:
 Protein rich foods help in healing process contribute to the growth of new tissues
and maintain the muscles post-surgery.
 Vitamin C speeds up the healing process and fights against the infections.
 Lots of blood is lost during C-section delivery, which may deplete the iron level of
the body and leave you exhausted and fatigued. Intake iron rich foods after the C-
section delivery because iron is required for the hemoglobin and to fulfill the blood
that lost during delivery.
Iron is important for the proper functioning of immune system.
 After the C-section, females should eat nutritious and easily digestible foods like
soups, broth, cottage cheese and yogurt.
 After C-section delivery mothers often experience increased gas and constipation,
they should avoid foods that cause the constipation and gas problems. Avoid fried
foods, carbonated drinks these produce gas and avoid processed foods like pasta,
breads etc. these are hard to digest and cause constipation.
 Intake fibrous foods to avoid constipation also fatty acids from flaxseeds and
primrose oil can help.
 Intake lots of yogurt to restore the intestinal bacterial balance.
 Drink plenty of water to avoid dehydration and avoid constipation.
 Hydration improve the bowel movement and increase the rate of recovery.
 Intake 8 to 10 glasses of water and other fluids like low fat milk, herbal teas, non-
citrus and unsweetened fruit juices and coconut water.
176
 Drinking plenty of water is also necessary during breast-feeding which can leave
you thirsty.
 To increase the breast milk production, drink calcium fortified juices, milk and
low-fat yogurt.
 Get sufficient vitamins especially vitamin C and E from food sources and
supplements that help the body to heal faster and fight against infections.
 Resume your normal diet when you do not feel pain during bowel movements and
digest foods easily.
8.1.2 Food Choices of Cesarean:
Foods Allowed Foods Not Allowed
Fish, chicken, eggs, meats, dairy foods

like cottage cheese and yogurt and also
nuts, peas and dried beans these are
protein sources
Red meat, liver, egg yolk, dried fruits and
dried beans these are rich sources of iron Fried foods, carbonated drinks,
calcium fortified juices, herbal teas, non- processed foods like pasta and breads
citrus and unsweetened fruit juices and
coconut water Warm soups, broth,
177
CASE: 2
8.2 Gestational Diabetes:

Gestational diabetes occurs when your body cannot make enough insulin during your
pregnancy. Insulin is a hormone made by your pancreas that acts like a key, to let
blood sugar into the cells in your body, for use as energy.
8.2.1 Medical Nutrition Therapy of GDM:

Basic Principle:
The MNT for GDM is primary a carbohydrate-controlled meal plan but it also
provides sufficient amount of necessary nutrients for maternal and fetus growth, gives
adequate amount of energy for required weight gain, maintains the normal blood
glucose level and also prevent the ketosis.
Dietary Guidelines:
 Carbohydrates requirement of a day of pregnant women should be divided into
three small or medium meals and two to four snacks
 The minimum amount of carbohydrates for pregnant woman are 175g/day.
 Evening snacks are important to prevent the ketosis in nighttime due to the low
blood glucose level.
 CHO are in high amount not much tolerated in morning or breakfast than other
meal due to cortisol and growth hormone so initial meal plan may have about 30g
of CHO in breakfast
 Caloric restriction for pregnant women should be, done with caution, moderate
caloric restriction is, recommended to slow down the weight gain in the obese or
overweight pregnant women with GDM.
 Small restriction of calories helps to slow down the maternal weight gain in
pregnant women with GDM without affecting the fetus normal growth.
 Less than 1700 to 1800 calories are not advice in pregnancy.
 Exercise helps in decreasing the insulin resistance and maintain the blood glucose
level, combination of exercise with appropriate diet gives maximum benefits, exact
exercise is unknown but fast walking after meal is, recommended.
 Breastfeeding reduces the risk of T2DM after pregnancy in those women having
GDM or preexisting diabetes during pregnancy.
 Overweight and obese women with GDM recommend to, reduce weight after
delivery, which reduces the risk of recurrent GDM and T2DM in future.
178
CASE: 3
8.3 Anemia:
Iron Deficiency Anemia (IDA) occurs due to the long-term iron deficiency in the
body or we can also say that anemia is the end stage of long-term iron deprivation. It
is, characterized by the small sized (microcytic) erythrocytes production and low level
of circulating hemoglobin.
Causes:
 Inadequate dietary intake
 Inadequate absorption due to celiac diseases, intestinal resection and drug
interference
 Inadequate utilization likes in gastrointestinal diseases
 Increased iron demand like in pregnancy
 Increased excretion of iron due to blood loss in injury, heavy menses and
hemorrhage
 Increased utilization of body's iron stores
Symptoms:
Early Iron Deficiency:
 Abnormal cognitive development in children
 Growth abnormalities
 Epithelial disorders
 Reduce gastric activity
 Low immunity
 Restless leg syndrome
 Alter neurotransmitter (dopamine)
Late Iron Deficiency (Anemia)
Anemia affects various body systems, which are:
 Impaired muscle function like decreased work performance and exercise tolerance
 Neurological disturbance
 Fatigue
 Anorexia
 Pica
 Pagophagia (ice eating)
Complications
If the iron deficiency anemia remains untreated then the complications arise which are:
 Glossitis
 Gastritis
 Achlorhydria
 Koilonychias
 Cardiac failure.
179
Medical Management:
 The basic aim of the treatment should be to identify the underlying cause of the
anemia.
 Ferrous is the more absorbable form of the iron in body than the ferric, oral
supplementation of the ferrous iron is the primary treatment of the anemia.
 Iron best absorbs in empty stomach but it can cause gastric irritation like nausea,
vomiting, diarrhea and constipation so it is, recommended that to intake, the iron
supplements with meals but it affects its absorbability.
 Chelated iron is more absorbable than the non-chelated iron and it also not affected
by iron absorption inhibitors, which are calcium, phosphate, oxalate and phytate.
8.3.1 Medical Nutrition Therapy of Iron Deficiency Anemia:
Objective
 The diet is, planned to maintain the iron level in the body. Diet should be consisting
on iron rich sources meat, chicken and fish, also provide acidic medium, which
enhances the iron absorption.
Dietary Guidelines:
 With supplemental iron it is important to paid attention to sufficient intake of
absorbable dietary iron
 A good source of iron provides at least 10% of the recommended dietary
allowance of
 Iron.
 1.8 mg of iron requires to meet the daily needs of 80% to 90% adult women and
adolescents’ boys and girls
 Bioavailability is more important in the treatment and prevention of iron
deficiency than the total amount of dietary iron consumed
 Absorption of iron depends on the individual's iron stores, more the iron
deficiency greater the iron absorption
 Anemic person absorbs approximately 20% to 30% dietary iron as compared with
5% to 10% absorb by healthy person
 There are two forms of the iron present in the foods which are heme iron and non-
heme iron
 Heme iron which is about 15% is absorbed is organic and present in the meat, fish
and poultry. It is more absorbable than the non-heme iron
 Non-heme iron present in the meat, fish, poultry, egg, grains, vegetables and
fruits, its absorption rate is about 3% to 8%.
 Vitamin C enhances the iron absorption by binding the iron and forms the readily
absorbable complex
 Diet should contain the vitamin C rich sources which are citrus fruits, cabbage and
potatoes
180
 There are different types of iron absorption inhibitors that inhibit its absorption at
varying degrees. Whole grain cereals and soybeans have carbonates, phytates and
oxalates that binds the iron and decrease its bioavailability
 In coffee and tea, tannin is present that binds the iron in egg phosvitin binds the
iron.
8.3.2 Table food choices for Anemia:

whole grain flour
seeds seeds
alcohol
181
Chapter No.9
PEDIATRIC WARD:
During the Ninth week of internship, the rotation placed at Pediatric ward.
Infancy is the life stage start from the birth to the 2 years of life.
1.1 Table of Equation for Calculating Estimated Energy Requirements for

Infants:
Age In Months Calculations
0-3 (89 * Weight of infant kg]-100) +175
4-6 (89*Weight of infant [kg]-100) +56
7-12 (89*Weight of infant[kg]-100) +22
13-35 (89*Weight of infant [kg[kg]-100) +20
1.1.1 Protein:
Protein is required for the tissue replacement, deposition of the lean body mass and
for growth. Infants require a larger amount of amino, for infants all amino acids are
essential while for adults not all are essential and require in relatively low amounts.
Histidine is essential for infants but not for adults. Tyrosine, cysteine and taurine are
may be essential for premature infants.
1.1.1.1 Table for Protein dietary intake for Infants:
Age Gram/kg/day
0-6 1.52g/kg/day
6-12 1.2g/kg/day
1.1.2 Water:
The water requirement for infants can be determine by the loss of water through skin, lungs,
feces, urine, and small amount require for growth. DRI is about 0.7L/day for infants up to 6
month and from 6 to 12 months 0.8L/day.
1.1.2.1 Table for Maintenance of Fluid for Infants and Children:
Weight in Kg Fluid Requirements

0-10 100ml/kg
182
10000ml
11-20
10kg+50mlal for each kg more
than 10 kg
1500ml for 20kg+20mlml for each kg more

More than 20
than 20kg
1.1.3 Table for Nutritional Ranges for Healthy Child of Age 1-3 years:
Nutrients Percentages
CHO 45%-65%
Fat 30%-40%
Protein 5%-20%
Intake should be consisting in these percentages for healthy child of age 4-18 years
1.1.4 Table for Nutritional Ranges for Healthy Child of Age 4-18 years:
Nutrients Percentages
CHO 45%-65%
Fat 25%-35%
Protein 10%-30%
1.1.5 Table for Protein dietary intake for Infants:
Age Gram/kg/day
1-3 1.05g/kg/day
4-8 0.95g/kg/day
9-13 0.95g/kg/day
183
1.1.6 Table for Maintenance of Fluid for Infants and Children:
Weight in Kg Fluid Requirements

0-10 100ml/kg
11-20 0ml for 10 kg+50mml for 10 kg + 50ml for

each kg more than 10 kg
More than 20 1500ml for 20kg+20nor 20kg + 20ml for

each kg more than 20kg
1.1.7 Table for Protein dietary reference intake:
Age Gram/kg/day
0-6 1.52g/kg/day
6-12 1.2g/kg/day
184
CASE: 1
9.1 Hypothyroidism:
Hypothyroidism, also called underactive thyroid, is, when the thyroid gland does not
make enough thyroid hormones to meet your body's needs. The thyroid is a small,
butterfly-shaped gland in the front of your neck.
9.1.1 Medical Nutrition Therapy of Iron Deficiency Anemia:

Dietary Guidelines:
Many nutrients are involved in the maintenance of the thyroid function specially the
iodine and the selenium, so in thyroid related problems iodine receives more attention.
Iodine
 It is the trace element in the body and its total amount in the body is about 10 to 15
mg and from this about 70% to 80% present in the thyroid gland for the synthesis
of thyroid hormones.
 Inadequate intake of iodine impairs the thyroid function and can cause the different
diseases
 Severe iodine deficiency during pregnancy increases the risk of spontaneous
abortion congenital abnormalities on fetus.
Goitrogens:
 Green leafy vegetables having the anti-thyroid effect, these inhibit the production of
thyroid hormones by producing the goitrin, which interfere in production.
 Soybean is an important protein source but it also shows goitrogenic properties in
the deficiency of iodine.
 Low iron status or anemia can cause low thyroid hormones production or
hypothyroidism
 Sufficient amount of iron is require for adequate production of the thyroxin.
185
CASE: 2
9.2 Typhoid Fever:

Typhoid is an infectious disease with an acute fever of short duration and occurs only
in humans. Salmonella typhi causes typhoid. Feces and urine of the patients or
carriers of the contaminated with feces from patients or persons recovered from the
disease. House flies help.
Symptoms:
 Inflammation of the intestine
 Intestinal ulcers
 Hemorrhage and enlargement of spleen.
 Peyer’s patches of lymphatic tissue situated in the small intestine are a seat of
infection in typhoid fever.
 The patient may complain of diarrhea or constipation and severe stomach pain.
9.2.1 Medical Nutrition Therapy of Typhoid fever:

Basic Principle:
A high calorie, high protein, high carbohydrate, high fluid, low fat, low fiber and
bland diet is, recommended for typhoid patients.
Dietary Guidelines:
 At first clear fluid diet is given followed by full fluid and soft diet
 Liquid diets may not meet high calorie and high protein requirements.
 Liquid diets are helpful in meeting water and electrolyte requirements。
 As the patient improves, a soft diet can be given。
 Because of intestinal inflammation, fiber and spices must be, eliminated in the diet.
186
References:
 ROLFES, SR • PINNA. K.AND WHITNEY,
E.2008.UNDERSTANDING NORMAL AND
CLINICAL NU1'RITION_ 8th ED. CENGAGE
LEARNING, BELMONT, CA 9002-3098.USA
1192 PAGES
 ANIS R.A., LARIK, Z., RIAZ, S., ALI, A.,
ATHAR.N, AN'D SALEEM, M. DIET MA1NUAL
FOR PAKISTAN NUTRITION WING MINISTRY OF
HEALTH ISLAMABAD, JSB.PAKISTAN 13.5
PAGES
 FOOD AND NUTRITON CARE PROCESS (EDITON I2th)
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INTERNSHIP REPORT

A report submitted in partial fulfillment for the award of degree of

Supervisor: Ms. Safa Akram

DEPARTMENT OF HUMAN NUTRITION AND DIETETICS (HND)

Ms. Safa Akram

Ms. Sania Khalid

Ms. Maryam Ashraf

I, Wafeera Moazzam (2019-GCUF-059127), declare that the contents of this Internship

Chapter No. Topic Page No.

Sr. No. Abbreviation Full Form

02 BMI Body Mass Index

03 IBW Ideal Body Weight

04 BMR Basal Metabolic Rate

05 SBP Systolic Blood Pressure

06 DBP Diastolic Blood Pressure

07 LDL Low Density Lipoprotein

08 HDL High Density Lipoprotein

09 VLDL Very Low-Density Lipoprotein

10 DASH Dietary Approaches to Stop Hypertension

11 CVD Cardio Vascular Disease

12 CHD Coronary Heart Disease

13 IHD Ischemic Heart Disease

14 PUFA Poly Unsaturated Fatty Acid

15 MUFA Mono Unsaturated Fatty Acid

17 FPG Fasting Plasma Glucose

18 GTI Gastro Intestinal Track

19 CAP 4 Community Acquired Pneumonia

20 GERD Gastro Esophageal Reflex Disease

21 COPD7 Chronic Obstructive Pulmonary Disease

22 DHA Decosa Hexanoicnoic Acid

23 EPA Ecosa Pentatonic Acid

24 AKI Acute Kidney Injury

1.6 Tools of Assessment

Ideal body weight (IBW)

Waist to hip ratio

1.7 Harris Benedict Equation (energy calculation)

Equation for female

2.1 Case Study:

2.1.2 Medical Nutrition Therapy of Fracture:

Smoking and Alcohol:

2.1.3 Table Food choices for Fracture:

Food Groups Foods Allowed Foods Restricted

 Patient name: Faisal Ahmed

Formula = Actual weight x 100  Actual weight= 50 kg

2.2.3 Table food choices for RA:

 Patient name: Salamat Ali

2.3.3 Table food choices for OA:

 Patient name: Azhar Ali

Adequate calcium and vitamin D:

 A high sodium intake may contribute to osteoporosis because of increased calcium

2.4.3 Table food choices for OP:

 Patient name: Zainab Ahmed

BMI: Height: 5’5 multiply first 5 feet with12 and

3.1.3 Table Food choices for Constipation:

3.2 Case Study:

Types Symptoms of IBS

IBS with diarrhea (IBS-D) 3 bowel movements per day

segments of bowel, and partial or complete obstruction of the intestinal characterize