DEFINITION Dietetics - The branch of therapeutics concerned
with the practical application of diet in relation to health and
disease.
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Dietetics - the science of applying nutritional principles to
the planning and preparation of foods and regulation of the diet in
relation to both health and disease.
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Dietitians in practice Clinical dietitians Clinical dietitians
work in hospitals, nursing care facilities and other health care
facilities to provide nutrition therapy to patients with a variety
of health conditions, and provide dietary consultations to patients
and their families. They confer with other health care
professionals to review patients' medical charts and develop
individual plans to meet nutritional requirements. Some clinical
dietitians will also create or deliver outpatient or public
education programs in health and nutrition.
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Community dietitians Community dietitians work with wellness
programs, public health agencies, home care agencies, and health
maintenance organizations. These dietitians apply and distribute
knowledge about food and nutrition to individuals and groups of
specific categories, life-styles and geographic areas in order to
promote health.
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Foodservice dietitians Foodservice dietitians or managers are
responsible for large-scale food planning and service. They
coordinate, assess and plan foodservice processes in health care
facilities, school food service programs, prisons, restaurants, and
company cafeterias. These dietitians may perform audits of their
departments to ensure quality control and food safety standards,
and launch new menus and various programs within their institution
to meet health and nutritional requirements.
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Gerontological /geriatric dietitians Gerontological dietitians
are specialist in nutrition and aging. They work in nursing homes,
community- based aged care agencies, government agencies in aging
policy, and in higher education in the field of gerontology (the
study of aging).
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Neonatal dietitians Neonatal dietitians provide individualized
medical nutrition therapy for critically ill premature newborns.
They are considered a part of the Neonatal Intensive Care Unit's
medical team.
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The neonatal dietitian performs clinical assessment of
patients, designs nutrition protocols and quality improvement
initiatives with the medical team, develops enteral and parenteral
regimens. They also help to establish and promote
lactation/breastfeeding guidelines and often oversees the
management of infection prevention in the handling, storage, and
delivery of nutritional products.
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Pediatric dietitians Pediatric dietitians provide nutrition and
health advice for infants, children, and adolescents. They focus on
early nutritional needs, and often work closely with doctors,
school health services, clinics, hospitals and government agencies,
in developing and implementing treatment plans for children with
eating disorders, food allergies, or any condition where a childs
diet factors into the equation, such as childhood obesity.
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Research dietitians Research dietitians are involved with
dietetics- related research conducted in hospitals, universities,
government agencies, food and beverage companies, and the
pharmaceutical industry. They may conduct research in clinical
aspects of nutrition, for example, the effects of diet on cancer
treatment.
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Administrative dietitians Administrative or management
dietitians oversee and direct all aspects of food policy and large-
scale meal service operations in hospitals, government agencies,
company cafeterias, prisons, and schools. They recruit, train and
supervise employees of dietetics departments including dietitians
and other personnel.
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Consultant dietitians Consultant dietitian is a term sometimes
used to describe dietitians who work under contract with health
care facilities or in private practice.
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Consultant dietitians are contracted independently to provide
nutrition services and educational programs to individuals and
health care facilities as well as sports teams, fitness clubs,
supermarkets, and other health and nutrition-related
businesses.
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The 6 Basic Principles of Diet Planning
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Ask most people what the word "diet" means and they describe
short-term weight loss goals and countless food restrictions.
However, the term "diet" simply refers to what we eat. A good diet
promotes positive change and helps you incorporate sensible eating
into your daily lifestyle. The six principles of diet planning
include; Adequacy Nutrient density Moderation Variety Balance
Calorie control
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Adequacy An adequate diet provides the human body with enough
energy and nutrients for optimal growth, maintenance and repair of
tissue, cells and organs. Water, carbohydrates, fats, proteins,
vitamins and some minerals comprise the six nutrient classes relied
upon for performance of essential functions and activities.
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These nutrients must be replaced through diet to keep the body
working efficiently. An adequate diet includes foods containing
proper amounts of these nutrients to prevent deficiencies, anemia,
headaches, fatigue and general weakness.
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Balance A balance diet provides foods of a number of types in
proportion to each other such that foods rich in some nutrients do
not crowd out of the foods that are rich in other nutrients.
Balance in the diet helps to achieve adequacy. The essential
minerals calcium and iron, taken together illustrate the importance
of dietary balance. Meat, fish and poultry are rich in iron but
poor in calcium. Similarly, milk and milk products are rich in
calcium but poor in iron.
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In fact, milk(except breast milk) and milk products are so low
in iron that overuse of these foods can actually lead to
iron-deficiency anemia by displacing iron-rich foods from the
diet.
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The art of balancing the diet involves using enough of each
type of food. Consuming the proper amount of servings from each
food group ensures a well- proportioned diet.
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Calorie Control Once you know what to eat, the next factor is
how much. It is possible to eat healthy foods and still
overindulge. Clearly, the task of designing an adequate, balanced
diet requires some thought and skillful planning. Even more thought
and skill are required to create an adequate and, balance diet
without overeating. Therefore, a reasonable calorie allowance must
be established. The amount of energy the body receives from
incoming food needs to match the amount of energy needed for the
body to sustain its biological and physiological activities.
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In other words, input needs to match output. An imbalance leads
to weight loss or gain.
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Nutrient density Eating well without overeating is often
challenging. Nutrient density is a measure of the nutrients a food
provides relative to the energy it provides. The more nutrients and
the fewer kcalories, the higher the nutrient density. Nutrient
density promotes adequacy and kcalorie control You must select
foods that pack the most nutrients into the least amount of
calories. For example, 1 oz. of cheese and 1 cup of fat-free milk
contain the same amount of calcium.
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While both foods are adequate sources of calcium, the milk is
more calcium-dense than the cheese because you get the same amount
of calcium with one-half the calories and no fat. Designing a
nutritionally sound diet requires proper "budgeting" of calories
and nutrients so that you eat less while supporting good
health.
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Moderation Socrates once said "Everything in moderation;
nothing in excess." Though over 2,500 years old, this adage still
holds true. Those who place severe restrictions on what they can or
cannot eat often find it difficult to stick to a pattern of
sensible eating.
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Depriving yourself of foods rich in fat and sugar is not
necessary. When eaten on occasion, these treats are not detrimental
to your health and often provide enough enjoyment to keep one
motivated to continue healthy eating practices.
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Variety It's possible for a diet to have all the aforementioned
characteristics, but still lack variety if the person eats the same
foods day after day. People should vary their choices within each
class of foods from day to day for three reasons. First, different
foods in the same group contain arrays of nutrients. Among the
fruits for example, strawberries are especially rich in vitamin C
while bananas are rich in potassium. Second, no food is guaranteed
entirely free of constituents that in excess, could be
harmful.
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Third, as the adage goes, variety is the spice of life. Even if
a person eats beans frequently, the person can choose red beans
today, garbanzo beans tomorrow, and baked beans on the weekend.
Good nutrition does not have to be boring.
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Diet planning guides To plan a Diet that achieves all of the
dietary ideals just outlined, a planner needs not only knowledge
but tools. Four of the most used tools for diet planning are;
1.Food group plans 2.Food exchange lists 3.Food guide pyramid 4.WHO
recommendations
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Food group plans This is a food planning tool that sorts foods
of similar origin and nutrient content into groups and then specify
that people should eat certain numbers of serving from each group.
Of the diet planning principles introduced earlier, food group
plans help the diet planner best to achieve dietary adequacy,
balance and variety Four food group plan 4 servings of vegetables
and fruits 4 servings of bread and cereals 2 servings of milk and
milk products 2 servings of meat and meat products
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Daily food guide The daily food guide differs from the four
food group plan by splitting vegetables from fruits, so that there
are five groups of foods. The numbers of serving suggested are also
more generous. 6--11 servings of breads and cereals 3 5 servings of
vegetables 2--4 servings of fruits 2 3 servings of meats and meat
products 2 servings of milk and milk products
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Food Exchange List This is a diet planning tool that organizes
foods by their nutrient and energy contents. Foods on any list can
be used interchangeably. Exchange list provide additional help in
achieving kcalorie control and moderation. Originally developed for
people with diabetes, exchange system have proved so useful that
they are now in general use for diet planning.
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Unlike the food group plan, which sort foods primarily by their
protein, vitamin, and mineral, the exchange sorts foods by their
proportions of carbohydrates, fat and protein. Portion sizes are
strictly defined so that the amount of energy provided by any food
item is the same as that from any other item within a given list.
All of the food portion in a given list provide approximately the
same amount of energy nutrients(carbohydrates, fat and protein) and
the same number of calories.
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Any food on the list can be exchanged or traded for any other
food on that same list without affecting a plans balance or total
calories. The six exchange list are as follows: Starch/bread- 1
slice bread(80 calories) Meat-1ounce lean beef(55 calories)
Vegetables-1/2 cup cooked carrots(25 calories) Fruits-1/2 banana(60
calories) Milk- 1 cup nonfat milk(90 calories) Fat- 1 teaspoon
butter(45 calories)
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Starch/bread exchange 1 slide of bread is like c ready-to-eat
cereals c cooked pasta 1/3 c cooked rice 1/3 c cooked beans corn 1
small( 3oz) potato (1 bread = 15g carbohydrate, 3g protein, trace
of fat, and 80 kcal)
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Food Guide Pyramid The most recent food guide designed to
provide sound nutritional advice for daily food selection is the
food guide pyramid. It is designed to provide visual image of the
variety of foods that people should eat, the proportion of calories
that should come from each of the groups, and the use of moderation
in consumption of fats, oils and sweets. The food guide pyramid is
result of years of deliberation by renowned nutrition scientists.
Although there are six categories of foods in the pyramid,
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Nutritionists do not regard fats, oil and sweets as an actual
food group. The base of the pyramid, which should constitute the
majority of daily calories, is represented by the bread, cereal,
rice, and pasta group(6-11 serving) and the fruit group(2-4
serving). These three foods group are derived from grains and
plants. Fewer servings are recommended from the milk, yogurt, and
cheese group(2-3 servings) and the meat, poultry, fish, dry beans,
eggs and nuts group derived primarily from animals.
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Fats, oils and sweets(not classified as a group) should be used
sparingly. Typical serving sizes are defined for each food item in
each group. eg, a serving of milk is 1 cup while a serving of
cooked or chopped vegetable is a cup.
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WHO recommendation According to WHO recommendation on daily
food selection; 60 % of daily calorie should come carbohydrates.
30% from fat. 10% from protein.
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HEALTHY DIET
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In the past most morbidity and mortality in the developed
nations were caused by nutrient- deficiency diseases and infectious
diseases, But advances in nutritional and medical sciences have
almost eliminated most of the adverse health consequences of
associated with these disease. Today, most morbidity and mortality
are associated with various chronic diseases(e.g., coronary heart
disease, stroke, cancer, diabetes, obesity), And most dietary
guidelines for healthful nutrition are targeted to prevent these
chronic diseases.
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An unhealthy diet is a major risk factor for a number of
chronic diseases including: High blood pressure, Diabetes, Abnormal
blood lipids, Overweight/obesity, Cardiovascular diseases, and
Cancer.
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The WHO estimates that 2.7 million deaths are attributable to a
diet low in fruit and vegetable every year. Globally, it is
estimated to cause about 19% of gastrointestinal cancer, 31% of
ischaemic heart disease, and 11% of strokes, thus making it one of
the leading preventable causes of death worldwide.
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The essence of healthy diet is to promote good health and
significantly reduce the risk of developing chronic diseases. The
following dozen guidelines represent what is called a healthy
diet.
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Healthy Diet 1.Balance the food you eat with physical activity
to maintain or improve your weight. 2. Eat a nutritional adequate
diet consisting of a wide variety of foods. 3. Choose a diet low in
fat, saturated fat and cholesterol. 4. Choose a diet with plenty of
whole grain products, legumes, fruits and vegetables, which are
rich in complex carbohydrates and fiber.
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5. Choose a diet moderate in sugars 6. Choose a diet moderate
in salts and sodium 7. If you drink alcoholic beverages, do so in
moderation. Pregnant women should not drink any alcohol. 8.
Maintain protein intake at a moderate, yet adequate level,
obtaining much of your daily protein from plant sources.
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9.Choose a diet adequate in calcium and iron 10. Children and
others susceptible to tooth decay should obtain adequate fluoride.
11. In general avoid taking dietary supplements in excess of the
RDA in any one day. 12. Eat fewer foods with questionable
additives
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1. Balance the food you eat with physical activity to maintain
or improve your weight Preventing obesity helps to reduce the risk
of numerous chronic diseases such as heart disease and cancer. To
avoid becoming overweight, you should consume only as many calories
as you expend daily. An aerobic exercise program and adherence to
the concept of nutrient density, could serve as the basis for sound
weight-control program.
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2. Eat a nutritionally adequate diet consisting of a wide
variety of foods Eating a wide variety of natural foods from within
and among the six food groups or Food Guide Pyramid or the Food
Exchange List will assure you of obtaining a balanced and adequate
intake of all essential nutrients. Stress foods that are high in
the key nutrients.
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3. Choose a diet low in total fat, saturated fats, and
cholesterol Currently, fat comprises almost 35 percent of total
daily calories. The recommended dietary goal is to obtain less than
30 percent of calories from fat. In addition, the amount of
saturated fat in the diet should be 10 percent or less, and
cholesterol intake should be limited to 300 milligrams or less per
day.
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However, it should be noted that some healthful diet plans
recommend lower values, such as 10-20 percent total fat, less than
7 percent saturated fat, and less than 200 milligrams of
cholesterol. The following practical suggestions will help people
meet the recommended dietary goal.
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Eat less meat with a high fat content. Avoid hot dogs, luncheon
meats, sausage, and bacon. Trim of excess fat before cooking. Eat
only lean red meat and more white meat, such as turkey and chicken,
which have less fat. Remove the skin from poultry. Eat more
fish.
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Many fish, such as sardines, salmon, tuna, and mackerel, are
rich in omega-3 fatty acids. White fish, such as flounder, is very
low in fat Calories. Eat no more than 6 ounce of animal meat per
day.
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Eat only two to three eggs per week. One egg yolk contain about
220-250 milligrams of cholesterol, close to the limit of 300
milligrams per a day. Egg whites have no cholesterol and are an
excellent source of high-quality protein. Eat fewer diary products
that are high in fat. Switch from whole milk to skim or nonfat
milk, such as yogurt and cottage cheese.
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If you like cheese, switch from hard cheese to soft cheeses
although most cheeses, except low-fat cottage cheese are still high
in fat and calories. Some fat-free cheeses are now available. Eat
less butter, which is high in saturated fats, by substituting soft
margarine made or polyunsaturated, such as corn oil
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Avoid margarine made from hydrogenated or partially
hydrogenated oils, which basically are metabolized like saturated
fat. Eat margarine sparingly. Some fat-free margarines are also
available. Eat fewer commercially prepared baked goods made with
eggs and saturated or hydrogenated fats.
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Limit your consumption of fast foods. Although fast-food chains
generally serve grade A foods, many of their products are high in
fat. The average fast-food sandwich contains approximately 50
percent of its Calories in fat. Some fast-food restaurant do serve
nutrient-dense foods. Wise choices, such as baked fish grilled
skinless chicken, lean meat, baked potatoes and salads can provide
healthy nutrition.
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Use food labels to help you select foods low in total fat,
saturated fat and fat Calories, all of which are listed on the food
label for most products. Broil, bake, grill, boil or microwave your
foods. Limit frying. If you must use in your cooking, try to use
monounsaturated oils such as olive or peanut oil.
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In general, decrease your intake of cholesterol, total fat, and
saturated fat by substituting monounsaturated, polyunsaturated and
omega-3 fatty acids for saturated or hydrogenated fats
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4. Choose a diet with plenty of whole-grains products, fruits
and vegetables, foods which are rich in fiber & complex
carbohydrates
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In general, about 60 percent or more of your daily Calories
should come from carbohydrates, about 50 percent from complex
carbohydrates, and the other 10 percent from simple, naturally
occurring carbohydrates. To accomplish this, you need to eat more
whole- grain products (breads and cereals), legumes (beans and
peas), and vegetables and fruits.
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Stress vegetables and fruits high in beta- carotene and vitamin
C ( the antioxidant vitamins) such as carrots and sweet potatoes.
Deep yellow and orange fruits and vegetables as well as dark-green
leafy vegetables are usually good sources of these vitamins.
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Also increase intake of cruciferous vegetables, those from the
cabbage family. These fruits and vegetables contain various
phytochemicals which protect people against several forms of
cancers.
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Another benefit of complex carbohydrates is their high fiber
content. Whole-grain products and numerous vegetables are excellent
sources of water insoluble fiber. The high fiber content of these
foods is believed to be important in the prevention of diseases
such as colorectal cancer and coronary heart disease. Food labels
list the total carbohydrates and the amount of dietary fiber per
serving.
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5. Choose a diet moderate in sugars The recommended dietary
goal is to reduce consumption of refined sugar from the current
level of 24 percent of daily Calories to 10 percent or less.
Excessive consumption of refined sugar has been associated with
high blood triglyceride level. Sticky sugars are a major
contributing factor to dental cavities.
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Sugars also significantly increase the caloric content of foods
without an increase in nutritional value, so they may contribute to
body weight problems. To meet this goal you should reduce your
intake of common table sugar and products high in refined
sugar.
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Sugar is one of the major additives to processed foods, so
check the labels. If sugar is listed first, it is the main
ingredient. Use naturally occurring sugar to satisfy your sweet
tooth. Most fruits have high sugar content, but also contain
vitamins, minerals, and fiber as well. Also look for terms such as
corn syrup, dextrose, fructose, and malt sugar, which are also
primarily refined sugars.
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6. Choose a diet moderate in salt and sodium Restrict sodium
intake to less than 2,400 mg daily, which is the equivalent of
6,000 milligram, or 6 grams, of table salt. This lower amount will
provide sufficient sodium for normal physiological
functioning.
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Sodium is found naturally in a wide variety of foods, so it is
not difficult to get an adequate supply. The following key
suggestions may help people reduce the sodium content in their
diets
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Get rid of your salt shaker. One teaspoon of salt is 2,000mg of
sodium; the average well-salt meal contains about 3,000 to 4,000mg.
Put less salt on your food both in your cooking pot and on your
table. Reduce the consumption of obviously high-salt foods such as
most koobi and potato chips, pickles and other such snacks
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Check food labels for sodium content, if salt or sodium is one
of the ingredients listed, you have a high-sodium food. Salt is a
major additive in many processed foods, often disguised by terms
such as monosodium glutamate and others. Food labels list the
sodium content per serving. Use fresh herbs, spices that do not
contain sodium, or little salt as seasoning alternatives.
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7 If you drink alcoholic beverages, do so in moderation
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The current available scientific evidence does not suggest that
light to moderate daily alcohol consumption will cause any health
problems to the healthy, nonpregnant adult. However, excessive
alcohol consumption is one of the most serious health problems in
our society today, and even small amounts may pose health problems
to some individuals.
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Light to moderate drinking is based upon a limit one drink for
nonpregnant woman and two drinks for a man. A drink is defined as a
dose of any alcoholic beverage that delivers oz of pure ethanol;
one 12-oz bottle of beer, one 4-oz glass of wine, or 1.5 ounces of
80-proof distilled spirits.
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8 Maintain protein intake at a moderate, yet adequate level,
obtaining much of your daily protein from plant sources.
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8. The recommended dietary intake is 0.8 grams of protein per
kilogram body weight, which average out to about 50 to 60 grams per
day or 10-12 percent of daily calories. It appears that most people
are staying within the guidelines. However, most of the protein
people eat is of animal origin.
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Although animal products are an excellent source of complete
protein, they tend to be higher in saturated fats and cholesterol
compared with foods high in plant protein. On the other hand,
animals protein is usually a better source of dietary iron and
other minerals like zinc and copper than plant protein is.
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Four ounces of meat, fish, or poultry, together with two
glasses of skim milk, will provide the average individual with
daily RDA for protein totaling about 45 grams. Combining this
animal protein intake with plant foods high in protein, such as
whole-grain products, beans and peas, and vegetables, will
substantially increase protein intake and more than meet your
needs.
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9. Choose a diet adequate in calcium and iron This is
particularly important for women and children. Skim or low-fat milk
and other low-fat dairy products are excellent source of calcium.
For example, one glass of skim milk provides nearly one-third the
RDA for calcium.
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Iron is found in good supply in the meat and starch exchanges.
Lean or very-lean meat should be selected so as to limit fat intake
and whole-grain or enriched products should be chosen over those
made with bleached, unenriched white flour.
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10. Children and others susceptible to tooth decay should
obtain adequate fluoride.
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This is particularly important during childhood when the
primary and secondary teeth are developing, for fluoride helps
prevent tooth decay by strengthening the tooth enamel. Your water
supply may contain sufficient fluoridenaturally or artificially- to
provide an adequate amount, but if not, fluoride supplements or use
of fluoride toothpaste is recommended.
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11. In general, avoid taking dietary supplements in excess of
the RDA in any one day
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Dietary supplements of most vitamins and minerals are not
necessary for individual consuming a balanced diet. If you adhere
to the recommendation listed here, you are not likely to need any
supplementation at all, for the consumption of nutrient dense foods
should guarantee adequate vitamin and mineral nutrition.
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12. Eat fewer foods with questionable additives. The general
consensus is that most additives used in processed foods are safe.
But several health agencies, recommend caution with additives such
as saccharin and nitrates, which have been linked to the
development of cancer in laboratory animals.
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And other substances such as sulfites and certain food colours,
which may cause allergic reaction in some individuals. Eating
fresh, natural foods is one of the best approaches to avoiding
additives.
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HEALTHY EATING STEPS
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Healthy Eating Steps To help make healthy choices of food easy,
all food have been arranged into three food steps.
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Step 3 Fats and oils-example palm oil, all types of vegetable
oil, palm soup, margarine, planta, sheabutter, avocado pear,
Example of one serving/meal 1/3 small tomato tin of oil(3
dessertspoon) match box size sheabutter 3 soup ladleful oily
soup(palm soup/groundnut soup avocado pear- 1/8 large, small, 2-3
servings daily
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Step 2 Animal and Vegetable protein Examples- all types of
meat, fish, chicken, beans, cheese, crab, eggs, milk, snails,
groundnuts and all nuts and plant seeds like agushie. Examples of
one serving/meal 1 joint chicken- remove skin 1-3 match box size
meat-lean meat 1 medium fish 2 eggs per week evaporated tin milk, 1
teaspoon- powdered milk 2-3 stewing spoons of beans
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Step 1 Starches, vegetables and fruit Starches- fufu, kenkey,
banku, akpler, omo tou, gari, bread, cassava, plantain, yam and
rice( eat enough to satisfy) 3-4 servings daily. Vegetables: okro,
garden eggs, tomatoes, aleefu, ayoyo, kontomire, cassava leaves,
sweet potatoes leaves, onion, pepper, green beans, cabbage,
carrots, lettuce, cucumber, bra, bito bitter leaves- 2-3 servings
daily.
Knowing how to interpret food label, to prepare foods, and to
avoid dietary contaminants may guide you in developing a
nutritious, safe, and healthful diets. By law, food labels must
contain the following information:
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List of ingredients-ingredients will be listed in descending
order by weight. Serving size- serving sizes must be expressed in
both household measures such as cups and metric measures such as
milliliters to accommodate users of both types of measure. Servings
per container.
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Amount per serving of the following: Total calories Calories
from fat Total fat Saturated fat Cholesterol
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Sodium Total carbohydrates Dietary fiber Sugars Protein Vitamin
A Vitamin C Calcium Iron
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The following may be listed voluntarily Calories from saturated
fat Polyunsaturated fat Monounsaturated fat Potassium Soluble fiber
Insoluble fiber Sugar alcohols
Slide 100
How can people use this information to select healthier diet To
provide information to help consumers see how foods may be part of
a daily diet plan, a new label reference value, the Daily Value(DV)
has been created. The DV for a nutrient represents the percentage
contribution one serving of the food makes to the daily diet for
that nutrient based on current recommendation for healthful
diets.
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A lower DV is desirable for total fat, saturated fat,
cholesterol, and sodium, while a higher DV is desirable for total
carbohydrates, dietary fiber, iron, calcium, vitamins A and C
Slide 102
The diet history: the technique of obtaining dietary
information
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A brief (assessment) diet history consists essentially of the
same steps but requires less detailed probing for quantities.
24-hour recall. Take the patient through the previous day meals
noting times of all meals and snacks and what was eaten.
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This is relatively easy to do, concentrates the patients mind
on food and gives a guide to meal patterns. If the respondent is an
in- patient, establish the pattern of a typical day at home. If the
24-hour recall is difficult, then a diet history is probably
impossible!
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Establish the quantities eaten on 24-hour recall. This relates
to one specific day, and is therefore less hypothetical than what
quantity might you eat? Get the patient to describe quantities,
which will give a guide to appetite and a cross-check on
reliability of later answers. If possible, use portion models.
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Establish the weekly pattern Is the specific 24-hour pattern
different in any way from the usual pattern? Take the patient
through the day again. What other dishes might be eaten at each
meal? What happen on Saturday and Sunday? What happen if the
respondent is working a different shift?
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How often does he go out? How often does he have visitors? What
dishes would be eaten? Probe specifically for sweets, and snack and
other items consumed between meals, also alcoholic drinks.
Slide 108
Establish likely quantities. Use portion models; it is easier
for the respondent to say my portion looks like that than to search
for verbal descriptions, particularly if inarticulate. The
interviewers interpretation is also likely to be more accurate.
Respondent who do their own shopping can also provide information
on quantities bought and for how many people.
Slide 109
Establish recipes for composite dishes. This is not always
possible with those who do not cook. Cross-checks the information
already obtained against a list of foods appropriate for the
purpose of the study.
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e.g. to assess vitamin C, only fruit and vegetable (and
composite dishes containing them) and squashes, need to be include.
The cross checking can take the form of a set of cards handed to
the respondent, rather than the interviewer questioning about each
food individually, for each food, ascertain how frequently a
portion is eaten on a daily, weekly or monthly basis.
Slide 111
Particularly in a full diet history this section demands the
best of the interviewers techniques, as it can be lengthy,
repetitious and boring.
Slide 112
Essential points to remember Do not assume anything about
patients meal patterns, recipes or portion sizes. It is all too
easy to assume meal patterns for people, e.g. Fridays we have fried
fish , what does the respondent mean by this? Is it cod coated in
butter and deep fried, or plaice lightly of tossed in butter, or
some thing else?
Slide 113
Do not assume it actually means what you think it means; check
it. If there is not a full description of the food, you may not be
able to complete the calculation later.
Slide 114
Write every thing down. If information is received from the
respondent but not recorded, then the interviewers memory becomes a
factor in the accuracy of the diet history.
Slide 115
Check that you have not made any obvious mistake like recording
1000g instead of 10g of sugar in tea. Checking that you have
recorded the respondent accurately is as important as checking that
the respondent has reported fully. It should be possible for
someone else to check and calculate a diet history and get the same
results as the interviewer. Use pre-designed form and not scraps of
paper.
Slide 116
Watch for non-verbal clues of boredom or irritation as it is
difficult to avoid the inquisitorial aspect. To counteract this,
break the flow of questioning by making some comments on how much
time is needed to complete the interview or a humorous reference to
the number of questions being asked.
Slide 117
Problems of the diet history Holding all the points on which
information is needed in ones head is difficult, particularly if
inexperienced. Questions may be phrased inappropriately,
particularly while thinking of others points to be covered.
Slide 118
It is easy to put words into the respondents mouth. Beware of
leading questions. Verbal descriptions of quantity may be very
unreliable and may be mistranslated by the interviewer. Bias is
introduced by the patients memory and subjective impressions.
Slide 119
For instance (a) A tendency to over remember proper meals. (b)A
tendency to under-remember snacks. (c)I always have fish on Fridays
may in fact mean two Fridays out of three. (d)Memory is weighted by
the last seven days. (e)Cross checking generally overestimates food
used infrequently, i.e. if liver is eaten once a mouth; it is
probably in fact less frequencies are probably more reliable.
Slide 120
The more irregular the pattern, the less reliable a diet
history tends to be. Patients may not be entirely truthful.
Slide 121
Analysis and interpretation of information Assessment of food
intake Depending on the purpose of taking the diet history, the
food intake may be assessed or analyzed in a variety of ways. By
relating the food intake to a daily food guide. By using knowledge
of food composition to make a judgment about some aspects of the
diet, e.g. the adequacy of fiber intake or the likely contribution
of the diet to dental caries.
Slide 122
By using a table of approximate food values to make a crude
calculation of the intake of one or more dietary constituents. By
using detailed tables of food composition to calculate the intake
of specific nutrients. Points1 3 above are relevant to the brief
diet history and point 4 to the full diet history.
Slide 123
Assessment of nutrient intake Nutrient intake =nutrient content
of food portion weight frequency of consumption. For example,
compare the relative contributions of parsley and milk to vitamin C
intake. Parsley provides 150mg/100g1gportion
once/week=0.2mg/day
Slide 124
Milk provides 1.5mg/100g30g portion eight/day=3.6 mg/day. Be
careful to select from the tables the food which best represents
the food described by the respondent. Similarly, care must be taken
in translating the respondents description of portion sizes into
weights.
Slide 125
Evaluation The quality of the personal contact. Was the
respondent relaxed and talking at ease? Validity: am I measuring
what I think I am measuring? Is the answer obtained the correct
answer? Reality: Can I get the same answer on two separate
occasions (unless the respondent has changed eating habits)?
Slide 126
Standardization of interview techniques and of tools used in
analysis (and methods of use) is essential otherwise different
interviews will obtain different result.
Slide 127
Verbal communication skills
Slide 128
During the presentation of questions the following ideas should
be considered. You credibility in the eye of the patient will
increase if you demonstrate expertise and show concern and
dedication. Try to be forceful but not overbearing. Rapport is
increased if the patient perceives some similarity with you, eg.
Physical similarity- age, sex, race, ethnic features, dress,
dialect, etc.
Slide 129
However, hidden barriers may be set up by the lack of such
similarities, e.g. Young dietitian and older patient, slim
dietitian and fat patient. Rapport is also helped if you begin with
an aspect that the patient would want to hear.
Slide 130
Show by your manner that you are interested and that your
attention is uninterrupted. Your manners and your words should not
indicate shock or surprise at answer and should not imply criticism
or impatience towards what is being said.
Slide 131
You have the power to reinforce many behaviors of the patient.
It should be used judiciously, e.g. Attentive listening;
eye-contact; addressing the person by name; saying good, that is
interesting, reinforce specific behaviours.
Slide 132
Pause for a few seconds after the patient has apparently
finished and before more questions are asked, in order to give him
a chance to speak further. Remember that under normal circumstances
there is no time for the patient to be prepared and there is the
inevitable pressure of trying to provide a quick reply when an
interviewer is waiting for your answer!
Slide 133
Return to topics on which the patient froze in order to
determine if lack of response is significant. Avoid bringing the
patient abruptly back when he digresses. Use appropriate wording
for probing question to maintain a good relationship, e.g. I am
interested in what you are saying could you tell me more about
that?.
Slide 134
You could also adopt a questioning tone when repeating key
sentences of the patient to indicate that you want
elaboration.
Slide 135
Leave any personal or potentially embarrassing question as near
to the end as possible so that a good rapport has already been
established. At the end of the interview, thank the respondent and
give a positive indication of the usefulness of the interview.
Slide 136
DIET LABORATORY
Slide 137
Specific objectives Learn to use local foods to prepare
nutritious meals. Learn to combine foods in a number of ways to
constitute a variety of meals to avoid monotony in feeding any
group of people. Learn the equivalents measures of the weights of
different foods items.
Slide 138
To familiarise oneself with appropriate serving portion for the
various age groups in the family. Learn to use Food Composition
Tables to calculate the energy and nutrient contents of foods and
meals. Be able to evaluate the nutritional adequacy of daily.
Slide 139
Assessment 10% for the paper work 10% for practical work Total
= 20%
Slide 140
Uses Of The Composition Table The nutrients values are based on
quantitative analysis of the food samples so it is important that
they represent the average composition of typical foods. They are
useful in clinical practice can be used to assess nutritionally
related disease and to accurately prescribe diets containing known
amounts of nutrients. It can be used to determine the nutrients
adequacy of diets. It can be used to detect imitation or substitute
food
Slide 141
Limitations No food composition can represent the exact
composition of food that is eaten. For prepared dishes the recipe
used in the table might not be same as the person whose dietary
data you are collecting. If adequate sampling was not done during
compilation of the table, you end up with food samples that are not
representative. There could also be analytical errors in the
determination
Slide 142
Assignment Plan, prepare and serve a suitable breakfast, lunch
and supper for a 10-year old boy from Eastern region. Attempt to
meet the RDA and cost the meal. RDA for a 10- year old boy(FAO/WHO)
Energy 2200 Protein- 34 gm
Slide 143
Meal planning steps Select the staple food item Select the
vegetable that goes very well with the staple. Select a
protein-rich item Select a oil if necessary Determine quantities of
ingredients
Slide 144
Lunch jollof rice 2 slices of pawpaw List of ingredients Rice
-- 1kg---10GHC Fresh tomatoes ----500grams----- 2GHC Oil(peanut)
Onions Pepper Salt Smoked fish(salmon) Beef Weigh all ingredients
and their prices on a sheet of paper.
Globally, as of 2010, an estimated 285 million people had
diabetes, with type 2 making up about 90% of the cases. Its
incidence is increasing rapidly, and by 2030, this number is
estimated to almost double. Diabetes mellitus occurs throughout the
world, but is more common (especially type 2) in the more developed
countries.
Slide 148
The greatest increase in prevalence is, however, expected to
occur in Asia and Africa, where most patients will probably be
found by 2030. The increase in incidence in developing countries
follows the trend of urbanization and lifestyle changes, perhaps
most importantly a "Western- style" diet.
Slide 149
Definition Diabetes is a metabolic disorder characterised by
high blood glucose and either insufficient or ineffective
insulin.
Slide 150
Pathophysiology An understanding of the pathophysiology of
diabetes rests upon knowledge of the basics of carbohydrate
metabolism and insulin action. Following the consumption of food,
carbohydrates are broken down into glucose molecules in the gut.
Glucose is absorbed into the bloodstream elevating blood glucose
levels. This rise in glycaemia stimulates the secretion of insulin
from the beta cells of the pancreas. Insulin is needed by most
cells to allow glucose entry.
Slide 151
Insulin binds to specific cellular receptors and facilitates
entry of glucose into the cell, which uses the glucose for energy.
The increased insulin secretion from the pancreas and the
subsequent cellular utilization of glucose results in lowered of
blood glucose levels. Lower glucose levels then result in decreased
insulin secretion.
Slide 152
If insulin production and secretion are altered by disease,
blood glucose dynamics will also change. If insulin production is
decreased, glucose entry into cells will be inhibited, resulting in
hyperglycemia. The same effect will be seen if insulin is secreted
from the pancreas but is not used properly by target cells. If
insulin secretion is increased, blood glucose levels may become
very low (hypoglycemia) as large amounts of glucose enter tissue
cells and little remains in the bloodstream.
Slide 153
Following meals, the amount of glucose available from
carbohydrate breakdown often exceeds the cellular need for glucose.
Excess glucose is stored in the liver in the form of glycogen,
which serves as a ready reservoir for future use. When energy is
required, glycogen stores in the liver are converted into glucose
via glycogenolysis, elevating blood glucose levels and providing
the needed cellular energy source.
Slide 154
The liver also produces glucose from fat (fatty acids) and
proteins (amino acids) through the process of gluconeogenesis.
Glycogenolysis and gluconeogenesis both serve to increase blood
glucose levels. Thus, glyceamia is controlled by a complex
interaction between the gastrointestinal tract, the pancreas, and
the liver.
Slide 155
Multiple hormones may affect glycemia. Insulin is the only
hormone that lowers blood glucose levels. The counter-regulatory
hormones such as glucagon, catecholamines, growth hormone, thyroid
hormone, and glucocorticoids all act to increase blood glucose
levels, in addition to their other effects.
Slide 156
Classification There are three major types namely; Type 1 Type
2 Gestational diabetes
Slide 157
Type 1 Diabetes The underlying pathophysiologic defect in type
1 diabetes is an autoimmune destruction of pancreatic beta cells.
Following this destruction, the individual has an absolute insulin
deficiency and no longer produces insulin.
Slide 158
Autoimmune beta cell destruction is thought to be triggered by
an environmental event, such as a viral infection. Genetically
determined susceptibility factors increase the risk of such
autoimmune phenomena.
Slide 159
The onset of type 1 diabetes is usually abrupt. It generally
occurs before the age of 30 years, but may be diagnosed at any age.
Most type 1 diabetic individuals are of normal weight or are thin
in stature. Since the pancreas no longer produces insulin, a type 1
diabetes patient is absolutely dependent on exogenously
administered insulin for survival.
Slide 160
Type 2 Diabetes The underlying pathophysiologic defect in type
2 diabetes does not involve autoimmune beta-cell destruction.
Rather, type 2 diabetes is characterized by the following three
disorders: Peripheral resistance to insulin, especially in muscle
cells. Increased production of glucose by the liver. Altered
pancreatic insulin secretion..
Slide 161
Increased tissue resistance to insulin generally occurs first
and is eventually followed by impaired insulin secretion The
pancreas produces insulin, yet insulin resistance prevents its
proper use at the cellular level. Glucose cannot enter target cells
and accumulates in the bloodstream, resulting in hyperglycemia. The
high blood glucose levels often stimulate an increase in insulin
production by the pancreas; thus, type 2 diabetic individuals often
have excessive insulin production (hyperinsulinemia).
Slide 162
Over the years, pancreatic insulin production usually decreases
to below normal levels. In addition to hyperglycemia, type 2
diabetic patients often have a group of disorders that has been
called "insulin resistance syndrome" or syndrome X
Slide 163
Obesity contributes greatly to insulin resistance, even in the
absence of diabetes. In fact, weight loss is a cornerstone of
therapy for obese type 2 diabetic patients. Insulin resistance
generally decreases with weight loss. Obesity also may explain the
dramatic increase in the incidence of type 2 diabetes among young
individuals in the world in the past 10 to 20 years.
Slide 164
Once considered a disease of adults, type 2 diabetes has
increased among the youth in direct correlation with the increase
in the average weight of children and young adults during that time
period.
Slide 165
Gestational Diabetes Gestational diabetes occurs in
approximately 4% of pregnancies. It usually develops during the
third trimester and significantly increases perinatal morbidity and
mortality. The proper diagnosis and management of gestational
diabetes improves pregnancy outcomes.
Slide 166
As with type 2 diabetes, the pathophysiology of gestational
diabetes is associated with increased insulin resistance. Most
patients with gestational diabetes return to a normoglycemic state
after parturition; However, about 30 to 50% of women with a history
of gestational diabetes will develop type 2 diabetes within 10
years.
Slide 167
Impaired Glucose Tolerance and Impaired Fasting Glucose The
conditions known as Impaired Glucose Tolerance (IGT) and Impaired
Fasting Glucose (IFG) represent metabolic states lying between
diabetes and normoglyceamia. People with IFG have increased fasting
blood glucose levels but usually have normal levels following food
consumption. Those with IGT are normoglycemic most of the time but
can become hyperglycemic after large glucose loads.
Slide 168
IGT and IFG are not considered to be clinical entities; rather,
they are risk factors for future diabetes. The pathophysiology of
IFG and IGT is related primarily to increased insulin resistance
whereas endogenous insulin secretion is normal in most patients.
Approximately 30 to 40% of individuals with IGT or IFG will develop
type 2 diabetes within 10 years after onset.
Without sufficient insulin, glucose accumulates in the blood,
resulting in hyperglycemia. Normally, the kidneys retain glucose
rather than excrete it, but when blood glucose rises too high, the
excess spills into the urine (glucosuria).
Slide 172
High blood glucose creates an osmotic effect, drawing water
from the cells into the blood. Furthermore, as glucose spills from
the blood into the urine, water leaves with it. Thus both the
intracellular fluid and extracellular fluid become depleted, and as
a consequence, people with uncontrolled diabetes can become
severely dehydrated.
Slide 173
They produce excessive urine (polyuria) and being dehydrated
they may also experience excessive thirst (polydipsia). These are
early symptoms of diabetes.
Slide 174
Both types of diabetes deprive cells of fuels they need for
energy. Amino acids and glucose may abound in the body fluids, but
the cells have little access to them and therefore mobilize their
own protein and fat supplies for energy. They break down large
amounts of fatty acids, and liver responds by making ketones
bodies, which accumulates in the blood (ketonemia).
Slide 175
Ketones in the blood lower its pH because they contain acid
groups in their their structure. Ketones may begin to appear in the
urine (ketonuria) In addition, sodium and potassium become depleted
because the kidneys excrete them along with ketones. The loss of
sodium and potassium, both base formers, worsens the acidosis. When
acidosis becomes severe enough, a potential fatal coma may
follow(diabetic coma or insulin shock).
Slide 176
Losses of glucose and ketone bodies(both energy sources) in the
urine, and protein breakdown, leads to weight loss. The person with
IDDM is likely to be thin and may eat excessively(polyphagia).
Slide 177
Risk factors Family history Obesity Lack of exercise Poor diet
Excess consumption sugar-sweetened drinks Saturated fats
Monounsaturated and polyunsaturated Urbanization Stress
Slide 178
Diagnosis Condition2 hour glucose mmol/l(mg/dl) Fasting blood
glucose mmol/l(mg/dl) Normal