Common Food Additives

A list of food additive categories appears in Table 18-2. Some serve the general function of preventives: acidic or alkaline agents, antioxidants, antimicrobial agents, curing and pickling and sequestrants. Lets look at some of the specific categories of additives to understand exactly why these are used and to learn more about the specific substances employed. ACIDIC OR ALKALINE AGENTS Acids, such as calcium lactate, have many uses in foods. As flavor-enhancing agents, they impact a tart taste to soft drinks, sherbets, and cheese spreads, for example. As preservatives, they inhibit microbial growth. As antioxidants, they prevent discoloration and rancidity. They also adjust acid and base balance. Adding acids during food processing reduces the risk of botulism from eating naturally low-acid vegetables, such as beets. Table 18-2 Food additive categories Anticaking agents Anti microbial agents Antioxidants Color and adjuncts Conditioners Curing and pickling Dough strengtheners Drying agents Emulsifiers Enzymes Firming agents Flavor enhancers Flavoring agents Flour treating Formulation aids: carriers, binders, fillers, plasticizers Fumigants Humectants Leavening Lubricants and release agents Nonnutritive sweeteners Oxidizing and reducing agents pH control Processing aids: clarifying, clouding catalyst, flocculants, filter aid, crystallization inhibitors Propellants Sequestrants Solvents and vehicles Stabilizers and thickeners Surface active agents Surface-finishing agents Synergists Texturizers

Alkaline products, such as sodium hydroxide, can alter the texture and flavor of foods, including chocolate. In processing, alkaline products are sometimes used to produce a milder flavor by neutralizing the acids produced during fermentation. ALTERNATIVE SWEETENERS Currently saccharin and acesulfame (Sunette) are the only nonnutritive sweeteners used in foods. Because aspartame (Nutrasweet) yields energy, it is considered a nutritive sweetener (see chapter 3). Saccharin is carcinogenic to rats when administered over two generations. The cancers found primarily in the bladder. However, population studies of humans have not found an public demanded the availability of saccharin for exposure to saccharin. The American public demanded the availability of saccharin for diet soft drinks even after reports of the came out. As noted in Chapter 3, Congress has prevented FDA from banning saccharin, due to this public demand. Still, a cancer-warning label must appear on any product that contains saccharin. This thus is one of the exceptions to the Delaney Clause. ANTICAKING AGENTS By absorbing moisture, compounds such as calcium silicate, ammonium citrate, magnesium stearate, and silicon dioxide keep table salt, baking powder, powdered sugar, and other powdered

food products free flowing. These chemicals prevent the caking and lumping that would make powdered or crystalline products hard to use. ANTIMICROBIAL AGENTS Sodium benzoate, sorbic acid, and calcium propionate are common preservatives. Sorbic acid is a potent inhibitor of molds and fungal growth. Calcium propionate, a natural part of some cheeses, inhibits mold growth. ANTIOXIDANTS This type of food preservative helps delay food discoloration from oxygen exposure, such as occurs when potatoes are diced. It also helps keep fats from turning rancid. Two widely used antioxidants are BHA (butylated hydroxyanisole) and BHT (butylated hydroxytoluene). Vitamin E and related compounds also serve as antioxidants. Sulfites, a group of sulfur-based chemicals, are widely used as antioxidants in foods. Some people (1 in 100 according to FDA estimates) are extremely sensitive to sulfites and may have difficulty breathing wheeze, and vomit, as well as develop hive, diarrhea, abdominal pain, cramps, and dizziness. As a result, FDA now limits the use of sulfites on raw fruits and vegetables-an action directed mainly at salad bars. FDA also requires manufactures to declare the presence of sulfites on labels of packaged foods containing at least 10 parts per million of sulfites. Labels on wine bottles often list a sulfite warning. COLORS Color additives dont improve nutritional qualities, but they can make foods more visually appealing. Food coloring cannot be used to deceive consumers-for example, by covering blemishes, concealing any inferiority, or misleading people in any way. Although coloring are arguably unnecessary additives, manufactures have satisfied FDA that color is necessary for the production of certain foods. Controversy has surrounded the use of some food colors. Currently the safety of using tartrazine (FD&C yellow No.5) is disputed. It has caused allergic symptoms-such as hives, itching, and nasal discharge-in sensitive individuals, especially in people allergic to aspirin. Although few Americans are sensitive to tartrazine, FDA requires manufacturers to list FD&C yellow No. 5 on labels of food products containing it. Some red dyes have also raised alarms, and some have been banned. Currently FDA requires manufacturers list all forms of synthetic colors on the labels of foods that contain them. Pigments extracted from plant sources are exempted from specific description on food labels. CURING AND PICKLING AGENTS Nitrates and the related form, nitrites, are used as preservatives, especially to prevent growth of Clostridium botulinum. Sodium and potassium nitrates and nitrates are used to preserve meats such as bacon, ham, salami, and hot dogs. Nitrates and nitrites have been used for centuries, in conjunction with salt, to preserve meat. An added effect of nitrates is their reaction with pigments in meat to form a bright pink color. This gives ham, hot dogs, and other cured meats their characteristic appearance. Nitrate consumption from both cured foods and natural vegetables has been associated with the synthesis of nitrosamines in the stomach. Some nitrosamines are cancer-causing agents, particularly for the stomach and esophagus. The actual risk appears to be low, however, except for people who secrete little stomach acid (some older people, for example). A slightly increased risk for childhood leukemia and brain tumors is also suspected, but the data are preliminary. FDA surmises that consumers take for granted a margin of microbial safety gained from nitrite use in cured meats. People often serve these meats cold or at least under heated. Consequently, government agencies have chosen not to ban nitrate or nitrite use in foods but rather to change manufacturing practices to lower amounts of performed nitrosamines and suggest

moderation in the use of these food products. Since 1975 there has been an 80% decrease in the amount of nitrites in cured meats. The addition of vitamin C (sodium ascorbate) to cured meats, such as bacon, is one way to reduce the amount of nitrosamines formed in foods. This is a common manufacturing practice today. Other antioxidants, such as sodium erythrobate, also inhibit synthesis of nitrosamines. EMULSIFIERS By distributing and suspending fat in water, these products improve the uniformity, smoothness, and body of foods such as baked goods, ice cream, and candies. In mayonnaise, for example, egg yolks act as emulsifiers in holding together the oil and the acid, such as vinegar or lemon juice. Lecithin, derived from soybeans, acts as an emulsifier in chocolate and margarine. Monoglycerides and diglycerides, found also as by products of fat digestion, are used as emulsifier in cake mixes. FAT REPLACEMENT Fat replacement such as Paselli SA2, Dur-Low, Oat rim, and Sta-Slim 143-are being produced for commercial use. These carbohydrate-based products are an addition to other players Simplesse and Olean- discussed in Chapter 4. FLVOURS AND FLAVORING AGENTS Both naturally occurring and artificial agents can impart more flavors to foods. These agents include extracts from spices and herbs, as well as synthetic agents. You have probably recognized flavors of some spices and of liquid derivatives of onion, garlic, cloves, and peppermint in foods. To meet the demand of industry, manufacturers have developed synthetic flavors that not only taste like natural flavors but also have the advantage of stability. Often artificial flavors, such as butter and banana flavors, have the same chemical composition as the natural flavor. FLAVOR ENHANCERS Flavor enhances are substances such as monosodium glutamate (MSG) that help bring out the natural flavors of foods. Note that the glutamate portion is simply a nonessential amino acid. A small percentage of people are sensitive to the glutamate portion in MSG and, after exposure, experience flushing, chest pain, facial pressure, dizziness, sweating, rapid heart rate, nausea, vomiting, high blood pressure, and headache. MSG is often used in Chinese food. The onset of symptoms occurs about 10 to 20 minutes after ingestion and may last from 2 to 3 hours. People who find themselves sensitive to MSG should avoid it. It may be present alone (look for the word glutamate), as well as in any isolated protein source (caseinate, texturized vegetable protein, etc.), yeast extract, bouillon, soup stock, and seasonings. Tomatoes, mushrooms, and Parmesan cheese are also source of free glutamate. Fortunately, most of us find that moderate use of MSG or glutamate in foods poses no significant risk to our health. FAD is currently contemplating label requirements for MSG. HUMECTANTS These chemical- such as glycerol, propylene glycol, and sorbitol- are added to foods to help retain proper moisture, fresh favor, and texture. They are often used in candies, shredded coconut, and marshmallows. LEAVENING AGENTS Air and steam can be used to create a light texture in breads and cakes; however carbon dioxide bubbles are much more reliable for this purpose. Common leavening agents that produce carbon dioxide gas include yeast, baking powder and baking soda. Baking soda must react with acids to generate carbon dioxide. Baking powder can be used in either acid or alkaline conditions.

MATURING AND BLEACHING AGENTS Such compounds as bromates, peroxides, and ammonium chloride hasten the natural aging and whitening process of milled flour. This shortens the time needed for flour to become usable in baking products. Without these agents, freshly milled flour lacks the qualities necessary to make a stable, elastic bough and requires several months to be useful in baking. NUTRIENT SUPPLEMENTS Vitamin and mineral supplements are added to foods to improve their nutritional quality. Sometimes they replace nutrients lost in processing, as occurs when enriching flour. Vitamin A is added to margarine and some forms of milk

DIABETES MELLITUS
Characterized by inability to metabolize CHO due to deficiency of insulin the metabolism of proteins & Fats is also affected. Diabetes means to run through or to siphon, mellitus means honey like. Diabetes has been defined as a genetically and clinically hetrogenous group of disorders all of which show glucose intolerance. It is partially or total lack of functioning insulin and alterations in CHO, Protein & Fat metabolism. The insulin defect may be a failure in to formation, liberation or action. Insulin is produced by the beta cells of the islets of langerhans, any reduction in the number of functioning cells will decrease the amount of insulin that can be synthesized. Many diabetics need stimulus to the islet tissue that the secretion can take place. The hormones of the anterior pituitary adrenal cortex, thyroid and alpha cells of the islet of langerhans are glucogenic (increase the supply of glucose). Blood glucose is controlled by two harmones from the beta cells of pancreas (insulin) which lowers blood sugar, and glucagon which raises it. A third harmone somatostain regulates the secretion of these two harmones. The sources of blood glucose are: 1. CHO 1005 digestible CHO converted to glucose. 2. 58% of protein converted to glucose. 3. Fats 10% converted to glucose. 4. Glycogen (livers emergency supply of CHO) converted to glucose when other sources are used up. Muscle tissue also contain glycogen that may be used emergencies. Treatment and diet therapy: the general classification is of two major types. Type I : IDDM (Insulin Dependent Diabetes Mellitus) Type II: NIDDM (Non-insulin Dependent Diabetes Mellitus) Type I: Most sever form of diabetes occurring most often in childhood or young adulthood. It may be or may not be an inherited trait. Recent research indicates that islet cells of the pancreas may have been damaged. Various genetic and environmental or acquired factors have been implicated. Factors: 1. Altered frequency of certain human lymphocyte antigens (HLA) on chromose 6. 2. Abnormal immune responses. 3. Auto immunity. 4. Islet cell antibodies. In some cases viral infections diseases such as measles or mumps may trigger the autoimmune response. Type II Genetic as well as environmental factors. Obesity may precipitate the disease the onset is slow. Some endogenous insulin is still produced. Obesity, physical in activity and hypertension are strong risk factors. The symptoms are similar to IDDM except there is no weight loss and very rarely retoacidosis. NIDDM is a milder form of diabetes and is most often controlled with weight. loss and an exercise programme. Occasionally an oral hypoglycemic drug will be necessary. Person with NIDDM have a high incidence of atherosclerosis making it advisable to counsel fat intake as well as reduced calories. As diabetics are living longer, there is an increased risks of developing major complication such as kidney disease, vascular disease, nerve impairment and disease of the retina. In fact 20% of the diabetic population become blind. Fluctuations of blood glucose from uncontrolled diabetes are thought to be one important factor in the onset of these conditions. Gestational Diabetes: This class includes women who developed glucose intolerance during pregnancy. Known diabetics who become pregnant are excluded from this class. Complex harmonal and metabolic changes are involved in the etiology and insulin resistance may play a part.

Clinical Characteristics: IDDM (Type I) is characterized by an absolute definition of endogenous insulin & prone to ketosis. Onset is abrupt (juvenile). They manifest the classic symptoms of diabetes. i) Polyuria- frequent urination and abnormally large volume of urine. ii) Polydipsia- excessive thirst. iii) Polyphagia- an increased appetite. Ketosis accumulation of lower fatty acids in the blood leads to the excretion of ketones in the urine ketonuria is accompanied by dehydration, acidosis & then coma. Type II NIDDM Do not depend on exogenous insulin. Not ketosis prone. Onset is generally after 40 years, 80% patients are obese. LAB STUDIES 1. Several tests are used in the diagnosis of diabetes. The test is done in the morning after 3 days of a diet containing 150g CHO. The subject should be empty stomach for 10-16 hours. A fasting sample is drawn after which a weighed amount of glucose is given. Glucose does is 75gm non-pregnant adult, children 1.75g 1kg of ideal weight. Blood samples are taken at , 1, 1 & 2 hours after ingestion of glucose. Diabetes is present if both the 2 hours. Glucose concentration and an intermediate value exceed the 80mg/ deciliter. 2.Glycosuria- the presence of an abnormal amount of sugar in the urine. 3.Hyperglycemia- A fasting plasma glucose of more than 140mg/ deciliter is suggestive of diabetes. Metabolism in Diabetes When insulin is not being produced or is ineffective, the formation of glycogen is decrease and the utilization of glucose in the peripheral tissues is reduced. As a consequence glucose is removed more slowly and hyperglycemia follows. Further accentuated by gluconeogenesis through which 58% of Protein 10% of Fat molecule can yield glucose. When the blood glucose level exceeds the rental threshhold 180mg / 100ml glycosuria occurs. The loss of glucose in the urine represents a wastage of energy and entails an increased elimination of water and sodium. With a deficiency of insulin lipogenesis decrease and lipolysis is greatly increased. The fatty acids released from adipose tissue or available by absorption from the intestinal tract are oxidized by the liver to form ketone bodies including acetoacetic acid, B hydroxybutric acid and acetons. The liver utilizes only limited quantities of the ketones and releases them to the circulation. In diabetes the ketones are produced at a rate that for exceeds the ability of the tissues to utilize them & concentration in the blood is increased. Acetone is excreted by the lungs gives the characteristics fruity odour to the breath. Acetoacetic acid & B hydroxybutyric acid are excreted in the urine. **** Being fairly strong organic acids these ketones combine with base so that the alkaline reserve is depleted and acidosis results. The accompanying dehydration leads to circulatory failure, renal failure and coma.

The rapid release of fatty acids into the blood circulation often result in hyperlipemia. The blood cholesterol are usually increased because of increased synthesis or decreased destruction by the liver. The development of atherosclerosis occurs in early age.

Muscle protein catabolism is accelerated thus amino especially alanine are released. Protein catabolism also increases the amount of Nitrogen that must be excreted as a result of deaminization. This is accompanied by the release of cellular potassium and its excretion in the urine. Rational for Dietary Management: 1. Improve the overall health of the patient by attaining and maintaining optimum nutrition. 2. To maintain the ideal body weight. 3. To provide for normal physical growth in the children and for adequate nutrition during pregnancy & location. 4. To maintain the plasma glucose as near the normal physiologic range as possible. 5. To prevent or delay the development of chronic complications of diabetes cardiovascular, renal, & neurologic. 6. To make the diet prescription as attractive and realistic as possible. NUTRITIONAL NEEDS Basic nutrition requirements will be determined by several factors. Some of the guidelines used are physical assessment health and diet histories and lab reports. Psychological aspects also help to determine diet prescription. NUTRIENT BALANCE * In the most widely used diabetic diets daily CHO intake provides 50-55% of the daily caloric requirement. * Protein of high biological value is stressed for diabetic diets especially for children and adolescents. * Protein provides 15 to 20% of the daily caloric intake. * Emphasis is placed on using poly-unsaturated fats & limiting cholesterol in the remaining 30% of permitted for dietary fat. * Example 2000 kcal, Protein 20%, 100g CHO 50% 250g fats 30% 66gms. Alcohol if at all is used, it is usually substituted for fat in the diet / alcohol 1ml gives 7 calories. Caloric requirement daily caloric need includes basal metabolism, activity rate and physiological stress/ growth, spurt or pregnancy. * If the patient is overweight, the caloric range is usually 1200 to 1500 cal/day. * For a growing patient it could be 3000 calorie. * Complex CHO Containing good amounts of fiber are stressed when menu planning is done. * Use of lean protein foods and very little animal is recommended. There are many ways to calculate daily caloric need for a diabetic patient. * Basal energy needs are generally figured at 1 kcal body weight / hour. * To this is added activity energy needs.

One technique is as follows: * Patients desirable weight = DW kg * Caloric need for sedentary patient = DW* 20-25 kcal / kg

* Caloric need for light activity = DW* 30 kcal / kg * Caloric need for patient with strenuous activity = DW* 35 kcal / kg * Total caloric need for obese or elderly patient = DW kg* 15-25 kcal / kg. For children Up to 1 year 1-10 years Adolescence Male: 11-15 years 16 20 years 120 kcal / kg of body weight. 100-80 kcal / kg declines as age increases. 65 kcal / kg. b.w 50 kcal / kg / high activity 40kcal / kg light activity 30 kcal / kg sedentary average 35 kcal / kg b.w average 30 kcal /kg b.w

Female: 11-15 years 16-up years

After the patients daily caloric need is determined the physician will prescribe the % of these calories from CHO, fats & proteins. Then the permitted weight of these three nutrients can be calculated. Depending on the need for insulin infections, oral drugs, activity or a combination of these, a meal-pattern is charted. Large amounts of food especially CHO should be avoided. A diabetic patient should have regular meal hours to avoid fluctuation in blood glucose. Using insulin preparations and oral hypoglycemic agents (OHA) or diabetic pills.

FOOD EXCHANGE LIST * The exchange system of dietary control is used to manage the diet of a Diabetic patient. * This permits flexibility in planning and preparation and allows measuring instead of weighing. * Offer variety of food choices * Starch list, Meat list, Milk list, Vegetable list, Fruit list of exchanges are charted out and explained to the patients. Refer exchange list G Peggy Caring for a diabetic child A. Dietary Characteristics i) Patient may be normal or under weight. ii) Onset of disease abrupt, increase in severity during growth periods. iii) Child is insulin dependent iv) As patient grows older, the requirement for insulin increases. B. Dietary treatment goals i) To permit normal growth and activity. ii) To control the disease. iii) To permit a normal school & social life iv) To correspond with the action of insulin treatment. C. Diet prescription i) 75-90 kcal / kg of childs ideals weight. ii) 3.3 to 2.2g of protein 1 kg body weight with decreasing amounts for increasing age.

iii) iv) v)

50% of total calories from complex carbohydrate, 20% from protein, 30% fat. Three meals and three snacks daily. Meal pattern coordinated with activities.

Dietary counseling: The diabetic patient needs to know. i) The nature of diabetes and the reasons for the measures that will be recommended. ii) importance of control. iii) The details of the dietary program. vi) The amounts, time intervals and methods of administration of insulin or oral drugs. v) Skin care and personal hygiene. vi) procedures for testing the urine. vii) Signs of hypoglycemia or acidosis & what steps to take in the event they occur. viii) Emergency measures to take during infection and illness until medical help is available. ix) The importance of periodic visits to the physician. Responsibility for education Physician, nature & dietician share the responsibility. In the hospital or outpatient clinic the dietitian usually initiates dietary instruction and continuing program of education. Individualized instruction which may be supplemented by group instruction. Each member of the family needs to understand that the diet for the diabetic patient is essentially a normal one. A diabetic diet should be prescribed accordingly to the income of the patient. Meal pattern & Sample Menu (1800 kcal) Breakfast Skim milk cup Orange 1 Toast 1 slice Butter 1teaspoon Mid day Lime juice Water melon 200gms Lunch Chicken 60g Chapati 2 Mixed vegetable 120g Salad 100g Fruit 1 No. Tea Open sandwich (1 Slice) Butter 5g Cucumber Coffee (skim milk) 1 cup Dinner Fish 60g Chapatties 2 Mixed vegetables Salad Fruit After dinner Skim milk 1 cup Acute complications of diabetes 1. Hypoglycemia 2. Diabetic Acidosis & coma

Hypoglycemia: insulin shock is caused by an overdose of insulin, a decrease in the available glucose because of delay in eating, omission of food, or loss of food by vomiting and diarrhea, or increase in exercise of the insulin dosage. Orange juice or any other fruit juice, sugar, candy, syrup, honey, carbonated beverage or any readily available carbohydrate may be given. Diabetic Acidosis & Coma Is a state of severe insulin deficiency characterized by hyperglycemia, acidosis and elevated blood ketones, which may progress to coma. Patient consumed additional foods failed to take correct amount of insulin or omitted it entirely. Diabetes first detected until coma occurred Infection Trauma, surgery aggravates. Small of insulin are given together with small carbohydrate feedings. Saline infusions for the correction of dehydration, alkali therapy for the correction of the severe acidosis. Patient can be given fruit juices, broths, gruel, ginger ale, tea, coffee etc. Chronic complications of Diabetes 1. Large vessel disease (atherosclerosis of the coronary and cerebral arteries) 2. Small vessel disease- generalized thickening of the capillary in long standing diabetes. Retinopathy (cataract, blindness) nephropathy (hypertension, albuminuria, edema). 3. Neuropathy- peripheral nerve dysfunction is common in diabetes. Large vessel complications are related to obesity and abnormal lipid metabolism, whereas small vessel disease and neuropathy are more closely related to hyperglycemia. Control of blood glucose level have a favorable effect in decreasing the latter type of complications. Special situations: 1. Surgery 2. Infection 3. Pregnancy 1. Surgery: ideally, the diabetic patient should have normal blood sugar, no glycosuria and no ketosis. Carbohydrate feeding should begin with in 3 hours, liquids (tea, coffee, orange juice) full or soft diet. 2. Infection: an infection lowers the carbohydrate tolerance and increases the insulin requirement, a mild diabetic may become a severe case, and infections may precipitate coma. 3. Pregnancy: a) Diabetes increases the hazards of pregnancy because of the dangers of glycogen depletion, hypoglycemia, acidosis and infection. b) Emphasis should be on control rate of weight gain and the prevention of edema. c) Insulin requirements are usually increased. d) Most diabetic women are unable to produce enough milk. ***************************

Common Food Additives : ACIDIC OR ALKALINE AGENTS Acids, such as calcium lactate, have many uses in foods. As flavor-enhancing agents, they impact a tart taste to soft drinks, sherbets, and cheese spreads, for example. As preservatives, they inhibit microbial growth. As antioxidants, they prevent discoloration and rancidity. They also adjust acid and base balance. Adding acids during food processing reduces the risk of botulism from eating naturally low-acid vegetables, such as beets. Alkaline products, such as sodium hydroxide, can alter the texture and flavor of foods, including chocolate. In processing, alkaline products are sometimes used to produce a milder flavor by neutralizing the acids produced during fermentation. ALTERNATIVE SWEETENERS Currently saccharin and acesulfame (Sunette) are the only nonnutritive sweeteners used in foods. Because aspartame (Nutrasweet) yields energy, it is considered a nutritive sweetener (see chapter 3). Saccharin is carcinogenic to rats when administered over two generations. The cancers found primarily in the bladder. ANTICAKING AGENTS By absorbing moisture, compounds such as calcium silicate, ammonium citrate, magnesium stearate, and silicon dioxide keep table salt, baking powder, powdered sugar, and other powdered food products free flowing. These chemicals prevent the caking and lumping that would make powdered or crystalline products hard to use. ANTIMICROBIAL AGENTS Sodium benzoate, sorbic acid, and calcium propionate are common preservatives. Sorbic acid is a potent inhibitor of molds and fungal growth. Calcium propionate, a natural part of some cheeses, inhibits mold growth. ANTIOXIDANTS This type of food preservative helps delay food discoloration from oxygen exposure, such as occurs when potatoes are diced. It also helps keep fats from turning rancid. Two widely used antioxidants are BHA (butylated hydroxyanisole) and BHT (butylated hydroxytoluene). Vitamin E and related compounds also serve as antioxidants. Sulfites, a group of sulfur-based chemicals, are widely used as antioxidants in foods. Some people (1 in 100 according to FDA estimates) are extremely sensitive to sulfites and may have difficulty breathing wheeze, and vomit, as well as develop hive, diarrhea, abdominal pain, cramps, and dizziness. COLORS Color additives dont improve nutritional qualities, but they can make foods more visually appealing. Food coloring cannot be used to deceive consumers-for example, by covering blemishes, concealing any inferiority, or misleading people in any way. Colours make food more visually appealing spinach juice, marigold flower, cochineal were used to get green, yellow & red color. Synthetic dyes are obtained from coal tar red pigment in Bixa Orelana, lipstick pod plant of South American Origin. Used for Annattodye a yellow to red coloring material extracted from the orange red pulp of the seeds Annatto coloring matter on butter, cheeses margarine. Caroline Carrots yellow color. Saffron, turmeric, Natural red color cochineal (Carcum) obtained by extraction from the female insect (Coccus Cacti) CURING AND PICKLING AGENTS Nitrates and the related form, nitrites, are used as preservatives, especially to prevent growth of Clostridium botulinum. Sodium and potassium nitrates and nitrates are used to preserve meats such as bacon, ham, salami, and hot dogs. Nitrates and nitrites have been used for centuries, in conjunction with salt, to preserve meat. An added effect of nitrates is their reaction with pigments in meat to form a bright pink color. This gives ham, hot dogs, and other cured meats their characteristic appearance.

Nitrate consumption from both cured foods and natural vegetables has been associated with the synthesis of nitrosamines in the stomach. Some nitrosamines are cancer-causing agents, particularly for the stomach and esophagus. The actual risk appears to be low, however, except for people who secrete little stomach acid (some older people, for example). A slightly increased risk for childhood leukemia and brain tumors is also suspected, but the data are preliminary. EMULSIFIERS By distributing and suspending fat in water, these products improve the uniformity, smoothness, and body of foods such as baked goods, ice cream, and candies. In mayonnaise, for example, egg yolks act as emulsifiers in holding together the oil and the acid, such as vinegar or lemon juice. Lecithin, derived from soybeans, acts as an emulsifier in chocolate and margarine. Monoglycerides and diglycerides, found also as by products of fat digestion, are used as emulsifier in cake mixes. FLAVORS AND FLAVORING AGENTS Both naturally occurring and artificial agents can impart more flavors to foods. These agents include extracts from spices and herbs, as well as synthetic agents. You have probably recognized flavors of some spices and of liquid derivatives of onion, garlic, cloves, and peppermint in foods. To meet the demand of industry, manufacturers have developed synthetic flavors that not only taste like natural flavors but also have the advantage of stability. Often artificial flavors, such as butter and banana flavors, have the same chemical composition as the natural flavor. FLAVOR ENHANCERS Flavor enhances are substances such as monosodium glutamate (MSG) that help bring out the natural flavors of foods. Note that the glutamate portion is simply a nonessential amino acid. A small percentage of people are sensitive to the glutamate portion in MSG and, after exposure, experience flushing, chest pain, facial pressure, dizziness, sweating, rapid heart rate, nausea, vomiting, high blood pressure, and headache. MSG is often used in Chinese food. The onset of symptoms occurs about 10 to 20 minutes after ingestion and may last from 2 to 3 hours. People who find themselves sensitive to MSG should avoid it. It may be present alone (look for the word glutamate), as well as in any isolated protein source (caseinate, texturized vegetable protein, etc.), yeast extract, bouillon, soup stock, and seasonings. Tomatoes, mushrooms, and Parmesan cheese are also source of free glutamate. Fortunately, most of us find that moderate use of MSG or glutamate in foods poses no significant risk to our health. HUMECTANTS These chemical- such as glycerol, propylene glycol, and sorbitol- are added to foods to help retain proper moisture, fresh favor, and texture. They are often used in candies, shredded coconut, and marshmallows. ANTICAKING: Calcium silicate, magnesium citrate, magnesium stearate silicon dioxide keep salt, backing powder, and powdered sugar free flowing. LEAVENING AGENTS Air and steam can be used to create a light texture in breads and cakes; however carbon dioxide bubbles are much more reliable for this purpose. Common leavening agents that produce carbon dioxide gas include yeast, baking powder and baking soda. Baking soda must react with acids to generate carbon dioxide. Baking powder can be used in either acid or alkaline conditions. MATURING AND BLEACHING AGENTS Such compounds as bromates, peroxides, and ammonium chloride hasten the natural aging and whitening process of milled flour. This shortens the time needed for flour to become usable in baking products. Without these agents, freshly milled flour lacks the qualities necessary to make a stable, elastic dough and requires several months to be useful in baking. NUTRIENT SUPPLEMENTS Vitamin and mineral supplements are added to foods to improve their nutritional quality. Sometimes they replace nutrients lost in processing, as occurs when enriching flour. Vitamin A is added to margarine and some forms of milk.

******

Cardiovascular Disorders Atherosclerosis: Thickening of the inside walls of arteries by

deposits of fat or cholesterol substances (plaques) Cardiovascular: relating to the heart and blood vessels. Cerebrovascular : When the blood vessels in the brain are deprived of oxygen by an obstruction (occluded). This may be due to plaque formation, blood clot (thrombus), aneurysm (rupture of the blood vessel). Absence of oxygen to the brain tissue for more than 5-6 minutes leads to irreversible cerebral changes, commonly called a stroke. Coronary: encircling Coronary: Closing off a coronary artery- most often caused by the plaques of Atherosclerosis.

Coronary heart disease (CHD): Coronary arteries supply all the blood to the heart muscle. Occlusion deprives it of its nutrients and causes death to the part of heart muscle. Myocardial Infarction: Death of tissue of an area of the heat muscle as a result of oxygen deprivation, which in turn was caused by an obstruction of the blood supply commonly referred to as a heart attack . Angina pectoris: Tight pressing, burning and sometimes severe pain across the chest that follows exertion that is a result of inadequate oxygen to the myocardium. Hyperlipidemia: The presence of abnormally large amounts of lipids, circulating in the blood, includes elevated LDL & blood triglycerides & low HDL. Ischemic Heart Disease: Ischemic heart disease may occur at any age, but most common over 45 years. Except those who have hypertension or diabetes mellitus 1HD is not common in women until after the menopause. A disturbed hormonal balance is believed by some to be the key factor underlying Ischemic heart disease. Multiple risk factors: Elevated serum cholesterol Elevated serum triglycerides Obesity Hypertension Poor eating habit & sedentary life style. Cigarette smoking Family history of early hearty disease. Myocardial Ischemia is a cardiac disability resulting from an inadequacy of the coronary arterial system to meet the needs of the heart muscle for oxygen nutrients. I. Myocardial infarction: a) An infarct is a localized area of necrosis that results when the supply of blood to that area is inadequate for cellular survival. b) If the infarct is small, the remainder of the organ can function. c) The functional capacity of the organ is curtailed to the extent that that tissue has been lost, thus repeated myocardial infarction continue to reduce the functional capacity of the heart. II. Angina Pectoris: Pain across the chest. As the coronary arteries become increasingly occluded, the pain develops with less and less exertion. III. Atherosclerosis: disease of the blood vessels resulting from the interaction of multiple factors (heredity, diet, activity, smoking life-style) a) Athromatous plaques begin as soft mushy accumulation of lipid material in the blood vessel. b) These plaques consist of proliferation of the blood vessel wall of connective tissue into which lipids are deposited. c) It develops gradually with increasing thickening of the arterial wall, loss of elasticity and narrowing of the lumen. d) Finally some event brings about Occlusion of the vessel and Ischemia of the affected part. e) Myocardial infarction are due to Atherosclerosis of the major coronary arteries, but many people with Atherosclerosis do not develop clinical disease. f) The reason about occlusion is under study- may be it is because of ulceration of atheroma and hemorrhage into the lumen with clot formation. g) The anatomic location of the atheroma, the extent to which the lumen has been narrowed, the changes in the blood lipids. Blood Studies related to coronary disease: 1. Total Cholesterol 200mg/ dl.

Over 240mg/ dl.- Abnormal Level 2. High Density lipoprotein 35mg/ dl. under this level 3. Ratio of total Cholesterol & High density lipoprotein 4:1 Iriglyceride 100-150mg/ dl. Total LDL = Total Cholesterol HDL - treglycerides 5 = 130 160 mg/ dl. Total cholesterol is a good indicator for people less than 50 years of age. For people above 50 years HDL & total cholesterol are the best indicator. (4:1) ratio. Low levels of HDL increase risk of heart attack. Serum LDL can be altered by dietary changes particularly in cholesterol and saturated fat intake. Serum triglycerides levels increase taking carbohydrates like suppose & fructose. Hyperlipoproteinemia Types of I toV Some hyperlipoprotenemias are induced by an excess of endogenous or exogenous fat, others by an intolerance to carbohydrates, especially sugars. Some others influenced by dietary cholesterol. Could be hereditary or by the intake of abnormal diet. frequently associated with diabetes mellitus. Xanthomas (tumors) are frequent in Type I & Type V abdominal pain and acute pancreatitis. In all types diet is the primary therapy. Type I. extremely high triglceride con , serum cholesterol being normal to high. There is an inability to clear the chilomicrons from the blood due to genetic deficiency of lipoprotein lipase. May be associated with diabetes diet is very low in fat 25 to 35gm daily for adults and 15gm for children. Cholesterol is not restricted. CHO is not make up the calories alcohol is contraindicated because it increases serum triglycerides levels when it is metabolized. Type II. decreased clearance of low density lipoprotein causes increased serum cholesterol levels. VLDL and triglycerides are normal in Type II(A). This type is a common heredity disorder (detected in first year of life). Type (B) cholesterol and triglycerides are both elevated. Calories are not restricted in Type II A but weight reduction is often indicated in Type II B. Cholesterol 300mg, CHO limited, alcohol used with discretion. Type III. Relatively uncommon increase in intermediate density lipoprotein (IDL). Overproduction of VLDL or inhibition of its conversion to LDL. Both serum cholesterol and triglycerides are elevated. Incidence of vascular disease is increased. Lesions on elbows, knees and buttocks are common. Calorie restricted, fat & CHO 40% cal Cholesterol 300mg/ day. Type IV. Very common pattern increase in VLDL, triglycerides elevated, serum cholesterol is normal. Abnormal glucose tolerance, hyper uricemia. Reduction in Calories, CHO 45%, Cholesterol 300-500mg/ day. Type V. Chylomicrons and VLDL are elevated, associated with diabetic acidosis, nephrosis, alcoholism and obesity. The liver and spleen may be enlarged abdominal pain is common. Calorie restriction, fat 25 to 30% cholesterol 300 500mg, CHO not more than 50% protein 20% to 25%. Sweet and alcohol contraindicated. Dietary modification: 1. Calories obesity, Reduction in calories 2. Fats saturated to unsaturated (Saturated fats 7-10% 1:1 or 1:2) 3. Cholesterol 300mg 1 day 4. Include dietary soluble fibers like pectins, gums which will lower serum cholesterol. 5. Soy protein is also hypocholestremic. 6. Habitual high salt intake increase the risk of hypertension.

7. Higher concentration of calcium and magnesium has protective effect. 8. Copper deficient diet showed significant increase in plasma cholesterol. Attention in copper balance are associated with irregularities in electrograms. 9. Pharmacologic does of zinc lowered HDL levels, thus increasing the risk of cardiovascular disorders. 10. Spaced meals frequency can reduce LDL. 11. Unfiltered coffee increases LDL 12. Iron supplements increase LDL 13. Fish contains omega- 3 fatty acids which reduce blood clothing. 14. Quercetin found in plants and related substances found in tea may reduce LDL. 15. Garlic 1 clove a day lower LDL by affecting cholesterol metabolism in the liver. 16. Vitamin E reduces cholesterol synthesis in the liver. 17. red wine- phenolic substances in the red wine may act as antioxidants and in turn reduce LDL 18. Monounsaturated oils like canola oil & olive oil have the same effect as polyunsaturated oils. Heart Disease and Sodium Restriction Dietary sodium restriction is an important medical treatment for hyper tension and congestive heart failure. Hypertension is a symptom and not a disease, leading contributor to heart attack and stroke, associated with kindly disease. Congestive heart failure occurs when the heart fails to pump out the returning blood to accumulate in the right side of the heart. This raises venous pressure causing fluid retention (edema) in the heart and its associated parts. Diet & hypertension: Primary hypertension is caused by unknown reasons. Secondary hypertension is caused by known factor such as kidney disorder. Dietary factors, obesity, excess salt, caffeine alcohol, calcium deficiency is also considered to be one of the factor. Low Sodium Diet supplemented with drug therapy hypertensives (contain diuretics which remove water and sodium from the body) Low cal diet with different levels of sodium restriction. Low fats, protein of high biological value, CHO 50%. High potassium foods recommended if loss in the urine present. Diet & Congestive heart failure: Rest to reduce the demands on heart drug therapy. Diet therapy to reduce edema and decrease the workload on the heart. 1. Reduce edema Low Sodium Diet 2. Decrease workload Soft, five to six meals, restricted cal, excess fluid not allowed. Sodium Restricted Diet Salt is 40% sodium by weight or 400mg in 1gm of salt. Main source is table salt naturally occurring sodium meats milk & eggs are high in sodium. Most plants, vegetables & fruits are low in sodium except green leafy vegetables, beets etc. Fruits and oils trace of sodium or none at all. Processed foods, canned foods, baked foods (biscuits) all are rich in sodium. Baking powder and baking soda are sodium salts. Potassium carbonate may be substituted in place of sodium carbonate. FDA requirement is labeling of all sodium containing preservatives used in processed foods. Maintenance of good nutrition. Acceptability of the program by the patient. Usually 10001200 kcal diet is suitable for an obese patient in bed. Those patients whose weight is at a desirable level are permitted a maintenance level of calories during convalescence. Usually 1600 to 2000 kcal will significance in some cases only 2 liters of fluid daily is permitted to lessen the burden of the kidneys. Liquids are served at room temperature for initial 2-3 days, beverages containing caffeine are omitted.

After the acute phase has passed semi solid to solid foods, small feeding, mild sodium rest 2gm/day is usually prescribed. In rehabilitative stage, calories are adjusted as necessary as to bring about weight change if needed. If decompensation (severe damage) is severe, sodium may be restricted to 500mg or less. Sodium restriction may vary from 200 to 300mg (extreme sodium restriction), 500mg to 700mg sodium 1000 to 1500mg. In all these cases no salt will be used in cooking.2000mg to 3000mg some salt may be used in cooking. This level is used as a maintenance diet in cardiac and renal diseases. Naturally occurring sodium in foods Animal foods is relatively high meat, poultry, fish, eggs, milk & cheese. Organ meat have relatively high sodium. Shell fish of all kinds are high Na. a few plant foods like spinach have more Na. Fruits, cereals and most vegetables are insignificant sources of sodium. Dietary Counseling: Perhaps no diet provides grater obstacles with respect to acceptance for taste appeal and understanding of the permissible food choices than does sodium restricted diet. Salt free food is considered to be insipid and patient eat forbidden foods brought by uninformed relative and friends. The purpose of the diet should be explained. Cultural patterns must be understood. Flavoring aids should be used. ********

Diet Therapy for renal Disorders

Renal Diets:
Renal disease can be caused by damaged to the kidneys themselves or other diseases, atherosclerosis or hypertension. Functions of kidneys: 1. Excretory functions 2. Maintenance of chemical homeostatis 3. Balancing of body fluids 4. Maintenance of normal pH 5. Controls blood pressure 6. Changes in sodium balance affect B.P as well as the rise in renin levels. 7. Renin is a proteolytic enzyme secreted by the kidneys, which acts in blood plasma to form angiotensive II, a powerful vasoconstrictor. 8. The damaged kidney also decreases its production of erythropoietion which is critical is critical determinant of erythroid activity, results in severe anemia present in chronic renal disease. 9. Diseased kidney will case to produce activity doses of vitamin D hormone so necessary to maintain calcium, Phosphorus ratio in the bone. i) Serum phosphorus rise as kidney are able to excrete phosphorus. Hyper phosphaturia occurs which lowers serum calcium levels. ii) Calcium is not absorbed, as calcitriol (D3) is the result of this imbalance. Osteodystrophy bones become soft calcium is deposited in the soft tissues. ACUTE GLOMERULONEPHRITIS Also known as hemorrhagic nephritis. Occurs mainly in Children and Young adults as a frequent sequel to steptococcic infections. Scarlet fever, tonsillitis, pneumonia and respiratory infections. Acute phase last from several days to a week but renal function returns to normal much more slowly. Modification of the diet: During acute phase, full nutritional requirement can not be met. Efforts are made to maintain fluid balance and to provide non-protein calories, either orally or parenterally, to minimize the catabolism of tissue proteins. Energy according to the condition of the patient. Protein unless oliguria (renal failure) develops, protein is not restricted. If it is determined that protein restriction is necessary, a diet not exceeding 40gms protein daily is used initially. When there is marked albumiusia the protein intake should be increased by the amount of protein lost in urine. Sodium: if there is edema or hypertension sodium restriction to mg or 1000mg may be prescribed. Fluid: fluids are restricted to prevent further edema. The volume permitted depends on the previous days output larger amounts to replace losses by vomiting, diarrhea, and excessive perspiration. Usually 1 to 1.5 liters more the previous days output. Selection of foods. 20gm, 40gm or 60gm proteins are used. The emphasis on protein foods of high biologic value. Especially eggs and milk: The caloric intake can be increased by using appropriate supplements. Low protein desserts, sugars, jellies candy, butter or vegetable oils and carbonated beverages. Cream may be substituted for part of the milk allowances. All foods must be prepared without salt and the allowances of salt may be weighed calculated and given to the patient giving full instructions to the patient.

Chronic Glomerulonephritis: Detected by lab studies, remains asymptomatic for months or years. Proteinnuria, hematuria, hypertension, vascular changes in the retina, frequent urination & nocturia & sometimes edema is present. Hypoprteinemia and anemia are there, symptoms of renal failure occur. Modification of the diet: Objectives: 1. Maintain good nutrition. 2. Control & Correct protein deficiency. 3. Prevent edema 4. Palatable meals adjusted individually. During the period when the kidneys are able to excrete wastes adequately the normal daily allowance of protein plus the amount of protein lost in urine. Progression of disease necessitates restriction of protein to 40g or less/ day. Sufficient CHO & fat to meet energy needs so that breakdown of protein avoided. Cal 2000 To 3000 Sodium rest to 500 to 1000mg when edema is present. During the diuretic phase of nephritis increased amounts of sodium may be excreted because of kidneys inability to reabsorb the ion. Thus a markedly restricted sodium diet could lead to body depletion with weakness, nausea and symptoms of shock experienced by the patient. Nephrotic Syndrome: Covers a group of symptoms resulting from kidney tissue damage and impaired nephron function. It may also occur due to diabetes or collagen disease (arthritis, rheumatic fever). Symptoms are massive edema proteinuria and body wasting reductions in plasma volume and blood flow. Consequently renal renin production leads to increased aldosterone secretion. Aldasterone favors sodium reabsorption and further contributes to the edema. Dietary Modifications: Dietary management covers the restoration of fluid and electrolyte balance reversal of body wasting and correction of hyperlipidemia. Sodium Sodium permitted is less than 2gms / day and in severe causes to 500mg/day till the edema is corrected. Modest restriction may be used prevent recurrence of edema. Protein and energy: 120gm/day and a high calorie intake 50 to 60gms/kg. Are needed for tissue repletion. High protein supplements may be incorporated. Fat Fats are restricted if hyperlipoproteinemia is present. Nephrosclerosis: or hardening of the renal arteries, Occurs after 35 years of age and is associated with arteriosclerosis. During last stages albumiuria, nitrogen retention and retinal changes develop. In a small number of younger persons Nephrosclerosis runs a stormy rapid course leading to uremia and death. This is called malignant hypertension. Modification of the diet: Weight reduction of obese is desirable 200mg. Sodium diet has been successfully used. Protein intake remains normal.

Renal Failure:
Acute Renal Failure includes an abrupt renal malfunction because of infection, trauma, injury, chemical poisoning, and pregnancy allergy. The symptoms are nausea, lethargy and anorexia. Oliguria (diminished urine secretion), Azotemia (accumulation of nitrogenous constituents in the blood) may be present. Anuria (100ml urine) in some cases is there. Progressive rise in serum creatinine and urea concentration. Acute renal failure may occur due to extensive burns, ingestion of poisons, crushing injuries or shock from surgery. Dialysis is employed until the kidney assumes its function.

Dietary Management: includes restoration of fluid and electrolyte balance, elimination of Azotemia and implementation of nutritional rehabilitation. Energy: 100gms glucose/24 hours in acute stage to reduce protein catabolism can be given intravenously. Protein: because of dialysis a liberal intake of proteins can be given otherwise a proteinrestricted diet is given 20 to 40g protein is permitted. Fluid: Fluid allowance is permitted in accordance with urinary output & additional losses like diarrhea & vomiting. During Oliguric phase, fluid permitted is less than 600ml/day. Potassium: Potassium allowances is individualized in accordance with serum levels. Sodium: the dietary sodium allowance is based on frequent measurements of the ion in serum and urine. For a nondialyzed patient in the Oliguric phase, restriction of sodium to 500 to 1000mg daily is necessary. On dialysis patients 1500 to 2000mg/day. Chronic Renal failure: The chronic renal failure symptoms appear when the glomerular failure symptoms appear when the glomerular filtration rate (GFR) is inadequate to excrete nitrogenous wastes. When the GFR is less than 10ml./mt. (normal 120ml/mt.) and blood urea Nitrogen (BUN) is more than 80mg/100ml (normal 8 to 18mg/ 100ml) dietary modifications bring improvement. When the GFR reduces to 3ml/mt. Dietary control alone is inadequate & dialysis is necessary. Symptoms involving gastrointestinal tract are often present CRF. The sight smell of food may bring about nausea and vomiting. The breath has ammoniacal order that interferes with the taste of food. Ulceration of the mouth and hiccups also interfere with food intake. The nervous system is usually affected patients are irritable & eventually sink into coma. Headache, dizziness, muscular twitching neuritis, failing vision occur accompanied by hypertension. The function of the heart is seriously disturbed. Congestive failure occurs when the heart failure is associated with retention of sodium and water. Death occurs when hyperkalemia (elevated serum potassium). Blocks the contraction of the heart many alterations in metabolic and endocrine function occur in end stage renal disease. Patients with terminal uremia have a progressively worsening anemia. Ulceration of G1 tract, hemolysis (break down of R.B.C), fatigue, weakness. When the GFR falls to 25ml./mt. The serum phosphorus level is elevated and hypocalcemia occurs. Parathyroid harmone secretion is increased to compensate for the evaluated phosphorus. The harmone decreases the reabsorption of phosphorus by the kidney and increases calcium reabsorption from the bone. Hypocalcemia occurs: Renal ostiodystrophy is induced by the disturbed calcium and phosphorus metabolism. Kidney is unable to convert D3 to its active form so that calcium absorption from the intestine is decreased. Excess fluoride also plays a role the bone mineralization seen in uremia. Elevation of serum triglycerides Type IV hyperlipoproteimia and increase the risk of cardiovascular disease. Hyperkalemia (excess of Potassium in the blood) and acidosis become increasingly severe and edema is marked. Mental disorientation, severe gastrointestinal symptoms, bleeding and coma are characteristics of the final stage.

Kidney Dialysis:
Diffusion from dissolved particles (solutes) from one side of the semipermeable membrane to the other. There are two types of kidney dialysis: 1. Hemodialysis 2. Peritoneal dialysis 1. Hemodialysis: uses a machine called artificial kidney outside the body. Blood is drawn or pumped out of the body and made to circulate through a special machine equipped with a synthetic semipermeable membranes. The dialysate in this case also contains glucose and

electrolyte, which resemble concentration of blood plasma found in the body. Much nitrogenous waste from patients blood plasma diffuses into the dialysate. The cleaned blood is returned to the patients body and the used dialysate is replaced with fresh. The patient undergoes Hemodialysis two to four times a week for 3-6 hours in the hospital. Between dialysis treatments, nitrogenous waste products potassium & sodium, fluid accumulate and dietary modifications are necessary to control them. Serum amino acids and water-soluble vitamin supplements are necessary. 2. Peritoneal Dialysis: may be intermittent or continuous with intermittent dialysis a catheter is placed in the abdominal cavity and one or two liters of dialysis fluid introduced into the abdominal cavity and removed every hour. This process is repeated until the blood urea drops to normal levels. Loss of blood protein and amino acids are greater in peritoneal dialysis than Hemodialysis. With continuous ambulatory peritoneal dialysis (CAPD) the patient does his or her dialysis. The dialysate is then drained and replaced with fresh fluid. With CAPD no dietary restriction of fluid sodium or potassium is necessary. Calcium supplements may be needed and phosphorus is restricted. No phosphate binding antacids are used. The dialysate contains dextrose, which is absorbed by the body. Calorie control and exercise program required to prevent excess weight gain. Continuous Cyclic Peritoneal Dialysis CCPD, uses a machine that performs frequent exchanges of dialysate while the patient is sleeping. The dialysate is left in place during the day. Patients require training in aseptic technique and dialysate exchange, as these treatments are carried out at home. Advise on Diet: CAPD patients are reluctant to give up their restrictions. Explain clearly the possible effects of a restricted diet while on CAPD. 1. Hypotension and dizziness from sodium depletion. 2. Nausea, vomiting, irregular heart beat and muscle weakness from potassium depletion. 3. Dehydration due to rapid fluid removal. Dietary Regime: 1. High protein 1:2 to 1.5g/kg. 2. Limit phosphorus intake to 1200 mg/day. a) Nuts & legumes 1 serving. b) Dairy products cup daily. c) Eggs not more than one. 3. High potassium- eat a wide variety of fruits and vegetables daily. 4. High intake of fluids to prevent dehydration. 5. Limit or avoid sweets & fats. 6. Control weight incorporate extra calorie from dialysate into total cal/day. 7. Exchange adequate consumption, CAPD patients are often anorectic.

Dietary Management in Chronic Renal failure

Provision of adequate calories 2000 to 3000 keal Regulation of protein, sodium, potassium and fluid intake restriction of phosphate. Supplements of phosphate Supplement of calcium, iron, and trace minerals. Ascorbic acid and B- Complex vitamin supplements.

Protein 0.6 gm/ kg body weight: 30g in nondialyzed cases. Generally of the protein allowance as high biologic- value protein.

Carbohydrate and fat: Type IV hyper lipoproteinemia is common in patients with chronic renal disease. Elevated serum, triglycerides can be lowered by controlling carbohydrate intake, restriction of dietary cholesterol and increasing the intake of polyunsaturated fat. Diet containing ratio of polyunsaturated to saturated 1:1, Cholesterol 300mg and CHO 50% of the calories is quite effective. Potassium: 1500 to 2000mg for nondialyzed patients. Potassium allowance is individualized in accordance with the patients blood chemistry, urinary output. Other minerals: Blood levels of phosphorus gradually increase in the uremia patients, thus contributing to the acidosis and also to metastatic calcification. Early restriction of phosphorus to 600 to 750 mg/day, calcium supplements, 1.5 to 2.0 gm daily along with vitamin D supplements are used to prevent hyper parathyrodism. Dairy products are restricted because of high phosphorus content.

Vitamins: Pyridoxine, folic acid requirement are increased because of drug therapy, Vitamin C,
B vitamins needs are more because of restriction of potassium (raw fruits & vegetable are rich in potassium). Vitamin D requirement requires its supplements. Fluids: rigid control of fluid intake is necessary to prevent excess fluid retention. The daily allowance is usually 400 to 600 ml. Diet counseling: Dietary treatment is an integral part of therapy. Rigid controls required make this diet a complex one. Each patient needs to know why the diet is important and what risks will be encountered if he/she fails to follow the diet. For potassium restricted diets canned fruits should be used as maximum potassium would have leached out into the syrup. For leavening (bread) yeast should be used. Potatoes boiled in large quantity of water and the thrown off (K leaches out) Diet following Renal transplantation: Mild sodium restriction is usually necessary because of administration of steroids, favors fluid retention.

URINARY CALCULI:
Kidney stones may be found in ureter bladders or urethra. About 90% of all stones contain calcium as the chief cation. More then half the stones are mixtures of calcium oxalate, magnesium ammonium phosphate. Excessive urinary calcium may result from prolonged use of high calcium foods such as milk and dairy products, from alkali therapy for peptic ulcer or from continued use of hard water supply. Excess vitamin D may cause increased calcium absorption from the intestine, as increased extraction of calcium from the bones. Prolonged immobilization may lead to withdrawal of calcium from the bones and increased calcium in the urine. Ascorbic acid intakes in excess of 4gm/day may induce formation of oxalate stones. Uric acid stones may form from rapid tissue breakdown (body wasting) purine breakdown (purine is body by product) prolonged use of high protein low CHO fad diets.

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Diet and Disorders of the Liver, Gallbladder and Pancreas

High-Protein, High Carbohydrate moderate fat diet, Fat restricted diet. Functions of liver: 1. Protein metabolism, Carbohydrate, lipid, vitamin, mineral metabolism. 2. Detoxification of bacterial decomposition products, mineral poisons, drugs. A normal liver regulates the proper digestion metabolism and absorption of food. A. The liver stores i) Approximate 1 Pound of glycogen ii) Fat solution and water solution vitamins. iii) More iron than any other part of the body. B. Circulation The liver regulates i) Blood volume ii) Blood transfer from the portal to systemic circulation. iii) Fluid transfers C. Metabolism i) CHO metabolism by interconverting glucose and glycogen as needed, it also converts amino acids to glucose. ii) Fat metabolism by providing bile salt for emulsifying fat, cholesterol, and lipoproteins and by converting excess amino acid and CHO to fats. D. Detoxification i) Drugs ii) Poisons Diet Therapy for diseases of the liver Hepatitis: Viral hepatitis, inflammation of the liver, is a major world health problem. Scientists have discovered five types of hepatitis: 1. Hepatitis A- infectious hepatitis, is spread by the oral- fecal route from an infected person through contaminated water and food. (Vaccine available). 2. Hepatitis B Virus (HBV)- (Serum hepatitis) Classified as a sexually transmitted disease (STD) because it is spread via body fluids, semen, saliva, tears, and by needle shading among drug users, major factor in chronic liver disease and liver cancer. 3. Hepatitis C Virus (HCV)- chronic active hepatitis, liver cirrhosis and liver cancer. 4. Hepatitis D Virus (HDV)- mortality 80-90% may be due to toxic injury such as with carbon tetrachloride etc. Medical Management 1. Optimum nutrition for healing 2. Complete rest to reduce inflammation and metabolism 3. Alcohol and all other drugs are prohibited. Diet Therapy 1. Protein 1.2 to 1.5gm/ kg body wt./day 2. CHO no CHO restriction, serum glucose should be monitored as hyper and hypoglycemia can result from liver dysfunction.

3. 4. 5. 6. 7.

Fats 305 of calories restriction when decrease in secretion of bile acids. Energy 25-35 Kcal/kg body wt./day. Multivitamin mineral supplement at 100% of the RDA may be necessary Fluids and sodium restriction may be necessary if edema or ascites is present. If adequate nutrition can not be maintained by oral feedings, enteral feeding or TPN may be indicated.(tube feedings or total parenteral Nutrition) Diet Therapy for cirrhosis: 1. Cirrhosis is the final stage of certain liver injuries including alcoholism, untreated hepatitis, biliary obstruction and drug and poison ingestion. 2. Malnutrition, chronic active hepatitis, excessive intake of vitamin A for a prolonged time also induces cirrhosis of liver. The liver is unable to generate new cells which are replaced with fibrous, non functioning tissue. Stages of Cirrhosis: Early Late a. Early Stages: affect the digestive system and cause such symptoms as nausea, vomiting Distention, diarrhea, anorexia. Dietary Management: is same as hepatitis- to support residual liver function and further cell destruction. Compliance with dietary and other medical recommendation will delay the onset of the late stages for years. In the later stages, the patient is severely undernourished. Edema, ascits, anemia, infections, intestinal bleeding, jaundice, esophageal varices may be present. Primarily a diet in high Protein CHO, Vitamin and Calories, moderate in fat is recommended. 1. Protein: If hepatic coma is not indicated, protein at 75g to 100g/day. However if the physician sees signs of impending intake to lessen the chance of coma, he may reduce protein intake to lessen the chance of coma. 2. Sodium: edema or ascites are counteracted by a 500 to 700 mg sodium daily. Fluid intake may be limited. 3. Texture: Esophageal varices if present semisolid or liquid diet is beneficial to avoid potential rupture or hemorrhage. These Patients should avoid tea, coffee, chilli powder and other irritating seasonings. If the cirrhosis is alcohol induced deficiency of magnesium and vitamin B complex is often present. Alcohol reduces vitamin absorption and increases mineral excretion. Hepatic Encephalopathy Hepatic Coma: caused by brain damage resulting from the inability of a damaged liver to metabolize ammonia compounds. Irritability, confusion, drowsiness, apathy, irrational behavior precede coma. Other signs are motor dysfunction and fecal breath odour. Ammonia is formed from protein in the intestines by bacterial action. Treatment includes antibiotics, psychotropic drugs, enemas to remove blood and protein from the bowel and diet therapy. Protein intake is limited to 0 to 50g daily depending on the blood ammonia level. Dietary proteins derived from milk and meats is of high biological value, it produces minimal ammonia because it is used optimally without waste provided it is not metabolized for energy. Supplements of amino acids (leucine, isoleucine, valine) can be given as a source of protein for heart, muscle and brain, they are not dependent on the liver for metabolism and are metabolized by other tissues. The diet provides 1500 to 2000 cal/day. Supplements of vitamins given intravenously, Vitamin K supplement to stop bleeding. Fluid output equal to intake. TPN or enteral feeding.

Jaundice
Is a symptom common to many diseases of the liver and biliary tract and consists of a yellow pigmentation of the skin and body tissues because of the accumulation of bile pigments in the blood. Obstructive jaundice: results from interference of the flow of bile by stones, tumors, or inflammation of the ducts. Hemolytic Jaundice: results from an abnormally large destruction of blood cells such as in yellow fever, pernicious anemia. Toxic Jaundice originates from poisons drugs or virus infections. Dietary modifications Since the liver is so intimately involved in the metabolism of foodstuffs, a nutrition diet is an important part of therapy and should be designed to enable it to function as efficiently as possible. With the exception of hepatic coma, generous amount of high quality protein should be provided, for tissue repairs and for prevention of fatty infiltration and degeneration of liver cells. A high carbohydrate intake ensures an adequate reserve of glycogen, with adequate protein stores has protective effect. Moderate amounts of fats is prescribed. Generous amounts of Vitamins, especially B complex, must be provided. Sodium restriction if edema and ascites is present. Diseases of the gallbladder Obesity correlates with the diseases of gallbladder, increases with age. Malabsorption of bite acids. Certain drugs increase the risk for gallstone formation. Function of the gallbladder The gallbladder concentrates bile formed in the liver and stores until needed for digestion of fats. Inflammation of the gallbladder is known as cholicystitis, gallstone formation cholelithiasis occurs when bile pigments, bile salts, calcium and other substances precipate out of the bile. Choledocholothiasis refers to stones lodged in the common duct. Diagnostic Test: Cholestography- administration of an iodine contrast dye. Presence of stones visualized by Xray. In some cases ultrasonography, or Computerized transaxial tomography (CAT) scan. Growth of stones involves several stages: 1. Genetic and metabolic stage in a susceptible individual 2. A chemical stage when the bile becomes supersaturated with cholesterol 3. A physical stage, in which the supersaturated bile is nucleated and growth of cholesterol crystals begins. 4. Aggregation of microscopic crystals into stones. 5. Symptomatic stage when stones initiate cholecystitis or block the cystic or common bile duct. Symptoms and Clinical findings: mild to severe pain abdominal distension nausea and vomiting, fever the pain occurs whenever the gallbladder contracts due to intake of fatty food Treatment

Dietary, medical or surgical The principal aim is to reduce discomfort by providing a die restricted in fat. Energy- excess calorie is the risk factor for development of gallbladder disease(obese).Low calorie diet for overweight and obese patients is prescribes. Fat- Patient receives no food initially during acute attacks of cholecystitis progression to 20 to 30gms fat diet is given. Finally increased to 50% to 60%gms. Carbohydrates are used liberally. Cholesterol: if a reduction in cholesterol is ordered, egg yolks, liver and other organ meats are omitted. Fiber: High fiber diet is prescribed Diet following cholecystectomy Some fat restriction is indicated for several weeks following the removed of gallbladder. Dissolution of gallstones i) Oral administration of certain bile acids induces dissolution of gallstones (litholysis) ii) Lethotripsy- ultrasonic waves or laser beams to mechanically break the stones into tiny fragments that can be eliminated.

PANCREATIC DISORDERS
Due to congenital or inflammatory diseases, trauma or tumors. Inadequate production of enzymes leads to impaired digestion, manifested by the presence of excess fat and undigested proteins in stools. Acute Pancreatitis 1. Initial measures are life saving: the aim of the therapy is to prevent the secretion of pancreatic enzymes. Both food and alcohol stimulate pancreatic secretions. Total Parenteral Nutrition (TPN): Feedings, replacement of fluid and electrolytes, blood transfusions and drugs for pain and inhibiting gastric secretions. Nasogastric suction may be used to remove gastric contents, nothing is given by mouth. 2. As healing progresses, clear liquid with amino acids, predigested fats, commercial preparations are added. The patient progresses to a bland diet given in six small feedings. No stimulantsCoffee, Caffeine, Tea, Colas, Alcohol are allowed. Chronic Pancreatitis The aim of diet therapy is to treat the malabsorption and prevent malnutrition. Diet therapy consists of a bland diet of soft or regular consistency in small meals at frequent intervals (six feedings). No stimulants, alcohol is forbidden. Use a low fat diet. Vitamins and minerals supplementations may be necessary especially fat soluble A, E, & K, B complex vitamin may need replacement. Tube feeding may be necessary. Patient can develop diabetes if the islet cells become malfunctioning. Calculate diet will be used.

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NUTRITION FOR THE CANCER PATIENT Nutritional status is adversely affected by cancer. A high proportion of Patients exhibit protein calorie malnutrition. The malnutrition affect tissue function and repair, immune status and metabolism of drugs. The nutritional status of the individual predicts tolerance and response to therapy. Individuals who do not lose weight have longer survival time than those who do. Malnourished are more likely to derive optimal benefits from the therapy. Nutrition therapy is highly individualized, depending on the bodys response to the disease. Patient has fatigue, anemia, anorexia esophagitis, nausea, Vomiting, edema negative nitrogen balance. Bodys response to cancer Difficulty in ingestion Malabsorption of nutrients Intestinal malignancies contribute to hypokalemia. Cancer within thyroid gland lead to hormonal imbalances Pancreatic cancer leads to loss of digestive enzymes and diabetes mellitus. Increased hemolysis, bleeding of lesion lead to anemias. The bodys response to Medical therapy Three major forms 1. Surgery 2. Radiation 3. Chemotherapy Nutrition support enhances chances of success of the treatment. Dietary Factors: Calories: an excess of calories is associated with increased risk for endometrial and possibly for breast cancer, need to be restricted for obese. Proteins: Cancer of the colon is related higher intake of meat and fat. Fat: Both types of fats (Saturated and polyunsaturated may influence tumor formation. High intake of fats increases anaerobic bacteria and biliary steroid secretion. Anaerobic bacteria are capable of synthesizing estrogens, which are believed to be potential carcinogens in mammary tissue from biliary steroids. One theory reports of cancer in men due to consumption of polyunsaturated fat for a prolonged period. Fiber: Dietary fiber is postulated to exert a protective effect against colon cancer. Shortening intestinal transit time, reducing the exposure time of epithelial surfaces to potential carcinogens, bile acid metabolism. Alcohol: Cancers of mouth, pharynx larynx and esophagus is increased in heavy smokes and consume large amounts of alcohol. Alcohol enhances the carcinogenic effects of smoking. Other nutritional Factors: Low serum retinal level Picked foods Dried salted fish

Dietary cholesterol Nitrites

Planning Diet Therapy Minimize weight loss. Correct nutrient imbalances so that the patient is in good nutritional status. All diets are individualized. Surgery: Provide optimal nutrition preoperatively and maximum support postoperatively to facilitate healing. Provide specific modifications of the nutrients according to the surgical site and organ function involved. Provide specific modifications of the nutrients according to the surgical site and organ function involved. Radiotherapy: Radiation to head and neck or esophagus affect oral mucose, salivary secretion taste sensation and sensitivity to temperature and texture of food. Radiation to abdomen may produce loss of intestinal villi and absorbing surfaces ulcer, inflammation, and obstruction. Chemotherapy: Chemotherapy has the same effect on normal cells as they do on cancer cells. This becomes most apparent in changes in the bone marrow hair follicles and G1 Tract. Bone marrow effects include interference with production of both white and red blood cells producing anemia, infection, bleeding. G1 effects nausea, vomiting, stomatitis anorexia ulcers, and diarrhea. Hair follicle effects hair loss and alopecia (baldness). Nutritional Considerations: The various modes of cancer therapy surgery, radiation and chemotherapy all have nutritional consequence. Assessment of nutritional status of cancer patient is essential to determine the patients who are likely to be at increased risk during treatment. They can be provided with appropriate nutritional support. Periodic monitoring of nutritional status should continue during therapy. Dietary Counseling: Need a good deal of guidance and encouragement, should be informed of typical dietary problems experience undergoing cancer therapy. Importance of weight maintenance should be stressed. Diet is modified in texture and composition. One who is undergoing radiation to the abdomen may need food low in lactose, fiber and fat. Constipation due to emotional stress, pain medications or chemotherapeutic drugs can be dealt by giving high fiber foods. Most patients fare better with small frequent meals. A high protein, high calorie and avoidance of sugars and fats. Taste preferences often change during therapy. Beverages, puddings, soups supplement the meals. Protein content of the diet can be increased by adding skin milk powder. Calories can be increased by adding butter or ghee to cooked cereals, honey to tea, jaggery & raisins to cooked cereals.