A lucid presentation Nutritional management of clinical disorders to facilitate easy-learning for medical , dental , pharmacology and biotechnology students.

1. Nutritional management of clinical disorders
Dr. Rohini C Sane

2. Management of Diabetes Mellitus Type 1
• Insulin administration( Hypoglycemic effect) in Diabetes Mellitus
Type1
• Administration of fluids and electrocytes to correct osmotic and
electrocyte imbalances
• Prevention of metabolic complications
• Alleviation of clinical symptoms
• Treatment with the immunosuppressive drug cyclosporin A to induce
remission in Diabetes Mellitus Type1

3. Nutritional Management of Diabetes Mellitus Type 2
• Weight reduction
• Dietary control:
1.Carbohydrate
A.comprises 40-60% of total intake
B.intake of complex carbohydrate that are absorbed slowly.
C.avoidance of simple sugars like glucose and sugars that are rapidly absorbed.
D.high intake of dietary fibres ,which causes satiety and lowers plasma glucose and
lipid levels
2. Proteins : comprise 15% of total energy intake.
3. Fats/lipids:
A.comprises 30-35% of total energy intake
B.restriction of total fat and saturated fat to prevent coronary heart disease (CHD)
C.intake of polyunsaturated fats , such as sunflower oil, soybean oil and
monounsaturated fats

4. Oral hypoglycaemic agents used in management of Diabetes Mellitus Type 2
Oral hypoglycaemic agents in Diabetes Mellitus Type 2 patients not
responding to diet therapy. These include the following:
• Administration of insulin during periods of stress
• Sulphonylureas (Tolbutamide and Chlorpropamide): increase insulin
output by beta pancreatic cells and enhance insulin action on
peripheral tissues via insulin receptors or through post receptors
• side effects of Sulphonylureas : hypoglycaemia from overdosage and
sometimes cardiovascular disease
• Biguanides (metformin and Phenformin): inhibit intestinal glucose
absorption ,gluconeogenesis, and TCA cycle
• side effects of Biguanides: Lactic acidosis

5. Management of water imbalance
• Management of dehydration(H2O):5% glucose
intravenous until urine volume>1500 ml
• Management of water and sodium depletion:
administration of sodium and water in isotonic amount
• Management of water excess: restriction of water intake .
Infusion of hypertonic saline if water intoxication occurs .

6. Management of sodium imbalance
• Management of sodium excess (Hypernitraemia):
1. Treatment of underlying cause
2. Restriction dietary sodium intake
3. Diuretic therapy(Bendrofluazide , Frusemide,Mannitol
and Spirolactone) to promote sodium excretion
4. Dialysis if kidney function is impaired.

7. Management of Potassium imbalance
• Management of Potassium excess (Hyperkalemia):
1. Treatment of underlying cause
2. Restriction dietary Potassium intake
3. correction of acidosis or water depletion or sodium depletion
• Management of Potassium depletion (Hyporkalemia):
A. oral administration of KCl
B. intravenous infusion of potassium if oral administration not possible

8. Management of acid base imbalance
• Management of metabolic acidosis :
1. Treatment of underlying cause
2. Bicarbonate administration in small amount to buffer hydrogen
ions when pH < 7.0.
• Management of metabolic alkalosis :
A. Treatment of underlying cause
B. infusion of NaCl solution to correct hypovolumia and
hypochloremia
C. increase excretion of bicarbonates

9. Nutritional anemias
• Anaemia is characterised by lower concentration of
haemoglobin (reference 14-16g/dL) with reduced ability
to transport oxygen.
Class of anaemia RBC size Nutritional deficiency
Microcytic reduced Iron, copper, pyridoxine
Macrocytic large and immature folic acid, vitaminB12
Normocytic normal (quantity in blood is low)
protein -energy
malnutrition

10. Management of anaemia
Category supplementation
of Iron
(mg)
supplementation of
Folic acid
( micrograms)
supplementation of
Vitamin C
(mg)
Pregnant
and
Lactating
women
100 500 60
Children 20 100 60

11. Management of anaemia
Management of Pernicious anaemia (megaloblastic anaemia) :
Intramuscular administration of (100-1000 microgram)+ Folic acid
• Management of Iron deficiency anaemia:
supplementation of Iron + folic acid + Vitamin C

12. Management of Iodine deficiency
• Iodine levels in blood : 5-10 micrograms /dL
• Recommended daily requirement of Iodine :150-200 micrograms
• Management of Iodine deficiency : intake of iodised table salt fortified with
Iodine, avoid intake of goitrogens .
• Goiter : caused by deficiency or excess of iodide
• Simple endemic goiter : due to iodine deficiency can be overcome by intake of
table salt fortified with iodine . In some cases administration of thyroid
hormones is employed.
• Goitrogens:
A. interfere with production of thyroid hormones.
B. include chemicals such as thiocyanates, nitrates and perchlorate .
C. include drugs such as thiourea, thiouracil and thiocarbamide.
D. present in plant food (cabbage , cauliflower and turnip mostly as thiocyanates).

13. Functions of Zinc
• stabilises Insulin in beta pancreatic cells forming zinc -insulin complex . Zinc
plays role in storage and secretion of insulin from beta pancreatic cells.
• Gusten (Zinc containing protein) in saliva important for taste sensation.
• Zinc dependent enzymes : 300 enzymes e.g. carboxypeptidase , carbonic
anhydrase , alkaline phosphatase ,lactate dehydrogenase , glutamate
dehydrogenase ,DNA polymerase(protein biosynthesis), alcohol
dehydrogenase , extracellular superoxide dismutase (cytosolic antioxidant)
• is required for wound healing , stabilising bio-membranes and proper
reproduction as it enhances cell growth and division.
• maintains normal physiological level of serum vitamin A as it promotes the
synthesis of retinol binding protein.It has role in the visual cycle as it is
responsible for mobilisation of vitamin A from liver.
• Commercially available preparation of Insulin:protein -Zinc -insulinate(PZI)
contains zinc.

14. Management of Zinc deficiency
Rich Dietary sources of Zinc : grains ,beans ,nuts ,cheese ,meat,fish,milk
• Serum Zinc level :80-120 micrograms /dL or 12-18 micromols /L
• Deficiency Manifestation of Zinc :
1. Dementia , depression (Zinc binds with amyloid to form a plaque in
Alzheimer ’s disease), neuropsychiatric disorders
2. loss of taste sensation, loss of appetite ,Diarrhoea
3. Anemia
4. growth retardation,poor wound healing ,lesions of skin,Alopecia
5. impaired spermatogenesis , hypogonadism ,congenital malformation of the
foetus
6. Acrodermititis enteropathica : defective absorption of Zinc from intestine
Category Daily Requirement of Zinc(mg)
Adults 10 -15
Pregnancy and lactation 15-20

15. Management of Cirrhosis
• Restriction of protein diet
• Restriction of intake of calorie,fluid and electrolyte
• Management of ascites by sodium restriction
• Avoid alcohol
• Laxative or enemas
• Neomycin treatment to reduce serum ammonia
• Hepatic encephalopathy by controlling GI bleeding

16. Management of Wilson’s disease
• Wilson’s disease : Ceruloplasmin level in blood is drastically reduced
(<20 mg/dL) causing Wilson’s hepatolenticular degeneration,cirrhosis and
haemolytic anaemia.
• Molecular basis of Wilson’s disease :mutation in gene encoding a copper
binding ATPase ( ATP7B gene )in liver cells . This ATPase is required for
excretion of copper from liver cells .
• Clinical manifestation of Wilson’s disease : Copper deposition in kidney,
liver (due to reduced excretion into bile) , lenticular nucleus of the brain and
Descement ’s membrane of the cornea (Kayser -Fleischer ring) .Increased
excretion of copper in urine(reduced incorporation of copper into
ceruloplasmin).
• Oral administration of Penicillamine : which helps in chelation and
excretion of copper from affected patient.
• Therapeutic use of Zinc in Wilson’s disease :Zinc decreases copper
absorption and hence reduce copper load in the body .

17. Inborn errors of metabolism and dietary advice
Inborn error of metabolism Dietary advice
Von Gierke’s disease
(Glycogen storage disease
type 1)
Avoid sucrose and fructose( fructose and lactose
are converted to glycogen in liver)high protein
diet to accelerate gluconeogenesis from amino
acids , moderate amount of carbohydrate in the
form of glucose or starch,
Phenylketonuria(PKU)
low phenylalanine diet (< 50mg)soon after birth
and kept on it for long time, breast feeding
should be stopped , the infants bottle fed with a
low phenylalanine milk substitute, intake of fruits
and vegetables permitted.
Galactosemia
breast feeding should be stopped immediately
and the infants should be given milk powder in
which lactose has been replaced by dextrin,
dextrose and maltose,avoid milk &milk products
restrict intake of galactosides (filler & flavouring)
Refsum’s disease
diet low in chlorophyll,removal of phytantic
acid,restrict fruits ,vegetables butter ,ruminant fat

18. Special diet in diseases
Disease Special diet
Chronic renal disease
Pre-dialysis= Low protein(0.6-0.8g/kg/day)
Dialysis = standard protein ( 1-1.2 g / kg/ day)
Fluid restriction (2kcal/ml formula )
Heart disease
salt restricted diet (permitted but NaCl should be
avoided), avoid overfeeding, fluid restriction (2kcal/ml
formula)
Hepatic disease
high calorie intake (35kcal /kg body weight /day)
if encephalopathy= protein restriction(0.6g /kg/day)
if no encephalopathy= standard protein (1-1.2g/kg/
day)
sodium restriction if ascites or edema
Pulmonary disease
calories (20-30kcal/kg/day)
30-50% of total kcal as fat , protein( 1-2 g /kg/day)

19. Dietary advice in diseases
Disease Dietary advice
Dyspepsia bland diets
Peptic ulcer
bland diet given in small amounts at frequent interval,
caffeine ,ethanol,nicotine should be restricted ,
milk ,eggs and fruit juice to patients with pylorospasm or
haemorrhageAcute
Gastritis
stop alcohol or drugs responsible for gastritis,
oral rehydration fluid for replacement for water and electrolyte
loss
Acute diarrhoea
diseases
oral rehydration solution [sodium chloride(table salt) 3.5 g,
sodium bicarbonate (baking soda)2.5g, Trisodium citrate 2.9g,
potassium chloride 1.5g, Glucose 20g dissolve in 1 litre of
potable water ]
intestinal
obstruction
infusion and intravenous feeding for loss of fluid and
electrolytes after surgery
Constipation
increased intake of dietary fibres by consumption fruits
(oranges , sweet limes )and green leafy vegetables,lactulose
and senna
Gout
(hyperuricaemia)
Avoid alcohol, heavy & rich meals, high in fat and purines (non-
vegeterian foods e.g. liver,kidney, fish, sweet breads ) ,
increase water intake

20. Thank You