EXPLAIN THE DIETARY MANAGEMENT OF NAMED DISORDERS

UNIT TASKS
UNIT TASK 1 DEFINING OF TERMS
Cytokines are any of a number of substances that are secreted by specific cells of the immune
system which carry signals locally between cells, and thus have an effect on other cells.
UNIT TASK 2 DISORDERS OF THE UPPER GASTRO-INTESTINAL TRACT
UNIT TASK 3 STATING THE CAUSES AND SYMPTOMS OF UPPER
GIT
Dental caries
Dental caries, also known as tooth decay or cavity, is a disease wherein bacterial processes
damage hard tooth structure (enamel, dentin and cementum). These tissues progressively break
down, producing dental caries (cavities, holes in the teeth). If left untreated, the disease can lead
to pain, tooth loss, infection, and, in severe cases, death.
Tooth decay is caused by specific types of acid-producing bacteria that cause damage in the
presence of fermentable carbohydrates such as sucrose, fructose, and glucose. The mineral
content of teeth is sensitive to increases in acidity from the production of lactic acid.
Specifically, a tooth (which is primarily mineral in content) is in a constant state of back-and-
forth demineralization and remineralization between the tooth and surrounding saliva. When the
pH at the surface of the tooth drops below 5.5, demineralization proceeds faster than
remineralization (i.e. there is a net loss of mineral structure on the tooth's surface). This results in
the ensuing decay. Depending on the extent of tooth destruction, various treatments can be used
to restore teeth to proper form, function, and aesthetics, but there is no known method to
regenerate large amounts of tooth structure. Instead, dental health organizations advocate
preventive and prophylactic measures, such as regular oral hygiene and dietary modifications, to
avoid dental caries.
GIT hemorrhage
There are many causes for upper GI hemorrhage. Causes are usually anatomically divided into
their location in the upper gastrointestinal tract.
Patients are usually stratified into having either variceal or non-variceal sources of upper GI
hemorrhage, as the two have different treatment algorithms and prognosis.
 Esophageal causes:
478
o Esophageal varices
o Esophagitis
o Esophageal cancer
o Esophageal ulcers
 Gastric causes:
o Gastric ulcer
o Gastric cancer
o Gastritis
o Gastric varices
o Gastric antral vascular ectasia, or watermelon stomach
o Dieulafoy's lesions
 Duodenal causes:
o Duodenal ulcer
o Vascular malformations, including aorto-enteric fistulae. Fistulae are usually secondary to
prior vascular surgery and usually occur at the proximal anastomosis at the third or fourth
portion of the duodenum where it is retroperitoneal and near the aorta.
o Hematobilia, or bleeding from the biliary tree
o Hemosuccus pancreaticus, or bleeding from the pancreatic duct

15.2.09 DISORDERS OF THE STOMACH

15.2.09T Specific Objectives
By the end of sub-module unit, the trainee should be able to:
identify the disorders of the stomach
state the causes and symptoms
explain the dietary management of the named disorders
Unit Tasks
Unit Task 1 Identifying disorders of the stomach
 Heartburn - Also called: Acid indigestion, Pyrosis
Heartburn is a burning sensation in the chest that can extend to the neck, throat, and face; it is
worsened by bending or lying down. It is the primary symptom of gastroesophageal reflux,
which is the movement of stomach acid into the esophagus. On rare occasions, it is due to
gastritis (stomach lining inflammation).
 GERD - Also called: Gastroesophageal reflux disease

A chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into
the esophagus, causing heartburn, acid indigestion, and possible injury to the esophageal lining.
479
Unit Task 2 Stating the causes and symptoms of disorders of the stomach
Peptic Ulcer - Also called: Duodenal ulcer, Gastric ulcer, Stomach ulcer, Ulcer
Peptic ulcer: A hole in the lining of the stomach, duodenum, or esophagus. A peptic ulcer of the
stomach is called a gastric ulcer, an ulcer of the duodenum is a duodenal ulcer, and a peptic ulcer
of the esophagus is an esophageal ulcer. A peptic ulcer occurs when the lining of these organs is
corroded by the acidic digestive juices which are secreted by the stomach cells.
Indigestion - Also called: Dyspepsia, Upset stomach
Indigestion, which is sometimes called dyspepsia, is a general term covering a group of
nonspecific symptoms in the digestive tract. It is often described as a feeling of fullness,
bloating, nausea, heartburn, or gassy discomfort in the chest or abdomen. The symptoms develop
during meals or shortly afterward. In most cases, indigestion is a minor problem that often clears
up without professional treatmentSymptoms of indigestion
If you have indigestion you may have the following symptoms:
 pain, fullness or discomfort in the upper part of your abdomen or chest
 heartburn
 loss of appetite
 feeling sick
 flatulence (gas passed from your rectum), burping or belching

Indigestion has several causes. Depending on what's causing your indigestion, your symptoms
may go very quickly, come and go, or they may be regular and last a long time.
The symptoms of indigestion may sometimes be caused by a serious underlying condition.
You should visit your GP for advice if you have:
 unintended weight loss
 unexplained and continual indigestion symptoms for the first time and you are aged 55 or
older
 severe pain, or the pain gets worse or changes

You need to seek urgent medical attention if you vomit blood, even if it's only present in the
vomit as specks of blood or blood that looks like coffee grains.
Causes of indigestion
Your stomach produces a strong acid that helps digest food and protects you against infection. A
layer of mucous lines the stomach, oesophagus and intestines to act as a barrier against this acid.
If the mucous layer is damaged, the acid can irritate the tissues underneath.
Some of the following can trigger symptoms of indigestion:
 drinking excess alcohol
 smoking
 stress and anxiety
 medicines such as aspirin and anti-inflammatory medicines used to treat arthritis
480
 eating certain foods can relax the valve (sphincter) at the join between your oesophagus and
stomach or cause direct irritation to the lining of your oesophagus
 not eating regular meals, as acid levels can build up if meals are missed

Gas in the Digestive Tract

You get gas in your digestive tract by swallowing air or during the breakdown process of certain
foods by the bacteria that is present in the colon
Heartburn
Heartburn is what most of us get from time to time. Chronic heartburn is a digestive disorder
called gastroesophageal reflux disease (GERD). GERD is caused by gastric acid that flows from
the stomach and into the esophagus.
15.2.10 DISORDERS OF THE LOWER GASTRO-INTESTINAL (G.I) TRACT
15.2.10T Specific Objectives
By the end of sub-module unit, the trainee should be able to:
1. identify the disorders of the lower G I tract
2. state the causes and symptoms
3. explain the dietary management of the named disorders

Unit Tasks
UNIT TASK 1 IDENTIFYING DISORDERS OF THE LOWER GASTRO-INTESTINAL
TRACT (GIT)
Crohn's disease
Crohn's disease (also known as granulomatous colitis and regional enteritis) is an inflammatory
disease of the intestines that may affect any part of the gastrointestinal tract from anus to mouth,
causing a wide variety of symptoms. It primarily causes abdominal pain, diarrhea (which may be
bloody), vomiting, or weight loss
Causes
 Genetics
Schematic of NOD2 CARD15 gene, which is associated with certain disease patterns in Crohn's
disease.
Some research has indicated that Crohn's disease may have a genetic link. The disease runs in
families and those with a sibling with the disease are 30 times more likely to develop it than the
normal population. 481
 Environmental factors
Diet is believed to be linked to its higher prevalence in industrialized parts of the world.
Smoking has been shown to increase the risk of the return of active disease, or "flares". The
introduction of hormonal contraception is linked with a dramatic increase in the incidence rate of
Crohn's disease. Although a causal linkage has not been effectively shown, there remain fears
that these drugs work on the digestive system in ways similar to smoking.
 Immune system
Abnormalities in the immune system have often been invoked as being causes of Crohn's
disease. Crohn's disease is thought to be an autoimmune disease, with inflammation stimulated
by an over-active cytokine response.
Unit task 4 Dietary management of named disorders
 Dietary management for Crohn's disease

i) Morbidity from Crohn's disease can be lessened by meticulous specialist management

ii) New techniques for clarifying the site of disease, activity, and complications include scanning
with radiolabelled leucocytes, ultrasound, computed tomography, and magnetic resonance
imaging
iii) Budesonide, high dose mesalazine and, for refractory disease, methotrexate and antitumour
necrosis factor antibody are new therapeutic options
iv) Other new therapeutic possibilities include a liquid formula diet, endoscopic stricture
dilatation, and laparoscopic surgery
v) The most effective measure for maintenance of remission is stopping smoking
vi) Patients should participate in decisions about their treatment

Colon and Rectal Cancer

Colon and Rectal cancer is also referred to as colorectal cancer. This type of cancer is a
malignant cell that is found in the colon or rectum region of the body.
.
Diarrhoea
Diarrhoea is watery stool, or an increased frequency in stool, or both as compared to the normal
amount of stool passed by the individual. .
Diverticular Disease
This disease occurs in small pouches that bulge out in the colon. It is an inflammation or
infection in the pouches. 482
.
Inflammatory Bowel Diseases
There are several different diseases that fall under this category all of which require a doctor for
treatment. Ulcerative colitis and Crohn’s disease are two of these diseases.
Irritable Bowel Syndrome
Irritable bowel syndrome – more commonly referred to as IBS – is an intestinal disorder that
causes cramping, gassiness, bloating and changes in the bowel habits of the individual with the
disorder.
Lactose Intolerance
People with lactose intolerance lack an enzyme that is called lactase. This enzyme is needed by
the body to digest lactose. Lactose is a sugar found in milk products. .
Stomach and Duodenal Ulcers
Ulcers are open sores or lesions. They are found in the skin or mucous membranes of areas of the
body. A stomach ulcer is called a gastric ulcer and an ulcer in the duodenum is called a duodenal
ulcer. Lifestyle, stress and diet used to be thought to cause ulcers. These factors may have a role
in ulcer formation; however they are not the main cause of them. .
UNIT TASK 2 STATING CAUSES AND SYMPTOMS
Refer to task 1
UNIT TASK 3 EXPLAINING THE DIETARY MANAGEMENT
Refer task 2
15.2.11 DISORDERS OF THE LIVER AND THE PANCREASES
Specific Objectives
By the end of sub-module unit, the trainee should be able to:
a) explain the functions of the liver
b) explain the functions of the pancreases
c) identify various types of liver and pancreas disorders
d) state the causes and symptoms
e) Discuss dietary management, formulation of diets and counseling of the named disorders.
483
UNIT TASKS
TASK 1; FUNCTIONS OF THE LIVER
Functions of the liver
The liver regulates most chemical levels in the blood and excretes a product called bile, which
helps carry away waste products from the liver. All the blood leaving the stomach and intestines
passes through the liver. The liver processes this blood 484
and breaks down the nutrients and drugs into forms that are easier to use for the rest of the body.
More than 500 vital functions have been identified with the liver. Some of the more well-known
functions include the following:
 production of bile, which helps carry away waste and break down fats in the small intestine
during digestion
 production of certain proteins for blood plasma
 production of cholesterol and special proteins to help carry fats through the body
 conversion of excess glucose into glycogen for storage (glycogen can later be converted back
to glucose for energy)
 regulation of blood levels of amino acids, which form the building blocks of proteins
 processing of hemoglobin for use of its iron content (the liver stores iron)
 conversion of poisonous ammonia to urea (urea is an end product of protein metabolism and is
excreted in the urine)
 clearing the blood of drugs and other poisonous substances
 regulating blood clotting
 resisting infections by producing immune factors and removing bacteria from the bloodstream

TASK 2; FUNCTIONS OF THE PANCREASES

Function of the Pancreas 485
The pancreas is a small organ located near the lower part of the stomach and the beginning of the
small intestine. This organ has two main functions. It functions as an exocrine organ by
producing digestive enzymes, and as an endocrine organ by producing hormones, with insulin
being the most important hormone produced by the pancreas. The pancreas secretes its digestive
enzymes, through a system of ducts into the digestive tract, while it secretes its variety of
hormones directly into the bloodstream. Abnormal pancreatic function can lead to pancreatitis or
diabetes mellitus.
The pancreas can also be thought of as having different functional components, the endocrine
and exocrine parts. Tumors can arise in either part. However, the vast majority arise in the
exocrine (also called non-endocrine) part. Since the parts have different normal functions, when
tumors interfere with these functions, different kinds of symptoms will occur. 486
Islets of Langerhans These are the endocrine (endo=
within) cells of the pancreas that
produce and secrete hormones
into the bloodstream. The
pancreatic hormones, insulin
and glucagon, work together to
maintain the proper level of
sugar in the blood. The sugar,
glucose, is used by the body for
energy.
Acinar cells These are the exocrine (exo=
outward) cells of the pancreas
that produce and transport
chemicals that will exit the body
through the digestive system.
The chemicals that the exocrine
cells produce are called
enzymes. They are secreted in
the duodenum where they assist
in the digestion of food.
Ascites is fluid build-up in the abdominal cavity, caused by fluid leaks from the surface of the
liver and intestine. Ascites due to liver disease usually accompanies other liver disease
characteristics such as portal hypertension. Symptoms of ascites may include a distended
abdominal cavity, which causes discomfort and shortness of breath. Causes of ascites may
include:
 liver cirrhosis (especially cirrhosis caused by alcoholism)
 alcoholic hepatitis
 chronic hepatitis
 obstruction of the hepatic vein

Ascites can also be caused by non-liver disorders.

What is liver encephalopathy?
Liver encephalopathy is the deterioration of brain function due to toxic substances building up in
the blood, which are normally removed by the liver. Liver encephalopathy is also called portal-
systemic encephalopathy, hepatic encephalopathy, or hepatic coma. Symptoms may include:
 impaired consciousness
 changes in logical thinking, personality, and behavior
 mood changes
 impaired judgement
 drowsiness
 confusion
 sluggish speech and movement
 disorientation
 loss of consciousness
 coma

What is liver failure?

Liver failure is severe deterioration of liver function. Liver failure occurs when a large portion of
the liver is damaged due to any type of liver disorder. Symptoms may include:
 jaundice
 tendency to bruise or bleed easily
 ascites
 impaired brain function
 general failing health
 fatigue
 weakness
 nausea
496
 loss of appetite

The pancreas is called the "hidden organ" because it is located deep in the abdomen behind the
stomach. About six to eight inches long in the adult, the organ contains thin tubes that come
together like the veins of a leaf. These tubes join to form a single opening into the intestine that
is located just beyond the stomach. The pancreas produces juices and enzymes that flow through
these tubes into the intestine, where they mix with food. The enzymes digest fat, protein, and
carbohydrates so they can be absorbed by the intestine. Pancreatic juices, therefore, play an
important role in maintaining good health. The pancreas also produces insulin, which is picked
up by the blood flowing through the organ. Insulin is important in regulating the amount of sugar
or glucose in the blood.
What Are the Diseases of the Pancreas?
 Diabetes mellitus
 Acute pancreatitis
 Chronic pancreatitis
 Pancreatic enzyme deficiency
 Pancreas tumor

Diabetes Mellitus
Many cases of diabetes are caused by a deficiency of insulin. Insulin is needed to help glucose,
which is a major source of energy, enter the body's cells. It is not known why insulin-producing
cells in the pancreas die off. When they cease to function, glucose accumulates in the blood and
eventually spills into the urine. These patients require daily insulin injections. More importantly,
high blood glucose levels, over time, result in significant changes in blood vessels in the eyes,
kidneys, heart, legs, and nerves. Damage to these vital organs represents the major risk for
patients with diabetes.
Other patients who develop diabetes later in life seem to have sufficient insulin in the pancreas,
but for some unknown reason it is not available for the body's use. These patients typically are
overweight; therefore, weight loss is critical for them. In addition, oral medications can be taken
that help release insulin from the pancreas. All diabetics need to maintain normal or near-normal
blood glucose levels to prevent or delay the complications of this disease.
Acute Pancreatitis
This condition occurs when the pancreas becomes quickly and severely inflamed. The major
causes are:
 Heavy alcohol ingestion
 Gallstones or gallbladder disease
497
 Trauma
 Drugs
 High blood fats (triglycerides)
 Heredity
 Unknown factors

Binge alcohol drinking is a common cause of acute pancreatitis. Gallbladder disease, especially
where a gallstone becomes lodged in the main bile duct next to the pancreas, also causes this
condition. Accidents, such as the upper abdomen hitting the steering wheel during a car accident,
can cause pancreatitis. Certain drugs, such as diuretics, can produce the disorder as can
extremely high blood fat levels (triglycerides). Heredity seems to play a role since, in some
families, the condition develops in several members of the family. Finally, there are the
occasional cases that occur for unknown reasons. In pancreatitis, the digestive enzymes of the
pancreas break out into the tissues of the organ rather than staying within the tubes (ducts).
Severe damage to the pancreas then results.
Symptoms, Diagnosis, and Treatment
The main symptoms of pancreatitis are acute, severe pain in the upper abdomen, frequently
accompanied by vomiting and fever. The abdomen is tender, and the patient feels and looks ill.
The diagnosis is made by measuring the blood pancreas enzymes which are elevated. A sound
wave test (ultrasound) or abdominal CT exam often shows an enlarged pancreas. The condition
is treated by resting the pancreas while the tissues heal. This is accomplished through bowel rest,
hospitalization, intravenous feeding and pain medications.
When pancreatitis is caused by gallstones, it is necessary to remove the gallbladder. This is
usually done after the acute pancreatitis has resolved. At times, an ERCP (Endoscopic
Retrograde CholangioPancreatography) test is recommended. This involves passing a flexible
tube through the mouth and down to the small intestine. A small catheter is then inserted into the
bile duct to see if any stones are present. If so, they are then removed with the scope.
Course and Outcome
Most patients with this condition recover well, although a few, especially those who have
alcohol-induced pancreatitis, may become desperately sick. When recovered, the patient needs to
make life-style changes to prevent a recurrence such as avoiding alcohol and drugs, reducing
blood triglycerides, or having gallbladder surgery.
Chronic Pancreatitis
This condition occurs mostly in alcoholics or people who repeatedly binge drink alcohol. The
main symptoms are recurrent, dull, or moderate pain without the severe toxic features of acute
pancreatitis. Treatment consists of rest, medication, and certain food restrictions. Alcohol
consumption is absolutely prohibited. In cases where damage is extensive, chronic pancreatitis
and pain can occur even when alcohol consumption has stopped. 498
Diagnosis of this condition is made by measuring blood enzymes and by performing abdominal
CT, x-rays, and ultrasound exams. An ERCP endoscopic test is often performed. In this test, a
flexible endoscope is passed through the mouth into the intestine while the patient is lightly
sedated. A small plastic catheter is inserted into the pancreas ducts and an x-ray dye is injected.
The internal anatomy of the pancreas can then be viewed by x-ray. Occasionally a problem
develops when the patient becomes dependent on, or even addicted to, narcotic pain medicines
used to control symptoms. In some cases, surgery is recommended to provide relief of pain.
Pancreas Enzyme Insufficiency
Digestive enzymes from the pancreas are necessary to break down protein, fat, and
carbohydrates in foods that are ingested. When there is a deficiency of these enzymes, nutrients
are not broken down, resulting in malnutrition and weight loss. This condition is called
malabsorption because the intestine is unable to absorb these vital nutrients. The two major
symptoms are diarrhea (frequently with fat droplets in the stool) and weight loss. This condition
can result from any cause of pancreatitis, including trauma and infection. Pancreatic enzymes
can be taken by mouth to replace those that are no longer made by the pancreas.
Pancreatic Tumors
The pancreas, like most organs of the body, can develop tumors. Some of these are benign and
cause no problems. Some benign tumors can secrete hormones which, when present in high
levels, have a detrimental effect. For example, insulin can be secreted in excessive amounts and
result in dangerously low blood sugar levels (hypoglycemia). Another hormone, gastrin, can
stimulate the stomach to secrete its strong hydrochloric acid causing recurrent stomach and
peptic ulcers, with many complications. Fortunately, there is much that can be done about these
tumors. Cancer of the pancreas is a serious malignancy that is difficult to treat. The disorder
occurs in middle or older-aged people, with the first symptom often being dull pain in the upper
abdomen that may radiate into the back. At times, skin jaundice occurs when the bile duct, which
carries yellow bile from the liver and through the pancreas, is blocked. Surgery is the only
effective form of treatment for pancreas cancer.
Diet - liver disease
A person with liver disease must eat a special diet. This diet is protects the liver from working
too hard and helps it to function as well as possible. 499
Function
Proteins normally help the body repair tissue. They also prevent fatty buildup and damage to the
liver cells.
In people with severely damaged livers, proteins are not properly processed. Waste products may
build up and affect the brain. Restricting the amount of protein in the diet can reduce the chance
that toxic waste products will build up.
The body stores carbohydrates in the form of glycogen. Increasing carbohydrates in the diet
helps preserve glycogen stores. People with liver disease may need to increase their intake of
carbohydrates in proportion to protein.
Low blood count, nerve problems, and nutritional deficiencies that occur with liver disease may
be treated with drugs and vitamin supplements.
Salt in the diet may worsen fluid buildup and swelling in the liver, because salt causes the body
to retain water. Most people with severe liver disease must restrict the amount of sodium in their
diet.
Food Sources
The liver is involved in the metabolism of all foods. Metabolism is the conversion of food into
energy.
Changing the diet by increasing or decreasing proteins, carbohydrates, fats, and vitamins may
further affect the function of the diseased liver, especially its protein and vitamin production.
Side Effects
Because liver disease can affect the absorption of food and the production of proteins and
vitamins, your diet may influence your weight, appetite, and the amounts of vitamins in your
body. Do not limit protein too much, because it can cause deficiencies of certain amino acids.
Recommendations
The dietary recommendations may vary, depending on how well your liver is working. It is very
important to be under the care of a doctor, because malnutrition can lead to serious problems.
In general, recommendations for patients with severe liver disease may include:
 Large amounts of carbohydrate foods. Carbohydrates should be the major source of calories in
this diet.
 Moderate intake of fat, as prescribed by the health care provider. The increased carbohydrates
and fat help preserve the protein in the body and prevent protein breakdown.
 About 1 gram of protein per kilogram of body weight. This means that a 154-pound (70-
kilogram) man should eat 70 grams of protein per day. This does not include the protein from
starchy foods and vegetables. A person with a severely damaged liver may need to eat less
protein than this, and may even be limited to
500
small quantities of special nutritional supplements. Avoid limiting protein too much, however,
because it can lead to malnutrition.
 Vitamin supplements, especially B-complex vitamins.
 Limit sodium (typically 1 - 2 grams per day) if you are retaining fluid.

SAMPLE MENU
 Breakfast
o 1 orange
o Cooked oatmeal with milk and sugar
o 1 slice of whole-wheat toast
o 2 teaspoons of margarine
o Strawberry jam
o Coffee or tea
 Lunch
o 4 ounces of cooked lean fish, poultry, or meat
o A starch item (such as potatoes)
o A cooked vegetable
o Salad
o 2 slices of whole-grain bread
o 2 teaspoons of margarine
o 1 tablespoon of jelly
o Fresh fruit
o Milk
 Mid-afternoon snack
o Milk with graham crackers
 Dinner
o 4 ounces of cooked fish, poultry, or meat
o Starch item (such as potatoes)
o A cooked vegetable
o Salad
o 2 whole-grain rolls
o 2 tablespoons of margarine
o Fresh fruit or dessert
o 8 ounces of milk
 Evening snack
o Glass of milk or piece of fruit

Usually, there are no cautions against specific foods.

If you have questions about your diet or symptoms, contact your doctor.
DIET AND PANCREATIC CANCER
This information is about diet and cancer of the pancreas. It has the following sections:
Blood sugar

Blood sugar 501

diarrhoea
You can read through it all or simply turn to the section that interests you.
How your diet can be affected
Having cancer of the pancreas will affect your eating and drinking habits, whatever your stage of
treatment. The pancreas is not only close to the stomach and bowel; it produces both insulin and
enzymes which help to digest food.
After surgery, you may have digestive problems, such as diarrhoea. If you've had all or part of
your pancreas removed, you may need to take insulin or tablets to regulate
your blood sugar. You may also need to take enzyme supplements when you eat to help your
digestion. It can take time to get the balance of these drugs right. Be patient, and make a note of
any digestive symptoms you have which might help your doctor to get things right more quickly.
Blood sugar If you are on insulin or tablets to regulate your blood sugar, your doctor will ask you
to check your urine for sugar. Too much sugar in the urine indicates that the sugar balance of
your body is not yet right. If you are on insulin, you will probably also have to test your blood
sugar levels. You will have to prick your finger and squeeze a drop of blood onto a test strip. The
colour of the test strip will show approximately how
much sugar is in your blood. You will then know how much insulin you should take. It takes
time to get used to doing these tests, but you will be shown how to do it before you leave
hospital. You may also have a nurse to visit you at home to help you and answer your questions.
What diet should I eat?
People with pancreatic disease often find it hard to digest fat. You should see a dietician before
you leave hospital. Your dietician will give you a diet plan to suit you.
Generally the diet is based on keeping fat intake low and carbohydrate intake high.
This is a balancing act, however. Fat contains more calories than carbohydrates or protein. So if
you are trying to build yourself up it is better to eat some foods that are high in fat. If you are
recovering from major surgery, you will also need plenty of protein to help your body repair
itself.
This is a balancing act, however. Fat contains more calories than carbohydrates or protein. So if
you are trying to build yourself up it is better to eat some foods that are high in fat. If you are
recovering from major surgery, you will also need plenty of protein to help your body repair
itself.
If you are taking enzymes to help you digest your food, you may need to adjust the amount you
take a few times before you get the level right and you may need to vary it depending on what
you have eaten. Again, your dietician should be able to help you with this.
Snacks and small meals
You may find it easier to have lots of small meals through the day, rather than sticking to the
traditional three meals a day. It is a good idea to have plenty of nutritious snacks to hand that you
can have whenever you feel like eating. If you can manage it, it is best to choose full fat versions
of yoghurts and puddings, so that you get the most calories. You could try 502
e
Some of these ideas may not suit your digestion, particularly if you are on a low fat diet, but they
are worth a try. If in doubt, check with your dietician. Try to think of quick ways of having the
things you like to eat. If possible, get someone to prepare your favourite foods in advance and
freeze in small portions. A microwave makes defrosting and heating easier and quicker.
Diarrhoea
If you are having problems with diarrhoea after pancreatic surgery, it is most probably related to
difficulty digesting fat. Even so, avoid very high fibre foods (such as cereal and dried fruit) for
the time being as these may make things worse. Tell your doctor or nurse. You may need some
medication to control your symptoms. It is worth asking to see a dietician to plan a more suitable
diet.
Suggested Teaching/Learning Resources
- Textbooks
- Internet
- Diet sheets
- Food composition tables

Evaluation
1. explain the functions of the liver
2. explain the functions of the pancreases
3. identify disorders of the liver and the pancreases
4. state the causes and symptoms
5. Discuss dietary management of the named disorders.

15.2.12 DIABETES
Theory
15.2.12T Specific Objectives
By the end of sub-module unit, the trainee should be able to:
1. define given terms
2. identify the types of diabetes
503
3. state the causes and symptoms of diabetes
4. discuss the dietary management and counseling

TASK 1: DEFINITIONS OF TERMS

Diabetes mellitus is a chronic disease caused by the inability of the pancreas to produce insulin
or to use the insulin produced in the proper way.
Description of Diabetes
After a meal, a portion of the food a person eats is broken down into sugar (glucose). The sugar
then passes into the bloodstream and to the body's cells via a hormone (called insulin) that is
produced by the pancreas.
Normally, the pancreas produces the right amount of insulin to accommodate the quantity of
sugar. However, if the person has diabetes, either the pancreas produces little or no insulin or the
cells do not respond normally to the insulin. Sugar builds up in the blood, overflows into the
urine and then passes from the body unused. Over time, high blood sugar levels can damage:
 eyes - leading to diabetic retinopathy and possible blindness
 blood vessels - increasing risk of heart attack, stroke and peripheral artery obstruction
 nerves - leading to diabetic neuropathy, foot sores and possible amputation, possible paralysis
of the stomach, chronic diarrhea

kidneys - leading to kidney failure

TASK 2: TYPES OF DIABETES
- TYPE 1– INSULIN DEPENDENT
- TYPE 2 – NON-INSULIN DEPENDENT
- GESTATION
- JUVENILE
- INSPIDUS
- MELLITUS
Diabetes has also been linked to impotence and digestive problems. It is important to note that
controlling blood pressure and blood glucose levels, plus regular screenings and check-ups, can
help reduce risks of these complications.
There are two main types of diabetes, Type I and Type II:
Type I diabetes or insulin-dependent diabetes (formerly called juvenile-onset diabetes, because it
tends to affect persons before the age of 20) affects about 10 percent of people with diabetes.
With this type of diabetes, the pancreas makes almost no insulin.
Type II diabetes or non-insulin-dependent diabetes. This was previously called "adult-onset
diabetes" because in the past it was usually discovered after age 40. However, with increasing
levels of obesity and sedentary lifestyle, this disease is now being found more and more in
adolescents - 504
and sometimes even in children under 10 - and the term "adult onset" is no longer used.
Type II diabetes comprises about 90 percent of all cases of diabetes. With this type of diabetes,
either the pancreas produces a reduced amount of insulin, the cells do not respond to the insulin,
or both.
There are three less common types of diabetes called gestational diabetes, secondary diabetes
and impaired glucose tolerance (IGT):
Gestational diabetes occurs during pregnancy and causes a higher than normal glucose level
reading.
Secondary diabetes is caused by damage to the pancreas from chemicals, certain medications,
diseases of the pancreas (such as cancer) or other glands.
Impaired glucose tolerance (IGT) is a condition in which the person's glucose levels are higher
than normal
T ASK 3: CAUSES AND SYMPTOMS
Causes and Risk Factors of Diabetes
The cause of Type I diabetes is genetically based, coupled with an abnormal immune response.
The cause of Type II diabetes is unknown. Medical experts believe that Type II diabetes has a
genetic component, but that other factors also put people at risk for the disease. These factors
include:
 sedentary lifestyle
 obesity (weighing 20 percent above a healthy body weight)
 advanced age
 unhealthy diet
 family history of diabetes
 improper functioning of the pancreas
 minority race (higher risk in Black, Hispanic, American Indian, westernized Asian and native
Hawaiian populations)
 medication (cortisone and some high blood pressure drugs)
 women having given birth to a baby weighing more than 9 lbs.
 previously diagnosed gestational diabetes
 previously diagnosed IGT
Symptoms of Diabetes
Usually, the symptoms of Type I diabetes are obvious. That is not true for Type II. Many people
with Type II do not discover they have diabetes until they are treated for a complication such as
heart disease, blood vessel disease (atherosclerosis), stroke, blindness, skin ulcers, kidney
problems, nerve trouble or impotence.
The warning signs and symptoms for both types are: 505
Type I: Frequent urination, increased thirst, extreme hunger, unexplained weight loss, extreme
fatigue, blurred vision, irritability, nausea and vomiting.
Type II: Any Type I symptom, plus: unexplained weight gain, pain, cramping, tingling or
numbness in your feet, unusual drowsiness, frequent vaginal or skin infections, dry, itchy skin
and slow healing sores.
Note: If a person is experiencing these symptoms, they should see a doctor immediately.
Diagnosis of Diabetes
Besides a complete history and physical examination, the doctors will perform a battery of
laboratory tests. There are numerous tests available to diagnose diabetes, such as a urine test,
blood test, glucose-tolerance test, fasting blood sugar and the glycohemoglobin (HbA1c) test.
A urine sample will be tested for glucose and ketones (acids that collect in the blood and urine
when the body uses fat instead of glucose for energy).
A blood test is used to measure the amount of glucose in the bloodstream.
A glucose-tolerance test checks the body's ability to process glucose. During this test, sugar
levels in the blood and urine are monitored for three hours after drinking a large dose of sugar
solution.
The fasting blood sugar test involves fasting overnight and blood being drawn the next morning.
The glycohemoglobin test reflects an average of all blood sugar levels for the preceding two
months.
TASK 4: DIETARY MANAGEMENT AND COUNSELING
Treatment of Diabetes
A landmark study, the 10-year, multi-center Diabetes Control and Complications Trial (DCCT),
has now shown that intensifying diabetes management with stricter control of blood sugar levels
can reduce long-term complications.
The results of DCCT are extraordinary in that they prove that tight control of glucose levels can
in fact dramatically slow the onset and progression of diabetic complications in both Type I and
Type II diabetes. Additionally, researchers have found strict attention to diet and exercise also
helps in the management of diabetes.
Management of Type I Diabetes
Virtually everyone with Type I diabetes (and more than one in three people with Type II) must
inject insulin to make up for their deficiency. Until recently, insulin came only from the
pancreases of cows and pigs (with pork insulin more closely duplicating human insulin). While
beef, pork and 506
beef/pork combinations are still widely used, there are now two types of "human" insulin
available: semisynthetic (made by converting pork insulin to a form identical to human) and
recombinant (made by using genetic engineering). All insulin helps glucose levels remain near
normal (about 70 to 120 mg/dl).
Different types of insulin work for different periods of time. The numbers shown below are only
averages. The onset (how long it takes to reach the bloodstream to begin lowering the blood
sugar), peaking (how long it takes to reach maximum strength) and duration (how long it
continues to lower the blood sugar) of insulin activity can vary from person to person and even
from day to day in the same person.
Rapid or Regular Activity: Onset is within half an hour and activity peaks during a 2 to 5 hour
period. It remains in the bloodstream for about 8 to 16 hours. These fast-acting, short-lasting
insulins are useful in special cases: accidents, minor surgery or illnesses, which cause the
diabetes to go out of control or whenever insulin requirements change rapidly for any reason.
These are also being used more and more in combination with a long-acting insulin or alone
(prior to meals and at bedtime).
Semilente: A special type of short-acting insulin that takes 1 to 2 hours for onset, peaks 3 to 8
hours after injection and lasts 10 to 16 hours.
Intermediate-Acting: Reaching the bloodstream 90 minutes after injection, intermediate-acting
insulin peaks 4 to 12 hours later and lasts in the blood for about 24 hours. There are two varieties
of this type of insulin: Lente (called L) and NPH (called N).
Long-Acting: These insulins, which take 4 to 6 hours for onset, are at maximum strength 14 to
24 hours after injection, lasting 36 hours in the bloodstream. Long-acting insulin is referred to as
U (for Ultralente).
Suggested Teaching/Learning Resources
- Textbooks
- Internet
- Charts
- Diet sheets
- Food composition tables
- Testing kits
Resource persons
Evaluation
1. define diabetes
2. identify the types of diabetes
3. state the causes and symptoms of diabetes
4. discuss the dietary management and counseling
507
.
Coronary heart disease
Coronary heart disease (CHD) is a narrowing of the small blood vessels that supply blood and
oxygen to the heart. CHD is also called coronary artery disease.
Coronary heart disease is usually caused by a condition called atherosclerosis, which occurs
when fatty material and a substance called plaque build up on the walls of your arteries. This
causes them to get narrow. As the coronary arteries narrow, blood flow to the heart can slow
down or stop. This can cause chest pain (stable angina), shortness of breath, heart attack, and
other symptoms.
Many things increase your risk for heart disease:
 heredity can increase your risk. You are more likely to develop the condition if someone in
your family has had a history of heart disease -- especially if they had it before age 50. Your risk
for CHD goes up the older you get.
 Diabetes is a strong risk factor for heart disease.
 High blood pressure increases your risk of coronary artery disease and heart failure.
 Abnormal cholesterol levels: your LDL ("bad") cholesterol should be as low as possible, and
your HDL ("good") cholesterol should be as high as possible.
 Metabolic syndrome refers to high triglyceride levels, high blood pressure, excess body fat
around the waist, and increased insulin levels. People with this group of problems have an
increased chance of getting heart disease.
 Smokers have a much higher risk of heart disease than nonsmokers.
 Chronic kidney disease can increase your risk.
 Already having atherosclerosis or hardening of the arteries in another part of your body
(examples are stroke and abdominal aortic aneurysm) increases your risk of having coronary
heart disease.
 Other risk factors including alcohol abuse, not getting enough exercise, and excessive amounts
of stress.

Symptoms
Chest pain or discomfort (angina) is the most common symptom. The pain usually occurs with
activity or emotion, and goes away with rest.
Other symptoms include shortness of breath and fatigue with activity (exertion).
Prevention and management
4. Management of risk factors.
5. Regular exercises
6. Lifestyle modification.
508
Food Allergy
Food allergy is an abnormal response to a food triggered by your body's immune system.
Allergic reactions to food can sometimes cause serious illness and death.
In adults, the foods that most often trigger allergic reactions include
 Fish and shellfish, such as shrimp, lobster and crab
 Peanuts
 Tree nuts, such as walnuts
 Eggs

Problem foods for children are eggs, milk (especially in infants and young children) and peanuts.
Sometimes a reaction to food is not an allergy. It is often a reaction called "food intolerance".
Your immune system does not cause the symptoms of food intolerance. However, these
symptoms can look and feel like those of a food allergy.
Signs and Symptoms
Symptoms of a food allergy usually develop within about an hour after eating the offending food.
The most common signs and symptoms of a food allergy include:
 Hives, itching, or skin rash
 Swelling of the lips, face, tongue and throat, or other parts of the body
 Wheezing, nasal congestion, or trouble breathing
 Abdominal pain, diarrhea, nausea, or vomiting
 Dizziness, lightheadedness, or fainting

In a severe allergic reaction to food—called anaphylaxis—one may have more extreme versions
of the above reactions. Or one may experience life-threatening signs and symptoms such as:
 Swelling of the throat and air passages that makes it difficult to breathe
 Shock, with a severe drop in blood pressure
 Rapid, irregular pulse
 Loss of consciousness

Management of allergies
 People allergic to certain food items should carefully read food labels before consuming any
product.
 medical alert bracelet or necklace or a card stating that one has a food allergy and are subject
to severe reactions should be worn.
509
 An auto-injector device containing epinephrine (adrenaline) one can get by prescription should
be carried and administered when one is experiencing a food allergic reaction.
 Seek medical help immediately if you experience a food allergic reaction, even if you have
already given yourself epinephrine.

15.2.13 GALL BLADDER AND RENAL DISORDERS

Theory
15.2.13T Specific Objectives
By the end of sub-module unit, the trainee should be able to:
a) explain the functions of the gall bladder and kidney
b) identify disorders of the gall bladder and kidney
c) state the causes and symptoms
d) discuss dietary management of the named disorders

specific objectives
The trainee should have the ability to:
1. identify the various types of gall bladder and renal disorders
2. formulate/plan modified diets for a given gall bladder and renal disorders
3. counsel patient

Content
UNIT TASKS
TASK 1; EXPLAIN THE FUNCTIONS OF THE GALL BLADDER AND KIDNEY
The gallbladder is a small organ situated near mid-abdominal area of the body. Its main function
is to store the bile that comes from the liver. Bile is a substance that helps in the digestion of fat.
Fat does not dissolve in water, so in order to emulsify fat something special is needed. The liver
produces the bile and then stores it in the gallbladder until the body needs to digest fats. When
this moment comes, the gallbladder starts to let the bile flow down into the intestine, inside the
duodenum, where fat is digested with its help and then absorbed by the organism. While bile sits
in the gallbladder, the water from it pours out through the gallbladder's walls, making the bile
more concentrated and therefore more effective. Bile also neutralizes some of the acids that are
found in certain types of food.
Just like every other organ in the body, the gallbladder can malfunction and cause illness. At
some people, usually women that are over 40 years of age, (but there have been quite a large
number of cases of men suffering from gallbladder too), the bile inside it can crystallize into
small stones, called gallstones. Gallstones are made of salt, calcium and cholesterol, all put
together in a small stone. These gallstones 510
can cause some problems, starting with the inflammation of the gallbladder and ending with
severe pain and blockage.
In 3 quarters of the patients gallbladder does not cause any visible symptoms, but in one quarter
something appears. These are the most encountered symptoms of the gallbladder disease:
-variable pain in the abdominal area. Variable because this pain is sometimes easy, sometimes
very bad, and sometimes it lasts long, sometimes it doesn't
-vomiting accompanied by temperature
-yellow-ish skin and eyes, when a gallstones obstructs the canal through which bile flows from
the liver into the gallbladder
Fortunately, gallstones can leave the body by themselves, but in some cases they get stuck on the
way and obstruct the flow of bile. If this happens surgery is required. The gallbladder surgery is
called cholecystectomy, and it consists of a procedure that removes the gallbladder from the
body and connects the liver directly to the stomach, so bile does not pass through it anymore.
This causes the fat substance digestion to be less effective.
In the most unfortunate cases, complications lead to gallbladder cancer. This can happen if
someone suffering from the gallbladder disease has weight problems and also smokes and drinks
a lot. Gallbladder cancer is a fatal illness, although advanced surgical tehniquies attempt to
remove it most of the patients with gallbladder die.
Gallbladder disease is in most cases almost harmless, but if you feel any of the symptoms you
should visit a doctor and listen to his advice. Patients that have been operated of gallbladder and
had it removed can soon return to their normal lives, but they need to pay attention to the
quantity of fat that they eat, because without the gallbladder the body can't handle the fat
substance digestion to well.
FUNCTIONS OF THE KIDNEY 511
What do the kidneys do?
The kidneys are bean-shaped organs, each about the size of a fist. They are located near the
middle of the back, just below the rib cage, one on each side of the spine. The kidneys are
sophisticated reprocessing machines. Every day, a person’s kidneys process about 200 quarts of
blood to sift out about 2 quarts of waste products and extra water. The wastes and extra water
become urine, which flows to the bladder through tubes called ureters. The bladder stores urine
until releasing it through urination.
The kidneys remove wastes and water from the blood to form urine. Urine flows from the
kidneys to the bladder through the ureters.
Wastes in the blood come from the normal breakdown of active tissues, such as muscles, and
from food. The body uses food for energy and self-repairs. After the body has taken what it
needs from food, wastes are sent to the blood. If the kidneys did not remove them, these wastes
would build up in the blood and damage the body.
The actual removal of wastes occurs in tiny units inside the kidneys called nephrons. Each
kidney has about a million nephrons. In the nephron, a glomerulus—which is a tiny blood vessel,
or capillary—intertwines with a tiny urine-collecting tube called a tubule. The glomerulus acts as
a filtering unit, or sieve, and keeps normal proteins and cells in the bloodstream, allowing extra
fluid and wastes to pass through. A complicated chemical exchange takes place, as waste
materials and water leave the blood and enter the urinary system. 512
In the nephron (left), tiny blood vessels intertwine with urine-collecting tubes. Each kidney
contains about 1 million nephrons.
At first, the tubules receive a combination of waste materials and chemicals the body can still
use. The kidneys measure out chemicals like sodium, phosphorus, and potassium and release
them back to the blood to return to the body. In this way, the kidneys regulate the body’s level of
these substances. The right balance is necessary for life.
In addition to removing wastes, the kidneys release three important hormones:
 erythropoietin, or EPO, which stimulates the bone marrow to make red blood cells
 renin, which regulates blood pressure
 calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for
normal chemical balance in the body

[Top]
What is renal function?
The word “renal” refers to the kidneys. The terms “renal function” and “kidney function” mean
the same thing. Health professionals use the term “renal function” to talk about how efficiently
the kidneys filter blood. People with two healthy kidneys have 100 percent of their kidney
function. Small or mild declines in kidney function—as much as 30 to 40 percent—would rarely
be noticeable. Kidney function is now calculated using a blood sample and a formula to find the
estimated glomerular filtration rate (eGFR). The eGFR corresponds to the percent of kidney
function available. The section “What medical tests detect kidney disease?” contains more
details about the eGFR. 513
Some people are born with only one kidney but can still lead normal, healthy lives. Every year,
thousands of people donate one of their kidneys for transplantation to a family member or friend.
For many people with reduced kidney function, a kidney disease is also present and will get
worse. Serious health problems occur when people have less than 25 percent of their kidney
function. When kidney function drops below 10 to 15 percent, a person needs some form of renal
replacement therapy—either blood-cleansing treatments called dialysis or a kidney transplant—
to sustain life.
[Top]
Why do kidneys fail?
Most kidney diseases attack the nephrons, causing them to lose their filtering capacity. Damage
to the nephrons can happen quickly, often as the result of injury or poisoning. But most kidney
diseases destroy the nephrons slowly and silently. Only after years or even decades will the
damage become apparent. Most kidney diseases attack both kidneys simultaneously.
The two most common causes of kidney disease are diabetes and high blood pressure. People
with a family history of any kind of kidney problem are also at risk for kidney disease.
Diabetic Kidney Disease
Diabetes is a disease that keeps the body from using glucose, a form of sugar, as it should. If
glucose stays in the blood instead of breaking down, it can act like a poison. Damage to the
nephrons from unused glucose in the blood is called diabetic kidney disease. Keeping blood
glucose levels down can delay or prevent diabetic kidney disease. Use of medications called
angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to
treat high blood pressure can also slow or delay the progression of diabetic kidney disease.
High Blood Pressure
High blood pressure can damage the small blood vessels in the kidneys. The damaged vessels
cannot filter wastes from the blood as they are supposed to.
A doctor may prescribe blood pressure medication. ACE inhibitors and ARBs have been found
to protect the kidneys even more than other medicines that lower blood pressure to similar levels.
The National Heart, Lung, and Blood Institute (NHLBI), one of the National Institutes of Health,
recommends that people with diabetes or reduced kidney function keep their blood pressure
below 130/80.
Glomerular Diseases
Several types of kidney disease are grouped together under this category, including autoimmune
diseases, infection-related diseases, and sclerotic diseases. As the name indicates, glomerular
diseases attack the tiny blood vessels, or glomeruli, within the kidney. The most common
primary glomerular diseases include membranous nephropathy, IgA nephropathy, and focal
segmental glomerulosclerosis. The first 514
sign of a glomerular disease is often proteinuria, which is too much protein in the urine. Another
common sign is hematuria, which is blood in the urine. Some people may have both proteinuria
and hematuria. Glomerular diseases can slowly destroy kidney function. Blood pressure control
is important with any kidney disease. Glomerular diseases are usually diagnosed with a biopsy—
a procedure that involves taking a piece of kidney tissue for examination with a microscope.
Treatments for glomerular diseases may include immunosuppressive drugs or steroids to reduce
inflammation and proteinuria, depending on the specific disease.
Inherited and Congenital Kidney Diseases
Some kidney diseases result from hereditary factors. Polycystic kidney disease (PKD), for
example, is a genetic disorder in which many cysts grow in the kidneys. PKD cysts can slowly
replace much of the mass of the kidneys, reducing kidney function and leading to kidney failure.
Some kidney problems may show up when a child is still developing in the womb. Examples
include autosomal recessive PKD, a rare form of PKD, and other developmental problems that
interfere with the normal formation of the nephrons. The signs of kidney disease in children
vary. A child may grow unusually slowly, vomit often, or have back or side pain. Some kidney
diseases may be silent—causing no signs or symptoms—for months or even years.
If a child has a kidney disease, the child’s doctor should find it during a regular checkup. The
first sign of a kidney problem may be high blood pressure; a low number of red blood cells,
called anemia; proteinuria; or hematuria. If the doctor finds any of these problems, further tests
may be necessary, including additional blood and urine tests or radiology studies. In some cases,
the doctor may need to perform a biopsy.
Some hereditary kidney diseases may not be detected until adulthood. The most common form of
PKD was once called “adult PKD” because the symptoms of high blood pressure and renal
failure usually do not occur until patients are in their twenties or thirties. But with advances in
diagnostic imaging technology, doctors have found cysts in children and adolescents before any
symptoms appear.
Other Causes of Kidney Disease
Poisons and trauma, such as a direct and forceful blow to the kidneys, can lead to kidney disease.
Some over-the-counter medicines can be poisonous to the kidneys if taken regularly over a long
period of time. Anyone who takes painkillers regularly should check with a doctor to make sure
the kidneys are not at risk.
How do kidneys fail?
Many factors that influence the speed of kidney failure are not completely understood.
Researchers are still studying how protein in the diet and cholesterol levels in the blood affect
kidney function. 515
Acute Kidney Injury
Some kidney problems happen quickly, such as when an accident injures the kidneys. Losing a
lot of blood can cause sudden kidney failure. Some drugs or poisons can make the kidneys stop
working. These sudden drops in kidney function are called acute kidney injury (AKI). Some
doctors may also refer to this condition as acute renal failure (ARF).
AKI may lead to permanent loss of kidney function. But if the kidneys are not seriously
damaged, acute kidney disease may be reversed.
Chronic Kidney Disease
Most kidney problems, however, happen slowly. A person may have “silent” kidney disease for
years. Gradual loss of kidney function is called chronic kidney disease (CKD) or chronic renal
insufficiency. People with CKD may go on to develop permanent kidney failure. They also have
a high risk of death from a stroke or heart attack.
End-stage Renal Disease
Total or nearly total and permanent kidney failure is called end-stage renal disease (ESRD).
People with ESRD must undergo dialysis or transplantation to stay alive.
What are the signs of chronic kidney disease (CKD)?
People in the early stages of CKD usually do not feel sick at all.
People whose kidney disease has gotten worse may
 need to urinate more often or less often
 feel tired
 lose their appetite or experience nausea and vomiting
 have swelling in their hands or feet
 feel itchy or numb
 get drowsy or have trouble concentrating
 have darkened skin
 have muscle cramps

What medical tests detect kidney disease?

Because a person can have kidney disease without any symptoms, a doctor may first detect the
condition through routine blood and urine tests. The National Kidney Foundation recommends
three simple tests to screen for kidney disease: a blood pressure measurement, a spot check for
protein or albumin in the urine, and a calculation of glomerular filtration rate (GFR) based on a
serum creatinine measurement. Measuring urea nitrogen in the blood provides additional
information. 516
Blood Pressure Measurement
High blood pressure can lead to kidney disease. It can also be a sign that the kidneys are already
impaired. The only way to know whether a person’s blood pressure is high is to have a health
professional measure it with a blood pressure cuff. The result is expressed as two numbers. The
top number, which is called the systolic pressure, represents the pressure in the blood vessels
when the heart is beating. The bottom number, which is called the diastolic pressure, shows the
pressure when the heart is resting between beats. A person’s blood pressure is considered normal
if it stays below 120/80, stated as “120 over 80.” The NHLBI recommends that people with
kidney disease use whatever therapy is necessary, including lifestyle changes and medicines, to
keep their blood pressure below 130/80.
Microalbuminuria and Proteinuria
Healthy kidneys take wastes out of the blood but leave protein. Impaired kidneys may fail to
separate a blood protein called albumin from the wastes. At first, only small amounts of albumin
may leak into the urine, a condition known as microalbuminuria, a sign of deteriorating kidney
function. As kidney function worsens, the amount of albumin and other proteins in the urine
increases, and the condition is called proteinuria. A doctor may test for protein using a dipstick in
a small sample of a person’s urine taken in the doctor’s office. The color of the dipstick indicates
the presence or absence of proteinuria.
A more sensitive test for protein or albumin in the urine involves laboratory measurement and
calculation of the protein-to-creatinine or albumin-to-creatinine ratio. Creatinine is a waste
product in the blood created by the normal breakdown of muscle cells during activity. Healthy
kidneys take creatinine out of the blood and put it into the urine to leave the body. When the
kidneys are not working well, creatinine builds up in the blood.
The albumin-to-creatinine measurement should be used to detect kidney disease in people at high
risk, especially those with diabetes or high blood pressure. If a person’s first laboratory test
shows high levels of protein, another test should be done 1 to 2 weeks later. If the second test
also shows high levels of protein, the person has persistent proteinuria and should have
additional tests to evaluate kidney function.
Glomerular Filtration Rate (GFR) Based on Creatinine Measurement
GFR is a calculation of how efficiently the kidneys are filtering wastes from the blood. A
traditional GFR calculation requires an injection into the bloodstream of a substance that is later
measured in a 24-hour urine collection. Recently, scientists found they could calculate GFR
without an injection or urine collection. The new calculation—the eGFR—requires only a
measurement of the creatinine in a blood sample.
In a laboratory, a person’s blood is tested to see how many milligrams of creatinine are in one
deciliter of blood (mg/dL). Creatinine levels in the blood can vary, and each laboratory has its
own normal range, usually 0.6 to 1.2 mg/dL. A person whose creatinine level is only slightly
above this range will probably not feel sick, but the 517
elevation is a sign that the kidneys are not working at full strength. One formula for estimating
kidney function equates a creatinine level of 1.7 mg/dL for most men and 1.4 mg/dL for most
women to 50 percent of normal kidney function. But because creatinine values are so variable
and can be affected by diet, a GFR calculation is more accurate for determining whether a person
has reduced kidney function.
The eGFR calculation uses the patient’s creatinine measurement along with age and values
assigned for sex and race. Some medical laboratories may make the eGFR calculation when a
creatinine value is measured and include it on the lab report. The National Kidney Foundation
has determined different stages of CKD based on the value of the eGFR. Dialysis or
transplantation is needed when the eGFR is less than 15 milliliters per minute (mL/min).
Blood Urea Nitrogen (BUN)
Blood carries protein to cells throughout the body. After the cells use the protein, the remaining
waste product is returned to the blood as urea, a compound that contains nitrogen. Healthy
kidneys take urea out of the blood and put it in the urine. If a person’s kidneys are not working
well, the urea will stay in the blood.
A deciliter of normal blood contains 7 to 20 milligrams of urea. If a person’s BUN is more than
20 mg/dL, the kidneys may not be working at full strength. Other possible causes of an elevated
BUN include dehydration and heart failure.
Additional Tests for Kidney Disease
If blood and urine tests indicate reduced kidney function, a doctor may recommend additional
tests to help identify the cause of the problem.
Kidney imaging. Methods of kidney imaging—taking pictures of the kidneys—include
ultrasound, computerized tomography (CT) scan, and magnetic resonance imaging (MRI). These
tools are most helpful in finding unusual growths or blockages to the flow of urine.
Kidney biopsy. A doctor may want to examine a tiny piece of kidney tissue with a microscope.
To obtain this tissue sample, the doctor will perform a kidney biopsy—a hospital procedure in
which the doctor inserts a needle through the patient’s skin into the back of the kidney. The
needle retrieves a strand of tissue less than an inch long. For the procedure, the patient lies
facedown on a table and receives a local anesthetic to numb the skin. The sample tissue will help
the doctor identify problems at the cellular level.
For more information, see the fact sheet Kidney Biopsy from the National Kidney and Urologic
Diseases Information Clearinghouse. 518
TASK 2; IDENTIFY TYPES OF DISORDERS OF THE GALL BLADDER AND KIDNEY
Although not essential to life or health, the gallbladder is the site and source of appreciable
suffering and disease in humans. With its cystic duct, the gallbladder constitutes a blind-ended,
lateral extension of the common bile duct. Besides acting as a reservoir for bile, the gallbladder
concentrates and otherwise alters the composition of bile. See also Gallbladder.
Gallstones are round, oval, or faceted concretions formed within the gallbladder from the salts
and pigment of bile. Although the mechanism and reason for their formation are not clearly
understood, the major predisposing factors are stasis (prolonged retention of bile in the
gallbladder), abnormal composition of the bile (excessive amounts of cholesterol, bilirubin, or
calcium), and infection. Passage of a gallstone through the ducts into the duodenum usually
produces severe pain, called biliary colic. If a stone causes obstruction of the ducts, the result
may be damage to the liver, pancreas, biliary system, and related structures either directly or
through concomitant inflammation. Gallstones are rare in animals, although they have been
found in nearly all species, especially in cattle. See also Bilirubin; Cholesterol; Cirrhosis. 519
Cholecystitis, or inflammation of the gallbladder, is a common disease in humans. It is nearly
always associated with gallstones and is particularly common in obese middle-aged women. It is
rare in animals. Most cases are thought to be the result of chemical irritation caused by
excessively concentrated bile, which is in turn the result of partial or complete obstruction to the
outflow of bile. Prolonged or recurrent episodes of inflammation result in chronic cholecystitis,
characterized by thickening and scarring of the wall, contraction, and impairment of normal
function.
Malignant tumors in the gallbladder are almost invariably associated with the presence of
gallstones. Because they produce little in the way of symptoms, and because they very soon
invade the liver, these tumors are rarely curable by surgical therapy at the time they are
discovered. Benign tumors of the gallbladder and ducts are rare in humans, and in animals both
benign and malignant tumors of these sites are extremely uncommon. See also Liver disorders.
Some urinary tract disorders rarely cause symptoms until the problem is very advanced; these
include kidney failure, tumors and stones that do not block urine flow, and some low-grade
infections. Sometimes, symptoms occur but are very general and difficult for the doctor to
connect to the kidney. For example, a general feeling of illness (malaise), loss of appetite,
nausea, or generalized itching may be the only symptoms of chronic kidney failure. In older
people, mental confusion may be the first recognized symptom of infection or kidney failure.
Symptoms that are more suggestive of a kidney or urinary problem include pain in the side
(flank), swelling of the lower extremities, and problems with urination.
Burning or Pain with Urination
Burning or pain with urination (dysuria) may be felt at the opening to the urethra or, less often,
over the bladder (in the pelvis, the lower part of the abdomen just above the pubic bone).
Occasionally, if a woman has vaginal irritation (for example, due to inflammation or infection of
the vagina or of the area surrounding the vaginal opening, called vulvovaginitis), she may feel a
burning sensation when urinating.
Causes
Dysuria is very common, particularly among adult women, in whom it is often caused by urinary
tract infections, such as cystitis and urethritis. However, dysuria can occur in men and women of
any age and can have many noninfectious causes
Doctors can sometimes get clues to the cause based on where symptoms are most severe. For
example, if symptoms are most severe just above the pubic bone, a bladder infection (cystitis)
may be the cause. Women with frequent episodes of cystitis may recognize characteristic
symptoms that suggest another episode. If symptoms are most severe at the opening of the
urethra, urethritis may be the cause. In men with a penile discharge, urethritis is often the cause.
If burning affects mainly the vagina and the woman has a discharge, vaginitis may be the cause.
520
Examination may confirm a condition that could be causing dysuria. For example, vaginal or
penile discharge can be confirmed. Inflammation or atrophy of the vagina or vulva may confirm
vulvovaginitis. An enlarged prostate may confirm benign prostatic hyperplasia. Tenderness of
the epididymis or testes may suggest epididymo-orchitis, and tenderness of the prostate may
suggest prostatitis.
Doctors do not always agree on the need for tests. Some doctors just treat adult women who have
symptoms that suggest cystitis. Other doctors usually do testing for all people or for people in
whom the diagnosis is not clear. The first test is usually a urinalysis. Urine culture is often done
to identify the organism causing infection and to determine which antibiotics will be effective.
For women, a sample of vaginal discharge is examined on a slide using a microscope. Men and
women with a urethral discharge are tested for gonorrhea and chlamydia.
Treatment
The cause is treated. Often, the cause is an infection, and treatment produces relief in 1 or 2 days.
If dysuria is severe, phenazopyridine Some Trade Names PYRIDIUM PLUS can be taken for the
first 2 days to relieve discomfort. Phenazopyridine Some Trade Names PYRIDIUM PLUS turns
the urine a red-orange color.
Flank pain
Pain caused by kidney disorders usually is felt in the side (flank) or small of the back.
Occasionally, the pain radiates to the center of the abdomen. Usually pain occurs because the
kidney's outer covering (renal capsule) is stretched by a disorder that causes rapid swelling of the
kidney. Severe kidney pain is often accompanied by nausea and vomiting.
Causes
A kidney stone causes excruciating pain when it enters a ureter. The ureter contracts in response
to the stone, causing severe, crampy pain (renal or ureteral colic) in the flank or lower back that
often radiates to the groin or, in men, to the testis. The pain typically comes in waves. A wave
may last 20 to 60 minutes and then stop. The pain stops without resuming again when the ureter
relaxes or the stone passes into the bladder.
A kidney infection (pyelonephritis) produces swelling of the kidney tissue, which stretches the
renal capsule, causing steady, aching pain. Kidney tumors do not usually cause pain until they
have become very large. 521
Other disorders that cause pain in the flank include acute blockage of blood flow to the kidney or
intestine, ruptured and occasionally unruptured abdominal aortic aneurysms, problems with the
spine or spinal nerves, musculoskeletal injuries, and tumors that involve the back of the abdomen
(retroperitoneum).
Evaluation and Treatment
After noting symptoms, the doctor examines the person and usually obtains a urinalysis to check
for red blood cells or excess white blood cells, which suggest an infection, and a urine culture
when appropriate. A person with very severe, colicky pain and blood in the urine is very likely to
have a kidney stone. A person with milder, steady pain, tenderness when the doctor taps over one
kidney, fever, and excess white blood cells in the urine is likely to have a kidney infection. If a
kidney stone is suspected, the doctor usually obtains a computed tomography (CT) scan to
determine the size and location of the stone and whether it significantly obstructs urine flow. An
intravenous contrast agent is not used for this CT scan. If the doctor is not sure of the cause of
pain, often a CT scan that uses an intravenous contrast agent or another imaging test is done.
The underlying disorder is treated. Mild pain can be relieved by taking acetaminophen Some
Trade Names TYLENOL or nonsteroidal anti-inflammatory drugs (NSAIDs). Pain from kidney
stones may be severe and may require use of intravenous opioids.
Swelling
Swelling results from accumulation of fluid in the tissues (edema). The swelling may cause
weight gain. Swelling is usually most noticeable in the ankles and feet, but it may also involve
the abdomen, lower back, hands, and face. If swelling is particularly severe, fluid may
accumulate in the lungs, causing difficulty breathing.
Causes
Swelling may occur if the kidneys are unable to excrete excess water and sodium from the body,
as in kidney failure. Swelling may also develop from a kidney disorder that causes the loss of
large amounts of blood protein (especially albumin) in the urine (nephrotic syndrome). When the
albumin level in the blood drops sufficiently, swelling occurs as fluid leaks from the circulation
into the tissues.
Other disorders may also cause swelling. Heart failure, caused by inadequate pumping by the
heart, signals the kidneys to retain salt and fluid, which may accumulate in tissues. Advanced
liver disease also signals the kidneys to retain salt and fluid; swelling is worsened by the
reduction in blood protein that occurs. This protein decrease causes fluid to leak into the tissues.
If swelling occurs in only one 522
limb, the cause is probably something related to the limb (such as a blood clot in a vein or an
injury) rather than a kidney, heart, or liver problem.
Evaluation and Treatment
Doctors usually assess the presence and degree of swelling by pressing on the person's shins. If
the skin retains the impression of the doctor's finger, extra fluid is present. The person's
symptoms and the doctor's physical examination suggest whether the kidneys, liver, or heart is
the cause, but doctors also obtain a urinalysis and blood tests of liver and kidney function. If
heart failure is suspected, a chest x-ray and sometimes an echocardiogram are obtained. To
diagnose nephrotic syndrome, doctors may assess urinary loss of protein by calculating the ratio
of total protein to creatinine in a urine specimen.
The underlying disorder is treated when possible. Swelling can often be relieved by a diuretic if
the kidneys are working properly. If the kidneys are not working properly and fluid has collected
in the lungs, the person may need dialysis.
Increased Urination
Most people urinate about 4 to 6 times a day, mostly in the daytime. Normally, adults pass
between 3 cups (700 milliliters) and 2 quarts (2 liters) of urine a day. Infants may pass as little as
1 cup (230 milliliters) per day. Urination can be increased if a person produces an excess volume
of urine or produces a normal volume of urine but feels the need to go more often (urinary
frequency).
Causes
Increased Volume: Excess urine can be caused by drinking too much fluid (polydipsia), by
taking diuretic drugs or substances that have a diuretic effect, such as alcohol or caffeine, or by
having a high level of sugar in the blood (as in diabetes mellitus). A rare condition called
diabetes insipidus causes excess urine because of problems with a brain hormone called
antidiuretic hormone (also called vasopressin). Antidiuretic hormone helps the kidney reabsorb
fluid. If too little antidiuretic hormone is produced (a condition called central diabetes insipidus)
or if the kidney is unable to properly respond to it (nephrogenic diabetes insipidus), the person
urinates excessively.
Increased Frequency: A frequent need to urinate without an increase in the total daily output of
urine can occur when something irritates or presses on the bladder. A urinary tract infection
(UTI) is the most common cause of bladder irritation. Rarer causes include a stone or tumor in
the bladder. A tumor or other mass (or even the uterus if a woman is pregnant) pressing on the
outside of the bladder can also cause a frequent urge to urinate because the mass reduces the
capacity of the bladder. An inability to fully empty the bladder because of partial obstruction,
often from an enlarged prostate (in men), can produce frequency. 523
Evaluation and Treatment
The doctor asks about the use of diuretics. Symptoms such as pain or burning may indicate
infection. For men, the doctor will examine the prostate by putting a gloved, lubricated finger in
the man's rectum. If the prostate is enlarged, a blood test (prostate specific antigen, or PSA, test)
and sometimes a prostate ultrasound are done. The doctor usually checks the urine for glucose
(suggesting diabetes mellitus) and bacteria or excess white blood cells (indicating infection). If
the cause is not clear, the doctor may measure levels of electrolytes in the blood and urine and
sometimes perform imaging tests of the kidney, ureters, or bladder (such as CT, ultrasound, or
magnetic resonance imaging [MRI]).
Treatment is directed at the underlying disorder.
Urinating at Night
Needing to urinate during the night (nocturia) is more common among older people. It can
contribute to sleep problems and to falls, especially if a person is rushing to the bathroom or if
the area is not well lit.
Causes
Nocturia may occur in the early stages of many kidney disorders. Nocturia is also common in
people with heart failure, liver failure, poorly controlled diabetes mellitus, or diabetes insipidus.
A person may have nocturia if the kidneys cannot concentrate urine normally. Frequent urination
of very small amounts at night may result when the flow of urine into and through the urethra is
obstructed and urine backs up in the bladder. An enlarged prostate is the most common cause of
obstruction in older men (see Prostate Disorders: Benign Prostatic Hyperplasia (BPH)).
Sometimes, however, the cause of nocturia may simply be drinking a large amount of fluids,
especially alcohol or caffeinated beverages (such as coffee or tea) in the late evening.
Bed-wetting (enuresis) is normal in young children. After about age 5 or 6, it may indicate a
delay in the maturation of the muscles and nerves of the lower urinary tract, which most often
resolves without treatment. If bed-wetting persists, other causes are considered, such as UTI,
diabetes, inadequate control of the nerves of the bladder, or psychologic causes.
Evaluation and Treatment
The cause of nocturia is often evident from the person's symptoms and the results of the
examination. In men, doctors examine the prostate. Testing may be needed, depending on what
possible causes are suspected. 524
Treatment is directed at the underlying disorder. In all people, minimizing intake of fluids,
alcohol, and caffeinated beverages during the late evening and voiding immediately before going
to bed may help limit nocturia.
Hesitating, Straining, and Dribbling
A hesitating start when urinating, a need to strain, a weak and trickling stream of urine, and
dribbling at the end of urination are common symptoms of a partially obstructed urethra. In men,
these symptoms are caused most commonly by an enlarged prostate that compresses the urethra
and less often by a narrowing (stricture) of the urethra. Similar symptoms in a boy may mean
that he was born with an abnormally narrow urethra or has a urethra with an abnormally narrow
external opening. The opening may also be abnormally narrow in women.
A doctor examines the prostate by inserting a gloved, lubricated finger into the man's rectum. If
the prostate is enlarged, a blood test to measure the PSA level and sometimes a prostate
ultrasound are obtained. If a urethral stricture is suspected, the doctor may insert a flexible
viewing tube into the bladder (cystoscopy).
To treat an enlarged prostate, drugs or surgery can be used. To treat a urethral stricture in a man,
doctors may insert a catheter into the bladder through the penis and perform dilation (stretching
the urethra). It may be necessary to insert a hollow tube to hold the urethra open (a stent).
Surgeons may rebuild the urethra or perform other surgical treatments.
Urgency
A compelling need to urinate (urgency), which may feel like almost constant painful straining
(tenesmus), can be caused by bladder irritation. Incontinence may occur if a person does not
urinate immediately. Urgency may be caused by a bladder infection. Caffeine and alcohol use
may contribute to urgency but rarely cause severe urgency by themselves. Rarely, a poorly
understood inflammation of the bladder (interstitial cystitis) is the cause.
Doctors can usually determine the cause of urgency by the person's symptoms, the results of the
physical examination, and urinalysis. If infection is suspected, urine culture may be needed.
Sometimes, particularly if interstitial cystitis is suspected, cystoscopy and bladder biopsy are
necessary.
Treatment is directed at the underlying disorder.
Incontinence
An uncontrollable loss of urine (incontinence) can have a variety of causes
Blood in the Urine 525
Blood in the urine can make the urine appear red or brown, depending on the amount of blood,
how long it has been in the urine, and how acidic the urine is. An amount of blood too small to
turn the urine red may be detected by chemical tests or microscopic examination.
Causes
Blood in the urine may be caused by infection, stones, tumors, injuries, or other problems in the
bladder, urethra, ureters, or kidneys. About half of the people who have blood in the urine
without pain have a disorder affecting primarily certain specialized blood vessels of the kidney
(glomeruli). Sometimes, sickle cell anemia or a related disorder is the cause. Blood in the urine
with pain is often the result of a kidney, bladder, or prostate infection or a stone or a blood clot
moving through one of the ureters or the urethra.
Evaluation and Treatment
Sometimes, a diagnosis can be made on the basis of the person's symptoms and the results of the
doctor's physical examination, urinalysis, and, if infection is suspected, urine culture. Often,
however, cystoscopy, imaging studies (such as CT, ultrasound, or MRI), or other tests are
needed. If a tumor is suspected, urine is examined for tumor cells. A blood test for sickle cell
anemia may be needed for people of African descent who are not known to have the disease.
Treatment is directed at the underlying disorder.
Gas in the Urine
Passing gas (air) in the urine, a rare symptom, usually indicates an abnormal connection (fistula)
between the urinary tract and the intestine, which normally contains gas. A fistula may be a
complication of diverticulitis, other types of intestinal inflammation, an abscess, or cancer. A
fistula between the bladder and the vagina may also cause gas to escape into the urine. Rarely,
certain bacteria in the urine may produce gas.
Doctors perform a pelvic examination in affected women. To diagnose fistulas, doctors may
perform cystoscopy, sigmoidoscopy, or both and obtain imaging studies, such as CT, MRI, or
ultrasound.
Fistulas are usually repaired surgically.
Changes in the Urine's Color
Normally, dilute urine is nearly colorless. Concentrated urine is deep yellow. Colors other than
yellow are abnormal. 526
Food pigments can make the urine red, and drugs can produce a variety of colors: brown, black,
blue, green, orange, or red. Brown urine may contain broken-down hemoglobin (the protein that
carries oxygen in red blood cells). Broken-down hemoglobin can leak into the urine when
bleeding occurs in the kidney, bladder, or it can be excreted into the urine as the result of certain
disorders that damage or destroy red blood cells (hemolytic anemia). Brown urine may contain
muscle protein (myoglobin), which is excreted into the urine after severe muscle injury. Urine
may be red because of pigments caused by porphyria, or black because of pigments produced by
melanoma.
Cloudy urine suggests the presence of excess white blood cells from a UTI, the presence of
crystals of salts from uric acid or from phosphoric acid, or the presence of a vaginal discharge.
Doctors usually can identify the cause of an abnormal color by examining the urine under a
microscope or by performing chemical tests. Treatment is unnecessary except if needed to treat
the underlying disorder.
Changes in the Urine's Odor
The odor of urine can vary and does not usually indicate a disorder except in people who have
certain rare metabolic disorders.
L 527
TASK 3; STATE THE CAUSES AND SYMPTOMS
SYMPTOMS OF GALLBLADDER PROBLEMS People can go for years with digestive
symptoms and never realize that they may be related to a gallbladder problem. That's because
they are so inter-related with other digestive symptoms. Constipation is one of the most
commonly missed ones.
The list provided here may be related to gallbladder but bear in mind that it could also be
something else. 528
The first four mentioned I feel are most indicative of gallbladder issues. It is not necessary to
have all or many symptoms to have gallbladder problems but the more you have from this list,
the more confirmation you have that the gallbladder is involved. Please note that it is still
adviseable to consult your doctor for an accurate diagnosis. Gallbladder attack symptoms are
listed below and again with more detailed explanation when you answer the three-minute gall
bladder symptom questionnaire at the top of this page. To get a clearer picture of the causes of
gall bladder symptoms check out risk factors for gallbladder disease.
 Pain or tenderness under the rib cage on the right side
 Pain between shoulder blades
 Stools light or chalky colored
 Indigestion after eating, especially fatty or greasy foods
 Nausea
 Dizziness
 Bloating
 Gas
 Burping or belching
 Feeling of fullness or food not digesting
 Diarrhea (or alternating from soft to watery)
 Constipation
 Headache over eyes, especially right
 Bitter fluid comes up after eating
 Frequent use of laxatives

GALLBLADDER ATTACK SYMPTOMS

specifically
Please note that if you are in severe pain and particularly if your attack symptoms are
accompanied by fever DO SEEK MEDICAL ATTENTION IMMEDIATELY. The following
symptoms are typical of a gallbladder attack.
 Moderate to severe pain under the right side of the rib cage
 Pain may radiate through to the back or to the right shoulder
 Severe upper abdominal pain (biliary colic)
 Nausea
 Queasiness
 Vomiting
 Gas
 Burping or belching
 Attacks are often at night
 Attacks often occur after overeating
 Pain will often but not always follow a meal with fats or grease
 Pain may be worse with deep inhalation
529
 Attacks can last from 15 minutes to 15 hours

SYMPTOMS OF GALLSTONES
Symtpoms of a gallbladder attack are often caused by gallbladder stones. A stone may block the
neck of the gallbladder or get stuck in a bile duct inhibiting the flow of bile or possibly causing a
backing up of bile. However, short of causing an actual attack, stones may be present for years
and never cause any symptoms at all. "Biliary pain can occur in about a third of the gallstone
patients" (which leaves two thirds NOT experiencing pain) and "sometimes the gallstone
symptoms are difficult to differentiate from that of dyspepsia." (indigestion)3 The gallstones can
impair the functioning of the gallbladder, however, which can result in any of the common
gallbladder symptoms.
Gall bladder symptoms can look and feel the same with or without stones. Therefore, all of the
symptoms on listed on this page can accompany gallstones and gallstones can also be
asymptomatic meaning you do not have any symptoms. These are called silent gallstones.
TASK 4; DISCUSS DIETARY MANAGEMENT, MODIFIED DIETS AND COUNSELING
OF THE NAMED DISORDERS
Diet
 The best general eating principles are outlined on pages 20 to 28 of Dr Cabot's "Healthy Liver
& Bowel Book" or following the eight week program found in "The Liver Cleansing Diet"
 Try to maintain a normal body weight. If overweight follow the program in "Can't Lose
Weight? Unlock the Secrets that Keep you Fat"
 Include often - high fiber foods like wholegrains, legumes, bran, raw fruits and vegetables,
especially apples and pears; also low-fat yoghurt; eggs and fish.
 Aim to limit your dairy product intake such as cow's milk, cream, processed cheese and butter.
Opt for organic yogurt and cheese such as parmesan, ricotta and cottage.
 Avoid foods that contain high counts of bacteria or fungi – these are all dairy products,
preserved meats, delicatessen meats, hamburger meats, smoked meats, and processed or junk
foods. This is because these foods will trigger or exacerbate gall bladder infections.
 Avoid saturated animal fats including fatty meats, butter, cream, ice cream, cheese, chocolate,
biscuits, fried foods (most gall stones are composed of cholesterol); refined sugars and refined
carbohydrates.
 Include healthy fats such as cold pressed nut and seed oils and foods rich in essential fats such
as cold water fish, avocados etc. Good fats are important
530
for the health of the gall bladder. An extremely low fat/no fat diet is NOT recommended.
 We also recommend that you avoid red meat for about three months
 Avoid artificial sweeteners - see www.dorway.com
 Drink plenty of filtered water throughout the day – 8 to10 glasses at least.

PROTEIN
Protein may be limited to 0.6 grams per kilogram ideal body weight per day. If the patient simply
cannot adhere to this restriction, then 0.75 grams per kilogram ideal body weight per day. For
your information, the Recommended Dietary Allowance (RDA) for protein in healthy persons is
0.8 grams per kilogram body weight per day. One can see there is very little difference in the
normal diet for healthy individuals and the diet that is recommended to delay the progression of
kidney disease. People probably eat twice the amount of protein needed to be healthy.
Here is an example of how the protein in the diet would be figured:
A man 5’7” tall and 150 pounds (70 kilos)
0.6 grams X 70 kilos = 42 grams protein per day 0.75 grams X 70 kilos = 52 grams protein per
day
Here are some samples of protein in foods:
1 egg = 7 grams protein 1 chicken thigh = 14 grams protein 8 ounces skim milk = 8 grams
protein 1 slice bread = 2 grams protein 1 cup cooked rice = 4 grams protein 1/2 cup corn = 2
grams protein
CALORIES
According to the National Kidney Foundation Guidelines, calories in this special diet should be
35 calories per kilogram per day for those less than 60 years of age and 30 calories per kilogram
per day for those over 60 years of age. Calories are found in carbohydrates, protein, fats and
alcohol. As alcohol is not a necessary nutrient, it is not recommended. People with diabetes may
need to eat more calories from carbohydrates to prevent weight loss. The medication to control
blood sugar may need to be adjusted and/or increased.
POTASSIUM
Potassium is not usually restricted until urine output begins to decrease. Sometimes people with
diabetes may need to have potassium limited.
Foods high in potassium are: Bananas, Oranges, Orange Juice, Milk, Prunes, Prune Juice,
Tomato Juice, Tomato Sauce, Nuts, Chocolate, Dried Peas and Beans
SODIUM AND BLOOD PRESSURE
High sodium foods can increase blood pressure. High blood pressure is one of the major causes
of kidney disease. New research tells us strict blood pressure control is 531
important. Ask your doctor what your target blood pressure should be. A person may require
more than one high blood pressure medicine. The first line of high blood pressure medication is
called an “ace inhibitor.” This may improve a condition known as “proteinuria” or protein in the
urine. This can affect diabetics and non-diabetics with high blood pressure. Some persons need a
diuretic or “water pill” to help control high blood pressure.
High sodium foods to avoid include: Salt, Bacon, Ham, Corned Beef, Pepperoni, Sausage, Pizza,
Chinese Food, Fast Foods, Pickles, Cheese, Soy Sauce, Canned Soups, Potato Chips, Fritos,
Cheetos
FLUID RESTRICTION
There is usually no restriction in the amount of fluids you can drink until severe kidney disease
(Stage 4 or 5) is reached. The amount of urine your kidneys can make will usually not decrease
until it is almost time to begin dialysis. It is called “kidney failure” because eventually the
kidneys fail to make urine.
PHOSPHORUS
Phosphorus is a mineral found in almost all foods. Normal kidneys will balance the amount of
phosphorus in our bodies. However, when the kidneys fail to eliminate this in the urine, the
phosphorus will increase in the blood. High phosphorus foods will need to be limited and/or
avoided. A medication called a phosphate binder (such as Oscal, Phoslo and Tums) may be
ordered by your physician to be taken every time you eat. This medication will bind the
phosphorus in the food and eliminate it in the stool. Control of phosphorus is very difficult for
kidney disease patients. Ignoring this problem can lead to bone disease with pain in the back and
joints.
High phosphorus foods to eliminate are: Milk (any kind) - Start learning to use a milk substitute
like Cremora (powdered) or Coffeemate (liquid) - Beans (red, black, white), Black Eyed Peas,
Lima Beans, Nuts, Chocolate, Yogurt, Cheese, Liver, Sardines, Desserts made with milk
ANEMIA
Healthy kidneys make a hormone that helps make red blood cells. One of the symptoms of
kidney disease is anemia, which causes weakness, tiredness and shortness of breath. Your kidney
doctor may give you an injection called “Procrit.” This may help improve your anemia. The
doctor may also order iron injections because in order to make red blood cells, you will need
enough iron. Unfortunately, in some people the special diet will not provide enough iron and iron
pills would be taken.
VITAMINS
Diseases of the heart and blood vessels remain the number one health problem in the U.S.
Recently, a new risk factor has been identified in kidney disease patients. It is an amino acid
called homocysteine. Over 75 percent of dialysis patients have increased homocysteine levels.
Too much homocysteine in the blood has been found to be associated with increased risk of heart
disease, stroke and blood vessel disease. Studies have shown that homocysteine levels in the
blood are strongly influenced by these specific vitamins: Folic Acid, Vitamin B12 and Vitamin
B6. 532
The American Heart Association has indicated that a reasonable therapeutic goal should be less
than 10 micromoles per liter. Ask your kidney doctor if you should be taking a special vitamin to
help prevent high levels of homocysteine.
DIABETICS
Since about 40 percent of all kidney disease patients are diabetic, it is important to know about
good control of your blood sugar. There is a special blood test called a “hemoglobin A1C.” This
test tells what your blood sugars have been in the past two to three months. The normal range is
4.5 to 6.0 percent. Poor control of blood sugar contributes to the progression of your kidney
disease. Be sure to ask your doctor how you are doing with blood sugar control. It may be
necessary to be referred to a diabetes educator for help.
Sample Menu: 40-50 grams protein (For non diabetic man 5’7” tall and 150 pounds (70 kilos)
with CKD)
BREAKFAST
• 1/2 cup (4 ounces) orange juice • 1 English muffin or 2 slices bread • At least one tablespoon
margarine with jelly • Coffee or tea with non-dairy creamer and sugar
SNACK
• 2 canned pear halves in heavy syrup
LUNCH
• 2 slices white bread • At least 2 tablespoons mayonnaise with lettuce and tomato • 1 ounce
chicken (such as a small thigh) or 1 hard boiled egg • 2 canned peach halves in heavy syrup • 7-
UP, lemonade or Hawaiian Punch
SNACK
• Baked apple with 1/2 cup non-dairy whipped topping
DINNER
• 3-4 ounces steak (weigh after cooking, without bone) , sauté in tablespoons olive oil • 1 small
baked potato with at least 2 tablespoons margarine • 1/2 cup fresh green beans, carrots or
broccoli with margarine • Lettuce, onions, cucumbers, green pepper • At least 2 tablespoons
olive oil with vinegar or lemon • 1/8 apple or cherry pie with 1/2 cup fruit sorbet (this is not
sherbet) • Iced tea with sugar and lemon or Sprite
SNACK
• 1 small banana and 10 vanilla wafers • Coffee or tea with non-dairy creamer and sugar
Here is a sample daily menu which might form part of a healthy renal diet plan. Please consult
your renal dietitian for a personal renal diet suitable for you.
Breakfast 533
1 scrambled egg 2 slices toast with margarine 1/2 cup strawberries 1/2 cup milk 1 cup coffee
Lunch
Turkey sandwich: 2 oz turkey 2 slices bread, lettuce & mayonnaise 1/2 cup coleslaw 1/2 cup
grapes 1 cup iced tea with lemon
Dinner
4 oz grilled pork chop 1/2 cup rice 1/2 cup green beans with onion and basil 1/2 cup applesauce
Dinner roll and margarine 1 cup water with lemon
Snack 1/4 cup tuna salad 5-6 No salt added crackers
Suggested Teaching/Learning Resources
- Textbooks
- Internet
- Charts
- Diet sheets
- Food composition tables
- Resource persons

Evaluation
1. explain the functions of the gall bladder and kidney
2. identify disorders of the gall bladder and kidney
3. state the causes and symptoms
534
15.2.14 CARDIOVASCULAR DISORDERS
Specific Objectives
By the end of sub-module unit, the trainee should be able to:
a) identify the types of cardiovascular disorders
b) state the causes and symptoms of cardiovascular disorders
c) Discuss the dietary management and modified diets and counseling of cardiovascular
disorders.

UNIT TASKS
TASK 1; IDENTIFICATION OF TYPES OF CARDIOVASCULAR DISORDERS
Heart disease is a broad term used to describe a range of diseases that affect your heart, and in
some cases, your blood vessels. The various diseases that fall under the 535
umbrella of heart disease include diseases of your blood vessels, such as coronary artery disease;
heart rhythm problems (arrhythmias); and heart defects you're born with (congenital heart
defects).
The term "heart disease" is often used interchangeably with "cardiovascular disease" — a term
that generally refers to conditions that involve narrowed or blocked blood vessels that can lead to
a heart attack, chest pain (angina) or stroke. Other heart conditions, such as infections and
conditions that affect your heart's muscle, valves or beating rhythm also are considered forms of
heart disease.
Heart disease is the No. 1 worldwide killer of men and women, including in the United States.
For example, heart disease is responsible for 40 percent of all the deaths in the United States,
more than all forms of cancer combined. Many forms of heart disease can be prevented or treated
with healthy lifestyle choices and diet and exercise.
Heart and Cardiovascular Diseases
When you think of heart disease, usually people think of coronary artery disease (narrowing of
the arteries leading to the heart), but coronary artery disease is just one type of cardiovascular
disease.
Cardiovascular disease includes a number of conditions affecting the structures or function of the
heart. They can include:
 Coronary artery disease (including heart attack)
 Abnormal heart rhythms or arrythmias
 Heart failure
 Heart valve disease
 Congenital heart disease
 Heart muscle disease (cardiomyopathy)
 Pericardial disease
 Aorta disease and Marfan syndrome
 Vascular disease (blood vessel disease)

Cardiovascular disease is the leading cause of death for both men and women in the U.S. It is
important to learn about your heart to help prevent heart disease. And, if you have cardiovascular
disease, you can live a healthier, more active life by learning about your disease and treatments
and by becoming an active participant in your care.
Coronary Artery Disease
Coronary artery disease (CAD) is atherosclerosis, or hardening, of the arteries that provide vital
oxygen and nutrients to the heart.

Abnormal Heart Rhythms

The heart is an amazing organ. It beats in a steady, even rhythm, about 60 to 100 times each
minute (that's about 100,000 times each day!). But, sometimes your heart gets out of rhythm. An
irregular or abnormal heartbeat is called an arrhythmia. An arrhythmia (also called a
dysrhythmia) can involve a change in the rhythm, producing an uneven heartbeat, or a change in
the rate, causing a very slow or very fast heartbeat.
Heart Failure
The term "heart failure" can be frightening. It does not mean the heart has "failed" or stopped
working. It means the heart does not pump as well as it should.
Heart failure is a major health problem in the U.S., affecting nearly 5 million Americans. About
550,000 people are diagnosed with heart failure each year. It is the leading cause of
hospitalization in people older than 65. 537
Heart Valve Disease
Your heart valves lie at the exit of each of your four heart chambers and maintain one-way
blood-flow through your heart.
Examples include mitral valve prolapse, aortic stenosis, and mitral valve insufficiency.
Congenital Heart Disease
Congenital heart disease is a type of defect in one or more structures of the heart or blood vessels
that occurs before birth.
It affects about 8 out of every 1,000 children. Congenital heart defects may produce symptoms at
birth, during childhood and sometimes not until adulthood.
In most cases scientists don't know why they occur. Heredity may play a role as well as exposure
to the fetus during pregnancy to certain viral infections, alcohol, or drugs.
Cardiomyopathies
Cardiomyopathies are diseases of the heart muscle itself. People with cardiomyopathies --
sometimes called an enlarged heart -- have hearts that are abnormally enlarged, thickened, and/or
stiffened. As a result, the heart's ability to pump blood is weakened. Without treatment,
cardiomyopathies worsen over time and often lead to heart failure and abnormal heart rhythms.
Common Cardiovascular Diseases 538
The four most common types of cardiovascular disease are coronary heart disease (which
includes heart attack and angina pectoris or chest pain), stroke, high blood pressure and heart
failure. Other forms include rheumatic fever/rheumatic heart disease, congenital cardiovascular
defects, arrhythmias (disorders of heart rhythm); diseases of the arteries, arterioles and capillaries
(including atherosclerosis and Kawasaki disease); bacterial endocarditis; cardiomyopathy;
valvular heart disease; diseases of pulmonary circulation; diseases of veins and lymphatics and
other diseases of the circulatory system.
Atherosclerosis occurs when the inner walls of the arteries become more narrow due to a buildup
of plaque, which consists of fats, cholesterol cellular waste products, calcium and other
substances. Plaques can grow large enough to significantly reduce the blood's flow through an
artery. But most of the damage occurs when they become fragile and rupture. Plaques that
rupture cause blood clots to form. If this blood clot blocks a blood vessel that feeds the heart, it
causes a heart attack. If it blocks a blood vessel that feeds the brain, it causes a stroke.
High blood pressure, also called hypertension, means the pressure in your arteries is consistently
above the normal range. Blood pressure is the force of blood pushing against blood vessel walls.
It's written as two numbers, such as 122/78 mm Hg. The top (systolic) number is the pressure
when the heart beats. The bottom (diastolic) number is the pressure when the heart is at rest.
High blood pressure is a consistently elevated pressure of 140 mm Hg systolic or higher and/or
90 mm Hg diastolic or higher. The great danger is that you usually can't tell you have high blood
pressure! There are no signs and no one knows exactly what causes it. High blood pressure can
lead to hardened arteries, heart failure, stroke or heart attack.
Heart attacks occur when the blood flow to a part of the heart is blocked, often by a blood clot. If
this clot cuts off the blood flow completely, the part of the heart muscle supplied by that artery
begins to die. Call 9-1-1 to get help fast if you feel any of the warning signs of heart attack.
Heart failure means that your heart isn't pumping blood as well as it should. It keeps working,
but the body doesn't get all the blood and oxygen it needs. See a doctor if you notice symptoms
such as:
 Swelling in feet, ankles and/or legs, called "edema"
 Fatigue that can be due to fluid buildup in lungs, called "pulmonary congestion"
Stroke and TIA ("mini" stroke) happen when a blood vessel that supplies oxygen to a part of the
brain gets blocked. Then that part of the brain can't work and neither can the part of the body it
controls. A stroke can also occur when a blood vessel supplying part of the brain ruptures. Call
9-1-1 to get help fast if you have any of the warning signs of stroke and TIA. 539
TASK 2; CAUSES AND SYMPTOMS OF CARDIOVASCULAR
Heart Disease
Study shows that Coenzyme Q10,an essential nutrient that helps support cardiovascular function,
does not have any side effects, and may be beneficial to people with heart diseases. Please visit
Coenzyme Q10 for more information.
Causes of Heart Disease
Heart Disease Risk Factors
Cardiovascular disease can take many forms: high blood pressure, coronary artery disease,
valvular heart disease, stroke, or rheumatic fever/rheumatic heart disease. According to the
World Health Organization, cardiovascular disease causes 12 million deaths in the world each
year. Cardiovascular disease is responsible for half of all deaths in the United States and other
developed countries, and it is a main cause of death in many developing countries as well.
Overall, it is the leading cause of death in adults. In the United States, more than 60 million
Americans have some form of cardiovascular disease. About 2600 people die every day of
cardiovascular disease. Cancer, the second largest killer, accounts for only half as many deaths.
Coronary artery disease, the most common form of cardiovascular disease, is the leading cause
of death in America today. But thanks to many studies involving thousands of patients,
researchers have found certain factors that play an important role in a person's chances of
developing heart disease. These are called risk factors. Risk factors are divided into two
categories: major and contributing. Major risk factors are those that have been proven to increase
your risk of heart disease. Contributing risk factors are those that doctors think can lead to an
increased risk of heart disease, but their exact role has not been defined. The more risk factors
you have, the more likely you are to develop heart disease. Some risk factors can be changed,
treated, or modified, and some cannot. But by controlling as many risk factors as possible,
through lifestyle changes and/or medicines, you can reduce your risk of heart disease. Major
Risk Factors High Blood Pressure (Hypertension). High blood pressure increases your risk of
heart disease, heart attack, and stroke. Though other risk factors can lead to high blood pressure,
you can have it without having other risk factors. If you are obese, you smoke, or you have high
blood cholesterol levels along with high blood pressure, your risk of heart disease or stroke
greatly increases. 540
Blood pressure can vary with activity and with age, but a healthy adult who is resting generally
has a systolic pressure reading between 120 and 130 and a diastolic pressure reading between 80
and 90 (or below). High Blood Cholesterol. One of the major risk factors for heart disease is high
blood cholesterol. Cholesterol, a fat-like substance carried in your blood, is found in all of your
body's cells. Your liver produces all of the cholesterol your body needs to form cell membranes
and to make certain hormones. Extra cholesterol enters your body when you eat foods that come
from animals (meats, eggs, and dairy products). Although we often blame the cholesterol found
in foods that we eat for raising blood cholesterol, the main culprit is the saturated fat in food. (Be
sure to read nutrition labels carefully, because even though a food does not contain cholesterol it
may still have large amounts of saturated fat.) Foods rich in saturated fat include butter fat in
milk products, fat from red meat, and tropical oils such as coconut oil. Too much low-density
lipoprotein (LDL or "bad cholesterol") in the blood causes plaque to form on artery walls, which
starts a disease process called atherosclerosis. When plaque builds up in the coronary arteries
that supply blood to the heart, you are at greater risk of having a heart attack. Diabetes. Heart
problems are the leading cause of death among people with diabetes, especially in the case of
adult-onset or Type II diabetes (also known as non-insulin-dependent diabetes). Certain racial
and ethnic groups (African Americans, Hispanics, Asian and Pacific Islanders, and Native
Americans) have a greater risk of developing diabetes. The American Heart Association
estimates that 65% of patients with diabetes die of some form of cardiovascular disease. If you
know that you have diabetes, you should already be under a doctor's care, because good control
of blood sugar levels can reduce your risk. If you think you may have diabetes but are not sure,
see your doctor for tests. Obesity and Overweight. Extra weight is thought to lead to increased
total cholesterol levels, high blood pressure, and an increased risk of coronary artery disease.
Obesity increases your chances of developing other risk factors for heart disease, especially high
blood pressure, high blood cholesterol, and diabetes. Many doctors now measure obesity in terms
of body mass index (BMI), which is a formula of kilograms divided by height in meters squared
(BMI =W [kg]/H [m2]). According to the National Heart, Lung, and Blood Institute (NHLBI),
being overweight is defined as having a BMI over 25. Those with a number over 30 are
considered obese. Smoking. Most people know that cigarette and tabacco smoking increases
your risk of lung cancer, but fewer realize that it also greatly increases your risk of heart disease
and peripheral vascular disease (disease in the vessels that supply blood to the arms and legs).
According to the American Heart Association, more than 541
400,000 Americans die each year of smoking-related illnesses. Many of these deaths are because
of the effects of smoking on the heart and blood vessels. Research has shown that smoking
increases heart rate, tightens major arteries, and can create irregularities in the timing of
heartbeats, all of which make your heart work harder. Smoking also raises blood pressure, which
increases the risk of stroke in people who already have high blood pressure. Although nicotine is
the main active agent in cigarette smoke, other chemicals and compounds like tar and carbon
monoxide are also harmful to your heart in a variety of ways. These chemicals lead to the
buildup of fatty plaque in the arteries, possibly by injuring the vessel walls. And they also affect
cholesterol and levels of fibrinogen, which is a blood-clotting material. This increases the risk of
a blood clot that can lead to a heart attack. Physical Inactivity. People who are not active have a
greater risk of heart attack than do people who exercise regularly. Exercise burns calories, helps
to control cholesterol levels and diabetes, and may lower blood pressure. Exercise also
strengthens the heart muscle and makes the arteries more flexible. Those who actively burn 500
to 3500 calories per week, either at work or through exercise, can expect to live longer than
people who do not exercise. Even moderate-intensity exercise is helpful if done regularly.
Gender. Overall, men have a higher risk of heart attack than women. But the difference narrows
after women reach menopause. After the age of 65, the risk of heart disease is about the same
between the sexes when other risk factors are similar. Heredity. Heart disease tends to run in
families. For example, if your parents or siblings had a heart or circulatory problem before age
55, then you are at greater risk for heart disease than someone who does not have that family
history. Risk factors (including high blood pressure, diabetes, and obesity) may also be passed
from one generation to another. Also, researchers have found that some forms of cardiovascular
disease are more common among certain racial and ethnic groups. For example, studies have
shown that African Americans have more severe high blood pressure and a greater risk of heart
disease than whites. The bulk of cardiovascular research for minorities has focused on African
Americans and Hispanics, with the white population used as a comparison. Risk factors for
cardiovascular disease in other minority groups are still being studied. Age. Older age is a risk
factor for heart disease. In fact, about 4 of every 5 deaths due to heart disease occur in people
older than 65. As we age, our hearts tend to not work as well. The heart's walls may thicken,
arteries may stiffen and harden, and the heart is less able to pump blood to the muscles of the
body. Because of these changes, the risk of developing cardiovascular disease increases with age.
Because of their sex hormones, women are usually protected from heart disease until menopause,
and then their risk 542
increases. Women 65 and older have about the same risk of cardiovascular disease as men of the
same age. Contributing Risk Factors Stress. Stress is considered a contributing risk factor for
heart disease because little is known about its effects. The effects of emotional stress, behavior
habits, and socioeconomic status on the risk of heart disease and heart attack have not been
proven. That is because we all deal with stress differently: how much and in what way stress
affects us can vary from person to person. Researchers have identified several reasons why stress
may affect the heart. Stressful situations raise your heart rate and blood pressure, increasing the
your heart's need for oxygen. This need for oxygen can bring on angina pectoris, or chest pain, in
people who already have heart disease. During times of stress, the nervous system releases extra
hormones (most often adrenaline). These hormones raise blood pressure, which can injure the
lining of the arteries. When the arteries heal, the walls may harden or thicken, making is easier
for plaque to build up. Stress also increases the amount of blood clotting factors that circulate in
your blood, and makes it more likely that a clot will form. Clots may then block an artery
narrowed by plaque and cause a heart attack. Stress may also contribute to other risk factors. For
example, people who are stressed may overeat for comfort, start smoking, or smoke more than
they normally would. Sex hormones. Sex hormones appear to play a role in heart disease.
Among women younger than 40, heart disease is rare. But between the ages 40 and 65, around
the time when most women go through menopause, the chances that a woman will have a heart
attack greatly increase. From 65 onward, women make up about half of all heart attack victims.
Birth control pills. Early types of birth control pills contained high levels of estrogen and
progestin, and taking these pills increased the chances of heart disease and stroke, especially in
women older than 35 who smoked. But birth control pills today contain much lower doses of
hormones. Birth control pills are considered safe for women younger than 35, who do not smoke
or have high blood pressure. But if you smoke or have other risk factors, birth control pills will
increase your risk of heart disease and blood clots, especially if you are older than 35. According
to the American Heart Association, women who take birth control pills should have yearly
check-ups that test blood pressure, triglyceride, and glucose levels. Alcohol. Studies have shown
that the risk of heart disease in people who drink moderate amounts of alcohol is lower than in
nondrinkers. Experts say that 543
moderate intake is an average of one to two drinks per day for men and one drink per day for
women. One drink is defined as 1?fluid ounces (fl oz) of 80-proof spirits (such as bourbon,
Scotch, vodka, gin, etc.), 1 fl oz of 100-proof spirits, 4 fl oz of wine, or 12 fl oz of beer. But
drinking more than a moderate amount of alcohol can cause heart-related problems such as high
blood pressure, stroke, irregular heartbeats, and cardiomyopathy (disease of the heart muscle).
And the average drink has between 100 and 200 calories. Calories from alcohol often add fat to
the body, which may increase the risk of heart disease. It is not recommended that nondrinkers
start using alcohol or that drinkers increase the amount that they drink. It is never too late 梠 r too
early 梩 o begin improving heart health. Some risk factors can be controlled, while others cannot.
But, by eliminating risk factors that you can change and by properly managing those that you
cannot control, you may greatly reduce your risk of heart disease.
Little Fact:
Lipitor is the best selling prescription drug for lowering blood cholesterol levels.
What are the risk factors for cardiovascular disease?
The most important behavioural risk factors of heart disease and stroke are unhealthy diet,
physical inactivity and tobacco use. Behavioural risk factors are responsible for about 80% of
coronary heart disease and cerebrovascular disease.
The effects of unhealthy diet and physical inactivity may show up in individuals as raised blood
pressure, raised blood glucose, raised blood lipids, and overweight and obesity; these are called
'intermediate risk factors'.
There are also a number of underlying determinants of CVDs, or, if you like, "the causes of the
causes". These are a reflection of the major forces driving social, economic and cultural change –
globalization, urbanization, and population ageing. Other determinants of CVDs are poverty and
stress.
What are common symptoms of cardiovascular diseases?
Symptoms of heart attacks and strokes
Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or
stroke may be the first warning of underlying disease. Symptoms of a heart attack include:
 pain or discomfort in the centre of the chest;
 pain or discomfort in the arms, the left shoulder, elbows, jaw, or back.
544
In addition the person may experience difficulty in breathing or shortness of breath; feeling sick
or vomiting; feeling light-headed or faint; breaking into a cold sweat; and becoming pale.
Women are more likely to have shortness of breath, nausea, vomiting, and back or jaw pain.
The most common symptom of a stroke is sudden weakness of the face, arm, or leg, most often
on one side of the body. Other symptoms include sudden onset of: numbness of the face, arm, or
leg, especially on one side of the body; confusion, difficulty speaking or understanding speech;
difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or
coordination; severe headache with no known cause; and fainting or unconsciousness.
People experiencing these symptoms should seek medical care immediately.
What is rheumatic heart disease?
Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the
inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by
streptococcal bacteria, which usually begins as a sore throat or tonsillitis in children.
Rheumatic fever mostly affects children in developing countries, especially where poverty is
widespread. Globally, almost 2% of deaths from cardiovascular diseases is related to rheumatic
heart disease, while 42% of deaths from cardiovascular diseases is related to ischaemic heart
disease, and 34% to cerebrovascular disease.
Symptoms of rheumatic heart disease
 Symptoms of rheumatic heart disease include: shortness of breath, fatigue, irregular heart
beats, chest pain and fainting.
 Symptoms of rheumatic fever include: fever, pain and swelling of the joints, nausea, stomach
cramps and vomiting.

Treatment
 Early treatment of streptococcal sore throat can stop the development of rheumatic fever.
Regular long-term penicillin treatment can prevent repeat attacks of rheumatic fever which give
rise to rheumatic heart disease and can stop disease progression in people whose heart valves are
already damaged by the disease.

Why are cardiovascular diseases a development issue in low- and middle-income countries? 545
 Over 80% of the world's deaths from CVDs occur in low- and middle-income countries.
 People in low- and middle-income countries are more exposed to risk factors leading to CVDs
and other noncommunicable diseases and are less exposed to prevention efforts than people in
high-income countries.
 People in low- and middle-income countries who suffer from CVDs and other
noncommunicable diseases have less access to effective and equitable health care services which
respond to their needs (including early detection services).
 As a result, many people in low- and middle-income countries die younger from CVDs and
other noncommunicable diseases, often in their most productive years.
 The poorest people in low- and middle-income countries are affected most. At household
level, sufficient evidence is emerging to prove that CVDs and other noncommunicable diseases
contribute to poverty. For example, catastrophic health care expenditures for households with a
family member with CVD can be 30 per cent or more of annual household spending.
 At macro-economic level, CVDs place a heavy burden on the economies of low- and middle-
income countries. Heart disease, stroke and diabetes are estimated to reduce GDP between 1 and
5% in low- and middle-income countries experiencing rapid economic growth, as many people
die prematurely. For example, it is estimated that over the next 10 years (2006-2015), China will
lose $558 billion in foregone national income due to the combination of heart

-fifth of the annual 1,000,000 deaths from CVD are attributable to smoking. Surveillance data
indicate that an estimated 1,000,000 young people become "regular" smokers each year.
disease as those who are physically active. Despite these risks, America remains a predominantly
sedentary society. Surveys show that more than half of American adults do not practice the
recommended level of physical activity, and more than one-fourth are completely sedentary.
people) are obese and thus have a higher risk for heart disease, high blood pressure, high
cholesterol, and other chronic diseases and conditions such as diabetes. Only 27% of women and
19% of men report eating the recommended five servings of fruits and vegetables each day. 546
TASK 3; DISCUSS THE DIETARY MANAGEMENT AND MODIFIED DIETS AND
COUNSELING OF CARDIOVASCULAR DISORDERS.
Dietary changes
Making small changes to your diet is one of the simplest and most effective ways to reduce your
risk of CVD. You can do this by
 reducing fat in your diet, especially saturated and trans-fats
 eating more fruit and vegetables, wholegrain food and soluble fibre
 drinking alcohol in moderation
 reducing salt to maintain a lower blood pressure

Fat
Reducing the proportion of fat in your diet, especially saturated fat, can help to reduce blood
cholesterol levels. There's a strong link between high blood cholesterol levels and the risk of
heart disease. For those who don't have CVD or aren't considered to be at high-risk of CVD,
normal blood cholesterol levels are below 5mmol/litre. This can be measured by your GP. People
with average energy needs should aim to consume no more than 70g/day of fat and less than
20g/day of saturated fat.
Trans-fatty acids are a particular kind of fat that are naturally occurring in meat and dairy
products but may also be produced when plant-based oils are hydrogenated to produce solid
spreads, such as margarines. They're often found in confectionery and processed food like pastry,
biscuits and cakes. They've been found to have the same effect on cholesterol levels as saturated
fat and should be avoided as much as possible. Thankfully, many manufacturers have now
modified processing techniques to keep these fats to a minimum. Check labels for hydrogenated
fats.
When reducing total fat, it's important not to cut out the heart healthy fats from your diet
including mono and poly-unsaturated fats and omega-3, mostly found in plant and fish oils.
How to modify your fat intake:
 use butter and other spreads sparingly
 choose lean cuts of meat or trim fat off
 grill, bake or steam food rather than frying
 swap saturated fats such as butter for unsaturated oils such as sunflower, rapeseed or olive oil
 limit your intake of trans-fats from processed food
 eat two to three portions of oily fish each week (eg sardines, mackerel, fresh tuna, salmon)
547
Essential fatty acids
Essential fatty acids such as omega-3s, which are found in oily fish, have been shown to reduce
the risk of CVD by lowering blood triglycerides, reducing blood clotting and regulating heart
rhythm. For general heart health try to eat two portions of fish per week, one of which should be
oily.
Stanols and Sterols
Certain plant-derived compounds, called stanol or sterol esters have been shown to reduce
cholesterol levels. Spreads, yoghurts, drinks and soya 'dairy alternatives' are now available
containing these products. These sterol enriched foods may be particularly useful for those with
raised blood cholesterol which has remained elevated even after making other dietary changes.
Clinical trials show that when used regularly, they can reduce high cholesterol levels.
Fruit and vegetables
Fruit and vegetables are rich in many essential nutrients including vitamins C and E and
carotenoids (which are all antioxidants). They may help to protect the heart by limiting the
damaging effects of cholesterol on body tissues. Aim for at least five servings of fruit and
vegetables a day. (See the Fruit and Vegetables article for more information on what a serving
is.)
Wholegrains and fibre
Studies of large groups of people in the US have shown that diets rich in wholegrain food can
reduce the risk of CVD by up to 30 per cent. You can include wholegrain food in every meal by
choosing wholemeal bread and wholegrain varieties of pasta and rice.
Soluble dietary fibre, found in oats, beans and pulses, can help to lower LDL cholesterol. These
foods should be included as part of an overall healthy balanced diet, at least two to three times
each week.
Alcohol
Consuming moderate amounts of alcohol - between one and two units a day - has been found to
reduce the risk of CVD. Alcohol can increase HDL cholesterol and makes it less likely that clots
will form. However, high intakes of alcohol are associated with increased risk. It's also worth
noting that saving up your weekly units for a weekend binge doesn't offer the same benefits.
Soya protein
A diet that includes at least 25g of soya per day has been associated with reductions in LDL
cholesterol and CVD. Soya isoflavones in particular have been shown to reduce CVD risk as
they inhibit the growth of cells that form artery-clogging plaque. Soya protein is also an excellent
substitute for meat and is available in a convenient and tasty form in many ready-made meals.
Another good source of soya protein is soya milk and yoghurt. 548
 Heart attacks and strokes are major–but preventable–killers worldwide.
 Over 80% of cardiovascular disease deaths take place in low-and middle-income countries and
occur almost equally in men and women. Cardiovascular risk of women is particularly high after
menopause.
 Tobacco use, an unhealthy diet, and physical inactivity increase the risk of heart attacks and
strokes.
 Cessation of tobacco use reduces the chance of a heart attack or stroke.
 Engaging in physical activity for at least 30 minutes every day of the week will help to prevent
heart attacks and strokes.
 Eating at least five servings of fruit and vegetables a day, and limiting your salt intake to less
than one teaspoon a day, also helps to prevent heart attacks and strokes.
 High blood pressure has no symptoms, but can cause a sudden stroke or heart attack. Have
your blood pressure checked regularly.
 Diabetes increases the risk of heart attacks and stroke. If you have diabetes control your blood
pressure and blood sugar to minimize your risk.
 Being overweight increases the risk of heart attacks and strokes. To maintain an ideal body
weight, take regular physical activity and eat a healthy diet.
 Heart attacks and strokes can strike suddenly and can be fatal if assistance is not sought
immediately.

Suggested Teaching/Learning Resources

- Textbooks
- Internet
- Charts
- Diet sheets
- Food composition tables
- Resource persons

Evaluation
a. identify the cardiovascular disorders
b. state the causes and symptoms of cardiovascular disorders
c. Discuss the dietary management and counseling of cardiovascular disorders.

15.2.15 SURGICAL AND BURN THERAPY

Specific Objectives
By the end of sub-module unit, the trainee should be able to:
a) define given terms
549
b) state the types and causes of burns
c) identify the feeding methods and planning of modified diets
a) explain the dietary management and counseling

UNIT TASKS
TASK 1; DEFINITION OF TERMS
Burns
Definition
Burns are injuries to tissues caused by heat, friction, electricity, radiation, or chemicals.
Description
Burns are characterized by degree, based on the severity of the tissue damage. A first-degree
burn causes redness and swelling in the outermost layers of skin (epidermis). A second-degree
burn involves redness, swelling and blistering, and the damage may extend beneath the
epidermis to deeper layers of skin (dermis). A third-degree burn, also called a full-thickness
burn, destroys the entire depth of skin, causing significant scarring. Damage also may extend to
the underlying fat, muscle, or bone.
The severity of the burn is also judged by the amount of body surface area (BSA) involved.
Health care workers use the "rule of nines" to determine the percentage of BSA affected in
patients more than 9 years old: each arm with its hand is 9% of BSA; each leg with its foot is
18%; the front of the torso is 18%; the back of the torso, including the buttocks, is 18%; the head
and neck are 9%; and the genital area (perineum) is 1%. This rule cannot be applied to a young
child's body proportions, so BSA is estimated using the palm of the patient's hand as a measure
of 1% area.
The severity of the burn will determine not only the type of treatment, but also where the burn
patient should receive treatment. Minor burns may be treated at home or in a doctor's office.
These are defined as first- or second-degree burns covering less than 15% of an adult's body or
less than 10% of a child's body, or a third-degree burn on less than 2% BSA. Moderate burns
should be treated at a hospital. These are defined as first- or second-degree burns covering 15%-
25% of an adult's body or 10%-20% of a child's body, or a third-degree burn on 2%-10% BSA.
Critical, or major, burns are the most serious and should be treated in a specialized burn unit of a
hospital. These are defined as first- or second-degree burns covering more than 25% of an adult's
body or more than 20% of a child's body, or a third-degree burn on more than 10% BSA. In
addition, burns involving the hands, feet, face, eyes, ears, or genitals are considered critical.
Other factors influence the level of treatment needed, including associated injuries such as bone
fractures and smoke inhalation, presence of a chronic disease, or a history of being 550
abused. Also, children and the elderly are more vulnerable to complications from burn injuries
and require more intensive care.
Debridement — The surgical removal of dead tissue.
Dermis — The basal layer of skin; it contains blood and lymphatic vessels, nerves, glands, and
hair follicles.
Epidermis — The outer portion of skin, made up of four or five superficial layers.
Shock — An abnormal condition resulting from low blood volume due to hemorrhage or
dehydration. Signs of shock include rapid pulse and breathing, and cool, moist, pale skin.
TASK 2; TYPES AND CAUSES OF BURNS
Causes and symptoms
Burns may be caused by even a brief encounter with heat greater than 120°F (49°C). The source
of this heat may be the sun (causing a sunburn), hot liquids, steam, fire, electricity, friction
(causing rug burns and rope burns), and chemicals (causing a caustic burn upon contact).
Signs of a burn are localized redness, swelling, and pain. A severe burn will also blister. The skin
may also peel, appear white or charred, and feel numb. A burn may trigger a headache and fever.
Extensive burns may induce shock, the symptoms of which are faintness, weakness, rapid pulse
and breathing, pale and clammy skin, and bluish lips and fingernails.
Diagnosis
A physician will diagnose a burn based upon visual examination, and will also ask the patient or
family members questions to determine the best treatment. He or she may also check for smoke
inhalation, carbon monoxide poisoning, cyanide poisoning, other event-related trauma, or, if
suspected, further evidence of child abuse.
Treatment
Burn treatment consists of relieving pain, preventing infection, and maintaining body fluids,
electrolytes, and calorie intake while the body heals. Treatment of chemical or electrical burns is
slightly different from the treatment of thermal burns but the objectives are the same.
Thermal burn treatment
The first act of thermal burn treatment is to stop the burning process. This may be accomplished
by letting cool water run over the burned area or by soaking it in cool (not cold) water. Ice
should never be applied to the burn. Cool (not cold) wet compresses may provide some pain
relief when applied to small areas of first- and second-degree burns. Butter, shortening, or
similar salve should never be applied to 551
the burn since it prevents heat from escaping and drives the burning process deeper into the skin.
If the burn is minor, it may be cleaned gently with soap and water. Blisters should not be broken.
If the skin of the burned area is unbroken and it is not likely to be further irritated by pressure or
friction, the burn
There are three classifications of burns: first-degree, second-degree, and third-degree burns.
should be left exposed to the air to promote healing. If the skin is broken or apt to be disturbed,
the burned area should be coated lightly with an antibacterial ointment and covered with a
sterile bandage. Aspirin, acetaminophen (Tylenol), or ibuprofen (Advil) may be taken to ease
pain and relieve inflammation. A doctor should be consulted if these signs of infection appear:
increased warmth, redness, pain, or swelling; pus or similar drainage from the wound; swollen
lymph nodes; or red streaks spreading away from the burn. Classification Of Burns
First-Degree (Minor) The burned area is painful. The outer skin is reddened. Slight
swelling is present.
Second-Degree The burned area is painful. The underskin is affected. Blisters
(Moderate) may form. The area may have a wet, shiny appearance because of
exposed tissue.
Third-Degree (Critical) The burned area is insensitive due to the destruction of nerve
endings. Skin is destroyed. Muscle tissues and bone underneath
may be damaged. The area may be charred, white, or grayish in
color.