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Appropriate and healthy feeding of your baby during the first year of life is very important. More growth occurs during the first year than at any other time in your child’s life. For the first few months, breast milk or formula is all that’s needed. As your baby grows, starting a variety of healthy foods at the proper time is important for proper growth and development. And starting good eating habits at this early stage will help set healthy eating patterns for life.

Feeding guide for your child’s first 4 months

Don’t give solid foods unless your baby’s healthcare provider advises you to do so. Solid foods shouldn’t be started for infants younger than age 4 months for the following reasons:

• Breast milk or formula gives your baby all the nutrients that are needed to grow.
• Your baby isn’t physically developed enough to eat solid food from a spoon.
• Feeding your baby solid food too early may lead to overfeeding and being overweight.
• As a general rule, solid foods don’t help babies sleep through the night.

All infants, children, and teens need to take in 400 IU of vitamin D each day to prevent complications from deficiency of this vitamin. This can be through supplements, formula, or cow’s milk. This should start soon after birth. Your baby’s healthcare provider can recommend the proper type and amount of vitamin D supplement for your baby.

Guide for formula feeding (0 to 5 months)

Age	Amount of formula per feeding	Number of breast or formula feedings per 24 Hours	Maximum volume of formula per 24 hours
1 month	2 to 4 ounces	6 to 8 times	24 ounces
2 months	5 to 6 ounces	5 to 6 times	32 ounces
3 to 5 months	6 to 7 ounces	5 to 6 times	32 ounces

Breastfeeding mothers often wonder how they know their baby is getting enough. What goes in must come out, so counting wet diapers is a good way to know your baby is getting plenty. In the first few days of life, your baby should have at least 5 wet diapers daily. If you notice your baby having fewer wet diapers, you should contact your baby’s healthcare provider or lactation consultant for help right away.

Feeding tips for your child

These are some things to consider when feeding your baby:

• When starting solid foods, give your baby 1 new food at a time. Don’t use mixtures like cereal and fruit or meat dinners. Give the new food for 2 to 3 days before adding another new food. This way you can tell what foods your baby may be allergic to or can’t handle.
• Start with small amounts of new solid foods. Try a teaspoon at first and slowly increase to a tablespoon.
• There are no strict rules about what order you should give different foods in. Many people start with an infant cereal and slowly add fruits, vegetables, and proteins.
• Don’t use salt or sugar when making homemade baby foods. Canned foods may contain large amounts of salt and sugar and shouldn’t be used for baby food.
• Don’t feed homemade spinach, beets, green beans, squash, or carrots to babies younger than age 6 months. These foods can have high amounts of nitrates. This raises the risk for a blood disorder (methemoglobinemia) that can interfere with oxygen delivery in the blood.
• Always wash and peel fruits and vegetables and remove seeds or pits. Take special care with fruits and vegetables that come into contact with the ground. They may contain botulism spores that cause food poisoning.
• Cow’s milk shouldn’t be added to the diet until your baby is age 12 months. Cow’s milk doesn’t provide the right nutrients for your baby.
• Fruit juice without sugar can be started when your baby is able to drink from a cup (around age 6 months or older). But, it’s not a necessary part of a healthy infant’s diet and should be limited to a maximum of 4 to 6 ounces daily. Fruit juice is linked to both obesity and malnutrition in children. Whole fruits and vegetables are a much healthier option.
• Feed all foods with a spoon. Your baby needs to learn to eat from a spoon. Don’t use an infant feeder. Only formula and water should go into the bottle.
• Avoid honey in any form for the first year because it can cause a type of botulism.
• Don’t put your baby in bed with a bottle propped in his or her mouth. Propping the bottle is linked to ear infections and choking. Once your baby’s teeth are present, propping the bottle can cause tooth decay.
• Your baby’s healthcare provider can advise you on how to wean your baby off the bottle.
• Avoid the clean plate syndrome. Forcing your child to eat all the food on his or her plate even when he or she isn’t hungry isn’t a good habit. It teaches your child to eat just because the food is there, not because he or she is hungry. Expect a smaller and pickier appetite as your baby’s growth rate slows around age 1.
• Healthy babies usually need little or no extra water. Ask your child’s healthcare provider about giving your baby additional fluids throughout the day. Once your child is taking solids, offering sips of water is usually fine.
• Don’t limit your baby’s food choices to the ones you like. Offering a wide variety of foods early can help lead to good eating habits later.
• Fat and cholesterol shouldn’t be limited in the diets of babies and very young children, unless advised by your baby’s healthcare provider. Children need calories, fat, and cholesterol for healthy growth.

WHO response

WHO is committed to supporting countries with implementation and monitoring of the “Comprehensive implementation plan on maternal, infant and young child nutrition”, endorsed by Member States in May 2012. The plan includes 6 targets, one of which is to increase, by 2025, the rate of exclusive breastfeeding for the first 6 months up to at least 50%. Activities that will help to achieve this include those outlined in the “Global strategy for infant and young child feeding”, which aims to protect, promote and support appropriate infant and young child feeding.

UNICEF and WHO created the Global Breastfeeding Collective to rally political, legal, financial, and public support for breastfeeding. The Collective brings together implementers and donors from governments, philanthropies, international organizations, and civil society. The Collective’s vision is a world in which all mothers have the technical, financial, emotional, and public support they need to breastfeed.

WHO has formed the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and Subsequent Relevant World Health Assembly Resolutions, also known as NetCode. The goal of NetCode is to protect and promote breastfeeding by ensuring that breastmilk substitutes are not marketed inappropriately. Specifically, NetCode is building the capacity of Member States and civil society to strengthen national Code legislation, continuously monitor adherence to the Code, and take action to stop all violations.

In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

WHO provides simple, coherent and feasible guidance to countries for promoting and supporting improved infant feeding by HIV-infected mothers to prevent mother-to-child transmission, good nutrition of the baby, and protect the health of the mother.

problems in feeding children in hospitals

Feeding can become a problem when your child is losing weight or having trouble gaining the right amount of weight for their age. Your child or baby has feeding problems when:

• They can’t eat or drink anything.
• They can’t eat and drink enough of the right things to stay healthy.
• They choose not to eat or drink enough of the right things to stay healthy.

With a baby, you might have breastfeeding problems. Other baby feeding problems might come from your baby not being able to suck, chew, or swallow.

Eating disorders in young children are called feeding disorders. They might also be called toddler eating disorders. (Usually, the term eating disorder is used for pre-teens, teenagers, and adults.)

Sometimes problems with eating get better without treatment. Sometimes your baby or child will need to be seen by a doctor.

With treatment, feeding disorders can get better. Eating can turn into a safer, easier, and happier experience for your child and the rest of the family. Treatment can also help your child become healthier.

Symptoms

Sometimes feeding problems are due to a child not being able to suck, chew, or swallow. This might stem from a physical problem such as a cleft palate or tongue tie. When the cause is less clear, you can look for these signs:

• Not gaining weight well
• Coughing, choking, or gagging when eating or drinking
• Throwing up often
• Choking on food or drink once during a meal and not eating again
• Eating and breathing coordination problems
• Not eating baby food purees by 8 months old
• Not eating table foods by 12 months old
• Not using a cup by 16 months old
• Eating baby foods at 16 months old
• Avoiding foods with a certain texture or from a certain food group (such as fruits and vegetables)
• Eating fewer than 20 kinds of food, especially when they stop eating certain foods and don’t replace them with other foods
• Crying or arching the back at most meals
• Taking more than 30 minutes to eat meals on a regular basis

Other signs within your family can include:

• Arguing with your child about food and feeding
• When feeding your child is difficult for everyone
• Eating problems you have that your child may get from you

When to See a Doctor

If your baby or child is losing weight or having trouble gaining the right amount of weight for their age, you should see a doctor. While some feeding problems can get better without treatment, it is best to make sure that the cause isn’t serious.

If your baby is very uncomfortable when eating or their spit up is green or bloody, you should take them to a doctor right away.

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Causes

Feeding disorders are more than picky eating. Feeding difficulties in children are almost always caused by some other medical problem, including:

• Gastroesophageal reflux [GAS-troh-ih-SOF-oh-JEE-uhl REE-fluhks]. This is a condition where acid from the stomach flows back into the esophagus, the tube that connects your child’s mouth to their stomach.
• Eosinophilic esophagitis [EE-oh-sin-oh-fil-ik EE-sof-a-jai-tis] or inflammation of the esophagus
• Other stomach or intestine problems
• Seizures
• Nervous system problems
• Premature birth
• Sensory system problems
• Autism
• Craniofacial [CRAY-nee-oh-FAY-she-awl] syndromes or abnormalities of the face or head
• Heart or lung problems
• Face and mouth muscle problems
• Problems swallowing certain liquids and food textures

When a baby has a problem with breastfeeding, these medical problems might not be the cause. Breastfeeding doesn’t necessarily come easily for everyone. You may have difficulty with positioning your baby or have sore or tender nipples. Your baby might be spitting up. Some spitting up is normal for all babies. It happens when they eat too fast or swallow air. Remember that it takes practice and patience to find a pattern that works best for you and your baby.

Diagnosis and Tests

Your child will have a clinical feeding evaluation at a therapy center. The feeding specialist (either a speech-language pathologist or an occupational therapist) will talk with you about:

• The foods your child eats
• Where and when your child eats
• Who feeds your child

The therapist will look at your child’s mouth and face. They will watch your child eat or be fed. By watching children eat, the specialist can learn how they move their mouths, think while eating, and control their bodies. They can also see a child’s general ability to eat. If the therapist thinks your child may not be swallowing safely, they will schedule another evaluation.

Treatments

After the feeding evaluations, the therapist may recommend several ways to help your child, including:

• Putting your child in certain safe eating and drinking positions
• Giving your child certain drinks and foods that are safe for them
• Helping your child to eat a wider variety of foods, and drink assorted drinks
• Teaching you and your child safe feeding and drinking skills
• Coordinating services with other medical and therapy professionals

Common feeding problems include gastroesophageal reflux, gastroenteritis, too much food, too little food, and dehydration (fluid loss).

• Some feeding problems resolve without treatment, but others require medical attention or hospitalization.
• Proper nutrition and feeding techniques can alleviate some feeding problems.

Feeding problems in infants and young children are usually minor but sometimes have serious consequences.

Spitting up

Spitting up (burping up) is the effortless return of swallowed formula or breast milk through the mouth or nose after feeding. Almost all infants spit up, because infants cannot sit upright during and after feedings. Also, the valve (sphincter) that separates the esophagus and stomach is immature and does not keep all of the stomach’s contents in place. Spitting up gets worse when an infant eats too fast or swallows air. Spitting up usually stops between the ages of 7 months and 12 months.

Spitting up can be reduced by

• Feeding infants before they get very hungry
• Burping them every 4 to 5 minutes
• Placing them in an upright position during and after feeding
• Making certain the bottle nipple lets out only a few drops with pressure or when the bottle is upside down

Spitting up that seems to cause an infant discomfort, interferes with feeding and growth, or persists into early childhood is called gastroesophageal reflux and may require medical attention. If the material that is spit up is green (indicating bile) or bloody or causes any coughing or choking, medical attention is needed immediately.

Vomiting

Vomiting is the uncomfortable, forced throwing up of feedings. It is never normal. For a more complete discussion, see Vomiting in Infants and Children.

Vomiting in infants is most often the result of acute viral gastroenteritis. Viral gastroenteritis is an infection of the digestive tract that causes nausea, vomiting, diarrhea, and cramps. Vomiting can also be caused by infections elsewhere in the body, such as ear infections or urinary tract infections.

Less commonly, vomiting occurs because of a serious medical disorder. Infants between the ages of 2 weeks and 4 months of age may rarely have forceful (projectile) vomiting after feedings because of a blockage at the stomach outlet (hypertrophic pyloric stenosis). Vomiting can also be caused by life-threatening disorders, such as meningitis (infection around the brain and spinal cord), intestinal blockage, metabolic disorders, and appendicitis.

Most vomiting caused by gastroenteritis stops without treatment. Giving the child fluids and electrolytes (such as sodium and chloride) from solutions available in stores or pharmacies prevents or treats dehydration (fluid loss). A child who is vomiting frequently may tolerate small amounts of solution given more often better than large amounts given less often. Older children can be given popsicles or gelatin, although red versions of these foods can be confused with blood if the child vomits again.

A doctor should see any child with vomiting who

• Has severe abdominal pain
• Is unable to drink and retain fluids
• Has a high fever
• Is lethargic or acting extremely ill or acting very different than usual
• Vomits for more than 12 hours
• Vomits blood or green material (bile)
• Does not urinate in 8 hours

These symptoms may signal dehydration or a more severe condition.

Overfeeding

Overfeeding is giving more nutrition than a child needs for healthy growth. Overfeeding occurs when children are automatically fed as a response to crying, when they are given a bottle as a distraction or activity, or when they are allowed to keep a bottle with them at all times. Overfeeding also occurs when parents reward good behavior with food or expect children to finish their food even if they are not hungry. In the short term, overfeeding causes spitting up and diarrhea. In the long term, overfed children can become obese.

Underfeeding

Underfeeding is giving less nutrition than a child needs for healthy growth. It is one of many causes of failure to thrive and may be related to the child or the caregiver. Underfeeding may result when a fussy or distracted infant does not sit well for feedings or has difficulty sucking or swallowing. Underfeeding can also result from improper feeding techniques and errors in formula preparation (see Formula Feeding). Poverty and poor access to nutritious food are major reasons for underfeeding. Occasionally, abusive parents and parents with mental health disorders purposely withhold food from their children. In infants, underfeeding can result in dehydration and yellowing of the skin (jaundice).

Community social agencies (such as the Women, Infants, and Children [WIC] program) can help parents purchase formula and can teach them proper techniques for formula preparation and feeding. If an infant is so far below expected weight that supervised feedings are necessary, the doctor may admit the child to a hospital for evaluation. If the parents are abusive or neglectful, Child Protective Services may be called.

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It’s defined as having hard, dry bowel movements, or going fewer than three times a week.Chronic constipation is infrequent bowel movements or difficult passage of stools that persists for several weeks or longer.Though occasional constipation is very common, some people experience chronic constipation that can interfere with their ability to go about their daily tasks. Chronic constipation may also cause people to strain excessively in order to have a bowel movement.

It happens most often due to changes in diet or routine, or due to inadequate intake of fiber. You should call your doctor if you have severe pain, blood in your stools, or constipation that lasts longer than three weeks.

Other key features that usually define constipation include:

1. Your stools are dry and hard.
2. Your bowel movement is painful and stools are difficult to pass.
3. You have a feeling that you have not fully emptied your bowl.

causes–

Common causes of constipation include:

1. low-fiber diet, particularly diets high in meat, milk, or cheese
2. dehydration
3. lack of exercise
4. delaying the impulse to have a bowel movement
5. travel or other changes in routine
6. certain medications, such as high calcium antacids and pain medications
7. pregnancy
8. 8.Tiny tears in the skin around the anus (anal fissure)
9. A blockage in the intestines (bowel obstruction)
10. Colon cancer
11. Narrowing of the colon (bowel stricture)
12. Other abdominal cancer that presses on the colon
13. Rectal cancer
14. Rectum bulge through the back wall of the vagina (rectocele)

Fiber-rich foods are generally made from plants. Fiber comes in soluble and insoluble forms. The soluble fiber can dissolve in water and creates a soft, gel-like material as it passes through the digestive system.

insoluble fiber retains most of its structure as it goes through the digestive system. Both forms of fiber join with stool, increasing its weight and size while also softening it. This makes it easier to pass through the rectum.

The colon’s muscles eventually propel the waste out through the rectum to be eliminated. If stool remains in the colon too long, it can become hard and difficult to pass.

Lack of fiber in the diet

People with a high intake of dietary fiber are less likely to experience constipation.

This is because fiber promotes regular bowel movements, especially when a person combines it with proper hydration.

High fiber foods include:

• fruits
• vegetables
• whole grains
• nuts
• lentils, chickpeas, and other legumes

Low fiber foods include:

• high fat foods, such as cheese, meat, and eggs
• highly processed foods, such as white bread
• fast foods, chips, and other premade foods

Learn more about foods that can prevent and treat constipation here.

Physical inactivity

Low levels of physical activity may also lead to constipation.

Some past studies have found that physically fit people, including marathon runners, are less likely to experience constipation than other people, although the exact reasons for this remain unclear.

A study from 2013 notes that increasing mobility might help improve constipation among older adults.

People who spend several days or weeks in bed or sitting in a chair may have a higher risk of constipation.

Some medications

Some medications can also increase the risk of constipation. These include:

Opioid pain relief drugs: These include codeine (present with acetaminophen in Tylenol #3), oxycodone (OxyContin), and hydromorphone (Dilaudid).

Tricyclic antidepressants: These include amitriptyline (Elavil) and imipramine (Tofranil).

Certain anticonvulsants: Examples include phenytoin (Dilantin) and carbamazepine (Tegretol).

Calcium channel blockers: These lower blood pressure, and certain types lower heart rate. They include diltiazem (Cardizem) and nifedipine (Procardia).

Antacids that contain aluminum: These include Amphojel and Basaljel.

Antacids that contain calcium: One example is Tums.

Diuretics: These remove excess fluid from the body. They include hydrochlorothiazide (Hydrodiuril) and furosemide (Lasix).

Iron supplements: Doctors prescribe these to treat iron deficiency anemia.

Irritable bowel syndrome

People with functional intestinal difficulty, such as irritable bowel syndrome (IBS), have a higher risk of constipation than people without the condition.

A person with IBS may experience:

• abdominal pain
• bloating
• distension
• changes in the frequency or consistency of stools

With IBS, constipation can fluctuate over time. When constipation is not present, there may instead be loose stools with diarrhea.

Aging

As people age, the prevalence of constipation tends to increase. Up to 40% of older people in the community and up to 60% of those in institutions may experience constipation.

The exact cause of this remains unclear. It may be that as people age, food takes longer to pass through the digestive tract. Many people also become less mobile, which may also contribute to constipation.

Medical conditions, medications, and a low intake of fiber or water may be other factors that lead to constipation with age.

Changes in routine

When a person travels, for example, their usual routine changes. This can affect the digestive system. In an article from 2008, scientists asked 83 people about the digestive changes they experienced while traveling outside of the United States.

The results showed that 9% of people experienced constipation when they went to another country.

Eating meals, going to bed, and using the bathroom at different times than usual could increase the risk of constipation.

Overuse of laxatives

Some people worry that they do not use the bathroom often enough, and they take laxatives to try to solve this problem. Laxatives can help with bowel movements, but regular use of certain laxatives allows the body to get used to their action.

This may cause a person to continue taking laxatives when they no longer need them. The person may also need higher doses to get the same effect.

In other words, laxatives can be habit forming — especially stimulant laxatives. This means that the more a person depends on laxatives, the greater their risk of constipation when they stop using them.

Overuse of laxatives can also lead to:

• dehydration
• an electrolyte imbalance
• internal organ damage

Some of these complications can become life threatening. For this reason, people should talk to a healthcare professional before they start using laxatives.

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Not using the bathroom when necessary

If a person ignores the urge to have a bowel movement, the urge may gradually go away until they no longer feel the need to go.

However, the longer they delay, the drier and harder the stool will become. This will increase the risk of fecal impaction.

Not drinking enough water

Regularly drinking enough water can help reduce the risk of constipation.

Other suitable fluids include naturally sweetened fruit or vegetable juices and clear soups.

It is important to note that some liquids can increase the risk of dehydration and make constipation worse for some people. For example, those who are prone to constipation should limit their intake of caffeinated sodas, coffee, and alcohol.

Colorectal problems

Some health conditions that affect the colon can impede and restrict the passage of stool, leading to constipation.

Examples of such conditions include:

• cancerous tumors
• a hernia
• scar tissue
• diverticulitis
• colorectal stricture, which is an abnormal narrowing of the colon or rectum
• inflammatory bowel disease (IBD)

Other conditions

Some other medical conditions can also cause or contribute to constipation.

These include:

Neurological conditions: Multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries, and chronic intestinal pseudo-obstruction can lead to constipation.

Conditions that involve hormonal function, electrolytes, or renal function: These include uremia, diabetes, hypercalcemia, and hypothyroidism.

Intestinal blockage: This can occur if a tumor blocks or squeezes part of the digestive system.

Conditions that affect the digestive system: Constipation can occur with celiac disease, IBD, and other inflammatory conditions.

Cancer treatment: Chemotherapy and opioid pain relief medications, can also trigger constipation.

Problems with the nerves around the colon and rectum

Neurological problems can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include:

1. Damage to the nerves that control bodily functions (autonomic neuropathy)
2. Multiple sclerosis
3. Parkinson’s disease
4. Spinal cord injury
5. Stroke

Risk factors

Factors that may increase your risk of chronic constipation include:

1. Being an older adult
2. menstrution
3. Being dehydrated
4. Eating a diet that’s low in fiber
5. Getting little or no physical activity
6. Taking certain medications, including sedatives, opioid pain medications, some antidepressants or medications to lower blood pressure
7. Having a mental health condition such as depression or an eating disorder

Complications

Complications of chronic constipation include:

1. Swollen veins in your anus (hemorrhoids). Straining to have a bowel movement may cause swelling in the veins in and around your anus.
2. Torn skin in your anus (anal fissure). A large or hard stool can cause tiny tears in the anus.
3. Stool that can’t be expelled (fecal impaction). Chronic constipation may cause an accumulation of hardened stool that gets stuck in your intestines.
4. Intestine that protrudes from the anus (rectal prolapse). Straining to have a bowel movement can cause a small amount of the rectum to stretch and protrude from the anus.

Marker study–

A marker study, also called a colorectal transit study, is used to test how food is moving through your colon. For this test, you’ll swallow a pill that contains tiny markers that will show up on an X-ray.

Anorectal manometry

An anorectal manometry is a test used to evaluate anal sphincter muscle function. For this test, your doctor will insert a thin tube with a balloon tip into your anus.

Barium enema X-ray

A barium enema X-ray is a type of test used to examine the colon. For this test, you’ll drink a special liquid the night before the test to clean out the bowel.

Colonoscopy

A colonoscopy is another type of test doctors use to examine the colon. In this test, your doctor will examine your colon using a tube that’s outfitted with a camera and light source (colonoscope).

Symptoms

Constipation makes it difficult to pass stools.

The main symptoms of constipation are:

• difficulty passing stool
• straining when passing stool
• passing less stool than usual
• lumpy, dry, or hard stool

Other symptoms include:

• pain and cramping in the abdomen
• feeling bloated
• nausea
• a loss of appetite

What does it mean if a person has abdominal pain as well as constipation?

In children and babies

Constipation can sometimes affect children and babies. The following sections discuss this in more detail.

Newborns

If a newborn does not pass meconium, their first solid stool, within 48 hours of birth, they may have Hirschsprung’s disease.

This is a condition wherein certain nerve cells are missing from part of the large intestine. Stool is unable to move forward in the affected area of colon, which causes a backup.

A healthcare provider will usually be able to spot these symptoms and recommend surgery as treatment. In most cases, the outlook is good for babies born with this condition.

Young infants

If a breastfed baby goes a week without passing stool, this is not usually a problem. Breastfed infants do not usually experience constipation.

However, if parents or caregivers have concerns about a baby’s bowel movements, they can seek medical advice.

More commonly, constipation can occur:

• when an infant first starts taking formula feeds
• during weaning
• during potty training
• at times of stress

If an infant experiences constipation while consuming formula feed, they may benefit from drinking extra water between feeds. Parents and caregivers should not add extra water to the formula, however.

If the infant is already consuming solids, they may need more fiber and water in their diet. Fruit can be a good option. However, do not force children to eat if they do not want to, as this can cause or add to stress.

During potty training, constipation can occur if a child feels stressed, especially if other changes are occurring, such as starting at nursery. Giving the child plenty of time to empty their bowels may help.

Apart from not passing stool, some symptoms that indicate constipation in children include:

• a firm or distended abdomen
• low energy
• reduced appetite
• irritability

In pregnancy

According to one source, around 40% of women experience constipation during pregnancy.

This can result from:

• hormonal changes
• physical changes, such as when the uterus presses on the intestines
• dietary or physical activity changes

Many women take iron supplements during pregnancy. These can contribute to constipation and other changes in bowel habits.

Treatment

Constipation usually resolves itself without the need for prescription treatment. In most cases, making lifestyle changes — such as getting more exercise, eating more fiber, and drinking more water — can help.

Allowing time for defecation, without stress or interruption, may also help. People should also not ignore the urge to have a bowel movement.

Laxatives can improve symptoms in the short-term, but people should use them with care and only when necessary. This is because some laxatives can have severe adverse effects.

The Food and Drug Administration (FDA) urge people to check with their doctor before using them, and to follow the instructions on the label with care.

If constipation persists, people should see a doctor. They may need stronger medication. The doctor may also test for any underlying conditions.

Keeping a record of bowel movements, stool characteristics, and dietary and other factors may help find a suitable treatment.

Laxatives

Some laxatives are available over the counter, while others are available with a prescription.

People should only consider using laxatives if making lifestyle changes has not helped. It is best to check with a doctor before use.

The following are some laxatives and stool softeners that may help ease constipation:

Fiber supplements: Also known as bulk-forming laxatives, these may be the safest option. FiberCon is one example. People should take these with plenty of water. Bulk-forming laxatives are available from pharmacies and to purchase online.

Stimulants: These cause the muscles in the intestines to contract rhythmically. Senokot is one example.

Lubricants: These help the stool move smoothly through the colon. One example is mineral oil (Fleet).

Stool softeners: These moisten the stool. Examples include Colace and Surfak.

Osmotics: These draw water into the colon to hydrate the stool and ease movement. Saline laxatives are a type of osmotic.

Neuromuscular agents: These include opioid antagonists and 5-HT4 agonists. They work at specific receptors to regulate movement through the gut.

How do stool softeners compare with other laxatives?

Other treatment options

If laxatives do not work, a doctor may need to remove impacted stool manually or surgically.

If constipation does not respond to treatment or if there are other symptoms, a doctor may suggest an abdominal imaging study — such as a CT scan, MRI scan, or X-ray — to see if there is a blockage due to an underlying disease process in the gut.

If there is, a person may need specific prescription medications or surgery to resolve it. Depending on the results of the tests and the person’s response to medical or surgical therapy, they may also need further treatment.

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Obesity is becoming a global epidemic in both children and adults. It is associated with numerous comorbidities such as cardiovascular diseases (CVD), type 2 diabetes, hypertension, certain cancers, and sleep apnea/sleep-disordered breathing. In fact, obesity is an independent risk factor for CVD, and CVD risks have also been documented in obese children. Obesity is associated with an increased risk of morbidity and mortality as well as reduced life expectancy. Health service use and medical costs associated with obesity and related diseases have risen dramatically and are expected to continue to rise. Besides an altered metabolic profile, a variety of adaptations/alterations in cardiac structure and function occur in the individual as adipose tissue accumulates in excess amounts, even in the absence of comorbidities. Hence, obesity may affect the heart through its influence on known risk factors such as dyslipidemia, hypertension, glucose intolerance, inflammatory markers, obstructive sleep apnea/hypoventilation, and the prothrombotic state, in addition to as-yet-unrecognized mechanisms. On the whole, overweight and obesity predispose to or are associated with numerous cardiac complications such as coronary heart disease, heart failure, and sudden death because of their impact on the cardiovascular system. The pathophysiology of these entities that are linked to obesity will be discussed. However, the cardiovascular clinical evaluation of obese patients may be limited because of the morphology of the individual. In this statement, we review the available evidence of the impact of obesity on CVD with emphasis on the evaluation of cardiac structure and function in obese patients and the effect of weight loss on the cardiovascular system.

Obesity is becoming a global epidemic, and in the past 10 years in the United States, dramatic increases in obesity have occurred in both children and adults.Historically, the Metropolitan Life Insurance Company data that express body fatness as percent ideal body weight have been used, but currently overweight and obesity are classified by body mass index (BMI). BMI (weight in kilograms/height² in meters) is frequently used as a surrogate measure of fatness in children and adults. In adults, overweight is defined as a BMI of 25.0 to 29.9 kg/m²; obesity is defined as a BMI ≥30.0 kg/m². shows the classification developed by a National Heart, Lung, and Blood Institute task force, along with the associated disease risk with increasing BMI. Through the use of the BMI, the epidemic of obesity that began in the 1980s has been tracked through the end of the century. The original alarm was sounded in 1994 by the National Center for Health Statistics when they reported their data from the first 3 years of the National Health and Nutrition Examination Survey (NHANES). The authors observed that from 1988–1994 (NHANES III) to NHANES 1999–2000, the prevalence of overweight in adults increased from 55.9% to 64.5%. During that same period, the prevalence of obesity increased from 22.9% to 30.5%.This sudden, unanticipated jump in the prevalence of obesity led the American Heart Association (AHA) to call for action to curb the consequences of this epidemic. More recently, the AHA has addressed and reviewed a variety of weight loss approaches for the management and treatment of obesity.Beyond an unfavorable risk factor profile, overweight and obesity also affect heart structure and function. Moreover, the cardiovascular clinical evaluation of obese patients may be limited because of the morphology of the individual. This statement reviews the available evidence of the impact of obesity on cardiovascular disease (CVD), with emphasis on the evaluation of cardiac structure and function in obese patients and the effect of weight loss on the cardiovascular system.

Diet and heart health

The role of diet is crucial in the development and prevention of cardiovascular disease (CVD). Diet is a key modifiable risk factor for CVD.

Change in eating habits

• Human beings’ average weight is increasing. The latter half of the 20th century saw major changes to daily diets, moving from plant-based diets to high-fat, animal-based diets
• The obesity epidemic is spreading to low- and middle-income countries as a result of new dietary habits and sedentary ways of life, fuelling chronic diseases and premature mortality

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Components of a healthy diet

• A healthy diet is low in saturated fats, salts and refined carbohydrates and high in fruit and vegetables. As well as this, eating whole grains, at least two servings of fish a week, and nuts can reduce the risk of CVD
• The World Health Organization (WHO) recommends individuals to:
  • Limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of transfatty acids
  • Increase consumption of fruits and vegetables, and whole grains and nuts. Adults should consume at least 500g of fresh fruit and vegetables a day.
  • Limit the intake of free sugars and salt (sodium) consumption from all sources . Recent guidance recommends eating less than 1,500 mg of sodium per day

Overweight and obesity

• Overweight and obesity are classified by an individual’s body mass index (BMI). BMI is measured by dividing a person’s weight by their height squared in metres
• In adults, overweight is defined as a BMI of 25.0 to 29.9 kg/m2; obesity is defined as a BMI of 30.0 kg/m2 or greater

Facts & figures: prevalence

• Latest projections from the WHO indicate that globally in 2005 approximately 1.6 billion adults aged 15 and above were overweight; at least 400 million adults were obese
• The WHO further projects that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese
• Once considered a problem only in high-income countries, overweight and obesity are now dramatically on the rise in low- and middle-income countries, particularly in urban settings

Impact of obesity on heart health

• Obesity is an independent risk factor for CVD
• An overweight person may develop hypertension, type-2 diabetes and musculoskeletal disorder, putting them at high risk of CVD
  • Increased body weight leads to increased risk of developing type-2 diabetes and incidence of hypertension rises. Statistics show that 58 per cent of diabetes mellitus globally and 21 per cent of chronic heart disease are attributable to a BMI above 21
  • Excess fat can also affect an individual’s blood pressure and blood lipid levels and interferes with their ability to use insulin effectively

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Metabolism is the chemical process your body uses to transform the food you eat into the fuel that keeps you alive.

Nutrition (food) consists of proteins, carbohydrates, and fats. These substances are broken down by enzymes in your digestive system, and then carried to the cells where they can be used as fuel. Your body either uses these substances immediately, or stores them in the liver, body fat, and muscle tissues for later use.

What is a metabolic disorder?

A metabolic disorder occurs when the metabolism process fails and causes the body to have either too much or too little of the essential substances needed to stay healthy.

Our bodies are very sensitive to errors in metabolism. The body must have amino acids and many types of proteins to perform all of its functions. For example, the brain needs calcium, potassium, and sodium to generate electrical impulses, and lipids (fats and oils) to maintain a healthy nervous system.

Metabolic disorders can take many forms. This includes:

• a missing enzyme or vitamin that’s necessary for an important chemical reaction
• abnormal chemical reactions that hinder metabolic processes
• a disease in the liver, pancreas, endocrine glands, or other organs involved in metabolism
• nutritional deficiencies

To help you create your best meal plan, we’ll send you expert, evidence-based guidance on nutrition and weight loss.

What causes metabolic disorders?

You can develop a metabolic disorder if certain organs — for instance, the pancreas or the liver — stop functioning properly. These kinds of disorders can be a result of genetics, a deficiency in a certain hormone or enzyme, consuming too much of certain foods, or a number of other factors.

There are hundreds of genetic metabolic disorders caused by mutations of single genes. These mutations can be passed down through generations of families. According to the National Institutes of Health (NIH)T, certain racial or ethnic groups are more likely to pass on mutated genes for particular inborn disorders. The most common of these are:

• sickle cell anemia in African Americans
• cystic fibrosis in people of European heritage
• maple syrup urine disease in Mennonite communities
• Gaucher’s disease in Jewish people from Eastern Europe
• hemochromatosis in Caucasians in the United States

Types of metabolic disorders

Diabetes is the most common metabolic disease. There are two types of diabetes:

• Type 1, the cause of which is unknown, although there can be a genetic factor.
• Type 2, which can be acquired, or potentially caused by genetic factors as well.

According to the American Diabetes Association, 30.3 million children and adults, or about 9.4 percent of the U.S. population have diabetes.

In type 1 diabetes, the T cells attack and kill beta cells in the pancreas, the cells that produce insulin. Over time, a lack of insulin can cause:

• nerve and kidney damage
• eyesight impairment
• increased risk of heart and vascular disease

Hundreds of inborn errors in metabolism (IEM) have been identified, and most are extremely rare. However, it’s estimated that IEM collectively affects 1 in every 1,000 infants. Many of these disorders can only be treated by limiting dietary intake of the substance or substances the body cannot process.

The more common types of nutritional and metabolic disorders include:

Gaucher’s disease

This condition causes an inability to break down a particular kind of fat, which accumulates in the liver, spleen, and bone marrow. This inability can result in pain, bone damage, and even death. It’s treated with enzyme replacement therapy.

Glucose galactose malabsorption

This is a defect in the transport of glucose and galactose across the stomach lining which leads to severe diarrhea and dehydration. Symptoms are controlled by removing lactose, sucrose, and glucose from the diet.

Hereditary hemochromatosis

In this condition, excess iron is deposited in several organs, and can cause:

• liver cirrhosis
• liver cancer
• diabetes
• heart disease

It’s treated by removing blood from the body (phlebotomy) on a regular basis.

Maple syrup urine disease (MSUD)

MSUD disrupts the metabolism of certain amino acids, causing rapid degeneration of the neurons. If not treated, it causes death within the first few months after birth. Treatment involves limiting the dietary intake of branched-chain amino acids.

Phenylketonuria (PKU)

PKU causes an inability to produce the enzyme, phenylalanine hydroxylase, resulting in organ damage, mental retardation, and unusual posture. It’s treated by limiting the dietary intake of certain forms of protein.

ymptoms of inherited metabolic disorders

Symptoms of metabolic disorders that run in families include:

• Body fluids that have a maple smell
• Bone abnormalities such as osteoporosis (thinning and weakening of the bones)
• Difficulty with memory, thinking, talking, comprehension, writing or reading
• Enlarged liver, heart, kidney or spleen
• Failure to thrive in infants and children
• Frequent infections
• Hypoglycemia (low blood sugar)
• Loss of vision or changes in vision
• Muscle twitching, spasms or seizures
• Muscle weakness
• Paralysis

Symptoms of acquired metabolic disorders

Symptoms of metabolic disorders that you can acquire during your lifetime include:

• Chronic or persistent diarrhea
• Fatigue
• Headache
• Irritability and mood changes
• Muscle cramping
• Nausea with or without vomiting
• Rapid breathing (tachypnea) or shortness of breath

Serious symptoms that might indicate a life-threatening condition

In some cases, metabolic disorders can be life threatening. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:

• Bluish coloration of the lips or fingernails
• Change in mental status or sudden behavior change, such as confusion, delirium, lethargy, hallucinations and delusions
• Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, choking
• Seizure

What are the risk factors for metabolic disorders?

A number of factors increase the risk of developing metabolic disorders. Not all people with risk factors will get metabolic disorders. Risk factors for metabolic disorders include:

• Certain chronic medical conditions, such as lung or kidney disease (includes any type of kidney problem, such as kidney stones, kidney failure and kidney anomalies)
• Family history of genetic metabolic disorder
• HIV/AIDS

How are metabolic disorders treated?

Treatment for metabolic disorders begins with seeking medical care from your health care provider. The treatment approach for metabolic disorders depends on the specific disorder. Inborn errors of metabolism (inherited metabolic disorders) are often treated with nutritional counseling and support, periodic assessment, physical therapy, and other supportive care options. Acquired metabolic disorder treatment will include normalizing the metabolic balance by both reversing the cause and administering medications.

Treatment options for inherited metabolic disorders

Multiple treatment options are available for inherited metabolic disorders. Examples include:

• Bone marrow transplantation
• Enzyme replacement therapy in selected patients
• Gene therapy in selected patients
• Medications to reduce symptoms, such as pain or low blood sugar
• Mineral supplementation
• Nutritional counseling
• Physical therapy
• Surgery to relieve pain or symptoms
• Vitamin supplementation

What are the potential complications of metabolic disorders?

Complications of untreated metabolic disorders can be serious, even life threatening in some cases. You can help minimize your risk of serious complications by following the treatment plan you and your health care professional design specifically for you. Complications of metabolic disorders include:

• Organ failure or dysfunction
• Seizures and tremors
• Unconsciousness and coma

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A healthy diet for Nephrotic Syndrome patients consists of low salt, low fat, and low cholesterol, with an emphasis on fruits and vegetables.

NOTE: The amount of protein and fluid a patient with Nephrotic Syndrome should have depends on the patient’s current condition, age, and weight. It is very important that a nephrologist and/or a renal dietitian be consulted. This information is meant to be used as a resource and is not meant to replace medical advice. Also, this is NOT geared towards those experiencing dialysis or transplant.

Maintaining a Healthy Diet

• Low sodium (salt) can help with swelling in the hands and legs
• Fiber from whole grains and fresh fruits and vegetables can help lower total and LDL cholesterol
• Low fat (1% or skim) dairy products
• Lean cuts of meat, less red meat, more chicken and fish
• SOMETIMES fluids should be restricted, as determined by a nephrologist
• SOMETIMES protein levels should be increased or decreased, as determined by a nephrologist
• RARELY should potassium or phosphorous be restricted, only if kidneys are failing and as determined by a nephrologist.

Healthy diet basics

With all meal plans, including the kidney-friendly diet, you need to track how much of certain nutrients you take in, such as:

• Calories
• Protein
• Fat
• Carbohydrates

To make sure you are getting the right amounts of these nutrients, you need to eat and drink the right portion sizes. All of the information you need to keep track of your intake is on the “Nutrition Facts” label.

Use the nutrition facts section on food labels to learn more about what is in the foods you eat. The nutrition facts will tell you how much protein, carbohydrates, fat and sodium are in each serving of a food. This can help you pick foods that are high in the nutrients you need and low in the nutrients you should limit.

When you look at the nutrition facts, there are a few key areas that will give you the information you need:

Calories

Your body gets energy from the calories you eat and drink. Calories come from the protein, carbohydrates and fat in your diet. How many calories you need depends on your age, gender, body size and activity level.

You may also need to adjust how many calories you eat based on your weight goals. Some people will need to limit the calories they eat. Others may need to have more calories. Your doctor or dietitian can help you figure out how many calories you should have each day. Work with your dietitian to make a meal plan that helps you get the right amount of calories, and keep in touch for support.

Protein

Protein is one of the building blocks of your body. Your body needs protein to grow, heal and stay healthy. Having too little protein can cause your skin, hair and nails to be weak. But having too much protein can also be a problem. To stay healthy and help you feel your best, you may need to adjust how much protein you eat.

The amount of protein you should have depends on your body size, activity level and health concerns. Some doctors recommend that people with kidney disease limit protein or change their source of protein. This is because a diet very high in protein can make the kidneys work harder and may cause more damage. Ask your doctor or dietitian how much protein you should have and what the best sources of protein are for you.

Use the table below to learn which foods are low or high in protein. Keep in mind that just because a food is low in protein, it is not healthy to eat unlimited amounts.

Lower-protein foods:

• Bread
• Fruits
• Vegetables
• Pasta and rice

Higher-protein foods:

• Red meat
• Poultry
• Fish
• Eggs

Carbohydrates

Carbohydrates (“carbs”) are the easiest kind of energy for your body to use. Healthy sources of carbohydrates include fruits and vegetables. Unhealthy sources of carbohydrates include sugar, honey, hard candies, soft drinks and other sugary drinks.

Some carbohydrates are high in potassium and phosphorus, which you may need to limit depending on your stage of kidney disease. We’ll talk about this in more detail a little later. You may also need to watch your carbohydrates carefully if you have diabetes. Your dietitian can help you learn more about the carbohydrates in your meal plan and how they affect your blood sugar.

Fat

You need some fat in your meal plan to stay healthy. Fat gives you energy and helps you use some of the vitamins in your food. But too much fat can lead to weight gain and heart disease. Try to limit fat in your meal plan, and choose healthier fats when you can.

Healthier fat or “good” fat is called unsaturated fat. Examples of unsaturated fat include:

• Olive oil
• Peanut oil
• Corn oil

Unsaturated fat can help reduce cholesterol. If you need to gain weight, try to eat more unsaturated fat. If you need to lose weight, limit the unsaturated fat in your meal plan. As always, moderation is the key. Too much “good” fat can also cause problems.

Saturated fat, also known as “bad” fat, can raise your cholesterol level and raise your risk for heart disease. Examples of saturated fats include:

• Butter
• Lard
• Shortening
• Meats

Limit these in your meal plan. Choose healthier, unsaturated fat instead. Trimming the fat from meat and removing the skin from chicken or turkey can also help limit saturated fat. You should also avoid trans fat. This kind of fat makes your “bad” (LDL) cholesterol higher and your “good” (HDL) cholesterol lower. When this happens, you are more likely to get heart disease, which can cause kidney damage.

Sodium

Sodium (salt) is a mineral found in almost all foods. Too much sodium can make you thirsty, which can lead to swelling and raise your blood pressure. This can damage your kidneys more and make your heart work harder.

One of the best things that you can do to stay healthy is to limit how much sodium you eat. To limit sodium in your meal plan:

• Do not add salt to your food when cooking or eating. Try cooking with fresh herbs, lemon juice or other salt-free spices.
• Choose fresh or frozen vegetables instead of canned vegetables. If you do use canned vegetables, drain and rinse them to remove extra salt before cooking or eating them.
• Avoid processed meats like ham, bacon, sausage and lunch meats.
• Munch on fresh fruits and vegetables rather than crackers or other salty snacks.
• Avoid canned soups and frozen dinners that are high in sodium. • Avoid pickled foods, like olives and pickles. • Limit high-sodium condiments like soy sauce, BBQ sauce and ketchup.

Important! Be careful with salt substitutes and “reduced sodium” foods. Many salt substitutes are high in potassium. Too much potassium can be dangerous if you have kidney disease. Work with your dietitian to find foods that are low in sodium and potassium.

Portions:

Choosing healthy foods is a great start, but eating too much of anything, even healthy foods, can be a problem. The other part of a healthy diet is portion control, or watching how much you eat.

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To help control your portions:

• Check the nutrition facts label on a food to learn the serving size and how much of each nutrient is in one serving. Many packages have more than one serving. For example, a 20-ounce bottle of soda is really two-and-a-half servings. Many fresh foods, such as fruits and vegetables, do not come with nutrition facts labels. Ask your dietitian for a list of nutrition facts for fresh foods and tips for how to measure the right portions.
• Eat slowly, and stop eating when you are not hungry any more. It takes about 20 minutes for your stomach to tell your brain that you are full. If you eat too quickly, you may eat more than you need.
• Avoid eating while doing something else, such as watching TV or driving. When you are distracted you may not realize how much you have eaten.
• Do not eat directly from the package the food came in. Instead, take out one serving of food and put the bag or box away.

Good portion control is an important part of any meal plan. It is even more important in a kidney-friendly meal plan, because you may need to limit how much of certain things you eat and drink.

How is a kidney-friendly diet different?

When your kidneys are not working as well as they should, waste and fluid build up in your body. Over time, the waste and extra fluid can cause heart, bone and other health problems. A kidney-friendly meal plan limits how much of certain minerals and fluid you eat and drink. This can help keep the waste and fluid from building up and causing problems.

How strict your meal plan should be depends on your stage of kidney disease. In the early stages of kidney disease, you may have little or no limits on what you eat and drink. As your kidney disease gets worse, your doctor may recommend that you limit:

• Potassium
• Phosphorus
• Fluids

Potassium

Potassium is a mineral found in almost all foods. Your body needs some potassium to make your muscles work, but too much potassium can be dangerous. When your kidneys are not working well, your potassium level may be too high or too low. Having too much or too little potassium can cause muscle cramps, problems with the way your heart beats and muscle weakness.

If you have kidney disease, you may need to limit how much potassium you take in. Ask your doctor or dietitian if you need to limit potassium.

Use the list below to learn which foods are low or high in potassium. Your dietitian can also help you learn how to safely eat small amounts of your favorite foods that are high in potassium.

Eat this … (lower-potassium foods)

• Apples, cranberries, grapes, pineapples and strawberries
• Cauliflower, onions, peppers, radishes, summer squash, lettuce
• Pita, tortillas and white breads
• Beef and chicken, white rice

Rather than … (higher-potassium foods)

• Avocados, bananas, melons, oranges, prunes and raisins
• Artichokes, winter squash, plantains, spinach, potatoes and tomatoes
• Bran products and granola
• Beans (baked, black, pinto, etc.), brown or wild rice

Your doctor may also tell you to take a special medicine called a potassium binder to help your body get rid of extra potassium.

Phosphorus

Phosphorus is a mineral found in almost all foods. It works with calcium and vitamin D to keep your bones healthy. Healthy kidneys keep the right amount of phosphorus in your body. When your kidneys are not working well, phosphorus can build up in your blood. Too much phosphorus in your blood can lead to weak bones that break easily.

Many people with kidney disease need to limit phosphorus. Ask your dietitian if you need to limit phosphorus.

Depending on your stage of kidney disease, your doctor may also prescribe a medicine called a phosphate binder. This helps to keep phosphorus from building up in your blood. A phosphate binder can be helpful, but you will still need to watch how much phosphorus you eat. Ask your doctor if a phosphate binder is right for you.

Use the list below to get some ideas about how to make healthy choices if you need to limit phosphorus.

Eat this … (lower-phosphorous foods)

• Italian, French or sourdough bread
• Corn or rice cereals and cream of wheat
• Unsalted popcorn
• Some light-colored sodas and lemonade

Rather than … (higher-phosphorous foods)

• Whole-grain bread
• Bran cereals and oatmeal
• Nuts and sunflower seeds
• Dark-colored colas

Fluids

You need water to live, but when you have kidney disease, you may not need as much. This is because damaged kidneys do not get rid of extra fluid as well as they should. Too much fluid in your body can be dangerous. It can cause high blood pressure, swelling and heart failure. Extra fluid can also build up around your lungs and make it hard to breathe.

Depending on your stage of kidney disease and your treatment, your doctor may tell you to limit fluid. If your doctor tells you this, you will need to cut back on how much you drink. You may also need to cut back on some foods that contain a lot of water. Soups or foods that melt, like ice, ice cream and gelatin, have a lot of water. Many fruits and vegetables are high in water, too.

Ask your doctor or dietitian if you need to limit fluids.

If you do need to limit fluids, measure your fluids and drink from small cups to help you keep track of how much you’ve had to drink. Limit sodium to help cut down on thirst. At times, you may still feel thirsty. To help quench your thirst, you might try to:

• Chew gum
• Rinse your mouth
• Suck on a piece of ice, mints or hard candy (Remember to choose sugar-free candy if you have diabetes.)

Special diet concerns

Vitamins

Following a kidney-friendly meal plan may make it hard for you to get all of the vitamins and minerals you need. To help you get the right amounts of vitamins and minerals, your dietitian may suggest a special supplement made for people with kidney disease.

Your doctor or dietitian might also suggest a special kind of vitamin D, folic acid or iron pill, to help prevent some common side effects of kidney disease, such as bone disease and anemia. Regular multi-vitamins may not be healthy for you if you have kidney disease. They may have too much of some vitamins and not enough of others. Your doctor or dietitian can help you find vitamins that are right for you.

Important! Tell your doctor and dietitian about any vitamins, supplements or over-the-counter medicines you are taking. Some can cause more damage to your kidneys or cause other health problems.

Following a kidney-friendly meal plan with diabetes

If you have diabetes, you need to control your blood sugar to prevent more damage to your kidneys. Your doctor and dietitian can help you create a meal plan that helps you control your blood sugar, while also limiting sodium, phosphorus, potassium and fluids.

A diabetes educator can also help you learn how to control your blood sugar. Ask your doctor to refer you to a diabetes educator in your area. A list of diabetes educators is available from the American Association of Diabetes .Educators at Medicare and many private insurance policies may help pay for appointments with a diabetes educator.

Find kidney-friendly recipes on Kidney Kitchen

In Kidney Kitchen, you can take a deep dive into what each nutrient means for people with kidney disease, and how much of these nutrients common foods contain. Learn what healthy eating means for people in every stage of kidney disease, including those on dialysis or living with a kidney transplant.

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The digestive system breaks food down into nutrients and energy that the body can use. Some types of food, including vegetables and yogurt, can help this process of digestion.

Eating certain types of food or making sudden changes to the diet can result in problems with digestion.

In some people, digestive problems can lead to symptoms including:

• bloating
• gas
• constipation
• diarrhea
• nausea
• vomiting
• heartburn

In this article, we list foods that are good for the digestive system. We also cover which ones to avoid.

Foods that help digestion

Adding ginger to food may reduce digestive problems.

As soon as food enters the body through the mouth, the process of digestion begins.

The body gradually moves it through the digestive system, which breaks the food down into smaller, more useable parts.

Various foods can help at different stages of this process. For example, some aid digestion in the stomach, while others support the intestines.

Fiber is essential to digestive health in general. If a person is not used to eating fiber often, it is best to increase fiber intake slowly, starting with soluble fiber such as from oatmeal, apples, and bananas.

Add around one serving of fiber to the diet every 4–5 days. Increasing fiber intake too quickly can be bad for digestion.

Drinking plenty of water is also important, as it combines with fiber and adds bulk to stool.

Specific foods that are good for digestion include:

Foods containing ginger

Ginger is a plant that can reduce bloating and other digestive problems.

Dried ginger powder is an excellent spice for flavoring meals, and a person can also use slices of ginger root to make tea.

Choose a quality ginger root powder for flavoring meals. For tea, choose fresh ginger root for the best results.

Unsaturated fats

This type of fat helps the body absorb vitamins. It also combines with fiber to help encourage bowel movements.

Plant oils such as olive oil are a good source of unsaturated fats.

Always consume fats in moderation. For an adult following a 2,000-calorie-per-day diet, for example, fat intake should not exceed 77 grams daily.

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Vegetables with skin

Vegetables are rich in fiber, which is an important nutrient for digestion. Fiber stimulates the bowels to move stool out of the body.

The skins of vegetables are often rich in fiber, and it is best to consume them whole. Some vegetables with skin rich in fiber include potatoes, beans, and legumes.

Fruits

Many fruits are also rich in fiber. They also contain vitamins and minerals that are good for digestion, such as vitamin C and potassium.

For example, apples, oranges, and bananas are nutritious fruits that could help with digestion.

Whole-grain foods

Whole-grain foods also have a high fiber content that aids digestion. The body breaks down whole grains slowly, which helps control blood sugar levels.

Many whole grain foods are available, including brown rice and quinoa.

Yogurt

Many yogurt products contain probiotics. These are live bacteria and yeasts that may have benefits for the digestive system.

Kefir

Kefir is a fermented milk drink that is filling and contains probiotics. As mentioned above, these may promote better digestion and gut health.

Leafy green vegetables

Leafy green vegetables are packed with nutrients that are helpful for digestion.

According to an article in the journal Nature Chemical Biology, these vegetables also contain sulfoquinovose. This is a sugar that may feed healthful bacteria in the stomach, thereby promoting digestion.

What to avoid

Eating too fast may hamper digestion.

Although most foods are fine to consume in moderation, some are not as helpful for digestion.

Some foods and drinks increase the risk of bloating, heartburn, and diarrhea. Examples of these include:

• artificial sweeteners, such as sugar alcohols
• carbonated beverages or sugar sweetened drinks
• refined carbohydrates, such as white bread
• alcohol
• milk or white chocolate
• foods high in saturated fats, such as cheese and cream
• coffee and other drinks containing caffeine
• spicy foods, such as some types of curry
• greasy foods, such as pizza

Some habits can also hamper digestion. These include eating too fast and lying down immediately after eating.

The body can also take longer to digest large meals, which may be problematic for some people. To enhance digestion, it is best to eat several small meals instead of one large one.

However, everyone’s digestive systems vary. For example, some people may have food intolerances and allergies, while others do not.

A doctor may recommend that people with digestive problems such as these keep a food diary. This can help identify foods and drinks that trigger digestive issues.

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Gastrointestinal diseases affect the gastrointestinal (GI) tract from the mouth to the anus. There are two types: functional and structural. Some examples include nausea/vomiting, food poisoning, lactose intolerance and diarrhea.

What are functional gastrointestinal diseases?

Functional diseases are those in which the GI tract looks normal when examined, but doesn’t move properly. They are the most common problems affecting the GI tract (including the colon and rectum). Constipation, irritable bowel syndrome (IBS), nausea, food poisoning, gas, bloating, GERD and diarrhea are common examples.

Many factors may upset your GI tract and its motility (ability to keep moving), including:

• Eating a diet low in fiber.
• Not getting enough exercise.
• Traveling or other changes in routine.
• Eating large amounts of dairy products.
• Stress.
• Resisting the urge to have a bowel movement, possibly because of hemorrhoids.
• Overusing anti-diarrheal medications that, over time, weaken the bowel muscle movements called motility.
• Taking antacid medicines containing calcium or aluminum.
• Taking certain medicines (especially antidepressants, iron pills and strong pain medicines such as narcotics).
• Pregnancy.

What are structural gastrointestinal diseases?

Structural gastrointestinal diseases are those where your bowel looks abnormal upon examination and also doesn’t work properly. Sometimes, the structural abnormality needs to be removed surgically. Common examples of structural GI diseases include strictures, stenosis, hemorrhoids, diverticular disease, colon polyps, colon cancer and inflammatory bowel disease.

Constipation

Constipation, which is a functional problem, makes it hard for you to have a bowel movement (or pass stools), the stools are infrequent (less than three times a week), or incomplete. Constipation is usually caused by inadequate “roughage” or fiber in your diet, or a disruption of your regular routine or diet.

Constipation causes you to strain during a bowel movement. It may cause small, hard stools and sometimes anal problems such as fissures and hemorrhoids. Constipation is rarely the sign that you have a more serious medical condition.

You can treat your constipation by:

• Increasing the amount of fiber and water to your diet.
• Exercising regularly and increasing the intensity of your exercises as tolerated.
• Moving your bowels when you have the urge (resisting the urge causes constipation).

If these treatment methods don’t work, laxatives can be added. Note that you should make sure you are up to date with your colon cancer screening. Always follow the instructions on the laxative medicine, as well as the advice of your healthcare provider.

Irritable bowel syndrome (IBS)

Irritable bowel syndrome (also called spastic colon, irritable colon, IBS, or nervous stomach) is a functional condition where your colon muscle contracts more or less often than “normal.” Certain foods, medicines and emotional stress are some factors that can trigger IBS.

Symptoms of IBS include:

• Abdominal pain and cramps.
• Excess gas.
• Bloating.
• Change in bowel habits such as harder, looser, or more urgent stools than normal.
• Alternating constipation and diarrhea.

Treatment includes:

• Avoiding excessive caffeine.
• Increasing fiber in your diet.
• Monitoring which foods trigger your IBS (and avoiding these foods).
• Minimizing stress or learning different ways to cope with stress.
• Taking medicines as prescribed by your healthcare provider.
• Avoiding dehydration, and hydrating well throughout the day.
• Getting high quality rest/sleep.

Hemorrhoids

Hemorrhoids are dilated veins in the anal canal, structural disease. They’re swollen blood vessels that line your anal opening. They are caused by chronic excess pressure from straining during a bowel movement, persistent diarrhea, or pregnancy. There are two types of hemorrhoids: internal and external.

Internal hemorrhoids

Internal hemorrhoids are blood vessels on the inside of your anal opening. When they fall down into the anus as a result of straining, they become irritated and start to bleed. Ultimately, internal hemorrhoids can fall down enough to prolapse (sink or stick) out of the anus.

Treatment includes:

• Improving bowel habits (such as avoiding constipation, not straining during bowel movements and moving your bowels when you have the urge).
• Your healthcare provider using ligating bands to eliminate the vessels.
• Your healthcare provider removing them surgically. Surgery is needed only for a small number of people with very large, painful and persistent hemorrhoids.

External hemorrhoids

External hemorrhoids are veins that lie just under the skin on the outside of the anus. Sometimes, after straining, the external hemorrhoidal veins burst and a blood clots form under the skin. This very painful condition is called a “pile.”

Treatment includes removing the clot and vein under local anesthesia and/or removing the hemorrhoid itself.

Anal fissures

Anal fissures are also a structural disease. They are splits or cracks in the lining of your anal opening. The most common cause of an anal fissure is the passage of very hard or watery stools. The crack in the anal lining exposes the underlying muscles that control the passage of stool through the anus and out of the body. An anal fissure is one of the most painful problems because the exposed muscles become irritated from exposure to stool or air, and leads to intense burning pain, bleeding, or spasm after bowel movements.

Initial treatment for anal fissures includes pain medicine, dietary fiber to reduce the occurrence of large, bulky stools and sitz baths (sitting in a few inches of warm water). If these treatments don’t relieve your pain, surgery might be needed to repair the sphincter muscle.

Perianal abscesses

Perianal abscesses, also a structural disease, can occur when the tiny anal glands that open on the inside of your anus become blocked, and the bacteria always present in these glands causes an infection. When pus develops, an abscess forms. Treatment includes draining the abscess, usually under local anesthesia in the healthcare provider’s office.

Anal fistula

An anal fistula – again, a structural disease – often follows drainage of an abscess and is an abnormal tube-like passageway from the anal canal to a hole in the skin near the opening of your anus. Body wastes traveling through your anal canal are diverted through this tiny channel and out through the skin, causing itching and irritation. Fistulas also cause drainage, pain and bleeding. They rarely heal by themselves and usually need surgery to drain the abscess and “close off” the fistula.

Other perianal infections

Sometimes the skin glands near your anus become infected and need to be drained, like in this structural disease. Just behind the anus, abscesses can form that contain a small tuft of hair at the back of the pelvis (called a pilonidal cyst).

Sexually transmitted diseases that can affect the anus include anal warts, herpes, AIDS, chlamydia and gonorrhea.

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Diverticular disease

The structural disease diverticulosis is the presence of small outpouchings (diverticula) in the muscular wall of your large intestine that form in weakened areas of the bowel. They usually occur in the sigmoid colon, the high-pressure area of the lower large intestine.

Diverticular disease is very common and occurs in 10% of people over age 40 and in 50% of people over age 60 in Western cultures. It is often caused by too little roughage (fiber) in the diet. Diverticulosis can sometimes develop/progress into diverticulitis

Complications of diverticular disease happen in about 10% of people with outpouchings. They include infection or inflammation (diverticulitis), bleeding and obstruction. Treatment of diverticulitis includes treating the constipation and sometimes antibiotics if really severe. Surgery is needed as last resort in those who have significant complications to remove the involved diseased segment of the colon.

Digestive Health Tips

From embarrassing gas to uncomfortable heartburn, everyone has digestive problems from time to time. The good news is there are some simple solutions for many of your troubles. Learn about what causes your discomfort, how to prevent and manage digestive problems, what questions to ask your pharmacist, and when to see a doctor.

The Digestive System

How does the digestive system work?

It may seem like digestion only happens in your stomach, but it’s a long process that involves many organs. Together they form the digestive tract.

Digestion begins in your mouth, where saliva starts to break down food when you chew. When you swallow, your chewed food moves to your esophagus, a tube that connects your throat to your stomach. Muscles in the esophagus push the food down to a valve at the bottom of your esophagus, which opens to let food into the stomach.

Your stomach breaks food down using stomach acids. Then the food moves into the small intestine. There, digestive juices from several organs, like your pancreas and gallbladder, break down the food more, and nutrients are absorbed. What’s left goes through your large intestine. The large intestine absorbs water. The waste then moves out of your body through the rectum and anus.

Digestive problems can happen anywhere along the way.

Gas & Bloating

Bloating and passing gas can be uncomfortable and embarrassing. Here’s what you need to know.

What is gas?

Gas is a normal part of healthy digestion. Air that is in your digestive tract is either released through your mouth as a burp or through your anus as gas. You typically pass gas 13 to 21 times a day.

What causes gas?

Gas is created when you swallow air, such as when you eat and drink. But it’s also a by-product of the breakdown of food. Some foods cause more gas than others. You may also be more sensitive to particular foods and may have more gas when you eat them.

Which foods cause gas?

You’ve probably noticed you feel gassy after eating certain foods. Cut back on the common culprits:

• Apples
• Asparagus
• Beans
• Broccoli
• Brussels sprouts
• Cabbage
• Cauliflower
• Milk and dairy products
• Mushrooms
• Onions
• Peaches
• Pears
• Prunes
• Wheat

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What causes bloating?

Continued

When gas builds up in your stomach and intestines, you may have bloating — swelling in your belly and a feeling of fullness. It may happen to you more often if you have:

• A stomach infection
• Irritable bowel syndrome (IBS). This digestive condition causes stomach pain, cramping, and diarrhea or constipation.
• Celiac disease (When people with this condition eat gluten, their bodies produce antibodies that attack the intestinal lining.)
• Hormonal changes that happen around women’s periods
• Constipation

While bloating is usually just uncomfortable, it can sometimes cause pain in your belly or sides.

How can I reduce gas and bloating?

Diet and lifestyle changes can make a big difference:

• Cut back on fatty foods.
• Avoid fizzy drinks.
• Eat and drink slowly.
• Quit smoking.
• Don’t chew gum.
• Exercise more.
• Avoid foods that cause gas.
• Avoid sweeteners that cause gas such as fructose and sorbitol. They are often found in candies, chewing gum, energy bars, and low-carb foods.

What OTC medicines treat excess gas?

If you have a lot of gas or are very uncomfortable, an over-the-counter medicine may help.

• Lactase supplements. If dairy is causing your problems, taking these tablets or drops just before you eat will help you digest lactose (the main sugar in dairy foods) and reduce gas.
• Alpha-galactosidase. This digestive aid comes as liquid or tablets. You take it before you eat to help your body break down the complex carbs or sugars that cause gas, such as those found in beans, broccoli, and cabbage. Caution: People with the genetic condition galactosemia should avoid it. It may also interfere with some diabetes drugs like acarbose (Precose) or miglitol (Glyset). If you take medication for diabetes, talk to your doctor or pharmacist before taking this aid.
• Simethicone (Mylicon). Taking these liquids or tablets can relieve the uncomfortable bloating and pain from gas.
• Probiotics. These supplements contain “friendly” bacteria that can help digestion. In addition to tablets and powders you sprinkle on your food, foods like yogurt, kefir, and sauerkraut contain probiotics.

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What is the psychology of eating?

What we eat affects how we feel. Food should make us feel good. It tastes great and nourishes our bodies. If you eat too little or eat too much, however, your health and quality of life could be affected. This can result in negative feelings toward food.

By learning how to make healthier and more mindful choices, you may be able to control compulsive eating, binging and weight gain. By taking charge of your appetite, you may also gain a feeling of calm, high energy levels and alertness from the foods you eat.

Overall, there are many benefits to changing deep-seated, unhealthy eating habits, such as:

• An increase in energy level and alertness.
• A more positive relationship with food.
• Improved health.
• Easier movement.
• Improved body image.

While we often have the best intentions to eat healthier, this is often a challenging task.

What factors influence our eating behaviors?

Experts believe many factors can influence our feelings about food and our eating behaviors. These factors include:

• Cultural.
• Evolutionary.
• Social.
• Family.
• Individual.
• Economic status.
• Psychological.

Many people use food as a coping mechanism to deal with such feelings as stress, boredom or anxiety, or even to prolong feelings of joy. While this may help in the short term, eating to soothe and ease your feelings often leads to regret and guilt, and can even increase the negative feelings. You aren’t actually coping with the problem causing the stress. Further, your self-image may suffer as you gain weight, or you may experience other undesired effects on your health, such as elevated blood sugars, cholesterol levels or blood pressure.

What role does psychology play in weight management?

Psychology is the science of behavior. It is the study of how and why people do what they do. For people trying to manage their weight, psychology addresses:

• Behavior: Treatment involves identifying the person’s eating patterns and finding ways to change eating behaviors.
• Cognition (thinking): Therapy focuses on identifying self-defeating thinking patterns that contribute to weight management problems.

What treatments are used for weight management?

Cognitive behavioral treatment is the approach most often used because it deals with both thinking patterns and behavior. Some areas that are addressed through cognitive behavioral treatment include:

• Determining the person’s “readiness for change”: This involves an awareness of what needs to be done to achieve your goals and then making a commitment to do it.
• Learning how to self-monitor: Self-monitoring helps you become more aware of what triggers you to eat in the moment, and more mindful of your food choices and portions. It also helps you stay focused on achieving long-term progress.
• Breaking linkages: The focus here is on stimulus control, such as not eating in particular settings, and not keeping unhealthy food choices in your home. Cognitive behavioral treatment also teaches distraction — replacing eating with healthier alternatives — as a skill for coping with stress. Positive reinforcement, rehearsal/problem-solving, finding social support and changing eating habits are specific techniques used to break linkages.

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What does cognitive behavioral treatment involve?

Cognitive therapy addresses how you think about food. It helps you recognize self-defeating patterns of thinking that can undermine your success at eating healthier and managing your weight/weight loss. It also helps you learn and practice using positive coping self-statements.

Examples of self-defeating thoughts include:

• “This is too hard. I can’t do it.”
• “If I don’t make it to my target weight, I’ve failed.”
• “Now that I’ve lost weight, I can go back to eating any way I want.”

Examples of positive coping self-statements include:

• “I realize that I am overeating. I need to think about how I can stop this pattern of behavior.”
• “I need to understand what triggered my overeating, so I can create a plan to cope with it if I encounter the trigger again.”
• “Am I really hungry or is this just a craving? I will wait to see if this feeling passes.”

What strategies will help me manage my weight?

To lose weight, it’s helpful to change your thinking. Weight management is about making a lifestyle change. It’s not going to happen if you rely on short-term diet after diet to lose weight.

To be successful, be aware of the role that eating plays in your life, and learn how to use positive thinking and behavioral coping strategies to manage your eating and your weight.

To help get you started, here are a few tips:

Tips for healthy eating

• Don’t skip meals.
• Do plan meals and snacks ahead of time.
• Do keep track of your eating habits. (See “food diary” below.)
• Do limit night eating.
• Do drink plenty of water.
• Do delay/distract yourself when experiencing cravings.
• Do exercise instead of eating when you are bored.
• Do be attentive when you eat. Don’t eat while watching TV, working, driving or standing.
• Do only eat in certain settings (kitchen table).
• Do watch your portion sizes.
• Do allow yourself to eat a range of foods without forbidding yourself a particular food.
• Do give yourself encouragement.
• Do look for a support person to help you stay motivated and accountable.
• Do be gentle with yourself! Try not to beat yourself up when you lapse.
• Do think of eating healthfully as a lifestyle change.
• Do use the scale mindfully. Weigh yourself no more than once a week.
• Do make healthy food choices.

The food diary

A food diary is a tool to record in detail:

• What food you eat.
• When you eat.
• How you feel when you’re eating.
• What you are doing (if anything) while you are eating.

The diary can help you get a better understanding of what you eat and why you eat it. It also can help your doctor, therapist, or dietitian work with you to make the necessary changes for successful weight management.

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Undernutrition is common in patients admitted for surgery and is often unrecognised, untreated and worsens in hospital. The complex synergistic relationship between nutritional status and the physiological responses to surgery puts patients at high nutritional risk. There are clear prospective associations between inadequate nutritional status and the risk of poorer outcomes for surgical patients, including infection, complications and length of stay. However, practically and ethically evidence that nutritional interventions can significantly reduce these poor outcomes is difficult to obtain. Nevertheless health professionals have a duty of care to ensure our patients are properly fed, by whatever means, to meet their physiological requirements.

Introduction

Well-nourished patients respond to, and recover from illness and surgery better than undernourished patients. While overnutrition is widely thought to be the primary nutritional problem in Australia, undernutrition and/or malnutrition are prevalent in population sub-groups. Studies consistently show that 30–40% of patients show evidence of poor nutrition on admission to hospital and that both normal and sub-optimal nutritional status deteriorate in hospital.¹The physiological and psychosocial stresses of surgery increase the risk of poor nutritional status, which is clearly linked to poorer outcomes Poor nutrition therefore has clinical, financial and quality of life consequences.

Definitions of malnutrition and undernutrition

Adequate nutritional status is more than the absence of nutrient deficiency disease. It is a broad concept which infers that an individual can achieve a food intake sufficient to meet their requirements for specific nutrients to support optimal health and well-being.

There is no universally accepted definition of malnutrition. The term is widely associated with severe food deprivation and the classic consequences of kwashiorkor, marasmus or micronutrient deficiency. Malnutrition may refer to overnutrition, but more commonly is used interchangeably with undernutrition.

Undernutrition refers to a continuum of inadequate nutritional status. It extends from inadequate intake and increased risk of poorer health outcomes, through to measurable functional or clinical changes that influence outcomes and are potentially reversed by nutritional interventions, and finally to clear physical and biochemical evidence of protein, energy or micronutrient deficiency.

Nutritional screening and assessment – how to recognise undernutrition

There is no ‘gold standard’ for identifying either nutritional risk or nutritional status. Nutrition screening aims to identify factors associated with poor nutrition and hence individuals at nutritional risk. It needs to be valid, simple, easy to interpret and sensitive so that it can be widely and consistently implemented by non-specialists. A range of screening tools have been developed and variably validated.They include self-reported indicators of either risk or direct evidence of poor or reduced intake .

Table 1 – Nutrition screening and assessment – commonly used indicators

Nutritional screening identifies patients ‘at risk’
Subjective/self-reported difficulty with access to food: money, shopping, cooking facilities, preparation, feeding, mobility, activities of daily livingsocial isolation, depression, anxiety < two meals per day excess alcohol use poor/decreased appetite nausea, chronic pain gastrointestinal symptoms > two weeksvomiting, diarrhoea indicators of protein intake (< three serves/day of dairy, meat, fish, eggs) < two serves of fruit and vegetables/day unintentional weight loss fluid intake	Objective comorbidities, disease state, duration/severity of symptoms poor dentition, oral health polypharmacy (> three drugs/day) dysphagia, respiratory disease prescribed dietary restrictions unintentional weight loss 10% in six months or > 5% in one month current weight, body mass index triceps skinfold (TSF), mid-arm circumference (MAC) mid-arm muscle circumference (MAMC cm) = MAC (cm) – TSF (mm) x 0.314 ascites, fluid retention pressure sores, skin ulcers serum albumin < 35 g/L
Nutritional assessment assesses the nutritional status of patients identified as ‘at risk’
physical examinationhistory – medical, social, nutritionalcurrent dietary intakeanthropometric measures – weight, height (stature), TSF, MAC, MAMCestimates body compositionfunctional status – grip strengthlaboratory data – serum albumin, transferrin, delayed hypersensitivity skin testing, lymphocyte count

If screening identifies individuals at risk, they should be referred for detailed assessment of their nutrition. Nutritional assessment is a comprehensive process used to define the patient’s nutritional status rather than risk. It helps to quantify the risk of complications and can be used to plan and monitor nutritional support.

Limitations of screening and assessment include reliance on self-reported data, inaccurate measurement of stature in injured or elderly patients and confounding of serum protein concentrations by infection and trauma. Nevertheless, the risk factors in Table 1 should be routinely considered in assessment and follow-up of pre- and postoperative patients. The general consensus is that unintentional weight loss, regardless of initial weight, is the simplest and most reliable way to identify nutritional risk.

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The impact of surgery on nutritional status

The complex response to the physiological stress of surgery and injury, mediated via hormonal changes and the sympathetic nervous system, is one of hypermetabolism and catabolism.There is marked salt and water retention and increases in basal metabolic rate and hepatic glucose production. Wound healing accounts for 80% of the increased glucose production and also requires protein synthesis.Fat (adipose tissue) and protein stores (lean muscle mass) are mobilised to meet the needs of glucose and protein synthesis which results in negative nitrogen balance and weight loss. Overall, the catabolic response increases energy and protein requirements, the magnitude and duration depending on the extent of the surgery.A critical point is that semi-starvation (that is, intake consistently below potentially increased requirements) is also catabolic and further exacerbates negative nitrogen balance and weight loss. Indeed, recent evidence suggests the catabolic response to surgery may not be obligatory and can be prevented by adequate intake.

Adequate energy and protein intakes are essential to limit net protein and fat losses. However, many patients are unable to eat enough to meet increased needs and/or prevent losses after surgery. Common and often underrated issues such as pain, nausea, medication, dry mouth, gastric discomfort and distension, fasting, unpleasant procedures, anxiety, unfamiliar food and hospital routines all potentially reduce appetite and intake. Inadequately or unfed patients will rapidly deplete their reserves of protein and fat. This has significant clinical consequences, particularly for those with preoperative undernutrition.

The impact of nutritional status on outcomes of surgery

Positive outcomes for surgery depend heavily on adequate immune defence and wound healing. Both rely on enhanced synthesis of new proteins, which is significantly limited by negative nitrogen and energy balance. A key point is that positive nitrogen balance (net protein synthesis) cannot be achieved with negative energy balance. Semi-starvation will result within days rather than weeks, when intake fails to meet requirements, particularly for protein and energy.

These problems are also common after surgery, so it is likely that the undernutrition associated with the surgery is contributing to poor outcomes for surgical patients.

Outcomes associated with semi-starvation and undernutrition in healthy people and surgical patients

Semi-starvation – healthy people and surgical patients	Undernutrition – surgical
weight lossanxiety, irritabilitydepressionapathy, malaise↓ organ function – gut, respiratory, cardiac↓ thermoregulatory functionimpaired immunity↓ resistance to infectionpoor wound healing↓ intellectual function↓ concentration↓ work capacity↓ growth	↑ postoperative infectionimpaired wound healing↓ quality of life↓ gut function↓ respiratory and cardiovascular function↑ complications (pneumonia)↑ length of convalescence↑ length of stay↑ readmission↓ return to own home↑ mortality↑ costs

Estimation of energy and protein requirements

Nutritional interventions can only be effective if energy requirements are both accurately estimated and then achieved. The standard approach is to estimate energy requirements from basal energy expenditure, using regression equations and activity and stress factors. Energy requirements range from 85–150 kJ/kg. Protein requirements are usually set at 7–8% of energy needs, although severely ill or injured patients may require 15–20% of their energy as protein. This is approximately 1.5–2.0 g of protein/kg of body weight.²Further research is required to characterise specific amino acid and micronutrient requirements in surgical patients. 

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Nutrition support is the provision of nutrients and any necessary adjunctive therapeutic agents to improve or maintain the nutritional status. Nutrition support is fundamental in the management of patients with a moderate-to-severe burn injury.

The primary goal of nutrition support following severe burn injury is to meet the distinctive demands placed upon the body by hypermetabolism. The adverse effects of the hypermetabolic response can result in life-threatening protein-calorie malnutrition. While management of nutritional needs in burn patients has many features in common with the nutritional management of other critically ill surgical patients, the severity, magnitude, and duration of the hypermetabolic response and the ensuing energy requirements for the severe burn patient are far greater.

Nutrition support is administered into the stomach or small intestine (enteral) and/or by intravenous infusion (parenteral). Enteral nutrition, which is administered through a nasogastric, gastric, or intestinal tube, is the preferred method of feeding critically ill patients and an important means of counteracting hypermetabolism. Supplemental parenteral nutrition should only be given to patients in whom enteral feeds are contraindicated, those who do not tolerate enteral feeds, or for patients who do not reach their target nutrient intake in a reasonable time on enteral feedings alone

The unique characteristics of nutritional requirements in the moderate and severe burn patient, including patient selection, initiation, and delivery of nutrition support, are reviewed. Other aspects of burn care are reviewed separately.

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Nutritional management for burn patients

• • Assessment
  • Goals of nutritional management
  • Objectives of nutritional management
  • Nutritional ManagementDepartment of Nutrition and Food ServicesRoyal Children’s Hospital, May 2000AssessmentAll inpatients with a deep burn injury are assessed by a dietitian, in order to establish whether a need exists for nutritional intervention.Goals of nutritional management
  1. To promote optimal wound healing and rapid recovery from burn injuries
  2. To minimise risk of complications, including infections during the treatment period
  3. To attain and maintain normal nutritional status
  4. To minimise metabolic disturbances during the treatment processObjectives of nutritional management
  1. Provide nutrition via enteral route within 6 – 18 hours post burn injury
  2. Maintain weight within 5 % – 10 % of pre-burn weight
  3. Prevent signs and symptoms of micronutrient deficiency
  4. Minimise hyperglycaemia
  5. Minimise hypertriglyceridaemia    Nutritional ManagementEnteral Feeding Should Be Commenced EarlyAppropriate nutritional management of the severely burned patient is necessary to ensure optimal outcome. Initiation of early enteral feeding, within 6 to 18 hours post-burn injury, is recognised as beneficial, and has been shown to be safe in children as well as adults. Advantages of utilising the enteral route, as opposed to the parenteral route, include improved nitrogen balance, reduced hypermetabolic response, reduced immunological complications and mortality.Aggressive Nutritional Support is Often RequiredAlthough oral nutrition is encouraged, young children with severe burn injuries often require naso-gastric feeding as they tend to have difficulty meeting their nutritional goals with oral intake alone.Energy Requirements are Elevated by the Burn InjuryThe hypermetabolic response associated with severe burn injury results in high calorie requirements to allow optimal healing and outcome. Several predictive equations exist which enable estimations of energy requirements. Changes in management of these patients in the past decade have resulted in some reduction in the metabolic response and care must be taken to avoid over-feeding. Variation in energy needs between individuals, as well as with time, means that indirect calorimetry is recommended where practical to aid in determining energy expenditure.Protein Requirements are Substantially IncreasedAggressive protein delivery, providing approximately 20 % of calories from protein, has been associated with improved mortality and morbidity.An Increased Requirement Exists for Nutrients Associated with Healing and Immune FunctionProvision of those nutrients known to be associated with healing and immune function, particularly vitamins A, C, E, some B vitamins and zinc, is especially important. Recent studies have indicated that benefits may also be achieved by supplementation with various additives, including fish-oil.
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