12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 litres per day. daily. One response to this is that we can all main- tain a kitchen garden in whatever little land we Here is an example of a Balanced Meal: a typi- have, or even in Gro-bags on the roof or terrace. cal Kerala thali. Rice is the centre of attention, but Fruit trees are not difficult to plant, and once they there is not much of it. Instead, there are a variety catch root they are practically zero-maintenance, of vegetable curries, an omelette, and curd. and frequently outlive those who planted them. The only problem is that, with the exception of Non-vegetarian food plantains and papayas, it usually takes many years for the tree to start bearing fruit, so we need to be Fish, eggs, chicken are all tasty. And rich in pro- patient. Vegetables don’t tax one’s patience, but teins, vitamins and minerals. As for vegetarians, require maintenance. pulses and nuts too are excellent source of pro- tein, vitamins, minerals. As they say in Hindi, “dal- Iron roti khao!” Fruits Among adolescents, 50% of girls and 25% of boys have iron deficiency. This is sad, as iron is im- Lucky us. The most nutritious AND the tastiest portant for growth of muscles and for blood for- fruits in the world are tropical fruits like mango and mation. The cause of iron deficiency is that there papaya and jackfruit. Very rich in Vitamin A and is not enough iron in the food we normally eat. other vitamins. Fruits and vegetables are low in Also, adolescents need much more iron than adults Sodium (which increases BP) and rich in Potassium because they are growing rapidly. (which reduces BP). Iron deficiency causes poor concentration and You have heard that “an apple a day keeps the memory at an age when there is a lot of studying Doctor away.” All it means is that “a fruit a day is to do. It decreases physical energy at a time when very good for the health”. The apple is the com- some adolescents become very keen on games and monest fruit in England, from where this proverb sports. Ironically, it reduces the appetite, so that came; it is as common there as plantains are in most iron intake further decreases. The solution? Take parts of India. Examine the nutritional value, and more of food that is rich in iron, like dark green you will be stunned to see that the humble plan- leafy vegetables, pulses and nuts, meat and eggs. tain is far superior to the apple in every way. Try to eat a plantain at the end of every meal. The apple The World Health Organization strongly recom- is tasty, but not particularly nutritious. mends Weekly Iron and Folate Supplementation or WIFS. The recommended tablet contains 100 mg Oranges and grapes are rich in Vitamin C and of iron + 0.5 mg of folate (a vitamin that is impor- poor in everything else. There is a popular belief tant for blood formation). The idea is to give 1 tab- that it is good to give oranges and grapes to ba- let a week to all children aged 10-18 in school, usu- bies. Cow’s milk is poor in Vitamin C, but breastmilk ally on a Monday. Unfortunately, some adolescents is one of the richest sources of Vitamin C, so it is a get stomach discomfort or feel uneasy after taking waste to give these fruits to a breastfeeding baby. the tablet, so they refuse to take it, and this also discourages their friends from taking it. You can Vegetables break the tablet into two, and take one half on Monday and the other half another day; the un- All vegetables are good; each one has a mixture comfortable symptoms disappear when the dose of vitamins and minerals, and if one is rich in Vita- is reduced. min A the other is rich in Vitamin B or C or Iron. To get all the vitamins and minerals we need to eat a Iodine variety of vegetables, which is also the tastiest op- tion. Vegetables also have a lot of roughage, which In many parts of the world the soil is poor in prevents constipation. iodine. This frequently manifests as a goitre (a swelling of the thyroid gland in the front of the The practical difficulty is that vegetables, and neck), usually during adolescence. There may also especially fruits, are too costly to be consumed 51
Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala be poor thyroid function, called hypothyroidism, bone fractures, which heal poorly. This is called which reduces the IQ. Thyroid cancer too may oc- osteoporosis. cur. In developed countries it is mandatory to use only iodated salt for cooking. Iodated salt contains Thattu kada 15 mg of Iodine added to 1,000,000 mg Salt. It is safe and effective. Some have complained that io- Adolescents love to have food from thattukadas; dating salt doubles its cost, but since a family needs it is low-cost and tasty. The food has a unique less than 1 kg of salt monthly, the actual increase flavour, which is partly due to the special ingredi- in expense is a trivial sum of Rs 10-20 a month. ents left on it by roadside dust and flies. There are also free add-ons, like amoebiasis, jaundice and Vitamin D and Calcium typhoid. The water provided is warm water – but it is not boiled water that is cooled before serving; it The sun is not our enemy; the body needs sun- is boiled water to which tap water is added as light to manufacture Vitamin D. Despite being a needed, as keeping the water boiling all the time land of bright sunlight, we are often deficient in needs a lot of fuel. Vitamin D as we avoid the sun when it is hot, and also use umbrellas and even sunscreens. Conclusion: Why Eat Right? We should also drink a glass of milk every day, • To be taller which is the best source of Calcium, but children in Kerala do not drink milk because of a false belief • Better appearance that milk causes allergies. We need to have enough Vitamin D and Calcium to develop strong bones. • Better complexion Those who have weak bones usually suffer when they grow older – they tend to fall down and have • Better in studies • Better in sports CYTOGENIX HEALTH CARE Mob: 09447707017, 09562690232 1. UBIUM - D3 drops (Cholecalciferol 400IU/ml) 2. RESMINIC Syp (Phenylephrine HCl 5mg+ CPM 2 mg/5 ml) 3. REDIAL Syp (Multivitamin syrup) 4. REDIAL DROPS (Multivitamin drops) 5. K zinc Syp (Zinc acetate 20 mg/5 ml) 6. XYLOVENT NASAL DROPS (Xylometazoline HCl 1%) 7. XYLOVENT- P NASAL DROPS (Xylometazoline HCl 0.05%) 8. ROLDEX Syp (Ambroxol 15 mg+Guaiphenesin 50mg+Terbutaline 1.25 mg/5 ml) MONTEWAY- LC Tab (Montelukast 10 mg+ Levocetrizine 5 mg) CYCLAV 625 Tab ( Amoxycillin 500 mg+Clavulanic acid 125 mg) HYDRALKA Syp (Disodium hydrogen citrate 1.25 g/5 ml) Laprogut sachet, Lactobacillus Acidophilus Lactobacillus rhamnosus, Bifidobacterium Longum Saccharomyces boulardii, Sachet with FOS 52
12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 Pediatric obesity- evaluation and management Dr Thomas P Varghese Prevention and early identification of obesity is extremely impor- tant in the day to day current pediatric practise .It is important be- Asst.Professor of Pediatrics cause early identification makes the treatment of obesity easier as Govt.Medical college, well as it prevents development of comorbidities and prevent early Kottayam mortality in the later life. Identification:Obesity and overweight are defined using BMI per- centiles for children= 2 years old and weight for length percentiles for babies = 2 years.The criteria for childhood obesity is BMI=95thpercentile and for overweight is BMI between 85th and 95th centile. If the child is above 2 years plot the calculated BMI on the BMI centile chart.But if the child is below 2 years, weight for length chart is to be used and if the weight is above 99th centileon that chart obesity is diagnosed. Etiology: Adiposity is the result of a complex interplay between genetically determined body habitus,appetite,nutritional intake,physical activity and energy expenditure.Obesity with normal or increased stature,normal development and no dysmorphism think of exogenous obesity. Drugs including antipsychotics,antiepileptics like valproate and carbamazepine can cause weight gain. Obesity with short stature endocrine causes like cushing syndrome, GH deficiency, Hypothyroidism, Hyperinsulinism should be considered. Developmental delay,extreme obesity,extreme hyperphagia, asso- ciated visual or hearing problems think of genetic obesity syndromes. Comorbidities: Pediatric obesity cause increased risk of morbidity and mortality later in life.Important ones include type 2 diabetes,hypertension, hyperlipidemia,non-alcoholic liver disease, obstructive sleep apnea ,joint problems like Blount disease and slipped capital femoral epiphysis, PCOD, psychiatric as well as psychosocial issues like depression ,anxiety, low self-esteem,social isolation, poor scholastic performance, problems of being bullied. 53
Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala All children with above 85th centile of BMI cation, physical activities and other behavioural should be periodically screened for each of these modifications. Interventions should be family based comorbidities. and should consider the child’s developmental age.As obesity is multifactorial,not all children and Screening: Include fasting glucose, HbA1c , C- adolescents will respond to the same approach. peptide levels to identify type1 diabetes. Encourage exclusive breast feeding for 6 months, Fasting total cholesterol, HDL, LDL, triglycerides complementary feeding only after 6 months, no for dyslipidaemia fruit juices or sweetened beverages, family based meal,no forced feeding, no fast food and infrequent Ultrasound abdomen,AST,ALT for Non-alcoholic high sugar containing foods. fatty liver disease Add adequate fruits and vegetables to the diet. Pelvic ultrasound, testosterone, FSH,LH for PCOS Fixed meal and snacks time, no fasting. Serial blood pressure monitoring for detect hy- No TV watching during eating,restrict screen pertension. time, adequate sleep Hip and knee radiographs in case of Blount dis- Keep infants and young children active and for ease or slipped capital femoral epiphysis. older children structured play for one hour. Adequate psychiatric evaluation for psychoso- Pharmacotherapy: No drugs are approved by cial problems FDA for under 12 years.Can be used for adolescents with obesity as an adjunct to diet and activity Specific studies for obstructive sleep apnea. interventions.But use of pharmacotherapy are lim- ited by its low efficacy and tolerability. Specific investigations: Endocrine evaluation if short stature and low height velocity. In children between 12- 16 years Orlistat is ap- proved by FDA.Drugs used in above 16 yrs old and Neurodevelopmental delay or severe hyperph- adults are Phenteramine,Liraglutide,Topiramate agia needs genetic evaluation. etc. Suspected Prader-Willi syndrome DNA methy- Metformin can be used in above 10 years with lation studies are needed associated type 2 diabetes. Use in children with- out diabetes of not much use. Measuring Leptin levels needed in suspected leptin deficiency. Leptin can be used in congenital leptin defi- ciency disorder. Intervention:It includes Intensive life style therapy Bariatric surgery: Can be used in those who has completed puberty and achieved their final height Pharmacotherapy and after all the initial interventions and pharmaco- therapy fails. Bariatric surgery Measure and plot BMI at each OPD visit. Intensive life style therapy include diet modifi- 54
12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 Medical Nutrition Therapy in Type 1 Diabetes Mellitus Dr Riaz I Nutritional management is one of the cornerstones of diabetes care and education. Dietary recommendations for children with diabetes Associate Professor, are based on healthy intake recommendations appropriate for all Pediatrics children and adults and as a result, the whole family. Nutritional Nodal Officer, Mittayi Clinic suggestion must be adapted to cultural, ethnic and family traditions MO i/c Pediatric & and the psychosocial needs of the individual child. Regularity in meal- Adolescent Endocrine Clinic times and routines in the family help to establish better eating practices & Diabetes Clinic and monitoring of food intake. This has been shown to be allied with better glycemic outcomes. Aims of nutritional management * Promote suitable eating behavior and healthy life long eating habits while preserving social, cultural and psychological wellbeing. * Three meals a day incorporating a wide variety of nutritious foods from all food groups, with suitable healthy snacks (if necessary), will supply all essential nutrients, maintain a healthy weight, prevent binge-eating. * Make available sufficient and appropriate energy intake and nutrients for best possible growth, development and good health. * Accomplish a balance between food intake, metabolic requirements, energy expenditure, and insulin action profiles to attain optimum glycemic control. * To prevent the development or progression of diabetes-related microvascular and macrovascular complications. * Address individual nutrition needs, incorporating personal, social, and cultural preferences. * Improve overall health through appropriate food choices. 55
Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Energy balance, energy intake and food components 1. Energy Balance · Due to age, growth rate, physical activity and important environmental factors such as the type and availability of food, energy intake varies greatly within subjects on a daily basis. · Optimal growth and an ideal body weight should be achieved by sufficient energy intake. · Regular revision in dietary advice or meal planning to meet changes in appetite and insulin regimens and to ensure optimal growth. · Energy intake and nutritional demands increase substantially along with significant increases in insulin dosage during puberty. 2. Maintenance of healthy body weight · Energy intake may be regulated by appetite, excess energy intake contributes to obesity. · Prevention and management of overweight or obesity are key strategies of care. Family food choices, energy density of foods, meal routines and physical activity is essential. · Important aspects of management in the prevention of overweight are: Scheming the growth curve every 3 months. Habitual review by a dietician Moderate-dynamic physical activity for 60 minutes a day, on a daily basis. During physical activity, adjustment of insulin in preference to intake of additional carbohydrate for hypoglycemia prevention Consistent advice on the prevention and appropriate treatment of hypoglycemia (to prevent over treatment). 3. Energy intake recommendations A guide to the allocation of macronutrients according to total daily energy intake is as below. Dietary patterns that restrict intake from one macronutrient may compromise growth and lead to nutritional deficiencies. Nutritional recommendations for individuals with Type 1 diabetes mellitus • Carbohydrate: 50–55% (Sucrose intake < 10%) • Fat 25–35%Saturated fat + trans fatty acids: < 10% Trans fatty acids < 1% Polyunsaturated fat: 10% Monounsaturated fat: 10-20% • Protein 15–20% 4. Food components Carbohydrates 50-55% of total calories is recommended as carbohydrate intake. Too much carbohydrate control may hamper growth in children and adolescents. In the Indian Subcontinent, approximately two- third of calories is obtained from carbohydrates in individuals with diabetes, which is higher than the suggested amount. Therefore, it is essential in Indians with diabetes to monitor carbohydrate intake and reduce if possible. In addition, the South and East Indian diets are rich in simple 56
12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 carbohydrates. Wholegrain bread and cereals/ millets, legumes (peas, beans, and lentils), fruits, vegetables, and low-fat dairy products etc are healthy sources of carbohydrate foods. With a reduction in the intake of carbohydrate components in the diet, the intake of fat increases. In this situation, execute vigilance to ensure the consumption of good quality fat. Fiber Dietary fiber is a non-digestible complex carbohydrate derived from foods of plant origin. The recommended dietary fiber intake for children of and abve one year of age is 14 g per 1000 kcal. ‘Age in years + 5 g’ is another way of calculating the daily dietary fiber requirement in children over two years. Encourage consumption of foods such as legumes, fruits, vegetables, and wholegrain cereals to make sure adequate fiber intake. Higher fiber foods may help to progress in satiety and replace more energy-dense foods. Soluble fiber helps moderate postprandial blood glucose levels and lower serum cholesterol levels to prevent cardiovascular disease. Good sources of soluble fiber include oats and oatmeal, legumes like peas, beans, and lentils; barley, fruits, and vegetables especially oranges, apples and carrots. Insoluble fiber also offers several benefits to intestinal health, including a reduction in the risk of hemorrhoids and constipation. Most of the insoluble fibers come from the bran layers of cereal grains. It is good to increase fibers gradually to avoid bloating and discomfort. Fat Up to 30% of total calories is recommended as daily intake for fats. Infants and children younger than two years of age may have a higher daily fat intake of up to 35%. Excess consumption of saturated fats and cholesterol increases serum LDL cholesterol associated with increased cardiovascular disease risk. Hence, the daily intake of saturated fats should be limited to less than 10% of the total calories and dietary cholesterol to less than 300 mg/day. The common foods rich in saturated fats and cholesterol include egg yolk, bacon, red meats, whole milk, cheese, butter, ghee, cream, and cream- based desserts, vanaspati, coconut oil, palm oil and it is best to limit their consumption. The right options for low cholesterol and low saturated fat foods are fish, lean chicken, low-fat milk and curd, low-fat cheese, buttermilk, and cooking oils rich in healthy fatty acids. Unsaturated fatty acids are essential components of lipid membranes and include polyunsaturated and monounsaturated fatty acids. They are derived mainly from plant and vegetable sources. These fats have beneficial effects on LDL cholesterol and, in the case of monounsaturated fatty acids, also on HDL cholesterol and glycaemic control. These help to reduce the risk of cardiovascular disease. Monounsaturated fatty acids (MUFA) are there in olive, canola, groundnut, peanut, sesame, rice bran, mustard oils, almonds, and avocados. This form of fat particularly MUFA with cis-configuration is most lipid-friendly, and 10-20% of the total daily calories should be from their intake. Polyunsaturated fatty acids (PUFA) should be less than 10% of total daily calories. Omega-6 PUFA and Omega-3 PUFA are significant components of PUFA. Omega-3 PUFAs lower serum triglycerides. Encourage regular Omega-3 intake from natural food sources rather than supplements. Coldwater fatty fishes like mackerel, salmon, sardine, herring, and tuna are good non-vegetarian sources of Omega--3 PUFA whereas flaxseeds, walnuts, chia seeds, soybean oil, canola oil, kidney beans, tofu, broccoli, spinach, cauliflower, and Chinese cabbage are good vegetarian sources of Omega-3 PUFA. Omega-6 PUFA helps to reduce serum LDL cholesterol and is found in various vegetable cooking oils such as sunflower, soy, cottonseed, corn, canola, peanut, and sesame; pulses, vegetables, cereals, walnuts, seeds, eggs, and poultry. Plant sterol and stanol esters, typically found in enriched foods, may modestly reduce total and LDL cholesterol and may be considered for children above five years with high serum total or LDL cholesterol. Trans-fatty acids, though unsaturated fatty acids, are structurally different and have adverse health effects. They not only increase LDL cholesterol but also reduce HDL cholesterol. 57
Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Hence, the use of trans-fats should be limited as much as possible, ideally to less than 1% of total caloric intake. They form when vegetable oils are processed to make them solid (partial hydrogenation). They are scarce in nature but are commonly found in packaged baked goods (cakes, cookies), snack foods (potato chips), fried food (French fries, doughnuts, fried chicken) and margarine (stick margarine, vanaspati as a cooking medium). Proteins The protein requirement in children and adolescents varies from 2 g/kg at one year, 1 g/kg at ten years to 0.8-0.9 g/kg in adolescence. Recommended protein intake is 15-20% of the caloric requirement. Protein promotes growth only when calorie intake is sufficient, and high protein intake may compromise growth by reducing calorie intake and may also reduce vitamin and mineral intake. Proteins from animal sources (fish, milk, egg white, poultry, and meats) are of better quality as they provide all essential amino acids, but their use is associated with higher salt and saturated fat content. Remove the skin and visible fat while consuming the animal sources of proteins. On the other hand, proteins from vegetarian sources (soy, beans, and lentils) contain less saturated fat and are rich in fiber and complex carbohydrates. Hence, the consumption of proteins from both vegetarian and low-fat non-vegetarian sources, preferably in equal amounts, is recommended. In patients with diabetic nephropathy, daily protein intake should not be restricted to less than 0.8 g/kg body weight to avoid the risk of malnutrition. There is no benefit of protein intake less than 0.8 g/kg body weight on glycemia, cardiovascular risk, or decline in glomerular filtration rate. Vitamins and Minerals Vitamin and mineral requirements in children with diabetes are the same as in other healthy children. There is no clear evidence to suggest that routine vitamin or mineral supplementation in children with diabetes is beneficial. Ensure the RDA of all vitamins and minerals in the diet by appropriate choice of macronutrients. Salt Recommendations for salt intake in children with diabetes are similar to that of healthy children. Daily salt intake should be limited to 1000 mg (2.5 g salt) in 1–3 years old children, 1200 mg (3 g salt) in 4–8 years old children, 1500 mg (3.8 g salt) for children and adolescents aged of and above nine years and 2300 mg (6.0 g salt) in adults. Processed foods are rich in salt, and hence their intake should be limited. Sweeteners The commonly used non-nutritive and hypocaloric sweeteners include saccharin, neotame, aspartame, acesulfame K, stevia, alitame, and sucralose. They are commonly used in low sugar, ‘light’ or ‘diet’ products to improve sweetness and palatability and are also used to replace table sugar in cooking at home. Intake of sweeteners not exceeding acceptable daily intakes (ADI) is considered safe4. They have the potential to replace caloric or carbohydrate intake if substituted for caloric sweeteners. However, the benefits of their use for better glycemia, weight reduction, or reduction of cardiometabolic risk factors are limited. Carbohydrate assessment, glycaemic index (GI), glycaemic load (GL) and carbohydrate counting The glycaemic index is an indicator of the quality of carbohydrates in food and measures the rapidity of increment in plasma glucose after ingestion of a food item. glycaemic index is evaluated by calculating 58
12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 the area under the curve for blood glucose rise for 2 hours after consuming 50 g of a test food compared to that of 50 g of oral glucose (preferably) or white bread (reference food). A value of 100 represents, rise in blood glucose similar to pure glucose. The glycaemic index of foods varies from 0 to 100. Foods with a low glycaemic index produce a lower rise in blood glucose during the first 2-3 hours after their ingestion. Table II presents the classification of common Indian foods as low ( 55), medium (56-69), and high ( 70) glycaemic index. Glycaemic index is not a sole criterion for deciding diet composition as there are certain limitations to its use. Some food products (such as ice cream) may have a large amount of fat, delaying the absorption of carbohydrate and rendering a relatively low glycaemic index value but may have adverse health effects in the long term. Glycaemic load is a measure of both the quality (GI value) and quantity (g per serve) of a carbohydrate in a meal. Determine foods Glycaemic load by multiplying its GI by the amount of carbohydrate the food contains in each serve and dividing the product by 100. Therefore, the Glycaemic load provides a summary measure of the relative glycaemic impact of a “typical” serving of the food. Classify foods with a GL < 10 as low GL and those with 20 as high GL value. Classification of commonly used foods based on the Glycemic index (GI) Low GI ( d” 55) Medium GI (56-69) High GI ( e” 70) Peanuts (14±8), Prunes (29±4), Apricot (57), Mango Watermelon (76±4), Jowar Soy Boiled (18±3), Rajma (19), (60±16),Papaya (60±16), Whole (77±8), Pumpkin (75), Ragi (84), Cherries (22), Fructose (19±2), greengram (57±6), Basmati Rice White Baked Potato (78±4), Grapefruit (25), Barley (57±4), Oatmeal (69), Ice cream Parsnips (97±19), Glucose (99±3), (28±2),Whole milk (31), Low- (61±7), Honey (55±5), Bajra Dates (103±21), Corn flakes fat milk (37±4), Skimmed milk (67), Pineapple (59±8), Raisins (81±6), White bread(75±2) (37±4), Yogurt (28), Red Kidney (64±11), Cream of wheat (66), beans boiled (19), Apple (38), White rice (64), Beets (64±16), Greengram dal (29), Rye, Pinto Boiled potatoes (58), Table beans (39), Pear (30), Plum sugar (63), Coca- Cola (regular) (24), Black-eyed beans (38), (63), Grapes (59), Brown Rice Peach (34), Black beans (30), (68±4), Orange (40), Boiled Carrots (33), Kiwi fruit (50), Horse gram (51), Sweet Potato (41), Peas boiled (51), Buckwheat (55), Banana (51) Carbohydrate counting For patients using continuous subcutaneous insulin infusion (CSII), carbohydrate counting is essential. Carbohydrate counting is also beneficial for patients on a basal-bolus regimen. There are three levels of carbohydrate counting. In level 1, consistent carbohydrate intake is encouraged using an exchange or portion lists of measured quantities of food. The level 1 carbohydrate counting is useful for patients on twice daily insulin doses for whom a consistent carbohydrate intake from day-to-day is essential. Level 2 (pattern management principles) is an intermediate step. In this, patients use a consistent baseline insulin dose, continue to eat regular carbohydrates, and frequently monitor blood glucose (BG) levels to recognize patterns of BG response to carbohydrate intake and the impact of insulin doses and exercise on it. Based on this knowledge, insulin doses are adjusted for food and exercise to achieve BG goals. Level 3 [insulin to carbohydrate ratios (ICRs)] is the most commonly recommended one and is the most appropriate for patients using multiple daily injections (MDI) or CSII. ICR varies from patient to patient 59
Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala based on age, sex, pubertal status, duration of diagnosis, and activity. Initially, ICR can be calculated using the formula 500 divided by total daily dose (TDD) of insulin and represents the g of carbohydrate that would be covered by 1 unit of rapid-acting insulin. Replace the number 500 with 450 for regular insulin. ICR helps to adjust the prandial insulin dose according to carbohydrate intake. Fine-tune the ratio by checking BG level before and 2 hours after the meal to maintain a BG increment of less than 60 mg/dl. The various carbohydrate counting methods involve gram increments, 10–12 g carbohydrate portions, and 15 g carbohydrate exchanges. None of the methods are superior over the other. Cover all major meals and snacks containing more than 10-15 g of carbohydrates with a bolus insulin. Dietary recommendations for specific insulin regimen Divide daily calorie intake in 6-7 meals (3 major meals, and 3-4 snacks). In general, represent breakfast with 20% of total caloric needs, lunch, and dinner with 25- 30%, and each snack with 10% of daily calorie inputs. Each meal should be taken at a particular time during the day with no significant and frequent deviations. A bedtime snack is considered an essential part of the regimen to prevent nocturnal hypoglycemia and should include at least 7-8 g of protein (milk, cashew nuts, pea nuts etc). Most of the T1DM patients will have absolute insulin deficiency. Hence, nutritional intake should match that of a specific insulin regimen that patient is receiving. CSII and MDI provide flexibility in eating patterns, whereas pre-mix preparations and fixed insulin regimens demand food intake at fixed quantity and time. In patients on MDI with analogs or CSII, relatively higher GI major meals can be allowed, but the inter-meal snacks should contain relatively fewer carbohydrates. On the other hand, while using a basal-bolus regimen with regular insulin, relatively low GI major meals with moderate carbohydrate containing inter-meal snacks should be encouraged. 60
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Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala Gabriel C Francis (Child with Downsyndrome) We want to earn and live proudly like everyone else in this society. Bringing my very different face to every home and letting my friends and I want to live in this community. 76
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12th Annual Conference of Nutrition Chapter IAP Kerala Ped nutricon 2022 COMMITTEE MEMBERS: Dr Thomas P Varghese Dr Manu M Dr Divya Davis C Dr Bini Mariam Chandy Dr Suresh S Dr Harikumar G Dr Sajini Varghese Dr Sunu John Vadakkedom Dr Bindu KP Dr Murari K S Dr Jelesh K S Dr Alex Mani Dr Rajiv Suku Dr Omana S Dr Surya KK Dr Jacob George Dr Jayadev D 79
Ped nutricon 2022 12th Annual Conference of Nutrition Chapter IAP Kerala 80 GREEN FROG KTM
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