UNIT 4

BURNS
Burns are injuries to tissues that result from heat, electricity, radiation or chemicals.
They are usually caused by heat (thermal burns), such as fire, steam, tar or hot liquids.
While burns caused by chemicals are similar to thermal burns those caused by
radiation, sunlight and electricity tend to be different.
Thermal and chemical burns usually occur because heat or chemicals come in contact
with part of the body’s surface, most often the skin.
Thus, the skin usually sustains most of the damage.However, severe surface burns
may penetrate to deeper body structures, such as fat, muscle, or bone.
When tissues are burned, fluid leaks into them from the blood vessels, causing
swelling and pain.
In addition, damaged skin and other body surfaces are easily infected because they
can no longer act as a barrier against invading organisms.
The most accurate rule of thumb for predicting mortality after severe burn injury is
the Baux Score (age + percent burn, e.g. age 50 years + 20% burns = 70% mortality).
A more recent revised baux formula is used in case of severe burn with inhalation
injury. Revised Baux Score = Age + Surface area burnt + 17.

Classification of Burns

Classification of Burns Burns can be classified on the basis of the extent, depth,
patient age and associated illness or injury.
On the basis of depth, burns are usually classified by degree.
Burns are classified based on their depth and severity, which helps determine the
appropriate treatment and potential outcomes. The classification system includes
four main degrees of burns: first, second, third, and fourth degree.
First-Degree Burns (Superficial Burns):

 First degree burns or erythema, i.e., redness of the skin produced by coagulation
of the capillaries with cell destruction above the basal layer of epidermis. First
degree burns are not blistered.
 Affect only the epidermis (the outer layer of skin).
 The burn site is red, dry, and painful without blisters.
 Typically heals within 3 to 6 days without scarring.
 Mild sunburn is a common example of a first-degree burn.

Second-Degree Burns (Partial Thickness Burns):

 Second degree burns is erythema and is characterized by blistering with necrosis

within the dermis.
 Involve the epidermis and part of the dermis (the second layer of skin).
 The burn site appears red, blistered, swollen, and painful.
 Usually heals within 7 to 21 days; may result in changes in skin color but
generally does not lead to significant scarring.
 Severe sunburn that causes blisters is an example of a second-degree burn.

Third-Degree Burns (Full Thickness Burns):

 Third degree burns lead to total loss of skin including the fat layer, hair follicles
and sweat glands First- and second-degree burns heal in days to weeks without
scarring.
 Larger third-degree burns require skin grafting.
 Destroy both the epidermis and dermis, potentially affecting deeper tissues such
as fat, muscle, or bone.
 The burn site may appear white, leathery, or charred. There is usually no pain in
the area due to nerve damage.
 Requires more than 21 days to heal and often results in severe scarring; surgical
intervention may be necessary for proper healing.
 Burns from flames or prolonged exposure to hot objects can be classified as third-
degree burns.

Fourth-Degree Burns:
 Extend through all layers of skin and underlying tissues, including muscle and
bone.
 The burn site is charred or blackened with no sensation due to complete
destruction of nerve endings.
 These burns are severe and typically require extensive surgical intervention,
including possible amputation.
 Electrical burns or severe fire burns that penetrate deep into tissues are classified
as fourth-degree burns.

Understanding the classification of burns is essential for appropriate management and

treatment planning. Each degree of burn presents different challenges regarding
healing time, potential complications, and necessary interventions. Accurate
assessment is crucial for optimizing patient care and outcomes following burn injuries.
 Complications of Burns

Most minor burns are superficial and do not cause complications. However, deep
second-degree and third-degree burns swell and take more time to heal.
In addition, deeper burns can form a scar tissue. This scar tissue shrinks (contracts) as
it heals.
If the scarring occurs at a joint, the resulting contracture may restrict movement.
Severe burns can result in serious complications due to extensive fluid loss and tissue
damage.
Complications from severe burns may take hours to develop.
The longer the complication is present, the more severe are the problems it tends to
cause.
Young children and older adults tend to be more seriously affected by complications
than other age groups.
Dehydration eventually develops in people with widespread burns, because fluid
seeps from the blood to the burned tissues.
Shock develops if dehydration is severe.
Destruction of muscle tissue occurs in deep third-degree burns.
The muscle tissue releases myoglobin, one of the muscle’s proteins, into the blood. If
present in high concentrations, myoglobin harms the kidneys.
Thick, crusty surfaces (eschars) are produced by deep third-degree burns.
Eschars (a dry scab) can become too tight, cutting off blood supply to healthy tissues
or impairing breathing.
Burn injuries can lead to a variety of complications that significantly affect
recovery and overall health. These complications can be classified into local and
systemic categories, each with distinct implications for patient care.

Local Complications

1. Burn Wound Infection

Burn wound infections are among the most common complications and can lead to
increased morbidity and mortality. The risk of infection is heightened due to:
- Immunosuppression: Significant thermal injuries compromise the immune system,
making patients more susceptible to infections.
- Impaired Skin Barrier: The skin's integrity is crucial for protecting against pathogens;
burns disrupt this barrier.
- Sepsis Risk: Infections can progress to sepsis, particularly in patients with extensive
burns or those requiring invasive procedures.

2. Scarring and Contractures

- Hypertrophic Scarring: This occurs when the body produces excessive collagen
during healing, leading to raised, thickened scars. The incidence of hypertrophic scars
can range from 32% to 94%, particularly in deep partial-thickness burns.
- Keloid Formation: Keloids are raised scars that extend beyond the original injury
site and can cause discomfort.
- Contractures: Scarring can lead to tightness in the skin, restricting movement,
especially over joints.
3.Respiratory Complications
Inhalation injuries from smoke or hot air can result in severe respiratory issues:
- Airway Obstruction: Swelling and inflammation can block airways.
- Pneumonia: Patients with inhalation injuries have a higher risk of developing
pneumonia due to impaired mucociliary clearance and weakened immune response.
- Acute Respiratory Distress Syndrome (ARDS): This serious condition may develop
following significant lung injury.

4. Gastrointestinal Complications
Burns can lead to gastrointestinal issues such as:
- Paralytic Ileus: A temporary cessation of bowel function that can occur after severe
burns.
- Curling’s Ulcer: Stress-induced gastric ulcers that may develop in critically ill
patients.
- Bacterial Translocation: The movement of bacteria from the gut into the
bloodstream, potentially leading to sepsis.

Systemic Complications

1. Fluid Loss and Hypovolemia

Burns can cause significant fluid loss through damaged skin, leading to hypovolemia
(low blood volume), which may result in:
- Shock: A life-threatening condition if not promptly addressed.
- Organ Dysfunction: Prolonged hypovolemia can lead to multiple organ failure.

2. Metabolic Changes
The metabolic response to burns is profound:
- Increased Energy Expenditure: Patients may require significantly more calories to
support healing and recovery.
- Electrolyte Imbalances: Direct fluid loss and kidney injury can lead to imbalances
such as hypernatremia (high sodium) followed by hypokalemia (low potassium) and
other electrolyte disturbances.

3. Immunosuppression
The systemic inflammatory response following a burn injury can lead to:
- Increased Susceptibility to Infections: The body’s ability to fight off infections is
compromised due to both direct effects of the burn and secondary complications like
sepsis.

4. Psychological Impact
Patients recovering from severe burns may experience psychological complications,
including:
- Depression and Anxiety: Emotional distress related to body image changes, pain,
and prolonged recovery times.
- Post-Traumatic Stress Disorder (PTSD): Particularly in cases of traumatic burns or
those resulting from violence.
Complications from burns are multifaceted, affecting both local areas of injury and
systemic health. Effective management requires a multidisciplinary approach that
includes careful monitoring for infections, nutritional support, rehabilitation for
scarring and contractures, respiratory care, and psychological support.
 Fluid management in burns patient

Nutritional support is a major part of therapy for a patient with burns in view of the
large catabolic losses, essential anabolic demands and to meet personal support needs.
Nutritional care plan and outcome is dependent on factors, like Age Elderly
people, very young children pregnant women and lactating mothers are highly
vulnerable.

Health condition
Presence of diabetes, cardiovascular or renal disease complicates the care process.
Severity of burns
The location and severity of the burns and time lapse before treatment.
Nutritional support needs are calculated on the basis of body surface area burnt.
Second and third degree burns covering 15-20% or more of body surface, or even 10%
in children and elderly persons cause extensive fluid loss and therefore require
intravenous fluid therapy. Severe burns covering more than 50% of the body surface
area are often fatal.

Nutritional care for a patient in the burns is adjusted to individual needs and is
given in three stages:

Shock period: During the initial burns after injury, the focus is on counteracting the
stress induced neurohormonal and physiologic responses that accelerate the body’s
metabolism by a series of events.
Loss of skin on the burn site and exposure of extra cellular fluids lead to immediate
loss of water and electrolytes, mainly sodium and also protein depletion.
As a result, the body water shifts from extra cellular spaces in other parts of the body
to the burn site adding to continuous loss of fluids and electrolytes.
Due to this there are changes in the capillary fluid shift mechanism resulting in
decreased volume hypotension, low haemo-concentration and diminished urine output.
Intracellular water is also drawn out to balance extra cellular fluid losses leading to
cellular dehydration.
Patients with extensive burns need immediate fluid and electrolyte replacement during
the first 12 to 24 hours after injury.
Abalanced salt solution such as lactated Ringer’s solution is given to correct
hypovolemia and prevent metabolic acidosis. Because the exact volume of fluid and
infusion rate depend on the patient’s response to fluid delivery, ongoing fluid
replacement is based on close monitoring of the patient.
The goal is to maintain an adequate blood pressure and haematocrit and a urine output
of > 50 to 100 ml/hr (0.5 to 1 ml/kg/hr) in an adult or 1 ml/kg/hr in a child while
avoiding circulatory overload.
To maintain hydration status of patient parkland formula is used which is given
below:
During this initial period, nutritional requirements of protein and energy are not
attempted to be met as the entire focus is on rapid and effective fluid and electrolyte
therapy so as to prevent shock.

Flow or Recovery Period :

After 48 to 72 hours, fluids and electrolytes are reabsorbed into the general circulation
and excess fluid is excreted.
Fluid balance is gradually reestablished and massive tissue loss is reversed.
Fluid intake and output must be checked to prevent dehydration or over hydration.
The patient usually returns to pre-injury weight by the end of first week and adequate
bowel function returns.

At this time, increased nutritional needs must be met for the following reasons:

 Replace losses of protein and electrolytes due to burn injury.

 Replace lean body mass due to extensive tissue breakdown.
 Meet increased metabolic needs for energy due to sepsis or fever, increasing
the need for carbohydrates and B vitamins.
 Minerals and vitamins are also needed for tissue regeneration.
 Providing healthy tissue for subsequent successful skin grafting.

Anabolic Phase:
 During this period the patient is well hydrated and the reactions due to metabolic
stress are under control.
 The patient may still be hypermetabolic and has depleted reserves of all nutrients.
 Rigorous nutrition support during this period is essential to promote fast recovery
and proper rehabilitation.
 Proper nutritional care during this period can help in preparing patient physically
for undergoing successful skin grafting/ any other surgery.
Nutrient requirement and dietary management during the flow and anabolic
Phase
By the end of the flow phase, the patient usually is well hydrated and has body weight
close to the pre-injury weight.
The return of bowel movements is an indication that the patient can now be slowly
introduced to nutrition support in the form of oral intake, enteral feeds or parenteral
nutrition.
A combination of any two alterations in these routes is required on a day-to-day basis
depending upon the changing clinical parameters and the severity of burns.

Dietary Management for Burns

Dietary management should be such as to fulfill the following objectives:

 providing enough calories to prevent subsequent weight loss
 maintaining fluid and electrolyte balance
 minimizing stress response to pain and anxiety
 maintaining a positive nitrogen balance
 replenishing the depleted reserves of vitamins and minerals

Energy: The energy needs of the burned patient vary according to the depth and size
of the burn. The requirements of course would be highest in third degree burns
Although several formulas have been developed to determine the energy needs;
Currie formula is most commonly utilized and is mentioned below:
Carbohydrates : Liberal amounts of carbohydrates should be given i.e. around 60%
to 65% of the total energy.
However, care must be taken regarding the maximum rate of administration feasible
keeping in mind the fact that the maximum tolerance level is about 7 mg/kg/min
above which glucose is not oxidized to release energy but is converted to fat.
Blood glucose levels should be closely monitored to prevent hyperglycemia and its
associated complications such as dehydration, coma, respiratory problems etc.
During the anabolic phase when the patient can eat orally and has normal defecation
process, a combination of simple and complex carbohydrates may be given.
Providing good amounts of foods rich in mono and di saccharides, as well as, starches
help in preparing meals which are nutrient dense, have small volume and are easy to
digest.

Fat :
The administration of lipids should be carried out carefully in all critically ill patients.
A careful monitoring of immune function, feeding tolerance and serum triglycerides is
required during lipid administration.
Most of the patients are able to tolerate around 12-15% of the total calories in the
form of lipids.
Structured lipids and medium chain triglycerides are currently being preferred.
A low fat diet is preferred during the initial phases of recovery in view of its
association with improved respiratory function, reduced incidence of pneumonia,
faster recovery.
During the later phases of anabolism (near discharge) the fat intake may be
normalized.
In view of the impaired gastro-intestinal function among many patients it is advisable
to lay emphasis on foods rich in emulsified fat and medium chain triglycerides
(MCT’s).

Protein:
It is one of the most crucial nutrient which determines the ultimate outcome
of burns.
Amino acid requirements are high due to increased losses through wounds
and urine, increased requirement for promoting synthesis of blood proteins and
wounds.
Fluid loss from a burn wound may be considerable and can contain
4-6 g protein/100 ml, representing 25-50% of total nitrogen loss.
Nitrogen losses via faeces have been estimated to be around 1-3g N/day.
Thus, adult patients should be given 20-25% of the increased energy from protein.
Among children the requirements are still higher i.e. 2.5 to 3.0 g per kg usual body
weight per day.
Protein intake beyond this level is not recommended in view of the increased burden
on the kidneys.
Blood urea nitrogen, serum creatinine and level of hydration must be monitored
carefully.
The protein intake may need to be curtailed if the burnt area has involved the kidney /
excretory system.
High biological value protein food sources such as eggs, milk, cheese, yoghurt,
marine food, meat, poultry, legumes and pulses should be included liberally but in an
easy to digest form.
Hospital based tube feeds may be prepared by using soya milk, milk proteins (casein,
whey protein, lactalbumin), eggs and flour of pulses particularly soyabean.

Vitamins and Minerals:

Generally recommended to give plenty of fresh fruits and vegetables if an oral intake
is feasible.
When the patient is on tube feeds it is suggested to provide around 500 mg (twice
daily) vitamin C and 5000 I.U of vitamin A per 1000 Kcals of energy being provided.
Hyponatremia which is frequently observed due to fluid losses during change of
dressings/ application of grafts, can be corrected by restricting the oral consumption
of sodium-free fluids /water.
Supplements of calcium, phosphate, zinc and iron are generally required. Anaemia
may need to be treated with administration of red packed blood cells.

Other considerations:
Oral intake is generally feasible only during the anabolic phase wherein the patient
should be given a high-energy, high protein, micronutrient rich diet.
The diet should have a small volume, it should be nutrient dense and easy to digest.

Mode of Feeding/ Nutrition Support

Oral feeding is desirable if tolerated by the patient.

Concentrated oral liquids with protein hydrosylates or amino acids must be given to
ensure adequate intake.
Solid food should be gradually introduced according to food preferences.
Support and encouragement help the patient to eat better.
Food should be attractive and appetizing and individual like and dislikes must be
considered.

Enteral nutrition can be utilized judiciously alone or in combination with other

forms of feeding during various stages and purposes during the course of treatment
forinstance some patients may initially require tube feeding, low bulk defined formula
solutions may be given.
Commercial high protein formulas may also be used.

Parenteral Feeding is required for some patients to provide extra nutritional support
if oral intake and tube feedings are inadequate to meet the high nutritional needs.
This form of feeding is more commonly used during the ebb and flow phase.
Continuous nutritional support is important to maintain tissue integrity for successful
skin grafting or plastic reconstructive surgery.
Persistent supportive care – medical, nutritional and nursing helps the patient to cope
with the stress situation.
 CANCER
The word ‘cancer’ comes from the Latin for crab. It refers to any malignant growth or
tumor caused by abnormal and uncontrolled cell division. Body cells, we know, are
the basic units of life each of us has trillions of them. Our cells help us to carry out
all functions of life from the beating of the heart to the throwing of a football.
Cancers are new growths of cells in our bodies. Through expression of these
properties, it can cause destruction of major organs, and in some cases, life
threatening disturbances in body function
When a cell is set loose from normal control, it becomes what is known as
transformed. Basically, the cell no longer looks like its neighbours in terms of its
shape, size, and its internal components. This transformed property is conferred upon
all of the daughter cells. That is, all subsequent cells that arise from that initially
transformed cell will also look different and grow in an uncontrolled manner. This is
the transmissible nature of cancer once one cell becomes cancerous, all cells that arise
from this abnormal cell also take on this characteristic. There are different forms of
cancer with different characteristics, requiring different types of treatment. The causes
(etiological factors) are also found to be different. So to make it simpler, cancer is a
tumor or new growth which has a high growth factor.

Cancer development is a process and not a single event. The initiating event may be
either chemical or physical. The chemical event may occur when a carcinogen
intrudes into the cell and alters the genetic material. The physical event may occur
when radiation bombards the cell and alters the genetic material. What ever is the
reason, the protein making machinery of the cell changes so that the DNA produces
an odd structural protein. Then the cells begin to multiply out of control forming a
tumor.

Malignant tumors can be classified as:

Carcinomas: these tumors arise from the epithelial lining (the squamous cells) e.g.
skin, tongue, breast, stomach, large intestine (the latter three arise from the glandular
tissues).
Sarcomas: these arise from the connective tissue e.g. bone, cartilage and fat.
Melanoma : arise from pigmented layers of skin e.g. pigmented moles.
Gliomas: these arise from the central nervous system e.g. brain and spinal cord.
Reticulo – endothelial tumors: these involve the lymphatic system.
Adenoma : the growth arises from a gland e.g. thyroid gland.
 Risk factors

Cancer risks are climbing due to increasingly sedentary lifestyles and diets that are
high in fat and sugar but low in fruits, vegetables, legumes and whole grains.

Major Risk Factors

Tobacco Use: Tobacco smoking is the leading preventable cause of cancer,
responsible for approximately one-third of cancer deaths globally. It is linked to
various cancers, including lung, mouth, throat, and bladder cancers.

Alcohol Consumption: Excessive alcohol intake is associated with an increased risk

of several cancers, including those of the liver, breast, and esophagus. The risk
escalates with the amount consumed and is compounded when combined with
tobacco use.

Obesity and Physical Inactivity: Being overweight or obese significantly raises the
risk for various cancers, such as breast (postmenopausal), colon, and endometrial
cancers. Physical inactivity also contributes to obesity and is a direct risk factor for
cancer.

Dietary Factors: A diet high in processed foods, red meats, and low in fruits and
vegetables can increase cancer risk. Certain cooking methods, like grilling or smoking
foods, may also contribute to carcinogenic exposure.

Environmental Exposures: Pollution (air and water), exposure to harmful chemicals

(like asbestos and benzene), and radiation (both ionizing and ultraviolet) are
significant environmental risk factors for cancer development.

Infections: Certain chronic infections can lead to cancer. For instance, human
papillomavirus (HPV) is linked to cervical cancer, while hepatitis B and C viruses are
associated with liver cancer.

Genetic Factors: Family history plays a role in cancer susceptibility. Genetic

mutations inherited from parents can increase the likelihood of developing certain
cancers, such as breast and colorectal cancers.

Age: The risk of developing cancer increases with age due to accumulated exposures
to risk factors over time and decreased effectiveness of cellular repair mechanisms.
 Carcinogens

Carcinogens are substances, organisms, or agents that can cause cancer in living
tissues. They can be categorized into several types based on their origin and
mechanism of action.

Dietary constituents - carcinogenic:

The incidence of cancers, especially stomach cancers is high in parts of the world
where people eat a lot of heavily smoked, pickled or salt-cured foods that produce
carcinogenic nitrosamines.
Alcohol has also been associated with a high incidence of some cancers, especially
cancers of the mouth and throat.
Nitrosamines are a broad class of compounds formed from the nitrosation of
substituted amides, ureas and guanidines. Nitrosamides are direct acting carcinogens
meaning that the activation is non-enzymatic occurring by spontaneous hydrolysis.
There is a lot of epidemiological evidence to show that there is an association between
the high intake of calories by humans and increased risk for endometrial and gall
bladder cancer.
Some epidemiological studies suggest that risk for cancer increased with high protein
intakes.
Some researchers have suggested a possible association between high intakes of total
protein or animal protein and the risk of these specific cancers.
Both the type and amount of fat are believed to influence tumor formation in animals.
A high fat intake in humans has been linked to increased risk for breast and colon
cancers.
The possible mechanism that has been given is a high fat intake increased intestinal
anaerobic bacteria and biliary steroid secretion.
These anaerobic bacteria are capable of synthesizing estrogens.
The estrogens are believed to be potential carcinogens in mammary tissues.
In addition, bile acids are degraded by intestinal bacteria to the secondary bile acids
such as deoxycholate and lithocholate. These may act as carcinogens in the colon.

Non- Dietary constituents - carcinogenic:

A large number of agents cause genetic damage and induce neoplastic transformation
of cells. They fall into the following categories.

1. Oncogenic viruses 2. Chemical carcinogens 3. Radiant energy

Oncogenic Viruses: Certain viruses that interfere with the functions of the regulatory
genes have been identified. These viruses are called oncogenic viruses.
. A large number of DNA and RNA viruses have been proved to be oncogenic in
animals.
DNA viruses: The three DNA viruses found to cause human cancers are EBV, HBV
and HPV.

Epstein-Barr virus (EBV): EBV belongs to herpes family. It causes Burkitt’s

lymphoma. It is a tumor of B-lymphocytes. EBV is found to be closely associated
with nasopharyngeal carcinoma.
Hepatitis B Virus (HBV): Hepatitis B virus infection is found to be closely
associated with formation of liver cancer.

Human Papilloma Virus (HPV): HPV gives rise to multiple warts, which are benign
squamous papillomas. Squamous cell carcinoma of cervix has been found to be
associated with HPV.

RNA Viruses: All oncogenic RNA viruses are retroviruses. They are of 2 types. They
are acute transforming retroviruses and slow transforming retroviruses.
Acute transforming viruses include type C viruses and cause rapid induction of
tumors in animals. They contain viral oncogenes (virus).
The slow transforming retroviruses transformation of the cells slowly.

2. Chemical Carcinogens: Chemicals have been shown to be carcinogenic. Some are

naturally occurring components of plants and microbial organisms. Some are
synthetic products created by industry. Chemical carcinogens can be classified into
two general categories based on the ability of compounds to bind to DNA.

Compounds that bind to DNA are genotoxic, whereas compounds that are
carcinogenic, but have no evidence of DNA binding are termed epigenetic.
Some of the major chemical carcinogens are alkylating agents, acylating agents, and
aromatic amines. Aflatoxin B1 ,nitrosamines and amides, vinyl chloride, nickel,
chromium insecticide and fungicide are also some of the chemical
carcinogens.Tobacco, smoking, drug abuse are also known to cause cancers.

3. Radiant Energy : Radiant energy whether in the form of the ultraviolet rays of
sunlight or as ionizing electromagnetic and particulate radiation can transform all cell
types in vitro and induce neoplasm in vivo in both human and experimental animals.
Ultraviolet ray s: There is ample evidence from epidemiological studies that ultra
violet rays derived from the sun induce an increased incidence of squamous cell
carcinoma, basal cell carcinoma and melano carcinoma of the skin.
Ionizing Radiation : Electromagnetic (X-rays, gamma rays) and particulate ( -
particles, - particles, protons, neutrons) radiations are all carcinogenic.

Stress Factors

Clinicians and researchers have reported that psychic trauma, seems to carry strong
correlations with cancer.
 Nutritional problems of cancer therapy

Cancer therapy can lead to various nutritional problems that significantly

impact patients' health, treatment tolerance, and overall quality of life.
Understanding these issues is crucial for effective management and support.

Weight Loss and Malnutrition:

Many cancer patients experience unintentional weight loss due to a combination of
factors, including the cancer itself and the side effects of treatment. Studies indicate
that malnutrition affects 30% to 85% of cancer patients, contributing to increased
treatment toxicities and decreased survival rates.
This weight loss is often linked to the cancer's stage; patients with metastatic disease
(M1) show a higher incidence of unintentional weight loss compared to those without
metastasis (M0) .
Several factors contribute to malnutrition in cancer patients:
Anorexia: Many patients experience a loss of appetite due to the disease or treatment
side effects, such as nausea and vomiting.
Altered Metabolism: Tumors can disrupt normal metabolic processes, leading to
increased energy expenditure and reduced nutrient absorption.
Gastrointestinal Issues: Symptoms such as mucositis, diarrhea, and constipation can
hinder food intake and nutrient absorption.
Psychological Factors: Depression and anxiety related to cancer diagnosis and
treatment can further decrease appetite and food intake.
The consequences of malnutrition in cancer patients are severe:
Impaired Immune Function: Malnutrition compromises the immune system,
increasing susceptibility to infections.
Reduced Treatment Tolerance: Malnourished patients often experience greater
toxicity from chemotherapy and may tolerate fewer treatment cycles.
Decreased Quality of Life: Patients facing malnutrition report lower quality of life
scores related to physical function and overall well-being.

Cancer cachexia:
Cancer cachexia is a complex and multifaceted syndrome characterized by severe
weight loss, muscle wasting, and metabolic changes that cannot be solely attributed to
reduced food intake. This condition significantly complicates cancer treatment and is
associated with a poor prognosis.
Cachexia, also known as wasting syndrome, involves a continuous decline in skeletal
muscle mass, with or without fat loss.
It is distinct from simple weight loss as it encompasses changes in metabolism and
body composition that are not fully reversible through nutritional support alone.
Patients may experience significant physical deterioration, including:
Severe weight loss: Often exceeding 5% of body weight within a year.
Muscle wasting: Loss of muscle mass that contributes to weakness and fatigue.
Anorexia: A marked decrease in appetite that complicates nutritional intake.
Anemia: Low red blood cell counts contributing to fatigue and weakness.
The underlying mechanisms of cachexia involve complex interactions between the
tumor and the host's metabolic processes. Key factors include:
Increased metabolism: Tumors can induce a hypermetabolic state, leading to
accelerated calorie consumption.
Insulin resistance: Muscle and fat cells may become less responsive to insulin,
impairing glucose utilization for energy.
Inflammatory cytokines: Cancer can trigger the release of pro-inflammatory cytokines
that promote muscle breakdown and fat loss.

Treatment-Induced Side Effects Affecting Nutrition:

Cancer treatments, including chemotherapy and radiation therapy, can lead to various
side effects that significantly impact nutritional status. These side effects can
complicate treatment and affect patients' overall quality of life.
Anorexia:
Loss of appetite is a common side effect of cancer treatments. It can lead to decreased
caloric intake, making it challenging for patients to maintain their weight and
nutritional status. Anorexia may be influenced by both the cancer itself and the
psychological stress associated with a cancer diagnosis and treatment.
Nausea and Vomiting:
Nausea and vomiting are prevalent side effects that can make eating difficult and
unpleasant. These symptoms not only discourage food intake but can also lead to
dehydration and electrolyte imbalances if not managed properly.Patients often report
that these symptoms interfere with their ability to consume adequate nutrition.
Altered Taste and Smell:
Changes in taste and smell perception are frequently reported by cancer patients
undergoing treatment. These alterations can make food less appealing, leading to
reduced food intake. Patients might find that foods they previously enjoyed no longer
taste the same, which can further exacerbate anorexia.
Mucositis:
Mucositis refers to inflammation of the mucous membranes in the mouth and throat,
which can cause pain during eating. This condition is particularly common in patients
receiving chemotherapy or radiation therapy to the head and neck region, making it
difficult for them to eat solid foods .Painful swallowing (dysphagia) may also occur,
compounding the challenges of maintaining proper nutrition.
Diarrhea and Constipation:
Gastrointestinal issues such as diarrhea and constipation can complicate nutrient
absorption and dietary choices. Diarrhea may lead to malabsorption of nutrients,
while constipation can cause discomfort that discourages eating.Both conditions
require careful management to prevent further nutritional decline.

Nutritional problems during cancer therapy are multifaceted and require a

comprehensive approach that addresses both physical and psychological aspects of
care.
By prioritizing nutrition through assessment, individualized interventions, and
ongoing support, healthcare providers can enhance treatment outcomes and improve
the quality of life for cancer patients.
 Dietary management of cancer

Energy :It must be clear to you that cancer imposes increased energy demands
because of the hypermetabolic state of the disease process and increased energy
requirement to spare proteins for tissue healing and promote weight gain. In view of
the inhibitory factors associated with food intake (cancer cachexia); it may not be
feasible to promote an intake beyond 2000 Kcal/day. However, by the help of appetite
stimulants and / or nutrition support systems (enteral tube feeding) malnourished
patients can be motivated to consume around 30-35 Kcal/kg body weight/ day (2500-
3000 Kcal/day.). A high energy diet is helpful in inhibiting the side-effects of
chemotherapy and cancer cachexia.

Protein : Both the metabolic stress of cancer, as well as, chemotherapy result in
increased tissue catabolism. Hypoalbuminemia and anaemia are also very common.
Tissue protein synthesis, a necessary component of healing and rehabilitation,
requires essential amino-acids and nitrogen.
Efficient protein utilization which depends upon protein: energy ratio help to promote
tissue anabolism, prevent catabolism and help build up body reserves. Emphasis of
course should be laid on the inclusion of high biological value protein rich food
sources as milk, eggs, marine foods, and poultry. Renal and liver function tests must
be closely monitored under such conditions. However, 1.2-2.0 g/kg ideal body weight
protein can be administered.

Fat: Enhanced mobilization of free fatty acids from adipose tissues resulting in
subsequent depletion of total body fat. Around 25-30% of the modified energy
requirements should be provided from fat as they help in making the meals calorie
dense and improve palatability.
Emphasis should be laid on the incorporation of emulsified fats and vegetable oils
particularly those which are rich in medium chain triglycerides.
Visible sources of animal fat (pure ghee, lard etc.) and flesh food (red meat) should be
restricted in diet.
A combination of vegetable oils (olive, coconut, safflower etc.) cream, butter etc. can
help in improving taste and providing variety in terms of flavour in different meals.

Carbohydrate: Adequate amount (60% of total energy ) of carbohydrates should be

provided. If a very high calorie diet is being given, emphasis may be required on the
incorporation of easy-to-digest carbohydrates (mono/disaccharides and starches) so as
to make the meals small in volume and energy dense.However, some patients may
experience hyperglycemia. In such situations inclusion of food particularly those
which are rich in soluble fibre (pulses and legumes) would be helpful.

Vitamins, Minerals and Phytochemicals : Several vitamins particularly those of the

B-group are essential to promote adequate metabolism of energy and protein. Vitamin
A, C and E should be provided liberally as they help in reducing the morbidity and
mortality due to cancer, (required for tissue synthesis, cell differentiation and for
maintaining cell integrity). Among the minerals, zinc and selenium are particularly
important and their intake should be slightly increased by giving supplements. The
role of phytochemicals (carotenoids, flavonoids, plant sterols, allium compounds,
indols, phenols etc.) is gaining importance over the past few years. Incorporation of
good amount of fresh fruits/ vegetables preferably with their edible peels, soyabean
and certain Indian condiments/ herbs such as turmeric can help in promoting the
dietary intake of phytochemicals. The role of epigallacatechin gallate in green tea,
curcumin in turmeric, genistein in soya and folic acid in reducing the morbidity
associated with cancer .
Fluids: Adequate fluid intake is imperative to replace losses due to gastrointestinal
disturbances, infection/fever can also to help the kidney’s dispose off the metabolic
breakdown products from the destroyed cancer cells, as well as, from the toxic drugs
used in the treatment. Adequate intake of fluids/beverages helps in providing relief
from xerostomia and other swallowing problems. Menu’s should be planned such that
they include dishes rich in moisture/ water along with a beverage. Dry meals may not
be preferred by most patients.

Role of Antioxidants in Cancer Prevention

Antioxidants are important naturally occurring nutrients, (vitamins, minerals) which

help to protect body from certain types of cancers. Vitamin A, vitamin C and vitamin
E are well proved antioxidants in treating cancers such as gastrointestinal, cervical
and breast cancers. Also, antioxidants decrease the risk of cancer mortality.
Antioxidants help prevent widespread cellular destruction by willingly donating
components to stabilize free radicals. More importantly, antioxidants return to the
surface of the cell to stabilize rather than damage other cellular components.
Lycopene is a carotenoid which colours fruits and vegetables and is most abundantly
present in the prostrate gland. Fat-soluble vitamin A compounds include retinol,
retinal and retinoic acid. This group is vital for eye and retinal function, protects the
mucous membrane and reduces the risk of infection. Therefore, it is called an immune
enhancer and reduces the risk of cancer. Apart from reducing the cancer mortality, it
helps in treating cancer patients who have had surgery to remove primary tumors.
VitaminAand carotenoids antioxidant and immune stimulatory property have
developed synergistic cancer treatment application. Vitamin A levels decrease during
chemotherapy. Hence, additional intake of vitamin A is recommended during
chemotherapy.
Vitamin C based on research evidence plays an important role in the prevention and
treatment of cancer. Its anti cancer properties are:
Scavenging cancer causing free radicals such as hydrogen peroxide to prevent lipid
peroxidation, Neutralizing carcinogenic chemicals, Generating potent
antioxidant vitamin E, Enhancing lymphocyte function and rapid mobilization of
phagocytes, Potent antiviral and antibacterial activity, Enhancement of
immunoglobulins IgA, IgM, Modulation of interferon synthesis, and Increasing
synthesis of prostaglandin.
Neutropenic diet:
A neutropenic (nu-tro-PEE-nik) diet is for people with weakened immune
systems. Another name for the neutropenic diet is the low-microbial diet.

The neutropenic diet, also known as a low-bacterial or low-microbial diet, was

developed in response to observations that patients with low neutrophil counts were at
an increased risk of infections due to their weakened immune systems.
It is particularly recommended for cancer patients undergoing chemotherapy or other
treatments that compromise their immune function. The goal is to limit the intake of
foods that may harbor harmful bacteria, thereby reducing the risk of infection.

Neutropenia is a condition that is caused by one having a low white blood cell count.
Patients that may have a weakened immune system are more likely to develop an
infection.
This is due to the fact that the body may not be able to protect itself from harmful
organisms that can be found in some food or beverages.
It involves choosing foods and preparing them in a way that lowers your risk of
foodborne illness.
If you have a weakened immune system, your doctor may recommend that you follow
a neutropenic diet to limit your exposure to harmful microbes and bacteria.
The basic principles of this diet involve practicing proper food safety and avoiding
foods that are more likely to expose you to microbes and bacteria.

Doctors often recommend this diet before and after certain types
of chemotherapy and other cancer treatments.
A blood test called an absolute neutrophil count (ANC) can help determine the body’s
ability to fight off infection.
Many cancer patients have this blood test done routinely.
When the ANC is less than 500 cells/mm3, the patient is often instructed to follow a
neutropenic diet.
People who have had an organ transplant or who are being treated for HIV/AIDS also
may need to follow this diet.

The neutropenic diet is designed to help individuals with neutropenia—particularly

those undergoing cancer treatment—reduce their risk of foodborne infections. This
diet emphasizes foods that are less likely to harbor harmful bacteria while avoiding
those that pose a higher risk. Here’s a detailed overview of the foods to eat and avoid
on a neutropenic diet.

Foods to Eat on a Neutropenic Diet

The neutropenic diet emphasizes well-cooked, processed, or canned foods that

are less likely to contain harmful bacteria. Here are the categories of foods
typically included:

Dairy Products
Allowed: All dairy must be pasteurized. Acceptable options include:
- Milk (pasteurized)
 - Yogurt (pasteurized)

Starches
Allowed: Cooked and processed starches:
- Whole grains (cooked)
- Beans, corn, and peas

Vegetables
Allowed: Only cooked vegetables are acceptable:
- Canned or frozen vegetables
- Well-cooked fresh vegetables

Fruits
Allowed: Canned or frozen fruits and juices are safe:
- Whole fruits should be washed thoroughly and peeled; thick-skinned fruits like
bananas and oranges can be consumed if prepared properly.

Proteins
Allowed: Well-cooked meats and proteins:
- Chicken, fish (cooked thoroughly)
- Canned meats (e.g., tuna, chicken)
- Hard-cooked or boiled eggs
- Pasteurized egg substitutes

Allowed: - Bottled or distilled water

- Canned drinks

Foods to Avoid on a Neutropenic Diet

Dairy Products
Avoid:
- Unpasteurized milk and dairy products
- Soft cheeses (e.g., Brie, feta)
- Aged cheeses
- Yogurt with live cultures

Raw Fruits and Vegetables

Avoid:
- All fresh fruits and vegetables unless they can be thoroughly washed and peeled.
- Salads and raw herbs.

Raw or Undercooked Proteins

Avoid:
- All raw meats (including deli meats)
- Sushi
- Cold cuts
- Undercooked eggs (including those with runny yolks)
- Raw seafood
Unwashed Foods
Avoid:
- Any unwashed raw fruits or vegetables
- Unpasteurized juices
- Homemade beverages like fresh lemonade.

The primary goal of the neutropenic diet is to reduce the risk of infections in patients
with weakened immune systems due to low neutrophil counts. Neutrophils are critical
for fighting off bacterial infections; thus, when their levels are low, even minor
exposures to pathogens can lead to serious complications.

Food Storage Guidelines

Avoid keeping food on the counter longer than necessary.
Check that your refrigerator is set at 40 degrees Fahrenheit (F) or below.
Bacteria grow best between 40 and 140 degrees F.
Refrigerate or freeze fresh or frozen food immediately after purchase.
Refrigerate or freeze leftover food within two hours of eating.
 FOOD ALLERGY
 Allergy is a hypersensitivity disorder of the immune system of human body.
 Allergic reaction is nothing but when the body’s immune system reacts
abnormally to substance which is present in the environment.
 The substance causing allergic reaction is called as allergen.
 The over production of specialized antibodies called ‘Immunoglobulin E (IgE)’
by immune system are responsible for producing allergic symptoms.
 The proteins which are highly responsible for allergic reactions are especially
found in eggs, peanuts, sea foods, cow’s milk, soy and wheat.
 Presence of even very minimal quantity of offending food may causes very
serious allergic reactions in individuals who are susceptible for specific allergy.
 Food allergy can develop at any age but the prevalence is more common among
children below five years of age.

SYMPTOMS OF FOOD ALLERGY

MECHANISMS OF ALLERGIC REACTIONS IN THE BODY

Allergic reactions are complex immune responses triggered by exposure to specific

allergens.
Allergies occur when the immune system mistakenly identifies a harmless substance
as a threat.
Common allergens include pollen, dust mites, pet dander, certain foods, and insect
stings.
The immune response involves several steps, including sensitization and subsequent
re-exposure to the allergen.

Sensitization Phase
The first exposure to an allergen does not typically result in symptoms but
instead leads to sensitization:

Antigen Presentation: Upon entering the body, allergens are processed by antigen-
presenting cells (APCs), which present fragments of the allergen to T-helper cells.
IgE Production: In response, T-helper cells stimulate B cells to produce
immunoglobulin E (IgE) antibodies specific to that allergen. These IgE antibodies
bind to mast cells and basophils, priming them for future encounters with the allergen.
The Allergic Cascade
Upon re-exposure to the same allergen, a series of events known as the allergic
cascade occurs:

Cross-linking of IgE: The allergen binds to IgE antibodies on the surface of sensitized
mast cells and basophils. This cross-linking triggers degranulation, where these cells
release various chemical mediators.
Release of Mediators:
Histamine: Causes vasodilation, increased vascular permeability, and smooth muscle
contraction.
Leukotrienes: Contribute to bronchoconstriction and inflammation.
Prostaglandins: Involved in pain and inflammation responses.

Allergic reactions can be categorized into two main phases: immediate reactions
and late-phase reactions. Each phase has distinct characteristics and involves
different biological processes.

Immediate Reaction
The immediate reaction occurs within minutes of re-exposure to an allergen. It is
primarily characterized by symptoms such as itching, swelling, and
bronchoconstriction, largely due to the release of histamine from mast cells and
basophils. Histamine acts on various receptors in the body, leading to:
Vasodilation: This increases blood flow to the affected area, causing redness and
localized swelling.
Increased vascular permeability: This allows fluids to escape into surrounding tissues,
contributing to swelling.
Smooth muscle contraction: Particularly in the airways, this can lead to
bronchoconstriction, causing difficulty in breathing.

Late Phase Reaction

The late-phase reaction occurs several hours after the initial exposure and is
characterized by a more sustained inflammatory response. This phase involves the
recruitment of additional inflammatory cells, particularly eosinophils and neutrophils,
which contribute to prolonged inflammation and tissue damage.
Eosinophil Activation: These cells are attracted to the site of inflammation by
mediators released during the immediate reaction. Once activated, eosinophils release
cytotoxic granules that can exacerbate tissue damage.
Sustained Inflammation: The late-phase response can lead to chronic symptoms if the
allergen is not removed or if exposure continues. This phase is crucial in conditions
like allergic asthma, where ongoing inflammation can lead to airway remodeling and
increased sensitivity.

Cell types play critical roles in allergic responses:

Mast Cells: Located in tissues, they are central to initiating allergic reactions through
degranulation.
Basophils: Circulate in the blood and also release mediators upon activation.
Eosinophils: Attracted during the late phase; they release cytotoxic granules that
exacerbate inflammation.
 CLASSIFICATIONS OF MAJOR FOOD ALLERGENS

Classification by Mechanism
Food allergies are primarily categorized into three groups based on the
mechanism of the allergic response:

IgE-mediated (Type I Hypersensitivity): This is the most common type, where the
immune system produces Immunoglobulin E (IgE) antibodies in response to specific
food proteins. Reactions typically occur shortly after ingestion and can lead to severe
symptoms, including anaphylaxis.
Non-IgE mediated (Type IV Hypersensitivity): This type involves immune responses
that do not involve IgE antibodies. Symptoms may manifest hours after consuming
the allergen, complicating diagnosis and management.
Mixed IgE and Non-IgE mediated: This category includes reactions that involve both
IgE and non-IgE mechanisms, presenting a combination of symptoms typical of both
types
Major Food Allergens
Food allergens can be classified based on the types of immune responses

Cow’s milk

It was estimated that globally around 2.5% of the infants are affected by cow’s milk
allergy whereas 34% of the children in the age group of 3-5 have intolerance to it. The
allergic reactions towards milk allergy are caused by the IgE mediated or cell
mediated origin. Substitute for the milk allergy with sheep’s milk or goat’s milk
cannot be done as the children react to these milk as well. The IgE antibodies are
triggered by the proteins present in the cow’s milk like casein and whey protein. It
was found that children who are allergic to cow’s milk have higher risk for
developing other types of food allergies and inhalant allergies.

Hen’s egg
Approximately 2.5% of the children and infants are allergic to hen’s egg and tolerance
towards this is achieved only after 5 years. The protein responsible for allergic
reaction in hen’s egg is found in egg white. Children who develop allergy to hen’s egg
have greater risk of developing respiratory allergens in later part of life.
Peanut

Peanut allergy is common among the adults with the symptom of asthma. Individuals
should be cautious because even the small traces of this protein in the processed food
are problematic and are advised to avoid the refined peanut product and oils.

Soybean

Soybean is reported for both IgE and cell mediated allergic reactions having clinical
manifestations in infants and young children. But processed soy bean oil is well
tolerated by persons with this allergy.

Fish

Finned fish allergy is potentially very severe. The allergen found in the fish
responsible towards allergic reactions is ‘parvalbumin’. Similar to the finned fish,
allergen found in crab, shrimp and lobster are severe. Tropomyosin, a muscle protein
is responsible for allergic reaction which is also found in some invertebrates like
insects and cockroaches.

Seeds

Life threatening IgE mediated allergic reaction have been reported when some seeds
like cotton seed, caraway, fennel and coriander are consumed. There are reports on
certain allergic symptoms to sesame, sunflower and mustard seeds.
Vegetables and fruits

The most common food allergy (IgE antibody – mediated) in adults reported is due to
fruits and vegetables. Symptoms occur predominantly in oral cavity due to
sensitization to pollen and grains. This type of allergy is called as “pollen-food
syndrome” or “oral allergy syndrome”.Reactions to fruit have been associated with
the presence of IgE antibody to specific protein called ‘lipid transfer protein or
storage protein’ that are sensitized with specific allergen called ‘profilin’ leading to
gastrointestinal symptoms.

Genetically Modified Foods (GMF)

Increasing population needs greater demand for agricultural stuffs. To meet the
demands, many commonly consumed foods are produced more by altering the gene
which is called as genetically modified foods. These transgenic plant foods could
cause severe allergic reaction because of the presence of endotoxin . These endotoxins
could also lead to anaphylactic shock.

Beverages

Alcoholic beverages may cause clinical manifestations of allergy, both specifically

and nonspecifically. Their specific allergic actions are due to traces of foreign
substances derived fromfood materials employed in the preparations or clarifying the
beverage, such as barley malt and ayeast in beer; rye, corn, and wheat in whisky; fish;
glue, egg white, or yeast in cheap whitewine and champagne. The non-specific
reactions are due to the effect of alcohol in increasing permeability of the membranes
of gastrointestinal tract thus facilitating the absorption ofincompletely digested food
proteins which may cause allergic reactions. Allergic reactions to coffee and tea can
occur occasionally. Chlorogenic acid, one of the active phenolic compoundsfound in
coffee may be responsible for the allergic reaction.

Fermented Foods

Moulds can cause allergy. All fermented foods should be avoided as anything that has
beenfermented could harbour other strains of mould spores. Fermentation is involved
in processingraisins, beer, wine, blue cheese, pickles and vinegar.

Food Contaminants

The contaminants of food for example preservatives, insecticides, and insect excreta
orfragments may act as allergens and the food by itself may be harmless. Such
contaminants mayenter the plant food in the field or enter the food during storage,
processing and shipping. Thecommon additives include colour, flavouring materials,
preservatives and insecticides. Additivesmost frequently cited as causing reactions are
sulphites (preservative), tartrazine (colour),monosodium glutamate and aspartame
(flavour and taste enhancers). MSG is associated withChinese restaurant syndrome
causing migraine with sensations of thoracic, cervical and facialtightness. For
example, Nordihydroguaiaretic acid (NDGTA) is an antioxidant used in food fats.It
has been found to produce allergic reactions in some individuals.
 DIAGNOSIS

Dietary History

A careful dietary history should be taken. In certain cases, if symptoms develop very
rapidly and dramatically after immediate ingestion of the offending food, the patient
can make his.own diagnosis. But-difficult to associate symptoms to any particular
food especially when there is a delay of some hours and there may be an error
sometimes. In cases of doubt, the patient is given a diary in which he should record all
foods eaten and should also record anv.disturbances occurring due to food allergy.

Provocative Test

In this test, the patients are given a small quantity of the suspected food in a disguised
form.so the patient is unaware of the presence of particular food. Typical symptoms
appear at the-appropriate time after the meal. The test should be conducted for a
minimum of 3 times before-obtaining confirmative results. The provocative test
should not be conducted in patients whodevelop severe allergic reactions asmay prove
dangerous.

Elimination Diet

In this the patient omits one suspected food each day and keeps record of signs and
symptoms.This can be adapted in infants and children because of the limited variety
of foods they eat, forexample, elimination of eggs, milk and wheat which are common
allergens in children. Thisis difficult to follow in adults who live on a wide variety of
foods to which sensitivity maydevelop. Various types of elimination diets have been
devised with the object of finding outthe offending food. These elimination diets are
difficult and complicated and normally suitedfor investigation of patients in hospitals
with a dietetic department and physician experiencedin study of allergy.

Laboratory Testing

Skin test: The usefulness of this test in diagnosis of food allergy is limited. In intra
dermal test.minute quantities of extracts containing suspected antigens are packed into
the skin over thearm. In scratch test a small amount of the solution containing the
antigen is placed into a seriesof scratches made into the skin. In patch test the antigen
is applied to a piece of filter paperover the skin and covered with cellophane paper
and kept for 24 hours. If a red inflammationor hive like wheal appears at the site of
contact, the food is suspected to contain the allergen.Sometimes oedema or erythema
due to vasodilation is seen.

Radio allergosorbent test: It is the skin prick test that aims to detect the presence of
IgEantibodies. They aim to measure the binding of IgE to allergens such as milk, eggs
or fish. Anarbitrary score from 0-4 is given. Allergic patients usually have a score
above 2. These testsare expensive and not very informative.
Basophil histamine release assays: This measures histamine release from whole
bloodbasophils which are exposed to various food antigens and can be used to test for
IgE-mediatedallergy. This method provides no additional information beyond
standard in vitro and skintesting methods.

Food sensitivity in children

Food sensitivity in infants and children is common. Most children with food
sensitivity adverse reactions to food grow out of their sensitivities. The changed
reactivity can be due tothe decreased absorption of immunologic food proteins as the
intestinal mucosa and secretory immune system nature.

Cow's milk is probably the most common single allergen in infants. It is reaction in
infancy and usually appears in the first few months of life. Other common sensitivities
seen in children are egg white and fish. The child may overcome egg white sensitivity
but fish sensitivity often persists.

Milk sensitivity in infants can affect the gastrointestinal tract followed by respiratory
system and skin. Most of the infants present with diarrhea and mucous. Vomiting,
especially withinan hour of feeding, is the second most common manifestation.

FOOD INTOLERANCE

Food intolerance is different from food sensitivity.

It is an abnormal, nonimmunologicresponse to an ingested food that may be
pharmacological metabolic or toxic.Pharmacologic reactions to food are the result of
natural or added chemicals that produce an effect resembling that of a drug. Examples
of natural constituents are alkaloids, such as those found in mushrooms; goitrogens,
such as those found in cabbage; or pressor aminesfound in bananas. Metabolic
reactions from the effect of the food on the metabolism of the recipient for example,
lactase deficiency. Food toxicity is caused by toxins contained in thef ood or released
by microorganisms that contaminate the product(Aflatoxin and pesticides
areexamples of contaminants).
Food intolerance is different from food allergy in that it does not involve the body’s
immune system. Food intolerance is a digestive system response rather than an
immune system response. It occurs when a food component irritates a person’s
digestive system or when a person is unable to properly digest or breakdown, the food.
It may be triggered by a physical reaction to a food or food additive or caused by a
metabolic reaction to an enzyme deficiency such as the inability to digest milk
properly (lactose intolerance), by pharmacologic agents in foods, by food poisoning
such as ingesting contaminated or spoiled fish. The situation is therefore rather
different from a food allergy where a specific person’s body for whatever reason
reacts against a certain food.
Factors in detail:
(a) Enzyme deficiency or defects: A food sensitivity or intolerance can occur when
the body has difficulty in digesting a particular food and therefore reacts against it. In
normal digestion, the foods we eat are broken down (through chewing and the action
of the acids etc. in our stomach and our intestines) into their component parts. The
useful ones (the nutrients) are absorbed into the blood stream through the digestive
tract (or ‘gut wall’), the redundant ones are flushed out through the bowel. However,
if the foods are not properly broken down through some digestive malfunction the
body either will not be able to absorb them properly or, since they have not been
properly ‘processed’, may react against them. In the case of lactose intolerance, for
example, the body fails to manufacture the enzyme lactase that is needed to digest the
lactose sugar in milk. Without lactase, the digestion cannot process the lactose sugar
in the milk. The digestion cannot cope with the raw lactose sugar so reacts against it
in the form of cramps, vomiting, diarrhoea, abdominal pain etc.
One other example is phenylketonuria (PKU), which is an inborn error of metabolism.
In normal people the enzyme phenylalanine hydroxylase converts phenylalanine (an
amino acid) to tyrosine (another amino acid), which is then utilized by the body. In
PKU since phenylalanine cannot be hydroxylated to tyrosine, its metabolites
accumulate and cause damage to the central nervous system and result in unusual
irritability, eczema etc.
Galactosemia due to deficiency of the enzyme galactose-1-phospahte uridyl
transferase which converts galactose-1- phosphate to glucose-1-phosphate leads to
accumulation of galactose causing various symptoms such as vomiting, fever,
jaundice etc.

(b) Naturally occurring food chemicals (pharmacologic effect): Pharmacologically

active substances include vasoactive amines such as histamine, tyramine, tryptamine,
phenylethylamine, and serotonin. These substances are present naturally in many
foods, and produced during fermentation, cooking, ageing and storage in other foods.
These are substances, which cause a reaction like an allergic reaction. For example,
histamine can reach high levels in cheese, some wines, and certain kinds of fish such
as tuna and mackerel. These substances may also be consumed in foods such as
fermented foods (i.e. sauerkraut, pork sausages, canned tuna), brewer’s yeast, canned
fish, avocados and bananas. In susceptible people, these foods can trigger urticaria,
facial flushing, decreased blood pressure and headaches. Further, certain foods, such
as irritants, can trigger histamine release from intestinal immune cells, particularly if
taken in large quantities. The most familiar of these substances is caffeine, found in
tea, coffee, chocolate and cola drinks. A large intake of caffeine can cause tremor,
migraine and palpitations. Other irritant substances include lecithin in legume, paprika,
chilli, pepper, paprika, acidic foods, and alcohol.
(c) Reaction to food additives: Food additives such as preservatives, flavour
enhancers and colouring agents have been linked to adverse food reactions. Additives
implicated include tartrazine (the yellow-orange colour dye used in foods, soft drinks,
medicine), benzoic acid or sodium benzoate (added in soft drinks some cheeses,
processed potato products) causing hives, rash and asthma. Sulphite are a group of
sulphite-based compounds that may occur naturally or may be added to food a flavour
enhancer and preservative. Sulphites (including sodium sulphite, potassium sulphite,
sodium metabisulphite, sodium bisulphite etc.) are added to many foods and
beverages to prevent browning, control microbial growth, modify texture etc. have
been well documented to cause adverse reactions such as acute asthma and
anaphylaxis, loss of consciousness.
Monosodium glutamate (MSG) is thought to be safe for most people, but in some
cases, adverse reaction to this flavouring agent includes headache, nausea, flushing,
abdominal pain and asthma.

(d) Reaction to microbial contamination: The illness described in appears to be

scombroid fish poisoning, which results from the ingestion of histamine-
like substances formed when bacteria degrade the flesh of certain marine fish.
Ingestion of improperly handled and stored seafood (yellowfin tuna, bonita and
mackerel) causes scombroid poisoning. These types of fish contain bacteria in the
intestine, which break down the protein (histidine) in the tissue (to histamine) if fish is
not immediately gutted and cooled after being caught (i.e. improper storage).
Histamine, at high concentrations, is risk a factor for food intoxication whereas
moderate levels may lead to food intolerance. A host of symptoms, including skin
flushing, facial swelling, dizziness, throbbing headache, oral burning, metallic, sharp
or peppery taste in mouth, abdominal cramps, nausea, vomiting, diarrhoea,
palpitations, and a sense of unease. Another example of microbial contamination is
paralytic shellfish poisoning. The causative agent is saxitoxin. It is a powerful
neurotoxin produced by Gonyaulax catenella. Initial symptoms of poisoning, which
can be seen within 30 minutes of consuming shellfish, mussels, clams) include
headache, a floating feeling, dizziness, tingling, burning, numbness in the extremities,
which spreads quickly throughout the body producing general lack of muscular
coordination.
(d) Food indigestibility: Certain food components, when ingested in large amounts
cannot be digested properly and end up in the large intestine where bacteria feed on
them. This can lead to bloating, flatulence and diarrhoea. Examples of such foods
include fructose, xylitol, sorbitol, cellulose, hemicellulose, lignin, gums etc.

Food intolerance reactions can include: the skin (rashes, swelling), airways
(asthma, stuffy or runny nose, frequent colds and infections), gastrointestinal tract
(irritable bowel symptoms, colic, bloating, diarrhoea, vomiting, frequent mouth ulcers,
reflux, bedwetting), central nervous system (migraines, headaches, anxiety,
depression, lethargy, impairment of memory and concentration, panic attacks,
irritability, restlessness, inattention, sleep disturbance, restless legs, mood swings etc.).
Symptoms of food intolerance can come and go and change throughout life.
For food intolerance, particularly the diagnosis is via elimination and challenge with
food substances/chemicals. Delayed reactions and non IgE-mediated reactions can,
only be diagnosed by an elimination diet. Diagnosis requires identification of the
suspected food, proof that the food causes an adverse response, and verification of
immunological involvement.
EXAMPLE:

Lactose intolerance relates to insufficiency of the disaccharidase

‘lactase’ which is found in the greatest quantity in the outer
membrane of the mucosal cell of the jejunum.
Lack of lactase does not break down the disaccharide sugar, lactose in milk, to
glucose and galactose, which hence passes unchanged into the large intestines where
it gets converted to lactic acid by the bacteria, which subsequently causes diarrhoea
and other symptoms of discomfort, and distension, abdominal pain. The problem is
gene related and often seen in infants and young children commonly but may also be
present in adults.
The dietary treatment is based upon the determination of lactase activity as the
treatment depends on the level of activity of lactase enzyme. Depending on the level
of activity (very low level, moderate level) the dietary treatment could be planned.

Very low level of lactase activity: At very low level of lactase activity all milk
products must be eliminated substitutes of milk like soya milk, groundnut milk and
their preparations could be given. Enzyme such as Lactaid and Maxilact are available
in the market. Addition of these in the milk or milk products could digest 90% of
lactose in milk and thus minimize the symptoms of lactose intolerance.

Moderate level of lactase activity : Intake of milk is restricted depending on the

tolerance. Fermented and cooked form of milk preferred as it is better tolerated.
Fermentation converts a major part of Lactose to Lactic acid and in cooked product
lactose gets bound and the concentration reduces. It is better tolerated in the form of
buttermilk, curds, custards, porridges and cottage cheese or when mixed with cereals,
cocoa etc. These allow gradual lactose breakdown and decrease the symptoms of
lactose intolerance. Curds are better tolerated possibly due to microbial culture that
facilitates lactose digestion in the intestine. Small amount of milk can be taken with
the meal. Lactose is present in dairy products such as milk, cheese, yoghurt, ice cream
etc. Hidden sources of lactose may include bread, candy, cookies, biscuits, sauces,
gravies, soups etc. Hence, depending upon the amount of lactose an individual can
handle, major or minor dietary restrictions may be imposed. Because dairy products
are restricted or avoided, which are a major source of calcium, which children need to
develop strong bones, it is important to serve calcium-rich foods to make up for the
loss. Tofu, broccoli, pulses (Bengal gram whole, horse gram, rajmah), nuts and
oilseeds, green leafy vegetables (particularly amaranth, fenugreek), fish and sea foods
are excellent sources of calcium.
 ELIMINATION DIETS

 The elimination diets are prescribed for short term, under supervision and only
for a good reason.
 Elimination diets are therapeutic trials.
 The elimination diet, as the name suggests, is a diet that eliminates a single or
several foods depending on the medical and dietary history.
 This diet eliminates foods and food additives considered to be common allergens,
such as wheat, dairy products, eggs, corn, soy, citrus fruits, nuts, peanuts,
tomatoes, food colouring agents and preservatives, coffee, chocolate etc.
 In immediate type food reaction the culprit is often known and only the offending
food is eliminated.
 If the reactions are delayed, multiple foods may need to be eliminated.
 The type of elimination diet selected depends on the diet history, symptoms and
severity of the reactions.
 The elimination diet may be basic, targeted or severe elimination diets.
 The use of a basic elimination diet may be helpful in assessing the role of food
allergy. In the targeted elimination diet foods based on patients history and/or the
results of specific IgE tests to the foods in question is eliminated.

The common elimination diets are:

Simple Exclusion Diets: When a single food like milk, egg or wheat is
suspected,patients are advised how to consume a diet free of these. This is not simple
in practice.Exclusion of foods like milk in children, require dietary expertise to ensure
that nutritional requirements are met.
Multi Exclusion Diet: If it is not clear from dietary enquiry or simple exclusion diet
which foods are responsible, a complex exclusion diet has to be tried on trial and error
basis.
Initial exclusion diets: Initially a wide range of foods which may provoke intolerance
is removedfrom diet and after a period of time, reintroduced singly into the diet so the
offending item is identified.
Graduated exclusion diet: The number of foods excluded from a diet is gradually
increased.

An elimination diet is a structured dietary approach aimed at identifying food

intolerances, sensitivities, and allergies.
This method involves removing specific foods from the diet for a set period and then
gradually reintroducing them to observe any adverse reactions.
The primary goal is to pinpoint foods that may be causing discomfort or health issues,
allowing individuals to make informed dietary choices.
Food intolerances and allergies are common issues that can lead to a variety of
symptoms, including gastrointestinal distress, skin reactions, and respiratory problems.
Food intolerances often result from the body’s inability to properly digest certain
foods, while allergies involve an immune response to specific proteins in foods.

An elimination diet typically consists of two main phases: the elimination phase
and the reintroduction phase.
Elimination Phase

During the elimination phase, which lasts between **two weeks to two months**,
individuals remove suspected trigger foods from their diet. Commonly eliminated
foods include:

- Dairy products
- Eggs
- Wheat and gluten
- Shellfish
- Soy
- Certain fruits and vegetables (especially nightshades)

This phase allows the body to clear potential allergens, providing a baseline for
symptom observation. Individuals are encouraged to keep a food diary to track their
intake and any symptoms experienced during this period .

Reintroduction Phase

After the elimination period, foods are gradually reintroduced one at a time over
several days. This process helps identify specific food triggers by monitoring for any
return of symptoms after each reintroduction. If a food elicits a reaction, it is typically
removed from the diet permanently.

Types of Elimination Diets:

Standard Elimination Diet: Focuses on removing common allergens such as dairy and
gluten.
Low-FODMAP Diet: Targets fermentable carbohydrates that can cause digestive
distress, particularly beneficial for individuals with irritable bowel syndrome (IBS).
Few Foods Diet: Involves consuming only a limited selection of foods that are not
typically associated with allergies or intolerances.
Fasting Elimination Diet: Involves an initial fasting period followed by gradual
reintroduction of foods; this should only be done under medical supervision due to
potential health risks .

Benefits of Elimination Diets

Symptom Relief

Many individuals report significant improvements in symptoms associated with

various conditions, such as IBS, eczema, migraines, and chronic fatigue syndrome.
For example, studies have shown that participants following an elimination diet for
IBS experienced up to a 26% reduction in symptoms when adhering strictly to the
dietary guidelines .

Improved Digestive Health

By removing potentially irritating foods from the diet, individuals often experience
reduced bloating, gas, diarrhea, and constipation. This can lead to improved overall
digestive health and comfort.

Enhanced Nutritional Awareness

Elimination diets encourage individuals to become more mindful of their food choices
and how different foods affect their bodies. This awareness can foster healthier eating
habits in the long term.

Identification of Hidden Allergens

For those with suspected food allergies, elimination diets can help uncover hidden
allergens that may not be identified through traditional allergy testing methods .

Considerations Before Starting an Elimination Diet:

Medical Supervision: It is crucial for individuals with known allergies or severe

reactions (such as anaphylaxis) to consult with a healthcare professional before
starting an elimination diet. Medical guidance ensures safety during the reintroduction
phase.

Nutritional Balance: Care must be taken to maintain nutritional balance during the
elimination phase. A well-planned diet should include a variety of fruits, vegetables,
lean proteins, and healthy fats to prevent deficiencies.

Potential Psychological Impact: Restrictive diets can sometimes lead to unhealthy

relationships with food or anxiety about eating; it is essential to approach such diets
with a positive mindset.

Elimination diets serve as a powerful tool for identifying food intolerances and
allergies while promoting overall health and well-being.
By systematically removing and reintroducing foods, individuals can gain valuable
insights into their dietary needs and make informed choices that enhance their quality
of life.
However, it is essential to undertake this process thoughtfully and under appropriate
guidance to ensure safety and nutritional adequacy.