Diet Therapy in Fever & Infectious

Diseases

Albert ChengSaturn DagwaseDavid L. Santos

FEED A COLD, STARVE A FEVER?

“Fede a cold and starb of feber.”

Normal Physiology• Body Temperature controlled by

hypothalamic thermoregulatory center, receives 2 signals:1. Warmth/cold receptors on skin2. Temperature of blood - maintenance of maximum oral

temperature at 37.2 C at 6 am and 37.7 C at 4 pm

- Temperature which elevates hypothalamic set defines a fever

Pathophysiology of a FEVERInfection, microbial

toxins, mediators of inflammation,

immune reactions

Monocytes/ macrophages

and endothelial

cells

Pyrogenic cytokines: IL-1, IL-6, TNF,

IFN

circulation

Microbial toxins

Hypothalamic

endothelium

PGE2

Cyclic AMP

Elevated thermoregulatory

set point

Heat conservation

Heat production

FEVER

• Terminologies– Hyperpyrexia – Fever at > 41.5 degree

C– Hyperthermia – Uncontrolled increase

in body temperature that exceeds the body’s ability to lose heat• Ex: Heat Stroke

Metabolic Effects of Fever

1. Increase metabolic rate: For every one degree rise in temperature above the normal (Celsius) the metabolic rate is increased by approximately 13%

2. Increased protein catabolism, which is especially excessive in typhoid fever, malaria, typhus and others. The end products of protein catabolism excreted as urea places a heavy burden upon the kidneys.

3. Decreased glycogen stores and adipose tissue4. Loss of body fluids and electrolytes especially

sodium and potassium5. Decreased gastrointestinal motility affecting

absorption of nutrients

Diet in Infections and Fever

• Calorie is increased to meet the demand of increased metabolic rate. “Starving a fever” leads to a prolonged convalescence and acute deficiency diseases.

• Protein is increased by 50-100% of the recommended daily allowances to correct negative nitrogen balance that arises from the increased tissue catabolism

• Carbohydrate is increased– To provide energy– To spare body proteins from being utilized for

energy– To replenish depleted glycogen stores – To prevent ketosis

• Fat is given in normal or adequate amounts to help increase the caloric content of the diet without too much bulk

• Liberal fluids and salts– To compensate for water and salt loss form overt

perspiration and insensible loss– To permit adequate volume of urine for excreting

metabolic wastes• Vitamins, especially the B-vitamins are increased

because there are parts of the coenzymes involved in metabolism. Thiamine, riboflavin, niacin and pyridoxine in particular are increased automatically whenever the caloric content of the diet is increased

Malaria• Malaria is a disease caused by a

parasite (plasmodium) that is transmitted person-to-person by the bite of an infected Anopheles mosquito.

• Malaria is the major causes of morbidity and mortality in many tropical and subtropical countries.

• Approximately 300 million people worldwide are affected by malaria and between 1 and 1.5 million people die from it every year.

• Over 90% of the deaths are in Africa, 2/3 among children.

Malaria Symptoms

• Fever• Chills• Headache• Muscle ache• Nausea• Sometimes vomiting, diarrhea, and

coughing

TREATMENT

DIETARY MANAGEMENT

• High Calorie due to high metabolic rate during attack

• High Protein due to protein destruction by protozoa.

• Hugh Carbohydrates to replenish depleted reserves.

• Moderate fats to reduce workload of impaired liver

• Liberal fluids and salts to restore salt and water balance to eliminate toxins.

• Vitamin supplements.

Emphysema

• Chronic lung disease characterized • by abnormal permanent enlargement of the

airspaces distal to the terminal bronchiole and is accompanied by destruction of their walls.

• This result from an imbalance between elastase predominating and leading to excessive destruction of elastin and further proteolysis.

• Cigarette smoking is the major cause of emphysema.

• In patients with emphysema, normal lung tissue is often replaced by large “bullae,” large balloon- like structures that press on normal lung tissue and reduce the person’s lung capacity even further. If the lungs are full of bullae, the lungs become too large for the chest cavity and cannot expand properly.

Signs and symptoms:

• shortness of breath

• -tissue wasting and weight loss

• -abdominal distress

• -coughing, usually with very thick mucus.

Treatment:

• -give patient considerable relief• -correct or diminish conditions

causing the disability• -light exercise• -nutritional rehabilitation

Diet Therapy

• “There is little that a diet, even a healthy one, can do to help prevent the onset of emphysema. But once you have the disease diet will play a big role”

• Malnutrition (problem) – the marked decrease in lung function = use extra calories just to take a breath + diminished appetite = more pronounced DOB.

Diet Therapy1. high calorie – to combat tissue wasting

and weight loss.

2. low carbohydrate – to prevent CO2 retention

• increasing the caloric content of the diet

• -serve gravy on meat and potatoes• -serve mayonnaise, oil and salad

dressing whenever possible with sandwiches, salad and vegetable

• -along with breakfast eggs, serve bacon, ham or sausage

• -serve cream soups instead of clear bouillon

3. high Protein- to correct the negative nitrogen balance.

*There is no doubt that diet is closely associated with the functioning of the immune system.

Eat food that have a high protein content to help maintain muscle strength and tone in all your muscles, including the muscles that help you breathe.

The American Lung Association suggests that you eat two high-protein servings per day. Foods that are high in proteins are red meat, fish, eggs and poultry.

Meat and dairy products are high in protein and help keep your muscles strong. Good sources include peanut butter, tofu, nuts, and sees are also high in protein. Many of these foods are also higher in fat and can help you prevent weight loss.

Regular exercise

• It is a very important part of helping your feel better.

• Muscles that are out of shape require more “fuel” (oxygen) and make you become more easily run out of breath. Exercise helps tone muscles so tha they are more efficient and use less oxygen.

• You should build up your strength slowly especially with activities that you enjoy.

4. high vitamin supplements- Vitamin B complex – thiamine, riboflavin, niacin pyridoxine part of coenzymes involved in metabolism.- Vitamin C- improve the immune system.

5. Eat several small meals of high nutritional value– large meals leaving you feeling full will

restrict full inflation of the lungs, making it more difficult to breathe.

– Eat six small meals a day instead of three large ones. A stomach that is too full can cause shortness of breath.

– Eat your main meal early in the day so that you will have more energy throughout the day.

6. Eat soft foods that are easy to masticate because of the difficulty in chewing

7. Maintain a Healthy Weight– Being underweight can decrease your

energy and make you more prone to infection and further weight loss/ tissue wasting.

– Excess weight can increase shortness of breath.

– Weigh yourself twice a week.

8. Drink lots of fluids– Drinking lots of fluids helps keep

mucus thin and easier to bring up. Water, juices and nectar, and mineral waters are best.

• Your dietitian may also recommend a low-salt diet to avoid a build-up of fluids.

• Limit your salt intake. Sodium causes fluid retention, which may interfere with breathing.

• Some people with emphysema, who need diuretics, may develop low levels of potassium in their bodies. Muscles need potassium for proper contraction. Low potassium levels add to overall weakness and impaired strength of the muscles needed for breathing. Foods high in potassium include lima beans, split peas, fresh mushrooms, sweet potatoes, raw nuts, fresh spinach, dates, raisins, dried fruits, oranges and orange juice, bananas, halibut, dry skim milk and beef.

Rheumatic Fever• Leading cause of chronic illness in children,

especially the underprivileged• Characterized

– High fever– Painful swelling of joints similar to those of early RA

and inflammation of the heart muscle and valves.– Preceded usually by pharyngitis

• Treatment– Penicillin– Steroids

• Shortens the period of acute illness• Lessens it severity• Decreases the likelihood of cardiac involvement

Dietary treatment• Full liquid diet for acute infections is satisfactory

during the acute phase of rheumatic fever.• Progression from liquid to soft then regular diet

depends on the rate of patients rehabilitation• Caloric increased because increase in metabolic

and protein rates to correct the negative nitrogen balance.

• Increase in ascorbic acid as a antistress factor.• Iron supplement is recommended due to the

presence of anemia• Sodium should be restricted to 1000 mg a day

when steroids are used because of the sodium-retaining property of the drug to avoid edema

Tuberculosis• Tuberculosis is a chronic infectious,

contagious disease and one of the major causes of illness and death in undeveloped countries.

• Common among malnourished, immunocompromised and elderly

• Affects the lungs especially the apex and the hilar lymph nodes

• Etiology– M. tuberculosis– M. bovis– M. africanum

Mode of Transmission• M. Tuberculosis is transmitted via

air droplets from patients with PTB.• M. bovis can be acquired from

unpasteurized contaminated milk

Clinical manifestations of TB

• Fever• Night sweats• Generalized malaise and weakness• Anorexia• Cough

– Productive/non-productive with purulent sputum or blood streaked

• Massive hemoptysis• Shortness of breath

– Sign of presence fo air or fluid in the pleural space

• Pleuritic chest pain

Lab Dx TB

• Chest x-ray– Irregular white

areas against a normal dark background

– Tuberculin skin test

– Sputum analysis

Management of TB• Drugs

– INH, streptomycin, PAS, ethionamide, rifampicin• Dietary

– High calorie to meet the demands of high metabolic rate– High protein (75-100g)

• Restore nitrogen balance• Promote wound healing• Help regenerate serum albumin levels

– High Carbohydrate• Provide calories• To spare proteins

– Minerals• Calcium to promote healing by calcification of TB lesion and iron

supplement if there is hemorrhage– Vitamins

• Increased vitamin A, ascorbic acid, pyridoxine, vitamin K and B-complex vitamins

Typhoid Fever

• Etiologic agent: Salmonella typhii– Gm(-) bacilli– Flagellated– Motile, non-spore

forming– Pathogenic only to

human– Handy organism and

easily survives in natural habitat like water or inorganic material

• Public health immunization programs have greatly reduced the incidence, while the use of antibiotics has shortened the course of the disease from what used to be a chronic fever to one of short duration.

• Length of convalescence is to a large extent still dependent upon nutritional therapy

• Peyer’s patches and diarrhea are early involvements and may interfere with absorption

• During the height of the fever the metabolic rate may increase 50% above the normal.

• Protein destruction is great, approximating three times that which occurs during normal health.

Treatment of Typhoid Fever

• Drugs– Ceftriaxone – drug of choice; 30

mg/kg/day– Cefoperazone – 60 mg/kg/day– Chloramphenicol – resistance is

increasing– Quinolones – follow up oral therapy;

must not be given to prepubertal B patients

– Ampicillin – alternative therapy; 100 mg/kg/day IV or IM in 4 divided doses for 14 days

• Dietary treatment– Acute infections – proteins 100 gm or

more– Low amount of fiber in diet – not to

traumatized the inflamed bowels to precipitate hemorrhage or perforation

– Frequent small feedings to prevent burden to the stomach

– Three to six eggs daily, soft custard are well tolerated

– Milk and provide calories, proteins, minerals and vitamins

Cholera• Cholera is an infection

of the intestines by Cholera vibrio organisms transmitted through contaminated foods and drinks.

• Characterized– Sudden and massive diarrhea

usually with vomiting leading to a rapid loss of water and electrolytes with consequent dehydration, hypovolemia and shock.

– Death may occur within hours– Intravenous rehydration with

salts and glucose plus antibiotics to combat the infection have saved lives of infected individuals.

Cholera

• most feared epidemic diarrheal disease because of its severity

• 7 documented pandemics have occurred since 1817 – all originating from Asia.

• Agent: Vibrio cholerae

CholeraThe infectious dose • with water: 103-106 organisms. • with food: 102-104 organisms • enterotoxin promotes the secretion of

fluid and electrolytes into the lumen of the small intestine.

• Colon relatively insensitive to toxin, but overwhelmed by volume of fluid:rice water stools

Cholera

• The drugs used for adults include:tetracycline, doxycycline,

cotrimoxazole & ciprofloxacin.• For children:

erythromycin, cotrimoxazole and furazolidone are the drugs of choice.

Cholera

Disease of fluid management. Two steps: rehydration and maintenance

Rehydration: • 50-100 mL/kg/h• Lactated Ringer solution is preferred over

isotonic sodium chloride solution because saline does not correct metabolic acidosis

Maintenance – maintain normal hydration status by replacing ongoing losses.

• The oral route is preferred• Oral rehydration solution (ORS) at a rate of 500-

1000 mL/h is recommended