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From Editor’s Desk


SRNM Self Assessment Programme


Test your understanding of renal nutrition through questions given below. Scorecard is given below the answers given at the end.


Q1 Diabetic nephropathy is one of the most common causes of end stage renal disease. Treatments that lower urinary albumin excretion may slow progression of diabetic kidney disease and improve clinical outcomes. Which of the following is true?

  1. Currently there is insufficient evidence to assume that lowering albuminuria levels will necessarily lead to improvements in clinical outcomes such as progression of chronic kidney disease (CKD) stage 5, cardiovascular disease(CVD) events or death.

  2. Albuminuria change may be an acceptable surrogate marker for clinical outcome in diabetic kidney disease

  3. In normotensive people with diabetes and microalbuminuria use of an ACE inhibitor or ARB should not be considered

  4. Normotensive people with diabetes and macroalbuminuria should not receive ACE inhibitor or and an ARB

  5. Blood pressure in diabetic individuals tends to be salt sensitive therefore reduced sodium intake (<5g sodium chloride) lowers blood pressure


Q2 Multiple risk factors are managed concurrently in patients with diabetes and chronic kidney disease (CKD) and the incremental effects of treating each of these risk factors appear to add up to substantial clinical benefits.

  1. People with diabetes and CKD should adopt healthy lifestyles that include nutrition, exercise and smoking cessation.

  2. Control of hyperglycemia, blood pressure and hyperlipediemia do not improve other relevant health outcomes in people with diabetes irrespective of the presence of CKD.

  3. A body mass index of 30.0 kg /m2 may reduce the risk of loss of kidney function and cardiovascular disease(CVD)

  4. Patients with overt nephropathy should restrict protein intake to 0.8g/kg/d and as glomerular filtration rate (GFR) decreases, further restriction to 0.6g/kg/d should be considered

  5. Treatment goals for diabetes and CKD include blood pressure <130/80 mmHG, glycosylated hemoglobin <7.0%, total cholesterol <175mg/dL, triglycerides ,150mg/dL.


Q3 Severalmechanisms leading todevelopmentofmetabolic riskfactorsas wellas adipocyte derived factors in response to obesity may lead to kidney damage, albuminuria and loss of glomerular filtration rate. Mechanisms which have strong association between obesity and chronic kidney disease (CKD) are

  1. Physical compression of the kidneys by visceral obesity

  2. Sympathatic activation

  3. Over nutrition may lead to kidney damage, albuminuria and loss of glomerular filtration rate.

  4. Blood pressure elevation may lead to kidney damage, albuminuria and loss of glomerular filtration rate.


Q4 Presence of microalbuminuria in pregnant women with type 1 diabetes increases risks of adverse maternal and child outcomes including pre-eclamsia and preterm delivery. Which of the following statements are correct?

  1. Insulin is the preferred pharmacological therapy for hyperglusemia in pregnant women with diabetes and chronic kidney disease (CKD)

  2. Dyslipidemia should not be treated during pregnancy in women with diabetes and CKD.

  3. Dietary protein intake should not be restricted during pregnancy with diabetes and CKD. Protein intake should be increased to 1.0-1.2g/kg prepregnancy weight /d.

  4. Pregnant women with diabetes and CKD stage 5 treated by kidney transplantation or dialysis should not be managed according to the recommendations for earlier stages of CKD

  5. Risk of fetal abnormalities (congenital malformations of the cardiovascular system, central nervous system and kidney) during ACE-inhibitor treatment extends to the first trimester. Therefore rennin angiotensin (RAS) inhibitors should be discontinued immediately after a missed menstrual or a positive pregnancy test in women with diabetes and CKD.


Q5 Nephrolithiasis is associated with a variety of abnormalities in urinary composition. These abnormal urinary risk factors are due to dietary indiscretions, physiological-metabolic disturbances or both. Which of the following area correct?

  1. Hypercalciuria is the most common etiology of urolithiasis in children and adults.

  2. The main factor that leads to the formation of bladder stones in children is a nutritionally poor diet that is low in animal protein, calcium and phosphate, but high in cereal and is acidogenic

  3. In many hypercalciuric children, a low-Na/high-K diet one is effective while in most others, the addition of potassium citrate is well tolerated, which normalizes calciuria and protects against new stone formation

  4. Calcium intake of the renal stone patients should not be matched to their 24-h urinary calcium excretion

  5. Dietary treatment of calcium oxalate lithiasis includes reducing or eliminating nutritional oxalate intake by restricting cocoa drinks, chocolate, candies, black tea, excessive coffee intake, spinach rhubarb, asparagus, celery, parsley and tomato, almonds, peanuts, cashews walnuts, beetroot, cheeko, chocolate, strawberries, eggplant, soy products, tofu, wheat bran and rice bran.

Q6 Early nutritional intervention and prevention and treatment of metabolic deficits are key components in preservation of growth in child with chronic kidney disease (CKD). Which of the following parameters should be considered in children with CKD stages 2 to 5 and 5D?

  1. Length or height for age percentile or standard deviation score (SDS)

  2. Estimated dry weight and weight for age percentile or SDS

  3. rhGH therapy should not be considered in children with CKDstage 2 to 5 and 5D if short stature persists beyond 3 months despite treatment of nutritional deficiencies and metabolic abnormalities.

  4. Serum bicarbonate level should be maintained at 15 mmol/L

  5. Normalized protein catabolic rate (nPCR) in hemodialyzed adolescents


Q7 Poor energy intake is common in children with chronic kidney disease (CKD) stages 2 to 5 and 5D due to reduced appetite, and vomiting. Which of the following measures are correct?

  1. Energy requirement for children with CKD should be 100% of the estimated energy requirement for chronological age, individually adjusted for physical activity level and body size

  2. In infancy feeds should be of breast milk or a whey based infant formula with a low renal solute load if needed

  3. When estimating energy requirements, calorie contribution from peritoneal dialysis fluid should not be taken into account.

  4. Energy dense feeds should not be given to children with CKD stage 5 with oligoanuria

  5. High oral intake during dialysis can prevent achievement of prescribed dry weight


Q8 Growing evidence for major impact of phosphorus overload on cardiovascular morbidity in children and adults with chronic kidney disease (CKD) provides rationale to avoid excessive protein intake in this population.

  1. It is suggested to maintain dietary protein intake at 100% to 140% of daily recommended intake for ideal body weight in children with CKD stage 3 and 100% to 120% in children with CKD stage 4 and 5

  2. In children with CKD stage 5D, dietary protein in take should be 70% of daily recommended intake for ideal body weight.

  3. Use of protein supplements should not be considered in children in stages 2 to 5.

  4. For patients on maintenance hemodialysis, at least 0.3 to 0.4 g/kg of dietary protein should be added to the intake recommended for healthy subjects

  5. Protein requirements should not be increased in patients with proteinuria and during recovery from intercurrent illness.


Q9 Daily dietary allowance for patients on twice weekly or thrice weekly maintenance hemodialysis should be

  1. Protein intake should be 1.2.g/kg/d

  2. Energy intake should be 20 kcal/kg/day

iii) Cholesterol intake should be >400mg/day

  1. Phosphorus intake should be 800-1000mg/day

  2. Calcium intake should be between 1500-2000mg/day

Q10 An ideal marker for assessment of nutritional status for a patient undergoing peritoneal dialysis would be one that is easily measured, reliable, inexpensive and unaffected by patient’s underlying disease or inflammatory status.

  1. Assessment of nutritional status is best with careful physical examination.

  2. Subjective global assessment is a clinical tool that incorporates patient’s medical history, dietary intake, gastrointestinal symptoms, and functional impairment.

  3. Anthropometric measures should not be used for assessment of nutritional status

  4. Serum albumin and prealbumin are not good measures of nutritional status

  5. Bioelectrical impedance analysis is a technique used for determining body composition by providing estimate of body water, fat and fat free mass.


Q11 Nephrotic syndrome is characterized by hypoalbuminemia and consequently marked muscle wasting occurs in patients with continuous proteinuria. Which of the following is true.

  1. Several causes of hypoalbuminemia are albumin loss in urine, inappropriate increase in fractional catabolic rate of albumin and insufficient increase in the synthesis rate of albumin to replace the loss.

  2. Recommended dietary protein intake for a nephrotic syndrome is 1.5g/kg/day

  3. High dietary sodium intake is recommended in nephrotic syndrome

  4. Fluid restriction is not advisable if the patient is edematous

v) In nephritic syndrome recommended dietary intake of cholesterol should be >300 mg/day

vi) Patient with nephritic syndrome are advised high fat diet


Q12 For individuals with chronic renal failure (CRF, GFR<25ml/min) who are not undergoing maintenance dialysis carefully planned dietary regime may prevent onset of uremic symptoms.

  1. High protein diet providing 1.0 g/kg/protein should be considered for patients suffering from CRF as this will help in preserving glomerular filtration rate (GFR).

  2. Low - calorie diet providing 18 to 20 kcalories/kg/day is advisable for maintaining good nutritional status.

  3. Fluid intake should be restricted to 24 hour urine output plus 500 ml for insensible losses.

  4. Phosphate binders should be discontinued in CKD stage 5.

  5. Use of alpha keto-analogues should be encouraged in patients who have protein-energy-wasting.


Q13 Successful transplantation of a kidney restores near normal renal function and is expected to correct nutritional abnormalities arising from renal insufficiency.

  1. Drug induced obesity, hyperlipidemia and diabetes are major concerns after renal transplant

  2. First month after transplantation protein intake should be 1.3 to 1.5 g/kg/day with 30 to 35 kilocalories/ kg/d of energy intake

  3. After first month protein intake should be increased to 2.0 gl/kg /d and energy intake should be 40 kcal/kg/d

  4. After three months of transplantation calcium supplements should be stopped and diet providing high salt (15g/d), high potassium and high cholesterol should be recommended.

  5. In up to 25 % of cyclosporine treated recipients of renal transplant hypomagnesemia develops.

Q14 Nutritional management for acute kidney injury (AKI) is more complicated because the regimen has to devised keeping in view of complex alterations in metabolic and nutrient balances that occur with acute loss of kidney function.

  1. Major problem in management of AKI is retention of water and products of amino acids because of impaired excretory functions which restricts administration of fluid and electrolytes.

  2. Goals of nutritional support in AKI are To prevent protein–energy wasting and to preserve lean body mass, nutritional status and to avoid further metabolic derangements

  3. Nutritional support should improve wound healing and support immune function

  4. Nutritional support should minimize inflammation and improve antioxidant activity and endothelial function in AKI.

  5. Nutritional support in AKI should provide high protein (1.5g/kg/d) and high calories (35kcalories/ kg/d)


Q15 In acute kidney injury (AKI), abnormal plasma amino acid pattern, increased levels of non- essential amino acid and reduced essential amino acid cause malnutrition. Other causes of malnutrition (protein catabolism) in AKI include

  1. Inflammation

  2. Acidosis

  3. Acute phase reaction- systemic inflammatory responses syndrome (activation of cytokine network)

  4. Protein losses (peritoneal dialysis (PD))and amino acid losses (hemodialysis (HD) and peritoneal dialysis), catabolism associated with HD and PD and catabolism associated with dialyzer incompatibility

  5. Decreased glucagon levels, decreased cortisol, decreased parathyroid hormone (PTH), and decreased proteases.


Q16 A 40 year old male with chronic kidney disease, diabetes and hypertension, serum creatinine

3.6 mg/dL, serum albumin 2.9 g/dL and 4+ proteinuria presents with anorexia, and generalized edema. Nutritional management will include

  1. protein intake less than 0.6g/kg/d

  2. protein intake to 1.2 g/kg/d

  3. Advise protein intake 0.6 g/kg/d plus 1 g of protein lost in urine

  4. Advise oral supplement if dietary intake is <20kcal/kg/d

  5. prescribe loop diuretic 40 mg twice a day


Q17 A 6 year old child presents with edema, 4 g proteinuria, cholesterol 300mg/dL and blood pressure 130/90 mmHg. Management will include

  1. A liberal fluid intake

  2. protein intake to recommended dietary allowance for chronological age

  3. Restrict salt to less <2 g/d

  4. Advise dietary cholesterol 300 mg/d

  5. Restrict protein intake

Q18 Eight years old child presents with facial puffiness, pedal edema, short stature and blood pressure 128/95 and 4+ proteinuria. Management will include

  1. no antihypertensive medication as blood pressure is normal for age

  2. 4.0g sodium/d

  3. Fat intake more than 60g/d to improve calorie intake

  4. Restrict fat intake and fluid intake

  5. protein intake according to recommended dietary allowance for chronological age


Q19 Eightyearsoldpostrenaltransplantpatientontrippleimmunosuppressionwysolone, tacrolimus and cellcept, serum creatinine of 0.8mg/dL, blood pressure 110/70 mmHg, and hemoglobin of 12.5g/dL and serum albumin 3.5g/dL, serum calcium 6.0mg/dL and pedal edema. Management will include

  1. protein intake 0.8g/kg/d

  2. restrict dietary calcium intake

  3. increase fluid intake

  4. advise grape fruit juice

  5. Restrict fluid intake


Q20 Thirty two years old male presents with bilateral small sized kidney, with facial puffiness, generalized weakness, pedal edema, decreased urine output, blood pressure 140/95, serum creatinine 4.3, serum calcium 6.4 mg/dL, serum phosphate 5.8 mgdL and 4+ proteniria.

Management will include

  1. Fluid restriction according to 24 hour urine output

  2. Advise intake of 6g of sodium

  3. Protein intake should be 0.6g/kg/d

  4. Correct serum calcium with calcium supplement taken with meals

  5. Advise calcium supplements between two meals or on empty stomach and non calcium based phosphate binder with meals


Q21 A 20 years old female presents with post partum acute kidney injury. She is edematous, oliguric with serum creatinine of 7.9mg/dL, blood pressure 135/90 mmHg, hemoglobin of 6.5g/Dl, serum albumin 3.2g/dL and serum calcium 6.6.mg/dL . Management will include

  1. Liberal fluid intake

  2. Increase protein intake to 1.3-1.5g/kg/d

  3. Restrict protein intake to 0.6g/kg/d

  4. Give blood transfusion to correct anemia

  5. Recommend oral protein supplement and intradialytic parenteral nutrition

Q22 Forty seven years old post renal transplant patient presents with severe pain abdomen, diarrhea, high grade fever, raised amylase and lipase, rise in serum creatinine from 1.6 mg/dL to 2.5 mg/ dL, hemoglobin 13.5/dL , and serum sodium 129 mg/dL serum potassium 2.9 g/dL. Urine output is 3000ml. Management will include

  1. oral protein supplements

  2. Stop oral feeds

  3. Administer intravenous fluids

  4. provide parenteral nutrition

  5. supplement potassium chloride and sodium


Q23 Forty six years old post renal transplant patient with chronic allograft nephropathy on tripple immunosuppressive medication has serum creatinine of 3.6mg/dL, blood pressure 140/90 mmHg, and hemoglobin 11.0g/Dl, serum albumin 3.5g/dL and serum potassium 5.0mg/dL .

Management will be

  1. Restrict protein intake to 0.6g/kg/d

  2. Increase protein intake to 1.2 g/kg/d

  3. Restrict fluid intake according to thirst

  4. Restrict fruits, fruit juices and vegetable soups

  5. Target blood pressure below 120/80mmHg


Q24 Fifty years old male with end stage kidney disease on continuous ambulatory peritoneal dialysis (CAPD) on two 2.5 % and one 1.5 % exchanges, presents with body weight 55 kg, generalized edema, mild abdominal pain, high grade fever, loose stools, loss of appetite, rise in creatinine from 7.2 to 12.9 mg/dL, blood pressure 110/70 mmHg, hemoglobin of 10.5g/dL and serum albumin 2.8g/dL and serum calcium 7.0mg/dL . Management will include

  1. High protein diet 1.3-1.5g/kg/d

  2. Advise 0.8g /kg/d protein intake

  3. Advise oral nutritional supplements

  4. Advise liberal intake of fluid

  5. Few hemodialysis sessions to bring down serum creatinine and to provide intradialytic parenteral nutrition to improve nutritional status


Q25 Young children suffering from end-stage-renal disease on maintenance dialysis

  1. Should be advised protein according recommended dietary allowances for age plus extra protein for losses due to dialysis

  2. Protein loss is inversely proportional to body size

  3. Salt intake should not be restricted

  4. Recombinant human growth hormone therapy should be considered if growth is stunted

  5. Supplement zinc, selenium and water soluble vitamins if dietary intake is below recommended allowance.

Q26 A 30 years old pregnant female presents with diabetic nephropathy. Her blood pressure is 140/90, serum creatinine is 1.6g/dL, and she has poor glycemic control. Management will include

  1. control blood pressure with ACE inhibitors

  2. Target HBA1c should be HbA1c as close to normal as possible (<1% above upper limit of normal)

  3. Advise protein 1.0-1.2g/kg preconception bodyweight/d

  4. Advise liberal intake of fruit juices

  5. Advise high intake of salt


Q27 Following is advisable to maintain nutritional status of end stage renal disease patients on maintenance dialysis

  1. Serum albumin 4g/dL

  2. Serum pre albumin 30mg/dL

  3. Serum bicarbonate level should be maintained at 16 mmol/L

  4. Subjective global assessment scores can be used for evaluation of nutritional status

  5. Energy intake of 20kcal/kg/d


Q28 In patients with chronic kidney disease measures to control hypertension include

  1. Restrict Na to <2.0g/d

  2. Restrict fat to <20g/d

  3. Increase fiber intake to 20-25g/d

  4. Target blood pressure in CKD stages 1-4 should be < 160/90 mmHg.

  5. Use ACE inhibitor or an ARB, in combination with a diuretic.


Q29 Patients who use diet alone to control blood glucose levels (that is patients on fixed dose of insulin or oral hypoglycemic medications, low literacy) emphasis should be placed on

  1. Keeping amount of CHO relatively constant for each meal

  2. Must not have regular meal time

  3. Insulin dose should be adjusted around constant CHO intake rather than CHO being altered to meet insulin regimen.

  4. Patients with decreased kidney function (CKD stages 3 to 5) have increased risks for hypoglycemia

  5. Target HbA1c should be < 7.0%, irrespective of the presence or absence of CKD.


Q30 Protein energy wasting in chronic kidney disease is caused by

  1. Metabolic acidosis

  2. Reduced nutrient intake

  3. Increased serum albumin level

  4. Uremia

  5. Absence of inflammation

Q31 Daily dietary allowance for patients on twice weekly or thrice weekly maintenance hemodialysis should be

  1. Protein intake should be 1.2.g/kg/d

  2. Energy intake should be 20 kcal/kg/day

iii) Cholesterol intake should be >400mg/day

  1. Phosphorus intake should be 800-1000mg/day

  2. Calcium intake should be between 1500-2000mg/day


Q32 A 38 year old female with chronic kidney disease, diabetes and hypertension, and polyarthritis serum creatinine 4.0 mg/dL , serum albumin 2.9 g/dL and 4+ proteinura presents with anorexia, and generalized edema. Nutritional management will include

  1. Protein intake less than 0.6g/kg/d

  2. Protein intake to 1.2 g/kg/d

  3. Advise protein intake 0.6 g/kg/d plus 1 g of protein lost in urine

  4. Advise oral supplement if energy intake is <20kcal/kg/d

  5. Advise loop diuretic 40 mg twice a day


Q33 A 6 year old child presents with edema, 4 g proteinuria, cholesterol 300mg/dL and blood pressure 130/90 mmHg. Management will include

  1. Liberal fluid intake

  2. Advise one egg yolk daily

  3. Restrict salt to less <2 g/d

  4. Advise dietary cholesterol 300 mg/d

  5. Restrict protein intake


Q34 A 7 year old child presents with facial puffiness, pedal edema, short stature and blood pressure 128/95 and 4+ protenuria. Management will include

  1. No antihypertensive medication as blood pressure is normal for age

  2. Advise liberal intake of salt to loose weight

  3. Restrict protein to 0.4 g/kg/d

  4. Restrict fat intake and fluid intake

  5. Advise protein intake according to recommended dietary allowance for chronological age

Q35 An 8 years old post renal transplant patient on tripple immunosuppression wysolone, tacrolimus and cellcept, serum creatinine of 0.8mg/dL, blood pressure 110/70 mmHg, and hemoglobin of 12.5g/dL and serum albumin 3.5g/dL, serum calcium 6.0mg/dL and pedal edema. Management will include

  1. Protein intake 0.8g/kg/d

  2. Restrict dietary calcium intake

  3. Increase fluid intake

  4. Advise grape fruit juice

  5. fluid intake


Q36 30 years old male presents with bilateral small sized kidney, facial puffiness, generalized weakness, pedal edema, decreased urine output, blood pressure 140/95, serum creatinine 4.3 mg%, serum calcium 6.4 mg/dL, serum phosphate 5.8 mgdL and 4+ protenuria. Management will include

  1. Fluid restriction according to 24 hour urine output

  2. Advise intake of 6g of sodium

  3. Protein intake should be 0.6g/kg/d

  4. Correct serum calcium with calcium supplement taken with meals

v) Advise >2000 mg of calcium


Q37 A nondiabetic 30 years old female presents with acute kidney injury. She is edematous, oliguric with serum creatinine of 14.0 mg/dL, blood pressure 135/90 mmHg, hemoglobin of 4.5g/Dl, serum albumin 3.2g/dL and serum calcium 6.6.mg/dL . Management will include

  1. Dialysis treatment

  2. Increase protein intake to 1.3-1.5g/kg/d

  3. Restrict protein intake to 0.3g/kg/d

  4. Intradialytic perenteral nutrition

  5. Correct anemia with blood transfusion


Q38 A 25 years old post renal transplant patient presents with severe pain abdomen, high grade fever, raised amylase and lipase, rise in serum creatinine from 1.6 mg/dL to 2.5 mg/dL, hemoglobin 13.5/dL , and serum sodium 129 mg/dL serum potassium 2.9 g/dL, serum calcium 5.5 mg, serum albumin 3.9 g/dL. Urine output is 3000ml. Management will include

  1. Oral protein supplements for first three days

  2. Stop oral feeds

  3. Administer intravenous fluids for nutrition

  4. Monitor blood glucose

  5. Supplement potassium chloride and sodium

Q39 46 years old post renal transplant patient with chronic allograft nephropathy on tripple immunosuppressive medication has serum creatinine of 3.6mg/dL, proteinuria 4+, blood pressure 140/90 mmHg, and hemoglobin 11.0g/Dl, serum albumin 3.5g/dL and serum potassium 5.0mg/dL . Management will be

  1. Restrict protein intake to 0.6g/kg/d plus 1 gram for each gram of protein lost in the urine

  2. Increase protein intake to 1.2 g/kg/d

  3. Restrict fluid intake according to thirst

  4. Advise fruits, fruit juices and vegetable soups

  5. Increase dose of ACEi/ARB’s


Q40 A 25 yearsoldfemaleoncontinuousambulatoryperitonealdialysis(CAPD) presents, generalized edema, loss of appetite, rise in creatinine from 7.2 to 12.9 mg/dL, blood pressure 110/70 mmHg, hemoglobin of 10.5g/dL and serum albumin 2.2g/dL . Management will include

  1. Advise 0.8g /kg/d protein intake

  2. High protein diet 1.2g/kg/d

  3. High protein diet 1.3g/kg/d

  4. Advise oral nutritional supplements

  5. Advise hemodialysis twice weekly along with CAPD


Q41 Chronic kidney disease is usually associated with

  1. Inflammation

  2. High IL6 levels

  3. Leptin levels are unaffected

  4. Synthesis of albumin can be impaired


Q42 A 19 years old female with six months of gestation presents with drop in urine output, pressure is 198/100 mmHG, serum creatinine 4.6g/dL, and blood glucose >470 mg/dL. Management will include

  1. Control blood pressure with ACE inhibitors

  2. Advise her to continue pregnancy

  3. Advise 1.0 g/kg/d protein

  4. Advise liberal intake of fruit juices

  5. Advise high intake of salt

Q43 Preservation of nutritional status is an important aspect of treatment of CKD.

  1. Its not true

  2. Nutrition is not important for kidney patients

  3. Sodium potassium and 25% dextrose are not supplemented to kidney patients even if they are deficient in electrolytes and are not eating.

  4. Metabolic acidosis effects nutritional status

  5. Subjective global assessment scores should be repeated every fortnight

  6. Energy intake of 20kcal/kg/d is sufficient for CKD patients


Q44 In patients with chronic kidney disease dietary measures to control hyperkalemia include

  1. Restrict dietary potassium

  2. Advise fruit juice and vegetable soup

  3. Increase fruit intake

  4. Advise potassium binding resins


Q45 To control blood glucose levels (that is patients on fixed dose of insulin or oral hypoglycemic medications, low literacy) emphasis should be placed on

  1. Small but frequent meals

  2. Must not have regular meal time

  3. Increase intake of fiber

  4. Advise patients to take foods with low glycemic index GI


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Score Card

Excellent >25

Good 20-24

Average 11- 19

Poor <10


Dr Anita Saxena

Editor