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DRY EYE: EMERGING OPHTHALMIC PROBLEM

DR. M. R. JAIN M.S, FICS ( USA), FACLP ( London ) FAMS
MEDICAL DIRECTOR
M. R. J INSTITUTE AND JAIN EYE HOSPITAL, JAIPUR

Dry eye is the most frequent disorder in Ophthalmology. Fortunately, only infrequently it becomes the most severe. Although the condition was recognized as a clinical disorder in the year 1920 and described clinically in the early 1930’s, the greatest amount of information both from an epidemiological and pathogenetic perspective has accrued during the last ten years.

What is dry eye?

Dry eye is a disorder of the preocular tearfilm that results in damage to the ocular surface and is associated with symptoms of ocular discomfort. Dry eye is characterized by instability of the tearfilm that can be due to insufficient amount of tear production or due to poor quality of tearfilm, which results in increased evaporation of the tears.
Dry eye therefore can be divided in two groups, namely
1. Aqueous production deficient
2. Evaporative

Prevalence of dry eye.

No authentic prevalence survey has been conducted in India but it is noted that out of the patients above the age of 30 years attending the outdoor, one out of every five has a complaint pertaining to dry eye. A recent survey conducted in year 2002, based upon a well – characterized population of adult men and women in the USA, identified a prevalence of 6.7 percent in women over the age of 50 and 2.3 % in men over the age of 55.These rates extrapolate to potentially 9.1 million dry eye patients in USA alone.
In women at the age of 50-52 when menopause usually sets in, an imbalance occurs between the oestrogen and androgen hormone due to decrease of androgens after the menopause. Decrease in androgen levels, excites inflammation in lacrimal gland and ocular surface, disrupting the normal homeostatic maintenance of the lacrimal gland and ocular surface.
The factors which has increased the incidence of dry eye can be narrated as under
a. increasing longitivity of the population
b.increased consumption of medication, both systemically and topically which have adverse effect on the production of high quality of tears
c. increased computer use
d. increased contact lens use and cosmetic surgery of LASIK/ LASEK
e better understanding and diagnosis of dry eye.
f possibly, adulteration in the food?

Pathogenesis of Dry Eye

It is an established fact that any lacrimal gland damage would result in decreased tear flow. This leads to decreased washout of the tear surface debris and bacterias as well as increased presence of inflammatory cytokines and decreased growth factors to maintain ocular surface integrity.
Almost all tear flow is due to a reflex mechanism due to stimuli from cornea sending impulses to the brain and to the lacrimal gland. Any thing which disturbs corneal sensations like hormonal imbalance, contact lenses, LASIK surgery or any other trauma to the eye, may it be surgical or accidental.

The aqueous deficient dry eye (keratoconjunctivitis sicca) is a disturbance of the neuro-humoral interaction of the ocular surface which interrupt secretomotor nerve impulses to the lacrimal gland that results in inflammatory suppression of aqueous secretion, a necessary component of the tearfilm, with subsequent damage to the ocular surface, producing symptoms of ocular irritation and discomfort. The evaporative dry eye is a disturbance of the stability of the tearfilm, which is usually due to abnormalities of Meibomian gland secretion or abnormal eyelid position and movement. Both types of dry eye results in damage to the ocular surface and symptoms of ocular discomfort and impaired visual function.

Tear Film
It comprises of three layers
Outer Lipid layer
It is formed by the oily secretion of Meibomian glands. It acts as a lubricant and prevent evaporation of tears.
Middle Aqueous Layer
It is the main tear fluid liberated from lacrimal gland and Accessory glands. It contains proteins, immunoglobulins, lysozyme, lactoferin and betalycin. It provides moisture to the eye, nutrition to the cornea and antibacterial activity. It provides the epithelial cells with glucose, oxygen and growth factors. It flushes out the debris and organisms from the corneal surface and drains into nasolacrimal canal.
Inner Mucous Layer
The innermost mucous layer of the tear film forms a highly hydrophilic wetting surface over the hydrophobic epithelial surface of the cornea and conjunctiva. The mucous also reduces the surface tension between the lipid layer of the tear film and the water layer, thus contributing to the stability of the tear film.

Classification Based On Etiology

1. Age Related. Lacrimal secretion begins to decrease after the age of 30 years. At the age of 6o, we reach the borderline between the production and need. At the age of 90, almost all persons have dry eye.
2. Hormonal. At the age of menopause almost every women develops dry eye either mild or moderate. Recent research has shown that it is due to lowering of androgen levels produced by the ovaries. Men develop dry eye related to hormones with less frequency and intensity than women.
3. Pharmacological. There is adverse effect on production of tears due to preservatives in teardrops used for long period. Glaucoma patients are more prone to this problem due to prolonged therapy.
Systemic drugs like antidepressants, antihypertensives, antihistaminics, anticholinergics, antipsychotics, angiolytics, antiparkinsonians, diuretics and hormones too can cause dry eye.

4. Immunological: This is related to autoimmune reaction in exocrine glands affecting outside body secretion like secretion of tears, saliva, sweat and vaginal secretions. The Sjogren’s syndromes are those in which patient’s immunological system attacks its own exocrine glands. Rheumatism, cicatricial pemphigoid and erythema multiform can lead to Sjogren’s syndrome.
5. Infection. Chronic infection of conjunctiva can affect mucous secretion leading to mucin deficiency and infection of lacrimal glands can affect aqueous secretion. Inflammation of lids may affect oily secretion. Any of the component if affected, tearfilm is disturbed.
6. Hypo nutrition. Avitaminosis A, and alcoholism that leads to poor intestinal absorption may give rise to dry eye.
7. Traumatic: Any trauma to the eye may it be accidental or surgical, can precipitate dry eye. Major surgeries like removal of tumour etc has more chances to cause dry eye. Cataract or glaucoma surgery too can be responsible especially in older persons.
8. Neurological.
a. Post LASIK. Lasik leads to the development of temporary dry eye in about 4 percent of patients. The Lasik induced dry eye tends to resolve approximately within 6 months.

b. Contact lens wear. Contact lenses when worn for prolonged period, affect corneal sensations and hence decrease tear secretion.
9. Defective glands. Responsible for aqueous, mucin and lipid secretions.
10. Inability to utilize tears. There is normal production of tears but cornea is unable to use them due to:
a. Epitheliopathy or corneal dystrophy, which decreases corneal, wet ability.
b. Due to lipid defect the lids are unable to circulate the tears over the entire ocular surface (lid paralysis, ectropion, lagophthalmos)
Symptoms
Dry eye patient can present any one of them or multiple symptoms:
Itching, burning, irritation, pain, discomfort. There may be pain and photophobia and blurred vision that improves with blinking. There is usually stringy ropy mucous discharge, which can increase in the afternoon. The discomfort in the eye usually increases while reading, watching T.V or working on the computer. At times there may be excess of watering, specially during breeze.
All these symptoms are exaggerated during dry and windy conditions.
Some of the patients give a typical history of desire to frequently sprinkle water into the eyes.
Signs

Tear Lake. Normally at the lower lid margin there is there is concave tear meniscus of 0.3 to 0.5 mm, which is called Tear Lake. In dry eye it is usually less than 0.1mm.
Debris. There is increased debris in the decreased tear lake. Mucous threads may be seen.
Other Signs. Redundant conjunctiva, injection of the conjunctival vessels, and sometimes mild chemosis may be present. In advanced cases, the conjunctival and corneal dryness may be very evident.
Staining.

1. Fluorescein stain. Fluorescein may stain any denuded area of corneal epithelium. The reduced tear lake could easily be appreciated with fluorescein.
2. Rose Bengal Stain. Rose Bengal (solution 1 % or strip) stains the damaged devitalized epithelial cells of the conjunctiva and cornea. It can detect even mild cases of Keratoconjunctivis Sicca (KCS) by staining the palpabral conjunctiva in the form of two triangles with their base towards limbus..
Tear Film Break Up Time. (TBUT)
It is a quantative measurement of tear film stability. A mucous deficiency results in beading of the aqueous tear around the small amount of available mucous on the epithelial surface and reduction of TBUT.
Diagnosis.

Diagnosis is most often based on the complaint of the patient without any evident cause in the eye. Quite often, persistent fishing for ropy mucous discharge is very classical and so is the importance of the complaint of increased discomfort in dry and windy environment.
Diagnostic tests mostly employed are as under
a. Shirmer Test. The test is used to quantitatively measure the tear secretions by the lacrimal gland, and should be done before any other examination as the manipulation of the eyelid and eye can alter the results of the test.
Shirmer I Test. Is used to measure tear secretion rate without anesthesia.
Shirmer II Test is done similar to Shirmer one but after instillation of anesthetic drops.
Other employed tests are :
a. Tear Function Index (TFI)
b. Fluophotometery.
c. Tear Osmolarity.
Treatment

Conservative
1. Patient Information. Patient must be educated and fully informed about the disease as well as he must be explained the limitations of medical management. This maintains the patient’s confidence in your line of treatment.
2. Controlling the surroundings. Special stress must be put to control the surroundings to minimize the severity of the condition.
a. Still Air. Patient must avoid sitting facing direct flow of air from air conditioners, ventilators, windows or fans. It is better that patient avoid sitting in front of door in a room. While driving car, the car window must be closed and the patient should use glasses. Car A.C. wind should not blow directly on the face.
b. Humid Air. Even if there is no refractive error, patient must wear glasses. Just by wearing spectacles, the humidity between the eyes and the spectacles rises by 2 %. Spectacles with side panels and moist chamber may be reserved for more severe cases. Humidifiers must be used in the rooms. There are air-conditioners available with attached humidifiers.
Special glasses with moist inserts ameliorate severe dry eye symptoms. The moist inserts on the side panels increase the ambient humidity, resulting in a decrease in the tear evaporation from the ocular surface. Another type of moist chamber is obtained more easily and less expensively by using swimming goggles. The most favorable range of relative humidity for minimizing tear evaporation is reported to be 40% to 50 %. Wet gauze mask is an alternative treatment modality.
c. Pure Air. Polluted air is very harmful for dry eye patients. Palpabral aperture must remain open as little as possible. Closed window in the car, helmet with a shield while driving scooter and covering your eyes with goggles while driving bicycle gives some relief. While reading books, the book should be kept as close to chest as possible so as to have minimum palpabral aperture. While looking down, ocular surface exposed to the air is just 1 square centimeter, whereas while looking straight, 2.0 sq. cm. and while looking up, 3,0 sq. cm.
Computer Vision Syndrome. While looking at the monitor, the eyes have the tendency to stare at the screen thereby reducing the blink to about 6-7 blinks a minute. If the computer is at a higher level than the eye, there is further increased evaporation of tears. To avoid computer vision syndrome, one must keep the computer at the lower level than the eyes and a habit must be formed to blink about 10-12 times per minute. When working for long period, one must close the eyes for some time or use some artificial teardrops.

Medical Management

Tear Substitutes.

Tear substitutes are the mainstay in the medical management of dry eye. Variety of tear substitutes is available. Hypotonic non-viscous solutions counteract the hyper tonicity in dry eye syndrome and can last up to two hours. Viscous solution contains cellulose as their base and thus last longer. Preservatives are added to increase the shelf life and the stability of the solution. The commonly used preservatives include benzalkonium chloride, thimerosal, and chlorhexidine. In spite of their low concentration, they can produce toxic effect on the cornea and conjunctiva and adversely affect the dry eye condition.

THE use of unpreserved collyria, and more recently preservatives that are transient or which rapidly oxidize to non-toxic compounds upon exposure to air and the ocular surface, has become routine for those patients requiring more than three or four lubricant drops per day. The tear supplements have focused on maintaining a hypotonic collyrium with normalization of electrolyte concentration to combat the damaging effects of hyper tonicity.

In India, preservative free tear substitutes used are :

Refresh Tear Drops (Allergan),
Gen Teal drops (Novartis) ,
Eye Mist Drops (Avesta) ,
Tear Drops (Milmet)
Celluvisc 1 % (Allergan)
Refresh Liquigel (Allergan)
Tear substitutes are instilled in the eyes 3- 6 times a day
depending on the severity of the condition. If necessary, Refresh
Liquigel or Celluvisc is instilled at bedtime.
Androgens

Role of androgen as a therapy is yet not well established though it is known that in females, lack of Androgens play important role in its etiology.
Topically, androgenic supplementation of artificial tears, appears to lower the Osmolarity of patient’s tears either by retarding evaporation or possibly stimulating tear secretion.

Tear Stimulants
Tear stimulants have as yet not proved very useful.
Recent trials with purinergic P2Y2 agonist has reached phase three trial in USA. The medication designated diquafosol tetrasodium (Inspire Pharmaceuticals, USA) has been extremely well tolerated and increases tear film volume and mucin content. The pharmacological action is to increase fluid transport across the conjunctiva and stimulate mucin release from goblet cells.

Cyclosporine A

Looking to the immunological aspect of the disease, cyclosporin A in the form of topical drops (0.005 %) is being used in moderate to severe form of DES to treat inflammation of the ocular surface and lacrimal gland. The drops are instilled twice a day and the beneficial results are observed within four to six months. The drug may have to be used for whole life. Cyclomune is an immunomodulator. It selectively suppresses lymphocytic functions involved in a disease without actually suppressing the entire immune system. It inhibits T helper cells that are known to cause inflammation of the ocular surface and lacrimal glands in patients with dry eye. The main indication for the use of Cyclomune is surface staining of the cornea. Instillation of drops is associated with stinging sensations, which gradually decrease.
Cyclosporine drops are marketed by Allergan as Restasis in USA and by Avesta in India as Cyclomune

Meibomitis.
A recent study in USA has shown that about 38 % patients with dry eye has concurrent Meibomian gland involvement. Hot wet compresses, betadain scrub, eyelid massage and oral tetracycline or doxycycline, may treat Meibomian inflammation.

Topical Steroids (Soft steroids)

Topical steroids are being tried in some of the resistant or advanced cases of dry eye or in patients who have severe itching. Lodeprednol etabonate 0.2 % is a good choice for long-term use. It is soft steroid that is activated by enzymes as it passes through the cornea. It seems to have very little effect on IOP. It is marketed as Alrex by Bausch & Lomb
Mucolytics.
Topical 5 percent Acetylcysteine drops are recommended for instillation four times a day. It is effective in eyes with excessive mucous.
Future Therapies.
Apart from tear substitutes, anti-inflammatory therapy, androgen hormone replacement, and tear stimulant diquafosol tetrasodium may form main therapeutic measures. Herbal supplements such as oil of primrose and flax seed oil are reported to be help in relieving symptoms of dry eye and Meibomitis. Essential fatty acids of omega 3 and specially omega 6 category as food supplements are showing some promising results.
Surgical Management

A. Canalicular Obstruction by Punctal Plugs
It is a simple procedure that decreases the tear drainage markedly and improves the qualitative and quantitative component of tears. A decrease in osmolarity of the tears is noted. Improvement can be seen by Schirmer and TBUT test.
B. Punctal Patch Technique This is most efficacious surgical technique for long lasting occlusion of the lacrimal drainage system. In this technique a raw area is created surrounding upper and lower puncta. A piece of bulbar conjunctiva is taken and transplanted to the punctal wound with its raw surface in contact with the lid and sutured to it with four 9. 0 stitches.
Summary

Dry eye disease appears to be on increase due to multiple factors. Inspite of great advance in understanding and diagnosing the disease, the disease remains a challenge to medical profession. Preservative free drops have significantly improved the quality of life of dry eye patients. Anti-inflammatory therapy, androgen hormones and tear stimulant, namely, diquafosol tetrasodium and probably some herbal drugs hold great hope for a DES patient.

YOGIC DIET: HEALTHY EATING

World Now Knows: Vegetarian Food Is Ideal and The Best




Healthy eating is not about strict nutrition philosophies, staying unrealistically thin with zero figures or depriving yourself of the foods you relish... Rather, it’s about feeling great, having more energy, and keeping yourself as healthy as possible – all which can be achieved by learning some nutrition basics and incorporating them in a way that works for you.
Choose the types of foods that improve your health and avoid the types of foods that raise your risk for such illnesses as hypertension, heart disease, diabetes and cancer, and Obesity. Expand your range of healthy choices to include a variety of delicious foods. We need more than 40 different nutrients for good health and no single food can supply them all. That's why consumption of a wide variety of foods is necessary for good health and any food can be enjoyed as part of a healthy diet. Some studies have linked dietary variety with longevity. In any event, choosing a variety of foods adds to the enjoyment of meals and snacks. Learn to use guidelines and tips for creating and maintaining a satisfying, healthy diet.

Basic principles

Eat enough calories but not too many. Maintain a balance between your calorie intake and calorie expenditure—that is, don't eat more food than your body uses. The average recommended daily allowance is 2,000 calories, but this depends on your age, sex, height, weight, and physical activity.
Eat a wide variety of foods. Healthy eating is an opportunity to expand your range of choices by trying foods—especially vegetables, whole grains, or fruits—that you don't normally eat.
Keep portions moderate, especially high-calorie foods. In recent years serving sizes have ballooned, particularly in restaurants. Choose a starter instead of an entrée, split a dish with a friend, and don’t order supersized anything.
Eat plenty of fruits, vegetables, grains, and legumes—foods high in complex carbohydrates, fiber, vitamins, and minerals, low in fat, and free of cholesterol. Try to get fresh, local produce
Limit sugary foods, salt, and refined-grain products. Sugar is added to a vast array of foods. In a year, just one daily 12-ounce can of soda (160 calories) can increase your weight by 16 pounds. See suggestions below for limiting salt and substituting whole grains for refined grains.
Don’t be too fussy. You can enjoy your favorite sweets and fried foods in moderation, as long as they are an occasional part of your overall healthy diet. Food is a great source of pleasure, and pleasure is good for the heart. Limit your intake wherever you can and balance your diet.
Be physically active and spend energy. A healthy diet improves your energy and feelings of well-being while reducing your risk of many diseases. Adding regular physical activity and exercise will make any healthy eating plan work even better.
How to eat
Healthy eating begins with learning how to “eat smart”. It's not just what you eat, but how you eat. Paying attention to what you eat and choosing foods that are both nourishing and enjoyable helps support an overall healthy diet.
• Take time to chew your food: Chew your food slowly to make it digestible. Never gulp or be in hurry to eat.
• Avoid stress while eating: When we are stressed, our digestion can be compromised, causing problems like colitis and heartburn. Avoid eating while working, driving, arguing, or watching TV (especially disturbing programs or the news). Talk some thing interesting and try to sit with your family and friends when you eat.
• Listen to your body: Ask yourself if you are really hungry, and stop eating when you feel full. It actually takes a few minutes for your brain to tell your body that it has had enough food, so eat slowly. Eating just enough to satisfy your hunger will help you remain alert, relaxed and feeling your best, rather than stuffing yourself into a “food coma”! It is always better to eat little less than what gives you feeling of fullness. Hot food is always better- more digestible, more satisfying.
• Eat early, eat often: Starting your day with a healthy fulsome breakfast can jumpstart your metabolism, and eating the majority of your daily caloric allotment early in the day gives your body time to work those calories off. Also, eating small, healthy meals throughout the day, rather than the standard three large meals, can help keep your metabolism going and ward off snack attacks. Diabetic patients must essentially eat small but frequently.

Healthy Eating:
Locally-grown food is fresher than what you'll find in the supermarket, which means that is tastier and more nutritious. And since the food travels a shorter distance to get to you, it is better for the environment and helps us reduce our dependence on foreign oil. Buying local food also supports your local economy. T
Balanced Food
Despite what certain fad diets would have you believe, we all need a balance of carbohydrates, protein, fat, fiber and vitamins to sustain a healthy body. But what are good carb, protein, and fat choices for developing your own healthy eating plan?
Carbohydrates
Carbohydrates – food composed of some combination of starches, sugar and fiber - provide the body with fuel it needs for physical activity by breaking down into glucose, a type of sugar our cells use as a universal energy source.
• Bad carbs are foods that have been “stripped” or processed in order to make cooking fast and easy, like white flour (maida), refined sugar, and white rice. They digest so quickly that they cause dramatic elevations in blood sugar, which can lead to weight gain and harmful to diabetics.
• Good carbs can’t be digested easily. This keeps your blood sugar and insulin levels from rising and falling too quickly, helping you get full quicker and feel fuller longer. Good sources of carbs include whole grains, beans, fruits, and vegetables, which also offer lots of additional health benefits, including heart disease and cancer prevention.
Fiber
Dietary fiber is found in plant foods (fruit, vegetables and whole grains) and is essential for maintaining a healthy digestive system. Fiber helps support a healthy
diet by:
• Helping you feel fuller faster and longer, which can help prevent overeating.
• Keeping blood sugar levels even, by slowing digestion and absorption so that glucose (sugar) enters the bloodstream slowly and steadily.
• Maintaining a healthy colon - the simple organic acids produced when fiber is broken down in the digestive process helps to nourish the lining of the colon.
Two types of fiber are soluble and insoluble:
• Soluble fiber can dissolve in water and can also help to lower blood fats and maintain blood sugar. Primary sources are beans, fruit and oat products.
• Insoluble fiber cannot dissolve in water, so it passes directly through the digestive system. It’s found in whole grain products and vegetables.
A healthy diet should contain approximately 20 to 30 grams of fiber a day, but most of us only get about half of that amount.
Protein
During digestion, protein in food is broken down into the 20 amino acids that are the basic building blocks our bodies use to create its own protein. Our bodies need protein to maintain our cells, tissues and organs. A lack of protein in our diets can result in slow growth, reduced muscle mass, lower immunity, and weaken the heart and respiratory system. Protein gives us the energy to get up and go –and keep going.
 A complete protein source is one that provides all of the essential amino acids. Examples are animal-based foods such as meat, poultry, fish, milk, eggs, and cheese.
• An incomplete protein source is one that is low in one or more of the des the Omega-3 group of fatty acids which your body can’t make and are found in very few foods – primarily cold water fatty fish and fish oils. Foods rich in certain omega-3 fats called EPA and DHA can reduce cardiovascular disease, improve your mood and help prevent dementia. See below for more on Omega-3. Other sources of polyunsaturated fats are sunflower, corn, soybean, and flaxseed oils, and walnuts.
How much fat is too much? It depends on your lifestyle, your weight, your age and most importantly the state of your health. Recommended fat intake is:
• Keep total fat intake to 20-35% of calories
• Limit saturated fats to less than 10% of your calories (200 calories for a 2000 calorie diet)
• Limit trans fats to 1% of calories (2 grams per day for a 2000 calorie diet)
• Limit cholesterol to 300 mg per day, less if you have diabetes.
Food Pyramid
Food Pyramid gives a clear picture as to how you must balance your food to remain healthy.




Food Pyramid





Vegetables and Fruits: Vitamin, Antioxidant and fiber powerhouses


Fruits and vegetables are low in calories and are packed with vitamins, minerals, protective plant compounds and fiber. They are a great source of nutrients and vital for a healthy diet.
Fruits and vegetables should be part of every meal, and be your first choice for a snack. Eat a minimum of five portions each day. The antioxidants and other nutrients in these foods help protect against developing certain types of cancer and other diseases.
Go for the Brights: The brighter, deeper colored fruits and vegetables contain higher concentrations of vitamins, minerals and antioxidants - mustard greens, butternut squash and sweet potatoes are several excellent choices. For fruits, choose fresh or frozen, and focus on variety. Berries are cancer-fighting, apples provide fiber, oranges and mangos offer vitamin C, and so on.Tomatoes is rich in antioxidants. It contains lycopene which is extremely useful to prevent prostate cancer and Age Related Macular Degeneration of eyes. Garlic and Onion are loaded with phytochemicals, prevent cancer, decreases bad cholesterol and prevents heart diseases. Spinach is one of the most nutrient food. It is a rich source of folic acid, which helps fight cancer, heart diseases and mental disorders.Lutein, the main pigment found in spinach can protect our vision.
Avoid: Fruit juices can contain up to 10 teaspoons of sugar per cup; avoid or dilute with water. Canned fruit often contains sugary syrup, and dried fruit, while an excellent source of fiber, can be high in calories. Avoid fried curries or ones smothered in dressings or sauces – you may still get the vitamins, but you’ll be getting a lot of unhealthy fat and extra calories as well.
Whole Grains for long-lasting, healthy carbohydrate energy
In addition to being delicious and satisfying, whole grains are rich in phytochemicals and antioxidants, which help to protect against coronary heart disease, certain cancers, and diabetes. Studies have shown people who eat more whole grains tend to have a healthier heart. Make whole grains an important part of every meal.
Make sure you're really getting whole grains. The words stone-ground, multi-grain, 100% wheat, or bran, don’t necessarily mean that a product is whole grain. If there is no stamp look for the words “whole grain” or “100% whole wheat,” and check the ingredients to make sure each grain listed is specified as whole grain. Some good sources of whole grains are dark breads, whole wheat, brown rice, oatmeal, barley, millet, toasted wheat cereals.
Avoid: Refined grains such as breads, pastas, and breakfast cereals that are not whole grain. Avoid Fast foods may it be Pizza, Patties, Burger, Noodles, Magi or Pasta.
Healthy Fats and Oils to support brain and body functions
Foods rich in certain omega-3 fats called EPA and DHA can reduce cardiovascular disease, improve your mood and help prevent dementia. The best sources for the EPA and DHA omega-3 fats are fatty fish such salmon, mackerel, anchovies, sardines, and some cold water fish oil supplements. Vegetarians can have Omega-3 from foods rich in ALA fatty acids. Main sources are vegetable oils and nuts (especially walnuts), flax, soybeans, and tofu.
Proteins for Vegetarians:
Beans, nuts, nut butters, Walnuts, black beans, lentils, peas, and soy products are good sources of protein, fiber, vitamins, and minerals. Many of the foods in this group provide iron, which is better absorbed when a source of vitamin C is consumed with the meal
Avoid: Salted or sugary nuts; refried beans.
Dairy products and other sources for calcium and vitamin D
Dairy products provide a rich source of calcium, necessary for bone health. Most are fortified with vitamin D, which helps the small intestine absorb calcium. Calcium can also be found in dark green, leafy vegetables as well as in dried beans and legumes. Lemon juice when mixed with cooked vegetables, leads to better absorption of iron and prevents anemia.
Recommended calcium levels are 1000 mg per day, 1200 mg if you are over 50 years old. Take a vitamin D and calcium supplement if you don’t get enough of these nutrients from your diet. If you are Non vegetarian and a lady, be more careful about calcium deficiency.
Choose non-fat or low-fat dairy products. If you're lactose-intolerant, choose lactose-free and lower-lactose products, such as lactose free milk, hard cheeses and yogurt. Avoid full-fat dairy products. Cow’s milk is safer than the buffalo.
Be cautious about all white things: Sugar, Salt and Butter.
Soft Drinks and Sweets
Enjoy sweets as an occasional treat, but keep sugary soft drinks to a minimum – they are an easy way to pack calories and chemicals into your diet without even noticing it. Cokes & Colas must be No? No? And just because a soda is sugar-free doesn’t make it healthy. Recent studies have shown that the artificial sugar substitutes used in soft drinks may interfere with your body's natural regulation system and result in your overindulging in other sweet foods and beverages.
Salt
Limit sodium to 2,300 mg per day – the equivalent to one teaspoon of salt. Processed foods like canned soups or frozen meals can contain hidden sodium that can quickly surpass this recommended amount. Many of us are unaware of how much sodium we are consuming in one day. Remember that the normal amount of salt in food items is sufficient for the health of a person. Most of the salt that we use to garnish is extra and can be a cause of hypertension. Low salt food is always better especially in old age.
Vitamins & Supplements
Get most of your vitamins and minerals from foods, not from supplements. Supplements cannot always substitute for a healthy diet comprising of green vegetables and fruits, which supplies nutrients and other compounds besides vitamins and minerals. A well-balanced diet usually provides the right amount and type of vitamins and minerals, but young children, pregnant women, older people and individuals with specific health conditions or concerns may benefit from additional vitamins and minerals in their diet. Antioxidants namely Vit A, natural carotenoids,Vitamin C, E, B12, lysine, arginine, selenium, copper, Zink, reduced glutathione, etc are useful to combat the oxidants liberated in the body due to oxidative processes in every part of the body, specifically in the GIT tract due to consuming rich fried and non-vegetarian food.
Lutein and zeazanthine are specific antioxidants indicated in Age Related Macular Degeneration.




The yogic diet is a vegetarian one, consisting of pure, simple, natural foods which are easily digested and promote health. Simple meals aid the digestion and assimilation of foods. Nutritional requirements fall under six categories:
Protein, Carbohydrates, Minerals, Fats, Vitamins and Antioxidants
One should have reasonable knowledge of dietetics in order to balance the diet. Eating foods first-hand from nature, grown in fertile soil (preferably organic, free from chemicals and pesticides) will help ensure a better supply of these nutritional needs. Processing, refining and overcooking destroy much food value.
Many people worry about whether they are getting enough protein, but neglect other factors. The quality of the protein is more important than the quantity alone. Dairy products, legumes, nuts and beans, dry fruits etc provide vegetarians an adequate supply of quality proteins. Depending more on animal food, may provide quantitatively larger protein causing deprivation of calcium resulting in its deficiency and consequent complication i.e., osteoporosis.
We must understand that the purpose of eating is to provide us lifeforce, or Prana, the vital life energy. The Yogic Diet Mantra is ‘simple diet of natural fresh foods’.
However, the true Yogic diet is actually even more selective than this. The Yogi is concerned with the subtle effect that food has on his mind and astral body. He therefore avoids foods which are overly stimulating, preferring those which render the mind calm and the intellect sharp. One who seriously takes to the path of Yoga would avoid ingesting meats, fish, eggs, onions, garlic, coffee, tea (except herbal), alcohol and drugs. Any change in diet should be made gradually. Start by substituting larger portions of vegetables, grains, seeds and nuts until

Finally all flesh products have been completely eliminated from the diet. The Yogic diet will help you attain a high standard of health, keen intellect and serenity of mind.
Remember: Excess of even most nutritious food is bad, may it be tomatoes, cabbage, soyabeans, peanuts, fish or sprouts. Excess of tomatoes may cause urinary stones; cabbage rich in antioxidants and phytonutrients may cause iron deficiency and gastric disorders; soyabeans which is a vegetarian’s answer to animal proteins, when taken raw can cause thyroid suppression (due to goitrogens), flatulence and nausea; peanuts contain healthy fats which reduce triglycerides but they contain omega-6 fats which when taken in excess distort the omega-3 and omega-6 ratio which can facilitate Alzheimer’s, rheumatoid arthritis and diabetes; fish which are rich in omega fatty acids are known for anti-aging properties, contain methyl mercury which can cause neurological problem; and even the raw sprouts which are favourite of weight watchers and are rich in fibre and excellent source of vitamin B and C can cause digestive problems.
Know About Cholesterol and Triglyceride
Know knowledge is complete till you know something about lipids and their merits and demerits
What is Cholesterol and how much is good?
Knowledge about ideal diet is incomplete till one knows all about cholesterol.
Cholesterol has an important task in our body to carry out a variety of biological processes, but if you have too much of it in the body, it can potentially cause heart disease. It would seem that cholesterol has been demonized with good reason, yet our bodies cannot live without the soft, waxy stuff. Cholesterol is present in every cell and promotes hormone production, digestion, and the conversion of sunlight into vitamin D. Approximately 75% of the cholesterol present within the blood is produced by the liver, while the remaining cholesterol present is derived from diet.
The worst problem with high cholesterol is that you usually don't even know you have it, unless you've had your cholesterol recently tested.
There are many factors that can place you at risk for having high cholesterol, including your age, certain diseases, diet and lifestyle. Leading a sedentary lifestyle that consists of high-fat foods and no exercise or no yoga can contribute to having high cholesterol levels. Additionally, having a family history of high cholesterol, such as a parent or sibling being diagnosed with high cholesterol levels, also places you at risk of having this condition. Knowing your risks for high cholesterol can help you to address — and in some cases, correct — them by diet modification, exercise or more intensive yoga before they lead to further complications.
Cholesterol problems can affect anyone. Monitoring cholesterol levels is crucial because individuals with unhealthy cholesterol levels typically do not develop specific symptoms. High cholesterol, which is defined as a total cholesterol level greater than 240 milligrams per deciliter (mg/dL), is much more common than very low levels. The target cholesterol level for a normal, healthy adult is below 200 mg/dL, while levels between 200 mg/dL and 239 mg/dL are considered borderline high. Current guidelines recommend even lower normal levels and healthy adults must get their cholesterol levels checked at least once every two years.
Individuals with elevated total cholesterol or LDL levels have a significantly increased risk for developing heart disease, which is the number one cause of death in the world. Approximately 25.6 million adults are diagnosed with heart disease annually in USA, resulting in 650,000 deaths each year. Several tests are used to evaluate cholesterol levels in the blood. The simplest test measures total cholesterol, which is the combined levels of LDL ("bad cholesterol), HDL ("good cholesterol"), and triglycerides (the main form of body fat). A lipid profile test, which is performed after 12 hours of fasting, provides a detailed breakdown of cholesterol levels by lipid type (LDL, HDL and triglycerides).
Current healthy cholesterol level guidelines recommend:
• LDL ("bad cholesterol"): Levels below 100 mg/dL are considered healthy. Levels above 190 mg/dL are unhealthy.
• HDL ("good cholesterol"): Levels above 60 mg/dL are healthy. Levels below 40 mg/dL are unhealthy.
• Triglycerides: Levels below 150 mg/dL are healthy. Levels above 500 mg/dL are unhealthy.
HDL cholesterol -- the "good cholesterol" -- works like a cleanup crew in the bloodstream by ferrying "bad cholesterol" (LDL) to the liver for safe disposal. That means higher HDL levels are good for the heart.
Maintaining a healthy level of cholesterol is important for maintaining a healthy heart. According to the National Cholesterol Education Program (NCEP), an initiative of the National Heart, Lung, and Blood Institute, high total cholesterol levels are particularly dangerous for individuals who smoke. Additionally, individuals who are diabetic or obese, or have low HDL cholesterol, high blood pressure, or a family history of heart disease, should strive to maintain healthy cholesterol levels.
Approximately 7 in every 1,000 adults suffer from familial hypercholesterolemia, a genetic condition that can elevate cholesterol levels to two times the normal level.
In addition to lifestyle and overall health, age is also a risk factor for developing high cholesterol. Older individuals, particularly men over 45 years of age and women over 55 years of age, are more likely to see their cholesterol levels increase because their bodies are not as efficient at processing and excreting cholesterol. In fact, men with high cholesterol levels often have their first heart attack when they are between 40 to 50 years of age.
However, even young people are not immune to the dangers of high cholesterol. Researchers have found that fatty plaques of cholesterol can actually begin forming well before adulthood, leading to narrowed arteries and, potentially, a heart attack or stroke.
In most cases, changes in diet and increased exercise are the first response to lowering high cholesterol levels. The NCEP recommends getting at least 30 minutes of exercise or yoga every day. It is important to choose an activity that you will enjoy and stick with. Dancing, brisk walking, bicycling and even vigorous gardening or Yoga or anything that gets the heart rate up, can all be great ways to enjoy the time you spend exercising. If you get bored with an activity, just switch to something else. Remember, the intensity of the workout does not matter as much as the duration of the exercise you are doing. In other words, your 30+ minutes a day of Yoga or other exercise are beneficial whether you spend them jumping over hurdles or walking the dog -- so do something you will enjoy on a regular basis. In many studies, it took as little as 12 weeks to see an increase in HDL and a sharp drop in triglycerides. The most significant results in other measures, such as LDL, were seen after 20 weeks or more, when notable weight loss had occurred.
Other recommended strategies include avoiding saturated fats and cholesterol, and maintaining a healthy weight. Trans-fats (hydrogenated oils and fats), namely Dalda, vanaspati Rath etc must be totally avoided.Trans fats are used in fast foods. Authors League (HEAL) in 2007 found that the trans-fatty acids in French fries is 4.2% - 6.1%, it is 9.5% in bhatura, 7.8% in parantha and 7.6% each in puri and tikkis. It is predicted that by 2010, 60 percent of world’s heart patients shall be in India. Obesity often leads to elevated total cholesterol levels because excess body fat can increase the concentration of cholesterol and triglycerides within the blood.
Foods that have been shown to reduce cholesterol include fish, walnuts and other nuts, oatmeal, psyllium (and other soluble fibers) and foods fortified with plant sterols or stanols. Foods to avoid if you have high cholesterol levels include white bread, white potatoes, and white rice, whole-fat dairy products, and any highly processed sugars or flours.
However, if lifestyle changes alone are not effective, your doctor may prescribe a particular class of drugs known as statins, which help reduce LDL and triglyceride levels and increase HDL levels. Statins, the most widely prescribed class of cholesterol-lowering drugs, act by by inhibiting cholesterol production within the liver. Your doctor may prescribe one of many available statin medications: Lipitor (atorvastatin), Zocor (simvastatin), Mevacor (lovastatin), Lescol (fluvastatin), Crestor (rosuvastatin) or Pravachol (pravastatin).





Eat To live. Not Live To Eat and Be Your Own Enemy

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