BSc Clinical Nutrition Dietetics 2nd year syllabus Manipal MAHE MCHP curriculum

MAHE Manipal College of Health Professions BSc Clinical Nutrition Dietetics subjects semester 3 4

https://collegedunia.com/university/25617-manipal-academy-of…

mkdir -p /home/daytona/workspace/study-guide && ls /home/daytona/workspace/

~/study-guide/build_guide.py

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import ListFlowable, ListItem

OUTPUT = "/home/daytona/workspace/study-guide/BSc_CND_2nd_Year_Study_Guide.pdf"

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    title="BSc Clinical Nutrition & Dietetics – 2nd Year Study Guide",
    author="Orris AI | MAHE Manipal MCHP"
)

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def B(text): return f"<b>{text}</b>"
def I(text): return f"<i>{text}</i>"
def bullet_list(items):
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# ═══════════════════════════════════════════════════════════════════════════
# BUILD CONTENT
# ═══════════════════════════════════════════════════════════════════════════
story = []

# ── COVER PAGE ───────────────────────────────────────────────────────────────
cover_bg = Table(
    [[Paragraph("BSc Clinical Nutrition &amp; Dietetics", cover_title)],
     [Paragraph("2nd Year Comprehensive Study Guide", cover_sub)],
     [Spacer(1, 0.4*cm)],
     [Paragraph("Semesters 3 &amp; 4", cover_sub)],
     [Spacer(1, 0.8*cm)],
     [Paragraph("Manipal College of Health Professions (MCHP), MAHE Manipal", cover_info)],
     [Spacer(1, 0.3*cm)],
     [Paragraph("Academic Year 2026–27", cover_info)],
     [Spacer(1, 1.5*cm)],
     [Paragraph("Compiled with reference to: Guyton &amp; Hall Medical Physiology | Harrison's Internal Medicine<br/>"
                "Park's Preventive &amp; Social Medicine | Sleisenger &amp; Fordtran's GI &amp; Liver Disease<br/>"
                "Lippincott Biochemistry | Robbins Pathology",
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story.append(PageBreak())

# ── HOW TO USE THIS GUIDE ────────────────────────────────────────────────────
story.append(section_header("How to Use This Study Guide"))
story.append(Spacer(1, 0.3*cm))
story += bullet_list([
    "Each subject section opens with a Topic Overview, followed by detailed Key Concepts, and closes with a Quick Revision Box.",
    "Tables summarise important data such as RDA values, diet modifications, and disease criteria — memorise these for exams.",
    "Clinical Application boxes link theory directly to patient-care scenarios you will encounter during hospital rounds.",
    "Work through one subject per week; revisit the Quick Revision Box 24 hours before each exam.",
    "Cross-reference with your textbooks: Guyton & Hall (physiology), Lippincott Biochemistry, Park's PSM (community nutrition).",
])
story.append(Spacer(1, 0.4*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# TABLE OF CONTENTS (manual)
# ═══════════════════════════════════════════════════════════════════════════
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story.append(Spacer(1, 0.3*cm))
toc_items = [
    ("SEMESTER 3", [
        "Subject 1 – Clinical Nutrition I",
        "Subject 2 – Life Cycle Nutrition I (Maternal & Infant)",
        "Subject 3 – Nutritional Biochemistry",
        "Subject 4 – Pathophysiology for Dietitians",
    ]),
    ("SEMESTER 4", [
        "Subject 5 – Clinical Nutrition II (Therapeutic Diets)",
        "Subject 6 – Life Cycle Nutrition II (Child, Adolescent, Elderly, Sports)",
        "Subject 7 – Food Service Management",
        "Subject 8 – Community & Public Health Nutrition",
        "Subject 9 – Research Methodology & Biostatistics",
    ]),
    ("APPENDICES", [
        "Appendix A – Indian RDA 2020 Summary Table",
        "Appendix B – Normal Lab Values for Dietitians",
        "Appendix C – Key Therapeutic Diet Quick Reference",
        "Appendix D – Recommended Textbooks & Resources",
    ]),
]
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    story.append(Spacer(1, 0.2*cm))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SEMESTER 3 BANNER
# ═══════════════════════════════════════════════════════════════════════════
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story.append(sem3)
story.append(Spacer(1, 0.5*cm))

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 1 – CLINICAL NUTRITION I
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 1: Clinical Nutrition I"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Clinical Nutrition I introduces the systematic application of nutritional science to patient care. "
    "You will learn how disease alters nutritional requirements, how to assess nutritional status, and how "
    "to plan hospital diets. This subject forms the clinical foundation for all therapeutic nutrition you "
    "will study in later semesters.", body))
story.append(Spacer(1, 0.2*cm))

story.append(subsection_header("1.1 Nutritional Assessment"))
story.append(Paragraph(B("ABCD Framework"), h3))
story += bullet_list([
    B("A – Anthropometry:") + " Weight, height, BMI, waist circumference, mid-arm circumference (MAC), "
    "triceps skinfold thickness (TSF). BMI cut-offs for Indians: Underweight <18.5, Normal 18.5–22.9, "
    "Overweight 23–24.9, Obese ≥25 kg/m² (Asian cut-offs differ from Western).",
    B("B – Biochemical:") + " Serum albumin (normal 3.5–5 g/dL; <3.5 = hypoalbuminaemia), prealbumin "
    "(sensitive short-term marker, normal 16–30 mg/dL), haemoglobin, serum ferritin, 24-hr urine urea "
    "nitrogen (UUN) for nitrogen balance.",
    B("C – Clinical:") + " Physical signs of deficiency — angular cheilitis (B2), glossitis (B3/B12), "
    "bitot's spots (Vit A), koilonychia (iron), Chvostek's sign (Ca/Mg), petechiae (Vit C/K).",
    B("D – Dietary:") + " 24-hour recall, food frequency questionnaire (FFQ), diet history, "
    "food diary. Identify gaps versus RDA.",
])
story.append(Spacer(1, 0.15*cm))

story.append(Paragraph(B("Nitrogen Balance"), h3))
story.append(Paragraph(
    "Nitrogen Balance = Nitrogen Intake - Nitrogen Output<br/>"
    "Nitrogen intake = Protein intake (g) ÷ 6.25<br/>"
    "Nitrogen output = UUN (g/24h) + 4 g (insensible losses)<br/>"
    "<b>Positive balance</b>: anabolism (growth, recovery). "
    "<b>Negative balance</b>: catabolism (surgery, infection, starvation).", body))

story.append(subsection_header("1.2 Hospital Diet Types"))
story.append(make_table(
    ["Diet Type", "Consistency/Form", "Indication", "Key Points"],
    [
        ["Normal/General", "Regular foods", "No dietary restriction required", "Full balanced diet per RDA"],
        ["Soft Diet", "Soft-cooked, easy to chew", "Post-surgery, dental problems, elderly", "Avoid raw vegetables, tough meats, fried foods"],
        ["Semi-Solid", "Porridge, khichdi, mashed", "Swallowing difficulties (dysphagia), gastritis", "High moisture content; no lumps"],
        ["Liquid Diet", "Clear or full liquids", "Post-op GI surgery, acute illness", "Clear: broth, juice; Full: milk, strained soups, ice cream"],
        ["High Protein", "Normal texture", "Burns, wounds, malnutrition, post-surgery", "1.5–2.5 g/kg/day protein; monitor renal function"],
        ["High Calorie", "Energy-dense foods", "Cancer cachexia, malnutrition, COPD", "Small frequent meals; fortify with oil, butter, milk powder"],
        ["Low Sodium", "<2 g Na/day", "Hypertension, cardiac failure, oedema", "Avoid processed foods, pickles, papads"],
        ["Low Fat", "<30% calories from fat", "Cholelithiasis, pancreatitis, hyperlipidaemia", "Limit visible fats; choose lean proteins"],
    ],
    col_widths=[3*cm, 3.5*cm, 4*cm, 6.5*cm]
))
story.append(Spacer(1, 0.3*cm))

story.append(subsection_header("1.3 Enteral & Parenteral Nutrition"))
story.append(Paragraph(B("Enteral Nutrition (EN)"), h3))
story += bullet_list([
    "Preferred route when GI tract is functional — 'If the gut works, use it'.",
    "Routes: Nasogastric (NG), Nasojejunal (NJ), Percutaneous Endoscopic Gastrostomy (PEG), Jejunostomy.",
    "Standard formula: 1 kcal/mL; high-calorie: 1.5–2 kcal/mL; disease-specific: renal, hepatic, pulmonary.",
    "Complications: Aspiration (keep HOB 30–45°), diarrhoea (hyperosmolar formula), tube blockage.",
    "Monitor: Gastric residual volume (GRV) every 4–6 hours; hold if >500 mL.",
])
story.append(Spacer(1, 0.1*cm))
story.append(Paragraph(B("Parenteral Nutrition (PN)"), h3))
story += bullet_list([
    "Indicated when GI tract is non-functional (ileus, short bowel syndrome, obstruction, severe pancreatitis).",
    "TPN components — Protein: 4 kcal/g; Carbohydrate (dextrose): 3.4 kcal/g; Fat (IVFE): 10 kcal/g.",
    "Standard PN calculation: Protein 1.2–2.0 g/kg/day; Fat 1 g/kg/day; remainder as dextrose.",
    "Complications: Hyperglycaemia (most common), line sepsis, refeeding syndrome (hypophosphataemia).",
    "Refeeding syndrome: Occurs in severely malnourished patients. Rapid re-feeding shifts phosphate intracellularly → "
    "hypophosphataemia, arrhythmias, respiratory failure. Prevention: Start low (10 kcal/kg/day), increase slowly.",
])
story.append(Spacer(1, 0.15*cm))
story.append(info_box("Clinical Pearl – PN Calculation Example (70 kg patient)",
    [Paragraph("Calories needed: 25 kcal/kg = 1750 kcal<br/>"
               "Protein: 1.2 g/kg = 84 g → 84 × 4 = 336 kcal<br/>"
               "Fat: 1 g/kg = 70 g → 70 × 10 = 700 kcal<br/>"
               "Dextrose: 1750 − 336 − 700 = 714 kcal ÷ 3.4 = ~210 g dextrose<br/>"
               "Water: 30 mL/kg = 2100 mL<br/>"
               "<i>Source: Sleisenger &amp; Fordtran's GI &amp; Liver Disease</i>", body)],
    bg=LIGHT))
story.append(Spacer(1, 0.2*cm))

# Quick Revision Box
story.append(info_box("Quick Revision – Clinical Nutrition I Key Points",
    bullet_list([
        "ABCD of nutritional assessment: Anthropometry, Biochemical, Clinical, Dietary",
        "BMI for Indians: Overweight ≥23, Obese ≥25 kg/m² (Asian cut-offs)",
        "Serum albumin: normal 3.5–5 g/dL; best long-term protein marker",
        "Enteral > Parenteral whenever gut is functional",
        "PN: Protein 4 kcal/g | Dextrose 3.4 kcal/g | IVFE 10 kcal/g",
        "Refeeding syndrome: hypophosphataemia in malnourished patients given rapid nutrition",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 2 – LIFE CYCLE NUTRITION I
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 2: Life Cycle Nutrition I – Maternal & Infant Nutrition"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "This subject covers the nutritional requirements across the earliest stages of life — "
    "preconception, pregnancy, lactation, and infancy. The nutritional decisions made during "
    "these periods have lifelong consequences for both mother and child (Barker hypothesis / DOHaD).", body))

story.append(subsection_header("2.1 Nutrition During Pregnancy"))
story.append(Paragraph(B("Physiological Changes Affecting Nutrition"), h3))
story += bullet_list([
    "Greatest fetal growth occurs in the last trimester — weight nearly doubles in the last 2 months.",
    "Cardiac output increases 30–40% above normal by week 27.",
    "Blood volume increases ~30% above normal by term (extra 1–2 litres).",
    "Minute ventilation increases ~50% (progesterone sensitises respiratory centre to CO₂).",
    "GI motility slows (progesterone effect) — increased nutrient absorption time (beneficial for Ca, Fe).",
    "Gestational weight gain recommendations: Underweight BMI <18.5 → 12.5–18 kg; "
    "Normal BMI 18.5–24.9 → 11.5–16 kg; Overweight → 7–11.5 kg; Obese → 5–9 kg.",
])
story.append(Spacer(1, 0.15*cm))
story.append(Paragraph(B("Key Nutrient Requirements in Pregnancy"), h3))
story.append(make_table(
    ["Nutrient", "Additional Requirement", "Why", "Deficiency Risk"],
    [
        ["Energy", "+350 kcal/day (2nd tri)\n+450 kcal/day (3rd tri)", "Fetal growth, placenta, increased BMR", "IUGR, low birth weight"],
        ["Protein", "+23 g/day above normal", "Fetal tissue synthesis", "Growth retardation"],
        ["Iron", "35 mg/day (vs 21 mg/day non-pregnant)", "Fetal blood formation (375 mg needed); extra maternal blood", "Hypochromic anaemia; maternal iron store often only 100–700 mg"],
        ["Calcium", "1200 mg/day", "Fetal bone/teeth mineralisation", "Maternal bone loss, neonatal hypocalcaemia"],
        ["Folic Acid", "500 mcg/day (start pre-conception)", "Neural tube closure (weeks 3–4 of gestation)", "Neural tube defects (spina bifida, anencephaly)"],
        ["Vitamin D", "600 IU/day", "Calcium absorption (poorly absorbed without Vit D)", "Neonatal rickets, maternal osteomalacia"],
        ["Vitamin K", "Supplemented near term", "Prothrombin synthesis in neonate", "Neonatal haemorrhagic disease"],
        ["Iodine", "250 mcg/day", "Fetal thyroid development, brain maturation", "Cretinism, intellectual disability"],
    ],
    col_widths=[2.5*cm, 3.5*cm, 5*cm, 6*cm]
))
story.append(Spacer(1, 0.2*cm))

story.append(subsection_header("2.2 Nutrition During Lactation"))
story += bullet_list([
    "Extra energy: +500 kcal/day above pre-pregnancy needs.",
    "Protein: +25 g/day (to produce ~750–800 mL breast milk/day).",
    "Calcium: 1200 mg/day (breast milk calcium is 300 mg/day).",
    "Fluid: Increase by ~700 mL/day; thirst is a reliable guide.",
    "Foods to avoid: Excessive caffeine, alcohol, raw fish. Cruciferous vegetables may cause infant gassiness.",
    "Contraindications to breastfeeding: Active TB (until treated), HIV (in resource-rich settings), "
    "maternal chemotherapy, galactosaemia in infant.",
])
story.append(Spacer(1, 0.15*cm))
story.append(subsection_header("2.3 Infant Nutrition (0–1 year)"))
story.append(Paragraph(B("Exclusive Breastfeeding (EBF)"), h3))
story += bullet_list([
    "WHO/UNICEF recommend EBF for 6 months — no water, juice, or other foods.",
    "Colostrum (first 2–3 days): rich in sIgA antibodies, lactoferrin, Vit A, growth factors. Called 'liquid gold'.",
    "Breast milk composition: 87% water, 7% lactose (carbohydrate), 3.8% fat, 1% protein.",
    "Benefits: Reduced risk of infections, allergies, obesity, SIDS; maternal bonding; economic.",
])
story.append(Paragraph(B("Complementary Feeding"), h3))
story += bullet_list([
    "Start at 6 months — breast milk alone cannot meet all nutrient needs beyond 6 months.",
    "Start with semi-solid single-ingredient foods (rice cereal, mashed dhal, pureed banana).",
    "Iron-rich foods are priority at 6 months (iron stores from birth deplete by 6 months).",
    "Progression: 6–8 months (mashed/pureed); 9–11 months (minced/chopped); 12 months (family foods).",
    "Avoid: honey (botulism risk <1 year), whole cow's milk as main drink (<1 year), added salt/sugar, nuts (choking hazard).",
])
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Life Cycle Nutrition I",
    bullet_list([
        "Folic acid 500 mcg/day from pre-conception → prevents neural tube defects",
        "Iron stores in pregnant women often only 100–700 mg; fetus needs 375 mg",
        "Blood volume ↑ 30% in pregnancy; cardiac output ↑ 30–40% by week 27",
        "WHO: Exclusive breastfeeding for 6 months; complementary feeding from 6 months",
        "Colostrum = sIgA + lactoferrin + Vit A (first 2–3 days)",
        "Honey contraindicated <1 year (Clostridium botulinum spores)",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 3 – NUTRITIONAL BIOCHEMISTRY
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 3: Nutritional Biochemistry"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Nutritional biochemistry bridges basic biochemistry with clinical nutrition. You need to understand "
    "how macronutrients and micronutrients are metabolised, regulated, and what happens when they are "
    "deficient or in excess. This is the 'why' behind every dietary prescription.", body))

story.append(subsection_header("3.1 Carbohydrate Metabolism"))
story += bullet_list([
    B("Glycolysis") + ": Glucose → Pyruvate (cytoplasm). Net yield: 2 ATP, 2 NADH per glucose.",
    B("TCA Cycle / Krebs Cycle") + ": Acetyl-CoA enters; produces 3 NADH, 1 FADH₂, 1 GTP per turn. "
    "Enzymes: Citrate synthase, Isocitrate dehydrogenase, α-Ketoglutarate dehydrogenase.",
    B("Oxidative Phosphorylation") + ": NADH → 2.5 ATP; FADH₂ → 1.5 ATP. Total ATP per glucose: ~30–32.",
    B("Gluconeogenesis") + ": Fasting/starvation — glucose synthesised from lactate, glycerol, amino acids "
    "(alanine, glutamine). Primarily in liver. Key enzyme: PEPCK.",
    B("Glycogen Synthesis/Breakdown") + ": Insulin promotes glycogen synthesis (glycogenesis); "
    "glucagon/adrenaline promotes glycogenolysis.",
    B("Dietary fibre") + ": Slows glucose absorption, reduces postprandial glycaemia, feeds gut microbiome "
    "(prebiotics → short-chain fatty acids like butyrate).",
])

story.append(subsection_header("3.2 Protein Metabolism"))
story += bullet_list([
    "Essential amino acids (9): Histidine, Isoleucine, Leucine, Lysine, Methionine, Phenylalanine, "
    "Threonine, Tryptophan, Valine. Mnemonic: PVT TIM HaLL.",
    "BCAAs (Branched Chain Amino Acids: Leucine, Isoleucine, Valine) — metabolised in muscle (not liver); "
    "important in sports nutrition and hepatic encephalopathy management.",
    "Transamination: Amino group transferred to α-ketoglutarate → glutamate. Enzymes: AST, ALT (liver markers).",
    "Urea Cycle: Converts toxic ammonia → urea (excreted by kidneys). Defects → hyperammonaemia.",
    "Protein quality: BV (Biological Value) — egg albumin = 100 (reference). Complete proteins contain all EAAs.",
    "Protein deficiency: Kwashiorkor (protein deficiency with adequate energy — oedema, skin changes) vs "
    "Marasmus (overall calorie-protein deficiency — wasting, no oedema).",
])

story.append(subsection_header("3.3 Lipid Metabolism"))
story += bullet_list([
    B("Fatty acid oxidation (Beta-oxidation)") + ": Occurs in mitochondria. "
    "Palmitate (16C): yields 129 ATP total.",
    B("Lipogenesis") + ": Excess glucose/carbs converted to fatty acids (liver). Stimulated by insulin.",
    B("Ketogenesis") + ": During prolonged fasting/starvation — acetyl-CoA accumulates → ketone bodies "
    "(acetoacetate, β-hydroxybutyrate, acetone). Brain adapts to use ketones after 3–4 days starvation.",
    B("Lipoprotein classes") + ": Chylomicrons (dietary fat transport from gut) → IDL → LDL "
    "(cholesterol delivery to tissues; 'bad') → HDL (reverse cholesterol transport; 'good') → VLDL (liver-derived TG).",
    B("Essential fatty acids") + ": Linoleic acid (ω-6) and Alpha-linolenic acid (ω-3) — cannot be "
    "synthesised; must come from diet. Deficiency: dermatitis, impaired wound healing.",
])

story.append(subsection_header("3.4 Vitamins & Minerals – Key Clinical Points"))
story.append(make_table(
    ["Vitamin/Mineral", "Function", "Deficiency Disease", "Food Sources"],
    [
        ["Vit A (Retinol)", "Vision (rhodopsin), immunity, epithelial integrity", "Night blindness → Xerophthalmia → Bitot's spots", "Liver, egg yolk, dairy, beta-carotene (carrots, mango)"],
        ["Vit D (Calciferol)", "Calcium absorption (stimulates calbindin)", "Rickets (children), Osteomalacia (adults)", "Sunlight, fish liver oils, fortified milk"],
        ["Vit C (Ascorbic acid)", "Collagen synthesis (hydroxylation of proline/lysine)", "Scurvy: perifollicular haemorrhage, gum bleeding", "Amla, citrus, guava, bell peppers"],
        ["Vit B1 (Thiamine)", "Coenzyme in pyruvate dehydrogenase, alpha-KG DH", "Beriberi (wet/dry); Wernicke's encephalopathy", "Whole grains, legumes, pork"],
        ["Vit B3 (Niacin)", "NAD⁺/NADP⁺ (electron carrier in redox reactions)", "Pellagra: Dermatitis, Diarrhoea, Dementia (3Ds)", "Meat, poultry, fish, groundnuts"],
        ["Vit B12 (Cobalamin)", "DNA synthesis, myelin maintenance", "Megaloblastic anaemia, subacute combined degeneration of cord", "Only animal foods; supplement in vegans"],
        ["Folate (B9)", "1-carbon metabolism, DNA synthesis", "Megaloblastic anaemia; NTDs in fetus", "Green leafy vegetables, legumes, fortified cereals"],
        ["Iron", "Haemoglobin (O₂ transport), enzyme cofactor", "Iron deficiency anaemia (microcytic, hypochromic)", "Heme iron: meat, fish. Non-heme: spinach, dals"],
        ["Calcium", "Bone/teeth, muscle contraction, nerve conduction", "Rickets, osteoporosis, tetany", "Dairy, ragi, sesame, small fish with bones"],
        ["Zinc", "Enzyme cofactor (>300 enzymes), wound healing, immunity", "Growth retardation, hypogeusia, impaired healing", "Meat, shellfish, legumes, pumpkin seeds"],
        ["Iodine", "Thyroid hormone synthesis (T3, T4)", "Goitre, hypothyroidism, cretinism (neonatal)", "Iodised salt, seafood"],
    ],
    col_widths=[3.2*cm, 4*cm, 4.8*cm, 5*cm]
))
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Nutritional Biochemistry",
    bullet_list([
        "9 essential amino acids – PVT TIM HaLL",
        "BCAAs metabolised in muscle (not liver) – key in hepatic encephalopathy",
        "Ketones formed in starvation: acetoacetate, β-hydroxybutyrate",
        "Kwashiorkor = protein def. + oedema | Marasmus = total calorie-protein def. + wasting",
        "PN caloric values: Protein 4, Dextrose 3.4, Fat 10 kcal/g",
        "Vit C needed for collagen synthesis (hydroxylates proline/lysine)",
        "B12 only in animal foods; supplement strictly in vegans",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 4 – PATHOPHYSIOLOGY
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 4: Pathophysiology for Dietitians"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Understanding disease mechanisms is non-negotiable for a dietitian. You cannot prescribe a "
    "therapeutic diet without knowing the underlying pathophysiology. Focus on how disease alters "
    "metabolism and what dietary modifications that dictates.", body))

story.append(subsection_header("4.1 Inflammation & Malnutrition"))
story += bullet_list([
    "Acute phase response: IL-1, IL-6, TNF-α → liver produces C-reactive protein (CRP), "
    "fibrinogen; simultaneously albumin synthesis decreases.",
    "This means serum albumin falls during acute illness NOT due to malnutrition alone — it is "
    "a negative acute phase protein. Always interpret albumin in context of inflammation (CRP).",
    "Cachexia (cancer/chronic disease): systemic inflammation → hypermetabolism, muscle wasting, "
    "anorexia. Different from simple starvation — not reversed by feeding alone.",
    "GLIM Criteria for malnutrition (2019): Phenotypic criteria (weight loss, low BMI, low muscle mass) "
    "+ Etiologic criteria (reduced food intake OR disease burden/inflammation).",
])

story.append(subsection_header("4.2 Gastrointestinal Diseases"))
story.append(make_table(
    ["Disease", "Pathophysiology", "Nutritional Impact", "Diet Strategy"],
    [
        ["GERD", "Lower oesophageal sphincter incompetence → acid reflux", "Oesophagitis, stricture, Barrett's", "Small meals; avoid fat, caffeine, alcohol, chocolate, spicy foods; elevate HOB"],
        ["Peptic Ulcer", "H. pylori or NSAIDs → mucosal barrier breakdown", "Pain, bleeding, malabsorption", "Small frequent meals; avoid irritants; no diet causes ulcers – H. pylori does"],
        ["Celiac Disease", "Gluten (gliadin) → T-cell attack on intestinal villi → villous atrophy", "Malabsorption of fat-soluble vitamins, iron, B12, calcium", "Strict Gluten-Free Diet (GFD): no wheat, barley, rye; substitute rice, millet, amaranth"],
        ["Inflammatory Bowel Disease", "Crohn's: transmural inflammation (any GI segment); UC: mucosal (colon only)", "Malnutrition, weight loss, deficiencies (B12 in terminal ileum Crohn's)", "Low-residue in flare; high-protein; specific supplements; EN in Crohn's (bowel rest)"],
        ["Pancreatitis (Acute)", "Enzyme autoactivation → pancreatic self-digestion, inflammation", "Fat malabsorption, hyperglycaemia", "NPO in severe; early EN via NJ tube preferred over PN; low fat; avoid alcohol"],
        ["Short Bowel Syndrome", "Massive resection → < 200 cm small bowel remaining", "Severe malabsorption, dehydration", "Initially TPN; transition to enteral; high-energy dense, small meals; B12 injection"],
    ],
    col_widths=[2.5*cm, 4*cm, 4*cm, 6.5*cm]
))

story.append(subsection_header("4.3 Metabolic Diseases"))
story.append(Paragraph(B("Diabetes Mellitus"), h3))
story += bullet_list([
    "Type 1: Autoimmune destruction of beta cells → absolute insulin deficiency. Ketosis-prone.",
    "Type 2: Insulin resistance + relative insulin deficiency. Associated with obesity, metabolic syndrome.",
    "Gestational Diabetes Mellitus (GDM): First detected in pregnancy; screening at 24–28 weeks (OGTT).",
    "Diagnosis criteria: FBS ≥126 mg/dL; 2-hr OGTT ≥200 mg/dL; HbA1c ≥6.5%; or random glucose ≥200 mg/dL with symptoms.",
    "Diet targets: Carbohydrate 45–60% of calories; focus on low GI carbs; protein 15–20%; fat <30%.",
    "GI (Glycaemic Index): How fast a carbohydrate raises blood glucose compared to white bread/glucose.",
    "Glycaemic Load = GI × carbohydrate content (g) ÷ 100. More practically useful than GI alone.",
])
story.append(Paragraph(B("Obesity"), h3))
story += bullet_list([
    "BMI ≥30 kg/m² (Western); ≥27.5 kg/m² (Asian/Indian cut-off for metabolic risk).",
    "Central obesity (Indian criteria): Waist circumference >90 cm (men), >80 cm (women).",
    "Energy deficit for weight loss: 500–750 kcal/day deficit = 0.5 kg/week weight loss.",
    "Diet approaches: Low calorie (1200–1500 kcal/day), DASH, Mediterranean, Low-carb (ketogenic).",
    "Sarcopenic obesity: High body fat + low muscle mass — common in elderly and type 2 diabetics.",
])
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Pathophysiology",
    bullet_list([
        "Albumin is a negative acute phase protein — falls in inflammation independent of nutrition",
        "GLIM criteria: phenotypic + etiologic criteria together for malnutrition diagnosis",
        "Celiac: gluten → villous atrophy → malabsorb fat-soluble vitamins, Fe, Ca, B12",
        "Diabetes diagnosis: FBS ≥126 OR HbA1c ≥6.5% OR 2-hr OGTT ≥200 mg/dL",
        "Indian obesity cut-off: BMI ≥27.5; Waist >90 cm (M) / >80 cm (F)",
        "Early enteral nutrition (EN) preferred over TPN in acute pancreatitis",
    ]), bg=CREAM))
story.append(PageBreak())

# ── SEMESTER 4 BANNER ────────────────────────────────────────────────────────
sem4 = Table([[Paragraph("<b>SEMESTER 4</b>", S("Normal", fontSize=20, textColor=WHITE,
               alignment=TA_CENTER, leading=26))]],
              colWidths=["100%"])
sem4.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 20),
    ("BOTTOMPADDING", (0,0), (-1,-1), 20),
]))
story.append(sem4)
story.append(Spacer(1, 0.5*cm))

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 5 – CLINICAL NUTRITION II
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 5: Clinical Nutrition II – Therapeutic Diets"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "This subject is the core of your clinical training. You will master Medical Nutrition Therapy (MNT) "
    "for major chronic and acute diseases. Each condition requires understanding of pathophysiology, "
    "nutritional impact, and the evidence-based diet intervention.", body))

story.append(subsection_header("5.1 Cardiovascular Disease Nutrition"))
story += bullet_list([
    B("Hypertension:") + " DASH Diet (Dietary Approaches to Stop Hypertension) — rich in fruits, "
    "vegetables, low-fat dairy; low sodium (<2.3 g/day or <1.5 g/day in stage 2 HTN); "
    "high potassium (bananas, potatoes, coconut water), magnesium, calcium.",
    B("Dyslipidaemia:") + " Reduce saturated fat (<7% of calories), trans fats (eliminate), "
    "dietary cholesterol (<200 mg/day). Increase soluble fibre (oats, psyllium — lowers LDL). "
    "Omega-3 FA (fish, flaxseed) reduces TG by 20–30%.",
    B("Heart Failure:") + " Sodium restriction 2–3 g/day; fluid restriction 1.5–2 L/day; "
    "small frequent meals (dyspnoea during eating); monitor weight daily.",
    B("Post-MI:") + " Cardiac Phase I diet (liquid/soft, low sodium, low cholesterol); "
    "progress to Heart Healthy Diet. Mediterranean diet reduces recurrence.",
])

story.append(subsection_header("5.2 Renal Disease Nutrition"))
story.append(make_table(
    ["Parameter", "CKD Stage 3–4", "Dialysis (Haemodialysis)", "Nephrotic Syndrome"],
    [
        ["Protein", "0.6–0.8 g/kg/day (low protein diet)", "1.2–1.4 g/kg/day (high – losses during dialysis)", "1.0 g/kg/day + urinary losses"],
        ["Potassium", "Restrict <2–3 g/day if hyperkalaemic", "Restrict <2 g/day", "Usually normal; restrict only if ↑K⁺"],
        ["Phosphorus", "Restrict <800–1000 mg/day", "Restrict <800 mg/day; phosphate binders", "Usually normal"],
        ["Sodium", "2–3 g/day (restrict)", "2 g/day or less", "2–3 g/day (for oedema)"],
        ["Fluid", "Based on urine output", "1 L/day + urine output", "Restrict if oedematous"],
        ["Calories", "30–35 kcal/kg/day", "30–35 kcal/kg/day", "35 kcal/kg/day"],
    ],
    col_widths=[3.5*cm, 4.2*cm, 4.2*cm, 5.1*cm]
))
story.append(Spacer(1, 0.15*cm))
story += bullet_list([
    "Low protein diet in CKD slows progression (reduces intraglomerular pressure, less urea generation).",
    "Leaching vegetables (boiling and discarding water) reduces potassium content by 30–50%.",
    "Nephrotic Syndrome: protein loss in urine → hypoalbuminaemia → oedema; hyperlipidaemia (liver overproduces lipoproteins).",
])

story.append(subsection_header("5.3 Liver Disease Nutrition"))
story += bullet_list([
    B("Hepatitis (Acute):") + " High calorie (35–40 kcal/kg), high protein (1.2–1.5 g/kg), "
    "high carbohydrate (60–70%) to spare protein, low fat if steatorrhoea present.",
    B("Liver Cirrhosis:") + " Energy: 35–40 kcal/kg; Protein: 1.2–1.5 g/kg/day. "
    "Do NOT restrict protein routinely — old practice; current evidence supports adequate protein.",
    B("Hepatic Encephalopathy (HE):") + " Elevated blood ammonia → cerebral dysfunction. "
    "Restrict BCAAs' antagonists (aromatic amino acids rise; BCAAs fall). "
    "BCAA supplements improve encephalopathy. Lactulose (laxative) reduces gut ammonia absorption.",
    B("Ascites:") + " Sodium restriction 2 g/day; fluid restriction 1–1.5 L/day.",
    B("Alcohol-related liver disease:") + " Total alcohol cessation; thiamine (B1) supplementation "
    "(prevent Wernicke's); high calorie dense diet; zinc supplementation.",
])

story.append(subsection_header("5.4 Nutrition in Critical Illness & Surgery"))
story += bullet_list([
    "Metabolic stress response (Cuthbertson phases): Ebb phase (first 24–48 hrs — low metabolic rate, "
    "resuscitate fluid); Flow phase (hypermetabolism — protein catabolism, hyperglycaemia).",
    "Energy needs in critical illness: 25–30 kcal/kg/day (avoid overfeeding — causes hyperglycaemia, "
    "fatty liver, respiratory failure from excess CO₂).",
    "Protein: 1.5–2.5 g/kg/day in sepsis/burns/trauma.",
    "Immunonutrition (ESPEN guidelines): Arginine, glutamine, omega-3 FA, antioxidants — "
    "reduce infections, ICU stay (primarily pre-operative).",
    "Post-surgery: Early oral feeding within 24 hours if tolerated (ERAS protocol).",
    "Burns Nutrition (Curreri formula): 25 kcal/kg + 40 kcal × %BSA burned = daily calories.",
])
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Clinical Nutrition II",
    bullet_list([
        "DASH diet for HTN: Low Na (<2.3g), high K/Mg/Ca, fruits, vegetables, low-fat dairy",
        "CKD pre-dialysis: protein 0.6–0.8 g/kg | Dialysis: 1.2–1.4 g/kg (losses during dialysis)",
        "Leaching reduces vegetable K⁺ by 30–50%",
        "Hepatic encephalopathy: BCAA supplements; lactulose to reduce ammonia",
        "Burns: Curreri formula = 25 kcal/kg + 40 kcal × %BSA burned",
        "Critical illness: 25–30 kcal/kg; avoid overfeeding",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 6 – LIFE CYCLE NUTRITION II
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 6: Life Cycle Nutrition II – Child, Adolescent, Elderly & Sports"))
story.append(Spacer(1, 0.3*cm))

story.append(subsection_header("6.1 Paediatric Nutrition (1–12 years)"))
story += bullet_list([
    "Growth monitoring: WHO growth charts; weight-for-height Z-score (WHZ); "
    "Mid-upper arm circumference (MUAC) — <11.5 cm indicates severe acute malnutrition (SAM).",
    "PEM (Protein Energy Malnutrition): "
    "Kwashiorkor = oedematous malnutrition (protein deficiency + adequate energy; hair changes, skin peeling, hepatomegaly). "
    "Marasmus = non-oedematous (total calorie-protein deficiency; wasting, 'old man face', bag of bones appearance).",
    "SAM Management (F-75/F-100 protocol): Stabilisation phase (F-75 — 75 kcal/100 mL); "
    "Rehabilitation phase (F-100 — 100 kcal/100 mL); Transition over 48–72 hours.",
    "National programs: ICDS (Integrated Child Development Services), Mid-Day Meal scheme, "
    "Poshan Abhiyan (POSHAN 2.0) — address child malnutrition.",
    "School-age: 1600–2000 kcal/day; iron needs ↑ during growth; calcium important for bone density.",
])

story.append(subsection_header("6.2 Adolescent Nutrition"))
story += bullet_list([
    "Rapid growth spurt: highest energy/protein needs per kg relative to adults.",
    "Girls: puberty onset 10–11 yrs; Iron needs ↑ sharply with menarche (21 mg/day).",
    "Boys: puberty onset 12–13 yrs; protein needs ↑ for muscle mass development.",
    "Calcium needs peak in adolescence: 1200–1300 mg/day (peak bone mass formation).",
    "Common problems: Iron deficiency anaemia (especially girls), eating disorders (anorexia nervosa, bulimia), "
    "obesity, acne (no strong dietary link proven).",
    "Eating disorders – brief: Anorexia Nervosa (BMI <17.5, distorted body image, restrictive eating); "
    "Bulimia (bingeing + purging; normal or overweight). Both need multidisciplinary management.",
])

story.append(subsection_header("6.3 Geriatric (Elderly) Nutrition"))
story += bullet_list([
    "Energy needs decrease with age (BMR falls ~2% per decade after 30); "
    "but protein, calcium, Vit D, B12 needs remain high or increase.",
    "Sarcopenia: age-related loss of muscle mass and strength. "
    "Prevention: Protein 1.0–1.2 g/kg/day; resistance exercise.",
    "Micronutrient concerns: Vit D (reduced skin synthesis), B12 (achlorhydria → reduced intrinsic factor), "
    "Calcium (osteoporosis risk), Zinc (impaired wound healing), Vit C.",
    "Mini Nutritional Assessment (MNA): validated tool for elderly nutritional screening.",
    "Dysphagia: common in elderly + stroke patients; texture modification (IDDSI framework levels 0–7).",
    "Dehydration risk: blunted thirst sensation; minimum 1.5–2 L fluids/day.",
])

story.append(subsection_header("6.4 Sports Nutrition"))
story += bullet_list([
    B("Energy needs:") + " Depends on type, duration, intensity. Endurance athlete: 50–80 kcal/kg/day.",
    B("Carbohydrate:") + " Primary fuel. Recommendations: 6–10 g/kg/day for moderate to heavy training. "
    "Carbohydrate loading (glycogen supercompensation): 10–12 g/kg/day 1–3 days before endurance event.",
    B("Protein:") + " 1.4–2.0 g/kg/day (strength athletes may go up to 2.2 g/kg). "
    "Leucine-rich sources (whey, eggs) most anabolic.",
    B("Fat:") + " 20–35% of calories; essential fatty acids for inflammation modulation.",
    B("Hydration:") + " 500 mL water 2 hours before exercise; 150–250 mL every 15–20 min during; "
    "replace 1.5× fluid deficit after exercise. Sports drinks (6% CHO) for events >60 min.",
    B("Timing:") + " Pre-exercise (1–4 hrs): High CHO, low fat, moderate protein. "
    "Post-exercise (within 30 min): 1.2 g CHO/kg + 0.3 g protein/kg for recovery/glycogen repletion.",
    B("Supplements:") + " Creatine monohydrate (evidence-based for strength/power); Caffeine "
    "(3–6 mg/kg 60 min pre-exercise — endurance benefit); Beta-alanine (buffers lactic acid in high-intensity).",
    "Iron deficiency anaemia: very common in female athletes (foot-strike haemolysis, menstrual loss, "
    "inadequate dietary intake). Screen regularly.",
])
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Life Cycle Nutrition II",
    bullet_list([
        "MUAC <11.5 cm = SAM in children; F-75 stabilisation then F-100 rehabilitation",
        "Kwashiorkor: oedema + protein deficiency | Marasmus: wasting + total calorie-protein deficiency",
        "Adolescent calcium: 1200–1300 mg/day (peak bone mass window)",
        "Elderly: sarcopenia = muscle loss → protein 1.0–1.2 g/kg + resistance exercise",
        "Sports nutrition: CHO 6–10 g/kg/day; protein 1.4–2.0 g/kg/day",
        "Post-exercise recovery: 1.2 g CHO/kg + 0.3 g protein/kg within 30 min",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 7 – FOOD SERVICE MANAGEMENT
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 7: Food Service Management"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Food service management deals with the organisation, planning, and delivery of food in institutional "
    "settings (hospitals, schools, canteens). As a hospital dietitian, you will oversee or work within "
    "a diet kitchen — this subject gives you the administrative and food safety framework.", body))

story.append(subsection_header("7.1 Types of Food Service Systems"))
story.append(make_table(
    ["System", "Description", "Example", "Pros/Cons"],
    [
        ["Conventional", "Food prepared and served in same facility (cook-serve)", "Hospital kitchen", "Fresh quality; high labour cost"],
        ["Cook-Chill", "Cooked, rapidly chilled, stored 0–3°C, reheated before service", "Large hospital chains", "Reduced labour; quality maintained if done correctly"],
        ["Cook-Freeze", "Cooked, blast frozen (-18°C), reheated", "Airline caterers, large institutions", "Long shelf life (6 months); some quality loss"],
        ["Assembly-Serve", "Purchased pre-prepared foods assembled and served", "Fast food, school cafeterias", "Minimal skill needed; less control over quality"],
    ],
    col_widths=[3*cm, 4.5*cm, 3.5*cm, 6*cm]
))

story.append(subsection_header("7.2 HACCP – Hazard Analysis Critical Control Points"))
story += bullet_list([
    "HACCP is a systematic preventive approach to food safety. Mandatory in most institutional kitchens.",
    B("7 Principles of HACCP:"),
    "1. Conduct Hazard Analysis (biological: bacteria/viruses; chemical: pesticides; physical: glass/metal).",
    "2. Identify Critical Control Points (CCPs) — points where hazards can be prevented/eliminated/reduced.",
    "3. Establish Critical Limits (e.g., internal temp of meat ≥75°C).",
    "4. Establish Monitoring Procedures.",
    "5. Establish Corrective Actions.",
    "6. Establish Verification Procedures.",
    "7. Establish Record-Keeping and Documentation.",
    B("Temperature Danger Zone:") + " 5°C–63°C — bacteria multiply rapidly. Hot foods kept >63°C; cold foods <5°C.",
])

story.append(subsection_header("7.3 Menu Planning for Hospitals"))
story += bullet_list([
    "Master menu (cycle menu, e.g., 7-day or 14-day cycle) reduces planning burden and ensures variety.",
    "Diet order flow: Physician prescribes → Dietitian translates to diet specification → Diet kitchen prepares → Ward delivery.",
    "Therapeutic diet labels: Low sodium, diabetic, renal, post-surgery — must be clearly tagged.",
    "Portion control: Standardised recipes with defined portion sizes maintain cost and nutritional consistency.",
    "Cost management: Food cost ratio = food cost / sales price × 100. Target 25–35% in hospitals.",
    "Waste management: First In First Out (FIFO) for stock rotation; FEFO (First Expire First Out) for perishables.",
])

story.append(subsection_header("7.4 Food Safety & Sanitation"))
story += bullet_list([
    "Personal hygiene: handwashing 20 seconds with soap; no jewellery, nail polish; clean uniform/apron.",
    "Cross-contamination: separate cutting boards for raw meat/poultry/seafood vs vegetables/cooked food.",
    "Food storage temperatures: Freezer: ≤−18°C; Refrigerator: 1–4°C; Hot holding: ≥63°C.",
    "FSSAI (Food Safety and Standards Authority of India): Regulatory body under Ministry of Health, India. "
    "Sets food safety standards and licensing for food businesses.",
])
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Food Service Management",
    bullet_list([
        "Temperature danger zone: 5–63°C (bacterial multiplication rapid)",
        "HACCP 7 principles: Hazard analysis → CCPs → Critical limits → Monitor → Corrective action → Verify → Record",
        "Cook-chill: cook then chill to 0–3°C; shelf life 5 days",
        "Hospital diet order flow: Physician → Dietitian → Kitchen → Ward",
        "FIFO: First In First Out | FEFO: First Expire First Out",
        "FSSAI: India's food safety regulatory body",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 8 – COMMUNITY & PUBLIC HEALTH NUTRITION
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 8: Community & Public Health Nutrition"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Public health nutrition shifts focus from the individual patient to populations. "
    "You will learn about the burden of malnutrition in India, national programs, nutrition surveillance, "
    "and policy. This is the foundation for work in government health systems, NGOs, and public health.", body))

story.append(subsection_header("8.1 Double Burden of Malnutrition in India"))
story += bullet_list([
    "India faces a double burden: undernutrition (stunting, wasting, anaemia) AND overnutrition "
    "(obesity, diabetes, CVD) — often in the same household, community, or even the same individual.",
    B("Stunting") + " (chronic malnutrition): Height-for-age Z-score < -2SD. India: ~35% children under 5 stunted (NFHS-5).",
    B("Wasting") + " (acute malnutrition): Weight-for-height Z-score < -2SD. India: ~19% children under 5.",
    B("Anaemia:") + " Affects 67% of children 6–59 months and 57% of women 15–49 yrs (NFHS-5).",
    "Causes of undernutrition: Poverty, food insecurity, poor sanitation (WASH), frequent infections, "
    "early marriage, low maternal education, inadequate complementary feeding.",
])

story.append(subsection_header("8.2 National Nutrition Programs (India)"))
story.append(make_table(
    ["Program", "Ministry/Agency", "Target Group", "Key Intervention"],
    [
        ["ICDS (Integrated Child Development Services)", "Women & Child Development", "Children 0–6 yrs, pregnant/lactating women", "Supplementary nutrition, immunisation, pre-school education, health checkup"],
        ["Mid-Day Meal Scheme (PM POSHAN)", "Education", "School children classes 1–8", "Free cooked meal in schools; 450–700 kcal, 12–20 g protein/day"],
        ["POSHAN Abhiyan (POSHAN 2.0)", "Women & Child Development", "Pregnant women, lactating mothers, adolescent girls, children <6", "Reduce stunting, wasting, underweight, anaemia"],
        ["SABLA / Kishori Shakti Yojana", "Women & Child Development", "Adolescent girls 11–18 yrs", "Nutrition, health, life skills education"],
        ["National Iron Plus Initiative", "Health & Family Welfare", "Children 6 mos–10 yrs, adolescents, pregnant/lactating women", "Weekly/biweekly iron-folic acid supplementation"],
        ["RMNCH+A", "Health", "Reproductive, maternal, newborn, child, adolescent health", "Nutrition counselling, iron/folate, deworming"],
        ["Antyodaya Anna Yojana (AAY)", "Food & Public Distribution", "Below poverty line households", "35 kg food grains/month at subsidised rates"],
    ],
    col_widths=[4*cm, 3*cm, 3.5*cm, 6.5*cm]
))

story.append(subsection_header("8.3 Nutritional Epidemiology & Surveillance"))
story += bullet_list([
    B("NNMB") + " (National Nutrition Monitoring Bureau) — surveys dietary intake and nutritional status in India.",
    B("NFHS") + " (National Family Health Survey) — DHS survey; tracks nutrition indicators (stunting, wasting, anaemia, breastfeeding). NFHS-5 (2019–21) is current.",
    B("ICMR-NIN RDA 2020:") + " Updated Recommended Dietary Allowances for Indians. "
    "Key change: revised energy estimates using doubly-labelled water method.",
    "Nutritional indicators: Prevalence of stunting/wasting/underweight (children); "
    "anaemia prevalence; birth weight <2.5 kg; BMI; dietary diversity score.",
    B("Food Security:") + " FAO definition — all people have physical, social, economic access to "
    "sufficient, safe, nutritious food. Four pillars: Availability, Access, Utilisation, Stability.",
])

story.append(subsection_header("8.4 Balanced Diet for Indians (ICMR-NIN)"))
story += bullet_list([
    "Balanced diet: variety of foods providing adequate energy, protein (10–15%), fat (15–30%), "
    "carbohydrate (remainder), and micronutrients for health and vitality.",
    B("Indian RDA 2020 (Adult Male, Moderate Work):") + " 2730 kcal energy, 54 g protein, 1000 mg calcium, 19 mg iron, 300 mcg folate, 80 mg Vit C.",
    "Food groups (MyPlate India / Eat Right India): Cereals (50–60%), Pulses/Legumes (10–15%), "
    "Milk/Dairy (2–3 servings), Vegetables (min 3 cups/day), Fruits (2 servings), Fats/Oils (<30 g/day).",
    "Eat Right India initiative (FSSAI): Promotes safe, healthy, sustainable food choices.",
])
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Community Nutrition",
    bullet_list([
        "Stunting: HAZ < -2SD (chronic); Wasting: WHZ < -2SD (acute) — NFHS-5 data",
        "ICDS targets children 0–6 yrs + pregnant/lactating women",
        "Mid-Day Meal: 450–700 kcal, 12–20 g protein for school children",
        "4 pillars of food security: Availability, Access, Utilisation, Stability",
        "ICMR-NIN RDA 2020: Adult male moderate work → 2730 kcal, 54 g protein",
        "NFHS-5: 35% stunting, 19% wasting, 67% anaemia in children <5 yrs",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# SUBJECT 9 – RESEARCH METHODOLOGY & BIOSTATISTICS
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Subject 9: Research Methodology & Biostatistics"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(
    "Research methods and biostatistics enable you to critically read nutrition research and eventually "
    "conduct your own studies. This subject is essential for evidence-based practice.", body))

story.append(subsection_header("9.1 Types of Study Designs"))
story.append(make_table(
    ["Study Design", "Description", "Hierarchy of Evidence", "Example"],
    [
        ["Systematic Review / Meta-Analysis", "Combines results of multiple studies statistically", "Highest (Level I)", "Meta-analysis of fish oil RCTs for CVD"],
        ["Randomised Controlled Trial (RCT)", "Participants randomly assigned to intervention/control", "Level II", "Mediterranean diet vs low-fat diet for weight loss"],
        ["Cohort Study", "Follow exposed vs non-exposed over time; measures incidence", "Level III", "Nurses' Health Study (diet and cancer)"],
        ["Case-Control Study", "Compare cases (disease) vs controls (no disease); looks backward", "Level IV", "Diet patterns in gastric cancer vs controls"],
        ["Cross-Sectional Survey", "Snapshot in time; prevalence data", "Level V", "Dietary intake survey in school children"],
        ["Case Report/Series", "Single patient or small group description", "Level VI (Lowest)", "Novel dietary management of rare metabolic disorder"],
    ],
    col_widths=[3.5*cm, 4*cm, 2.5*cm, 7*cm]
))

story.append(subsection_header("9.2 Key Biostatistics Concepts"))
story += bullet_list([
    B("Mean, Median, Mode:") + " Mean (average); Median (middle value — better for skewed data); "
    "Mode (most frequent value).",
    B("Standard Deviation (SD):") + " Measures spread of data around mean. "
    "Normal distribution: 68% data within ±1 SD; 95% within ±2 SD.",
    B("p-value:") + " Probability the result occurred by chance. p < 0.05 = statistically significant. "
    "Does NOT equal clinical significance.",
    B("Confidence Interval (CI):") + " Range within which the true population value lies with 95% certainty. "
    "If CI for a ratio/difference does not include 1.0/0, result is significant.",
    B("Relative Risk (RR):") + " Incidence in exposed ÷ incidence in unexposed (used in cohort studies).",
    B("Odds Ratio (OR):") + " Used in case-control studies. OR >1 = increased risk; OR <1 = protective.",
    B("Sensitivity vs Specificity:") + " Sensitivity = true positive rate (best for screening); "
    "Specificity = true negative rate (best for confirmation).",
    B("Correlation (r):") + " Measures linear relationship. r = +1 (perfect positive); "
    "r = -1 (perfect negative); r = 0 (no correlation). Correlation ≠ Causation.",
])

story.append(subsection_header("9.3 Nutritional Assessment Tools in Research"))
story += bullet_list([
    B("24-Hour Dietary Recall:") + " Quick, non-reactive; single day may not represent usual intake; "
    "multiple days (≥3) improve accuracy. Relies on respondent memory.",
    B("Food Frequency Questionnaire (FFQ):") + " Lists foods with frequency options; captures long-term usual diet; "
    "semi-quantitative or quantitative. Used in epidemiological studies.",
    B("Weighed Food Record:") + " Most accurate; respondent weighs all food before eating. "
    "High respondent burden; potential dietary modification.",
    B("Doubly-Labelled Water (DLW):") + " Gold standard for measuring energy expenditure in free-living subjects. "
    "Expensive; used to validate other methods.",
    B("MUAC:") + " Simple, inexpensive, community-level screening for acute malnutrition. <12.5 cm = MAM; <11.5 cm = SAM.",
])
story.append(Spacer(1, 0.2*cm))
story.append(info_box("Quick Revision – Research & Biostatistics",
    bullet_list([
        "Evidence hierarchy: Systematic review > RCT > Cohort > Case-control > Cross-sectional > Case report",
        "p < 0.05 = statistically significant (but may not be clinically relevant)",
        "RR used in cohort studies; OR used in case-control studies",
        "FFQ captures long-term usual intake; 24-hr recall is quick but single-day snap",
        "Gold standard energy expenditure: Doubly-Labelled Water (DLW)",
        "MUAC <11.5 cm = SAM; <12.5 cm = MAM in children",
    ]), bg=CREAM))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# APPENDIX A – Indian RDA 2020
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Appendix A: Indian RDA 2020 – Key Values"))
story.append(Spacer(1, 0.3*cm))
story.append(make_table(
    ["Category", "Energy (kcal)", "Protein (g)", "Iron (mg)", "Calcium (mg)", "Vit C (mg)", "Folate (mcg)"],
    [
        ["Man – Sedentary", "2110", "54", "19", "1000", "80", "300"],
        ["Man – Moderate work", "2730", "54", "19", "1000", "80", "300"],
        ["Man – Heavy work", "3490", "54", "19", "1000", "80", "300"],
        ["Woman – Sedentary", "1660", "46", "21", "1000", "65", "300"],
        ["Woman – Moderate work", "2230", "46", "21", "1000", "65", "300"],
        ["Pregnant woman", "+350 (2nd tri)", "+23", "35", "1200", "80", "500"],
        ["Lactating (0–6 mo)", "+500", "+25", "21", "1200", "90", "300"],
        ["Adolescent girl 13–15", "2330", "52", "26", "1200", "65", "300"],
        ["Adolescent boy 13–15", "2750", "55", "19", "1200", "65", "300"],
        ["Child 7–9 yrs", "1690", "29.5", "13", "800", "40", "200"],
    ],
    col_widths=[3.5*cm, 2.5*cm, 2*cm, 2*cm, 2.5*cm, 2*cm, 2.5*cm]
))
story.append(Spacer(1, 0.2*cm))
story.append(Paragraph(
    I("Source: ICMR-National Institute of Nutrition, Nutrient Requirements for Indians – RDA & EAR, 2020"),
    small))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# APPENDIX B – Normal Lab Values
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Appendix B: Normal Lab Values for Dietitians"))
story.append(Spacer(1, 0.3*cm))
story.append(make_table(
    ["Lab Test", "Normal Range", "Nutritional Significance"],
    [
        ["Haemoglobin (Hb)", "Men: 13.5–17.5 g/dL\nWomen: 12–15.5 g/dL", "Iron, B12, folate deficiency → anaemia"],
        ["Serum Albumin", "3.5–5.0 g/dL", "Long-term protein status; negative acute phase protein"],
        ["Serum Prealbumin", "16–30 mg/dL", "Short-term (2–3 day) protein marker; more sensitive than albumin"],
        ["Serum Ferritin", "Men: 20–250 ng/mL\nWomen: 10–120 ng/mL", "Iron stores; elevated in inflammation"],
        ["Serum Iron", "60–170 mcg/dL", "Iron status"],
        ["Total Iron Binding Capacity (TIBC)", "250–370 mcg/dL", "↑ in iron deficiency; ↓ in anaemia of chronic disease"],
        ["Fasting Blood Glucose (FBS)", "70–100 mg/dL", "Diabetes screening (<100 normal; 100–125 pre-diabetes; ≥126 diabetes)"],
        ["HbA1c", "<5.7%", "<5.7% normal; 5.7–6.4% pre-diabetes; ≥6.5% diabetes"],
        ["Serum Creatinine", "0.6–1.2 mg/dL", "Kidney function; elevated in renal disease"],
        ["Blood Urea Nitrogen (BUN)", "7–20 mg/dL", "Protein catabolism; elevated in renal disease, high protein intake"],
        ["Serum Potassium (K⁺)", "3.5–5.0 mEq/L", "Hyperkalaemia in CKD; hypokalaemia in diarrhoea/diuretics"],
        ["Serum Sodium (Na⁺)", "136–145 mEq/L", "Hyponatraemia in fluid overload; hypernatraemia in dehydration"],
        ["Total Cholesterol", "<200 mg/dL", "CVD risk; diet-modifiable"],
        ["LDL Cholesterol", "<100 mg/dL (optimal)", "Target <70 mg/dL in high CVD risk"],
        ["HDL Cholesterol", "M: >40 mg/dL; F: >50 mg/dL", "Protective; raised by exercise, omega-3, niacin"],
        ["Triglycerides (TG)", "<150 mg/dL", "Elevated by excess carbs/alcohol; reduced by omega-3"],
        ["Serum Calcium", "8.5–10.5 mg/dL", "Hypocalcaemia → tetany; hypercalcaemia in Vit D toxicity"],
        ["Serum Phosphorus", "2.5–4.5 mg/dL", "↑ in CKD; ↓ in refeeding syndrome"],
        ["C-Reactive Protein (CRP)", "<1 mg/L (high sensitivity)", "Inflammation marker; affects interpretation of albumin/prealbumin"],
        ["25-OH Vitamin D", "30–100 ng/mL", "<20 = deficiency; 20–29 = insufficiency"],
    ],
    col_widths=[5*cm, 4.5*cm, 7.5*cm]
))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# APPENDIX C – Therapeutic Diet Quick Reference
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Appendix C: Therapeutic Diet Quick Reference"))
story.append(Spacer(1, 0.3*cm))
story.append(make_table(
    ["Condition", "Energy", "Protein", "Key Restrictions/Modifications"],
    [
        ["Type 2 Diabetes", "As per BEE × AF\n(weight loss if obese)", "15–20%", "Low GI carbs; 45–60% CHO; reduce sat fat; high fibre"],
        ["Hypertension", "As required", "Normal", "Na <2.3 g/day; DASH diet; ↑K/Mg/Ca; alcohol limit"],
        ["CKD (pre-dialysis)", "30–35 kcal/kg", "0.6–0.8 g/kg", "Low K, low P, low Na; leach vegetables"],
        ["Haemodialysis", "30–35 kcal/kg", "1.2–1.4 g/kg", "Low K, low P, low Na, fluid restrict"],
        ["Liver Cirrhosis", "35–40 kcal/kg", "1.2–1.5 g/kg", "No routine protein restriction; low Na (ascites); small meals"],
        ["Cardiac Failure", "As required", "Normal–high", "Na <2 g; fluid restrict 1.5–2 L; small frequent meals; daily weight"],
        ["Celiac Disease", "As required", "Normal", "Strictly Gluten-Free: no wheat/barley/rye; supplement Ca, Vit D, Fe, B12"],
        ["Crohn's Disease (flare)", "35–40 kcal/kg", "1.5 g/kg", "Low residue; elemental EN; avoid trigger foods; B12 supplement"],
        ["Post-GI Surgery", "25–30 kcal/kg then ↑", "1.5–2 g/kg", "Start liquid → soft → normal (ERAS); avoid concentrated sweets (dumping)"],
        ["Burns", "Curreri formula", "2–2.5 g/kg", "Very high energy; high protein; Vit C, Zinc for wound healing"],
        ["Cancer Cachexia", "30–35 kcal/kg", "1.5 g/kg", "Energy-dense foods; small meals; oral supplements; address anorexia"],
        ["Obesity (weight loss)", "500–750 kcal deficit", "1.2 g/kg (preserve lean mass)", "Low calorie; high protein; high fibre; limit processed/ultra-processed"],
    ],
    col_widths=[3.5*cm, 2.5*cm, 2.5*cm, 8.5*cm]
))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════
# APPENDIX D – Recommended Resources
# ═══════════════════════════════════════════════════════════════════════════
story.append(section_header("Appendix D: Recommended Textbooks & Study Resources"))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(B("Core Textbooks"), h2))
story.append(make_table(
    ["Subject Area", "Recommended Textbook", "Edition"],
    [
        ["Clinical Nutrition (MNT)", "Krause and Mahan's Food & the Nutrition Care Process", "15th / Latest"],
        ["Clinical Nutrition (Indian)", "Bhaskarachary et al. – Nutritional Requirements of Indians (NIN)", "2020"],
        ["Nutritional Biochemistry", "Lippincott Illustrated Reviews: Biochemistry", "8th Ed"],
        ["Pathophysiology", "Kumar, Abbas, Aster – Robbins & Cotran Pathologic Basis of Disease", "10th Ed"],
        ["Physiology", "Guyton & Hall Textbook of Medical Physiology", "14th Ed"],
        ["Community Nutrition", "Park's Textbook of Preventive & Social Medicine", "26th Ed"],
        ["Food Science", "Potter & Hotchkiss – Food Science", "5th Ed"],
        ["Sports Nutrition", "Burke L. – Clinical Sports Nutrition", "5th Ed"],
        ["Research Methods", "Guyatt et al. – Users' Guide to Medical Literature", "3rd Ed"],
        ["Food Service Mgmt", "Puckett – Food Service Manual for Health Care Institutions", "4th Ed"],
    ],
    col_widths=[4.5*cm, 9*cm, 3.5*cm]
))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph(B("Online Resources"), h2))
story += bullet_list([
    "NIN India (nin.res.in) – RDA 2020, dietary guidelines, NNMB reports",
    "FSSAI (fssai.gov.in) – Food safety, Eat Right India resources",
    "WHO/UNICEF (who.int) – Global nutrition guidelines, infant feeding",
    "ESPEN Guidelines (espen.eu) – Clinical nutrition guidelines (enteral/parenteral)",
    "Academy of Nutrition and Dietetics (eatright.org) – Evidence-based practice resources",
    "PubMed (pubmed.ncbi.nlm.nih.gov) – Search peer-reviewed nutrition research",
    "Nutrient Analysis: IFCT 2017 (Indian Food Composition Tables) – ifct2017.com",
])
story.append(Spacer(1, 0.4*cm))
story.append(HR())
story.append(Paragraph(
    I("This study guide was compiled for BSc Clinical Nutrition &amp; Dietetics students at MCHP, MAHE Manipal. "
      "Content is drawn from authoritative textbooks including Guyton &amp; Hall Medical Physiology, "
      "Sleisenger &amp; Fordtran's GI &amp; Liver Disease, Park's Preventive &amp; Social Medicine, "
      "and Lippincott Biochemistry. Always cross-reference with your course lectures and faculty guidance. "
      "Compiled July 2026."),
    S("Normal", fontSize=8, leading=12, textColor=colors.HexColor("#888888"), alignment=TA_CENTER)))

# ── BUILD ────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")

cd /home/daytona/workspace/study-guide && python build_guide.py 2>&1

ls -lh /home/daytona/workspace/study-guide/BSc_CND_2nd_Year_Study_Guide.pdf