| a SSeS EEEeeee Eee eee UU SEE EE TEE ETO TESTOSE TOE | ema Dce nt ” | || UNIT 9 Therapeutic Diets C} THERAPEUTIC 9.1.1. Definition A meal plan that monitors the consumption of certain food nutrients is termed as a therapeutic diet. It is usually prescribed by a physician, planned by a Getician, and also plays a role in the treatment of a medical condition. It is a form of modified regular diet. (sing food for the treatment of illness is called diet therapy. This can be schieved by altering the regular diet of the patient so as to meet the changing weeds resulting from any diseases or injuries. Therapeutic diet is a part of the treatment that is prepared for a controlled intake of specific food items and nutrients. Generally, it is prescribed by a physician and planned by a dietician, depending on the disease and nutrient requirements of the patient. A therapeutic diet is planned by modifying a regular diet by altering mutrients, texture, food allergies, or food intolerances. . Objectives of Therapeutic Diet Ingeneral, therapeutic diet is prescribed for the following reasons: 1) For maintaining, restoring, and correcting nutritional status. 2) For reducing calorie intake to control weight. 3) For providing additional calories for weight gain. 4) For balancing carbohydrates, fat and protein intake to control diabetes. 5) For providing nutrients (protein, fatty acids) in greater amount. 6) For reducing the amount of a nutrient, such as sodium. For cutting down foods causing allergies or intolerance. 8) For making texture modifications due to problems with chewing and/or swallowing. | 9.1.3, Principles of Therapeutic Diet |) The diet should be planned keeping in mind the changes in metabolism as a result of disease. 2) The diet should be planned as per the food habits of the patient, depending on Socioeconomic status, culture, personal preferences, religion, physiological and psychological status, satiety, and appetite. 3) As much as possible, diet changes should be introduced gradually, with enough explanations provided for any changes made.178 4) SS eo n 9.2. DIET MOD ‘Applied Nutrition and Dietetcy The food should not be forced in patient with short and acute illness because appetite is very poor but soon the regular appetite can recover. Yet the quantity of food in prolonged illness should be enough to avoid tissue wastage. There should be a variety of foods to choose from a given diet plan. Frequent and small feedings are preferred over the traditional three meals. Hot foods should be served hot and cold foods should be served cold ATIONS 9.2.1. Introduction ‘Changes that are made during food making, processing, and intake to enhance the bioavailability of micronutrients and lower micronutrient deficiencies in food at commercial or individual/household level are referred to as dietary modifications, According to Nutrition Essentials for Nursing Practice by Susan G. Dudek, a modified diet is any diet altered to include or exclude certain components, such as calories, fat, vitamins and minerals. For therapeutic reasons, like treatment of under. weight, high blood pressure, or lack of vitamin and mineral, changes are made in a diet. A physician should be consulted regarding diet changes that can help a condition, and a nutritionist should be consulted to make the best dietary options. 9.2.2. Objectives of Diet Modifications The regular diet can be changed: Dn 2) 3) 4) yd 6) To offer modification in consistency, like fluid and soft diets. To enhance or reduce the energy values, i.e., reducing diets. To incorporate more or less quantity of one or more nutrients, i.e., high protein and low fibre diets. To enhance or reduce bulk, i.e., high and low fibre diets. To offer bland in flavour foods to include or exclude certain foods if causing allergy. To change the intervals of eating meals. 9.2.3. Principles of Diet Modification 1» 2) 3) 4) ‘The diet should be modified after considering the nutritional requirements of each patient. Modified diet has some specific food constituents and differs from the normal diet. Process of diet modification may include one or several steps. The diet may be modified temporarily, i.e., for one day, one month, for the duration of illness, or lifelong. Modifications in the diet should be rational and should be made according 10 the facts and findings. Permanent diet modifications should be made in case of chronic diseases. The patient should be aware of the objectives and i ee Purposes of diet‘Therapeutic Diets (Unit 9) 179 7) Diet modifications should be done according to the diseases and drugs. as both affect the body functions. 8) Diet modification also includes changed diet behaviour of the patient. 9.2.4. Methods of Diet Modifications 1) Changing the form of diet, i.e., liquid diet or soft diet in place of solid diet. 2) Increasing or decreasing the dietary caloric value. 3) Changing the quantity of any dietary nutrient: i) High- or low-protein diet. ii) High- or low-fat diet. iii) High- or low-carbohydrate diet. iv) High- or low-fibre diet. v) Low or salt-restricted diet. 4) Increasing or decreasing the meal size. 5) Increasing or decreasing the number or frequencies of diets. 6) Changing the flavour and odour of diet, e.g., bland diet (without chillies and spices). 7) Increasing the interval between diets. 8) Changing the route of diet (e.g., tube feeding). 924.1. Modification of Diets in Consistency The consistency of food depends on the patient condition. Diet consistency incorporates: 1) Clear Liquid Diet: This diet is prescribed for patients with severe food intolerance characterised by nausea, vomiting, loss of appetite, etc. The types of foods incorporated in this diet are coffee, weak tea, gelatin, strained fruit juices, clear meat broth, glucose water, carbonated beverages, sugar, and cereal water. This diet provides fluids, some electrolytes, and little portion of energy. This diet is not approved for more than 1 or 2 days as it lacks many nutrients. The volume of fluid is initially limited to 50-100mV/hour and gradually enhanced to 125ml/hour as the patient tolerates and the condition gets better. Full-Liquid Diet: This diet is prescribed for patients who are unable to chew or swallow or digest solid foods. This diet consists of liquid or semi-liquid at room temperature, e.g., gelatin, ice cream, milk, eggs, cereals porridge, fruit juices, and soups. The average full-liquid diet offers enough energy (1000-1500kcal) and least need of fats, proteins, vitamins and minerals. A cautious planning may enhance the nutrient portion of diet. Suitable liquid diets can be planned for tenal failure, diabetes, and other disorders. 3} Soft Diet: This diet is prescribed for patients suffering from fever, acute infections, gastrointestinal disorders and post-operative conditions. It is a change between a liquid and a normal diet. This diet has a soft consistency and is slightly low in cellulose and residue, ice, it is easy to digest and has very less spices and condiments.180 Applied Nutrition and Dietetics Soft diet foods are as follows i) Cooked soft rice and bread. ) Pulses with no skin, properly mashed, and cooked. iii) Milk and milk items, like paneer, curd, cheese, buttermilk, kheer, etc. iv) Eggs, half-boiled, scrambled, ground meat, chicken and fish. v) Soft fruits, such as mango, bananas, citrus fruits, etc. vi) Vegetables, like pumpkin, potatoes, bottle gourd, and other non-fibrous vegetables. vii) Butter, custard, jam, soups, and strained fruit juices. Soft diet does not include: i) Whole pulses ii) Chapatis iii) Fried eggs iv) Mutton and other tough variety v) Raw vegetables, like radish, cucumbers, lettuce, carrots, etc. vi) Raw and tough fruits, like apples, unripe guavas, etc. vii) Whole grain cereals, containing bran viii) Soups containing high fat ix) Highly seasoned and fried foods x) Spicy foods, like chutneys, pickles, and hot sauces. 4) Mechanically Soft Diet: This diet is prescribed for patients with poor dentition or having some dental issues. The consistency of regular diet is modified without limiting the choice of foods in this diet. Following are the foods included in mechanically soft diet: i) Soft cooked rich, porridge. ii) Breads with no curst. iii) Well-cooked pulses. iv) Half boiled, scrambled eggs. v) Ground meat and fish. vi) Cooked non-fibrous vegetables. ; vii) Raw vegetables, like finely grated cucumbers, chopped tomatoes, mint and coriander chutneys. viii) Raw fruits, like mango pulp, bananas, water melon, grapes, honey dew, cantaloupe, ripe peaches, plums, pears, with no skin, etc. ix) Baked or cooked apples after peeling, like apple sauce, apple stew, etc. 9.2.4.2. Modification of Diets in Different Nutrients Prescribing the correct type of diets for the nutritional needs of patients suffering from various diseases is the purpose of therapeutic nutrition, Following can be the objectives of diet therapy: 1) To rectify the existing dietary shortage and maintain good nutritional state of the patient. 2) To plan a diet for meeting the requirements of patient based on food habits. 3) To educate the patient about the importance of adhering to the prescribed diet. 4) In most cases, diet therapy is not a cure, rather a measure that supplements of improves the effectiveness of medical or surgical treatment.‘herapentic Diets (Unit 9) 2 Dietary changes in diseases may involve alteration in various constituents. like 1) Omitting spices and condiments, and bland diets. 2) High or low fibre diet. 3) High or low protein diet 4) High or low fat diet 5) High or low carbohydrate diet §) High or low calorie diet. 7) Low sodium diet Invarious diseases, the kinds of modification needed in the diets are 1) Modification in Calorie Content: Diet rich in calorie is needed in infectiom fever and hyperthyroidism. Diet low in calorie is for the treatment of heart diseases and obesity. 2) Modification in Carbohydrate Content: Diet rich in carbohydrate is needed for pre-operative conditions and liver diseases. Diet low im carbohydrate is for the treatment of diabetes mellitus. 3) Modification in Protein Content: Diet rich in protein is needed for PEM and liver cirrhosis. Diet low in protein is for hepatic coma and nephritis. 4) Modification in Fat Content: Diet slightly high in fat is needed for the treatment of severe under-nutrition. Diet Iow in fat is essential in heart diseases, obesity, and hepatic diseases. Modification in Mineral Content: Diet rich in calcium is needed for the treatment of osteomalacia and rickets. Diet with limited calcium is for kidney stones. Diet with limited sodium is for the treatment of kidney diseases. hypertension, and cardiac failure. Modification in Fibre Content: Diet rich in fibre is needed for the treatment of constipation. Diet low in fibre is for the treatment of peptic ulcer, diarrhoea, and dysentery. 1) Modification in Vitamin Content: Different brands of vitamin supplements are present in the market. Usually, therapeutic diets are deficient in vitamins which can easily managed by prescribing a specific vitamin supplement. §) Modification in other Constituents: Diet low in purine is needed for gout. Diet low in oxalic acid, calcium, uric acid, and phosphorus is for renal calculi, depending on the nature of stones. FEEDING TECHNIQUES 53.1, Introduction Patients, who cannot eat adequate food or in whom nutrient absorption does not ‘cur, need artificial feeding. It aims to supply all the essential nutrients for ‘uvival of body, and for normal growth and development in young patients. s Yor example, artificial feeding is required for patients in coma or with paralysed. throat muscles who cannot swallow food; artificial feeding is required in patients, Whose diseased small intestine has been surgically removed, thus not leaving ‘equate surface for nutrient absorption; artificial feeding is also required in Patients with major infection or severe injury. Such patients need large amounts fnutrients and artificial supplements.182 Applied Nutrition and Dietetic, 9.3.2. _ Nasogastric Intubation In nasogastric intubation, a thin, plastic tube is inserted into the nostril, passeq through the oesophagus, and down into the stomach. After placing the nasogastric tube properly, nurses deliver food and medicines directly into the stomach or obtain substances from it. 1) 2) 3) 4) 5) 6) To feed with fluids in patients who cannot intake food orally. To dilute and remove consumed position. To instil ice cold solution for controlling gastric bleeding. To prevent stress on operated site by decompressing. To relieve vomiting and distension. To collect gastric juice for diagnostic purposes. Equipment 1) 3) » Nasogastric tube of appropriate size. 2) ‘K-basin. Stethoscope. 4) Bowl with water. Adhesive scissor. 6) Syringe (20cc or 10cc). End of Nasal cavity nnasogastic tabs Nasogastric tube ‘Stomach Figure 9.1: Correct Placement of Nasogastric Tube Preparation 1) 2) 3) 4) 5) 6) 1 8) The nurse should explain the procedure to the patient. She should arrange all the equipment at the bedside. She should provide privacy. She should place the patient in a comfortable position. She should place the Mackintosh and towel across the patient’s chest. She should remove the dentures (if any) and place it in a bow of clean water. She should give mouthwash to the patient to help him/her in cleaning the teeth. She should clean the patient’s nostrils with swab sticks dipped in saline, if there are secretions or crust formation. Procedure 1) 2) 3) 4) The nurse should wash hands thoroughly. She should measure the distance of tube from the tip of patient’s ear lobe nose to tip of xiphoid process. She should mark the distance of the tube. She should lubricate about 6-8 inches of the tube with a lubricant using 48 Piece or a paper square.a ‘Therapeutic Diets (Unit 9) 193 5) She should hold the tube coiled in the right hand and introduce the tip into the left nostril. 6) She should pass the tube gently and quickly backwards. 1) When the tube reaches the pharynx, the patient may gag. 8) She should let the patient rest for a moment and sip water. 9) On command, she should advance the tube 3-4 inches each time the patient swallows 10) After ensuring that the tube is in stomach, she should close the other end of tube with spigot, and secure the tube on nose using adhesive in ‘T’ or butterfly. 93.3. | Nasogastric Tube Feeding or Gastric Gavage Nasogastric tube feeding involves giving food and fluids through a tube inserted through the nose into the stomach of a patient who cannot take food by mouth. 1) To supply proper nutrition. 2) To give large amounts of fluids for therapeutic purpose. 3) To evaluate tolerance of feeds in post-operative patients. 4) To introduce food into stomach of a patient who cannot eat food. 5) To introduce food into stomach of a patient whose mouth or oesophagus condition makes swallowing difficult. Indications 1) In unconscious or semi-conscious patients. 2) Inpatients undergone mouth and throat surgeries. 3) In patients who face difficulty in swallowing. 4) In premature babies. 5) Inpatients who are unable to retain the food, e.g., anorexia nervosa and vomiting. Equipment 1) Mackintosh and towel. 2) 20ce syringe. 3) Stethoscope. 4) Bowl with water. 5) Adhesive with scissors. 6) Feeds and water. 7) Ounce glass. Procedure: 1) Syringe Method i) The nurse should wash hands. ii) She should place towel around the patient’s neck to protect his/her clothing and bed linen. iii) She should ensure that the tube is in stomach before giving feeds. iv) She should remove spigot, pinch tube to prevent the entry of air, and remove plunger from syringe and connect to tube, v) She should keep syringe 12 inches above patient’s head. vi) She should first introduce small amount of water slowly and steadily to prevent the entry of air in tube. i) She should not force fluid and let it flow under the effect of gravity. viii) Lastly, she should flush the tube by pouring small amount of water, and remove the syringe and replace with spigot.a 164 ‘Applied Nutrition and Dieaiy 2) Syphon Method i) She should place towel around the patient's neck t protect hishhe, clothing and bed linen. ii) She should ensure that the tube is in stomach before giving feeds, iii) She should immediately dip the tube tip in prepared feed to prevent the entry of air in tube. iv) She should raise the fluid container 12 inches above patient's head wy ‘observe the fluid flow. v) Lastly, she should flush the tube by pouring small amount of water, ang pinch tube and close with spigot 9.3.4. Gastrostomy Feeding Gastrostomy feeding involves making an opening, via surgical process to connect the inside of the stomach to the abdominal wall. A tube is inserted into the opening to introduce food in the stomach Methods of Gastrostomy Feeding Syringe Feeding: In this method, a 5Ucc syringe is used to introduce feed in the stomach as per the doctor’s orders. Indications of Gastrostomy Feeding 1) In patients with impaired swallowing and decreased level of consciousness, 2) In patients with tumours and fistulas on the upper alimentary tract. 3) In patients who have undergone surgeries in the upper alimentary tract, and food cannot reach the stomach via normal route. Equipment | 1) A feeding up with water. 2) Kidney tray. | 3) 50cc and Sec clean syringes. 4) Ounce glass. | Procedure | 1) The nurse should evaluate the patient's need for gastrostomy feeding. | 2) She should auscultate for bowel sounds before feeding, and should consult the doctor in case of absence of bowel sounds. 3) She should obtain baseline weight and laboratory values. 4) She should verify the doctor’s order for formula, rate, route, and frequency. 5) She should evaluate the gastrostomy site for breakdown, irritation or drainage. 6) She should explain the procedure to the patient. 7) She should wash her hands, 8) She should prepare the feeding container to administer the feed by: i) Conducting tube feeding at room temperature. ii) Connecting the tube to container or preparing a ready-to-hang containet- iii) Shaking the formula and adding in the container and tube. 9) She should raise the head of bed at 30-45°. 10) She should wear gloves and verify tube placement.enpeate Diets (Unit 9) toe She should attach the syringe and aspirate gastric contents or secretions, observe their appearance and measure pH value. 1») Aspirated contents in <100ml volume should be returned to the stomach. If the content volume is >100ml, feeding should be stopped to inform the doctor. 13) She should administer water through the feeding tube either with or between S. feedings. 1s) She should flush the tube by pouring 30ml of water into it in every 4-6 hours and before and after administration of medication via tube. |)When not feeding, she should cap or clamp the proximal end of the gastrostomy tube. 16 She should rinse the container and tube with warm water after feeding. 1) She should keep the gastrostomy exit site open to air. However, dressing of the site should be changed daily and the drainage should be reported to the doctor. 18) She should dispose of the supplies and wash hands. 93.5. Total Parenteral Nutrition (TPN) Joal Parenteral Nutrition (TPN) is a feeding method that bypasses the GIT. In this method, fluids are administered via intravenous route to provide maximum tutrients the body needs. TPN is used when a person is unable to or should not meive feedings or fluids orally. Types of TPN |) Central Parenteral Nutrition (CPN): In this method, fluids are delivered through a central vein, mainly the superior vena cava that is present beneath the collarbone and directly goes to the heart. Through the larger central vein, a larger catheter can be used to deliver higher concentrations of calorie-rich nutrients. Thus, CPN is used to deliver total parenteral nutrition. 2) Peripheral Parenteral Nutrition (PPN): In this method, fluids are delivered through a smaller, peripheral vein in the neck or one of the limbs. PPN is used to temporarily provide partial parenteral nutrition, using the quicker and easier access of peripheral vein. Composition of TPN is a mixture of all the essential nutritional components, including protein, ‘it, calories, vitamins, and minerals. TPN solutions should be modified as per the ‘eed of each patient, depending on their age and state of organ function. Figure 9.2: Central Parenteral Nutrition The major three macronutrients provided by TPN are: !) Proteins: ') A specially prepared mixture of synthetic, essential amino acids is supplied intravenously. The 200ml bottles containing 8-9% of amino acids are available for IV use.Applied Nutrition and Dieteticy ii) Patients with serious diseases, with normal hepatic or renal function neeq 1.5. gm protein/kg/day. Chronic renal patients should be administered TPN in 0.6-0.8 mg/kg/day rate and hepatic encephalopathy patients should be administered TPN in 0.8 mg/kg/day rate. 2) Calories: i ‘Calories are administered as 20-25% dextrose in water through a centraj ____ Yein. 3.4 calories is obtained from a gram of dextrose. ii) Other sources of carbohydrates, like fructose, xylitol, sorbitol and glycerol, are under study for use in TPN. 3) Fats: i) Lipids provide calories and prevent Essential Fatty Acid Deficiency (EFAD), which may occur within 3 weeks of fat-free TPN. Some common sources of lipids in TPN are soyabean/safflower oil, egg yolk Phospholipids in 10, 20 and 30% concentration, respectively. Milky emulsions of soyabean or safflower oil in combination with emulsifying agent and glycerol are also available. ii) 1.1 calories are obtained from ml of 10% emulsion. 500-1000m1 of 10% of emulsion is injected per week to prevent deficiency syndrome. The micronutrients provided by TPN are: 1) The commercially available multivitamin preparations contain essential vitamins, like thiamine, riboflavin, niacin, biotin, ascorbic acid, cyanocobalamin, etc. 2) Copper, zinc, selenium, and chromium are the trace elements commonly added in TPN. Level of these trace elements is monitored every month. 3) Sodium (100-150 mEq), Potassium (50-100 mEq), Magnesium (8-24 mEq), Calcium (10-20 mEq), and Phosphorous (15-30 mEq) are recommended per litre of TPN solution. Indications of TPN TPN should be administered if the digestive system is not functioning properly or if the patient has a gastrointestinal disease that demands complete rest. Some people might need general nutrition therapy, but might have medical reasons why enteral feeding does not work for them. Specific conditions that may require TPN include: 1) Abdominal surgery. 2) Chemotherapy. 3) Intestinal ischemia. 4) Intestinal obstructions. 5) Intestinal pseudo-obstruction. 6) Prolonged ileus. 7) Gastrointestinal bleeding. 8) Radiation enteritis. 9) Extremely premature birth. 10) Necrotising enterocolitis. 11) Prolonged diarrhoea. 12) Inflammatory bowel diseases. 13) Short bowel syndrome. 14) Persistent chyle leak. 15) Graft-versus-host disease of the gut.“Therapeutic Diets (Unit 9) 187 LA Procedure 1) TPN is administered through central venous catheter. Tunneled catheter and implanted catheter are the commonly used ones. Tunneled catheter has a tube segment outside the skin and another portion tunneled under the skin before entering the vein. Implanted catheter is completely inserted under the skin. 2) The patient is anaesthetised and the catheter is placed into a large vein that % goes to the heart. : Base solution of TPN is a mixture of amino acids and dextrose that is prepared daily by mixing both the solutions in laminar flow hood in hospital pharmacy. Minerals and vitamins are also added to this base solution. 4) Starting dose of TPN is one litre of base solution per day. If this initial dose is . tolerated by the patient, the quantity infused is increased by 0.5-1 litre every day. & 5). While discontinuing TPN, the amount of glucose infused should be gradually reduced. ‘ 9.4. DIET IN DISEASES 9.4.1. Obesity Obesity is a condition characterised by abnormal growth of adipose tissues under dermis due to enlargement of fat cell size or increase in fat cell number or both. The most effective method of controlling obesity is by dietary modification resulting in effective weight loss, whether used alone or with other lifestyle changes, including increase in physical activity. Modifications in Diet 1) Energy: For loosing around Ikg/week, there should be a decrease of 1,000kcal. Reduction of 500kcal results in a weight loss of nearly 1/2 kg/week. 2) Protein: Protein intake should be increased slightly than normal and provide 20% of total energy by fats. Unsaturated fats should be recommended and fried foods should be avoided completely. The following foods help in reducing weight: 1) Low-calorie, high-fibre and high-protein diet. 2) Low-fat, sugar and refined carbohydrate. 3) Lean meat. 4) Three meals a day. 5) Vegetable soups, salad, plain lassi, and lemon water. 6) All cereals, pulses, egg, and milk. One day menu plan for obese person is given in table 9.1: Table 9.1; One Day Menu Plan for Obese Person (1000kcal) 8 Meals Foodstuffs Quantity Early morning Lemon water T glass Lemon tea without sugar 1 glass Breakfast Toned milk T glass Missi roti 1 Curd or 125gm Bread with egg 2 slices 1 egg (boiled) or Mixed vegetables, dalia 130gm (100gm+30gm)Applied Nuteition and Dietetics Buiter milk/iassi without sugar 400c¢ ocettrus fait 1 Salad No restriction ‘Chapatti 2 Groen lealy vegetables. 2 bowls | Cunt a 1 bow! | i 4 Salt biscuits 2 | Roasted channa 25gm | Vegetables soup F742 cups Chapatti 1-2 | Vegetable stew 2 bow! Dal or paneer 1 bowl/35gm | ‘or chicken 100gm Foods to be Avoided 1) High Fat Foods: Butter, processed cheese, chocolates, creams, fatty meats, fried food, etc. 2) High Carbohydrate Foods: Bread, cakes, dried fruits, rice pulao, potatoes, ‘Table 9.2: Low Calorie Diet for an Adult Suffereing from Obesity Requirement Food Stuffs 1100keal__| 1300 keal Veg. | Non-veg. | Veg. ‘Non-veg._ Cereals | 80 80 100 100 Pulses 60 40 70 50 Skim milk 1000 500 1000 0 Cheese 50 - 50 - Meat fish = 50 : 60 Ege ae 60 . 80 Fruits 50 50 50 50 Vegetables 450 450 450 450 Sugar/jaggery 50 15 20 20 Fats and oils 450 15 20 20 9.4.2. Diabetes Mellitus Following facts and nutrients should be kept in mind while preparing a diet plan for diabetic patients: 1) For diabetic patients, the percentage of proteins, fats and carbohydrates should be around 20%, 30%, and 50%, respectively. 2) Diet plan should be prepared by a dietician according to type I (IDDM) and type II (NIDDM) diabetes. 3) Vitamins and minerals should be taken in sufficient quantity. 4) While planning a diet for a diabetic patient, his/her religious/cultural background, height and weight, occupation and general activity should also be considered. 5) The diet plan should be such that it includes more number and variety of servings with a strict control on the quantity of diet.‘therapeutic Diets (Unit 9) 189 6) Sugar should be avoided while cooking food for a diabetic patient, and also syrup. honey, sugar jelly, jam, etc., should not be served with meals, Fruit juices/cold drinks, should be completely stopped. 7) Beverages, like tea and coffee, should not be consumed, or should be consumed without sugar. 8) The quantity of salad in diet should be increased and it is better to use unsaturated fatty acids. 9) The calorie intake and diet chart should be planned according to the individual requirement. Simultaneously, food items like milk, fat, bread, fruits, and vegetables, can be used to control quantity of calories and blood sugar. 10) A diabetic diet should have the following properties: i) The diet should be designed to attain and maintain desirable body weight according to the individual needs. ii) Simple carbohydrates (sugars) should be replaced with complex carbohydrates (starches). iii) Consumption of polysaturated fats should be preferred over saturated fats. iv) Special care is needed for those who are on insulin therapy. For such patients, regular meals are important; therefore, fasting or over-eating should be completely avoided. Number of diet should be scheduled according to the type and dosage of insulin. Table 9.3: One Day Menu Plan for Diabetic Patient Meal Food Stuff | Quantity in | Quantity in | Quantity in Sedentary | Moderate | Heavy Worker t Worker Worker |Early morning |Lemon water cup Tcup lcup | Lemon tea cup lcup lcup L Toned milk lcup cup 2cup| Breakfast Bread slices 2 slices 2 2 slices | Missi roti 1 1 i | Curd (200gm) 1 katori 1 katori 1 katori | Butter a - 10gm t Fruit citrus 1 1 1 Mid-morning | Sprouted dals 30gm 30gm 30gm Black gram 30gm 30gm 30gm Roasted 30gm 30gm 30gm channa Lunch/Dinner [Salad 1 plate I plate 1 plate Diabetic 1 2 3 chapati — Green leafy ‘vening tea | Vegetables 1 Katori 1 Katori 1 katori Dal or Chicken Tea 1 katori 1 katori 1 katori Bran biscuits 1cup 1 cup 1 cup Le or 2 2 4 Paneer 30gm_ 30gm 30gm190 Applied Nutrition and Dieteticy 9.4.3. Cardiovascular Diseases (CVD) In individuals with cardiovascular diseases, the diet plan should be such that it provides rest to heart, protect it from angina and myocardial infarction, prevent or eliminate fluid accumulation in the body, and maintain good nutritional status, For acute phase of MI or cardiac failure, the sample menu is given in tabl re pI gi les 9.4 ‘Table 9.4: Sample of Daily Diet for Cardiac Patient with Acute Phase (1000 Calories) Foodstuffs Amount Milk and milk products 750ml Egg white 1 Fruits for juice 200gm Vegetables for soup 200gm Cereal (for idge, | 1 ; porridge, | 100gm Oil (unsaturated) 10gm Sugar 20gm Source: Guidelines for Standardised Hospital Diets, DGHS, MOHFW. 1) This diet should be low in fat, cholesterol, sodium, and caloric value. Once the acute phase is over and patient’s condition starts stabilising, the following maintenance diet is prescribed: Table 9.5: Sample of Daily Diet for Cardiac Patient with Maintenance Phase (1800cal) Foodstuffs Amount ‘Milk and milk products 750ml Egg white 1 Paneer/meat or chicken 30/50gm Fruits 200gm Vegetables 400gm Cereal 200gm il (unsaturated) 15gm Sugar 20gm_ ‘Source: Guidelines for Standardised Hospital Diets, DGHS MOHFW. 2) Salad or foods with added salt or baking powder should be avoided. 3) Cholesterol sources, high sodium or high fat foods, and alcohol-based beverages should be avoided. 4) The Chronic Heart Diseases (CHD) can be controlled by including a low- cholesterol, low-fat, high-fibre and sodium-restricted diet. Table 9.6: One Day Menu Plan for CV Diseases Meal__| Food Stuff Quantity Early morning (Breakfast) | Lemon water 1 glass Milk (skimmed) 1 cup 200ml Sugar 1 tsp Missi roti or stuffed roti 1 Curd Ya katori Boiled egg (white) 12 Bread 1-2 slices | |cerspeutie Diets (Unit 9) tor | f Mid-moming | Fresh Aj Lunch Salad 150gm 2-3 (30gm each) GOgmn (raw) 250gm See __| 1 katori (200g) | Evening tea | Dinner Vegetable soup cup ‘Chapati 2 (30gm each) Vegetables 250gm Dal sabot 1 katori Paneer Chicken or fish 100gm Whole day’s cooking oil 14.4. Under-weight oor nutrition can Jead to under-weight which can be a matter of concern. The y fails to function normally if it does not get enough quantity of nutrients, and ult in metabolism imbalance. For improved functioning of the body, a healthy et should be followed for under-weight that can provide the required nutrients. 40 under-weight person can use these quick health tips for a diet plan: ¢ Heavy food products that are rich in calories are taken. 0 Nutrient-rich foods are taken on a regular basis, whether as snacks, shakes, or juices, or as full meals. Ingredients that are rich in calories are added to a regular diet; for example, eggs and bananas are added in morning breakfast to result in weight gaim. 4 Protein supplements in addition to enough quantity of vegetables and fruits are added to a regular diet. Calorie rich food and continuing a balanced diet can result in weight gain. The diet must not be started abruptly, but rather gradually, so that the body becomes adapted to it. Products that can be Included in the Under-weight Diet Plan Lean Red Meat: Steaks are rich in protein and iron, Red meat has high cholesterol content due to this most food professionals do not suggest it to be included in a healthy diet more than a few times in a week. Real Nut Butters: Natural peanut butter is rich in protein and fats, and thus | itis a great option for those who want to gain weight in a healthy way. One {_ blespoon of real nut butter provides about 100 calories and 4 grams of protein. Whole Fat Milk: Dieticians state that when trying to gain weight, skim milk should be replaced with whole milk. It has fats which gives about 60 more calories per glass. @ Tropical Fruits: Papaya, mango, pineapple, and bananas are great options as they are rich in natural sugars and provide great energy.Applied Nutrition and Dietetics 5) Avocado: These are best way to add heart-healthy fats to the diet. One half of an avocado has 140 calories, and is also rich in vitamin E, potassium, and folic acid, 6) Natural Granola: No added sugar, natural granola is a good cereal if want to gain weight. This snack is made from rolled oats, healthy fats (nuts and coconut oil), and also include dried fruit and nuts. 7) Whole Wheat Bread: Nutritionists state that eating healthy, whole grain bread items can be a great way to start gaining weight. 8) Nuts: These are amazing snack for weight gain as they are rich in fat, fibre, and other nutrients. Having only a handful of nuts can keep a person full for hours. 9) Cheese: Try Swiss cheese with roasted chicken, goat cheese with eggs, and Parmesan on top of asparagus. Alone also, cheese can be a great snack as it is rich in protein. Foods to be Avoided 1) Fried food 2) Refined carbohydrates 3) Sugary food items 4) Carbonated drinks (5) Candies 9.4.5. Renal Diseases Kidney helps to eliminate waste products from the body. Chronic renal failure results due to slow progressive destruction of kidneys. This is a condition of mild, moderate or severe kidney damage. In renal failure, kidney fails to eliminate waste products properly, hence resulting in their accumulation in the body. Dietary Pattern 1) In case of renal failure, low-protein and low-sodium diet should be followed (table 9.7). Table 9.7: Daily Nutrient Requirement for Chronic Renal Disease Patient Nutrients Allowance | Sedentary Worker | Moderate Worker | Heavy Worker Proteins 20gm 30gm 40m Calories 2,040 2,197 2,363 [— Sodium 180mg _ 215mg 255mg Potassium 1,226mg 1,382mg 1,982mg Phosphorus 441mg 586mg 71 Tmg. 2) Low-protein diet should be followed. 3) Milk and its products or egg should be included in the planned diet. 4) Cereals, pulses, peas, and beans should be taken in recommended amount. 5) Fats and carbohydrates should be consumed in small amount. 6) Cakes, biscuits, bakery products, jams, and sharbats can be used, except when sugar is restricted, 7) Fruits and their juices should be consumed to obtain vitamins and minerals. 8) Small amount of spices and condiments should also be included in the diet.Therapeutic Diets (Unit 9) fa 20 Table 9.8; One Day Menu Plan for Chronic Kenal Failure Patlent Meal Sedentary Workers | Moderate Worker | Heavy Worker | reakfast | | Bread mixhit 1 slice 2 slices | 2 slices ; rer 10gm 20gm | 0 Egg/pane | gm eB Mik | Et - Lanch w a od rice I serving | serving 1 serving UF | chapati Aree i |_| Fried potatoes (1kg) | serving serving 1 serving 8) | Yopetbies 1 serving 1 serving 1 serving lf | Ys katori Ya katori 4 katori Curd _ Yakatori | _ 2 Jcup Jcup een | Sweet sago __| serving 1 serving 1 serving | Dinner . lei 1 serving "serving 1 serving | Chapt b serving 1 1 ( |Mashed potatoes serving - I vaeeaay 1 katori 1 katori 1 katori Vegetables i i i | Dat 1 katori 1 katori 1 katori (94.6. Hepatic Disorders Some liver disease sufferers need to follow a particular diet. This diet effects the functioning of liver and also shields the liver from overwork. In case a person is suffering from liver disease, he/she should regulate his/her diet as follows: 1) Energy: At first, due to loss of appetite, only 1500-2000 kcal may be acceptable. The energy intake should be gradually increased to 20-30% greater than usual. 2) Fats: Digestion and absorption of fat is affected by liver diseases because | bile production is hindered. Different people may have different levels of fat tolerance. As a result, mild to moderate instances may be treated with 40- 50gm of total fat per day. The overall amount of fat may be limited to 20- 30gm/day in severe cases due to liver impairment. Fat quality needs to be altered and changed. Since bile is not necessary for their emulsification, emulsified fats (milk and egg fat) should be consumed, 3) Minerals and Vitamins: All minerals, including calcium and iron, should be present in sufficient quantities in the diet. A, K, C, and B group vitamin supplements should be taken because fat-soluble vitamins, including vitamin: A and D tend to be low due to decreased fat intake, 4) Proteins: Increasing protein consumption is necessary to reverse a negative nitrogen balance, boost the regeneration of liver cells, and stop fatty infiltration of liver. Therefore, depending on the severity of liver damage, it is important to modify protein consumption. A high intake of 1.5-2gm of protein per kg of body weight is indicated in mild to moderate instances. However, in severe cases, protein intake should be much Jower than usual.A Applied Nutrition and Dietericy 5) Carbohydrates: A high- carbohydrate dict is advised for people with liver disease. Patients with liver illness are advised to consume 300-400gm of simple carbohydrates per day, such as glu honey, sugarcane juice. fruits, fruit juice, starches including cereals, and root vegetables 6) Feeding Pattern: In case of anorexia, well-cooked as well as attractive foods should be served. Regarding the requirements for diet consistency and feed frequency, adjustments are made. In contrast to acute hepatitis, which may te treated with a liquid or soft diet, or in very severe cases, tube feeding, patients with moderate hepatitis may be able to consume a normal consistency meal. 7) Foods to be Included: Sugars, milk and milk products, glucose, honey pulses, eggs, fruits, and vegetables should be consumed. ° 8) Foods to be Avoided or Restricted: Foods that are fried or greasy, fats, oils, nuts, oil seeds, and intensely flavoured meats and vegetables should not be consumed. Alcohol consumption is likewise strictly inhibited. 9.4.7. Constipation When bowel motions become less frequent and faeces become harder to evacuate, this is known as constipation. Changes in food or lifestyle, as well as a lack of fibre, are the most common causes. Constipation symptoms can include: 1) Pain or discomfort while passing stools 2) Small, dry, or hard stools 3) Bloating The portion of foods which a person eats that cannot be completely digested is referred to as roughage or fibre. A balanced diet should include a sufficient amount of fibre, which has been linked to numerous health advantages, including improved gut health, Adults are usually advised to consume 30gm of dietary fibre daily. y Therefore, function of fibre in the body is as follows: 1) It aids in appropriate gut muscle function. 2) It gives the faeces bulk and also softens them to make them easier to pass. 3) It can encourage the development of good bacteria in the intestines to enhance gut health. The following high fibre foods need to be included in diet: 1) Wholegrain Carbohydrates: i) Wholegrain breakfast foods, including branflakes, shredded wheat, fruit and fibre, muesli, and porridge oats. ii) Pita bread, chapatti, whole-wheat rolls, and wraps. iii) Brown rice and brown pasta iv) Potatoes with skin v) Oat cakes vi) Crackers and cookies made with whole grains or seeds.mews Trerapencc Die (Unit 9) " 2D, Praits and Vegetables: i) At least five different servings of fruits and vegetables each day if) Fresh, canned. frozen, and dried fruits and vegetables. iti) A serving of fruits or vegetables, such as a handful of grapes, is abort the size of palm. iv) Extra vegetables or a side salad with meals. ¥) Increase the amount of vegetables in soups, casseroles, curries, pasta meals, and chilli | 3) Beams and Pulses: 3) All beans, including haricot, butter, and kidney beans. i) Baked beans iii) Peas, chickpeas, and lentils iv) Hummus 4) Nats and Seeds: i) Every types of nut and seed, including peanuts, cashews, almonds. pine nuts, brazil nuts, sunflower seeds, and pumpkin seeds. ii) Handful of nuts and seeds as a snack or added to cereal, porridge, yoghurt or salads. [Foods to be Avoided 1) Dairy products 2) Red meat Chips 4) Frozen dinners (Cookies 6) Bananas Fried foods 948. Diarrhoea . Diarrhoea is defined by faeces that are excessively loose or watery. Bacteria, © viruses, and parasites are the most common causes of diarrhoea. It might range ic diarrhoea ftom a minor, transient ailment to a potentially fatal illness. Chronic di can also be caused by digestive system problems. Dietary Management 1) Diasrheic patients should never be starved because digestive enzymes are still active and over 60% of digestion is still possible in acute state. 2) Resting the gut can be particularly harmful because it may cause structural changes in gut membrane. 3) Carbohydrates that are simple to digest can offer calories. The patient’s tolerance is taken into account when progressively increasing calorie intake. The realistic goal is a 200-300 Kcal increase. 4) Persistent and chronic diarrhoea increase the need for proteins. However, milk is prohibited due to its high residue content or a relative lactase enzyme deficit in GIT. Curd, buttermilk, yoghurt, and other fermented milk products are better tolerated and support digestive health. 5) High fat intake is reduced because its digestion and absorption have been changed. There is a provided emulsified form of fat that is high in MCT.196 Applied Nutrition and Dietetics 6) During treatment, simple sugars should be administered rather than complex sugars. It is advisable to consume soluble fibre in the form of stewed fruits and vegetables as it helps to bind the stool and promotes a healthy intestinal environment. 7) Supplemental vitamins and minerals should be taken. 8) ORS solutions should be taken to replace sodium and potassium and to stop. fluid and electrolyte loss. Foods to be Allowed 1) All cereals, like wheat flour 2). Suji, rice, rice flakes, ete. 3) Washed pulses 4) Sago 5) Jams 6) Honey 7) Fruits 8) Vegetables 9) Eggs, chicken 10) Skimmed milk with cereal 11) Curd, buttermilk, paneer 12) Fruit juices (tetra packs) 13) Probiotic drink (yakult). Foods to be Avoided 1) Whole milk 2) Fried foods 3) Green leafy vegetables 4) Whole pulses 5) High fibre foods. 9.4.9. Diet in Pre- and Post-operative Period Planning is required to get ready for surgery. The person must be mentally and physically prepared for a procedure that will put some strain on body. It can be benefited from having a healthy diet. The person should start having a healthy and balanced diet few days before surgery. He/she should also stop smoking for at least 10 days before surgery, and alcohol consumption should be completely stopped 24 hours before surgery. These bad habits raise blood pressure, restrict blood vessels, and impair circulation. The pre-surgery diet has to include: 1) Fruits and Vegetables: These are easily digestible, which will aid in keeping the weight stable throughout the recovery phase after surgery when the body needs to relax. Vitamin C, which is abundant in fruits and vegetables, encourages collagen production, which is necessary for healing, recovery, and increasing energy. 2) Slow Carbohydrates (Rice or Pasta): These enhance digestion, which is crucial before urgent medical treatments because surgery causes the body to be suspended, which encourages constipation. Fast carbohydrates are easily absorbed, contribute to mood elevation, and stimulate the release of serotonin (happy hormone), which can be inhibited by inactivity and insufficient exercise. 3) Proteins: Meat from chicken or turkey, red meat, fish, eggs, and seafood should be consumed. These benefit the muscles, and after the operation these might stay inactive for a few weeks due to the required period of rest and the inability to lift any significant weight.| ‘Therapeutic Diets (Unit 9) 197 4) Unsaturated Fats: Fats found in avocado, olive oil, oily fish, nuts, and dried fruits are the only kinds that the body can use for pre-surgery preparation. These fats are helpful and vital when utilised appropriately. But it is crucial to monitor the weight. The post-surgery diet has to include: | Itis crucial to keep up a healthy diet after surgery to enable a quicker recovery and assist the patient in getting back to his/her favourite activities (as feasible). { Some people experience appetite loss following surgery and when taking pain- (killers. However, surgery raises the body's calorie requirements, and healing | quires extra calories. 1) If the patient's appetite has diminished, he/she needs to have smaller meals more frequently. ‘The patient should consume fruits, vegetables, cooked beans, and whole grains to add fibre to meals and snacks. Fibre supports regular bowel movements. 3) For muscles and bones, the patient should consume protein with each meal. In addition to cooked dried beans, protein can also be found in meat, fish, eggs, poultry, nuts, dairy products, and soy products. The patient should eat yoghurt, cheese, drink milk or calcium-fortified drinks. If he/she does not receive enough calcium from meals, the doctor may advise a calcium and vitamin D supplement. 5) Bone development and wound healing are aided by vitamin C. The patient should consume citrus fruits, green and red peppers, broccoli, spinach, strawberries, tomatoes, and potatoes because they are good sources of vitamin C. 16) The patient should drink at least 6-8 cups of fluid each day to prevent constipation. (9.5.1. Multiple Choice Questions 1) A meal plan that monitors the consumption of certain food nutrients is termed as a a 4 a) Therapeutic diet b) Mediterranean diet ©) Balanced diet 4). Diabetic diet 4 feeding involves giving food and fluids through a tube inserted through the nose into the stomach of a patient. a) Gastrostomy b) Nasogastric tube ©) Oral tube 4) Total parenteral nutrition 9) TPNis a mixture of all the essential nutritional components, including a) Protein, vitamins, and minerals b) Fat, calories ©) Water, oil, sugar 4) Both (a) and (b) 4) The 200ml bottles containing __of amino acids are available for IV use. a) 26% b) 5-7% ©) 3-5% d) 89% Copper, zinc, selenium, and chromium are a) Multivitamins b) Trace elements ©) Proteins d) Carbohydrates198 Applied Nutrition and Dietetc, 6) TPN is administered through a) Coated foley catheters b) Central venous catheter ©) Three-way foley catheter d) Indwelling catheter 7) Chronic renal failure results due to slow progressive destruction of , a) Heart b) Kidneys c) Lungs d) Liver 8) Patients with liver illness are advised to consume of simple carbohydrate, per day. a) 100-200gm b) 300-400gm c) 150-200gm 4) 130-250gm 9) When bowel motions become less frequent and faeces become harder to evacuate this is known as : a) Diarrhoea b)_ Peptic ulcers ©) Constipation 4) Bloating 10) The portion of foods which a person eats that cannot be completely digested referred to as A my : a) Fibre b) Carbohydrates c) Mineral 4) Vitamins Answers: Da 2b 3) d 44 5) b 6) b yb 8) b ve 10) a 9.5.2. | Very Short Answer Type Questions 1) Define the following: i) Therapeutic diet ii) Nasogastric intubation iii) Gastric gavage iv) Obesity v) Total parenteral nutrition 2) Write the objectives and principles of therapeutic diet 3) List down any three objectives of diet modification. 4) Name of the equipment used in nasogastric intubation, 5) Write down the purpose of nasogastric tube feeding. 6) Give the composition of TPN. 7) What diet is administered in constipation? 9.5.3. Short Answer Type Questions 1) Enumerate the modification of diets in different nutrients. 2). Explain the methods, indications and procedure of nasogastric intubation, 3) Elaborate about Total Parenteral Nutrition (TPN). 4) Discuss about the diet given in following disease: i) Obesity ii) Diabetes mellitus iii) Cardiovascular diseases iv) Under-weight v) Renal diseases 9.5.4. Long Answer Type Questions 1) Write the objectives, principles and methods of diet modifications. 2) Discuss about preparation, equipment and procedure of nasogastric tube feeding of gastric gavage. : 3) Briefly discuss the diet in following diseases: i) Hepatic disorders Constipation iii) Diarrhoea iv) Pre- and post-operative period