Nutrition and Dietetics

UNIT 2 PLANNING DIETS

Structure
2.0 Objectives

2.1 Introduction

2.2 Planning Diets

2.3 Diets for Normal Individuals

2.3.1 Concept of an Adequate or a Balanced Diet
2.3.2 Food Groups and Adequate or Balanced Diets
2.3.3 Influence of Age, Sex, Activity Level and Physiological State
2.3.4 Use of Recommended Dietary Intakes in Planning Balanced Diets
2.3.5 Guidelines for Planning Adequate/Balanced Diets

2.4 Diet Planning in Disease

2.4.1 How Disease Affects Nutritional Requirements
2.4.2 Influence of Disease on Food Intake and Dietary Patterns
2.4.3 Types of Dietary Modifications
2.4.4 Special Feeding Methods
2.4.5 Planning Diets for Patients and High Risk Individuals

2.5 Social, Economic and Psychological Factors in Diet Planning

2.6 Let Us Sum Up

2.7 Key Words

2.8 Answers to Check Your Progress

2.0 OBJECTIVES
After studying this unit, you should be able to:
● explain the rationale for diet planning;
● describe the use of food groups and recommended dietary intakes in planning balanced
diets for normal individuals;
● discuss
and explain significant issues related to the influence of age, sex, activity alevel
and physiological state in planning diets;
● list the major steps involved in planning balanced diets;
● describe the influence of disease on nutritional requirements and dietary patterns;
● explain the concepts and techniques of nutritional support; and
● identify the role of physiological factors.

2.1 INTRODUCTION
As competent professionals in health care, you may interact with a number of patients in
hospital, clinic and community settings. Very often the doctor might write out a prescription
looking like the one given in Fig. 2.1.
The prescription highlights the fact that many patients would require dietary modifications
in addition to medicines. As a nurse you may be asked by patients and their relatives about
these basic elements of therapy. It would be satisfying and reassuring for the patient his/her
family to undersand from you the basis of the therapy. Hospitals/Clinics also have dietitians
who perform the role of planning diets for patients and also explaining these therapeutic
measures to them. There may be several occasions when you might interact with a dietitian.
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Planning Diets
Remember that you are a vital link between the doctor, dietitian, and the patient. In public health fieldwork you
may have to do the diet planning with families.

So, you need to know more about diet planning. As you glanced at the structure of this
unit you wold have noticed the emphasis on planning diets for normal individuals. There is
a reason for this. Therapeutic diets are based on normal diets. This is why we have to
discuss diet planning for normal individuals. Once you have understood this, it becomes
easier to appreciate the rationale for therapeutic diets.

DIETARY TREATMENT

Patient details = Mrs. Raj Rani, House Wife

45 years old, female, 50 kg wt.

Diagnosis = Diabetic Mellitus

Day’s Dietary Requirement for Raj Rani (Vegetarian)

1) Total Calorie requirement 25-30 Kcal per Kg ´ 50 Kg. = 1250-1500 Kcal

2) Total carbohydrate requirement (mainly starch NOT Sugar) = 1000-1500 gm.

20-30 gm per kg ´ 50 kg.

3) Total Fat requirement = 1500-2500 gm Fat

30-50 gm per kg ´ 50 kg. = (preferably oils from
seeds)

4) Total Protein requirement = 50-75 gm of Protein

1-15 gm. Per kg ´ 50 kg.

5) Vitamins and minerals from fruits and vegetables

6) Water = 8-10 glasses

7) Fibres from fruits, vegetables

Fig. 2.1: Prescription for dietary treatment

Now coming to the section on diet planning in disease. Several diseases affect the
requirements for one or more nutrients. This means we have to change the diet accordingly.
In addition, disease can affect the appetite or the ability to chew, swallow, digest, absorb or
excrete. This also necessitates changes in dietary patterns. In this unit we will just take a
quick look at these aspects as well as the types of dietary modifications generally made.
The types of special feedings (e.g. tube feeding and intravenous feeding are discussed in
some detail. In Units 4 and 5 we will discuss dietary management in disease. You are also
aware that very often other members of a patient’s family may be at risk. It is essential to
identify individuals at risk and advise them on dietary changes in their normal diets if
required. As a nurse you could detect, nutritional problems, implement and ensure dietary
changes made or help the patient to eat or councelled.
Finally, we cannot ignore the special role of social and psychological factors. Keeping
these considerations in mind one can spell the difference between success and failure in
diet therapy. The patient is a person with his or her own likes and dislikes and attitudes.
These must be respected. This shows we care.

2.2 PLANNING DIETS

Is planning a diet essential? Yes, it is essential.

In the previous unit we discussed the importance of eating nourishing food in preventing
nutritional disorders as also in promoting a sense of well-being. In this context planning
diets has a special role; it is a way of ensuring a desirable dietary pattern.
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Nutrition and Dietetics
Planning diets helps us to answer the following questions quite accurately: ● Which foods
to include?

● How much of each food to include?

In other words, this useful exercise helps us to ensure that the nutrients required will be
supplied in adequate amounts. In essence it involves ‘‘selecting the right foods in the right
amounts” for each individual according to the needs.

When you seek to provide adequate health care to people, you also need a systematic
outline of what they are supposed to eat. A diet plan helps to convey this information to
patients just as it conveys facts to you, the doctor and the dietitian. It summarizes the
 special food needs of a patient depending on the:

● disease and its severity

● age factor

● sex

● activity level

● physiological state (i.e. pregnancy/lactation, in the case of woman) and

● socio-economic constraints and cultural characteristics.

A diet plan is quantitative in nature and, therefore, it reduces the chances of

misunderstanding once the patient is familiar with how to measure fodstuffs using
household equipment such as cups, spoons, katories or plates.

In addition it becomes easier to explain how much food should be eaten at each of the meals.
The meal frequency (i.e. number of meals in a day) is quite an important consideration in diet
therapy and needs careful attention.

In seriously ill patients nutritional support is required. Oral feeding may not be possible so
nutrients have to be supplied either by tube feeding or intravenous feeding. Such special
feeding also requires careful planning and management.

2.3 DIETS FOR NORMAL INDIVIDUALS

We have just discussed the fact that planning diets helps us to select the right foods in the
right amounts for each individual. This is a simple description of the process of planning a
nutritionally adequate or balanced diet. You will have to wait for sub-section 2.3.1 to
appreciate the meaning of the important concept of adequate /or balanced diets.

We can select the right food for a person by using food groups. Each food group includes a
specific list of food items, which share the same function and contribute similar nutrients.
As you know, the functions of the food are dependent on the major nutrients they supply.
Once the food groups have been identified, items can be selected from each food group for
each meal. If we do this, we an be reasonably sure that all nutrients will be provided by the
day’s diet. Sub-section 2.3.2 elaborates on these aspects.

However, that does not give an answer to the question : how much of each food to
include? This would, of course, depend on the nutrient requirements of the individuals for
whom we are planning the diets. The Indian Council of Medical Research (ICMR) has laid
down recommendations for daily Recommended Dietary Allowances (RDA)/nutrient
intakes based on age, sex , activity level and physiological state (pregnancy, lactation).
See Fig. 2.2. The standards are laid down by most countries for their population. The
RDA for Indian population is presented in Table 2.5 in sub-section 2.3.4. The Dietary
reference value for all nutrients as recommended by the WHO, UK and USA is presented
in Appendix 1, Practical Manual of BNSL-102.
26

Selecting right foods based on ® Recommended Dietary Intakes

®

food groups Deciding the amount to be (RDIs)

included based on DIET PLAN
Planning Diets

Fig. 2.2: Planning a diet

This highlights the importance of identifying the special needs of the person. An older
adult’’ nutrient requirements would be different from that of a young adult. A labourer
doing heavy physical work requires more energy than a company executive. An
adolescent’s needs are different from those of a man. We take a quick look at the
influence of age, sex, activity level and physiological state in sub-section 2.3.3. This
forms the basis for our discussion in sub-section 2.3.4 on the use of recommended
dietary intakes (RDIs) in planning adequate/or balanced diets.

So let’s begin with trying to understand the concept of an adequate or balanced diet.

2.3.1 Concept of an Adequate or Balanced Diet

A adequate/or balanced diet can be defined as one which contains different types of
food in such quantities and proportions that the need for calories, carbohydrate, fats,
proteins (macronutrients) and minerals, vitamins (micronutrients) and water are
adequately met and a small provision is made for extra nutrients to withstand short
durations of learners. The definition should also include fibre as it is important in a
diet.

If you look at the definition carefully, you would realize that a adequate/or a balanced
diet:

● consists of different types of food items.

● meets the minimum need for nutrients for the individual.

● providesfor periods of leanness when the diet may possibly not supply adequate
amounts of nutrients.

Let us talk about each of these aspects.

A balanced diet consists of different types of food items: An adequate/or balanced diet
includes a variety of foods. But how do we select these foods? The major aim is to
ensure that all nutrients are supplied. This can be achieved by first classifying food into
groups, each group supplying certain specific nutrients and then selecting items from
each food group to plan a balanced meal or diet, including items from each food group
ensure that all the nutrients will be supplied, as we mentioned earlier.

An adequate/or balanced diet meets the nutrient needs: A balanced diet meets nutrient
needs because of the amounts and proportions of the foods selected.

How much should a person consume of individual foods to meet his need? This would
be based on the recommended dietary intakes (RDIs) for the individual for whom the diet
is planned. You will study more about RDIs in sub-section 2.3.4.

Adequate/or Balanced diets provide for periods of leanness: We have now examined the
first two aspects of the definition of a adequate/or balanced diet. Adequate/or Balanced
diets also provide for periods of leanness. This implies that there is a “safety margin” or
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Nutrition and Dietetics
a “little extra nutrition” for those times when you are unable to meet your nutrient needs adequately. A
normal individual consumes a variety of foods. It is possible that on a
given day he may not consume foods in the amounts he requires. How, then, can we
provide for such periods of leanness? Actually we do not need to make any special
adjustments because RDIs already includes a margin of safety. Planning diets on the
basis of RDIs would take care of this aspect as well.

2.3.2 Food Groups and Adequate/or Balanced Diets

Food, as you learnt in Unit 1, has three basic physiological functions - energy-giving,
body-building and protective/regulatory functions. You are also familiar with the fact that
food performs these functions because of the specific nutrients it contains. Foods rich in
carbohydrates or fats or both provide energy for instance. Similarly, foods rich in protein
aid in body-building or in other words, addition of new tissues and repair of worn out
tissues. Vitamins and minerals present in food contribute to preventing disease. This is
called the regulating body functions as you have learnt earlier. Food can, therefore, be
classified into the following three categories based on function:

Group 1 : Energy-giving foods

Group 2 : Body-building foods

 Group 3 : Protective/regulatory foods

The energy-giving category includes three types of foods:

● Carbohydrate-rich foods A Cereals

Roots and tubers

● Carbohydrate-rich foods B Sugar

Jaggery

● Fat-rich foods Fats, oils, nuts and oil seeds

The primary nutrients provided by these, as you see, are carbohydrates/fat. In addition
to carbohydrate, cereals also provide some protein, vitamins and minerals. Similarly, fats
and oils provide fat-soluble vitamins in addition to fat.

The body-building group includes those foods which are rich in protein. The group
includes:

● Milk and milk products

● Meat, fish and poultry

● Pulses

● Eggs

● Nuts and oil seeds.

The primary nutrient provided by all these foods is protein. These foods provide several
other nutrients as well, some of them in significant amounts (see Unit 1, Table 2). Nuts
and oilseeds, for example, are excellent sources of fat in addition to protein.

The third food group is called the protective/regulatory group. The primary nutrients
provided by foods in this group are vitamins and minerals.

Foods in the protective/regulatory category include:

Fruits ● Yellow and orange fruits (e.g. mango, papaya)

● Citrus fruits (e.g. lemon, lime, orange)

28 ● Others (e.g. plum, banana)

Vegetables ● Green leafy vegetables (e.g. spinach, fenugreek, need

mustard leaves) ● Yellow and orange vegetables (e.g. carrot,

pumpkin)

● Others (e.g. ladies finger, brinjal, cauliflower, cabbage)

Green leafy vegetables, yellow and orange fruits are N

utrient
particularly rich in carotene/vitamin C as well as minerals. Planning Diets

This is a simple classification. However, it is useful in

planning meals/diets and is the most commonly used
classification. One has to ensure that each and every meal
includes foods from the energy-giving, body-building and
protective/regulatory groups. In this manner the diet would
supply all essential nutrients and would become balanced. See
Fig. 2.3.

(a)Nutrient
Supply Nutrient
 S
upply
(b)
N
utrient
nee
d

Nutrient

N need
(c) utrient Supply

Fig. 2.3: (a) Balanced Food, (b&c) Unbalanced Food

Now that we have studied this simple way of classifying food, let us understand how food
groups can be used to plan meals. Let us take lunch as an example. See Tables 2.1, 2.2,
2.3 and 2.4.

Meal: Lunch (based on three group classification)

Table 2.1: Plan for Lunch

Food group Food items selected

Alternative 1 Alternative 2

Energy-giving Rice, fat Wheat, fat, sugar, potato

Body-building Pulses (Rajmah, green Meat, milk grams) or nutrinaggets

Protective/Regulatory Onion, tomato, spinach Carrot, onion, tomato

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Nutrition and Dietetics
Two alternative lists of food items selected from each food group are mentioned. Now we must ranslate
this into a list of dishes to be served. Such a list is called a menu. The following
chart gives you an idea of how to convert these lists of food items into the magic of menus.
Table 2.2: Plan for a Menu
Alternative Name of dish Ingredients used for preparation
Alternative 1 Steamed Rice Rice
Rajmah curry Rajmah, onion, tomato, fat
Spinach with tomato and onion (dry) Spinach, onion, tomato, fat
Alternative 2 Chapatis Wheat flour
Meat curry Mutton, onion, tomato, fat
Carrot-potato vegetable Carrot, potato, fat
Sweet curd Curd, sugar
Let us now take an example of the South Indian tiffin (a meal consumed in the afternoon
after a heavy breakfast).
Table 2.3: Plan for a Meal Called Tiffin

Food group Food selected Menu (ingredients)

Energy-giving Rice, fat, potato Idlis (rice and urad dal)

Body-building Urad dal, arhar or tur da Vegetable (arhar dal,
ladies finger, potato, drumstick,
brinjal and fats).
Protective/Regulatory Ladies finger, drumstick, brinjal

You can use the three group classification to plan any meal. Remember to include a cereal
and a source of fat. It could be ghee, vanaspati or a vegetable oil from the energy-giving
group in each meal. If you are including a sweet item, sugar would also be part of the energy
giving group. You would also have noticed that it is not necessary to include three items in
a menu because there are three food groups. In fact, a single dish can also be a balanced
 meal. The following example will make this point clear.
Table 2.4: Plan for a Balanced Single Dish

Food group Food item selected Menu

Energy-giving Rice, fat, potatoes Vegetable pulse, Khichri

Body-building Green gram, dal
Protective/Regulatory Spinach, onion, tomato

You have now gained knowledge about how to plan balanced meals. Some more important
aspects regarding the planning of balanced diets will be discussed later in this unit.
Check Your Progress 1
Let us play a food square game. Look at the following food squares. Each square mentions
the name of a food item and assigns to it a number. Select the food squares you will use to
plan the following balanced meals.
1) Lunch in a hospital setting
2) Tea time meals at home
1 2 34 5
Wheat Rice Urad dal Beans Milk
6 7 8 9 10
Meat Moong dal Cabbage Carrot Mango
11 12 13 14 15
Sugar Fish Soyabean Cauliflower Onion
16 17 18 19 20
Milk products (paneer) Poultry Arhar dal Spinach Tomato
21 22 23 24 25
Fenugreek Brinjal Coconut Vegetable oil Ladies finger
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Planning Diets
Mention the specific dishes you would prepare with the ingredients required for each (square numbers) e.g.
Khichri (ingredients: rice, moong dal and green leafy vegetables i.e. Nos. 2, 19).

1) Lunch (food square selected) 2) Tea (food square selected)

............................................................ ....................................................
............................................................ ....................................................
............................................................ ....................................................
............................................................ ....................................................
menu menu
............................................................ ....................................................
............................................................ ....................................................
............................................................ ....................................................
............................................................ ....................................................

2.3.3 Influence of Age, Sex, Activity Level and Physiological State

The Indian Council of Medical Research (ICMR) has laid down recommended dietary
intakes for the Indian population based on the following factors:
● Age

● Sex

● Adult Activity level

● Physiological state (pregnancy or lactation) in adult women.
Let us discuss each one of these one by one.
Age
The period from infancy to adolescence in the lifespan of an individual is associated with
growth and development. Once adulthood is reached growth ceases and as age advances
certain degenerative changes begin. This explains the fact that the need for most nutrients
increase from infancy to adolescence and by the time the person is an adult they stabilize at
a particular level. (From the age of 10 years, sex also determines nutrient needs as you will
soon read.) However, after the age of 40 years, need for some nutrients decrase. For
example, energy needs reduce because of less energy required for the working of the
internal organs such as of heart, lungs, kidney etc. This is called the basal metabolic rate.
Also as we grow our physical activity is also reduced and hence less energy in required.
This is a new concept. Do you notice that we have now mentioned another factor - activity
level? The importance of this in the case of adults is highlighted in the following
discussion.
It might help you if we summarize the characteristics and recommendations for each age
group. This would help you not only in appreciating certain dietary mesures, but also in
understanding the special needs of each age group. So let’s begin with infancy.
Infancy (0-1 year)
The following are the specific features of infancy:
i) There is no substitute for breast milk. The first milk secreted or colostrum has anti
infective and growth promoting substance. Only in cases of lactation failure formula
feeds should be given.
ii) Introduction of supplementary foods should begin at 6 months with gradual increase in
variety and amounts of foods offered. Here supplementary foods refers to foods given
in addition to breast milk initially and which finally replace breast milk. This is
important as the milk production by the mother does not match the nutrient needs of
the infant hence the supplementary food after 6 months for support becomes
absolutely necessary.
iii) It is the formative period for most organs and tissues; there is an increase in size and
improvement in functional capacity. 31
Nutrition and Dietetics
iv) As a result of rapid growth and development, the need for nutrients is substantial.
v) As the digestive system develops, the infant is able to eat solid foods by the end of
the first year. Upto 4-6 months only liquid foods can be consumed. By the age of 6
months we can progress to semi-solid foods of a rather liquidy consistency. At 8-10
months thicker porridges can be given and even small, coarse pieces of food can be
tolerated.
vi) The following nutrients need to be emphasized in the diets of infants : energy
(carbohydrates and fats), protein, calcium, iron, vitamin A and C.
vii) There is an extremely fast rate of growth and rapid increase in weight and height.
Preschoolers (1-6 years)
i) Rate of growth is lower than in infancy but still rapid.
ii) Physical activity is high
iii) Nutrients to be emphasized include: energy (carbohydrates and fats, protein,
calcium,iron, and vitamin A and C.)
iv) Giving frequent meals and offering less food in each meal is better than giving a less
number of meals which are heavy and large.
v) Foods rich in spices and fibre should be avoided.
vi) Variety in colour, texture and flavour is important in motivating the child to eat.
However, too many sweet items should not be included. New foods should be
introduced gradually.
vii) Likes and dislikes can be pronounced.
viii) Snacks as finger foods rich in several nutrients particularly energy and protein, vitamin
A/iron should be offered.
School Going Children (7-12 years)
i) Growth rate shows down relatively as compared to infancy and preschool age but
growth continues at a steady pace during these years.
ii) Functioning of most tissues and organ systems improves.
iii) The school years can be considered a preparation for adolescence.
iv) Sex differences appear and begin to influence nutrient needs.
v) Nutrients to be emphasized include: energy (carbohydrates, fats), protein, iron and
calcium. Other nutrients such as vitamin C and vitamin A also need to be included.
vi) Snacks rich in energy, protein, calcium/iron should be given .
 vii) Frequent consumption of chips, pizzas, hamburgers and aeriated beverages replasing
main meals should be discouraged. Foundation for good food habits should be laid
early in life and hence concentrated nutritions snacks are good because of high
physical activity of these children.
Adolescence (13-18 years)
i) This period witnesses major physical, mental and emotional changes.
ii) There is a sudden increase in the rate of growth (adolescent growth spurt) at different
times in boys and girls.
iii) Sex characteristics appear in both boys and girls: sharp differences become evident
between the sexes in body build and composition.
iv) During this phase of the lifespan all organs and body systems reach their maximum
possible level of maturity and development.
v) The rapid growth and development influences nutrient needs. Nutrients to be
emphasized include: energy, protein, iron, calcium, iodine, vitamins A and C.
32
Planning Diets
vi) Snacks play an important role and should be rich in energy and protein, iron and calcium.
vii) Foods very rich in fat or sugar should be restricted or avoided; instead foods such as
milk, green leafy vegetables, deep yellow vegetables, fruits and whole cereals should
be emphasized.
viii) Physical activity is high; athletes need to pay particular attention to meeting their
needs for water and electrolytes.
Adulthood (Above 18 years)
1) This is the stable state in life when growth and development has been completed;
nutrients required during the stage is mainly for maintenance of body structure and
function.
2) As the individual ages the Basal Metabolic Rate is reduced (BMR) and physical
activity levels also go down. Since energy requirements are based on both the
metabolic rate and activity, ageing brings down energy requirements. We must explain
here that the higher the BMR the higher the energy needs. Similarly the higher the
activity level, the more the energy needs.
3) Ageing affects the functioning of many body systems because the number of
functioning cells is reduced. As a result, changes take place such as ineffective
removal of water from the body, reduced sensitivity to taste, problems with dentition,
reduction in saliva secretion and secretion of digestive enzymes as well as
demineralization of bones, making them weak and brittle. Tissue breakdown becomes
significant particularly in the later years. This means that we should lay emphasis on
good quality proteins, iron, calcium, Vitamin B Complex and C in diets of the elderly.
Check Your Progress 2

How does age bring about changes in nutritional requirements?

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

Sex
You learnt that sex differences appear in nutrient needs after the age of 9 years. Why does
this happen? This is because differences appear in body build and composition. The boy
begins to accumulate relatively more muscle tissue while the girl accumulates more of the
relatively inactive fatty tissue or adipose tissue. More muscle tissue means more energy
needs. In addition to this, boys begin to weight more than girls and the body build alters as
well. The difference in body weight alters protein needs. The requirements for iron also
differe due to sex differences as you will find on reading the next subsection.
Activity Level
Compare the activity level of a company executive, a postman and a coolie. Isn’t there a
sharp contrast? The activity level of an executive would be sedentary - mostly desk work.
A postman can be considered a moderately active individual whereas a labourer would be a
heavy worker. An increase in activity level is associated with increased energy needs. This
is because when you work energy is consumed. And the more vigorous the work and longer
its duration, the more the energy expended.
Physiological State
Pregnancy and lactation are periods of physiological stress for the woman. Nutrient
requirements increase sharply to meet the needs of the growing foetus during pregnancy.
Expansion of maternal tissues also takes place and this also has a nutrient cost. Nutritional
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Nutrition and Dietetics
requirements in lactation are even higher than those in pregnancy. This is because of the substantial
outflow of nutrients through breast milk which has to be met with.
Now let’s talk about some of the specific features of diets for pregnant and lactating women
and some of the important points to remember about the two phases.
Pregnancy
i) There is a steady gain in weight. This weight gain is accounted for by the growing
foetus, and other changes in the mother’s body such as increase in uterine size,
placental development, fat deposition, increased blood volume and volume of total
body fluids as well as an increase in the size of the breast.
ii) Maximum weight gain occurs during the second and third trimesters of pregnancy. You
would probably be aware of the fact that the period of pregnancy is divided into three
trimesters: first trimester (0-3 months), second trimester (3-6 months) and the third
trimester (6-9 months).
iii) Problems such as nausea and vomiting are common in early pregnancy while
constipation is a common complaint later (during the third trimester).
iv) The basal metabolic rate increases during pregnancy particularly from the second
trimester onwards. This of course, increases the energy needs.
v) Nutrient needs increase substantially from the second trimester. Needs keep pace with
the growth of the foetus and the expansion of the supporting maternal tissues.
vi) The nutrients to emphasize in pregnancy include: energy, protein, calcium, iron, Vitamin
B Complex and folic acid.
vii) Foods with strong flavours, foods rich in fat and excessive spices should be avoided.
viii) Foods rich in fibre and plenty of fluids should be included in the diet.
ix) Iron and folic acid tablets prescribed to prevent anaemia. Use iodized salt also.
x) Increase the frequency of meals. Instead of eating 3 or 4 times a day you could eat 5 or
6 times.
Lactation
i) Nutrient needs should be fulfilled to allow optimal output of milk. Less breast milk is
produced after the infant crosses six months of age. Hence nutrient needs of the
mother are more during the first six months of lactation.
ii) Nutrients to be emphasized include energy, protein, calcium, vitamin A and vitamin C.
iii) Meal frequency should be increased and nutritious snacks should be included.
iv) Increasing fluid intake is very important. Taking extra fluid half an hour before a feed is
benificial
v) No food needs to be restricted unless the mother cannot tolerate it or if the infant
reacts adversely to the breast milk on days when a particular food is consumed by the
mother.
2.3.4 Use of Recommended Dietary Intakes in Planning Balanced Diets
The Recommended Dietary Intake (RDI) is the amount of a nutrient to be actually consumed
in order to meet the requirements of the body. The RDI for a particular nutrient is the
minimum amount that needs to be consumed to prevent symptoms of deficiency and to
maintain satisfactory levels of the nutrient in the body together with a safety margin
(Fig. 2.4).
The safety margin is added on to cover factors like:
● variation in requirement from individual to individual
 ● periods of low intake (periods of leanness)
● nature of diet

34 ● cooking losses

RDI = + Safety margin based on

Requirement based on Planning Diets

Physiological state Activity Level requirements Nature of diet

Age Sex Variation in Periods of low intake Cooking losses

Fig. 2.4: Body requirements plus safety margins based on RDIs

Some of these points can be well illustrated with the following example. In
experiments conducted with adults it was found that when the intake of Vitamin C was
20mg/day, vitamin maintained in the body. Since all the persons studied were able to
satisfactorily maintain body vitamin C levels at an intake of 20 mg/day, there was no
need to make allowances for individual variation. Now, how is this figure for
requirement converted into a figure for RDI in the case of adults? Let us take the
example of vitamin C. Vitamin C is easily destroyed on cooking. On the average, a
figure of 50 per cent cooking losses was considered reasonable. The recommended
intake was therefore fixed at double the requirement i.e. 40 mg.
In addition to the factors already discussed, the nature of the diet has a significant
influence on the RDIs fixed for certain specific nutrients. Take protein for example.
Many Indians are vegetarians. They consume a diet which supplies vegetable protein.
Since vegetable protein is utilized to a relatively lower extent, more protein needs to be
consumed and therefore RDIs increase. Quality of vegetarian protein can also be
improved by combining foods e.g. pulses and cereals eaten together supply better quality
protein. Similarly, in the case of iron, the availability of iron to the body depends on the
type of food consumed. Absorption of iron from typical Indian diets is low. Therefore,
more iron needs to be consumed to meet the requirement i.e. the RDI is fixed at a higher
level.
You have now gained an idea about the concepts of requirement and recommened
dietary intakes. There are three important points that you need to remember:
1) RDIs are set high enugh to meet the needs of almost all healthy people. In other
words a generous margin is usually given for individual variation in a population
of normal healthy individuals.
2) RDIs do not apply to people who are suffering from a disease (or malnourished)
which influences the nutrient needs. A disease can cause an increase or decrease in
the requirement of one or more specific nutrients. Sometimes medicines prescribed
during illness influence nutrient need. For instance, when one takes antibiotics one
also has to consume more of the B-complex vitamins. The RDIs only apply to
individuals who are normal and not suffering from a disease likely to influence
nutrient requirement.
3) Recommended dietary intakes for adults are based on age, sex, body size and activity
level. In the case of adults, there are substantial variations in RDIs, particularly for
energy and protein depending on the body weight and activity pattern. This is why
working out RDIs on the basis of a ‘reference individual’ is useful. RDIs have, in
fact, been fixed using this principle. The Reference man is an Indian man in the
age group of 20-39 years doing moderate work and weighing 60 kg. Similarly, an
Indian woman 20-39 years old doing moderate work and weighing 50 kg is
referred to as the Reference woman. You would notice that the age range, weight
and activity level have been specified in both cases.
Adjustments can be made in the case of RDIs for individuals who deviate from
the standard references.
35
 Nutrition and Dietetics
Let us now examine the recommended dietary intakes for Indians (Table 2.5). The table lists the
RDIs for several nutrients.

Some of the salient features of recommended dietary intakes and how they are expressed
are summarized in the following points. You will also come across explanations for
various terms used in the table:

i) RDI are expressed in kilocalories (Kcal), grams (g) milligrams (mg) or micrograms
(ug). RDIs for energy are expressed in Kcal. One kilocalorie is the amount of heat
required to raise the temperature of one kilogram of water through 10C.

1000 milligrams (mg) make one grm and 1000 micrograms (ug) make one milligram.
The RDIs for protein are given in grams, while RDIs for vitamins are expressed in
milligrams or micrograms.

ii) RDIs for energy for adult men and women are based on activity levels.Activity
levels can be described as sedentary (light), moderate or heavy. The more the
activity, the higher would be RDIs for energy as we mentioned in the previous
subsection.

iii) RDIs for thiamine, riboflavin and niacin are dependent on RDIs for energy. The
relationship between the RDIs for these vitamins and energy is as follows:

RDI for thiamine = 0.5 mg/1000 Kcal; RDI for riboflavin = 0.6 mg./100 kcal; RDI for
niacin = 6.6 mg/1000 Kcal. Can you explain why such a relationship exists? These
three vitamins play a vital role in the release of energy from carbohydrates, fats
and proteins.

iv) RDIs for energy and protein are given as additional intakes in pregnancy and
lactation. Pregnancy and lactation are periods of “Physiological stress” because
nutrient needs increase considerably to meet the needs of the growth of the foetus
(in the case of pregnancy) and production of milk (in the case of lactation when
the mother breastfeeds the baby). RDIs are given in terms of additional intakes
(indicated by a “+” sign) for some nutrients like energy and protein. RDIs for the
other nutrients are given as total intake figures.

v) In infancy RDIs for energy, protein, iron, thiamine, riboflavin and niacin are
expressed per kg body weight. Here the expression “body weight” refers to the
ideal body weight expected for a healthy, normally growing infant. Infancy is also
a period of physiological stress just like any period characterized by rapid growth.

vi) RDIs for vitamin A have been given in terms of retinol or alternatively in terms of
beta carotene. Carotene is a presursor of vitamin A. As you know, this means the
body uses carotene to make retinol, i.e. vitamin A.

We have so far studied the concept of requirements and recommended dietary intakes.
We have also examined the RDIs for Indians. Now we can move on to the study of
how these are used in planning balanced diets.

The amounts of different foods to be consumed would depend on the RDIs. The
higher the RDI for a particular nutrient, the more should be the consumption of foods
rich in that nutrient. The amount of cereal consumed by a heavy worker for example
should be more than that consumed by a light worker. Why is this so? This is because
of the fact that energy requirement are far more for heavy workers and because cereals
are a major source of carbohydrates and, therefore, energy. Detailed information on
balanced diets for infants, preschoolers, school children, adolescents, pregnant and
lactating women is given in Appendix 2. In all cases, the amount of food to be
consumed would be dependent primarily on the RDIs.

However, the foods actually selected from each food group would depend on several
factors such as income, place of residence/regional considerations. These are explored
briefly in the next sub-section.
36
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37
S

Nutrition and Dietetics

Check Your Progress 3
“There is very little distinction between minimum nutrient requirement and RDI for a
particular nutrient.” Do you agree with this statement? Explain giving reasons for your
answer.

................................................................................................................................................

................................................................................................................................................

................................................................................................................................................

................................................................................................................................................

................................................................................................................................................

2.3.5 Guidelines for Planning Adequate/Balanced Diets

You have gained considerable knowledge about the principles underlying the planning
of balanced diets. Let us now look at some important aspects. We have to remember
that balanced diets are:
● individual-specific

● region-specific, and
● income-specific.

What do we mean by these terms? Why are these important in planning adequate/
balanced diets? You will find the answers to these questions in the subsequent
discussion.
A adequate/balanced diet is never generalized and suitable for all individuals. It is
specific firstly, to an individual of a given age (age-range) and sex. In the case of adults
 it is also specific to a given activity level ----- sedentary, moderate or heavy work. A
adequate/balanced diet for a sedentary worker (e.g. typist or clerk) would differ from
that of a heavy worker (e.g. construction labourer). A balanced diet for an infant would
be very different from than of an adult (influence of age). A diet for an adolescent girl
would be different compared to one for an adolescent boy (influence of sex).
Secondly adequate/balanced diets are always region-specific. The particular foods
available in a region can be used in planning. Using others would be impractical and
unsuitable. There is no point in including a cereal like ragi in a diet meant for a north
Indian, because ragi is grown only in the south. A balanced diet for a particular region
must reflect the characteristic meal patterns, and the social and religious practices of
that region. These factors must be taken into consideration to ensure that the diet
planned is acceptable. So the selection of foods should be region based.
Thirdly, adequate/balanced diets are income-specific. Balanced diets for an individual
of a given age and sex (and activity level where relevant) vary depending on income.
A adequate/balanced diet would imply the use of all food groups----- energ-giving,
body-building and protective/regulatory ----- in each and every meal. However, the
selection of foods and the amounts in which they are consumed would vary depending
on income. As income increases, consumption of cereals reduces and consumption of
milk and other animal protein foods, vegetables and fruits, fat and sugar tend to
increase. While planning balanced diets for the affluent, these trends are kept in mind
but excessive amounts of fat, sugar and even salt are not recommended.
Having more money does not mean spending more on fat, sugar and expensive foods
like meat/cheese, nuts and dry fruits. It means consuming the amounts absolutely
necessary so as to maintain good health and avoiding putting on weight and
developing health problems. Having more money, however, enables a person to add
more variety to the diet; unusual foods or foods not locally available, nonseasonal food
or exotic foods. Judicious selection of food is, however, as important for the rich as for
the poor. The ultimate aim is always to meet the nutritional requirements.
38
Planning Diets
Let us now study the major steps in planning, adequate/balanced diets. These are given in the chart below.
Steps in Planning Adequate/Balanced Diets
1) IDENTIFY THE INDIVIDUAL AND HIS/HER SPECIFIC CHARACTERISTICS
● Age
● Sex
● Activity level (for adults)
● Income
● Socio-economic background
● Religion
● Region where residing

2) CONSULT RDIs FOR ENERGY AND PROTEIN (This ensures adequacy of

other nutrients)
3) DECIDE ON TOTAL AMOUNTS OF THE FOLLOWING GROUPS
Energy giving Cereals
Roots and tubers
Fats and oils
Sugar and jaggery
Body-building Milk and milk products
Meat/fish/poultry/egg
Pulse
Protective/regulatory Vegetables (green leafy) and Fruits
4) DECIDE ON NUMBER OF MEALS TO BE CONSUMED
5) DISTRIBUTE TOTAL AMOUNTS DECIDED BETWEEN MEALS
6) DECIDE ITEMS AND THEIR AMOUNTS WITHIN EACH GROUP FOR EACH
MEAL ---- PLAN THE MENU
7) CHECK DAY’S DIET FOR INCLUSION OF EACH FOOD GROUPS AND
AMOUNTS DECIDED

1) Identify the individual and his/her specific characteristics

You know the individual’s characteristics and background would determine the type of diet
planned. Income, socio-economic background, religion and the region where the individual
stays are also important, as you are aware, in planning the diets.
2) Consult RDIs for energy and protein
Generally diets which meet energy and protein needs meet the needs of other nutrients as
well if care is taken to include rich sources of vitamins and minerals. Therefore in planning
diets the total energy and protein needs are specified first.

3) Decide on total amounts of specific groups

The amounts of cereals, fat, sugar, milk, meat/fish/poultry/eggs, pulses, vegetables and
fruits to be consumed are decided based on the income. The amount included would be
such that RDIs can be met for energy and protein.
4) Decide on number of meals to be consumed
Meal frequency varies depending on income, the occupation, school schedule and
convenience. People belonging to the higher income group consume more meals. Consider
the following lists of meals consumed in a day in many middle income group or high income
group of our families:

(A) (B) (C) (D)

Breakfast Breakfast Breakfast Bed Tea
Lunch Lunch Mid morning meal Breakfast
Dinner Tea Lunch Mid-morning meal
Dinner Tea Lunch
Dinner Mid-afternoon meal
Tea
Dinner
Bed time

39
Nutrition and Dietetics
(A), (B) and (C) are common in the middle income group, (D) is common in the high income group.
As you noticed this is a rather westernized meal pattern that has been adopted by the richer
sections of the community. However, traditionally most regions of the country have two or
three main meals in the day consumed - mid-morning and or late afternoon and the last meal
in the evening night.
Variations are often necessitated because of age. A child may not be able to consume much
at a time. So he would need to consume more meals. The occupation or schedule also
becomes important.
5) Distribute total amounts decided between meals
The total amount of each food group decided must be distributed over the day’s meals.
6) Decide on items and their amounts within each group for each meal ---- Plan the menu
The dishes to be included for each meal are decided based on the amount of each item in
each of the three food groups decided on earlier. For specific dishes to be included specific
items are selected from each food group as you learnt earlier.
7) Check day’s diet for inclusion of each food group and the amounts decided
By step 6 we have decided on the menu and listed the amounts of each ingredient used in
the preparation of the dishes. Now we have to check that we have included each item in the
amounts decided in step 3 according to the distribution arrived at step 5. Look Appendix 3
for details on food plans prepared for different population groups.
Learning about diet planning in practice in practice is beyound the scope of this unit. But
the details we have given here give you a fairly good idea of the process.

2.4 DIET PLANNING IN DISEASE

A diet for a patient suffering from a specific disease is called a “therapeutic diet.” As we
learnt earlier in this unit, therapeutic diets are adaptations of the normal or regular diet.
At this point you may wonder—why does the diet have to change in certain disease
conditions? What types of changes are frequently made? And, finally, do we need to make
dietary modifications only in the case of persons suffering from a disease, or those at a risk
of a disease condition.
You just need to wait a little while for the answers to these crucial questions. To arrange the
information systematically, we will discuss the issue with respect to:
● How does disease affect the nutritional requirements?
● Influence of disease on food intake and dietary patterns
● Dietary modifications
In addition you will be introduced to the process of planning diets for patients suffering
 from a disease and high risk subjects.
This section is of particular relevance to you. Do concentrate here. Remember that we will
study dietary management of various diseases and disorders in detail in Units 4 and 5. So let
us begin.
2.4.1 How Disease Affects the Nutritional Requirements?
Several diseases bring about changes in the body’s need for nutrients. Why? The reason is
usually a change in metabolic or physiological processes as well as accompanying changes
in the structure and/or function of specific organs and tissues.
A few examples will help to clarify these aspects.
Example A: Shama is a 8 year old girl suffering from nephrosis (Nephrosis is the
degeneration of basement membrane. As this process continues the porosity of the
membrane increases and large amounts of protein is lost in the urine. Sodium may be

40 retained and swelling appears.

Planning Diets th
Example B: Ghanshyam completed his 45 birthday last week. He has been suffering from diabetes for five
years now. Due to lack of insulin (or lack of functional insulin) his body is
unable to utilize carbobydrates efficiently, he feels an urge for water and sweets. He needs
complex carbohydrates, sufficient proteins and moderate fats.
Example C: Raju is suffering from typhoid. He is extremely weak and has lost a lot of weight.
High fever continues to trouble him along with abdominal pain.
Can you predict which nutrient requirements will be influenced by each?
In nephrosis the inability of the kidneys to function effectively result in large losses of
albumoedema and retention of electrolytes, and water. A problem like this requires to make
up for the protein loss. Good quality of proteins and nearly the double amounts has to be
given. Calories must be sufficient so that proteins are not used for energy purposes. To
prevent in the salt levels have to be reduced.
Raju has high fever. Fever increases the metabolic rate. Do you remember what influence
the metabolic rate has on energy needs? If the metabolic rate increases, energy needs will
also increase. In other words, Raju would need a diet which supplies more energy. He is
losing weight because of loss of muscle tissue. How is this to be replaced? Obviously by
giving more protein. Needless to say, adequate intake of calories is required so that the
protein is in fact used for body building.
We have used these examples, to indicate just some of the changes in nutrient needs caused
by these diseases. These are not the only dietary modifications required in diseases such as
diabetes, typhoid and nephrosis. Several others such as modification in texture and
inclusion/exclusion of specific foods may be required.
In general we can say that diseases that cause the loss of a particular nutrient would
increase the needs of that nutrient. On the other hand, if a disease results in accumulation
of a particular nutrient the intake of that nutrient, is usually restricted or it may be given in a
different form.
One point that we must emphasise here is the fact that sometimes the diseases process does
not alter nutrient needs and yet we may need to make dietary modifications. We will take a
closer look at this aspect in the subsequent discussion.
Remember, however, that requirements depend on
● nutritional status (i.e. condition of health as influenced by intake of nutrients)
● modification in activity
● increased or decreased metabolic demands made by illness and
● efficiency of digestive, absorptive and excretory mechanisms.
Check Your Progress 4
Read the following statements carefully. Indicate whether each is true or false. Correct the
false statements if required.
1) In fever, energy needs go up and hence need for B complex vitamins goes down.
........................................................................................................................................
........................................................................................................................................
2) Dietary modifications are not required in the case of all diseases.
........................................................................................................................................
........................................................................................................................................
3) In high fever a patient who is on bed rest will have lower calorie requirements than his
normal requirement.
........................................................................................................................................
41
........................................................................................................................................
Nutrition and Dietetics
2.4.2 Influence of Disease on Food Intake and Dietary Patterns
The disease process very often influences both the quality and quantity of the diet. Further,
changes in meal frequency and other aspects of the dietary pattern may be required.
Disease may cause the patient to:
● lose appetite and therefore eat less
● feel more hungry and therefore eat more
● have problems with digestion or absorption of food or specific nutrients leading to
changes in the types of foods which can be tolerated as also the frequency of feeding.
Let us elaborate a little more on how illness modifies food acceptance. Some diseases result
in marked anorexia or lack of appetite. Conditions associated with jaundice are notable
examples. On the other hand, hormonal imbalances can make a person eat excessively
resulting in overweight and obesity. Also specific foods may be poorly tolerated and lead
to distention or flatulence (gas production). Others may irritate the gastrointestinal tract. A
good example is the irritating effect of high fibre foods in conditions where the
gastrointestinal tract is inflamed or ailcerated.
Now let us study the major therapeutic modifications of the normal diet. What are the types
of quantitative and qualitative changes generally made? Read on to find out.
2.4.3 Types of Dietary Modifications
Our previous discussion has highlighted the fact that dietary modifications need to be made
in the case of several diseases. We must remember that therapeutic diets are always
modification of normal diets.
What are the types of dietary modifications that become necessary? Take a quick look at
the checklist:
● Change in consistency (e.g. fluid and soft diets)
● Increase or decrease in the amount of food
● Inclusion of more or less amounts of one or more nutrients (e.g. low purine diet in gout
or high vitamin A diet in deficiency of Vitamin A).
● Increase or decrease in fibre content
● Elimination of spices and condiments (e.g. bland diets)
● Inclusion or exclusion (i.e. giving or not giving) of specific fods e.g. diets for allergic
conditions
● Change in intervals of feeding i.e. meal frequency
You will find examples of all these types of modifications in the later units of this block. At
present we will spend some time explaining the first modification in this checklist - change in
consistency.
Look at the following flow chart:

Normal diet

Soft and
Full fluid diets Modification consistency Clear fluid diets mechanically soft diets
 Fluid diets are of two types—clear fluid and full fluid. Fluid diets are used in febrile states,
post-operatively or whenever the patient is unable to tolerate solid foods.
42
Planning Diets
A clear fluid diet is prescribed when intake of nutrients must be restricted and when an acute illness or surgery
results in a marked intolerance for food as may be evident by nausea,
vomiting, anorexia, distention and diarrhoea. Obviusly a clear fluid diet aims at replacement
of fluids and electrolytes and supplies very little of nutrients. This is the reason why it
cannot be continued for long.
A full fluid diet, on the other hand, is prescribed whenever a patient is acutely ill or is unable
to chew or swallow solid food. A full fluid diet includes all food liquid at room temperature
and at body temperature. Such a diet can be continued for relatively long periods though
iron supplementation becomes necessary.
Let us now talk about the soft and mechanical/dental soft diets. The term “soft” refers to the
fact that foods included in this type of diet are soft in consistency, easy to chew and made of
simple, easily digestible foods. Such diets also contains no harsh fibre or strong flavor. A
soft diet may be used in acute infections, some gastrointestinal disturbances and following
surgery. It is usually recommended when a patient from a full fluid diet progressed to a soft
diet and then a normal diet. In this sense it is a dietary step between the full fluid and a
normal diet. Unlike the fluid diets, properly planned soft diets are nutritionally adequate.
Mechanical or dental soft diets are normal diets modified to help people who have dental
problems e.g. elderly persons. No food is restricted unlike in the case of the customary soft
diet we have just described. Removing the skin and seeds, cutting or chopping into fine
pieces and cooking well are procedures usually employed.

2.4.4 Special Feeding Methods

Special feeding methods are an effective method for preventing and treating nutritional
deficiencies. Depending upon the patients health status feeding may be done based on the
route of introduction of the feed by two methods namely (1) Enteral feeding (2) Parenteral
feeding
A) Enteral feeding (use of the gastrointestinal tract)
Short term-I 1) Nasogastric
2) Nasodeudenal
3) Nasojejunal
Long term-II 1) Gastrostomy
2) Jejunostomy
Long term-III 1) Perentaneous endoscopic
Short term-I: An infusion of a formulated enteral diet is with or without the peristaltic pump via
a nasal fine bore passed into the stomach, deudenum or jejunum. Some problems faced by this
method may be increased risk of aspiration or misplacement of tube.
Long term-II: In this a stoma (a small opening) is made directly into the stomach or jejunum
and the formulated enteral feed introduced directly. It is a better method as the flow of the
feed is smooth and aspiration and misplacement in less.
Long term-III: In this a percutaneous endoscopic gastrostomy is done and this method is
more aesthetic and no problems of tube misplacement.
Enteral feeding is given to parents who cannot take adequate amount of food but have the
intestinal tract functions of digestion and absorption intact.
Many clinical situations require this form of feeding e.g. anorexia, chewing and swallowing
disorders, malabsorption syndromes, partial bowel obstruction, inflamantaory bowel disease,
fistulas, hepatic failure, cystic fibrous or even in hypermetabolic states such as trauma,
burns, sepsis, surgical stress conditions and even in renal failure.
The enteral route using the gastrointestinal tract is preferred because:
● It is clinically safer
● It is easy to operate
● Requires less medical or nursing attention
43
Nutrition and Dietetics ● It is a more ‘physiological’ or natural method of feeding and prevents the gut from any damage.
● It is much more satisfying to the patient and
 ● It is cheaper than the parenteral feeding
Enteral feeding solutions include homogenates, suspension and powders mixed with water.
These can also be prepared in the kitchens (the dietitian can tell you how they prepare it
from natural foods) but now commercial mixtures are available such as ‘Ten-o-lip’ and ‘critic
care’. In India this method of feeding is still in its infancy, but in developed countries more
than 100 varieties of enteral feeds are available.
Enteral feeding is indicated in a subject when he/she is:
● unconscious or semiconscious
● has persistent anorexia, nausea and vomiting
● has had surgery of head and neck or
● gastrointestinal surgery
The formula fed to the patient is selected depending on the condition of the patient, particularly
the ability to digest and absorb food/nutrients.
Several methods exist by which enteral feeding can be done. These are:
● Bolus method: About 300-350 ml of meal is given by mouth at the rate of 50 ml/min. The
number of meals given depend on the nutrients need of the subject.
● Intermediate method: About 240-300 ml fluid can be given in about 30 minutes time.
● Continuous method: About 2-3 litres of fluid is given in 8-20 hours. 50 ml per hour should
be given in the beginning and gradually increased till a rate of 125 ml/hour is attained.

Types of Special Feeds

Elemental diets contain glucose or sucrose as the carbohydrate source
combined with amino acids, mineral salts, vitamins and small quantities of fat with
a high content of the essential fatty acid called linoleic acid. Such liquid diets
were found to be relatively expensive to produce and hyperosmolar. Hyperosmolar
solution are concentrated and tend to draw water into the intenstine. This leads to
diarrhoea. Elemental diets cannot readily be used for oral supplementary feeding
because they are unpapatable. Elemental diets are rarely used now.
Currently available enteral feeds can be classified into three broad categories :
polymeric, chemically defined and modular formulas. Polymeric feeds are
prepared from normal foods processed by blending to produce a liquid feed.
Polymeric formulas can also be based on a combination of macroonutrients.
Blenderised formulas are inexpensive and contain all the required nutrients.
However they are thick (high viscosity) and also inefficient source of energy and
nutrients. Milk based formulae are used in cases where the GIT is normal i.e.
functioning properly. For patients who cannot tolerate milk, sugar or lactose,
lactose-free formulas based on salts of the milk protein, casein or soya products
are used.
In chemically defined formulas, proteins and carbohydrates are predigested into
simpler forms with low residue. The solution is hyperosmolar but nutritionally
complete. All chemically defined feeds are lactose-free and intended for patients
with limited expensive. Chemically defined formulas are also available for specific
organ failure e.g. hepatic failure, renal failure.
Modular products supply only a single nutrient or a combination of nutrients and
serve as supplementation.

B) Parenteral Feeding
The administration of nutrients of varifying strengths directly into the circulation is called
parenteral nutrition. This method of feeding is done only when the gut cannot be used for
44 feeding.
Planning Diets
Parenteral feeding is of two types: Parenteral Feeding

Partial Parenteral Nutrition Total Parenteral Nutrition

(PPN) (TPN)

Partial Parenteral Nutrition (PPN): It is a good nutrition support to mildly malnourished

subjects. It may be used as a supplement in oral feeding. It is generally given through small
peripheral vessels of the hand/wrist. It is a part of routine hospital care in which patients
may receive dextroxse or aminoacid solutions.

Total Parenteral nutrition (TPN): When the gut is totally obstructed and the same is by
passed then all the nutrient needs of the subject are provided by the method through a large
central vein such as jugular vein, subclavian vein or even femoral vein.
Many clinical situations require this type of feeding. Such as patients showing a poor
response to oral feeding or partial parenteral nutrition (PPN), conditions of severe
malnutrition with fluid or electrolytic abnormalities, massive surgeries on the gut, fistulas,
severe inflammatory diseases of the gut, excessive vomitting, hypermetabolic states (burns,
trauma or sepsis.)
Large quantities of food carbohydrates (glucose) proteins (amino acids ) fat (fatty acids),
minerals and vitamins can be given by this method through various formulas commercially
available.
This method of feeding is much more complicated than a simple oral or enteral method of
feeding because:
● it is a complex method of feeding, requires regular biochemical testing.
● causes metabolic and electrolyte and other abnormalities
● it is difficult to operate
● requires regular medical-and nursing attention
● it is not a natural method of feeding
● it is psychologically depressing for the patient
● it is a very expensive method of feeding.
Total Parenteral Nutrition: Patients whose condition is very serious and whose
gastrointestinal tract is not functional cannot sustain themselves on partial parenteral. Total
parenteral nutrition (supplied directly into a larger central vein) can provide a fully adequate
supply of most of the nutrients. Total parenteral nutrition involves the continuous infusion
of a hypertonic solution of a certain % of glucose, amino acids or protein hydrolysate, fatty
acids, vitamins and minerals.
Once the patient can take in food by mouth, liquid diets are administred. Such diets are
mentioned in Table 2.6.
Table 2.6: Liquid Diets

1000 Kcal diet 1500 Kcal diet

Milk 750 ml Milk 1 litre

Sugar 50 g Sugar 250 g
Fruit for juice 200 g Fruit for juice 200 g
Dal/Protein hydrolysate 25g Sugar 100 g
Oil 10 g Vegetables 200 g
Rice (for gruel) 75 g
Cream 50 g
Dal/egg 60 g

Milk based dishes such as custard can also be served.

45
Nutrition and Dietetics
We have highlighted some of the special feeds below:

Miscellaneous applications

Indications for Parenteral Nutrition

You have learnt the conditions under which parenteral nutrition support is to be used.
These conditions may be classified as follows:

● Conditions characterized by loss of partial GIT or bowel

● Conditions characterized by functional bowel disease

● Conditionscharacterized by excessive nutritional demands associated with relatively

poor functioning of GIT

● Conditions characterized by injury or damage or pharynx or oesophagus

● Other conditions
 ● Persistent, uncontrolled diarrhoea/vomiting

● Coma,conditions where GIT must be allowed to rest e.g. intestinal surgery,

pancreatitis, Crohn’s disease.

You could use this classification to help you remember the conditions where parenteral
feeding becomes necessary as you will study in Units 4 and 5. Though this gives an
indication of conditions where parenteral feeding is usually necessary, there may be cases
where enteral feeding is preferred because the patient can eat an adequate oral diet. The
severity of the problem is often the deciding factor.

In all the special feeding and nutritional support to the individual patient, what is your
role?

Your role in nutritional care: You have a crucial role to play in ensuring the medical and
nutrition success of therapy. You could;

1) KEEP IN TOUCH WITH THE DOCTOR AND DIETITIAN REGARDING THE

PATIENT’S MEDICAL AND DIETARY NEEDS.

Specific Tasks

Understanding the type and amount of drugs given

Obtaining a diet prescription if there is one and arranging for food service to the patient

● Providing the dietitian and physician with information regarding the patient’s response
to the diet

● Serving as liaison between the patient physician and the dietitian

2) ASSIST THE PATIENT AT MEAL TIMES

Specific Tasks

● Preparing the patient for the meal and educating him/her on importance of eating

● Giving assistance in feeding and otherwise to the patient if needed

● Encouraging the handicapped to self-feed

● Giving encouragement and support to the patient

46 ● Making mealtimes pleasant and releaxed.

Planning Diets
3) HELP THE DIETITIAN IN SPECIFIC TASKS The Tasks are:

● Interpreting the diet to the patient

a) Explaining the reasons for a modified diet and what to expect with reference to diet
therapy.

● Observing, recording and reporting the patient’s response to diet

b) Finding out information regarding food habits, likes and dislikes and attitudes
towards the diet or specific foods.

c) Noting adequacy of food intake according to the diet prescription.

d) Reporting patient’s response to dietitian and physician e.g. weight loss/gain.

4) PLAN FOR HOME CARE

Specific Tasks

● Identify needs for outside assistance.

● Arranging for counselling regarding home diet with the patient as well as family members.

2.4.5 Planning Diets for Patients and High Risk Individuals

We cannot plan a diet for a patient without keeping the person and his or her special needs in
mind. Before actually planning the diet, the following information is carefully collected:

● the nature and duration of the disease

● underlying causes of the disease

● food habits of the person

● nature of dietary changes required

● food allergies

On the basis of this a dietary prescription is worked out as also the need for any special
feeding methods. The prescription should ideally specify the amount of calories, protein
and any other nutrients that must be supplied. In addition, foods to be restricted or given
freely should also be clearly outlined.

This is the point where the dietitian takes over and an individualized nutritional care plan is
made. The plan includes:

i) an estimate of adequacy of the patient’s usual dietary intake

ii) any nutritional problems

iii) solutions for overcoming nutritional and other related problems of the patient

iv) notes on progress of the patient and

v) an evaluation of medical and nutritional therapy and solutions to sustain the treatment

Several social, economic, religious, psychological and emotional factors play a role in diet
planning. We will discuss these aspects in some detail in Section 2.5.

In this context we also need to take a quick look at how nutritional care is administered in a
hospital or clinic setting. A patient is the responsibility of a “health team”. The chief members
of this team are the physician or doctor, the nurse and the dietitian.
47
Nutrition and Dietetics
What is your role as a nurse in nutritional care? Your contact with the patient is actually the maximum and
most constant and therefore there is much you can do to help in the treatment
given by the specialist both the doctor and the dietitian.

Check Your Progress 5

1) List the type of diets which are modified in consistency.

.......................................................................................................................................

.......................................................................................................................................

2) What is your role in nutritional care in the hospital or clinic where you work now?

.......................................................................................................................................

.......................................................................................................................................

.......................................................................................................................................

2.5 SOCIAL, ECONOMIC AND PSYCHOLOGICAL

FACTORS IN DIET PLANNING
As you read the previous section you may have realized that (as a student of nursing) you
need more information on the:

● Acute and chronic conditions which require a change in diet;

● Rationalefor dietary changes, characteristics of diets and their beneficial and possibly
adverse effects;

● Nutritional limitations of various modified diets, and indications and contraindications

for use; and

● Ways in which drug therapy may influence food intake or utiliazation.

 It will be our endeavour to provide you with this information in the subsequent units of this
block.

Now let us turn our attention to a vital aspect. The patient’s needs must come first in
therapy. We must never forget that a well planned diet is useful only if it is acceptable to the
patient. This becomes very important in the case of therapeutic diets which substantially
change the type of food offered in terms of texture or taste. A patient may need to give up
foods he or she particularly likes or may have to eat foods which are disliked. Such changes
are difficult to accept. In addition to personal preferences, consideration of social,
religious, cultural factors is crucial. The cost and availability of foods also becomes
important if a diet has to be adopted for a long duration, even a lifetime.

In your interactions with patients you may have come across people who cope with
hospitalization with difficulty. You probably realized that a sick person is plagued by many
fears and doubts:

i) Do I really have this disease?

ii) Will I get well?

iii) What will happen to me and my family?

iv) Will others interact with me in the same way as before?

As a nurse you may have helped to console a worried patient and the family members. This
kind of stress can interfere with the patient’s food intake. Reassurance is essential but
while talking to a patient we need to be realistic too. A diabetic for example will have to
make difficult adjustments for life. It is necessary to help him cope with this realization
48 rather than avoid his troubles.
Planning Diets
Some key points to remember are: ● Consider the patient as a “person”, an individual with unique needs

● Try to make care as personalized as possible

● Be realistic about the modes of treatment being followed

● Let the patient participate in his or her own care if he/she is able to do so

● Consider the background of the patients but guard against superior, intolerant, resentful
or critical attitudes.

To return to some aspects of preparing nutritional care plans and your interaction with
dietitians in this regard. It is the primary responsibility of the dietitian to prepare a plan
for nutritional care. The dietitian is the specialist who transforms the doctor’s diet
prescription into a diet with practical recommendations for foods, nutritional products or
formulas. Designing appropriate meal patterns acceptable to the patient is most
important. However, any information you can give would be most valuable. In addition
you have a vital role in putting the diet plan into practice. Where there is no dietitian
such as in public health nursing field you may have to advise the patients and families
on dietary treatment.

Check Your Progress 6

Look at the following sample menu for an obese patient who is recovering from myocardial
infraction. Evaluate this menu on the basis of food groups included.

Meal/Menu Amount
Breakfast
Tea/coffee 1 cup
Skim or toned milk 1 glass
1 teaspoon sugar
Bread/Dalia 2 slices or 1 slice + 1/2 cup cooked dalia or cornflakes
Mid-morning
Fruit juice 3/4 cup
Biscuit 2
Lunch
Vegetable soup 3/4 cup
Bread Khichri or Rice and 2 slices or khichri 1/2 cup
Dal Khichri
 Mixed vegetable 1/2 cup
Jelly 1/2 cup
Tea
Tea/coffee 1 cup
Sugar 1 teaspoon
Biscuits 2
Dinner
Same as for lunch Same as for lunch

..............................................................................................................................................

..............................................................................................................................................

..............................................................................................................................................

..............................................................................................................................................
49
Nutrition and Dietetics
2.6 LET US SUM UP
The main points highlighted in this unit include the following:

● Adequate/Balanced diets are based on including suitable amounts of foods from each
of the three food groups—energy-giving, body-building, and protective/regulatory.
The amounts are decided on the basis of the recommended dietary intakes (RDIs) for
the person for whom the diet is being planned.

● Adequate/balanced diets are individual-specific, income-specific and region-specific.

Age, sex, activity level and physiological state are individual-specific factors which are
extremely important. In brief, as age advances, nutrient requirements tend to increase.
However, after the age of forty, requirements for energy decrease. Women require less
energy and protein than men because of differences in body build and composition.
As activity level go up, so do energy needs. Pregnancy and lactation both increase
nutrient needs substantially. Periods of rapid growth in the lifespan are associated with
high nutrient requirements.

● Diseases influence the body’s utilization of nutrients. They also influence appetite and
food intake. This necessitates various types of dietary modifications.

● Therapeutic diets are modified versions of normal diets. The modifications made are :
change in consistency; increase or decrease in energy content; inclusion of more or
less amount of one or more nutrients; increase or decrease in fibre content; elimination
of spices and condiments; inclusion or exclusion of specific foods and change in
feeding interval.

● Special feeding methods may be required in the case of some patients who are unable
to eat by mouth. These are enteral or parenteral administration.

● Social, religious, cultural, economic and psychological factors must be considered in

diet planning both for normal individuals and those suffering from disease.

2.7 KEY WORDS

Basal Metabolic Rate (BMR) : The amount of energy required to carry on the involuntary
work (i.e. internal work) of the body measured in the
postabsorptive state when the person is reclining but awake,
relaxed and free from stress. The body temperature should
be normal and measurement should be conducted at
comfortable room temperature and humidity.

Demineralization : Less of bone mineral i.e. calcium and phosphorus

compounds in the bone which give it strength and rigidity.
 Dentition : A term referring to teeth

Jejunum : Part of the small intestine

Physiological stress : Stress on the body due to normal physiological events

unlike the stress caused by disease or pathological stress;
periods of physiological stress are generally rapid growth
phases (e.g. infancy, adolescence, pregnancy and lactation).

Triglycerides : A lipid made of three molecules of a fatty acid and one

molecule of glycerol.
50
50
Planning Diets
2.8 ANSWERS TO CHECK YOUR PROGRESS Check Your Progress 1
First select items from each of the three food groups which you think can be used for a menu
for lunch/tea time. Then on the basis of the items selected list the dishes to be included.
Use the format mentioned for your answer.

Check Your Progress 2

From infancy to adulthood requirements for nutrients increase. This is because of growth.
As new tissues are added, body mass increases and more nutrients is needed to sustain this
process and to keep the individual healthy and ensure proper development. Once
adulthood is reached nutrient needs stabilize. However, after the age of forty, energy needs
decrease because of lowered metabolic rate, loss of active tissue and reduced activity level.

Check Your Progress 3

The statement is false. There is a clear distinction between requirement and recommended
dietary intake. Requirement refers to the minimum amount of a nutrient required to prevent
deficiency and maintain satisfactory body levels of that nutrient for the majority of the
people. An additional safety margin for individual variation, cooking losses, periods of low
intake is added to the requirement figure to arrive at the RDI.

Check Your Progress 4

1) False. As energy needs go up, needs for B complex vitamins also go up.

2) True

3) True

Check Your Progress 5

1) Clear fluid, full fluid, soft, mechanical soft.

2) Answer on the basis of your own experience.

Check Your Progress 6

Look for the three food groups in each and evaluate accordingly. Suggest modifications, if any,
required.
51