MFNL- 005

Clinical and
Indira Gandhi
National Open University
Therapeutic Nutrition
School of Continuing Education

Clinical and Therapeutic Nutrition

PRACTICAL 1
Exchange List and Food Composition Tables for Meal Planning 7
PRACTICAL 2
Special Feeding Methods 16
PRACTICAL 3
Nutritional Management of Fevers 29
PRACTICAL 4
Nutritional Care of Weight Management 50
PRACTICAL 5
Planning Diets for Metabolic Diseases 77
PRACTICAL 6
Nutritional Management of Gastrointestinal Disorders 106
PRACTICAL 7
Nutritional Management in Liver, Gall Bladder and
Pancreatic Diseases 134
PRACTICAL 8
Planning Diets for Renal Diseases 173
PRACTICAL 9
Nutritional Management of Coronary Heart Diseases 220
Expert Committee
Prof. Tara Gopaldas Dr. Shobha Udipi Dr. Indira Chakraborthy
Tara Consultancy Services Rtd. Professor All Indian Institute of Hygiene
Bangalore-560093 Department of Foods and Nutrition and Public Health
SNDT University, 110, Chittaranjan Avenue
Mumbai. Kolkatta
Dr. Kumud Khanna Dr. Sushma Sharma Dr. Umesh Kapil
Former Director Former Reader Human Nutrition Unit
Institute of Home Economics, Department of Foods and Nutrition All India Institute of Medical
F-4, Hauz Khas Enclave Lady Irwin College, New Delhi Sciences
New Delhi New Delhi

Mrs. Mary Mammen Parvathi Eashwaran Dr. Ulvir V Mani

Christian Medical College and Department of Food Service Professor,
Hospital Management; Avinashilingam Department of Food and Nutrition
Udam Seudder Road Institute of Home Science College of Home Science
Post Box No.3 and Higher Education for Women M.S.University
Vellore Deemed University, Coimbatore Vadodara

Ms. Rekha Sharma Dr. (Mrs.) Molly Joshi Dr. (Mrs.) K. Puri
Ex. Chief Dietitian, Ex. Chief Dietitian, Rtd. Professor
All India Institute of Medical Department of Dietetics Foods and Nutrition Department
Sciences CMC Hospital Punjab Agricultural
New Delhi Ludhiana, Punjab University, Ludhiana
Dr. Shikha Khanna Prof. Deeksha Kapur (Convenor) Dr. Annu J Thomas
Ex. Chief Dietitian Discipline of Nutritional Sciences School of Continuing Education,
Ram Manohar Lohia Hospital, School of Continuing Education IGNOU
New Delhi IGNOU, New Delhi New Delhi

M.Sc. (DFSM) Programme Coordinator

Prof. Deeksha Kapur
Discipline of Nutritional Sciences
School of Continuing Education
IGNOU, New Delhi

Course (MFNL-005) Preparation Team

Content Contributor Editing and Transformation
Prof. Deeksha Kapur (Practical 1, 2, 6) Prof. Deeksha Kapur
Dr. Sukhneet Suri (Practical 3, 4, 5, 6, 7, 8) Discipline of Nutritional Sciences
Ms. Prinyanka Sagar (Practical 9) School of Continuing Education
IGNOU, New Delhi

Course (MFNL-005) RevisionTeam (2019)

Prof. Deeksha Kapur Ms. Isha Nagrath
Discipline of Nutritional Sciences Academic Associate
School of Continuing Education School of Continuing Education
IGNOU, New Delhi IGNOU, New Delhi
Print Production
Mr. Arvind Kumar
Assistant Registrar (Pub.)
SOCE,IGNOU
July, 2019 (Revised)
 Indira Gandhi National Open University, 2006
ISBN-81
All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other means,
without permission in writing from the Indira Gandhi National Open University.
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Printed and published on behalf of the Indira Gandhi National Open University by School of Continuing Education.
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MANUAL INTRODUCTION
The practical manual for the course‘Clinical and Therapeutic Nutrition’ (MFNL-005),
has been so designed to train individuals to function as medical nutrition therapist. It
focuses on providing knowledge and developing appropriate skills and attitudes in learners
for nutritional diagnostic, counseling services and planning diets for the purpose of disease
management. Examples of conditions treated with medical nutrition therapy include
cardiovascular disease, congestive heart failure, eating disorders, food allergies (such as
sprue and lactose intolerance), hyperlipidemia (high cholesterol), hypertension (high blood
pressure), irritable bowel syndrome, non-insulin dependent diabetes (type 2), insulin
dependent diabetes (type 1), chronic renal (kidney) disease, enteral nutrition, weight
management for adults and children etc. This practical manual will provide an in-depth
review on proper diet, lifestyle strategies and therapeutic nutrient intervention to correct
nutritional insufficiencies, promote optimal health, and prevent, manage, or correct some
of these medical problems.
MFNL-005, the ‘Clinical and Therapeutic Nutrition’ practical course is worth 2 credits
(i.e. 60 study hours) and consists of 9 practicals with suitable activities at the end of each
practical for a thorough understanding of the subject by the students. Starting from
understanding the fundamental principle of diet planning and use of food composition
tables and exchange list for planning diets to planning therapeutic diets for disease conditions
are covered in this manual. A brief review of each of the practical included in this manual
follows.
Practical 1 focuses on the fundamental principles of meal planning, with a focus on
understanding exchange list and food composition tables the basic tools used for planning
diets. This is the basic preparatory practical for learners. The practice activity included
in this practical will help the learners understand the concept and use of exchange list/
food composition table in planning diets for different disease conditions covered in this
manual.
Sometimes person cannot eat any or enough food because of an illness. The stomach or
bowel may not be working quite right, or a person may have had surgery to remove part
or all of these organs. Under those conditions, nutrition must be supplied in a different
way. Practical 2 discusses the special feeding methods, with special focus on enteral
nutrition. What are the different types of enteral feeds and their characteristics? How to
prepare home blend tube feeds? These are a few aspects covered in this practical.
Undertaking the two activities included in this practical will help the learners plan and
prepare blenderized feeds for ill, malnourished patients and get a deep insight into the
various commercial enteral feeds available in the Indian market.
Practical 3 deals with the nutritional implications of fever and the dietary management
of different types of fevers. Undertaking the two activities included in this practical will
equip the learners to plan diets for patients suffering from typhoid and tuberculosis, which
are acute and chronic fevers, respectively.
The epidemic of obesity with its attendant co-morbidities  heart disease, hypertensions,
stroke and diabetes – is a problem fast emerging as a public health concern in our country.
On the other hand, underweight or the inability to gain weight/achieve and maintain an
ideal (normal) body weight is already a big public health issue which needs to be addressed.
Practical 4 describes the various practical aspects of weight management. The various
principles of dietary/ life-style management have been highlighted including the two activities
which will help the learners learn/improve their skills pertaining to the overall assessment
and management of under/over-weight conditions in a spectrum of physiological/clinical
situations.
Practical 5 deals with the nutritional management of metabolic disorders. The various
practical aspects/principles of dietary management which are imperative for the successful
treatment/management of diabetes mellitus and gout, are included in this practical. The three
activities included in this practical would help the learners internalize the step-by-step
process required for individualized diet planning as per the requirements of the patients.
Practical 6 introduces the dietary management of some of the disorders of the
gastrointestinal tract namely peptic ulcer, ulcerative colitis and lactose intolerance. In
order to prevent the development of these disorders, the gut must remain healthy so that
the GI tract functions can be carried out normally. Nutrition, therefore, plays an important
role in the management of these disorders. By undertaking the three activities included in
this practical, the learners will not only be able to counsel patients regarding what foods to
include or exclude in the diet but also be able to plan nutritious meals for patients suffering from
these disorders.
Practical 7 covers the diseases of the liver, gall bladder and pancreas. Hepatitis, cirrhosis,
cholecystitis/cholelithiasis and pancreatitis are the major diseases which are included in this
practical. The three activities included in this practical will help learners understand and learn
about the applied aspects related to working out a day’s diet for each of these diseases.
The various renal problems followed by the nutrient requirements during these conditions and
the translation of nutritional requirements into suitable food sources as per the RDI so as to
result in the development of an appropriate diet is the focus of Practical 8. The five activities
included in this practical will help learners plan diets for renal diseases including glomerulonephritis,
nephrotic syndrome, chronic/acute renal failure and nephrolithiasis.
Coronary heart diseases are a group of diseases of the heart. Practical 9 focuses on some of
these conditions namely hypertension, atherosclerosis, myocardial infarction and congestive
heart failure. The main focus in this practical is on the dietary guidelines and principles involved
in planning diets for these heart conditions. There are three activities in this practical.
There are 14 sessions planned for you for this practical component of the Clinical and Therapeutic
Course (MFNL-005). Each session will be of 4 hours. Each session will be preceded by a
PRE-LAB session, where the instructions/important points shall be discussed by the counselor
with you and followed by a POST-LAB session. At the post-lab you will be expected to hand
in written work relating to the practical, unless other arrangements have been announced.
Conclusions from the practical exercises and any problems arising during the practical will be
discussed. Attendance at Pre, During and Post Lab sessions is an essential part of the practical
course. Non-attenders may be penalised. Practical laboratory work will contribute 40% to the
assessment of this course (MFNL-005). Sixty per cent weightage is for the term-end practical
exam. Examinations will be held in the 15th session at the end of the practical course being
undertaken by the learner. The examination shall be of 6 hour duration and shall be based on
material presented in the manual and in the class.
A sample format of the practical/activities to be conducted during the 14 sessions is enumerated
herewith. The final format shall be given to you by your course counselor. The programme
study centre coordinator shall arrange for the practical course work. So please be in touch with
the coordinator for the allotment of the practical schedule.
Format for Practical Session
SESSIONS/ PRACTICAL/ACTIVITY
DURATION
I PRACTICALS 1 and 2
(4 HOURS) Introduction to the Manual
Discussion on Exchange List and Food Composition Tables and How to
Use them in Diet Planning
Instructions Related to Practical 2 and How to Carry Out a Survey.
Activity 1: Review Exercise: Diet Planning Using the Exchange List and
the Food Composition Table
II PRACTICAL 2: Special Feeding Methods
(4 HOURS) Activity 1: Planning Home Blend Feeds
Activity 2: Survey for Commercial Enteral Feeds Available in the Indian
Market
III PRACTICAL 3: Nutritional Management of Fevers
(4 HOURS) Activity 1: Diet Plan for Typhoid
Activity 2: Diet Plan for Tuberculosis
Preparing one dish from each activity
IV PRACTICAL 4: Nutritional Care of Weight Management
(4 HOURS) Activity 1: Diet Plan for Overweight Obser Individuals
Activity 2: Diet Plan for Underweight Individuals
Preparing one dish from each activity
V PRACTICAL 5: Planning Diets for Metabolic Diseases
(4 HOURS) Activity 1: Diet Plan for Non-Insulin Dependent Diabetes Mellitus
(NIDDM)
Activity 2: Diet Plan for Insulin Dependent Diabetese Mellitus (IDDM)
 VI PRACTICAL 5: Planning Diets for Metabolic Diseases
(4 HOURS) Activity 3: Diet Plan for Gout
Prepare one dish from each activity in Practical 5.

VII PRACTICAL 6: Nutritional Management of Gastrointestinal

(4 HOURS) Disorders
Activity 1: Diet Plan for Peptic Ulcer
Activity 2: Diet Plan for Ulcerative Colitis

VIII PRACTICAL 6: Nutritional Management of Gastrointestinal

(4 HOURS) Disorders
Activity 3: Diet Plan for Lactose Intolerance
Prepare one dish from each activity in Practical 6.

IX PRACTICAL 7: Nutritional Management in Liver, Gall Bladder

(4 HOURS) and Pancreatic Diseases
Activity 1: Diet Plan for Hepatitis
Activity 2: Diet Plan for Liver Cirrhosis
Prepare one dish from each activity

X PRACTICAL 7: Nutritional Management in Liver, Gall

(4 HOURS) Bladder and Pancreatic Diseases
Activity 3: Diet Plan for Choletihiasis/Cholecystitis
Activity 4: Diet Plan for Pancreatitis.
Prepare one dish from each activity

XI PRACTICAL 8: Planning Diets for Renal Diseases

(4 HOURS) Activity 1: Diet Plan for Glomerulonephritis
Activity 2: Diet Plan for Nephrotic Syndrome
Prepare one dish from each activity

XII PRACTICAL 8: Planning Diets for Renal Diseases

(4 HOURS) Activity 3: Diet Plan for Chronic Renal Failure
Activity 4: Diet Plan for Acute Renal Failure
Activity 5: Diet Plan for Nephrolithiasis
Prepare one dish from each activity

XIII PRACTICAL 9: Nutritional Management of Coronary Heart

(4 HOURS) Diseases
Activity1: Diet Plan for Hypertensive
Activity 2: Diet Plan for Acute Myocardial Infarction and
Hypercholesterolemia

XIV PRACTICAL 9: Nutritional Management of Coronary Heart

(4 HOURS) Diseases
Activity 3: Diet Plan for Congestive Heart Failure
Prepare one dish from each activity in Practical 9.

RECORDING PRACTICAL WORK

The practical manual for the course is actually a workbook. It contains not only the
background information and concepts necessary for you to conduct the exercises, but it
also serves as a practical file or workbook. You are expected to write your observations,
calculations, results, inference, conclusions etc. related to a particular activity in the manual
itself in the space specified. Record the practical work directly into the bound practical
manual (workbook), never on loose-leaf sheets. Every entry in the practical manual
should be dated, and your own observations (including comments such as the difficulties
you found in doing certain procedures, or ideas that occurred to you) should be written
down as a permanent record. Recognize that your practical manual is the true record of
what you did and observed at the time. You can (if you wish) use the back pages of your
practical manual for making calculations, note etc.
 LIST OF ACTIVITIES

S.No. ACTIVITIES PAGE NO.

1 Planning Home Blend Feeds 23

2 Survey for Commercial Enteral Feeds Available in the 27

Market

3 Diet Plan for Typhoid 39

5 Diet Plan for Tuberculosis 45

6 Diet Plan or Overweight/Obese Individuals 65

7 Diet Plan for Underweight Individuals 71

8 Diet Plan for Non-Insulin Dependent Diabetes 90

Mellitus (NIDDM)

9 Diet Plan for Insulin Dependent Diabetes 96

Mellitus (IDDM)

10 Diet Plan for Gout 101

11 Diet Plan for Peptic Ulcer 117

12 Diet Plan for Ulcerative Colitis 123

13 Diet Plan for Lactose Intolerance 129

14 Diet Plan for Hepatitis 150

15 Diet Plan for Liver Cirrhosis 155

16 Diet Plan for Cholelithiasis/Cholecystitis 161

17 Diet Plan for Pancreatitis 167

18 Diet Plan for Glomerulonephritis 190

19 Diet Plan for Nephrotic Syndrome 195

20 Diet Plan for Chronic Renal Failure 201

21 Diet Plan for Acute Renal Failure 206

22 Diet Plan for Nephrolithiasis 211

23 Diet Plan for Hypertension 226

24 Diet Plan for Acute Myocardial Infarction and 231

Hypercholesterolemia

25 Diet Plan for Congestive Heart Failure 235

 Exchange List and Food
PRACTICAL 1 EXCHANGE LIST AND FOOD Composition Tables for
Meal Planning
COMPOSITION TABLES FOR
MEAL PLANNING
Structure
1.1 Introduction
1.2 The Food Composition Table
1.3 The Exchange List
1.3.1 Steps in the Development of Exchange List
1.4 Steps in Planning Diets
1.5 Review Exercise

1.1 INTRODUCTION
This first practical in the manual will orient you to the concept of the food composition
table and the exchange list. This is a basic practical, which will prepare you for
planning diets for different individuals and disease conditions. The basic steps to be
followed in planning diets are also highlighted in this practical. This information will
equip you to carry out the various activities included in this manual. So study this practical
very carefully. Understand the principles explained herewith and carry out the review
exercise given at the end of the practical so as to internalize the concepts.
Objectives
After undertaking this practical, you will be able to:
 explain the concept of the food composition tables and the exchange list,
 enlist the steps involved in planning diets, and
 use the food composition table and the exchange table in planning diets.

1.2 THE FOOD COMPOSITION TABLE

The nutritive value of foods can be calculated from the Food Composition Tables. The
food composition tables for Indian foods give the nutritive content or composition of
almost all common Indian foodstuffs available in our country. These Tables have been
developed by the National Institute of Nutrition (a unit of the Indian Council of Medical
Research), Hyderabad. The Tables under the title “Indian Food Composition Tables,
2017” are now available. As a student of Dietetics and Nutrition, certainly you may
have used this book some time. If not, we suggest you obtain a copy of this book or you
can download PDF version from internet.
The food composition tables provide information regarding the energy, protein, fat,
carbohydrate, fibre, mineral (calcium, phosphorous, iron) and vitamin (vitamin A,
vitamin C, thiamin, riboflavin, niacin, folic acid and vitamin B12) content of various
commonly used foodstuffs in Indian households. The nutrient content of foodstuffs
given in the Table is based only on the 100 g edible portion of raw foodstuffs. By edible
portion we mean the portions of the food stuffs which are really consumed/eaten.
For example, in case of peas, the edible portion is the peas inside the pod. The inedible
portion is the pod or shell, which we throw away. In case of foodstuffs like milk, atta
etc., these are 100 per cent edible. The food composition tables can thus be used to
calculate the nutrient content of edible portion of the foodstuffs for amounts consumed.
These can also be used for calculating the nutritive content of a meal or a dish.
At this stage, we suggest you undertake a small exercise, whereby you calculate the
nutritive value of a meal using the Food Composition Table. You may calculate the
nutritive value of the meal you have just consumed or perhaps calculate the nutritive
value of the meal given herewith. Calculate the energy and protein content of the meal
for the amounts specified against each ingredients in the format given herewith. 7
8
Clinical and
Therapeutic Nutrition

Source : Recommended DietaryAllowances for Indians, ICMR, 2010.

 Review Exercise Exchange List and Food
Composition Tables for
Meal Menu Ingredients Amt Energy Protein Meal Planning
(g) (Kcal) (Kcal)
Lunch Rice Rice 40
Chapati Wheat Flour 60
Dal Bengal Gram Dal 30
Brinjal Potato Brinjal 80
Vegetable Potato 40
Curd Onion 30
Fat 5
Curd 125
So then was that an easy exercise? Not really! You may have realized that using the
Food Composition Tables is cumbersome, time-consuming and needlessly precise and
that you may not have the time to calculate for each day, each meal the energy and
nutrient composition of the food required to fulfill the dietary needs of individuals. To
overcome this problem, an Exchange List was evolved. What is an exchange list? Let
us find out next.
But first refer to Table 1.1 which presents the recommended dietary intakes for Indians.
The table lists the RDI for several nutrients.

1.3 THE EXCHANGE LIST

An exchange list is a grouping of foods in which specified amounts of all the foods
provide approximately equal amount of (the same amount) carbohydrate, protein
and fat and hence, energy content. Specific foods within the group may vary slightly
in nutritive value from the averages stated in the group. These differences in composition
tend to cancel out because of the variety of foods selected from day to day. Thus any
food within a given list can be substituted or exchanged for any other food in that list in
the given quantities. We are already familiar with the categorization of foods into groups
i.e. the energy-giving group, the body-building group and the protective group as highlighted
here in Table 1.2. These groups or exchanges represent commonly measured or purchased
unit of food or its multiples. These exchanges also limits food items to those in common
usage.
Table 1.2: The three food groups
Food Groups Food Items
Energy-giving Cereals
(provides carbohydrates or fats) Roots and Tubers, Sugar, Jaggery
Fats and Oils
Body-building (provides proteins) Milk
Pulses
Meat/Fish/Poultry/Egg
Protective/Regulatory Green Leafy Vegetables
(provides vitamins and minerals) Other Vegetables
Fruits
Food exchange system allows one to choose a variety of foods from within a group with
adequate nutrients. Thus the exchange list has brought about simplicity, flexibility and
standardization into the selection of values of foods used in quantitative diets. The food
exchange system is important in planning a nutritious diet. Essentially, the Food Exchange
System allows variety to be introduced into the diets without altering the energy or the
macronutrient contents. The exchange lists are especially useful in planning diets for
metabolic diseases and are very useful in the management of obesity.
Let us then quickly review the steps involved in planning/developing an exchange list.
This will help you plan meals using the exchange list.
1.3.1 Steps in the Development of Exchange List
Given herewith are the steps, which when followed, will guide you in developing the
exchange list. 9
Clinical and 1) An important first step in developing an exchange list is to group together similar
Therapeutic Nutrition foods. As mentioned above, when we group together similar food items so that
each supplies a constant amount of a particular nutrient we call the group a food
exchange. For example, in Table 1.2, cereals, roots and tubers, sugar, fats and oils
are grouped under the energy-giving group or exchange. Similarly, we have listed
the category fruits, green leafy vegetables as part of the protective/regulatory group/
exchange.
2) The second important step in developing an exchange list is the standardization of
serving or portion sizes. The portion sizes vary considerably in India. Idlis, dosas,
chapattis and puris of different sizes in different states and in different households
is a common scene. Despite this, some attempts have been made to define portion
sizes.
3) The third step is to calculate the energy, carbohydrate, protein and fat content of
one serving or portion size of the different dishes. This can be done by converting
the cooked weight of one serving of a dish into raw weight of the ingredients that
have gone into it. Although allowances should be made for cooking losses, this has
not been done. Future exchange lists must take care of this. From the raw weights
of the ingredients in one serving and using the Indian food composition Tables, the
energy, carbohydrate, protein and fat content of one serving can be calculated.
4) The fourth step is to create an exchange list of different dishes in terms of standard
portion sizes that would provide approximately the same energy or carbohydrate or
fat as the case may be. Since foods contain widely varying amount of the
macronutrients, serving or portion sizes are defined for a group of more or less
homogeneous foods. For example, all cereals provide approximately the same number
of calories, approximately 350 per 100 g raw weight and about the same amount of
carbohydrates, about 70 g per 100 g raw weight (Refer to Table 1.3). Therefore,
cereal exchanges are grouped together. Similarly, there are vegetable, fruits, milk
and meat exchanges. Within each of these food groups, the composition of the
different items in terms of carbohydrate, protein and fats remain similar.
Table 1.3: Nutritive values used in the development of the exchange list for cereals
Food Group Energy CHO Protein Fat
(Kcal) (g) (g) (g)
Bajra 348 61.8 10.96 5.4
Jowar 334 67.7 9.9 1.7
Maize, dry 334 64.8 8.8 3.8
Ragi 320 66.8 7.2 1.9
Rice, raw 356 78.2 7.9 0.5
Parboiled 351 77.2 7.8 0.5
Flakes 354 76.5 7.4 1.9
Puffed 362 77.7 7.5 1.6
Whole wheat flour 320 64.2 10.3 1.5
Maida 352 74.3 10.4 0.8
Semolina 334 68.4 11.4 0.7
Vermicelli 333 70.4 9.7 0.4
Mean 342 70.6 9.8 1.7
Bread, White 265 49 9.0 3.2
Brown 293 54 11 3.3
Source: Indian Food Composition Tables, 2017
To help you understand the exchange list concept more clearly, we have included an example of a comprehensive
exchange list developed by the Lady Irwin College, New Delhi. Refer to Table 1.4. As you may have noticed,
the list consists of three exchange groups. These are energy-giving, body-building and protective/regulatory
exchange. A brief review of these exchanges follows:
 Under the energy-giving exchange, cereal exchange per serving (20 g) , provides 75 Kcals, 15 g carbohydrate
10 and 2 g protein. Likewise the roots and tubers, sugar, fats and oil exchanges are defined (see Table 1.4).
 Exchange List and Food
Composition Tables for
Table 1.4: Food exchanges Meal Planning
Exchange No. of Amount Energy Protein Carbohydrate Fat
(Food Group) Exchanges (g) KJ Kcal (g) (g) (g)
(Energy Giving group)
Cereals 1 20 315 75 2 15 0.5
Roots and Tubers 1 100 210 50 1.5  Negligible
Sugar and Jaggery 1 6 84  Negligible  Negligible
Fats and Oils 1 5 190  Negligible Negligible 5
Oilseeds 1 8-12 190 45 2.9 Negligible 5
(Body-building group)
Milk 1 250 750 180 8 12 11
Skimmed Milk 1 320 390 94 8 15 Negligible
Pulses 1 30 420 100 7 17 Negligible
Meat/fish/poultry (Meat 1) 1 40 334 80 7 Negligible 5
(Meat 2) 1 40 146 35 7 Negligible 1
(Protective/regulatory Group)
Green leafy vegetables 1 100 124 30 3 2.5 Negligible
Other vegetables 1 100-150 124 30   Negligible
Fruits 1 80-150 190 45 1 10 Negligible
Meat 1 : Egg, Hilsa, Chicken (skinless), Goat (chops, legs, brain), Sardines, Paneer
Meat 2 : Egg white, Chicken (liver), Goat (Kidney, liver), Sheep (liver), Katla, Prawn, Rohu, Crab
Source: Adapted from Technical Series 6, Compilation of Food Exchange List, 2017 developed by Lady Irwin College, University of Delhi.
 Within the body-building group, milk exchange provides per serving (250 ml) 180 Kcals,
12g carbohydrate, 8 g protein and 11g fat; meat exchange provides per serving (40 g)
80 Kcals and varying amounts of CHO, 7 g protein and 5 g fat.
 Under protective/regulatory group, fruit exchanges provide per serving (80 - 100 g) 45
Kcals and 10 g carbohydrate, the vegetable group exchange provides 30 Kcals.
Using the steps elaborated above, we hope you will be in a position to use the exchange
system to calculate a diet pattern, which calculates the diet order in kinds and number of
servings of food exchanges to be consumed by any individual or a patient each day.
Although the exchange system, you would have noticed, reflects average and not specific
energy and nutrient values, the therapeutic success that results when the values are used to
calculate the diet pattern demonstrate that the method is accurate enough to serve this
purpose.
The exchange list described above, you may have realized, is a handy and simple tool to
calculate therapeutic diets and balanced meals for individuals. It is important that you
understand this concept very clearly here now, because we shall use this exchange list in
planning diets for different disease conditions subsequently in this manual. To help you in this
task, here we have included an exercise, which will provide you practical experience of
using the exchange list given in Table 1.4 above for planning diets. Before you move to the
exercise, we suggest you review the steps involved in planning diets.

1.4 STEPS IN PLANNING DIETS

As you go through the practical included in this manual, you will realize that in each activity,
the steps involved in planning diet are the same. These steps have been highlighted here for
your understanding and guidance.
STEPS IN PLANNING DIETS
Step I : Identify the individual and his/her Specific Characteristics
 Age
 Sex
 Activity Level
 Income
 Socio-economic background
 Religion
 Region where residing 11
Clinical and Step II : Consult RDIs
Therapeutic Nutrition
Step III : Decide on Total Exchanges for each Group
Step IV : Decide on the Meal Pattern and Distribute the above Selected Exchanges
according to the Meal Pattern
Step V : Decide on the Menu
Step VI : Select Appropriate Quantities for each Dish as per the Exchanges Available
and Calculate the Nutrient Content for the Detailed Diet Plan.
Step VII : Compare the Amount of the Nutrients Provided through the Detailed Menu
Plan with the RDI.
Now that you have a good insight about the exchange list and the steps involved in planning
diets, let us help you understand this concept further with the help of an example. Here is an
exercise related to planning a diet for an individual using the exchange table and the food
composition table. The step by step procedure to be followed has been explained here in this
activity. Follow the steps carefully as you go
about reading the exercise. Towards the end, you will have to undertake some basic calculations
for calculating the nutrient content of the diet using the Food Composition Tables. So please
have a copy of these Tables handy. This exercise will prepare and guide you for undertaking the
other activities included in this manual.

1.5 REVIEW EXERCISE

Activity: Diet Planning Using the Exchange List and the Food Composition Table.
Aim: To plan a diet for an individual using the exchange list and the food composition table.
Case Study: Ramu is a sedentary adult man 25 years of age. He belongs to a middle income
family living in North India. He is a vegetarian. Plan & calculate a day’s diet for Ramu. Based
on this case study or Ramu, we shall plan a diet using the steps elaborated in Section 1.4 above.
Step I: Identify the individual and his/her specific characteristics
From the case study of Ramu let us specify the characteristics as under :
Age: 25 years
Sex: Male
Activity Level: Sedentary
Income: Middle income level
Region where residing: North India
Now move on to step II i.e.find out the nutrient requirement for Ramu.
Step II: Consult RDI for Energy and Protein
(Hint: Ramu is an adult sedentary worker; hence look up the energy and protein requirement in Table 1.1
for adult man sedentary worker. Based on the RDI, Ramu’s requirements are given in the format herewith).
RDA for Ramu
Energy (Kcal) Protein (g)
2320 60
Having calculated Ramu’s energy and protein requirement and move on to step III.
Step III: Decide on Total Exchange
(So as to meet the RDI, select exchanges for each food group. Look at the exchange distribution given in
the format herewith). This is one example you may distribute the exchanges differently so as the obtain
2320 Kcal and 60 g proteins.
Exchange No. Energy (Kcal) Protein (g)
Cereal 14 1050 28
Roots and Tubers 2 100 3
Pulse 2 200 14
Milk and Milk products 2 360 16
Meat   
Green leafy vegetables 1  
Other vegetables 3 90 6
Fruit 3 135 
Sugar 6 120 
Fat 4 180 
Oil Seed/ Nuts 1 45 2.9
12
Total 2310 Kcal 76 gms
Once the total exchange(s) are decided, we move to step IV. Exchange List and Food
Composition Tables for
Meal Planning
Step IV: Decide on the meal pattern and distribute the above selected
exchanges according to the meal pattern.

(Hint: Since Ramu is a sedentary worker, he is likely to have 3-4 meals/day as shown
in the format herewith. The above selected exchanges can be distributed among these
meals as shown in the format herewith)

Exchange No. Exchange for Day’s Menu

Early Breakfast Mid- Lunch Tea Dinner Post

Morning Morning Dinner
Cereal 14  4 1 4 1 4 

Roots and Tubers 2  1/2 1/2 1/2  1/2 

Pulse 2  1/2   1/2  

Milk and Milk 2 1/4   1/2 1/4  

Products

Meat        
Green leafy 1    1/2   
vegetables
Other vegetables 3  1     

Fruit 3       
Sugar 6 1    1  1.5

Fat 5       

Oil seed/ Nuts 1 1      

The distribution of exchange for a day’s meal, you would realize, is useful in deciding
the menu which is step V.
Step V: Decide on the menu
(Using the exchange available for each meal (as decided in step II) prepare a menu for Ramu by
selecting the most appropriate foodstuffs).
Menu for Ramu

Early Breakfast Mid- Lunch Tea Dinner Post

Morning Morning Dinner
Almond Paushtik Methi Masala Salad Stuffed Salad Milk/Fruit
(4-5) Roti (2) Oats Chapati Chilla Chapati Custard
(Before Curd/Milk + Vegetable Tea Vegetable
Tea) Fruit Dal Dal
Tea + Sweet Curd
Biscuit Mint Chutney
The menu given above is one example. You may think or plan a different menu. Once
the menu is ready, we can calculate the nutritive content of the meals included in the
menu using the Food Composition Table. This is step VI.
Step VI: Select appropriate quantities for each dish as per the exchanges
available and calculate the energy and protein content for the detailed diet plan.
(This is an exercise for you to perform. The appropriate quantity for each dish as per the
exchange available is already given in the format given next. Complete the calculations using
the food composition table). 13
Clinical and
Therapeutic Nutrition Meal Menu Ingredient Amt Exchange Energy Protein
(g) (Kcal) (g)

Early Almond Almond 8-10 1

Morning Tea Milk 50 1/4
Sugar 5 1
Biscuit Biscuit 1-2 -

Breakfast Paushtik Wheat Flour 80 4

Methi Roti Besan 10 ½
Curd/ Milk Onion 50 ½
Fenugreek leaves 50 ½
Oil 10 2
Milk 150 ½
Sugar 5 1

Mid- Masala Oats 30 1

Morning Oats Onion 25 1/4
Peas 25 1/4
Oil 2.5 ½
Fruit Fruit 200 2

Lunch Salad (Cucumber, Carrot, 50 ½

Chapati Onion, Tomato)
Vegetable Wheat Flour 80 4
Dal Beans-Potato Veg 100 1
Sweet Dal 30 1
Curd Curd 150 ½
Sugar 7.5 1½
Oil 5 1
Mint Mint leaves 50 ½
Chutney

Tea Stuffed Rice Flour 30 1

Chilla Besan 10 ½
Tea Milk 100 1/4
Sugar 5 1

Dinner Salad (Cucumber, Carrot, 50 ½

Onion Tomato)
Chapati Wheat Flour 80 4
Vegetable Lady Finger 100 1
Dal Dal 30 1
Oil 5 1

Post Fruit Milk 175ml ½

Dinner Custard Sugar 7.5 1½
Fruit 100 1

Total
14
Now, let us evaluate how good our plan is. Move to step VII. Exchange List and Food
Composition Tables for
Step VII: Compare the amount of the nutrients provided through the detailed menu Meal Planning
plan with the amount of the nutrients computed in the RDI.
(Write the amount of nutrients provided through the detailed menu plan in the format given
below : Compare them with the RDI. Give your suggestions for improvement).
Nutrient Amount Amount Computed Suggestions for
Computed through diet Improvement
from RDA
Energy (Kcal) 2320
Protein (g) 60
Now that you have completed the exercise, we hope you have got a good insight into the
concepts related to planning diets. Perhaps you may need to go through this practical once
again before you move on to the other practical and the activities included in this manual.
So go ahead revise this practical once again and then move on to Practical 2.

15
Clinical and
Therapeutic Nutrition PRACTICAL 2 SPECIAL FEEDING
METHODS
Structure
2.1 Introduction
2.1 Special Feeding Methods: An Overview
2.3 Enteral Nutrition: Benefits and Types
2.4 Enteral Nutrition: Nutrient Requirement
2.5 Blenderized Feeds/Home Blend Formulas
Activity 1: Planning Home Blend Feeds
Activity 2: Survey for Commercial Enteral Feeds Available in the Indian Market

2.1 INTRODUCTION
The goal of nutrition intervention is to supply adequate nutrients to meet the patient’s
nutrient requirement by the most physiologic, safety and cost effective route. Sometimes
person cannot eat any or enough food because of an illness. The stomach or bowel may
not be working quite right, or a person may have had surgery to remove part or all of
these organs. Under those conditions, nutrition must be supplied in a different way i.e
through enteral and parenteral route. In this practical we shall review these special feeding
methods, with special focus on enteral nutrition. What are the benefits and indications for
enteral nutrition? What are the enteral feeds and their characteristics? How to prepare
home-based blenderized formulas? These are a few aspects covered in this practical.
Objectives
After undertaking this practical, you will be able to:
 differentiate between enteral and parenteral nutrition,
 indicate the conditions when special feeding is required,
 discuss the types of enteral feeds, and
 prepare blenderized feeds for patients.

2.2 SPECIAL FEEDING METHODS: AN OVERVIEW

Parenteral and enteral nutrition are the two special feeding methods for nutritional support
to the critically ill individuals.
Enteral Nutrition is defined as provision of nutrition support through the GI tract or
by accessing the gut. It also refers to feeding into the GI tract through a feeding tube.
Enteral nutrition (EN) can be administered via transoral (oral ingestion of food),
transnasal (administration of liquid feeds through feeding tube through the nose), or
percutaneous transgastric routes (through stomach), or by a tube into the small intestine
called a jejunostomy or percutaneous endoscopic jejunostomy (PEJ). Hence, enteral nutrition
is often called tube feeding.
Parenteral nutrition is one another way by which critically ill patient receives food when
they cannot eat. It is a special liquid food mixture given into the blood with a needle
through a vein. The mixture contains all the protein, sugars, fat, vitamins, minerals and
16 other nutrients needed. It is sometimes called total parenteral nutrition or TPN.
Here in this practical we will focus only on the enteral method of feeding. You Special Feeding
may recall studying about these special feeding methods in the theory course Methods
(MFN-005) in Unit 4. Here we will recapitulate the salient characteristics and
benefits of enteral nutrition and learn how to plan and prepare few simple
blenderized enteral formulas/feeds.
So let us get started with the benefits and types of enteral nutrition.

2.3 ENTERAL NUTRITION: BENEFITS AND

TYPES
It must be evident to you by now that, enteral nutrition is used when the gut is
still partially working, but then patient cannot eat or absorb enough nutrients to
stay healthy.
Some of the benefits of EN, therefore, include:
 it is easier to administer, present fewer metabolic and infectious
complications,
 enteral access is easy, gut integrity and motility are preserved and the
stress response is attenuated,
 it reduces the incidence of pathogen entry or bacterial translocation into
the stomach cavity or circulation,
 it provides more complete nutrients, trace elements and short chain fatty
acids, as well as, fibre, and
 it provides a trophic effect on the gut by promoting pancreatic and biliary
secretion, as well as, endocrine, pancrine and neural factors that help
promote the physiological and immunologic integrity of the GI tract.
Other than the benefits, can you suggest what the conditions are when enteral
feeding is indicated? You may recall studying about these conditions also in
the theory course in sub-section 4.3.1. Patients with the following conditions
may be more likely to need enteral feedings:
 Acquired immunodeficiency syndrome (AIDS)
 Burns
 Cancer
 Infections, prolonged
 Kidney problems
 Liver problems
 Lung problems
 Pancreas problems
 Stomach problems
 Surgery
 Trauma
 Vomitting, prolonged
 Malnutrion, malabsorption, failure to thrive (as in the case of children)
17
Clinical and Once it has been decided that enteral feeding is the choice of special feeding method,
Therapeutic Nutrition next we need to plan what type of enteral feeds or formula needs to be given. You may
recall studying about the polymeric, oligomeric, modular or blenderized formulas earlier
in the theory course. These different types of enteral feeds with their salient features
are presented here as well in Table 2.1 for your convenience.
Table 2.1: Enteral feeds and their specific characteristics
Enteral Feeds/formula Specific Characteristics

Polymeric formulas  Provide nitrogen as whole protein, often casein, egg

(also called formula diets) white solids or soy protein.
This is the general purpose, most widely prescribed
 Carbohydrate is provided as corn syrup,
feed. It is the sole source of nutrition intake for
maltodextrins or glucose oligosaccharides, with
critically ill individuals with or near normal GI
sucrose added for sweetness in oral formulas.
function.
 Fat is usually provided as soy oil, although corn oil
and safflower oil may be used. Medium-chain
triglycerides (MCT oil) are rarely used.

Oligomeric formulas  Most of these formulas provide enough protein,

(also called elemental or semi-elemental diets) calories, water, electrolytes, minerals, vitamins and
trace elements in 2 L/day for most “non-stressed”
Oligomeric diets are predigested formulated to patients
require minimal digestion by the gastrointestinal  Provide nitrogen as oligopeptides from partially
tract. hydrolyzed whole protein or as crystalline amino
In other words, these diets are “complete.” acids.
 Carbohydrate tends to be provided as glucose
oligosaccharides or glucose.
 Fat is usually present in small quantities, enough to
meet the requirement for linoleic acid (an essential
fatty acid), which is about 2-4% of total calories.
MCT oil is added to some formulas.
 Oligomeric diets have been commercially promoted
as ideal for patients with decreased bile output
(cholestasis), pancreatic insufficiency and short
bowel.

Modular formulas/feeds  Modular formulas are those that contain or

(used when a particular component of the diet predominantly contain one kind of nutrient.
requires an increased intake or if a patient requires
a special blend of diets)  There are commercially available modules for
protein, fat, carbohydrates, vitamins, electrolytes and
These modules are not required for the majority of trace elements.
patients, and are rarely used.
Examples of this might include burns or protein-
losing enteropathy, if more protein is to be given, or
renal disease, if less protein is to be given.

Blenderized Feeds  Prepared by mixing the ingredients and delivered

(For chronically ill patients with normal GI in an easily digestible form.
functions)  Provide carbohydrates, proteins and fat in the
amount as in the balanced diet.
 For long-term nutritional management.
 Natural food items are used to prepare the feed.
18
 Special Feeding
Methods

Disease Specific Feeds  For renal patients

(these are specially formulated polymeric enteral  For liver disease patients
feeds)
(specialized amino acid solutions have been made
for use in special circumstances. For example, liver
disease, renal disease and “stress,” such as trauma
and sepsis. For liver disease, these solutions are
composed mostly or exclusively of branched-chain
amino acids, whereas for renal disease the
solutions are predominantly essential amino acids).

Opportunistic Feeds Addition and substitution include:

(with nutritional addition and substitution which are  more middle chain triglycerides (MCT)
suggested to improve various aspects of organ  increased level of n-3 fatty acids, carnitine, beta
function) carotene, RNA, arginine, glutamine etc.

Drink Feeds Nutritionally complete enteral feeds based on

(for those who cannot eat solid foods but can ingest polymeric enteral diets
liquid diets) Palatable

Having gone through the types of enteral feeds, it is important to understand that functional
status of the GI tract and absorptive capacity are the predominant factors in choosing a
formula. Other considerations include: nutritional status/medical therapy, renal function,
fluid tolerance/electrolyte balance, and route of delivery. Formulas are categorized
according to their type and amount of protein and calories; some are tailored for different
disease states. It is important that we have a thorough knowledge about these special
formulas before being involved in the selection of formula and substitution of a product, if
necessary. You would realize that different types of enteral formulas are commercially
available for use with critically ill patients. Here, however, our focus will be to get a better
insight into blenderized formulas which can be easily prepared at home. Let us review the
blenderized feeds in greater details. But first, we shall study about the nutrient requirements
of enteral nutrition.

2.4 ENTERAL NUTRITION: NUTRIENT

REQUIREMENT
The nutrient requirement for an enteral formula in highlighted in Box 2.1. While planning
for an enteral formula, it is important to note that the recommended dietary allowances
serve as initial guidelines in the selection and modification of a formula. All nutrients of
the final formula should be calculated and compared with RDA for age. Vitamin mineral
supplementation may be needed.

Box: 2.1 Enteral Formula Composition

 Energy : Most of the formulas provide 1.0 - 1.2 Kcal/ml. In high concentrations,
they may provide 1.5-2.0 Kcal/ml and are used for patients who have elevated
calorie needs (ranging from 30-35 Kcal/kg). Most individuals generally require a
range of 25-35 Kcal/kg of body weight/day.
 Proteins in enteral formulas provide 4% to 32% of total calories. Those formulas
providing 18 to 32% of calories are considered high-protein solutions. Protein
requirements (for adults) usually is 1g/kg body weight/day, with modifications
19
Clinical and
Therapeutic Nutrition (seldom >1.5 g/kg body weight/day) to account for increased needs due to healing
wounds, or acute or chronic disease. If a patient is malnourished, nutrient needs
may be greater at first to restore nutritional status. Protein sources are provided
as intact proteins (egg white solids), protein hydrolysates or crystalline amino
acids. Predominate sources of protein include soy and casein.
 Carbohydrates contribute 40% to 90% of total calories in enteral formulas.
Carbohydrate sources used in formulas are pureed fruits and vegetables, corn
syrup solids, corn and tapioca starch hydrolysates, maltodextrins, sucrose, fructose
and glucose.
 Fats/Lipid provides 1.5% to 55% of the total calories of enteral formulas. The
principle source of fat includes vegetable oils, medium chain triglycerides (MCT),
lecithin, and mono - and diglycerides.
 Vitamins and minerals are essential components of enternal formulas. They
generally provides 100% of Recommended Dietary allowances (RDA). Different
pathological conditions may require high or low amount of micronutrients.
 Water recommended:

 Healthy adult: 1 ml/Kcal or 35 ml/kg body weight/day,

 Healthy infant: 1.5 ml/Kcal or 150 ml/kg.

 Elderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider

35 ml/kg if history of dehydration.

 Normal tube feeding: 1 Kcal/ml; 80% to 85% water.

Let us understand the water recommendation with the help of an example. In

case of a patient receiving 1500 Kcals, he/she would receive 1200 ml (80%) of
water from the formula. If the patient weighs 60 kg, he needs an additional 700
ml of water each day.

 Fiber containing formulas are useful in patients requiring bowel management.

Fiber can help manage diarrhoea by absorbing excess water from the stool, and
can help manage constipation by providing bulk to the stool. Component of fiber
is insoluble (cellulose, hemicellulose), or soluble fiber (pectin, mucilage, algal
polysaccharide, gum). Soy polysaccharide is the fiber most often used in formulas
and it contains 95% insoluble and 5% soluble fiber. Content of fiber-supplemented
formula ranges from 5 to 15 g of fiber per liter. Recommended intake of dietary
fiber is approximately 20 to 25 g / 1000 kcal (ICMR).

Now that we have a good knowledge about the different types of enteral feeds and their
nutritive content, let us focus in greater details on blenderized feeds.

2.5 BLENDERIZED FEEDS/HOME BLEND

FORMULAS
Many a times, you would realize that patient requests or is required to prepare
tube feeding at home. Though this is possible and does have some benefits, there are
some significant points to be considered when home blend formulas are prescribed to
the patient. Blenderized formulas can be prepared from ordinary foods of a normal
diet by using a blender or hand mixers. It is important to note that while preparing
a blenderized formula, any “approved” food item should be completely blenderized

20
 Table 2.2: Advantages and disadvantages of home blenderized tube feeding Special Feeding
Methods
Advantages Disadvantages

Family can take an active part in food It requires more time and energy to
preparation for the patient prepare than commercial products

Less costly. Commercial preparations Special equipment is needed i.e. high-

can be 10-50% more expensive speed blender or food processor,
measuring utensils, refrigerator etc.
Increased amount of fibre can be
provided Special care is to be taken to liquefy the
content of the blender completely, as food
Sense of ‘being different’ is lessened
particles can clog the feeding tube.
since the patient can enjoy the same
table food as his or her family Feeds must be prepared daily

Manipulation of individual nutrients is Daily ingredient selection should be

easier as compared to commercial feeds carefully made to ensure nutrition
adequacy of the feed.
Unpleasant taste is less likely to occur
May need vitamin and mineral
supplementation

Higher incidence of bacterial

contamination may occur.

Clean food preparation techniques must

be emphasized

and then strained through a medium strainer before being instilled into the tube. Some of the
advantages and disadvantages of home blend formulas are highlighted in Table 2.2.

Table 2.3: Composition of Blenderized Tube-feeding Formulation: Pure Vegetarian

Ingredients Amount Calories Protein CHO Fat

(g) (Kcal) (kJ) (g) (g) (g)
Rice 90 320 1340 7.0 70.4 0.4
Green gram dal 50 162 680 11.9 26.0 0.6
Bread 20 12.6 53 1.8 9.8 0.6
Milk 200 ml 146 610 6.5 9.9 9.0
Skimmed Milk Powder 75 270 1130 18.8 38.7 1.1
Spinach 50 12.2 51 1.1 1.0 0.3
Pumpkin 50 11.6 48.5 0.4 2.0 0.1
Carrots 50 19.1 80 0.5 3.4 0.2
Banana 70 77.4 324 0.9 17.5 0.2
Sugar 60 240 1008 - 60 -
Refined Oil 20 180 753 - - 20
Butter 7 51 214 - - 5.7
(Add Water to make 1500 ml)

Total 1502 6284 50 238 38

21
Clinical and Table 2.4: Composition of Blenderized Tube-feeding Formulation: Vegetarian with Egg
Therapeutic Nutrition
Ingredients Amount Calories Protein CHO Fat
(g) (Kcal) (kJ) (g) (g) (g)
Rice 90 320 1340 7.0 70.4 0.4
Green gram dal 50 162 680 11.9 26.0 0.6
Bread 20 12.6 53 1.8 9.8 0.6
Milk 200 ml 146 610 6.5 9.9 9.0
Skimmed Milk Powder 75 270 1130 18.8 38.7 1.1
Spinach 50 12.2 51 1.1 1.0 0.3
Pumpkin 50 11.6 48.5 0.4 2.0 0.1
Carrots 50 19.1 80 0.5 3.4 0.2
Banana 70 77.4 324 0.9 17.5 0.2
Sugar 45 180 753 - 45 -
Refined Oil 20 180 753 - - 20
Butter 7 51 214 - - 5.7
Egg 50 73.8 309 6.7 - 5.3
(Add Water to make 1500 ml)

Total 1516 6342 56 223 43.3

Table 2.5: Composition of Blenderized Tube-feeding Formulation: Non-Vegetarian
Ingredients Amount Calories Protein CHO Fat
(g) (Kcal) (kJ) (g) (g) (g)
Rice 90 320 1340 7.0 70.4 0.4
Green gram dal 50 162 680 11.9 26.0 0.6
Bread 20 12.6 53 1.8 9.8 0.6
Milk 200 ml 146 610 6.5 9.9 9.0
Skimmed Milk Powder 75 270 1130 18.8 38.7 1.1
Spinach 50 12.2 51 1.1 1.0 0.3
Pumpkin 50 11.6 48.5 0.4 2.0 0.1
Carrots 50 19.1 80 0.5 3.4 0.2
Banana 70 77.4 324 0.9 17.5 0.2
Sugar 40 160 669 - 40 -
Refined Oil 20 180 753 - - 20
Butter 7 51 214 - - 5.7
Mutton 50 73.8 309 6.7 - 5.3
Egg 50 46.12 193 9.11 - 1.0
(Add Water to make 1500 ml)
Total 1542 6452 65 218 44.3
Source: Adapted from Kawli A. Sreenivasan L. Eapen S, Pradhan S.A. Diet for cancer patients – tube-feeding formulations.
Indian J. Cancer 1982; 19: 226-30.
Based on these examples, in the same manner you can plan and prepare blenderized feeds. To help you in
understanding the concept better, we have included two activities in this practical. Go ahead read the case
22 studies and carry out the activities as suggested.
 Special Feeding
ACTIVITY Methods

PLANNING HOME BLEND FEEDS 1

To help you get a better understanding on blenderized feeds, here are few examples Date :
of home blend formulas, which you can easily plan and prepare at home.

Aim : To plan and prepare a home blend feed for a patient recovering
from a stomach problem.
Case Study : Devi is 38 year old cancer patient who is suffering from malnutrition
postoperatively. She weighs 45 kg and is 5ft and 4 inch in height.
She has been suggested a special enteral feed. Plan and prepare a
home blend feed suitable for her condition.
Based on the case study carry out the activity following the instructions given herewith.
Introduction
(Briefly elaborate on Devi’s disease condition and the need and benefits of blenderized feed in
the space provided herewith).

Step I
(Read the case study carefully and identify the important points that may determine nutrient
intake/diet planning. Identify specific disease characteristics. Based on the risk factors, comment
on the patient’s profile).
Patient/Case Profile
Age:
Gender:
Activity pattern:
Weight:
Height:
BMI:
Diet recommended:
Medical problem:
23
Clinical and Based on the patients profile, list the general considerations you will keep in mind
Therapeutic Nutrition while planning the feed in the space provided herewith:

Step II: Assessment of the nutritional needs of the patient.

(In the format given herewith, present the recommended dietary intake for Devi. Refer to section
2.4 for calculating the modified RDA for Devi. Work out your calculations for reaching the modified
RDI and record those in the space provided herewith. Compare her requirement with the requirement
of a sedentary healthy female).

Recommended Dietary Intake for 24 hours

Nutrients Normal RDA for Modified RDA for Devi
Sedentary Female
Calories (Kcal)
Proteins (g)
Carbohydrates (g)
Fat (g)
Fluids (ml)

Calculations :

24
Step III: Based on the modified RDA, now plan a home blend feed for Devi in Special Feeding
Methods
the format given herewith:
Name of the Home Blend Feed:
Ingredients required for preparing the Home Blend Feed
(Write the composition, quantity and cost of the feed in the format given herewith).

Ingredients Amount Cost

Total

Step IV: Calculate the nutritive content of the home blend feed
(Calculate the nutritive content of the feed in the format given herewith).

Ingredients Amt Energy Protein Fat Carbohydrate

(g) (Kcal) (g) (g) (g)

Total

Nutritive Content
per 100 g

Nutrient Content
per ml

25
Clinical and Step V: Plan the feeding schedule most suitable for the patient
Therapeutic Nutrition
(Present the schedule in the space provided herewith. Hint: You may present information regarding
the timings for giving the feed, total serving per day, serving size etc.).

Serving Size:

Total Serving per Day:

Timing for Feeding:

Step VI: Evaluate the home blend feed

(Prepare the feed and evaluate based on the parameters given in the format).

Parameter Description of Parameter Suggestions for Improvement

Appearance

Smell

Overall taste

Sweetness

After Taste

Nutritive Content

Submit your activity for evaluation.

—————————
Counselor’s Signature
26
 Special Feeding
ACTIVITY Methods

SURVEY FOR COMMERCIAL ENTERAL FEEDS

AVAILABLE IN THE MARKET 2
Aim : To carry out a survey in the local market to identify commercial enteral
feeds available in India. Date :
Survey : Carry out a survey in your region (local market, chemist shop, hospital
pharmacy etc.) to identify the various types of commercial enteral feeds
available in your region. Present the special characteristics, composition and
the nutritive content of any five enteral feeds identified by you in the format
given herewith.
Begin the activity with an overview on the enteral feeds.

Introduction
(Present a brief write-up on enteral feeds, their benefits, types and when indicated in the space
provided herewith),

Survey Result
(Present the survey results for any five commercial enteral feeds in the format given herewith).

Enteral feed

Enteral Feed Composition Nutritive Indicative for Cost

(Name and Type) Content which Disease
Condition

27
Clinical and
EnteralNutrition
Therapeutic feed Composition Nutritive Indicative for Cost
(Name and Type) Content which Disease
Condition

Conclusion
(Comment on the cost and availability of the commercial feeds available in the market in the space
provided herewith).

Submit your activity for evaluation.

—————————
Counselor’s Signature
28
 Nutr itio nal
PRACTICAL 3 NUTRITIONAL Management of
Fevers
MANAGEMENT OF
FEVERS
Structure
3.1 Introduction
3.2 Fevers: An Overview
3.3 Different Types of Fever
3.3.1 Acute Fever
3.3.2 Chronic Fever
3.3.3 Fevers of Unexplained Origin

3.4 Impact of Fever on Nutritional Status

3.5 Management of Fevers
3.5.1 Principles of Dietary Management
3.6 Review Exercises
Activity 1: Diet Plan for Typhoid
Activity 2: Diet Plan for Tuberculosis

3.1 INTRODUCTION
Fever is a symptom and not a disease itself. It is a response to stress, trauma or
altered immune/metabolic system of the body. Since fever can develop in association
with several forms of trauma, communicable/non-communicable diseases; dietary
modifications may be required keeping in mind the nutritional demands imposed by
fever and other associated diseases. Therefore, in this practical, we shall learn about
the nutritional implications of fever and the dietary management of different types of
fevers. We have already studied about fevers and their management in the Clinical
and Therapeutic Nutrition Theory Course (MFN-005) in Unit 3. We suggest you look
up the unit once again and refresh your knowledge before you get down to this practical
and the activities included in this practical.
Objectives
After undertaking this practical, you will be able to:
 describe the different types of fevers,
 explain the impact of fever on the nutritional status,
 discuss the dietary management of different types of fevers, and
 plan diets for patients suffering from typhoid and tuberculosis.

3.2 FEVERS: AN OVERVIEW

The average normal oral body temperature (taken in the mid-morning is) 36.7C
(range 36.0C37.4C). This includes mean and  2 standard deviations, thus
encompassing 95% of normal population. The normal rectal or vaginal temperature is
0.5C higher than the oral temperature and the auxiliary temperature is correspondingly
lower. Rectal temperature is more reliable than oral temperature. The normal diurnal 29
Clinical and temperature variation is 0.5 1.0C, being lowest in the early morning and highest
Therapeutic Nutrition in the evening. There is a slight sustained temperature rise following ovulation, during
the menstrual cycle, and in the first trimester of pregnancy.
Thus, fever is a regulated rise to a new “set point” of body temperature. The elevation
in temperature results from:
 Increased heat production (e.g. shivering)
 Decreased loss of heat (e.g. peripheral vaso-constriction).
The maximum of increase in body temperature has been outlined in Figure 3.1.
Exogenous/Endogenous agent(s)
 Activation
Phagocytes
 Release
Endogenous pyrogen (fever inducing hormone)

 Synthesis
Prostaglandins
 Stimulate
Thermo-regulatory center in anterior hypothalamus

Increase in normal set point of body temperature

Fever

Figure 3.1: Mechanism of increase in body temperature

Let us now brief ourselves on the various forms of fever and the common terms
associated with fever.

3.3 DIFFERENT TYPES OF FEVER

Several forms of fever have been identified; most of them being a symptom of an
underlying disease. The most common forms of fever occur in association with
infections, autoimmune disorders, central nervous system and malignant diseases.
Several cardiovascular and gastrointestinal diseases are also associated with fever.
Depending upon the duration and severity of rise in body temperature, fevers can be
classified as acute and chronic. Let us briefly recapitulate.
3.3.1 Acute Fever
Most febrile illnesses are due to common infections and are short lived. Acute fevers
are of short duration but the body temperature may rise to even above 104F. Fevers
associated with common infections such as typhoid, tonsillitis, influenza, chickenpox,
pneumonia and certain parasitic infestations are acute in nature. A brief review on
typhoid follows:
Typhoid – An Acute Fever
Causative agent: Salmonella typhosa
Salient features/Symptoms:
 Slow (stepladder) rise in fever to maximum (plateau in 7-10 days)
 Reese spots (pink paple 2-3 mm in diameter) on trunk
 Sore throat and cough
 Headache
30
 Nutr itio nal
 Malaise Management of
Fevers
 Pea-soup diarrhoea or marked constipation
 Leukopenia (abnormally low WBC count)
 Bradycardia (a slow heart rate)
 Splenomegaly (enlargement of spleen)
 Complications: thrombophlebitis, (inflammation of a vein associated with blood
dot), nephritis (inflammation of kidneys), cholecystitis (inflammation of gall
bladder) etc.
Diagnostic tests:
 Blood, stool and urine cultures
Treatment:
 Drugs (Ampicillin, chloramphenical, trimethoprim-sulfamethoxazole)
 Dietary management
 Bed rest and keeping the patient warm.

3.3.2 Chronic Fever

These are characterized by elevated body temperatures over a period of three weeks
or even for several months. The temperature usually does not rise above 33C
(average). Tuberculosis and HIV/AIDS are the most common forms of fever due to
infection. Chronic fevers are also seen in association with stress, chronic gastro-
intestinal diseases, cancer and severe malnutrition. A brief review on tuberculosis
follows:

Tuberculosis – A Chronic Fever

Causative agent: Mycobacterium tuberculi
Salient features/symptoms:
 Cough with expectoration
 Fatigue
 Unintentional weight loss
 Coughing up blood
 Fever (usually below 39C) and night sweats
 Wheezing, difficulty in breathing
 Chest [pain tuberculin lesions in the infection organ (haemorrhages, bleeding)]
 Gastric disorders (anorexia, diarrhoea)
Diagnostic tests:
 Sputum cultures
 Tuberculin skin test
 Chest X-ray
 Bronchoscopy
 Thoracentesis
 CT scan (lungs, kidney, heart, other organs)
 Biopsy or affected tissues
Treatment:
 Drugs (Isoniazid, Rifampin, Pyrazinamide, Ethambutol, Streptomycin)
 Dietary Management
 Bed rest and rehabilitations (if required)
31
Clinical and 3.3.3 Fevers of Unexplained Origin
Therapeutic Nutrition
Unexplained cases of fever exceeding 33.3OC on several occasions for atleast 3
weeks in patients without neutropenia or immunosuppression are referred to as
“fevers of unknown origin” (FUO). FUO are most commonly associated with
AIDS, mycobacterium avium infection, pneumocystis carinii pneumonia,
cytomegalovirus infection, lymphoma and disseminated histoplasmosis.
Having looked at the different types of fevers, next let us briefly recapitulate the
impact of fever on nutritional status, since this will influence the dietary management
of fevers.

3.4 IMPACT OF FEVER ON NUTRITIONAL

STATUS
Irrespective of the cause, a rise in body temperature above normal (37 OC) results in
several metabolic changes in the body. These changes in nutritional status occur in
proportion to the severity of elevation in body temperature, as well as, the duration of
fever. The following changes occur in the metabolic and nutritional status of an
individual during fever.
 Elevation of body temperature results in an increase in basal metabolic rate.
The BMR increases by nearly 13% for every 1C rise in body temperature.
 Since fevers are associated with anorexia on one hand and increased energy
expenditure due to elevatd BMR on the other; they result in depleted reserves of
glycogen and adipose tissues.
 Negative energy balance over a prolonged duration results in breakdown of
tissue/muscle proteins as alternative sources of energy. Enhanced protein
catabolism results in increased load on kidneys for the excretion of nitrogenous
waste products.
 Risk of dehydration increases due to sweating associated with fever and also
due to the enhanced urine output  a response initiated by the kidneys to excrete
nitrogenous wastes.
 Due to enhanced sweating, urination and at times, diarrhoea/vomitting, there are
also enhanced losses of several electrolytes particularly sodium, potassium and
chloride.
 The intake, as well as, absorption of nutrients is low thereby increasing the chances
for the development of deficiency diseases.
 Depleted reserves of both macro- and micronutrients results in loss of weight
and increased susceptibility to subsequent infections.
 High temperature during the first trimester of pregnancy may cause birth defects,
such as anencephaly.
 Fever also increases insulin requirements and alters the metabolism and disposition
of drugs used for the treatment of the diverse diseases associated with fever.
So then fevers can have a profound impact on the metabolism and the nutritional
status. What then is the treatment of fevers? Let us find out.

3.5 MANAGEMENT OF FEVERS

The management of fevers is based on the following measures:
 Dietary management
 Measures for removal of body heat
 Treatment of etiological factor(s)
 Medications such as antipyretic drugs and anti-microbial therapy
32 Here we shall focus only on the dietary management.
3.5.1 Principles of Dietary Management Nutr itio nal
Management of
Fevers
You must be very well aware of the fact that fever imposes nutritional demands on
the body. The requirements for nutrients increases in direct proportion to the rise in
temperature, as well as, duration. In our subsequent discussion, we shall learn about
the various principles of dietary management for acute (typhoid) and chronic
(tuberculosis) fevers.
A) Dietary Management  Typhoid
In view of the clinical characteristics of typhoid fever and its impact on the nutritional
status of the patient; the following objectives of dietary management must be kept in
mind:
 to promote and maintain a positive energy and nitrogen balance,
 to replenish the depleted reserves of all nutrients,
 to prevent further damage and promote healing of Peyer’s patches (any of the
several lymph nodes in the walls of the intestine), and
 to provide rest and maintain an optimum nutritional status.
The various aspects of dietary management which can help in promoting and
maintaining a good nutritional status of the patient during typhoid and also prevent the
development of complications, are presented next. We will start with the requirements
for energy and then proceed for other nutrients.

Energy: During typhoid, there is a peak rise (as high as 104F) in the body temperature
during the first phase (7-10 days) followed by a plateau and then a decline. The
BMR also increases in proportion to the elevation of body temperature which results
in loss of muscle and fat mass as alternative sources of energy. Thus, the diet should
provide enough calories to prevent the onset of negative energy balance. Most of the
non-ambulatory patients benefit by increasing the energy intake by 10-20% above
the RDI.

Protein: A high protein intake which provides 1.5-2.0 g protein/kg body weight/day is
recommended during and immediately after the recovery from infection to reduce
the risk for reoccurrence. During the active phase of typhoid there is massive
destruction of body tissues to release energy (food intake being low). A high protein
diet is also required to ensure rapid healing of peyers patches. High biological value
proteins such as milk/milk products, eggs, meat, marine foods, chicken, pulses and
legumes should be included in liberal amounts. If the patient is on a full fluid diet,
good amount of milk and beaten eggs can be included. However, if diarrhoea/
abdominal distension is severe, milk intake may need to be restricted.

Carbohydrates: Nearly 60% of the total energy should be provided from

carbohydrates. The type of carbohydrates included should be easy to digest i.e. foods
rich in mono and disaccharides, as well as, starches should be included in liberal
amounts. The intake of plant polysaccharides in the form of dietary fibre should be
kept to a minimum as they increase gastric discomfort, are difficult to digest and
reduce the nutrient density of meals. Foods rich in simple/easy to digest carbohydrates
include semolina, rice, chirwa, murmura, refined flour, sago, arrowroot, starchy roots/
tubers, jaggery sugar, honey, dextrose fruits such as banana, mango, sapota, grapes
etc. The patient’s diet can include dishes such as upma/poha/dalia/khichdi with
vegetables and sprouts, stewed fruits with honey, fruit cream custard, pureed
vegetables and pulses, vegetable soup with cream/butter, potato dumplings, roasted
yam/potato, ice-cream, puddings, souffle, etc. Raw foods (fruits and vegetables) should
be avoided.
Fluids: Liberal intake of fluids to compensate for the losses from sweat and to permit
adequate volume of urine for excreting the nitrogenous waste products is important.
The patient should therefore be given plenty of mechanically, chemically and thermally 33
Clinical and bland clear fluids and full-fluids such as kanji, lemon water, fruit juices, soup, coconut
Therapeutic Nutrition water/milk, squashes (without citric acid), sugarcane juice, high energy glucose/
electrolyte drinks, whey water, buttermilk, lassi, soya milk, milk shakes etc.

Vitamins: In view of infection, gastrointestinal disturbances etc., the requirements for

vitamin A, vitamin C and B-group vitamins increases. Apart from including plenty of
well-cooked fruits and vegetables; employing special measures such as cooking food
in red-palm-oil, incorporating spirulina, curry leaves, amla, lemon (squash/murabba)
can help in improving the vitamin content of meals.

Minerals: Although the requirement for all minerals increases but that of calcium,
phosphorus, iron, sodium, potassium and chloride are particularly high. Incorporating
liberal amounts of milk/whole milk products, green leafy vegetables (particularly
Bengal gram leaves), chirwa, jaggery and a variety of fruits can help in increasing the
mineral content of diet. If there is severe diarrhoea and/or there has been considerable
amount of sweating during the progressive phase of typhoid; oral rehydration therapy
(ORS) and high mineral beverages should be initiated.

We will now quickly brief ourselves on the important aspects of meal planning
(when and how to provide the above discussed nutrients to the patient). Improper
meal timings/inappropriate selection of foods, cooking methods or mode of feeding
can be a determined factor in the outcome of the disease. Hence, few special
considerations are highlighted herewith:

Special Considerations

 High energy, high protein, bland diet, moderate in fat and fibre with plenty of
fluids should be given to the patient.

 During the first 2-3 days when the fever is very high and/or inflammation of
peyer’s patches is severe, a full-fluid diet followed by a semi-soft diet needs to
be given. Full-fluids (soups, juices, coconut milk/water, egg nog, milk based
beverages etc.) may be given at every 2-21/2 hour, interval throughout the day.

 The diet should be chemically, mechanically and thermally non-irritating. Therefore,

avoid the use of spices/condiments, raw fruits, salads, improperly cooked whole
cereal grains and whole pulses. Strongly flavoured foods, as well as, very hot
and very cold food should be avoided (ice-cream, frozen desserts, very hot
beverages- kava, tea, coffee, soup.)

 Most of the patients remain anorexic during and even after recovery from typhoid.
It is, therefore, important that the dietician attempts to stimulate interest in the
meals by creating variety in terms of colour, texture, taste and mouthfeel. This is
particularly important for paediatric patients. Wherein meals should be served
attractively such as sprinking crushed orange/strawberry flavoured sugar candy
on beaten curd, incorporating leafy vegetables in cutlets (baked), roti, burfi etc.,
using jam/honey toppings on desserts, fruits, milk shakes etc. preparing
sandwiches in different shapes etc.

 Isolated proteins such as soya, casein, whey can be sprinkled/ mixed with
already prepared/ ready-to-serve dishes. Commercially available high energy
high protein supplements such a complan, horlicks, build-up etc. can also be
given. Enteral feed formulas may be used if the gastrointestinal functions are
severely impaired.

With a brief review on typhoid, let us now study about the dietary mangement of
tuberculosis, which we learnt, is a chronic type of fever.

34
B) Dietary Management  Tuberculosis Nutr itio nal
Management of
Fevers
Keeping the clinical implications and impact of tuberculosis on nutritional status in
mind, let us identify and outline the objectives of dietary management.
Objectives of Dietary Management
The objectives of dietary management of tuberculosis is:
 to create positive energy and nitrogen balance,
 to help in replenishing the depleted nutritional reserves,
 to maintain an optimum nutritional status during the period for treatment, and
 to accelerate recovery and help in proper rehabilitation of the patient.
We can meet the above objectives by making suitable modifications in the nutrient
intake and food choices of the patient. There may also be a need to bring about
changes in the behaviour/ life-style (if required). Subsequent discussions will be focused
on dietary/nutritional modifications and diet pattern. Let us begin by reviewing the
nutrient requirements during tuberculosis.

Energy : Patients suffering from tuberculosis are generally malnourished and

underweight. Increased energy expenditure due to elevated basal metabolic rate,
recurrent cough, anorexia, gastrointestinal disturbances and respiratory discomfort
result in a negative energy balance which leads to weight loss. Thus, energy intake
through diet should be increased to achieve and maintain weight gain. The energy
intake should be increased by atleast 5-10% if the temperature is about 39C.
Alternatively, we can increase the energy intake by about 500 Kcal above the usual
food intake/RDI to promote weight gain. A very enthusiastic approach towards
increasing the calorie intake is not helpful as it may only precipitate gastrointestinal
discomfort.

Protein : There is considerable wasting of body tissues during chronic fevers because
they are utilized as alternative sources of energy. Majority of the patients have low
muscle mass and depleted serum protein levels. Patients benefit by taking 1.2 to 1.5 g
protein per kg body weight per day. Proteins of high biological value such as those
present in milk, curd, yoghurt, khoa, meat, chicken, fish and other marine food, pulses
and legumes can be taken in good amounts. However, if the patient belongs to low-
income group, it is important to counsel him/her regarding cheap sources of protein
such as incorporating milk, curd, Bengal gram, peas (seasonal) in their diet. Adopting
sprouting, fermentation and combination of cereals with pulses or milk etc. can help in
improving the quality and bio-availability of meals.

Fat : Fat intake should remain normal (20% to 25% of total energy as recommended
for a non-tuberculosis healthy adult/child). Emphasis should be laid on invisible, medium
chain triglycerides and emulsified fat if the patient is suffering from gastric discomfort.
Fried foods and high-fat snacks (poories, bhatooras, pakoras, kachories, samosas etc.)
need to be avoided. Including some amount of fat helps to ensure adequate intake of
fat-soluble vitamins and also make the meals nutrient dense/palatable.
Carbohydrate: Around 60% of the total energy should be provided from carbohydrates
to promote positive energy balance (to ensure weight gain) and spare the proteins for
anabolic processes. A combination of simple and complex carbohydrates should be
included, but care should be taken that the diet contains moderate amount of fibre in a
soft cooked form. Thus, whole cereals such as jowar, bajra, cracked wheat, oats
should be softened/cooked well (serve bajra kheer, cracked wheat porridge, bajra/
cracked wheat, khichdi etc.).
Minerals: Majority of TB patients are chronically under nourished and suffer from
deficiencies of several minerals. Good amounts of milk/milk products and whole
35
cereal/ pulse products should be included to provide adequate amount of calcium and
Clinical and phosphorus. This is essential for the healing of tuberculin lesions and also to replenish
Therapeutic Nutrition depleted reserves of calcium. Iron deficiency due to poor absorption, iron deficient
diet and/or haemorrhages is also frequently observed. Economical measures such as
sugar with jagerry, consuming good amounts of seasonal fruits and vegetables, lotus
stem (dry), chirwa (flattened rice), jowar, bajra, roasted Bengal gram, lentils, animal
foods, particularly liver (haem iron) can help in improving the iron status of the patient.

Vitamins: Patients suffering from tuberculosis generally have depleted levels of all
water and fat soluble vitamins. In order to ensure adequate absorption of calcium and
in view of the impaired conversion of -carotene to retinol, the diet should provide
good amounts of vitamin D and A, respectively. Therefore, we should include liberal
quantity of milk/milk products and some amount of animal food (eggs, meat etc.).
Among the water-soluble vitamins; folic acid, vitamin B6 and ascorbic acid should be
provided by including liberal amounts of seasonally available fresh vegetables and
fruits.

Fluids : During the progressive phase of tuberculosis when the body temperature may
be around 39C, there is considerable breakdown of muscle tissues. This tends to
increase the workload on kidney’s for excreting high amounts of nitrogenous waste
products. Thus, the patient should consume more than 1.5 litres of water everyday.
The fluid intake should be particularly high if they are also suffering from diarrhoea.

Other Special Considerations

 Small, frequent, nutrient dense and easy to digest meals should be given during
tuberculosis.

 During the acute phase (progressive tuberculosis), a semi-soft or soft diet is

recommended (khichdi, kheer, boiled/mashed/pureed vegetables and/or fruits,
yoghurt etc.). A regular diet is suggested during the recovery phase. Indoor
patients suffering from severe pulmonary tuberculosis may need to be given a
full-fluid diet which can be supplemented with high energy, high protein enternal
feeds.

 Meal pattern should be adjusted according to work schedule of the patient. It

has generally been observed that several ambulatory patients (particularly
sweepers, carpenters, construction workers, rickshaw pullers) follow a 2 or
maximum a 3 meal pattern. They should be encouraged to consume meal more
frequently and advised regarding the concept of carrying easy to digest, nutrient
dense, non-perishable food-items such as paranthas stuffed with sprouts, missi
roti, dhokla, vegetable poha/upma/dal with sprouts/panjiri, besan ladoo etc.

 Majority of the patients (particularly LIG) suffering from tuberculosis have limited
purchasing power. They should therefore be counseled effectively regarding the
low-cost nutritious foods available in their region such as red palm oil, spirulina,
Bengal gram leaves, lotus-stem, dates, guava, jaggery, jowar, bajra, chirwa, milk
and milk products (prepared at home-curd etc.). They should also be made to
understand the benefits and process of sprouting/fermentation and combining
cereals with protein rich foods. Preservation of seasonal vegetables such as
drying of raddish leaves/curry leaves, pickling etc. may also be advocated.

 To ensure proper rehabilitating and prevent reoccurrence, the patient should be

convinced and encouraged to:
 consume drugs (medicines) as per the schedule,
 avoid residing in areas with poor hygiene/sanitation conditions, and
 avoid smoking and spitting bulgum on roads/public places and rooms in his/
or house.
36
So far we have discussed about the important aspects of diet planning and life-style Nutr itio nal
Management of
modifications during acute and chronic fever(s). You should now make an attempt to Fevers
answer the questions mentioned in review exercises and self-check your progress.
If you are able to complete the exercise satisfactorily; proceed ahead and carry out
the activity 1 and 2 given herewith. Through these activities you will learn how to plan
diet(s) for patients suffering from tuberculosis/typhoid.

3.6 REVIEW EXERCISES

1) ‘‘Typhoid is an acute enteric fever”. Elaborate upon this statement.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) What is the significance of giving micronutrient rich meals to a patient suffering
from typhoid?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

3) Enlist a few useful tips that can help to encourage an increased food intake by
paediatric patients having typhoid infection.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

4) Give two examples each of the breakfast menu, mid morning and evening snacks
for typhoid patients.

Breakfast Mid Morning Evening

I)

II)

37
Clinical and 5) Define the term “chronic fever” in relevance to tuberculosis.
Therapeutic Nutrition
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
6) The requirement of which vitamin(s) increases during long-term cases of
tuberculosis?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Now, move on to the activities given next.

38
 Nutr itio nal

ACTIVITY
Management of
Fevers

DIET PLAN FOR TYPHOID 1

Aim : To plan a diet for a patient suffering from typhoid. Date :

Case Study : Charu is an 11 year old girl studying in Kendriya Vidyalaya and has
come to the OPD complaining of fever for the past 6 days. The
fever has been gradually increasing and today it is 103OF. The
elevated temperature has remained almost constant since yesterday.
Medical examination has indicated mild bradycardia (slow heart beat),
splenomegaly (enlargement of the spleen) along with abdominal
distension and tenderness. She has been complaining of headache,
sore throat and cough. Blood, urine and stool cultures are positive
for Salmonella typhii and she has been diagnosed to be suffering
from diarrhoea. She has been prescribed drugs (trimethoprim-
sulfamethoxazole). Her medical history reports a poor resistance
to infection. She has been advised to consume a high energy, high
protein micronutrient rich diet and also lay emphasis upon the
incorporation of iron rich foods as her blood haemoglobin levels are
low (10.1 gm%).
Based on this case study, now carry out the activity following the instructions given
herewith. Start with the Introduction.

Introduction
(Comment what type of fever (infection) is Charu suffering from? Briefly describe the salient
characteristic features of this fever. Also identify the key nutrients for which the nutritional
demands may have increased/decreased).

Nutrient Requirements
Reasons
Increased Decreased

1)

2)

3)

4)

5)

Now, move on to step I. 39

Clinical and Step I
Therapeutic Nutrition
Identify the salient features of the case which may play an important role in planning the diet/
meals. So, read the case carefully and fill in the patient details in the format given below.

Patient /Case Profile

Name:
Age:
Gender:
Activity:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:

Clinical Profile
Patient Value Normal Value
Body temperature (F)
Haemoglobin (g%)
Based upon your understanding regarding typhoid (acute fever) and the details
mentioned in the case, identify the various goals of dietary modifications and enlist
them in terms of their priority in ascending order herewith.
Objectives of dietary management


Step II
Next, assess/calculate the nutritional needs of Charu and compare them with the RDI for a 11
year old girl (Refer to RDI table given in Practical 1). You may want to read the principles of
dietary management for typhoid (sub-section 3.5.1) once again for a quick recapitulation.

Recommended Dietary Intake

Nutrients Normal Modified

Energy (Kcal)
Protein (gm)
Fat (g)
Carbohydrate (g)
Vitamin A (µg)
Iron (mg)
Vitamins C (mg)
40
Calculations: Nutr itio nal
Management of
(Write the calculations for the modified nutrient intake in the space provided herewith). Fevers

Step III
On the basis of RDI, carefully select the food exchanges and list them in the format given
herewith, that can help in maintaining a good nutritional status for Charu.

Exchange No. Energy Protein(g) Carbohy- Fat (g)

(Kcal) drates (g)
Milk
Meat
Pulse
Cereal
Roots/Tubers
Other
Vegetable
Green Leafy
Vegetales
Fruit
Sugar

Fat

Step IV
In view of the symptoms being experienced by Charu and her nutritional requirements, identify
an appropriate meal pattern and distribute the exchanges for providing balanced nutrition
throughout the day. You may add or remove a meal from the meal pattern mentioned below.

Exchange No. Early Break- Mid Lunch Evening Dinner Post

Morning fast Morning Tea Dinner

Whole Milk
Meat
Pulse
Cereal
Roots/Tubers
Other
Vegetable
Green Leafy
Vegetales

Fruit
Sugar
Fat 41
Clinical and Step V
Therapeutic Nutrition
Now plan a day’s menu for Charu in accordance with the exchanges available for each meal.
Remember to include dishes/ingredients which are nutrient dense and easy to digest (refer to
sub-section 3.5.1).

Menu for Charu

Early Morning Evening Tea

Breakfast Dinner

Mid Morning Post Dinner

Lunch

42
Step VI: Detailed menu plan Nutr itio nal
Management of
(Based on the menu planned in Step V, calculate the nutritive content of the diet using the Fevers
food composition take in the format given herewith).

Meal Menu Ingredient Amt. Energy Protein Vitamin A (g) Iron Vitamin C
(g) (Kcal) Retinol -Carotene (µg) (mg)

Total

43
Clinical and Conclusions
Therapeutic Nutrition
Compare the grand total obtained for various nutrients in the detailed menu plan with
the computed modified RDI and interpret as follows:

Nutrient Modified Detailed Diet + % of Suggested for

RDI Plan Difference Improved Intake
Energy (Kcal)

Protein (g)

Iron (mg)

Vitamin A (IU)

Vitamin C (mg)

Submit the activity for evaluation.

——————————-
Counselor’s Signature
44
 Nutr itio nal

ACTIVITY
Management of
Fevers

DIET PLAN FOR TUBERCULOSIS 2

Aim : To plan a diet for a patient suffering from tuberculosis. Date :

Case Study : Mrs. Dayawati is a 34 year old sweeper residing in an urban slum.
Of late she has been experiencing fatigue, weight loss, fever (33OC),
sweating at night and recurrent cough with massive expectoration. She
was therefore advised to take help from a nearby district hospital. Her
chest radiograph is indicative of pulmonary infiltrates and the tuberculin
skin test reaction is positive. Acid-fast bacilli has been identified on
the smear of sputum and the culture has been found to be positive for
mycobacterium tuberculosis. At present she has been prescribed drugs
(isoniazid, riflampin and pyrazinamide) for a period of 3 months (under
DOT) and would be required to get hospitalized, if her condition does
not improve.
Now based on this case study, carry out the activity following the instructions given
herewith.
Introduction
(In the space provided herewith, describe the clinical condition which Dayawati is
suffering from).

Identify any four nutrients, the nutritional requirements of which may change due to
her disease condition.
Nutrient Intake Increase/Decrease Reason

1)

2)

3)

4)

5)

6)

Now, based on this information, proceed towards planning a diet for Dayawati. 45
Clinical and Step I : Patient’s Profile
Therapeutic Nutrition
As per the details given in the case, fill the patient profile in the format given below.

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Socio-economic status:
Pathophysiological stress:
Dietary habits:
Diet prescribed:
Next, identify the key objectives of dietary management. This can be done easily by
reading the case and the principles of dietary management (presented in sub-section
3.5.1B) earlier. List the objectives in the space provided herewith.

Objectives







Step II
Next, assess/calculate the nutritional requirements of Dayawati which can help her in
maintaining a good health status and compare them with the RDI (Refer to Table 1.1
in Practical 1) (ICMR) for an healthy adult woman (moderately active).
Recommended Dietary Intake

Nutrients Normal Modified

Energy (Kcal)

Protein (gm)

Calcium (mg)

Iron (mg)

Folic acid (mg)

Calculations:
(Give the calculations in the space provided herewith).
46
Step III Nutr itio nal
Management of
Select most appropriate food exchanges that can help in providing nutrient as per the Fevers
modified RDI. Write down the exchanges in the format given herewith.
Exchange No. Energy Protein Carbohy- Fat
(Kcal) (g) drates (g) (g)
Milk
Meat
Pulse
Cereals
Roots/Tubers
Other
Vegetables
Green Leafy
Vegetables
Fruit
Sugar
Fat

(Note: Incorporate adequate amounts of cereals and sugar).

Step IV
Identify an appropriate meal pattern for Dayawati with regards to her clinical profile/
activity/ work pattern and time available for preparing food. (You may add or remove
a meal from the meal pattern mentioned below.) Now distribute the exchanges selected
above for preparing meals throughout the day.

Exchange No. Early Break- Mid Lunch Evening Dinner Post

Morning fast Morning Tea Dinner

Meat

Pulse

Cereal

Roots/Tubers

Other
Vegetables

Green Leafy
Vegetables

Fruit

Sugar

Fat

Step V
Plan a day’s menu for Dayawati by using the exchanges available for each meal.
Remember that Dayawati belongs to low income group. Plan meals which are nutrient
dense, easy to digest, economical and easy to prepare. Her mid-morning snack and
lunch should be easy to carry.
47
Clinical and Menu for Dayawati
Therapeutic Nutrition
Early Morning Lunch

Breakfast Evening Tea

Mid Morning Dinner

Step VI: Detailed menu plan

(Give the detailed menu plan in the format given herewith).

Meal Menu Ingredient Amount Exch- Energy Protein Iron Folic Calcium
(g) ange (Kcal) (g) (mg) Acid (mg)
(mg)

48
 Nutr itio nal
Management of
Fevers

Meal Menu Ingredient Amount Exch- Energy Protein Iron Folic Calcium
(g) ange (Kcal) (g) (mg) Acid (mg)
(mg)

Total

Conclusions
Compare the grand total obtained for various nutrients in the detailed menu plan with
the computed modified RDI and interpret as follows:
Nutrient Modified Detailed Diet + % of Suggested for
RDI Plan Difference Improved Intake
Energy (Kcal)
Protein (g)
Iron (mg)
Calcium (mg)
Folic Acid (mg)

Give a few behaviour/life-style modification tips to Dayawati which can help her in recovering fast/prevent
subsequent development of complications.

Submit the activity for evaluation.

——————————-
Counselor’s Signature
49
Clinical and
Therapeutic Nutrition PRACTICAL 4 NUTRITIONAL CARE OF
WEIGHT MANAGEMENT
Structure
4.1 Introduction
4.2 Introduction to Weight Management
4.3 Weight Imbalance
4.4 Methods of Assessment
4.4.1 Visual Inspection
4.4.2 Standard Weight and Height Measures
4.4.3 Skin-Fold Thickness
4.4.4 Circumference Measurement

4.5 Principles of Diet Planning

4.5.1  Overweight/ Obesity
Principles of Diet Planning
4.5.2 Principles of Diet Planning  Underweight

4.6 Review Exercises

Activity 1: Diet Plan for Overweight Obese Individuals
Activity 2: Diet Plan for Underweight Individuals

4.1 INTRODUCTION
In view of the rapidity with which traditional diets and life-styles are changing in many
developing countries, it is not surprising that food insecurity and undernutrition persist
in the same countries where chronic diseases are emerging as major public health
problems. The epidemic of obesity with its attendant co-morbidities – heart disease,
hypertensions, stroke and diabetes – is not a problem limited to industrialized countries.
Inability to gain weight/achieve and maintain an ideal (normal) body weight is a big
public health issue which needs to be addressed to, especially in view of its association
with IUGR (intrauterine growth retardation), low birth weight and hence an intra-
generational increased risk for the development of chronic degenerative diseases and
early mortality.
Thus, in this practical, we shall learn about the various practical aspects of weight
management. We shall begin with a briefing on the various components of weight
which shall be followed by different forms of weight imbalance.
We will also learn about the various methods which a dietitian can employ for quick
evaluation/assessment of overweight/underweight. The various principles of dietary/
life-style management will be followed by a few review exercises and planning of
diet(s) to help you in learning/improving your skills pertaining to the overall assessment
and management of under/overweight conditions in a spectrum of physiological/clinical
situations.
Objectives
After undertaking this practical, you will be able to:
 discuss the components of body weight and the concept of weight management,
 describe the conditions linked with weight imbalance,
 explain the methods of assessment of weight imbalance,
 elaborate on the principles of dietary management for the weight imbalance
conditions, and
50  plan diets for obese and underweight individuals.
 Nutritional Care of
4.2 INTRODUCTION TO WEIGHT MANAGEMENT Weight Management

Body weight, as we all know, is the sum of bone, muscle, organs, body fluids and
adipose tissue. Some or all of these components are subject to normal change as a
reflection of growth, reproductive status, variation in exercise levels and the effects of
ageing. Achievement/maintenance of an ideal/normal body weight involves a complex
interaction of several physiological (normal, hormonal and chemical) and/or
environmental (dietary and life-style) factors. Alterations in the above mentioned
factors causes changes in the body weight components and hence fluctuations in the
weight of a person.
Thus, before we proceed to learn in-depth about the various aspects of weight
management, let us clearly understand the various components which contribute to
the total body weight of an individual. This information shall help us in understanding
the inter-relationship between nutrient intake and physical actually vis-à-vis body
composition.
Components of Body Weight
Body weight is often described in terms of its composition. According to the most
commonly used “two-compartment model”, body weight is comprised of two parts
namely:
i) Fat-free mass (FFM)
ii) Fat mass
i) Fat-free Mass literally means tissue devoid of all extractable fat. It is very
frequently used in close association with the term . “Lean body Mass” which
includes parts of the body free of adipose tissue i.e. skeletal muscles, water,
bone and a small amount of essential fat in the internal organs, bone marrow and
nerve tissues. FFM is higher in men than in women, increases with exercise, is
lower in older adults and is a major determinant of the resting metabolic rate.
ii) Fat Mass, which is a critical factor for weight management, can be categorized
as either “essential” or “storage”. Essential fat, which is necessary for normal
physiologic functioning, is stored in small amounts in the bone marrow, heart,
lung, liver, spleen, kidneys, muscles and lipid-rich tissues in the nervous system.
Nearly 3% and 12% of the total body fat is considered to be essential among
men and women, respectively. The range of total body fat (essential fat plus
storage fat) associated with optimum health is 8% to 24% in men and 21% to
35% among women.
Mentioned in Box 4.1 is the Behnke’s Theoretical Body Composition Model which
gives normal ranges of various body components for men and women.
Box 4.1 Behnke’s Theoretical Body Composition Model
Body Components Males Females
Total fat 8% - 24% 21% - 5%
a) Storage fat 5% - 21% 9% - 23%
b) Essential fat 3% 12%
Muscle 44.8% 38%
Bone 14.9% 12%
Remainder 16.3% - 32.3% 15% - 29%
Source : Am J Clin Nutr 72: 694, 2000.

4.3 WEIGHT IMBALANCE

A specific weight can be maintained throughout life if we can attain a balance between
our energy intake and energy expenditure. 51
Clinical and In the Theory Course (MFN-004) in Unit 2, you may recall studying about the two
Therapeutic Nutrition major forms of weight imbalance i.e.
 underweight (caused by chronic energy deficiency), and
 overweight/obesity
Underweight is a condition when the body weight is 10-20% less than the average
expected for one’s height, age and sex. If the body weight is less by 20% or more
than ideal body weight (IBW), the individual is grossly underweight.
Overweight i.e. excessive accumulation of storage fat is a condition when an individual’s
body weight is 10-20% in excess of ideal body weight. However, when the body
weight is 20% above the ideal body weight, it is termed as obesity.
While planning diets for helping a patient to increase or decrease weight we need to
know his/her body composition/extent of weight imbalance. Assessment of body
composition though more accurate, is an expensive method for identifying ‘at-risk’
individuals. In clinical settings, especially for out-door and non-critical patients, we
need to employ methods which are easy-to-perform, quick and yield accurate results.
In the subsequent section, we will discuss the various tools/techniques that can be
employed for assessing the severity of weight imbalance in an individual.

4.4 METHODS OFASSESSMENT

Underweight and obesity/overweight can be assessed in a variety of ways, depending
on the necessity for accuracy and availability of required resources. The most common
ones are as follows:
4.4.1 Visual Inspection
This is the simplest method of assessing whether an individual is lean/thin or overweight.
This can also be used for identifying the type of obesity i.e. android or gynoid. For
instance, when the trunk to hip ratio is more, the body shape resembles that of an
apple. This type of obesity (android obesity) is more common in men and it increases
the pre-disposition to cardiovascular diseases, hypertension, diabetes, stroke,
respiratory disorders etc. On the other hand, if the trunk to hip ratio is low, the body
shape resembles that of a pear and it is termed as gynoid obesity. It is more
common among women.
4.4.2 Standard Weight and Height Measures
Basic anthropometric data i.e. weight and height can be most valuable indications of
under/over nutrition especially if recorded over a period of time. The patients weight
and height data can be utilized in the following ways:
a) Comparison of the patient’s present weight and height with the data given by
Life Insurance Corporation of India. It is based on life expectancy data. (Refer to
theory course MFN-005, Unit-9, Table 9.3).
b) Computing the ideal body weight of the patient and comparing with actual
body weight. This can be done by using the HAMWI method, which is as
follows:
Females: 100 lbs (45.5 kg) for the first 5 feet + 5 lb (2.3 kg) for each additional inch
( +10% for small/ large built).
Males: 106 lbs (48.0 kg) for the first 5 feet + 6 lb (12.7 kg) for each additional inch
( + 10% for small/large build)
For example, we can calculate the ideal body weight of a medium built man
with height 5ft 4” inches as follows:
48.0 kg for first five feet + 2.7  4 kg (2.7 kg for each additional inch)
i.e. 48.0 kg + 10.8 kg = 58.8 kgs.
52 Thus, the ideal body weight of the referred man is 58.8 kgs.
The actual body weight of the patient should then be compared with his ideal body Nutritional Care of
Weight Management
weight to interpret the level of obesity/under weight as mentioned in Table 4.1.

Table 4.1: Computing the ideal body weight in comparison with

actual body weight

Present Body Weight Categorization/Interpretation

> 20% above IBW Obese
< 20% to > 10% above IBW Overweight
<10% above to < 10% below IBW Normal weight
> 10% to 20% below IBW Underweight
> 20% below IBW Severely/ grossly underweight

c) Comparison of the actual/present body weight with usual body weight. This
is a useful parameter for critically ill/ hospitalized patients especially to indicate
weight loss (if any). Comparison of present and usual body weight helps to
assess immediate/recent changes in the weight status. Weight loss (lbs/kgs)
reflects an immediate inability to meet nutritional requirements and thus may
indicate nutritional risk. The percentage of weight loss is highly indicative of the
extent and severity of an individual’s illness. It can be classified as follows:

Significant Weight Loss 5% loss in 1 month, 7.5% loss in 3 months, 10% loss in
6 months.

Severe Weight Loss > 5% loss in 1 month, > 7.5% loss in 3 months, >10%
weight loss in 6 months
The minimum necessary actual body weight required for survival is 48% to 55%
of usual body weight.

d) Calculating the Body Mass Index and comparing with standards. The Quetlet’s
Index (W/H2), the most widely used height weight index, is commonly referred
to as Body Mass Index (BMI) and is a validated measure of nutritional status. It
is a measure of relative body fitness and can be computed by using weight
(kgs); (minimal clothing) and height (metres, without shoes).
BMI = Weight (kg) / Height (m2)
The computed BMI can then be used to identify the level of under/over nutrition on
the basis of the WHO classification as given in Table 4.2 and Table 4.3.
Table 4.2: Weight status according to BMI
Classification BMI (kg/m2)
International Asian
Underweight <18.5 < 18.5
Normal 18.5-24.9 18.5-22.9
Overweight 25.0 - 29.9 23.0-24.9
Obese >30 >25
Obese (Grade I) 30-34.9
Obese (Grade II) 35.0-39.9
Obese (Grade III) > 40
*Source : WHO, 2004 53
Clinical and Table 4.3: FAO/WHO classification for chronic energy
Therapeutic Nutrition deficiency and/or underweight
Chronic Energy Underweight Grade (WHO) BMI(kg/m2 )
Deficiency Grade (FAO)
Normal Normal > 18.5

Grade I Mild Underweight 17.0 - 18.4

Grade II Moderate Underweight 16.0 - 16.9

Grade III Severe Underweight < 16.0

BMI can also be assessed quickly by using the Bray’s Nomogram as illustrated in
Figure 4.1.

Figure 4.1: Nomogram for body mass index

4.4.3 Skin-Fold Thickness

The skin-fold or fat-fold thickness measurement is a means of assessing the
amount of body fat in an individual. The skin fold sites identified as most reflective of
body fatness are:
 over the triceps and the biceps
 below the scapula
 above the iliac crest (suprailiac)
 upper thigh
Refer to Figure 4.2 which illustrates some of the skin fold measurements.
Normal sub-cuetaneous fat is about 11% and 18% of the total body weight in men
and women, respectively. Refer to Table 4.4 for checking any abnormal values for
54 tricep skinfold.
 Table 4.4: Percentile tricep skinfold measurements Nutritional Care of
Weight Management
Percentile
Men Women

55-65 y 65-75 y 55-65 y 65-75 y

Tricep skinfold (mm)

10th 6 6 16 14

50th 11 11 25 24

95th 22 22 22 36

Tricep skinfold > 95th percentile

Measurement of the subscapular Skin-fold callipers measuring

skin-fold thickness the thickness of subcutaneous fat (in millimeters)

Figure 4.2: Skin fold measurements

4.4.4 Circumference Measurement

In recognition of the fact that fat distribution is an indicator of risk for several diseases;
circumferential or girth measurement are used more frequently today. The presence
of excess body fat around the abdomen out of proportion to total body fat is considered
a risk factor for diseases associated with obesity/ metabolic syndrome. Most common
circumference measurements are:

 Waist and hip circumference: Waist is measured around the navel. Hip is
measured around its broadest part. A measurement of waist greater than 40
inches (100 cm) for men and greater than 35 inches (90 cm) for women are
independent risk factors for disease when out of proportion to total body fat.
Waist to hip ratio (WHR) serves as an important tool to assess the type of
obesity. A WHR of > 1.0 for men and > 0.85 for women is an indicator of
abdominal obesity.

 Mid-arm circumference (MAC) : Combining MAC with TSF (tricep skin fold)
measurements allows indirect determination of the arm muscle area (AMA) and
arm fat area (AFA). The AMA, or bone free muscle area, is a good indication
of lean body mass and thus an individual’s skeletal protein reserves. Refer to
Figure 4.3 and 4.4 which illustrates the arm anthropometry for children and adults,
respectively. Using this graph, you can measure the fat area and/or the muscle
area. 55
Clinical and
Therapeutic Nutrition

To obtain muscle circumferene:

1 . Lay ruler between values of arm circumferene
and fatfol.
2 . Read off muscle circumference on middle line.
To obtain tissue areas:
1 . The arm areas and muscle areas are alongside
their respective circumferences.
2 . Fat area = arm area - muscle area

Figure 4.3: Arm anthropometry for children

To obtain muscle
circumferene:

1 . Lay ruler between

values of arm
circumferene and
fa tfol.

2 . Read off muscle

circumference on
middle line.

To obtain tissue areas:

1. The arm areas and

muscle areas are
alongside their
respective
circumferences.

2 . Fat area = arm

area - muscle area

Figure 4.4: Arm anthropometry for adults

56 Next, let us recapitulate some basic principles of diet planning.

 Nutritional Care of
4.5 PRINCIPLES OF DIET PLANNING Weight Management

We shall now discuss in detail the overall dietary and life-style modifications that can
help an individual/patient in attaining and maintaining a desirable body weight. Let us
first begin with our discussions on dietary management of overweight/obesity.

4.5.1 Principles of Diet Planning  Overweight/Obesity

There is convincing evidence that a high intake of energy-dense foods and/or sedentary
life style promote weight gain. Although it is well known that diets high in non-starch
polysaccharides, proteins and micronutrients can help in achieving and maintaining an
ideal body weight; yet we all come across several overweight/obese patients who
have tried to reduce weight by adopting formula diets/meal replacement programmes
etc. Drastic weight reduction causes weakness and alterations in metabolic processes.
Severe calorie restrictions/non-diet approaches do not help in maintaining the
weight loss.

In this sub-section we shall learn about the various essential features of weight reduction
diets. As a dietitian our objective should be to help the patient reduce weight gradually
without suffering from muscle loss or micronutrient deficiencies.

Objectives of Diet Planning

The objectives of diet planning for overweight patients include:

 to promote gradual weight reduction,

 to prevent muscle loss and other nutritional deficiencies,

 to help in maintaining a desirable body weight, and

 to bring positive behavioural changes (diet/life style management).

In order to fulfill the above objectives, we need to bring about following nutritional
modifications.

Energy: There is convincing evidence that a high intake of energy coupled with a
sedentary life-style results in a positive energy balance which leads to excessive weight
gain over a period of time. Thus, the energy intake needs to be reduced to promote
weight loss. It is advisable to reduce weight at the rate of 0.5 to 1.0 kg a week for
which we need to restrict the calorie intake by 500 Kcal to 1000 Kcal per day,
respectively. The amount of energy restriction as per the rate of weight loss can be
calculated as follows:
 1 gram of dietary fat provides 9 Kcal
 1 gram of body fat (adipose tissues) provide 7.7 Kcal.
 Therefore, a 500 gram of weight reduction would be equivalent to 500  7.7 Kcal
i.e. 3,850 Kcal.
 Thus, to facilitate ½ kg (500 g) weight loss in a week, we need to reduce energy
intake by 3850 divided by 7 i.e. 550 Kcal/day from the RDI or usual dietary
intake.
Similarly, if we want to reduce 1 kg (100 Kcal) in a week (7 days) we need to reduce
energy intake by 3850 + 3850 = 7,700 Kcal divided by 7 = 1,100 Kcal/day the RDI or
usual dietary intake.
However, the energy intake should never be restricted to less than 1000-1200 Kcal
for women and 1500-1800 Kcal for men as drastic calorie restrictions may cause
weakness, deficiency of several nutrients, nervous exhaustion and disturbances in
57
various metabolic processes.
Clinical and Thus, the energy intake for an overweight/obese patient can be computed by two
Therapeutic Nutrition methods:
i) Reducing around 500 Kcal/day from the usual dietary intake if the patient is
overweight (weight loss rate = ½ kg per week) and 750 Kcal to 1000 Kcal/day
from the usual dietary intake if the patient is obese (weight loss rate = 1 kg per
week).
ii) Calculating the energy intake based upon the activity and ideal body weight of
the patient by using the values of kilocalories prescribed per Kg IBW for obese
individuals as indicated in Table 4.5.

Table 4.5: Daily energy requirements based on body weight and activity

Energy Requirements
(Kcal/kg Ideal Body Weight/day)

Activity Obese Normal Underweight

Sedentary 20-25 30 35

Moderate 30 35 40

Heavy 35 40 45-50

Protein: Around 20% of the total energy (modified) should be provided by proteins.
Providing adequate amount of proteins helps in:

 preventing muscle loss and hence weakness,

 providing satiety patients have a longer intestinal transit time as compared to

simple carbohydrates),

 maintaining a good nutritional status, and

 delaying/preventing the onset of complications associated with obesity (due

to high intake of fat/refined carbohydrates i.e. heart diseases, diabetes,
hypertension etc.)

Good quality proteins rich food sources which are low in saturated fat/cholesterol
such as low-fat milk/their products (yoghurt, curd, paneer), egg white, lean meats
(marine foods, chicken), pulses and legumes should be included in the diet. High fat-
protein foods such as red meats (cow, buffalo, pork etc.), egg yolk and processed
cheese should be avoided. Incorporating sprouted pulses in sandwiches, rotis, salads,
soup, pulao are good options for increasing the protein content of meals.

Fat: The diet should not provide more than 20% of the total energy from fat. The
total fat intake comprises of both visible and invisible fat (refer to Box 4.2) Conscious
efforts must be made by the patient to restrict the intake of cooking fat, as well as,
that present inherently in foods. Food sources of invisible fat (particularly saturated
fat) such as red meats, egg yolks, nuts, oilseeds, margarine, certain bread spreads,
bakery products should be completely restricted. The visible fat intake can be
curtailed by avoiding fried food, using non-stick cookware/ micro-wave or cooking
food by roasting, grilling and baking (dry heat). Butter, cream, pure ghee should be
avoided and vegetable oils rich in MUFA’s/PUFA’s (low in SFA’s) such as olive,
safflower, corn, sunflower should be used in limited amounts. The dietary cholesterol
intake should be kept below 300 mg/dl if the patient is not suffering from any heart
disease. However, hyperlipidemic obese patients may benefit by lowering the dietary
cholesterol intake to < 200 mg/day.
58
 Nutritional Care of
Box 4.2 Visible and Invisible Fat Weight Management

Total Fat (g) = Invisible Fat (g) + Visible Fat (g)

(as per modified RDI)
For planning diets, the visible fat allowance can be computed as follows:
Total fat (g) – Invisible fat (g) = Visible fat allowance for the day.
(as per modified RDI)

Carbohydrates: Around 55-60% of the total energy should be provided by

carbohydrates. However, emphasis should be laid on the consumption of foods rich
in non-starch polysaccharides. This is so because dietary fibre rich foods have a
longer intestinal- transit time and hence a higher satiety value as compared to
foods rich in simple carbohydrates. For instance, a bowl of salad (sprouts + vegetables)
will provide a higher satiety as compared to soup prepared from the same. Obese
individuals should prefer to consume whole grains/their products, whole pulses/
pulses with husk (rajmah, soyabean, horsegram, Bengal gram, whole moong, whole
urad, cowpea) raw vegetables and fruits (preferably with their edible peels) as compared
to refined cereals (rice, chirwa, suji, maida)/ their products (bread, pastas, biscuits
etc.) washed pulses, starchy roots and tubers which are low in dietary fibre.
Sugar, jaggery, honey, maple syrup, sugar candies, chocolates etc. should be strictly
restricted.

Minerals and Vitamins: A weight reduction diet, if well planned, can provide adequate
amount of all vitamins and minerals. Obese individuals should be encouraged to consume
liberal amounts of raw non-starch vegetables and good amounts of low-calorie fruits
preferably with their edible peels (raddish, cucumber, severely restricted in fat several
months as in case of Grade III obesity; the patient may be at risk of developing
deficiencies of fat-soluble vitamins. Thus, care must be taken to ensure adequate
intake of vitamin E (green leafy vegetables, almonds etc.), -carotene ( yellow and
orange coloured fruits/vegetables) and vitamin D (sunlight, oils fortified with vitamin
A/D). Incorporating fermented foods and sprouted pulses/legumes can help in improving
the bioavailability of several nutrients.

Alcohol: Alcohol consumption should be completely restricted as it contributes

towards the total calorie intake in the diet. Further, alcoholic beverages are frequently
consumed along with snacks (such as namkeens, pakoras, kabeb’s, cutlets etc.) which
are rich in fats and carbohydrates. If consumed for social reasons, the patient should
be advised to take a small serving which is diluted with a liberal amount of drinking
soda/water.

Exercise and Lifestyle: Physical activity and physical fitness are important
determinants of morbidity and mortality related to over-weight/obesity. Exercise
(particularly a combination of aerobic and resistance trainings) should be an integral
part of the weight reduction regime.

According to FAO/WHO (2004), preventing weight gain after substantial weight

loss probably requires 60-90 minutes of moderate intensity exercise per day.
A total of one hour per day of moderate intensity activity, such as walking
everyday is required to maintain a particular stable weight for individuals with sedentary
life-style.

While the above mentioned principles of dietary/lifestyle management can help in

reducing weight, it is important to bring about behavioural modifications so that a
desirable body weight can be maintained throughout life. Effective patient counseling
sessions during and after weight reduction can help in preventing the “Y0-Y0 effect”
of repeated episodes of weight gain/loss. Here are a few useful tips. 59
Clinical and
Therapeutic Nutrition Patient Counseling Tips
 Low Fat/fat-free milk and their products (cottage cheese, yoghurt, curd etc.)
should be preferred over whole milk/ its products. Some amounts of milk
should be consumed regularly to prevent bone loss frequently associated with
weight loss.
 Whole cereals, whole pulses, pulses with husk and legumes should be preferred
over low fibre cereals such as refined flour, semolina, rice, chirwa, pastas,
breads etc.
 Low fat, white or lean meats should be preferred over red/high fat meats.
Avoid animal foods such as egg yolk, lamb, goat, pork, cow and buffalo meat.
 Liberal servings of low calorie fruits and vegetables should be consumed
everyday. It is advisable to start meals with a bowl of salad (raw vegetables
and sprouted pulses) and end meals with a serving of low-carbohydrate fruit.
Low calorie vegetables: leafy vegetables, tomato, cucumber, raddish, cabbage,
turnip, ridge gourd, beans etc.
 Low calorie fruits: water/musk melon, orange, mausambi, loquat, lime, apple,
pear etc.
 Cooking oil to be used sparingly. Olive, corn, rice bran and safflower are
good options and can be used in rotation to maintain the n-3/ n-6 ratio. Dry
heat methods of cooking such as roasting, grilling, sautéing on non-stick
cookware and microwave can help in reducing the amount of oil used for
cooking food.
 Sugar, honey, jaggery, sugarcane, maple syrup should be completely avoided.
Desserts and sweet meats prepared by using artificial sweeteners may be
taken occasionally if they are low in fat. Indian sweets such as gulabjamun,
jalebis should be completely avoided. Low fat ice-cream/frozen desserts,
soufflés, puddings may be taken in small amounts.
 “ Khaties”, kachories, muthias, namakparas and most bakery products (cake,
pasties, biscuits) contain high amount of fat particularly hydrogenated fat.
They should not be consumed.
 Both nibbling and binging on food should be avoided.
 Roasted/puffed whole cereals/ pulses/ legumes, steamed sprouts and vegetable
chaat, dalia/dhokla/ idli/ roti prepared by using sprouted legumes can be taken
as evening snacks.
 Prefer to take low-calorie micronutrient rich beverages such as lemon-
water jal-zeera, kanji over squashes, cold-drinks etc.
 Oat bran/ Oat meal/cracked wheat porridge, grilled sandwiches, missi roti
or vegetable and sprouts stuffed paranthas along with a low calorie fruit
are healthy breakfast options.
A sample menu is included herewith for your reference.
Sample Menu
Early Morning Lunch /Dinner
Lemon Water/ Green Tea (6.00-6.30 am) Salad (sprouts + vegetables)
Skimmed Milk (7.00-7.30 am) Multi Grain/ Bran Chapati
Whole pulse/fish/chicken curry
Breakfast Beans/ladyfinger vegetable
Oat bran porridge Raita/curd/dessert
Grilled chicken/Paneer
sandwich with cabbage Evening Tea
Tea
Mid- morning Vegetable Dhokla
Water melon and Guava (1 serving)
60
 Nutritional Care of
Weight Management
4.5.2 Principles of Diet Planning  Underweight
Underweight, we learnt, is a state when a person is in a negative energy balance i.e.
energy intake is less than energy expended on various activities. Underweight individuals
are generally malnourished and they usually have low reserves of adipose tissues,
muscle and bone mass.
In this section, we shall learn about the various essential features related to dietary
management of underweight individuals. Let us begin with identification of objectives:
Objectives of Diet planning
The objectives of diet planning for an underweight individual include:
 to help the patient in gaining/attaining a desirable/ideal body weight,
 to replenish the depleted nutritional reserves of the body,
 to cure/treat the underlying cause, and
 to bring about behavioural modifications that can help in maintaining a good
nutritional and health status.
We will now begin with our discussion on nutrient modifications and how to achieve a
positive energy balance which is essential for increasing body weight.
Energy: Irrespective of the cause, weight loss is almost always associated with negative
energy balance in the body. This energy deficiency could be due to a low food intake
or increased requirements of the body (elevated RMR/increased expenditure on
physical activity). Based upon the principles discussed in sub-unit on obesity, we will
increase the energy intake by 500 Kcal to 1000 Kcal above the usual intake/RDI per
day in order to help the patient in increasing his/her body weight by half to one kg in a
week. We can also follow the procedure of calculating the IBW for the patient and
then computing the energy intake by multiplying the IBW with energy prescribed for
underweight individuals (with respect to their activity level) as given in Table 4.5
earlier.
Protein: Body composition details of underweight individuals indicate depleted
protein reserves and a low muscle mass content. A high protein diet providing around
1.5-2.0 g of protein per kg IBW per day is recommended. Easily digestible proteins of
high biological value should be given to the patient. The diet should therefore include
milk/milk products, eggs, meat, fish, chicken, pulses (greater emphasis on pulses without
husk.). Fermented foods (dhokla, idli, dosa etc.) being easy to digest should be included
in the diet. Overnight soaking of whole pulses makes them easier to digest and more
nutritious. Soy products such as tofu, soy milk and texturized soy meal/protein should
be incorporated in the daily culinary practices.
Fat: Although underweight patients usually have depleted reserves of adipose tissue,
we should not provide more than 25% of the energy from fats, keeping in mind the
digestive capacity of the patient/tolerance limits. Incorporation of adequate amounts
of fat help to make the meals energy dense and reduce bulk and improve palatability
which can help in promoting an increased food intake. Emphasis should be laid on the
inclusion of foods which contain appreciable amounts of invisible fat such as whole
milk, curd/paneer/khoa/lassi prepared from whole milk, eggs, flesh foods, nuts etc.
Emulsified fats like butter and cream, as well as, oils rich in medium chain triglycerides
(coconut oil/coconut milk) would be better tolerated as compared to pure ghee,
vanaspati and fried foods.
Carbohydrates: Carbohydrates should provide remaining energy or about 60% of
the modified RDI for energy. Foods rich in simple carbohydrates should be preferred
and those high in dietary fibre need to be avoided. This is so because such foods are
easier to digest, have a low bulk and can thus help in promoting an increased food
intake. High fibre foods increase bulk and may cause flatulence which can inhibit
61
food intake. Sugar, honey, maple syrup, cane sugar, dextrose, dates, starchy tubes,
Clinical and fruits and vegetables, cereals such as semolina, rice, chirwa (flattened rice), corn,
Therapeutic Nutrition sago, arrowroot, bread, pastas can be incorporated in liberal amounts. High fibre
cereals such as bajra, jowar, ragi, whole/cracked wheat and fibrous vegetables/fruits
should be avoided or given in small amounts.
Vitamins and Minerals: Deficiencies of several micronutrients can be commonly
observed in underweight individuals. Plenty of fruits and vegetables in soft cooked
form should be included in the diet. Since B-group vitamins particularly thiamin helps
in releasing energy from food, they should be included in adequate amounts. Similarly,
small amounts of citrus fruits (amla, lemon etc.) and yellow/orange coloured vegetables/
fruits should be included to provide adequate amounts of vitamin A and C (improved
immune function). If the diet contains good amount of milk, eggs and animal foods;
deficiencies of vitamin D and A would not arise.
Special Considerations
Underweight patients should be advised to consume small, frequent, easy to digest,
nutrient dense meals. The meals should have variety in terms of colour, texture, taste,
flavour and mouth feel so that the patient feels interested and motivated to consume
adequate amount of food. Plate waste must be accounted for and adjusted in
subsequent meals especially if the patient is severely underweight. The diets of
patients suffering from grade III of chronic energy deficiency may be required to
be supplemented with high energy-high protein nasogastric tube feeds. Oral
health supplements can also be added to the diet. Protein powders such as whey
protein, soy protein, casein can be added to the prepared dishes to increase their
nutritive value.
So far we have discussed about the important aspects of diet planning and life-style
modifications during the management of obese and underweight patients. You should
now make an attempt to answer the questions mentioned in review exercises and
self-check your progress. If you are able to complete the exercise satisfactorily;
proceed ahead and carry out the activity 1 and 2 given herewith. Through these
activities you will learn how to plan diet(s) for obese and underweight patients.

4.6 REVIEW EXERCISES

1) Enlist the various components which contribute towards the total body weight of
an individual.

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

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

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

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

2) Calculate the body mass index and identify the level of under/overnutrition for
Mrs. Mala, housewife who is 5 ft. 3 inches tall and weights 78 kgs.
Calculations of BMI:

Level/Category of Under/Overnutrition:

62
3) Krishna is a sedentary busy office executive who has been experiencing Nutritional Care of
Weight Management
breathlessness while performing basic personal activities. He is also finding it
difficult to walk and sweats profusely on slight exertion. He is 5 ft. 6 inches tall
and presently weighs 95 kgs. He has been advised to reduce weight. Based on
the above details of the case, answer the following:
a) Compute Krishna’s ideal body weight.

b) How much weight does Krishna needs to reduce to achieve his ideal body
weight?
.............................................................................................................
.............................................................................................................
c) Calculate the energy, protein and fat requirements for Krishna to help him
in reducing weight (show your calculations here).

4) Tina is a 25 years old college student who loves to binge on fast food. She also
nibbles on ready-to-eat snacks during late evening. Enlist atleast ten counseling
tips for her that can help her from adding on excess body fat. At present she is
4.0 kgs above her ideal body weight.

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

5) What are the clinical implications of being underweight?

.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
..................................................................................................................... 63
Clinical and 6) How can you make the following dishes nutrient dense so as to facilitate gain in
Therapeutic Nutrition weight?
1) Tomato cucumber sandwich
2) Oat bran and cornflakes porridge
3) Missi roti and curd
4) Carrot beans soup with wheat puffs.
Suggestions

7) Enlist any three cooking methods which can help in increasing the calorie (energy)
content of various dishes.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
8) Kapil is a 32 years old busy, active marketing executive who has lost 5½ kgs in
the past 2 months. He has been advised to modify his food choices/dietary
habits to suit his work schedule. Enlist a few useful tips for him, which can be
helpful in preventing subsequent weight loss/promoting weight gain.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Now that you have completed the exercises get down to planning diets for the obese
and underweight in Activity 1 and 2 given herewith, as part of this practical.

64
 Nutritional Care of

ACTIVITY
Weight Management

DIET PLAN OR OVERWEIGHT/

OBESE INDIVIDUALS 1
Aim : To plan a diet for an obese individual. Date :
Case Study : Mr. Sharma is a 43 years old Food-Service Manager. He is 5 ft
6 inches tall and weighs 89 kgs. As part of his job, he socializes a
lot and is fond of eating bakery products and non-vegetarian/fried
snacks. He usually takes 2 servings of whisky everyday in the
evening. He was diagnosed to be overweight (for the first time)
around 15 years back. Since then he has tried to reduce his weight
several times by keeping fasts or taking severe calorie restricted
diets. Even if he is able to reduce 5-6 kgs at a given period, he is not
able to maintain it. At present, he is experiencing breathlessness on
walking and begins to sweat profusely while eating and performing
essential personal and social activities. His clinical parameters i.e.
total blood cholesterol, LDLs and triglycerides are indicating an
upward (increasing) trend over the past six years.
Mr. Sharma has been identified to be ‘at risk’ of developing diabetes
and coronary artery disease due to his excess body weight. He has
been advised to reduce weight.
Based on this case study, now carry out the activity following the instructions given
herewith.
Introduction
(Elaborate on what is overweight/obesity highlighting the causative factors in the space
provided herewith).

Next, read the case carefully and identify at least three disease for which Mr. Sharma
is at an increased risk.
Write down the risk/complications of obesity for Mr. Sharma.

65
Clinical and Step I
Therapeutic Nutrition On the basis of the details mentioned in the case study fill in the patient details in the format
given below.
Patient/Case Profile
Name:
Age:
Gender:
Activity Lifestyle:
Dietary habits
Socio-economic status:
Pathopysiological stress:
Diet prescribed:
Clinical Profile
Patient Value Normal Value
Body Weight
Body Mass Index
How much weight does Mr. Sharma need to reduce? …………….. kg.
Now identify the various goals of dietary modifications and enlist them in terms of
their priority in ascending order in the space provided herewith.
Objectives of Dietary Modification

Step II
Keeping in mind the case details (identified in Step I), assess/calculate the nutritional needs of
Mr. Sharma and compare them with the RDI for a healthy sedentary adult men. Write the
calculation is the space provided herewith.

Recommended Dietary Intake

Nutrients Normal Modified
Energy (Kcal)
Protein (g)
Carbohydrate (g)
Fat (g)
Dietary Fibre (g)
Dietary Cholesterol (mg)

(Note: In order to compute his energy requirements, you may need to calculate his IBW and then
multiply the IBW with calories recommended for a sedentary obese adult man.)

Calculations:

66
Step III Nutritional Care of
Weight Management
Based upon the modified RDI, carefully write the food exchanges most suitable for Mr. Sharma
in the format given herewith.

Exchange No. Energy Protein Carbohydrate Fat

(Kcal) (g) (g) (g)

Skim Milk

Meat

Pulse

Cereals

Roots/Tubers

Other
Vegetables

GLV

Fruit

Fat (Oil)

Sugar (optional)

Step IV: Decide on the meal frequency most appropriate for Mr. Sharma.
(Hint: Perhaps a 4-5 meal pattern would be appropriate. Distribute the exchanges for
providing balanced nutrition throughout the day in the format given herewith).

Exchange No. Early Break- Lunch Evening Dinner

Morning fast Tea

Milk

Skim Milk

Meat (lean)

Pulses

Cereals

Roots/Tubers

Other Vegetables

GLV

Fruit

Fat (oil)

Step V: Using the exchanges available for each meal, plan a day’s menu for Mr. Sharma.
Remember to include dishes/ingredients which have a large volume but are low in calories
(high fibre but low in fat and single carbohydrates) i.e. they should have a high satiety value/
long intestinal transit time. 67
Clinical and Menu for Mr. Sharma
Therapeutic Nutrition
Early Morning Breakfast Lunch Evening Tea Dinner

68
Step VI: Detailed menu plan Nutritional Care of
Weight Management
Calculate the energy, protein and other nutrient content of the diet in the format given herewith.

Meal Menu Ingredient Amt Exchange Energy Dietary Crude Visible Invisible
(g) (Kcal) Fibre Fibre Fat Fat
(g) (g) (g) (g)

Total

69
Clinical and Using the values obtained for visible and invisible fat in the detailed menu plan;
Therapeutic Nutrition compute the total fat being provided in the diet. Also find out the difference (%)
between the modified RDI for fat and that being provided through the diet.
Invisible fat (g) being provided through the diet planned…………..
Visible fat (g) being provided through the diet planned…………..
Total fat being provided through the diet plan ……………. (g)
Modified RDI for total Fat …………….. (g)
Difference = ±…………….. (g)
% difference = ± …………. %
Mr. Sharma has never been able to maintain his last weight. Can you give him
a few suggestions to help him in reducing and maintaining lost weight.

Related to Diet

Related to Life style

Conclusion
Compare the amount of the nutrients provided through the detailed menu plan with
the amount of the nutrients computed for the modified RDI. Give your suggestions
for improvement.

Nutrient Amount Amount Suggestions

Computed Computed for for
through Diet Modified RDI Improvement

Energy (Kcal)

Fat (g)

Dietary Fibre (g)

Submit your activity for evaluation.

——————————
70 Counselor’s Signature
 Nutritional Care of

ACTIVITY
Weight Management

DIET PLAN FOR UNDERWEIGHT INDIVIDUALS 2

Aim : To plan a diet for an underweight individual. Date :
Case Study : Shweta is an 18 year old girl studying in class XIIth of a public school.
Her height is 5 feet 3 inches and she weighs 41 kgs at present. She
has been losing weight for the past six months when she suffered
from an episode of typhoid. Prior to fever, her weight was 52 kgs.
She is fond of out-door sports but at present is not able to play much
due to weakness. She is finding it difficult to keep pace with her
studies as she feels lethargic, listless dizzy and tired. After school
she goes to a coaching center for 21/2 hours. On her way back she
goes to nearby market to buy stationary/groceries on alternate days.
She prefers to commute by walking/cycling. Her recent medical
check-up has indicated following details:
Total fat = 17%
Muscle mass = 23%
Haemoglobin = 10.1 gm/dl
Vitamin B12 (serum) = 119 pg/ml (normal range : 140-820 pg/ml)
Serum retinal = 25 g/dl (normal = 30-80 g/dl)
She has been advised to select high energy, high protein foods which are also good
sources of vitamin A and vitamin B12. Her case has been forwarded to a dietitian to
plan a day’s diet in accordance with her activity and study schedule. Her school/
coaching and other important timings are :
School timings : 8.00 am to 2.30 p.m.
Coaching timings : 4.00 p.m. to 6.30 p.m.
Market work : 6.30 p.m. to 7.45. p.m.
Sports/play (active) : one hour in school
Total walk/ cycling : 45 minutes
Now, based on this case study, plan a diet for Shweta.
Introduction
Define underweight and identify the risk factors associated with weight loss.

71
Clinical and Classify Shweta’s body weight as per the chronic energy deficiency classification
Therapeutic Nutrition given earlier in Table 8.3 and write the response below:
Shweta is suffering from ……. stage of CED
Now plan a diet for Shweta following the steps indicated herewith.
Step I
Read the case carefully and identify the following details for developing a diet plan for Shweta.

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathopysiological stress:
Diet prescribed:

Clinical Profile
Patient Value Normal Value
Haemoglobin (g%):
Vitamin B12 (pg/ml):
Retinon (mg/dl):
Body weight (kg):
Body mass index (kg/m2):
Total Body fat (%):
Total body muscle mass (%):
How much weight does Shweta needs to increase to achieve her ideal body weights?
……………..kgs.
How many weeks would you target for the above mentioned weight gain?
……….weeks.
In view of Shweta’s clinical/health profile and life-style; enlist the various objectives
of her dietary/life-style management in the space provided herewith:
Objectives of Diet Planning :

72
Step II Nutritional Care of
Weight Management
Keeping in mind the case details, assess/calculate the nutritional needs of Shweta and write
them in the format given herewith. Compare her requirements with the RDI for a normal healthy
18 year old girl. (Refer to Table 1.1 given in Practical 1).

Recommended Dietary Intake

Nutrients Normal Modified

Energy (Kcal)
Protein (g)
Carbohydrate (g)
Fat (g)
Vitamin A (mg)
Iron (mg)

(Note: The total food intake should be increased gradually. Underweight patients are usually
anorexic and a drastic intake may also cause gastric discomfort etc.)

Calculations: (Write the calculations in the space provided herewith).

Step III
Now select suitable food exchanges that can provide the above mentioned nutritional
requirements for Shweta.

Exchange No. Energy Protein Carbohydrate Fat

(Kcal) (g) (g)

Whole Milk

Meat

Pulse

Cereals

Roots/Tubers

Other
Vegetables

GLV

Fruit

Fat
73
Sugar
Clinical and Step IV
Therapeutic Nutrition
Based upon the fact that small frequent nutrient dense meals can help in facilitating increased
food intake; carefully distribute the above mentioned exchanges for different meals (6-7 meals/
day) in the format given herewith.

Exchange No. Early Break- Mid Lunch Evening Dinner Post

Morning fast Morning EarlyLate Dinner

Whole Milk

Meat
Pulses

Cereals
Roots/Tubers

Other
Vegetables

GLV
Fruit

Fat
Sugar

Step V
Using the exchanges available for each meal, plan a day’s menu for Shweta. Do keep in mind to
include nutrient dense dishes liked by adolescents/young girls. You may need to refer back to
the text on diet/life-style management. Also mention the meal timings.
Menu:
Early Morning Breakfast Mid Morning Lunch
(Tiffin-short break) (Tiffin-Long break)

Early Evening Late Evening Dinner After

Dinner

74
Step VI Nutritional Care of
Weight Management
Now, develop a detailed menu plan. (Try to select the ingredients which can help in preparing
meals which are nutrient dense/easy to digest and have a small volume).

Meal Menu Ingredients Amount Exchange Energy Carbohy- Protein Iron Vitamin A
(g) (Kcal) drate (g) (g) (µg)
(g)

Total
75
Clinical and Enlist a few counseling tips to help Shweta is coordinating her meal timings with
Therapeutic Nutrition her activity schedule.

Conclusions:
Compare the amount of the nutrients provided through the detailed menu plan with the
amount of the nutrients computed for the modified RDI. Give your suggestions for
improvement.

Nutrient Amount Computed Amount Computed Suggestions for

through Diet for Modified RDI Improvement
Energy (Kcal)
Protein (g)
Carbohydrate (g)
Iron (mg)
Vitamin A (µg)

Submit your activity for evaluation.

——————————
76 Counselor’s Signature
 Planning Diets for
PRACTICAL 5 PLANNING DIETS FOR Metabolic Diseases

METABOLIC DISEASES
Structure
5.1 Introduction

5.2 Different Types of Metabolic Diseases

5.3 Principles of Dietary Management  Diabetes Mellitus

5.4 Principles of Dietary Management  Gout

5.5 Review Exercises

Activity 1: Diet Plan for Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Activity 2: Diet Plan for Insulin Dependent Diabetese Mellitus (IDDM)

Activity 3: Diet Plan for Gout

5.1 INTRODUCTION
In this practical unit, we shall first quickly recapitulate about the various characteristic
features and clinical symptoms of diabetes and gout about which you have already
studied in the theory course (MFN-005) in Unit 12 and 13. Thereafter, we shall learn
about the various practical aspects/principles of dietary management which are
imperative for the successful treatment/management of the above mentioned diseases.
These will be followed by practice exercises that would help you in learning about the
step-by-step process required for individualized planning diets as per the requirements
of the patients.

Objectives

After undertaking this practical, you will be able to:

l describe the different types of metabolic diseases,

l discuss the practical aspects/principles of dietary management which are

imperative for the successful treatment/management of diabetes mellitus and
gout, and

l plan diets for individuals suffering from diabetes and gout.

5.2 DIFFERENT TYPES OF METABOLIC

DISEASES
Metabolic diseases can be described as those arising due to clinical and/or
biochemical changes/ interruptions in the normal metabolic processes of the
human system. Several metabolic disorders have been identified and the spectrum
includes very commonly prevalent diseases such as diabetes mellitus, gout,
phenylketonuria, as well as, those which are very rare such as hartnup disease,
valienemia, cystathionuria etc. to name a few.

You may have already studied about these diseases in the Unit 12 and 13 of theory
course on Clinical and Therapeutic Nutrition (MFN-005). However, mentioned below
is a brief description/review regarding diabetes mellitus and gout which is the focus of
this practical.
77
Clinical and A) Diabetes Mellitus
Therapeutic Nutrition
Diabetes mellitus is a chronic metabolic condition characterized by derangements in
the metabolism of glucose, as well as, abnormalities in the metabolism of fat, protein
and other substances.

As has been mentioned in the theory course, in Unit 12, diabetes is a metabolic
disorder characterized by the following symptoms: Glycosuria, Hyperglycemia,
Polyuria/nocturia, Polydipsia, Dehydration and Ketoacidosis.

Diabetes is a chronic metabolic disorder which cannot be completely cured/

treated. It can however be managed carefully in order to prevent/delay the
development of complications. The major treatment/management objectives should
be targeted towards:

l Dietary modifications

l Life-style management

l Adherence to drug/insulin schedule

We shall now proceed towards the salient features of Gout.

B) Gout

Gout is a metabolic disease of heterogeneous nature, often familial, associated with

abnormal amounts of urates in the body and characterized early by a recurring acute
arthritis. The associated hyperuricemia is due to overproduction or/and under-excretion
of uric acid. Adult men (>30 years) and post-menopausal women are ‘at-risk population’
for gout.

The characteristic features/symptoms and signs of gout include:

 Elevated serum uric acid (>7.5 mg/dl) levels. The risk of developing uric acid
renal stones increases by 50% when the serum urate levels reach above 13 mg/
dl.

 Erythrocyte Sedimentation Rate and White cell count rise during an acute attach.

 Patient generally experience a rise in body temperature (> 39C).

 The metatorsopharyngeal joint of the great toe is the most susceptible joint
(‘podagra’), although others, especially those of the feet, ankles and knees are
commonly affected.

 The involved joints are swollen and exquisitely tender. The overlying skin is
tense, warm, dusky red and painful to touch.

 Tophi may be found in the external ears, hands, feet, olecranon and prepatellar
bursas. Their size may be as small as that of a pin head to as big as a golf ball.
Tophus a characteristic lesion of gout, is a nodular deposit of monosodium urate
mono hydrate crystals, with an associated foreign body reaction.

 Material aspirated from a tophus shows typical crystals of sodium urate which is
used as a laboratory test to confirm diagnosis.

The treatment schedule of gout generally includes taking care of the acute phase first
followed by management of hyperuricemia.

a) Acute Phase:

 Complete bed rest for at least the first 24 hours after an acute attack.
78 Early ambulation may precipitate recurrences.
  Drugs generally prescribed include: Non- steroidal, anti-inflammatory drugs Planning Diets for
Metabolic Diseases
(NSAID’S), Colchicine, Cortico-steroids and Analgesics.

b) Management between attacks:

 Diet modifications

 Avoidance of hyperuricemic medications

c) Chronic Tophaceous Arthritis

 Maintaining serum uric acid levels below 5 mg/dl (diet and drugs)

 Surgical excision of large tophi.

With this basic review, let us now learn about the objectives and principle of dietary
management for diabetes viz. non-insulin and insulin dependent diabetes mellitus, and
gout.

5.3 PRINCIPLES OF DIETARY MANAGEMENT

DIABETES MELLITUS
Look up Unit 12, section 12.3 in the theory Course (MFN-005) for the details related
to the dietary management of diabetes. Dietary management of diabetes has gone
through several phases of modification. It was as early as in 1797, that John Rollo,
a British Army Surgeon-General, recommended a very low carbohydrate, high fat
diet (complete avoidance of almost all vegetables too). In 1865, a French clinician
Appolinaire Bouchardat developed a more palatable low carbohydrate, high fat diet
by eliminating milk and allowing some boiled vegetables. His reports further popularized
the already widely accepted practice of using a low-carbohydrate- energy restricted
diet for diabetic individuals in the pre-insulin era. The famous “Allen Starvation
Treatment” was developed by Frederick M.Allen in 1912 wherein the lives of patients
were sustained on a 1,000 Kcal diet providing only 10 grams of carbohydrate. High
carbohydrate energy-restricted diets were advanced by Thomas Willis in 1675 and
the “insulin era” began in 1921 with the discovery of insulin.

The dietary management of diabetes as is being practiced today is based on the following
objectives:

 to achieve and maintain normal blood glucose levels,

 to attain and maintain a desirable/ideal body weight,

 to prevent/delay/reduce the onset/severity of short - and/or long-term

complications,

 to maintain an optimum nutritional status by providing individualized care, and

 to help the patient with self-care and monitoring of diabetes.

The diabetic nutrition plan should therefore be individualized and must focus not only
on the diabetic state but also on overall health and well-being of the patient. Let us
quickly recapitulate the basis of assessing the requirements of the patients.

Energy : The requirement for energy should be computed on the basis of age, gender,
type of diabetes, drugs/insulin and activity pattern, as well as, pathophysiological stress
(if any). For adult diabetics the energy requirements are generally based on the
achievement and maintenance of ideal body weight. In case of juvenile diabetics, we
also need to take care for providing adequate calories/other nutrients to facilitate
normal physiological growth and development. Thus, for adult diabetics (generally
NIDDM patients) the ideal body weight can be calculated on the basis of height: 79
Clinical and IBW (Men) = 48 kg for first 5 feet + 2.7 kg for each additional inch ( + 10% for build)
Therapeutic Nutrition
IBW (Women) = 45.5 kg for first 5 feet + 2.3 kg for each additional inch ( +10% for
build)
The value of IBW can then be utilized for computing the energy requirements of
normal, under/over weight patients as given in Table 5.1.

Table 5.1: Energy requirements for diabetic patients

Energy Requirements (Kcal per kg IBW Per Day)

Activity Obese Normal Underweight

Sedentary 20-25 30 35

Moderate 30 35 40

Heavy 35 40 45-50

Protein: The protein intake should be kept to normal or slightly increased intake
because in poorly regulated cases of diabetes; large quantities of nitrogen get
excreted in the urine. Secondly, since proteins have a longer gastrointestinal transit
time; the post-prandial increase in blood glucose would be slower and tapered as
compared to after the consumption of meals low in proteins. Plant origin protein
food sources (legumes, whole, pulses and their products) being high in fibre but low
in saturated fat/cholesterol should be preferred over animal origin protein food
sources particularly in case of adult/overweight/hypercholesterolemic diabetics.

Thus, we can include adequate amounts of whole pulses (horsegram, Bengal gram,
green gram whole, rajmah, cowpea), legumes, beans, skimmed milk, cottage cheese
(paneer)/curd/yoghurt made from skimmed milk, tofu, soya milk, lean meat such as
chicken, egg white, fish and other marine foods may be included in the diet.
Cereals/cereal flour can be substituted with whole Bengal flour, soya flour, besan
to increase the protein and fibre content of chappatis and breads. Similarly, sprouts
can be added to salads, sandwiches, chelas, patties, idlis etc.

Carbohydrates: Both the quantity and quality of carbohydrates play a crucial role
in the management of diabetes. The carbohydrate allowance may vary from 55%
to 60% depending upon the severity of hyperglycemia, weight, type of drugs/
insulin, activity pattern, age and gender of the patient. While a carbohydrate intake
of <100gm may cause ketosis (hypoglycemia); an intake of >300 gm may elicit a
hyperglycemic shock. The National Diabetes Associations of several countries
recommend a nutrition plan that provides generous amounts of complex carbohydrates
and fibre as it lowers the glycemic index (glycemic response) of a particular food/
meal.

The total carbohydrate should be evenly distributed throughout the day depending
upon the drugs/insulin being given to the patient. For instance, NIDDM patients
on hypoglycemic drugs need to consume carbohydrate in equal amounts for breakfast,
lunch and dinner. Patients on a combination of intermediate and long acting insulin
need to take some carbohydrate early morning, as well as, after breakfast apart
from that in breakfast, evening, lunch and dinner. Patients on short acting insulin
must consume meals within half-an-hour of administering the injection.

Diets providing liberal amounts of fibre and complex carbohydrates have been
highly recommended for diabetics. Most of the patients benefit from diets providing
25 gm dietary fibre for each 1,000 Kcals consumed. The benefits of incorporating
80 fibre rich foods in the diet have been enlisted in Box 5.1.
 Planning Diets for
Box 5.1 Advantages of High Fibre Intake for Diabetics Metabolic Diseases

 Slows nutrient digestion and absorption.

 Decreases post-prandial plasma glucose
 Increases tissue insulin sensitivity
 Increases insulin receptor number
 Stimulates glucose use
 Attenuates hepatic glucose output
 Decreases couter-regulatory hormone release (such as glucagon)
 Lowers serum cholesterol
 Lowers fasting and post-prandial serum triglycerides
 May attenuate hepatic cholesterol synthesis

Source: Anderson JW, Nutrition, management in Diabetic Mellitus in: Modern Nutrition in Health
and Disease Yong and Shills.

High fibre foods also have a low glycemic index. Look up sub-section 12.3.3 in
Unit 12 in the theory (MFN-005) course to recapitulate your understanding about
the glycemic index concept. Diabetics should be recommended to preferably
consume whole cereal grains (wheat, jowar, bajra, ragi), whole pulses (soyabean,
horsegram, whole Bengal gram, rajmah, cowpea, whole moong, whole urad, sprouts),
high fibre vegetables (cabbage, lotus-stem, drumstricks, beans etc.) and fruits
(guava, pineapple, apple, peaches, avocado etc.) with a lower glycemic index.
Susbtitution of cereals with pulses/vegetables (chappati prepared by using whole
wheat flour + soyaflour/ whole Bengal gram flour/ besan methi/ spinach or vegetable
idli/uttpam, pulao with sprouts etc.) can also help in lowering the glycemic response
to food. Preparations like roasted channa chappaties, sprouted dal are more
suitable than boiled rice, khichri, washed dals and fruit juices. Similarly, raw
vegetables (salads) will have a lower glycemic response as compared to their
cooked counterparts. Sipping 50 grams glucose slowly over several hours shall
produce a smaller increase in blood glucose than would a rapid intake. Box 5.2
gives a list of food stuffs with their respective glycemic index.

Box 5.2 Glycemic Index of Foods

Item Glycemic Item Glycemic
Index Index

White wheat bread 75 + 2 Apple (raw) 36 + 2

Whole wheat bread 74 + 2 Orange 43 + 3

Wheat Roti 62 + 3 Banana 51 + 3

Chappathi 52 + 4 Pineapple 59 + 8

White boiled Rice 73 + 4 Mango (raw) 51 + 5

Brown Boiled Rice 68 + 4 Watermelon (raw) 76 + 4

Barley 28 + 2 Potato (boiled) 79 + 4

81
Clinical and
Item Glycemic Item Glycemic
Therapeutic Nutrition
Index Index

Instant oat porridge 79 + 3 French Fries 63 + 5

(potato)

Rice porridge/ Congee 78 + 9 Carrots (boiled) 39 + 4

Millet porridge 67 + 5 Dairy Products

Sweet corn 52 + 5 Milk (full fat) 39 + 3

Cornflakes 81 + 6 Milk (skim) 37 + 4

Ice Cream 51 + 3

Miscellaneous Pulses

Chocolate 40 + 3 Chickpeas 28 + 9

Popcorn 65 + 5 Soya Beans 16 + 1

Soft drinks/ soda 59 + 3 Lentils 32 + 5

Honey 61 + 3

Glucose 103 + 3

Fat: Fats being concentrated sources of non-carbohydrate calories, can be given in

normal amounts i.e. 20-25% of the total energy to juvenile and adult diabetics (non-
obese) without coronary artery diseases or hypercholesterolemia. The total fat intake
should comprise of <1/3rd each from saturated and poly-unsaturated fats, whereas
the remaining >1/3 rd should come from mono-unsaturated fats. In case of
hyperlipidemic diabetics; the saturated fat intake should be <7% and the
dietary cholesterol allowance should be < 200 mg/day. However, in case of diabetics
without coronary heart disease the dietary cholesterol intake can be more liberal i.e.
300 mg/day.

Animal foods such as red meats (goat, buffalo, pork etc.) egg yolk, whole milk and
whole milk products you may recall are rich sources of cholesterol, as well as, saturated
fats. Plant foods do not contain cholesterol as such but certain plant foods such as
nuts and oilseeds being rich in saturated fatty acids can result in the elevation of
serum lipids among obese and other ‘at risk’ individuals. These should therefore be
avoided. Lean meats (marine food, chicken), curds, yoghurt and cheese (paneer)
made from skimmed milk are low in cholesterol and can be taken in recommended
amounts.

Alcohol: Alcohol intake should be discouraged because it is a concentrated source

of calories (7 Kcal/gm). This is particularly important for overweight/obese
diabetics with or without cardiac/liver/nerve complications. The calories consumed
through alcoholic drinks should be counted in the total energy intake by the patient
from carbohydrate. Wine, beer or shandy has more starch; spirits like whisky, rum,
gin are lower in carbohydrates and therefore a better choice. If consumed for social
reasons, not more than one serving should be consumed one to two times in a week.
Alcoholic beverages not only increase the risk for gastritis, liver and nerve damage;
but they also upset the timings of food thereby spoiling diabetic control. Calorie and
sodium content if some alcoholic beverages in given in Table 5.2. You may use this
information while planning diets or while counseling patients regarding use of alcoholic
beverages.
82
 Table 5.2: Calorie and sodium content of some alcoholic beverages Planning Diets for
Metabolic Diseases
Drink Calories (Kcal) Sodium (mg)
Beer, regular 41 5.3
Beer, light 28 2.8
Gin, rum, vodka, whiskey 250 trace
Table Wine, 12.2% alcohol/vol. 86 3.5
Dessert wine, 18.5% alcohol/vol. 137 3.3
Note: Alcoholic beverages are customarily served in special glassware, the size
of which tends to standardize the alcoholic content.

1 cordial glass = 20 ml 1 sherry glass = 60 ml 1 champagne glass = 150 ml

1 brandy glass = 30 ml 1 cocktail glass = 90 ml 1 tumbler = 240-360 ml
1 jigger = 45 ml 1 burgundy glass = 120 ml 1 mixing glass = 360 ml

Artificial Sweeteners: Artificial sweeteners can be consumed by diabetics as a

substitute for sugar in moderation. A sugar substitute is a food additive which duplicates
the effect of sugar in taste, but often with less food energy. Aspartame, saccharin,
acesulfame-K and cyclamate are most commonly consumed non-nutritive sweetners,
whereas, fructose and polyalcohols of sucrose, mannose and xylose (sorbitol, manitol
and xylotol) are frequently used nutritive sweetners.

Life Style and Exercise: An active scheduled life style involving regular and sustained
exercise(s) can help in improving glycemic control. An active life style and regular
exercise helps in:

 preventing sharp increase in the post-prandial blood glucose levels,

 enhancing insulin sensitivity,
 helping in weight management,
 reducing the dependence/requirement of drugs/insulin,
 improving muscle mass, and
 reducing the risk of constipation, heart disease etc.

As a dietitian, we may need to check the exercise schedule of our patients carefully.
Depending on the type, duration/severity of exercise changes may need to be made in
the amount/type/distribution of carbohydrates. For instance, a 20 minutes walk may
not need any additional carbohydrate unless it is immediately prior to a scheduled
meal. However, a short session of vigorous exercise (badminton, volleyball, football)
may necessitate 10-20 gram carbohydrate beforehand. Similarly, rapidly absorbed
carbohydrate (glucose drink/tablets, small chocolate bar) may be necessary before a
burst of intense activity, whereas, more slowly absorbed carbohydrates (sandwich,
biscuits) may be appropriate for sustained exercises. Dietitians must effectively counsel
school going children and adolescents to take their meals/snack before their games
period/exercise.

Having discussed the various aspects of dietary management for diabetics in association
with lifestyle and drugs, let us now translate the above information in terms of practical
tips that can be utilized during patient counseling. As we all know that effective
counseling can help the patient in adhering to self-discipline which plays a crucial role
in maintaining a good glycemic control and is critical towards the prognosis of diabetes
(delaying the onset/severity of complications).

83
Clinical and Here are a few useful tips. You may add or modify these points according to the
Therapeutic Nutrition individual requirements of the patient.
Handy Tips Related to Diet for the Diabetics
 Whole grain cereals (wheat, jowar, bajra, ragi), whole grain cereal flours, sprouted
cereals, bread prepared by using whole wheat flour, cracked wheat, wheat bran
should be preferred over low fibre cereals such as rice, chirwa, suji, refined
wheat flour (maida), arrowroot, sago and their products such as vermicelli, pastas,
bread/biscuits/bakery products/kulchas etc.

 Foods rich in SFA’s i.e. butter, cream, margarine, pure ghee, egg yolk and animal
fat should be completely avoided. Emphasis should be laid on the use of vegetable
oils rich in PUFA’s, MUFA’s such as olive, safflower, rice bran, corn, cottonseed
oil etc.

 It is a good option to keep changing oils used for cooking. For instance, olive,
safflower, corn and rice-bran oil may be used interchangeably over a period of 6
months.

 Fried foods should be consumed in restricted amounts.

 Margarine, several spreads/bread-spreads are prepared by using hydrogenated

fat and should therefore be avoided. Bakery products (Patties, cookies, biscuits),
kachori or mathri is more “khasta” it would contain a higher amount of
hydrogenated fat (vanaspati)/oil.

 Food should preferably be cooked by dry heat methods (roasting, sautéing, grilling,
baking, micro-wave). Moist heat methods (boiling, simmering) should be avoided
as far as possible. Non-stick cookware helps in reducing the amount of fat used
for cooking and can be helpful particularly for obese and/or hypercholesterolemic
diabetics.

 Roasted channas/soyabean/Bengal gram dal, soya and wheat puffs mixed with
oat/wheat flakes are good ready-to-eat snacks.

 Whole pulses (soyabean, cowpea, rajmah, whole moong, whole urad, whole Bengal
gram, horse gram), legumes, sprouts and whole pulse flour (whole Bengal gram
flour, soya flour, whole moong flours as a substitute for cereals) should be preferred
over de-husked washed pulses (“dhuli dal”) such as arhar, washed moong/masoor/
urad.

 Tubers and starchy vegetables such as potato, yam, colocasia sweet potato should
be avoided.
 Skimmed/low-fat and skim milk products such as curd, yoghurt, paneer should
be preferred particularly by adult and obese diabetics.
 Lean meats such as poultry (chicken, egg white), fish should be preferred over
red meals (goat, buffalo, cow, pork) and egg yolk.
 High fibre and/ or low calorie vegetables should be preferred such as amla,
cabbage, drumstick, raddish, cucumber, lotus-stem, beans, ladyfinger, tinda, bitter
gourd (karela) and leafy vegetables (amaranth, lettuce, fenugreek, mustard) should
be consumed liberally.
 High fibre and/or low calorie fruits such as apple, guava, pineapple, raspberries,
musk melon, water melon, pear, bael should be preferred over mango, banana,
grapes etc.
 It is advisable to consume plenty of raw vegetables especially in the form of
salads (with sprouted cereals/pulses) before meals and along with their edible
84 peels wherever feasible.
 Raw, whole fruits (1-2 servings per day) should preferably be consumed with Planning Diets for
Metabolic Diseases
their edible peels.
 Idlis, poha, dalia, uttapam, dhokla prepared by incorporating sprouted pulses/
legumes and plenty of vegetables are nutritious evening snacks.
 If the patient is hypertensive; restrictions may be required in the use of cooking/
table salt. Pickles, chutneys, preserves, baked items, canned food and salted
snacks should also be avoided.
 Lemon water, zeera pani, kanji, lemon tea, tea, butter milk (lassi) are better
options over fruit juices, fruit drinks and soft-drinks (colas etc.).
 The fibre intake can be increased by using commercially available sources of
fibre such as guar-gum (obtained from seeds of cluster bean), Xanthum gum,
neem bark/leaves powder, husk/bran of cereals/pulses and edible peels of raw
fruits/vegetables.
Handy Tips Related to Meal Pattern
 As a thumb rule, diabetics should avoid both feasting and fasting.
 A fixed meal pattern should be followed and meals should be consumed within
½ to 1 hour of taking hypoglycemic drugs/ short-acting insulin (refer to Box 5.3
for more information regarding food intake with respect to insulin type).
Box 5.3 Food Intake with respect to Insulin Type

Type Action Starts Duration of Critical Meal

Action Tmings

Humalog 5 min ½ - 2 hrs Immediately or before

Plain/regular ½ hr 2 - 4 hrs Within ½ hr
NPH ½ hr 4 - 12 hrs 1 hr, 9th to 10th hr
st

Lente ½ hr 4 - 16 /hrs 1½hr to 2nd hr, 5th to

6th hr, 10th to 12th hr
Ultralente 4 hrs 6 - 24 hrs 4th hr, before bedtime

 Also distribution of carbohydrates according to type of insulin should be considered

while planning diet which is shown in Table 5.3 below:
Table 5.3: Distribution of Contribution of Carbohydrates according to type of
insulin

Mode of Breakfast Lunch Tea Dinner Bedtime

Treatment
None or Oral 1/3 1/3 20-30 g 1/3 None
Short acting insulin 2/5 1/5 - 2/5 None
(At Breakfast and Dinner)
Intermediate 1/7 2/7 1/7 2/7 1/7
(NPH/Lente)
Long acting + regular 1/5 2/5 - 2/5 20-40 g CHO
Long acting + regular 1/3 1/3 - 1/3 20-40 g CHO
insulin (At breakfast)
Intermediate + regular for 2/10 + 2/10 1/10 3/10 1/10
Type 1 Diabetes 1/10
during mid
morning
85
Clinical and  Exercise should always be after a meal and in case of vigorous sports/games, a
Therapeutic Nutrition small snack may be consumed to avoid hypoglycemia.
 Food should be consumed in normal quantity during common illness such as
diarrhoea/vomitting or fever. However, the blood glucose levels may rise
unexpectedly. Therefore, it is recommended to check blood glucose every 4-6
hours and take small amounts of short-acting insulin/drugs accordingly. To avoid
hyperglycemic shock (coma) the patients should also be advised to check urine
for ketones (with Gluketur strips).
 Diabetics who habitually smoke or drink alcohol have higher frequency of
morbidity and mortality particularly due to cardiac complications. If alcoholic
drinks need to be taken for social reasons, it is advised to take a small diluted
drink and sip it slowly over a period of 30-45 minutes atleast.
 Diabetics can occasionally consume fast-foods. The former or the subsequent
meal must comprise of a liberal serving of raw vegetables and sprouted legumes,
as well as, plenty of fluids preferably plain water.
 White consuming meals in a social gatherings (parties, marriage conference
etc.); an attempt should be made to choose low calorie foods. Guide the patient
to take liberal amount of salads, yoghurt/curd preparations and small amounts of
cereal preparations. Avoid fried and sweet high carbohydrate foods such as
pastries, ice-cream, gulabjamun, halwas, potato cutlets, samosas. Do not miss
the insulin/drug before going to such gatherings.
A sample menu for a non insulin dependent diabetic patient is given for your reference
herewith.

Sample Menu for a non insulin Dependent Diabetic

Early Morning Breakfast

High fibre cracked wheat biscuits Egg white/chicken /paneer preparation

Tea or Warm water with Lemon Oat meal/ bran porridge (S.milk)
Toast/cheela/chappati
Guava/pineapple

Evening Tea Lunch/Dinner

Tea or coffee or lassi or soya milk Salad with sprouts (whole moong,
Vegetable dalia channa, rajmah etc.)
or Mixed vegetable (cabbage, ladyfinger,
Sprouted Channa/wheat brinjal etc.)
Whole pulse
After Dinner Chappati (wheat flour substituted with
soya flour, whole Bengal gram flour)
Bajra kheer or cracked wheat Raita/plain curds cone meal)
pudding. Fruit (in one meal)

With a sample menu for NIDDM we end our study on the dietary management of
diabetes mellitus. Next, we move on to gout.

5.4 PRINCIPLES OF DIETARY MANAGEMENT

GOUT
Dietary management is an important aspect of treatment during symptom free periods
of gout and is intended to minimize urate deposition in tissues, which causes chronic
tophaceous arthritis, and to reduce the frequency and severity of reoccurrences. The
objectives of dietary management are highlighted next.
86
Objectives: Planning Diets for
Metabolic Diseases
 to reduce the serum uric acid levels (< 5 mg/dl),
 to help in achieving and maintaining an Ideal Body Weight,
 to maintain an optimum nutritional status, and
 to prevent subsequent episodes of gout.
Let us recapitulate the nutrient requirements next.
Energy: Several epidemiological studies indicate that patients with gout have a higher
frequency of obesity, and some of the correlates of obesity, such as diabetes,
hypertension and ischemic heart disease, occur with a greater frequency with a
subsequent increase in body weight; particularly when the body weight increases by
30% and above IBW. Thus, overweight/obese patients should be prescribed a weight
reduction diet. A reduction in the energy intake by 500 Kcal/ day can help in reducing
500 grams of body weight in a week.
As has been discussed earlier, we can compute the modified energy intake for an
adult sedentary man/woman by using the following formula:
IBW (Men) = 48 kg for first 5 feet + 2.7 kg for each additional inch
IBW (Women) = 45.5 kg for first 5 feet + 2.3 kg for each additional inch ( + 10% for
build)
Using this IBW, we can calculate the energy requirements for the patient as follows:
Energy intake for 24 hrs.= 20-25 Kcal/kg/IBW i.e. 20-25 Kcal  IBW
Protein: A high protein diet, particularly animal products have been found to be closely
associated with a greater incidence of gout. Although the contribution of dietary
purines to uric acid production is only small, regular or excessive consumption of
purine rich foods (typically those rich in cell nuclei such as yeast rich foods or fish
roes) has an impact on the total uric acid pool. Thus, foods particularly high in purines,
such as sweet breads, fish roe, anchovies, sardines, liver and kidney should be
completely avoided, foods moderately rich in purines such as animal meats, seafoods,
beans, lentils, spinach and peas should be consumed in moderate amounts whereas,
low purine foods such as cheese, eggs, fat, fruits, vegetables, nuts, milk, refined, cereals
and certain beverages (tea, coffee) can be consumed liberally. Box 5.4 presents a list
of high purine and low purine foods for your reference.
Box 5.4 The Purine Content of Foods
Low-Purine Foods
 Refined cereals and cereal products, cornflakes, white bread, pasta, flour,
arrowroot, sago, tapioca, cakes
 Milk, milk products and eggs
 Sugar, sweets and gelatin
 Butter, polyunsaturated margarine and all other fats
 Fruit, nuts and peanut butter
 Lettuce, tomatoes and green vegetables
 Cream soups made with low-purine vegetables but without meat or meat
stock.
 Water, fruit juice, cordials and carbonated drinks
High Purine Foods
 All meats, including organ meats and sea food
 Meat extracts and gravies
 Yeast and yeast extracts, beer and other alcoholic beverages
 Beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower and 87
mushrooms.
Clinical and Carbohydrate: The amount of carbohydrate to be provided in the diet remains the
Therapeutic Nutrition same as for normal individuals. However, emphasis should be laid on the inclusion of
high fibre foods such as whole pulses/legumes, cabbage, carrots, drumstick, jackfruit,
lotus-stem, apple, guava etc; especially if the person is overweight/obese.
Fat: The quantity and quality of fat remains the same as for normal individuals. However,
if the patient is overweight, obese or is at risk of heart disease; the diet should not
provide more than 20% of the total energy from fat. Emphasis should be laid on the
inclusion of vegetable oils high in MUFA/PUFA’s such as soyabean, seasame, olive,
rice bran oil.
Alcohol: Excessive alcohol consumption has been associated with gout for centuries,
although it is less certain whether this is a direct effect of alcohol pe se, or an indirect
effect of either the high purine content of some types of alcohol (particularly beer) or
the contribution of alcohol to excessive energy intake and obesity. Alcoholic beverages
particularly beer (light/regular/root) being high in purines, calories and sodium should
be completely restricted.
Fluids: In order to lessen the risk of crystallization of urate in the urine, particularly if
uricosuric drugs are used, it is important that patients consume sufficient fluid, possibly
as much as 3.0–3.5 litres/day.

A sample menu for a gout patient is given herewith for your reference.
Sample Menu for a Gout Patient
Early Morning Breakfast
Tea/ Warm Water with lemon Cracked Wheat Porridge
Wheat bran biscuits Poha
Guava/Water Melon
Lunch/Dinner Evening Tea
Salad (cucumber, raddish etc.) Tea
Curd/Raita Paneer-tomato sandwich or
Pulse preparation (Urad/ Whole moong dal) Puffed wheat and roasted channa
Vegetable preparation (Carrots, egg plant, dal and lotus stem mix.
ladyfinger, lotus stem etc.)
Chappati (wheat flour + fenugreek/
Bengal gram flour etc.)
So far we have discussed about the important aspects of diet planning and life-style
modifications during the metabolic diseases. You should now make an attempt to answer
the questions mentioned in review exercises and self-check your progress. If you are
able to complete the exercise satisfactorily; proceed ahead and carry out the three
activities given herewith. Through these activities you will learn how to plan diet(s) for
88 patients suffering from diabetes mellitus and gout.
 Planning Diets for
5.5 REVIEW EXERCISES Metabolic Diseases

1) What do you understand by the term GLYCEMIC INDEX of food? How can
we calculate glycemic index of food?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
2) Why do the requirements for proteins increase slightly during diabetes?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) Give five useful tips to Sunil who is a diabetic pertaining to food selection and
intake during an office party.
1)
2)
3)
4)
5)
4) What are purines? What is their contribution to the total uric acid pool in the
body?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
5) What is the association between fluid intake and uric acid pool in the body/
hyperuricemia?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
6) Calculate the Ideal Body Weight of Mrs. Gupta, a housewife who is 5’3” tall.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
7) Enlist any five food stuffs which are very rich sources of purine.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Now carry out the activities included in this practical.
89
Clinical and
ACTIVITY
Therapeutic Nutrition

1 DIET PLAN FOR NON-INSULIN DEPENDENT

DIABETES MELLITUS (NIDDM)
Aim : To plan a diet for a non insulin dependent diabetic patient.
Date :
Case Study : Mr. Khanna is a busy office executive who was diagnosed to be
suffering from NIDDM about three years back. Over the past
3 years he has experience several episodes of hyper and hypo-
glycemia. He is 5’7” tall and weighs 93 kgs. He is fond of non-
vegetarian foods and has to socialize a lot as part of his work. At
present he is on drugs glipizide 10 mg B.D. and Repaglinide 1.0 mg
O.D. (15 minutes before breakfast). His major clinical parameters
are:
Blood Glucose (F) 198 mg/dl
Blood Glucose (P.P.) 418 mg/dl
Glycosylated Haemoglobin (HbA1c) 8.6 %
Blood pH < 7.3
Serum bicarbonates < 15 meq/L
Plasma acetone 4+
Serum Triglycerides 280 mg/dl
Total cholesterol 217 mg/dl
Systolic Blood Pressure 104 mmHg
Diastolic Blood Pressure 65 mmHg

He has been advised to get involved in a regular physical exercise schedule and
adhere to meal and medication timings. His case has been forwarded to a dietitian,
for effective dietary management of his disease condition. Based on your understanding
of diabetes carry out the following exercises in this activity.

a) Enumerate the patient profile.

b) Prioritize and enlist the various objectives of his treatment and management.

c) Compare his clinical parameters with normal values.

d) With respect to his anthropometrics and biochemical parameters, calculate his

modified RDA.

e) Plan a day’s diet for him and calculate carbohydrate, crude fibre, cholesterol and
sodium for the detailed menu plan.

f) As a dietitian, enlist the various points that should be remembered for patient
counseling regarding:

 diet and meal pattern

 exercise and life-style
 managing social life.

Begin the activity by first presenting a brief review on diabetes mellitus in the
introduction section.
90
Introduction Planning Diets for
Metabolic Diseases
(Present a brief write-up on what is diabetes and its types with special reference to non insulin
dependent diabetes).

Step I : Patient’s Profile

(Write the profile of the patient as per the format given herewith)

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:
Patient weight (Present):
Patients Ideal Body weight:
Medical problems:

Nutritional problems (if any):

Step II
Assess/calculate the nutritional needs of Mr. Khanna and compare them with the RDI for a
healthy adult man (refer to Table 1.1 in Pactical 1) in the format given herewith:
Recommended Dietary Intake
Nutrients Normal Modified
Energy
Protein
Carbohydrate
Cholesterol
Fat
Crude Fibre
Dietary Fibre
91
Clinical and Note: Points that may help you in calculating the dietary requirements and planning the diet
Therapeutic Nutrition are highlighted herewith.
1) First calculate the ideal body weight (IBW) of the patient using the formula given herewith.
48 kg for first 5 feet + 2.7 kg for each additional inch
i.e. 48 kg + 2.7  7 = ……… kg (IBW)
The value obtained for IBW can then be employed for calculating the energy requirements of
Mr. Khanna (to help him in reducing his excess body weight). Energy requirements for an
adult sedentary man can be calculated as follows:
20 - 25 Kcal/ kg IBW/ day
Note: Since the patient is overweight/obese, his calorie intake should be restricted.
Step III: Based upon the modified RDI, carefully select the food exchanges
most suitable for Mr. Khanna.
Exchange No. Energy Protein Carbohydrate Fat
(Kcal) (g) (g) (g)
Milk*
Meat
Pulse
Cereals
Roots/Tubers
Other vegetables
GLV
Fruit
Fat (Oil)
Total
*preferably skimmed
Hint: Foods rich in complex carbohydrates, particularly dietary fibre (soluble) should be
included in the diet. Carbohydrate content of the exchanges should be calculated.
Step IV: Distribute the above selected exchanges
Distribute the exchanges keeping in mind the following :
 Meal (5-6 meal pattern may be followed)
 Medications
 Amount of carbohydrates to be provided in each meal (1/3 rd ).
Now distribute the exchanges in the format given herewith.
Exchange Early Breakfast Mid Lunch Evening Dinner Bedtime
Morning -Morning Tea

No. CHO(g) No. CHO(g) No. CHO(g) No. CHO(g) No. CHO(g) No. CHO(g) No. CHO(g)
Milk
Meat
Pulses
Cereals
Other
Vegetables
GLV
Fruit
Fat
Total CHO
CHO : Carbohydrates
92
Check: The sum total of carbohydrate in Breakfast + Evening Tea = 1/3 rd of the total Planning Diets for
Metabolic Diseases
carbohydrate being provided through the exchange plan. Similarly, carbohydrate being
provided in Lunch+ Early morning = 1/3rd of total carbohydrate. And carbohydrate
being provided in Dinner + Bed Time = 1/3rd of total CHO. Further, the Grand Total
for carbohydrates being provided through each meal should be equal to the amount of
carbohydrate computed in the exchange plan (selection of exchanges) in Step III.

Step V: Plan a menu

Using the exchanges available for each meal, prepare a menu (in the format given herewith) by
selecting the food-stuffs most appropriate for NIDDM patients with elevated lipids. You may
like to refer to the sample menu given earlier in sub-section 5.3.1 for planning the menu here for
Mr. Khanna.

Menu for a Day

Early Morning Breakfast

Lunch Evening Tea

Dinner After Dinner

Note: Choice of foodstuffs, pre-preparation and cooking methods should be such as to keep
the glycemic index the lowest. 93
Clinical and Step VI: Detailed menu plan
Therapeutic Nutrition
Calculate the energy, protein and other nutrient content of the diet in the format given
herewith.

Meal Menu Ingredients Amt Exch- Energy Protein CHO Fat Fibre
(g) ange (Kcal) (g) (g) (g) (g)

Total

Note : The sum total of carbohydrate of the detailed menu plan should be equal ( + 05%) to carbohydrate calculated in the
exchange plan. Supplements of dietary fibre/soluble fibre can be added to the dishes to increase the fibre content of the
diet. Guar-Gum, neem bark powder, bitter gourd powder, pectin, bran can be easily incorporated in the chappati/dishes.

94
Patient Counseling Planning Diets for
Metabolic Diseases
In this section, write down some handy tips related to diet and meal pattern and life
style which you would advocate for Mr. Khanna.
Diet and Meal Pattern
(Enlist points pertaining to selection of food stuffs, substitution/choices, more appropriate
methods of cooking food labels, meal pattern w.r.t medications).

Exercise and Life Style

(Househeld chores, preference for stairs over elevators, meal and exercise, duration
and type of exercise).

Managing Social Life

(Correct choice of food-stuffs (quantity and quality) and beverages, snack substitution
for meals, medications and meals consumed during socialization).

Conclusions
Compare the grand total obtained for various nutrients in the detailed menu plan with
the computed modified RDI and interpret as follows:

Nutrient Modified RDI Detailed Diet + % of Suggestions for

Plan Difference Improved Intake

Energy (Kcal)
Protein (g)
CHO (g)
Fat (g)
Fibre (g)

Submit the activity for evaluation.

——————————
Counselor’s Signature

95
Clinical and
ACTIVITY
Therapeutic Nutrition

2 DIET PLAN FOR INSULIN DEPENDENT DIABETES

MELLITUS (IDDM)

Date : Aim : To plan a diet for a non insulin dependent diabetic patient.
Case Study : Shweta is a 11 year old school student suffering from IDDM for the
past 6 years. She commutes to school and back home by school bus
and her school timings are 8.30 a.m. to 1.30 p.m. She has a games
period everyday at around 10.30 –11.00 a.m. and is fond of outdoor
sports. She likes to indulge in fast food and has the habit of nibbling
particularly late in the evening. She has suffered from hypoglycemic
shocks several times in the school and has been prescribed to take a
combination of intermediate and depot insulin in the morning before
going to school. Her average (6 months) fasting and post-prandial
blood glucose levels have been 75 mg/dl and 220 mg/dl, respectively.
She has been advised to take wholesome snacks/ meals as her tiffin
to the school and avoid taking food from the canteen. Shweta’s
meal timmings as suggested by the Dietitian are:
Breakfast : 7:30-8:00 a.m.
Short break (school) : 10.15–10.30 a.m.
Long-break: 12.0012.20 p.m.
Lunch : 2.15 p.m.
Evening tea: 4.00 p.m.
Dinner : 7.30 p.m.
Bed Time: 10.00 p.m.
Now with this basic information, plan a diet for Shweta. Start the activity by first
presenting a brief review on diabetes mellitus in the introduction section herewith.

Introduction
(On the basis of the details mentioned in the case and your understanding about IDDM, briefly
describe this metabolic disorder and enumerate the major objectives of dietary management in
terms of their priority).

96
Step I: Read the case carefully and mention the details of the patient in the formal given Planning Diets for
below: Metabolic Diseases
Patient/Case Profile:
Name: Age:
Gender: Activity:
Dietary habits: Socio-economic status:
Patient weight (Present): Patients Ideal Body weight:
Medical problems:

Nutritional problems (if any):

Clinical Profile
Patient value Normal Value
Blood Glucose (Fasting)
Blood glucose (Post Prandial)
Step II: Keeping in mind the case details assess/calculate the nutritional needs of Shweta
and compare them with the RDI for a healthy child (refer to Table 1.1 in Practical 1).

Recommended Dietary Intake

Nutrients Normal Modified
Energy (Kcal)
Protein (g)
Carbohydrates (g)
Fat (g)
Dietary Fibre (g)
Iron (mg)
Calcium (mg)

Calculations: (Write the calculations for deriving the calorie and protein requirement
in the space provided herewith).
Step III: Based upon the modified RDI, carefully select the food exchanges most suitable
for a school going diabetic child.

Exchange No. Energy Protein Carbohydrate Fat

(Kcal) (g) (g) (g)
Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetable
GLV
Fruit
Fat
Sugar
Total 97
Clinical and Step IV: Distribute the above selected exchanges
Therapeutic Nutrition
Distribute the exchanges keeping in mind the following points:
 School timings
 Meal timings
 Peak and tapering action of insulin
 Carbohydrate distribution for each meal
 Activity pattern
Write the exchanges in the format given herewith.

Exchange Early Morning Breakfast Lunch Evening Dinner Bedtime

No. CHO No. CHO No. CHO No. CHO No. CHO No. CHO
(g) (g) (g) (g) (g) (g)
Milk
Meat
Pulses
Cereals
Roots/Tubers
Other
Vegetable
GLV
Fruit
Fat
Total
Check: As mentioned for the diet plan of NIDDM, the sum total of carbohydrate for all the meals should be equal to the carbohydrate
calculated through the selection of various food exchanges (Step III). The amount of carbohydrate provided through distribution
of exchanges for each meal should be equal to stipulated amount. For example, if we want to provide 1/7 th of the total
carbohydrate for evening tea; then the distribution of exchanges should be such that they provide only 1/7 th of the total
carbohydrate.

Step V: Using the exchanges available for each meal, prepare a menu for selecting the food-
stuffs most appropriate for insulin dependent diabetic children going to school.

A Day’s Menu for Shweta

98
Step VI: Detailed menu plan Planning Diets for
Metabolic Diseases
Calculate the energy, protein and other nutrient content of the diet in the format given
herewith.

Meal Menu Ingredients Amt Exch- Energy Protein CHO Fat Fibre
(g) ange (Kcal) (g) (g) (g) (g)

Total

99
Clinical and Step VII: Patient Counseling
Therapeutic Nutrition
Enlist handy tips for Shweta regarding food choices, meal pattern with respect to school
timings, games period and activity pattern in the space provided herewith.

Enlist the suggestions you would give to Shweta and her mother regarding diet and
meal pattern during weekends, holidays and vacations in the space provided herewith.

Conclusions
Compare the grand total obtained for various nutrients in the detailed menu plan with
the computed modified RDI and interpret as follows:

Nutrient Modified RDI Amount + % of Suggestions for

Diet Plan Difference Improved Intake

Energy (Kcal)
Protein (g)
Crude Fibre (g)
Dietary Fibre (g)
Iron (mg)
Vitamin A (I.U.)

Submit the activity for evaluation.

———————————
100 Counselor’s Signature
 Planning Diets for

EXERCISE Metabolic Diseases

3 DIET PLAN FOR GOUT

Aim : To plan a diet for a patient suffering from gout.
Date :
Case Study : Mr. Sen is a 49 year old shopkeeper. His height is 5^7^^ and he weighs
72 kgs. He is a chronic alcoholic and is fond of non-vegetarian foods.
He is an old case of gouty arthritis and has suffered from several
acute attacks over the past 6 years. He was admitted to the hospital
complaining of acute pain and swelling in the big toes. At present, he
is in the remission phase and his clinical parameters are as follows:
Serum uric acid: 8.9 mg/dl
Erythrocyte Sedimentation Rate: 16.7 mm/hr
White cell count: 12.1 103 l
He has been prescribed to take attopurinal 300 mg/day in order to help in maintaining
serum uric acid and lends within the normal range. He has also been adviced to
consult a Dietitian to manage his condition.
Now, based upon your understanding of the disease condition carry out this activity
and plan a diet for Mr. Sen. Begin by presenting an overview of the gout disease in the
introduction section.

Introduction
Briefly describe the clinical conditions mentioned in the case and enlist atleast three
characteristic features for the same, in the space provided herewith:

101
Clinical and Step I: Read the case carefully and write the patient profile as per the format given below:
Therapeutic Nutrition
Patient/Case Profile:
Name: Socio-economic status:
Age: Pathophysiological stress:
Gender:
Activity:
Dietary habits:

Diet prescribed:
Compare the clinical parameters of the patient with normal values in order to
ascertain the severity of the disease.
Clinical Profile
Patient Value Normal Value
Uric acid (Serum)
E.S.R.
W.B.C.Count

Step II: Assess/Calculate the nutritional needs

Keeping in mind the disease condition and case profiles; assess/calculate the nutritional needs
of Mr. Sen and compare them with the RDI for a healthy adult man (sedentary). Record your
answer in the format given herewith.

Recommended Dietary Intake

Nutrients Normal Modified
Energy (Kcal)
Protein
Carbohydrates
Fat
Fluids
Calculations: (write the calculations for deriving at the energy and protein requirements in
the space provided herewith).

Note: We need to calculate the IBW for Mr. Sen in order to compute his energy requirements
for weight reduction. The IBW can be calculated using the formula:

48 kg for first 5 feet + 2.7 kg for each additional inch

Energy requirements for an adult sedentary man can be calculated as follows:

20 - 25 Kcal/ kg IBW/ day

102
Step III: Select the food exchanges Planning Diets for
Metabolic Diseases
Based upon the modified RDI, carefully select the food exchanges most suitable for Mr. Sen.
Write the exchanges in the format given herewith.

Exchange No. Energy Protein Carbohydrate Fat

(Kcal) (g) (g) (g)
Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetables
GLV
Fruit
Fat (oil)
Sugar
Step IV: Distribute the exchanges for the most suitable meal pattern
Write the distribution of exchanges in the format given herewith. (Hint: You may provide a
5 meals/day pattern).

Exchange Early Breakfast Lunch Evening Dinner

Morning Tea
Milk
Meat
Pulses
Cereals
Roots/Tubers
Other Vegetables
GLV
Fruit
Fat
Sugar

Step V: Plan a menu

Using the exchanges available for each meal, prepare a menu by selecting the food-stuffs
most appropriate for gout and overweight/obese patients. (Hint: Include plenty of low-
calorie beverages and low/no purine foodstuffs).
Menu for Mr. Sen
Early Morning Breakfast Lunch Evening Tea Dinner

103
Clinical and Step VI: Detailed menu plan
Therapeutic Nutrition
Calculate the energy, protein and other nutrient content of the diet in the format given
herewith.

Meal Menu Ingredients Amt Exch- Energy Protein Fibre Sodium Fluid
(g) ange (Kcal) (g) (g) (g) (g)

Total

104
Conclusions Planning Diets for
Metabolic Diseases
Compare the grand total obtained for various nutrients in the detailed menu plan with
the computed modified RDI and interpret as follows:

Nutrient Modified RDI Amount + % of Suggestions for

Diet Plan Difference Improved Intake

Energy (Kcal)

Protein (g)

Fibre (g)

Sodium

Submit the activity for evaluation.

——————————
Counselor’s Signature

105
Clinical and
Therapeutic Nutrition PRACTICAL 6 NUTRITIONAL
MANAGEMENT OF
GASTROINTESTINAL
DISORDERS
Structure
6.1 Introduction
6.2 Peptic Ulcers
6.2.1 Pathophysiology
6.2.2 Principles of Dietary Management

6.3 Ulcerative Colitis

6.3.1 Pathophysiology
6.3.2 Principles of Dietary Management

6.4 Lactose Intolerance

6.5 Review Exercises
Activity 1: Diet Plan for Peptic Ulcer
Activity 2: Diet Plan for Ulcerative Colitis
Activity 3: Diet Plan for Lactose Intolerance

6.1 INTRODUCTION
Disorders of the gastrointestinal tract encompass a wide range of diseases which may
be as mild and ubiquitous in prevalence such as dyspepsia, gastritis, nausea, vomitting,
diarrhoea to not so frequent in occurrence such as carcinomas, inflammatory bowel
disorders, lactose intolerance, gluten enteropathy etc. The dietary management of
some of the disorders can be as simple as modification in consistency to as complex
as elimination of certain nutrient or providing elemental/ hydrolyzed formulas. Diseases
such as peptic ulcers can be life threatening whereas; diseases such as ulcerative
colitis can progress towards the development of carcinomas (requiring surgery). In
this unit we shall learn and practice the dietary management of peptic ulcers and
ulcerative colitis. Let us first begin with their pathophysiology and the impact of the
disease condition on the nutritional status of the patient. Before we begin, we suggest
you look up Unit 6 in the Applied Physiology Course (MFN-001) to revise the physiology
of the gastrointestinal system. Also review Unit 14 in the Clinical and Therapeutic
Nutrition Course (MFN-005) to recapitulate the causes, important signs and symptoms
and the dietary management of peptic ulcer and ulcerative colitis.

Objectives

After undertaking this practical, you will be able to:

 discuss few disorders linked with the gastrointestinal tract,

 describe the principles of dietary management for peptic ulcer and ulcerative
colitis, and lactose intolerance, and

 plan diets for individuals suffering from these disorders i.e. peptic ulcer, ulcerative
colitis and lactose intolerance.
106
 Nutritional Management
6.2 PEPTIC ULCERS of Gastrointestinal
Disor ders

Peptic ulcer, you may be aware by now, is any localized erosion or a break in the
gastric/duodenal mucosa that arises when the normal mucosal defensive factors are
impaired or are overwhelmed by aggressive luminal factors such as acid and pepsin.
Let us first review the pathophysiology of peptic ulcers followed by the principles of
dietary management.

6.2.1 Pathophysiology
Ulcers may develop in the stomach/jejunum (gastric ulcers) or /and in the duodenum
(duodenal ulcers). Let us review these conditions.
Gastric Ulcers occur most frequently along the lesser curvature of the stomach.
Look up Figure 6.8 in Unit 6 in the Applied Physiology Course (MFN-001) which
illustrates the stomach. Gastric ulcers are associated with gastritis, inflammatory
involvement of the oxyntic (acid producing) cells and atrophy of the acid and pepsin-
producing cells with advancing age. Morbidity and mortality are higher among gastric
ulcers due to haemorrhages as compared to in duodenal ulcers.
Duodenal Ulcers generally occur within the first few centimeters of the duodenal
bulb, in an area immediately below the pylorus. They are characterized by increased
acid secretion particularly nocturnal acid secretion and decreased bicarbonate secretion.
The major causes of ulcers are:
 Chronic infection of helicobacter pylori
 Consumption of hypersecretory agents such as non-steroidal anti-inflammatory
drugs
 Alcohol, tobacco consumption and cigarette smoking
 Tea, coffee, spices
 Physical/emotional stress
The sign and symptoms which may adversely affect the nutritional status of patients
suffering from ulcers include:
 Epigastric pain which is frequently described as gnawing, dull, aching or “hunger-
like”
 Nocturnal pain
 Nausea, anorexia, dyspepsia
 Gastrointestinal haemorrhage (melena)
 Weight loss
Symptoms of ulcers are characterized by rhythmicity and periodicity. Approximately
half of the patients report relief of pain with food or antacids (especially duodenal
ulcers) and a recurrence of pain 2-4 hours later. This is an important factor which
must be taken into consideration while deciding the meal timings and frequency for
the patient.
The treatment of the problem is based on:
 Alleviation of the underlying cause,
 Drugs (anti secreatory, enhance mucosal defense),
 Providing relief from symptoms/complications, and
 Dietary management to promote a good nutritional status.
In the subsequent sub-section we shall learn about the essentials of dietary management
during the various stages of peptic ulcers and also for the successful management of
complications that may arise as a result of gastric surgery performed for the treatment
of complicated cases of peptic ulcers. 107
Clinical and 6.2.2 Principles of Dietary Management
Therapeutic Nutrition
The dietary management regime of peptic ulcers has witnessed several changes.
The most popular conservative diet therapy was the Sippy’s diet wherein 6 small 1-2
hourly feedings comprising of mainly cream and milk were given to the patient.
However, this resulted in the elicitation of nutritional disorders such as
hypercholesterolemia, scurvy, alkalosis and tetany (Milk-Alkali Syndrome) to name a
few. At present we are following a more liberal approach which was initiated by
Meulen Gracht. We shall now discuss in detail the various aspects of dietary
management for peptic ulcers. However, let us first identify the objectives of nutritional
care for a peptic ulcer patient.

Objectives
The objectives of nutritional care for a peptic ulcer patient include:
 to prevent further erosion and promote healing of the mucosal lining,
 to maintain an optimum pH in the alimentary tract,
 to coordinate acid secretion with food intake, and
 to correct nutritional deficiencies and promote a good nutritional status.

In light of the above mentioned objectives we shall discuss the requirements for various
nutrients. We will first discuss the energy needs for the patient.

Energy : The requirements for energy should be based upon the existing health status
of the patient. Majority of the patients are malnourished due to abdominal pain
associated with food intake and to poor digestion/absorption. Thus, if the patient is
ambulatory; it is recommended to increase the energy intake by about 10%. However,
in case of hospitalized (bed-rest) patients; normal energy intake (as per RDI) would
suffice for the extra needs. Providing 35 Kcal/kg IBW to promote weight gain may
not be feasible during the active phase. This is generally recommended during the
recovery stage (latent).

Let us now learn how to provide the recommended energy through various
macronutrients viz. proteins, fats and carbohydrates.

Proteins: The protein intake should be increased by about 25% to 50% above the
RDI. Proteins should be increased to:

 promote synthesis of new tissues and thus healing of eroded mucosa,

 replenish the blood proteins lost due to gastrointestinal bleeding, and

 provide buffering effect – since proteins have a longer intestinal transit time than
carbohydrates.

High biological value proteins, which are at the same time easy to digest, should be
provided. While eggs and washed pulses can be included liberally; meat and milk
should be given in moderation (since calcium present in milk and meat stimulate acid
secretion). Whole pulses and legumes, if given, should be in a soft cooked/ blended or
pureed form (boiled, fermented, sprouted and steamed etc.). Protein supplements
such as complan, casilan, Pro Mode, threptin biscuits may be included in the menus.
Sprouts/dal khichdi, uttapam, idly, egg nog, soufflé, baked custard, puddings, poached/
boiled egg, porridge, baked/steamed chicken/fish etc. (small serving) can be given to
patient.

Carbohydrates: Nearly 60% of the total energy should be provided from carbohydrates
to ensure maintenance of body weight and to ensure spairing of proteins for tissue
synthesis. However, emphasis should be laid on foods rich in mono/disaccharides
108
and/or starches. The intake of dietary fibre, particularly insoluble fibre (husk, bran, Nutritional Management
of Gastrointestinal
peels etc.) should be avoided to prevent irritation to the ulcers. For the same reason Disor ders
food should be well cooked and blended/pureed to make it mechanically bland. Fruits
should be steamed before serving. Care should be taken to exclude harsh sources of
fibre such as seeds of citrus fruits and vegetables. Tomatoes if used as soups/purees
can be tolerated in moderation (seeds get crushed). For the same reason wheat flour
should be sifted through a fine mesh and whole cereal (bajra, jowar, ragi etc.) flours
should not be included in the diet. Among the cereals rice, semolina, refined flour,
sago, pasta, arrowroot/potato powder would be good options.

Fat : Nearly 20-25% of the total energy should be provided from fat because fat in
any form delays gastric emptying, suppresses gastric acid secretion and motility. The
quality of fat however should be selected according to the age and present health
status of the patients. It is generally recommended to lay stress on emulsified fats
and those rich in medium chain triglycerides (olive oil, coconut oil). Foodstuffs rich in
emulsified fats (eggs, whole milk, cream, butter) are generally good sources of saturated
fatty acids etc. Thus, middle aged ulcer patients, especially those at risk of developing
coronary artery diseases, should lay greater emphasis on MCT’s or vegetable oils
rich in MUFA’s/PUFA’s rather than emulsified fats.

Vitamins/Minerals: The requirements of iron, calcium, and vitamin C increase during

ulcers. While iron deficiency may arise due to bleeding; calcium reserves may get
depleted (chronic cases) as milk/milk products are used in moderation. Fresh but
cooked fruits and vegetables should be consumed in good amounts to get an adequate
intake of vitamin C.

Besides the nutrient requirements discussed above, let us also review a few other
considerations to be kept in mind while planning diets for ulcer patients.

General Considerations

The following general considerations need to be considered:

 Small, easy to digest meals should be given to the patient at very short intervals.
An eight meal pattern is generally recommended during the acute phase while
during recovery/latent phases, the patient should preferably adhere to a 5-6 meal
pattern.

 Regular meal timings should be followed.

 The patient should be counseled to consume meals in a relaxed and calm

environment.

 Fasting and long intervals between meals should be avoided.

 The meals should be chemically, mechanically and thermally bland i.e.:

 Foods consumed should not stimulate gastric acid secretion. Thus, stimulating
beverages such as tea, coffee, cocoa, carbonated drinks, spices, condiments,
should be avoided. Patients may be given small servings of decaffeinated
tea/coffee. Studies have shown that small amounts of condiments in the
form of powder (cardamom) do not promote/aggravate acid secretion. Red
and black pepper have been associated with mucosal damage and increased
gastric acid secretion.

 Mechanically irritating foods should be avoided as they may cause physical

damage to the ulcerated regions. Thus, food rich in insoluble fibre should be
avoided. Raw food should not be served. Similarly, alcoholic beverages
(ethanol) may cause physical inquiry to the mucosal lining of the stomach
and should therefore be avoided.
109
Clinical and  Foods which are very hot/cold may stimulate acid secretion and should
Therapeutic Nutrition therefore be avoided.
 Certain foods (whole pulses, cauliflower, cabbage etc.) have been identified
to be “gas formers” cause flatulence which may inhibit food intake. The
effect may be individualistic and vary from one person to another, soaking
of pulses overnight, sprouting/fermentation, as well as, employing boiling,
pressure cooking, blending can help in reducing /alleviating the problem.
 Antacids should generally be take either an hour before meals or atleast
3 hours after meals.
 Smoking should be strictly restricted.
With this, we end our study of peptic ulcer. Next, let us get to know about ulcerative
colitis and its dietary management.

6.3 ULCERATIVE COLITIS

Ulcerative colitis is an idiopathic inflammatory condition that involves the mucosal
surface of the colon, resulting in diffuse friability and erosions with bleeding. Let us
recapitulate the pathophysiology of this disease condition.

6.3.1 Pathophysiology
Look up Figure 6.16 in Unit 6 in the Applied Physiology Course (MFN-001) to
recapitulate the structure of the colon. Yes, colon begins at the caecum and terminates
at the rectum and anal canal. Approximately 50% of the patients have disease confined
to the recto-sigmoid region; 30% extend to the splenic flexure (left-sides colitis); a
less than 20% extend more proximally (extensive colitis). It occurs most frequently
among individuals in the age group of 15 to 50 years; with a secondary peak at 50-60
years of age. In most patients, the disease is characterized by period of symptomatic
flare-ups and remissions.
The treatment and management of this inflammatory bowel disease is individualistic
and dependent upon the characteristic features during the acute and remissions phases.
The major signs and symptoms include:
 Diarrhoea with blood
 Rectal bleeding/inflammation/tenderness
 Abdominal pain/cramps
 Faecal urgency
 Hypotension
 Anaemia (usually severe)
 Hypoalbuminemia
 Mild fever
The treatment of ulcerative colitis is enumerated next.
Treatment
Treatment of ulcerative colitis is targeted towards meeting the objectives of terminating
an acute symptomatic attach and preventing recurrence. The most frequently adopted
regime includes:
 Dietary modifications for both acute and remission phase
 Drugs (anti diarrhoeal/anti inflammatory and immunosuppressive agents)
110  Surgery
In the subsequent section, we shall learn about the dietary management of Nutritional Management
of Gastrointestinal
patient suffering from ulcerative colitis during the phases of acute attack, as well as, Disor ders
remission.

6.3.2 Principles of Dietary Management

Malnutrition is very common among most patients suffering from ulcerative colitis.
Repeated episodes of acute and remission phase deplete the nutritional reserves
immensely which in turn makes the patient more vulnerable to subsequent episodes of
inflammation, diarrhoea and bleeding. The potential nutrition related problems associated
with ulcerative colitis include:

 anaemias related to bleeding and poor food intake,

 malabsorption due to diarrhoea,

 reduced food intake related to nausea, bloating and abdominal pain,

 food aversions, anxiety and fear of eating related to experiences with abdominal
pain, bloating, vomitting and diarrhoea,

 true /perceived food intolerance,

 self-imposed dietary restrictions, and

 weight loss, macro/micronutrient deficiencies.

In view of the above nutritional implications, we shall now discuss the nutrient
requirements and dietary modifications for patients during acute and remission phases
of ulcerative colitis. But first let us review the objectives of nutritional care for ulcerative
colitis patient.

Objectives
The objectives of nutritional care for ulcerative colitis patient include; to help in man:
 to help in managing/alleviating symptoms such as diarrhoea
 to maintain a positive nitrogen balance
 to help in replenishing the depleted reserves of vitamins, minerals and electrolytes
 to prolong the phase of remission and hence delay the frequency/severity of
acute attacks
 to promote the management of clinical complications such as anaemia
 to prepare the patient for surgery (if required)
 to maintain a good nutritional status.

Now let us start with the energy requirements.

Energy: Patients are generally in a negative energy balance due to poor appetite and
diarrhoea. Majority of the patients are ambulatory and tend to loose some weight due
to repeated episodes of acute attack. During the acute phase, the patient is usually on
a low energy, liquid diet (parenteral or enteral nutrition). Whereas, during the remission
phase, the patient should be advised to consume energy as per the RDI or that sufficient
to maintain an ideal body weight. Thus, the energy intake may vary from 25-35 Kcal/
kg IBW.

Protein: In view of the inflammation, anaemia and hypo-albuminemia, the protein

requirements increase. Adequate intake of protein is essential, particularly if the
patient is a candidate for surgery. Adequate intake of protein would also help in
alleviating malnutrition which is related to compromised digestive/absorptive function
and increased permeability of the GI tract to potential inflammatory agents. 111
Clinical and The proteins intake should therefore be increased by 25% to 50%. Although emphasis
Therapeutic Nutrition should be laid on high biological value proteins; they can be provided from a variety of
sources. If no food intolerance has been identified; include good amounts of egg,
meat, poultry, marine foods, washed pulses, legumes. In view of the restrictions in
particle size, it may be imperative to include whole pulses in a soft cooked blenderized
form. Some patients may experience flatulence associated with the intake of milk, in
such cases, milk may be avoided as a beverage but may be used in the form of milk
products.
Carbohydrate: The quantity of carbohydrate to be provided through the diet should
remain the same as far a healthy adult. Low residue, low fibre diets are occasionally
helpful because of their role in modifying the microbial load in the colon. Emphasis
should be laid on the inclusion of easy to digest carbohydrates i.e. mono/disaccharides
and polysaccharides; principally starches. High fibre cereals should be avoided. Thus,
the patient may be given adequate amounts of semolina, rice, refined flour, sago,
arrowroot, breads/buns/pastas, potatoes, sweet potatoes, yam, colocasia, starchy fruits
(banana, mangoes) sugar, jaggery, dextrose etc.
Fat : Nearly 20% of the total energy should be provided from fat. Emphasis should be
laid on n-3 fatty acids (-linolenic acid, eicosapentaenoic acid and decosahexaenoic
acid) in view of their anti inflammatory effect. Foods rich in n-3 fatty acids include
marine food (such as salmon, mackrel, halibut, tuna, herring) and cod liver oil, flax-
seed oil, olive oil, soya bean oil, wheat germ and oil. The patient should incorporate
good amounts of well cooked/ blenderized soyabean - its products such as temphe,
miso, soyamilk, tofu etc. Emulsified fat should be the second option of choice and
fried foods should be completely omitted.
Vitamins and Minerals: Deficiencies of vitamin D,K,C, B12 folate, calcium, magnesium,
zinc, sodium and potassium are usually present due to poor food intake, poor absorption
and bleeding from the inflamed mucosal surface of the colon. Thus, good amounts of
well cooked (boiled, steamed, pressure cooked) low fibre fruits and vegetables in the
form of purees, soups, well blended juice, stewed fruits, fruit jellies, milk shakes can
be incorporated in the diet.
Fluids: Deydration resulting in hypovolemia/hypotension is frequently observed during
the active phase of ulcerative colitis. While earlier emphasis used to be laid on parenteral
nutrition, now-a-days patients are able to tolerate enteral nutrition and/or oral intake
of liquid diet. Clear fluids supplemented with medium chain triglycerides are helpful
during acute and severe exacerbations of the disease. Inflammation/scarring may
result in a partially obstructed bowel and thus fibre may have to be restricted or
limited to minute particles to pass through the narrowed lumen. Small amounts of
isotonic, liquid, oral supplements may be valuable in restoring intake without provoking
symptoms.
Special Considerations
In everyday life, patients may have intermittent “flares” of the disease. Patients
therefore need to counsel regarding proper management of their diseases. Some
important dietary considerations include:
 Small frequent easy to digest meals should be given to the patient.
 The meals/beverages should have a small particle size. A low to moderate fibre
diet is recommended during the latent phases while a low residue diet may be
beneficial during the active stages or if abdominal discomfort is severe.
 Prebiotic foods (oligosaccharides, fermentable fibres and resistant starches) can
be helpful in attenuating the inflammatory process.
 Probiotic foods such as sauerkraut, yoghurt, spirulina, alfa-alfa, organic barley/
wheat grass and certain fermented drinks can help in prolonging the period of
112 remission.
 Food should be well cooked and preferably have a small particle size. Blending, Nutritional Management
of Gastrointestinal
pressure cooking, steaming, stewing, summering, baking should be the preferred Disor ders
methods of cooking.
 Commercially available fibre supplements decrease diarrhoea and rectal symptoms
such as psyllium: 3-4 g twice daily, methylcelluose: 2.0 g twice daily.
Before we end our study on ulcerative colitis, we would like you to review a sample
menu for the acute and the remission phase of the ulcerative colitis condition. These
menus will help you in planning diets and menus for ulcerative colitis patients.
Sample Menu – Ulcerative Colitis
Acute Phase
7.00 a.m. : Sugar Cane juice
Arrowroot biscuits
9.00 a.m. : Rice kanji
Half boiled egg
Fruit jelly
11.00 a.m. : Strained fruit juice
Boiled potato
11.30 p.m. : Vegetable soup
Moong dal sago puree
3.00 p.m. : Fruit yoghurt
5.30 p.m. : Strain carrot juice
7.30 p.m. : Cream of potato soup
Blended massoor dal and rice khichdi
9.00 p.m. : Sweet mango lassi
11.00 p.m. : Custard

Remission Phase

Early Morning: Early Evening Tea:

Lemonade/sugarcane juice Carrot kanji
Arrowroot biscuit Cake/muffin

Breakfast: Late Evening:

Poached egg Fruit jelly with cream
Soya milk
Vegetable (steamed ) upma Dinner:
Pulse/Meat/Chicken
Mid-Morning: Preparation (blended)
Sweet lassi Pumpking subzi (blended)
Potato dumpling Rice or Khichdi (blended)

Lunch : Post Dinner:

Vegetable soup Rice pudding
Steamed fish/Boiled Potatoes
Steamed mango
Sprouted pulse and rice khichdi (blended)
Baked custard
113
Clinical and From ulcerative colitis we move on to lactose intolerance which is a malabsorption
Therapeutic Nutrition syndrome. Let’s find out about the nutritional management of this condition.

6.4 LACTOSE INTOLERANCE

Lactose intolerance is categorized as a Malabsorption Syndromes. The term
‘malabsorption syndrome’, as you have learnt earlier in the theory course (MFN-
005) in Unit 14, sub-section 14.2.8, is used to describe deficient absorption to a variable
degree of a number of substances such as fats, proteins, carbohydrates, vitamins,
minerals and water. Lactose intolerance relates to insufficiency of the disaccharidase
‘lactase’ which is found in the greatest quantity in the outer membrane of the mucosal
cell of the jejunum. Lack of lactase does not break down the disaccharide sugar,
lactose in milk, to glucose and galactose, which hence passes unchanged into the
large intestines where it gets converted to lactic acid by the bacteria, which
subsequently causes diarrhoea and other symptoms of discomfort, and distension,
abdominal pain. The problem is gene related and often seen in infants and young
children commonly but may also be present in adults.

The dietary treatment is based upon the determination of lactase activity as the treatment
depends on the level of activity of lactase enzyme. Let us focus on the nutritional
management next.

Nutritional Management

Diagnostic tests are available that can give information about the level of lactase
activity of the lactase enzyme. Depending on the level of activity (very low level,
moderate level) the dietary treatment could be planned. Let us see how.

 Very low level of lactase activity: At very low level of lactase activity all milk
products must be eliminated substitutes of milk like soya milk, groundnut milk
and their preparations could be given. Enzyme such as Lactaid and Maxilact are
available in the market. Addition of these in the milk or milk products could
digest 90% of lactose in milk and thus minimize the symptoms of lactose
intolerance.

 Moderate level of lactase activity : Intake of milk is restricted depending on

the tolerance. Fermented and cooked form of milk preferred as it is better tolerated.
Fermentation converts a major part of Lactose to Lactic acid and in cooked
product lactose gets bound and the concentration reduces. It is better tolerated
in the form of buttermilk, curds, custards, porridges and cottage cheese or when
mixed with cereals, cocoa etc. These allow gradual lactose breakdown and
decrease the symptoms of lactose intolerance. Curds are better tolerated possibly
due to microbial culture that facilitates lactose digestion in the intestine. Small
amount of milk can be taken with the meal.

Lactose is present in dairy products such as milk, cheese, yoghurt, ice cream etc.
Hidden sources of lactose may include bread, candy, cookies, biscuits, sauces, gravies,
soups etc. Hence, depending upon the amount of lactose an individual can handle,
major or minor dietary restrictions may be imposed.
Because dairy products are restricted or avoided, which are a major source of calcium,
which children need to develop strong bones, it is important to serve calcium-rich
foods to make up for the loss. Tofu, broccoli, pulses (Bengal gram whole, horse gram,
rajmah), nuts and oilseeds, green leafy vegetables (particularly amaranth, fenugreek),
fish and sea foods are excellent sources of calcium.
To help you remember the important aspects, some handy tips are enumerated
114 herewith.
Remember : Nutritional Management
of Gastrointestinal
Disor ders
 Identify the level of lactase activities (diagnostic tests)
 Depending on the enzyme activity eliminate milk and milk products
 Substitute milk and milk products by giving soya sources like  tofu, soymilk, soy
curd and groundnut milk
 Give a well balanced diet
 If moderate lactase activity is present small amounts of lactose (within individuals
tolerance level) can be given several times a day
 Small amounts in moderate lactose activity can be tolerated if taken with other
foods e.g. after a meal or a snack
 Curds is better tolerated than milk
 In case low lactose foods available commercially like ice cream, cottage cheese
try them
 Lactose enzymes are available these should be added in the milk
 Deficiency of lactose and calcium could be supplemented by giving other foods
rich in the same
With this we end our study of gastrointestinal disorders.
There are three activities included in this practical. We shall practice and learn how
to plan diets during the peptic ulcer and during the acute and remission phases of
ulcerative colitis in the first two activities. The third activity deals with diet planning
for lactose intolerance. Before you move on to these activities, do check your
understanding on this topic by answering the review exercises included next. These
are self-check exercises.

6.5 REVIEW EXERCISES

1) How are gastric ulcers different from duodenal ulcers?
Gastric Ulcers Duodenal Ulcers
................................................. ........................................................
................................................. ........................................................
................................................. ........................................................
................................................. ........................................................
................................................. ........................................................

2) Why should we lay emphasis on providing a mechanically soft diet to patients

suffering from ulcers?
....................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
115
Clinical and 3) Mentioned below is a meal (lunch) being prepared for Rama’s family. Rama is
Therapeutic Nutrition suffering from peptic ulcers. Help his wife by giving suggestions regarding
appropriate modification (s) of the existing meal menu so as to make it appropriate
for Rama.
Present Meal Menu Modified Menu
Cabbage Carrot Tomato Salad
Fried fish curry
Spinach chappati
Bajra kheer
Suggestions regarding cooking/serving methods:

4) What is ulcerative colitis?

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

5) Give the requirement for the following nutrients for a patient suffering from
peptic ulcer and for a patient suffering from ulcerative colitis.
Peptic Ulcer Ulcerative Colitis
Energy (Kcal)
Protein (g)
Carbohydrates (g)
Fats (g)
Minerals and Vitamins
6) What special considerations will you keep in mind while planning a diet for an
ulcerative colitis patient?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
7) Lactose intolerance is caused due to the insufficiency of which enzyme and
what are its consequences.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
8) Which foods need to be avoided from the diet of a patient suffering from lactose
in intolerance? Enumerate.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Now carry out the activity included in this practical.

116
 Nutritional Management

ACTIVITYof Gastrointestinal
Disor ders

DIET PLAN FOR PEPTIC ULCER 1

Aim : To plan a diet for a patient suffering from peptic ulcer. Date :

Case Study : Kapila is a 37 year old news reporter who was admitted two weeks
back complaining of constant radiating pain in the epigastrium. She
had been diagnosed to be suffering from ulcers about a year back.
Of late she had been complaining of nocturnal pain. Laboratory
examinations have indicated anaemia, mild leukocytosis and general
malnutrition. Kapila’s height is 5’4” and her usual weight has been
53 kgs. At present she weighs 49 kgs. Endoscopy and other imaging
tests have indicated perforation of ulcers and she has been
diagonised to be suffering from gastric ulcers. Kapila was initially
put on enteral tube feeds and is presently being given a high energy,
high protein bland soft diet. She has also been prescribed drug
therapy. Her condition is being monitored for subsequent gastro-
intestinal bleeding/perforations. At present her condition is stable
and she is on stage II diet.
Kapila is suffering from an advanced stage of peptic ulcers. At present her condition
needs to be managed carefully. Both the consistency and composition of diet need to
such so as to prevent further damage to the mucosal lining and at the same time
promote healing. Keeping this in mind, proceed towards planning a diet for Kapila,
following the instructions given in this activity.

Introduction
(Present a brief write up on the disease condition in the space provided herewith).

117
Clinical and Step I: Identify the case details
Therapeutic Nutrition
Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathopysiological stress:
Based upon the clinical condition identify the nutritional implications affecting her
health status.
Symptom / conditions Nutritional Implications
1)
2)
3)
4)
5)
Diet prescribed:

Objectives of Nutritional Care

(Identify the objectives of nutritional care related to the present disease conditions of
Kapila. Refer to sub-section 6.2.2 earlier and write the objectives here in the space
provided).

Step II: Assess and compute the nutritional requirements

Calculate the requirements and record them in format given below. Now compare them with the
RDI for a healthy sedentary adult woman. (Refer to Table 1.1, Practical 1).

Recommended Dietary Intake

Nutrient Normal Modified

Energy (Kcal)
Protein (g)
Carbohydrate (g)
Iron (mg)
Vitamin C (mg)
Vitamin A (I.U.)
Dietary Fibre (g)
Crude Fibre (g)
118
Calculations: Nutritional Management
of Gastrointestinal
Disor ders

Step III: Select the food exchanges

On the basis of the modified RDI and clinical condition, select the food exchanges for Kalpila
that can help to promote recovery. Record them in the format given herewith.

Exchange No. Energy(Kcal) Protein(g) Carbohydrate(g) Fat(g)

Whole Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetables
GLV
Fruit
Fat
Sugar

Step IV: Distribute the exchanges

Identify an appropriate meal pattern for Kapila and distribute the exchanges for providing
balanced nutrition throughout the day in the format given herewith.

Exchange No. Early Breakfast Mid Lunch Evening Dinner Post

Morning Morning Tea Dinner
Early Late
Whole Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetables
GLV
Fruit
Fat
Sugar

(Note: You may modify the meal pattern as per your discretion).
119
Clinical and Step V: Plan a day’s menu for Kapila
Therapeutic Nutrition
In accordance with exchanges available for each meal plan in menu. Lay emphasis of planning
nutrient dense, easy to digest bland meals. Remember, the consistency of diet plays an equally
important role as the composition in determining the outcome of peptic ulcers.

Sample Menu for Kapila

Early Morning Breakfast Mid Morning

Lunch Evening Tea (Ist) Evening Tea (IInd)

Dinner Post Dinner

120
Step VI : Detailed menu plan Nutritional Management
of Gastrointestinal
Disor ders
Meal Menu Ingredient Amt Exchange Energy Protein Crude Dietary Iron Vitamin A
(g) (Kcal) (g) (mg) Fibre (mg) (  g)

Total

121
Clinical and Conclusion
Therapeutic Nutrition
Compare the grand total obtained for various nutrients in the detailed menu plan with the
computed modified RDI and interpret as follows:

Nutrient Modified RDI Detailed + % of Suggestions for

Diet Plan Difference Improved Intake
Energy (Kcal)
Protein (g)
Crude Fibre (g)
Dietary Fibre (g)
Iron (mg)
Vitamin A (I.U.)

Submit the activity for evaluation.

—————————-
Counselor’s Signature
122
 Nutritional Management

ACTIVITYof Gastrointestinal
Disor ders

DIET PLAN FOR ULCERATIVE COLITIS 2

Aim : To plan a diet for a patient suffering from ulcerative colitis. Date :
Case Study : Mr. Narang is a 53 years old sedentary office worker weighing
52 kgs. (height 5ft. 6 inches) who is fond of consuming baked and
fried snacks in the evening. About two years back, his weight was
71.5 kgs. He was admitted to the general ward of a government
hospital complaining of severe lower abdominal pain and rectal
bleeding along with diarrhoea. Sigmoidoscopy confirmed that he is
suffering from an acute phase of ulcerative colitis. His medical reports
indicated that he was diagnosed to be suffering from colitis about 2½
years back. His biochemical physical and imaging reports indicate
the following:
Haemoglobin : 8.3 g/dl
Pulse : 92 per minute
Haematocrit : 33%
ESR : 29 mm/hr
Albumin : 3.0 g/dl
He was immediately given blood transfusion. Intravenous therapy followed by enteral
tube feedings helped in preventing dehydration and a sharp decline in the existing
nutritional status. His condition is presently stable and he has been prescribed a
nutrient dense semi-soft diet. His oral intake was started a week before wherein
clear fluids and full fluids devoid of mechanical irritants were given. He is presently
on micronutrient supplements and drugs to inhibit inflammation.
Keeping this in mind, now plan a diet for Mr. Narang, following the instructions given
in this activity.
Introduction
(Present a brief write up on the disease condition in the space provided herewith).

Identify the key clinical symptom of Mr. Narang which may affect his nutritional
status.
Symptoms Implications on Nutritional Status
1)
2)
3)
4)
5) 123
Clinical and Step I: Patient’s Profile
Therapeutic Nutrition
Read the case details and fill in the patient details in the format given below:

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathopysiological stress:
Diet prescribed:

Clinical Profile
Patient Value Normal Value
Body weight
Haemoglobin
Pulse
Haematocrit
ESR
Albumin

Step II: Assess/compute the nutritional requirements

Calculate the nutrient requirements during the recovery phase and compare them with the RDI
recommended for a sedentary healthy adult man.

Recommended Dietary Intake

Nutrient Normal Modified

Energy (Kcal)
Protein (g)
Iron (mg)
Folic acid (µg)
Calcium (mg)
Dietary Fibre (g)
Crude Fibre (g)

Show your Calculations here:

124
 Nutritional Management
Step III: Select the food exchanges of Gastrointestinal
Several modifications are required in the quantity and quality of nutrients which need to be Disor ders
provided to the patient. These changes in turn affect the choice of foodstuffs required for
planning and preparing meals. Based upon the modified RDI, select the most appropriate food
exchanges suitable for Mr. Narang.

Exchange No. Energy Protein Carbohydrate Fat

(Kcal) (g) (g) (g)
Whole Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetables
GLV
Fruit
Fat
Sugar

Step IV: Plan a menu

As per the clinical details mentioned in the case Mr. Narang was admitted to hospital during an
acute attack of ulcerative colitis during which a semi-soft cum full fluid diet is given. However,
at present Mr. Narang is on a soft diet. Plan suitable menu’s for a day for :

 Acute phase
 Recovery phase (based upon the food exchanges available)

Menu for Acute Phase

125
Clinical and Menu for Recovery Phase
Therapeutic Nutrition
Early Morning Breakfast Mid Morning Lunch

Early Evening Late Evening Dinner Post Dinner

Step V: Distribute the food exchanges

Identify an appropriate meal pattern for Mr. Narang for the recovery phase and distribute the
above selected exchanges so as to provide a balanced meal throughout the day.

Exchange No. Energy Protein Carbohydrate Fat

(Kcal) (g) (g) (g)
Whole Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetable
GLV
Fruit
Fat
Sugar
126
Step VI: Detailed menu plan Nutritional Management
of Gastrointestinal
(Give the detailed menu plan in the format given herewith). Disor ders

Meal Menu Ingredients Amt Exch- Energy Protein Iron Calcium Folic Acid Dietary
(g) ange (Kcal) (g) (mg) (mg) (µg) Fibre(g)

Total

127
Clinical and Conclusion
Therapeutic Nutrition
Compare the grand total obtained for various nutrients in the detailed menu plan with
the computed modified RDI and interpret as follows:

Nutrient Modified RDI Detailed Diet + % of Suggested for

Plan Difference Improved Intake

Energy (Kcal)

Protein (g)

Crude Fibre (g)

Dietary Fibre (g)

Iron (mg)

Vitamin A (I.U.)

Submit the activity for evaluation.

————————————
Counselor’s Signature
128
 Nutritional Management

ACTIVITYof Gastrointestinal
Disor ders

DIET PLAN FOR LACTOSE INTOLERANCE 3

Aim : To plan a diet for a patient suffering from lactose intolerance. Date :

Case Study : Meenu is 14 year old girl who complains of periodic diarrhoea since
past few years. She weighs 25 kg. No recent weight change has
been recorded. Routine medical and clinical examination is normal.
A lactose load of 40 g gives a maximal rise of blood sugar.
Her physician diagnosed her condition as lactose intolerance and
refers her to a dietitian for nutritional management of her condition.
Now based on the case study plan and calculate a diet for Meenu
following the instructions given herewith.

Introduction
(Briefly elaborate on Meenu’s disease condition and on the significance of the nutritional
management of her condition in the space provided herewith).

129
Clinical and Step I: Patient’s Profile
Therapeutic Nutrition
(Read the case details and fill in the patient details in the format given herewith).

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Pathopysiological stress:

Diet prescribed (suggest the diet you would recommend):

Step II: Assess/compute the nutritional requirements of Meenu

(Keeping the disease condition in mind compute the nutrient requirement of Meenu and com-
pare them with the RDI recommended for a 14 year old healthy girl ).

Recommended Dietary Intake

Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Calcium (mg)

Step III: Select the most appropriate food exchanges suitable for Meenu
(Several modifications are required in the quantity and quality of nutrients which need to be
provided to the patient. These changes in turn affect the choice of foodstuffs required for
planning and preparing meals. Based upon the modified RDI, select the most appropriate food
exchanges suitable for Meenu and write these in the format given herewith).

Exchange No. Energy(Kcal) Protein(g) Carbohydrate(g) Fat(g)

Milk (Lactose
Free)

Cereals

Roots/Tubers

Meat

Pulse

Other Vegetables

GLV

Fruit

Fat
130 Sugar
Step IV: Distribute the above selected exchanges according to the meal Nutritional Management
of Gastrointestinal
pattern most suitable for the patient. Disor ders

Exchange No. Break- Mid Lunch Evening Dinner After

fast Morning Tea Dinner
Milk (Lactose free)

Cereals
Roots/Tubers

Pulses
Meat

Leafy Vegetables
Other Vegetables

Fruits
Sugar

Fat
Total

Step V: Plan a menu for Meenu

(As per the selected exchanges in step IV above plan a suitable menu’s for a day for Meenu in
the space provided herewith. You may decide on a different meal pattern than the one given in
the format herewith and accordingly plan a menu).
Menu for Meenu
Breakfast Mid Lunch Evening Dinner After
Morning Tea Dinner

131
Clinical and Step VI: Detailed menu plan
Therapeutic Nutrition
(Give the detailed menu plan in the format given herewith).

Meal Menu Ingredients Amt Exchange Energy Protein Calcium

(g) (Kcal) (g) (mg)

Total

132
Conclusion Nutritional Management
of Gastrointestinal
Compare the grand total obtained for various nutrients in the detailed menu plan with the Disor ders
computed modified RDI and interpret as follows:

Nutrient Modified RDI Detailed Diet + % of Suggested for

Plan Difference Improved Intake

Energy (Kcal)

Protein (g)

Calcium (mg)

Dietary Counseling Points

List the foods which you would recommend to be avoided in the diet of Meenu

List the foods which can be substituted and included in the diet of Meenu to
ensure good health

Submit the activity for evaluation.

——————————
Counselor’s Signature
133
Clinical and
Therapeutic Nutrition PRACTICAL 7 NUTRITIONAL
MANAGEMENT IN LIVER,
GALL BLADDER AND
PANCREATIC DISEASES
Structure
7.1 Introduction

7.2 Liver, Gall Bladder and Pancreatic Diseases: An Overview

7.3 Diseases of the Liver: Pathophysiology and of Dietary Management Principles

7.3.1 Infectious Hepatitis
7.3.2 Liver Cirrhosis

7.4 Diseases of Gall Bladder

7.4.1 Principles of Dietary Management  Cholelithiasis/Cholecystitis

7.5 Diseases of the Pancreas

7.5.1 Principles of Dietary Management  Pancreatitis

7.6 Review Exercises

Activity 1: Diet Plan for Hepatitis

Activity 2: Diet Plan for Liver Cirrhosis

Activity 3: Diet Plan for Choletihiasis/Cholecystitis

Activity 4: Diet Plan for Pancreatitis

7.1 INTRODUCTION
In the previous practical we learnt about the dietary management of the diseases
associated with the gastrointestinal tract. In this unit we will discuss about the diseases
of the liver, gall bladder and pancreas. Hepatitis, cirrhosis, cholecystitis/cholelithiasis
and pancreatitis are the major diseases which will be discussed in this practical. We
will begin with a brief on the pathophysiology (impact on nutritional status), characteristic
symptoms of the above mentioned diseases and thereafter focus on the various aspects
of dietary management. The activities included in this practical will help us to understand
and learn about the applied aspects related to working out a day’s diet for each disease.
Before you begin, we suggest you look up the concepts related to the pathophysiology
and principles of diet planning related to these disease already covered in the theory
course (MFN-005) in Unit 15.

Objectives

After undertaking this practical, you will be able to:

 discuss the diseases of the liver, gall bladder and pancreas,

 describe the various aspects of dietary management of the liver, gall bladder and
pancreas diseases, and

 plan diets for hepatitis, cirrhosis, cholecystitis/cholelithiasis and pancreatitis.

134
 Nutr itio nal
7.2 LIVER, GALL BLADDER AND PANCREATIC Management in Liver,
Gall Bladder and
DISEASES:AN OVERVIEW Pancreatic Diseases

Nutritional support plays a major role in the clinical management of patients with liver,
pancreas and biliary disease(s). It has widely been recognized that malnutrition
adversely affects outcome in both chronic and acute form of diseases of the liver, gall
bladder and/or arise in patients with chronic forms of hepatobiliary and pancreatic
disorders. Thus, the objectives of the nutritional support shall be to provide nutrient in
the correct quantity and form, to restore and maintain nutritional status, correct specific
deficiencies, treat clinical symptoms and promote regeneration of the lost tissues.
Wide spectrums of diseases are associated with the insufficiency and/or dysfunction
of liver, gall bladder and pancreas and the most important ones include:
Liver Gall Bladder Pancreas
 Acute viral hepatitis  Cholecystitis  Acute pancreatitis
 Liver cirrhosis  Cholelithiasis  Chronic pancreatitis
 Hepatic Encephalopathy  Cystic fibrosis
or Hepatic Coma  Tumors
 Pancreatic abscesses
 Fistulas
Let us briefly recapitulate the pathophysiology, symptoms and dietary management
related to these disorders.

7.3 DISEASES OF THE LIVER:

PATHOPHYSIOLOGYAND DIETARY
MANAGEMENT PRINCIPLES
Liver is a vital organ required for our survival. It is required for the proper metabolism
of proteins, carbohydrates and fat. Liver is involved in the storage, activation and
transport of many vitamins and minerals such as vitamin A, D, B12, zinc, iron, copper,
magnesium etc. It also plays an important immunological and detoxification functions.
Diseases of the liver can be acute or chronic, inherited or acquired. The most common
one’s being hepatitis (acute, fulminant, chronic, alcoholic), cirrhosis, hepatic
encephalopathy. The major pathological changes associated with liver diseases are
atrophy, fatty infiltration, fibrosis and neurosis of the hepatic cells.
Jaundice which is synonymously used for hepatitis is actually a symptom common to
all liver diseases and is characterized by elevated levels of bilirubin in the blood.
Hyperbilirubinemia may be due to abnormalities in the formation, transport, metabolism
and excretion of bilirubin. Normal plasma bilirubin levels are 2-8 mg/litre.
Clinical signs of jaundice generally appear when the plasma concentrations are
between 8-20 mg/litre.
We have already discussed in Unit 15 (in the Theory Manual) the clinical details and
etiological factors for some commonly encountered diseases of the liver. In this section
we will, therefore, recapitulate the pathophysiology and the dietary management
principles for the liver diseases.
Let us first learn about hepatitis.
7.3.1 Infectious Hepatitis
Infectious hepatitis, you may recall studying, is a disease characterized by inflammation
and degeneration of the liver cells. Hepatitis may occur due to reactions with drugs,
toxic agents and various viruses. The most common form of hepatitis is that caused 135
Clinical and by faecal contamination of food and water with Type A virus. Serum hepatitis (Type
Therapeutic Nutrition B) is next most frequently occurred form.
As for the symptoms, mild constant abdominal pain, malaise, easy fatigability,
upper respiratory symptoms, anorexia, nausea, frequent episodes of vomitting along
with diarrhoea or constipation may occur during the initial stages. Jaundice occurs in
5-10 days and there is worsening of the above mentioned symptoms. In the convalescent
phase, increasing sense of well being, return of appetite along with reduction in the
severity of jaundice, abdominal pain, tenderness of liver and fatigability is experienced.

While the above mentioned symptoms may subside in 2-8 weeks; complete recovery
takes a long-time. Majority of the symptoms associated with the term ‘jaundice’
adversely affect the food intake. Further, patient may also experience low grade
fever thereby increasing the nutritional demands on the body. Efficient treatment and
management of hepatitis is a must to prevent its progression towards cirrhosis/ hepatic
encephalopathy etc. Let us then study about the treatment of hepatitis.

Treatment
The treatment focuses on:
 Dietary management to maintain a good nutritional status.
 Bed rest or avoidance of strenuous physical activity.
 Drugs, if required (non-metabolism).
 Avoidance of hepatotoxic agents particularly alcohol.

Let us focus on the dietary management of hepatitis next.

Dietary Management of Hepatitis

Irrespective of the cause of hepatitis, regeneration of the lost liver cells is essential to
promote recovery and hence promote proper functioning of the organ. Relapse of
hepatitis or progression of acute hepatitis to a chronic form/cirrhosis occurs many-at-
times due to impaired nutritional status. Liver being a store house for several nutrients
(particularly vitamins/minerals), the nutritional reserves may get depleted during
hepatitis. Thus, the major objectives of dietary management include:

 to promote a positive energy and nitrogen balance,

 to promote recovery and prevent progression of the disease,

 to replenish the depleted reserves, and

 to ensure satisfactory convalescence and maintain an optimum nutritional status.

We will now discuss the nutrient modifications necessary to promote quick recovery
and prevent further degeneration of hepatic cells. Let us start with the calorie
requirement.

Energy : Majority of the patients experience weight loss and are malnourished due to
reduced food intake. Low grade fever is generally present during viral hepatitis which
also imposes increased demands for calories due to an increase in basal metabolic
rate. Adequate energy intake is also essential to ensure proper utilization of proteins.
The energy requirements may increase by 15 to 30% depending upon the existing
nutritional status. However, the energy intake should be increased gradually. An
aggressive increase in energy results in aggravating gastrointestinal disturbance. Due
to severity of jaundice during the early stages it may not be feasible to provide more
than 1200 Kcal per day. However, during the convalescence phase, adequate intake
of energy is feasible and a must to ensure complete recovery. If the patient is grossly
underweight, the energy intake may be calculated as 35 Kcal/kg IBW to ensure weight
gain and replenishment of glycogen reserves.
136
Protein: The protein intake should be increased by 50% to 100% in mild and moderate Nutr itio nal
Management in Liver,
cases of hepatitis i.e. the patient should be given 1.5 to 2.0 gm protein per kg IBW per Gall Bladder and
day. However, if hepatitis is severe and there is risk of developing cirrhosis; the Pancreatic Diseases
protein intake should not exceed 1.0 g/kg IBW/day i.e. the protein should be provided
as per the RDI.
Fat: Fats should not be severely restricted as they can make the food unpalatable.
About 20% of the total calories should be from fat. MCTs are preferred as they are
easily digestible and assimilable (40-50 g). For example, dairy fat cream and butter
are preferable.
Carbohydrates: In mild and moderate cases of hepatitis, carbohydrates should provide
atleast 60% of the total energy. Liberal intake of carbohydrate helps in replenishing
the glycogen reserves and sparing the proteins for tissue regeneration. However, in
severe chronic hepatitis determining the carbohydrate needs is often a challenge
because liver failure reduces glucose production, glucose utilization and there is
preference for the use of lipids and proteins as alternative sources of protein. In such
situations the carbohydrate intake should not exceed 60% of the total energy. Emphasis
should be laid on the inclusion of food rich in monosaccharides, disaccharides and
starches. Dietary fibre intake should be kept minimum. All fibre rich foods should
preferably be avoided and if given, should be in a soft cooked form. Thus, include
good amounts of glucose, dextrose, jaggery, honey, sugar, ago, rice, refined four, pastas,
starchy roots and tubers (potato, yam, colocasiac etc.), high carbohydrate fruits (banana,
mango, sapota, raisins etc.)
Vitamins and Minerals: Impaired liver function and its associated symptoms can
result in increased demand of B-group vitamins, ascorbic acid, vitamin A, K, calcium,
and iron. Among all the nutrient, fat malabsorption is the greatest, therefore -carotene
rich foods should be included in the diet. Include adequate amount of fresh fruits and
vegetables in soft cooked form such as mashed pureed vegetables, vegetable soup,
fruit juice, stewed fruit, fruit jellies, fruit jam, milk shakes, etc.
Fluids: Fluid intake may need to be increased if the patient is suffering from diarrhoea
and/or constipaton. In such cases include good amounts of clear and full-fluids in the
diet such as:
a) Clear fluids: Coconut water, tea/coffee (without milk,) barley water, strained
vegetable/ pulse/ meat soup, strained fit juices, strained carrot/rice kanji etc.
b) Full fluids: Milk based beverages such as tea, coffee, milk shake, soufflé,
baked custard, soup, juice, egg nog, fruit jellies etc.
General Considerations
The other considerations include:
 High energy high protein diet should be given to patients suffering from mild to
moderate hepatitis.
 During acute hepatitis or if vomitting/diarrhoea is severe, a full fluid or a semi-
soft diet may need to be given.
 Small, frequent, easy to digest bland meals should be served to the patient. The
meals should particularly be mechanically and chemically bland.
 Since patients experience nausea and anorexia, it is essential to prepare palatable
meals which are attractively served. Inclusion of variety in terms of colour,
texture, taste, flavour and mouth feel is important to motivate the patient
(particularly children) to consume food.
 Moist heat methods of cooking such as boiling, pressure cooking, stewing, steaming
should be preferred over dry heat methods such as roasting, grilling etc.
137
Clinical and Sample Menu
Therapeutic Nutrition

Early Morning Lunch/Dinner

One cup milk Chicken /Vegetable soup
Cake slice (one)
Washed moong dal/arhar/masoor
Breakfast
Ridge gourd/pumpkin or tinda potato sabji
Boiled or poached egg
Cornflakes porridge or suji porridge Rice/Chapati
Stewed apple (without peels ) Spinach burfi/phirni/custard/ice-cream
with honey
Evening Tea
Mid-Evening Milk shake/orange soufflé vegetable and
Sugarcane pineapple juice sprouts upma.
Muffin or dhokla

We shall now brief ourselves about the dietary management of liver cirrhosis which is
a more serious form of liver diseases and if not treated promptly can result in irreversible
changes leading to death of the patient.

7.3.2 Liver Cirrhosis

Liver cirrhosis is the end result of hepato-cellular injury wherein the fibrous connective
tissue replaces the functioning liver cells. It is a serious form of end-stage liver
disease wherein the liver looses majority of its functional capacity.
Hepatic encephalopathy may develop if cirrhosis is not treated properly and is
characterized by day-night reversal, tremor, dysarthria, delirium and ultimately coma.
Thus, proper treatment of cirrhosis is very crucial and is highlighted next.
Treatment
The treatment of cirrhosis includes:
 Dietary management as per the changing needs of the patient.
 Drugs treatment.
Next, let us identify the objectives and elaborate upon the principles of dietary
management for cirrhosis.
Dietary Management of Cirrhosis
Dietary modifications during liver cirrhosis should be based upon the symptoms and
etiological factors.
 to maintain energy and nitrogen balance,
 to promote regeneration of hepatic cells,
 to replenish depleted nutritional reserves and maintain an optimum nutritional
status,
 to cure the underlying cause, and
 to promote recovery and prevent progression of the disease.
Let us now focus on the modifications required in the quantity and quality of various
nutrients. We shall begin with the calorie requirements of the patient.
Energy : Majority of the patients are on complete bed rest and moderately/severely
malnourished. Since the actual body weight of the patient may be difficult to record
due to oedema; it is advisable to use usual body weight or ideal body weight for
calculating the energy requirements of the patient. Most of the patients would benefit
on a diet providing calories as per the RDI (ICMR) or 30 Kcal per kg ideal body
weight or usual body weight.
138
Protein: Cirrhosis is a catabolic disease characterized by increased protein breakdown Nutr itio nal
Management in Liver,
and inadequate synthesis. The detoxification functions also get impaired. During Gall Bladder and
uncomplicated stable cirrhosis, the protein requirements remain 1.1-1.2 g per kg IBW Pancreatic Diseases
or usual body weight. If there is risk of impending coma (Grade I-II), we should keep
the protein intake below 0.8-1 g/kg ideal or usual body weight. However, if signs of
impending coma (Grade III-IV) appear, the protein intake should be reduced till the
ammonia level improved i.e. 0.6g/kg ideal or usual body weight.
Identifying and selecting protein rich foods are difficult for liver cirrhosis patients.
While on one hand, we need to give proteins which are of high biological value i.e. rich
in essential amino acids; on the other hand, the intake of proteins rich in aromatic
amino acids (tyrosine, trytophan, phenylalanine etc.) should be avoided. Thus, we
need to avoid animal foods and lay more emphasis on the plant origin protein foods.
Thus, milk and milk products should be given in moderation; meat/fish/poultry should
be avoided, whereas majority of the proteins should come from pulses and legumes/
their products (besan, soy flour, soy milk, tofu etc.). Commercially available formulas
which are low in aromatic amino acids, can be used in addition to the natural foods in
order to ensure low intake of aromatic amino-acids.
Carbohydrate: The carbohydrate intake is generally recommended to remain between
60-65% of the total energy requirements. Most of the patients are able to tolerate a
300 gm carbohydrate diet. Patients suffering from severe cirrhosis (severe gastro-
intestinal bleeding) may initially be put on enteral or parenteral feedings (glucose,
medium chain triglycerides and branched chain amino-acids). Details regarding the
quality of protein to be provided remain the same as far hepatitis patients. Since the
load of non-essential amino acids needs to be reduced, it is advisable to substitute the
cereal exchanges with that of starch while planning diets for the patients.
Fat: During cirrhosis, there is elevation of fasting plasma free fatty acids, glycerol and
ketone bodies. The body prefers lipids as an energy substrate. At the same time,
there is marked steatorrhoea. During the acute/progressive phase most patients are
able to tolerate 15-20% of fat from the total energy. As the condition improves, the fat
intake may be increased gradually.
However, it is the quality of fat which is of utmost importance. Emphasis should be
laid on emulsified fats and some amount of long chain triglycerides should be replaced
by medium chain triglycerides. Appropriately 15 ml of liquid MCT oil, 3-4 times per
day is recommended (15 ml provides = 15 Kcal). Very strict fat restriction reduced
the palatability of meals and should therefore be avoided. Visible fat should be used
sparingly. Invisible and emulsified fat should be included in the meals such as in the
form of egg, milk, cream, white butter, legumes, pulses, wheat germ etc.
Minerals and Vitamins: In all patients with cirrhotic ascites, dietary sodium intake
may initially be restricted to 400-800 mg/day; the intake may be liberalized slightly
after diuresis starts. Thus, both table salt and cooking salt should be avoided. Leaching
of food is generally not advocated but it is advisable to restrict the intake of pickles,
chutney, papad, ketchup, preserves, canned food, bakery products etc. (Refer to Unit
15 in the Theory Manual for sodium restricted diets). Milk/milk products, green leafy
vegetables (low in sodium) and soft cooked/pureed whole pulses/legumes should be
included in the diet. Fresh fruits and vegetables which are low in sodium should be
incorporated in the diet.
Fluids: Free matter excretion gets impaired during cirrhosis and hyponatremia may
develop. Restriction of fluid intake (800-1000 ml per day) is required for patients with
hyponatremia (serum sodium < 125 meq/L). Patients should be counseled regarding
the fluid allowance for each day and the restrictions in the intake of water and other
beverages. The dietitian should preferably prepare dishes which are low in fluids/
water i.e. avoids the preparation of curries and beverages. Do remember that fluid
restriction is not required for all patients. It is essential only for patients developing
hyponatremia. 139
Clinical and General Considerations
Therapeutic Nutrition
 Oral intake may need to be supplemented/substituted with enteral/parenteral
tube feedings according to the complications of cirrhosis.
 Small, frequent, easy to digest meals should be attractively served to the patient.
 Avoid high sodium foods, cooking salt/table salt, as well as, non-vegetarian foods.
 Patient should be counseled regarding the benefits of reading labels and interpret
the presence of sodium as part of an additive/preservative.
A sample menu for cirrhosis patient is given herewith.
Sample Menu  Liver Cirrhosis
Early Morning : Weak Tea
Arrowroot biscuits
Breakfast : Sago porridge
Stewed peach and plums
Potato roll
Mid Morning : Sweet Vermicilli
Rice Kanji
Lunch : Washed Masoor dal
Carrot potato sabzi
Rice
Curd
Evening Tea : Paneer tomato onion sandwich
Weak tea

Dinner : Arhar dal

Seasonal Vegetable Preparation
Rice
Jaggery coated sweet potato

Post Dinner : Baked custard with fruit jelly

With this, we end our study about the liver diseases. The digestion of food requires a
coordinated functioning of both the liver, as well as, the gall bladder. Diseases of the
liver may be found in association with that of the gall bladder; both or any one of them
can have serious nutritional implications. We shall now proceed towards the
understanding of the major disorders associated with disturbed functioning/altered
physiology of the gall bladder.

7.4 DISEASES OF THE GALL BLADDER

As we all know, our gall bladder is a pear shaped organ which is connected to the liver
and the duodenum. Refer to Unit 6, Figure 6.13, in the Applied Physiology Course
(MFN-001) to review the structure of the gall bladder. The gall bladder stores about
50 ml of bile, which is released when food containing fat enters the digestive tract,
stimulating the secretion of cholecystokinin.
You must have read about the etiological factors for the gall bladder diseases in the
Unit 15 of the Theory Manual (MFN-005). In this practical, we shall discuss about
the dietary management of:
 cholecystitis (inflammation of the gall bladder)
 cholelithiasis (gall stones).
140
The major symptoms which may alter food intake and hence affect the nutritional Nutr itio nal
Management in Liver,
status of the patient include: Gall Bladder and
Pancreatic Diseases
 abdominal fullness (flatulence)
 severe and recurrent right upper quadrant or epigastric pain. It is more severe
after eating or drinking fatty foods or fluids and on taking deep breaths.
 fever
 nausea, vomitting and heartburn
 chills and shaking
 chest pain under the breast bone
The treatment of cholelithiasis include:
 Laparoscopic or conventional open cholecystetomy.
 Lithotripsy in combination with bite salt therapy
 Dietary management
The treatment of cholecystites include:
 Dietary modifications
 Drugs to alleviate pain (meperidine)
 Ultra-sound guided aspiration of the gall bladder or percutaneous cholecystostomy.

Here in this practical we will focus on the dietary modifications necessary for the
successful management of cholelithiasis and/or cholecystitis.

7.4.1 Principles of Dietary Management  Cholelithiasis/

Cholecystitis
Diseases of the gall bladder such as cholelithiasis (gall stones) and cholecystitis
(inflammation of the gall bladder) generally occur in association with each other. An
inflamed mucosa of the gall bladder may affect its reabsorptive capacity and alter the
composition of bile juice resulting in precipitation of its component(s) and hence the
development of gall stones. However, at times the physical presence of stones over a
prolonged period may cause inflammation/injury to the mucosa of the gall bladder.

Changing dietary habits and life-style practices are resulting in an increased incidence
of cholelithiasis/cystitis. A high cholesterol intake, lack of dietary fibre, deficiency of
PUFAs and irregular meal timings are predisposable factors associated with
cholelithiasis/cystitis. While cholelithiasis is generally asymptomatic and chronic in
nature, it may be found in association with acute attacks of cholecystitis. Both the
diseases may necessitate altered nutrient intake by the patient. We shall first briefly
discuss about the dietary management of an acute attach of gall bladder diseases and
then proceed towards nutritional modifications during cholelithiasis.

Acute Phase  Cholecystitis and/or Cholelithiasis

An acute attack is characterized by sudden onset of piercing sustained upper
quadrant pain in the abdomen after the consumption of a meal containing fat. The
major objective(s) of patient management is:
 to keep the gall bladder inactive,
 to provide the relief from pain,
 to treat the underlying cause, and
 to provide nutritional support during the phase of remission.
It is generally a state of emergency demanding complete withdrawal of oral intake of
food and fluids for atleast the first 12 to 24 hrs. The patient is given antibiotic(s) and
141
Clinical and analgesic(s) along with parenteral or enteral tube feedings. Enteral foods which are
Therapeutic Nutrition low in fat or contain elemental fat should be used till it is confirmed that a surgery is
to be done. In case surgery is not required or can be postponed, a low fat diet may be
initiated.
Chronic Phase - Cholelithiasis
The presence of gall stones in the gall bladder may remain asymptomatic even after
their diagnosis. Dietary management of cholelithiasis patient should be carried out
with the following objectives in mind:
 to prevent further progression of cholelithiasis,
 to promote and maintain an optimum nutritional status, and
 to help in alleviating the underlying cause (hypercholesterolemia, excess body
weight), if feasible.
Our subsequent discussions will help us in understanding what dietary modifications
can facilitate in meeting the above mentioned objectives. We shall first discuss the
nutrient modifications and then proceed towards dietary habits. Let us first begin
with energy.
Energy : Ambulatory patients having a healthy body weight need not modify their
calorie intake. However, higher incidence has been found among overweight/obese
individuals, those on a very-low calorie diet or these who consume meals after a
prolonged gap. Thus, the energy intake of the patient should be calculated on the
basis of his ideal body weight and usual/present body weight. The procedure for
calculating the energy requirements on the basis of IBW has been discussed in Practical
4 (Diet during Weight Management) earlier. Follow the procedure mentioned in this
practical.
Fat : A low fat diet is generally recommended. Total dietary fat should provide 20%
of the total energy in the diet. More drastic restriction is not suggested. Emphasis
should be laid on the inclusion of emulsified fats and those rich in medium chain
triglycerides (coconut oil, olive oil). Thus, skim milk/skim milk products (cottage
cheese, curd, yoghurt etc.), lean meat (poultry, marine food), egg whites, most legumes,
vegetables and fruits (except avocado) should be preferred. Ample amounts of
vegetables and sprouts should be included in the diet but in a cooked/easy to digest
form, especially if the person is overweight/obese. Dietary cholesterol restrictions
are not very useful for the prevention of cholelithiasis. However, during the course of
treatment, it is recommended to keep the dietary intake as low as 10-100 mg/day.
Thus, animal products should be consumed in very limited amounts. Refer to Table
7.1 which presents the daily food allowances to provide 40 g fat in the diet.

Table 7.1: Daily food allowance (40 g fat diet)

Food Amount

Toned Milk 2 cups

Lean meat fish, poultry 30 g
Pulses/legumes 2-3 serving
Egg whites three-four per week
Vegetables > 3 servings (> 1 dark green leafy veg.)
Fruits 3 servings (atleast 1 citrus)
Cereals as per recommendation
Fat < 4 exchanges
Desserts/sweets Optional/ to be avoided.
142
Protein : The protein intake should remain the same as for healthy individuals i.e. 1.0 Nutr itio nal
Management in Liver,
gm/kg ideal body weight per day. However, in case of Cholecystitis slight increase in Gall Bladder and
protein may be recommended i.e. 1.1-1.2 g/kg ideal body weight. A combination of Pancreatic Diseases
plant and animal proteins should be provided to maintain a good nutritional status of
the patient (especially important pre- and post-operatively). Lean meats, egg whites,
skim milk, skim milk products (yoghurt, curd, paneer), well cooked whole pulses/
legumes/sprouts, pulses without husk, soya flour, Bengal gram flour, soya milk, tofu
etc. can be given to the patient in moderate amounts.

Carbohydrates : Nearly 60% of the total energy should come from carbohydrates.
The frequency of gall bladder diseases has been found to be higher among populations
consuming a low fibre diet thereby indicating a protective role of fibre. Certain
components of fibre modify the composition of bile acid pool and also increase the
amount of chenodeoxycholic acid which enhances the solubility of biliary cholesterol.
However, high fibre foods may at the same time aggravate the problem of abdominal
flatulence. Thus, all high fibre foods should be included in a well cooked form. The
patient should avoid consuming raw vegetables and whole pulses, should preferably
be soaked overnight before cooking. Similarly, sprouts may be sautéed/steamed rather
than consuming them raw.

Vitamins and Minerals: An increase or decrease in the requirement of vitamins and

minerals has not been reported. However, if the patient remains on a fat restricted
diet for a long-time; fat-soluble vitamins need to be included in the diet. Thus,  -
carotene rich foods (green leafy vegetables, orange and yellow coloured fruits/
vegetables) should be included in the diet. Vitamin K supplements may be required
during an acute attach due to itching, jaundice and bleeding problems.

Fluids : Plenty of fluids need to be given, particularly during the acute phase. This is
particularly important if the patient is suffering from vomitting. In such cases, around
2-3 litres of fluids should be consumed in 24 hrs to prevent dehydration. If vomitting
is severe/persistent; the patient should be given clear fluids at hourly intervals. This
may be followed by a full-fluid diet till the absorption improves. Therefore, give plenty
of clear fluids such as coconut water, rice/carrot kanji, clear soups, clear broths, jelly,
sugar candies, glucose water, lemon/barley/saunf water etc. These may be followed
by full fluids such as milk shakes, tea, coffee, soufflé, fruit juice, vegetable/pulse soup,
custard etc.

Special Considerations
 Large and high fat meals should be completely avoided.
 Small, frequent low fat meals should be consumed and a fixed meal pattern
should be adopted.
 Certain foods such as cauliflower, cabbage, rajmah etc. are potential gas formers
which should be avoided if the patient is experiencing abdominal fullness.
 Well cooked, easy to digest meals should be given. Moist heat methods of
cooking such as pressure cooking, steaming, boiling, stewing, broiling should be
preferred.
 The fat allowance should be distributed evenly throughout the day to facilitate
drainage of bile from the gall bladder.
 Patient must be counseled to prevent starvation/fasts as it increases the risk for
precipitation of bile components in the gall bladder.
 Very low calorie/fat diets and starvation therapies should be completely avoided
by such patients.
A sample menu for a low fat diet is presented next for your reference. 143
Clinical and Sample Menu: Low Fat Diet
Therapeutic Nutrition

7.00 a.m. : Weak tea or 1 cup skim milk

9.00 a.m. : Egg Nog, pureed sago in vegetable
juice
11.00 a.m. : Fruit juice (pineapple)
1.00 p.m. : Cream of potato soup, Rice kanji
Soft custard
3.30 p.m. : Mango yoghurt
5.30 p.m. : Banana shake
7.30 p.m. : Semolina pudding
9.00 p.m. : Pulse and veg puree
Soufflé with gelatin dessert
11.30 p.m. : Milk or fruit ice-cream with jelly

We shall now brief ourselves with the pathophysiology related to the diseases of the
pancreas.

7.5 DISEASES OF THE PANCREAS

Pancreas is an organ located posterior to the stomach and in close association with
the duodenum. Refer to Figure 6.11 in Unit 6 in the Applied Physiology Course
(MFN-001) to refresh your knowledge about the pancreas pathophysiology. The
pancreas, you may recall studying, produces enzymes that break down all categories
of digestible foods (exercise) and secretes hormones that affect carbohydrate function
(endocrine).
The most common diseases of the pancreas are:
 Benign tumors
 Carcinoma of pancreas
 Cystic fibrosis
 Diabetes Mellitus
 Pancreatic insufficiency
 Pancreatitis (acute/chronic)
In this section we will discuss the acute and chronic pancreatitis in detail. The major
focus shall be on the dietary management of these conditions. Diabetes disorder
associated with the endocrine function of pancreas has already been discussed in
Practical 4 earlier.

7.5.1 Principles of Dietary Management  Pancreatitis

Acute pancreatitis, you may recall studying, is rapid inflammation of the pancreas
which results from ‘escape’ of pancreatic enzymes from acinar cells into the
surrounding tissues.
Chronic pancreatitis generally occurs as recurrent episodes of acute inflammation
in previously injured pancreas or as chronic damage with persistent pain or
malabsorption.
144
Patients with pancreatic disease are particularly likely to have nutrition-related problems Nutr itio nal
Management in Liver,
and be nutritionally depleted. Undernutrition is a high risk as a result of poor dietary Gall Bladder and
intake (due to anorexia and /or alcohol/drug abuse), malabsorption (pancreatic exocrine Pancreatic Diseases
insufficiency), hypercatabolic effects and the need for food withdrawal during acute
phases of the disease. As discussed earlier, both acute and chronic pancreatitis can
markedly affect the nutritional status of the patient. Nutritional support therefore
plays an important role in the prognosis of the disease. We will first brief ourselves
regarding the nutritional support required during acute pancreatitis.

Nutrition Support during Acute Pancreatitis

In view of the fact that acute pancreatitis is generally accompanied by duodenal ileus
and prolonged gastrointestinal dysfunction, as well as, pain which is associated with
the release of pancreatic enzymes and bile; it is advisable to withhold oral and enteral
feeding atleast for the first few days i.e. provide ‘rest’ to the pancreas. The nutritional
support regime generally followed includes:

 Adopt “NPO”, no oral /enteral feeding on admission.

 Maintaining fluid and electrolyte balance by intravenous feeding.
 If condition is expected to improve within a week; include enteral nutrition in the
dietary regime.
 For more severe cases adopt parenteral nutrition. Parenteral formulas may contain
dextrose or dextrose with lipid emulsions if serum triglycerides < 400 mg/dl).
 A clear liquid diet (6-8 feeds per day) with negligible fat should then be initiated
and the patient should be monitored carefully.
 Aggressive nutrition support may involve attempts to use the gastrointestinal
tract. Polymeric formulas stimulate the pancreas more than elemental/ hydrolyzed
formulas. Thus, enteral nutrition (elemental/gastric phases of exocrine pancreatic
stimulation are eliminated) as per the tolerance level of the patient.

A sample menu for acute pancreatitis is given herewith for your reference.
Sample Menu:Clear Liquid Diet

7.00 a.m. : Strained apple juice with honey

9.00 a.m. : Lemonade and fruit ice

11.00 a.m. : Tea without milk
1.00 p.m. : Meat broth, ginger water
3.30 p.m. : Consomme’ (vegetable)
5.30 p.m. : Orange gelatin, coconut water
7.30 p.m. : Strained pineapple juice
9.00 p.m. : Chicken broth, barley water, strained moong
dal water
11.30 p.m. : Grape fruit jelly

Let us now discuss the principles of dietary management during chronic pancratitis/
remission phase after successful management of acute pancreatitis.
Nutrition Support during Chronic Pancreatitis
Maintenance of an adequate nutritional status is the most crucial objective to be met in
view of the recurrent attacks of epigastric pain associated with meals and presence of
nausea, vomitting and/or diarrhoea. Patient usually present symptoms and signs of
145
Clinical and malnutrition such as gradual weight loss, deficits of lean muscle/adipose tissue, visceral
Therapeutic Nutrition protein depletion and impaired immune function. Thus the major objective of nutritional
care is to:
 prevent further damage to pancreas,
 reduce episodes of pain associated with meals,
 correct malnutrition, and
 maintain a positive energy and protein balance (if feasible), and
 decrease steatorrhoea and other gastrointestinal disturbances.
Thus, the following dietary modifications may be necessary to improve the overall
health status of the patient. We will begin our discussions with energy and then proceed
to macro- and micro-nutrient intake.
Energy : Most of the patients are severely emaciated and in a compromised state of
health. Persistent indigestion and an increase in resting energy expenditure are the
major reasons of weight loss. Ideally, the patient should be given liberal calories to
promote weight gain i.e. ~35 Kcal/kg IBW/day which is practically not possible during
the clear liquid or liquid diet. The patient maybe required to be fed easy to digest
(soft, semi-soft or blenderized meals) food so as to help in minimizing gastric discomfort.
Protein: High amount of protein i.e. 1.0 - 1.2g/kg body weight/ day should be provided
to prevent further nutritional depletion. Enzyme supplementation therapy may be
required to facilitate proper digestion of proteins. Emphasis must be laid on easy to
digest high biological value proteins. However, we should choose those foods which
are at the same time low in their fat content. Thus, red meats, egg yolk, whole milk
and whole milk products should be avoided. Egg white, lean meats, skimmed milk/
skimmed milk products, pulses, legumes, soya milk, tofu should be preferred. Isolated
intact/ hydrolyzed proteins/ protein supplements like whey protein, soy protein, casein,
etc. may be used depending upon the tolerance level of the patient.
Fat : The fat intake should be minimized to as low as feasible. Initially it can be
progressed from no fat to low fat soft- diet. The amount of fat incorporated in the diet
depends upon the severity of steatorrhoea, enzyme replacement therapy and the
degree of malnutrition. The average fat intake should be kept below 15-20% of the
total energy. Further, majority of the visible fat should be in the form of medium chain
triglycerides (MCTs). Natural MCTs are found in milk fat, coconut oil and palm
kernel oil. Low fat foods should be preferred such as fish, chicken, egg white, low fat
milk, low fat milk products (curd, yoghurt, cheese) etc. Fried foods, high fat foods
such as bakery products or dishes prepared by sautéing in liberal amounts of fat,
cream, butter, margarine, bread spreads with fat base, and cooking oils should be
completely restricted. Boiling, low-fat baking, steaming, micro-wave cooking and the
use of non-stick cook-ware are helpful in reducing the fat content of meals. Commercial
MCT oils can easily be incorporated in the meals after cooking especially in soups,
cereal, desserts, vegetable/pulse preparations.
Carbohydrates : Liberal amounts of carbohydrates (>60% of the total energy) should
be provided in the diet to promote weight gain and spare proteins and fat for necessary
metabolic functions. Low fibre, easy to digest carbohydrates should be provided in
the diet. Foods rich in mono/disaccharides and starches should be incorporated in the
diet such as sugar, honey, dextrose, sugarcane juice, date, sugar candies, starchy
roots/tubers (potato, yam, colocasia), arrowroot, sago, rice, refined four, pastas,
semolina, white bread, chirwa (flattened rice), murmura (puffed rice) etc. The intake
of dietary fibre should be minimized in view of gastrointestinal disturbances. Thus,
fruits such as mango, banana, grapes, and dates should be preferred over guava,
pear, pineapple etc.
Vitamins and Minerals : Steatorrhoea may result in impaired absorption of fat-soluble
146 vitamins, as well as, deficiency of calcium and iron. Vitamin B12 deficiency may also
arise due to the deficiency of pancreatic protease. Appropriate pancreatic enzyme Nutr itio nal
Management in Liver,
supplementation therapy can help in alleviating steatorrhoea and facilitating proper Gall Bladder and
digestion and absorption of food/nutrients. A balanced diet containing a variety of Pancreatic Diseases
easy to digest foods can help in alleviating steatorrhoea and facilitating proper digestion
and absorption of food/nutrients.
Fluids: Dehydration may develop during the acute phases of chronic pancreatitis or
when steatorrhoea may get aggravated due to high intake of fat. The fluid intake
should be increased by including clear-fluids/full-fluids such as rice kanji, vegetable
stock/soup, fruit juices, pulse/legume water, egg nog, coconut water, barley water,
soufflé, jelly, syrups etc.
Special Considerations
 Small, frequent, low fat easy-to-digest feeds/meals should be given to the patient.
 If steatorrhoea is severely aggravated (before/during the initiation of enzyme
replacement therapy), the diet would need to be modified in consistency. The
patient may initially be given full-fluid diet followed by a semi-soft and then a
soft diet.
 In view of the impaired gastrointestinal capacity, it is essential to provide well-
cooked meals to the patient. If the need be, blenderized meals may be given
(purees, khichdi etc.)
 Fat used for cooking food should be kept to a minimum. Thus, steaming, boiling,
pressure cooking should be preferred. Frying, high fat stewing should be avoided.
Roasted and grilled foods need to be avoided as they are difficult to digest.
Now, we end our study on the dietary management of pancreatitis. Based on this
knowledge, let us now plan diets for the different disease conditions discussed in this
practical. There are three activities included in this practical. These activities will
help you practice what you have learnt so far. Before you begin with the activities, try
attempting the questions included in the review exercises given next. This will help
you consolidate your understanding of the crucial aspects discussed in this practical
so far.

7.6 REVIEW EXERCISES

1) Discuss Jaundice with relevance to hepatitis.
..................................................................................................................
..................................................................................................................
..................................................................................................................
2) Which type of cooking methods should be preferred while preparing meals
for individuals suffering from hepatitis. Give reason(s).
..................................................................................................................
..................................................................................................................
..................................................................................................................
3) Why should we restrict sodium intake of a liver cirrhosis patient? Enlist the
foods to be restricted/avoided and those which can be taken liberally in a
moderate sodium restricted diet.
..................................................................................................................
..................................................................................................................
.................................................................................................................. 147
Clinical and 4) Plan two breakfast menu’s for liver cirrhosis patients.
Therapeutic Nutrition
Menu 1 Menu 2
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
5) Compute the modified nutritional requirements of Kamsa, a 39 years old
women suffering from cirrhosis due to acute recurrent attacks of infective
hepatitis. She has mild portal hypertension and ascites.
Recommended Dietary Intake
Nutritent Normal Modified
Energy (Kcal)
Protein (g)
Fat (g)
Sodium (mg)
6) What is the benefit of consuming medium chain triglycerides during
cholelithiasis?
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
7) Differentiate between acute and chronic pancreatitis.
Acute Pancreatitis Chronic Pancreatitis
1)
2)
3)
4)
5)

8) Chronic pancreatitis is associated with depleted reserves of several

micronutrients. Identify any four such micronutrients and enlist their dietary
management.
1) ..........................................................................................................
2) ..........................................................................................................
3) ..........................................................................................................
4) ..........................................................................................................
148
9) How can we reduce the fat content of the following meal menu’s? Nutr itio nal
Management in Liver,
Gall Bladder and
Menu 1 (Lunch) Menu 2 (Evening Tea) Pancreatic Diseases

 Chicken curry Butter Biscuit

 Spinach kofta in tomato sauce Coffee
 vegetable pulao
 Boondi raita
 chappati
10) Enlist a few counseling tips for Radha regarding low-fat food choices. She is
suffering from chronic pancreatitis and anaemia.
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
Now carry out the activities included in this practical.

149
Clinical and
ACTIVITY
Therapeutic Nutrition

1 DIET PLAN FOR HEPATITIS

Date : Aim : To plan a diet for a patient suffering from hepatitis.

Case Study : Ritesh is a 12 year old boy studying in a public school who is fond
of eating street foods. For the past ten days he has been
experiencing anorexia, nausea, vomitting and malaise. At present
he is having a mild fever (< 38O C average), enlarged tender liver
and jaundice. His biochemical reports have indicted a low white
cell count and markedly elevated aminotransferases. Liver biopsy
has indicated mild hepatocellular necrosis. Blood culture is
indicative of hepatitis A virus. Ritesh has been advised to take
complete bed rest. He has been prescribed a high energy, high
protein, soft, bland diet. Adequate precautions such as thorough
washing of hands (especially after bowel movements) and careful
cleaning of patient’s belongings have been advocated.
Based on this case study now plan a diet for Ritesh following the instructions given
herewith.

Introduction
(In the space provided herewith, describe the disease which Ritesh is suffering from. Elaborate
on why has he been advised to consume a high energy high protein diet).

150
Step I: Patient’s Profile Nutr itio nal
Management in Liver,
On the basis of the details mentioned in the case; fill in the case profile in the format given Gall Bladder and
below: Pancreatic Diseases

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:
In view of the case details and the principles of dietary management discussed earlier in this
practical, carefully identify and prioritize the major objectives of nutrient modifications so as to
help in preventing reoccurrence/development of complications, as well as, promoting quick
recovery for Ritesh.

Objectives of dietary management

Step II: Assess the nutritional requirements of Ritesh

Write the RDI for Ritesh in the format given herewith. Also write the calculations in the space
provided.

Recommended Dietary Intake

Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Carbohydrate (g)
Vitamin A ( g)

Calculations:

151
Clinical and Step III: Now carefully select the food exchanges that can help in providing
Therapeutic Nutrition
the nutrients as per the modified RDI.
Exchange No. Energy Protein Carbohydrates Fats
(Kcal) (g) (g) (g)
Whole Milk
Skim Milk
Meat
Pulse
Cereals
Roots/
Tubers
Other
Vegetables
Leafy
Vegetables
Fruit
Fat
Sugar
(Note: Avoid giving too many exchanges of fat because the digestion of fat get impaired
during hepatitis).
Step IV: Select an appropriate meal pattern for Ritesh
Remember, anorexia, nausea, vomitting, and other symptoms associated with jaundice reduce
the food intake and result in malnutrition. Small, frequent, nutrient dense meals prove to be
beneficial. Decide on the meal pattern and distribute the exchanges within the meal pattern in
the format given herewith. (Note:You may modify the meal timing/frequency given in the
format below).
Exchange No. Early Light Mid Early Evening Dinner Post
Morning Breakfast Morning Lunch Tea Dinner
Early Late

Whole Milk
Skim Milk
Meat
Pulse
Cereals
Roots/
Tubers
Other
Vegetables
Leafy
Vegetables
Fruit
Fat
Sugar

Step V: Next, we need to plan a day’s menu for Ritesh by keeping in mind his
clinical condition and nutritional needs.
Identify dishes in accordance with the age of the patient. You may follow the 7 meal pattern
(Early Morning, Light Breakfast………Post Dinner etc.) given in Step IV above or modify the
meal frequency and timings as per your understanding. Write the days menu in the space
152 provided herewith.
 Sample Menu for a Day Nutr itio nal
Management in Liver,
Gall Bladder and
Early Breakfast Mid- Lunch Evening Tea Dinner PostDiseases
Pancreatic
Morning Morning (Early/Late) Dinner

Step VI : Detailed menu plan

(Give the detailed menu planning in the format given herewith).

Meal Menu Ingredients Amt Exch- Energy Protein Carbo- Vitamin

(g) ange (Kcal (g) hydrates A (µg)
(g)

153
Clinical and
Meal Nutrition
Therapeutic Menu Ingredients Amt Exch- Energy Protein Carbo- Vitamin
(g) ange (Kcal (g) hydrates A (µg)
(g)

Total

Conclusion
Compare the amount of the nutrients provided through the detailed menu plan with
the amount of the nutrients computed for the modified RDI. Give your suggestions
for improvement.

Nutrient Modified RDI Detailed Diet + % of Suggestions for

Plan Difference Improved Intake

Energy (Kcal)

Protein (g)

Carbohydrate (g)

Vitamin A(µg)

Submit the activity for evaluation.

——————————
Counselor’s Signature
154
 Nutr itio nal

ACTIVITY
Management in Liver,
Gall Bladder and

2
Pancreatic Diseases

DIET PLAN FOR LIVER CIRRHOSIS

Aim : To plan a diet for a patient suffering from liver cirrhosis. Date :
Case Study : Mr. Patra is a 49 years old business man who was admitted to the
hospital complaining of abdominal pain, oedema in the lower limbs,
severe nausea and vomitting. Imaging tests such as ultrasound etc.
have confirmed the diagnosis of varices veins, ascites and an enlarged
liver with orange coloured nodules. He is presently excreting tea-
coloured urine and clay-coloured stools. His biochemical parameters
are as follows:
Blood Ammonia : 63 µg/dl
Alkaline Phosphatase : 133 units /L (++++)
Serum bilirubin : 47 mg/Litre
Serum albumin : 1.9 g/dl
Haemoglobin : 7.5 g/dl
Folic acid (red cells) : 103 µg/ml
Prothrombin Time : >23 seconds
Systolic Blood Pressure : 165 mmHg
Diastolic Blood Pressure : 104 mmHg
Over the past four months, he has been complaining of profound weakness and has
been gradually loosing weight. Mr. Patra was a chronic alcoholic for about 15 years
and has left consuming hard drinks for the past 2 years. He has been an old case of
chronic alcoholic hepatitis with parenchymal necrosis.
At present his diagnosis is indicative of liver cirrhosis. He has been advised to take
bed rest and consume a high energy, protein and sodium restricted, soft, bland diet.
He will be kept under close medical observation/treatment to prevent the development
of hepatic encephalopathy.
Based on this case study now plan a diet for Mr. Patra following the instructions given
herewith.

Introduction
(Identify and describe the clinical condition of Mr. Patra in the space provided herewith).

155
Clinical and Comment on the significance of the following parameters with reference to the
Therapeutic Nutrition nutritional/health status of the patient.
a) Serum bilirubin
b) Blood Ammonia
c) Serum albumin
d) Prothrombin time

Step I: Patients Profile

On the basis of the clinical condition discussed in the case, fill the patient details in the format
given below.

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:
Clinical Profile
Patient Value Normal Value
Blood Ammonia
Alkaline Phosphatase
Serum bilirubin
Serum albumin
Haemoglobin
Folic acid (red cells)
Prothrombin Time
Systolic Blood Pressure
Diastolic Blood Pressure
Keeping in mind the clinical symptoms of Mr. Patra, identify and prioritize the various
objectives of dietary modifications. List them in the space provided herewith.
Objectives of dietary management

156
Step II: Assess/calculate the nutritional requirements of Mr. Patra Nutr itio nal
Management in Liver,
Write in the format given herewith. Compare Mr. Patra’s RDI with the RDI for a healthy Gall Bladder and
sedentary adult man. Pancreatic Diseases

Recommended Dietary Intake

Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Calcium (mg)
Iron (mg)
Vitamin A (g)
Sodium (mg)

Calculations:

Step III: Now based on the modified RDI, carefully select the food exchanges
that can help in providing relief to Mr. Patra, in the format given herewith.
Exchange No. Energy Protein Carbohydrates Fats
(Kcal) (g) (g) (g)
Whole Milk
Skim Milk
Meat
Pulse
Cereals
Roots/
Tubers
Other
Vegetables
Leafy
Vegetables
Fruit
Fat
Sugar
157
Clinical and Step IV: Distribute the food exchange for each meal
Therapeutic Nutrition
Mr. Patra is suffering from abdominal pain, severe nausea and vomitting. Select an appropriate
meal pattern which can help in facilitating an adequate food intake. Distribute the food exchanges
accordingly.

Exchange No. Early Light Mid Early Evening Dinner Post

Morning Breakfast Morning Lunch Tea Dinner

Early Late

Whole Milk
Skim Milk
Meat
Pulse
Cereals
Roots/tubers
Other
Vegetables
Leafy
Vegetables
Fruit
Fat
Sugar

Step V: Plan a day’s menu for Mr. Patra

Do remember his clinical condition (enlarge liver, ascites, varices veins) and plan a menu for
him which is nutrient dense, easy to digest and bland. (You may modify the meal frequency/
timings).
Sample Menu for Mr. Patra
Early Breakfast Mid- Lunch Evening Dinner Post
Morning Morning Tea Dinner

158
Step VI : Detailed menu plan Nutr itio nal
Management in Liver,
(Give the detailed menu plan in the format given herewith). Gall Bladder and
Pancreatic Diseases

Meal Menu Ingredients Amt(g) Exchange Protein Carbo- Vitamin A

(g) hydrates (µg)
(g)

Grand Total

159
Clinical and Conclusion
Therapeutic Nutrition
Compare the amount of the nutrients provided through the detailed menu plan with the amount
of the nutrients computed for the modified RDI. Give your suggestions for improvement.

Nutrient Modified Detailed Diet + % of Suggestions for

RDI Plan Difference Improved Intake

Energy (Kcal)

Protein (g)

Carbohydrate (g)

Vitamin A (µg)

What counseling tips would you give to Mr. Patra/his care-givers regarding the
food choices/intake (give special emphasis to sodium intake)?

Submit the activity for evaluation.

———————————
Counselor’s Signature
160
 5^3^^

Nutr itio nal

Management in Liver,
ACTIVITY Gall Bladder and
Pancreatic Diseases
DIET PLAN FOR CHOLELITHIASIS/
CHOLECYSTITIS 3
Aim : To plan a diet for a patient suffering from cholelithiasis. Date :

Case Study : Mala, a 57 years old women (height 5^3^^ ; weight 64 years) was
admitted to the gastroenterology ward of a hospital when she
complained of sudden onset of severe steady epigastric pain, nausea
and recurrent vomitting. She had been diagnosed to be having small
stones in her gall bladder about a year ago. Imaging tests on admission
have indicated inflammation of the gall bladder, along with
cholelithiasis. Some of the biochemical tests conducted was:
White blood cells: 14, 500 µl
Serum bilirubin: 3.9 mg/dl
Serum aminotransferase: 300 units/ml
She was given drugs to relieve pain and was kept on an NPO regime for 12 hrs.
Thereafter, she was given enteral tube feed for about 24 hours. At present she has
been advised to adhere to a low fat weight reduction diet and her condition shall be
monitored for one month. Mala is being counseled for conducting laproscopic
cholecystectomy (if required).
Based on this case study, now plan a diet for Mala following the instructions given
herewith.

Introduction
(Elaborate on what is cholelithiasis and discuss the association between cholelithiasis and
cholecystitis in the space provided herewith).

Comment how can an NPO regime and low-fat enteral tube feeds be helpful during
the recessive phase of an acute attack during cholecystitis?

161
Clinical and Step I: Patient Profile
Therapeutic Nutrition
Identify the case details and mention them in the format given below:

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:
Clinical Profile
Patient Value Normal Value
White Blood Cells
Serum bilirubin
Serum amino transferase
Ideal Body Weight
Body Mass Index
Mala is suffering from both cholelthiasis, as well as, its associated cholecystitis. Based
upon the principles of dietary management discussed in section 7.4 and the case
details identified above, prioritize the objectives of dietary management for her in the
space provided herewith.
Objectives

Step II: Assess and compute the nutritional requirements of Mala

Remember that the patient is overweight/obese and is suffering from cholelithiasis. Oral intake
is generally resumed when the inflammation has subsided. Accordingly calculate the nutrient
requirements and compare them with the requirements of normal individual.

Recommended Dietary Intake

Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Carbohydrate (g)
Fat (g)
Crude Fibre (g)
Cholesterol (mg)
Calcium (mg)
162
Calculations: Nutr itio nal
Management in Liver,
Gall Bladder and
Pancreatic Diseases

Step III: Next select the food exchanges that can help in providing the
nutrients as per the nutritional needs (modified RDI) of the patient given
above.
Exchange No. Energy Protein Carbohydrates Fats
(Kcal) (g) (g) (g)
Skim Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Fat
Sugar
(Note: Fat should be given in limited amounts because of its association with contraction of
the gall bladder.)

Step IV: Select an appropriate meal pattern for Mala

Due to impaired functioning of the gall bladder and abdominal pain/flatulence, small frequent
meals are recommended for patients suffering from diseases of the gall bladder. Therefore,
select an appropriate meal pattern for Mala and distribute all the food exchanges proportionately
throughout the day in the format given herewith.

Exchange No. Early Light Mid Early Evening Dinner Post

Morning Breakfast Morning Lunch Tea Dinner
Early Late

Skim Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Fat
Sugar
163
Clinical and Step V: Select appropriate dishes to plan a day’s menu for Mala
Therapeutic Nutrition
Remember, the meals should be low in calories, easy to digest, bland and at the same time
provide satiety to promote recovery, prevent progression of the disease and at the same time
facilitate weight reduction. (You may modify meal frequency/timings).

Sample Menu for Mala

Early Breakfast Mid Lunch Evening Dinner Post
Morning Morning Tea Dinner
Early Late

Step VI: Detailed menu plan

(Write the detailed menu plan in the format given herewith).

Meal Menu Ingredients Amt Exch- Energy Protein Carbo- Vitamin A

(g) ange (g) hydrates (µg)
(g)

164
 Nutr itio nal
Management in Liver,
Meal Menu Ingredients Amt Exch- Energy Protein Carbo-Gall Vitamin
Bladder andA
(g) ange (g) hydrates
Pancreatic (µg)
Diseases
(g)

Total

165
Clinical and Conclusion
Therapeutic Nutrition
Compare the grand total obtained for various nutrients in the detailed menu plan with
the computed modified RDI and interpret as follows:

Nutrient Computed Detailed + % of Suggestions for

Modified RDI Diet Plan Difference Improved Intake

Energy (Kcal)

Protein (g)

Crude Fibre (g)

Dietary Fibre (g)

Iron (mg)

Vitamin A (g)

Comment on what is the significance of calculating dietary fat/cholesterol and

crude fibre content of the detailed menu plan.

Submit the activity for evaluation.

———————————
Counselor’s Signature
166
 5^5^^

Nutr itio nal

Management in Liver,
ACTIVITY Gall Bladder and
Pancreatic Diseases

4 DIET PLAN FOR PANCREATITIS

Date : Aim : To plan a diet for a patient suffering from pancreatitis.
Case Study : Mr. Ramesh is a 39 years old (height 5^5^^, weight 61 kg) accountant
working in middle cadre export house. He was admitted to the hospital
during an acute phase of chronic pancreatitis. He was complaining
of persistent/recurrent episodes of epigastric and left upper quadrant
pain radiating towards the upper left lumbar region. He has been
experiencing anorexia, nausea, vomitting and steatorrhoea for more
than 6 months. Laboratory findings have indicated elevated levels of
serum amylase, lipase and alkaline phosphatase. He has been advised
to completely restrict alcohol intake. At present he is on a full fluid
diet for 24 hours and thereafter he has been prescribed a high energy,
low fat, soft diet. Mr Ramesh has been put on pancreatic enzyme
supplementation therapy in view of steatorrhoea, gastric discomfort
and weight loss due to malabsorption.
Based on the case study, plan a diet for Mr. Ramesh following the instructions given
herewith.

Introduction
(In the space provided herewith, describe the term ‘chronic pancreatisis’. Comment, why
Mr.Ramesh has been prescribed a full-fluid diet before the initiation of high energy-low fat soft
diet).

167
Clinical and Step I : Patient’s Profile
Therapeutic Nutrition
Read the case carefully, and mention the patient details in the format given below:
Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:
Diet prescribed a)…………………………
b)………………………..
Body Weight Present…………………..kg
Ideal Body Weight……………………..kg
Keeping in mind the clinical and laboratory findings of Mr. Ramesh, identify and
prioritize the objectives of dietary modification here in the space provided.
Objectives

Step II: In view of the present health status of Mr. Ramesh, assess/calculate
his nutritional requirements that would enhance recovery and promote weight
gain/nutritional status.

Recommended Dietary Intake

Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Carbohydrate (g)
Fat (g)
Fibre (g)
Calcium (mg)
Vitamin A (µg)

Calculations:

168
Step III: Now select the food exchanges that would be most appropriate for Nutr itio nal
Management in Liver,
providing the nutrients as per the needs of Mr. Ramesh. Gall Bladder and
Pancreatic Diseases
Do remember the restrictions required for fat intake with respect to steatorrhoea.

Exchange No. Energy Protein Carbohydrates Fats

(Kcal) (g) (g) (g)
Whole Milk
Skim Milk
Meat
Pulse
Cereals
Roots/Tubers
Other Vegetables
Green Leafy
Vegetables
Fruit
Fat (limit)
Sugar

Step IV: Distribute the selected exchanges according to the meal pattern
most suitable during chronic pancreatitis.
Select a meal pattern for Mr. Ramesh that can help in alleviating / reducing symptoms associated
with steatorrhoea and which can promote weight gain (You may add or modify the meal pattern
mentioned in the format given herewith).

Exchange No. Early Light Mid Early Evening Dinner Post

Morning Breakfast Morning Lunch Tea Dinner

Early Late

Skim Milk

Whole Milk

Meat

Pulse

Cereals

Roots/Tubers

Other Vegetables

Green Leafy
Vegetables

Fruit

Fat

Sugar
169
Step V:and
Clinical Plan a day’s menu for Mr. Ramesh
Therapeutic Nutrition
By using the exchanges (given in step IV above) available for each meal. Lay emphasis on low fat, moderate protein, high energy
soft and easy to digest meals. You may refer to sub-section 7.5.1 earlier for completing this exercise.

Sample Menu for Mr. Ramesh

Early Breakfast Mid Lunch Evening Dinner Post
Morning Morning Tea Dinner
Early Late

Step VI :Detailed menu plan

(Give the detailed menu plan in the format given herewith).

Meal Menu Ingredients Amt Exchange Energy Protein Fat (g) Calcium
(g) (Kcal) (g) Visible/ (mg)
Invisible

170
 Nutr itio nal
Meal Menu Ingred Amt Exchange Energy Protein Fat (g) Calcium
Management in Liver,
-ients (g) (Kcal) (g) Visible/ Gall Bladder
(mg) and
Pancreatic Diseases
Invisible

Total

171
Conclusion
Clinical and
Therapeutic Nutrition
Compare the grand total obtained for various nutrients in the detailed menu plan with the
computed modified RDI and interpret as follows:

Nutrient Computed Detailed + % of Suggestions for

Modified RDI Diet Plan difference Improved Intake

Energy (Kcal)

Protein (g)

Fat (g)

Calcium (mg)

Submit the activity for evaluation.

———————————
Counselor’s Signature
172
 Planning Diets for
PRACTICAL 8 PLANNING DIETS FOR Renal Diseases

RENAL DISEASES
Structure
8.1 Introduction
8.2 Renal Diseases An Overview
8.2.1 Glomerulonephritis/ Acute Glomerular nephritis
8.2.2 Nephrotic Syndrome
8.2.3 Chronic Renal Failure (CRF)
8.2.4 Acute Renal Failure/ Acute Kidney Injury
8.2.5 End-Stage Renal Disease (Dialysis)
8.2.6 Nephrolithiasis or Renal Calculi

8.3 Review Exercises

Activity 1: Diet Plan for Glomerulonephritis
Activity 2: Diet Plan for Nephrotic Syndrome
Activity 3: Diet Plan for Chronic Renal Failure
Activity 4: Diet Plan for Acute Renal Failure
Activity 5: Diet Plan for Dialysis
Activity 6: Diet Plan for Nephrolithiasis

8.1 INTRODUCTION
In this practical, our focus shall be on planning suitable diets for renal diseases. We
shall review the various renal problems followed by the nutrient requirements during
these conditions and the translation of nutritional requirements into suitable food sources
as per the RDI so as to result in the development of an appropriate diet. Before you
start studying this practical, we suggest you look up Unit 16 in the theory course
Clinical and Therapeutic Nutrition (MFN-005) which presents a detail review on the
various renal disorders covered in this practical.
Objectives
After undertaking this practical you will be able to:
 describe the different renal disorders,
 discuss the dietary management of the renal disorders, and
 plan diets for patients suffering from glomerulonephritis, nephrotic syndrome,
chronic/acute renal failure, end-stage renal disease and nephrolithiasis.

8.2 RENAL DISEASES – AN OVERVIEW

Renal disease or diseases of the kidney are among the most ‘critical to treat’
disorders. Their treatment and management is still a challenge to medical science.
Despite receiving prompt and efficient treatment; many of these diseases leave
degenerative diseases that may increase the risk for the development of renal failure
with advancing age.
Glomerulonephritis, nephrotic syndrome, chronic/acute renal failure, end-stage renal
disease and nephrolithiasis are the most common forms of renal diseases. In the
subsequent section, we shall learn about different types of renal disease and their 173
dietary management.
Clinical and 8.2.1 Glomerulonephritis
Therapeutic Nutrition
Glomerulonephritis, as you may recall studying, refers to inflammation of the nephrons;
the key functional unit of the kidney(s). It generally occurs due to the antigen- antibody
reactions that occur in response to a particular infection (generally a streptococcal
infection). It is characterized by fever, uremia (accumulation of nitrogenous waste
products and other urinary constituents in blood), oedema, hypertension and oliguria/
anuria (reduced or no urine output because of reduced GFR). Figure 8.1 illustrates the
flow diagram for the development of glomerulonephritis. Going through the flow chart
will help you recapitulate the progression of glomerulonephritis about which you have
already studied in Unit 16 in the theory course.
Inflamed/damaged (scar) Nephrons
 
Leakage of plasma Acidosis
proteins and blood 
cells in urine Reduced GFR ( 50%)


Oliguria
(reduced urine output; ½ - 1 Litre/day)

 
Reduced excretion of sodium Oedema
Hypertension


Hyperkalemia Cardiac arrest
 Elevated levels of urea
and creatinine in blood

 } Anorexia
Nausea
Vomitting

Low food intake

Tissue catabolism to
release energy &
protein for basal
needs
Figure 8.1: Flow diagram for glomerulonephritis

The treatment of glomerulonephritis is based on antibiotic therapy, complete bed rest

and maintenance of optimum nutritional status. Let us review the dietary management
of glomerulonephritis in greater details.
Dietary modifications of both macro- and micronutrients are required for the effective
management of glomerulonephritis and is based on the following objectives:
Objectives
The objectives of dietary management of glomerulonephritis are to:
 cure the underlying disease,
 reduce/prevent the severity of oedema and uremia,
 maintain fluid and electrolyte balance,
 maintain nitrogen balance, and
 help in maintaining an adequate nutritional status.
The nutrient needs for glomerulonephritis are enumerated next.
Energy : The total calories provided through diet to the patient depend upon the
presence/absence of fever, current activity level (ambulatory/complete bed rest) and
present body weight. Elevation of body temperature results in an increase in basal
174 metabolic rate (BMR) and hence the energy intake may be increased by about 10%.
When patients are suggested complete bed rest; their energy expenditure on Planning Diets for
Renal Diseases
routine activities is minimal. In such cases, the energy intake may be reduced by 5%
to 10% from the levels suggested by RDI for non-ambulatory patients. Adults may
need 30-40 Kcal/kg dry weight and children about 100 Kcal/kg dry weight or more,
based on age.
Protein: The protein intake should be calculated in accordance with the severity of
uremia (blood urea nitrogen levels (BUN) and oliguria. Initially, 0.6 to 0.8 g protein/kg
ideal body weight (IBW) is provided using principally high quality protein. Normal
levels of protein (1 g/kg IBW) may be provided if BUN levels remain within the
normal range.

Note: If the patient is suffering from oedema, the present body weight should
not be used to calculate his protein intake. In such cases, the protein intake may
be calculated on the following basis:
 The weight documented in his previous medical records (< 6 mths).
 Calculate patient’s IBW based upon his height by using the formula:
Men: 48 kg for first 5ft + 2.7 kg for each additional inch
Women: 45.5 kg for first 5ft + 2.3 kg for each additional inch. ( ±10% for small/
large build in both cases)

Since the protein intake is restricted, we must lay emphasis on high biological value or
good quality proteins. Generally, proteins present in animal foods contain a higher
proportion of essential amino acids as compared to those of plant origin. Eggs, milk
and certain milk products (curd, paneer), meat, fish, poultry, whole pulses/legumes
and their products particularly soyabean, soya-milk, tofu, texturized soya protein can
help in improving the essential amino-acid content of the diet. Since cereals (wheat,
wheat products, rice, maize etc) are poor sources of good quality protein; they are
generally substituted by starch rich foods (potato, colocasia, yam, sago, arrowroot
flour etc). Sago khichdi, scrambled egg, halwa, cottage cheese preparations, tofu or
dal stuffed roti, substitution of soya milk for water in the preparation of pulses/legumes/
vegetables/kneading of dough are good options for feeding these patients.
A sample menu for a glomerulonephritis patient is included here for your reference.
Sample Menu
Early Morning Tea (Cream substituted for milk)
Arrowroot biscuits
Breakfast Sago porridge
Potato stuffed roti
Mid Morning Carrot halwa/ Potato halwa
Lunch Vegetable Preparation
Egg/Meat Preparation
Arrowroot and wheat flour chappati
Evening Tea Sago vada
Tea
Dinner Meat/paneer preparation
Vegetable preparation
Chappati
Suji Ladoo
Bed Time Sago-corn pudding
Next, let us study about the nephrotic syndrome.

175
Clinical and 8.2.2 Nephrotic Syndrome
Therapeutic Nutrition
Nephrotic syndrome referred to as ‘Nephrosis’, is characterized by impaired nephrons
function and reduced reabsorptive capacity of renal tubules which results in massive
proteinuria and severe oedema. It generally occurs among children. The clinical
symptoms include proteinuria, haematuria, hyperalbuminemia, periphral oedema, ascites,
malnutrition etc. Figure 8.2 illustrates the progressive damage of nephrons a a result
of nephrotic syndrome.
Progressive Damage of Nephrons

Increased amount of proteins filtered through
Glomecular basement membrane

Anaemia  Proteinuria

  
Hypothyroidism Hypoalbuminemia Peripheral oedema
 and 
Low plasma osmotic ascites
 pressure
Reduced plasma volume


Reduced renal blood flow 


Enhanced renin angiotensin
aldosterone mechanism

Increased reabsosption of
sodium and water

Figure 8.2: Flow diagram for nephrotic syndrome

The treatment of nephrotic syndrome is based on the cure of the underlying cause,
maintain optimum nutritional status so as to prevent the onset of complications and
handle undernutrition effectively. The dietary requirements for nephrotic syndrome
patients is highligted next.

Energy : Most of the nephrotic syndrome patients are severely malnourished and in a
catabolic state. Adequate amount of energy is required to promote a positive energy
balance so as to promote effective utilization of dietary proteins for the synthesis of
blood proteins and also to prevent subsequent weight loss. The energy intake should
be increased by 10% i.e. around 35-40 Kcal/kg ideal body weight in case of adults and
about 100 Kcal/kg body weight for children.

Protein : Protein intake of 0.8 g/kg ideal body weight plus 1 g/g of proteinuria is
recommended. This helps in maintaining a positive nitrogen balance which helps to
promote hepatic synthesis of albumin and replenish body stores of plasma proteins.
Emphasis should be laid on high biological value proteins such as milk, curd, paneer,
egg whites, lean meats such as poultry/marine foods and whole pulses/legumes.
Although animal proteins contain a higher proportion of essential amino acids as
compared to plant proteins; they are also rich sources of sodium.

A combination of plant and animal protein food sources may be included in the diet.
Besides, we should employ alternative methods of food preparation such as sprouting
and fermentation which help to improve the bio-availability of proteins. Sprouted grain/
legumes (rajmah, whole green gram dal, horse gram, Bengal gram, whole wheat) may
176
be added to any vegetable preparation, paranthas, pulaos, salads, raitas, sandwiches, Planning Diets for
Renal Diseases
cutlets, soups etc. Fermented dishes such as dosa, uttapam, idli, dhokla can also be
included.
Carbohydrates: A high carbohydrate intake (~60 - 65% of total energy is generally
recommended for protein sparying action). A combination of both simple and complex
carbohydrates may be given. Dietary fibre intake may be slightly reduced if the patient
is experiencing gastrointestinal disturbances. Emphasis should always be laid on soluble
fibre and all high fibre foods should preferably be given in a soft cooked form.
Carbohydrate foods help to reduce bulk and facilitate easier/faster digestion which
can help in ensuring an adequate food intake. Since sago, arrowroot, yam, potato are
low in sodium and easy to digest, they should be preferred over jowar, bajra, ragi etc.
(high fibre) which are difficult to assimilate and may cause flatulence. Rice, suji,
maida, wheat flour, breads/pastas (manufactured without using sodium salts) can be
included in the diet.
Fat: Fat intake may remain normal or slightly restricted. Emphasis should be laid on
the inclusion of vegetable oils which are low in saturated fats and are good sources of
poly-unsaturated/mono-unsaturated fatty acids. Animal fats and red meats being high
in saturated fatty acids and cholesterol may be avoided. The diet should not provide
more than 200 mg cholesterol per day if the patient is hypercholesterolemic.
Therefore, we must avoid cream, butter, ghee, margarine, hydrogenated fats
(particularly bakery products), red meats (lamb, pork, bufallo, cow), egg yolk, whole
milk, pistachios, cashewnuts etc. We must also avoid the inclusion of fried/high fat
foods such as mathris, namakparas, kachories, certain biscuits, khaties, creamed
cakes/pastries etc.
Sodium: Although the underlying cause of oedema is proteinuria; restrictions in the
intake of sodium can help in preventing further accumulation of fluids and electrolytes.
Approximately 2-3 g of sodium/day may be recommended. Usually added salt is
prohibited in these patients. Refer to Table 16.2 in Unit 16 and Table 11.6 in Unit 11 in
the theory course which presents the foodstuffs high in sodium. Avoid these foods in
the diet of the nephrotic syndrome patient.
Potassium: Unlike glomerulonephritis, patients suffering from nephrotic syndrome
may suffer from hypokalemia. Potassium deficiency may occur due to prolonged
proteinuria and/or if the patients are being treated with diuretics. Pulses/legumes such
as cowpea, green gram dal, red gram dal, brinjal, cauliflower, carrot, potato, papaya
are fairly good sources of potassium. These may be included in the diet. If potassium
levels get severely depleted, potassium salts such as potassium glutamate may be
used for cooking. This can also help in improving the palatability of meals.
Calcium: In patients suffering from prolonged proteinuria, deficiency of
specialized binding proteins may result in deficiency of calcium. This may result in
bone rarefaction (bone pain and weakness). The blood phosphorus levels should also
be checked regularly to assess the phosphorus status. Therefore, calcium
supplementation along with moderate protein is recommended. Foods rich in calcium
but low in sodium should be selected such as whole pulses/legumes (Bengal gram
whole, black gram whole, green gram whole, rajmah, soyabean), carrots, beans, onion
etc. Skimmed milk and milk products should be used in moderation in accordance
with the sodium and fluid allowance of the patient.
Other Vitamins and Minerals: Most of the patients have a poor nutritional status.
Although anaemia is principally due to loss of blood in urine and an impairment of the
regulatory function of kidneys i.e reduced production of the erythroprotein factor;
majority of the patients also have poor reserves of B-group vitamins such as folic acid,
thiamin and riboflavin. Restrictions on the inclusion of fruits and vegetables make the
diets poor sources of several water - soluble vitamins and minerals. Some food sources
of vitamin C may be included in the diet such as amla, lemons, orange, guava depending
upon the level of sodium restriction as it helps in wound healing. Though vitamin A 177
plays an important role in cell multiplication/differentiation and also in maintaining the
Clinical and integrity of epithelial cells; much stress on the inclusion of vitamin A rich foods/vitamin
Therapeutic Nutrition A supplements is not laid if the nephrotic syndrome is progressing towards renal failure.
To promote calcium absorption and bone calcification, vitamin D may also be provided
in sufficient amounts. Fats and fat rich food sources provide good amount of vitamin
D but need to be restricted due to hypercholesterolemia. Thus, vitamin and mineral
supplements may be required in severe situations.
Fluids: Fluid intake remains normal (~1500 ml/day) as there is no oliguria in
patients suffering from nephrotic syndrome. However, if the condition progresses
towards renal failure, fluid intake may be monitored in accordance with the
urine output.

Some other useful tips for planning diet are also highlighted herewith.

Useful tips for planning diet

l Since the patients are anorexic but at the same time have increased nutritional
requirements, small nutrient dense meals should be served at frequent intervals.
Thus, a 6-7 meal pattern (early-morning, breakfast, mid-morning, lunch, evening
tea, dinner and bed-time) should be followed.

l Majority of the patients being children, serving the meals attractively with variety
in terms of colour, texture, taste, flavour and mouthfeel can prove to be beneficial
in improving the overall intake of the patient. For example; an orange/strawberry
sugar toffee (sugar hardball/candy) can be crushed and sprinkled over curd/sago
porridge to make it appear attractive.

l A variety of cooking methods should be employed. Use of non-stick cook ware,

baking, boiling, roasting and microwave cooking may be helpful.

l Small amounts of alternative flavourings such as small amounts of coriander,

mint, ginger, lemon drops, cardamom, clove, drumstick may be used to improve
the palatability of meals.

l Most of the protein rich food sources particularly those of animal origin is also
high in their sodium content. This may restrict their intake. Thus, if the patient is
suffering from severe proteinuria and oedema; protein supplements such as whey
protein, soya protein and casein may be added to the meals to increase the protein
intake. These can be sprinkled over cooked dishes, mixed with flours while
kneading dough or mixed with curd/milk.

l If the patient is hypercholesterolemic, we should avoid foods high in cholesterol

and/or saturated fats. Thus, egg yolks, red meats, whole milk/whole milk products
and majority of nuts should be strictly avoided.

Next, we move on to chronic renal failure.

8.2.3 Chronic Renal Failure

Chronic renal failure (CRF) is a condition characterized by progressive loss of
renal tissues which affects the excretory, regulatory and metabolic functions of the
kidneys. The clinical symptoms include reduced glomerular filtration rate, uremia
(elevated blood urea and creatinine), nocturia, overhydration/dehydration, anaemia
etc.

All these symptoms and the progression of chronic renal failure also referred to as
‘chronic kidney disease’ have been discussed in the Theory Manual (MFN-005) i n
Unit 16. Let us quickly take an overview of the various stages/symptoms that
take place during the development progression of CRF which are illustrated in
178
Figure 8.3.
 Loss of renal reserve Planning Diets for
Renal Diseases

Increased load of solutes

Osmotic diuresis

Increased urine excretion + Nocturia



Reduction in plasma volume Increased thirst
 
Reduced arterial blood pressure Increased fluid intake
 
Reduced renal blood flow Overhydration
 
Reduced glomerular filtration rate Oedema

Changes in the excretory/regulatory/metabolic function of the kidneys

  
Excretory Regulatory Metabolic
 Uremia/Azotemia  Hypertension Acidosis
 Oliguria  Compensatory  Bone disease
 Oedema  hyperventilation Anaemia
 Elevated levels of  Increased capillary
sodium, potassium fragility
phosphate


Hypertensive encephatopathy/uremic coma
Pulmonary oedema
Skin, nose and G.I. haemorrhages  Death
Cardiac arrest
Severe infection

Figure 8.3: Flow diagram for CRF

Let us now discuss the various principles of dietary management that are essential for
the effective treatment of chronic renal failure (CRF) which is also referred to as
chronic kidney disease (CKD). While regression of CRF is usually not possible, as a
Dietitian our endeavour should be to prevent the progression and delay the onset/
severity of complications. The various objectives (which must be identified in terms of
their priority) can be outlined as mentioned below.
Objectives
The objectives of dietary management of chronic renal failure are to:
l prevent/control uremia and tissue catabolism,
l maintain fluid and electrolyte balance,
l correct acidosis,
l prevent the onset and/or manage/treat the complications arising due to renal
degeneration,
l prevent further progression of Kidney damage, and
l maintain an optimum nutritional status.
Nutritional modifications are particularly crucial in case of protein, cholesterol, sodium,
potassium, phosphate, calcium and water intake. Before we begin to prepare a diet 179
Clinical and plan, let us brief ourselves regarding the changes in the quantity/quality of foodstuffs
Therapeutic Nutrition for each nutrient. Refer to Table 8.1 for the dietary guidelines.
Table 8.1: Dietary guidelines for CRF
Nutrients Comments
Energy 30-40 Kcal/kg/day for adults and 100-150 Kcal/kg/
day for children.
Carbohydrates 300-400 g/day to avoid endogenous protein
catabolism, gluconeogenesis and subsequently
uremia.
Proteins 0.6-0.8 g/kg/day, with 60-70% as high BV protein.
To reduce N2 load, a mixture of essential amino
acids is recommended.
Sodium 500 mg - 2.0 g/day. Additional Na in case of weight
loss and decreasing urine volume and restriction of
Na in case of oedema and hypertension.

Potassium Intake must be kept at 1500 mg/day (3.0 mEq/day)

and in case of significant losses, potassium
supplements should be given.
Calcium and Calcium supplementation – 1 to 2 g/day and
Phosphorous phosphate to be restricted to 800-1200 mg/day
Vitamin Multivitamin supplements, specially vitamin D3
Fluid Intake is dependent on urine output and water
balance.

Leaching of foods can lower the sodium and potassium content of foods. Read the
information in Box 8.1 for more information on this topic.

Box 8.1 Leaching of Foods can Lower their Sodium and Potassium
Content.
How can we leach vegetables and certain fruits?
1. Peel the vegetable/fruit, cut into small pieces and place in a large pot of
water.
2. Rinse the vegetable/fruit.
3. Fill the pot with clean water and let the vegetable soak for atleast 4 hours
at room temperature (overnight, if in refrigerator).
4. After soaking, rinse the vegetables.
5. Discard water.
6. Cook as desired and limit the portion size to no more than ½ cup.
Note:
 Cauliflower, mushrooms, carrots, peas, potato, bottlegourd, guava etc. can
easily be leached.
 Avoid vegetables/fruits which have a soft mushy texture (tomatoes,
pumpkin, bananas…..) as they would get dissolved in water during the
process of soaking.
Disadvantage: Leaching not only reduces the sodium and potassium content; it
also lowers the amount of water soluble vitamins and several minerals. It should
preferably be practiced only when sodium intake is restricted to ~500 mg/day.
180
Further, hyperkalemia has been found to be a critical factor related to morbidity and Planning Diets for
Renal Diseases
mortality among CRF patients. Therefore, potassium levels in blood can be maintained
by:
 Avoiding processed foods.
 Avoiding ‘low salt’ snacks/ready-to-eat foods, if table salt (NaCl) has been
substituted by a potassium salt.
 Consuming a small serving size of fruits and vegetables even if they are inherently
low in potassium.
 Adhering to the dialysis schedule.
We should choose low/high potassium foods (listed in Box 8.2) according to the blood
potassium levels.

Box 8.2 Food Sources of Potassium

Food >300 mg/ 100 g 200-300 mg/ 100g <200 mg/ 100g
(High Sources of Potassium) (Medium Source of Potassium) (Low sources of Potassium)
Avocados, Bananas, Dried Berries, Grapes, Lemon, Mango, Papaya, Orange,
Fruits fruits, Kiwi, Apricot, Dried Peaches, Plum, Pineapple, Apple, Litchi
Orange/prune juice. Watermelon, Cherries

Artichoke, Dried beans and Tomato, Cabbage, Eggplant, BottleGourd, Pumpkin

Potato, Cooked spinach, Green Beans, Lettuce, Onions, (Green,Cylinderical), Cucumber
Vegetables Sweet potato, Vegetable soup, peas, Bitter gourd (short),
Cauliflower Pumpkin (Orange, round)

Dairy Khoa, Yoghurt, Ice-cream. Non-dairy creamers, Rice milk Milk, Paneer
(unenriched), Non-dairy
whipped toppings.

Snacks Chocolate, Seeds & nuts, Salt Sorbet, Jelly, Hard Candies, Plain
substitutes Donuts, Unsalted Popcorn.

Source: Compiled from Indian Food Composition Tables, ICMR, 2017

Few other useful tips are highlighted herewith.
Useful Tips for Planning the Diet
 Since most of the patients are anorexic, it is important to give small frequent
meals; a 6-7 meal pattern can be helpful in feeding adequate amount of food.
 Keeping in view the bad taste in mouth; the meals should have a variety of
flavour, colour, texture, taste and mouthfeel.
 If the fluid allowance is restricted, the patients may experience thirst, dry tongue/
mouth and difficulty in swallowing dry meals. In such cases, include saliva stimulants
(very small amounts) in meals such as lemon drops, mint, mango powder, dry
pomegranate seeds etc. Some of these may also help in improving the flavour of
meals. The patient may also be advised to hold thin slices of ice, leached fruit
slices between lips but should not swallow them. Use of certain sodium-free
mouth washes can also provide temporary relief from the fetid odour in mouth.
 The patient should be accurately weighed atleast once in every 24 hours. Any
gain in weight would be an indicator of fluid retention (oedema) in the body
indicating worsening of the disease condition. In such situations, changes may be
required in the fluid allowance along with nutrient modifications. The plan of
action for dialysis Renal Replacement Therapy (RRT) may also be required to
be initiated. 181
Clinical and  Several tube feeds are exclusively available for renal patients. These may be
Therapeutic Nutrition given when the nutrient requirements of the patient can not be met by the naturally
available foods. Tube feeds are generally given during stage V of CRF.
 Leaching of vegetables and fruits (where feasible) reduces the water soluble
vitamin/mineral content apart from that of sodium and potassium. Thus, nutritional
deficiencies need to be prevented by giving adequate amount of supplements.
 Patient and family counseling regarding dietary restrictions is very important for
both indoor and OPD patients.
Next a brief review on acute renal failure.
8.2.4 Acute Kidney Injury (Acute Renal Failure)
When the kidneys are not able to maintain the normal concentration of composition of
blood, it is called ‘renal failure’.
Acute renal failure can be described as a condition characterized by sudden stoppage
of renal function following either a traumatic injury or some other metabolic disturbances
in the body and is associated with a sharp reduction in the glomerular filtration rate
(GFR below 10 ml/min); thereby indicating that the functional capacity of kidneys has
reduced by nearly 90%. Figure 8.4 illustrates the flow diagram for acute renal failure
which will help you understand the progression of the disease condition.
Excessive loss of blood/plasma/fluids

Low blood volume

Hypotension (low blood pressure)

Reduced renal blood flow


 Reduced glomerular filtration rate (< 10 ml/min)
Reduced supply of O2
and nutrients to kidneys
 
Reduced urine output

Reduced functional 
(excretory/regulatory) Azotemia/uremia
capacity of the kidneys
+ 
Ischemic damage  Anaemia
to nephrons  Oseodystrophy 
 Metabolic acidosis

 DEATH

Dialysis is initiated to prevent death and to provide rest to the kidneys.

Underlying cause is treated.


Initiation of Diuretic phase i.e.
Increased urine output  excessive dehydration
 
Excretion of nitrogenous waste products Low blood volume
Excretion of metabolites from blood 
 Reduced GFR
Reduction in BUN/creatinine levels

Figure 8.4: Flow diagram for acute renal failure

182
The treatment of acute renal failure is based on management and cure of the underlying Planning Diets for
Renal Diseases
cause, kidney dialysis, dietary management and complete bed rest. The dietary guidelines
for acute renal failure are summarized in Table 8.2 for your easy reference.
Table 8.2: Dietary guidelines in acute renal failure
Nutrients Comments
Protein Unnecessarily protein respriction should not be
practiced in AKI. If not on dialysis, 0.8-1 g/kg/day.
If on dialysis, 1-1.5 g/kg. If on renal replacement
therapy (RRT) and upto maximum of 1.7 g/kg/ d for
continuous renal replacement therapy (CRRT) from
dietary or parenteral sources (KDIGO, 2012).
Kilocalories Provide sufficient amount for weight maintenance
or 25-30 Kcal/Kg body height. Increase to 30-35
Kcal/kg in hypercatabolic subjects. Encourage non-
protein calories from fats and simple carbohydrates.
Sodium In oliguric phase, restrict to 500-1000 mg (20-40
mEq). On diuresis, the amount may be increased.
Potassium If hyperkalemia present, restrict to 1000-2000 mg
(25-50 mEq). On improvement, increase to
60-70 mEq.
Fluids Limit fluids of an amount equal to urine volume plus
500 ml.
General considerations for the patient
 If oral intake is feasible, a 6-7 meal pattern should be adopted.
 During the oliguric phase, the diet may need to be supplemented with enternal/
parenteral nutrition particularly to meet the protein and sodium requirements of
the patient.
 Since most patients are anorexic and have dry mouth due to restrictions in fluid
intake during the oliguric phase; attempts must be made to introduce variety in
terms of colour, texture, taste, flavours, mouthfeel, variety of dry heat cooking
methods and saliva stimulants (small amounts of herbs, condiments) may be
useful in improving food intake.
 Fluid intake should be monitored carefully in accordance with the urine output
and oedema (if any).
 Counseling and preparation for renal replacement therapy of the patient should
be carried out with sensitive care.
 Techniques such as continuous arteriovenous haemofiltration and nutritional dialysis
may help in improving the emanicipated condition of the patient and/or may help
in releasing the dietary restrictions slightly.
A sample menu for an acute renal patient is given here for your reference.
Early Morning Breakfast Mid-Morning
Tea (with cream and sugar) One Egg white Rice/Sago
Arrowroot biscuits (2) Bread slices (2) Kheer
Jam/Unsalted butter
Sago Kanji (optional-fluid
allowance)
Lunch/Dinner Evening After Dinner
Chappati Rice kanji (optional) Potato halwa
Rice Sago wada (1/2 serving)
Curd (1/2 serving)/Paneer Potato fingers/ Brownies
Vegetable preparation (leached)
183
Clinical and Note:
Therapeutic Nutrition
 Sugar, honey, dextrose, unsalted cream, cooking oil should be used liberally to
increase the energy content of diet.
 Table/cooking salt should not be used. Vegetables (where feasible) should be
leached to reduce their sodium and potassium content.
Next, let us review the end stage renal disease.
8.2.5 End-Stage Renal Disease/Nutritional Management during
Dialysis
End-Stage Renal Disease (ESRD) can be clinically defined as a state of chronic
kidney disease when the glomerular filtration rate falls below 15 ml/min. This stage
usually required the initiation of “Renal Replacement Therapy”. Dietary management
and drugs can only help in delaying the need for renal replacement therapy (RRT).
RRT generally involves kidney dialysis and/or kidney transplantation about which you
have already studied in the theory course. We suggest you look up Unit 16, sub-
section 16.10.2 once again for a better understanding of dietary management of this
condition. Here for your understanding nutritional care during dialysis are highlighted
in Table 8.3.
Table 8.3 : Dietary Guidelines during dialysis
Nutrients Comments
Energy 30-40 Kcal/Kg/day for adults and 100 Kcal/Kg/day for childrem
Carbohydrates 300-400 Kcal for protein sparing action.
Proteins 1.2g/Kg/day in hemodialysis and 1.2-1.5 g/kg/day in peritoneal
dialysis
Sodium 1500-2500 mg/day. This helps to prevent pulmonary oedema or
congestive heart failure.
Potassium 1500-2500 mg/day is prescribed to prevent hyperkalemia.
Phosphorus 800-1200 mg/day if the serum phosphate level rises above 5.5 mg/
dl or pH levels are >300 pg/ml
Vitamin Supplements usually given as these are lost in dialysate.
Fluid Individualized according to urine output.
Fluid management during ESRD is also an important issue. It is restricted according to
urine output of patient. Therefore Box 8.3 present general formula and important
information related to calculation of fluid allowances for end stage renal diseases.
Box 8.3 How can We Calculate Fluid Allowance for 24 hours?

Formula :
Fluid (24 hours) = Insensible losses + Urine output in + Fluid losses due to
(500 ml) previous 24 hours diarrhoea/vomitting
Fluid losses due to diarrhoea/ vomitting
Remember, we are here referring to the term “fluid” and not “water”. Thus, the
fluid allowance calculate will include:
 Moisture present in food (ICMR food composition table)
 Water present in prepared dishes (curries, vegetable preparations, curd etc.)
 Water used in beverages or as such for taking medicines
 Water as a beverage to quench thirst.
Spraying mouth washes, sucking ice-chips/chilled fruit/lemon drops or chewing
184 gums containing citric acid can be helpful when fluid is restricted.
Finally, let us study about nephrolithiasis. Planning Diets for
Renal Diseases

8.2.6 Nephrolithiasis or Renal Calculi

As we all know, both environmental and nutritional factors have been shown to affect
stone nucleation and growth by their effects on urinary constituents and pH. The
formation of stones requires supersaturated urine, the greater the concentrations of
ions the more likely they are to precipitate. The concentration of ion depends on the
urinary pH, ionic strength and solute concentration. All these are very closely
associated with the quantity and quality of food (nutrients) we eat. So let us quickly
brief ourselves regarding the dietary management for various forms of renal calculi.
We begin with the objectives of dietary management.
Objectives
The objectives of dietary management of renal stones are:
 to bring about a change in the pH of urine by adjusting the pH of diet,
 to reduce the solute content of urine, and

 to promote excretion of calculi constituents in a bound form.

 Calcium Stones

 Uric Acid Stones

 Struvite Stones

 Cystine Stones
Although, role of diet in the formation of urinary stones is not well established, it is
advisable to have liberal fluid intake, a balanced diet and restrict foods based on the
main constituent of the stones. Table 8.4 gives information related to different stones
and their corresponding diet restriction.
Table 8.4: Different stones and their corresponding diet restrictions

Main Constituents Diet Restriction Urine pH

 Calcium stones Calcium – 400-600 mg Acid
 phosphate Phosphorus – 1000-1200 mg
 oxalate
 Struvite stones Low phosphorus Acid
 Uric acid Low purine Alkaline
 Cystine Low methionine Alkaline

Besides liberal fluid intake and some dietary restriction, urine pH control helps based
on the chemical composition of the stone, mainly via acidifying or alkalinizing agents
or diet. Binding agents to bind the stone constituent may also be used.

Enlisted below are a few examples of low, moderate and high sources of oxalic
acid and also food sources of phosphorous. You may use this information while
planning diets for renal stone patients where oxalate or phosphorous needs to be
restricted.

185
Clinical Therapeutic FOOD STUFF ACCORDING TO THEIR OXALIC ACID CONTENT
Nutritio n

Low Moderate High

(< 2 mg/100 g (2-10 mg/100 g (>10 mg/100 g
edible portion) edible portion) edible portion)
Rice Barley Wheat
Green gram dal Maize, tender Jowar
Red gram dal Lentil dal Bajra
Watermelon Bengal gram whole/dal Most leafy vegetables
Plum Cabbage Beet root
Maize, Sweet Banana Drum sticks
Beans Pineapple, Lotus stem (dry)
Bottle gourd Poha, Almonds
Cashewnuts
Dates Rice, puffed
Gingely seeds
Star fruit Papaya Amla
Cherries Seetaphal
Apple
Beef
Cowpea
Lady finger

FOOD SOURCES OF PHOSPHORUS

mg/100 gm edible portion
Low Moderate High
(<50 mg) (>50-100 mg) (> 100 mg)
Cabbage Vermicelli Most cereals (except
Lettuce Fenugreek Leaves Vermicelli)
Spinach Bathua All pulses
Potato Amarnath
Turnip Lotus stem
Most fruits Capsicum
(except bale, dates, Broad beans
Apricot dried) Raisins
Beet root Dates
Cauliflower
Cucumber
With this, we end our study about the renal diseases and their dietary management.
To recapitulate what you have learnt so far, we suggest you undertake the review
exercises given next. These are self check exercises. Once you have attempted them
successfully, you can move on to the activities included here in this practical. There
are 5 activities, which will provide you hands down experience of planning diets for
various renal conditions.

8.3 REVIEW EXERCISES

1) What would be the fluid allowance for a glomerulonephritis patient whose urine
output was 473 ml in the previous 24 hrs.
Step1: Write the formula for calculating fluid allowance.

Step 2: Put figures in the formula and derive the intake.

186
2) Comment upon the quality and quantity of protein to be included in the diet of Planning Diets for
Renal Diseases
7 year old girl suffering from nephritic syndrome.
Quality:..........................................................................................................
.....................................................................................................................
Quantity: .......................................................................................................
.....................................................................................................................
3) While planning diet for nephritic syndrome, why do we lay stress on the inclusion
of a combination of “starches and cereals” rather than “cereals only” in the
diet.
.....................................................................................................................
.....................................................................................................................
4) Explain the step-wise process of leaching. What are its advantages/
disadvantages.
.....................................................................................................................
.....................................................................................................................

Advantages Disadvantages

5) What suggestions would you give to a patient suffering from CRF who is
experiencing severe thirst, dry tongue and mouth due to strict fluid restrictions?
.....................................................................................................................
.....................................................................................................................

6) Identify any four nutrients; the intake of which may significantly influence the
prognosis of CRF. Give reasons for the selection of these nutrients.
Nutrients Increased/Decreased intake Reason
1)
2)
3)
4)

7) What changes should be brought in the sodium, potassium and fluid intake of
ARF patients?
.....................................................................................................................
.....................................................................................................................

8) Choose any ten processed food-stuffs and enlist the name of the preservative/
additive present in them.
Name of the foods stuff Preservative/additive
1) Processed chicken
2) Canned Beans
187
Clinical Therapeutic 3) Butter Cookies
Nutritio n
4) Ketchup
5) ….
6) ….
7) ….
8) ….
9) ….
10) ….
How many of these foods contain a sodium preservative/additive which contains
sodium.
9) Enlist at least five food stuffs which are poor/moderate/rich sources of oxalate.
Low Moderate High
1)
2)
3)
4)
5)
10) What is the RDI of calcium for an adult man/woman? What level of calcium
restriction is suggested for a patient suffering from calcium phosphate stones?
.....................................................................................................................
.....................................................................................................................
11) How can we increase the fluid intake of patients suffering from uric acid stones?
Enlist atleast five points.
1)
2)
3)
4)
5)
12) Using the food composition table, enlist atleast five low sodium (< 50 mg/100 gm
edible portion) and five low potassium fruits and vegetables each. Write in
ascending order.
Low Sodium
Fruits Vegetables
1) 1)
2) 2)
3) 3)
4) 4)
5) 5)
Low Potassium
Fruits Vegetables
1) 1)
2) 2)
3) 3)
4) 4)
5) 5)

188
 Planning Diets for

ACTIVITY Renal Diseases

DIET PLAN FOR GLOMERULONEPHRITIS 1

Aim : To plan a diet for an individual suffering from glomerulonephritis. Date :

Case Study : Meenu is an 11 year old girl from a middle income group family,
suffering from glomerulonephritis. She is having elevated BUN levels
and creatinine. Her feet are swollen indicating fluid retention and
her urine output was 710 ml yesterday. She is severely anorexic
and has been advised complete bed rest during her stay at the hospital.
Plan a diet for Meenu.
Start the exercise by presenting a brief introduction on Meenu disease condition.

Introduction

Step I : Patient’s Profile

Read the case study carefully and identify the important points that may determine nutrient intake/diet
planning.

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:

Step II: Assessment of the nutritional needs of the patient

Hint: For this, first identify the key symptoms which are most crucial for the treatment of the
disease. For instance, in this case, nitrogenous waste products being toxic; treatment control
of oliguria and hence uremia is more important. Based upon the symptoms, identify the nutrients
that need to be modified in terms of quantity/quality and record them in the format given
herewith. Protein, fluid and sodium intake would therefore be modified in view of uremia,
oliguria, oedema and hypertension. You may refer to the nutrient requirements for
glomerulonephritis discussed earlier in sub-section 8.2.1. Refer to Table 1.1 and identify the
energy and protein allowances of an healthy 11 years old girl. Record these values under
normal column given next.
189
Clinical Therapeutic Recommended Dietary Intake for 24 hours
Nutritio n
. Normal Modified
Energy (Kcal)
Protein (g)
Sodium (g)
Potassium (mg)
Fluids (ml)

Always work out your calculations for reaching the modified RDI. Record those in
the space provided herewith.
Calculations:

Step III: Based upon the modified RDI, select exchanges for each food group.
(Record the exchanges in the format given herewith).

Exchange No. Energy Protein Carbohydrates Fats

(Kcal) (g) (g) (g)
Milk
Meat
Pulse
Cereal
Starches/
Roots/Tubers
Other Vegetable
Leafy Vegetable
Fruit
Sugar
Fat
Total
190
Step IV: Distribute the food exchange Planning Diets for
Renal Diseases
Distribute the above selected exchanges according to the meal pattern most suitable for the
patient.

Exchange No. Early Break- Mid Lunch Evening Dinner Bed

Morning fast Morning Tea Time
Milk
Meat
Pulse
Cereal
Starches
Roots/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat

Step V: Plan a menu for Meenu

Using the exchange available for each meal, prepare a menu for Meenu by selecting the most
appropriate foodstuffs (nutritional needs of the patient).

Menu for Meenu

Early Breakfast Mid Lunch Evening Dinner Bed
Morning Morning Tea Time

191
Clinical Therapeutic Step VI: Detailed meal plan
Nutritio n
Select appropriate quantities for each dish as per the exchanges available and calculate sodium
and potassium (K) content for the detailed diet plan.

Meal Menu Ingredient Amt. Exchange Energy Protein Sodium Potassium

(g) (Kcal) (g) (mg) (mg)

Total

192
Conclusion Planning Diets for
Renal Diseases
Compare the amount of the nutrients provided through the detailed menu plan with the
amount of the nutrients computed for the modified RDI. Give your suggestions for
improvement.

Nutrient Amount Amount + % of Suggestions

Computed Computed Difference for
through Diet Plan for Modified RDI Improvement

Energy (Kcal)

Protein (g)

Sodium (mg)

Potassium (mg)

What counseling tips would you give to Meenu or her care-givers regarding the
food choices/intake (give special emphasis to sodium intake)?

Submit the activity for evaluation.

———————————
Counselor’s Signature

193
Clinical Therapeutic

ACTIVITY
Nutritio n

2 DIET PLAN FOR NEPHROTIC SYNDROME

Date : Aim : To plan a diet for a patient suffering from nephrotic syndrome.
Case Study : Vishal is an 5 year old boy studying in a public school. He was
admitted to the renal ward of hospital with marked abdominal oedema
and ascites. The results of medical examinations are indicative of
hypoalbuminemia and severe urine protein loss of >2g/day with
elevated serum cholesterol levels. Some of his clinical parameters
are as follows:
Previous day urine output : 400 ml
Serum albumin : 2.2 g/dl
Total serum protein : 5.1 g/dl
Haemoglobin : 5.3 g/dl
Serum sodium : 151 meq/l
Serum cholesterol : 280 mg/dl
Vishal is fond of non-vegetarian foods and bakery products. He is being given mild
diuretics and shall be kept under observation in the hospital for atleast 15 days. Plan a
diet for Kanak.

Introduction
(Begin the activity by first describing Vishal’s disease condition. Also, identify five most
critical symptoms that would influence the dietary intake of the patient and the objectives of
the dietary management of her disease condition).

Symptoms:
1)
2)
3)
4)
5)
194
Objectives of dietary management: Planning Diets for
Renal Diseases

Step I : Patient’s Profile

Keeping the case details in mind, fill the patient profile in the format given below:

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Pathophysiological stress:

Diet prescribed:

Also, compare the biochemical/clinical parameters of the patient with the normal
values.
Parameter Patient Value Normal Value Inference
Serum albumin
Total serum protein
Haemoglobin
Serum sodium
Serum cholesterol

195
Clinical Therapeutic Step II : Assessment nutrient requirement
Nutritio n
On the basis of case details and principles of diet planning for Nephrotic syndrome, assess/
calculate the nutrient needs of Vishal and compare them with the RDI of a healthy boy (age
specific).
Recommended Dietary Intake
Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Carbohydrate (g)
Fat (g)
Cholesterol (mg)
Iron (mg)
Calcium (mg)

Work out your calculations for reaching the modified RDI in the space provided herewith.
Calculations:

Step III : Select the food exchanges

Select appropriate food exchanges that would help in meeting the nutritional needs of Vishal.
Do remember to select food exchange which would help in providing good amounts of protein
but low in saturated fat, cholesterol and sodium.

Exchange No. Energy Protein CHO Fat

(Kcal) (g) (g) (g)
Skim Milk
Meat
Pulse
Cereal
Roots/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat (oil)
Total
196
Step IV : Distribute the above selected exchanges according to the meal Planning Diets for
Renal Diseases
pattern most suitable for the patient.
(Hint: Since the patient is complaining of abdominal fullness due to ascites; a small frequent
meal pattern should be adopted to promote adequate food intake and hence help in maintaining
a good nutritional status).

Exchange No. Early Break- Mid Lunch Evening Dinner After

Morning fast Morning Tea Dinner
S. Milk
Meat
Pulse
Cereal
Starches
Root/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat

Step V : Plan a day’s menu for Kanak

Prepare a day’s menu for Kanak .Try to lay emphasis on snacks/dishes preferred/liked by
young children. Select the dishes as per the exchanges available for each meal in step IV
above.

Sample Menu for Kanak

Early Breakfast Mid Lunch Evening Dinner Bed
Morning Morning Tea Time

197
Clinical Therapeutic Step VI: Detailed menu plan
Nutritio n
Select appropriate quantities for each dish as per the exchanges available and calculate sodium
and cholesterol content for the detailed diet plan. Also calculate potassium (K) content for the
detailed diet plan.

Meal Menu Ingredient Amt Exchange Energy Protein Cholesterol Iron Calcium
(g) (Kcal) (g) (mg) (mg) (mg)

Total

198
Conclusion Planning Diets for
Renal Diseases
Finally, compare the amount of each nutrient provided through the detailed menu plan
with the modified nutritional needs. Give your interpretations and suggestions for
improvement.

Nutrient Amount Amount + % of Suggestions

Computed for Computed Difference for
Modified RDI through Diet Plan Improvement

Energy (Kcal)

Protein (g)

Cholesterol (mg)

Iron (mg)

Calcium (mg

Submit the activity for evaluation.

——————————
Counselor’s Signature
199
Clinical Therapeutic
Nutritio n
ACTIVITY
3 DIET PLAN FOR CHRONIC RENAL FAILURE
Date : Aim : To plan a diet for a patient suffering from chronic renal failure.
Case Study : Mrs. Darshan is a 65 years old woman who was admitted to the
ICU of renal ward. She had oedema, pale conjunctiva, shortness
of breath, chest pain, parasthesia and reduced urine output. She
was experiencing severe gastrointestinal disturbances such as
anorexia, nausea and vomitting due to which her food intake has
reduced drastically. Clinical diagnosis was indicative of chronic
renal failure with mild hyperkalemia, metabolic acidosis and
hypertension. Some of her clinical parameters are:
Glomerular filtration rate : 20 ml/min
Serum bicarbonates : 12 meq/L
Serum potassium : 5.3 meq/L
Systolic blood pressure : 156 mmHg
Diastolic blood pressure : 98 mmHg
Serum sodium : 150 meq/l
Serum creatinine : 1.9 mg/dl
Blood Urea Nitrogen : 29 mg/dl
Urine output in previous 24 hrs. : 326 ml
Her medical reports have been forwarded to the dietitian to help the patient with
dietary counseling and also to plan diet for Mrs. Darshan during her hospital stay.
Now plan a diet for Mrs. Darshan.
Start the exercise with the introduction.

Introduction
(Describe the clinical condition which the patient is suffering from. Enlist atleast five
characteristic symptoms of CRF and the objectives of dietary management of CRF, in the space
provided herewith).

200
Step I : Patient’s Profile Planning Diets for
Renal Diseases
Now, read the case carefully and fill the patient profile in the format given below:

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:

Diet prescribed:
Next, compare the patient’s clinical parameters with the normal values/standard values.
(Refer to Table 16.1, Unit 16 in MFN-005 theory course for standard values).
Patient Value Normal Values/range
Glomerular filtration rate
Serum bicarbonates
Serum potassium
Systolic blood pressure
Diastolic blood pressure:
Serum sodium
Serum creatinine
Blood Urea Nitrogen

Step II: Assess the nutrient requirement of Mrs. Darshan

Based upon your understanding of the disease condition and the patient’s profile, assess/
calculate the nutritional needs of Mrs. Darshan and compare them with the RDI for a sedentary
elderly woman.

Recommended Dietary Intake

Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Sodium (mg)
Potassium (mg)
Iron (mg)
Calcium (mg)

[Note: Energy requirements for elderly change after 60 years. For instance, the energy needs
of a 65 year old women (reference weight 50 kg) would be 1704 Kcals].

Step III : Select the food exchanges

Keeping in mind the various mineral and electrolyte imbalance which frequently develop during
CRF apart from uremia; carefully select appropriate food exchanges to meet the nutritional
requirements of the patients. You may need to once again read the food sources for some
201
important nutrients such as protein, sodium, potassium, phosphorus and calcium.
Clinical Therapeutic
Nutritio n Exchange No. Energy Protein Carbohydrate Fat
(Kcal) (g) (g) (g)
S. Milk
Meat
Pulse
Cereal
Starches
Root/Tubers
Other Vegetable
Leafy Vegetable
Fruit
Sugar
Fat (oil)

Step IV : Distribute the food exchanges

Note: The above selected exchanges need to be distributed judiciously through out the day
depending upon the meal pattern most suitable for the patient. Since Mrs. Darshan is
experiencing severe gastrointestinal disturbances and shortness of breath; it would be essential
to give small frequent easy to digest meals through out the day. Write the exchanges in the
format given herewith.

Exchange No. Early Break- Mid Lunch Evening Dinner After

Morning fast Morning Tea Dinner
S. Milk
Meat
Pulse
Cereal
Starches
Root/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat
Step V : Plan a day’s menu for Mrs. Darshan
Prepare a day’s menu most suitable to the clinical conditions of Mrs. Darshan. Select the
dishes as per the exchanges available for each meal in Step IV above.
Sample Menu for Mrs. Darshan
Early Breakfast Lunch Evening Dinner After
Morning Tea Dinner

202
Step VI: Detailed menu plan Planning Diets for
Renal Diseases
Select appropriate quantities for each dish as per the exchanges available and calculate the
followinh nutrient content for the detailed diet plan.

Meal Menu Ingredients Amt. Exchange Energy Protein K Ca Na Iron

(g) (Kcal) (g) (mg) (mg) (mg) (mg)

Total

203
Clinical Therapeutic Conclusion
Nutritio n
Now, compare the amount of computed nutrient with the modified RDI.

Nutrient Computed Amount + % of Suggestions

Amount through as per the Difference for Improvement
Diet Plan Modified RDI
Energy

Protein

Sodium

Potassium

Calcium

Iron

Submit the activity for evaluation.

———————————
Counselor’s Signature

204
 Planning Diets for
Renal Diseases
ACTIVITY

DIET PLAN FOR ACUTE RENAL FAILURE 4

Aim : To plan a diet for a patient suffering from acute renal failure. Date :

Case Study : Mrs. Kiran is a 47 years old office executive (weight 51.5 kgs)
who had suffered from severe blood loss following a limb surgery.
Thereafter she went into a state of shock and her urine output
reduced suddenly to 40 ml/ 24 hrs. Her vital clinical parameters
include: BUN = 42 mg/100 ml, Serum creatinine = 7.8 mg/ 100 ml,
sodium (serum) = 14.3 mEq/L, Hypotension (100/61 mmhg),
Haemoglobin = 5.8%.
At present she is on blood transfusion and her urine output has increased to 218 ml/ 24
hrs. If her condition does not improve in the subsequent 48 hrs., she shall be put on
haemodialysis. Plan a day’s diet for her for today (i.e. prior to dialysis) based on the
above mentioned clinical parameters.

Introduction
(In the space provided herewith describe the disease condition affecting Kiran).

Step I : Patient’s Profile

Now, read the case carefully and fill the patient profile in the format given below:

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:
205
Clinical Therapeutic Step II: Assess the nutrient requirement of Mrs. Kiran
Nutritio n
Read the case carefully to identify whether the patient is oliguric/diuretic phase. Although the
urine output has increased; Mrs. Kiran is still suffering from oliguria and uremia. She is
presently not on dialysis.

Based upon your understanding of the disease condition and the patient’s profile, assess/
calculate the nutritional needs of Mrs. Darshan and compare them with the RDI for a healthy
adult sedentary woman (Refer to Table 1.1 in Practical 1).

Recommended Dietary Intake

Nutrients Normal Modified

Energy (Kcal)
Protein (g)
Sodium (mg)
Potassium (mg)
Fluids (ml)

Calculations:

Step III: Select the food exchanges

Based Upon the modified RDI, select the food exchanges and write in the format given
herewith.

Exchange No. Energy Protein Carbohydrate Fat

(Kcal) (g) (g) (g)

Milk

Meat

Pulse (Optional)

Cereal

Starches
Root/Tubers

Other Vegetables

Leafy Vegetables

Fruit

Sugar

Fat
Total
206
Step IV : Distribute the exchanges Planning Diets for
Renal Diseases
Distribute the above selected exchanges according to the meal pattern (6-7 meals/day) most
suitable for the patient (anorexia, vomiting, impaired digestion/absorption).

Exchange No. Early Break- Mid Lunch Tea Dinner After

Morning fast Morning Dinner

Milk

Meat

Pulse
(optional)

Cereal

Starches
Roots/Tubers

Other Vegetables

Leafy Vegetables

Fruit

Sugar

Fat

Step V : Plan a day’s menu

Using the exchanges available for each meal, prepare a menu by selecting the food-stuffs most
appropriate for Mrs. Kiran’s nutritional needs.
Sample menu for Mrs Kiran
Early Breakfast Mid Lunch Tea Dinner After
Morning Morning Dinner

207
Clinical Therapeutic Step VI: Detailed menu plan
Nutritio n
Select appropriate quantities for each dish as per the exchanges available and calculate the
following nutrient content for the detailed diet plan.

Meal Menu Ingredients Amt. Exchange Energy Protein K Na Fluids

(g) (Kcal) (g) (mg) (mg) (mg)

Total

208
Conclusion Planning Diets for
Renal Diseases
Now, compare the amount of computed nutrient with the modified RDI.

Nutrient Computed Amount + % of Suggestions

Amount through as per the Difference for Improvement
Diet Plan Modified RDI

Energy (Kcal)

Protein (g)

Sodium (mg)

Potassium (mg)

Fluid (ml)

Also give examples of the following feeds which can be given to a patient suffering
from acute renal failure.

Total Parenteral Nutrition Enternal Feeds

Submit the activity for evaluation.

———————————
Counselor’s Signature

209
Clinical Therapeutic
Nutritio n
ACTIVITY
5 DIET PLAN FOR HEMODIALYSIS
Date : Aim : To plan a diet for a patient undergoing regular dialysis.
Case Study : Mr. Harish is a 55 years old man who was admitted to the ICU of
renal ward for the third time. Patient’s renal profile has been altered
from last two years and he was on medication. Now, patient is
suffering from anuria (Nil urine output) from last one day.
Nephrologist has advised the patient to undergo hemodialysis. Mr.
Harish is having history of hypertension and diabetes and was on
antihypertensive and hypoglycemic drugs. Some of his clinical
parameters are:
Glomerular filtration rate : 15 ml/min
Hemoglobin : 8.9 mg/dl
Urea : 78 mg/dl
Creatinine : 3.2 mb/dl
Serum sodium : 151 mmol/l
Serum Potassium : 4.9 mmol/l
Albumin : 2.6 g/dl
Blood Pressure : 140/90 mg Hg
Random Blood Glucose : 200 mg/dl
Urine output in previous 24 hrs. : Nil
His medical reports have been forwarded to the dietitian to help the patient with
dietary counselling during dialysis. Patient’s weight is 68 kgs and height is 5’7”. Plan
a diet for Mr. Harish.
Start the exercise with introduction.

Introduction
(Describe the clinical condition which the patient is suffering from. Write the objectives of
dietary management and nutritional therapy for hemodialysis in the space provided herewith).

210
Step I : Patient’s Profile Planning Diets for
Renal Diseases
Now, read the case carefully and fill the patient profile in the format given below:

Patient/Case Profile
Name:
Age:
Gender:
Activity:
Dietary habits:
Socio-economic status:
Pathophysiological stress:

Diet prescribed:
Next, compare the patient’s clinical parameters with the normal values/standard values.
(Refer to Table 16.1, Unit 16 in MFN-005 theory course for standard values).
Patient Value Normal Values/range
Glomerular filtration rate
Serum potassium
Systolic blood pressure
Diastolic blood pressure:
Serum sodium
Serum creatinine
Blood Urea Nitrogen
SerumAlbumin

Step II: Assess the nutrient requirement of Mr. Harish

Based upon your understanding of the disease condition and the patient’s profile, assess/
calculate the nutritional needs of Mr. Harish and compare them with the RDI for a sedentary
elderlyman.

Recommended Dietary Intake

Nutrient Normal Modified
Energy (Kcal)
Protein (g)
Sodium (mg)
Potassium (mg)
Iron (mg)
Calcium (mg)

[Note: Energy requirements for elderly change after 60 years. For instance, the energy needs
of a 65 year old women (reference weight 50 kg) would be 1704 Kcals].

Step III : Select the food exchanges

Keeping in mind the various mineral and electrolyte imbalance which frequently develop during
ESRD apart from uremia; carefully select appropriate food exchanges to meet the nutritional
requirements of the patients. You may need to once again read the food sources for some
211
important nutrients such as protein, sodium, potassium, phosphorus and calcium.
Clinical Therapeutic
Exchange
Nutritio n No. Energy Protein Carbohydrate Fat
(Kcal) (g) (g) (g)
S. Milk
Meat
Pulse
Cereal
Starches
Root/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat (oil)

Step IV : Distribute the food exchanges

Note: The above selected exchanges need to be distributed judiciously through out the day
depending upon the meal pattern most suitable for the patient. Since Mr. Harish is experiencing
severe gastrointestinal disturbances and shortness of breath; it would be essential to give
small frequent easy to digest meals through out the day. Write the exchanges in the format
given herewith.

Exchange No. Early Break- Mid Lunch Evening Dinner After

Morning fast Morning Tea Dinner
S. Milk
Meat
Pulse
Cereal
Starches
Root/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat
Step V : Plan a day’s menu for Mr. Harish
Prepare a day’s menu most suitable to the clinical conditions of Mr. Harish. Select the dishes
as per the exchanges available for each meal in Step IV above.
Sample Menu for Mr. Harish
Early Breakfast Lunch Evening Dinner After
Morning Tea Dinner

212
 Planning Diets for
Step VI: Detailed menu plan Renal Diseases
Select appropriate quantities for each dish as per the exchanges available and calculate the
following nutrient content for the detailed diet plan.

Meal Menu Ingredients Amt. Exchange Energy Protein K Ca Na Iron

(g) (Kcal) (g) (mg) (mg) (mg) (mg)

Total

213
Clinical Therapeutic
Nutritio n Conclusion
Now, compare the amount of computed nutrient with the modified RDI.

Nutrient Computed Amount + % of Suggestions

Amount through as per the Difference for Improvement
Diet Plan Modified RDI
Energy

Protein

Sodium

Potassium

Calcium

Iron

Submit the activity for evaluation.

———————————
Counselor’s Signature

214
 Planning Diets for
Renal Diseases
ACTIVITY

DIET PLAN FOR NEPHROLITHIASIS 6

Aim : To plan a diet for a patient suffering from kidney stones. Date :

Case Study : Mr. Swaran is a 50 years old chef. His height is 5^6^^ and is
slightly overweight. Of late he has been experiencing discomfort
during urination. His urine analysis indicated a high solute conent
(particularly of calcium), traces of blood and slightly alkaline pH
(7.4). He has a positive family history of renal stones and had
suffered from calcium oxalate stones around 8 years back. He is
slightly hypertensive (145/ 42 mm Hg) and is a borderline case of
hypercholesterolemia. Plan a diet for Mr. Swaran.

Introduction
(Describe Mr. Swaran’s disease condition in the space provided herewith).

Step I: Patient’s Profile

Now, read the case carefully and fill the patient profile in the format given below.

Patient Profile/Case Details

Name:
Age:
Gender:
Activity:
Socio-economic status:
Pathophysiological stress:
Diet prescribed:
N ot e: Points that may help you in planning the diet.
 Low calcium diet (< 400 mg/day) helps in reducing hypercalcuria.
 Low oxalate (<10 mg/100 g edible portion) food stuffs should be preferred.
 Protein restriction (0.8 m/kg/day) has been found to be associated with reduced
excretion of calcium and oxacalate.
 It may be important to modify the quality of fat (marine foods are helpful as they contain
EPA).
 A low sodium diet is suggested for calcium oxalate and hypertensive patients.
 Fluid intake should be increased to atleast 3.0-3.5 lit/day.
215
Clinical Therapeutic Step II : Assess nutrient requirement
Nutritio n
Assess/calculate the nutrient needs and compare them with the RDI of a healthy adult man.

Recommended Dietary Intake

Nutrients Normal Modified
Energy (Kcal)
Protein (g)
Sodium (mg)
Calcium (mg)
Fluids (ml)

Step III : Select the food exchanges

Based upon the modified RDI, select the food exchanges.

Exchange No. Energy (Kcal) Protein (g) CHO(g) Fat(g)

S. Milk
Meat
Pulse
Cereal
Roots/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat (oil)
Total

Step V : Distribute the selected exchanges

Distribute the above selected exchanges according to the meal pattern (6-7 meals/ day) most
suitable for the patient .
Exchange No. Early Breakfast Lunch Tea Dinner
Morning
S. Milk
Meat
Pulse
Cereal
Root/Tubers
Other Vegetables
Leafy Vegetables
Fruit
Sugar
Fat (oil)
216
StepV : Plan a day’s menu for Mr. Swaran Planning Diets for
Renal Diseases
Keeping in mind the exchanges available for each meal, prepare a menu for Mr. Swaran by
selecting the food stuffs most appropriate for his condition.
Sample menu for Mr. Swaran
Early Breakfast Lunch Tea Dinner
Morning

Note:
 Table/cooking salt should not be added .
 Since the patient is borderline hypercholesterolemic; a commercial source of fibre (guar-
gum, psyllium husk, neem bark powder etc.) may be added to meals as several high fibre
foods (whole pulses, whole cereals ) are also good sources of calcium which need to be
avoided.

217
Clinical Therapeutic Step VI: Detailed menu plan
Nutritio n
Select appropriate quantities for each dish as per the exchanges available and calculate the
following nutrient content for the detailed diet plan.

Meal Menu Ingredient Amt. Exchange Energy Protein Calcium Sodium Fluids
(g) (Kcal) (g) (mg) (mg) (ml)

Total

218
Conclusion Planning Diets for
Renal Diseases
Now, compare the amount of computed nutrient with the modified RDI.

Nutrient Computed Amount + % of Suggestions

Amount through as per the Difference for Improvement
Diet Plan Modified RDI

Energy (Kcal)

Protein (g)

Sodium (mg)

Calcium (mg)

Fluid (ml)

Submit the activity for evaluation.

——————————
Counselor’s Signature
219
Clinical and
Therapeutic Nutrition PRACTICAL 9 NUTRITIONAL
MANAGEMENT OF
CORONARY HEART
DISEASES
Structure
9.1 Introduction

9.2 Coronary Heart Disease: An Overview

9.3 Hypertension

9.4 Atherosclerosis

9.5 Myocardial Infarction

9.6 Congestive Heart Failure

9.7 Review Exercises

Activity 1: Diet Plan for Hypertension

Activity 2 : Diet Plan for Acute MI and Hypercholesterolemia

Activity 3 : Diet Plan for Congestive Heart Failure

9.1 INTRODUCTION
Coronary heart diseases are a group of diseases of the heart. You may recall studying
about the coronary heart diseases in Unit 11 in the theory course (MFN-005). Some
of the common ones that we shall review in this practical are:

 Hypertension
 Atherosclerosis
 Myocardial infarction
 Congestive heart failure

These coronary diseases are of prime importance as we see that the incidence of
these diseases is rising at an enormous rate and they account for an appreciable
proportion of mortality and morbidity in the populations groups. The main focus in this
practical will be on the dietary guidelines and principles involved in planning diets for
these heart conditions.

Objectives

After undertaking this practical you will be able to:

 discuss different types of coronary heart diseases, their etiologies,

 describe established risk factors of coronary heart diseases,

 gain insight into the dietary management goals and modify diets according to the
guidelines, and

 plan diet for patients suffering from hypertension, myocardial infarction and
220
congestive heart failure.
 Nutr itio nal
9.2 CORONARYHEART DISEASE:AN OVERVIEW Management of
Coronary Heart
Di se as e s
Coronary heart disease is a leading cause of death in the general population, affecting
the majority of adults past the age of 60 years. Men are more likely to develop and to
do so at an earlier age than women.
Established multiple risk factors in coronary heart disease are -
a. Non-modifiable risk factors, which are the personal characteristics such as
sex, age and family history.
b. Modifiable risk factors, which are behavioural (such as smoking and sedentary
life-styles, food habits) (like excessive fat, excessive sugar, excessive salt etc.)
physiological (such as hyperlipidemia, obesity, diabetes mellitus etc.) and
psychological (such as stress).
Though we have already studied about the etiological risk factors and pathophysiology
of coronary heart diseases in detail earlier in the theory course, here in this practical
we will once again recapitulate some of the important coronary diseases, with the
main focus on the principles of dietary management. You may recall studying in section
11.4 in the theory course (MFN-005) about the preventive measures for coronary
heart diseases. WHO recommended nutrition guidelines for prevention of heart disease
include:
 Sufficient calories to maintain appropriate weight for a given height
 Total fat between 20-30% of total calories
 Cholesterol not to exceed 300 mg/day
 Saturated fats less than 10% of total calories
 Polyunsaturated fats less than 8% of total calories
 Linoleic acid between 3-7% of total calories
 Alpha linolenic acid less than 1% of total calories
 Proteins to provide 15-20% of total calories
Mentioned in Table 9.1 are details regarding nutrient intake and food choice checklists
that can be used as effective tools for modifying the dietary intake of the masses at
large as recommended by WHO.
Table 9.1 : Dietary recommendations for the prevention of
Coronary Heart Disease (WHO)
Calories : Sufficient to maintain ideal body weight
Total fat : 20-30% of calories
Cholesterol : < 300 mg/day
SFA : < 10% of total calories
PUFA : < 8% of total calories
P/S ratio : 0.8-1.0
Linoleic acid (LA/n-6) : 3-7% of total calories
Alpha linolenic acid (ALNA/n-3) : < 1 % of total calories
LA/ALNA ratio : 5-10
Proteins : 15-20% of total calories
Carbohydrates : 55-65% en with emphasis on complex
carbohydrates
Sugars : < 10% of total calories
Salt : 5-7 g/day
Dietary fibre : 40 g/day 221
Clinical and Keeping these recommendations in mind, let us now take up specific coronary heart
Therapeutic Nutrition disease conditions and study about their dietary management, in particular.
We begin our review with hypertension.

9.3 HYPERTENSION
Hypertension is usually defined as a blood pressure of 130/80 or greater. Normal
blood pressure is 120/80 or less. A systolic blood pressure of 120-129 and a diastolic
blood pressure of <80 is considered elevated blood pressure. Table 9.2 presents the
classification given by American Centre for Cardiology/ American Heart Association
(ACC/AHA), 2017 on Hypertension.

Table 9.2: Classification of blood pressures and stages of

hypertension in adults

Blood Pressure Range Classification

SBP/DBP
120/80 Normal (optimal)
120-129/<80 Elevated
130-139/80-89 Hypertension (Stage I)
> 140/> 90 Hypertension (Stage II)
> 180/> 120 Hypertensive Crisis

Source: ACC/AHA, 2017.

As for the causative factors, 90% of the times the etiology of hypertension is not
known. High blood pressure in the absence of any underlying disease is called primary
hypertension. Elevated blood pressure due to some underlying disease is secondary
hypertension. Increase in blood volume, heart rate and peripheral vascular resistance
can lead to hypertension. Being overweight, excessive intake of salt and lack of
physical exercise can all contribute to increase in BP.

Next, let us review the treatment and management of hypertension, with a focus on
nutritional management. We begin with the objectives of nutritional management.

Objectives of nutritional management

The objective of nutritional management of hypertension includes:

 to achieve gradual weight loss in overweight and obese individuals and maintain
weight slightly below the normal levels,

 to reduce sodium intake and maintain fluid and electrolyte balance,

 to maintain adequate nutrition,

 to lead a healthy lifestyle (no smoking, high physical activity), and

 to retard the onset of complications.

In order to meet the above objectives, we need to understand the nutrient

requirements and modification required in the diet during hypertension. These are
enumerated next.

222
Modifications in diet and Recommended dietary allowances Nutr itio nal
Management of
 Choosing foods low in calories and fat. Calorie requirement is based on the Coronary Heart
Di se as e s
concept of maintaining ideal body weight. Protein should contribute
15-20% of the total energy need. The fats incorporated in the diet should be
rich in unsaturated fatty acids and should not provide more than 20% of the
total energy.
 Choosing foods that are low in sodium (salt).
 Mild sodium restriction means 2-3 grams of salt/day.
 Moderate sodium restriction means 1 gm salt/day.
 Strict restriction means 0.5 grams a day of salt.
(Refer to Table 11.6 in Unit 11 and Table 16.2 in Unit 16 in theory course for sodium
content of some food items).
 Choosing foods high in fiber. About 60-65% energy should be provided from
carbohydrates which are polysaccharides (complex carbohydrates) rather than
simple sugars (monosaccharides and disaccharides).
 Maintaining a healthy weight or losing weight, if overweight.
 Limiting serving sizes.
 Increasing physical activity as it redistributes body water and eases transit of
blood through peripheral arteries.
 Practicing moderation if consuming alcoholic beverages. In moderation alcohol
relaxes the peripheral arteries and so reduces blood pressure but high doses
clearly increases BP. Moderation means no more than one drink for women and
two drinks per day for men.
 Adequate amounts of calcium, magnesium, potassium and vitamin C is also
necessary as the deficiency may lead the walls of the arteries to constrict causing
hypertension.
 It has been proposed that fish oil supplements may have a variety of protective
cardiovascular effects, including a reduction in systemic blood pressure (BP).
Fish intake in combination with weight loss may have additive effects on blood
pressure reduction in hypertensive patients
Next, let us review the pathophysiology and the dietary management of atherosclerosis.

9.4 ATHEROSCLEROSIS
Atherosclerosis, you may recall studying, in sub-section 11.3.2 in Unit 11 in the Theory
Course (MFN-005), is a disease affecting arterial blood vessels. It is an arterial lesion
characterized by patchy thickening of the intima comprising of fat and layers of collagen
like fibres.
It is unknown exactly how atherosclerosis begins or what causes it. There is a gradual
build-up of plaque or thickening of the inside of the walls of the artery, causing a
decrease in the amount of blood flow, and a decrease in the oxygen supply to the vital
body organs and extremities. A heart attack may occur if the oxygenated blood supply
is reduced to the heart. A stroke may occur if the oxygenated blood supply is cut off
to the brain. Gangrene may occur if the oxygenated blood supply is reduced to the
arms and legs.
Atherosclerosis has been associated with the following risk factors such as elevated
cholesterol and triglyceride levels, high blood pressure, smoking, diabetes mellitus,
223
obesity, physical inactivity and older age.
Clinical and Next, let us learn about the nutritional management goals of this disorder.
Therapeutic Nutrition
Nutritional management goals
The nutritional management goals of atherosclerosis include:
 Reduction of weight if overweight or obese.
 Reduction in total fat, saturated fat and cholesterol.
 Consuming a balanced adequate diet, rich in calcium, chromium, iron and zinc.
 Medication if required for treating lipid disorders and controlling BP.
 Lifestyle changes - increase in physical exercise, moderation in alcohol intake.
No smoking, restricting coffee.
 Medical management is through various lipid lowering drugs.
Dietary modifications and the nutrient requirements for this condition are enumerated
next.
Modifications in diet and Recommended dietary allowances
 Calories: to maintain ideal body weight
 Carbohydrates should constitute 55-65% of calories with emphasis on
polysaccharides (complex carbohydrates)
 Sugar less than 10% of total calories
 Dietary fibre : >40 g/day
 Proteins: 15-20% of modified energy
 Fat: 20% of total energy
 Dietary cholesterol: < 200-300 mg/day
Some other considerations include:
 Saturated fatty acids (SFA) – SFA intake is associated with
hypercholesterolemia and atherosclerosis in humans. Some dietary SFAs like
palmitic, myristic (most potent) and lauric acids have the most hypercholesterolemic
effects as they elevate LDL-c. They are found in butterfat, coconut and palm
kernel oils. Saturated fat must constitute no more than 10% of calories.
 Poly unsaturated fatty acids (PUFAs)  PUFAs are known to lower total serum
cholesterol; especially the n-6 series is more beneficial. n-3 series also have
positive effects by reduction of platelet aggregation, as well as, favourable
changes on blood lipids and blood pressure. n-6 PUFAis found in corn, sunflower,
safflower and soybean oils. Sources of linolenic acid (n-3) include wheat, bajra,
Black gram, cowpea, rajmah, soyabean, green leafy vegetables, fenugreek and
mustard seeds (spices) apart from fish. Linolenic acid can also be obtained
from oils like mustard, soyabean, canola and rice bran oil. ICMR (1998) has
given dietary guidelines to maintain n-6/n-3 ratio of 5-10 and PUFA/SFA of
0.8-1.0 which ensures long-term health. Hence, the choice of cooking oil
should be:
a) Moderate linoleic acid oils (n-6) like groundnut oil, rice bran oil or sesame oil
OR
Soyabean oil [containing both linoleic and alpha linolenic acid (n-3)], and
b) Combination of two oils in approximately equal proportion:
Use high linoleic acid oils like sunflower oil, safflower oil and cottonseed oil
with palm oil (low linoleic acid)
OR
Mustard oil (containing alpha-linolenic acid) along with any other cooking
oil (this will reduce erucic acid from mustard oil and thereby its undesirable
224 health effects)
 Include monounsaturated fatty acids. Its sources are olive oil, canola oil, Nutr itio nal
Management of
groundnut oil, rice bran oil, red palm oil and sesame oil. Coronary Heart
Di se as e s
 Trans fatty acids : Trans fatty acids raise blood cholesterol levels, increasing the
risk of CVD though to a lesser degree than the saturated fatty acids. Patients
are recommended to restrict their trans fatty acid such as margarine, shortenings,
partially dehydrogenated oils, vanaspati ghee, cookies, crackers and fried foods.
 Dietary cholesterol : Dietary cholesterol raises total cholesterol and LDL
cholesterol. It is found in animal foods such as meat, fish and poultry. Egg yolks
and organ meats are particularly rich sources. Limited intake of cholesterol i.e.
< 200 - 300 mg/d is recommended.
 Dietary fiber : Soluble fiber sources include oats, legumes, fruit pectin etc. Soluble
fiber lowers serum cholesterol and LDL cholesterol, promotes insulin sensitivity,
increase satiety, promote lower energy intake, thus causing lower incidence of
CHD. Total fiber should be 40g/ 2000 kcal for adults, 25% of which should be
soluble. Two mechanisms are known for soluble fiber - (1) fiber binds bile acids,
which lowers serum cholesterol to replete the bile acid pool, and (2) bacteria in
the colon ferment the fiber to compound acetate, propionate and butyrate which
inhibits cholesterol synthesis.
 Soy proteins : Soy have been found to decrease total cholesterol, LDL and
triglyceride without lowering HDL-c levels. Approximately, 50 g/d of soy protein
may be replaced with animal protein to achieve the cholesterol lowering effect.
The phytosterol and phytoestrogen content of soy protein also plays role in this
lowering. It may be found in tofu, soy milk, soy protein supplemented drinks etc.
 Alcohol : When its intake is in excess, alcohol is related to cause adverse affects
causing liver damage and cirrhosis, cardiomyopathy and elevated blood pressure.
Moderate intake is related to lowering incidence of CHD in some populations.
Alcohol raises HDL cholesterol; wine contains an antifungal compound that
increases HDL cholesterol and inhibits LDL oxidation.
With these considerations, we end our study on atherosclerosis. Next, we shall
review myocardial infarction.

9.5 MYOCARDIAL INFARCTION

Acute myocardial infarction (AMI or MI), commonly known as a heart attack, is a
serious, sudden heart condition usually characterized by varying degrees of chest pain
or discomfort, weakness, sweating, nausea, vomiting and arrhythmias, sometimes
causing loss of consciousness.
The medical term myocardial infarction derives from myocardium (the heart muscle)
and infarction (tissue death), in this case caused by an obstruction of blood flow. It
occurs when a part of the heart muscle is injured, and this part may die because of
sudden total interruption of blood flow to the area. It is often a life-threatening medical
emergency which demands immediate attention.
The nutrient requirements and the overall dietary managemnt of MI patient is reviewed
next. We begin our study by highlighting the objectives of dietary managemnt of MI.
Objectives of dietary managemnt
The objectives of dietary management of myocardial infarction patient are as follows:
 to provide rest to the injured heart,
 to maintain an optimum nutritional status,
 to achieve and maintain a desirable body weight, and 225
Clinical and  to prevent the development of another attack of MI and /or congestive heart
Therapeutic Nutrition failure.
For meeting the above objectives the dietary modifications and the nutrient requirement
recommended are detailed next.
Modifications in diet and Recommended dietary allowances

Long term diet therapy is implemented when the patient is out of immediate medical
danger. Diet is tailored to meet individual needs and deal with conditions such as
hyperlipidemia, hypertension, obesity and diabetes. The important aspects to be
considered include:

1) A low calorie diet (1200-1500) is used to avoid the metabolic stress caused by
larger intakes and to begin promoting weight loss. The energy intake may initially
begin with 800 Kcal which can be slowly progressed to a 1200 Kcal diet till the
patient is discharged. Thereafter, the patient’s energy intake should be governed
on the maintenance of body weight which is preferably 1 to 2 kg below ideal
body weight.

2) Large meals are avoided (more than 600-700 Kcal) because they increase heart
rate and stroke volume. Recommend the patient to adhere to small frequent
meal pattern.

3) Majority of MI patients are also hyperlipidemic and have elevated serum

triglyceride levels. In such cases, the calorie contribution from fat should not be
above 20% and the dietary cholesterol intake should remain below 200 mg per
day. Recommend reducing saturated fat intake by substituting skimmed or 1 per
cent milk for whole milk, and by replacing animal products with those of vegetable
origin as much as possible.

4) Carbohydrates should provide 60% of the total energy. However, emphasis

should be laid on the inclusion of easy-to-digest simple carbohydrates, which are
low in fibre. Low fibre cereals, roots and tubers should be served in a soft, well
cooked/blended form (purees etc.).

5) A moderate sodium restriction (2-3 gms/day) to control tendency of oedema and

congestive heart failure to develop.

6) When fats are needed for cooking, spreads, and other uses, recommend oils
with high amounts of monounsaturated and/or polyunsaturated fatty acids,
especially n-3 polyunsaturated fats such as canola, olive oils and soybean oil.

After a brief review of measures specific to myocardial infarction, we finally take a

look at the congestive heart disease condition.

9.6 CONGESTIVE HEART FAILURE (CHF)

CHF is a syndrome in which heart can no longer adequately pump blood through the
circulatory system. It is also called chronic heart failure.

CHF results from decreased myocardial efficiency, it can be caused by an MI, valve
disease, thiamin deficiency and other conditions. Renal blood flow may decrease with
impaired excretion of sodium and water. Peripheral and pulmonary oedema with ascites
often results.

Nutritional care is a little difficult in congestive heart failure, since oedema complicates
the nutritional assessment of the subject. Nevertheless, the objectives of dietary
226
management are enumerated herewith.
Objectives of dietary management Nutr itio nal
Management of
Coronary Heart
The objectives of dietary management of congestive heart disease include: Di se as e s

 to minimize stress workload on the heart,

 to correct and maintain fluid and electrolyte imbalance,

 to maintain a desirable body weight, and

 to maintain an optimum nutritional status.

Dietary goals in CHF are to increase energy intake because organ systems  heart
and lungs must work extra hard to maintain their functions. Blood flow and nutrient
supply is affected and weight loss usually goes unnoticed due to anorexia and altered
taste. Thus CHF patients are subjected to protein-calorie malnutrition. Chronic PEM
which develops due to heart failure is called cardiac cachexia. Keeping the above
objectives in mind, let us review the nutrient requirements and the dietary modifications
required for the dietary management of this condition.

Modifications in diet and Recommended dietary allowances

To ensure proper nutrition, therefore the dietary guidelines include:

1) Patients on artificial oxygen support systems and/or those who are obese are
recommended 1200 Kcal diet. Ambulatory and /or normal weight patients are
usually able to tolerate around 20-25 Kcal/kg IBW per day. Providing adequate
calories is vital but providing too much may increase the metabolic stress on the
body taxing the heart.

2) About 1g of protein per kg ideal body weigh should be incorporated in the diet.
Since CHF is a form of cardiomyopathy and there is weakness of cardiac muscles,
it is essential to supply good amounts of dietary proteins particularly high biological
value proteins to facilitate tissue synthesis.

3) Fats should not provide more than 20% of the total energy and the diet should be
low in cholesterol (< 200 mg/day) depending upon the lipid profile of the patient.

4) Mild to moderate sodium restriction (2.0 - 3.0 g Na per day) is often beneficial
for most patients. Restriction of table salt and cooking salt is recommended for
all patients. High sodium fruits and vegetables such as fenugreek leaves, lettuce,
spinach, beetroot, tomato, grapes, musk melon, as well as, processed foods and
preserves should be avoided.

5) Dietary fiber is carefully adjusted. Goal is to provide more of soluble fiber than
insoluble fiber to avoid constipation and to prevent gas production.

6) For clients who are unable to eat, calorie and nutrient dense formulas are given
which have less water and can prevent PEM.

7) Fluid intake should be reduced to reduce the circulatory volume. It can range
from 1-1.5 lit/day.

Few other considerations are highlighted next.

Other considerations

 Subjects with congestive cardiac failure often tolerate frequent meals better than
larger infrequent meals as these are tiring to consume, can contribute to abdominal
distention and markedly increase oxygen consumption. 227
Clinical and  Alternative seasonings and flavouring agents such as mild herbs and condiments
Therapeutic Nutrition
may be used sparingly if sodium restriction is moderate to severe in order to
ensure adequate food intake.
 The menu should be planned by keeping in mind the fluid allowance for the day.

 The patient should be advised to chew the food slowly. Sweating and chest
discomfort are indicators of oxygen deficiency. Food ingestion should be stopped
in such situations.

 Meals should be soft and well cooked. Raw food should be completely avoided.

 If the patient is on ventilator, oral intake may not be feasible. In such situations;
enteral tube feeding should be started.

With these considerations, we end our study of congestive heart failure. We hope the
discussion above may have given you a good insight into the coronary heart diseases
and their dietary management. Let us then review what we have learnt so far by
answering the review exercises given next. After completing these exercises, we
can move on to planning diets for the disease conditions included in this practical.
There are three activities given in this practical. Undertaking these activities will help
you apply the knowledge you have gained so far in planning diets for patients suffering
from hypertension, arthrosclerosis, myocardial infarction and congestive heart failure.
So get started.

9.7 REVIEW EXERCISES

1) What is coronary heart disease?

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

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

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

2) What diet modification would you recommend for a patient with increased
cholesterol levels?

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

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

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

3) Give three sources of SFA, MUFA and PUFA each.

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

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

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

4) What are n-3 and n-6 fatty acids? What is the healthy ratio in the RDA as per
ICMR guidelines?

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

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

......................................................................................................................
228
5) What is the reason to put a post-MI patient on a low calorie diet? Nutr itio nal
Management of
Coronary Heart
...................................................................................................................... Di se as e s

......................................................................................................................
......................................................................................................................
6) What is cardiac cachexia in CHF? Explain why CHF patients are prone to protein
malnutrition.
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
Now, let us get started with the activities.

229
Clinical and
Therapeutic Nutrition
ACTIVITY
1 DIET PLAN FOR HYPERTENSION
Date : Aim : To plan a diet for a hypertensive patient

Case study : Mr Verma is a 50 yr old high school cricket coach. He is 80 kgs with
a height of 5^5^^ and smokes one pack of cigarettes a day. He is
admitted for further evaluation and for his essential hypertension. His
BP on admission is - 150/90

Chief complaint- “I have tried to cut down on my salt but food just doesn’t taste good
without it….I want to control my hypertension – my mother just passed away because
of a heart attack..”

Patient history- He has a strong family history of heart disease. He was given a diet
sheet of 2 gram salt diet (no added salt) since he was detected with hypertension but
he has not been able to eat properly since then as the food doesn’t taste good anymore
which discourages him to stick to the low salt diet and encourages him to skip his
meals or overindulge.

His wife is also working, so on an average, they eat out 2-3 times a week.

His doctor has prescribed some antihypertensive medications and wants him to see a
dietitian for a diet plan and low salt food list.

Based on the case study presented above, plan a diet following the instructions given
herewith. Start the activity with a brief introduction on the disease condition.

Introduction
(Describe briefly Mr. Verma’s disease condition in the space provided herewith).

Step I : Patient’s Profile

(Read the case study carefully and identify the important points that may determine nutrient
intake/diet planning. Identify specific disease characteristics. Based on the risk factors, comment
on the patient’s profile).

Patient/Case Profile
Age: Smoking habit:
Gender: Drinking habit:
Family history of heart disease: Yes/No Activity pattern:
Weight: Usual BP:
230
Step II: Assessment of the nutritional needs of the patient. Nutr itio nal
Management of
(In the format given herewith, present the recommended dietary intake for Mr. Verma. Work out Coronary Heart
Di se as e s
your calculations for reaching the modified RDI and record those in the space provided herewith.
Compare his requirement with the requirement of a sedentary healthy male). Refer to Table 1.1
in Pratical 1.
Recommended Dietary Intake for 24 hours
Nutrients Normal RDA for Modified RDA for
Sedentary Male Mr. Verma

Calories (Kcal)
Total fat
Cholesterol
SFA
PUFA
Proteins (g)
Carbohydrates (g)
Salt (mg)
Dietary fiber
Calculations:

List 3 main nutritional considerations/goals for this patient.

Step III: Based upon the modified RDI, now select exchanges for each food
group.
(Plan a food exchange plan for Mr. Verma. Rrecord the exchanges in the format given herewith).

Exchanges No. Calories Carbohydrates Proteins Fat

(Kcal) (g) (g) (g)
Milk
Cereals
Roots/Tubers
Pulses
Meat
Green Leafy
Vegetables
Other Vegetables
Fruits
Sugar
Fat
Total 231
Clinical and Step IV: Distribute the above selected exchanges according to the meal
Therapeutic Nutrition
pattern most suitable for the patient.
Exchange No. Early Break- Lunch Evening Dinner
Morning fast Tea
Milk
Cereals
Roots/Tubers
Pulses
Meat
Veg. A
Veg. B
Fruits
Sugar
Fat
Total

Step V: Using the exchange available for each meal prepare a menu for
Mr. Verma by selecting the most appropriate foodstuffs (nutritional needs of
the patient).
Menu for Mr. Verma
Early Morning Breakfast Lunch Evening Tea Dinner

232
Step VI: Detailed meal plan Nutr itio nal
Management of
Select appropriate quantities for each dish as per the exchanges available and calculate the Coronary Heart
nutrient content for the detailed diet plan as per the format given herewith. Di se as e s

Meal Menu Ingredient Amt. Exchange Energy Protein Sodium Dietary

(g) (Kcal) (g) (mg) Fibre

Total

233
Clinical and Conclusion
Therapeutic Nutrition
Compare the amount of the nutrients provided through the detailed menu plan with
the amount of the nutrients computed for the modified RDI. Give your suggestions
for improvement.
Nutrient Computed Amount + % of Suggestions
Amount through as per the Difference for Improvement
Diet Plan Modified RDI

Energy (Kcal)

Protein (g)

Sodium (mg)

Fibre (mg)

What dietary counseling would you give to Mr. Verma regarding foods to be avoided
and allowed? Write in the format given herewith.
Foods to be Avoided Foods Allowed

Identify 5 foods using the ‘Nutritive Value of Indian Foods’ book which are low in
sodium, moderate in sodium and high in sodium content.

Submit the activity for evaluation.

——————————-
Counselor’s Signature

234
 Nutr itio nal
Management of
ACTIVITY Coronary Heart

DIET PLAN FOR ACUTE MYOCARDIAL Di se as e s

INFARCTION AND HYPERCHOLESTEROLEMIA 2

Aim : To plan a diet for a patient with acute MI and hypercholesterolemia Date :
Case study : Mr. Khanna is a 61 year old male who was admitted to the
emergency ward because of sudden onset of a pressure like pain
radiating to the jaw and left arm. He also noted an episode of
vomitting and nausea. He admits to smoking 1 pack of cigarette
for last 40 years. He has past history of hypertension and increased
cholesterol levels. His height is 5’10” and weighs 82 kgs.
Treatment plan: Angioplasty of distal right coronary artery and stenting was done to
limit infarcted area. His lipid profile is as under:

Lipid Profile:

Mr. Khanna’s levels (mg%)

HDL-C : 30
VLDL-C : 45
LDL-C : 160
LDL/HDL : 5.3
TG : 150
Cholesterol : 220

Patient is now admitted at the rehabilitation center and doctor has called a dietitian to
plan a diet for him as he is ready for discharge.
Based on the case study, now plan a diet for Mr. Khanna. Follow the instructions
given herewith.

Introduction
(Describe briefly Mr. Khanna’s disease condition in the space provided herewith).

235
Clinical and Step I : Identify specific disease characteristics. Based on the risk factors, comment on the
Therapeutic Nutrition
patient’s profile.

Patient/Case Profile
Age: Smoking habit:
Gender: habit:
Family history of heart disease: Yes/No Activity pattern:
Biochemical indices: Weight:
Past medical history:
Symptoms of MI:
Clinical Profile
Patient Value Normal Value
HDL-c
VLDL-c
LDL-c
LDL/HDL
Triglycerides
Cholesterol

Step II: Assessment of the nutritional needs of the patient.

Work out your calculations for reaching the modified RDI for Mr. Khanna and record those in
the space provided herewith. Compare the RDA for Mr. Khanna (a patient with
hypercholesterolemia and MI) with that of a healthy sedentary male.

Nutrients Normal RDA for a Modified RDA for

Healthy Male Mr. Khanna
Calories (Kcal)
Total fat (g)
Cholesterol (mg)
SFA
PUFA
Proteins (g)
Carbohydrates (g)
Salt (mg)
Dietary fiber (mg)

Calculations:

236
List 4 main nutritional considerations/dietary goals for dietary management of Mr. Khanna Nutr itio nal
Management of
Coronary Heart
Di se as e s

Step III: Based upon the modified RDI, now select exchanges for each food group.
(Plan a food exchange plan for Mr. Khanna. Rrecord the exchanges in the format given herewith).
Exchanges No. Calories Carbohydrates Proteins Fat
(Kcal) (g) (g) (g)
Milk
Cereals
Roots/Tubers
Pulses
Meat
Other Vegetables
Leafy Vegetables
Fruits
Sugar
Fat
Total

Step IV: Distribute the above selected exchanges according to the meal pattern most suitable for the
patient.
(Note: You may plan a different meal pattern than the one given in the format herewith).

Exchange No. Early Break- Lunch Evening Dinner

Morning fast Tea
Milk
Cereals
Roots/Tubers
Pulses
Meat
Green Leafy
Vegetables
Other Vegetables
Fruits
Sugar
Fat
Total
237
Clinical and Step V: Using the exchange available for each meal prepare a menu for Mr. Khanna by
Therapeutic Nutrition
selecting the most appropriate foodstuffs.
Menu for Mr. Verma
Early Morning Breakfast Lunch Evening Tea Dinner

Step VI: Select appropriate quantities for each dish as per the exchanges available and
calculate the nutrient content for the detailed diet plan as per the format given herewith.

Meal Menu Ingredient Amt Exchange Energy Protein Sodium Dietary

(g) (Kcal) (g) (mg) Fibre

Total

238
 Nutr itio nal
Meal Menu Ingredient Amt. Exchange Energy Protein Sodium Dietaryof
Management
(g) (Kcal) (g) (mg)Coronary
Fibre
Heart
Di se as e s

Total

Conclusion
Compare the amount of the nutrients provided through the detailed menu plan with the
amount of the nutrients computed for the modified RDI. Give your suggestions for
improvement.
Nutrient Computed Amount Suggestions
Amount through Computed for for Improvement
Diet Plan Modified RDI

Energy (Kcal)
Protein (g)
Sodium (mg)
Fibre (mg)

List foods which can be allowed in abundance and should be taken in moderation by
Mr. Khanna who is suffering from MI with hypercholesterolemia.

Foods that can be taken in Abundance Foods to be Avoided

Submit the activity for evaluation.

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239
Counselor’s Signature
Clinical and

ACTIVITY
Therapeutic Nutrition

3 DIET PLAN FOR CONGESTIVE HEART FAILURE

Aim : To plan a diet for a patient suffering from congestive heart failure.
Date :
Case Study : Asha Rani is a 75 year old retired teacher who is admitted with
acute symptoms related to CHF which she has for the past 2 years
and hypertension. She has a long history of heart disease including
previous MI and mitral valve disease. She has ascites and pedal
oedema. Electrocardiogram revealed cardiomegaly (enlarged
heart) secondary to CHF.
Doctor has restricted her fluid intake to 1 liter a day. She has difficulty in eating due
to severe nausea. Her calorie count during hospitalization was around 700 Kcal/day
and 25-30 gms protein/day. At discharge, doctor recommends an 1800 Kcal diet, 80
gms protein/day and 1000 ml fluid with a low fat diet. To provide the calories, doctor
had permitted her to use a whey protein powder to supplement her diet. Its values are
(1 scoop of powder =35 grams) - (Energy = 133 Kcals; Carbohydrates = 9 gms;
Protein = 21 gms; Fat = 1.5 gms)
Plan a diet for Asha Rani following the instructions given herewith.

Introduction
(Describe briefly the Mr. Verma’s disease condition in the space provided herewith).

Step I : Identify specific disease characteristics of Asha Rani. Based on the

risk factors, comment on the patient’s profile in the format given herewith.

Patient/Case Profile

Age: Smoking habit:

Gender: Drinking habit:

Past history of heart disease: Yes/No

240 Physical symptoms related to CHF:

Step II: Assessment of the nutritional needs of the patient. Nutr itio nal
Management of
(Work out your calculations for reaching the modified RDI for Asha Rani and record those in Coronary Heart
the space provided herewith. Compare the RDA for Asha Rani with that of a healthy sedentary Di se as e s
female).

Nutrients Normal RDA for a Modified RDA for

Healthy Male Mr. Khanna
Calories (Kcal)
Total fat (g)
Cholesterol (mg)
SFA
PUFA
Proteins (g)
Carbohydrates (g)
Salt (mg)
Fluid Intake (ml)

Calculations:

List 4 main nutritional considerations/dietary goals for the treatment of this patient.

Step III: Plan a food exchange plan for Asha Rani

(Note: The doctor has prescribed a 1800 Kcal and 80 gm protein diet. Due to nausea and poor
appetite she is not eating much. But to provide the calories, doctor had permitted her to use a
wheyprotein powder to supplement her diet. Its values are 1 scoop of powde r = 35 grams.Energy
= 133 Kcals; Carbohydrates = 9 gms; Protein = 21 gms; Fat = 1.5 gms). Using this powder 2
times a day, plan a food exchange for the patient).

Food group Exchanges Calories Carbohydrates Proteins Fat

No. (Kcal) (g) (g) (g)
Milk
Cereals
Roots/Tubers
Pulses
Meat
Other Vegetables
Leafy Vegetables
Fruits
Sugar
Fat
Total
241
Clinical and Step IV: Distribute the above selected exchanges according to the meal pattern
Therapeutic Nutrition most suitable for the patient.
(Note: You may plan a different meal pattern than the one given in the format herewith)
Exchange No. Early Mid Break- Lunch Evening Dinner After
Morning Morning fast Tea Dinner

Milk
Cereals
Roots/Tubers
Pulses
Meat
Green Leafy
Vegetables
Other Vegetables
Fruits
Sugar
Fat
Total

Step V: Plan a menu for Asha Rani

Using the exchange available for each meal prepare a menu for Asha Rani by selecting the most
appropriate foodstuffs.
(Note: Do include the whey protein supplement in the menu).
Menu for Asha Rani
Early Mid Breakfast Lunch Evening Dinner After
Morning Morning Tea Dinner

242
Step VI: Select appropriate quantities for each dish as per the exchanges Nutr itio nal
Management of
available and calculate the nutrient content for the detailed diet plan as per Coronary Heart
the format given herewith. Di se as e s

Meal Menu Ingredient Amt. Exchange Energy Protein Sodium Fluid

(g) (Kcal) (g) (mg) Intake

Total
243
Clinical and Conclusion
Therapeutic Nutrition
Compare the amount of the nutrients provided through the detailed menu plan with the
amount of the nutrients computed for the modified RDI. Give your suggestions for
improvement.

Nutrient Computed Amount + % of Suggestions

Amount through as per the Difference for Improvement
Diet Plan Modified RDI

Energy (Kcal)

Protein(g)

Sodium (mg)

Fluid (ml)

Suggest why sodium restriction is recommended in CHF?

Submit the activity for evaluation.

—————————-
Counselor’s Signature

244