Therapeutic diet introduction .pptx

1. THERAPEUTIC DIET Therapeutic diet- slight alteration in the normal dietary intake of an individual with a view to treat or improve his existing physical condition or ailment .

2. Nutrition Includes study of process by which food is ingested, digested, absorbed and utilized in the body. Dietetics “Science and art of feeding individuals based on the principles of nutrition”. “Science and art of human nutritional care” “Application of diet therapy principles in patient related settings”

3. Adaption of normal to Therapeutic Diet To provide consistency-fluid or soft. 2. Increase Or Decrease energy values 3. Increase Or Decrease one more Nutrients. 4. Increase Or Decrease bulk in diet 5.Provide bland flavored diet 6.Include or exclude specific foods which are allergic 7.To modify the feeding intervals

4. Construction of Therapeutic Diet 1.Qualitative Balanced diet- 60-65% CHO 10-20% Protein 20-30% Fat 2. Quantitative Food groups Food guide pyramid Food Exchange System

5. USDA Food Guide Pyramid

6. Food Exchange List An exchange list is a grouping of foods in which specified amounts of all foods listed are of approximately equal carbohydrate, protein, and fat value. Specific foods within the lists may differ slightly in their nutritive value from the averages stated for the group.

7. Any food from the given exchange list can be substituted or exchanged for any other food in that list. In the fruits list, e.g. one small mango can be substituted for one medium sweet lime or four small tomatoes. In all, there are eight exchange lists: 1. Milk exchange 2. Legume and pulse exchange 3. Flesh food exchange 4. Vegetable A exchange 5. Vegetable B exchange 6.Fruit exchange 7. Cereal exchange 8. Fat exchange

8. FOOD EXCHANGE LIST Food groups portion Energy Protein Carbohydrates Fat Cereals and Millets 30 100 3 20 0.8 Pulses 30 100 6 15 0.7 Egg 50 85 7 - 7 Meat, Chicken , fish 50 100 9 - 7 Milk 100 70 3 5 3 Roots and Tubers 100 70 3 5 3 Green leafy vegeta 100 45 3.6 - 0.4 Other vegetables 100 30 1.7 - 0.2

9. Food groups Portion Energy (kcal) Protein (g) Carbohydrate (g) Fat (g) Fruits 100 40 - 10 - Sugar 5 20 - 5 - Fats & Oils 5 45 - - 5

10. Measures 1 cup= 150ml 1 glass = 200 ml 1 katori = 150 ml 1 tsp. (tea spoon ) = 5 ml or g 1 tbsp. (table spoon) = 15 ml or g

11. Routine hospital diet Soft diet- Acute infection, GI disturbances, following surgery. Liquid –Febrile, post-operatives, intolerant to solid foods. Clear fluid- Acute illnesses, marked intolerance for foods -Nausea, vomiting, anorexia, distension diarrhea. 30-60 ml/hr. gradually , 1 to 2 day Full Fluid- Unable to chew or swallow solid food. Include all foods liquid at room temperature & body temperature.

12. Liquid diet Clear liquid: Foods with low residue content – help minimize load of digestion in intestine Foods are clear and liquid at room temperature Purpose – to provide fluid and electrolyte to prevent dehydration Inadequate in calories and essential nutrients Should not be provided for more than 1-3 days as a sole source of nourishment

13. Initial feeding progression between IV and full fluid or solid food following surgery. May be used as a dietary preparation for bowel examination or surgery Acute GI disturbances, any illness associated with high fever. 50-100ml/hr or two at frequent intervals Do not use solid foods

14. Recommended foods Clear, fat-free broth Light coffee/tea (without milk/cream) Strained fruit juices Tender coconut water, whey, barley water Gelatin Sugar & salt added to liquids High protein supplements honey

15. Full fluid – liquid or semi-liquid at room temperature. Do not use solid foods Intermediate between clear liquid and regular diet Provides oral source of fluids to people- Incapable of chewing, swallowing or digesting solid foods Post-surgery after IV/ clearfluid Chewing or swallowing disorders Jaw-wiring Oesophageal or GI strictures Moderate GI inflammation Acute illness

16. Nutrient composition depends on type and amount of liquid the patient can consume Diet is low in iron, vit B12, vit A & thiamine By careful planning, it can be made adequate for maintenance requirements except fibre Liquid nutritional supplements or blenderized foods could be added -  nutritional adequacy 2-4 hours interval Inadequate in fibre – leads to constipation In case of prolonged use, vitamins, iron or liquid nutritional supplements must be added.

17. Recommended foods- full fluid Soups and broth Cereal porridge (refined cereals) Milk and milk beverages, yoghurt Coffee, tea, fruit juices Butter, cream, oil added to foods Plain puddings, custard, ice-cream, jelly Sugar, honey, salt and mild flavourings

18. Soft Diet Provides soft whole foods, lightly seasoned and moderately low in fibre Soft texture, easy to digest Small volumes of meals are offered until patient tolerates solid foods Transition between liquid and normal Post-operative cases, Acute infection GI disturbance Chewing problem

19. Individualized according to clinical diagnosis, surgery, appetite, food tolerance, pre-nutritional status, chewing and swallowing ability Nutritionally adequate Mechanical soft diet – normal diet that is modified only in texture for ease of mastication. Used when patient cannot chew or use facial muscles, dental, medical or surgical conditions Foods may be liquid, chopped, pureed or regular with soft consistency.

20. Soups – mildly flavoured –broths and cream soups Beverages – all Meat – moist, tender meat, fish or chicken, cottage cheese, eggs (except fried egg) Fat – butter, cream, oil, salad dressing Milk – milk, milk beverages, yoghurt Cereals – soft, cooked refined cereals – rice, pasta, bread, porridges

21. Vegetables – soft, cooked vegetables Fruits – cooked and soft fruits, fruit juices Desserts – custard, ice-cream, jelly, cake (sponge), puddings without nuts Sweets – sugar, honey, plain candies Avoid – fried food and nuts, rich pastries and desserts, raw vegetables, heavily spiced foods, gas-forming vegetables, skin and seeds of vegetables and fruits. Rich gravies, sauces, pickles, fried foods, rich cakes and nuts

22. Special feeding methods Illness may interfere with eating, digestion & absorption to such a degree that foods cannot supply the necessary Nutrients. 1.Enteral – a.Provides nutrients using GI tract b.Includes oral diets or supplements. c.Supplies nutrients directly to stomach or intestine via a flexible tube. 2.Parental Nutrition- a.provides Nutrients intravenously b.Those who do not have adequate GI function

23. It is not possible to give the feeding orally and tube feeding or parenteral feeding is restored in the following condition a. Those who cannot swallow due to paralysis of the muscles of swallowing or cancer of the oral cavity or larynx. b. Those who cannot be persuaded to eat. c. Those with persistent anorexia requiring forced feeding. d. Semiconscious or unconscious patients. e. Severe malabsorption requiring administration of unpalatable formula. .

24. g. Those who are undernourished or at risk of becoming so. h. Those who cannot digest and absorb i . After surgery j. Patients with neurological and renal disorders or have continued fevers or diabetes. k. Babies of very low birth weight.

25. ENTERAL FEEDING Indications -the preferred route - "If the gut works, use it" Mechanical GI tract dysfunction/disorders - may have normal digestive & absorptive function with an oral/mechanical/physiological obstruction Facial/jaw injuries, head & neck , swallowing disorders, obstruction of the upper GI tract, GI tract fistulas, short bowel syndrome (feed beyond the obstruction/fistula) Metabolic GI tract dysfunction - may have impaired ability to digest & absorb nutrients

26. Pancreatitis, inflammatory bowel disease, chemotherapy Hypermetabolic conditions - may have increased energy & protein requirements that cannot be met with regular oral intake Major burns, trauma, sepsis, post-operative recovery following surgery

27. Contraindication for Enteral Therapy: GI tract not working Intractable vomiting Intestinal obstruction Upper GI tract hemorrhage Severe, intractable diarrhea Severe, acute pancreatitis Expected need less than 5-10 days

28. A satisfactory tube feeding must be Nutritionally adequate Well tolerated by patient so that vomiting is not induced. Easily digested with no unfavourable reaction such as distension, diarrhoea or constipation Easily prepared and Inexpensive FORMULAS Many new commercial modular formulas are available. From the standpoint of accuracy in measuring, sanitation, and convenience, most hospitals prefer commercial mixtures. A 24-hour intake of three litres would furnish 3,000 calories.

29. Feeding routes Nasogastric (NG) : tube is placed into the stomach via the nose. Nasoenteric : tube is placed into the GI tract via the nose. ( Nasoenteric feedings usually refer to nasoduodenal and Nasojejunal feedings.) Nasoduodenal (ND): tube is placed into the duodenum via the nose. Nasojejunal (NJ): tube is placed into the mouth. This method is often used to feed infants because a nasogastric tube can hinder the infant’s breathing.

30. Orogastric : tube is placed into the GI tract via the mouth. This method is often used to feed infants because a nasogastric tube can hinder the infant’s breathing. Enterostomy (EN- ter -OSS-toe- mee ): an opening into the GI tract through which a feeding tube can be passed. Gastrostomy (gas –TROSS-toe- mee ): an opening into the stomach through which a feeding tube can be passed. A nonsurgical technique for creating a gastrostomy under local anesthesia is called Percutaneous endoscopic gastrostomy (PEG).

31. Jejunostomy (JE- ju -NOSS-toe- mee ): an opening in the jejunum through which a feeding tube can be passed. A nonsurgical technique for creating a jejunostomy is called Percutaneous endoscopic jejunostomy (PEJ).The tube can either be guided into the jejunum via a gastrostomy or passed directly into the jejunum (direct PEJ) ROUTES: Short-term: Nasogastric , Nasoduodenal , Nasojejunal Long-term: Gastrostomy & Jejunostomy (surgically placed) and PEG - percutaneous- esophago - gastrostomy & PEJ - percutaneous- esophago - jejunostomy ( endoscopically placed)

32. Parenteral feeding Total Parenteral Nutrition is defined as provision of all nutrients essential for normal homeostasis and growth in the required amounts through parenteral route that is directly into a vein TPN includes glucose emulsified fat crystalline amino acids Vitamins including B12, folic acid and vitamin K Electrolytes: sodium, chlorine, phosphorus, potassium, calcium and magnesium Trace elements:zinc , copper, chromium, manganese and iodine Water

33. Indications Patients who do not have functioning GI tracts and who are either malnourished or likely to become so. The following conditions may require use of parenteral nutrition: 1.Severe pancreatitis. 2.Malabsorption disorders. 3.Intestinal obstructions or fistulas. 4.Major trauma or burns. 5.Critical illnesses or wasting disorders. 6.Bone marrow transplants. 7.Being malnourished and having a high risk of aspiration. 8. Short-bowel syndrome (a portion of the intestine has been removed).

34. There are two parenteral or intravenous feeding methods. One method injects nutrients into the blood via a peripheral vein (for example, a vein in the arm, near the surface). The other method injects nutrients into the blood via a central vein (those deeper into the central portion of the system; for example, the subclavian located under the collarbone.

35. Peripheral Parenteral Nutrition (PPN): A type of nutrition support in which intravenous feedings are delivered into peripheral veins. PPN can supply only limited amounts of energy and protein. PPN is most often used in patients who need short-term nutrition support (about 7 to 10 days and who do not have high nutrient needs or fluid restrictions.

36. Total Parenteral Nutrition (TPN): A type of nutrition support in which intravenous feedings are delivered into a central vein; also called nutrition. Central veins lie close to the heart where the large volume of flood rapidly dilutes TPN solutions. Therefore, patients with very high nutrient needs or fluid restrictions are able receive the nutrient-dense solutions they require. TPN is also preferred for patients who require long-term intravenous feedings.

37. ENERGY CALCULATIONS Calculate the ideal body weight: Eg:5’ 6’’ =5 x 30.48=? And 6 x 2.54=? ?/2.2=IBW OR Height_100 =IBW Calculation of BMR Harris benedicts merthod : Men : 66+(13.7x IBW)+5 x Ht (cm)-6.76 x Age Women : 655 + (9.6 x IBW) + 1.8 x Ht(cm)-4.7 x Age. BMR x Physical activity= Energy requirements

38. Physical activity: Little/ No exercise: 1.2 Light activity: 1.375 Moderate exercise: 1.55 Heavy exercise: 1.725 Very heavy: 1.9

39. Diet Planning Principles Adequacy Balance, Kilocalorie ( energy), control Nutrient density Moderation Variety