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D IETETIC TREATMENT Dr. Sumbul Fatma

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O BJECTIVE To discuss the nutritional care process and how the basic principles of nutrition can be applied to the treatment of disease

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D IETETIC T REATMENT Also referred to as diet therapy or diet in disease Involves the modification or adaptation of the normal or basic diet according to the needs of the individual

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W HY ? To maintain or improve nutritional status To improve clinical or subclinical nutritional deficiencies To maintain, increase or decrease body weight To rest certain organs or the whole body To eliminate certain food constituents to which the individual may be allergic To adjust the composition of the normal diet to meet the ability of the body to adjust, metabolize, and excrete certain nutrients and other substances

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T HE DIET PRESCRIPTION It is written in terms of energy requirements based on individuals weight and activity and requirements for protein, fat, carbohydrate, minerals, vitamins and fiber with regard for the increased or decreased needs for each because of the patients illness The prescription is translated into foods and meals by the dietitian, who, in turn, instructs the patient regarding the diet, its importance as a single therapeutic measure or as a supplement to medication

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F ROM BASIC TO THERAPEUTIC DIET An increase or decrease in the following The energy value (kilocalories) Fiber Specific nutrient(s) Specific food or types of food (such as allergens for persons with allergies, fried foods, or gas forming foods) Anyone of these modified diets may be further altered to become a soft or liquid diet

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E XAMPLES OF THERAPEUTIC DIETS M ODIFICATIONS IN CONSISTENCY Tube feeding- for patients with an esophageal obstruction or severe burns or who have undergone gastric surgery Restricted-residue diet- for patients with gastritis, Crohns disease, severe diarrhea, ulcerative colitis, diverticulitis, typhoid fever

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M ODIFICATIONS IN CARBOHYDRATE, PROTEIN AND FAT Diabetic diet- carefully calculated for each patient to minimize the occurrence of hyperglycemia and glycosuria and to attain the ideal body weight Low calorie diet- to achieve weight loss in individuals with cardiovascular and renal diseases, hypertension, gallbladder disease, gout or hyperthyroidism, and for severely ill patients

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M ODIFICATIONS IN FAT Restricted-fat diet- for pateints with disease of the liver, gall bladder or pancreas in which the disturbances of digestion and absorption of fat may occur Fat-controlled Low-cholesterol diet- In individuals with elevated blood cholesterol and for patients with atherosclerosis

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M ODIFICATIONS IN PROTEIN Restricted-protein diet- for patients in hepatic coma or with chronic uremia, renal disease or liver disease Gluten-free diet- Individuals with celiac have gluten intolerance and must be on gluten-free diet Restricted-purine diet- A decrease in purines is useful in lowering the blood uric acid level in gout High protein diet- is used to correct a protein inadequacy from any source- pre- and postoperative, high fever, burns, injuries, increased metabolism, pernicious anemia, hepatitis, cystic fibrosis etc

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M ODIFICATIONS IN CARBOHYDRATE Lactose-free diet- patients with total or partial inability to metabolize this milk sugar must avoid lactose in their diet Dumping syndrome diet- Patients who have had a gastrectomy or gastric bypass surgery may require this special diet

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M ODIFICATIONS IN ELECTROLYTES AND MINERALS Restricted-sodium diet- prescribed for patients with congestive heart failure, hypertension, renal disease with edema, cirrhosis of the liver with ascites, pre-eclampsia and eclampsia and ACTH therapy Restricted-potassium diet- when potassium is not being excreted properly from the body High-calcium and high-phosphorus diet- desirable in rickets, osteomalacia, tetany, dental caries, and acute lead poisoning High-iron diet- nutritional and hemorrhagic anemia High-vitamin diet- If a specific vitamin deficiency is diagnosed e.g. vit A to combat night blindness and xerophthalmia, vit D for rickets and osteomalacia, vit K in liver and gallbladder disease

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N UTRITIONAL A SSESSMENT Dietary history Anthropometry Biochemical and clinical data Laboratory tests of blood and urine to compare with normal ranges for hemoglobin, albumin, transferrin, total plasma protein etc. (all associated with body protein stores) Nitrogen content in 24 hour urinary output (a negative nitrogen balance signifies that the body is using some of its protein reserves for energy Skin tests Immunity to certain diseases Response to antigens

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N UTRITIONAL M ANAGEMENT IN D IABETES M ELLITUS Kilocalories- The amount of kilocalories needed by the individual with diabetes should be the same as the RDA for the person without diabetes but adjustments in kcal may be necessary to maintain or attain the normal weight Protein- The %age of kcal derived from protein is usually 15- 20%. This allows the individual with diabetes from 1-1.5g of protein/kg of body weight and should approximate the RDA Carbohydrates- are no longer restricted as much as they once were. The recommended allowance is 50-60% of total calories. Complex carbohydrates are emphasized as are high- fiber foods Fat- ~20-30% of the total calories. Low-fat foods, lean meats, and polyunsaturated fats are emphasized to prevent cardiovascular disease (a common complication of diabetes)

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R ENAL D ISEASES The kidneys perform two main functions 1. To excrete waste products, unnecessary material and superfluous fluids (water) from the body 2. To retain all material valuable to the system In disturbances of the kidney two sets of phenomenon are noticeable 1. Accumulation in the blood of substances which should have been eliminated 2. Excretion from the blood of material that should have been retained

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R ENAL D ISEASES Management of the renal disease is complex involves controlling several nutritional components like- proteins, kcalories, phosphorus, sodium and potassium Generally all are restricted except kcal, which need to be maintained at a high level to prevent protein from being broken down for energy needs, resulting in nitrogenous waste material Once the dialysis begins the restrictions are often reversed in order to compenstate for the excess losses incurred The reduction of nitrogenous excretory wastes resulting from the breakdown of proteins is crucial in the prevention of further kidney damage

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D IETARY TREATMENT FOR RENAL DISEASES Calories- Adequate calories are provided in the treatment of renal disease, particularly when the diet is restricted in protein, so that the body protein will not be used to meet energy needs (~35-45kcal/kg body weight) Protein- An adequate amount of protein is provided as long as the kidney function remains unimpaired. Amounts range from very low(20g) to low (40-50g) to high (100-125g), depending on the disorder. Protein is increased to make up for the albumin loss in urine or it is restricted to various levels with lessened kidney function and retention of end products of protein metabolism in blood. Calculations are based on 0.5-1.5g/kg, depending on the disorder

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D IETARY TREATMENT FOR RENAL DISEASES CONTD.. Electrolytes- A low protein diet will also be a restricted- sodium diet, because protein foods are high in sodium. A more liberal sodium restriction is appropriate for hypertension without edema Potassium is restricted because its excretion lessens with progressive kidney damage, and it is retained in the blood of patients with renal failure- usually to the 1.5 g level. Restricting phosphorus to 450-600mg should maintain desirable serum phosphorus levels Fluids- are restricted for patients with renal failure; a balance between intake and output must be achieved. The general guidelines are 500ml plus urinary output

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C ARDIOVASCULAR D ISEASES The main nutrition-related risk factors associated with CVD are obesity (the need to reduce calories) Hypertension (the need for a reduction in sodium intake) Elevated levels of blood cholesterol and LDL (the need for reduction in total dietary fat, saturated fat, and cholesterol, and a moderate increase in PUFA and soluble fiber) Diabetes mellitus (the need for control of blood glucose levels)

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AHA NUTRITIONAL GUIDELINES Kcal modification is necessary to achieve and maintain ideal weight Total dietary fat reduction to 30% of total kcal consisting of 10% each of saturated, MUFA and PUFA fats Dietary cholesterol reduction to less than 300mg daily Dietary carbohydrate consisting mainly of fruits, vegetables, whole grain and enriched breads, and cereals

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D IETARY THERAPY FOR HIGH BLOOD CHOLESTEROL NutrientRecommended Intake Step One dietStep two diet Total fatLess than 30% of total calories Saturated fattyacids < 10% of total