therapeutic-diets

Therapeutic Diets

Therapeutic diets are adaptations of the normal or regular diets. In other words,is a diet for a patient suffering from a specific disease Such as heart failure, hypertension,renal failure, diabetes etc.

The disease process also influences both the quality and quantity of the diet. The other aspects that may require changes include meal frequency.

Purposes of Therapeutic dietary adaptation

  • To maintain or restore Optimum nutritional status,
  • To provide rest or releive an affected organ (e.g soft or liquid in gastritis)
  • To adjust to the body’s ability to digest, absorb, metabolize or excrete ( e.g a low fat diet for fat malabsorption)
  • To adjust to tolerance of food intake by mouth ( e.g tube feeding for patients with cancer of oesophagus)
  • To adjust mechanical difficulties ( e.g soft diet for Patient with dental problems)
  • To increase or decrease body weight / body composition ( e.g high calorie, low calorie etc)

Types of dietary adaptations for therapeutic needs

  • Changes in consistency of foods, such as liquid diet, soft diet , low fibre diet , high fibre diet.
  • Increase or decrease in energy value of the diet such as low calorie diet for Weight reduction, high calorie diet for burns.
  • Changes in specific nutrients Such as sodium restricted diet, lactose restricted diet, high fibre diet, high potassium diet.
  • Elimination of spices and condiments, such as bland diets.
  • Omission of specific foods such as allergy diets , gluten free diet.
  • Adjustment in the ratio and balance of protein, fat, carbohydrate such as diabetic diet, ketogenic diet, renal diet, cholesterol lowering diets.
  • Rearrangement of the number and frequency of the meals such as diebetic diet, postgastrectomy diet, diet for peptic ulcer disease.
  • Test diets : These are single meals or diets lasting one or few days that are given to the patients in connection with certain tests e.g the fat absorption test used to determine if steatorrhoea is present.
  • Change in feeding intervals i.e meal frequency.

Diet prescription

The diet prescription designates the type, amount, frequency of feeding based on an individual’s disease process and disease management goals. The disease may require a calorie level or other restrictions to be implemented. It may also limit or increase various components of the diet such as carbohydrate, protein, fat, vitamins, minerals, fibres, phynutrients or water. Another aspect Which the diet prescription takes into account includes-

  • Economic Status,
  • Food habits,
  • Food intolerance,
  • Allergy,
  • Occupation and meal timings.

Assessment of nutrients intake

An individual’s energy requirements can be determined calculating either:

Required number of Kcal /kg/ day OR percentage increase over basal metabolic demands.

You can estimate the Basal Energy Expenditure ( BEE) from anthropometric data using the following Harris- Benedict formula :

For men : BEE = 66+ ( 13.7× W) + ( 5×H)- (6.8 ×A)

For women : BEE = 655 + ( 9.6 ×W) + ( 1.85 ×H) –(4.7 × A)

Where, W=  body weight in kgs ,H = height in cms, A= age in years.

The additional factors is added on the activity level of patient and if patient is under physiological stress or not.

Mild stress – 20% over BEE

Acute infection or burns – may require 100% over basal

You should determine the actual energy requirements based on the assessment of  the individual,his/her activity, medical conditions etc.

Carbohydrates

Carbohydrates provide bulk energy to the diet and along with fats. The comparatively inexpensive form of the Carbohydrate in a high calorie diet can include chapattis, bread, biscuits. In a low calorie diet these must be used sparingly.

Protein

Once the energy requirements have been estimated, protein requirements is to be addressed. The aim is to achieve nitrogen balance. There are several factors influencing protein requirements and these include total energy  intake, the metabolic state of the patient  and protein losses. However, it is important to keep in mind that protein synthesis requires Energy. The RDA for protein is 0.8 gm to 1.0 gm / kg  body weight for adults. The actual minimum amount of protein needed to maintain nitrogen balance in healthy adults is 0.5 gm /kg . The requirements varies with specific Disease status. E.g – larger amounts of protein is required for severe protein wasting such as enteropathy or extensive drainage from wounds and fistulas. Protein should be restricted for those patient who are suffering from acute renal failure or hepatic insufficiency.

Fats

As we are already aware, fats are reservoir of calories. In addition to Carbohydrate , fats can also be an important source of needed calories. In certain therapeutic conditions  fat is necessary to prevent essential fatty acids deficiency. A high calorie diet should contain fatty foods ( such as cream, butter, ghee, oil) while a low calorie diet contains a little or no fat. Patient requiring low animal fat diets, must restrict their total fat consumption less than 30%  of their energy needs  and ideally 2/3 ratio of this must be in the form of PUFA ( Poly unsaturated Fatty acid) and MUFA ( Mono unsaturated fatty acids) This can be achieved by avoiding foods thats are rich in saturated Fatty acid ( SFA)  such as all fried meats and fish , whole milk,cream, cheeses and butter etc. While food products such as poultry, fish, egg white, cottage cheese, skimmed milk, wholemeal cereals, fruits vegetables, wholemeal bread can be taken in liberation or under the supervision of the dietitian.

Sodium

The recommended dietary intake of sodium is limited to 2300mg/day, this limit was established based on the evidence from clinical studies that sodium intakes above 2300mg per day can adversely affect blood pressure and increase heart disease risk. Foods containing high sodium such as ( processed and cured meats, tinned or smoked fish, tinned vegetables and soups, dehydrated and pre packed meals, salted biscuits, nuts etc) must be avoided.

Potassium

The daily requirement of Potassium for normal healthy adults are 2300mg-3400mg per day and respectively for pregnant and lactating mother it would increase upto 4700mg per day.

Potassium restricted diets are important for patients with advanced renal failure undergoing conservative treatment or Haemodialysis. The high potassium levels in mushroom,spinach,tomatoes,dry and split peas,lentils,fruits e.g. : prunes, dates, currants, grapefruit,oranges,banana etc must be avoided. Vegetables should not be eaten raw they require leaching before consumption. The patients must also be aware of and warned against using salt substitutes.

Fluid allowances

During certain clinical conditions such as renal failure when the fluid intake can be detrimental to the prognosis of the disease; the fluid allowance is calculated by using following formula :

Fluid allowance ( 24 hours) = 500 ml + urine output in previous 24 hours ( insensible losses) + fluid lost due to diarrhoea or vomiting ( if any)

Types of Therapeutic Diets

  • Regular diet
  • Liquid diet
  • Soft diet
  • Diabetic diet
  • Calorie controlled diet Low cholesterol diet
  • Fat restricted (low-fat) diet
  • Sodium restricted diet
  • Protein diet
  • Bland diet Low residue diet

Regular Diet

  • Balanced diet usually used for ambulatory patients
  • At times is has a slightly reduced caloric content
  • Foods such as rich desserts, cream sauces, salad dressings and fried foods may be decreased or omitted

Liquid Diets

Nutritionally inadequate and should only be used for short periods of time

Uses:
  • After surgery or a heart attack
  • Patients with acute infections or digestive problems
  • To replace fluids lost by vomiting or diarrhea
  • Before some Xrays and ultrasonography of digestive tract or abdomen.
2 types :
  • Clear liquid diet : Water, apple or grape juice, fat-free broths, plain gelatin, popsicles, ginger ale, tea, coffee
  • Full liquid diet : Everything on clear liquid diet plus strained soups and cereals, fruit and vegetable juices, yogurt, hot cocoa, custard, ice cream, pudding, sherbet, eggnog and smoothie.

Soft Diet

Similar to regular diet but foods must require little chewing and be easy to digest.

Food to avoid in Soft diet 
  • Fried foods and nuts
  • Rich pastries and dessert
  • Raw vegetebles
  • Heavily spcied foods
  • Gas forming vegetables
  • Skin and seeds of vegetables And fruits

Avoid  rich gravies sauces pickles etc.

Diabetic Diet

  • Used for patients with diabetes mellitus (body does not produce enough insulin to metabolize carbohydrates)
  • Diet contains exchange lists
  1. Goods are grouped according to type, nutrients, and calories
  2. Pts are allowed a certain number of items from each exchange list according to individual needs
  • Avoid sugar-heavy foods such as candy, soft drinks, desserts, cookies, syrup, honey, condensed milk, sugared gum, jams, and jellies
  • New trend is to count only carbs as blood sugar levels are most affected by carbs
  • Patient then takes an amount of insulin based upon amount of carbs eaten

Calorie Controlled Diet Low-Calorie Diet

  • Used for patients who are overweight
  • Avoid or limit high calories foods such as: Butter, cream, whole milk, cream soups or gravies, sweet soft drinks, alcoholic beverages, salad dressings, fatty meats, candy and rich desserts
  • Used for pts who are underweight, or who have anorexia nervosa, hyperthyroidism, or cancer
  • Extra proteins and carbs are included
  • Avoid high-bulk foods such as green salads, watermelon and fibrous fruits
  • Avoid high-fat foods such as fried foods, rich pastries, and cheese cake because they digest slowly and spoil appetite

Low Cholesterol Diet

  • Restricts foods containing cholesterol
  • Used for patients with atherosclerosis and heart disease
  • Limit foods high in saturated fats such as beef, liver, pork, lamb, egg yolk, cream, cheese, natural cheeses, shellfish, whole milk, and coconut and palm oil products

Fat Restricted or Low-Fat Diet

  • Used for patients with gallbladder and liver disease, obesity, and certain heart diseases
  • Avoid cream, whole milk, cheese, fats, fatty meats, rich desserts, chocolate, fried foods, salad dressings, nuts, and coconut

Sodium Restricted Diet (Low Sodium or Low Salt Diet)

•Used for patients with cardiovascular diseases such as hypertension or congestive heart disease, kidney disease, and edema •Avoid or limit addition of salt to any food, smoked meats or fish, processed foods, pickles, sauerkraut, olives, and processed cheeses

High Protein Diet

  • Used for children and adolescents who need additional growth, pregnant or lactating women, before and/or after surgery, pts suffering from burns, fevers, or infections
  • Regular diet with added protein rich foods such as meats, fish, milk, cheese, and eggs

Low Protein Diet

  • Used for patients with certain kidney diseases and for certain allergic conditions
  • Regular diet with limited or decreased protein rich foods

Bland Diet

  • Consists of easily digested foods that do not irritate the digestive tract
  • Used for patients with ulcers and other digestive diseases
  • Avoid coarse foods, fried foods, highly seasoned foods, pastries, raw fruits and veggies, alcohol, carbonated beverages, nuts, coffee, tea, smoked and salted meats and fish.

Low Residue Diet

  • Used for patients with digestive and rectal diseases such as colitis or diarrhea
  • Eliminates or limits foods high in bulk or fiber such as raw fruits and veggies, whole grains and cereals, nuts, seeds, beans and peas, coconut, and fried foods

Some special diets

High fibre diets : The patients are advised to eat high fibre cereals as whole grain flour and bread, whole grain breakfast cereals, whole wheat pasta and brown rice, all kinds of fruits and vegetables ( with their edible peels). Unprocessed bran can also be added to cereals or soups to give more fibre.

Gluten –free diet : It is a diet recommended for the patients with gluten enteropathy. Gluten is present in wheat , the, barley, oats. Thus, foods containing these should not be eaten. A number of gluten free products are available on prescription and these include gluten-free flour, bread, buiscuits.

Elimination diets : This type of diet is used in a patient with suspected food intolerance, food allergies or Crohn’s disease.

Exclusion diets : Specific dietary exclusion becomes a necessity in case of food allergy or food intolerance. The therapeutic use of such diets requires a detailed discussion between the patient and the dietitian. Each patient is provided with a list of foods that are permissible and avoided. Also the need of scrutinize the ingredient lists in all convenience and manufactured goods is emphasized.

The examples of these diets inclue :

  • Wheat freediet : Here, foods to be avoided are ordinary breads, buiscuits, cakes,pastries, pasta, spaghetti and all wheat containing breakfast cereals.
  • Milk free diet : As the name implies, all foods containing milk protein must be avoided such as cheese, yoghurt, ice cream, butter
  • Egg free diet:  In this, eggs and all products containing eggs are excluded from the diet such beef burgers,pies,cakes, meringues as well as Bournvita And Ovaltine.

Additive free diets : Here,  Additives  include permitted food colours such as tartrazine , sunset yellow, ponceus 4R and preservatives such as benzoic acid, salicylates etc are excluded from the diet.

Ketogenic diet: It is occasionally used to facilitate the control of epilepsy. Here, the patient is initially fasted for 48 hours and thereafter, half the energy requirements is provided as MCT ( Medium Chain Triglycerides). Energy intake from ordinary food must be restricted to prevent the suppression of ketones.

Mode of feeding

The diet of an individual could be managed by using oral, tube, peripheral vein or total parenteral  feeding as per patient’s physical condition. The Dietitian should understand the limitations of the patients and enlist the help of the nurse or patient relative.

The different feeding method includes :

  • Oral feeding
  • Tube or enteral feeding
  • Peripheral vein feeding Total parenteral feeding ( TPN)

Oral feeding :  This is the preferred and most palatable method of feeding for meeting the increased nutritional demands of catabolism, it should be used as long as possible. If needed, nutrient supplements added to the oral diets.

Tube or enteral feeding : Ideally  the patient must be fed orally , but  in cases where the patient is unable to take  solid foods, a part or all of intake is usually given by the tube. These are the cases where the gastrointestinal tract is functioning and can be used. Here, an alternate form of enteral feeding by tube provides nutritional support. Enteral  nutrition can be provided by supplying intact,semi or completely hydrolyzed formulas through nasogastric/ duodenal/ jejunal routes or by the help of gastrostomies/ jejunostomies. These conditions inclue oral surgery, gastrointestinal surgery, dysphagia, unconsciousness, anorexia or oesophageal obstruction. Various commercial formulas are available for enteral tube feeding.

Peripheral vein feeding: Intravenous feeding is a method of providing parenteral nutrition when a patient cannot take in food or formula through the gastrointestinal tract. Various solutions of dextrose,aminoacids,vitamins, minerals and lipids can be fed through peripheral veins. But in this method the nutrient and kcal intake is limited. It is used only when the nutritional need is not extensive and long term, where  it is provided peripherally as a mixture of 5 to 10% glucose, a 3.5 to 5 % amino acid solution and  10 to 20 % lipid emulsion. The total fat intake should not be exceed 2.5 gm / kg/day. Vitamins minerals and electrolytes are added as necessary, based on requirements and intake. The osmolarity of the solution should not be greater than 600 mOsm/L.

For more details you can also refer the for Video.

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