23 Dietetics[1]
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Transcript of 23 Dietetics[1]
By: Ma. Jenee C. Virtudazo, RN-D
Clinical DietitianAssociate Diabetes Educator
Dietary Management of
Heart Disease, Diabetes
Mellitus, and Arthritis
TOPICSTOPICS
� Review
� ABCD’s of Assessment
� Diet Prescription
� Diet Instruction
� Monitoring/ Follow-up
Principles of Dietary ManagementPrinciples of Dietary Management
� Liberalization
� Individualization
� Simplification
Principles of Dietary ManagementPrinciples of Dietary Management
Two Broad Classification of Therapeutic Diets
� Modification in Consistency
� Modification in Composition
ABCD’sABCD’s of Assessmentof Assessment
� Anthropometry
� Biochemical
� Clinical
� Dietary
AnthropometryAnthropometry
� Height
� Weight
ABW % Std Wt
DBW BMI
� Nutritional Classification
I. Methods of Estimating Desirable I. Methods of Estimating Desirable
Body Weight ( DBW) in InfantsBody Weight ( DBW) in Infants
A. First 6 months: DBW (g) = Birth weight + (Age X 600 )
If birth weight is not known use 3000 g
Ex. 4 month old infant
DBW = 3000 +(4 X 600)=5400 or 5.4 kg
7-12 months: DBW = birth weight + ( Age X 500 )
Ex. 8 month old infant
DBW = 3000 = ( 8 X 500) = 7000 or 7 kg
I. Methods of Estimating Desirable I. Methods of Estimating Desirable
Body Weight ( DBW) in InfantsBody Weight ( DBW) in Infants
B. DBW ( kg) = (Age in months/ 2) + 3
Ex. 8 month old infant
DBW = (8/2) = 3 = 7
II. Methods of Estimating DBW in II. Methods of Estimating DBW in
ChildrenChildren
DBW ( kg) = (Age in years X 2) + 8
Ex. 7 years old
DBW = ( 7 X 2 ) + 8 = 22 kg
III. Methods of Estimating DBW in III. Methods of Estimating DBW in
AdultsAdults
A. Tannhauser’s Method
DBW( kg) = ( Ht in cm – 100) – 10%
Ex. 5’2’ = 62” X 2.54 cm = 157.48
= 157.48 – 100 = 57.48
= 57.48 – 5.74 = 51.74 or 52 kg
III. Methods of Estimating DBW in III. Methods of Estimating DBW in
AdultsAdults
B. Adopted Method
For 5 ft use 106 lbs for male & 100 for female,
for every inch above 5 ft add 6 lbs for male and
5 lbs for female
Ex. 5’2” Female
= 5 ft = 100 lbs + 2 inches X 5 = 10 lbs
= 100 + 10 = 110 lbs
3. Body Mass Index
= Weight ( kg)
Height (m)2
Ex. 60 kg , 5’2”
= 60 kg
2.46
= 24
III. Methods of Estimating DBW in III. Methods of Estimating DBW in
AdultsAdults
Cut Off Values for BMI
BMI< 20 = underweight
BMI 20-24.9 = normal
BMI 25-30 = overweight
BMI > 30 = obese
III. Methods of Estimating DBW in III. Methods of Estimating DBW in
AdultsAdults
BIOCHEMICALBIOCHEMICAL
� Laboratory data
Blood Chemistry
CBC
Urinalysis
BP
� Interpretation
CLINICALCLINICAL
� Signs and Symptoms of Malnutrition
DIETARYDIETARY
� Food Recall
� Food likes
� Food dislikes
� Food taboos
� Food allergy
� Oral Function
� Diet regimen
General DataGeneral Data
� Name
� Age
� Religion
� Attending Physician
� Referred By
DiagnosisDiagnosis
� HPN
� DM
� Dyslipidemia
� IHD
� Gouty Arthritis
� Obesity
� Cancer
Steps in Preparing Diet Steps in Preparing Diet
PrescriptionPrescription
1. Determine Desirable Body Weight (DBW).
2. Calculate the Total Energy Requirement (TER).
3. TER is converted in grams of CHO, PRO and Fat based on the percentages.
Steps in Preparing Diet Steps in Preparing Diet
PrescriptionPrescription
4. The grams of CHO, PRO , & Fat are converted in servings of foods using the Food Exchange Lists ( FEL).
5. The number of daily food servings within each
group is distributed among the 3 major meals & snacks.
6. Once the diet prescription is established, individual meals can be planned by selecting servings of appropriate foods from the FEL.
Methods of Estimating Total Methods of Estimating Total
Energy Requirement (TER)Energy Requirement (TER)
I. INFANTS
110 – 120 kcals /KDBW
Ex. 4 month old infant
DBW = 5.4 kg X 120 = 648 cals
Methods of Estimating Total Methods of Estimating Total
Energy Requirement (TER)Energy Requirement (TER)
II. CHILDREN
A. Cals/day = 1000 + (100 X Age in years) = 1800 cal
B. Age Range Cals/ KDBW
1-3 100
4-6 90
7-9 80
10-12 70 boys
60 girls
50 adolescents
Determination of TER in AdultsDetermination of TER in Adults
A. Krause Method
DBW (kg) X Physical Activity (kcal/kg)
Activity Factor (kcal/kg) Example of Activity
Bed Rest = 27.5 hospital patients
Sedentary = 30 mostly sitting
Light = 35 tailor, nurse, student
Moderate = 40 carpenter, house work
Heavy = 45 farmer, laborer, fisherman
Ex. DBW = 52 kg with light activity
TER = 52 kg X 35 kcal = 1820 kcal or 1800 kcal
Distribution of TER Into Distribution of TER Into
Carbohydrate, Protein & FatsCarbohydrate, Protein & Fats
Method I. By Percentage Distribution
% of TER
1. Carbohydrates 50-70% or average of 60%
2. Proteins
Infants & Children 10%
Adolescents & Adults 10-12%
3. Fats
Normal Adults &
Moderately Active 20-25%
Children, Adolescents &
Very Active Individuals 30-35%
Method II. Determine the protein calories first according to normal allowance in g/KDBW and divide the non-protein calories (NPC) into:
CHO - 55-80% or average of 70%
FAT - 20-45% or average of 30%
Distribution of TER Into Distribution of TER Into
Carbohydrate, Protein & FatsCarbohydrate, Protein & Fats
Normal Protein Allowance/Day
gm/ KDBW
Infants 2.5-3.0
Children 2.0
Adolescents 1.5
Adults 1.1
Distribution of TER Into Distribution of TER Into
Carbohydrate, Protein & FatsCarbohydrate, Protein & Fats
Diet Prescription Diet Prescription
� Compute for the diet prescription
Female 5’2” ABW = 62kg
Rx Diet Cals CHO CHON FAT
a. Percent Distribution
b. Non-Protein Calories Method
Composition of Food ExchangesComposition of Food Exchanges
Food Measure C P F Energy
(g) (g) (g) (Kcal)
Veg A 1 c. raw - - - -
½ c. cooked - - - -
Veg A 2 c. raw 3 1 - 16
1 c. cooked
Veg B ½ c. raw 3 1 - 16
½ c. cooked
Fruit varies 10 - - 40
Composition of Food ExchangesComposition of Food Exchanges
Food Measure C P F Energy
(g) (g) (g) (Kcal)
Milk
Whole varies 12 8 10 170
Low fat 4 T 12 8 5 125
Skimmed varies 12 8 tr 80
Rice varies 23 2 - 100
Meat
Low fat varies - 8 1 41
Med fat varies - 8 6 86
High fat varies - 8 10 122
Fat 1 t - - 5 45
Sugar 1 t 5 - - 20
Diet InstructionDiet Instruction
� Rx Diet
� Translate the Rx Diet to actual foods
� Make a meal plan
� Explain the meal plan to the patient
- rationale of the Rx Diet
- serving portions divided into 3m/2sn
- FEL
- Qualitative instruction
UpdatesUpdates
Dietary Management of Heart
Diseases and Dyslipidemia
Prevalence of Overweight / Obesity Prevalence of Overweight / Obesity
among Filipino Adultsamong Filipino Adults
11.80%
1.70%
14.00%
2.60%
16.90%
3.20%
19.60%
4.90%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Pre
va
len
ce
1987 1993 1999 2003
Obese
Overweight
FNRI, 1987 to 2003
Disease Risk Associated with Excess Disease Risk Associated with Excess Body Mass IndexBody Mass Index
Willet WC et al. N Engl J Med 1999;341:427-434.
Type 2 diabetes CholelithiasisHypertension CHD
BMI (kg/m2)
Women
Relative Risk
21 22 23 24 25 26 27 28 29 30
BMI (kg/m2)
Men
21 22 23 24 25 26 27 28 29 300
1
2
3
4
5
6
0
1
2
3
4
5
6
Disease Risk Associated with Excess Disease Risk Associated with Excess Body Mass IndexBody Mass Index
Willet WC et al. N Engl J Med 1999;341:427-434.
Type 2 diabetes CholelithiasisHypertension CHD
BMI (kg/m2)
Women
Relative Risk
21 22 23 24 25 26 27 28 29 30
BMI (kg/m2)
Men
21 22 23 24 25 26 27 28 29 300
1
2
3
4
5
6
0
1
2
3
4
5
6
MORTALITY: LEADING CAUSESRate per 100,000 Population
Philippines 1995
MORTALITY: LEADING CAUSESMORTALITY: LEADING CAUSESRate per 100,000 PopulationRate per 100,000 Population
Philippines 1995Philippines 1995
Dis. of the HeartDis. of the Heart
T.B. All FormsT.B. All Forms
Dis. of the
Vascular System
Dis. of the
Vascular System
Malignant
Neoplasms
Malignant
Neoplasms
Chronic ObstructivePulmonary Dis. &Allied Conditions
Chronic ObstructivePulmonary Dis. &Allied Conditions
AccidentsAccidents
Diabetes MellitusDiabetes Mellitus
Other Dis. of
Respiratory System
Other Dis. of
Respiratory System
20 1000 40 60 80Rate
Causes
PneumoniaPneumonia
Diarrheal Dis.Diarrheal Dis.
Lifestyle Interventions: Lifestyle Interventions:
Dietary Therapy, Physical Dietary Therapy, Physical
Activity, Weight ControlActivity, Weight Control
-60%-40%-20%0%
Primary Prevention: Primary Prevention: Crucial Opportunity to Crucial Opportunity to
Reduce the Burden of CHDReduce the Burden of CHD
Law MR et al. BMJ 1994;308:367-372.
Age 70Age 70
Reduction in risk in men with 10% reductionReduction in risk in men with 10% reduction
in total cholesterol (10 cohort studies)in total cholesterol (10 cohort studies)
Age 50Age 50
Age 40Age 40
Therapeutic diet to Therapeutic diet to
lower LDLlower LDL--CC
New Options to Lower LDLNew Options to Lower LDL--CC
� Avoid
– Trans fatty acids* (hydrogenated oils)
� Add
– Dietary fiber (soluble fiber)
– Plant sterol/stanol ester margarines
Expert Panel. JAMA 2001;285:2486-2497.
* Keep trans fatty acids low
TransTrans Fatty Acids (TFA)Fatty Acids (TFA)
� TFA more densely packed than cis forms
� Usual intake: only 2–3% of energy
�If consumed in high amounts:
↑↑↑↑ LDL-C; ↓↓↓↓ HDL-C
Lichtenstein AH et al. N Engl J Med 1999;340:1933-1940
Conclusion:Conclusion: Consume products low in Consume products low in
saturated and TFAsaturated and TFA
Primary Prevention: Primary Prevention: Adverse Adverse
Life Habit ChangesLife Habit Changes
�Atherogenic diet
�Sedentary lifestyle
�Obesity
Expert Panel. JAMA 2001;285:2486-2497.
Saturated FatSaturated Fat� Examples of Saturated Fatty Foods
– Bacon
– Butter
– Coconut, grated*
– Coconut cream*
– Coconut oil*
– Cream cheese
– Latik*
– Margarine
– Shortening or lard
– Sour cream
– Sitsaron
– Whipping cream
– Kropeck
Dietary Options Dietary Options —— Benefit Benefit
Independent of LDLIndependent of LDL--C LoweringC Lowering
�� AvoidAvoid
– Megavitamins (adverse effects shown for supplements of beta-carotene, no convincing clinical trial benefit for vitamin E supplementation)
�� AddAdd
– Fish
– Plant sources of omega-3 fatty acids
– Fruits and vegetables
Sources of Fiber ComponentsSources of Fiber ComponentsSources of Fiber ComponentsSources of Fiber ComponentsSources of Fiber ComponentsSources of Fiber ComponentsSources of Fiber ComponentsSources of Fiber Components
�Soluble
indigestible food components that readily dissolve in
water and often impart gummy or gel-like characteristics
to foods.
Gums Pectin
Oats Apples
Legumes Citrus Fruits
Guar Strawberries
Barley Carrots
DIABETIC DIETDIABETIC DIET
� Meal plan based on the individual’s food intake
� Spacing of meals is encouraged
� Weight control is important
� Caloric Distribution:
– CHO: 50-70%
– CHON: 10-20%
– FATS 20-30%
DIABETIC DIETDIABETIC DIET
� Cholesterol -300 mg, 10% saturated fats
� Fiber 25 g/1000 calorie
� Sodium – 3000 mg
HIGH CARBOHYDRATE & LOW HIGH CARBOHYDRATE & LOW
CARBOHYDRATECARBOHYDRATE
HIGH CARBOHYDRATE (65- 75% of TER)
Foods Allowed:
Emphasis on high carbohydrate foods such as
rice, cereals, bread, sugar & sugar products,
root crops, noodles, fruits & legumes
Indications For Use:
Diseases requiring low protein & low fat diets
(renal & liver)
HIGH CARBOHYDRATE & LOW HIGH CARBOHYDRATE & LOW
CARBOHYDRATECARBOHYDRATE
LOW CARBOHYDRATE ( <50% of TER )
Foods Allowed:
Emphasis on foods high in protein
Adequate to high fat foods
Indications for Use:
� Obesity, Celiac Disease
� Dumping Syndrome
� Hyperinsulinism, COPD ( w/ ventilator)
PURINE RESTRICTEDPURINE RESTRICTED
Protein is not more than 10% of TER
Purine = 120-150 mg
CLASSIFICATION OF FOODS ACCORDING TO PURINE CONTENTCategory 1 Category 2 Category 3Very large; 150-1000 mg Large;75<150 mg Moderate < 75 mgPurine/100 g Purine/100 g Purine/100 gOrgan Meats Hog; liver, spleen, intestines lung, kidney, tongue, head uterus ,bloodCattle: liver, spleen lung, uterus, kidney small& large
heart, brain, reticulum intestines, bloodtripe
Carabao: liver, spleen lung , kidney, tripe uterus, small &tripe, reticulum large intestines
tripeChicken: liver, kidney, gizzard, intestinesShellfishesDilis Halaan, PusitTamban Hipon,puti, Tuna, Karpa, Salmon, IgatTunsoy Tahong, Talaba, Tulya
HIGH PROTEIN & LOW PROTEINHIGH PROTEIN & LOW PROTEIN
HIGH PROTEIN ( 15-20% of TER or 1.5g – 2g/KDBW)
Foods Allowed:
Emphasis on HBV proteins such as meat, fish, poultry,
cheese, milk, soy beans & soy products
Indications For Use:
� Protein Energy Malnutrition
� Hypercatabolic States
� Hepatitis, Portal Cirrhosis
HIGH PROTEIN & LOW PROTEINHIGH PROTEIN & LOW PROTEIN
LOW PROTEIN ( 0.6-0.8 g/ KDBW; 2/3 HBV)
Foods Allowed:
Protein limited to prescribed amounts
Indications For Use:
� Chronic Kidney Disease
� Hepatic Coma
MODIFICATIONS IN COMPOSITIONMODIFICATIONS IN COMPOSITION
HIGH CALORIE
Indications For Use:
� Protein Energy Malnutrition
� Hypercatabolic States
MODIFICATIONS IN COMPOSITIONMODIFICATIONS IN COMPOSITION
Ways of Prescribing High Calorie:
1.Compute TER using DBW
Ex: 5’2” = DBW = 52 kg
TER = 52 X 30 cals = 1560or 1550 cals
2. Add 500-1000 cal/day to TER
Ex: 1550 + 500 = 2050 cals
1550 + 1000 = 2550 cals
3. Add 50-100% to the TER
Ex: 1550 + 775 (50%) = 2325 cals
1550 + 1550 ( 100%) = 3100 cals
LOW CALORIE
Foods Allowed:
Sufficient bulk, low in fat & sugar
Indications For Use:
� Obesity & Overweight
� Diseases requiring reduced energy requirements
MODIFICATIONS IN COMPOSITIONMODIFICATIONS IN COMPOSITION
Ways of Prescribing Low Calorie :
Given: Height 5’2” ; Physical Activity: sedentary
DBW = 52 kg ABW: 80 kg
Actual Caloric Intake: 3000 cals
1. Compute TER based on DBW
Ex: TER = 52 X 30 cals = 1560 0r 1550 cals
2. Calculate TER based on ABW
Ex. TER= 80 kg X 30 cal 2400 cals
3. Actual Caloric Intake – 500 or 1000 cals
Ex. TER= 3000 cals – 500 cals = 2500 cals
4. Allow 20-25 cal/KDBW
Ex. TER = 52 kg X 25 cal = 1300 cals
MODIFICATIONS IN COMPOSITIONMODIFICATIONS IN COMPOSITION
Modification in ConsistencyModification in Consistency
CLEAR LIQUID
Foods Allowed:
clear, fat –free broth
strained juices, tea, black coffee, ginger ale & non-carbonated drinks
plain gelatin, sugar, plain candies
Indications For Use:
� Pre- operative & post- operative cases with NGT function
FULL LIQUID
Foods Allowed
Strained cream soups & lugao mashed potato
Strained meats, SCE, milk & milk drinks
Vegetable & fruit purees, juices
Plain ice cream, gelatin, soft pudding or baked custard
Cream, butter or margarine
Indications for Use
� Post-operative cases with N GIT function
� Dysphagia
Modification in ConsistencyModification in Consistency
SOFT & MECHANICAL SOFTSOFT & MECHANICAL SOFT
SOFT DIET
Foods low in cellulose & fiber; free from tough
connective tissues, mildly seasoned & easily digested; simply prepared
Indications For Use:
- Post- operative cases when patient can tolerate
solid food but not a full diet
- Fevers & mild infections
- Gastrointestinal disturbances
SOFT & MECHANICAL SOFTSOFT & MECHANICAL SOFT
MECHANICAL SOFT
Indications for Use
� Oral lesions & poor dentures
� After oral, head & neck surgery
� Difficulty of chewing
LOW RESIDUE & BLAND LOW RESIDUE & BLAND
LOW RESIDUE
Foods Allowed:
Diet consisting of mildly seasoned & easily digested foods
Indications For Use:
� Spastic Constipation
� Chronic Diarrhea
� Ulcerative Colitis
LOW RESIDUE & BLAND LOW RESIDUE & BLAND
BLAND DIET
Foods Allowed:
Mild in flavor & non stimulating
No coarse fiber & connective tissues
Foods Avoided:
pepper, chili powder, alcohol, strong coffee, cocoa, tea, cola beverages
HIGH FIBER & LOW FIBERHIGH FIBER & LOW FIBER
HIGH FIBER
Foods Allowed:
Long- fibered vegetables , raw fruits & vegetables
Whole grain cereals , coarse breads
Indications For Use:
� Atonic Constipation
� Diverticular Disease
� Irritable Bowel Syndrome
� Gastric Ulcers
� Chronic Diseases ( DM, CVD, Ca, etc)
LOW FIBER
Foods Allowed:
Young immature vegetable
Well- cooked fruits, fruits w/o
skin & seeds
Tender cuts of meats
HIGH FIBER & LOW FIBERHIGH FIBER & LOW FIBER
Tube FeedingTube Feeding
Foods Allowed:
Foods included in liquid & soft diets ,
selected foods from regular diet, well
blended
Tube FeedingTube FeedingComparison of Different Formulas
Formula CHO PRO FATS
(%) (%) (%)
Nutren 1.0 51 16 38
Nutren (Fiber) 51 16 33
Ensure 55 14 32
Isocal 50 14 37
Ultracal 46 17 37
Glucerna 50 17 33
Pulmocare 55 17 28
Respalor 39 20 41
Nepro 43 14 43
Suplena 51 30 43
Polycose powder 3.8 kcal/g
Casec powder 3.7 kcal/g
ProMod powder 4.2 kcal/g
LOW SODIUMLOW SODIUM
I. 500 mg Sodium (Strict Restriction)
� No salt & salt containing spices or foods high in sodium
(processed foods)
II. 1000 mg Sodium (Moderate Restriction)
� More liberal selection of foods or if preferred 1/4 teaspoon salt
(1.25) may be added; processed foods omitted
LOW SODIUMLOW SODIUM
III. 2000-3000 mg Sodium (Mild Restriction)
� Liberal use of salt in preparation, no patis, toyo on the
table, no canned or processed foods
IV. 3000-4000 mg Sodium (No Processed)
� Normal diet w/o processed foods
LOW POTASSIUMLOW POTASSIUM
Potassium (1-1.8 g)
Usual diet has 2-6 g
Vitamins A & C likely to be low
Indications for Use:
� Hyperkalemia
� Addison’s Disease
Foods Avoided:
seafoods, leafy vegetables, rootcrops, nuts, corn, fruits such as banana, apple, atis, lanzones, guava, melon, pakwan, raisins, prunes, non fat milk