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 )


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


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


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


AdultsAdults

Cut Off Values for BMI

BMI< 20 = underweight

BMI 20-24.9 = normal

BMI 25-30 = overweight

BMI > 30 = obese


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


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%



Normal Protein Allowance/Day

gm/ KDBW

Infants 2.5-3.0

Children 2.0

Adolescents 1.5

Adults 1.1



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

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


� 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


� Chronic Kidney Disease

� Hepatic Coma

MODIFICATIONS IN COMPOSITIONMODIFICATIONS IN COMPOSITION

HIGH CALORIE


� Protein Energy Malnutrition

� Hypercatabolic States


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


� Obesity & Overweight

� Diseases requiring reduced energy requirements


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


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


� 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


- 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


� 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


� 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

23 dietetics[1]

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