Final Dietetics 1 Notes 2021 Exchange in Meal Planinng-1

Exchange Lists for Meal
Planning
By
Dr. Ali Imran
Definition
• Exchange is a list of foods grouped together according to similarities in
food values.
• The exchange system sorts foods into three main groups by their
proportions of carbohydrate, fat, and protein. These three groups—the
carbohydrate group, the fat group, and the meat and meat substitutes
group (protein)—organize foods into several exchange lists
• Then any food on a list can be “exchanged” for any other on that same list
• Each exchange group consist of foods in different amounts but provide
equal amounts of nutrients so that any food item within a given exchange
list can be substituted, thus making the diet planning simple, flexible and
more practical.
Importance
• The exchange system helps in planning a nutritionally balanced diet
by choosing adequate number of exchanges from each group.
• The selection of foods from vegetable and fruit exchanges should be
given importance in order to meet the vitamin A and requirements
• The exchange system help us to cover the following aspect of meal
planning.
Importance
• Portion Sizes
• The exchange system helps people control their
energy intakes by paying close attention to portion
sizes. The portion sizes have been carefully adjusted
and defined so that a portion of any food on a given
list provides roughly the same amount of
carbohydrate, fat, and protein and, therefore, total
kcalories.
• For example, a person may select either 17 small
grapes or 1⁄2 large grapefruit as one fruit portion,
and either choice would provide roughly 60
kcalories
Continue----
• The Foods on the Lists Foods do not always appear on the
exchange list where you might first expect to find them. They
are grouped according to their energy nutrient contents
rather than by their source (such as milks), their outward
appearance, or their vitamin and mineral contents
Continue----
• Controlling Energy and Fat By assigning items to the fat list, the
exchange system alerts consumers to foods that are unexpectedly
high in fat. Even the starch list specifies which grain products contain
added fat (such as biscuits, muffins, and waffles).
Serving size
Food Groups Serving Sizes
Milk & Milk Products 1 exchange = 1 cup/glass or 8 ounces of milk or ¾ cup of yogurt
Meat & meat Substitutes 1 exchange = 1 egg or 1 ounces of cooked meat (1 inch cube) or 2 tbsp of cheese
Bread or Cereal 1 exchange = 1 slice of bread or ½ chapatti or ½ cup of cereal, pasta or starchy
vegetables
Vegetables 1 exchange = ½ cup cooked vegetables or 1 cup raw
Fruits 1 exchange = 1 small fruit or ½ cup of juice or ½ cup plums or 3 oz grapes
Fats 1 exchange = 1 tsp or 6 nuts

USDA Exchange System
• The exchange system sorts foods into three main groups by their
proportions of carbohydrate, fat, and protein. These three groups are the
carbohydrate group, the fat group, and the meat and meat substitutes
group (protein)
• The carbohydrate group covers these exchange lists:
• Starch (cereals, grains, pasta, breads, crackers, snacks, starchy vegetables,
and dried beans, peas, and lentils).
• Fruit.
• Milk (fat-free, reduced fat, and whole).
• Other carbohydrates (desserts and snacks with added sugars and fats).
• Vegetables.
• The fat group covers this exchange list:
• • Fats.
• The meat and meat substitutes group (protein) covers these exchange
lists:
• • Meat and meat substitutes (very lean, lean, medium-fat, and high-
fat).
Milk exchange list
• The milk exchange list includes milk from common sources and a
variety of milk products. Each exchange of milk provides
• ➢ 8 g protein
• ➢ 12 g carbohydrate
• ➢ 0-8 g fat
• ➢ 150 K.cal.
MEAT EXCHANGE LIST
• The meat exchange list includes meat, fish, poultry, egg and other
commercial products rich in protein. Each meat exchange provides
• ➢ 7 g protein
• ➢ 5 g fat
• ➢ 70 K. cal
• ➢ negligible carbohydrate
• In general, a meat exchange is 1 oz meat, poultry, or cheese; 1⁄2 c
dried beans (weigh meat and poultry and measure beans after
cooking).
Starch exchange list
• one starch exchange is 1⁄2 c cooked cereal, grain, or starchy
vegetable; 1⁄3 c cooked rice or pasta; 1 oz of bread; 3⁄4 to 1 oz snack
food.
• ➢ 15 g of carbohydrate
• ➢ 80 K. cal
• ➢ 3 g of protein
• ➢ 0-1g fat
VEGETABLE A EXCHANGE LIST
• Vegetable exchange list
• In general, one vegetable exchange is 1⁄2 c cooked vegetables or
vegetable juice; 1 c raw vegetables.
• ➢ 5 g carbohydrate
• ➢ 2g of protein
• ➢ 25 K. cal
• ➢ 0 g of fat
FRUIT EXCHANGE LIST
• The fruit exchange list includes fruits which are locally available and
commonly consumed. In general, one fruit exchange is 1 small fresh
fruit; 1⁄2 c canned or fresh fruit or unsweetened fruit juice; 1⁄4 c
dried fruit. Each exchange provides
• ➢ 15g carbohydrate
• ➢ 60 K. cal
• ➢ Negligible protein and fat
Fat exchange list
• The fat exchange list includes all the oils and hydrogenated fats used
for cooking purpose, commercial products such as margarine,
mayonnaise and nuts and oil seeds. Each fat exchange which amounts
to 5 g (1 t.sp.) provides 45 K. cal, 5 g of fat and negligible
carbohydrate and protein. Nuts contribute little protein. 1 fat
exchange _ 5 g fat and 45 kcal. In general, one fat exchange is 1 tsp
regular butter, margarine, or vegetable oil; 1 tbs regular salad
dressing.
Sweets, Desserts, and Other
Carbohydrates List
• 1 other carbohydrate exchange _ 15 g carbohydrate, or 1 starch, or 1

fruit, or 1 milk exchange
• 1 pratha+ I egg+I cup doodh pati=80*4+70*1+150*1=540
• I CUP SHAKE (1/2 m+1/2 F)= 75+30=105
• I plate rice+2roti+ I cup salad=2*80+4*80+1*25=505
• 10 grapes+ 4 dates=60*1
• No meal
• Your task
• Identify CCPs in this pattern
• 2 broewniees+icup ice cream with 1 tbs honey= 2 c+2
f=80*2+45*2=160+90=250KCal+2c+4F=160+180=340+80
Free foods
• A free food is any food or drink which contains less than 20 calories per serving. These foods can be taken in liberal amounts in two or three servings
throughout the day, these foods include Green leafy vegetables
• • Tomato
• • Radish
• • Cucumber
• • Cabbage
• • Gourds (All)
• • Lime
• • Clear soups
• • Butter milk
• • Black tea and coffee
• • Plain soda
• • Coffee/Tea
• • Carbonated water
• • Mineral water
• • Sugar substitutes
• a. 1 Cup of youghart+ 2brown bread slice+I.5 cup orange juice+1 cup
of Ice Cream = 190+80+180+160+180=
• b. one boiled egg+1.5 Naan+ 1Cup of salad+ two cup vegetable gravy
+ meat salan of 120 g with 30 g ghee
c. 1 barbecue+ salad platter contains 5 kabab+4 .BQ Boti (180g Meat)
+1/2 cup vegetable salad
Diet Modification
By
Dr. Ali Imran
Diet Modification
• Dietary modification is defined as the elimination, manipulation or
introduction of dietary components to achieve dietary goals.
• Skillful assessment is required to identify all the factors that may
influence the success of dietary intervention.
• Dietary modification requires the use of a range of dietetic skills,
including communication skills and the skills to change health
behaviour.
• A total diet approach should be adopted and dietary advice should
be given in terms of food choice not nutrients
Principles of dietary modification
• Knowledge
• Achievability
• Motivation
• communication
Process of dietary modification
• Rationale
• The first step in dietary modification is to ascertain the
purpose of the modification based on a comprehensive assessment and the
identification of the nutritional problem
The aim of dietary modification may be to
• Achieve a nutrient profile that offers greater health benefits
• Meet dietary needs in a safer way.
• Correct a dietary deficiency or surplus.
• Avoid the consumption of a particular dietary component.
• Achieve symptom relief
• Achieve specific metabolic or clinical effects
Need For diet modification
• To provide change in consistency as in fluid and soft diets.
• To increase or decrease the energy values–reducing diets.
• To include greater or lesser amounts of one or more nutrients–high
protein and low fibre diets.
• To increase or decrease bulk–high and low fibre diets.
• To provide foods bland in flavour.
• To include or exclude specific foods as in allergic conditions.
• To modify the intervals of feeding.
MODIFICATION IN CONSISTENCY
• These diets are used in the treatment of gastro intestinal tract. They can be from
a very low residue diet to a very high fibre diet. Method of feeding is by mouth,
unless otherwise indicated
• TYPES
• Liquid diets consist of a variety of foods that are liquid or liquify at room
temperature.
• These diets are used in:
• Febrile states
• Post operative condition
• Wherever the patient is unable to tolerate solid food.
• Liquid diets are of two types namely
Clear fluid dietFull fluid diet
Clear Fluid Diet
• This diet is indicated in:

• Acute illness
• Surgery
• Gastrointestinal disturbances
• A clear fluid diet is usually used for 1 or 2 days. After that a more liberal liquid diet is given.
• The amount per feeding is 30 – 60 ml/hour. As the patients tolerance improves, the amounts can
be increased.
• Foods Permitted
• Tea with lemon and sugar
• Coffee
• Fat free broths.
• Carbonated beverages
• Cereal waters.
Full Fluid Diet
• This diet is indicated when a patient is:

• Acutely ill.
• Unable to chew or swallow solid food.
• This diet includes all foods which are liquid at room temperature.
• It is free from cellulose and irritating condiments.
• Iron is provided at inadequate levels.
• Six or more feedings can be given daily.
• The protein content of the diet can be increased by incorporating whole egg, egg
white, nonfat dry milk in beverages and soups.
• The calorie value of the diet can be increased by adding butter to cereal gruels
and soups, glucose in beverages and using ice creams, dessert.
• If decreased volume of fluid is desired, non fat dry milk can be substituted for the
part of the fluid milk
Foods Allowed
• Beverages — Cocoa, coffee or tea.

• Cereal — Fine or strained gruels.
• Dessert — Soft custard, gelatin.
• Eggs — Raw in broth with fruit juices or milk.
• Fruit — All strained juices.
• Meat — Strained in soups.
• Vegetables — Puree, soups.
• Miscellaneous — Butter, cocoa, sugar, salt.
Commercial Liquid Formulas
• These are used to supplement other external diets.

• These formulas vary in composition and source of nutrients.
• Most of the formulas are milk based.
• For persons who cannot tolerate milk, protein source is meat, soy or
casein hydrolysate.
• Fat and carbohydrate composition and proportions also vary to
accommodate persons with different needs and restriction.
Criteria for Selection of Appropriate Formulae
• The protein sources

• The composition and proportion of fats and carbohydrates
• The osmolality
• The palatability
• The cost.
DIETS WITH SOLIDS
• Soft and Low Fibre Diets

• Soft diet is between liquid diet and normal diet.
• Soft diet includes both liquid and solid foods which contain restricted
amount of indigestible carbohydrates and no tough connective tissue. The
diet can be made mechanically soft by cooking, mashing, pureeing
• the foods used in a normal diet. Further reduction in indigestible
carbohydrate can be achieved by the
• use of refined breads, cereals immature vegetables and fruits.
• The skin and seeds of fruits have to be removed.
• Soft fruits like banana can be used as it is.
• Tough connective tissue can be reduced, by selecting tender meat and
cooking very soft.
CONTI…
• Meat and meat broths have to be restricted because the non protein nitrogen
products such as creatine, creatinine, purines and other products which are
present in muscle tissue is extracted into the gravy which stimulates gastric juice.
• Strong flavoured vegetables such as onions, radish, dried beans, cabbage,
cauliflower have to be omitte if necessary.
• With proper cooking (Short cooking time, vessel uncovered, serving immediately)
it is desirable to eliminate
• those vegetables which the individual patient cannot tolerate.
• It is not necessary to eliminate all spices, only gastric irritants like black pepper,
chilli pepper, cloves etc. can be eliminated.
• This diet is nutritionally adequate.
• It is soft in texture and bland in flavour.
Low Residue Diets
• The diet is made up of foods which can be completely absorbed,

thereby leaving little or no residue for formation of faeces. This diet
provides insufficient minerals and vitamins.
• It must be supplemented.
• Foods high in fibre should be omitted.
• Food which contain residue but not fibre such as milk are also
omitted or restricted.
• Strained fruits and vegetables without skins are usually permitted.
• Meat should be tender or ground to reduce connective tissue
The Diet is Usually Used in
• Severe diarrhoea to afford rest to the gastrointestinal tract.

• Acute phases of diverticulitis.
• Ulcerative colitis in initial stages.
• Operations.
• Partial intestinal obstruction.
• Whenever necessary to reduce bulk in the gastrointestinal tract
High Fibre Diets
• Dietary fibre plays a significant role in colonic function.

• High fibre diet is mainly used for atonic constipation and
diverticulosis.
• This is a normal diet with fibre increased to 15–20 gms daily.
• Fluid intake is also increased.
• Concentrated foods should be replaced by those of greater bulk.
• Foods which can be included in the diet are plenty of long fibered
vegetables, salads, fruits and whole cereal grains.
• Highly refined and concentrated foods, excessive amounts of rough
brans and excessive seasoning should be avoided.
• Intervals of feeding should be three meals daily
Foods allowed Foods avoided
Beverages
Coffee, tea, fruit and vegetable juices, Milk or curds in excess of two cups.
carbonated
beverages, milk (2 cups/day) curds.
Cereals
Refined wheat bread, refined cereals and
millets, Whole grain bread or cereals, brown or
dry cereals that are not whole grain, white rice.
spaghetti,
macaroni, noodles, rice.
Desserts
Simple pudding made from milk
allowance, plain ice All deserts containing coconut, nuts,
cream, plain gelatin deserts, plain cakes, seeds, fruits,
cookies jams, preserves, milk sweets.
and pies and sweets made from allowed
foods.
Fats
Cooking oils, butter, cream, mayonnaise Fried foods, high fat gravy, spicy salad
dressings
Foods allowed Foods avoided
Fruits All others fruits with seeds and skins.

Fruit juices, peeled apricots, cherries, baked
apple,
ripe banana, orange and citrus fruits without
membrane.
Meat/Meat Substitutes
Tender chicken, fish, lamb, liver pork, eggs,
cottage Fried and highly seasoned, smoked or pickled
cheese. meat,
Soups fish or poultry.
Plain cream soup made from milk allowance,
clear Soups made with vegetables not allowed
broth, noodles or rice
• Diet modification can e achieved by wo methods
➢Through Modification in the Diet
➢Through Food Exchange Method
• Through Modification in the Diet
• Diet modification means serving the meal cooked for the
family to any member after varying it in quantity, quality
and frequency of eating
1. Quantitative modification of diet
▪ This refers to the increase or decrease in the number of
times a meal is taken and/or the portion size (Portion size
the amount of a particular dish eaten at a meal).e.g.
❖pregnant women, sick people or older persons need to eat
smaller meals but at shorter intervals, that is, they may
need 6-8 meals instead of four meals a day.
❖adolescent boys needs larger portions at each meal (may be
more rice/chapattis, more dal/curd) and also more frequent
meals to meet their nutritional needs.
▪ Persons who are dieting are advised to reduce the amount
of food eaten at each meal. This will force the body to use
stored reserves which will help in reducing boy weight
2. Qualitative modification of diet
▪ It refers to the change in nutrients, consistency, flavour,
amount of spices and fibre content of the diet. E.g.
❖the increased protein requirement of a pregnant woman can be
met by increasing the quantity of protein rich foods in her diet.
❖Slightly elder children are fed well cooked and mashed ‘Khichri’.
❖Older people need a diet soft in consistency and less spicy.
▪ This is a qualitative modification of diet.
3. Modification in terms of frequency
This means the should take something in between the
main meals. This is diet modification in terms of
frequency.
MODIFICATION IN NUTRIENTS
• High Calorie Diets
• These diets are prescribed for
• Weight loss
• Fever
• Hyperthyroidism
• Burns.
• This is a normal diet with an increase in the calorie level to 3000 or more. If
appetite is poor, small servings of highly reinforced foods are given. The
diet may be modified in consistency and flavour, according to specific
needs.
• Excessive amounts of bulky low calorie foods, fried foods or others which
may interfere with appetite should be avoided.
Low Calorie Diet
• These diets are prescribed for weight reduction in

• Diabetes Mellitus
• Cardiovascular diseases
• Hypertension
• Gout
• Gall bladder disease
• Preceding surgery.
• This is a normal diet with energy values reduced to 1500, 1200 or 1000
calories.
• Protein levels should be at 65 to 100 gms.
• Supplements of Vitamin A and thiamine are usually required for diets
below 1000 calories.
High Protein Diet
• High protein diet of 100 – 125 g per day may be prescribed for
a variety of conditions like
• Fever
• Hyper thyroidism
• Burns
• Nephrotic syndromes
• Haemorrhage
• After surgery
• Diarrhoea
• Ulcerative colitis
• Sprue
• Celiac disease
• Cystic fibrosis
• Infective hepatitis
• Elderly Alcoholics.
Low Protein Diet
• Low protein diets are usually prescribed for conditions like
• Hepatic encephalopathy
• Acute and chronic glomerulonephrites
• Nephroslerosis
• Acute and chronic renal failure
• In-born errors of metabolism
Why Low protein diet is prescribed
• In severe liver disorders, protein cannot be used for synthesis, the
amino acids are catabolised and excess ammonia cannot be
converted to urea for excretion and the patient develops hepatic
coma.
• In this situation protein levels must be decreased or completely
restricted for a few days.
• In celiac disease, the protein gluten in wheat and rye brings out a
metabolic defect in the intestinal mucosal cells. The protein gluten is
composed of two fractions glutenin and gliadin. The latter protein
causes the difficulty.
Fat Controlled Diet
• Usually fat controlled diets are prescribed for—

• Gall bladder diseases
• Celiac disease
• Cystic fibrosis
• Atherosclerosis
• Myocardial infarction
• Hyperlipidemisa etc.
• Fat controlled diets regulate the amount and type of fat allowed.
• The calories from fat should provide about 30% and 35% of the total
calories with 10% from saturated fat and 12 – 14% from poly-
unsaturated fats.
Low Sodium Diet
• The mineral content of the diet may also be modified.

• Four levels of sodium restriction are most often used — 250, 500,
1000 and 2400 – 4500 mgs.
• The first diet is a severe restriction that excludes salty foods and salt
in cooking and at the table.
• This diet is used both to prevent and treat edema.
• Therefore, it is prescribed for congestive heart failure, hypertension,
toxemia of pregnancy, liver and renal diseases.
• Some renal patients may not be able to regulate sodium excretion
and become hyponatremic.
• Then sodium must be added back by means of the diet.
• In renal patients with chronic uremia it may be necessary to also
restrict potassium and phosphorous.
• Guidelines for reduction of phosphorous.
• Omit milk, yoghurt and ice cream. Use non dairy cream substitutes.
• Use meat poultry and fish only in amounts compatible, with high biological value protein
intake.
• Exclude dried beans and peas.
• Omit cola beverages.
• Following above guidelines diets will contain about 15 mg
phosphorous per 1 g protein. For example 50 g protein diet will
contain about 750 mg phosphorous
Food High in Phosphorus
• Cheese (Processed, Cheddar) liver, fish, egg, milk and milk products,
whole grain cereals, lima beans, mushrooms, peas (cooked) etc.
Beverages Whole milk, beverage with cream or ice cream.
Skim milk, coffee, tea, fruit juices. Sweet rolls with fat, french toast.
Cereals Sweets containing fats, chocolate cream, nuts,
All cooked cereals without bran, macaroni, noodles, cookies, cakes, doughtnuts, icecream, pastries, pies
spaghetti. rich puddings.
Breads
All kinds except those with added fat.
Desserts
Fruit pudding, gelatin, cereal puddings using part
of milk allowance.
Eggs - 3 per week
Fat – Vegetable oil
Meats Fried eggs.
Boiled, baked, roasted or stewed without fat, lean Cooking fats, cream, salad dressing.
chicken, lamb, fish. Fatty meats, poultry or fish bacon, duck, goose, fish
Seasonings canned in oil, organ meats, smoked or spiced meats.
In moderation — Salt, pepper, spices, herbs,
flavouring extracts. Sometimes not tolerated — Pepper, meta sauced,
Soups — Clear excessive spices, vinegar.
Sweets
Jam, jelly, marmalade sugars, sweets, with limited Cream soups.
fat. Sweets with excessive fat, nuts and chocolate.
Vegetables — All kinds Strongly flavoured vegetables — Cabbage,
Miscellaneous cauliflower, cucumber, onion, radish, beans, dried
cooked peas.
Fried foods, gravies, nuts, butter, pickles,
relishes,popcorn.
Cereals Breads, crackers with salted tops, salted snack foods.
Salt free bread, rice, wheat, millets, biscuits, muffins
Meat/Meat substitutes
Fresh or frozen lamb, liver, pork, chicken, fresh fish, Smoked, salted pickled meat, fish, poultry, beef etc.
salt free cheddar cheese, cottage cheese and peanut
butter, egg.
Milk
Skim milk, milk.
Beverages Butter milk, instant cocoa mixes.
Tea, coffee, carbonated beverages, wine, beer.
Fats Softened water.
Unsalted butter, oils. Meat extractives, highly salted salad dressings.
Vegetables Brine cured vegetables, tomato pastes, sauces,
Green beans, cabbage, cucumber, mushrooms, purees, commercially canned vegetables, frozen
onions, peas, potato, pumpkin, radish, tomato peas, carrots frozen, lima beans.
Fruits
Fresh fruits Fruits with sodium preservative, dried figs and
Deserts raisins
Plain gelatin desserts, cakes and cookies with low
sodium baking powder
Therapeutic Diets
2/7/2021 Dietetics II 73
ANTI-REFLUX DIET
• PURPOSE
• The purpose of the anti-reflux diet is to reduce discomfort associated
with esophageal reflux by decreasing the reflux of gastric contents
into the esophagus and excluding foods that inflame the esophageal
mucosa
DIET PRINCIPLES
• This diet restricts items that may stimulate gastric
acid production
• caffeine, colas, coffee, alcohol and red pepper)
• Cause esophageal irritation
• (citrus, tomato, vinegar, coffee, black pepper)
• Reduce esophageal sphincter pressure
• fat, caffeine, chocolate, alcohol, peppermint
oil, spearmint oil, garlic and onions)
• Cause air to come up from the stomach
• carbonated beverages and bellpeppers
ADEQUACY
• This diet meets the Dietary Reference Intakes (DRIs) for most
nutrients
CONTI….
CONTI….
CHOLESTEROL CONTROLLED DIET
• PURPOSE
• This diet is to reduce the amount of cholesterol and other foods high
in saturated fats in the body. This diet is used in the management of
cardiovascular disease and hypercholesterolemia
DIET PRINCIPLES
• The proportion of monounsaturated and polyunsaturated fatty acids

is increased while the saturated fatty acids are decreased.
• Increased intake of foods high in fiber is recommended.
• The suggested amount of cholesterol is 300 mg or less per day.
Classification of LDL, Total, and HDL
Cholesterol (mg/dl)
ADEQUACY:
nutrients.
Cholesterol controlled diet sample menu approximately 300
mg. Cholesterol
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) DIET
• PURPOSE
• This diet is indicated for individuals with COPD for the purpose of
minimizing fatigue while eating, decreasing excess carbon dioxide
production and improving overall client outcome.
DIET PRINCIPLES
• The diet is tailored to each individual’s caloric
needs, eating habits, treatment goals, and
presence of other medical conditions.
• The following should be considered for
individuals with COPD:
• Adequate calories provided in less volume (e.g.
smaller more frequent feedings)
• if the individual is easily fatigued while eating,
sodium restriction for peripheral edema and
adjustment of calories as needed to achieve
desirable body weight (excess calories should be
avoided).
CONTI….
• Diets with 40-55% of calories from carbohydrate
are usually tolerated.
• Protein and fat may be the preferred calorie
source for individuals with hypercapnea since
less CO2 is produced than with carbohydrate
metabolism.
• Pulmonary formulas (high fat/low carbohydrate)
are available for oral or tube feeding
• Potential side effects of a high fat/low
carbohydrate diet (e.g. decreased gastric
emptying, increased gastrointestinal side effects
CONTI….
• Fluid intake should be high, especially if the individual is febrile. Use
1ml/kcal as a general rule
• ADEQUACY: This diet meets the Dietary Reference Intakes (DRIs) for
most nutrients.
• FOODS ALLOWED: All.
• FOODS TO AVOID: None
CONSISTENT CARBOHYDRATE DIET
• PURPOSE:
• The consistent carbohydrate diet aids in the attainment and
preservation of the best possible blood glucose and lipid levels.
DIET PRINCIPLES:
• The consistent carbohydrate diet is only one part of the total team
management of the individual with diabetes mellitus. It is essential that a
registered dietitian plans the diet and be involved in the care of a individual
with diabetes mellitus.
• General food guide, such as the USDA MY Pyramid Food Guidance System
or the Food Guide to Healthy Eating, is an appropriate meal pattern
• The meal plan must be adjusted to the individual’s usual food intake, usual
activity pattern, and based on the individual’s nutrition assessment.
• Use of the terms “ADA diet,” “no concentrated sweets” and “no sugar
added”
• The following are general guidelines for nutrients when planning a
consistent carbohydrate diet.
• Approximate Composition
• Carbohydrate: 45-60 % of total calories
• Protein: 10-20 % of total calories
• Fat: Less than 30 % of total calories Saturated Fat less than 10% of
total calories
• Fiber: 20-35 grams
ADEQUACY:
• The consistent carbohydrate diet can be planned to meet the Dietary
Reference Intakes (DRIs) for most nutrients. The need for vitamin and
mineral supplementation should be assessed on an individual basis.
FAT CONTROLLED DIET
• PURPOSE:
• The fat controlled diet is used for to relieve symptoms of diarrhea,
steatorrhea, and flatulence or to control nutrient losses caused by the
ingestion of excess dietary fat. This diet may be used in the treatment
of diseases of the hepatobiliary tract, pancreas, intestinal mucosa,
and the lymphatic system as well as the malabsorption syndromes.
DIET PRINCIPLES:
• The fat intake is restricted as low as 25 grams per day depending on
the severity of the condition and per physician’s order.

ADEQUACY:
• The diet meets the Dietary Reference Intakes (DRIs) for most
nutrients. Prolonged conditions of steatorrhea or diarrhea may cause
nutrient deficiencies of calcium, magnesium, iron, fat-soluble
vitamins, folic acid, Vitamin B-12 and B complex vitamins. Vitamin
and mineral supplementation may be necessary.

FIBER CONTROLLED DIET
• PURPOSE:
• This diet may be used when a reduction in stool frequency and volume is
desirable. Diet is generally for short-term use following diarrhea, colitis, partial
bowel obstruction, diverticulitis, megacolon and before or after bowel surgery.

DIET PRINCIPLES:
• This diet reduces non-digestible food fibers and residue. This diet can also be
used for a low residue diet by limiting milk to two cups or less per day and
reducing fat.
• ADEQUACY: This diet may not meet the Dietary Reference Intakes (DRIs) for
calcium and Vitamin D if fluid milk is restricted

HIGH FIBER DIET
• PURPOSE: This diet may be used in the treatment of constipation,

hemorrhoids, diverticular disease, irritable bowel syndrome and
obesity.
• DIET PRINCIPLES: A high fiber diet is a house diet with the addition of
high fiber foods. It is recommended to consume 20 to 35 grams of
dietary fiber from a variety of sources. Adequate fluid intake is also
recommended
• ADEQUACY: This diet meets the Dietary Reference Intake (DRIs) for
most nutrients.

KETOGENIC DIET
• PURPOSE:
• The Ketogenic Diet is designed to establish and maintain ketosis.
• The diet is used for children and adults with myoclonic or atonic seizures who
are resistant to anticonvulsant medications or who are experiencing drug-
related side effects.
• DIET PRINCIPLES:
• The diet is high in fat and low in carbohydrate to promote ketosis.
• Medium chain triglyceride (MCT) oil may be used in planning the diet.
• Fluids are generally limited to 1 cc per calorie.
CONT….
• ADEQUACY:
• A multivitamin, calcium, and iron supplement should be ordered since the
diet does not meet the Dietary Reference Intake (DRIs) for some nutrients.
• The diet should be used only under strict supervision.
• Long-term use can compromise growth in children if not monitored.
• FOODS ALLOWED:
• All foods, except those listed as “Foods to Avoid” are allowed in the amounts
specified in the individualized meal plan.
• FOODS TO AVOID:
• Cake, candy, catsup, chewing gum, cookies, honey, ice cream, jam, jelly,
molasses, pastries, pies, pudding, sherbet, sugar, sweetened condense milk,
syrup, sugar sweetened carbonated beverages and ALL bread, bread products
and cereals, unless they are calculated into the meal plan.
REACTIVE HYPOGLYCEMIA DIET
• PURPOSE:
• This diet is designed to prevent symptoms of hypoglycemia
(low blood sugar), which occur after food ingestion due to
carbohydrate sensitivity.
• Reactive Hypoglycemia (postprandial) is one of two primary
categories of hypoglycemia.
• The main focus of the diet is to slow the quick absorption
and utilization of carbohydrates.
• Current American Diabetes Association recommendations
are as follows:
• Provide adequate calories based on individual needs.
• More frequent meals, usually five to six meals daily.
• Smaller meals, which may help alleviate hypoglycemia symptoms, in
individuals who normally consume large meals.
• Appropriately timed meals and snacks to control all symptoms.
CONT….
• Mixed meals including complex carbohydrates, protein, fat and fiber
which can help in delaying absorption of carbohydrates.
• Limit caffeine, which may reduce blood flow and, therefore, glucose
supply to the brain.
• Use of carbohydrate counting, which may be helpful in regulating
total carbohydrate intake.
• Consuming consistent amount of carbohydrate at meals and snacks
may also be helpful
• ADEQUACY:
• Calorie levels above 1500 meet the Dietary Reference
Intakes (DRIs) for most nutrients.
• To ensure adequate intake of nutrients in lower calorie
intakes, a multivitamin with mineral supplement should
be provided.
CONT….
• FOODS ALLOWED:
• All foods are allowed. However, complex carbohydrates and proteins, which
are more slowly absorbed than simple sugars, may be preferable for
preventing symptoms of hypoglycemia (sweating, dizziness, weakness,
fatigue, confusion, agitation or blurred vision).
• FOODS TO AVOID:
• None
REACTIVE HYPOGLYCEMIA DIET SAMPLE MENU
SODIUM CONTROLLED DIET
(2000 – 2500 mg)
• PURPOSE:
• The diet is indicated to reduce hypertension and promote the
loss of excess fluids in edema and ascites.
• This diet is used in the management of essential hypertension,
impaired liver function, cardiovascular disease, severe cardiac
failure, renal disease and chronic renal failure.
• This is a 2000 - 2500 mg sodium (87 - 108 mEq) diet. This diet
contains up to one-half teaspoon of table salt daily or the
equivalent amount of sodium is allowed in prepared foods.
• Reading labels of manufactured foods will provide information
on sodium content of these foods.
• ADEQUACY:
nutrients.
SODIUM CONTROLLED DIET SAMPLE MENU
RENAL DIET
• PURPOSE:
• The diet is to be used in the treatment of impaired renal function or renal failure.
• The purpose of the diet is to reduce the production of wastes that must be excreted
by the kidney, to avoid fluid and electrolytes imbalance, slow the progression of
renal disease, and to delay the need for dialysis, if not already on dialysis.
• The nutritional management of individuals with renal disease focuses on the intake
of protein, sodium, potassium, phosphorus and fluids.
• The level of restriction of these nutrients depends upon the clinical and biochemical
status of the individual.
• The calculation of each nutrient must be carefully calculated to meet needs of each
individual. A Registered Dietitian must be consulted for the careful planning of the
diet as it is individualized and comprehensive.
CONT….
• ADEQUACY:
• Nutritional needs vary from person to person. If the protein allowance
of the diet is above 0.8 gram per kilogram of body weight, the diet will
meet the Dietary Reference Intakes (DRIs) for most nutrients.
• When the protein allowance is below 40 grams, it is difficult to meet
the DRIs.
• Specific vitamin/mineral supplementation must be determined on an
individual basis.
• Water-soluble vitamins are advised for hemodialysis and peritoneal
dialysis patients. The assistance of a Registered Dietitian is necessary in
planning a renal diet.
• FOODS ALLOWED:
• This will vary based on each individual’s diet. Usually, the diet is low or
restricted in protein, sodium, potassium, phosphorus and fluids.
• FOODS TO AVOID:
• This will vary based on each individual’s diet.
DIET PRESCRIPTION IN RENAL DISEASE
FOOD CHOICE LIST
• FOOD CHOICE LIST:
• The renal diet is planned using a food choice list. Foods with similar amounts
of protein, sodium, and potassium are grouped together to aid in planning
diet patterns.
• The chart below lists how foods are grouped in the food choice list. The actual
list can be obtained from the American Dietetic Association’s National Renal
Diet.
ADVERSE REACTIONS TO FOODS DIETS
EGG-FREE DIET
• PURPOSE:
• The egg-free diet is designed for individuals with an egg allergy.
• An egg-free diet is a house diet with the omission of eggs and foods
containing eggs.
• Check labels and avoid ingredients such as egg, egg white, dried egg or
albumin.
• ADEQUACY:
• The egg –free diet meets the Dietary Reference Intakes (DRIs) for most
nutrients.
EGG – FREE DIET SAMPLE MENU
FOODS TO AVOID
• Be sure to avoid foods that contain any of the following ingredients:
• Albumin
• Egg white
• Egg yolk
• Dried egg
• Egg powder
• Egg solids
• Egg substitutes
• Eggnog
• Globin
• Livetin
• Lysozyme (used in Europe)
• Mayonnaise • Meringue • Ovalbumin • Ovomucin • Ovomucoid • Ovovitellin •
Simplesse™ (used as a fat substitute and is made from either egg or milk protein)
GLUTEN-FREE DIET
• PURPOSE:
• This diet is used in the treatment of gluten induced enteropathy
(non-tropical sprue, celiac disease).
• Celiac sprue is a permanent digestive disease requiring
adherence to the diet for the individual’s entire life.
• A gluten-free diet is a house diet that eliminates those foods
that contain gluten, such as wheat, rye, oats, barley, or their
derivatives, such as malt from barley.
• Foods that contain these grains as a base, stabilizer, emulsifier,
or thickening agent are also eliminated.
• Small amounts of gluten can damage the intestines without
causing symptoms.
• Gluten is sometime used as an additive in medications.
• Many individuals with gluten sensitivity may have secondary
lactose intolerance related to mucosal damage.
GLUTEN-FREE DIET SAMPLE MENU
MILK-FREE DIET
• PURPOSE:
• The milk-free diet is designed to prevent or reduce symptoms associated with
ingesting cow’s milk and cow’s milk containing products.
• A milk-free diet is a house diet that eliminates all cow-milk-containing
products.
• Foods avoided include milk and milk products. Other food ingredients avoided
include cream, butter, dry skim milk, buttermilk and cheese and products
containing whey, milk solids, curds, casein or lactose. Lactose is sometimes
used as filler in medications.
MILK-FREE DIET SAMPLE MENU
LACTOSE CONTROLLED DIET
• PURPOSE:
• The lactose controlled diet is designed to prevent or reduce symptoms
associated with ingesting lactose-containing products such as milk and other
dairy products (for instance, cheese, ice cream, yogurt).
• It is designed for individuals who have symptoms of lactose intolerance, or
are diagnosed with lactase deficiency and possibly gluten intolerance.
• Lactose is sometimes used as filler in medications. Lactate,
lactalbumin, lactylate, and calcium compounds are salts of lactic acid
and do not contain lactose.
• The lactose controlled diet is a house diet with the elimination of lactose
containing foods and beverages.
LACTOSE CONTROLLED DIET SAMPLE MENU
ENTERAL ALIMENTATION
(Tube Feeding)
• PURPOSE:
• Tube feedings are indicated as means of nourishment when
normal swallowing has been inhibited or interfered with as in:
• Difficulty with sucking and/or swallowing with demonstrated risk of
aspiration.
• Anomalies: Cleft palate, Esophageal atresia, Tracheoesophageal
fistula, other GI tract anomalies.
• Neurologic disorders.
• Head and neck surgery.
• Mandibular fractures.
• Severe comatose or unconscious states.
• Trauma or paralysis of oral pharyngeal cavity.
• When nutrient needs cannot be met orally: Anorexia, weight loss,
growth failure, inadequate nutrient intake, hypermetabolic states,
chronic non-specific diarrhea, short gut syndrome.
• Other GI problems.
Conti……
Special Diets

DASH Diet

Diet and Hypertension
• Non-pharmacologic way of treating hypertension
• DASH diet
• Dietary Approaches to Stop Hypertension
• High in whole grains, fruits, vegetables, and low-fat dairy
• Adequate Calcium, Potassium, Magnesium
• Low in red meat, sweets and sugar beverages
• Low in saturated and trans fat, cholesterol

DASH is Unique
• Tested dietary pattern rather than single nutrients
• Experimental diets used common foods that can be incorporated into
recommendations for the public
• Investigators planned the DASH diet to be fully compatible with
dietary recommendations for reducing risk of CVD, osteoporosis and
cancer

Mineral Intake and Hypertension
Potassium
• Clinical trials and meta-analyses indicate potassium (K)
supplementation lowers BP
• Adequate K intake, preferably from food sources, should be
maintained
• Evidence is strong enough to support a health claim on high
potassium foods
• Best sources are fruits and vegetables

Magnesium
• Evidence suggests an association between lower dietary magnesium
intake and high blood pressure
• Food sources are nuts, beans, vegetables

Calcium
• American Heart Association Statement
• Increasing calcium intake may preferentially lower blood pressure in salt-
sensitive people
• Benefits more evident with low initial calcium intakes
(300-600 mg/day)
• Best food sources are dairy products.

DASH Reduces Homocysteine Levels
• Effect a result of diet high in vitamin B-rich milk and
milk products, fruits and vegetables
• Lowering homocysteine with DASH may reduce CVD
risk an additional 7%-9%
Appel, et al. Circulation, 102:852, 2000

DASH Diet Pattern
based on a 2,000 calorie diet
Food Group Servings*

Grains 6-8
Vegetables 4-5
Fruits 4-5
Low-fat or fat free dairy 2-3
Meats, poultry, fish less than 6
Nuts, seeds, dry beans and peas 4-5/week
Fats and oils 2-3
Sweets 5/ week
Sodium 2300 mg
* Per day unless indicated

Dash Diet
• Slowly increase intake of

fruits and vegetables to 8
or more per day
• Three servings of low fat
and non-fat dairy
products a day
• Nuts, seeds and dried
beans 4-5 times per week

DASH Diet continues...
• More whole grain cereals and

breads
• 6 ounces or less of meat, fish or
poultry per day
• Small amounts of liquid or soft
margarine or oil

Eat Less Sodium
• DASH is more effective if

also reduce sodium
• Less than 2400
milligrams per day
• Reduce slowly in 2-3
weeks so that taste buds
will get use to less salt

Ways to Cut Sodium
• Remove salt shaker
• Add little if any salt to
cooking
• Buy more fresh or plain
frozen “no added salt”
veggies
• Use more herbs and
spices
• Make soups and stews
ahead without salt and
let flavors blend
• Use fresh poultry, lean
meat, and fish
Ways to Cut Sodium
We get most of our salt from
convenience foods.
• Use unsalted canned or
frozen vegetables. If use
regular, rinse canned foods
to reduce sodium.
• Choose convenience foods
low in salt when available.
• Use fewer convenience
foods
• Compare labels
2/7/2021 Image:Dietetics
http://www.nlm.nih.gov
II 151
Ways to Cut Sodium
• Most restaurant foods are

very high in sodium
• Eat out less often
• Make more foods from
scratch.

Using the Food Label to Cut Sodium
• Sodium is a chemical that makes • Choose more foods with Daily
up ½ of table salt Value less than 10%
• Limit to 2400 milligrams per day • Balance higher sodium foods
• Look for “low sodium” or “salt with lower sodium foods
free” – watch “reduced sodium”

• Look for the amount of
sodium in foods by
finding it on the
Nutrition Facts Label.
• Choose foods that have
lower amount of
sodium based on the
label.

BRAT DIET
• The BRAT diet is a bland-food diet that is often recommended for
adults and children
• BRAT stands for
• Bananas
• Rice
• Applesauce
• Toast
• The BRAT diet can help you recover from an upset stomach or
diarrhea for the following reasons: It includes “binding” foods.
CONTI…..
• It includes “binding” foods. These are low-fiber foods that can help make
your stools firmer.
• It includes bananas, which are high in potassium and help replace nutrients
your body has lost because of vomiting or diarrhea
• When should I follow the BRAT diet?
• After you have diarrhea or vomiting, follow the BRAT diet to help your body
ease back into normal eating. This diet may also help ease the nausea and
vomiting some women experience during pregnancy.
• You can add other bland foods to the BRAT diet. For example, you can try
saltine crackers, boiled potatoes or clear soups. Don’t start eating dairy
products and sugary or fatty foods right away. These foods may trigger
nausea or lead to more diarrhea.

• When should I avoid the BRAT diet?
• Solid foods, like those in the BRAT diet, are not recommended for
adults or children who are actively vomiting. Instead, stick to clear
liquids at first and wait until you can eat solid foods without vomiting.
If you have been vomiting or have diarrhea, drinking an electrolyte
beverage (some brand names: Pedialyte, Rehydralyte) can help
protect against dehydration. Use these products according to your
doctor’s instructions.

CONTI…..
• How long should I follow the BRAT diet?
• Both adults and children should follow the BRAT diet for only a short
period of time because it does not provide all the elements of a
healthy diet. Following the BRAT diet for too long can cause your body
to become malnourished. This means you are not getting enough of
many important nutrients. If your body is malnourished, it will be
hard for you to get better.
• You should be able to start eating a more regular diet, including fruits
and vegetables, within about 24 to 48 hours after vomiting or having
diarrhea.

Fad diet or crash Diet
• A fad diet is a weight loss plan or aid that promises dramatic results.
These diets typically don't result in long-term weight loss and they are
usually not very healthy. In fact, some of these diets can actually be
dangerous to your health. Some common diet types are listed in the
box below.

Diet Type Some Examples
Controlled Carbohydrates •Dr. Atkins' New Diet Revolution
•The Carbohydrate Addict's Diet
•Protein Power
•Sugar Busters
•The Zone
High Carbohydrate/Low Fat •Dr. Dean Ornish: Eat More, Weigh Less
•The Good Carbohydrate Revolution
•The Pritikin Principle
Controlled Portion Sizes •Dr. Shapiro's Picture Perfect Weight Loss

•Volumetrics Weight-Control Plan
Food Combining •Fit for Life

•Suzanne Somers' Somersizing
Liquid Diets •Cambridge Diet
•Slim-Fast
Diet Pills/Herbal Remedies •Dexatrim Natural
•Hydroxycut
•Metabolife 356
Other •Eat Right For Your Type: The Blood Type Diet
•Macrobiotics
•Mayo Clinic Diet*

Low-purine Diet
• What is a low-purine diet?

• A low-purine diet is an eating plan that limits foods that contain
purine. Purines are a natural substance found in some foods. When
your body digests purine, a waste product called uric (say: “yur-ick”)
acid is produced. A buildup of uric acid crystals in the joints can cause
a type of arthritis known as gout.
• Purines are found in many healthy foods. The purpose of a low-purine
diet is not to completely avoid purines. Instead, the goals are to limit
and monitor how much purine is in the food you eat, and to learn
how your body responds when you eat different foods that contain
purine.

• Who should follow a low-purine diet?
• Your family doctor may recommend that you follow a low-purine diet
if you have gout or another condition caused by high levels of uric
acid (also called hyperuricemia). Following a low-purine diet may help
reduce symptoms such as pain, redness and tenderness in your joints.
• How do I get started?
• Start by learning which of the foods that you eat are high in purine.
Try to avoid eating high-purine foods and limit the amount of
moderate-purine foods you eat. See the chart below for some
suggestions.
Avoid Limit Enjoy
Beer Chicken, beef, pork and duck At least 12 cups of fluid, such as
water or fruit juice
Soft drinks that contain sugar Crab, lobster, oysters and shrimp Low-fat and fat-free dairy products,
such as cheese and yogurt
Fatty food Lunch meats, especially high-fat Eggs (in moderation)

versions
Organ meats, such as liver, from any Liquor Peanut butter and nuts
animal source
Bacon, veal and venison Rice, noodles, pasta and potatoes
Yeast Fruits
Anchovies, sardines, herring, Vegetables
mussels, codfish, scallops, trout and
haddock
Gravy Wine (in moderation)

Coffee (in moderation)
Vegan Diet
• People who follow a vegan diet avoid eating all animal products,
including meat, eggs and dairy.
• They also don’t eat food products that have an animal source, like
gelatin and honey.
• What are the benefits of following a vegan diet?
• Vegans avoid many of the unhealthy substances found in animal
products, like cholesterol and saturated fat. They also tend to take in
more vital nutrients from fruits, vegetables and grains. The food
choices of a vegan diet can lower the risk of high blood pressure, type
2 diabetes, certain cancers and heart disease.
Challenges For VEGAN Diet
• Iron .
• Calcium
• Protein
• Vitamin D
• Vitamin B-12
• Zinc
• Omega-3 fatty acids

Ketogenic Diet
• The ketogenic diet is a high-fat, adequate-protein, low-carbohydrate diet that in

medicine is used primarily to treat difficult-to-control (refractory) epilepsy in children.
• Ketogenic diet initially was developed in 1920 in response to the observation that fasting
had antiseizure properties.
• Ketogenic diet can stimulate metabolic effects of starvation
• Principle
• The diet forces the body to burn fats rather than carbohydrates.
• Normally, the carbohydrates contained in food are converted into glucose, which is then
transported around the body and is particularly important in fueling brain-function.
• However, if there is very little carbohydrate in the diet, the liver converts fat into fatty
acids and ketone bodies. The ketone bodies pass into the brain and replace glucose as an
energy source. An elevated level of ketone bodies in the blood, a state known as ketosis,
leads to a reduction in the frequency of epileptic seizures
Mechanism of action
• In ketogenic diet body uses fat as primary source.
• Fat break down in liver-Ketones
• In neuronal tissue ketones are used in mitochondria to generate ATP.
• Relation between urine ketones and seizure control is imprecise
• Enhancement of GABA function by ketone bodies and increases the
expression of GAD
• Saturated fatty acid and PUFA has neuro protective effect.
Arachidonic acid inhibit voltage gated sodium channels
• Brain metabolizes ketone better under conditions of reduced
glucose(calorie restriction)
CONTI….
• The typical ketogenic diet, called the "long-chain triglyceride diet,"
provides 3 to 4 grams of fat for every 1 gram of carbohydrate and
protein.
• A ketogenic diet "ratio" is the ratio of fat to carbohydrate and protein
grams combined. A 4:1 ratio is more strict than a 3:1 ratio, and is
typically used for most children. A 3:1 ratio is typically used for
infants, adolescents, and children who require higher amounts of
protein or carbohydrate for some other reason.
Kinds
• Today there are four kinds of dietary treatments: the classic ketogenic
diet, the MCT (medium chain triglyceride) diet, the modified Atkins
diet (MAD), and the low glycemic index treatment (LGIT).
• All of these have their role, which one to choose depends on your
family and neurologist.
• The ketogenic diet is inadequate in vitamin B-complex vitamins,
folate, iron, calcium, and zinc.
• The diet must be supplemented with vitamins, iron and calcium in
forms that are sugar-free
Sources
• Butter, mayonnaise, heavy whipping cream, olive oil, canola oil, eggs,
bacon, chicken, ground beef, green vegetables, strawberries,
blueberries, almonds, cheese, avocado, tuna fish, lettuce, artificial
sweeteners, mushrooms, hot dogs, sausages, macadamia nuts.
• Formulas
• Nutricia KetoCal
• Solace KetoVolve
Dietary factors that worsen seizure:
• Glutamate eg: MSG
• Caffeine
• Alcohol
• betel nuts
• Herbal remedies
Nutrition care process
By
Dr. Ali Imran
Assistant Professor, Institute of Home & Food Sciences, GCU, FSD
2/7/2021 176
Nutrition in health care
➢Many medical problems alter the nutritional needs resulting
malnutrition
➢Poor nutrition enhance the severity and course of disease
➢40-60% Hospitalized patients are malnourished and other may
develop it after 3 weeks of their admission
➢Altogether, it compromise the patient immune system and reduce the
rate of its recovery
➢Illness caused severe effect on nutritional status
2/7/2021 177
2/7/2021 178
Nutrition care process
• An organized approach to nutrition care that consists of assessing,

diagnosing, intervening, monitoring, and evaluating the patient’s
problems.
• It is the systematic approach that deals with the problem solving
aptitude based upon the logical reasoning and evidence based
detection of nutrition related problem
• The nutrition care process enables the practitioners both in out and
indoor facilities in quick identifications of malnourished patients,
possible diagnosis, best possible intervention and it also provides help
for the continuous monitoring of the provided intervention
2/7/2021 180
Objectives
• The following objectives are achieved by the efficient utilization of
Nutrition care process.
• Provide improvements and enhance consistency in the management of
clients nutrition care
• Enhance the quality of individualized patient/client care
• Increase the predictability of the patient/client outcomes
• Helps practitioners in the monitoring and evaluation of the ongoing
intervention
• Provide solid foundations for the research data
• Lat out the Standard operating procedure in the management of specific
disease.
Steps• of NCP
Nutrition screening is the initial step (Pre Nutrition care
process) in the nutrition care process
• This step involves the nutrition screening of patients regarding
their malnourished or well nourished status.
• The nutrition screening is carried out some specific nutrition
screening tools based upon some specific questioner asked
about the history of clients different aspects.
• The patients who fail to comply to pass in nutrition screening
referred to nutrition care process where detailed care is
provided in four distinct steps
• The four distinct steps of the nutrition care process are:
• Nutrition assessment.
• Nutrition diagnosis.
• Nutrition intervention.
• Nutrition monitoring and evaluation
2/7/2021 183
Nutritional screening
• Nutrition screening: an examination process that identifies patients

who require intervention for existing or potential nutritional problems
• Nutrition screening is the first step in identifying patients who are at
risk for nutrition problems or who have undetected malnutrition. It
allows for prevention of nutrition-related problems when risks are
identified and early intervention when problems are confirmed. Early
detection and treatment are not only cost-effective but result in
improved health and quality of life of the older patient. Several
screening and assessment tools are available.
2/7/2021 184
CONTI…
• Regardless of the tool used, the screening process can be completed in any
setting. Screening includes the collection of relevant information to
determine risk factors and evaluates the need for a comprehensive
nutrition assessment. Irrespective of nature, the nutrition screening tool
must have the following properties for its efficient utilization
• Simple and easy to complete
• Routine data
• Cost effective
• Effective in identifying nutritional problems
• Reliable and valid
Tools
• Among the different nutritional screening tools following has been
adapted universally in different settings
• Subjective-Objective-Assessment- Plan System (SOAP Protocol)
• Malnutrition universal screening tool (MUST)
• Subjective Global Assessment (SGA)
• Mini nutritional assessment (MNA)
SOAP Protocol
• SOAP format can be easily applied to all aspects of
nutritional management i.e.,
• Assessment
• Care
• Education
• SOAP means
• S : Subjective evaluation. This is the information collected
from the patient or relatives.
• O : Objective evaluation. This includes actual
measurements i.e., assessment of anthropometric
measurements, or analysis of blood/urine.
• A : Assessment. This is the reasoning process which results
in the determination of nutritional status from which a
nutritional care plan can be evolved.
• P : The plan for nutritional care or therapy should be
2/7/2021 written very specifically instead of vague generalities. 187
Data Base. Subjective:
• Dietary history
• Family history
• 24-hour recall
• Activity record
• Physical signs
• Food intolerances/allergies
2/7/2021 188
Objective:
• Anthropometry
• Height,
• Weight,
• Relative weight
• Triceps fatfold
• Body fat, %
• Physical signs
• Biochemical measurements
• Diet order
2/7/2021 189
Assessment
• Example:
• Dietary history and 24-hour recall indicate daily energy intake of 3000
Kcal.
• Relative weight for height is 200% and triceps fatfold is 50% above
normal.
• Physical signs include several bulging fatfolds.
2/7/2021 190
Plan
• (a) More information needed for diagnosis (Dx).

• (b) Specific treatment or nutritional care plan (Rx).
2/7/2021 191
MUST
• MUST’ is a five-step screening tool to identify adults, who are
malnourished, at risk of malnutrition (undernutrition), or obese. It
also includes management guidelines which can be used to develop a
care plan.
• It is for use in hospitals, community and other care settings and can
be used by all care workers.
2/7/2021 192
The 5 ‘MUST’ Steps
• Step 1
• Measure height and weight to get a BMI score using chart
provided. If unable to obtain
• height and weight, use the alternative procedures shown in
this guide.
• Step 2
• Note percentage unplanned weight loss and score using
tables provided.
• Step 3
• Establish acute disease effect and score.
• Step 4
• Add scores from steps 1, 2 and 3 together to obtain overall
2/7/2021 risk of malnutrition. 193
2/7/2021 194
Subjective Global Assessment
• A good and appropriate technique to asses the nutritional status of
hospitalized patients
• In which patient history and physical examination will be determined
to evaluate his or her nutritional status
• Five features of the history are elicited.
• The first is weight loss in the previous 6 months, expressed as both
kilograms and proportionate loss. We
• consider less that 5% as a “small” loss, between 5 and
• 10% as a “potentially significant“ loss, and greater than
• 10% as a “definitely significant” loss
2/7/2021 195
CONTI….
• The second feature of the history is dietary intake in relation to a
patient’s usual pattern. Patients are classified first as having normal or
abnormal intake
• The third feature of the history is the presence of significant
gastrointestinal symptoms (anorexia, nausea, vomiting, diarrhea).
• fourth feature of the history is the patient's functional capacity or
energy level (bedridden to full capacity)
• The last feature of the history concerns the metabolic demands of the
patient's underlying disease state.
2/7/2021 196
Conti…
• There are four features of the physical examination which are noted
as either normal (0), mild (1 +), moderate (2+), or severe (3+). The
first is the loss of subcutaneous fat measured in the triceps region
and the mid-axillary line at the level of the lower ribs.
• The second feature is muscle wasting in the quadriceps and deltoids
• The presence of edema in both the ankles and the sacral region and
the presence of ascites are noted.
2/7/2021 197
Subjective Global assessment
2/7/2021 198
2/7/2021 199
Mini Nutritional Assessment
• The MNA®-SF provides a simple and quick method of identifying
elderly persons who are at risk for malnutrition, or who are already
malnourished. It identifies the risk of malnutrition before severe
changes in weight or serum protein levels occur
• The MNA®-SF was developed by Nestlé and leading international
geriatricians and remains one of the few validated screening tools for
the elderly. It has been well validated in international studies ina
variety of settings5-7 and correlates with morbidity and mortality.
2/7/2021 200
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2/7/2021 203
Nutrition Care Process
• An organized approach to nutrition care that
consists of assessing, diagnosing, intervening,
monitoring, and evaluating the patient’s
problems and progress.
• Malnutrition increases:
• Morbidity
• length of hospital stay = more care
• mortality
• higher costs ($$$$$$$)
2/7/2021 204
The Nutrition Care Process: Driving Effective
Intervention and Outcomes
2/7/2021 205
Steps of NCP
• A – Nutrition Assessment
• D – Nutrition Diagnosis

Problem, Etiology, Signs and Symptoms
• I – Nutrition Intervention
• M – Nutrition Monitoring
• E – Evaluation
Through nutrition reassessment, dietetics practitioners
perform nutrition monitoring and evaluation to
determine if the nutrition intervention strategy is
working to resolve the nutrition diagnosis, its etiology,
2/7/2021 and/or signs and symptoms 206
Nutritional Assessment
• Nutrition assessment, the first step of the nutrition care process,
involves the collection of information needed to evaluate a patient’s
nutrition status and nutrient needs.
• The assessment data are used to develop a plan of action to prevent
or correct any nutrient imbalances.
• Assessments are also done after nutrition care to help determine
whether a care plan is working.
• Remember that malnutrition can be caused by an illness or medical
treatment and not just by inadequate dietary intake
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CONTI….
• To help determine the cause of a deficiency and therefore the best
course of intervention, nutrition assessments draw on many sources of
information including
Medical, social, and diet histories.
• Anthropometric data.
• Biochemical analyses.
• Physical examinations.
• A meaningful assessment depends on both accurate information and
a careful interpretation of findings
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Nutrition Assessment Components
• Gather data, considering
• Dietary intake
• Nutrition related consequences of health and disease condition
• Psycho-social, functional, and behavioral factors
• Knowledge, readiness, and potential for change
• Compare to relevant standards
• Identify possible problem areas
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Nutrition Diagnosis
• After completing a nutrition assessment, the dietitian can identify
existing or potential nutrition problems and formulate specific
nutrition diagnoses.
• This step requires careful and objective analysis of the patterns and
relationships among the data. Each problem receives a separate
diagnosis, which is documented in the medical chart.
• Nutrition diagnoses, similar to nursing diagnoses, are stated in a
format that includes the specific nutrition problem, the etiology or
cause, and the signs and symptoms that provide evidence of the
problem.
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CONTI…
• For example, a nutrition diagnosis might state, “Unintentional weight

loss (the problem) related to insufficient kcaloric intake (the etiology
or cause) as evidenced by a 10-pound weight loss (representing 8
percent of body weight) in the past few months (the sign o
symptom).” Note that unlike medical diagnoses, a nutrition diagnosis
can change during the course of an illness
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Nutrition Diagnosis
Purpose
• Identify and label the nutrition problem
• Nutrition diagnosis
NOT medical diagnosis
• EXPLICIT statement of nutrition diagnosis
Note: Documentation is an on-going process that

supports all the steps in the Nutrition Care Process
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Nutrition Intervention
• After nutrition problems have been identified, the appropriate treatments
can be determined. The nutrition care plan typically includes behaviors and
educational materials that can improve risk factors and correct nutrition
problems.
• For example, an intervention may include dietary modifications, nutrition
handouts, or a change in medication
• It should take into account an individual’s food habits, lifestyle patterns,
and other personal factors.
• To ensure cost-effective and high-quality implementation, the plan must be
consistent with the care plans of other members of the health care team.
• Nutrition interventions used by dietitians are “evidence based”; that is,
they are based on scientific rationale and supported by the results of high-
quality research.
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Conti….
• Goals of nutrition interventions are stated in terms of measurable
outcomes, such as results of laboratory tests or anthropometric data.
• For example, the measurable outcomes for an overweight person
with diabetes might include target ranges for blood glucose levels and
body weight.
• Other important outcomes include positive changes in dietary
behaviors and lifestyle: an interview with a heart disease patient may
reveal that he or she has learned to use leaner cuts of meat and low-
fat milk products and has started a regular walking program
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Nutrition Intervention
Purpose
• Plan and implement purposeful actions to address
the identified nutrition problem
• bring about change
• set goals and expected outcomes
• client-driven
• based on scientific principles and best available evidence
Note: Documentation is an on-going process that supports all the

steps in the Nutrition Care Process
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Nutrition Monitoring & Evaluation
Purpose
• Determine the progress that is being made toward the client’s
goals or desired outcomes
Monitoring: review and measurement of status

at scheduled times
• Evaluation: systematic comparison with previous status,
intervention goals, reference standard
Note: Documentation is an on-going process that

supports all the steps in the Nutrition Care Process
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Nutrition Monitoring and Evaluation
• After a nutrition intervention has begun, the effectiveness of the
nutrition care plan must be evaluated.
• The original goals and outcome measures are typically reviewed at
previously designated dates and compared with earlier assessment
data and diagnoses.
• Sometimes the patient’s situation changes in a way that alters
nutritional needs; for example, a change in medical treatment or
medication may alter the ability to tolerate certain foods.
• A nutrition care plan needs to be flexible to adapt to the new
situation.
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Nutrition Assessment
• Historical Information
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INTRODUCTION
The nutritional status of an individual is

often the result of many inter-related
factors.
It is influenced by food intake, quantity &

quality, & physical health.
The spectrum of nutritional status spread

from obesity to severe malnutrition
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Nutritional Assessment Why?
The purpose of nutritional assessment is

to:
Identify individuals or population groups

at risk of becoming malnourished
Identify individuals or population groups

who are malnourished
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Nutritional Assessment Why? 2
To develop health care programs that

meet the community needs which are
defined by the assessment
To measure the effectiveness of the

nutritional programs & intervention
once initiated
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Who should be nutritionally assessed?
•Conditions suggesting nutritional risk.
• Inadequate nutrient intake.
• Inadequate nutrient absorption.
• Decreased nutrient utilization.
• Increased nutrient losses.
• Increased nutrient requirements.
•Those whose preliminary assessment show the following:

• Serum albumin less than 3.2 g/dl.
• Total lymphocytes less than 1500 mm .3
• Nonvoluntary weight loss.

• History of nutritional deficiency.
• Statement from client indicating change in appetite
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Methods of Nutritional Assessment
Nutrition is assessed by two types of

methods; direct and indirect.
The direct methods deal with the
individual and measure objective
criteria
while indirect methods use
community health indices that reflects
nutritional influences.
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Direct Methods of Nutritional
Assessment
These are summarized as ABCD
• Anthropometric methods
• Biochemical, laboratory methods
• Clinical methods
• Dietary evaluation methods
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Indirect Methods of Nutritional Assessment
These include three categories:

Ecological variables including crop
production
Economic factors e.g. per capita income,
population density & social habits
Vital health statistics particularly infant &
under 5 mortality & fertility index
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Anthropometry
Anthropometry is the most frequently used method to assess nutritional status.
It is precise and accurate;

It uses standardized technique;
It is suitable for large sample sizes, such as representative
population samples;
It does not require expensive equipment, and skills can be
learnt quickly.
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Anthropometric Methods
• The term ‘anthropometric’ refers to
comparative measurements of the body,
which are used in nutritional assessments
in order to understand human physical
variation.
• It is used to evaluate both under & over
nutrition.
The measured values reflects the current
nutritional status & don’t differentiate
between acute & chronic changes .
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History of anthropometric measurements
• First appeared in 1956 by Brozek and jelliffe and they defined this as
• Measurement of variations in Physical dimensions and gross
composition of body at different age and nutrition
• 1966-1969 a number of SOPs has been devolved to determine type
of methods under the different categories
• Todays most appropriate method for nutritional assessment.
Type of anthropometric measurement
• Anthropometric measurements are of two types
• Growth
• Body composition measurement
• Body fat
• Fat free mass determination
Measurements for Growth
• Measurement of HEAD CIRCUFERANCES
• Measurement of recumbent length
• Measurement of height
• Measurement of knee height
• Measurement of weight in infants and children
• Measurement of weight in older children
• Measurement of elbow breadth
Indices Derived from growth measurements
• HC/Age
• W/A
• W/H
• H/A
• Weight changes
• W/H RATIO
Body composition measurement
• Assessment of Body fat

• Skin fold thickness
• Waist to hip ratio
• Limb fat area
• Body fat determination through skinfold measurement via body density
• Fat free area
• MAMC
• MAC
• MAMA
Head circumference
• Head circumference is a good index of brain growth.
• It is usually taken from infants and children as a screening test for
microcephaly and macrocephaly.
• As a nutritional indicator head circumference may not add
significantly to the nutritional information gained from weight, height,
skinfold thickness, and mid arm muscle circumference (MAMC), but
the measurement is a standard procedure in pediatric practice.
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Measurement of recumbent length
• Calculate the length of children less than two years of age.

Measurement of height
Measurement of knee height
• Knee height is highly corelated with stature and my be used to

estimate height of the person with severe spinal curves.
Measurement of elbow breadth
• Elbow breadth is measured as the distance between the epicondyle
of the humerus. For the purpose right arm is used at the angle of 90.
Indices Derived from growth measurements
HC/A
• Determine the status of chronic protein energy malnutrition during
first two years
• Chronic malnutrition first few month of life
• Intrauterine growth retardation
• Decrease number of brain cells
• Abnormally low head circumferences
• Beyond age two year
• Growth head circumferences slow
• Its Measurement no longer useful
W/A
• Weight-for-height Acute malnutrition (wasting)

• Height-for-age Chronic malnutrition (stunting)
• Weight-for-age Any protein-energy malnutrition (underweight)
Other Measurements
Mid-arm circumference
Skin fold thickness
Head circumference
Head/chest ratio
Hip/waist ratio
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Weight
• Body weight is one of the most convenient and useful indicators of

nutritional status. At birth, the low birth weight of an infant suggests
that the child is at risk.
• Frequently, a lowbirth-weight infant is the offspring of a poorly
nourished mother.
• Once it has been established that the change is in one of the other
body compartments, rapid and marked weight changes are usually
associated with increased morbidity and mortality.
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Measurement for Body composition
Anthropometric measurements for body
composition
• They based upon model that utilized two chemically differentiate
body compartments
• Fat
• Fat free mass (Skeleton Muscle, Non-skeleton tissue, Lean Tissue)
Length and Height
• In the case of infants and toddlers, length is measured with the
subject in flat position, looking straight up, using an apparatus with a
fixed headboard and a sliding foot board.
• For older children and adults, height is measured using a horizontal
arm that moves vertically on a calibrated scale. The patient should be
without shoes, heels together, against a straight surface, and with the
head level and erect.
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Skinfold Thickness
• A skinfold consists of two layers of subcutaneous fat

without any muscle or tendon. As a correlation
exists between subcutaneous fat and the fat within
the body.
• SFT measurements are used to estimate total body

fat. Skinfold thickness can be measured at several
sites (e.g., triceps, biceps, subscapular, and
supraliac), but the triceps is usually employed in
assessing the fat stores in adults for practical
reasons (i.e., easy access) and because edema is not
usually present at this site.
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Head circumference
• Head circumference is a good index of brain growth.
• It is usually taken from infants and children as a screening test for
microcephaly and macrocephaly.
• As a nutritional indicator head circumference may not add

significantly to the nutritional information gained from weight, height,
skinfold thickness, and mid arm muscle circumference (MAMC), but
the measurement is a standard procedure in pediatric practice.
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Mid arm muscle circumference
•Mid arm muscle circumference can serve as a general index of
nutritional status.
• It reflects both caloric adequacy and muscle mass. Mid arm
circumference is measured at the midpoint of the left upper arm by a
fiberglass flexible-type tape.
•Protein–calorie malnutrition and negative nitrogen balance induce
muscle wasting and decrease muscle circumference. Mid arm muscle
circumference values can be compared to reference graphs available
for both sexes and all ages.
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Waist circumference
Waist circumference predicts mortality better than
any other anthropometric measurement.
It has been proposed that waist measurement alone

can be used to assess obesity, and two levels of risk
have been identified
MALES
FEMALE
LEVEL 1 > 94cm > 80cm
LEVEL2 > 102cm >
88cm
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Waist circumference/2
Level 1 is the maximum acceptable waist
circumference irrespective of the adult
age and there should be no further
weight gain.
Level 2 denotes obesity and requires

weight management to reduce the risk of
type 2 diabetes & CVS complications.
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Hip Circumference
Is measured at the point of greatest

circumference around hips to the nearest
0.5 cm.
Both measurement should taken with a
flexible, non-stretchable tape in close
contact with the skin, but without
indenting the soft tissue.
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Interpretation of WHR
High risk WHR= >0.80 for females & >0.95 for males i.e. waist
measurement >80% of hip measurement for women and >95% for
men indicates central (upper body) obesity and is considered high
risk for diabetes & CVS disorders.
A WHR below these cut-off levels is considered low risk.
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ADVANTAGES OF ANTHROPOMETRY
• Objective with high specificity & sensitivity
• Measures many variables of nutritional
significance (Ht, Wt, MAC, HC, skin fold
thickness, waist & hip ratio & BMI).
• Readings are numerical & gradable on
standard growth charts
• Readings are reproducible.
• Non-expensive & need minimal training
2/7/2021 259
Limitations of
Anthropometry
❖Inter-observers errors in measurement
❖Limited nutritional diagnosis
❖Problems with reference standards, i.e.

local versus international standards.
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CLINICAL ASSESSMENT
It is an essential features of all nutritional surveys
It is the simplest & most practical method of
ascertaining the nutritional status of a group of
individuals
It utilizes a number of physical signs, (specific & non
specific), that are known to be associated with
malnutrition and deficiency of vitamins &
micronutrients.
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CLINICAL ASSESSMENT/2
Good nutritional history should be obtained
General clinical examination, with special attention to organs like
hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles,
bones, & thyroid gland.
Detection of relevant signs helps in establishing the nutritional
diagnosis
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CLINICAL ASSESSMENT/3
• ADVANTAGES
• Fast & Easy to perform
• Inexpensive
• Non-invasive
• LIMITATIONS
• Did not detect early cases
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Clinical signs of nutritional deficiency
HAIR
Spare & thin Protein, zinc, biotin
deficiency
Easy to pull out Protein deficiency
Corkscrew Vit C & Vit A

Coiled hair deficiency
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MOUTH
Glossitis Riboflavin, niacin, folic acid,
B12
Bleeding & spongy gums Vit. C,A, K, folic acid & niacin
Angular stomatitis, B 2,6,& niacin
cheilosis & fissured
tongue
leukoplakia Vit.A,B12, B-complex, folic
acid & niacin
Sore mouth & tongue Vit B12,6,c, niacin ,folic acid
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EYES
Night blindness, Vitamin A deficiency

exophthalmia
Photophobia- Vit B2 & vit A

blurring, deficiencies
conjunctival
inflammation
2/7/2021 267
NAILS
Spooning Iron deficiency
Transverse lines Protein deficiency
2/7/2021 268
SKIN
Pallor Folic acid, iron, B12
Follicular Vitamin B & Vitamin C
hyperkeratosis
Flaking dermatitis PEM, Vit B2, Vitamin A,
Zinc & Niacin
Pigmentation, Niacin & PEM
desquamation
Bruising, purpura Vit K ,Vit C & folic acid
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Thyroid gland
• in mountainous areas
and far from sea places
Goiter is a reliable sign
of iodine deficiency.
2/7/2021 270
Joins & bones

• Help detect signs of
vitamin D deficiency
(Rickets) & vitamin C
deficiency (Scurvy)
2/7/2021 271
DIETARY ASSESSMENT
• Nutritional intake of humans is assessed by five different methods.
These are:
• 24 hours dietary recall

• Food frequency questionnaire
• Dietary history since early life
• Food diary technique
• Observed food consumption
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24 Hours Dietary Recall
A trained interviewer asks the subject to recall all food & drink
taken in the previous 24 hours.
It is quick, easy, & depends on short-term memory, but may not be
truly representative of the person’s usual intake
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Meals Meal Timings Food Items Amount Calories (Kcal)
Breakfast
Mid-day snack
Lunch
Evening snack
Dinner
Bedtime
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Food Frequency According to Food Groups
Food Groups Number of times weekly intake
Milk & Milk Products (milk, yogurt, lassi, cream &

desserts prepared with milk)
Meat & Meat substitute (egg, meat, poultry, fish)
Vegetables
Fruits
Bread and cereals
Fats & oils (type of ghee oil, butter, margarine)

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Some Particular Questions to ask in Diet history
• Which type of milk do you take? Fresh one or tetra packed.

• Which type of yogurt do you eat? Fresh one or packaged?
• Which type of flour do you use? Whole wheat from “Chakki” or
added white flour.
• Which oil and ghee do you use?
• How often do you take carbonated drinks?
• How often do you go for outdoor eating?
• Are you taking any nutritional supplement? If yes, then which
ones?
• Do you smoke?
• Have you been on a special diet?
• (Specially ask when the patient is trying to lose weight)
2/7/2021 279
Food Frequency Questionnaire
In this method the subject is given a list of around 100
food items to indicate his or her intake (frequency &
quantity) per day, per week & per month.
inexpensive, more representative & easy to use.
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Food Frequency Questionnaire/2
Limitations:
 long Questionnaire
 Errors with estimating serving size.
 Needs updating with new commercial food products

to keep pace with changing dietary habits.
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DIETARY HISTORY
It is an accurate method for assessing the nutritional
status.
The information should be collected by a trained
interviewer.
Details about usual intake, types, amount, frequency
& timing needs to be obtained.
Cross-checking to verify data is important.
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FOOD DIARY
Food intake (types & amounts) should be recorded
by the subject at the time of consumption.
The length of the collection period range between 1-

7 days.
Reliable but difficult to maintain.
2/7/2021 285
Stage Depletion stage Methods
1 Dietary inadequate Dietary
2 Decreased level in reserve tissue store Biochemical
3 Decreased level in body fluids Biochemical
4 Decreased functional level in tissue Biochemical/anthropometric
5 Decreased activity in nutrient dependent enzymes Biochemical
6 Functional change Behavioral/physiological
7 Clinical symptoms Clinical
8 Anatomical sin Clinical

Anthropometric indicator Associated deficiency Reference value
Weight to height W/H Acute malnutrition (wasting) Estimated through growth charts
Height to age H/A Chronic malnutrition (stunting) Estimated through growth charts
Weight to age W/A Any protein-energy malnutrition (underweight), Estimated through growth charts
acute as well as chronic
Head circumferences HC chronic protein energy malnutrition during first Estimated through growth charts
two years, Intrauterine growth retardation
Body mass index BMI Under and over nutrition <18.5 under weight and > or = 30kg/m2 is obesity
Waist to hip ratio WHR Obesity and CVD risk For male > 94cm
For Female >80cm
Total body fat Hyperlipidemia, obesity 22% for male
32% for female
Visceral fat Abnormal fat deposition around the organs >9%
Skinfold thickness Total body fat estimation Triceps skin fold

Male 12.5 mm
Female 16.5mm
Weight changes Onset of chronic disease and poor nutrient More then 5% weight loss in one month
absorption and growth
MAMC Protein energy malnutrition Male 25.3 cm

Female 23.5 cm
MAMA Muscle growth, indicator of nutrition status Derived by equation
MAC Indicator of good growth with special reference to Male 29.3 cm

PEM Female 28.5 cm
Biochemical Analysis
➢The approaches to nutrition assessment discussed previously
examine only external attributes.
➢Biochemical analyses help to determine what is happening to the

body internally.
➢Tests are usually based on analyses of blood and urine samples,

which contain proteins, nutrients, and metabolites that reflect
nutrition status
2/7/2021 288
Evaluation of Laboratory Indices
• All the laboratory indices are estimated by adapting the two
techniques
• Comparing the observed values with references/normal values which
are derived from a reference sample
• Comparing the observed values with cut-off points based on data
from subjects with clinical or functional manipulations of a nutrient
deficiency.
Different test required in Nutritional assessment
➢Plasma Proteins
➢Most important indicators for assessing the level of nutrition
➢Fluctuations in plasma proteins are not specific to only one illness or nutrition
problem
➢For example, both PEM and liver disease can reduce plasma protein levels.
➢Metabolic stress causes the release of hormones that alter plasma protein
levels
2/7/2021 290
Conti….
➢Plasma protein values are also influenced by changes in hydration,
pregnancy, kidney function, and some medications
➢Because plasma proteins are affected by so many factors, the values

must be considered with other data to evaluate nutrition status.
2/7/2021 291
Albumin
➢Albumin is the most abundant plasma protein, and its levels are
routinely measured
➢Albumin is influenced by many medical conditions but is slow to
reflect changes in nutrition status because of its large body pool and
slow rate of degradation
➢In people with chronic PEM, albumin levels remain normal for long
periods of time despite depletion of body proteins; levels fall only
after prolonged malnutrition
➢Likewise, albumin concentrations increase slowly with appropriate
nutrition support, so albumin is not a sensitive indicator of response
to nutrition therapy.
2/7/2021 292
Transferrin
➢Transferrin transports iron, so its concentrations respond to both

PEM and iron status. Transferrin breaks down in the body more
rapidly than albumin, but it is relatively slow to respond to nutrition
therapy.
➢Transferrin levels rise as iron deficiency worsens and fall as iron status
improves
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Prealbumin and Retinol-Binding Protein
➢Levels of prealbumin (also called transthyretin) and retinol-binding

protein decrease rapidly during PEM and respond quickly to changes
in protein intake.
➢ Thus these proteins are more sensitive than albumin to changes in
protein status. Also, their synthesis in the liver can be impaired by
zinc deficiency.
2/7/2021 294
Liver Function Tests
• Liver is the site of accumulation and synthesis of material and has
vital role in numerous life sustaining processes
• Liver function tests (LFTs or LFs) are groups of blood tests that give
information about the state of a patient's liver. The liver health is
examined by the different liver function tests
• If body is in state of oxidation and too much fatty meals are
consumed the enzymes that are present inside the liver may leak
owing to the oxidation of liver membrane
• The important enzymes are
2/7/2021 295
➢These tests include
➢prothrombin time (PT/INR), aPTT,
➢albumin,
➢bilirubin (direct and indirect)
➢Liver transaminases (AST or SGOT)
➢ ALT or SGPT are useful biomarkers of liver injury in a patient with
some degree of intact liver function
2/7/2021 296
Conti…
• Albumin levels are decreased in chronic liver disease,
such as cirrhosis
• AST is raised in acute liver damage
• ALT/SGPT most important indicator of liver damage
• Bilirubin (direct and indirect) indicates liver ability to
clear the toxins it is elevated in terms of liver disorder
• INR international normalized ratio (INR) are used to

determine the clotting tendency of blood, in the
measure of warfarin dosage, liver damage, and vitamin
K status.
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Kidney Function test
➢These test evaluate the role of kidneys

➢SERUM CRETININE
➢SERUM UREA
➢URIC ACID
➢Elevated values indicated kidney damage
2/7/2021 298
Lipid Profile
• Total cholesterol
• LDL
• HDL
• TRIGLYCERIDES
• Total body fat
• Elevated values from normal of all indicated lipid abnormalities

except for HDL
2/7/2021 299
Glycemic Response
• BLOOD GLUCOSE
• INSULIN
• GLYCETED HEAMOGLOBAN
2/7/2021 300
RED Blood Cell indices
• The complete blood count (CBC) is a test that evaluates the cells that circulate in blood.
Blood consists of three types of cells suspended in fluid called plasma: white blood cells
(WBCs), red blood cells (RBCs), and platelets (PLTs). They are produced and mature
primarily in the bone marrow and, under normal circumstances, are released into the
bloodstream as needed.
• A standard CBC includes the following:
• Evaluation of white blood cells: WBC count; may or may not include a WBC differential
• Evaluation of red blood cells: RBC count, hemoglobin (Hb), hematocrit (Hct) and RBC
indices, which includes mean corpuscular volume (MCV), mean corpuscular hemoglobin
(MCH), mean corpuscular hemoglobin concentration (MCHC), and red cell distribution
width (RDW). The RBC evaluation may or may not include reticulocyte count.
• Evaluation of platelets: platelet count; may or may not include mean platelet volume
(MPV) and/or platelet distribution width (PDW)
• White Blood Cells
There are five different types of WBCs, also called leukocytes, that the body
uses to maintain a healthy state and to fight infections or other causes of
injury. They are neutrophils, lymphocytes, basophils, eosinophils, and
monocytes. They are present in the blood at relatively stable numbers.
These numbers may temporarily shift higher or lower depending on what is
going on in the body. For instance, an infection can stimulate the body to
produce a higher number of neutrophils to fight off bacterial infection.
With allergies, there may be an increased number of eosinophils. An
increased number of lymphocytes may be produced with a viral infection.
In certain disease states, such as leukemia, abnormal (immature or mature)
white cells rapidly multiply, increasing the WBC count.
Platelets
Platelets, also called thrombocytes, are special cell fragments that play
an important role in normal blood clotting. A person who does not
have enough platelets may be at an increased risk of excessive
bleeding and bruising. An excess of platelets can cause excessive
clotting or, if the platelets are not functioning properly, excessive
bleeding. The CBC measures the number and size of platelets present.
Complete Blood Examination
Test Purpose/Definition Normal Range Discussion
Discussion
Red blood cells (RBCs) Measures the number of M: 4.5 – 6.0 Decreased values
RBCs in whole blood million/mm3 occur with:
F: 4.0 – 5.5 anemia chronic
million/mm3 infection
leukemia
Increased values
occur with:
dehydration
Hemoglobin (Hgb) Part of the red blood M: 13 – 18 g/100 Decrease in case of

cells that carries oxygen dL anemia
and carbon dioxide in F: 12 – 16 g/100 dL
the blood
2/7/2021 305
Test Purpose/Definition Normal Discussion
Range
Discussion
Hematocrit (HCT) Measures the percent M: 42% – 52% Hematocrit is commonly used
of RBCs in the total F: 37% – 47% to diagnose iron deficiency,
blood volume even
though it is an inconclusive
measure of iron status
Mean corpuscular Measures the 32% – 36% Values <30 indicate advanced
hemoglobin concentration of Hgb iron deficiency anemia
concentration (MCHC) per unit of red blood
cells
Mean corpuscular Measures the average 80 – 95 mm3 Increased values indicate

volume (MCV) size of the RBC . pernicious anemia. Decreased
. values indicate iron deficient
anemia.
2/7/2021 306
Test Purpose/Definition Normal Discussion
Range
Discussion
Ferritin Provides an index of M: 12 – 300 Significantly higher in mend

iron stores in iron g/L and post menopausal women.
deficiency and iron F: 10 – 150 Decreased values occur with
overload g/L iron or protein deletion.
. Increased values occur with
iron excess.
Mean corpuscular Measures the 32% – 36% Values <30 indicate advanced
hemoglobin concentration of Hgb iron deficiency anemia
concentration (MCHC) per unit of red blood
cells
Mean corpuscular Measures the average 80 – 95 mm3 Increased values indicate

volume (MCV) size of the RBC . pernicious anemia. Decreased
. values indicate iron deficient
anemia.
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Conti…
Test Purpose/Defin Normal Range Discussion
ition Discussion
White blood Total no of 5-10 x l0r/mmr Increased (leukocytosis) in those with
cell white blood infection, neoplasia, and stress decreased
cells (leucopenia) in those with PEM,
autoimmune diseases or overwhelming
infections or who are receiving
chemotherapy or radiation therapy
55%-70Y. Neutroph i lia: Ketoacidosis,t rauma,

Differential neutrophils stress,pus-forming infections,
20-40"/o Leukemia Neatrnpeni:a P EM, aplastica
lymphocytes nemia,c hemotherapy,o verwhelming
2-87o Eosinophili:a P arasitic infestation, allergy,
monoc).tes eczema,le ukemia,
l"/o-4Y" autoimmune disease
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eosinophils EosinopeniaIn: creaseds teroid production 308
0.57"-17" BasophiliaL: eukemia
CLASSIFICATION OF SOME ANEMIAS
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Conti…..
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Advantages of Biochemical Method
It is useful in detecting early changes in body
metabolism & nutrition before the appearance of overt
clinical signs.
It is precise, accurate and reproducible.
Useful to validate data obtained from dietary methods
e.g. comparing salt intake with 24-hour urinary
excretion.
2/7/2021 311
Limitations of Biochemical Method
Time consuming
Expensive
They cannot be applied on large scale
Needs trained personnel & facilities
2/7/2021 312
2/7/2021 313
Food Labels
A. Required Information
 Name of the product (statement of identity)
 Name & address of the manufacturer
 Net contents in terms of weight, measure or count
 Ingredients list with items listed in descending order
by weight
 The Nutrition Facts Panel, unless the package is too
small
Cont’d
B. Nutrition Fact Panel
 Serving or portion size
 Servings or portions per container
 Calories per serving
 Calories from fat
 The amounts of total fat, saturated fat,
cholesterol, sodium, total carbohydrate,
dietary fiber, sugars, protein, vitamin A,
vitamin C, calcium & iron
Meal mangment 318
Cont’d
C. Daily Values
 Compares the amounts of specific nutrients in
one serving to the amount recommended for
daily consumption
 Provided for both a 2,000-calorie diet & a
2,500-calorie diet
 The daily values for vitamins & minerals are
calculated using the RDI’s
Cont’d
D. Nutrient & Health Claims
 Nutrient content claims: claims such as “low-fat” & “low-
calorie” used on food labels to give consumers an idea of a
food’s nutritional profile without having to look at the Nutrition
Facts Panel
• These claims must adhere to specific definitions established
by the Food & Drug Administration
Cont’d
• Health Claims: a statement on the food label linking the food to
a reduced risk of a particular disease
• The claim must be supported by scientific evidence
• These claims must adhere to specific definitions established
by the Food & Drug Administration
Health Claims
• Calcium-rich foods and osteoporosis
• Low-sodium foods and reduced risk of high blood pressure
• Low-fat diet and reduced risk of cancer
• A diet low in saturated fat and cholesterol and reduced risk of heart
disease
• High fiber foods and reduced risk of cancer
Health Claims (cont)
• Soluble fiber in fruits, vegetables and grains and reduced risk of heart disease
• Soluble fiber in oats and psyllium seed husks and reduced riak of heart disease
• Fruit and vegetable-rich diet and reduced risk of cancer
• Folate-rich foods and the reduced riak of neural tube defects
• Sugar alcohols and reduced risk of tooth decay
Health Claims (cont)
• Soy protein and reduced risk of heart disease
• Whole-grain goods and reduced risk of heart disease and certain
cancers
• Plant stanol and plant sterol esters and heart disease
• Potassium and reduced risk of high blood pressure and stroke
Meal mangment 328
Meal mangment 329
Meal mangment 330
Meal mangment 331
Meal mangment 332
Meal mangment 333
Dates on labels and what they mean
• Freshness or quality assurance date
• Pull date
• Expiration date
• Pack date
Dates on labels and what they
mean
1- Freshness or Quality
assurance date
•The last day the

product will be of
optimum quality.
Often preceded by
“best when used by.”
Dates on labels
and what they
mean
2- Pull date
The last day a store will sell an
item, even through the food may
be safe for consumption for a
little while longer.
Dairy and other perishable and
semi-perishable items have a pull
date that indicates the last day a
store should sell the item.
Such items are often priced very
low and are a good buy if used
within a short period of time.
and what they
mean
3- Expiration date
•The last day a food should be
consumed.
•Certain products that will
“expire” such as baking
powders, yeast packages, and
refrigerated dough, need to
show expiration dates to let
consumers know weather or
not they are still capable of
making baked products rise.
Dates on labels
and what they
mean
4- Pack date
•The date the food was
packed at the processing
plant.
•Canned, bottled, or frozen
goods have pack dates that
inform consumers how old
the food is when
purchased.
•It is often used by stores,
which need to know when
to rotate stock.

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Final Dietetics 1 Notes 2021 Exchange in Meal Planinng-1

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Exchange Lists for Meal

Vegetables 1 exchange = ½ cup cooked vegetables or 1 cup raw

Fruits 1 exchange = 1 small fruit or ½ cup of juice or ½ cup plums or 3 oz grapes

Fats 1 exchange = 1 tsp or 6 nuts

• 1 other carbohydrate exchange _ 15 g carbohydrate, or 1 starch, or 1

• This diet is indicated in:

• This diet is indicated when a patient is:

• Beverages — Cocoa, coffee or tea.

• These are used to supplement other external diets.

• The protein sources

• Soft and Low Fibre Diets

• The diet is made up of foods which can be completely absorbed,

• Severe diarrhoea to afford rest to the gastrointestinal tract.

• Dietary fibre plays a significant role in colonic function.

Fruits All others fruits with seeds and skins.

• These diets are prescribed for weight reduction in

• Low protein diets are usually prescribed for conditions like

• Usually fat controlled diets are prescribed for—

• The mineral content of the diet may also be modified.

• The proportion of monounsaturated and polyunsaturated fatty acids

• Increased intake of foods high in fiber is recommended.

• The suggested amount of cholesterol is 300 mg or less per day.

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• PURPOSE: This diet may be used in the treatment of constipation,

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Appel, et al. Circulation, 102:852, 2000

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Food Group Servings*

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• Slowly increase intake of

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• More whole grain cereals and

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• DASH is more effective if

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• Most restaurant foods are

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Controlled Portion Sizes •Dr. Shapiro's Picture Perfect Weight Loss

Food Combining •Fit for Life

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• What is a low-purine diet?

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Fatty food Lunch meats, especially high-fat Eggs (in moderation)

Bacon, veal and venison Rice, noodles, pasta and potatoes

Gravy Wine (in moderation)

2/7/2021 Dietetics II 165

• The ketogenic diet is a high-fat, adequate-protein, low-carbohydrate diet that in

• An organized approach to nutrition care that consists of assessing,