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DIETARY MANUAL-JMC-updated
DIETARY MANUAL-JMC-updated
Utilize the manual for guidance in meal planning for differing ages, conditions and
needs, to aid physicians in prescribing modified diets, and by health care staff to
interpret and carry out diet orders. Dietetics practitioners may use it as a general
guide for providing nutrition care.
CHAPTER 1
The terms nutritional/dietary goals, guidelines and recommendation are often used
interchangeably. Bengoa et. Al. defined nutritional goals are recommendations considered
appropriate for a population for purposes of promoting health, controlling deficiencies or
excesses, and minimizing the risk of diseases related to nutrition. Dietary guidelines, on the other
hand are indications of practical ways to reach the nutritional goals of the population. They are
based on the habitual diet of the population and suggest desirable modifications.
In 1990, the food and nutrition research institute constituted a committee to formulate
guidelines for Filipinos. The committee adopted the term Nutritional Guidelines rather than
Dietary Guidelines.
The committee also decided that the guidelines are to be intended for the general
population, not for people suffering illnesses which required specific or individualized dietary
modifications.
The purposes of the Nutritional Guidelines are: a) to provide the general public with
primary recommendations on proper diet and wholesome practices to promote nutritional health
for themselves and their families; and b) to provide those concerned with nutritional information
and educations and a handy reference.
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5. PRACTICE A HEALTHY LIFESTYLE
The sub-message under this recommendation is: be moderate in what you eat and drink;
Avoid smoking and control stress; and maintain good dental health.
Wise meal planning strategies do not suggest complete avoidance of specific foods but
instead recommend a judicious use of those foods containing factor known to be somehow
related to the development of diseases- e.g., fat, especially saturated fat, salt, sugar, alcohol,
―junk‖ food, etc. moderation is likewise recommended in the use of food or dietary factors
known to have health benefits- e.g. polyunsaturated fat, fish oil concentrates, fiber concentrates,
even vitamins and minerals. Excessive amount of these are either toxic or unnecessary.
Heavy cigarette smoking has been associated with increased incidence of lung cancer and
cardiovascular diseases, while stress is etiologic or complicating factor in many diseases.
Poor dental health, especially among children and elderly, affects nutritional status by
interfering with food intake.
Since the two sets of guidelines are in many ways similar, they may be consolidated into
one set as follows:
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prevents the preoxidation of low density lipoproteins (LDL). It hypothesized that oxidized LDL
may play a role in atherogenesis.
There is an increasing interest in phytochemicals in plant foods other than dietary fiber
and beta carotene. Animal and epidemiologic studies have suggested that these phytochemicals
may have anti-cancer properties.
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CHAPTER 2
The nutritional care of in- patients and out-patients essentially consists of the following steps:
All the above steps should be documented in the patient’s medical record chart to allow proper
communication and interaction among member of the health care team. The nutritional care of
patients is a team effort involving various personnel in the health care facility.
NUTRITIONAL ASSESSMENT
A through nutritional assessment is the basis of a nutritional care plan. Its primary
purpose is to identify the patient’s nutritional problems and needs. It also identifies a high risk
patient who needs special attention.
Nutritional assessment involved the collection and analysis of anthropometric, biochemical
clinical, dietary and psychosocial data as well as a consideration of the planned therapeutic
management. A wide variety of parameters as shown in Table 1 are needed to make a complete
and through nutritional assessment. However, in clinical practice, it is virtually impossible to
measure all these parameters. The amount and type of information to be collected depends on the
patient’s illness as well as on the available facilities. Considered basic are:
OBJECTIVE SETTING
After the problems and needs are identifies, the next step is to set the objectives of
nutritional care. For each problem, there should be a corresponding objective.
Characteristics of objectives
Objectives should be specific and patient-centered. This means they must be stated in
terms that show what the patient will achieve if the objectives are met. They may be started in
terms of changes, e.g., in body weight, blood chemistry or clinical findings, or in terms of
behavioral changes. Objective should be time-bound, which means the time frame for the
attainment of each objective should be set.
Objectives should be realistic. They should consider what can be realistically achieved
within time-frame set as well as resources available.
Objectives should be measurable. They should be stated in quantifiable terms in order to
permit monitoring and evaluation of the nutritional care.
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IMPLEMENTATION, MONITORING AND EVALUATION
Table1.
The Data Base for the Assessment of Nutrition Status
GENERAL SPECIFICS
ANTHROPOMETRIC Weight, Height, and weight charges.
Growth parameters in infants, children,
adolescents, chest circumference;(in
pregnant women):
Weight gain.
Skin fold thickness: triceps, scapular,
abdominal, etc.
Mid- upper arms circumference
(MUAC)
Wrist circumference
Biochemical Blood, serum, plasma measurements
Urinary measurements
Tissue assays or biopsies
Clinical Finding indicative of nutritional status
Findings indicative of disease that
may affect nutritional status
Pertinent medical history
Diagnosis Underlying disease
Secondary disease(s)
Nutritional History Dietary intake
Nutrition-related information:
-use vitamin and mineral
supplements
-allergies, food intolerances
-nutrition knowledge
-physical activity
Psychosocial Information Pertinent social history
Cooking and eating atmosphere
Attitudes toward food and eating
Number of persons in household
Economic factors
Food buying and cooking facilities
Ethnic background
Planned Therapeutic Surgery
Management Radiotherapy
Drug and medications
Repeated tests X-rays
Hospitalization duration
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Table2.
Guide for Identifying High Risk Patients
Signs of malnutrition on Underlying Disease
admission
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CHAPTER 3
PLANNING THE
DIET
Selection of the appropriate dietary intervention will entail calculation of diet prescription
which usually based on desirable body weight synonymous to reference, ideal, expected or
standard. The Food and Nutrition Research Institute and the Philippines Pediatric society has
come out with ―Anthropometric Table and Chart for Filipino Children‖ which may be used as
reference. For the adults, the ―Weight for Height Tables for Filipinos (25-65 years)‖may be
utilized. If these references are not available, the following may be used:
1. Infants:
A. 1st 6 months:
DBW (gms) =Birth weight (gms) + (age in mos. X 600)
If the birth weight is not known, use 3000 gms.
Example: 4-month old infant =
DBW (gms)= 3000 + (4 x 600)
=3000 + 2400
=5400 gms or 5.4 kg.
7-12 months:
DBW (gms) = Birth weight (gms) + (age in mos. X 500)
Example: 8-month old infant
DBW (gms)=3000 +(8x 500)
=3000 + 4000
=7000 gms or 7 kg.
b. DBW (kg.)= (age in month ÷2) +3
Example:8-month old infant
DBW (kg.) = (8÷2) +3
=4 + 3
=7 kg.
INFANT’S WEIHGT:
--Doubled at 5-6 mos.
--tripled at 12 mos.
--quadrupled 24 mos.
HEIGHT OR LENGTH:
Example:
At birth: 50 cm 50 cm
At 1 yrs.: +24 cm 50 + 24 = 74 cm
At 2 yrs.: + 12 cm 74 + 12 = 86 cm
At 3 yrs.: + 8 cm 86 + 8 = 94 cm
At 4-8 yrs.: + 6 cm every year at 4 yrs. + 6 = 100 cm
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1. Body Mass Index-based formula
Body mass index (BMI) is widely used to identify lean, overweight or obese individuals.
It is computed as weight in kilograms divided by height in meters squared (W/H 2), and has been
found to be relative weight index that shows the highest correlation with independent measures
of body fat. The BMI range of 20 to 24.9 is generally considered normal.
The joint FAO/WHO/UNU Expert Consultation on Energy and Protein Requirements
computed the energy requirements of adult based on BMI=22 for men and BMI=21 for women.
The weight of given height equivalent to these BMI values may be read off directly from a BMI
monograms. In the absence of such monograms, the following formulas have been found, during
a consultative meeting Metro Manila dietitians, to give weights closely equivalent to =22 for
men and BMI=21 for women.
For men 5 feet (1.52m) tall, DBW= 122 lbs (51 kg)
For women 5 feet (1.52m)tall, DBW = 106 lbs (48 kg)
For both sexes, add 4 lbs (1.8 kg) for every inch above 5 feet.
Sample calculation:
Male, 5’3‖ tall: DBW = 112 +(3 x 4)=124 lbs (56 kg)
Female, 5’1‖ tall: DBW = 106 + (1 x 4)= 110 lbs (50 kg)
H (m) 2
Desirable BMI for men = 22
Desirable BMI for women =20.8 or
21
Sample calculation:
Male 5’3‖ (1.6 m) tall
DBM (kg.) =22 x 1.6 m 2
=22 x 2.56 m
=56.32 or 56
3. Tannhauser’s method:
Measure height in centimeters. Deduct from this factor 100 and the answer is the DBW in
kg. The DBW obtained applies to Filipinos stature by taking off 10%
Examples:
Height: 5’2‖=62‖
62‖ x 2.54 cm.= 157.48 cm. –100 = 57.48 kg.
57.48 kg.
- 5.74 (10% of 57.48)
51.74 or 52 kg.
4. ―Adopted‖ Method:
For 5 ft. use 105 lbs. for every inch above 5 feet, add 5 lbs.
Examples:
Ht.5’2‖
5 feet = 105 lbs.
2 inches = 5 x 2 = + 10
115 lbs. or 52 kg.
B. Estimating of Total Calorie Requirement Per Day or Total Energy Requirement (TER)/day:
1. Infants: TER/day = 120-110 Cals./KDBW
Example:
4-month old –
TER- 5.4 kg. (DBW) x 120 Cals/kg.= 648 or 650
Cals. 8-month old—
TER- 7 kg. (DBW) x 110 Cals/Kg. 770 or 750 Cals.
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2. Children:
a. TER/day = 1000 + (100 x age in years)
Ref: Narins & Weil
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Examples:
7-years old child—
TER/day =1000 + (100 x
7)
=1000+700
=1700
B. Age Range Cals/KDBW 1989 RDA CBMRG (cooper, burber, ect.)
1-3 105 102 100
4-6 90 89.6 90
7-9 75 73.2 80
10-12 65(boys) 65.3 70
55(girls) 54.6 60=13-15 yrs.
50= 15 yrs. and above
Examples:
7-years old child—
TER/day = 22 kg (DBW) x 80 = 1760 or 1750 Cals.
3. Adolescents 1998 RDA
13-15—55 (boys) 53.2
45 (girls) 45.7
16-19—45 (boys) 46.9
40(girls) 42.1
Average both sexes = 45 Cals KDBW
A. Adults:
a. method l (cooper, et. all) b. Method ll (Krause)
Basal Metabolic Needs= 1 cal/ Cals/KDBW/Day
KDBW/hr. Activity
+ physical activity = % above basal
Bed rest 10(10-20 krause) Bed rest 27.5
Sedentary 30 Sedentary 30
Light 50 Ligth 35
Moderate 75 moderate 40
Heavy 100 heavy 45
c. Harris-Benedict Energy expenditure
HBEE (males) =66.47 + 13.75(W) + 5.0 (H)—6.75 (A)
(female) =655.1 + 9.56(W) + 1.85 (H) --4.67 (A)
Where:
W =Kg Body Weight
H =Height (cm)
A =Age (years)
d. NDAP Formula
Activity level Male Female
In bed but mobile 35 30
Light 40 35
Moderate 45 40
Heavy 50 --
Examples of activities:
Sedentary—secretary, clerk, typist (using electric typewriter) administrator, cashier, bank
teller
Light—teacher, nurse, student; lab. Technitian, housewife with maids Moderate—
housewife without maid, vendor, mechanic jeepney and car driver
Heavy—farmer, laborer,cargador, coal miner, fisherman, heavy equipment operator
Examples: Method l
DBW = 52 kg.
A. activity= moderate (housewife without maid)
52 x 24 =1248 Cals. For basal metabolic
needs
1248 x .75= Cals for activity
1248 +936=2184 or 2200 Cals/day
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Calories are rounded off the nearest
50
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B. Activity Bed Patient
52 x 24 = 1248 Cals. For basal metabolic
needs 1248 x .20 =249.6 Cals. For activity
1248 x 250 =1500 Cals.
Examples: Method ll
a. Using the same individual(moderately
active) 52x 40 cals =2080 or 2100 Cals/day
b. Activity= Bed patient
52x 27.5= 1430 or 1450 Cals
6. Lactating women:
TER/day = normal requirement + 500 cals
C. distribution of total energy requirement (TER) into Carbohydrate, protein and Fat:
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Method ll: determine the protein calories first according to the normal allowance in gm/KDBW
and provide the non-protein calories (NPC) into:
CHO: 55-80% or an average of 70%
Fats: 20-45% or an average of 30%
Normal protein allowances/day:
Gm/KBDW
Infants 1.6
Children 1.5
Adolescents 1.2
Adults 1.1
Examples:7- year old child with TER of 1700 kcal
P/day =22(DBW) x 1.5 = 33 g or 35 g
35 x 4 =140 protein calories
1700 – 140 = 1560 non-protein calories
CHO/day =1560 x .70 = 1092 ÷ 4 =273 or 275 g
F/day =1560 x .30 = 468 ÷ 9 52 or 50
g Rx Diet =1700 C275P35F50
Examples: Moderate active housewife, DBW of 52 kg.
TER/day= cals
P/day =52x 1.1 = 57.2 or 55gms
55x 4 ==220 protein
calories
2200—220 = 1980 NPC
CHO/day = 1980 x .70= 1386 ÷ =345 gms.
F/day =1980 x .30= 594 ÷ 9 64.9 or 65
gms. Rx Diet =2200 CalsC345P55F
D. Meal Planning With Exchange Lists
The food exchange system is a used tool used by dietitians to facilitate meal planning. In
this system foods with similar composition are grouped together under a ―List‖. These lists and
their composition are shown in table 3.
A publication of the Food and Nutrition Research Institute entitled ―Meal planning with
Exchange Lists‖ contains a comprehensive listing of foods together with amount of each that
constitutes an exchange.
Table 3.
COMPOSITION OF FOOD EXCHANGES
CHO PRO FAT ENERGY
LIST FOOD GROUP MEASURE (g) (g) (g) (kcal) (kj)
2 cups raw 3 1 -- 16 67
1 cup cooked
l.B. Veg. B ½ cup, raw 3 1 -- 16 67
½ cup
ll. Fruit cooked varies 10 -- -- 40 167
lll. Milk
Full cream varies 12 8 10 170 711
Low fat 4 tablespoons 12 8 5 125 523
Skimmed varies 12 8 tr 80 335
iv. Rice varies 23 2 -- 100 418
v. meat and fish
Low fat varies -- 8 1 41 172
Med. Fat varies -- 8 6 86 360
High fat varies -- 8 10 122 510
Vl. Fat 1 teaspoon -- -- 5 45 188
Vll. Sugar 1 teaspoon 5 -- -- 20 84
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How to use the food exchange list in meal planning
To translate the prescription with given calories, carbohydrates and fat into food
exchanges, the procedure is as follows:
1. List down all the foods furnishing carbohydrates, i.e., vegetables, fruits, milk, rice and sugar.
A. it is customary to allow 1 to 2 servings of list A an B vegetable per day.
B. allow usual amount of sugar consumed per day unless contraindicated.
C. unless there is a drastic caloric/carbohydrates restriction, 3 to 4 servings of fruits allowed per day.
D. The amount of milk allowed depends upon the patient’s needs, food habits and other
economic considerations.
4. Followed the same procedure for fat, using 5 as the devisor since 1 fat exchange contains 5 g
of fat.
An allowance of + 5 grams the prescribed amount for protein, carbohydrate and fat and + 50
kilocalories for energy are given so the fractions of servings are avoided.
Distribute carbohydrates for breakfast, lunch, supper and snacks accordingly, depending
on the patient’s eating habits. Proteins and fats are distributed to balance the meal reasonably
well.
Sample calculation
Diet Prescription: 1500 (6300 kj)225—55—40
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CHAPTER 4
Conditions effecting or
Involving liver, gallbladder
And exocrine pancreas
Cirrhosis protein-restricted, sodium-restricted,
Fluid-restricted
Gallbladder disease low-fat, calories-restricted, regular
Pancreatitis low-fat; regular; small, frequent
feedings; Tube-fidings, TPN
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Conditions of the
Endocrine pancreas*
carbohydrates-controlled
* The pancreas produces both external (exocrine) and internal (endocrine) secretions. The
external secretions (enzymes) play an important role in the digestion of food; the internal
secretions (insulin and other hormones) play a primary role in the regulation of glucose
metabolism.
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Malabsorption syndromes
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CHAPTER 5
The following are some dietary management strategies for selected non-specific
nutritional/feeding problems:
1. Anorexia
Small, frequent feeding are preferable to large meals. Often, the mere sight of
large portions of food can induce nausea and anorexia.
Have snacks and fruit juices qt the patient’s bedside for him to take whenever
hungry.
Consider the patient’s food preferences.
Choose calories-dense foods and beverages.
If fruits are better tolerated, serve a variety of flavored milk-based drinks such as
shakes and frappes and protein-fortified fruit juices. Some of these may be made
into puddings with cornstarch as thickener to add calories and provide a variety of
texture.
Drink liquids half-hour before eating instead of with meals.
Serve food attractive. Avoid disposables as these tend to aggravate the patient’s
feeling of isolation.
When anorexia is due to drugs, altering their timing may help. For instance,
infusion of pentamidine, a drug used in pneumocystis carinii pneumonia, may
begin after meal time to improve intake at meals.
When taste and smell perceptions are altered, bland foods rather than highly
flavored foods are better tolerated. Foods served at room temperature have fewer
aromas than hot foods and therefore may be more acceptable.
Use wine as appetite stimulant.
Consult with attending physician regarding the use of appetite stimulant drugs.
Encourage dining with friends or families in pleasant surroundings.
Clear liquids, salty foods and fruit like watermelon are occasionally tolerated.
Too sweet and greasy foods may initiate or increase discomfort.
Strong odors, particularly that of food cooking, are sometimes objectionable
Drinking or eating rapidly, or sudden movement may stimulate vomiting.
In the absence of oral or esophageal lesions, give flavorful (e.g. spicy) foods.
Serve attractively prepared food.
4. Hypergeusia (heightened taste perception)
If there is aversion to several of the most popular protein foods. Look for
alternatives that are more palatable and also good sources of protein such as milk,
ice cream, blank cheese, cottage cheese and peanut butter.
Small frequent feeding.
Take liquids high protein diet supplement.
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6. Chewing and swallowing difficulty
9. Esophagitis
Avoid highly seasoned, acidic, extremely hot and extremely cold foods that cause
irritation. Consuming foods at room temperature may be soothing.
Give a mechanical soft diet (high calories, high protein fluids, and puddings,
finely chopped or pureed food) that requires minimum chewing.
Avoid hard, dry, crisp, or rough textured of foods.
Soak-dry foods in liquid such as gravy, sauces, coffee, tea, or milk.
If chewing and swallowing are impaired, give a blenderized diet or a polymeric
formula (e.g. ensure, suscatal)orally or enterally. Due to high cost of commercial
and enteral formulas, some hospital in Metro Manila use these product only to
fortify blenderized
Tube feedings.
If swallowing is badly impaired and these is danger of aspiration,
- Thin liquids may need to be omitted;
- Thickening liquid to a semi-soft consistency with powdered milk, mashed
potatoes, cornstarch or oatmeal should be tried, if liquid cause choking;
- eliminate solid food and foods such s stews;
- avoid foods that stick to the palate such as peanut butter, and white bread,
and slippery foods, such as bologna, macaroni, gelatin, saluyot and okra;
- consult with a specialist such as speech therapist.
Monitor patient’s tolerance to milk-based diet. There are anecdotal reports that
adult Filipinos tolerate milk poorly. Signs of intolerance include abdominal
pain, fat malabsorption, bloating, distention and diarrhea.
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- if intolerance is manifested, give a cereal based blenderized diet or
formula,enriched with protein hydrolysates or a lactose-free supplement (Casec,
Ensure , Sustagen premium 1 and medium chain triglycerides).
Use a straw for drinking liquids to avoid irritating lesions and causing soreness.
Practice good oral and dental hygiene.
Rinse with a topical anesthetic.
Give hard candy and chewing gum to stimulate saliva production if mouth is
dry.
11. Heart burn
Bland diet
Small frequent feeding
Do not lie down for two or three hours after meals.
Keep head and chest elevated with pillows or put a six-inch bed block under
the head of the bed.
Avoid chemical irritants such as hot, spicy foods, coffee, liquor, smoking and
stress.
12. Indigestion
Small frequent feeding; bland diet.
Avoid overeating and foods that may cause indigestion.
13. Bloating
Eat frequent small meals.
Avoid fatty, fried and greasy foods, gas-forming vegetables (broccoli, cabbage,
cauliflower, corn, cucumber, beans, green peppers, sauerkraut and turnips),
carbonated beverages, chewing gums and milk.
Emphasize sweet or starchy foods and low-fat protein foods.
Sit up or walk around after meals.
14. Diarrhea
In nonspecific diarrhea, there is an increased frequency of bowel movement. The stools
usually contain mucus, and are commonly loose and less formed than the normal stool. Bowel
frequency in unrelated to food intake.
To manage diarrhea:
Determine cause.
If treatable, bowel rest and total parenteral nutrition may be indicated until diarrhea
subsides so that oral or enteral feeding can be giver. Maintaining adequate nutrition on bowel
regeneration through oral or enteral feeding is important. A nutrient knows to be essential for
bowel structure and function is glutamine which unfortunately, is not contained in parenteral
formulas currently available.
- if there are bacteria’s over growth due to prolonged antibiotic therapy, supplementation
with lactobacillus acidophilus cultures through fermented dairy products (e.g. yakult, yoghurt )
may be helpful.
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-if steatorrhea is present, give lactose-free, low fat diet; try yogurt and cheese in
small amounts.
-if ulcerative lesions are present in the GI tract, give a low roughage diet.
-to prevent dehydration, encourage liberal intake of fluids such as broths, fruit
juices, gelatin and provide high potassium foods such as banana, meat and
potatoes for replacement of electrolytes.
If cramping is a problem, avoid foods that may cause gas or cramps, such as
carbonated drinks, beans, cabbage, broccoli, cauliflower, highly spiced foods, too
for any sweet and sorbitol sweetened chewing gums.
15. Malabsorption
Start with a polymeric formula or a lactose- free formula, orally and enterally
If sign of malabsorption persist, consider given an elemental diet or
TPN. For fat malabsorption:
Omit fat in the diet. Medium-chain triglycerides (e.g. coconut oil) are usually
tolerated.
For vitamins and minerals malabsorption:
Gives supplements.
For lactose intolerance:
Omit regular milk. Soybeans milk or low- lactose formulas may be used for
children and adults requiring a high protein diet.
16. Weight loss, muscle loss
Give high protein, high calorie diet.
17. Neurologic complications
These include impairment of motor function, confusion, dementia and
neuropathy. The following strategies may be helpful.
Simplify meal tray; use special utensils, if available.
Modify food consistency if there is difficulty in swallowing.
In advanced cases of neurologic involvement, the patient may need feeding
assistance, or consider tube feeding.
18. Dehydration
Take frequent feedings liquids or food that become liquid to the stomach,
fruits with high fluid content; ice cream, sherbet, fruit ice cream and
popsicles.
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REFFRENCES
A. Nutritional Guidelines
Azurin, J.C Diabetes Mellitus Survey and Control Program in the Philippines. Progress
Report, MOH 1983
Bengoa, J.M. et al. Nutritional Goal from Latin America. Food and Nutrition Bull. 11(1):4-
20,1989.
Bitara, E.D.T. et al. Control Program of Diabetes Mellituts in the Philippines . l.Retrospective
Study and Mass Screening in Metro Manila. Acta Med. Phil. 16,5-2:19-20,1980.
Claudio, V.S. et. Al. Basic Diet Therapy for Filipinos, Revised edition. Merriam and Webster
Inc. p. 266, 1983.
De Guzman , M.P.E. and A.R. Aguinaldo Food Safety, in search of an advocacy, a crusade.
JNDAP
5:109-118,1991.
Ericson, K.L.et. al. The Role of Dietary Fat in Mammary Tumorigenesis,food technology
39;69-73, 1985.
Flores, E.G. et. Al. Second Nationwide Survey. Part B Anthropometry, Anemia and clinical
Survey. Phil. J. Nutr 35:51-56,1985.
Geizerova, H. and J.V Layson, Jr. Primary Prevention of Coronary Heart Disease: Same
Strategical
Aspects of Filipinos. Phil.J. Int. Med.23114-164, July- Aug. 1985.
McGinnes, JM and M. Nestle. The Surgeon General Deport on Nutrition and Health Policy
implications and Implementation Strategies. Am J. Clinical Nut. 49:23-8,1989.
Gregly, M.J. Sodium and Potassium, in Nutrition Reviews Present knowledge in nutrition, 5th
ed. ch. 31. The nutrition foundation, Inc., Wash. DC, 1984.
Koh,K. Nutritional Approach to Cancer Prevention with Emphasis on Antioxidants and
Carotene. JNDAP 6:16-25,1992.
Kuizon, M.D.et. al. Development Of Nutrition Guidlines for Filipinos. JNDAP 3:103-
109,1990.
Levy, V.et. al. The Antioxidant Effect of Beta Carotene: Oxidation in Response to Oral
Supplementation of the vitamins(Abst.)Abstract Book,Xllth Intl. Congress of
Dietetics.Jerusalen, Israel, 1992.
Limbo, A.B. et. al. A Comparative Analysis of Some of Methods of Evaluating Diets and
Preschool Children
From Low Income Families. Phil. J. Nutrition 27: 182-193,1984.
Lung Center of the Philippines. National Smoking Prevalence Survey. Phil. J. Int. med
27:133-156, 1989.
McGinnes, J.M. Nestle. The Surgeon General Report on Nutrition and Health Policy
implications
And Implementation Strategies. Am. J. Clinical Nut. 49:23-8, 1989.
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National Research Council. Diet and Health Implications for Reducing Chronic Disease Risk,
1989.
National Research Council Executive Summery: Diet, Nutrition and Cancer. Nutrition
today 17:20-25 1982.
Nutrition and health. Chapter 17 Alcohol.
Sanchez, F.S. Cardiovascular diseases: Grapping with a Gripping and Spreading Malady.
EHSC Newscap Vol. 3 No. 1 Jan-March 1989.
Tanchoco, C. Fiber: fiber sense or nonsense, JNDAP 4:113-118,1990
Tanchoco, C.C. et. al. Formulation of Nutrition Guidelines for the prevention of chronic
Degenerative disease. JNDAP 6:26-29,1992.
Tashev, T. Nutritional aspects of obesity and diabetes and their relationship to CVD and
Mortality. Food and Nutrition bull. 8(3):12-14 1986
Williamsom , N.E. Breastfeeding Trends and Breastfeeding Promotion Program in the
Philippines. Int. J. Gynecol. Oct 31 (Suppl. 1):35-41, 1990.
B. Nutritional Care Process
Anderson, L.,M.V. Dibble, P.R. Turki , H.S. mitchelle and H.J. Rynberg. In 1982. Nutrition in
health and Disease,17th ed: J.B. Lippincott,Pa.
Krause, M.V. and L.K. Mahan 1984. Food Nutrition and Diet Therapy, 7th ed. W.B. Saunders
Co. Pa.
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CHAPTER 6
GENERAL DIETS
The regular of full diet, the most frequently used of all hospital diets, is design to
maintain optimal nutritional status. It follows the principles of good meal planning and permits
the use of all foods.
Nutritional requirements vary depending on age, sex, size, and activity level. The Food
Plan
Outlined below provides approximately 1900 kilocalories and 60 grams protein. It is thus
adequate in protein f or most adult and meets the energy allowance for a moderate activity
Filipino woman.
Adjustment in caloric value may be made by increasing (e.g. for males) or decreasing (e.g. for
bed patients) the sugar, fat or rice exchanges.
Depending on the specific food choices, the food plan meets the recommended
allowances for vitamins and minerals for healthy persons.
Breakfast Fruit
Egg or Substitute
Rice or Bread with Butter, Margarine or Jam
Hot Beverage
Lunch Soup
Meat, fish, Poultry or substitute
Vegetable
Rice or Substitute
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B. Simple Modification of the Regular Diet
The full bland diet, also called bland V is a regularly diet in which the only restriction
are foods which stimulates gastric acid secretion and motility. Aside from the restrictions (see
food guideline) foods selection and methods of preparation are the same as for all or regular diet.
Small frequent meals help to reduce gastric acid secretion and motility.
Certain foods like cabbage, onion, garlic, etc. may cause distress some patients. An
individualized approach to meal planning is thus necessary.
Sample Menu
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Mid-Morning Meat Sandwich
Gelatin desert
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Lunch noodles soup
Broiled fish
Mixed vegetable Guisado
Rice (not more than 1
cup) Banana
Mid-afternoon Ensaymada
Cheese
Chocolate milk drinks
Vegetarian Diets
Either for religious reason of out of concern for ecologic basic health principles,
many individuals today are choosing a vegetarian dietary regimen. Vegetarian diets are classified
as lacto-ovo- vegetarian, lacto-vegetarian, ovo-vegetarian, pesco -vegetarian, semi-vegetarian or
total vegetarian .seasoning and condiments’ derived from animal sources such as patis and
bagoong are not used to strict vegetarian diets.
Pesco-vegetarian diet
This diet is similar to lacto-ovo-vegetarian diet but allows fish
Semi-vegetarian diet
This is lacto-ovo vegetarian’s diet with the inclusion of chicken and fish red meats are
excluded.
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Total vegetarian diet (VEGAN)
This does not include all foods of animal origins and is thus likely to be deficient in
many nutrients.
An extremely type of the total vegetarian diet is the Zen Micro biotic Diet. This
regimen
Consist of ten stages, each one becoming more restrictive until finally, only rice is allowed. The
diet is an adequate and prolonged use may result in multiple nutrition deficiency disease.
C. Pediatric Diets
Supplements Diet
(One to Six
Months)
The main food for infant is milk. Breast milk is the best and the breast feeding should
be encouraged at all times. Breast milk has specific characteristics suited to the nutritional needs
and psychological development of infant. Furthermore, breast feeding enhances the bonding
process between mother and child during the first year of life.
Except for vitamin D, the nutritional needs of the infant for the first six months of life
can be met by breast milk alone provided breast feeding is adequate. The main aim of
supplemental feeding between 4 and 6 months is to introduce spoon feeding and new texture and
flavored to the infant to prepare him for later weaning and to establish healthy eating habits early
in life.
Early supplementation with the vitamin D is desirable.
Ordering information
When additional foods are desired for infants aged 4 to 6 months (or younger) order
should be specific and state the food and amount to be given.
Infant diet
(6 – 12 months)
The diet for infants aged 6 to 12 months is designed to meet their increasing
nutrition needs which can no longer be met by milk alone. Breast milk is still the best for babies
at this age and mother should be encouraged to continue breast feedings as long as they can.
Excluding milk, the foods listed in the food plan below provide about 470 -
670kcalories
And about 18 – 22 grams protein. The diet tends to be low in iron since our rice, the most
common cereal used for infants, is not enriched. Iron supplementation is thus desirable.
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Indication for use
This diet is designed for infants aged 6-12 months. The infant’s individual growth
and development pattern is the most suitable guide to determine to introduce semi-solid and solid
foods as well as how much introduce. Indications of readiness for solid foods are when:
The infants has double his or her birth weight
The infant consume 8 oz. formula and is hungry in less than 4 hours;
The infant consume 32 oz. of milk a day and wants more;
The infant is 6 months
old. Ordering information
The order should state the age of infant.
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Daily Food Plans and Food Selection Guide
AMOUNT
Milk
2 cups
meat, fish or substitute
2-3 exch. 3-4 exch. Chopped or ground lean
Meat, liver, chicken; flaked
fish, eggs ; mashed dried
beans;
fruit Mild cheeses.
1-2 exch. 2 exch.
One should be One should
be
vitamin C- rich vitamin
vegetable C- rich
all except strong
1-2 exch. 2 exch. flavored for the younger
children; chopped or cut in a
small pieces, skin, seeds, and
long fiber if any removed
Foods to Avoid
Whole kernel corn, nuts and malagkit for the younger toddlers
Highly seasoned and strongly-flavored vegetables
Highly spiced, canned or cured meat, fish; fish with small bones, sharp cheeses.
Nuts and coconuts, unless properly processed
Candy and excess sweets rich cakes and
pastries Highly seasoned soups
Coffee, tea, carbonated beverages
Monosodium glutamate (vetsin) and salt pepper (salitre)
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Suggested meal pattern
Breakfast fruit
Egg or substitute
Buttered toast or cereal
Warm beverage
These diets are designed to meet the increased nutrients needs during pregnancy and
lactation due to normal physiologic changes. The calcium and iron contents of the diets outlined
below somewhat lower than the RDA. More milk are frequent use of dillis will improve the
calcium contents of the diets, while iron supplementation is highly recommended. The vitamin A
and C of the diets can be assured trough a wise choice of food.
The food list for pregnancy outlined below supplies about 2300 kcalories and 75 g
protein
While that for lactation supplies about 2500 kcalories and 85 g protein.
Adolescent pregnant girls require a diet higher in calories, protein, vitamins and minerals
to meet both the needs of the developing fetus and their growth.
Breakfast fruit
Egg or substitute
Bread with butter or jam
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Cereal
Hot beverage
Note: the higher food requirement in lactation may be met by serving both a dessert and fruit for
upper and by giving milk drink at bedtime.
The diet outline below is lower in energy value than the full or regular diet since energy
requirements are reduced in the elderly. The diet provides about 1700 kcals and 60 grams
protein.
Daily food plan
FOOD GROUP AMOUNT
Milk As tolerated
1 tablespoons
Fat
5 tablespoons
Sugar
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Food selection guide
The foods selection guide for the regular diet may be followed with the following
modifications:
1. Avoid fried and fatty foods, gravies, cream sauces, salad dressings rich desserts.
2. Avoid excessive spices and seasonings.
3. Avoid strong coffee and tea, if these cause nervousness and sleeplessness. Decaffeinated
coffee or coffee substitute may be used instead.
4. Large and hard pieces of food may be chopped, group or pureed if a mechanical soft diet is
need
5. Certained foods such as dried beans, cabbage, cauliflower, radishes may be omitted these
cause stress.
6. Limit foods with little nutritive value such as gelatin desserts, clear broth and carbonated
beverages.
7. Include liberal amounts of fruit and vegetable for dietary fiber.
8. Encourage plenty of fluids.
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CHAPTER 7
There is no one ―diabetic diet‖ that will suit the individual and special needs of
persons with diabetes as revealed trough an adequate nutrition assessment .this
assessment which considers anthropometric and clinical laboratory data (especially blood
glucose, glycated hemoglobin and lipid level) as well as lifestyle data such as activity,
food habits etc.,is the basis for identifying treatment goals and invention. Thus, the diet
for an individual with diabetes can only be defined as a ―dietary prescript ion based
nutrition assessment and treatment goals‖
Ordering information
The diet prescription should state the calories, carbohydrates, protein and fat levels desired.
Other special instructions such as distribution of carbohydrates into meal amount of fiber
/s sodium level, etc., should also be
modifications
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Carbohydrates and fat distribution prescribed should be individualized depending on nutrition
assessment and treatment goals.
For individual normal lipid level and reasonable body weight: 30 % or less of
total energy may come from total fat and about 10 % total energy from saturated
fat.
It obesity and weight loss are the primary issues: use the lowest fat level (20-
25% of total calories)
If elevated low density lipoprotein cholesterol (LLD-C) is primary problem : <7
% of total calories may come from saturated fat:30% or less than total fat: and
limit dietary cholesterol to 200 mg per day. This is step two diet of national
cholesterol education program.
If elevated triglycerides and very low density lipoprotein cholesterol (VLDL-C)
are the primary problems :< 10 % of energy from saturated energy from
fats,<10% for polyunsaturated and up to 20% from monounsaturated; 10-20 %
from protein; remainder from carbohydrates. But if the individual is obese or a
triglycerides level is> 1000 mg/dl, reduce total calories and all type of fat. This
way, the absolute amount of is not increased.
CHILDREN ~120
0-12 MONTHS 100-80
1- 10 YEARS OLD
YOUNG MEN
11 – 15 years
16-20 years
Moderate active ~40
Very active ~50
Sedentary ~30
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The 1994 guideline issued by the American diabetes association state that ―from
clinical perspective, priority should given to the total amount of carbohydrates
consumed rather than the source‖.
Sucrose: the same guideline has liberalized the recommendation for sucrose
consumption. However, to avoid abuses which as experience as shown, follow
liberalization of recommendations, it is best to limit the use of sucrose and
sucrose containing foods.
Non-nutrient sweeteners: saccharine, aspartame and acesulfame K may be used in
moderation.
Dietary fiber: Aim for about 20 g/day or more. Excessive amount are not
necessary.
5. Sodium –limit about 3000 mg/day; less for people with hypertension or renal complications.
6. Alcohol- moderate amounts may be allowed, contingent on good metabolic control.
7. Vitamin and mineral supplement- not usually necessary, but may be given to individuals
on On reduced calorie diet (1400 kcal/day or less).
Chronic renal insufficiency is also called predialysis diet. The diet is restricted in two
major nutrients: protein and phosphorus. Restrictions in sodium, potassium, fluid, and calories
are based on individual needs. Because of restrictions in certain foods, the diet is deficient in
calcium, iron,
Vitamin B12 and zinc. A low protein diet may also be deficient in thiamin, riboflavin, and
niacin. The need of vitamin and mineral supplementation should be assessed on an individual
basis.
The diet aim is to reduce the workload of diseased kidney(s) by reducing the urea. Uric
acid, creatinine and electrolytes (especially phosphates) that must be excreted, prevent
acceleration of nephrotic damage resulting from excessive protein intake, prevent calcification
secondary to renal dystrophy, prevent renal osteodystrophy and at the same time, to promote a
filling of well being and postponed the need for dialysis.
The diet order should state the level calories, protein and electrolytes desired.
Dietary Modifications
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Food selection guide
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Ordering Information
The diet order should state the calorie, protein and electrolyte level desired.
Dietary Modifications
Dietary Factor Hemodialysis Peritoneal Dialysis
20-25 g/d
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Acute Renal Failure
The diet for acute renal failure (ARF) aims to reduce the accumulation of the uremic
toxins,
Control electrolyte abnormalities, and correct fluid retention while maintaining nutrient status.
Dietary factors that need to be controlled include protein, potassium, sodium, phosphorus, and
fluid with adequate calories depending on individual needs and frequency of dialysis treatment.
The diet is for patients with AFR with and without dialysis treatment.
Ordering Information
The diet order should state the calories, protein and electrolytes levels desired.
Dietary Modifications
Nutrients Recommendation
Protein 0.5 – 0.6 g/kg present body weight (but not less
than 40 g/d); increase as GFR return to a
normal; dialysis allow
1.0 -1.5 g/kg of present weight/d.
during AFR
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Food selection guide- refer to diet for chronic renal insufficiency
The diet renal transplantations design to provide adequate calories and protein to
counteract the catabolic effect of surgery during the early post transplant period and to manage
nutritional side effect of immunosuppressive drugs.
The diet is used for used for patient with chronic renal failure who has undergone renal
transplantation.
Dietary modifications
First month after Transplant After first Month
Nutrient and During Treatment for
Acute Rejection
Protein 1.3- 1.5 g/kg/d 1.0 g/kg/d
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Nephritic syndrome
The protein – and sodium controlled diet for nephritic syndromes (NS) is design to
minimized edema and proteinuria, control hypertension, retard the progression of renal disease
prevent muscle catabolism and protein malnutrition, and supply adequate energy
The diet is for persons with NS who are not dialyzed.
Ordering information
The diet order should state the energy, protein and sodium level desired.
Dietary Modification
Nutrient Recommendation
The dietary modifications for urolithiasis are designed to minimize the super generation of
components in the urine associated the information of renal calculi. Generally dietary
intervention
Includes combining the restriction of specific dietary constituent associate with the formation of
the stone with the generous fluid intake. Most calculi contain variable amounts of calcium,
cystine or uric acid surrounded by calcium oxalate.
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Calcium urolithlasis
The diet for the calcium urolithlasis is essentially a low calcium die
Dietary modifications
Dietary factor Recommendation
2. Oxalate Urolithiasis
The diet for oxalate urolithiasis is essentially a low oxalate diet.
Fats : nuts
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The adult treatment panel of nutrition cholesterol education programs (NCEP)(US)has
formulated dietary recommendations for the management of hypercholesterolemia. These
are show in the following table.
The food plans outlined below provide about 1800 kcalories with 50 gm fat,270 gm
carbohydrate and 65 gm protein contributing 25%, 60€%, and 15%, respectively of total
calories. In the step 1 Food Plan saturated, polyunsaturated and monounsaturated fatty acid
provide 8%, 8.5% and 8.5% of total calories, while in the step 2 plan, the corresponding value
are 4.5%, 9% and 11.5%.
Ordering information
The diet order for step 1 or step 2 diets should state the calories level the desired.
Fat:
Corn oil 5 teaspoons 5 teaspoons
Olive oil 2 teaspoons 4 teaspoons
Coconut oil 2 teaspoons
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Suggested meal pattern
Breakfast fruit
Egg1 low fat meal exchange
With allowed fat
Bread and/or rice
Hot beverage with powdered non- fat milk
Or non-dairy cream or substitute.
Lunch and supper fat- free broth or clear
soup Vegetable
Low fat meal exchange
Fruit
(Use allowed type and amount of fat for cooking)
The following regime is used at the Philippines Heart Center for post-open heart surgery
Patients.
Principles
1. Avoid delay; serve malnutrition is a medical emergency.
2. Aim at 100 to 200 kcalories and 2 to 4 grams protein per kilogram of actual body
weight.
3. Fluid: allow 120 -250 ml per kilogram of actual body weight.
4. Start with infant recipes, and then progress to a soft diet. With recovery, use diet for
age.
5. Give small frequent feeding -4 to 6 times daily; necessary, 30 ml of formula
feeding may be given hourly by teaspoon or medicine drooper nasograstric
tube.
6. Give vitamin A capsule
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Food to be included
1. Milk
a. Powder skim or full cream, 1 level teaspoon per half cup of water, or 2 tablespoon
evaporated full cream or reconstituted milk plus water to make ½ cup. Filled may
be tried cautiously if no other is available; condense milk is not suitable but may
be used as a last resort. If skim is add 1 teaspoon oil and 1 teaspoon sugar.
Increase concentration of milk as improvement accors.
b. allow about ½ cup per kg as actual body weight (for example: three –fourths to 1
cup three times a day for a 5 kg child).offer as milk to drink in cup or in from
bottle, or incorporate directly into other foods as rice, banana, etc. allow 1 level
teaspoon milk powder or 2 tablespoons evaporated milk per kg of actual weight of
the body. Increase allowance and concentration according to tolerance.
2. Rice or substitute
a. Aim at ½ cooked rice 4 times a day. Start in one cup rice gruel, thin at
first and the gradually thickened.
b. Rice substitute: ground corn gruel, oatmeal, rolled wheat (from CARE,
CRS and other such agencies), potato, sweet potato (yellow variety
preferred) and other tubers; strained or mashed at first for several
malnutrition children.
3. Animal proteins
child)
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Other vegetables as desired
Mid- afternoon mashed banana 1
Milk ½ cup
1. Vitamins
- give vitamin A capsules to all severely malnourished children.
-give vitamin A for all stages active exophthalmia including night blindness, bito’s spots
And corneal lesions.
-give a dose of vitamins A to every child with measles in area where measles is serve.
2. for anemia
- if hemoglobin is below 10 gm/100 ml. give colloidal iron,1/2 teaspoon three times daily
;if below 8 gm/100 ml, transfuse.
-megaloblastic, given vitamin
2. Keep in hospital 2 to 3 months if possible and advisable, and until weight gains is
more than 1
Kilogram over minimal weight recorded during confinement.
Complications
Discharge
Teach mother about proper diet.
-if available, give skimmed milk powder and other food distributed by UNICEF, CARE
Catholic
Charities ect. Or refer to local nutrition committee for food assistance.
-give advice on us of other animal foods and legumes leafy/yellow vegetables/fruit and
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Addition of oil to staple foods.
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-demonstrate preparation of dilis power, dried bean flours and nutripack (see appendix
for
Procedures); advised liberal used user of these in absence or other animal foods
children Principles
Management
1. Mild Diarrhea
Give milk (1 part milk to 4 parts of water) or banana powder formula and oral
rehydration solution (ORS, available in health centers) or sugar/saline, ½ per kg of body
weight daily. Use gavage (slowly) if necessary. Introduce solid foods o second day;
discontinue sugar/saline or molasses/saline. (if child is malnourished, follow DIETARY
MANAGEMENT OF MALNOTRITION IN CHILDREN) .
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Mixtures Using Banana Powder
1. Banana with Thin Rice Gruel
1 cup thin rice
gruel 1 pack
banana
1 tablespoon sugar
2. Banana with Milk
1 tablespoon skimmed milk powder
1 pint water
4 teaspoon oil
4 teaspoon sugar
1 pack banana powder
3. Banana with Vegetable Broth
1 cup vegetable broth (moderately salted)
1 pack banana powder
Note: Selection of mixture using banana powder will depend on the patient’s condition age and
tolerance.
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CHAPTER 8
NUTRITIONAL SUPPORT
Enteral Nutrition
Enteral nutrition refers to the delivery food and nutrients both orally and by tube directly
into the gastrointestinal tract. Many health professionals prefer to use the term enteral nutrition to
refer by feeding tube alone to differentiate it from oral feeding and frequently use enteral
nutrition interchangeably with tube feeding.
Ordering Information
Diet prescription for tube feeding (standard or blenderized) should specified the amount
of total calories with percentage distribution into carbohydrates, proteins, and fat; total volume
caloric density; rate of administration; diet modification, etc. and special supplements as
necessary e.g. vitamins, trace elements and minerals.
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Blenderized Tube Feeding
Steps in the formulation of a food plan for a blenderized formula are as follows:
A. Convert the dietary prescription (Rx) into grams carbohydrates (C), protein (P), and
fat (F).
Example: 1800 kca: C-60 %; P-15&; F-25% or 1800 kcal: C-270g.; F-50g.
B. Distribute into a Food Item
1. Vegetables: usually 2 serving, one each from list A and B, or as desired by patient.
2. Fruits: usually 2 to 3 servings
3. Milk: allow the usual amount consume by patient, if adult; for children, 1 to 2 cups.
4. Sugar: allow 4 teaspoon, or more on high calorie diets restrict on low calorie diets
5. Rice exchanges
a. Take the subtotal of the carbohydrates derived from no. 1, 2, 3, and 4.
b. Subtract from the total carbohydrates prescribed.
c. Divide the difference by 23 to get the number of rice exchanges to be allowed
round off to the nearest haft serving. For every 5 Gms less than the prescribed
carbohydrates, add one teaspoon of sugar.
6. Meat exchanges:
a. Take the subtotal of the protein derived from no. 1, 3, and 4.
b. Consider the kind of meat to be used weather low or medium fat
c. Allow 1 or 6 grams fat for low and medium fat meat, respectively.
d. Subtract from the total protein prescribed.
e. Divide the difference by 8 to get the number of meat exchanges to be
allowed. Round off the to the nearest whole serving.
7. Fat exchanges:
a. Take the subtotal of the fat derived from no. 3 and 5.
b. Subtract from the total fat prescribed
c. Divide the difference by 5 to get the no. of fat exchanges to be allowed. Round
off to the nearest whole serving.
If white bread is used as the exclusive rice exchange, the total volume c the above
food plan is usually less than the prescribed volume. Add sufficient water to make
up volume prescribed. If lugao is to be use proceed to the next step.
Cal Rx = volume
Cal density
e.g. Cal Rx =1800 kcal
Cal Density =1 cal/ml
Translate the exchanges of food items into a household measures and compute fluid content.
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Food item Exch. C P F calories
Veg B 2 6 2 - 32
Fruits 3 30 - - 120
Milk 1 12 8 10 170
Rice 9 207 18 - 900
Meat: medium fat 1 - 8 6 86
Low fat 4 - 32 4 164
Fat 6 - - 30 270
Sugar 3 15 - - 60
Total 270 68 50 1802
1. Peripheral vein rout used for patient with mild to moderate nutritional deficiencies and
those at risk of deficiencies. It provides calories and nitrogen on a temporary basis as
follow.
a. Short term maintenance for a person who is not hyper metabolic but is taking nothing
by mouth. (< 2 weeks)
b. Energy and protein supplemental to an oral diet.
c. Additional energy and protein while a person is being weaned.
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