CHAPTER 1 NUTRITIONAL GUIDELINES FOR FILIPINOS A.

Nutritional guidelines for the general population 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. The Guidelines and their rationale are as follow: 1. EAT VARIATY FOODS EVERYDAY Since no single foods or food group can supply all the essential nutrients, eating variety of foods daily is one way of an adequate diet. A study by Limbo showed that the more diverse the diet, the higher is its mean nutrient adequacy ratio. 2. PROMOTE BREASFEEDING AND PROPER WEANING The Nutritional Guidelines Committee decided to include the recommendation in view of the observed decline in breastfeeding and in recognition of the superiority of breastfeeding over the artificial feeding in giving children a nutritional head start. It has been observed that breastfeed babies grow well during the first five or six months, but growth rate begins to falter thereafter, presumably due to inadequate supplementary feeding. Thus the promotion of proper weaning should go hand-in-hand in promotion of breastfeeding. 3. ACHIEVE AND MAINTAIN DESARABLE BODY WEIGTH Under nutrition and Over nutrition, manifested as underweight and overweight, respectively, have similar consequences for individuals in terms of reduced life span, increased susceptibility to diseases, reduced productivity and lowered quality of life in general. 4. EAT CLEAN AND SAFE FOODS In the survey of extent of the public concern over food safety conducted in 1987 in eight major Asian countries, the Philippines sadly ranked in second lowest. While reliable data on the prevalence of food-borne illnesses are not available, surveys have indicated that 69 percent of population may have parasites, mostly food-borne. Diarrhea, of which contaminated food and water are major causes, is one of the leading causes of morbidity and mortality. Furthermore, there are increasing reports of outbreaks of typhoid, cholera, hepatitis A and food poiso

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. B. Nutritional Guidelines for the Prevention Chronic Degenerative Diseases The prevalence of diseases of affluence, so called because of their close association with over consumption or over nutrition, is on rise according to available statistics. Diseases of the heart as a group and disease of vascular system as a group have become second and third leading causes of mortality, respectively, while the heart diseases are ninth leading causes of morbidity. Data from the Philippines heart Center reveal that one of 20 Filipinos aged 40 years and over have coronary artery disease (CAD). The prevalence of hypertension is estimated to be 11-13% in urban areas and 7-9% in rural areas. Diabetes mellitus, which has many similar etiopathologic characteristics as CAD rose in rank from sin in 1973 to second in 1978 as leading cause of hospitalization at the Philippine General Hospital. A DOH survey in 1982 revealed a diabetes prevalence of 4.1 percent nationwide. As for cancer, malignant neoplasms have become fourth leading cause of death and tenth causes of morbidity. It was estimated in 1989 that one out of 1000 Filipinos had cancer. In view of this alarming statistics. A special committee constituted by the FNRI formulated two set of Nutritional Guidelines-one set for the primary prevention of heart diseases (particularly CAD) and diabetes mellitus, and another set for reducing the risk to cancer. While the guidelines are meant to be primary preventive measures for people at risk of developing CAD, diabetes and cancer, may be used as bases for planning individualized nutritional care for individuals with these diseases.

Since the two sets of guidelines are in many ways similar, they may be consolidated into one set as follows: 1. EAT FOODS LOW IN FAT AND CHOLESTEROL There is strong evidence for an association between high fat and cholesterol consumption and hyperlipidemia. Hyperlipidemia is a portent risk factor in CAD and is common finding in diabetes mellitus. High fat intake has also been implemented in the development of cancer, particularly breast cancer. 2. INCREASE CONSUMPTION OF FRUITS, VEGETABLESS (ESPECIALLY GREEN AND YELLOW) AND UNREFINED CERIALS These foods are rich in fiber. Furthermore, fresh fruits are good sources of vitamin C, while dark green vegetables and yellow vegetables and fruits are good sources of beta carotene. This beneficial effect of dietary fiber of bowel function has long been appreciated. Now, there is accumulating evidence that fiber has other beneficial effect such as helping in the control of blood sugar and blood cholesterol levels as well as reducing the risk of colon cancer. Since different dietary fibers have different physiologic and metabolic effects, it is recommended that a wide variety of fiber sources be included in the daily diet. As antioxidants, vitamins C and beta carotene may prevent cancer by inhibiting the formation of carcinogens such as nitrosamines and free radicals in the body. Beta carotene also

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. 3. LIMIT INTAKE OF SALTY FOOD Studies have linked high salt intake to hypertension, particularly in salt-sensitive individuals. Hypertension leads to a number of debilitating condition including heart failure, heart attack, and stroke and kidney disorders. 4. MAITAIN DESIRABLE BODY WEIGHT Maintain desirable body weight is an important measure for reducing the risk of diabetes, atherosclerosis and cancer in the general population, and more so in the sub-population with a hereditary predisposition. For the overweight and obese, weight reduction should not be viewed simply in terms of reduction of energy intake. An adequate intake of protein, vitamins and minerals must be ensured, together with an increase in physical activity. 5. FOLLOW A REGULAR EXERSICE PROGRAM Besides being an important component of weight reduction program, exercise helps maintain normal blood lipid levels and normal blood sugar levels by promoting the utilization of glucose and enhancing insulin sensitivity. Exercise also improves cardiovascular fitness and helps to relieve stress. It is important that exercise be regular since many of its metabolic effects are short-lived. 6. REGULATE ALCOHOL INTAKE AND STOP SMOKING Too much alcohol leads to increase blood levels of LDL cholesterol and triglycerides, lowered HDL cholesterol as well as to hypertension and erratic blood glucose. It may also lead to certain forms of cancer. The nicotine in cigarettes causes blood vessel constriction and increased heart rate, which in turn elevates blood pressure. Nicotine also promotes the formation of thrombi or blood clots particularly in areas of the arterial wall with a diminished oxygen supply. The carbon dioxide in cigarette smoke reduces the oxygen supply to the heart and other organs. Cigarette smoking has likewise been liked to lung cancer. The Lung Center of the Philippines estimated that cigarette smoking is responsible for one million deaths each year. 7. HAVE A REGULAR MEDICAL CHECK-UP Early detection and early intervention can delay or even reverse many of pathologic changes in generative diseases. Additional Guidelines for Cancer Prevention 8. LIMITS CONSUMPTION OF SMOKED OR CHARCOAL BROILED MEAT AND FISH, SALT-CURED AND PICKLED FOODS Benzopyrene , a potential carcinogen, is formed on the surface of meat and fish when these are smoked or broiled over charcoal. Salt-cured meats usually contain nitrites and nitrates as preservatives. These may be converted into nitrosamines, also potential carcinogens. A high salt intake itself can promote cancer development by arritating the gastric mucosa, making at vulnerable to carcinogens. 9. AVOID MOLDY FOOD Aflatoxin is produced by a mold, aspergillus flavus. Moldy nuts, cereal grains and tubers contain high levels of aflatoxin, a potential carcinogen.

CHAPTER 2 NUTRITIONAL CARE PROCESS

The nutritional care of in- patients and out-patients essentially consists of the following steps: 1. Assessment of nutritional status and identification of nutritional problems and needs; 2. Setting of objectives to meet identified problems and needs; 3. Selection of appropriate interventions; 4. Implementation of selected interventions; 5. Monitoring and evaluation of nutritional care; All the above steps should be documented in the patients 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 patients 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 patients illness as well as on the available facilities. Considered basic are: Signs of malnutrition on admission, Laboratory and clinical findings pertinent to the underlying illness, and Planned actions.

Table 2 is a guide for identifying high risk patients. While important dietary assessment cannot be used alone to assess nutritional health. It is an aid in the interpretation of anthropometric, clinical and laboratory findings and provides a foundation for dietary counseling. The different methods used in evaluating a patients diet are described in appendix A. 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. SELECTION OF APPROPRIATE INTERVENTIONS Interventions are action to achieve the desired objective the desired objectives. They may include the diet prescription, nutrition counseling, provision of food and necessary supplements (if the patient hospitalized), and vitamin and mineral medication.

IMPLEMENTATION, MONITORING AND EVALUATION Implementation means carrying out the planned interventions, while monitoring is collecting data that will indicate progress towards the set objectives. Such data are called indicators and they should be determined at the outset. For example, if the objective is a change in body weight then body weight is the indicator and body measurements must be made initially and then periodically thereafter. Or if the objective is a change in calorie intake, then this is the indicator and an estimation of daily calories intake must be done. Evaluation is a dynamic and continuous process. It involves measuring the progress of the patient toward achieving the set objectives of his nutritional care plan. In effect, evaluation is a reassessment or addition to the initial assessment. This may lead to revision of the plan and to changes in intervention, if needed. 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

Table2. Guide for Identifying High Risk Patients Signs of malnutrition on Underlying Disease admission

CHAPTER 3 PLANNING THE DIET

A. Estimating the desirable body weight 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.) = (82) +3 =4 + 3 =7 kg. INFANTS 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 2. Children: DBW (kg.) = (No. of years x 2) + 8 Example: 7-year old child DBW (kg.)= (7 x 2) + 8 = 14 + 8 =22 kg. + 2 kgs for every year 3. Adults Desirable body weight (DBW) or ideal body weight(DBW) as used in nutrition and diet therapy refers to the weight for height found statistically to be the most compatible with health and longevity. There are several tables or monograms which give the DBW of adults of given height. However, in practice it is often necessary to compute an individuals DBW quickly. The following are some formulas that may be used.

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/H2), 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, 53 tall: DBW = 112 +(3 x 4)=124 lbs (56 kg) Female, 51 tall: DBW = 106 + (1 x 4)= 110 lbs (50 kg) 2. Derived formula based on body mass index DBW (kg) = Desirable BMI X H (m) 2 Desirable BMI for men = 22 Desirable BMI for women =20.8 or 21 Sample calculation: Male 53 (1.6 m) tall DBM (kg.) =22 x 1.6 m 2 =22 x 2.56 m =56.32 or 56 3. Tannhausers 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: 52=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.52 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.

2. Children: a. TER/day = 1000 + (100 x age in years) Ref: Narins & Weil

Examples: 7-years old child TER/day =1000 + (100 x 7) =1000+700 =1700 B. Age Range Cals/KDBW 1989 RDA 1-3 105 4-6 90 7-9 75 10-12 65(boys) 65.3 55(girls) 54.6

CBMRG (cooper, burber, ect.) 102 100 89.6 90 73.2 80 70 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 13-1555 (boys) 53.2 45 (girls) 45.7 16-1945 (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: Sedentarysecretary, clerk, typist (using electric typewriter) administrator, cashier, bank teller Lightteacher, nurse, student; lab. Technitian, housewife with maids Moderatehousewife without maid, vendor, mechanic jeepney and car driver Heavyfarmer, 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 Calories are rounded off the nearest 50

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 Example: Method lll Weight 50 kg. Height = 165.1 cm. Age =45 yrs. HBEE(males) =66.47 +13.75(50)+5.0(165.1)6.75(45) =66.47 +687.5 + 825.5303.75 = 1275.72 or 1275 cals 5. Pregnant women: TEr/day = normal requirement + 300 cals 6. Lactating women: TER/day = normal requirement + 500 cals C. distribution of total energy requirement (TER) into Carbohydrate, protein and Fat: Method lby percentage distribution % of TER 1. Carbohydrates 50-70 % or average of 60% 2. Proteins Infants 10% Children Adolescents Adults 10-12 3. Fats Normal adults, Moderately active 20-25 Children, adolescents; Very active individuals 30-35% Example: 7-year old child TER/day = 1700 Cals CHO/day= 1700 x .60= 1020 Cals 4= 255 gms. P/day =1700 x .10= 170 cals 4 =42.5 or 45 gms. F/day = 1700 x .30 = 510 cals 9 = 56.6 or 55 gms.

C,P, & F are rounded off to the nearest 5 Rx Diet = 1700 CalsC255P45F55 Example: moderate active housewife,DBW of 52 kg. TER/day = 2200 Cals CHO/day =2200 x .60 1320 cals 4 = 330 gms. P/day =2200 x .10 =220 Cals 4 = 55 gms. F/day =2200 x .30 = 660 Cals 9= 73.3 or 75 gms. Rx Diet =2200 CalsC330P55F75

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 2200220 = 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) l.A Veg. A 1 cup raw cup, cooked 2 cups raw 1 cup cooked cup, raw cup cooked varies varies 4 tablespoons varies varies varies varies varies 1 teaspoon 1 teaspoon ------

3 3 10

1 1 --

----

16 16 40

67 67 167

l.B. ll. lll.

Veg. B Fruit Milk Full cream Low fat Skimmed Rice meat and fish Low fat Med. Fat High fat Fat Sugar

iv. v.

12 8 10 12 8 5 12 8 tr 23 2 -----5 8 8 8 --1 6 10 5 --

170 711 125 523 80 335 100 418 41 86 122 45 20 172 360 510 188 84

Vl. Vll.

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 patients needs, food habits and other economic considerations. 2. To determine how many rice exchanges: A. adds the carbohydrates (CHO) from vegetables, fruit, milk and sugar. B. subtracts this sum from the prescribed CHO. C. divide the difference by 23 (g CHO furnished by 1 rice exchange). D. the nearest whole quotient is the number of rice exchange allowed. 3. To determine how many meat exchange are allowed: A. adds the protein furnished by the food groups already listed. B. subtracts this sum from the prescribed protein. C. divides the difference by 8 (g protein per meat exchange). D. the nearest whole quotient is the number of meat exchange allowed. 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 patients eating habits. Proteins and fats are distributed to balance the meal reasonably well. Sample calculation Diet Prescription: 1500 (6300 kj)2255540

CHAPTER 4 SUMMARY OF MODIFIES DIETS BY ORGAN SYSTEM Disorders recommended diet Prescription/modifications Conditions and affecting or Involving the mouth, Esophagus, stomach and Duodenum Broken jaw Dental caries Dry mouth Dumping syndrome mechanical soft mechanical soft mechanical soft carbohydrate-restricted; no concentrated sugars; Small, frequent feedings; fluid and electrolytes Replacement mechanical soft, tube feeding, Total parenteral nutrition (TPN) low-fiber, bland small, frequently feedings; low fat; bland; weight loss mechanical soft low-fiber; bland; small frequent feedings mechanical soft low-fiber; bland; small frequent feedings mechanical soft bland mechanical soft mechanical soft, tube feeding, TPN small, frequent feedings, low fat; bland; weight control mechanical soft, bland fluid and electrolyte replacement

Dysphagia Gastritis Hiatal hernia Lll-fitting dentures Indigestion (dyspepsia) Missing teeth Nausea Oral surgery Peptic ulcer Periodontal disease Plastic surgery of head or neck Reflux esophagitis Ulcer of mouth or gums Vomiting

Conditions affecting the Small intestine and colon Constipation Diarrhea Diverticulitis Diverticulitis Inflammatory bowel disease Irritable bowel syndrome Short bowel syndrome Ulcerative colitis Disorders Conditions effecting or Involving liver, gallbladder And exocrine pancreas Cirrhosis Gallbladder disease Pancreatitis high-fiber, increased fluids liquid, low fiber, regular, fluid and electrolyte Replacement low-fiber high-fiber low-fiber, low-fat, high-calorie, high-protein, fluid and Electrolyte replacement high-fiber; natural laxative foods low-fat, high calorie, high protein, fluid and electrolyte replacement low-residue, tube feeding, TPN recommended diet prescription/modifications

protein-restricted, sodium-restricted, Fluid-restricted low-fat, calories-restricted, regular low-fat; regular; small, frequent feedings; Tube-fidings, TPN

Conditions of the Endocrine pancreas* Diabetes mellitus Functional hypoglycemia (Hyperinsulinism) Conditions affecting the Heart and blood vessels Atherosclerosis Congestive heart failure Coronary heart disease Hyperlipidemias Hypertension Myocardial infarction fat-controlled, calories-restricted, sodium-restricted, High-fiber sodium-restricted; calories-restricted; low-fiber; bland; Small frequent feedings; fluid-restricted fat-controlled, calories-restricted, sodium-restricted, High-fiber fat-controlled, calories-restricted, carbohydratecontrolled low sodium, calories-restricted, high-potassium; Fat-controlled low-sodium; calories restricted; low-fiber; bland, small Frequent feedings; moderate temperature foods; fat-controlled individualized diet no concentrate sweets; small frequent feedings

Conditions affecting The kidneys Acute renal disease protein-restricted, high-calorie, fluid-controlled, Sodium-controlled, potassium-controlled, fat controlled, 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.

Disorders Conditions affecting Kidneys Chronic renal disease Kidney stones Nephritic syndrome Urinary tract infection

recommended diet prescription/modifications

protein-restricted, low-sodium, fluid-restricted, potassium-restricted, phosphorus-restricted increased fluid intake, calcium-controlled, low oxalate sodium-restricted, high-calorie, high-protein, potassiumrestricted increased fluid intake, acid ash diet

Malabsorption syndromes Celiac disease Cystic fibrosis Lactose intolerance Malabsorption gluten-restricted fat-restricted, high-calories, high-protein lactose-restricted low-fat, high-calories, high-protein, fluid and electrolyte replacement

Conditions affecting the Lungs and respiratory system Chronic obstructive Pulmonary disease Tuberculosis Conditions affecting many Organ systems Burns Cancer high-calories, high-protein, increased fluid intake high-calories, high-protein,(see also specific associated condition: dry mouth, indigestion, Malabsorption, nausea plastic surgery of The head or neck, ulcer of Mouth or gums, vomiting, etc. ) elimination of offending substance galactose-restricted calorie-restricted, high-fiber phenylalanine-restricted mechanical soft, regular, tube feeding high-calories, high-protein soft, high-calories, small frequent feeding low-carbohydrate, high-fat high-calories, high-protein

Food sensitivities Galactosemia Obesity, overweight Phenylketonuria (PKU) Stroke Underweight

CHAPTER 5 MANAGEMENT OF NON-SPECIFIC NUTRITIONAL PROBLEMS The following are some nutritional/feeding problems: 1. Anorexia dietary management strategies for selected non-specific

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 patients bedside for him to take whenever hungry. Consider the patients 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 patients 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.

2. Nausea and vomiting 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. 3. Hypogeusia (heightened taste perception) In the absence of oral or esophageal lesions, give flavorful (e.g. spicy) foods. Serve attractively prepared food. 4. Hypergeusia (heightened taste perception) Serve bland foods. Serve cold foods or foods with minimal odors. 5. Taste blindness (dysgeusia) 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.

6. Chewing and swallowing difficulty Adjust diet to patients tolerance. Give thick consistency fluids or semi-solid foods. Avoid sticky foods. Consider tube feeding. 7. Xerostomia (dry mouth) Soft bland foods, especially cool or cold foods with high fluid content. Take solid foods with gravies, sauces, melted butter, broths, mayonnaise, yoghurt or salad dressing. Dunk bread and other baked foods in milk, tea or coffee for easy swallowing. If solid food is not tolerated, try pureed diet or full liquid diet. Give salivary stimulant like citric acid containing beverages, lemon drops or gums. 8. Thick viscous saliva Give clear liquid like tea, Popsicle and slushes. Saline rinses before eating may help. 9. Esophagitis Avoid secretagogues like alcohol, caffeine, spicy and salty foods. Give cold, clear liquids or semi-solids initially.

10.oral and esophageal pain due to lesions 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 patients 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.

- 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). 11. Heart burn 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. 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 bacterias over growth due to prolonged antibiotic therapy, supplementation with lactobacillus acidophilus cultures through fermented dairy products (e.g. yakult, yoghurt ) may be helpful. If cause is highly resistant to treatment, a nutrition therapy goal would be to promote patient comfort through -medication to minimized symptoms; -small frequent meals served at room temperature; -intravenous fluid to maintain fluid electrolyte balance; -fiber containing supplements; -total parenteral nutrition (TPN), if bowel rest will relieve symptoms. If cause is undetermined, treatment should aim at relieving symptoms.

-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.

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):420,1989. 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. Department of Health, Disease intelligence Service. Philippines Health Statistics, 1987. 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 3:103109,1990. Lasang, S. L. Diabetes and exercise. Diabete Watch 7:3, 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.

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. Nutrition Aspects of Emerging diseases in modernizing societies: A Reaction JNDAP 4:90-33, 1990. Tanchoco, C.C. Nutrition and Nutrition-Revealed health problems in the Philippines, JNDAP 4:94- 102, 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. Passmore, R. and M.A. Eastwood,1986.Davidson and Passmores human nutrition and dietetics, 8th ed. ELBS/Churchill Livingstone. Robinson, C.H., M.R.,Lawler , R. Chenoweth and A. Garwick, 1986.Normal and therapeutic nutrition 17th ed. Macmillan Bublishing Co. Whitney, E.N., C.B.Cataldo and and S. Rolfs,1987.understanding normal and clinical nutrition 2nd ed. West Publishing Co. Mn.william, S.R. 1989. Nutrition and Diet Therapy , 6th ed. Times Mirror/Cosoy College Publishing,St Louis, Mis. Zeman, f and D.M. Ney, 1988. Application Of Clinical Nutrition. Prentise Hall, eaglewood Cliffs,. N.J.

CHAPTER 6 GENERAL DIETS

A. Regular or Full Diet 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. Indications for Use. For ambulatory or bed patients whose conditions do not necessitate a modified diet. Food Selection Guide All foods are allowed. Daily Food Plan Food Group Vegetables Fruits Milk, evaporated Rice or substitute Meat, fish or substitute

Amount At least 2 servings; 1/2 - cup cooked per serving One should be leafy green or yellow. 2 3 servings; one should be vitamin C-rich . At least 2 tablespoons. 10 13 exchanges. 5 6 exchanges; liver on glandular organs once a week; eggs 3 4 times a week;1/2 cup cooked dried beans may be used in place of 1 meant and fish exchange. 2 tablespoons. 23 tablespoons.

Fat Sugar or sweets

Suggested Meal Pattern Breakfast Fruit Egg or Substitute Rice or Bread with Butter, Margarine or Jam Hot Beverage Soup Meat, fish, Poultry or substitute Vegetable Rice or Substitute Same as Lunch As Desired, if necessary

Lunch

Supper Snacks

B. Simple Modification of the Regular Diet High Fiber Diet This is essentially a regular diet which includes liberal amounts of foods rich in dietary fiber. Fluids are also increased. Indication for Use Atonic constipation Diverticular disease Irritable bowel syndrome Gastric Ulcers Cancer of the colon Cardiovascular disease Diabetes mellitus Food Section Guide All selection is allowed. The following foods are emphasized. Vegetables leafy, legumes (lentils, dried beans and peas); Fruits Those with edible skin and seeds; ripe papaya, Dried, like prunes, raisins and dried mongo.

Rice or Substitute

whole grain like unpolished rice pinipig, See Rolled oats, whole kernel corn, whole wheat or rye Bread; ready to eat high fiber breakfast cereals. Others Cereal (rice, wheat etc.) bran and fiber supplements. ONLY HAVE PRESCRIBED BY PHYSICIAN; Also Dietary Management Cardiovascular Diseases and diabetes Mellitus. Full Bland 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. Indication for Used Hyperacidity Gastric and duodenal ulcers Daily Foods Plans and Selection Guide See Regular or Full Diet. Avoid: Hot spices like black pepper, chills (whole, powdered or sauce) Caffeine- containing beverages like regular coffee, tea, cola drinks. Alcoholic beverage Certain foods like cabbage, onion, garlic, etc. may cause distress some patients. An individualized approach to meal planning is thus necessary. Sample Menu Breakfast Ripe Papaya Sausage with tomato Slice Rice (not more than 1 cup) Decaffeinated Coffee with Cream and Sugar Meat Sandwich Gelatin desert

Mid-Morning

Lunch

noodles soup Broiled fish Mixed vegetable Guisado Rice (not more than 1 cup) Banana Ensaymada Cheese Chocolate milk drinks

Mid-afternoon

Supper

Chicken Tinola with Chayote and Sili Leaves Rice Plain Pudding or Custard crackers Hard cooked egg Fruit juice or milk

Bed time

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. Lacto Ovo- vegetarian Diet This diet includes plants foods and allows moderate use dairy products, preferably low fat and infertile eggs (thus balut is not allowed). The meal plans is similar to regular diet except that a main dish of legumes or meet analogues or textured vegetables protein (TVP) made from cereals, glutens, legumes, and/or nuts is substituted for meat, fish or poultry. The diet includes liberal amounts of fruit and vegetables, and when well planed, meets the nutrition needs of normal adults. Growing children and pregnant and lactating women should take an iron supplement. Besides tokwa or tofu, there are now a number of meat analogues available in the market which may be used as main dishes for vegetarian diets. They are popularly called vegemeat and come in different forms- chunks, chop lets, or ground. They may be prepared just like any meat recipe- asado, menudo, steak, meat balls, etc. A critical nutrient lacking is most vegetarian diets are vitamins B12 since this vitamins in found only in animal food products. Lacto Vegetarian Diets This diet includes plant foods and dairy products but no eggs. This plan can also provide the recommended nutrient if well planned. Ovo- Vegetarian Diet This diet includes plant foods allows the use of eggs, It may be low in calcium Pesco-vegetarian diet This diet is similar to lacto-ovo-vegetarian diet but allows fish Semi-vegetarian diet This is lacto-ovo vegetarians diet with the inclusion of chicken and fish red meats are excluded.

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. Indications for use The diet outlined bellowed as suitable and healthy infants aged 4 to 6 months. Earlier supplementation depends of the needs and developmental readiness of the infant as determine by the attending physician. 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. Food selection guide Supplemental foods Cereals, strained or blenderized, Thin lugao or scraped or mashed fruit, Vegetable water Thick lugao vegetable purees Strained juiced Flaked fish or ground meat, Hard cooked egg yolk 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.

age started 4 months

5 months

6 months

Indication for use This diet is designed for infants aged 6-12 months. The infants 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. Daily Food Flan and Food Selection Guide The amounts of some foods given in the table are ranges, the lower limits of which are for the younger infants in this age group. Gradually increasing amounts are recommended for older infants. Likewise, mashed or pureed foods are appropriate for younger infants, while food may be shopped or finely diced for older ones. FOOD GROUP Rice or substitute AMOUNT 1-3 exchanges ALLOWED FOODS Preferably enriched; rice gruel soft cooked for the older infants; strained oatmeal, farina toast or crackers. Sucrose, corn syrup Butter or margarine Prepared according to formulas Mashed hard cooked egg yolk; whole egg after ninth month; pureed or sieved, chopped, thinly slice lean meat, liver, chicken; flaked fish and mashed dry beans. Pureed or mashed, finely diced, sliced banana, papaya, ripe mango, avocado apple souse fruit juices. Pureed, sieved, mashed or shopped squash, chayote, carrots, upo, and green leafy vegetables.

Sugar Fat Milk(if not breastfed)

6 teaspoons 2 teaspoons As ordered by Physician 1-2 exchanges

Fruit

3-4 tablespoons

vegetable

4-5 tablespoons

Daily Food Plans and Food Selection Guide AMOUNT FOOD GROUP TODDLER SCHOOL CHILD (1-3 YEARS) 5-6exch. PREALLOWED FOODS

Rice or substitute

Sugar Fat Dessert

6 tsp. 5tsp. As needed: allowance

(4-6 years) 7-8 exch. All except whole kernel corn and malagkit for young toddlers 6 tsp. Sucrose, syrups 6 tsp. Jams, jellies. Cream, butter or margarine. made from food Plain pudding, gelatin, ice cream, cakes and cookies.

Soup and beverages Made from foods

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; Mild cheeses.

fruit 1-2 exch. One should be be vitamin C- rich rich 2 exch. One should vitamin C-

vegetable

1-2 exch.

all except strong 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)

Suggested meal pattern Breakfast fruit Egg or substitute Buttered toast or cereal Warm beverage

Mid-morning Supper D. Diets for Pregnancy and Lactation

milk drink same as lunch

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. Daily Food Plan FOOD GROUP Rice or substitute Sugar Fat Milk Meat or substitute

PREGNANCY 12 exchanges 6 teaspoons 7 teaspoons 1 cup

LACTATION 13exchanges 6 teaspoons 7 teaspoons 1 cup

4 exchanges liver or glandular 4-5exchanges liver or Organs twice a week; eggs 3 glandular organs twice a week to 4 times a week ;1 egg daily 3 to 4;2 of which should vitamins C-rich Same as pregnancy

Fruit

Vegetables

3 exchanges; 1 to 2 of which should be leafy or green 4 exchanges; 2 of which should be leafy green

Food selection guide All foods allowed. Suggested meal pattern Breakfast fruit Egg or substitute Bread with butter or jam

Cereal Hot beverage Mid morning Lunch and Supper sweetened fruit juice cookies soup meat, fish, poultry or substitute Vegetables Salad with dressing Rice fruit or desert milk

Mid-afternoon

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. E. diet for elderly 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

Vegetables

At least 2 servings:1/2-3/4 cup cooked per serving; one should be leafty,green or yellow. 2-3 exchanges: one should be vitamin C- rich As tolerated 10 exchanges 5-6 exchanged: liver or glandular organs once a week ; eggs 3-4 times a week; c cooked dried beans may be substituted for 1 meat exchange 1 tablespoons

Fruit Milk Rice or substitute Meat, fish or substitute

Fat Sugar 5 tablespoons

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.

CHAPTER 7 NUTRITIONAL MANAGEMENT OF SELECTED DISEASE CONDITIONS

A. Nutritional Therapy in Diabetes Mellitus Nutrition Therapy is the terminology adopted by the American diabetes association in March 1994 lieu of diet therapy to emphasize the need for a team approach to enhance the ability of each patient with the diabetes to achieve good metabolic control. The team includes a registered nutritionist- dietitian, a registered nurse, a physician, the persons with diabetes, and other health care professional as needed. 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 Aims of Nutrition therapy 1. Maintenance of as near-normal blood glucose level as possible by balancing foods intakes with insulin (endogenous or exogenous) or oral hypoglycemic agents. 2. Achievement of optimal serum lipid levels. 3. Provision of adequate energy to maintain/ achieve reasonable body weight in adults or normal growth and development rates in children and adolescents or to meet increased metabolic needs during the pregnancy, lactation and recovery from catabolic illnesses. 4. Prevention and treatment of the acute complications of insulins-treated diabetes such as hypoglycemia, short term illnesses and exercise illnesses and exercise-related problems, and of long-term complication of diabetes such as renal diseases autonomic neuropathy, hypertension and cardiovascular disease. 5. Improvement of overall health through optimal nutrition. Indication for use Condition characterized by elevated blood glucose level such as diabetes mellitus (insulin dependent and non-insulin dependent) impaired glucose tolerance and gestational diabetes. Note: When other medical conditions such as renal complications are present, further modifications of the diet are required. 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 stated. Recommended dietary modifications 1 totals calories- sufficient to maintain/achieve reasonable weight in adults,or meet increased needs children , adolescents, pregnant , and lactating women and individuals recovering from catabolic illness. Chronic distributionCarbohydrates: 50-70% Protein : 10- 20 % Fat : 20-30%

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 (2025% 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.

The following table may use as a guide in determining calories needs: AGE KCALL REQUIREMENTS PER KG RDW1 ~120 100-80

CHILDREN 0-12 MONTHS 1- 10 YEARS OLD

YOUNG WOMAN 11-15 years 6 years YOUNG MEN 11 15 years 16-20 years Moderate active Very active Sedentary MEN AND PHYSICAL ACTIVE WOMEN MOST WOMEN, CEDENTARY MEN, AND ADULTS AGE OVER 55 PREGNANT WOMEN First Trimeste2 Second/Third trimester3 WEIGHT REDUCTION FOR ADULTS 3. Cholesterol limit to 300 m/day or less. 4. Carbohydrates and sweeteners-

~35 ~30

~40 ~50 ~30 ~30 ~28

~28-32 ~36-38 ~36-38 ~20

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). Nutritional management of renal disorder 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 Dietary Factor Protein (g/kg IBW) Energy (kcal/kg IBW) Recommendation 0.6-0.8 Normal weight :35 kcal/ kg IBW Obese :20-30 Under weight or catabolic :50 8-12 1000-3000** Typical not restricted Typical not restricted Typical not restricted 20-25 g/d

Phosphorus (mg/kg IBW) Sodium (mg/day) Potassium Fluid Calcium (mg/day) fiber

Food selection guide Food Group Vegetable Allowed All fresh is allowed amounts Avoided or Restricted Picked vegetables, salt fermented vegetable like burong mustasa, sauerkraut kim chi; canned and frozen vegetable.

Fruit

All except those avoided list, Maraschino cherries, candied in allowed amount fruits, dried fruits.

Milk

Evaporated whole, allowed Commercial foods made with amounts milk, condensed milk, melted milk, milk mixed sherbet, chocolate cocoa.

Rice

Rice, bread, bihon, macaroni, spaghetti, corn, all of these and their product in amount allowed

Commercially prepared desserts, mixes and pastries; potato chips, pretzel, snacks chips cereals, or cracker containing baking powder, baking soda, salt, or other sodium compounds; bran cereal boxed, frozen or canned meals, whole wheat/grain breads and cereals, mami, mike, misua, instant noodles.

Chronic Renal Failure The diet for chronic renal failure (CRF) is designed to meet nutritional requirements, Minimize uremic complications; maintain accessible blood chemistries, blood pressure and fluid status in patients with impaired renal function, and at the same time, to promote well being. Generally, the diet has controlled amount of protein, potassium, sodium, phosphorus, and fluid and additional modifications of fat, cholesterol, triglycerides, and fiber may be necessary depending on individual requirements. The diet is used patient with CRF requiring hemodialysis or peritoneal dialysis treatments.

Ordering Information The diet order should state the calorie, protein and electrolyte level desired. Dietary Modifications Dietary Factor Protein (g/kg IBW)

Hemodialysis 1.1 1.4; at least 60% High biologic value

Peritoneal Dialysis 1.2 1.5 1.2 1.3 for maintenance 1.5 for repletion 1.2 for reduction or if with diabetes 25-35 for maintenance 35-50 for repletion 20-25 for reduction 35 if with diabetes (for CRPD and CCPD include dialysate calories) 1

Energy (kcal/kg IBW)

30-35 for weight maintenance 25-30 for weight reduction 40-50 for weight gain

Phosphorus

Sodium

Potassium

Fluid

< or approximately 1200 mg/d <17 mEq or approximately (keep serum level at maximum 800 1200 mg/d. of 6 mg/100 ml) (Keep serum level at maximum of 4 6 mg/100 ml. ) Individualized based on blood pressure and weight. 2000-3000 mg/d Generally unrestricted with CAPD and CCPD for IPD: 40 mg/kg IBW or 2000- 3000 ml/day approximately 50-80 mEq.d CAPD and CCPD, (1250-2000 mg/d) approximately 2000- 3000 ml/day based on daily weight 500- 750 mL/d plus daily fluctuation and blood urine output or approximately pressure; IPD, same as for 750- 1500 ml/d hemodialysis. Same as for hemodialysis approximately 1000- 1800 mg/d; supplements as needed depending on serum level Same as for hemodialysis Limit cholesterol to less than 300 mg/d; emphasize poly unsaturated fats. Same as for hemodialysis 20-25 g/d

Calcium(mg.d)

Fat

Fiber

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 Protein Recommendation 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. 35-50 kcal/kg present body weight ; energy must take into consideration the stress accompanying AFR. Individualize according to laboratory values. Anuric- oliguric phase: 500 1000 mg/d Diutric phase; replaces looses depending urinary and sodium levels, edema, and frequency of dialysis. Potassium Anuric- oliguric phase: 1000 mg/day

Energy

Phosphorus Sodium

Diuretic phase: replaces looses as indicated by urinary volume, serum and urinary potassium levels, frequency of dialysis and drug therapy Fluid Assess on daily basis Anuric-oliguric phase: replace output (urine, vomits and diarrhea) plus 500 ml from the previous day. Diuretic phase: large amount of fluid may be needed. Calcium Fat Individualize based on laboratory values No modification indicated during AFR

Food selection guide- refer to diet for chronic renal insufficiency Post kidney transplantation 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 Nutrient Protein Calories First month after Transplant After first Month and During Treatment for Acute Rejection 1.3- 1.5 g/kg/d 1.0 g/kg/d 30-35 kcal/kg/d (more if underweight ) sufficient to achieve/ optimal intake weight for height

Fats

Carbohydrates

Potassium

Sodium

No more than 35% of calories Same , Cholesterol <400 mg/d; Polyunsaturated-saturated ration >1 Same Remainder of total calories , encourage complex carbohydrates Same Variable, restrict or supplement as necessary based on serum level Not more 3 g/d 2-4 g/d may be necessary in acute rejection Same 1200 mg/d Same

Calcium

Phosphorus Fluids

1200 mg/d, some patients require supplements Same Ad lib unless fluid retention And hypertension worsens.

Food selection guide The diet for normal diets may be followed if there are no complications. To meet the increased need for calcium and phosphorus, give 3-4 glasses of milk per day, or give calcium and phosphorus (calcium phosphate) if milk is poorly tolerated.

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 Protein Recommendation Adults: 0.6 to 1.0 g/ka IBW plus replacement of urinary protein looses children: RDA for age plus replacement of urinary protein looses 1-3 g.d Generally restricted <30 % of total calories per day <300 mg/d dietary cholesterol Sufficient to achieve and maintain edema-free IBW Supplement may be necessary if protein intake in 60 g or less /d

Sodium Fluid Fats Cholesterol Energy

Vitamins and minerals

Food selection guide-refer to diet chronic renal insufficiency Urolithiasis (kidney stones) 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. Indication for use Diet modifications may be used with the medical treatment to increase the predominant components in urine that cause stone information.

Calcium urolithlasis The diet for the calcium urolithlasis is essentially a low calcium die Dietary modifications Dietary factor fluid Recommendation 3 L taken divided doses throughout the day; 50% of the total volume from water <100 mg/d in presence of hypercalciuria 400- 600 mg/d in presence of absorptive hypercalciuria.

Sodium Calcium

<100 mg/d in presence of hypercalciuria with normal obsorption of calcium. Oxalate

idiopathic intestinal

50-60 mg- d in presence of hypercalciuria or if stone composition data indicates calcium oxalate crystals; used simultaneously with calcium restricted regime.

Protein

Moderate intake (12% -14% of calories);encourage vegetable protein sources; Decreased animal protein intake particularly flesh and muscular protein sources rich in purines.

2. Oxalate Urolithiasis The diet for oxalate urolithiasis is essentially a low oxalate diet. Food selection guide The foods to restrict are the following: Vegetables : beans, celery, eggplant, leafy green, leeks, okra, green pepper, squash: CANNED vegetable soup, tomato soup. Fruits Milk Rice : : : berries, grapes, fruit cocktail, lemon, lime, orange peels, tangerine. chocolate and chocolate beverage, cocoa. wheat germ, corn grits sweet potatoes. beans with tomato sauce, tofu.

Meat, fish or : Substitute Fats :

nuts

C. NCEP recommendation in lower blood cholesterol

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. Dietary factor Total fat Total saturated fatty acids Polyunsaturated fatty acid Monounsaturated acids Carbohydrates Protein Cholesterol Total calories Step one <30% of total calories <10% of total calories Up to 10 % of total calories Remainder 50- 60% of total calories 10-25 % of total calories <300 mg/day To maintain desirable body weight Step two Same as step 1 <7 % of total calories Same as step 1 Remainder Same as step 1 Same as step 1 <200 mg/day Same as step 1

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%. Indication for use Hyperlipoprotenemia Coronary altery disease Ordering information The diet order for step 1 or step 2 diets should state the calories level the desired. Food selection guide See fat and cholesterol controlled diet (previous selection). Daily food Plan Food Group Vegetable Fruit Milk, powdered non fat rice meat or fish exchanges: low fat group Fat: Corn oil Olive oil Coconut oil Sugar

steno one

step two

2 servings, one should be leafy green, yellow 3 exchange, one should be vitamins C-rich 2 teaspoons 10 exchanges 5 exchanges1 2 teaspoons 10 exchanges 10 exchanges2

5 teaspoons 2 teaspoons 2 teaspoons 1 teaspoons

5 teaspoons 4 teaspoons

1 teaspoons

Suggested meal pattern Breakfast

Lunch and supper

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. fat- free broth or clear soup Vegetable Low fat meal exchange Fruit (Use allowed type and amount of fat for cooking)

Snacks any allowed food D. Dietary Regime after an Open heart Surgery The following regime is used at the Philippines Heart Center for post-open heart surgery Patients. 1. Coronary care diet # 1 (acute phase) This is clear liquid diet providing 500 to 800 calories per day in a volume of 1800 or 1500 mL. Beverage containing caffeine is restricted since it acts as a stimulant and may increase the heart rate. Thus, coffee, colas and cocoa are not allowed. Decaffeinated coffee is allowed. Extremes in temperature of liquid are avoided. 2. Coronary care diet # 2 (sub-acute phase) This is full liquid diet providing 800 to 1000 calories per day in volume of 1800 to 2000 mL. Restrictions are caffeine, saturated fat and cholesterol containing beverages. Hence, coffee, colas, cocoa, whole milk, and whole eggs are not allowed, and foods are prepared with skim milk and egg whites. Thick fluids pureed foods rather than thin liquids are given. Sodium may or may not restrict. Colonary care diet # 3 (convalescent phase) A soft bland 1200 1400 calories diet is given. Food which are easily digestible, free of gastric irritants soft and low in roughage are given. Lugao is served instead of rice. The physician specialist the sodium level. Small frequent feedings are given.

3.

4. Colonary care diet # 4 (rehabilitative phase) The diet is basically soft although a wide variety of foods are given depending on the patients tolerance. Sift rice instead of lugao is served. The Physician is specifies the sodium level. Decaffeinated beverage of served. E. Dietary management and malnutrition in children 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

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 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 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 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 a. Egg 1 a day, if possible, hard, soft or scrambled. b. Fish or meat: 2 ounces or some, boiled, steamed or canned; for severely malnourished children grind and cooks rice and vegetables. 4. Vegetable and proteins a. Dried beans, nuts, soybeans; grind before cooking or mashed before cooking to make legume easily digestible. b. Allow to 1 tablespoon raw beans per kg body weight; more in animal proteins foods are not easily available. 5. Vegetable and fruits a. Leafy greens;1/2 cup daily b. Yellow vegetables and fruit: include frequently, or 2 portions may take a place of 1 serving of leafy greens. c. Others: as desired or tolerated Sample menu (amounts are for a 5 kg child) Breakfast rice or substitute Egg Milk 1 cup

Mid-morning

mashed yellow sweet potato 1 With mashed beans 4 tbsp (raw measure) Milk cup rice Squash and ground beef Or flaked fish Other vegetables cup cup 30 gm as desired

Lunch

Mid- afternoon

mashed banana Milk rice Leafy vegetables Ground fish fish or beans Milk milk

1 cup cups cups 30 gm cups I cup

Supper

Bed-time

Supplements (to be ordered by pediatrians) 1. Vitamins - give vitamin A capsules to all severely malnourished children. -give vitamin A for all stages active exophthalmia including night blindness, bitos spots And corneal lesions. -give a dose of vitamins A to every child with measles in area where measles is serve. Corneal eye involvement is an emergency, act fast to save sight. Over 1 year of age Immediately on diagnosis 200,000 IU vit. A orally

The following day 1-4 weeks later

200,000 IU vit. A orally 200,000 IU vit. A orally

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 B12 Other treatments 1. Weight child on admission and then once or twice weekly thereafter. -loss of edema fluid may cause initial weight loss of stationary weight; -thereafter, expected gains is 100 to 200 gms, weekly. 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 1. For infection, diarrhea, or parasitism, give proper medication (prescribed by pediatrician) 2. For diarrhea, see DIATERY MANAGEMENT OF DIARRHEA IN CHILDREN. 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 Addition of oil to staple foods.

-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 Encourage return visit for follow-up. Dietary management of diarrhea in children Principles 1. Replacement of fluid and electrolytes is prime consideration, may be done parenterally, if necessary. 2. Resume a normal feeding as early as possible, especially malnourished child. 3. Give antibiotics (to be described by pediatriciaton) if diarrhea is bacterial in origin. 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, 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) . Sugar/Saline boil together: Sugar Salt Potassium salt (citrate, chloride) Water

2 heaping tbsp 1 level tbsp tsp 1 pint

Banana Powder Formula Latundan (4 pieces), green a. Slice green latunday thinly b. Sun-dry for one whole day or bake in a low temperature oven for 2 hours. c. Grind or pound with the use of mortar and pestle (losong) Yield: 121 pack at 7 grams (2 tsp). Actual Composition per 100 grams: Moisture, percent -12.0 Protein, gm -4.0 Fat, gm -0.9 Crude Fiber, gm -1.2 Ash, gm -2.0 Ca, mg -41 Phosphorus, mg -154 Iron, mg -5.2 Kcalories -262 2. Severe diarrhea with vomiting and/or dehydration Intravenous therapy is necessary. For small children about 100 ml/kg body weight daily of 1/3 normal saline in 5 % glucose (or other regimen as directed by pediatrician). Begin oral rehabilitation within 24 hours or as soon as vomiting is controlled.

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 patients condition age and tolerance.

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. Indication for Tube Feeding Patients who have a functioning gastrointestinal tract (GIT) but unable to ingest nutrients orally or have very nutrient requirements Types of Enteral Formulations Enteral formulations may be purchased in ready-to-use liquid or powdered form or may be prepared from liquid and blenderized common foods. Ready-to-use formulation may be: nutritionally complete and can be used alone, providing the total nutrient needs in a specified volume of formula; modular, providing different forms of individual nutrient to supplement existing formulas; or combined to meet specific therapeutic needs. Carbohydrates are the major calorie source is most commercial formulas and mat differs in form (i.e. as starch, glucose polymers, disaccharide, and monosaccharides) and concentration. Proteins maybe in the form of intact protein, protein hydrolysates, or crystalline amino acids. Lipids may be in the form of long-chain triglycerides (LCTs) medium-chain triglycerides (MCTs) lecithin, monoglyceridesor triglycerides. Tube feeding may also be prepared from regular foods that are liquid or maybe liquefied by mechanical means like blenderizer. The standard tube feeding is based largely on milk, sugar and soft cooked eggs and is suitable for a patient with a good tolerance for these foods. It is essentially fiber free and is high in cholesterol, fat and sugar and is not suitable for patient with hypercholesterolemia, hypertriglyceridemia and coronary altery disease. The food plan out line below provides about 1800 kcaaltery disease. The food plan out line below provides about 1800 kcalorie and 70 grams protein. Vitamin and iron supplements are recommended .the blenderized tube feeding includes foods normally included in the soft diet which can be blenderized easily. It is individually planned meet the patients specific needs such as low cholesterol, low fat, high fiber, etc. 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. Standard Tube Feeding Daily Food Plan FOOD GROUP Fruit Milk Egg Sugar

AMOUNT 3exchanges 4exchsnges whole 2exchanges skim 3 medium 10tbsp

ALLOWED Juices only 2 cups evaporated cup skin milk powder Strained soft cooked Sucrose, glucose, lactose or corn syrup

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. Compute for the total fluid volume using the formula: Cal Rx = volume Cal density e.g. Cal Rx =1800 kcal Cal Density =1 cal/ml Volume = 1800 cal = 1800ml 1 cal/ml Convert the ml into cups. Translate the exchanges of food items into a household measures and compute fluid content. 1. Start with vegetable, sugar, meat or soft-cooked egg and oil. 2. Using the prescribed volume as you guide decide on the following: a. Type and amount of fruits e.g. banana or fruit juice; b. Type of milk ; c. Compute for the sub total of fluid content. Compute for the remaining fluid left for rice. Example; Rx 1800 kcal with calorie density = 1kcal/ml 1. Volume = 1800 cal =1800 ml or 7.5 cups 1 cal/ml 2. Food distribution (e.g. determined in step B)

Food item Veg B Fruits Milk Rice Meat: medium fat Low fat Fat Sugar Total

Exch. 2 3 1 9 1 4 6 3

C 6 30 12 207 15 270

P 2 8 18 8 32 68

F 10 6 4 30 50

calories 32 120 170 900 86 164 270 60 1802

3. Translate into household measures compute fluid content. Food group Veg. b Sugar Egg Meat Oil Fruit Milk Total fluid Food Boiled squash Sugar Soft-cooked Boiled chicken Breast Corn oil Banana Evap. milk Exchanges 2 3 1 4 6 3 1 Household measures 1 cup 3 tsp 1 pc. 8 tbsp 6tsp 3 pcs. cup Fluid (ml) 50 30 120 300

Routes of parenteral feeding 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.