DIETS

-
Structure

2.2 Therapeutic Diets

2.3 Qpes of Dietary Adaptations for Therapeutic Needs
2.4 Normal Nutrition: A Base of Therapeutic Diet
2.5 Diet Prescription
2.6 Constructing Therapeutic Diets

2.7 Routi~leHospital Diets

2.7.1 Normal or General Diets
2.7.2 Liquid Diets
2.7.3 Soft Diets

2.8 Mode oE Feeding

2.8.1 Oral Fcecling
2.8.2 Tube or Enteral Feeding
2.8.3 Pcriphcral Vein Feeding
2.8.4 Total Parenteral Nutrition

2.9 Let Us Sum Up

2.10 Glossary
2.11 Answers to Check Your Progress Exercises

In the first unit we discussed the role of a clinical dietitian and the various steps or
processes necessary for rendering effectiye nutritional care.
This unit deals wit11 therapeutic diets and the ways in which the normal diet of an .
individual can be modified to suit thcrapeutic needs. The clinical dietitian is educated ._
and trained to interpret the science of nutrition to enhance the quality of life of individuals
and groups in heallh and disease. Each diet prescribed for an individual has iQ own i ,
rationale and purpose. You as a dietitian should have the knowledge, skills and attitudes
to ensure quality of work.
In this unit, we shall learn about different therapeutic diets that are available in hospital
for specific disease conditions. Also, we shall deal with the different modes of feeding,
through oral enteral and parentera1 route, Let us first understand what a therapeutic
diet is and what purpose does it serve,
Objectives
After studying this unit, you will be able to:
e discuss the purpose(s) of therapeutic diet adaptations,
explain the different ways by which the normal diet can be modified to suit 37
therapeutic needs,
CIinical Therapeutic e plan a diet prescription,
Nutrition
0 describe the principles of general hospital diets - normal, liquid and soft diets,
and
e elaborate on the different modes of feeding.

2.2 THE EUTIC DIETS

Therapeutic diets are adaptations of the normal or regular diet. In other words, it
is a diet for a patient suffering from a specific disease such as heart failure, hypertension,
renal failure, diabetes etc. Why do you think that the diet has to be changed in these
conditions? What changes must be frequently made? These are a few issues which
we shall deal in this subsection.
Well, you already know that there are certain diseases which can be cured by food or
nutrient concentrates, such as deficiency diseases. In diseases such as diabetes, making
alterations in the diet can help to coiltrol the extent of the disease and prevent the
onset of complications. Similarly, in genetic diseases (about which you have studied in
Nutritional Biochemistry Course (MFN 002, Unit 12), simple dietary modifications
can kcep a check on the progression of the disease and syinptoms which otherwise
could be fatal. The disease process also influences both the quality and quantity of
the diet. The other aspects that may require changes include meal frequency. These
changes result as a consequence of the following reasons:
s loss of appetite and therefore low intake,
s feel more hungry and therefore an increase in the intake, and
o problems with mastication, swallowing, digestion or absorption of food or specific
/
nutrients (due to structural and/or functional changes) leading to changes in
types of food that can be tolerated, as well as, feeding frequency.
Let us next have a look at the purpose of dietary adaptations.

Purpose of Therapeutic Dietary Adaptations

A therapeutic diet is a quantitative/ qualitative modified version of a basic nutritious
diet which has been tailored to suit the changing nutritional needs of a patient/ disease
condition. Tlie regular or normal diet may be modified for one or more of the following
reasons:
.e to maintain or restore optimum nutritional status,
e to provide rest or relieve an affected organ (e.g. soft or liquid diet in gastritis),
e to adjust to the body's ability to digest, absorb, metabolize or excrete (e.g. a low
fat diet for fat malabsorption),
m to adjust to tolerance of food intake by mouth (e.g. tube feeding for patients with
cancer of oesophagus),
e to adjust to mechanical difficulties (e.g. soft diet for patients with denture
problems), and
e to increase or decrease body weightbody compositioll (e.g. high calorie, low
calorie etc.).
While going through the above poiilts you must have come across the terms like soft
diet, liquid diet, tube feedings etc. What are these and what do we mean by these?
Don't panic, we shall get to know about these terms later in this unit.
T h e modified diet may reduce symptoms, make the patient more comfortable or
improve the quality of life. The types of dietary adaptations for therapeutic needs are
reviewed next.
 Adaptation of
2.3 TYPES OF DIETARY ADAPTATIONS FOR Thcrapeutlc Diets

TRERAPIEUTIC NEEDS
Normal nutrition is the founda,tion upon which therapeutic modifications are based.
We have already discussed in previous sections about the purpose of dietary
adaptations. The adaptations ofthe normal diet to suit therapeutic needs may lake the
followingforms:
r Change in consistency of foods, such as liquid diet, soft diet, low fibre diet, high
fibre diet.
e Increase or decrease in energy value of the diet such as low calorie diet for
weight reduction, high calorie diet for burns.
r Increase or decrease in specific nutrients or type of food consumed, such
as sodium restricted diet, lactose restricted diet, high fibre diet, high potassium
diet.
e Elimination of spices and condiments, such as bland diets.
m Omission of specific foods such as allergy diets, gluten free diet.
a Adjustment in tlie ratio and balance of proteins, fats and carbohydrate such as
diabetic diet, ketogenic diet, renal diet and cholesterol-loweri~~g
diets.
a Rearrangement of the numbel and frequency df the meals such as diabetic diet,
postgastrectomy diet, diet for peptic ulcer disease.
e Test diets: These are single.mealsor diets lasting one or few days that are given
to patients in connection with certain tests e.g. the fat absorption test used to
determine if steatorrhoea is present.
r Change in feeding intervals i.e., meal frequency. I
4%

Having reviewed the types of dietary adaptations next let us get to know the basis of
planning therapeutic diets.

2.4 NORMAL NUTRITION: A BASE OF

THERAPEUTIC DIET
Normal nutrition is the foundation upon which the therapeutic modifications are based.
The primary principle of dietlnutrition therapy is that it is based on the patient's normal
nutritional requiremeiits. Any therapeutic diet is only a modification of the normal
nutritional needs of an individual to suit what hisher specific condition requires. A
person's 'diet' is defined as that person's intake of food and drink.

All detailed dietarymodifications should be presented with choices, clear guidelines,

- menu guidance and supporting information as to alternatives possible. Patients should
be encouraged to understand the key relationship between a food and a diet. The
value of afood depends on the amount of nutrient in the food and the frequency with
which the food is consumed. Dietarychanges necessary are more likely to be followed
if clear explanations and simple instructions are provided as to why the diet has to be
changed. TJe Recommended Dietary Allowances (RDA) are often used as a basis
for evaluating the*adequacyof therapeutic diets. Nutrient requirements specific to a
particular disease state or a disorder must be kept in mind when planning the dibt, As
a dietitian, you also need to remember that an individual's diet is affected by various
. factors such as lifestyle, income, knowledge, taste preferences, religious beliefs and
various other socio cultural factors. Failure to account for these could result in an
impractical therabutic diet planning. 39
Clinical Thcr-npeutic What is therapeutic diet planning or diet prescription? We will get to know about this
Nutrition
in the next section. But, first let us recapitulate what we l~avelearnt so far.
Check Your Progress Exercises I
1. What is a therapeutic diet? Discuss the purpose behind modifying a normal
or regular diet.
........................................................................................................................
........................................................................................................................
........................................................................................................................
2. List the types of dietary adaptations to meet therapeutic needs.
.......................................................................................................................
......I .................................................................................................................
........................................................................................................................
3. Normal ~lutritioilis a basis for a therapeutic diet. Discuss.
........................................................................................................................
........................................................................................................................
........................................................................................................................

The diet prcscription designates the type, amount and hequency of feeding based on
an individual's disease process and disease management goals. The disease may require
a calorie level or other restriction to be implemented. It may also liinit or increase
various components of the diet such as carbohydrate, protein, fat, vitamins, minerals,
fibre, phytonutrients or water. Another aspect which the dietetic prescription takes
into account includes the economic status, food habits (such as vegetarian, ovo-
vegetarian, non-vegetarian), food illtolerances (such as lactose intolerance, gluten-
sensitive enteropathy), allergy (such as milk, eggs), occupation of the patient and meal
timings. Next, let us have a look at each of these.
r Ecorloniic Status : It is one of the important practical considerations to be kept in
mind while formulating a diet prescription. During an acute jllness, a few expensive
items may be permissible but for more prolonged or chronic illnesses like diabetes
or peptic ulcer,;ihe recommended foods must be within the means of the patient.
e Food Hubits: These must be known so that the diets can be recommended
keeping in mind the food preferences of the patient. Whether a person is a
vegetarian or no&must be known. If vegetarian, then the degree of vegetarianism
should be assessed. For instance, ovo-vegetarians eat egg but no flcsh; egg and
fish vegetarians eat just egg and fish but not animal flesh. While home-vegetarians
prefer to remain vegetarian at home but consume meat/chickcn at a restaurant
or a party.
e Food Ir~tolerances: The intolerances of the patient for specific food items must
be assessed. For example, inilk may lead to diarrhoea in some people while
constipation in others. Those with colonic disorders are likely to get flatulence
with whole pulses. Hence, while prescribing the diet, Ule food intolerances must
be clearly indicated and known to the dietitian.
Allergy: Food allergies manifest themselves as urticaria, abdominal cramps or
bleeding asthma and angioedema. Many are found to be allergic to milk or egg
and thesc foods may have to be excluded from the diet of the patient as you will
 learn later in Unit 6 in this course. Gluten enteropathy (celiac disease) may result Adnptntion of
Thcrnpeutic Diets
as a consequence to gluten (a protein fraction in cereals and millets) sensitivity
and colitis in young children due to milk consumption.
8 Occupation artd Meal Things: The occupation and the time at which the meal
is consumed daily must be considered. A factory worker who works on different
shifts requires more detailed information for a peptic ulcer diet than a manager
whose hours of work are fixed.
Next, let us, get to know how assessment of nutrient intake is done based on the
patient's state of health.
Energy Allowance : The patient's requirement for energy varies with the physical
activity and physiological condition. For instance, coilsider a person confined to bed.
He tends to consume less than the one undergoing physical exertion. An example of a
pllysiological state that leads to an increase in caloric needs is fever. A diet high in
calories is indicated for under nourished patients. They are advised to take more of
energy-dense foods such as starchy foods, sweets, cereals, butler and oils. While a
low-calorie diet is indicated for all obese patients. The patient is encouraged to eat
three meals a day, not to eat in-between the meals and to avoid energy-dense foods.
These consist of raw and coolced vegetables, fruits, egg, meat, fish, chickcn and skimined
milk with a low intake of cereals. An individual's energy requirement can be determilled
calculating either:
- required number of Kcal/kg/day OR
- percentage increase over basal metabolic demands.
You can estimate the basal energy expenditure (BEE) from anthropoinetricdata using
the following Harris-Benedict formula:
For men: BEE = 66 + (13.7 x W) -t (5 x I-I) - (6.8 x A)
For women: BEE = 655 + (9.6 x W) + (1.85 x H) - (4.7 x A)
where, W = kg body weight, H = height in cms and A = age in years.
An additional factor is added depending on the activity level of the patient. Another
factor may also have to be added if the patient is under physiologic stress. You will
learn more about this concept later in Unit 5 in this course.
Mild stress - 20% over BEE
Acute infections or burns - may require 100% over basal.
You should determiile the actual energy requirements based on the assessmeilt of the
individual, hisher activity and hisher medical condition.
Carbohydrates: Carbohydrates provide bulk to the diet and along with fats, form the
chief source of calories. The comparatively inexpensive form of carbohydrates in a
high calorie diet can include chapaties, bread and biscuits. In a low-calorie diet these
must be used sparingly.
Prdtein: Once the energy requirements have been estimated, protein requirements
can be addressed. The aim is to achieve nitrogen balance. There are several factors
influencing protein requirements and these include total energy intake, the metabolic
state of the patient and protein losses. However, it is important to keep in mind that
protein synthesis requires energy. The RDA for protein is 0.8 g to 1.0 g/kg body
weight for adults. The actual minimum amount of protein needed to maintain nitrogen
balance in healthy adults is O.Sg/kg, The requirement varies with specific
disease states or protein needs related to specific conditions or illnesses, For instance,
a larger amount of proleins may be needed during severe protein wasting, such as 41
Clinical Therapeutic enteropathy or extensive drainage from wounds aiid fistulas. Protein restriction may
Nutrition
be needed in acute renal failure or hepatic insufficiency as you would read later in
Unit 15 and 16.

Patients who require high protein diets are encouraged to drink 600-800 mL of milk a
day. Now, you must be wondering how one can consume such a large portioil of milk
daily. Can you suggest a few ways by which the patients get the required amouilt of
protein comfortably? Well, this can be done by a number of methods. Of these, one
could be giving a different flavour to the milk by addition of coffee, ovaltine, chocolate
or consuming milk as milk shakes, ice-creams, yoghurt. Another way could be
consuming proteins from a different source such as egg, cheese, sausages etc.

Patients on protein-restrictedor low protein diets include the ones with pohal systemic
encephalopathy, CRF etc. In such cases, the diet is based upon a daily allowance of
protein foods with an emphasis on high class proteins. Afew examples of low protein
foods include beetroot, carrots, cabbage, mushrooms, tomatoes, turnips and most of
the fruits.

Fats: As you are already aware, fats are reservoir of calories. I11 addition to
carbohydrates, fats can a1s.o be an important source of needed calories. In certain
therapeutic conditions, fat is necessary to prevent essential fatty acid deficiency. A
high calorie diet should contain fatty foods (such as cream, butter, ghee and oil) while
a low calorie diet contains a little or no fat.
Patients requiring low animal fat diets must restrict their total fat coilsumption to
less than 30% of their energy needs and ideally 2131~of this must be in the form
of polyunsaturated fatty acids (PUFA) and moliosaturated fatty acids (MUFA).
This can be achieved by avoiding foods that are rich hi saturated fatty acids (SFAs)
such as all fried meats and fish, whole milk, fried eggs, cream, cheese, and nuts
(peanuts, coconut) chocolales, butter etc. While food products such as poultry, white
fish, egg whites, cottage cheese, skimmed milk, wholemeal cereals, fruits and
vegetables, wholemeal bead, meringues, plain biscuits and fatless sponge require no
restriction.

Mineral and Vitanlins: The requiremeilts for vitamins such as ascorbic acid and B-
complex vitamins and minerals sucli as zinc may need to be increased to promote
wound healing. Also in cases of long-term nutrition support, a careful assessment of
vitamin and mineral status is essential to prevent the development of deficit or toxicities.
You should consider the following factors to determine an appropriate vitamin and
mineral intake:

ij the requirements for healthy individuals,

ii) nature
.. ..
of disease and injury,

iu) body stores of specific nutrients,

iv) normal and abnormal losses through the skin, urine or intestinal tract, and

v) drug - nutrient interactions. '

Next, let us have a look at sodium and potassium.

Sodium (Nu): In sodium-restricted diets, no salt is added to the diet which still provides
approximately 50 mmoL Na. Foods containing high Na content must be avoided and
the examples include processed or cured meats, tinned or smoked fish, tinned vegetables
and soups, dehydrated and pre-packed meals, salted biscuits, nuts and crisps. There
are very low Na diets as well which contain 20 mmoL Na. These are much less
palatable since no added salt is used at the table or during cooking. Unsalted butter is
used and milk is restricted to 250 mL. We will learn more about these diets later in
Unit 11.
Potassium (K) : Potassium restricted diets are important for patients with advanced Adaptation of
Thernpcutic Diets
renal failure undergoing conservative treatment or haemodialysis. The high potassium
foods such as wholegrail1 breakfast cereals, vegetables e.g. beetroot, beans, broccoli,
leeks, mushrooms, spinach, tomatoes, dry and split peas, lentils, fruits e.g. prunes,
dates, currants, grapefruit, oranges, banana etc. must be avoided. Vegetables should
not be eaten raw rather they require leaching before consumption. The patients must
also be aware of and warned against using salt substitutes as you will learn later in
Unit 16, sub-section 16.11.3
Fluids: Fluid diets are given to patients with more advanced dysphagia or fractured
jaws. The diet may include fruit juices, thin strained porridge with milk, egg in milk,
strained soups, thin milk pudding, ice-cream or yoghurt. Also, whole protein polymeric
liquid feeds can be given. Since such diets lack bulk and can cause coloilic dysfunction,
these are available with fibre supplements.
A normal healthy adult at rest needs 1800 to 2500 mL/ fluids day (or approxiinately
lmI,/Kcal consumed). If sufficient water is not consumed, it call lead to constipation.
Optimal convalescence requires adequate tissue hydration. The water intake must be
liberal to ensure passage of light coloured urine. Additional fluids inust be added to
replace water lost by excessive perspiration, vomiting, diarrhoea, tube drainage or
other conditions marked by increased water loss. If sufficient water is not obtained
through fluid intake and foqd, it must be supplied parenterally, usually along with
electrolytes. Fluid restriction is needed in cases when excretion is impaired as in acute
nephritis and kidney failure. Fluid requirements per day are calculated as 500 ml a
day to replace the insensible loss in perspiration and sweating plus the volume of
urine passed during the previous 24 hours.
During certain clinical conditions such as renal fdilme when the fluid intake can be
detrimental to the prognosis of the disease; the fluid allowance is calculated by using
the formula:
Fluid allowance = 500 ml t urine output in previous 24 hours + Fluid lost due to
(24 hrs.) (insensible looses) diarrhoea1
vomiting
(if any)
High fibre diets: The patients are advised to eat high fibre cereals as wholc grain
flour and bread, whole grain brealdast cereals, whole wheat pasta and brown rice, all
kinds of fruits and vegetables (with their-edible peels). Unprocessed bran call also be
added to cereals or soups to give more fibre. Look up Unit 12 for more details on
dietary fibres.
Gluten-free diet: It is a diet recommended for the patients with gluten enteropathy.
Gluten is present in wheat, rye, barley and oats. Thus, fuods containing these should
not be eaten. A number of gluten free products are available on prescription and
these include gluten-free flour, bread and biscuits. Unit 18 presents details on this.
Elimination diets: This type of diet is used in a patient with suspected food
intolerance, food allergy or 'Crohn's disease. You will read about this subsequently
in Unit 6.
Exclusion diets: Specific dietary exclusion becomes a necessity in case of food
allergy or food intolerance. The therapeutic use of such diets requires a detailed
discussion between the patient and the dietitian. Each patient is provided with a list of
foods that are permissible and avoided. Also, the need of scrutinize the ingredient lists
in all convenience and manufactured foods is emphasized. The examples of these
diets include:
- Wheatfide diet: Here, foods to be avoided are ordinary bread, biscuits, cakes,
pastries, pasta and spaghetti and all wheat-containing breakfast cereals.
- Milkfree diet : As the name implies, all foods containing milk protein must be
avoided such as cheese, yoghurt, cream, ice-cream and butter.
Clinical Therapeutic - Egg free diet: In this, eggs and all products containing eggs are excluded
Nutrition
from the diet such beef burgers, pies, cakes, meringues as well Bournvita and
ovalthe.
- Additive free diets: Additives here include permitted food colours such as
tartrazine, sunset yellow, ponceus 4,R and preservatives such as benzoic acicl
salicylates etc.
- Ketogenic diet: It is occasionally used to facilitate the control of epilepsy. Here,
the patient is initially fasted for 48 hours and thereafter, balf the energy requirement
is provided as MCT (medium chain trig1yeeride) oil. Energy intake from ordinary
food must be restricted to prevent the suppression of ketones. Unit 17 presents
details on ketogenic diets.
- Diabetic diets: Tlzessc arc therapeutic rnodificutions in the quantity1 quality
of various mncranutrier~tspcrrliculai-ly ca;.bolzydratcr. We will read more
about this in unit 12.

The discussion so far is focussed on diet prescriptiol~and the fidctors which need to
be coilsideredwhile presenting diets. Next, we shall get to know about how to construct
therapeutic diets.

2.6 CONS'FWCTING THE EUTIC DIETS

You could do this by either using qualitative methods or quantitative methods. At
times a combination of both may also be required. What do we mean by these
methods? How are these carried out? Let us read the following section and find out.
We shall begin with the qualitative methods.

a) Qualitative Metlzods: This is where you give the individual choices, clear
guidelines, menu guidance and supporting infolmatio~l such as advice on suitablc
manufactured products. You should encourage the patient to understand the ltey
relationship between a food and a diet. Tlie value of a food depends on the
amount of nutrient in the food and the frequency with which the food is consumed.
The various qualitative methods include:

e Guidelines issued for healthy eating

e . The Food Guide Pyramid

e List of Desirable Food Choices, and

~r Elimination diets

I>) Quuntitative Methods: These are often essential for constructing Lherapeutic
diets. The two ways by which this could be done are as follows:

i) Using an exchange system which delivers a fixed amount of nutrient

per food portion. An example of this is the carbohydrate exchange
system used in planning diets for insulin dependent diabetics. Tbe
desired level of intake is specified and the diet is constructed from an
exchange list.

ii) Quantifying the portion size of foods and the frequency of their consumption.
This diet is constructed from normal sized portions of foods but those foods
which have the highest content of a particular nutrient per portion are
excluded from the diet. We learnt about this aspect earlier also, where we
got to know about fat, Na and K restricted diets. We also had a look at the
permitted and excluded food items based on their nutrient content.
Frequency of consumption of the various types of foods should also be considered. Adaptation of
Therapeutic Diets
This method is used typically when a diet is a ltey component of a n~ultifactorial
condition e.g. coronary heart diseasc.
- - -- -

Check Your Progress Exercise 2

1. A male patient is admitted to the hospital whose weight is 70 kg, height
170 cms and age 60 years. Calc~ilatehis basal energy expenditure.

.......................................................................................................................
2. Enlist any five therapeutic diets. What do you inean by exclusioil diets?

3. What are the different dietary adaptations that are made to meet the
therapeutic needs?

4. Discuss quantitativc method used for constructiilg Lherapeutic diets.

So you are clear about dict prescriptio~land how to construct a therapeutic diet. Next,
we shall learn about the routine hospital diets.

2.7 ROUTINE HOSPITAIL DIETS

The most common diets that are prescribed or ordered in hospital situations are
enumerated in this section and in Figure 2.1 Lel us review them one by one.

I Hospital Diets I

x
Clear Liquid
Liquid Diet

Full Fluid
1 Normalor f 1 Soft Diets I

Figure 2.1: Routine hospital diets

Clinical Therapeutic 2.7.1 Normal or General Diet
Nutrition
This diet is planned to be consistent with the Recommended Dietary Allowances
(RDAs) of nutrients and is based on the food groups. It is usually based on cyclic
menus planned according to the region, type of hospital and clientele. Nutritional
adequacy depends on the patient's selection of food, as well as, the patient's intake of
food. It is the responsibility of the clinical dietitian to monitor food selection and food
intake to ensure adequate nutritional intake. The general diet is intended for the
hospitalized patient whose medical condition does not warrant a therapeutic modification.
A sample diet plan for your reference is given here in Table 2.1.
Table 2.1: A Day's Normal Diet for an Adult
Foods Quantity Carbohydrates Proteins Fats
(9) (s) (g) (g)
Cereals and cereal products 275 187 30.8 4
Milk and milk products (3% fat) 500 22 16.0 16
Pulscs and grams 50 30 12.0
Green vegetables 125 ' 6 4.0 1
Root vegetables 125 9 3.0
Other vegetables 50 12 1.0 -
Fluits 125 12 1.0
- -

Cooking oil 15 15
*Sugar 20 20 -

Re) Sl~ur-nzaReklm, Diet Manngenzaz4 2'ldd.1999, Clzurchill Livingstorze.

Approximate food value: Calories = 1800 Kcal; Carbohydrates= 298 g, Proteins=

68 g, Fats= 36 g.
For Non vegetarians1 egg = l/z cup of milk; rnuttonlchicke~i75 g = 1 bowl of pulse
+ a bowl of curd
This diet is used for a11 patients who do not require specific diet therapy.
2.7.2 Liquid Diets
A liquid diet is the one which consists of foods that can be served in liquid or strained
form at room temperature. These are usually prescribed after certain kinds of surgery.
The two lnajor types of liquid diets include - Clear liquids and Full liquids.
Clem.Liquid Diet: It is composed of foods with low residue content which help to
minimize the load of food needing digestion in the intestines. The clear liquid diet
provides foods and fluids that are clear and liquid at room temperature. The type of
liquid provided may vary depending upon the clinical condition of the patient,' the
diagnostic test or procedure, or specific surgery a patient is undergoing. The purpose
of the clear liquid diet is to provide fluids and electrolytes to prevent dehydration. The
diet is inadequate in calories and in essential nutrients. The clear liquid diet should not
be the sole source of nourishment for more than 1 to 3 days without protein, calorie,
vitamin and mineral supplementation. The clear liquid diet leaves minimal residue in
the gastrointestinal tract. It also minimizes stinlulation of the gastroiiitestinal tract.
The diet is used as an initial feeding progression between intravenous feeding and a
full liquid or solid diet that follows surgery. I could be used as a dietary preparation for
bowel examination or for surgery. It is also useful at times of acute disturbance
of gaslrointestinal function. It has application in many illnesses characterized by a
high fever.
Recommended food items include: Adaptation of
Therapeutic Diets
- clear, fat free soups/broths
- light coffee, tea (without milk or cream)
- strained fruit juices
- tender coconut water, whey water, barley water
- gelatin, fruit ice, popsicle.
- sugar and salt added to liquids
- carbonated beverages as tolerated
- commorcial high protein high calorie supplements (to be dissolved in a beverage
or water), and
- honey.
- ice
- do not use any other food
Small amounts of fluids are offered at frequent intervals (50-100 mL every hour or
two). The nutrient composition of the clear liquid diet will vary depending upon the
types and amount of liquids provided and consumed by thc patient. Do no1 use any
solid food.
Full Liquid Diet:This diet provides foods and fluids that are liquid or semiliquid at
room temperature. The type of food provided may vary depending upon the clinical
condition of the patient. It is used as a step between a clear liquid diet and a regular
diet.
The purpose of the diet is Lo provide an oral source of tluids for individuals who are
incapable of chewing, swallowing or digesting solid food. It is used as an intermediate
progression to solid foods following surgery, in coi~junctionwith parenteral nutrition or
in the presence of chewing or swallowing disorders or certain procedures such as
jaw wiring. It is also used in the presence of oesophageal or gastrointestinal strictures,
during moderate gastrointestinal inflammatioils and for acutely ill patients. Do not use
any solid food.
Recommended food items include:
- soups and broths
- cereal porridges (refined cereals)
- milk and milk beverages, yoghurt
- coffee, tea, fruit juices, carbonated beverages
- butter, cream and oil added to foods
- plain puddings, custard, ice-cream, jelly, and
- sugar, honey, salt and mild flavourings,
The nutrient composition of the diet will depend upon the type(s) and amount(s) of
liquids the patient can consume. The diet is low in iron, vitamin BIZ,vitamin A
and thiamine. By careful planning the diet can be made adequate for
maintenance requirements, except for fibre. Liquid nutritional supplements or
blenderized' foods could be added to improve nutritional adequacy. The feeds are
usually given at 2-4 hour intervals. Because this diet generally is inadequate in fibre,
constipation may result from prolonged use. If it has to be used for long periods,
vitamins, iron or liquid nutritional supplements must be added.
Clinical Thel.opeutic 2.7.3 Soft Diets
Nutrition
The soft diet provides soft whole food that is lightly seasoned and moderately low in
fibre. The foods have a soft texture and are easy lo digest. Small volume meals are
offered until the patient's tolerance to solid food is established.
The soft diet provides a transition between a liquid and a normal diet. It may be
ordered for post operative cases, for patients with acute infections, gastrointestinal
conditions or chewing problems. The soft diet should be individualized according to
the clinical diagnosis, surgery, the patient's appetite, food tolerances,previous nutritional
stat~~s,and chewing and swallowing ability.
I
The soft diet can be nutritionally adequate provided the patient is able to consume i
adequate amounts of food. Supplements or between meal feedings could be used to
increase nutrient intake. I

Foods allowed in soj2 diet include: I

Soups - mildly flavoured - broths and cream soups.

Beverages - all I

Meat - moist, tender meat, fish or chicken, cottage cheese, eggs (except
fried)
Fat - butter, cream, oil, salad dressing.
Milk - milk, milk beverages, yoghurt
Cereals - soft cooked refined cereals - rice, pasta, bread, porridges.
Vegetables - soft, cooked vegetables.
Fruits - cooked and soft fruits, fruit juices
Desserts - custard, ice-cream, jelly, cake (sponge), puddings without nuts
Sweets - sugar, honey, plain candies
Foods to avoid ilzclude:
fried foods and nuts,
e rich pastries and desserts,
raw vegetables,
heavily spiced foods,
9 gas-forming vegetables,
e skin and seeds of vegetables and fruits.
Avoid rich gravies, sauces, pickles, fried foods, rich cakes and nuts.
The lneclzanicnl soft diet is a normal diet that is modified only in tcxture for ease of
mastication. This is used when a patient cannot chew or use thc facial muscles, for a
variety of dental, medical or surgical conditions. The hods in the diet nlay be liquid,
chopped, pureed or regular foods with a very soft consistency. Huving reviewed the
various hospital diets, we shall finally look at the different modes of fceding used for
therapeutic purpose.

MODE QF FEEDING
As a clinical dietitian you may also have to decide the mcthorl of fecding to be adopted.
The method used will depend upon the patient's condilio~l.The diet 01 an individual
could be managed by u s i ~ ~oral,
g tube, periphcri~lvein or loti11 parentera1 feeding.
Sometimes, the patient may require assisliulce in feeding. Thc dietitian should
understand the limitations oP the patients and enlist the help of the nursc or patient's
relative. The challenge is to be innovative and responsive. It is the clinical dietitian's Adaptation of
Therapeutic Dlets
responsibility to provide a combination of emotional support and technical nutrition
advice on how to best achieve each patient's goals. Individuals who are hospitalized
are sick and often have to be motivated or encouraged to eat. The food should be
hygienically and attractively served. The food should be at the proper temperature
and served in portions appropriate for the patient. The server sliould be pleasant. A
correctly planned diet is successful only if it is eaten. There should also be effective
cornmunicatioil between the physician, dietitian and nurse.
The differeni feeding methods include:

2.8.1 Oral Feeding

This is the preferred and most palatable method of feeding for meeting the increased
nutritional demaiids of catabolism, it should be used as long as possible. If needed,
nutrient supplements could be added to the oral diets.

2.$.2 Tube or Enteral Feeding

Ideally the patient must be fed orally, but in cases where the patient is unable to take
solid foods, a part or all of intake is usually given by the tube. These are the cases
where the gastrointestinal tract is functioning arid can be used. Hcre, an altel.nate
form of enteral feeding by tube provides nutritional support. Enteral nutrition can be
provided by supplying intact, semi or completely hydrolyzed forniulas through
nasogastrici duodenal/ jejunal routes or by the help of gastrostomies/ jejunos tomies.
These conditions include oral surgery, gastroeintestinal surgery, dysphagia,
U ~ C O I I S C ~ ~ U Sa~iorexia
~ ~ S S , or oesophageal obstruction. Various commercial formulas
are available for enteral tube feeding. Special formulas can also be calculated and
blends prepared but these have a greater risk of contamination. We will learn in detail
about enteral feeding later in Unit 4.

2.8.3 Peripheral Vein Feeding

Intravenous feeding is a method of providing parenteral nutrition when a patient
'
cannot take in food or formula through the gastrointestinal tract. Various solutions of
dextrose, aminoacids, vitamins, minerals and lipids can be fed through peripheral veins.
But in this method the nutrient and kilocalorie intake is limited. It is used only when
the nutritional need is not exlensive or long term, where it is provided peripherally as
a mixture of 5-10%glucose, a 3.5-5% amino acid solution and 10-20%lipid emulsion.
The total fat intake should not exceed 2.5 g,kg/day. Vitamins, minerals and electrolytes
are added as necessary, based on requirements and intake. The osmolarity of the
solution should not be greater than 600 mOsin/L, What do you understand by this?
Well, it simply means that large amounts of solution are needed to meet nutritional
requirements. It is also used as a supplement to oral feeding in patients who cannot
meet nutritional requirements completely by the oral or enteral route.

2.8.4 Total Parenteral Nutnition OPN)

11 is a rnelhod of providing, complete nutritional support in which the gastrointestinal
(GI) tract is bypassed by introducing assimilable nutrients into a central vein. This is
done in cases where a patient's nutritional need is great and assisted feeding is required
for a longer time. You might wonder why specifically a central vein (mostly superior
vena cava) is used. Well, this is because it is the central vein which can tolerate a
hyperosmolar solution and hence nutritional support can be provided in a form that
will meet all nutritional needs. Total Parenteral Nutrition (TPN) is a special surgical
procedure in which special nutrient solutions are administered by a nutrition support
team which includes the physician, dietitian, pharmacist and nurse. The patient needs
special care and support. We shall learn more about parenteral and enteral nutrition
later in Unit 4 of this course. Let us now attempt the check your progress exercise
mentioned below.
Clinical Therapeutic
Nutrition Check Your Progress Exercise 3
1. State whether the following statements are True or False:
a) Ah11 liquid diet will not meet the normal nutritional requirements of an
adult.
b) TPN is the preferred mode of feeding for a sick individual whose GI
tract is functioning.
c) The normal diet of an individual is the basis for planning his therapeutic
diet.
d) Cream of tomato soup is a good item to include in a clear fluid diet.
e) In times of physiologic stress the energy requirement of an individual is
increased.
2. How is a clear liquid diet different from a full liquid diet?
.......................................................................................................................

1 ......................................................................................................................
...............................................................................................
3. What is a mechanical soft diet? List any five foods to be avoided in a soft
diet.
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
4. What are the various modes of feeding a patient? Which one of these is
most preferred?
.......................................................................................................................
........................................................................................................................
............................................................................................................
.........I

LET US SUM UP
Therapeutic nutrition refers to the role of food and nutrition in the treatment of various
diseases and disorders. In this unit, we learnt what are therapeuic diets, and the different
types of dietary modification done in a normal diet to meet the therapeutic needs of a
patient. We also learned that all therapeutic diets are modifications of the normal diet.
Then we discussed the purposes for dietary modifications and the various types of
therapeutic adaptations possible. These included liquid diets, soft diets and various
modes of feeding such as oral feeding, tube feeding, peripheral vein feeding and total
parenteral nutrition. Nutritional support is an integral part of medical therapy. As a
clinical dietitian accurate perception and se~isitivityis essential to translate nutrition
knowledge into a language appropriate for the individual client's need. Adequate
knowledge, skills and proper attitudes are required to achieve or maintain optimal
nutrition status.

Acute Renal failure : renal failure associated with burns or other trauma or with
acute infection or obstruction of the urinary tract.
Angio-edema : swelling of the mucous membranes, tissues beneath the
skin or an internal organ due to an allergic reaction.
Crohn's disease : a chronic, recurrent disease characterized b y patchy Adnptntion of
Tl~ernpeutlcDiet8
inflammation of any portion of digestive tract from the mouth
to anus.
Portal Systemic : a syndrome associated with advanced liver disease.
Encephalopathy
Fistulas : an abnormal opening between an internal cavity and another
cavity or the surface.
Haemodialysis : removal of chemical waste from the blood using blood flow
through an artificial kidney.
Urticaria : a skin condition characterized by the development of itchy,
raised white lumps surrounded b y an area of r e d @
inflammation.
Osmolarity : The osmotic concentration of a solution expressed as
osmoles of solute per unit of solution.

2.11 ANSWERS TO CHECK YOUR PROGmSS

EXERCISES
Check Your Progress Exercise 1
1. Therapeutic diet is the adaptations of the nornlal or regular diet. (quantitylquality
to meet the altered nutritional requirements of a patient). The diet may be modified
for one or more of the following reasons as eilumerated in section 2.2. Read the
section and write the answer.
2. Several forms of dietary adaptations can be made to meet the changing therapeutic
needs of a patient. The modifications can be both quantitative and/or qualitative.
#
Quantitative adaptations such as: sodium restricted diet (hypertension), highenergy
high protcin diet (nephrotic-syndrome, weight gain, PEM), protein restricted weight
reduction diet (Gout).
Qualitative adaptatioils such as: changes in consistency i.e. soft, semi-soft, full
fluid, clear fluid, oral/ tube feeds and modifications in meal frequency to suit the
altered structurelfunctional capacity of an orgadgland.
3. Health promotive1 effective therapeutic diets are generally prepared by keeping
the recommetlded dietary intake as the base. Tlie amount of nutrients recommended
for a healthy human being can be used as standards1 benchmarks, above or below
which the dietary intake of a patient can be computed. Adhering to the principles
of normal nutrition can help in preventing the development 01toxicity or deficiency
during the treatment of excess/deliciency of a nutritional1 metabolic'disorder.
Check Your Progress 'Exercise 2
I. BEE = ~G+(~~.~xW)+(~XH)-(G.~XA)
= 66 t (13.7 X 70) + (5 X 170) - (6.8 X GO)

= 1467 Kilo calories.

2. Any five of the following: Na-restricted diet, K-restricted diet, high fibre diet,
gluten-free diet, elimination diet, exclusion diet, wheat free, milk free, egg
free, additive free, ketogenic, diabetic. A n exclusion diet refers to the dietary
maaagement requiring restrictions/ornissions in the intake of certain nutrients
food's.
3. The different dietary adaptations that are made to meet the therapeutic needs
include changes in energy requirement, carbohydrates, protein, fat, mineral, fluid,
fibre intake etc. Look up section 2.5 for greater details. 51
Clinical Therapeutic 4. Quantitative methods are often essential for constructing therapeutic diets. This could be
Nutrition
done by using an exchange system which delivers a fixed amount of nutrient per food
portion and quantifying the portion size of foods and the frequency of their consumption.
Checlr Your Progress Exercise 3
1. a) True
b) False
c) True
d) False
e) . True
2. The purpose of the clear liquid diet is to provide fluids and electrolytes to prevent
dehydration. The diet is inadequate in calories and in essential nutrients.
The purpose of the full liquid diet is to provide an oral source of fluids for individuals who
are incapable of chewing, swallowing or digesting solid food. Full fluids can provide good
amount of energy, macro and micro-nutrients. Unlike clear fluids; full fluids contain good
amount of residue and fibre.
3. The mechanical soft or a mechanically bland diet is a normal diet that is modified only in
texture for ease of mastication. This is used when a patient cannot chew or use the facial
muscles, for a variety of dental, medical or surgical conditions.
The foods to be avoided include fried foods and nuts, rich pastries and desserts, raw
vegetables, heavily spiced foods, gas-forming vegetables, and skin and seeds of vegetables
and fruits, bran and husk of whole cereals/pulses.
4. Oral tube, peripheral veil] and TPN are the modes of feeding a patient. Oral feeding is
most preferred.