fnd603 THERAPEUTIC MODIFICATION OF THE NORMAL DIET (1).pptx

THERAPEUTIC MODIFICATION OF THE NORMAL DIET

2 CONTENTS THERAPEUTIC DIET
DIET THERAPY
OBJECTIVES OF DIET THERAPY
CLASSIFICATION OF MODIFIED DIETS:
NORMAL DIET
LIQUID DIET
SOFT DIET
BLAND DIET
MODIFICATIO
N IN
NUTRITIVE
VALUE
MODIFICATION IN QUANTITY
MODIFICATION IN METHOD OF FEEDING

Dietetics is concerned with planning of diets in maintaining health and in prevention
and treatment of disease.
Diet therapy: strategy that consist of use of diet (food and drink) not only in the care of
the sick, but also in the prevention of disease and maintenance of health.
It is concerned with the use of food as an agent in effecting recovery from illness.
Principles of therapeutic diet
A well planned diet providing all the specific nutrients to the body helps to achieve
nutritional homeostasis in a normal, healthy individual.
However, in disease conditions, the body tissues either do not receive proper nutrients
in sufficient amounts or cannot utilize the available nutrients owing to faulty digestion,
absorption or transportation of food elements, thus affecting the nutritional homeostasis
of the sick person.
The diet, therefore needs to be suitably modified. However, it is imperative that the
basis for planning such modified diets should be the normal diet.
Therefore diet therapy is concerned with the modification of normal diet to meet the
requirements of the sick individual.

3 THERAPEUTIC DIETS
Therapeutic diets are diet planned to maintain or restore good nutrition in the
patient. Therapeutic diet is a normal diet, qualitatively & quantitatively modified
as per the patient's special need & in line with the general principles of meal
planning.
4DIET THERAPY
Diet therapy means the use of diet ( food and drink) not only in the care of the
sick, but also in the prevention of disease & the maintenance of the health.
5 OBJECTIVES OF DIET THERAPY
To maintain a good nutritional status.To correct nutrition deficienciesTo afford
rest to the whole body or to specific organs affected by the disease.To adjust
the food intake to the body‘s ability to metabolize the nutrients during the
disease.To bring about the changes in the body weight whenever necessary.

Following principles are important while planning therapeutic diets
1. Type of disease: It is essential to determine the diet in accordance to disease, otherwise it
may have adverse effects e.g., low carbohydrate diet in diabetes, fibrous food in case of
constipation.
2. Duration of disease: The diet should be planned after determining the duration of the
disease whether it is long or short duration. In long duration diseases, the planning should
not be always be same to avoid monotony in the diet. Making changes from time to time
is very important
3. Selection of food products suitable to the disease: The amount and type of food should
be changed after analyzing the modification required in food products which aims at
curing the disease.
4. Case history of food of the patient: The food habits, liking and disliking, meal timings,
economic conditions, availability a food, knowledge of cooking methods, etc., should be
obtained and diet should be planned accordingly.
5. Psychology of the patient: Diet plans should take care of the psychological factors of the
patient. His whole personality should be considered as one unit, i.e., emotional, economic
status, social status, etc, should be kept in mind. The diet of a patient should be planned in
such a way that the patient should not feel different from the others.
6. Variety and attraction in meals: The patient is normally disturbed by his disease and if he
is given the same diet every day, he will lose interest in food. Therefore, it is important to
add variety to the diet of the patient. Food should be attractive, properly cooked, and
served in congenial environment. A well planned meal is fruitful only if the patients eat it
completely. Taste of the food is also very important.

The advantages of using normal diet as the basis
for therapeutic diets are:
 It emphasises the similarity of psychological and social needs of
those who are well, even though there is quantitative and
qualitative differences in requirements, thus ensuring better
acceptability.
 Food preparation is simplified when the modified diet is based
upon the family pattern and the number of items requiring
special preparation is reduced to a minimum.
 The calculated values for the basic plan are useful in finding out
the effects of addition or omission of certain foods. e.g; if
vegetables are restricted, vitamin A or Vitamin C deficiency can
occur.

Factors to consider in planning therapeutic diets
1. The underlying diseased condition which requires a change in
the diet.
2. The possible duration of the disease.
3. The factors in the diet which must be altered to overcome
these conditions.
4. The patients tolerance for food by mouth. In planning meals for
a patient his economic status, his food preferences, his
occupation and time of meals should also be considered.
The four attributes of a therapeutic diet are:
• Adequacy • Accuracy • Economy • Palatability

The classification of therapeutic diets in different diseases are
briefly discussed below:
I. Belief-based diets: Some people's dietary choices are influenced
by their religious, spiritual or philosophical beliefs.
Buddhist diet: While Buddhism does not have specific dietary rules,
some buddhists practise vegetarianism based on a strict
interpretation of the first of the Five Precepts.
Hindu and Jain diets: Followers of Hinduism and Jainism often follow
lactovegetarian diets, based on the principle of Ahimsa (non-
harming).
Islamic dietary laws: Muslims follow a diet consisting solely of food
that is halal – permissible under Islamic law.
Kosher diet: Food permissible under Kashrut, the set of Jewish
dietary laws, is said to be Kosher and the diet followed by Jews is
Kosher diet.

II. Vegetarian diets: A vegetarian diet is one which excludes meat.
Vegetarians also avoid food containing by-products of animal slaughter,
such as animal derived rennet and gelatin.
a. Fruitarian diet: A diet which predominantly consists of raw fruit.
b. Lacto vegetarianism: A vegetarian diet that includes certain types of
dairy, but excludes eggs and foods which contain animal rennet.
c. Lacto-ovo vegetarianism: A vegetarian diet that includes eggs and
dairy.
d. Vegan diet: In addition to the requirements of a vegetarian diet,
vegans do not eat food produced by animals, such as eggs, dairy
products, or honey.
A vegetarian does not eat any animal flesh such as meat, poultry, or fish.
A vegan is a stricter vegetarian who also avoids consuming dairy, eggs,
and any other ingredients derived from animals.

III. Semi-vegetarian diets
a. Flexitarian diet: A predominantly vegetarian diet, in which meat is
occasionally consumed.
b. Kangatarian: A diet originating from Australia. In addition to foods
permissible in a vegetarian diet, kangaroo meat is also consumed.
c. Pescetarian diet: A diet which includes fish but not meat.
d. Plant-based diet: A broad term to describe diets in which animal products
do not form a large proportion of the diet. Under some definitions a plant-
based diet is fully vegetarian; under others it is possible to follow a plant-
based diet whilst occasionally consuming meat

IV. Weight control diets A desire to lose weight is a common motivation to change dietary habits, as is a
desire to maintain an existing weight. Many weight loss diets are considered by some to entail varying
degrees of health risk, and some are not widely considered to be effective. This is especially true of
"crash" or "fad" diets. The weight control diets can be further classified into low carbohydrate diets and
crash diets.
A. Low-carbohydrate diets
  Atkins diet: A low-carbohydrate diet, populised by nutritionist Robert Atkins in the late-20th and
early 21st centuries. Proponents argue that this approach is a more successful way of losing weight
than low-calorie diets; critics argue that a lowcarbohydrate approach poses increased health risks.
  Dukan Diet: A multi-step diet based on high protein and limited carbohydrate consumption. It
starts with two steps intended to facilitate short term weight loss, followed by two steps intended
to consolidate these losses and return to a more balanced long-term diet.
  ITG Diet: A 3-step diet based on limiting carbohydrate consumption combined with low fat
protein to maintain muscle, with the objective of returning to a healthy balanced diet for long term
weight maintenance
B. Crash diets Crash diet and fad diet are general terms. They describe diet plans which involve making
extreme, rapid changes to food consumption, but are also used as disparaging terms for common
eating habits which are considered unhealthy.
Both types of diet are often considered to pose health risks.
A fad diet is a diet that is popular, generally only for a short time, similar to fads in fashion, without
being a standard scientific dietary recommendation, and often making unreasonable claims for fast
weight loss or health improvements; as such it is often considered a type of pseudoscientific diet. A fad
diet is a plan that promotes results such as fast weight loss without robust scientific evidence to
support its claims.

VII. Other diets Alkaline diet: The avoidance of

relatively acidic foods – foods with low pH levels – such
as grains, dairy, meat, sugar, alcohol, caffeine and fungi.
Eat-clean diet/Organic diet: Focuses’ on eating foods

without preservatives, and on mixing lean proteins with
complex carbohydrates. High-protein diet: A diet in

which high quantities of protein are consumed with the
intention of building muscle. High residue diet: A diet

in which high quantities of dietary fiber are consumed.
High-fiber foods include certain fruits, vegetables, nuts
and grains. Low carbon diet: Consuming food which

has been produced, prepared and transported with a
minimum of associated greenhouse gas emissions. An
example of this was explored in the book 100-Mile
Diet, in which the authors only consumed

V. Detox diets Detox diets involve either not consuming or attempting to flush out substances
that are considered unhelpful or harmful. Examples include restricting food consumption to
foods without colorings or preservatives, taking supplements, or drinking large amounts of
water. The latter practice in particular has drawn criticism, as drinking significantly more water
than recommended levels can cause hyponatremia.
Juice fasting: A form of detox diet, in which nutrition is obtained solely from fruit and vegetable
juices.
Juice fasting, also known as juice cleansing, is a fad diet in which a person consumes only fruit
and vegetable juices while abstaining from solid food consumption. It is used for detoxification,
an alternative medicine treatment, and is often part of detox diets

6 In case, the patient cannot consume food orally, then administration of nutrients through parental
route or through nasogastric tube is essential to avoid starvation and loss of proteins and other
nutrients from the tissues. The types of changes required in the diets in different diseases are briefly
discussed below:
7 CLASSIFICATION OF MODIFIED DIETS
CONSISTENCY: 1. Clear liquid2. Full liquid3. Soft4. Mechanical soft diet5.Light diet6. Pureed
diet7.Bland diet
NUTRIENT CONTENT:1. High fiber2. Low protein3. Na restricted4. Low fat5. Low fiber
QUANTITY:1. Obesity2. Vomiting3. Diarrhea 4.
Diabetes
SPECIAL METHD OF FEEDING: 1. Enteral( tube feeding)2. Parenteral(intravenous fluid)
7 MODIFICATIONS IN CONSISTENCY
NORMAL DIET- A normal diet is defined as one which consist of any and all food eaten by the
person in health.It is planned keeping the basic food groups in mind so that optimum amounts of all
nutrients provided.Since the patient is hospitalized or at
bed rest, a reduction of 10% in energy intake should be made.
8FLUID DIETS Fluid diets are used in febrile states, post-operatively or whenever the patient is
unable to tolerate solid foods.Fluid diet are of two types depending upon nutritional adequacy-Clear
fluid dietFull fluid diet

9 CLEAR FLUID DIET- CONSIST OF ONLY CLEAR FLUIDS. FOODS INCLUDED:-
The diet is free from any solids, even those found in milk.The clear fluid diet is
inadequate in all nutrients & use only for 1-2 days.PURPOSE- to prevent
dehydration and relieve thirst.USED FOR- short periods such as in acute vomiting
or diarrhea.High in simple sugars & need to be modified for diabetic
patients.AMOUNT OF FLUID GIVEN- initially 40-80ml/hour, which is than gradually
increased to ml/day.FOODS INCLUDED:-Fruit juices- apple, orange grapeCereal
water- barley, arrowroot water, sago kanji, rice kanjiSoups- clear soups, fat
freeBeverages- tea, coffee with lime & sugar (no milk), lime juice, coconut water,
sugarcane juiceFlavored gelatin and fruit ices
10FULL FLUID DIETPRESCRIBED TO- individuals who are unable to chew, swallow
or tolerate solid foods.GIVEN- after clear fluid & before starting solid
diet.Composed of foods that are liquid at room temperature.It is free from
cellulose & irritating condiments or spices.It is well planned to meet most of the
RDA‘s .PRESCRIBED DURING- acute infections, gastritis, after surgery, & for
people too ill to eat solid food..Diet provide-

approx kal, 55-65g protein and adequate minerals and vitaminsFOODS
INCLUDED- Cream soups, daal soup, whipped potatoes.Milk shakes, plain ice
cream, custard.Oat meal, arrowroot, & sago kanji with milk.Soyamilk, complain,
lassi
11 SOFT DIET FOODS INCLUDED- Soft diet is nutritionally adequate diet.
Refined cerealsWashed pulses- form of soups & in combination of cereals &
vegetables.Milk & milk products.Eggs & lean meats.Soft fruits like papaya,
banana, mango etc.Fats like butter, cream vegetable oils.Salt & sugar in
moderation.FOODS RESTRICTED-Spicy, highly seasoned & fried foods are
avoided.Raw vegetables & fruits.Whole grain cereals &their products.Dried
fruits & nuts.Soft diet is nutritionally adequate diet.It is soft in consistency &
easy to chew.Made up of simple, easily digested foodsIt is moderately low in
cellulose.Prescribed in- conditions where
mechanical ease in eating or digestion both are desired.Given during- acute
infections , GI disorders , & after surgery.SOFT DIET SUPPLIES kcal, 55-65g
protein.

12MECHANICAL SOFT DIET Also called as dental diet.It includes foods which
are easy to chew & swallow.No restriction on seasoning or method of
preparation.Food may be modified by-mechanical processing Such as
mashing, blendrizing, or chopping.LIGHT DIET OR GENERAL HOSPITAL DIET-
Similar to the soft diet.Also includes –simple salads,fruit salads, &paneer.
13 BLAND DIET PRESCRIBED FOR-
FOODS INCLUDED-Milk & milk products.Refined cereals & rice.Cream,
butterCooked fruits & vegetables without peel & seed.All egg preparations
except omelet's & fried eggs.FOODS AVOIDED-Strong tea, coffee, alcoholic
beverages, condiments & spices.High fiber foods & hot soups & beverages.Fried
foods.PRESCRIBED FOR- individuals suffering from gastric or duodenal ulcers,
gastritis, & ulcerative colitis.INCLUDES-foods which are mechanically, chemically
& thermally non irritating , foods low in fiber are recommended.

14 MODIFICATIONS IN NUTRIENT CONTENT
The nutrient content of the diet is modified to treat deficiencies, change body
weight, or control diseases such as hypertension & diabetes.Fiber, sodium and
fat content are modified in some conditions.MODOFICATION IN FIBER- bulk &
fiber has been used for all indigestible polysaccharides which remains after
digestion of food.Fiber can be modified in two ways-HIGH FIBER DIET-USED TO-
prevent & treat constipation.Also prescribed in obesity to increase the volume of
food..LOW FIBER DIET-PRESCRIBED DURING - acute infections of the GI tract.such
as ulcerative colitis, severe diarhea.
15 DISEASES WITH NUTRIENT MODIFICATION
NUTIENT MODIFICATIONAtherosclerosisF at controlled, low cholesterol
dietHepatitisRestricted fat dietsAnemia, High fever, InjuryHigh protein
dietHypertension, Cardiovascular diseaseSodium restricted dietLactose
intoleranceLactose free dietHepatic comaLow protein dietUnderweight,
MalnutritionHigh calorie diet

16 MODIFICATONS IN QUANTITY
The quantity of food served to the patient needs to be modified:-to check
tolerance,control nutrient levels, &bring about weight loss.Example- in a diabetic
diet, the quantity of CHO in each meal is as important as the the quantity of CHO
consumed in a day
17 MODIFICATIONS IN METHOD OF FEEDING
Enteral feeding- EN is provision of liquid formula diet delivered via a feeding tube
is the method for patients with a functional GI tract who requires NS.Enteral
feeding is required when oral feeding is not possible.Parenteral feeding-
parenteral fluids contain water, glucose, amino acids, fatty acids, minerals, &
vitamins to meet the individual need for all nutrients.These fluids are given
through the peripheral & central veins.
18 DIETS FOR COMMON DISORDERS

19 Diet for Diabetes mellitus patients
Foods recommendedFoods to be avoidedComplex carbohydrates rich in dietary
fiber- millets , wheat, pasta, bread.1. Simple sugar and refined carbohydrates
sugars, jaggery, sweets.2.Higher proportion of PUFA vegetable oils.2. Saturated
fats and cholesterol in moderation hydrogenated fats ,ghee, butter, cream.3.
Good quality proteins- Lean meat, fish, eggs, pulses, milk.3. Alcohol, soft drinks,
sweet meats , nuts and oil seeds.4.Salads, leafy vegetables ,other vegetables.
20 DIET IN FEVER & INFECTIONS
21 High Calorie , High Protein diet
FOOD RECOMMENDEDFOOD TO BE AVOIDEDAll foods should be liquid to semi
solid consistency. Smooth texture with no harsh irritating fibers , strong flavors
or spicy foods.Solid foods which are hard or tough , requiring lot of
mastication .1 Cereals- Refined cereals in the form of kanji ,custard , kheer ,
phulka, boiled rice .1 Cereals- Millets , cereal or irritating dietary fibers such as
whole grain cereals and cereal

products .2 Good quality , easy to digest proteins , chicken soups, milk based
beverages , strew , Egg nob , sweet freshly set custards, complain ,soft cooked
khichdi, custard ,boiled vegetables such as pumpkin ,bottle gourd, potato.
Strewed fruits, soft fruits , fruit juices, sugar.2 Fried , spicy pulse and meat – fish
– poultry preparations
.Leafy vegetables , raw fruits , and vegetables with harsh fibersPickles, papad .
22 Risk Factors for Heart Disease
Personal factorsDiet patternOther diseasesHeredity or strong family
history.AlcoholicHypertensionMalesFemales after menopauseConsumes rich
foodsAtherosclerosisSmokingHigh in fats and cholesterolDiabetesObesityLow in
fiberAge group yrsRefined CHO and sugarsHigh blood lipid levelsWork load-
Tension and stressHigh salt intakeSedentary life style
23 Modified Fat Diet in hypertension
Food recommendedFood to be avoidedFoods low in cholesterol and
saturated fatsCholesterol rich foods1. Skimmed milk , paneer (skimmed
milk)1. Whole milk ,

butter, cream, mava, cheese(processed).2. Cereals (Whole grains, pulses)2. Indian
sweetmeats , rich puddings, bakery products.3 .High fiber and soluble fiber such
as Oat meal, millets, pectin, gums.3. Organ meats(liver ,brain ,etc)4. Salad
vegetable ,fruits, green leafy vegetables ,other vegetables.4. Egg yolk, fish ,
shellfish, fatty meat , processed meats.5. Lean meat , egg white , fish5. Nuts,
oilseed, pickles.6.Vegetable oils, sugar, jaggery.6. Margarine, vanaspati, fried
foods.7. Alcohol.
24 Sodium Restricted Diet
Foods recommendedFoods to be avoidedFoods low in sodiumFood rich in
cholesterol and fat, food rich in sodium1. cereals- wheat, rice, oatmeal, millets1.
Baking power- cake ,cookies2.All fruits- fresh and canned2. Soda bicarbonate-
nankhatai3. Cabbage, cauliflower, tomato , potato onion .3. Monosodium
glutamate- Chinese foods and food served in restaurant.4. sugar, honey, jam,
jelly.4.Sodium benzoate- tomato sauce5.
Low sodium seasonings instead of salt.5. Sodium propionate- bread6.
Lime juice.6.Sodium chloride- salted shanks, wafers, nuts.

25 Sodium Restricted Diet
7. Mint, parsley, dill, basil.7.Papad, pickles, vegetables in brine solution.8. Fresh
vegetables.8. Celery , beetroot and spinach.9. All other vegetables, root
vegetables.9. Foods rich in cholesterol and saturated fats- salted butter and
processed cheese.10. Vegetables oil as a cooking medium.11. Milk in
moderation.
26 DIET FOR PEPTIC ULCERS Foods recommended Foods to be avoided
1. Cereals- all refined cereals, bread, rice, pasta.1. All whole grain cereals2. Milk-
all milk beverages and all milk products, weak tea.2. All stimulating beverages-
alcohol, tea, coffee, aerated drinks.3. Egg, lean, meat, fish, poultry as protein to
heal ulcer.All fatty meats.4. Dehusked pluses, boiled and mashed4. Whole
pulses5. Stewed fruits, vitamins c for healing5. Raw fruits6. Butter, cream, ice
cream6. Spices, condiments, fried foods7. Cooking method- boiling, baking,
stewing, poaching.7. Frying, barbecuing, salted, smoking foods

27 High Fiber, Moderate- Fat Diet for constipation
Food recommendedFoods to be avoided1. Fluids- at least 1.5 liters1. Refined
cereals- rice, seived flour2. Cereals- whole grain cereals, millets, oats.2.
Dehusked pluses3.
Pluses with husk- Rajmah, ground nuts, peas.3. Castor oil4. Fruit – raw and
cooking fruit and vegetables, guavas, figs, pears, apple, citrus fruits.5.Milk, butter
milk, butter, ghee6.Soup , tea, coffee7. Green leafy vegetable, salads use fruits
and vegetables with edible skin and peel.
28 High- Protein, High Carbohydrate, Low to moderate fats diet
Foods recommendedFoods to be avoided1. Nutrition beverages1. Strongly
flavored vegetables2. Soft- cooked cereals and pluses2. Fried foods3. Fruits3.
Food with high- fat content4. Vegetables4. Nuts and oilseeds5. Milk and meat
products5. Rich desserts and pastries6. Lean meat, fish, poultry6. Spicy and
highly seasoned foods7. Egg, jam, jelly, sugar, simple desserts.

29 NUTRITION SUPPORT
30Contents What is Nutrition Support (NS)
Need for nutrition support
Conditions that require specific nutritional support
Introduction to EN
Indications for EN
Type and route of administration
Formula selection
Type of formula
Method of administration
Enteral formulation
Enteral equipments
Complications of Enteral nutrition
31 WHAT IS NUTRITION SUPPORT
The nutrition support involves deciding whether a patient requires nonvolitional feeding and if
so, selecting the most effacious method.Benefits of nutrition support (NS) includes-Improved
clinical outcomeShorter hospitalizations
32 Need for the nutrition support
The 1st step in determining the need for NS is to assess whether the patient can consume

intake is necessary to determine what percentage of nutritional requirements
can be consumed by mouth.
33 Need for the Nutrition Support (NS)
When the functioning of GI tract has been compromised by trauma or surgery, an
upper GI & a small bowel x-ray study may be required before initiating
feedings.NS appears to be the most beneficial in patients who are severely
malnourished.Guidelines from the American Society for Parenteral and Enteral
Nutrition (ASPEN) suggest that NS should be initiated in patients with inadequate
oral intake for 7 to 14 days .
34 Conditions That Require Specialized Nutrition Support
Enteral—Impaired ingestion—Inability to consume adequate nutrition orally—
Impaired digestion, absorption, metabolism—Severe wasting or depressed
growthParenteral— Gastrointestinal incompetency—critical illness with poor
enteral tolerance or accessibility

35 Introduction to Enteral Nutrition
EN is provision of liquid formula diet delivered via a feeding tube is the
method for patients with a functional GI tract who requires NS.
36Enteral NutritionNS via tube placement through the nose, esophagus, stomach,
or intestines (duodenum or jejunum).EN promotes better outcomes and less
costly compared with PN (due to reduction in septic complications)Timings is also
important because EN delivered immediately after injury may improve wound
healing and limit the degree of hyper-metabolism.
37 Indications for Enteral Nutrition
EN is indicated in patients with adequate digestive and absorptive capacity of
the GI tract but who cannot or will not eat enough.Specific indications for EN
includes:-Poor nutrient retentionInsufficient intake

Gastrointestinal DiseaseShort bowel syndromeInflammatory bowel
diseaseDiarrhea of infancyIntestinal obstructionChronic liver diseaseSevere
dysphagia or esophageal obstruction,
Preterm infantsNeurologicStatic encephalopathyDysphagiaCNS
tumorCardio- respiratoryCystic fibrosisCongenital heart disease
MalignancyPoor intake: radiation / chemotherapyHyper-metabolic
statesBurnsTrauma / head injuryOtherAnorexia nervosaChronic renal
diseasePsychiactric disorders,
41 Why does a child need enteral feeding?
Unable to take sufficient nutrition by mouthUsing more energy than
normal intake.Unable to digest food effectively

42 Sites for Enteral feeding
J Daglish,L Herd Reviewed J Lanni Nov 2007
43 Route of Enteral Administration
Nasoenteric routesNasogastricNasodododenalNasojejunalTube
enterostomy(Percutaneous or surgically placed feeding tube)PEG
(percutaneous endoscopic gestrostomy)PEJ (percutaneous endoscopic
jejunostomy)
44 NASOENTERIC FEEDING TUBES
Nasoenteric feeding tubes are generally used when therapy is expected to be
short lived.( less than 4-6 weeks).Nasoenteric feeding tubes are the most
common devices for short-term enteral access, because they are relatively
inexpensive & easy to place and safer than venous access devices.The most
common complication associated with placement of nasoenteric or nasogastric
feeding tube is tube malposition.

45 NASOENTERIC FEEDING TUBES
Tube malposition comprised 58% of total compilcations.METHOD OF PLACEMENT-
Nasoenteric feeding tubes can be placed intraoperatively, with endoscopic or
fluroscopic guidance, or blindly at bedsite.Intrapoerative placement requires the
feeding tube to be placed manually during surgery, but this is not common in
most institutions.
46 NASOGASTRIC TUBE FEEDING
Passing of food through the nose to the stomach.feeding into the stomach
rather than small bowel, is usually preferred in patients with an intact gag reflex
& normal gastric function because it is more physiologic.Transpyloric feeding
tubes should be reserved for patients at risk for aspiration or who have
gastroparesis.
47Transpyloric feedsInfants who have severe gastroesophageal reflux or
problems with gastric emptying, may need to be fed transpylorically.The
bedside nurse will attempt to place the transpyloric feeding tube in the
duodenum. A KUB should be

obtained to verify tube position.Transpyloric feeds must always be
continuous infusions.
48 NASODUODENAL TUBE FEEDING
Passing of food through the nose to the duodenum.Used For short term enteral
NS of up to 3-4 weeks in patients with gastric motility disorders, esophageal
reflux, or persistent nausea & vomitting .Nasoduodenal tube placed
postpylorically (into the small bowel) are appropriate.
49 NASOJEJUNAL TUBE FEEDING-
Passing of food through the nose to the jejunum.For short term enteral NS of up
to 3-4 weeks in patients with gastric motility disorders, esophageal reflux, or
persistent
nausea & vomitting.Nasojejunal tube placed postpylorically (into the small
bowel) are appropriate.

50 Route of Enteral Administration
TUBE ENTEROSTOMYFor long term tube feedingUsed for patient when nasal
intubation is impossibleUsed during abdominal surgery.Types:Percutaneous or
surgically placed feeding tubesPercutaneous endoscopy Gastrostomy
(PEG)Percutaneous endoscopic Jejunostomy (PEJ)Direct Percuteneous
endoscopic jejunostomy (DPEJ)Surgically placed EnterostomiesMultiple Lumen
tubes
51 Percutaneous or surgically placed feeding tubes
Long term access requires a percutaneous or surgically placed feeding
tube.Percutaneous or surgically placed feeding tubes are usually reserved for
when EN
is expected to continue longer than 4-6 weeks.
52 Percutaneous endoscopy Gastrostomy (PEG)
The PEG is a non-surgical technique for placing a tube directly into the
stomach through the abdominal wall, performed using an endoscope & with
the patient under local anesthesia.The PEG tube is placed after introducing an

stomach.A local anesthetic is administered through the abdominal wall, & a stab
wound is created.PEG tubes are more popular compared with surgically placed
tubes because they are less costly.
53 PEJ (percutaneous endoscopic jejunostomy)
PEJ tube may be used in post-operative patients with a dysfunctional GI tract or
in those who are at high risk of aspiration.With the PEJ, the tubing is advanced
through the stomach & into the proximal small intestine.Used – who have
gastroesophageal reflux & are at risk for aspiration.However, this procedure
require higher degree of skill & carries greater risk.
54 Surgically placed enterostomies
Surgical gastrostomies & jejunostomies are placed in patients requiring EN who
are undergoing a sugical procedure or in whom endoscopic & radiologic
techniques are not possible.The simplest surgical procedures for placing a
gastrostomy tube are the stamm & witzel technique.A Witzele jejunostomy &
needle catheter jejuostomy (

creating a feeding opening by a small-bore needle insertion into the jejunum at time of
surgery) are short term small bowel access methods.They are usually used for early
postoperative enteral nutrition in combination with gastric decompression.
55 Witzele jejunostomy
56 Needle catheter jejunostomy (NCJ) or DPEJ
A Direct Percuteneous endoscopic jejunostomy (DPEJ )or needle catheter jejuostomy
can also be used to assess the small bowel for EN.A DPEJ is placed endoscopivally as a
PEG, except that the endoscope is passed through the duodenum, past the ligament of
Trietz, into a loop of jejunum adjacent to the abdominal wall.An NCJ is placed intra-
operatively & involves inserting a small catheter into the lumen of jejunum proximal to
the ligament of Trietz.ADVAVTAGE OF NCJ-Has low complication rateNutrients can be
administered almost immediately.

57Multiple Lumen TubesGastrojejunal dual tubes are available for either
endoscopic or surgical placement.These tubes are designed for patients in whom
prolonged GI decompression is anticipated.The tube has one lumen for
decompression, & the other lumen is used to feed into small bowel.Used for-
early preoperative feeding.
58FORMULA SELECTIONThe wide variety of enteral feeding products are
commercially available.The choices can be narrowed down by answering a few
basic questions:-Are the patient‘ digestive & absorptive capabilities intact?Does
the patient have significant organ dysfunction?Does the patient have high
metabolic rate?Does the patient require a fluid restriction?Evaluating the patient‘s
digestive & absorptive capacity helps determine whether to use a polymeric or a
pre-digested formula
59 Types of formula POLYMERIC FORMULAS It contain intact nutrients .
PF are appropriate for most patient‗s with normal gut function.It should be the 1st
line of treatment for most patients who require tube feeding.It can be infused
into jejunum via percutaneously or surgically placed tubes with good results.

60PREDIGESTED FORMULASIt Contains hydrolyzed proteins (peptides & free
amino acids), CHO (glucose), fat (combinations of long & medium chain
TG‘s).INDICATED FOR- patients with compromised GI tracts.Because hydrolyzed
nutrients require less active digestion.It is also used as starter regimens for
patients who have not received enteral feedings for long periods.NCJ is
preferable.Predigested formula has lower viscosity than polymeric formulas.
61 Blenderized Formula Formulated from natural and whole foods
Has high viscosityRisk to contamination is more.
62Modular feedingModules of individual macronutrient- can be added to
food and enteral formulas
63 Categorization Type Indication Polymeric Normal GI function
Chemically defined MalabsorptionModular Special requirements

64 Disease specific enteral formulas
It is designed for severe liver or kidney dysfunction.Formulas for liver failure are
enriched in BCAA & contain smaller amounts of AAA.Formulas for renal failure
are low in protein but contain large percentage of EAA.Fluid restrction or high
metobolic requirements may require the use of a callorically dense formula to
provide adequate nutrients without exceeding the patient‘s fluid limits.Formulas
supplemented with fiber to improve bowel function & glucose control.Chemically
defined formulas are specialised monomeric formulas.They are low in fat ,
contain short chain CHO & peptides & amino acids.They are used for patients
with condition of maldigestion or malabsorption.
65 Method of Administration
Tube feeding can be administered via-Bolus methodIntermittent
methodContinuous method

66Bolus methodBolus feedings are administered by gravity over a short time,
usually 5 minutes or less.Rapid administration of formula on a short period of
time.It causes delayed gastric emptying, may cause reflux and vomiting.It would
be like receiving a dose, then waiting a certain number of hours and taking
another dose.
67A bolus would be if a syringe or small bag were filled with formula and
allowed to drain in without restriction.Using a bag with tubing attached would
and restricting the flow with the roller clamp can be referred to as a gravity
feed.A gravity feed can be done slowly by adjusting a roller clamp on the
tubing to create a slower flow rate so bolus could refer to fast and gravity to
slow.
68 Intermittent methodIntermittent feeding are administered over a longer
period of time
, usually minutes , using a feeding container & gravity dip.The total formula
needed in one day is divided into equal portions.The bolus & intermittent
methods are usually reserved for gastric feeding.

69Continuous feedingControlled delivery of a prescribed volume of formula at
constant rate over a continuous period of time.Continuous feedings are delivered
slowly over 12 to 24 hours.Uses infusion pumpFewer GI side effectsTranspyloric
feedings require continuous infusion.It is necessary when patient cannot tolerate
bolus & intermittent feeding.
70 Enteral formulations Water & Caloric density
Enteral formulas can be divided into 3 categories of caloric density:-1 Kcal/ml
(about 85% water)- appropriate for patients with no fluid restrictionkcal/ml
(about 78-82% water)2 kcal/ml (about71% water)- necessary for patients with
the renal failure, pulmonary edema, liver failure , other conditions in which
fluid intake is restricted.
71OsmolalityOsmolality & osmolarity are measures of the concentration of
molecules in an aqueous solution.Osmolality is defined as milliomoles per
kilogram of solvent.The major contributors to osmolality in enteral formulas are
electrolytes, minerals & small organic compounds.Enteral product osmolality
ranges from 270 mOsm/kg – about 700

mOsm/kg, depending on the concentration of water components.The higher the
caloric density, the less water in the formula & highest the osmolality.
72 Osmolarity Osmolarity is the milliomoles per litre of solution.
General purpose formula- between mOsm/l Which is close to the osmolarity of
blood & body fluid.Concentrated formulas- are ranging from mOsm/l.Chemically
defined formula- 900 mOsm/l.
73 VISCOSITY The viscosity of a formula depends on the-
concentration & characteristics of the macronutrientsfiber.Higher viscosity
products may effect the rate of delivery of feeding pumps.The relative viscosity
of isolated fibers has so far limited the caloric density of fiber-containing
formulas to 1.5 kcal/ml.
74PROTEINAmount of protein- varies from about of 6% calories in very
protein restricted formulas intended for patients with renal failure to 25% of
calories.It is important to provide adequate water for excretion of
nitrogenous waste to patients

receiving high protein formulas.Determination of protein quality is a complex
process involving –assessment of the amino acid profileprotein & amino acid
digestibilityeffects of other components.
75AMINO ACIDSEnteral formulas called elementral formulas have individual
amino acids as their sole source of protein.Elementral formulas are the most
expensive products & have the highest osmolality.Their use is usually
restricted to tube feeding because of the unpleasant odor & taste.
76PEPTIDESPeptides based enteral formulas contain protein that has been
partially hydrolyzed to mixtures of peptides of varying chain lengths.Absorption
may be improved with peptides compared with amino acids and intact
proteins.Useful in patients with inadequate digestive enzymes, short bowel
syndrome ,or other forms of mal-absorption.

77BCAAFormulas specifically designed for patients with Hepatic encephalopathy
(HE) contain increased amounts of the BCAA ( valine, leucine,
isoleucine).Decreased amount of AAA (phenylalanine, tyrosine, &
tryptophan)BCAA make up 45% to 50% of total protein compared with 20 % in
standard formulas.
78GLUTAMINEGlutamine has been found to be a primary fuel for the GI tract.An
exogenous source of glutamine may be beneficial during the stress response in
reducing skeletal muscle breakdown to provide glutamine to the liver.Enteral
glutamine may improve acid-base balance by increasing plasma bicarbonate &
renal acid secretion.AMONTS OF GLUTAMINE- In Enteral formulas have been
calculated from the glutamine content of their protein sources.Values are g/1000
kcal for standard enteral formulas.
79ARGININEArginine stimulates release of several hormones, including glucagon,
insulin, & growth hormone.In cell culture, arginine is required for maximal cell
growth & optimal lymphocyte function.Arginine is present in all enteral formulas
made from intact

proteins.Additional arginine is added to several formulas intended to enhance
immune function .It is also available as a powdered supplement.
80TAURINEβ- amino acid.Act as an antioxidant, neuromodulator & regulator of
Calcium homeostasis.Also important for immune function & inflammatory
response.Although taurine can be synthesized in liver & brain, dietary sources
provide a significant portion of the body‘s taurine.Plasma taurine levels are
elevated in renal failure or decreased in trauma, sepsis, or cancer.
81PROTEIN AND AMINO ACID CONTENT OF SPECIALIZED ENTERAL
FORMULAS
PROTEIN (% kcal)ARGININE (g/ 1000 kcal)CARNITINE (mg/ 1000 kcal)GLUTAMINE (
g/1000 kcal)TAURINE(mg/1000 kcal)STANDARD FORMULAS13-250-1503-80-211
82CARBOHYDRATEAll forms of CHO are used in enteral formulas to provide
energy.The amount of CHO in enteral formulas ranges from about 40% to 80% of
total

calories .Formulas with fiber & and a reduced CHO content have been
developed to improve blood glucose control in patients with diabetes mellitus
or stress induced hyperglycemia.
83FATFat provides energy & essential fatty acids in both oral diets & enteral
formulas.The fat content of enteral formulas varies from 5 % -55% in formulas
intended to reduce CHO intake in patients with CO2 retention, diabetes mellitus,
or glucose intolerance.Standard formulas contain 15 – 35% of total calories as
fat.Formulas with high fat content may delay gastric emptying.
84Omega-3 fatty acidsPatients with various acute or chronic diseases may have
abnormal plasma fatty acid profiles that could be corrected by omega-3 fatty
acids.Omega-3 fatty acids also have a range of effects on CVD, which could
influence their use in enteral formulas.

85FIBER Dietary fiber has always been present in blenderized formulas.
The term residue refers to the increase in fecal weight caused by undigested
food material.Enteral formulas without added fiber are considered very low
in residue, because their macronutrients are highly digestible.Fibers used in
enteral formulas
include- soy polysaccharide, gums, pectin.Fiber has not been added to formulas
with a caloric density greater that 1.5 kcal/ml.
86 Vitamins, Minerals & Electrolytes
Formulas intended for use in renal & hepatic failure are intentionally low in
specific vitamins, minerals, & electrolytes.In contrast, disease specific formulas
often are supplemented with antioxidants, vitamins & minerals with the
intention of improving immune function & accelerating wound
healing.Electrolytes are provided in relatively modest amounts compared with
the oral diet & may supplemented when diarrhea occur.

87 ENTERAL EQUIPMENT Feeding tubes Enteral feeding containers
Enteral pumps
88 Enteral Feeding Tubes Polyvinylchloride (PVC) Silicone (Silastic)
Polyurethane
89 Composition Tube Advantages Disadvantages
PVC Easy to place Risk of damageResists collapse Replace every 3 daysSilastic
Flexible comfortable Smaller diameterthan polyurethanePolyurethane
FlexibleGood
patient tolerance
90 ENTERAL PUMPSENTERAL CONTAINERS
91 Complications of Enteral Nutrition
Access ProblemsAdministration ProblemsMetabolicGastrointestinal
92 Access Problems- Pressure necrosis/ ulceration Tube displacement
Tube obstructionLeakage from ostomy siteTube
fracturesIrritationinfectionAbdominal

leakage of gastric contents from a gastrotomy site can cause skin erosion &
skin breakdown, leading to infection.
93 Administration Problems
RegurgitationAspirationMicrobial contaminationTo minimize the risk of
aspiration, patients should be positioned with their heads & shoulders above
their chests during & immediately after feeding.
94 Metobolic complications
Refeeding syndromeDrug – nutrient interactionsGlucose intolerance /
hypergycemia / hypoglycemiaHydration status- dehydration/
overhydrationHyponateremiaHyperkalemia/ hypokalemiaHyperphosphetemia/
hypophosphatemia.Micronutient deficiency.

95GI Complications Nausea / vomiting Distension / bloating / cramping
Delayed gastric emptyingConstipationHigh gastric
residualsDiarrheaOsmotic pressureHypoalbunemiaMaldigestion /
Malabsorption
96DiarrheaDiarrhea is a most common complication associated with enteral
nutrition.The most likely causes of diarrhea among enterally fed patients are-
Bacterial overgrowth, antibiotic therapy.GI motility disorders are associated with
acute & critical illness but not the enteral nutrition.Hyper-osmolar medications
such as mg containing anta-acids, sorbitol containing elixirs & electrolyte
supplements also contribute to diarrhea.Adjustment of medications or
admininstration methods can frequently correct the diarrhea.The addition of
soy polysaccharide, a prebiotic, pectin, & other fibres, bulking agents, probiotics
& anti-diarrheal medications can also be beneficial.
97 REFERENCES BOOKS- Contemporary nutrition support practice –
By Laura E matarese, Michele, M. Gottschlich.Krause‘s Food & Nutrition
Therapy12th

editionA Text book of Nutrition & DietiticsBy- Kumud KhannaFood Science
and NutritionInternet
98 ConclusionsEnteral feeding is the preferred form of nutritional supportSafe
and efficaciousWell-toleratedSafer, cheaper, simpler, and more effective than
Parenteral Feeding

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