TOPIC: DIET MODIFICATION

MODIFIED DIETS
MORDIFICATION OF DIETS
Introduction: Modified diets are diets that have been qualitatively or quantitatively
altered as per patient’s special needs and in line with general principals of meal planning.
i.e. normal diet may be modified and become a specific therapeutic diet

Factors that may determine dietary modification

a. Disease symptoms
b. Severity of the symptom or disease (Condition of the patient)
c. Nutritional status of the patient
d. Metabolic changes involved
e. Physiological state
THERAPEUTIC MODIFICATION OF NORMAL DIET
Modification can be done in the following ways

 Modification in consistency (to provide change in consistency) e.g. fluid and soft
diets
 Modification in fibre content e.g. low fibre or high fibre
 Modification in energy e.g. high (increase) or low (decrease) calorie diet

 Modification in the content of one or more nutrients

 Modification in flavor (foods bland in flavor)

 Modification by including or excluding specific foods

 Modify the intervals of feeding e.g. frequent feeding

 Modify the mode of feeding e.g. Parenteral feeding and enteral feeding

1. MODIFICATION IN CONSISTENCY
LIQUID DIETS
Liquid diets are commonly ordered for patients with conditions requiring nourishment
that is easily digested and consumed or that has minimal residue.
The two varieties of oral liquid diets are:
f. Clear liquid diet
g. Full liquid diet

pg. 1
CLEAR LIQUID DIET
Purpose
This is a diet modified to provide oral fluids to prevent dehydration, provide small
amount of electrolytes, relieve thirst and provide a small amount of energy in a form that
requires minimal digestion and stimulation of the gastrointestinal tract.

This diet is served at frequent intervals to supply the tissue with fluid and relieve thirst.

It is an inadequate diet composed chiefly of water and carbohydrates; therefore it should

be used for a very short time (It is indicated for short term use -24hrs to 48hrs).
Nutritionally depleted patients should receive additional nutritional support through use
of nutritionally complete minimal residue supplements or parenteral nutrition.

NB: Additional modifications may be necessary when used in some clinical

conditions such as cardiac disease or prior to some tests. Indication and
characteristics for clear liquid diet

Diet Indications Characteristics of the diet

 E.g. Black tea, broth,  Used in Pre- and  Composed of water and
apple juice, coffee, Post-operation, carbohydrates.
strained fruit/ vegetable  As a transition from  Clear liquid at room
juices, carbonated intravenous feeding temperature
beverages etc. to a full liquid diet,  Leaves minimal amount
 Foods to be avoided  When other liquids of residue in the
include milk and milk and solid foods are Gastrointestinal (GI)
products not tolerated, tract.
 During bowel  Provides approximately
preparation prior to 400-500kcals, 5-10g
diagnostic proteins, 100-120g CHO
visualization or and no fat.
surgery  Should be of low
 In the initial concentration
recovery phase after  Milk and milk drinks are
abdominal surgery omitted
 Following acute  Improve energy level by
vomiting or diarrhea addition of sugar
 Are nutritionally
inadequate in all nutrients

FULL LIQUID DIET

pg. 2
Purpose
The full liquid diet is an adequate diet designed to provide nourishment in liquid form
and facilitate digestion and optimal utilization of nutrients in acutely ill patients who are
unable to chew or swallow certain foods. The diet is often used as a transition between
the clear liquid diet and a soft regular diet. Patients with hypercholesterolemia full liquid
diet to be modified to have low fat by substituting high saturated fats with low fat dairy
products and polyunsaturated fats and oils. Increasing protein and caloric value of full
liquid diet becomes necessary when the diet is used for a period extending over 2-3
weeks. Table 24 below provides indications for and characteristics of full liquid diet.
Indications and characteristics of full liquid diet

Diet Indications Characteristics of the diet

 Soft desserts  For post-operative patients  Foods should be liquid at
from milk and  For acutely ill patients or room temperature
eggs, those with esophageal/GIT  Free from condiments and
 Pureed and disorders and cannot spices
strained soups, tolerate solid foods  Provides between 1500-
ice creams,  Following surgery of the 2000kcal/day
milk or yoghurt, face-neck area or dental or  Large percentage is milk
etc. jaw wiring based foods; lactose
intolerant individuals need
special consideration.
 The diet may be
inadequate in
micronutrients and fiber

Thick Liquid Diet (Blended or Semisolid Diet)

This diet is moderately low in cellulose and connective tissue to facilitate easy digestion.
Tender foods are used to prepare the diet. Most raw fruits and vegetables, coarse breads,
cereals, tough meats and nuts are eliminated. Fried and highly seasoned foods are
omitted.
Purpose of the diet
The blended liquid diet is designed to provide adequate calories, protein and fluid for the
patients who are unable to chew, swallow or digest solid foods. The diet prescription
should be individualized to meet medical condition and tolerance. Patients with wired
jaws may use a syringe, spoon, or straw to facilitate passage of liquid through openings in
the teeth, depending on the physician’s recommendation
Blended foods should be used immediately but can be refrigerated up to 48hrs or frozen
immediately after blending to prevent growth of harmful bacteria.

pg. 3
Indications and characteristics of thick liquid diet

Die Indications Characteristics of the diet

t
 After oral surgery or plastic  Fluids and food blended to a liquid form
surgery of the face or neck  Viscosity ranges from the thickness of
area with chewing or fruit juice to that of cream soup
swallowing dysfunctions  All liquids can be used to blend foods.
 For acutely ill patients and However, nutrient dense liquids with
those with oral, esophageal similar or little flavor are preferable. Use
or stomach disorders who are of broth, gravy, vegetable juices, cream
unable to tolerate solid foods soups, cheese and tomato sauces, milk
due to stricture or anatomical and fruit juices is recommended
irregularities  Multivitamin and mineral
 Those progressing from full supplementation is recommended
liquid to a general diet.
 Patients who are too weak to
tolerate a general diet.
 Those whose dentition is too
poor to handle foods in a
general diet.
 -Those for whom a light diet
has been indicated e.g. post
operative

SOFT OR LIGHT DIET

This is an adequate diet soft in consistency, easy to chew and is moderately low in
cellulose and connective tissue. This diet is designed to provide nutrients for patients
unable to physiologically tolerate a general diet in which mechanical ease in eating,
digestion or both are desired. The diet should be individualized based on the type of
illness or surgery and the patient’s appetite, chewing and swallowing ability and food
tolerance.
Indication and characteristics of soft diet

Diet Indications Characteristics of the diet

 Fruit juices or  Post operative patients  Moderately low in
cooked fruits,  Patients with mild gastro cellulose and
 Well-cooked intestinal problems connective tissues
cereals, strained if  Non-surgical patients  Tender foods
necessary; whose dentition is too  Fluids and solid foods
 Fresh spinach weak or whose dentition is may be lightly
 Amaranth inadequate to handle a seasoned
(Terere); general diet|(patients with  Food texture ranges
 Pumpkin leaves; few or no teeth) from smooth and

pg. 4
  Managu  For transition from thick creamy to moderately
 Strained peas; liquid to a general diet crispy
 Potatoes, baked,  Most raw fruits and
boiled, or mashed. vegetables, course
 Fats: butter, thin breads and cereals gas
cream. producing foods and
 Milk: plain, in tough meats are
scrambled egg, in eliminated
cream soups, in  Fried and highly
simple desserts. seasoned foods, strong
 Eggs: soft-cooked, smelling foods should
omelettes, custards. be omitted
Simple desserts;
custards, ice cream,
gelatine desserts,
 Cooked fruits or
cereal puddings
 Minced meat, soft
fish

2. MODIFICATION IN FIBER CONTENT

Fiber is the portion of carbohydrates not capable of being digested by enzymes in the
human digestive tract, thus contributing to increased fecal output. There are two types of
fiber; soluble and insoluble fiber. Diseases affecting digestive system generally require
modification in fiber content. This can be high or low fiber diet.

FIBER RESTRICTED (LOW RESIDUE) DIET

This diet is composed of foods containing low amounts of fiber which leave relatively
little residue for formation of fecal matter. Residue is the dietary elements that are not
absorbed and the total post digestive luminal contents present following digestion. The
diet excludes certain raw fruits, raw vegetables, whole grains and nuts high in fiber and
meats high in connective tissue. The diet is modified to meet the clients caloric, protein,
fat as well as vitamins and minerals requirements.

Purpose of the diet

The fiber (low residue) restricted diet is designed to prevent blockage of an inflamed
gastrointestinal tract and reduce the frequency and volume of fecal output while
prolonging intestinal transit time.

pg. 5
Indications and characteristics for fiber restricted diet

Die Indications Characteristics of the diet

t
 Gastro-intestinal disorders colitis,  Low in complex
colostomy carbohydrates
 Inflammatory bowel disease, diarrhea,  Has refined cereals and
hemorrhoids, etc grains
 Acute phase of diverticulosis  Legumes, seeds and whole
 Ulcerative colitis in initial stage nuts should be omitted
 Partial intestinal obstruction
 Pre and post-operative periods of the large
bowels
 convalescents from surgery, trauma or
other illnesses before returning to the
regular diet
 post - perennial suturing

pg. 6
 HIGH FIBER DIET
This diet contains large amounts of fiber that cannot be digested. Fiber increases the
frequency and volume of stools while decreasing transit time through the gastro-intestinal
tract. This promotes frequent bowel movement and results in softer stools. The
recommended fiber intake for women aged 50 years and below is 21-25g/day and for
men aged 50 years and below is 30-38g/day. Men over 50 years should consume at least
30g/day while women above 50 years should consume 21g/day.

Purpose
The diet is designed to prevent constipation and slow development of hemorrhoids,
reduce colonic pressure and prevent segmentation. The diet also reduces serum
cholesterol levels by decreasing absorption of lipids, reduces transit time and can be used
to control- glucose absorption for diabetic patients and overweight clients. Dietary fiber
reduces the risk of cancer of the colon and rectum.
Indications and characteristics of high fiber diet

Die Indications Characteristics of the diet

t
 Gastro-intestinal disorders:  High in complex
 Diverticular disease: high carbohydrates
 Cardiovascular disease  Has less of refined cereals
(hypercholesterolemia):
 Cancer prevention:
 Diabetes mellitus:
 Weight reduction:

NB: Intake of excessive dietary fiber may bind and interfere with absorption of calcium,
copper, iron, magnesium, selenium and zinc. This results in their deficiency. Therefore,
excessive intake of dietary fiber is not recommended for children and malnourished
adults.
3. MODIFICATION IN ENERGY INTAKE

This may be high or low energy depending on the metabolic activity patterns and the
weight of a patient.

HIGH ENERGY DIET

High energy diet is recommended to provide an energy value above the total energy
requirement per day in order to provide for regeneration of glycogen stores and spare
protein for tissue regeneration. Energy dense foods are used to avoid complication of
bulky diet. For effective metabolism, an extra of 500kcal of the RDA is recommended
per day. If there is poor appetite small servings of highly reinforced foods should be

pg. 7
given. The diet may be modified in consistency and flavor according to specific needs.
Excessive amounts of low calorie foods, fried foods or others which may interfere with
appetite are avoided.

Indications and characteristics of high energy diet

Diet Indications Characteristics of the

diet
Energy dense foods  Hyperthyroidism  Increased kilocalorie
include butter, sugar,  wasting energy
honey and ghee which  Typhoid 35-40kcal/kg/day in
are added to the normal  Malaria adults
diet to increase energy  HIV/AIDS
content  All cases of prolonged
degenerative illnesses

CALORIE RESTRICTED DIET

These diets are prescribed for weight reduction. The recommended kilocalorie level is
20-25kcal/kg/day. The diet should comprise of complex carbohydrates and should
provide 50-60% of the total calories. Fats should provide <30% of the total calorie.
Purpose
To provide adequate nutrition, maintain desirable body weight, maintain normal glucose
and lipid levels and to prevent, delay and treat diabetic related complications.
Indications and characteristics of calorie restricted diets

Diet Indications Characteristics of the diet

 Vegetables,  Overweight and  The diet should provide20-
 carbohydrates obesity 25kcal/kg Bodyweight/day
 Hypertension with  Complex carbohydrates
excess weight  High in dietary fiber
 Hyper lipidemia  Proteins should be within the DRI
 Diabetes mellitus with
excessive weight
 Gout
 Gall bladder diseases
preceding surgery

4. MODIFICATION IN THE CONTENT OF ONE OR MORE NUTRIENTS

There are four ways to modify the content of one or more nutrients as listed below:
 Moderate fat diet/fat restricted diet
 High protein, high calorie diet
 High or low protein diet

pg. 8
 Low sodium diet
 High carbohydrates

FAT RESTRICTED DIET

The diet is designed to restrict fat intake for patients who experience symptoms of
nutrient losses when high fat foods are eaten. A fat restricted diet limits the amount of fat
you can consume each day and may be prescribed conditions that make it difficult for the
body to digest fat. Provision of fat restricted diet will minimize the unpleasant side
effects of fat malabsorption such as diarrhea, gas and cramping.

Indications and characteristics of fat restricted diet

Die Indications Characteristics of the diet

t
 Gall bladder  The diet provides overall fat between
diseases 25-50g/kg/day
 Biliary tract and  This diet is tailored to provide <30% of total
lymphatic system calorie and < 10% saturated fat acids. Levels of
 Hepatic cirrhosis restriction are as follows:
(liver cirrhosis)  Mild restriction-25-30% of total calories
 Pancreatic  Moderate restriction-20-25% of total
insufficiency calories
 Malabsorption  Severe restriction-15-20% of total calories
syndromes  The base of the diet should be composed of
 Intestinal resections grains, vegetables and fruits
 Overweight and  Meat fish, poultry and eggs should be limited to
obesity 180g per day
 Cardiovascular
diseases (CVDs
 bloating, diarrhea,
steatorrhea

Adequacy
It is possible to meet nutrient requirements on this diet, but depending on how long you
follow it and how much fat you can digest a supplement may be recommended. Patients
with prolonged stearrhoea or diarrhea may develop vitamin or mineral deficiencies.
Vitamin A, D, E and K are fat soluble which means they need fats to be absorbed and this
requires advice from the nutritionist/dietitian or doctor.

HIGH PROTEIN-HIGH CALORIE DIET

This diet is tailored to provide higher amounts of calorie and protein than usual diet. It is
prescribed where tissue regeneration is required. Its purpose is to help heal wounds,

pg. 9
maintain or increase weight, promote growth, decrease respiratory complications, resist
or fight infections and support the immune system. For a high protein diet, adequate
energy from carbohydrates and fats must be supplied.
Purpose
The diet is designed to maintain a positive nitrogen balance, promote normal osmotic
pressure, promote body tissue repair, prevent excessive muscle atrophy in chronic disease
states and build or repair worn out tissues of severely malnourished individuals. This diet
can also be used to meet increased energy and protein demands during illness, during
certain periods like pregnancy and lactation. Table 32 below shows indication for and
characteristics of the diet.
Indications and characteristics of high protein-high calorie diet

Die Indications Characteristics of the diet

t
 Febrile conditions  The diet must provide adequate
 Cancer protein carbohydrates ratio of (2:1).
 Wounds  The diet should provide i.e.35-
 Burns 40kcal/kg body weight/day
 Tissue injuries and trauma 1.5-2.0g/kg body weight/day
 After surgery  Consist more of high biological value
 Acute and chronic fever e.g. TB, protein
Malaria and Typhoid.
 Certain physiological alteration
- pregnancy and
lactation/infancy

pg. 10
LOW PROTEIN DIET
A low protein diet is temporarily indicated/ prescribed to avoid breakdown of tissue
protein which can lead to undesirable levels of nitrogen constituents in the blood. It is
essential that the calorie intake from carbohydrates be sufficient to avoid excessive
breakdown of tissue protein. Low protein may range from (0.6g-0.8g/kg/day).
Indications and characteristics of low protein diet

Die Indications Characteristics of the diet

t
 Hepatic coma  Low biological value protein can be
 Acute and chronic renal used during this time.
failure  The amount can be reduced to 20-
 Liver cirrhosis 35gms per day.
 Acute and chronic
glomerulonephritis

pg. 11
LOW SODIUM DIET
Sodium is a mineral that naturally occurs in some foods. However it can also added to food in
form of salt to help preserve them and add flavor. Limit sodium intake to less than 3000mg per
day. RDI should be limited to 2400mg
3000mg (130mEq) -Eliminate or eat sparingly processed foods and beverages such as fast foods,
salad dressings, smoked and salted meats. Omit 2000mg (87mEq)-prepared foods high in sodium
do not allow salt in preparation of food or table.
1000 (45mEq) eliminate processed foods and prepared foods and beverages high in sodium.
Omit many frozen foods and fast foods. Limit milk and milk products to 16oz per day. Do not
allow any salt in food preparation or table use. This meal plan used in the inpatient setting for a
short term basis
500 (22mEq) omit processed or canned foods high in sodium. Omit vegetables containing high
amounts of natural sodium limit milk to 16 oz daily and meat to 5 oz daily and meat products.
Use low sodium bread and distilled water for cooking where available.
Allow up to ¼ tsp table salt in cooking or at the table
Purpose
The purpose of a low sodium diet is to aid control of blood pressure (BP) in salt sensitive people
and to promote the loss of excessive fluids in edema and assist and manage hypertension. Table
34 below shows the indications for and characteristics of low sodium diet
Indications and characteristics of low sodium diet

Diet Indications Characteristics of the diet

 Unprocessed  Impaired liver  A diet low in processed foods and beverages
foods and functions  Diet should be low in canned foods,
beverages  Cardiovascular margarine, cheeses, and salad dressings.
 Low sodium diseases
bread  Severe cardiac
failure
 Acute and chronic
renal diseases

5. MODIFICATION IN FLAVOR (FOODS BLAND IN FLAVOR)

BLAND DIET
This is a diet modified to avoid irritation of any kind to the alimentary tract. Such diets are
chemically, mechanically and thermally modified. In bland diet, strong spices, stimulants and
strongly flavored vegetables and fruits that irritates should be avoided. The food should be served
at room temperature.
6. MODIFICATION BY INCLUDING OR EXCLUDING SPECIFIC FOODS
EXCLUSION OF CERTAIN FOODS (ALLERGIES)
In allergic conditions certain specific foods to which the individual is extremely allergic should
be excluded from the diet. Some people are allergic to protein foods like milk, eggs, peanut, soya
and seafood e.g lactose free diet or gluten free diet in allergic conditions

Diet for renal conditions

The purpose of diet for renal cases is to control protein, potassium, sodium and fluid levels in the
body.
It is used in acute and chronic renal failure and in hemodialysis.
Foods allowed include high-biological proteins such as meat, fowl, fish, and cheese
Vegetable such as cabbage, cucumber, and peas are lowest in potassium and are so advocated.
Potassium is usually limited to 500 mg/day
Fluid intake is restricted to the daily volume plus 500 ml, which represents insensible water loss.
Foods avoided include bread, macaroni, noodles, spaghetti, avocados, kidney beans, potato chips,
raw fruit, yams, soybeans, nuts, gingerbread, apricots, bananas, grapefruit, oranges, coca-cola

7. MODIFY THE INTERVALS OF FEEDING E.G FREQUENT FEEDING

INCREASING FREQUENCY OF FEEDING

In some disease conditions patients may not be able to eat very large amounts of food at one
time. It may thus become essential to give smaller meals at frequent intervals as in the case of
fevers, diarrhea and ulcers. In such cases provide small but frequent meals at each interval.
8. MODIFY THE MODE OF FEEDING E.G. PARENTERAL FEEDING AND
ENTERAL FEEDING

TOPIC : DRUG – NUTRIENT INTERACTIONS

Definition of terms
a) Drug – A substance that is used as a medicine or narcotic.
b) Medicine – Something that treats, prevents or alleviates (provides relief from e.g. pain)
the symptom of a disease.
c) Narcotic – Drug taken for pleasure, numbness or reduce pain and extensive use can lead
to addiction.
d) Drug abuse – Excessive use of a drug.
e) Absorption - the process of movement of a drug from the site of administration into the
systemic circulation
f) Bioavailability - the degree to which a drug or other substance reaches the general
circulation and becomes available to the target organ or tissue
g) Drug-nutrient interaction - the result of the action between a drug and a nutrient that
would not happen with the nutrient or the drug alone or it refers to changes to a drug
caused by a nutrient, or changes to a nutrient as a result of the drug
Functions of drugs
1. Prevents occurrence of a disease.
2. Treats a disease.
3. Alleviates or provides relief from pain.

Stages of how drugs pass into the body

1. The drug dissolves in the stomach if taken orally.
2. The drug is absorbed into the bloodstream and goes into the area that needs it.
3. The body reacts with the medicine.
4. The kidney or liver, or both get rid of the drug and this is called detoxification.

Effects of food on drugs /Impacts of food on effectiveness of drugs

Just like foods, drugs or medicines also have ingredients. Some foods may interact with
ingredients of drugs preventing the drug from working properly by; Delaying or speeding up its
absorption into the body, Speeds up the absorption into the blood., Also speeds up the rate
of elimination in the body, thus, interfering with the effectiveness of the drug e.g. Acidic
foods can decrease the power of antibiotics such as penicillin. Alcohol also interferes with the
absorption of some drugs.

Examples of effects of food on drugs

i) Drug Aspirin is absorbed more slowly when taken with food. Vitamin C can alter
urinary PH and limit the excretion of aspirin.
ii) Foods that stimulate secretion of digestive juices increases absorption of some drugs
e.g. Griseofulvin. (an antibiotic)
iii) Some foods e.g. Candy can change the acidity of the GIT thereby causing the slow
acting asthma medication to dissolve too quickly.
iv) Alcohol produces prolonged hypoglycemic effects when taken with insulin and oral
hypoglycemic agents.
v) Foods rich in dopamine e.g. (Cheese, chicken, liver, red wine, bread etc) cause
hypertensive crisis when taken alongside certain anti-depressants and thus can result
into accidents.
vi) Pyridoxine in food, blocks the effects of levodopa used in the treatment of Parkinson
disease.

Effects of drugs on foods

Effect of drug on food intake:
1. Drugs that may stimulate one’s appetite;
Appetite may be stimulated by certain drugs resulting in an increase in nutrient intake due to
more food being taken/eaten. On the other hand, drugs may also cause a decrease in nutrient
intake thus drugs affect nutritional status.
The following drugs may stimulate appetite and result into weight gain;
a) Anti – histamines (antibiotics); treat cold or allergies.
b) Anti – anxiety drugs; Relieves tension.
c) Tricycle anti – depressants.
d) Insulin: Hypoglycemia that may lead to a coma or death can occur in a person with type 1
diabetes, if food is not taken immediately after an insulin injection. If excess food is consumed to
avoid or treat hypoglycemia, weight gain may occur.
d) Steroids.
2. Drugs that may depress one’s appetite;
a) Alcohol
It can lead to loss of appetite; reduce food intake and malnutrition due to effects of alcoholism
such as gastritis (inflammation of the lining of the stomach), cirrhosis etc.
b) Amphetamines (depress appetite)

Effects of drugs on change of smell and taste

Change of smell or taste may stop people from eating or overeating and this affects their
nutritional status e.g. Antibiotics such as ampicillin, tetracycline etc., flagyl that may cause
metallic taste in the mouth. Anesthetics such as cocaine. Anti-coagulants, Anti-histamines,
Anti-hypertensive agents, toothpaste ingredients – sodium laurym sulphate.
Drugs that may lead to Gastro Intestinal effects
Drugs such as non – steroidal anti-inflammatory drugs (NSAIDS) e.g. Aspirin, Ibuprofen,
Antihistamines. {They cause stomach irritation. Sometimes the irritation is so severe and can
result into serious gastric bleeding.
Effect of drugs on nutrient / food absorption
A number of drugs can increase nutrient absorption thus benefit nutritional status while others
can decrease nutrient absorption in the body e.g.
Anti-acids can interfere with iron absorption in the body.
Alcohol abuse can result into malsabsorption of thiamine and folic acid causing anemia.
Some anti-acids bind phosphorus thus hindering its absorption.
 Chemotherapy drugs can damage mucosal cells thereby affecting nutrient absorption.
Neomycin may reduce lipase activity hence interfering with fat digestion.
Some drugs may also interfere or result into mineral depletion e.g.
Diuretics – taken to increase amount of water and aslant secreted from the body through
urine. Alcohol – may result to loss of potassium, magnesium and zinc.
Anti-acids – may result to phosphate deficiency, muscle weakness, convulsions and
calcification.
Other may also result into vitamin deficiency e.g.
Oral contraceptives that may result into loss of foliate, riboflavin, vitamin C and B12.
Some cancer drugs may also result into foliate deficiency.
Effect of drugs on nutrient excretions e.g.
Diuretics may result into increased excretion of sodium and potassium.
Aspirin may result into increased excretion of plasma protein carrier hence affecting
excretion of the protein.

TOPIC: DIET PLANNING

THERAPEUTIC DIETS
Therapeutic diet is a diet prescribed to a person with a disease or a disorder such as
injury, infection, nutritional deficiency, liver cirrhosis, diabetes etc to hasten
recovery. A therapeutic diet controls the intake of certain foods or nutrients. It is
part of the treatment of a medical condition and are normally prescribed by a
physician and planned by a dietician. It is usually a modification of a regular diet.
It is modified or tailored to fit the nutrition needs of a particular person. .
Therapeutic diets can be grouped into two types namely:

a) Normal diet

b) Modified diet

NORMAL DIET

This is a regular diet either vegetarian or non-vegetarian well balanced and

adequate for nutrition. It is the foundation of all diets and is designed to provide
adequate nutrition for optimal nutrition and health status in persons who do not
require medical nutrition therapy. This diet is used when there is no required diet
modification or restrictions. Individual requirements for specific nutrients may vary
based on age, sex, height, weight, activity level and different physiological status.

A normal diet consists of three (3) main meals and may include various snacks
depending on individual needs. In planning the meal, there are six principles which
should be considered.

Principles in meal planning

Adequacy

An adequate diet should provide enough energy and enough nutrients to meet the
needs of healthy people. For example, a person whose diet fails to provide enough
iron-rich foods may develop the symptoms of iron deficiency anemia.

Balance of foods and nutrients in the diet

This means not over consuming any one food. The art of balance involves the use
of enough but not too much or too little of each type of the seven food groups for
example use some meat or meat alternatives for iron, use some milk or milk
products for calcium and save some space for other foods. The concept of balance
encompasses proportionality both between and among the groups.

Energy control/density

This is the amount of energy in kilocalories in a food compared with its weight.
Examples of energy dense foods are nuts, cookies, and fried foods. Low energy
density foods include fruits, vegetables and any food that incorporates a lot of
water during cooking. They contribute to satiety without giving much calories.
This principle involves the management of food energy intake.

Nutrient density

This means eating foods that deliver the most nutrients for the least energy.
Nutrient density is a relative ratio obtained by dividing a food's contribution to the
needs for a nutrient by its contribution to calorie needs. This is assessed by
comparing the nutrient content of a food with the amount of calories it provides. A
food is nutrient dense if it provides a large amount of nutrient for a relatively small
amount of calories.

Moderation

This mainly refers to portion size. In planning the diets, the goal should be to
moderate rather than eliminate intake of some foods. Foods rich in fats and sugar
should also be eaten in moderation they provide few nutrients with excess energy

Variety

This means choosing a number of different foods within any given food group
rather than eating the same food daily. People should vary their choices of food
within each class of food from day to day. This makes meals more interesting,
helps to ensure a diet contains sufficient nutrients as different foods in the same
group contain different arrays of nutrients and gives one the advantage of added
bonus in fruits and vegetables as each contain different phytochemicals

NUTRITION GUIDE/TOOLS FOR A HEALTHY DIET

Knowledge of the nutritive content of a diet is meaningless unless it can be

compared to some standards. This lead to the development of nutrition tools which
serve as reference values for intakes of essential nutrients that will maintain health
in practically all healthy individuals. They assist individuals to meet their
nutritional needs, in prevention of under nutrition and over nutrition that results in
chronic disease.

Nutrition guides are of three types

1. Nutrition/Dietary standards

2. Dietary guidelines

3. Food guides

1. Nutrition/Dietary standards
Dietary standards are guidelines that help us understand how much of a
particular nutrient is needed by a healthy human being. These are amounts of
essential nutrients considered sufficient to meet the physiological needs of
practically all healthy persons in a specified group and food sources of energy
needed by members of the group. These figures are derived from compilation of
experimental studies designed to determine the nutrient requirements of human
beings. Quantitatively, dietary standards are not requirements but rather are
estimates of reasonable levels of nutrients intake that should support normal
function in most healthy people. Dietary standards are obtained by:

 Survey of food intake of large numbers of apparently healthy individuals.

 Surveys that include both food intake and nutritional status.
 Controlled metabolic experiments (with limited number of individuals).
 Relevant studies on several species of animals.
Most developed countries have developed their own nutrient standards and these
differ slightly for individual nutrients partly because populations, environmental
conditions and available food supplies differ. The following are some of the
different dietary standards for some countries.

Recommended dietary allowances (RDA).

These standards were developed for use in America. They represent quantities of
nutrients to meet known nutritional needs of practically all healthy people.
Allowances refer to the amount of nutrients to be actually consumed.

Recommended nutrient intakes (RNI)

This is the Canadian own version of the RDA. It estimates nutrients needed to
support good health.

Safe intake of nutrients (SIN)

These dietary standards were developed by the FOOD and Agriculture

Organization (FAO) and the World Health Organization (WHO) for
underdeveloped countries where supply of protein and other sources may be
limited

Recommended intakes of nutrients (RIN)

These standards were developed for use in the United Kingdom (UK)

Uses of RDA

1. Evaluating the adequacy of the national food supply; setting goals for food
production

2. Setting standards for menu planning for publicly funded nutritional

programme e.g. school feeding programmes

3. Establishing nutrition policy for public assistance, nursing homes and

institutions

4. Interpreting the adequacy of diets in food consumption studies

5. Developing materials for nutrition education

6. Setting patterns for normal diets in hospital

7. Establishing labeling regulation

8. Setting guidelines for formulation of new products or the fortification of

specific foods

Limitations and misuse of RDA

1. They are complex for direct use by consumers.

2. They do not state ideal or optimal levels of intakes.
3. Allowances for some age categories e.g. adolescents and elderly are based
on limited data.
4. Data on food content of some nutrients especially the trace minerals are
limited.
 5. They do not evaluate nutritional status.
6. They may not apply to sick people.
Nb...In 1990, nutrition experts recommended the framework of the RDAs be
expanded to address the following three emerging issues
a. The growing population of older people
b. The dangers of inappropriately high intakes of specific nutrients
c. The health benefits that might be achieved with higher intakes of certain
nutrients even though research was limited
-The expanded set of standards that evolved was given the working title of dietary
reference intakes (DRIs)

The Dietary Reference Intakes (DRIs)

DRIs reference values that are quantity estimates of nutrient intakes to be used for
planning and assessing diets for healthy people. The DRIs consist of four reference
intakes:

 Recommended Daily Allowances (RDA)-it serves as a reference for all

healthy

 Tolerable Upper Intake Level (UL)-It is the highest amount of nutrient that
can be safely consumed with no risk of toxicity/likely pose no danger to
most individuals in the group. It helps health care providers when advising
individuals on the use of dietary supplements

o Tolerable Lower Intake Level (LL)-It is the lowest amount of a

nutrient likely to pose no danger to most individuals in the group.

 Estimated Average Requirement (EAR)- It is the nutrient intake estimated to

meet the requirement of half of the healthy individuals in a particular life
stage and gender group

 Adequate Intake (AI) - It is the level thought to meet or exceed the

requirements of almost all members of a life stage/gender group. It is used
when there is not a sufficient amount of research to develop RDA
2. Dietary guidelines

They were 1st developed in 1980.It is developed from the RDIs and other research
evidence describing the types and amount of food to eat and the physical guidelines
for optimum health and growth e.g in weight management

3. Food Guide/Daily food guide

It helps individuals in day to day meal planning. They give a practical
interpretation of both dietary standards and dietary guidelines. Most food guides
group foods into a particular categories based on their nutrient content and
recommends a certain number of servings from each group. The mostly used food
guides are
a) Food pyramid
b).Food exchange list
c).Food composition table
d).Signal system(Healthy food choices)
e). Hand jive
f). Plate model
g). Glycemic index

a). Food composition tables

These are charts or tables showing the relative nutrient content found in a given
quantity of food. They were developed by FAO/WHO for developing countries.
The nutrient compositions of foods were obtained in laboratory after food analysis.
The food composition tables:

 Serve as a basis for comparing one food with another in terms of nutrient
content. For example, when you examine different foods for calcium
content, you will discover that that milk is the best source of calcium.
  Enable the calculation of the nutritive value of any diet and compare these
values with the standards.
 Are valuable in planning diets that meet requirements for specific needs such
as low sodium and high protein diets.
 They provide a ready reference to answer numerous questions concerning
the nutritive value of foods.

b). Food group plan (Food pyramid)

This is a diet planning tool that sort out food of similar origin and nutrient content
into groups and then specifies that people eat a certain number of servings from
each group every day. The number of servings to be consumed from group depends
on a person’s age and energy needs. In the six food group plan, foods are classified
into six groups in which the breath/base of the pyramid shows that grains deserve
most emphasis in the diet. The tip is smallest and so these foods-fat, oils and
sweets- should be used sparingly, Figure 1.1. shows the six food group plan. In this
pyramid foods are classified into six groups.

Group 1: Breads, cereals, rice and pasta (6-11 servings)

Group 2: Vegetables (3-5 servings)

Group 3: Fruits (2-4 servings)

Group 4: Meat, poultry, fish, dry beans, eggs etc

Group 5: Milk, yoghurt, cheese (2-3 servings)

Group 6: Fats, oils and sweets (use sparingly).

c). Food exchange system
This refers to a system of classifying foods into numerous lists based on their
macro-nutrient composition and establishing serving sizes so that one serving of
each food on a list contains the same amount of carbohydrates, protein, fat, and
energy (kilocalories). Any food on the list can be exchanged or traded for any
other food on that same list without affecting a plan’s balance or total kilocalories.
It was originally developed for planning diabetic diets.

The system organizes food into seven exchange lists.

1. Starch/Bread
2. Milk
3. Meat
4. Fruits
5. Vegetables
 6. Fats
7. Sugar
The six exchange list
All the foods listed together are approximately equal in proteins, carbohydrates and
fat value. Exchange lists provide additional help in achieving kilocalorie control
and moderation. Originally developed for people with diabetes, exchange systems
have proved so useful that they are now in general use for diet planning.
The number of kilocalories is calculated given the number of grams of
carbohydrates, fats and proteins in a food (1g of carbohydrate/ protein yields 4
kcal; 1g of fat yields 9 kcal). To apply the system successfully, users must become
familiar with portion sizes. The table below shows exchanges for carbohydrates,
proteins, fat and energy values that pertain to each list
List Portion size per serving Amount CHO Protein Fats Kcal/
(ml or g) serving
Starch  1/3 cup arrowroots 30 g  15  2  - 80
 1/3 cup ugali  15  2 Trace
 1 slice bread  15  2
 1/3 cup cassava  15  2
 ½ cup cooked bananas  15  2
 ½ cup dried cooked beans  15  7
 ½ cup cooked rice  15  2
 ½ cup cooked pasta  15  2
 ½ cup sweet potatoes  15  2
 ½ cup porridge  15  2
 ½ cup Irish potatoes  15  2
 ½ chapatti  15  2


Milk  ½ cup fresh milk  250  12  8  Trace  90

 Nonfat  ¼ cup ice cream ml  12  8  5  120
 Low 75 ml or one scoop  250  12  8  8  150
fat  1 cup yoghurt ml 
 Whole  250
ml

Meat  Size of matchbox meat  30 g -  7  3  55

  Lean  Palm size of fish  30 g  7  5  75
 Mediu  A leg, thigh or breast  30 g  7  8  100
m fat chicken  30 g  7  3  75
 High  2 tbsp peanut
fat  ½ cup fresh bean
 Egg  ½ cup omena
Vegetable  ½ cup cooked vegetable 100-150 5 2 - 25
s  1 cup raw vegetable g
Fruits  1 small apple, peach, Varies 15 - - 60
orange, apple or grape
fruit juice (pure juice)
 ¾ cup diced fruits
Fats  1 tsp margarine or oil - - 5 45
 10 large peanuts
 1/8 medium avocado
 1 slice bacon
 1 tbsp shredded coconut
 1 tbsp cream cheese
 1 tbsp salad dressing
 5 large olives
Sugar 1 tsp 5 20

Procedure for calculating diets using exchange lists

Suppose that 1,200 – calorie diet is to be planned with the following levels, CHO
120g, protein 70g, and fat 30g.Estimate the amounts of milk, vegetables and fruits
to be included. The amounts are dictated somewhat be the preferences of the clients
but the following are minimum levels that should ordinarily be included: Milk 2
cups for adults, 3-4 cups for children and for pregnant/lactating mother; fruits – 2
exchanges; vegetables – 2 exchanges
1. Fill the carbohydrate, protein and fat values for the tentative amount of milk,
vegetables and fruit.
2. Determine the number of bread exchanges. Add up the CHO value of milk,
vegetables and fruit. Subtract this total from the total amount of CHO
prescribed. Then divide the remainder by 15 (the CHO value of one bread
exchange). Use the nearest whole number of bread exchanges. Fill in the
bread.
 3. Total the CHO column. If the total deviates more than 3-4 from the
prescribed amount, adjust the amounts of vegetable, fruit and bread. No diets
should be planned with fractions of an exchange, since awkward measures of
food would sometimes be encountered.
4. Determine the number of meat exchanges. Add up the protein value of all
food so far calculated. Subtract this total from the amount of proteins
prescribed. Divide remainder by 7 (the protein value of one meat exchange).
Fill in the protein and fat values
5. Determine the number of fat exchange. Add up the fat value from the milk
and meat. Subtract this total from the amount of fat prescribed. Divide the
remainder by 5 (the fat content of one fat exchange). Fill in the fat value.
6. Check the entire diet for the accuracy of the computations. Divide the day’s
food allowances into a meal pattern suitable for the client.

List Food Measure CHO (g) Protein Fat (g) Calories

(g) Kcal
1. Milk, low 2 24 16 10 250
fat exchanges
2. Vegetable 2 10 4 - 56
exchanges
3. Fruits 3 30 - - 120
exchanges 64
4. Bread 4 60 8 - 272
exchanges 124 24
5. Meat, Low 7 49 21 385
fat exchanges
6. Fat 2 - - 10 90
exchanges
TOTAL 124 70 40 1173

Signal System: Principle of Healthy Food Choices and Cooking Methods

This system is based on traffic light concept of red for ‘stop’ which also denotes danger, yellow
for ‘go slow’ or cautious, and green for ‘go’ or safer road (see table 63 below). It uses
universally understood symbols which makes it simple and highly useful way for a person to
make an informed choice. Importantly it focuses attention on processing and cooking, lays stress
 on the Glycemic Index (GI), fiber content of food, the amount and type of fat used and the mode
of cooking. It removes negative feelings about being on a diet and avoiding certain foods. It
empowers the person to make a behavior change towards healthy eating. Table 63: Principles of
Healthy Food Choices, Signal system
Principles Green Yellow Red
Refined cereals Low Moderate to high High
and sugars
Saturated fat Low Low High
Total fat Low Moderate High
Glycemic index low Moderate high High GI
Fiber High Low Negligible
Cooking method Steaming, boiling, Pan fried, sautéed, stir Deep fried, extra butter,
roasting, grilling, fry; moderate amount ghee added, rich
tandoor, dry heat, of fat in cooking sauce/dressing, rich in
less fat in cooking added sugar
Processing Rich fiber, parboiled, Low fiber, refined, Low fiber processed, ready
hand pounded. milled to eat
How much to Eat as permitted Moderation Restrict
eat

Hand Jive
The Zimbabwe hand jive shown in figure 14 below, suggested by Dr K Mawji, illustrates how to
measure the amount of food 'imaginatively', in a reasonably accurate manner, without scales etc.
Hand Jive Protein: Choose an amount
the size of the palm of your
hand and the thickness of
Carbohydrates ( starch and fruit):
Choose an amount the size of
your little finger.
your 2 fists.

Fat: Limit fat to an amount

Vegetables: Choose as much as you can the size of the tip of your
hold in both hands. Choose low thumb.
carbohydrate vegetables (e.g. green or Drink no more than 250 mL
yellow beans, cabbage, lettuce). of low-fat milk with a meal.

Figure 14: The Zimbabwe Hand Jive

Plate model method

The Plate Method is a simple method for teaching meal planning. A 9-inch dinner plate
serves as a pie chart to show proportions of the plate that should be covered by various
food groups. This meal planning approach is simple and versatile. Vegetables should
cover 50 percent of the plate for lunch and dinner. The remainder of the plate should be
divided between starchy foods, such as bread, grains, or potatoes, and a choice from the
meat group. A serving of fruit and milk are represented outside the plate. Figure 15
below shows how a sample basic meal should appear in the plate for a normal healthy
individual.

Sample Basic Meal

Planning Guide

Fruit Meat/ Milk

Protein
Starch/
bread
Vegetables

American
Diabetes 31
Association®

Figure 15: Simple Basic Meal Planning Guide for Healthy individual

Figure 16 shows a sample plate for a diabetic patient. Note the difference in the portion
sizes of vegetables.

Model Plate
 Fruit

Milk/ Yoghurt
Protein

Vegetable

Vegetable

Starch /cereal

Figure 16: Model Plate for a Diabetic Patient

Combined with the plate model the signal system is a practical and easy way to
implement diet advice for a newly diagnosed person with type 2 diabetes
Figure 17 shows plates usually seen for many people which are not in line with the
principles of meal planning

Plate Formats Usually Seen

Milk/yoghurt Milk / yoghurt

Vegetable Vegetable

Starch /cereal
Protein

Starch /cereal Protein

Rich in starch/cereals, low in vegetablesRich in proteins, low in vegetables and cereals

Figure 17: Plate Formats usually seen not in Line with Meal Planning

: NUTRITION SUPPORT
Enteral and Parenteral Nutrition
This refers to the provision of food and nutrients to the patient when the conventional
feeding methods are not adequate or cannot meet nutrition needs. These include Enteral
and parenteral nutrition. Selection of the mode of feeding is dependent upon several
factors. Figure 4.2 below outlines the factors to consider in selection of a feeding method.
Figure: Choice of route of nutrition administration Adopted from JPEN 1993; 17 (4):
1SA.
Enteral Nutrition
Enteral nutrition is a way of providing nutrition to the patients who are unable to
consume an adequate oral intake but have at least a partially functional GI tract. Enteral
nutrition may augment the diet or may be the sole source of nutrition. It is recommended
for patients who have problems chewing, swallowing, prolonged lack of appetite, an
obstruction, a fistula or altered motility in the upper GIT; are in coma or have very high
nutrient needs.

Types of Enteral Nutrition Formula

There are various types of enteral feeds available as ready to use or powdered mixes
specifically designed to meet the needs of the patient. The formulas are commonly
categorized by the complexity of the proteins they contain. There are two major types of
Enteral feeds namely: standard and hydrolyzed.

Standard Formulas
These are also known as polymeric or intact formula. They are made from whole proteins
as found in the diet (e.g. eggs, meat) or protein isolates [semi-purified high biological
value proteins that have been extracted from milk, soybean or eggs]. Because they
contain whole complex molecules of protein, carbohydrate and fat, standard formulas are
used for patients who have normal digestive and absorptive capacity. They come in
variety such as standard, high protein, high calorie and disease specific.

Hydrolyzed Formulas
Partially hydrolyzed formulas contain proteins that are partially digested into small
peptides. Completely hydrolyzed formulas are commonly known as elemental formula
and they contain protein in its simplest form; free amino acids. Hydrolyzed formulas also
provide other nutrients in simpler forms that require little or no digestion e.g. very low fat
in form of medium-chain triglycerides (MCT). Hydrolyzed formulas are meant for
patients with impaired digestion or absorption such as people with inflammatory bowel
syndrome, short gut syndrome and pancreatic disorders.
Indications for Enteral Nutrition
During periods of decreased oral intake, anticipated less than 50% of required nutrient
intake orally for 7-10 days as seen in severe dysphagia (difficulty swallowing), metabolic
stress, major bowel resections, low-output fistulas and coma. Neurological disorders and
psychological conditions.
Malnourished patients expected to be unable to eat > 5 days
Normally nourished patients expected to be unable to eat >5 days
Adaptive phase of short bowel syndrome
Following severe trauma or burns
Contraindications
 Intestinal obstruction that prohibits use of intestine
 Paralytic illus
 Intractable vomiting
 Peritonitis
  Severe diarrhea
 High output fistulas between the GI tract and the skin
 Severe acute pancreatitis
 Inability to gain access
 Aggressive therapy not warranted

Determining nutrient requirements

The type of formula, volume and hence the total nutrient required are determined by the
patients physiological condition. Several equations are available for estimating nutrient
requirements of patients depending on their clinical condition.
The calorie to nitrogen ratio should be >150:1 (1g nitrogen is equivalent to 6.25g
protein). If the C: N ratio is less than 200:1, then the protein supplied by such a feed will
be inadequate for critically ill patients.

Tube feeding
This is the delivering of food by tube in to the stomach or intestine. It is indicated
whenever oral feeding is impossible or not allowed.
Tube feeding routes
The decision regarding the type of feeding route/tube depends on the patient’s medical
status and the anticipated length of time that the tube feeding will be required.

Mechanically inserted tubes;

Nasogastric tubes where by a feeding tube is pushed through the nose into the stomach
Orogastric tubes whereby a feeding tube is pushed through the mouth into the stomach
Nasoduodenal tubes – the tube is pushed through the nose past the pylorus into the
duodenum
Naso-jejunal tube – the tube is passed during the endoscopy from the nose past the
pylorus into the jejunum
Surgically inserted tubes
Oesophagostomy: A surgical opening is made at the lower neck through which a feeding
tube is inserted to the stomach
Gastrostomy: A surgical opening is made directly into the stomach
Jejunostomy : A surgical opening is made into the jejunum
Figure 7 below illustrates different routes of enteral nutrition administration, while table
35 shows methods of administration.

Figure2: Different route of enteral nutrition administration

Advantages of Enteral nutrition
There is a stimulation of GI hormones and consequent regulated metabolism and
utilization of nutrients.
It ensures adequate nutrient supply to the mucosal wall, and protection against atrophy of
intestinal Villi.
It offers physiological protection against ulcers due to its buffering effect from gastric
acids.
Table1: Methods of administration
Method Administration Remarks
Bolus Initially – 50ml then Most appropriate when feeding in to the
feeding increase gradually up to a stomach
maximum of 250 to 400ml
Check aspirate before each feeding
over approximately 30
minutes, 3 to 4 hourly daily Feeds may poorly tolerated causing nausea,
(in 24 hrs) vomiting, diarrhea, cramping or aspiration
Intermittent 400 – 500ml infused by Patient retains freedom of movements in
slow gravity over approximately between feeds
gravity 20 -30 minutes to 1 hr. 3 to Improved tolerance of feeds
feeding. 4 hourly daily (in 24 hrs)

Continuous Total volume of feed Most suitable when feeding in to the

required is slowly duodenum or jejunum where elemental
administered; approximately diets are most appropriate
100ml/hour over 18 – 24hrs
May also be suitable for feeding in to the
stomach
Method may slow peristalsis
Feeds are better tolerated

Tube feeding instructions

 Tube feeding should be used at room temperatures, cold mixtures can cause
diarrhea
 Ensure proper placement of tube and feed at slow constant rate
 Prescribed intervals and volumes of feeding should be adhered to
 Care should be taken to ensure that the tube feeds meet the patient’s nutrient
requirements
 Prepared mixture should be well covered, properly labeled including time of
preparation and stored in a refrigerator for up to 24 hours
 In the absence of refrigeration, quantities lasting only six to twelve hours should
be prepared
 All feeding equipment should be cleaned before and after each feed
 Shake/stir well before use

Commonly used equipment in enteral feeding

Feed preparation equipment for kitchen made feeds and powder feeds include measuring
jars and cups and spoons, mixing bowls, blender, flask, sterile water
Ready to hang (RTH) feeds: giving sets for gravity or giving sets for the pump system,
Enteral feeding pumps, dual port connector and a feeding bag where applicable
Liquid diets in easy bags: giving sets (gravity or pump), feeding pump and/or dual port
connector where applicable
Feed delivery equipment; funnel especially in gastrotomy and Jejunostomy for
controlling viscous flow, syringe for naso-gastric bolus or intermittent feeding and the
feeding tubes where applicable
NB: Feeding pump is recommended as it eases feeding workload because it flows
without constant supervision, enhances accuracy, hygiene and sanitation.
The table below shows methods of estimating daily fluid allowance
Table2: Methods of estimating daily fluid allowance
Basis of estimation Calculation
Body weight
Adults
Young active :16 – 30 years 40 ml/kg
Average: 25 – 55 years 32 ml/kg
Older: 55 – 65 years 30 ml/kg
Elderly:> 65 years 25 ml/kg
Children
1 – 10kg 100 ml/kg.
11 – 20kg An additional 50ml per each kg > 10kg.
21kg or more An additional 25ml per each kg > 20kg
Energy intake 1 ml per Kcal.
Nitrogen plus energy intake 100 ml/g nitrogen intake plus 1 ml per Kcal*
* Useful with high protein feeding

Tube feeding complications

Sometimes a client does not respond to a tube feeding as expected. If the client continues
to lose weight, for example health care professionals must find out why. Perhaps they
have underestimated energy and nutrient requirements.
Commonly seen complications can be classified into: gastro-intestinal, mechanical,
metabolic, and pulmonary. Table 37 and 38 provides a summary of the complications
alongside prevention/management strategies.
Table3: Gastrointestinal complications of tube feeding
Gastro intestinal Prevention/management
complications
Diarrhea Slow feeding rate
Supplemental fluid and electrolytes
 Use lactose free formula
Prevent formula contamination
Consider different formula
Check antibiotic/drug therapy
Check flow rate of feed
Consider Enteral nutrition with added fiber
Use ant diarrheal agent
Check osmolarity of feeds (< 500mosl/l recommended
Constipation Give supplemental fluid.
Check if fiber inadequate or excessive
Check physical activity
Nausea or vomiting Reduce flow rate
Discontinue feeding until underlying condition is managed
Change to polymeric feeds if on elemental diet
Check gastric emptying and review narcotic medications,
initiate low fat diet, reduce flow rate
Malabsorption/Mal- Identify the cause (crohn’s disease, radiation enteritis, HIV,
digestion pancreatic insufficiency etc)
Select appropriate Enteral product
PN may be necessary in selected patients
Abdominal distension Assess the cause
Check feed temperature (give at room temperature)
Do not give rapid formula administration
Table4: Other Medical Complications of tube feeding
Mechanical Prevention/management
complications
Tube placement To be placed by trained personnel using defined protocol to
reduce complications

Feeding tube Use small bore feeding tube to minimize upper airway
problems
Tube clogging Select appropriate tube size
Flash with water
Dilute formula with water
Dislocation of tube Ascertain tube placement before each feed
Clearly mark tube at insertion
Nasopharyngeal Use small lumen tube.
irritation
Use pliable tube
Esophageal erosion Discontinue tube feeding
Recommend parenteral nutrition
Metabolic Prevention/management
complications
(Fluid and electrolyte Check adequacy of daily nutrient supply of macro and
imbalance, trace micronutrients during EN.
element, vitamin and
Check possibility of Malabsorption
mineral deficiencies,
essential fatty acid
deficiencies
Hyperglycemia Reduce flow rate.
Give oral hypoglycemic agents or insulin.
Change formula
Tube feeding syndrome Reduce protein intake or increase water intake.
For conscious patients education and counseling is needed
Hypernatremia Increased water intake and reduce sodium
(dehydration)
 Replace sodium loses
Hyponatremia (over- Replace sodium loses
hydration)
Re-asses nutrient requirement, check volume administration,
change to nutrient dense formula
Pulmonary Prevention/management
complications
Pulmonary aspiration Incline head of bed 300 – 450 during feeding 1 hr after
feeding.
Check tube placement.
Monitor symptoms of gastric reflux.
Check abdominal distension.
Check residual volumes before feeds.
Change to jejunal feeding.
Reduce volume of feed.
Change from bolus to continuous feeding

When a patient has been put on enteral feed, it is important that the administration is
monitored regularly to avoid or identify any complications early and address them. The
table below provides a checklist for monitoring clients/patients recently put on tube
feeding.
Table5: Checklist for monitoring patients recently placed on tube feeding
Action Check
Before starting a new Complete a nutrition assessment
feeding
Check tube placement
Before each intermittent Check gastric residual
feeding:
Check gravity drip rate when applicable
Every half hour
Check pump drip rate, when applicable
Every hour
Check vital signs, including blood pressure, temperature,
Every 4 hours pulse, and respiration
Every 6 hours Check blood glucose, monitoring blood glucose can be
discontinued after 48hrs if test results are consistently
negative in a non-diabetic client
Every 4 to 6 hours of Check gastric residual
continuous feeding
Every 8 hours Check intake and output
Check specific gravity of urine
Check tube placement
Chart clients total intake of, acceptance of, and tolerance
to tube feeding
Every day Weigh clients where applicable
Check electrolytes and BUN when needed
Clean feeding equipment
Check all laboratory equipment
Every 7 to 10 days Check all laboratory Findings
Re-assess nutrition status
As needed Observe client for any undesirable responses to tube
feeding; for example delayed gastric emptying, nausea,
vomiting, and diarrhea
Check nitrogen balance
Check laboratory data
 Chart significant details

As had been highlighted earlier there are different enteral formula classifications. Table
40 below shows the enteral formula classifications.
Table6: Enteral formula classifications
Enteral formula Sub-category Characteristics Indications
Polymeric Standard Similar to average diet. Normal digestion
High nitrogen Protein > 15% of total Catabolism Wound
Kcal. healing
Calorie dense 2 Kcal/ml Fluid restriction
Volume intolerance
Fiber containing Fiber 5 – 15/l Regulation of bowel
function
Monomer Partially One or more nutrients Impaired digestive
hydrolyzed are hydrolyzed, and absorptive
elemental peptide composition varies. capacity
based
Disease specific Renal Whole protein with Renal failure
modified electrolyte
content in a caloric
Hepatic High
denseBCAA,
formula.low AA, Hepatic
encephalopathy
Pulmonary High % of calories ARDS
from fat.
Diabetic Low carbohydrate Diabetes mellitus
Immune Critically ill Arginine*, glutamine, Critically ill.
enhancing omega-3 fatty acids,
Formulas anti-oxidants
* is contraindicated in critical illness
There a wide range of enteral feeds available in the market. The table below further
highlights some examples of enteral feed formulations. However, it is worth noting that
this is not a complete list of all the formula’s currently available in the market.
Table7: Examples of enteral feed formulations
Feed Composition – 100g powder Indications
Infant feeding CHO-55.9% mainly lactose and For low birth weight,
formulas maltodextrin. premature or light for
date babies when breast
PRO-14.4% mainly whey
milk is not available.
protein and casein.
FAT-24.0% MCT, milk, fat,
corn oil, soybean.
CHO-56.2% For infants of normal
birth weight (mature,
PRO-12.5%
normal for date) when
FAT-27.7% breast milk is not
available.
CHO-55.4% For infants and low birth
weight, light for date
PRO-11.4%
babies when breast milk
FAT-27.7% corn oil, soy oil, is not adequate or not
coconut oil. available

Lactose free infant CHO-55.4% mainly For infants

formulas maltodextrin
PRO-14.0%
Soy protein isolate.
FAT-25% palm, soya and
coconut oil.
CHO-52% For infants and adults
when lactose or cow’s
Corn syrup solids
milk should be avoided.
PRO-14%
Soy protein isolate
FAT-27%
Blend of vegetable oils.
CHO-50% corn syrup, sucrose. For infants and adults
when lactose or cow’s
PRO-15.6% soy protein isolate.
milk should be avoided.
CHO-40% For infants and adults
when lactose or cow’s
Glucose polymer and corn
milk should be avoided.
syrup solids.
PRO-12% Soy isolate.
FAT-48% soy oil, coconut oil.
Feed Composition – 100g powder Indications
High protein powder CHO-37.4% A protein caloric
supplements supplement that can be
PRO-25%
incorporated in liquid or
Full cream powdered 2. CHO-54% A protein caloric
milk supplement useful where
PRO-36.4%
Dried skimmed milk CHO-68% low fat dietfat
Controlled is required
diets
powder (DSM)
Corn syrup solids, glucose,
lactose.
PRO-24%
CHO-54% Glucose and tapioca For oral or tube feedings.
starch Useful in Malabsorption
and low fat modified diets
PRO-11% Hydrolyzed casein and
amino acids
FAT-35% corn oil, MCT oil
CHO-6.7% Useful in high protein, low
calorie low fat, fat residue
Lactose, sucrose
diets
PRO-17.1%
Calcium caseinate
FAT-0.6%
CH0-30% A protein, vitamin and
mineral supplement ideal
PRO-55%
for high protein diets, low
FAT-1% fat diets and cases of
malabsorption useful for
Calories per 100g – 366g patient allergic to
lactalbumins
Nutritionally CHO-13.8g = 55% of total Cal. Nutritionally complete
complete liquid diets liquid diet for total or
PRO-3.8g = 15% total Kcal.
supplemental feeding, tube
FAT – 3.4g = 30% of total Kcal l. feeding or oral feeding
CHO-17g = 54.6% of total Kcal. High caloric formula
suitable for tube or oral
PRO-7.5g = 15.1% of total Kcal.
feeding especially where
FAT-68g = 30.3% of total Kcal. energy intake is increased,
where fluid is restricted
 CHO-12g = 53% of total Kcal. Nutritionally complete feed
for oral or tube feeding in
PRO-3.4g = 15% of total Kcal
diabetics.
FAT-3.2g
CHO-58%=of32%
totalofKcal.
total Kcal Nutritionally complete feed
for oral or tube feeding as a
PRO-15% of total Kcal.
total diet or supplemental
CHO-61.5g = 54% of total Kcal. diet. Lactose free
Nutritionally with fiber
complete feed
for oral or tube feeding as a
PRO-15.8g = 14% of total Kcal.
total or supplemental diet.
FAT-15.8g = 32% of total Kcal. Lactose free feed, low in
cholesterol and sodium
ENERGY = 100 Kcal per 100ml.

Parenteral Nutrition
This refers to nutrition directly into the systemic circulation, bypassing the gastro-
intestinal tract (GIT) and the first circulation through the liver. The primary objective of
parenteral nutrition is to maintain or improve the nutritional and metabolic status of
patients who have temporary or permanent intestinal failure.
Characteristics of parenteral nutrition
Patients on TPN (Total Parenteral Nutrition) have similar requirements as enterally fed
patients
The six major nutrients covered are: carbohydrates, proteins, fats, vitamins, minerals and
water
Feeds must provide adequate calories
Nutrient form must be specialized for infusion into blood count prior to digestion
Standardized concentration may be modified to suit individual requirements
Indications for Parenteral Nutrition
Patients who are candidates for parenteral nutrition cannot eat adequately to maintain
their nutrient stores. These patients are already, or have the potential of becoming
malnourished.
Peripheral Parenteral Nutrition (PPN) may be used in selected patients to provide partial
or total nutrition support for up to 2 weeks in patients who cannot ingest or absorb oral or
enteral tube delivered nutrients or when central-vein parenteral nutrition is not feasible.
Parenteral nutrition (PN) support is necessary when parenteral feeding is indicated for
longer than 2 weeks, peripheral venous access is limited, nutrient needs are large, or fluid
restriction is required, and the benefits of PN support outweigh the risks. Patient has
failed Enteral Nutrition (EN) trial with appropriate tube placement (post-pyloric).
EN is contraindicated or the intestinal tract has severely diminished function due to
underlying disease or treatment. Specific applicable conditions are as follows:
Paralytic ileus
Mesenteric ischemia
Small bowel obstruction
GI fistula except when Enteral access may be placed distal to the fistula or volume of
output (<200 mL/d) supports a trial of EN
Diseases of the small intestine
Intractable vomiting/diarrhea
Massive small bowel resection
Trauma
Inflammatory Bowel Disease
Enterocolitis (AIDS, chemotherapy, radiotherapy)
Pancreatitis
Burns
Cancer
Immaturity (premature babies)
As occurs in postoperative nutrition support, the exact duration of starvation that can be
tolerated without increased morbidity is unknown. It has been suggested that wound
healing would be impaired if PN is not started 5–10 days. This is for postoperative
patients unable to eat or tolerate enteral feeding.
The patient’s clinical condition is considered in the decision to withhold or withdraw
therapy. Conditions where nutrition support is poorly tolerated and should be withheld
until the condition improves are severe hyperglycemia, azotemia, encephalopathy and
hyperosmolarity and severe fluid and electrolyte disturbances.
Contraindications
Functional GIT
Existence of an advanced terminal condition for which aggressive therapy is not provided
Parenteral nutrition in infants Very preterm infants, who often have relatively delayed
gastric emptying and intestinal peristalsis, may be slow to tolerate the introduction of
gastric tube feeds. These infants may need intravenous nutrition while enteral nutrition is
being established or when enteral nutrition is not possible—for example, because of
respiratory instability, feed intolerance, or serious gastrointestinal disease.
Examples of feeds for pediatrics
Protein source: Amino venous
CHO source: dextrose
LIPIDS (Fat) source: Lipovenous 10%
Total parenteral nutrition consists of a glucose and amino acid solution with electrolytes,
minerals, and vitamins, plus fat as the principal non-protein energy source. Bloodstream
infection is the most common important complication of parenteral nutrition use.
Delivery of the solution via a central venous catheter rather than a peripheral catheter is
not associated with a higher risk of infection. Extravasation injury is a major concern
when parenteral nutrition is given via a peripheral cannula. Subcutaneous infiltration of a
hypertonic and irritant solution can cause local skin ulceration, secondary infection, and
scarring. Extravasation injury may occur when a peripheral cannula is used to deliver the
parenteral nutrition solution
Routes of administration of parenteral nutrition
Intravenous solutions can be provided in different ways. The methods used depend on the
person’s immediate medical and nutrient needs, nutrition status and anticipated length of
time on IV nutrition support. They include:
Peripheral Parenteral Nutrition (PPN)
Central Parenteral Nutrition (TPN)
The general decisions to use PPN instead of CPN are based on comparative energy
demands and anticipated time of use.

Peripheral Parenteral Nutrition

This refers to use of peripheral veins to provide a solution that meet nutrient needs for
infusion. It has lower dextrose (5% to 10% final concentration) and amino acid (5% final
concentration) concentration than CPN. It may provide full or partial nutritional
requirements to patients.
PPN can be administered in to peripheral veins if solutions used have osmolarity below
800 - 900mosm/l for a brief period of less than 14 days. Short catheters (cannulas) and
mid-way catheters are normally used. However, PPN administration is possible for
several weeks with fine bore catheter.
PPN may be used in patients with mild or moderate malnutrition to provide partial or
total nutrition support when they are not able to ingest adequate calories orally or
enterally or when central vein PN is not feasible.
All in one admixture are highly recommended compared to the single bottle system
during PPN.
Central Parenteral Nutrition (CPN)
CPN is often referred to as “Total Parenteral Nutrition” since the entire nutrient needs of
the patient may be delivered by this route. It requires a central venous system for long
term infusions.
The sites mainly used are the Vena jugularis external, Vena jugularis internal, Vena
subclavia, Vena cephalica and Vena basilica for solutions with osmolarity above 800 -
900 mosm/l.
Peripherally Inserted Central Catheters (PICC) for short - and long term infusions are
possible. Implantable system for central venous access (Ports) Lasts for years after
implantation and patients may go on TPN for years with the catheters being changed
every 5 - 10 years. Central Parenteral Nutrition is complete nutrition similar to
physiological nutrition and can be provided for unlimited period (weeks to years). PN can
be used in hospitalized patients and those who have returned home or are in assisted
living, extended care facilities or nursing homes.
Access routes for parenteral nutrition include:
Peripheral Access Routes
One of the easiest and safest ways to access the vascular system is to place a cannula into
a peripheral vessel. The adequacy of the vein limits the use of the peripheral system for
infusion. Catheter tips that are located in a peripheral vessel are not appropriate for the
infusion of PN formulas > 900 mosm/L.
The indications for peripheral infusion are short-term access needs. Specially formulated
PN may be administered by peripheral access. These solutions are based on a decreased
dextrose concentration and osmolarity and have been reported to be used for short-term
therapies (<-10–14 days) when fluid restriction is not necessary.
The leading complication associated with peripheral access is peripheral venous
thrombophlebitis. The hallmark symptoms of infusion phlebitis (an inflammation of the
cannulated vein) are pain, erythema, tenderness or a palpable cord. Peripheral devices
have the lowest risk of catheter related infections.
Central Venous Access
Central venous access is defined as a catheter whose distal tip lies in the distal vena cava
or right atrium. The most common sites of venipuncture for central access include the
subclavian, jugular, femoral, cephalic, and basilic veins.
Figure 8 below illustrates administration of PN through the sub-clavian vein.

Figure 3: Administration of parenteral nutrition through sub clavian vein

Calculating the nutrient content of Intra Venous (IV) formulas
The energy/nutrient requirements of patients on parenteral nutrition comprises of a
complete nutrition similar to physiological nutrition. These requirements can be
calculated using several different available formulas and no standard prescription
provides an answer for all patients. Nutrient requirements are also adjusted at all times to
suit the patient’s current medical or surgical condition. One of the standard parenteral
nutrition regime that is suited for 80% of patients and calculated as per the kilogram body
weight is as shown in table 42 below:
Table8: Nutrient requirements for IV formulas
Nutrients Requirements
Amino acids 1 - 1.5g
Energy (as fat and glucose) 25 - 30 kcal (NPE - 3 - 5g (>2g/kg, <7g/kg)
Non Protein Energy)of which glucose
Fat (LCT) 1- 2g (<0.3g/kg, <3g/kg)
Vitamins and trace elements Basic needs
Water and electrolytes Basic needs

Note:
Protein Energy (NPE): Stand for energy from carbohydrate and fat only, excluding the
energy from protein. The protein requirements are then calculated separately as per the
patient’s body weight.
The proportion of carbohydrate to fat is then calculated at a proportion of 70: 30 or 50: 50
depending on the patient’s condition. This means that 70% of the NPE will be the
required energy from Carbohydrate and 30% of NPE will be the required energy from fat.
Total energy (TE) requirements can also be calculated from e.g. the Harris Benedict
Equation (HBE) or any other equation or formulas available. The ratio of energy to
nitrogen is then calculated as follows:
Calorie nitrogen ratio – An adequate energy provision is necessary to support the use of
protein for anabolism. The recommended non-protein calorie nitrogen ratio (C: N) for the
different conditions is calculated as shown in the table below.
Table9: Recommended non-protein calorie nitrogen ratio (C: N) for the different
conditions
Conditions Calorie: Nitrogen Ratio (gN)
For normal body maintenance 300:1
Stressful conditions 150:1
Renal failure 250: 1
PPN 70:1
Children 300:1

The percentage of nutrient requirements can also be calculated from the TE as follows:
50 – 60% of the TE from Carbohydrate
15 – 20% of TE from Protein
25 - 30% of TE from FAT

Precautions in Parenteral Nutrition

 Osmolarity – ensure appropriate osmolarity is infused via the appropriate veins to
avoid thrombosis and small blood vessel damage. E.g. osmolarity > 900 should be
administered centrally.

Calculation of the osmolarity of parenteral nutrition solutions

Multiply the grams of dextrose per liter by 5 mosm/g
Example: 50g of dextrose x 5 = 250mOsm/L
Multiply the grams of protein per liter by 10 mosm/g
Example: 30g of protein x 10 = 300mOsm/L
Fat is isotonic and does not contribute to osmolarity
Electrolytes further add to osmolarity for example: 1 mosm/me of individual electrolyte
additive
Total osmolarity is then derived from the sum of the osmolarity of all nutrients infused
  Infusion rate – always check label and package inserts. The maximum infusion
rate recommended for specific solutions should not be exceeded in order to avoid
complications

Vital signs should be monitored daily

Discontinuation should also be gradual to avoid hypoglycemia
Infuse parallel, it is best to infuse parallel. If parallel infusion is not possible then infuse
directly
First carbohydrates with electrolytes, second amino-acid with electrolytes, third fat
Administration of parenteral nutrition
Parenteral Nutrition feeds can be administered in the following forms:
1). Single bottle system: These are single products/bottles providing either one of amino
acid solution, dextrose solution or lipid emulsions or vitamins or trace elements or a
combination of Amino acid and dextrose. The single bottle system may also contain
electrolytes.
2). All in One (AIO) admixtures: These formulations may be prepared as a single product
by the hospital pharmacist or industrial admixtures. The industrial admixtures are mixed
up at the factory and delivered to the hospital. Refrigeration is required and they have a
short shelf life.
3). Chamber bags: Two and three chamber bags. These AIO parenteral nutrition feeds
have a much longer shelf life and are mixed prior to administration.
Complications of Parenteral Nutrition
These complications are mainly divided into two main categories as follows:
Catheter related complications which involve:
Occlusion of the catheter
Catheter blockage (check the type, diameter, period of use)
Catheter related infections - these infections may come from the skin or systemic
circulation (gram negative organisms and fungi)
Catheter related sepsis - there is need to use antiseptic techniques at all times
Metabolic Complications
Hepatibiliary or Gastrointestinal complications
Abnormal liver function (caused by underlying diseases, i.e. sepsis, malignancy, IBD,
pre-existing liver disease) bacterial overgrowth in the intestines, biliary sludge and
gallstones. Steatosis which may be caused by sole infusion of dextrose as an energy
source without fat emulsions or excessive glucose load (above or equals to 7g of
glucose/kg/day). Sole glucose infusion without fat may also cause essential fatty acid
deficiency (EFAD).
Macronutrient Complications
These are risks associated with underfeeding or overfeeding. |:
Hyperglycemia - several factors may cause hyperglycemia including overfeeding
Hypoglycemia - this may occur mainly if weaning off parenteral nutrition is not done
appropriately or if there is excess insulin administration
Azotemia can result from dehydration, excessive and/or inadequate non protein calories.
Omission of fat emulsions during PN may cause EFAD
Too much infusion may cause hyperlipidemia
Micronutrient Related Complications
Fluid imbalance (Dehydration from osmotic diuresis, fluid overload)
Electrolyte imbalance
Vitamin, mineral and trace elements deficiency may only occur

The above complications can greatly be reduced and avoided if there is a multi-
disciplinary nutrition team with experienced clinicians available to insert the central
feeding catheters, designated nurses to care for the catheters, and an experienced
registered dietician to prescribe the right parenteral nutrition formulation and make the
necessary follow ups, monitoring and necessary adjustments. The table below shows
complications of total parenteral nutrition.
Table10: Complications of total parenteral nutrition
Catheter related complications Metabolic complications
Bacteraemia (staphylococcal) Cholestatic jaundice
Invasive fungal infection Hyperglycaemia or glycosuria
Thrombosis Vitamin deficiencies or excesses
Extravasation injuries Hyperammonaemia
Cardiac tamponade

Examples of parenteral nutritional formulations:

You can have confidence in IV solutions if you know what they contain. The basic thing
to remember is that the percentage of a substance in solution tells you how many grams
of that substance are present in 100mL e.g. a 5% dextrose solution contains 5g of
dextrose per 100 ml; a 3.5% amino acid solution contains 3.5g of amino acids per 100ml.
A 0.9% normal saline solution contains 0.9g of NaCl per 100mL. Table 45 shows
examples of parenteral formula feeds. Table 46 on the other hand, shows pediatric
parenteral nutrition formulations.
Table11: Examples of parenteral formula feeds
Amino acid solutions Features Presentation
These are standard Amino acids for 200ml,500ml and
parenteral nutrition which contain 1000ml bottles
Standard Amino
WHO recommended ratio for
Acids
essential and non essential amino
5% (50g AA/L) acids and may contain electrolytes or
may be electrolyte free
10% (100g AA/L)
Essential nitrogen balance
15% (150g AA/L)
Special Amino Acids May be balanced AA solution 200ml, 500ml bottle
containing Glutamine and tyrosine ,
Arginine
Special Amino Acids Disease specific formulation 50ml, 100ml, 200ml
containing AA glutamine bottles
Special AA for These are disease specific 200ml, 500ml bottles
Hepatic insufficiency formulations.
8% (80g AA/L) Specially designed to compensate the
AA disorders in hepatic insufficiency,
rich in BCAA and quite low in AAA.
Special AA for renal Adapted to the metabolic AA disorder 200ml, 250ml and
insufficiency in renal failure and contains a 500ml bottles
balanced profile of EAA and NEAA
7% (70g AA/L)
and the dipeptide glycyl-tyrosine
10% (100g AA/l)
Well balanced AA pattern specifically
designed for infants (preterm, new
born, babies) and young children.
Contains EAA and NEAA similar to
human breast milk.
Contains taurine an EAA for neonates
Carbohydrates Features Presentation
solutions
5% (50g /L) These carbohydrate feeds mainly 50ml, 100ml, 500ml,
contain glucose but some may contain 1000mls bags or bottles
6% (60g/ L)
xylitol and or sorbital
10% (100g/L)
20% (200g/L)
25% (250g/L)
50% (500g/L)
Solutions with both These parenteral nutrition solutions 200ml, 500ml, 1000ml
Carbohydrate and contain both carbohydrate and amino bottle
Amino acids. acid including electrolytes and may be
administered peripherally. e.g.
3% AA and 6% carbohydrate plus
electrolytes.
5% AA and 5% sorbital.
Lipid Emulsions Features Presentation
10% These are lipid emulsions for 200ml, 250ml and
parenteral nutrition with different 500ml bottle or bag
20%
special functions
30%
different lipid formulations may
20% MCT-LCT contain the following:
contains soybean oil (LCT) rich in
EFA
contain EFA, MCFA & LCFA
contain mixture of MCT and LCT
Rapid clearance and energy
production preference fuel in
conditions like carnitine
Isotonic
Mean globule size similar to
chylomicrons
Lipid Emulsion Contain fish oil 50ml and 100ml bottles
(fish oil)
Rich in EPA and DHA
Has anti-inflammatory and
immunomodulatory effect
All in One Features Presentation
All in One Three (triple) chamber bags with 1000ml, 15000ml,
Parenteral Nutrition separate compartments for amino 2000ml, 25000ml. bags
formulations acids, fat and a combination of
glucose or sorbital and electrolytes for
central or peripheral parenteral
Nutrition, depending on the
osmolarity and specifications.
Vitamins and minerals are added into
the bag prior to infusion.
Two chamber bags Two chamber bags with separate 1000ml, 1500ml,
compartments for amino acid and 2000ml bags
glucose with or without electrolytes.
 Other nutrients may be added i.e. fat,
vitamins, trace elements as per the
specifications
Vitamins Contains all the water soluble and or 10ml vials
fat soluble vitamin based on
9 water soluble 10ml ampules.
international recommendations.
vitamins
These are added into the parenteral
4 fat soluble
nutrition product prior to infusion,
vitamins
once daily.
Water soluble vitamins to be added
into water base products e.g.
Dextrose, amino acids or the all in
One PN bags but NOT to be added
into the single bottle of fat emulsion.
The fat soluble vitamins can only be
added into the fat emulsion bottle or
the All in One PN bags
follow instructions as specified
Trace element in adults for parenteral 10ml ampoule
nutrition based on international
Trace elements 1ml, 3ml, 10ml vials
recommendations e.g. zinc, copper,
chromium, manganese, selenium.
Table12: Pediatric Parenteral Nutritional Formulations
Feed Composition per 10 0mls Presentation
Special AA for Well balanced AA pattern 100ml, 250ml and 500ml
pediatrics specifically designed for infants bottles.
(preterm, new born, babies) and
6.5% (65g AA/l)
young children
7% (70g AA/L) Dosage: As per the child’s
Contains EAA and NEAA
age, weight and
10% (100g AA/L)
Similar to human breast milk recommendations
Contains taurine an EAA for
neonates
Special Amino acids As above for children above 6 As above
for hepatic and renal months of age
Dosage: As per the child’s
failure
age, weight and
recommendations
Carbohydrate The carbohydrate solutions 100ml, 500ml bottles
solutions mainly contain glucose
Dosage: As per the child’s
(presentations as age, weight and
Above for adults) recommendations
Lipid emulsions As Adults 100ml bottles
Dosage: As per the child’s age,
weight and recommendations
Vitamins: As Adults 10ml vial
Water soluble Dosage: As per the child’s age,
vitamins weight
Requirements will be calculated
as per the child’s weight
Fat soluble vitamins A multivitamin preparation of 10ml ampoule
for infants lipid soluble vitamins for
Dosage: As per the child’s
parenteral nutrition for infants
age, weight and
recommendations
Trace elements for Trace element additive for 10ml vial
children children in parenteral nutrition
based on international Dosage: As per the child’s
recommendations, to meet the age, weight and
basal requirements of trace recommendations
elements during intravenous
nutrition in infants and children
Current formulations in the market have the three chamber bags for peripheral and central
parenteral infusion.
Vitamin requirements in Parenteral Nutrition
It is recommended that all adult/pediatrics PN patients, be supplemented daily with a standard
multivitamin package. Table 47 below provides the standard vitamin package/requirement for
parenteral nutrition.
Table13: Vitamin requirements in parenteral nutrition
Vitamins Daily Requirements
B1 3.0 mg
B2 3.6 mg
Niacin 40.0 mg
Pantothenic Acid 15.0 mg
B6 4.0 mg
Biotin 60,0 mg
Folacin Acid 400.0 mg
B12 5.0 mg
C 100.0 mg
A 3,300 IU
D 200 IU
E 10 IU
K 300-500 mg
* AMA Recommendation, JPEN 1979
** Nutritional advisory group, JPEN 1998
Note: Vitamin supplementations for pediatrics are calculated as per the child’s weight.
Determining trace element requirements
The trace elements zinc, copper, chromium, manganese, iodine, iron, and selenium must be
provided in PN to prevent clinical deficiency. It is recommended that all adult PN patients be
supplemented daily with a standard trace element package as shown in the table below.
Table14: Recommendations for trace elements in parenteral nutrition
Adult patients mg/day µmol/day
Chromium (Cr) 0.010-0.015 0.19-0.29
Cobalt (Co)
Copper (Cu) 0.5-1.5 8-24
Fluorine (F) 1-3 53-158
Iron (Fe) 1-2 18-36
Iodine (I) 0.1-0.2 0.79-1.6
Manganese (Man) 0.15-0.8 2.7- 15
Molybdenum (Mo) 0.015-0.030 0.16-0.31
Selenium (Se) 0.03-0.06 0.38-0.76
Zinc (Zn) 2.5-4.0 38-61

Monitoring of Parenteral Nutrition

This is necessary to assess whether the regimen is suitable for the patient and also to confirm
and, if necessary correct the prescribed regime. To prevent possible complications, for example,
catheter related complications and metabolic related complications
Be careful to check:
The general condition of the patient
Patient’s daily body weight - bed weighing scales may be practical to check body weight daily at
the same time.
Nitrogen balance
Fat elimination - check fat tolerance test and plasma triglycerides
Blood electrolytes - including phosphate
Blood glucose
Micronutrients in the long-term parenteral nutrition patients
Summary of Parenteral Nutrition Guidelines in the Critical Care Unit
Source: JPEN 1998
All patients receiving less than target in 3 days enterally to receive PN within 24 to 48 hours of
admission once haemodynamically stable
NPE requirements to be calculated at 25 kcal/kg/d and increased to target over 2 – 3 days
Carbohydrate to be given at a minimum of 2g/kg/d as glucose, monitor blood sugars (BS), BS
>10mmol/l to be avoided
Lipids to be given at a dose of 0.7 – 1.5g/kg/d, EFA, EPA and DHA, live oil based, fish oil
added
Protein to be given at 1.3 –1.5g ideal body weight (IBW)
Amino acid solution should contain glutamine at a dose of 0.2 -.04g /kg/Bodyweight/d (0.3 –
0.6g alanyl-glutamine dipeptide)
Daily dose of multivitamin and trace element to be adhered to
PN admixtures to be administered as a complete All in One bag. If there is evidence of PEM on
admission and enteral nutrition is not feasible, it is appropriate to initiate parenteral nutrition as
soon as possible following admission and adequate resuscitation
If a patient is expected to undergo major upper GI surgery and EN is not feasible, PN should be
provided under specific conditions: If the patient is malnourished PN to be given 5-7 days
preoperatively and continued into the postoperative period
Wean PN gradually
Discontinue once the patient is able to adequately tolerate 60% of caloric requirements enterally

WEIGHT MANAGENT

ENERGY AND WEIGHT MANAGEMENT

Weight management for a healthy living depends on energy output and input.
If energy input is more than energy output you get a positive energy balance thus an
increase in weight whereas if energy input is less than energy output you get a negative
energy balance thus decrease in weight.
 For proper weight gain you need a positive energy balance and a negative energy balance
for weight loss therefore
o Energy balance = Energy intake – energy output
Component of weight
 Body weight = Bone + muscle + Organs + body fluids + Adipose tissue.
  Water consistent 60 – 65% body weight whereas adipose tissues varies through weight
gain and weight loss.

Adipose (fat) tissue – The primary form in which energy is stored. (Energy is stored in
the form of glycogen-that last only 12-36 hours; Muscle mass; and adipose (fat)
tissue).Adipose tissue fat is in form of triglycerides in the fat cells. Adult female require
an appropriate body fat of 20 – 25% body weight and 12% of this should be essential
including that of breast, thighs and pelvic region.
Adult male require 12 – 25% of body weight with 5 – 7% as essential fat.
Essential fat is stored both in bone marrow, lungs, kidney, intestines, muscles, brain,
heart and liver.
Storage fat – Fat that accumulates under the skin and internal organ and prevent them
from traumas.
Fat cell development
 Adipose tissues increases either by increase in the size of the cell (hypertrophy) or
increase in the number of fat cell (hyperplasia) or a combination of hypertrophy and
hyperplasia.
 Obesity is usually characterized by hypertrophy and fat deposits can expand up to 1000
times.
 Once fat cells are formed they are permanent and cannot be decreased in their numbers.
 After weight loss, the reduced cell size is unhappy and seeks to restore normal volume
hence the risk of weight gain.
Overweight and Obesity
 Overweight refers to a state in which the weight exceeds a standard based on height. (It is
a condition of excessive fatness).
Types of obesity
 Obese (equals or more than 30)
 Obese class I (30.0-39.9
 Obese class II (35.0-39.9).
 Obese class III (equals or more than 40)
Central obesity-It is where someone is obese and most of the fat is located in the central
abdominal parts of the body.(Obesity where there is a visceral fat in the body mostly the
abdomen).
N/B. Visceral fat (fat that collects deep within the central abdominal area of the body) may lead
to diabetes, stroke, hypertension and coronary artery disease. The risk from all causes may be
higher for those with central obesity than for those whose fat accumulates elsewhere in the body.
Assessment of weight
Weight can be assessed by the following methods.
 BMI
 Waist Hip ratio Waist circumference: It is a good indicator of fat distribution and
the best tool for evaluating central obesity/abdominal fat. Women with a waist
circumference ≥35 inches (88.9 cm) and men with a waist circumference greater than
40 inches (101.6 cm) have a high risk of central obesity – related health problems.
 Ideal body weight
 Percentile Chart for children
 Skinfold measurement- Provide an accurate estimate of total body fat and a fair
assessment of the fat’s location. About half of the fat in the body lies directly beneath
the skin, so the thickness of this subcutaneous fat is assumed to reflect total body fat.
Measures taken from central body sites (around the abdomen) better reflect changes
in fatness than those taken from upper sites (arm and back).
Causes of predisposing/risk factors to obesity and overweight
 Overweight and obesity are consequences of energy imbalance due to diet high in
energy/diet high in fat.
Hereditary/Genetics
 Obesity tends to run in families the probability of becoming obese when you have a lean
parents is 9 – 14% and 41 – 50% when you have a lean and obese parent. When you have
obese parents 66 – 80%.
Physiological factors
 Inability to respond to hunger and satiety may lead to obesity and overweight.
Hormonal factors
 Play a role on how a person may eat e.g. during stress you may eat less.
Regulatory dysfunction
 Some people respond to external cues than internal cues e.g. if given appetizing food
some people are unable to resist over eating.
Inactivity
 Poor physical activity is a risk factor to obesity and overweight.
Health Risks Associated with overweight and obesity
Health risks increase as BMI falls rise above 24.9. Independently, factors such as smoking habits
raise health risks, and physical fitness lowers them.
 Excess weight contributes to hypertension thereby increasing the risk of heart attack and
strokes. Obesity raises blood pressure in part by altering kidney function and promoting
fluid retention.
  Increased risk of type 2 diabetes. Most adults with type 2 diabetes are overweight or
obese, and these cause some degree of insulin resistance.
 High blood lipids
 Cardiovascular diseases
 Sleep apnea (abnormal ceasing of breathing during sleep)
 Osteoarthritis
 Abdominal hernias
 Some cancers
 Varicose veins
 Gout
 Gallbladder disease
 Kidney stones
 Respiratory problems
 Complications in pregnancy and surgery
Management of obesity and overweight
There are ways of management – diet, regular physical activity, behavior modification and
surgery.
1. Diet
 Energy-Calorie restricted diet is needed to achieve negative energy balance. It should
be nutritionally adequate except for energy which should be low to a point where fat
stores are mobilized. Most adults will loose weight at intakes of 1200 – 1300kcal/day.
However diet less than 1500 kcals pauses a risk since it is likely to lead to excessive
loss of lean tissues.
 Protein: To preserve lean body mass, daily protein intake should be in the range of
0.8 to 1.2 g/kg of body weight
 Fat: Fat should account for 20% to 30% of total energy. Saturated fats should be
limited to less than 6% to 8% of total fat energy. Diets with low to moderate fat
intake (15% to 30% of total energy) tend be lower in total energy and highest in diet
quality when compared to low-carbohydrate diets.
 Carbohydrates: Carbohydrates should account for 50% to 60% of total energy.
Carbohydrates can help prevent the loss of lean tissue.
 Calcium: A review of evidence suggest calcium intake lower than the recommended
level is associated with increased body weight. The research suggests that a calcium
rich diet especially one that include dairy sources(with limit to total calories) not only
helps young women keep weight in check may reduce overall levels of body fat.
Calcium may depress certain hormones which consequently improves the body’s
ability to breakdown fat in cells and slow fat production
 High fiber diet.
N/B. Benefits of high fiber-Low in calorie, High in minerals and vitamins especially greens, give
satiety, help in regulating bowel movements, reduce blood cholesterol, promote chewing and
decreases rate of ingestion/constipation
 Adequate water/fluids: in weight management, water is to satisfy thirst. Water helps
with weight management in several ways
o Food with high water content increase fullness, reduce hunger and
consequently reduce energy intake
o Drinking a large glass of water before a meal may ease hunger, fill the
stomach, and reduce energy intake/food intake. Water adds no kcalories, and
it helps the GI tract adapt to a high fiber diet.
2. Regular physical activity
 The burning of kcals is influenced by duration and frequency of physical activity.
Exercise can help increase BMR, manage stress and increase vascularity of blood vessels.
Benefits of regular physical activity
 Improve cardiovascular functions.
 Increases HDL and lower insulin resistance.
 Lead to weight loss.
 It regulates appetite and increases BMR.
 It decreases stress especially diet related.
 Increases bone mineralization thereby decreasing the risk of bone weakening.
3. Behavior Modification (e.g. watching TV, rate of chewing)
 It helps control energy intake and weight loss. It involves self-evaluation to identify the
behavior that is bringing the weight gain.
4. Bariatric surgery
 It advised for patients with a BMI of more than 40 or for diabetic obese patients with
BMI of 35-40. Bariatric surgery is where the volume of the stomach is reduced mostly
through gastric bypass
Rate and extent of weight loss
 It’s recommended to loss ½(0.5) kg/weight leading to a loss of approximately 10% of
weight reduction and this can be achieved by reducing kcals intake by 500kcals to
1000kcals/day.
 The final goal should be individualized and realistic e.g. for people with morbid obesity,
ideal body weight or BML may not be realistic.
 WHO recommends a weight loss of 0.5-1kg per week
Advantages of weight loss
 Reduction in blood pressure
  Reduces total cholesterol and LDL cholesterol
 Increases in physical activity that comes with more benefits
 Lower blood glucose level
 Reduced risks of diabetes mellitus, heart diseases and cancer
WEIGHT MANAGENT

ENERGY AND WEIGHT MANAGEMENT

 Weight management for a healthy living depends on energy output and input.
 If energy input is more than energy output you get a positive energy balance thus an
increase in weight whereas if energy input is less than energy output you get a negative
energy balance thus decrease in weight.
 For proper weight gain you need a positive energy balance and a negative energy balance
for weight loss therefore
o Energy balance = Energy intake – energy output
Component of weight
 Body weight = Bone + muscle + Organs + body fluids + Adipose tissue.
 Water consistent 60 – 65% body weight whereas adipose tissues varies through weight
gain and weight loss.

Adipose (fat) tissue – The primary form in which energy is stored. (Energy is stored in
the form of glycogen-that last only 12-36 hours; Muscle mass; and adipose (fat)
tissue).Adipose tissue fat is in form of triglycerides in the fat cells. Adult female require
an appropriate body fat of 20 – 25% body weight and 12% of this should be essential
including that of breast, thighs and pelvic region.
Adult male require 12 – 25% of body weight with 5 – 7% as essential fat.
Essential fat is stored both in bone marrow, lungs, kidney, intestines, muscles, brain,
heart and liver.
Storage fat – Fat that accumulates under the skin and internal organ and prevent them
from traumas.
Fat cell development
 Adipose tissues increases either by increase in the size of the cell (hypertrophy) or
increase in the number of fat cell (hyperplasia) or a combination of hypertrophy and
hyperplasia.
 Obesity is usually characterized by hypertrophy and fat deposits can expand up to 1000
times.
 Once fat cells are formed they are permanent and cannot be decreased in their numbers.
 After weight loss, the reduced cell size is unhappy and seeks to restore normal volume
hence the risk of weight gain.
Overweight and Obesity
 Overweight refers to a state in which the weight exceeds a standard based on height. (It is
a condition of excessive fatness).
Types of obesity
 Obese (equals or more than 30)
 Obese class I (30.0-39.9
 Obese class II (35.0-39.9).
 Obese class III (equals or more than 40)
Central obesity-It is where someone is obese and most of the fat is located in the central
abdominal parts of the body.(Obesity where there is a visceral fat in the body mostly the
abdomen).
N/B. Visceral fat (fat that collects deep within the central abdominal area of the body) may lead
to diabetes, stroke, hypertension and coronary artery disease. The risk from all causes may be
higher for those with central obesity than for those whose fat accumulates elsewhere in the body.
Assessment of weight
Weight can be assessed by the following methods.
 BMI
 Waist Hip ratio Waist circumference: It is a good indicator of fat distribution and
the best tool for evaluating central obesity/abdominal fat. Women with a waist
circumference ≥35 inches (88.9 cm) and men with a waist circumference greater than
40 inches (101.6 cm) have a high risk of central obesity – related health problems.
 Ideal body weight
 Percentile Chart for children
 Skinfold measurement- Provide an accurate estimate of total body fat and a fair
assessment of the fat’s location. About half of the fat in the body lies directly beneath
the skin, so the thickness of this subcutaneous fat is assumed to reflect total body fat.
Measures taken from central body sites (around the abdomen) better reflect changes
in fatness than those taken from upper sites (arm and back).
Causes of predisposing/risk factors to obesity and overweight
 Overweight and obesity are consequences of energy imbalance due to diet high in
energy/diet high in fat.
Hereditary/Genetics
 Obesity tends to run in families the probability of becoming obese when you have a lean
parents is 9 – 14% and 41 – 50% when you have a lean and obese parent. When you have
obese parents 66 – 80%.
Physiological factors
  Inability to respond to hunger and satiety may lead to obesity and overweight.
Hormonal factors
 Play a role on how a person may eat e.g. during stress you may eat less.
Regulatory dysfunction
 Some people respond to external cues than internal cues e.g. if given appetizing food
some people are unable to resist over eating.
Inactivity
 Poor physical activity is a risk factor to obesity and overweight.
Health Risks Associated with overweight and obesity
Health risks increase as BMI falls rise above 24.9. Independently, factors such as smoking habits
raise health risks, and physical fitness lowers them.
 Excess weight contributes to hypertension thereby increasing the risk of heart attack and
strokes. Obesity raises blood pressure in part by altering kidney function and promoting
fluid retention.
 Increased risk of type 2 diabetes. Most adults with type 2 diabetes are overweight or
obese, and these cause some degree of insulin resistance.
 High blood lipids
 Cardiovascular diseases
 Sleep apnea (abnormal ceasing of breathing during sleep)
 Osteoarthritis
 Abdominal hernias
 Some cancers
 Varicose veins
 Gout
 Gallbladder disease
 Kidney stones
 Respiratory problems
 Complications in pregnancy and surgery
Management of obesity and overweight
There are ways of management – diet, regular physical activity, behavior modification and
surgery.
1. Diet
 Energy-Calorie restricted diet is needed to achieve negative energy balance. It should
be nutritionally adequate except for energy which should be low to a point where fat
stores are mobilized. Most adults will loose weight at intakes of 1200 – 1300kcal/day.
However diet less than 1500 kcals pauses a risk since it is likely to lead to excessive
loss of lean tissues.
  Protein: To preserve lean body mass, daily protein intake should be in the range of
0.8 to 1.2 g/kg of body weight
 Fat: Fat should account for 20% to 30% of total energy. Saturated fats should be
limited to less than 6% to 8% of total fat energy. Diets with low to moderate fat
intake (15% to 30% of total energy) tend be lower in total energy and highest in diet
quality when compared to low-carbohydrate diets.
 Carbohydrates: Carbohydrates should account for 50% to 60% of total energy.
Carbohydrates can help prevent the loss of lean tissue.
 Calcium: A review of evidence suggest calcium intake lower than the recommended
level is associated with increased body weight. The research suggests that a calcium
rich diet especially one that include dairy sources(with limit to total calories) not only
helps young women keep weight in check may reduce overall levels of body fat.
Calcium may depress certain hormones which consequently improves the body’s
ability to breakdown fat in cells and slow fat production
 High fiber diet.
N/B. Benefits of high fiber-Low in calorie, High in minerals and vitamins especially greens, give
satiety, help in regulating bowel movements, reduce blood cholesterol, promote chewing and
decreases rate of ingestion/constipation
 Adequate water/fluids: in weight management, water is to satisfy thirst. Water helps
with weight management in several ways
o Food with high water content increase fullness, reduce hunger and
consequently reduce energy intake
o Drinking a large glass of water before a meal may ease hunger, fill the
stomach, and reduce energy intake/food intake. Water adds no kcalories, and
it helps the GI tract adapt to a high fiber diet.
2. Regular physical activity
 The burning of kcals is influenced by duration and frequency of physical activity.
Exercise can help increase BMR, manage stress and increase vascularity of blood vessels.
Benefits of regular physical activity
 Improve cardiovascular functions.
 Increases HDL and lower insulin resistance.
 Lead to weight loss.
 It regulates appetite and increases BMR.
 It decreases stress especially diet related.
 Increases bone mineralization thereby decreasing the risk of bone weakening.
3. Behavior Modification (e.g. watching TV, rate of chewing)
 It helps control energy intake and weight loss. It involves self-evaluation to identify the
behavior that is bringing the weight gain.
4. Bariatric surgery
 It advised for patients with a BMI of more than 40 or for diabetic obese patients with
BMI of 35-40. Bariatric surgery is where the volume of the stomach is reduced mostly
through gastric bypass
Rate and extent of weight loss
 It’s recommended to loss ½(0.5) kg/weight leading to a loss of approximately 10% of
weight reduction and this can be achieved by reducing kcals intake by 500kcals to
1000kcals/day.
 The final goal should be individualized and realistic e.g. for people with morbid obesity,
ideal body weight or BML may not be realistic.
 WHO recommends a weight loss of 0.5-1kg per week
Advantages of weight loss
 Reduction in blood pressure
 Reduces total cholesterol and LDL cholesterol
 Increases in physical activity that comes with more benefits
 Lower blood glucose level
 Reduced risks of diabetes mellitus, heart diseases and cancer
UNDERWEIGHT
This is when a patient, adult has BMI less than 18.5
Health risk factors of low body weight.
 Increase in morbidity and mortality due to lowered resistance and infection and injuries.
 Under functioning of some glands e.g. Pituitary, thyroid adrenal and gonads which could
lead to infertility and loss of menstruation.
 Chronic fatigue.
 Anemia
 Psychological problems e.g. Anorexia, bulimia, depression, anorexia nervosa.
 Underweight and significant weight loss are also associated with osteoporosis and bone
fractures

Causes of underweight
1. Inadequate intake of calories to meet activity needs.
2. Excess activities or compulsive athletic training.
3. Poor absorption and utilization of food.
4. Metabolic and pathological condition/diseases e.g. HIV, cancer, TB
5. Psychological or emotional stress e.g. nervosa and bulimia
Management of underweight
Assessment of the cause and extent of the underweight should be done before starting any
treatment. The diet should be high in energy and protein to build the muscles.
Strategies of weight gain
Energy. For increasing weight the total calorie intake should be in excess of the energy
requirement. An additional 500kcals per is recommended this will result into a weekly
gain of 1/2kg or
Limiting low calorie foods or by enriching the foods/giving energy dense foods e.g.
adding sugar, honey.
Protein: Instead of 1 g of protein, over 1.2 g per kg is recommended for tissue building
Fats: Increased fat is recommended. Easily digestible fats are recommended. Fried foods
and fatty foods are not recommended as they may cause diarrhea. Fatty foods should not
be taken at the beginning of a meal as they reduce appetite. High calorie fatty foods such
as cream, butter, margarine and oils help to increase weight
Carbohydrates: High carbohydrate sources must form the basis of the diet.
Fluids: Fluids should not be taken before or with a meal but only after a meal so that
food intake is not reduced
Regular meals, no skipping of meals at least 3 meals daily and if possible 6 meals a day.
Regular moderate exercise to stimulate appetite and build up muscles.
GASTRO INTESTINAL DISEASES
Introduction
The gastro intestinal tract also called the alimentary canal; is a long hollow tube that begins at
the mouth and ends at the anus.
It’s made up of the mouth, esophagus, stomach, small intestine, large intestine (colon) and
rectum. Other organs that lie outside the tract but support its work by secretion of important
enzymes and digestive fluids are gall bladder and the liver.
1. Disorder of the mouth/mouth problems

Tissues of the mouth often reflect a person nutritional status. In malnutrition, tissues of the
mouth deteriorate and become inflamed and are more vulnerable to infection, injury, pain and
difficulties with eating. The conditions of the mouth are:
 Gingivitis

This refers to inflammation of the gums and the affected gums bleed during tooth brushing.
 Stomatitis

This refers to the inflammation of the oral mucosa lining of the mouth.
  Glossitis

Refers to inflammation of the tongue whereby there is wounds in the tongue.

 Cheilosis

Refers to the cracking at the corner of the mouth affecting the lips and the corner angers making
opening of the mouth to receive food difficult.

Nutrition implications
1. Reduced food intake and difficulty in swallowing (dysphagia).
2. Loss of blood.

Management
1. Nutrition therapy

Give high protein diet for wound healing

High caloric liquid and then soft food (diet)
Give non acidic and without strong spices to avoid irritation.
Do not give hot foods which may cause pain
Give foods reach in vitamin C and iron
Give small quantity of food but at a frequent interval
2. Medical therapy

Use of mouth washes before meals to relieve pain

Use of antibiotics

2. Esophagus problem/disorders
Esophagus is a long muscular tube lined with mucus membrane that extends from the
pharynx/throat to the stomach. It has 2 sphincters that control the movement of food into the
esophagus and into the stomach that is the upper and lower sphincter and it’s about 25cm long.
Lower esophageal sphincter problems
Achalasia
This is where the lower esophageal sphincter (LES) does not relax normally when presented with
food during swallowing, thus resulting into obstruction at the gastro-esophageal junction ie it’s a
disorder in which the esophagus is less able to move food towards the stomach.
Nutrition implications and signs
1. Dysphasia (difficulty in swallowing)
2. Regurgitation
3. Chest pain
4. Heart burn
5. Weight loss

Management
1. Give nutrient dense liquid and semi solid foods taken at moderate temperature.
2. Give small quantities of food but at frequent intervals.

Gastro esophageal reflux diseases (GERD)

This refers to the backflow/regurgitation of gastric contents from the stomach into esophagus.
The regurgitation of the acid gastric contents into the lower part of the esophagus causes
irritation (burning sensation) of the walls of the esophagus as its wall do not have linings to
prevent it from the acid.
Signs and symptoms
 Heart burn
 Regurgitation
 Chronic bleeding and aspiration which may result into coughing and dyspnea
 Sour throat
 Excessive belching
 Frequent throat clearing
 Breathing problems (sinusitis)
 Dysphagia

Causes of GERD
1. Pregnancy (estrogen and progesterone) can reduce LES pressure thus causing the valve
separating the esophagus and stomach not to close properly.
2. Hiatel – hernia
3. Obesity
4. Nasogastric tubes can cause aspirations
5. Use of some drugs to treat certain conditions
6. Radiation such as for lung cancer treatment
7. Aging
8. Fungal infection
 9. Stress

Aims of nutritional management

 Prevent irritation of the oesophageal mucosa in the acute phase
 Prevent oesophageal reflux
 Decrease the irritating capacity or acidity of gastric juice

Management of GERD
1. Nutrition therapy – nutrition plays a major role in the management of GERD
 Provide low fat food and small frequent meals
 Avoid acidic foods such as citrus fruits, tomato products, coffee, carbonated drinks,
alcohol and spices.
 Iron supplements/iron rich foods for chronic bleeding
 Avoid large meals at night
 Reduce weight if overweight
 Avoid smoking as it triggers acid production

N/B Symptoms are aggravated by lying down or by any increase of abdominal pressure e.g. tight
clothing
2. Medical therapy – Many people do use anti acids and other drugs e.g. omeprazole but
the use of antacids has a nutritional complications e.g.

They have effects on the absorption of vitamin and iron and therefore it should be taken at least 2
hours before/after iron supplementation.
Effects of the aluminum containing anti acids may be decreased by high protein meals.
Folate absorption/utilization may be impaired by anti acids thus resulting into neural tube defects
as well as genital abnormalities of the heart, palate and urinary tract. Provide folate
supplementation to offset the increased risk.
Prolonged anti acid used with excessive consumption of calcium may cause high calcium levels
that may result into serious metabolic diseases.
3. Mechanical management
 Reduce weight
 Avoid bending/leaning over or lying down immediately after meals
 Avoid tight clothing
 Elevate head of bed/use pillows

Lifestyle
 avoid smoking as it triggers acid production
  Avoid alcohol

N/B (LES- is a valve at the entrance of the stomach. LES closes as soon as food passes through
it. If LES does not close all the way or if it happens too often, acid produced by your stomach
can move up into the esophagus causing a burning chest pain called heartburn. If acid reflux
symptoms happens more than twice a week then you have acid reflux disease also known as
GERD

Hiatel – hernia
This is where a portion of the upper part of the stomach protrudes through the hiatus (diaphragm)
into the chest.
Diagram
Food is easily held in this herniated area of the stomach and mix with acid, then regurgitated
back up into the lower part of the esophagus. Gastritis (inflammation of the lining of the
stomach) may occur in the herniated portion of the stomach and cause bleeding and anemia
Symptoms as in GERD
Management
As in GERD
Large hiatal hernia may require surgical operation
Other esophagus problem: Esophagitis-This refers to the inflammation of the esophagus
usually caused by GERD

3. Problems of the stomach and duodenum

i) Peptic ulcer disease
Definition of terms
Mucosa – Mucus secreting membrane lining all body cavities
Mucosal membrane – a thin sheet of material that covers the organs or cavities
Sub mucosa – the connective tissue that lies below the mucosa membrane.
Ulcer – refers to the loss of tissue on the surface of the mucosa or ulcers are open sores or
lessons. They are found in the skin or mucus membrane of the body.
Peptic ulcer is the general term for an eroded lining or sore of the lower portion of esophagus,
stomach and first portion of the duodenum (central portion of the GI tract). It occurs when these
 central GI tract is corroded by pepsin (an enzyme produced by the cells of the stomach that splits
proteins into peptones. This enzyme is acidic in nature).The pepsin wears away the protective
mucus layer of the central GI tract. Ulcer can also be caused by HCL. A peptic ulcer of the
stomach is called gastric ulcer; of the duodenum, a duodenal ulcer. And of esophagus, an
esophageal ulcer.
Although there is much overlap, symptoms of a gastric ulcer may differ from those of a duodenal
ulcer.
i. Duodenal ulcer
 Pain may occur or worsen when the stomach is empty, usually two to five hours after a
meal.
 Symptoms may occur at night between 11 PM and 2 AM, when acid secretion tends to be
greatest.
 Duodenal ulcers is the most common and normally occur at age 20-30
 Patients with duodenal ulcers may gain weight from frequent eating to counteract pain.
ii. Gastric ulcer
 Symptoms of a gastric ulcer typically include pain soon after eating.
 Symptoms are sometimes not relieved by eating or taking antacids.
 Normally occur at age 45-60
 Weight loss is common
Cause of peptic ulcers
 Peptic ulcers is caused by helicobacter pylori (H pylori produces urease which
neutralizes the stomach acid –from HCL and pepsin and allows H pylori to grow in acid
free zone. This enzyme also injure the cells of the stomach or duodenum) or
 Intake of non-steroidal anti-inflammatory drug (NSAIDS) e.g. Aspirin, declophenac,
Panadol, brufen. They damage the stomach lining thus living the stomach vulnerable to
the effects of HCL and pepsin

Other risk factors include; they aggravate the existing ulcer

 Stress which causes vasoconstriction or reduced blood supply to the gastric mucosa
leaving it unprotected.
 Hereditary factors; Family history of ulcers is often in ulcer patients.
 Eating habits; eating hurriedly, improper mastication of food and skipping of meals.
 Irritants e.g. alcohol, cigarettes, caffeine and spices. Smoke has nicotine that concentrate
the HCL and induce increased production

Symptoms of peptic ulcer

 Painful hunger (burning, gnawing, aching) contractions usually in the upper

abdomen
 Anemia
  Blood in the stools
 Hemorrhage
 Bloating
 Low plasma protein levels
 Vomiting
 Low weight in gastric ulcer and gain weight in duodenal ulcer.

NB: The amount of concentration of hydrochloric acid is higher in duodenal ulcers while in
gastric ulcer the amount and concentration is normal.

Management
Medical therapy – take medicine regularly as prescribed e.g. Use of anti- acids, antibiotics and
omeprasoles one to three hours after meals or before bed times.
Nutritional management –
1. Limit the foods and seasoning that increase acid secretions/inhibit healing.
a) Caffeine (including coffee and strong tea) and chocolate, spices and black pepper
b) Unripe citrus fruits like oranges
c) Sour foods
d) Seasonings such as pepper, garlic, ginger, chilies and strong spices.

2. Avoid foods that are high in fiber that are irritating

3. Eat slowly
4. Give foods high in iron/iron supplements may be provided
5. Fat: a moderate intake of fat is beneficial since fat delays the empting of the stomach but
fatty foods should be avoided e.g. fried foods and fatty foods
6. Give small quantity but frequent meals to ensure that the stomach is not empty, at least 3
regular meals daily.
7. Protein: a high protein intake to promote healing of the wounds and to provide buffering
action
3. Eating less than 2 hours before bed time
4. Use of probiotics

Foods high in vitamin C, A, Protein, zinc enhance the healing of the gut wall
NB 1: Milk (a historical food for peptic ulcer diseases) does not aid in ulcer healing and
actually promote gastric acid promotion i.e. Milk is an alkaline that neutralizes the
stomach acid thus provides a temporary relief however, it increase acid secretion thus
delays the healing of the ulcers. Other foods that increase acid secretion are coffee, soft
drinks and alcohol.
N/B 2. Fermented milk is good in the prevention of ulcers as the probiotic (the live
bacteria-e.g. lactobacillus bulgaricus) in milk prevents the growth of ulcer causing bacteria,
H-Pylori. Combining probiotic treatment with omeprazole, amoxicillin, and clarithromycin
in H pylori–improves the treatment effectiveness, compared with drug treatment alone.

Some specific foods to be given are

 Cabbage-cabbage has anti-inflammatory effects.
 Spinach- has low fiber.
 Potatoes: nutritive and anti-acid
 Okra: contain mucilage capable of protecting gastric mucosa
 Other vegetables are carrots.
 Fruits: apples, ripe bananas, avocado, pawpaw, pears, guava, orange juice
 Cereals: oat meal, porridge with low fibre, chapatti, macaroni, spaghetti, rice, matoke
 Tea-has flavonoids resposibles for healing effect
 Eggs e.g. scrambled
 However roast beef and lamp, stewed/ baked should be taken in moderation as they
contain pureness (that stimulate gastric mucosa)

Lifestyle habits:
 Avoid alcohol, cigarette smoking and NSAIDS
 Minimize stress as stress cause hyper secretion of gastric acid

N/B. Not everyone with “ulcer” symptoms has an ulcer. Symptoms similar to those of peptic
ulcers can be caused by a wide variety of conditions. The differential diagnoses of peptic ulcers
are:-
 Functional dyspepsia (i.e., the presence of ulcer-symptoms without a specific cause)
 Abnormal emptying of the stomach
 Acid reflux
 Gallbladder problems
 Much less commonly, stomach cancer.
 2. INDIGESTION (dyspepsia)
This refers to any discomfort in the digestive tract or it refers to a feeling of fullness or
discomfort during or after meal
It’s mainly caused by gall bladder disease, chronic appendicitis, ulcer, stress, rapid eating, poor
mastication etc.
Symptoms
 Discomfort in the digestive tract
 Feeling of fullness or discomfort during or after meal

Nutritional implication
 Inadequate food and nutrient intake

Nutrition therapy/dietary management

 Provide a well-balanced diet
 Avoid rapid eating and poor mastication of food
 Give plenty of water

3. Acute Gastritis
This is a temporary inflammation of the gastric mucosa (the lining of the stomach). Unlike
chronic gastritis that develop slowly, acute gastritis occurs suddenly
Causes
 Overeating
 Overuse of alcohol and tobacco
 Chronic and excessive uses of aspirin/non-steroidal anti-inflammatory drugs (NSAIDS),
trauma and shock, fever, renal failure, burns, food poisoning, H pylori and chronic
vomiting etc.

Symptoms
 Nausea
 Vomiting
 Feeling of fullness in the upper part of abdomen
 Burning pain in your upper abdomen

Nutrition implications
 Anemia
  Loss of nutrients
 Increased metabolism

Dietary management
1. To allow the stomach time to rest and heal, withhold food for 24 – 48 hours or longer
depending on whether there is bleeding or not.
2. Give fluids intravenously during this period.
3. Increase the amount of foods according to the patient’s tolerance until a full regular diet
is achieved.
4. Avoid seasoned foods.

4. Chronic Gastritis
This refers to a condition (gastritis) that occurs slowly overtime resulting into irreversible
atrophy of the gastric mucosa related to chronic inflammation.
Loss of mucosal cell functions may lead to lack of HCL in the stomach, anemia and malnutrition.
5. Damping syndrome (rapid gastric emptying)
Damping syndrome is a condition where the lower end of the small intestine (jejunum) fills too
quickly with undigested food from the stomach. It develops after a survey to remove part of the
stomach usually pyloric sphincter/after surgery to bypass the stomach to help you loose weight,
bariatric surgery/weight loss surgery.
This causes partially digested food to rapidly enter jejunum too quickly (in an uncontrolled,
abnormal fast manner) causing hyperosmolar load.
Fluids from the intestinal capillarities enter the jejunum thus resulting into low blood pressure
and also stimulates peristalisis thus resulting into diarrhea.
Causes of the Dumping Syndrome
 Gastric surgery – removal of part of the stomach/gastric bypass surgery

Symptoms
 Abdominal cramps
 Diarrhea
 Vomiting
 Bloating
 Sweating
 Rapid pulse rate
 Shortness of breath
  Weakness
 Dizziness and paleness

 Early dumping syndrome-It is where people develop signs and symptoms (diarrhea,
nausea, vomiting, bloating, shortness of breath and abdominal cramps) during or right
after meal (10-30 minutes)
 Late dumping syndrome- It is where people develop signs and symptoms 1-3 hours after
eating
 While others have both early and late symptoms

Nutritional implications
 Loss of nutrients
 Weight loss

Nutrition therapy
 All fluids and foods by mouth should be withheld for 3 – 5 days and the patients feed by
Nasogastric tube
 Give pectin, a dietary fibre found in fruits and vegetables as it helps in treating dumping
syndrome by delaying gastric empting and slow carbohydrate absorption.
 Vitamin and mineral supplementation may be necessary.
 Serve liquids between meals rather with meals to slow the passage of the food mass.
 Limit simple carbohydrates
 Lie down immediately after eating to help slow the transit of food to the intestine but
clients with reflux should not lie down after eating.

4. Disorders of the small intestine

1. Diarrhea and Malabsorption
Diarrhea refers to an increase in frequency of bowel movements compared with the usual
pattern/excess water content of stools affecting consistency/volume/both.
Diarrhea is not a disease but a symptom of a medical condition either in the small intestine, large
intestine, pancreas or other conditions such as lactose intolerance, HIV, mal absorption and
irritable bowel syndrome etc.
NB: General diarrhea may result from basic dietary excess e.g. excess fiber/sugar.
Categories of diarrhea
Acute diarrhea – characterized by sudden onset and frequent passage of watery stool. It lasts for
24 – 48 hours.
Symptoms: abdominal pain, fever and vomiting.
Chronic diarrhea – persist for a longer period of time and may last for several weeks.
Management
Medical therapy
 Treat the underlying cause
 Ors may be given in severe acute diarrhea.

Dietary modification
 Give a low fiber diet, mostly simple carbohydrates
 Low fat diet (to avoid malabsorption)
 Bland diet: Spicy diet may cause irritation of the stomach.
 Plenty of fluids to provide for lost fluids and electrolytes
 Energy – increase energy if the diarrhea is accompanied by fever.
 Increased intake for vitamin for the loss of vitamins
 Increased mineral intake mostly sodium and potassium
 Small quantities of food at frequent intervals. Excess will cause pressure in the GIT

Malabsorption
This is where there is interference with how nutrients are absorbed/digested
There are 4 malabsorption conditions
1. Celiac disease
2. Cystic fibrosis
3. IBD (inflammatory bowel diseases)
4. Short bowel syndrome

Celiac disease
It’s an inherited disorder that causes damage to the small intestine and interferes with the
absorption of the nutrients.
People who have celiac diseases cannot tolerate gluten, a protein found in cereal grains such as
Wheat, barley etc.
Gluten molecules combine with antibiotics in the small intestine causing the usually brush like
lining of the intestine to flatten thus affecting the digestion and absorption of foods.
Management
 Avoid food with gluten

Cystic fibrosis
It’s an inherited disorder that mostly affects the white people and can be classified as either
gastro – intestinal disorder or respiratory disorder
It’s where there is a high mucus secretion that obstructs endocrine glands, the lungs and ducts.
Symptoms
 Bulky, foul smelling, oily stool
 Malabsorption
 Excessive sweeting in hot weather
 Thick mucus that accumulates on the endocrine glands, lungs

Nutrition therapy
 High energy diet
 High protein diet

Inflammatory bowel disease

The term inflammatory bowel is used to apply to two intestinal conditions that result into
inflammation of the bowel i.e. crohn’s disease and ulcerative colitis
Predisposing factors
 Hereditary
 Environment e.g. crohn’s disease is higher in industrialized areas
 Immune functions

Difference between crohn’s disease and ulcerative colitis

Difference
Definition Crohn’s disease( a chronic Ulcerative colitis( a chronic
inflammation of the intestine) inflammation of the large intestine
that begins in the rectum)
Cause Inadequate intake of food, zinc Unknown but it’s likely that intestinal
deficiency, malabsorption of fats and allergy caused by some food e.g. Milk
protein, fever may be responsible
Cite of Any part of the GIT (from mouth to Inflammation and ulceration of large
inflammation the anus) but mostly the small intestine(colon) that always begin in the
intestine. rectum .Rectal bleeding is common
The inflammation affects the GIT
 from mouth to anus but may skip
certain areas
Symptoms:
Weight loss : common Weight loss: Common
Diarrhea: common (passage of loose Common (alternating periods of
stools with mucus and blood diarrhea and constipation)
accompanied by pain)
Steatorrhea: sometimes it can result No steatorrhea
into loss of calcium, magnesium and
zinc.
Fever: yes No

Other symptoms: anorexia, fatigue Loss of appetite, rectal bleeding,

cramping dehydration, electrolyte imbalance,
anorexia mal absorption

Crohn’s disease
Definition
 Crohn’s disease is a chronic inflammatory bowel disease that affect any part of the GIT,
from mouth to the anus, but the inflammation mostly occurs in the small intestine.

Cause:
 Inadequate intake of food
 zinc deficiency,
 malabsorption of fats and protein
 fever

Symptoms of Crohn’s disease

 Fatigue,
 Anorexia
 variable weight loss
 right lower quadrant pain or cramping
 diarrhoea
 steatorrhea
 Fever.
Nutrition implications
 Inadequate food and nutrient intake
 Malabsorption and mal-digestion
 Increased nutrient needs
Aims of nutrition management
 Restoration of good nutritional status
 Relief of discomfort

Management

Dietary management
 During acute flare-ups bowel rest and parenteral nutrition is recommended
 Later in patients who cannot tolerate whole foods elemental oral formula maybe useful
 Energy and protein content of the diet should be high to promote healing and restore
weight. Provide 40 – 50Kcal/Kg, and for protein 1 – 1.5g/Kg
 Give a low fibber diet to minimize bowel stimulation
 Give small frequent meals that are better tolerated than three large meals, this may help
maximize intake
 Assess status of calcium, magnesium and zinc since steatorrhea promotes their loss

Medical therapy
 Drugs e.g. antibiotics
 Surgical operation mostly for people suffering from people suffering from ulcerative
colitis where the colon or rectum may be removed.

Nutrition therapy
 Low fiber diet
 Give iron because of bleeding
 High protein diet for wound healing 1-1.5g/kg/body weight
 High calorie diet 40-50 kcal/kg body weight
 Low fat diet
 Small frequent meals
 Provision of vitamin A,C, E, B12, and Folate
 Provision of pro-biotic and pre-biotic to promote growth of flora in the colon and
intestine.

Provision of calcium ,zinc and magnesium since Ulcerative colitis

Definition
 Ulcerative colitis is a chronic inflammation of the large intestine (colon) that begins in
the rectum)
Cause: Unknown but it’s likely that intestinal allergy caused by some food e.g. Milk may be
responsible
Symptoms
 Passage of loose stool with mucus and blood accompanied by pain and spasms
 Loss of appetite
 Rectal bleeding
 Ulcerative lesions in the mucosa of the large intestines
 Dehydration
 Electrolyte imbalance
 Anorexia
 Malnutrition
Nutrition implications
 Anaemia due to rectal bleeding
 Increased nutrient needs
 Fluid imbalance
 Food mal-digestion and nutrient malabsorption
Aims of nutrition management
 To relieve pain and inflammation
 To restore and maintain optimal nutritional status
Dietary management
 Same as in Crohn’ disease. However, no dietary interventions seem to lessen disease
activity. And unlike Crohn’s disease where intestinal surgery fails to cure the disorder,
removal of the colon and the rectum does cure ulcerative colitis

Gastroenteritis-This refers to the inflammation of the stomach and intestine

Short Bowel Syndrome
 It is a malabsorptive condition that results after surgical removal of the parts of the small
intestine (usually 2/3 of the ileum and the ileocecal valve) with extensive dysfunction
of the remaining portion of the organ or it refers to malabsorptive condition that results
after surgical removal of more than 50% of the small intestine
 Ileocecal valve is the valve between ileum and the caecum. It prevents the backflow of
materials from the large intestine to the small intestine.
 Removal of some parts of the ileum and the valve promotes a transit time too rapid for
sufficient absorption of nutrients such as water, electrolytes, proteins, fats, carbohydrates,
vitamins and minerals thus resulting into malnutrition. Resection (surgical removal of
about 50% of the small intestine) can be done to conditions such as crohn’s disease,
abdominal injury and traumas.
Management
  Enteral or parenteral nutrition as the small intestine adapts to its function( remaining
villi may enlarge and lengthen to increase the absorptive surface area of the
remaining intestine)
 Reduced fat intake as the remaining intestine adopts.
 Increased electrolyte intake, vitamin and mineral.
Disorders of the large intestine
1. Flatulence – refers to the condition of having excessive stomach/intestinal gas as a result
of swallowed air (when eating, swallowing and chewing gum) or production in the GIT.
Most swallowed air is expelled from the stomach by belching and is odorless. Some
travel into the large intestines and is mixed with the gas produced by the bacteria in the
large intestine and is expelled through the anus. Increased amount of rectal gas indicate
excessive bacterial fermentation and suggest malabsorption of a fermentable substance
The unpleasant odor of the flatulence is as a result of the gases that contain sulphur
produced by the bacteria that mix with the odorless CO2, O2, hydrogen, nitrogen and
sometimes methane that are produced in the intestine or swallowed
Management
Medical therapy
 Use of drugs
Nutrition therapy
 Reduction in the amount of gas swallowed(aerophogia)-aerophagia can be avoided by
eating slowly, chewing with mouth closed and refraining from drinking through straws
 Reduction in fiber intake and other foods that results into increased production of gases
eg beans, cabbage, broccoli, whole grains, milk and its products, onions, apples, pears,
potatoes and decrease in intake of food that contains artificial sweeteners e.g gums
NB: Rice is the only starch that does not produce a gas
2. Irritable Bowel Syndrome
 A disorder where there is a recurrent abdominal pain and diarrhea that often alternating
with periods of constipation
 It differs from one person to another. Some experience only diarrhea or constipation
whereas others experience and alternating patterns of both.
 It’s more common with females than men.
Symptoms
 More than three bowel movements per day or fewer than three
 Lumpy/hard or loose/ watery stool
 Passage of mucus
 Bloating (swelling of the abdomen caused by excessive gas)
Management
  For constipation, give high fiber diet
 For diarrhea give low fiber diet
3. Diverticular Disease
Diverticulum or diverticular is a small tubular sack that protrudes from the main canal or cavity
in the body (diverticular refers to a small out pouching in the GIT i.e. from the esophagus to
the colon)
It is caused by pressure within the intestinal lumen which may be related to chronic constipation
and a low fiber diet
It can either be
i. Diverticulosis – presence of multiple diverticular in the walls of the GIT mostly colon. It
mostly occurs in older adults.
ii. Diverticulitis – refers to the inflammation of the diverticular
The common term for the conditions is diverticular disease
Symptoms
 Gross bleeding
 Low Hb and albumin level
 Cramping of the stomach
 Alternating periods of diarrhea and constipation
 Bad breath
 Regurgitation and fever
 Dysphagia
Nutritional implications
 Anaemia
 Increased nutrient needs
Aims of nutrition management
 To restore nutritional status
 To relieve pain and enhance healing

Management
 Provision of high fiber for the management of the diseases and low fiber diet for the
diverticulitis
 High protein for repair of worn out tissues
 Low fat diets in acute cases, provide clear liquid diet with progression to a very low-
residue diet

5. Constipation
Refers to the retention of feces in the colon beyond normal empting time (or this is where bowel
movement become difficult or less frequent thus resulting into hard stool that is more difficult to
pass.
A person is said to be constipated if he/she goes longer than three days without bowel
movement (without passing a stool) or when he passes dry or hard stool often or often having
difficulty pushing out stool
It is more common in older adults.
Causes
 Low fiber diet
 Inadequate fluid/water intake
 Lack of exercise
 Changes in social settings
 Inadequate activity or exercise
 Stress/worries
 Overuse of laxatives (stool softeners) which overtime weaken the bowel muscles
 A disruption of regular diet or routine/change of diet
 Excessive/ prolong use of anti-acids containing calcium or aluminum
 Ignoring the urge to pass stool
 Some medications e.g. iron supplements
Management
To manage the problem, you need to make your stool softer by
Increased fiber intake (both soluble and insoluble fiber), this is found in vegetables,
fruits and cereals
 Increased fluid intake
 Increased physical activities. Avoid sitting or lying down for long
 use of laxatives(medical therapy)
Other management strategies
 You also need to have a good toilet routine-go to the toilet at a regular time and place
where you feel comfortable
 Use the toilet when you feel the urge

Other conditions of large intestine are acute and chronic gastritis, indigestion and the
hemorrhoids

Hemorrhoids (piles)
Hemorrhoids are swollen (enlarged) and inflamed veins in the rectum and anus that cause
discomfort and bleeding (they occur when the veins in the anus are enlarged)
Types of hemorrhoids
 Internal hemorrhoids-located inside the rectum. They cannot be seen or felt
(Not visible from outside). They are normally painless and rarely cause
discomfort. Straining when passing stool can damage the surface of the
hemorrhoid and cause bleeding (The first sign is rectal bleeding)
Occasionally straining can push an internal hemorrhoid through the anal opening.
This is known as protruding or prolapsed hemorrhoid
 External hemorrhoid-develops under the skin around the anus and therefore not
visible. They are painful. Straining when passing stool cause them to bleed
Causes of hemorrhoids
 Straining during bowel movement
 Obesity
 Sitting for long period of time on the toilet
 Pregnancy-increases pressure on the anus veins during later period of pregnancy
(as the uterus enlarges, it presses on the vein in the colon, causing it to bulge)
 Chronic diarrhea
 Chronic constipation
 Anal intercourse- can cause or worsen existing ones
 Aging-It is most common among the adults aged 45-65 years. However the young
people and children can also get it
 Low fiber diet
 Lifting heavy objects repeatedly
 Genetics-Some people inherit tendency to develop hemorrhoids

Symptoms
 Discomfort during bowel movement or sitting
 Swelling around the anus
 Bleeding during bowel movement
 Itching in anal region
 A lump near the anus (protruding from the anal region)
 Feces may leak out unintentionally

Prevention
 Nutrition therapy-high fiber diet( more fruits, vegetables and whole grains) to
soften stool and increase its bulk thus avoiding the straining caused by
hemorrhoids
 Drink plenty of water
  Fiber supplementation
 Stool softeners
 Do not strain-Straining and holding your breath when trying to pass a stool
creates greater pressure in the veins of the lower rectum
 Go to the toilet as soon as you feel the urge. This prevents the stool from
becoming dry and harder to pass
 Exercise to prevent constipation and reduce pressure on veins
 Avoid long periods of sitting more so on the toilet. Long periods increases
pressure on the veins of the anus
 Sufficient rest
Treatment
 Nutrition therapy-High fiber diet, Increased protein, increased iron intake,
increased vitamin C, increased intake of water
 Use of cream and ointment containing hydrocortisone
 Ice parks and cold compress- applied to the affected areas may help with swelling
 Moist towelettes-dry toilet paper may aggravate the problem
 Analgesics-painkillers e.g. aspirin, ibuprofen to alleviate pain
 Surgical operation