CHAPTER 1

NUTRITIONAL GUIDELINES FOR FILIPINOS

A. Nutritional guidelines for the general population

The terms nutritional/dietary goals, guidelines and recommendation are often used
interchangeably. Bengoa et. Al. defined nutritional goals are recommendations considered
appropriate for a population for purposes of promoting health, controlling deficiencies or
excesses, and minimizing the risk of diseases related to nutrition. Dietary guidelines, on the other
hand are indications of practical ways to reach the nutritional goals of the population. They are
based on the habitual diet of the population and suggest desirable modifications.

In 1990, the food and nutrition research institute constituted a committee to formulate
guidelines for Filipinos. The committee adopted the term Nutritional Guidelines rather than
Dietary Guidelines.

The committee also decided that the guidelines are to be intended for the general
population, not for people suffering illnesses which required specific or individualized dietary
modifications.

The purposes of the Nutritional Guidelines are: a) to provide the general public with
primary recommendations on proper diet and wholesome practices to promote nutritional health
for themselves and their families; and b) to provide those concerned with nutritional information
and educations and a handy reference.

The Guidelines and their rationale are as follow:

1. EAT VARIATY FOODS EVERYDAY

Since no single foods or food group can supply all the essential nutrients, eating
variety of foods daily is one way of an adequate diet. A study by Limbo showed that the more
diverse the diet, the higher is its mean nutrient adequacy ratio.

2. PROMOTE BREASFEEDING AND PROPER WEANING

The Nutritional Guidelines Committee decided to include the recommendation in view of
the observed decline in breastfeeding and in recognition of the superiority of breastfeeding over
the artificial feeding in giving children a nutritional head start.
It has been observed that breastfeed babies grow well during the first five or six months,
but growth rate begins to falter thereafter, presumably due to inadequate supplementary
feeding. Thus the promotion of proper weaning should go hand-in-hand in promotion of
breastfeeding.

3. ACHIEVE AND MAINTAIN DESARABLE BODY WEIGTH

Under nutrition and Over nutrition, manifested as underweight and overweight,
respectively, have similar consequences for individuals in terms of reduced life span, increased
susceptibility to diseases, reduced productivity and lowered quality of life in general.

4. EAT CLEAN AND SAFE FOODS

In the survey of extent of the public concern over food safety conducted in 1987 in eight
major Asian countries, the Philippines sadly ranked in second lowest. While reliable data on the
prevalence of food-borne illnesses are not available, surveys have indicated that 69 percent of
population may have parasites, mostly food-borne. Diarrhea, of which contaminated food and
water are major causes, is one of the leading causes of morbidity and mortality. Furthermore,
there are increasing reports of outbreaks of typhoid, cholera, hepatitis A and food poiso
5. PRACTICE A HEALTHY LIFESTYLE
The sub-message under this recommendation is: be moderate in what you eat and drink;
Avoid smoking and control stress; and maintain good dental health.
Wise meal planning strategies do not suggest complete avoidance of specific foods but
instead recommend a judicious use of those foods containing factor known to be somehow
related to the development of diseases- e.g., fat, especially saturated fat, salt, sugar, alcohol,
―junk‖ food, etc. moderation is likewise recommended in the use of food or dietary factors
known to have health benefits- e.g. polyunsaturated fat, fish oil concentrates, fiber concentrates,
even vitamins and minerals. Excessive amount of these are either toxic or unnecessary.
Heavy cigarette smoking has been associated with increased incidence of lung cancer and
cardiovascular diseases, while stress is etiologic or complicating factor in many diseases.
Poor dental health, especially among children and elderly, affects nutritional status by
interfering with food intake.

B. Nutritional Guidelines for the Prevention Chronic Degenerative Diseases

The prevalence of ―diseases of affluence‖, so called because of their close association

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

Since the two sets of guidelines are in many ways similar, they may be consolidated into
one set as follows:

1. EAT FOODS LOW IN FAT AND CHOLESTEROL

There is strong evidence for an association between high fat and cholesterol consumption
and hyperlipidemia. Hyperlipidemia is a portent risk factor in CAD and is common finding in
diabetes mellitus. High fat intake has also been implemented in the development of cancer,
particularly breast cancer.

2. INCREASE CONSUMPTION OF FRUITS, VEGETABLESS (ESPECIALLY GREEN

AND YELLOW) AND UNREFINED CERIALS
These foods are rich in fiber. Furthermore, fresh fruits are good sources of vitamin C,
while dark green vegetables and yellow vegetables and fruits are good sources of beta carotene.
This beneficial effect of dietary fiber of bowel function has long been appreciated. Now,
there is accumulating evidence that fiber has other beneficial effect such as helping in the control
of blood sugar and blood cholesterol levels as well as reducing the risk of colon cancer. Since
different dietary fibers have different physiologic and metabolic effects, it is recommended that a
wide variety of fiber sources be included in the daily diet.
As antioxidants, vitamins C and beta carotene may prevent cancer by inhibiting the
formation of carcinogens such as nitrosamines and free radicals in the body. Beta carotene also
prevents the preoxidation of low density lipoproteins (LDL). It hypothesized that oxidized LDL
may play a role in atherogenesis.
There is an increasing interest in phytochemicals in plant foods other than dietary fiber
and beta carotene. Animal and epidemiologic studies have suggested that these phytochemicals
may have anti-cancer properties.

3. LIMIT INTAKE OF SALTY FOOD

Studies have linked high salt intake to hypertension, particularly in salt-sensitive
individuals.
Hypertension leads to a number of debilitating condition including heart failure, heart attack, and
stroke and kidney disorders.

4. MAITAIN DESIRABLE BODY WEIGHT

Maintain desirable body weight is an important measure for reducing the risk of diabetes,
atherosclerosis and cancer in the general population, and more so in the sub-population with a
hereditary predisposition. For the overweight and obese, weight reduction should not be viewed
simply in terms of reduction of energy intake. An adequate intake of protein, vitamins and
minerals must be ensured, together with an increase in physical activity.

5. FOLLOW A REGULAR EXERSICE PROGRAM

Besides being an important component of weight reduction program, exercise helps
maintain normal blood lipid levels and normal blood sugar levels by promoting the utilization of
glucose and enhancing insulin sensitivity. Exercise also improves cardiovascular fitness and
helps to relieve stress.
It is important that exercise be regular since many of its metabolic effects are short-lived.

6. REGULATE ALCOHOL INTAKE AND STOP SMOKING

Too much alcohol leads to increase blood levels of LDL cholesterol and triglycerides,
lowered HDL cholesterol as well as to hypertension and erratic blood glucose. It may also lead to
certain forms of cancer.
The nicotine in cigarettes causes blood vessel constriction and increased heart rate, which
in turn elevates blood pressure. Nicotine also promotes the formation of thrombi or blood clots
particularly in areas of the arterial wall with a diminished oxygen supply. The carbon dioxide in
cigarette smoke reduces the oxygen supply to the heart and other organs. Cigarette smoking has
likewise been liked to lung cancer. The Lung Center of the Philippines estimated that cigarette
smoking is responsible for one million deaths each year.

7. HAVE A REGULAR MEDICAL CHECK-UP

Early detection and early intervention can delay or even reverse many of pathologic
changes in generative diseases.

Additional Guidelines for Cancer Prevention

8. LIMITS CONSUMPTION OF SMOKED OR CHARCOAL BROILED MEAT AND
FISH, SALT-CURED AND PICKLED FOODS
Benzopyrene , a potential carcinogen, is formed on the surface of meat and fish when
these are smoked or broiled over charcoal. Salt-cured meats usually contain nitrites and nitrates
as preservatives. These may be converted into nitrosamines, also potential carcinogens. A high
salt intake itself can promote cancer development by arritating the gastric mucosa, making at
vulnerable to carcinogens.

9. AVOID MOLDY FOOD

Aflatoxin is produced by a mold, aspergillus flavus. Moldy nuts, cereal grains and tubers
contain high levels of aflatoxin, a potential carcinogen.
 CHAPTER 2

NUTRITIONAL CARE PROCESS

The nutritional care of in- patients and out-patients essentially consists of the following steps:

1. Assessment of nutritional status and identification of nutritional problems and needs;

2. Setting of objectives to meet identified problems and needs;
3. Selection of appropriate interventions;
4. Implementation of selected interventions;
5. Monitoring and evaluation of nutritional care;

All the above steps should be documented in the patient’s medical record chart to allow proper
communication and interaction among member of the health care team. The nutritional care of
patients is a team effort involving various personnel in the health care facility.

NUTRITIONAL ASSESSMENT
A through nutritional assessment is the basis of a nutritional care plan. Its primary
purpose is to identify the patient’s nutritional problems and needs. It also identifies a high risk
patient who needs special attention.
Nutritional assessment involved the collection and analysis of anthropometric, biochemical
clinical, dietary and psychosocial data as well as a consideration of the planned therapeutic
management. A wide variety of parameters as shown in Table 1 are needed to make a complete
and through nutritional assessment. However, in clinical practice, it is virtually impossible to
measure all these parameters. The amount and type of information to be collected depends on the
patient’s illness as well as on the available facilities. Considered basic are:

 Signs of malnutrition on admission,

 Laboratory and clinical findings pertinent to the underlying illness, and
 Planned actions.

Table 2 is a guide for identifying high risk patients.

While important dietary assessment cannot be used alone to assess nutritional health. It is
an aid in the interpretation of anthropometric, clinical and laboratory findings and provides a
foundation for dietary counseling.
The different methods used in evaluating a patient’s diet are described in appendix A.

OBJECTIVE SETTING
After the problems and needs are identifies, the next step is to set the objectives of
nutritional care. For each problem, there should be a corresponding objective.

Characteristics of objectives
Objectives should be specific and patient-centered. This means they must be stated in
terms that show what the patient will achieve if the objectives are met. They may be started in
terms of changes, e.g., in body weight, blood chemistry or clinical findings, or in terms of
behavioral changes. Objective should be time-bound, which means the time frame for the
attainment of each objective should be set.
Objectives should be realistic. They should consider what can be realistically achieved
within time-frame set as well as resources available.
Objectives should be measurable. They should be stated in quantifiable terms in order to
permit monitoring and evaluation of the nutritional care.

SELECTION OF APPROPRIATE INTERVENTIONS

Interventions are action to achieve the desired objective the desired objectives. They may include
the diet prescription, nutrition counseling, provision of food and necessary supplements (if the
patient hospitalized), and vitamin and mineral medication.
IMPLEMENTATION, MONITORING AND EVALUATION

Implementation means carrying out the planned interventions, while monitoring is

collecting data that will indicate progress towards the set objectives. Such data are called
indicators and they should be determined at the outset. For example, if the objective is a change
in body weight then body weight is the indicator and body measurements must be made initially
and then periodically thereafter. Or if the objective is a change in calorie intake, then this is the
indicator and an estimation of daily calories intake must be done.

Evaluation is a dynamic and continuous process. It involves measuring the progress of

the patient toward achieving the set objectives of his nutritional care plan. In effect, evaluation is
a reassessment or addition to the initial assessment. This may lead to revision of the plan and to
changes in intervention, if needed.

Table1.
The Data Base for the Assessment of Nutrition Status
GENERAL SPECIFICS
ANTHROPOMETRIC  Weight, Height, and weight charges.
Growth parameters in infants, children,
adolescents, chest circumference;(in
pregnant women):
Weight gain.
 Skin fold thickness: triceps, scapular,
abdominal, etc.
 Mid- upper arms circumference
(MUAC)
 Wrist circumference
Biochemical  Blood, serum, plasma measurements
 Urinary measurements
 Tissue assays or biopsies
Clinical  Finding indicative of nutritional status
 Findings indicative of disease that may
affect nutritional status
 Pertinent medical history
Diagnosis  Underlying disease
 Secondary disease(s)
Nutritional History  Dietary intake
 Nutrition-related information:
-use vitamin and mineral
supplements
-allergies, food intolerances
-nutrition knowledge
-physical activity
Psychosocial Information  Pertinent social history
 Cooking and eating atmosphere
 Attitudes toward food and eating
 Number of persons in household
 Economic factors
 Food buying and cooking facilities
 Ethnic background
Planned Therapeutic  Surgery
Management  Radiotherapy
 Drug and medications
 Repeated tests X-rays
 Hospitalization duration
Table2.
Guide for Identifying High Risk Patients
Signs of malnutrition on Underlying Disease
admission
 CHAPTER 3

PLANNING THE DIET

A. Estimating the desirable body weight

Selection of the appropriate dietary intervention will entail calculation of diet prescription
which usually based on desirable body weight synonymous to reference, ideal, expected or
standard. The Food and Nutrition Research Institute and the Philippines Pediatric society has
come out with ―Anthropometric Table and Chart for Filipino Children‖ which may be used as
reference. For the adults, the ―Weight for Height Tables for Filipinos (25-65 years)‖may be
utilized. If these references are not available, the following may be used:

1. Infants:
A.1st 6 months:
DBW (gms) =Birth weight (gms) + (age in mos. X 600)
If the birth weight is not known, use 3000 gms.
Example: 4-month old infant =
DBW (gms)= 3000 + (4 x 600)
=3000 + 2400
=5400 gms or 5.4 kg.
7-12 months:
DBW (gms) = Birth weight (gms) + (age in mos. X 500)
Example: 8-month old infant
DBW (gms)=3000 +(8x 500)
=3000 + 4000
=7000 gms or 7 kg.
b. DBW (kg.)= (age in month ÷2) +3
Example:8-month old infant
DBW (kg.) = (8÷2) +3
=4 + 3
=7 kg.
INFANT’S WEIHGT:
--Doubled at 5-6 mos.
--tripled at 12 mos.
--quadrupled 24 mos.
HEIGHT OR LENGTH:
Example:
At birth: 50 cm 50 cm
At 1 yrs.: +24 cm 50 + 24 = 74 cm
At 2 yrs.: + 12 cm 74 + 12 = 86 cm
At 3 yrs.: + 8 cm 86 + 8 = 94 cm
At 4-8 yrs.: + 6 cm every year at 4 yrs. + 6 = 100 cm

2. Children: DBW (kg.) = (No. of years x 2) + 8

Example: 7-year old child
DBW (kg.)= (7 x 2) + 8
= 14 + 8
=22 kg.
+ 2 kgs for every year
3. Adults
―Desirable body weight‖ (DBW) or ―ideal body weight‖(DBW) as used in nutrition and
diet therapy refers to the weight for height found statistically to be the most compatible with
health and longevity. There are several tables or monograms’ which give the DBW of adults of
given height. However, in practice it is often necessary to compute an individual’s DBW
quickly. The following are some formulas that may be used.
1. Body Mass Index-based formula
Body mass index (BMI) is widely used to identify lean, overweight or obese individuals.
It is computed as weight in kilograms divided by height in meters squared (W/H2), and has been
found to be relative weight index that shows the highest correlation with independent measures
of body fat. The BMI range of 20 to 24.9 is generally considered normal.
The joint FAO/WHO/UNU Expert Consultation on Energy and Protein Requirements
computed the energy requirements of adult based on BMI=22 for men and BMI=21 for women.
The weight of given height equivalent to these BMI values may be read off directly from a BMI
monograms. In the absence of such monograms, the following formulas have been found, during
a consultative meeting Metro Manila dietitians, to give weights closely equivalent to =22 for
men and BMI=21 for women.
 For men 5 feet (1.52m) tall, DBW= 122 lbs (51 kg)
 For women 5 feet (1.52m)tall, DBW = 106 lbs (48 kg)
 For both sexes, add 4 lbs (1.8 kg) for every inch above 5 feet.
Sample calculation:
Male, 5’3‖ tall: DBW = 112 +(3 x 4)=124 lbs (56 kg)
Female, 5’1‖ tall: DBW = 106 + (1 x 4)= 110 lbs (50 kg)

2. Derived formula based on body mass index

DBW (kg) = Desirable BMI X H (m) 2

Desirable BMI for men = 22
Desirable BMI for women =20.8 or 21

Sample calculation:
Male 5’3‖ (1.6 m) tall
DBM (kg.) =22 x 1.6 m 2
=22 x 2.56 m
=56.32 or 56
3. Tannhauser’s method:
Measure height in centimeters. Deduct from this factor 100 and the answer is the DBW in
kg. The DBW obtained applies to Filipinos stature by taking off 10%
Examples:
Height: 5’2‖=62‖
62‖ x 2.54 cm.= 157.48 cm. –100 = 57.48 kg.
57.48 kg.
- 5.74 (10% of 57.48)
51.74 or 52 kg.
4. ―Adopted‖ Method:
For 5 ft. use 105 lbs. for every inch above 5 feet, add 5 lbs.
Examples:
Ht.5’2‖
5 feet = 105 lbs.
2 inches = 5 x 2 = + 10
115 lbs. or 52 kg.
B. Estimating of Total Calorie Requirement Per Day or Total Energy Requirement (TER)/day:
1. Infants: TER/day = 120-110 Cals./KDBW
Example:
4-month old –
TER- 5.4 kg. (DBW) x 120 Cals/kg.= 648 or 650 Cals.
8-month old—
TER- 7 kg. (DBW) x 110 Cals/Kg. 770 or 750 Cals.

2. Children:
a. TER/day = 1000 + (100 x age in years)
Ref: Narins & Weil
 Examples:
7-years old child—
TER/day =1000 + (100 x 7)
=1000+700
=1700
B. Age Range Cals/KDBW 1989 RDA CBMRG (cooper, burber, ect.)
1-3 105 102 100
4-6 90 89.6 90
7-9 75 73.2 80
10-12 65(boys) 65.3 70
55(girls) 54.6 60=13-15 yrs.
50= 15 yrs. and above
Examples:
7-years old child—
TER/day = 22 kg (DBW) x 80 = 1760 or 1750 Cals.
3. Adolescents 1998 RDA
13-15—55 (boys) 53.2
45 (girls) 45.7
16-19—45 (boys) 46.9
40(girls) 42.1
Average both sexes = 45 Cals KDBW
A. Adults:
a. method l (cooper, et. all) b. Method ll (Krause)
Basal Metabolic Needs= 1 cal/ Cals/KDBW/Day
KDBW/hr. Activity
+ physical activity = % above basal
Bed rest 10(10-20 krause) Bed rest 27.5
Sedentary 30 Sedentary 30
Light 50 Ligth 35
Moderate 75 moderate 40
Heavy 100 heavy 45
c. Harris-Benedict Energy expenditure
HBEE (males) =66.47 + 13.75(W) + 5.0 (H)—6.75 (A)
(female) =655.1 + 9.56(W) + 1.85 (H) --4.67 (A)
Where:
W =Kg Body Weight
H =Height (cm)
A =Age (years)
d. NDAP Formula
Activity level Male Female
In bed but mobile 35 30
Light 40 35
Moderate 45 40
Heavy 50 --
Examples of activities:
Sedentary—secretary, clerk, typist (using electric typewriter) administrator, cashier, bank
teller
Light—teacher, nurse, student; lab. Technitian, housewife with maids
Moderate—housewife without maid, vendor, mechanic jeepney and car driver
Heavy—farmer, laborer,cargador, coal miner, fisherman, heavy equipment operator
Examples: Method l
DBW = 52 kg.
A. activity= moderate (housewife without maid)
52 x 24 =1248 Cals. For basal metabolic needs
1248 x .75= Cals for activity
1248 +936=2184 or 2200 Cals/day
Calories are rounded off the nearest 50
B. Activity Bed Patient
52 x 24 = 1248 Cals. For basal metabolic needs
1248 x .20 =249.6 Cals. For activity
1248 x 250 =1500 Cals.
Examples: Method ll
a. Using the same individual(moderately active)
52x 40 cals =2080 or 2100 Cals/day
b. Activity= Bed patient
52x 27.5= 1430 or 1450 Cals

Example: Method lll

Weight 50 kg.
Height = 165.1 cm.
Age =45 yrs.
HBEE(males) =66.47 +13.75(50)+5.0(165.1)—6.75(45)
=66.47 +687.5 + 825.5—303.75
= 1275.72 or 1275 cals
5. Pregnant women:
TEr/day = normal requirement + 300 cals

6. Lactating women:
TER/day = normal requirement + 500 cals

C. distribution of total energy requirement (TER) into Carbohydrate, protein and Fat:

Method l—by percentage distribution

% of TER
1. Carbohydrates 50-70 % or average of 60%
2. Proteins
Infants— 10%
Children—
Adolescents—
Adults— 10-12
3. Fats
Normal adults,
Moderately active 20-25
Children, adolescents;
Very active individuals 30-35%
Example: 7-year old child
TER/day = 1700 Cals
CHO/day= 1700 x .60= 1020 Cals ÷4= 255 gms.
P/day =1700 x .10= 170 cals ÷ 4 =42.5 or 45 gms.
F/day = 1700 x .30 = 510 cals ÷ 9 = 56.6 or 55 gms.

C,P, & F are rounded off to the nearest 5

Rx Diet = 1700 CalsC255P45F55
Example: moderate active housewife,DBW of 52 kg.
TER/day = 2200 Cals
CHO/day =2200 x .60 1320 cals ÷4 = 330 gms.
P/day =2200 x .10 =220 Cals ÷ 4 = 55 gms.
F/day =2200 x .30 = 660 Cals ÷ 9= 73.3 or 75 gms.
Rx Diet =2200 CalsC330P55F75
Method ll: determine the protein calories first according to the normal allowance in gm/KDBW
and provide the non-protein calories (NPC) into:
CHO: 55-80% or an average of 70%
Fats: 20-45% or an average of 30%
Normal protein allowances/day:
Gm/KBDW
Infants 1.6
Children 1.5
Adolescents 1.2
Adults 1.1
Examples:7- year old child with TER of 1700 kcal
P/day =22(DBW) x 1.5 = 33 g or 35 g
35 x 4 =140 protein calories
1700 – 140 = 1560 non-protein calories
CHO/day =1560 x .70 = 1092 ÷ 4 =273 or 275 g
F/day =1560 x .30 = 468 ÷ 9 52 or 50 g
Rx Diet =1700 C275P35F50
Examples: Moderate active housewife, DBW of 52 kg.
TER/day= cals
P/day =52x 1.1 = 57.2 or 55gms
55x 4 ==220 protein calories
2200—220 = 1980 NPC
CHO/day = 1980 x .70= 1386 ÷ =345 gms.
F/day =1980 x .30= 594 ÷ 9 64.9 or 65 gms.
Rx Diet =2200 CalsC345P55F
D. Meal Planning With Exchange Lists
The food exchange system is a used tool used by dietitians to facilitate meal planning. In
this system foods with similar composition are grouped together under a ―List‖. These lists and
their composition are shown in table 3.
A publication of the Food and Nutrition Research Institute entitled ―Meal planning with
Exchange Lists‖ contains a comprehensive listing of foods together with amount of each that
constitutes an exchange.
Table 3.
COMPOSITION OF FOOD EXCHANGES
CHO PRO FAT ENERGY
LIST FOOD GROUP MEASURE (g) (g) (g) (kcal) (kj)

l.A Veg. A 1 cup raw -- -- -- -- --

½ cup, cooked

2 cups raw 3 1 -- 16 67
1 cup cooked
l.B. Veg. B ½ cup, raw 3 1 -- 16 67
½ cup cooked
ll. Fruit varies 10 -- -- 40 167
lll. Milk
Full cream varies 12 8 10 170 711
Low fat 4 tablespoons 12 8 5 125 523
Skimmed varies 12 8 tr 80 335
iv. Rice varies 23 2 -- 100 418
v. meat and fish
Low fat varies -- 8 1 41 172
Med. Fat varies -- 8 6 86 360
High fat varies -- 8 10 122 510
Vl. Fat 1 teaspoon -- -- 5 45 188
Vll. Sugar 1 teaspoon 5 -- -- 20 84
How to use the food exchange list in meal planning
To translate the prescription with given calories, carbohydrates and fat into food
exchanges, the procedure is as follows:

1. List down all the foods furnishing carbohydrates, i.e., vegetables, fruits, milk, rice and sugar.
A. it is customary to allow 1 to 2 servings of list A an B vegetable per day.
B. allow usual amount of sugar consumed per day unless contraindicated.
C. unless there is a drastic caloric/carbohydrates restriction, 3 to 4 servings of fruits allowed per day.
D. The amount of milk allowed depends upon the patient’s needs, food habits and other
economic considerations.

2. To determine how many rice exchanges:

A. adds the carbohydrates (CHO) from vegetables, fruit, milk and sugar.
B. subtracts this sum from the prescribed CHO.
C. divide the difference by 23 (g CHO furnished by 1 rice exchange).
D. the nearest whole quotient is the number of rice exchange allowed.

3. To determine how many meat exchange are allowed:

A. adds the protein furnished by the food groups already listed.
B. subtracts this sum from the prescribed protein.
C. divides the difference by 8 (g protein per meat exchange).
D. the nearest whole quotient is the number of meat exchange allowed.

4. Followed the same procedure for fat, using 5 as the devisor since 1 fat exchange contains 5 g
of fat.

An allowance of + 5 grams the prescribed amount for protein, carbohydrate and fat and + 50
kilocalories for energy are given so the fractions of servings are avoided.

Distribute carbohydrates for breakfast, lunch, supper and snacks accordingly, depending
on the patient’s eating habits. Proteins and fats are distributed to balance the meal reasonably
well.

Sample calculation
Diet Prescription: 1500 (6300 kj)225—55—40
 CHAPTER 4

SUMMARY OF MODIFIES DIETS BY ORGAN SYSTEM

Disorders recommended diet Prescription/modifications
Conditions and affecting or
Involving the mouth,
Esophagus, stomach and
Duodenum

Broken jaw mechanical soft

Dental caries mechanical soft
Dry mouth mechanical soft
Dumping syndrome carbohydrate-restricted; no concentrated sugars;
Small, frequent feedings; fluid and electrolytes
Replacement
Dysphagia mechanical soft, tube feeding,
Total parenteral nutrition (TPN)
Gastritis low-fiber, bland
Hiatal hernia small, frequently feedings; low fat; bland; weight loss
Lll-fitting dentures mechanical soft
Indigestion (dyspepsia) low-fiber; bland; small frequent feedings
Missing teeth mechanical soft
Nausea low-fiber; bland; small frequent feedings
Oral surgery mechanical soft
Peptic ulcer bland
Periodontal disease mechanical soft
Plastic surgery of head or neck mechanical soft, tube feeding, TPN
Reflux esophagitis small, frequent feedings, low fat; bland; weight control
Ulcer of mouth or gums mechanical soft, bland
Vomiting fluid and electrolyte replacement

Conditions affecting the

Small intestine and colon

Constipation high-fiber, increased fluids

Diarrhea
Diverticulitis
Diverticulitis
Inflammatory bowel disease
Irritable bowel syndrome
Short bowel syndrome
Ulcerative colitis
liquid, low fiber, regular, fluid and electrolyte
Replacement
low-fiber
high-fiber
low-fiber, low-fat, high-calorie, high-protein, fluid and
Electrolyte replacement
high-fiber; natural laxative foods
low-fat, high calorie, high protein, fluid and electrolyte
replacement
low-residue, tube feeding, TPN

Disorders recommended diet prescription/modifications

Conditions effecting or
Involving liver, gallbladder
And exocrine pancreas
Cirrhosis
Gallbladder disease
Pancreatitis
protein-restricted, sodium-restricted,
Fluid-restricted
low-fat, calories-restricted, regular
low-fat; regular; small, frequent feedings;
Tube-fidings, TPN
Conditions of the
Endocrine pancreas*
Diabetes mellitus
Functional hypoglycemia
(Hyperinsulinism)
Conditions affecting the
Heart and blood vessels
Atherosclerosis
Congestive heart failure
Coronary heart disease
Hyperlipidemias
Hypertension
Myocardial infarction
Conditions affecting
The kidneys
Acute renal disease
* The pancreas produces both external (exocrine) and internal (endocrine) secretions. The
external secretions (enzymes) play an important role in the digestion of food; the internal
secretions (insulin and other hormones) play a primary role in the regulation of glucose
metabolism.
Disorders
Conditions affecting
Kidneys
Chronic renal disease
Kidney stones
Nephritic syndrome
Urinary tract infection
individualized diet
no concentrate sweets; small frequent feedings
fat-controlled, calories-restricted, sodium-restricted,
High-fiber
sodium-restricted; calories-restricted; low-fiber; bland;
Small frequent feedings; fluid-restricted
fat-controlled, calories-restricted, sodium-restricted,
High-fiber
fat-controlled, calories-restricted, carbohydrate-
controlled
low sodium, calories-restricted, high-potassium;
Fat-controlled
low-sodium; calories restricted; low-fiber; bland, small
Frequent feedings; moderate temperature foods;
fat-controlled
protein-restricted, high-calorie, fluid-controlled,
Sodium-controlled, potassium-controlled, fat controlled,
carbohydrates-controlled
recommended diet prescription/modifications
protein-restricted, low-sodium, fluid-restricted,
potassium-restricted, phosphorus-restricted
increased fluid intake, calcium-controlled, low oxalate
sodium-restricted, high-calorie, high-protein, potassium-
restricted
increased fluid intake, acid ash diet
Malabsorption syndromes

Celiac disease gluten-restricted

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

Conditions affecting the

Lungs and respiratory system

Chronic obstructive soft, high-calories, small frequent feeding

Pulmonary disease low-carbohydrate, high-fat
Tuberculosis high-calories, high-protein

Conditions affecting many

Organ systems

Burns high-calories, high-protein, increased fluid intake

Cancer high-calories, high-protein,(see also specific associated
condition: dry mouth, indigestion,
Malabsorption, nausea plastic surgery of
The head or neck, ulcer of
Mouth or gums, vomiting, etc. )
Food sensitivities elimination of offending substance
Galactosemia galactose-restricted
Obesity, overweight calorie-restricted, high-fiber
Phenylketonuria (PKU) phenylalanine-restricted
Stroke mechanical soft, regular, tube feeding
Underweight high-calories, high-protein
 CHAPTER 5

MANAGEMENT OF NON-SPECIFIC NUTRITIONAL PROBLEMS

The following are some dietary management strategies for selected non-specific
nutritional/feeding problems:

1. Anorexia
 Small, frequent feeding are preferable to large meals. Often, the mere sight of
large portions of food can induce nausea and anorexia.
 Have snacks and fruit juices qt the patient’s bedside for him to take whenever
hungry.
 Consider the patient’s food preferences.
 Choose calories-dense foods and beverages.
 If fruits are better tolerated, serve a variety of flavored milk-based drinks such as
shakes and frappes and protein-fortified fruit juices. Some of these may be made
into puddings with cornstarch as thickener to add calories and provide a variety of
texture.
 Drink liquids half-hour before eating instead of with meals.
 Serve food attractive. Avoid disposables as these tend to aggravate the patient’s
feeling of isolation.
 When anorexia is due to drugs, altering their timing may help. For instance,
infusion of pentamidine, a drug used in pneumocystis carinii pneumonia, may
begin after meal time to improve intake at meals.
 When taste and smell perceptions are altered, bland foods rather than highly
flavored foods are better tolerated. Foods served at room temperature have fewer
aromas than hot foods and therefore may be more acceptable.
 Use wine as appetite stimulant.
 Consult with attending physician regarding the use of appetite stimulant drugs.
 Encourage dining with friends or families in pleasant surroundings.

2. Nausea and vomiting

 Clear liquids, salty foods and fruit like watermelon are occasionally tolerated.
 Too sweet and greasy foods may initiate or increase discomfort.
 Strong odors, particularly that of food cooking, are sometimes objectionable
 Drinking or eating rapidly, or sudden movement may stimulate vomiting.

3. Hypogeusia (heightened taste perception)

 In the absence of oral or esophageal lesions, give flavorful (e.g. spicy) foods.
 Serve attractively prepared food.
4. Hypergeusia (heightened taste perception)

 Serve bland foods.

 Serve cold foods or foods with minimal odors.
5. Taste blindness (dysgeusia)

 If there is aversion to several of the most popular protein foods. Look for
alternatives that are more palatable and also good sources of protein such as milk,
ice cream, blank cheese, cottage cheese and peanut butter.
 Small frequent feeding.
 Take liquids high protein diet supplement.
6. Chewing and swallowing difficulty

 Adjust diet to patient’s tolerance.

 Give thick consistency fluids or semi-solid foods.
 Avoid sticky foods.
 Consider tube feeding.

7. Xerostomia (dry mouth)
 Soft bland foods, especially cool or cold foods with high fluid content.
 Take solid foods with gravies, sauces, melted butter, broths, mayonnaise,
yoghurt or salad dressing.
 Dunk bread and other baked foods in milk, tea or coffee for easy swallowing.
 If solid food is not tolerated, try pureed diet or full liquid diet.
 Give salivary stimulant like citric acid containing beverages, lemon drops or
gums.

8. Thick viscous saliva

 Give clear liquid like tea, Popsicle and slushes.
 Saline rinses before eating may help.

9. Esophagitis

 Avoid secretagogues like alcohol, caffeine, spicy and salty foods.

 Give cold, clear liquids or semi-solids initially.

10.oral and esophageal pain due to lesions

 Avoid highly seasoned, acidic, extremely hot and extremely cold foods that cause
irritation. Consuming foods at room temperature may be soothing.
 Give a mechanical soft diet (high calories, high protein fluids, and puddings,
finely chopped or pureed food) that requires minimum chewing.
 Avoid hard, dry, crisp, or rough textured of foods.
 Soak-dry foods in liquid such as gravy, sauces, coffee, tea, or milk.
 If chewing and swallowing are impaired, give a blenderized diet or a polymeric
formula (e.g. ensure, suscatal)orally or enterally. Due to high cost of commercial
and enteral formulas, some hospital in Metro Manila use these product only to
fortify blenderized
 Tube feedings.
 If swallowing is badly impaired and these is danger of aspiration,
- Thin liquids may need to be omitted;
- Thickening liquid to a semi-soft consistency with powdered milk, mashed
potatoes, cornstarch or oatmeal should be tried, if liquid cause choking;
- eliminate solid food and foods such s stews;
- avoid foods that stick to the palate such as peanut butter, and white bread, and
slippery foods, such as bologna, macaroni, gelatin, saluyot and okra;
- consult with a specialist such as speech therapist.

 Monitor patient’s tolerance to milk-based diet. There are anecdotal reports that
adult Filipinos tolerate milk poorly. Signs of intolerance include abdominal
pain, fat malabsorption, bloating, distention and diarrhea.
 - if intolerance is manifested, give a cereal based blenderized diet or
formula,enriched with protein hydrolysates or a lactose-free supplement (Casec,
Ensure , Sustagen premium 1 and medium chain triglycerides).

 Use a straw for drinking liquids to avoid irritating lesions and causing soreness.
 Practice good oral and dental hygiene.
 Rinse with a topical anesthetic.
 Give hard candy and chewing gum to stimulate saliva production if mouth is
dry.
11. Heart burn
 Bland diet
 Small frequent feeding
 Do not lie down for two or three hours after meals.
 Keep head and chest elevated with pillows or put a six-inch bed block under the
head of the bed.
 Avoid chemical irritants such as hot, spicy foods, coffee, liquor, smoking and
stress.
12. Indigestion
 Small frequent feeding; bland diet.
 Avoid overeating and foods that may cause indigestion.
13. Bloating
 Eat frequent small meals.
 Avoid fatty, fried and greasy foods, gas-forming vegetables (broccoli, cabbage,
cauliflower, corn, cucumber, beans, green peppers, sauerkraut and turnips),
carbonated beverages, chewing gums and milk.
 Emphasize sweet or starchy foods and low-fat protein foods.
 Sit up or walk around after meals.
14. Diarrhea
In nonspecific diarrhea, there is an increased frequency of bowel movement. The stools
usually contain mucus, and are commonly loose and less formed than the normal stool. Bowel
frequency in unrelated to food intake.
To manage diarrhea:
Determine cause.
If treatable, bowel rest and total parenteral nutrition may be indicated until diarrhea
subsides so that oral or enteral feeding can be giver. Maintaining adequate nutrition on bowel
regeneration through oral or enteral feeding is important. A nutrient knows to be essential for
bowel structure and function is glutamine which unfortunately, is not contained in parenteral
formulas currently available.
- if there are bacteria’s over growth due to prolonged antibiotic therapy, supplementation
with lactobacillus acidophilus cultures through fermented dairy products (e.g. yakult, yoghurt )
may be helpful.

 If cause is highly resistant to treatment, a nutrition therapy goal would be to

promote patient comfort through
-medication to minimized symptoms;
-small frequent meals served at room temperature;
-intravenous fluid to maintain fluid electrolyte balance;
-fiber containing supplements;
-total parenteral nutrition (TPN), if bowel rest will relieve symptoms.
 If cause is undetermined, treatment should aim at relieving symptoms.
 -if steatorrhea is present, give lactose-free, low fat diet; try yogurt and cheese in
small amounts.
-if ulcerative lesions are present in the GI tract, give a low roughage diet.
 -to prevent dehydration, encourage liberal intake of fluids such as broths, fruit
juices, gelatin and provide high potassium foods such as banana, meat and
potatoes for replacement of electrolytes.
 If cramping is a problem, avoid foods that may cause gas or cramps, such as
carbonated drinks, beans, cabbage, broccoli, cauliflower, highly spiced foods, too
for any sweet and sorbitol sweetened chewing gums.
15. Malabsorption
 Start with a polymeric formula or a lactose- free formula, orally and enterally
 If sign of malabsorption persist, consider given an elemental diet or TPN.
For fat malabsorption:
 Omit fat in the diet. Medium-chain triglycerides (e.g. coconut oil) are usually
tolerated.
For vitamins and minerals malabsorption:
 Gives supplements.
For lactose intolerance:
 Omit regular milk. Soybeans milk or low- lactose formulas may be used for
children and adults requiring a high protein diet.
16. Weight loss, muscle loss
 Give high protein, high calorie diet.
17. Neurologic complications
 These include impairment of motor function, confusion, dementia and
neuropathy. The following strategies may be helpful.
 Simplify meal tray; use special utensils, if available.
 Modify food consistency if there is difficulty in swallowing.
 In advanced cases of neurologic involvement, the patient may need feeding
assistance, or consider tube feeding.
18. Dehydration
 Take frequent feedings liquids or food that become liquid to the stomach, fruits
with high fluid content; ice cream, sherbet, fruit ice cream and popsicles.
REFFRENCES

A. Nutritional Guidelines

Azurin, J.C Diabetes Mellitus Survey and Control Program in the Philippines. Progress
Report, MOH 1983
Bengoa, J.M. et al. Nutritional Goal from Latin America. Food and Nutrition Bull. 11(1):4-
20,1989.

Bitara, E.D.T. et al. Control Program of Diabetes Mellituts in the Philippines . l.Retrospective
Study and Mass Screening in Metro Manila. Acta Med. Phil. 16,5-2:19-20,1980.

Claudio, V.S. et. Al. Basic Diet Therapy for Filipinos, Revised edition. Merriam and Webster
Inc. p. 266, 1983.
De Guzman , M.P.E. and A.R. Aguinaldo Food Safety, in search of an advocacy, a crusade.
JNDAP
5:109-118,1991.

Department of Health, Disease intelligence Service. Philippines Health Statistics, 1987.

Ericson, K.L.et. al. The Role of Dietary Fat in Mammary Tumorigenesis,food technology
39;69-73, 1985.
Flores, E.G. et. Al. Second Nationwide Survey. Part B Anthropometry, Anemia and clinical
Survey. Phil. J. Nutr 35:51-56,1985.
Geizerova, H. and J.V Layson, Jr. Primary Prevention of Coronary Heart Disease: Same
Strategical
Aspects of Filipinos. Phil.J. Int. Med.23114-164, July- Aug. 1985.
McGinnes, JM and M. Nestle. The Surgeon General Deport on Nutrition and Health Policy
implications and Implementation Strategies. Am J. Clinical Nut. 49:23-8,1989.

Gregly, M.J. Sodium and Potassium, in Nutrition Reviews Present knowledge in nutrition, 5th
ed. ch. 31. The nutrition foundation, Inc., Wash. DC, 1984.
Koh,K. Nutritional Approach to Cancer Prevention with Emphasis on Antioxidants and
Carotene. JNDAP 6:16-25,1992.

Kuizon, M.D.et. al. Development Of Nutrition Guidlines for Filipinos. JNDAP 3:103-
109,1990.

Lasang, S. L. Diabetes and exercise. Diabete Watch 7:3, 1990.

Levy, V.et. al. The Antioxidant Effect of Beta Carotene: Oxidation in Response to Oral
Supplementation of the vitamins(Abst.)Abstract Book,Xllth Intl. Congress of
Dietetics.Jerusalen, Israel, 1992.
Limbo, A.B. et. al. A Comparative Analysis of Some of Methods of Evaluating Diets and
Preschool Children
From Low Income Families. Phil. J. Nutrition 27: 182-193,1984.

Lung Center of the Philippines. National Smoking Prevalence Survey. Phil. J. Int. med
27:133-156, 1989.
McGinnes, J.M. Nestle. The Surgeon General Report on Nutrition and Health Policy
implications
And Implementation Strategies. Am. J. Clinical Nut. 49:23-8, 1989.
 National Research Council. Diet and Health Implications for Reducing Chronic Disease Risk,
1989.

National Research Council Executive Summery: Diet, Nutrition and Cancer. Nutrition today
17:20-25 1982.
Nutrition and health. Chapter 17 Alcohol.
Sanchez, F.S. Cardiovascular diseases: Grapping with a Gripping and Spreading Malady.
EHSC Newscap Vol. 3 No. 1 Jan-March 1989.
Tanchoco, C. Fiber: fiber sense or nonsense, JNDAP 4:113-118,1990

Tanchoco, C.C. Nutrition Aspects of Emerging diseases in modernizing societies: A Reaction

JNDAP 4:90-33, 1990.

Tanchoco, C.C. Nutrition and Nutrition-Revealed health problems in the Philippines, JNDAP
4:94- 102, 1990.

Tanchoco, C.C. et. al. Formulation of Nutrition Guidelines for the prevention of chronic
Degenerative disease. JNDAP 6:26-29,1992.
Tashev, T. Nutritional aspects of obesity and diabetes and their relationship to CVD and
Mortality. Food and Nutrition bull. 8(3):12-14 1986
Williamsom , N.E. Breastfeeding Trends and Breastfeeding Promotion Program in the
Philippines. Int. J. Gynecol. Oct 31 (Suppl. 1):35-41, 1990.
B. Nutritional Care Process
Anderson, L.,M.V. Dibble, P.R. Turki , H.S. mitchelle and H.J. Rynberg. In 1982. Nutrition in
health and Disease,17th ed: J.B. Lippincott,Pa.
Krause, M.V. and L.K. Mahan 1984. Food Nutrition and Diet Therapy, 7th ed. W.B. Saunders
Co. Pa.

Passmore, R. and M.A. Eastwood,1986.Davidson and Passmore’s human nutrition and

dietetics, 8th ed. ELBS/Churchill Livingstone.
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nutrition 17th ed. Macmillan Bublishing Co.
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, 6th ed. Times Mirror/Cosoy College Publishing,St Louis, Mis.
Zeman, f and D.M. Ney, 1988. Application Of Clinical Nutrition. Prentise Hall, eaglewood
Cliffs,. N.J.
 CHAPTER 6

GENERAL DIETS

A. Regular or Full Diet

The regular of full diet, the most frequently used of all hospital diets, is design to
maintain optimal nutritional status. It follows the principles of good meal planning and permits
the use of all foods.
Nutritional requirements vary depending on age, sex, size, and activity level. The Food
Plan
Outlined below provides approximately 1900 kilocalories and 60 grams protein. It is thus
adequate in protein f or most adult and meets the energy allowance for a moderate activity
Filipino woman.
Adjustment in caloric value may be made by increasing (e.g. for males) or decreasing (e.g. for
bed patients) the sugar, fat or rice exchanges.
Depending on the specific food choices, the food plan meets the recommended
allowances for vitamins and minerals for healthy persons.

Indications for Use.

For ambulatory or bed patients whose conditions do not necessitate a modified diet.

Food Selection Guide

All foods are allowed.
Daily Food Plan
Food Group Amount

Vegetables At least 2 servings; 1/2 - ¾ cup cooked per

serving
Fruits One should be leafy green or yellow.
Milk, evaporated 2 – 3 servings; one should be vitamin C-rich .
Rice or substitute At least 2 tablespoons.
Meat, fish or substitute 10 – 13 exchanges.
5 – 6 exchanges; liver on glandular organs
once a week; eggs 3 – 4 times a week;1/2 cup
cooked dried beans may be used in place of 1
Fat meant and fish exchange.
Sugar or sweets 2 tablespoons.
2—3 tablespoons.

Suggested Meal Pattern

Breakfast Fruit
Egg or Substitute
Rice or Bread with Butter, Margarine or Jam
Hot Beverage

Lunch Soup
Meat, fish, Poultry or substitute
Vegetable
Rice or Substitute

Supper Same as Lunch

Snacks As Desired, if necessary

B. Simple Modification of the Regular Diet

High Fiber Diet

This is essentially a regular diet which includes liberal amounts of foods rich in dietary
fiber.
Fluids are also increased.
Indication for Use
Atonic constipation
Diverticular disease
Irritable bowel syndrome
Gastric Ulcers
Cancer of the colon
Cardiovascular disease
Diabetes mellitus

Food Section Guide

All selection is allowed. The following foods are emphasized.
Vegetables leafy, legumes (lentils, dried beans and peas);

Fruits Those with edible skin and seeds; ripe papaya,

Dried, like prunes, raisins and dried mongo.

Rice or Substitute whole grain like unpolished rice pinipig,

See Rolled oats, whole kernel corn, whole wheat or rye
Bread; ready to eat high fiber breakfast cereals.
Others Cereal (rice, wheat etc.) bran and fiber supplements.
ONLY HAVE PRESCRIBED BY PHYSICIAN;
Also Dietary Management Cardiovascular Diseases and diabetes Mellitus.

Full Bland Diet

The full bland diet, also called bland V is a regularly diet in which the only restriction
are foods which stimulates gastric acid secretion and motility. Aside from the restrictions (see
food guideline) foods selection and methods of preparation are the same as for all or regular diet.
Small frequent meals help to reduce gastric acid secretion and motility.

Indication for Used

Hyperacidity
Gastric and duodenal ulcers
Daily Foods Plans and Selection Guide
See Regular or Full Diet. Avoid:
 Hot spices like black pepper, chills (whole, powdered or sauce)
 Caffeine- containing beverages like regular coffee, tea, cola drinks.
 Alcoholic beverage

Certain foods like cabbage, onion, garlic, etc. may cause distress some patients. An
individualized approach to meal planning is thus necessary.

Sample Menu

Breakfast Ripe Papaya

Sausage with tomato Slice
Rice (not more than 1 cup)
Decaffeinated Coffee with Cream and Sugar

Mid-Morning Meat Sandwich

Gelatin desert
Lunch noodles soup
Broiled fish
Mixed vegetable Guisado
Rice (not more than 1 cup)
Banana

Mid-afternoon Ensaymada
Cheese
Chocolate milk drinks

Supper Chicken Tinola with Chayote and Sili Leaves

Rice
Plain Pudding or Custard

Bed time crackers

Hard cooked egg
Fruit juice or milk

Vegetarian Diets

Either for religious reason of out of concern for ecologic basic health principles,
many individuals today are choosing a vegetarian dietary regimen. Vegetarian diets are classified
as lacto-ovo- vegetarian, lacto-vegetarian, ovo-vegetarian, pesco -vegetarian, semi-vegetarian or
total vegetarian .seasoning and condiments’ derived from animal sources such as patis and
bagoong are not used to strict vegetarian diets.

Lacto – Ovo- vegetarian Diet

This diet includes plants foods and allows moderate use dairy products, preferably low
fat and infertile eggs (thus balut is not allowed). The meal plans is similar to regular diet except
that a main dish of legumes or meet analogues or textured vegetables protein (TVP) made from
cereals, glutens, legumes, and/or nuts is substituted for meat, fish or poultry. The diet includes
liberal amounts of fruit and vegetables, and when well planed, meets the nutrition needs of
normal adults. Growing children and pregnant and lactating women should take an iron
supplement.
Besides tokwa or tofu, there are now a number of meat analogues available in the
market which may be used as main dishes for vegetarian diets. They are popularly called
―vegemeat‖ and come in different forms- chunks, chop lets, or ground. They may be prepared
just like any meat recipe- asado, menudo, ―steak‖,‖ meat‖ balls, etc.
A critical nutrient lacking is most vegetarian diets are vitamins B12 since this vitamins
in found only in animal food products.

Lacto Vegetarian Diets

This diet includes plant foods and dairy products but no eggs. This plan can also
provide the recommended nutrient if well planned.

Ovo- Vegetarian Diet

This diet includes plant foods allows the use of eggs, It may be low in calcium

Pesco-vegetarian diet
This diet is similar to lacto-ovo-vegetarian diet but allows fish

Semi-vegetarian diet
This is lacto-ovo vegetarian’s diet with the inclusion of chicken and fish red meats are
excluded.
Total vegetarian diet (VEGAN)
This does not include all foods of animal origins and is thus likely to be deficient in
many nutrients.
An extremely type of the total vegetarian diet is the Zen Micro biotic Diet. This
regimen
Consist of ten stages, each one becoming more restrictive until finally, only rice is allowed. The
diet is an adequate and prolonged use may result in multiple nutrition deficiency disease.

C. Pediatric Diets

Supplements Diet
(One to Six Months)

The main food for infant is milk. Breast milk is the best and the breast feeding should
be encouraged at all times. Breast milk has specific characteristics suited to the nutritional needs
and psychological development of infant. Furthermore, breast feeding enhances the bonding
process between mother and child during the first year of life.
Except for vitamin D, the nutritional needs of the infant for the first six months of life
can be met by breast milk alone provided breast feeding is adequate. The main aim of
supplemental feeding between 4 and 6 months is to introduce spoon feeding and new texture and
flavored to the infant to prepare him for later weaning and to establish healthy eating habits early
in life.
Early supplementation with the vitamin D is desirable.

Indications for use

The diet outlined bellowed as suitable and healthy infants aged 4 to 6 months. Earlier
supplementation depends of the needs and developmental readiness of the infant as determine by
the attending physician.

Ordering information
When additional foods are desired for infants aged 4 to 6 months (or younger) order
should be specific and state the food and amount to be given.

Food selection guide

Supplemental foods age started
Cereals, strained or blenderized, 4 months
Thin lugao or scraped or mashed fruit,
Vegetable water

Thick lugao vegetable purees 5 months

Strained juiced

Flaked fish or ground meat, 6 months

Hard cooked egg yolk

Infant diet
(6 – 12 months)

The diet for infants aged 6 to 12 months is designed to meet their increasing
nutrition needs which can no longer be met by milk alone. Breast milk is still the best for babies
at this age and mother should be encouraged to continue breast feedings as long as they can.
Excluding milk, the foods listed in the food plan below provide about 470 -
670kcalories
And about 18 – 22 grams protein. The diet tends to be low in iron since our rice, the most
common cereal used for infants, is not enriched. Iron supplementation is thus desirable.
Indication for use
This diet is designed for infants aged 6-12 months. The infant’s individual growth
and development pattern is the most suitable guide to determine to introduce semi-solid and solid
foods as well as how much introduce. Indications of readiness for solid foods are when:
 The infants has double his or her birth weight
 The infant consume 8 oz. formula and is hungry in less than 4 hours;
 The infant consume 32 oz. of milk a day and wants more;
 The infant is 6 months old.
Ordering information
The order should state the age of infant.

Daily Food Flan and Food Selection Guide

The amounts of some foods given in the table are ranges, the lower limits of
which are for the younger infants in this age group. Gradually increasing amounts are
recommended for older infants. Likewise, mashed or pureed foods are appropriate for younger
infants, while food may be shopped or finely diced for older ones.

FOOD GROUP AMOUNT ALLOWED FOODS

Rice or substitute 1-3 exchanges Preferably enriched; rice
gruel soft cooked for the older
infants; strained oatmeal,
farina toast or crackers.

Sugar 6 teaspoons Sucrose, corn syrup

Fat 2 teaspoons Butter or margarine
Milk(if not breastfed) As ordered by Prepared according
Physician to formulas
1-2 exchanges Mashed hard cooked egg yolk;
whole egg after ninth month;
pureed or sieved, chopped,
thinly slice lean meat, liver,
chicken; flaked fish and
mashed dry beans.
Fruit 3-4 tablespoons Pureed or mashed, finely
diced, sliced banana, papaya,
ripe mango, avocado apple
souse fruit juices.
vegetable 4-5 tablespoons Pureed, sieved, mashed or
shopped squash, chayote,
carrots, upo, and green leafy
vegetables.
Daily Food Plans and Food Selection Guide

AMOUNT

FOOD GROUP ALLOWED FOODS

TODDLER PRE-
SCHOOL CHILD
(1-3 YEARS) (4-6 years)
Rice or substitute 5-6exch. 7-8 exch. All except whole kernel corn
and malagkit for young
toddlers
Sugar 6 tsp. 6 tsp.
Sucrose, syrups
Fat 5tsp. 6 tsp. Jams, jellies.
Cream, butter or margarine.
Dessert As needed: made from food
allowance Plain pudding, gelatin, ice
cream, cakes and cookies.
Soup and beverages
Made from foods

Milk
2 cups

meat, fish or substitute

2-3 exch. 3-4 exch. Chopped or ground lean
Meat, liver, chicken; flaked
fish, eggs ; mashed dried
beans;
fruit Mild cheeses.
1-2 exch. 2 exch.
One should be One should
be
vitamin C- rich vitamin C-
vegetable rich

all except strong

1-2 exch. 2 exch. flavored for the younger
children; chopped or cut in a
small pieces, skin, seeds, and
long fiber if any removed

Foods to Avoid
Whole kernel corn, nuts and malagkit for the younger toddlers
Highly seasoned and strongly-flavored vegetables
Highly spiced, canned or cured meat, fish; fish with small bones, sharp cheeses.
Nuts and coconuts, unless properly processed
Candy and excess sweets rich cakes and pastries
Highly seasoned soups
Coffee, tea, carbonated beverages
Monosodium glutamate (vetsin) and salt pepper (salitre)
Suggested meal pattern

Breakfast fruit
Egg or substitute
Buttered toast or cereal
Warm beverage

Mid-morning milk drink

Supper same as lunch

D. Diets for Pregnancy and Lactation

These diets are designed to meet the increased nutrients needs during pregnancy and
lactation due to normal physiologic changes. The calcium and iron contents of the diets outlined
below somewhat lower than the RDA. More milk are frequent use of dillis will improve the
calcium contents of the diets, while iron supplementation is highly recommended. The vitamin A
and C of the diets can be assured trough a wise choice of food.
The food list for pregnancy outlined below supplies about 2300 kcalories and 75 g
protein
While that for lactation supplies about 2500 kcalories and 85 g protein.
Adolescent pregnant girls require a diet higher in calories, protein, vitamins and minerals
to meet both the needs of the developing fetus and their growth.

Daily Food Plan

FOOD GROUP PREGNANCY LACTATION
Rice or substitute 12 exchanges 13exchanges

Sugar 6 teaspoons 6 teaspoons

Fat 7 teaspoons 7 teaspoons

Milk 1 cup 1 cup

Meat or substitute 4 exchanges liver or glandular 4-5exchanges liver or

Organs twice a week; eggs 3 glandular organs twice a week
to 4 times a week ;1 egg daily

Fruit 3 to 4;2 of which should

vitamins C-rich Same as pregnancy

Vegetables 3 exchanges; 1 to 2 of which

should be leafy or green 4 exchanges; 2 of which
should be leafy green

Food selection guide

All foods allowed.

Suggested meal pattern

Breakfast fruit
Egg or substitute
Bread with butter or jam
 Cereal
Hot beverage

Mid –morning sweetened fruit juice cookies

Lunch and soup

Supper meat, fish, poultry or substitute

Vegetables
Salad with dressing
Rice fruit or desert
Mid-afternoon milk

Note: the higher food requirement in lactation may be met by serving both a dessert and fruit for
upper and by giving milk drink at bedtime.

E. diet for elderly

The diet outline below is lower in energy value than the full or regular diet since energy
requirements are reduced in the elderly. The diet provides about 1700 kcals and 60 grams
protein.
Daily food plan
FOOD GROUP AMOUNT

Vegetables At least 2 servings:1/2-3/4 cup cooked per

serving; one should be leafty,green or yellow.

Fruit 2-3 exchanges: one should be vitamin C- rich

Milk As tolerated

Rice or substitute 10 exchanges

Meat, fish or substitute 5-6 exchanged: liver or glandular organs once

a week ; eggs 3-4 times a week; ½ c cooked
dried beans may be substituted for 1 meat
exchange
Fat
1 tablespoons
Sugar
5 tablespoons
Food selection guide
The foods selection guide for the regular diet may be followed with the following
modifications:
1. Avoid fried and fatty foods, gravies, cream sauces, salad dressings rich desserts.
2. Avoid excessive spices and seasonings.
3. Avoid strong coffee and tea, if these cause nervousness and sleeplessness. Decaffeinated
coffee or coffee substitute may be used instead.
4. Large and hard pieces of food may be chopped, group or pureed if a mechanical soft diet is
need
5. Certained foods such as dried beans, cabbage, cauliflower, radishes may be omitted these
cause stress.
6. Limit foods with little nutritive value such as gelatin desserts, clear broth and carbonated
beverages.
7. Include liberal amounts of fruit and vegetable for dietary fiber.
8. Encourage plenty of fluids.
 CHAPTER 7

NUTRITIONAL MANAGEMENT OF SELECTED DISEASE CONDITIONS

A. Nutritional Therapy in Diabetes Mellitus

―Nutrition Therapy‖ is the terminology adopted by the American diabetes

association in March 1994 lieu of ―diet therapy‖ to emphasize the need for a team
approach to enhance the ability of each patient with the diabetes to achieve good
metabolic control. The team includes a registered nutritionist- dietitian, a registered
nurse, a physician, the persons with diabetes, and other health care professional as
needed.

There is no one ―diabetic diet‖ that will suit the individual and special needs of
persons with diabetes as revealed trough an adequate nutrition assessment .this
assessment which considers anthropometric and clinical laboratory data (especially blood
glucose, glycated hemoglobin and lipid level) as well as lifestyle data such as activity,
food habits etc.,is the basis for identifying treatment goals and invention. Thus, the diet
for an individual with diabetes can only be defined as a ―dietary prescript ion based
nutrition assessment and treatment goals‖

Aims of Nutrition therapy

1. Maintenance of as near-normal blood glucose level as possible by balancing

foods intakes with insulin (endogenous or exogenous) or oral hypoglycemic
agents.
2. Achievement of optimal serum lipid levels.
3. Provision of adequate energy to maintain/ achieve reasonable body weight in
adults or normal growth and development rates in children and adolescents or to
meet increased metabolic needs during the pregnancy, lactation and recovery
from catabolic illnesses.
4. Prevention and treatment of the acute complications of insulin’s-treated
diabetes such as hypoglycemia, short term illnesses and exercise illnesses and
exercise-related problems, and of long-term complication of diabetes such as
renal diseases autonomic neuropathy, hypertension and cardiovascular disease.
5. Improvement of overall health through optimal nutrition.
Indication for use
Condition characterized by elevated blood glucose level such as diabetes mellitus (insulin
dependent and non-insulin dependent) impaired glucose tolerance and gestational diabetes.
Note: When other medical conditions such as renal complications are present, further
modifications of the diet are required.

Ordering information
The diet prescription should state the calories, carbohydrates, protein and fat levels desired.
Other special instructions such as distribution of carbohydrates into meal amount of fiber
/s sodium level, etc., should also be stated.

Recommended dietary modifications

1 totals calories- sufficient to maintain/achieve reasonable weight in adults,or meet

increased needs children , adolescents, pregnant , and lactating women and individuals
recovering from catabolic illness.
Chronic distribution-
Carbohydrates: 50-70%
Protein : 10- 20 %
Fat : 20-30%
Carbohydrates and fat distribution prescribed should be individualized depending on nutrition
assessment and treatment goals.
 For individual normal lipid level and reasonable body weight: 30 % or less of
total energy may come from total fat and about 10 % total energy from saturated
fat.
 It obesity and weight loss are the primary issues: use the lowest fat level (20-
25% of total calories)
 If elevated low density lipoprotein cholesterol (LLD-C) is primary problem : <7
% of total calories may come from saturated fat:30% or less than total fat: and
limit dietary cholesterol to 200 mg per day. This is step two diet of national
cholesterol education program.
 If elevated triglycerides and very low density lipoprotein cholesterol (VLDL-C)
are the primary problems :< 10 % of energy from saturated energy from
fats,<10% for polyunsaturated and up to 20% from monounsaturated; 10-20 %
from protein; remainder from carbohydrates. But if the individual is obese or a
triglycerides level is> 1000 mg/dl, reduce total calories and all type of fat. This
way, the absolute amount of is not increased.

The following table may use as a guide in determining calories needs:

AGE KCALL REQUIREMENTS PER

KG RDW1

CHILDREN ~120
0-12 MONTHS 100-80
1- 10 YEARS OLD

YOUNG WOMAN ~35

11-15 years ~30
6 years

YOUNG MEN
11 – 15 years
16-20 years
Moderate active ~40
Very active ~50
Sedentary ~30

MEN AND PHYSICAL ACTIVE WOMEN ~30

MOST WOMEN, CEDENTARY MEN, ~28

AND ADULTS AGE OVER 55

PREGNANT WOMEN ~28-32

First Trimeste2 ~36-38
Second/Third trimester3 ~36-38

WEIGHT REDUCTION FOR ADULTS ~20

3. Cholesterol – limit to 300 m/day or less.

4. Carbohydrates and sweeteners-
  The 1994 guideline issued by the American diabetes association state that ―from
clinical perspective, priority should given to the total amount of carbohydrates
consumed rather than the source‖.
 Sucrose: the same guideline has liberalized the recommendation for sucrose
consumption. However, to avoid abuses which as experience as shown, follow
liberalization of recommendations, it is best to limit the use of sucrose and
sucrose containing foods.
 Non-nutrient sweeteners: saccharine, aspartame and acesulfame K may be used in
moderation.
 Dietary fiber: Aim for about 20 g/day or more. Excessive amount are not
necessary.

5. Sodium –limit about 3000 mg/day; less for people with hypertension or renal complications.
6. Alcohol- moderate amounts may be allowed, contingent on good metabolic control.
7. Vitamin and mineral supplement- not usually necessary, but may be given to individuals on
On reduced calorie diet (1400 kcal/day or less).

Nutritional management of renal disorder

Chronic renal insufficiency is also called predialysis diet. The diet is restricted in two
major nutrients: protein and phosphorus. Restrictions in sodium, potassium, fluid, and calories
are based on individual needs. Because of restrictions in certain foods, the diet is deficient in
calcium, iron,
Vitamin B12 and zinc. A low protein diet may also be deficient in thiamin, riboflavin, and
niacin. The need of vitamin and mineral supplementation should be assessed on an individual
basis.

The diet aim is to reduce the workload of diseased kidney(s) by reducing the urea. Uric
acid, creatinine and electrolytes (especially phosphates) that must be excreted, prevent
acceleration of nephrotic damage resulting from excessive protein intake, prevent calcification
secondary to renal dystrophy, prevent renal osteodystrophy and at the same time, to promote a
filling of well being and postponed the need for dialysis.

 The diet order should state the level calories, protein and electrolytes desired.

Dietary Modifications

Dietary Factor Recommendation

Protein (g/kg IBW) 0.6-0.8

Normal weight :35 kcal/ kg IBW
Energy (kcal/kg IBW) Obese :20-30
Under weight or catabolic :50

Phosphorus (mg/kg IBW) 8-12

Sodium (mg/day) 1000-3000**

Potassium Typical not restricted

Fluid Typical not restricted

Calcium (mg/day) Typical not restricted

fiber 20-25 g/d

Food selection guide

Food Group Allowed Avoided or Restricted

Vegetable All fresh is allowed amounts Picked vegetables, salt

fermented vegetable like
burong mustasa, sauerkraut
kim chi; canned and frozen
vegetable.

Fruit All except those avoided list, Maraschino cherries, candied

in allowed amount fruits, dried fruits.

Evaporated whole, allowed Commercial foods made with

Milk amounts milk, condensed milk, melted
milk, milk mixed sherbet,
chocolate cocoa.

Rice Rice, bread, bihon, macaroni, Commercially prepared

spaghetti, corn, all of these
and their product in amount
allowed
desserts, mixes and pastries;
potato chips, pretzel, snacks
chips cereals, or cracker
containing baking powder,
baking soda, salt, or other
sodium compounds; bran
cereal boxed, frozen or canned
meals, whole wheat/grain
breads and cereals, mami,
mike, misua, instant noodles.

Chronic Renal Failure

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

The diet order should state the calorie, protein and electrolyte level desired.

Dietary Modifications
Dietary Factor Hemodialysis Peritoneal Dialysis

Protein (g/kg IBW) 1.1– 1.4; at least 60% 1.2 – 1.5

High biologic value 1.2 – 1.3 for maintenance
1.5 for repletion
1.2 for reduction or if with
diabetes

25-35 for maintenance

Energy (kcal/kg IBW)
30-35 for weight maintenance
25-30 for weight reduction
40-50 for weight gain
35-50 for repletion
20-25 for reduction
35 if with diabetes (for CRPD
and CCPD include dialysate
calories) 1

< or approximately 1200 mg/d

Phosphorus <17 mEq or approximately (keep serum level at maximum
800 – 1200 mg/d. of 6 mg/100 ml)
(Keep serum level at
maximum of 4 – 6 mg/100 ml.
) Individualized based on blood
Sodium pressure and weight.
2000-3000 mg/d
Generally unrestricted with
Potassium CAPD and CCPD for IPD:
40 mg/kg IBW or 2000- 3000 ml/day
approximately
50-80 mEq.d CAPD and CCPD,
Fluid (1250-2000 mg/d) approximately 2000- 3000
ml/day based on daily weight
500- 750 mL/d plus daily fluctuation and blood
urine output or approximately pressure; IPD, same as for
750- 1500 ml/d hemodialysis.

Calcium(mg.d) Same as for hemodialysis

approximately 1000- 1800

mg/d; supplements as needed
Fat depending on serum level Same as for hemodialysis

Limit cholesterol to less than

300 mg/d; emphasize poly
Fiber unsaturated fats. Same as for hemodialysis

20-25 g/d
Acute Renal Failure

The diet for acute renal failure (ARF) aims to reduce the accumulation of the uremic
toxins,
Control electrolyte abnormalities, and correct fluid retention while maintaining nutrient status.
Dietary factors that need to be controlled include protein, potassium, sodium, phosphorus, and
fluid with adequate calories depending on individual needs and frequency of dialysis treatment.
The diet is for patients with AFR with and without dialysis treatment.

Ordering Information
The diet order should state the calories, protein and electrolytes levels desired.
Dietary Modifications

Nutrients Recommendation

Protein 0.5 – 0.6 g/kg present body weight (but not less
than 40 g/d); increase as GFR return to a
normal; dialysis allow
1.0 -1.5 g/kg of present weight/d.

Energy 35-50 kcal/kg present body weight ; energy

must take into consideration the stress
accompanying AFR.

Phosphorus Individualize according to laboratory values.

Sodium Anuric- oliguric phase: 500 – 1000 mg/d

Diutric phase; replaces looses depending

urinary and sodium levels, edema, and
frequency of dialysis.

Potassium Anuric- oliguric phase: 1000 mg/day

Diuretic phase: replaces looses as indicated by

urinary volume, serum and urinary potassium
levels, frequency of dialysis and drug therapy

Fluid Assess on daily basis

Anuric-oliguric phase: replace output (urine,

vomits and diarrhea) plus 500 ml from the
previous day.

Diuretic phase: large amount of fluid may be

needed.

Calcium Individualize based on laboratory values

Fat No modification indicated during AFR

Food selection guide- refer to diet for chronic renal insufficiency

Post kidney transplantation

The diet renal transplantations design to provide adequate calories and protein to
counteract the catabolic effect of surgery during the early post transplant period and to manage
nutritional side effect of immunosuppressive drugs.
The diet is used for used for patient with chronic renal failure who has undergone renal
transplantation.

Dietary modifications
First month after Transplant After first Month
Nutrient and During Treatment for
Acute Rejection
Protein 1.3- 1.5 g/kg/d 1.0 g/kg/d

Calories 30-35 kcal/kg/d sufficient to achieve/ optimal

(more if underweight ) intake weight for height

Fats No more than 35% of calories Same

,
Cholesterol <400 mg/d;
Polyunsaturated-saturated
ration >1
Carbohydrates Same
Remainder of total calories ,
encourage complex
carbohydrates
Potassium Same
Variable, restrict or
supplement as necessary based
on serum level
Sodium Not more 3 g/d
2-4 g/d may be necessary in
acute rejection Same
Calcium
1200 mg/d
Same
Phosphorus 1200 mg/d, some patients
require supplements
Fluids Same
Ad lib unless fluid retention
And hypertension worsens.

Food selection guide

The diet for normal diets may be followed if there are no complications. To meet the
increased need for calcium and phosphorus, give 3-4 glasses of milk per day, or give calcium and
phosphorus (calcium phosphate) if milk is poorly tolerated.
Nephritic syndrome
The protein – and sodium controlled diet for nephritic syndromes (NS) is design to
minimized edema and proteinuria, control hypertension, retard the progression of renal disease
prevent muscle catabolism and protein malnutrition, and supply adequate energy
The diet is for persons with NS who are not dialyzed.

Ordering information
The diet order should state the energy, protein and sodium level desired.

Dietary Modification

Nutrient Recommendation

Protein Adults: 0.6 to 1.0 g/ka IBW plus replacement

of urinary protein looses
children: RDA for age plus replacement of
urinary protein looses

Sodium 1-3 g.d

Fluid Generally restricted

Fats <30 % of total calories per day

Cholesterol <300 mg/d dietary cholesterol

Energy Sufficient to achieve and maintain edema-free

IBW

Vitamins and minerals Supplement may be necessary if protein intake

in 60 g or less /d

Food selection guide-refer to diet chronic renal insufficiency

Urolithiasis (kidney stones)

The dietary modifications for urolithiasis are designed to minimize the super generation of
components in the urine associated the information of renal calculi. Generally dietary
intervention
Includes combining the restriction of specific dietary constituent associate with the formation of
the stone with the generous fluid intake. Most calculi contain variable amounts of calcium,
cystine or uric acid surrounded by calcium oxalate.

Indication for use

Diet modifications may be used with the medical treatment to increase the predominant
components in urine that cause stone information.
Calcium urolithlasis
The diet for the calcium urolithlasis is essentially a low calcium die

Dietary modifications

Dietary factor Recommendation

fluid 3 L taken divided doses throughout the day;

50% of the total volume from water

Sodium <100 mg/d in presence of hypercalciuria

Calcium 400- 600 mg/d in presence of absorptive

hypercalciuria.

<100 mg/d in presence of idiopathic

hypercalciuria with normal intestinal
obsorption of calcium.

Oxalate 50-60 mg- d in presence of hypercalciuria or if

stone composition data indicates calcium
oxalate crystals; used simultaneously with
calcium restricted regime.

Protein Moderate intake (12% -14% of

calories);encourage vegetable protein sources;
Decreased animal protein intake particularly
flesh and muscular protein sources rich in
purines.

2. Oxalate Urolithiasis
The diet for oxalate urolithiasis is essentially a low oxalate diet.

Food selection guide

The foods to restrict are the following:

Vegetables : beans, celery, eggplant, leafy green, leeks, okra, green pepper, squash:
CANNED vegetable soup, tomato soup.

Fruits : berries, grapes, fruit cocktail, lemon, lime, orange peels, tangerine.

Milk : chocolate and chocolate beverage, cocoa.

Rice : wheat germ, corn grits sweet potatoes.

Meat, fish or : beans with tomato sauce, tofu.

Substitute

Fats : nuts

C. NCEP recommendation in lower blood cholesterol

 The adult treatment panel of nutrition cholesterol education programs (NCEP)(US)has
formulated dietary recommendations for the management of hypercholesterolemia. These
are show in the following table.

Dietary factor Step one Step two

Total fat <30% of total calories Same as step 1

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

The food plans outlined below provide about 1800 kcalories with 50 gm fat,270 gm
carbohydrate and 65 gm protein contributing 25%, 60€%, and 15%, respectively of total
calories. In the step 1 Food Plan saturated, polyunsaturated and monounsaturated fatty acid
provide 8%, 8.5% and 8.5% of total calories, while in the step 2 plan, the corresponding value
are 4.5%, 9% and 11.5%.

Indication for use

Hyperlipoprotenemia
Coronary altery disease

Ordering information
The diet order for step 1 or step 2 diets should state the calories level the desired.

Food selection guide

See fat and cholesterol controlled diet (previous selection).

Daily food Plan

Food Group steno one step two

Vegetable 2 servings, one should be leafy green, yellow

Fruit 3 exchange, one should be vitamins C-rich

Milk, powdered non – fat 2 teaspoons 2 teaspoons

rice 10 exchanges 10 exchanges

meat or fish exchanges:

low fat group 5 exchanges1 10 exchanges2

Fat:
Corn oil 5 teaspoons 5 teaspoons
Olive oil 2 teaspoons 4 teaspoons
Coconut oil 2 teaspoons

Sugar 1 teaspoons 1 teaspoons

Suggested meal pattern
Breakfast fruit
Egg1 low fat meal exchange
With allowed fat
Bread and/or rice
Hot beverage with powdered non- fat milk
Or non-dairy cream or substitute.
Lunch and supper fat- free broth or clear soup
Vegetable
Low fat meal exchange
Fruit
(Use allowed type and amount of fat for cooking)

Snacks any allowed food

D. Dietary Regime after an Open heart Surgery

The following regime is used at the Philippines Heart Center for post-open heart surgery
Patients.

1. Coronary care diet # 1 (acute phase)

This is clear liquid diet providing 500 to 800 calories per day in a volume of 1800 or
1500
mL. Beverage containing caffeine is restricted since it acts as a stimulant and may
increase the heart rate. Thus, coffee, colas and cocoa are not allowed. Decaffeinated
coffee is allowed. Extremes in temperature of liquid are avoided.

2. Coronary care diet # 2 (sub-acute phase)

This is full liquid diet providing 800 to 1000 calories per day in volume of 1800 to
2000 mL. Restrictions are caffeine, saturated fat and cholesterol containing
beverages. Hence, coffee, colas, cocoa, whole milk, and whole eggs are not allowed,
and foods are prepared with skim milk and egg whites. Thick fluids pureed foods
rather than thin liquids are given. Sodium may or may not restrict.

3. Colonary care diet # 3 (convalescent phase)

A soft bland 1200 – 1400 calories diet is given. Food which are easily digestible,
free of gastric irritants soft and low in roughage are given. Lugao is served instead of
rice. The physician specialist the sodium level. Small frequent feedings are given.

4. Colonary care diet # 4 (rehabilitative phase)

The diet is basically soft although a wide variety of foods are given depending on the
patient’s tolerance. Sift rice instead of lugao is served. The Physician is specifies the
sodium level. Decaffeinated beverage of served.

E. Dietary management and malnutrition in children

Principles
1. Avoid delay; serve malnutrition is a medical emergency.
2. Aim at 100 to 200 kcalories and 2 to 4 grams protein per kilogram of actual body
weight.
3. Fluid: allow 120 -250 ml per kilogram of actual body weight.
4. Start with infant recipes, and then progress to a soft diet. With recovery, use diet for
age.
5. Give small frequent feeding -4 to 6 times daily; necessary, 30 ml of formula feeding
may be given hourly by teaspoon or medicine drooper nasograstric tube.
6. Give vitamin A capsule
Food to be included

1. Milk
a. Powder skim or full cream, 1 level teaspoon per half cup of water, or 2 tablespoon
evaporated full cream or reconstituted milk plus water to make ½ cup. Filled may
be tried cautiously if no other is available; condense milk is not suitable but may
be used as a last resort. If skim is add 1 teaspoon oil and 1 teaspoon sugar.
Increase concentration of milk as improvement accors.

b. allow about ½ cup per kg as actual body weight (for example: three –fourths to 1
cup three times a day for a 5 kg child).offer as milk to drink in cup or in from
bottle, or incorporate directly into other foods as rice, banana, etc. allow 1 level
teaspoon milk powder or 2 tablespoons evaporated milk per kg of actual weight of
the body. Increase allowance and concentration according to tolerance.

2. Rice or substitute
a. Aim at ½ cooked rice 4 times a day. Start in one cup rice gruel, thin at
first and the gradually thickened.
b. Rice substitute: ground corn gruel, oatmeal, rolled wheat (from CARE,
CRS and other such agencies), potato, sweet potato (yellow variety
preferred) and other tubers; strained or mashed at first for several
malnutrition children.
3. Animal proteins

a. Egg 1 a day, if possible, hard, soft or scrambled.

b. Fish or meat: 2 ounces or some, boiled, steamed or canned; for severely
malnourished children grind and cooks rice and vegetables.

4. Vegetable and proteins

a. Dried beans, nuts, soybeans; grind before cooking or mashed before

cooking to make legume easily digestible.
b. Allow ½ to 1 tablespoon raw beans per kg body weight; more in animal
proteins foods are not easily available.

5. Vegetable and fruits

a. Leafy greens;1/2 cup daily

b. Yellow vegetables and fruit: include frequently, or 2 portions may take a
place of 1 serving of leafy greens.
c. Others: as desired or tolerated

Sample menu (amounts are for a 5 kg child)

Breakfast rice or substitute ½

Egg 1
Milk ½ cup

Mid-morning mashed yellow sweet potato 1

With mashed beans 4 tbsp (raw measure)
Milk ½ cup

Lunch rice ½ cup

Squash and ground beef ½ cup
Or flaked fish 30 gm
Other vegetables as desired
Mid- afternoon mashed banana 1
Milk ½ cup

Supper rice ½ cups

Leafy vegetables ½ cups
Ground fish fish or beans 30 gm
Milk ½ cups

Bed-time milk I cup

Supplements (to be ordered by pediatrians)

1. Vitamins
- give vitamin A capsules to all severely malnourished children.
-give vitamin A for all stages active exophthalmia including night blindness, bito’s spots
And corneal lesions.
-give a dose of vitamins A to every child with measles in area where measles is serve.

Corneal eye involvement is an emergency, act fast to save sight.

Over 1 year of age

Immediately on diagnosis 200,000 IU vit. A orally

The following day 200,000 IU vit. A orally

1-4 weeks later 200,000 IU vit. A orally

2. for anemia
- if hemoglobin is below 10 gm/100 ml. give colloidal iron,1/2 teaspoon three times daily
;if below 8 gm/100 ml, transfuse.
-megaloblastic, given vitamin B12

Other treatments

1. Weight child on admission and then once or twice weekly thereafter.

-loss of edema fluid may cause initial weight loss of stationary weight;
-thereafter, expected gains is 100 to 200 gms, weekly.

2. Keep in hospital 2 to 3 months if possible and advisable, and until weight gains is more
than 1
Kilogram over minimal weight recorded during confinement.

Complications

1. For infection, diarrhea, or parasitism, give proper medication (prescribed by

pediatrician)
2. For diarrhea, see DIATERY MANAGEMENT OF DIARRHEA IN CHILDREN.

Discharge
Teach mother about proper diet.
-if available, give skimmed milk powder and other food distributed by UNICEF, CARE
Catholic
Charities ect. Or refer to local nutrition committee for food assistance.
-give advice on us of other animal foods and legumes leafy/yellow vegetables/fruit and
Addition of oil to staple foods.
 -demonstrate preparation of dilis power, dried bean flours and nutripack (see appendix
for
Procedures); advised liberal used user of these in absence or other animal foods

Encourage return visit for follow-up.

Dietary management of diarrhea in children

Principles

1. Replacement of fluid and electrolytes is prime consideration, may be done parenterally, if

necessary.
2. Resume a normal feeding as early as possible, especially malnourished child.
3. Give antibiotics (to be described by pediatriciaton) if diarrhea is bacterial in origin.

Management

1. Mild Diarrhea
Give milk (1 part milk to 4 parts of water) or banana powder formula and oral
rehydration solution (ORS, available in health centers) or sugar/saline, ½ per kg of body
weight daily. Use gavage (slowly) if necessary. Introduce solid foods o second day;
discontinue sugar/saline or molasses/saline. (if child is malnourished, follow DIETARY
MANAGEMENT OF MALNOTRITION IN CHILDREN) .

Sugar/Saline – boil together:

Sugar 2 heaping tbsp
Salt 1 level tbsp
Potassium salt ½ tsp
(citrate, chloride)
Water 1 pint

Banana Powder Formula

Latundan (4 pieces), green
a. Slice green latunday thinly
b. Sun-dry for one whole day or bake in a low temperature oven for 2 hours.
c. Grind or pound with the use of mortar and pestle (losong)
Yield: 121 pack at 7 grams (2 tsp).

Actual Composition per 100 grams:

Moisture, percent -12.0
Protein, gm -4.0
Fat, gm -0.9
Crude Fiber, gm -1.2
Ash, gm -2.0
Ca, mg -41
Phosphorus, mg -154
Iron, mg -5.2
Kcalories -262
2. Severe diarrhea with vomiting and/or dehydration
Intravenous therapy is necessary. For small children about 100 ml/kg body weight
daily of 1/3 normal saline in 5 % glucose (or other regimen as directed by
pediatrician). Begin oral rehabilitation within 24 hours or as soon as vomiting is
controlled.
Mixtures Using Banana Powder
1. Banana with Thin Rice Gruel
1 cup thin rice gruel
1 pack banana
1 tablespoon sugar
2. Banana with Milk
1 tablespoon skimmed milk powder
1 pint water
4 teaspoon oil
4 teaspoon sugar
1 pack banana powder
3. Banana with Vegetable Broth
1 cup vegetable broth (moderately salted)
1 pack banana powder

Note: Selection of mixture using banana powder will depend on the patient’s condition age and
tolerance.
 CHAPTER 8

NUTRITIONAL SUPPORT
Enteral Nutrition

Enteral nutrition refers to the delivery food and nutrients both orally and by tube directly
into the gastrointestinal tract. Many health professionals prefer to use the term enteral nutrition to
refer by feeding tube alone to differentiate it from oral feeding and frequently use enteral
nutrition interchangeably with tube feeding.

Indication for Tube Feeding

Patients who have a functioning gastrointestinal tract (GIT) but unable to ingest nutrients
orally or have very nutrient requirements

Types of Enteral Formulations

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

Ordering Information
Diet prescription for tube feeding (standard or blenderized) should specified the amount
of total calories with percentage distribution into carbohydrates, proteins, and fat; total volume
caloric density; rate of administration; diet modification, etc. and special supplements as
necessary e.g. vitamins, trace elements and minerals.

Standard Tube Feeding

Daily Food Plan

FOOD GROUP AMOUNT ALLOWED
Fruit 3exchanges Juices only
Milk 4exchsnges whole 2 cups evaporated
Egg 2exchanges skim ½ cup skin milk powder
Sugar 3 medium Strained soft cooked
10tbsp Sucrose, glucose, lactose or
corn syrup
Blenderized Tube Feeding
Steps in the formulation of a food plan for a blenderized formula are as follows:

A. Convert the dietary prescription (Rx) into grams carbohydrates (C), protein (P), and fat
(F).
Example: 1800 kca: C-60 %; P-15&; F-25% or 1800 kcal: C-270g.; F-50g.
B. Distribute into a Food Item
1. Vegetables: usually 2 serving, one each from list A and B, or as desired by patient.
2. Fruits: usually 2 to 3 servings
3. Milk: allow the usual amount consume by patient, if adult; for children, 1 to 2 cups.
4. Sugar: allow 4 teaspoon, or more on high calorie diets restrict on low calorie diets
5. Rice exchanges
a. Take the subtotal of the carbohydrates derived from no. 1, 2, 3, and 4.
b. Subtract from the total carbohydrates prescribed.
c. Divide the difference by 23 to get the number of rice exchanges to be allowed
round off to the nearest haft serving. For every 5 Gms less than the prescribed
carbohydrates, add one teaspoon of sugar.
6. Meat exchanges:
a. Take the subtotal of the protein derived from no. 1, 3, and 4.
b. Consider the kind of meat to be used weather low or medium fat
c. Allow 1 or 6 grams fat for low and medium fat meat, respectively.
d. Subtract from the total protein prescribed.
e. Divide the difference by 8 to get the number of meat exchanges to be allowed.
Round off the to the nearest whole serving.
7. Fat exchanges:
a. Take the subtotal of the fat derived from no. 3 and 5.
b. Subtract from the total fat prescribed
c. Divide the difference by 5 to get the no. of fat exchanges to be allowed. Round off
to the nearest whole serving.
If white bread is used as the exclusive rice exchange, the total volume c the above
food plan is usually less than the prescribed volume. Add sufficient water to make
up volume prescribed. If lugao is to be use proceed to the next step.

Compute for the total fluid volume using the formula:

Cal Rx = volume
Cal density
e.g. Cal Rx =1800 kcal
Cal Density =1 cal/ml

Volume = 1800 cal = 1800ml

1 cal/ml
Convert the ml into cups.

Translate the exchanges of food items into a household measures and compute fluid content.

1. Start with vegetable, sugar, meat or soft-cooked egg and oil.

2. Using the prescribed volume as you guide decide on the following:
a. Type and amount of fruits e.g. banana or fruit juice;
b. Type of milk ;
c. Compute for the sub total of fluid content. Compute for the remaining fluid left for
rice.
Example; Rx 1800 kcal with calorie density = 1kcal/ml
1. Volume = 1800 cal =1800 ml or 7.5 cups
1 cal/ml
2. Food distribution (e.g. determined in step B)
Food item Exch. C P F calories
Veg B 2 6 2 - 32
Fruits 3 30 - - 120
Milk 1 12 8 10 170
Rice 9 207 18 - 900
Meat: medium fat 1 - 8 6 86
Low fat 4 - 32 4 164
Fat 6 - - 30 270
Sugar 3 15 - - 60
Total 270 68 50 1802

3. Translate into household measures compute fluid content.

Food group Food Exchanges Household measures Fluid (ml)

Veg. b Boiled squash 2 1 cup -
Sugar Sugar 3 3 tsp -
Egg Soft-cooked 1 1 pc. 50
Meat Boiled chicken 4 8 tbsp -
Breast
Oil Corn oil 6 6tsp 30
Fruit Banana 3 3 pcs. -
Milk Evap. milk 1 ½ cup 120
Total fluid 300

Routes of parenteral feeding

1. Peripheral vein rout used for patient with mild to moderate nutritional deficiencies and
those at risk of deficiencies. It provides calories and nitrogen on a temporary basis as
follow.
a. Short term maintenance for a person who is not hyper metabolic but is taking nothing
by mouth. (< 2 weeks)
b. Energy and protein supplemental to an oral diet.
c. Additional energy and protein while a person is being weaned.