 Nutrition , Clinical Nutrition Significance, Basic concepts, Diet therapy

 Types of diets: Regular Diet and Modified diets, Changes in consistency

 Feeding routes, Prevention of chronic diseases Preparing for career, Scope

CHAPTER 2 CLINICAL NUTRITION and DIETETICS

Clinical Nutrition and Dietetics, is concerned with nutritional requirements of

patients suffering from different diseases.

CLINICAL NUTRITION
The specialised area of nutrition which deals with nutrition during
illness is ‘Clinical Nutrition’. also called Medical Nutrition Therapy.

Dietetics
Dietetics:  is the science of how food and nutrition affects human health.
 Dietician: uses nutrition and food science to help people improve their health.

Nutrition

Nutrition is the process of ingestion, digestion, absorption and utilization of food

for the utilizing of food for the well being of the body .

Health :

According to WHO health is the state of complete physical , intellectual, social and
spiritual well being and not merely an absence of a diseases or ill health .

Nutrition is the science of food, nutrients and other substances as well as their
digestion, absorption and utilization by the body. Nutrition is also concerned with the
social, psychological and economic aspects of food and eating.

Relationship of health and nutrition

 DIET and good nutrition (as well as a healthy lifestyle) can control and
delay the age of onset of chronic diseases.

Consequences of good nutrition Consequences of poor/ inadequate nutrition

i. body has immunity /protection i. Low immunity leads to health
from infection, problems

ii. helps to manage chronic diseases Delay in healing wounds

i. promotes speedy recovery from a Diminished response of body to

variety of illnesses medications

Impaired function of organs e.g

High intake of fruits and vegetables & legumes sluggish liver
, lean meat, low fat diary and fish ( rich in
omega 3 fatty acids). - lowers risk of heart
disease.
In all these conditions, it is important to ensure that the person is adequately
nourished.

Table 2.1 Prevention of Chronic Diseases: Reasons for chronic

diseases in people/ change in diets of urban Indians

High intake of following Low / reduced intake of

i. processed foods i. fibre
e.g.-ascorbic acid,
sodium benzoate
ii. colour additives e.g. ii. vitamins and minerals./
beta carotenene , yellow vegetables and fruits
5 in juices ,
iii. (HFSS) high in iii. Less physical activity
fats sugar and
salt )fat sugar,
salt
iv. refined foods- iv. potassium-rich fruits,
refined flour vegetables, grains and
/maida legumes
v. animal protein / v. calcium intakes,
non vegetarian
foods

consequences of dietary changes are increased incidence of chronic

diseases such as

i. obesity
ii. cancer of the colon,
iii. diabetes,
 iv. hypertension.

 Less case of heart attack seen in people who consume fish once

a week( rich in omega 3 fatty acids- can protect heart from

abnormal heart rhythm (fatal arrhythmias )

 People consuming more fruits and vegetables, legumes,

whole grains, low fat diary , lean meat - lived longer

( longevity )

Clinical nutrition focusses on the nutritional management of patients with

confirmed disease. The patient is the prime focus of the nutritional care process
NUTRITIONAL CARE
Nutritional care is a systematic approach of providing high quality nutrition care
to patients.
Nutritional care during illness Involves four phases/ activities (flow diagram )
1. Assessment of the nutritional status of the client- in this data is collected
about the patient –(history , medical reports , anthropometric measurements ,
any allergies, etc ( for example note , height weight of patient, medical
reports , food intake , , etc ) physical assessment –signs and symptoms
2. Nutrition Diagnosis : on the basis of collected data of patients , their diet
is reviewed to see which nutrient may be deficient ) ie, name the particular
problem . for example pregnant woman suffering from anemia due to iron or
folic acid deficiency )

3. Nutrition Intervention: the root cause of the problem is then dealt with by
suggesting the suitable nutrition For example suggest foods rich in iron , folic acid
such as green leafy vegetables, beetroot etc.)
4. Nutrition Monitoring and Evaluation: in the final step the nutritional care
outcomes /progress is monitored and evaluated For example , meals are supervised
and hemoglobin is checked after few days )
 Nutritional assessment is required to obtain information on the patient’s nutritional

status and nutrient needs. It involves:

(i) Obtaining detailed information on health, diet, personal & medication histories.

(ii) Anthropometric measurements are series of quantitative measurements used to assess

the composition of the body.( height, weight, body mass index (BMI), body

Circumferences (waist, hip, and limbs), and skinfold thickness.)

(iii) Relating the information on laboratory and physical measurements with the

above and the physician’s diagnosis.

(iv) Interpreting all of the above to identify potential nutritional deficiencies and risk

of future deficiencies.

SIGNIFICANCE OF NUTRITIONAL CARE / clinical nutrition /nutrition

medical therapy
During illness ,

• patient cannot eat or swallow and has poor digestion and metabolism
• One damaged function of the body may affect the other body
functions in the long run
• Results in nutrient imbalances
The professional clinical nutritionist/dietitian

1 uses a systematic and logical approach to the nutrition care process.

2 Focuses on each person/patient’s unique needs and deals with them

in an individualistic and holistic manner

3 Patients recover quickly with appropriate nutritional care .

4 Hospitalization of patients is reduced .

Reasons for increase in demand of clinical

nutrition
1. India is likely to be the diabetes ‘capital’ of the world.Diseases like
diabetes are occurring at a much younger age.
2. More and more number of people are requiring nutritional care and
counseling ( adolescents , elderly )
3. Newer diseases such as HIV/AIDS have emerged.
4. Increase of non-communicable diseases / life style diseases
 5. - obesity, hypertension, diabetes ,
6. Advances in the food and pharmaceutical industry
 Newer methods of nutritional assessment
 newer techniques and supplements for nourishing the patient
 New scientific knowledge and research
7. Role of individual nutrients in gene expression --antioxidants like
beta-carotene, selenium, vitamin E and vitamin C and -substances
such as nutraceuticals, Medical foods and
Phytochemicals/Bioactive compounds.
 nutraceuticals, are components in natural or
manufactured foods that have health benefits. E.g
dietary supplements , fortified foods ,etc
 .Medical foods are those products that are specially
manufactured for the specific dietary management of
a disease can be used only with a doctor’s prescription
e.g theraptin , ensure

 Phytochemicals/ Bioactive compounds are constituents
present in foods e.g. curcumin in turmeric anti-inflammatory
& antioxidant that have health benefits
 Bioactive compounds e.g.tannins( tea ),
lycopene( tomatoes )

Dietitians have to Plan diets for following people / Target group

(1) Hospitalized / out house patients
(2) pregnant women,
(3) elderly persons,
(4) healthy persons who are clients of fitness/wellness centres
(5) athletes/sports persons,
(6) people working in space, and submarines,
(7) defense personnel,
(8) Industrial workers, etc
(9) Institutions - old age homes, schools, orphanages etc.
what is diet therapy ?
Diet therapy is a branch of dietetics concerned with the use of food for
therapeutic purpose.

It concerns with recovery from illness by giving specialized dietary

regimes or meal plans and prevention of disease .

These specialized diet regimes are called therapeutic diet

Therapeutic diet refers to a meal plan that controls the intake of

certain foods or nutrients. They are adaptation of the normal, regular
diet. Some common examples of therapeutic diets include clear liquid
diet, gluten free diet, low fat diet, high fiber diet etc. Therapeutic diets
are usually prescribed by dietitians, nutritionists or physicians.

The objectives of diet therapy are ( flow diagram )

 1 Plan diets to meet the nutritional needs of the patients taking into
consideration their food habits and food acceptance
2 Modify the existing diets to keep the disease under control;
3 correct nutritional deficiencies;
4 prevent short term and long term complications in case of chronic
diseases;
5 Educate and counsel of the patient to follow the prescribed diet.

ROLE OF DIETITICAN

Promote better health in the community and better efficacy of services in

health care institutions/ establishments in terms of better patient care
management, holistic( complete ) care, and contribute to better survival
and recovery.

1. Prescribes diets to
 Patients and Pre and post surgery patients .
 healthy individuals from the womb to the tomb (at different stages of the
life cycle, i.e., pregnancy/ fetus , infancy and childhood , adolescents , adults
and old age)

2.Translate technical information ( diets prescribed by doctor )into

dietary guidelines.

The study of clinical nutrition enables professionals to:

(i) Plan diets to meet the nutritional requirements at various stages of
the life cycle.
(ii) Modify diets in various disease conditions, keeping in mind the physical state,
occupation, cultural, ethnic and socio-economic background, the treatment
regimen and the individual’s likes and dislikes.
(iii) Plan diets for athletes/sports persons, for individuals in special situations such
as nutrition in space, persons working in submarines, defence personnel,
industrial workers, etc.
(iv) Promote health and well-being of patients admitted to hospital or in outpatient
clinics as well as in institutional settings.
(v) Manage food services in a variety of institutional settings such as old age
homes, schools, orphanages etc.
(vi) Help patients with chronic diseases such as diabetes and heart disease in
management, to prevent complications and improve quality of life.
(vii) Promote better health in the community and better efficacy (ability to produce
desired result) of services in health care institutions/ establishments in terms of
better patient care management, holistic care, and contribute to better survey and recovery

Factors to be considered while modifying diets

Besides this the dietician has to consider the following factors while
modifying diets :

1. Effect of illness on food acceptance – may not want to eat food /loss of
appetite )

2. Acceptability of modified therapeutic diets- ( does not like bland food ,

green leafy vegetables , low sugar/salt etc. )

3. Nutritional stress ( severe deficiency of some nutrient – e.g PCM , fasting )

4. Psychological stress ( depressed, anxiety )
Other factors to be kept in mind
 5. the physical state- can they eat /swallow / operated / Feeling of
hunger – not hungry – give in small portions
6. Health status / nutritional status age , gender ,
7. the individual’s likes and dislikes- change the form of food shakes
lassi -instead of milk
8. Frequency of intake of different types of food
9. Dietary and other supplements used
10.occupation, /physical activity - sedentary worker ( lesser calories )or
a heavy worker( give more calories )
11.cultural, practices /ethnic/ background )
religious beliefs/ religion /region traditions do they eat onions, garlic/
vegetarian ?
12.socio-economic background - income /purchasing power
13. treatment regimen/diagnosis of diseases /doctor’s prescription –
have doctor asked not to include any spinach /tomatoes / spices etc.
14.Food pattern( eat regularly or skip meals ) / life styles – sedentary
life styles/ too much of junk foods

Types of diets
There are two of diets

1. standard /normal and balanced diet

2. modified / therapeutic

Standard or regular diet is one that includes all food groups and meets the
needs of healthy individuals ( balanced diet ).

5 FOOD GROUPS ( ICMR 2010 )

1. cereal
2. Pulses
3. Milk /meat /fish/eggs/chicken
4. Fruits and vegetables
5. Fats and oils
NOTE : According to ICMR 2010 no need of sugar as it is
availbale in many natural foods such as fruits ( fructose ,
milk( lactose )
A therapeutic diet  is a modification of a regular diet that controls the intake
of certain foods or nutrients, to meet the medical needs of a patient.
It is part of the treatment of a medical condition and are normally
prescribed by a physician and planned by a dietician.
A diet may need to be altered and adjusted in many ways before it meets the
therapeutic needs of an individual patient.

Therapeutic /Modified diets- may involve one or more of the following

1. Change in consistency/ texture

2. Change in calories
3. Change in nutrients
4. Change in frequency

1 Change in consistency of foods such as liquid diet, clear liquid and soft
diet. This modification is done in case of problem of chewing ,
swallowing digestion , ulcers or post operative conditions
a)Liquid diet
In this, foods are served in liquid form and served at room
temperature. Liquid diet is given when a person is unable to
chew or swallow
Advantages
Nutrients get easily absorbed if gastro intestinal tract is
functioning normally.
Examples are – Coconut water , fruit juice , soup, milk , buttermilk ,
milk shakes
b)Clear liquid diet is thinner than liquid diet. Given just after
surgery for 1-2 days
Limitations not easy to meet the nutritional requirements of the
patient .
Examples are – Clear soups, strained juices , light tea
c) soft diet is soft in consistency and includes simple digestible
foods with no harsh fibre, no fat and no spices . Food should
minimize risk of indigestion, abdominal distention, nausea,
cramping, or any other gastrointestinal problems.
Examples are : Khichri , sago kheer , custard , boiled eggs. etc.

Mechanical soft diets are soft foods which does not require
much chewing.include soft, mashed and pureed foods . these are
planned for elderly who cannot chew .
Examples are blanched vegetables , mashed potatoes , scrambled eggs, ice
cream, minced meat , cottage cheese , stewed fruit, etc

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Different methods of cooking are used to change the consistency

of the diets to soft diets like steaming, poaching, baking , boiling
yield bland diets which are light and digestible.

2 Change( increase or decrease ) in Calories

increase in the energy (Calorie decrease in the energy (Calorie
intake intake )
Given during fever , Low calorie diet for weight
underweight , burns , cancer , etc. reduction
 3. Nutrients and foods
Change( increase or decrease ) in
Modification is done either to maintain , restore or correct
nutritional status by decreasing, increasing or balancing a
specific nutrient . For this a are given in specific conditions as
shown in the table. Modifications are also made to exclude
foods that cause allergies or intolerance. high or low calorie
diet , high or low carbohydrates diet , high or low protein
diet or high and low fibre diets , low sodium or no sugar
diets. Some examples have been given in the following table

High/ increase Low / decrease

Protein Surgery Kidney failure
Fibre laxatives Constipation Diarrhea
Fat Constipation Jaundice
Salt/Sodium intake Low blood pressure Hypertension
Fluids Fever Restrict fluids during
Odema
Allergy / intolerance Include certain foods Exclude certain foods eg
spinach rich in oxalates

5 Change in frequency of meals- sometimes the patients are not

able to digest normal meals ( breakfast, lunch , evening tea and
dinner ) or large portions of food at one time this may be due to
fever, diabetes , peptic ulcer , diarrhea , pregnancy or infancy .
They are given small meals at the interval of 2 to 3 hours .
 Need for modifying normal diet

 To increase or decrease body weight ( underweight /obesity )

 To replete malnourished ( cancer)
 To adjust to tolerance of food intake (gluten intake )
( low
Tofat
exclude
diet in food due to allergies ( eggs, lactose )
fat malabsorbtion)
 To increase a nutrient (high protein – fever)
 To decrease a nutrient ( low protein – kidney disorder )
 To restore deficiencies nutritional status ( fever)
 To provide rest to an affected organ ( liver – jaundice )
 Mechanical difficulty – denture problems- cannot chew /swallow
 To adjust to body’s ability to digest, absorb , metabolize

WAYS TO FEED A PATIENT /Feeding Routes: patients are fed by the following
ways :

1. Orally or by mouth

- Patients are fed by mouth when they are conscious and able to
eat. Mostly liquid or soft diets are given to the patients.

2 Tube feeding-- In tube feeding, nutritionally complete feeds are

delivered directly to the stomach , through a tube . This is given to
patients who are unconscious or have any problem with the
esophagus . tube feeding is done only for those patients who are able to
digest food , as their gastrointestinal tract is functional .

Tube feeding

3.Intravenous feeding : is a method of getting nutrition in to the body

through the veins. The patient is nourished with special solutions which
are given through a drip in a vein. This is used when the digestive tract
cannot adequately absorb nutrients, as occurs in severe malabsorption disorders

Intravenous feeding
Desirable professional qualities of a clinical nutritionist or dietitian?
nutritionist or dietitian must have following qualities

1 knowledge of :

i. nutrition, food science , food composition

ii. physiological changes in disease conditions ,

iii. Recommended daily allowances ( ICMR in illness according to age,

nutritional status, gender and activity

iv. traditional and ethnic cuisines

Skills of

v. assessing nutritional status of patients using their medical reports

vi. Diet planning according to specific disease conditions

vii. . Adapting diets according to the socio-economic background of the

patient

viii. Communication skills for diet counselling

ix. Administering diets Supervising diets of patients

Scope after clinical nutrition

1. Dietitian.
2. Diet counsellor ( prescribe diets )
3. Clinical nutritionist
4. Weight Loss Consultant.
5. Sports Nutritionist
6. Researcher ( research on nutrients )
7. Production of medical foods / nutraceuticals , tube feeds , functional foods
8. Corporate consultant
9. Teacher in school – BSC/ M Sc/ B. Ed
10. Professor/ researcher in colleges and universities (after clearing ( UGC)
national or state eligibility test and doing Ph.D )

PREPARING FOR A CAREER IN Nutrition and Dietetics

B.Sc. degree Postgraduate

in Home Diploma in
Pass 10+2 Registered
Science and Dietetics
level dietitian.
specializatio with an
n in Nutrition internship

post graduate
Postgraduate M.Sc. in Food
in
Diploma in Science and Registered
Microbiology
Life Sciences, Nutrition or dietetician
or
Biochemistry Dietetics
Biotechnology
Questions

1 Define nutrition and dietetics.

2 What do you understand by clinical nutrition/ Medical nutrition therapy and
therapeutic nutrition?
3 What is the relation between nutrition and health ?
4 What is the significance of the study of clinical nutrition and dietetics?
5 Write four consequences of sedentary life style on health .
6 Analyse ten possible reasons for the rise in life style diseases.
7 How have the changes in urban food habits affected the health of the population?
8 What do you understand by nutritional care /What is the significance of nutritional care
?
9 Explain the role of the diet in disease causation? ?
10 What is the role of diet in disease prevention?
11 What are nutraceuticals, Medical foods and Phytochemicals/Bioactive compounds.?
Give one example of each
12 What are the objectives of diet therapy ?
13 What do you mean by Nutritional Assessment and Anthropometric measurements ?
14 Explain the different types of meal modifications with the help of an example each.
15 Define Normal diet / Balanced diet give an example.
16 what eight points each would you keep in mind while planning diets for a patient ?
17 explain four specific factors a dietician must consider while planning diets for
patients?

18 Suggest one dietary tip in case of Kidney disorder / hypertension / constipation /

diarrhea ?
19 How does the study of clinical nutrition and dietetics help medical professionals?
20 Other than oral , what are the two types of feeding / mode of feeding / Explain tube
feeding /intravenous feeding
21 What do you mean by the following diets? Give two examples of each
i. Soft / semi solid
ii. Liquid diet
iii. Clear diet
iv. Mechanical diet
v. bland diet

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