THERAPEUTIC MODIFICATION OF

THE NORMAL DIET

SUBMIT\\TED BY--

CONTENTS THERAPEUTIC DIET DIET THERAPY OBJECTIVES OF DIET THERAPY CLASSIFICATION OF MODIFIED DIETSa. NORMAL DIETb. LIQUID DIET c. SOFT DIET d. BLAND DIET MODIFICATION IN NUTRITIVE VALUE MODIFICATION IN QUANTITY MODIFICATION IN METHOD OF FEEDING

THERAPEUTIC DIETS

Therapeutic diets are planned to maintain or restore good nutrition in the patient.

Therapeutic diet is a normal diet, qualitatively & quantitatively modified as per the patient's special need & in line with the general principles of meal planning.

DIET THERAPY

Diet therapy means the use of diet ( food and drink) not only in the care of the sick, but also in the prevention of disease & the maintenance of the health.

OBJECTIVES OF DIET THERAPY To maintain a good nutritional status.

To correct nutrition deficiencies

To afford rest to the whole body or to specific organs affected by the disease.

To adjust the food intake to the body’s ability to metabolize the nutrients during the disease.

To bring about the changes in the body weight whenever necessary.

CLASSIFICATION OF MODIFIED DIETS

MODIFIED DIETS

CONSISTENCY

1. Clear liquid 2. Full liquid

3. Soft4. Mechanical

soft diet5.Light diet

6. Pureed diet7.Bland diet

NUTRIENT CONTENT

1. High fiber2. Low protein

3. Na restricted4. Low fat

5. Low fiber

QUANTITY

1. Obesity 2. Vomiting3. Diarrhea 4. Diabetes

SPECIAL METHD OF FEEDING

1. Enteral ( tube feeding)

2. Parenteral (intravenous fluid)

MODIFICATIONS IN CONSISTENCY

NORMAL DIET-

A normal diet is defined as one which consist of any and all food eaten by the person in health.

It is planned keeping the basic food groups in mind so that optimum amounts of all nutrients provided.

Since the patient is hospitalized or at bed rest, a reduction of 10% in energy intake should be made.

FLUID DIETS Fluid diets are used in febrile states, post-

operatively or whenever the patient is unable to tolerate solid foods.

Fluid diet are of two types depending upon nutritional adequacy-

1. Clear fluid diet2. Full fluid diet

CLEAR FLUID DIET-

CONSIST OF ONLY CLEAR FLUIDS.

The diet is free from any solids, even those found in milk.

The clear fluid diet is inadequate in all nutrients & use only for 1-2 days.

PURPOSE- to prevent dehydration and relieve thirst.

USED FOR- short periods such as in acute vomiting or diarrhea.

High in simple sugars & need to be modified for diabetic patients.

AMOUNT OF FLUID GIVEN- initially 40-80ml/hour, which is than gradually increased to 100-120 ml/day.

FOODS INCLUDED:-

Fruit juices- apple, orange grape

Cereal water- barley, arrowroot water, sago kanji, rice kanji

Soups- clear soups, fat free

Beverages- tea, coffee with lime & sugar (no milk), lime juice, coconut water, sugarcane juice

Flavored gelatin and fruit ices

FULL FLUID DIET PRESCRIBED TO- individuals who are unable to

chew, swallow or tolerate solid foods.

GIVEN- after clear fluid & before starting solid diet.

Composed of foods that are liquid at room temperature.

It is free from cellulose & irritating condiments or spices.

It is well planned to meet most of the RDA’s .

PRESCRIBED DURING- acute infections, gastritis, after surgery, & for people too ill to eat solid food..

Diet provide- approx. 1500-2000 kal, 55-65g protein and adequate minerals and vitamins

FOODS INCLUDED-

Cream soups, daal soup, whipped potatoes.

Milk shakes, plain ice cream, custard.

Oat meal, arrowroot, & sago kanji with milk.

Soyamilk, complain, lassi

SOFT DIET Soft diet is nutritionally adequate diet.

It is soft in consistency & easy to chew.

Made up of simple, easily digested foods

It is moderately low in cellulose.

Prescribed in- conditions where mechanical ease in eating or digestion both are desired.

Given during- acute infections , GI disorders , & after surgery.

SOFT DIET SUPPLIES- 1800-2000 kcal, 55-65g protein.

FOODS INCLUDED-

Refined cereals Washed pulses- form of soups & in

combination of cereals & vegetables. Milk & milk products. Eggs & lean meats. Soft fruits like papaya, banana, mango

etc. Fats like butter, cream vegetable oils. Salt & sugar in moderation.

FOODS RESTRICTED-

Spicy, highly seasoned & fried foods are avoided.

Raw vegetables & fruits. Whole grain cereals &their products. Dried fruits & nuts.

MECHANICAL SOFT DIET

Also called as dental diet.

It includes foods which are easy to chew & swallow.

No restriction on seasoning or method of preparation.

Food may be modified by-

mechanical processing Such as mashing, blendrizing, or chopping.

LIGHT DIET OR GENERAL HOSPITAL DIET-

Similar to the soft diet.

Also includes – simple salads, fruit salads, & paneer.

BLAND DIET PRESCRIBED FOR-

individuals suffering from gastric or duodenal ulcers, gastritis, & ulcerative colitis.

INCLUDES-

foods which are mechanically, chemically & thermally non irritating , foods low in fiber are recommended.

FOODS INCLUDED-

Milk & milk products. Refined cereals & rice. Cream, butter Cooked fruits & vegetables without peel

& seed. All egg preparations except omelet's &

fried eggs.

FOODS AVOIDED-

Strong tea, coffee, alcoholic beverages, condiments & spices.

High fiber foods & hot soups & beverages.

Fried foods.

MODIFICATIONS IN NUTRIENT CONTENT

The nutrient content of the diet is modified to treat deficiencies, change body weight, or control diseases such as hypertension & diabetes.

• Fiber, sodium and fat content are modified in some conditions.

MODOFICATION IN FIBER- bulk & fiber has been used for all indigestible polysaccharides which remains after digestion of food.

Fiber can be modified in two ways-

HIGH FIBER DIET-

USED TO- prevent & treat constipation.

Also prescribed in obesity to increase the volume of food..

LOW FIBER DIET-

PRESCRIBED DURING - acute infections of the GI tract.

such as ulcerative colitis, severe diarhea.

DISEASES WITH NUTRIENT MODIFICATION

DISEASE NUTIENT MODIFICATION

Atherosclerosis F at controlled, low cholesterol diet

Hepatitis Restricted fat diets

Anemia, High fever, Injury High protein diet

Hypertension, Cardiovascular disease Sodium restricted diet

Lactose intolerance Lactose free diet

Hepatic coma Low protein diet

Underweight, Malnutrition High calorie diet

MODIFICATONS IN QUANTITY The quantity of food served to the patient

needs to be modified:- to check tolerance, control nutrient levels, & bring about weight loss.

Example- in a diabetic diet, the quantity of CHO in each meal is as important as the the quantity of CHO consumed in a day

MODIFICATIONS IN METHOD OF FEEDING

Enteral feeding- EN is provision of liquid formula diet delivered via a feeding tube is the method for patients with a functional GI tract who requires NS.

Enteral feeding is required when oral feeding is not possible.

Parenteral feeding- parenteral fluids contain water, glucose, amino acids, fatty acids, minerals, & vitamins to meet the individual need for all nutrients.

These fluids are given through the peripheral & central veins.

DIETS FOR COMMON DISORDERS

Diet for Diabetes mellitus patients

Foods recommended Foods to be avoided

1. Complex carbohydrates rich in dietary fiber- millets , wheat, pasta, bread.

1. Simple sugar and refined carbohydrates sugars, jaggery, sweets.

2.Higher proportion of PUFA vegetable oils.

2. Saturated fats and cholesterol in moderation hydrogenated fats ,ghee, butter, cream.

3. Good quality proteins- Lean meat, fish, eggs, pulses, milk.

3. Alcohol, soft drinks, sweet meats , nuts and oil seeds.

4.Salads, leafy vegetables ,other vegetables.

DIET IN FEVER & INFECTIONS

High Calorie , High Protein dietFOOD RECOMMENDED FOOD TO BE AVOIDED

All foods should be liquid to semi solid consistency. Smooth texture with no harsh irritating fibers , strong flavors or spicy foods.

Solid foods which are hard or tough , requiring lot of mastication .

1 Cereals- Refined cereals in the form of kanji ,custard , kheer , phulka, boiled rice .

1 Cereals- Millets , cereal or irritating dietary fibers such as whole grain cereals and cereal products .

2 Good quality , easy to digest proteins , chicken soups, milk based beverages , strew , Egg nob , sweet freshly set custards, complain ,soft cooked khichdi, custard ,boiled vegetables such as pumpkin ,bottle gourd, potato. Strewed fruits, soft fruits , fruit juices, sugar.

2 Fried , spicy pulse and meat – fish – poultry preparations .

Leafy vegetables , raw fruits , and vegetables with harsh fibers

Pickles, papad .

Risk Factors for Heart DiseasePersonal factors Diet pattern Other diseases

Heredity or strong family history.

Alcoholic Hypertension

Males\Females after menopause

Consumes rich foods Atherosclerosis

Smoking High in fats and cholesterol Diabetes

Obesity Low in fiber Obesity

Age group 35-55 yrs Refined CHO and sugars High blood lipid levels

Work load- Tension and stress

High salt intake

Sedentary life style

Modified Fat Diet in hypertension Food recommended Food to be avoided

Foods low in cholesterol and saturated fats

Cholesterol rich foods

1. Skimmed milk , paneer (skimmed milk) 1. Whole milk , butter, cream, mava, cheese(processed).

2. Cereals (Whole grains, pulses) 2. Indian sweetmeats , rich puddings, bakery products.

3 .High fiber and soluble fiber such as Oat meal, millets, pectin, gums.

3. Organ meats(liver ,brain ,etc)

4. Salad vegetable ,fruits, green leafy vegetables ,other vegetables.

4. Egg yolk, fish , shellfish, fatty meat , processed meats.

5. Lean meat , egg white , fish 5. Nuts, oilseed, pickles.

6.Vegetable oils, sugar, jaggery. 6. Margarine, vanaspati, fried foods.

7. Alcohol.

Sodium Restricted Diet Foods recommended Foods to be avoided

Foods low in sodium Food rich in cholesterol and fat, food rich in sodium

1. cereals- wheat, rice, oatmeal, millets 1. Baking power- cake ,cookies

2.All fruits- fresh and canned 2. Soda bicarbonate- nankhatai

3. Cabbage, cauliflower, tomato , potato onion .

3. Monosodium glutamate- Chinese foods and food served in restaurant.

4. sugar, honey, jam, jelly. 4.Sodium benzoate- tomato sauce

5. Low sodium seasonings instead of salt. 5. Sodium propionate- bread

6. Lime juice. 6.Sodium chloride- salted shanks, wafers, nuts.

7. Mint, parsley, dill, basil. 7.Papad, pickles, vegetables in brine solution.

8. Fresh vegetables. 8. Celery , beetroot and spinach.

9. All other vegetables, root vegetables. 9. Foods rich in cholesterol and saturated fats- salted butter and processed cheese.

10. Vegetables oil as a cooking medium.

11. Milk in moderation.

Sodium Restricted Diet

DIET FOR PEPTIC ULCERS Foods recommended Foods to be avoided

1. Cereals- all refined cereals, bread, rice, pasta.

1. All whole grain cereals

2. Milk- all milk beverages and all milk products, weak tea.

2. All stimulating beverages- alcohol, tea, coffee, aerated drinks.

3. Egg, lean, meat, fish, poultry as protein to heal ulcer.

All fatty meats.

4. Dehusked pluses, boiled and mashed 4. Whole pulses

5. Stewed fruits, vitamins c for healing 5. Raw fruits

6. Butter, cream, ice cream 6. Spices, condiments, fried foods

7. Cooking method- boiling, baking, stewing, poaching.

7. Frying, barbecuing, salted, smoking foods

High Fiber, Moderate- Fat Diet for constipation

Food recommended Foods to be avoided

1. Fluids- at least 1.5 liters 1. Refined cereals- rice, seived flour

2. Cereals- whole grain cereals, millets, oats.

2. Dehusked pluses

3. Pluses with husk- Rajmah, ground nuts, peas.

3. Castor oil

4. Fruit – raw and cooking fruit and vegetables, guavas, figs, pears, apple, citrus fruits.

5.Milk, butter milk, butter, ghee

6.Soup , tea, coffee

7. Green leafy vegetable, salads use fruits and vegetables with edible skin and peel.

High- Protein, High Carbohydrate, Low to moderate fats diet

Foods recommended Foods to be avoided

1. Nutrition beverages 1. Strongly flavored vegetables

2. Soft- cooked cereals and pluses 2. Fried foods

3. Fruits 3. Food with high- fat content

4. Vegetables 4. Nuts and oilseeds

5. Milk and meat products 5. Rich desserts and pastries

6. Lean meat, fish, poultry 6. Spicy and highly seasoned foods

7. Egg, jam, jelly, sugar, simple desserts.

NUTRITION SUPPORT

Contents What is Nutrition Support (NS) Need for nutrition support Conditions that require specific nutritional support Introduction to EN Indications for EN Type and route of administration Formula selection Type of formula Method of administration Enteral formulations Enteral equipments Complications of Enteral nutrition

WHAT IS NUTRITION SUPPORT The nutrition support involves deciding

whether a patient requires nonvolitional feeding and if so, selecting the most effacious method.

Benefits of nutrition support (NS) includes-

Improved clinical outcome Shorter hospitalizations

Need for the nutrition support The 1st step in determining the need for NS is to

assess whether the patient can consume adequate nutrients orally.

Oral consumption of a standard diet is always the first option when the GI tract is functional, accessible, and “safe to use.”

Assessing oral intake is necessary to determine what percentage of nutritional requirements can be consumed by mouth.

Need for the Nutrition Support (NS)

When the functioning of GI tract has been compromised by trauma or surgery, an upper GI & a small bowel x-ray study may be required before initiating feedings.

NS appears to be the most beneficial in patients who are severely malnourished.

Guidelines from the American Society for Parenteral and Enteral Nutrition (ASPEN) suggest that NS should be initiated in patients with inadequate oral intake for 7 to 14 days .

Conditions That Require SpecializedNutrition Support Enteral

—Impaired ingestion—Inability to consume adequate nutrition orally—Impaired digestion, absorption, metabolism—Severe wasting or depressed growth

Parenteral—Gastrointestinal incompetency —critical illness with poor enteral tolerance or

accessibility

Introduction to Enteral Nutrition

EN is provision of liquid formula diet delivered via a feeding tube is the method for patients with a functional GI tract who requires NS.

Enteral Nutrition NS via tube placement through the

nose, esophagus, stomach, or intestines (duodenum or jejunum).

EN promotes better outcomes and less costly compared with PN (due to reduction in septic complications)

Timings is also important because EN delivered immediately after injury may improve wound healing and limit the degree of hyper-metabolism.

Indications for Enteral Nutrition

EN is indicated in patients with adequate digestive and absorptive capacity of the GI tract but who cannot or will not eat enough.

Specific indications for EN includes:- Poor nutrient retention Insufficient intake

Indications for Enteral Nutrition Gastrointestinal Disease

Short bowel syndromeInflammatory bowel diseaseDiarrhea of infancyIntestinal obstructionChronic liver diseaseSevere dysphagia or esophageal obstruction,

Indications for Enteral Nutrition

Preterm infants

NeurologicStatic encephalopathyDysphagiaCNS tumor

Cardio-respiratoryCystic fibrosisCongenital heart disease

Indications for Enteral Nutrition Malignancy

Poor intake: radiation / chemotherapy

Hyper-metabolic statesBurnsTrauma / head injury

OtherAnorexia nervosaChronic renal diseasePsychiactric disorders,

Why does a child need enteral feeding?

Unable to take sufficient nutrition by mouth

Using more energy than normal intake.

Unable to digest food effectively

J Daglish,L Herd Reviewed J Lanni Nov 2007

42

Sites for Enteral feeding

Route of Enteral Administration

Nasoenteric routes

1. Nasogastric2. Nasodododenal3. Nasojejunal

Tube enterostomy

(Percutaneous or surgically placed feeding tube)

PEG (percutaneous endoscopic gestrostomy)

PEJ (percutaneous endoscopic jejunostomy)

NASOENTERIC FEEDING TUBES Nasoenteric feeding tubes are generally used when

therapy is expected to be short lived.( less than 4-6 weeks).

Nasoenteric feeding tubes are the most common devices for short-term enteral access, because they are relatively inexpensive & easy to place and safer than venous access devices.

The most common complication associated with placement of nasoenteric or nasogastric feeding tube is tube malposition.

NASOENTERIC FEEDING TUBES Tube malposition comprised 58% of total

compilcations.

METHOD OF PLACEMENT- Nasoenteric feeding tubes can be placed intraoperatively, with endoscopic or fluroscopic guidance, or blindly at bedsite.

Intrapoerative placement requires the feeding tube to be placed manually during surgery, but this is not common in most institutions.

NASOGASTRIC TUBE FEEDING

Passing of food through the nose to the stomach.

feeding into the stomach rather than small bowel, is usually preferred in patients with an intact gag reflex & normal gastric function because it is more physiologic.

Transpyloric feeding tubes should be reserved for patients at risk for aspiration or who have gastroparesis.

Transpyloric feeds

Infants who have severe gastroesophageal reflux or problems with gastric emptying, may need to be fed transpylorically.

The bedside nurse will attempt to place the transpyloric feeding tube in the duodenum. A KUB should be obtained to verify tube position.

Transpyloric feeds must always be continuous infusions.

NASODUODENAL TUBE FEEDING

Passing of food through the nose to the duodenum.

Used For short term enteral NS of up to 3-4 weeks in patients with gastric motility disorders, esophageal reflux, or persistent nausea & vomitting .

Nasoduodenal tube placed postpylorically (into the small bowel) are appropriate.

NASOJEJUNAL TUBE FEEDING-

Passing of food through the nose to the jejunum.

For short term enteral NS of up to 3-4 weeks in patients with gastric motility disorders, esophageal reflux, or persistent nausea & vomitting.

Nasojejunal tube placed postpylorically (into the small bowel) are appropriate.

Route of Enteral Administration

TUBE ENTEROSTOMY For long term tube feeding

Used for patient when nasal intubation is impossible

Used during abdominal surgery.

Types:

Percutaneous or surgically placed feeding tubes

Percutaneous endoscopy Gastrostomy (PEG)

Percutaneous endoscopic Jejunostomy (PEJ)

Direct Percuteneous endoscopic jejunostomy (DPEJ)

Surgically placed Enterostomies

Multiple Lumen tubes

Percutaneous or surgically placed feeding tubes

Long term access requires a percutaneous or surgically placed feeding tube.

Percutaneous or surgically placed feeding tubes are usually reserved for when EN is expected to continue longer than 4-6 weeks.

Percutaneous endoscopy Gastrostomy (PEG)

The PEG is a non-surgical technique for placing a tube directly into the stomach through the abdominal wall, performed using an endoscope & with the patient under local anesthesia.

The PEG tube is placed after introducing an endoscope into the stomach.

A local anesthetic is administered through the abdominal wall, & a stab wound is created.

PEG tubes are more popular compared with surgically placed tubes because they are less costly.

PEJ (percutaneous endoscopic jejunostomy)

PEJ tube may be used in post-operative patients with a dysfunctional GI tract or in those who are at high risk of aspiration.

With the PEJ, the tubing is advanced through the stomach & into the proximal small intestine.

Used – who have gastroesophageal reflux & are at risk for aspiration.

However, this procedure require higher degree of skill & carries greater risk.

Surgically placed enterostomies Surgical gastrostomies & jejunostomies are placed in patients requiring

EN who are undergoing a sugical procedure or in whom endoscopic & radiologic techniques are not possible.

The simplest surgical procedures for placing a gastrostomy tube are the stamm & witzel technique.

A Witzele jejunostomy & needle catheter jejuostomy ( creating a feeding opening by a small-bore needle insertion into the jejunum at time of surgery) are short term small bowel access methods.

They are usually used for early postoperative enteral nutrition in combination with gastric decompression.

Witzele jejunostomy

Needle catheter jejunostomy (NCJ) or DPEJ

A Direct Percuteneous endoscopic jejunostomy (DPEJ )or needle catheter jejuostomy can also be used to assess the small bowel for EN.

A DPEJ is placed endoscopivally as a PEG, except that the endoscope is passed through the duodenum, past the ligament of Trietz, into a loop of jejunum adjacent to the abdominal wall.

An NCJ is placed intra-operatively & involves inserting a small catheter into the lumen of jejunum proximal to the ligament of Trietz.

ADVAVTAGE OF NCJ- Has low complication rate Nutrients can be administered almost

immediately.

Multiple Lumen Tubes Gastrojejunal dual tubes are

available for either endoscopic or surgical placement.

These tubes are designed for patients in whom prolonged GI decompression is anticipated.

The tube has one lumen for decompression, & the other lumen is used to feed into small bowel.

Used for- early preoperative feeding.

FORMULA SELECTION The wide variety of enteral feeding products are commercially

available.

The choices can be narrowed down by answering a few basic questions:-

1. Are the patient’ digestive & absorptive capabilities intact?2. Does the patient have significant organ dysfunction?3. Does the patient have high metabolic rate? 4. Does the patient require a fluid restriction?

Evaluating the patient’s digestive & absorptive capacity helps determine whether to use a polymeric or a pre-digested formula

Types of formula

POLYMERIC FORMULAS

It contain intact nutrients .

PF are appropriate for most patient‘s with normal gut function.

It should be the 1st line of treatment for most patients who require tube feeding.

It can be infused into jejunum via percutaneously or surgically placed tubes with good results.

PREDIGESTED FORMULAS

It Contains hydrolyzed proteins (peptides & free amino acids), CHO (glucose), fat (combinations of long & medium chain TG’s).

INDICATED FOR- patients with compromised GI tracts. Because hydrolyzed nutrients require less active digestion.

It is also used as starter regimens for patients who have not received enteral feedings for long periods.

NCJ is preferable.

Predigested formula has lower viscosity than polymeric formulas.

Blenderized Formula

Formulated from natural and whole foods Has high viscosity Risk to contamination is more.

Modular feeding

Modules of individual macronutrient- can be added to food and enteral formulas

Categorization

Type Indication

Polymeric Normal GI function

Chemically defined Malabsorption

Modular Special requirements

Disease specific enteral formulas It is designed for severe liver or kidney dysfunction.

Formulas for liver failure are enriched in BCAA & contain smaller amounts of AAA.

Formulas for renal failure are low in protein but contain large percentage of EAA.

Fluid restrction or high metobolic requirements may require the use of a callorically dense formula to provide adequate nutrients without exceeding the patient’s fluid limits.

Formulas supplemented with fiber to improve bowel function & glucose control.

Chemically defined formulas are specialised monomeric formulas. They are low in fat , contain short chain CHO & peptides & amino acids. They are used for patients with condition of maldigestion or malabsorption.

Method of Administration

Tube feeding can be administered via-

Bolus method Intermittent method Continuous method

Bolus method

Bolus feedings are administered by gravity over a short time, usually 5 minutes or less.

Rapid administration of formula on a short period of time.

It causes delayed gastric emptying, may cause reflux and vomiting.

It would be like receiving a dose, then waiting a certain number of hours and taking another dose.

A bolus would be if a syringe or small bag were filled with formula and allowed to drain in without restriction.

Using a bag with tubing attached would and restricting the flow with the roller clamp can be referred to as a gravity feed.

A gravity feed can be done slowly by adjusting a roller clamp on the tubing to create a slower flow rate so bolus could refer to fast and gravity to slow.

Intermittent method

Intermittent feeding are administered over a longer period of time , usually 20-30 minutes , using a feeding container & gravity dip.

The total formula needed in one day is divided into equal portions.

The bolus & intermittent methods are usually reserved for gastric feeding.

Continuous feedingo Controlled delivery of a prescribed volume of formula at

constant rate over a continuous period of time.

o Continuous feedings are delivered slowly over 12 to 24 hours.

o Uses infusion pump

o Fewer GI side effects

o Transpyloric feedings require continuous infusion.

o It is necessary when patient cannot tolerate bolus & intermittent feeding.

Enteral formulationsWater & Caloric density

Enteral formulas can be divided into 3 categories of caloric density:-

1 Kcal/ml (about 85% water)- appropriate for patients with no fluid restriction

1.2-1.5 kcal/ml (about 78-82% water)

2 kcal/ml (about71% water)- necessary for patients with the renal failure, pulmonary edema, liver failure , other conditions in which fluid intake is restricted.

Osmolality Osmolality & osmolarity are measures of the concentration of

molecules in an aqueous solution.

Osmolality is defined as milliomoles per kilogram of solvent.

The major contributors to osmolality in enteral formulas are electrolytes, minerals & small organic compounds.

Enteral product osmolality ranges from 270 mOsm/kg – about 700 mOsm/kg, depending on the concentration of water components.

The higher the caloric density, the less water in the formula & highest the osmolality.

Osmolarity Osmolarity is the milliomoles per litre of solution.

General purpose formula- between 300- 500 mOsm/l Which is close to the osmolarity of blood & body fluid.

Concentrated formulas- are ranging from 400-700 mOsm/l.

Chemically defined formula- 900 mOsm/l.

VISCOSITY The viscosity of a formula depends on the- 1. concentration & characteristics of the

macronutrients 2. fiber.

Higher viscosity products may effect the rate of delivery of feeding pumps.

The relative viscosity of isolated fibers has so far limited the caloric density of fiber-containing formulas to 1.5 kcal/ml.

PROTEIN Amount of protein- varies from about of 6% calories in very

protein restricted formulas intended for patients with renal failure to 25% of calories.

It is important to provide adequate water for excretion of nitrogenous waste to patients receiving high protein formulas.

Determination of protein quality is a complex process involving –

assessment of the amino acid profile protein & amino acid digestibility effects of other components.

AMINO ACIDS Enteral formulas called elementral formulas

have individual amino acids as their sole source of protein.

Elementral formulas are the most expensive products & have the highest osmolality.

Their use is usually restricted to tube feeding because of the unpleasant odor & taste.

PEPTIDES Peptides based enteral formulas contain protein

that has been partially hydrolyzed to mixtures of peptides of varying chain lengths.

Absorption may be improved with peptides compared with amino acids and intact proteins.

Useful in patients with inadequate digestive enzymes, short bowel syndrome ,or other forms of mal-absorption.

BCAA Formulas specifically designed for patients

with Hepatic encephalopathy (HE) contain increased amounts of the BCAA ( valine, leucine, isoleucine).

Decreased amount of AAA (phenylalanine, tyrosine, & tryptophan)

BCAA make up 45% to 50% of total protein compared with 20 % in standard formulas.

GLUTAMINE Glutamine has been found to be a primary fuel for the GI tract.

An exogenous source of glutamine may be beneficial during the stress response in reducing skeletal muscle breakdown to provide glutamine to the liver.

Enteral glutamine may improve acid-base balance by increasing plasma bicarbonate & renal acid secretion.

AMONTS OF GLUTAMINE- In Enteral formulas have been calculated from the glutamine content of their protein sources.

Values are 2.8- 7.3 g/1000 kcal for standard enteral formulas.

ARGININE Arginine stimulates release of several hormones, including

glucagon, insulin, & growth hormone.

In cell culture, arginine is required for maximal cell growth & optimal lymphocyte function.

Arginine is present in all enteral formulas made from intact proteins.

Additional arginine is added to several formulas intended to enhance immune function .

It is also available as a powdered supplement.

TAURINE β- amino acid.

Act as an antioxidant, neuromodulator & regulator of Calcium homeostasis.

Also important for immune function & inflammatory response.

Although taurine can be synthesized in liver & brain, dietary sources provide a significant portion of the body’s taurine.

Plasma taurine levels are elevated in renal failure or decreased in trauma, sepsis, or cancer.

PROTEIN AND AMINO ACID CONTENT OF SPECIALIZED ENTERAL FORMULAS

PROTEIN (% kcal)

ARGININE (g/ 1000 kcal)

CARNITINE (mg/ 1000 kcal)

GLUTAMINE ( g/1000 kcal)

TAURINE(mg/1000 kcal)

STANDARD FORMULAS

13-25 1.2- 2.4 0-150 3-8 0-211

CARBOHYDRATE All forms of CHO are used in enteral formulas to

provide energy.

The amount of CHO in enteral formulas ranges from about 40% to 80% of total calories .

Formulas with fiber & and a reduced CHO content have been developed to improve blood glucose control in patients with diabetes mellitus or stress induced hyperglycemia.

FAT Fat provides energy & essential fatty acids in both oral

diets & enteral formulas.

The fat content of enteral formulas varies from 5 % -55% in formulas intended to reduce CHO intake in patients with CO2 retention, diabetes mellitus, or glucose intolerance.

Standard formulas contain 15 – 35% of total calories as fat.

Formulas with high fat content may delay gastric emptying.

Omega-3 fatty acids Patients with various acute or chronic

diseases may have abnormal plasma fatty acid profiles that could be corrected by omega-3 fatty acids.

Omega-3 fatty acids also have a range of effects on CVD, which could influence their use in enteral formulas.

FIBER Dietary fiber has always been present in blenderized formulas.

The term residue refers to the increase in fecal weight caused by undigested food material.

Enteral formulas without added fiber are considered very low in residue, because their macronutrients are highly digestible.

Fibers used in enteral formulas include- soy polysaccharide, gums, pectin.

Fiber has not been added to formulas with a caloric density greater that 1.5 kcal/ml.

Vitamins, Minerals & Electrolytes

Formulas intended for use in renal & hepatic failure are intentionally low in specific vitamins, minerals, & electrolytes.

In contrast, disease specific formulas often are supplemented with antioxidants, vitamins & minerals with the intention of improving immune function & accelerating wound healing.

Electrolytes are provided in relatively modest amounts compared with the oral diet & may supplemented when diarrhea occur.

ENTERAL EQUIPMENT

Feeding tubes Enteral feeding containers Enteral pumps

Enteral Feeding Tubes

Polyvinylchloride (PVC)

Silicone (Silastic)Polyurethane

Composition

Tube Advantages Disadvantages

PVC Easy to place Risk of damage Resists collapse Replace every 3

days

Silastic Flexible comfortable Smaller diameter

than polyurethane

Polyurethane Flexible Good patient tolerance

ENTERAL PUMPS ENTERAL CONTAINERS

Complications of Enteral Nutrition

Access Problems Administration Problems Metabolic Gastrointestinal

Access Problems- Pressure necrosis/ ulceration Tube displacement Tube obstruction Leakage from ostomy site Tube fractures Irritation infection

Abdominal leakage of gastric contents from a gastrotomy site can cause skin erosion & skin breakdown, leading to infection.

Administration Problems Regurgitation Aspiration Microbial contamination

To minimize the risk of aspiration, patients should be positioned with their heads & shoulders above their chests during & immediately after feeding.

Metobolic complications Refeeding syndrome Drug – nutrient interactions Glucose intolerance / hypergycemia /

hypoglycemia Hydration status- dehydration/ overhydration Hyponateremia Hyperkalemia/ hypokalemia Hyperphosphetemia/ hypophosphatemia. Micronutient deficiency.

GI Complications Nausea / vomiting Distension / bloating / cramping Delayed gastric emptying Constipation High gastric residuals Diarrhea Osmotic pressure Hypoalbunemia Maldigestion / Malabsorption

Diarrhea Diarrhea is a most common complication associated with enteral nutrition.

The most likely causes of diarrhea among enterally fed patients are- Bacterial overgrowth, antibiotic therapy.

GI motility disorders are associated with acute & critical illness but not the enteral nutrition.

Hyper-osmolar medications such as mg containing anta-acids, sorbitol containing elixirs & electrolyte supplements also contribute to diarrhea.

Adjustment of medications or admininstration methods can frequently correct the diarrhea.

The addition of soy polysaccharide, a prebiotic, pectin, & other fibres, bulking agents, probiotics & anti-diarrheal medications can also be beneficial.

REFERENCESBOOKS- Contemporary nutrition support practice –By Laura E matarese, Michele, M. Gottschlich.

Krause’s Food & Nutrition Therapy12th edition

A Text book of Nutrition & DietiticsBy- Kumud Khanna

Food Science and Nutrition

Internet

Conclusions Enteral feeding is the preferred form of

nutritional support Safe and efficacious Well-tolerated Safer, cheaper, simpler, and more effective

than Parenteral Feeding