By: Ma. Jenee C.

Virtudazo, RN-D
Clinical Dietitian
Associate Diabetes Educator
Dietary Management of
Heart Disease, Diabetes
Mellitus, and Arthritis
TOPICS
TOPICS
Review
ABCDs of Assessment
Diet Prescription
Diet Instruction
Monitoring/ Follow-up
Principles of Dietary Management
Principles of Dietary Management
Liberalization
Individualization
Simplification
Principles of Dietary Management
Principles of Dietary Management
Two Broad Classification of Therapeutic Diets
Modification in Consistency
Modification in Composition
ABCDs
ABCDs
of Assessment
of Assessment
Anthropometry
Biochemical
Clinical
Dietary
Anthropometry
Anthropometry
Height
Weight
ABW % Std Wt
DBW BMI
Nutritional Classification
I. Methods of Estimating Desirable
I. Methods of Estimating Desirable
Body Weight ( DBW) in Infants
Body Weight ( DBW) in Infants
A. First 6 months: DBW (g) = Birth weight + (Age X 600 )
If birth weight is not known use 3000 g
Ex. 4 month old infant
DBW = 3000 +(4 X 600)=5400 or 5.4 kg
7-12 months: DBW = birth weight + ( Age X 500 )
Ex. 8 month old infant
DBW = 3000 = ( 8 X 500) = 7000 or 7 kg
I. Methods of Estimating Desirable
I. Methods of Estimating Desirable
Body Weight ( DBW) in Infants
Body Weight ( DBW) in Infants
B. DBW ( kg) = (Age in months/ 2) + 3
Ex. 8 month old infant
DBW = (8/2) = 3 = 7
II. Methods of Estimating DBW in
II. Methods of Estimating DBW in
Children
Children
DBW ( kg) = (Age in years X 2) + 8
Ex. 7 years old
DBW = ( 7 X 2 ) + 8 = 22 kg
III. Methods of Estimating DBW in
III. Methods of Estimating DBW in
Adults
Adults
A. Tannhausers Method
DBW( kg) = ( Ht in cm 100) 10%
Ex. 52 = 62 X 2.54 cm = 157.48
= 157.48 100 = 57.48
= 57.48 5.74 = 51.74 or 52 kg
III. Methods of Estimating DBW in
III. Methods of Estimating DBW in
Adults
Adults
B. Adopted Method
For 5 ft use 106 lbs for male & 100 for female,
for every inch above 5 ft add 6 lbs for male and
5 lbs for female
Ex. 52 Female
= 5 ft = 100 lbs + 2 inches X 5 = 10 lbs
= 100 + 10 = 110 lbs
3. Body Mass Index
= Weight ( kg)
Height (m)2
Ex. 60 kg , 52
= 60 kg
2.46
= 24
III. Methods of Estimating DBW in
III. Methods of Estimating DBW in
Adults
Adults
Cut Off Values for BMI
BMI< 20 = underweight
BMI 20-24.9 = normal
BMI 25-30 = overweight
BMI > 30 = obese
III. Methods of Estimating DBW in
III. Methods of Estimating DBW in
Adults
Adults
BIOCHEMICAL
BIOCHEMICAL
Laboratory data
Blood Chemistry
CBC
Urinalysis
BP
Interpretation
CLINICAL
CLINICAL
Signs and Symptoms of Malnutrition
DIETARY
DIETARY
Food Recall
Food likes
Food dislikes
Food taboos
Food allergy
Oral Function
Diet regimen
General Data
General Data
Name
Age
Religion
Attending Physician
Referred By
Diagnosis
Diagnosis
HPN
DM
Dyslipidemia
IHD
Gouty Arthritis
Obesity
Cancer
Steps in Preparing Diet
Steps in Preparing Diet
Prescription
Prescription
1. Determine Desirable Body Weight (DBW).
2. Calculate the Total Energy Requirement
(TER).
3. TER is converted in grams of CHO, PRO and
Fat based on the percentages.
Steps in Preparing Diet
Steps in Preparing Diet
Prescription
Prescription
4. The grams of CHO, PRO , & Fat are converted in
servings of foods using the Food Exchange
Lists ( FEL).
5. The number of daily food servings within each
group is distributed among the 3 major meals &
snacks.
6. Once the diet prescription is established,
individual meals can be planned by selecting
servings of appropriate foods from the FEL.
Methods of Estimating Total
Methods of Estimating Total
Energy Requirement (TER)
Energy Requirement (TER)
I. INFANTS
110 120 kcals /KDBW
Ex. 4 month old infant
DBW = 5.4 kg X 120 = 648 cals
Methods of Estimating Total
Methods of Estimating Total
Energy Requirement (TER)
Energy Requirement (TER)
II. CHILDREN
A. Cals/day = 1000 + (100 X Age in years) = 1800 cal
B. Age Range Cals/ KDBW
1-3 100
4-6 90
7-9 80
10-12 70 boys
60 girls
50 adolescents
Determination of TER in Adults
Determination of TER in Adults
A. Krause Method
DBW (kg) X Physical Activity (kcal/kg)
Activity Factor (kcal/kg) Example of Activity
Bed Rest = 27.5 hospital patients
Sedentary = 30 mostly sitting
Light = 35 tailor, nurse, student
Moderate = 40 carpenter, house work
Heavy = 45 farmer, laborer, fisherman
Ex. DBW = 52 kg with light activity
TER = 52 kg X 35 kcal = 1820 kcal or 1800 kcal
Distribution of TER Into
Distribution of TER Into
Carbohydrate, Protein & Fats
Carbohydrate, Protein & Fats
Method I. By Percentage Distribution
% of TER
1. Carbohydrates 50-70% or average of 60%
2. Proteins
Infants & Children 10%
Adolescents & Adults 10-12%
3. Fats
Normal Adults &
Moderately Active 20-25%
Children, Adolescents &
Very Active Individuals 30-35%
Method II. Determine the protein calories first
according to normal allowance in g/KDBW and
divide the non-protein calories (NPC) into:
CHO - 55-80% or average of 70%
FAT - 20-45% or average of 30%
Distribution of TER Into
Distribution of TER Into
Carbohydrate, Protein & Fats
Carbohydrate, Protein & Fats
Normal Protein Allowance/Day
gm/ KDBW
Infants 2.5-3.0
Children 2.0
Adolescents 1.5
Adults 1.1
Distribution of TER Into
Distribution of TER Into
Carbohydrate, Protein & Fats
Carbohydrate, Protein & Fats
Diet Prescription
Diet Prescription
Compute for the diet prescription
Female 52 ABW = 62kg
Rx Diet Cals CHO CHON FAT
a. Percent Distribution
b. Non-Protein Calories Method
Composition of Food Exchanges
Composition of Food Exchanges
Food Measure C P F Energy
(g) (g) (g) (Kcal)
Veg A 1 c. raw - - - -
c. cooked - - - -
Veg A 2 c. raw 3 1 - 16
1 c. cooked
Veg B c. raw 3 1 - 16
c. cooked
Fruit varies 10 - - 40
Composition of Food Exchanges
Composition of Food Exchanges
Food Measure C P F Energy
(g) (g) (g) (Kcal)
Milk
Whole varies 12 8 10 170
Low fat 4 T 12 8 5 125
Skimmed varies 12 8 tr 80
Rice varies 23 2 - 100
Meat
Low fat varies - 8 1 41
Med fat varies - 8 6 86
High fat varies - 8 10 122
Fat 1 t - - 5 45
Sugar 1 t 5 - - 20
Diet Instruction
Diet Instruction
Rx Diet
Translate the Rx Diet to actual foods
Make a meal plan
Explain the meal plan to the patient
- rationale of the Rx Diet
- serving portions divided into 3m/2sn
- FEL
- Qualitative instruction
Updates
Updates
Dietary Management of Heart
Diseases and Dyslipidemia
Prevalence of Overweight / Obesity
Prevalence of Overweight / Obesity
among Filipino Adults
among Filipino Adults
11.80%
1.70%
14.00%
2.60%
16.90%
3.20%
19.60%
4.90%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
P
r
e
v
a
l
e
n
c
e
1987 1993 1999 2003
Obese
Overweight
FNRI, 1987 to 2003
Disease Risk Associated with Excess
Disease Risk Associated with Excess
Body Mass Index
Body Mass Index
Willet WC et al. N Engl J Med 1999;341:427-434.
Type 2 diabetes Cholelithiasis Hypertension CHD
BMI (kg/m
2
)
Women
R
e
l
a
t
i
v
e

R
i
s
k
21 22 23 24 25 26 27 28 29 30
BMI (kg/m
2
)
Men
21 22 23 24 25 26 27 28 29 30
0
1
2
3
4
5
6
0
1
2
3
4
5
6
Disease Risk Associated with Excess
Disease Risk Associated with Excess
Body Mass Index
Body Mass Index
Willet WC et al. N Engl J Med 1999;341:427-434.
Type 2 diabetes Cholelithiasis Hypertension CHD
BMI (kg/m
2
)
Women
R
e
l
a
t
i
v
e

R
i
s
k
21 22 23 24 25 26 27 28 29 30
BMI (kg/m
2
)
Men
21 22 23 24 25 26 27 28 29 30
0
1
2
3
4
5
6
0
1
2
3
4
5
6
MORTALITY: LEADING CAUSES
Rate per 100,000 Population
Philippines 1995
MORTALITY: LEADING CAUSES
MORTALITY: LEADING CAUSES
Rate per 100,000 Population Rate per 100,000 Population
Philippines 1995 Philippines 1995
Dis. of the Heart
Dis. of the Heart
T.B. All Forms
T.B. All Forms
Dis. of the
Vascular System
Dis. of the
Vascular System
Malignant
Neoplasms
Malignant
Neoplasms
Chronic Obstructive
Pulmonary Dis. &
Allied Conditions
Chronic Obstructive
Pulmonary Dis. &
Allied Conditions
Accidents
Accidents
Diabetes Mellitus
Diabetes Mellitus
Other Dis. of
Respiratory System
Other Dis. of
Respiratory System
20
100
0 40 60 80
Rate
Causes
Pneumonia
Pneumonia
Diarrheal Dis.
Diarrheal Dis.
Lifestyle Interventions:
Lifestyle Interventions:
Dietary Therapy, Physical
Dietary Therapy, Physical
Activity, Weight Control
Activity, Weight Control
-60% -40% -20% 0%
Primary Prevention:
Primary Prevention:
Crucial Opportunity to
Crucial Opportunity to
Reduce the Burden of CHD
Reduce the Burden of CHD
Law MR et al. BMJ 1994;308:367-372.
Age 70
Age 70
Reduction in risk in men with 10% reduction Reduction in risk in men with 10% reduction
in total cholesterol (10 cohort studies) in total cholesterol (10 cohort studies)
Age 50
Age 50
Age 40
Age 40
Therapeutic diet to
Therapeutic diet to
lower LDL
lower LDL
-
-
C
C
New Options to Lower LDL
New Options to Lower LDL
-
-
C
C
Avoid
Trans fatty acids* (hydrogenated oils)
Add
Dietary fiber (soluble fiber)
Plant sterol/stanol ester margarines
Expert Panel. JAMA 2001;285:2486-2497.
* Keep trans fatty acids low
Trans
Trans
Fatty Acids (TFA)
Fatty Acids (TFA)
TFA more densely packed than cis forms
Usual intake: only 23% of energy
If consumed in high amounts:
LDL-C; HDL-C
Lichtenstein AH et al. N Engl J Med 1999;340:1933-1940
Conclusion:
Conclusion:
Consume products low in
Consume products low in
saturated and TFA
saturated and TFA
Primary Prevention:
Primary Prevention:
Adverse
Adverse
Life Habit Changes
Life Habit Changes
Atherogenic diet
Sedentary lifestyle
Obesity
Expert Panel. JAMA 2001;285:2486-2497.
Saturated Fat
Saturated Fat
Examples of Saturated Fatty Foods
Bacon
Butter
Coconut, grated*
Coconut cream*
Coconut oil*
Cream cheese
Latik*
Margarine
Shortening or lard
Sour cream
Sitsaron
Whipping cream
Kropeck
Dietary Options
Dietary Options

Benefit
Benefit
Independent of LDL
Independent of LDL
-
-
C Lowering
C Lowering

Avoid
Avoid
Megavitamins (adverse effects shown for
supplements of beta-carotene, no convincing
clinical trial benefit for vitamin E supplementation)

Add
Add
Fish
Plant sources of omega-3 fatty acids
Fruits and vegetables
Sources of Fiber Components Sources of Fiber Components Sources of Fiber Components Sources of Fiber Components
Sources of Fiber Components Sources of Fiber Components Sources of Fiber Components Sources of Fiber Components
Soluble
indigestible food components that readily dissolve in
water and often impart gummy or gel-like characteristics
to foods.
Gums Pectin
Oats Apples
Legumes Citrus Fruits
Guar Strawberries
Barley Carrots
DIABETIC DIET
DIABETIC DIET
Meal plan based on the individuals food intake
Spacing of meals is encouraged
Weight control is important
Caloric Distribution:
CHO: 50-70%
CHON: 10-20%
FATS 20-30%
DIABETIC DIET
DIABETIC DIET
Cholesterol -300 mg, 10% saturated fats
Fiber 25 g/1000 calorie
Sodium 3000 mg
HIGH CARBOHYDRATE & LOW
HIGH CARBOHYDRATE & LOW
CARBOHYDRATE
CARBOHYDRATE
HIGH CARBOHYDRATE (65- 75% of TER)
Foods Allowed:
Emphasis on high carbohydrate foods such as
rice, cereals, bread, sugar & sugar products,
root crops, noodles, fruits & legumes
Indications For Use:
Diseases requiring low protein & low fat diets
(renal & liver)
HIGH CARBOHYDRATE & LOW
HIGH CARBOHYDRATE & LOW
CARBOHYDRATE
CARBOHYDRATE
LOW CARBOHYDRATE ( <50% of TER )
Foods Allowed:
Emphasis on foods high in protein
Adequate to high fat foods
Indications for Use:
Obesity, Celiac Disease
Dumping Syndrome
Hyperinsulinism, COPD ( w/ ventilator)
PURINE RESTRICTED
PURINE RESTRICTED
Protein is not more than 10% of TER
Purine = 120-150 mg
CLASSIFICATION OF FOODS ACCORDING TO PURINE CONTENT
Category 1 Category 2 Category 3
Very large; 150-1000 mg Large;75<150 mg Moderate < 75 mg
Purine/100 g Purine/100 g Purine/100 g
Organ Meats
Hog; liver, spleen, intestines lung, kidney, tongue, head uterus ,blood
Cattle: liver, spleen lung, uterus, kidney small& large
heart, brain, reticulum intestines, blood
tripe
Carabao: liver, spleen lung , kidney, tripe uterus, small &
tripe, reticulum large intestines
tripe
Chicken: liver, kidney, gizzard, intestines
Shellfishes
Dilis Halaan, Pusit
Tamban Hipon,puti, Tuna, Karpa, Salmon, Igat
Tunsoy Tahong, Talaba, Tulya
HIGH PROTEIN & LOW PROTEIN
HIGH PROTEIN & LOW PROTEIN
HIGH PROTEIN ( 15-20% of TER or 1.5g 2g/KDBW)
Foods Allowed:
Emphasis on HBV proteins such as meat, fish, poultry,
cheese, milk, soy beans & soy products
Indications For Use:
Protein Energy Malnutrition
Hypercatabolic States
Hepatitis, Portal Cirrhosis
HIGH PROTEIN & LOW PROTEIN
HIGH PROTEIN & LOW PROTEIN
LOW PROTEIN ( 0.6-0.8 g/ KDBW; 2/3 HBV)
Foods Allowed:
Protein limited to prescribed amounts
Indications For Use:
Chronic Kidney Disease
Hepatic Coma
MODIFICATIONS IN COMPOSITION
MODIFICATIONS IN COMPOSITION
HIGH CALORIE
Indications For Use:
Protein Energy Malnutrition
Hypercatabolic States
MODIFICATIONS IN COMPOSITION
MODIFICATIONS IN COMPOSITION
Ways of Prescribing High Calorie:
1.Compute TER using DBW
Ex: 52 = DBW = 52 kg
TER = 52 X 30 cals = 1560or 1550 cals
2. Add 500-1000 cal/day to TER
Ex: 1550 + 500 = 2050 cals
1550 + 1000 = 2550 cals
3. Add 50-100% to the TER
Ex: 1550 + 775 (50%) = 2325 cals
1550 + 1550 ( 100%) = 3100 cals
LOW CALORIE
Foods Allowed:
Sufficient bulk, low in fat & sugar
Indications For Use:
Obesity & Overweight
Diseases requiring reduced energy requirements
MODIFICATIONS IN COMPOSITION
MODIFICATIONS IN COMPOSITION
Ways of Prescribing Low Calorie :
Given: Height 52 ; Physical Activity: sedentary
DBW = 52 kg ABW: 80 kg
Actual Caloric Intake: 3000 cals
1. Compute TER based on DBW
Ex: TER = 52 X 30 cals = 1560 0r 1550 cals
2. Calculate TER based on ABW
Ex. TER= 80 kg X 30 cal 2400 cals
3. Actual Caloric Intake 500 or 1000 cals
Ex. TER= 3000 cals 500 cals = 2500 cals
4. Allow 20-25 cal/KDBW
Ex. TER = 52 kg X 25 cal = 1300 cals
MODIFICATIONS IN COMPOSITION
MODIFICATIONS IN COMPOSITION
Modification in Consistency
Modification in Consistency
CLEAR LIQUID
Foods Allowed:
clear, fat free broth
strained juices, tea, black coffee, ginger ale & non-carbonated drinks
plain gelatin, sugar, plain candies
Indications For Use:
Pre- operative & post- operative cases with NGT function
FULL LIQUID
Foods Allowed
Strained cream soups & lugao mashed potato
Strained meats, SCE, milk & milk drinks
Vegetable & fruit purees, juices
Plain ice cream, gelatin, soft pudding or baked custard
Cream, butter or margarine
Indications for Use
Post-operative cases with N GIT function
Dysphagia
Modification in Consistency
Modification in Consistency
SOFT & MECHANICAL SOFT
SOFT & MECHANICAL SOFT
SOFT DIET
Foods low in cellulose & fiber; free from tough
connective tissues, mildly seasoned & easily
digested; simply prepared
Indications For Use:
- Post- operative cases when patient can tolerate
solid food but not a full diet
- Fevers & mild infections
- Gastrointestinal disturbances
SOFT & MECHANICAL SOFT
SOFT & MECHANICAL SOFT
MECHANICAL SOFT
Indications for Use
Oral lesions & poor dentures
After oral, head & neck surgery
Difficulty of chewing
LOW RESIDUE & BLAND
LOW RESIDUE & BLAND
LOW RESIDUE
Foods Allowed:
Diet consisting of mildly seasoned & easily
digested foods
Indications For Use:
Spastic Constipation
Chronic Diarrhea
Ulcerative Colitis
LOW RESIDUE & BLAND
LOW RESIDUE & BLAND
BLAND DIET
Foods Allowed:
Mild in flavor & non stimulating
No coarse fiber & connective tissues
Foods Avoided:
pepper, chili powder, alcohol, strong
coffee, cocoa, tea, cola beverages
HIGH FIBER & LOW FIBER
HIGH FIBER & LOW FIBER
HIGH FIBER
Foods Allowed:
Long- fibered vegetables , raw fruits & vegetables
Whole grain cereals , coarse breads
Indications For Use:
Atonic Constipation
Diverticular Disease
Irritable Bowel Syndrome
Gastric Ulcers
Chronic Diseases ( DM, CVD, Ca, etc)
LOW FIBER
Foods Allowed:
Young immature vegetable
Well- cooked fruits, fruits w/o
skin & seeds
Tender cuts of meats
HIGH FIBER & LOW FIBER
HIGH FIBER & LOW FIBER
Tube Feeding
Tube Feeding
Foods Allowed:
Foods included in liquid & soft diets ,
selected foods from regular diet, well
blended
Tube Feeding
Tube Feeding
Comparison of Different Formulas
Formula CHO PRO FATS
(%) (%) (%)
Nutren 1.0 51 16 38
Nutren (Fiber) 51 16 33
Ensure 55 14 32
Isocal 50 14 37
Ultracal 46 17 37
Glucerna 50 17 33
Pulmocare 55 17 28
Respalor 39 20 41
Nepro 43 14 43
Suplena 51 30 43
Polycose powder 3.8 kcal/g
Casec powder 3.7 kcal/g
ProMod powder 4.2 kcal/g
LOW SODIUM
LOW SODIUM
I. 500 mg Sodium (Strict Restriction)
No salt & salt containing spices or foods high in sodium
(processed foods)
II. 1000 mg Sodium (Moderate Restriction)
More liberal selection of foods or if preferred 1/4 teaspoon salt
(1.25) may be added; processed foods omitted
LOW SODIUM
LOW SODIUM
III. 2000-3000 mg Sodium (Mild Restriction)
Liberal use of salt in preparation, no patis, toyo on the
table, no canned or processed foods
IV. 3000-4000 mg Sodium (No Processed)
Normal diet w/o processed foods
LOW POTASSIUM
LOW POTASSIUM
Potassium (1-1.8 g)
Usual diet has 2-6 g
Vitamins A & C likely to be low
Indications for Use:
Hyperkalemia
Addisons Disease
Foods Avoided:
seafoods, leafy vegetables, rootcrops, nuts, corn, fruits such as
banana, apple, atis, lanzones, guava, melon, pakwan,
raisins, prunes, non fat milk