College of Health Sciences

Integrated Sciences Department

LFS 233
Nutritional care. Tools for diet
instruction and weight control
Reference text:
Introductory Nutrition and Diet Therapy. (Eschleman, M.M., J.B. Lippincott,
Philadelphia, 2nd edition)
 Objectives
1. Explain the elements of the problem-solving approach.
2. Differentiate between diet plan & meal plan and give
examples.
3. Use the exchange lists and prepare a sample menu for any
given meal plan.
4. Define the terms overweight and obesity.
5. Discuss the methods for determination of obesity.
6. Define BMI and mention how it is calculated
7. Explain the complications of obesity.
8. Differentiate apple-shaped obesity & pear-shaped obesity.
 Objectives
9. Given body measurements of an individual, calculate upper body
obesity.
10. Identify the causes of obesity.
11.Compare the merits of various types of diets for weight control.
12.Identify different methods used in the treatment of obesity.
13.Define the term underweight.
14.Discuss the causes of underweight.
15.Explain the methods used in the treatment of under weight
 Nutritional Care - A problem-solving
approach

4 Elements of Nutritional Care

• Assessment
• Planning
• Implementation
• Evaluation
 Elements of Nutritional care
Assessment – Client’s nutritional status is
determined - methods outlined in module 1.

Planning – Client sets his or her own goals.

• Should be realistic and acceptable to both

Implementation: two functions :

a) Providing adequate normal /modified diet
b) Providing nutrition education & counseling
 Implementation ;- Providing an Adequate
Normal or Modified Diet
How will you ensure that a sick person is getting adequate
nutrition to meet his increased needs?
Increase quality of diet & create environment that
promotes the appetite

• Reduce intake of bulky, low-calorie foods (salads, soups)

• Increase low-volume, high-calorie foods (meats,
starches, fortified milk beverages)
• Small, frequent meals
• Arranging for the client to eat with other persons
 Categories of change in diets
Texture E.g. liquid, soft, high-fiber diets
Amount of nutrients – E.g. Protein restricted or
increased, sodium & fat restricted
Frequency of meals – E.g. increased
Selection of foods – E.g. wheat products are
eliminated for clients who are allergic to wheat.
Diet should be similar to usual diet
 Implementation;- Providing Nutrition
Education:

• Help the client change attitude and behavior

• Use informal and formal teaching methods
• Educational approach must suit the client’s
educational level and personality

• Diet orders - clear and specific

• Sodium 500 mg/day instead of "severe sodium
restriction".
Evaluation:
Has the client gained or lost the appropriate
amount of weight?

If progress has not been made,

• the cause is determined
• new plan is developed.
 II. TOOLS FOR DIET INSTRUCTION:
A. Diet Plans and Meal Plans:
• A diet plan provides a framework for a diet.
• Guidelines indicating how many servings from
each food group per day. (Appendix 1)
• Instructional materials are also given
• A meal plan indicates the number of servings
from each exchange group for each meal and
snack in the day. (Appendix-2)
 Diet Plan - Sample
DIETARY MODIFICATIONS TO LOWER BLOOD CHOLESTEROL
Diet modifications designed to reduce intake of total fat, saturated
fat, and cholesterol while maintaining a nutritionally adequate
dietary intake.
1. Adjust calorie intake to achieve and maintain desirable body
weight.
2. Limit total fat intake to less than 30% of total calories.
3. Limit meat and substitutes to no more than 7 oz/day and fats and
oils to no more than 8 tsp/day.
4. Limit high-cholesterol foods, such as egg yolks, liver organ meats,
and butter fat-containing dairy products. Plant foods do not
contain cholesterol.
5. Increase intake of complex carbohydrates such as fruits,
vegetables, whole grains, and legumes to replace foods high in fat.
 Daily Diet & Meal Plan for 1,800-kcal Diet Using
Exchange Lists
DAILY DIET PLAN
Nutritional Composition- Amount & Kind of Food. Choose From
• Protein 84 g
• Carbohydrate 249 g
• Fat 55 g
• 9 Starch/bread exchanges
• 5 Meat exchanges (lean-medium fat)
• 3 Vegetable exchanges
• 5 Fruit exchanges
• 2 Skim milk exchanges
• 6 Fat exchanges (unsaturated)
 B) Exchange Lists:
• Foods that have a similar nutritional
composition (calories & target nutrients) are
grouped together.
• Exchange lists simplify meal planning
• Provides a wide choice of foods
Exchange Lists should be used together with a
Meal Plan.
E.g. the Meal Plan allows two starch/bread
exchanges for dinner. What would you
choose?
 MEAL PLAN SAMPLE MENU
Breakfast ½ cup of orange juice ( 1 fruit )
1 fruit exchange ¾ cup of cornflakes (1 bread)
3 bread exchanges 2 slices of whole-wheat toast (2 bread )
2 fat exchanges 2 tsp of margarine ( 2 fat )
1 skim milk exchange 1 cup of skim milk ( 1 milk )
Lunch: 2 oz. turkey boiled ( 2 meat )
2 meat exchanges (lean-medium fat) 2 slices of rye bread ( 2 bread )
2 bread exchanges 1 large tomato ( 1 vegetable )
1 vegetable exchange 1 tsp of mayonnaise ( 1 fat )
1 fat exchange 1 banana 9 inch long ( 2 fruit )
2 fruit exchanges 1 cup of skim milk ( 1 milk )
1 skim milk exchange
Dinner 3 oz. of roast lamb ( 3 meat )
3 meat exchanges (lean-medium fat) ½ cup of mashed potatoes (1 starch bread )
3 bread exchanges 1 slice of whole-wheat bread ( 1 starch bread )
2 vegetable exchanges 1 cup of green beans ( 1 vegetable )
3 fat exchanges 1 cup of pickled beets ( 1 vegetable )
1 fruit exchange 3 tsp of margarine ( 3 fat )
½ cup of sugar-free pudding (1 starch bread 0
1/3 cantaloupe ( 1 fruit )
Coffee or tea, if desired Tea with Artificial sweetener
Evening Snack 3 squares whole wheat crackers ( 1 starch bread
1 bread exchange )
1 fruit exchange ½ cup pineapple chunks ( 1 fruit )
1 skim milk exchange 1 cup skim milk ( 1 milk )
 C) Counting Calories With Exchange Lists:

• Provides a quick way of estimating the caloric

content of a diet.
• See Table E1 (in Exchange Lists booklet)

• When nutritional labeling is provided on a

food packet, the caloric value given on the
label may be used.
 Counting Calories With Exchange Lists:
DIET PLAN K.CAL.

9 Starch/bread exchanges 9 x 80 = 720

5 Meat exchanges – lean 5 x 55 = 275

3 Vegetable exchanges 3 x 25 = 75

5 Fruit exchanges 5 x 60 = 300

2 Skim milk exchanges 2 x 90 = 180

6 Fat exchanges – Unsat. 6 x 45 = 270

TOTAL K.CAL 1820

 Calculate the grams of carbohydrate, protein, fat & energy
value of the diet plan given below.
DIET PLAN Carb Protein Fat K.cal.

9 Starch/bread exchanges 9x15=135 9x3=27 - 9x80=720

5 Meat exchanges – lean - 5x7=35 5x3=15 5x55=275

3 Vegetable exchanges 3x5=15 3x2=6 - 3x25=75

5 Fruit exchanges 5x15=75 - - 5x60=300

2 Skim milk exchanges 2x12=24 2x8=16 - 2x90=180

6 Fat exchanges – Unsat. - - 6x5=30 6x45=270

TOTAL 249 84 45 1820

 PROBLEM 1
Mona is obese. The doctor gave her the following diet plan:
• 2 skim milk exchanges
• 7 starch/bread exchanges
• 4 lean meat exchanges
• 3 vegetable exchanges
• 3 fruit exchanges
• 5 fat exchanges
Calculate the grams of carbohydrate, protein, fat & energy value
of Mona’s diet plan.
• Mona prefers a light breakfast, moderate lunch & a large
dinner. Convert the diet plan into a meal plan & use the
exchange list to prepare a suitable sample menu.
 Calculate the grams of carbohydrate, protein, fat & energy
value of the diet plan given below.
DIET PLAN Carb Protein Fat K.cal.

7 Starch/bread exchanges 7x15=105 7x3=21 - 7x80=560

4 Meat exchanges – lean - 4x7=28 4x3=12 4x55=220

3 Vegetable exchanges 3x5=15 3x2=6 - 3x25=75

3 Fruit exchanges 3x15=45 - - 3x60=180

2 Skim milk exchanges 2x12=24 2x8=16 - 2x90=180

5 Fat exchanges – Unsat. - - 5x5=25 5x45=225

TOTAL 189 71 37 144 0

 Problem 2
• Nabeel is a diabetic & obese. His daily diet plan allows the following no. of
exchanges per day : 4 bread, 6 meat, 2 skim milk, 3 fruit, 2 vegetable and 3
fat. Nabeel’s usual daily diet is as follows.
Breakfast: Bread Meat Milk Fruit Veg Fat
2 bananas (each 9 in long or
1cup.)
1 cup low fat milk
Lunch:
1 cup macaroni cheese
1 cup cream of chicken soup
Snack:
½ cup foules medames
Dinner:
3 oz corned beef
¼ of a 10 in cheese pizza
a) Calculate the no. of exchanges he eats from each food.
b) Compare his diet with the recommended diet..
 Problem 2 - Answers
• Nabeel is a diabetic & obese. His daily diet plan allows the following no. of
exchanges per day : 4 bread, 6 meat, 2 skim milk, 3 fruit, 2 vegetable and 3
fat. Nabeel’s usual daily diet is as follows.
Breakfast: Bread Meat Milk Fruit Veg Fat
2 bananas (each 9 in or 2 4
1cup.) 1
1 cup low fat milk
Lunch:
1 cup macaroni cheese 2 1 med 2
1 cup cream of chicken soup 1 1
Snack:
½ cup foules medames 1 ½ lean
Dinner:
3 oz corned beef 3 high
¼ of a 10 in cheese pizza 2 1 med 1
8 5½ 1 4 4
 D) Portion Sizes:
• Accurate estimation of portion sizes is
important, especially for calorie controlled
diets.

• All food should be weighed or measured after

cooking.
• Meats, weigh less after cooking
• starches increase in volume after cooking.
 E) Special Foods For Modified Diets:

• Care must be taken in the purchase of so-

called dietetic foods.
• All food labeled as dietetic may not be
permissible

• It is important to evaluate these products

carefully or to seek advice about them from a
dietitian.
 III WEIGHT CONTROL
• In the developing countries obesity is
becoming more prevalent than underweight.
 Weight control
• Balancing food energy with energy needs
• Positive energy balance = Weight Gain
• Negative energy balance = Weight loss

• 1 lb. body fat represents approx. 3,500 kcal.

• Few excess Cals. daily  Reason for Middle

age weight gain
 DEFINING OBESITY:
• Difference between obesity & Overweight
• Generally most individuals who are
overweight have excess fat.
 Determination of obesity:
1.Height – Weight Tables : not an accurate tool of
determining obesity. Why?
2. Measuring of body fat : more accurate
• Skin-fold thickness test
• Underwater weighing
• Computer instruments
3. Body Mass Index : Identifies persons whose health is
threatened by obesity.
 How to calculate BMI?
Calculate the BMI of a boy whose wt is 65 kg and
height 173 cm.
• First convert cms into metres (173cm/100 = 1.73m

• Find the square of 1.73 (1.73multiplied by 1.73) =

2.9929
• BMI = 65/2.9929=21.7
 Assessment of Body Weight using
Body Mass Index
Degree of obesity based on BMI
• BMI 20 – 25  Normal
• BMI 26 – 30  Overweight
• BMI 30 – 40  Obese
• BMI > 40  Morbidly Obese
• Weight 20% above desirable weight is harmful
What are the harmful effects of obesity?
 Apple-shaped vs pear-shaped
• Upper-body obesity determination:
• waist measurement / hip measurement.
• High risk if > 0.95 for men
• And 0.80 for women
 CAUSES OF OBESITY:
• Body weight = balance between caloric intake
and energy expenditure.
Other factors are:
• Environmental
• Economic
• Hereditary
• Metabolic
• Emotional factors
• Activity levels
 Factors that affect body weight and fat
content
1. Genetics
2. Diet
3. Psycho-social factors
4. Lack of physical activity
1. Genetics
A person who is predisposed to obesity may have more
difficulty maintaining weight.
A)Fat Cell Theory:
B) Set Point Theory:
C) Efficient metabolism: (lower BMR)
 Genetics – fat cell theory
A. Fat cell theory—says that obesity depends on size and number of
cells
• Adult obesity—due to increase in size of fat cells only
• Childhood obesity—due to increase in no of fat cells only
Childhood obesity—more difficult to lose b/c this person has to
decrease the size of fat cells to below normal as he cant reduce the
number. Whereas adult has to decrease the size of cells to normal
Genetics – fat cell theory
 Genetics –set point theory
B. Set point theory
• Each person has a set point for body weight

• Hormones and enzymes program a persons body weight and

amount of fat and lean tissue

• Body resists anything which tends to change weight above or

below the set point
 Genetics- efficient metabolism
C. Efficient metabolism
• Many obese people consume the same amount of
calories as lean people.
• This is due to efficient metabolism in lean
 Factors that affect body weight and fat
content
2. Diet:
• Size & Composition of the diet is important.
3. Psycho-Social Factors:
• A family eating pattern that promotes obesity
is Diet high in meats.
 Factors that affect body weight and fat
content
3. Psycho-Social Factors:
• A family eating pattern
• Many celebrations
• Psychological factors - frustration, anger, anxiety.
4. Lack of Physical Activity:
• Major cause of recent increases of obesity in
many populations.
• Modern technology - reduced energy expenditure
TREATMENT OF OBESITY:
Approaches used :
• Diet
• Exercise
• Behavior modification
• Drugs
• Surgery
 1. DIET:
• A major part of most weight loss programs.
• A variety of dietary programs are available to the
general public.
Diets can be classified according to the approaches used:
a) Novelty Diets - popular self-prescribed diets that
promote certain, foods as magical.
• e.g. Fit for life Diet, Beverly Hills Diet, Slimfast, Combo,
Cabbage soup diet, Milwards etc
• Limits placed on food selection person eats less
Increase risk of nutritional deficiencies.
 1. DIET:
b) Severe Restriction of Carbohydrate:
• At first, rapid weight loss due to water loss,
• If carbohydrate consumption is less than 100g.
ketosis may develop.

c) Very Low-Calorie Diets: (< 800 kcal /day).

• for persons who are severely obese.
• Heart rate disturbances and sudden death have been
associated
• Medical supervision is necessary
 1. DIET:
d) Formula Diets:
• Liquid formula diets - attractive - no making
decisions - no food preparation
• The liquid diet program is severely limited in
calories,
• The adverse effects associated with the very
low-calorie diet, discussed above, apply here.
 1. DIET:
e) Moderate Calorie Restriction:
• Energy deficit of about 500 kcal/day
• When combined with exercise and behavior modification,
bring about gradual weight loss.
• Diets range from 1,200 to 1,800 or more kcal/day
• Nutritionally adequate and generally safe.

YO-YO DIETING:
• Harmful to health.
• Reduces metabolic rate, making permanent weight loss more
difficult to achieve.
• Changes body composition - increases proportion of body fat
& reduces muscle tissue.
 2. EXERCISE:

Increased physical activity is important

• Aerobic exercises - best for weight loss.
• Examples of aerobic exercise: walking, cycling,
swimming, jogging, running.
Benefits of aerobic exercise :
a) Permits a more liberal calorie intake.
b) Improves muscle tone.
c) Muscle tissue requires more energy than fat, more
muscle tissue, more calories burnt.
d) Increases the metabolic rate during exercise.
 2. EXERCISE( benefits cont)
d) Promotes the loss of body fat and the
retention of muscle tissue.
• By combining diet and exercise the loss of
body weight is increased and the loss of
body protein is decreased.
e) Reduces stress and tension and improves
adherence to a weight control program.
f) Helps prevent the regaining of weight.
 3. BEHAVIOR MODIFICATION:
Behavior modification is based on the theory that bad eating habits are learned
behaviors and that they can be replaced by other, better behaviors.
Thus, if the problem is obesity and eating habits are changed, weight loss follows.

Some Techniques that help build better eating habits include the following:
• Eat slowly and concentrate on the smell, taste, and texture of what you are
eating.
• Plan a pause midway through the meal so you can assess whether you have
become full.
• Celebrate or reward yourself with treats other than food, such as a movie,
some time for yourself, or a new dress.
• Serve food directly onto your plate. Do not place serving dishes of food on
the table.
• Separate eating from other activities. Do not eat while doing other things,
like reading.
 4. DRUGS:
• Reduce appetite or increase satiety (make you feel
full – usually fiber rich).
• Harmful side effects, including insomnia, dizziness,
hypertension and rapid heart beat

5. SURGERY:
For grossly or morbidly obese persons when obesity
is seriously interfering with their health. Types of
surgery -Intestinal bypass
- gastric bypass.
 TYPES OF WEIGHT CONTROL PROGRAMS:

• Dieting on their own

• Getting private counseling
• Joining a group

Dieting alone works best when only a few pounds are

involved. Best way is
• Reducing portion size.
• Limiting fat & sugar
• Increasing physical activity
• Crash dieting or the use of restrictive fad diets should be
avoided.
 MODERATE CALORIE-RESTRICTED DIET:
A successful weight loss program is one that promotes permanent
weight loss while maintaining overall health.

A weight reduction diet should do the following:

Satisfy all nutrient needs except energy.
Meet individual tastes and habits.
Minimize hunger and fatigue.
Be readily obtainable and socially acceptable.
Maintain overall health

The moderate calorie restriction diet satisfies all these.

 UNDERWEIGHT:
Weight is 10 to 20 lb < desirable weight
Causes:
• Genetic – Less number of adipose
• Prolonged illness
• Endocrine disorder (hyperthyroidism)
• Anorexia nervosa.
Effects:
• Susceptible to infection (particularly TB)
• Complicated pregnancy.
• Psychological harm.
Note: Thin people are least affected by chronic heart, liver,
and kidney diseases and diabetes
 Treatment:
• High calorie-diet with supplements of vitamins and minerals.
• Regular exercise and plenty of rest
Suggestions for underweight people
• Calories must be increased gradually to be > need
• Increasing the amount of food eaten at each meal, more
frequent feeding
• increasing carbohydrate and fat intake.
• Vitamins and minerals, especially thiamin, must be adequate
• Reduced consumption of low cal foods (e.g. soup, salads, coffee,
and tea)
• More carbohydrates should be eaten.
• Fatty foods are higher in calories, but may depress the appetite.