MODERN NUTRITIONAL DIETETIC PRACTICE

Modern nutritional dietetic practice

They include but not limited to:
i) Nutraceuticals / functional foods-Provides additional physiological benefits beyond that of
meeting basic nutritional needs.
Examples:
- Citrus fruits- protective against a variety of human cancers.
- Fish- fish contains omega 3 (n-3) fatty acids which plays a major role in cardiovascular disease
risk reduction.
- Dairy products- contain probiotics which help improving its intestinal microbial balance
Nutraceuticals- chemicals found as a natural component of foods or ingestible forms that have
been determined to be beneficial to the human body in preventing or treating one or more disease
or improving physiological performance
ii) Food supplements- They are concentrated sources of nutrients or other substances with
nutritional or physiological effect, whose purpose is to supplement the normal diet.
Note: Excessive intake of vitamins and minerals may be harmful or cause unwanted side effects,
maximum levels are necessary to ensure their safe use in food supplements.
iii) Enteral nutrition-It refers to nutrition support using liquid formula ducts via oral intake or
by tube feeding.
iv) Parentral nutrition-This is nutrition directly into the veins hence by passing the GIT.
Nutrients must therefore be in liquid form (solution or emulsion and monomolecular). It is
indicated for patients with inability to eat and absorb nutrients via the GIT due to:-
Non-functioning GIT
Diseases of the small intestines
Massive small bowel resection
Chemotherapy reaction
Contemporary issues in nutrition and dietetics.
a) Fortification
Addition of one or more nutrients such as vitamins, minerals and amino acids to food so that it
contains more of the nutrients than were originally present. In Kenya example include
fortification of blue band with vitamin A, some maize flour have also been fortified with vitamin
b) Public awareness
This is making the people to be aware of nutrition hence increasing nutrition knowledge to help
deal with nutrition related problems. This is done through nutrition education.
c) Diabetes
This is a metabolic disease due to absolute or relative insulin deficiency. Diabetes mellitus is a
common clinical condition. Nutrition is very important in managing diabetes.
d) Cancer
It is common term for a malignant cellular growth that tends to spread due to the inability of the
DNA to normal physiologic stimuli. The observation that cancers of the stomach and liver are
prevalent types is of interest, as these organs are directly involved in nutrient utilization.
e) Obesity
Obesity and overweight are on the rise in Kenya. Like several public health challenges, it should
be tackled and prevented early as envisioned in the WHO global strategy on diet, physical
activity and health.
f) HIV/AIDS
The HIV/AIDS epidemic poses an inescapable challenge to the world at large and Africa in
particular. A massive effort is needed to cushion the impact of the epidemic, and nutritional care
and support should be integral elements of any action taken. Under nutrition is common among
people living with HIV/AIDS.

e) The coronavirus disease (COVID-19) pandemic has brought the world to its knees in 2020.
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has challenged 21st
century medicine and wrought havoc on sophisticated and less well-resourced economies alike,
touching everyone. It will remain the contemporary issue of the decade and possibly the
century.1 As we brace ourselves to ride out the long road in search of a vaccine, health experts
are referring back to the 1918 to 1920 Spanish flu pandemic over 100 years ago for insights on
how to cope. The COVID-19 pandemic thus reminds us that in contemporary times, many
lessons can be learnt from the past.

PRINCIPLES OF DIETETICS

Estimated Average Requirement (EAR) is the average daily nutrient intake level estimated to
meet the requirement of half of the healthy individuals in a particular life stage and gender
group.

Recommended Dietary Allowance (RDA) is the average daily dietary nutrient intake level
sufficient to meet the nutrient requirement of nearly all (97 to 98 percent) healthy individuals in a
particular life stage and gender group.

Adequate Intake is the recommended average daily intake level based on observed or
experimentally determined approximations or estimates of nutrient intake by a group (or groups)
of apparently healthy people, that are assumed to be adequate — used when an RDA cannot be
determined. In the Indian context, this is referred to as acceptable Intake.

Tolerable Upper Intake Level (UL) is the highest average daily nutrient intake level that is likely
to pose no risk of adverse health effects for almost all individuals in the general population. As
intake increases above the UL, the potential risk of adverse effects increases

6.2 Recommended dietary allowances/nutrient and adequate intakes

The RDA is derived from the individual variability, and (ii) the nutrient bio-availability from the
habitual diet.

I. Individual variability:

Definition of RDA takes into account the variability that exists in the requirement of a given
nutrient between individuals in a given population group. The distribution of nutrient
requirement in a population group is considered normal and the RDA corresponds to a
requirement, which covers most of the individuals (97.5%) in a given population.

II. Bio-availability:

Bio-availability of a given nutrient from a diet, that is, the release of the nutrient from the food,
its absorption in the intestine and bio response have to

be taken into account. It is the level of the nutrient that should be present in the diet to meet the
requirement. This bioavailability factor is quite important in case of calcium and protein and
trace elements like iron and zinc.

The RDA of an individual depends upon various factors which are as follows:

Age: Adults require more total calories than a child, whereas a growing child requires more
calories per kg of body weight than an adult.

Sex: Males with high Basal Metabolic Rate (BMR) require more calories than females.

Activity: The type of activity also determines the energy requirements. The activities are
classified as sedentary, moderate and heavy based on the occupation of an individual.

Physiological Stress: Nutrient requirements are increased in conditions of physiological stress

such as pregnancy and lactation.

Students’ assignment

NUTRIENT INTAKE AND UTILIZATION

Factors influencing nutrient intake

There are many physiological and psychological mechanisms affecting our daily patterns in
consumption of food. Appetite is co-ordinated through the interaction of various complex
systems within the body involving the gut and the brain. Genetic factors and the environment
also have a role to play in food intake. The factors therefore include:

Physical activity: higher food intake is associated with increased physical activity. However,
regular exercise will help regulate appetite and help limit excess food consumption.

Metabolism: people with naturally high metabolic rates have higher appetites. If you are dieting
it is important to maintain your metabolic rate by eating and exercising regularly.

Hormones: there are many different hormones at play within the body – ghrelin is secreted by the
stomach to tell you that you are hungry and insulin is secreted by the pancreas to tell you that
you are full.

Temperature: cold climates has a tendency to be associated with an increase in appetite – this
could be due to the body needing to warm itself up quickly, or because dark days mean that
people are not getting enough sunlight which causes depression and people eat out of comfort.

Palatability: the tastier the food, the greater the pleasure derived from the food and the greater
the appetite will be. On the other hand, it is argued that having food that is very bland will cause
overeating because one does not feel satisfied from the food.

Psychology: stress and boredom often result in increased food intake. The best way of avoiding
this is to exercise regularly – this will help you to relax and to reduce boredom.

Factors affecting nutrient intake.

Social influences: eating habits are often influenced by one‘s upbringing – the three meals a day
routine is often a cause for eating out habit rather than out of hunger. Many social events, such as
Christmas celebrations, revolve around eating, drinking or both.

There Social Factors That Impact Nutrition

Social factors that may influence intake, nutritional requirements, or nutrition counseling

needs include a history or evidence of

• Illiteracy

• Language barriers
• Limited knowledge of nutrition and food safety

• Altered or impaired intake related to culture

• Altered or impaired intake related to religion

• Lack of caregiver or social support system

• Social isolation

• Lack of or inadequate cooking arrangements

• Limited or low income

• Limited access to transportation to obtain food

• Advanced age (>80 years)

• Lack of or extreme physical activity

• Use of tobacco or recreational drugs

• Limited use or knowledge of community resources Factors affecting nutrient intake

Nutritional intake depends on many factors like

 appetite,

 taste,

 availability,

 mood

 age

 gender

 psychological status

Adequate amount of food intake is essential for optimal nutritional status. Excessive intake can

lead to obesity and decreased intake leads to under nutrition.

Factors influencing food choice

Food choices for a balanced diet depend on many factors, such as:
Individual energy and nutrient needs- The amount of energy, carbohydrate, fat, protein,
vitamins and minerals needed differs between different age groups and between males and
females
Health concerns- Diets which exclude many foods due to a person‘s health concerns or for
medical reasons need to be planned carefully.
Cultural or religious practices-Ethical and religious practices, such as avoiding meat, may limit
the range of foods people eat.
Cost- Cost of food is a particularly important factor for people with low incomes. Food prepared
food at home is often cheaper than eating out or buying take-away.
Food availability- Most foods are grown in a particular season of the year. These are called
‗seasonal foods‘. Buying foods when they are in season will often ensure the food price is lower.
Food preferences- Not everyone likes the same food, but some foods are particularly popular or
unpopular. The taste, texture or appearance of foods can affect people in different ways.
Social considerations- Human welfare and fair trading, where growers or producers in
developing countries are paid a good minimum price to cover their costs, can be a high concern
for some people
Environmental considerations- Scientific intervention in the food chain also causes concerns
for some people. Genetically modified (GM) ingredients changing a plant, animal or micro-
organism's genes or inserting one from another organism. These foods are labeled so people may
decide to choose non-genetically modified food products.
Advertising and other point of sale information- Advertisements encouraging people to
choose certain foods often appear on the television, internet, radio, posters, magazines and
newspaper. The point of purchase information and product placement are strategies often used to
provide information to consumers. This can assist people in making healthier choices.
Factors influencing nutrient availability
Nutrient bioavailability refers to the proportion of a nutrient that is absorbed from the diet and
used for normal body functions.
The bioavailability of macronutrients – carbohydrates, proteins, fats – is usually very high at
more than 90% of the amount ingested. On the other hand, micronutrients, i.e. vitamins and
minerals, and bioactive phytochemicals (e.g. flavonoids, carotenoids) can vary widely in the
extent they are absorbed and utilized. The following sections will illustrate the different stages at
which nutrient bioavailability can be influenced:
a) Effects of food matrix and chemical form of nutrients
The first step in making a nutrient bioavailable is to liberate it from the food matrix and turn it
into a chemical form that can bind to and enter the gut cells or pass between them. Collectively
this is referred to as bio accessibility. Nutrients are rendered bio accessible by the processes of
chewing (mastication) and initial enzymatic digestion of the food in the mouth, mixing with acid
and further enzymes in the gastric juice upon swallowing, and finally release into the small
intestine, the major site of nutrient absorption. Here, yet more enzymes, supplied by the
pancreatic juice, continue breaking down the food matrix.
b) Enhancers of nutrient bioavailability
Nutrients can interact with one another or with other dietary components at the site of absorption,
resulting in either a change in bioavailability or if enhancers and inhibitors cancel each other out.
Enhancers can act in different ways such as keeping a nutrient soluble or protecting it from
interaction with inhibitors.
c) Impact of inhibitors on nutrient bioavailability
Inhibitors may reduce nutrient bioavailability by: binding the nutrient in question in a form that
is not recognized by the uptake systems on the surface of intestinal cells, rendering the nutrient
insoluble and thus unavailable absorption or competition for the same uptake system. Phytic acid
is highly abundant in certain plant food.
d) Host factors
Internal or host-related factors can be subdivided into gastrointestinal and systemic factors. The
role of gastrointestinal factors is illustrated by the absorptive pathway of vitamin B12. This
vitamin requires gastric acid to be released from the food matrix and then it undergoes a
sequence of binding to R protein, release from R protein, binding to the protein ―intrinsic
factor‖ (IF) and finally absorption of the intact IF-vitamin B12 complex in the lower intestine.
e) Impact on nutrient recommendations
For several nutrients – primarily calcium, magnesium, iron, zinc, folate and vitamin A –
knowledge of their bioavailability is needed to translate physiological requirements into actual
dietary requirements.
Factors affecting nutrient utilization.
Utilization is the ability of the body to make maximum use of the nutrients/food consumed. A
number of factors influence utilization of nutrients and it includes:
An adult with moderate activity needs around 2400 Kcal/day. The intake should also be in
adequate proportions (balanced diet).
-Diabetes and other co-morbid conditions: When food utilization consumed by the body is
hampered, nutritional status is also hampered. When glucose utilization is disturbed, other
biochemical processes (lipid and protein metabolism) in the body go berserk, usually
accompanied by loss of weight. In addition, diet restrictions also lead to deficiency of vital
minerals and vitamins in people suffering from diabetes.
Chronic and acute infections can lead to weight loss. This can occur in three ways. One is loss of
appetite, and the second is breakdown. The third is cytokine mediated weight loss, which occurs
only in people suffering from chronic infections.
Emotional factors like mood and taste can also affect appetite and food intake. Depression can
cause a person to go into starving unknowingly and hence become underweight. Sometimes,
depressed people also tend to overeat, leading to obesity.
Cultural factors like festivals and religious customs that require consumption of certain foods on
certain days and certain times can also influence nutritional status. Sometimes these are
beneficial, but most times it either leads to unhealthy starving or unhealthy eating.
Economic factors are very important elements that affect nutritional status of a population.
Poorer communities are either unable to afford healthy food, or in some situations are not able to
afford food at all. On the other hand, affluent communities, while able to afford healthy food, at
times succumb to temptations of consuming unhealthy food, which again leads to nutritional
imbalance.
 Sickness
Nutrients can be lost because of illness. The illness may inhibit the absorption/drain the nutrients
away through diarrhea and vomiting.
 Bioavailability
Bioavailability indicates the amount of a nutrient that is absorbed in the intestine from the diet
and is available to the body for its biological functions. The amount of a nutrient that is
consumed is not fully absorbed and available for its metabolic function in the body.
Bioavailability of a nutrient is governed by external and internal factors. Some nutrients enhance
nutrient absorption while others hinder the absorption. The absorption rate of some nutrients can
be enhanced when paired with other nutrients.
For instance, iron that is found in plant source is less bioavailable than iron found in animal
sources. To enhance the absorption of iron, consume vitamin C alongside a serving of iron
sources especially from vegetarian sources.
Vitamin C is a strong enhancer of iron absorption. This means having a glass of orange juice
with a bowl of breakfast cereal helps the body use more of the iron in the cereal.
Inhibitors reduces nutrient bioavailability in three ways:
a. Binding the nutrient in question in form that is not recognized by the uptake systems on the
surfaces of the intestinal cells

b. Rendering the nutrient insoluble and thus unavailable for absorption

c. Competing for the same uptake system e.g. interaction between calcium and non-haem iron.

d. Both minerals bind to a transporter on the surface of intestinal absorptive cells

 Use of medication
Nutrient needs may be altered because of long-term medication use for instance use of drugs
such as anticonvulsants and /phenobarbital for epilepsy, antacids, anti-inflammatory drugs, and
laxatives can interfere with calcium and vitamin D absorption, which negatively influences bone
metabolism
Alcohol affects the absorption of nutrients in a number of ways:
a) It acts as a diuretic, which promotes excretion of stored minerals like calcium, zinc and
magnesium

b) Impairs nutrient absorption by damaging the cells lining the stomach and intestine and
disabling the transport of some nutrients into the blood.

 Biological value
Is a measure of the proportion of absorbed protein from a food which becomes incorporated into
the proteins of the organism‘s body. It captures how readily the digested protein can be used in
protein synthesis in the cells of an organism. When a protein contains the essential amino acids
in a proportion similar to that required by the body, it has high biological value. When one or
more essential amino acids are missing or present in low numbers, the protein has low biological
value. Proteins from animal sources generally are of high biological value while those from plant
sources are of low biological value.
UNIT 8: PRINCIPLES OF DIET PLANNING
Unit Objectives
At the end of this unit, the learner should be able to:
1. Explain the principles of diet planning
2. Understand the diet planning tools
8.1 Principles of diet planning
i. Adequacy in all nutrients
An adequate diet provides the human body with energy and nutrients for optimal growth,
maintenance and repair of tissue, cells and organs. Water, carbohydrates, fats, proteins, vitamins
and some minerals comprise the six nutrient classes relied upon for performance of essential
functions and activities. These nutrients must be replaced through diet to keep the body working
efficiently. An adequate diet includes foods containing proper amounts of these nutrients to
prevent deficiencies, anemia, headaches, fatigue and general weakness
ii. Balance of foods and nutrients in the diet

This means not over consuming any one food. The art of balance involves the use of enough but
not too much or too little of each type of the seven food groups for example use some meat or
meat alternatives for iron, use some milk or milk products for calcium and save some space for
other foods. The concept of balance encompasses proportionality both between and among the
groups.
A balanced diet includes foods containing sufficient amounts of each class of nutrients. For
example, while milk is a good source of calcium and fish provides necessary iron and protein,
the two are not enough alone. Other essential vitamins, carbohydrates and fats are found in
whole grains, vegetables and fruits. The U.S. Department of Agriculture provides a great
blueprint for a balanced diet with its five food groups -- grains, proteins, vegetables, fruit and
dairy. Consuming the proper amount of servings from each category ensures a well-proportioned
diet.
iii. Nutrient density

This is the relative ratio obtained by dividing a food's contribution to the needs for a nutrient by
its contribution to calorie needs. This is assessed by comparing the vitamin and mineral content
of a food with the amount of calories it provides. A food is nutrient dense if it provides a large
amount of nutrient for a relatively small amount of calories.
iv. Energy density

This is the amount of energy in kilocalories in a food compared with its weight. Examples of
energy dense foods are nuts, cookies, and fried foods. Low energy density foods include fruits,
vegetables and any food that incorporates a lot of water during cooking. They contribute to
satiety without giving many calories.

(Nutritional) Density
Eating well without overeating is often challenging. You must select foods that pack the most
nutrients into the least amount of calories. For example, 1 ounce of cheese and 1 cup of fat-free
milk contain the same amount of calcium. While both foods are adequate sources of calcium, the
milk is more calcium-dense than the cheese because you get the same amount of calcium with
one-half the calories and no fat. In another example, calorie allowance is not a useful tool by
number alone. Although a bowl of grapes and a can of soda contain roughly the same number of
calories, the grapes contain far more nutrients than the cola. Designing a nutritionally sound diet
requires proper "budgeting" of calories and nutrients so that you eat less while supporting good
v. Moderation in the diet
Socrates once said "Everything in moderation; nothing in excess." Though over 2,500 years old,
this adage still holds true. Those who place severe restrictions on what they can or cannot eat
often find it difficult to stick to a pattern of sensible eating. Depriving yourself of foods rich in
fat and sugar is not necessary. When eaten on occasion, these treats are not detrimental to your
health and often provide enough enjoyment to keep one motivated to continue healthy eating
This mainly refers to portion size. This requires planning the entire day‘s diet so as not to
under/over consume any one food. In planning the diets, the goal should be to moderate rather
than eliminate intake of some foods.
Moderation
Socrates once said "Everything in moderation; nothing in excess." Though over 2,500 years old,
this adage still holds true. Those who place severe restrictions on what they can or cannot eat
often find it difficult to stick to a pattern of sensible eating. Depriving yourself of foods rich in
fat and sugar is not necessary. When eaten on occasion, these treats are not detrimental to your
health and often provide enough enjoyment to keep one motivated to continue healthy eating
Calorie Control
Once you know what to eat, the next factor is how much. It is possible to eat healthy foods and
still overindulge. Therefore, a reasonable calorie allowance must be established. The amount of
energy the body receives from incoming food needs to match the amount of energy needed for
the body to sustain its biological and physiological activities. In other words, input needs to
match output. An imbalance leads to weight loss or gain.

vi. Variety in food choice

This means choosing a number of different foods within any given food group rather than eating
the same food daily. People should vary their choices of food within each class of food from day
to day. This makes meals more interesting, helps to ensure a diet contains sufficient nutrients as
different foods in the same group contain different arrays of nutrients and gives one the
advantage of added bonus in fruits and vegetables as each contain different phytochemicals
8.1.1 Factors considered in diet planning
a) Target Groups: Energy requirements of people vary depending on sex, age and activity level.
b) Occupation: Occupational activity of an adult affects energy and nutrient requirements and
this should be noted when planning meals.
c) Health Concerns and Special Dietary Needs: Some people have special dietary needs and
precautions that need to be taken in meal planning regarding the types of food to be taken or
avoided.
d) Climate factors
8.2 Diet planning tools.
To achieve the dietary ideals outlined above, there are several tools used for diet planning. Some
of the commonly used tools are:
 Dietary Reference Intakes (DRI)
 Recommended Dietary Allowances (RDA)
 Daily Food Guide
 Food Guide Pyramid
 Exchange Lists

8.2.1 Dietary Reference Intake

This is a set of four separate reference values used to plan and evaluate diets. These includes the
updated Recommended Dietary Allowance (RDAs), Estimated Average Requirement (EAR),
Adequate Intake (AI) and the Tolerable Upper and Lower Intake Level. Each of these reference
values has a specific purpose and represents a different level of intake. They are used to plan
menus for specific populations in different settings such as hospitals, nursing homes, feeding
programs, school etc. DRIs are not suitable for teaching people how to make healthy food
choices. This is because people eat food and not nutrients and therefore the nutrition education
and even counselling should be in terms of food.
Recommended Dietary Allowances (RDA)-This refers to the average daily dietary intake
levels sufficient to meet the nutrient requirement of 97-98% of healthy individuals in a particular
life stage and gender group.
Following will be a discussion of the specific aspects of RDA:
Energy RDA Each individuals food energy intake must equal the energy expended, in order for
the person to maintain their body weight. The average energy consumption is aimed at setting a
standard for people to work from and it gives an example of how many calories are reasonable
for this group. An output side of the energy balance equation, how much energy people should
expend, has not been established.
Protein RDA Protein recommendations are mainly based on the individuals body weight. The
protein RDA is high, to cover most person’s needs. The average requirement for protein is 0.6
grams per kilogram of body weight; the RDA is 0.8 grams this is said to meet 97.5% of the
population’s needs.
RDA for Carbohydrate and Fat The amount of protein recommended represents a small
percentage of a person’s energy allowance; with the remainder acquired from carbohydrates and
fats. The general guideline for carbohydrate and fat is that more than half of daily energy should
come from carbohydrates, with no more than one-third from fat.
Water Recommendation The larger and more active a person the greater the need for water.
Most
people need a least 6 to 8 eight-ounce glasses of liquids a day. This is truly an area neglected by
most individuals.
Fiber recommendation There is no recommendation for fiber, however it is recommended that
sufficient fiber be obtained from fruits, vegetables, legumes, and whole-grain products, which
also provide vitamins, minerals and water.
The RDA for vitamins and minerals
The recommendations for vitamins and minerals are specific, as they have been studied for
decades.
Predicting a minimal requirement These recommendations have been set on the basis of studies
taken from healthy people involving the various states of depletion of their nutrient stores. From
these studies an average is determined as to the body’s need for each nutrient, which is seen as
an
amount sufficient to maintain body processes. Neglecting these intakes can lead to deficiency
symptoms.
Establishing a Generous Recommendation The average requirement for each nutrient is
probably
closest to most people’s need, however if all persons were to stick to the average we
would probably have a situation where half the population would develop deficiencies of some
sort. A person should not have an intake more than the average recommended as this may lead to
a situation; if going above ‘upper safe’ level, where some nutrients can be toxic. Individuality is
the key, however the tables are suffice for providing an example as to what the average nutrient
intake should be, especially relating in terms of “safe and adequate” ranges, “safe” meaning “not
too high” and “adequate” meaning “not too low“.
Upper safe: the amount that appears safe for most healthy people and beyond which people may
experience toxicity symptoms
It must be noted that it is recommended, to the more ‘diligent’, individuals that they seek advice
regarding there own individual needs relating to their own individual height, weight and their
daily amount of energy expenditure (energy expenditure relating to daily training).
Estimated Average Requirement (EAR) is the nutrient intake estimated to meet the
requirement of half of the healthy individuals in a particular life stage and gender group.
Adequate Intake (AI) is the level thought to meet or exceed the requirements of almost all
members of a life stage/gender group. An AI is set when there are insufficient data to define an
RDA.
a value based on observed or experimentally determined
approximations of nutrient intake by a group (or groups) of healthy people—used when
an RDA cannot be determined
Tolerable Upper Intake Level is the highest average daily intake level of a nutrient likely to
pose no danger to most individuals in the group. the highest level of daily nutrient intake that is
likely
to pose no risk of adverse health effects to almost all individuals in the general
population. As intake increases above the UL, the risk of adverse effects increases

8.2.2 The food guide pyramid

The food pyramid translates the food guide into a graphic image. The broad base of the pyramid
displays water followed by cereals; rice, pasta, bread and other foods made from grains. It also
includes the roots and tubers. Fruits and vegetables make the next layer. Dairy products such as
milk and yoghurt are included in the same tier as meats, poultry, eggs beans and nuts. The foods
at the top of the pyramid which include fats, oils, sugars and sweets are to be consumed
sparingly.
8.2.2 Exchange lists
A food exchange list is a simple grouping of common foods according to generally equivalent
nutritional values. This system is used for any situation requiring caloric and food value control.
All the foods listed together are approximately equal in proteins, carbohydrates and fat value.
Exchange lists provide additional help in achieving kilocalorie control and moderation.
Originally developed for people with diabetes, exchange systems have proved so useful that they
are now in general use for diet planning.
Any food on a list can be exchanged or traded for any other food on that same list without
affecting a plan‘s balance or total kilocalories. The system organizes food into seven exchange
lists: starch, milk , meat ,vegetables, sugar, fruits and fats .
The number of kilocalories associated with each food is an average for the group. The number of
kilocalories is calculated given the number of grams of carbohydrates, fats and proteins in a food
(1g of carbohydrate/ protein yields 4 kcal; 1g of fat yields 9 kcal). To apply the system
successfully, users must become familiar with portion sizes. The table below shows exchanges
for carbohydrates, proteins, fat and energy values that pertain to each list .
List Portion Amount CHO Protein Fats Kcal/
size per (ml or g) serving
serving
Starch 30 g -Trace 80
 1/3 cup  15 2
arrowroots  15 2
 1/3 cup  15 2
ugali  15 2
 1 slice  15 2
bread  15 7
 1/3 cup  15 2
cassava  15 2
 ½ cup  15 2
cooked  15 2
bananas  15 2
 ½ cup  15 2
dried
cooked
beans
 ½ cup
cooked
 rice
 ½ cup
cooked
pasta
 ½ cup
sweet
potatoes
 ½ cup
porridge
 ½ cup
Irish
potatoes
½
chapatti

Milk Trace
 Nonfat  ½ cup  250 ml  12 8 5  90
 Low fat fresh milk  250 ml  12 8 8  120
 Whole  ¼ cup  250 ml  12 8  150
ice cream 

75 ml or
one scoop
 1 cup
yoghurt

Meat -
 Lean  Size of  30 g 7 3  55
 Medium matchbox  30 g 7 5  75
fat meat  30 g 7 8  100
 High fat  Palm  30 g 7 3  75
 Egg size of fish
 A leg,
thigh or
breast
chicken
 2 tbsp
peanut
 ½ cup
fresh bean
 ½ cup
omena

Vegetables 100-150 g 5 2 - 25
 ½ cup
cooked
vegetable
 1 cup
raw
vegetable

Fruits Varies 15 - - 60
 1 small
apple,
peach,
orange,
apple or
grape fruit
juice (pure
juice)
 ¾ cup
diced fruits
Fats - - 5 45
 1 tsp
margarine or
oil
 10 large
peanuts
 1/8
medium
avocado
 1 slice
bacon
 1 tbsp
shredded
coconut
 1 tbsp
cream cheese
 1 tbsp
salad
dressing
 5 large
olives

Sugar 1 tsp 5 20
v

UNIT 9: NUTRITION IN DISEASE MANAGEMENT

Unit Objectives
At the end of this unit, the learner should be able to:
1. Understand nutrition disease management and the nutritional requirements in different disease
conditions
9.1 Disease management using nutrition and Nutrient requirements for various disease
conditions
The objectives of nutrition management depend on the disease but include:
 Maintain adequate nutrition

 Restore positive nitrogen balance

 Provide relief from symptoms.

 Correct and maintain water and electrolyte balance.

 To restore nutritional status.

 To relieve pain and enhance healing.

i) Diabetes Mellitus.
Aim -To control blood sugar and prevent development of disease complications
The components of management are:-
 Medical therapy.

 Medical nutrition therapy.

 Exercise and physical activity

Objectives of nutrition therapy are:

 Attain and maintain blood glucose levels as close to normal as possible.

 Prevent hypo and hyperglycemia.

 Attain optimum blood lipids and blood pressure control and reduce the risk of macro vascular
disease.

 Assess energy intake to achieve optimum body weight.

 Promote physical, social and psychological well-being.

 Prevent, delay or minimize the onset of chronic degenerative complications e.g. Hypertension
and renal disease.

 Achieve and maintain optimal metabolic and physiological outcomes.

 Provides relief from symptoms.

 Individualize meal plan according to a person`s lifestyle and based on usual dietary intake.

ii) Gout
Aim of nutrition management
Prevent excessive accumulation of uric acid.
Nutritional Management
 Use of low purine diet by restricting consumption of red meat, fish, alcohol, stimulations and
high protein foods to avoid exogenous addition of purines to the existing high uric acid load is
recommended

 Encourage consumption of alkalizing foods e.g. lemon tomatoes grains, beans, fruit milk and
milk products

 Intake of fluids to enhance excretion of uric acids based on assessment is recommended

 Moderate protein intake (0.8g/kg/day)

 Maintain adequate carbohydrate intake to prevent ketosis

 Limit fat intake

 Avoid large and heavy meals late in the evening

 Encourage consumption of whole grains

iii) Cognitive Heart Failure

Aim of management
 To reduce the work load of the heart

 To provide adequate nutrients

 To reduce weight for the overweight

Nutritional management
 Restrict sodium caffeine, and fat intake

 Encourage gradual weight loss where necessary

 Use of liquid formula of high nutrients density as a oral supplement or enteral/ tube feeding to
prevent or reverse malnutrition

 Adjust dietary fiber to avoid constipation but avoid amount and types that produce gas and
abdominal digestion

 Counsel overweight patients on weight reduction

 Restrict cholesterol intake to 300mg/day

 Reduce intake of saturated fats

 Increase intake of dietary fibre to control glucose/ fats absorption

 Reduce alcohol intake and encourage patient to avoid smoking

iv) Hypertension
The aims of nutrition management include:
 To control blood pressure within normal ranges

 To achieve gradual weight loss in overweight and obese individual

 To reduce sodium intake based on severity

 To maintain adequate nutrition Regulate fat intake

Nutritional management
 Provide low caloric diet if patients is overweight until ideal weight is achieved

 Regulate fat intake –encourage intake of unsaturated fats(oil)

 Restrict sodium intake

 Avoid stimulant e.g. caffeine and spirits

 Avoid cigarettes smoking which may lead to atherosclerosis

 In some case it may be necessary to restrict fluid intake

 Encourage physical activity for those living a sedentary lifestyle Diseases Caused By
Nutritional Deficiencies:
1. Rickets:
Deficiency of Vitamin D along with calcium and potassium in the body causes rickets. Rickets is
characterized by weak and soft bones, bowed legs and bone deformities. Fish, fortified dairy
products, liver, oil and sunlight are some rich sources of Vitamin D. One may need to resort to
dietary supplements for making up for the lack of the “sunshine vitamin” in the body.
2. Pellagra:
Dementia, diarrhea, dermatitis and death are “the four Ds” that characterize Pellagra, a disease
caused by the lack of Niacin or B3 in the body. The deficiency of niacin is also accompanied by
a short supply of the amino acids, tryptophan and lysine or the excessive presence of lysine in the
body. Foods enriched with niacin are tuna, whole grains, peanuts, mushrooms, chicken etc.
These
should be consumed regularly to ward off this disease.
3. Scurvy:
Alarmingly reduced levels of Vitamin C or ascorbic acid in the body can cause scurvy. Scurvy
basically inhibits the production of collagen in the body which is the structural protein that
connects the tissues. Decaying of the skin and gums, abnormal formation of teeth and bones,
delay or inability to heal wounds and bleeding are the effects of scurvy on the body. One must
ensure optimal consumption of Vitamin C by having citrus fruits like oranges, lemon, strawberry
Etc. and broccoli regularly.

4. Beri Beri:
Lack of Vitamin B1 or thiamine in the body leads to the disease called beri beri. The most
common symptoms of this illness are altered muscle coordination, nerve degeneration and
cardiovascular problems. Meat, eggs, whole grains, dried beans etc are rich in thiamine and thus,
should be consumed in proper amounts everyday to avoid this painful ailment.
5. Xerophthalmia or Night Blindness:
Xerophthalmia or night blindness is characterized by blindness due to the poor growth, dryness
and keratinisation of epithelial tissue or chronic eye infection. The cause of this disease is
attributed to the deficiency of Vitamin A in the body. In worsened situations, night blindness can
aggravate to complete loss of vision. The safest way to enhance the Vitamin A levels in the body
is by consuming natural food sources like carrots, green and leafy vegetables, cantaloupes etc.
6. Goitre:
Iodine in the body is essential for normal cell metabolism in the body and deficiency of iodine
may cause goitre. Goitre leads to enlarged thyroid glands causing hypothyroidism, poor growth
and development of infants in childhood, cretinism and even mental retardation. This disease is
commonly found to occur in places having iodine deficit soil. Iodised salt and saltwater fish are
rich sources of iodine, and must be consumed regularly to avoid goitre.
7. Iron Deficiency Anaemia:
Iron deficiency anaemia is a disease caused by the deficiency of iron in the body. It is
characterized by a decrease in the red blood cell count or hemoglobin in the body, resulting in
fatigue, weakness, dyspnoea and paleness of the body. It can be easily treated by changing to a
healthy diet and consuming iron supplements on a regular basis. Squashes, nuts, tofu, bran etc
are rich sources of iron for the body.
8. Kwashiorkor:
Kwashiorkor is a deficiency disease caused by lack of protein and energy in the body. It is
characterized by anorexia, an enlarged liver, irritability and ulcerating dermatoses. These are the
one of the nutritional deficiencies in children, especially from famine-struck areas and places
with poor food supply, Kwashiokor is caused by malnutrition. A healthy and balanced diet
enriched with protein and carbohydrate sources like eggs, lentils, rice etc helps combat this
problem.

9. Depression:
Problems of depression, hair loss, rashes and mental issues are caused by the deficiency of
Vitamin B7 or biotin. This deficiency can be fatal if present in an aggravated form. Consume
poultry products, dairy items, peanuts, nuts etc that are rich sources of biotin. These must be
consumed along with supplements to recover and prevent these illnesses.
10. Osteoporosis:
Deficiency of Vitamin D and calcium in the body can negatively affect the health of the bones
and spine. It leads to unhealthy, soft and brittle bones that are prone to fractures and defects in
the spine structure. Bananas, spinach, milk, okra, soy and sunlight are natural sources of Vitamin
D and calcium that act to eliminate this deficiency.