1. THERAPEUTIC MODIFICATION OF THE NORMAL DIET
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2. CONTENTS THERAPEUTIC DIET DIET THERAPY OBJECTIVES OF DIET THERAPY
CLASSIFICATION OF MODIFIED DIETS
NORMAL DIET
LIQUID DIET
SOFT DIET
BLAND DIET
MODIFICATION IN NUTRITIVE VALUE
MODIFICATION IN QUANTITY
MODIFICATION IN METHOD OF FEEDING

3. 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.

4. 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.

5. 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.

6. CLASSIFICATION OF MODIFIED DIETS
CONSISTENCY
1. Clear liquid
2. Full liquid
3. Soft
4. Mechanical soft diet
5.Light diet
6. Pureed diet
7.Bland diet
NUTRIENT CONTENT
1. High fiber
2. Low protein
3. Na restricted
4. Low fat
5. Low fiber
QUANTITY
1. Obesity
2. Vomiting
3. Diarrhea
4. Diabetes
SPECIAL METHD OF FEEDING
1. Enteral
( tube feeding)
2. Parenteral
(intravenous fluid)

7. 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.

8. 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-
Clear fluid diet
Full fluid diet

9. CLEAR FLUID DIET- CONSIST OF ONLY CLEAR FLUIDS. FOODS INCLUDED:-
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 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

10. 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 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

11. SOFT DIET FOODS INCLUDED- Soft diet is nutritionally adequate diet.
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.
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 kcal, 55-65g protein.

12. 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.

13. BLAND DIET PRESCRIBED FOR-
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.
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.

14. 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.

15. DISEASES WITH NUTRIENT MODIFICATION
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

16. 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

17. 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.

18. DIETS FOR COMMON DISORDERS

19. Diet for Diabetes mellitus patients
Foods recommended
Foods to be avoided
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.

20. DIET IN FEVER & INFECTIONS

21. High Calorie , High Protein diet
FOOD 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 .

22. Risk Factors for Heart Disease
Personal 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
Age group yrs
Refined CHO and sugars
High blood lipid levels
Work load- Tension and stress
High salt intake
Sedentary life style

23. 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.

24. 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.

25. Sodium Restricted Diet
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.

26. 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

27. 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.

28. 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.

29. NUTRITION SUPPORT

30. 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

31. 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

32. 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.

33. 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 .

34. Conditions That Require Specialized Nutrition 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

35. 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.

36. 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.

37. 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

38. Indications for Enteral Nutrition
Gastrointestinal Disease
Short bowel syndrome
Inflammatory bowel disease
Diarrhea of infancy
Intestinal obstruction
Chronic liver disease
Severe dysphagia or esophageal obstruction,

39. Indications for Enteral Nutrition
Preterm infants
Neurologic
Static encephalopathy
Dysphagia
CNS tumor
Cardio-respiratory
Cystic fibrosis
Congenital heart disease

40. Indications for Enteral Nutrition
Malignancy
Poor intake: radiation / chemotherapy
Hyper-metabolic states
Burns
Trauma / head injury
Other
Anorexia nervosa
Chronic renal disease
Psychiactric disorders,

41. 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

42. Sites for Enteral feeding
J Daglish,L Herd Reviewed J Lanni Nov 2007

43. Route of Enteral Administration
Nasoenteric routes
Nasogastric
Nasodododenal
Nasojejunal
Tube enterostomy
(Percutaneous or surgically placed feeding tube)
PEG (percutaneous endoscopic gestrostomy)
PEJ (percutaneous endoscopic jejunostomy)

44. 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.

45. 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.

46. 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.

47. 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.

48. 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.

49. 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.

50. 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

51. 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.

52. 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.

53. 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.

54. 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.

55. Witzele jejunostomy

56. 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.

57. 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.

58. FORMULA SELECTION
The wide variety of enteral feeding products are commercially available.
The choices can be narrowed down by answering a few basic questions:-
Are the patient’ digestive & absorptive capabilities intact?
Does the patient have significant organ dysfunction?
Does the patient have high metabolic rate?
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

59. 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.

60. 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.

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

62. Modular feeding
Modules of individual macronutrient- can be added to food and enteral formulas

63. Categorization Type Indication Polymeric Normal GI function
Chemically defined Malabsorption
Modular Special requirements

64. 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.

65. Method of Administration
Tube feeding can be administered via-
Bolus method
Intermittent method
Continuous method

66. 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.

67. 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.

68. Intermittent method
Intermittent feeding are administered over a longer period of time , usually 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.

69. Continuous feeding
Controlled delivery of a prescribed volume of formula at constant rate over a continuous period of time.
Continuous feedings are delivered slowly over 12 to 24 hours.
Uses infusion pump
Fewer GI side effects
Transpyloric feedings require continuous infusion.
It is necessary when patient cannot tolerate bolus & intermittent feeding.

70. Enteral formulations Water & 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
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.

71. 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.

72. Osmolarity Osmolarity is the milliomoles per litre of solution.
General purpose formula- between mOsm/l Which is close to the osmolarity of blood & body fluid.
Concentrated formulas- are ranging from mOsm/l.
Chemically defined formula- 900 mOsm/l.

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

74. 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.

75. 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.

76. 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.

77. 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.

78. 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 g/1000 kcal for standard enteral formulas.

79. 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.

80. 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.

81. 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
0-150
3-8
0-211

82. 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.

83. 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.

84. 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.

85. 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.

86. 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.

87. ENTERAL EQUIPMENT Feeding tubes Enteral feeding containers
Enteral pumps

88. Enteral Feeding Tubes Polyvinylchloride (PVC) Silicone (Silastic)
Polyurethane

89. 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

90. ENTERAL PUMPS
ENTERAL CONTAINERS

91. Complications of Enteral Nutrition
Access Problems
Administration Problems
Metabolic
Gastrointestinal

92. 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.

93. 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.

94. Metobolic complications
Refeeding syndrome
Drug – nutrient interactions
Glucose intolerance / hypergycemia / hypoglycemia
Hydration status- dehydration/ overhydration
Hyponateremia
Hyperkalemia/ hypokalemia
Hyperphosphetemia/ hypophosphatemia.
Micronutient deficiency.

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

96. 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.

97. REFERENCES BOOKS- Contemporary nutrition support practice –
By Laura E matarese, Michele, M. Gottschlich.
Krause’s Food & Nutrition Therapy
12th edition
A Text book of Nutrition & Dietitics
By- Kumud Khanna
Food Science and Nutrition
Internet

98. Conclusions
Enteral feeding is the preferred form of nutritional support
Safe and efficacious
Well-tolerated
Safer, cheaper, simpler, and more effective than Parenteral Feeding