Hospital Diets

For example, postoperative patients need 1–1.5 g/kg/day. Sepsis increases protein needs to 1.2–1.5 g/kg/day...
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

INTRODUCTION ― Therapeutic diet refers to dietary changes that play a role in the management of a medical condition (see Table 1). These dietary modifications, which usually require a certified nutritionist's order, typically call for a change in the consistency of the food served or an adjustment in the quantity of one or more nutrients in the diet. Most hospitals have diet manuals available for reference, and registered dietitians are usually on staff for consultation in clinical situations that necessitate a therapeutic diet.

Table (1). Hospital Diets
Diet Guidelines Indications
House/regular Adequate in all essential nutrients
    • All foods are permitted
    • Can be modified according to patient’s food preferences
 No diet restrictions or modifications
Mechanical soft Includes soft-textured or ground foods that are easily masticated and swallowed Decreased ability to chew or swallow
    • Presence of oral mucositis or esophagitis
    • May be appropriate for some patients with dysphagia
Pureed Includes liquids as well as strained and pureed foods Inability to chew or swallow solid foods
Presence of oral mucositis or esophagitis
May be appropriate for some patients with dysphagia
Full liquid Includes foods that are liquid at body temperature
    • Includes milk/milk products
    • Can provide approximately:
        • 2500–3000 mL fluid
        • 1500–2000 cal
        • 60–80 g high quality protein
        • < 10 g dietary fiber
        • 60–80 g fat/d
 May be appropriate for patients with severely limited chewing ability
Not appropriate for lactase-deficient patients unless commercially available lactase enzyme tablets provided
Clear liquid Includes foods that are liquid at body temperature
Foods are
    • Very low in fiber
    • Lactose-free
    • Virtually fat-free
    • Can provide approximately:
        • 2000 mL fluid
        • 400–600 cal
        • < 7 g low-quality protein
        • 1 g dietary fiber
        • < 1 g fat/d
    • This diet is inadequate in all nutrients and should not be used >3 d without supplementation
 Ordered as initial diet in the transition from NPO to solids
Used for bowel preparation before certain medical or surgical procedures
For management of acute medical conditions warranting minimized biliary contraction or pancreatic exocrine secretion
Low-fiber Foods that are low in indigestible carbohydrates
    • Decreases stool volume, transit time, and frequency
 Management of acute radiation enteritis and inflammatory bowel disease when narrowing or stenosis of the intestinal lumen is present
Carbohydrate controlled diet (ADA) Calorie level should be adequate to maintain or achieve desirable body weight (DBW)
    • Total carbohydrates are limited to 50–60% of total calories
    • Ideally fat should be limited to ≈30% of total calories
 Diabetes mellitus
Acute renal failure Protein (g/kg DBW) 0.6 For patients in renal failure who are not undergoing dialysis
Calories 35–50
Sodium (g/d) 1–3
Potassium (g/d) Variable
Fluid (mL/d) Urine output + 500
Renal failure
Hemodialysis Protein (g/kg DBW) 1.0–1.2 For patients in renal failure on hemodialysis
Calories (per kilogram DBW) 30–35
Sodium (g/d) 1–2
Potassium (g/d) 1.5–3
Fluid (mL/d) Urine output + 500
Peritoneal dialysis Protein (g/kg DBW) 1.2–1.6 For patients in renal failure on peritoneal dialysis
Calories (per kilogram DBW) 25–35
Sodium (g/d) 3–4
Potassium (g/d) 3–4
Fluid (mL/d) Urine output + 500
Hepatic
  • In the absence of encephalopathy do not restrict protein
  • In the presence of encephalopathy initially restrict protein to 40–60 g/d then liberalize in increments of 10 g/d as tolerated
  • Specify sodium and fluid restriction according to severity of ascites and edema
 Management of chronic liver disorders
Low lactose/lactose-free Limits or restricts milk products
Commercially available lactase enzyme tablets can be used		 Lactase deficiency
Low-fat < 50 g total fat per day Pancreatitis
Fat malabsorption
Fat/cholesterol restricted Total fat > 30% total calories
    • Saturated fat limited to 10% of calories
    • < 300 mg cholesterol
    • < 50% calories from complex carbohydrates
 Hypercholesterolemia
Low-sodium
  • Sodium allowance should be as liberal as possible to maximize nutritional intake yet control symptoms
  • “No added salt” is 4 g/d; no added salt or highly salted food; 2 g/d avoids processed foods (ie, meats)
  • < 1 g/d is unpalatable and thus compromises adequate intake
 Indicated for patients with hypertension, ascites, and edema associated with the underlying disease

ENERGY AND PROTEIN REQUIREMENTD

CALORIC EXPENDITURE ― For adults in most clinical settings, a range of 25–30 kcal/kg of body weight is a reasonable estimate of daily energy expenditure.

          Concerns about overfeeding and unfavorable outcome have eliminated the once common practice of providing as much as 35–40 kcal/kg/day to critically ill patients. The weight-based system has a wide margin of error for obese patients. When a patient’s BMI falls into an obese category, many clinicians use adjusted body weight (ABW) to determine energy needs. The formula for ABW takes into account that not all of a person’s excess weight is adipose tissue but that a portion is metabolically active, lean body mass...

  • AdjIBW = IBW + [0.25 × (actual weight - IBW)].

    Ideal body weight is computed in MEN as 50 + [0.91 × (height in centimeters − 152.4)] and in WOMEN as 45.5 + [0.91 × (height in centimeters − 152.4)].

Consensus does not exist regarding the optimal level of energy intake for obese patients. Studies in which patients received as little as 50% of estimated energy expenditure or 20 kcal/kg of ABW have shown positive outcomes. Further research is needed, however, for accurate prediction of optimal levels of energy intake for obese patients. Infants and growing children need much higher energy intake per kilogram of body weight than adults. Infants may need as much as 110 kcal/kg/day. Energy intake remains elevated to support growth through the teenage years, but wide variation occurs. Satisfactory growth is the best indication that a child’s energy intake is adequate.

PROTEIN REQUIREMENTS ― Healthy persons with normal renal function need 0.8 g of protein per kilogram of body weight per day, but illness and injury can dramatically increase protein needs. For example, postoperative patients need 1–1.5 g/kg/day. Sepsis increases protein needs to 1.2–1.5 g/kg/day. Daily protein intake for patients with multiple trauma should fall within 1.3–1.7 g/kg, and burn victims may need 1.8–2.5 g/kg/day. With the exception of patients with burn injuries, guidelines set the upper limit for protein intake at 2 g/kg/day. Research suggests that doses of protein above this level exceed the patient’s utilization capacity and can lead to azotemia. As with energy intake, protein intake for obese patients should be based on ABW.

          Protein needs for children vary with age. The requirement is greatest in the first year of life and then gradually declines. Healthy infants need 2–3 g/kg/day, and children up to age 10 need 1.0–1.2 g/kg/day. The protein requirement of critically ill children is approximately 1.5 g/kg/day.

MODIFYING CONSISTENCY OF FOOD

Changing the consistency or texture of the diet is a simple way to make food easier to chew, swallow, and digest. For instance, patients with poor dentition may benefit from a pureed diet. Another use of this type of therapeutic diet is the postoperative diet progression that begins with clear liquids and advances to regular food as tolerated. Although doubt exists concerning the need to step through slow diet advancement postoperatively, the practice remains common after some types of surgery. Patients who have undergone elective colonic resection, for example, can usually receive a regular diet after they tolerate one meal of clear liquids, whereas those who have undergone surgery involving the esophagus, stomach, or small intestine may benefit from a more conservative approach.

          Patients with dysphagia frequently need a change in texture or consistency of food to enhance the safety of eating. An evaluation of swallowing function by a speech–language pathologist is essential in determining the appropriate diet for patients with impaired swallowing. Dysphagia occurs most often as a result of neurologic conditions, but many medical and surgical problems can compromise swallowing. A swallowing evaluation is warranted before the start of oral intake in any situation that increases the risk of dysphagia, including cognitive or functional decline, surgery or radiation of structures involved in swallowing, prolonged intubation, and recent tracheostomy.

MODIFYING NUTRIENT CONTENT OF THE DIET

Because illness frequently alters nutrient requirements or nutrient tolerance, diet modification is a common therapeutic intervention in the management of many chronic diseases. In some cases, the therapeutic diet may simply limit a single nutrient, such as sodium. At other times diet prescription may require broad changes in eating habits. The dietary changes recommended for prevention and treatment of cardiovascular disease fall into the latter category. Any diet that restricts one or more nutrients poses nutritional risks. One concern is that in adhering to a dietary restriction, patients may unintentionally omit other essential nutrients. In addition, patients frequently find restrictive diets unpalatable, a problem that leads to poor intake or noncompliance. A patient with a prescription for a therapeutic or modified diet need instruction by a clinical dietitian before discharge or as an outpatient.

ORAL NUTRITIONAL SUPPLEMENTS

For patients unable to tolerate sufficient food to maintain adequate nutritional status, oral nutritional supplements can halt or reverse nutritional decline and improve clinical outcome. For elderly patients, for example, the use of oral supplements improves nutritional status and reduces mortality. The nutritional products, which are available without a prescription, come in a variety of forms, including high-protein, high-calorie beverages, puddings, snack bars, and soups. Ensure (Abbott), Neo-Mune (Otsuka), Boost (Nestile health science), Supportan (Fresenius Kabi) are common examples of liquid oral supplements. These products are flavored for oral consumption, but they are also appropriate for administration through a feeding tube. Depending on the circumstances, patients can consume these products in addition to regular meals or as a meal replacement. Most oral supplements on the market are lactose-free, an important consideration for persons who cannot tolerate milk-based supplements. Unlike most snack foods, commercially prepared oral supplements provide a balanced mix of nutrients, including vitamins and minerals. Encourage patients to try a variety of supplements to avoid taste fatigue, a common problem among patients who consume only one supplement over an extended period. Adding flavoring such as chocolate or coffee syrup to oral supplements can improve palatability. Sustained success with oral supplements frequently requires the creative support of the entire health care team.

REFERENCES