MODULE 1.

MNT TERMS AND BASIC COMPUTATIONS

Dietetics - The combined science and art of regulating the planning, preparing, and serving of
meals to individuals of groups under various conditions of health and disease according to the
principles of nutrition and management with due consideration to economic, social, cultural, and
psychological factors

Nutritionist Dietitian - A person professionally qualified to provide leadership and assume

responsibilities for the promotion of the nutritional well-being of individuals and groups within
the framework of community of life. These responsibilities include the preventive, therapeutic,
and food service administration.

Diet Therapy - Branch of dietetics that is concerned with the use of food for therapeutic
purposes. It is also the modification of the normal diet to meet the physiological requirements of
the sick individual.

Nutrition Therapy - This refers to interventions used in the treatment of a disorder or illness and
includes diet therapy, nutrition counseling and/or the use specialized nutrition therapies.

Clinical Nutrition - Branch of health science having to do with the diagnosis, treatment, and
prevention of human disease caused by deficiency, excess or metabolic imbalance of dietary
nutrients.

Health - A state of complete, physical, mental, and social well-being and not merely the absence
of disease and infirmity.

Illness - Deviation of bodily functions from the normal or usual well-feeling and its perception is
both physiological and psychological

Diet - An allowance of food and drink consumed regularly by an individual.

Dietary Requirement or Minimum Requirement – The minimum amount of a specific nutrient
needed by the body to attain a specific state of health or it refers to the least amount of ingested
nutrient that will prevent symptoms
and clinical signs of nutrient deficiency

Diet History - A record of the usual day-to-day food intake of an individual . It is part of the
nutritional history and can be taken by means of recall or food records.

Nutrition Assessment - It is a method of obtaining, verifying, and interpreting data needed to

identify nutrition related problems, their causes, and significance

Nutritional Status - The condition of the body resulting from the utilization of the essential
nutrients available to the body.

Review of Basic Computations

DBW of Infants
 First 6 months: DBW (grams) = birth weight (grams) + (age in months x 600)
 7-12 months: DBW (grams) = birth weight (grams) + (age in months x 500)
 0-12 months (General Formula): DBW (kg) = (No. of years ÷ 2) + 3

NOTE:
Infant’s weight:
 Doubles at 5 to 6 months
 Triples at 12 months
 Quadruples at 24 months

Infant’s height:
 Increases by 24, 12, and 8 cm during the first, second, and third year of life, respectively,
then by 4 cm every year thereafter up to the eighth year.

TER of Infants
 0-6 months: TER/day = 95 kcal/kg DBW
 7-12 months: TER/day = 80 kcal/kg DBW
DBW of Children
DBW (Kg) = (no. of years x 2) + 8

TER of Children
Children (1-12 yrs old): TER/day = 1000 + (100 x age in years)

DBW of Adolescents
Tannhauser Method
Hamwi Method
TER of Adolescents
2002 RENI
Age Range Kcal/KDBW
13-15 55 (Boys)
45 (Girls)
16-18 50 (boys)
40 (girls)
DBW of Adults
Tannhauser’s Method
DBW = (height in cm – 100) – [10% (height-100)]
Hamwi Formula
Women Men
100 lbs for the first 5 ft of height 106 lbs. for first 5 ft
+5 lbs for each additional inch +6 lbs for each inch
Adopted Method
DBW: 5ft = 105lbs
Add/Subtract 5lbs for every inch above/below 5ft
Ador Dionisio
DBW: 5ft = 110lbs (men)
DBW: 5ft = 100lbs (women)
Add 2lbs for every extra inch
Add 2 for every 5 year interval between 25-30 years
NDAP
DBW for men, 5 ft is 112 lbs.
DBW for women, 5 ft is 106 lbs.
Add/subtract 4lbs for every inch above/below 5 ft

TER for Adults

Method I (Krause)
TER = DBW (kg) x PA Factor
Physical Activity Factor
Bed Rest 27.5
Sedentary 30
Light 35
Moderate 40
Heavy 45

Method II (NDAP Formula)

TER = DBW (kg) x PA Factor
Activity Level Male Female
In bed but mobile 35 30
Light 40 35
Moderate 45 40
Heavy 50 -

Method III (Cooper et al)

BMR = 1 kcal/kg DBW/hr (male) TEF = 10% (BMR+PA)
BMR = 0.9 kcal/kg DBW/hr (female) TER = BMR + PA + TEF
PA (% above BMR)
Bed Rest 10
Sedentary 30
Light 50
Moderate 75
Heavy 100
Harris-Benedict Energy Expenditure
Determine REE
HBEE (males) = 66.47 + 13.75 (W) + 5.0 (H; cm) – 6.75 (A; y)
(females) = 655.1 + 9.56 (W) + 1.85 (H) – 4.67 (A)

Adjustment for activity = REE x activity factor

Type of Activity Factor Type of Activity Factor

Bed rest 1.0-1.1 Moderate 1.6-1.7
Very light 1.2-1.3 Heavy 1.9-2.1
Light 1.4-1.5 Strenuous 2.2-2.4

Provision for illness = BEE x stress or injury factor

Type of Stress/Injury Factor
No illness/no stress 1.0
Convalescence, mild malnutrition,
Post-operative (no complication),
Mild illness, noncatabolic 1.1
Confined to bed 1.2
Ambulatory/out of bed 1.3
Infection and stress, catabolic
Mild 1.1-1.2
Moderate 1.3-1.4
Severe, hypercatabolic 1.5-1.7
Sepsis 1.8-2.0
Burns, <20% body surface 1.2-1.4
20-40% body surface 1.5-1.7
>40% body surface 1.8-2.0
Fracture, long bone 1.2-1.3
Respiratory/renal failure 1.4-1.5
COPD 1.4-1.6
Cancer with chemotherapy or
Radiation, cardiac cachexia 1.5-1.6
Surgery, minor/elective 1.1-1.2
Surgery, major 1.2-1.3
Trauma, skeletal/blunt 1.3-1.4
Trauma, multiple/head injury 1.5-1.6
Mifflin St. Jeor
Men: (9.99 x actual weight) + (6.25 x H in cm) – (4.92 x A in years) + 5
Women: (9.99 x actual weight) + (6.25 x H in cm) – (4.92 x A in years) - 161

Oxford
18 - 30 years old
Men: (16.0 x weight in kg) + 545
Women: (13.1 x weight in kg) + 558

30 - 60 years old
Men: (14.2 x weight in kg) + 593
Women: (9.74 x weight in kg) + 694

60-69 years old

Men: (13.0 x weight in kg) + 567
Women: (10.2 x weight in kg) + 572

70+ years old

Men: (13.7 x weight in kg) + 481
Women: (10.0 x weight in kg) + 577

Pregnant Women: TER/day = normal adult requirement + 300 kcal

Lactating Women: TER/day = normal adult requirement + 500 kcal

Example of Activities
Sedentary – secretary, clerk, typist, administrator, cashier, bank teller
Light – teacher, nurse, student, lab technician, housewife with maids
Moderate – housewife without maids, vendor, mechanic, jeepney and car driver
Heavy – farmer, laborer, cargador, coal miner, fisherman, heavy equipment operator
Adjusted Body Weight
For weight (TER)
Underweight – use DBW
Normal – Actual
Overweight/Obese – Adjusted Body Weight
Adjusted Body Weight = (Actual Weight – DBW) x 0.25 + DBW

I. Distribution of TER
A. Method I (percentage)
1. CHO 50-70% or average of 60%
2. CHONs 10-20% or average of 15%
3. FATs
Normal adults, moderately active 20-30% or average of 25%
Children, adolescents, very active individuals 30-35%

B. Method II (NPC)
Determine the protein calories (PC) first according to the normal allowance in gm/kg
DBW and divide the non-protein calores (NPC) into
CHO : 55-80% or an average of 70%
FAT : 20-45% or an average of 30%

Normal protein allowance/day:

gm/KDBW
Infants 1.5
Children 2.0
Adolescents 1.3
Adults 1.1

DBW x CHON allowance = CHON g

CHON g x 4 = total CHON kcal
TER/day – total CHON = remaining kcal
CHO = remaining kcal x .70 / 4
FAT = remaining kcal x .30 / 9

ADDITIONAL INFO:
  General Formula is used for the unknown birth weight.
 Midpoint is 25 and 75 for rounding up and down
 Use whole number in kg for adults
 Use TER for Adolescent
 In a clinical setting, usually use 30 in NDAP formula for TER
 HBEE use DBW. HBEE is used for seniors and critical care. HBEE PA lower range is for females and upper
range is male.
 PA Light - Normal day to day activities
 PA Moderate - longer periods of time working out; heavy works
 Normal TER for Woman is 1600 (Light)
 Round off to the whole number each macronutrient.
 HF Meat should not be used in MNT; only in healthy individuals.
 CHO CHON FAT - only ± 5; KCAL - only ± 50
 No need for BMIs: Edema (fluid retention), Pregnant, and 1st 6 months of lactation
 2nd and 3rd trimester = +300kcal
 Lactating = +500
 Lactating mothers should not solve for BMI in the first 6 months. It is not appropriate to determine if they
are nutritionally at risk due to the additional weight from pregnancy.
 Nutrition inadequacy - compute the total 24hr recall divided by TER/day times 100 to get percentage (This
is also a way we can determine for our PES)
o More than 125% - excessive energy intake
o 75% - 125% adequate
o 74% or less is inadequate

Nutrition Care Process

as a systematic framework to recognize, diagnose, and intervene upon nutrition-related problems
for which a nutrition intervention is the primary treatment.

Nutrition Assessment - a comprehensive approach to diagnosing nutrition problems that uses a

combination of the following: medical, nutrition, and medication histories; physical examination;
anthropometric measurement; and laboratory data.

Nutrition Diagnosis - food and nutrition professional's identification and labelling of an exisitng
nutrition problem that the food and nutrition professional is responsible for treating
independently
Nutrition Intervention - is a purposefully planned action(s) designed with intent of changing a
nutrition - related behavior, risk factor, environmental condition, or aspect of health status.

Nutrition Monitoring and Evaluation - identifies the amount of progress made and whether
goals/expected outcomes are being met. This identifies outcomes relevant to the nutrition
diagnosis and intervention plans and goals.

Dietary Instruction / Patient Counseling

Diet counseling is the process of providing individualized professional guidance to assist a
person in adjusting his daily food consumption to meet his health needs

Objectives
1. To help the patient/client understand and follow the physician's diet prescription in terms
of the kind and amounts of food prepared in specific ways.
2. To advise the patient/client on lifestyle changes needed to support medical and nutritional
management, particularly of chronic ailments
3. To motivate the patient/client to make necessary modifications in diet and lifestyle.

Basic Concepts and Principles of Diet Therapy

 Diet Therapy which is part of Nutrition Therapy is the treatment component for a patient
that involves the modification of food intake
 All Hospital Diets are modifications of the normal diets and aim to accomplish one or
more of the following:
1. To maintain good nutritional status
2. To correct deficiencies
3. To provide rest to the whole body
4. To adjust the food intake and body's ability to metabolize the nutrients
5. To bring about changes on body weight whenever necessary.
 To attain the goals mentioned, a normal diet may be modified according to these
categories:
1. Nutrient Level
2. Energy or Caloric Intake
 3. Specific non-nutrient substance
4. Texture and Flavor

MODULE 2. DIET MODIFICATIONS AND THERAPEUTIC DIETS

Principles of Dietary Modification and Overview of Routine and Therapeutic Diets
Full Diet
 Also called normal or full diet, formerly named as DAT (Diet As Tolerated)
 Designed for the adult patient who does not need any dietary modification
 For ambulatory patients whose conditions do not require any dietary modification

Soft Diet
 Diet consists of food that are tender but not ground or pureed
 Diet follows the pattern of the regular diet with modification in consistency and texture
Transition diet from liquid diet
 Helps ease gastric distress

Mechanical Soft Diet

 Used for patients with difficulty in chewing due to poor dental condition, lack of teeth or
presence of sores in the mouth
 Foods should be well-cooked, easy to chew, chopped, ground, or minced

Clear Liquid Diet

 Diet consists of clear fluid and juices that provide little residue and are easily absorbed
Inadequate in all nutrients so prolonged use is not encouraged (should not exceed more
than 3 days) Aims to provide fluids without stimulating extensive digestive process and
to relieve thirst
 Examples: strained fruit juice, clear soup, popsicle

General Liquid Diet

 Diet includes fluids and semi-solid foods that are liquid at body temperature
Diet used as intermediate step in post-operative dietary regimens in which GI function is
moderately reduced
  Transition diet from Clear Liquid Diet
 Examples: soft boiled egg, milk, pureed lugaw, popsicle

Dysphagia Diet
 Dysphagia is defined as difficulty in swallowing and as symptom of a disease or
dysfunction that results from neurological, mechanical, structural or behavioral disorder.
 Purpose of nutrition care is to provide adequate energy, nutrients, and fluids in a
consistency tolerated by the patient

Finger Food Modification Diet

 Diet is designed to prompt self-feeding and independence of impaired patients
Individuals may benefit from this eating approach to decrease frustration, enhance dignity
and self- esteem, and increase morale and motivation. Improvement in appetite may
occur
 Examples: nuggets, burger patties, crackers

Low Residue Diet

 Diet similar to a low fiber diet but typically includes restrictions on foods that increase
bowel activity, such as milk and milk products and prune juice
 Low Residue Diet typically contains 10-15 grams of fiber per day

Minimal Residue Diet

 Diet limits or eliminates the intake of foods that leave a high amount of residue in the
colon after digestion in order to minimize fecal volume.
 Diet aims to reduce both stool bulk and stool water, in order to diminish intestinal
muscular activity
 Foods to Avoid: vegetables with pulp, milk, whole grains

High Fiber Diet

 Also called high roughage diet
 A normal diet with an additional 2 or 3 servings of foods rich in dietary fiber
 The goal of the diet is to increase the intake of fiber rather than to attain a precise level of
intake
  Used to treat IBS and diverticulosis

Low Fiber Diet

 Diet consisting of less than 10 to 15 grams of fiber per day and eliminates foods known
to increase the amount of stool
 The diet contains a minimal amount of indigestible carbohydrates or dietary fiber to
avoid large fecal volume that might distend and further inflame tissue
 Foods high in Fiber: fruits & vegetables, beans, whole grains

Vegetarian Diets
 Vegan or Total Vegan - all animal-based foods and products are avoided
 Lacto-vegetarian - milk and milk products are allowed
 Ovo-vegetarian – eggs and egg products are allowed
 Lacto-ovo-vegetarian - eggs and milk products are allowed
 Semi-vegan - plant origin, milk, eggs, fish and chicken are consumed
 Pesco-vegetarian - fish and fish products are included

LOW OXALATE DIET

Food to Eat:
 Fruits: bananas, blackberries, blueberries, cherries, strawberries, apples, apricots, lemons, peaches
Vegetables: mustard greens, broccoli, cabbage, cauliflower, mushrooms, onions, peas, zucchini
 Grains and starches: white rice, corn flour, oat bran Proteins: eggs, meat, fish, poultry
Dairy products: yogurt, cheese, milk, butter Beverages: coffee, water, fruit juice
 Herbs and spices: cinnamon, black pepper, turmeric, cilantro, cumin, dill

Foods to Avoid:
 Fruits: rhubarb, kiwis, dates, raspberries, oranges, tangerines
 Vegetables: spinach, chard, potatoes, beets, turnips, yams, okra, carrots Legumes: navy beans,
fava beans, kidney beans, refried beans
 Nuts: almonds, walnuts, pistachios, macadamia nuts, cashews
 Seeds: sunflower seeds, pumpkin seeds
 Chocolate and cocoa
 Grains and starches: brown rice, couscous, millet, bulgur, cornmeal, corn grits
 Beverages: chocolate milk, hot chocolate, tea, tomato juice
 Soy products: tofu, soybeans, soy burgers

Pros: helps reduce risk of developing kidney stones

Cons: could lead into nutrient deficit, can interfere with social activities, difficult to follow
Alternative for this diet are: limit salt intake, avoid vitamin C supplements, stay hydrated
LOW PURINE DIET
HYPOALLERGENIC DIET
GLUTEN FREE DIET
LOW SODIUM DIET
KETOGENIC DIET
 Foods Allowed: Cheese, eggs, meats, nuts, avocado, beans, legumes, nuts, seeds
 Foods avoided: all carbs, controlled amount of carbs (not allowed extra sources of carbs), pasta,
bread, rice.
 Before there were no meds for epilepsy. So keto was used to prevent and minimize epileptic
seizures.
 Keto is exercising and restricting themselves for food.
LOW FAT DIET
HIGH CALORIE DIET
NEUTROPENIC DIET
[For foods allowed in a neutropenic diet includes:
 Dairy: all pasteurized milk and dairy products
 Starch: all breads, cooked pastas, chips, beans, corn, peas, and whole grains
 Vegetables: all cooked or frozen vegetables
 Fruits: all canned and frozen fruit and fruit juices, along with thoroughly washed and
peeled thick-skinned fruits like bananas, oranges, and grapefruit]
 [Protein: thoroughly cooked (well-done) meats and canned meats, as well as hard-cooked
or boiled eggs and pasteurized egg substitutes
 Beverage: all tap, bottled, or distilled water, as well as canned or bottled drinks,
individually canned sodas, and instant or brewed tea and coffee]

[Foods to avoid in a neutropenic diet include:

 Dairy: unpasteurized milk and yogurt, yogurt made with live or active cultures, soft
cheeses (Brie, feta, sharp Cheddar), cheeses with mold (like blue cheese), aged cheeses,
cheeses with uncooked vegetables, and Mexican-style cheeses like queso
 Raw starch: bread with raw nuts, uncooked pasta, raw oats, and raw grains
 Vegetables: raw vegetables, salads, uncooked herbs and spices, and fresh sauerkraut]
 [Fruits: unwashed raw fruits, unpasteurized fruit juices, and dried fruits
 Protein: raw or undercooked meat, deli meats, sushi, cold meat, and undercooked eggs
with runny yolk
 Beverages: sun tea, cold brewed tea, eggnog made with raw eggs, fresh apple cider, and
homemade lemonade

So, basically a neutropenic diet is similar from a regular diet; however, preparation and handling
of food items should be more cautious and must be cooked through.]
LOW POTASSIUM DIET
LOW PHOSPHORUS DIET
More Notes about Diet Modifications:
 2gNa - low sodium
 Renal patients - 4gNa
 1tsp of salt throughout the day
 Paleo is adopted in Paleolithic era. Humans were hunter gatherers.
 Clear soup - fat-free strained soup
 Low residue: From clear diet to general liquid to soft
 Concentrated source: Vitamin c food supplements not allowed in low oxalate diet
 Purine breaks down into uric acid which can form into crystals that deposit in your joints
and cause pain and inflammation. Joint pain is referred to as gout or gout attack.
o Mediterranean diet lowers the risk of developing high uric anti-inflammatory and
antioxidant.
o Avoid: red meat, shellfish, fast-food,
o Foods allowed: Purine-free foods: breads, cereals, milk / milk product,
o White meat or flesh meat to recommend on purine diet; avoid red or bloody
fishes, darker color in purine;
o A byproduct of purine is uric acid
o Substitute beer to wine because of malt
 In a hospital, when you see hypoallergenic, no need to ask the patient what specific.
 o Hypoallergenic is in general to avoid the major 8 allergens. This law identified
eight foods as major food allergens: milk, eggs, fish, Crustacean shellfish, tree
nuts, peanuts, wheat, and soybeans.
o Itchy Vegetables with seeds irritating asthmatic reaction
o When a specific allergy is specified, make sure
o Allergies - immunological; reactions from immune system
o Intolerances - associated to digestive system.
 Gluten is a protein mostly found on grains like wheat barley and rye
o Celiac diseases - body mistakes it as a foreign substance and overreacts to the
protein which damages the small intestine.
o NCGS - feel uncomfortable with food with gluten but no celiac disease
o gluten ataxia - like celiac, immune attacks nervous system can cause neurological
symptoms
o wheat allergy
 Low fat dairy products, fruits, and vegetables,
 WARFARIN DIET: avoid green leafy vegetables and other food that are vitamin K rich

International Dysphagia Diet Standardization Initiative

 IDDSI is an international collaboration of professionals who developed a standardized
framework for labeling texture-modified foods and thickened liquids. The framework is
designed to avoid the confusion created by variable terminology and definitions to
describe modified diets around the world.
 Dysphagia is difficulty swallowing — taking more time and effort to move food or liquid
from your mouth to your stomach. Dysphagia can be painful. In some cases, swallowing
is impossible.
Level 0 – Thin
 Flows like water
 Fast flow
 Can drink through any type of teat/nipple, cup or straw as appropriate for age and skills
 Rationale: Functional ability to safely manage liquids of all types

Level 1 – Slightly Thick

 Thicker than water
 Requires a little more effort to drink than thin liquids
 Flows through a straw, syringe, teat/nipple
 Similar to the thickness of most commercially available ‘Anti-regurgitation’ (AR) infant formulas
 Rationale: Often used in the paediatric population as a thickened drink that reduces speed of flow
yet is still able to flow through an infant teat/nipple. Also used in adult populations where thin
drinks flow too fast to be
controlled safely.

Level 2 – Mildly Thick

 Flows off a spoon
 Sippable, pours quickly from a spoon, but slower than thin drinks
  Mild effort is required to drink this thickness through standard bore straw (standard bore straw =
5.3 mm diameter)
 Rationale: If thin drinks flow too fast to be controlled safely, these Mildly Thick
liquids will flow at a slightly slower rate

Level 3 – Moderately Thick

 Can be drunk from a cup
 Cannot be piped, layered or molded on a plate because it will not retain its shape
 Cannot be eaten with a fork because it drips slowly in dollops through the prongs
 Can be eaten with a spoon
 No oral processing or chewing required – can be swallowed directly
 Rationale:
o Allows more time for oral control
o Needs some tongue propulsion effort
o Pain on swallowing

Level 4 – Pureed / Extremely Thick

 Usually eaten with a spoon (a fork is possible)
 Cannot be drunk from a cup because it does not flow easily
 Cannot be sucked through a straw
 Does not require chewing
 Falls off spoon in a single spoonful when tilted and continues to hold shape on a plate
 No lumps
 Not sticky
 Rationale: If tongue control is significantly reduced, this category may be easiest
to control

Level 5 – Minced and Moist

 Can be eaten with a fork or spoon
 Could be eaten with chopsticks in some cases, if the individual has very good hand control
 Can be scooped and shaped (e.g. into a ball shape) on a plate
 Soft and moist with no separate thin liquid
 Rationale:
o Minimal chewing is required
 o Tongue force alone can be used to separate the soft small particles in this texture
o Tongue force is required to move the bolus
o Pain or fatigue on chewing

Level 6 - Soft and Bite Size

 Can be eaten with a fork, spoon or chopsticks
 Can be mashed/broken down with pressure from fork, spoon or chopsticks
 Soft, tender and moist throughout but with no separate thin liquid
 Chewing is required before swallowing
 Rationale:
o Food piece sizes designed to minimize choking risk
o Tongue force and control is required to move the food and keep it within the mouth for
chewing and oral processing
o Tongue force is required to move the bolus for swallowing

Level 7 - Easy to Chew

 Normal, everyday foods of soft/tender textures that are developmentally and age appropriate
Any method may be used to eat these foods
 Rationale:
o Requires the ability to bite soft foods and chew and orally process food for long enough
that the person forms a soft cohesive ball/bolus that is ‘swallow ready’. Does not
necessarily require teeth.
o Requires the ability to chew and orally process soft/tender foods without tiring easily
o May be suitable for people who find hard and/or chewy foods difficult or painful to chew
and swallow

Level 7 - Regular
 Normal, everyday foods of various textures that are developmentally and age appropriate
 Any method may be used to eat these foods
 Foods may be hard and crunchy or naturally soft
 Rationale:
o Ability to bite hard or soft foods and chew them for long enough that they form a soft
cohesive ball/bolus that is ‘swallow ready’
o An ability to chew all food textures without tiring easily
 o An ability to remove bone or gristle that cannot be swallowed safely from the mouth

MODULE 3. MNT ON FEBRILE CONDITIONS AND INFECTIONS

Introduction
Definitions
 Infection - result of successful invasion, establishment, and growth of pathogenic
microorganisms in host.
 There are five major categories of infectious agents are viruses, bacteria, fungi, protozoa,
and helminths
  Fever - medically termed as pyrexia, is a rise in body temperature above normal of
98.6°F. You have a low grade fever if you have an internal body temperature of 37.2°C-
38.1°C. A high-grade fever above 38.2°C and a very high fever above 40°C.
 Sepsis occurs when infection has spread from one part of the body to other areas via the
circulatory system

Metabolic Effects of Fever

 Increased basal metabolic rate: 13% for every degree Celsius rise in body temperature
above normal.
 Increased tissue catabolism, hence great protein loss
 Increased loss of body water, especially in the form of urine and perspiration.
 Increased electrolyte loss, especially sodium and potassium
 Poorer appetite with feelings of nausea and sometimes vomiting
 General weakness and exhaustion

Classification of Infection
Infections can be classified as:
 Acute Infection - usually short duration, with sudden onset and rapid progression. Seen in
colds, influenza, tonsillitis, pneumonia, measles, chickenpox, etc.
 Chronic Infection - last for weeks, months, or years. Seen in tuberculosis, hepatitis, etc.
 Recurrent Infection - occur at periodic intervals

Principles of Nutrition Therapy

Goals of Nutrition Therapy are:
1. to provide adequate nourishment to counteract hypermetabolic state and support body's
host defense system.
2. to prevent and correct dehydration, hypoglycemia, and anorexia
3. to replace nutrient and electrolyte losses
4. to correct iron deficiency anemia if present
 Calories - Dubois recommends an increase of 13% for every degree Celsius rise in the
body temperature, an additional 10% for tissue catabolism.
 Protein - 2g/kg body weight protein allowance to replace losses in tissue catabolism
  Carbohydrate - liberal supply of easy to digest carbohydrate is recommended to spare
protein, provide quick energy.
 Fats - intake of fats in emulsified form such as eggs, cream, butter, milk to supply
additional calories
 Water - increased water intake is needed to replenish fluid losses from vomiting,
urination, diarrhea, or sweating. Water needs may be as high as 3-4 liters per day.
 Minerals - electrolyte balance has to be restored hand in hand with water balance.
 Vitamins - enhance diet with vitamins A, C, B complex from food and beverages sources.

Specific Febrile Conditions and Infections

1. Upper Respiratory Infection: Also known as a common cold. It is caused by a virus that
inflames the membranes in the lining of the nose and throat, colds can be the result of
more than 200 different viruses.
2. Influenza: A highly contagious airborne pathogen that causes an acute febrile illness and
results in variable degrees of synthetic flu symptoms, ranging from mild fatigue to
respiratory failure.

Nutrition Therapy: a soft to regular diet with adequate calories is given. Increase fluid intake
will help keep the lining of the nose and throat moist and help prevent dehydration.
3. Measles: An acute highly infectious communicable disease usually recognized by
presence of fever, rashes, and symptoms in the upper respiratory tract. It is preceded by
grayish pecks (Koplik spots) of the cheeks and rashes in the face and body.
a. Nutrition Therapy: A liquid to soft consistency and in increasing amounts. Some
cases may require tube feeding
4. Cholera: A self-limiting, acute dehydrating disease of the intestines particularly the small
intestines caused by Vibrio cholerae. This causes hypersecretion of sodium and water in
the gut leading to diarrhea.
a. Nutrition Therapy: Patient is placed at NPO for 12 hours with IVF and
electrolytes. Oral Rehydration Therapy with addition of resistant starch is
advisable to reduce fecal fluid loss and shorten duration of loose bowel
movement.
5. Dengue: An acute infectious mosquito-borne fever in which it is a major international
public health concern. It results in a severe, flu-like illness which affects infants, children,
and adults. Some cases may lead to dengue hemorrhagic fever.
a. Nutrition Therapy: A high calorie liquid diet with ample amount of water and
fruit juices. As tolerance progresses, diet can be modified to high calorie diet.
b. NCCF (no choco color food) may alter the stool color.
c. Anything processed with red not allowed to observe if the digestive tract has any
hemorrhage.
d. Red – bleeding from intestine
e. Black – bleeding from stomach
6. Diptheria: An acute infectious and communicable disease caused by Corynebacterium
diphtheriae. It affects the respiratory system. Symptoms include moderate temperature,
malaise, sore throat.
a. Nutrition Therapy: a fluid diet consisting of warm milk, broth, fruit juices, and
gelatin to ease sore throat. Soft diet may be given.
7. Mumps: An acute generalized viral infection usually diagnosed by the sudden onset of
painful swelling in one or both parotid glands.
a. Nutrition Therapy: a liquid diet is given and gradually progressing to soft bland
diet to minimize discomfort.
8. Pertussis: An acute serious communicable disease involving the respiratory tract. It is
caused by Bordatella pertussis and B. parapertussis and can spread by droplet infection.
a. Nutrition Therapy: a soft diet is given when oral feedings are tolerated to prevent
mucus secretions
9. Poliomyelitis: a disease cause by infection with the poliovirus. Transmitted via direct
personal contact by eating contaminated food or drink. It affects the nervous system and
may cause paralysis.
a. Nutrition Therapy: for patient with acute paralysis, provide high calorie, high
protein liquid diet or tube feeding. It may progress to a soft, bland diet.
10. Rheumatic Fever: An auto-immune disease-causing inflammatory conditions affecting
the connective tissue and causing joint pain, swelling, fever, rash, jerky movements, and
 carditis. This is caused by untreated streptococcal infection. Long term effect may lead to
Rheumatic Heart Disease
a. Nutrition Therapy: high calorie, high protein, full liquid diet is indicated during
acute infection. As treatment progresses, gradually change to soft to regular diet.
11. Malaria: A recurrent infection caused by the genus Plasmodium, a parasitic protozoa
found in mosquitoes. Main symptoms are intermittent fever, chills, swelling of the liver
and spleen
a. Nutrition Therapy: the diet aims to counteract losses during the attack of fever
and chills. A high calorie diet, a high protein diet, moderate fat is recommended.
12. Pneumonia: An acute infectious disease of the respiratory tract typically caused by the
pneumococcus bacteria resulting in the inflammation of the alveolar spaces of the lungs.
Signs and symptoms include difficult, painful respirations, shortness of breath, chills,
fever, malaise, productive cough, and anorexia.
a. Community acquired Pneumonia (CAP) – certain risk factors
b. CAP MR (moderate risk) – has different risk level of pneumonia
c. Nutrition Therapy: High calorie soft diet is given to prevent weight loss from
hypermetabolic state. Prevention and correction of dehydration is done by giving
3-3.5 liters of fluid per day
13. Tuberculosis: a highly infectious chronic disease caused by the tubercle bacillus
(Mycobacterium tuberculosis) characterized by the formation of tubercles and caseous
necrosis in the tissue. Most TB cases affect the lungs, but it can also spread in other parts
of the body
a. TB can affect the brain, spine, and digestive tract
b. Pulmonary TB – main infection in the lungs
c. Active TB – have tb bacteria, has symptoms (productive cough and fever), and
contagious
d. Laten TB – have TB bacteria but do not manifest the symptoms and not
contagious.
e. Nutrition Therapy: Adequate nutrition is important because many patients with
TB are debilitated by the disease and malnutrition can contribute to weakened
immune system.
 14. Severe Acute Respiratory Syndrome (SARS): SARS is respiratory illness that is caused by
coronavirus. SARS was first reported in Asia in 2003. It is spread through respiratory droplets
which may enter in another person through eyes, nose, or mouth.
a. Nutrition Therapy: a high calorie high protein diet is given. Usually, a soft diet in
small frequent feedings is better tolerated.

MODULE 4. MNT FOR SURGICAL CONDITION, BURNS, AND TRAUMA

Surgery
 Surgery is the term used for treatments that involve cutting or stitching tissue, laser
surgery, and robotic surgical procedures.
 Nutrition is important during pre or post operative
 Pre: certain diet must have, time sensitive, nutrient sensitive
 Post: transition from gen surgery, then provide normal or full diet to the patient

 Major surgery involves opening a major body cavity, such as the abdomen (laparotomy)
or the skull in a craniotomy. General anesthesia, a surgical team, and a hospital stay are
required.
 Minor surgery may be done in an outpatient or emergency room setting, often with
minimal anesthetic treatment.

Surgery Process
1. Pre-operative Evaluation
2. Main surgery
3. Post-operative care

Classification based on Urgency

 Emergency Surgery - performed when the nature of illness require an immediate intervention
(blood loss, gallstone removal, cesarian section when long labor process and child is suffering,
appendectomy when appendix has burst)
 Elective Surgery - allows reasonable time to prepare the patient for surgery (transplant,
appendicitis, removal of cyst or cancerous malignant tumors growth, heart bypass, kidney stones
removal, c-section, biopsy, plastic surgeries, amputations, hernia repair)

Metabolic Response in Surgery

Surgery is accompanied by stress response.
The stress response involves an increase in the secretion of:
 Epinephrine
 Norepinephrine
 Corticosteroids

resulting in the breakdown of: (Identified in a hyper catabolic state)

 Glycogen
 Fat stores
 Protein stores, especially in skeletal muscle

The net effect in severe cases is:

 increased urinary nitrogen loss
 Muscle wasting
 Weight loss

Pre-operative Diet
 Aims to improve nutritional status of the patient
 Help hasten post-operative recovery
 Build up glycogen stores
 Strengthen bodily resistance to infections

A. Emergency Operation
1. If patient is in good nutrition status NPO 6-8 hours prior to surgery. To avoid vomiting during
anesthesia, and decrease irks of post-operative gastric retention
2. If patient is in poor nutrition status parenteral administration of whole blood. For adequate stores
of serum protein to prevent hypoproteinemia.
3. In addition, 5% glucose (dextrose) in water, ACL saline solution, and potassium. For adequate
nutrition

B. Elective Surgery
1. High calorie for underweight. To build up any weight deficit
2. Low to adequate calories for others. If patient is overweight, weight reduction is indicated to
reduce surgical risks
 3. High carbohydrates. For glycogen stores and to spare protein for tissue synthesis. Glycogen is
stored in the liver.
4. High protein. To build reserves for anticipated blood losses during surgery and increased tissue
catabolism.
5. Increased in vitamins C & B for wound healing and prevention of hemorrhage (K).
6. Increased minerals, especially phosphorus, potassium and chloride, iron to replace electrolyte
losses and correct anemia.
7. Increased fluids. Replace losses due to vomiting and diuresis

Immediate Pre-operative
 A light meal is given the night prior to surgery, and nothing is given by mouth for at least 8 hours
before general surgery.

Post Operative Diet

 Maintenance of fluid and electrolyte balance (orally if possible, can be supplied intravenously).
 Adequate calorie and protein intake (using the right formulas in the TER for adequate calorie, use
protein recommendation for adequate protein intake; accurate FEL)
 Adequate total nutrient intake to promote wound healing (micronutrient food or food
supplementation)

A. Minor Surgery
1. Provide liquids within a few hours after surgery and resume normal diet as soon as activity of
GIT is restored.

B. Major surgery
1. NPO 24-28 hours
2. Nutrition support if needed
3. Transition oral diet (liquid to full diet) clear liquid, full liquid, soft diet to full diet

Specific Surgical Conditions

1. Surgery of Mouth Throat Esophagus
 Characteristics: Inability to chew and swallow
 Nutrition Therapy:
o Liquid Diet to Soft Diet to Full Diet until tolerated
o Tube Feeding when necessary
2. Gastrectomy
 A gastrectomy is a medical procedure where all or part of the stomach is surgically removed.
 Patient is at high risk for: decreased oral intake, maldigestion, & malabsorption
 Needs to be removed: remove part or whole stomach to connect the end of esophagus of the
intestine

Metabolic Changes:
1. Weight Loss
2. Protein Digestion is impaired
3. Impairment of fat utilization (biliary and pancreatic secretion for mixing and emulsifying)
4. Increased intestinal motility (most process is in the intestines)
5. Iron is less readily absorbed
6. Vitamin b12 deficiency (needs the intrinsic factor in the stomach)

 Nutrition Therapy involves two Periods: (1) Immediate post-operative period & (2) Later period
involving Dumping Syndrome
o NPO first 24-48hrs
o Days 2-4 iced water with intravenous feeding
o Day 5: 2 oz of water and milk given alternately per hour
o Day 6: soft low fiber foods
o Day 7: tender meats, cottage cheese, pureed vegetables
o Meals are divided into 5 to 6 small feedings daily with emphasis on food high in protein
and fat.
o All food and drinks should have moderate temperature. Cold drinks tend to cause
increased gastric activity.

3. Dumping Syndrome
 A complex physiological response to the presence of undigested food in the jejunum usually
associated with gastrectomy.

Characteristics:
 Withdrawal of circulating fluid after partial gastrectomy
 Decrease in plasma volume which can lead to palpitation, exhaustion and faintness
 Intestinal distention which increases intestinal peristalsis
  Hypoglycemia
 Symptoms: abnormal cramping, abdominal pain, diarrhea, feeling warmth, dizziness, weakness,
tachycardia (more than 100bpm)

Nutrition Therapy:
 Small frequent meals
 High protein
 High fat
 Restricted simple sugars (decreases osmolarity of the jejunum)
 Dry solid diet
 Low fiber, low residue
 Avoid alcohol and carbonated beverages

4. Intestinal Surgery
 Surgical resection (removal of parts of intestine) of the intestinal will produce changes in
absorption, motility, and production of waste products.
 Ileostomy: removal of the entire colon rectum and anus, an opening made from the ileum, is
brought through the abdominal wall for waste elimination. Bag is cleaned out every now and then
to prevent infections, foul smell.
 Colostomy – involves the removal of only the rectum and anus and attaching the proximal end of
the resected colon to an opening in the abdominal wall. Some ability to absorb water is retained
so that the feces are formed. Only the rectum and anus still have the colostomy bag a whole in the
stomach wall
 Jejunoileostomy - short segment of the jejunum is joined to the terminal ileum, effectively by
passing about 90% of the small bowel. Weight loss follows as a result of shortened transit time
and reduced surface area for absorption.

Indications for Ileostomy and Colonostomy:

1. Obstruction
2. Diverticulitis
3. Perforation
4. Malignancy

Nutrition Therapy:
 supplementation for micronutrient deficiencies
  Small frequent meals divided throughout the day
 Avoiding spicy and oily foods
 Drink 8-10 cups of fluids per day
 Avoid gas-forming foods and high fiber foods

5. Rectal Surgery
 hemorrhoidectomy: removal of either external or internal hemorrhoids

Dietary Management:
 NPO for the first 24 hours
 Clear liquid
 Low fiber-low residue (fruits and vegetables are omitted unless strained fruit juices)

6. Fractures
Metabolic changes in fractures
 Increased protein breakdown
 Development of osteoporosis
 Loss of fluids and electrolytes

Nutrition Therapy:
 High calories
 High protein
 Increased electrolytes and fluids
 Calcium from natural sources

7. Burns
 First degree - erythema and cell necrosis above the basal layer of the epidermis
 Second degree - erythema and blistering necrosis within the dermis (Body Surface Area 15% for
adults, 10% children)
 Third degree - full thickness skin loss, including the fat layer (do not really feel pain because
nerves are destroyed)

Metabolic changes:
 Loss of tissue
 Dehydration
  Protein loss
 Electrolyte imbalance
 Increased energy needs
 Weight loss

TER:
 Adults: 25 x preburn weight in kg + (40kcal x % BSA burned)
 Children: 30 to 100kcal x preburn weight in kg + (40kcal x % BSA burned)
 Burns: add for 50kcal for fast estimation

Nutrition therapy goals:

 Correct fluids and electrolyte imbalance
 Prevent tissue catabolism (CHON 2-3g/kg BW) 20-25%
 Prevent weight loss
 Hasten wound healing
 Nutrition support may be provided

8. Other Surgeries and Removal of Organs