Alimentazione terapeutica

The concept of therapeutic feeding

A therapeutic diet is a diet for a sick person, the purpose of which is firstly to help the person recover and secondly to provide as many of the necessary nutrients to the body as possible. In a number of cases (diabetes, gastric and duodenal ulcer, colitis, obesity, etc.) therapeutic nutrition can act as the main therapeutic measure.

In most cases, therapeutic feeding should be used in conjunction with other therapies. Sometimes it serves as an obligatory therapeutic background for the application of other, including specific therapies (e.g. for infectious diseases).

The diet is appointed by the attending physician, taking into account the nature of the disease, indications and contraindications, characteristics of the course of the main and related diseases, the patient’s tastes, his national traditions.

The principles of therapeutic diet

Current principles of therapeutic nutrition include:

1. application of diets, capable of affecting the body as a whole, not just the diseased organ;
2. sparing or training of the diseased enzymatic systems by the introduction or exclusion of specific food factors; and therapeutic fasting, i.e. helping the organism to achieve a state of relaxation;
3. variability in the use of diets, i.e. their application in accordance with the course of the disease. For instance, diets that are not very effective can lead to a weakening of the organism if used over a long period of time.

Nutritional therapy tactics

There are two different systems of curative nutrition ~ group and individual, which are built on the principle of prescribing diets.

In all cases the principle of sparing is usually used at the beginning of treatment. It consists in observing a strict diet. Later on, in order to prevent partial starvation in respect to certain food substances and to train shallowly disturbed functional mechanisms in order to restore them, one must switch to the principle of training. This is carried out in a “step” and “zigzag” system.

The “step” system. This involves a gradual expansion of the initial strict diet through the gradual elimination of restrictions. When moving on to the training principle, it should be borne in mind that excessive haste in expanding the diet – as well as over-extending it – can have a negative effect. To avoid this, the dynamics of clinical signs, the status of impaired functional mechanisms as well as their associated effects should be guided. This system, in the case of elimination of the pathological process, allows a gradual expansion of the diet – up to the transition to a rational diet corresponding to the physiological needs of the body.

The zig-zag system.

This system involves relatively abrupt, short-term changes in diet. Such diets and correspondingly their days are called contrast diets.

Contrast diets (days) are of two types: loading (“plus-zigzag”) and unloading (“minus-zigzag”).

Load diets (“plus-zigzags”) are used according to the principle of training. They are also called “holiday diets”. They involve the inclusion of nutrients in the diet, the content of which is sharply limited or excluded altogether from the basic diet. The periodic prescription (at the beginning of 1 to 7 days) of load diets helps to stimulate weakened functions. These diets ensure the introduction of deficient nutrients into the body, increase appetite by introducing variety into the diet of the patient and facilitate tolerance of the often long and very strict dietary regime.

Load diets also serve as a functional test. A good tolerance to a stress diet has an important psychological and prophylactic value: it strengthens the patient’s confidence in the positive changes that have occurred and indicates the possibility of switching to a more varied dietary regime. A gradual increase in the frequency of load days and the degree of strain with good tolerance leads to the fact that the main diet may become a load diet, and the one that was previously the main diet becomes a discharge diet. In this way, a zigzag transition is made from a strict diet to a more varied and nutritious diet.

Unloading diets (“minus-zigzags”) are based on limiting the energy value or are connected with purposeful reconstruction of the chemical composition of the diet, ensuring sparing of damaged functional mechanisms, as well as correcting metabolic disorders. Special days off can be prescribed periodically once every 1-10 days in a number of diseases (from the beginning of treatment, against a relatively strict diet).

Carrying out unloading days is advisable even after the recovery of the impaired functions, as during this period they are characterized by some lability and need periodic unloading and sparing.

These diets are recommended for:

• cardiovascular diseases (hypertension, circulatory insufficiency, atherosclerosis and coronary heart disease with obesity);
• obesity;
• diabetes with obesity;
• acute stomach and bowel diseases in the first days of treatment;
• kidney diseases (acute nephritis, renal failure); liver and biliary diseases (acute chronic cholecystitis, gallstone disease, liver failure etc.);
• gout;
• urolithiasis.

According to the predominance of food in the diet unloading diets are divided into vegetarian – only plant foods (fruits, potatoes, vegetables, rice), dairy (milk, cottage cheese, etc.), sugar, meat and fish, liquid (juices of vegetables and fruits).

Unloading diets incomplete in chemical composition and energy value, can cause hunger, so at home they are appointed for 1-2 days and no more than 1-2 times a week, taking into account the nature of the disease, tolerance of certain diets and treatment conditions: in acute illness or exacerbation of chronic disease – with a temporary loss of ability to work (sick leave) or a chronic disease with preserved ability to work (in the latter case, the unloading diet should be timed to weekends). If these diets are used for two consecutive days, it is advisable to vary them: for example, if the first day of obesity – apple diet, the second – meat (fish).

Mode of eating patients

Should build individually, depending on the nature of the disease and its course, the presence of appetite, other therapies, general and labor regimes. However, in any case you should not allow gaps between individual meals: during the day – more than 4-5 hours, between the last evening meal and breakfast – 10-11 hours.

For medical and preventive institutions, the Ministry of Health of the Russian Federation in accordance with the general regime established as a minimum four meals a day. For many diseases (digestive organs, cardiovascular system, infectious diseases, etc.) more frequent meals are required – 5-6 times a day. With five meals a day is advisable to enter into the regime of the second breakfast, and at six meals a day – and afternoon snack.

Fever patients should eat the main amount of food during the hours of lowering the body temperature, when it usually improves appetite.

Therapeutic feeding systems

When prescribing therapeutic food in principle two systems can be used: elemental and dietary.

The elemental system

This involves developing a personalised diet for each individual patient, with a specific listing of each element of the daily food intake.

Dietary system

This entails individual prescription of a diet from a list of pre-established and tested diets.

The dietary system is mainly used in health facilities. In our country were predominantly used diets, recommended and approved by the Ministry of Health for general use, which were developed at the clinic of medical nutrition of the Institute of Nutrition RAMS, with a numbered notation system by the nomenclature proposed by MI Pevzner.

This system of therapeutic feeding, formerly referred to as a group, provides 15 basic therapeutic diets (tables) and a group of contrast, unloading diets. In addition, some of the basic diets (1,4,5,7,9,10) have several versions, indicated by capital letters of the Russian alphabet, which are added to the number of the basic diet (eg 1a, 16, 5a, etc.).

Each diet and its variants are characterised by:

1. indications for use;
2. Their purpose (treatment)
3. energy value and chemical composition;
4. characteristics of cooking;
5. dietary regime;
6. list of permitted and recommended meals.

The dietary system allows the organization and individualization of therapeutic feeding in terms of serving a large number of patients with different diseases. This is achieved by applying one of the most

suitable basic diet or its variants with appropriate adjustments (by adding or removing certain foods and dishes, allowing to regulate the chemical composition and cooking). In addition, it is recommended to use foods with certain therapeutic properties (cottage cheese, milk, liver, watermelon, apples). Without violating the principle of dietary diversity, the same foods in different forms of preparation and dishes in different combinations can be introduced in several diets.

Organization and supervision of therapeutic meals

The daily organization of meals for patients in hospitals and sanatoria is handled by a dietitian, who is responsible for drawing up a menu listing for all curative diets and prescribing additional meals or products for medical reasons.

The doctor on duty and the dietitian together assess the quality of the food prepared in the kitchens of medical establishments. Immediately before the food is handed out, a so-called sampling (rejection) takes place. The actual yield of the meals, their temperature, organoleptic indicators (appearance, taste, smell, etc.), compliance with the diet are determined. The results of the sample for each dish are recorded in the menu layout, and a general assessment of cooked food in the cracking log.

For organoleptic evaluation of food it is necessary to have a cook’s needle (to determine the readiness of meat or fish), spoons, fork, knife, thermometer, a bowl with boiling water (to rinse spoons), plates, a glass with cold tea (to rinse the mouth).

When determining the appearance and consistency of food pay attention to its colour, shape, size, structure (in section), homogeneity, juiciness, crumbly, crumbly, etc. Smell is determined before sampling and when the food is swallowed after chewing. When determining the taste the food is held in the mouth, rolling it with the tongue for even distribution in the oral cavity. Taste evaluation starts with the least salty, sweet and other foods with a strong taste.

It is necessary to take breaks between samplings, avoid sampling the same food several times (the first sampling gives the most flavour perception) and avoid delaying the taste sensation by rinsing the mouth with tea. Tasting is done at moderate satiety – in the middle of the interval between the last meal and the next meal.

The quality of the food is assessed using a five-point system:

• 5 points (excellent) – the dish corresponds in all respects to the layout, diet and culinary requirements;
• 4 points (good) – the dish has minor correctable defects (insufficient salt, lack of decoration, etc.);
• 3 points (satisfactory) – the dish has deviations from culinary requirements (violations of consistency, non-compliance with the form of cutting, etc.), but is suitable for consumption.

Periodically average samples of prepared dishes are sent for laboratory analysis to the SSESC: this is necessary to assess the actual yield of dishes, determining their compliance with the menu layout in terms of chemical composition and caloric content.

In addition, if bacteriological examination is required (in case of food poisoning), samples of cooked food are taken and stored in a refrigerator for at least 24 hours.

The persons in charge of sanitary supervision of the canteen are obliged to be persistent and uncompromising when violations of sanitary regulations are detected.

Therapeutic and preventive nutrition and its aims

Although the measures are aimed at creating the conditions that exclude any harmful effect on health in the process of labor and sports activities, harmful and dangerous factors which lead to occupational illnesses are present at some production facilities.

The basis for the prevention of occupational diseases is the improvement of working conditions, technical and sanitary improvement of enterprises, as well as the strict observance of safety regulations. Along with the improvement of the environment are of great importance measures aimed at increasing the body’s resistance to the adverse effects of physical and chemical factors of the working environment. Among these measures one of the first places belongs to preventive nutrition.

Therapeutic and prophylactic nutrition is provided free of charge and includes a set of products with a specific focus. Its task is to promote not only the general resistance of the body and the functional ability of organs and systems, but also to reduce the absorption of toxic substances and their rapid removal from the body.

There are three types of therapeutic and preventive nutrition:

1.  therapeutic and preventive diets;
2.  vitamin preparations;
3.  milk, dairy products and pectin.

The use of therapeutic and prophylactic food is also indicated in some sports (speedway motorbike racing, etc.).