Meal planning and therapeutic diets

What to remember

• A good meal plan is adequate, balanced, varied, affordable and acceptable. It covers all food groups, suits the person's age, activity and physiological state, and fits local food habits and budget.
• A therapeutic diet is a normal diet changed in nutrients, texture, or the way it is fed, to treat a disease. The change should be as small as needed, and the diet should stay as close to the family meal as possible.
• Energy value: carbohydrate 4, protein 4, fat 9, alcohol 7 kilocalories per gram. Almost every numerical question in this area uses these values.

Basics of meal planning

A balanced diet gives all nutrients in the right amounts and proportions to maintain health, with a small reserve for short periods of stress. The reference values used in India are the Recommended Dietary Allowances (RDA) prepared by ICMR-NIN (the National Institute of Nutrition, Hyderabad).

Principles of meal planning:

• 1. Adequacy: meets the needs for energy and all nutrients.
• 2. Balance: includes cereals, pulses, vegetables, fruits, milk and fats in the right ratio.
• 3. Variety: different foods and colours, different cooking methods, to avoid boredom and cover all nutrients.
• 4. Economy: use seasonal and local foods; plan by budget.
• 5. Satiety: the meal should keep a person satisfied. Fat and fibre delay hunger.
• 6. Acceptability: food habits, culture, religion, taste and appearance matter.
• 7. Preparation time and skill: plan a feasible menu with available fuel, time and skill.
• 8. Food safety and hygiene.

Steps to plan a day's menu: find the person's energy and nutrient need; decide the number of meals; allot the food groups to meals; choose recipes; check totals; adjust for cost and likes.

Food groups (five group system used in India): cereals and millets; pulses and legumes (with meat, fish, egg); milk and milk products; fruits and vegetables (including green leafy vegetables, which protect with vitamins and minerals); fats, oils and sugars. A simple three-group idea is also taught: energy-giving, body-building and protective foods.

Exchange list (food exchanges): foods in a list have about the same energy, protein, fat and carbohydrate in a given household portion. A cereal portion can be swapped for another cereal portion. This helps to plan diets for diabetes and weight control.

Calculation of energy from food (worked example): a food gives 10 g protein, 5 g fat and 30 g carbohydrate. Energy = (10 × 4) + (5 × 9) + (30 × 4) = 40 + 45 + 120 = 205 kcal.

Another example: if a diet gives 2,000 kcal and 60 per cent comes from carbohydrate, then carbohydrate energy = 1,200 kcal, and 1,200 ÷ 4 = 300 g carbohydrate.

Cooking and nutrient loss: washing rice many times and discarding extra water, long boiling, and adding soda destroy water-soluble vitamins (B and C). Steaming, pressure cooking and using the cooking water preserve nutrients. Sprouting and fermentation increase vitamins and improve mineral absorption. Combining cereals and pulses improves protein quality (supplementary action of proteins).

Modification of diets

Hospital diets are normally classified by consistency:

Tube feeding (enteral) is used when swallowing is impossible but the gut works. Parenteral feeding (through a vein) is used when the gut cannot be used.

Therapeutic diets: key diseases

Fever and infection: energy and protein needs rise, so give light, high calorie, high protein, plenty of fluids, and small frequent feeds. In typhoid, a soft, low-fibre diet is given.

Diarrhoea: the main danger is dehydration. Give oral rehydration solution (ORS) and zinc. Continue breastfeeding and normal food. Home fluids such as rice water, dal water, buttermilk and coconut water are useful. Standard low osmolarity ORS contains sodium chloride, glucose, potassium chloride and sodium citrate. Mothers should be taught to prepare it with clean water.

Protein energy malnutrition: kwashiorkor is mainly protein deficiency (swelling, skin changes, hair changes). Marasmus is mainly energy deficiency (severe wasting, "old man" face). Treatment is gradual refeeding with energy dense and high protein food, with micronutrient and electrolyte correction under medical care.

Obesity and weight management: a low energy diet with fibre, vegetables and fruits, less fat and sugar, and regular activity. Do not skip meals. Aim for slow weight loss.

Underweight: energy dense foods, frequent meals, healthy snacks, and treatment of infections.

Diabetes mellitus: control blood sugar by meal timing, controlled carbohydrate, high fibre and complex carbohydrates (whole grains, millets, pulses, vegetables), limited sugar and refined food. Meals should be regular and not skipped. The glycaemic index shows how fast a food raises blood sugar; low glycaemic index foods (pulses, millets, most vegetables) are preferred. Sweets and sugary drinks are avoided; fruits are taken in controlled portions.

Hypertension: reduce sodium (salt, pickles, papad, processed foods), keep a healthy weight, eat more fruits, vegetables, low fat milk and potassium-rich foods. This is the idea behind the DASH diet (Dietary Approaches to Stop Hypertension).

Heart disease and high cholesterol: reduce saturated fat (ghee, butter, coconut oil, fried foods) and trans fat, use less cholesterol-rich food such as egg yolk and organ meat, and add fibre (oats, pulses), nuts and fish. Use a variety of oils.

Anaemia: iron-rich foods (green leafy vegetables, jaggery, liver, meat, ragi), vitamin C at meals (lemon, amla, guava) to raise iron absorption, folic acid and B12 foods, and IFA tablets. Avoid tea and coffee at meals.

Constipation: more fibre, fluids and activity.

Peptic ulcer and acidity: small frequent meals, avoid very spicy food, strong tea and coffee, alcohol and smoking.

Jaundice and hepatitis: a high carbohydrate, moderate protein, low fat diet during acute illness, small frequent meals, and no alcohol. In liver failure (hepatic coma) protein is restricted.

Kidney disease: in chronic kidney disease, limit sodium, potassium, phosphorus and fluid, with protein controlled by the stage and the treatment (dialysis changes the protein need). Nutrition plans must be set by the doctor and dietitian.

Gout: avoid purine-rich food such as organ meat; drink fluids.

Food allergy and intolerance: remove the cause. In lactose intolerance, milk is replaced by curd or lactose-free products. In coeliac disease, gluten (wheat, barley, rye) is removed.

Meal planning for the Anganwadi

Anganwadi meals are planned so that children and women get a part of their daily needs through hot cooked meals, snacks and take-home rations. A good menu uses local cereals and millets, pulses, vegetables, jaggery and oil, with eggs and milk when provided, and is fortified where suitable. Fixed menus rotate to give variety. Hygiene, safe water and storage matter as much as the recipe.

Planning for different groups

A day's menu is usually built around three main meals and one or two snacks. Cereal and pulse form the base of every main meal, a vegetable (one leafy vegetable at least once a day) adds vitamins and fibre, and a small amount of oil or ghee adds energy. Milk or curd, an egg, a fruit or a handful of groundnuts or sprouts are used as extras.

Meal planning is done first for the family, and then adjusted for each member, so that the cook is not forced to prepare many different dishes.

Exam traps

• Carbohydrate and protein give 4 kcal per gram; fat gives 9; alcohol gives 7.
• Clear liquid diets give almost no energy; they are for short use only.
• Kwashiorkor is protein deficiency (oedema); marasmus is energy deficiency (wasting).
• In diabetes, the aim is controlled and regular carbohydrate, not zero carbohydrate.
• In hypertension the restriction is for sodium; potassium-rich foods are encouraged (except in advanced kidney disease).
• In hepatitis the diet is low in fat, but not low in carbohydrate.
• Vitamin C helps iron absorption; tea and coffee reduce it.
• Exchange lists group foods with similar nutrient content; they are not a list of foods that are prohibited.

One-liners

• 1. Carbohydrate gives 4 kcal per gram.
• 2. Fat gives 9 kcal per gram.
• 3. A balanced diet has all nutrients in the right proportion.
• 4. The ICMR-NIN fixes the recommended dietary allowances for India.
• 5. ORS and zinc are the treatment for diarrhoea.
• 6. A low glycaemic index food raises blood sugar slowly.
• 7. DASH diet is used to control blood pressure.
• 8. Cereals plus pulses improve protein quality.
• 9. A soft diet is used in typhoid.
• 10. Steaming loses fewer vitamins than long boiling.
• 11. Gluten is removed in coeliac disease.
• 12. Saturated fat should be reduced in heart disease.

Practice questions

1. The energy value of 1 g of fat is

   1. 4 kcal
   2. 7 kcal
   3. 9 kcal
   4. 2 kcal
   Answer

   C. 9 kcal

   Fat gives 9 kcal per gram; carbohydrate and protein give 4.

2. The energy value of 1 g of alcohol is

   1. 5 kcal
   2. 9 kcal
   3. 4 kcal
   4. 7 kcal
   Answer

   D. 7 kcal

   Alcohol gives 7 kcal per gram.

3. A balanced diet is one that provides

   1. only protein in large amounts
   2. all nutrients in the right amounts and proportions
   3. only energy-giving foods
   4. only vegetables and fruits
   Answer

   B. all nutrients in the right amounts and proportions

   Balance means all nutrients in the correct proportion.

4. Recommended dietary allowances for Indians are prepared by

   1. NITI Aayog
   2. FSSAI
   3. ICMR-NIN
   4. NABARD
   Answer

   C. ICMR-NIN

   The ICMR National Institute of Nutrition, Hyderabad, fixes the RDA.

5. Which group of foods is called protective?

   1. ghee and butter
   2. oils and sugar
   3. rice and wheat
   4. green leafy vegetables and fruits
   Answer

   D. green leafy vegetables and fruits

   They supply vitamins, minerals and fibre.

6. Which diet is given to a patient just after some surgeries or in severe diarrhoea as the first step?

   1. clear liquid diet
   2. regular diet
   3. fried food diet
   4. high fibre diet
   Answer

   A. clear liquid diet

   Clear liquids are easily absorbed and leave little residue.

7. The solution used to treat dehydration in diarrhoea is

   1. glucose biscuit solution
   2. oral rehydration solution
   3. sugar syrup
   4. lemon squash
   Answer

   B. oral rehydration solution

   ORS replaces water and salts; zinc is added for children.

8. Kwashiorkor is mainly caused by deficiency of

   1. energy alone
   2. vitamin C
   3. protein
   4. iodine
   Answer

   C. protein

   Kwashiorkor is mainly protein deficiency with oedema; marasmus is energy deficiency.

9. Which therapeutic diet restricts sodium?

   1. diet for anaemia
   2. diet for diarrhoea recovery
   3. diet for underweight
   4. diet for hypertension
   Answer

   D. diet for hypertension

   Reducing salt helps control blood pressure.

10. The glycaemic index of a food shows

    1. how fast it raises blood glucose
    2. its protein content
    3. its vitamin content
    4. its fat content
    Answer

    A. how fast it raises blood glucose

    Low glycaemic index foods raise blood sugar slowly.

11. A person who cannot digest wheat, barley and rye because of gluten has

    1. coeliac disease
    2. scurvy
    3. gout
    4. pellagra
    Answer

    A. coeliac disease

    Gluten must be removed from the diet in coeliac disease.

12. Which cooking method best preserves water-soluble vitamins?

    1. frying in deep oil
    2. prolonged boiling
    3. repeated washing and discarding water
    4. steaming or pressure cooking
    Answer

    D. steaming or pressure cooking

    Short cooking with little water preserves vitamins B and C.

13. Which food combination shows the supplementary effect of proteins?

    1. rice with sugar
    2. cereal with pulse
    3. oil with salt
    4. tea with milk
    Answer

    B. cereal with pulse

    Cereals lack lysine while pulses lack methionine; together they complement each other.

14. The DASH diet is mainly used to manage

    1. goitre
    2. kidney stones
    3. high blood pressure
    4. night blindness
    Answer

    C. high blood pressure

    DASH stands for Dietary Approaches to Stop Hypertension.

15. In a patient with typhoid fever, the diet is best

    1. soft, low fibre, high energy and high fluid
    2. very low calorie
    3. hard and spicy
    4. high fibre and raw
    Answer

    A. soft, low fibre, high energy and high fluid

    The gut is inflamed, so a soft low-residue diet is used.

16. A diabetic person should preferably choose

    1. fruit juice with sugar
    2. sweets and sugary drinks
    3. whole grains, millets and pulses
    4. white bread and jam
    Answer

    C. whole grains, millets and pulses

    Complex carbohydrates with fibre have a low glycaemic index.

17. For a patient with high blood cholesterol, which change is most helpful?

    1. reduce saturated fat and add fibre
    2. increase ghee and butter
    3. add more egg yolk and organ meat
    4. take only refined starch
    Answer

    A. reduce saturated fat and add fibre

    Saturated and trans fats raise cholesterol; fibre lowers it.

18. Which is best advised to a person with iron deficiency anaemia?

    1. tea after every meal
    2. fried snacks daily
    3. only milk and rice
    4. jaggery, leafy vegetables and a vitamin C source at meals
    Answer

    D. jaggery, leafy vegetables and a vitamin C source at meals

    Vitamin C enhances iron absorption.

19. During acute hepatitis, which diet is most suitable?

    1. very high fat
    2. alcohol-containing tonic
    3. high carbohydrate, low fat, small frequent meals
    4. very high protein only
    Answer

    C. high carbohydrate, low fat, small frequent meals

    Fat is poorly tolerated; carbohydrate provides energy.

20. In lactose intolerance, which replacement is most suitable for milk?

    1. wheat flour
    2. curd
    3. groundnut oil
    4. sugar
    Answer

    B. curd

    Curd has less lactose because bacteria ferment it.

21. Exchange lists in diet planning are used to

    1. ban all cereals
    2. swap foods with similar nutrient value
    3. increase cost
    4. increase salt
    Answer

    B. swap foods with similar nutrient value

    Foods in a list have about equal energy, protein, fat and carbohydrate per portion.

22. A food provides 10 g protein, 5 g fat and 30 g carbohydrate. Its energy is

    1. 180 kcal
    2. 165 kcal
    3. 250 kcal
    4. 205 kcal
    Answer

    D. 205 kcal

    10x4 + 5x9 + 30x4 = 40 + 45 + 120 = 205 kcal.

23. A diet gives 2,000 kcal and 60 per cent of energy comes from carbohydrate. The carbohydrate in grams is

    1. 480 g
    2. 150 g
    3. 300 g
    4. 1,200 g
    Answer

    C. 300 g

    60% of 2,000 = 1,200 kcal; 1,200 / 4 = 300 g.

24. A person eats 20 g of fat in a day. The energy from this fat is

    1. 180 kcal
    2. 140 kcal
    3. 100 kcal
    4. 80 kcal
    Answer

    A. 180 kcal

    20 x 9 = 180 kcal.

25. A meal has 50 g carbohydrate and 20 g protein and no fat. Its energy is

    1. 180 kcal
    2. 280 kcal
    3. 350 kcal
    4. 210 kcal
    Answer

    B. 280 kcal

    50x4 + 20x4 = 200 + 80 = 280 kcal.

26. A diet gives 2,400 kcal with 15 per cent from protein. The protein in grams is

    1. 360 g
    2. 150 g
    3. 60 g
    4. 90 g
    Answer

    D. 90 g

    15% of 2,400 = 360 kcal; 360 / 4 = 90 g.

27. A diet gives 1,800 kcal with 25 per cent from fat. The fat in grams is

    1. 25 g
    2. 100 g
    3. 450 g
    4. 50 g
    Answer

    D. 50 g

    25% of 1,800 = 450 kcal; 450 / 9 = 50 g.

28. A meal of 600 kcal contains 20 g fat. The percentage of energy from fat is

    1. 30 per cent
    2. 15 per cent
    3. 20 per cent
    4. 45 per cent
    Answer

    A. 30 per cent

    20 x 9 = 180 kcal; 180 / 600 = 30%.

29. A person takes 10 g of alcohol in a drink. Its energy is

    1. 40 kcal
    2. 100 kcal
    3. 70 kcal
    4. 90 kcal
    Answer

    C. 70 kcal

    10 x 7 = 70 kcal.

30. A person eats 250 g carbohydrate in a diet of 2,000 kcal. The share of energy from carbohydrate is

    1. 25 per cent
    2. 50 per cent
    3. 60 per cent
    4. 40 per cent
    Answer

    B. 50 per cent

    250 x 4 = 1,000 kcal; 1,000 / 2,000 = 50%.

31. A 100 g portion of dal gives 24 g protein. The energy from its protein is

    1. 216 kcal
    2. 120 kcal
    3. 24 kcal
    4. 96 kcal
    Answer

    D. 96 kcal

    24 x 4 = 96 kcal.

32. 100 g of a food has 70 g carbohydrate, 8 g protein and 1 g fat. Its energy is

    1. 321 kcal
    2. 290 kcal
    3. 350 kcal
    4. 400 kcal
    Answer

    A. 321 kcal

    280 + 32 + 9 = 321 kcal.

33. An Anganwadi menu for a 4-year-old child should be

    1. energy dense, soft, and made with local foods
    2. very spicy and fried
    3. only liquid sweets
    4. low in oil and protein
    Answer

    A. energy dense, soft, and made with local foods

    Small stomach and high needs call for energy dense, locally acceptable food.

34. Consider: 1. Marasmus is mainly due to energy deficiency. 2. Kwashiorkor is mainly due to protein deficiency with oedema. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct descriptions.

35. Consider: 1. A diabetic person should skip meals to control sugar. 2. Regular timing of meals helps control blood sugar. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Skipping meals can cause swings in blood sugar.

36. Consider: 1. In hypertension pickles and papad are encouraged. 2. In hypertension salt should be reduced. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Pickles and papad are high in sodium.

37. Consider: 1. In diarrhoea, breastfeeding should be continued. 2. In diarrhoea, ORS and zinc are given. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are standard care for diarrhoea.

38. Consider: 1. Vitamin C-rich foods improve iron absorption. 2. Tea at meals improves iron absorption. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Tea reduces iron absorption.

39. Consider: 1. A therapeutic diet should be unrelated to family food. 2. A therapeutic diet is a normal diet modified for a disease. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    It should stay as close to the family diet as possible.

40. Consider: 1. Sprouting increases vitamin content in pulses. 2. Washing rice repeatedly and discarding the water increases B vitamins. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Repeated washing removes water-soluble vitamins.

41. Consider: 1. They should take strong tea and spicy food. 2. Peptic ulcer patients should take small frequent meals. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Spicy food, strong tea and coffee irritate the stomach lining.

42. Match the disease (I) with the diet advice (II). I: a. Hypertension b. Diabetes c. Typhoid d. Anaemia. II: 1. Soft, low fibre diet 2. Low sodium 3. Iron with vitamin C 4. Low glycaemic index foods.

    1. a-3, b-4, c-1, d-2
    2. a-4, b-2, c-1, d-3
    3. a-2, b-1, c-4, d-3
    4. a-2, b-4, c-1, d-3
    Answer

    D. a-2, b-4, c-1, d-3

    Hypertension-low sodium; diabetes-low GI; typhoid-soft diet; anaemia-iron with vitamin C.

43. Match the diet (I) with its use (II). I: a. Clear liquid b. Full liquid c. Soft d. Regular. II: 1. Normal patients 2. Convalescence and ulcer 3. Pre-surgery and severe diarrhoea 4. Fever and acute illness.

    1. a-3, b-2, c-4, d-1
    2. a-1, b-2, c-3, d-4
    3. a-3, b-4, c-2, d-1
    4. a-2, b-3, c-4, d-1
    Answer

    C. a-3, b-4, c-2, d-1

    Clear liquid-pre-surgery/diarrhoea; full liquid-fever; soft-ulcer; regular-normal.

44. Match the food (I) with its group (II). I: a. Ragi b. Dal c. Spinach d. Ghee. II: 1. Fats 2. Protective 3. Body-building 4. Energy-giving (cereal).

    1. a-4, b-2, c-3, d-1
    2. a-4, b-3, c-1, d-2
    3. a-3, b-4, c-2, d-1
    4. a-4, b-3, c-2, d-1
    Answer

    D. a-4, b-3, c-2, d-1

    Ragi is a cereal-millet; dal gives protein; spinach protects; ghee is fat.

45. In which condition should the diet be planned only by a doctor and dietitian?

    1. change of season
    2. mild constipation
    3. dislike of cabbage
    4. chronic kidney disease
    Answer

    D. chronic kidney disease

    Fluid, potassium, phosphorus and protein must be individualised in kidney disease.