Chapter 3: Carry out feeding care plan interventions

Feeding care plan interventions are critical in the practice of Nutrition and Dietetics, especially in managing patients with communicable and non-communicable diseases. These interventions involve tailored dietary counselling and ensuring food safety to optimize nutritional status and support recovery or disease management. In the Kenyan healthcare context, dietitians play a vital role in guiding patients and caregivers through culturally appropriate, evidence-based nutrition advice while emphasizing safe food practices to prevent further health complications.

3.1 Dietary counselling

Dietary counselling is the intervention in which the dietitian talks with a client, and with the person who cooks for the client, to turn the feeding care plan into daily eating. It is a two-way conversation that finds out what the client eats, what the client can change and what the client is willing to do, then agrees on specific actions and follows them up. The content of the advice depends on the disease. In communicable disease the aim is to protect nutritional status and support recovery during infection, and in non-communicable disease the aim is to control the disease and its risk factors over many years. The four types of plan are used in both groups, but the messages differ.

3.1.1 Dietary counselling in communicable diseases

Infections such as HIV, tuberculosis and diarrhoeal disease affect nutrition in several ways, and counselling is built on these effects.

• Raised energy and protein needs: fever, infection and tissue repair increase the need for energy and protein, so a client who eats as before loses weight.
• Micronutrient deficiencies: shortage of vitamin A, vitamin C, zinc and iron weakens defence against infection, and infection in turn lowers the stores of these nutrients.
• Loss and poor absorption of nutrients: diarrhoea and some infections of the gut reduce absorption and cause loss of fluid, salts and nutrients.
• Loss of appetite: infection, mouth sores and some medicines reduce the wish to eat, so intake falls when need is greatest.
• Medicine effects: some medicines cause nausea, taste changes or need to be taken in a set way in relation to food.

The goals of counselling are to raise intake to meet the increased need, correct or prevent micronutrient deficiencies, keep up appetite and intake despite symptoms, help the client manage the food effects of the medicines, and protect the client from foodborne infection.

3.1.1.1 Nutrition education and counselling

The counselling session has a set structure: build rapport, ask about the client's meals and any food problems, agree on one to three priorities, teach the skill, check understanding and arrange the next visit. The messages are chosen for the infection.

• Tuberculosis: explain that the body needs extra energy and protein to recover, encourage three meals and snacks each day with foods such as legumes, eggs, milk and groundnuts, and stress that medicines must be completed even if the client feels better.
• HIV infection: advise on a varied diet, how to manage nausea or mouth sores, and good food safety, since infection is more dangerous when immunity is low. Medicines are taken as the pharmacist and doctor direct.
• Diarrhoeal disease: advise the caregiver to keep feeding and breastfeeding, to give extra fluid and oral rehydration solution mixed in the volume of clean water stated on the packet, and to wash hands with soap before preparing food and after using the toilet.
• Demonstrating: show the caregiver how to mix oral rehydration solution, enrich porridge or wash and prepare vegetables safely, then ask the caregiver to do it.
• Checking and following up: ask the client to repeat the main points, give a short take-home reminder in simple language and agree on the date to review weight and eating.

3.1.1.2 Supplementation

Supplementation in communicable disease covers products that are taken together with food to meet a raised need or to correct a deficiency. Counselling ensures that the client and the caregiver use them correctly.

• Take as directed: the dose, frequency and duration come from the prescriber or national guidelines, and the client is told to follow them and not to take extra.
• Zinc and oral rehydration in diarrhoea: a child with diarrhoea may be given a zinc course together with rehydration, and the caregiver is told to complete the course even when the diarrhoea has stopped.
• Vitamin A and other micronutrients: the caregiver is told which supplements are given at clinic visits and why, and to bring the child's health card.
• Therapeutic and supplementary foods: products used to treat malnutrition during or after infection are for the sick child only and are not shared with other children or used as family food.
• Food first: a supplement adds to meals and does not replace them, so the client is encouraged to keep eating the foods planned.
• Side effects: the client is told what to expect, for example dark stools or constipation with iron, and what to report.

3.1.1.3 Fortification

Counselling on fortification helps clients with an infection to get more nutrients from the food they can afford and tolerate.

• Choosing fortified staples: advise the client to look on the label for fortified flour, cooking oil and iodised salt, and to use them in the usual meals.
• Enriching the meal: show the caregiver how to stir a beaten egg into hot porridge, or add finely ground dried small fish to a sauce or soup, so that a small portion carries more protein for a client with a poor appetite.
• Using micronutrient powders: check with the caregiver that the sachet is mixed into one portion of cooled food and eaten at once.
• Keeping food safe: fortified or enriched food is prepared with clean hands, clean utensils and safe water, as unsafe handling can cause diarrhoea that wastes the added nutrients.
• Realistic expectations: fortification supports the diet and does not replace a varied diet or medical treatment.

3.1.1.4 Diet modification

Diet modification in communicable disease changes the food, the meal pattern or the preparation to suit the symptoms.

• Small frequent meals: five or six small meals and snacks suit a client who feels full quickly or has no appetite.
• Energy- and protein-dense foods: choose dishes that carry more in a small portion, such as porridge made with milk instead of water or a thick bean and vegetable stew.
• Soft and mild foods: clients with mouth sores or sore throat manage soft, moist and mildly seasoned foods better than hard, dry, hot or spicy ones.
• Managing nausea and taste changes: cold or room-temperature foods smell less strong, and small sips of fluid between meals instead of with them help some clients.
• Continue feeding in diarrhoea: feeding is continued with easily digested foods, extra fluid is given, and very sugary drinks and very fatty foods are avoided.
• Safe foods when immunity is low: foods are well cooked, eggs and meat are not eaten raw or undercooked, and unpasteurised milk is boiled.
• Timing with medicines: meals are arranged around the medicines that need an empty stomach or food, as the pharmacist instructs.

3.1.2 Dietary counselling in non-communicable diseases

Non-communicable diseases such as diabetes, hypertension, heart disease, obesity and chronic kidney disease are long-term and are strongly influenced by diet. Counselling has to help the client change habits and keep the change for years. In towns, clients often buy processed foods, drinks and fried snacks that add salt, sugar and fat, so the advice concentrates on reading labels and reducing them. In rural areas, the advice concentrates on using affordable local staples, legumes and vegetables well. In both settings the counselling supports weight management, better quality of carbohydrate, fat and protein, less salt and more fibre.

3.1.2.1 Nutrition education

Nutrition education for non-communicable disease teaches the client how food affects the condition and gives the skills to manage it daily. The main topics are:

• Energy balance and weight: explain how portion size, frequent snacking and sweetened drinks add energy, and set a realistic weight goal.
• Understanding the disease: link the disease to food, for example how carbohydrate raises blood glucose in diabetes and how salt raises blood pressure.
• Reading labels and choosing foods: teach the client to read labels for salt, sugar and fat and to compare similar products.
• Self-monitoring: a food diary, regular weighing and, where prescribed, home measurement of blood glucose or blood pressure show the client what works.
• Behaviour change support: motivational interviewing explores the client's reasons for change, goal setting breaks the change into small steps, and problem solving prepares the client for parties, travel and setbacks.
• Family involvement: because the household shares the food, the person who cooks is included in the sessions.

3.1.2.2 Supplementation

Supplementation in non-communicable disease is used selectively, because food and medicine are the main treatment. Counselling ensures that supplements are taken safely and for a reason.

• Supplements fill specific gaps: vitamin D and calcium may be given to a client at risk of weak bones, and a client who takes metformin over many years may have vitamin B12 checked, as the medicine can lower it. The doctor decides and the dietitian explains.
• Supplements do not replace diet change: vitamin pills do not make up for a diet high in salt, sugar or fat.
• Oral nutritional supplements: drinks are sometimes used for a client with kidney failure or advanced disease who cannot eat enough, and the choice depends on the client's limits for protein, potassium and phosphorus.
• Safety with kidney disease: clients with kidney disease do not take supplements, herbal remedies or salt substitutes that contain potassium without advice from the doctor or dietitian.
• Declare all products: the client tells the doctor and pharmacist about every supplement and herbal product used.

3.1.2.3 Fortification

Fortified foods may help clients with non-communicable disease, but they must fit the client's limits.

• Iodised salt is still salt: it supplies iodine, yet it adds sodium, so a client with hypertension uses less of it in cooking and at the table.
• Check the label: many fortified cereals, drinks and snacks also carry sugar, salt or fat, so a client with diabetes, hypertension or obesity chooses those with little added sugar and salt.
• Fortified oils and flours: these are suitable in the usual amounts, as the client is advised to use oil in measured spoonfuls.
• Calcium and vitamin D: a fortified milk or milk alternative can help a client who needs more of these, within the energy and sugar limits.
• Fortified is not the same as healthy: the benefit of added nutrients does not make up for excess energy, salt or sugar.

3.1.2.4 Diet modification

Diet modification is the main dietary treatment in non-communicable disease. The change is set to the condition, and the dietitian helps the client to find swaps within foods already eaten.

Counselling gives the client a short list of changes to start with, because many changes at once are hard to keep. Changes are reviewed at follow-up visits and adjusted to the client's weight, blood glucose, blood pressure or blood fats.

Chapter Summary

This chapter explored the execution of feeding care plan interventions with a focus on dietary counselling tailored for both communicable and non-communicable diseases. It detailed the components of dietary counselling including nutrition education, supplementation, fortification, and diet modification, illustrating how these elements address the specific nutritional needs arising from different disease conditions. Emphasis was placed on safe food handling procedures, highlighting the critical roles of personal hygiene, proper food storage, individualized food preparation, and careful serving and consumption to prevent contamination and ensure client safety. Various types of safe food handling techniques were discussed to reinforce best practices in nutrition care. The chapter also underscored the significance of thorough documentation of client feeding plans, ensuring continuity of care and effective monitoring of nutritional interventions. Together, these topics provide a comprehensive framework for implementing feeding care plans that support recovery and health maintenance.