Chapter 1: Assess systemic disorder client

In the practice of nutrition and dietetics within Kenya’s health sector, assessing clients with systemic disorders requires meticulous attention to safety and hygiene protocols. Nutrition professionals often work closely with patients suffering from conditions such as diabetes, cardiovascular diseases, renal failure, and infectious diseases, where exposure to biological hazards is likely. The use of Personal Protective Equipment (PPE) is crucial to protect both the client and the practitioner during nutritional assessments, ensuring safe handling of clinical materials and minimizing cross-contamination risks. This chapter focuses on understanding PPEs, their types, and their significance in the context of diet therapy for systemic disorders.

1.1 Definition of terms

Diet therapy rests on a small set of terms that every member of the health team must use in the same way. A dietitian who writes "therapeutic diet" or "diet modification" in a client's record must mean what the physician and the nurse understand when they read it. This topic defines six terms used throughout the unit: nutrition, therapeutic diet, diet modification, normal diet, nutrition care and diet therapy. The examples come from the care of clients with systemic disorders, which are conditions that affect several organs or the body as a whole, such as liver disease, febrile illness and HIV infection.

1.1.1 Nutrition

Nutrition is the way in which the body obtains food, breaks it down, absorbs the nutrients and puts them to use for energy, growth, repair of tissues and protection against disease. The word also names the science that studies how food and health are linked. A person is well nourished when the intake of each nutrient matches the body's need. A mismatch gives malnutrition, which covers undernutrition, overnutrition and deficiency of a particular vitamin or mineral. Example: a clinic client with tuberculosis who loses weight over three months is undernourished because the illness raises the body's needs while appetite and intake fall.

Classes of nutrients

The food a client eats supplies seven groups of substances that the body uses.

• Carbohydrates: a major source of energy, found in maize, rice, millet, cassava, potatoes and bread.
• Proteins: build and repair tissues and make enzymes and antibodies, found in beans, lentils, eggs, fish, meat and milk.
• Fats and oils: give concentrated energy and carry vitamins A, D, E and K, found in cooking oil, groundnuts and avocado.
• Vitamins: needed in small amounts to regulate body processes, for example vitamin A for the eyes and for resistance to infection.
• Minerals: build the body and regulate its chemistry, for example iron for the blood, calcium for the bones and iodine for the thyroid gland.
• Water: carries nutrients and waste, and helps to control body temperature, so fever and diarrhoea quickly raise the need for it.
• Dietary fibre: is not digested but keeps the bowel working well and slows the absorption of sugar.

Nutrition in illness

Illness can change the balance between need and intake in four ways: it can raise the need, as fever and infection do; it can reduce intake, as loss of appetite, nausea and pain do; it can reduce absorption, as diarrhoea and bowel disease do; and it can increase losses, as vomiting, sweating and wounds do. This is why the nutritional status of every client with a systemic disorder is assessed at the start of care.

1.1.2 Therapeutic diet

A therapeutic diet is a diet planned to treat a disease or condition, or to help the body recover from it, by changing what the client eats, how much, or in what form. It differs from the normal diet in at least one way and is written as a diet order that the kitchen, the nurse and the client can follow. The dietitian plans it with the physician, who is responsible for the medical treatment. Example: a client on a medical ward with cirrhosis and fluid in the abdomen receives a diet with a limited amount of salt, so that less water is held in the body.

Common therapeutic diets

Six kinds of therapeutic diet are named here so that the terms are familiar. Each is planned in detail when the feeding plan is formulated.

• Texture-modified diet: changes the thickness or firmness of food, from clear and full fluids to soft and pureed food, for clients who cannot chew or swallow safely or whose bowel needs rest.
• Energy- and protein-enriched diet: raises the amount of energy and protein in each meal for clients who are wasting, for example during chronic infection.
• Sodium-controlled diet: limits salt and salty foods for clients who retain fluid.
• Fat-modified diet: changes the amount or the spread of fat eaten, for example small low-fat meals during a gallbladder attack, for clients with disease of the gallbladder, pancreas or liver.
• Carbohydrate-controlled diet: controls the type and amount of carbohydrate for clients whose blood glucose is raised.
• Fluid-restricted diet: limits the total amount of fluid for clients who cannot pass or remove fluid normally.

1.1.3 Diet modification

Diet modification is the act of changing the normal diet to meet the needs of a client who is ill. It is the method, and the therapeutic diet is the result. A diet can be modified in the amount of energy or of a nutrient, in the texture or consistency of the food, in how often meals are given, in the foods included or removed, and in the way the food is prepared. The aim is to change as little as the condition requires, so that the client still eats enough, enjoys the food and keeps to the plan. Example: a client with painful, inflamed bowel may be given the same maize meal as the family, but cooked softer as porridge and eaten in five small meals instead of three large ones.

Ways of modifying a diet

• Quantity: increasing or reducing the energy or a nutrient, such as protein or salt.
• Quality: replacing one food or type of fat with another, such as using vegetable oil in place of hard cooking fat.
• Consistency: changing the texture of the food, for example mashing or blending it.
• Frequency: dividing the day's food into smaller, more frequent meals.
• Exclusion: removing a food that causes harm or symptoms, such as alcohol in liver disease.
• Preparation: changing the cooking method, the amount of salt or oil, or the way food is served.

Principles of diet modification

A modification is written for one client, not for a disease. It keeps the diet adequate in all nutrients that are not being restricted, uses foods that are available and affordable to the household, respects the client's beliefs and food habits, and is reviewed as the client's condition changes.

1.1.4 Normal diet

A normal diet, also called a regular or general diet, is a diet that supplies enough energy and nutrients for a healthy person of a given age, sex and level of activity, with no restriction on any food group. It is the point of comparison for diet therapy: the dietitian asks how far the client's intake differs from a normal diet and what change the illness requires. Example: a plate of ugali, beans and sukuma wiki, followed by a fruit, is a balanced normal meal for an adult, and it can be modified for a client by changing the texture or the amount of salt.

Features of a normal diet

• Adequate: it supplies the energy and nutrients the body needs for its activity and state, so that weight is kept steady in an adult.
• Balanced: it combines staples, protein foods, vegetables, fruits and a small amount of fat in sensible proportions.
• Varied: it uses different foods within each group, so that no single vitamin or mineral is missed.
• Safe: the food is clean, properly cooked and stored.
• Acceptable: it fits the family's culture, taste and income, so that people can keep to it day after day.

A normal diet is not the same for everyone. A pregnant woman, a growing child and a farm labourer each need different amounts, although the same balance of food groups applies.

1.1.5 Nutrition care

Nutrition care is the whole of what the nutrition professional does to help a client reach and keep good nutritional status. It follows a set sequence called the nutrition care process, which is repeated for as long as the client is under care. The four steps are the pattern of this unit.

1. Nutrition assessment: collecting and interpreting information about the client's food intake, body measurements, laboratory results and clinical signs.
2. Nutrition diagnosis: naming the nutrition problem, its cause and the evidence for it in a short statement.
3. Nutrition intervention: planning and carrying out the feeding care plan, including counselling and the choice of feeding route.
4. Nutrition monitoring and evaluation: checking whether the plan is working, then adjusting the plan, or referring the client, when it is not.

Example: a client with chronic diarrhoea from HIV infection is assessed and found to be losing weight on a low intake; the diagnosis names inadequate energy intake; the plan adds small frequent meals, oral rehydration solution between meals and soft moist foods; and the dietitian weighs the client at each visit to see whether the weight is stable. Nutrition care also includes working with the other health professionals and recording each step.

1.1.6 Diet therapy

Diet therapy is the use of diet to treat a disease, relieve its symptoms, support recovery and prevent complications. It is part of medical care and works together with medicines, procedures and nursing care, not in place of them. Diet therapy is delivered through therapeutic diets, which are made by modifying the normal diet, and it is guided by the steps of nutrition care.

Aims of diet therapy

• Correct deficiencies: replacing nutrients that are low, such as iron in anaemia or vitamin A in a malnourished child with measles.
• Restore and maintain nutritional status: stopping weight loss and rebuilding lost tissue.
• Relieve symptoms: easing nausea, diarrhoea, pain after eating and swelling from fluid.
• Prevent complications: for example, avoiding dehydration in diarrhoea or bleeding from irritation of the gut.
• Support treatment: helping medicines to work, for example by timing meals with medicines as the pharmacist advises.

Example: a client with chronic inflammation of the pancreas eats small, frequent meals through the day, avoids alcohol, and takes with each meal and snack the enzyme medicine that the physician has prescribed. The dietitian plans and teaches the diet, the physician prescribes the medicine, and the two together relieve the client's symptoms and protect nutritional status.

Chapter Summary

This chapter provides a comprehensive overview of assessing clients with systemic disorders in the context of diet therapy. It begins by defining the nutrition disorder client and explaining the concepts of therapeutic diets, diet modification, normal diets, nutrition care, and diet therapy as essential components in managing such clients. The importance of personal protective equipment is introduced, detailing its types and significance in ensuring safety during client assessment and care. Various systemic disorders are explored, including digestive disorders affecting the gastrointestinal tract, pancreas, liver, and gallbladder, as well as febrile conditions such as malaria, typhoid, tuberculosis, and HIV/AIDS. The chapter then presents several methods of dietary assessment, including the 24-hour dietary recall, food frequency questionnaire, diet history, and dietary diversity score, which are vital for accurate nutritional evaluation. It proceeds to discuss nutrition diagnosis, focusing on identifying problems, determining etiology, and recognizing signs and symptoms associated with systemic disorders. Finally, the formulation and documentation of the nutrition diagnostic PES statement are explained as critical steps in developing an effective nutrition care plan.