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General principles of clinical nutrition

 Feeding during the illness should restore balance in the body by adapting the chemical composition and physico-chemical state of food in exchange characteristics of the organism.

Any diet has an effect not only on the affected organ, but also on the whole organism. Sparing and training the sick organ regimes are built taking into account the main violations that characterize this disease. There can be no universal sparing, “easy” diet. A diet that makes little demands on the stomach can put a lot of stress on other organs, such as the liver.

Sparing diets are always associated with a known restriction in food. In this case, the patient receives insufficient nutrition, in connection with which prolonged adherence to such a regimen affects the general condition of the body. Mild diets should be used for a limited time and be considered only as the first stage of treatment. In the future, freer, training diets are prescribed that stimulate compensatory mechanisms and allow the patient to receive a more diverse and nutritious diet. The principle of "training" can be carried out by a step system or a zigzag system. In the first case, a strictly limited diet is expanded gradually. The zigzag system provides for a relatively sharp short-term change in diet. Such diets and, accordingly, the days of their use are called contrasting. So, sometimes against the background of strict diets, patients are periodically given more general nutrition for a short time. This kind of load exerts an exciting effect on the body and is beneficial for a sluggish course of the disease.

Unloading diets, the so-called fasting days (fruit, vegetable, dairy, cottage cheese, etc.) are widely recommended. Such diets have a stimulating effect on the body, at the same time, the unloading of the digestive and metabolic organs meets the requirements of their sparing.

In addition to the quantity and quality of food, diet is essential - the time of eating, the intervals between meals, distribution throughout the day. Clinical nutrition should be designed in such a way that the meal was at least 4-5 times a day. Long breaks in food lead to irritation of the nervous system, to overloading the digestive organs, since a lot of food is consumed at one time, which makes digestion difficult. If the patient always eats at the same time, he develops a conditioned reflex at the time of eating. The digestive organs, as it were, are preparing for this, and thereby the process of digestion and assimilation is improved.

In order for the diet to favorably affect the patient's body, food must be subjected to certain culinary processing and at the same time take care of maintaining its nutritional values. However, the food should be tasty and give pleasure to the patient. In this regard, not only the method of preparation plays an important role, but also the design of the dish, the environment in which the person eats.

Each medical diet is prescribed only by the attending physician. They are used in a specific, relatively short period. Only in rare cases, medical nutrition has to be used constantly.

Nutrition and the occurrence of diseases of the digestive system

Digestive system diseases often lead to temporary disability, and sometimes even disability.

Acute and chronic diseases of the stomach and intestines most often occur due to a violation of the diet (irregular meals and long breaks between them), eating poor-quality and indigestible food, overeating and insufficient chewing, abuse of spicy dishes, dry food, and also a monotonous malnutrition. With long breaks in food, appetite increases sharply, which is accompanied by the release of gastric juice even when food has not yet entered the stomach. The secreted gastric juice does not interact with food, but with the mucous membrane of an empty stomach, causing irritation, which leads to the development of acute inflammatory processes that turn into chronic ones.

A certain influence on the occurrence of chronic diseases of the digestive system is exerted by food temperature. Very cold (temperatures below 7 ° C), as well as excessively hot (temperatures above 70 ° C) foods and drinks cause digestive disorders. From cold food, the excretory function and acidity of the contents of the stomach increase, followed by their reduction and weakening of the digestive power of the gastric juice. The use of excessively hot food leads to atrophy of the gastric mucosa, which is accompanied by a sharp decrease in the secretion of hydrochloric acid and pepsin in the gastric juice.

Diseases of the stomach, in particular chronic gastritis, can occur as a result of overloading the stomach with plentiful food. Digestion of excess amounts of food requires increased activity of gastric juice, but since its intake is insufficient in comparison with the volume of food, the processes of gastric and intestinal digestion are delayed. This leads to incomplete breakdown of foods.

Defective, unilateral nutrition has a negative effect on the functional state of the digestive system. For example, insufficient intake of proteins often reduces gastric secretion and impairs liver function. The lack of vitamins in food also has an adverse effect.

The reasons for diseases of the stomach and intestines are irritants such as alcohol and nicotine.

Clinical nutrition in chronic gastritis

Chronic gastritis is a prolonged inflammatory state of the gastric mucosa, in which its secretory function is impaired: in some cases, secretion increases, excessively much gastric juice is secreted; in others, on the contrary, the secretion of gastric juice and the content of hydrochloric acid in it are reduced.

In chronic gastritis with increased secretion of gastric juice, the diet should be designed for mechanical sparing of the stomach, inhibition of secretory function (chemical sparing) and for accelerating the evacuation of food from the stomach. This is done by appropriate selection of food products and their culinary processing.

Mechanical sparing involves reducing each serving of food while increasing the number of meals up to 5-6 times a day. Food should not be coarse, that is, it should not contain a lot of dietary fiber (fiber) and hard-to-digest fats (lard, lamb and beef fats, overalls, etc.). Avoid eating too cold or hot food. Food should be well chopped, for this food products are boiled, rubbed through a sieve or passed through a meat grinder.

In order to avoid chemical irritation of the stomach, substances and products that stimulate the secretory activity of the stomach are excluded from food: alcoholic beverages, beer, smoked meats, marinades, pickles, cocoa, spices, fried meat and fish, cheese, canned food, meat and fish broths (broths), bread from rye flour, carbonated drinks, strong tea and coffee, cabbage, cucumbers, vegetable juices.

Weak secretion pathogens are recommended (boiled vegetables and fruits, boiled meat, pumpkin, carrots) and secretion inhibiting substances (cream, fat milk, fat cottage cheese, soft-boiled eggs, vegetable fats, sugar, starch, steam cutlets, boiled fish, white dried bread , cottage cheese, cheese curd puddings).

With a pronounced exacerbation of gastritis, treatment usually begins with the introduction of a strict diet (diet No. 1a) and, as health improves, they switch to a less strict one (diet No. 16), gradually adapting the digestive system to an expanded rational diet. First, the diet includes individual dishes of general nutrition, then the food is brought closer to normal. For 2-3 days a week, contrast food is used, followed by a return to the diet.

Strict diets (Nos. 1a and 16), of course, limit the use of certain foods, so such diets are prescribed for a short time, followed by a transition to a more diverse assortment of foods and dishes.

Gastritis with reduced secretion requires mechanical sparing of the stomach and stimulation of its secretory activity (diet No. 2 is introduced). Therefore, the diet includes meat, fish and vegetable decoctions, kefir, in a limited amount of pickles.

Fresh bread and other fresh pastry, fatty meats and fish, spicy, salty dishes, cold drinks, ice cream are forbidden. The principles of mechanical gastric sparing and diet remain the same as in chronic gastritis with increased secretion.

Dietolechenie peptic ulcer

Clinical nutrition for peptic ulcer disease is aimed at creating the most favorable conditions for ulcer healing, which can be achieved by mechanical sparing of the gastric mucosa, inhibition of gastric secretion and reduction of peristalsis of the affected organ.

Functional sparing of the gastric mucosa involves frequent (at least 6 times a day) meals in small portions with the use of liquid and jelly-like foods during an exacerbation. Frequent meals contribute to the binding of hydrochloric acid in the stomach and thereby "prevent the occurrence of pain and heartburn, which prevents the occurrence of constipation, which patients with peptic ulcer are prone to. This ensures regular entry into the intestines of bile and pancreatic juices, improves digestion and absorption of nutrients.

Diet for peptic ulcer should be complete in the content of proteins, fats, carbohydrates and vitamins. Proteins improve ulcer scarring, reduce the acidity of gastric juice, so it is useful to include a sufficient amount of meat, dairy and egg products in food. Butter and vegetable oils, cream inhibit the secretion of gastric juice and thereby increase the therapeutic effect of the diet. Simple carbohydrates during an exacerbation of peptic ulcer disease should be limited in the diet, as they can intensify hungry night pains, dyspeptic symptoms. At all stages of treatment, it is necessary to take care of the sufficient intake of vitamins and minerals with food.

During a sharp exacerbation of peptic ulcer disease, accompanied by severe pain, diet No. 5a is prescribed for 7-1 days. In this case, the patient is usually in a hospital and adheres to bed rest. He is given slimy soups of semolina, rice, oatmeal with the addition of an egg-milk mixture. Meat and fish dishes are prepared once a day from minced meat twice passed through a meat grinder in the form of a steam soufflé. Allowed whole and condensed milk, cream, pureed fresh cottage cheese with milk, curd steam soufflé. You can eat up to 1 eggs a day, boiled soft-boiled or cooked as a steam omelet. Only pureed vegetables are allowed. Porridge is also prepared pureed: from rice, semolina, oat and buckwheat with the addition of milk or cream. Drinks are recommended tea with milk or fresh cream, rosehip decoction, sweet fruit and berry juices diluted with water, jelly. At this stage of treatment, bread and bakery products are excluded from the diet.

At the second stage, when the exacerbation decays, a diet No. 16 is prescribed (for 5-7 days). At the same time, wheat crackers (1-75 g per day) are added to the products provided for by diet No. 150a. For meat and fish dishes, steam cutlets, meatballs, vegetable dumplings - potato, carrot, beetroot puree with milk and butter, and steam soufflé are used. Dairy, sour cream or egg-butter sauces are allowed.

After 10-14 days from the start of treatment, they switch to diet No. 1, which is recommended to be followed after discharge from the hospital for another 2-4 months. Compared to the diets described above, diet No. 1 consists of more diverse foods. It contains dishes either boiled or steamed and provides for frequent meals in small portions.

Diet No. 1 consists of the following basic products: yesterday’s wheat bread, white crackers, unbread cookies, baked pies with meat and eggs, rice and apples, jam from sweet varieties of apples and fresh fruits, cheesecakes with cottage cheese, milk, cream, soft-boiled eggs , boiled or steamed meat and fish of low-fat varieties, cottage cheese, mild cheese, soups and cereals from mashed cereals (rice, oatmeal, buckwheat and semolina), jelly, tea, jelly. Butter and vegetable oils are added to the finished dishes. The diet includes boiled and sometimes mashed potatoes, carrots, beets, cauliflower, zucchini, pumpkin, green peas. Ripe tomatoes - up to 100-150 g per day.

According to this diet, products that irritate the gastric mucosa and are slowly evacuated from it are contraindicated: refractory fats (beef, mutton, goose), turnip, radish, radish, peas, legumes, fruits with rough skin and berries, sinewy and fatty meat, fatty fish, goose and duck meat, hard-boiled eggs, brown bread, as well as products stimulating the secretory activity of the stomach: fried and smoked fish and meat products, pickles, spices and marinades, fish and meat broths, vegetable and mushroom broths, cabbage, cold drink Ice cream. Prohibited alcoholic beverages, coffee, cocoa.

You should not stay on diet No. 1 for a long time in a satisfactory condition, especially in cases when the patient, after recovery, performs work at work associated with significant physical exertion. However, the transition to a common diet should be carried out gradually, by including in the diet more and more foods that are not subjected to significant mechanical processing. But even during the period of remission (no exacerbation), it is necessary to limit oneself in the use of foods that are active stimulants of gastric secretion and to eat at least 4 times a day.

Meals patients after gastrectomy

Treatment of patients after resection (partial removal) of the stomach in the first stage is carried out in a hospital. This creates maximum peace of the digestive system, which contributes to wound healing. In the first 2-3 days, patients are injected with nutrient fluids into a vein. On the third or fourth day, with good health and no signs of stagnation in the stomach, they are prescribed liquid and jelly-like foods (tea with a little sugar, jelly, broth of wild rose) - 2 tablespoons 6-7 times a day. On the fifth or sixth day, you can eat soft-boiled eggs, mucous soups, meat and curd puree or soufflé. Food is taken 5-6 times a day, 70-100 ml.

From the seventh day, the diet expands due to the inclusion of protein egg omelet and porridge. By the tenth day, potato and carrot puree, meat and fish steamed soufflé, dumplings or meatballs, soft-boiled eggs, protein omelette, curd souffle are introduced into the diet. Food is taken 5-6 times a day for 200-300 g, with each meal, protein dishes are used.

Starting from the second week, for 2-4 months, a diet with mechanical gastric sparing is recommended. This is a physiologically complete diet, valued at 12 561 kJ, containing 140 g of protein, 110 g of fat and 380 g of carbohydrates. An increased amount of proteins in it is necessary to improve metabolic processes. All dishes should be boiled, steam, mashed. Both hot and cold meals should be avoided.

Of the protein-rich foods, lean meats in the form of paste or jelly and fish are used. It is recommended to use one soft-boiled egg per day (or omelet from one egg), freshly acidified pureed mashed cottage cheese, milk (with tea or in dishes), mild grated cheese.

Are useful creamy (fresh and baked) oil, vegetable oil. Sour cream and cream are used only for filling dishes.

The content of carbohydrates in the diet should be within the lower limit of the norm (due to the restriction of simple carbohydrates). Complex carbohydrates in the form of starch, slowly absorbed, do not lead to abrupt changes in enzyme and hormonal systems, which reduces the risk of complications after gastric resection. The use of sugar is limited to 40 g per day. Allowed wheat bread of yesterday's baking, croutons from it, uncooked biscuits, boiled mashed vegetables, fruit and berry unsweetened mashed compotes, jelly, jelly, mousses, unsweetened juices (except for grape), viscous cereals, puddings, casseroles of rice, rolled oats, finely chopped pasta.

Within 4 months after the resection of the stomach, the use of sugar, honey, jam, sweets, fruits with coarse fiber, especially grapes, edible salt (up to 10 g) is limited.

It is forbidden to consume pastry, brains, liver, kidneys, pickles, smoked sausages and fish, cold and carbonated drinks, cocoa, chocolate, ice cream, white cabbage, legumes, spinach, sorrel, radishes, rutabaga, onions, garlic, spices, mushrooms, alcoholic beverages of any strength.

4 months after the resection of the stomach (sometimes later), it is recommended to switch to a “non-mashed” diet, which contains 140 g of protein, 110 g of fat, 390 g of carbohydrates. The energy value of such a diet is 12 979 kJ. The amount of table salt in it is increased to 15 g per day. Dishes are cooked boiled or steam, served uncooked. Allowed to use separate dishes baked without a rough crust. Go to ungrated food should be gradual. First, a limited amount of non-mashed vegetables are given in the first courses. Then included wheat-rye (slightly stale) bread, sauerkraut, various salads.

After 6-12 months after resection of the stomach in the absence of complications, you can switch to a diet with the usual culinary processing of products. However, the patient must comply with the principle of frequent meals in small portions and restriction of dishes that provoke exacerbation (sweets, sweet milk porridges, very hot and cold dishes). Food should be taken slowly, chewing carefully.

Special diets without bread, vegetables, fruits, eggs, milk have been developed.

 Dairy-free diet. Whole milk and dairy products, including milk powder, butter, cheese, are excluded. Sauces and seasonings containing milk and dairy products, cookies, pastries, cakes, pies and breads made with milk, sweets for the manufacture of which milk is used are excluded.

 A diet without eggs. Eggs, as well as dishes that contain even a small amount of egg white or yolk, are completely excluded. Mayonnaises, creams and sauces containing eggs are prohibited; varieties of bread, pastries, cookies and sweets made using eggs; soups with eggs.

 Bezzlakovaya diet. Cereals and cereal products are excluded, including white bread, cookies, wheat flakes, cakes, biscuits, waffles, pancakes, pies, as well as all products containing flour.

To reliably exclude suspected products, the patient is recommended to have separate dishes. The condition of the patient may be affected by food taken by other family members, since the smell of some products can maintain the state of allergization and prevent the complete exclusion of the allergen.

To identify the allergen, it is recommended to eat simpler food, with fewer ingredients, that is, limit the range of products for each meal. At the same time, during the day, you need to diversify the menu so that there is no excessive consumption of the same product that can increase the body's sensitivity to adverse factors. You can use the so-called rotational principle of diet, which is as follows. Each product suspected of allergenicity is consumed no more than once every 5-7 days. In many cases, this avoids sensitization of the body (increased sensitivity to adverse factors). It is advisable to draw up a weekly menu in which the use of foods with a probable or proven allergenic effect is not more often than once a week.

It should be remembered that the exclusion of an allergenic product for a sufficiently long period of time, which is determined individually in each case, leads in many patients to a loss of hypersensitivity to this product. This is due to the disappearance from the blood and tissues of antibodies to the corresponding food allergens.

Reducing the symptoms of allergic diseases contributes to the culinary processing of food (cooking, frying, etc.), leading to the denaturation (loss of properties) of proteins.

Of the recommended foods for food allergies, the following are preferred: beef, rabbit meat, kefir, yogurt, cottage cheese, sour cream, carrots, rutabaga, fruits (especially baked apples, pears and plums), pumpkin, turnips, as well as rice, corn, millet, oatmeal and pearl barley. It is very important to cook food only from fresh products stored in the refrigerator for no more than one day. Do not eat hot.

Prevention of allergies should be carried out in early childhood. Even during pregnancy, and then feeding the baby to women suffering from allergic diseases, it is forbidden to use products with a high allergenic potential. These same products must be excluded from the diet of children whose parents have allergic diseases.

An important preventive measure is the reasonable use (only as prescribed by a doctor) of antibiotics and other medicines, often causing drug allergic reactions that change reactivity in general.

Dietetic therapy at an atherosclerosis, chronic ischemic heart disease and myocardial infarction

When building a diet for patients with atherosclerosis and coronary heart disease, it is necessary to take into account, on the one hand, the main mechanisms of the development of diseases, their phase, stage and nature of concomitant diseases, and on the other hand, the peculiarities of the influence of individual nutrients on the function of the body's regulatory systems.

In the diet for patients with atherosclerosis, foods containing cholesterol and saturated fatty acids (butter, egg yolk, liver, kidneys, brains, etc.) rich in ergocalciferol (fatty fish, liver) are limited. Foods containing easily digestible simple carbohydrates (sugar, honey, confectionery), dishes with extractives are limited in the diet. The consumption of table salt should not exceed 8 g per day, butter - 15-20 g per day, eggs - 2-3 pcs. in Week. The diet should include vegetable fats.

Proteins for atherosclerosis are recommended in sufficient quantities (about 100 g per day). Of these, 60% should be animal proteins that come with fish, low fat cottage cheese, lean meat, milk, egg white, rich in essential amino acids and choline.

The diet needs to be enriched with vitamins, especially ascorbic acid, vitamin P, pyridoxine, nicotinic acid, riboflavin, cyanocobalamin, inositol, found in blackcurrant, rosehip, sweet pepper, lemons, apples, legumes, buckwheat, meat, wholemeal bread.  It should be included in the diet of potassium, magnesium, iodine salts. The source of potassium is fruits and vegetables; magnesium - buckwheat, carrots, apricots; iodine - seafood (sea fish, shrimp, squid, seaweed).

It is forbidden to use fatty varieties of meat and fish, fatty meat broths, beef and mutton fats, fatty sausages, ham, sprats, fatty creams, white bread, ice cream, chocolate, pastry, marinades, pickles, coffee, alcoholic beverages.

The basic principles of clinical nutrition for chronic coronary heart disease are the same as for atherosclerosis.

Therapeutic nutrition in acute myocardial infarction depends on the period of the disease and motor regimen. So, in the first 2-3 days of acute myocardial infarction, the patient is recommended juices (carrot, apple, plum, beetroot), rosehip broth, kefir, yogurt, and compote. The total energy value of the diet should be 2093-2512 kJ, and the amount of injected liquid should not exceed 400-500 ml. It is recommended to eat 6-8 times a day in small portions. It is not recommended to use grape juice and milk, as they increase flatulence, as well as tomato juice, which stimulates blood coagulation. Limit the use of edible table salt. Useful baked potatoes containing potassium salts, preventing heart rhythm disturbance and having a diuretic effect.

Starting from the fourth day from the onset of the disease and for 8-12 days, the energy value of food is increased to 3768-4605 kJ. Fluids are given to the patient no more than 800 ml per day. Eat should be 5-6 times a day, mashed, in a warm form. Vegetable and cereal soups, buckwheat, oatmeal, mashed potatoes, low-fat meat and fish, steamed meatballs and meatballs, soufflé, mashed fruits and vegetables, kefir, yogurt, jelly, crackers are recommended.

From the fourteenth to fifteenth day, the patient's diet value should be 6699 kJ per day, and the amount of fluid in it should not exceed 800 ml. The amount of salt consumed is still limited (up to. 3 g per day). Food - six times a day. The diet expands due to the inclusion of low-fat boiled meat and fish in a piece, vegetable, cereal, milk soups, chopped vegetables, non-mashed cereals, stale white bread (150 g). The composition of dishes increases the amount of butter (up to 20-25 g) and sugar (up to 40-50 g).

From the fourth week, when the patient is allowed to walk, the diet's value expands to 8374–9211 kJ due to proteins (70–80 g), fats (60–70 g) and carbohydrates (220–250 g). The daily amount of salt is increased from 3 to 5 g. The intake of free fluid is 800-900 ml. Food is taken 5 times a day. The diet is complemented by chopped raw fruits and vegetables, pasta, lean meats and poultry, boiled and then fried in a piece or baked. Sugar consumption increases to 50-60 g, butter - up to 25-30 g. For the prevention of constipation, you must include kefir, yogurt, plum, carrot and beetroot juices in the diet.

Excluded from food are foods that cause constipation and fermentation processes in the intestines: fresh milk, legumes, grape juice, fresh bread; rich in edible salt - pickles, seasonings, spicy marinades, as well as drinks that stimulate the activity of the heart (strong tea, coffee, alcohol).

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