Nutrition and Dietetics III: Nutrition Policies and Programmes, Food and Nutrition Security, Clinical and Therapeutic Nutrition, Diet Counselling, and Research Designs
2. Clinical and therapeutic nutrition
A therapeutic diet is the normal diet modified to meet the needs of a disease. It may be modified in consistency (clear liquid, full liquid, soft, regular), in energy, in one or more nutrients (protein, fat, sodium, potassium, fibre), in the frequency of feeding, or in the route: enteral feeding by tube into a functioning gut, or parenteral nutrition into a vein when the gut cannot be used. The guiding rule is to modify as little as the condition requires, so that the diet stays as close as possible to the patient's usual food and stays acceptable.
| Condition | Textbook dietary principles |
|---|---|
| Diabetes mellitus | Energy to reach and keep a healthy weight; regular meals; complex, high-fibre carbohydrates of low glycaemic index; limited free sugars; carbohydrate distributed through the day and matched to medication |
| Hypertension | Sodium restriction (the WHO advises under 2 g sodium, about 5 g salt, a day for adults); the DASH pattern rich in fruits, vegetables, whole grains and low-fat dairy; weight control; limiting alcohol |
| Coronary heart disease and dyslipidaemia | Saturated fat below 10 per cent and trans fat below 1 per cent of energy; more fibre, fruits and vegetables; omega-3 sources |
| Obesity | A moderate energy deficit (about 500 kcal a day gives roughly half a kilogram of loss a week), adequate protein, fibre, physical activity and behaviour change |
| Chronic kidney disease | Protein moderated before dialysis and raised on dialysis; control of sodium, potassium, phosphorus and fluid according to stage |
| Liver disease | Hepatitis: high energy, adequate protein, small frequent meals; cirrhosis: protein is no longer routinely restricted, sodium is limited when there is ascites |
| Diarrhoea (children) | Low-osmolarity oral rehydration solution and zinc for 10 to 14 days, continued feeding and breastfeeding |
| Fevers such as typhoid | High energy and protein to offset raised metabolism and tissue breakdown, plenty of fluids, soft easily digested foods |
| Coeliac disease | Lifelong gluten-free diet excluding wheat, barley and rye |
The glycaemic index compares the rise in blood glucose after a food with that after the same amount of available carbohydrate as glucose (glucose = 100); a GI of 55 or less is low, 56 to 69 medium and 70 or more high. The glycaemic load also accounts for the amount eaten: GL = GI × grams of available carbohydrate in the portion / 100, with 10 or less low and 20 or more high. A portion with 50 g of available carbohydrate and a GI of 70 has a GL of 35; a portion of 30 g at a GI of 40 has a GL of 12. So a high-GI food eaten in a small amount can have a low load.
3. Diet counselling and management
Diet counselling is a supportive process in which the counsellor helps the client set priorities, establish goals and create individualised plans that the client takes responsibility for. It moves through rapport building, assessment of the client's diet, lifestyle, resources and readiness, joint goal setting, planning and teaching, and follow-up with monitoring and revision. Advice that ignores the family's food habits, budget and cooking arrangements is seldom followed, however correct it is.
| Stage of change (Prochaska and DiClemente) | Client's position | Counsellor's task |
|---|---|---|
| Precontemplation | Not considering change | Raise awareness of risks without pressure |
| Contemplation | Thinking about change, ambivalent | Explore pros and cons, resolve ambivalence |
| Preparation | Intends to act soon | Set small, specific goals and a plan |
| Action | Changing behaviour | Reinforce, solve problems, prevent relapse |
| Maintenance | Sustaining change for months | Support, follow-up, plan for high-risk situations |
Motivational interviewing, developed by Miller and Rollnick, is a client-centred style suited to the early stages: it uses open questions, affirmations, reflective listening and summaries to draw out the client's own reasons for change, rather than arguing for it. Directive counselling tells; non-directive counselling follows the client; most dietitians work eclectically, combining information with the client's own choices.
4. Research methods II: research designs, principles and purpose
A research design is the plan and structure of an investigation, conceived to obtain answers to research questions and to control variance. It follows from purpose: exploratory research seeks insight into a little-understood problem, descriptive research portrays characteristics and frequencies, and explanatory or causal research tests cause-and-effect relationships. R. A. Fisher's three principles of experimental design are replication (repeating treatments to estimate error), randomisation (allocating units by chance to remove bias) and local control (grouping similar units into blocks to reduce error). Fundamentals and ethics were set out in chapter 2; types of research follow in chapter 8.
| Design (Campbell and Stanley notation: R random assignment, X treatment, O observation) | Structure | Comment |
|---|---|---|
| One-shot case study (pre-experimental) | X O | No comparison; weakest |
| One-group pretest-posttest (pre-experimental) | O X O | History and maturation cannot be ruled out |
| Non-equivalent control group (quasi-experimental) | O X O / O O, groups not randomised | Common in field trials with intact villages or schools |
| Pretest-posttest control group (true experimental) | R O X O / R O O | Randomisation controls most threats to internal validity |
| Solomon four-group (true experimental) | Four randomised groups, two pretested, two not | Detects the effect of the pretest itself |
| Factorial design | Two or more factors crossed, e.g. 2 × 3 = 6 treatment combinations | Tests main effects and interactions |
- Completely randomised design: treatments allotted wholly at random; suits homogeneous units, as in laboratory food trials.
- Randomised block design: units grouped into homogeneous blocks (by age, village) and treatments randomised within each block, applying local control.
- Latin square: controls two sources of variation at once, each treatment appearing once in every row and column.
- Epidemiological designs: cross-sectional (prevalence at one time), case-control (from outcome back to exposure; odds ratio), cohort (from exposure forward to outcome; relative risk), and the randomised controlled trial, ideally double-blind, as the strongest test of an intervention.
Key takeaways
- Food security rests on availability, access, utilisation and stability; nutrition security adds care, health, water and sanitation.
- ICDS (1975) gives six services and now sits within Mission Saksham Anganwadi and Poshan 2.0; POSHAN Abhiyaan began in 2018; PM-POSHAN replaced the Mid-Day Meal scheme in 2021; NFSA 2013 grants 5 kg per person a month; Anaemia Mukt Bharat uses a 6 × 6 × 6 strategy.
- Therapeutic diets modify consistency, energy, nutrients, frequency or route; glycaemic load = GI × available carbohydrate / 100.
- Diet counselling fits the stage of change and uses client-centred methods such as motivational interviewing, within the Nutrition Care Process.
- Designs range from pre-experimental through quasi-experimental to true experimental; Fisher's principles are replication, randomisation and local control.
Practice questions (10)
Attempt each one before opening the answer. Every explanation names the tempting wrong option as well as the right one, because that is where marks are lost.
Which of the following are among the six services of ICDS? Select all that apply.
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Answer: A — Pre-school non-formal education; B — Immunisation; C — Supplementary nutrition
ICDS offers supplementary nutrition, pre-school non-formal education, nutrition and health education, immunisation, health check-up and referral. Foodgrain for households is the public distribution system's entitlement under the National Food Security Act.Which scheme replaced the National Programme of Mid-Day Meal in Schools from 2021-22?
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Answer: B — PM-POSHAN
PM-POSHAN (Pradhan Mantri Poshan Shakti Nirman) replaced the Mid-Day Meal scheme and extended the hot cooked meal to Balvatika. POSHAN Abhiyaan (2018) is a convergence mission, Anaemia Mukt Bharat an anaemia strategy and Mission Indradhanush an immunisation drive.A portion of cooked rice contains 50 g of available carbohydrate, and the rice has a glycaemic index of 70. What is the glycaemic load of the portion? Type the number.
Numerical answer — type the value.
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Answer: 35
GL = GI × available carbohydrate / 100 = 70 × 50 / 100 = 35. A load of 20 or more is high, so this portion is a high-load portion.Which dietary pattern is specifically associated with lowering blood pressure through fruits, vegetables, low-fat dairy and reduced sodium?
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Answer: C — The DASH diet
DASH (Dietary Approaches to Stop Hypertension) combines fruits, vegetables, whole grains and low-fat dairy with reduced sodium. A gluten-free diet treats coeliac disease, and a clear liquid diet is a short-term consistency modification.Assertion (A): A small serving of a high-GI food can have a low glycaemic load. Reason (R): Glycaemic load multiplies the glycaemic index by the amount of available carbohydrate actually eaten. Choose the correct option.
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Answer: A — Both A and R are true, and R is the correct explanation of A
Both are true and R explains A. For example, 10 g of available carbohydrate at a GI of 80 gives a GL of 8, which is low, because GL scales the index by the quantity consumed.A client says, "I know my sugar is high and I have been thinking about changing my diet, but I am not sure I can give up sweets." In the transtheoretical model, the client is in:
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Answer: A — Contemplation
The client recognises the problem and is thinking about change but is ambivalent, which is contemplation. Precontemplation would deny any need to change, and action and maintenance require the change already to be under way.Which statements about research designs are correct? Select all that apply.
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Answer: C — A non-equivalent control group design lacks random assignment; D — The Solomon four-group design can detect the effect of the pretest itself
The Solomon design's unpretested groups isolate pretest sensitisation, and the non-equivalent control group design is quasi-experimental because its groups are not randomised. A one-group design has no comparison group to rule out maturation, and it is the cohort study, not the case-control study, that moves from exposure to outcome.A study crosses 2 cooking methods, 2 storage temperatures and 3 storage periods in a full factorial design. How many treatment combinations are there? Type the number.
Numerical answer — type the value.
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Answer: 12
In a full factorial design every level of each factor meets every level of the others, so the combinations are 2 × 2 × 3 = 12. Each combination is then replicated to estimate error.Grouping experimental units into homogeneous blocks and randomising treatments within each block applies which of Fisher's principles?
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Answer: D — Local control
Blocking similar units together is local control, which removes block-to-block variation from the error, and it is the basis of the randomised block design. Replication repeats treatments; blinding and triangulation are not among Fisher's three principles.Under the National Food Security Act 2013, an Antyodaya Anna Yojana household is entitled each month to:
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Answer: B — 35 kg of foodgrain per household
The Act gives Antyodaya households 35 kg per household per month, and priority households 5 kg per person per month. The grain has been distributed free of cost since January 2023.