Treatment diets in Estonian health care institutions

Summary. New system and nomenclature of diets for Estonian health care institutions have been developed in the university hospital based on theoretical and practical experience obtained over several years of cooperation with medical scientists from different fields of specialization. The nomenclature of diets includes ordinary food and eight groups of diet food with subgroups. The normative values of the basic nutrients are in accordance with the Estonian and Nordic nutritional recommendations. The whole system includes the menus and recipes of nutritional food portions. The system of treatment diets helps to optimize proper nutrition in different departments and organize better patient care.


Introduction
The present article introduces the nomenclature of new modern treatment diets used at the University Hospital in Tartu since 1995. The patient's nutrition has been of interest to investigators in the practical work of clinical medicine, health promotion, and physical education for many years. The WHO management guidelines for nutrition are effective to the quality hospital care and were used in medical and nursing practice in hospitals (1). However, various guidelines for nutrition have been worked out in different countries. The purpose of the general European project (EFCOSUM) was to develop a method for a European food consumption survey that delivers internationally comparable data on the set of policy relevant nutritional indicators. It is concluded that there is broad European consensus on the most suitable method for a pan-European dietary survey for the purposes of the EU Health Monitoring Program (2). The Finbalt Health Monitor project collects standardized information on health and health-related behavioral activity and related trends in Finland and those of the Baltic countries that have major public health problems with noncommunicable diseases related to the lifestyle and behavioral factors (3). These projects were also partly used as examples for the development of the new system and the nomenclature of diets at our hospital.

Basis of the development of nutritional recommendations
The new system of dietary nutrition at the Tartu University Clinicum replaces the nomenclature of diets developed by professor M. I. Pevsner , which consisted of 15 basic diets and several subgroups and was earlier compulsory in Estonia and in the Soviet Union (4). The new nomenclature of diets has been developed at the university hospital on the basis of the theoretical and practical experience obtained during more than 10 years of cooperation with medical scientists from different fields of specialization (5-7). The Tartu University Clinicum consists of 17 clinics, and therefore, special catering service is obligatory in order to provide everyday different diets for about 1000 patients. The normative values of the basic nutrients are in accordance with the Estonian nutritional recommendations (8), the nutrition guidelines of the WHO Regional Office for Europe (9), and Regulation No. 131, Health Protection Requirements for Nutrition in Health Care and Social Welfare Institutions, issued on November 14, 2002, by the Estonian Ministry of Social Affairs (10). The experience of the medical scientists of the Department of Clinical Nutrition of Kuopio University and the dieticians of Meilahti Hospital of Helsinki University obtained from 1991-1995 has been taken into consideration (11).

Nutritional recommendations in Estonian health care institutions
The names and indications of the nomenclature of diets and the respective recommendations for the consumption of daily energy and basic nutrients are given in Table. The new nomenclature of diets (Table) includes ordinary food and seven groups of diet food,   which are in turn divided into subgroups. The detailed description, the amount of basic nutrients, and the list of indications for the use of respective diet food in the event of various diseases have been added to each subgroup. The basis of the Nordic and Estonian Nutritional recommendations are calculated for a standard person, a man weighing 70 kg and a woman -60 kg (8,12). The recommended intake of fat, carbohydrates, and protein as percentages of total energy intake (E%) for groups of 15-65 years with a heterogeneous age and sex distribution are given in Table. Proteins should provide 10-20 E%. The diet minimum daily protein requirement is 0.6-0.9 g/kg. Fat, calculated as the total fat content including glycerol and other lipid components, should provide 25-35 E%. Carbohydrates should provide 50-60 E% (8,12).
Individual recommendations for energy intake are given in respect to the metabolic rate, the body composition, and the degree of physical activity.
The four different treatment diets for diabetics are categorized based on the carbohydrate content and deserve particular attention. Enteral and parenteral nutrition have been examined, and four different options of tube food for standardized enteral nutrition have been offered. The possible compositions of individual diets have been provided.
In order to use the nomenclature of treatment diets rationally, each item on the nomenclature includes a list of particular foodstuffs used as diet food. The foodstuffs are classified into the following groups: the cereal, milk, meat, potato and vegetable group, the berries and fruits group, the fat and sweet substance group, the drinks, flavorings and additives group. The list of foodstuffs in each group has in turn been divided into three groups: recommended, not recommended, and prohibited foodstuffs. Each item in the nomenclature of treatment diets includes the recommended diet foods composed of the foodstuffs in the above-mentioned list. Those are divided into soups, roasts, sauces, casseroles, hotpots, porridges, desserts, pastries, salads, sandwiches, additives, and drinks.
The whole system includes 227 recipes to specify the foodstuffs and the nutrient content of each food. Energetic value has been calculated in kilocalories and kilojoules. The nutritional content of each component of the food has been calculated based on the edible parts of the foodstuffs. Each recipe specifies to which diet the particular food belongs.
In order to facilitate the organization of dietary nutrition in the hospital, the sets of daily specimen menus, composed of diet food, have been prepared according to the nomenclature (breakfast, lunch, dinner; snacks, if necessary). Different daily specimen menus for ordinary food are provided for 20-day periods. For each subdivision of the diet food nomenclature, daily specimen menus have been composed for five different days. Each daily specimen menu specifies the amount of food energy and basic nutrients.
The complete nomenclature of diet food and additional data: 1.A list of foodstuffs, 2.Diet food, 3.Daily specimen menus.
All the data of the diet nutrition have been linked to the clinic's integrated computer system since 1997. Example menus and recipes were published in Estonian as a handbook for doctors and dieticians (13).

Discussion
The new system of treatment diets in Estonia helps to optimize proper nutrition in different departments and organize better patient care. The Ministry on Social Affairs of Estonia recently accepted the present nutritional recommendations as a basis work in the development of the new system of treatment diets in all the Estonian health care institutions (13). There are differences between national databases in the various countries concerning nutrient intakes, and more research is needed for the development of food composition databases in the certain region (14). Several misunderstood dietary concepts are still prevalent in the Baltic countries. The correct beliefs related to salt intake and the types of fat were not consistent predictors of healthier food behaviors. In-depth qualitative investigations are needed to better describe and understand the dietary beliefs and attitudes in the Baltic countries and to identify the barriers to the adoption of healthy food habits (15). The mean proportion of energy from fat was high in Lithuania (44%) and Latvia (42%) compared with Estonia (36%). In contrast, the percentage of energy from carbohydrate, protein, and alcohol was higher in Estonia. The mean protein intake was generally not high in some population subgroups. Median vegetable intakes were very low (<200 g/day) in the Baltic countries (16). The nutrition programs aimed at the dietary change have a long history of public responsibility in several Nordic and Northern European countries (17). Roos, Lean, and Anderson have described the organization and the implementation of nutrition policies, and examined the intervention strategies for the dietary change in three Scandinavian countries (18). The recommendations concerning healthy diet among population are also acceptable in our country.
Beside regional differences in dietary habits, there are indeed many problems concerning the nutrition needs for patients with different diseases. Therefore, the development of the modern system of treatment diets in Estonian hospitals was difficult. In addition, nutritional counseling of patients that represents a part of patient care and rehabilitation had been set up. Many aspects like patient age, gender, diagnosis, also functional status and cognitive function should be taken into account (19). Moreover, the nutritional status assessment should be used in routine clinical practice. In the clinical study of Kuopio University Hospital, the role of the body composition during rapid weight loss in obese persons with the metabolic syndrome was assessed (20). Both aspects -the nutritional counseling and the nutritional status assessment -were taken into account by the author, and a proper system was set up with the help of clinicians at the university hospital. The best results of collaboration were achieved with pediatricians, intensive care unit doctors, endocrinologists, and nephrologists (21). There are lots of data about the importance of diet, for example, in the treatment of renal diseases. The lower levels of dietary protein intake slow the increase in proteinuria and renal disease progression both in clinical and experimental studies (22)(23)(24). Based on the meta-analyses and secondary analyses of the randomized trials, it can be concluded that protein restriction slows the progression of the renal disease. When patients are carefully monitored, protein-restricted diets, rather than inducing malnutrition, may even prevent it (25,26). Different specialties have specific nutritional problems and many studies have been performed in order to demonstrate the importance and the need for various diets. The hospitalized patients insufficient food intake was often attributed to the causes other than the disease, there should be a potential to improve the hospital meal service (27). The departments had been screened for nutritional problems the hospital's were not followed. The patients' in hospital had an inadequate nutritional status and the dietary requirements on practical aspects (28).
A prospective study investigated the structure and the organization of dietary nutrition in German hospitals (29), and in conclusion, better patient care was achieved with proper nutrition. Undernutrition is a serious problem in the clinical practice (28), especially in the intensive care unit (7). For instance, in critically ill patients, the risk of death was 56% lower in patients who received enteral nutrition (30). Hakala et al. studied the differences in foods between the two countries' results and experiences from a Swedish-Finnish study and the methodological differences in the assessment of nutrient intakes (31). In children with functional gastrointestinal disorders, less-organized food habits considering their association with psychosocial factors were revealed (32). Monitoring dietary intake in the children is important in order to explore and prevent the onset of adult health problems (33). The diets rich in fruits and vegetables have been of interest because of their potential health benefits against chronic diseases such as cardiovascular diseases and cancer (34). Information on phyto-estrogen intake in foods was reported in the Finnish National Food Composition Databases (35). In conclusion, the systematization of nomenclature of treatment diets in the multiprofile health care institutions is essential in patients' care.

Conclusion
In the current study, a new nomenclature of diets has been developed at the university hospital based on the theoretical and practical experience obtained over several years of cooperation with medical scientists from different fields of specialization. The nomenclature of diets includes ordinary food and eight groups of diet food with subgroups. The normative values of the basic nutrients are in accordance with the Estonian nutritional recommendations. The whole system includes the menus and the recipes of nutritional food portions. The systematization of the nomenclature of treatment diets in the multiprofile health care institution is essential in patients care.