Typhoid is often called enteric fever because the infection or bacteria is found in the intestines and attaches itself to the epithelium of the intestinal wall where it multiplies I or finally reaches the blood causing damage and increase in the body temperature.
Typhoid is an enteric fever, which relates to acute infection of short duration. It is caused by bacteria called Salmonella typhosa.The mode of spread of this infection is through the fecal-oral route. The source of I infection is the drinking water, milk and food contaminated by intestinal contents, (through feces and urine) of the patients or “carriers’ ‘ or by flies which transmit the disease. It may affect all age groups but is commonly observed in children. The incidence and magnitude of typhoid fever has greatly reduced in the present context due to improved sanitation and vaccines and effective drugs available.
Observation seen in Typhoid
- Massive loss of lean body mass or muscle due to tissue breakdown (250-500 gm muscle tissue is lost day) leading to excessive nitrogen losses.
- Body stores of glycogen are quickly depleted because of increased energy requirements.
- The gastrointestinal tract is highly inflamed and irritable as the seat of typhoid infection is the Peyer’s patches of the intestine. The bacteria attaches to the epithelium of the intestinal wall, penetrates and multiplies in the mesenteric lymph nodes, eventually reaching the bloodstream which in turn leads to secondary infection of the intestines.
- Excessive diarrhoea, vomiting and perspiration can cause a lot of fluid and electrolyte losses.
- Inflammation of the GI tract can lead to intestinal ulceration and bleeding.
Clinical symptoms of Typhoid
- Graded fever which follows an upward ladder pattern.
- Abdominal pain, cramps and diarrhoea.
- Anorexia and vomiting
- Internal haemorrhage and malena (gastrointestinal bleeding and black tarry stools)
Management of typhoid patient
- Bed rest
- Antibiotic therapy
- Modification of diet
Dietary Management Of Typhoid
The golden rule in the dietary management of ally fever is “feed the fever”. Considering that enteric (typhoid) fever is accompanied by anorexia, vomiting and high grade temperature, the diet has to be modified as per the patients’ tolerance. The patient needs to be encouraged to eat. Feeding several times a day improves tolerance. The texture of foods given would depend on the severity of infection. Bland, low fibre and soft foods are beneficial.
The dietary principles underlying the enteric diet include:
- High’ calorie
- High protein
- High carbohydrate
- Moderate fat
- High fluid
- Low fibre and soft diet.
Specifications of each nutrient
Fever is characterized by elevation of BMR, thus caloric requirements are increased.. The increase in caloric needs is dependent on severity of infection and degree of rise of temperature. During fevers there is a decrease in appetite, as well as, a decreased tolerance due to enteric infection, thus a desired increase in calories is 10-20% above the nominal recommended requirements. The actual intake can be adjusted and given as per patients’ tolerance.
The requirement of protein is increased in typhoid, as there is a massive tissue loss. Thus, the protein intake should be increased above the normal of 1 g/kg/ day to 1.5-2g of protein/kg/day. A high protein diet should be supported with a high carbohydrate intake to favour efficient protein utilization for anabolic or tissue building purposes. Foods providing appreciable and good quality protein (high biological value) should be incorporated in liberal amounts. Use of protein supplements is recommended to add on to the nutrient density without increasing the bulk of the diet.
Carbohydrate intake should be liberal.Well cooked, easily digestible carbohydrates like simple starches, glucose, honey, jam should be included as they require much less digestion and are well assimilated. Glucose can be supplemented in a variety of beverages and light desserts as it is less sweet than sucrose and adds on to the total calorie intake.
Typhoid patients have an inflamed intestinal mucosa, which can be easily perforated and ulcerated leading to internal haemorrhage. Thus foods high in fibre such as certain green leafy vegetables, whole pulses or cereals, thick skins or fruits or vegetables must be avoided. (These are rich in insoluble fibres). Soluble fibres can be given.
Use of fats should be in moderation. This is because the typhoid patient has a compromised ability to digest and assimilate due to peyer’s patches (elongated thickening of the intestinal epithelium) which result in repeated episodes of diarrhoea. This helps in increasing the energy density of the food without increasing the bulk of the diet, but the aspect which needs to be emphasized is the type of fat. Use of dairy fats like butter, cream, fats in milk products, egg yolk etc. help in easy digestion as they contain medium chain triglycerides. Excessive use of fat in cooking, eating fried foods can aggravate nausea, impair digestion and lead to severe diarrhoea. These should be avoided.
Loss of electrolytes and water is observed due to diarrhoea. Thus liberalizing on sodium intake through salty soups, beverages are desired. Potassium intake can be increased by emphasizing cooked fruits, low fibre vegetables, washed and dehusked pulses. Food preparations in forms like juices, stews, soups and dal water are beneficial. The other minerals, which are of importance, include iron particularly if blood is lost due to haemorrhage in the intestines. Losses of zinc and chromium have also been observed.
Vitamins which need to be emphasized include B complex, considering the increase in the energy requirement and a decreased ability of the intestine to assimilate and synthesize some of the B complex vitamin due to compromised digestive processes and altered microbial flora. As a result, antibiotics are prescribed. In addition, vitamins A and C are also needed to boost immunity, favour wound healing and maintenance of the integrity of epithelial membrane (gut mucosa). Vitamin supplementation may be given in the early stages of the infection when the patient is anorexic and has low food tolerance.
Liberal fluid intake is desired to compensate for the fluid losses from the body. A daily fluid intake of 2.5 to 3.5 litres may be recommended. Fluid intake can be accomplished through a variety of beverages, soups, juices, broths, dal besides plain Nutritional Management of Infections and Fevers water. Adequate fluid intake helps in eliminating wastes and maintaining water balance in the body.
- Juices, soups, dal water, broths.
- Refined cereals and their products (e.g. maida, rava, bread, rice, noodles, washed dals, pureed vegetables, stewed fruits). These foods contain low insoluble fibre.
- Eggs, cottage cheese, tender steamed or baked chicken, fish. These contain high biological value proteins.
- Fruit juices, gelatin, honey, sugar and milk products. Calorie and protein-rich desserts could be prepared.
Foods to be restricted
- Excessive milk and milk products and dairy fats such as cream and butter.
Food to be avoided
- High fibre foods like whole grain cereals and their products (e.g. whole wheat flour, cracked wheat, whole pulses)
- Raw vegetables and fruits
- Fried fatty foods
- Chemical irritants like spices, pickles, papad, ketchups etc.