Fat diet - minimal LCT plus MCT
This document is part of the ACI Diet Specifications for Paediatric Inpatients. It is not to be used for patient education.
Aim
To provide a diet low in long chain triglycerides (LCT) and high in medium chain triglycerides (MCT) to bypass lymphatic chylomicron transport and decrease lymph flow or for the management of inborn errors of fatty acid oxidation.
Characteristics
Low fat diet supplemented with MCT oil. Lean meat, dairy products. MCT oil obtained on prescription needs to be incorporated into food prior to service (i.e. added to foods as dressings/sauces; added to beverages). MCT can also be used in baking or shallow frying to boost energy intake. MCT butter may be used to substitute other spreads. Sugars or glucose polymers may be used to add extra energy.
Indications
- post Chylothorax
- Chyluria
- Lymphangiectasia
- inborn errors of long chain fatty acid oxidation such as long chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHAD), trifunctional protein deficiency (TFPD), very long chain acyl-CoA dehydrogenase deficiency (VLCAD), carnitine/acylcarnitine translocase deficiency (CACT), carnitine palmitoyl transferase deficiency (CPT)
Nutritional adequacy
This diet may not provide adequate energy and intake of fat soluble vitamins. Essential fatty acids may be compromised and should be assessed by a dietitian. Nutritional supplements and/or high MCT formulas may be required to meet the patient’s energy and/or nutrient needs. Adequate energy intake and avoidance of fasting is essential in the management of inborn errors of long chain fatty acid oxidation to prevent hypoglycaemia. Adequate amounts of essential fatty acids must be provided to prevent deficiency, usually requiring supplementation with very long chain omega 3 fatty acid docosahexaenoic acid (DHA). Supplementation with fat soluble vitamins (A, D, E) may also be required.
Precautions
To be initiated on physician’s advice only and to be used under supervision of a dietitian.
Weight and growth must be monitored regularly. Patients need an authority prescription to obtain MCT oil or high MCT formulas. Advice on how to use in preparation and recipes for use need to be provided. Adequate amounts of essential fatty acids must be provided to prevent deficiency. Monitor progress regularly and re-introduce a normal diet as soon as possible as indicated by medical team.
Specific menu planning guidelines
| Allowed | Not allowed | |
|---|---|---|
| Hot main dishes | All mains to be < 6g long chain fat per serve (e.g. skinless chicken breast, white fish, very lean meat, tuna canned in brine) Soy products (e.g. TVP), legumes and dishes made from them Egg whites only MCT could be used for shallow/pan frying or add 10mL MCT oil or equivalent MCT supplement serve to hot main dishes or sauces/gravies to be served with the hot main dish | All other meats including fatty meats and smallgoods (e.g. bacon, sausages, offal) Fried foods, unless fried in MCT oil Foods cooked with white sauces or coconut milk Egg yolks Pastry, pizza Dishes containing cheese |
| Sauces, gravies | Low fat sauces/gravies < 1g long chain fat per serve Tomato sauce, sweet and sour sauce Make sauces/gravy with MCT oil or add 10mL MCT oil or equivalent MCT supplement to meal before serving | Cream or milk-based sauces |
| Starchy vegetables/pasta/rice | All raw, steamed or boiled Potato mashed with water or skim milk and MCT oil | Fried/roasted/mashed vegetables with fat such as butter, cooking margarine, oil, sour cream, full cream milk, cheese |
| Vegetables | All raw, steamed or boiled without added fat | Fried/roasted/mashed vegetables with fat such as butter, cooking margarine, oil, sour cream, full cream milk, cheese Vegetables served with cream or cheese-based sauces |
| Soups | Low fat soups only with < 2g fat per serve | All other soups including with added milk, cream, sour cream, coconut milk |
| Sandwiches | < 5g fat per serve Bread (white or wholemeal) with no standard margarine or butter. Can use MCT butter (see recipe below) Vegemite™, jam, honey Salad fillings Sliced chicken breast cooked without fat Deli meat < 3% fat, tuna canned in brine Egg white Cheese < 3% fat (e.g. cheese slices with < 3% fat, cottage cheese, ricotta cheese) | Cheese > 3% fat, higher fat meat fillings, egg yolk, peanut butter Avocado, olives Margarine, butter, cream cheese, mayonnaise |
| Salads, dressings | < 5g fat per serve as main meal Side salad vegetables Served with fat-free dressing or lemon wedge or 10mL MCT oil dressing | Other cheese, higher fat meats Coleslaw or potato salad Full fat dressings; mayonnaise Olives, avocado |
| Breads, cereals | Breads, breakfast cereals, rice cakes, corn thins with <2% fat Rolled oats made on water or skim milk Raw muesli of rolled oats and dried fruit | Toasted muesli Raw muesli with nuts or seeds Rolled oats made with full cream milk Cereals with coconut or chocolate |
| Spreads | Jam, honey, Vegemite™, MCT butter (see recipe below) | Butter, margarine Peanut butter, cream cheese, hazelnut spread |
| Hot breakfast choices | Spaghetti, baked beans <2% fat, grilled plain or herbed tomatoes Egg white only | Bacon, sausages, egg yolk |
| Fruit | Fresh/canned/dried fruits Juices | Avocado |
| Yoghurt | Fat-free (skim milk) yoghurts < 1% fat | Full fat or soy yoghurts |
| Desserts | Canned and fresh fruit, jelly Meringue, pavlova (meringue only) Desserts made using egg white < 1% fat Low fat custard and skim milk dessert < 1% fat | Cake, pastries, puddings Dairy/milk based desserts Cream, ice-cream |
| Milk and cheese | Skim milk, Shape™, milk with < 1% fat Soy beverage with < 1% fat Recipe for MCT special skim milk (see below) Cottage cheese, ricotta cheese, some very low fat cheese slices (< 3% fat) | Milk with > 1% fat, (e.g. full-cream milks) Soy beverage with > 1% fat Cream, sour cream All other cheeses |
| Beverages | Water Skim milk, Shape™, milk with < 1% fat Soy beverage with < 1% fat High MCT formula/nutritional supplements as prescribed by dietitian | Milk with > 1% fat Soy beverage with > 1% fat |
| Biscuits | < 2g fat per serve Biscuits using MCT oil as fat source Spread crackers with MCT butter if appropriate | All others |
| Miscellaneous | Herbs and spices Sugar Lollies (e.g. boiled lollies, jelly snakes) Ice blocks MCT oil/supplement may be prescribed MCT oil/supplement can be added to gravy, dressings, casseroles, etc. Glucose polymers | Nuts and seeds Chocolate |
Recipe for MCT butter
1 tablespoon cornflour
¾ cup skim milk powder
1 tablespoon lemon juice
¾ cup water
1 cup MCT oil
few drops yellow food colouring
Method:
Mix dry ingredients with lemon juice and water in a blender
Cook over gentle heat until thickens
Remove from heat and gradually beat in MCT oil
Add yellow colouring
Will keep for 2 weeks in the fridge
Recipe for MCT Special Skim Milk
600mL skim milk
60g skim milk powder
1 tablespoon MCT oil
6 tablespoon glucose polymer powder
Method:
Mix all ingredients together well
References
- Agency for Clinical Innovation. Nutrition standards for paediatric inpatients in NSW hospitals. Sydney 2011.
- Agency for Clinical Innovation. Nutrition standards for adult inpatients in NSW hospitals. Sydney 2011.
- Dietitians Association of Australia. 2009. Nutrition Manual 8th ed. Canberra: DAA.
- American Dietetic Association. Paediatric Nutrition Care Manual. Chicago: ADA.
- Mahon LK and Escott-Stump S. 2008. Krause’s Food and Nutrition Therapy. 12th edition. St Louis: Saunders Elsevier.
- Smoke A, DeLegge MH. Chyle leaks: consensus on management? Nutr Clin Prac. 2008;23:529-532.
- Shaw V and Lawson M. 2007. Clinical Paediatric Dietetics. 3rd Edition. Blackwell Publishing.
- Acosta PB. 2010 Nutrition Management of Patients with Inherited Metabolic Disorders Jones and Bartlett Publishers.