Protein diet - reduced (metabolic)

Aim

To provide a reduced protein intake but adequate energy intake, for patients who are unable to metabolise normal protein intake.

Characteristics

Diet includes no animal protein, no dairy, no soy/legumes or nuts. Bread, pasta, biscuits and cereal are tolerated, but special commercial low protein products may be ordered as an alternative to adjust protein intake to meet individual requirements. To maintain adequate energy intake, high energy supplements may be needed such as sugars, glucose polymers and fats. Nutritional supplements of amino acids and/or vitamins and minerals are required for nutrient adequacy but need to be prescribed depending on the metabolic disorder and dietary intake.

Each individual patient’s meal plan needs to be planned by a dietitian in consideration of the specific metabolic disorder and patients’ requirements. The requirements may change during the admission depending on clinical need and biochemical monitoring.

Indications

For patients with inborn errors of protein metabolism who have moderate tolerance of protein based on biochemical monitoring appropriate for their metabolic conditions, e.g. Hyperphenylalaninaemia, some organic acidaemias, some urea cycle disorders.

Metabolic disorders are rare but increasingly diagnosed and managed throughout the lifecycle. Treatment protocols are different for different conditions. An individual’s treatment protocol will also change with age and with biochemical monitoring and can change throughout the admission.

Nutritional adequacy

Nutritionally inadequate – must be used in conjunction with prescribed dietary supplement(s). Energy needs must be met for adequate metabolic control. This diet will be inadequate in many nutrients including vitamin B12, iron and calcium unless supplemented. The diet must be planned for each individual patient by a dietitian and regular follow-up provided.

Precautions

Must only be used when ordered by a physician and under supervision of a dietitian.

Prolonged use may precipitate metabolic crisis.

Where appropriate, should be used in conjunction with prescribed dietary supplement. Specific daily amounts of dietary supplements may be required and intake of these needs to be monitored.

This diet is a baseline diet only that will need to be modified dependent on the individual patients’ tolerance of protein. Tolerance of protein will depend on patients’ age, weight, height, growth rate and medical condition and may change during the course of a hospital admission.

Assessment and follow up by a dietitian is essential. Growth, weight, and nutrient intake must be monitored as these can be compromised on such a restrictive diet. Regular biochemical monitoring is essential to prevent metabolic crisis and ensure nutritional adequacy.

Special low protein products are not essential for this baseline diet, but may be ordered by a dietitian if the individual patient has a lower protein tolerance.

Some metabolic conditions have specific treatment to be followed during illness, which may differ from the diet the patient usually follows. Medical status of patient must be assessed before deciding on degree of dietary restriction.

Specific menu planning guidelines

	Allowed	Not allowed
Hot main dishes	Vegetarian main dishes < 8g protein per serve Added oil, margarine, cream/sour cream (portion controlled servings)	Any containing meat, chicken, fish, egg, milk, cheese, yoghurt, soy, nuts, legumes, vegetarian products (e.g. TVP)
Sauces, gravies	Cream/sour cream, sweet and sour sauce, tomato based sauces Tomato sauce Commercial mayonnaise Single portion controlled soy sauce	Meat/chicken/fish based gravy or stock, milk or cheese sauce, yoghurt
Starchy vegetables/pasta/rice	Pasta, rice, potatoes, couscous Low protein products such as low protein pasta and low protein rice may be used Serve with 10g margarine/10g butter/10mL oil	Dishes if prepared with the addition of meat, milk, egg, cheese, yoghurt, nuts or legumes
Vegetables	All vegetables other than legumes or individual serves of peas Serve with 10g margarine/10g butter/10mL oil	Legumes Peas as an individual serve or main ingredient in a vegetable dish Any other vegetables prepared with the addition of meat, milk, cheese, yogurt or nuts
Soups	< 5g protein per serve Tomato, pumpkin or vegetable soup containing vegetable stock or cream/sour cream	Any containing meat, chicken, fish, egg, milk, cheese, yoghurt, soy, nuts, legumes, peas, meat/fish/chicken stock
Sandwiches	< 8g protein per serve (i.e. 2 slices + filling) Standard bread (or may use low protein bread) with margarine/butter and low protein fillings (e.g. cucumber, tomato, salad vegetables, commercial mayonnaise, jam, honey, Vegemite™) Use 2 x serve spread	Fillings of meat, chicken, fish, cheese, nut pastes, egg
Salads, dressings	< 5g protein/serve (can include appropriate Band 3 salads) Salad vegetables (e.g. carrot, cucumber, capsicum, tomato, eggplant, lettuce, etc.) Serve with high fat dressings (e.g. French dressing of oil and vinegar/lemon) Mayonnaise, tomato sauce	Any salads containing meat, chicken, fish, egg, milk, cheese, yoghurt, soy, nuts, legumes or large proportion of peas
Breads, cereals	Standard breads and cereals Low protein bread and low protein breakfast cereals may be required	None, except those that contain meat/cheese/ nuts
Spreads	Margarine, butter, jam, honey, Vegemite™	Peanut butter, fish pastes, hazelnut spread
Hot breakfast choices	Fried/grilled plain or herbed tomato, mushrooms, hash browns, pancakes made with egg replacer and milk substitute, corn/ creamed corn, tinned spaghetti	All others, including eggs, bacon, sausages, baked beans
Fruit	All fruit – fresh, canned, cooked or dried Serve with 20mL cream or 20mL glucose polymer syrup to fortify energy	-
Yoghurt	None	All
Desserts	< 4g protein per serve Jelly made from vegetable gum Low protein custard made on milk substitute, cream and custard powder Creamy rice made on rice and milk substitute or cream	All others including egg and gelatine Diet jelly
Milk and cheese	< 0.4g protein/100mL milk substitute Rice beverage not containing chickpeas, commercial low protein milk alternatives and prescribed nutritional supplements Cream cheese (small portion only)	Milk Cheese
Beverages	Fruit juice, soft drinks/cordials containing sugar Energy content of drinks may be fortified with glucose polymer/fat supplement/cream	Drinks containing aspartame (additive numbers 951 and 962) or other artificial sweeteners Any beverages containing milk
Biscuits	Plain crackers and biscuits	None
Miscellaneous	Sugar, cream (portion controlled servings)	Nuts

Coffee whitener recipe: 12g coffee whitener made up to 100mL with water
Cream beverage recipe: 20mL cream made up to 100mL with water  
9kJ/mL Glucose polymer syrup recipe: 56g glucose polymer added to 60mL water (makes 100mL)

References

1. Agency for Clinical Innovation. Nutrition standards for paediatric inpatients in NSW hospitals. Sydney 2011.
2. Agency for Clinical Innovation. Nutrition standards for adult inpatients in NSW hospitals. Sydney 2011.
3. Dietitians Association of Australia. 2009. Nutrition Manual 8th ed. Canberra: DAA.
4. American Dietetic Association. Paediatric Nutrition Care Manual. Chicago: ADA.
5. Food Standards Australia New Zealand. 2010. NUTTAB 2006 Online version. Foods that contain protein.
6. Shaw V and Lawson M. 2007. Clinical Paediatric Dietetics. 3rd Edition. Blackwell Publishing.
7. Acosta PB. 2010 Nutrition Management of Patients with Inherited Metabolic Disorders. Jones and Bartlett Publishers.