Nutrition in ALS

Healthy Diet for healthy life

Amyotrophic lateral sclerosis (ALS) is associated with high risk of malnutrition. Due to changing disease status diet modification may need to be done frequently. To maintain energy level good nutrition plays vital role. Patient can become deprived of proteins, calories and vitamins very quickly because of feeding difficulties. Early nutritional assessment and intervention is important to prevent malnutrition and enhance quality of life. A Nutritionist can be a great help in planning a balanced diet & suggest modification according to status of swallowing & other complications.

Five stages of swallowing problems

1.  Normal Eating Habits: It is right time to start educating patient about balanced diet and proper hydration before development of speech and swallowing difficulties
2.  Early eating problem: Weakness in jaw muscles results in difficulty in chewing and swallowing & coughing while eating which results in prolonged meal time.
   Diet modification like smaller bite size and inclusion of food which are easier to chew and swallow will help.
3.  Dietary consistency changes: As symptoms progresses difficulty in eating dry food and drinking thin liquids can lead to weakness and dehydration.
   • Mechanically soft (mashed ) food can be included with thick liquids.
   • If difficulty increases soft cooked food like soft rice with curry or khichdi.
   • Pureed food can be given if difficulty in having soft food.
   • Small & frequent meals will help increase calorie intake.
4.  Tube feeding: As dysphagia and feeding problems progress providing adequate nutrition orally becomes difficult. PEG (Percutaneous endoscopic gastrostomy) tube placement can be considered at this stage.
5.  Nothing by Mouth: When final level of dysphagia is reached patient can take nothing orally. Tube feeding is permanent at this stage.

Aim of nutrition therapy is:

• To supply nutritional needs for all stages of disease progression.

• Maximize protein.

• Ensure oral feeding and indicate early nutritional support.
  Diet should be High calorie, high protein, normal lipids, high fiber and balanced in all nutrients.

Sources of Nutrients

• Calorie dense foods: Sheera , custards, puddings, kheer etc.

• 

  Calorie dense foods

  Protein rich: meat and Chicken, eggs, fish, sprouts, dal, oil seeds, soybean, and nuts

• Lipid: sources of omega 3 &6 – Sources include almond, walnuts, olive oil, mustard oil, canola oil, flax seeds, cod liver oil/ fish oil.

• Fiber: vegetables in boiled and mashed form. Include fruit puree like papaya, oranges.

• Water: Foods with high liquid content like fruit juice, fruit and vegetable puree, smoothies.

• Vitamins and Minerals:

Thick liquids

1. Vitamin D: High exposer to sunlight ,egg yolk, liver, oily fish

2. Calcium: milk, cheese, yogurt, milk pudding, and sesame seed, rajgira seeds. 

3. Vitamin B12: milk & milk products, meats, cheese, eggs, fish.

4. Vitamin E : almonds, Hazel nuts, sunflower seeds, sunflower oil, safflower oil

5. Vitamin C: orange, sweet lime, guava, papaya, amla

Special considerations

• Give small and frequent meals.

• Try to include food from all food groups.

• Try and modify consistency of food as per patient’s tolerance.

• Give enough time to chew and swallow then only feed next bite.

• Make sure patient is well hydrated.

• Consult your dietitian at intervals.

• Nutritional assessment at intervals is necessary to check for any malnutrition and need for tube placement.

Special considerations for PEG feeding

• Always feed the patient in propped up position

• Do not give very hot or very cold feeds.

• Strain each feed twice before giving

• Do not mix feed and medication together

• Flush the tube with water after every feed.

• Do not give very thick consistency feeds it may block the tube.

• Give Nutrition supplement as per dietician’s instructions.

Foods which can be included in PEG feeding are

• 

  PEG Tube Feeding

  Ragi porridge

• Khichdi(rice+dal puree)

• veg soups

• milkshakes

• fruit juices

• Inclusion of nutrition supplement is necessary sometimes to ensure proper delivery of required nutrients.