2Pulling Ideas Together IDA Taskforce SurveyIDA Publications CommitteeBlackwell PublishingICD-HCFDistrict Association MeetingsDietary Managers AssociationDepartment of Inspections & AppealsIDA Board and Council
3Chapter 1 Guidelines for Diet Planning MyPyramid 2005Dietary Guidelines for Americans 2005
4Dietary Guidelines for Americans 2005 Consume a variety of foodsControl calorie intake to manage body weightBe physically active every dayIncrease daily intake of fruits and vegetables, whole grains, low-fat milk and milk products
5Dietary Guidelines for Americans 2005 5. Choose fats wisely for good health6. Choose carbohydrates wisely for good health7. Choose and prepare foods with little saltIf you drink alcoholic beverages, do so in moderationKeep food safe to eat
7Daily Amount of Food from Each Group Calorie Level1,0001,2001,4001,6001,8002,0002,2002,4002,6002,8003,0003,200Fruits(cups)11.522.5Vegetables33.54Grains(ounce equivalents)5678910Meat and Beans5.56.5MilkOils/Fat(tsp)11Discretionary Calorie Allowance165171132195267290362410426512648
9Chapter 2 Routine Diets General Diet Milk 2-3 cups Meat and Beans 2-3 servings (total 2-7 ounce-equivalents)Fruits cupsVegetables 1-4 cupsGrains 3-10 servingsOils/Fat Use sparinglyFluids 6-8 cups
10Chapter 2 Routine Diets General Diet Milk 2-3 cups Meat and Beans 2-3 servings (total 2-7 ounce-equivalents)Fruits cupsVegetables 1-4 cupsGrains 3-10 servingsOils/Fat Use sparinglyFluids 6-8 cupsNutrition Guidelines for Pregnancy and Lactation, Normal Infants, Children
11Chapter 2 Routine Diets General Diet Milk 2-3 cups Meat and Beans 2-3 servings (total 2-7 ounce-equivalents)Fruits cupsVegetables 1-4 cupsGrains 3-10 servingsOils/Fat Use sparinglyFluids 6-8 cupsNutrition Guidelines for Pregnancy and Lactation, Normal Infants, ChildrenMeeting Nutritional Needs for Older Adults
12Meeting Needs of Older Adults Use General Diet as much as possibleLeast restrictive diet is encouraged, especially residents of long-term care facilitiesMinor changes to a well-planned general diet may meet the needs of people with high blood cholesterol, diabetes, or those that need weight management.
13Chapter 3 Consistency Altered Diets ADA National Dysphagia DietsLevel 1: Dysphagia PureedLevel 2: Dysphagia Mechanically AlteredLevel 3: Dysphagia Advanced DietADA National Dysphagia Diet Liquid Consistency Levels
15Level 3: Dysphagia Advanced Diet Food GroupsRecommendedAvoidBreadsAny well-moistened breads, biscuits, muffins, pancakes, waffles, etc. Need to add adequate syrup, jelly, margarine, butter, etc., to moisten well.Dry bread, toast, crackers, etc.Tough, crusty breads such as French bread or baguettes.CerealsAll well-moistened cereals.Coarse or dry cereals such as shredded wheat or All BranFruitsAll canned and cooked fruits.Soft, peeled fresh fruits such as peaches, nectarines, kiwi, mangos, cantaloupe, honeydew, watermelon.Soft berries with small seeds.Difficult-to-chew fresh fruits such as apples or pears.Stringy, high-pulp fruits such as papaya, pineapple, or mango.Fresh fruits with difficult-to-chew peels such as grapes.Meats, Meat Substitutes, EntreesThin-sliced, tender, or ground meats and poultry.Well-moistened fish.Eggs prepared any way.Casseroles with small meat chunks, ground meats, or tender meats.Tough, dry meats and poultry.Dry fish or fish with bones.Chunky peanut butter.Yogurt with nuts or coconut.Potatoes and StarchesAll, including rice, wild rice, moist bread dressing, and tender, fried potatoes.Tough, crisp-fried potatoes.Potato skins.Dry bread dressing.SoupsAll soups except those in the Avoid list.Soups with tough meats.Corn or clam chowders.Soups that have large chunks of meat or vegetables >1 inch.VegetablesAll cooked, tender vegetables.Shredded lettuce.All raw vegetables except shredded lettuce.Cooked corn.Nontender or rubbery cooked vegetables.
17Level 2: Dysphagia Mechanically Altered Diet Food GroupsRecommendedAvoidBreadsSoft pancakes, well moistened with syrup or sauce.Pureed bread mixes, pregelled or slurried breads that are gelled through entire thickness.All othersCerealsCooked cereals with little texture, including oatmeal.Slightly moistened dry cereals with little texture.Unprocessed wheat bran stirred into cereals for bulk.Very coarse cooked cereals that may contain flax seed or other seeds or nuts.Whole-grain dry or coarse cereals.Cereals with nuts, seeds, dried fruit and/or coconut.FruitsSoft drained canned or cooked fruits without seeds or skin.Fresh soft/ripe banana.Fruit juices with small amount of pulp.Fresh or frozen fruits.Cooked fruit with skin or seeds.Dried fruits.Fresh, canned, or cooked pineapple.Meats, Meat Substitutes, EntreesMoistened ground or cooked meat, poultry, or fish. Moist ground or tender meat may be served with gravy or sauce.Casseroles without rice.Moist macaroni and cheese, well-cooked pasta with meat sauce.Moist meatballs, meat loafProtein salads such as tuna or egg without large chunks.Cottage cheese, smooth quiche.Poached, scrambled, or soft-cooked eggs.Dry meats, tough meats (such as bacon, sausage, hot dogs, bratwurst).Dry casseroles or casseroles with rice or large chunks.Cheese slices and cubes.Peanut butterHard-cooked or crisp fried eggs.Sandwiches.Pizza.
18Level 2: Dysphagia Mechanically Altered Diet (Continued)Level 2: Dysphagia Mechanically Altered DietFood GroupsRecommendedAvoidPotatoes and StarchesWell-cooked, moistened, boiled, baked, or mashed potatoes.Well-cooked shredded hash brown potatoes that are not crisp. (All potatoes need to be moist and in sauces.)Well-cooked noodles in sauce.Potato skins and chips.Fried or French-fried potatoes.Rice.SoupsSoups with easy-to-chew or easy-to-swallow meats or vegetables: particle sizes in soups should be <1/2 inch.Soups with large chunks of meat and vegetables.Soups with rice, corn, peas.VegetablesAll soft, well-cooked vegetables.Vegetables should be <1/2 inch. Should be easily mashed with a fork.Cooked corn and peas.Broccoli, cabbage, brussels sprouts, asparagus, or other fibrous nontender or rubbery cooked vegetables.
20Level 1: Dysphagia Pureed Diet Food GroupsRecommendedAvoidBreadsCommercially or facility-prepared pureed bread mixes, pregelled slurried breads, pancakes, sweet rolls, Danish pastries, French toast, etc., that are gelled through entire thickness of product.All other breads, rolls, crackers, biscuits, pancakes, waffles, French toast, muffins, etc.CerealsCereals may have just enough milk to moisten.Smooth, homogenous, cooked cereals such as farina-type cereals. Cereals should have a “pudding-like” consistency.If thin liquids allowed, also may have: Enough milk or cream with cereals to moisten; they should be blended well.All dry cereals and any cooked cereals with lumps, seeds, chunks.Oatmeal.FruitsPureed fruits or well-mashed fresh bananas.Fruit juices without pulp, seeds, or chunks.Whole fruits (fresh, frozen, canned, dried).Meats and Meat SubstitutesPureed meats.Braunschweiger.Whole or ground meats, fish, or poultry.Nonpureed lentils or legumes.Cheese, cottage cheese.Peanut butter, unless pureed into foods correctly.Nonpureed fried, scrambled, or hard-cooked eggs.SoupsSoups that have been pureed in a blender or strained.Soups that have chunks, lumps, etc.VegetablesPureed vegetables without chunks, lumps, pulp, or seeds.All other vegetables that have not been pureed.
22SAMPLE MENU PLAN FOR NATIONAL DYSPHAGIA DIETS (Select from foods for the day in the General Diet or any other diet. Follow theportion sizes for the appropriate diet using the textural modifications.)MealGeneralDysphagia AdvancedDysphagia MechanicalDysphagia PureedBreakfastOrange Juice*Oatmeal or cornflakes*Fried EggCinnamon RollMargarineMilk*Scrambled EggSlurried Cinnamon RollOrange Juice, no pulp*Malt-O-MealPureed Scrambled EggLunch orSupperBaked ChickenBaked PotatoPeas and CarrotsRoll/MargarineApple PieGround ChickenBaked Potato-no skinPeas and Carrots, tenderGround Chicken, moistenedBaked Potato- no skinPureed Peas and CarrotsSlurried Roll/MargarineApple Pie- no top crustPureed ChickenMashed Potatoes with butterPureed pieDinnerChicken Noodle Soup*CrackersGrilled Cheese SandwichCherriesCrackers in soupCherries, cannedPureed Chicken Noodle Soup*Crackers pureed into soupPureed Grilled CheesePureed CherriesSnackCookieCookie, softSoaked CookiePureed Cookie*If thin liquids restricted, thicken to appropriate consistency
25Treatment Algorithm for Assessment of Overweight and Obesity Patient EncounterHx of >25 BMI?BMI taken in past 2 years?Measure weight, height, and waist circumferenceCalculate BMIPeriodic Weight CheckAssess risk factorsBMI > 25 or waist circumference >88 cm (F)>102 cm (M)BMI>30 or BMI or waist circumference > 88 cm F >102 cm AND 2 risk factorsDoes patient want to lose weight?Clinician & patient devise goals & treatment strategy for weight loss a& risk factor controlProgress being made/goal achieved?Hx BMI > 25?Brief reinforcement or education on weight managementAdvise to maintain weight & address other risk factorsAssess reasons for failure to lose weightMaintenance:Diet therapyBehavior therapyPhysical activityYesNoTreatment Algorithm for Assessment of Overweight and ObesitySource: National Heart, Lung and Blood Institute (part of the National Institutes of Health & U.S. Dept of Health and Human Services) and North American Association for the Study of Obesity. Oct The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.
28Bariatric/Gastric Bypass Diet Roux-en-Y procedure Eat 1-3 “meals” per day, snack rules varyConsume max of 2-4 Tbsp per “meal”Consume max of 60 gm protein dailyNo liquids with meals and 30 minutes before and after eating solidsTake small bites, chew 25 times per biteConsume at least 64 oz water dailyDo not use straws
29Chapter 6 Diets for Diabetes Deletion of Limited Concentrated Sweets (LCS) DietConsistent Carbohydrate DietMenu Planning GuidelinesGestational Diabetes Meal PlanTreatment of Hypoglycemia
30American Dietetics Association position statement (2001) “Providing adequate nutrition is the primary concern for the residents of long-term care facilities if malnutrition is to be prevented or corrected. Experience has shown that residents eat better when they are given less-restrictive diets with regular foods… with consistent amounts of carbohydrate at meals and snacks….”
31Chapter 6 Diets for Diabetes Deletion of Limited Concentrated Sweets (LCS) DietConsistent Carbohydrate DietMenu Planning GuidelinesGestational Diabetes Meal PlanTreatment of Hypoglycemia
32Menu PlanningCarbohydrate ChoicesGrams of CarbohydrateCarbohydrate Ranges11511-2023026-3534541-5046056-6557571-80
34SUGGESTED MENU PLAN FOR CONSISTENT CARBOHYDRATE DIET (Select from foods described)MEAL PATTERNCONSISTENT CARBOHYDRATE DIETGENERAL DIETBreakfast5 carbohydrate choices=~75 grams carbohydrate½ cup orange juice (1 choice)½ cup oatmeal (1 choice)1 slice toast (1 choice)1 egg1 cup milk (1 choice)1 Tbsp regular jelly (1 choice)1 tsp margarinecoffee½ cup orange juice½ cup oatmeal1 slice toast1 cup milk1 Tbsp jellyLunch or Supper5 carbohydrate choices =3 oz roast beef½ cup mashed potatoes (1 choice)½ cup broccoli1 dinner roll (1 choice)2 tsp margarine2x2 brownie/frosting (2 choices)½ cup mashed potatoes½ cup broccoli1 dinner roll2x2 brownie/frosting
35Chapter 7 Fat Restricted Diets Low Fat Diet(40-50 g fat)Cholesterol/Saturated Fat Restricted Diet(NCEP/AHA Diet: less than 200 mg cholesterol, 25-35% of calories from fat)
36Chapter 8 Sodium Restricted Diets No Added Salt Diet(3,000-4,000 mg sodium)Low Sodium Diet(2,000 mg sodium)
37Chapter 9 Diets for Renal and Liver Disease Protein and Electrolyte Controlled DietModified Renal DietFluid Restrictions
38Chapter 9 Diets for Renal and Liver Disease Protein and Electrolyte Controlled DietModified Renal DietFluid Restrictions
39“The Modified Renal Diet may be prescribed for individuals with End-Stage Renal Disease (ESRD) who are on dialysis and reside in a long-term health care setting.”
40Modified Renal Diet“The use of a standardized menu in the LTC setting make it possible to individualize the person’s nutritional needs based on their biochemistry.”
42Energy Adequate caloric intake is essential Ensure food substitutions provide the same energy as those provided in the General diet
432. CarbohydratesThe addition of refined carbohydrates and simple sugars, i.e. desserts, can be useful in achieving adequate protein-sparing calories.If the person has diabetes, refer to the Consistent Carbohydrate Diet.
443. Protein Protein requirements are higher for persons on dialysis Double egg portion at breakfastLarge portion of meat at midday and evening mealMeat sandwich for snack
454. SodiumRestriction varies according to the person’s hydration status including fluid retentionSubstitute lower sodium meats to replace high sodium meats as listed in the NAS dietSubstitute all soup with low sodium soups or low/medium potassium vegetableAvoid salt substitutes, seasoning mixes
465. Phosphorus Needs to be limited to limit bone loss Substitute refined CHO for whole grain or bran-containing breads and cereals, including oatmealAvoid beans and legumesRestrict milk to ½ cup per dayLimit cheese intake to ½ oz per day
476. PotassiumIntake should be individuals as dictated by potassium lab valuesSubstitute citrus, prune, tomato juices with cranberry, apple or other low K+ juiceSubstitute citrus fruit, bananas, tomatoes, and prunes with low/med K+ fruits.Allow mashed or boiled potatoes, only ¼ cup per day. No baked potatoes.
48Fluid limits, when needed, must be individualized.
57Chapter 11 Other Modified Diets Food Allergies and IntolerancesLactose Restricted DietGluten Restricted DietPhenylalanine Restricted Diet
58Chapter 11 Other Modified Diets Food Allergies and IntolerancesLactose Restricted DietGluten Restricted DietPhenylalanine Restricted Diet
59Phenylalanine Restricted Diet PKU is caused by the lack of an enzyme that normally converts phenylalanine to tyrosine.This causes phenylalanine to build up in the blood and brain and causes mental retardation.A special diet will prevent this mental retardation if it is started soon after birth.
60PKU (cont)Now, every child is screened within a couple of days of birth for PKU.Before newborn screening began in the 1960’s, most children had some degree of mental retardation before they were identified as having PKU.Some of these individuals are now in group homes or other residential settings.
61PKU (cont)Even though the mental retardation cannot be reversed, it is still recommended these individuals be placed on a phenylalanine restricted diet as some of the behavior problems associated with untreated PKU improve when put on the diet.
62DIET PRINCIPLESConsume a special formula that has the phenylalanine removed, but still has all the other amino acids.Avoid all foods high in protein.Avoid all foods containing Nutrasweet. Saccharin and Splenda are ok.May eat measured amounts of fruits, vegetables, grains, and low protein foods.
63PKU (cont)A registered dietitian familiar with the PKU diet should assist in menu planning and teaching.
64Sample PKU Meal Special metabolic formula Fruit Vegetable Low protein food and/or grain product
65Chapter 12 Dining Assistance/Special Needs Feeding Guidelines for Individuals with DementiaNutrition for Individuals with Developmental Disabilities
66Study Guide Questions Chapters Rearranged Inclusion of Study Guide Questions after each chapterSuggested Responses in Appendix
67Appendixes Updated Dietary Reference Intakes (DRI’s) Body Mass Index Table (expanded to include morbid obesity)Addition of calcium and iron foodsADA Exchange Lists for Meal Planning, 2003
68Simplified Diet Manual Tenth Edition Publication Date: January 2007Edited by Andrea Maher and the Iowa Dietetic AssociationOrdering InformationPhone:Mail: Wiley-BlackwellCustomer Care10475 Crosspoint Blvd.Indianapolis, IN 46256Fax:Website: