1 cup milk = 240 ml 3 oz. pork chop with 1⁄4 c gravy = negligible 1⁄2 cup broccoli = negligible 1⁄2 cup sherbet = 120 ml 1 cup milk = 240 ml Total = 240 + 120 + 240 = 600 ml

1. Nutrition Fundamentals and Medical
Nutrition Therapy
Modify Diet Plans
Corresponds with
LEARNING PLAN 11
Copyright 2016 Association of Nutrition and Foodservice
Professionals

2. Objectives
 Develop Menus
 Implement nutrition plan to meals/foods to be served
 Respect client needs and food habits
 Use nutrition analysis data to modify menus for
» Calories, carbohydrates, proteins, fats, and minerals
» Fiber content, texture or feeding needs
» Medical or other personal condition (including allergies)
» Racial, cultural and religious differences
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

3. Factors That Influence What Foods
Are Chosen by Clients
 Availability of Food
 Personal Taste
 Aesthetic Influences
 Aesthetic Concerns
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

4. Brain Break
 Availability of Food
 Personal Taste
 Aesthetic Influences
 Aesthetic Concerns
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11
» Food budget; proximity to grocery
store
» Ability to taste and/or smell
» Color of food; how food is
presented
» While the menu is the
fundamental tool for planning
diets, the CDM must ensure that
menus are satisfying to clients
For each factor that affects what foods are selected by clients, provide an example

5. Menu Planning Guidelines
 Must meet the nutritional needs of clients
» DRI-RDA
» choosemyplate.gov
» Nutritional standards for specific meal programs
- Child Care Centers
- Home Day Cares
- Congregate Feeding Sites/Home Delivered Meals
- Correctional Facilities
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

6. Types of Menus
 Fixed
» Most commonly found in restaurants
» Offers the same food every day
 Cycle
» Most commonly found in institutional settings
» Menu that repeats itself over a defined period of time such as
five weeks
 Single Use
» Used in institutional settings for monotony breakers
» Used only once
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

7. Menu Options
 Selective Menu
» Adaptation of a cycle menu allowing more client choice
» Additional monitoring may be needed to review menu choices
before they are served to clients
» What happens if selected menu choices are not on a client’s
prescribed diet?
- Adjustments may need to be made in portion sizes, consistency,
or addition of nutritional supplement
- Additional training for staff to assist clients when foods not on the
diet are selected
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

8. Menu Options
 Non-selective menu
» Clients do not make choices for main dishes
» Typical in group dining experience such as assisted living
» Substitutions for individualized food preferences will be
important
- Substitutions must be of equal nutritional value and similar color
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

9. Brain Break
 If a client doesn’t like Brussels sprouts, what would be a
good nutritional substitute?
» Steamed pea pods
» Steamed broccoli
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

10. Lifecycle Menu Planning
Pregnancy
 Pregnancy weight gain is dependent upon pre-pregnancy
weight status
 RECOMMENDED WEIGHT GAIN RANGES
» Underweight: BMI < 18.5 28-40 lbs.
» Normal Weight: BMI 18.5-24.9 25-35 lbs.
» Overweight: BMI 25-29.9 15-15 lbs.
» Obese: BMI > 30 11-20 lbs.
 Energy (caloric) needs increase during pregnancy and lactation
» During the second trimester consume an additional 300 calories
per day
» During the third trimester consume approximately an extra ~425
calories per day
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

11. Lifecycle Menu Planning
Pregnancy
 Nutrient needs to asses during pregnancy
» Overall diet and use of PNV as prescribed
» Protein needs increase during pregnancy
» Important to add omega-3 fatty acids to diet
» Iron status and intake is important
» Calcium and folate intake is important
» Vitamins C and A requirements increase
» Vitamin B12 is a consideration if the mother is a vegan
» Monitor for herbal supplements
 Watch for nausea, vomiting, diarrhea, heartburn
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans• Learning Plan 11

12. Lifecycle Menu Planning
Lactation
 All breastfeeding and postpartum women are encouraged
to continue use of prenatal vitamin/mineral supplements
and maintain proper nutrition
 During lactation, women may need 300-500 extra
calories per day and hydration needs may increase
 Continued increased nutrient needs for mom during
lactation
 Support mom during this time as breastfeeding can be
difficult for some
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

13. Lifecycle Menu Planning
Infants
 Breastfeeding provides optimal nutrition for infants and is also
deemed an important global health initiative for Healthy People
2020.
 Mothers should be educated and supported during pregnancy
and beyond
 Breastfeeding can promote
» normal tooth and jaw alignment,
» decrease risk of ear infections and
» may reduce the risk of sudden infant death syndrome (SIDS).
» In addition, data suggests that breastfeeding may decrease the
risk of chronic health problems like obesity and some allergies
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

14. Lifecycle Menu Planning
Infants
 Formula-an alternate choice for mothers who cannot or choose
not to breastfeed
 3 Forms
» Ready-to-feed
» Liquid concentrate
» Powdered
- Each must be handled using safety and sanitation guidelines
 Cow’s milk formula alternates (soy) and specialty formulas are
available for babies not tolerating formula
 Place emphasis on no cow’s milk or milk alternative for the
first year—only breastmilk and formula
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

15. Lifecycle Menu Planning
Infants
 Vitamin D-
» Oral vitamin D supplementation is suggested for infants who are either
breastfed or consuming less than ~34 ounces of formula per day.
» Suggested that infants begin receiving 400 IU in the first few days of life
 Iron-
» Stores are generally sufficient for the 4-6 months of life for full-term infants.
» Certain pre-term infants or those that are not consuming sufficient iron-rich
foods between 4-6 months may benefit from supplementation
 Fluoride
» Fluoride supplement is not generally recommended for infants less than six
months of age
» For infants older than six months of age, water sources should be
evaluated for over or under consumption of fluoride, and determine if
supplementation is necessary.
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

16. Lifecycle Menu Planning
Infants
 Infants grow rapidly in the first year of life-adequate
nutrition is important
 Breastmilk or formula for the first year of life
 Complementary Feedings
» Begin at approximately 4-6 months by spoon and progress
feeding stages as developmentally ready
- Rice cereal is often a “first food”
» Cup may be used with water, breastmilk or formula
- Infant juice is not necessary in the diet and shows no benefit over
fruits and vegetables. If given should be given by cup
» Add new foods one at a time in case of an allergic reaction
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

17. Lifecycle Menu Planning
Infants
 Foods to avoid the first year
» Honey
» Potentially allergenic foods
- Milk, eggs, wheat, nuts, chocolate, shellfish, soy
» Foods that may cause choking
- Hot dogs, nuts, raisins, popcorn, grapes, apple chunks
 Whole milk should be offered after 12 months, but not
before
» Gradually switch to lower fat milk and fat-free by age 5
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

18. Lifecycle Menu Planning
Preschoolers
 Preschoolers may be subject to food jags
 Offer child-friendly portions
 Offer variety of preparations
» Raw, cooked, mixed, separate
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

19. Lifecycle Menu Planning
Preschoolers
 Caution with hot or strongly flavored foods
 Enhance cooked foods and mixed dishes with added
cooked vegetables
 Snacks are important because of limited intake at one
time; finger foods are excellent choices
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

20. Lifecycle Menu Planning
School-Age Children
 Time of rapid growth rate, so nutritional needs are in high
demand
 Protein, calcium and iron are particularly in demand
 Snack choices are important to fulfill nutritional needs
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

21. Brain Break
 What would be good menu choices for children 18 to 24
months and why?
» Finger foods such as slightly cooked vegetables or softer
fruits such as strawberries cut into small pieces; no hot dogs.
Children this age are still learning small motor skills and
picking up finger foods are an important part of the child’s
development.
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

22. Lifecycle Menu Planning
School-Age Children
 Overweight and obese children is an adverse health
trend
 Strategies to help
» Eat a healthy breakfast
» Eat fewer processed foods
» Reduce sugar sweetened beverages
» Limit intake of fruit juice and choose fruits and vegetables
» Consume fewer fast food restaurant meals
» Eat smaller portions of nutrient-rich choices
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

23. Lifecycle Menu Planning
Adolescents
 Time of rapid growth spurt
 Adolescents begin exercising control over food choices
 Many outside influences in food choices
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

24. Lifecycle Menu Planning
Adolescents
 Nutritional concerns
» Anorexia nervosa
» Bulimia
» Binge eating disorder
» Obesity
 Nutrients of primary concern due to inadequate intake
» Calcium, iron, vitamin A, vitamin C; sometimes calories and
protein
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

25. Brain Break
 What is the number one nutritional concern today for
children and adolescents ages 2 through 19?
» Overweight and obesity
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

26. National School Lunch Program
(NSLP)
 Initiated in 1946
 2010 Healthy, Hunger Free Kids Act sparked many changes
 USDA supports free or low cost school breakfasts and lunches
 School meals must meet the recommendations of the Dietary
Guidelines for calories, protein, fat, and several vitamins and
minerals (federal guidelines)
 Each school determines their own menu based on meeting the
federal guidelines, as well as providing foods that the students
will enjoy
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

27. Lifecycle Menu Planning
Elderly
 Older Americans are our fastest growing population group
 Foodservice operations serving older adults or elderly will
continue to increase
 Elderly have specific nutritional needs that influence nutrition
» BMR declines
» Physiological factors
» Psychosocial factors
» Socioeconomic factors
 Likely to be at nutritional risk
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

28. Menu Planning Challenges for the
Elderly
 Illness
 Meeting DRI – RDA/caloric
intake
 Dentition
 Functional disabilities
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11
 Taste and smell
 Changes in the GI tract
 Medications
 Thirst

29. CMS Regulations in LTC
 Each client receives, and facility provides, at least three meals daily, at regular times
comparable to normal mealtimes in the community
 There must be no more than 14 hours between a substantial evening meal and
breakfast the following day (or 16 hours if a nourishing snack is provided at bedtime)
 An evening meal should provide at least 20 percent of the day’s total nutritional
requirements
 The facility must offer snacks at bedtime daily
 Food is attractive and palatable, incorporating needs as identified through
observation, client and staff interviews and review of client council minutes
 If a food group is missing from the client’s daily diet, the facility has an alternative
means of satisfying the client’s nutrient needs
 Substitutes of similar nutritive value are offered to clients who refuse food served
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

30. Brain Break
 What techniques can the CDM use to overcome meal
planning challenges for the elderly?
» Add high-fiber foods that have a softer texture
» Increase protein by adding nonfat dry milk to casseroles,
sauces, gravies
» Increase the use of herbs and spices
» Serve nutrient dense desserts (e.g. oatmeal cookies,
custards, puddings, pies with graham cracker crusts)
» Serve moderately sized meals to avoid excessive calories
and wasted food
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

31. Translate Nutrition Needs into
Food Choices
 After nutrition screening and assessment, the CDM uses
this information to provide food to the client
 Determine total amount of calories in food
» Carbohydrate – 4 calories per gram of CHO
» Fat – 9 calories per gram of fat
» Protein – 4 calories per gram of protein
» Alcohol – 7 calories per gram
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

32. Translate Nutrition Needs into
Food Choices
 Determine percent of calories of each food component to
equal 100%
 Percent of calories from CHO, Pro and Fat will help
shape the medical nutrition therapy for the client
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

33. Calculating Total Calories
 Use Figure 11.9 to calculate the total calories for one
serving of crackers
» Total fat - 4 gm
» Total Carbohydrate - 22 gm
» Total Protein - 3 gm
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11
4 g fat x 9 cal/gm = 36 calories
22 g CHO x 4 cal/gm = 88 calories
3 g Pro x 4 cal/gm = 12 calories
Total Calories = 136 calories per serving

34. Calculating Percent Calories
 Continue to use Figure 11.9
» Using the information from the previous slide, calculate the
percent of calories from carbohydrate
» 88 calories from carbohydrate ÷ total calories
» 88 ÷ 136 = 65%
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

35. Calculating Fluid Intake
 Additional water may be advised
» Dehydration
» Risk factors when dehydrated
- Coma
- Fluid loss
- Increased fluid needs
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

36. Calculating Fluid Intake
 Water may be restricted
» Renal failure, liver failure, congestive heart failure
» Expressed as a specific ml. 1000 ml (milliliters)
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

37. Calculating Fluid Intake
» Facility policy determines how much fluid is allowed from
nutrition services, and how much is allowed from nursing
» 1 cup of water = 8 oz. = 240 ml
» Count anything that ‘looks’ like a liquid at room temperature
» Adjust menu to make meals palatable and reasonable
» Nursing removes water pitcher from client’s room
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

38. Brain Break
 Calculate the fluid in the following menu in ml
» 1 cup milk
» 3 oz. pork chop with ¼ c gravy
» ½ cup broccoli
» ½ cup sherbet
» 1 cup milk + ½ c sherbet = 12 oz. or 360 ml
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

39. Sources of Nutrient Information
 Assurance of scientific research and standardization
 USDA Nutrient Database
 Nutrient Analysis Software – uses USDA data
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

40. Sources of Nutrient Information
 Nutrition Facts Label
» Designed for consumers
» On most foods except meat and poultry
» Identifies portion size
» Expresses % daily value
» Provides information about specific nutrients
» Uniform definitions and scientifically substantiated claims
Nutrition Fundamentals and Medical Nutrition Therapy • Food Preferences and Customs • Learning Plan 1

41. Calculation of Nutrients
 Exchange Lists
» Valuable method to quickly analyze a daily intake and
macronutrients for a client
- Assign foods consumed to an exchange list group
- Total exchanges for each group
- Multiply total exchanges by the standard CHO, fat, protein and
caloric values for each group
- Total values
- 15 gm CHO = 1 CHO serving
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

42. Calculation of Nutrients
 Carbohydrate Counting
» Concern is on carbohydrate intake
» Foods distributed evenly throughout the day
» Based upon Exchange Lists
» Other parameters such as weight is monitored
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11

43. Brain Break
 A client is counting carbohydrates and is allowed 60
grams for breakfast, 50 grams for lunch, 60 grams for
dinner and 35 grams for snacks. Using the exchange list
information below, plan a lunch that meets the allowance
for carbohydrate.
Nutrition Fundamentals and Medical Nutrition Therapy • Modify Diet Plans • Learning Plan 11
1 bread exchange = 15 grams
1.5 fruit exchange = 22 grams
1 vegetable exchange = 5 grams
½ milk exchange = 6 grams