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NFMNT Chapter 11 Modify Diet Plans
- 1. Nutrition Fundamentals andMedical 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 InfluenceWhat 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 Availabilityof 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 SelectiveMenu » 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-selectivemenu » 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 Ifa 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-AgeChildren 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 Whatwould 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-AgeChildren 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 Whatis 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 LunchProgram (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 Challengesfor 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 inLTC 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 Whattechniques 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 Needsinto 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 Needsinto 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 Calculatethe 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 NutrientInformation 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 NutrientInformation 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 Aclient 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
Editor's Notes
- #6 A common standard for nutritional evaluation is the DRI-RDA. An analysis of the DRI-RDA is most effective when it spans a period of days. Many programs have specific government regulations for nutrition requirements.
- #7 Review Chapter 1 Foodservice Management By-Design for detail re the various menus
- #12 PNV prenatal vitamin Iron supplementation beyond the PNV may be recommended for some women. Encourage a balanced diet. Dieting is not recommended
- #17 AAP does suggest delaying solids until six months, but some infants may be ready between four and six months of age. Infant developmental readiness and offering solids should be discussed with a qualified healthcare provider. Solids should not be introduced later than eight months of age. juice is included in the diet, AAP suggests that it should be limited to four to six ounces daily. One hundred percent juice should be offered only by cup and can be diluted with water and may be offered during “snacks.” In addition, other “sugary drinks and beverages” should not be offered to an infant.
- #19 it’s important to understand that the entire growth process involves building new tissue at a rapid rate.
- #20 Try to make sure each meal includes: • One softer food that is easy to chew • One crisp or chewy food (important for developing chewing skills, but beware of choking hazards) • One colorful food, like a fruit or vegetable • Two finger foods
- #21 Offer balanced options at snack times for quality nutrition
- #23 School Lunch Program regulations have changed over the past few years.
- #24 Teens may choose sugary beverages and energy drinks more often as well as foods that lack nutrition needed for growth
- #27 In 2010, with the passage of the Healthy, Hunger-Free Kids Act, the USDA implemented changes that reflect the recommendations for school-age children: more fruits and vegetables, whole grain products, and less fat and sodium. School meals must meet the recommendations of the Dietary Guidelines for Americans, with no more than 30 percent of calories from fat, and less than 10 percent from saturated fat. Regulations also establish a standard for school meals to provide whole grains, fruits and vegetables, lean meats and low-fat milk within an established calorie range (based on grade). There are also sodium restrictions, rules on competitive foods and a focus on providing opportunities to make healthy choices during the school day.
- #28 Sound nutrition is needed to combat common problems. This is especially important in at-risk populations
- #30 regulations emphasize clients’ rights—their options to exert control over their own care. This certainly extends to meals and menus. Both the menu as planned and the manner in which Certified Dietary Managers implement it must address these rights. If a client specifically refuses a food or requests a substitute, it is up to the Certified Dietary Manager to be of service in every way that is practical. If the facility uses a nonselective menu, it is especially important to make alternates available upon request. A client also has the right to refuse treatment, including a therapeutic diet. In making choices, a client should be well informed. It is up to the Certified Dietary Manager to work with other members of the healthcare team, as needed, to review any diet-related concerns and assure that clients’ rights are being honored
- #37 Again this is a great place to review the CMS requires use of cc but mL will be used as well!
- #41 This will be changing in the future
- #43 This is a preferred option as it leads to greater satisfaction and choice