nfmnt chapter 11 modify diet plans

Nutrition Fundamentals and Medical Nutrition Therapy

Modify Diet Plans

Corresponds with LEARNING PLAN 11 Copyright 2016 Association of Nutrition and Foodservice Professionals

11

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

Factors That Influence What Foods Are Chosen by Clients Availability of Food

Personal Taste

Aesthetic Influences

Aesthetic Concerns


Brain Break

Availability of Food

Personal Taste

Aesthetic Influences

Aesthetic Concerns


» 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

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


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


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


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


Brain Break

If a client doesn’t like Brussels sprouts, what would be a good nutritional substitute?

» Steamed pea pods» Steamed broccoli


Lifecycle Menu PlanningPregnancy

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


Lifecycle Menu PlanningPregnancy 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

Lifecycle Menu PlanningLactation 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

Lifecycle Menu PlanningInfants

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



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


Lifecycle Menu PlanningInfants 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.



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



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


Lifecycle Menu PlanningPreschoolers

Preschoolers may be subject to food jags

Offer child-friendly portions

Offer variety of preparations» Raw, cooked, mixed, separate


Lifecycle Menu PlanningPreschoolers

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


Lifecycle Menu PlanningSchool-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


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.


Lifecycle Menu PlanningSchool-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


Lifecycle Menu PlanningAdolescents

Time of rapid growth spurt

Adolescents begin exercising control over food choices

Many outside influences in food choices


Lifecycle Menu PlanningAdolescents

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


Brain Break

What is the number one nutritional concern today for children and adolescents ages 2 through 19?

» Overweight and obesity


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


Lifecycle Menu PlanningElderly

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


Menu Planning Challenges for the Elderly Illness

Meeting DRI – RDA/caloric intake

Dentition

Functional disabilities


Taste and smell

Changes in the GI tract

Medications

Thirst

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


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


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


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


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


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

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%


Calculating Fluid Intake

Additional water may be advised» Dehydration» Risk factors when dehydrated

- Coma- Fluid loss- Increased fluid needs



Water may be restricted» Renal failure, liver failure, congestive heart failure» Expressed as a specific ml. 1000 ml (milliliters)



» 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


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


Sources of Nutrient Information

Assurance of scientific research and standardization

USDA Nutrient Database

Nutrient Analysis Software – uses USDA data


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


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


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


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.


1 bread exchange = 15 grams

1.5 fruit exchange = 22 grams

1 vegetable exchange = 5 grams½ milk exchange = 6 grams

nfmnt chapter 11 modify diet plans

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