Diet Manual for Long Term Care

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Diet Manual for Long-Term Care Residents

2014 Revision

The Office of Health Care Quality is pleased to release the latest revision of the Diet Manual for

Long-Term Care Residents. This manual is a premier publication—serving as a resource for

providers, health care facilities, caregivers and families across the nation.

In long-term care facilities, meeting nutritional requirements is not as easy as it sounds. It is

important to provide a wide variety of food choices that satisfy each resident’s physical, ethnic,

cultural, and social needs and preferences. These considerations could last for months or even

years. Effective nutritional planning, as well as service of attractive, tasty, well-prepared food

can greatly enhance the quality of life for long-term care residents.

The Diet Manual for Long Term Care Residents was conceived and developed to provide

guidance and assistance to nursing home personnel. It has also been used successfully in

community health programs, chronic rehabilitation, and assisted living programs. It serves as a

guide in prescribing diets, an aid in planning regular and therapeutic diet menus, and as a

reference for developing recipes and preparing diets.

The publication is not intended to be a nutrition-care manual or a substitute for individualized

judgment of a qualified professional. Also included, is an appendix that contains valuable

information to assess residents’ nutritional status.

On behalf of the entire OHCQ agency, I would like to thank the nutrition experts who

volunteered countless hours to produce this valuable tool. We also appreciate Beth Bremner and

Cheryl Cook for typing the manual. The full committee includes:

Committee Chairs

Beth Bremner and Jan Madden

Committee Members

Heather Albertson, Pat Cierniak, Blenda Eckert, Nancy Ferrone, Anita Gathogo, Angela Lang,

Jonine Natale, Siony Placiente, Jean Smith, Tim Smith-Kayode, Joan Todd and Becky Weavil.

Patricia Tomsko Nay, MD, CMD, CHCQM, FAAFP, FAIHQ, FAAHPM

Executive Director and Acting Medical Director

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Diet Manual 2014 Revision

Table of Contents

Regular Diet 5-7

Mechanical Soft (Dental Diet) 8-10

Dysphagia Level 1 (Pureed Diet 11-14

Dysphagia Level 2 (Mechanically Altered Diet) 15-19

Dysphagia Advanced Level 3 Diet 20-23

Full Liquid Diet 24-26

Clear Liquid Diet 27-28

Restricted Fiber Diet / Restricted Residue Diet 29-30

Increased Fiber Diet 31-33

Pleasure Feedings 34

Small Regular and Large Portion Sizes 35

Small Portions Diet 36-37

Large Portion Diet 38

Vegetarian Diet 39-41

Lacto-Ovovegetarian Meal Plan 42

Vegan Meal Plan 43

No Added Salt Diet 44

Low Sodium Diet (2 – 4 grams) 45

Cholesterol Restricted and Fat Controlled Diet 46-49

Limited K+ Diet & Liberalized Renal Diet 50

Renal Diet 51-53

Potassium Containing Foods (over 300 mg K+ per serving) 54-63

Renal Diet High Phosphorus Foods 64

Renal Diet Continued 65

Simplified Guideline for Standard Carbohydrate Controlled Diet 66-67

Carbohydrate Controlled Diet 68-95

Calorie Restricted (Low Calorie) Diet 96

Limited Concentrated Sweets (LCS) Diet 97-99

Diabetic Diet Calculated 100

Lactose Reduced Diet 101-102

Kosher Diet 103-107

Enteral Nutrition 108-110

Parenteral Nutrition 111-113

Gluten Free Diet 114-118

Finger Food Diet 119-122

Thickened Liquids 123

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Appendix

Estimated Calorie Needs Method I 124-125

Estimated Calorie Needs Method II 126

Estimated Protein Needs 127-128

Miffin – St. Jeor Equation and Cheat Sheet 129

Estimated Fluid Needs/Serum Osmolality 130-131

Estimated Height 132

Nutrition Assessment Guidelines: When adjustments are required 133

Calculation Metabolically Active Weight and Ireton Jones Equation 134-135

References and Recommended Readings for Calculating Energy Needs 136

Body Mass Index & Table 137

MAO Inhibitors and Food Interactions 138-139

Fiber Content of Common Food 140-144

Recipes for Fiber Supplements 145

Caffeine Content of Foods and Beverages 146-147

Scoop Sizes 148

Milligrams and Milliequivalent Conversions 149

Measures and Metric Conversions 150

Abbreviations 151

Official “Do No Use” List 152-153

Recipe for Puree Bread 154-158

French Toast Souffle Recipe 159

Super Shake Recipe 160

Food Guide Pyramid, Dietary Guidelines for Americans 2005 and

DASH Diet, DRI’s 2010, My Plate For Older Adults, Information

regarding risks of tube feeding for older adults and Culture Change

Movement. 161

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Regular Diet

I. Description

The regular diet is designed for residents who do not require any dietary

restrictions. The “Dietary Guidelines for Americans”, 2010 and “My Plate for Older

Adults” 2011 (see appendix) have been used as the basis for this and all other

diets and menus in this edition. The meal patterns and daily amounts of each food

group in the regular diet have been calculated to meet the needs of sedentary

males and females age 51 and over. Refer to Appendix 5, 6, and 7 of the Dietary

Guidelines for Americans 2010 to adjust the meal patterns for other age/gender

and activity levels. Individual meal preferences must also be considered in

planning this and other diets in the manual.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

III. Adequacy

This diet contains all nutrients necessary to provide and maintain adequate

nutrition based on the Dietary Reference Intakes, 2010

FOOD GROUPS FOODS INCLUDED DAILY AMOUNTS

Milk All types; yogurt 3 or more servings

(1 serving equals 8 ounces)

Meat and equivalents Meat, fish, shellfish, At least 5 meat

poultry, cheese, eggs, equivalents

dried beans, peas and

lentils, peanut

butter, seeds, and nuts 1 meat equivalent

equals:

Lean meats, fish, 1 oz. cooked meat, fish,

poultry no skin, lower shellfish, ¼ cup canned tuna

fat cheeses or salmon, 1 oz. poultry,

1 oz. cheese

¼ cup cottage or ricotta

cheese, 1 egg, 2 egg whites

Legumes and meat ½ cup cooked dried

alternatives beans, peas, lentils, 2 tbsp

peanut butter, 4 oz. of tofu;

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Regular Diet

FOOD GROUPS FOODS INCLUDED DAILY AMOUNTS

Fruits All types 2 or more servings

Citrus or high 1 serving equals:

vitamin C fruit ½ cup fruit,

daily 1 medium fresh fruit or

4 ounces fruit juice

Vegetables All types, including 3 or more servings

potatoes, corn, lima 1 serving equals:

beans, peas; legumes, 1 cup chopped raw; or

dark green leafy or ½ cup cooked; or 4–6

yellow vegetables ounces vegetable juice

(3-4 times a week)

Soups All types As desired

1 serving equals:

6 ounces

Bread, Cereal All types, especially 6 or more servings

& Grains whole grains 1 serving equals:

1 slice of bread;

3/4 cup ready to

eat cereal;

½ cup cooked cereal;

½ cup rice, or

½ cup pasta

Fats Oils, soft margarine, As needed for adequate

butter, (avoid trans-fat) caloric intake

Desserts All types As desired for adequate

caloric intake

Beverages All types, include 8 or As needed to meet

more cups of water fluid requirement

or other fluids per day

Miscellaneous Sugar, condiments, jam, As desired for flavor and

jelly, preserves, syrup, palatability

sweets, herbs, spices,

flavorings, salt, pepper

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Regular Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal ½ cup

Meat or equivalent Eggs, scrambled 1

Bread Toast, whole wheat 1 slice

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 tablespoon

Sugar 2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch or Supper

Meat or Equivalent Tuna salad ½ cup

Vegetable Vegetable soup 6 ounces

Salad Tossed salad 1 cup

Fat Italian dressing 1 ounce

Bread Whole wheat bread 2 slices

Dessert Chilled peaches ½ cup

Milk Milk, 2% 8 ounces

Miscellaneous Beverage of choice 6-8 ounces

Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Dinner

Meat or equivalent Baked chicken breast ½ breast (3 ounces)

Potato Mashed potatoes, gravy ½ cup, 1 ounce

Vegetable Seasoned carrots ½ cup

Salad Mixed fruit salad ½ cup

Bread Dinner roll, whole wheat 1

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Dessert Vanilla ice cream ½ cup

Beverage Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Evening Nourishment

Juice 4 ounces

Graham crackers 3 squares

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Mechanical Soft (Dental) Diet

I. Description

This diet modifies the consistency of the regular diet and is used when an

individual has difficulty chewing regular food. Most foods on the regular diet may

be included, with mechanical alterations based on individual tolerance.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

III. Adequacy

This diet provides all nutrients necessary based on the Dietary Guidelines for

Americans 2010.

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Milk All types; yogurt None

Meat and Equivalent Ground meat & poultry (gravy/ Whole meats,

sauces may be added to whole hot dogs,

moisten); soft boneless fish; hard cheeses; any

ground meat casseroles; other difficult-to-chew

cheese sauce, soft cheese, foods

cottage cheese; shaved

luncheon meat; eggs;

creamy peanut butter; meat

loaf/ham loaf, Salisbury Steak;

finely chopped meat, tuna or

egg salads

Fruit All fruit juices, cooked or Dried fruits; hard

canned fruit, soft fresh fruit fresh fruits

as tolerated

Vegetables All vegetable juices; Whole raw

well-cooked soft vegetables: vegetables; corn on the cob

chopped or diced; shredded

salads as tolerated

Soups All types Any not tolerated

Bread & Cereal Breads, crackers, dry cereals; Granola or

& Grains French toast, pancakes and granola-type

waffles with syrup; doughnuts, cereals, any foods

muffins without nuts/seeds, with nuts or dried

croissants, pastries without fruits, bagels

nuts or dried fruit

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Mechanical Soft (Dental) Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Potatoes & Starches Baked, boiled or mashed Wild rice

potatoes, french fries; pasta

Fats All types, crisp bacon as None

tolerated

Desserts Most types Any containing nuts,

coconut, or dried fruit

Beverages All types None

Miscellaneous Herbs, spices, salt, pepper Nuts, coconut, whole

gravies/sauces, ketchup, pickles, popcorn

mayonnaise, mustard,

pickle slices

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Mechanical Soft (Dental) Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal ½ cup

Meat or equivalent Egg, scrambled 1

Bread Whole wheat toast 1 slice

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 tablespoon

Sugar 2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch or Supper

Meat or equivalent Finely chopped tuna salad ½ cup

Vegetable Vegetable soup 6 ounces

Salad Shredded tossed salad ½ cup

Potato or equivalent Sweet potatoes ½ cup

Fat Italian dressing 1 ounce

Bread Whole wheat bread 2 slices

Dessert Chilled peaches ½ cup

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Dinner

Meat or equivalent Moist ground chicken breast 3 ounces

with gravy 1 ounce

Potato or Equivalent Mashed potatoes/gravy ½ cup/1 ounce

Vegetable Cooked sliced carrots ½ cup

Fruit Canned fruit salad ½ cup

Bread Soft dinner roll 1

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Dessert Vanilla ice cream ½ cup

Beverage of choice 6-8 ounces

Sugar 1-2 packets

Creamer as desired

Salt, pepper 1 packet each

Evening Nourishment

Apple juice 4 ounces

Graham crackers 3 squares

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Dysphagia Level 1/Pureed Diet

I. Description

The pureed diet is used for individuals who have difficulty chewing and/or

swallowing. Any foods from the regular diet that can be appropriately pureed

should be included in this diet. Individuals requiring a pureed diet simply due to

chewing difficulties may be able to tolerate additional food items on an individual

basis. This should be specified in the individual’s care plan. Procedures should be

developed for pureeing food to provide correct and adequate portions equivalent

to the portions used in a regular diet. The consistency should be smooth and thick

enough to mound on the plate, and similar in consistency to that of pudding.

*NOTE: Additional modifications may be required if the individuals are on

thickened liquids.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

III. Adequacy

This diet provides all nutrients necessary to provide and maintain adequate

nutrients based on the Dietary Guidelines for Americans 2010.

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Milk All types; yogurt Any yogurt containing

without chunks, seeds or nuts chunks of fruit, coconut,

nuts or seeds

Meat and equivalents Pureed meat, eggs, fish, Whole or ground

and poultry; soufflés that are meats, fish or poultry;

homogenous and smooth; non-pureed lentils or

hummus or other pureed legumes; peanut butter

legumes; softened tofu; (unless pureed into foods

Braunschweiger, pureed correctly); non-pureed

cheese and pureed cottage fried, cooked or scrambled

cheese; creamy peanut butter eggs

mixed with other pureed food;

pureed eggs

Fruits Pureed fruits, Whole fruits (fresh, frozen,

fruit juices without pulp, canned or dried); juices with

well-mashed fresh bananas pulp

Vegetables Pureed vegetables, All other non-pureed

vegetable juices with vegetables, including those

pulp or seeds with seeds or hulls that

cannot be properly pureed

Soups Broth, bouillon, Non-pureed soups

Strained or pureed soups with lumps or chunks

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Dysphagia Level 1/Pureed Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Bread, Cereal, Pureed bread mixes; All other breads, rolls

& Grains pregelled slurried breads, crackers, pancakes,

pancakes, French toast, waffles, biscuits,

danish, pastries, sweet rolls, muffins etc.

etc. that are softened

throughout entire thickness

of product.

Smooth, homogenous All dry cereals and

cooked cereals, such cooked cereals with

as farina-type cereals. chunks, lumps or seeds;

Cereals should have a oatmeal

“pudding-like” consistency

Potatoes & Starches Mashed potatoes; All others

Pureed potatoes (moistened

with gravy, butter, margarine

or sour cream for individuals

with dysphagia)

Pureed well-cooked pasta,

Noodles, bread dressing

or rice (blenderized

to a smooth homogenous

consistency.

Fats Butter, margarine, Any fats with course

mayonnaise, cream cheese, or chunky additives

whipped topping, strained

gravy, sour cream

Smooth sauces, such as

cheese sauce, white sauce,

or hollandaise sauce

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Dysphagia Level 1/Pureed Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Desserts Smooth custards, puddings Fruited yogurt,

and yogurt cookies, cakes, pies,

pastries, course or textured

Pureed desserts and puddings, bread puddings

soufflés, fruit whips pies

* Ice cream sherbet, ices

gelatins, milk shakes/malts,

eggnog, frozen yogurt,

and nutritional supplements

* Items that are liquid at room

temperature may not be

appropriate for individuals

requiring thickened beverages

Beverages Smooth, homogenous All other beverages

Beverages without lumps,

Chunks or pulp.

Miscellaneous Sugar, sugar substitute, Coarsely ground

salt, finely ground pepper pepper and herbs

and spices

Catsup, mustard, barbeque Seeds, nuts, sticky foods,

sauce and other smooth sauces with lumps, etc.

sauces and gravies

Clear jam, jelly, syrup, Chunky fruit

and honey preserves and jams/jellies

with seeds

Very soft, smooth candy Candy with nuts, sprinkles,

etc.; chewy candies such

as caramels or licorice

* Pureed bread recipes in appendix

* Most beverages and soups will need to be thickened for individuals requiring

thickened liquids. This includes all items that are liquid at room temperature, such

as ice cream, shakes, gelatin, etc.

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Dysphagia Level 1/Pureed Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Cream of wheat ½ cup

Meat or equivalent Pureed egg, 1

Bread Slurried bread 1 slice

Fat Margarine 1 teaspoon

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch and Supper

Meat or Equivalent Pureed tuna salad ½ cup

Vegetable Pureed vegetable soup 6 ounces

Pureed beets ½ cup

Bread Pureed bread 1 slice

Fat Margarine 1 teaspoon

Dessert Pureed Peaches ½ cup

Beverage of choice 6-8 ounces

Milk Milk, 2% 8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Dinner

Meat or equivalent Pureed skinless baked ½ cup (3 ounces

chicken edible)*

Gravy 1 ounce

Potato or equivalent Whipped potatoes w/ gravy ½ cup

Vegetable Pureed carrots ½ cup

Bread Pureed bread 1 serving

Fat Margarine 1 teaspoon

Milk Milk, 2% 8 ounces

Dessert Vanilla ice cream ½ cup

Beverage of choice 6-8 ounces

Sugar 1-2 packet

Creamer as desired

Salt, Pepper 1 packet each

Evening Nourishment

Vanilla pudding ½ cup

Apple juice ½ cup

*Portion size is based on a standardized procedure for pureeing cooked chicken to

provide 3 meat equivalents.

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Dysphagia Level 2/Mechanically Altered Diet

I. Description

This diet consists of foods that are moist and easily formed into a bolus. Meats

(ground or minced) should be no larger than one-quarter inch pieces. All foods

from the Dysphagia Level 1/pureed diet are acceptable on this diet. It is based on

the National Dysphagia Diet Level 2 Dysphagia Mechanically Altered diet, and is

designed for individuals who have difficulty swallowing regular foods. It is designed

to be a transition from pureed to more solid textures. Some mixed textures are

acceptable on this diet, and chewing ability is required. Individuals should be

monitored periodically to determine if swallowing function improves or declines.

*NOTE: Additional modifications may be required if the individuals are on

thickened liquids.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

III. Adequacy

This diet provides all nutrients necessary based on the Dietary Guidelines for

Americans 2010.

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Milk All types – Beverages None

may require thickening when

thin liquids are to be avoided

Meat and Equivalent Moist ground meats or Dry or tough meats

poultry; moist soft fish; such as bacon,

casseroles without rice; hot dogs, sausage,

moist macaroni and cheese; and bratwurst

well-cooked pasta with

meat sauce; soft moist Dry casseroles,

lasagna; moist meatballs, casseroles with rice

meat loaf, ham or fish loaf; or large chunks

protein salads without

large chunks, celery, or Cheese slices and

onion; cottage cheese; cubes; hard-cooked or

smooth quiche without large crisp fried eggs;

chunks; scrambled eggs;

poached pasteurized eggs; Sandwiches; pizza

soft soufflés; tofu; well-cooked

slightly mashed moist Peanut butter

legumes, such as baked beans;

All meat or protein substitutes

should be served with sauces

or moistened.

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Dysphagia Level 2/Mechanically Altered Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Fruit Soft drained canned or cooked Fresh or frozen fruits,

fruits without seeds or skin; cooked fruits with skins or

soft/ripe banana; fruit juice seeds; dried fruits;

fresh, canned or cooked

pineapple

Vegetable Soft, well-cooked vegetables, Cooked corn and peas;

less than ½ inch in size and broccoli, cabbage,

should be easily mashed with asparagus, Brussels

a fork; vegetable juices sprouts, or other fibrous,

nontender/rubbery

raw or cooked vegetables

Soups Soups with easy-to-chew/ Soups with large

swallow meats or vegetables; chunks of meat and

particle size in soups vegetables; soups with rice,

should be less than ½ inch corn or peas

Soups may require thickening

for residents on thickened

liquids

Bread, Cereal Soft pancakes moistened All other breads

& Grains with syrup or sauce;

pureed bread mixes,

pregelled or slurried breads

that are gelled throughout

entire thickness of product

Cooked cereals with little Very course cooked

texture, including oatmeal; cereals that contain

slightly moistened dry nuts or seeds;

cereals with little texture, whole-grain dry

such as corn flakes, or coarse cereals;

Rice Krispies ®, cereals with nuts, seeds,

Wheaties®, etc. dried fruit and/or coconut

Un-processed wheat bran

stirred into cereals for bulk-

Liquid should be absorbed

into the product when thin

liquids are contraindicated.

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Dysphagia Level 2/Mechanically Altered Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Potatoes and Starches Well-cooked, moistened, Potato skins and

Baked, boiled, or mashed chips; fried or french-fried

potatoes potatoes; rice

Well-cooked noodles in sauce;

soft dumplings moistened with

butter, sauce or gravy;

well-cooked shredded hash

browns (not crisp) in sauce

Fats Butter, margarine, cream, Any fats with coarse,

Gravy, sauces, mayonnaise, chunky additives

salad dressing, sour cream,

whipped toppings, cream

cheese, dip and spreads

with soft additives -

Thickening agents may be

required when thin liquids

are contraindicated

Desserts Pudding, custard, soft fruit Pineapple;

pies with bottom crust only; any foods with dried fruit,

pre-gelled cookies, or soft nuts, coconut, or seeds

cookies that have been

moistened in milk, coffee, or

other liquid; soft-moist cakes

with icing, or slurried cakes;

crisps and cobblers with soft

breading or crumb mixture

(without seeds or nuts);

Frozen yogurt, ice cream,

sherbets, ices, malts,

milk shakes, eggnog,

gelatin and nutritional

supplements – items that

are liquid at room temperature

may require thickening when

thin liquids are contraindicated

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Dysphagia Level 2/Mechanically Altered Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Beverages All beverages with minimal

amounts of texture, pulp, etc.

Milk, juice, coffee, tea, soda,

alcoholic beverages, nutritional

supplements – liquids may

require thickening if thin

liquids are contraindicated

Miscellaneous Jams and preserves without Seeds, nuts, coconut, sticky

seeds; jelly foods

Sauces, salsas, etc. that may Chewy candies such as

have small tender chunks caramel or licorice

less than ½ inch in size

Soft, smooth chocolate bars

that are easily chewed

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Dysphagia Level 2/Mechanically Altered Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal ½ cup

Meat or equivalent Egg, scrambled 1

Bread Pureed bread 1 serving

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 tablespoon

Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch or Supper

Meat or equivalent Soft flaked fish with sauce 3 ounces/1 ounce

Vegetable Green beans ½ cup

Potato or equivalent Mashed potatoes/gravy ½ cup/1 ounce

Bread Pureed bread 1 serving

Fruit Canned peaches ½ cup

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Dinner

Meat or equivalent Moist ground chicken/gravy 3 ounces/1 ounce

Potato or equivalent Whipped potatoes/gravy ½ cup/1 ounce

Vegetable Cooked sliced carrots ½ cup

Fruit Canned fruit without pineapple ½ cup

Bread Puree bread 1 serving

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Dessert Vanilla ice cream ½ cup

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Evening Nourishment

Vanilla pudding ½ cup

Apple juice ½ cup

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Dysphagia Advanced/Level 3 Diet

I. Description

This diet consists of food of nearly regular textures with the exception of very hard,

sticky or crunchy foods. Foods should be moist and in “bite-size” pieces. It is

meant to be a transition to a regular diet. Adequate dentition and mastication are

required. It is expected that mixed textures are tolerated on this diet. This diet is

based on the National Dysphagia Diet Level 3 Dysphagia Advanced diet.

*NOTE: Additional modifications may be required if the individuals are on

thickened liquids.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

III. Adequacy

This diet provides all nutrients necessary based on the Dietary Guidelines for

Americans 2010.

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Milk All types – None

Beverages may require

thickening when thin liquids

are contraindicated

Meat and Equivalent Thin-sliced, tender or ground Tough, dry meats and

meats and poultry poultry

Well-moistened fish Dry fish, fish w/ bones

Eggs prepared any way Chunky peanut butter

Yogurt without nuts/coconut Yogurt w/ nuts or coconut

Casseroles with small chunks

of meat, ground meats or

tender meats

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Dysphagia Advanced/Level 3 Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Fruit All canned and cooked fruits Difficult to chew fruits, e.g.

apples or pears

Soft, peeled fresh fruits, e.g. Stringy, high-pulp fruits, e.g.

peaches, kiwi, melons papaya, pineapple, mango

without seeds, nectarines

Soft berries w/ small seeds Fresh fruits w/ difficult to

such as strawberries chew skins, such as grapes

Uncooked dried fruits, e.g.

prunes, apricots

Fruit leather, fruit roll-ups,

fruits snacks, dried fruits

Vegetable All cooked, tender vegetables Raw vegetables except

shredded lettuce

Shredded lettuce Cooked corn

Nontender or rubbery

cooked vegetables

Soups All soups except those Soups w/ tough meats

on the excluded list

Corn or clam chowders

Strained corn or clam Soups w/ large chunks of

chowder (may require meat or vegetables > 1 inch

thickening if thin liquids

are contraindicated)

Bread, Cereal & Well-moistened breads, Dry bread, toast, crackers,

Grains biscuits, muffins, pancakes, etc.

Waffles, etc. Need to add

Adequate syrup, butter, jelly, Tough, crusty breads, e.g.

etc. to moisten sufficiently French bread or baguettes

All well-moistened cereals Course or dry cereals, e.g.

(May have ¼ cup milk or Shredded Wheat or All Bran

just enough to moisten if

thin liquids are restricted)

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Dysphagia Advanced/Level 3 Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Potatoes & Starches All – including rice, wild rice Tough, crisp-fried potatoes

moist bread dressing, tender,

fried potatoes Potato skins

Dry bread dressing

Fats All fats except those on the Fats w/ course, difficult-to-

excluded list chew or chunky additives,

e.g. cream cheese spread

with nuts or pineapple

Desserts All desserts except those Dry cakes, cookies that are

on the excluded list chewy or very dry

*Malts, milk shakes, frozen Anything w/ nuts, seeds, dry

yogurt, ice cream, gelatin, Fruits, coconut, pineapple

nutritional supplements,

sherbet

*These items become

thin liquids at room and/or

body temperature, and

should be avoided if thin

liquids are contraindicated

Beverages Any – depending on

Recommendations for liquid

consistency

Miscellaneous All seasonings & sweeteners Nuts, seeds, coconut

All sauces Chewy, caramel or taffy-

type candies

Non-chewy candies without Candies w/ nuts, seeds or

nuts, seeds, or coconut coconut

Jams, jellies, honey, preserves

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Dysphagia Advanced/Level 3 Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal ½ cup

Meat or equivalent Egg, scrambled 1

Bread Whole wheat toast 1 slice

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 tablespoon

Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch or Supper

Meat or equivalent Soft flaked fish with sauce 3 ounces/1 ounce

Vegetable Green beans ½ cup

Potato or equivalent Mashed potatoes/gravy ½ cup/1 ounce

Bread whole wheat bread 1 slice

Fruit Canned peaches ½ cup

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Dinner

Meat or equivalent Tender chicken/gravy 3 ounces/1 ounce

Potato or equivalent Whipped potatoes/gravy ½ cup/1 ounce

Vegetable Cooked sliced carrots ½ cup

Fruit Canned fruit without pineapple ½ cup

Bread Dinner roll, whole wheat 1 serving

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Dessert Vanilla ice cream ½ cup

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Evening Nourishment

Vanilla pudding ½ cup

Apple juice ½ cup

24

Full Liquid Diet

I. Description

The full liquid diet consists of foods that are primarily liquid.

This diet is indicated for residents who are acutely ill or who are

unable to swallow or chew solid foods. Nourishments are

served between meals. After 3-5 days, the need for this diet

should be evaluated to assure adequate nutrition. If

circumstances indicate that this diet is required for any extended

period of time commercially prepared, nutritionally adequate

supplements should become an essential component of this

diet.

II. Approximate Composition

Calories Varies

Protein Varies

III. Adequacy

This diet may not contain all nutrients necessary to provide and

maintain adequate nutrition based on the Dietary Guidelines for

Americans 2010.

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Milk All types; cocoa, Yogurt, with nuts,

hot chocolate, milk seeds, skins,

whole fruits

shakes, instant

breakfast, eggnog,

smooth yogurt (plain or

flavored

Meat and Equivalents Eggs or egg All others

substitutes in

custard or pudding

Fruits All juices and nectars All others

without pulp

Vegetables Vegetable juices, All others

vegetable purees that

are strained in soups

25

Full Liquid Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Soups Bouillon, broth; All others

strained meat,

vegetable and

cream soups

Cereals Cooked refined All others

cereals; strained

oatmeal thinned with

liquid

Fats Margarine or All others

butter, cream, or

non-dairy creamer

Desserts Pudding, custard, All others

gelatin; plain ice cream,

ice milk, sherbet, fruit ice;

popsicles; plain frozen

yogurt; commercially

prepared pudding-

type nutritional

supplements

Beverages All types including None

commercially prepared

liquid nutritional

supplements

Miscellaneous Sugar, clear jelly, None

syrup, honey; hard

candy (if tolerated),

chocolate syrup

Salt, pepper

26

Full Liquid Diet

Sample Menu Plan

Breakfast

Fruit Orange juice, pulp free 8 ounces

Cereal Oatmeal 1 cup

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 3 packets

Creamer as desired

Midmorning Nourishment Commercial 8 ounces

liquid supplement

Lunch & Supper

Fruit Juice Apple juice 8 ounces

Soup Strained vegetable soup 8 ounces

Dessert lemon pudding ½ cup

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 3 packets

Creamer as desired

Salt, pepper 1 packet each

Midmorning Nourishment Commercial 8 ounces

liquid supplement

Dinner

Juice Cranberry juice 8 ounces

Soup Strained cream 6 ounces

of mushroom soup

Dessert vanilla ice cream ½ cup

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 2 packets

Creamer as desired

Salt, pepper 1 packet each

Evening Nourishment Sherbet ½ cup

Ginger ale 8 ounces

27

Clear Liquid Diet

I. Description

The clear liquid diet is used for acute stages of illness until a full

liquid diet or solid foods are tolerated. Nourishments between

meals are necessary.

II. Approximate Composition

Calories Varies

Protein Varies

III. Adequacy

This diet is inadequate in all nutrients. It should be used for

limited periods of time, usually no longer than 48 hours.

FOODS INCLUDED FOODS EXCLUDED

Clear broth, bouillon All others

Flavored gelatin

High protein gelatin

Water ice, popsicles, fruit ice

Fruit juices: apple, grape, cranberry juice

Cocktail, cran-apple, cran-grape, cran-raspberry,

Orange or grapefruit juice without pulp

Beverages: water, tea, coffee, carbonated beverages,

fruit flavored drinks, commercially prepared high

protein clear liquid products

Sugar, sugar substitutes

28

Clear Liquid Diet

Sample Menu Plan

Breakfast

Pulp free orange juice 8 ounces

Cherry gelatin 1 cup

Carbonated cola 8 ounces

Beverage of choice 6-8 ounces

Ice water 8 ounces

Sugar 3 packets

Midmorning Nourishment Grape juice 8 ounces

Raspberry gelatin ½ cup

Lunch

Apple juice 8 ounces

Chicken broth 6 ounces

Lemon ice ½ cup

Beverage of choice 6-8 ounces

Iced water 8 ounces

Sugar 3 packets

Mid Afternoon Nourishment

Pulp free orange juice 8 ounces

Lemon-lime 8 ounces

Carbonated beverage

Dinner

Cranberry juice 8 ounces

Beef bouillon 6 ounces

Cherry gelatin 1 cup

Beverage of choice 6-8 ounces

Iced water 8 ounces

Sugar 3 packets

Evening Nourishment

Lime gelatin 1 cup

Ginger ale 8 ounces

29

Restricted Fiber/Restricted Residue Diet

I. Description

The fiber restricted diet limits the amount of dietary fiber. The purpose for using

the fiber restricted diet is to decrease stool weight, fecal output and frequency.

The restricted fiber diet may be used for the short-term treatment of acute

ulcerative colitis, regional enteritis (Crohn’s disease), acute diverticulitis and as

necessary for bowel rest. This diet is used as a temporary measure during the

transition to a regular diet. Once symptoms subside, high fiber foods should be

gradually added to the diet. This diet should be tailored to the individual resident

based on food preferences, tolerances and type of illness. The fiber restricted

diet provides 15 grams or less of fiber per day. Milk, meat, fish, poultry, eggs

and beverages provide little or no dietary fiber and can be included in this diet

without restriction when planning the low fiber diet follow the guidelines for the

regular diet for minimum daily amounts of these and other food groups.

Substitute lower fiber content foods by following these guidelines:

1. Include only white or refined breads and cereals; omit all whole wheat

and whole grain breads and cereals and products containing bran.

2. Include fruit and vegetable juices without pulp (omit prune juice), canned

or cooked fruits; omit raw or dried fruit and all berries.

3. Include most well cooked vegetables without seeds (omit sauerkraut,

winter squash, peas, corn and raw vegetables).

4. Omit dried beans and peas, lentils, legumes, peanut butter, and any

foods containing seeds, nuts, coconut and dried fruits.

5. Limit milk to 2 cups/day.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

Fiber 15 grams or less

III. Adequacy

Depending on individual food choices and tolerances, the diet is adequate in all

nutrients based on the Dietary Guidelines for Americans 2010. However, the

Dietary Reference Intake (DRI) for iron will not be met for pregnant, lactating and

pre-menopausal women following this diet. Residents on restricted fiber diets

may need to be supplemented with ascorbic acid, folate and magnesium.

30

Restricted Fiber Diet

Sample Menu Plan

Breakfast

Fruit or Juice Orange juice (pulp free) 4 ounces

Cereal Corn flakes 1 cup

Meat or equivalent Egg, scrambled 1

Bread Toast, white 1 slice

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 tablespoon

Sugar 2 packets

Creamer as desired

Salt , Pepper 1 packet

Lunch

Soup Cream of tomato soup 6 ounces

Meat or equivalent Plain tuna salad with mayo. ½ cup

Bread White bread 2 slices

Salad Pickled beets, canned ½ cup

Fat Soft margarine 1 packet

Dessert Chilled peaches ½ cup

Beverage Cold or Hot 8 ounces

Miscellaneous Sugar, Salt, Pepper 1 packet each

Dinner

Meat or equivalent Baked chicken breast 3 ounces

Vegetable Carrots, cooked ½ cup

Vegetable juice ½ cup

Starch Mashed potatoes ½ cup

Bread Roll/ white bread 1

Milk Milk, 2% 8 ounces

Beverage Cold or Hot 8 ounces

Dessert Water ice ½ cup

Iced water 8 ounces

Miscellaneous Sugar, Salt, Pepper 1 packet each

Evening Nourishment

Juice 4 ounces

Graham Crackers 3 squares

31

Increased Fiber Diet

I. Description

This diet emphasizes the use of high fiber food sources such as whole

grain breads and cereals, fruits, vegetables, dried beans and peas. The

purpose for using the increased fiber diet is to promote normal bowel

function. Fiber adequately decreases the transit time of foods through the

gastrointestinal tract and, with adequate fluid intake, results in soft stools.

Dietary fiber is the portion of plant materials which is resistant to digestive

enzymes in the body and includes cellulose, hemicellulose, lignin and

pectin. The increased fiber diet may be used for the treatment of

diverticulosis*, mild diverticulitis*, hemorrhoids, irritable bowel syndrome,

diarrhea and constipation. When planning the increased fiber diet, follow

the daily amounts of the food groups on the regular diet. Substitute higher

fiber content foods by following these guidelines:

1. Include 1 serving of high fiber cereal (5 gms. of fiber or more) such

as raisin bran, oatmeal, all bran, per day at breakfast or as a bedtime

snack. Top with fruit for more fiber.

2. Choose whole wheat or whole grain breads such as 100% whole

wheat, rye, pumpernickel, oatmeal bread, cornbread (made from

whole, ground cornmeal) and bran muffins.

3. Choose whole fresh fruits and vegetables (with the skin) more often

than juices.

4. Add baked beans, dried beans and peas to the menu 2-3 times per

week; try adding bean soup, bean salads and hummus to the menu.

5. Choose high fiber snacks such as fresh fruit, raw vegetables, and

nuts, or sprinkle unprocessed bran on yogurt for residents on

mechanically altered diets. Offer stewed, dried fruits, date or fig

spread on whole wheat bread or crackers, or any of the fiber-

supplemented cookies or bars. Refer to the appendix for Fiber

Content of Common Foods.

The National Cancer Institute and the Academy of Nutrition and Dietetics

recommend a daily fiber intake of 20-35 grams of fiber per day. A wide

variety of foods should be used to increase fiber intake. Encourage fluid

intake of eight cups per day. Gradually increasing fiber intake is

recommended to prevent cramping, abdominal distention and flatulence.

32

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

Fiber 20-35 grams

III. Adequacy

This diet contains all nutrients necessary to provide and maintain

adequate nutrition based on the Dietary Guidelines for Americans 2010.

*The avoidance of foods with nuts, seeds and a high content of cellulose and

lignin (e.g. corn, popcorn) is recommended for diverticulitis.

33

Increased Fiber Diet

Sample Menu Plan

Breakfast

Juice Orange juice 4 ounces

Fruit Prunes 3

Cereal Oatmeal with bran ½ cup

Meat or equivalent Egg, scrambled 1

Bread Toast, whole wheat 1 slice

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 packet

Sugar 2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch or Supper

Soup Vegetable soup 6 ounces

Meat or equivalent Tuna salad ½ cup

Salad Tossed salad 1 cup

Fat Italian dressing 1 ounce

Bread Bread, whole wheat 2 slices

Dessert Chilled peaches ½ cup

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1 packet

Creamer as desired

Salt, Pepper 1 packet each

Dinner

Meat or equivalent Baked chicken breast 3 ounces

Vegetable Carrots, cooked ½ cup

Salad Mixed fruit salad ½ cup

Potato or equivalent Red skinned potatoes ½ cup

Bread Dinner roll/ whole wheat 1

Fat ` Soft margarine 1 packet

Milk Milk, 2% 1 cup

Dessert Ice cream/oatmeal raisin cookie ½ cup/1

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1 packet

Salt, Pepper 1 packet each

Evening Nourishment Juice 4 ounces

Graham Crackers 3 squares

Fresh apple 1

*The avoidance of foods with nuts, seeds and a high content of cellulose and lignin (e.g. corn,

popcorn) is recommended

34

PLEASURE FEEDINGS

Pleasure foods may be ordered for the resident who is receiving enteraI

feedings to meet their nutritional needs or for residents who are on

hospice/terminal care and will only ingest soft, easy to eat comfort foods.

Pleasure foods may vary depending on each resident’s need and tolerance.

Feedings should be planned accordingly. Speech language pathologist‘s

(SLP) recommendations need to be considered, e.g. thickened liquids, food

consistency. Examples of pleasure feedings are ice cream, puddings, cream

soup, applesauce and soft fruits. The resident and family should be consulted

to obtain food preferences. These feedings are intended to improve a resident’s

quality of life and may not meet their nutritional needs.

35

Small, Regular and Large Portion Sizes

Portion sizes may be adjusted to meet the nutritional needs

and personal preferences of an individual resident. Before

any adjustment is done, the dietitian should review the

individual resident’s nutritional needs and ascertain if the

increase or decrease in portion sizes will be advantageous

to the resident. Portion size changes may be warranted due

to resident preferences and/or individuals on the small portion

diet, multivitamin or additional supplementation may be

necessary.

Food Item Regular Small Large

Meats (breakfast) 1 oz. 1 oz. 2 oz.

(lunch) 3 oz. 2 oz. 4 oz.

(dinner) 3 oz. 2 oz. 4 oz.

Starches 1/2c. 3 ¼ oz (#10) 6 oz.

Cereals -hot 1/2c. 3 ¼ oz. (#10) 1 cup

-cold ¾ c. ¾ c. 1 1/2c.

Vegetables 1/2c. 3 ¼ oz. (#10) 6 oz.

Bread 1 Slice 1 Slice 1 Slice

Juice 4 oz. 4 oz. 4 oz.

Milk 8 oz. 8 oz. 8 oz.

Fruit ½ c. ½ c. ¾ c.

Dessert 1 svg. 1 svg. 1 svg.

Small portions are usually requested by residents with small appetites who feel

overwhelmed by regular size portions or for weight control or weight reducing diet.

Snacks may be needed to make up for decreased nutrient density with this diet.

Most residents do not request small portions of these items

36

Small Portions Diet

I. Description

Portion sizes may be adjusted to meet the nutritional needs and personal

preferences of an individual resident. Before any adjustment is done, the

dietitian will review the individual resident’s nutritional needs and ascertain

if the decrease in portion sizes will be advantageous to the resident.

Small portions may be warranted due to resident’s request and/or calorie

and protein needs that are less than what the regular diet provides.

II. Approximate Composition

Calories 1350-1750

Protein 55-60 grams

III. Adequacy

This diet may be nutritionally inadequate based on the Dietary Guidelines

for Americans 2010. A multivitamin or additional supplementation may be

necessary.

Small Portions Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal #10 scoop

Meat or equivalent Scrambled egg 1 serving

Bread Toast, whole wheat 1 slice

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 tablespoon

Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch and Supper

Meat or equivalent Tuna salad #10 scoop

Vegetable Vegetable soup 6 ounces

Salad Tossed salad #10 scoop

Fat Italian dressing 1 ounce

Bread Bread, whole wheat 1 slice

Dessert Chilled peaches ½ cup

Milk Milk, 2% 8 ounces

Beverage of choice 6 ounces

Miscellaneous Sugar 1 packet

Creamer as desired

Salt, Pepper 1 packet each

37

Small Portion Diet

Dinner

Meat or equivalent Baked chicken breast 2 ounces

Starch Mashed potatoes, gravy #10 scoop

Fat Soft margarine 1 packet

Vegetable Seasoned carrots #10 scoop

Salad Mixed fruit #10 scoop

Bread Dinner roll, whole wheat 1

Milk Milk, 2% 8 ounces

Dessert Vanilla ice cream ½ cup

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1 packet

Salt, Pepper 1 packet each

Evening Nourishment

Juice 4 ounces

Graham crackers 3 squares

38

Large Portion Diet

Sample Menu Plan____________________________________________

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal 1 cup

Meat or equivalent Scrambled egg 2 servings

Bread Toast, whole wheat 1 slice

Fat Soft margarine 1 packet

Milk Milk, 2% 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly 1 tablespoon

Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch/Supper

Meat or equivalent Tuna salad # 6 scoop

Vegetable Vegetable soup 6 ounces

Salad Tossed salad 1 cup

Fat Italian dressing 2 ounces

Bread Bread, whole wheat 1 slice

Dessert Chilled peaches ¾ cup

Milk Milk, 2% 8 ounces

Beverage of choice 6 ounces

Miscellaneous Sugar/salt/pepper 1 packet each

Creamer as desired

Dinner

Meat or equivalent Baked chicken breast 4 ounces

Starch Mashed potatoes, gravy 6 oz.

Fat Soft Margarine 1 packet

Vegetable Seasoned carrots 6 oz.

Fruit Fruit Cocktail ¾ cup

Bread Dinner roll, whole wheat 1

Milk Milk, 2% 8 ounces

Dessert Vanilla ice cream ½ cup

Beverage Sugar 1 packet

Miscellaneous Salt, Pepper 1 packet

Evening Nourishment

Juice 4 ounces

Graham crackers 3 squares

39

Vegetarian Diet

I. Description

The vegetarian diet is a modification of the regular diet. The diet is

predominately composed of plant foods and may or may not include eggs

and dairy. Traditionally, vegetarian diets have been classified by the type

of animal products that have been excluded. These classifications include:

Lacto-ovovegetarian Meat, poultry and fish are excluded

Lacto-vegetarian Meat, poultry, fish and eggs are excluded

Ovovegetarian Meat, poultry, fish, milk and milk products

are excluded

Vegan Meat, poultry, fish, eggs, milk and milk

products are excluded

No matter which classification is practiced, the vegetarian diet should

provide a variety of foods that ensure adequate amounts of all nutrients

required for tissue repair, growth and maintenance. Careful evaluation of

the resident’s diet history is therefore imperative to identify the specific

food practices of individual vegetarians. A variety of protein-containing

foods should be planned over the course of the day to supply the amino

acids needed.

The lacto-ovovegetarian diet and the vegan diet are illustrated to provide a

guide to ensure nutritional adequacy.

II. Approximate Composition

Calories 1600 – 2000

Protein 60 – 75 grams

III. Adequacy

The lacto-ovovegetarian diet contains all nutrients necessary to provide

and maintain adequate nutrition based on the Dietary Guidelines for

Americans 2010.

The vegan diet requires special attention to ensure that all nutrients are

provided. Vitamin D and Vitamin B12 may be deficient in the vegan diet.

Fortified soy milk, fortified cereals and multi-vitamins with mineral

supplements may be served daily to meet nutrient requirements.

40

Vegetarian Diet

FOOD GROUPS FOODS INCLUDED DAILY AMOUNT

Dairy products and All types; yogurt; soy Up to 3 servings

(optional) dairy milk fortified with calcium 1 serving equals

alternatives and Vitamin D 1 cup

Meat equivalents Cheese: dried beans, At least 5 meat

and (eggs, cheese peas, and lentils; equivalents with

optional) alternatives peanut butter, nuts; tofu; 1 equivalent

soy milk; cottage cheese equaling; 1 ounce

or ricotta; whole egg (limit cheese or ¼ cup

egg yolks to 4 per week); ricotta and cottage

egg whites and yolk free cheese; or 1 egg or

products are unlimited 2 egg whites or 2

tablespoons nut

butter; ¼ cup nuts;

½ cup cooked dried

beans, peas and

lentils; or 2

tablespoons nut

butter; 4 ounces tofu;

or tempeh,

1 cup soy milk

Nuts (check nutritional 2 tablespoons

analysis of individual

items for amounts

needed)

Fruits All types; citrus or a high 3 or more servings

vitamin C fruit daily

1 medium apple,

pear, orange,

banana; or ½ cup

chopped, canned,

cooked or frozen

fruit; or ¾ cup fruit

juice

Vegetables All types, including 3 or more servings, 1

potatoes; corn, lima beans, serving equals; 1 cup

peas; dark green leafy or raw or ½ cup cooked

deep yellow vegetables or chopped raw; or

3-4 times a week ¾ cup juice

41

Vegetarian Diet

FOOD GROUPS FOODS INCLUDED DAILY AMOUNT

Soups All types made with As desired

vegetable stock 1 serving equals;

6 ounces or ¾ cup

Breads, Grains All types, especially whole 6 or more servings

& Cereals grains 1 serving equals;

1 slice of bread;

or ¾ - 1 ounce ready

to eat cereal; or ½ cup

cooked cereal; ½ cup

cooked pasta or rice

Fats All types as desired As needed for

adequate caloric intake

Desserts All types as desired As needed for

adequate caloric intake

Beverages All types, including at least As needed to meet

6 to 8 cups of water and other fluid requirements

fluids per day

Miscellaneous Sugar, condiments, jelly As desired for

preserves, syrup, sweets, adequate caloric

herbs, spices, salt, and intake, flavor,

flavorings and palatability

42

Lacto-Ovovegetarian Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice ¾ cup

Cereal Oatmeal 1 cup

Meat equivalent Scrambled egg 1

Bread Whole wheat toast 1 slice

Fat Soft Margarine 1 teaspoon

Beverage of choice 6-8 ounces

Milk Milk, 2% 8 ounces

Miscellaneous Sugar 3 packets

Creamer, non-dairy as desired

Salt, pepper 1 packet each

Lunch

Soup Vegetable Soup 1 cup

Bread Whole wheat bread 2 slices

Meat equivalent American cheese 2 ounces

Mayonnaise 1 tablespoon

Salad Tossed salad 1 cup

Fat Italian Dressing 1 ounce

Dessert Chilled peaches ½ cup

Beverage of choice 6-8 ounces

Milk Milk, 2% 8 ounces

Miscellaneous Sugar 1-3 packets

Creamer, non dairy as desired

Salt, pepper 1 packet each

Evening Nourishment Graham cracker 3 squares

Fruit juice 4 ounces

Dinner

Meat equivalent Black beans 1 cup

Potato or equivalent Brown rice ½ cup

Vegetable Sliced carrots ½ cup

Salad Mixed fruit salad 1 cup

Bread Roll, whole wheat 1 l

Fat Soft margarine 1 teaspoon

Dessert Vanilla ice cream ½ cup

Beverage of choice 6-8 ounces

Milk Milk, 2% 1 cup

Miscellaneous Sugar 1-2 packets

Creamer, non-dairy as desired

Salt, pepper 1 packet each

43

Vegan Meal Plan

Sample Menu Plan

Breakfast

Fruit or juice Orange juice ¾ cup

Cereal Oatmeal – prepared with 1 cup

soy milk

Meat equivalent Peanut butter 2 tablespoons

Bread Whole wheat toast 1 slice

Fat Soft margarine 1 teaspoon

Beverage Coffee 6 ounces

Ice water 8 ounces

Milk Equivalent Soy milk 1 cup

Miscellaneous Sugar 3 packets

Creamer, non-dairy 2 packets

Salt, pepper 1 packet each

Lunch

Meat equivalent Black beans 1 cup

Potato or equivalent Brown rice ½ cup

Salad Vegetable soup 1 cup

Tossed salad 1 cup

Italian Dressing 1 ounce

Bread Bread, whole wheat 1 slice

Fat Soft margarine 1 packet

Dessert Chilled peaches ½ cup

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-3 packets

Salt, pepper 1 packet each

Evening Nourishment Graham crackers 3 squares

Fruit juice 4 ounces

Dinner

Meat equivalent Tofu 1 cup

Vegetable Sliced carrots ½ cup

Salad Citrus section salad ½ cup

Bread Dinner roll, whole wheat 1 slice

Fat Soft margarine 1 packet

Dessert Cherry gelatin 1 cup

Beverage of choice 6-8 ounces

Soy milk 1 cup

Miscellaneous Sugar 1-2 packets

Creamer, non-dairy 2 packets

Salt, pepper 1 packet each

For more information see website:

Vegetarian Resource Group Food Guide Pyramid for vegetarian meal planning

www.veg.org/nutrition/adapyramid.htm

44

No Added Salt (NAS) Diet

This diet is a regular diet with the exception that no salt may be added to food

after preparation. No salt is allowed with the resident’s meals. Salt substitute

should be used only with a physician’s order.

45

Low Sodium Diet (2-4 grams)

I. Description

This diet may be used to help control mild hypertension or edema. It may

be effective when used in conjunction with drug therapy when either

condition is more severe but a stricter diet regime is not feasible. The

FOODS INCLUDED on this diet are similar to that of a regular diet, with

the omission of highly salted foods and table salt.

The following guidelines are used for planning and preparation of the diet.

1. Use a moderate* amount of salt in cooking but serve no salt on

the tray.

2. Avoid highly salted foods such as bouillon, soup and gravy

bases, canned soups and stews; bread and rolls with salted

toppings, salted crackers; salted nuts, popcorn, potato chips,

pretzels, and other salted snacks. (Reduced sodium products

may be used, check label).

3. Avoid all salt cured, smoked and processed smoked meats, such

as ham, bacon, cold cuts, chipped and corned beef, frankfurters,

Koshered or Kosher style meats; canned meat and poultry.

(Reduced sodium products may be used; check label.)

4. Avoid salted and smoked fish, such as cod, herring, sardines;

canned salted salmon and tuna.

5. Avoid sauerkraut, olives, pickles, relishes, and other vegetables

prepared in brine; tomato and vegetable cocktail juices canned

with salt.

6. Avoid seasonings such as celery salt, garlic salt, Worcestershire

sauce, soy sauce, and others containing salt; no salt substitutes

unless ordered by the physician.

7. Serve cheeses, e.g., cheddar, mozzarella, provolone, and

processed cheeses such as American, in limited amounts

(approximately two times a week) unless low sodium (read

labels).

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

Sodium 2-4 grams

III. Adequacy

This diet contains all nutrients necessary to provide and maintain

adequate nutrition based on the Dietary Reference Intakes-2005 Revision.

*A moderate amount of salt is the amount usually called for in a standardized

recipe. If no salt is used in the cooking, the sodium content of the diet may be

below 2 grams.

46

Cholesterol Restricted and Fat Controlled Diet

I. Description

This diet is designed to limit total fat, saturated fat, and cholesterol intake.

The intent is to reduce and maintain an acceptable blood cholesterol level

for the resident. This diet may also be used for disorders of the gall

bladder, pancreas, and liver. The American Heart Association

recommends total fat be no more than 20-25 percent of the total daily

calories, with saturated fat limited to approximately 10 percent of total fat.

The American Heart Association recommends limiting the amount of trans

fats you eat to less than one percent of your total daily calories. That

means if you need 2000 calories a day, no more than 20 of those calories

should come from trans fats. That is less than 2 grams of trans fat a day.

There are “low fat” and “fat free” products currently available which are

suitable for use on this diet and which may not be identified here. Read

labels carefully to verify the appropriateness of the product(s) for use.

Fat Free – no more than 0.5 grams of fat per standardized serving

Low fat – no more than 3 grams of fat per standardized serving

Low saturated fat – no more than 1 gram of saturated fat per standardized

serving

Low cholesterol – no more than 20 milligrams of cholesterol per

standardized serving

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

Cholesterol 300 milligrams

III. Adequacy

This diet provides all nutrients necessary to provide and maintain

adequate nutrition based on the Dietary Guidelines for Americans 2010.

47

Cholesterol Restricted and Fat Controlled Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Milk 1% Skim, buttermilk and All others including

lowfat yogurt and milk whole milk, 2%

Milk products

Meat and equivalents Limit to 6 ounces per Marbled or fatty

day: lean beef, veal, meats; fried or

lamb and pork, crab, sautéed; Skin of

shrimp, lobster and chicken and

oysters. Select from the turkey; duck;

following for other meats: goose; fish canned

chicken and turkey in oil;

without skin; fish, regular luncheon

including canned water meats; canned

packed salmon and tuna; meats; salt pork,

peanut butter in limited frankfurters and

amounts, lowfat cold hot dogs; bacon;

cuts; meats, poultry and fish

should be baked, broiled,

roasted, simmered, or steamed

and all visible fat removed

Low fat cheeses; ricotta and Other cheeses,

cottage cheese; dips, and

spreads

Eggs, cooked, Eggs, prepared with

without additional fat additional fat

(limit egg yolks to 3 per

week); without additional

fat and in cooking.

Unlimited cholesterol free Seasoned with any

egg products; dried beans, food not allowed

peas, and lentils.

48

Cholesterol Restricted and Fat Controlled Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Fruits All types None

Vegetables All types Any prepared with

bacon, meat

drippings, butter,

cream, whole or

2% milk

Soup Bouillon, consommé, clear All others

broth; soups made with

fat free broth or skim milk

Breads, Cereals

& Grains All types including Sweet rolls,

noodles, pasta and rice; quick breads;

waffles and pancakes; (muffins, biscuits,

cornbread),

doughnuts

Fats Use sparingly Saturated fats such

as butter, cream,

bacon, shortening;

oils; high fat salad

dressing.

Desserts Lowfat cake, pudding, High fat desserts

fruit and cream

pie and ice cream; cookies

gelatin; sherbet; fruit

whips; water ice;

Beverages Carbonated beverages, All others

coffee, tea, fruit drinks

Miscellaneous Sugar, condiments, jam, Chocolate candy;

jelly, preserves, syrup, baking chocolate

honey, hard candy, gum

drops, jelly beans,

marshmallows

49

Cholesterol Restricted and Fat Controlled Diet

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal ½ cup

Meat equivalent Cholesterol free egg 1

Bread Toast whole wheat 1 slice

Fat Soft margarine 1 teaspoon

Beverage of choice 6-8 ounces

Milk Skim milk 8 ounces

Miscellaneous Jelly 1 packet

Sugar 2 packets

Creamer as desired

Salt, pepper 1 packet each

Lunch or Supper

Meat equivalent Tuna salad ½ cup

Vegetable Vegetable soup 6 ounces

Salad Tossed salad 1 cup

Fat Lowfat Italian dressing 1 ounce

Bread Whole wheat bread 2 slices

Dessert Chilled peaches ½ cup

Milk Skim milk 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, pepper 1 packet each

Dinner

Meat equivalent Baked chicken breast ½ (3 ounces EP)

(without skin)

Potato Mashed potatoes ½ cup

low fat gravy 1 ounce

Vegetable Seasoned carrots ½ cup

Salad Mixed fruit salad ½ cup

Bread Dinner roll, whole wheat 1

Fat Soft margarine 1 teaspoons

Milk Skim milk 8 ounces

Dessert Rainbow sherbet ½ cup

Beverage of choice 6-8 ounces

Miscellaneous Sugar 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Evening Nourishment Juice 8 ounces

Graham crackers 3 squares

50

Limited K+ Diet

Avoid the following foods and beverages;

● Bananas

● Prunes and prune juice

● Orange Juice

● Baked potatoes and sweet potatoes

● Tomatoes, tomato juice, V-8 juice

Encourage the following lower k+ beverage choices in addition to water:

● Cranberry juice

● Lemonade

● Apple juice

● Grape juice

● Fruit punch

● Clear soda

Liberalized Renal Diet

Follow K+ guidelines above

Limit obviously salted foods

● Meats: sausage, bacon, scrapple, ham, chipped beef, corned beef, hot dogs,

Canned meats

● Potato chips, salty snack foods

● Pickles, olives, sauerkraut

51

Renal Diet

I. Description

This diet is designed for residents with acute or chronic renal failure.

There are two categories of the Renal Diet including:

1. A predialysis diet in which the purpose is to restrict the intake of

protein and phosphorus, potassium, sodium and fluid as medically

indicated.

2. A dialysis diet is a liberalized and less restrictive diet. This diet is

used to encourage the resident to improve their oral intake and

help prevent malnutrition.

The renal diet order for potassium and sodium is usually written in

milliEquivalents (mEq) but the food content of these minerals is

generally given in milligrams (mg). To convert one measure to the other,

see the appendix (page 122).

When planning a renal diet, the Carbohydrate Control Exchange Lists

should be used. The pattern for each resident should be planned

according to individual needs including labs, weights and preferences.

Four commonly ordered renal diets are included that can be used as

guides in planning menus.

II. Approximate Composition

Predialysis Dialysis

Calories 2000 2000

Protein 45 gram (gm) 75 gm

Potassium (K) As medically indicated As medically indicated

Sodium (Na) 2-4 gm Na 2-4 gm Na

Phosphorus (PO4) 850 mg 1000 mg less than 1700 mg

Fluid (ml/d) As medically indicated As medically indicated

III. Adequacy

The 45 gm protein diet is deficient in thiamine, riboflavin, niacin, calcium,

vitamin C, vitamin D, vitamin A, copper, magnesium, zinc and iron based

on the Dietary Guidelines for Americans 2010.

The 60 gram protein diet is inadequate in calcium, pantothenic acid,

copper, vitamin A, vitamin B6, magnesium and zinc based on the Dietary

Guidelines for Americans 2010.

In addition, the patient who is receiving hemodialysis treatment will lose

water soluble vitamins during dialysis.

52

Renal Diet

Protein Levels*

45 grams 60 grams 75 grams 90 grams

Breakfast

Whole Milk ½ cup 1 cup 1 cup 1 cup

Egg 1 1 1 1

Starch 2 2 2 3

Fruit 1 1 1 1

Fat 2 2 3 3

Lunch

Meat 1 2 3 3

Starch 2 2 2 2

Vegetable 1 1 1 1

Fruit 1 1 1 1

Fat 3 3 3 3

Dinner

Meat 1 1 2 3

Starch 2 2 2 2

Vegetable 1 1 1 1

Fruit 1 1 1 1

Fat 3 3 3 3

Evening Snack

Fruit 1 1 1 1

Starch 1 1 1 1

Meat 0 0 0 1

Fat 0 0 0 1

*follows carbohydrate control exchange list

**protein needs are increased for the resident undergoing dialysis

53

Renal Diet

Fluid Restriction Distribution Guide

This guide is to be followed until an individualized plan is developed by the

dietitian and/or nursing service along with the resident’s input. It is suggested to

use applesauce for the administration of medications.

Anything liquid at room temperature should be considered a liquid, eg:

ice cream, gelatin, sherbet, popsicle, syrup, gravy, juice in canned fruits.

KEEP NO WATER CUP AT THE BEDSIDE (unless ordered by physician).

120 ml =1/2 cup 240 ml =1 cup

TYPE AMOUNT OF FLUID IN ml

BREAKFAST

Juice 120 120 120 240 240

Beverage 120 240 240 240 240

NOON MEAL

Beverage 120 240 240 240 240

EVENING MEAL

Milk 120 120 120 240 240

Beverage 120 120 240 240 240

HS SNACK

Milk 120 120

Juice 120 120 240

FROM NURSING 280 240 420 480 560

TOTAL FLUIDS

IN 24 HOURS 1000 1200 1500 1800 2000

54

Potassium Containing Foods

(Over 300mg K+ per serving)

Values are for edible portion of foods Potassium (K) mg

Items

Serving

Mg K+

FRUITS & JUICES

Apricots, fresh

3 medium

313

Apricots dried halves

10 each

482

Avocado-California

1 med

1097

Florida

1 med

1484

Banana

1 med

451

Blackberry juice

1 cup

425

Cantaloupe, cubes

1 cup

494

Cherries, sweet, fresh, pitted

1 cup

325

Dates, whole, pitted

10 ea

541

Grape Juice, canned/bottled

1 cup

334

Grapefruit, half, canned

sections

1 cup

328

Grapefruit juice, fresh

1 cup

400

Prepared from frozen

1 cup

337

Canned unsweetened

1 cup

378

Canned sweetened

1 cup

405

Honeydew Melon, cubes

1 cup

461

Lemon Juice: Fresh

1 cup

303

Melon

Casaba Cubes

1 cup

357

Orange Juices

Chilled, fresh

1 cup

473

Prep. From frozen

1 cup

474

Canned, unsweetened

1 cup

436

Orange Grapefruit juice

1 cup

390

Papaya

1 each

780

Passion fruit juice

Purple

1 cup

343

Yellow

1 cup

687

Plantains, cooked

1 cup

716

Pineapple Juice

1 cup

338

Pomegranate

1 ea

399

Prunes, dried

10 ea

626

Prune juice

1 cup

707

Raisins

1 cup

1089

Rhubarb, fresh

1 cup

351

VEGETABLES

Artichoke, hearts marinated

6 oz

438

Asparagus, frozen

1 cup

392

Bamboo shoots, cooked fresh

1 cup

640

Baked beans, dry white

w/sauce

1 cup

907

55

Black Beans

1 cup

611

Black eyed peas, cooked from

froz

1 cup

860

Cooked from fresh

1 cup

690

Canned

1 cup

413

Cooked from dry

1 cup

476

Bok choy, fresh cooked

1 cup

630

Broad bean, canned

1 cup

620

Broccoli

Fresh chopped, cooked

1 cup

456

Frozen, cooked

1 cup

331

Brussel sprouts

frozen cooked

1 cup

504

Fresh cooked

1 cup

491

Cabbage cooked

1 cup

308

Carrot juice

½ cup

358

Celery, cooked, fresh

1 cup

426

Chard, Swiss fresh -cooked

1 cup

961

Collards, cooked from frozen

1 cup

307

Eggplant, fresh cooked

1 cup

397

Garbanzo beans, dry cooked

1 cup

477

Great Northern beans, dry

cooked

1 cup

692

Green (snap) beans, cooked

fresh

1 cup

373

Green peas, cooked fresh

1 cup

383

Hyacinth Beans, cooked, dry

1 cup

653

Kale, cooked from frozen

1 cup

417

Kidney beans, canned

1 cup

658

Cooked from dry

1 cup

713

Kohlrabi fresh

1 cup

490

Cooked

1 cup

561

Lentils, Cooked from dry

1 cup

731

Lotus root, cooked fresh

10 each

323

Parsnips, cooked from fresh

1 cup

573

POTATOES: (unless leached)

Chips

14 chips = 1 oz

369

Baked, Flesh & skin

1 each

844

Flesh only

1 each

610

Potato Skin

1 each

332

Boiled w/skin, flesh only

1 each

515

French Fries, fried in oil

10 each

366

Hash browns, Frozen

1 cup

680

Mashed, w/milk/marg

1 cup

607

Prepared w/milk

1 cup

628

From instant

1 cup

428

Pumpkin, mashed, fresh

1 cup

564

56

Rutabaga, fresh cubed

1 cup

471

Sauerkraut, canned

1 cup

401

Soybeans, dry cooked

1 cup

886

Spinach, frozen cooked

1 cup

566

Fresh cooked

1 cup

838

Fresh

1 cup

312

Canned, drained

1 cup

740

Squash, Summer, sliced

Crookneck, fresh cooked

1 cup

346

Zucchini, cooked fresh

1 cup

455

Winter Squash

Acorn (Danish), baked

1 cup

1071

Butternut, baked

1 cup

697

Hubbard, baked

1 cup

859

Succotash, cooked from fresh

1 cup

757

Frozen cooked

1 cup

451

Sweet potatoes, baked

1 cup

397

Taro, fresh

1 cup

615

TOMOTOES:

Fresh chopped

1 cup

400

Cooked from fresh

1 cup

670

Juice

1 cup

537

Paste

1 cup

2442

Sauce

1 cup

908

Puree

1 cup

1051

Mixed Vegetables (corn, peas,

Limas, green beans, carrots)

frozen, cooked

1 cup

308

Canned, drained

1 cup

474

MILK & DAIRY

CHEESE:

Ricotta, part skim

1 cup

307

CREAM, Sweet fluid,

Half & Half

1 cup

314

CREAM, sour

Cultured dairy

1 cup

331

Imitation non-dairy

1 cup

369

CREAM SUBSTITUTES, non

dairy

Coffee whitener (powder)

1 cup

763

MILK

Skim

1 cup

406

Lowfat 1 %

1 cup

381

Lowfat 2 %

1 cup

377

Whole (3.3% fat)

1 cup

370

Buttermilk (<1% fat)

1 cup

371

Canned, skim evap

1 cup

845

Canned, whole

1 cup

764

Dry, instant nonfat, envelope

1 each

1552

57

Dried, buttermilk

1 cup

1910

Milk (other):

Goat

1 cup

499

Soy Milk

1 cup

338

Chocolate

Low fat 1%

1 cup

425

Low fat 1 %

1 cup

422

Whole (3.3 % fat)

1 cup

417

Egg Nog, commercial

1 cup

420

Malted Milk, w/whole milk

Chocolate flavor

1 cup

499

Natural Flavor

1 cup

529

Milkshakes 10 Fl Oz, 1.25 c

Chocolate

1.25 cup

567

Strawberry

1.25 cup

516

Vanilla

1.25 cup

492

MILK DESSERTS:

Custard Baked

1 cup

387

Soft Served ice cream,

vanilla

1 cup

338

Ice milk soft serve 3 %fat

1 cup

412

Chocolate Pudding

1 cup

366

YOGURT

Lowfat plain

1 cup

531

Lowfat w/fruit

1 cup

442

Lowfat, coffee/vanilla

1 cup

497

Nonfat

1 cup

579

Whole

1 cup

352

Yogurt, cheese

1 cup

666

MEAT, FISH & POULTRY

BEEF

Rib, lean only, roasted

3 ounces

320

Round Steak, lean only

broiled

3 ounces

352

Round Steak, lean & fat

broiled

3 ounces

311

Round tip lean only, roasted

3 ounces

328

Sirloin Steak, lean only,

broiled

3 ounces

336

T-Bone Steak, lean only

broiled

3 ounces

346

Beef fried liver

3 ounces

309

58

PORK

Center loin chop broiled

lean,

& fat, (cut 3 per lb = 4.4 oz-

raw

w/o bone, 5.3 oz-raw

w/bone)

Broiled, lean & fat

1 each

312

Broiled, lean only

1 each

302

Pan fried, lean & fat, center

1 each

323

Pan fried, lean only

1 each

305

Center rib chop: (cut 3 per

lb,

5.3 oz raw w/bone

3.9 oz w/o bone )

Pan Fried, lean & fat

1 each

309

Pork roast, leg, lean only

3 ounces

317

Pork roast, average loin & rib,

lean only

3 ounces

333

Spare ribs, cooked 1 lb raw

6.25 oz

566

Veal (calf) liver, pan fried

3 ounces

372

POULTRY:

CHICKEN: 3 lb = 1.45 lb raw,

=1.1 lb cooked

Fried

1 cup

360

Roasted

1 cup

340

Goose, domestic Roasted

Meat only

3 oz

330

TURKEY:

Roasted all types

1 cup

418

Sausages and Lunchmeats

Ham Salad Spread

1 cup

359

Grains & Grain Products:

Amaranth grain

1 cup

714

Buckwheat Flour, dark

1 cup

490

Buckwheat Flour, light

1 cup

314

Corn Flour

1 cup

369

Masa Harina, enriched

1 cup

340

59

Cornmeal, dry:

Nearly whole broiled

1 cup

303

FLOUR:

Macaroni, cooked:

Vegetable enriched

1 cup

413

NOODLES:

Oat bran (1 T = 6g)

1 cup

532

PASTA:

Quinoa grain, dry

1 cup

1258

RICE, cooked:

Rice bran

1 cup

1233

Rye Flour, Dark

1 cup

934

Soy Flour, stirred:

Low fat flour

½ cup

1131

Defatted

½ cup

1192

Full fat, raw

½ cup

1069

WHEAT:

Wheat bran

½ cup

355

FLOURS, unbleached

Semolina

1 cup

311

Whole Wheat

1 cup

486

Wheat Germ

Raw

1 cup

892

Toasted

1 cup

1070

Wheat, rolled, dry

1 cup

323

MIXED DISHES & FAST

FOODS

Beef & Vegetable stew

Recipe

1 cup

613

Canned

1 cup

417

Beef, macaroni, tomato Sauce,

Recipe

1 cup

562

Beef Pot Pie, homemade

1 piece

334

BURRITO

Bean Burrito

1 each

427

Beef Burrito

1 each

363

Beef & Bean Burrito

1 each

388

Deluxe Combination

1 each

433

Chicken a la king, recipe

1 cup

404

Chicken Chow Mein

Homemade

1 cup

473

Canned

1 cup

418

Chicken curry, homemade

1.5 cup

410

Chicken pot pie, recipe, 1/3

1 piece

343

Chili w/beans, canned

1 cup

932

Chop suey, beef/pork

1 cup

425

Corn pudding

1 cup

402

60

Corned beef hash, canned

1 cup

440

LASAGNA, recipe

with meat

1 piece

507

without meat

1 piece

424

Manicotti, frozen entree

1 each

347

Moussaka (lamb & eggplant)

1 cup

695

PIZZA, cheese

Regular crust, 1/8 of 15“

1 piece

474

Thick crust, ½ of 10

1 piece

367

Potato salad w/mayo & eggs

1 cup

635

Ravioli, beef, canned = 16/cup

1 cup

553

SANDWICHES, Fast Food

Cheeseburger, 4 oz beef

1 each

407

Fish Sandwich

Large, w/o cheese

1 each

375

Hamburger, 4 oz beef

1 each

404

Roast beef w/bun

1 each

338

SANDWICHES, on part

whole

Wheat bread, unless stated

as

rye

Avocado, cheese, tomato,

sprouts

1 each

562

Ham & Cheese

1 each

334

Ham & Swiss on rye

1 each

342

Ham on rye

1 each

311

Patty melt, on rye

1 each

410

Reuben, grilled

1 each

313

Roast beef sandwich

1 each

314

Turkey ham & cheese on rye

1 each

319

SPAGHETTI, pasta & tomato

Sauce with cheese

Homemade

1 cup

408

Canned

1 cup

303

SPAGHETTI, pasta & tomato

Sauce w/meat:

Homemade

1 cup

665

Tostada:

Beans & Beef

1 each

442

Beans & chicken

1 each

358

Refried Beans

1 each

422

Tuna salad

1 each

531

61

NUTS & SEEDS

Almonds dried whole

1 cup

1034

Brazil nuts, dry

1 cup

840

Cashews

Dry roasted

1 cup

774

Oil roasted

1 cup

689

Chestnuts, roasted

1 cup

846

Coconut:

Dried, unsweetened

1 cup

423

Coconut cream, raw

1 cup

780

Coconut milk, canned

1 cup

497

Coconut water, raw

1 cup

600

Filberts (hazelnuts), whole

1 cup

601

Macadamias, oil roasted

1 cup

441

MIXED NUTS w/peanuts

(almonds, brazil nuts,

cashews,

Filberts, peanuts & pecans)

Dry roasted

1 cup

817

Oil roasted

1 cup

825

MIXED NUTS w/o peanuts

(cashews, almonds, brazil

nuts,

Pecans& filberts:

Oil roasted

1 cup

783

PEANUTS:

Dry roasted

1 cup

960

Oil roasted

1 cup

982

Pecans, dried, chopped

1 cup

466

Pistachios, dried, shelled

1 cup

1399

Pumpkin seed

Roasted kernels

1 cup

1830

Whole, roasted

1 cup

588

Sesame Seeds:

Whole seed, dried

1 cup

674

Kernels, dried

1 cup

611

Soybeans, roasted

½ cup

1264

Sunflower seed kernels:

Dried seeds

1 cup

992

Oil roasted

1 cup

652

Walnuts, chopped:

Black

1 cup

655

English

1 cup

602

62

Cheese sauce: mix with milk

1 cup

552

Spaghetti sauce, plain:

Homemade

1 cup

915

Canned

1 cup

957

Spaghetti sauce, w/meat:

Homemade

1 cup

615

Canned

1 cup

444

White sauce

Recipe, medium

1 cup

381

Mix with milk

1 cup

444

SOUPS: soups are prepared

From canned unless

Otherwise stated. RTS =

Ready to serve. For Soup

Prep. w/milk, assume

whole

Milk.

Bean w/bacon

1 cup

403

Celery, cream of, w/milk

1 cup

309

Cheese soup w/milk

1 cup

340

Chili beef

1 cup

525

Clam chowder

New England style

1 cup

300

Gazpacho soup, RTS

1 cup

356

Lentil & Ham RTS

1 cup

356

Minestrone soup

1 cup

312

Potato, cream of, w/milk

1 cup

323

Split pea

1 cup

399

Tomato Soup

Prep with milk

1 cup

450

Tomato Rice Soup

1 cup

330

Turkey soup, chunky, RTS

1 cup

814

Vegetable, chunky, RTS

1 cup

396

OTHER

Cooking ingredients,

Condiments, fat, flavorings,

Spices, sweets, etc

Baking powder, low sodium

1 tsp

471

Barbecue sauce

1 cup

435

Candy and Candy bars:

Chocolate coated:

Almonds

1 cup

1011

Peanuts

1 cup

857

Raisins

1 cup

1153

Carob Flour

1 cup

852

Chili sauce:

Tomato based

1 cup

1010

Chocolate:

63

Cocoa Powder

1 cup

1000

Hummous

1 cup

427

Molasses:

Blackstrap

2 T

1171

Natto (Soybean products)

½ cup

1276

Salt substitutes vary, check

label

Lite Salt (Morton)

1 tsp

1500

Salt Substitiute (Morton)

1 tsp

2800

Seasoned Salt Substitute

(Morton)

1 tsp

2100

Sugar

Brown

1 cup

757

SPICES

Cream of tartar

1 T

361

Tempeh (soybean product)

1 T

609

BAKED GOODS

PIE: piece is 1/16 th of 9 “ pie

Mincemeat pie

1 piece

349

Pumkin pie

1 piece

400

Banana Cream, commercial

1 piece

308

EGGS

Egg substitutes vary by

brand.

Check label

1 cup

Liquid

1 cup

828

For fresh potatoes (white or sweet) peel, slice and soak in cold water at least 4 hours

(preferably overnight) drain, add fresh water and cook. Use no more than 2 times per week.

64

Renal Diet

High Phosphorus Foods

These foods may need to be limited when planning a renal diet.

MILK PRODUCTS NUTS AND SEEDS

(limit to 1 serving/day)

1 oz Cheese 1 oz Almonds

½ cup Cream soup 1 oz Cashews

1 tbsp Creamer half and half 1 oz Peanuts

½ cup Ice cream, ice milk 2 tbsp Peanut butter

½ cup Milk 1 oz Pecans

½ cup Milk shakes 1 oz Pumpkin seeds

½ cup Pudding *1 oz Sunflower seeds

½ cup Yogurt 1 oz Walnuts

GRAIN PRODUCTS MISCELLANEOUS

1 Biscuit from mix Beer

* ¾ cup Bran cereals *1 cup Cocoa made with milk

1 Bran muffins 1 oz Chocolate, semi sweet

1 Cornbread 12 oz Cola

½ cup Oatmeal

2 pancakes from mix

1 slice Pumpernickel bread

1 Waffles, except Eggo’s (not banana or oats)

1 Whole wheat bread

LEGUMES PROTEIN FOODS

½ cup baked beans *3 oz liver

½ cup Black-eyed peas *1 oz macaroni and cheese

½ cup Chick peas (garbanzo beans) *1 slice Pizza

½ cup Lentils *3 oz Tuna

½ cup Lima beans *3 oz Salmon

½ cup Navy beans *3 oz Beef, Turkey or Ham

½ cup Red kidney beans

*½ cup Soybean products

*½ cup Tofu, raw, firm

*These foods have greater than 200 mg of phosphorus per serving size noted. It is

important to adhere to the portion sizes listed and follow the Renal Diet Pattern.

65

Renal Diet

I. Suggested bag lunch when sending your resident out prior to the facility

lunch meal; choose a sandwich, beverage and fruit from the following list

and add additional items based on need and preference.

II. Sensible Snack Suggestion

SANDWICHES

Roast beef, meat loaf, sliced chicken, sliced turkey, chicken salad, tuna,

salad, seafood salad, egg salad, turkey salad, roast pork, jelly or cream

cheese.

BEVERAGES

Cranberry drink, apple juice, grape juice, Hi-C, Hawaiian punch, Kool-aid,

Tang, clear soda

DESSERTS

Rice crispy bar, 4 sugar cookies, 3 butter cookies, 3 vanilla cream cookies,

angel food cake, pound cake, 4 shortbread cookies, fruit pie, 3 gingersnaps,

or 4 vanilla wafers

FRUIT

Applesauce, apple, tangerine, grapes, blueberries, cherries, strawberries,

canned pears or canned pineapple

STARCHES

Bagel with cream cheese and jelly, muffin with margarine and jelly, Danish,

donut, tortilla chips, graham crackers with cream cheese, unsalted popcorn,

unsalted crackers and pretzels

CANDY

Gum drops, jelly beans, hard candy, marshmallows, lollipops, candy corn or

butter mints

66

Simplified Guideline for Standard Carbohydrate Controlled Diet

I. Description

Because of the importance of proper diet in the treatment and control of

diabetes, whenever possible the carbohydrate controlled diet should be

created by a registered or licensed dietitian/nutritionist to assure optimal

variety, client satisfaction and therapeutic benefit. However, the following

guideline can be used to prepare a more standard carbohydrate controlled

menu. It can be used by caregivers responsible for preparing

carbohydrate controlled menus in smaller assisted living programs. Once

written, these menus should then be reviewed and approved by a

registered/licensed dietitian/nutritionist.

II. Approximate Composition

The accepted calorie range for the regular diet (upon which the

carbohydrate controlled diet is based) is 1700-2400 calories per day.

Therefore, these simplified guidelines are designed to create a menu plan

providing approximately 2000-2100 calories, 75 grams of protein, 270

grams of carbohydrate and 50 grams of fat. (Note: Calculations are

based upon the use of primarily leaner meats and reduced fat (2%) milk.

However, the use of whole milk is acceptable.

III. Adequacy

This diet contains all nutrients necessary to provide and maintain

adequate nutrition based on the Recommended Daily Intakes (RDI), 2005.

IV. Suggested Guidelines

The diet will provide three meals and one bedtime snack daily. By using

the following guidelines, the carbohydrate is distributed in equal amounts

across breakfast, lunch and dinner, with a smaller amount provided at the

bedtime snack.

Breakfast Lunch Dinner Bedtime

3 starch servings

4 starch servings

3 starch servings

1 starch serving

1 fruit serving

1 vegetable serving

2 vegetable serving

1 milk serving

1 oz meat or

substitute

3 oz meat or

substitute

3 oz meat or

substitute

1 oz meat or

substitute

1 fat serving

67

Simplified Guideline for Standard Carbohydrate Controlled Diet

In general, one starch serving is: In general, one vegetable serving is:

½ cup of cereal grain, pasta, or starchy ½ cup of cooked vegetables,

vegetable, 1 ounce of a bread 1 cup vegetable juice or

product, such as 1 slice of bread or 1 cup raw vegetables

crackers

In general, on fruit serving is: In general, 1 oz. meat or substitute is:

1 small to medium fresh fruit 1 oz meat, poultry, fish or cheese

½ cup canned or fresh fruit or juice 1 egg or ¼ cup cottage cheese

¼ cup dried fruit ½ cup beans, peas, lentils (also count

as one starch)

2 tablespoon salad dressing

See the Exchange Lists for Meal Planning at the end of this section for more detail.

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Carbohydrate Controlled Diet

I. Description

This diet is designed for residents with diabetes mellitus. It is based upon

the regular diet but, since the carbohydrate content of meals produces the

largest influence on blood sugar levels, meals are planned to provide a

consistent amount of carbohydrate from day to day. Concentrated sweets

are not prohibited but must be planned into the total carbohydrate

allowance. This diet can be used for any diabetic resident who does not

require a calorie restriction.

II. Approximate

Calories 1700-2400

Protein 65-75 grams

III. Adequacy

This diet contains all nutrients necessary to provide and maintain

adequate nutrition based on the Dietary Guidelines for Americans 2010.

IV. Basis for Calculation of Carbohydrates

The carbohydrate controlled diet is most easily planned by using the

Exchange Lists for Meal Planning. There are four food exchange groups

which contain carbohydrate; these are starches, fruits, milks and

vegetables. In the 1994 revision to the exchange lists, another group

called “other carbohydrates” was added to accommodate carbohydrate-

containing foods which cannot be categorized as a starch, fruit, milk or

vegetable. Examples are sweets and high fat snack foods. The 1994

edition of the exchange lists for meal planning are found at the end of this

section.

V. Steps In Planning the Carbohydrate Controlled Diet (example)

A. Establish the calorie level of the diet. The American Diabetes

Association guidelines for nutritional care of individuals with

diabetes suggest that 50-60 percent of calories come from

carbohydrates. Because the carbohydrate content of the diet is

based upon calories, it is necessary to write menus which contain a

set daily calorie level. Each might determine the average daily

number of calories needed by the majority of diabetic residents who

will be receiving the diet. Or, taking the midpoint of calories

suggested under the regular diet guidelines would also be

appropriate.

Accepted Calorie Range – Regular Diet 1700-2400

Suggested Midpoint for the Carbohydrate Controlled Diet 2000

69

Carbohydrate Controlled Diet

B. Calculate the daily carbohydrate content in grams. (Every gram of

carbohydrate contains four calories. Fifty to sixty percent of calories from

carbohydrate would be acceptable.)

2000 Calories x 55% carbohydrate = 1100 carbohydrate calories per day

1100 carbohydrate calories ÷ 4 calories/gram = 275 grams

carbohydrate per day

C. (Plan how the carbohydrates will be distributed throughout the day.)

There is no single correct way to spread the carbohydrate throughout the

day. The goal is to distribute the carbohydrates as evenly as possible but,

in general the largest or most popular meals should contain more

carbohydrate than lighter meals or snack.

TIP: Because carbohydrate foods in the exchange lists contain an average

15 grams carbohydrate per serving, it is suggested that carbohydrate

distribution goals be in multiples of 15 to provide the simplest meal

formula.

Example for a facility where meals are approximately the same size:

Breakfast 75 grams carbohydrate (5 carbohydrate servings)

Lunch 75 grams carbohydrate (5 carbohydrate servings)

Dinner 75 grams carbohydrate (5 carbohydrate servings)

Snack 45 grams carbohydrate (3 carbohydrate servings)

Total 270 grams carbohydrate/day*

D. Other considerations

1. While the focus of this diet is on total carbohydrates per meal and

per day, it is still important to plan menus which are nutritionally

balanced and provide at least 2 servings of milk, 2 servings of fruit,

3 servings of vegetables, 6 servings of starch and 5 oz. of protein

per day.

2. This diet does not specifically prohibit regular condiments such as

regular sugar, regular jelly, regular syrup, etc. However, these

foods may be wasted carbohydrates. For example, a single 2 oz.

container of regular syrup would “waste” 30 grams of

carbohydrate, or two carbohydrate choices, at that meal. This

might make it impossible to provide adequate amounts of other

carbohydrate foods (e.g. juice and milk) to provide a well-balanced

meal.

*Note: The goal for total carbohydrate per day was 275 grams. 270 grams is

close enough.

70

Carbohydrate Controlled Diet

3. This diet allows the diabetic resident to enjoy regular desserts

as long as the total carbohydrate within the meal is controlled

(see “Other Carbohydrates” exchange list). However, like all

well-planned menus, regular dessert should only be included

when all nutritional needs have been met and adequate

calories remain to allow the regular dessert to be included.

Often portions of regular dessert are small so that the menu

does not exceed the allowed amount of carbohydrates or

calories. At times, a lower sugar, “dietetic” dessert may still be

the best choice for a menu. To avoid confusion among staff

and residents, it may be wise to try to establish a pattern for

incorporating regular desserts - every Sunday and Thursday at

the main meal, for example.

VI. EXCHANGE LIST FOR MEAL PLANNING

See next page.

71

Carbohydrate Controlled Diet

Traditional Exchange Lists for Meal Planning

Exchange Group Carbohydrate (g) Protein (g) Fat (g) Calories

Starches 15 3 0-1 80

Fruits 15 - - 60

Milk

Skim 12 8 0-1 90

Low Fat 12 8 5 120

Whole 12 8 8 150

Other Carbohydrates 15 varies varies -

Vegetables 5 2 - 25

Meat

Very Lean (VL) - 7 0-1 35

Lean (L) - 7 3 55

Medium Fat (MF) - 7 5 75

High Fat (HF) - 7 8 100

Fats - - 5 45

*Note that the meat and fat exchange groups do not contain carbohydrate.

To simplify meal planning based on carbohydrate content, it is common for starches,

fruits, milks and “other carbohydrates” servings to all be averaged to 15 grams of

carbohydrate per serving. Foods in any of these groups simply become “carbohydrate

foods” and become interchangeable in the diet. For example, on the carbohydrate

controlled diet, an 8 ounce glass of skim milk and a medium peach are both calculated

to contain 15 grams of carbohydrate. Providing either, would be providing one

carbohydrate serving.

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Carbohydrate Controlled Diet

Simplified Exchange Lists for Carbohydrate Planning

Exchange Group Carbohydrate (g) Protein (g) Fat (g) Calories

Starches 15* 3 0-1 80*

Fruits 15* 3 0-1 80*

Milk

Skim 15* 8 0-1 80*

Low Fat 15 8 5 120

Whole 15 8 8 150

Other Carbohydrates 15 varies varies -

Vegetables** 5* 2 - 25

Meat

Very Lean (VL) 0 7 0-1 35

Lean (L) 0 7 3 55

Medium Fat (MF) 0 7 5 75

High Fat (HF) 0 0 8 100

Fats 0 0 5 45

*It is acceptable to average the carbohydrate and calorie content of the three main

“carbohydrate” groups to further simplify meal calculations.

**Because of the small carbohydrate content in vegetables, it is acceptable not to

include them in carbohydrate calculations unless three or more exchanges are served

together. For example, a chef salad might contain 3 cups of assorted raw vegetables.

This would be three vegetable exchanges, 15 grams of carbohydrate, and one serving

of carbohydrate.

Other methods of counting carbohydrates, such as nutritional information lists or books,

and food labels can also be used in planning the Carbohydrate Controlled Diet.

However, there are three benefits of calculating carbohydrate using the exchange lists:

1. Most dietary staff members are already familiar with the exchange lists.

2. Resident preferences can be accommodated more easily. For

example, if Mrs. Jones dislikes milk, it is not necessary to rewrite the

entire carbohydrate controlled diet for her. Her diet care plan would

simply note that the milk in her meals would need to be substituted

with another “carbohydrate” serving – such as an extra fruit serving or

starch serving – to keep the calculated carbohydrate amounts intact.

3. The same system is used to calculate calorie controlled diabetic diets

(see next section), so that the dietary staff does not need to learn two

different diabetic diet methods.

73

Carbohydrate Controlled Diet

Carbohydrate Controlled Meal Plan

(Based upon 55% of calories from carbohydrate or approximately 206 grams) Carbohydrate

Distribution 60-65-65-30

Menu Carbohydrates Calories

Breakfast

4 oz orange juice (1 fruit) 15 80

¾ cup (1 oz) cold cereal or 4 oz oatmeal (1 starch) 15 80

1 egg, scrambled in PAM (1 MF meat) 0 75

1 piece of toast or 2 - 4” reduced fat pancakes (1 starch) 15 80

1 pat margarine (1 fat) 0 45

1 cup skim milk (1 milk) 15 80

60 440

Lunch

4 oz orange juice (1 fruit) 15 80

2 oz baked chicken with skin (2 L meat) 0 110

2/3 cup rice, plain (2 starch) 30 160

½ cup carrots plain (1 veg) 5 25

1 pat margarine (1 fat) 0 45

½ cup fresh fruit cup (1 fruit) 15 80

65 500

Dinner

8 oz vegetable soup 15 80

1 cup tossed salad (1 veg) 5 25

1 packet fat free dressing 0 0

2 slices wheat bread (2 starch) 30 160

½ cup tuna, water-packed (2 VL meat) 0 70

1 tbsp light mayonnaise (1 fat) 0 50

½ cup diet peaches (1 fruit) 15 80

65 465

Snack

1 cup skim milk (1 milk) 15 80

4 whole wheat crackers (low fat) 15 80

30 160

DAILY TOTAL 220 1565

74

Carbohydrate Controlled Diet

Carbohydrate Controlled Meal Plan

(Based upon 55% of calories from carbohydrate or approximately 275 grams) Carbohydrate

Distribution 75-75-75-45

One starch exchange equals 15 grams carbohydrate, 3 grams protein 0-1 grams fat and 80

calories.

Menu Carbohydrates Calories

Breakfast

4 oz orange juice (1 fruit) 15 80

¾ cup (1 oz) cold cereal or 4 oz hot cereal (1 starch) 15 80

1 egg, scrambled in PAM (1 MF meat) 0 75

1 piece of toast or 4 - 4” reduced fat pancakes (2 starch) 30 160

2 pats margarine (1 fat) 0 45

1 cup skim milk 15 80

75 520

Lunch

1 cup vegetable soup 15 80

2 packet crackers (2 starch) 7.5 40

1 cup tossed salad (1 veg) trace 25

1 packet light Italian dressing (1 fat) 0 45

2 slices wheat bread (2 starch) 30 160

½ cup tuna, water-packed (2 VL meat) 0 70

1 tbsp light mayonnaise (1 fat) 0 50

½ cup skim milk (1/2 starch) 7.5 40

½ cup chilled peaches (1 starch) 15 80

75 670

Dinner

3 oz baked chicken with skin (3lean meat) 0 165

2/3 cup rice, plain (2 starch) 30 160

6 oz V-8 juice (1 veg)* 15 80

1 cup carrots, plain (2 veg) (*together=1 starch)

1 roll, small (1 starch) 15 80

1 pat margarine (1 fat) 0 45

½ cup ice cream, vanilla (1 starch, 1 ½ fat) 15 150

75 670

Snack

1 cup skim milk (1 starch) 15 80

1 oz angel food cake (1 starch) 15 80

1/2 cup natural applesauce (1 starch) 15 80

45 240

DAILY TOTAL 270 2020

75

Carbohydrate Controlled Diet

Carbohydrate Controlled Meal Plan

One starch exchange equals 15 grams carbohydrate, 3 grams protein 0-1 grams fat and 80

calories.

Bread Cereals and Grains

Bagel ½ (1 oz) Bran cereals ½ cup

Bread, reduced-calorie 2 slices Bulgur ½ cup

Bread, white, whole-wheat Cereals ½ cup

Pumpernickel or rye 1 slice Cereals, unsweetened,

Bread sticks, crisp, ready-to-eat ¾ cup

4 in long x ½ in 2 (2/3 oz) Cornmeal (dry) 3 tbsp

English muffin ½ Couscous 1/3 cup

Hot dog or hamburger bun ½ (1 oz) Flour 3 tbsp

Pita, 6 in across 1/2 Granola, low fat ¼ cup

Roll, plain, small 1 Grape nuts ¼ cup

Raisin bread, unfrosted 1 slice Grits ½ cup

Tortilla, corn, 6 in across 1 Kasha 1 ½ cup

Waffle, 4 ½ square Millet ¼ cup

Reduce fat 1 Muesli ¼ cup

Oats ½ cup

Pasta ½ cup

Puffed cereal 1 ½ cup

Rice milk 1 ½ cup

Rice, white or brown 1/3 cup

Shredded wheat 1 ½ cup

Sugar-frosted cereal ½ cup

Wheat germ 3 tbsp

76

Carbohydrate Controlled Diet

One starch exchange equals 15 grams carbohydrate, 3 grams protein 0-1 grams fat and 80

calories.

Starchy Vegetables Beans, Peas, and Lentils

Baked beans 1/3 cups Beans and peas (garbanzo,

Corn ½ cup pinto kidney, white, split,

Corn on cob, medium 1 (5 oz) black-eyed ½ cup

Mixed vegetables with corn, Lima beans 2/3 cup

peas or pasta 1 cup Lentils ½ cup

Plantain ½ cup Miscellaneous 3 tbsp

Potato (mashed) 1 small (3 oz)

Squash, winter

(acorn, butternut) 1 cup

Yam, sweet potato, plain ½ cup

Crackers and Snacks

Animal crackers 8

Graham crackers, 2 ½” Square 3

Matzo ¾ oz

Melba toast 4 slices

Oyster crackers 24

Popcorn (popped, no fat added

Or low fat microwave 3 cups

Pretzels ¾ oz

Rice cakes 4 inch across 2

Saltine type crackers 6

Snack chips, fat-free (tortilla,

Potato 15-20 (3/4 oz)

Whole-wheat crackers,

No fat added 2-5 (3/4 oz)

77

Carbohydrate Controlled Diet

One starch exchange equals 15 grams carbohydrate, 3 grams protein 0-1 grams fat

and 80 calories.

Starchy Foods Prepared with Fat Common Measurements

Biscuit, 2 ½ inch across 1 3 tsp = 1 tbsp

Chow mein noodles ½ cup 4 tbsp = ¼ cup

Corn bread, 2 in cube 1 (2 oz) 5 1/3 tbsp = 1/3 cup

Crackers, round butter type 6 4 oz = ½ cup

Croutons 1 cup 8 oz = 1 cup

French fried potatoes 16-25 (3 oz) 1 cup = ½ pint

Granola ¼ cup

Muffin, small 1 (1 ½ oz)

Pancake, 4 inch across 2

Popcorn, microwave 3 cups

Sandwich cracker, cheese or

Peanut butter filling 3

Stuffing, bread (prepared) 1/3 cup

Taco, shell, 6 inch square 2

Waffle, 4 ½ inch square 1

Whole-wheat crackers,

fat added 4-6 (1 oz)

Starches often swell in cooking so a small amount of uncooked starch will become a

much larger amount of cooked food. The following table shows some of the changes.

Food (Starch Group) Uncooked Cooked

Oatmeal 3 tbsp ½ cup

Cream of Wheat 2 tbsp ½ cup

Grits 3 tbsp ½ cup

Rice 2 tbsp 1/3 cup

Spaghetti ¼ cup ½ cup

Noodles 1/3 cup ½ cup

Macaroni ¼ cup ½ cup

Dried beans ¼ cup ½ cup

Dried peas ¼ cup ½ cup

Lentils 3 tbsp ½ cup

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Carbohydrate Controlled Diet

Fruit Exchanges

One fruit exchange equals 15 grams carbohydrate and 60 calories. The weight includes

skin, core, seeds, and rind.

Fruit

Apple, unpeeled, small 1(4oz)

Applesauce, unsweetened ½ cup Pineapple, canned ½ cup

Apples, dried 4 ring Plums, small 2 (5 oz)

Apricots, fresh 4 whole Plums, canned ¼ cup

(5 ½ oz) Prunes, dried 3

Apricots, dried 8 halves Raisins 2 tbsp

Apricots, canned ½ cups Raspberries 1 cup

Banana, small 1 (4 oz) Strawberries 1 ¼ cup

Blackberries ¾ cup whole berries

Blueberries ¾ cup Tangerines, small 2 (8 oz)

Cantaloupe, small 1/3 melon Watermelon 1 slice or

or 1 cup cubes 1 ¼ cup cubes

Cherries, sweet, fresh 12 (3 oz)

Cherries, sweet, canned ½ cup

Dates 3 Fruit Juice

Figs, fresh 1 ½ large or

2 medium Apple juice/cider ½ cup

(3 ½ oz) Cranberry juice

cocktail 1/3 cup

Figs, dried 1 ½ cup Cranberry juice cocktail,

Fruit cocktail ½ cup reduced calories 1 cup

Grapefruit, large ½ (11 oz) Fruit juice blends,

Grapefruit sections, canned ¾ cup 100% juice 1/3 cup

Grapes, small 17 (3 oz) Grape juice 1/3 cup

Honeydew melon 1 slice (10 oz) Grapefruit juice ½ cup

or 1 cup cubes Orange juice ½ cup

Kiwi 1 (3 ½ oz) Pineapple juice ½ cup

Mandarin oranges, canned ¾ cup Prune juice 1/3 cup

Mango, small ½ fruit

(5 ½ oz) or 1 cup

Nectarine, small 1 (5 oz)

Orange, small ½ fruit (8 oz)

or 1 cup cubes

Papaya ½ fruit (8 oz)

or 1 cup cubes

Peach, medium, fresh 1 (6 oz)

Peaches, canned ½ cup

Pear, large, fresh ½ (4 oz)

Pineapple, fresh ¾ cup

79

Carbohydrate Controlled Diet

Milk Exchanges

One milk exchange equals *12 grams carbohydrate and 8 grams protein.

*For ease of menu planning, starches, fruits, and skim milk servings can all be averaged

and calculated as 15 grams carbohydrate and 80 calories

Skim and Low fat Milk Reduced Fat

(0-3 grams fat per serving) (5 grams fat per serving)

Skim milk 1 cup 2% milk 1 cup

1/2 % skim milk 1 cup Plain low fat yogurt ¾ cup

1 % milk 1 cup Sweet acidophilus milk 1 cup

Nonfat or low fat buttermilk 1 cup

Evaporated skim milk ½ cup Whole Milk

Nonfat dry milk 1/3 cup dry (8 grams fat per serving)

Plain nonfat yogurt 1 cup

Nonfat or low fat Whole milk 1 cup

Fruit-flavored yogurt Evaporated whole milk ½ cup

sweetened with aspartame or Goat’s milk 1 cup

with a no nutritive Kefir 1 cup

sweetener 1 cup

Other Carbohydrates List

You can substitute menu choices from this list for a starch, fruit or milk choice on your

meal plan. Some choices will also count as one or more fat choices.

Nutrition Tips

1. These foods can be substituted in your meal plan, even though they contain

added sugars or fat. However, they do not contain as many important vitamins

and minerals as the choices on the Starch, Fruit or Milk list.

2. When planning to include these foods in your meals, be sure to first include foods

from all the lists to provide a balanced meal.

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Carbohydrate Controlled Diet

Other Carbohydrates List

3. Because many of these foods are concentrated sources of carbohydrate and fat,

the portion sizes are often very small.

4. Many fat-free or reduced fat products made with fat replacers contain

carbohydrates. When eaten in large amounts, they may need to be counted.

Check labels for carbohydrate content.

5. Use fat-free salad dressings in smaller amounts on the Free Foods lists.

Other Carbohydrates

One exchange equals 15 grams carbohydrate or 1 starch or 1 fruit or 1 milk

Food Serving Size Exchanges per Serving

Angel food cake, unfrosted 1/12

th

cake 2 carbohydrates

Brownie, small unfrosted 2 inch square 1 carbohydrate, 1 fat

Cake, unfrosted 2 inch square 1 carbohydrate, 1 fat

Cake, frosted 2 inch square 2 carbohydrates, 1 fat

Cookie, fat-free 2 small 1 carbohydrate

Cookie or sandwich cookie

with cream filling 2 small 1 carbohydrate, 1 fat

Cranberry sauce, jellied ¼ cup 1 ½ carbohydrates

Cupcake, frosted 1 small 2 carbohydrates, 1 fat

Doughnut, plain cake 1 medium (1 ½ oz) 1 ½ carbohydrates, 2 fats

Doughnut, glazed 3 ¾ inch across (2 oz) 2 carbohydrates, 2 fats

Fruit juice bars, frozen,

100% juice 1 bar (3 oz) 1 carbohydrate

Fruit snacks, chewy

(pureed fruit concentrate) 1 roll (¾ oz) 1 carbohydrate

Fruit spreads, 100% fruit 1 tbsp 1 carbohydrate

Gelatin, regular ½ cup 1 carbohydrate

Gingersnaps 3 2 carbohydrate

Granola bar 1 bar 1 carbohydrate, 1 fat

81

Carbohydrate Controlled Diet

Other Carbohydrates

Food Serving Size Exchanges per Serving

Honey 1 tbsp 2 carbohydrates

Hummus 1/3 cup 1 carbohydrate, 1 fat

Ice cream 1/3 cup 1 carbohydrate, 1 fat

Ice cream, light ½ cup 1 carbohydrate, 1 fat

Ice cream, fat-free,

no sugar added ½ cup 1 carbohydrate

Jam or jelly, regular 1 tbsp 1 carbohydrate

Milk, chocolate, whole 1 cup 2 carbohydrate, 1 fat

Pie, fruit, 2 crusts 1/6 pie 3 carbohydrates, 2 fats

Pie, pumpkin or custard 1/8 pie 2 carbohydrates, 2 fats

Potato chips 12-18 (1 oz) 1 carbohydrate, 2 fat

Pudding, regular

(made with low fat milk) ½ cup 2 carbohydrates

Salad dressing, fat-free ¼ cup 2 carbohydrates

Sherbet, sorbet ½ cup 1 carbohydrate

Spaghetti or pasta sauce,

canned 1 tbsp 1 carbohydrate, 1 fat

Sugar 1 tbsp 1 carbohydrate

Sweet roll or Danish 1 (2 ½ oz) 2 ½ carbohydrate, 2 fats

Syrup, light 2 tbsp 1 carbohydrate

Syrup, regular ¼ cup 4 carbohydrates

Tortilla chips 6-12 (1 oz) 1 carbohydrate, 2 fats

Vanilla wafers 5 1 carbohydrate, 1 fat

Yogurt, frozen, low fat

fat-free 1/3 cup 1 carbohydrate, 0-1 fat

Yogurt, low fat with fruit 1 cup 3 carbohydrates, 0-1 fat

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Carbohydrate Controlled Diet

Vegetable Exchange

One vegetable exchange equals 5 grams carbohydrate, 2 grams protein, 0 grams fat

and 25 calories.

Artichoke Okra

Artichoke hearts Onions

Asparagus Pea pods

Beans (green, wax, or Italian) Peppers (all varieties)

Bean sprouts Radishes

Cabbage Salad greens (endive, escarole)

Carrots lettuce, romaine or spinach)

Cauliflower Sauerkraut

Celery Spinach

Cucumber Summer squash

Eggplant green onions or scallions Tomato

Greens (collard, kale, mustard or turnip) Tomatoes, canned

Kohlrabi Tomato sauce

Leeks Tomato vegetable juice

Mixed vegetables (without corn, peas or pasta) Turnips

Note: Because the carbohydrate content of this list is so low, 3 servings have to be

planned at one time to count as 1 carbohydrate food choice.

1 serving of vegetables is: ½ cup of cooked vegetables, 1 cup of vegetable juice or

1 cup of raw vegetables.

83

Carbohydrate Controlled Diet

Meat Exchange

Very Lean Meat and Substitutes List

(One exchange equals 0 grams carbohydrate, 7 grams protein, 0-1 grams fat and 35 calories)

One very lean meat exchange is equal to any one of the following items.

Poultry: Chicken or turkey (white meat, no skin), 1 oz

Cornish hen (no skin)

Fish: Fresh or frozen cod, flounder, haddock, halibut 1 oz

or trout; tuna fresh or canned in water

Shellfish: Clams, crab, lobster, scallops, shrimp, 1 oz

Imitation shellfish

Cheese: With 1 gram or less fat per ounce:

Nonfat or low-fat cottage cheese ¼ cup

Fat-free cheese 1 oz

Other: Processed sandwich meats with 1 gram or less fat

per ounce, such as deli thin, shaved meats, chipped

beef, turkey, ham 1 oz

Egg whites 2

Egg substitutes, plain ¼ cup

Hot dogs with 1 gram or less fat per ounce 1 oz

Kidney (high in cholesterol) 1 oz

Sausage with 1 gram or less fat per ounce 1 oz

One very lean meat and one starch exchange is equal

to any one of the following items: beans, peas, lentils

(cooked) ½ cup

84

Carbohydrate Controlled Diet

Meat Exchange

Lean Meat and Substitutes List

(One exchange equals 0 grams carbohydrate, 7 grams protein, 3 grams fat and 55 calories)

One lean meat exchange is equal to any one of the following items.

Beef: USDA Select or Choice grades of lean beef trimmed 1 oz

of fat, such as round, sirloin and flank steak;

tenderloin, roast (rib, chuck or rump); steak (T-bone,

porterhouse or cubed), ground round

Pork: Lean pork, such as fresh ham; canned, cured or 1 oz

Boiled ham; Canadian bacon; tenderloin, center

Loin chop

Lamb: Roast, chop, leg 1 oz

Veal: Lean chop, roast 1 oz

Poultry: Chicken, turkey (dark meat, no skin), chicken 1 oz

(white meat, with skin), domestic duck or goose

(well-drained of fat no skin)

Fish: Herring (uncreamed or smoked) 1 oz

Oysters 6 medium

Salmon (fresh or canned), catfish 1 oz

Sardines (canned) 2 medium

Tuna (canned in oil, drained) 1 oz

Game: Goose (no skin), rabbit 1 oz

Cheese: 4.5% fat cottage cheese ¼ cup

Grated Parmesan 2 tbsp

Cheeses with 3 grams or less fat per ounce 1 oz

Other: Hot dogs with 3 grams or less fat per ounce 1 ½ oz

Processed sandwich meat with 3 grams or less 1 oz

fat per ounce, such as turkey pastrami or kielbasa

Liver, heart (high in cholesterol) 1 oz

85

Carbohydrate Controlled Diet

Meat Exchanges

Medium Fat Meat and Substitutes List

(One exchange equals 0 grams carbohydrate, 7 grams protein, 5 grams fat and 75 calories)

One medium fat meat exchange is equal to any one of the following items.

Beef: Most beef products fall into this category; ground 1 oz

beef, meatloaf, corned beef, short ribs, prime grades

of meat trimmed of fat, such as prime rib

Pork: Top loin, chop, Boston butt cutlet 1 oz

Lamb: Rib roast, ground 1 oz

Veal: Cutlet (ground or cubed, unbreaded) 1 oz

Poultry: Chicken (dark meat, with skin), ground turkey or 1 oz

ground chicken, fried chicken (with skin)

Fish: Any fried fish product 1 oz

Cheese: With 5 grams or less fat per ounce:

Feta 1 oz

Mozzarella 1 oz

Ricotta 2 oz (1/4 cup)

Other: Egg (high in cholesterol, limit 3 per week) 1

Sausage with 5 grams or less fat per ounce 1

Soy milk 1 cup

Tempeh ¼ cup

Tofu 4 oz or ½ cup

86

Carbohydrate Controlled Diet

Meat Exchanges

High Fat Meat and Substitutes List

(One exchange equals 0 grams carbohydrate, 7 grams protein, 8 grams fat and 100 calories)

Remember these items are high in saturated fat, cholesterol and calories and may raise blood

cholesterol levels if eaten on a regular basis.

One high fat meat exchange is equal to any of the following items.

Pork: Spare ribs, ground pork, pork sausage 1 oz

Cheese: All regular cheeses, such as:

American, Cheddar, Monterey Jack or Swiss 1 oz

Other: Processed sandwich meats with 8 grams or less fat 1 oz

per ounce, such as bologna, pimento loaf and salami

Sausage, such as bratwurst, Italian, or Knockwurst, 1 oz

Polish, smoked

Hot dog (turkey or chicken) 1 (10/lb)

Bacon 3 slices

(10 slices/lb)

One high fat meat exchange plus one fat exchange is equal to one of the following items:

Hot dog (beef, pork or combination) 1 (10/lb)

One high fat meat exchange plus two fat exchanges is equal to the following item:

Peanut butter (contains unsaturated fat) 2 tbsp

87

Carbohydrate Controlled Diet

Meat Exchanges

Monounsaturated Fats List

(One fat exchange equals 5 grams fat and 45 calories)

Avocado: Medium 1/8 (1 oz)

Oil: Canola, olive or peanut 1 tsp

Olives: Ripe (black) 8 large

Green, stuffed 10 large

Nuts: Cashews, almonds 6 nuts

Mixed (50% peanuts) 6 nuts

Peanuts 10 nuts

Pecans 4 halves

Peanut butter, smooth or crunch 2 tsp

Sesame seeds 1 tbsp

Tahini paste 2 tsp

Polyunsaturated Fats list

(One fat exchange equals 5 grams fat and 45 calories)

Margarine: Stick, tub or squeeze 1 tsp

Lower fat (30% to 50% vegetable oil) 1 tsp

Nuts: Walnuts, English 4 halves

Oil: Corn, Safflower or Soybean 1 tsp

Salad dressing: Regular 1 tbsp

Reduced fat 2 tbsp

Miracle Whip® salad dressing

Regular 2 tsp

Reduced fat 1 tbsp

Seeds: Pumpkin, sunflower 1 tbsp

88

Carbohydrate Controlled Diet

Meat Exchanges

Saturated Fats List

(One fat exchange equals 5 grams fat and 45 calories)

Bacon: Cooked 1 slice

(20 slices/lb)

Butter: Stick 1 tsp

Whipped 2 tsp

Reduced fat 1 tbsp

Chitterlings: Boiled 2 tbsp (1/2 oz)

Coconut: Sweetened, shredded 2 tbsp

Cream: Half and half 2 tbsp

Cream cheese: Regular 1 tbsp (1/2 oz)

Reduced fat 2 tbsp

Shortening or lard: 1 tsp

Sour cream: Regular 2 tbsp

Reduced fat 3 tbsp

89

Carbohydrate Controlled Diet

Free Foods

A free food is any food or drink that contains less than 20 calories or less than 5 grams of

carbohydrate per serving. Foods with a serving size listed should be limited to three

servings per day. Be sure to spread them out throughout the day.

Fat free or Reduced fat Foods

Cream cheese, fat free 1 tbsp

Creamers, non dairy, liquid 1 tbsp

Creamers, non dairy, powder 2 tsp

Mayonnaise, fat free 1 tbsp

Mayonnaise, reduced fat 1 tsp

Margarine, fat free 4 tbsp

Margarine, reduced fat 1 tsp

Miracle Whip®, non fat 1 tbsp

Miracle Whip®, reduced fat 1 tsp

Nonstick cooking spray -

Salad dressing, fat free 1 tbsp

Salad dressing, fat free, Italian 2 tbsp

Salsa ¼ cup

Sour cream, fat free, reduced fat 1 tbsp

Whipped topping, regular or light 2 tbsp

90

Carbohydrate Controlled Diet

Free Foods

Sugar free or low sugar foods

Candy, hard, sugar free 1 tbsp

Gelatin dessert, sugar free -

Gelatin, unflavored -

Gum, sugar free -

Jam or jelly, low sugar or light 2 tsp

Sugar substitutes*

Syrup, sugar free 2 tbsp

* Sugar substitutes, alternatives or replacements that are approved by the Food and Drug

Administration (FDA) are safe to use. Common brand names include:

Equal®, (aspartame)

Sprinkle Sweet® (saccharin)

Sweet One® (acesulfame K)

Sweet-10® (saccharin)

Sugar Twin® (saccharin)

Sweet’n Low® (saccharin)

Splenda® (sucralose)

91

Carbohydrate Controlled Diet

Free Foods

Drinks

Bouillon, Broth, consommé -

Bouillon or broth, low-sodium -

Carbonated or mineral water -

Club soda -

Cocoa powder, unsweetened 1 tbsp

Coffee -

Diet soft drinks, sugar free -

Drink mixes, sugar free -

Tea, Tonic water, sugar free -

92

Carbohydrate Controlled Diet

Free Foods

Condiments

Catsup 1 tbsp

Horseradish 1 tsp

Lemon juice -

Mustard -

Pickles, dill 1 ½ large

Soy Sauce, regular or light 1 tbsp

Taco sauce 1 tbsp

Vinegar -

Seasonings

Flavoring extract -

Garlic -

Herbs, fresh or dried -

Pimiento -

Spices -

Tabasco® or hot pepper sauce -

Wine, used in cooking -

Worchester sauce -

93

Carbohydrate Controlled Diet

Combination Foods List

Food

Entrees Serving Size Exchanges per Serving

Tuna noodle casserole, 1 cup (8 oz) 2 carbohydrates,

lasagna, spaghetti with 2 medium fat meats

meatballs, chili with beans

or macaroni and cheese

Chow mein (without 2 cups (16 oz) 1 carbohydrate,

noodles or rice) 2 lean meats

Pizza, cheese, thin crust ¼ of 10 in (5 oz) 2 carbohydrates, 2 medium

fat meats, 2 fats

Pizza, meat topping, ¼ of 10 in (5 oz) 2 carbohydrates, 2 medium

Thin crust fat meats, 2 fats

Pot pie 1 (7 oz) 2 carbohydrates, 1 medium

fat meats, 4 fats

Frozen Entrees

Salisbury steak with gravy 1 (11 oz) 2 carbohydrates, 3 medium

fat meats, 3-4 fats

Turkey with gravy, mashed 1 (11 oz) 1 carbohydrate, 1 fat

potatoes, and dressing 2 carbohydrates

Entree with less than 300 1 (8 oz) 2 carbohydrates,

Calories 3 lean meats

94

Carbohydrate Controlled Diet

Combination Foods List

Food

Entrees Serving Size Exchanges per Serving

Soup

Bean 1 cup 1 carbohydrates,

1 very lean meat

Cream Soup 1 cup (8 oz) 1 carbohydrate, 1 fat

(made with water)

Split pea ½ cup (4 oz) 1 carbohydrate

(made with water)

Tomato 1 cup (8 oz) 1 carbohydrate

(made with water)

Vegetable beef, chicken

noodle or other broth-type 1 cup (8 oz) 1 carbohydrate

95

Carbohydrate Controlled Diet

Fast Food Entrees Serving Size Exchanges per Serving

Burritos with beef 2 4 carbohydrates, 2 medium

fat meats, 2 fats

Chicken nuggets 6 1 carbohydrate, 2 medium

fat meats, 1 fat

Chicken breast and wing, 1 each 1 carbohydrate, 4 medium

breaded and fried fat meats, 2 fats

Fish sandwich with tartar 1 3 carbohydrate, 1 medium

sauce fat meat, 3 fats

French fries, thin 20-25 2 carbohydrates, 2 fats

Hamburger, regular 1 2 carbohydrates, 2 medium

fat meat

Hamburger, large 1 2 carbohydrates, 3 medium

fat meats, 1 fat

Hot dog with bun 1 1 carbohydrate, 1 high fat

meat, 1 fat

Individual pan pizza 1 5 carbohydrates, 3 medium

fat meats, 3 fats

Soft serve cone 1 medium 2 carbohydrates, 1 fat

Submarine sandwich 1 sub (6 in) 3 carbohydrates, 1

vegetable, 2 medium fat

meats, 1 fat

Taco, hard shell 1 (6 oz) 2 carbohydrates,

2 medium fat meats, 2 fats

Taco, soft shell with meat 1 (3 oz) 1 carbohydrate, 1 medium

fat meat, 1 fat

96

Calorie Restricted Diet (Low Calorie)

I. Description

The low calorie diet is indicated when reduction in weight is desirable and

resident agrees. The diet follows the pattern for the regular diet with modification

made in total calorie content. It provides a range of 1200-1800 calories.

*See the Carbohydrate Controlled Diet Plan for “Free Foods” and “Foods for

Occasional Use” for additional suggestions

II. Approximate Composition

Calories 1200-1800 based on individual calculated needs and preferences

Protein 60-75 grams

III. Adequacy

This diet includes the basic food groups in adequate amounts but fats and

carbohydrates are limited to reduce total calories below normal requirements.

97

Limited Concentrated Sweets (LCS) Diet

I. Description

This diet closely resembles the regular diet, restricting only those foods which are

high in sugar or other concentrated sweets. It can be used for any diabetic

patient whose weight and blood sugar levels are under control. It does not

require adherence to a strict meal pattern nor does it necessarily restrict calories.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

III. Adequacy

This diet contains all nutrients necessary to provide and maintain adequate

nutrition based on the Dietary Guidelines for Americans 2010.

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Milk All types Chocolate milk,

sweetened

condensed milk

Meat and equivalent All types Glazed, honey

coated meats or

prepared with sugar

or syrup

Fruits All types Fruit canned or

frozen in syrup,

sugar or syrup

sweetened juices;

candied fruit

Vegetables All types Candied vegetables

98

Limited Concentrated Sweets (LCS) Diet

FOOD GROUPS FOODS INCLUDED FOODS EXCLUDED

Soups All types Fruit soups made

with sugar

Breads, Cereal All types Danish rolls, sweet

& Grains rolls, glazed

doughnuts, sugary

cereals

Fats All types None

Desserts* Any made with foods Regular potion size of;

allowed; small serving cake with frosting, cookies with

frosted cake(1” x 2”), ice icing, pudding, gelatin, other

cream, plain cakes and dessert items

cookies (no icing), ice milk

sherbet, sweetened limited

to 3 times per week.

Beverages All types without Beverages

added sugar sweetened with

sugar

Miscellaneous Sugar substitutes; Sugar, regular jam,

dietetic and all-fruit jelly, preserves,

jam, jelly, preserves; syrup, honey,

low calorie diet syrup molasses

cocoa powder

chocolate flavoring

herbs, spices, flavorings

salt, catsup, vinegar, pickles,

mustard, Worcestershire

sauce, soy sauce

*See the Carbohydrate Controlled Diet for the “Free Foods” and “Foods for Occasional Use”

99

Limited Concentrated Sweets (LCS)

Sample Menu Plan

Breakfast

Fruit or juice Orange juice 4 ounces

Cereal Oatmeal ½ cup

Meat or equivalent Scramble eggs 1

Bread Toast, whole wheat 1 slice

Fat Soft margarine 1 packet

Milk 2% milk 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Jelly, diet 1 packet

Sugar substitute 2 packets

Creamer as desired

Salt, Pepper 1 packet each

Lunch or Supper

Meat or equivalent Tuna salad ½ cup

Vegetable Vegetable soup 6 ounces

Salad Tossed salad 1 cup

Fat Italian dressing 1 ounce

Fat Mayonnaise 1 tablespoon

Bread Whole wheat bread 2 slices

Dessert Chilled peaches ½ cup

Milk 2% milk 8 ounces

Beverage of choice 6-8 ounces

Miscellaneous Sugar substitute 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Dinner

Meat or equivalent Baked chicken breast 3 ounces (cooked)

(without skin) (½ breast)

Potato or equivalent Mashed potato/gravy ½ cup/1 ounce

Fat Soft margarine 1 teaspoon

Milk 2% milk 8 ounces

Vegetable Seasoned carrots ½ cup

Salad Mixed fruit salad ½ cup

Bread Dinner roll, whole wheat 1

Dessert Diet vanilla ice cream ½ cup

Beverage of choice 6-8 ounces

Miscellaneous Sugar substitute 1-2 packets

Creamer as desired

Salt, Pepper 1 packet each

Evening Nourishment

Juice 4 ounces

Graham crackers 3 squares

100

Diabetic Diet (Calculated)

SUGGESTED MEAL PLANS

Suggested plans for diabetic caloric controlled diets are based on the use of medium fat

meat and skim milk exchanges.

CALORIES

1200 1500 1800

Breakfast

Milk 1 1 1

Vegetable - - -

Fruit 1 1 1

Bread 1 2 2

Meat 1 1 1

Fat 1 1 1

Lunch

Milk - - -

Vegetable 1 1 1

Fruit 1 2 2

Bread 1 2 3

Meat 2 2 2

Fat 0 1 1

Dinner

Milk - - 1

Vegetable 1 1 1

Fruit 2 2 2

Bread 1 2 2

Meat 2 2 2

Fat 0 1 1

Evening Nourishment

Milk 1 1 1

Bread 1 1 1

Total exchanges per day

Milk 2 2 3

Vegetable 2 2 2

Fruit 4 5 5

Bread 4 7 8

Meat 5 5 5

Fat 2 3 5

101

Lactose Reduced Diet

I. Description

The lactose reduced diet is used for residents who can consume a

moderate amount of lactose (milk sugar) in their daily diets without

symptoms of lactose intolerance such as gastrointestinal cramping, gas

and diarrhea. Residents who exhibit such symptoms after consuming

even a small amount of lactose, should follow a strict regimen that

eliminates all sources of lactose.

When planning the daily menu, the list of Lactose Content of Foods which

follows should be consulted to avoid exceeding the amount of lactose.

The meals should also be planned to meet the individual tolerance of each

resident.

Those residents who can tolerate milk treated with lactase, the enzyme

which reduces lactose to the monosaccharides glucose and galactose

may use it as freely as tolerated. The enzyme can be purchased and

added to the milk before use (read the label for directions). The enzyme

in tablet form can be taken orally immediately before consuming an

offending food. Milk already treated with the enzyme and ready for

consumption is available commercially. Additionally, consuming milk with

a meal improves lactose tolerance.

II. Approximate Composition

Calories 1600-2000

Protein 60-75 grams

Lactose as tolerated

Calcium and Vitamin D supplements may be indicated if milk products are

very restricted.

III. Adequacy

Based on the Dietary Guidelines for Americans 2010. This diet is

inadequate in calcium, riboflavin and vitamin D.

102

Lactose Reduced Diet

Lactose Content of Food

Foods Grams of Lactose

Milk Whole, skim, buttermilk or chocolate 9-13

Sweetened condensed (1 cup) 35

Cream Light, heavy, sour (2 tablespoons) 1-2

Yogurt 8 ounces 10-15

Butter 2 pats (10 gm) .1

Margarine - 0

Ice cream Ice milk (1 cup) 9-10

Sherbet Orange (1 cup) 4

Cheese 1 ounce

Brick, Feta, Liederkranz, Muenster 0

Provolone, Romano, Roquefort

Bleu, Brie, Cheddar, Colby, Limburger .7

Camembert, Mozzarella .1

Cottage, ½ cup

creamed 2.5-3

uncreamed 3.5-4

Cream .8

Edam, Neufchatel .3

Gouda .3-.6

Parmesan .9

Primost 12.2

Ricotta .4-1

Swiss 1.7

Pasteurized processed, American, .4-1.7

Swiss, Pimento

*Most commercially prepared nutritional supplements and tube feeding formulas are

lactose free. Read labels to verify the nutritional content of the products being used.

103

Kosher Diet

I. Description

The Kosher diet is based on the Biblical rules for food (dietary laws) for the Jewish religion. It may

be best to consult a Rabbi in your area for specific questions related to the diet as rules can be

very complex. For those wishing a kosher diet, one should interview the individual or a family

member to determine the extent of their observance to the diet. Some may accept foods coming

from a non-kosher kitchen, while others may not. The Kosher diet may also be an acceptable diet

for those practicing the Muslim religion.

The Kosher Diet rules pertain mainly to the selection, slaughter and preparation of meats. All

animals and fowl must be inspected for disease and must be slaughtered according to specific

rules. Blood is forbidden for consumption. The koshering process removes all blood before

cooking. This is achieved by soaking the meat in water, salting it thoroughly, draining and

washing it three times to remove the salt. Only the forequarter of the quadrupeds with cloven

hooves that chew cud are allowed (i.e. bison, cattle, deer, goats, sheep). The hindquarter of

quadrupeds is not allowed except when the hip sinew of the thigh vein is removed. In order to

meet the rules for a Kosher Diet, any meat must come from a kosher butcher.

Chicken, duck, goose, pheasant and turkey are allowed. Eggs may be eaten, however, eggs with

any blood in the yolk are not allowed. Fish with fins and scales, but should not be consumed with

meat. Shellfish, catfish, squid and eel are not allowed.

Milk and milk products may not be consumed with meat. Separate dishes, glasses and utensils

must be used for milk verses meat meals. A facility that does not have a kosher kitchen may

choose to use disposables for all dairy meals. Milk and or milk products may be consumed

immediately before a meat meal, but not with a meat meal. The individual must wait 6 hours after

eating meat before milk can be consumed. Eggs may be eaten with milk or meat. Foods that are

considered neutral (pareve or “parve”) may be eaten with any meal: fruits, vegetables, grains,

eggs, non-dairy beverages.

Kosher kitchen keep two completely separate kitchens to separate equipment, dishes and

silverware (one for meat and one for milk meals). Saturday is the Sabbath day (day of rest) and no

food may be cooked on the Sabbath. All foods to be eaten on the Sabbath must be cooked the

day before and held in the oven or served cold. Friday evening meal is usually large and includes

brisket and chicken.

All foods must be prepared under kosher standards and have the appropriate hechsher ( symbol

for kosher). Fresh fruits and vegetables must be free of any insects. Any prepared food mixtures

must be made under kosher standards.

Kosher certified items are fairly readily available in the US. Pre-cooked frozen kosher meals are

available, but when reheated in a non-kosher oven they must be covered with two layers of foil, or

in a non-kosher microwave, by double wrapping the food.

104

Kosher Diets follow the biblical rules for food for the Jewish Religion which pertain mainly to the

selection, slaughter and preparation of meals. Only kosher meats, fish and poultry are allowed.

All foods except of fresh fruits and vegetables must be produced under Kosher Standards and

have appropriate hechsher (symbol for kosher). These guidelines are intended for use with adults.

To meet 100% of the US RDA/AI for the majority of individuals as defined by the National

Research Council, provide adequate nutrients by following these daily guidelines to plan three

balanced meals and up to three snacks.

II. Approximate Composition

Calories 1800-2200

Protein 60-77 grams

III. Adequacy

This diet contains all nutrients necessary to provide and maintain adequate

Nutrition based on the Dietary Guidelines for Americans 2010.

Food Item

Amount Each Day

Protein Foods (fish seafood, lean meat, poultry

eggs, dried beans/peas/lentils, soy products, nuts,

etc.) Fish eggs and peanut butter are pareve. If they

are made as part of the meat meal they are

considered “meat” and cannot be consumed with

milk. If they are prepared as part of the dairy meal

they can be consumed with dairy. Do not consume

with milk.

5-6 oz or equivalent

Encourage 8 oz of cooked seafood per week

NOTE: Must wait 6 hours after eating meat

before consuming milk

Dairy (fortified with vitamins A and D) Do not

consume with meat – must wait 6 hours after eating

meat before consuming milk.

3 cups or equivalent: 1 cup is equal to 1 cup of

liquid milk or yogurt, 1 ½ oz natural cheese or 2 oz

processed cheese

Fruits (include a variety) with more whole fruit than

juice as appropriate

≥ 1 ½ cups or equivalent : ½ cup equals ½ cup

canned, juice or 1 piece fresh

Vegetables (include more dark green and leafy,

red/orange vegetables) dry beans/peas/lentils

≥ 2 cups or equivalent: ½ cup equals ½ cup

cooked/canned, juice or 1 cup raw

Grains (include as much whole grain/enriched as

possible) at least half grains should be whole

≥ 6 oz equivalent: 1 oz equals 1 slice bread, ½

bun or bagel, 1 cup cold cereal, ½ cup hot cereal,

½ cup cooked rice or pasta

Fluids (especially water)

≥ 8 (8 oz) glasses of fluid daily.

≥ 1500 Ml unless contraindicated

Solid Fats and Added Sugars (SoFAS)

Avoid added fats, saturated fats, trans fats & sugars.

Most fat should come from healthy oils

Use in limited quantities to round out the menu for

a pleasing appearance, and satisfying meals.

Alcohol in moderation and appropriate

Follow menus & recipes approved by RD, LDN

105

Kosher Symbols

O or O – Signifies that the product is

considered kosher.

Additional symbols that may be used with the

O or O :

D - Signifies that the product is acceptable

with dairy meals (it has dairy ingredients)

DE – Signifies that the product is acceptable

with milk meals (it may also be processed on

equipment that also processes dairy

ingredients

M – Signifies that the product is acceptable

with meat/poultry meals (it contains

meat/poultry or is processed on equipment

that also processes meat/poultry.

P - Signifies that the product is kosher for

Passover, but may not be Pareve (non-milk or

meat)

Hechsher symbol for Kosher

There are many kosher symbols which are specific to the certifying agency where the food is processed.

Jewish Holidays

Rosh Hashanah is the Jewish New Years which is celebrated in September.

Yom Kippur is the Day of Atonement. It occurs 10 days after Rosh Hashanah. Yom Kippur

is a day of fasting; no food or beverages of any kind may be consumed from sundown the

evening before Yom Kippur until sundown on the day of Yom Kippur. (The two exceptions

are for people who are ill and pregnant women)

Passover occurs in the spring and lasts for eight days. During this time leavened bread

and cakes is not allowed. Instead, Matzah, an unleavened bread is served. All cake and

baked goods are made from ground Matzah or potato starch, and leavened only with

whipped egg whites. Iodized salt is not allowed in the traditional Passover Matzah. Any

grain or product made from barley, corn, rice, rye or wheat is restricted during Passover, as

are dried beans, peas, and soybeans. The kitchen and all equipment are thoroughly

cleaned to remove traces of leavened bread or “chometz”. The usual pans, dishes, plates,

and silverware cannot be used for Passover food. Different pans, dishes, cups and

silverware are used especially for, and only for Passover. All foods, except fresh fruits and

vegetables (including beverages), must be certified “kosher for Passover”.

Purim is a spring celebration. A traditional triangle shaped, filled cookie called

Hamentashen is served.

Succot is a fall harvest holiday.

Chanukah is the Festival of Lights which is celebrated for 8 days in mid winter. Foods

traditionally served are fried in oil i.e., latkes (potato pancakes) and sufganiot (doughnuts).

106

Foods Allowed

Foods to Avoid

Protein Foods (Low fat as appropriate)

Kosher beef, lamb, mutton, veal, goat, or deer meat.

Kosher chicken, duck, goose, pheasant or turkey.

Kosher Frankfurters, deli meats.

Fish with fins and scales: bluefish, cod, haddock

hake, halibut, salmon, scrod, swordfish, tuna.

Eggs from domestic fowl

Any non-kosher meat or poultry.

Pork (bacon, ham, Canadian bacon, sausage)

Rabbit

Regular Frankfurters, deli meat.

Shellfish (clams, crab, lobster, mussels, oysters,

shrimp), eel, frog, octopus, shark, (Note: Fish should not

be consumed with meat. Milk may be consumed

immediately before a meat meal but not with a meat

meal. One must wait 6 hours after consuming meat to

drink milk.

Dairy (Low fat as appropriate)

Kosher cheese (May not be served with meat) and

other milk products

All dairy when meat is served.

Non-kosher cheese, cheese served with meat.

Note: Meat may not be served with milk and milk

products. Milk may be consumed immediately before a

meat meal but not with a meat meal. One must wait 6

hours after consuming meat to drink milk.

Fruits

All canned and frozen fruits identified as Kosher

Any canned or frozen fruits which are not identified as

Kosher.

Vegetables (Low fat as appropriate)

All fresh Kosher canned or frozen.

Non-kosher vegetable products (canned or frozen)

No sauces containing dairy are allowed when meat is

served.

Grains (Low fat as appropriate)

Bakery items prepared under kosher standards. (If it

contains dairy, may not be eaten with meat).

Any bakery items that are not prepared by kosher

standards (or containing animal fat such as lard).

Fluids

All except those listed under foods to avoid

Non-kosher canned or frozen vegetable juices

Solid Fats and Added Sugars (SoFAS), Alcohol

and Miscellaneous

Kosher alcohol, beer or wine.

Beverages made from crystal powders, carbonated

beverages, coffee, tea.

Any prepared food mixtures prepared under kosher

standards (desserts, soups, etc)

Pudding, ice cream or sherbet with dairy meals only.

Kosher candy, chocolate, jam, jelly, honey, pepper,

salt, sugar, sugar substitutes.

Animal fats (bacon grease or lard)

Dark Beer

Non-kosher desserts, soups

Gelatin or products made with gelatin, unless identified

as Kosher by the hechsher (symbol for Kosher)

Marshmallows

Non-kosher candy, grape jam, jelly.

Beverages that are not identified as Kosher.

107

Kosher Diet

Sample Daily Meal Plan for a Well Balanced Diet

Breakfast

Lunch

Dinner

½ c Orange Juice

½ c Oatmeal

¼ c Scrambled Eggs

1 slice Whole Wheat

Toast

1 tbsp Jelly or Fruit

Spread

1 tsp Margarine*

1 c Low Fat Milk and /or

Yogurt

Condiments as Desired+

Beverage of Choice

3 oz Kosher Roast Beef

½ c Seasoned Rice

½ c Seasoned Peas

w/Mushrooms

1 c. Green Salad Dressing

1 Whole Wheat Roll

½ c Fruit Sorbet with

¼ cup Strawberries

No Milk

Condiments as Desired+

Beverage of Choice

6 oz Vegetable Soup

2 oz Baked Fish

½ c Mashed Potato

½ c Green Beans

1 Slice Bread

1 Baked Apple

1 c Low Fat Milk (6 hours later

than lunch)

Condiments as Desired+

Beverage of Choice

P.M. Snack

2 Kosher Cookies

1 c Milk

Bold/ italicized items indicate differences from a Regular Diet menu

*Low in Trans fats

+May include pepper or other spices, sugars, sugar substitute, salt, coffee creamer, etc. based on

nutrition goals

Recommended Nutritional Composition

Calories

1800 - 2200

Fluids based on individual needs

Carbohydrates

45 – 65% of Calories

Sodium 2300 mg (higher with

processed/convenience foods and added salt)

Protein

10 – 35% of Calories

Calcium ≥ 1000 – 1200 mg

Vitamin D 600 – 800 IU

Fat

20 – 35% of Calories

<10% from sat. fat

<300 mg cholesterol

Vitamin C 90 mg

Nutrients may vary day to day, but should average to the above estimates

108

Enteral Nutrition

I. Description

Feeding tubes may be used to deliver enteral formulas to residents who are

unable to meet nutritional requirements with oral intake and who have a

functioning gastrointestinal tract. A tube may be passed through the nasal

passage to the stomach (nasogastric) or on into the small intestine

(nasoduodenal or nasojejunostomy). Or a tube may be placed through a stoma

(opening) in the abdomen, directly into the stomach (gastrostomy) or small

intestine (jejunostomy). Careful consideration should be taken to ensure the

residents wishes are honored prior to inserting a feeding tube.

A variety of formulas are available to meet the specific needs of each resident.

When choosing a formula, it is important to take into account the resident’s

specific nutritional needs, clinical condition, and the route of administration.

Standard enteral formulas provide 1-1.2 Kcal/ml. Concentrated solutions

(1.5-2.0 kcal/ml) are appropriate for residents on a fluid restriction or who have

high caloric needs. Semi-elemental formulas, containing protein in a mixture of

elemental amino acids and dipeptides are recommended for residents who have

malabsorption disorders or are unable to tolerate other formulas. Fiber-containing

formulas are used to assist with bowel regulation. .

Periodically flushing the tubing helps to maintain its patency. Fluids

recommended for flushing include water, normal saline and half-normal saline.

Fluids such as cola beverages and cranberry juice are not recommended as

rinsing agents; the dried residues can further narrow the lumen of the tube and

contribute to clogging.

All feedings must be monitored for tolerance and the volume of enteral formula

administered should be recorded. The enteral feeding schedule should take into

account planned downtime to ensure the total daily volume is delivered.

The physician is responsible for ordering enteral access placement and the tube

feeding regimen. The order should include:

1. Name of the product

2. Total daily volume to be delivered

3. Route of administration

4. Method of administration

5. Strength of solution, and if not full-strength the order must include a planned

schedule to increase to full strength

6. Intermittent Feeding: number of feedings per day with amount (in ml) of

formula for each feeding.

109

Enteral Nutrition

7. Continuous Feedings: hourly rate (in ml) of formula and the number of hours

per day, start time and end time for the feeding

8. Flushes: volume and number of times the tubing is to be flushed, and the

content of the flushes

9. Amount of water to be used with medications

10. Total calories to be delivered per day

II. Composition

The nutritional content of the tube feeding will depend upon the amount and type

of formula used.

III. Adequacy

A variety of commercial tube feeding formulas are available to meet specific

needs of each resident. Care should be taken to note the volume specified by

the manufacturer to achieve 100 percent of the Recommended Dietary

Allowances for vitamins and minerals. If a lesser volume is to be delivered, a

vitamin/mineral supplement (preferably liquid) should be given daily. If the

formula falls short of macronutrient requirements (e.g. protein, carbohydrate or

fat), modular products are available that can be added to the formula to meet the

estimated daily needs.

A thorough nutritional assessment of the individual should be conducted prior to

determining the desired formula, rate and strength. In addition to determining

daily protein, calorie and fluid needs, the assessment should consider specific

micronutrient needs that may be higher for that individual (e.g. iron, calcium,

etc.). Calculation of the final content of the tube feeding should include a free-

water calculation, and additional flushes ordered to meet the individual’s fluid

needs.

Tube feeding products are classified in a number different ways including:

isotonic, elemental, semi-elemental and intact protein containing formulas, high

calorie, high protein, fiber added, specialty formulas, etc. Manufacturers provide

product handbooks for complete information on each formula. Information on

many formulas is also available online.

110

Enteral Nutrition

IV. Methods of Administration

Enteral feedings may be given in a variety of ways.

Continuous Feeding

Continuous feedings are administered at a constant rate over a 16-24 hour

period using a gravity flow set or a feeding pump to control the flow of the

formula. A feeding pump should be used for feeding into the duodenum or

jejunum as the small bowel is unable to tolerate larger volumes and sudden

rate changes. Continuous feeding is associated with lower residual

volumes and reduced risk of aspiration.

Cyclic Feeding

Cyclic feedings are delivered continuously, but at an increased rate over

8-16 hours, often overnight, using a pump. This method favors increased

oral intake during the day for individuals receiving a tube feeding as a

supplemental nutrient source. It also provides greater mobility to the

individual during the day and is a good method to use when transitioning

residents from enteral feeding to an oral diet.

Intermittent Feedings

Intermittent feedings can be given at specific intervals during the day, often

patterned after a normal meal schedule, and are given by gravity drip or

feeding pump over 30-120 minute period. This method is useful for

residents in rehabilitation.

Bolus Feedings

Bolus feedings are usually given in less than 15 minutes via a syringe, or

feeding bag. The feeding should be initiated as no more than 120 mL of

isotonic formula every 4 hours, advancing by 60 ml every 8-1 hours as

tolerated. Bolus feedings should not exceed 400-500 mL per feeding.

The web sites are:

Ross Labs http://www.ross.com/

Nestle http://www.nestle.com/

111

Parenteral Nutrition

Parenteral nutrition (PN) is a means of providing intravenous protein, carbohydrate,

fat, vitamins, and mineral to those who are unable to be adequately fed via the

gastrointestinal (GI) tract.

When PN provides for all of the macronutrient needs of the resident, it is referred to as

total parenteral nutrition (TPN) and must be provided via a central venous catheter or

a peripherally inserted central catheter (PICC). Indications for TPN include: GI

fistulas, severe pancreatitis, severe catabolism/malnutrition with inability to feed less

than or equal to 5 days, intractable vomiting, short bowel syndrome, inflammatory

bowel disease with need for bowel rest, and major surgery with inability to feed within

7-10 days post-surgery.

TPN should only be used when other means of nutrition support are unavailable, as it

presents a significant risk to the patient. Common complications include:

hyperglycemia, catheter-related sepsis, and electrolyte imbalances.

When PN is provided via a peripheral vein, it is referred to as peripheral parenternal

nutrition (PPN). The primary purpose of PPN is to provide sufficient macronutrients to

meet the needs of glycolysis, and spare protein stores. It is generally used for

residents with a short-term (less than or equal to 5 days) inability to utilize the GI tract.

It is not adequate for residents with severe malnutrition.

Nutrient content of PN components

Lipid: Carbohydrate: Protein:

20% lipid = 2 kcal/ml D50=50% dextrose Protein=% (amino acid) aa s

10% lipid = 1.1 kcal/ml D25=25% dextrose, etc. 1 gm protein = 4 Kcal

1 gm dextrose = 3.4 Kcal

Calculation of TPN Solutions

The TPN solution may be calculated according to the initial volumes of each of its

components. Calculations are given per liter of solution, and are then multiplied by the

total volume delivered.

For example: a solution containing 400 ml D50, 500 ml 10% aa and 200 ml 20%lipid

is calculated as follows:

Dextrose = 400 ml D50 = 400 x 0.5 (% dextrose) = 200 gms

Kcal from dextrose = 200 gms x 3.4 kcal/gm = 680 kcal per liter of solution.

Protein = 500 ml of 10% amino acids = 500 x 0.1 (% a.a.) = 50 gms

Kcal from protein = 50 gms x 4 kcal/gm = 200 kcal per liter of solution.

Lipid = 200 ml of 20% lipid = 200 x 2 kcal/ml = 400 kcal per liter of solution.

112

Parenteral Nutrition

TOTALS PER LITER

Total kcal per liter = 1280 kcal

Total gms protein/liter = 50 gms

Total gms dextrose/liter = 200 gms

If this solution is given continuously over 24 hours, at a rate of 80 ml/hour, the total

volume given will equal 1920 ml. The total amounts for each component must be

multiplied by 1.92, giving the following results:

Total Kcal = 1280 kcal x 1.92 = 2,458 kcal

Total protein = 50 gms x 1.92 = 96 gms

Total dextrose = 200 gms x 1.92 = 384 gms

Grams of dextrose in any solution should be within the recommended range for the

resident’s maximum glucose utilization rate which is calculated using the resident’s

body weight in grams as follows: 4.3-7.2 gms dextrose/kg body weight/day.

Lipid content should not exceed the maximum recommended rate, which is calculated

as follows: 1.5 gms lipid/kg body weight/day.

Protein content should not exceed 25% of total kcal, which can also be calculated as

follows: 1.5-2 gm protein/kg body wt/day.

If calcium and phosphorus are added to the solution the sum of the calcium

concentration in mEq/L and the phosphate concentration in mMol/L should not exceed

30. This calculation is important to assure a safe administration of the solution; calcium

and phosphate ions, if excessive, may form a crystalline precipitate in the solution.

Electrolytes and other additives should be carefully managed according to the specific

need of the resident receiving the parenteral nutrition.

Calculation of PPN Solutions

Calculation for components of the PPN solution are similar to that of TPN, however PPN

is subject to restrictions that limit the amount of nutrients that can be delivered to the

resident. Its primary benefit is to provide enough kcal to prevent catabolism of lean

body mass.

113

Parenteral Nutrition

Since the solution will be administered via a peripheral vein, it must not exceed

900 mOsm/L. Concentrations above this level dramatically increase the risk of

phlebitis. Thus lipid becomes the primary source of Kcal for a PPN solution

(40-60% of total Kcal). Dextrose is provided in concentrations of 5-10%. The

following table provides helpful information for calculating PN solutions:

Component Kcal/L mOsm/L gms/L

10% dextrose 340 504 100

20% dextrose 680 1008 200

5.5% aa 220 575 55

8.5% aa 340 890 85

10% lipids 1100 260 100

20% lipids 2000 260 200

Electrolytes --- 235 ---

114

GLUTEN-FREE DIET

I. Description

The Gluten-free diet is a modification of the regular diet. This diet is designed for

residents with celiac disease (CD). The diet should be individualized based on the

residents needs. Celiac disease is also sometimes referred to as nontropical sprue,

celiac sprue, or gluten-sensitive enteropathy. Celiac disease is an autoimmune

genetic disorder in which the villi in the duodenum and small intestine are damaged

in response to the ingestion of gluten.

Gluten is a storage protein (prolamins) found in all forms of wheat. Strict avoidance

of any gluten-containing item is necessary to prevent reoccurrence of symptoms,

i.e. bloating, diarrhea, and nausea. Careful review of food items including

medications, toothpastes, mouthwashes, lip sticks, communion wafer, as additives,

preservatives and stabilizers may contain gluten.

Malabsorption of fat, fat-soluble vitamins, folate, B12, and iron may occur.

Supplemental vitamins and minerals should be considered in these cases. In

addition, lactose intolerance is common in these cases until the diet is well

controlled.

Note: This is not a complete list. Always read food labels. If in doubt, check with the

manufacturer.

115

GLUTEN-FREE DIET

Food Products FOODS INCLUDED Foods in Question FOODS EXCLUDED

Milk Products milk, buttermilk, Flavored yogurt, Malted Milk

plain yogurt, sour cream,

cheese, cream frozen yogurt

cheese, cottage

cheese

Bread, Cereal Bread or baked Rice crackers, Bread and baked

& Grains products made rice cakes, containing wheat, rye,

from corn, rice commercial barley, oat bran, bulgur,

arrowroot breads spelt wheat –based

cornstarch soy, semolina, rye, oats,

amaranth potato couscous, triticale, graham

flour, sago, potato flour, semolina wheat

starch, tapioca, flour, durum flour, filler

whole-bean flour, Kamut, imported foods

flax, arrowroot, rice labeled Gluten-free

bran, buckwheat, einkorn, seitan, emmer, bromated

millet , teff, cornmeal flour, farina, orzo, phosphate

cornmeal, pea flour, flour, plain flour, white flour,

corn tacos, corn self-rising flour

tortillas, cassava,

garfava, nut flours

Cereals cream of rice, soy Flour or Cereals with wheat, rye,

cereal, hominy, cereal products oats, triticale, barley,

hominy grits, brown, cereals made with added

white and wild malt extract and extract

rice, cornmeal, and malt flavorings

quinoa flakes, caramel color

buckwheat groats,

puffed rice, puffed corn

Pastas Macaroni, spaghetti pastas made from wheat,

and noodles from wheat starch, modified food starch

rice, quinoa, corn, and other ingredients not allowed.

soy, potato, peas,

beans, or other

allowed flours.

116

Food Products FOODS INCLUDED Foods in Question FOODS EXCLUDED

Meats & Alternatives

Meat, fish & Fresh, frozen, Prepared or Fish canned in vegetable

Poultry canned, salted preserved meats broth containing (HVP)

and smoked such as ham, hydrolyzed vegetable & wheat

luncheon meat, protein or (HPP)

bacon pate, hydrolyzed plant protein,

sausages, meat turkey basted or injected

and sandwich with HVP/HPP

spreads, meat

product extenders,

hot dogs, salami,

sausage

Eggs Eggs Egg substitutes, Imitation bacon

dried eggs and Imitation seafood

egg whites

Others Lentils, chickpeas Baked beans, dry

beans, nuts, tofu, roasted nuts,

seeds, peas, peanut butter

legumes, sorghum communion wafers

Fruits Fresh, frozen Dried fruits, fruit

canned fruits and pie filling

fruit juices

Vegetables Fresh, frozen French fried Batter dipped vegetables

or canned veg., potatoes

yucca

Soup homemade broth, Canned soups, Soups made with

gluten-free bouillon, dried soup mixes, ingredients not allowed.

cream soups and soup base, and Bouillon containing HPP

stocks made from bouillon cubes or HVP

allowed ingredients.

Fats butter, lard, cream, Salad dressing, Packaged suet

shortening, some mayonnaise prepared marinades

margarine,

homemade dressing

from allowed

ingredients

117

Food Products FOODS INCLUDED Foods in Question FOODS EXCLUDED

Desserts and ice cream, sherbet, Milk puddings, Ice cream with not

Sweets ice whipped custard mixes, allowed ingredients.

toppings, egg pudding mixes ice cream cones; cakes

custard, gelatin, icing, powdered cookies, pastries made

cakes, cookies sugar spreads, with not allowed

pastries made candies, chewing ingredients.

with ingredients gum, lemon Licorice, candies with

allowed honey, lemon curd, not allowed ingredients.

jam, jelly, sugar marshmallow.

Snack Foods Plain popcorn Dry roasted nuts, Pizza, unless made

and nuts. flavored potato with allowed ingredients

chips, tortilla chips

Energy bars

Condiments plain pickles, olives Worcestershire Soy sauce, mustard

relish, ketchup, sauce, mixed pickles, imitation pepper,

mustard, vinegars, spices (i.e. curry malt vinegar

pure black pepper, powder, chili

pure spices and powder)

herbs, tomato

paste, Gluten free

soy sauce,

modified food

starch from

tapioca, corn potato

Other sauces and gravies Baking powder, Sauces and gravies

made with allowed beer made with not allowed

ingredients pure ingredients, oat gum.

cocoa, chocolate

chips, MSG, cream

of Tartar, coconut,

aspartame, baking

soda, carob chips

and powder, yeast,

brewer’s yeast, distilled

alcoholic beverages,

Indian rice grass,

Job’s tears.

118

GLUTEN-FREE SUBSTITUTIONS

Substitution for 1 Tablespoon of Wheat flour.**

½ tablespoon Cornstarch

½ tablespoon Potato starch of flour

½ tablespoon White rice flour

½ tablespoon Arrowroot starch

2 teaspoon Quick-cooking tapioca or Tapioca starch

2 tablespoon Uncooked rice

Substitution of 1 cup wheat flour:

Mix together 2 cups brown rice flour, 2 cups sweet rice flour and 2 cups rice polish.

Store in an airtight container and use 7/8 cup of the mixture in place of 1 cup of wheat

flour.

**A combination of flours/starches produces a better gluten-free product.

Resource Organizations

Celiac Disease Foundation Gluten Intolerance Group of North American

13251 Ventura Blvd., Suite 3 15110 10 Avenue SW, Suite A

Studio City, CA 91604 Seattle, WA 98166-1820

818-990-2354 206-246-6652

www.gluten.net

National Institutes of Health

http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/ www.csaceliac.org

877-csa-4csa

Center for Celiac Research, University of Maryland, School of Medicine

www.celiaccenter.org

www.celiac.com

www.celiachealth.org

1. The American Dietetic Association Manual of Clinical Dietetics, 2002 edition.

2. Miletic ID. Miletic VD. Sasttely-Miller, EA, et al. Identification of gliadin presence in

pharmaceutical products. J Pediatr Gastroenterol Nutr. 1994; 19: 27-33

3. Murray, JA. The widening spectrum of celiac disease. Am J Clin Nutr. 1999; 69:

354-365.

4. Case, Shelly-Gluten free diet: a comprehensive resources guide 2004.

119

FINGER FOOD DIET

Suggested Menu Ideas

PURPOSE To provide adequate nutrition while promoting independence in

eating for individuals with dementia-related diseases, such as

Alzheimer’s cognitive impairments, or other neuromuscular

disorders.

CHARACTERISTICS A regular diet consistency which can be easily eaten with the

fingers and not requiring silverware. It is the policy that finger

food meals will be offered to any resident identified as having

difficulty efficiently feeding themselves with utensils, possibly

leading to risk of poor nutrition.

NUTRITIONAL

ADEQUACY Depending on individual food choices, this diet is adequate in

all nutrients.

SERVING

SUGGESTIONS Use of adaptive equipment, such as plate stabilizers, plate

guards, “nosey” cups, covered or spouted cups, and cups or

mugs with large or double handles may be helpful for some

individuals.

Liquids, including soups, cold cereal in milk, or thin, cooked

cereal should be served in a mug or with a straw.

Food should be cut in bite-sized pieces, slices, wedges, or

made into sandwiches.

Baby carrots, tomato or lettuce wedges, or small pieces or

other raw vegetables or fruit are easier to eat.

Whole, fresh fruit may served if the individual can bite off

pieces.

Potatoes should be served in pieces that can be picked

up easily.

Eggs should be hard cooked (boiled, scrambled or fried).

Dry cereals should be larger pieces served without milk.

120

FINGER FOOD DIET

Suggested Menu Ideas

Peanut butter should be served on crackers or bread quarters.

Sandwiches, pancakes, waffles, toast, bread, quick breads or

cake should be cut into quarters or sliced into sticks.

Foods in sauce or those soft, slippery, crumbly, large or small

are hard to handle.

Pasta such as rotini, tortellini, or novelty shapes are

recommended because they are thicker and easier to pick up.

Do not overcook or serve in sauce.

Gravies, sauces, salad dressings or syrup are served in cups

so foods can be dipped.

121

FINGER FOOD DIET

Suggested Menu Ideas

Bread, Cereal

& Grains

Toast (whole wheat, rye, white) brushed with margarine

Crackers (variety)

Bread Sticks

Rolls

French Toast Strips brushed with margarine

Waffles/Pancake Strips brushed with margarine

Plain cold cereals (enriched with vitamins and minerals)

Cereal/Breakfast Bars (Granola/NutriGrain)

Muffins

Pita Bread

Potatoes

Cubes, slices, wedges

Tater Tots

French Fries

Potato Chips

Sweet Potatoes (slices or patties)

Potato Triangles

Fruits

Sliced, diced, fresh, frozen, canned, or dried

Vegetables

Salads (may be portioned into pocket pita)

Baby Carrots

Green Beans

Vegetable Strips

Meat/Meat Substitutes

Hard Boiled Eggs, Deviled Eggs

Chicken, Beef, Turkey, Pork Strips

Chicken Nuggets

Fish Nuggets (Cod, Catfish, Halibut)

Sausage Link

122

FINGER FOOD DIET

Suggested Menu Ideas

Dairy Products

Cheese Cubes, Cheese Sticks (variety)

Yogurt/Jello Cubes

Combination Meal

Sandwich sliced into strips or cut in half and placed on each side of plate

Scrambled Egg in Pita Pocket

Egg Sandwich

Casseroles and Stews (may be portioned in a pita pocket)

Desserts

Jello Jigglers

Ice Cream Bars

Ice Cream Sandwiches

Cookies/Cookie Bar (Fortified, if possible)

Cake Squares

Non-finger foods with service/presentation modification

Casseroles served in cereal bowls with soup spoon utensil

Short pasta noodles to replace spaghetti (elbow macaroni, orzo, ziti)

served in cereal bowls

Soup served in mugs

123

Thickened Liquids

Nectar-like thickened liquids – able to go through straw, glides off a spoon e.g. fruit

nectars, shakes, eggnogs.

Honey-like thickened liquids will not go through a straw and will flow slowly off a spoon.

Pudding (spoon thick) – need to be fed with a spoon, of a pudding consistency.

Residents ordered thickened liquids should not be given foods that become liquid at

room temperature e.g. gelatin, ice cream, sherbet, water ices.

Follow directions on thickener to achieve desired consistency.

Suggested sites for additional information on thickened liquids and puree foods –

www.darlingtonfarms.com/caringcuisine puree bread and cornbread mix

www.simplythick.com – instant thickener for beverages

National Dysphagia Diet: Standardization for Optimal Care by American Dietetic Association

124

Estimated Caloric Needs – Method I

The following methods for estimating total daily caloric needs may be used as

guidelines when assessing the resident’s needs. The dietitian must observe for signs of

caloric excess or deficiency and make adjustment(s) as needed. In these equations,

use the metabolically active weight (MAW) for the obese resident, i.e., 20 percent and

25 percent above ideal body weight (IBW) for women and men respectively. For the

resident who is 10 percent or more under ideal body weight, use the ideal body weight.

If actual body weight is used in the Harris-Benedict Equation for a resident that is

underweight or has experienced significant weight loss, 500 additional calories should

be added to the injury and activity factor to promote weight gain. There may be other

accepted formulas that are not listed.

Method I This method, based on height, weight, gender and age, can be used for

any adult or adolescent.

Step 1. Using the Harris-Benedict Equations, calculate the basal

energy expenditure (BEE) in calories.

Male BEE = 66 + (13.7 x wt. (kg))

+ (5 x ht. (cm))

- (6.8 x age)Y

Female BEE =655 + (9.6 x wt. (kg.))

+ (1.8 x ht. (cm))

- (4.7 x age)

Step 2. To calculate the estimated total daily calories (ETDC)

needed, multiply the BEE times the activity factor (AF)

times the injury factor (IF).

ETDC = (BEE) x (AF) x (IF)

This information was adapted from:

http://dukehealth1.org/obesity/tpn_orders.asp

http://www.findarticles.com/p/articles/mi_qa3977/is_200101/ai_n8929946

Pocket Resource for Nutrition Assessment, DHCC, 2013.

125

Estimating Kilocalorie Needs Based on Activity and Injury Factor

Activity Factors (AF):

Bedridden 1.1

Sedentary (no independent movement) 1.2

Active (walks, wheels own wheelchair) 1.3

Seated work, little movement, little leisure activity 1.4 – 1.5

Standing work 1.6 – 1.7

Strenuous work or highly active leisure activity 1.8 – 1.9

30 – 60 minutes strenuous leisure activity

4 – 5 times per week

Injury (Stress) Factor (IF):

None 1.0

Recent minor surgery 1.1

Recent major surgery 1.2

Wound healing * 1.2 - 1.6

Burns (% total body surface):

0 – 20 1.00 – 1.50

20 – 40 1.50 – 1.85

40 – 100 1.85 – 2.05

Cancer 1.2 – 1.45

Mild infection/ Stage II pressure sore 1.2

Moderate infection/ Stage III pressure sore 1.3 – 1.4

Severe infection/ Stage IV pressure sore 1.8

Pulmonary disease 1.3

Recent long bone fracture 1.3

Fever (for every degree fever above normal +7%

for every 1 degree increase in temperature) 1.7

Multiple trauma with patient on ventilator 1.50 – 1.25

Peritonitis 1.4

Sepsis 1.2 – 1.4

Severe infection/multiple trauma 1.3 – 1.55

Trauma with steroids 1.60 – 1.70

*The dietitian will determine the adjustments required based on the number and severity of decubiti.

126

Estimated Caloric Needs – Method II

This method of estimating caloric needs addressed only physically healthy persons who

are sedentary and moderately active. It is based on body weight, regardless of height,

age and gender. It does not allow for injury or stress situations. Physically healthy

elderly sedentary residents may require fewer calories for maintenance than used here.

CALORIC LEVELS

Weight Goals Sedentary Moderate Activity

Weight Maintenance 30 cal/kg 35 cal/kg

Weight gain 35 cal/kg 40 cal/kg

Weight loss 20-25 cal/kg 30 cal/kg

__________

The above was compiled from:

1. Pocket Resource for Nutrition Assessment. DHCC, 2013.

127

Estimated Protein Needs

Protein Factors: grams protein /kg body weight

0.8 – 1.0 Average adult (non-stressed)

1.2-1.5 Draining wounds, fracture, or recent major surgery

1.0-1.1 Stage I pressure sore

1.2 Stage II pressure sore

1.3-1.4 Stage III pressure sore

1.5-1.6 Stage IV pressure sore

*Increase fluids & monitor renal function

1.0-1.2 Mildly depleted serum albumin (3.5 – 3.2 mg/dl)

1.2-1.5 Moderately depleted serum albumin (3.2-2.8 mg/dl)

1.5-2.0 Severely depleted serum albumin (<2.8)

Cast Weights:

½ leg 2-4 #

Long leg 4-6 #

Arm 2-3 #

Short arm 1-2 #

Immobilizer 1-2 #

Adjustment in weight for paralysis

Paraplegia 5% - 10% decrease in IBW

Quadriplegia 10% - 15% decrease in IBW

Adjustment of IBW for Amputations

Foot 1.8% \Below knee 6.0%\At knee 9.0%\Above knee 15%\Whole leg 18.5%\

Hand 8%\Forearm & hand 3.1%\Whole arm & Hand 6.5%

Estimated Protein Needs

For the obese resident, i.e., 20 percent and 25 percent above ideal body weight (IBW)

for women and men respectively, use the adjusted body weight found elsewhere in the

appendix. For the resident who is 10 percent or more below ideal body weight, use the

ideal body weight.

Clinical judgment should be utilized when calculating protein needs. The rationale

should be documented in the medical record.

http://www.nutriciame-clinicalnutrition.com/whatecn.htm

128

Protein Needs

Protein needs may vary depending on a number of factors, including but not limited to;

Renal status

Hepatic function

Presence of metabolic stress (i.e. pressure ulcer or wound, infection, etc.)

Undernutrition or protein-energy malnutrition (PEM)

Presence of hepatic (liver) disease

Comprehensive nutrition assessment is needed to determine the appropriate level of protein.

Diseases and Conditions

Protein Needs

Critical illness including burns, sepsis,

traumatic brain injury

1.5-2.0 gm/kg/day

GI Issues

Inflammatory bowel disease

Short bowel syndrome

1.0-1.5 gm/kg/day

1.0-1.2 gm/kg/day

Hepatic disease

Hepatitis

Cirrhosis

1.0-1.5 gm/kg/day

1.0-1.2 gm/kg/day

Obesity, with hypocaloric feeding:

BMI>27, normal function of kidneys, liver

Class I or II obesity with trauma (ICU)

Class III obesity with trauma (ICU)

1.5-2.0 gm/kg/IBW/day

1.9 gm/kg/IBW/day

2.5 gm/kg/IBW/day

Pulmonary Disease

1.2-1.5 gm/kg/day

Renal Disease

Predialysis

Hemodialysis

Peritoneal dialysis

Continuous renal replacement therapy

(CRRT

See Renal/Chronic Kidney Disease section of

this manual for more detail information

0.6-0.8 gm/kg/day

1.2-1.3 g/kg,up to 1.5-1.8 gm/kg/day

>1.5-2.5 gm/kg/IBW/day

Stroke

1.0-1.25 gm/kg/day

129

Miffin - St. Jeor Equation (MSJ) Cheat Sheet

Weight Height Age

Pounds kg MSJ* Feet Inches cm MSJ* Years MSJ*

85 38.64 386.36 4’9” 57 144.78 904.88 70 350

90 40.91 409.09 4’10’ 58 147.32 920.75 72 360

95 43.18 431.82 4’11” 59 149.86 936.63 74 370

100 45.45 454.55 5’ 60 152.4 952.50 76 380

105 47.73 477.27 5’ 1” 61 154.94 968.38 78 390

110 50.00 500.00 5’ 2” 62 157.48 984.25 80 400

115 52.27 522.73 5’ 3” 63 160.02 1000.13 82 405

120 54.55 545.45 5’ 4” 64 162.56 1016.00 83 410

125 56.82 568.18 5’ 5” 65 165.1 1031.88 84 415

130 59.09 590.91 5’ 6” 66 167.64 1047.75 85 420

135 61.36 613.64 5’ 7” 67 170.18 1063.63 86 425

140 63.64 636.36 5’ 8” 68 172.72 1079.50 87 430

145 65.91 659.09 5’ 9” 69 175.26 1095.38 88 435

150 68.18 681.82 5’ 10” 70 177.8 1111.25 89 440

155 70.45 704.55 5’ 11” 71 180.34 1127.13 90 445

160 72.73 727.27 6’ 72 182.88 1143.00 91 450

165 75.00 750.00 6’ 1” 73 185.42 1158.88 92 455

170 77.27 772.73 6’ 2” 74 187.96 1174.75 93 460

175 79.55 795.45 6’ 3” 75 190.5 1190.63 94 465

180 81.82 818.18 95 470

185 84.09 840.91 96 475

190 86.36 863.64 REE for Males: 97 480

195 88.64 886.36 * (MSJ weight + MSJ Height - MSJ 98 485

200 90.91 909.09 age) + 5 99 490

205 93.18 932.82 * REE for Females: 100 495

210 95.45 954.55 (MSJ weight + MSJ Height - MSJ 101 500

215 97.73 977.27 age) - 161 102 510

220 100.00 1000.00 103 515

225 102.27 1022.73 * Always use actual body weight

* Activity factor: 1.20 confined to bed

* Activity factor: 1.30 out of bed / Ambulatory

*Disclaimer – Use discretion when using this formula for resident’s that are

severely underweight and severely overweight.

Note: According to the American Dietetic Association (ADA) Evidence Analysis Library,

if it is not possible to measure RMR, then the Mifflin-St Jeor equation using actual

weight is the most accurate for estimating RMR for overweight and obese individuals

when BMI is >30.

Male REE = 9.99(wt kg) + 6.25 (ht cm) - (4.92xage) + 5

Female REE = 9.99(wt kg) + 6.25 (ht cm) – (4.92xage) - 161

130

Estimated Fluid Needs

Water requirements is adults range from 1500 to 2000 milliliters (ml) per day with

additional needs ranging from 500 to 1500 ml/day if the resident has a fever, fistular

draining, wounds, vomiting, diarrhea or excessive perspiration. Also, consider additional

fluid is needed when a resident is utilizing an air fluidized bed. Consider water restriction

for adults with congestive heart failure, renal failure, cardiac cachexia or hyponatremia.

Total daily fluid requirements for residents not needing fluid restriction can be estimated

using the following methods:

Method I This method is based on energy intake in calories regardless of age and

weight. This method may be used for residents receiving tube feedings.

1 ml/kcal This calculation underestimates fluid needs in obese patients.

Method II This method is based on actual body weight in kilograms and age. This

method may be used for residents within their ideal body weight.

Age in Years cc/kg

18-54 30-35 ml/kg actual body weight

55-65 30 ml/kg actual body weight

over 60 25-30 ml/kg actual body weight

Method III This method may be used for residents who are overweight.

1500 ml for the first 20 kg + 15 ml for every kg over 20 kg

Method IV This method adjusts for extremes in body weight.

100 ml fluid per kg for the first 10 kg actual body weight

50 ml fluid per kg for the next 10 kg actual body weight

15 ml fluid per kg for the remaining kg actual body weight

*Clinical judgment needs to be utilized when selecting formula to use. The rationale should be

documented in the medical record.

__________

This above information was adapted from:

Zeman, F. Clinical Nutrition and Dietetics. 2

nd

edition, New York: MacMillan Publishing

Company, 1991.

Pocket Resource for Nutrition Assessment. DHCC,2013.

Chidester J.C., Spangler, A.A. “Fluid intake in the institutionalized elderly.” J Am Diet

Association. 1997.

131

Estimated Fluid Needs

Clinical assessment for estimating fluid needs: Comparison of intake and output,

urine volume and concentration, skin and tongue turgor, dry mucous membranes, body

weight, thirst, tearing and salivation, appearance and temperature of skin, edema,

temperature, pulse and respiration, blood pressure, neck vein filling, hand vein filing and

facial appearance.

Clinical signs of fluid and electrolyte imbalances:

Water deficiency: Loss of skin turgor, dry mucous membranes, increased temperature

and pulse, delirium and coma, concentrated urine and thirst. Water excess: Pulmonary

and peripheral edema, abdominal and skeletal muscular twitching and cramps, stupor,

coma or convulsions.

The above information was adapted from:

Grant, A., DeHoog, S.: Nutritional Assessment and Support. 4

th

edition, Washington:

Northgate Station, 1991.

Serum Osmolality

Osmolality measures the concentration of particles in solution. Osmolality increases

with dehydration (loss of water without loss of solutes) and decreases with over

hydration.

Greater than normal levels may indicate: Dehydration, Diabetes Insipidus,

Hyperglycemia, Hypernatremia, Uremia.

Lower than normal levels may indicate: Hyponatremia, Over hydration, inappropriate

ADH secretion.

Serum Osmolality = (2x(Na + K)) + (BUN/2.8) +(glucose/18)

(An online calculator of serum osmolality is available at

www.intmed.mcw.edu/clincalc/osmol.html)

Normal range is 285-295 mOsm/kg.

132

Estimated Height (Stature)

Height may be obtained by vertical measurement of the resident standing erect or by

measuring the length of a bedfast resident. Either of these figures may be inaccurate

due to obesity, shortening with age, and deformities caused by vertebral collapse,

arthritis, kyphosis, scoliosis, osteoporosis, contractures, and pulmonary disease, all of

which affect trunk length but not limb length. For all adult residents, true stature may be

estimated from limb length.

Method I Arm Span Measurement

In adults, a rough estimate (within approximately 10%) of height can be

obtained by measuring arm span. The arm span measurement is

obtained by fully extending the upper extremities, including the hands,

parallel to the floor. The distance between the tip of the middle finger on

one hand to the tip of the middle finger on the other hand is measured,

providing the arm span, or an estimate height.

If necessary, one arm can be used. With the resident’s arm (either) and

hand stretched out straight perpendicular to the side, measure the

distance from the sternal notch (mid sternum) to the tip of the middle

finger of the outstretched hand. Double the figure to obtain the height.

Method II Knee Height

Measure the residents knee height from the bottom of the heel to the top

of the knee when the knee is bent at a 90 degree angle and use the

following formula to calculate the height.

Male: Height (cm) = 64.19-(0.04 x age)+(2.02 x knee height [cm])

Female: Height (cm) = 84.88-(0.24 x age)+(1.83 x knee height[cm])

____________

The above information was adapted from:

Zeman, Frances J. Clinical Nutrition and Dietetics 2/e. Englewood Cliffs, New

Jersey: Macmillan Publishing Company, 1991.

Pocket Resource for Nutrition Assessment. DHCC, 2013.

133

http://www.rxkinetics.com/height_estimate.html

134

Nutrition Assessment Guidelines: When Adjustments Are Required

Ideal Body Weight (IBW)

Men: IBW=106 pounds (lb) for first 5 feet + 6 lb for each inch over 5 feet

Women: IBW=100 lb for first 5 feet + 5 lb for each inch over 5 feet

For the individual shorter than 5 feet, subtract 2 lb for each inch under 5 feet

IBW frame size adjustment

Add or subtract 10% IBW

Large Frame: IBW + (IBW x 0.10)

Small Frame: IBW – (IBW x 0.10)

Adjustment for patients with disabilities

Paraplegia: Subtract 5%-10% from IBW

Quadriplegia: Subtract 10%-15% from IBW

Consultant Dietitians in Health Care Facilities, CD-HCF Pocket Resource for

Nutrition Assessment, 2005 Revision.

Adjustment For Patients With Amputations

Use the percentage of total body weight contributed by individual body parts:

Trunk without extremities 50.0%

Entire leg (and foot) 16.0%

Below the knee 6.0%

Foot 1.5%

Entire arm (and hand) 50.0%

Forearm 2.3%

Hand 1.0%

References:

American Dietetic Association Evidence Analysis Library. Adult weight management topics and questions.

Available at: http://www.adaevidencelibrary.com/topic.cfm?cat=3047. Accessed March 14, 2010.

135

Obesity is usually defined as 125% or more of ideal (IBW) or a Body Mass Index

(BMI)>30. Since body fat is not nearly as metabolically active as other tissue

using actual body weight to calculate caloric needs will result in a figure

that is too high. Alternatively, using Ideal Body Weight (IBW) to calculate caloric

needs will result in a figure that is too low because it will not take into account the

additional lean body mass to support the excess weight or extra calories needed

to move it.

The following equation may be used to obtain the metabolically active weight

(MAW) for estimating total daily calorie and protein requirements. This calculation

is not used to calculate fluid needs. Actual body weight should be used to

calculate fluid needs.

MAW = [(Actual Body Weight) – IBW) x 0.25] + IBW

__________

The above information was adapted from:

Mahan, L. Kathleen and Arlin, Marian. Krause’s Food, Nutrition & Diet Therapy,

8

th

edition. Philadelphia: W. B. Saunders Company, 1992.

Energy Requirements for Adults

Energy prediction equations

For resting energy expenditure (REE) or resting metabolic rate (RMR), where weight (W) in kilograms

(KG), height (H) in centimeters and age (A) in years.

Ireton-Jones

Legend:

B=Diagnosis of burn (present=1, absent=0)

O=Obesity, body mass index (BMI>27kg/m2 (present=1, absent=0)

S=Sex (male=1, female=0)

T=Diagnosis of trauma (present=1, absent=0)

Spontaneously Breathing: 629-11(A)+25(W)-609(O)

Ventilator-Dependent (original, 1992): 1925-10(A)+5(W)+281(S)+292(T)+851(B)

Ventilator-Dependent (revised, 2002): 1784-11(A)+5(W)+244(S)+239(T)+804(B)

136

Owen

Note: Indirect calorimetry is the preferred method for determining RMR in critically ill patients. If it is necessary to

use predictive equations, according to ADA evidence-based practice guidelines, the Ireton-Jones (1992) is one of the

equations cited as having the best prediction accuracy. Harris-Benedict and Mifflin-St Jeor are not recommended

for critically ill patients.

Men: 879+(10.2xW)

Women: 795+(7.18xW)

Total energy requirements

Total energy requirements (TEE)=REE x(activity factor) x (injury factor) +/- 500 calories (for desired weight loss or

weight gain, if applicable) + fever factor

Activity factors (AF)

Comatose 1.1

Confined to bed: 1.2

Confined to chair: 1.25

Out of bed: 1.3

Injury factors (IF):

Surgery

Minor: 1.0-1.2

Major: 1.1-1.3

Skeletal trauma: 1.6-1.8

Head Trauma: 1.6-1.8

Pressure ulcers

Stage I: 1.0-1.1

Stage II: 1.2

Stage III: 1.3-1.4

Stage IV: 1.5-1.6

Infection

Mild: 1.0-1.1

Moderate: 1.2-1.4

Severe: 1.4-1.8

Burns (% body surface area)(BSA)

<20% BSA: 1.2-1.5

20%-40% BSA: 1.5-1.8

>40% BSA: 1.8-2.0

Fever factor

Fahrenheit scale: add 7% of REE for every 1 degree over normal

Centigrade scale: add 13% of REE for every 1 degree over normal

137

References and Recommended Readings

American Dietetic Association. ADA Evidence Analysis Library. Available at:

www.adaevidence library.com. Accessed October 14, 2010.

Breen HB, Ireton‐Jones CS. Predicting energy needs in obese patients. Nutr. Clin

Pract. 2004; 19:284‐289.

Campbell CG, Zander E, Thorland W. Predicted vs measured energy expenditure in critically

ill underweight patients. Nutr Clin Pract. 2005; 20: 276‐280.

Frankenfield D, Roth‐Yousey L, Compher C. Comparison of predictive equations

for resting metabolic rate in healthy non‐obese adults and obese adults: a

systematic review. J Am Diet Association. 2005; 105: 775‐789.

Ireton‐Jones CS, Jones JD. Improved equations for predicting energy expenditure

in patients: The Ireton –Jones equations. Nutr Clin Pract.2002; 17:29‐31.

Ireton‐Jones CS, Turner WW Jr, Leipa GU, Baxter CR. Equations for estimation of

energy expenditures in patients with burns with special reference to ventilator

status. J Burn Care Rehabil. 1992:13: 330‐333.

138

Body Mass Index (BMI)

Weight (lb)

Height 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205

5’ 0” 20 21 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

5’ 1” 19 20 21 22 23 24 25 26 26 27 28 29 30 31 32 33 34 35 36 37 38 39

5’ 2” 18 19 20 21 22 23 24 25 26 27 27 28 29 30 31 32 33 34 35 36 37 37

5’ 3” 18 19 19 20 21 22 23 24 25 26 27 27 28 29 30 31 32 33 34 35 35 36

5’ 4” 17 18 19 20 21 21 22 23 24 25 26 27 27 28 29 30 31 32 33 35 34 35

5’ 5” 17 17 18 19 20 21 22 22 23 24 25 26 27 27 28 29 30 31 32 33 33 34

5’ 6” 16 17 18 19 19 20 21 22 23 23 24 25 26 27 27 28 29 30 31 32 32 33

5’ 7” 16 16 17 18 19 20 20 21 22 23 23 24 25 26 27 27 28 29 30 31 31 32

5’ 8” 15 16 17 17 18 19 20 21 21 22 23 24 24 25 26 27 27 28 29 31 30 31

5’ 9” 15 16 16 17 18 18 19 20 21 21 22 23 24 24 25 26 27 27 28 30 30 30

5’ 10” 14 15 16 17 17 18 19 19 20 21 22 22 23 24 24 25 26 27 27 29 29 29

5’ 11” 14 15 15 16 17 17 18 19 20 20 21 22 22 23 24 24 25 26 26 28 28 29

6’ 0” 14 14 15 16 16 17 18 18 19 20 20 21 22 22 23 24 24 25 26 27 27 28

6’ 1” 13 14 15 15 16 16 17 18 18 19 20 20 21 22 22 23 24 24 25 26 26 27

6’ 2” 13 13 14 15 15 16 17 17 18 19 19 20 21 21 22 22 23 24 24 25 26 26

6’ 3” 12 13 14 14 15 16 16 17 17 18 19 19 20 21 21 22 22 23 24 24 25 26

6’ 4” 12 13 13 14 15 15 16 16 17 18 18 19 19 20 21 21 22 23 23 24 24 25

139

Monoamine Oxidase (MAO) Inhibitors and

Food Interactions

Monoamine oxidase (MAO) inhibitors are antidepressants which can cause dangerous

reactions such as hypertensive crisis when taken with foods containing tyramine,

dopamine, alcohol and caffeine. It is recommended that the diet continue for four

weeks following discontinuation of the drug.

MAO Inhibitors

Examples

Brand (Generic Name) Marplan (isocarboxazid)

Nardil (Phenelzine) Eldepryl (selegiline)

Parnate (Tranylcypromine)

Foods and Beverages to Avoid

Aged cheeses:

Cheddar Processed

Camembert Gruyere Boursault

Emmenthaler Gouda Parmesan

Swiss Natural brick Romano

Stilton Mozzarella Provolone

Bleu Imitation cheese

Beer Vermouth

Ale Ginseng

Wine Alcohol free and reduced

Alcohol beer and wine products

Salted, dried cod and herring

Pickled herring

Meat extracts and bouillons

Summer sausage

Any unfresh meat, stored or aged beef, aged game

Beef or Chicken livers

Fermented (hard) sausage

Bologna

Pepperoni

Salami

Italian broad beans

Excessive amounts of chocolate and caffeine (coffee, tea, and cola)

Overripe fruit, banana peel

Marmite yeast, yeast extracts, Brewers yeast

Liquid and powdered protein supplements

Hydrolyzed protein extracts used as a base for sauces, soups or gravies

Fermented bean curd and soya bean paste, miso (Use soy sauce with caution.)

Fava Beans

Avocados

140

Foods and drinks low in tyramine may be consumed with reason, but never in excess.

They include caffeine containing drinks, chocolate, soy sauce, cottage cheese, cream

cheese, yogurt and sour cream.

__________

This information was compiled from:

Manual of Clinical Dietetics, Yale-New Haven Hospital. New Haven: Department of

Food and Nutritional Services, 1990.

Physician’s Desk Reference 53

rd

edition. Montvale: Medical Economics Data, 1999.

Pronsky, Z.M., Food Medication Interactions. Birchrunville, PA. 14

th

Edition, 2006

Drug Facts and Comparisons. Facts and Comparisons, 2000. Applied therapeutics:

The Clinical Use of Drugs, Applied Therapeutics, 1995. The American Psychiatric

Press Textbook of Psychopharmacology. American Psychiatric Press, Inc., 1998.

141

Fiber Content of Common Foods

Food Item Serving Total Fiber Soluble Insoluble

Size per serving Fiber per Fiber per

(g) serving (g) serving(g)

Cereals

All Bran 1/3 cup 8.6 1.4 7.2

Cheerios 1 ¼ cup 2.5 1.2 1.3

Corn flakes 1 cup 0.5 0.1 0.4

Cream of wheat, 2 ½ tbsp 1.1 0.4 0.7

Regular (uncooked)

Fiber one ½ cup 11.9 0.8 11.1

40% Bran flakes 2/3 cup 4.3 0.4 3.9

Grapenuts ¼ cup 2.8 0.8 2.0

Grits, corn, quick 3 tbsp 0.6 0.1 0.5

(uncooked)

Oat bran (cooked) ¾ cup 4.0 2.2 1.8

Oat bran flakes ½ cup 2.1 0.8 0.3

Oatmeal (uncooked) 1/3 cup 2.7 1.4 1.3

Product 19 1 cup 1.2 0.3 0.9

Puffed rice 1 cup 0.2 0.1 0.1

Puffed wheat 1 cup 1.0 0.5 0.5

Raisin bran ¾ cup 5.3 0.9 4.4

Rice Krispies 1 cup 0.3 0.1 0.2

Shredded wheat 2/3 cup 3.5 0.5 3.0

Shredded wheat & bran 2/3 cup 2.5 0.6 1.9

Special K 1 cup 0.9 0.2 0.7

Total, whole wheat 1 cup 2.6 0.6 2.0

Wheaties 2/3 cup 2.3 0.7 1.6

Grains

Cornmeal 2 ½ tbsp 0.4 0.1 0.3

Macaroni, white (cooked) ½ cup 0.7 0.4 0.3

Macaroni, whole wheat ½ cup 2.1 0.4 1.7

(cooked)

Noodles, egg (cooked) ½ cup 1.4 0.4 1.0

Popcorn, popped(cooked) 3 cups 2.0 0.1 1.9

Rice, white (cooked) 1/3 cup 0.5 trace 0.5

Spaghetti, white (cooked) ½ cup 0.9 0.4 0.5

Spaghetti, whole wheat ½ cup 2.7 0.6 2.1

(cooked)

Wheat bran ½ cup 12.3 1.0 11.3

Wheat germ 3 tbsp 3.9 0.7 3.2

142

Fiber Content of Common Foods

Food Item Serving Total Fiber Soluble Insoluble

Size per serving Fiber per Fiber per

(g) serving (g) serving(g)

Bread and Crackers

Bagel, plain ½ 0.7 0.3 0.4

Biscuit, baked 1 0.5 0.3 0.2

Bread 1 slice 0.7 0.3 0.4

Bran muffin 1 muffin 1.8 0.2 1.6

Cornbread 2 in 1.4 0.3 1.1

Cracked, wheat 1 slice 1.9 0.3 1.6

French 1 slice 0.9 0.3 0.6

Mixed grain 1 slice 1.9 0.3 1.6

Pita, white ½ pocket 0.5 0.2 0.3

Pumpernickel 1 slice 2.7 1.2 1.5

Raisin 1 slice 1.8 0.8 1.0

Rye 1 1.8 0.8 1.0

White 1 slice 0.6 0.3 0.3

Whole wheat 1 slice 1.5 0.3 1.2

Bun, hamburger ½ 0.7 0.2 0.5

Crackers, matzo 1 1.0 0.5 0.5

Saltine 6 0.5 0.3 0.2

Saltine, wheat 5 0.5 0.2 0.3

Snack, whole wheat 4 2.0 0.3 1.7

Wheat 5 0.6 0.2 0.4

English muffin ½ 0.8 0.2 0.6

Pretzels, hard ¾ oz 0.8 0.2 0.6

Rolls, brown-and-serve 1 roll 0.8 0.3 0.5

Taco shell 2 1.4 0.2 1.2

Tortilla, corn 1 1.4 0.2 1.2

Tortilla, flour 1 0.7 0.3 0.4

Waffle, toasted 1 0.7 0.3 0.4

143

Fiber Content of Common Foods

Food Item Serving Total Fiber Soluble Insoluble

Size per serving Fiber per Fiber per

(g) serving (g) serving(g)

Fruits

Apple, red, fresh 1 small 2.8 1.0 1.8

with skin

Applesauce, canned ½ cup 2.0 0.7 1.3

Unsweetened

Apricots, canned, drained 4 halves 1.2 0.5 0.7

Apricots, dried 7 halves 2.0 1.1 0.9

Apricots fresh, with skin 4 3.5 1.8 1.7

Avocado, fresh, flesh only 1/8 1.2 0.5 0.7

Banana, fresh ½ small 1.1 0.3 0.8

Blueberries, fresh ¾ cup 1.4 0.3 1.1

Cherries ½ cup 1.8 0.9 0.9

Dates, dried 2 ½ medium 0.9 0.3 0.6

Figs, dried 1 ½ 2.3 1.1 1.2

Fruit cocktail, (canned) ½ cup 2.0 0.7 1.3

Grapefruit, fresh ½ medium 1.6 1.1 1.2

Grapes, red, fresh 15 small 0.4 0.2 0.2

With skin

Kiwifruit, fresh, 1 large 1.7 0.7 1.0

flesh only

Melons, cantaloupe 1 cup cubed 1.1 0.3 0.8

Melons, honeydew 1 cup cubed 0.9 0.3 0.6

Melons, watermelon 1 ¼ cup 0.6 0.4 0.2

cubed

Nectarine, fresh 1 small 1.8 0.8 1.0

Orange, fresh 1 small 2.9 1.8 1.1

Peaches ½ cup 3.7 0.7 3.0

Pears ½ cup 3.7 0.7 3.0

Pineapple, canned 1/3 cup 1.4 0.2 1.2

Plum, red, fresh 2 medium 2.4 1.1 1.3

Prunes 3 medium 1.7 1.0 0.7

Raisins, dried 2 tbsp 0.4 0.2 0.2

Raspberries, fresh 1 cup 3.3 0.9 0.2

Strawberries, fresh 1 ¼ cup 2.8 1.1 1.7

144

Fiber Content of Common Foods

Food Item Serving Total Fiber Soluble Insoluble

Size per serving Fiber per Fiber per

(g) serving (g) serving(g)

Vegetables

Asparagus, (cooked) ½ cup 1.8 1.7 1.1

Bean sprouts, fresh 1 cup 1.6 0.6 1.0

Beets, flesh only(cooked) ½ cup 1.8 0.8 1.0

Broccoli, (cooked) ½ cup 2.4 1.2 1.2

Brussels sprouts(cooked) ½ cup 3.8 2.0 1.8

Cabbage, fresh 1 cup 1.5 0.6 0.9

Cabbage, red (cooked) ½ cup 2.6 1.1 1.5

Carrots, (canned) ½ cup 1.5 0.7 0.8

Carrots, fresh 7 ½ in long 2.3 1.1 1.2

Carrots, sliced (cooked) ½ cup 2.0 1.1 0.9

Cauliflower, (cooked) ½ cup 1.0 0.4 0.6

Celery, fresh 1 cup 1.7 0.7 1.0

chopped

Corn, whole kernel ½ cup 1.6 0.2 1.4

(canned)

Cucumber, fresh 1 cup 0.5 0.2 0.3

Green beans (cooked) ½ cup 2.0 0.5 1.5

Kale, chopped, frozen ½ cup 2.5 0.7 1.8

Lettuce, iceberg 1 cup 0.5 0.1 0.4

Mushrooms, fresh 1 cup pieces 0.8 0.1 0.7

Okra, frozen (cooked) ½ cup 4.1 1.0 3.1

Olives, (canned) 10 small 1.0 0.1 0.9

Onion, fresh, (chopped) ½ cup 1.7 0.9 0.8

Peas, green (canned) ½ cup 3.2 0.4 2.8

Peas, green, frozen ½ cup 4.3 1.3 3.0

(cooked)

Pepper, green, fresh 1 cup 1.7 0.7 1.0

chopped

Potato, sweet (canned) 1/3 cup 0.8 0.3 0.5

Potato, white, flesh only ½ cup 1.5 0.3 1.2

(cooked)

Pumpkin, canned ½ cup 3.5 0.6 2.9

Snow peas, fresh(cooked) ½ cup 1.4 0.6 0.8

Spinach (cooked) ½ cup 1.6 0.5 1.1

Squash, yellow, ½ cup 1.3 0.5 0.4

crookneck, frozen

145

Fiber Content of Common Foods

Food Item Serving Total Fiber Soluble Insoluble

Size per serving Fiber per Fiber per

(g) serving (g) serving(g)

Vegetables

Tomato (canned) ½ cup 1.3 0.5 0.8

Tomato, fresh 1 medium 1.0 0.1 0.9

Tomato, sauce 1/3 cup 1.1 0.5 0.6

Turnip (cooked) ½ cup 4.8 1.7 3.1

V-8 juice ½ cup 0.7 0.2 0.5

Zucchini, sliced (cooked) ½ cup 1.2 0.5 0.7

Legumes

Black beans (cooked) ½ cup 6.1 2.4 3.7

Black-eyed peas (canned) ½ cup 4.7 0.5 4.2

Butter beans, dried ½ cup 6.9 2.7 4.2

(cooked)

Chick peas (canned) ½ cup 4.3 1.3 3.0

Kidney beans, dark, red ½ cup 6.9 2.8 4.1

dried, cooked

Lentils, dried (cooked) ½ cup 5.2 0.6 4.6

Lima beans (canned) ½ cup 4.3 1.1 3.2

Navy beans, dried, ½ cup 6.5 2.2 4.3

(cooked)

Pinto beans (canned) ½ cup 6.1 1.4 4.7

Split peas, dried ½ cup 3.1 1.1 2.0

(cooked)

White beans, Great ½ cup 7.2 2.2 5.0

Northern (canned)

Nuts and Seeds

Almonds 6 whole 0.6 0.1 0.5

Brazil nuts 1 tbsp 0.5 0.1 0.4

Coconut, dried 1 ½ tbsp 1.5 0.1 1.4

Coconut, fresh 2 tbsp 1.1 0.1 1.0

Hazelnuts, (filberts) 1 tbsp 0.5 0.2 0.3

Peanut butter, smooth 1 tbsp 1.0 0.3 0.7

Peanuts, roasted 10 large 0.6 0.2 0.4

Sesame seeds 1 tbsp 0.8 0.2 0.6

Sunflower seeds 1 tbsp 0.5 0.2 0.3

Walnuts 2 whole 0.3 0.1 0.2

146

RECIPES FOR FIBER SUPPLEMENTS

BRAN-PRUNE JUICE SUPPLEMENT

Yield: 32 oz Serving size: 1-4 oz/day

9 oz bran buds

23 oz prune juice

1 cup unsweetened applesauce

Combine all ingredients in a large blender. Blenderize until well mixed. Cover, label

with date and time processed. Discard after 72 hours.

Total dietary fiber per ounce: 2.23 gm.

OATMEAL WITH BRAN

Yield: 14 cups Serving size: ½ cup

21 oz oatmeal

9 oz bran buds

Cook oatmeal according to directions. When cooked, add bran. Stir, and serve

immediately.

Total dietary fiber per serving: 4.06 gm.

PRUNE WHIP

Yield: 16 oz Serving size: 1 oz

1 cup unsweetened applesauce

1 cup unprocessed bran, all bran or bran buds

½ cup prune juice

2 tablespoons honey

Combine all ingredients and blend until smooth. Cover and label product with date and

time processed. Store in refrigerator. Discard after 72 hours.

Total dietary fiber per ounce: 2.2 gm.

147

CAFFEINE CONTENT OF FOODS AND BEVERAGES

Item Caffeine/mg Item Caffeine/mg

Range Range

Coffee (5 oz cup ) Brewed Chocolate Products

Nuts and Seeds

Drip 110-150 Cocoa hot (5 oz) 2-15

Percolated 40-70 Cocoa dry (1 oz) 6

Decaffeinated 2-5 Chocolate milk (8 oz) 8

Coffee (5 oz cup) Instant Milk chocolate (1 oz) 1-15

Freeze, dried 40-108 Dark chocolate, semi-sweet

(1 oz) 5-35

Decaffeinated 2-3

Tea (bags or loose) (5 oz) Bakers chocolate (1 oz) 25

1 minute brew 9-33 Chocolate-flavored syrup

(2 tbsp) 5

3 minute brew 20-46

5 minute brew 20-50 Chocolate malted, milk

powder (3 heaping tbsp) 8

Tea Products

Instant (5 oz cup) 12-29 Chocolate chips,

semi-sweet (2 oz) 12-15

Iced tea (12 oz cup) 22-36

Soft Drinks, Diet

Soft Drinks, Regular (12 oz)

(12 oz)

Tab 46

Mello Yellow, Mountain Dew,

Kick 52-55 Diet Cola, Dr. Pepper 36-59

Soft Drinks, Diet

Soft Drinks, Regular (12 oz)

(12 oz)

Tab 46

Mello Yellow, Mountain Dew,

Kick 52-55 Diet Cola, Dr. Pepper 36-59

Cola, Dr. Pepper, Barqs, 35-46 Sugar-free Big Red 38

Root Beer

Pepsi, RC Cola, Big Red, 18-38 Diet Mr. Pibb 40

Aspen

Canada Dry Diet Cola, 1-4

Mr. Pibb 40 Fresca

148

CAFFEINE CONTENT OF FOODS AND BEVERAGES

Item Caffeine/mg Item Caffeine/mg

Range Range

Caffeine-free Diet Cola 0

Club soda, Seltzer, Diet Sprite, Diet Slice,

Sparkling water, Diet Orange, Diet Root Beer,

Caffeine-free cola, Diet 7-Up 0

Ginger ale, Sprite, Slice

Fresca, 7-Up, Root beer, Jolt 72 mg

Orange, Grape,

Strawberry, Power Aide, Diet Orange slice 40-48 mg

tonic water 0

Jolt 72

Orange Slice 40-48

Coke Zero 45

Pepsi Max 43

149

Scoop Sizes

Number Approximate Liquid Volume

6 2/3 cup (5 fluid ounces)

8 ½ cup (4 fluid ounces)

10 3/8 cup (3 ¼ fluid ounces)

12 1/3 cup (2 2/3 fluid ounces)

16 ¼ cup (2 fluid ounces)

20 3 1/5 tablespoons (1 3/5 fluid ounces)

24 2 2/3 tablespoons (1 1/3 fluid ounces)

30 2 1/5 tablespoons (1 fluid ounce)

40 1 3/5 tablespoons (0.8 fluid ounce)

60 1 tablespoon (0.5 fluid ounce)

Scoops, also called dippers, are used to measure volume not weight. Originally used to

measure and serve ice cream, each scoop’s number indicates the number of serving

found in a quart (32 fluid ounces) of ice cream. For example, using a number eight

scoop, eight half-cup servings (4 fluid ounces each) would be obtained from a quart of

ice cream. Two number 8 scoops of ice cream equals one cup (8 fluid ounces) but

weighs only 4.7 ounces.

150

Milligram and MilliEquivalent Conversions

Formula for converting milligrams (mg) to milliEquivalents (mEq):

milligrams x valence = milliEquivalents

atomic weight

Example: 1000 mgNa x 1 = 43 mEq

23

Formula to use when converting milliEquivalents (mEq) to milligrams (mg):

milliEquivalents x atomic weight = milligrams

valence

Example: 60 mEq K x 39.1 = 2346 milligrams

1

Mineral Atomic Weight Valence

Zinc (Zn+) 65.4 2

Sodium (Na+1) 23.0 1

Potassium (K+) 39.1 1

Calcium (Ca+1) 40.1 2

Chlorine (C1-) 35.5 1

Phosphorus (P-) 31.0 2

Magnesium (Mg+) 24.3 2

Sulfur (S-1) 32.1 2

Salt and Sodium Conversions

To convert milligrams of sodium (Na+) to milligrams of salt (NaCl):

sodium milligram ÷ .40 = salt milligrams

To convert milligrams of salt (NaCl) to milligrams of sodium (Na):

Salt milligrams x .40 = sodium milligrams

1 teaspoon salt (5gm) = 2300 mg Na

1 salt packet (5/8 gm) = 288 mg

151

Measures and Metric Conversions

Liquid measure – volume equivalent

1 teaspoon = 1/3 tablespoon = 5 ml

1 tablespoon = 3 teaspoons = 15 ml

2 tablespoons = 1 fluid ounce = 30 ml

8 tablespoons = ½ cup = 120 ml

16 tablespoons = 1 cup (8 fluid ounces) = ½ pint, 240 ml

2 cups = 1 pint (16 fluid ounces) = .4732 liters

2 pints = 1 quart (32 fluid ounces) = .9462 liters

1.06 quarts = 34 fluid ounces = 1000 ml

4 quarts = 1 gallon = 3785 ml

Dry measure-volume equivalent

1 quart = 2 pints = 1.101 liters

Dry measure and quarts are about 1/6 larger than liquid measure pints and quarts.

Linear measure

1 inch = 2.54 centimeters (rounded to 2.5)

Weights

Avoirdupois Metric

1 ounce = 28.32 grams (rounded to 30)

1 pound (16 ozs) = 453.6 grams (rounded to 454)

1 pound (16 ozs) = .45 kilogram

2.2 pounds = 1 kilogram

Conversions

kilograms x 2.2 = pounds (lb)

pounds x 0.4 = kilograms (kg)

inches x 2.5 = centimeters (cm)

centimeters 2.5 = inches (in)

grams x 1000 = milligrams (mg)

liter x 1000 = millilters (ml)

liter x 100 = centiliter (cl)

liter x 10 = deciliter (dl)

Note: “Ounce” may mean 1/16 of a pound or 1/16 of a pint; however, the former is weight

measure and the latter is volume measure. Except for water (or other substances with the

same density as water), a fluid ounce and a weight ounce are not equivalent and should not

be used interchangeably.

152

Abbreviations

The following official and unofficial abbreviations are used frequently in residents’

medical records. This list should be modified according to the facility’s policies for

approved abbreviations.

ml milliliter

a. before N.P.O. nothing by mouth

a.c. before food or meals nothing may pass orally

ad lib as desired OOB out of bed

A.D.L. activities of daily living .T. occupational therapy

A.S.C.V.D. arteriosclerotic cardiovascular disease OTC over the counter

A.S.H.D. arteriosclerotic heart disease oz ounce

b.m. bowel movement p.c. after meals

p.r.n. whenever necessary, or p.o. postoperative or by mouth

B.M.R. basal metabolism rate at patient request

B.P. blood pressure P.T. physical therapy

B.S. bowel sounds q every

B.U.N. blood urea nitrogen q.h. every hour

c with R.B.C. red blood count

Ca calcium R/O rule out

CA cancer R.O.M. range of motion

C.B.C. complete blood count Rx prescription, treatment

C.H.F. congestive heart failure S without

CHO carbohydrate S.O.B. shortness of breath

C.N.S. central nervous system S.S. soap suds

C.O. complains of stat immediately

C.V.A. cerebrovascular accident tbsp tablespoon

D/C discontinue t.i.d. three times a day

DX diagnosis T.P.R. temperature, pulse and

E.E.G. electroencephalogram respiration

E.K.G. electrocardiogram tsp teaspoon

E.N.T. ear, nose, throat U.R.I. upper respiratory

F.B.S. fasting blood sugar infection

gd good UTI urinary tract infection

gm gram wt. weight

gr grain

gtt drop

hgb hemoglobin

hct hematocrit

h.s. bedtime

lb pound

lt liter

mEq milliEquivalent

153

Official “Do Not Use” List

Do Not Use Potential Problem Use Instead

U (unit) Mistaken for “O” (zero), the Write “unit”

Number “4” (four) or “cc”

IU (International Unit) Mistaken for IV (intravenous) Write

or the number 10 (ten) “International

Unit”

Q.D., QD, q.d., qd (daily) Mistaken for each other Write “daily”

Q.O.E., QOD, q.o.d, qod Period after the Q mistaken for Write “every

(every other day) “I” and the “O” mistaken for “I” other day”

Trailing zero (X.0 mg)* Decimal point is missed Write X mg

Lack of leading zero (.X mg) Write 0.X mg

MS Can mean morphine sulfate or Write “morphine

Magnesium sulfate sulfate”

Write

“magnesium

sulfate”

MSO4 and MgSO4 Confused for one another

1 Applies to all orders and all medication-related documentation that is handwritten

(including free-text computer entry) or on pre-printed forms.

*Exception: A “trailing zero” may be used only where required to demonstrate the level

of precision of the value being reported, such as for laboratory results, imaging studies

that report size of lesions, or catheter/tube sizes. It may not be used in medication

orders or other medication-related documentation.

154

Additional Abbreviations, Acronyms and Symbols

(For possible future inclusion in the Official “Do Not Use” List)

Do Not Use Potential Problem Use Instead

>(greater than) Misinterpreted as the number Write “greater

than”

<(less than) “7” (seven) or the letter “L” Write “less than”

Confused for one another

Abbreviations for drug names Misinterpreted due to similar Write drug

Abbreviations for Names in full

Multiple drugs

Apothecary units Unfamiliar to many Use metric units

Practitioners

Confused with metric units

@ Mistaken for the number Write “at”

“2” (two)

cc Mistaken for U (units) when Write “ml” or

poorly written “milliliters”

ug Mistaken for mg (milligrams) Write “mcg” or

resulting in one thousand-fold

overdose

155

RECIPES FOR PUREE BREAD

Pureed Bread

Bread 2 ½ loaves

Broth 1 gallon

Margarine ¼ lb

Season to taste

In steam table, pan break bread slices into small pieces

Pour broth/melted margarine mixture over bread

Lightly mix bread and liquid together

Bake uncovered at 325 degrees F. until browned – approximately 20 minutes

Hold at 145 degrees F. or above

Yield: 40 servings - #12 scoop

Variations:

Add ground pepper, pureed onion and celery

Choose broth flavor depending on meat served

Example: seafood broth, beef, pork or poultry broth

Season with sage, poultry seasoning, garlic powder or Old Bay seasoning to

compliment meal

156

Recipe – Pureed Bread, Warm

______________________________________________________________

Yield: 25 Size of Serving: 1/3 cup

______________________________________________________________

AMOUNT INGREDIENT PREPARATION STEP

8 1/3 cup Japanese Bread Crumbs 1. Combine margarine, milk, water

½ gal Milk, 2% low fat and chicken base in sauce pan.

1 3/8 cup Water #1 Simmer over medium heat just

½ cup Margarine, hard stick until margarine has melted.

1 3/8 tbsp Chicken base Remove from heat. Add bread

crumbs, mix thoroughly until all

bread crumbs are moistened.

2. Let bread mixture stand for 5

minutes to transfer to a greased

2” deep hotel pan. **Note**

Length of pan required will

depend on number of

servings prepared.

Cover pan with plastic wrap.

3. Cook in steamer for 20 minutes

or until internal temperature

reaches 165 degrees for 15

seconds.

4. Portion with a #12 scoop for

service.

157

Recipe – Pureed Bread, Cold

______________________________________________________________

Yield: 25 Size of Serving: 1/3 cup

______________________________________________________________

AMOUNT INGREDIENT PREPARATION STEP

8 1/3 cup Japanese Bread Crumbs 1. Combine margarine, milk, water

½ gal Milk, 2% low fat and chicken base in sauce pan.

1 3/8 cup Water #1 Simmer over medium heat just

½ cup Margarine, hard stick until margarine has melted.

1 3/8 tbsp Chicken base Remove from heat. Add bread

1 pint Water #2 crumbs, mix thoroughly until all

bread crumbs are moistened.

2. Let bread mixture stand for 5

minutes transfer to a greased

2” deep hotel pan. **Note**

Length of pan required will

depend on number of

servings prepared.

Cover pan with plastic wrap.

3. Cook in steamer for 20 minutes

or until internal temperature

reaches 165 degrees for 15

seconds.

4. Cool the bread in refrigerator

until it reaches an internal

temperature of 40 degrees or

below.

5. Prior to service, add water to the

cooled bread mixture stirring until

the mixture is a smooth mashed

potato consistency.

6. Portion with a #12 scoop for

service.

158

Recipe – Pureed Bread, Cinnamon

______________________________________________________________

Yield: 25 Size of Serving: 1/3 cup Cost per serving: $

Cooking Time: Temperature: Method: (None)

AMOUNT INGREDIENT PREPARATION STEP

8 1/3 cup Japanese Bread Crumbs 1. Combine margarine, milk, water

½ gal Milk, 2% low fat in sauce pan.

1 3/8 cup Water #1 Simmer over medium heat just

½ cup Margarine, hard stick until margarine has melted.

½ cup Sugar, Granulated Remove from heat. Add bread

1/3 Tsp Cinnamon, Ground crumbs, sugar and cinnamon

mix thoroughly until all

bread crumbs are moistened.

2. Let bread mixture stand for 5

minutes. Transfer mixture to a

greased 2” deep hotel pan.

**Note** Length of

pan required will depend on

number of servings prepared.

Cover pan with plastic wrap.

3. Cook in steamer for 20 minutes

or until internal temperature

reaches 165 degrees for 15

seconds.

4. Portion with a #12 scoop for

service.

159

Pureed Bread

Portion Size: #16 Scoop

Number of Servings: 24

Ingredients Amount Unit

Wheat Bread 24 Slices

Apple Juice 12 Ounces

Hot water 12 Ounces

Procedure CCP Monitor Corrective Action

1. Place slices of Wheat bread in food processor.

2. Add hot water and blend for approximately 30 seconds.

3. Add fruit juice and continue to blend. You may add flavoring or spices at this time also.

4. Hot serve. Heat in CCP Monitor Corrective Action

Steamer. Temp of 165° for 15 sec.

5. Transfer to steam table CCP Measure temp. If temperature falls to less

at time of service. Serve than 140° F. reheat food to

with #16 scoop. 165° F. one time only.

6. Cold Serve: Transfer CCP Monitor temp. Chill by approved method to

product to shallow pan 40°

and cool from 140° to 70°

in 2 hours and from 70°

to 40° in 4 hours. Portion

and serve during service

#16 scoop.

(NOTES)

Optional variations:

Cinnamon ¼ tsp. to every 12 slices bread

Vanilla flavoring ½ tsp. to every 12 slices of bread

Orange or cranberry juice may be substituted for apple juice for variety.

(DIABETIC EXCHANGES)

#16 scoop = 1 CHO/Bread

160

FRENCH TOAST SOUFFLE

May be used for a puree diet and/or to add calories

16 slices white bread without crust

1 8 ounces block of cream cheese

8 pasteurized eggs or liquid equivalent

1 ½ cups milk

2/3 cup Half and Half

½ cup maple syrup (light syrup is okay)

1 teaspoon vanilla

Cinnamon to taste

Serve with powdered sugar and maple syrup

1. Spray a 13 x 9 baking dish with cooking spray/Pam

2. Rip bread into quarters and place in baking dish

3. Beat cream cheese at medium speed until smooth

4. Add eggs, one at a time, mixing after each addition

5. Add milk, creamer, maple syrup, vanilla, and cinnamon

6. Pour mixture over bread, cover, and refrigerate overnight

7. Preheat oven to 375 degrees

8. Let bread mixture stand at room temperature for 15 minutes

9. Tent aluminum foil over dish and bake for 40 minutes

10. Remove foil and bake another 10 minutes or until golden brown

11. Sprinkle with powdered sugar and serve with maple syrup

161

SUPER SHAKE

120 ml provides approximately 200 calories and 6 grams protein.

SUPER SHAKE RECIPE

Number of 120 ml servings 9

Carnation Instant Breakfast 2 packs

Whole milk 1 cup (8 ounces)

Evaporated Milk 1 can (13 ounces)

Ice Cream 1 ½ - 8 ounce scoop

Corn Syrup ½ cup

162

For information regarding the 2005 Food Guide Pyramid, Dietary Guidelines for

Americans 2005 and the DASH diet, DRI’s 2010, My Plate For Older Adults, Information

regarding risks of tube feeding for adults and Culture Change Movement.

See the following websites:

http://www.fda.gov/oc/opacom/hottopics/obesity.html

Consumer information on weight loss. Has material on meal planning setting weight

loss goals, approved treatment, and diet scams. It also links to information on how to

lose weight by adding exercise to your daily routine.

www.healthierus.gov/dietaryguidelines

for a copy of the Dietary Guidelines for Americans 2005

www.mypyramid.gov/

for a copy of the 2005 Food Guide Pyramid

Here is a link to the updated DRIs from 2010.

http://fnic.nal.usda.gov/nal display/index.php?

info center=4&tax_level=3&tax subject=256&topic id=1342&level3 id=5140

The web site for My Plate for Older Adults is

www.nutrition.tufts.edu/research/myplate-older-adults

Information regarding risks of inserting tube feeding in residents with end stage dementia.

Finucare TE, Christmas C, Travis K.

Tube Feeding in patients with advanced dementia A Review of the evidence.

JAMA, October 13, 1999, 282 : 14: 1365 – 1370

The Culture Change Movement. New Dining Practice Standards.

http://pioneernetwork.net/data/documents/newdiningpracticestandards.pdf