IT’S MORE THAN A MEAL

Nutrition Basics

Culture and Food

Special Nutrition Needs of Older Adults

Planning Healthful Meals and Snacks

Health at Home Fact Sheets

Crediting Foods

Resources

Nutrition Resource Manual for Adult Day Health Programs Promoting Good Nutrition in Adult Day Health Programs

Additional resources and downloadable fact sheets are available on the accompanying website www.morethanameal.info

This manual was developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program.

The Massachusetts Department of Education, an Affirmative Action employer, is committed to ensuring that all of its programs and facilities are accessible to all members of the public. We do not discriminate on the basis of age, color, disability, national origin, race, religion, sex, or sexual orientation.

© 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

WELCOME

Welcome to It’s MORE than a Meal! We are pleased to introduce you to this nutrition resource manual. We have prepared this manual for our colleagues in adult day programs participating in the Child and Adult Care Food Program (CACFP) and similar settings who provide services to older adults. Since your clients consume many of their weekly meals in your program, you have a unique opportunity to contribute to their nutritional well- being and their caregivers’ knowledge of good nutrition.

You are invited to use this manual to learn more about the following topics:

• Nutrition basics: General nutrition advice based on the 2005 Dietary Guidelines and USDA Pyramid; nutrients in foods

• Special nutrition needs of older adults: Aging and health; fluids; nutrient needs; obesity; chronic diseases; food allergies; dietary supplements; food-medicine interactions; barriers to healthy eating

• Planning healthful meals and snacks: Food labels; modifying recipes and menus; healthy snacks

• Culture and food: Culturally sensitive interactions; cultural foods

• Crediting Foods for CACFP reimbursement: Child and Adult Care Food Program (CACFP) reimbursement guidelines; serving sizes; tips for crediting foods

• Resources for Adult Day Health programs: Fact sheets; other resources

Additional resources and downloadable fact sheets are also available on the accompanying website www.morethanameal.info.

As you expand your knowledge of these topics, you can play a greater role in promoting your clients’ health and well-being. You can also learn how to recover meal costs while serving healthful foods.

We hope that you find this manual a valuable addition to your resource collection, and commend you for your role in meeting the needs of older adults in your community.

Massachusetts Department of Education Child and Adult Care Food Program

IT’S MORE THAN A MEAL

Table of Contents

Massachusetts Department of Education Child and Adult Care Food Program i IT’S MORE THAN A MEAL

OverviewPurpose ...... 3 Background ...... 4 Development Team ...... 5

NutritionIntroduction & Adult ...... Day...... Health...... Programs ...... 9 The Role of Your Program in Promoting Health ...... 10 Facts about the Child and Adult Care Food Program (CACFP) ...... 11

NutritionIntroduction Basics ...... 17 The 2005 Dietary Guidelines ...... 18 The 2005 Pyramid ...... 21 Nutrients in Foods ...... 29

SpecialIntroduction Nutrition . . . . . Needs...... of. . . . Older...... Adults ...... 37 Aging and Nutritional Well-Being ...... 38 Good Nutrition for Seniors ...... 39 Determining Nutritional Risk ...... 39 Nutritional Risk Checklist ...... 40 Promoting Fluid Intake ...... 42 Nutrient and Calorie Needs ...... 43 Obesity ...... 44 Chronic Diseases ...... 44 Food Allergies and Intolerances ...... 52

Nutrition Resource Manual for Adult Day Health Programs ii IT’S MORE THAN A MEAL

Dietary Supplements ...... 54 Medicines and Older Adults ...... 55 Barriers to Healthy Eating ...... 57

PlanningIntroduction Healthful ...... Meals ...... and...... Snacks...... 63 Using Food Labels to Make Healthful Food Choices ...... 64 Modifying Recipes and Menus ...... 74 Preparing Healthful Snacks ...... 85 Keeping Foods Safe for Older Adults ...... 87 Frequently Asked Questions ...... 97

CulturIntroductione and F .ood ...... 101 Why Consider Culture? ...... 102 Culturally Sensitive Interactions ...... 103 Cultural Foods ...... 106 Sources of Information on Culture and Food ...... 119

CreditingIntroduction Foods . . . . .for . . . . CACFP...... Reimbursement...... 123 CACFP Guidelines for Crediting Meals and Snacks ...... 124 Tips for Crediting Foods ...... 127 Tips for Crediting Recipes ...... 133 CACFP Regulations: Crediting Grains/Breads ...... 143 CACFP Regulations: Crediting Fruits and Vegetables ...... 159 CACFP Regulations: Crediting Meat and Meat Alternates ...... 169 CACFP Regulations: Crediting Milk Products ...... 179

Massachusetts Department of Education Child and Adult Care Food Program iii IT’S MORE THAN A MEAL

ResourcesIntroduction for . . Adult...... Day...... Health...... Programs ...... 187 Child and Adult Care Food Program (CACFP) ...... 188 Aging-Related Programs and Services ...... 188 Fact Sheets ...... 189 Other Resources (organized by topic) ...... 189

HealthIntroduction at Home: . . . . . F. .act . . . . .Sheets ...... 199 Fact Sheets Healthful Eating for Older Adults Make Healthful Meals Choose Healthful Snacks Drink Enough Fluids Eat Healthy when Eating Out Keep Foods Safe to Eat Dietary Supplements Medicines Physical Activity Plan for an Emergency

EvaluationIntroduction ...... 203 Evaluation Form

Nutrition Resource Manual for Adult Day Health Programs iv IT’S MORE THAN A MEAL

Table of Contents 3 ...... Purpose 4 ...... Background 5 ...... Development Team Overview

Massachusetts Department of Education Child and Adult Care Food Program 1 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 2 OVERVIEW

PurposeThis resource manual is designed to promote good nutrition for older adults in adult day health programs. Because your participants consume many of their weekly meals and snacks in your setting, you have a unique opportunity to contribute to their nutritional well-being and their caregivers’ knowledge of good nutrition.

Recent trends show that more Americans than ever are living longer lives. Many older adults live on their own, with a spouse, or as members of extended families. Preventive health can help maintain their independence and quality of life. Good nutrition is an important part of preventive health.

As you expand your knowledge about nutrition and health, meal planning, food safety, cultural issues, and educational resources, you can play a greater role in promoting your participants’ health. Also, as you learn more about implementing Child and Adult Care Food Program guidelines for meal reimbursement, you can help keep costs down while serving healthful foods.

Massachusetts Department of Education Child and Adult Care Food Program 3 IT’S MORE THAN A MEAL

BackgroundIn 2002, the Massachusetts Department of Education contracted with the University of Massachusetts Extension Nutrition Education Program to assess nutrition and food safety education needs of adult day health programs participating in the U.S. Department of Agriculture’s Child and Adult Care Food Program (CACFP). They conducted surveys to identify the nutrition and health needs of older adults attending these programs, as well as the educational needs of staff and caregivers.

This manual was developed to address the needs identified in the surveys. It builds on What’s in a Meal? A Resource Manual for Providing Nutritious Meals in the Child and Adult Care Food Program. The original manual was developed in 1994 by the USDA Food and Nutrition Service, Midwest Region. The fourth edition was released in 2003 and was reproduced by the National Food Service Management Institute.

It’s MORE than a Meal includes the topics from the 2003 edition of the USDA manual. Some content has been edited to highlight CACFP guidelines for older adults. Other content has been updated to reflect recent recommendations for nutrition and physical activity from the U.S. government’s 2005 Dietary Guidelines and USDA Pyramid.

It’s MORE than a Meal also covers other topics not found in the USDA manual. These include: facts about CACFP; nutrition and older adults; healthful snacks; food safety issues for older adults; culturally sensitive interactions; physical activity and older adults; resources for adult day health programs; and fact sheets for older adults and caregivers.

Nutrition Resource Manual for Adult Day Health Programs 4 OVERVIEW

DevelopmentThe Massachusetts Department Team of Education and the University of Massachusetts Extension Nutrition Education Program would like to thank the members of the advisory board for contributing their time, energy, and knowledge in developing this manual.

MASSACHUSETTS DEPARTMENT OF EDUCATION Jennifer Bedell, Graphic Designer

Nutrition Health & Safety Mary Jane Laus, Nutrition Manager 350 Main Street, Malden, MA 02138 Lynne Ivers Thompson, Graphic Designer Kathleen Millett, Administrator [email protected] Judith Treu, Project Coordinator, Phase II

Mary Anne Gilbert, Outreach Coordinator May May Leung, Project Coordinator, Phase I

Rita Brennan Olson, ADVISORY BOARD Nutrition Education & Training Coordinator Shirley Chao, Nutrition Director Arlene Langseth, Education Specialist MA Executive Office of Elder Affairs, Boston, MA

Amy Socolow, Education Specialist Chandra Ganapathy, Nutrition Director Christanne Smith-Harrison,Nutrition Education HESSCO Elder Services, Sharon, MA & Training Coordinator, Phase I Susan Bourque, Extension Educator Cape Cod Cooperative Extension, Barnstable, MA UNIVERSITY OF MASSACHUSETTS EXTENSION Elizabeth Thayer, Director NUTRITION EDUCATION PROGRAM, Thayercare, Inc. Adult Day Health Center, Hadley, MA DEPARTMENT OF NUTRITION

202 Chenoweth Lab, 100 Holdsworth Way Judy Rogers, Director Amherst, MA 01003 Valley Opportunity Council, Adult Day Health Chicopee, MA Nancy Cohen, Professor & Department Head [email protected] Jean Seero, Director Mary Immaculate Adult Day Health, Inc., Beth Armour, Web Designer and La Casa de Maria Inmaculada, Lawrence, MA

Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program.

The Massachusetts Department of Education, an Affirmative Action employer, is committed to ensuring that all of its programs and facilities are accessible to all members of the public. We do not discriminate on the basis of age, color, disability, national origin, race, religion, sex, or sexual orientation.

© 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non- commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Massachusetts Department of Education Child and Adult Care Food Program 5 Nutrition Resource Manual for Adult Day Health Programs 6 IT’S MORE THAN A MEAL

Nutrition and Adult

Table of Contents Nutrition and Adult Day Care Programs Day Health 9 ...... Introduction 10 ...... The Role of your Program in Promoting Health 11 ...... Facts About the Child and Adult Care Programs Food Program (CACFP)

Massachusetts Department of Education Child and Adult Care Food Program 7 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 8 NUTRITION AND ADULT DAY HEALTH PROGRAMS

larify your program’s role in C promoting your participants’ health. Learn how the Child and Adult Care Food Program (CACFP) works to promote good nutrition.

This section will cover the following topics:

TheThis section Role will explainof your the role Program of your program in Promoting in promoting the Healthhealth of your participants who are older adults.

Facts About the Child and Adult Care Food Program (CACFP)This section will also provide some facts about the Child and Adult Care Food Program (CACFP) that you may find useful, whether you are new to CACFP or have already been participating in this program. These include:

• A description of the CACFP program

• The types of facilities that provide CACFP benefits

• How the meals are paid for

• How much federal reimbursement is available

• How programs receive credits for providing meals

• Who prepares the meals for these programs

• Who controls the content of meals

• Where your program can get more information

Massachusetts Department of Education Child and Adult Care Food Program 9 IT’S MORE THAN A MEAL

The Role of Your Program in Promoting Health Recent trends show that more Americans than ever are living longer lives. These days, few older adults live in nursing homes. The majority of older adults live in a community setting with a spouse, family members, or friends, or alone. Preventive health can help maintain or improve their independence and quality of life.

Nutrition and physical activity are important parts of preventive health. Since older adults in day health programs eat many of their meals in this setting, your program can help contribute to a healthful diet. Your program can also play a role (when appropriate) in encouraging physical activity to help improve well-being, increase flexibility, improve bone health, and reduce the risk of falls leading to injuries or fractures.

Many older adults face changes that can affect their food intake and nutritional status. The changes may be physical, health-related, social, or psychological. The nature and extent of these changes will vary among adults. Good nutrition can address many of these changes to help older adults improve their health and maintain their quality of life.

This manual will focus on nutrition and health, nutrients in foods, special needs of older adults, and cultural issues and foods that may be relevant to your program. It will show you how to apply this information to plan healthful meals, and to choose foods that qualify for reimbursement from the Child and Adult Care Food Program. The manual is accompanied by educational materials that you can share with staff, older adults, and caregivers. As you expand your knowledge about nutrition, foods, and cultural issues, you can play a greater role in promoting your participants’ health and well-being.

Nutrition Resource Manual for Adult Day Health Programs 10 NUTRITION AND ADULT DAY HEALTH PROGRAMS

Facts about the Child and Adult Care Food Program (CACFP) WHAT IS CACFP?

CACFP is the Child and Adult Care Food Program. What types of facilities participate in CACFP? This federal program provides healthy meals and Many facilities choose to participate in CACFP. snacks to children in day care centers and adults These may include childcare centers, family day in day health programs. It plays a vital role in care homes, after-school care programs, adult improving the quality of care and making it day health programs, and homeless shelters. more affordable to families. This manual will focus on issues and needs CACFP reimburses participating programs for their relative to adult day health programs. meal costs. There are three tiers of administration Adult day health programs are public, private, for the CACFP program: federal, state and local. nonprofit, and some for-profit adult day health At the federal level, CACFP is managed by the facilities that provide structured, comprehensive Food and Nutrition Service (FNS), an agency of services to functionally impaired, non-resident the U.S. Department of Agriculture. In most adults. To qualify for CACFP meals and snacks, states, the state education department or health adult participants must be functionally impaired department administers CACFP. At the local level, or age 60 and older. They may receive up to 2 independent centers and sponsoring organiza- meals and 1 snack each day at the adult day tions enter into agreements with their state health programs that participate in CACFP. agencies to operate the program. The website address for CACFP is www.fns.usda. How are the meals paid for? gov/cnd/care/cacfp/cacfphome.htm. Some adult day health participants are charged the full price for their meals. Others qualify for free or reduced-price meals. Those from families with annual gross incomes at or below 130% of the federal poverty level may qualify for free meals; those from families with income between 130% and 185% of the federal poverty level may qualify for reduced-price meals; and those from families with income above 185% of the federal poverty level pay full price.

Massachusetts Department of Education Child and Adult Care Food Program 11 IT’S MORE THAN A MEAL

How much reimbursement is available? Who prepares the meals for these programs?

Most programs include meals as part of their Adult day health programs make different fees. Programs receive payments based on the arrangements for meals. Some programs prepare type of meal served and adults’ eligibility for their own meals. Some are located in a nursing free, reduced-price, or paid meals. As of July 1, home that prepares meals for residents as well as 2005,* programs in most states also receive an day health program participants. Some contract average of 17.5 cents in commodities (or cash in out to a vendor for meals. There are a variety lieu of commodities) for each lunch or supper of vendors. Examples are local restaurants, served, in addition to these rates: school food service programs, or community food service agencies that also operate Meals * Rates change annually on July 1. on Wheels programs. Reduced- Meal Type Free Paid Price

Breakfast $1.27 $0.97 $0.23 Who controls the content of the meals?

Lunch or Due to the variety of meal arrangements and $2.32 $1.92 $0.22 Supper vendors, the degree to which your program Snack $0.63 $0.31 $0.05 can influence the content of meals will vary. In all cases, meals and snacks that qualify for

How do programs receive credit for meals? reimbursement in the CACFP must meet standardized specifications (see the CACFP Meal Programs must serve meals and snacks that meet Pattern for Adults in the Crediting Foods section federal guidelines. Information on crediting meals of this manual). These specifications meet and snacks is in the Crediting Foods section of nutrient needs using a variety of food groups, this manual. The USDA has prepared documents in specific quantities of foods, with specific that describe the full set of regulations. kinds of ingredients (such as whole grain or enriched flour). However, the meals may vary in terms of the source of these foods. Some vendors may use USDA commodity foods as ingredients for some of their meals. Other vendors may purchase packaged foods from other sources, or buy fresh foods from a local supplier.

Nutrition Resource Manual for Adult Day Health Programs 12 NUTRITION AND ADULT DAY HEALTH PROGRAMS

Some vendors must comply with regulations Where can your program get more information? different than, or in addition to, those set by • To learn more about the CACFP in CACFP. For example, a school food service vendor Massachusetts, contact the Massachusetts may also be subject to regulations set by its local Department of Education, Nutrition Health school district. A vendor that also provides meals and Safety Unit, 350 Main Street, Malden, for congregate meals in a community center or Massachusetts 02148, phone 781-338-6498. home-delivered meals (such as Meals on Wheels) • To learn about CACFP in other states, must also comply with standards of the U.S. refer to the list of state agencies in the Administration on Aging’s Elderly Nutrition Resources section of this manual. This Program (Elder Affairs Menu Policies and Nutrition list was current as of June 2005. You Standards) which specify that meals provide a can also find the most recent list of state certain amount of calories while staying within agencies at this website: www.fns.usda.gov/ specific guidelines for fat and sodium. cnd/Contacts/StateDirectory.htm. Many adult day health programs do not use the • To learn about USDA’s nutrition assistance CACFP program for snacks. They may have more programs, check the Food and Nutrition options for purchasing food, and for types of Service website at www.fns.usda.gov/fns. foods to serve. You can contact the FNS public information In implementing the recommendations of this staff by phone at 703-305-2286, or by mail manual, your program will need to evaluate the at 3101 Park Center Drive, Room 914, degree of direct control that you have over the Alexandria, Virginia 22302. If you have content of meals and snacks. You can then further questions that state or local agencies decide how many changes you can implement to cannot answer, contact the Food and improve the content and appeal of meals and Nutrition Service headquarters by email at snacks, and to address the diversity of older [email protected]. adults served by your program.

Massachusetts Department of Education Child and Adult Care Food Program 13 Notes

Nutrition Resource Manual for Adult Day Health Programs 14 IT’S MORE THAN A MEAL

Table of Contents

Introduction ...... 17

The 2005 Dietary Guidelines ...... 18

18 ...... Background 18 ...... Basic Messages Nutrition The 2005 Pyramid ...... 21

21 ...... Background 21 ...... Basic Messages 21 ...... Food Groups at Different Calorie Levels Basics 22 ...... Pyramid Food Groups 28 ...... The Pyramid and Physical Activity

Nutrients in Foods ...... 29

29 ...... Protein 29 ...... Carbohydrates 30 ...... Fats and Cholesterol 31 ...... Vitamins 33 ...... Minerals 33 ...... Water

Massachusetts Department of Education Child and Adult Care Food Program 15 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 16 NUTRITION BASICS

his section is a starting point for T learning about good nutrition.

This section will cover the following topics:

1 2

2005What is the Dietary latest advice Guidelines for nutrition and physicaland Pyramidactivity from the U.S. Government? Although most of this advice is geared toward Americans in general, it does include some specific guidelines for older adults.

NutrientsWhat are some keyin nutrientsFoods found in foods? What roles do these nutrients play in promoting health and preventing disease? Which foods and beverages are good sources of these nutrients?

After you learn these basics of good nutrition, you can move on to the next section to learn about the specific nutritional needs of older adults.

1 Information on the Dietary Guidelines has been adapted from the Dietary Guidelines for Americans, 2005, U.S. Department of Health and Human Services, U.S. Department of Agriculture, www.healthierus.gov/dietaryguidelines

2 Information on the Pyramid has been adapted from the MyPyramid food guidance system, 2005, U.S. Department of Agriculture Center for Nutrition Policy and Promotion, www.mypyramid.gov

Massachusetts Department of Education Child and Adult Care Food Program 17 IT’S MORE THAN A MEAL

The 2005 Dietary Guidelines BACKGROUND

The Dietary Guidelines for Americans provide • Additional advice for older adults science-based advice to promote health. They were Consume extra vitamin B12 from fortified first published in 1980 by the U.S. government, foods or supplements. and are revised every five years to reflect the latest Consume extra vitamin D from fortified scientific knowledge. The 2005 edition stresses the foods or supplements. role of diet and physical activity in promoting health and reducing the risk for obesity and Weight Management chronic diseases (such as heart disease, high blood pressure, diabetes, and osteoporosis). • Key recommendations

The Dietary Guidelines translate nutrition To maintain body weight in a healthy range, knowledge into advice for a general eating balance the calories from foods and beverages pattern. The 2005 edition provides a set of with the calories used in exercise and messages that encourage most Americans to daily activities. eat fewer calories, be more active, and make To prevent gradual weight gain as you get wiser food choices. older, make small decreases in how much food you eat (“calories in”) and increase BASIC MESSAGES physical activity (“calories out”).

• Additional advice for overweight adults Adequate Nutrients within Calorie Needs Aim for a slow, steady weight loss by eating fewer calories while eating enough nutrients • Key recommendations and increasing physical activity. Consume a variety of nutrient-dense foods and beverages within the basic food groups. Before starting a weight-loss program, Aim for foods low in saturated fat, trans fat, consult a healthcare provider to manage cholesterol, added sugars, salt, and alcohol. other health conditions.

Adopt a balanced eating pattern such as the USDA Pyramid.

Nutrition Resource Manual for Adult Day Health Programs 18 NUTRITION BASICS

Physical Activity Fats

• Key recommendations • Key recommendations Engage in physical activity to promote Consume less than 10% of daily calories health, psychological well-being, and a from saturated fats.

healthy body weight. Saturated fats Daily calories (up to 10% of calories) Include cardiovascular conditioning, stretching exercises for flexibility, and 1,600 Up to 18 grams resistance exercises or calisthenics for 2,000 Up to 20 grams muscle strength and endurance. 2,500 Up to 25 grams

Keep total fat intake in the range of • Additional advice for older adults 20% to 35% of calories. If you are able to do so, participate in regular physical activity to reduce some of the Most fats should come from foods such as fish, effects of aging. For example, strengthening nuts, and vegetable oils that are good sources muscles and improving balance can reduce of polyunsaturated and monounsaturated fats.

falls and injuries. Choose meat, poultry, and milk products that are lean, low-fat, or fat-free. Food Groups to Encourage Consume as few trans fats as possible.

• Key recommendations Trans fats are hydrogenated or partially Consume plenty of fruits and vegetables hydrogenated fats. while staying within calorie needs. Consume less than 300 milligrams per day

Choose a variety of fruits and vegetables of cholesterol. each day. Select from all 5 vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times each week.

Whole grains should make up at least half of the grains eaten.

Consume 3 cups each day of fat-free milk or equivalent milk products.

Massachusetts Department of Education Child and Adult Care Food Program 19 IT’S MORE THAN A MEAL

Carbohydrates Alcoholic Beverages

• Key recommendations • Key recommendations Choose fiber-rich fruits, vegetables, and Those who drink alcoholic beverages should whole grains often. limit intake to 1 drink per day for women and up to 2 drinks per day for men. Choose foods and beverages with few added sugars or caloric sweeteners. Alcoholic beverages should be avoided by people who abuse alcohol, take medicines Reduce the risk for dental cavities by that interact with alcohol, have certain practicing good oral hygiene. medical conditions, or do activities that • Additional advice for older adults require attention, skill, or coordination Consume foods rich in dietary fiber (such as driving or operating machinery). to help prevent constipation.

Food Safety Sodium and Potassium • Key recommendations • Key recommendations Clean hands and food contact surfaces. Consume less than 2,300 milligrams of Rinse fruits and vegetables before eating them. sodium (about 1 teaspoon of salt) per day. Don’t wash or rinse meat and poultry. This includes the sodium already in foods, plus any salt added at the table. Separate raw, cooked, and ready-to-eat foods.

Choose and prepare foods with little salt. Cook foods to a safe temperature to kill microorganisms. Consume potassium-rich foods, such as fruits and vegetables. Chill (refrigerate) perishable food promptly and defrost foods properly. • Additional advice for older adults and people with high blood pressure • Additional advice for older adults Consume less than 1,500 mg of sodium per day. Older adults have a risk of developing potentially life-threatening illnesses caused Consume at least 4,700 mg of potassium by bacteria. To reduce this risk, avoid per day from food sources. unpasteurized milk; raw or undercooked eggs, meat, poultry, or fish; unpasteurized juices; and raw sprouts. Only eat frankfurters that have been heated to steaming hot.

Nutrition Resource Manual for Adult Day Health Programs 20 NUTRITION BASICS

The 2005 Pyramid BACKGROUND

The USDA Pyramid is an eating pattern based on the Dietary Guidelines. It was developed by the U.S. Department of Agriculture in 1992, and revised in 2005. The 2005 edition is flexible enough to adapt to a wide range of calorie levels, food preferences, and cuisines to meet the needs of different people. An interactive version, MyPyramid, is available on the website www.mypyramid.gov. It estimates how many calories a person needs based on age, gender, and physical activity.

BASIC MESSAGES

• Get the most nutrition out of the day’s calories. • Make smart choices from every food group. • Mix up your choices within each food group. • Find your balance between food and physical activity.

FOOD GROUPS AT DIFFERENT CALORIE LEVELS

Most older adults need to consume about 1600 to 2400 calories per day, unless they have a high level of physical activity. Within each calorie level, the Pyramid gives advice for how many foods to consume within each food group. The next few pages list tips on what counts as a Pyramid serving in each food group. The source of this information is the USDA Pyramid (available at the website address of www.mypyramid.gov).

Note: Pyramid servings may not always be equal to servings of food listed for crediting purposes. Adult day health programs operating under CACFP must follow CACFP Meal Pattern Requirements. See the Crediting Foods section for these requirements.

CALORIE LEVELS FOOD GROUP 1600 1800 2000 2200 2400 Grains 5 oz 6 oz 6 oz 7 oz 8 oz (ounces)

1 1 Vegetables 2 c 2 ⁄2 c2⁄2 c 3 c 3 c (cups)

1 1 Fruits (cups) 1 ⁄2 c 1 ⁄2 c 2 c 2 c 2 c Milk (cups) 3 c 3 c 3 c 3 c 3 c

1 1 Meat and Beans 5 oz 5 oz 5 ⁄2 oz 6 oz 6 ⁄2 oz (ounces) Oils (tsp) 5 tsp 5 tsp 6 tsp 6 tsp 7 tsp

Massachusetts Department of Education Child and Adult Care Food Program 21 IT’S MORE THAN A MEAL

PYRAMID FOOD GROUPS

GRAINS: What Counts as 1 Ounce in the Pyramid?

Note: Pyramid servings may not always be equal to servings of food listed for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements.

1 In general, 1 slice of bread, 1 cup of ready-to-eat cereal, or ⁄2 cup of cooked rice, cooked pasta, or cooked cereal counts as 1 ounce from the grains group.

Larger Portion Sizes Amount that Counts and Their Equivalent Grain Food as 1 ounce of Grains in Ounces of Grains

1 Bagels ⁄2 “mini” bagel 1 large bagel (4 oz) Biscuits 1 small biscuit, 2” 1 large biscuit (2 oz) Breads 1 regular slice 4 snack-size slices

1 Bulgur ⁄2 cup cooked bulgur Cereal, 1 cup cereal flakes 1 Ready-to-eat 1 ⁄4 cup puffed cereal

1 Cereal, ⁄2 cup cooked Oatmeal 1 packet instant Cornbread 1 small piece Crackers 5 whole-wheat crackers 2 rye crisp crackers 7 round crackers

1 English muffins ⁄2 English muffin 1 English muffin (2 oz) Muffins 1 small muffin 1 large muffin (3 oz)

1 Pancakes 1 medium pancake, 4 ⁄2” 3 medium pancakes (3 oz) 2 small pancakes, 3” Popcorn* 3 cups popcorn, popped 1 bag microwave popcorn (4 oz)

1 Rice ⁄2 cup cooked rice 1 cup cooked rice (2 oz) 1 ounce dry rice

1 Pasta – spaghetti, ⁄2 cup cooked pasta 1 cup cooked pasta (2 oz) macaroni, noodles 1 ounce dry pasta Tortillas 1 small tortilla, 6” 1 large tortilla, 12” (4 oz)

* Not a creditable CACFP food.

Nutrition Resource Manual for Adult Day Health Programs 22 NUTRITION BASICS

VEGETABLES: What Counts as 1 Cup in the Pyramid?

Note: Pyramid servings may not always be equal to servings of food listed for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements.

In general, 1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw leafy greens count as 1 cup. Below are specific amounts that count as 1 cup of vegetables. Each week, older adults should consume vegetables from each of the 5 subgroups listed below.

Dark-Green Vegetables Broccoli ...... 1 cup chopped OR 3 spears Greens (collards, mustard greens, kale) ...... 1 cup cooked Spinach ...... 2 cups raw OR 1 cup cooked Raw leafy greens ...... 2 cups raw Orange Vegetables Carrots ...... 1 cup chopped OR 2 medium carrots OR 12 baby carrots Pumpkin ...... 1 cup mashed, cooked Sweet potato ...... 1 large baked OR 1 cup mashed, cooked Winter squash (acorn, butternut, hubbard) . . 1 cup cubed, cooked Dry beans and peas Beans (black, garbanzo, kidney, pinto), soybeans, black-eyed peas, split peas ...... 1 cup, cooked 1 Tofu* ...... 1 cup of ⁄2-inch cubes (8 ounces) Starchy Vegetables Corn, yellow or white ...... 1 cup OR 1 large ear Green peas ...... 1 cup White potatoes ...... 1 cup diced, mashed OR 1 medium potato OR 20 French fries Other Vegetables Bean sprouts ...... 1 cup cooked Cabbage ...... 1 cup, chopped or shredded Celery ...... 1 cup, diced OR 2 large stalks Cucumbers ...... 1 cup raw Green or wax beans ...... 1 cup cooked Green or red peppers ...... 1 large pepper OR 1 cup chopped Lettuce, iceberg or head ...... 2 cups, chopped Mushrooms ...... 1 cup raw or cooked Onions ...... 1 cup chopped, raw or cooked Tomatoes ...... 1 large raw whole OR 1 cup chopped Tomato or mixed vegetable juice ...... 1 cup Summer squash or zucchini ...... 1 cup cooked, sliced or diced

* Not a creditable CACFP food

Massachusetts Department of Education Child and Adult Care Food Program 23 IT’S MORE THAN A MEAL

FRUITS: What Counts as 1 Cup in the Pyramid?

Note: Pyramid servings may not always be equal to servings of food listed for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements.

1 In general, 1 cup of fruit or 100% fruit juice, or ⁄2 cup of dried fruit counts as 1 cup from the fruit group. The following specific amounts count as 1 cup of fruit.

Fruit Amount that Counts as 1 Cup of Fruit

1 Apple ...... ⁄2 large OR 1 small 1 cup sliced or chopped Applesauce ...... 1 cup Banana ...... 1 large OR 1 cup sliced Cantaloupe ...... 1 cup diced Grapes ...... 1 cup OR 32 grapes Grapefruit ...... 1 medium OR 1 cup of sections Mixed fruit/Fruit cocktail ...... 1 cup Orange ...... 1 large OR 1 cup of sections Peach ...... 1 large OR 1 cup sliced or diced 2 halves, canned Pear ...... 1 medium OR 1 cup sliced or diced Pineapple ...... 1 cup chunks, sliced or crushed Plum ...... 1 cup sliced OR 3 medium OR 2 large plums Strawberries ...... About 8 large berries OR 1 cup Watermelon ...... 1 small wedge (1” thick) 1 cup diced

1 Dried fruit (raisins, prunes, etc.) ...... ⁄2 cup 100% Fruit juice (orange, apple, etc.) ...... 1 cup

Nutrition Resource Manual for Adult Day Health Programs 24 NUTRITION BASICS

MILK, YOGURT, AND CHEESE: What Counts as 1 Cup in the Pyramid?

Note: Pyramid servings may not always be equal to servings of food listed for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements

Food or Beverage Amount that Counts as 1 Cup of Milk Milk Choose fat-free or 1 cup of fluid milk low-fat milk most often. 1 half-pint container of fluid milk 1 ⁄2 cup evaporated milk Yogurt* Choose fat-free or low-fat 1 regular container (8 fluid ounces) yogurt most often. 1 cup Cheese* 1 Choose low-fat cheeses 1 ⁄2 oz hard cheese most often. (cheddar, mozzarella, Swiss, parmesan) 2 oz processed cheese (American) 1 ⁄3 cup shredded cheese 1 ⁄2 cup ricotta cheese 2 cups cottage cheese Milk-based desserts* Choose fat-free or low-fat 1 cup pudding made with milk types most often. 1 cup frozen yogurt 1 1 ⁄2 cups ice cream (3 scoops)

* Not CACFP-creditable as fluid milk.

Massachusetts Department of Education Child and Adult Care Food Program 25 IT’S MORE THAN A MEAL

MEAT, POULTRY, FISH, DRY BEANS, EGGS, AND NUTS: What Counts as 1 Ounce in the Pyramid?

Note: Pyramid servings may not always be equal to servings of food listed for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements

1 In general, 1 ounce of meat, poultry or fish, ⁄4 cup cooked dry beans, 1 egg, 1 tablespoon of peanut

1 butter, or ⁄2 ounce of nuts or seeds count as a 1 ounce equivalent.

Foods Amount that Counts Common Portion Sizes as 1 Ounce of Meat and Their Equivalent

Meats 1 oz lean beef, cooked 1 small steak (4 oz) 1 oz lean pork or ham, cooked 1 small lean hamburger (3 oz)

1 Poultry 1 oz chicken or turkey, cooked, no skin ⁄2 small chicken breast (3 oz) 1 1 sandwich-sized slice of turkey ⁄2 Cornish game hen (4 oz)

Fish 1 oz fish or shellfish, cooked 1 can of tuna, drained (3 oz) 1 salmon steak (4 to 6 oz) 1 small trout (3 oz)

Eggs 1 egg

1 Nuts & seeds ⁄2 oz nuts 1 oz nuts or seeds 1 ⁄2 oz seeds, hulled (counts as 2 oz meat) (pumpkin, sunflower or squash) 1 Tbsp peanut butter

1 Dry beans ⁄4 cup cooked dry beans 1 cup split pea soup 1 & peas ⁄4 cup cooked dry peas (counts as 2 oz meat) 1 ⁄4 cup baked beans or refried beans 1 cup bean soup 1 ⁄4 cup roasted soybeans (counts as 2 oz meat) 1 ⁄4 cup (about 2 oz) tofu* 1 soy patty 2 Tbsp hummus (counts as 2 oz meat)

* Not a creditable CACFP food.

Nutrition Resource Manual for Adult Day Health Programs 26 NUTRITION BASICS

OILS: How Much Are in Foods?

Note: Pyramid servings may not always be equal to servings of food listed for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements

Amount of Food Amount of Oil

Vegetable Oils 1 Tbsp 3 tsp

Foods Rich in Oils: 1 Margarine, soft (trans fat free) 1 Tbsp 2 ⁄2 tsp 1 Mayonnaise 1 Tbsp 2 ⁄2 tsp Salad dressing, mayonnaise-type 1 Tbsp 1 tsp Salad dressing, Italian 2 Tbsp 2 tsp 1 Salad dressing, Thousand Island 2 Tbsp 2 ⁄2 tsp 1 Olives, ripe, canned 4 large ⁄2 tsp 1 Avocado1 ⁄2 medium 3 tsp Peanut butter2 2 Tbsp 4 tsp Peanuts, dry roasted2 1 oz 3 tsp Nuts, dry roasted2 1 oz 3 tsp Sunflower seeds2 1 oz 3 tsp

1. Avocados are part of the fruit group. 2. Nuts and seeds are part of the meat and beans group.

Massachusetts Department of Education Child and Adult Care Food Program 27 IT’S MORE THAN A MEAL

THE PYRAMID AND PHYSICAL ACTIVITY

What is Physical Activity? • Resistance, strength building, and weight- bearing activity help maintain bones and Physical activity is movement of the body that muscles by working them against gravity. uses energy. Walking, gardening, and climbing Examples are lifting weights and walking. the stairs are examples. Physical activity and nutrition work together for better health. • Balance and stretching activities enhance physical stability and flexibility, which reduces

What are the Benefits? risk of injuries. Examples are gentle stretch, dance, yoga, and tai chi. • Improved self-esteem and feeling of well-being. How Much Physical Activity is Needed? • Increased fitness level. If possible, do moderate intensity activity for • Building and maintaining bones, muscles, at least 30 minutes most days of the week, in and joints. addition to usual daily activities. Increasing the • Building endurance and muscle strength. intensity or time can have extra health benefits

• Increased flexibility and better posture. and may help control body weight. Older adults should see a health care provider before starting • Helping to manage weight. any physical activity program. • Lower risk of heart disease, colon cancer, and type 2 diabetes. Tips to Increase Physical Activity • Helping to control blood pressure. • Make physical activity a regular part of the • Reduced feelings of depression and anxiety. day. Choose activities that are enjoyable and can be done regularly. Fit activity into a daily

Do Different Types of Physical Activity routine. It helps to be active most days of the Provide Different Benefits? week and make it part of daily routine. Aim for at least 10 minutes of activity at a time. Shorter • Aerobic activities speed the heart rate and bursts will not have the same health benefits. breathing, and improve heart and lung fitness. Examples are brisk walking, jogging, • Ideas for older adults: walk with others, do and swimming. strength and flexibility exercises, care for a garden, take a yoga class, do upper body exercises, or take a nature walk.

Nutrition Resource Manual for Adult Day Health Programs 28 NUTRITION BASICS

Nutrients in Foods Many nutrients are needed to maintain health. Some food sources of protein include: These include protein, carbohydrates, fat, vitamins, • Meat/Meat Alternates: meat, fish, poultry, dry minerals and water. Most foods contain more than beans, dry peas, nuts and seeds, cheeses, one nutrient. To provide the greatest amount of yogurt nutrients, serve a variety of foods in meals and • Milk: fluid milk snacks throughout the week. Some foods provide more nutrients than others. Also, a food may be a good source of some vitamins and minerals, but still lack other important ones. A “perfect” CARBOHYDRATES food with all essential nutrients does not exist. Carbohydrates provide energy to the body. They The next few pages describe several key nutrients come in three forms: sugar, starch, and fiber. and list the foods that are good sources of these Sugars either occur naturally in foods, or are nutrients. The food groups listed are based on added to foods during processing or at the table. CACFP meal patterns. The examples provided are Naturally-occurring sugars are in milk, fruits, creditable foods in the CACFP program and do fruit juices, and vegetables. These foods contain not necessarily follow the Pyramid guidelines. some sugar, along with nutrients important to For example, yogurt counts as a serving from the health. Added sugars are found in processed and milk group in the Pyramid; however, in the sugary foods and beverages, such as doughnuts, CACFP pattern, only fluid milk can count as a cakes, cookies, hard candy, and soda. They include serving in this category. brown sugar, cane sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, high fructose PROTEIN corn syrup, honey, invert sugar, lactose, malt Proteins play a role in growth, maintenance, and syrup, maltose, maple syrup, molasses, sucrose, repair of body tissues. They form certain hormones and sugar syrup. Limiting foods and beverages and enzymes that regulate body processes. They with added sugars can help maintain a healthy also help fight infections and heal wounds. As a weight, and can make room in the diet for more result, protein needs can increase during surgery, nutritious foods. illness, or disease. Older adults lose protein easily due to the loss of skeletal muscle.

Massachusetts Department of Education Child and Adult Care Food Program 29 IT’S MORE THAN A MEAL

Major Sources of Added Sugars in the United States

• Soft drinks • Ice cream and other dairy desserts • Cakes, cookies, and pies • Hard candy • Fruit drinks such as fruit punch and lemonade

Adapted from U.S. Department of Agriculture, United States Department of Health and Human Services. Home and Garden Bulletin Number 232; Dietary Guidelines for Americans, 2000.

Starch is a major source of energy for the body. • Grains/Breads: whole grains such as brown Sources of starch include grains (wheat, oats, rice, bulgur, whole grain corn, oatmeal, corn, rice) and products made from grains such popcorn, pearl barley, whole oats, whole rye, as flour, pasta, breads and cereals. Other sources whole wheat are starchy vegetables such as potatoes, sweet • Meat/Meat Alternates: dry beans, potatoes, and dry beans. dry peas, lentils Dietary fiber is present in plant foods. It is not See the section on Planning Meals and Snacks broken down during digestion. Eating fiber- for tips on increasing dietary fiber. containing foods such as fruits, vegetables, and whole grains promotes proper bowel function. FATS AND CHOLESTEROL Dietary fiber provides bulk for stool formation and prevents constipation. Fats supply energy and essential fatty acids. Fats are the most concentrated calorie source in the Consuming dietary fiber may help satisfy the diet (1 gram of fat provides 9 calories, while appetite by creating a satisfying full feeling. 1 gram of protein or carbohydrate provides 4 Eating plenty of fruits, vegetables, and whole calories). Fats are required for brain develop- grain foods as part of a healthy eating pattern ment, vision, forming some hormones, and pro- may also help protect against some chronic tecting the organs. They also transport vitamins diseases. Fiber may also help control blood A, D, E and K in the body. sugar levels in people with diabetes. We need some fat in our diets. However, we Some food sources of fiber include: should try not to eat too much fat. The Dietary

• Fruits: apples, bananas, blueberries, Guidelines advise that most people keep their cantaloupe, cherries, peaches, pears, total fat intake in the range of 20% to 35% of prunes, raspberries, strawberries calories, and limit their saturated fat intake to no more than 10% of calories. • Vegetables: broccoli, carrots, cauliflower, celery, corn, green beans, peppers, potatoes, tomatoes

Nutrition Resource Manual for Adult Day Health Programs 30 NUTRITION BASICS

Foods contain different types of fats known as cholesterol is only found in foods of animal origin saturated, monounsaturated, polyunsaturated, such as meat, milk, cheese, and eggs. Some foods and trans fats. Different foods contain different that contain fat, saturated fat and cholesterol also amounts of each type of fat. contain high-quality protein and are good sources of certain vitamins and minerals. Most varieties Saturated fats are present in most fats, but many of lean meat, poultry and fish contain similar animal fats contain more saturated fat than fat amounts of cholesterol per serving. However, from plant foods, except tropical oils (e.g., palm organ meats such as liver, heart, and kidney and coconut oils). Foods high in saturated fats contain more cholesterol than other meats. tend to raise blood cholesterol. These foods include high fat dairy products (cheese, whole milk, cream, butter, and regular ice cream), fatty VITAMINS meats, poultry skin, poultry fat, lard, palm oil, The body needs vitamins to function properly. and coconut oil. Many chemical reactions in the body depend on Unsaturated fats are liquid at room temperature. vitamins. As adults age, they may need vitamin D Using monounsaturated and polyunsaturated fats and B12 supplements because their bodies cannot in place of saturated fats can help keep blood absorb these vitamins efficiently. cholesterol levels down. Vitamin A is an antioxidant that helps protect • Monounsaturated fats are found in large the body’s cells from damage. It is important for amounts in olive, canola, and peanut oils. healthy skin, hair, and mucous membranes. It helps people see in dim light. Beta-carotene, a •Polyunsaturated fats are found in corn, precursor of vitamin A, may reduce the risk of soybean, cottonseed, and safflower oils. chronic diseases and macular degeneration. Trans fats can raise blood cholesterol levels because they act like saturated fats. They are Some food sources of vitamin A include: found in hydrogenated vegetable oils. Foods high in these oils are commercially-made baked • Fruits: cantaloupe, mandarin oranges, goods (such as muffins, pastries, doughnuts), mangos, nectarines, peaches, plums snack crackers, and fried foods. • Vegetables: broccoli, carrots, greens, kale,

Cholesterol is a fat-like substance produced in pumpkin, spinach, winter squash, sweet humans and animals. It is used to make hormones, potatoes, tomatoes cell membranes, and other body substances. High • Meat/Meat Alternates: liver, whole blood cholesterol levels increase the risk of heart eggs, yogurt disease. Eating foods high in saturated fat and • Milk: fluid milk cholesterol may affect cholesterol levels. Dietary

Massachusetts Department of Education Child and Adult Care Food Program 31 IT’S MORE THAN A MEAL

Vitamin C is an antioxidant that helps protect • Oils: vegetable oils such as corn, cottonseed, the body’s cells from damage. It plays a role in safflower, and soybean oils; mayonnaise, forming collagen, a protein that gives structure margarine, salad dressing to bones and muscles. Vitamin C also helps the Folate (also called folic acid or folacin) is a body absorb iron. B-vitamin that helps build cells. It plays a role Some food sources of vitamin C include: in red blood cell production.

• Fruits: cantaloupe, citrus fruits and juices Some food sources of folate include: (grapefruit, orange, etc.), kiwi, pineapple, • Meat/Meat Alternates: black-eyed peas, raspberries, strawberries, watermelon lentils, red kidney beans • Vegetables: asparagus, broccoli, cabbage, • Vegetables: green peas, leafy green vegetables cauliflower, kale, peppers, romaine lettuce, (such as spinach and mustard greens), spinach, sweet potatoes, tomatoes romaine lettuce, spinach Vitamin D is needed to build and maintain strong • Grains/Breads: whole-grain bread products; bones because it helps the body absorb calcium. fortified ready-to-eat breads, cereals, pasta Your skin can make vitamin D from sunlight, but • Fruits: melons, oranges, orange juice, plums, loses some of this ability with aging. raspberries, strawberries, tangerines Some food sources of vitamin D include: The other B vitamins (besides folate) are thiamin, • Meat/Meat Alternates: fatty fish riboflavin, niacin, and vitamins B6 and B12. They (e.g., salmon, mackerel) help the body release energy during metabolism. • Milk: vitamin D-fortified fluid milk Vitamin B12 is found only in animal-based foods or vitamin B12-fortified foods. Vitamin E is another antioxidant. It helps keep cell membranes stable and regulates oxidation Some food sources of B vitamins include: reactions in the body. • Grains/Breads: Enriched and fortified bread Some food sources of vitamin E include: products are good sources of thiamin, riboflavin, niacin, and vitamin B6. • Meat/Meat Alternates: nuts, seeds, salmon, shellfish, shrimp • Meat/Meat Alternates: Pork products are

• Fruits: apples, apricots, nectarines, peaches good sources of thiamin. Poultry and fish are good sources of niacin. All meats are a good • Vegetables: dark green leafy vegetables, source of vitamin B12. pumpkin • Milk: Fluid milk is a good source of riboflavin. • Grains/Breads: multi-grain and enriched breads and cereals

Nutrition Resource Manual for Adult Day Health Programs 32 NUTRITION BASICS

MINERALS WATER

Minerals have important roles in the body systems. Water is often a “forgotten nutrient.” It plays They help convert carbohydrate, protein, and vital roles in transporting nutrients throughout fat into energy. They help maintain body fluids. the body, removing wastes, and regulating body They also play a role in muscle contractions. temperature. Water is an important part of an Examples are calcium, iodine, iron, magnesium, adequate diet. It is needed to replace body potassium, sodium, and zinc. water lost in urine, sweat, and the breath.

Iron is used to make hemoglobin in red blood cells. Dehydration is a common problem for many Its primary role is to carry oxygen in the body, seniors. A decreased thirst sensation and use of both in the blood and muscles. If the body has medications may affect the body’s ability to low iron levels, energy levels may seem low, too. regulate fluid balance. Dehydration worsens symptoms of kidney dysfunction and constipation. Some food sources of iron include: To prevent dehydration, older adults need at • Meat/Meat Alternates: dry beans, least 8 cups of fluids each day. Many sources dry peas, eggs, meat, poultry can contribute toward the recommendation for • Grains/Breads: whole grain, fortified, fluid: water, fruit juices, milk, soups, fruit, and or enriched breads and cereals decaffeinated coffee and tea.

• Vegetables: dark green leafy vegetables, For more information on fluids, see the section dry beans, dry peas, lima beans, spinach on Special Nutrition Needs of Older Adults.

Calcium helps the body build and maintain bones and teeth. It also helps muscles to contract, blood to clot, and nerves to send messages. Older adults may need calcium supplements in their diets.

Some food sources of calcium include:

• Milk: fluid milk

• Vegetables: broccoli, spinach, turnip greens, collards

• Fruits: calcium-fortified orange juice

• Meat/Meat Alternates: cheeses, yogurt

• Grains/Breads: calcium-fortified products such as breakfast cereals

Massachusetts Department of Education Child and Adult Care Food Program 33 Notes

Nutrition Resource Manual for Adult Day Health Programs 34 IT’S MORE

Table of Contents THAN A MEAL

Introduction ...... 37

Aging and Nutritional Well-Being ...... 38

Good Nutrition for Seniors ...... 39

Determining Nutritional Risk ...... 39

Nutritional Risk Checklist ...... 40

Promoting Fluid Intake ...... 42

Nutrient and Calorie Needs ...... 43 Obesity ...... 44 Special Chronic Diseases ...... 44

44 ...... Heart Disease 46 ...... High Blood Pressure 47 ...... Diabetes Nutrition 51 ...... Osteoporosis

Food Allergies and Intolerances ...... 52 Dietary Supplements ...... 54 Needs of Medicines and Older Adults ...... 55

Barriers to Healthy Eating ...... 57 57 ...... Poor Appetite Older 57 ...... Dental Problems 58 ...... Swallowing Problems 59 ...... Sensory Impairments Adults 60 ...... Cognitive Impairments

Massachusetts Department of Education Child and Adult Care Food Program 35 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 36 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

ow that you have This section will cover the following topics: N learned the basics of good nutrition, you can learn AgingHow does theand aging Nutritional process affect nutritional Well-Being health? about some special nutrition needs that older adults may have. GoodWhat are someNutrition goals for good for nutrition? Seniors

DeterminingHow can you identify Nutritionaladults at risk of poor Risk nutrition?

Fluid,Why do older Nutrient, adults need andplenty ofCalorie fluids? Needs How can older adults meet their nutrient needs?

ObesityWhat causes some older adults to gain excess weight?

ChrWhich onicchronic Diseasesdiseases have a link to nutrition?

FoodWhat are Allergiessome examples andof food Intolerances allergies or intolerances? What are the symptoms of a serious allergic reaction?

DietaryShould older adultsSupplements use vitamin, mineral, or herbal supplements?

Caution: Adult day health staff should never diagnose health conditions; prescribe supplements; MedicinesWhat are some common and sideOlder effects Adultsof medicines? put participants on special diets; How do medicines affect the nutritional status of older adults? nor revise, change or interpret diet orders. These roles are the responsibility of your participants’ health care providers. BarrierWhat barrierss mightto Healthy prevent older Eating adults from eating well? How can you address these barriers to promote healthy eating?

Massachusetts Department of Education Child and Adult Care Food Program 37 IT’S MORE THAN A MEAL

AgingMany older and adults Nutritionalface changes that Well-Beingcan affect their food intake and nutritional status. The changes may be physical, health-related, social, or psychological. The nature and extent of these changes will vary among adults. Good nutrition can help older adults to improve their health and maintain their quality of life, in spite of these changes.

PHYSICAL CHANGES

• Older adults may need fewer calories to maintain their weight, but still need the same amounts (or even more) of vitamins and minerals as they did in their younger years.

• Changes in vision, taste, or smell can affect appetite or enjoyment of foods.

• Dental problems may limit intake of certain foods.

• Digestive changes can affect the way the body absorbs certain nutrients.

• A decreased sense of thirst can raise the risk of dehydration.

CHANGES IN HEALTH STATUS

• Immune function may decline and prolong recovery from illness.

• Aging can affect how medicines work in the body, and how they interact with foods. Medicines can alter appetite or taste.

• Acute illness can lead to decreased appetite.

• Older adults are at increased risk for chronic diseases such as obesity, diabetes, heart disease, high blood pressure, cancer, or osteoporosis.

PSYCHOLOGICAL OR SOCIAL CHANGES

• The loss of a spouse or partner can lead to changes in eating patterns.

• Less income after retirement may lead to cutting nutritious foods from the budget.

• A reduced ability to drive may make it hard to buy food from the grocery store.

• Cognitively impaired adults are less able to buy foods, prepare meals, or use utensils.

Nutrition Resource Manual for Adult Day Health Programs 38 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

GoodThe following Nutrition are goals to forhelp maintain Seniors the health and nutritional status of older adults. By following the advice of the Dietary Guidelines and USDA Pyramid, along with additional advice in this manual, you can plan meals and strategies to help meet these goals:

• Meet nutrient needs on fewer calories. • Increase the appeal of meals.

• Eat a variety of nutritious foods. • Address any barriers to healthy eating.

• Eat more dietary fiber. • Stay physically active, if possible.

• Consume enough fluids. • Prevent or treat chronic diseases.

• Maintain health and nutritional status. • Minimize food/drug interactions.

DOlderetermining adults who consume Nutritional low levels of Risknutrients may be at risk for poor nutrition. The risk may be compounded by self-medication, alcohol, disease, dental problems, or physical limitations. Identifying problems early may help older adults to live longer, healthier lives.

The Nutrition Screening Initiative has developed a screening tool called Determine Your Nutritional Health (see an adapted version titled Nutritional Risk Checklist on the next two pages) to assess nutritional risk in older adults. The goal of the checklist is to identify potentially high-risk adults before the appearance of any signs or symptoms of poor nutrition. This tool helps to determine whether an older adult might need medical or nutritional assistance. You should refer any high-risk older adult to a dietitian, physician, or other heath care professional.

Massachusetts Department of Education Child and Adult Care Food Program 39 IT’S MORE THAN A MEAL

NutritionalKnow the warning Risksigns of Checkpoor nutritional List health. Use this checklist to learn whether you, or someone you know, is at risk for poor nutrition.

Read the statements below. For each YES answer, circle the number in the “yes” column. Then total the score.

STATEMENT YES I have an illness or condition that has made me change 2 the amount or kind of food that I eat. I eat fewer than 2 meals each day. 3 I have 3 or more drinks of beer, liquor, or wine, almost every day. 2 I eat few fruits, vegetables, or milk products. 2 I have tooth or muscle problems that make if hard to me to eat. 2 I don’t always have enough money to buy the food I need. 4 I eat alone most of the time. 1 I take 3 or more different prescription or over-the counter medicines each day. 1 In the last 6 months, I’ve lost or gained 10 pounds without wanting to. 2 I am not always physically able to shop, cook, or feed myself. 2

TOTAL:

SCORE WHAT DOES THIS SCORE MEAN? 0 to 2 GOOD! Re-check your score in 6 months. 3 to 5 You are at MODERATE nutritional risk. Try to improve your eating habits and lifestyle. Seek advice from your office on aging, senior nutrition program, senior center, or health department. 6 or more You are at HIGH nutritional risk. Bring this checklist to your next appointment with your doctor, dietitian, or other qualified health professional. Tell them about any problems you may have. Ask for help to improve your nutritional health.

Note: These warning signs suggest risk, but they are not meant to diagnose any condition. Turn the page to learn more about the warning signs of poor nutritional health.

Adapted from: Determine Your Nutritional Health, developed by the Nutrition Screening Initiative. A project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging.

Nutrition Resource Manual for Adult Day Health Programs 40 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

USE THE WORD DETERMINE TO REMIND YOU OF THE WARNING SIGNS.

D ISEASE Disease, illness, or chronic conditions affect the way that people eat. Confusion or memo- ry loss can make it hard to remember what, or whether, they have eaten a meal. Feeling depressed can affect appetite, digestion, energy level, weight, and well-being. E ATING POORLY Poor nutritional health can be caused by eating too little, eating too much, skipping meals, or eating the same foods day after day. It can also be caused by eating too few fruits, vegetables, or milk products. T OOTH LOSS OR MOUTH PAIN Missing or loose teeth, or poor-fitting dentures, can make it hard to eat. E CONOMIC HARDSHIP People on a reduced income may find it hard to afford the foods they need. R EDUCED SOCIAL CONTACT Having fewer contacts with other people can have a negative effect on morale, well-being, and appetite. MULTIPLE MEDICINES Growing old may change the way that older adults respond to these medicines. The more medicines that they take, the greater the risk for side effects such as constipation, diarrhea, drowsiness, nausea, or a change in appetite or taste. I NVOLUNTARY WEIGHT LOSS OR GAIN This is an important warning sign that should not be ignored. N EEDS ASSISTANCE IN SELF-CARE Some older adults have trouble walking, shopping, or buying or cooking food. E LDER YEARS ABOVE AGE 80 Most older people lead full and productive lives. But as age increases, the risk of frailty or health problems increases.

Adapted from: Determine Your Nutritional Health, developed by the Nutrition Screening Initiative. A project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging.

Massachusetts Department of Education Child and Adult Care Food Program 41 IT’S MORE THAN A MEAL

Promoting Fluid Intake FLUIDS ARE IMPORTANT AT ANY AGE

Fluids play important roles in the body. They prevent constipation, regulate body temperature, carry nutrients to cells, and regulate the balance of fluids in body cells. They also make it easier for people to chew and swallow foods.

Every day, people lose fluids when they sweat, breathe, urinate, and have bowel movements. Thus, they need to replenish fluids to prevent dehydration and help their bodies function smoothly.

AGING AND FLUID NEEDS

1 As adults get older, they continue to need about 1 ⁄2 to 2 liters of fluids each day. However, older adults may find it harder to maintain fluid balance, for several reasons:

• They may have a reduced sense of thirst, leading them to drink less fluids.

• They may drink less fluids due to poor bladder control, poor mobility, or illnesses.

• Their bodies may have lost water due to diarrhea or poor intestinal absorption.

• They may use diuretics and laxatives that raise the risk for dehydration.

• They may be using other medications that increase fluid needs.

PREVENTING DEHYDRATION

Dehydration can be a serious health problem for older adults. To prevent dehydration, many experts recommend consuming at least 8 cups of fluids each day. Fluids are not limited to water! Fruit juice, milk, soup, fruit, and decaffeinated coffee and tea also count.

Your day health program can help promote fluid intake by offering fluids every 2 or 3 hours, including with meals and snacks. Encourage older adults to drink fluids regularly, since they may fail to recognize their thirst.

Nutrition Resource Manual for Adult Day Health Programs 42 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

Nutrient and Calorie Needs

AGING AND CALORIE NEEDS ESTIMATED CALORIE NEEDS FOR ADULTS 51 YEARS AND OLDER Compared to their younger years, older adults need fewer calories to maintain their weight. Sedentary Moderately Active Active This is because their metabolism tends to slow down, and because they may be less physically Women 1600 1800 2000-2200 active. The chart at right lists the estimated Men 2000 2200-2400 2400-2800 daily calorie needs for older adults based on Source: Dietary Guidelines for Americans, 2005. their level of physical activity.

FINDING THE RIGHT BALANCE Older adults need the right balance between eating too many calories or too few calories. Too many calories can lead to obesity, which raises the risk for high blood pressure, diabetes, heart attack, and stroke. Too few calories can lead to weight loss, frailty, or fatigue, and can prevent adequate intake of essential nutrients.

MEETING NUTRIENT AND CALORIE NEEDS While calorie needs decrease with aging, vitamin and mineral needs remain the same. In fact, the need for some nutrients (such as vitamin B6, vitamin D, and calcium) increases. Thus, older people face the challenge of meeting their nutrient needs on fewer calories. For this reason, they should choose a variety of nutrient-dense foods each day.

Nutrient-dense foods are rich in vitamins and minerals and relatively low in calories. Examples are whole grain breads, fortified cereals, fruits and vegetables, lean meats, and low-fat dairy products. Because each food group provides a variety of nutrients, it is important to include all food groups in the daily diet. It is also important to vary choices within each food group.

Foods with a low nutrient density provide calories but few vitamins and minerals. They have added sugars, saturated fats, trans fats, and alcohol. Regularly eating these foods makes it hard to get enough nutrients without gaining weight, especially for people with sedentary lifestyles.

Many Americans (including older adults) consume more calories than they need without getting enough nutrients. They should choose foods and beverages that are high in nutrients, but low to moderate in calories. Overall, they should eat more fruits, vegetables, whole grains, legumes, and low-fat milk and milk products. They should eat less refined grains, cholesterol, saturated fats, trans fats, salt, and added sugars.

Massachusetts Department of Education Child and Adult Care Food Program 43 IT’S MORE THAN A MEAL

Obesity Chronic Diseases WHY OBESITY IS A PROBLEM HEART DISEASE The prevalence of obesity in the U.S. has doubled Coronary heart disease involves a progressive in the past two decades. Obesity raises the risk for blockage of coronary arteries that reduces blood premature death, type 2 diabetes, high blood flow to the heart. This can raise the risk of chest pressure, stroke, heart disease, gall bladder disease, pain, heart attack, and death. Coronary heart gout, osteoarthritis, and some types of cancers. disease is the leading cause of death among older adults. CAUSES OF WEIGHT GAIN There are many possible causes of weight gain If too much cholesterol circulates in the blood, in older adults. The major cause is being less it can build up in the walls of the arteries. physically active. Other possible causes are Over time, the arteries become narrow and slow burning fewer calories with age due to a slower down the blood flow to the heart. Since blood metabolism; having an underactive thyroid or carries oxygen to the heart, chest pains can occur other medical disorder; or taking medications when less oxygen is available. If no oxygen gets with a side effect of promoting weight gain. to the heart, a heart attack can happen.

ACHIEVING AN OPTIMAL BODY WEIGHT Risk Factors for Heart Disease Ideally, adults should achieve and maintain a body • Some risk factors are beyond control. weight that is good for their health. For obese They include age (45 or older for men; adults, even losing as little as 10 pounds provides 55 or older for women) and family history health benefits. Reducing caloric intake by as little of early heart disease. as 50 to 100 calories per day may help prevent weight gain. Eating 500 fewer calories per day is a • Other risk factors can be controlled through common goal in weight-loss programs. Strategies diet and lifestyle changes. These include high to reduce calories include serving smaller portion blood pressure, high blood cholesterol, high sizes, and serving foods with fewer calories, such LDL (“bad” cholesterol), low HDL (“good” as low-fat foods and foods without added sugars. cholesterol), cigarette smoking, diabetes, overweight, and lack of exercise. TREATING OBESITY Treating obesity requires the advice and supervision of a participant’s health care providers (doctor, registered dietitian, and nurse). It may involve a supervised program of diet and exercise.

Nutrition Resource Manual for Adult Day Health Programs 44 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

What do the Numbers Mean?

Different types of cholesterol and fat travel • HDL cholesterol (high-density lipoprotein) is through the body. the “good” cholesterol. It prevents

• LDL cholesterol (low-density lipoprotein) is cholesterol from building up in the arteries; called the “bad” cholesterol. therefore, it protects against heart disease. It is the main cause of cholesterol build-up • Total cholesterol is the sum of LDL, VLDL and blockage in arteries. and HDL cholesterol levels.

• VLDL cholesterol (very low-density lipoprotein) • Triglyceride is a type of fat in the blood that is also called “bad” cholesterol because it acts can raise the risk of heart disease. in much the same way as LDL cholesterol.

IDEAL LEVELS OF CHOLESTEROL AND TRIGLYCERIDES TO REDUCE THE RISK OF HEART DISEASE

Blood Level: Aim for: Total Cholesterol Less than 200 mg/dL LDL Cholesterol • Low risk patients ...... Less than 160 mg/dL • Moderately high risk patients ...... Less than 130 mg/dL • High risk patients ...... Less than 100 mg/dL • Very high risk patients...... Less than 70 mg/dL HDL Cholesterol More than 60 mg/dL Triglycerides Less than 150 mg/dL

Source: National Cholesterol Education Program Adult Treatment Panel III, 2004.

Preventing and Treating Heart Disease To help prevent heart disease, adults should work with their health care providers to change their diets and lifestyles. A heart-healthy eating plan can help control the risk factors of high blood pressure, high cholesterol levels, overweight, and diabetes.

Serving heart-healthy meals and incorporating physical activity into the daily routine can help older adults lower their risk of heart disease. A heart-healthy eating plan provides less than 30% of calories from fat. It includes foods low in saturated fat, cholesterol, and sodium. It also includes fiber from whole grains, fruits, and vegetables.

Treating heart disease may involve a prescribed diet, medications, and a supervised physical activity program. It also may require surgery.

Massachusetts Department of Education Child and Adult Care Food Program 45 IT’S MORE THAN A MEAL

HIGH BLOOD PRESSURE

Blood pressure is the force that blood exerts against the artery walls. It is measured in two Normal High Blood Pressure Blood Pressure numbers. The top number is systolic pressure (as the heart beats). The bottom number is diastolic Systolic 120 or less 140 or higher pressure (as the heart relaxes between beats). Diastolic 80 or less 90 or higher Blood pressure is affected by several factors and Source: Your Guide to Lowering Blood Pressure, can vary over the course of a day. Therefore, National Institutes of Health, 2003. blood pressure measures should be repeated over a few days to get an accurate reading.

High blood pressure, or hypertension, is blood Guidelines to Help Prevent High Blood Pressure pressure that remains elevated for a long time. • Maintain a healthy weight. It is prevalent in older adults, and often has no • Include fruits, vegetables, low-fat dairy foods. warning signs or symptoms. It can be dangerous because it makes the heart overwork and raises • Choose foods with less salt and sodium. the risk of atherosclerosis (buildup of fat in • Limit alcohol intake. arteries). It can also lead to kidney disease or • Be physically active. congestive heart failure.

Treating High Blood Pressure Sodium and Blood Pressure Treating high blood pressure may involve Sodium plays a major role in controlling blood following the guidelines above, along with stricter pressure, since it helps maintain fluid pressure sodium restrictions. People unable to control within the blood. For some people, consuming their high blood pressure with diet and lifestyle foods high in salt can lead to elevated sodium changes alone may also require medications such levels in the body, which can result in high as diuretics and other drugs. This may especially blood pressure. be true if they have a strong family history of high blood pressure.

Nutrition Resource Manual for Adult Day Health Programs 46 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

Focus on Sodium

• According to the Dietary Guidelines, most Type 2 diabetes is most prevalent in adults. people should aim for less than 2,300 mg of The body makes insulin, but cannot use it sodium per day. This is about 1 teaspoon of properly. Risk factors include age over 40 years, salt. Older adults and people with high blood overweight (more than 20% of ideal body pressure should aim for less than 1,500 mg of weight), and having a closely related family sodium per day. member with diabetes. It can often be treated with diet and exercise (exercise helps muscles • High amounts of sodium (as salt) are often use glucose for energy). Treatment may also added to processed and prepared foods. require medications. • Most unprocessed foods are naturally low in sodium. These include fruits; fresh or frozen Possible Complications vegetables; and fresh or frozen fish, fish, poultry, and meat. Diabetes can cause some serious problems over time. It can lead to blindness, kidney • Read food labels for sodium content. damage, heart disease, nerve damage, and Avoid adding salt in recipes or at the table. other health problems. • Use spices and herbs for seasonings.

Signs and Symptoms DIABETES The signs and symptoms of diabetes may include: Diabetes is a disease that affects how the body • Feeling hungry or thirsty all the time. uses carbohydrates (sugars and starches) from foods. Usually, the sugars and starches that • Urinating more than usual. people eat are broken down into a sugar called • Feeling tired more than usual. glucose, and their blood carries the glucose to • Blurred vision. cells in the body. A hormone called insulin helps move glucose from the blood into the • Cuts or bruises that won’t heal. cells for fuel and storage. • Tingling or numbness in hands and feet.

People with diabetes either cannot make insulin or cannot use it properly, depending on what type of diabetes they have. Either way, the glucose stays in the blood longer and cannot be used properly by the cells. The result is a high blood glucose level.

Massachusetts Department of Education Child and Adult Care Food Program 47 IT’S MORE THAN A MEAL

Diabetes and Older Adults

Many older adults may have type 2 diabetes without even knowing it. They may be surprised to be diagnosed with diabetes, because they haven’t noticed any symptoms or felt sick. Therefore, it is extremely important that older adults have their blood glucose checked on a regular basis. If they have diabetes, they should see their doctor and a licensed registered dietitian to design a meal plan that best fits their needs.

Preventing Type 2 Diabetes Goals for People with Diabetes

• Maintain a healthy weight. • Follow special dietary advice from your doctor and a licensed registered dietitian. • Consume plenty of fiber. • Take insulin or diabetes medications • Eat appropriate portion sizes. if prescribed. • Be physically active, if possible. • Be physically active, if possible.

• Maintain a healthy weight.

• Aim for blood glucose levels within the recommended range.

The chart below shows general goals for most people with diabetes who self-test their blood glucose levels. An individual’s health care team should determine specific target goals and develop a program of regular glucose monitoring to manage his/her diabetes.

GOALS FOR BLOOD GLUCOSE CONTROL

Time of Check Whole Blood Values Plasma Values

Before Meals 80-120 mg/dL 90-130 mg/dL

Bedtime 100-140 mg/dL 110-150 mg/dL

Source: If You Have Diabetes, Know Your Blood Sugar Numbers.National Diabetes Education Program, National Institutes of Health and the Centers for Disease Control and Prevention, 2002.

Nutrition Resource Manual for Adult Day Health Programs 48 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

Hypoglycemia in People with Diabetes a diabetes meal plan. Examples are following Hypoglycemia is low blood sugar. It can occur in the USDA Pyramid, rating your plate, exchange someone with diabetes who is taking medications. lists, and carbohydrate counting. Check with Be alert to the signs and symptoms, which your participant’s heath care provider for include feeling weak, feeling hungry, sweating individual recommendations. more, or having sudden changes in heartbeat. Immediately test the blood glucose level of a Tips for Feeding Participants with Diabetes: person with these symptoms. If his/her glucose • Follow scheduled eating times. Serve meals level is below 70 mg/dL, the person should and snacks at about the same time each day immediately consume one of the following: to maintain a consistent supply of sugar in

1 the blood. Eating too much food at one time • ⁄2 cup fruit juice can raise blood glucose to dangerous levels. 1 • ⁄2 cup regular soft drink Skipping a meal can cause the blood glucose (not diet or sugar-free) to drop too low, resulting in hypoglycemia. • 5 or 6 pieces of hard candy • The Idaho Plate Method provides a quick and • 1 or 2 teaspoons of sugar or honey easy way to know how much space each food

1 • 2 or 3 glucose tablets group should occupy on a dinner plate (fill ⁄2

After 15 minutes, retest the blood glucose level of the plate with bright, colorful vegetables,

1 and see if it has returned to a more acceptable ⁄4 of the plate with a starchy food, and the

1 level. After the blood glucose level stabilizes, other ⁄4 with a protein food). You can order offer the person a snack if it will be at least this guide from the Idaho DCE Plate Method, 1 hour until the next scheduled meal. PO Box 441, Rexburg, Idaho 83440-0441, website: www.platemethod.com, phone: Diabetes Meal Plan 208-624-7279.

Following a proper meal plan is important in • See the next page for a sample diabetic menu controlling blood glucose levels. Along with with different amounts of food at different exercise and medications (insulin or oral diabetes calorie levels. Observe how small changes or pills), eating well-balanced meals in the correct additions in foods bring the menu up to a amounts can help keep blood glucose levels as higher calorie level. Note that serving sizes close to normal as possible. and food items are not necessarily those A diabetes meal plan tells how much and what creditable by CACFP. kinds of food a person can eat at meals and snack • Check with the participant’s healthcare times. It should fit in with the person’s schedule provider for individual recommendations. and eating habits. There are many ways to follow

Massachusetts Department of Education Child and Adult Care Food Program 49 IT’S MORE THAN A MEAL

Sample Diabetic Menu Note: This is only a sample of a menu for people with diabetes. It is NOT designed specifically for your program’s participants with diabetes. Serving sizes and food items shown below are not necessarily creditable by CACFP. Any meal or menu substitutions that vary from CACFP regulations require documentation from a medical authority. MEAL AND FOODS DAILY CALORIES 1600 1800 2000 2200 Breakfast 3 3 3 3 Orange juice ⁄4 cup ⁄4 cup ⁄4 cup ⁄4 cup 1 1 1 1 Oatmeal ⁄2 cup ⁄2 cup ⁄2 cup ⁄2 cup Whole-wheat toast 1 slice 1 slice 2 slices 2 slices Margarine/butter 1 tsp 1 tsp. 1 tsp 1 tsp. 1 1 1 Skim milk ⁄2 cup ⁄2 cup ⁄2 cup 1 cup Morning Snack Graham cracker squares 3 squares 3 squares 3 squares 3 squares Orange 0 1 orange 1 orange 1 orange Lunch Vegetable soup 1 cup 1 cup 1 cup 1 cup Tuna sandwich/sandwiches 1 1 1 3 Water-packed tuna ⁄2 cup ⁄2 cup ⁄2 cup ⁄4 cup 1 1 1 Low-fat mayonnaise 1 ⁄2 Tbsp 1 ⁄2 Tbsp 1 ⁄2 Tbsp 2 Tbsp Tomato slices 2 slices 2 slices 2 slices 3 slices Whole-wheat bread 2 slices 2 slices 2 slices 3 slices Apple 1 apple 1 apple 1 apple 1 apple 1 1 1 1 Skim milk ⁄2 cup ⁄2 cup ⁄2 cup ⁄2 cup Afternoon Snack Muffin 1 muffin 1 muffin 1 muffin 1 muffin 1 Skim milk ⁄2 cup 1 cup 1 cup 1 cup Dinner 1 1 1 1 Chicken breast (skin removed) ⁄2 breast ⁄2 breast ⁄2 breast ⁄2 breast Baked potato 1 potato 1 potato 1 potato 1 potato Margarine/butter 1 tsp 1 tsp 1 tsp 1 tsp 1 1 1 1 Carrots and peas ⁄2 cup ⁄2 cup ⁄2 cup ⁄2 cup Green salad 1 cup 1 cup 1 cup 1 cup Low-fat dressing 2 Tbsp 2 Tbsp 2 Tbsp 2 Tbsp Grapes 15 grapes 15 grapes 15 grapes 15 grapes Oatmeal cookies 0 0 2 cookies 2 cookies Water 1 glass 1 glass 1 glass 1 glass Evening Snack Gingersnap cookies 3 cookies 6 cookies 6 cookies 6 cookies Banana 1 banana 1 banana 1 banana 1 banana Skim milk 1 cup 1 cup 1 cup 1 cup

Adapted from: Diabetes and Your Diet: Using the Dietary Guidelines for Americans as a Guide to Healthy Eating; University of Wisconsin Extension – Cooperative Extension, publication NCR 576, 2004.

Nutrition Resource Manual for Adult Day Health Programs 50 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

OSTEOPOROSIS • Older adults need 1,200 mg of calcium each day. Low-fat milk, cheese, and yogurt are Osteoporosis is a gradual process of bone loss great sources of calcium. that results in weak, brittle bones. It is a major cause of bone fractures of the hip, spine, and • Older adults also need extra vitamin D to help wrist. Every year, over 25 million people in the their bodies absorb calcium. Vitamin D is United States are afflicted with this disease. found in fatty fish and fortified milk.

Osteoporosis is called a “silent disease” because • Calcium supplements with vitamin D may be a often people are not diagnosed until they have necessary addition to the meal plans of older broken a bone. As people get older, the risk of adults who do not consume enough calcium- osteoporosis increases. rich foods and vitamin D-fortified milk.

• Physical activity, especially weight-bearing Who Has the Greatest Risk for Osteoporosis? exercise such as walking, lifting, or dancing, Women make up 80% of people with osteo- can strengthen bones and actually reverse porosis. Women are especially at risk if they: the effects of osteoporosis.

• Are past menopause. FOOD SOURCES OF CALCIUM • Have a small body frame. The following are good sources of calcium:

• Have a family history of osteoporosis. Amount of Calcium Food Source • Are Caucasian or Asian. • 1 cup milk • Don’t exercise (since exercise leads 350-375 mg • 1 cup soy milk, calcium-fortified to stronger bone). 300-350 mg • 3 oz sardines, with bones • Eat diets low in calcium and vitamin D. • 1 slice (1 oz) Swiss cheese 200-225 mg • Smoke or drink more than 3 glasses • 1 slice (1 oz) Cheddar cheese • 1 cup cottage cheese of alcohol per day. • 1 cup baked beans 125-150 mg Older men are also at risk for osteoporosis. • 1 piece pumpkin pie 1 ( ⁄8 of 9” pie)

3 • 1 slice ( ⁄4 oz) Maintaining Bone Health 100-125 mg American cheese 1 • ⁄2 cup vanilla pudding Osteoporosis can be prevented or delayed by • 1 cup cooked broccoli consuming vitamin D and calcium and taking 50-100 mg • 1 cup ice cream part in regular physical activity. Following the • 1 cup soy milk, unfortified

CACFP pattern and offering milk with each meal Source: USDA National Nutrient Database for Standard will help provide calcium and vitamin D. Reference, Release 17 (2004).

Massachusetts Department of Education Child and Adult Care Food Program 51 IT’S MORE THAN A MEAL

Food Allergies and Intolerances A food allergy or intolerance is an improper reaction by the body to a food or additive. Although there is a difference between food allergies and intolerances, they both cause problems in susceptible people. Symptoms may include wheezing, bronchitis, runny nose, vomiting, diarrhea, rashes, itching or headaches. Some reactions can cause discomfort, while others can be life-threatening.

It is important to: (1) learn about any food allergies or intolerances that your participants may have, (2) recognize the symptoms, and (3) minimize the chance of exposure to foods or additives that cause them.

ANAPHYLACTIC REACTIONS reactions when eating certain foods such as bananas, kiwi, avocados, or chestnuts Anaphylaxis is a sudden, severe, potentially fatal, (or less commonly, potatoes, tomatoes, or pitted systemic allergic reaction that can involve the fruits such as peaches, plums, or cherries). Some skin, respiratory tract, gastrointestinal tract, and people are so sensitive that even a trace amount cardiovascular system. It can involve a reaction to of a problem food can cause a reaction. a food, medication, insect sting, or latex.

Anaphylactic reactions can range from mild to LACTOSE life-threatening. Symptoms occur within minutes to 2 hours after contact with the allergy-causing Lactose, or “milk sugar,” is found in food products substance. In rare instances, they may occur up containing milk or milk solids. It is also found as to 4 hours later. Life-threatening reactions may an ingredient in some non-dairy foods, baked progress over hours. foods, and processed foods. Lactose is digested in the body by the enzyme lactase. People with Symptoms may start with a tingling sensation, lactose intolerance have too little of this enzyme, itching, or metallic taste in the mouth. Other and cannot properly digest lactose. They may symptoms can include hives, a warm feeling, experience gastrointestinal discomfort such as swelling of the mouth and throat area, difficulty stomach cramps, gas and diarrhea. Native breathing, vomiting, diarrhea, cramping, a drop Americans and people from Africa and Asia are in blood pressure, and loss of consciousness. If particularly susceptible to lactose intolerance. you see someone experiencing an anaphylactic Some people with lactose intolerance may be reaction, seek professional medical help quickly. able to tolerate certain dairy foods such as Peanuts, tree nuts, shellfish, fish, milk, and eggs yogurt and some cheeses. Lactase pills and commonly cause anaphylactic reactions. Some lactose-free milk products are available for people with latex allergy may also develop people who cannot tolerate any lactose.

Nutrition Resource Manual for Adult Day Health Programs 52 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

FISH OR SHELLFISH

Allergic reactions to fish and shellfish can be severe. Shellfish allergies appear to be more common in adults than fish allergies. Shellfish known to cause allergic reactions include shrimp, crab, oysters, clams, scallops, mussels, squid, crayfish, and snails. These allergies usually last a lifetime, and the reactions become more severe as the frequency of exposures increases.

NUTS OR PEANUTS

Nuts or peanuts can cause severe allergic reactions in susceptible people. These people should avoid nuts or peanuts, and any products that contain even small amounts of these foods (such as cookies, crackers, chocolate candy, or certain flavors of ice cream). Read the ingredient lists of products carefully to ensure that you are preventing exposure to these foods in susceptible people.

SOYBEANS

Soybeans are becoming more common as an ingredient in processed food products. Soybeans and soy products are sometimes found in baked goods, canned tuna, cereals, crackers, infant formulas, sauces, and soups. Some people have allergic reactions to soybeans and soy products.

GLUTEN

Gluten is a protein found in wheat, oats, rye and barley. These grains and their byproducts should be carefully watched in people with gluten intolerance, and strictly avoided by people with celiac disease.

CASEIN

Casein is a milk protein that may be found in non-dairy creamers and baked goods such as crackers. Some people are sensitive to casein.

SULFITES

Sulfites are often added to dried fruit and vegetables. People with asthma may be sensitive to sulfites.

Massachusetts Department of Education Child and Adult Care Food Program 53 IT’S MORE THAN A MEAL

Dietary Supplements VITAMIN AND MINERAL SUPPLEMENTS Deceptive advertising and the large variety of

Ideally, people should be able to meet their supplements on the market may lead older nutrient needs from food sources alone. adults to buy supplements that are unnecessary However, older adults may find it challenging to or in potentially harmful doses. Taking high obtain enough vitamins and minerals from their amounts of some nutrients (such as vitamin A, diets, especially during illness and other times of iron, and zinc) can lead to toxic levels in their low food intake. bodies. Low-dose supplements are less likely to have adverse side effects. A daily multivitamin-mineral supplement can be one way to help older adults meet their nutrient HERBAL SUPPLEMENTS needs. However, they should first consult a physi- cian to be sure that supplements are appropriate Herbal supplement use has grown dramatically in for them. The decision to use supplements should recent years. Examples are ginkgo biloba, ginseng, be based on their unique needs and dietary St. John’s wort, and Echinacea. The health claims intake. It should not be a substitute for proper for these supplements may make them particularly eating or seeking appropriate medical care. appealing to older adults. However, the jury is

Supplement Health Claim Possible Harmful Effects Ginkgo Biloba • Enhanced memory • Gastrointestinal disturbances • Improved circulation • Headaches, allergic skin reactions • Antioxidant function • Interactions with anticonvulsants • Bleeding if combined with certain medications Ginseng • Enhanced memory • Interactions with medications • Increased energy (Coumadin, Digoxin, MAO inhibitors) St. John’s wort • Enhanced mood • Interactions with medications • Reduced depression (Coumadin, Mevacor, cancer drugs, • Improved sleep anticonvulsants, immunosuppressants) • Sensitivity to sunlight Echinacea • Enhanced immunity • Not for use in autoimmune or systemic • Cold & flu protection diseases (lupus, scleroderma, HIV, multiple sclerosis, tuberculosis)

Source: Nutrition and Aging – Herbal Supplements: Facts for Professionals. Pennsylvania State University Nutrition and Extension Partnership Project, 2001.

Nutrition Resource Manual for Adult Day Health Programs 54 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

still out on their effectiveness. Some studies As with medicines, herbal supplements can have have shown potential benefits, while others have potentially harmful side effects. Some can also shown no demonstrable results. Currently, large- interact with certain drugs or nutrients. scale studies are underway to further test their Therefore, older adults should always discuss any effectiveness. Until the results are in, it may be current or planned supplement use with their too soon to justify any recommendations. health care providers.

Medicines and Older Adults Older adults consume a high proportion of THE RISK OF OVERMEDICATION prescription and nonprescription medicines Older adults are sometimes at risk for being compared to the rest of the population. overmedicated. Risk factors include: Compared to younger adults, they are more • Increased age. likely to experience adverse effects of medicines. This may be due to interactions between medi- • Female gender. cines, interactions between foods and medicines, • A history of adverse drug reactions. or age-related changes that affect the way their • The use of multiple medicines, especially if bodies use medicines. prescribed by more than one doctor or if prescriptions are filled at more than one COMMON SIDE EFFECTS pharmacy. At times, it may be hard to tell whether a • Failure to follow prescriptions properly. symptom is due to disease or is a side effect of • Reduced blood flow and less efficient kidneys, one or more medicines prescribed. Common side which may allow medicines to remain in the effects may include: body for a longer time. • Upset stomach, diarrhea, or constipation To reduce the risk of overmedication, older adults • Blurred vision should take medicines only as prescribed. They • Dizziness or their caregivers should keep all physicians • Decreased appetite and pharmacists informed of all medicines

• Mood changes (over-the-counter and prescription) that the older adult is taking. • Skin rashes

Massachusetts Department of Education Child and Adult Care Food Program 55 IT’S MORE THAN A MEAL

FOOD/MEDICINE INTERACTIONS

Medicines can potentially affect a person’s nutritional status.

• They can affect appetite or alter how foods taste or smell.

• Some medicines can cause nausea or vomiting.

• Side effects of some medicines can interfere with food intake. Examples are dizziness, sleepiness, confusion, shaking, or agitation.

• Medicines can change the way the body absorbs or uses nutrients.

Foods, in turn, can affect the way that medicines work.

• Some foods can reduce, delay, or increase the absorption of medicines.

• Some medicines are better absorbed on an empty stomach. Others are better absorbed with a meal.

• Some foods can interact with medicines. For example, grapefruit juice can increase the potency of certain medicines.

• Some foods can change the amount of acid in urine, which can affect the rate at which the body eliminates medicines.

REDUCING THE RISK OF ADVERSE EFFECTS

To reduce the risk of adverse effects from medicines, older adults or their caregivers should communicate with doctors and pharmacists. They should inform them about all the prescription and over-the-counter medicines, vitamin-mineral supplements, or herbal supplements that the older adult is taking.

Nutrition Resource Manual for Adult Day Health Programs 56 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

Barriers to Healthy Eating POOR APPETITE DENTAL PROBLEMS

Poor appetite can be common in older adults. Chewing problems may cause older adults to Possible causes include: overly restrict foods important for proper health.

• Grief or bereavement. Poorly fitting dentures and missing teeth may cause older people to avoid fresh fruits and • Fewer social contacts for meals. vegetables, which are important sources of • Acute or chronic illness. vitamins, minerals and fiber.

• Sensory changes (vision, taste, or smell). To promote dental health: • Medicines that affect appetite. • Serve foods rich in calcium and phosphorus.

Tips to help older adults with a poor appetite: • Serve a variety of firm, fibrous foods

• Offer beverages that increase calorie or to stimulate the release of saliva.

nutrient intake, such as milk, soup, or hot • Encourage or provide opportunities for chocolate, in place of coffee and tea. brushing and flossing teeth daily.

• Enhance the flavor of meals with spices • Encourage older adults to brush their teeth or and herbs. rinse their mouths with water after meals.

• Add variety and color to meals. • Encourage regular visits to the dentist.

• Encourage them to eat smaller meals more frequently, instead of large meals. To address chewing difficulties in older adults: • Offer plenty of water or fluids with meals. • Make eating a special occasion. Create a positive atmosphere for dining that includes • Offer foods that are soft and easy to chew.

attractive lighting, tablecloths, a nice table  Tender cuts of meat setting, and appealing music.  Soft protein foods: eggs, milk, cheese, yogurt • Make eating a social occasion. Create special  Fruits and vegetables with peels removed “events” with themes that participants will  enjoy together as a group. Fruit juices, canned fruits, and cooked vegetables

 Cooked cereals, rice, or pasta

 Mashed or pureed food, if needed

Massachusetts Department of Education Child and Adult Care Food Program 57 IT’S MORE THAN A MEAL

SWALLOWING PROBLEMS

Swallowing is a complex act. It involves the Common causes of swallowing problems mouth, throat area, and esophagus, which in in the esophagus: turn are controlled by many nerves and muscles. • Something that blocks the passage of food. Swallowing is partly under conscious control. Examples are tumors, foreign bodies, or a However, most of the swallowing process is narrowed esophagus caused by radiation, involuntary. medication, or ulcers. Someone with difficulty swallowing has the • Nerve and muscle problems resulting from sensation that food is stuck in the throat or certain diseases. upper chest. This sensation may be felt high in the neck, or lower down, behind the breastbone To address swallowing problems in older adults: (sternum). It may result from problems that arise in chewing food, moving it to the back of the • Chop foods in the blender. mouth, or moving it through the esophagus • Avoid dry, chunky foods. Choose foods toward the stomach. with a smooth texture.

• Add cream, gravy, or oil to foods. Common causes of swallowing problems • Avoid serving hot or cold foods. in the mouth or pharynx: • Avoid serving sticky foods. • Something that blocks the passage of food or liquid. Examples are anxiety, a tumor, or • Encourage older adults to rinse their mouths cervical spine disease. before and after eating.

• Nerve and muscle problems resulting from • Encourage them to eat in small bites, stroke, Parkinson’s disease, Huntington’s and to chew food well.

disease, multiple sclerosis, myasthenia gravis, • Refer them to their health care provider ALS (Lou Gehrig’s disease), muscular dystrophy, if the problem continues, even if the polio, or syphilis. symptoms are intermittent.

• If they suddenly show signs of choking and breathing problems, perform the Heimlich maneuver immediately.

Source: Medline Plus Medical Encyclopedia: Swallowing Difficulty, website www.nlm.nih.gov/medlineplus/ ency/article/003115.htm

Nutrition Resource Manual for Adult Day Health Programs 58 SPECIAL NUTRITION NEEDS OF OLDER ADULTS

SENSORY IMPAIRMENTS

As people get older, they become more likely to have sensory impairments (losses in vision, hearing, smell, or taste). These impairments can limit their quality of life, and affect their appetite and interest in foods.

Impaired vision can result from age-related eye changes or from diseases that affect the eyes (cataracts, glaucoma, diabetes, or macular degeneration). Vision may become less sharp. Older adults may find it harder to judge distances, focus on objects at different distances, or see items on the outside edges of the visual field. Their eyes may need stronger light to recognize objects, along with more contrast between light and dark objects. They may find it hard to read recipes, food labels, and labels on medicines.

Hearing problems can result from changes in the inner ear or from tinnitus (ringing or roaring sounds). Older adults may be less able to understand conversations or hear announcements, particularly in noisy or crowded environments. They may withdraw from social interactions with others at group meals.

A reduced ability to smell or taste can make it harder to discriminate between fine tastes, such as between turkey and chicken. Older adults may find it harder to distinguish between sweet, sour, and salty flavors. This can make them lose their appetite or their interest in food, and reduce their ability to detect bad odors in spoiled foods.

Tips for serving meals to adults with sensory impairments:

• Create a positive atmosphere for dining that includes attractive lighting, tablecloths, a nice table setting, and appealing music.

• Minimize distractive noises such as televisions and radios.

• Provide a strong contrast in color (such as cream of wheat in a dark bowl).

• Provide easy-to-grasp glasses and utensils.

• Enhance the flavor of meals with spices and herbs.

• Marinate meats in fruit juices, salad dressing, or sweet-and-sour sauce for extra zest.

• Use colorful garnishes to make foods more appetizing.

• Add variety and color to meals.

Sources: (1) Desai M et al. Trends in Vision and Hearing among Older Americans. Aging Trends, March 2001. Centers for Disease Control and Prevention. (2) Institute on Aging Learning Modules, University of North Carolina, www.uncioa.org/ioalearning.

Massachusetts Department of Education Child and Adult Care Food Program 59 IT’S MORE THAN A MEAL

COGNITIVE IMPAIRMENTS • Provide easy-to-grasp glasses and utensils.

Cognitive impairments in older adults can range • Model the use of utensils to encourage others from minor memory loss to progressive dementia. to mimic your behavior. Use verbal cues Causes may include stroke, Alzheimer’s disease, (“place the fork in your hand”) if necessary. neurological disorders, nutritional deficiencies, or • Remove utensils if using them becomes the side effects of taking medicines. As a result, dangerous. these adults may have a diminished attention • Put foods on small bowls or plates, span, an increased risk of choking, an inability to and serve them one at a time. recognize thirst, an inability to recognize food, confusion about meal times, and confusion • Serve small portions of tasty foods that are about how to use utensils. spiced to their liking.

Tips for serving meals to adults • Offer some finger foods unless there is a risk with cognitive impairments: of choking. Examples are mini-sandwiches and bite-size chunks of fruits, vegetables, • Serve meals in small dining rooms with a or cheese. home-like atmosphere. • To minimize the risk of choking, avoid hard- • Provide meals and snacks at consistent times. cooked eggs, chunks of meat, nuts, whole • Provide a consistent seating arrangement to grapes, orange halves, popcorn, and hard offer structure and cues to mealtimes. candy. Remove any pits, peels, or bones • Seat people next to compatible tablemates to from foods. Serve raw carrots in long slices. reduce agitation. Dilute peanut butter with applesauce.

• Provide adequate lighting to help them • If they fail to recognize foods, encourage recognize foods. them to touch or smell the foods first. Feed them orally by hand if necessary. • Minimize distractive noises such as televisions and radios. • Provide fluids on a routine basis (at least every 2 hours). • Use square place mats to help define personal territory and reduce the chances for people If these tips prove unsuccessful in encouraging taking each other’s silverware by mistake. food intake, refer older adults’ caregivers to their health care providers. • Use plain tablecloths and place mats

to minimize distractions. Source: Bakker R. Sensory Loss, Dementia, and Environments. Generations: Journal of the American Society on Aging. • Provide a strong contrast in color (such as Spring 2003. cream of wheat in a dark bowl).

Nutrition Resource Manual for Adult Day Health Programs 60 Table of Contents Introduction ...... 63

Using Food Labels to Make IT’S MORE Healthful Food Choices ...... 64 64 ...... Food Labels are a Valuable Tool THAN A MEAL 64 ...... Which Foods Have Food Labels? 64 ...... The Ingredient List 65 ...... Nutrition Facts Panel 70 ...... Sample Comparison: Two Kinds of Milk 71 ...... Sample Comparison: Two Kinds of Yogurt 72 ...... Health Claims on Food Labels 73 ...... Nutrient Content Claims

Modifying Recipes and Menus ...... 74

75 ...... How to Use Less Fat 76 ...... How to Use Less Trans Fat 77 ...... How to Use Less Sodium 79 ...... How to Use Less Sugar 80 ...... How to Add More Fiber 81 ...... How to Add More Fruits 81 ...... How to Add More Vegetables 82 ...... Modifying Menus to Make Them More Healthful Planning 82 ...... Adapting Menus for Swallowing Difficulties 83 ...... Sample Menus for Regular & Modified Diets Preparing Healthful Snacks ...... 85 Healthful 85 ...... Benefits of Snacking 85 ...... Tips for Choosing Healthful Snacks

Keeping Foods Safe for Older Adults ...... 87 87 ...... How Foodborne Illness Occurs Meals & 88 ...... Foodborne Contamination 89 ...... Microbial Growth 90 ...... How You Can Prevent Foodborne Illness 95 ...... “Control Time and Temperature” Chart Snacks 96 ...... Food Safety Education and Certification

Frequently Asked Questions ...... 97

Massachusetts Department of Education Child and Adult Care Food Program 61 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 62 PLANNING HEALTHFUL MEALS AND SNACKS

f you have read the previous sections, I you have already learned about good nutrition and about older adults’ special nutrition needs. Now you can learn how to apply this information to plan healthful meals for older adults.

This section will cover the following topics:

UsingWhich foods Food have food Labels labels on tothem? Make What kind Healthful of health claims Food (such asChoices helps reduce the risk of high blood pressure) and nutrient content claims (such as low-fat or light) can be listed on food labels? How can you use the Nutrition Facts panel and the ingredient lists on food labels as tools to select healthful foods to serve your participants?

ModifyingHow can you reduce Recipes the amount and of fat, Menustrans fat, sodium, and sugar in recipes? How can you add more fiber, fruits, and vegetables to recipes?

PreparingWhat are the benefits Healthful of snacking? Snacks What are some tips to choose healthful snacks?

KeepingWhat is foodborne Foods illness, Safeand how forcan you Older prevent Adultsit?

FrequentlyHere are answers to Asked some questions Questions that you may have about serving meals and snacks.

Note: You may also have questions about how to choose foods and beverages that are reimbursable within CACFP guidelines. This topic will be addressed in the Crediting Foods section of this manual.

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Using Food Labels to Make Healthful Food Choices

FOOD LABELS ARE A VALUABLE TOOL INGREDIENT LIST

You can use food labels as a tool to plan healthful By law, the ingredients on a food label must meals and snacks that meet CACFP criteria and appear in a certain order by weight. The the Dietary Guidelines. Food labels provide key ingredient that contributes the most weight to information to help you select foods to serve the food appears first on the list. The one that for meals and snacks. This information includes contributes the least weight appears last. health claims, nutrient content claims, an You can use this information to fine-tune your ingredient list, and the Nutrition Facts panel. purchasing decisions. For example, you can check the list of ingredients in a loaf of bread to see WHICH FOODS HAVE FOOD LABELS? how much of the flour is made from whole

Most packaged foods have food labels. The U.S. grains. If a whole-grain flour appears first on the government is responsible for assuring that list, the bread has a high proportion of whole- they contain truthful and accurate information. grain flour. If wheat flour appears first on the list, The Food and Drug Administration (FDA) over- and a whole-grain flour is listed second, the sees the labeling of most food products. bread has a lower proportion of whole-grain However, the U.S. Department of Agriculture flour. (USDA) oversees products that contain mainly fresh meat and poultry.

By law, every food label must provide:

• The common name of the product.

• The name and address of the manufacturer, packer, or distributor.

• The net content in terms of weight, measure, or count.

• The ingredients.

• Nutrition information.

• Serving size.

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THE NUTRITION FACTS PANEL*

The Nutrition Facts panel provides valuable details about food products (serving size, number of servings, calories, and nutrient information). The footnote on larger food packages shows recommended daily intakes of certain nutrients based on 2,000 and 2,500 calorie diets. Sample Label for Macaroni & Cheese:

Nutrition Facts 1. Serving size and Serving Size 1 cup (228g) number of servings Servings Per Container 2 Amount Per Serving 2. Calories Calories 250 Calories from Fat 110 % Daily Value* 3. Limit these nutrients: Total Fat 12g 18% Total fat Saturated Fat 3g 15% Saturated fat Trans fat Trans Fat 3g Cholesterol Cholesterol 30mg 10% Sodium 6. % Daily Value Sodium 470mg 20% 5% or less is low Total Carbohydrate 31g 10% 20% or more is high 4. Get enough of Dietary Fiber 0g 0% these nutrients: Sugars 5g Dietary fiber Protein 5g Vitamins A and C Calcium Vitamin A 4% • Vitamin C 2% Iron Calcium 20% • Iron 4% *Percent Daily Values are based on a 2,000 calorie diet. Your Daily Values may be higher or lower depending on your calorie needs:

Calories 2,000 2,500 * The information about the Nutrition Facts Panel has Total Fat Less than 65g 80g been adapted from How to 5. Footnote Sat Fat Less than 20g 25g Understand and Use the Cholesterol Less than 300mg 300mg Nutrition Facts Label, a Sodium Less than 2,400mg 2,400mg pamphlet issued in June 2000 Total Carbohydrate 300g 375g by the U.S. Food and Drug Dietary Fiber 25g 30g Administration Center for Food Safety and Applied Nutrition, Calories per gram: and updated in July 2003 and Fat 9 • Carbohydrate 4 • Protein 4 November 2004.

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1. SERVING SIZE AND NUMBER OF SERVINGS

Serving sizes help you to compare similar foods. They appear in familiar units (such as cups or pieces), followed by the weight in grams (g) or milligrams (mg).

The calories and amounts listed are for a particular size of a serving. Pay attention to serving sizes, especially to how many servings are in a food package. On the sample label below, 1 serving of macaroni and cheese equals 1 cup. If you ate the whole package, you would eat 2 cups. That doubles the calories and nutrients!

Single Serving % DV Double Serving % DV Serving Size 1 cup (228 g) 2 cups (456 g) Calories 250 500 Calories from Fat 110 220 Total Fat 12 g 18% 24 g 36% Trans Fat 1.5 g 3 g Saturated Fat 3 g 15% 6 g 30% Cholesterol 30 mg 10% 60 mg 20% Sodium 470 mg 20% 940 mg 40% Total Carbohydrate 31 g 10% 62 g 20% Dietary Fiber 0 g 0% 0 g 0% Sugars 5 g 10 g Protein 5 g 10 g Vitamin A 4% 8% Vitamin C 2% 4% Calcium 20% 40% Iron 4% 8%

Source: How to Understand and Use the Nutrition Facts Label. U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. June 2000; Updated July 2003 and November 2004.

2. CALORIES (AND CALORIES FROM FAT)

Calories are a measure of how much energy you get from a serving of this food. The number of servings you consume determines the number of calories that you actually eat.

In the sample label, there are 250 calories in 1 serving of macaroni and cheese. Of these calories, 110 come from fat. Note Amount Per Serving that fat provides almost half the calories in 1 serving. Calories 250 Calories from Fat 110

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3. LIMIT THESE NUTRIENTS

Eating too much fat, saturated fat, trans fat, cholesterol, Total Fat 12g 18% Saturated Fat 3g 15% or sodium may increase the risk of heart disease, high Trans Fat 3g blood pressure, or some cancers. Health experts recommend Cholesterol 30mg 10% keeping intake of these nutrients as low as possible. Sodium 470mg 20%

4. NUTRIENTS TO CONSUME IN ADEQUATE AMOUNTS Dietary Fiber 0g 0% Eating enough dietary fiber, vitamin A, vitamin C, calcium, and iron can improve health and help reduce the risk of Vitamin A 4% some conditions. For example, calcium may reduce the risk Vitamin C 2% of osteoporosis. Dietary fiber promotes healthy bowel Calcium 20% function. A diet rich in fruits, vegetables, and whole grain Iron 4% products that is low in saturated fat and cholesterol may reduce the risk of heart disease.

*Percent Daily Values are based on a 2,000 5. FOOTNOTE calorie diet. Your Daily Values may be higher or lower depending on your calorie needs:

The * after the % Daily Value refers to the Footnote at Calories 2,000 2,500 the bottom, which tells you % DVs are based on a 2,000 Total Fat Less than 65g 80g Sat Fat Less than 20g 25g calorie diet. This statement must appear on all food Cholesterol Less than 300mg 300mg labels. The rest of the footnote may not appear if the Sodium Less than 2,400mg 2,400mg Total Carbohydrate 300g 375g label size is too small. The full footnote is consistent on Dietary Fiber 25g 30g products, and shows recommended dietary advice for all Americans. It is not about a specific food product.

6. DAILY VALUES AND PERCENT OF DAILY VALUES

The circled amounts are the Daily Values (DVs) for each nutrient listed based on health experts’ advice. DVs are recommended levels of intakes based on a 2,000 or 2,500 calorie diet. Note how the DVs for some nutrients change, while others (cholesterol and sodium) remain the same for both calorie amounts.

Each nutrient listed has a Daily Value, a % DV, and a recommended dietary goal, based on a 2,000 calorie diet. The goal for some nutrients is to eat less than a certain amount. The goal for other nutrients is to eat at least a certain amount.

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DV and % DV Based on a 2,000 Calorie Diet

Nutrient DV % DV Goal Total Fat 65 g = 100% DV Less than 65 mg Saturated Fat 20 g = 100% DV Less than 20 mg Cholesterol 300 mg = 100% DV Less than 300 mg Sodium 2,400 mg = 100% DV Less than 2,400 mg Total Carbohydrate 300 g = 100% DV At least 300 mg Dietary Fiber 25 g = 100% DV At least 25 g

Source: How to Understand and Use the Nutrition Facts Label. U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. June 2000; Updated July 2003 and November 2004.

PERCENT OF DAILY VALUE (% DV): % Daily Value*

% DV shows whether a serving of food is high or Total Fat 12g 18% low in a nutrient, and how much it contributes Saturated Fat 3g 15% to your daily allowance for this nutrient. % DVs Trans Fat 3g are based on daily allowances for key nutrients Cholesterol 30mg 10% for someone consuming 2,000 calories a day. For Sodium 470mg 20% diets at other calorie levels, the % DV can still Total Carbohydrate 31g 10% act as a general guide. Dietary Fiber 0g 0%

You don’t need to calculate % DV. The label Sugars 5g does the math for you. It puts the grams and Protein 5g milligrams on the same scale for the day Vitamin A 4% (between 0 and 100% DV). The rows in the % Vitamin C 2% DV column don’t add up to 100%. Instead, the Calcium 20% % DV for each nutrient is based on 100% of its Iron 4% daily allowance.

Quick Guide to % DV: 5% DV or less is low 20% DV or more is high

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USING THE % DV:

• Comparisons: The % DV makes it easy to compare similar products or brands. Make sure the serving sizes are similar, especially the weight of each product.

• Nutrient Content Claims: The % DV can help you examine nutrient content claims that companies put on their products, such as reduced fat or light. Compare the % DVs on food products to see which product is higher or lower in the nutrient.

• Dietary Trade-Offs: The % DV can help you make dietary trade-offs with other foods over the course of a day. You can balance a favorite high-fat food with lower fat foods at other times of the day. Pay attention so the total fat for the day stays below 100% DV.

NUTRIENTS WITH A % DV, BUT NO LISTED WEIGHT

Vitamins A, C, and D, iron, and calcium show a % DV, but not a weight.

Spotlight on Calcium Use % DV for calcium to learn how much 1 serving contributes to the total amount needed per day. A food with 20% DV contributes a lot of calcium. A food with 5% DV contributes a little. The 100% DV for calcium is 1,000 mg based on a 2,000 calorie diet. Experts advise women after menopause to consume 1,200 mg calcium daily, which is 120% DV.

Quick Guide to Calcium 30% DV = 300 mg calcium = 1 cup milk, or equivalent

1 100% DV = 1,000 mg calcium = 3 ⁄3 cups milk, or equivalent 120% DV = 1,200 mg calcium = 4 cups milk, or equivalent

NUTRIENTS WITHOUT A % DV

• Protein: If the food company makes a claim such as high in protein, it must list a % DV for that nutrient.

• Sugars: There is no DV for sugars. Sugars listed on the Nutrition Facts panel include those that occur naturally in foods such as fruits or milk, as well as sugars added to foods or drinks. Check the ingredient list for the names of any added sugars. Added sugars include brown sugar, cane sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, high fructose corn syrup, honey, invert sugar, lactose, malt syrup, maltose, maple syrup, molasses, sucrose, and sugar syrup.

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SAMPLE COMPARISON: TWO KINDS OF MILK

Compare the Nutrition Facts panels for 2% fat milk and non-fat chocolate milk. Each lists a serving size of 1 cup. Which milk has more calcium? Which has more calories and fat?

REDUCED FAT MILK: 2% Milkfat CHOCOLATE MILK: Non-fat Nutrition Facts Nutrition Facts Serving Size 1 cup (236ml) Serving Size 1 cup (236ml) Servings Per Container 1 Servings Per Container 1 Amount Per Serving Amount Per Serving Calories 120 Calories from Fat 45 Calories 80 Calories from Fat 0 % Daily Value* % Daily Value* Total Fat 5g 8% Total Fat 0g 0% Saturated Fat 3g 15% Saturated Fat 0g 0% Trans Fat 0g Trans Fat 0g Cholesterol 20mg 7% Cholesterol Less than 5mg 0% Sodium 120mg 5% Sodium 120mg 5% Total Carbohydrate 11g 4% Total Carbohydrate 11g 4% Dietary Fiber 0g 0% Dietary Fiber 0g 0% Sugars 11g Sugars 11g Protein 9g 17% Protein 9g 17% Vitamin A 10% • Vitamin C 4% Vitamin A 10% • Vitamin C 4% Calcium 30% • Iron 25% Calcium 30% • Iron 25% *Percent Daily Values are based on a 2,000 *Percent Daily Values are based on a 2,000 calorie diet. Your Daily Values may be higher or calorie diet. Your Daily Values may be higher or lower depending on your calorie needs: lower depending on your calorie needs:

Source: How to Understand and Use the Nutrition Facts Label. U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. June 2000; Updated July 2003 and November 2004.

ANSWERS:

1. Both kinds of milk have the same amount of calcium.

2. One cup of 2% reduced fat milk has 40 more calories than 1 cup of chocolate non-fat milk.

3. One cup of 2% reduced fat milk has 5 grams of total fat and 3 grams of saturated fat. There is no fat in 1 cup of chocolate non-fat milk.

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SAMPLE COMPARISON: TWO KINDS OF YOGURT

1. Compare the Nutrition Facts panels for the 2 sample yogurts. What is the serving size for each yogurt? How do they compare in terms of protein and sugar?

PLAIN YOGURT FRUIT YOGURT Nutrition Facts Nutrition Facts Serving Size 1 container (226g) Serving Size 1 container (227g) Amount Per Serving Amount Per Serving Calories 110 Calories from Fat 0 Calories 240 Calories from Fat 25 % Daily Value* % Daily Value* Total Fat 0g 0% Total Fat 3g 4% Saturated Fat 0g 0% Saturated Fat 1.5g 9% Trans Fat 0g Trans Fat 0g Cholesterol Less than 5mg 1% Cholesterol 15mg 5% Sodium 160mg 7% Sodium 140mg 6% Total Carbohydrate 15g 5% Total Carbohydrate 46g 15% Dietary Fiber 0g 0% Dietary Fiber Less than 1g 3% Sugars 10g Sugars 44g Protein 13g Protein 9g Vitamin A 0% • Vitamin C 4% Vitamin A 2% • Vitamin C 4% Calcium 45% • Iron 0% Calcium 35% • Iron 0% *Percent Daily Values are based on a 2,000 *Percent Daily Values are based on a 2,000 calorie diet. Your Daily Values may be higher or calorie diet. Your Daily Values may be higher or lower depending on your calorie needs: lower depending on your calorie needs:

Source: How to Understand and Use the Nutrition Facts Label. U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. June 2000; Updated July 2003 and November 2004.

ANSWERS:

1. The two yogurt containers have similar serving sizes (226 and 227 grams).

2. The fruit yogurt has less protein and more sugar than the plain yogurt.

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2. Compare the ingredient lists of the two sample yogurts. Why does the plain yogurt have any sugar? What are the sources of sugar in the fruit yogurt?

ANSWERS: PLAIN YOGURT 1. The plain yogurt has a naturally-occurring Ingredients: Cultured Pasteurized Grade A nonfat milk, whey protein concentrate, pectin, sugar (lactose) found in milk. carrageenin.

2. The fruit yogurt has 3 sources of sugar: the lactose in the milk, the naturally-occurring FRUIT YOGURT Ingredients: Cultured Grade A reduced fat milk, sugar in apples, and an added sugar (high apples, high fructose corn syrup, cinnamon, fructose corn syrup). nutmeg, natural flavors, and pectin. Contains active yogurt and L. acidophilus cultures. To limit added sugars, compare labels of similar products and choose the food with the lowest amount. Check ingredient lists to see if any added sugars are listed.

HEALTH CLAIMS ON FOOD LABELS

The Nutrition Labeling and Education Act of 1990 allows certain health claims about the relationship between nutrients and a reduced risk for certain diseases. Examples of currently allowed nutrients are listed below.

Chronic Disease Health Claims Allowed on the Food Label

Diets ADEQUATE in these foods or Diets LOW in these nutrients nutrients can help reduce the risk. can help reduce the risk.

Osteoporosis Calcium

Dietary Fiber Certain Cancers Fruits and Vegetables Total Fat Whole Grain Foods

Dietary Fiber Saturated Fat Heart Disease Fruits and Vegetables Cholesterol Whole Grain Foods

High Blood Pressure Potassium Sodium

Source: A Food Labeling Guide. Appendix C. U.S. Food and Drug Administration, September 1994. Editorial revisions June 1999.

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NUTRIENT CONTENT CLAIMS

Government regulations state which terms may be used to describe the levels of nutrients in foods, and how they can be used.

CLAIM DEFINITION Free The reference amount contains none of the nutrient claimed, or less than 5 calories, 5 mg sodium, 0.5 g total fat. 0.5 g saturated fat, 2 mg cholesterol, or 0.5 g sugar. Low The reference amount has no more than 40 calories, 140 mg sodium, 3 g total fat, 1 g saturated fat, or 20 mg cholesterol. Lean The reference amount of meat, poultry, or seafood contains less than 10 g total fat, 4.5 g saturated fat, and 95 mg cholesterol. Extra Lean The reference amount of meat, poultry, or seafood contains less than 5 g total fat, 2 g saturated fat, and 95 mg cholesterol. High The reference amount contains 20% or more of the Daily Value (DV) for a particular nutrient. Good Source The reference amount contains 10-19% of the Daily Value (DV) for a particular nutrient. Reduced or Less The reference amount of an altered food has 25% less calories, total fat, saturated fat, cholesterol, sodium, or sugars than a reference food. Reduced cannot be used if the reference food already meets the requirement for a low claim.

1 Light or Lite An altered food has at least ⁄3 less calories or less than half the fat found in a reference food. If at least half the calories come from fat, the food must have at least 50% less fat per reference amount. If less than half the calories come from 1 fat, the food must have at least 50% less fat or ⁄3 less calories. or The sodium in a low-calorie, low-fat food is reduced by 50%. or Light can describe properties such as texture and color, as long as the label explains the intent (for example, light and fluffy). More One serving has at least 10% more of the Daily Value (DV) of a nutrient than a reference food. May only be used for vitamins, minerals, protein, dietary fiber, and potassium. % Fat Free A product must be low-fat or fat-free. The claim must reflect the amount of fat in 100 g of a food. A “95% fat-free” food has 5 g fat in 100 grams of food. No Added Sugars No sugar or sugar-containing ingredient is added during processing. Healthy A food that is low in fat and saturated fat, and contains minimal amounts of sodium and cholesterol. One serving has no more than 360 mg sodium for an individual food, 480 mg sodium for a meal, and no more than 60mg cholesterol. In addition, a single- item food must provide at least 10% of the DV of 1 or more of vitamins A or C, iron, calcium, protein, or fiber. A meal-type product such as a frozen entree must provide 10% of 2 or 3 of these vitamins, minerals, protein, or fiber. Fresh A raw food that has not been frozen, heat processed, or otherwise preserved. Fresh Frozen A food that has been quickly frozen while still fresh.

Source: A Food Labeling Guide. Appendix A and B. U.S. Food and Drug Administration, September 1994. Editorial revisions June 1999.

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Modifying Recipes and Menus Planning menus means more than thinking of When buying foods, compare the Nutrition Facts foods that taste good together. You must also and ingredient lists on the labels of several brands. consider their nutritional value. Be aware that the Choose brands with the least amount of fat, sodi- Dietary Guidelines apply to the overall balance of um, and sugar, and the greatest amount of fiber. the daily or weekly diet, rather than to a single When modifying a recipe, start by making just meal or food. An occasional high-fat, sugary or one change at a time. At first, alter an ingredient salty food can fit into a menu if balanced with by a small amount to see how this change other low-fat, low-sugar or low-salt foods. So affects the quality and taste of the food. Later, consider the overall pattern of many meals when you may want to alter the recipe further. determining whether your menus are following Baked products require more careful adjustments the Dietary Guidelines. than casseroles or soups. For example, drastically This section offers tips to reduce the fat, sodium, cutting the sugar in a cake or the fat in biscuits and sugar and increase the fiber in foods. It also may result in unsatisfactory products. If you provides tips to alter menus for people with reduce fat or sugar, you may need to add more swallowing difficulties. liquid to compensate.

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HOW TO USE LESS FAT

Meat, Poultry, and Fish Oils, Toppings, and Condiments

 Choose ground beef that is at least 80% lean  To sauté or brown foods, use half the amount (less than 20% fat). of oil listed in the recipe, or use a non-fat  Use lean ground turkey in place of all or part cooking spray. of ground beef in recipes.  Use low-fat mayonnaise in place of regular  Use lean meat instead of frankfurters, mayonnaise. bologna, or other processed meat.  Skip the gravy on meat and potatoes.

 Bake, broil, or roast meat rather than frying.  If you do use gravy, chill it, and then skim off  Trim off all visible fat from meats. hardened fat before reheating.

 Drain all fat from cooked meats.  Top vegetables with spices, herbs, or lemon juice in place of butter.  Remove skin from poultry. Trim off the fat.

 Garnish fish with lemon juice rather Soups and Stews than tartar sauce.  Chill soups and stews, and skim off hardened  Buy water-packed tuna rather than fat before reheating. oil-packed tuna.  Limit the use of creamed condensed soups.

Milk Products  If you make condensed soups, use skim milk instead of whole milk.  Replace whole-milk cheeses with low-fat and part-skim cheeses. Breads/Grain Products  Use low-fat yogurt instead of sour cream.  For cookies or cakes, replace half of the  Use skim milk instead of whole milk. butter or margarine with applesauce.  Use evaporated skim milk instead of cream.  Limit the use of high-fat breads such as  Use ricotta cheese instead of cream cheese. croissants and some muffins.

 Replace high-fat crackers with lower-fat crackers.

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HOW TO USE LESS TRANS FAT AMOUNTS OF TOTAL FAT IN COMMON INGREDIENTS  Margarine (in stick form) and vegetable Fat shortening are often high in trans fat. 1 Tablespoon of: (grams) They have been partially hydrogenated, Vegetable oil (corn) 14 a commercial process that makes liquid oils Vegetable shortening 13 more solid. Margarine in tub or liquid form Butter 11 tends to be lower in trans fat. Margarine 11 Reduced-calorie margarine 5  Read the Nutrition Facts panel on food labels. Mayonnaise 11 Choose products with 0 grams of trans fat. Reduced-calorie mayonnaise 3  Read the ingredient list on margarine White sugar 0 packages. Look for soft margarines (tub Honey 0 or liquid) that do not contain hydrogenated 1 Cup of: or partially hydrogenated oils. Whole milk 8  When using a recipe, experiment with Low-fat milk 5 replacing the stick margarine or shortening Skim milk Trace amount with soft margarines or vegetable oils (except Half-and-half 28 coconut and palm kernel oils). Be aware that Evaporated skim milk 1 this may change the texture or taste of the Cream, heavy whipping 88 food you are preparing. Sour cream 48 Plain low-fat yogurt 4 Plain nonfat yogurt 0 Eggs and Egg Whites: 1 whole egg 5 2 egg whites 0

* Values are approximate. Check product labels for nutritional values of specific brands.

Adapted From: Updating Food Preparation to Promote Health, by P. Kendall, Colorado State University Cooperative Extension. Publication number 9.316, 3/00. Reviewed 1/03.

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HOW TO USE LESS SODIUM

Table Salt and Other Salt Products Alternative Flavors

 Omit table salt in recipes, or use  Replace most of the salt in a recipe with

1 ⁄2 the amount listed in the recipe. herbs, spices, seasonings, and vegetables.

 Avoid seasoned salts such as celery, garlic, Try these ideas: or onion salt. Instead, use unsalted powders • Cucumbers with chives, dill, garlic, or vinegar such as garlic or onion powder. • Green beans with lemon juice or sautéed onions  Use low-sodium soy sauce instead of • Potatoes topped with parsley regular soy sauce. • Beef with bay leaf, fresh mushrooms,  Use low-sodium Worcestershire sauce onion, or thyme instead of regular Worcestershire sauce. • Poultry with lemon juice, marjoram, paprika,  Use low-sodium bouillon instead of regular parsley, sage, or thyme bouillon. • Fish with bay leaf, curry powder, lemon  Avoid using monosodium glutamate (MSG). juice, or paprika

 Try the following low-sodium seasoning Food Products blend recipes.  Buy fresh or frozen foods rather than canned foods. SODIUM LEVELS IN COMMON INGREDIENTS Sodium  If you buy canned foods, choose lower 1 Tablespoon of: (milligrams) sodium versions. For example, choose Salt 2,130 mg low-sodium soups and broths, soy sauce, Garlic salt 1,900 mg canned vegetables, and tomato products. Onion salt 1,700 mg  Buy processed meats only occasionally. Baking soda 1,260 mg

Soup Stock Baking powder 490 mg Monosodium glutamate (MSG) 490 mg  Make soup stock from turkey, chicken Soy sauce 340 mg or beef bones. Garlic powder 1 mg  Use low-sodium bullion cubes or powder. Onion powder 1 mg

Source: Revitalize Your Recipes for Better Health. FN-432 (Revised), 2004, Division of Nutritional Sciences, Cornell University.

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Recipes for Low-Sodium Seasoning Blends

ALL-PURPOSE SEASONING All-purpose seasoning for meats, vegetables, and tomato-based foods 2 Tbsp. dry mustard 2 tsp. black or white pepper 2 Tbsp. onion powder 2 tsp. thyme

1 2 Tbsp. paprika ⁄2 tsp. ground basil 2 Tbsp. garlic powder Blend spices thoroughly. Store in a tightly covered container.

1 Yield: about ⁄2 cup

ITALIAN SEASONING For pasta sauces or Italian dishes 4 Tbsp. dried parsley, crushed 1 tsp. ground thyme or marjoram 4 tsp. dried minced onion 2 tsp. celery seed 1 tsp. ground oregano 1 tsp. garlic powder

1 2 tsp. dried basil, crushed ⁄4 tsp. black pepper Blend spices thoroughly. Store in a tightly covered container.

1 Yield: about ⁄2 cup

Source of Recipes: U.S. Department of Agriculture, Midwest Region. What’s in a Meal? A Resource Manual for Providing Nutritious Meals in the Child and Adult Food Care Program, Fourth Edition, 2003. Reproduced by the National Food Service Management Institute.

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HOW TO USE LESS SUGAR Baked Goods and Desserts

 1 Fruits Use up to ⁄3 less sugar in traditional recipes for cookies, muffins, quick breads, puddings,  Use frozen fruit that is unsweetened, and pie fillings. This includes sugar, brown without added sugars. sugar, corn syrup, honey, and molasses. Do  Use fruit canned in juice or water, not cut back on sugar in plain yeast breads rather than in syrup. because it provides food for the yeast and  Use fresh fruit, which has no added sugars. promotes rising.

 Serve quick breads rather than high-sugar Fruit Juices cakes or cookies. Try banana, carrot, cranberry,  Serve full-strength (100%) fruit juice. This is pumpkin, or zucchini bread. pure juice without added water, sweeteners,  Add more cinnamon or vanilla to enhance spices, or flavorings. Examples are apple, the impression of sweetness. grape, grapefruit, orange, pineapple, prune,  Serve seasonal fresh fruits for dessert. tangerine, and any combination of full- strength juices. Added Sugars  Avoid serving fruit drink or punch. These are  Limit the amount of added sugars used in made from juice with added water. They may other recipes and products. These include also contain added sweeteners (such as corn brown sugar, cane sugar, corn sweetener, corn syrup), spices, flavorings, or other ingredients. syrup, high fructose corn syrup, dextrose, Examples are nectars, lemonade, or cranberry fructose, glucose, honey, invert sugar, lactose, juice cocktail. These contain less than 50% malt syrup, maltose, maple syrup, molasses, full-strength juice. and sucrose.

Snacks Non-sugar Sweeteners  Serve plain yogurt combined with fresh fruit,  Non-sugar sweeteners can be used in modera- rather than commercially packaged fruit tion. However, some of these sweeteners yogurt that contains added sugars (such as don’t work well in cooked or baked foods. corn syrup). Others may leave a bitter aftertaste. Choose recipes already tested for use with non-sugar Condiments sweeteners. Or you can simply use less sugar  Limit the use of jams, jellies, or flavored in your traditional recipes, without needing gelatins. to substitute non-sugar sweeteners.

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HOW TO ADD MORE FIBER

Meals Snacks

 Use oatmeal or whole grain bread crumbs in  Make smoothies by blending milk or yogurt meatloaf or meatballs. with fruits.

 Add vegetables to quiche and casseroles.  Top cereals with sliced bananas or peaches.

 Prepare potatoes with skins, rather than peeled.  Serve fresh fruits or vegetables as a snack.

 Use whole grains such as barley or brown rice. Breads and other Baked Goods  Use rolled oats as breading for baked chicken or fish.  Buy whole grain breads, such as whole wheat bread.

Soups, Salads, and Side Dishes  Replace half of the white flour in recipes

 Make soups with dried beans, split peas, with whole-wheat or oat flour. or lentils.  Add raisins or chopped prunes to recipes.

 Use brown rice instead of white rice.

 Add cooked vegetables to spaghetti sauce.

 Add extra fruits and vegetables to dishes.

AMOUNT OF FIBER IN FOODS Source of Data: U.S. Department of Agriculture, National Nutrient Database for Standard Reference, Release 18. Fiber Fiber Dried Beans Serving Fruits Serving (grams) (grams)

1 Black beans, cooked ⁄2 cup 7 g Apple, raw, with skin 1 apple 3 g

1 Kidney beans, cooked ⁄2 cup 6 g Banana, raw 1 banana 3 g

Baked beans, canned, 1 ⁄2 cup 5 g Orange, raw 1 orange 3 g with pork and sauce Fiber Fiber Vegetables Serving Cereals, Grains & Breads Serving (grams) (grams) Potato, baked with skin 1 potato 4 g Cereal, raisin bran 1 cup 5 g

Broccoli, chopped, 1 ⁄2 cup 2 g Cereal, oatmeal, cooked 1 cup 4 g frozen, cooked

1 Carrots, frozen, cooked ⁄2 cup 2 g Bread, whole wheat 1 slice 2 g

1 Cereal, shredded Green beans, cooked ⁄2 cup 2 g 1 cup 2 g mini-wheats

Rice, brown, long grain, 1 ⁄2 cup 2 g cooked

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HOW TO ADD MORE FRUITS  Make a fruit smoothie. Blend milk or yogurt with fresh or frozen fruits. Tips for Choosing Fruits

 Buy fruits that are fresh, dried, frozen, HOW TO ADD MORE VEGETABLES or canned (in water or juice).  Fresh fruits in season may be less costly For the Best Nutritional Value and at their peak flavor.  Vary your vegetable choices. Vegetables  Buy pre-cut packages of fruit for a healthy differ in nutrient content. snack in seconds.  Reduce sodium intake by choosing fresh or frozen vegetables, or by buying canned For the Best Nutritional Value vegetables labeled “no salt added.”  Vary your fruit choices. Fruits differ  Watch out for sauces or seasonings that can in nutrient content. add calories, fat, and sodium.  Select fruit canned in 100% fruit juice or

water rather then in syrup. Add Vegetables to Meals  Choose fruit rather than juice, for the  Plan some meals around a vegetable main benefit of fiber. dish such as a stir-fry or soup.

 Try a main dish salad for lunch. Fruits at Meals Use a low-fat salad dressing.  Top cereal with fresh fruit, or add blueberries  Add shredded carrots or zucchini to meatloaf, to pancakes. casseroles, and quick breads.  Add oranges or grapes to a tossed salad.  Include chopped vegetables in pasta sauce  Try meat dishes with fruit, such as chicken or lasagna. with apricots.  Use cooked potatoes to thicken stews, soups  For dessert, serve baked apples, pears, or a and gravies. fruit salad.

Make Vegetables More Appealing Fruits as Snacks  Many vegetables taste great with a low-fat  Serve cut-up fruit as a snack. dip or dressing.  Mix fruit with low-fat yogurt.  Add color to salads by adding carrots, red  Top frozen yogurt with berries. cabbage, or spinach leaves.

 Try frozen juice bars (100% juice)  Include cooked dry beans or peas in flavorful as a low-fat snack. mixed dishes and soups.

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MODIFYING MENUS TO MAKE THEM MORE HEALTHFUL

A few simple changes can make a lunch or dinner more healthful. Here is an example.

Note: Servings listed on this menu may not be equal to servings of food used for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements.

Menu Calories Grams of Fat Chicken breast, boneless, fried, with skin 1 220 9 ( ⁄2 breast = equivalent of 3 oz. chicken) French fries, deep fried (1 small serving) 225 12 Tomato catsup (1 Tbsp) 15 0 Italian bread (1 slice) 80 1 Stick margarine (1 tsp) 35 4

1 Peaches in heavy syrup ( ⁄4 cup) 95 0 Whole milk (1 cup) 145 8 Total 815 34 g fat * * 38% of the calories in this meal are from fat Menu Make-Over Calories Grams of Fat Chicken breast, boneless, baked, no skin 1 140 3 ( ⁄2 breast = 3 oz. chicken) Baked potato (medium) 160 0 Sour cream, reduced fat (1 Tbsp) 20 2 Whole wheat bread (1 slice) 70 1 Margarine spread – 60% fat (1 tsp) 25 3

1 Peaches, canned in juice ( ⁄2 cup) 55 0 Skim milk (1 cup) 85 0 Total 555 9 g fat * * 15% of the calories in this meal are from fat

Source: Examples of foods in the menus are adapted from U.S. Department of Agriculture, Midwest Region. What’s in a Meal? A Resource Manual for Providing Nutritious Meals in the Child and Adult Food Care Program Fourth Edition, 2003. Reproduced by the National Food Service Management Institute. Foods have been analyzed for their nutrient content using the USDA National Nutrient Database for Standard Reference, Release 18. Calories have been rounded to the nearest multiple of 5. Grams of fat have been rounded to the nearest whole number.

ADAPTING MENUS FOR PEOPLE WITH SWALLOWING DIFFICULTIES

• Chop foods into small pieces.

• Avoid dry, chunky foods. Choose foods with a smooth texture.

• Add broth, gravy, milk, or oil to foods to moisten them and make them easier to swallow.

• To minimize the risk of choking, avoid hard-cooked eggs, chunks of meat, nuts, whole grapes, orange halves, popcorn, and hard candy. Remove any pits, peels, or bones from foods. Dilute peanut butter with applesauce.

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SAMPLE MENU FOR REGULAR AND MODIFIED DIETS (Low Salt, Low Fat/Cholesterol, and Swallowing Difficulties)*

Below is a sample 5-day lunch menu. The menu includes possible modifications for a low sodium diet, a low-fat diet, a low-cholesterol diet, or a diet for people with swallowing difficulties.

* The items in the last column are based on general recommendations for modified diets. Please see your consultant dietitian for specific instructions for modifying his or her diet.

Note: Servings listed on this menu may not be equal to servings of food used for crediting purposes. See the Crediting Foods section for CACFP Meal Pattern Requirements.

Day 1

Portion Foods for a Low Salt Low Fat and Modifications for Size Regular Diet (2 g Sodium) Cholesterol Swallowing Difficulties 1 cup Spaghetti, cooked

1 ⁄2 cup Meat sauce Low sodium No chunks 1 ounce Parmesan cheese Omit Omit

1 ⁄2 cup Peas Plain Blend Blend with a small 1 slice French bread amount of milk 1 tsp Margarine/butter Liquid margarine

1 ⁄2 cup Mandarin oranges Blend 1 cup Milk, whole Milk, skim

Day 2

Portion Foods for a Low Salt Low Fat and Modifications for Size Regular Diet (2 g Sodium) Cholesterol Swallowing Difficulties 3 ounces Chicken thigh Grind 2 ounces Gravy

1 ⁄2 cup Whipped potatoes

1 ⁄2 cup Asparagus Plain Blend Blend with a small 1 Dinner roll amount of milk 1 tsp Margarine/butter Liquid margarine

1 ⁄2 cup Crushed pineapple Blend 1 cup Milk, whole Milk, skim

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Day 3 Portion Foods for a Low Salt Low Fat and Modifications for Size Regular Diet (2 g Sodium) Cholesterol Swallowing Difficulties 3 ounces Fish nuggets Baked fish Baked fish Baked fish 4 ounces Tater tots Whipped potatoes Whipped potatoes Whipped potatoes

1 ⁄2 cup Spinach Plain Blend Blend with a small 1 slice Wheat bread amount of milk 1 tsp Margarine/butter Liquid margarine

1 ⁄2 cup Apricots Blend 1 cup Milk, whole Milk, skim

Day 4 Portion Foods for a Low Salt Low Fat and Modifications for Size Regular Diet (2 g Sodium) Cholesterol Swallowing Difficulties 1 cup Turkey noodle soup Low-sodium soup Blend with bread 1 pkg. Crackers Salt-free Omit 2 ounces Sliced ham Baked chicken Grind Remove crust 2 slices Rye bread Blend with soup

1 ⁄2 cup Mixed vegetables Plain Blend

1 ⁄2 cup Fresh fruit Blend, or use banana 1 cup Milk, whole Milk, skim

Day 5 Portion Foods for a Low Salt Low Fat and Modifications for Size Regular Diet (2 g Sodium) Cholesterol Swallowing Difficulties 3 ounces Hamburger meat Grind with gravy 1 Bun Blend with vegetable

Potato salad 1 ⁄2 cup Potato salad Use less salt with fat-free Blend the potato salad mayonnaise

Cole slaw 1 Replace with ⁄2 cup Cole slaw Use less salt with fat-free blended peas mayonnaise

Fat-free 1 Sundae cup ice cream 1 cup Milk, whole Milk, skim

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Preparing Healthful Snacks BENEFITS OF SNACKING

Snacks can be a healthful addition to your program’s daily meal plan, if they are chosen carefully for their nutritional value. Nutrient-dense snacks that are low to moderate in calories and low in fats and added sugars are ideal for older adults. They can satisfy hunger, provide fuel, and help supplement the nutrient needs of older adults, particularly those who eat small portions at mealtimes. In addition, snacks that are high in water content (such as fruits, 100% fruit or vegetable juices, or soups) can help older adults to meet their fluid needs.

TIPS FOR CHOOSING HEALTHFUL SNACKS

1. Use food labels as a tool to control percent of the Daily Value of the diet. portion sizes and select healthful snacks. Check the ingredient list for added sugars. Look for products with the nutrient claims Go easy on snacks that list any added sugars fat free, low fat, light, low sodium, lightly as the first ingredient. salted, reduced calorie, reduced fat, or 2. Limit snack foods that are high in reduced sodium on the front of the calories, saturated fat, trans fat, package. These claims are descriptive terms total fat, sodium, or added sugars. that must meet strict government criteria to be placed on food packages. Be aware, These types of snack foods tend to be low in though, that fat-free is not calorie-free. nutrient density, and can increase the risk A food can be low in fat but high in calories. for heart disease or high blood pressure. Also, fat-free or low-fat versions of snack Avoid snack foods with lard, beef tallow, foods may contain more added sugars or palm, palm kernel or coconut oils; these sodium to compensate for the loss of flavor are high in saturated fat. that occurs when fat is removed. 3. Replace regular snack foods with similar Check the Nutrition Facts panel for the foods that are lower in calories, total fat, serving size and number of servings in a saturated fat, trans fats, sodium, or added package to tell whether a snack food is high sugars; or that are higher in fiber. in total fat, saturated fat, trans fat or sodium For example, more healthful alternatives in each serving. Serving sizes are listed in to many kinds of crackers now appear on both household and metric units – for grocery stores next to the original products. example, 14 chips (28 g) – and are standard Or canned fruits that are packed in their across product lines to help you compare own juices appear on shelves next to similar products, such as baked potato chips fruits canned in heavy syrups. Often and fried potato chips. these alternatives taste quite similar to Check the Nutrition Facts panel for the the original products. amount of fat and other nutrients as a

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TIPS FOR CHOOSING HEALTHFUL SNACKS (CONTINUED)

4. Replace regular snack foods with • Cooked cereals different foods that are more healthful. • Soft protein foods: Instead of… Try… milk, cottage cheese, yogurt Ice cream Nonfat frozen yogurt • Fresh soft fruits and vegetables with Ice cream bar Frozen juice bar peels removed Milkshake Shake made with fruit • Canned fruits and low-fat milk • 100% fruit or vegetable juices Potato chips Low-salt pretzels Doughnut Whole wheat bagel 8. Combine foods from different food groups Frosted chocolate cake Angel food cake with fruit in appealing ways. Cheddar cheese Reduced-fat cheese • Melt low-fat cheddar cheese on a whole and crackers and whole-grain crackers wheat tortilla. Candy Fruit • Combine low-fat or non-fat yogurt with a 5. Choose snack foods that are small amount of orange juice or lemonade nutrient-dense. concentrate. Chill and serve as a dip with Nutrient-dense foods provide vitamins, fruit chunks. minerals, or fiber and a low to moderate • Top a low-sugar cereal with fresh fruit, amount of calories. These include fruits, and add low-fat milk. vegetables, whole grain breads and cereals, • Create a non-fat milk shake with skim milk, low-fat dairy products, and low-fat meats fruit, and vanilla in a blender. and meat alternates. • Create a fruit smoothie by combining plain non-fat yogurt with fruit. 6. Choose snack foods that can be credited • Create a cottage cheese dip and serve it with within the CACFP program. slices of soft raw vegetables. For each cup of Check the Crediting Foods section and non-fat cottage cheese, add 2 to 4 table- select snacks that qualify for reimburse- spoons of skim milk, and dill weed or chives ment. This can help your program save to taste. money on snacks. 9. Use snacks as an opportunity 7. Choose appropriate snack foods for to promote fluids. older adults who find it hard to chew You can serve water, other beverages, or swallow foods. or other foods that are high in water. Offer foods that are soft and easy to chew, Try these flavorful tips: with a smooth texture. Avoid serving dry, • 100% fruit juice • Fruits and vegetables chunky foods to these adults. • 100% vegetable juice, low-sodium • Milk, low-fat • Fruit juice with seltzer water • Milk shake, low-fat • Fruit smoothie • Yogurt, low-fat • Frozen fruit bars (100% fruit juice)

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Keeping Foods Safe for Older Adults

In spite of the overall safety of the U.S. food If you suspect that a participant has foodborne supply, each year millions of people get sick from illness, treat these symptoms much like you the food they eat. The symptoms of foodborne would treat the flu. If the person has a chronic illness include diarrhea, vomiting, and sometimes illness or has very severe symptoms, contact a fever. These conditions can be disabling for some health care provider as soon as possible. people, but are more likely to be devastating and even deadly for vulnerable populations. HOW FOODBORNE ILLNESS OCCURS

In general, people over 65 and people with Foodborne illness can happen when food chronic illnesses are more likely to suffer severe becomes contaminated and/or when microbial consequences of foodborne diseases. Several growth is allowed to occur in food. Any food factors contribute to this increased risk: or beverage can become contaminated. • A weakened or compromised immune However, certain foods are considered to be system due to: more risky because they support the growth of  Aging pathogens or have been involved in foodborne illness outbreaks.  Existing chronic diseases such as diabetes and kidney disease  Major surgery or some cancer treatments. Foods Associated with Foodborne Illness

• Decreased stomach acidity creating a more • Ready-to-eat foods are foods that are neutral environment in which harmful bacteria usually eaten without cooking or additional can survive and increasing the likelihood of preparation. They include: foodborne illness.  raw, washed, cut fruits and vegetables  whole raw fruits and vegetables that can • Slowing down of the digestive process be eaten without peeling allowing time for more rapid growth of  pathogens in the gut. meat, dairy products or other high protein foods that have already been cooked or • Malnutrition increasing the risk of infections. other foods that can be eaten without The onset of symptoms can vary from as short as washing or cooking. one hour after consuming the contaminated These foods may carry microorganisms or other food to as long as a few days. contaminants that can make people sick.

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• Potentially Hazardous Foods (PHFs) are growth of pathogenic microorganisms or often moist foods with high protein or toxin formation. These foods include: carbohydrate content and a neutral or slightly  animal foods such as meat, poultry, fish, acid pH. These components support the rapid shellfish, tofu, milk, or cheese growth of microorganisms. According to the  plant foods that are heat-treated – 2005 Food Code (www.cfsan.fda.gov/~dms/ such as cooked rice, pasta and cereal fc05-toc.html) these foods are also grains, cooked vegetables designated as time/temperature control  raw seed sprouts, cut melons, or for safety (TCS) because they require garlic-in-oil mixtures. time/temperature control to limit the

FOODBORNE CONTAMINATION

From a regulatory perspective, participants Contamination occurs when something harmful in adult day health programs are considered gets into the food. Bacteria or other harmful to be a “highly susceptible” population. substances can travel to food by hands, Therefore, your program must adhere to equipment or utensils used to prepare food. special requirements in food service to protect There are three different types of contamination: program participants. The following foods are not allowed to be served: 1. Physical contaminants are things that can be seen or felt. They include dirt, broken glass • Unpasteurized juice or plastic flatware, toothpick, hair, fingernail, • Raw shell eggs, or foods made from raw or or bandage. undercooked eggs including eggnog, soft 2. Chemical contaminants are found in some of cooked eggs, hollandaise sauce or meringue the materials that are used to clean, store or • Raw or undercooked animal foods such as protect foods. They include: raw fish or shellfish, lightly cooked fish, and rare meat • Cleaning chemicals, sanitizing agents Chemicals used to clean and sanitize • Raw sprouts pots, pans or dishes can be a source of Additional safeguards prohibit re-serving chemical contamination if proper cleaning foods. For more information about these procedures are not followed. If too restrictions, check with your local health strong a concentration of sanitizer is used, inspector or contact the state Department consumers can get sick from the residue of Public Health. left on the food contact surface.

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• Toxic metals are poisonous compounds • Bacteria cause most cases of foodborne that form when high acid foods like citrus illness. The FDA “Bad Bug Book” or tomato products are left in metal cans (www.cfsan.fda.gov/~mow/intro.html) or containers. provides basic information about dozens of • Pesticides that are not used properly microorganisms and the illnesses they cause. can leave residues on foods or food While bacteria and other microorganisms are contact surfaces. common in the environment, in people, and in To keep food safe, read labels and follow the or on food, most of them are not pathogenic. directions on any chemicals or pesticides. However, when they are allowed to grow to harmful levels, or if they are from virulent 3. Biological contamination comes from micro- strains, older adults can become sick. organisms that occur naturally in some foods or are introduced through cross-contamination MICROBIAL GROWTH with other foods or food contact surfaces. While chemical and physical contaminants Food becomes unsafe when bacteria and other can make people sick, it is most often pathogens grow to harmful levels. With the right microorganisms that cause foodborne illness. components (protein and moisture) and warm enough temperatures, bacteria can multiply in Most foodborne pathogens fall into four relatively short periods of time. categories: • Temperatures between 41°F and 140°F are • Molds and yeasts usually cause food to spoil. considered the “Danger Zone” because However, molds can be dangerous because bacteria will grow well in this range, with the they may produce toxins that can make elderly most rapid growth between 70°F and 110°F. and other susceptible populations ill. These When foods are left in the Danger Zone for poisons are not removed when mold is cut off more than 2 hours, the number of bacteria foods like cheese, fruit or breads. can increase to harmful levels. • Parasites have been found in foods produced Neither refrigerator nor freezer temperatures or processed with contaminated water or kill bacteria – they just slow down the rate of handled by people who do not practice growth. Bacteria remain alive and viable in the good personal hygiene. freezer (0-32°F). In the refrigerator (41°F or • Viruses are a major cause of foodborne below) bacteria survive and grow slowly. Some illness. Most of these viruses are carried to bacteria such as Listeria and certain types of E. people by foods that have been touched by coli grow well even in the refrigerator. people who are ill with the virus. Only temperatures above 140ºF will kill bacteria.

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HOW YOU CAN PREVENT FOODBORNE • Wash Your Hands ILLNESS Improper or inadequate handwashing is a major cause of foodborne illness. To prevent foodborne illness, food handlers must Washing hands can remove bacteria follow these two basic rules: and other pathogens. 1) Prevent Contamination

2) Control Microbial Growth Before touching food follow these 4 steps:

Prevent Contamination  Wet hands with warm, running water. Habits as simple as washing hands and keeping things clean will help keep pathogens and other  Add soap and rub hands to contaminants from spreading to food. make a lather. Wash fronts Practice Good Health and Hygiene: Humans are and backs of hands, between the source of many microorganisms that cause fingers and under nails for foodborne disease. Some bacteria are found 20 seconds. naturally on our skin, hair, nose and throat.

Many others live or survive in our intestines.  Rinse hands well under These bacteria can easily be spread from one warm running water. Let person to another by hands touching foods, water run into sink, not food contact surfaces and other household down the elbows. objects like faucets or tables.

• Be in Good Health  Dry hands thoroughly with Foodborne illness can be spread when a a clean (paper) towel. person who is ill prepares or serves food. If a food worker or server is ill with any Keep Food Contact Surfaces Clean: Cross- of the following symptoms, they should not contamination occurs when bacteria spread from make or serve food: one food to another. Prevent cross-contamination  fever by keeping foods – especially raw PHFs – away  sore throat from ready-to-eat foods.  diarrhea Food contact surfaces are any items that touch  vomiting food such as cutting boards, can openers, dishes,  jaundice (yellow skin and eyes) kitchen utensils and counter tops. When they are

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washed the “soil” (dried gravy, sauces and food) teaspoon per gallon) is the minimum concentra- is removed. Sanitizing adds another step to tion recommended. If more than the 200 ppm is reduce bacteria to levels where they are no used, a chlorine residue will be left as a potential longer harmful. source of chemical contamination.

Approved methods for sanitizing include heat or To prevent chemical contamination, use a test hot water, and chemicals such as chlorine bleach strip for the sanitizer to check the concentration or quaternary ammonium compounds (quats). of the sanitizing solution.

To sanitize follow these 4 steps: Keep food safe from contamination at all steps in handling.  Wash • Use reputable, licensed suppliers.

• Establish policies for staff or volunteers to:

 Report illnesses or symptoms like diarrhea

 Rinse or nausea before they work with food.  Cover any cuts, burns, sores or skin infections completely with a bandage if they prepare or serve food.  Sanitize  Wash hands before handling food or touching clean dishes.

Establish policies and procedures for practices listed below.  Air Dry • When you receive or shop for foods:

 Keep raw meat, poultry and seafood away from other foods. For chlorine bleach (5.25% sodium hypochlorite),  Check packages for tears or leaks. use this recipe:  Make sure cans are free from dents 1 teaspoon of bleach and bulges. to 1 gallon of warm water • When you store foods: The concentration of this solution will yield  Store food away from cleaning supplies 50-100 ppm (parts per million). The maximum and other chemicals. amount of chlorine allowed to sanitize food  Keep all foods covered. contact surfaces is 200 ppm; 50 ppm (less than a

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 Wrap raw meats and poultry or put in Control Pests containers or dishes. Place below other Insects and rodents are also sources of foods – on the bottom shelf or drawer contamination. It is important to keep flies, of the refrigerator. cockroaches, mice and rats away from the  Keep the refrigerator clean. food preparation and storage areas.  Store food only in containers designed for • Keep pests out. Put screens on doors and food. Do not store poison or cleaning windows. Keep trash cans covered. chemicals in food containers. • Keep the kitchen and eating area clean.  Throw away moldy cheese, bread or fruit, Clean food crumbs and wipe up even fermented juices. small spills. • When you prepare foods: • Use pesticides only if they are absolutely  Always wash hands. necessary. Store these like any other  Use disposable gloves, mixing spoons and chemicals away from food in a locked serving utensils to make and serve food cabinet. Follow the manufacturer’s instead of using your hands. directions for use.  Wash fruits and vegetables before you To control these pests: Throw out any food serve them. that shows signs of pest infestation, or has  Wash, rinse and wipe tops of cans before contacted a surface that was contaminated opening. with pesticide.  Use different cutting boards for raw meats and ready-to-eat foods. Control Microbial Growth  If you can’t use separate utensils after they come in contact with raw meat, poultry or Time and temperature play important roles in fish, then wash and sanitize them. the growth of bacteria. By controlling the  Put cooked meat, poultry or seafood on a temperature of foods, and limiting the amount clean or different plate than you used for of time foods spend in the Danger Zone, you can the uncooked foods. help prevent bacteria from growing to harmful  Use a clean spoon if you taste foods as you levels and producing toxins. prepare them. To control temperature:  Don’t mix (or store) old and new batches • Use a food thermometer to check internal of the same food. temperatures of foods.

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• Insert the tip of the thermometer into the  Store eggs in their original carton in the thickest part or middle of the food. Wait for refrigerator – not on the door. the temperature reading to be steady (at  Make sure the vents in these appliances least 15 seconds). are not blocked so that cold air can

• Sanitize the thermometer between uses to circulate. Don’t overstuff the refrigerator. prevent cross-contamination. • When you prepare foods:

• Calibrate the thermometer regularly to insure  Thaw foods properly. its accuracy. In the refrigerator: Place frozen meat or other PHFs in a pan or tray below ready- Keep cold foods cold (41°F or below) to-eat foods. at all steps in handling. Plan for enough time for the size of the • When you receive or shop for food: item. For example, one pound of ground  Buy cold or frozen items last. Check to beef or a thin chicken breast may take make sure frozen foods are frozen and cold less than a day to thaw while a 10 pound foods have been kept at 41°F or below. turkey may take 4-5 days.

 If you shop for food, pack cold foods in After thawing, use or cook meats within insulated containers when the weather 1-2 days. is warm. In cold running water: Make sure that the • When you store foods: food is sealed in a package or bag.

 Set your refrigerator no higher than 41ºF One pound of ground meat will take about and your freezer at 0ºF. one hour. For a whole turkey, plan on 30  Place a refrigerator thermometer in the minutes per pound. It is best to use this middle of the refrigerator or freezer. method if the food item can be thawed Check the temperature of your refrigerator within 2 hours. Foods thawed using this each day. method must be cooked immediately.  Put away potentially hazardous foods into In the microwave: Always cover the food the refrigerator or freezer first. to prevent juices from contaminating the  Put raw PHFs in the back of the refrigerator parts of the microwave oven. Follow the where it is coldest. Use the refrigerator directions for the microwave, rotating the door for condiments and other foods such food several times to make sure it thaws as jams and juices. evenly. Foods thawed this way must be cooked immediately.

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Some frozen foods like frozen vegetables • When you cool foods: and thin foods such as hamburger patties,  Use a food thermometer to check that hot fish portions and shaved steak, can also be foods have been cooled according to these thawed as part of cooking. recommended methods: Always cook thawed foods thoroughly Two-stage method: from 140ºF to 70ºF before refreezing. within 2 hours and 70ºF to 41ºF or below within 2 additional hours Do not thaw foods at room temperature. OR The outside of the food may reach temperatures above 41ºF while the One-stage method: from 140ºF to 41ºF inside is still icy. or below within 4 hours Bacteria on the surface may grow to harmful levels.  Cool foods quickly. Divide large amounts of leftovers into  Chill ingredients before mixing. Refrigerate small, shallow containers. ingredients such a mayonnaise, tuna or Set large pots of soup, stew or sauce other ingredients for salads before mixing. in an ice bath. Marinate meats in covered containers in the refrigerator. Don’t pack the refrigerator. Make sure there is room for cool air to circulate and • When you serve foods: keep foods at a safe temperature.  Keep foods refrigerated at 41ºF or below until just before serving. Keep hot foods hot at all steps in handling.  Check the temperature of the foods to be Use a food thermometer to check the temperature 41ºF every 2 hours. of foods to make sure that they are cooked  Throw away any food that has been above thoroughly and held at the proper temperatures. 41ºF for more than 2 hours. Be careful not to hit fat or bone in meats.  Use ice and insulated containers to transport • When you receive hot foods: foods when taking a trip or outing.  Check the temperature of the foods to be 140 ºF or above.  Refuse foods that are below this temperature.

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• When you cook foods: • When you serve hot foods:

 Do not interrupt cooking times.  Check the temperature of the foods to Partial cooking can raise temperatures to be 140ºF or above every 2 hours. Danger Zone levels without being hot  Throw away any food that has been enough to kill bacteria. below 140ºF for more than 2 hours.  Follow the minimum internal cooking • When you reheat leftovers: temperatures recommended in the  Bring gravies, soups and sauces Food Code. to a boil when reheating.  Heat other leftovers to 165ºF for 15 seconds.

Control Time and Temperature 165°F REHEAT all foods

165°F COOK (for 15 seconds) • Poultry, stuffed meats, stuffed fish, and stuffed pasta • Stuffing containing meat, poultry, or fish • Ground poultry or turkey • Any animal food cooked in a microwave 140ºF 155°F COOK (for 15 seconds) • Ground meats (beef and pork) • Injected meats, comminuted fish and meats

145°F COOK (for 15 seconds) Danger Zone • Fish, seafood • Pork, beef (cubes, slices, etc.), veal, lamb, mutton

145°F COOK (for 3 minutes) • Whole roast beef, whole pork roasts and corned beef roasts

41ºF 140°F HOLD • All hot foods

140°F to 70°F COOL all foods • within 2 hours

70°F to 41°F • within 4 hours From FDA Food Code, 1999.

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FOOD SAFETY EDUCATION AND CERTIFICATION

For programs that prepare and serve meals and snacks for participants, some states, such as Massachusetts, require that there be at least one person who can demonstrate knowledge of foodborne illness. This regulation often requires that this person has successfully completed a food manager certification exam. Check with your local health inspector to see if this requirement applies to your program.

Food safety is everyone’s responsibility. All staff and volunteers should have the opportunity to learn about the risks of foodborne illness and what they can do to prevent it. Materials and training resources are listed the Resources section of this manual. Share this information with caregivers as well.

Regulations for food safety and sanitation may change to reflect new food safety issues, scientific evidence and technologies. For information about any changes or new developments, check with your local health inspector or contact the state Department of Public Health.

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Frequently Asked Questions

1. Since cheese is high in fat and cholesterol, number of calories per serving. Margarine may should we serve it to adults? be in liquid, soft, or stick. Different kinds of margarine may vary in the amount of saturated, Cheese is a good source of protein, calcium and monounsaturated, polyunsaturated, and trans riboflavin. Serve low-fat cheeses such as part- fats that they contain. skim mozzarella, part-skim ricotta, reduced-fat American or Cheddar cheese, or reduced-fat cottage cheese. 4. What types of desserts should we serve? How often should we serve desserts?

2. What is the difference between ice cream Only certain types of desserts are creditable in and frozen yogurt? the Child and Adult Care Food Program. You can serve fruits as often as desired for dessert. Grain- Frozen yogurt typically has less fat and more based desserts such as cakes and cookies are not protein than ice cream. Ice cream has 10% to creditable in the CACFP as a dessert at lunch or 18% fat or more by weight. Frozen yogurt supper. However, you may serve grain-based and low-fat ice cream are other alternatives to desserts as a component of snacks. Do not serve regular ice cream. However, frozen yogurt and cookies and other baked products for snacks low-fat ice cream are not necessarily lower in more than 2 times per week. Some desserts are calories than regular ice cream. These frozen high in sugar and fat, and should only be eaten dairy products do not count in the Child and in moderation. Adult Care Food Program meal pattern.

5. How many calories do older adults need? 3. What is the difference between butter and margarine? The average daily caloric need of older adults range between 1,600 to 2,200 calories per day. Both margarine and butter get 100% of their The number of calories needed depends on calories from fat. Butter is a fat made from several factors, including the amount of physical milk. Margarine is made from vegetable oil. It is activity, amount of lean body mass, and existence made solid by the process of hydrogenation. of any chronic health conditions that can affect Both butter and margarine supply the same calorie needs.

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6. How often can we serve eggs 9. What advice can we give older adults to older adults? who request a vegetarian diet?

To limit cholesterol intake, aim for no more You should caution older adults that unless than 3 whole eggs each week. This includes eggs the vegetarian diet is carefully planned, served plain and those used in baked or cooked essential nutrients may not be supplied in products. There is no limit on egg whites, the amounts needed. because they have no cholesterol.

10. How many servings of the grains group 7. Can we serve water as the beverage do older adults need each day? at snack time? Depending on how many calories they need, most Yes, you can and should offer water as a beverage older adults need to consume the equivalent of in addition to the required 2 snack components. 5 to 8 ounces from this food group each day. Older adults need to be offered water throughout In general, 1 slice of bread, 1 cup of ready-to-eat

1 the day. Other fluids such as fruit juice and milk cereal, or ⁄2 cup of cooked rice or pasta count as count towards the fluid requirements. 1 ounce.

8. Are there good and bad foods? 11. Can a diet high in fruits and vegetables help with vision problems? The nutritional quality of a diet is not defined by any single food, but rather the diet eaten Yes, a diet high in fruits and vegetables will over time. increase intake of beta-carotene, which can help with vision problems such as age-related macular degeneration. Studies have shown that consuming dietary antioxidants found in fruits and vegetables (such as beta-carotene, lutein, and zeaxanthin) can help reduce vision problems.

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Introduction ...... 101 THAN A MEAL Why Consider Culture? ...... 102 Culturally Sensitive Interactions ...... 103

103 ...... Cultures Have Different Styles of Communication 104 ...... Build Communication Bridges with Participants and Families 104 ...... Create Open Dialogues About Foods 105 ...... “LEARN” to Negotiate Solutions in a Culturally Sensitive Way

Cultural Foods ...... 106

109 ...... Caribbean: Cuba, Dominican Republic, Haiti, Jamaica, Puerto Rico 107 ...... South American: Brazil 108 ...... European: Ireland, Italy, Poland, Portugal, Russia Culture 113 ...... Middle Eastern: Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia, Syria, Turkey, The United Arab Emirates, Yemen and 114 ...... West African: Benin, Burkina Faso, Cape Verde, Gambia, Ghana, Guinea, Guinea Bissau, Ivory Coast, Mali, Mauritania, Niger, Nigeria, Senegal, Food Sierra Leone, Togo 115 ...... Asian: China, India, Japan 118 ...... Southeast Asian: Burma, Cambodia, Laos, Thailand, Vietnam

Sources of Information on Culture and Food ...... 119

Massachusetts Department of Education Child and Adult Care Food Program 99 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 100 CULTURE AND FOOD

his section will address traditional T communication styles and eating patterns that may be common in diverse cultures.

This section will cover the following topics:

WhyWhat cultural Consider trends are Culturoccurring ine? the U.S. population of older adults? Why is it important to consider issues involving culture and diversity?

CulturHow can youally interact Sensitiv with participantse Inter andactions staff in a culturally sensitive way? Learn some tips that focus on:

• recognizing that different cultures may have different styles of communication

• building communication bridges with people from diverse cultures

• creating dialogues about food

• learning to negotiate solutions in a culturally sensitive way

CulturWhat are someal F foodsoods and eating patterns of cultures in different parts of the world? This section will feature foods commonly consumed in the Caribbean, South America, Europe, Middle East, West Africa, Asia, and Southeast Asia. Although the examples are not comprehensive, they may help you identify some foods that may be common to certain cultures.

Note: The purpose of this section is to stimulate awareness of cultural groups and respect for and acceptance of these groups. The following tips and examples are not meant to stereotype cultures, favor any cultures at the exclusion of others, or imply that all people from the same culture are identical. Food groupings in this section may differ from food groupings of the CACFP meal pattern.

Massachusetts Department of Education Child and Adult Care Food Program 101 IT’S MORE THAN A MEAL

Why Consider Culture?

The population of older adults in the United RACIAL/ETHNIC BACKGROUNDS OF States is becoming more culturally diverse. As AMERICANS AGED 65 AND OLDER a result, adult day health programs are more 2% Asian/Pacific likely to be serving participants from a variety Islander of cultures and ethnic backgrounds. 6% Hispanic 0.4% Native American 8% Non-Hispanic The concept of culture is broader than race Black or ethnicity. It also encompasses language, communication styles, social values, and religious behaviors. Culture shapes how people view the world, their attitudes about health, and their food preferences. 84% Caucasian Cultural cuisines reflect the geography, climate, and history of the location where the culture developed. Within each culture (and within different regions where the culture is dispersed), people may prefer certain foods, food preparation methods, and food combinations for meals and snacks. Source: U.S. Government, 2000 Census Keep in mind that diversity within cultures is as important as diversity between cultures. People Due to this diversity within cultures, you cannot from the same cultural or ethnic group tend to assume that all members of a culture share the have had some similar experiences. Within each same communication styles, health beliefs, and group, however, individuals may vary in terms of food preferences. General knowledge of cultural income, social class, religion, age, education, differences can provide a starting point for geographic origin, and the length of time that discussions about foods and people from they have lived in the United States. diverse cultures.

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Culturally Sensitive Interactions CULTURES HAVE DIFFERENT STYLES OF COMMUNICATION

They may vary in terms of these commonly accepted communication practices:

• Interactions with others. Some cultures • Physical space. Some cultures are comfortable prefer a non-confrontational style. Others with close body space. Others are more value a more assertive style of interaction. comfortable standing or sitting at a greater distance from each other. • Expression of emotions. Some cultures prefer to directly express their emotions. Others • Body movements. Some cultures perceive feel that directly expressing emotions is vigorous handshaking as aggressive, while confrontational, and prefer to indirectly others consider it a gesture of goodwill. express or mask their emotions. Some cultures perceive finger-pointing or foot-pointing as disrespectful, while others • Disclosure of information. Some cultures consider these gestures to be benign. Some are hesitant to disclose personal or family cultures perceive arm-waving as friendly, information to a stranger. Others are more while others consider it a sign of contempt. willing to do so. • Gender roles. Some cultures have traditional • Volume of speech. Some cultures prefer role expectations based on gender. Others speaking in a soft tone. Others prefer a are more flexible about gender roles. stronger tone of voice. • Perception of time. Some cultures value • Silence. Some cultures are comfortable with promptness. Other cultures are less oriented long periods of silence in a conversation. around being “on time.” Others consider it appropriate to speak

before another person has finished talking. Source: Elizabeth Randall-David. Strategies for Working with Culturally Diverse Communities and Clients. Office of • Eye contact. Some cultures prefer looking Maternal and Child Health, U.S. Department of Health and Human Services, 1989. people straight in the eye. Others consider this to be rude, disrespectful, or a sign of hostility.

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BUILD COMMUNICATION BRIDGES WITH PARTICIPANTS AND FAMILIES Prevent Misinterpretations of Your Words or Intentions Culturally sensitive communication skills can allow for more rewarding interactions with • Avoid using slang, metaphors, and other participants and their families. Here are some expressions that may be hard to understand. tips to enhance your skills: • Instead of judgments about behaviors, make observations.

Arrange for a Comfortable Meeting • Explain that you have some questions to ask • Schedule enough time so that no one and do not intend to offend them. Ask them feels rushed and you can address any to let you know if they prefer not to answer communication barriers. any questions.

• Encourage family members to choose • Follow your intuition if you feel that something seating that provides a comfortable degree you are doing is causing a problem. Ask if this of personal space and eye contact. is the case. If so, apologize and say that you did not mean to offend anyone.

Use a Personal Approach Source: Boyle MA, Community Nutrition in Action, 3rd Edition, 2003, Wadsworth/Thompson Learning, Belmont CA. • Smile, show warmth, and be friendly.

• Learn the greetings and titles of respect CREATE OPEN DIALOGUES used in their languages. ABOUT FOODS • Ask the participant and family how they • Ask about favorite foods, and discuss how prefer to be addressed. they can be incorporated into meal plans. • Speak clearly and in a normal volume. • Ask about foods used for celebrations • When interacting with people with limited and special occasions. English-speaking skills, keep in mind that • Use visual aids such as photographs or plastic their limited use of the English language is models of foods when appropriate. not a reflection of their intellectual abilities, • Most people will be pleased to educate you or of their ability to communicate effectively about their food preferences and habits, in their own language. but some may feel that your questions are too probing.

Source: Boyle MA, Community Nutrition in Action, 3rd Edition, 2003, Wadsworth/Thompson Learning, Belmont CA.

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“LEARN”(TO NEGOTIATE SOLUTIONS IN A CULTURALLY SENSITIVE WAY)

You can use the following steps to negotiate solutions with your participants or families in a way that respects cultural values and any differences of opinion.

L Listen with sympathy and understanding, in a curious and non-judgmental way. Show that what the person has to say is very important to you.

E Explain your understanding of what the person is telling you. This will create an opportunity to clarify any misunderstandings.

Example: “It sounds like you’re saying that … .”

“Am I understanding you correctly?”

A Acknowledge similarities and differences between you about a given situation. Example: “You and I both want to make sure that … .”

“You feel that …, and our staff members feel that we need to … .”

R Recommend culturally relevant and practical options. Offer more than one option from which to choose.

Example: “You could either try the … or the … .”

“There might be a couple of ways to solve this: … .”

N Negotiate an agreement that allows the person or family to take part in the decision-making process.

Example: “Which of these options would you prefer?”

“Would you rather drink the … or the … ?”

“What time of day would work best for you?”

“Is there a way to…. while making sure that you still….?”

Adapted from: Berlin EA. & Fowkes WC, Jr.: A Teaching Framework for Cross-Cultural Health Care: Application in Family Practice, Western Journal of Medicine, 1983, 139: 934-938. Also adapted from related guidelines in M.A. Boyle, Community Nutrition in Action, 3rd Edition, 2003, Wadsworth/Thompson Learning, Belmont CA.

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Cultural Foods CARIBBEAN (Cuba, Dominican Republic, Haiti, Jamaica, Puerto Rico)

GRAINS/BREADS: POPULAR FOODS OR INGREDIENTS: Cassava bread, cornmeal, millet, oatmeal, • Adobo: seasoning mix of lemon, pasta, rice, breads garlic, and spices (Puerto Rico)

• Arroz con pollo: rice with chicken VEGETABLES: (Puerto Rico) Arrowroot, avocado, bell pepper, broccoli, • Bacalao: dried salt cod (Puerto Rico) cassava, chili pepper, eggplant, plantain, • Chicharrones de pollo: fried chicken pumpkin, squash, sweet potato, tomato, tubers marinated in lime juice and soy sauce (Cuba) (malanga, manioc, tanier, yucca) • Coocoo: cornmeal-okra bread (from Africa)

FRUITS: • Foofoo: okra and plantain dish (from Africa) Banana, berries, breadfruit, grapefruit, guava, • Pepper pot: spicy vegetable soup (Jamaica) lemon, lime, mango, orange, papaya, passion • Picadillo: beef hash with olives, raisins, fruit, pear, pineapple, plum, soursop, tamarind tomatoes, and chili peppers (Cuba)

MILK, YOGURT, AND CHEESE: • Sancocho: stew made with pork intestines Cheese (Dominican Republic) • Sofrito: onions, garlic, cilantro, sweet peppers, MEAT, POULTRY, FISH: and tomatoes cooked in lard (Puerto Rico) Beef, goat, pork, chicken, duck, cod, crab, crayfish, fish, lobster, shrimp SWEETS OR OTHER DESSERT FOODS: Ice cream, pastries EGGS, DRY BEANS, AND NUTS: Eggs, black beans, black-eyed peas, kidney MEAL PATTERN: beans, legumes Breakfast, lunch, dinner, and snacks

FATS/OILS: Olive oil, palm oil, peanut oil

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SOUTH AMERICAN: Brazil

GRAINS/BREADS: POPULAR FOODS OR INGREDIENTS: Bread (rye or wheat), cheese rolls, corn bread, • Aipim frito: fried pieces of manioc cornmeal porridge, noodles, rice, rice flour • Arroz brasileiro: rice fried in oil, garlic, and onion before boiling VEGETABLES: • Bacalhau a portuguesa: salted cod fish baked Bell pepper, beet, capers, corn, eggplant, with potatoes and tomatoes green beans, hearts of palm, jilo (a bitter green • Camarones empanados: shrimp fried in batter vegetable), kale, leek, lettuce, manioc (a tuber), mushrooms, onion, plantain, potato, yam • Caruru: okra cooked in palm oil with dried smoked shrimp, ground peanuts, ground FRUITS: cashews, peppers, and cilantro

Aerola (a cherry), ata (sugar apple), banana, • Cozido a brasieleira: stew with beef, pork, berries, breadfruit, caja (hog plum), caju (cashew linguica sausage, sweet potatoes, winter apple), carambola (star fruit), coconut, guarana, squash, plantains, sweet manioc, and corn jaca (jack fruit), lemon, passion fruit, pineapple, • Sopa de crème de palmito: creamy hearts-of- pitanga (a cherry) palm soup

MILK, YOGURT, AND CHEESE: DESSERT FOODS OR SWEETS: Milk, cheese • Amore em pedacos: cookie-dough bars topped with meringue and almonds MEAT, POULTRY, FISH: • Arroz doce: sweet rice pudding topped with Beef, chourico (pork sausage), lamb, pork, veal, caramelized sugar or cinnamon chicken, catfish, cod, grouper, lobster, mackerel, shrimp, tuna • Canjica: dessert of corn, coconut milk, condensed milk, peanuts, cinnamon, and cloves

EGGS, DRY BEANS, AND NUTS: • Manjar branco: pudding made from corn- Eggs, almonds, Brazil nuts, cashews, chestnuts, starch, eggs, and coconut milk hazelnuts, black beans, lentils, soybeans MEAL PATTERN: FATS/OILS: Breakfast, lunch, late dinner, snacks Butter, olive oil, palm oil

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EUROPEAN: Ireland

GRAINS/BREADS: FATS/OILS: Arrowroot starch, barley, biscuits, scones, Butter, cream, sour cream, goose fat, salt pork, oatmeal, porridge, rice, rye, soda bread, lard, margarine, olive oil, vegetable oil tapioca, wheat POPULAR FOODS OR INGREDIENTS: VEGETABLES: • Bangers and mash: sausages and mashed Artichokes, asparagus, beet, Brussels sprouts, potatoes cabbage, carrot, cucumber, leek, lettuce, • Boxty: potato pancake mushrooms, onion, parsnip, potato, turnip, • Corned beef with cabbage tomato • Fish and chips: battered deep-fried fish

FRUITS: with fried potatoes Apple, apricot, berries, cherries, currants, grapes, • Irish stew: meat and vegetable stew melon, orange, peach, pear, plum, rhubarb • Shepherd’s pie: meat pie with leftover ground meat, onions, and mashed potatoes MILK, YOGURT, AND CHEESE:

Cheese, milk, yogurt DESSERT FOODS OR SWEETS: Cakes, pastries, minced pies MEAT, POULTRY, FISH:

Beef, ham, lamb, liver, pork, veal, venison, MEAL PATTERN: chicken, goose, bass, clams, crabs, cod, crayfish, Breakfast, lunch, afternoon tea, dinner haddock, herring, kippers (salted and smoked fish), lobster, mackerel, mussels, oysters, perch, pike, salmon, sardines, sole

EGGS, DRY BEANS, AND NUTS: Eggs, almonds, chestnuts, filberts, pecans, walnuts, kidney beans, lentils, lima beans, split peas

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EUROPEAN: Italy

GRAINS/BREADS: • Baccal: dried salt cod

Bread, breadsticks, cornmeal, focaccia, gnocci • Calzone: pizza dough folded over a cheese, (dumplings), pasta, pizza dough, rice ham, or salami filling and baked or fried

• Fettucine Alfredo: flat egg noodles mixed VEGETABLES: with butter, cream, and grated cheese Artichokes, asparagus, broccoli, cabbage, • Lasagna verdi al forno: spinach-flavored capers, carrots, cauliflower, eggplant, lasagna noodles baked in a sauce mushrooms, pepper, tomato, zucchini • Pesto: a paste made with cheese, herb,

FRUITS: nuts, and basil Apple, apricot, banana, cherries, citron, date, figs, • Risotto: rice cooked in butter and chicken grapefruit, grapes, orange, peach, pear, tangerine stock, flavored with cheese and saffron

• Saltimbocca: veal slices rolled with ham and MILK, YOGURT, AND CHEESE: cooked in butter and wine Cheese • Scampi: shrimp seasoned with oil, garlic, parsley, and lemon juice MEAT, POULTRY, FISH: • Tortellini: egg pasta stuffed with meat, Beef, chicken, lamb, pork, sausage, veal, cod, cheese, and eggs lobster, mussels, perch, shrimp

DESSERT FOODS OR SWEETS: EGGS, DRY BEANS, AND NUTS: • Cannoli: pastry shells filled with ricotta Eggs, almonds, hazelnuts, pine nuts, walnuts, cheese, shaved chocolate, and citron lupine seeds, broad beans, chickpeas, fava beans, lentils, white beans • Gelato: fruit or nut ice cream • Granita: strongly flavored ices FATS/OILS: • Spumoni: ice cream with a layer of Butter, cream, olive oil whipped cream, nuts, and fruits

POPULAR FOODS OR INGREDIENTS: MEAL PATTERN: • Antipasto: appetizer of salads, pickled Light breakfast, lunch as the main meal vegetables, cheeses, cold meat, and fish with several courses, light dinner

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EUROPEAN: Poland

GRAINS/BREADS: FATS/OILS: Barley, dumplings, oats, rice, rye, wheat Butter, lard, shortening, sour cream

VEGETABLES: POPULAR FOODS OR INGREDIENTS: Asparagus, beets, broccoli, Brussels sprouts, • Bigos: a stew of layered cabbage or sauer- cabbage, carrots, cauliflower, cucumber, kraut, mixed meats, game and sausage eggplant, green beans, leek, mushrooms, • Chicken Kiev: breaded fried chicken breasts onion, potato, tomato, turnip filled with herb butter

• Cholodnik: a cold beet and sour cream soup, FRUITS: garnished with vegetables and shrimp Apple, apricot, berries, cherries, currants, dates, • Dried, pickled, and fermented foods: grapes, peach, plum, prunes, rhubarb cucumber pickles, sour cream, sauerkraut

MILK, YOGURT, AND CHEESE: • Dumplings: made with potato or flour

Milk, buttermilk, cheese, cottage cheese • Kielbasa: a garlic-flavored pork sausage

• Pierogi: dumplings filled with meat, liver, MEAT, POULTRY, FISH: bacon, potatoes, or fruit Beef, lamb, pork, kielbasa (garlic-flavored pork sausage), smoked ham, chicken, duck, goose, fish DESSERT FOODS OR SWEETS: Cakes, pastries EGGS, DRY BEANS, AND NUTS: Eggs, almonds MEAL PATTERN: Breakfast, lunch as the main meal, light dinner

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EUROPEAN: Portugal

GRAINS/BREADS: POPULAR FOODS OR INGREDIENTS: Barley, bread, cornbread, farina, rice, vermicelli • Acorda d’azedo: a mix of onions, garlic, vinegar, lard, saffron, and cornbread

VEGETABLES: • Caldo verde: a green soup made from Cabbage, cauliflower, eggplant, green beans, kale or cabbage and potatoes greens, leek, onion, pumpkin, spinach, tomato • Chourico: pork sausage

• Figos com presunto: fresh figs with smoked FRUITS: cured ham Apricot, banana, cherries, figs, grapefruit, orange, peach, pineapple, plum, strawberry • Gaspacho a Alentejana: a type of gazpacho soup

MILK, YOGURT, AND CHEESE: • Isca de figado: beef liver seasoned with Cheese (queijo), milk vinegar, pepper, and garlic

• Linguica: pork and garlic sausage MEAT, POULTRY, FISH: • Pan doce: Portuguese sweet bread Beef, lamb, pork sausage, poultry, clams, dried salt cod, salmon, sardines, shrimp, squid, tuna DESSERT FOODS OR SWEETS: • Arroz doce: rice pudding EGGS, DRY BEANS, AND NUTS: • Malassadas: doughnut Almonds, black beans, black-eyed peas, broad beans, butter beans, red beans, white beans MEAL PATTERN: Four meals plus several snacks (light breakfast, FATS/OILS: midmorning breakfast, afternoon snack, lunch Butter, olive oil, peanut oil, vegetable oil as the main meal, late afternoon snack, evening snack, light supper in late evening)

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EUROPEAN: Russia

GRAINS/BREADS: FATS/OILS: Bread (rye and wheat), buckwheat, dumplings, Butter, lard, sour cream farina, oats, rice POPULAR FOODS OR INGREDIENTS: VEGETABLES: • Blini: buckwheat yeast pancakes topped with Artichoke, beet, Brussels sprouts, cabbage, carrot, jelly, sour cream, bleu cheese, cottage cheese, cucumber, green beans, lima beans, mushrooms, butter, caviar, herring, or tuna onion, potato • Holubky: stuffed cabbage

• Pirog: meat pie FRUITS: Apple, berries, dried fruits DESSERT FOODS OR SWEETS: • Layers of pastry drenched in custard MILK, YOGURT, AND CHEESE: • Sweet dough filled with fruit and sour cream Cheese • Tart or sour cream cake MEAT, POULTRY, FISH: Beef, pork, sausage, chicken, caviar, herring, MEAL PATTERN: smoked fish, sardines Breakfast, lunch, dinner

DRY BEANS, EGGS, AND NUTS: Eggs

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MIDDLE EASTERN: (Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia, Syria, Turkey, the United Arab Emirates, and Yemen)

GRAINS/BREADS: FATS/OILS: Barley, bulgur, corn meal, farina, millet, pasta, Butter (often clarified), nut oils, olive oil, sesame pita bread, rice, wheat dough (for pies) oil, vegetable oil, rendered lamb fat

VEGETABLES: POPULAR FOODS OR INGREDIENTS: Artichokes, beets, broccoli, cabbage, cauliflower, • Baba ghanoug: a spread made from sesame corn, cucumber, eggplant, green beans, leeks, paste, eggplant, lemon, garlic, and olive oil lettuce, okra, olives, onion, pepper, potato, • Dolmas or dolmades: stuffed grape leaves spinach, squash, tomato, zucchini • Falafel: fried ground chickpeas and herbs served in pita bread with sauce FRUITS: Apple, apricot, avocado, banana, cantaloupe, • Ful medames: fava beans cooked with oil, dates, figs, grapes, lemon, lime, melon, orange, lemon, garlic, and parsley, and served with plum, pomegranate, raisins, strawberries, tanger- hard-cooked eggs ine, watermelon • Hummus: a chickpea dip

• Kibbeh: a paste made from fine cracked MILK, YOGURT, AND CHEESE: wheat, grated onion, mint, and vegetables Cheese and milk (goat, sheep, camel, or cow), feta cheese, lebneh (yogurt cheese), yogurt • Pilaf: rice sautéed in onions and butter or oil, then steamed in beef or chicken broth

MEAT, POULTRY, FISH: • Shish kabob: marinated meat grilled on Beef, goat, lamb, rabbit, veal, chicken, duck, skewers with tomatoes, onions, and peppers turkey, anchovies, clams, cod, crab, crayfish, • Tabouli: mint, parsley, cucumber, tomato, flounder, halibut, lobster, mackerel, mussels, onions, olive oil, lemon juice, and bulgur oysters, salmon, sardines, shrimp • Tahini: sesame seed paste

EGGS, DRY BEANS, AND NUTS: DESSERT FOODS OR SWEETS: Eggs, almonds, cashews, hazelnuts, peanuts, pine Fruits as usual dessert; other desserts served nuts, pumpkin seeds, sesame seeds, sunflower on special occasions seeds, chickpeas, fava beans, horse beans, lentils, navy beans, red beans MEAL PATTERN: Breakfast, lunch as the main meal around 2 p.m., snacks, late supper

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WEST AFRICAN: (Benin, Burkina Faso, Cape Verde, Gambia, Ghana, Guinea, Guinea Bissau, Ivory Coast, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Togo)

GRAINS/BREADS: POPULAR FOODS OR INGREDIENTS: Corn, millet, rice • Deep fried fish with chili pepper sauce

• Fried plantain chips VEGETABLES: • Gari foto: cassava meal with scrambled eggs, Cassava, cassava leaves, chili pepper, eggplant, onions, chili peppers, tomatoes (Nigeria) okra, onion, pumpkin, sweet potato, taro, • Snack balls made from steamed rice, tomato, tubers black-eyed peas, yams, or peanuts

FRUITS: • Stews made with tubers (root vegetables), Akee apple, baobab, guava, lemon, papaya, okra, or peanuts, and flavored with small pineapple, watermelon amounts of fish, chicken, or beef

MILK, YOGURT, AND CHEESE: DESSERT FOODS OR SWEETS: Dairy products are not part of the regular diet • Kanya: peanut candy • Baked bananas flavored with sugar, MEAT, POULTRY, FISH: honey, or coconut

Mostly fish; some beef and chicken • Sweetened dough balls made from millet or wheat flour EGGS, DRY BEANS, AND NUTS: Eggs, cashews, groundnuts, peanuts, cow peas, MEAL PATTERN: black-eyed peas, sesame seeds Meals plus frequent snacks

FATS/OILS: Coconut oil, palm oil, peanut oil

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ASIAN: China

GRAINS/BREADS: EGGS, DRY BEANS, AND NUTS: Buckwheat, dumplings, millet, noodles, rice, Eggs, bean paste, tausi (cooked fermented black rice porridge, tapioca, won ton wrapper beans), broad beans, cowpeas, mung beans, red beans, soybeans, tofu, almonds, peanuts, sesame VEGETABLES: seeds Amaranth, asparagus, baby corn, bamboo shoots, bean sprouts, bok choy, broccoli, cauliflower, FATS/OILS: chili pepper, cucumber, eggplant, garlic, ginger Butter, lard, corn oil, peanut oil, sesame oil, root, kohlrabi, leek, lily blossom, long beans, soybean oil mushrooms, onion, snow peas, string beans, water chestnut, yam POPULAR FOODS OR INGREDIENTS:

• Congee: rice porridge FRUITS: • Egg roll: wheat flour wrapper with a meat, Apple, Asian pear, banana, coconut, dates, vegetable, or mixed filling (steamed or fried) kumquat, lime, litchi, longan, mango, melon, orange, papaya, passion fruit, persimmon, • Spring roll: very thin wheat flour wrapper pineapple, plum, pomegranate folded over a filling

• Hot and sour soup MILK, YOGURT, AND CHEESE: • Mu shu pork wrapped in wheat pancakes Soy milk (dairy products are not part of the • Peking duck regular diet except in parts of southern China) • Steamed or fried dumplings stuffed with

MEAT, POULTRY, FISH: meat or seafood Beef, lamb, pork, chicken, duck, quail, eel, clams, • Stir-fried dishes cod, herring, lobster, mandarin fish, salmon, sea bass, sea perch, shad, shrimp, sole, tuna, turtle DESSERT FOODS OR SWEETS: Rice-flour puddings

MEAL PATTERN: Breakfast, lunch, dinner, snacks

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ASIAN: India

GRAINS/BREADS: peas, chickpeas, kidney beans, lentils (many Basmati rice, bulgur wheat, chapati, lentil flour, varieties and colors), mung beans millet, rice, roti FATS/OILS: VEGETABLES: Coconut oil, ghee (clarified butter), mustard oil, Amaranth, artichokes, bamboo shoots, beets, peanut oil, sesame seed oil broccoli, cabbage, carrots, cauliflower, collard greens, cucumbers, eggplant, lettuce, lotus root, POPULAR FOODS OR INGREDIENTS: manioc (tapioca), mushrooms, onion, plantain, • Chapati: flatbread cooked on a griddle potato, squash, tomato, turnip, water chestnuts, without oil water lily • Chutney: fresh pickles

• Curry: flavoring blend of coriander, cumin, FRUITS: fenugreek, turmeric, black pepper, cayenne Apple, avocado, banana, chutney, coconut, pepper, clover, cardamom, cinnamon, and dates, figs, grapes, guava, lime, litchi, loquat, chili peppers mango, melon, orange, papaya, persimmon, pineapple, pomegranate, star fruit, tangerine • Dosas: spicy fried pancakes made from lentil flour

MILK, YOGURT, AND CHEESE: • Masalas: mixtures of spices and herbs that are Buffalo milk, buttermilk, curds, evaporated milk, either fresh or dried lassi (yogurt drink), milk, yogurt • Raita: a mix of yogurt, seasonings, and fruit or vegetables MEAT, POULTRY, FISH: • Rice dishes, wheat dishes, or vegetable dishes Beef, chicken, goat, mutton, port, chicken, duck, with curry seasonings carp, clams, crab, herring, mackerel, sardines, shrimp, turtle DESSERT FOODS OR SWEETS: (30% of the population are strict vegetarians • Gajar halva: carrot pudding who consume some milk products) • Kheer: rice pudding

EGGS, DRY BEANS, AND NUTS: Eggs, almonds, betel nuts, cashews, peanuts, MEAL PATTERN: pistachios, sunflower seeds, walnuts, black-eyed Breakfast, lunch, dinner, snacks

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ASIAN: Japan

GRAINS/BREADS: FATS/OILS: Bean noodles, buckwheat noodles, ramen Butter, cottonseed oil, olive oil, peanut oil, noodles, wheat noodles, rice, soy flour sesame seed oil, vegetable oil

VEGETABLES: POPULAR FOODS OR INGREDIENTS: Artichokes, bamboo shoots, bean sprouts, • Miso: fermented bean paste burdock root, cabbage, chrysanthemum leaves, • Sushi: rice mixed with a rice vinegar, and coltsfoot, daikon (long white radish), eggplant, often served with sliced raw fish kelp, lotus root, mushrooms, peas, seaweed, • Teriyaki sauce: soy sauce plus a sweet red wine snow peas, water chestnuts, yam, zucchini • Nabe: one-pot dishes served in the middle of

FRUITS: the table and shared with others Apple, apricot, banana, cherries, dates, figs, • Pickled vegetables (such as cabbage, grapefruit, kumquat, Japanese plum, kiwi, cucumber, eggplant, or radishes) lemon, lime, loquat, mandarin orange, pear, • Shoyu: soy sauce persimmon, tangerine, watermelon • Sunomono: vinegared salad

MILK, YOGURT, AND CHEESE: • Wasabi: a very pungent green horseradish used as a garnish Milk, soy milk (dairy products are not part of the regular diet) DESSERT FOODS OR SWEETS:

MEAT, POULTRY, FISH: • Fresh fruit, a light gelatin, or ice cream Beef, deer, lamb, pork, rabbit, veal, chicken, • Mochigashi: rice cakes with a sweet duck, goose, carp, cod, clams, crab, eel, globe- bean paste fish, koi fish, lobster, oysters, shrimp, shark, squid • Yokan: sweet bean jelly

EGGS, DRY BEANS, AND NUTS: MEAL PATTERN: Eggs, tofu, chestnut, ginkgo nuts, peanuts, Breakfast, lunch, dinner, snack walnuts, poppy seeds, sesame seeds, black beans, red beans, lima beans, soybeans

Massachusetts Department of Education Child and Adult Care Food Program 117 IT’S MORE THAN A MEAL

SOUTHEAST ASIAN (MAINLAND): (Burma, Cambodia, Laos, Thailand, Vietnam)

GRAINS/BREADS: EGGS, DRY BEANS, AND NUTS: Arrowroot, cornstarch, rice, rice noodles, tapioca, Chickpeas, lentils, mung beans, soybeans, soy wheat bread, wheat noodles products (tempeh, tofu), almonds, cashews, chestnuts, locust seeds, macadamia nuts, VEGETABLES: peanuts, pili nuts, sesame seeds Amaranth, artichokes, asparagus, bamboo shoot, banana leaves, beans, breadfruit, broccoli, FATS/OILS: cabbage, calabash, carrot, cassava, chayote squash, Bacon, butter, lard, margarine, peanut oil, chard, daikon (Chinese radish), chrysanthemum, vegetable oil eggplant, leek, lotus root, matrimony vine, mushrooms, mustard, okra, peas, pepper, potato, POPULAR FOODS OR INGREDIENTS: pumpkin, spinach, sweet potato, taro, tomato, • Agar-agar: seaweed gelatin turnip, water lily green, water chestnut, yam • Coconut-flavored dishes (Cambodia, Laos)

• Crab and asparagus soup (Vietnam) FRUITS: Apple, banana, coconut, date, durian, figs, • Fermented fish sauce or paste guava, jackfruit, jujube, lemon, lime, litchi, • Grilled lemon grass beef (Vietnam) longan, mandarin orange, mango, melon, • Hot and sour stir fried vegetables with rice orange, papaya, persimmon, pineapple, plum, pomegranate, pomelo, rambutan, sapodilla, • Pad Thai: stir-fried noodles with shrimp, tofu, star fruit, soursop, tamarind peanuts, fish sauce, and other flavors

MILK, YOGURT, AND CHEESE: DESSERT FOODS OR SWEETS: Sweetened condensed milk, soy milk (dairy Cakes, pastries, coconut milk and cream, sweets products are not part of the regular diet) made from sticky rice

MEAT, POULTRY, FISH: MEAL PATTERN: Beef, lamb, pork, chicken, duck, quail, most Two or three meals per day, with optional snacks varieties of seafood (fresh and dried)

Nutrition Resource Manual for Adult Day Health Programs 118 CULTURE AND FOOD

Sources of Information on Culture and Food The descriptions of cultural foods provided in this section are based on information from the following sources:

• U.S. Department of Agriculture, Midwest Region. What’s in a Meal? A Resource Manual for Providing Nutritious Meals in the Child and Adult Food Care Program. Fourth Edition, 2003. Reproduced by the National Food Service Management Institute. (The original source for cultural foods in this manual was Foods Around the World, Dairy Council of Wisconsin.)

• Pamela Goyan Kittler and Kathryn P. Sucher. Cultural Foods: Traditions and Trends. 2000: Wadsworth/Thomson Learning, Belmont CA.

• Pamela Goyan Kittler and Kathryn P. Sucher. Food and Culture in America: A Nutrition Handbook, Second Edition. 1998: West/Wadsworth, an International Thomson Publishing Company.

• Joan and David Peterson. Eat Smart in Brazil. 1995: Ginkgo Press, Inc., Madison WI.

• Southeast Michigan Dietetic Association, website www.semda.org/info (website information was most recently accessed on 2/21/06).

Massachusetts Department of Education Child and Adult Care Food Program 119 Notes

Nutrition Resource Manual for Adult Day Health Programs 120 Table of Contents Introduction ...... 123

CACFP Guidelines for Crediting IT’S MORE Meals and Snacks ...... 124 124 ...... Creditable vs. Non-Creditable Foods THAN A MEAL 124 ...... Meeting Meal Pattern Requirements 125 ...... CACFP Meal Pattern For Adults 126 ...... “Offer vs. Serve” Option 126 ...... “Family Style” Option

Tips for Crediting Foods ...... 127

127 ...... Grains and Breads 128 ...... Fruit Juices 128 ...... Processed Meats 129 ...... Reading Ingredient Lists 130 ...... Crediting Commercial Grains/Bread Products 132 ...... Crediting Combination Foods Crediting Tips for Crediting Recipes ...... 133

133 ...... Determining Whether a Recipe Can be Credited 133 ...... Abbreviations Used in Recipes Foods for 133 ...... Measures and Equivalents Used in Recipes 134 ...... Weights of 1 Cup of Ingredients 134 ...... Converting Weights to a CACFP Fraction of a Cup 135 ...... Determining the Number of Grains/ Breads Servings in a Recipe 137 ...... Recipe Analysis Worksheet Reimbursement 139 ...... Common Food Yields

CACFP Regulations: Crediting Grains/Breads . . . . 143

CACFP Regulations: Crediting Fruits and Vegetables ...... 159

CACFP Regulations: Crediting Meat and Meat Alternates ...... 169

CACFP Regulations: Crediting Milk Products . . . . 179

Massachusetts Department of Education Child and Adult Care Food Program 121 UNLESS OTHERWISE NOTED, INFORMATION IN THIS SECTION IS ADAPTED FROM THE FOLLOWING SOURCE: U.S. Department of Agriculture, Midwest Region. What’s in a Meal? A Resource Manual for Providing Nutritious Meals in the Child and Adult Food Care Program, Fourth Edition, 2003. Reproduced by the National Food Service Management Institute.

Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 122 CREDITING FOODS FOR CACFP REIMBURSEMENT

f you have read the previous sections of this manual, you have already learned Iabout good nutrition, special nutrition needs of older adults, and planning healthful meals. Now you can learn how to select nutritious foods that qualify for reimbursement from the Child and Adult Care Food Program (CACFP).

This section will cover the following topics:

CACFPWhat criteria areGuidelines used to decide whetherfor Crediting foods can be creditedMeals for and reimbursement? Snacks How do creditable and non-creditable foods fit into a CACFP meal pattern? Can combination foods (containing foods from 2 or more food groups) be credited? Which foods – and in what amounts – count in the CACFP meal pattern requirements?

TWhatips do f youor need Cr editingto know to creditFoods grains/breads, fruit juices, and processed meats? How can you use ingredient lists on food labels to decide if foods are creditable? How can you convert servings of commercial grains/breads to CACFP serving sizes? What documentation do you need to credit combination foods?

TWhatips kind for of informationCrediting must Recipes appear on a creditable recipe? What kinds of abbreviations are commonly used in recipes? What information do you need to convert measures in a recipe? (for example, 3 teaspoons equal 1 tablespoon) What are the weights of some commonly used ingredients? How do you convert measures listed by weight to measures in cups? How do you determine the number of breads/grains servings in a recipe? How do you analyze recipes for the number of servings of each food group? (breads/grains, fruits/vegetables, meats/meat alternates, and milk)

CACFP Regulations: CreditingWhat are the CACFP Foods regulations from for creditingEach individual Food foodsGroup within each food group? (breads/grains, fruits/vegetables, meats/meat alternates, and milk)

Massachusetts Department of Education Child and Adult Care Food Program 123 IT’S MORE THAN A MEAL

CACFP Guidelines for Crediting Meals and Snacks The Child and Adult Care Food Program (CACFP) Non-creditable foods do not meet requirements reimburses adult day health programs for costs for any component in the meal pattern. However, related to the preparation, service, and cleanup they may help meet participants’ calorie needs, of meals. Adults who are functionally impaired and may provide extra protein, vitamins, and or age 60 or older may receive up to 2 meals and minerals. You can use them to improve accept- 1 snack each day as part of CACFP. To qualify, ability, satisfy appetites, and supplement the your program must serve meals and snacks that required meal components. meet federal guidelines. This section provides lists of creditable and non- CACFP reimburses programs for meals served, creditable foods in the grains/breads, fruits and rather than for individual foods. A reimbursable vegetables, meat and meat alternates, and milk meal provides foods in amounts required by the categories. These lists focus on foods that adult meal pattern for a specific age group. Meals with day health centers often inquire about, or foods extra foods (in addition to all components speci- that they often credit incorrectly. Use of product fied in the meal pattern) are also reimbursable. brand names does not constitute USDA approval Reimbursement rates are established annually by or endorsement. Product names are used solely the U.S. Department of Agriculture (USDA). for clarification. If you have a question about crediting items not listed here, contact your CREDITABLE VS. NON-CREDITABLE FOODS state agency.

Creditable foods count toward meeting the MEETING MEAL PATTERN REQUIREMENTS requirements for a reimbursable meal. The decision to consider a food as creditable The chart on the next page shows the amounts depends on the following criteria: and types of foods in meals and snacks that are reimbursable in CACFP. For details on meal options, • Nutrient content of the food. refer to the “offer vs. serve” and “family style” • Function of the food in a meal. meal options described on the following page. • Regulations on the quantity of the food. Some combination foods can also count as • FDA Standards of Identity. creditable foods. These are dishes with foods

• USDA Standards for meat and meat products. from 2 or more food groups. It is recommended that combination foods be credited for only 1 or • Administrative policy decisions on the 2 meal pattern components. Tips for crediting crediting of particular foods. these foods appear later in this section.

Nutrition Resource Manual for Adult Day Health Programs 124 CREDITING FOODS FOR CACFP REIMBURSEMENT

CACFP MEAL PATTERN FOR ADULTS BREAKFAST Select All 3 Components for a Reimbursable Meal Milk, fluid ...... 1 cup

1 Fruit, vegetable, and/or juice (juice must be full-strength) ...... ⁄2 cup Grains/Breads: Bread: whole-grain, bran, germ, or enriched ...... 2 slices Cornbread, biscuit, roll, or muffin ...... 2 servings 1 Cold dry cereal (whole grain, enriched, or fortified) ...... 1 ⁄2 cups Hot cooked cereal (whole grain, enriched, or fortified) ...... 1 cup Pasta, noodles, or grains ...... 1 cup SNACK Select 2 of 4 Components for a Reimbursable Snack Milk, fluid ...... 1 cup

1 Fruit, vegetable, and/or juice (juice must be full-strength) ...... ⁄2 cup Grains/Breads: Bread: whole-grain, bran, germ, or enriched ...... 1 slice Cornbread, biscuit, roll, or muffin ...... 1 serving 3 Cold dry cereal (whole grain, enriched, or fortified) ...... ⁄4 cup 1 Hot cooked cereal (whole grain, enriched, or fortified) ...... ⁄2 cup 1 Pasta, noodles, or grains ...... ⁄2 cup Meat or meat alternate Lean meat, poultry, or fish (cooked, edible portion) ...... 1 oz. Alternate protein product ...... 1 oz. Cheese ...... 1 oz. 1 Egg ...... ⁄2 egg 1 Cooked dry beans or peas ...... ⁄4 cup Peanut or other nut or seed butter ...... 2 Tbsp. Nuts and/or seeds ...... 1 oz. 1 Yogurt (plain or flavored, sweetened or unsweetened) ...... 4 oz. or ⁄2 cup LUNCH OR SUPPER Select All 4 Components for a Reimbursable Lunch Select All 3 Components (not Milk) for a Reimbursable Supper Milk, fluid (required at lunch only) ...... 1 cup Fruit, vegetable, and/or juice (juice must be full-strength) ...... 1 cup total Grains/Breads: Bread: whole-grain, bran, germ, or enriched ...... 2 slices Cornbread, biscuit, roll, or muffin ...... 2 servings 1 Cold dry cereal (whole grain, enriched, or fortified) ...... 1 ⁄2 cups Hot cooked cereal (whole grain, enriched, or fortified) ...... 1 cup Pasta, noodles, or grains ...... 1 cup * Nuts and seeds can Meat or meat alternate 1 meet only ⁄2 of the Lean meat, poultry, or fish (cooked, edible portion) ...... 2 oz. total serving of the Alternate protein product ...... 2 oz. meat/meat alternate Cheese ...... 2 oz. requirement for lunch Egg ...... 1 egg 1 or supper. You must Cooked dry beans/peas ...... ⁄2 cup combine them with Peanut butter or other nut or seed butters ...... 4 Tbsp. another meat/meat Nuts and/or seeds ...... 1 oz.* = 50% alternate to fulfill Yogurt (plain or flavored, sweetened or unsweetened) ...... 8 oz. or 1 cup the requirement.

Massachusetts Department of Education Child and Adult Care Food Program 125 IT’S MORE THAN A MEAL

“OFFER VS. SERVE” OPTION FOR • SNACK: Offer vs. serve is not available for MEAL REIMBURSEMENT snacks, since the snack has only 2 food items.

Your program may choose to use the “offer vs. serve” option. With this option, you must offer “FAMILY STYLE” OPTION FOR MEAL each participant all of the required food items REIMBURSEMENT with each meal. However, at your discretion, your Your program may also choose to serve meals in program may allow participants to decline a cer- a “family style” setting. This option can enhance tain number of items without affecting the price participants’ acceptability of foods, and give or CACFP reimbursement for the meal. In other them latitude in choosing initial servings. With words, you must offer all of the meal items, but this option, you must follow these guidelines to participants may decline a certain number of be eligible for CACFP reimbursement: items. This option is not available for snacks. • You must place sufficient quantities of • BREAKFAST: Participants may decline 1 prepared food on each table to provide the serving of the 4 meal items: full required portions of each meal item for 1 serving of milk all participants at the table. 1 serving of fruit, vegetable, and/or juice • You must initially offer participants the full 1 serving of grains/breads required portion of each meal item. 1 serving of grains/breads • During the meal, the supervising adult(s) must • LUNCH: Participants may decline 2 actively encourage each participant to accept servings of the 6 meal items: the full required portion for each meal item. 1 serving of milk If a participant initially refuses an item or 1 serving of fruit, vegetable, and/or juice accepts less than the full portion, the super- 1 serving of fruit, vegetable, and/or juice vising adult should offer the meal item again 1 serving of grains/breads to the participant. 1 serving of grains/breads 1 serving of meat or meat alternate SOURCE: CACFP Adult Day Care Handbook, USDA Food and Nutrition Service, October 1993. • SUPPER: Participants may decline 2 servings of the 5 meal items: 1 serving of fruit, vegetable, and/or juice 1 serving of fruit, vegetable, and/or juice 1 serving of grains/breads 1 serving of grains/breads 1 serving of meat or meat alternate

Nutrition Resource Manual for Adult Day Health Programs 126 CREDITING FOODS FOR CACFP REIMBURSEMENT

Tips for Crediting Foods GRAINS AND BREADS

Grains and breads are creditable for the CACFP if When the bran and germ are removed, some made from whole grain, bran, germ, or enriched essential nutrients, including fiber, are lost. meal and/or flour. Refined bread products are only creditable if they are enriched and/or • Enriched products are refined grains that fortified. See the Crediting Foods section for have had nutrients (thiamin, niacin, riboflavin, required serving sizes. and iron) added at levels specified by law.

Grains and breads provide B vitamins (thiamin, If a product is made from enriched flour, the riboflavin, niacin, folate, and vitamin B6) and ingredient list will state that enriched flour vitamin E. They also provide minerals (iron, was used. If the product itself (rather than its selenium, zinc, and copper). Whole-grain breads flour) is enriched, the ingredient list will state often have more vitamins and minerals than that these nutrients were added. refined enriched breads. • Fortified products have had at least one

• Dietary fiber is found in significant amounts vitamin, mineral, or protein added to the in most bread products. Check the label for food. The food label will state that the fiber content. Breads with 2 or more grams of product has been fortified.

fiber per slice are good sources of fiber. • Whole-wheat bread contains the whole

• Flour is made by finely grinding wheat, rye, grain, including the fiber-rich bran and corn, oats, or other grains. germ. Whole-wheat flour should be the first ingredient listed. • Meal is made by coarsely grinding wheat, rye, corn, oats, or other grains. • Wheat bread often has wheat flour or enriched wheat flour (not whole-wheat flour) as the • Whole grain is the edible part of grains. main ingredient. This bread is low in fiber It includes the bran, germ, and endosperm. unless the manufacturer has added fiber. Whole grain flour is made by grinding the entire grain. If a flour or meal does not con- • Oat bread is usually white bread with a small tain the entire grain, it is not whole grain. amount of oats added. Check the ingredient list to see whether oats appear near the top of • Refined grains have had their coarse parts the list. If oats appear toward the end of the removed. They have lost the bran and germ. list, the bread contains little fiber from oats.

Massachusetts Department of Education Child and Adult Care Food Program 127 IT’S MORE THAN A MEAL

FRUIT JUICES PROCESSED MEATS

Full-strength (100%) fruit juices are creditable Hot dogs, bologna, knockwurst, and Vienna for the CACFP. Fruit drinks are not creditable. sausage may be served in the CACFP. Only the meat (Some state agencies credit fruit drinks with at in these products can be credited. If the binder/ least 50% fruit juice when twice the required extender is a fortified vegetable protein product, amount is served). it may be credited along with the meat portion of the binder. All other binders and extenders • Full-strength (100%) fruit juice is pure juice may not count as meat/meat alternates. Soy- based binders/extenders can generally count without added water, sweeteners, spices, or as vegetable protein products (VPP), and only flavorings. Examples are apple (including when fortified and used according to regulations pasteurized cider), grape, grapefruit, (7 CFR 226, Appendix A) can they be credited toward the meal pattern as a meat alternate. orange, pineapple, prune, tangerine, and any combination of full-strength juices. Since it’s hard to determine the amount of meat in processed meat products, it’s recommended • Fruit drink is full-strength juice with added that meat products with any non-VPP binders/ water. It may also contain added sweeteners extenders not be credited. Meat products without binders/extenders may be fully credited (such as corn syrup), spices, flavorings, or based on weight. An exception to this rule is a other ingredients. Examples are nectars, meat product with fortified VPP as the only lemonade, or cranberry juice cocktail. These binder/extender. contain less than 50% full-strength juice. • Binders and extenders hold processed meats • Read the labels carefully. Look for 100% together and may help retain moisture. fruit juice. Examples include: Soy flour Cereal Soy protein Dried milk concentrate Calcium-reduced dried Isolated soy protein skim milk Starchy vegetable flour Carrageenan

Many processed meats contain large amounts of binders and extenders. You need to know the composition of processed meats to credit the meat/meat alternate portion.

Nutrition Resource Manual for Adult Day Health Programs 128 CREDITING FOODS FOR CACFP REIMBURSEMENT

READING INGREDIENT LISTS

You can use ingredient lists for some foods to determine if they meet the meal pattern requirements.

Processed Meats

LOW FAT POLISH SAUSAGE HOT DOGS Ingredients: pork, water, turkey, beef, starch Ingredients: pork, turkey, water, salt, corn (modified food and vegetable), hydrolyzed syrup, dextrose flavoring, sodium erythorbate, milk protein, dextrose, corn syrup, salt, flavor- sodium nitrite. ings, autolyzed yeast, sodium lactate, sodium phosphate, gelatin, vitamin C (ascorbic acid), sodium nitrite. This product is all meat, without any binders/extenders. It is creditable toward This product contains modified starch and the meal pattern. hydrolyzed milk protein, which are binders/extenders. It is creditable only if the manufacturer adequately describes the amount of meat in 1 serving. Only the meat portion is creditable.

Fruit Juices

APPLE MIXED FRUIT JUICE – FRUIT PUNCH 100% PURE FRUIT BLEND Ingredients: water, corn syrup, fruit juice from Ingredients: concentrated juices (apple, grape, concentrate (apple, cherry, pineapple), citric pear, and boysenberry), water, citric acid, calcium acid, xanthan gum, sodium citrate, ascorbic hydrate, malic acid, natural flavor, and vitamin C. acid (vitamin C), gum arabic, glycerol abietate, brominated vegetable oil, citrus oils, natural and artificial flavors, artificial color (red #40). This is a blend of full-strength fruit juices

It is creditable. This product contains less than 50% full- strength fruit juice. It is not creditable. Some state agencies and sponsors credit drinks with at least 50% fruit juice when twice the required amount is served.

SOURCE: U.S. Department of Agriculture, Midwest Region. What’s in a Meal? A Resource Manual for Providing Nutritious Meals in the Child and Adult Food Care Program, Fourth Edition, 2003. Reproduced by the National Food Service Management Institute.

Massachusetts Department of Education Child and Adult Care Food Program 129 IT’S MORE THAN A MEAL

CREDITING COMMERCIAL GRAINS/BREADS PRODUCTS

You can use the Nutrition Facts panel and the product weight on the package label to determine the CACFP serving sizes of commercial grains/breads products. You can use this step-by-step worksheet as a guide. (You may want to make extra copies of this worksheet to credit multiple products.) See the next page for an example of how to use the worksheet.

What Amount of Food Equals 1 CACFP Serving?

1. Determine the serving size of a food item for an older adult Use the Meal Pattern chart in this section...... ______

2. Select the group that includes the food being evaluated. Use the Grains/Bread chart in this section. Determine the weight in grams of 1 CACFP serving...... ______

3. Record the net weight stated on the food package...... ______

4. Divide the package weight (step 3) by the CACFP serving weight (step 2 to determine the number of CACFP servings in the package.* ...... ______

5. Use the Nutrition Facts label to determine the number of food items in the package. Multiply the serving size by the number of servings in the package...... ______

6. Divide the total number of items in the package (step 5) by the number of CACFP servings (step 4), to show how many items must be served for 1 CACFP serving for this age group. Round up to the nearest reasonable serving.* ...... ______

*Due to rounding, a package may not have as many CACFP servings as calculated by weight.

How Many CACFP Servings are in 1 Serving of a Food?

1. Determine the serving size of a food item for an older adult. Use the Meal Pattern chart in this section...... ______

2. Select the group that includes the food being evaluated. Use the Grains/Breads chart in this section. Determine the weight in grams of 1 CACFP serving...... ______

3. Use the Nutrition Facts label to determine the weight in grams of 1 serving of food...... ______

4. Divide the weight of 1 serving of food (step 3) by the weight required for 1 CACFP serving (step 2). Round down to the nearest quarter serving...... ______

Nutrition Resource Manual for Adult Day Health Programs 130 CREDITING FOODS FOR CACFP REIMBURSEMENT

EXAMPLE: What Amount of Food Equals 1 CACFP Serving?

1. Determine the serving size of a food item for an older adult. Use the Meal Pattern chart in this section...... ______1 1 slice of bread for a snack for an older adult

2. Select the group that includes the food being evaluated. Use the Grains/Bread chart in this section. Determine the weight in grams of 1 CACFP serving ...... ______25 1 slice of bread = 25 grams

3. Record the net weight stated on the food package...... ______680 Pepperidge Farm Whole-Wheat Bread: Net package weight = 680 grams

4. Divide the package weight (step 3) by the CACFP serving weight (step 2). to determine the number of CACFP servings in the package.* ...... ______27 680g ÷ 25g per CACFP serving = 27 CACFP servings

5. Use the Nutrition Facts label to determine the number of food items in the package. Multiply the serving size by the number of servings in the package...... ______20 1 slice x 20 slices per package = 20 slices

6. Divide the total number of items in the package (step 5) by the number of CACFP servings (step 4), to show how many items must be served for 1 CACFP serving for this age group. Round up to the nearest reasonable serving.* ...... ______1 20 slices ÷ 27 CACFP servings = 0.75 slice (round up to 1 slice)

*Due to rounding, a package may not have as many CACFP servings as calculated by weight.

EXAMPLE: How Many CACFP Servings are in 1 Serving of a Food?

1. Determine the serving size of a food item for an older adult. Use the Meal Pattern chart in this section...... ______1 1 slice of bread for a snack for an older adult

2. Select the group that includes the food being evaluated. Use the Grains/Breads chart in this section. Determine the weight in grams of 1 CACFP serving...... ______25 1 slice of bread = 25 grams

3. Use the Nutrition Facts label to determine the weight in grams of 1 serving of food. ______34 1 slice of bread = 34 grams

4. Divide the weight of 1 serving of food (step 3) by the weight required for

1 1 CACFP serving (step 2). Round down to the nearest quarter serving...... ______1 ⁄4

1 34 g per slice ÷ 25 g per slice = 1.36 slice (round to 1 ⁄4 slice)

Massachusetts Department of Education Child and Adult Care Food Program 131 IT’S MORE THAN A MEAL

CREDITING COMBINATION FOODS

Dishes that contain foods from more than one food group are combination dishes. It is recommended that combination dishes be credited for only 1 or 2 meal pattern components. This is to ensure that participants do not go hungry if they dislike a particular dish. For example, those who refuse to eat lasagna will miss out on consuming meat/meat alternate, fruit/vegetable, and grains/breads components in the meal.

It can be hard to determine the amount of bread, meat, fruit, or vegetables in some commercially prepared foods. Examples are the meat or cheese in frozen ravioli, the tomatoes in canned chili, or the breading on fish sticks. If you do not know the actual content of these food components, do not credit them toward meeting a meal component.

You can credit a commercially processed combination food if you can document that the food contains enough of a specific ingredient to count toward the meal pattern. To do so, you must have a product analysis sheet on file. It must state the amount of cooked lean meat/meat alternate, grains/breads, and/or fruit/vegetable components in 1 serving of the food. It must be signed by an official representative of the manufacturer (not by a salesperson). For more information, contact your state agency.

Nutrition Resource Manual for Adult Day Health Programs 132 CREDITING FOODS FOR CACFP REIMBURSEMENT

Tips for Crediting Recipes DETERMINING WHETHER A RECIPE CAN BE CREDITED

To qualify to be credited, a recipe must list specific information about its ingredients. For example, a recipe should state:

•1 15-oz. can of fruit cocktail Not 1 can of fruit cocktail

• 3 cups cooked rice Not 3 cups rice

1 • ⁄2 cup finely chopped onion Not 1 small onion

ABBREVIATIONS USED IN RECIPES

tsp or t = Teaspoon pt = Pint °F = Degrees Fahrenheit Tbsp or T = Tablespoon qt = Quart g = Gram c = Cup gal = Gallon mg = Milligram oz = Ounce wt = Weight L = Liter fl oz = Fluid ounce No. = Number mL = Milliliter lb or # = Pound pkg = Package

MEASURES AND EQUIVALENTS USED IN RECIPES

1 T = 3 tsp 1 lb = 454 g

1 4 T = ⁄4 cup 2 c = 1 pt

1 8 T = ⁄2 cup 4 c = 1 qt

1 16 T = 1 cup 8 c = ⁄2 gal 1 oz. = 28.3 g 1 pt = 2 c

1 4 oz. = ⁄4 lb 2 pt = 1 qt

1 1 8 oz = ⁄2 lb 2 qt = ⁄2 gal

3 12 oz = ⁄4 lb 4 qt = 1 gal 16 oz = 1 lb

Massachusetts Department of Education Child and Adult Care Food Program 133 IT’S MORE THAN A MEAL

WEIGHTS OF 1 CUP OF COMMONLY USED INGREDIENTS

The use of company or product names does not imply approval or endorsement of products by the USDA. Product names are listed only for clarification.

Food Item (1 cup) Type Grams Barley Uncooked 195 Cooked 162 ine, dry 107 Converting Weights to a Fraction of a Cup Breadcrumbs F Soft 43 If the recipe involves a fraction of a cup of Bulgur Uncooked 140 Cooked 182 any of the ingredients shown in the table All-bran 61 Bran buds 75 at left, use the conversions listed here to Cheerios 28 Corn chex 29 convert the weights to a fraction of a cup. Cereals Corn flakes, crushed 80 Corn flakes, whole 29 Puffed rice 13 To find the Multiply the weight Rice chex 33 Rice krispies 27 weight of: of 1 cup by: 1 Wheaties 32 ⁄8 cup 0.12 Cornmeal, Yellow, degerminated 151 1 enriched, uncooked Yellow, stone-ground 132 ⁄4 cup 0.25

Graham 84 1 Cracker crumbs ⁄3 cup 0.33 Snack, round 80 1 Unsifted, dipped 119 ⁄2 cup 0.50 Flour, cake Unsifted, spooned 111 2 Sifted, spooned 99 ⁄3 cup 0.66 Flour, rice, brown Unsifted, spooned 158 3 ⁄4 cup 0.75 Flour, rice, white Unsifted, spooned 149 Flour, rye, dark Unstirred, spooned 128 Stirred, spooned 127 Flour, rye, light Unstirred, spooned 101 Stirred, spooned 88 Flour, wheat, Unsifted, dipped 143 all-purpose Unsifted, spooned 126 Sifted, spooned 116 Unsifted, dipped 136 Flour, wheat, bread Unsifted, spooned 123 Sifted, spooned 117 130 Flour, wheat, Unsifted, dipped self-rising Unsifted, spooned 127 Sifted, spooned 106 Flour, whole-wheat Stirred, spooned 120 Wheat germ Spooned 115 Wheat bran* Untoasted 60 Toasted 84 Oat bran* Raw 93 Cooked 220 73 Oats, rolled, quick Uncooked Ground 109 *Source: Pennington, Jean, A.T. Food Values of Portions Oats, rolled, regular Uncooked 75 Commonly Used, 16th edition, 1994.

Nutrition Resource Manual for Adult Day Health Programs 134 CREDITING FOODS FOR CACFP REIMBURSEMENT

DETERMINING THE NUMBER OF GRAINS/BREADS SERVINGS IN A RECIPE

Use this information to help select recipes for foods that meet CACFP meal pattern requirements. One serving of grains/breads must contain 14.75 grams of whole-grain meal, bran, germ, or enriched flour, or 25 grams of whole-grain cereals.

Instructions: 1. Under Ingredients A (1), list any oatmeal, cornmeal, whole-grain bran, germ, or enriched flour used in the recipe. List the quantity of these ingredients under Quantity (1). Use the chart in this section to convert fractions to decimal values. 2. Under Ingredients B (2), list any other dry, whole-grain cereal ingredients used in the recipe. List the quantity of these ingredients under Quantity (2). Use the chart in this section to convert fractions to decimal values. 3. Use the chart Weights of 1 Cup of Commonly Used Ingredients from this section to determine the gram weight of each ingredient listed. Record this under Grams per Cup (3). 4. Multiply the Quantity (1 and 2) by the Grams per Cup (3) to determine the Total Gram Weight (4) of the ingredients. 5. Divide the Total Gram Weight (4) by the factor indicated to determine the Grains/Breads Contribution (5). 6. Add all values under Grains/Breads Contribution (5) to determine the Total Grains/Breads Contribution (6). 7. Divide the Total Grains/Breads Contributions (6) by the number of servings in the recipe to 1 determine the Grains/Breads per Serving of Recipe. Round down to the nearest ⁄4 serving (7).

Quantity Grams Total Gram Grains/Breads Ingredients – A (in cups) per cup Weight Contribution ______(1) ______(1) ______(3) ______(4) ÷ 14.75 = ______(5) ______(1) ______(1) ______(3) ______(4) ÷ 14.75 = ______(5) ______(1) ______(1) ______(3) ______(4) ÷ 14.75 = ______(5)

Quantity Grams Total Gram Grains/Breads Ingredients – B (in cups) per cup Weight Contribution ______(2) ______(2) ______(3) ______(4) ÷ 25 = ______(5) ______(2) ______(2) ______(3) ______(4) ÷ 25 = ______(5) ______(2) ______(2) ______(3) ______(4) ÷ 25 = ______(5)

Total Grains/Breads Contribution ______(6) ÷ Total Number of Servings ______Grains/Breads per Serving of Recipe ______(7)

Massachusetts Department of Education Child and Adult Care Food Program 135 IT’S MORE THAN A MEAL

EXAMPLE: Oatmeal Raisin Cookies

Yield: 24 Cookies

3 3 Ingredients: ⁄4 cup sugar ⁄4 cup all-purpose flour

1 2 Tbsp margarine ⁄4 tsp cinnamon

1 1 large egg ⁄8 tsp nutmeg

1 2 Tbsp low-fat milk 1 ⁄4 cups oatmeal, quick oats

1 1 ⁄4 cup applesauce ⁄2 cup raisins

Quantity Grams Total Gram Grains/Breads Ingredients – A (in cups) per cup Weight Contribution

______(1)Flour 0.75 ______(1) cup ______(3)126 ______(4)94.5 ÷ 14.75 = ______6.4 (5)

______(1)Oatmeal 1.25 ______(1) cups ______(3)73 ______(4)91.25 ÷ 14.75 = ______6.2 (5)

______(1) ______(1) ______(3) ______(4) ÷ 14.75 = ______(5)

Quantity Grams Total Gram Grains/Breads Ingredients – B (in cups) per cup Weight Contribution

______(2) ______(2) ______(3) ______(4) ÷ 25 = ______(5)

______(2) ______(2) ______(3) ______(4) ÷ 25 = ______(5)

______(2) ______(2) ______(3) ______(4) ÷ 25 = ______(5)

Total Grains/Breads Contribution ______12.6 (6)

÷ Total Number of Servings ______24 cookies

1 Grains/Breads per Serving of Recipe ______0.5 or ⁄2 grains (7)

Nutrition Resource Manual for Adult Day Health Programs 136 CREDITING FOODS FOR CACFP REIMBURSEMENT

RECIPE ANALYSIS WORKSHEET

Instructions:

1. List the ingredients in column 1, and the amount used in the recipe in column 2.

2. Find meats/meat alternates under Common Food Yields and Crediting Meat and Meat Alternates in this section. Convert the amount used in the recipe to the yield after preparation. Record the yield.

3. Find fruits/vegetables under Common Food Yields and Crediting Fruits and Vegetables in this

1 section. Convert the amount used in the recipe to the yield in ⁄2 cup servings. Record the yield.

4. Determine the yield of grains/breads servings using the chart in Crediting Grains/Breads. Convert the amount used in the recipe to the yield in 1-slice bread equivalents. Record the yield.

5. Under Calculations, determine the number of 2-ounce meat/meat alternate servings for older adults by dividing the total by 2.

6. Round the total servings of fruits/vegetables and grains/breads down to the nearest whole number.

Amount Meat/Meat Fruit/Vegetable Grains/Breads Milk Ingredients Used in the Alternate 1 (1 slice bread ( ⁄2 cup servings) (Served as Recipe (ounces) or equivalent) a beverage)

Total:

Calculations: Number of Servings:

It is recommended that recipes with foods from more than 2 food groups be credited for no more than 2 different meal components.

Massachusetts Department of Education Child and Adult Care Food Program 137 IT’S MORE THAN A MEAL

EXAMPLE: RECIPE ANALYSIS FOR A “CHILI MAC” RECIPE

Instructions:

1. List the ingredients in column 1, and the amount used in the recipe in column 2.

2. Find meats/meat alternates under Common Food Yields and Crediting Meat and Meat Alternates in this section. Convert the amount used in the recipe to the yield after preparation. Record the yield.

3. Find fruits/vegetables under Common Food Yields and Crediting Fruits and Vegetables in this

1 section. Convert the amount used in the recipe to the yield in ⁄2 cup servings. Record the yield.

4. Determine the yield of grains/breads servings using the chart in Crediting Grains/Breads. Convert the amount used in the recipe to the yield in 1-slice bread equivalents. Record the yield.

5. Under Calculations, determine the number of 2-ounce meat/meat alternate servings for older adults by dividing the total by 2.

6. Round the total servings of fruits/vegetables and grains/breads down to the nearest whole number.

Amount Meat/Meat Fruit/Vegetable Grains/Breads Milk Ingredients Used in the Alternate 1 (1 slice bread ( ⁄2 cup servings) (Served as Recipe (ounces) or equivalent) a beverage)

Ground beef 1 pound 11.5 oz 8 oz. ÷ 0.9 oz. = Elbow macaroni 8 ounces dry wt. equiv of 9 slices

1 Tomato sauce 2 8-ounce cans 3 ⁄4 servings

1 Grated cheese ⁄2 cup = 8 Tbsp If 6 Tbsp = 1 oz 8 Tbsp = 1.3 oz Green pepper, 1 1 chopped ⁄4 cup ⁄2 serving

1 1 Onion, chopped ⁄4 cup ⁄2 serving

1 Total: 13.8 ounces 4 ⁄4 servings 9 servings 1 ( ⁄2 cup each) (1 slice each) Calculations: 13.8 ÷ 2 = 6.9 Number 7 servings 4 servings 9 servings 1 of Servings: (2 oz each) ( ⁄2 cup each) (1 slice each)

It is recommended that recipes with foods from more than 2 food groups be credited for no more than 2 different meal components.

Nutrition Resource Manual for Adult Day Health Programs 138 CREDITING FOODS FOR CACFP REIMBURSEMENT

COMMON FOOD YIELDS

The following are common ingredients used in recipes served in adult day care centers. Yields and servings correspond to required amounts for adults for lunch or supper.

MEAT/MEAT ALTERNATES Number of 2 oz. Meat/Meat Alternate Amount as Purchased Yield After Preparation Servings or Equivalent Beef, ground 3 (no more than 26% fat) 1 pound 11.5 oz 5 ⁄4 servings Cheese 1 pound 16 oz 8 servings Cheese spread, 16 oz processed cheese food 1 pound (2 oz = 1 oz meat alt) 4 servings

1 Chicken, boneless 1 pound 11.2 oz 5 ⁄2 servings

1 Chicken, with bone 1 pound 7.04 oz 3 ⁄2 servings

1 Cottage cheese 1 cup 1 cup 2 servings ( ⁄2 cup each)

1 Dry beans 1 pound 5.9 cups 12 servings ( ⁄2 cup each)

1 Ham, boneless 1 pound 9.28 oz 4 ⁄2 servings Pork, ground 3 (no more than 26% fat) 1 pound 11.5 oz 5 ⁄4 servings

1 Tuna 1 6.0 oz can 5.26 oz 2 ⁄2 servings

1 Turkey, ground 1 pound 11.2 oz 5 ⁄2 servings

GRAINS/BREADS

1 Grain/Bread Amount Uncooked Number of ⁄2 Cup Servings Egg noodles, uncooked 1 pound 20 servings, cooked

1 Elbow macaroni, uncooked 1 pound 19 ⁄2 servings, cooked

Lasagna noodles, uncooked 1 pound 14 servings, cooked

1 Rice, white, enriched, uncooked 1 cup dry = 3.25 cups cooked 6 ⁄2 servings, cooked

Rice, white, enriched, uncooked 1 pound dry = 7.5 cups cooked 15 servings, cooked

1 Spaghetti, uncooked 1 pound 10 ⁄2 servings, cooked

Massachusetts Department of Education Child and Adult Care Food Program 139 IT’S MORE THAN A MEAL

VEGETABLES

1 Vegetable Amount Raw Number of ⁄2 Cup Servings

1 Broccoli, fresh or frozen 1 pound 4 ⁄2 servings

1 Carrots 6 sticks (4” x ⁄2”)* 1 servings Celery, fresh (sliced) 1 pound, chopped 6 servings

1 6 sticks (4” x ⁄2”)* 1 serving

1 1 Corn, canned, whole kernel 15 ⁄4 oz (No. 300 can) 2 ⁄2 servings (liquid packed, drained) 106 oz (No. 10 can) 20 servings

1 Corn, frozen, whole kernel 1 pound 5 ⁄2 servings

1 Cucumber, fresh 8 slices ( ⁄8” thick)* 1 serving

1 1 Green beans, canned, 14 ⁄2 oz (No. 300 can) 2 ⁄2 servings cut, drained

1 Green beans, frozen, cut 1 pound 5 ⁄2 servings

1 1 Kidney beans, canned 15 ⁄2 oz (No. 300 can) 2 ⁄2 servings

1 1 Lettuce, iceberg 2 pieces (4 ⁄4” x 4 ⁄4”)* 1 serving

1 1 Peas, canned, drained 15 ⁄4 oz (No. 300 can) 2 ⁄2 servings

1 Peas, frozen 1 pound 4 ⁄2 servings Potatoes, white, fresh 1 pound 4 servings

1 Potatoes, hash browns, frozen 1 pound 3 ⁄2 servings Potatoes, tater tots 1 pound 6 servings or rounds, frozen

1 Tomatoes, canned 14 ⁄2 oz (No. 300 can) 3 servings Tomatoes, cherry, fresh 6 cherry tomatoes* 1 serving

1 Tomatoes, fresh 1 pound, diced 5 ⁄2 servings 4 slices (1/8” thick)* 4 servings

1 Tomato paste 12 oz (1 Tbsp = ⁄4 cup sauce) 10 servings

1 Tomato puree 16 oz (2 Tbsp = ⁄4 cup sauce) 7 servings Tomato sauce 15 oz 3 servings

3 Tomato soup (condensed) 1 can (10 ⁄4 oz) 1 serving

*Numbers are approximate.

Nutrition Resource Manual for Adult Day Health Programs 140 CREDITING FOODS FOR CACFP REIMBURSEMENT

FRUITS

1 Fruit Amount Raw Number of ⁄2 Cup Servings

1 Apples, fresh 1 pound, raw, cored, peeled 5 ⁄2 servings 1 pound, raw, cored, unpeeled 7 servings Bananas, fresh 1 pound, sliced 3 servings

1 Blackberries, fresh 1 pound 5 ⁄2 servings

1 Blackberries, frozen 1 pound, thawed, sugar added 4 ⁄2 servings

1 Blueberries, fresh 1 pound 5 ⁄2 servings

1 Blueberries, frozen 1 pound, thawed, unsweetened 5 ⁄2 servings

1 Cantaloupe, fresh, 1 pound 2 ⁄2 servings cubed or diced Cherries, sweet, fresh 1 pound 4 servings 14 cherries* 1 serving

1 Cherries, frozen 1 pound 3 ⁄2 servings (drained fruit)

1 Dates, dehydrated, pitted 1 pound 5 ⁄2 servings Grapes, fresh, seedless 1 pound 5 servings 14 large grapes* 1 serving Melon, honeydew, 1 pound 2 servings fresh, cubed Oranges, fresh, 138 count 1 pound 3 servings 1 orange 1 serving

1 Peaches, fresh 1 pound 5 ⁄2 servings 1 peach 1 serving Raisins 1 pound 6 servings 1 1.3 oz – 1.5 oz package ⁄2 serving Raspberries, fresh 1 pound 6 servings Strawberries, fresh 1 pound 5 servings

1 Strawberries, frozen 1 pound 3 ⁄2 servings Watermelon, fresh 1 pound 3 servings

*Numbers are approximate.

Note: The numbers of servings for each food have been re-calculated from those listed in the 2003 edition of the USDA manual to reflect CACFP serving sizes for adults. Because the numbers of servings in the 2003 edition of the USDA manual were rounded to the nearest whole number, the numbers listed in these tables are approximate values based on the data available.

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Notes

Nutrition Resource Manual for Adult Day Health Programs 142 CREDITING FOODS FOR CACFP REIMBURSEMENT

CACFP Regulations: Crediting Grains/Breads • Breakfast, lunch and supper must contain • A creditable item must serve the customary grains/breads servings in the amounts specified function of bread in a meal. At lunch or for older adults. For specific guidelines, refer supper, it must accompany the main dish to the CACFP Meal Pattern for Adults chart in (such as dinner rolls), or be a recognizable this section. integral part of the main dish (such as taco shells, potpie crust or spaghetti). • For snacks, a grains/breads item may count as 1 of the 2 components. For specific guidelines, • There are 9 groups of grains/breads items, refer to the CACFP Meal Pattern for Adults listed in a chart on the next 3 pages. Each chart in this section. group’s required weight is based on the key nutrients in 1 slice of bread (25 g or 0.9 oz) or • The following grains/breads products an equal amount (14.75 g) of whole-grain, may be credited: bran, germ or enriched flour. Within each  Whole grain, bran, germ or enriched group, all items have approximately the same grains/breads products nutrient and grain content in each serving.  Products made with whole grain, bran, Items with fillings, toppings, or frostings germ, and/or enriched flour require larger serving sizes to meet minimum  Cereals that are whole grain, bran, grain content. The chart classifies products by germ, enriched, or fortified groups and credits them according to product  Enriched products that meet the Food weights based on FNS Instruction 783-1, Rev 2. and Drug Administration’s Standards of Identity for enriched bread, macaroni • For homemade products, you can determine and noodle products, rice, cornmeal or serving sizes based on the grains and/or cereal corn grits. The grains/breads item must content, following the steps in Tips for contain enriched flour, bran, germ and/or Crediting Recipes in this section . whole-grain as specified on the label or • For dessert-type items, serve no more according to the recipe or must be than 2 of these items as a snack each week. enriched in preparation or processing Examples of dessert-type items are in the and labeled “enriched.” chart in this section.

• For more information on crediting grains/ breads, contact your state agency.

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GRAINS/BREADS FOR ADULT NUTRITION PROGRAMS

GROUP A

1 3 ⁄4 serving = 5 g (0.2 oz.) ⁄4 serving = 15 g (0.5 oz.)

1 ⁄2 serving = 10 g (0.4 oz.) 1 serving = 20 g (0.7 oz.)

Breading type coating Crackers, saltines Pretzels, hard Bread sticks, hard Crackers, snack Stuffing, dry Chow mein noodles Croutons

GROUP B

1 3 ⁄4 serving = 6 g (0.2 oz) ⁄4 serving = 19 g (0.7 oz)

1 ⁄2 serving = 13 g (0.5 oz) 1 serving = 25 g (0.9 oz)

Bagels Crackers, graham Rolls, potato (all shapes) Batter type coating Rolls, white Crackers, animal Biscuits Rolls, wheat Egg roll skins Breads, white Rolls, whole-wheat English muffins Breads, wheat Tortillas, corn Pita bread, white Breads, whole-wheat Tortillas, wheat Pita bread, wheat Breads, French Tortilla chips, corn Pita bread, whole-wheat Breads, Italian Tortilla chips, wheat Pizza crust Buns, hamburger Taco shells Pretzels, soft Buns, hot dog

GROUP C

1 3 ⁄4 serving = 8 g (0.3 oz) ⁄4 serving = 23 g (0.8 oz)

1 ⁄2 serving = 16 g (0.6 oz) 1 serving = 31 g (1.1 oz)

Cookies, plain Pancakes, purchased Pie crust, meat Cornbread Pie crust, dessert pies Pie crust, meat alternate Corn muffins Pie crust, fruit turnovers Waffles, purchased Croissants

Nutrition Resource Manual for Adult Day Health Programs 144 CREDITING FOODS FOR CACFP REIMBURSEMENT

GROUP D

1 3 ⁄4 serving = 13 g (0.5 oz) ⁄4 serving = 38 g (1.3 oz)

1 ⁄2 serving = 25 g (0.9 oz) 1 serving = 50 g (1.8 oz)

Doughnuts, cake, unfrosted Granola bars, plain Sweet roll, unfrosted Doughnuts, yeast, unfrosted Muffins (except corn muffins) Toaster pastry, unfrosted

GROUP E

1 3 ⁄4 serving = 16 g (0.6 oz) ⁄4 serving = 47 g (1.7 oz)

1 ⁄2 serving = 31 g (1.1 oz) 1 serving = 63 g (2.2 oz)

Cookies with nuts Doughnuts, cake, glazed Granola bars with raisins Cookies with raisins Doughnuts, yeast, frosted Granola bars with chocolate pieces Cookies with chocolate Doughnuts, yeast, glazed pieces Granola bars with fruit French toast Cookies with fruit purees Sweet rolls, frosted Grain fruit bars Doughnuts, cake, frosted Toaster pastry, frosted Granola bars with nuts

GROUP F

1 3 ⁄4 serving = 19 g (0.7 oz) ⁄4 serving = 56 g (2 oz)

1 ⁄2 serving = 38 g (1.3 oz) 1 serving = 75 g (2.7 oz)

Cake, plain, unfrosted Coffee Cake

Massachusetts Department of Education Child and Adult Care Food Program 145 IT’S MORE THAN A MEAL

GROUP G

1 3 ⁄4 serving = 29 g (1 oz) ⁄4 serving = 86 g (3 oz)

1 ⁄2 serving = 58 g (2 oz) 1 serving = 115 g (4 oz)

Brownies, plain Cake, all varieties, frosted

GROUP H

1 3 3 ⁄4 serving = 2 Tbsp. cooked or 6 g (0.2 oz) dry ⁄4 serving = ⁄8 cup cooked or 19 g (0.7 oz) dry

1 1 1 ⁄2 serving = ⁄4 cup cooked or 13 g (0.5 oz) dry 1 serving = ⁄2 cup cooked or 25 g (0.9 oz) dry

Barley Macaroni, all shapes Ravioli, noodle only Breakfast cereals, cooked Noodles, all varieties Rice, enriched brown Bulgur (cracked wheat) Pasta, all shapes Rice, enriched white

GROUP I

1 1 3 ⁄4 serving = ⁄4 cup or 0.3 oz (whichever is less) 1 serving = ⁄4 cup or 1 oz (whichever is less)

1 1 ⁄2 serving = ⁄3 cup or 0.5 oz (whichever is less)

Ready-to-eat breakfast cereal (cold, dry)

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Bagels X Group B Bagels are relatively low in fat and high in complex carbohydrates. Enriched bagels contain significant amounts of thiamin, riboflavin, iron, and niacin. Whole-grain varieties are good sources of fiber. Banana bread X See: quick bread. Bagel chips X See: chips. Barley X Group H Batter-type coating X Batters may be credited (as Group B) Foods with a batter-type coating when served as a part of the main may be high in fat. dish of the meal. Crediting is based on the amount of whole-grain, bran, germ, and/or enriched meal or flour in the recipe. It may be difficult to determine the amount of batter on products. It is recommended that another bread item be served with the meal. Biscuits X Homemade biscuits may be credited Biscuits may be high in fat. based on the amount of whole grain, bran, germ, and/or enriched meal or flour in the recipe. For commercial biscuits, use Group B. Boston brown X See: quick bread. bread Bread pudding X Bread pudding may be credited for Serve no more than 2 dessert type a snack only, based on the amount items as a snack each week. of whole grain, bran, germ, or enriched bread in a serving. Breads (white, rye, X Breads may be credited based on Breads are excellent sources of whole wheat, the amount of whole-grain, bran, complex carbohydrates and fiber, pumpernickel, germ and/or enriched meal or flour along with thiamin, riboflavin, seven grain, in the recipe. niacin, and iron. Breads are usually Italian, Roman low in fat. meal, French, etc.) For commercial breads, use Group B. Bread sticks, hard X Group A

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Bread stuffing/ X Homemade stuffing may be credited Bread stuffing may be high in fat dressing, dry based on the amount of bread in depending on the recipe. the recipe. For commercial stuffing made from croutons or quick stuffing mixes, use Group A. Breading X Breading may be credited when Breaded foods may be high in fat. served as a part of the main dish of a meal. Crediting is based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. It may be difficult to determine the amount of breading on products. It is recommended that another bread item be served with the meal. For commercial breading, use Group A. Brownies, plain X Plain brownies may be credited for Serve no more than 2 dessert type snack only, based on the amount of items as a snack each week. whole-grain, bran, germ and/or enriched meal and flour in the recipe. For commercial brownies, use Group G. Brownies, frosted, X or with fillers such as cream cheese, nuts, etc. Bulgur X Group H Buns, hamburger X Homemade buns may be credited and hot dog based on the amount of whole- grain, bran, germ and/or enriched meal or flour in the recipe. For commercial buns, use Group B. Cake X Homemade cake may be credited Serve no more than 2 dessert type based on the amount of whole- items as a snack each week. grain, bran, germ and/or enriched meal or flour in the recipe.

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Cake (continued) X For commercial cake, unfrosted, use Group F. For commercial cake, frosted, use Group G. Caramel corn X Popcorn does not meet the Popcorn is a good source of fiber. definition of grains/breads. Carrot bread X See: quick bread. Cereal bars X See: granola bars. Serve no more than 2 dessert type items as a snack each week. Cereal, cooked X Group H Cereal, dry X Group I Cheese puffs X See: chips. Cheese puffs may be high in fat and salt. Chips X Chips made from whole-grain, bran, Chips may be high in fat and salt. germ and/or enriched meal or flour are creditable using Group B. Chow mein noodles X Group A Cinnamon roll X See: sweet rolls. These rolls may be high in fat and sugar. Serve no more than 2 dessert type items as a snack each week. Cobbler, fruit X The bread portion of the cobbler is Serve no more than 2 dessert type creditable for snack only, based on items as a snack each week. the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. See: fruit/vegetable section for additional crediting information. Coffee cake X Homemade coffee cake is creditable Serve no more than 2 dessert type for breakfast/snack only, based on items as a snack each week. the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. Commercial coffee cake may be credited using Group F.

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Cookies X Homemade cookies may be credited Serve no more than 2 dessert type for snack only, based on the amount items as a snack each week. of whole-grain, bran, germ and/or enriched meal or flour in the recipe. For commercial cookies, plain, use Group C. For commercial cookies with nuts, raisins, chocolate pieces, peanut butter, fillings and/or fruit purees, use Group E. Corn X See: fruits and vegetables. Corn is considered a vegetable. Cornbread X Homemade cornbread may be credited based on the amount of whole-grain and/or enriched meal or flour in the recipe. For commercial cornbread, use Group C. Corn chips X See: chips. Corn dog batter X See: batter-type coating. Corn meal X If corn meal is used in a recipe: 1 serving = 14.75 g Corn muffin X Homemade corn muffins may be credited based on the amount of whole-grain and/or enriched meal or flour in the recipe. For commercial corn muffins, use Group C. Couscous X See: pasta. Crackers X For saltine or snack crackers, Some crackers are high in fat use Group A. and/or salt. They should be served For graham or animal crackers, in moderation. use Group B. Cream puff shells X Homemade cream puff shells may Cream puffs and traditional custard be credited for snack only based on or cream fillings are high in fat. the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe.

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Cream puff shells X For commercial cream puff shells, Serve no more than 2 dessert type (continued) use Group D. items as a snack each week. For commercial filled cream puffs, use Group E. Crepes X Homemade crepes may be credited based on the amount of whole- grain bran, germ and/or enriched meal or flour in the recipe. For commercial crepes, use Group C. Crisp X The grains/breads portion of the Serve no more than 2 dessert type crisp is creditable for snack only, items as a snack each week. based on the amount of cereal and/or whole-grain, bran, germ and/or enriched meal or flour in the recipe. See: fruit/vegetable section for additional crediting information. Croissants X Group C Croissants may be high in fat. Croutons X Group A Cupcakes X See: cake. Serve no more than 2 dessert type items as a snack each week. Danish pastry X See: sweet rolls. Serve no more than 2 dessert type items as a snack each week. Doughnuts X Homemade doughnuts are Doughnuts may be high in fat creditable for breakfast/snack only and sugar. based on the amount of whole- grain, bran, germ and/or enriched Serve no more than 2 dessert type meal or flour used in the recipe. items as a snack each week. For commercial doughnuts, unfrosted, use Group D. For commercial doughnuts, frosted glazed and/or filled, use Group E. Dressing X See: bread stuffing. Dumplings X See: batter-type coating. Egg roll or wonton X Group B wrappers

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information English muffins X Group B French bread X See: breads. French toast X Homemade French toast may be credited based on the amount of whole-grain, bran, germ and/or enriched bread in the recipe. For commercial French toast, use Group E. Fried bread X Fried bread may be credited based Fried bread is high in fat. on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. Ginger bread X See: cake. Serve no more than 2 dessert type items as a snack each week. Glorified rice X See: rice pudding. Serve no more than 2 dessert type items as a snack each week. Grain fruit bars/ X Grain fruit bars may be credited for Serve no more than 2 dessert type fruit and cereal breakfast/snack only, using Group E. items as a snack each week. bars Granola bars X Granola bars may be credited for Granola bars may be high in sugar breakfast/snack only based on the and fat. They can be a good source amount of cereal and/or whole- of fiber and complex carbohydrates. grain, bran, germ and/or enriched meal or flour in the recipe. Serve no more than 2 dessert type For commercial granola bars, plain, items as a snack each week. use Group D. For commercial granola bars with nuts, raisins, chocolate pieces and/or fruit, use Group E. Grits, corn, X Corn grits must be enriched to enriched be credited. If corn grits are served as a cooked cereal, use Group H. If corn grits are used in a recipe: 1 serving = 14.75 g

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Hominy X Hominy is not creditable. It is not made from the whole kernel of corn, and therefore does not meet the criteria for grains/breads. Hush puppies X Homemade hush puppies may be credited based on the amount of cereal and/or whole-grain, bran, germ and/or enriched meal or flour in the recipe. For commercial hush puppies, use Group C. Ice cream cones X Ice cream cones may be credited for Serve no more than 2 dessert type snack only. It may take 2 or 3 cones items as a snack each week. to equal 1 serving. Group A Lefsa X Lefsa is a unleavened bread made primarily of potatoes and flour. It is often rolled with butter, jams, brown sugar, or cinnamon and sugar. Lefsa is credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. Macaroni, X Macaroni must be whole-grain, all shapes bran, germ or enriched. Group H Melba toast X Group A Millet X Group H Muffins X Homemade muffins may be credited based on the amount of whole- grain, bran, germ and/or enriched meal or flour in the recipe. For commercial corn muffins, use Group C. For other muffins, use Group D. Nachos X See: chips. Noodles X Noodles must be whole-grain, bran, germ or enriched. Group H Nut or seed meal X Nuts and seeds are not grains. There or flour are no standards for enrichment.

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Oat bran X If oat bran is used in a recipe: 1 serving = 14.75 g Oatmeal X If oatmeal is served as a cooked cereal, use Group H. If oatmeal is used in a recipe: 1 serving = 14.75 g Pancakes X Homemade pancakes may be credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. For commercial pancakes, use Group C. Party mix X Party mix may be credited based on Some party mixes are high in salt. the cereal content per serving. Group I Pasta, all shapes X Pasta must be whole-grain, bran germ or enriched. Group H Pie crust X Homemade pie crust in dessert pies, Pie crust may be high in fat. meat/meat alternate pies and Dessert pies may be credited for turnovers may be credited based on snack only. the amount of whole-grain, bran germ and/or enriched meal or flour Serve no more than 2 dessert type in the recipe. items as a snack each week. For commercial pie crust, use Group C. Pineapple-upside- X Upside-down cakes may be credited Serve no more than 2 dessert type down cake for snack only, based on the whole- items as a snack each week. grain, bran, germ and/or enriched meal or flour in the recipe. Crediting by weight may be impractical. Pita bread X Group B Pita bread is a good source of complex carbohydrates. Enriched pita is a good source of thiamin, riboflavin, and iron. Whole wheat pita can be high in fiber.

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Pizza crust X Homemade pizza crust may be credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. Commercial pizza crust may be credited using Group B Pop Tarts X See: toaster pastry. Serve no more than 2 dessert type items as a snack each week. Popcorn X Popcorn does not meet the general requirements for grains/breads. Popovers X Homemade popovers may be credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. Commercial popovers may be credited using Group C. Potato chips or X Potato chips are not a grain-based shoe string potatoes chip and not creditable. Potato pancakes X Potato pancakes contain a minimal quantity of flour. Potatoes X See: fruits and vegetables. Potatoes are a vegetable. Pound cake X See: cake. Serve no more than 2 dessert type items as a snack each week. Pretzel chips X See: pretzels, hard. Pretzels, hard X Group A Pretzels, soft X Soft pretzels may be credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe using Group B. Puff pastry X Homemade puff pastry may be Puff pastry may be high in fat. credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. For commercial puff pastry, use Group D. Pumpernickel bread X See: breads.

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Pumpkin bread X See: quick bread. Quick bread X Homemade quick breads may be credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. Commercial quick breads may be credited using Group D. Quinoa X Quinoa is a cereal-like plant product. Group H Raisin bread X See: breads. Ravioli X The pasta in homemade ravioli is creditable based on the amount of whole-grain, bran, germ or enriched meal or flour in the recipe. For commercial ravioli, use Group H. Rice, white X Rice must be whole-grain Rice is a good source of or brown or enriched. Group H complex carbohydrates. Rice cakes X Rice cakes must be enriched or whole-grain. Rice cakes made from puffed rice may be credited based on the serving size for cereal. Group I Rice cereal bars X Rice cereal bars may be credited Serve no more than 2 dessert type based on the amount of cereal in items as a snack each week. a serving. Group I Rice pudding X Rice pudding may be credited for Serve no more than 2 dessert type snack only based on the amount of items as a snack each week. whole-grain or enriched rice in a serving. Rolls, all varieties X See: breads. Roman meal bread X See: breads. Rye wafers X Group A Scones X Homemade scones may be credited based on the amount of whole-grain bran, germ and/or enriched meal or flour in the recipe. For commercial scones, use Group E.

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Sopaipillas X Homemade sopaipillas may be Serve no more than 2 dessert type credited for snack only based on items as a snack each week. the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. For commercial sopaipillas, use Group C. Spoon bread X Spoon bread may be credited based on the amount of whole-grain, bran, germ and/or enriched meal or flour in the recipe. Squash bread X See: quick bread. Stuffing, bread X See: bread stuffing. Sweet rolls, X Homemade sweet rolls may be These rolls may be high in sticky buns, credited for breakfast/snack only fat and sugar. cinnamon rolls, based on the amount of whole- Danish pastries, grain, bran, germ and/or enriched Serve no more than 2 dessert type caramel rolls meal or flour in the recipe. items as a snack each week. For commercial rolls, unfrosted, use Group D. For commercial rolls, frosted, use Group E. Taco chips X See: chips. Taco shells X Group B Tapioca pudding X Tapioca is not a grain. Toaster pastry X Toaster pastry may be credited Serve no more than 2 dessert type for breakfast/snack only. items as a snack each week. For unfrosted toaster pastry, use Group D. For frosted toaster pastry, use Group E. Tortilla chips, X See: chips. wheat or corn Tortillas, X Tortillas must contain whole-grain, wheat or corn bran, germ or enriched meal or flour. Group B

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GRAINS/BREADS Creditable? Food Item Yes No Comments Nutrition Information Turnovers X See: pie crust. Turnovers may be high in fat. Serve no more than 2 dessert type items as a snack each week. Waffles X Homemade waffles may be credited based on the amount of whole- grain, bran, germ and/or enriched meal or flour in the recipe. For commercial waffles, use Group C. Wheat germ X If wheat germ is used in a recipe: 1 serving = 14.75 g Wild rice X Group H Zucchini bread X See: quick bread. Zwieback X Group A

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CACFP Regulations: Crediting Fruits and Vegetables • Breakfast must contain 1 serving of fruit(s) or vegetable(s) or full-strength fruit or vegetable juice, or an equivalent quantity of any combination of these foods.

• Lunch and supper must each contain at least 2 separate servings of fruits or vegetables. Full-strength fruit or vegetable juice may count as up to half of this requirement.

• For snacks, a fruit or vegetable serving may count as 1 of the required 2 components.

• Juice cannot count as 1 component of a snack when milk is served as the only other component.

• Cooked dry beans or peas may count as a vegetable or as a meat alternate, but not as both in the same meal.

• Small amounts (less than 1/8 cup) of fruits and vegetables used as garnishes cannot count toward the fruit and vegetable component.

• Dishes with more than 1 fruit or vegetable (such as fruit cocktail, mixed fruit, mixed vegetables, or tossed salad may count toward only 1 of the 2 required components for lunch and supper.

• Home-canned products cannot be credited due to health and safety reasons. For more information on canned foods, contact your state agency.

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information “Ade” drinks X “Ade” drinks are not 100% “Ade” drinks are usually (lemonade, full-strength juice. high in sugar. limeade, etc.) Apple butter X Apple butter does not contain enough fruit for crediting purposes. Apple cider X Apple cider is a full-strength juice Only pasteurized apple cider should be served. Apple fritters X Apple fritters may be credited as Apple fritters are high in fat. homemade part of the total requirement for fruits/vegetables if each serving has 1 at least ⁄8 cup of apples. Aspic X See: gelatin salads. Banana bread X Fruit and vegetable breads, such as banana bread or zucchini bread, do not contain enough fruit/vegetable to count toward the fruit/vegetable requirement. They contain less than 1 ⁄8 cup per serving. See: grains/breads section for more information. Banana pudding X Banana pudding may be credited based on the amount of fruit in each serving of pudding. Fruit may count as a fruit/vegetable if each serving 1 has at least ⁄8 cup of bananas. Barbecue sauce X Barbecue sauce does not contain Barbecue sauce may be high in salt. enough vegetable per serving Choose lower sodium varieties or to be credited. limit the use of barbecue sauce. Bean sprouts X Bean sprouts can be credited if at 1 least ⁄8 cup is served. Beans and peas, X Beans and peas, canned or cooked Beans and peas are good sources canned or dry from dry (kidney, garbanzo, black of protein, fiber, and iron, and are beans, etc.) may count as a vegetable. naturally low in fat. They cannot count as a meat/meat alternate and a fruit/vegetable in the same meal.

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Beverages, fruit X Fruit drinks (ades, juice drinks, punches) contain less than 50% full-strength juice. They are mainly sugar, flavors, and water.

1 Cake containing X Cakes with at least ⁄4 cup fruit fruit per serving can be credited. See: pineapple upside down cake in the grains/breads section for more crediting information. Carrot bread X See: banana bread Catsup X Catsup does not contain enough Catsup has a high sodium content. vegetable to be credited. Chili sauce X Chili sauce does not contain enough vegetable to be credited. Coconut X Coconut does not contribute Compared to other fruits, coconut 1 towards the meal pattern. It is is high in fat. A ⁄4 cup serving has considered a nut or seed product. about 7 g fat. Most other fruits have less than 1 g fat per serving. Coleslaw X Only the fruit/vegetable Cabbage is a good source ingredients can count toward the of vitamin C. fruit/vegetable requirement. Corn chips X See: chips in the grains/breads section. Chips are high in fat and salt. Corn syrup X Corn syrup is mainly sugar and does not count as a fruit/vegetable. Cranberries X Cranberries are a good source of vitamin C and fiber. Cranberry juice X Cranberry juice (not cocktail) blended blend with another full-strength juice is creditable. An example is a blend of 100% cranberry juice and 100% apple juice. Cranberry juice (100%) that is not blended with other juices is not commercially available as a fruit juice. Cranberry juice X Cranberry juice cocktail contains less cocktail than 50% full-strength juice. Cranberry relish X Only sauces with whole or crushed or sauce berries can be credited 1 Jellied sauces are up to ⁄2 sugar and cannot be credited.

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Drinks, fruit X Fruit drinks contain less than 50% full-strength juice. They are mainly sugar, flavors, and water. Dry spice mixes X Fig bar cookies X The amount of fig in the cookies is too small to count toward the fruit/vegetable component. See: cookies in the grains/breads section for more information. Frozen fruit X Frozen fruit flavored bars flavored bars do not contain enough fruit juice (commercial) to be creditable. Frozen fruit juice X The fruit juice portion of the bars bars (homemade may count toward the fruit/ or commercial) vegetable requirement. Commercial fruit juice bars with 100% juice can count. Other commercial fruit juice bars cannot count because it is impossible to determine the amount amount of fruit juice in each bar. Fruit in breads X See: banana bread. or muffins (banana, carrot, cranberry, pumpkin, zucchini, etc.) Fruit cobblers X The fruit may contribute toward Depending on the recipe, many (homemade) the fruit/vegetable requirement if 1 fruit cobblers may be high in 1 serving has at least ⁄8 cup fruit. See: sugar and fat. cobbler in the grains/breads section for more crediting information. Fruit crisps X The fruit may contribute toward Fruit crisps may be high in fat. (homemade) the fruit/vegetable requirement if 1 1 serving has at least ⁄8 cup. See: fruit pie filling (below) and crisp in the grains/breads section for more crediting information. Fruit, dried X Check the Food Buying Guide for serving sizes of various dried fruits.

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Fruit drinks X See: drinks, fruit in this section. Fruit flavored X Fruit flavored punch does not Fruit punch is high in sugar. punch contain a sufficient amount of full-strength juice. Fruit flavored X Fruit flavored powders and syrups Fruit flavored powders are powders and syrups do not contain a sufficient amount mainly sugar and flavoring. of fruit to contribute toward the fruit/vegetable requirement. Fruit juice bases X Fruit juice bases do not contain a sufficient amount of fruit to contribute toward the fruit/ vegetable requirement. Fruit pie filling, X If the first item in the ingredient list The use of fruit pies to meet the commercial (except is fruit, the filling may provide one- fruit/vegetable requirement should 1 lemon pie filling) half credit ( ⁄2 cup of fruit pie filling be limited due to high fat and 1 will provide ⁄4 cup of fruit credit). sugar contents. Fruit pie filling, X In a homemade or center-made pie, The use of fruit pies to meet the homemade (except the amount of fruit can be credited fruit/vegetable requirement should lemon pie filling) based on the amount of fruit in be limited due to high fat and each serving. sugar contents. Fruit sauces, X The fruit portion of the sauce may homemade be credited. One serving must 1 provide a minimum of ⁄8 cup (2 Tbsp.) of fruit. Fruit snacks X It is impossible to determine the amount of fruit in products such as fruit bars, roll-ups, wrinkles, or candy. Gelatin salads or X The fruit/vegetable in gelatin salads desserts with fruit/ or desserts may be credited toward fruit juice/vegetable the fruit/ vegetable requirement if 1 each serving contains at least ⁄8 cup fruit, vegetable, or full-strength fruit or vegetable juice. Gravy bases X Honey X Ice cream, X Fruit flavored ice cream contains an fruit flavored insufficient amount of fruit to credit toward the meal pattern.

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Jam X Jam contains an insufficient amount Jams are high in sugar. of fruit per serving to credit toward the meal pattern. Jelly X Jelly contains an insufficient Jellies are high in sugar. amount of fruit per serving to credit toward the meal pattern. Juice bars X Juice bars made from 100% juice can be credited. Juice blends – X Juice blends that are made of all fruit juice full-strength juices can be credited. Only pasteurized fruit juices should be served. Ketchup X Ketchup does not contain enough Ketchup has a high sodium content. vegetable to be credited.

1 Kiwi fruit X ⁄4 cup serving = Kiwi is a good source 1 about 6 slices of ⁄4 inch each of vitamin C. Kool-Aid X See: fruit-flavored powders Lefsa X Lefsa is an unleavened bread made Lefsa is often served with butter, primarily of potatoes and flour. brown sugar, jams, or cinnamon 1 Lefsa with at least ⁄8 cup potato and sugar. These toppings are per serving is creditable as a high in fat and/or sugar. fruit/vegetable. See: lefsa in the grains/breads section. Lemon pie filling X Lemon pie filling contains an insufficient amount of fruit per serving. Lemonade X Lemonade is not creditable because it must be diluted beyond the 50% fruit juice level and have sugar added to be palatable. Maple syrup X Mayonnaise X Mustard X Muffins with fruit X See: banana bread Nectar (apricot, X Nectars usually contain less than pear, peach, etc.) 50% full-strength juice. Oil, salad X

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Olives X Olives can be credited if each Olives are high in salt and fat. 1 serving is at least ⁄8 cup (2 Tbsp.). Onion rings X Onion rings are creditable if they Fried onion rings are high in fat. are homemade, or if a product specification sheet is available that states the amount of onion. Pickles X Pickles can be credited if each Pickles are high in sodium. 1 serving is at least ⁄8 cup (2 Tbsp.). Pickle relish X Pickle relish is considered a garnish or condiment. Pineapple upside X See: cake containing fruit. down cake

1 Pizza sauce X At least ⁄8 cup (2 Tbsp.) per serving 1 is needed. ⁄8 cup of pizza sauce = 1 ⁄8 cup vegetable. Pop Tart filling X See: toaster pastry filling. Popsicles X Popsicles contain an insufficient Popsicles are high in sugar. amount of fruit juice for crediting. Posole X Posole is a thick soup. It usually contains pork or chicken, broth, hominy, onion, garlic, dried chili peppers, and cilantro. Potato chips X Potato chips are high in fat and salt. Potatoes and X Potato skins are high in fiber. potato skins Potatoes and potato skins can be high in fat if fried. Toppings such as sour cream, cheeses, butter, or margarine are also high in fat. Preserves X Preserves contain an insufficient amount of fruit per serving for crediting. Pumpkin in bread X See: banana bread. Pudding with fruit X The pudding must contain at least 1 ⁄8 cup or 2 Tbsp. fruit per serving.

1 1 Raisins X ⁄4 cup raisins = ⁄4 cup fruit. Raisins are high in sugar. 1 Larger serving sizes may be ⁄4 cup has almost 3 Tbsp. sugar. impractical. Serve raisins with Raisins are high in iron and fiber. other fruits or vegetables.

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Rice X Rice is a grain. See: rice in the grains/breads section. Salad dressing X Salsa X Salsa with all vegetable ingredients and small amounts of spices or flavorings is creditable. At least 1 1 ⁄8 cup (2 Tbsp.) is needed. ⁄8 cup 1 salsa = ⁄8 cup vegetable. If salsa contains non-vegetable components such as gums, starches, or stabilizers, only the vegetable portion may be credited. Sherbet X Sherbet contains an insufficient amount of fruit for crediting. Sorbet X Sorbet made from 100% juice is creditable. Soup, canned, X Based on reconstituted soup: Broth-based soups with a variety 1 condensed 1 cup soup = ⁄4 cup vegetable of vegetables can be a nutritious, 1 1 (1 part soup to 1 part ⁄2 cup soup = ⁄8 cup vegetable low-calorie main dish or liquid): clam chowder; accompaniment to a meal. 1 minestrone; split pea; A serving of less than ⁄2 cup soup tomato; tomato with does not contribute to the fruit/ Some canned soups may be basic components such vegetable requirement. high in sodium. as rice or vegetables; vegetable with basic Cream-based soups are high in fat. components such as meat or poultry

1 Soup, canned, X 1 cup soup = ⁄4 cup vegetable Broth-based soups with a variety 1 1 ready-to serve: ⁄2 cup soup = ⁄8 cup vegetable of vegetables can be a nutritious, clam chowder; low-calorie main dish or 1 minestrone; split pea; A serving of less than ⁄2 cup soup accompaniment to a meal. tomato; tomato with does not contribute to the fruit/ basic components such vegetable requirement. Some canned soups may be as rice or vegetables; high in sodium. vegetable with basic components such as Cream-based soups are high in fat. meat or poultry

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Soup, canned, X These types of canned soups Broth-based soups with a variety beef with vegetables contain an insufficient amount of of vegetables can be a nutritious, and barley; beef, chicken, vegetable to contribute toward low-calorie main dish or or turkey noodle; chicken the fruit/vegetable requirement. accompaniment to a meal. gumbo; chicken with rice or stars; cream of celery, Some canned soups may be cream of chicken; cream high in sodium. of mushroom; French onion; homestyle beef or Cream-based soups are high in fat. chicken; pepper steak; chicken corn chowder Soup, dehydrated X Dehydrated vegetables may be Dry soups may be high in sodium. soup mix credited; their yields must be based on the rehydrated volume, not the dry volume stated on the label. Rehydration yields vary from brand to brand. To determine the vegetables’ rehydrated volume: (1) rehydrate them by adding liquid according to the manufacturer’s directions; (2) measure their rehydrated volume; (3) calculate the number of servings provided; (4) keep a record of yield data for referral. Soup, homemade X When making homemade soups, use a quantity of vegetables that results 1 in at least ⁄8 cup (2 Tbsp.) vegetable per serving for crediting purposes.

1 Spaghetti sauce X At least ⁄8 cup (2 Tbsp.) per serving 1 is needed to be credited. ⁄8 cup 1 spaghetti sauce = ⁄8 cup vegetable. Sprouts: alfalfa X Sprouts are a potential food bean, etc. safety hazard. Squash in bread X See: banana bread.

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FRUITS AND VEGETABLES Creditable? Food Item Yes No Comments Nutrition Information Toaster pastry X These do not contain enough fruit filling to count toward the fruit/vegetable requirement. See: toaster pastry in the grains/breads section.

1 Tomato paste X 1 Tbsp. = ⁄4 cup vegetable

1 Tomato puree X 2 Tbsp. = ⁄4 cup vegetable

1 1 Tomato sauce X ⁄4 cup = ⁄4 cup vegetable V-8 juice X See: vegetable juice blends. Vegetable juice X Vegetable juice blends are mixed, Vegetable juice blends may contain blends full-strength vegetable juices. a variety of nutrients. However, they may be high in sodium. Vegetable, X Vegetables may count toward the chopped meal pattern if each serving has 1 least ⁄8 cup (2 Tbsp.) vegetables. Vinegar X Wild plants X USDA does not recommend using Dark green leafy vegetables wild plants due to the possibility of and greens are good sources gathering look-alikes or poisonous of iron and vitamin A. plants. Mustard or dandelion greens, if used, should be purchased from a reputable commercial source. Yogurt with fruit, X Commercially prepared yogurt with 1 commercial fruit contains less than ⁄8 cup fruit per serving. Fruit added to yogurt is creditable. See meat/meat alternates section for crediting yogurt. Zucchini bread X See: banana bread.

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CACFP Regulations: Crediting Meat and Meat Alternates • Lunches and suppers must contain a serving of meat or meat alternates as specified in the meal pattern.

• Snacks may include meat or meat alternates as 1 of the 2 components.

• Foods that count as meat and meat alternates are as follows:

• Meat includes lean meat, poultry, or fish.

• Meat alternates include cheese, eggs, cooked dry beans or peas, nuts and seeds, and their butters (except for acorn, chestnut, and coconut), and yogurt.

• Meat and meat alternates must be served in a main dish, or in a main dish with one other item, to meet this requirement.

• The usual serving size of meat or meat alternates for adults is 2 ounces at meals and 1 ounce at snacks. To count toward meeting any part of the meat/meat alternate requirement, a menu item must provide a minimum of 1 ounce of cooked lean meat or equivalent. The rest of the required serving must be met by adding other meat or meat alternates.

1 • Nuts and seeds may fulfill no more than ⁄2 of the meat/meat alternate requirement for lunch and supper, or all of the meat/meat alternate requirement for a snack.

• Vegetable protein products may count as meeting part of the meat or meat alternate requirement. State agencies can provide information on the preparation, serving, and crediting of vegetable protein products.

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MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information Acorns X Acorns have a low protein content. Baco-bits X Baco-bits are low in protein and high in fat. Bacon or imitation X Bacon is low in protein and high bacon products in fat. It is also high in sodium. Bacon, turkey X See: processed meat and poultry products. Beans, canned X Beans and peas cooked from dry The types of beans and peas that or dry count as a meat/meat alternate. can count as meat/meat alternates Canned black, garbanzo, kidney, are good sources of protein and pinto, etc. beans count as a meat/ fiber, and are low in fat. meat alternate or as a fruit/vegetable, but not both. Canned green or yellow beans and green peas count only as vegetables. Beef jerky X Beef jerky made with pure beef Beef jerky does not serve the may be credited as a snack only. customary function of meat in a †he label should state: “beef jerky meal. Beef jerky is very high chopped and formed,” “natural in sodium. jerky,” or “beef jerky sausage.” Bologna X See: processed meat and poultry Bologna and other processed meats products. can be high in fat and sodium. Like all processed meats, bologna has less protein than fresh meat by weight. Canadian bacon X 1 lb. (16 oz.) will yield 11 servings Canadian bacon is high (1 oz. each) of cooked meat. in sodium. Refer to the Food Buying Guide or your state agency for information. Canned or frozen X These are creditable only if a product Processed combination foods such food, commercial: analysis sheet signed by an official as these are usually higher in fat beef stew, chili of the manufacturer (not a sales- and sodium than homemade foods. mac, meat stew, person) is on file that states the pizza, pot pies, amount of cooked lean meat/meat ravioli, etc. alternate per serving. Canned pressed X See: processed meat and poultry Canned pressed luncheon meat luncheon meat products. is usually high in fat and sodium. (Spam)

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MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information

1 Cheese, cottage X 2 oz. ( ⁄4 cup) cottage cheese = Cottage cheese requires a greater 1 oz. meat serving size than meat because it contains less protein per ounce. Cheese, cream X Due to low protein and high fat Cream cheese has more fat and content, a serving size that would less protein than other cheeses. provide enough protein would be excessively large. Cheese food and X 2 oz. cheese food or cheese Cheese food and cheese spread are cheese spread spread = 1 oz. meat often high in sodium, so look for (Velveeta, Cheese lower sodium varieties. Compared Whiz, and reduced- to natural cheeses, these foods have fat, lite, or non-fat more moisture and less protein. substitutes) Cheese, imitation X Products labeled “imitation” are not creditable. Cheese, natural X 1 oz. natural or processed cheese = Some cheeses are high in fat and or processed 1 oz. meat cholesterol. Cheese is a good source (American, brick, source of protein, calcium, and cheddar, Colby, vitamins A and D. Monterey jack, mozzarella, Muenster provolone, Swiss); includes reduced-fat, lite, or non-fat substitutes Cheese, Neufchatel X Due to low protein and high fat Neufchatel cheese has less protein content, a serving size that would and more fat than creditable cheeses. provide enough protein would be excessively large. Cheese, Parmesan X 6 Tbsp. Parmesan cheese = 1 oz. meat If served as a garnish, the cheese is not creditable because the serving size is too small. Cheese, pimento X 2 oz. pimento cheese = 1 oz. meat Cheese products X “Cheese product” is a category name and is not standardized.

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MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information

1 Cheese, ricotta X 2 oz. ( ⁄4 cup) ricotta cheese = Ricotta cheese has less protein and 1 oz. meat a higher moisture content than natural cheese. Cheese, Romano X 6 Tbsp. cheese = 1 oz. meat If served as a garnish, the cheese is not creditable because the serving size is too small. Chestnuts X Chestnuts are very low in protein. Chicken nuggets X See: processed meat and poultry products. Chitterlings X Chitterlings are too low in protein Chitterlings are high in fat. to be credited. Coconuts X Coconuts cannot count as either Coconuts are very low in protein. a meat/meat alternate or a fruit/vegetable. Corndogs X The frankfurter can count as a meat/ Corndogs are high in fat. meat alternate if it meets criteria for frankfurters. See: batter-type coating in the grains/breads section additional crediting information. Crab, imitation X See: imitation seafood. No standard of identity. Cream cheese X See: cheese, cream. Deviled eggs X Cooked eggs may be credited. Deviled eggs are high in fat and See: eggs. cholesterol. For less fat, use a reduced fat mayonnaise instead of regular mayonnaise. Eggs X Cooked eggs may be credited. Eggs Eggs are a good source of protein. cannot be credited when part of a However, they contain a significant homemade custard or pudding. amount of cholesterol. Fish X Fish is a good source of protein and iron. Many varieties have less fat than meats. Try to broil or bake fish rather than frying it. Fish, non- X For safety reasons, home-caught commercial fish should not be served. (home-caught) Fish sticks or X Only the edible fish portion counts nuggets toward the meat requirement.

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MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information Frankfurters, X imitation Frankfurters, X See: processed meat and poultry Up to 80% of the calories in meat and poultry products. frankfurters may be from fat. They may also be high in sodium and cholesterol. Game (venison, X For health and safety reasons, these squirrel, rabbit, etc.) are not creditable unless inspected and approved by the appropriate federal, state, or local agency. Garbanzo beans X See: beans, canned or dry in this section. Hamhocks X They are high in fat and low in protein by weight. Home-slaughtered X To be credited, home-raised animals meat and poultry must be slaughtered at a USDA facility with a USDA inspector on duty. Poultry is subject to state inspection. Hot dogs X See: processed meat and poultry Up to 80% of the calories in hot dogs products. may be from fat. They may also be high in sodium and cholesterol. Imitation seafood X No standard of identity. Kidney X Kidney beans X See: beans, canned or dry products in this section. Legumes X See: beans, canned or dry products in this section. Liver X Liver is high in fat and cholesterol. Liverwurst X See: processed meat and poultry Liverwurst is high in fat products. and cholesterol. Luncheon meat X See: processed meat and poultry products. Macaroni and X The powdered cheese in commercial cheese, commercial mixes cannot count toward the meat requirement. See: macaroni in the grains/breads section.

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MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information Macaroni and X The cheese in homemade macaroni cheese, homemade and cheese may be may be credited based on the amount of cheese in each serving. See: macaroni in the grains/breads section. Meat sauce, X The meat in commercial sauce commercial cannot be credited. Meat sauce, X The meat in homemade sauce can homemade be credited based on the amount of meat in each serving. Neufchatel cheese X See: cheese, Neufchatel. Nuts X Nuts and seeds may count as a Nuts and seeds are good sources serving of meat alternate for a of protein. They have no cholesterol, 1 snack, but as only ⁄2 serving of but are high in fat and low in iron. meat alternate at lunch or supper. Serve only ground or finely chopped nuts and seeds to adults who are at risk of choking. Nut or seed meal X Nut or seed meal or flour cannot or flour be credited unless it meets the requirements for vegetable protein products. Contact your stage agency for information. Pasta products with X See: canned or frozen food, meat, commercial commercial in this section. Pasta products with X Pasta products may be credited meat, homemade based on the amount of meat in each serving. See: pasta in the grains/breads section. Peanut butter, X reduced fat Peanut butter, X Unlike nuts, peanut butter and other Peanut butter is high in fat. regular 100% nut butters can fulfill 100% of It has no cholesterol. the meat/meat alternate requirement for lunch or supper.

Nutrition Resource Manual for Adult Day Health Programs 174 CREDITING FOODS FOR CACFP REIMBURSEMENT

MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information Peanut butter X Peanut butter spreads do not spreads meet the FDA Standard of Identity for peanut butter. Peas, dry or canned X See: beans, dry or canned. Pepperoni X See: processed meat and poultry Pepperoni is high in fat and sodium. products in this section. Pig’s feet X Pig’s feet provide an insufficient Pig’s feet are high in fat. amount of meat. Pig neck bones X Pig neck bones provide an Pig neck bones are high in fat. insufficient amount of meat. Pig tails X Pig tails provide an insufficient Pig tails are high in fat. amount of meat. Pimento cheese X See: cheese, pimento in this section. Pinto beans X See: beans, canned or dry in this section. Pizza, commercial X See: canned or frozen food, commercial in this section. Pizza, homemade X Homemade pizza may be credited based on the amount of meat/meat alternate in each serving. See: pizza crust in the grains/breads section. Polish sausage X See: processed meat and poultry Polish sausage, like most sausages, products in this section. is high in fat and sodium. Pot pies, X See: canned or frozen food, The crust and sauce may both commercial commercial in this section. be high in fat. Pot pies, X Homemade pot pies can be credited The crust and sauce may both homemade based on the amount of meat/meat be high in fat. alternate in each serving. See: pie crust in the grains/breads section. Potted meat X See: processed meat and poultry Potted meat is high in sodium. products in this section. Powdered cheese X See: macaroni and cheese, in macaroni commercial in this section. Pressed meat X See: processed meat and poultry Pressed meat products are high in products products in this section. sodium. Use them infrequently.

Massachusetts Department of Education Child and Adult Care Food Program 175 IT’S MORE THAN A MEAL

MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information Processed meat and X Processed meat and poultry products To provide a reasonable serving poultry products and sausages may be served in the size, it is recommended that all CACFP. Only the meat in these meat or poultry products be products can be credited. Since purchased. many processed meats contain large amounts of binders and extenders, you need to know their composition to properly credit the meat/meat alternate portion. Meat products without binders/extenders may be fully credited based on weight. For information on crediting meats with vegetable protein products as an extender, refer to the processed meats tips under Tips for Crediting Foods in this section. Quiche X The eggs, meat, and/or cheese in quiche may be credited based on the amount of meat/meat alternate in each serving. See: pie crust in the grains/breads section for crediting information. Ravioli, X See: canned or frozen food, commercial commercial in this section. Salt pork X Salt pork is not creditable due to its high fat and low protein content. Sausage X See: processed meat and poultry products in this section. Scrapple X Scrapple provides an insufficient amount of meat. Seeds X See: nuts in this section. Shellfish X Only the edible portion of shellfish is creditable. The shellfish must be fully cooked.

1 Soups, homemade X Homemade soups with at least ⁄4 oz. meat/meat alternate per serving may contribute toward the meat requirement.

Nutrition Resource Manual for Adult Day Health Programs 176 CREDITING FOODS FOR CACFP REIMBURSEMENT

MEAT/MEAT ALTERNATES Creditable? Food Item Yes No Comments Nutrition Information

3 Soups, commercial: X ⁄4 cup of bean, lentil, or split pea Commercial soups are often bean, lentil, or soup may count as 1.5 ounce high in sodium. 3 split pea only ( ⁄8 cup) of meat alternate. Soups, commercial: X These soups contain insufficient other than bean, quantities of meat. lentil, or split pea Soy burgers or X Vegetable protein products may be other soy products credited if the quantity (by weight) of the fully hydrated vegetable protein product does not exceed 30 parts to 70 parts meat, poultry, or seafood on an uncooked basis. Soy butter X Soy butter made from 100% soy nuts is creditable. It is a good alternate to peanut butter, and is nutritionally comparable to meat or other meat alternates. Tempeh X Tempeh is fermented soybean. Because there is no standard of identity for this food, and it could vary from manufacturer to manufacturer, it cannot be credited. Tofu X Tofu is soybean curd. Because there is no standard of identity for this food, and it could vary from manufacturer to manufacturer, it cannot be credited. Tripe X Tripe has low quality protein. Vienna sausage X See: processed meat and poultry products in this section. Yogurt, plain or X Yogurt is creditable as a meat/meat Yogurt is a good source of 1 sweetened and alternate. 4 oz. (by weight) or ⁄2 cup calcium and phosphorus. flavored plain or sweetened flavored yogurt is equivalent to 1 oz. meat/meat alternate. Yogurt products: X There is not enough yogurt in frozen yogurt, yogurt these products to be creditable. bars, yogurt coating on fruit or nuts

Massachusetts Department of Education Child and Adult Care Food Program 177 IT’S MORE THAN A MEAL

Notes

Nutrition Resource Manual for Adult Day Health Programs 178 CREDITING FOODS FOR CACFP REIMBURSEMENT

CACFP Regulations: Crediting Milk Products • Breakfast must include fluid milk. It can be served as a beverage, used on cereal, or used in part for each purpose.

• Lunch must include fluid milk, served as a beverage.

• Snacks may include fluid milk as 1 of the components (unless juice is served as the only other component). It can be served as a beverage, used on cereal, or used in part for each purpose.

• To qualify for crediting, milk must be pasteurized and meet state or local standards for fluid milk. It should contain vitamins A and D at levels specified by the Food and Drug Administration.

• Milk that can be credited includes:  Flavored or unflavored milk: • Whole milk • Reduced fat (2%) milk • Low-fat (1%) milk • Non-fat (skim) milk  Cultured buttermilk

• Milk can not be credited when cooked in:  Cereals  Puddings  Other foods

Massachusetts Department of Education Child and Adult Care Food Program 179 IT’S MORE THAN A MEAL

MILK Creditable? Food Item Yes No Comments Nutrition Information Acidified milk X Acidified milk is fluid milk that has been made sour by an acidifying agent. Examples are acidified kefir milk and acidified acidophilus milk. Buttermilk X Buttermilk is low in fat. Certified raw milk X Certified raw milk is not pasteurized. Regulations require the use of pasteurized milk. Pasteurized milk is heated at a high temperature for a period of time to destroy microorganisms. Cheese X Cheese cannot be credited toward the milk requirement, because it does not meet the definition of milk as “fluid.” However, cheese can count toward the meat/meat alternate requirement. Chocolate milk X Try to limit the use of flavored milks due to their high sugar content. Cocoa X Cocoa made with fluid milk is creditable. Credit the fluid milk portion only. Cocoa made from water is not creditable. Cream X Cream does not meet the definition of milk. Cream sauces X To be credited, milk must be served as fluid milk, not cooked in cereals, puddings, cream sauces, or other foods. Cream soups X To be credited, milk must be served as fluid milk, not cooked in cereals, puddings, cream sauces, or other foods. Cultured milk X Cultured milk is fluid milk with a unique flavor and/or consistency as a result of adding certain micro- organisms under controlled conditions. Examples are cultured buttermilk and cultured kefir milk.

Nutrition Resource Manual for Adult Day Health Programs 180 CREDITING FOODS FOR CACFP REIMBURSEMENT

MILK Creditable? Food Item Yes No Comments Nutrition Information Custard X To be credited, milk must be offered as a serving of fluid milk, not cooked in cereals, puddings, cream sauces, or other foods. Eggnog: X Eggnog made with cooked eggs is commercial or creditable. Only the fluid milk homemade portion is creditable. Eggnog made with uncooked eggs is NOT creditable due to the risk of Salmonella enteritidis, a foodborne Illness related to uncooked or undercooked eggs. Eggnog flavored X Try to limit the use of flavored milks milk due to their high sugar content. Evaporated milk X Evaporated milk does not meet the definition of milk. Flavored milk X Try to limit the use of flavored milks due to their high sugar content. Frozen yogurt X Frozen yogurt does not meet the definition of milk. Goat’s milk X Goat’s milk must meet state standards for fluid milk to be creditable. Half and half X Half and half does not meet the definition of milk. Hot chocolate X Hot chocolate made with fluid milk Try to limit the use of flavored milks is creditable. Credit the fluid milk due to their high sugar content. portion only. Ice cream X To be credited, milk must be Ice cream contains 11% to 20% fat. provided as a serving of fluid milk. Ice cream, low fat X To be credited, milk must be Low-fat ice cream contains (ice milk) provided as fluid milk. 2% to 6% fat. Imitation milk X Imitation milk does not meet the definition of milk. Lactose reduced X People who cannot digest lactose milk found in standard milk may be able to drink lactose reduced milk.

Massachusetts Department of Education Child and Adult Care Food Program 181 IT’S MORE THAN A MEAL

MILK Creditable? Food Item Yes No Comments Nutrition Information Low fat milk X Whole, reduced fat, low fat, and (1% or light) nonfat milk provide equal amounts of nutrients. They differ in fat content and therefore, the number of calories per serving. Milk and X When milk is combined with a fruit drink full-strength juice, either the fruit juice or milk may be credited as a snack component, but not both. Milkshakes, X Milkshakes containing at least homemade and 1 cup fluid milk per serving are commercial creditable. Only the fluid milk portion is creditable. Nonfat milk X Nonfat milk contains virtually no (fat free or skim) fat. Nonfat milk provides equal amounts of the same nutrients as whole, reduced fat, and low fat milk (except for fat). Nonfat dry milk, X Nonfat dry milk may be used only reconstituted in emergency situations where the availability of milk has been affected. Contact your state agency for approval. Pudding X To be credited, milk must be provided as a serving of fluid milk, not cooked in cereals, puddings, cream sauces, or other foods. Pudding pops X To be credited, milk must be provided as a serving of fluid milk, not cooked in cereals, puddings, cream sauces, or other foods. Reduced fat milk X Whole, reduced fat, low fat, and nonfat milk provide equal amounts of nutrients. They differ in fat content and therefore, the number of calories per serving. Sherbet X Sherbet does not meet the definition of milk.

Nutrition Resource Manual for Adult Day Health Programs 182 CREDITING FOODS FOR CACFP REIMBURSEMENT

MILK Creditable? Food Item Yes No Comments Nutrition Information Skim milk (nonfat X Skim milk contains virtually no fat. or fat free milk) Skim milk provides equal amounts of the same nutrients as whole, reduced fat, and low fat milk (except for fat). Sour cream X Sour cream does not meet the Sour cream is high in fat. definition of milk. Look for reduced fat sour cream as an alternative. Soy milk X Soy milk is creditable only if used as a substitution due to medical or other dietary needs. A statement signed by a medical authority must be on file for a person being served soy milk. UHT (ultra-high X UHT milk is Grade A pasteurized temperature) milk milk heated to 280°F, then cooled. It can be stored without refrigeration until opened. Whole milk X Whole milk contains 3.3% fat. Reduced fat, low fat, or skim milk provide equal amounts of the same nutrients, with less fat. Yogurt X Yogurt does not meet the definition Yogurt is a good source of of milk. Yogurt can be credited as a calcium, phosphorus, and protein. meat alternate. See: yogurt in the meat/meat alternate section.

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Notes

Nutrition Resource Manual for Adult Day Health Programs 184 IT’S MORE THAN A MEAL

Resources for Adult Day Health Programs

Introduction ...... 187

Child and Adult Care Food Program (CACFP) ...... 188

Aging-Related Programs and Services ...... 188 Fact Sheets ...... 189 Resources Other Resources (Organized by Topic) ...... 189

189 ...... Nutrition 190 ...... Health Issues for Older Adults for Adult Alzheimer’s Disease ...... 190 Diabetes ...... 191 Heart Disease ...... 191 Day Health High Blood Pressure ...... 191 Osteoporosis ...... 192 Senior Health (Multiple Topics) ...... 192 192 ...... Medicines and Older Adults 193 ...... Physical Activity and Older Adults Programs 193 ...... Emergency Food Plans 194 ...... Food Safety 194 ...... Caregiving

Massachusetts Department of Education Child and Adult Care Food Program 185 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 186 RESOURCES FOR ADULT DAY HEALTH PROGRAMS

his section will provide you with additional T resources for your program. You can use these resources to complement this manual and the accompanying set of Health at Home fact sheets for caregivers.

The resources listed in this section include:

• Website addresses for the Child and Adult Care Food Program (CACFP) at the federal level and for a directory of agencies that administer CACFP in each state

• Contact information for the Massachusetts CACFP office

• Aging-related programs and services.

• Fact sheets that can be downloaded from other websites

• Other resources on the following topics:

 Nutrition

 Health issues for older adults (Alzheimer’s disease, diabetes heart disease, high blood pressure, osteoporosis, and senior health)

 Medicines and older adults

 Physical activity and older adults

 Emergency food plans

 Food safety

 Caregiving

NOTE: The resource information provided in this section was current as of February, 2006.

Massachusetts Department of Education Child and Adult Care Food Program 187 IT’S MORE THAN A MEAL

Child and Adult Care Food Aging-Related Program (CACFP) Programs and Services Massachusetts Department of Education Massachusetts Department of Public Health Child and Adult Care Food Program Office of Healthy Aging

Nutrition Health and Safety Unit Bureau of Family and Community Health 350 Main Street 250 Washington Street Malden, Massachusetts 02148-5023 Boston, MA 02108

Phone: 781-338-6498 Phone: 617-624-5440

Website: www.doe.mass.edu/cnp/ Website: www.mass.gov/dph/fch/elderhealth programs/cacfp.html Massachusetts Executive Office of Elder Affairs

U.S. Department of Agriculture 1 Ashburton Place, 5th floor Child and Adult Care Food Program (The McCormack Building) Website: www.fns.usda.gov/cnd/ Boston, MA 02108

Care/CACFP/cacfphome.htm Phone: 617-727-7750 or 800-243-4636

Website: www.800ageinfo.com Directory of State Agencies Administering CACFP

Website: www.fns.usda.gov/cnd/Contacts/ Website Links to Other Programs and Services StateDirectory.htm (Assembled by Somerville-Cambridge Elder Services) Food Buying Guide Website: www.eldercare.org/Information/ Website: http://teamnutrition.usda.gov/ Links.shtm#HealthInformation resources/foodbuyingguide.html This website provides a comprehensive set of links to agencies, associations, organizations, partnerships, directories, databases, and resources related to the following topics: • Advocacy • Aging Services • Benefits • Caregiving • Disability Information • Health Information • Legal and Financial • Local Resources • Longterm Care (in Cambridge and Somerville)

Nutrition Resource Manual for Adult Day Health Programs 188 RESOURCES FOR ADULT DAY HEALTH PROGRAMS

Rutgers University Cooperative Research and Extension The Caring Connection – Fact Sheets FactThe following Sheets websites contain downloadable for Caregivers fact sheets. Website: www.rce.rutgers.edu/pubs/sub University of Massachusetts Extension category.asp?cat=10&sub=68

Nutrition Education Program (NEP) This website has fact sheets with resources and Website: www.umass.edu/umext/nutrition information on caregiving, and tips for care- givers to take care of themselves. This website has fact sheets on multiple topics, including food preparation, food safety, food labels, and healthy eating. Other Resources Colorado State University Cooperative Extension (Organized by Topic) Food and Nutrition Fact Sheets

Website: www.ext.colostate.edu Nutrition University of Massachusetts Extension This website has fact sheets on multiple topics, Nutrition Education Program including nutrition and aging, chronic diseases, University of Massachusetts food preparation, food safety, medications, and Department of Nutrition supplements. 205 Chenoweth, 100 Holdsworth Way Amherst, MA 01002-9282 Ohio State University Extension Phone: 413-545-0552 Senior Series Fact Sheets Website: www.umass.edu/umext/nutrition Website: ohioline.osu.edu/ss-fact The UMass Extension Nutrition Education Program This website has fact sheets on multiple topics, (NEP) provides a variety of nutrition education including nutrition & aging, chronic diseases, resources and programs for consumers and profes- food preparation, food safety, medication sionals. Some materials are available in multiple supplements, and caregiver tips. languages. Online professional development opportunities are offered through UMassONE.

Massachusetts Department of Education Child and Adult Care Food Program 189 IT’S MORE THAN A MEAL

adults) American Dietetic Association

Website: www.eatright.org This website is a directory to credible nutrition information and resources. It links to the Dietary The American Dietetic Association has an Guidelines, MyPyramid, and a database of the online catalog of materials sold to professionals nutrient content of foods. and consumers. Click on Shop Online to access the catalog. U.S. Food and Drug Administration (FDA)

Phone: 888-INFO-FDA (888-463-6332) DETERMINE Nutritional Risk Checklist National Food Service Institiute FDA provides Eating Well as We Age a free downloadable booklet. Website: www.nfsmi.org/information/adult_ fact_sheets.html Website: www.fda.gov/opacom/lowlit/ englow.html This downloadable checklist has questions to assess whether older adults are at high risk for poor nutrition. Strong and Healthy, a companion to the checklist, gives tips to improve their Health Issues for Older Adults nutritional health. ALZHEIMER’S DISEASE

Alzheimer’s Association Nutrition.Gov Helpline: 800-548-2111 (Massachusetts chapter) Website: www.nutrition.gov Websites: www.alz.org National office This website offers nutrition information and www.alzmass.org (MA chapter) links to the Dietary Guidelines and MyPyramid. This website describes Alzheimer’s disease. Nutrition Information About…Elderly links to web- It includes a caregivers’ section with information sites on nutrition, exercise, supplements, osteo- on other resources, and tips on dealing with porosis, and food safety issues for older adults. daily challenges.

U.S. Department of Agriculture National Institute of Health – Senior Health Food and Nutrition Information Center (FNIC)

Phone: 301-504-5719 Email: [email protected]

Email: [email protected] Website: www.nihseniorhealth.gov

Website: www.nal.usda.gov/fnic (main website) This website explains the symptoms, progression, www.nal.usda.gov/fnic/etext/ diagnosis, and treatment of Alzheimer’s disease. 000002.html (nutrition for aging It includes tips for caregivers.

Nutrition Resource Manual for Adult Day Health Programs 190 RESOURCES FOR ADULT DAY HEALTH PROGRAMS

National Institute on Aging Information Center HEART DISEASE Phone: 800-222-2225 American Heart Association Website: www.niapublications.org Phone: 800-242-8721 The Alzheimer’s Disease section has free fact Website: www.americanheart.org sheets. Other free downloadable materials include an Alzheimer’s Disease: Unraveling the This website provides general information on Mystery booklet and CD-Rom speaker kit to heart disease. educate family, staff, and volunteers. National Heart, Lung, and Blood Institute

DIABETES Phone: 301-592-8573

TTY: 240-629-3255 American Diabetes Association Website: www.nhlbi.nih.gov Phone: 800-DIABETES (800-342-2383) This website provides general information on Website: www.diabetes.org heart disease. Some resources are downloadable. This website is a useful resource for general Others must be ordered and received by mail. information on diabetes.

HIGH BLOOD PRESSURE Idaho Plate Method (For People with Diabetes)

Phone: 208-624-7279 American Heart Association

Website: www.platemethod.com Phone: 800-242-8721

This guide shows how much space each food Website: www.americanheart.org group should occupy on a 9-inch plate This website provides general information on It includes menus and diabetes survival tips. high blood pressure. Check for current prices. National Heart, Lung, and Blood Institute National Institute of Diabetes Phone: 301-592-8573 & Digestive and Kidney Diseases TTY: 240-629-3255 Phone: 800–860–8747 E-mail: [email protected] Email: [email protected] Website: www.nhlbi.nih.gov Website: diabetes.niddk.nih.gov This website provides general information on high This website provides general information on blood pressure. Some resources are downloadable. diabetes. It links to fact sheets and publications Others must be ordered and received by mail. written in English and Spanish.

Massachusetts Department of Education Child and Adult Care Food Program 191 IT’S MORE THAN A MEAL

OSTEOPOROSIS Medicines and Older Adults National Institute of Health – Food and Drug Administration (FDA) Osteoporosis and Related Bone Diseases FDA provides Medicines and Older Adults a free Phone: 202-223-0344 or 800-624-BONE downloadable booklet at the following website:

Website: www.niams.nih.gov/bone (www.fda.gov/opacom/lowlit/englow.html) This website has information on osteoporosis.

It offers fact sheets on a variety of topics. Ohio State University Extension Senior Series Fact Sheets

National Osteoporosis Foundation Website: ohioline.osu.edu/ss-fact

Phone: 202-223-2226 This website provides five downloadable fact sheets on medications: Website: www.nof.org Adverse Drug-Drug and Food-Drug Interactions This website has information on osteoporosis. Aging Increases the Risk for Medication Problems It provides free fact sheets and instructions to Medication Misuse among Older Adults order publications sold by the foundation. Over-the-Counter Medication Labels Over-the-Counter Medications are Drugs, Too SENIOR HEALTH (MULTIPLE TOPICS)

NIH Senior Health

Website: http://nihseniorhealth.gov

This website from the National Institutes of Health provides reliable health information and printable documents. Senior-friendly features include large print, short easy-to-read information, and simple navigation. Seniors can click on icons to hear text read aloud, or increase contrast to make it more readable.

Nutrition Resource Manual for Adult Day Health Programs 192 RESOURCES FOR ADULT DAY HEALTH PROGRAMS

Physical Activity Emergency Food Plans and Older Adults American Red Cross American College of Sports Medicine (ACSM) Phone: 202-303-4498

Phone: 317-637-9200 The Red Cross provides Food and Water in an Website: www.acsm.org Emergency a free downloadable pamphlet.

Current Comments are statements on exercise Website: www.redcross.org/static/file_cont39_ topics written for the public. Topics relevant to lang0_24.pdf older adults are the physiology of aging; exercise and the older adult; exercise and cardiovascular Federal Emergency Management Agency (FEMA) disease; and exercise and chronic obstructive Phone: 800-621-FEMA (National office) pulmonary disease. Go to the home page, and 617-956-7506 (Regional office serving click on General Public. CT, MA, ME, NH, RI, VT)

FEMA provides free downloadable pamphlets. Centers for Disease Control Website: www.fema.gov/library/index.jsp and Prevention (CDC)

Growing Stronger: Strength Training for Older Adults Florida International University Website: www.cdc.gov/nccdphp/dnpa/ The university provides HealthyHurricane/Disaster physical/growing_stronger Cookbook a free downloadable cookbook with Click on Print-Friendly Version to download a recipes for meals that require little water and no 126-page booklet called Growing Stronger: electricity to prepare. Strength Training for Older Adults. Website: www.fiu.edu/~health/hurricaneseason/ Cookbook.pdf National Institute on Aging Information Center

Phone: 800-222-2225

Website: www.niapublications.org

The Healthy Aging section provides a free down- loadable 86-page exercise guide for older adults. A kit with the guide and companion video can be ordered for $7.

Massachusetts Department of Education Child and Adult Care Food Program 193 IT’S MORE THAN A MEAL

University of Massachusetts Extension Nutrition Education Program (NEP) and the Massachusetts Food Safety Partnership for Food Safety Education Massachusetts Department of Public Health Website: www.umass.edu/umext/nutrition/ Food Protection Program programs/food_safety/resources/index.html 305 South Street

This website provides emergency and food safety Jamaica Plain, MA 02130 education materials for consumers and profes- Phone: 617-983-6700 sionals. Some materials are available in multiple Website: www.mass.gov/dph/fpp/ languages. Downloadable fact sheets include: This agency is responsible for state food safety Keeping Food Safe If the Power Goes Out regulations and resources as well as preventing Keeping Your Family Fed If the Power Goes Out and investigating foodborne illness outbreaks. The website provides food safety information for food service operations and consumers. U.S. Department of Agriculture Food Safety and Inspection Service Technical Service Center University of Massachusetts Extension Nutrition Education Program (NEP) Phone: 402-221-7400 (24-hour hotline: 800-233-3935) Website: www.umass.edu/umext/nutrition/ programs/food_safety/resources/index.html USDA provides two free downloadable fact sheets. The UMass Extension Nutrition Education Program (NEP) and the Massachusetts Partnership for Website: www.fsis.usda/gov/Fact_Sheets/ Food Safety Education food safety education Emergency_Preparedness_Fact_Sheets resources and programs for consumers and professionals. Many materials are available in multiple languages.

Gateway to Government Food Safety Information

Website: www.foodsafety.gov

This website provides food safety advice for consumers and food service professionals. It also links to food safety alerts and food product recalls.

Nutrition Resource Manual for Adult Day Health Programs 194 RESOURCES FOR ADULT DAY HEALTH PROGRAMS

U.S. Food and Drug Administration National Family Caregivers Association Center for Food Safety and Applied Nutrition Phone: 800-896-3650

Phone: 888-INFO-FDA (888-463-6332) Email: [email protected]

USDA provides two free downloadable booklets. Website: www.nfcacares.org

Keep Your Food Safe This website mostly links to other websites and Website: www.fda.gov/opacom/lowlit/ organizations. The Education and Support englow.html section has tips to care for older adults.

To Your Health! Food Safety for Seniors Other materials are available for sale. Website: www.cfsan.fda.gov/~acrobat/sr2.pdf Rutgers University Cooperative Research and Extension

Caregiving The Caring Connection – Family Caregiver Alliance Fact Sheets for Caregivers

Phone: 800-445-8106 or 415-434-3388 Website: www.rce.rutgers.edu/pubs/

Email: [email protected] subcategory.asp?cat=10&sub=68

Website: www.caregiver.org This website has fact sheets with resources and information on caregiving, and tips for This website offers advice on caring for older caregivers to take care of themselves. adults, and information on nursing facilities and residential care. It has fact sheets in English, Spanish, and Chinese. U.S. Administration on Aging National Family Caregiver Support Program

National Eldercare Locator Phone: 202-619-0724

Phone: 800-677-1116 Website: www.aoa.gov/prof/aoaprog/ caregiver/caregiver.asp Website: www.eldercare.gov This website provides caregiver resource This website helps people locate programs and information in different languages. services. The Resources section has fact sheets on adult day care, assisted living, home health care, home modifications, hospice and respite care, and government-assisted housing.

Massachusetts Department of Education Child and Adult Care Food Program 195 IT’S MORE THAN A MEAL

Notes

Nutrition Resource Manual for Adult Day Health Programs 196 IT’S MORE THAN A MEAL

Table of Contents Health Introduction ...... 199

• Healthful Eating for Older Adults • Make Healthful Meals • Choose Healthful Snacks at Home • Drink Enough Fluids • Eat Healthy When Eating Out • Keep Foods Safe to Eat • Dietary Supplements Fact Sheets • Medicines • Physical Activity • Plan for an Emergency

Massachusetts Department of Education Child and Adult Care Food Program 197 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 198 HEALTH AT HOME FACT SHEETS

elp older adults maintain their health at home through H good nutrition and physical activity. Photocopy these 10 fact sheets as needed to share with participants or caregivers. You can also download copies in 5 other languages from our website (www.morethanameal.info).

This section provides 10 Health at Home fact sheets, which focus on the following themes:

HealthfulHow does aging affectEating nutritional for health?Older What Adults are some goals for good health for older adults?

MakeWhat are someHealthful tips for buying Meals foods and preparing meals at home?

ChooseWhat are some Healthful tips for choosing Snacks healthful snacks?

DrinkWhy are fluids Enough important Fluids for older adults? What are some tips to consume enough fluids?

EatWhat are Healthy some healthful when food choicesEating to make Out in restaurants?

KeepWhy is food Foods safety important Safe forto older Eat adults? What are some tips to practice food safety at home?

DietaryWhat are dietary Supplements supplements, and should older adults use them? Note: The fact sheets provided in this manual are printed in English. Translations are avail- able in five other languages: How do foods and medicines potentially affect each other? Medicines Chinese, Polish, Portuguese, Russian, and Spanish. You can download free copies of the translated fact sheets from the PhysicalWhat are the benefits Activity of different types of exercise for older adults? It’s More than a Meal website at www.morethanameal.info.

PlanHow can f familyor an members Emer plang encyto have adequate food and water in an emergency?

Massachusetts Department of Education Child and Adult Care Food Program 199 Notes

Nutrition Resource Manual for Adult Day Health Programs 200 IT’S MORE THAN A MEAL

Evaluation Table of Contents

Introduction ...... 203

Evaluation

Massachusetts Department of Education Child and Adult Care Food Program 201 Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. © 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the “Massachusetts Department of Education.”

Nutrition Resource Manual for Adult Day Health Programs 202 EVALUATION

ow that you have reviewed and used this Nmanual, we would appreciate your feedback. Please tell us a bit about your program and what you found most useful in the manual and website.

To help us improve nutrition education resources for adult day health programs, please complete the evaluation form in this section and return it to:

Nutrition Education and Training Coordinator

ADH Massachusetts Department of Education 350 Main Street Malden, MA 02148-5023

(781) 338-3399 Fax:

Massachusetts Department of Education Child and Adult Care Food Program 203 ADH Manual Evaluation/Feedback Form We value your opinion about this resource manual. Please let us know how you have used or plan to use this manual by answering the following questions and returning a copy of this page to the Massachusetts Department of Education. Please check all that apply.

About the Manual

1) Which component(s) of the It’s More Than a Meal manual are most helpful? Please indicate any specific sections within any chapters that were particularly helpful. Chapter Comments H Nutrition & ADH Programs ______H Nutrition Basics ______H Special Nutrition Needs ______H Planning Meals & Snacks ______H Cultural Issues ______H Crediting Foods ______H Resources ______H None of the above ______2) a. Which Health at Home fact sheets did you or do you plan to use? (Please check all that apply.) H Healthy Eating H Dietary Supplements H Make Healthful Meals H Food Safety H Choose Healthful Snacks H Physical Activity H Drink Enough Fluids H Eating Out H Medicines H Plan for an Emergency b. With which groups did you use the fact sheets? H Staff H Consumers / Participants H Caregivers H Other (Please specify.) ______c. Which language(s) did you use? ______

About Your Program

3) Which meals do you provide at your facility? H Breakfast H Lunch H Dinner H Snack H None 4) How many participants do you have currently enrolled in your program? ______

5) Does your organization provide nutrition or food safety education to staff or caregivers? H Never or Rarely H Weekly or Monthly H Yearly 6) Topics Addressed: ______

7) Do you have any additional comments about the manual and its use? ______

______

Please mail or fax to ADH, Massachusetts Department of Education, Nutrition, Health and Safety, 350 Main Street, Malden, MA 02481-5023. Fax: 781-338-3399

Massachusetts Department of Education Child and Adult Care Food Program

United States Department of Agriculture cooperating. UMass Extension offers equal opportunity in programs and employment.