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Objectives

• Verbalize which level of the National Dysphagia is similar to the Dysphagia Diet • State one reason why the Low Diet has been changed to 2300 mg sodium • List five examples of • State two differences between the Modified and the Low Protein Modified Renal Diet

Calorie level of patterna 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200

Food Group b Daily Amount c of Food From Each Group (vegetable and protein foods subgroup amounts are per week)

Vegetables 1 c - 1 ½ 1 ½ 2 c- 2 ½ 2½ c- 3 c- 3 c- 3½ c- 3½ c- 4 c- 4 c-

e q c-eq c-eq e q c-eq e q e q e q e q e q e q e q

Dark-green vegetables ½ 1 1 1½ 1½ 1½ 2 2 2 ½ 2 ½ 2 ½ 2 ½ Chapter 1: Guidelines for Diet Planning (c-eq/wk)

Red and orange 2½ 3 3 4 5 ½ 5 ½ 6 6 7 7 7 ½ 7 ½ vegetables

(c-eq/wk)

Legumes (beans and ½ ½ ½ 1 1½ 1½ 2 2 2½ 2½ 3 3 peas) 2015-2020 Dietary Guidelines for Americans (c-eq/wk)

Starchy vegetables 2 3½ 3½ 4 5 5 6 6 7 7 8 8

(c-eq/wk)

Other vegetables 1½ 2½ 2½ 3½ 4 4 5 5 5½ 5½ 7 7

(c-eq/wk)

Fruits 1 c - 1 c- 1 ½ 1 ½ 1 ½ 2 c- 2 c- 2 c- 2 c- 2½ c- 2½ c- 2½ c- Includes Healthy U.S.-Style Eating Pattern e q e q c-eq c-eq c-eq e q e q e q e q e q e q e q Grains 3 oz-eq 4 oz-eq 5 oz-eq 5 oz-eq 6 oz-eq 6 oz-eq 7 oz-eq 8 oz-eq 9 oz-eq 10 oz-eq 10 oz-eq 10 oz-eq

Whole grainsd 1½ 2 2½ 3 3 3 3½ 4 4½ 5 5 5 It is designed to meet the Recommended Dietary Allowances (oz-eq/day) Refined grains 1½ 2 2½ 2 3 3 3½ 4 4½ 5 5 5 (RDA) and Adequate Intakes (AI) for essential nutrients, as well as (oz-eq/day) Acceptable Macronutrient Distribution Ranges (AMDR) set by the Dairy 2 c-eq 2½c-eq 2½c-eq 3 c-eq 3 c-eq 3 c-eq 3 c-eq 3 c-eq 3 c-eq 3 c-eq 3 c-eq 3 c-eq Protein Foods 2 oz-eq 3 oz-eq 4 oz-eq 5 oz-eq 5 oz-eq 5½ oz- 6 oz-eq 6½ oz- 6½ oz- 7 oz-eq 7 oz-eq 7 oz-eq Food and Board of the Institute of Medicine. eq eq eq Seafood (oz-eq/wk) 3 4 6 8 8 8 9 10 10 10 10 10

Meat, poultry, eggs 10 14 19 23 23 26 28 31 31 33 33 33

(oz-eq/wk)

Nuts, seeds, soy 2 2 3 4 4 5 5 5 5 6 6 6 products (oz-eq/wk) 1600 calorie plan is the lowest calorie level recommended Oils 15 g 17 g 17 g 22 g 24 g 27 g 29 g 31 g 34 g 36 g 44 g 51 g Limit on Calories for 150 100 110 130 170 270 280 350 380 400 470 610

Other Uses, calories (% of (15%) (8%) (8%) (8%) (9%) (14%) (13%) (15%) (15%) (14%) (16%) (19%) for adults. calories)e,f

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Calorie level of patterna 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200 Food Group b Daily Amount c of Food From Each Group (vegetable and protein foods subgroup amounts are per week) Vegetables 1 c-eq 1½ c-eq 1½ c-eq 2 c-eq 2½ c- 2½ c-eq 3 c-eq 3 c-eq 3½ c-eq 3½ c-eq 4 c-eq 4 c-eq eq Chapter 1: NEW in this edition Dark-green vegetables ½ 1 1 1½ 1½ 1½ 2 2 2 ½ 2 ½ 2 ½ 2 ½ (c-eq/wk)

Red and orange vegetables 2½ 3 3 4 5 ½ 5 ½ 6 6 7 7 7 ½ 7 ½ (c-eq/wk)

Legumes (beans and ½ ½ ½ 1 1½ 1½ 2 2 2½ 2½ 3 3 peas) Includes Healthy Mediterranean-Style Eating Pattern (c-eq/wk) Starchy vegetables 2 3½ 3½ 4 5 5 6 6 7 7 8 8 (c-eq/wk)

Other vegetables 1½ 2½ 2½ 3½ 4 4 5 5 5½ 5½ 7 7 (c-eq/wk) • A typical Mediterranean-style diet is abundant in nuts, berries, Fruits 1c-eq 1 c-eq 1½ c-eq 2 c-eq 2 c-eq 2½ c-eq 2½ c-eq 2½ c-eq 2½ c-eq 3 c-eq 3 c-eq 3 c-eq Grains 3 oz-eq 4 oz-eq 5 oz-eq 5 oz-eq 6 oz-eq 6 oz-eq 7 oz-eq 8 oz-eq 9 oz-eq 10 oz-eq 10 oz-eq 10 oz-eq Whole grainsd 1½ 2 2½ 3 3 3 3½ 4 4½ 5 5 5 seeds, legumes, rice, seafood, and olive oil with small servings of (oz-eq/day)

Refined grains 1½ 2 2½ 2 3 3 3½ 4 4½ 5 5 5 meat and poultry. (oz-eq/day) Dairy 2 c-eq 2½ c-eq 2½ c-eq 2 c-eq 2 c-eq 2 c-eq 2 c-eq 2½ c-eq 2½ c-eq 2½ c-eq 2½ c-eq 2½ c-eq • The Healthy Mediterranean-Style Eating Pattern contains more Protein Foods 2 oz-eq 3 oz-eq 4 oz-eq 5½oz-eq 6 oz-eq 6½oz-eq 7 oz-eq 7½oz-eq 7½oz-eq 8 oz-eq 8 oz-eq 8 oz-eq Seafood (oz-eq/wk)* 3 4 6 11 15 15 16 16 17 17 17 17 fruits and seafood and less dairy than does the Healthy U.S.-Style Meat, poultry, eggs 10 14 19 23 23 26 28 31 31 33 33 33 (oz-eq/wk) Eating Pattern. Nuts, seeds, soy 2 2 3 4 4 5 5 5 5 6 6 6 products (oz-eq/wk)

Oils 15 g 17 g 17 g 22 g 24 g 27 g 29 g 31 g 34 g 36 g 44 g 51 g Limit on Calories for Other Uses, 150 100 110 140 160 260 270 300 330 ( 350 430 570 calories (% of calories)e,f (15%) (8%) (8%) (9%) (9%) (13%) (12%) (13%) 13%) (13%) (14%) (18%)

Chapter 2: General Diet Chapter 2: Lifespan – Pregnancy/Lactation

• Pregnant and breastfeeding women should limit white (albacore) tuna to 6 • Include a variety of vegetables from all of the five subgroups. ounces per week and avoid tilefish, shark, swordfish, and king mackerel due to their high mercury content. • At least half of all fruit intake should come from whole fruits. • The EPA, FDA, and DGAs recommend pregnant women eat at least 8 ounces and • At least half of all grains eaten should be whole grains. up to 12 ounces (2 to 3 servings) per week of a variety of fish/seafood that are lower in mercury to support fetal growth and development. • Dairy: Other products sold as “milks” but made from plants (e.g., • almond, rice, coconut, and hemp “milks”) may contain calcium and be These amounts of fish are consistent with the Healthy U.S.-Style eating pattern. • The amount of fish in the Healthy Mediterranean-Style Eating Pattern exceeds consumed as a source of calcium, but they are not included as part of these recommendations. the dairy group because their overall nutritional content is not similar EPA-FDA Advisory on Mercury in Fish and Shellfish. U.S. Environmental Protection Agency website. to dairy milk and fortified soy beverages (soymilk). http://www.epa.gov/fish-tech/epa-fda-advisory-mercury-fish-and-shellfish Updated October 6, 2015 • Choose seafood at least twice per week. www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htm (marlin, orange roughy and big eye tuna added 1/18/17)

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Chapter 2: Lifespan – Pregnancy/Lactation Chapter 2: Lifespan - Children

Common Feeding Concerns in Young Children and Some foods should be avoided during pregnancy. This includes: • raw milk Possible Solutions • cheese made from unpasteurized milk (e.g., feta, brie, camembert, blue- 1. Refuses meats veined varieties, queso fresco, queso blanco, panela) 2. Drinks too little milk • raw or rare meat, raw or undercooked eggs, raw sprouts (e.g., bean, alfalfa), raw fish (e.g., sushi), and raw shellfish (e.g., oysters). 3. Drinks too much milk • Some ready-to-eat foods require reheating to 165°F before eating (e.g., 4. Refuses vegetables and fruits hot dogs, bologna, deli meats, dry ). 5. Eats too many sweets Food Safety for Moms-To-Be: While You're Pregnant. U.S. Food and Drug Administration website. http://www.fda.gov/Food/FoodborneIllnessContaminants/PeopleAtRisk/ucm083308.htm Updated June 11 2014.

Chapter 2: Lifespan – Older Adults Older Adults – Recommended Glycemic Targets

Patient Fasting or preprandial characteristics/health Rationale Reasonable A1C goal Bedtime glucose glucose status

Healthy (few coexisting chronic illnesses, intact Longer remaining life <7.5% 90–130 mg/dL 90–150 mg/dL cognitive and functional expectancy status)

Complex/intermediate (multiple coexisting Intermediate remaining chronic illnesses or 2+ life expectancy, high <8.0% 90–150 mg/dL 100–180 mg/dL instrumental ADL treatment burden, impairments or mild-to- hypoglycemia moderate cognitive vulnerability, fall risk impairment)

Very complex/poor health (LTC or end-stage Limited remaining life chronic illnesses or <8.5% 100–180 mg/dL 110–200 mg/dL expectancy makes moderate-to-severe benefit uncertain cognitive impairment or 2+ ADL dependencies)

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International Dysphagia Diet Standardisation Chapter 3: Consistency Altered Diets Initiative (IDDSI) 2015 The National Dysphagia Diets© is no longer in print and our request to print it was denied by AND. Therefore, it is NOT included in this edition of the Simplified Diet Manual. It has since been stated by AND that they no longer support the NDD. References for this chapter include: 1. National Dysphagia Diets© (2002) 2. International Dysphagia Diet Standardization Initiative (IDDSI) [2015] 3. Australian Standardised Terminology and Definitions for Texture Modified Foods and Fluids (2007) Julie Cichero was Project Officer (and she is co-chair of the IDDSI initiative) Input was gathered from and SLP who currently use the NDD.

Chapter 3: Pureed Diet Chapter 3: Pureed Diet

• The General Diet or other appropriate diet is modified in consistency Food for the Day Recommended Avoid by pureeing or modifying foods to a smooth consistency. Some foods may need to be thickened after they are pureed (e.g., melon or Grains Pureed or slurried breads, rolls, muffins. Any containing seeds, nuts, dried tossed salad) to achieve desired consistency. Plain crackers, if crushed and moistened. fruits, coconut. Moistened cracker or bread crumbs. Popcorn. Wild rice. Dry cereal. • It is most important to individualize to the tolerance of the resident. Smooth, lump-free cooked cereals. Pureed . Milk toast. Pureed Food for the Day Recommended Avoid pastas and rice. Vegetables Pureed vegetables without lumps. Mashed All raw vegetables. All vegetables potatoes without lumps. Vegetable . that are not pureed. Dairy Products Milk, nondairy milks (soy, almond, rice), Any containing nuts, seeds, pieces of fruit. Fruits Pureed fruits without lumps. Fruit and Dried fruits. Coconut. All non- smooth . Smooth cheese paste such All solid cheese. nectars. Raw, ripe —mashed. pureed raw fruit except . as smooth ricotta. Pureed . Cheese sauce.

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Chapter 3: Pureed Diet Chapter 3: Mechanical

Food for the Day Recommended Avoid Food for the Day Recommended Avoid Vegetables Soft, cooked, tender, chopped, Most raw or undercooked Protein Foods Pureed meats, pureed scrambled eggs. Meat, fish, poultry, legumes or Hummus or pureed lentils/legumes. lentils that are not pureed. shredded vegetables. Creamed corn. vegetables and those with Moistened soft . Vegetable juice. Shredded lettuce. tough skins. Whole kernel corn and peas. Fried vegetables. Oils, Solid Fats, Most fats present no problem, for example Any containing nuts, olives, coconut, Added Sugars butter, margarine, oils, mayonnaise. chocolate chips, or other Plain , , cheese cake, plain coarse or chunky pieces. Pastries, Fruits Fruit juice and nectars. Cooked, tender, Dried fruits. Coconut. Chunk , sherbet, yogurt, gelatin, jelly. pies; any containing nuts, coconut, canned fruits. Chopped seedless ripe pineapple. Fruit with tough skin Plain cakes and cookies soaked in milk or raisins. melon, ripe banana or other soft, raw such as whole grapes. juice. Jams with seeds or lumps. Fruit leather rolls. fruits. Crushed pineapple.

Fluids/ Soups that have been pureed or strained to No restrictions. Any containing remove lumps. lumps, chunks, or seeds.

Chapter 3: Dysphagia Diet - compared to NDD Level 2 (expect this to be similar to Minced and Moist with IDDSI) Chapter 3: Mechanical Soft Diet All foods from the pureed diet are acceptable.

Food for the Day Recommended Avoid Food for the Day Recommended Avoid Vegetables All tender, well-cooked All raw vegetables. Grains No changes vegetables. Vegetables should Corn, peas, broccoli, Dairy Products No changes be <½ inch. Should be easily cabbage, Brussels sprouts, Protein Foods No changes mashed with a fork. asparagus, or other Oils, Solid Fats, Added Butter, margarine, oils, mayonnaise. Any containing nuts, coconut, Vegetable juices*. fibrous, nontender or Sugars Plain, soft cookies, donuts, cakes. Soft . Well-cooked, moistened, boiled, rubbery vegetables. pies, puddings, cheese cake, plain ice Bacon, olives. baked, or mashed potatoes. Potato skins and chips. cream, sherbet, gelatin. Dry, hard, crunchy, chunky or Fried or French-fried Cheese puffs. sticky products such as chips and pretzels. potatoes. *Liquids may need to be thickened to recommended Fluids/Soups No changes consistency.

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Chapter 3: Dysphagia Diet - compared to NDD Level 2 Chapter 3: Dysphagia Diet All foods from the pureed diet are acceptable. as compared to NDD Level 2

Food for the Day Recommended Avoid Food for the Day Recommended Avoid Bread, crackers. Soft, drained, diced canned, or Fruit pieces larger than ½ Grains Moistened cracker or bread crumbs. Fruits Soft pancakes, well moistened with syrup or sauce. Whole-grain dry or coarse cereals. cooked fruits without seeds or skin. inch. Pureed bread mixes, pregelled or slurried breads that Cereals with nuts, seeds, dried fruit and/or coconut. are gelled through entire thickness. Fresh soft/ripe banana, seedless Fresh fruits except soft/ripe Rice. melon, or mango. banana, seedless melon, and Cooked cereals with no hard lumps, including oatmeal Hard pieces or crusts formed during Should be easily mashed with a fork. mango. (soft tender lumps less than ½ inch acceptable). baking or cooking such as bread Slightly moistened dry cereals with little texture such as dressing. Fruit juices with small amount of pulp. Cooked fruit with skin or , crispy rice. Unprocessed Fruit juices* and nectar*. seeds. bran stirred into cereals for bulk. Frozen or dried fruits. Note: if thin liquids are restricted, it is important that Fresh, canned, or cooked all of the liquid is absorbed into the cereal. Milk/liquid *Liquids may need to be thickened to should not separate off. pineapple. recommended consistency. Whole round fruits such as Well-cooked noodles in sauce. Soft, moist pieces of grapes and cherries. pasta in a sauce such as moist macaroni and cheese.

Chapter 3: Dysphagia Diet Chapter 3: Dysphagia Diet as compared to NDD Level 2 as compared to NDD Level 2

Food for the Day Recommended Avoid Food for the Day Recommended Avoid Protein Foods Moistened ground or cooked meat, poultry, or fish. Dry meats, tough meats (such as Any containing nuts, seeds, cereal, Dairy Products Milk*, smooth yogurt, soft cheese with small lumps Moist ground or tender meat may be served with gravy bacon, , hot dogs, or pieces of hard fruit. such as small-curd cottage cheese or sauce. Fish soft enough to break into small pieces bratwurst). Cheese slices and cubes. with a fork. Dry casseroles or casseroles with Meat pieces should Added Sugars, , . Casseroles without rice. rice or large chunks. Dry, coarse cakes and cookies. not exceed ¼ inch Soft fruit based desserts without hard bases, Moist macaroni and cheese, well-cooked pasta with and nuts. Desserts Anything containing nuts, seeds, cube and should crumbly or flaky pastry. Soft fruit pies with bottom meat sauce, tuna-noodle casserole, soft, moist lasagna. Hard-cooked or crisp fried eggs. coconut, chocolate chips, rhubarb, be moist and Moist , meat loaf, or fish loaf. crust only. Crisps and cobblers with soft breading or Sandwiches. pineapple, large hard fruit pieces, tender. Protein salads such as tuna or egg without large crumb mixture. Pizza. chunks, , or onion. Soft, moist cakes with icing or “slurried” cakes. or dried fruit. Smooth quiche or soufflé without large chunks. Pregelled cookies or soft, moist cookies that have Rice pudding. Hard pieces or crusts formed Poached, scrambled, or soft-cooked eggs (egg yolks been “dunked” in milk, coffee, or other liquid. should be moist and mashable with margarine, or other If thin liquids allowed, also may have: Ice cream, during baking or cooking such as bread pudding. moisture added to them). sherbet, shakes, nutritional supplements, frozen (Cook eggs to 155°F or use pasteurized eggs for safety). yogurt, and other ices. Hummus and soft tofu. Plain gelatin or gelatin with canned fruit, excluding Well-cooked, slightly mashed, moist legumes such as pineapple. baked beans.

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Chapter 3: Dysphagia Diet as compared to NDD Level 2 Chapter 3: Liquid Consistency Levels

Food for the Day Recommended Avoid Thin or unmodified Unmodified fluids do not have thickeners added Oils, Solid Fats No changes to them. May drink by cup or straw. Fluids/Soups Soups* with easy-to-chew or easy-to-swallow meats Soups with large chunks of meat Nectar-likeor mildly thick Fluids at this thickness run fast through the or vegetables: meat in soups should be <¼ inch and and vegetables. prongs of a fork and flow off a spoon. May be vegetables should be <½ inch. Soups containing rice, corn, peas, or drank from a cup. Effort is required to drink from All beverages* with minimal amounts of texture, legumes. a straw. pulp, etc. (Any texture should be suspended in the Honey-likeor moderately thick Fluids at this thickness slowly drip through the liquid and should not precipitate out.) prongs of a fork. Possible to drink from a cup but is difficult to drink from a straw. Spoon-thickor pudding-likeor extremely thick There is no flow and it does not pour or go Miscellaneous Jams and preserves without seeds or dried fruit, Seeds, nuts, coconut, sticky foods. through the prongs of a fork. These fluids keep Chewy candies such as caramel and jelly. their shape on a spoon but will fall off the spoon Sauces, salsas, etc., that may have small tender licorice. Popcorn. when it is tilted. It is not possible to drink from a chunks <½ inch. cup or straw. Spooning into the mouth is the best Soft, smooth chocolate bars that are easily chewed. way to take this liquid. The spoon should NOT be able to stand upright in fluids at this thickness.

Chapter 4: Liquid Diets and Modifications Chapter 4: References Online include websites

Clear : Websites • Some facilities allow hard candy on a clear liquid diet because it • Abbott Nutrition: http://abbottnutrition.com/brands/products/nutritional- provides variety, flavor, and dissolves to sugar and water at body products temperature. However, sugar-free hard candies sweetened with • Hormel Health Labs: sugar alcohols (e.g. sorbitol) should be used with caution because http://www.hormelhealthlabs.com/2colTemplate.aspx?page=Products these ingredients have a laxative effect. • Mead Johnson: https://www.meadjohnson.com/pediatrics/us-en/product- • See Chapter 6 for information on liquid diets for persons with information/products diabetes mellitus. New position paper from ADA does not state • Nestle Health Science: https://www.nestlehealthscience.us/brands persons with diabetes should receive 200 grams of carbohydrate/day • Nutricia North America: when on a clear liquid diet – so this has been removed. http://www.nutricialearningcenter.com/en/nutricia-portfolio/about- nutricia/nutricia-product-guide/

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Chapter 5: Diets for Weight Management Chapter 6: Diets for Diabetes - carbohydrates

• Deleted the Calorie-Controlled Diet section and incorporated it into the Weight Management Diet. • Chapter reorganized so that Diabetes Meal Planning Principles are • A 5 to 10% loss of current body weight is a reasonable goal. before the Consistent Carbohydrate Diet. • Resting metabolic rate may be estimated using the Mifflin-St. Jeor equation using actual body weight.* • There is no ideal amount of carbohydrate for persons with diabetes. • Choose foods that are moderate to small in portion size to meet weight loss goals. See the USDA Food Patterns in Chapter 1, the Small Portions Diet in Chapter 12, and • The DRIs recommend 45 to 65% of total calories from carbohydrates. the Heart in Chapter 7. • The Recommended Dietary Allowance (RDA) is a minimum of: • Calories may also be reduced by offering “free foods,” such as sugar-free or reduced- calorie condiments. • 130 grams of carbohydrate daily for children and adults • 175 grams daily for pregnant women *Frankenfield D, et al. Comparison of predictive equations for resting metabolic rate in healthy nonobese and obese adults: a systematic review. J Am Diet Assoc. 2005; 105(5):775-789. • 210 grams daily during lactation

Chapter 6: Diets for Diabetes – Chapter 6: Diets for Diabetes persons on mealtime insulin

Consistent Carbohydrate Diets in Institutions • For persons on flexible insulin doses (i.e., insulin-to-carbohydrate ratios), Many healthcare facilities use a consistent carbohydrate meal planning system. For insulin doses are adjusted based on the amount of carbohydrate consumed persons taking insulin secretagogues (i.e., sulfonylureas, glinides) or fixed doses of at each meal. Therefore, a General Diet containing regular food is insulin, a consistent carbohydrate meal plan is appropriate. * acceptable for diabetes meal planning. For persons using an insulin-to- The following diets are obsolete as they do not reflect current diabetes carbohydrate ratio, having a knowledge of carbohydrate counting is recommendations: no sugar added, no concentrated sweets, limited concentrated necessary. sweets, and low sugar.** • For persons on mealtime insulin who have an inconsistent dietary intake, one strategy to reduce hypoglycemia is to administer mealtime insulin *Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of immediately after to match carbohydrate intake. * adults with diabetes. Diabetes Care. 2013; 36(11): 3821-3842. *Munshi MN, Florez H, Huang ES, et al. Management of diabetes in long-term care and skilled **Munshi MN, Florez H, Huang ES, et al. Management of diabetes in long-term care and skilled nursing facilities: A position statement of the American Diabetes Association. Diabetes Care. 2016; nursing facilities: A position statement of the American Diabetes Association. Diabetes Care. 2016; 39(2):308-318. 39(2):308-318.

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Chapter 6: Chapter 6: Diets for Diabetes – Hypoglycemia Gestational Diabetes • Pure glucose is the preferred treatment but any carbohydrate food containing glucose may be used. It is recommended to use only carbohydrate to treat hypoglycemia and not to use foods • Traditionally, total carbohydrate intake is usually 40 to 45% of total calories. high in protein or fat. Protein can stimulate the pancreas to release insulin in type 2 diabetes and does not prevent a repeat low blood sugar. Fat slows down the absorption of carbohydrate • Emerging research using a higher fiber meal plan (enriched in complex leading to a delay in raising blood glucose. carbohydrates coming from grains, vegetables, and fruits) with mainly low to moderate glycemic index foods has shown that higher carbohydrate Good Choices Not recommended due to high protein and/or intakes may be tolerated. This diet contained 60% of the total calories from 15 gram carbohydrate portions fat content carbohydrates at each meal and snack, and resulted in blood glucose levels 4 glucose tablets or 1 tube glucose gel Donuts within current therapeutic targets. ½ cup fruit juice Ice cream, • Another study compared a diet containing 40% calories from carbohydrates ½ cup regular soda Candy bars to a diet containing 55% calories from carbohydrates; the carbohydrate 1 Tbsp. sugar Sandwiches amount did not influence insulin need or pregnancy outcome. 1Tbsp.honey Pies,cakes,cookies Reference: Glycemic Targets, American Diabetes Association Diabetes Care 2016 Jan; 39(Supplement 1): S39-S46.

Reasons for Change

#1 cause of death Chapter 7 Fat Modified Diets 1 every 40 seconds CHARLOTTE F. KOOIMA RDN, LD, LN

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Reason for Changes 4 Types of Saturated Fats

 ATP III NCEP study 2002  LDL main focus LauricAcid MyristicAcid + Stearic Acid  Many studies spiraled off • Coconut Oil • Coconut Oil • Red and white meat  Lipid lowering medication baby boom • Touted for • Butter microbial MAIN PROBLEM:  AHA and ACC study 2013 properties elongated to Palmitic  Coined “ATP IV” • Medicinal acid with a high  LDL still important but focus on type of fats in diet • Palm kernel oil carbohydrate diet  Lipid guidelines remain the same

https://www.nhlbi.nih.gov/files/docs/guidelines/atp3upd04.pdf

Absorption Issues Polyunsaturated Fats

 Short & Medium Chain  Liquid at room temperature and remain  Absorb directly into blood via capillaries in liquid under refrigeration intestines  Sources: corn, soybean, safflower,  Long Chain sunflower

 Transported into fatty walls of intestines  KEY FUNCTION:

 Reassembled into triglycerides  Lower LDL  Coated with cholesterol/protein  Lower Triglycerides  Transported to lymph system  Can Lower HDL  Chylomicrons  Stored for use later or metabolized for energy

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Monounsaturated Fats Heart Healthy Diet

 Liquid at room temperature Goal: to reduce cholesterol or lipids in the blood  Will start to thicken under refrigeration  Sodium is not restricted unless dx of HTN, CHF etc.

 Sources: olive, canola,  Total fat is not restricted. (1) almond, peanut oils  Main focus: saturated fat reduction.  KEY FUNCTION:  Trans fats should be avoided. Lower LDL  It is recommended persons consume fish (preferably oily) to obtain omega-3 fat in their diet. (at least 2 servings/week) Protect HDL

1. Jacobson TA, Maki KC, Orringer C, et al. National Lipid Association recommendations for patient- centered management of dyslipidemia: part 2. J Clin Lipidol. Published Online:September 18, 2015.

Heart Healthy Diet Tables

 Trans-fat lists

 TLC diet has been removed  Plant based food examples  Functional Foods  Fiber Sources  No improvement 3 months  plant sterols/stanols (∼2 g/day)  soluble fibers (5 to 10 g/day from foods and/or supplemental sources) is recommended. (1)

1. Jacobson TA, Maki KC, Orringer C, et al. National Lipid Association recommendations for patient- centered management of dyslipidemia:part 2. J Clin Lipidol. Published Online:September 18, 2015.

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Plant Based Spreads Soy Products

 Lower total cholesterol by 4-11%  Lowers LDL 4-24%  Lower LDL-C by 7-15% (AND EAL, 2011, US-FDA, 2015) (AND EAL, 2011; US-FDA, 2015)  25g of soy protein a day  Sterols come from soybeans  Soy milk, tofu, tempeh  Stanols come from other plant sources  compete with the body’s ability to absorb cholesterol  approximately 3 servings per day  lipid lowering medications have enhanced benefits

Omega 3 Fatty Acids Recommended Omega 3 Intake:

 American Heart Association recommends 2 servings per week  Patients without documented coronary heart disease (CHD)  Omega 3 fatty acid is a polyunsaturated fat  Twice a week.  Function: makes the blood less sticky and less likely to form clots  Patients with documented CHD  Help reduce elevated levels of triglycerides  1 g of EPA+DHA per day.  Improves cholesterol levels  EPA+DHA in capsule form could be considered .  Decreases blood pressure  Patients who need to lower triglycerides  Acts as an anti-inflammatory agent  2 to 4 grams of EPA+DHA per day provided as capsules  under a physician’s care.

https://doi.org/10.1161/CIR.0000000000000462 Circulation: Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association

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Nuts Fiber

 Can reduce CVD deaths by 24%  90% Americans do not get enough fiber (Afshin, 2014)  Eating approx 30g fiber daily can decrease  Walnuts heart attacks by 40%  Omega 3 Fatty Acids (PUFA)  Most Americans eat 5g or less per day  Almonds  National Academy of Sciences  Monounsaturated fats  Recommends 25g for women 19-50, 21g for women 50+. 38g for men 19-50 and 30g for 50+ SDM Appendix 14 table A.25/A.26 Afshin A, Micha R, Khatibzadeh S, Mozaffarian D. Consumption of nuts and legumes and risk of incident ischemic heart disease, stroke, and diabetes: A systematic review and meta-analysis. Am J Clin Nutr. 2014;100(1):278-288.

Lipid Level Recommendations Low-Fat Diet

 Total Cholesterol - less than 200mg/dl  Goal: to reduce total fat intake  HDL – 60mg/dl or more   less than 40mg/dl is low and is an independent risk factor for CHD gallbladder, liver, or pancreas disease

 LDL – 100mg/dl if heart disease present or 130mg/dl or less if no  disturbances in digestion and absorption of fat heart disease present  Amount will vary per individual  heart disease AND diabetes then LDL should be 70 mg/dl or LESS!!!  Less than 30% total calories from fat.  Triglycerides – 150mg/dl or less  No longer standard 40-50 grams of fat.

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Chapter 8: Sodium Restricted Diets – DASH Sodium Trial No Added Salt and DASH • In 2001, the DASH (Dietary Approaches to Stop )– Sodium trial, which was a phase IIa clinical trial (n = 412), • NAS is still 3000-4000 mg sodium daily. demonstrated a BP-lowering effect of reduced sodium intake to very • low levels (<1.5 g/day) over a 30-day period by using previously DASH 2300 mg sodium included again. prepared meals. • Analysis of the 1500 mg sodium diet reveals it cannot meet 27 key nutrients.* Therefore, we did not include DASH 1500 mg • Despite the study’s small size, findings from the DASH-Sodium trial sodium diet. have exerted more influence on guideline recommendations than any other trial because many guidelines currently recommend very low sodium intake levels (e.g., <1.5 g/day recommended by the American Heart Association), although this target was not achieved by either * Maillot M, Drewnowski A. A conflict between nutritionally adequate diets the TONE trial (2.4 gram sodium) or the TOHP trials (3.1 gram) [both and meeting the 2010 dietary guidelines for sodium. Am J Prev Med. 2012; 42(2):174–179 aimed for 1.8 grams sodium/day]. TONE (Trial of Nonpharmacologic Interventions in Elderly) – randomized control trial 975 people TOHP-II (Trials of Hypertension Prevention II) - 2382 people - randomized

Assumption Role of Sodium in the Body

• Despite the absence of clinical trials demonstrating the effect of low • Sodium is an essential nutrient, crucial to the action potential of cells sodium intake on (CVD), or any study showing and involved in first response to cutaneous injuries to prevent the feasibility of sustained low sodium intake in the general infections. population, the effect of sodium reduction on BP was considered • Sodium is required to maintain intravascular volume and is an sufficiently robust for most guidelines to endorse low sodium intake important determinant of blood pressure (BP). Although excess for the entire population. sodium intake is a risk factor for hypertension, extreme salt depletion causes hypotension and lethargy, and increased sodium intake is • It was assumed that all reductions in sodium intake would result in recommended in patients with symptomatic orthostatic hypotension. lowered BP in all populations, which in turn would be expected to • Reductions in sodium intake to low levels (<3 g/day) markedly translate directly into predictable decreases in CVD incidence. activate the renin-angiotensin-aldosterone system to conserve sodium.

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Increased CVD death with a low sodium Chapter 8: Sodium Restricted Diets – intake • A major challenge to the assumed benefit of low sodium intake on CVD events came from prospective cohort studies reporting, in 2011 and 2014, • Is now 2300 mg sodium daily. an increased risk of CVD and death with low sodium intake (compared The 2300 mg Low Sodium diet is the lowest sodium restriction recommended by with moderate intake). the Institute of Medicine to improve health outcomes in certain populations. • A 2014 meta-analysis of studies (n = 274,683) identified an increased CVD “The committee found that data among prehypertensive participants from two risk associated with sodium intake lower than 2.7 g/day and higher than related studies provided some evidence suggesting a continued benefit of lowering 5.0 g/day. Clearly, findings from these studies directly contradict sodium intake in these patients down to 2,300 mg per day. recommendations for lowering sodium intake to <2.3 g/day, and they The committee found no evidence for benefit and some evidence suggesting risk of suggest that moderate sodium intake is associated with the lowest CVD adverse health outcomes associated with sodium intake levels in ranges risk, thus mirroring what is known of sodium physiology. No prospective approximately 1,500 to 2,300 mg/day among those with diabetes, kidney disease, cohort study reported a significantly lower CVD risk with low sodium or CVD. Further, the evidence on both the benefit and harm is not strong enough to intake, compared with moderate intake, in general populations. indicate that these subgroups should be treated differently than the general U.S. population.” Journal of the American College of Cardiology Volume 68, Issue 15, October 2016 DOI: 10.1016/j.jacc.2016.08.008 Andrew Mente, Martin J. O’Donnell, Salim Yusuf How Robust Is the Evidence for Recommending Very Low Salt Intake in Entire Populations? Institute of Medicine: Sodium Intake in Populations: Assessment of Evidence, 2013.

Chapter 8: Sodium Restricted Diets – Chapter 8: Sodium Restricted Diets – Low Sodium Diet Low Sodium Diet • “Consequently, the AHA recommends that patients maintain a low • NKDEP (National Kidney Disease Education Program) Chronic Kidney Disease sodium diet, but acknowledges that the recommendation is based on expert (CKD) and Diet: Assessment, Management, and Treatment, April 2015. “Limit consensus only.” (1) sodium intake to 2,300 mg a day or less.” In this article (1), the 2.8 gram high sodium diet had better results than the 1.8 • ADA (American Diabetes Association) Evert AB, Boucher JL, Cypress M, et al. gram low sodium diet. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013; 36(11): 3821-3842 “Limit sodium intake to 2300 mg/day.” • “The best available evidence suggests that a 2.5 to 3 g sodium diet is effective in promoting adequate nutritional intake and decreasing risk of • JoAnne Arcand, et al. A high-sodium diet is associated with acute decompensated hospitalizations, particularly for patients with advanced heart failure.” (2) heart failure in ambulatory heart failure patients: a prospective follow-up study. Am J Clin Nutr 2011; 93 (2):332-337. 1. Rothberg MB, Sivalingam SK. The New Heart Failure Diet: Less Salt Restriction, More Micronutrients. Journal of General Internal Medicine. 2010; 25(10):1136-1137. "Based on the average intakes in our tertiles, our data suggested that the sodium 2. Lennie TA, Chung ML, Moser DK. What Should We Tell Patients with Heart Failure about Sodium intake recommendation for stable heart failure patients should not be dissimilar Restriction and How Should We Counsel Them? Current heart failure reports. 2013; 10(3):219-226. from the established tolerable upper intake for healthy adults of 2.3 g Na/d."

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Evidence Analysis Library: Sodium 2014 Chapter 9: Diets Liver Disease

• What is the effect of sodium intake on health outcomes in CHF patients? Carbohydrates: A carbohydrate rich bedtime snack helps maintain • CONCLUSION: Limited evidence suggests that a moderate dietary energy and blood sugar levels throughout the night. intake of about 2,760mg to 3,000mg per day decreases hospital re-admissions and mortality in patients with compensated CHF Sodium: 2000-3000 mg daily. A more severe restriction is unnecessary when compared to higher or lower intakes. However, it is not clear and may lead to malnutrition. from the studies analyzed at what level a lower sodium intake would have an unfavorable effect on health outcomes in CHF patients Fluids: May need to be limited if serum sodium levels are low or if fluid retention is not well controlled. Avoid fluid restriction if serum sodium is in the normal range.

EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and Chapter 9: Diets for Liver Disease hepatorenal syndrome in cirrhosis • Recommendations: Moderate restriction of salt intake is an important component of the management of ascites (intake of Liver Disease: sodium of 80–120 mmol/day, which corresponds to 4.6–6.9 g of salt/day). Older research suggested they could be helped by severely limiting protein, especially meat protein intake, but this is no longer • 1 mmol sodium = 23 mg sodium recommended as protein restriction can worsen their risk of • 1 g sodium = 43.5 mmol sodium malnutrition. • 1 g salt (sodium chloride) = 390 mg sodium • 1 tsp salt = 6 g salt ≈ 2,400 mg sodium = 104 mmol sodium Strict protein restrictions should be avoided due to the risk of malnutrition. The goal should be 1-1.5 grams protein per kg of ideal or 80 - 120 mmol = 1840 mg to 2760 mg sodium a reasonable “dry” weight or 60-90 grams per day for most people.

European Association for the Study of the Liver DOI: http://dx.doi.org/10.1016/j.jhep.2010.05.004

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Chapter 9: Diets for Renal Disease Chapter 9: Diets for Renal Disease

Phosphorus: Restrict dairy products to 1 to 2 servings per day. This includes milk, half-and-half, yogurt, custard, pudding, ice cream, frozen yogurt, cheese, and Phosphorus: cottage cheese. See Table 9.3 for dairy serving sizes. Almond milk is low in phosphorus and may be used in place of milk. • Emerging research indicates that 40 to 100% of phosphorus from Food Portion food additives may be absorbed and increase serum levels more than Milk ½ cup from the organic phosphorus present in food. Check food labels of Half and half ½ cup packaged and processed foods and avoid/limit the use of foods with Cheese 1 ounce phosphorus in the ingredient list. Cottage cheese ⅓ cup • By comparison, only about 50% of the phosphorus found in plant Yogurt (not Greek) ½ cup sources is absorbed. Custard ⅓cup Pudding ½ cup Ice cream or frozen yogurt ½ cup Eggnog ½ cup

Chapter 9: Diets for Renal Disease Chapter 10: Fiber Modified Diets

Addition of: Low Protein Modified Renal Diet • Prescribed for individuals with chronic kidney disease (CKD) stages 3, The High Fiber Diet contributes 25–38 grams of , defined 4, and 5, and end-stage renal disease (ESRD) who are not on dialysis. as plant materials resistant to digestion. • This diet is similar to the Modified Renal Diet but is more limited in protein. Protein may be limited to 0.8 g/kg/day. Sodium and The Low Fiber Diet goal is to eat less than 10 to 15 grams of fiber daily. phosphorus guidelines are similar to Modified Renal Diet. • Potassium restriction may not be indicated, but should be initiated when hyperkalemia is present.

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Chapter 10: Low Fiber Diet Chapter 10: Low Fiber Diet

Food for Recommended–Lowinfiber Notrecommended–Highinfiber the Day Food for Recommended– Low in fiber Not recommended– High in fiber Vegetables All strained vegetable juices; iceberg lettuce*; All raw vegetables except iceberg the Day 1–cups most well cooked or canned without seeds or lettuce*; vegetables with skins or Grains Choose grains with less than 2 grams of fiber skins; mashed potatoes without skins. seeds, and greens, winter per serving. squash, sweet potatoes, Brussels sprouts, peas, corn. Oils, Solid Vegetable oils, margarine, butter, cream, Coconut, ; salad dressings mayonnaise, mildly seasoned salad dressings. with seeds or berries. Fruits Melons and ripe bananas; most well cooked Prune juice; any juice with pulp; Fats 1–2.5 cups or canned fruits without skins, seeds most fresh fruits, berries, and Dairy or membranes; pulp free juice. other fruit with skin, seeds, or All milk and milk drinks; smooth yogurt; Yogurt, if flavored with fruit membranes; dried fruit. Products mild cheese; cottage cheese containing small seeds or added *avoid lettuce with esophageal stricture fiber.

Chapter 11: Gluten Restricted Chapter 11: Food Allergies and Intolerances

• In 2012, an international group of celiac experts classified non- • Addition of section on Food Allergen Labeling celiac gluten sensitivity as a distinct condition. There are no • Addition of Wheat Allergy guidelines clinical tests to identify non-celiac gluten sensitivity. Diagnosis relies on ruling out celiac disease and wheat allergy, and how the • Addition of Fructose Malabsorption and Low FODMAP Diet individual feels after avoiding gluten. • Expansion of Gluten Restricted Diet • A trial of a low FODMAP diet may be beneficial for persons with non-celiac gluten sensitivity. *

*Biesiekierski JR, Iven J. Non-coeliac gluten sensitivity: piecing the puzzle together. United European Gastroenterol J. 2015; 3(2):160–165. Doi:10.1177/2050640615578388

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Chapter 11: Gluten Restricted Chapter 11: Food Allergies and Intolerances

Care to avoid cross contamination in food preparation is essential. • Train food service staff to prepare and serve gluten-free meals and snacks. Require that they Lactose Intolerance: wear clean aprons/coats and gloves when preparing gluten-free foods. Keep all outside food and beverages out of the production area. Tolerance to lactose varies greatly. For example, one person may have • Designate a set of preparation and serving utensils, including measuring utensils and cutting boards, to be used only for gluten-free foods. Mark them clearly for gluten-free use only. severe symptoms after drinking a small amount of milk, while another • Thoroughly wash and rinse work surfaces and utensils to remove gluten from them. person can drink a large amount without having symptoms. • Use only pans and skillets without non-stick coatings. Many adolescents and adults may find that they can tolerate up to 12 • Store all gluten-free ingredients in sealed, marked packages and containers. Store gluten- free foods above other foods in the pantry. grams, the amount in 1 cup of milk, when consumed with meals.* • Purchase a toaster to be used only for gluten-free bread. • Cooking meat on foil on a grill protects it from cross-contamination. • Use squeeze bottles for condiments such as mayonnaise, ketchup, pickle relish, and jam. *Suchy FJ, Brannon PM, Carpenter TO, et al. National Institutes of Health consensus Or, provide these in single-serve packets to be opened at the table. development conference: lactose intolerance and health. Ann Intern Med. 2010; 152(12):792-796.

Chapter 11: Fructose Malabsorption and Chapter 11: Fructose Malabsorption the Low FODMAP Diet

• Fructose is an important nutrient found naturally occurring in fruit. • Fructose consumption has increased recently, due to increased Fructose is found as free fructose, bound with glucose (e.g. sucrose), consumption of sweetened beverages and processed foods with added and in fructans (present in some vegetables and wheat). fructose. High Fructose Corn Syrup is a concentrated form of fructose, used to sweeten processed foods such as fruit juices, sodas, and candy, and • During normal digestion, fructose is absorbed in the small intestine. sports drinks. When eaten alone or in excess (like a concentrated form of high • The Low FODMAP Diet is used to decrease GI symptoms in persons with fructose corn syrup [HFCS]), it may be poorly absorbed, resulting in fructose malabsorption or Irritable Bowel Syndrome (IBS). FODMAP stands symptoms like pain, gas, and diarrhea. for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. • Malabsorption results in bacterial fermentation, which leads to fatty acid formation, and gases. Gastrointestinal (GI) symptoms associated • When consuming foods/meals high in fructose, consuming glucose may improve tolerance. Glucose tablets may be used instead of food sources, with fructose malabsorption may include diarrhea, cramping, and are available at most pharmacies. bloating, and flatulence.

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Chapter 11: Fructose Malabsorption Chapter 11: Fructose Malabsorption and Diagnosis the Low FODMAP Diet

Poor reproducibility of breath hydrogen testing: Implications for its Some examples of FODMAPs: application in functional bowel disorders. Chu K Yao, Caroline J 1. Fructose such as fruits, honey, high-fructose corn syrup Tuck, Jacqueline S Barrett, Kim EK Canale, Hamish L Philpott, and Peter R Gibson 2. Lactose found in dairy products United European Gastroenterology Journal 2050640616657978, first 3. Fructans found in wheat, rye, garlic, onion, chicory (inulin) and published on June 27, 2016 doi:10.1177/2050640616657978 fructo-oligosaccharides (FOS) 4. Galactans found in legumes (e.g., dried beans, lentils, soybeans), Conclusions: Routine use of lactulose and fructose breath cashews, pistachios tests in functional bowel disorder patients is not supported 5. Polyols found in sweeteners containing isomalt, maltitol, mannitol, due to its poor reproducibility and low predictive value for sorbitol, xylitol, and stone fruits such as avocado, apricots, cherries, symptom responses. nectarines, , and plums as well as some vegetables (e.g., cauliflower, mushrooms).

Dannon® Oikos® Triple Zero Vanilla Flavor (no artificial sweetener and no added sugar)

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Chapter 11: Low FODMAP Diet Chapter 11: Low FODMAP Diet

Monash University resources: New Low FODMAP oral nutrition supplement ProNourish The Monash Low FODMAP Diet App

Low FODMAP Certification of foods

Chapter 11: Fructose Malabsorption and www.myginutrition.com/ the Low FODMAP Diet (University of Michigan and sponsored by Nestle)

FODMAPs are important in bowel health and should not be 1- Test one FODMAP group at a time discouraged unless a person is told to eliminate them by their 2- Keep avoiding the other FODMAPs healthcare professional. A low FODMAP diet should only be followed 3- Test with foods that contain only that one FODMAP for 2 to 6 weeks. Then foods may be reintroduced under the care of the health-care team, including a registered nutritionist. This 4- Eat a "normal" amount of the test food avoids unnecessary food restrictions and ensures adequate nutrients in 5- Try to test on 3 days during the week the diet. 6- Use the same test food each of the 3 days, but increase amounts by half 7- Track your symptoms every day during the challenge week

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Chapter 12: Other Modified Diets Chapter 12: Other Modified Diets High Nutrient Diet High Nutrient Diet

Examples of High Nutrient Foods Table 12.2 Strategies for increasing dietary protein and/or energy intakes Nutrient dense Cottage cheese, yogurt and other milk products, whole grains, foods fruits, vegetables, eggs, peanut butter, legumes, lean meats, • Fortified oatmeal at breakfast. (not necessarily poultry, fish, canola and olive oils. • 2 eggs at breakfast. high in protein) • Peanut butter on toast or bread at meals. • Side dish of cottage cheese. Enhanced foods Fortified oatmeal: 1/2 c. cooked oatmeal, 2 Tbsp instant • Extra ounce of meat or equivalent at lunch or supper. nonfat dry milk (NFDM), 1 tsp canola oil, 2 tsp sugar or 1 • Cheese or peanut butter sandwich as a snack. packet non-nutritive sweetener, 1 Tbsp peanut butter if • Yogurt snack. patient allows, milk to achieve the correct consistency. • Fortified milk at meals. Fortified milk: 8 oz milk, 3 Tbsp instant NFDM, 2 tsp sugar or • Lactose free commercial oral nutritional supplements may be one packet nonnutritive sweetener, vanilla flavor if desired. considered for patients with lactose intolerance. Blend well. • Protein powder added to cold beverages or other foods. Food fortifiers Non-fat dry milk, peanut butter, canola oil, protein powder.

Chapter 12: Other Modified Diets Chapter 12: Other Modified Diets High Nutrient Diet High Nutrient Diet

Table 12.4 Nutritional recommendations for patients with pressure and surgical wounds Table 12.4 Nutritional recommendations for patients with pressure and surgical wounds

Type of wound Possibleinterventionstoconsider Typeofwound Possibleinterventionsto consider Wounds—pressure. • Energy: Use the Mifflin-St Jeor equation unless indirect calorimetry is Wounds— • Energy: Obese patients may safely receive hypocaloric nutrition available. Clinical judgment should be used when setting energy (calorie) surgical. even as low as 22kcal/kg if protein intakes are at least 2.0 g/kg goals to prevent weight gain in normal weight, overweight, and obese (Major surgical IBW/day. patients and to prevent excessive or rapid weight gain in malnourished wounds) • Protein: 1.5-2.5 g/kg IBW/day for critical illness; obese patients patients. Hypocaloric, high protein diets are acceptable for obese receiving hypocaloric nutrition should receive 2.0-2.5 g/kg IBW. patients, however, hypocaloric, low protein diets are not. Clinical judgment should be used when setting protein goals. • Protein: 1.25-1.5 g/kg/day for patients with pressure wounds and malnutrition. Protein recommendations based on ideal body weight (IBW) are suggested for hospitalized obese patients at the level of 1.8- 1.9 g/kg IBW. Adjust the protein recommendation downward as patient recovers. Assessment of renal function is important to determine tolerance for high protein intakes. Clinical judgment should be used when setting protein goals.

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Chapter 12: Other Modified Diets Chapter 12: Other Modified Diets Halal Diet Halal Diet

Haram: • Adherents of Islam, known as Muslims, abide by the Qur’an. • All pork and its by-products, carnivorous animals, and birds of prey • One set of teachings found in the Qur’an relates to cleanliness; this (i.e., falcon, eagle, kite, hawk) are strictly haram . encompasses dietary laws with respect to permissible foods for consumption and appropriate preparation. • Alcohol and intoxicants are strictly prohibited. This includes any foods made with alcohol such as vanilla extract, sauces, dressings, certain baked • Two categories exist regarding what is lawful and unlawful: halal and goods, candies, or chocolates. haram • It is important to read all ingredients on the label to avoid the following: • Halal is an Arabic term meaning “permissible or lawful,” whereas alcohol, animal shortening, broth, gelatin, , bacon, lard, l-, haram means “sinful” or “not permitted.” lipase, pepsin, animal rennet, and margarine that contains monoglycerides or diglycerides from an animal source.

Chapter 12: K and Prothrombin Chapter 12: and Prothrombin Time Guidelines Time Guidelines – Additional Information

• The Adequate Intake for Vitamin K is 90 mcg daily for women and 120 mcg • daily for men. Dietary supplements can alter INR/PT. Use only supplements approved by your health care provider. Dietary supplements to avoid • Too little vitamin K or inconsistent vitamin K intake is a problem for people taking a blood thinning medication called warfarin. include …. • Vitamin K intake should be consistent from day to day when taking • Check with the health care provider and/or pharmacist before taking warfarin. fish oil or supplements. • If you take a vitamin supplement containing Vitamin K, be sure to take it every day. Do not take a vitamin supplement that contains more than 100 • Alcohol can affect warfarin. Check with the health care provider mcg/day of Vitamin K. before including alcohol in the diet. • Included is a list of foods very high in Vitamin K (more than 100 mcg), foods high in Vitamin K (45-100 mcg) and foods moderate in Vitamin K (30-44 • Large amounts of cranberry juice (1 quart or more daily) or cranberry mcg). juice concentrates in supplements may change the effect of warfarin.

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Chapter 12: Peptic Ulcer Chapter 12: GERD and Hiatal Hernia

The following recommendations are made: 1. Avoid cigarette smoking, salicylates (aspirin), and other NSAID agents. Previously the following foods were thought to increase symptoms. New research shows most people can include them in their diet. You 2. Avoid or limit alcohol. may eat the following foods unless they cause symptoms to worsen. 3. Individuals currently experiencing ulcers should be encouraged to avoid foods that exacerbate symptoms while also consuming adequate • chocolate amounts of dietary fiber from fruit and vegetable sources. Previously the • coffee and other highly caffeinated beverages following foods were thought to increase symptoms. However, new research shows most people can include them in their diet. You may eat • peppermint and spearmint the following foods unless you are actively experiencing peptic ulcers. It • high fat foods is also recommended to avoid/limit these foods if they have been found to cause an individual’s symptoms to worsen. • products and onions • black pepper, red pepper and chili powder • black and red pepper • drinks containing caffeine (e.g., coffee, tea, decaffeinated coffee and • alcoholic beverages tea, cola type soda) • citrus fruits

Chapter 12: Gout Chapter 12: Gout

• Foods high in purines increase uric acid levels, which can lead to uric acid • Avoid alcohol during a flare up. Limit alcohol during remission. Beer crystals being deposited in joints. has been found to have the greatest effect on uric acid levels. • Foods high in purine content, specifically those foods of animal origin, may increase symptoms of gout. Therefore, the purine found in meats should be • Consume more than 8 cups of fluids daily. limited to Dietary Guidelines for Americans recommendations. • Maintain a healthy weight and avoid high protein diets. • Alternatively, the protein found in non-meat sources is preferred (low-fat or nonfat dairy products, eggs, nut butters, and tofu). Vegetable sources of • Recently, studies have found the intake of cherries and cherry extract protein have not been shown to increase symptoms of gout. to decrease the risk of gout attacks. This research has only been • During a flare up, limit meat, fish and poultry to 4-6 ounces per day. conducted in small sample sizes and warrants further research before Protein from non-meat sources is recommended as noted above. Avoid recommendations can safely be made. organ meats such as liver, and limit sardines and shellfish as they are high in purines.

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Chapter 13: Dining Assistance/Special Needs Chapter 13: Developmental Disabilities Developmental Disabilities Table 13.4 – Common Drug-Nutrient Interactions with Developmental Disabilities Table 13.3 – Nutrition Side-Effects of Common Developmental Disabilities Drug Nutrition-Related Side-Effects Antibiotics Diarrhea, nausea, vomiting; destroys “good” intestinal bacteria; Condition Cerebral Spina Bifida Autism Down Prader Willi altered absorption of minerals, fats, and proteins Anticonvulsants Decrease absorption or stores of D, K, B6 and B12; Palsy Spectrum Syndrome folate, calcium Disorders Antipsychotics Decreased absorption of sodium and potassium; increased Feeding Aspiration Aspiration Sensorimotor Low muscle tone Distorted appetite with weight gain Concerns related to related to issues may lead can lead to sense of Antireflux Medications Long-term loss of iron, vitamin B12 and calcium, nausea, dysphagia; dysphagia; to selective difficulties /satiet diarrhea impaired motor impaired motor eating, closing mouth y leading to Antispasmodics Nausea, abdominal pain leading to decreased appetite; skills can limit skills can limit elimination of chewing, and excessive constipation; altered taste; difficulty swallowing (23) Corticosteroids Bone loss due to depletion of calcium and phosphorous; altered self-feeding self-feeding; entire food swallowing; may intake and glucose levels; increased appetite with weight gain; altered abnormal gag groups and eat very slowly consumption absorption/stores of , protein, , and reflux frequent meal- (limiting nutrient of non-food potassium; fluid retention with need to limit sodium; reflux, time behaviors intake) or rapidly items vomiting, and diarrhea (increasing risk Diuretics Loss of potassium, magnesium, calcium and folate stores; for aspiration) nausea, diarrhea and vomiting leading to poor appetite Laxatives Depletion of fat-soluble vitamins with long-term use Stimulants Decreased appetite leading to weight loss

IAND Website Appendices http://eatrightiowa.org/simplifieddiet/

• DRI tables not included – will have the link to these on our • Has all the references, additional resources, and websites website (and there is an App for that) from each chapter. • Choose Your Foods: Food Lists for Diabetes (2014) is included. • Letter templates for Healthcare Providers • Low Sodium Diet • Added Protein Content of Selected Foods • Consistency Altered Diets • Added List of Abbreviations • Patient education handouts have been expanded from 9 to 20 handouts.

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Chapter 6 REFERENCES DIETS FOR DIABETES REFERENCES 1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/nationaldiabetesreportweb.pdf 2. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013; 36(11): 38213842. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3816916/ ADDITIONAL RESOURCES American Association of Diabetes Educators. The Art and Science of Diabetes Self Management Education Desk Reference, 3rd edition. 2014. www.diabeteseducator.org American Diabetes Association. Websites American Association of Diabetes Educators: www.diabeteseducator.org American Diabetes Association: www.diabetes.org Diabetes Prevention Program Outcomes Study: https://dppos.bsc.gwu.edu/web/dppos/lifestyle

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