Planning a Healthy Menu a Toolkit for Supportive Living Sites

Planning a

Healthy

A Toolkit for Supportive

Living Sites

May 2017

Developed by Registered Dietitians

Copyright © (2015), updated May 2017. Alberta Health Services. This material is protected by Canadian and other international copyright laws. All rights reserved. These materials are intended for general information only and are provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. These materials are not a substitute for the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. This material may be reproduced without permission for non-profit education purposes. This material may not be changed without written permission from [email protected].

Table of Contents

1.0 Background Information 1.1 Introduction ...... 6 1.2 Government of Alberta Supportive Living Accommodation Standards ...... 7 1.3 Eating Well with Canada’s Food Guide ...... 9 1.4 Food Safety ...... 10 1.5 Food Allergies and Intolerances ...... 12 1.6 Cultural Considerations ...... 13

2.0 Menu Planning 2.1 How to Plan a Menu ...... 16 Part A: Menu Planning Guidelines...... 17 Part B: How to Choose and Prepare Healthy Foods ...... 19 Part C: How to Build a Cycle Menu Step-by-Step ...... 20 Part D: Example of a Completed Regular Menu Plan ...... 32 2.2 Healthy Standardized Recipes ...... 34 2.3 Standardized Portion Sizes ...... 36 2.4 Planning Healthy Meals in Smaller Supportive Living Sites ...... 45 2.5 Budgeting ...... 49

3.0 Menu Substitutions and Preparing Special Diets 3.1 Overview ...... 52 3.2 Special Diets ...... 53 Diabetes, Heart Healthy, and Low Sodium ...... 54 Kidney ...... 56 Vegetarian ...... 63 Gluten-Free ...... 66 High Protein, High Calorie ...... 70 3.3 Texture Modified Diets ...... 74 Easy to Chew ...... ………………………………………………………………………………………74 Dysphagia Soft...... 80 Minced ...... 88 Pureed ...... 97 Cut/Diced ...... 105 No Mixed Consistencies ...... 107 Pureed Bread Products ...... 109 Thick Fluids ...... 113 Education and Resources ...... 116

4.0 Right Diet to the Right Resident 4.1 Overview ...... 118 4.2 Assigning Tasks for Diet Process Flow for Meal Services ...... 120 Sample Diet Process Flow for Meal Services ...... 121

Appendices

1. Background Information

A. Food Allergies, Intolerances and Restrictions Record

2. Menu Planning

A. Sample One Week Regular Menu B. Sample Grocery List C. Nutrition and Menu Planning Resources D. Sample “Always on the Menu” E. Menu Substitution Form F. Low Sodium Substitutions G. Cycle Menu Template H. Menu Item Suggestions I. How to Calculate Canada’s Food Guide Servings for Mixed Dishes J. Recipes K. Menu Planning Checklist L. Serving Sizes from Canada’s Food Guide

3. Making Menu Substitutions

A. Texture Modified Diet Poster B. Thick Fluids Poster C. Texture Modified Diet Training

4. Right Diet to the Right Resident

A. Sample Resident Diet Request Form B. Colour Coded Special Diet Cards

5. Feedback or Questions

A. Feedback or Questions

1.0 Background Information

1.1 Introduction

The Planning a Healthy Menu toolkit is for operators of Supportive Living sites in Alberta. It is a “how- to-guide” to help the site; plan, prepare, and provide healthy menus to residents. This applies to both larger supportive living sites that have more than eleven residents and smaller sites less than eleven residents.

Who is this toolkit for?

All staff involved in food service and food programs including operators, food service staff, nursing, and recreation staff can use this toolkit.

How can this toolkit help supportive living sites?1

 Supports operators in meeting the Government of Alberta Supportive Living Accommodation Standards and Checklist.2  Provides menu examples and step by step guidance to build a healthy menu to meet the nutrition requirements of Canada’s Food Guide.3  Offers guidance to meet the dietary needs of residents requiring special diets, such as Texture Modified (for example, Pureed or Minced) or other diets (such as High Protein, High Calorie diets), by adapting available regular menu items.

What is in this toolkit?

This toolkit can be used to revise, improve or create a new menu. It provides:  Guidance on how to plan a menu step-by-step including a sample one week menu.  Information on how to standardize portion sizes, read labels, and budget for menu items.  Guidance on menu substitutions for special diets, such as texture modified, vegetarian, and gluten- free diets.  Helpful hints and processes to help ensure that all residents have the ability to meet their nutrition and fluid needs at each meal.

What are hyperlinks and how to use them in this toolkit?

Hyperlinks are direct links to a web site or page. The hyperlinks are outlined in blue and underlined in the toolkit. To use them, move your mouse over each hyperlink and click. The link will open in your internet browser and take you directly to the web site or page for additional information.

1.2 Government of Alberta Supportive Living Accommodation Standards

All Supportive Living sites must follow the Supportive Living Accommodation Standards as regulated by the Government of Alberta.2 The Standards support a safe and comfortable environment that helps maintain or increase the quality of life for Albertans residing in supportive living accommodations.

 The Standards are mandatory for all sites where four or more people live together and the operator provides or arranges for at least one meal per day.

 The Standards were released in April 2010 under the new Supportive Living Accommodation Licensing Act.

 The Accommodation Standards and Licensing Information Guide provides additional information on the standards.

 All supportive living accommodations are required to comply with the standards.

Standards 13 and 14 relate to the Nutritional and Menu Requirements from the Supportive Living Accommodation Standards and Checklist. This toolkit is designed to support operators in meeting the Standards. These two Standards are below for reference.

Nutritional Requirements2 Standard 13

13(1) An operator of a supportive living accommodation who provides residents with a meal, fluids and a snack daily shall ensure that a menu for residents, representing at a minimum a 3-week cycle, is prepared and that (a) the meals, fluids and snacks provided meet the current nutritional requirements of the Canada Food Guide, (b) the meals, fluids and snacks are (i) palatable, safe and pleasingly presented, and (ii) provided in sufficient quantities to ensure adequate hydration and that the residents’ nutritional needs are met, and (c) the menu and times at which the meals, fluids and snacks will be served are communicated to each resident in an appropriate manner.

13(2) In addition to the requirements of subsection (1), an operator of a supportive living accommodation that accommodates 11 or more residents shall ensure that the menu referred to in subsection (1) is reviewed and approved as meeting the current nutritional requirements of the Canada Food Guide by a registered dietitian or a food and nutrition manager registered with the Canadian Society of Nutrition Management.

Menu Requirements2 Standard 14

14(1) The operator of a supportive living accommodation shall ensure that the menu provided for residents (a) offers variety and seasonal variation, (b) provides residents with a choice from within at least one food group at every meal, and (c) as far as is reasonably practicable, recognizes residents’ food preferences, religious practices, and cultural customs in the planning, preparation, and service of meals.

14(2) Where substitutions must be made respecting items on a menu, those substitutions must be (a) from within the same food groups and provide similar nutritional value as the original menu items, and (b) communicated to the residents.

14(3) An operator shall ensure that residents’ opinions and feedback regarding meals, fluids, and snacks are periodically collected and considered in the development of the menu.

14(4) An operator shall ensure that residents are consulted on a periodic basis respecting the times of the day at which meals, fluids, and snacks are to be provided or made available to them and shall respond to the residents’ comments or concerns.

14(5) An operator shall ensure that a record is created of meals served and any substitutions made to the menu and that the record is maintained for at least 3 months.

1.3 Eating Well with Canada’s Food Guide

All supportive living sites must ensure all meals, snacks, and fluids provided meet the current nutrition requirements set forth by Canada’s Food Guide.3

Canada’s Food Guide defines and promotes healthy eating for Canadians of all ages.3 It describes the amount and types of food needed from each of the four food groups every day.  Vegetables and Fruit  Grain Products  Milk and Alternatives  Meat and Alternatives

Eating according to Canada’s Food Guide helps Canadians meet their individual nutrient needs, which contributes to overall health and vitality. This can help to reduce the risk of obesity and other chronic diseases.3

Canada’s Food Guide is available in languages other than English from the Health Canada website.

1.4 Food Safety

Safe food handling is important to reduce the risk of food-borne illness. If food is not safely prepared, handled, and stored; bacteria can grow on it and produce harmful substances called toxins. These bacteria and toxins in food (which cannot be seen, smelled, tasted, or felt) can cause food-borne illness if the food is eaten. It is commonly called “food poisoning”. Symptoms of food-borne illness vary, but can include nausea, vomiting, and/or diarrhea. Older adults, young children, pregnant women, and those with weakened immune systems are at greater risk for severe bouts of food-borne illness.4

The four principles of safe food handling are clean, separate, cook, and chill.4

1. Clean  Ensure all staff handling food; wash hands with warm water and soap for 20 seconds before handling food, during preparation, after using the toilet, and when finished preparing food.  Wash all vegetables and fruit under cool running water before eating or cooking.  Clean utensils and cooking surfaces (including microwaves) with soap and hot water, before, during, and after preparation.  Sanitize countertops, cutting boards, and utensils after use. Use the sanitizing solution available at the facility or mix a mild bleach solution by combining 1 tsp (5 mL) bleach to 3 cups (750 mL) water. Store the mild bleach solution in a spray bottle labeled “sanitizer”.  Wash the tops of cans and jars before opening.  Clean can openers, blenders, and mixer blades before/after each use.  Clean lunch bags every day with hot, soapy water, or bleach sanitizer.  Wash and sanitize the refrigerator and food preparation equipment on a regular established cycle. This should also include faucets, sink drains, fridge handles, and small appliances.

2. Separate  Store raw foods, including uncooked meat, fish, and poultry tightly covered in sealed containers below cooked foods in the refrigerator. Keep eggs covered or in original container.  Keep raw eggs, meats, poultry, fish, and their juices separated from other food during storage and preparation.  Use three separate cutting boards to prepare food. Use one board for produce, one for uncooked meat fish and poultry, and one for cooked meat.

3. Cook  Cook foods to recommended temperatures and serve immediately. Health Canada’s Safe internal cooking temperatures web page provides guidance for a variety of foods.  Reheat foods to 74ºC (165ºF).

4. Chill  Ensure refrigerator(s) and freezer(s) are set at the correct temperatures. The refrigerator temperature should be 4°C (40°F) or colder. The freezer temperature should be -18°C (0°F) or colder.  Refrigerate all raw meat, fish, poultry, eggs, fresh produce, and dairy products after delivery or as soon as possible after purchase.  Leftovers should be refrigerated or frozen within two hours of serving. Place in shallow, covered containers or zip locked plastic bags for quick cooling. Label with food name, preparation date, and time refrigerated.  Refrigerated and frozen leftovers should be used in accordance with the guidelines provided by Health Canada’s Safe food storage guidelines.4

For more information

 The Environmental and Public Health Education Program at Alberta Health Services offers home study courses in food safety and preparation. The online food safety course is recommended for operators that do not have a current food safety certificate.  For information on food safety, visit the Health Canada’s Safe food storage web pages.

1.5 Food Allergies and Intolerances It is important to know if any residents have food allergies, intolerances, or diseases which could affect the foods they can eat.

Food allergies

Food allergies can be life threatening. Common food allergens are – peanuts, eggs, milk, tree nuts, wheat, soy, sesame, seafood (fish, crustaceans and shellfish), sulphites, and mustard. A food allergy occurs when the body’s immune system responds to the protein in food in the wrong way.5 Health Canada’s website contains more information on Food Allergies.

A resident with food allergies can have severe reactions to even very small amounts of the food allergen. Ensure all meals, snacks, and drinks prepared for someone with a food allergy do not contain any of the food allergens. Some ingredients, or entire recipes from the menu, may have to be changed to meet the needs of the resident.

All food storage and preparation methods should ensure foods are kept separate to prevent cross contamination of foods at all stages.4 Cross-contamination occurs when a food or ingredient is accidentally spread to other foods or items by touching with hands, other foods, utensils, cutting boards, or counter tops.

Food intolerances

Food intolerance is a reaction to a food or food additive that does not involve the immune system. For example, lactose intolerance is sensitivity to the natural sugars found in some milk products. Some people may not be able to tolerate lactose containing foods at all, while others may be able to eat small servings of the lactose containing foods without side effects.6

If there are residents with food allergies or intolerances, it is important to have this information posted in the kitchen. A sample Food Allergies, Intolerances and Restrictions Record can be found in Appendix 1A. This record can be adapted to meet the needs of the facility.

1.6 Cultural Considerations

Many residents have important cultural considerations that influence their eating habits and the foods they choose. Food habits can be influenced by customs, traditions, and religion. Some examples may include a special dish to celebrate a holiday or an event, or restricting food or types of foods.

Ask each resident if they have specific food preferences or habits that will affect what, when and how they choose to eat.

Meeting needs of different cultures

You can offer more variety in the menu by using foods and recipes from different cultures. Below are some ideas for including multicultural foods and cooking methods in the menu:

 Serve legumes (beans, dried peas or lentils).  Add spices and herbs to make beans more flavourful.  Bean flour can be added to batters in place of refined white flour.  Use tofu (soft, firm, or flavoured with herbs).  Soya nuggets are found in Indian food markets. Cook with rice or pasta.  Make dips and spreads such as hummus with cooked legumes.  Asian cultures may prefer foods portioned and served in small bowls rather than on a big plate.  Use the Chinese method of quick stir-fry. Stir-fries may contain noodles or rice, vegetables, and include meat alternatives, like nuts or tofu.  Use whole grain flatbreads to make quick pizza, fajitas, quesadillas or wraps and choose the resident’s favourite fillings or toppings.  Grind vegetables and add them to flour dough (for example, Punjabi missi roti).  Grill colourful vegetables and fruit and use as pizza toppings, or as fillings in sandwiches and wraps. Serve grilled fruit as a dessert.  Use vegetables or fruit to make dips, spreads, or salsas (for example, an avocado can be used to make guacamole).

No pork and no beef diets

When a resident chooses to eliminate a specific type of food from their diet, there may be many foods which contain sources of that food item, which will also need to be avoided. Beef and pork are examples of two foods commonly avoided for cultural or religious reasons. Some foods containing pork and beef are shown in the lists below. These foods would also need to be eliminated from the diet. The information below provides a starting point in planning menus for residents who do not consume pork and/or beef.

No pork diet- Avoid pork in any form (meat, broth, gravy, by-products) No beef diet- Avoid beef in any form (meat, veal, broth, gravy, by-products)

Other ingredients to avoid on a no beef or no pork diet Gelatin-containing products–jellies, gelatin desserts, some yogurts, milk puddings, and cheeses Lard Shortening with unspecified sources of fat Tallow Processed cheese spreads Worcestershire sauce Some types of marshmallows Non-dairy creamers, artificial whipped toppings, and powdered coffee whitener

Note: the list above is not a complete list of foods.

Read ingredient lists on product labels to find other sources of beef and pork.

Document T2.0 Menu Planning itle Goes Here

Why is menu planning important?

2.1 How to Plan a Menu Overview:

A menu is a plan of all meals and snacks including portion sizes that will be served, over a specific period of time.

All Supportive Living sites must follow the Supportive Living Computer Tip! Accommodation Standards and Checklist as outlined by the Click on each hyperlink Government of Alberta.2 Standards 13 and 14 from the Supportive to take you to the website Living Accommodation Standards contain the nutrition and menu for more information. requirements. More detailed information on these standards can be found in the Accommodation Standards and Licensing Information Guide.

The standards indicate that supportive living sites must:  Provide a minimum 21-day menu cycle.  Communicate the complete menu and/or menu substitutions to residents in an appropriate manner.

The Standards require all sites with 11 or more residents to have their menu reviewed and approved by a Registered Dietitian (or by a Food and Nutrition Manager registered with the Canadian Society of Nutrition Management).2 This applies to all new menus (including seasonal menus). To find a Registered Dietitian in your area, visit the Dietitians of Canada Find a Dietitian7 website.

Having a planned, written menu helps to:1  Meet recommendations from Canada’s Food Guide.3  Increase healthy food choices to help promote a healthy eating environment.  Offer a variety of foods that look good, taste good, and are safe and appealing to eat.  Save money and time.  Reduce food waste.  Meet the needs of residents with special diets (such as Pureed or High Protein, High Calorie diets).

This section contains the following information to help operators plan, develop, and use a cycle menu: Part A: Menu Planning Guidelines Part B: How to Choose and Prepare Healthy Foods Part C: How to Build a Cycle Menu Step-by-Step Part D: Example of Completed Menu Plan

Other tools to assist with menu planning, especially for smaller sites, include:

 Budgeting: page 49  Using the food label: page 19  Sample Grocery List: Appendix 2B  Healthy Standardized Recipes: page 34  Menu Substitutions and Preparing  Planning Healthy Meals in Smaller Supportive Special Diets: page 52 Living Sites: page 45

Appendix 2A contains a Sample One Week Regular Menu which includes portion sizes and the number of Canada’s Food Guide servings for each day.

1,2,3,8,9 Part A: Menu Planning Guidelines How do I know that the menu is healthy and meets the Supportive Follow these guidelines to help create a healthy menu that Living Accommodation Standards?2 meets the Supportive Living Accommodation Standards and Checklist.2

1. Make sure the menu provides at least the minimum number of daily servings from each of the four food groups from Canada’s Food Guide. Offer meals, snacks, and drinks in amounts to meet the nutrition and fluid needs of all residents.

2. Aim to include foods from each of the four food groups at each meal.

3. Ensure each snack provides at least one of the four food groups and a drink.

4. Plan at least a 21-day cycle menu that includes three meals and 23 snacks per day, listing all food and drinks served. A cycle menu means that all meals and snacks are planned for a certain number of days, and then the menu is repeated.

5. List the standard portion size for each menu item. This helps with planning, purchasing, preparation, and serving. Refer to the Standardized Portions Sizes section of this document on page 36. Residents may ask for smaller or larger portions.

6. Improve meal acceptance and enjoyment by providing foods with a variety of: a. colour (for example, orange, green, yellow) b. texture (for example, soft, crisp) c. flavour (for example, sweet, sour, mild) d. shape (for example, round, sticks, diced) e. temperature (for example, cold salad, hot beef sandwich)

7. Offer foods that complement each other. For example, scalloped potatoes with ham, or whole wheat rolls with beef stew.

8. Provide at least 6 cups (1500 mL) of fluid per day. Offer at least 1 cup (250 mL) of fluid at each meal and snack. Fluids may be hot or cold. Water should be available at all meals and snacks.

9. Modify the regular menu to help residents with special diet needs, such as diets for disease management, food allergies or intolerances, or difficulty chewing and/or swallowing. Learn more about Menu Substitutions and Preparing Special Diets in section 3.

10. Include religious and cultural food items for residents. See page 13 to learn more.

11. For special occasions and celebrations, offer foods such as birthday cake that are not part of the regular menu.

12. Consider having “À la Carte” or “Always on the Menu” options for residents who may not eat the first or second choice menu items served. This helps residents to meet their daily nutrition requirements. “Always on the Menu” items are usually simple to prepare, easy to chew, widely accepted foods that can easily be adapted to suit the needs of the residents. Examples include a fresh fruit and cottage cheese plate, assorted sandwiches, or a bowl of soup. Other Sample Always on the Menu items can be found in Appendix 2D.

13. Revise and/or update menus at least twice per year to improve variety. Include seasonal and local foods when possible. A facility may use both a fall/winter and spring/summer menu or provide seasonal menu substitutions.

14. Collect feedback from residents prior to each seasonal menu change. Use feedback to improve the content and timing of meals and snacks as needed.

15. Post the menu in a common area, such as the dining room or kitchen for viewing by residents, family members, visitors, and staff.

16. Keep a record of all meals served, any changes to the menu and the reasons for the changes. Records must be kept on file for at least three months. Menu changes can be tracked using the Menu Substitution Form in Appendix 2E, or by changing and initialing the posted menu.

How can I plan a healthy menu Part B: How to Choose and Prepare and create a healthy eating Healthy Foods8 environment for my residents?

Using the food label

Food labels provide useful information for selecting menu items.

Health Canada’s Nutrition Labelling regulations specify the information food labels must contain. Food labels are required on almost all pre-packaged foods. The supplier can provide the label information if food is ordered in bulk. Label information can be used to compare products and choose healthy foods.

Nutrition information is found in three places on a food label: 1. Ingredient List 2. Nutrition Claims 3. Nutrition Facts table

The Nutrition and Menu Planning Resources list in Appendix 2C provides more information on label reading.

Preparing healthy foods

Food preparation methods can affect the nutrition content of menu items. Use recipes that contain less fat, sugar and salt. See the Nutrition and Menu Planning Resources list in Appendix 2C for more information. Below are some other healthy preparation tips:

1. Use a variety of healthy cooking methods that use little or no added fat. For example, bake, roast, steam, barbeque, broil, boil, microwave, stew, or sauté. Pan-fry or deep-fry least often.

2. Cook with and use healthy fats such as oils and soft margarines (instead of hard margarine, lard, and shortening that contain unhealthy saturated and trans fats).

3. Offer fresh cooked lean meats most often. Processed meat (bacon, ham, and deli meats) are high in salt (sodium) and can be high in fat. These meats should be offered less often than fresh meats.

4. Whenever possible, cook with and offer lower sodium foods. Foods high in sodium include soups, dried soup bases, condiments, sauces, and salad dressings. Use only small portions of high sodium items like soy, hoisin, Worcestershire sauces when offered.

5. Flavour food with garlic, onion, herbs, spices, and lemon juice instead of salt. For more ideas, see Appendix 2F on Low Sodium Substitutions.

Part C: How to Build a Cycle Menu Step-by-Step 1,8,10,11

Below is a flow chart of the steps to building a cycle menu. Each step is described in greater detail in the following pages. How to Build a Cycle Menu Step-by-Step Overview

Check the age range and gender of clients to determine the number of Canada’s Food Guide servings of each food group needed daily.

Gather menu planning materials needed Meat and Alternatives and/or Plan the food and drinks that will be Milk and Alternatives offered daily. Determine how many alternate choices will be offered. Select Grain Products drinks for all meals and snacks.

Plan breakfast for each day, in the order Vegetables and Fruit listed.

Meat and Alternatives Plan lunch and supper for each day, and/or in the order listed. Milk and Alternatives

Plan daily snacks which include at least Grain Products one food group from Canada’s Food Guide. Vegetables and Fruit Select condiments and garnishes for all meals and snacks as needed. Dessert/Fruit

Plan modifications for each day’s menu as Soups required for special diets.

Review the menu and complete the Menu Planning Checklist.

Test the menu.

Evaluate the menu.

Menu substitutions can be made throughout the year to allow for variety and seasonal variation. Keep a record to show that the menu has been altered throughout the different seasons. A new menu for spring/summer could include colder and lighter foods and seasonal items such as fresh fruit. A fall/winter menu could include warmer and comfort foods, such as hearty soups and stews. Develop one new menu. Then use it as a starting point to develop the second menu.

1. Check the age range and gender of residents.

Canada’s Food Guide outlines the number of food group servings to meet daily nutrient and energy requirements for each age group. The daily menu must meet the minimum number of servings from each food group as shown below:

Canada’s Food Guide 19-50 years 51+ years Food Groups Females Males Females Males Vegetables and Fruit 7-8 8-10 7 7 Grain Products 6-7 8 6 7 Milk and Alternatives 2 2 3 3 Meat and Alternatives 2 3 2 3

2. Gather menu planning resources such as feedback from residents (see page 18 and 31) and:

 Cycle Menu Template (Appendix 2G).  Menu Item Suggestions (Appendix 2H).  Food Allergies, Intolerances, and Restrictions Record (Appendix 1A).  Standardized Portion Sizes (see page 36).  Healthy Standardized Recipes (see page 34).

3. Plan the food and drinks to be offered daily.

a) Decide how many choices will be offered for each meal Residents must be offered an alternate choice from within at least one food group at each meal.2 For example, a choice of cereal (hot and cold), an entrée (beef or chicken), or soup (cream or broth). Ensure that the menu template allows space for extra choices as needed.

b) Select drinks for all meals and snacks o Provide water at all meals and snacks. o Offer both hot and cold drinks, such as milk, 100% juice, coffee or tea. Provide decaffeinated options, such as decaffeinated coffee, tea, or herbal tea. o Serve lower fat milk (2%, 1%, or skim) or fortified soy beverage at least twice a day. o Decide how often, and when to offer 100% juice, such as apple, orange, or cranberry juice blend. If vegetable juice is offered, a sodium-reduced juice is preferred.

9 Use the “Nutrition tips” in the right hand column for each meal and food group in your menu to help with healthy menu planning:9

 Offer most often foods (on a daily basis)

 Offer least often foods

4. Plan breakfast for each day. a) Select the Meat and Alternatives

Meat and Alternatives Nutrition Tips Examples include eggs, nut butters and baked Offer Most Often beans.  Egg substitutes can be used as a healthy Eggs can be included in the choice. For example, egg whites and egg menu daily, prepared in a white based omelets. variety of ways (for example, boiled,  Offer Least Often poached, or scrambled).  Ham, bacon, sausage, quiche and fried eggs.

Note: Milk and Alternatives such as cottage cheese, cheese and yogurt can be offered instead of a Meat and Alternative as long as the total number of servings for each group is met at other meals and snacks throughout the day.

Milk and Alternatives Nutrition Tips

Examples include milk and fortified soy Offer Most Often beverages, cottage  Yogurt with 2% M.F. or less. cheese, cheese and  Low fat milk or evaporated milk in coffee yogurt. or tea.  Lower fat cheeses with 20% M.F. or less. Check the Nutrition  No salt added cottage cheese. Facts label to ensure that milk and soy  Offer Least Often beverages are fortified with calcium and  Cream cheese, ice cream, coffee cream, vitamin D. whipping cream, and regular sour cream.  Processed cheese products such as processed cheese slices or spreads are high in salt.

b) Select the Grain Products

Grain Products Nutrition Tips Examples include cooked or cold cereals, toast, French Offer Most Often toast, muffins, pancakes, scones or waffles.  Make at least half of the grains offered each day whole grain. For Provide hot and cold cereal options. example, whole grain breads for Offer a high fibre cereal (that has at least toast, whole grain cold cereals, and 10 4 g of fibre per serving) as a choice each day. oatmeal.

 ® To learn how to find a high Bran cereal (such as Bran Buds ) fibre cereal, see Appendix can be offered on the side to increase 2C, Nutrition and Menu fibre content. Planning Resources for tips  Stove-top prepared hot cereals are on label reading. preferred over instant as they are lower in sodium. Starchy vegetables such as potatoes or corn can be  Ground flax seed, dried fruit, or nuts offered instead of a Grain Product at meals. If done, with hot cereals to increase fibre offer enough Grain Products at other meals and snacks to content and add more flavour and meet total daily grain servings. variety.

c) Select the Vegetables and Fruit

Vegetables and Fruit Nutrition Tips Examples include fresh, frozen or canned Offer Most Often fruits or vegetables, or 100% juice. Fresh  If canned fruit is used, then ‘no-sugar fruit and/or canned fruit can be offered in added’ or ‘in water or fruit juice’ is addition to, or instead of, juice at preferred over ‘in syrup’ varieties. breakfast.  Offer Least Often Vegetables can be added to mixed dishes, such as  Hash browns or fried potatoes. mushrooms or bell peppers in an omelet.

Vegetables and fruit such as tomato slices or fresh orange slices can be used as a garnish.

Offer fruit in a smoothie to increase variety.

Caution: Grapefruit and grapefruit juice Grapefruit and grapefruit juice can react with some medications so may not be safe or suitable for all residents. If these are served, provide another juice or fruit

choice.

5. Plan lunch and supper for each day.

Offer a main meal (with a hot entrée) and a lighter meal (with the option of cold foods) each day. The main meal may be provided at either lunch or supper.

a) Select the entrée using Meat and Alternatives choices

Meat and Alternatives Nutrition Tips The entrées offered at lunch and supper Offer Most Often should each provide at least one serving of  Provide fish at least twice a week3 Offer Meat and Alternatives. Examples include fish, fish such as salmon, mackerel, sardines, poultry, lean meat, legumes (beans, peas, and herring, Arctic char, anchovies and trout lentils), tofu, or eggs. that contain healthy fats.

 Sandwiches made with leftover meats (such as roasted/baked chicken) are lower in sodium and fat than those made with deli meats. Canned meats/fish (canned in water) or egg salad may also be used. Include a vegetarian option (meat alternative), at least once per week, such as baked beans.  Offer Least Often

 Have an alternate entrée available such as a Processed meats, such as bacon, bologna, ham, salami, sausage, and wieners. cold sandwich.  Deep fried foods.*

Note: Milk and Alternatives such as cottage cheese, cheese, and yogurt can be

offered instead of a Meat and Alternative as long as the total number of servings

for each group is met at other meals and snacks throughout the day.

Milk and Alternatives Nutrition Tips

Examples include milk and fortified soy Offer Most Often beverages, cottage cheese,  Yogurt with 2% M.F. or less. cheese and yogurt.  Low fat milk or evaporated milk in coffee or tea. Check the Nutrition Facts  Lower fat cheeses with 20% M.F. or less. label to ensure that milk  Offer no-sodium added cottage cheese. and soy beverages are fortified with calcium  Offer Least Often and vitamin D.  Cream cheese, ice cream, coffee cream, whipping cream, and regular sour cream.  Processed cheese products such as processed cheese slices or spreads are high in salt.

* If a deep fried food is offered, a non-fried option should also be available. For example, provide roast chicken as an alternative to fried fish or steamed rice if French fries are served.

b) Select the Grain Products to accompany the entrée

Grain Products Nutrition Tips Offer rice, pasta or Offer Most Often potatoes as a side at the  Make at least half of the grains offered main meal, unless they are each day whole grain. Examples of whole included as part of an grains include barley, brown rice, oats and entrée. For example, oatmeal, quinoa, whole wheat pasta, and shepherd’s pie, or chicken wild rice. stir-fry with brown rice.

Offer a variety of Grain Products to help meet cultural considerations.

For more tips on choosing whole grains, see the Nutrition and Menu Planning Resources list in Appendix 2C.

Note: Starchy vegetables such as potatoes or corn can be offered instead of a Grain Product at meals. If done, offer enough Grain Products at other meals and snacks to meet total daily grain servings.

c) Select at least 2 servings of Vegetables for each meal

Vegetables and Fruit Nutrition Tips Offer a variety of colours. For example, Offer Most Often potatoes with broccoli and carrots.  At least one dark green and one orange vegetable every day. A list of dark green Serve one hot vegetable and and orange vegetables can be found in one cold vegetable together. Appendix 2H, Menu Item Suggestions. For example, steamed cauliflower and raw spinach salad.

Fresh, frozen or canned vegetables can be used.

Salads can be provided as entrées if they include one serving of Meat and Alternatives per portion, such as Cobb or chef’s salads.

Try not to offer the same vegetable more than once per day. For example, if carrots sticks are offered at lunch, then avoid offering again at supper.

Use local seasonal vegetables whenever  Offer Least Often possible.  If canned vegetables are used, choose no salt added, sodium reduced, low sodium, or less salt varieties.

Note: If the main entrée or soup has more than ½ cup of vegetables per serving,

this could count as a serving of Vegetables and Fruit. For example, chicken vegetable soup or tuna vegetable casserole. See Appendix 2I, How to Calculate Canada’s Food Guide Servings for Mixed Dishes.

d) Select the Dessert for each meal

A healthy balanced diet should be offered to all residents. However, there are times when a resident may choose foods that are recommended least often, for quality of life. Therefore, the diet provided to that resident may offer more comfort foods (and less healthy choices) to help improve intake (for example, a higher calorie or higher fat dessert can be provided once a day). Use the nutrition tips below to provide a balanced menu at your site.

Dessert Nutrition Tips Offer fresh or canned Offer Most Often fruit as dessert most  If canned fruit is used choose ‘no-sugar often. added’ or ‘in water or fruit juice’ varieties.

 Always provide another dessert choice such as fruit or yogurt when serving desserts higher in sugar or fat.

For tips on healthy baking, see the Nutrition and Fruit based or milk based desserts are also good Menu Planning Resources list in Appendix 2C. options. Examples include fruit crumbles, milk pudding, custard, mousse, frozen yogurt and Appendix 2C. tofu desserts. Refer to dessert recipes: Apple and Peach Crisp, Slow Cooker Fruit Pudding,  Offer Least Often and Instant Berry-Mango Frozen Yogurt in  Dessert items which are higher in fat, Appendix 2J. sugar, and salt such as ice cream, cake, and pastries.

Note: Consider fruit based dessert/baked goods as a Vegetable and Fruit serving if the dessert contains at least ½ cup (125 mL) of fruit per serving.

e) Select Soups as needed

Soups Nutrition Tips Offer soup daily at the lighter meal. Soup can Offer Most Often also be offered at the main meal as an option.  Make or buy low salt and low fat varieties whenever possible. For example, low Soups can be included as an appetizer or an sodium chicken-noodle, and low fat cream entrée. If served as an entrée, ensure it provides of broccoli. at least ½ serving of Meat and Alternatives. (For more information, see Appendix 2I How to  Offer Least Often Calculate Canada’s Food Guide (Serving Sizes  Clear broth/consommé does not provide for Mixed Dishes). enough nutrition to be the soup choice.

Left-over meat, vegetables or pasta can be used in soups to help reduce food wastage.

Switch between broth and cream based soups for variety.

In summer, cold soups, such as chilled cucumber, can be offered to increase variety.

6. Plan snacks daily.

Snacks Nutrition Tips Each snack should include at least one food Offer Most Often group, and a drink.  Milk and Alternatives such as low-fat yogurt, and ‘light’ or ’partly-skimmed’ Snacks can be used to help ensure residents cheese. have enough choices from each food group  daily. For example, if a day is low in Choose lower fat cheeses with 20% M.F. Vegetables and Fruit at meals, offer a choice or less on the label. from this food group  Choose fresh fruit and vegetables for a as part of a snack to quick and healthy snack. meet requirements.  Always provide an alternative choice such

as fruit or yogurt when offering snacks The number and higher in fat or sugar. timing of snacks offered can vary depending on meal times and To access more healthy snack ideas and tips on specific resident needs. using less fat and sugar in baking, see the Nutrition and Menu Planning Resources list in Offer fresh fruit and/or canned fruit at least Appendix 2C.

23 times per day.  Offer Least Often  Dessert items higher in fat, sugar, and salt such as ice cream, cake, and pastries.  Snacks higher in fat, sugar, and salt. If snacks higher in fat, sugar, or salt are offered, serving sizes should be limited to:9 o 1 cup/ 250 mL (30 g) of chips and crackers or high sugar cereal o 2 cookies (30-38 g cookies) about and 1 small cereal bar (30 g) o 55 g baked goods (for example, pastries, muffins, doughnuts) o ½ cup/ 125 mL (85 g) frozen desserts (for example, ice cream, frozen ice cream bar) o 1 cup/250 mL sweetened drink (for example, iced tea, lemonade)

7. Select condiments and garnishes for all meals and snacks as needed.

Condiments and Garnishes Nutrition Tips All condiments and sauces should complement Offer Most Often the meal. For example, a lemon wedge or tartar  Salt and low sodium soy sauce can be sauce with baked fish, syrup with waffles, and available upon resident request instead of gravy for mashed potatoes. leaving them on the table or displayed.

Examples include ketchup,  Milk with coffee/tea. Cream or coffee mustard, relish, vinegar, jam, whitener can be available upon resident request. sugar, sugar substitutes, syrup, pepper, and herbs.  Soft, non-hydrogenated margarine more often. Butter can be available upon Garnishes are used for decoration and visual resident request. appeal, but can also add flavour. For example, cinnamon on hot cereal, parsley on lasagna, or  Crackers with unsalted tops. fresh dill on salmon filets.

Crackers with unsalted tops should be available with soup.

8. Plan how to change each day’s menu for special diets.

Consider residents that need special diet changes due to food allergies, to manage a chronic disease, or require a texture modified diet.  Changes can be written on the menu or written as separate menus. Keep a record of any changes to the menu (see page 18). Menu changes can be used using the Menu Substitution Form in Appendix 2E.  Check what special diets are needed for your residents. See Menu Substitutions and Special Diets, (Section 3) for more information.  Adapt the foods offered on the regular menu as much as possible. For example, if the menu offers roast beef, mashed potatoes and green beans, the same items can be pureed for those requiring a pureed diet. In situations where menu items cannot be modified to the recommended texture, such as corn on the cob, offer a substitute food from the same food group.  Inform the residents of what they are being served (through conversations and/or postings). 9. Review the menu and complete the Menu Planning Checklist.

 See Appendix 2K for a sample Menu Planning Checklist.

10. Test the menu.

 Test the complete menu with residents and get feedback. Adjust as needed and complete the menu checklist again.  Make note of any recipes that did not work as soon as they are made, as well as food waste from uneaten items. Consider changing a menu item or recipe if there is high food wastage.

11. Evaluate the menu.

 Collect feedback from residents prior to each seasonal menu change, at least twice a year. Use this feedback to improve the content and timing of meals and snacks as needed.

How do I use these guidelines to build a menu each day?

Part D: Example of a Completed Regular Menu Plan

Canada’s Food Guide Meal Menu Item Portion Size Servings Coffee/tea and water 1 cup/ 250 mL Standardized portion sizes 100% apple juice ½ cup/ 125 mL 1 Vegetables and Fruit for each menu Banana 1 medium 1 Vegetables and Fruit item Bran cereal with raisins ¾ cup/ 175 mL 1 Grain Products Whole grain toast 2 slices (1 oz/35 g each) 2 Grain Products Breakfast Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Peanut butter 1 tbsp/ 15 mL ½ Meat and Alternatives

Water and coffee/tea 1 cup/ 250 mL Beef barley soup 1 cup/ 250 mL ½ Grain Products Crackers, saltines 1 package (2 crackers) ¼ Grain Products Includes Turkey sandwich wrap on 1 wrap (2 ½ oz/75 g lean 1 Meat and Alternatives each of whole grain whole wheat turkey breast) the four food pita bread, with romaine 6 inch/15 cm (2 oz/70 g) 2 Grain Products lettuce and tomato slices groups whole grain pita bread at each 1 piece of romaine ½ Vegetables and Fruit meal Lunch 2 slices of tomato Carrot sticks 56 pieces 1 Vegetables and Fruit (3 inches/ 7 ½ cm long) Tossed salad ½ cup/ 125 mL ½ Vegetables and Fruit Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Grapes ½ cup/ 125 mL 1 Vegetables and Fruit

Water and coffee/tea 1 cup/ 250 mL

- Orange 1 medium 1 Vegetables and Fruit Oatmeal cookie 2 small cookies 1 Grain Products

After noon Snack (1-1 ½ oz/30-38 g total)

Water and coffee/tea 1 cup/ 250 mL Meatloaf 1 slice (2 x 4 x ½ inches/ 1 Meat and Alternatives 5 x 10 x 1.5 cm) Baked potato 1 medium 2 Vegetables and Fruit Green beans ½ cup/ 125 mL 1 Vegetables and Fruit

Supper Whole grain tray bun 1 small bun (1 oz/35 g each) 1 Grain Products Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Baked apple with cinnamon 1 medium 1 Vegetables and Fruit Vanilla pudding ½ cup/ 125 mL 1 Milk and Alternatives

Water and coffee/tea 1 cup/ 250 mL Salmon salad sandwich on ½ sandwich (1 ½ oz/ 30-45 g ½ Meat and Alternatives whole wheat bread salmon) Snack Evening Evening 1 slice bread (1 oz/35 g) 1 Grain Products

Canada’s Food Guide Number of Food Groups servings Provides the minimum number of servings each Vegetables and Fruit 10 day through meals and snacks. Grain Products 8 ¾ Milk and Alternatives 4 Meat and Alternatives 3 Fluid 9 ½ cups Provides a minimum of six cups of fluids daily, 2375 mL and at least one cup at each meal and snack.

2.2 Healthy Standardized Recipes

Using standardized recipes helps to make sure the quality and quantity of food is consistent each time the recipe is prepared. This can also help to control costs, reduce waste, and make planning and purchasing more efficient.

How to standardize a recipe1  Choose a recipe. Look for recipes that:  Use healthy cooking methods like grilling, baking, broiling, poaching, and steaming.  Contain lots of vegetables and fruits.  Are made with whole grains such as whole grain flour, brown rice or whole wheat pasta.  Use lower fat cheese (20% M.F. or less) and yogurt (2% M.F. or less).  Have lean meats or meat alternatives such as lentils, beans and chickpeas.  Include small amounts of healthy fats such as soft non-hydrogenated margarine or vegetable oil instead of lard, hard margarine, butter, or cream.  Are seasoned with herbs and spices instead of salt.  Have lower amounts of added sugars. 1. Check the recipe to make sure it is not missing any ingredients or instructions.

2. Convert the recipe to larger servings if necessary. Adjust weight and volume measures if needed. Please refer to Conversions and Equivalents on page 42 in the Standardized Portion Sizes section for information.

3. Prepare the recipe. Taste test with residents and staff, by selecting a group of people to provide feedback. Evaluate the recipe for quality, yield, portion size, flavour, colour, and texture, etc.

4. Adjust the recipe as needed based on feedback. Prepare the recipe again until there is an acceptable product.

5. Use a standardized recipe template to record details related to the recipe including:  Recipe title: Pick a name that describes the recipe.  Recipe category: Label the recipe as an entrée, grain, salad, dessert, etc.  Ingredients: List the ingredients used in a recipe in the order used in the directions. Include any preparation techniques (for example: carrots, peeled, diced).  Weight and/or volume of each ingredient: List each ingredient in both imperial and metric measurements. For example: Imperial Ingredient Metric 1 cup Bananas, mashed 250 mL

 Directions: List the steps for preparing the recipe. Use clear, concise language. Include cooking temperature and time and food safety tips as necessary (for example: proper thawing or internal cooking temperature).  Portion size: List the amount to be served in a single portion. See the Standardized Portion Sizes section on page 36 for more information.  Recipe yield: List the total amount of product after the recipe is made. This includes the weight or volume of food prepared and/or size and total number of servings.  List all equipment and utensils to be used during preparation.  Include the utensils needed for serving. For example, include the scoop number or size needed to serve each portion.

Refer to Appendix 2I on How to Calculate Serving Sizes for Mixed Dishes to see an example of a completed standardized recipe using a Shepherd’s pie recipe.

2.3 Standardized Portion Sizes

Using standardized portion sizes helps with planning, purchasing, and preparation of foods, as well as providing a Computer Tip! healthy diet for residents. Serving standardized portions to Click on each hyperlink residents can help ensure the recommended number of daily to take you to the website servings from Canada’s Food Guide is available. for more information.

Operators are responsible to ensure the minimum daily number of servings, are provided from each food group. Use the information which follows in menu planning to ensure these requirements are met. For more information about serving sizes, please refer to Appendix 2L Serving Sizes from Canada’s Food Guide.

This section provides a food portion size guide. For more information on healthy food choices, see How to Plan a Menu (page 16).

Food Portions and Servings

A portion is the amount of food a person plans to eat at one time. There are many factors that can affect food portion sizes. These factors can include the person’s age, gender, activity level and appetite, and where the food was obtained and eaten. To meet the needs of residents, serve portions that do not overwhelm the smaller eater, or leave the larger eater feeling that they need more. Assessing individual resident needs will help ensure that the right amounts and types of foods are made and served. This also helps to meet resident’s nutrition needs, prevents food wastage, and helps control food cost.

A serving is a set amount of food as recommended by Canada’s Food Guide. It may not be the portion of food a person eats at one sitting.

Using What is a Food Guide Serving? is a way of comparing the food eaten to the amount recommended each day for an individual.

The table on the following pages lists standard food portion sizes and compares these to Canada’s Food Guide Servings.

Standardized portions for food items

Listed below are suggested portion sizes .To provide more choice for residents, it is helpful to have the option of regular, small, or large portions.

Standard Food Number of Canada’s Food Item Portion Sizes Food Guide Servings Vegetables Mashed potato ½ cup/ 125 mL 1 serving Vegetables and Fruit (regular or sweet potato) #8 scoop Baked potato 1 medium 2 serving Vegetables and Fruit (regular or sweet potato) or ½ large ½ cup/ 125 mL Scalloped potatoes 1 serving Vegetables and Fruit #8 scoop 3 oz/ 90 g Potato wedges 1 serving Vegetables and Fruit 34 each ½ cup/ 125 mL Cooked vegetable 1 serving Vegetables and Fruit 4 oz portion server Leafy salads: tossed, 1 cup/ 250 mL 1 serving Vegetables and Fruit romaine, spinach, Caesar Raw vegetable salads ½ cup/ 125 mL (carrot raisin salad; broccoli 1 serving Vegetables and Fruit 4 oz portion server salad; corn salad) Tomato slices 2 ½ serving Vegetables and Fruit Vegetable sticks 56 pieces 1 serving Vegetables and Fruit (3 inches/ 7 ½ cm long) Juice, 100%; no salt added or ½ cup/ 125 mL 1 serving Vegetables and Fruit reduced in sodium Fruit ¼ cup/ 60 mL Prunes, cooked 1 serving Vegetables and Fruit 2 oz portion server Fresh fruit 1 whole, medium 1 serving Vegetables and Fruit Fruit cocktail, strawberries, pears, peaches, mandarin ½ cup/ 125 mL 1 serving Vegetables and Fruit oranges, pineapple, melon 4 oz portion server (diced), apricots, stewed fruit ½ cup/ 125 mL Fruit sauce 1 serving Vegetables and Fruit 4 oz portion server Juice, 100% / from ½ cup/ 125 mL 1 serving Vegetables and Fruit concentrate

Standard Food Number of Canada’s Food Item Portion Sizes Food Guide Servings Grain Products ¼ cup/ 60 mL Stuffing, bread ½ serving Grain Products #16 scoop ½ cup/ 125 mL Rice (steamed, pilaf) 1 serving Grain Products #8 scoop ½ cup/ 125 mL Pasta / Noodles 1 serving Grain Products 4 oz portion server 2 slices (1 oz/ 35 g each) 2 servings Grain Products Bread, slice (breakfast or lunch) 1 serving Grain Products 1 slice (1 oz/ 35 g) (supper) Bun / Roll 1 bun (1 oz/ 35 g) 1 serving Grain Products

Pita bread ½ pita (1 oz/ 35 g) 1 serving Grain Products

Soda crackers 1 package (2 crackers) ¼ serving Grain Products French toast, waffles, 2 (4 inches/ 10 cm) 2 serving Grain Products pancakes English muffin ½ muffin (1 oz/ 35 g) 1 serving Grain Products ¾ cup/ 175 mL Hot cereal 1 serving Grain Products 6 oz portion server ¾ cup/ 175 mL Cold cereal 1 serving Grain Products 6 oz portion server Milk and Alternatives Milk whole, 2%, 1%, or 1 cup/ 250 mL 1 serving Milk and Alternatives skim, chocolate, lactose free Fortified soy beverage 1 cup/ 250 mL 1 serving Milk and Alternatives Evaporated milk, canned ½ cup/ 125 mL 1 serving Milk and Alternatives (undiluted) 1 oz/ 25 g Powdered milk ⅓ cup/ 75 mL 1 serving Milk and Alternatives (to make 1 cup/ 250 mL) Buttermilk 1 cup/ 250 mL 1 serving Milk and Alternatives

Goat milk, fortified 1 cup/ 250 mL 1 serving Milk and Alternatives Block cheese (cheddar, 1 ½ oz/ 50 g 1 serving Milk and Alternatives Mozzarella, Swiss)

Standard Food Number of Canada’s Food Item Portion Sizes Food Guide Servings 1-2 slices Cheese slice ½ serving Milk and Alternatives 1 oz/ 30 g Cottage cheese or quark ½ cup/ 125 mL ½ serving Milk and Alternatives cheese #8 scoop ½ cup/ 125 mL Yogurt (plain and flavoured) ¾ serving Milk and Alternatives #8 scoop Yogurt drink ¾ cup/ 175 mL 1serving Milk and Alternatives 6 oz/ 175 g Kefir 1 serving Milk and Alternatives ¾ cup/ 175 mL Paneer 1 ½oz/ 50 g 1 serving Milk and Alternatives Pudding/custard ½ cup/ 125 mL 1 serving Milk and Alternatives (made with milk) #8 scoop ½ cup/ 125 mL Frozen yogurt, low fat ¼ serving Milk and Alternatives #8 scoop Meat and Alternatives

Bacon 3 slices ¼ serving Meat and Alternatives

Breakfast ham 1 oz/ 30 g ½ serving Meat and Alternatives Breakfast sausage 2 links ½ serving Meat and Alternatives (½ oz/ 15 g each) Egg (boiled or poached) 1 large ½ serving Meat and Alternatives ¼ cup/ 60 mL Egg (scrambled) ½ serving Meat and Alternatives #16 scoop Omelet, made with 2 eggs 1 1 serving Meat and Alternatives

Peanut butter 1 package/1 Tbsp/ 15 mL ½ serving Meat and Alternatives Legumes ½ cup/ 125 mL ¾ serving Meat and Alternatives (beans, lentils, dried peas) 4 oz portion server ¼ cup/ 60 mL (as snack) Hummus ¼ serving Meat and Alternatives 2 oz portion server ½ cup/ 125 mL Tofu ¾ serving Meat and Alternatives 4 oz portion server Roast meats 23 oz/ 6090 g 1 serving Meat and Alternatives (beef, pork, turkey)

Standard Food Number of Canada’s Food Item Portion Sizes Food Guide Servings 1 patty Salisbury steak 1 serving Meat and Alternatives 23 oz/ 6090 g 1 slice Meatloaf (about 2 x 4 x ½ inch/ 1 serving Meat and Alternatives 5 x 10 x 1 ½ cm slice) ¼ cup/ 60 mL Meat sauce ½ serving Meat and Alternatives 2 oz portion server 5 meatballs Meatballs 1 serving Meat and Alternatives (½ oz/ 15 g each) Baked ham 23 oz / 6090 g 1 serving Meat and Alternatives 1 sausage Sausage 1 serving Meat and Alternatives (23 oz/ 6090 g) 1 chop Pork chop 1 serving Meat and Alternatives 23 oz/ 6090 g 1 breast Chicken breast 1 serving Meat and Alternatives 23 oz/ 6090 g 2 drumsticks Chicken drumstick 1 serving Meat and Alternatives 23 oz/ 6090 g 1 leg and thigh Chicken leg and thigh 1 serving Meat and Alternatives 23 oz/ 6090 g 2 strips Chicken strips 1 serving Meat and Alternatives 23 oz/ 6090 g Fish 1 piece 1 serving Meat and Alternatives (salmon, cod, tilapia, etc.) 23 oz/ 6090 g Mixed Dishes

Fruit and yogurt smoothie 1 cup / 250 mL 1 cup/ 250 mL Soup (cream or broth) 8 oz portion server 1 cup/ 250 mL Stew / Chili 8 oz portion server See Appendix 2I: 1 cup/ 250 mL How to Calculate Canada’s Casserole 8 oz portion server Food Guide Servings for Mixed ¾ cup/ 175 mL Dishes. Chicken cacciatore 6 oz portion server 1 cup/ 250 mL Lasagna (meat or vegetarian) 8 oz portion server 1 whole Sandwich ½ whole (as snack)

Standard Food Number of Canada’s Food Item Portion Sizes Food Guide Servings Mixed Dishes 1 whole bun (1 oz/ 35 g) + Hamburger 1 patty (23 oz/ 6090 g) 1 piece Pizza (4 inch/ 10 cm slice) See Appendix 2I: 1 cup/ 250 mL How to Calculate Canada’s Shepherd’s pie 8 oz portion server Food Guide Servings for Mixed 1 piece (4 inch/ 10 cm slice) Dishes. Quiche 3 oz/ 90 g Perogies 3 (3 oz/ 90 g)

Desserts 1 small Muffin 2 servings Grain Products (2 ½ oz/ 70 g) ½ slice Loaf (e.g., banana loaf) ½ serving Grain Products (1 inch/ 2 ½ cm thick) ½ cup/ 125 mL Frozen yogurt ¼ serving Milk and Alternatives #8 scoop ½ cup/ 125 mL Milk pudding 1 serving Milk and Alternatives #8 scoop ½ cup/ 125 mL Custard (made with milk) 1 serving Milk and Alternatives #8 scoop ½ cup/ 125 mL Mousse #8 scoop The number of Food Guide servings provided by these menu ½ cup/ 125 mL Fruit crumble/crisp/cobbler items will depend on the recipe, 4 oz portion server preparation method or product 1 bar Cereal bar brand. Choose recipes that   (1 1 ½ oz/ 30 38 g) contain more fruit and/or milk 1 square Square and limited amounts of fat and 2 x 2 x 1 inch/ 5 x 5 x 2 ½ cm sugar. 2 small cookies See Appendix 2C, Nutrition and (2 ½ inches/ Cookie Menu Planning Resources for 6 cm diameter each) tips on making foods with less 1-1 ½ oz/ 3038 g fat and sugar.

High fat, sugar, and salt foods are not part of Canada’s Food Guide. Offer higher fat and/or sugar desserts such as ice cream, cake, and pastries least often. Always provide another healthier dessert choice such as fruit or yogurt.

Conversions and Equivalents

Volume 60 drops = 1 tsp Equivalents for 1 Tbsp (15 mL) = 3 tsp = 0.5 fl oz Liquids ⅛ cup (30 mL) = 2 Tbsp = 1 fl oz ¼ cup (60 mL) = 4 Tbsp = 2 fl oz ⅓ cup (80 mL) = 5 Tbsp + 1 tsp = 2.65 fl oz ⅜ cup (90 mL) = 6 Tbsp = 3 fl oz ½ cup (125 mL) = 8 Tbsp = 4 fl oz ⅝ cup (150 mL) = 10 Tbsp = 5 fl oz ⅔ cup (160 mL) = 10 Tbsp + 2 tsp = 5.3 fl oz ¾ cup (175 mL) = 12 Tbsp = 6 fl oz ⅞ cup (210 mL) = 14 Tbsp = 7 fl oz 1 cup (250 mL) = 16 Tbsp = 8 fl oz ½ pint (250 mL) = 1 cup = 8 fl oz 1 pint (480 mL) = 2 cups = 16 fl oz 1 quart (960 mL) = 2 pt = 32 fl oz 1 gallon = 4 qt = 128 fl oz

Equivalent 32 oz = 2 lb = 907 g Weights 16 oz = 1 lb = 454 g 12 oz = ¾ lb / 0.75 lb = 340 g 8 oz = ½ lb / 0.50 lb = 227 g 4 oz = ¼ lb / 0.25 lb = 113 g 1 1 oz = /16 lb / 0.063 lb = 28 g 2.2 lb = 1000 g = 1.0 kg

Scoop Sizes / No. 6 = 6 oz = ⅔ cup (160 mL) Volume Measure No. 8 = 4–5 oz = ½ cup (125 mL) No. 10 = 3–4 oz = ⅜ cup (90 mL) No. 12 = 2 ½3 oz = ⅓ cup (80 mL) No. 16 = 2–2 ½ oz = ¼ cup (60 mL) No. 20 = 1 ¾ oz = 3 ⅓ Tbsp (50 mL) No. 24 = 1 ⅓ oz = 2 ⅔ Tbsp (40 mL) No. 30 = 1–1 ¼ oz = 2 Tbsp (30 mL) No. 40 = ¾ oz = 1 ⅔ Tbsp (25 mL) 9 No. 60 = /16–½ oz = 3 ¼ tsp (16 mL)

Ladles / Portion 1 oz = ⅛ cup = 30 mL Servers 2 oz = ¼ cup = 60 mL 3 oz = ⅜ cup = 90 mL 4 oz = ½ cup = 125 mL 6 oz = ¾ cup = 175 mL 8 oz = 1 cup = 250 mL

*Use ladles for serving soups, stews, creamed dishes, sauces, gravies and other liquid products.

Use portion servers (solid or perforated) for portioning solids and semi-solids such as fruits and vegetables and condiments.

Conversions and Equivalents (Continued)

Steam Table Pan Size Portion Size Number Pan Capacity of Portions 12 x 20 x 2 ½ inches/ ½ cup/ 125 mL (4 oz ladle or No. 8 scoop) 64 30 x 50 x 6 cm ⅜ cup/ 90 mL (3 oz ladle or No. 10 scoop) 80 (capacity = 2 gal/ 7 ½ L) ⅓ cup/ 80 mL (No. 12 scoop) 96 ¼ cup/ 60 mL (2 oz ladle or No. 16 scoop) 128

12 x 20 x 4 inches/ ½ cup/ 125 mL (4 oz ladle or No. 8 scoop) 112 30 x 50 x 10 cm ⅜ cup/ 90 mL (3 oz ladle or No. 10 scoop) 135 (capacity = 3 ½ gal/ 13 L) ⅓ cup/ 80 mL (No. 12 scoop) 168 ¼ cup/ 60 mL (2 oz ladle or No. 16 scoop 224

12 x 20 x 6 inches/ 30 x ½ cup/ 125 mL (4 oz ladle or No. 8 scoop) 160 20 x 15 cm ⅜ cup/ 90 mL (3 oz ladle or No. 10 scoop) 200 (capacity = 5 gal/ 19 L) ⅓ cup/ 80 mL (No. 12 scoop) 250 ¼ cup/ 60 mL (2 oz ladle or No. 16 scoop 320

Cutting Diagrams for Portioning

See below for examples of cutting diagrams for portioning. For packaged items, please follow manufacturer’s instructions for cutting to achieve an appropriate portion size for serving.

For 25 servings make 4 cuts across and 4 cuts down.

For 50 servings make 4 cuts across and 9 cuts down (make the longest cuts first).

2.4 Planning Healthy Meals in Smaller Supportive Living Sites Computer Tip! This section is for smaller supportive living sites (with less than Click on each hyperlink 11 residents), that provide meals on a smaller scale as to take you to the website compared with larger supportive living sites. The information for more information. will help you plan and prepare healthy meals for residents in a smaller, home-like environment.

It is important to ensure the correct portion sizes are available at each meal and snack. How much a resident eats is as important as what they eat. Below are some tips on ideal portion sizes for meals and snacks.

Meals

If possible, food should be measured to provide standardized portion sizes. Below is a list of suggested equipment to manage standardized portion sizes.  Dry measuring cups or numbered scoops (#6, #8, #16 etc)  Liquid measuring cup  Measuring spoons  Food scale

Common household objects can also be used as visual guides to serving sizes from Canada’s Food Guide. Please refer to Appendix 2C, Nutrition and Menu Planning Resources for the handout on healthy food portions to learn more about the healthy plate and portion sizes.

If standardized portion equipment is unavailable, here are some tips to help manage portion sizes:  Use medium sized 23 cm/ 9 in plates (about the size of a Frisbee®) to help provide a healthy serving. If a large plate must be used, fill only the middle of the plate. Do not fill a larger plate right to the edge with food.

 ½ Plate Vegetables and Fruit: Fill half of the plate with a variety of colourful Vegetables and Fruit. Fruit can also be used as a dessert choice to Meat and Alternatives round out the meal. Milk and ¼ plate Alternatives  ¼ Plate Meat and Alternatives: Fill a quarter of Vegetables the plate with lower fat Meat and Alternatives. and Fruit This food group provides good sources of protein. Grain ½ plate Products  ¼ Plate Grain Products: Fill a quarter of the plate ¼ plate with Grain Products. Serve whole grain more often to provide residents with more fibre. Fruit  Complete the meal with a serving of Milk and Alternatives. For example, 1 cup (250 mL) of lower-fat milk.

Snacks

Snacks can be used to ensure the total number of servings from each group on Canada’s Food Guide are available each day.

To provide residents with healthy snack options:  Ensure each snack provides at least one of the four food groups from Canada’s Food Guide.  Include a healthy drink at each snack. Offer water, lower fat milk or fortified soy beverage as a drink most often. Juice should be limited. If provided, serve only 100% fruit juice or low-sodium vegetable juice in ½ cup / 125 mL portions, no more than once/day.  Space snacks evenly between meals.  Leave a bowl of prewashed fresh fruit on the counter.  Have fresh vegetables cut and readily available.  Baked goods (such as muffins and cookies) should be provided least often. If they are provided, also always offer a healthier choice such as fruit and yogurt, and ‘light’ or ‘partly-skimmed’ cheese.

For more healthy snack ideas, see the Nutrition and Menu Planning Resources list in Appendix 2C.

Bagged Meals

Residents may be away from home during meal times for many reasons, such as day programs or medical appointments. To help residents meet nutrition needs on days away from home, a well-balanced bagged meal should be available to take along.

The bagged meal should include a sandwich (or wrap, pita, etc.), fruit, beverage, and a dessert (if appropriate). Try to include the following:

Sandwich/Wrap/Pita:  Meat and Alternatives: o Choose lean and low sodium protein sources, such as peanut butter, canned fish, chicken, turkey, or egg fillings. o If using canned meat/chicken or fish, choose no salt-added brands or rinse salted products under water to decrease sodium content.  Grain Products: o Choose whole grain breads, buns, small bagels, pitas, tortillas, or crackers.  Spreads or condiments: o Choose from cranberry sauce, mustard, horseradish, jam, jelly, reduced fat mayonnaise, salad dressing (low sodium), or low-fat sour cream.  Toppings: o Choose from bean sprouts, bell peppers, cucumber, dark green lettuce (such as romaine or spinach), onions, roasted red peppers, or tomato slices.  Add flavour: o Choose from black pepper, curry powder, no salt added herb seasonings, red pepper flakes, sweet pickle relish, lemon juice, or vinegar.

 Vegetable or Fruit side: o Choose carrot or celery sticks, cucumber slices, snap peas, cauliflower, or broccoli. Fresh, frozen or canned fruit (packed in water or fruit juice), or dried fruit without added sugar are also great additions.

Build Your Own Bagged Meal Option 1 Option 2 Option 3 Option 4 Option 5 Meat and Turkey Chicken Egg Salad Tuna Salad Roast Beef Alternative Grain Small whole Whole grain Whole grain Pita Hamburger roll Product wheat bagel flour tortillas rye bread Vegetables Banana Carrot sticks Canned fruit Celery sticks Cucumber and Fruit with hummus with hummus slices Beverage Water or 100% Water or 100% Water or 100% Water or 100% Water or 100% fruit juice or fruit juice or fruit juice or fruit juice or fruit juice or low-fat milk or low-fat milk or low-fat milk or low-fat milk or low-fat milk or fortified soy fortified soy fortified soy fortified soy fortified soy beverage beverage beverage beverage beverage Desserts Milk based Canned fruit Granola bar Milk based Applesauce pudding pudding Spread or Cranberry Reduced fat Reduced fat Reduced fat Horseradish Condiment sauce mayonnaise mayonnaise mayonnaise and mustard included in egg included in salad tuna salad

Bagged meals provided to residents should be refrigerated after preparation and until served to ensure food safety. If refrigeration is not available, an ice pack can be included in the bagged meal. Refer to the Food Safety section on page 10.

Note: If the resident is on a special diet, please refer to the Menu Substitutions and Preparing Special Diets Section in this toolkit starting on page 52.

2.5 Budgeting Computer Tip! Planning ahead helps you make the most out of your food Click on each hyperlink budget. to take you to the website for more information. Plan Ahead1

 Food can be purchased from retail grocery stores, wholesale stores, or from a supplier. An up-to-date grocery list or order sheet can help with planning. Using a list can prevent extra grocery shopping later for forgotten items. A list can also be used to check deliveries if food is received from a supplier. A Sample Grocery List has been included in Appendix 2B.  If you operate more than one site, purchase all food in the same trip, instead of making a separate trip for each site.  Some grocery stores offer 1015% off your total bill if food is purchased on certain days of the month (often it is the first Tuesday of the month). Check with local grocery stores to find out about special shopping days.

In the Store1

 Whenever possible, purchase food at a wholesale store. Buying basic food and supplies such as pasta, potatoes, rice, flour, oatmeal, dried fruit, nuts, seeds, and beans in bulk can save money.  Check the “best before” or “expiry” date on perishable foods. Only purchase items which can be used before the best before or expiry date.  Purchase food on sale when possible. If the sale item is not available, ask for a “rain check”. A “rain check” can be used to purchase the food at a later date for the sale price.  Compare prices between name brands and store brands, and package sizes. Store brands are often available for a lower price.

Storing Food

Proper food storage can help food to last longer. Use the following tips:  Put groceries that need to be stored in the fridge and freezer away right after shopping or receiving them from your supplier.  Follow the “First In, First Out (FIFO)” rule. This means using foods with the shortest expiry dates first, and storing newer stock at the back to be used later. This can help reduce food waste, which saves money and time.  Please refer to Health Canada’s General Food Safety tips on Safe Food Storage for detailed information for proper food storage.

Document

T3.0

Substitutions

and Special

Diets

itle Goes

Here 51

3.1 Overview Computer Tip! Click on each hyperlink Menu substitutions occur for many different reasons, such as to take you to the website product unavailability, incorporating seasonal foods into the for more information. menu, ordering/shipping errors, preparation issues, equipment problems and/or adjustment for special diets.

The goal when making menu substitutions is to provide foods that contain the same nutrients. Foods within the same food group on Canada’s Food Guide contain similar nutrients. Most often, using another food item from the same food group on Canada’s Food Guide will meet the needs of residents on regular diets. For example, if roast chicken is not available, another food from the Meat and Alternatives food group could be used, such as roast turkey or beef. If green peas are not available, any other dark green vegetable, from the Vegetables and Fruits food group, such as asparagus or broccoli can be used. However, adaptation for special diets is more complex and food service staff will need an understanding of special diets to help meet resident’s needs.

For more information see What is a Food Guide Serving? Please refer to Appendix 2L Serving Sizes from Canada’s Food Guide.

3.2 Special Diets

This section will provide guidance on how to make menu substitutions, and meet the special diet needs of residents.

The regular menu may need to be adapted to meet the needs of residents with:  Diets for disease management  Food allergies or intolerances  Difficulty chewing and/or swallowing

When the regular menu changes for any of the above reasons, these diets are called special diets. Special diets altered to help with chewing and/or swallowing difficulties are collectively called texture modified diets. Texture modified diets require changing the texture of the foods on the regular menu, or choosing appropriate textured foods.

A dietitian can provide more information on any type of special diet to either the individual, and/or the facility.

Some residents may choose not to follow their special diet. A Managed Risk Agreement could be considered for these residents. This is an arrangement between a resident and a supportive living site that shows that the resident is aware of the risks of their choices and the site agrees to respect the resident’s decision and their right to take risks. The resident should be informed of all possible risks and benefits.

Diets for food allergies or intolerances and disease management are considered the main diet, and are ordered first. Texture modified diets, are divided into primary textures, and additional texture modifications. When ordering, a primary texture is ordered after the main diet is ordered; and if needed, additional texture modifications are added.

Examples of special diets included in this toolkit are:

Diets for disease management (Main Diet)  Diabetes, Heart Healthy and Low sodium  Kidney  Vegetarian  High Protein, High Calorie

Food allergies or intolerances (Main Diet)  Gluten free

Texture Modified Diets Primary Textures: Additional Texture Modifications:  Easy to Chew  Cut/Diced  Dysphagia Soft  Pureed Bread Products  Minced  No Mixed Consistencies  Pureed  Thick Fluids For more information on menu planning, please refer to How to Plan a Menu section (on page 16).

Diabetes, Heart Healthy and Low Sodium

A well-planned regular menu using Canada’s Food Guide eliminates the need for special diabetes, heart healthy and low sodium menus. A menu, based on the four food groups, includes meals and snacks prepared in a healthy way, with limited amounts of added fat, sugar and sodium.

For more information on making low sodium substitutions, please refer to Appendix 2F Low Sodium Substitutions.

Tips for Diabetes:

Though a special menu is not necessary considerations should be made for residents with diabetes. Sugar- reduced items should be available, to help to promote good blood sugar control. This includes providing:

 Sugar substitutes instead of granulated or brown sugar.  Condiments such as sugar-reduced or no sugar added spreads, syrups, and spices.  Lower sugar beverages such as water, tea, coffee, and sugar free soft drinks (for example, sugar free drink flavoured waters like sugar free lemonade).  Sugar- reduced dessert options, such as those listed below.

Dessert ideas for a Diabetic Diet Low fat, sugar reduced whole grain muffins, cookies or other baked goods in appropriate portions. See section 2.3 Standardized Portion Sizes. Sugar free gelatin or mousse desserts No sugar added custard No sugar added milk pudding No sugar added, fat free or low fat (0-2% M.F.) yogurt or frozen yogurt Fresh fruit or fruit canned in water or juice

Residents with diabetes may or may not need snacks. This will vary depending on the type of diabetes, medicines used to manage blood glucose and activity level of the individual. Snacks may be required if meals are 6 or more hours apart, but not when meals are closer together. The need for an evening snack will vary. If snacks are required, some healthy ideas include:

 sandwich (meat and/or cheese filling)  yogurt and fresh fruit  milk and plain cookies (arrowroot, digestives)  cheese and whole grain crackers with unsalted tops  peanut butter and whole grain toast  no salt added cottage cheese and fruit  unsweetened fruit sauce (any flavour) and piece of cheese  no sugar added cereal and milk

See section 2.3 (page 36) for information on Standardized Portion Sizes for these foods

Kidney

A kidney (renal) diet may be needed for residents with kidney disease and will vary depending on the individual’s kidney function. The amounts of nutrients such as protein, sodium, potassium, phosphorous, or fluid needed may be different for each person. A regular menu can be modified to meet the resident’s dietary needs. Each resident can choose the recommended foods and the portions from the modified regular menu to meet their own dietary needs.

The following information provides general guidance for food choices on a kidney diet that should be available so that residents can make choices as per their dietary needs.

Protein

The meal plan provided by the dietitian to a resident with kidney disease will specify the amount of protein needed per day.

Lean meats (beef, pork), poultry, fish, or eggs are the best sources of protein for these individuals. Beans, lentils, nuts and nut butters, seeds (pumpkin, sunflower), split peas, tofu, milk, yogurt, cheese, and soy beverages also contain protein.

Sodium

Individuals may have a specific sodium limit provided by their doctor or dietitian.

Canada’s Food Guide recommends choosing and preparing foods with little or no added salt (sodium). A lower salt menu is healthy for all residents, especially those with heart disease, high blood pressure or diabetes.

Refer to Appendix 2F for Low Sodium Substitutions.

Potassium (Kidney)

Some residents with kidney disease may need to limit the servings of higher potassium foods they eat. They may be allowed smaller amounts of these foods depending on the diet ordered by their health professional. The chart which follows shows foods which are lower and higher in potassium. Offer lower potassium food choices daily.

Foods lower in potassium Foods higher in potassium Vegetables and Fruit  Apple  Banana  Apple juice, grape juice, or cranberry 100% juice  Beets blend  Brussels sprouts  Bell pepper  Cantaloupe  Berries  Nectarine  Cabbage  Orange or tomato juice  Canned pears, peaches or fruit cocktail  Orange, navel  Carrot  Parsnips  Cauliflower  Potatoes: baked, whole boiled, hash  Coconut, raw or dried flakes browns, scalloped or fries  Corn  Prunes  Cucumber  Raisins  Garlic  Tomatoes, tomato sauce or chili sauce  Grapes, raw  Winter squash (acorn, butternut) and  Green or yellow beans, snow peas pumpkin  Honeydew  Lettuce, all varieties  Mandarin orange Tip: To help lower potassium: Peel potatoes  Mushroom and cut into small cubes or shred before  Onion boiling. Discard the water.  Peach  Pear  Pineapple  Summer squash, zucchini  Turnip  Watermelon Grain Products  Cooked oatmeal, cream of wheat  Cereals made with whole bran and foods  Enriched pasta made with these cereals  White, 60% whole wheat, light rye, or sourdough  Brown or wild rice breads  Whole grain products  White enriched grain products  White rice

Potassium (Kidney) (Continued)

Foods lower in potassium Foods higher in potassium Milk and Alternatives All milk products contain potassium. This includes fluid milks, soy beverages, yogurt, pudding, and ice cream. Most individuals following a kidney diet can have 1 cup / 250 mL or less of these milk products per day.  Cheese Meat and Alternatives  All lean meats, poultry, and fish with little to no  Canned beans, drained and rinsed (can added salt have up to ½ cup/ 125 mL cooked per  Tofu week)  Fried eggs  Fried or battered meat, poultry, or fish  Nuts or seeds  Nut butters with hydrogenated oils  Processed meats  Ribs  Salted meats Other Foods  Black tea and coffee, water  Chocolate  Jam, jelly, honey, margarine or butter  Salt substitutes with potassium chloride  Lemon juice  Pepper or low sodium herb and spice blends  Sherbet, sorbet, or popsicles  Sugar cookies, shortbread cookies, vanilla wafers or vanilla, lemon, or angel food cake  Unsalted popcorn or pretzels, rice cakes

Phosphorous (Kidney)

Some residents with kidney disease may need to limit the number of higher phosphorus foods they eat. They may be allowed smaller amounts of these foods depending on the diet ordered by their health professional. The chart which follows shows foods which are lower and higher in phosphorus. Offer lower phosphorus food choices with each meal.

Foods lower in phosphorus Foods higher in phosphorus Vegetables and Fruit  Fresh, frozen, or canned vegetables and fruit

Grain Products  60% whole wheat bread and bread products (French,  Bran and oat bran muffins Italian, white bread, pita bread)  Brown or wild rice  Cold cereal  Instant hot cereal, rolled oats  Muffins, homemade plain, berry, or oatmeal  Pancake or waffles (frozen or from  Cooked wheat cereal mix)  Crackers (soda crackers, Melba toast, whole wheat  Whole bran products unsalted)  Whole grain cereals  Pasta, white  Whole wheat pasta  White rice or couscous Milk and Alternatives All milk products contain phosphorus. This includes fluid milk, soy beverages, yogurt, puddings, cheeses and ice cream. Most individuals following a kidney diet can have 1 cup/ 250 mL or less of all milk products per day. 1 oz/ 30 g of cheese (block cheddar, mozzarella or Swiss) can be offered in place of ½ cup/ 125 mL of these milk products.  Processed cheese slices and spreads Meat and Alternatives  All lean meats, poultry, and fish with little to no  Canned beans, drained and rinsed (can added salt, eggs have up to ½ cup/ 125 mL cooked per  Canned salmon, with bones removed week)  Nuts and nut butters  Organ meats (example: liver)  Processed meats (sausage, bacon, ham, hot dogs, salami, pepperoni)  Salmon, canned with bones Other Foods  Jam, jelly  Hot chocolate mix, cocoa  Sherbet  Pizza  Sugar substitutes, sugar (white or brown), honey  Sour cream and whipping cream  Chocolate  Eggnog

Fluids (Kidney)

Some residents with kidney disease (and other health conditions, such as heart disease) may need to limit their fluid intake. A daily fluid limit may be advised by the doctor or dietitian.

What are fluids?

Anything liquid at room temperature is a fluid.

Examples of fluids include:

 All drinks (includes water, milk, juice, coffee, tea, and pop)  Crushed ice and ice cubes  Gelatin desserts  Ice cream and sherbet  Juice from canned fruit  Nutrition supplement drinks  Popsicles  Sauces and gravy  Soups and broth

Fluids provided at meals, snacks and to take pills should be considered if the resident has a daily fluid limit.

Kidney-Friendly Bagged Meals

All residents should receive three regular meals (and snacks as necessary) each day to meet their nutrition needs. Those with kidney disease may have medical appointments, be receiving dialysis or be enrolled in day programs, and may be offsite during meal times. It is important to provide a well-balanced bagged meal in these cases.

A bagged meal should include a sandwich (or wrap, pita, etc.), fruit (lower potassium, if appropriate), beverage and a dessert. The following are guidelines for kidney-friendly bagged meals:

Sandwich/Wrap/Pita  Meat and Alternatives: o Choose lean, fresh cooked and low sodium protein sources such as chicken, turkey breast, roast beef, pork, or fish, or healthy alternatives such as peanut butter or egg fillings.

o Avoid processed meats (hot dogs, bacon, bologna, salami, sausages, ham, pepperoni, etc).

o If using canned meat/chicken or fish, choose no-salt-added varieties, or rinse salted products thoroughly to reduce salt content.

 Grain Products: o Choose from: bagels, dinner rolls (white), flour tortillas, French bread, hamburger buns, Italian bread, light rye, pita bread, rice cakes, sourdough, or white bread.

 Spreads or condiments: o Choose from: cranberry sauce, low-fat cream cheese, mustard, horseradish, jam, jelly, ketchup (limit serving to 1 Tbsp/ 15 mL), low fat mayonnaise, salad dressing (low sodium), or low fat sour cream.

 Toppings: o Choose from: bean sprouts, bell peppers, cucumber, dark green lettuce (romaine and spinach), onions, roasted red peppers, tomato slice (1), or water chestnuts.

 Add flavour: o Choose from: black pepper, curry powder, flavoured oil, mixed herb seasoning, olive oil, red pepper flakes, sweet pickle relish, or vinegar.

Build Your Own Bagged Meal (Kidney)

Option 1 Option 2 Option 3 Option 4 Option 5 Meat and Turkey Chicken Egg salad Tuna salad Roast beef Alternatives Small bagel White flour Bread Pita (white) Hamburger (white) tortillas (60% whole bun (white) Grain Products wheat or white) Vegetables and Fruit Apple or Fruit cocktail Pear or Grapes or Peach or (drained canned fruit mandarin or grapes pineapple berries applesauce is acceptable) oranges Water, 100% Water, 100% Water, 100% Water, Water, fruit juice, fruit juice, fruit juice, 100% fruit 100% fruit Beverage low-fat milk, low-fat milk, low-fat milk, juice, low- juice, low- or fortified or fortified or fortified fat milk, or fat milk, or soy beverage soy beverage soy beverage fortified soy fortified soy beverage beverage Vanilla Sugar Graham Angel food Lemon cake Desserts wafers cookies crackers cake Cranberry Reduced fat Reduced fat Reduced fat Horseradish Spread or sauce mayonnaise mayonnaise mayonnaise Condiment or mustard

Kidney Diet Websites Below is a list of websites helpful in menu planning for a kidney diet:

 Kidney Foundation of Canada  Kidney Community Kitchen  National Kidney Foundation: List of Cookbooks  Alberta Kidney Disease Network  Renal Web – The Well Nourished Patient

Vegetarian

An individual may choose to follow a vegetarian diet for health, ethical, environmental or religious reasons. Below is a list of foods included on common vegetarian diets.

Type of Vegetarian Diet Includes: Excludes: Vegan All foods of animal origin, including red meats, poultry, fish, eggs, honey, milk and milk products Lacto Milk and milk products Red meats, poultry, fish and eggs Lacto-Ovo Eggs, milk, and milk products Red meats, poultry and fish Semi-Vegetarian May include some fish, and maybe even small amounts of meat and poultry

Examples of vegetarian choices from the Meat and Alternatives, and Milk and Alternatives groups on Canada’s Food Guide are shown below. The type of vegetarian diet will determine which alternatives are options.

Food Item Standardized Portion Size Meat and Alternatives Beans, lentils, or dried peas, cooked or canned ½ cup/ 125 mL Hummus ¼ cup/ 60 mL Egg 1 large Tofu ½ cup/ 125 mL Nuts or seeds, shelled ¼ cup/ 60 mL Peanut butter or nut butter 1 tbsp/ 15 mL Cooked fish, shellfish, poultry and lean meat 23 oz/ 6090 g Milk and Alternatives Milk (whole 3.25%, 2%, 1%, or skim) 1 cup/ 250 mL Yogurt (plain and flavoured) ½ cup/ 125 mL Cheese (cheddar, mozzarella, Swiss) 1 ½ oz/ 50 g Soy beverage, calcium and vitamin D fortified 1 cup/ 250 mL Almond/Rice beverage, calcium and vitamin 1 cup/ 250 mL D fortified (Note: Almond/Rice beverages contain little protein)

Sample Lacto Ovo Vegetarian Menu Plan

Below is a one day vegetarian menu that has been adapted from the Example of a Completed Regular Poached Cod Tail with Menu Plan on page 32. Changes made to the regular menu to fit the vegetarian diet are shown in bold. Mashed Potato and Minced Green Beans Canada’s Food Meal Menu Item Portion Size Guide Servings Coffee/tea and water 1 cup/ 250 mL

100% apple juice ½ cup/ 125 mL 1 Vegetables and Fruit Banana 1 medium 1 Vegetables and Fruit Bran cereal with raisins ¾ cup/ 175 mL 1 Grain Products Whole grain toast 2 slices (1 oz/ 35 g each) 2 Grain Products Breakfast Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Peanut butter 1 package (1 Tbsp/ 15 mL) ½ Meat and Alternatives

Water and coffee/tea 1 cup/ 250 mL Lentil soup 1 cup/ 250 mL ½ Meat and Alternatives Crackers, saltines 1 package (2 crackers) ¼ Grain Products Baked beans ¾ cup/ 175 mL 1 Meat and Alternatives Pita bread, whole grain whole 1 pita (2 oz/ 70 g) 2 Grain Products

wheat Romaine lettuce, tomato in 1 piece of romaine ½ Vegetables and Fruit

Lunch wrap 2 slices of tomato Carrot sticks 56 pieces 1 Vegetables and Fruit (3 inches/ 7 ½ cm long) Tossed salad ½ cup/ 125 mL ½ Vegetables and Fruit Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Grapes ½ cup/ 125 mL 1 Vegetables and Fruit

Water and coffee/tea 1 cup/ 250 mL

Orange 1 medium 1 Vegetables and Fruit Oatmeal cookie 2 small cookies 1 Grain Products (11 ½ oz/ 3038 g total) Snack

Afternoon

Sample Lacto Ovo Vegetarian Menu Plan (Continued)

Canada’s Food Meal Menu Item Portion Size Guide Servings Water and coffee/tea 1 cup/ 250 mL Tofu stir fry ¾ cup/ 175 mL 1 Meat and Alternatives Brown rice ½ cup/ 125 mL 1 Grain Products Broccoli and carrots (in stir-fry) ½ cup/ 125 mL 1 Vegetables and Fruit

Dinner Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Baked apple with cinnamon 1 medium 1 Vegetables and Fruit Vanilla pudding ½ cup/ 125 mL 1 Milk and Alternatives

Water and coffee/tea 1 cup/ 250 mL ¼ cup/ 60 mL ¼ Meat and Alternatives ing Hummus Whole wheat crackers 5 each ½ Grain Products Snack

Even

Canada’s Food Guide Number of Food Groups servings Provides the minimum number of Vegetables and Fruit 8 servings each day through meals Grain Products 7 ¾ and snacks. Milk and Alternatives 4 Meat and Alternatives 3 ¼ Provides a minimum of six cups of Fluid 9 ½ cups/ fluids daily and at least one cup at 2375 mL each meal and snack.

Gluten-Free

What is a gluten-free diet?3

A gluten-free diet is one that completely avoids the following grains:  Wheat  Rye  Barley

These grains contain a protein called gluten that can damage the small intestine in people who have celiac disease. When this happens, important nutrients are not absorbed into the body. This may lead to a variety of nutrient deficiencies.

If an individual has celiac disease, then the gluten-free diet should be strictly followed as it is the only way to keep the intestine healthy and reduce the risk of health problems.

What foods can be eaten on a gluten-free diet?

There are many foods that can be eaten on a gluten-free diet; some individuals can even tolerate oats in small amounts. A dietitian can provide dietary guidance for the residents or the supportive living facility. For more information on which foods to choose and avoid on a gluten-free diet, refer to the handout (Gluten-Free Diet) in Appendix 2C, Nutrition and Menu Planning Resources.

Gluten-free baking and cooking

When cooking or baking, it is important to keep foods gluten-free. Even a crumb from gluten-containing bread can affect the individual. Baking or cooking surfaces should be clean and gluten-free. Use these tips to keep foods from coming in contact with gluten (becoming “cross-contaminated”).

To avoid cross contamination:

 Buy flours labeled gluten-free. Flours without the gluten-free claim may be cross-contaminated during production.

 Store all gluten-free products separately. Have a separate cupboard and containers for gluten- free products.

 Use clean equipment for gluten-free food preparation. Make sure all pots, pans, utensils, utensil drawers and counter spaces are clean before using. Use a separate strainer for gluten-free foods.

 Prepare and cook gluten-free foods separately from regular foods. Glass or metal dishes are best. Avoid wooden cutting boards and utensils.

See the Canadian Celiac Association for more resources about gluten-free eating.

 Have a separate toaster. It’s best to buy a new toaster and use it only for gluten-free bread. A shared toaster will have crumbs from gluten containing breads. Another option is to use toaster bags. These re-useable bags cover bread so it can be placed in any toaster. They are available in some gluten-free stores and online.

 Use separate condiment containers. Have separate containers for items such as margarine, jam, peanut butter, honey, mayonnaise, relish, and mustard; or serve food with individually wrapped condiments. A shared dish or jar may have crumbs from gluten-containing foods.

Cooking and Baking Resources

Cooking and baking with gluten-free flours can be a challenge and often requires experimenting and practice. For ideas and tips on adapting recipes or substituting with gluten-free flours, visit the In the Kitchen section of the Canadian Celiac Association website.11 The association offers reliable information about the gluten-free diet.

Sample Gluten-Free Menu Plan

Below is a one day gluten-free menu that has been adapted from the Example of a Completed Regular Menu Plan on page 32. Changes made to the regular menu to fit the gluten free diet are shown in bold.

Canada’s Food Meal Menu Item Portion Size Guide Servings Coffee/tea and water 1 cup/ 250 mL

100% apple juice ½ cup/ 125 mL 1 Vegetables and Fruit Banana 1 medium 1 Vegetables and Fruit Gluten-free cereal ¾ cup/ 175 mL 1 Grain Products Gluten-free toast 2 slices (1 oz/ 35 g each) 2 Grain Products Breakfast Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Gluten-free peanut butter 1 package (1 Tbsp/ 15 mL) ½ Meat and Alternatives

Water and coffee/tea 1 cup/ 250 mL Beef vegetable soup (made 1 cup/ 250 mL ½ Vegetables and Fruit with gluten-free soup base) Gluten-free crackers, saltines 1 package (2 crackers) ¼ Grain Products Turkey wrap 23 oz/ 6090 g 1 Meat and Alternatives (on gluten-free pita) lean turkey breast Gluten-free pita 1 whole (2 oz/ 70g) 2 Grain Products

Lunch Romaine lettuce, tomato in 1 piece of romaine ½ Vegetables and Fruit sandwich 2 slices of tomato Carrot sticks 56 pieces 1 Vegetables and Fruit (3 inches/ 7 ½ cm long) Tossed salad ½ cup/ 125 mL ½ Vegetables and Fruit Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Grapes ½ cup/ 125 mL 1 Vegetables and Fruit

Water and coffee/tea 1 cup/ 250 mL

Orange 1 medium 1 Vegetables and Fruit oon

n Gluten-free oatmeal cookie 2 small cookies 1 Grain Products (11 ½ oz/ 3038 g total) Snack

After

Sample Gluten-Free Menu Plan (Continued)

Canada’s Food Meal Menu Item Portion Size Guide Servings Water and coffee/tea 1 cup/ 250 mL Meatloaf (with gluten-free 1 slice (approx 2 x 4 x ½ 1 Meat and Alternatives or no breadcrumbs) inch/5 x 10 x 1 ½ cm)

Baked potato 1 medium 2 Vegetables and Fruit Green beans ½ cup/ 125 mL 1 Vegetables and Fruit Gluten-free bun 1 bun (1 oz/ 35 g) 1 Grain Products Dinner Milk/fortified soy beverage 1 cup/ 250 mL 1 Milk and Alternatives Baked apple with cinnamon 1 medium 1 Vegetables and Fruit Vanilla pudding made with ½ cup/ 125 mL 1 Milk and Alternatives cornstarch

Water and coffee/tea 1 cup/ 250 mL

ng Salmon salad sandwich ½ sandwich (11 ½ oz/ ½ Meat and Alternatives i 3045 g salmon salad)

Snack Gluten-free bread 1 slice (1 oz/ 35 g) 1 Grain Products Even

Canada’s Food Guide Number of Food Groups servings Provides the minimum number of Vegetables and Fruit 10 ½ servings each day through meals Grain Products 8 and snacks. Milk and Alternatives 4 Meat and Alternatives 3 Provides a minimum of six cups of Fluid 9 ½ cups/ fluids daily, and at least one cup at 2375 mL each meal and snack.

Total CFG Servings: High Protein, High Calorie Vegetables and Fruit 9 Grain Products 8.5 A high protein, high calorie diet is used to improve nutrition status and helps reduce the risk of malnutrition Milk and Alternatives 4 due to poor intake, decreased appetite, or weight loss. Protein provides building blocks for healing and Meat and Alternatives 3 keeping the immune system strong. Eating extra protein and calories can help a resident to maintain or gain weight and strength. Fluid 9 cups Tips to improve protein and calorie intake:

 Include a source of protein at each meal, from either the Meat and Alternatives or Milk and Alternatives food group. Choose foods such as meat, fish, poultry, nuts, eggs, cheese, or milk.

 Offer snacks between meals. A resident may not be able to eat a big meal at one sitting, but may eat more if offered food throughout the day.

 Replace lower calorie drinks such as water, tea, coffee, and broth with more calorie-dense options such as juice, milk, and cream-based soup.

 Use the high protein, high calorie recipes which follow.

Recipes to increase protein and calories

High Protein Milk

Ingredients: 4 cups Homogenized milk, 3.25% M.F. 1 L ½ cup Skim milk powder 125 mL ½ cup Cereal cream 12% M.F. 125 mL Directions: 1. Mix the ingredients and refrigerate overnight. 2. Use in place of milk in recipes. 3. Stir before using. Use in place of milk in recipes.

Makes 4 servings, (1 cup/ 250 mL)

Nutrition information per serving: 216 calories, 12 g fat, 7 g saturated fat, 0 g trans fat, 12 g protein, 17 g carbohydrate, 157 mg sodium, 413 mg calcium.

______

Super Pudding Ingredients: 2 cups Evaporated skim milk 500 mL 2 Tbsp Canola oil 30 mL 1 package Instant pudding mix (any flavour) 1 package 2 Tbsp Skim milk powder 30 mL Directions: 1. Blend the milk and oil a bowl or large measuring cup. 2. Add the pudding mix and skim milk powder, mix well. 3. Pour evenly into 4 small bowls.

Makes 4 servings (½ cup/ 125 mL)

Nutrition information per serving: 246 calories, 15 g fat, 7 g saturated fat, 0 g trans fat, 9 g protein, 18 g carbohydrate, 172 mg sodium, 355 mg calcium.

For links to additional resources about adding protein and calories, please see Appendix 2C, Nutrition and Menu Planning Resources.

Sample High Protein, High Calorie Menu Plan

Below is a one day high protein, high calorie menu that has been adapted from the Example of a Completed Regular Menu Plan on page 32. Changes made to fit the high protein, high calorie diet are shown in bold.

Canada’s Food Meal Menu Item Portion Size Guide Servings Coffee/tea and water 1 cup/ 250 mL 100% apple juice ½ cup/ 125 mL 1 Vegetables and Fruit

Banana 1 medium 1 Vegetables and Fruit Bran cereal with raisins ¾ cup/ 175 mL 1 Grain Products Whole grain toast with extra 2 slices (1 oz/ 35 g each) 2 Grain Products margarine Breakfast High Protein milk/ soy 1 cup/ 250 mL 1 Milk and Alternatives beverage Peanut butter 1 package (1 Tbsp/ 15 mL) ½ Meat and Alternatives

Water and coffee/tea 1 cup/ 250 mL Beef barley soup 1 cup/ 250 mL ½ Grain Products Crackers, saltines 1 package (2 crackers) ¼ Grain Products Turkey sandwich wrap 23 oz/ 6090 g lean turkey 1 Meat and Alternatives (made with mayonnaise) breast Pita bread, whole grain whole 1 whole (2 oz/ 70g) 2 Grain Products wheat, spread with extra margarine, mayonnaise or hummus

Lunch Romaine lettuce, tomato in 1 piece of romaine ½ Vegetables and Fruit wrap 2 slices of tomato Carrot sticks, served with 56 pieces 1 Vegetables and Fruit Ranch dip (3 inches/ 7 ½ cm long) Tossed salad ½ cup/ 125 mL ½ Vegetables and Fruit High Protein milk/ 1 cup/ 250 mL 1 Milk and Alternatives soy beverage Grapes ½ cup/ 125 mL 1 Vegetables and Fruit

Water and coffee/tea 1 cup/ 250 mL

Apple 1 medium 1 Vegetables and Fruit Cheddar cheese slice 1 ½ oz/ 50 g 1 Milk and Alternatives

Snack

Afternoon Afternoon

Sample High Protein, High Calorie Menu Plan (Continued)

Canada’s Food Meal Menu Item Portion Size Guide Servings Water and coffee/tea 1 cup/ 250 mL Meatloaf, served with extra 1 slice (approx 2 x 4 x ½ inch/ 1 Meat and Alternatives gravy 5 x 10 x 1 ½ cm ) Baked potato, served with 1 medium 2 Vegetables and Fruit margarine, sour cream and grated cheese Green beans ½ cup/ 125 mL 1 Vegetables and Fruit

Dinner Whole grain tray bun 1 bun (1 oz/ 35 g) 1 Grain Products (with margarine) High Protein milk/ 1 cup/ 250 mL 1 Milk and Alternatives soy beverage Baked apple with cinnamon 1 medium 1 Vegetables and Fruit Super Pudding ½ cup/ 125 mL 1 Milk and Alternatives

Water and coffee/tea 1 cup/ 250 mL

k Salmon salad sandwich ½ sandwich (11 ½ oz/ 3045 g ½ Meat and Alternatives salmon salad)

Snac Whole wheat bread 1 slice (1 oz/ 35 g) 1 Grain Products Evening

Canada’s Food Guide Number of Food Groups servings Provides the minimum number of Vegetables and Fruit 10 servings each day through meals Grain Products 7 ½ and snacks. Milk and Alternatives 5 Meat and Alternatives 3 Provides a minimum of six cups of Fluid 9 ½ cups/ fluids daily, and at least one cup at 2375 mL each meal and snack.

3.3 Texture Modified Diets

Easy to Chew Description

An Easy to Chew diet is for people who have trouble chewing foods that are hard or crunchy. They may have poor fitting dentures or may be missing teeth. Easy to chew diets must provide the daily recommended number of servings from each food group in Canada’s Food Guide and should follow the Menu Planning Guidelines, on page 17.

Easy to chew foods need to be soft and moist.

Shown below are sample meals for an Easy to Chew diet:

Diced ham with macaroni Chicken à la king with Poached cod tail with and cheese and mashed potato and gravy canned green beans and French cut green beans and steamed carrots mashed turnip

Diced Ham with Macaroni and Chicken A La King with Cheese and French Cut Green Mashed Potato and Gravy and Foods Allowed and Not Allowed on an Easy to Chew Diet Beans Steamed Carrots Foods allowed include soft foods that are easy to chew. Foods not allowed are dry, crispy or hard foods; foods with long or stringy pieces and foods with tough skins. See the table which follows for foods allowed and not allowed on an easy to chew diet.

Foods Allowed Foods Not Allowed Vegetables and Fruit  Soft cooked fresh, frozen or canned vegetables  Hard and/or unripe raw vegetables and  Soft raw vegetables fruit  Finely shredded salads  Salads that are not shredded  Mashed or whipped potato, or other well  Potato skins, hash browns cooked potato side dishes  Uncooked dried fruit  Soft, frozen or canned fruit  All pineapple except crushed  Cooked or stewed dried fruit  Soft ripe fresh fruit including those with seeds (for example, pear, banana, melons)

Foods Allowed and Not Allowed on an Easy to Chew Diet (Continued)

Foods Allowed Foods Not Allowed Grain Products  Soft breads, buttered toast, buns, biscuits, soft  Dry, crusty, or chewy bread products, tortillas and moist muffins (for example, bagels, crusty buns,  Cooked hot cereals French bread, dry muffins, bread sticks,  Cold cereals softened in milk pitas)  Soft cooked pasta, rice, barley  Cold cereals that do not soften in milk  Hard crackers and granola bars  Hard toast Milk and Alternatives  Yogurt, milk pudding or custard, without  Yogurt, milk pudding or custard granola containing hard or large firm pieces  Cheeses (diced, cubed, grated, soft and cottage such as granola cheese) Meat and Alternatives  Tender moist meat or poultry or boneless fish,  Crispy refried meat, poultry and fish with sauces or gravy, prepared in one of the  Meats in hard casings (for example, following ways: kolbasa, garlic sausage)  Shaved, sliced, or whole meat  Fish (canned, fresh or frozen)  Fork tender meats that are either sliced or containing bones whole, shaved to paper thin  Whole fried eggs or egg substitutes  Sausages and wieners in soft casings, shaved  Large chopped or whole nuts or seeds processed meats  Smooth or crunchy nut butters served  Soft cooked legumes alone  All cooked eggs or egg substitutes, including quiche or omelets with allowed ingredients  Smooth or crunchy nut butters mixed into or spread on allowed foods

Mixed Dishes and Condiments  Soft casseroles, stews and chili made with  Most main entrée salads allowed ingredients  Wieners or hamburgers in a bun  Sandwiches with salad type or minced fillings,  Pizza shaved meat or cheese on regular bread with shredded vegetables  Grilled cheese sandwiches  All soups with allowed ingredients Drinks  All drinks

Tips for Preparing Easy to Chew Food

 Choose soft moist foods. Foods may need to be chopped, minced, or mashed to make them easier to chew.  Add butter, margarine, gravy or sauces, oils, salad dressing, or sour cream to moisten foods.  Blend fruits into smoothies, milkshakes, popsicles, puddings, or sauces.  Remove tough skins and/or seeds on fruit (for example, sliced apple and watermelon). Stew or cook dried fruit.  Soak bread, biscuits, hard cookies, or muffins in milk or soup to soften, if required.  Braise, boil, simmer, or poach meats slowly in water, broth, or juice to make them tender. Use of a slow cooker or pressure cooker can also help soften meats.  Cut meat into bite-sized pieces. Grind or blend meat if it is still too hard or chewy.

Taste and Appearance

 Offer a variety of colourful and appetizing foods.  Use appropriate texture garnishes to add colour and appeal.  Taste the food before serving it to make sure it is acceptable.  Serve meals at the right temperature (hot foods should be served hot, cold foods should be served cold).

Snack Ideas

 Crushed pineapple  Canned pears  Soft cereal bars  Tapioca, rice or bread pudding  Cottage cheese  Soft sandwiches

For more information, please see Appendix 2C, Nutrition and Menu Planning Resources for the handout Easy to Chew diet.

Sample Easy to Chew Menu Plan

Below is a one day Easy to Chew menu that has been adapted from the Example of a Completed Regular Menu Plan on page 32. Changes made to the Regular menu to fit the Easy to Chew diet are shown in bold. If a resident is on an Easy to Chew diet and has trouble cutting food, Cut/Diced foods may also be needed as an additional texture modification, as shown below. A  indicates no change from the Easy to Chew menu item. Easy to Chew Number of Canada’s Meal Regular Menu Item Easy to Chew Menu Item Portion Size with Cut/Diced Food Guide Servings Coffee/tea and water Coffee/tea and water  1 cup/ 250 mL 100% apple juice 100% apple juice  ½ cup/ 125 mL 1 Vegetables and Fruit Banana Banana Cut into bite-sized 1 medium 1 Vegetables and Fruit pieces Bran cereal with raisins Bran cereal (no raisins)  ¾ cup/ 175 mL 1 Grain Products softened in milk Whole grain toast Buttered whole grain toast Cut toast in halves or 2 slices (1 oz/ 35 g each slice) 2 Grain Products quarters Breakfast Milk/fortified soy Milk/fortified soy beverage  1 cup/ 250 mL 1 Milk and Alternatives beverage Peanut butter Peanut butter  1 package (1 Tbsp/ 15 mL) ½ Meat and Alternatives

Water and coffee/tea Water and coffee/tea  1 cup/ 250 mL Beef barley soup Beef barley soup  1 cup/ 250 mL ½ Grain Products Crackers, soda Crackers, soda  1 package (2crackers) ¼ Grain Products Turkey sandwich wrap on Turkey sandwich wrap (turkey Cut wrap into halves 1 whole (includes 23 oz/ 1 Meat and Alternatives whole grain whole wheat shaved paper thin) or quarters 6090 g lean turkey breast) pita bread, with romaine Pita bread, whole grain whole 1 whole (2 oz/ 70 g) 2 Grain Products lettuce and tomato slices wheat

Finely shredded romaine ¼ cup/ 60 mL lettuce ½ Vegetables and Fruit lettuce, tomato in wrap 2 slices tomato

Lunch Carrot sticks Soft cooked carrot sticks Cut into bite-sized 56 pieces 1 Vegetables and Fruit pieces (3 inches/ 7 ½ cm long) Tossed salad Finely shredded tossed salad  ½ cup/ 125 mL ½ Vegetables and Fruit Milk/fortified soy Milk/fortified soy beverage  1 cup/ 250 mL 1 Milk and Alternatives beverage Grapes Grapes  ½ cup/ 125 mL 1 Vegetables and Fruit

Sample Easy to Chew Menu Plan (Continued)

Easy to Chew Number of Canada’s Meal Regular Menu Item Easy to Chew Menu Item Portion Size with Cut/Diced Food Guide Servings Water and coffee/tea Water and coffee/tea  1 cup/ 250 mL Orange Orange  1 medium 1 Vegetables and Fruit (peeled and sectioned)  Snack Oatmeal Cookie Oatmeal cookie, soft baked 2 small cookies 1 Grain Products Afternoon Afternoon (1-1 ½ oz / 30-38 g total)

Water and coffee/tea Water and coffee/tea  1 cup/ 250 mL Meatloaf Meatloaf  1 slice ( 2 x 4 x ½ inch / 1 Meat and Alternatives 5 x 10 x 1 ½ cm) Baked potato Baked potato (with no skin) Cut into bite-sized 1 medium 2 Vegetables and Fruit pieces Green beans Green beans Cut into bite-sized ½ cup/ 125 mL 1 Vegetables and Fruit pieces Whole grain tray bun Whole grain tray bun (soft) Cut in halves or 1 bun (1 oz/ 35 g) 1 Grain Products quarters Supper Milk/fortified soy Milk/fortified soy beverage  1 cup/ 250 mL 1 Milk and Alternatives beverage Baked apple with Baked apple with cinnamon Cut into bite-sizes 1 medium 1 Vegetables and Fruit cinnamon pieces Vanilla pudding Vanilla pudding  ½ cup/ 125 mL 1 Milk and Alternatives

Water and coffee/tea Water and coffee/tea  1 cup/ 250 mL

Salmon salad sandwich on Salmon salad sandwich on  1-1 ½ oz/ 30-45 g salmon ½ Meat and Alternatives whole wheat bread whole wheat bread

Snack Evening Evening 1 slice bread (1 oz/ 35 g) 1 Grain Product

Canada’s Food Guide Number of servings Food Groups Provides the minimum number of servings from Vegetables and Fruit 10 each of the four food groups each day through Grain Products 8 ½ meals and snacks. Milk and Alternatives 4 Meat and Alternatives 3 Provides a minimum of six cups of fluids daily, Fluid 9 ½ cups/ 2375 mL and at least one cup at each meal and snack.

If a resident on an Easy to Chew diet has trouble cutting food, Cut/Diced foods may also be needed. For more details on Foods Allowed/Not Allowed on Cut/Diced, see page 105.

If ‘Cut/Diced’ is ordered  Toast, bread or buns should be cut into halves or quarters.  Sandwiches or wraps should be cut into halves or quarters.  Fruit and vegetables should be peeled and sectioned, mashed, cut or diced.  Meat, poultry, or fish should be cut into bite-sized pieces.

Dysphagia Soft

Description

A Dysphagia Soft diet may be needed for people who have trouble chewing or swallowing, but do not need food minced or pureed. A Dysphagia Soft diet must provide the daily recommended number of servings from each food group in Canada’s Food Guide and should follow the Menu Planning Guidelines, on page 17.

Dysphagia Soft food must be soft and moist. Some foods may need to be served with a sauce, gravy, or condiment. Firm foods need to be diced ½ inch/ (1 cm) cubed or less on the longest side. Other foods that can be mashed with a fork in one hand are soft enough to be served without dicing, such as cooked vegetables.

Shown below are sample meals for a Dysphagia Soft diet:

Soft Salmon Loaf Diced Ham Mashed Potato with Gravy Macaroni and Cheese Green Peas French Cut Beans

Poached cod tail Diced turkey and gravy, Soft salmon loaf with with mashed potato, peas with mashed potato and mashed potato and gravy, minced green beans and carrots and green peas

Foods Allowed/Not Allowed

Foods allowed include soft and moist foods. Though most food can be altered to fit into a Dysphagia Soft diet, some foods need to be avoided altogether. Avoid foods that are dry, crumbly, sticky, gummy, hard or chewy. Some foods need to be minced to be safe on a Dysphagia Soft diet. See the table below for a list of foods allowed and not allowed on a Dysphagia Soft diet.

Foods Allowed and Not Allowed on a Dysphagia Soft Diet

Foods Allowed Foods Not Allowed Vegetables and Fruit  Soft diced cooked vegetables (for example,  Raw vegetables diced carrots)  Whole kernel corn  Mashable cooked vegetables (for example,  Fruit with tough skins cooked peas, squash)  All pineapple except crushed  Fibrous or stringy vegetables like broccoli and  Dried fruit or fruit with hard seeds green beans need to be minced  Very finely shredded lettuce, coleslaw, and other leafy greens  Peeled finely diced cucumber  Soft ripe diced or mashed fruit Grain Products  Soft breads, buttered toast, buns, biscuits and  Dry, crumbly, crusty or chewy bread moist muffins containing allowable products ingredients served with a spread  Cold cereals that do not soften in milk  Cooked cereals; cold cereals softened in milk  Dry, loose rice (no hard pieces)  Fork-tender, mashable pasta with or without a sauce, couscous, or barley in a sauce or casserole, or moist rice that stays together  Pancakes, waffles or French toast served with syrup or applesauce to moisten Milk and Alternatives  All yogurt, custard or milk pudding, smooth  Yogurt, milk pudding or custard with or with small pieces of fruit or seeds large pieces of fruit, nuts or granola  Cheeses, sliced, diced, or grated  Crispy melted stringy cheese topping  Cottage cheese

Foods Allowed and Not Allowed on a Dysphagia Soft Diet (Continued) Foods Allowed Foods Not Allowed Meat and Alternatives  Tender moist meat, poultry or organ meat  Dry, or tough, breaded, battered or fried with sauces or gravies prepared in one of the meats, poultry or fish following ways:  Crispy whole fried eggs or egg substitutes  Diced (½ inch / 1 cm cubed) meat  Large chopped or whole nuts and seeds (for example, roast or Salisbury steak)  Crunchy nut butters  Fork tender, mashable meat (for example,  Smooth nut butters spread on foods Shepherd’s pie, meatloaf, meatballs)  Meat shaved and diced ½ inch (1 cm) on longest side  Processed meats shaved and diced (½ inch / 1 cm on longest side) such as deli-style meats, luncheon meats  Canned fish with bones removed, and tender, boneless flaked fish served with or without a sauce or gravy or in a moist coating  All cooked and mashable eggs or egg substitutes, including quiche or omelets with allowed ingredients  Smooth nut butters mixed into allowed foods (for example, peanut butter smoothie)  Soft cooked mashable legumes or tofu Mixed Dishes and Condiments  Very tender casseroles, stews and chili made  Casseroles, stews or chili made with not with tender diced or mashable allowed allowed ingredients ingredients (for example, lasagna, macaroni  Pizza and cheese, tuna macaroni casserole)  Shaved meat sandwiches  Sandwiches with salad type, finely minced  Wieners or hamburgers in buns fillings or cheese, on regular bread without  Soups containing not allowed foods or lettuce or whole raw vegetables larger pieces  Grilled cheese sandwiches  Sauces with larger pieces or not allowed  Soups with allowed ingredients or pureed ingredients, such as salsa with corn soups  Smooth gravies or sauces such as white sauce or cheese sauce, added to allowed foods  Sauces that are smooth or with small to medium pieces such as BBQ sauce, ketchup, horseradish, relish, and cranberry sauce  Jams or marmalades in jars if fruit pieces are less than ½ inch (1 cm) cubed and/or soft and mashable Drinks  All drinks

Tips for Preparing Dysphagia Soft Food

The preparation method for Dysphagia Soft foods depends on the type of food being served.

Foods that need to be diced should be less than ½ inch/ 1 cm, as shown.  Measure or portion out pieces before cutting to ensure they are the right portion size. Foods can be chopped or mashed with a knife, pastry blender, potato masher, or fork.  Cooked and mashable eggs or egg substitutes, peas, beans, or lentils are appropriate.  Tender moist meat, poultry or organ meat must be prepared in one of the following ways: o Diced (for example, roast, Salisbury steak, hamburger patty, breaded pork cutlet, liver). o Fork tender, mashable meat (for example, Shepherd’s pie, meatloaf, or meatballs) o Meat shaved and diced (½ inch/ 1 cm on longest side) or shaved paper thin (such as roast beef or ham) with a meat slicer or knife so that it looks like thinly-sliced deli meat.  Meat, poultry, and boneless fish should have added sauce/gravy to make it tender, soft, and moist.  Vegetables must be cooked until soft. Most can be served ‘as is’ once they are cooked to a soft texture, however, some will need to be diced or minced after cooking. For example, cooked vegetables that are fibrous and stringy like green beans and broccoli should be minced. Lettuce, coleslaw, and leafy green vegetables may be served raw as long as they are finely shredded.  Fruits that are canned, frozen, or fresh can be served as long as they are soft in texture. All fruits should be diced or mashed before serving.

Taste and Appearance

 Offer a variety of colourful and appetizing foods.  Use appropriate textured garnishes to add colour and appeal.  Taste the food before serving it to make sure it is acceptable.  Serve meals at the right temperature (hot foods should be served hot, cold foods should be served cold).

Snack Ideas

 Soft moist muffin  Ripe banana, diced or mashed  Smooth yogurt or pudding  Soft cooked, canned, or ripe fruit, with skins removed, diced or mashed  Cottage cheese  Soft crackers (such as soda crackers) with soft cubed cheese For more information, please see Appendix 2C, Nutrition and Menu Planning Resources for the handout Dysphagia Soft Diet.

Sample Dysphagia Soft Menu Plan

Below is a one day Dysphagia Soft menu that has been adapted from the Example of a Completed Regular Menu Plan on page 32. Changes hanges made to the Regular menu to fit the Dysphagia Soft diet are shown in bold. If a Dysphagia Soft diet is ordered along with another additional texture modification, such as Thick Fluids, No Mixed Consistencies, and/or Pureed Bread Products, more foods will need to be avoided or altered, as shown below. A  indicates no change from the Dysphagia Soft menu item.

Dysphagia Dysphagia Dysphagia Soft with Dysphagia Soft Soft with No Number of Canada’s Meal Regular Menu Item Soft with Pureed Portion Size Menu Item Mixed Food Guide Servings Thick Fluids Bread Consistencies Products Coffee/tea and water Coffee/tea and water  Thicken  1 cup/ 250 mL - 100% apple juice 100% apple juice  Thicken  ½ cup/ 125 mL 1 Vegetables and Fruit Bran cereal with raisins Oatmeal    ¾ cup/ 175 mL 1 Grain Products Whole grain toast Buttered whole grain   Slurried French 2 slices 2 Grain Products toast toast (see page (1 oz/ 35 g 109 for a each)

recipe on how to make a slurry)

Breakfast Banana Peanut Butter  (must be Thicken (Note:  1 medium 1 Vegetables and Fruit Milk/fortified soy Smoothie including: smooth) smoothies 1 cup/ 250 mL 1 Milk and Alternatives beverage Banana should not Milk/fortified soy Peanut butter contain any ice, 1 package ½ Meat and Alternatives beverage Smooth peanut butter ice cream or (1 Tbsp/ sherbet and must 15 mL) be smooth).

Sample Dysphagia Soft Menu Plan (Continued)

Dysphagia Dysphagia Dysphagia Soft with Number of Dysphagia Soft Soft with No Meal Regular Menu Item Soft with Pureed Portion Size Canada’s Food Menu Item Mixed Thick Fluids Bread Guide Servings Consistencies Products Water and coffee/tea Water and coffee/tea  Thicken  1 cup/ 250 mL - Beef barley soup Beef barley soup (beef Blend Blend and  1cup/ 250 mL ½ Grain Products needs to be tender and thicken less than ½ inch/ 1 cm cubed) Crackers, soda Crackers, soda Remove Remove Remove 1 package ¼ Grain Products (2 crackers) Turkey sandwich wrap Turkey salad sandwich   Pureed bread 1 whole (includes 1 Meat and on whole grain whole on Whole grain whole with turkey 23 oz/ 6090 g Alternatives

wheat pita bread, with wheat bread (no salad OR lean turkey romaine lettuce and lettuce or tomato mashed breast) tomato slices slices) potatoes with 2 slices bread 2 Grain Products

Lunch soft diced (1 oz/ 35 g each) turkey Carrot sticks Soft cooked diced    ½ cup/ 125 mL 1 Vegetables and Fruit carrots Tossed salad Very finely shredded    ½ cup/ 125 mL ½ Vegetables and salad Fruit Milk/fortified soy Milk/fortified soy  Thicken  1 cup/ 250 mL 1 Milk and beverage beverage Alternatives Grapes Diced kiwi Drain excess Drain excess  ½ cup/ 125 mL 1 Vegetables and Fruit liquid liquid

Sample Dysphagia Soft Menu Plan (Continued) Dysphagia Dysphagia Dysphagia Soft Soft with Number of Dysphagia Soft Soft with Meal Regular Menu Item with No Mixed Pureed Portion Size Canada’s Food Menu Item Thick Consistencies Bread Guide Servings Fluids Products Water and coffee/tea Water and coffee/tea  Thicken  1 cup/ 250 mL Orange Canned mandarin Replace with fruit Replace with  ½ cup/ 125 mL 1 Vegetables and Fruit oranges sauce (like apple) fruit sauce (like apple) Oatmeal Cookie Oatmeal cookie, soft   Replace with 2 small cookies 1 Grain Product Snack baked blended bread (11 ½ oz / Afternoon Afternoon pudding (125 3038 g total) mL/ ½ cup) Water and coffee/tea Water and coffee/tea  Thicken  1 cup/ 250 mL - Meatloaf Meatloaf topped with Serve gravy on Serve gravy  1 slice ( 2 x 4 x 1 Meat and gravy food, not on side on food, not ½ inch / Alternatives on side 5 x 10 x 1 ½ cm) Baked potato Baked potato (with no    1 medium 2 Vegetables and Fruit skin)

Green beans Minced green beans    ½ cup/ 125 mL 1 Vegetables and Fruit Whole grain tray bun Whole grain tray bun   Puree tray bun 1 bun 1 Grain Products

Supper (soft), with margarine (1 oz/ 35 g) Milk/fortified soy Milk/fortified soy  Thicken  1 cup/ 250 mL 1 Milk and Alternatives beverage beverage Baked apple with Diced baked apple with    1 medium 1 Vegetables and Fruit cinnamon cinnamon Vanilla pudding Vanilla pudding (must be smooth) (must be  ½ cup/ 125 mL 1 Milk and Alternatives smooth)

Water and coffee/tea Water and coffee/tea  Thicken  1 cup/ 250 mL - Salmon salad Salmon salad sandwich   Salmon salad 1-1 ½ oz/ ½ Meat and sandwich on whole on whole wheat bread with biscuit 30-45 g salmon Alternatives wheat bread slurry Snack 1 biscuit 1 Grain Products Evening (1 oz/35 g) 86

Canada’s Food Guide Number of servings Food Groups Provides the minimum number of servings from

Vegetables and Fruit 9 ½ each of the four food groups each day through Grain Products 8 ½ meals and snacks. Milk and Alternatives 4 Meat and Alternatives 3 Fluid 9 ½ cups/ 2375 mL Provides a minimum of six cups of fluids daily, and at least one cup at each meal and snack.

Below is a further description of foods that will need to be avoided or altered for the menu above if additional texture modifications are ordered along with the Dysphagia Soft Diet. For more details on Foods Allowed and Not Allowed for these diet modifications, see the pages as noted.

If ‘No Mixed Consistencies’ is ordered  Serve hot cereal only (no cold or dry cereal).  Blend/puree soups.  Serve yogurt or pudding that is smooth or with small soft pieces of fruit.  Ensure there are no firm fruit chunks or ice cubes in milkshakes or smoothies.  See page 107 for more information. If ‘Thick Fluids’ is ordered  Follow the changes for ‘No Mixed Consistencies’.  Provide juice, milk, hot beverages and soup thickened to the ordered consistency (Nectar, Honey, or Pudding thick).  Replace thin fluids (ice cream, sherbet, popsicles or gelatin) with thickened fluids.  Serve gravies/sauces on the food, not on the side. Gravies do not need to be thickened as long as they do not pool on the plate.  Smoothies or milkshakes can be offered if thickened to the appropriate consistency. Ice, ice cream, or sherbet should not be used, as these ingredients will melt, causing the smoothie or milkshake to change consistency after serving.  See page 113 for more information. If ‘Pureed Bread Products’ is ordered  Remove all regular texture bread products. Replace with pureed bread products or allowed grains.  Additional servings of Meat and Alternatives can be offered at meals so that snacks (for example, sandwiches) can be substituted with other items such as yogurt or pudding for ease of menu planning.  See page 109 for more information.

Minced

Description

A Minced diet is for people who have trouble chewing or swallowing. Minced diets must provide the daily recommended number of servings from each food group in Canada’s Food Guide and should follow the Menu Planning Guidelines on page 17.

Minced foods are grated, ground, or mashed, to a size less than ¼ inch or ½ cm. Minced food should be moist, stay together, and have no liquid separation. Minced food should require little chewing.

Shown below are sample meals for a Minced diet:

Minced baked beans and Baked fish with mashed Minced baked beans and Baked fish with mashed Minced minute steak with wieners with mashed potato and gravy, and wieners with mashed potato and gravy, and mashed potato and gravy, and potato and minced peas minced green beans potato and minced peas minced green beans minced parsnip/carrot medley

Foods Allowed/Not Allowed

Most regular foods can be altered to fit into a Minced diet, but some foods do not mince well and need to be avoided. These foods include:  Fruit with tough skins or hard seeds (for example, raspberries or pineapple)  Dry, crumbly, chewy breads (for example, bagels, and dry muffins)  Foods that are sticky and gummy (for example, toffee, licorice, or gum)

Some foods need to be pureed to be safe on a Minced diet (for example, kernel corn and stewed pitted prunes). Foods which do not require mincing, and can be part of a minced diet include: soft breads, muffins, pancakes, or buttered toast. See the table below for a list of foods allowed and not allowed on a minced diet.

Foods Allowed and Not Allowed on a Minced Diet

Foods Allowed Foods Not Allowed Vegetables and Fruit  Minced soft canned or soft cooked  Cooked vegetables that are rubbery, not vegetables and fruit tender or do not mince well (for example,  Mashed or whipped potato or other minced cooked peas, lima beans, broccoli, potato side dishes cabbage, Brussels sprouts)  Mashed ripe banana  Raw vegetables and salads  Fruit that has tough skins, hulls or seeds that do not mince well (for example, raspberries, whole grapes, pineapple)  Dried fruit Grain Products  Soft, moist regular bread products  Dry, crumbly, crusty or chewy bread  Smooth hot cereals products (for example, French bread,  Minced or bite sized pasta, cooked until crusty buns, bagels, dry muffins, very soft breadsticks)  Rice, barley or couscous in a sauce or  Hot cereals containing seeds, or hard casserole, or moist rice that stays together particles  All cold cereals  Dry, loose rice  Hard crackers Milk and Alternatives  Yogurt that is smooth or has soft pieces of  Yogurt, milk pudding or custard fruit containing firm pieces of fruit, dried fruit,  Smooth milk pudding or custard nuts, granola, seeds or other hard particles  Soft or grated cheese, creamed cottage  Slices or cubes of hard cheese cheese  Crispy melted stringy cheese topping Meat and Alternatives  Minced, moist meat and poultry with  Breaded or battered meats, even if smooth sauces or gravies minced; all nuts and seeds  Tender, boneless flaked fish or canned fish  Whole fried eggs or egg substitutes, with bones removed with or without sauce quiche or gravy or in a moist coating  All nuts or seeds in any form  Cooked scrambled eggs or egg substitutes  Crunchy nut butters  Hard cooked or poached eggs or egg  Smooth nut butters spread on foods substitutes, minced or finely mashed  Smooth nut butters mixed into allowed foods (for example, peanut butter smoothie)  All minced or mashed soft cooked legumes (beans, peas, or lentils)

Foods Allowed and Not Allowed on a Minced Diet (Continued)

Mixed Dishes and Condiments  Very tender casseroles, stews and chili  Main entrée salads made with minced or allowed ingredients  Pizza  Sandwiches with salad type or finely  Wieners or hamburgers in a bun minced fillings on regular bread with no  Grilled cheese sandwiches lettuce or vegetables  All unblended soups  Pureed soups  Hard cookies or cookies with large hard  Soft, moist, or easy to break cookies and pieces baked products  Sauces with larger pieces (for example,  Smooth gravies and sauces such as white salsa, cranberry sauce) sauce or cheese sauce, added to allowed foods (maximum 2 Tbsp/ 30 mL per menu item) Drinks  All drinks

Steps for Preparing Minced Food

1. Before mincing food, drain liquid from food portions to be minced, such as canned fruit. This will help avoid liquid separation.

2. Weigh or measure the number of portions required. Chop or dice larger pieces of food before mincing.

3. Process foods until uniform in size and texture. a. Mince small amounts of food using a blender, mini chopper, or a food processor. b. For larger amounts of food use a large institutional meat grinder or food processor. c. Mince soft foods with a fork, pastry blender, or potato masher.

4. Add liquid to get the right consistency. a. Use hot liquids for hot foods and cold liquids for cold foods. This helps to keep safe food temperatures during preparation. b. Do not use water. Use cooking liquids, gravy, milk, juice, melted margarine, or sauces to enhance colour, flavour, and the nutrient value of the food. c. When mincing food, add 1 Tbsp/ 15 mL of liquid at a time until it looks smooth and moist. Foods should be moist but should not have liquid separation.

5. Add spices (excluding salt) to enhance flavour.

6. The finished product should be uniform in size and texture. Food should be less than ¼ inch/ ½ cm thick. Take care not to over process food, or it will end up pureed.

Commercial Products

Commercial minced products are also available through various suppliers. Use of these products can help ensure consistency in products, nutrition, and safety. For further information on these products, please ask a dietitian.

Taste and Appearance

 Be positive when serving minced foods to the resident. This will help the resident accept and eat the food.  Offer a variety of colourful and appetizing food.  Offer each food item separately on the plate, without mixing or blending them together, to enhance the look and taste.  Use appropriate textured garnishes that add colour and appeal.  Taste the food before serving it to make sure it tastes good.  Serve meals at the right temperature (hot foods should be served hot, cold foods should be served cold).

Snack Ideas

 Minced canned fruit  Smooth yogurt or pudding  Sandwiches with minced filling  Soft cereal bars  Banana loaf

For more information, please see Appendix 2C, Nutrition and Menu Planning Resources for the handout Minced Diet.

Sample Minced Menu Plan Below is a one day Minced menu that has been adapted from the Example of a Completed Regular Menu Plan on page 32. Changes made to the Regular menu to fit the Minced diet are shown in bold. If a Minced diet is ordered along with additional texture modification, such as Thick Fluids, No Mixed Consistencies, and/or Pureed Bread Products, more foods will need to be avoided or altered, as shown below. A  indicates no change from the Minced menu item.

Minced with Minced with Number of Canada’s Regular Menu Minced Minced with Pureed Meal No Mixed Portion Size Food Guide Item Menu Item Thick Fluids Bread Consistencies Servings Products Coffee/tea and Coffee/tea and  Thicken  1 cup/ 250 mL - water water 100% apple juice 100% apple juice  Thicken  ½ cup/ 125 mL 1 Vegetables and Fruit Bran cereal with Oatmeal    ¾ cup/ 175 mL 1 Grain Products raisins Whole grain toast Buttered whole   Slurried French 2 slices (1 oz/ 2 Grain Products grain toast toast (see page 35 g each) 111 for a recipe on how to make a slurry) Breakfast Banana Peanut Butter  (must be Thicken (Note:  1 medium 1 Vegetables and Fruit Milk/fortified soy Smoothie smooth) smoothies should 1 cup/ 250 mL 1 Milk and Alternatives beverage including: not contain any Banana ice, ice cream or Peanut butter 1 package ½ Meat and Alternatives Milk/fortified soy sherbet and must beverage be smooth). (1 Tbsp/ 15 mL) Smooth peanut butter

Sample Minced Menu Plan (Continued)

Minced with Minced with Number of Canada’s Regular Menu Minced Minced with Pureed Meal No Mixed Portion Size Food Guide Item Menu Item Thick Fluids Bread Consistencies Servings Products Water and Water and  Thicken  1 cup/ 250 mL coffee/tea coffee/tea Beef barley soup Blended beef Blend Blend and thicken  1 cup/ 250 mL ½ Grain Products barley soup Crackers, soda Crackers, soda Remove Remove Remove 1 package ¼ Grain Products (softened in soup) (2 crackers) Turkey sandwich Turkey salad   Pureed bread 1 whole 1 Meat and Alternatives wrap on whole sandwich on with turkey (includes 2-3 oz/ grain whole wheat Whole grain salad OR 60-90 g lean whole wheat pita bread, with mashed turkey breast) bread (no lettuce h romaine lettuce and or tomato slices) potatoes with 2 slices bread 2 Grain Products tomato slices soft diced (1 oz/ 35 g each)

Lunc turkey

Carrot sticks Minced cooked    ½ cup/ 125 mL 1 Vegetables and Fruit carrots Tossed salad Pureed green peas    ½ cup/ 125 mL 1 Vegetables and Fruit Milk/fortified soy Milk/fortified soy  Thicken  1 cup/ 250 mL 1 Milk and Alternatives beverage beverage Grapes Minced kiwi Drain excess Drain excess  ½ cup/ 125 mL 1 Vegetables and Fruit liquid before liquid before and and after after mincing mincing

Sample Minced Menu Plan (Continued)

coffee/tea Orange Minced canned Remove and Remove and  ½ cup/ 125 mL 1 Vegetables and Fruit mandarin oranges replace with replace with fruit fruit sauce (like sauce (like apple) apple) Oatmeal Cookie Oatmeal cookie, soft   Replace with 2 small cookies 1 Grain Products baked blended bread (11 ½ oz /

Afternoon SnackAfternoon pudding (½ 30-38 g total)

cup/125 mL)

Water and Water and coffee/tea  Thicken  1 cup/ 250 mL coffee/tea Meatloaf Minced meatloaf Serve gravy on Serve gravy on  1 slice 1 Meat and Alternatives topped with food, not on side food, not on side ( 2 x 4 x ½ inch

2 Tbsp/ 30 mL gravy or /5 x 10 x 1 ½ cm) Baked potato Minced potato salad    ½ cup/ 125 mL 1 Vegetables and Fruit

Supper Green beans Minced green beans    ½ cup/ 125 mL 1 Vegetables and Fruit Whole grain tray Whole grain tray bun   Puree tray bun 1 bun (1 oz/35 g) 1 Grain Products bun (soft) with margarine Milk/fortified soy Milk/fortified soy  Thicken  1 cup/ 250 mL 1 Milk and Alternatives beverage beverage

Sample Minced Menu Plan (Continued)

cinnamon Vanilla pudding  (smooth) (smooth)  ½ cup/ 125 mL 1 Milk and Alternatives

Water and Water and  Thicken  1 cup/ 250 mL

coffee/tea coffee/tea Salmon salad Salmon salad   Salmon salad 11 ½ oz/ ½ Meat and Alternatives sandwich on whole sandwich on whole with biscuit 3045 g salmon Snack Evening wheat bread wheat bread slurry 1 slice bread 1 Grain Products (1 oz/ 35 g)

Canada’s Food Guide Number of servings Food Groups Provides the minimum number of servings from Vegetables and Fruit 9 each of the four food groups each day through Grain Products 8 ½ meals and snacks. Milk and Alternatives 4 Meat and Alternatives 3 Provides a minimum of six cups of fluids daily, Fluid 9 ½ cups / 2375 mL and at least one cup at each meal and snack.

If a Minced diet is ordered along with additional texture modifications, more foods will need to be avoided or altered. For more details on foods allowed for these diet modifications, see the corresponding section.

If ‘No Mixed Consistencies’ is ordered  Do not add crackers to soup.  See page 107 for more information. If ‘Thick Fluids’ is ordered  Follow the changes for ‘No Mixed Consistencies’.  Provide juice, milk, hot beverages, and soup thickened to the ordered consistency (Nectar, Honey, or Pudding thick).  Replace thin fluids (ice cream, sherbet, popsicles, or gelatin desserts) with thickened fluids.  Serve gravies/sauces on the food, not on the side. As long as they do not pool on the plate, these do not need to be thickened.  Smoothies or milkshakes can be offered if thickened to the appropriate consistency. Ice, ice cream, or sherbet should not be used, as these ingredients will melt, causing the smoothie or milkshake to change consistency after serving.  See page 103 for more information. If ‘Pureed Bread Products’ are ordered  Remove all regular texture bread products. Replace with pureed bread products or allowed grains.  See page 109 for more information.

Pureed

Description

A Pureed diet may be needed for people who have trouble chewing or swallowing, or have a sore or dry mouth. A Pureed diet must provide the daily recommended number of servings from each food group in Canada’s Food Guide and should follow the Menu Planning Guidelines, on page 17.

Pureed foods are soft, moist, and smoothly blended. Foods have the look and texture of a pudding or mousse and hold their shape when mounded on a spoon. There should be no lumps or visible particles. Pureed foods should not be thin or runny. Liquids and solids should not separate.

Shown below are sample meals for a Pureed diet:

Pureed roast beef with Pureed roast beef with mashed potato and mashed potato and carrot puree pureed peas

Foods Allowed/Not Allowed

Most foods can be altered to fit into a pureed diet, but some foods do not puree well and should be avoided. These foods include:  Vegetables and fruit with skin or seeds. For example, raspberries and blackberries.  All forms of pineapple.  Dried fruit such as coconut or raisins.  Grain products and cereals with any hard particles. For example, multigrain bread with seeds, granola, or dry rice.  Crispy cheese toppings, deep fried crispy, or battered meats.  Crunchy nut butters. Smooth nut butters can be included if mixed with other allowed foods. For example, a peanut butter smoothie.

See the table on the next page for a list of foods allowed and not allowed on a Pureed diet.

Foods Allowed and Not Allowed on a Pureed Diet

Foods Allowed Foods Not Allowed Vegetables and Fruit  All commercially prepared pureed vegetables  Vegetables and fruit with membranes, and fruit skin, hulls or seeds that do not puree well  Pureed vegetables and fruits with strained (for example, raspberries, whole grapes) skins and small seeds (for example, green  Raw vegetables and salads beans, corn)  All forms of pineapple  Smooth mashed or whipped potatoes, other  All fresh fruits except for pureed ripe pureed potato side dishes banana  Applesauce or other fruit sauces  Dried fruit, even if pureed  Pureed ripe banana Grain Products  Pureed bread products (for example, bread,  All regular texture bread products bread stuffing, pancakes)  Grain products containing nuts, seeds,  Slurried bread products (for example, muffins, chocolate chips, dried fruit, or any hard waffles, crackers, pancakes) food particles, even if pureed  Smooth hot cereals  All hot cereals containing seeds, whole  Pureed pasta, rice, barley, or couscous flax seeds, or any hard food pieces (for For more information and recipes on pureed and example, large flake oatmeal) slurried bread products, see page 109.  All cold cereals Milk and Alternatives  Smooth yogurt, custard, or milk pudding  Yogurt, custard, or milk pudding  Pureed rice pudding containing any hard particles  Melted or pureed cheese or cottage cheese  Crispy melted stringy cheese topping Meat and Alternatives  Pureed  Breaded, battered, or fried meats, poultry, o moist meat, poultry, or fish or fish (even if pureed) o sausages or wieners without the casing  Meat in casings (even if pureed) o cooked eggs or egg substitutes  Fish containing bones (even if pureed) o soft cooked legumes or tofu  All nuts or seeds in any form  Smooth nut butter mixed into allowed foods  Crunchy nut butters (for example, peanut butter smoothie)  Smooth nut butters spread on foods Mixed Dishes and Condiments  Pureed mixed entrees made with allowed  All unblended soups ingredients  Chunky sauces or condiments (for  Pureed soups example, jam, marmalade, relish)  Smooth gravies and sauces such as white  Any mixed consistencies sauce or cheese sauce added to allowed foods (maximum 2 Tbsp/ 30 mL per menu item) Drinks  All drinks

Steps for Preparing Pureed Food

1. Drain liquid from portions needing to be pureed, such as canned fruit. This will help avoid liquid separation.

2. Weigh or measure the number of portions needed. If making more than 10 servings, add 1 extra serving for every 10 servings. Some food can be lost in the preparation process.

3. Process foods fine and smooth in texture. a. Puree small amounts of food using a mini chopper, food processor, or blender. b. Use an institutional mixer or food processor for larger amounts of food.

4. Once food is pureed, add liquid until food looks smooth and moist, like a pudding or mousse. a. Use hot liquids for hot foods and cold liquids for cold foods. This helps keep safe food temperatures during preparation. b. Do not use water. Instead use cooking liquids, gravy, milk, juice, melted margarine, or sauces to enhance colour, flavou r, and the nutrition content of the food. c. Add liquid 1 Tbsp/ 15 mL at a time. This helps to avoid adding too much liquid which could result in a runny food.

5. If the food is too thin, use a commercial thickener to thicken to the right consistency. Do not use bread crumbs or flour.

6. The pureed food should be smooth without any lumps or stringy bits. There must be no visible particles. Oatmeal is the only exception to this –it is consistent in texture and is appropriate on a pureed diet.

Test consistency. Ensure that the solid pureed food is thick enough to spoon up a minimum of about 1 ½2 tsp /8 10 mL onto a teaspoon. Some liquids such as pureed soups may be thinner.

Commercial Products

Commercial pureed products are available through various suppliers. Use of these products can help ensure consistency in products, nutrition and safety. Compare the nutrition facts table on these products to choose one that meets the needs of residents. For further information on these products, please ask a dietitian.

Taste and Appearance

 Present a positive view of pureed foods to the resident. This will help the resident accept and eat the food.  Offer a variety of colourful and appetizing foods.  Use garnishes that are the appropriate texture to add colour and appeal.  Avoid mixing pureed foods together. This can change the look and taste of the food, which can decrease the resident’s intake and create a dislike for the food.  Taste the food before serving it to make sure it tastes good.  Serve meals at the right temperature (hot foods should be served hot, cold foods should be served cold).

Snack Ideas

 Muffin, pureed  Blended bread pudding  Soft cooked or canned fruit, pureed  Ripe banana, pureed  Smooth yogurt or pudding

Nutrition Tips

 Residents on a pureed diet may eat less food and therefore not consume enough calories and protein. This can lead to poor nutrition status. Snacks may need to be encouraged. Offer high protein high calorie snacks.  High protein high calorie foods can also be provided to a resident based on needs. Refer to High Protein High Calorie ideas on page 70 for more information.  Drinks such as water, coffee, and tea are important to provide enough fluids, but contain no calories or nutrients. Offer high protein high calorie drinks as well. For example, homogenized (3.25% M.F.) milk.

For more information, please see Appendix 2C, Nutrition and Menu Planning Resources for the handout Pureed Diet.

100

Sample Pureed Menu Plan Below is a one day Pureed menu that has been adapted from the Example of a Completed Regular Menu Plan on page 32. Changes made to the Regular menu to fit the Pureed diet are shown in bold. If a Pureed diet is ordered along with Thick Fluids, more foods will need to be avoided or altered, as shown below. A Pureed diet will automatically include both the texture modifications, Pureed Bread Products and No Mixed Consistencies (as described on pages 107109). A  indicates no change from the Pureed menu item.

Pureed with Thick Number of Canada’s Meal Regular Menu Item Pureed Menu Item Portion Size Fluids Food Guide Servings Coffee/tea and water Coffee/tea and water Thicken 1 cup/ 250 mL 100% apple juice 100% apple juice Thicken ½ cup/ 125 mL 1 Vegetables and Fruit Bran cereal with raisins Oatmeal  ¾ cup/ 175 mL 1 Grain Products 

Whole grain toast Slurried French toast 2 slices 2 Grain Products (See page 111 for a recipe on how (1 oz/ 35 g each) to make a slurry) Banana Peanut Butter and Banana Thicken (Note: smoothies 1 medium 1 Vegetables and Fruit

Breakfast Milk/fortified soy beverage Smoothie including: should not contain any ice, 1 cup/ 250 mL 1 Milk and Alternatives Banana Peanut butter ice cream, or sherbet). 1 package ½ Meat and Alternatives Whole (Homo) 3.25% Milk or fortified soy beverage (1 Tbsp/ 15 mL) Smooth peanut butter

101

Sample Pureed Menu Plan (Continued)

Pureed with Thick Number of Canada’s Meal Regular Menu Item Pureed Menu Item Portion Size Fluids Food Guide Servings Water and coffee/tea Water and coffee/tea Thicken 1 cup/ 250 mL Beef barley soup Blended beef barley soup Thicken as needed 1 cup/ 250 mL ½ Grain Products Crackers, soda Remove Remove - Turkey sandwich wrap on Pureed turkey salad with  2-3 oz/ 60-90 g 1 Meat and Alternatives whole grain whole wheat pureed whole grain whole lean turkey

pita bread, with romaine wheat bread (no lettuce or breast tomato slices) lettuce and tomato slices 2 slices 2 Grain Products OR Pureed turkey with pureed (1 oz/35 g each) Lunch pasta Carrot sticks Pureed carrots, topped with  ½ cup/ 125 mL 1 Vegetables and Fruit margarine Tossed salad Pureed green peas  ½ cup/ 125 mL 1 Vegetables and Fruit Milk/fortified soy beverage Whole (Homo) 3.25% Milk or Thicken 1 cup/ 250 mL 1 Milk and Alternatives fortified soy beverage Grapes Apple sauce  ½ cup/ 125 mL 1 Vegetables and Fruit

Water and coffee/tea Water and coffee/tea Thicken 1 cup/ 250 mL

Orange Pureed canned mandarin Drain excess liquid ½ cup/ 125 mL 1 Vegetables and Fruit

Snack oranges

Afternoon Afternoon Oatmeal Cookie Blended bread pudding  ½ cup/ 125 mL 1 Grain Products

102

Sample Pureed Menu Plan (Continued)

Pureed with Thick Number of Canada’s Meal Regular Menu Item Pureed Menu Item Portion Size Fluids Food Guide Servings Water and coffee/tea Water and coffee/tea Thicken 1 cup/ 250 mL Meatloaf Pureed meatloaf, topped with 2 Serve gravy on food, not on 1 slice 1 Meat and Alternatives Tbsp/ 30 mL gravy side (2 x 4 x ½ inch/ 5 x 10 x 1 ½ cm) Baked potato Smooth mashed potatoes, Serve gravy on food, not on ½ cup/ 125 mL 1 Vegetables and Fruit

topped with 2 Tbsp/ 30 mL side gravy Green beans Pureed green beans, topped  ½ cup/ 125 mL 1 Vegetables and Fruit with margarine Supper Whole grain tray bun Pureed whole grain tray bun  1 bun (1 oz/35 g) 1 Grain Products Milk/fortified soy beverage Whole (Homo) 3.25% Milk or Thicken 1 cup/ 250 mL 1 Milk and Alternatives fortified soy beverage Baked apple with cinnamon Pureed baked apple with  1 medium 1 Vegetables and Fruit cinnamon Vanilla pudding Vanilla pudding  ½ cup/ 125 mL 1 Milk and Alternatives

Water and coffee/tea Water and coffee/tea Thicken 1 cup/ 250 mL

Salmon salad sandwich on Pureed salmon with biscuit  1 – 1 ½ oz / ½ Meat and Alternatives whole wheat bread slurry 30-45 g salmon

Snack 1 biscuit 1 Grain Products Evening (1 oz / 35 g)

103

Canada’s Food Guide Number of servings Food Groups Provides the minimum number of servings from

Vegetables and Fruit 9 each of the four food groups each day through

Grain Products 8 ½ meals and snacks.

Milk and Alternatives 4

Meat and Alternatives 3 Provides a minimum of six cups of fluids daily, Fluid 9 ½ cups/ 2375 mL and at least one cup at each meal and snack.

Below is a further description on foods that will need to be avoided or altered for the menu above if Thick Fluids are ordered along with the Pureed Diet. For more details on Foods Allowed and Not Allowed for this diet modification, see the corresponding section.

If ‘Thick Fluids’ is ordered

 Provide juice, milk, hot beverages and soup thickened to the ordered consistency (Nectar, Honey or Pudding thick).  Replace thin fluids (ice cream, sherbet, popsicles, or gelatin desserts) with thickened fluids.  Serve gravies/sauces on the food, not on the side. As long as they do not pool on the plate, they do not need to be thickened.  Smoothies or milkshakes can be offered if thickened to the appropriate consistency. Ice, ice cream, or sherbet should not be used, as these ingredients will melt, causing the smoothie or milkshake to change consistency after serving.  See page 113 for more information.

104

Cut/Diced

Description

A Cut/Diced diet is not meant for those with chewing or swallowing problems. A Regular diet or an Easy to Chew diet can be modified to include Cut/Diced. The Cut/Diced diet must provide the daily recommended number of servings from each food group in Canada’s Food Guide and follow the Menu Planning Guidelines on page 17.

Foods on a Cut/Diced diet are bite-sized pieces or pieces that can be picked up easily to promote self- feeding. This is helpful for individuals who eat with one hand, or have trouble cutting food.

Shown below are sample meals for a Cut/Diced diet:

Diced turkey schnitzel Chicken à la king with Diced chicken breast with with mashed potato and mashed potato and mashed potato and gravy

canned green beans diced carrots and green peas

Foods Allowed/Not Allowed

All foods are allowed on a Cut/Diced diet, as long as the food is in bite sized pieces and meets the primary texture modification (Regular or Easy to Chew). See steps on the next page to prepare Cut/Diced foods.

For a list of snack ideas and a sample meal for Easy to Chew and Cut/Diced, refer to the Easy to Chew diet section starting on page 74.

105

Tip for preparing Cut/Diced foods

Cut food into bite-sized pieces, or into finger foods that can easily be picked up.  Fruit and vegetables should be peeled and sectioned, mashed, cut, or diced.  Toast or bread should be cut in half.  All meat, poultry, or fish, should be prepared in one of the following ways: o cut/diced (for example, roast, Salisbury steak, hamburger patty, breaded meat, poultry, or fish). o fork tender (for example, minced meats such as meatballs or Shepherd’s pie). o meats shaved to paper thin.  Sandwiches, hamburgers, or hotdogs should be cut in halves or quarters.

Taste and Appearance

 Offer a variety of colourful and appetizing foods.  Use garnishes to add colour and appeal.  Taste food before serving it to make sure it is acceptable.  Serve meals at the correct temperature (hot foods should be served hot, cold foods should be served cold).

106

No Mixed Consistencies

Description

Some people may not be able to control liquid and solid foods in the mouth at the same time due to chewing and/or swallowing problems. In these instances, mixed consistencies should be removed from the diet. The No Mixed Consistencies diet must provide the daily recommended number of servings from each food group in Canada’s Food Guide and should follow the Menu Planning Guidelines, on page 17.

“Mixed consistencies” are foods that have a thin fluid and a solid food in the same mouthful. Some examples include cold cereal with milk, soup with pieces of vegetables, noodles or meat, and canned fruit with juice. This also refers to foods that release liquid when chewed (for example, watermelon and cherry tomatoes).

Frozen yogurt, ice cream, soy frozen desserts, sherbet, and popsicles containing hard particles such as dried fruit, nuts, or granola become a thin fluid with solids once the frozen fluid has melted. These are mixed consistencies and should be avoided with a no mixed consistency diet.

Examples of mixed consistencies and how they can be modified are shown below:

Mixed consistencies Modify Modified

Regular Soup Blended Soup

Fruit Cocktail Blended Fruit

107

Foods Allowed and Not Allowed on No Mixed Consistencies

Foods Allowed Foods Not Allowed Vegetables and Fruit  Pureed stewed tomatoes, sliced  Whole, diced or mashed, stewed or baked tomatoes tomatoes, whole cherry tomatoes  Creamed corn  Green or wax beans  All canned fruit, even if drained  Watermelon, oranges (navel, canned or fresh mandarins) and grapes Grain Products  Hot cereals  Crackers, Melba toast, or rice cakes when added to soup  All cold cereal when milk or other thin liquid is added Milk and Alternatives  Yogurt, milk pudding or custard  Yogurt or sherbet containing dried fruit, nuts, that is smooth or contains soft granola, seeds, or any other hard particles fruit pieces  Milk pudding including rice pudding with or without raisins, custard Mixed Dishes and Condiments  Pureed soups  All unblended soups  Less than 2 Tbsp/30 mL of gravy  More than 2 Tbsp/30 mL of gravy pooling around pooling around meat meat  Frozen yogurt, ice cream, soy  Gelatin with fruit frozen desserts, sherbet, or  Frozen yogurt, ice cream, soy frozen desserts, popsicles that are smooth sherbet, or popsicles that contain hard particles such as dried fruit, nuts, or granola Drinks  Most drinks, except those listed  Drinks with firm fruit chunks or ice cubes, as not allowed (for example, milkshakes with fruit)

Altering foods to remove Mixed Consistencies

 Soup: Puree or strain soups so that no mixed consistencies remain. Do not serve with crackers.  Cereal: Serve hot cereal only. Do not serve any dry cereal.

Menu planning for texture modified diets with No Mixed Consistencies will depend on the primary texture modification ordered, for example; a patient, who needs Dysphagia Soft and No Mixed Consistencies modification, will have a much different menu than a patient needing Pureed and No Mixed Consistencies modification. Refer to the primary texture modification ordered for a list of snack ideas and a sample meal plan.

108

Pureed Bread Products

Description

A change from regular bread products to pureed bread products may be needed for some people with chewing and/or swallowing problems. When an individual is on a Pureed diet, Pureed Bread Products should automatically be provided. However, Pureed Bread Products can also be given with other primary texture modifications as needed. For example, Minced diet with Pureed Bread Products, or Dysphagia Soft diet with Pureed Bread Products.

Pureed bread products are soft and moist, like all other pureed foods. Bread products must be smoothly blended to a pudding or mousse consistency. Bread products include all breads, muffins, crackers, sandwiches, pancakes, cookies, cakes, and bread pudding.

Examples of pureed bread products:

Pureed bread Pureed waffle Oatmeal

Foods Allowed and Not Allowed on Pureed Bread Products

Foods Allowed Foods Not Allowed Grain Products  Pureed or slurried bread products (including  All regular texture bread products bagels, biscuits, bread, cakes, cookies,  All grain products that contain chocolate crackers, muffins, pancakes, pastry crust, chips, nuts, seeds, dried fruit, or any hard pita, buns, or any other bread product) particles, even if pureed or slurried  Smooth hot cereals  Hot cereal with seeds; large flake oatmeal  Rice, couscous, or barley in a sauce or  All cold cereals gravy.  Dry, loose rice  Minced or bite-sized pasta, cooked until very soft, and served in a sauce or casserole  Pureed sandwiches with allowed ingredients Drinks  All drinks allowed depending on the diet texture and fluid order

109

Steps for Preparing Pureed Bread Products

Pureed bread products can be made by either pureeing or by making a slurry.

Pureeing To make a pureed bread product, use a hand blender with a chopper attachment, mini chopper, food processor, or blender.

1. Take one serving of bread product and break into small pieces if needed. 2. Add 1 Tbsp/ 15 mL of liquid, such as milk, juice, syrup, broth, melted butter or margarine to puree the food. 3. Blend together until smooth and moist like a pudding or mousse.

If the pureed food is too thick:  Add extra liquid to your pureed food. Add 1 Tbsp/ 15 mL of liquid at a time.  Puree food again to make bread product smooth and moist.

If the pureed food is too thin:  Thicken using more of the food being pureed or add a commercial thickener.  Puree food again. If pureed food is still too thin, repeat the steps above.

Slurries Slurries can be used to soften bread or baked items to ensure the right texture for the pureed diet. The finished product looks like the initial product, but feels like pudding in the mouth. A slurry is made using liquid (juice or milk) and a commercial thickener.

Examples of slurries include; a bread slurry, a French toast, pancake or waffle slurry, a muffin slurry, a cake/cookie slurry, or a brownie/bar slurry. Foods prepared as a slurry, should not contain; nuts, seeds, dried fruit or coconut.

Directions and recipes for slurries can be found on the next page.

Commercial Pureed Products

Commercial pureed bread products are available through many suppliers. Using these products will help ensure consistency in products, nutrition and safety.

Planning Menus with Pureed Bread Products

Menu planning for texture modified diets with pureed bread products will depend on the primary texture modification ordered. For example, a resident on Dysphagia Soft with Pureed Bread Products will have a different menu than a resident on Easy to Chew with Pureed Bread Products. Refer to the primary texture modification for a list of snack ideas and a sample meal plan.

For more information, please see Appendix 2C, Nutrition and Menu Planning Resources for the handout Pureed Bread Products.

110

Preparing Slurries

Below is a recipe for a Slurry Mix, followed by two recipes that show how to use the mix.

Slurry Mix:

Ingredients: 1 Tbsp Commercial thickener 15 mL ½ cup 1% Milk, heated 125 mL

Directions: 1. Mix commercial thickener with hot milk and stir until smooth.

Makes 1 serving (½ cup/ 125 mL)

Nutrition information per serving: 66 calories, 1g fat (0.8 g saturated fat, 0 g trans fat), 63 mg sodium, 10 g carbohydrate, 4 g protein, 145 mg calcium.

Note: A higher fat milk (such as homogenized- 3.25% M.F.) or cream may be used for individuals who require extra calories. Hot juice, water, or a nutrition supplement can also be used. If another liquid is used it will change the nutrition content of the recipe.

111

Slurry Cookies:

Ingredients: ¼ cup Slurry mix (see above) 50 mL 2 each Digestive cookies 2 each

Directions:

1. Place two digestive cookies in a dish. 2. Cover with slurry mix. Let stand until soft, and then serve.

Makes 1 serving (2 cookies)

Nutrition information per serving: 119 calories, 4 g fat, (1.7 g saturated fat, 0 g trans fat), 116 mg sodium, 17 g carbohydrate, 3 g protein, 73 mg calcium.

______

Slurry Pancake:

Ingredients:

½ cup Slurry mix (see above) 125 mL

1 each Pancake, frozen 1 each

Directions: 1. Place pancake in a dish and add slurry mix. Spread evenly and cover. Put in the refrigerator overnight to let the pancake absorb the slurry mix. 2. Warm in a microwave, oven, or toaster oven. Remove and serve.

Makes 1 serving (1 pancake)

Nutrition information per serving: 152 calories, 5 g fat (1.6 g saturated fat, 0 g trans fat), 230 mg sodium, 21 g carbohydrate, 6 g protein, 226 mg calcium.

112

Thick Fluids

Description

Thick fluids may be needed for people with swallowing difficulties, to safely manage taking fluids by mouth. Thick fluids can be controlled in the mouth and swallowed more safely. This reduces the risk of the fluid going down the wrong way, into the lungs.

A fluid is any liquid like water, juice, soup or milk. A fluid can also be a food that melts at body temperature, such as gelatin or ice cream. The thickness of fluids can vary but most fluids are naturally thin.

Below are examples of three different thick fluid levels:

Nectar Thick Fluids

 Mildly thick  Pours like fruit nectar  Fluid runs freely off the spoon but leaves a thin coating on the spoon

Honey Thick Fluids

 Moderately thick  Fluid slowly drips in dollops off the end of the spoon  Pours slowly, like liquid honey

Pudding Thick Fluids

 Extremely thick  Fluid sits on the spoon, and does not flow off

Images used with permission from Nestlé HealthCare Nutrition.

Most people on Thick Fluids can also tolerate thicker fluid levels than ordered, but not thinner fluid levels. For example, a person needing Honey Thick can usually tolerate both Honey, and Pudding Thick, but not thinner fluids like Nectar Thick. Check with the residents’ health care provider to confirm their tolerance.

113

Foods Allowed and Not Allowed with Thick Fluids

Foods Not Allowed Foods Allowed (Unless Thickened) Nectar Thick fluids Thin fluids  Some brands of tomato juice  Au jus  Fruit nectar (such as prune nectar)  Broth   Yogurt that is smooth or contains soft fruit pieces (for Buttermilk example, plain or flavoured) at a Nectar Thick consistency  Coffee  Eggnog  Pureed or strained soup thickened to Nectar Thick consistency  Fruit juice  Fluids thickened to Nectar consistency  Gelatin desserts Honey Thick fluids  Gravy  Liquid honey  Ice  Ice cream  Yogurt that is smooth or with soft fruit pieces (for example,  plain or flavoured) at a Honey Thick consistency Liquid medications  Milk  Pureed or strained soup thickened to Honey Thick consistency  Milkshake  Fluids thickened to a Honey consistency  Nutrition supplement drinks Pudding Thick fluids  Pop  Popsicles  Pureed fruit at a Pudding thickness  Sauces  Smooth cooked cereal  Sherbet  Smooth custard or pudding  Slushy drinks  Yogurt that is smooth or contains soft fruit pieces (for  Spirits, wine, alcohol example, plain or flavoured) at a Pudding Thick consistency  Soup  Pureed foods that sit on the spoon  Syrup  Pureed or strained soup thickened to a Pudding Thick  Table cream (10-36% M.F.) consistency  Tea  Thin fluids thickened to a Pudding consistency  Vegetable juice (except some brands of tomato)  Water

114

Tips for Thickened Fluids

 Smooth yogurt available in the grocery store may vary in thickness from nectar to pudding depending on brand and type. Smooth yogurt consistency should not be changed by adding thickener.  Small amounts of thin milk or cream (1 ½2 tsp/ 810 mL) and/or sugar can be added to already thickened beverages such as coffee and tea without changing the consistency.  Gravies, sauces, and syrups do not need to be thickened if served in standard portions on top of the food item (for example, on top of the mashed potatoes). If these items are “pooling” on the plate or are served on the side, they will need to be thickened to the proper consistency.

Steps for Preparing Thickened Fluids

1. Portion the amount of fluid and sprinkle the required amount of powder or gel thickener on top and mix briskly until dissolved. Always follow the directions on the commercial thickener container to thicken the fluids correctly. Different fluids will need different amounts of thickener. 2. Wait 5 minutes to ensure the fluid is thickened to the right consistency. (Or longer, if specified by the manufacturer). 3. Test the thickness to match the description.

Commercial Thickeners and Pre-Thickened Beverages

 Commercial thickeners are products that can be added to a fluid to thicken it up to a desired and safe consistency (Nectar, Honey, or Pudding). There are both powder and gel forms. These are made from a starch or gel which acts as a thickening agent.  Pre-thickened beverages such as water, juice, milk, and coffee can be purchased from local pharmacies or food suppliers. Using these products will help ensure consistency in products, nutrition and safety.

Fluid Needs

Residents must be provided with at least 6 cups/ 1500 mL of fluid each day. Refer to the How to Plan a Menu section of this toolkit for more information on meeting fluid needs.

For more information, please see Appendix 2C, Nutrition and Menu Planning Resources or the resource Thick Fluids.

115

Education and Resources

It is important that food service staff are aware of the foods and fluids appropriate for various special diets and how much to serve. The following tools may be useful:  The Texture Modified Diet poster in Appendix 3A and the Thick Fluids poster in Appendix 3B can be used as a quick reference for production staff on appropriate food and fluid choices.  The Texture Modified and Thick Fluids Preparation Training programs can be found in Appendix 3C.

A registered dietitian can provide staff with more education on special diets.

116

Document

4.0 Right Diet

to the Right

Resident

itle Goes Here

117

Computer Tip! Click on each hyperlink to take you to the website 4.1 Overview for more information.

Written processes and clear communication are needed within food production, delivery and service. Providing residents with the right food at meals and snacks is important to keep them safe and to help meet their nutritional needs. Food service and other staff should be familiar with the dietary needs of individual residents. A system should be in place to ensure the correct food and fluids are provided at each meal. Policies and procedures related to food service should be developed and staff should be educated on the processes.

Tips for Diet Process Flow8

Have a process in place for clearly communicating and identifying residents with special diets, food allergies, intolerances or restrictions, and/or likes and dislikes.

 Communicate all new requests or changes to a diet to nursing, food service and dining room staff: o A “Diet Request Form” completed by an assigned staff member can help outline special dietary requirements for all diet types. A Sample Diet Request Form is available in Appendix 4A. o Any diet changes should be communicated using the diet request form. The assigned staff member (see section 4.2 for staff assignments) should update the form and make sure all areas, such as the kitchen, dining area and resident’s chart reflect the change. o A similar process can also be used to update the “Food Allergies, Intolerances and Restrictions Record” (see Appendix 1A). o New requests or changes should follow the sites privacy policy.

 Identify each resident following a special diet. o This can be done using a dining room table card with the resident’s name and special diet (see Appendix 4B, Colour Coded Special Diet Cards), diet binder/kardex, spreadsheet or whiteboard. These can list a resident’s dietary needs such as special diet, food allergies/intolerances, restrictions (for example, religious or cultural), and food likes/dislikes. o Use this system to cross check all diets to ensure residents are receiving the correct meals and snacks daily. Keep this cross check system regularly updated and easily available for staff to reference. o Any process developed should meet the privacy policy requirements of the site.

 Ensure meals and snacks are prepared and labeled to meet any special dietary requirements. See Section 3.1, Menu Substitutions and Preparing Special Diets for more information.

 Have a system to transport bulk meals to the dining room following food safety guidelines. Check the temperature of the food to make sure it is appropriate (keep hot foods hot, and cold foods cold). See Section 1.4 Food Safety for more information.

118

 Plate meals for individual residents as appropriate and ensure the right meal goes to the right resident. o Use the correct size serving utensils to ensure standard portions when plating foods. Please refer to the Standardized Portion Sizes section of the toolkit on page 36 for further information.

 Have processes in place for meal service and distribution. o Ensure residents are in the dining area at the start of meal service so there are no delays. o Make sure meals are served at the posted time. o Everyone at the same table should be served at the same time. o Have extra food and beverage servings available. o Rotate the order of table-by-table service on a regular basis to allow each resident the chance to be served first. o Assign staff regular tables so they become familiar with the dietary needs and preferences of individuals. o Inform the residents of what they are being served.

 Provide meal and snack assistance. o Review seating patterns often to ensure individuals are eating with suitable tablemates. o As appropriate, seat those requiring assistance (such as help opening packages or having foods cut up) at tables together.

Tray Service: Tray service is where the complete meal is assembled on a tray ahead of time and brought to the resident. If using tray service, meals need to be plated and labeled with the individual’s name and special diet before bringing the meal to the individual in the dining room or their room.

119

4.2 Assigning Tasks for Diet Process Flow for Meal Services

A variety of staff members may be involved in ensuring the process of providing the right diet to the right resident flows smoothly. The Sample Diet Process Flow Chart on the next page, outlines food service tasks to be completed and the suggested staff member(s) responsible. The chart provides space to list individuals assigned to each task. The staff completing these tasks can vary from site to site, but all these tasks should be clearly defined and assigned. Place the diet process flow chart where all staff can access it, such as the site’s policies and procedures manual.

120

Sample Diet Process Flow for Meal Service

Suggested Staff Assigned Staff Task Member Member

Develop policies and procedures Food Service related to food service and provide Manager, Supervisor education to staff on the processes.

Communicate all new requests or changes to diet using a ‘diet request Chef, Food Service Staff, form’. Update form with any changes, Case Manager, Nursing ensuring the kitchen, dining area and Staff, Dietitian resident’s chart reflect changes.

Identify residents following special diets using a dining room table card, Chef, Food Service Staff, diet binder/kardex, spreadsheet, etc. Nursing Staff Use the system to cross check meals and snacks when served.

Prepare meals and appropriate special diet items. Label special and/or texture Chef, Food Service Staff modified meal items for residents.

Transport meals in bulk to the dining area. Check food temperatures to ensure foods are in the safe Food Service Staff temperature zone.

Use the correct serving utensils to plate appropriate meals with standard Food Service Staff portions for individual residents.

Distribute meals to residents. using Food Service Staff, the cross check system to ensure the Nursing Staff right food goes to the right resident.

Provide meal and snack assistance to residents as required, (for example, Food Service Staff, help open packages or cutting up Nursing Staff foods.

121

References

1 British Columbia Ministry of Health. Meals and more manual: a food and nutrition manual for homes of adults and children with 24 or fewer persons in care. [Online]. 28 November 2008 [cited 2012 March 01]. Available from:/www.health.gov.bc.ca/library/publications/year/2008/Meals_and_More_Manual.pdf 2 Government of Alberta. Supportive living accommodation standards and checklist. [Online]. April 2010 [cited 2012 March 01]; Available from: http://www.health.alberta.ca/services/supportive-living- licensing.html 3 Health Canada. Eating well with Canada’s food guide. [Online]. 2011 [cited 2012 March 01]. Available from: www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php 4 Health Canada. Safe food storage [Online]. 2013 [cited 2012 March 01]. Available from: www.healthycanadians.gc.ca/eating-nutrition/safety-salubrite/storage-entreposage-eng.php 5 Health Canada. Food allergies. [Online]. Updated 2011 Feb 10 [cited 2011 Nov 21]. Available from: http://www.hc-sc.gc.ca/fn-an/securit/allerg/fa-aa/index-eng.php 6 Health Canada. Food allergies and intolerances. [Online]. Updated 2010 Aug 26 [cited 2011 Nov 21]. Available from: http://www.hc-sc.gc.ca/fn-an/securit/allerg/index-eng.php 7 Dietitians of Canada. Find a dietitian. [Online]. 2012 [cited 2012 June 22]. Available from: http://www.dietitians.ca/Find-a-Dietitian 8 Health Canada. Eating well with Canada’s food guide: a resource for educators and communicators. [Online]. 2011 [cited 2012 March 01]. Available from: http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb- dgpsa/pdf/pubs/res-educat-eng.pdf 9 Government of Alberta. Alberta nutrition guidelines for adults. [Online]. August 2012 [cited 2014 March 01]. Available from: http://www.health.alberta.ca/documents/Nutrition-Guidelines-AB-Adults.pdf 10 Health Canada. Food and nutrition: nutrient content claims and what they mean [Online.] 2012 [cited 2012 March 01]. Available from: http://healthycanadians.gc.ca/eating-nutrition/label- etiquetage/nutrient_claims-allegations_nutriment-eng.php 11 Canadian Celiac Association. In the kitchen. [Online] March 2012 [cited 2012 March] Available from: [Online]: http://www.celiac.ca/?page_id=685

122