1 fried egg
½ c. oatmeal (may be fortified)
1 slice whole wheat toast
1 Tbsp. jelly
1 Tbsp. peanut butter
1 c. whole milk
Hot beverage
Sugar, pepper (optional)
½ c. mashed “power” potatoes with gravy
½ c. mixed vegetables
1 oz. whole wheat roll
2 tsp. soft margarine
½ cup strawberry ice cream
1 c. whole milk
Water
1Tbsp. mayonnaise
2 tomato slices
1 c. leafy greens salad with grated parmesan cheese and walnuts
1 Tbsp. salad dressing
½ c. fruit cocktail canned in heavy syrup
1 c. whole milk
Water
Milkshake or medical nutrition supplement
3 c. popcorn with butter
REFERENCES
1. Morley JE, Thomas DR, Kamel HK. Nutritional deficiencies in long-term care. Part I: detection and diagnosis. Supplement to Annals of Long Term Care. 2004;12:2, 1–7.
2. Morley JE. The anorexia of aging: physiologic and pathologic. Am J Clin Nutr. 1998;66:760–73.
3. Dinarello C. Interleukin-1 and interleukin-18 as mediators of inflammation and the aging process. Am J Clin Nutr. 2006;83:2, 447S–55S.
4. Knoops KTB, Slump E, de Groot LCPGM, et al. Body weight changes in elderly psychogeriatric nursing home residents. Journals of Gerontology: Series A. 2005;60:4, 536–39.
5. Evidence Analysis Library, American Dietetic Association. What is the relationship between nutrient-dense oral supplements/fortified foods and weight gain in adults over age 65? Available at http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250778.
6. Varma R. Risk for drug-induced malnutrition is unchecked in elderly patients in nursing homes. JADA. 1994;94:2, 192–94.
7. Thomas DR, Kamel HK, Morley JE. Nutritional deficiencies in long-term care. Part II: management of protein energy malnutrition and dehydration. Supplement to Annals of Long Term Care. 2004;12:2, 8–14.
8. National Pressure Ulcer Advisory Panel, Dorner B, Posthauer ME, et al. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper, 2009. Available at http://www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf.
9. Horn SD, Bender SA, Ferguson ML, et al. National pressure ulcer long-term care study: Pressure ulcer development in long-term care residents. J Amer Geriatr Soc. 2004;52:3, 359–67.
10. Bergstrom N, Horn SD, Smout RJ, et al. The National Pressure Ulcer Long-Term Care Study: Outcomes of pressure ulcer treatments in long-term care. J Amer Geriatr Soc. 2005;53:10, 1721–29.
11. Marik PE, & Zaloga GP. Immunonutrition in high-risk surgical patients: a systematic review and analysis of the literature. J Parenter Enteral Nutr. 2010;34:4, 378–86.
12. Doley J. Nutrition management of pressure sores. Nutr Clin Pract. 2010;25:1, 50–60.
13. Skipper A. Challenges in nutrition, pressure ulcers, and wound healing. Nutrition in Clinical Practice. 2010;25:1, 13–15.
14. Castellanos VH, Marra MV, Johnson P. Enhancement of select foods at breakfast and lunch increases energy intakes of nursing home residents with low meal intakes. J Am Diet Assoc. 2009;109:445–51.
15. Silver HJ, Dietrich MS, Castellanos VH. Increased energy density of the home-delivered lunch meal improves 24-hour nutrient intakes in older adults. J Am Diet Assoc. 2008; 108:2084–89.
16. Turic A, Gordon KL, Craig LD, et al. Nutrition supplementation enables elderly residents of long-term-care facilities to meet or exceed RDAs without displacing energy or nutrient intakes from meals. J Am Diet Assoc. 1998;98:1457–59.
17. Wilson MM, Purushothaman R, Morley JE. Effect of liquid dietary supplements on energy intake in the elderly. Am J Clin Nutr. 2002;75:944–47.
SMALL PORTIONS DIET
Use
The Small Portions diet follows the principals of the General Diet, except for the reduced portion sizes of some foods. This diet is indicated for patients who need a reduced portion size for weight maintenance or weight reduction or for individuals who request a reduced portion because the portion size offered on the General Diet is too overwhelming.
Small Portion Diet principles may be adjusted to accommodate individual preferences and nutritional needs.
Adequacy
The suggested food plan reduces the calories from the General Diet to prevent undesired weight gain or promotes gradual weight loss, depending on the individual’s energy needs. It provides adequate protein intake but may not meet all Dietary Reference Intakes (DRIs) of some individuals as recommended by the National Academy of Sciences for adults. The need for vitamin and mineral supplementation should be assessed on an individual basis by the healthcare team. Individuals consuming a small portion diet should be weighed frequently and monitored for poor food intake, resulting in undernutrition.
Diet Principles
1. Meats, meat alternates, or entrée: offer same portion as General Diet.
2. Vegetables: portion reduced to 
cup.
3. Fruits: offer same portion as General Diet.
4. Milk and milk products: offer same portion as General Diet.
5. Grains other than fortified breakfast cereals: portion reduced to half serving; ½ slice of bread, ¼ cup of pasta or rice.
6. Fluids other than milk: offer same portion as General Diet.
7. Discretionary calories (desserts, alcohol): portion reduced to half serving.
Table 11.2 Suggested Menu Plan for Small Portion Diet
| Breakfast |
| ½ c. orange juice 1 egg ½ c. oatmeal ½ slice whole wheat toast 1 tsp. jelly 1 tsp. soft margarine 1 c. fat-free milk Hot beverage Sugar, pepper (optional) |
| Lunch |
| 2 oz. roasted chicken breast ¼ c. mashed potatoes with gravy  c. mixed vegetables ½ oz. whole wheat roll 1 tsp. soft margarine ¼ cup ice cream 1 c. fat-free milk Water |
| Supper |
6 oz. tomato soup  c. tuna salad on 1 slice whole wheat bread ½ c. leafy greens salad 1 Tbsp. sunflower oil and vinegar dressing ½ c. fruit cocktail 1 c. fat-free milk Water |
| Snack Ideas |
| ½ c. cantaloupe ½ c. carrot sticks 1 c. popcorn |
ADDITIONAL RESOURCES
Position Paper of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc. 2005 Dec;105(12):1955–65.
Yager R., Department of Developmental Services, State of California Health and Human Services Agency. Small Diet. In: Diet Manual, pp. 1.3–1.4.
VEGETARIAN DIETS
Use
The use of the vegetarian diet is for individuals wishing to avoid foods that come from animals. The diet exclusions vary depending on the type of vegetarian. Vegetarian-style eating patterns have been associated with improved health outcomes—lower levels of obesity, a reduced risk of cardiovascular disease, and lower total mortality. (1)
- Vegan or Total Vegetarian Diet excludes meat, fowl, seafood, eggs, and dairy and foods that contain them.
- The Lacto-Vegetarian Diet excludes meat, fowl, seafood, eggs, and foods that contain them. Consumes plant foods, cheese, and other dairy products.
- Lacto-Ovo-Vegetarian Diet excludes meat, fowl, and seafood and foods that contain them. Consumes plant foods, cheese, other dairy products, and eggs.
- Semi-Vegetarian Diet excludes red meat but may include chicken or fish and most other animal products. The use of the General Diet with proper exclusions is recommended for this diet.
Adequacy
The suggested food plans include foods in amounts that will provide the DRIs recommended by the National Academy of Sciences for adults. Vegetarian diets when planned appropriately are nutritionally adequate for individuals during all stages of the life cycle including, pregnancy, lactation, childhood, adolescence, and athletes. Additional modifications may be needed during illness. The Dietary Guidelines for Americans 2010 include USDA Food Patterns and vegetarian variations to help individuals carry out diet recommendations; they can be viewed at www.dietaryguidelines.org in the DGA Policy Document.
Diet Principles
1. Obtain an accurate diet history and assessment to determine the extent to which foods are limited, excluded and to determine the quality of the foods they consume.
2. Provide adequate nutrients by including mostly foods rich in nutrients and fortified. Limit low-nutrient foods, sweets, and fats.
3. Limit highly processed grains and other refined carbohydrates to ensure adequate intake of trace nutrients.
4. Avoid excess cholesterol intake by limiting eggs to three or four egg yolks a week for those who consume eggs.
5. Careful consideration should be given to the following when planning vegetarian diets:
a. Protein. Plant proteins alone can provide enough amino acids (the building blocks of protein) when a variety of plant proteins are eaten throughout the day and the total caloric intake meets the individual’s energy needs. It is no longer recommended that complementary proteins be eaten at the same meal. Protein needs may be higher than the Recommended Daily Allowances in those whose main protein source is from cereals and legumes, especially when quantity is limited. Increase in the total quantity of these foods or inclusion of more beans and soy products is recommended. Substitutes for 1 ounce of meat are:
8 ounces fortified soy milk
½ cup cooked dry beans
2 tablespoons peanut butter or other nut butter
2 tablespoons nuts or seeds
4 ounces tofu, tempeh, or vegetable burger
1 whole egg or 2 egg whites (Lacto-Ovo-Vegetarian)
b. n-3 (Omega) Fatty Acids. Vegans in particular who do not consume fish, eggs, or algae may have lower levels of omega-3 fatty acids: docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Additional plant-based n-3 fatty acid a-linolenic acid (ALA) can be consumed and used for conversion into DHA and EPA. Good sources of ALA for vegans are flaxseed, walnuts, canola oil and soy.
c. Calcium intake of vegans tends to be low. Vegans tend to have a ratio of calcium to protein that is similar or lower than nonvegetarians, which some studies find is a good predictor of bone health. Therefore, calcium fortified foods or dietary supplements should be used. Fortified foods include fruit juices, soy milk, rice milk, and breakfast cereal or bars.
d. Vitamin D. Sun exposure and intake of fortified foods are important in meeting recommended vitamin D needs. Foods that are fortified with vitamin D include cow’s milk, some brands of soy milk, rice milk, and orange juice, and some breakfast cereals and margarines. Those who have limited exposure to sunlight and insufficient intake of foods are recommended to use a vitamin D supplement.
e. Iron in plants is not as readily absorbed as that in meats. Foods rich in vitamin C can enhance absorption by reducing the inhibitory effects of phytate. The following can also interfere with iron absorption: tea, herbal tea, coffee, and cocoa. See Iron Content of Selected Food in Appendix 8 for good sources of iron.
f. Vitamin B12. Only animal products contain vitamin B12. Diets of vegetarians who eat dairy products and eggs are rarely deficient in vitamin B12. Vegans need a reliable source of vitamin B12; good fortified sources include fortified cereals, fortified soy or rice beverages, some brands of nutritional (brewer’s) yeast, meat analogs, and a daily vitamin supplement.
g. Zinc. The absorption of zinc is decreased by phytic acid (commonly higher in vegetarian diets). Vegetarians usually have adequate zinc status. Foods containing zinc include fortified cereals, beans, wheat germ, nuts, and seeds.
h. Iodine. Vegans consuming plant based diets typically are low. A diet including iodized salt is recommended. Sea vegetables can assist in meeting needs (content can vary). Additionally, it is important to note that Kosher and sea salt and tamari typically do not contain iodine.
6. Read product labels carefully to avoid hidden ingredients such as meat extracts, animal fats, eggs, and milk.
7. The Dietary Guidelines for Americans 2010 include Lacto-ovo Vegetarian and Vegan Adaptions of the USDA Food Patterns, visit http://dietaryguidelines.gov.
Table 11.4 has guidelines for the Lacto-Ovo-Vegetarian Diet. Items marked with an asterisk would be omitted from a vegan (no animal products) meal plan.
Table 11.3 Vegetarian Diet
| Food for the Day | Recommended | Avoid |
| Vegetables 1–4 cups | Any fresh, canned, frozen; vegetable juice | Deep-fried or battered and fried vegetables |
| Fruits 1–2.5 cups | Any fresh, canned, frozen, dried; 100% fruit juice | Dried fruit with added sweetener |
| Grains 3–10 ounce equivalents At least half of all grains eaten should be whole grains | Whole wheat grain products: pasta, tortillas, waffles, crackers, bread and cereal Popcorn, oats, millet, quinoa, brown rice | Enriched grains, or grains with excess sweeteners |
| Dairy products 2–3 cups | Fat-free* or low-fat (1%) milk* Almond, coconut, hemp, oat, soy, or other dairy alternatives Low-fat flavored or plain yogurt,* soy yogurt Low-fat cheese* or soy cheese. | Whole* or reduced fat milk*, chocolate milk.* high-fat cheese*, sour cream*, cream cheese.* |
| Protein foods 2–7 ounce-equivalents | Eggs,* meat alternatives, tofu, tempeh, seitan, textured vegetable protein; vegan jerky Legumes, dried beans, edamame Nuts and nut butters including soy nut butter, tahini and hummus | Refried beans, fried meat alternatives |
| Oils, Solid Fats, Added Sugars Use sparingly | Vegetable oils and soft margarines from vegetables. Low-fat, moderately sweetened such as pudding/custard made with fat-free milk.* Angel food cake,* graham crackers, vanilla wafers, flavored yogurt,* light ice cream,* frozen yogurt,* fruit and nut bars | Hydrogenated oils, palm kernel oil, palm oil, stick margarine, partially hydrogenated oil High sugar, high-fat desserts such as pie,* pastries,* frosted cake,* candy, ice cream,* and frozen treats. |
| Fluids | Water, bottled and sparkling, milk,* coffee, tea, coconut water. | Beverages with added sweeteners. |
| Other | Vegetable broth, herbs and spices, hummus, low sodium seasonings, nutritional yeast, brewer’s yeast, wheat germ, flax seed, chia seed, stevia |
*These items would be omitted from a vegan (no animal products) meal plan.
Table 11.4 Suggested Menu Plan for Lacto-Ovo Vegetarian Diet
| Breakfast |
| ½ c. orange juice 1 egg or 1 Tbsp. peanut butter ½ c. oatmeal 1 slice whole wheat toast 1 c. fat-free milk Hot beverage Sugar, pepper (optional) |
| Lunch |
| 2 oz. meatless burger, soy-based ½ c. mashed potatoes (made without chicken stock) ½ c. mixed vegetables 1 oz whole wheat roll 1 tsp. soft margarine 1 c. fat-free milk Water |
| Supper |
| 1 oz. low-fat cheese 1 oz. seasoned pinto beans served over 1 c. leafy greens salad 1 Tbsp. sunflower oil and vinegar dressing 2 tomato slices 1 whole-grain bagel 1 tsp. soft margarine ½ c. fruit cocktail 1 c. fat-free milk Water |
| Snack Ideas |
| 1 c. cantaloupe ½ c. carrot sticks 3 c. popcorn |
Table 11.5 Suggested Menu Plan for Vegan Diet
| Breakfast |
| ½ c. orange juice 1 Tbsp. peanut butter ½ c. oatmeal made with fortified soy milk 1 slice whole wheat toast 1 c. fortified soy milk Hot beverage Sugar, pepper (optional) |
| Lunch |
| 2 oz. meatless burger, soy-based ½ c. mashed potatoes made with fortified soy milk ½ c. mixed vegetables 1 oz. whole wheat roll 1 tsp. soft margarine 1 cup strawberries with 3 graham cracker squares 1 c. fortified soy milk |
| Supper |
| 2 oz. seasoned pinto beans served over 1 c. leafy greens salad 1 Tbsp. sunflower oil and vinegar dressing 2 tomato slices 1 whole-grain bagel 1 tsp. soft margarine ½ c. fruit cocktail 1 c. fortified soy milk |
| Snack Ideas |
| 1 c. cantaloupe ½ c. carrot sticks 3 c. popcorn |
REFERENCES
1. US Department of Agriculture, & US Department of Health and Human Services. Dietary Guidelines for American, 2010, 7th ed. Washington, DC: US Government Printing Office, 2010.
ADDITIONAL RESOURCES
American Dietetic Association. Eating Well: The Vegetarian Way. 2006. Available at http://www.eatright.org/shop/product.aspx?id=6442463017.
American Dietetic Association. Becoming Vegetarian. 2007. Available at http://www.eatright.org/shop/product.aspx?id=11270.
American Dietetic Association. Position Paper of the American Dietetic Association: Vegetarian diets J Am Diet Assoc. 2009 July;109(7):1266–82. http://www.eatright.org/ada/files/veg.pdf
Havala S. Vegetarian Cooking for Dummies. New York: Wiley, 2001.
Websites
MyPyramid Vegetarian diets: http://www.mypyramid.gov/tips_resources/vegetarian_diets_print.htm
Vegetarian Nutrition Dietetic Practice Group: http://vegetariannutrition.net/index.php
FOOD ALLERGIES AND INTOLERANCES
If someone has an unpleasant reaction to something they ate, they might wonder if they have a food allergy. Food allergies affect up to 6 to 8% of children under the age of 3 and 2% of adults. One out of three people either believe they have a food allergy or modify their or their family’s diet. Food allergy is commonly suspected, yet healthcare providers diagnose it less frequently than most people believe. In many cases, it is a food intolerance—not a true allergy—that is causing the problem.
Food Allergy
A food allergy is an abnormal response to a food triggered by the body’s immune system. It causes the body to produce antibodies called immunoglobulin E (IgE) to fight it. Symptoms may be immediate or delayed up to a few hours and range from uncomfortable (e.g., hives, stomach upset) to life threatening (e.g., swelling of the tongue, closing of the throat). A severe type of reaction is called anaphylaxis, commonly known as anaphylactic shock. Anaphylactic shock can produce symptoms such as those listed in addition to a drop in blood pressure, unconsciousness, and even death. Diagnosis of a food allergy can usually be made based on skin or lab tests and a detailed diet history. If a severe food allergy exists, an antihistamine or epinephrine kit (i.e., EpiPen) should be on hand per medical prescription.
Food allergies and food intolerances are often mistaken for one another. Most people with a food allergy need to totally eliminate the offending food, however, for some food intolerances, such as lactose intolerance, smaller portions (e.g., 4 oz milk) or a modified version of the offending food (e.g., lactose-reduced or lactose-free milk, yogurt, or cheese) may be well tolerated.
