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Transcript
Education Consultant Marking Guidelines
Food Services and Nutrition Management
Program
Year Two Semester Two
2013-2014
© 2013 Canadian Healthcare Association. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise without
expressed permission of the publisher.
Canadian Healthcare Association
17 York Street, Suite 100
Ottawa, Ontario
K1N 9J6
www.cha.ca
© 2013 Canadian Healthcare Association. All rights reserved.
2
Food Services and Nutrition Management
2013-2014
Table of Contents
Unit 1: .........................................................................................................................................5
Grading Guidelines .....................................................................................................................6
Unit 2 .......................................................................................................................................20
Grading Guidelines ...................................................................................................................21
Unit 3: ......................................................................................................................................48
Grading Guidelines ...................................................................................................................49
Unit 4: ......................................................................................................................................72
© 2013 Canadian Healthcare Association. All rights reserved.
3
FSNM Yr 2 Sr 2
Introduction
Introduction
The following answer keys are intended as a reference for evaluating the content of student
answers. This contributes to consistent grading across Canada. The points in the answer keys
are those which should appear in an average answer. Education Consultants must also
evaluate presentation, evidence of reading and adherence to length.
Students who provide a more comprehensive or sophisticated grasp of the issue should be
graded higher. Superficial answers should be assigned a lower grade.
In questions requiring an essay-style answer, a variety of approaches is possible. The answer
key may not be the only correct approach. Education Consultants should not hesitate to give
appropriate recognition to students who write innovative and appropriate answers which differ
from the answer keys.
Education Consultants may want to use points in the answer keys to indicate shortcomings in
the students’ answers. This is encouraged. But, please do not copy the answers verbatim or
provide copies of the answer keys to students.
Please refer to the general CHA Learning Education Consultant Guide for more information
regarding policies and procedures.
© 2013 Canadian Healthcare Association. All rights reserved.
4
FSNM Yr 2 Sr 2
Unit 5 Assignment
Food Services and Nutrition Management
Unit 5: Nutritional Care
5
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Se 2
Unit 7 Assignment
Grading Guidelines
Question 1 (10 Marks Total)
1. Short Answer Questions
a)
Nutrition Screening is used to identify patients at risk for malnutrition.
(½ mark)
i) True
ii) False
b)
A diet history: (choose two) (½ mark)
i)
is used to evaluate and interpret a client's food intake.
ii) is often compared with medical and social information on the client.
iii) is obtained from notes in facility records.
c)
Diets containing foods that are modified in texture or consistency are prescribed to
treat disorders or conditions that primarily affect the: (½ mark)
i) Musculoskelatal system
ii) Upper gastrointestinal tract
iii) Urinary tract
iv) Lower gastrointestinal tract
d)
The Nutritional Care Plan differs greatly from the Nursing Care Plan. (½ mark)
i) True
ii) False
e)
S.O.A.P refers to a charting format that includes
assessment
, and plan. (1 mark)
f)
Two types of fluid diets are
g)
A diet history should not include a person's food likes and dislikes. (½ mark)
i) True
ii) False
h)
Which of the following types of drugs may cause unintentional weight gain? (½
mark)
i) antipsychotics
ii) antiretrovirals
iii) antinauseants
iv) antibiotics
i)
Three months ago, Mr. Jones weighed his usual weight of 86.45 kg. He has been
admitted to your facility because his family had noticed his weight loss and felt he
clear
subjective , objective
and
full
. (1 mark)
© 2013 Canadian Healthcare Association. All rights reserved.
6
FSNM Yr 2 Sr 2
Unit 5 Assignment
was no longer able to look after himself. His weight at admitting is 173 lbs. Based on
the sample screening tool in your study guide, what is his level of nutritional risk and
the next step? (1 mark)
86.45 kg = 190.19 lbs. He has lost 17.19 lbs in 3 months.
% weight loss in three months = 17.19/190.19 x 100 = 9.0%
He is Priority #1 – High Nutritional Risk – requires further assessment and follow up
by the clinical dietitian.
j)
Using the Harris Benedict Equation calculate the Resting Metabolic Rate (show your
calculations). (2 marks)
a)
Men:
male age 64, 5 feet, 9 inches; weight 180 lbs.
RMR: 66.5 + (13.75 x wt (kg)) + (5.003 x ht (cm)) - (6.755 x age (yrs))
66.5 + (13.75 x 81.81) + (5.003 x 175) - (6.755 x 64) =
66.5 + 1124.88 + 876.82 - 432.32 = 1635.88 kcal
b)
female age 36, height 5 feet, 4 inches; weight 136 lbs.
Women: RMR: 655.1 + (9.563 x wt (kg)) + (1.85 x ht (cm)) - (4.676 x age (yrs))
655.1 + (9.563 x 61.82) + (1.85 x 162.56) - (4.676 x 36)
655.1 + 591.16 + 300.736– 168.336 = 1378.68
k)
Describe how hair, nails, lips and skin can be affected by nutrient imbalances.
(2 marks)
Hair:
Dull, brittle, dry, loose; falls out (PEM); corkscrew hair (copper)
Nails:
Ridged (PEM); spoon shaped, pale (iron)
Lips:
Dry, cracked, or with sores in the corner of the lips (B vitamins)
Skin:
Poor wound healing (PEM, vitamin C, zinc); dry, rough, lack of fat under
skin (essential fatty acids, PEM, vitamins); bruising, bleeding under skin (vitamins C
and K)
7
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
Question 2 (15 Marks Total)
2. Source: DeBruyne, L.K., Pinna, K., Whitney, E.N. (2008). Nutrition and Diet Therapy, 7th
edition; Wadsworth/Thomson Learning, Belmont, CA., USA, p. 422.
Elise Walden is an 85 year old retired businesswoman who has been a widow for 10 years. She
uses a walker and has poorly fitting dentures. She was recently admitted to the hospital with
pneumonia and also has congestive heart failure and diabetes. She routinely takes several
medications to control blood glucose, hypertension and heart function, and in addition to these,
the physician ordered antibiotics to treat the pneumonia. During an initial nutrition screening,
Mrs. Walden stated that she had been eating very poorly over the past two weeks. She said that
she usually weights about 125 lbs; a fact that was documented in her medical chart from a
previous visit. She is a medium frame size. Although she felt she was losing weight, she didn’t
know how much weight she may have lost or when she started losing weight. Upon admission
to the hospital, Mrs. Walden weighted 115 lbs and is 5 feet 2 inches tall. Her serum albumin
level was 30 g/L. A physical exam revealed edema and several other laboratory tests confirmed
that she was retaining fluid. As a result of the nutrition screening, Mrs. Walden was referred to a
dietitian for a complete nutrition assessment.
a)
From the brief description provided, explain which items in Mrs. Walden’s medical,
social and diet histories might alert the dietitian that she is at risk of malnutrition? (8
marks)
Items
85 yr. old widow
Poorly fitting dentures
Pneumonia, diabetes &
CHF
Takes several
medications
Eating poorly
Weight loss
Low albumin
edema
b)
Explanation
Social isolation/ depression may influence poor eating
habits; age
May be impacting poor eating habits or food choices
(mechanical)
Can impact food intake (desire to eat); energy
requirements – illness increases energy needs, but
decrease appetite due to difficulty in breathing
Medication can affect nutrient absorption (GI tract) and
appetite (food intake)
Aware that she is not eating well – could indicate low in
certain nutrients, energy, etc.
Weight loss may reflect changes in hydration status, and
involuntary weight loss can signify PEM
May reflect early signs of PEM or illness
Fluid retention can accompany malnutrition, infection or
injury.
Calculate a BMI for Mrs Watson; Using BMI, identify a healthy body weight range
for Mrs. Walden. Calculate her %UBW. What do the results reveal? – explain.
(show calculations and formula or marks will be deducted). (5 marks)
Usual weight is 125 lbs (56.8 kg); Current weight 115 lbs (52.3 kg); height: 62” or 1.57 m
BMI = Wt (kg)/Ht (m)2 = 52.3/2.46 = 21.3 Healthy BMI (see comments below)
8
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
Healthy weight range based on BMI of 18.5 – 24.9 (see comments) = (101 – 135 lbs)
Calculation:
Wt (kg) = BMI x height (m)2
Elise
18.5 x
24.9 x
(1.57)2 =
(1.57)2 =
46 kg
61
101 lbs
135
%UBW = 115/125 = 92% (mild malnutrition) (1 mark)
Although Mrs. Walden is still within a healthy weight range, the fact that she has sustained
unintentional weight loss is a concern, and has a UBW of 92%.suggesting mild malnutrition
And also because of her age. And the use of BMI for this group (Students may note – as
indicated in their readings, “For persons 65 years and older the 'normal' range may begin
slightly above BMI 18.5 and extend into the 'overweight' range (25-29.9).” so her weight loss is
a concern (2 mark for the explanations)
c)
What effect does fluid retention have on Mrs. Walden’s weight? What physical
symptoms may have suggested that she was retaining excess fluid? (1 mark)
She may even weigh less than the 115 lbs measured upon admission because her edema is
causing an increase in weight due to water.
Physical symptoms of retaining excess fluid include: weight gain, facial puffiness, swelling of
limbs, abdominal distention and tight fitting shoes.
d)
What tools can be used to estimate Mrs. Walden’s usual food intake? (1/2 mark)
A 24-hour recall, a food frequency questionnaire, a food record, or a kcalorie count can be used
to estimate Mrs. Walden’s usual food intake.
e)
Describe other types of assessment information the dietitian may need before
developing a nutrition care plan. (1/2 mark)
In addition to a more thorough medical, social and nutrition history the dietitian will need to
assess her the biochemical data available. The dietitian will need to estimate Mrs. Walden’s
energy, protein and fluid needs in order to develop her nutrition care plan.
Question 3 (15 Marks Total)
3. A volunteer who delivers meals on wheels noticed that Mrs. H. was not eating her meat
or her raw fruits and vegetables. She reported this to her supervisor and a visit was
made by the Home Care Worker. They recommended Mrs. H. be admitted to the nursing
home where you are the food service supervisor.
Mrs. H. has been at your facility for a week. An initial evaluation has been made by the
physician and the nurse. The following data has been charted.
"Mrs. H. is a 76 year old widow who lives alone. Her income is based on Canada
Pension with some savings from the sale of her home. She is 160 cm tall and weighs 42
Kg. Her usual weight is 47 Kg but she has recently lost weight. Her haemoglobin is 94
g/L, haematocrit 33% and serum albumin 28 g/L. She takes buffered aspirin twice a day
9
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
for relief from arthritis. She is depressed about not being in her own home and dislikes
apartment living.
Her typical day at home is as follows. She rises at 8 a.m. and has meals at 9 a.m., noon
and 5 p.m. She seldom snacks. She doesn't smoke or drink alcoholic beverages. She
has poorly fitting dentures and her appetite is poor. She has constipation. Her favourite
foods are bread and canned fruit, which she eats twice daily. She doesn't drink milk. She
has a sedentary lifestyle. She goes to bed at 11:00 pm and sleeps well.
From this case study, answer the following questions:
a)
Complete a nutritional assessment form for Mrs. H. who has been admitted to your
facility. (You many use an assessment form from your facility or one in the Study
Guide) (5 marks)
Any assessment form may be used, but it should include the anthropometric data, lab data,
problems and plan for intervention.
b)
Describe specific factors and the corresponding indicators, which are affecting Mrs.
H’s food intake and impacting her nutritional status? (5 marks)
1 - ill fitting dentures
2 - constipation
3 - loss of weight
4 - poor appetite
5 - arthritis
c)
- poor intake of meat, fruits and vegetables
- low fibre intake, low fluid intake
- poor food intake overall
- eats alone, has limited number of foods she likes
- affects dexterity with cooking, moving about and aspirin may give
GI problems
Develop a nutritional care plan for Mrs. H. (5 marks)
The nutritional care plan should be linked to those items identified in a) and b) as problems.
Sample Nutritional Care Plan could be as follows:
1) Modification of texture of meals.
2) Increase fibre and fluid intake.
3) Counselling regarding Canada's Food Guide for inclusion of all food groups in diet.
4) Encourage socializing at meal times in dining room setting.
5) Monitor weight at regular intervals with overall goal of some weight gain.
Question 4 (15 Marks Total)
4. You have been asked to meet with a patient/resident who is newly admitted to your
facility.
a) Write down questions you would ask this patient/resident to complete a nutritional
assessment. Include in your answer the type of patient/resident you are dealing with
and any relevant details with regard to the individual (e.g. weight, height, medical
history, etc.). (5 marks – maximum 200 words)
10
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
The questions should indicate that considerable planning was done previous to the actual
interview.
b) Using the questions you developed in 4a, conduct a 10 minute (pretend) interview
with a patient/friend/family member or co-worker. This interview must be assessed
and signed by a registered dietitian. It is up to you to find a registered dietitian
willing/able to assess your interview – if you are unable to find a dietitian to do
this then please contact the FSNM Program Manager ASAP so alternate
arrangements can be made. (10 marks)
Appendix A of your assignment document has the dietitian assessment sheet that
must be submitted with your completed assignment.
Question 5 (5 Marks Total)
5. In the following two case studies, (a) identify the stage of change for the behaviour as
described in Dr. James Prochaska’s Stages of Change Model, and (b) the approach and
interventions you would use when counselling the individual.
Case study 1: Mr. A
 75 year old man with high blood pressure
 He has no intention of following the No added salt diet; he feels he is too old to follow a
special diet
 Wants to use the salt shaker at meals
 R.N’s have been telling you he is eating salted peanuts every night before bed.
Case study 2: Youth S
 17 year old male who is lactose intolerant
 has been having severe GI upset when he eats milk products
 he has cut back on milk
 continues to have ice cream every night but is thinking about cutting that out; doesn’t
know what else to cut down on.
Mr. A
Precontemplation Stage regarding reducing his salt intake
 Ask him an open ended question such as “What do you see as the benefits to following
this diet?”
 Educate him about the effects of high BP on his immediate well being (today) vs long
term.
Youth S
Preparation Stage
 Provide information about foods that contain lactose
 Assist him to develop a specific plan
 Encourage and support
Please see reading in Study Guide – Tailor your counselling with the Stages of Change model.
The third page gives a very good summary chart of the characteristics of the stages and key
11
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
approaches to be used at the different stages. The student should have the correct stage, but
their sample approach may differ from the answer key example. You are looking for a stage
appropriate approach.
2 ½ marks for each case study. ½ mark for correct stage and 2 marks for sample
strategies/approach.
Question 6 (5 Marks)
6. An elderly woman in a residential home has been losing weight since her arrival at the
home. She has been taking several medications to treat both a heart problem and a mild
case of bronchitis. You notice that she eats only a few bites at meal times and seems
disinterested in food.
Describe several steps you can take to learn whether her medications are interfering
with her food intake in some way.
Students answers may vary, but they should come up with enough information to warrant 5
marks…i.e., 3 to 5 actions. For example:
1.
-
Interview the patient to rule out other causes of her poor appetite.
Had she been eating normally prior to admission to the facility?
Does she like the type of food served
Are the symptoms new
2.
Determine if she is taking the medication properly
3.
Find out about the side effects of the medicine she is taking and recommended use i.e.,
with or without food
4.
Inform her that unusual symptoms may be the result of medication and may influence
her interest in food, or ability to eat
has her taste changed
does she feel nauseated
-
Question 7 (5 Marks Total)
7. A man with a dysphagia problem has been receiving a puree /dysphasic diet and
beverages with ‘thin’ consistencies (such as coffee, soft drinks, and juices). You notice
that he coughs repeatedly while eating meals and eats only small portions of the foods
on his plate. You suspect that the diet is inappropriate and he may need a more
restrictive dysphagia diet.
a)
Which health professionals should you consult, and what information would you
require from each of them? (2 marks)
Speech pathologist or physical therapist: swallowing evaluation and recommendations for
appropriate consistency of foods. Dietitian: nutrition assessment and recommendations for
12
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
appropriate diet order. Physician: medical diagnosis and therapies that affect the patient’s ability
to swallow (and sign-off on any diet order change); Occupational therapist: Evaluation of special
feeding needs, including positioning at meals to enhance swallowing ability, and tools and
techniques to improve feeding.
b)
The next meal is due within the hour. You suspect the man will be intolerant to the
foods he is scheduled to receive, and you have not yet heard from the health
practitioners you consulted. Based on the policies in your facility, how might you
handle this immediate problem? (3 marks)
In some provinces the student may say – if it is suspected that a patient is at risk for aspirating
his meal, it would be prudent to hold the patient’s tray until his swallowing ability can be
accurately and safely assessed.
In Ontario LTC you would speak to the charge nurse in the dining room – holding a tray may not
be an option.
If the student chooses to give the patient his tray, then the answer should indicate that they
recognize the risk for aspiration, and will monitor the patient (closely) during the meal and
continue to request a referral ASAP
Question 8 (15 Marks Total)
8. Answer the following questions.
a)
Create a one-day menu plan for a person who requires long-term use of a pureed
dysphagia diet and tolerates only liquids that have a ‘honey-like” consistency.
Include an alternate entrée at both lunch and dinner, as well as nourishments. (8
marks)
Sample menu for pureed dysphagia diet with ‘honey-like’ liquids…I have not included alternative
choice or nourishments – this is just to provide sample ideas.
Breakfast: Cream of wheat, yogurt, mashed banana, coffee or tea thickened to honey-liked
consistency with commercial thickener product
Lunch: Pureed chicken, mashed potatoes with thickened gravy, pureed carrots, pudding
Dinner: Pureed beef and pasta casserole with tomato sauce, pureed spinach, applesauce,
thickened milk (commercial product).
b)
Explain why you feel the menu you developed will help your patient accept this
mechanically altered diet. (2 marks)
The textbook provides (pp 466) tips on improving acceptance of mechanically altered foods:
 Prepare a person’s favourite foods and foods that have a pleasant smell –help to stimulate
appetite;
 Prepare foods with strong flavours/ use seasonings, etc.
 Consider color and shape
 Try layering foods – make an effort to improve visual appearance of foods.
13
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
 ….of course, well-balanced, meet Canada’s food guide, etc.
c)
Calculate the amount of kcalories and nutrients provided by the sample clear diet
menu below. Discuss your findings in terms of the nutritional adequacy of clear
liquid diets. (5 marks)
Sample menu – clear diet
Energy kcal
Breakfast
1 cup bouillon
1 cup apple juice
½ cup AJ (HS)
½ cup flavored gelatin
1 cup coffee with 1 tsp sugar
Lunch
1 cup clear broth
1 cup grape juice
1 popsicle
1 cup tea with 2 tsp sugar
Dinner
1 cup bouillon
½ cup flavored gelatin
12 oz cola beverage
1 cup coffee
CHO g
18
Total
177
45
88
19
20
4
18
162
54
35
40
14
9
18
88
165
3
845
Fat g
PRO g
1
3
tr
tr
2
1
tr
3
2
1
20
44
tr
3
2
tr
196
3
15
They should reference their source and perhaps discuss why clear diets are not recommended
as a long term diet. You should be provided with a chart showing what the kcals and nutrients
are for these food items.
Question 9 (10 Marks Total) CHECK MARK ALLOCATION
9. You are called by the nurse to visit Mrs. S who is a 47 year old woman with recent hip
replacement surgery. She is complaining of poor appetite with some nausea after
meals. You review the chart and see that Mrs. S has a history of obesity, hypertension,
gastroesophageal disease and chronic constipation. She is on 8 different medications
daily for these conditions as well as for pain.
a)
What questions would you ask Mrs. S. to determine the reason for her poor
appetite? (3 marks)
In the answer, you are looking for evidence of a logical, thorough approach.
Questions could include:
What is the length of time that she has had each condition?
How does she cope with these conditions at home?
Is she receiving any new or unfamiliar medications?
Is she eating any food brought from home?
14
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
What did she eat for breakfast that morning?
Has she marked her own menu?
Are there any foods that she dislikes? Any food intolerances?
b)
Based on your conversation with Mrs. S how would you form your nutrition care
plan? How would you encourage Mrs. S. to take part in making these decisions? (2
marks)
Answer to Part B can depend on the answers to the questions above but may include:
Review one issue at a time
Ask patient for her input in making changes to her diet
c)
Write a concise note that will be entered in the patient’s chart outlining the initial visit
and planned nutrition care for the patient. (4 marks)
Again, responses will vary but should include:
Date and time of entry / Name and designation of writer
Date of initial visit
Brief outline of issues and discussion
Brief summary of nutrition care plan
Plan for follow up to ensure compliance and/or satisfaction with plan
Suggestions/recommendations include:
Patient should sit up during and after eating
Change to more high fibre foods
Have prunes or prune juice with meals or before bed
Avoid spicy foods which may cause gastric pain
Chew slowly
Keep fluids and solids separate during meals
Eat small portions at meals and provide small snacks between meals if patient agrees
Complete menu so that she receives foods she is willing to eat
d)
Charting styles vary by facilities. The content is more important than the particular
format used. Describe the charting template and guidelines adhered to in your
facility. (1 mark)
15
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
Question 10 (5 Marks Total- ½ mark each)
10.
Match the following statements with the correct placement for their recording in the
medical record, by placing the appropriate letter by each of the statements. Each choice
may be selected more than once.
S
O
A
P
=
=
=
=
Subjective
Objective
Assessment
Plan
S
(1) The patient states he doesn't like milk.
P
(2) Will arrange a diet counselling session with the patient and his spouse.
O
(3) Serum cholesterol is elevated at 7.2 on laboratory report.
S
(4) The patients wife states that he enjoys cooking.
A
(5) Analysis of patients diet indicates that her diet is low in calcium.
O
(6) Ate one-half of the foods offered at breakfast lunch and dinner.
P
(7) Contact physician to change energy content of diet to allow for gradual weight
loss.
O
(8) Height is 178 cm, Weight is 90 Kg
A
(9) Resident regularly eats foods from all four food groups so nutritional intake
appears adequate.
(10) Will follow daily weights and lab reports for one week.
P
16
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 5 Assignment
APPENDIX A
Canadian Health Care Association
FSNM Year 2
INTERVIEW EVALUATION
Assignment Question 4 (b)
Assignment:
Using the questions you developed in 4a, conduct a 10 minute (pretend) interview with a
patient/friend/family member or co-worker. This interview must be assessed and signed by a
registered dietitian. Explain to the individual what type of patient/resident they are supposed to
be. Then ask your questions presented in 4 a).
* Prior to witnessing and grading the ‘role-play’ or patient interview, student must present a
written description of the scenario and the questions developed in the first part (a) of the
assignment to the evaluator.
Evaluation:
1.
Preparation
/2
2.
Introduction/ Building Rapport
/2
3.
Data Collection
a)
Questions based on objectives of interview
b)
Flow of questions
c)
Wording of questions and statements (non-judgemental)
/4
4.
Closing
/2
Total:
/10
Dietitian Signature:
Name (please print):
Address or Facility:
Contact (email or phone):
17
© 2013 Canadian Healthcare Association. All rights reserved.
FSNM Yr 2 Sr 2
Unit 6 Assignment
Food Services and Nutrition Management
Unit 6:
Nutrition Therapy I - Weight Management &
Nutritional Management of Diabetes,
Cancer and AIDS
© 2013 Canadian Healthcare Association. All rights reserved.
18
FSNM Yr 2 Sr 2
Unit 6 Assignment
Grading Guidelines
Question 1 (15 Marks Total)
1. Answer the following questions.
a)
Explain the concept of energy balance. (2 marks)
Energy intake is the amount of calories taken in through consumption of food. Energy output is
the amount of calories expended for basic body functions, the processing of food and physical
activity. A balance between energy intake and energy output plays an important role in the
regulation of body weight.
b)
Discuss the difference between intra-abdominal fat and subcutaneous fat. (2 marks)
Intra-abdominal fat is the fat that collects deep within the abdominal area and around the organs.
It is more likely to lead to health problems. Subcutaneous fat is the fat stored just under the skin.
It is less likely to lead to health problems.
c)
What are the 3 key components of a healthy weight management program?
(3 marks)
- a healthful eating plan (healthy eating)
- physical activity
- behaviour and attitude (behaviour modification)
d)
Describe four main differences between type 1 and type 2 diabetes. (2 marks)
In type 1 diabetes, the person is unable to produce insulin. In type 2 diabetes, the person
produces insulin, but they produce an insufficient amount and/or the cells respond to it with less
sensitivity (insulin resistance).
Age of onset
Associated conditions
Insulin required
Cell response to insulin
Clinical findings
Prevalence in diabetics
Type 1
<20
Viral infection, heredity
Yes
Normal
Ketoacidosis
5-10 %
© 2013 Canadian Healthcare Association. All rights reserved.
Type 2
>40 (10-19)
Obesity, heredity, aging …
Sometimes
Resistant
No ketoacidosis
90-95%
19
FSNM Yr 2 Sr 2
e)





Unit 6 Assignment
Explain the benefits of physical activity for a person with type 2 diabetes. (2 marks)
Improved blood glucose control
Weight loss
Improved blood lipid levels
Lower blood pressure
Reduced stress
f)
Describe and explain the effect not receiving sufficient insulin would have on blood
glucose levels. (2 marks)
insufficient insulin --> hyperglycemia. Glucose is unable to enter the cells because there is not
enough insulin available to "open the doors" of the cells. Glucose remains in the blood
increasing the blood glucose level above the normal range.
g)
Describe and explain the effect alcohol has on blood glucose levels and why a
person with diabetes has to be particularly careful about consumption levels.
(2 marks)
Alcohol is a source of food energy. The liver is the site of most alcohol metabolism. As there is
no storage pool for alcohol and it can be toxic to cells, its metabolism in the liver takes priority
over that of other substances. Alcohol suppresses both the storage of glycogen and the
availability of glucose between meals. Heavy drinkers are at risk of developing hypoglycaemia,
an effect that is accentuated in people with diabetes who use insulin or medication to reduce
insulin levels. So, a person with diabetes should drink in moderation and be prepared and aware
of signs/symptoms of hypoglycaemia.
Question 2 (10 Marks)
2. Assess a current weight reduction diet of your choice using the ”Guidelines for Identifying
Fad Diets and Other Weight-Loss Scams” on page 187 of your textbook. Based on the
10 criteria, explain what makes this a sound or unsound diet. Be sure to include a copy of
the diet with your answer.
The guidelines on page 199 of the text will help students to answer this question. Answers
should show consideration of the following:
- the diet is not overly restrictive in calories
- the diet contains appropriate amounts of protein, fat and carbohydrate
- the diet includes all food groups from Canada’s Food Guide to Healthy Eating
- the diet offers a variety of ordinary foods
- the diet is realistic and promotes gradual weight loss
- the diet is not based on selling products, services or unproved weight loss aids.
© 2013 Canadian Healthcare Association. All rights reserved.
20
FSNM Yr 2 Sr 2
Unit 6 Assignment
Question 3 (5 Marks)
3. The following is an 1800 kcal diabetic meal plan. Using the Beyond the Basics food
group values (if you do not have the resource, “Beyond the Basics: Meal Planning for
Healthy Eating, Diabetes Prevention and Management”, the chart is in your study guide.
Do not use Good Heath Eating Guide values.
Calculate the number of grams of carbohydrate, protein, fat and calories for the day. Show
your calculations. Based on your calculations; does this diet meet the nutritional
recommendations for Diabetes? Explain.
**Assume the meat choices have 4g of fat and vegetables are free – that is, vegetables do
not count for 2g of Protein; milk is all 2% fluid milk
Breakfast
Grains & Starch
2
Fruit
1
Vegetables
Milk (2%) &
0.5
Alternatives
Choice
1
Meat &
1
Alternative
Fats
1
Hint:
Lunch
2
1
1
PM Snack
1
Dinner
2
1
2
1
2
1
HS Snack
1
Total
8
3
3
1
0.5
3
1
1
3
3
1
7
1
3
Create the following table to display your calculations
Grains &
Starch
Fruit
Vegetables
Choice
Milk (2%) &
Alternatives
Meat &
Alternative
Fats
Total
Choice
s
CHO
g
8
120
3
3
3
45
45
-
3
-
3
45
15
24
7
28
49
3
15
Total g
FAT
g
PRO
g
24
255
58
100
Total kcal 1020
% kcal 52.5
522
27
400
20.5
Total
kcal
1942
Handy chart for your reference
© 2013 Canadian Healthcare Association. All rights reserved.
21
FSNM Yr 2 Sr 2
Unit 6 Assignment
FOOD
GROUPS
Beyond the
Basics
Grains &
Starches
15 g carb
3 g protein
0 g fat
15 g carb
1 g protein
0 g fat
15 g carb
8 g protein
variable fat
15 g carb
variable fat &
protein
<5 g carb**
2 g protein
0 g fat
0 g carb
7 g protein
3- 5 g fat
0 g carb
0 g protein
5 g fat
<5 g carb **
less than 5 g
carb considered
free
Fruits
Milk &
Alternatives
Other
Choices
Vegetables
Meat &
Alternatives
Fats
Extras
Calories from carbohydrate = 255 g x 4 kcal/g = 1020 kcal
Calories from protein = 100 g x 4 kcal/g = 400 kcal
Calories from fat = 58 g x 9 kcal/g = 522 kcal
Total calories = 1942 kcal
% of calories from carbohydrates = 1020 kcal / 1942 kcal x
100% = 52,5 %
% of calories from protein = 400 kcal/1942 kcal x 100% =20.5
%
% of calories from fat = 522kcal/1942 kcal = 27 %
The diet meets the nutritional recommendations for
diabetes, which is 50-55% of total calories from
carbohydrate, 15-20% from protein and less than 30% from
fat. (BTB) is a guideline and therefore the protein is
acceptable.
© 2013 Canadian Healthcare Association. All rights reserved.
22
FSNM Yr 2 Sr 2
Unit 6 Assignment
Question 4 (10 Marks)
4. You have been introduced to two meal planning guides: Canada’s Food Guide and the
Canadian Diabetes Association, Beyond the Basics meal planning guide. There are eight
food groups in Beyond the Basics – each one makes a unique contribution to good health
and the enjoyment of food. Describe what is special about each of the eight food groups
and compare the similarities and/or differences between CFG and BTB (i.e., portion size/
food choices in food groups/ recommendation for use).
It is not uncommon for students to confuse recommendations and portion sizes from CFG with
BTB. The objective of this question is to force the students to do a systematic comparison. Their
comparison should speak to both similarities and differences. Start by assigning 10 marks and
subtract ½ marks for insufficient comments/information in sections.
Food Group
BTB
Grains &
This group includes
Starches
breads, cereals,
grains as well as
starchy vegetables:
*corn and *potatoes
Fruits
CFG
Called grain products.
Portion size for breads
is similar to BTB
BTB recognizes the
CHO content of fruit.
Recommends fruit
over juice
Comments
Cereal portion sizes for cooked
hot cereal is the same, but cold
cereal in BTB is smaller
portion.
Both recommend whole grain,
high fibre choices
Serving sizes are similar
except BTB fresh berry portion
size for one serving is 1 cup
vs. CFG portion size for
veg/fruit in general is ½ cup
Fruits and vegetables
are combined into one
group.
Recommendations
encourage variety &
whole food over juice
Milk &
Both recognize the contribution of the vitamin (D) and mineral (calcium) content
Alternatives of this food group; both recommend choosing the lower fat varieties; portion sizes
are similar. CFG includes cheese in this food group
Other
Specifies up to 10%
No specific group but,
Clearly there has to be more
choices
of daily energy is
directional statement
specific guidelines for use for a
allowed from this
speaks to limiting foods person with diabetes
group
and beverages high in
compared to a non-diabetic
calories, fat, sugar or
individual.
salt
Vegetables Other then the vegetables that are recognized as “Grains” both guides
recommend eating lots of vegetables, variety and dark colour veggies.
Meat &
30 g is portion size
75 g is portion size for
Both guides put eggs in this
Alternatives fro one serving;
one serving
group but BTB serving size is 1
Includes cheese in
egg and CFG single serving
this group.
size is 2 eggs
Fats
Recommendation for Not a specific group –
use is very similar to just provides directional
CFG
statements on use
Extras
Refers to sauces and - no comments CFG encourage water
spreads
consumption
© 2013 Canadian Healthcare Association. All rights reserved.
23
FSNM Yr 2 Sr 2
Unit 6 Assignment
Question (10 Marks)
5. Case Study  48 year old female
 Type 2 diabetes; well-controlled with diet and exercise (hiking, strength training)
 Works full-time, brings lunch to work
 Enjoys vegetables and fruit and whole grains
 Looking for advice on healthy snacks before exercising
 Would like more ideas for including low glycemic index foods
 Estimated calorie requirement = 2000
Develop a menu based on the 2000 calorie meal plan below. Indicate portion size. Present your
menu in a chart format similar to the sample in your study guide.
Meal Plan
2000 Calories – Sample
Breakfast AM
Snack
Carbohydrate 4
1
(grams /
choices)
Grain & 2
Starches
Fruits 1
1
Milk & 1
Alternatives
Other Choices
Vegetables
Meat & 1
Alternative
Fats
Extra
1
Lunch
Dinner
4
PM
Snack
2
2
1
1
1
2
Total
Choices
5
HS
Snack
2
1
2
1
8
1
1
1
1
5
4
1
2
1
1
1
2
2
7
1
1
4
Sample Menu should include healthy snacks and lower glycemic index foods
Sample – only…students will vary– ensure that their menu matches the plan
Breakfast
2 sl. stone ground w. w. toast
2 Tbsp peanut butter
1 cup skim milk
½ grapefruit
Lunch
1 cup lentil/barley soup
½ ww pita bread
1 cup salad
2 tsp salad dressing
1 cup melon
1 cup skim milk
Snack
1 small apple
Snack
½ whole wheat pita
© 2013 Canadian Healthcare Association. All rights reserved.
Supper
Chicken stir-fry:
3 oz chicken,
2/3 cup basmati rice,
1 cup vegetables, 1 tsp oil
1 cup yogurt
1 tbsp maple syrup
½ cup mixed fruit
Snack
1 cup skim milk
24
FSNM Yr 2 Sr 2
Unit 6 Assignment
1 oz skim milk cheese
1/3 cup hummus
1 medium orange
1 slice pumpernickel bread
1 tsp margarine
Question 6 (10 Marks Total)
6. Answer the following questions.
a)
Using the 8400 KJ (2000 Kcal) diabetic meal plan (nutritional care plan) below make
appropriate choices on the attached hospital menu A. Indicate specific portion sizes
to be served. (8 marks)
Nutritional Care Plan (8400 Kj)
AM
Snack
Breakfast
Carbohydrate
(grams /
choices)
Grain &
Starches
Fruits
Milk &
Alternatives
Other Choices
2
1
1
2
1
1
HS
Snack
Dinner
3
2
1
1
1
3
1
10
2
1
1
2
Total
Choices
3
3
1
1
1
1
Vegetables
Meat & 1
Alternative
Fats 1
Extra
PM
Snack
Lunch
1
1
2
8
4
Refer to attached menu A for marking this question. There is not one correct menu. Deduct 2
marks for serious errors in portion sizes or indicating food groups. Where the student has made
errors, explain why and what would be better alternatives.
b)
What would you serve for between meal snacks? Refer to the above meal plan.
(2 marks)
Sample only
AM snack – 1 oz skim milk cheese and apple slices (1 small apple)
PM snack – tea/coffee, ½ toasted bagel with 1 tsp margarine plus jam
HS snack - 250 mL 2% milk, sandwich (2 sl bread, 30 g meat or cheese, 1 tsp margarine)
© 2013 Canadian Healthcare Association. All rights reserved.
25
FSNM Yr 2 Sr 2
Unit 6 Assignment
Question 7 (10 Marks Total- maximum 200 words)
7. Mr. A is a 82 year old male staying in the hospital to recover from a recent round of
chemotherapy. The nurse says he weighs 60kg and is 173cm tall, but that he looks
thinner than he was during his last admission. Mr. A has been eating about ¼ of his
meals and leaving the remainder on the plate, and sometimes he declines his entire
supper. The nurse states that sometimes he coughs while eating and drinking and that
he complains that his mouth feels rough and dry. He also states that the foods in the
hospital don’t taste right (complains of metallic taste) and are not appetizing to him. The
nurse is concerned that he will not recover properly if he is not eating an adequate diet.
a) What additional information would you want to know about this patient (e.g. what
questions would you ask if you interviewed the patient)? (4 marks)
- What is the history of his cancer? What type of cancer is it? Where is it located (primary sites
and metastases)? How long has he had it? How has it affected food intake (currently and in
the past)?
- How much weight has he lost? Over what time frame?
- Is Mr. A having trouble chewing and swallowing foods and fluids? Does he wear dentures and
if so do they fit well? Is a swallowing assessment necessary?
- Are dry foods harder to swallow than moist foods? Would Mr. A benefit from a moist diet or
texture-modified diet?
- Is he getting full quickly? Are the portion sizes too large? Would he like smaller portions with
snacks between meals?
- What is the history of his taste changes? Do they occur with all foods? Which foods give off
the most “metallic taste”?
- What foods are appetizing to him? What are his favorite foods?
- When, during the day, is his appetite best?
b) Based on the above information, and any additional information you would collect, what
diet changes would you recommend for this patient? Please describe your reason for
making each change. (4 marks)
Possible diet changes to recommend
1.
Offer Mr. A foods that he likes (favorite foods)
2.
Maximize food intake and energy protein status by encouraging intake when appetite is
good (e.g. earlier in the day in this case)
3.
Offer Mr. A a high protein snack to improve energy and protein status and promote
weight gain/maintenance
4.
Recommend a diet for Mr. A with moist foods or a soft diet to make it easier for him to
manage food and increase oral intake
5.
Provide smaller portions at an increased frequency during the day to promote energy
intake and weight maintenance/gain
© 2013 Canadian Healthcare Association. All rights reserved.
26
FSNM Yr 2 Sr 2
Unit 6 Assignment
c) Write a chart note to summarize the key aspects of your assessment, recommendations,
and actions regarding the nutritional care of this patient. You may make up hypothetical
answers for questions that you would ask the patient. The purpose of this note is to
inform other members of your facility about the actions you have taken. (2 marks)
Sample chart note: Information will vary depending on hypothetical answers, but should include:
Date and time of entry
Name and designation of writer
Date of initial visit
Brief outline of issues and discussion
Brief summary of nutrition care plan
Plan for follow up to ensure compliance and/or satisfaction with plan.
Question 8 (10 Marks Total)
8. Alex is a 14 year old teenager with diabetes. His diabetes is well controlled by diet and
insulin. Recently, he has become rebellious and refused to adhere to his diet. He
sometimes skips breakfast; sometimes spends his school lunch money for sweets and
stops with friends for snacks after school. Today he was very excited about his
graduation party and he skipped his breakfast and only ate 2 items in his lunch. The party
started at 4 p.m. immediately after classes ended. Alex enjoyed the dancing. He
suddenly felt unwell and collapsed and was admitted to the hospital emergency room. (In
the hospital emergency room he was conscious)
a)
What factors caused Alex to collapse? (1 mark)
Alex probably had hypoglycaemia because of several reasons:
- he was overly excited
- there was more activity than usual
- he did not eat a sufficient quantity and quality of food to prevent a reaction.
b)
While Alex's diet is essentially a normal one, how might it differ from those of his
friends? (2 marks)
The differences might be:
- he would require regular meals with no more than 4 hours between them
- he should eat foods from at least 3 of the food groups at each meal
- he would require healthy snack daily e.g. sandwich and juice; muffin and milk.
- his portions should be controlled, no excesses of one item
- he would need to carry food with him and eat before performing physical activities.
© 2013 Canadian Healthcare Association. All rights reserved.
27
FSNM Yr 2 Sr 2
c)
Unit 6 Assignment
What would you tell Alex about snacking? (1 mark)
The following information should be given to Alex:
- snacks are a required part of his diet
- they have to be eaten at regular specific intervals
- the snacks should include 3 food groups; usually protein and starch
- snacks must be nutrient-dense
- the snack needs to be larger before doing exercises.
d)
Alex likes pizza. What food choices (refer to “Beyond the Basics”) would be included
in this food? Indicate the number of each of the food choices. (2 marks)
One slice of pizza could be 1 Grain/starch - the crust
+1 fat - crust if thick and oily
+1 veg - tomato sauce and vegetables on top
+1 or +2 - if meat on topping/ and cheese on topping.
e)
Alex asks why he needs insulin and why it needs to be injected rather than taking it
in pill form? How would you answer? (1 mark)
Insulin is required because his body is not able to produce any to help the glucose into the body
cells. It must be injected because it would be digested as a protein in the stomach.
f)
What could Alex do to prevent this collapse another time? (1 mark)
Alex needs to bring extra carbohydrate with him, such as candy or a drink. He also needs to eat
well before going to a party. He should have regular meals and snacks throughout the day and
not skip meals
g)
Review the list of complications associated with long-term diabetes. How might you
explain the importance of glycemic control to a 14 year old? (2 marks)
Chronic complications of diabetes include cardiovascular disease, retinopathy, nephropathy and
neuropathy. It would be important to explain to Alex that his future health depends on his taking
care of his diabetes. He will need to take care of himself and that includes checking blood
glucose levels, not skipping meals and injecting insulin.
© 2013 Canadian Healthcare Association. All rights reserved.
28
FSNM Yr 2 Sr 2
Unit 6 Assignment
Question 9 (10 Marks Total)
9. Mary D., 58, is (62 in.) 157.5 cm tall and weighs (148 lbs) 67 kg. Her waist circumference
is (38 in.) 96.5 cm and her body could be described as ‘apple’ shaped. Mary’s daughter,
Kate, 33, is (67 in.) 170 cm tall and weighs (172 lbs) 78 kg. Her waist circumference is
(33 in.) 84 cm and her body could be described as ‘pear’ shaped.
Mary and Kate have started following the latest fad diet to lose weight. The pursuit of
thinness has been something that mother and daughter have been working towards
since Kate was a child. They are usually successful at losing weight but have been never
been able to keep it off. After the diet, they turn right back to their favourite fast food
restaurants and high calorie snack foods.
a)
Using Health Canada’s body weight classification - calculate Body Mass Index for
both Mary and Kate. What does the BMI measure? (2 marks)
Both Mary and Kate have a BMI of 27. The BMI is calculated from the values for height and
weight. It is not a direct measure of body fat but it is the most widely investigated and most
useful indicator, to date, of health risk associated with under and overweight. They are both
considered overweight and have an increase risk for developing health problems as a result of
their weight.
b)
Using healthy BMI range, what would be a healthy weight range for Mary? Using
healthy BMI range, what would be a healthy weight range for Kate? Show your
calculations. (2 marks)
Calculation:
Mary
18.5 x
(1.57)2 = 46 kg
101 lbs
2
2
24.9
x
(1.57)
=
61
135
Wt (kg) = BMI x height (m)
2
Kate
18.5 x
(1.70) = 53.4
118
24.9 x
(1.70)2 = 72
158
Healthy weight range for Mary is (101-135 lbs) 46-61 kg.
Health weight range for Kate is (118-158 lbs) 53-72 kg
c)
Whose weight poses more of a healthy risk? Explain why. (1 mark)
Mary’s weight poses more of a health risk due to waist circumference over (35 in.) 88 cm. Her
‘apple’ shape is also an indicator of intra-abdominal obesity which is more likely to lead to health
problems that subcutaneous fat.
d)
-
Kate blames her mother for her weight problem. Discuss why, in part, this may be
true. (1 mark)
Genetics is an important factor in determining body weight
Lifestyle behaviours including eating and exercise patterns are established within the family
of origin. It appears Kate’s mother still influences her eating patterns.
© 2013 Canadian Healthcare Association. All rights reserved.
29
FSNM Yr 2 Sr 2
e)
Unit 6 Assignment
Using the following 1600 kcal plan, plan a healthy work day menu based on
Canada’s Food Guide. Both work outside the home and usually meet for lunch at a
popular submarine sandwich restaurant.
Show the grams of Protein, Fat and CHO in your menu, as well as the percentage of
energy they represent. Reference your sources. Present your information in an easy
to read chart format. (4 marks)
Number of Choices
Food Group
1600kcal
Grain Products
Fruit & Vegetables
Milk & Alternatives
Meat & Alternatives
# of servings
7
7
3
2
Protein, g
Fat, g
Carbohydrate, g
Energy, kcal
Menus should provide variety and follow the 1600 kcal plan. Menus should be aesthetically
pleasing and lunch ideas should be healthy choices available at a submarine sandwich
restaurant. The serving sizes of the menu should be consistent with the serving sizes in CFG.
Interestingly, Subway provides the nutrition information for all their sandwiches at:
http://www.subway.com/Nutrition/Files/CanNutritionValues.pdf
For example: Sweet Onion Chicken Teriyaki: 370 calories; 5g of Fat; 59g CHO; 26g protein
© 2013 Canadian Healthcare Association. All rights reserved.
30
FSNM Yr 2 Sr 2
Unit 6 Assignment
Question 10 (10 Marks Total)
10. Jeremy A., age 27, had a history of intravenous drug use in his late teens. He
successfully completed a drug rehabilitation program, returned to college and was
‘turning things around”. Currently he is working as a salesman for a large company with
good employment prospects for the future.
Recently, symptoms of fatigue, an unplanned weight loss of 13 lbs, diarrhea, and a sore
mouth lead him to visit the local health clinic. Jeremy tested positive for the HIV virus. A
team of HIV specialists including a dietitian, nurse, psychologist, physician and social
worker met with Jeremy. An assessment and care plan were prepared.
Jeremy lives alone in a studio apartment. For breakfast, he usually gets coffee and a
pastry on the way to work. For lunch, he generally eats with his co-workers at a fast-food
restaurant or food court. He likes Asian stir-frys and/or sushi plates. For supper he
usually cooks, but lately he has been too tired, so picks up pre-cooked dinners, like
lasagne or chicken a-la-king, meat pies. He is not much of a milk drinker, and while he
likes fresh salads and vegetables his mouth has been tender, and he does not feel like
preparing them.
a) Why is it more appropriate to compare Jeremy's present weight to his usual weight, then
compare it to a weight chart? What would be the disadvantage of the latter? (1 mark)
The population of individuals with HIV or AIDS do not fit in the normal height/ weight tables
which are somewhat useful to assess an individual's weight with that of a healthy population. An
involuntary weight loss of 10 % or more in one month is one of the diagnostic indicators for HIV.
It is also an important indicator for the potential for serious nutritional risk. A person with HIV or
AIDS who has lost 10% or more of usual weight but is still within a normal weight range for age
and height may not be identified as requiring nutritional risk.
b) Given his weight loss and low energy what specific dietary/ menu planning suggestions
do you have for Jeremy? Give him specific suggestions based on nutritional adequacy
and his lifestyle. (4 marks)
Suggestions should be reasonable and should take into consideration his lifestyle
c) What would you suggest for controlling diarrhea? (1 mark)
To control diarrhea:
- decrease fat content of diet
- decrease the lactose content
- decrease insoluble fiber content
- decrease caffeine intake
© 2013 Canadian Healthcare Association. All rights reserved.
31
FSNM Yr 2 Sr 2
Unit 6 Assignment
d) What suggestions would you make for controlling his sore mouth? (1 mark)
To control sore mouth:
- change the consistency of the diet to soft easily chewed foods which are moist
- avoid spicy or acidic foods
- avoid very hot or very cold foods
- use a liquid nutritional supplement
- use an analgesic for the mouth
e) Prepare a one page flyer on the topic of food safety and HIV. (3 marks)
The flyer should explain the importance of food safety, be easily read and contain specific
information relating to safe food handling and related it to the importance of someone with HIV.
© 2013 Canadian Healthcare Association. All rights reserved.
32
FSNM Yr 2 Sr 2
MENU A
Unit 6 Assignment
FOR ASSIGNMENT QUESTION 6
Name:
Room:
BREAKFAST
mL Rolled Oats
mL. Shredded
Diet:
LUNCH
mL Cream of
Mushroom Soup
Wheat
1 Tbsp Natural Bran
Diet Bran Muffin
Sl White toast
Sl Whole Wheat
Toast
Vegetable Lasagna
( 2 meat, 1
grain/starch, 1 fat )
Sliced Ham Salad
Plate
Individual Omelette
slices Back Bacon
DINNER
Beef Broth
mL Cream of
Asparagus Soup (1/2 milk)
Roast Beef
Chicken Stew ( 2
meat & 1 starch)
Tea Biscuit ( 1 starch
)
( 2 meat, 1
grain/starch)
Parsley Potatoes
Green Beans
Mixed Vegetables
Tossed Salad
mL Salad Dressing
mL Diet Salad
Cup Orange Juice
Prunes
Vanilla Ice Cream
Diet Pears
Dressing
mL Milk
(2%, 1 % or skimspecify)
15 mL Milker
Diet Jam
mL Butter
mL Margarine
mL Diet Pineapple
Bavarian ( 1 fruit & 1 fat)
mL Frozen
Strawberries
Equal
Sl White Bread
Sl Whole Wheat Bread
Crackers
Sl White Bread
Sl Whole Wheat
Bread
Crackers
mL Milk (2%, 1 % or
skim- specify)
15 mL Milker
Coffee
Tea
Decaffeinated Coffee
Equal
mL Milk (2%, 1 % or
skim- specify)
Salt
Pepper
15 mL Milker
Equal
Coffee
Tea
Decaffeinated Coffee
mL Butter
mL Margarine
Coffee
Tea
Decaffeinated Coffee
Salt
© 2013 Canadian Healthcare Association. All rights reserved.
mL Butter
mL Margarine
Salt
Pepper
Pepper
33
mL gravy
FSNM Yr 2 Sr 2
Unit 7 Assignment
Food Services and Nutrition Management
Unit 7: Nutrition Therapy IINutritional Management of
Gastrointestinal Disorders, Surgery
and Supplemental Feeding
© 2013 Canadian Healthcare Association. All rights reserved.
34
FSNM Yr 2 Sr 2
Unit 7 Assignment
Grading Guidelines
Question 1 (10 Marks Total- 1 mark each)
1. Fill in blanks/ True/False/ multiple choice
a)
A protrusion of a portion of the stomach up through the opening of the diaphragm where the
esophagus comes through.
___________hiatal hernia______________
b)
Inflammation of the lining of the stomach ________gastritis_______
c)
Enteral formula delivery systems that require formula to be transferred from its original
packaging to a feeding container before it can be administered through a feeding tube.
___open feeding system___
d)
Name two routes which can be used for a tube feeding.
Nasogastric / nasoduodenal / nasojejunal / Gastrostomy / Jejunostomy
e)
Which of the following diets is most appropriate for the patient/resident with dumping
syndrome?
i)
restricted fat
ii)
restricted protein
iii)
restricted fibre (residue)
iv)
none of the above
f)
Diarrhea is not a disease condition but a symptom of a disease. True or False?
g)
A surgically formed opening through the abdominal wall ____stoma_____
h)
List three foods that commonly cause food allergies in children.
eggs
wheat
chocolate
corn
fish
tomatoes
milk
bananas
nuts
white potato
strawberries
citrus fruit
i)
People with diverticulosis require no medications, but are advised to eat a high-fibre diet to
reduce pressure in the colon and stimulate peristalsis. True or False?
j)
Another name for the cardiac sphincter: Lower esophageal sphincter (LES) or
gastroesophageal sphincter
© 2013 Canadian Healthcare Association. All rights reserved.
35
FSNM Yr 2 Sr 2
Unit 7 Assignment
Question 2 (20 Marks Total)
2. The attached menu is the recorded 24 hour food intake of an individual. Modify the menu for the
following diet restrictions. Try to keep as much of the actual menu as possible and only alter
those food items that are affected by the diet change.. Highlight or indicate your changes
i.
Please rewrite the entire completed revised menu for each modification. (show amounts in
the original and revised menu)
a. increased protein - total intake of 150 grams (4 marks)
b. low fibre - 10 grams ( 4 marks)
c. high fibre - 35 grams (4 marks)
d. restricted lactose (4 marks)
ii.
Name two conditions for which each diet would be used. (4 marks)
Diet
Indications for use
Increased Protein
-
AIDS
Burns
Cancer
cystic fibrosis
pre-surgery
-
diverticulitis
colostomy
ileostomy
Crohn's Disease
chronic diarrhea
-
constipation
diverticulosis
irritable bowel
-
lactase deficiency/lactose intolerant
G.I.infection or inflammatory bowel disease
chronic diarrhea
Low Fibre
High Fibre
Restricted Lactose
© 2013 Canadian Healthcare Association. All rights reserved.
36
FSNM Yr 2 Sr 2
Unit 7 Assignment
Note: Calculate the grams of protein in diet A and grams of fibre in diets B and C. Please cite your
reference sources. Use the readings for foods allowed on the diet and foods to avoid.
Quantity
Breakfast
AM Snack
Lunch
1
250 ml
75 ml
3 slices
2 slices
15 mL
30 mL
500 mL
30 mL
250 mL
1
250
mL
4
1
60 g
1
250 mL
250
250 ml
30 mL
1
Dinner
PM Snack
Food
Orange
Rice Krispies
2% milk
Side bacon
White toast
Butter
Strawberry Jam
Coffee
Coffee cream
Diet Coke
Blueberry Muffin
Vegetable Soup
Soda Crackers
Croissant
Roast Beef-sirloin
Dill Pickle
Strawberry
Ice
Cream
mL Diet Coke
Caesar Salad
Salad Dressing
Baked Potato (no
skin)
90 g
Baked Ham
15 mL
Sour Cream
125 mL
Frozen Peas
1
Crusty White Bun
5 mL
Butter
1 square Chocolate Layer
Cake
(no icing)
125 mL
2% milk
250 mL
Coffee
30 mL
Coffee cream
250 mL
Herbal Tea
4
Chocolate
Chip
Cookies
TOTAL
Protein
(g)
1
2
2
9
4
tr
4
2
Fibre
(g)
2.4
.3
0
1.2
.4
2.6
.5
1
5
20
tr
4
.3
1.6
0
.7
-
-
1
3
1
3.4
20
4
6
5
0
3.7
n/a
2.1
4
4
0
-
97
21
.8
Make sure the students only alter the food items that are affected by the diet. They need to cite
references. The fibre and protein content above have been obtained from Nutrient Value of Some
Common Foods,1999. They have been provided only as a guide to help marking.
© 2013 Canadian Healthcare Association. All rights reserved.
37
FSNM Yr 2 Sr 2
Unit 7 Assignment
Students should calculate the menu using Nutrient Value of Some Common Foods and suggestions in
the [email protected] handouts supplied in the readings.
Question 3 (10 Marks)
March is nutrition month. Plan a nutrition education program (using this year’s Canadian
theme) for your clients or residents or staff. (NOTE: You must use this year’s Canadian Nutrition
Month Theme – failure to do so will result in a grade of zero for this question).
3.
Write a report of planned activities in the style of a business report. Include the following
information:





your target audience and the characteristics of your audience (include limitations or
challenges relating to the group.
your intended message.
your method of delivery of the message.
An outline of your presentation. (include time-line)
Attach any printed information or hand-outs you would use.
The student should identify who they will be targeting the information. Challenges or limitations might
include short attention span, fatigue, mental ability; and for staff, lack of time or motivation to attend an
education program.
The message should be consistent with Canada’s Food Guide and related to current theme of nutrition
month
The method of delivery of the message should be suitable for the target audience & their limitations.
The verbal outline of the presentation should be well organized and flow logically.
Any printed information should be valid & reliable.
(Give zero if Nutrition month theme not used!)
Question 4 (4 Marks)
4.
Referring back to Chapter 13, review some effects of aging on the GI tract. A number of
disorders of the GI tract described in this unit are associated with aging. Review both Chapters
17 and 18. List 2 GI disorders that might be a result of, or exacerbated by the effects of ageing
on the GI tract. Explain why.
Symptoms and disorders of the GI tract associated with aging
Symptom/Disorder
Effects of Aging
Constipation
Decreased physical activity, decreased thirst, limited intake of fruits
and vegetables due to chewing problems or limited diets,
medications
Diverticular disease Inadequate fluid and fibre intake
Oropharyngeal
Increase in cardiac disease complications with aging such as stroke
dysphagia
Atrophic gastritis
Abnormalities in stomach acid secretion, medication that irritate
stomach lining.
© 2013 Canadian Healthcare Association. All rights reserved.
38
FSNM Yr 2 Sr 2
Unit 7 Assignment
Question 5 (5 Marks)
5.
Modify the attached menu to comply with the nutritional recommendations for a person with
celiac disease. Only alter those food items that are affected by the diet change. Rewrite the
entire revised menu.
Each student may have different substitutions for gluten containing products.
Breakfast
125 mL Orange Juice
125 mL Granola/125 mL whole milk
2 slice White Toast
60 g Scrambled Egg
Coffee/Cream/Sugar
Breakfast
Orange juice
Puffed Corn/whole milk
Gluten free bread (rice bread)
Scrambled eggs
Coffee/cream/sugar
Lunch
200 mL Cream of Broccoli Soup
200 mL Lasagna
125 mL Tossed Salad/Creamy Garlic
Dressing
1 Crusty White Dinner Roll/5 mL
Margarine
1 slice Apple Pie
Lunch
Homemade gluten free cream of broccoli
soup
Homemade lasagna (gluten free noodles)
Tossed salad/ Change creamy garlic
dressing to homemade oil/vinegar
Gluten free roll/margarine
Change apple pie to Applesauce
Supper
125 mL Fruit Punch
90 g Baked Ham
125 mL Pan Fried Potatoes
125 mL Cauliflower/Cheese Sauce
125 mL Three Bean Salad
1 slice Corn Bread/5mL Margarine
125 mL Chocolate Ice Cream
Coffee/Cream/Sugar
Dinner
Change fruit punch to Apple juice
Baked ham (allowed ingredients)
Pan fried potatoes
Cauliflower no cheese sauce
Three bean salad (allowed ingredients)
Change corn bread to Gluten free bread
Vanilla ice cream
Coffee/cream/sugar
Snack
Half Bologna Sandwich
250 Whole Milk
Snack
Change bologna to Roast beef sandwich on
gluten free bread
Milk
Pg. 182-184 Manual of Clinical Dietetics
© 2013 Canadian Healthcare Association. All rights reserved.
39
FSNM Yr 2 Sr 2
Unit 7 Assignment
Question 6 (15 Marks Total)
6.
Answer the following questions.
a)
What steps can be taken to prepare a patient or resident for tube feeding? (2 marks)
Explain the role that nutrition plays in recovery; try to alleviate fears by allowing patient to examine
(touch) tubes; explain how it will be inserted and assure them it is only temporary (if it is only
temporary!)
b)
List 3 nutrition-related factors that help determine or influence the selection of the
appropriate tube feeding formula for a patient. (3 marks)
Selecting a formula that meets the client’s nutrient needs, including energy, protein, and fluid:
 the need for residue or fibre modifications;
 Individual tolerances (food allergies and sensitivities);
 Cost and availability of formula;
 Size of tube.
(textbook)
c)
The diet order arrives as: nasogastric tube feeding 80 mL/hour x 24 h. How many cans of
235 mL would you send to the floor for the 24 hour period. (1 mark)
= 8.17 cans/day.
Send 9 cans/day for that patient.
d)
The diet order in the above example has been changed to 120 mL/hour full strength. How
much formula would the patient be receiving over a 24 hour period? Calculate the amount of
energy delivered, assuming that the formula had 1.1 cal/ mL. (2 marks)
120 mL/hr x 24 h = 2880 mL total quantity.
2880 x 1.1 kcal/mL = 3168 kcal (amount of energy being delivered.
e)
Explain the difference between continuous and intermittent tube feeding, including the
advantages and disadvantages of each and briefly indicate when each would be used.
(5 marks)
Continuous tube feedings are where the formula is delivered continuously on an hourly basis for 8 to 24
hour periods. This method permits a larger daily volume of formula to be given, is usually associated
with fewer complications, such as diarrhea and bacterial growth as the formula is being given at a
constant rate with no variance and it is good for jejunal feedings. It would be used when there is a high
energy requirement and the patient is not mobile. E.g. in acute situations
Intermittent feedings are where the formula is delivered over a 30 minute minimum time period, much
like a meal time. The stomach acts as a reservoir and the nutrients are digested gradually into the
intestine. This method allows the patient greater freedom to move around without the tube attachment,
it is good for stomach feedings and diarrhea is less likely when the stomach is being used as a
reservoir. It is used in situations where the patient requires mobility, such as in rehabilitation or for home
enteral feeding.
© 2013 Canadian Healthcare Association. All rights reserved.
40
FSNM Yr 2 Sr 2
f)
Unit 7 Assignment
In what situations might a nasoduodenal placement of the feeding tube be preferred to
nasogastric placement? (2 marks)
First, gastric feeding is always preferred whenever possible. Gastric feedings are not possible for people
with gastric obstructions or conditions that significantly interfere with the stomach’s ability to empty.
Also, when there is a risk of aspiration (severe dysphagia), feeding directly into the intestine may be
preferred.
Question 7 (10 Marks Total)
7.
Roy, age 34 is a perfectionist, meticulous about his grooming, the care of his home, and his work
as a carpenter. Recently he has begun to worry about being laid off as business is slow.
Roy is a chain smoker. His usual breakfast is orange juice, toast, and several cups of black coffee.
He sometimes takes a sandwich and thermos of coffee along to work. Often he becomes so
preoccupied in his work that he does not bother to stop for lunch, although he will drink the coffee
throughout the day. Dinner is eaten at home and usually includes meat, fish or poultry, a starch, a
cooked vegetable, bread and a salad. He has little interest in food and rushes through meals so
he can get on to some project in his home workshop or garden. He will eat most foods, but has
asked his wife to leave cucumbers, radishes, and onions out of the dinner salad because they
give him gas.
Roy has been having occasional abdominal pains that seem to come on especially stressful days.
He has found that drinking milk or taking an antacid will relieve the pain.
One day everything seems to be going wrong. His wife is sick, his work is not up to his standards
and his child has an accident at school which Roy has to deal with as his wife is not home.
That night Roy awakes with an excruciating pain in his abdomen. Although it is relieved with an
antacid, he decides, at his wife’s urging, to see a physician. An upper GI series reveals a
duodenal ulcer. An H. pylori infection is found. Occult blood is found in his stool, and his
haemoglobin is 120g/l. He is put on an histamine drug, an antibiotic and an iron supplement. A
normal diet as tolerated is recommended.
a)
Although Roy’s prescribed diet is basically normal, list some principles to keep in mind when
planning it. (2 marks)
The basic principles include:
 individualizing the diet
 appropriate energy intake for weight
 nutritionally adequate according to CFG
 moderation- avoid excessive use of any one food group
 regularity of meal times
 omit bedtime snack
 avoid foods which will irritate stomach.
© 2013 Canadian Healthcare Association. All rights reserved.
41
FSNM Yr 2 Sr 2
b)


Unit 7 Assignment
What food and beverages should Roy avoid? (1 mark)
Avoid foods that aggravate the ulcer
Limit foods that cause discomfort - avoid alcohol-containing beverages and limit, if necessary,
caffeine, black pepper, garlic, cloves, and chilli powder
c)
Plan two lunches Roy might pack to take to work (there is no kitchen/microwave for reheating at the worksite). Explain to Roy why regularity in meals is important. (4 marks)
As with other menu questions, the lunch should be well balanced, aesthetically pleasing and be
appropriate to carry to work.
Regular meal times are important to prevent excessive exposure of the gastric mucosa to acid, to
ensure adequate nutrition and to promote a sense of relaxation while eating.
d)
Why was he put on an antibiotic and iron supplement? (1 mark)
The antibiotic is to combat H. Pylori bacteria. This bacteria causes an irritation of the stomach mucosa
leaving it more vulnerable to the gastric acids to cause an erosion or ulcer. The iron supplement is
because his haemoglobin is slightly low – an indication of low iron.
e)
What factors in Roy’s history, lifestyle, and personality might make him at risk to develop an
ulcer? Give some practical suggestions for modifying factors other than diet that may have
contributed to the development of the ulcer. (2 mark)
Factors which may have contributed to the development of the ulcer:
 he is a perfectionist
 he has significant worries- job, family
 he chain smokes
 he skips meals and eats at irregular times
 excessive caffeine intake
The suggestions should relate to the non-dietary factors identified above. Probably the easiest to
change are the increased caffeine intake and the irregular rushed meals. Students may suggest
a stop smoking program, relaxation exercises and becoming less demanding of himself.
EC’s should remind students that it would be difficult for Roy to change everything
simultaneously. Refer students to the reading “Tailor Your Counselling to the Stages of Change
Model” in unit 5.
© 2013 Canadian Healthcare Association. All rights reserved.
42
FSNM Yr 2 Sr 2
Unit 7 Assignment
Question 8 (10 Marks Total)
8.
Source: DeBruyne, L.K., Pinna, K., Whitney, E.N. (2008). Nutrition and Diet Therapy, 7th 8th
edition; Wadsworth/Thomson Learning, Belmont, CA., USA, pp. 489.
New College Graduate with Irritable Bowel Syndrome
Shannon Calloway is a 22-year-old recent college graduate who began her first professional job
in a bank one month ago. As a college student, she occasionally experienced abdominal pain
and cramping after eating. She also had frequent bouts of diarrhea and felt somewhat better
after bowel movements. Once Shannon began her new job, her symptoms occurred more
frequently. At first she attributed he symptoms to job stress, but when the symptoms continued
for several months, she decided to see her physician. After taking a careful history and
conducting tests to rule out other bowel disorders, the physician diagnosed irritable bowel
syndrome. The physician prescribed bulk-forming agents and advised Shannon to keep a record
of her food intake and symptoms for one week. Shannon was then referred to a dietitian for a
review of her dietary record. The dietitian noticed that Shannon routinely drank several cups of
coffee in the morning and had large meals for lunch and dinner. Shannon often ate out in
Mexican restaurants and favored highly spiced foods and refried beans. Between meals, she
snacked on low-carbohydrate foods sweetened with sugar alcohols and drank several cans of
soda daily. Her dietary fiber intake, however, totalled only about 13 grams daily.
a)
Describe the characteristics of irritable bowel syndrome to Shannon, and indicate the role
that stress might play in her illness. (5 marks)
Although the causes are not clear, patients with IBS experience excessive colonic responses to meals,
GI hormones and stress. Many exhibit hypersensitivity to intestinal distention and intestinal motility
which are exaggerated by stress. It is advisable for Shannon to manage her stress levels a little more
effectively.
b)
Explain how the record of food intake and symptoms might be helpful in devising an
appropriate diet plan for Shannon. Are any of the foods in Shannon’s diet likely to be
aggravating her symptoms? (3 marks)
A food record may help her identify which foods are triggers for GI symptoms during the day. The
coffee, large meals, spiced foods, beans, sugar alcohols, soda and low fiber intakes may also be
contributing to her symptoms.
c)
What dietary measures might benefit individuals with irritable bowel syndrome? What
problems might the dietary changes cause? (2 marks)
It is advised to increase fiber in her diet; however, this may exacerbate diarrhea. In order to minimize
these symptoms, she should increase fiber gradually and avoid gas-producing foods. Fluids should be
encouraged as well.
© 2013 Canadian Healthcare Association. All rights reserved.
43
FSNM Yr 2 Sr 2
Unit 7 Assignment
Question 9 (10 Marks Total)
9.
DeBruyne, L.K., Pinna, K., Whitney, E.N. (2008). Nutrition and Diet Therapy, 8th edition;
Wadsworth/Thomson Learning, Belmont, CA., USA, pp. 469
Accountant with GERD
Elyssa Rinaldi is a 39-year-old accountant who is 5 feet 4 inches and weighs165 lbs. During a
recent physical examination, she mentioned to her physician that he had been feeling fairly well
until she began experiencing heartburn, which has progressively become more frequent and
painful. The heartburn often occurs after she eats a large meal and is particularly bad after she
goes to bed at night. By direct examination of the esophageal lumen using an endoscope, the
physician found evidence of reflux esophagitis and a slight narrowing throughout the length of
the esophagus.
Mrs. Rinaldi’s medical history does not indicate any significant health problems. During her last
physical, her physician advised her to sop smoking cigarettes and to lose 20 lbs, but she has not
attempted either. The nutrition assessment reveals that Mrs. R. is feeling stressed because it is
the middle of the tax season. She usually has little time for breakfast, eats a lunch of fast foods
while continuing to work at her desk, and eats a large dinner at around 8:00 pm. She generally
has wine with dinner and another alcoholic beverage later in the evening.
a)
Explain to Mrs. Rinaldi the meaning of the medical diagnoses “reflux esophagitis” and
“esophageal stricture”. (4 marks)
Reflux esophagitis is when gastric acid remains in the esophagus long enough to damage the
esophageal lining resulting in inflammations. An esophageal stricter is an abnormal narrowing of the
esophageal lining resulting in inflammation., scarring or other structural changes. Reflux esophagitis can
lead to an esophageal strictures.
b)
From the brief history provided, list the factors and behavious that increase Mrs. Rinaldi’s
risks of experiencing reflux. What recommendations can you make to help her change these
behaviors? (4 marks)
The factors that increase Mrs. R.’s risk of reflux are:

Overweight

Eating large meals

Smoking

Stress

High-fat meals

Alcohol
c)
What medications might the physician prescribe and why? (2 marks)
Her physician will prescribe medications that suppress gastric acid secretion to help heal the
esophageal tissue, such as proton pump inhibitors and histamine – 2 receptor blockers. Proton pump
inhibitors are the most effective antisecretory agents, whereas histamine-2 blockers neutralize gastric
acid. These medications will prevent further damage to the esophageal tissue from acid reflux. This, in
combination with her diet and lifetstyle modifications, should resolve Mrs. R’s GERD.
© 2013 Canadian Healthcare Association. All rights reserved.
44
FSNM Yr 2 Sr 2
Unit 7 Assignment
Question 10 (6 Marks Total)
10.
Read the article, To supplement or Not to Supplement? by Andrea Olynyk and answer the
following questions:
a) Why are nutritional supplements (drinks and puddings) administered/ delivered to residents by
nursing staff instead of the dietary department? (2 marks)
Nutritional supplements that provide vitamins, minerals and energy are regulated by Health Canada
and require a drug identification number. Since they are considered drugs with pharmacological
action, they are administered via a Medpass program where nursing staff are responsible for
ensuring that residents receive the ‘medicine’ at times prescribed by the registered dietitian or
physician.
b) What are key factors in determining whether to recommend a supplement or not? Is weight loss
alone a sufficient indicator to suggest supplementation? (2 marks)
The ultimate decision to supplement or not to supplement revolves around the resident’s ability to
maintain his or her weight within the prescribed goal weight range and to receive adequate nutrition
through meals and snack rotations. No, weight loss alone is not a sufficient indicator. The cause
behind the weight loss has to be considered and whether the person can achieve adequate nutrition
and calories through meals and snacks (i.e., high density or high calorie snacks)
c) Describe, with as much detail as possible (see chart below) an enteral supplement used in your
facility. What type of patient are they used for?** (2 marks)
Name of formula
Kcal/mL
% calories from carbohydrates
source of carbohydrate
% of calories from protein
source of protein
% of calories from fat
source of fat
fibre g/l
source of fibre
volume to meet RDI
% of water
**If your facility (i.e., retirement home) does not use enteral products, research the internet and describe
one of the following: Portagen®; Isosource HN; Jevity® 1 Cal; or Nutren®Replete®
EC – just ensure the student provides sufficient detail about their product.
© 2013 Canadian Healthcare Association. All rights reserved.
45
FSNM Yr 2 Sr 2
Unit 8 Assignment
Food Services and Nutrition Management
Unit 8: Nutrition Therapy IIINutritional Management of Heart
Disease, Renal and Gallbladder
Disorders and Pancreatitis
© 2013 Canadian Healthcare Association. All rights reserved.
46
FSNM Yr 2 Sr 2
Unit 8 Assignment
Grading Guidelines
Question 1 (10 Marks Total- 1 mark each)
1. Short Answer Questions
a)
Examples of saturated fats include:
(1) butter fat
(2) coconut oil
(3)
(4)
hydrogenated vegetable oil
all of the above
b)
An elemental formula contains hydrolyzed nutrients that require minimal digestion
and are easily absorbed. True or False?
c)
In a NAS or 130 mmol sodium diet, all commercial salad dressings should be
omitted. True or False?
Salad dressings are permitted in limited amounts except for those containing bacon fat, bacon
bits and salt pork
d)
One primary function of the gallbladder is to store ___bile__. (Study Guide)
e)
Commercial salt substitutes or salt free cheese may be unsuitable for patients with
renal disease. True or False?
f)
Controlling __protein___intake is a primary goal in the treatment of chronic renal
failure.
g)
In the storage, metabolism and detoxification of certain foods and drugs, the
__liver___ is one of the most important body organs.
h)
A low potassium diet includes a restriction in the following foods:
(1) dairy products
(3) whole grain bread
(4) all of the above
(2) citrus fruits
i)
Ascites is:
(1) Yellowing of the eyes, skin and
mucous membrane
(2) inflammation of the liver
j)
(3)
(4)
fluid accumulation in the
abdomen
Elevated blood ammonia levels
Fatty liver arises from eating too much fat. True or False? (½ mark)
Question 2 (5 Marks Total- 1 mark each)
2. Definitions: Definitions should be expressed in your own words in order that you
understand them. Definitions should state what the item is and what it does or causes.
© 2013 Canadian Healthcare Association. All rights reserved.
47
FSNM Yr 2 Sr 2
Unit 8 Assignment
a)
C.H.D. - coronary heart disease which is the narrowing of coronary arteries caused
by fatty deposits, resulting in a reduction of blood flow to the heart muscle.
b)
jaundice - a yellowness of skin, membranes and excretions due to the presence of
bilirubin and bile pigments - a symptom of liver and gallbladder disorders.
c)
uremia - an excess in the blood of nitrogenous end products of protein and amino
acid metabolism - a sign of chronic renal failure.
d)
hyperkalemia - abnormally high potassium concentration in the blood, most often
due to defective renal excretion, as in kidney disease.
e)
steattorhea - excess fat in the feces due to a malabsorption syndrome or certain
diseases (e.g. pancreatitis).
Question 3 (15 Marks Total)
3. The attached menu is the recorded 24 hour food intake of an individual. Modify the menu
for the following diet restrictions. Try to keep as much of the actual menu as possible and
only alter those food items that are affected by the diet change. Please rewrite the
original and the entire completed revised menu for each modification indicating amounts
in each. Name one disease or condition in which this diet would be used.
a)
low fat - 45 g (5 marks)
b)
restricted protein - 40 g (5 marks)
c)
restricted sodium - 87 mmol (5 marks)
See next page
© 2013 Canadian Healthcare Association. All rights reserved.
48
FSNM Yr 2 Sr 2
Unit 8 Assignment
MENU FOR ASSIGNMENT QUESTION 3
Breakfast
A.M. Snack
Lunch
Dinner
Evening Snack
250 mL
125 mL
2 sl
2
1
10 mL
250 mL
15 mL
250 mL
1
250 mL
4
1
20
30 mL
1
1sl
1
250 mL
15 mL
90g
125 ml
125 mL
2
10 mL
1/8
250 mL
1
250 mL
DIET MODIFICATION
Orange juice
2% Milk
Back Bacon
Egg, scrambled
English Muffin
Butter
Coffee
White Sugar
Coffee
Apple Danish
Cream of Tomato Soup
Soda Crackers
Grilled Cheese Sandwich on White Bread
French Fries
Ketchup
Dill Pickle
Coconut Cream Pie
Regular Pepsi
Greek Salad (with olives)
Oil/Vinegar Dressing
Roast Ham
Scalloped potatoes
Carrots
Dinner Rolls
Butter
Honeydew Melon
Milk (2%)
Granola Bar
Tea
DISEASE OR CONDITION
Low fat diet - 45 g
-
hyperlipoproteinemias
fat malabsorption and maldigestion
pancreatitis
cholecystiti
Restricted Protein - 40 g
- cirrhosis of the liver
- renal failure
Restricted Sodium - 90 mmol
- renal disease
- hypertension
- congestive heart failure
-
© 2013 Canadian Healthcare Association. All rights reserved.
49
FSNM Yr 2 Sr 2
Unit 8 Assignment
Calculate and show the grams of fat in diet A, the grams of protein in diet B and mg of
sodium in diet C to ensure you meet the requirement. Please cite your reference sources.
Make sure the students only alter the food items that are affected by the diet. They need to cite
reference sources.
FAT (g)
Breakfast
250 mL
125 mL
2 slices
1
2
10 mL
15 mL
250 ml
A.M.
Snack
1
250 ml
Lunch
250 mL
4
1 small
10 mL
20
1
1/6 pie
250 mL
Dinner
250 mL
15 mL
90g
125 ml
Protein
(g)
Sodium
(mg)
Orange Juice, canned
2% Milk
Back bacon, grilled
English Muffin
Eggs,scrambled
Butter
White sugar
Coffee
2.5
4
1
14
12
0
2
4.5
11
4
13
-
5
64.5
719
262
476
84
8
Danish pastry, fruit
Coffee
13
0
4
-
251
8
Cream of Tomato Soup
Soda Crackers
Whole wheat Grilled Cheese
Sandwich (processed)
Ketchup
French Fries
Dill Pickle
Coconut Cream Pie
Regular Cola
5
1
12
6
1
14
987
129
962
4
11
0
2
1
0
*120
14
833
163
10
Greek salad
Oil/Vinegar dressing
Roasted Ham, boneless, regular
Scalloped potatoes, home
prepared
Carrots
Dinner Rolls, plain
Butter
Honey Dew melon
2% Milk
13
10
6
5
4
15
4
315
235
1053
434
4
12
5
4
1
9
296
84
13
129
0
4
133.5
0
2
92.5.5
8
86
7748.5
125 ml
2
10 mL
1/8 slice
250 mL
HS Snack
250 mL
Tea, brewed
1
Granola Bar, hard, choc chip
Total
"Nutrient Value of Some Common Foods"
© 2013 Canadian Healthcare Association. All rights reserved.
50
FSNM Yr 2 Sr 2
Unit 8 Assignment
Question 4 (5 Marks)
4. You are going to be giving a class to several patients with congestive heart failure about
the nutritional care of CHF. Prepare an outline of the presentation. In essay format
present the material you will cover. As the main dietary recommendation for CHF is
moderate sodium intake, it is expected that your presentation will focus on sodium. You
may consider using additional reference sources beyond your textbook. Include any
patient handouts you will use during the presentation. Please remember that a
presentation generally has an introduction, key points covered, and a summary or a way
to “pull it all together.”
What is Congestive Heart Failure?
CHF is usually a chronic, progressive heart condition that results from other cardiovascular
illnesses. Treatment of CHF includes drug therapies that reduce congestion and strengthen
heart function. The main dietary recommendation is moderate sodium intake of 2,000 to 3,000
milligrams daily, depending on the severity of the illness.
(In marking this question start with 5 marks and remove ½ marks for missing information)
This is not set in stone, but the student’s answers should include the following information:
- a definition of sodium
- sources of sodium in the diet
- effects on the body
- the role of sodium on fluid balance and in particular with congestive heart failure
- ways to reduce sodium intake
- alternative seasonings
- special products available
- cooking techniques
- eating away from home and in restaurants
Question 5 (10 Marks Total)
5. Answer the following questions.
a)
Based on the chart below, compare the diets for hemodialysis and predialysis. (2
marks)
Predialysis
Hemodialysis
Kcal
~ same
~ 35 kcal/kg
Protein
More restricted
~ 1.2 g/kg
Fat
As needed
As needed
Fluid
Mostly unrestricted
.5-1L + urine output
Potassium Individualized according to
Limited to 2000-3000 mg/day
laboratory values for predialysis
patients.
Sodium
1-3g
1-3g
Phosphorus Same or Individualized according Limited to 800-1000 mg/day
to laboratory values for
predialysis patients.
Calcium
1000 - 1500 mg/day
< 2000 mg/day from diet and
medications
Textbook: table 23-5, pp 604
© 2013 Canadian Healthcare Association. All rights reserved.
51
FSNM Yr 2 Sr 2
b)
Unit 8 Assignment
Why is it easy for a patient/resident on C.A.P.D. to gain weight? (2 marks)
Weight gain occurs because the dialysate contains dextrose/sugar which is absorbed by the
body providing a substantial source of energy
Textbook pp. 604
c)
As kidney disease progresses, what factors must be considered when determining
fluid and sodium restriction? (2 mark)
Total urine output, changes in body weight and blood pressure and serum sodium levels. Fluid is
not restricted until urine output decreases.
Textbook pp. 605
d)
Why should renal patients take phosphate binders with their meals? (2 mark)
Phosphate binders are consumed to combine with dietary phosphorus in the gastrointestinal
tract and prevent its absorption. The phosphorus is excreted in the stool (feces) Text book pp.
606
e)
Why do renal patients frequently have a poor appetite? (2 mark)
Prior to dialysis, uremia can be responsible for a loss of appetite as a result of symptoms of
nausea. Even with dialysis some patients still feel certain degrees of nausea. Also, the fact that
a patient must follow a number of dietary restrictions can lead to a loss of appetite as favourite
foods may be restricted or the diet may appear overwhelming. As well, patients may be fatigued
and feeling full with CAPD.
Study Guide
Question 6 (10 Marks)
6. The following nutritional care plan has been calculated by a renal dietitian for a dialysis
patient. Using the diet plan, fill out the attached menu that is located on the next page.
Include appropriate portion sizes and add an hs snack as in the diet plan. Do not forget
to show how the fluid restrictions (1000 ml) are met.
B
Protein
Starch
Milk
Fruit
Veg
Fat
Bev
other
1
3
1
1
2
C
am
L
pm
D
2
2
3
1
1
1
2
T
15 mL
1
2
2
T
15
mL
hs
1
1
1
total
7
7
1
3
3
7
Totals
g
Prot
49
14
4
1.5
6
0
mmol
Na
14
42
3
0
3
14
mmol
K
21
7
5
12
12
0
mg
mL
Phos Fluid
490
350
125
125
45
90
0
375
30
74.5
g
76
mmol
57
mmol
1100
mg
530
mL
total
Diet Prescription: 75 g protein; 60 mmol K; 90 mmol Na; < 1200mg Phos; 1000 mL Fluid/day
© 2013 Canadian Healthcare Association. All rights reserved.
52
FSNM Yr 2 Sr 2
Unit 8 Assignment
Note: On the meal pattern for lunch and dinner, a milker of 15 mL is included. C/T refers to
coffee and tea. The vegetable group includes potato.
There is not one correct answer. Sample next page. Ensure the student has taken fluid and
sodium restrictions into consideration
© 2013 Canadian Healthcare Association. All rights reserved.
53
FSNM Yr 2 Sr 2
Unit 8 Assignment
Menu for Assignment Question 6
Snacks: 1000mL – 530mL= 470 mL fluid available for snacks. Could have cranberry juice
or noncola soft drinks between meals and hs snack. Hs snack: ½ sandwich or SF
crackers and cheese (3x/wk) or peanut butter 4x/wk also possible They should add in
the fat as margarine or butter on the crackers.
Breakfast
Lunch
Dinner
Rolled Oats
____Cream of Wheat regular
____Corn Flakes
____Tuna Salad Sandwich on White
__1_ Chicken Pot Pie
(2 Protein, 1 Vegetable)
____Cheddar Cheese
_1__Poached Egg
____Peanut Butter
____Coleslaw, SF Dressing
____SF Mashed Potato
____SF Green Beans
_2sl_White Toast
_2__Margarine
____Banana Muffin
____Butter
____Pancake/Syrup
____Jam
(1 Starch)
_2__Jelly
____SF Ketchup
Mustard
____Honey
____Orange Juice
____Cranberry Juice
_1__Apple Juice
____Low K Fruit Salad
_125mL_1% Milk
________Whole Milk
________Cream Substitute
Please Circle:
Coffee 125mL Decaf Coffee
Tea
Hot Water
Sugar x2
Lemon
Cream Substitute x1
Low Sodium Seasoning
Pepper
_125mL___SF White Rice Pilaf
__________SF Mashed Potato
_125mL___SF Julienne Carrots
____SF
_1__Applesauce
1sl_White Cake
____Low K Fresh Fruit
1sl_White Bread
Bread
_2__Margarine
_75-90__g Low Fat Meatloaf
_30mL___SF Gravy ____Reg
Gravy
________SF Sweet & Sour Pork
____Wholewheat
_1__Tossed Salad
Dressing
_1__Regular Dressing
____SF
____SF Ketchup
Mustard
_1__Margarine
____Butter
____SF
____Butter
____Cranberry Juice
_1__Diced Peaches
____Blueberry Crisp
____Low K Fresh Fruit
____Cranberry Juice
Please Circle:
Coffee
Decaf Coffee
Tea 125mL
Hot Water
Sugar x2
Lemon
Cream Substitute x1
Low Sodium Seasoning
Pepper
Please Circle:
Coffee
Decaf Coffee
125mL
Hot Water
Sugar x2
Lemon
Cream Substitute x1
Low Sodium Seasoning
Pepper
This is a low potassium meal plan: for Low potassium diets choose 2 low and 1 medium fruit &
veg each day. Serving size (1): juice ½ cup, except for cranberry juice cocktail (1 cup); vegs ½
cup;5 mL for fats/jams etc.; syrup is a no; Cereals ready to eat – ¾ cup; cooked cereal ½ cup;
bread 1 sl; milk ½ cup; ¼ cup tuna salad; 4 crackers; protein choice 25-30g; (Bananas, orange,
potatoes and prunes are no.)
© 2013 Canadian Healthcare Association. All rights reserved.
54
Tea
FSNM Yr 2 Sr 2
Unit 8 Assignment
Question 7 (6 Marks Total- 2 marks each)
7. Many people develop protein-energy malnutrition and wasting during the course of an
illness associated with liver disease. Table 20-5 (p. 527) provides examples of possible
causes of malnutrition in liver disease. For the following three nutritional problems,
describe dietary or medical treatments that may help in managing the problem.
(Note: the answers are basically found on Table 20-6, pp. 528 in their textbook)
a)
Abdominal discomfort and early satiety caused by ascites.
Four to six small meals per day may increase intake tolerance. Diuretics and a reduced-sodium
diet (2000 milligrams or less per day) may help ease ascites. Fluid restriction may be necessary
if ascites is accompanied by a low concentration of serum sodium.
b)
Steatorrhea caused by fat malabsorption as a result of reduced bile being produced
from the diseased liver.
Restrict fat intake and use medium-chain triglycerides (MCT) to provide additional energy.
Supplements of essential fatty acids, fat-soluble vitamins, calcium, magnesium and zinc are
warranted with fat malabsorption.
c)
Inadequate protein synthesis (the making of protein) caused by damage to the liver
that results in low stores of albumin, clotting proteins and transport proteins.
Medical nutrition therapy includes adequate protein to maintain nitrogen balance (0.8-1.2 grams
per kilogram desirable body weight per day). Adequate calories must also be provided to prevent
protein catabolism.
Question 8 (15 Marks Total- 3 marks each)
8. Malabsorption of nutrients can occur as a result of disorders with the intestines, as well
as disorders of organs. Describe how each of the following disorders can lead to
malabsorption, what nutrients are of most concern and the nutritional intervention/
therapy.
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55
FSNM Yr 2 Sr 2
a) Celiac disease
the mucosal surface is eroded by
sensitivity to the protein gluten. The
villi are malformed and deficient in
number with few microvilli resulting
in a very large reduction in the
absorbing surface
b) Crohn’s disease of the small
intestines inflames the intestinal mucosa and
thus reduces the intestinal surface
area for absorption
c) Pancreatitis
the secretion of the digestive
enzymes needed to break down
macronutrients is impaired.
d) Cystic fibrosis
thick secretions of mucus can
impair the functioning of the
pancreas and damage the bile duct
and liver. /the pancreas secretes
enzymes needed in digestion.
Secretion of bile needed to
emulsify fats is interfered with, as
well.
e) Cirrhosis
In alcoholics with cirrhosis,
pancreatic damage and liver
changes can limit the input of
pancreatic enzymes and bile salts
leading to mal-digestion and
Unit 8 Assignment
Nutritional intervention
Nutrients – may malabsorb Gluten – free diet
all nutrients to some
degree, especially the
macronutrients, fat-soluble
vitamins, electrolytes,
calcium, magnesium, zinc,
iron, folate, and vitamin
B12
Nutrient concern –
malabsorption leading to
Protein energy malnutrition
and multiple nutrient
deficiencies (vitamin B12,
calcium & vitamin D)
Therapy varies according
to the symptoms &
complications that may
develop.; vitamin
supplements usually
required; may require a low
fat diet; small frequent
meals. During ‘active’
phases a low-fibre diet is
recommended to allow th e
bowel to rest
Nutrients – fat
malabsorption, which is
associated with losses of
food energy, essential fatty
acids, fat-soluble vitamins
and some minerals
Acute: oral fluids & food
are withheld until pain and
tenderness subside (fluids
& electrolytes supplied
intravenously); progress to
regular diet as tolerated.
Low fat diet may be
required. Chronic: protein
& energy needs high when
patient is malnourished.
Dietary supplements may
be needed. Avoid alcohol.
Nutrients of concern – like
pancreatitis, fat
malabsorption is an issue
so losses of food energy,
essential fatty acids, fatsoluble vitamins and some
minerals
Energy needs are high –
high caloric intake
required.
Pancreatic enzyme
replacement therapy –
these supplements
required with all meals and
snacks; Dietary vitamin
supplements required
Nutrients – Protein energy
malnutrition and multiple
nutrient deficiencies
Diet therapy is customized
to patient needs, however
further level damage must
be prevented so want to
avoid: alcohol, herbal
© 2013 Canadian Healthcare Association. All rights reserved.
56
FSNM Yr 2 Sr 2
resulting mal-absorption of
nutrients
© 2013 Canadian Healthcare Association. All rights reserved.
Unit 8 Assignment
supplements and vitamin
or mineral megadoses.
Usually have igh energy
needs – frequent small
meals; restrict sodium to
minimize ascites.
57
FSNM Yr 2 Sr 2
Unit 8 Assignment
Question 9 (10 Marks Total)
9. Cataldo, C.D., DeBruyne, L.K., Whitney, E.N. (2003). Nutrition and Diet Therapy, 6th
edition; Wadsworth/Thomson Learning, Belmont, CA., USA. Pg. 646.
History Professor with Cardiovascular Disease.
Mr. Jablonski, a 48 year-old history professor, has a blood lipid profile that includes elevated
LDL cholesterol. He is 5 feet 7 inches tall and weighs 200 pounds. Mr. Jablonski has a family
history of CHD. His diet history shows excessive intakes of food energy, cholesterol, total fat,
saturated fat, and salt. He smokes a pack of cigarettes a day, and his lifestyle leaves him little
time for physical activity. Mr. Jablonski also has hypertension, for which anti hypertensive
agents have been prescribed. He frequently forgets to take his pills and as a result, his blood
pressure is often quite high.
a)
Name the risk factors for CHD and hypertension in Mr. Janblonski’s history. Which of
them can he control? (2 marks)
Risk factors
Control
LDL cholesterol
Hypertension
Smoking
Obesity
Lack of physical activity
No control
Male Gender
48
Family history
Which can be helped by diet?
Diet can help to decrease LDL cholesterol levels, control hypertension in some individuals, and
decrease body weight.
Which complications might you expect if his condition goes untreated?
If his condition goes untreated, he is likely to have a heart attack or stroke.
b)
What type of diet would you recommend to treat Mr. Jablonski’s high
LDL cholesterol and hypertension? (4 marks)
His current diet will change in relationship to energy, cholesterol, total fat and saturated fat. He
should consume primarily grains and cereals, fruits and vegetables, non-fat dairy products, and
lean meats and meat alternatives. Diet therapy for hypertension would emphasize weight
reduction, physical activity, salt restriction if he is salt-sensitive, and consumption of foods high in
potassium, calcium and magnesium.(1 mark)
Explain the rationale for the diet change.
The diet is designed to achieve desirable body with and decrease LDL cholesterol levels. (1
mark)
© 2013 Canadian Healthcare Association. All rights reserved.
58
FSNM Yr 2 Sr 2
Unit 8 Assignment
What is the target amount that Mr. Jablonski should aim for when it comes to daily
intake of total fat, saturated fat, and cholesterol.
Limit total fat to less than 30% of total Kcalories, reduce saturated fat to less than 7% of total
Kcaloires, decrease cholesterol intake to less than 200 mg/day. (2 marks)
c)
Prepare a day’s menu for Mr. Jablonski. What suggestions might you offer to help
him make the necessary diet changes? (4 marks)
To help him make the necessary diet changes would recommend that he reduce salt
gradually, experiment with salt substitutes, and replace salt with spices and herbs. The
diet changes for hypertension are consistent with those for reducing LDL cholesterol.
A day’s menu (sample)…accept something reasonable
Breakfast
a high fiber cereal with skim milk
fresh fruit
Lunch
salad with lettuce, tomatoes, carrots, cucumber, mushrooms and water pack tuna,
low fat salad dressing
whole wheat crackers
fresh fruit
skim milk
Dinner
Lean baked skinless chicken breast
Fresh green beans
Baked potato
Margarine
Whole wheat role
© 2013 Canadian Healthcare Association. All rights reserved.
59
FSNM Yr 2 Sr 2
Unit 8 Assignment
Question 10 (5 Marks Total- 1 mark each)
10. Jason, 74 years old, developed chronic renal failure after suffering from a streptococcal
infection (strep throat). His renal function declined steadily over 5 years. He has been
receiving hemodialysis 3 times each week for several months. He followed a low
sodium, protein and phosphorus diet prior to starting hemodialysis and now has had to
restrict potassium and fluid as well. He finds meal preparation and keeping house difficult
and he has begun to lose weight. He has wondered if he could use the meal
replacement products he sees in the stores. His labs are in good range.
a)
Has his protein allowance changed since starting dialysis?
He has had to increase his protein allowance from .8g/kg to 1-1.2 g/kg.
b)
Can he use frozen prepared meals? Meal replacements?
Yes, if he uses the lower potassium and sodium containing ones. He should also not choose a
cheese-containing meal each day. The liquid meal replacements can be used if he chooses the
renal ones: Novasource Renal and Nepro.
c)
How can the non protein calories in the diet be increased?
He can be instructed to add extra sugar and margarine/butter to his diet, and not drink calorie
free beverages.
d)
What would you tell him if he asked if he could use a salt substitute?
The herb mixtures are fine, but not the potassium containing white crystal ones that look like
table salt.
e)
List several protein-containing snacks he could try.
Peanut butter and crackers, extra sandwiches made from bread or pita bread or tortilla wraps, or
he can use his milk choice as a pudding/yogurt.
© 2013 Canadian Healthcare Association. All rights reserved.
60
FSNM Yr 2 Sr 2
Unit 8 Assignment
Question 11 (9 Marks)
11. Using the menu in Appendix A, plan cycle menus for:
 a low sodium diet,
 a diabetic diet,
 a low fat, low cholesterol diet.
Keep as much of the menu as possible. Change only the items that need changing. Please
provide a brief description of the guidelines you used to make your menu modifications.
For example: “My menu modifications for the low sodium diet are based on a NAS diet, or
a menu that adheres to no more than 3g of sodium per day.”
ECs – the menu modifications are very general, and it is up to the student to decide how
they interpret “low sodium’ or how liberal the diabetic diet is- they general choose what is
done in their own place of work –but they should say if the diabetic menu is considered
very ‘liberal’ or if they have followed their facility guidelines in making their modifications.
see next page
© 2013 Canadian Healthcare Association. All rights reserved.
61
FSNM Yr 2 Sr 2
Unit 8 Assignment
Appendix A Menu for Question 11
Monday
Tuesday
Wednesday
Thursday
Friday
BREAKFAST
Prune or Orange Apple or
Juice
Grapefruit Juice
Orange or Prune Apple or
Juice
Grapefruit Juice
Pineapple or
Cranberry Juice
Cream of Wheat
or
Assorted Cold
Cereals
Oatmeal or
Assorted Cold
Cereals
Cream of Wheat Oatmeal or
or
Assorted Cold
Assorted Cereals Cereals
Peanut Butter
Boiled Egg
Breakfast
Sausage
Blueberry Muffin
or
Choice of Toast
Waffles with
Syrup or
Choice of Toast
Cream of Wheat
or
Assorted Cold
Cereals
Poached Egg
Orange Juice or
Cream of Celery
Soup
Sunday
Pineapple or
Prune Juice
Orange or
Cranberry Juice
Oatmeal or
Assorted Cold
Cereals
Cream of Wheat
or
Assorted Cold
Cereals
Scrambled Egg
Bacon
Carrot Muffin
Cinnamon Scone
Oatmeal Apple
Choices of Toast Choice of Toast French Toast with Muffin
Syrup
Choice of Toast
Choices of Toast
LIGHT MEAL
V8 Juice or
Cranberry Juice
Seafood Chowder or
Soup
Harvest Pumpkin
Soup
Tasty Tuna
Juicy Hamburger Hearty Beef Pot Potato & Cheddar
Noodle Casserole with Lettuce and Pie with Gravy
Perogies
Creamy Fettucini
with Green Peas Tomato & Potato and Creamy
with Bacon, Sour Alfredo with
Wedges
Coleslaw
Cream and
Garlic Toast &
Butterscotch
Onions
Sliced Carrots
Pudding or
Broken Glass
Ice Cream or
Ginger Cookie or
Diced Pears
Parfait or
Banana Slices
Fresh Apple
Custard or
Peach Halves
Fruit Cocktail
Alternate:
Alternate:
Alternate:
Alternate:
Corned Beef on Egg Salad
Ham & Cheese
Chicken Caesar Alternate:
Rye with
Sandwich &
Kaiser with
Salad and a
Salmon Salad
Three Bean
Assorted Raw
Beet Citrus Salad Dinner Roll
Sandwich with
Salad
Vegetables
Celery & Pepper
Sticks
Apple Juice or
Grape Juice or
Butternut Squash Garden
Soup
Vegetable Soup
Saturday
Breakfast Ham
Slice
Pancakes with
Syrup or
Choice of Toast
Grape Juice or
Leek & Potato
Soup
Apple Juice or
French Canadian
Pea Soup
Grilled Cheese
Sandwich
With Garden
Salad & pickled
beets
Hearty Beef
Goulash with
Mixed Vegetables
Oatmeal Raisin
Cookie or
Diced Pears
Alternate:
Cottage Cheese
Fruit Plate
Alternate:
Hot Dog on a Bun
with
Coleslaw
Vinagrette
Lemon Tart or
Pineapple Tidbits
FSNM Yr 2 Sr 2
Unit 8 Assignment
Tomato Juice
Tropical Punch
Apple Juice
Tender Roast
Beef, with
Mushroom Gravy,
Baked Potato &
Yellow Beans
Sweet & Sour
Pork with
Steamed Rice &
Baby Corn
Chicken
Parmesan with
Spaghetti &
Asparagus
Spears
Raspberry Tart or Iced Banana
Kiwi Fruit Cup
Cake or
Green Grapes
Alternate:
Four Cheese
Alternate:
Pasta
Homestyle
with Broccoli
Cabbage Rolls &
Scandinavian
Mixed Vegs
MAIN MEAL
Pineapple Juice
Orange Juice
Tomato Juice
Tropical Punch
Swedish
Meatballs with
Gravy, Mashed
Potato &
Baked Tomato
Half
Succulent Shrimp
Stir Fry with
Fried Rice and
Steamed Bok
Choy & Teriyaki
sauce
Glazed Baked
Ham with
Scalloped
Potatoes and
Brussel Spouts
Roast Turkey with
Dressing,
Whipped Potato,
Gravy &
Winter Vegetable
Blend
Lemon Meringue
Pie or
Strawberry
Melon Cup
Mousse or
Apricot Slices
Alternate:
Lightly Breaded Alternate:
Fish with Herbed Hearty Pork
Potatoes &
Vegetable Stew
Braised Cabbage with a Biscuit
Iced Chocolate
Cake or
Plums
Blueberry Pie or
Fresh Fruit
Bread Pudding or
Mandarin
Oranges
Alternate:
Fish Nuggets with
Alternate:
Tatar Gems,
Alternate:
Breaded baked
Tater Sauce &
Vegetarian
Veal Patty with
Baked Squash
Lasagna with
Mushroom Gravy,
Garlic Bread &
Whipped Potato,
Tomato Slices
& Beets
Note: Whole Wheat Bread, Butter, Margarine, 125 ml Water, 125 ml Milk, 180 ml Coffee/Tea are served at each meal. Jams, Jellies,
Marmalade and Honey are available at Breakfast