Introduction

Proper nutrition is important for all of us. Home Health Aides/Personal Care Aides have very important roles to fill with regard to helping their patients obtain proper nutrition. This module will explore the basics of nutrition. We will discuss all the important types of food that should be in a patient’s diet. We will also talk about the type of food that should be avoided. We will learn how to use the USDA’s nutrition guidelines by learning how to plan meals using ChooseMyPlate guidelines. We will talk about food preparation and safe food handling. We will also explore what different types of diets mean and what foods should and should not be included in those special diets.

Unit A: The Basics of Nutrition

The Major Nutrients

All living things require nutrients in order to survive and to grow and develop normally. Nutrients are components (parts) of food that provide nourishment in order for us to survive. Nutrients provide our bodies with energy, help build and maintain body tissues, organs, bones, and teeth, and help regulate body functions such as metabolism and blood pressure (Lehman, 2014). Nutrients include protein, carbohydrates, fats, vitamins and minerals.

The Care Plan will direct a HHA/PCA as to what the patient’s dietary requirements and restrictions are. Home Health Aides/Personal Care Aides should always be sure to follow these as they are in place to best promote good health for the patient. If they are ever in doubt about whether a patient can have a certain food, they should seek guidance from their supervisor.

Protein

Proteins are the essential (necessary) building blocks that our body needs in order to properly function. We need protein in order to build and repair body tissues, such as muscles, organs, and skin. Sources of protein include poultry, meat, fish, eggs, milk, cheese, nuts and nut butters, peas, dried beans, and soy products. Our bodies can also use protein as an energy source or convert it to fat (Lehman, 2014). The amount of protein that a person needs depends on their body size, age, activity level, and their general well-being (U.S. Department of Agriculture, 2015a). People who are sick, undernourished, and healing generally require higher amounts of protein in order to help the body’s tissues heal.

Sources of Protein:

• Poultry (chicken, turkey)
• Beef (steak, ground beef, stew meat, hamburgers, hot dogs)
• Fish (tuna, salmon, trout, bass, cod)
• Shellfish (shrimp, lobster, crab)
• Milk
• Eggs
• Soy products (tofu, tempeh, veggie burgers)
• Legumes (beans such as white beans, kidney beans, chickpeas)
• Peas
• Nuts (almonds, pistachios, walnuts, cashews, peanuts)
• Seeds (pumpkin, sunflower, squash seeds)
• Peanut butter and other nut butters

Carbohydrates

Carbohydrates are the essential nutrients our body needs in order to provide us with energy. Carbohydrates are the major way our body gets energy in order to effectively function. Carbohydrates provide our body with sugar, starch, and fiber. Starches include grains, potatoes, beans, and peas. Sugars include fruits, vegetables, and sweeteners. Foods that have fiber in them include whole grain foods such as cereals and breads, fruits, and, vegetables. Fiber is important as it helps aid in digestion, helps to lower cholesterol, and helps us to feel fuller longer. Fiber is also necessary to aid with bowel elimination (Leahy, Fuze & Grafe, 2013).

There are two basic types of carbohydrates: complex and simple. Complex carbohydrates are found in grain products such as bread, cereal, pasta, rice, and vegetables. Simple carbohydrates are foods found in sugars, sweets, syrups, and jellies. Complex carbohydrates have more nutritional value than simple carbohydrates.

The body uses sugars and starches for energy. Extra carbohydrates or carbohydrates that we take in but do not need at the time, are converted to fat, which are then stored (Lehman, 2014). A diet in excess of carbohydrates can lead to obesity (being over the ideal weight for a person’s body size).

Sources of Carbohydrates:

• Grains
• Breads of all kinds
• Potatoes
• Beans
• Peas
• Oatmeal
• Rice (white, wild, brown)
• Breakfast cereals
• Tortillas
• Grits
• Pasta, noodles
• Popcorn
• Quinoa
• Crackers (all kinds)
• Couscous
• Muesli

Fats

Fats are essential nutrients in our diets. Even though we tend to think of fats as bad for us, we do need a certain amount of fat in our diets. Fat helps to protect our organs, is necessary for all the membranes in most the cells in our body, for brain and nerve function, is used to insulate the body and help us prevent heat loss, and is a carrier for other nutrients ((Leahy, Fuze & Grafe, 2013; Lehman, 2014). Extra fat can also be used as energy for the body, or it can be stored.

While we need a certain amount of fat in our diet, caution must be taken to not eat too much fat. A diet high in fat can lead to serious complications such as high cholesterol, myocardial infarction (heart attack), coronary artery disease, and cerebrovascular accidents (strokes). Sources of fat include oils, butter, margarine, salad dressings, and animal fats found in meat, fish, and milk.

Some fats are healthier options than others. For example, choosing to eat a handful of nuts is a healthier option than choosing to eat a handful of potato chips. There are three main types of fats: monounsaturated fats, polyunsaturated fats and saturated fats (Leahy, Fuze & Grafe, 2013). Monounsaturated fats include vegetable fats such as olive oil and canola oil. Polyunsaturated fats include corn, soy, safflower, and sunflower oils, and omega-3-fatty acids. Saturated fats include butter, bacon, lard, coconut oil, and peanut oil. Saturated fats are less healthy options than monounsaturated and polyunsaturated fats. They should be consumed in limited quantities.

Sources of Fat:

• Oils (all kinds)
• Butter
• Milk
• Eggs
• Fish
• Meat
• Nuts and seeds
• Avocados
• Margarine
• Salad dressings
• Olives
• Peanut butter
• Animal fats found in meat

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Vitamins

Vitamins are essential to help our body use other nutrients we take in, and they also help to promote tissue growth. There are several kinds of vitamins, all of which have a specific purpose and which we need every day. With the exception of Vitamin D and Vitamin K, our body needs to obtain vitamins through our diets. We make a certain amount of Vitamins D and K within our bodies. While most people who eat a well-balanced diet do not need to take vitamin supplements, other people may need a daily supplement in order to meet their nutritional needs. The patient’s physician will discuss the specific vitamin supplements the patient needs, if any. If the patient has a question about a vitamin, Home Health Aides/Personal Care Aides should inform their supervisor about the patient’s question.

Vitamin A is necessary to help keep the skin in good condition and also supports eye health. Vitamin A can be found in dark green, yellow, and orange vegetables.

Vitamin B is needed to help the nervous and digestive systems function properly. It also is important for protein, carbohydrate, and fat metabolism. Metabolism is the process by which the body converts (changes) what we eat and drink into usable energy. Foods high in vitamin B are those found in animal products such as meat, milk and milk products, green leafy vegetables, and fortified grain products. When foods are fortified, they have nutrients added to them in order to make them more nutritious. For example, many grain or bread products are fortified, or enriched with extra minerals and vitamins for extra nutrition.

Vitamin C helps to strengthen blood vessel walls and aids in the healing of wounds and bones. It also helps the body to absorb iron. Foods rich in vitamin C include fruits such as oranges, strawberries, grapefruit, and vegetables like broccoli, Brussel sprouts, and green cabbage.

Vitamin D is needed for our body to build strong bones and teeth. Sources of vitamin D include milk, butter, salmon, sardines, tuna, liver, fish liver oils, and fortified orange juice. We also synthesize (make) our own vitamin D when we get sunlight on our skin.

Vitamin E is an antioxidant, which is a substance used to remove potentially damaging agents called free radicals. This helps to promote a good immune system. Sources of vitamin E are wheat germ, fish, fruits, vegetables, cereals, and nuts.

Minerals

Our bodies also require a number of minerals in order to best function. Minerals are compounds that our body needs in order to perform a variety of functions. There are a number of essential minerals that our bodies need. For example, we need calcium, which is a mineral, in order to help keep our bones and teeth strong. There are a number of minerals that we need to take in through eating a well-balanced diet. Calcium, potassium, chloride, sodium, phosphorus, and magnesium are known as major minerals (Lehman, 2014). Iron, fluoride, zinc, copper, selenium, chromium, and iodine are known as minor minerals (Lehman, 2014). Whether a mineral is major or minor has to do with the amount we need in our diets. We need a greater amount of calcium within our diet as compared to zinc, for example.

Calcium: is a mineral that is needed for bone and teeth strength, blood clotting, proper muscle contraction, and a healthy heart. Milk and milk products such as cheese, ice cream, yogurt, leafy green vegetables, and canned fish, such as sardines (which have soft bones) are good sources of calcium.

Potassium: helps the heart to function properly, helps muscles to contract, and is necessary for good nerve conduction. Foods high in potassium include tomatoes, potatoes, squash, dried apricots, yogurt, and bananas.

Iron: iron combines with protein to make hemoglobin, which is a part of our red blood cells that carries oxygen. Good sources of iron include red meat, chicken, pork, dark green leafy vegetables such as spinach, iron fortified cereals and grain products, and dried fruits such as raisins.

Iodine: is needed for proper functioning of the thyroid gland. The thyroid is important for our body’s metabolism. Sources of iodine in the diet can include cod, shrimp, canned tuna, iodized table salt and even milk and yogurt.

Sodium: helps our body to maintain normal fluid balance. Foods high in sodium include most processed food, many canned food such as meats and soups, olives, pickles, packaged mixes, and canned foods such as vegetables. While we need sodium in our diet, we should limit the amount of sodium we take in.

Water

Water is essential to all life, including human life. Without it, we cannot survive. We could only live for a few days without water. We need water for digestion, elimination, and control of our body temperature. The majority of our body is made up of water. We need about 8 glasses, or 64 ounces, of water each day to stay adequately hydrated. Liquids such as coffee, tea, juices, milk, and soda also provide us with fluid we need. However, it is healthier to select drinks such as water, milk, or juice rather than soda.

It is important to remember to keep a patient hydrated. Some patients may not be able to or may forget to ask for a drink of water. It is a good idea for Home Health Aides/Personal Care Aides to offer a drink of water at least once every two hours. When turning and positioning a bedridden patient, offer them a glass of water at that time.

Nutrients Work Together

It is important to have a well-balanced diet. While each of the individual nutrients discussed above are important, it is important that a person take in a combination of all of them to make a well-balanced diet. Together they work to keep the body working at its optimum (best) level.

Self-Check Activity m8-2

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Unit B: Meal Planning

Well-Balanced Diet

A well–balanced diet means a diet in which all the nutrients our body needs for proper functioning and energy are taken in. A well-balanced diet contains a variety of foods from all the food groups, as well as all the necessary vitamins and minerals we need. It also means taking in an adequate supply of water for adequate health. A well-balanced diet can be planned by selecting healthy foods from each of the food groups.

USDA‘s ChooseMyPlate Dietary Guidelines

The United States Department of Agriculture (USDA) developed healthy eating guidelines for Americans to follow to help them make healthy food choices. According to the USDA, The ChooseMyPlate icon (symbol) serves as a reminder for people to help them build a healthy plate at meal times. The emphasis is on the five food groups that are necessary for good health: vegetables, fruits, grains, proteins, and low-fat dairy foods. ChooseMyPlate.gov is a scientifically based and up-to-date resource which can provide Home Health Aides/Personal Care Aides with useful information for planning meals and educating their patients about healthy food choices and physical activity. All recommended daily servings and food group sources discussed in this module are according to the guidelines set forth by the USDA and can be downloaded from www.choosemyplate.gov.

When selecting foods included in the milk group, low fat and fat-free choices should be made to promote good health. In general, 1 cup of milk, soy milk, yogurt, and 1 ½ ounces of cheese are considered a serving size (U.S. Department of Agriculture, 2015a).

Milk Sources:

• Milk (low fat, fat free, whole)
• Lactose-free and lactose-reduced milk
• Yogurt
• Pudding
• Ice cream
• Frozen yogurt
• Calcium fortified soy milk
• Hard cheeses (cheddar, mozzarella, swiss, parmesan)
• Soft cheeses (ricotta, cottage cheese)
• Calcium fortified juices and cereals

Recommended daily servings of milk products:

Children	2-3 years old 4-8 years old 9-18 years old	2 cups 2 ½ cups 3 cups
Women	19 + years old	3 cups
Men	19+ years old	3 cups

Source: U.S. Department of Agriculture (2015a)

Protein Foods Group

ChooseMyPlate.gov suggests selecting a variety of foods high in protein with 8 ounces of seafood per week. In general 1 ounce (oz.) of meat, ¼ cup of beans, 1 tablespoon of peanut butter, or ½ ounce of nuts or seeds are considered a serving of protein (U.S. Department of Agriculture, 2015a). You can view sources of protein by visiting choosemyplate.gov at http://www.choosemyplate.gov/foodgallery–protein–foods

Protein sources:

• Beef
• Pork (ham, pork chops)
• Lamb
• Veal
• Poultry (chicken, turkey)
• Beans (black, kidney, chickpeas, lentils, navy, pinto, white, soy beans, split peas)
• Eggs
• Canned fish (sardines, salmon, tuna, anchovies, clams)
• Fish (cod, tuna, sea bass, catfish, flounder, halibut, swordfish, trout, mackerel)
• Shellfish (shrimp, lobster, crab, mussels, oysters, scallops)
• Nuts (almonds, walnuts, hazelnuts, pistachios, peanuts, pecans)
• Seeds (sesame, pumpkin, squash, sunflower)

Recommended daily servings of protein:

Children	2-3 years old 4-8 years old	2 ounces 4 ounces
Girls	9-18 years old	5 ounces
Boys	9-13 years old 14-18 years old	5 ounces 6 ½ ounces
Women	19-30 years old 31 + years old	5 ½ ounces 5 ounces
Men	19-30 years old 31-50 years old 51 + years old	6 ½ ounces 6 ounces 5 ½ ounces

Source: U.S. Department of Agriculture (2015a)

Fruit Group

Most fruits are low in fat and all fruits have no cholesterol (U.S. Department of Agriculture, 2015a). Fruits are considered an important part of our diets and have many protective health benefits. Eating a diet high in fruits has been shown to reduce the risk of heart disease, some types of cancer, obesity, and type 2 diabetes (U.S. Department of Agriculture, 2015a). In general, 1 cup of fruit or fruit juices or ½ cup of dried fruit is considered a serving size from the fruit group (U.S. Department of Agriculture, 2015a).

Fruit Sources:

• Apples
• Apricots
• Bananas
• Blueberries
• Cantaloupe
• Cherries
• Fruit juices (100% fruit juice, all varieties)
• Grapefruit
• Grapes
• Kiwi
• Lemons
• Limes
• Mangoes
• Nectarines
• Oranges
• Papayas
• Peaches
• Pears
• Pineapples
• Plums
• Raisins
• Raspberries
• Strawberries
• Watermelon

Recommended daily servings of fruit:

Children	2-3 years old 4-8 years old	1 cup 1-1 ½ cups
Girls	9-18 years old	1 ½ cups
Boys	9-13 years old 14-18 years old	1 ½ cups 2 cups
Women	19-30 years old 31 + years old	2 cups 1 ½ cups
Men	19-51 + years old	2 cups

Source: U.S. Department of Agriculture, 2015a

Vegetable Group

Most vegetables are low in fat and all vegetables have no cholesterol (U.S. Department of Agriculture, 2015a). Vegetables are considered an important part of our diets and have many protective health benefits. Eating a diet high in vegetables has been shown to reduce the risk of heart disease, some types of cancer, obesity, and type 2 diabetes (U.S. Department of Agriculture, 2015a). In general, 1 cup of raw or cooked vegetables or 2 cups of leafy greens counts as one serving of vegetables (U.S. Department of Agriculture, 2015a).

Vegetable Sources:

• Artichokes
• Asparagus
• Bok choy
• Broccoli
• Celery
• Collard greens
• Corn
• Cucumbers
• Green lima beans
• Green peas
• Lettuce
• Kale
• Mushrooms
• Mustard greens
• Onions
• Peppers (green, red, orange, yellow)
• Potatoes
• Spinach
• Squash (all varieties)
• Sweet potatoes
• Taro
• Tomatoes
• Turnip greens
• Water chestnuts

Recommended daily servings of vegetables:

Children	2-3 years old 4-8 years old	1 cup 1 ½ cups
Girls	9-13 years old 14-18 years old	2 cups 2 ½ cups
Boys	9-13 years old 14-18 years old	2 ½ cups 3 cups
Women	19-50 years old 51+ years old	2 ½ cups 2 cups
Men	19-50 years old 51+ years old	3 cups 2 ½ cups

Source: U.S. Department of Agriculture, 2015a).

Grain Group

Foods made from wheat, rice, cornmeal, rye, barley or other grains are considered grain products. Grain products are important sources of energy for our bodies. In general, 1 slice of bread, 1 cup cold cereal, ½ cup cooked cereal, rice, or pasta are considered to be a serving size of grain (U.S. Department of Agriculture, 2015a).

Diets high in whole grain foods have been shown to reduce the risk of heart disease, stroke, type 2 diabetes, colorectal cancer, inflammatory diseases, helps to maintain a healthy blood pressure (American Heart Association, 2014b) reduce constipation, and help maintain a healthy weight. Select choices from the grain group from those that are high in fiber and made with whole grains for the most health benefit. You should strive to make at least half of your grains whole grains (U.S. Department of Agriculture, 2015a). You can view sources of grains by visiting choosemyplate.gov at

http://www.choosemyplate.gov/grains

Grain Sources:

• Barley
• Bread (all kinds)
• Bulgur
• Cereals (all kinds)
• Cornbread
• Cornmeal
• Couscous
• Crackers
• Millet
• Muesli
• Oatmeal
• Rice
• Pasta (including whole wheat)
• Popcorn
• Pretzels
• Tortillas

Recommended daily servings of grains:

Children	2-3 years old 4-8 years old	3 ounces 5 ounces
Girls	9-13 years old 14-18 years old	5 ounces 6 ounces
Boys	9-13 years old 14-18 years old	6 ounces 8 ounces
Women	19-50 years old 51+ years old	6 ounces 5 ounces
Men	19-30 years old 31-50 years old 51 + years old	8 ounces 7 ounces 6 ounces

Source: U.S. Department of Agriculture (2015a)

Oils

Oils are NOT a food group, although they provide essential nutrients we need for our body (U.S. Department of Agriculture, 2015a). Oils include items such as butter, oils, margarine, mayonnaise, salad dressings. These food items should be used sparingly. Foods such as fish, nuts, and avocados are good choices of fats. Many foods we eat, especially those that are processed, often are high in fat. This should be considered when planning meals. In general, 1 ounce of nuts, 1 tablespoon margarine, mayonnaise, or oils, and 2 tablespoons of salad dressings count for one serving of oils (U.S. Department of Agriculture, 2015a). You can view sources of oils by visiting choosemyplate.gov at http://www.choosemyplate.gov/oils

Recommended daily servings of oils:

Children	2-3 years old 4-8 years old	3 tsp. 4 tsp.
Girls	9-18 years old	5 tsp.
Boys	9-13 years old 14-18 yrs. old	5 tsp. 6 tsp.
Women	19-30 years old 31+ years old	6 tsp. 5 tsp.
Men	19-30 years old 31+ years old	7 tsp. 6 tsp.

Source: U.S. Department of Agriculture (2015a)

Using ChooseMyPlate in Meal Planning

Creating a basic menu plan involves selecting a food from each food group. To help create well-balanced meals, it is helpful to follow the ChooseMyPlate food guidelines. ChooseMyPlate.gov suggests the following key points:

• Focus on fruits
• Vary your vegetables
• Make half your plate fruits and vegetables
• Make at least half your grains whole grains
• Go lean with protein
• Get your calcium rich foods

Dietary Guidelines

In addition to taking in well-balanced foods and creating healthy meal plans, it is important for Home Health Aides/Personal Care Aides to keep the following in mind when planning and preparing meals to serve their patients:

• Consume a variety of foods within and among the basic food groups. This ensures meals are well-balanced and interesting.
• Control caloric intake in order to maintain an optimal weight.
• Be physically active every day. Even people who have physical limitations can engage in exercise within the constraints of their limitations. For example, people who have limited mobility can do leg and arm exercises independently or with help, rock in a rocking chair, turn side to side, and do simple exercises. Follow the guidelines set forth in the Care Plan that will detail the kind of activity the patient can engage in.
• Increase daily intake of fruits, vegetables, whole grains and nonfat or low fat milk and milk products.
• Switch to fat free or low fat milk and milk products.
• Choose fats wisely.
• Choose carbohydrates wisely. Select complex carbohydrates rather than simple carbohydrates which tend to have more sugar content in them.
• Choose and prepare foods with little sodium (salt). Read labels to check for sodium content and avoid prepackaged and boxed foods.
• Switch to water and reduce consumption of sugary drinks.
• If the patient drinks alcohol, they should do so in moderation. Guidelines suggest that women should consume no more than 1 drink per day and men no more than 2 drinks per day.
• Keep foods safe to eat and follow good hygiene practices during food preparation.

Other Considerations

Home Health Aides/Personal Care Aides should involve their patients in meal planning. Use the communication skills learned throughout this course to educate patients about healthy food choices. When planning meals, they must take into consideration their patient’s food preferences, cultural and or religious background, eating habits, ability to chew and digest food, convenience of preparation, and calorie and special nutrient needs. Food preferences are determined by our family, culture, religious beliefs, foods we may choose not to eat, such as animal products for vegetarians, and the area we grew up or in which we live. There may be regional or ethnic differences in food preferences. Talk to the patient about their food preferences and beliefs. Watch the types of foods they eat. Make suggestions and ask for feedback. Ask them to share the foods they most enjoy. Always also assess for any allergies to foods, as these would be items to avoid purchasing or preparing in the patient’s home.

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Cost of Food

It is also important to consider the cost of food and the family’s ability to afford various types of food. If Home Health Aides/Personal Care Aides have a concern that the family is not getting enough to eat, they should speak to a supervisor. Various community resources are available to help families who cannot afford enough food. Use coupons when shopping for food and look for sales. Assist patients to plan meals weekly. Use items that are on hand or that wi ll spoil sooner first. Make a shopping list and stick to it. Purchase items such as dried beans and canned fishes to help provide less expensive sources of protein. When possible, buy in bulk. Purchase produce when it is in season as it will be freshest and cheaper.

Unit C: Food Preparation and Serving

Food Preparation

When selecting foods to plan a menu and foods to offer a patient, Home Health Aides/Personal Care Aides should use the basics of good nutrition and follow the ChooseMyPlate guidelines found at www.choosemyplate.org

• Choose a variety of foods to keep it interesting.
• Choose foods that are low in fat, low in saturated fat, and low in cholesterol
• Select lean meats, fish, and poultry. Avoid fatty cuts of meats. Remove the skin from poultry to reduce fat.
• Use sugar and salt in moderation.
• Herbs and spices can be used to help flavor food and according to the patient’s preferences.
• Choose plenty of fruit, vegetable, and grain products for snacks and meals.
• Avoid frying foods as this adds extra calories, fat, and cholesterol.
• Steam vegetables to maintain the most flavor and nutrition.
• Bake, broil, or microwave foods rather than frying or sautéing in butter or oil.
• Avoid convenience foods such as those that are pre-made or prepackaged. When foods are prepared fresh, you always know the ingredients and there will be less preservatives, sodium, fat, and calories.

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Patient Involvement

It is very important for Home Health Aides/Personal Care Aides to involve their patient in the planning and preparing of meals. Not only is the patient more likely to eat foods if they choose them, but it also helps to promote independence and self-determination. Working with a patient to plan meals and prepare foods can also help to strengthen the relationship. Share tasks of food preparation, keeping in mind any physical or cognitive limitations a patient may have.

Home Health Aides/Personal Care Aides should not allow their patient to perform unsafe tasks if they are unable to do so. For example, young children should not be allowed to use sharp knives and dangerous equipment. A person with dementia who may forget what they are doing should be closely supervised while using knives or the stove. If adaptive equipment is available, teach and encourage the patient to use it. If they can assist to provide their own care, this will help promote self-esteem and independence.

Getting involved in meal planning and preparation can also provide mental and physical stimulation, as well as relaxation and distraction. It can be a time where patients are encouraged to be creative and draw upon their strengths and talents, especially if they enjoy cooking. Many people enjoy food, either cooking or eating it. Home Health Aides/Personal Care Aides can make this time fun and relaxing by going through cookbooks and magazines with attractive pictures to help stimulate interests in food. Make a list of items that are on hand and Home Health Aides/Personal Care Aides can even make planning a meal with on-hand ingredients a fun game.

Available Cooking Equipment

While preparing food in a patient’s home, Home Health Aides/Personal Care Aides may only have access to the available equipment they have on hand. There may not be a lot of equipment to choose from. They may need to get creative in order to adequately meet their patient’s nutritional needs. Discuss ideas with a supervisor about how to best do this.

Serve Quality Food

• Purchase food that will not expire soon. Check expiration dates on all food in order to ensure it is fresh. Discard food that is past its expiration date.
• Select fresh fruits and vegetables. Don’t select those that are overripe, bruised, or have brown spots.
• Cook foods only until tender, unless the patient’s preferences and diets state otherwise. Overcooking foods destroys good nutrients.
• Serve food that is eye-appealing. Food that looks attractive will more likely be eaten and could help stimulate a person who has a poor appetite to eat.

Serving Meals

Mealtime is an excellent time to spend with a patient and their family. Home Health Aides/Personal Care Aides can use it as a time to talk, to learn more about their patient and to allow their patient time to socialize with them and others. Make sure to always plan for extra time during meals so the patient does not feel rushed. Sit next to or across from them whenever possible. Avoid doing other tasks while the patient is eating. Instead, use this time to socialize with them, unless they do not prefer it.

If the patient has a swallowing problem, remember not to ask them questions while they are trying to chew or swallow, as this could lead to choking. Plan conversation for the time in between bites. If the patient requires assistance to eat, sit next to them. This will allow Home Health Aides/Personal Care Aides to be close enough so they do not have to overextend their back while feeding the patients. Be patient as they chew and do not rush them by trying to give them another bite of food while they are still chewing the first.

Food Appearance, Texture, and Portion Size

Select nutritious foods that are contrasting colors and textures. This adds to visual and chewing appeal. Try to vary the colors of the foods being served. Avoid serving foods that are all one color. Even for people who must have a mechanical diet, which is a diet that is altered in texture, such as food that is pureed or finely chopped, different colored foods can be selected. For example, select a green, soft vegetable (spinach), a red, crunchy fruit (an apple), and colorful, chewy wild rice to go along with a piece of chicken and a glass of milk. This lends visual and chewing appeal as the patient can see different colors and feel different textures as they chew.

Home Health Aides/Personal Care Aides should be observant about changes in their patient’s appetite, and report any significant decreases of appetite to their supervisor. A poor appetite should be investigated.

Some possible explanations of a poor appetite are:

• Illness or depression. When we do not feel well or are depressed, our appetite is diminished.
• Dissatisfaction with the food. If a patient does not like the food, they will be less likely to eat. Find out their preferences and plan meals accordingly.
• Improper mouth care. A poorly cared for mouth can lead to chewing problems.
• Loose or broken teeth or problems with the gums or tongue. This makes chewing difficult.
• Chewing difficulties. It is difficult to eat if chewing is painful.
• Improperly fitting dentures. Poorly fitting dentures makes eating difficult and painful.
• Patient fear of choking. Patients who are afraid to choke may hesitate to eat.
• Patient has confusion. Patients who are confused may forget what they are doing. They may need to be encouraged to eat.
• Side effects of medications. Some medications decrease a person’s appetite.

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Unit D: Food Shopping, Storage, Handling, & Food Safety

How to Save on Food Costs

Food can be expensive. Families on a tight budget may have trouble purchasing food. If Home Health Aides/Personal Care Aides ever observe that a patient does not appear to have enough food in the house, they should discuss this concern with their supervisor.

Here are some tips for Home Health Aides/Personal Care Aides to keep in mind to help cut food costs:

• Use coupons
• Look through weekly store circulars for items on sale
• Avoid convenience foods such as those that are pre-made, pre-packaged, or that come from sections of the grocery store such as the deli, bakery, or salad bar. These items tend to be much more expensive than if you purchased the ingredients and prepared it yourself.
• Check food labels for nutritional value.
• Purchase items such as produce when it is in season. It will be less expensive and fresher.
• Purchase items in bulk, but be aware of storage space. If it can’t be stored or used up before it expires, you will not be saving money.
• Plan meals for a week at a time. Make a grocery list and stick to it.
• Use meat and protein substitutes that tend to be less expensive. Canned tuna, dried beans, yogurt, and eggs are excellent sources of protein.
• When buying meat, check the expiration date to ensure you are buying the freshest meat possible. Spoiled meat is wasted money.
• When possible, buy meat in bulk as costs tend to be lower. Cutting up a whole chicken or cutting a pork roast into chops tends to be less expensive than buying individual pieces of chicken or pork.
• Always stick within the allowed food budget. Never buy more than you are told or that the patient can afford.

Self-Check Activity m8-6

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Food Storage

It is important to properly store food. Food that is improperly stored can lead to illness and is also a waste of money as it will have to be thrown out. You can read more about refrigeration and food safety at the United States Department of Agriculture website: http://www.fsis.usda.gov/wps/portal/fsis/topics/food–safety–education/get–answers/food–safety–fact–sheets/safe–food–handling/refrigeration–and–food–safety/ct_index

Here are some things for Home Health Aides/Personal Care Aides to keep in mind, based on recommendations from the United States Department of Agriculture (2015b):

• Buy cold foods and get them home quickly to avoid spoilage.
• Keep eggs in their original packaging on a shelf, not the door in the refrigerator. Since the door is opened often, it risks the eggs becoming spoiled or cracked.
• Immediately refrigerate all meats, fish, poultry, eggs, milk, and milk products.
• Store dry food in covered containers. For example, dried beans, lentils, pasta, and rice should be stored in clean, closed containers such as plastic storage containers. Ensure pests cannot get to packaged food.
• Rotate stock. Use older items first. Make it a point to rotate cans and boxes before putting away newly purchased items.
• NEVER store food with cleaning supplies.
• NEVER store food beneath plumbing, such as beneath a sink.
• Eggs, milk, milk products (cheese, yogurt), salad dressings, and mayonnaise should be refrigerated.
• Always read the label to see if the product should be refrigerated once it is open. Items such as ketchup can be kept stored in a cupboard BEFORE it is opened. Once it has been opened, it must be stored in the refrigerator.
• Refrigerate fresh fruit only after it is ripe.
• Refrigerated food should always be covered or placed into a closed container and dated.
• Label items to be stored in the freezer with the name of the item and date if you repackaged it. Once food is frozen, it can be difficult to tell what it is.
• Use frozen foods within six months.
• NEVER thaw frozen food on a counter at room temperature. This allows bacteria a chance to multiply. Thaw food in a refrigerator overnight.
• Ensure refrigerators and freezers are in good working order. Keep a thermometer in each to ensure the temperature is correct. Refrigerators should be kept at or below 40 degrees F. Freezers should be kept at 0 degrees F.
• Cooked foods and leftovers should be used within 4 days.
• Raw meat, poultry, and fish should be used within 1-2 days.
• Keep refrigerator shelves clean and wipe up spills using hot soapy water immediately.
• Clean the refrigerator once per week and discard perishable items. Ensure there is enough space between items in the refrigerator so that air can circulate and keep foods properly chilled. Avoid overcrowding the refrigerator or freezer.

Appliance	Safe Temperature Range
Refrigerator	40 degrees F or below
Freezer	0 degrees F

Source: United States Department of Agriculture (2015b)

Type of Food	Days to Use Within
Cooked food & leftovers	Use within 4 days
Raw meat, poultry & fish	Use within 1-2 days

Source: United States Department of Agriculture (2015b)

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Safe Food Handling

When handling food, it is important to keep safety at the forefront of food preparation. You can read more about safe food handling guidelines developed by the United States Department of Agriculture at: http://www.fsis.usda.gov/wps/wcm/connect/18cece94-747b-44ca-874f-32d69fff1f7d/Basics_for_Safe_Food_Handling.pdf?MOD=AJPERES#page=2

Home Health Aides/Personal Care Aides should follow these guidelines for safe food handling:

• ALWAYS wash your hands before and after food preparation. Follow proper hand washing guidelines. Always wear gloves when handling food.
• ALWAYS wash your hands after handling raw meat, poultry, fish, or eggs.
• Use one cutting board for raw meats, poultry, and fish. Use another one for vegetables, fruits, and foods that are ready to eat, such as bread.
• Wash cutting boards in hot soapy water or run them through the dishwasher.
• Non Porous acrylic, plastic, glass, or wood cutting boards can be safely washed in the dishwasher. Discard cutting boards that are worn or that have a lot of grooves where bacteria can hide and contaminate food.
• Immediately wipe up spills from raw meat, poultry, and fish using an antibacterial cleanser or a diluted bleach solution.
• Clean the workspace before and after food preparation using hot soapy water. Clean the workspace and wash your hands after handling raw meats, poultry, or fish before moving on to the next step in food preparation.
• Cutting boards and work surfaces can be sanitized using an antibacterial cleanser or a homemade solution of 1 tablespoon liquid chlorine bleach to 1 gallon of water. Spray solution onto surface, allow a few minutes to work, rinse, and then let air dry or pat dry with a paper towel.
• Keep raw meat, poultry, and fish separate from other items in your food cart to avoid juices contaminating other food. Place these items in plastic bags separate from other food.
• When storing raw meat, poultry, and fish in the refrigerator, place them in containers or on a dish to prevent juices from dripping on other foods. Store these items on the lowest shelf in the refrigerator to prevent dripping from higher shelves onto food stored on lower shelves.
• Your clothes and apron should always be clean.
• Avoid coughing or sneezing during food preparation. If you cough or sneeze, step away from the food preparation area and wash your hands immediately afterwards.
• Use clean dishes, bowls, pots, and dish towels.
• Use hot, soapy water to wash dishes.
• Never taste food and stir food with the same spoon. If you need to taste food, or the patient would like to taste the food during food preparation, use a clean spoon to remove some from the pot or pan, and then discard that spoon into the sink to be washed.
• Hot foods can be placed in the refrigerator immediately. Do not let them sit on the stove or counter for several hours. This encourages bacteria to multiply.
• NEVER use a damaged can or a can that is bulging or dented. It could be spoiled and you risk food poisoning.
• Do not eat raw eggs or use eggs that have cracks in them. Never undercook eggs. You risk salmonella if you do so. Store eggs in their original container in the refrigerator.
• Use a food thermometer to ensure that meat is cooked to the proper doneness.
• When using a microwave, rotate the dish while cooking to avoid cold spots where bacteria may live and multiply.
• When reheating food, bring it up to proper temperature. Sauces, gravies, and soups should be brought to a rolling boil before eating.
• NEVER use foods that are moldy or have a bad smell to them.
• Keep hot foods hot (above 140 degrees F).
• Keep cold foods cold (at or below 40 degrees F).
• Do not refreeze food that has already been frozen.
• Always use food within the recommended time and by the expiration date. When in doubt, do not use it and ask a supervisor for guidance.

Safe Temperature
Hot Foods	Keep at 140 degrees F or above
Cold Foods	Keep at 40 degrees F or below

Source: United States Department of Agriculture (2013a)

Self-Check Activity m8-8

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Safe Microwave Defrosting and Cooking

Many people use a microwave to cook or reheat food. It is important for the Home Health Aide/Personal Care Aide to follow safety precautions when using a microwave for food preparation. The United States Department of Agriculture has specific guidelines for safe use of a microwave for food preparation. You can read more about the following guidelines based on the USDA (2013b) recommendations for safe microwave use at: http://www.fsis.usda.gov/wps/portal/fsis/topics/food–safety–education/get–answers/food–safety–fact–sheets/appliances–and–thermometers/cooking–safely–in–the–microwave/cooking–safely–in–the–microwave–oven

• When heating or cooking foods in a microwave, always use microwave safe dishes. Never use plastic or foam trays. These items can warp, causing harmful chemicals to spill into the food.
• Cover food with microwave safe covers. Loosen the lid slightly to allow steam to escape to prevent burns. This allows moisture to stay inside which provides for even heating. Unevenly heated or cooked foods can have areas where bacteria live.
• When defrosting, remove packaging food came in. Do not use plastic or foam trays.
• Cook food immediately after defrosting. Do not defrost and save the food to cook later.
• Cook large cuts of meat at 50% power for a longer time rather than at 100% power. This allows enough time for heat to reach the center without overcooking outer areas.
• Stir and rotate food halfway during cooking or reheating to avoid cold spots where bacteria can live.
• Always allow foods cooked in a microwave to stand for a couple of minutes to avoid being burned by steam.
• Always ensure reheated foods have reached a temperature of 165 degrees F. Use a thermometer to check for doneness.

Safe Cooking Temperatures

The USDA has guidelines about safe food cooking temperatures. To avoid food-borne illnesses, these should be followed. Home Health Aides/Personal Care Aides should always check food for doneness with a thermometer. Just because food appears to be cooked from the way it looks on the outside does not mean it is cooked in the center. Insert a thermometer into the thickest part of the meat or the center of the food. Do not allow the thermometer to touch bone, fat, or gristle (United States Department of Agriculture, 2011).

Type of Food	Temperature to which to reheat
Beef, pork, lamb, and veal steaks, chops, or roasts	145 degrees F
Ground beef, pork, lamb, veal	160 degrees F
Poultry	165 degrees F
Egg dishes	160 degrees F
Reheating leftovers	165 degrees F

Source: United States Department of Agriculture, 2011

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Food Money Procedures

If Home Health Aides/Personal Care Aides will be purchasing food for their patient and their family, they must always follow their agency’s procedures about handling money. They should save all receipts and turn them in to the appropriate place, and account for all money that was spent as soon as possible after shopping. Use checks instead of cash whenever possible.

Always keep to the food budget and the grocery list. They should never purchase items for themselves or borrow money from their patient to buy something for themselves while shopping for the patient. They also cannot do their own shopping while doing a patient’s grocery shopping. Not only is this stealing company time, but they risk mixing up items, receipts, and money. This could lead to trouble.

Unit E: Modified Diets

Being Specific When It Comes to the Diet

Some patients may require a modified diet due to health conditions, diseases, or problems with chewing, swallowing, or choking. Sometimes, certain medications may even interact with certain foods, and a patient may need to have more or less of a certain food while on that medication. Modified diets are changes made in a particular nutrient or the texture of the food. Diets may be ordered by a physician. A Registered Dietician will often be involved in planning the patient’s diet in these cases.

The patient may need to have more or less of a certain nutrient. For example, they may have an order to eat foods low in potassium if they have kidney disease or low in sodium if they have heart failure. Or, they may have an order that says they should eat a diet high in protein. Home Health Aides/Personal Care Aides should always follow the diet as specified in the Care Plan. It is in place for the health and safety of their patient. When in doubt, they should seek guidance from a supervisor.

The Meaning Of “High” And “Low” Diet Orders:

• High Diet Orders: A diet that has the word high in it means that there should be an increase in a particular nutrient. Diets requiring “high” amounts should have extra of the nutrient added. Examples of diets with “high” amounts include high calorie, high protein, high residue (fiber), or high potassium.
• Low Diet Orders: A diet that has the word low in it means that there should be a decrease in a particular nutrient. There may also be a need to cut the nutrient out altogether. For example, patients who are on gluten-free diets should not have any gluten in their diet. Other examples of diets that may have “low” amounts include low sodium, low cholesterol, low fat, low calorie, low protein, low potassium, low residue (fiber), or low sugar diets.

Decreasing the Intake Of Certain Foods

Low Calorie and Low Fat

Low calorie foods are foods that are low in calories. Foods may be labeled as reduced calorie, low calorie, or light. Generally, these foods have fewer calories than other products of the same type. Low fat foods are foods that are low in fat. Foods may be labeled as nonfat, reduced fat, fat free, or light (Leahy, Fuzy & Grafe, 2013). Keep in mind that baked goods that are labeled low fat tend to have extra things like sugar in them to make them taste better without the fat (Leahy, Fuzy & Grafe, 2013). Always read the label. Patients should not reduce caloric intake without speaking to their doctor. It can be very difficult to follow a low calorie and low fat diet, especially long-term.

Low Sodium/Salt

Low sodium foods are foods that are low in sodium or salt. They may be labeled as low sodium, low salt, sodium free, very low sodium, or no salt added (Leahy, Fuzy & Grafe, 2013). Read food labels to check for the amount of sodium listed. For patients who are on low sodium diets, this is a special concern. Foods that contain a lot of sodium tend to be prepared foods, frozen dinners, canned soups and meats, and prepared boxed foods such as macaroni and cheese and pastas that are ready to eat with sauce. For patients who require a low sodium diet, Home Health Aides/Personal Care Aides should not add salt while preparing foods. Offer herbs, spices, and lemon or lime zest to improve the flavor of foods for these patients. It can take some getting used to not eating a high amount of sodium in the diet.

Sugar Free/No Sugar Added

Sugar free or no sugar added foods are those that do not have sugar in them or that do not add sugar to the ingredients. Patients who are diabetic may be on a sugar free diet and need to watch the amount of sugar they consume. Sugar free products tend to have artificial sweeteners such as saccharin or aspartame. Always read the nutrition label to check for the amount of sugar in a food. Sugar is added and hidden in many food products.

Increasing the Intake of Certain Foods

High Protein/High Calorie

For patients who require a high protein or high calorie diet, an extra amount of protein and/or calories would be added to their diet. Patients on these types of diets may need extra calories or protein to help promote healing or weight gain if they are malnourished. It is best to provide snacks throughout the day or smaller meals in order to increase the amount of calories or protein in the diet, rather than to serve larger meals with a larger amount of food. The University of Pittsburgh Medical Center (UPMC) has suggestions for increasing protein into the diet. These can be found at: http://www.upmc.com/patients–visitors/education/nutrition/Pages/tips–for–increasing–protein–in–your–diet.aspx

Here are some suggestions based on UPMC (2015) that Home Health Aides/Personal Care Aides can follow to increase calorie or protein intake for their patients:

• Add cheese slices to sandwiches, eggs, and fruit desserts.
• Grate cheese and add to soups, sauces, casseroles, mashed potatoes, rice, pasta, or cooked meats like meatloaf.
• Use milk instead of water while preparing foods such as hot cocoa, pudding, or hot cereal.
• Add cream sauces made with milk to vegetables and pasta.
• Add a tablespoon of non-fat, dry powdered milk to regular milk, mashed potatoes, and cream soups.
• Use nutritional drinks or shakes, such as drinks that have added nutrients or calories to supplement intake as directed by the Care Plan.
• Make milkshakes with ice cream.
• Use yogurt with fruit and milk to make fruit smoothies.
• Add chopped or sliced eggs to salads, sandwiches, vegetables, and casseroles.
• Add extra egg yolks to scrambled eggs, omelets, pancakes, and French toast.
• Serve hard boiled or deviled eggs as snacks.
• Add nuts, seeds, and wheat germ to salads, cereal, or yogurt.
• Use peanut butter to serve with fruits, vegetables, crackers, as a topping for ice cream, and on sandwiches.
• Add beans to meat and casserole dishes.
• Add meat to salads, on top of potato dishes, with pasta dishes, and to egg dishes.
• Serve yogurt topped with wheat germ, or with fruit for snacks.

Types of Modified Diets

The type of diet the patient has been prescribed can be found in the Care Plan. There are numerous reasons why a patient may be on a modified diet. Below are some of the more common types of modified diets and food suggestions that Home Health Aides/Personal Care Aides may encounter.

Low Sodium/Low Salt Diets

Patients who have conditions such as heart disease, heart failure, high blood pressure, coronary artery disease, and kidney disease may require a diet low in sodium/salt. This is because excess sodium causes the body to retain (hold in) more water. This excess water causes the heart to pump harder. For people who have heart or kidney problems, this makes their organs have to work harder than they are able. Excess sodium in their diets can cause a progression (worsening) of their disease. The excess fluids can also lead to edema (swelling) in their bodies. The Care Plan will specify how much sodium the patient should have in their diet.

Here are some tips for Home Health Aides/Personal Care Aides to help people who have to be on low sodium diets:

• Always read the food label for salt or sodium amounts.
• Avoid canned soups, stews, meats, pastas, and prepared foods that are high in sodium.
• Avoid frozen and prepackaged meals that are high in sodium.
• Avoid items such as soy sauce, ketchup, barbeque sauce, and other bottled sauces and marinades, which tend to be high in sodium.
• Don’t add salt to foods during food preparation.
• Use herbs, mustard, pepper, onion, garlic, and other spices the patient enjoys to enhance the flavor of food.
• Salt substitutes can often be used to add flavor to food. Check with the Care Plan if the patient can have a salt substitute, as these often have extra nutrients such as potassium which patients with kidney disease need to avoid.

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Fluid-Restricted Diets

Patients who have heart and kidney disease may also need to watch their fluid intake. Just as in high sodium diets, excess water can make their heart and kidneys have to work harder. For patients with these types of problems, excess fluids can lead to a worsening of their disease. The excess fluids can also lead to edema (swelling) in their bodies.

Here are some tips for Home Health Aides/Personal Care Aides to help people who are on restricted fluids:

• Measure all fluids taken in accurately. Use measuring cups and document intake.
• Measure all urine output accurately. Use a graduated cylinder and document output.
• Don’t offer pitchers of water or other drinks. Instead, give one glass at a time.
• Count foods such as ice cream, sherbet, sorbet, frozen yogurt, popsicles, and soups as fluid intake. These foods have high fluid content.
• Juice, milk, coffee, tea, and soda, in addition to water, all count as fluid intake.
• Avoid foods with high sodium/salt content. They can lead to fluid retention.

High Potassium Diet

Patients who are taking medications such as diuretics may need to be on a high potassium diet (Leahy, Fuze & Grafe, 2013). Diuretics are medications that help the body to reduce fluid volume. Many people take diuretics to help lower blood pressure, or if they have heart disease. They help the heart to work less hard, as diuretics help remove water from the body. Too much water in the body makes the heart work harder, which weakens the heart and may cause or worsen heart failure. Some diuretics also remove potassium from the body. Other patients may have low potassium levels from other reasons such as excessive diarrhea, sweating, or vomiting and may need to eat diets higher in potassium to replace potassium that is lost. As we have discussed, potassium is necessary for a healthy body and heart. Low levels of potassium can cause an irregular heart rate, weakness, fatigue, muscle cramps, and constipation (Mayo Clinic, 2014). A list of foods high in potassium can be found at the National Kidney Foundation at: https://www.kidney.org/atoz/content/potassium

According to the National Kidney Foundation (2015), here are some foods which are high in potassium:

• Bananas
• Potatoes (white and sweet)
• Tomatoes (and tomato sauce)
• Dried or fresh apricots, figs, dates, and prunes
• Avocados
• Nuts and peanut butter
• Oranges and orange juice
• Prune juice
• Squash
• Cantaloupe
• Honeydew
• Beans and lentils
• Dark greens such as broccoli and spinach

Low Potassium Diets

Some patients need to avoid taking in extra potassium in their diets. This may be due to kidney disease or from taking certain diuretics. While many diuretics deplete (get rid of) potassium, some diuretics help the body hold onto potassium. For these patients, they may be asked to not consume extra potassium. Just as not enough potassium can lead to problems, too much potassium can also lead to problems, such as irregular heart rhythms. If potassium levels are too high in the body, the patient may feel weakness, numbness, or tingling, and too high levels of potassium can cause an irregular heart rate or heart attack (National Kidney Foundation, 2015). Diets low in potassium may be prescribed for these patients.

Instead of encouraging the foods found on the high potassium list, Home Health Aides/Personal Care Aides should teach patients to avoid these foods. Also be cautious to avoid using salt substitutes, which are high in potassium. A list of foods low in potassium can be found at the National Kidney Foundation at: https://www.kidney.org/atoz/content/potassium

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Low Fat/Low Cholesterol

Some patients may need to limit their fat or cholesterol intake. People with heart disease, high cholesterol levels, gallbladder disease, liver disease, and some digestive problems may have to limit how much fat or cholesterol is in their diets.

Here are some tips for Home Health Aides/Personal Care Aides to help a patient on a low fat/low cholesterol diet:

• Eat only lean cuts of meats, fish, and poultry.
• Remove the skin from poultry before cooking.
• Limit the amount of egg yolks consumed. Use more egg whites when scrambling eggs or making an omelet.
• Avoid adding extra oils and butter to foods.
• Use light or diet margarine.
• Do not fry foods. Steam, bake, or roast foods.
• Use low-fat or fat-free milk and milk products.
• Eat lots of vegetables and fruit, which are low in fat and have no cholesterol.

Bland

Patients who have digestive problems such as Crohn’s disease or Irritable Bowel Syndrome, or ulcers in their digestive tract may be required to be on a bland diet. This means that foods that are irritating to the gastric mucosa (stomach lining) need to be eliminated. This is because certain foods make the stomach produce more acid. Increased acid can lead to irritation of the stomach or other parts of the digestive tract such as the small or large intestine. Foods high in acid content can also irritate the esophagus as they are being swallowed.

Here are some foods to avoid for a bland diet:

• Alcohol
• Caffeine (tea, cola, coffee)
• Spices (peppers such as black pepper, chili pepper, cayenne pepper)
• Citrus fruits and juices (oranges, grapefruit, lemons, limes)

Gluten-Free Diet

Some people may be required to be on a gluten–free diet. Gluten is a protein in wheat, rye, and barley, and helps to hold foods together (Celiac Disease Foundation, 2015c). Gluten can also be found in foods in which it may be unexpected that gluten would be so it is important that Home Health Aides/Personal Care Aides always read food labels when preparing food for patients on a gluten-free diet. People on a gluten-free diet may have digestive problems, such as celiac disease.

Celiac disease is an autoimmune disorder in which ingestion of gluten leads to damage to the small intestine. Eating gluten leads to damage on the villi, which are finger-like projections lining the small intestine. These villi are important to help us absorb nutrients. When they are damaged, malabsorption (difficulty absorbing nutrients) can occur. This can lead to many health problems. According to the Celiac Disease Foundation (2015b) about 1 in 100 people around the world have Celiac disease with 2.5 million Americans undiagnosed with this potentially health-complicating disease.

Some people have a gluten intolerance, which does not damage the villi but causes symptoms such as abdominal pain, gas, and diarrhea (Leahy, Fuze & Grafe, 2013). Other people may just prefer to be on a gluten-free diet.

Here is a list of foods to avoid for people on a gluten–free diet:

• Wheat (found in breads, baked goods, crackers, tortillas, soups, cereals, sauces, and salad dressings)
• Barley (found in malt, food coloring, soups, and beer)
• Rye (found in breads, cereals, and rye beer)

It can be frustrating for a person who cannot have gluten to find foods they can have. As a Home Health Aide/Personal Care Aide you can assist your patient to make healthy food selections to help them be compliant with their diet. Many foods are naturally gluten-free such as fruit, vegetables, meat, poultry, dairy, beans, legumes, and nuts (Celiac Disease Foundation, 2015a).

Here is a list of items according to the Celiac Disease Foundation that a person on a gluten–free diet can have:

• Fruits
• Vegetables
• Meat, poultry, and fish
• Beans, legumes, and peas
• Milk and milk products
• Rice
• Cornmeal
• Soy
• Potato
• Quinoa
• Tapioca
• Juices, soda, sport drinks

There are many products now found on the market that make bread, cereals, and pasta without gluten in them. These items may be more expensive. It is important to always read the label. Many foods are made with wheat in them, which is often used as a thickener.

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Vegetarian Diet

Some people may be on a vegetarian diet for health, personal, or religious reasons. There are many different types of vegetarian diets, which indicate what types of foods are avoided. According to the American Heart Association (2014a) there are several types of vegetarian diets, including lacto-vegetarian, ovo-vegetarian, vegan, and semi-vegetarian.

Lacto–vegetarian: excludes meat, fish, poultry, and eggs. This diet allows dairy products, along with fruits, vegetables, nuts, seeds, grains, legumes, lentils, and peas.

Ovo–vegetarian: excludes meat, fish, poultry, and dairy, but allows eggs, along with fruits, vegetables, nuts, seeds, grains, legumes, lentils, and peas.

Vegan: excludes all meat, fish, poultry, eggs, dairy products, and any food with these ingredients. Foods allowed include fruits, vegetables, nuts, seeds, grains, legumes, lentils, and peas.

Semi–vegetarian: excludes red meat, but may allow poultry, fish, eggs, and dairy products, along with fruits, vegetables, nuts, seeds, grains, legumes, lentils, and peas.

It is important to remember that people who eat vegetarian type diets need to consume enough nutrients in their diets for good health. While they do not get protein from meat, fish, and poultry, protein can be found in other food sources. Excellent alternatives to meat protein include soy proteins and protein from legumes, lentils, peas, and milk products.

Liquid Diet

Liquid diets are those that patients may be on for a short period of time for a specific reason. Some people may need to be on a liquid diet prior to a medical procedure, test, or surgery. Others may be on a liquid diet in order to help heal their stomach or intestines from a medical condition. Foods on a liquid diet must be in their liquid state. There are two types of liquid diets: clear liquid and full liquid. A rule of thumb for clear liquid diets is that you should be able to see through them. They may be colored, such as popsicles and jello, but you can see through these foods.

Clear liquid diet:

• Clear juices (apple, grape)
• Broth
• Gelatin
• Popsicles
• Coffee, tea (no milk or cream)
• Gelatin (jello)
• Sugar, honey
• Hard candies

Full liquid diet:

• All items on the clear liquid diet list
• All fruit and vegetable based drinks
• Cream based soups
• Milk and milk products
• Milk shakes
• Yogurt (no fruit or seeds)
• Pudding
• Ice cream, frozen yogurt
• Cream of wheat, cream of rice

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Soft Diet

Soft diets are used for people who may have poor dentition, (this refers to the strength, number of, and arrangement of teeth in the mouth) who are recovering from a gastrointestinal surgery, and people who have difficulty with chewing and swallowing. When a patient is on a soft diet, the HHA/PCA must be concerned with the consistency of the diet. Soft foods require almost no chewing. They are easy to chew and swallow. Raw fruits and vegetables, hard-to-chew meats, and dry foods that can easily be choked on such as crackers and dry toast should be avoided.

Mechanically Altered Diets

A mechanically altered diet is a diet in which the texture (consistency) of the food is changed to help the person chew or swallow. A mechanically altered diet is given to a person who has dysphagia. Dysphagia means difficulty chewing or swallowing. A dysphagia diet or mechanically altered diet makes it easier to chew and swallow food and reduces the risk of aspiration (Ohio State University Wexner Medical Center, 2013). Dysphagia can occur due to many reasons, including reflux which can eventually cause the esophagus to narrow, making food difficult to pass through, neurological disorders such as from a stroke, cerebral palsy, multiple sclerosis, Alzheimer’s disease, and Parkinson’s disease (Jackson, 2015). For a comprehensive list of food suggestions on mechanically altered diet as well as recipes, visit http://gicare.com/diets/dysphagia–diet/

Mechanical soft diet

A mechanical soft diet is a diet that consists of food that is made softer and easier to chew and swallow by changing the texture of the food. For example, by cooking chopped or diced carrots until soft, they can be mashed or pureed. Cooked foods can also be chopped, diced, or ground. This helps a person who has trouble chewing and swallowing to still take in the nutrients they need.

Preparing mechanically altered diets:

• Chopping food means to cut it into small pieces. Foods should be about ½ inch in size, which would be about the size of uncooked elbow macaroni or small croutons (Jackson, 2015). Food can be chopped by using a sharp knife on a cutting board.
• Grinding food means to cut it into even smaller pieces. Foods should be ¼ inch or less, which is about the size of a grain of rice (Jackson, 2015). Foods can be ground by cutting food that is chopped into even smaller pieces using a knife on a cutting board. Foods can also be ground in a food processor or blender. You may need to add a small amount of liquid to help the food become ground.
• Pureed means to put cooked and cut up foods into a blender or processor, while adding some liquid in order to make it into mashed potato-like consistency (Jackson, 2015). Foods can also be pureed by pushing soft, cooked foods through a colander or sieve with the back of a spoon.
• Meats, fish, and poultry can be cooked, finely chopped, and then ground or pureed using a food processor or blender. About an ounce of liquid such as gravy, milk, or water can be added to about 3 ounces of cooked meats to help them easily process in the blender (Jackson, 2015).
• Sauce and gravy can be added to help the person swallow, while also giving the food good taste.
• Cooked vegetables and fruits can also be blended by adding about an ounce of liquid to help them puree.
• Always cook foods such as meats prior to grinding or pureeing.
• Do not mix foods in the blender. Blend your meats, grains, vegetables, and fruits separately. Keep them separated on the serving plate just as you would for any other diet.
• Seasonings, sauces, gravies, spices, and herbs can be added for flavor, unless the Care Plan states otherwise.

Pureed diet

A diet that is pureed consists of food that is cooked and then chopped, blended, or ground into a thick paste that is the consistency of baby food or mashed potatoes. No chewing is required for this type of diet.

Mechanical soft diet food suggestions:

• Soft, moist ground or finely diced meats, poultry, fish
• Meatloaf
• Egg salad, tuna salad, chicken salad (avoid adding chopped onions or celery)
• Sloppy Joe (without the bun)
• Chili (make sure the pieces are cut or diced)
• Cottage cheese
• Scrambled and soft cooked eggs
• Moist macaroni and cheese or small pastas
• Bananas, cut into small pieces
• Soft canned or cooked chopped or diced fruits (avoid seeds and skin)
• Pancakes or French toast with syrup, cut into small pieces
• Hot cooked cereal
• Applesauce
• Soft cooked, cut up vegetables
• Yogurt
• Pudding or custard
• Jello
• Ice cream, frozen yogurt
• Cream or broth based soups (thicken according to Care Plan)

Foods to avoid:

• Dry, tough meats
• Raw fruits or vegetables
• Fruits or vegetables with skin or seeds
• Nuts, seeds
• Peanut butter
• Hard cooked eggs
• Bread and bread products
• Granola
• Popcorn, chips, or pretzels
• Crackers
• Dried fruits
• Salads
• Soups with meat, rice, corn, peas
• Gum, hard candy

Check your answers!

Provide nutritious and attractive mechanically altered food

When food is mechanically altered (chopped, ground, or pureed) it may lose its appeal to the patient. It looks different than the food they are used to. It is important for Home Health Aides/Personal Care Aides to remember to maintain nutritious meal planning using ChooseMyPlate guidelines, and to try to present food in an appealing way.

Important things to keep in mind when preparing mechanically altered diets:

• Use different colored foods for visual appeal.
• Put sauces and gravies on top of food as you normally would, even if it looks different.
• Keep foods separated on the serving plate. The plate should look like any other plate. It should not be a mix of all the foods into one pile.
• Tell patients what the food is as it will look different than the food they are used to. Even though it looks different, remind them that it can still taste delicious.
• Use special molds to make the food look attractive. Many food molds are on the market to make food look like what it is. For example, fish shaped molds help indicate the food is fish, even if it does not look it.
• Use food thickeners as indicated and according to package instructions.
• Encourage the use of adaptive eating equipment such as cups, plates, and eating utensils to allow independence during meal time.
• If a patient has a weak side, feed to the stronger side.
• Encourage or feed only small bites at a time. Allow the patient to chew/swallow completely before serving the next bite. If necessary, check the inside of their mouth for pocketed food.
• Be cautious about patient positioning during feeding, especially for patients who have trouble chewing or swallowing.
• Always sit a patient in an upright position to avoid choking or aspiration (when food enters areas of the respiratory tract such as the lungs where it does not belong, which could lead to pneumonia).
• Encourage the patient to tuck their chin down and bend their body forward while swallowing. This encourages the food to move down the esophagus.
• Keep the patient in an upright position for 30-60 minutes after eating.

Check your answers!

Follow safe food preparation and storage guidelines

Always use proper food safety and storage precautions. This applies to preparing any type of food, even foods that are mechanically altered.

Keep the following important points in mind:

• Wash your hands before preparing foods.
• Keep your preparation space clean.
• Wash equipment such as blenders and food processors thoroughly and allow to air-dry before storing.
• Use safe knife skills while chopping and grinding foods.
• Only use a sharp knife as a dull one increases your chance of getting cut.
• When leaving your preparation area, ensure knives are placed away from the counter edge to avoid someone accidentally getting cut.
• Follow proper food storage guidelines.
• Keep hot foods hot and cold foods cold.
• Refrigerate or freeze leftovers immediately to avoid spoilage.

Post-test

1. These types of nutrients provide the major source of energy for our body. Examples include breads, crackers, oatmeal, rice, potatoes, peas, and pasta.
   1. Protein
   2. Carbohydrates
   3. Fats
2. These are the building blocks which the body needs to repair muscle, tissues, organs, and skin. Examples include beef, chicken, turkey, fish, peanut butter, and eggs.
   1. Protein
   2. Carbohydrates
   3. Fats
3. The body needs these to help make cell membranes, prevent heat loss, and cushion organs. Examples include butter, margarine, peanut butter, and olive oil.
   1. Protein
   2. Carbohydrates
   3. Fats
4. True or False: The HHA/PCA should never suggest a patient take a vitamin. All patient questions should be referred to the supervisor and diet guidelines to be followed are those stated within the Care Plan.
5. True or False: Unless a doctor states otherwise, patients should drink about 8 glasses of water per day for optimum health.
6. True or False: Sodium, which can be found in canned soups, meats, vegetables, and packaged or frozen foods causes hypertension and fluid retention and intake should be limited.
7. Diets high in fruits and vegetables have been shown to reduce the risk of which of the following? Select all that apply.
   1. Heart disease
   2. Certain types of cancer
   3. Pneumonia
   4. Type 2 diabetes
   5. Glaucoma
   6. Obesity
8. At what temperature should refrigerated foods be kept at?
   1. 55 degrees or above
   2. 0 degrees
   3. 40 degrees or below
   4. 45 degrees
9. At what temperature should frozen foods be kept at?
   1. 55 degrees or above
   2. 0 degrees
   3. 40 degrees or below
   4. 45 degrees
10. At which temperature should poultry be cooked to?
    1. 165 degrees
    2. 145 degrees
    3. 160 degrees
    4. 155 degrees
11. At which temperature should ground beef be cooked to?
    1. 165 degrees
    2. 145 degrees
    3. 160 degrees
    4. 155 degrees
12. At which temperature should leftovers be reheated to?
    1. 165 degrees
    2. 145 degrees
    3. 160 degrees
    4. 155 degrees
13. At which temperature should steaks, chops, and roasts be cooked to?
    1. 165 degrees
    2. 145 degrees
    3. 160 degrees
    4. 155 degrees
14. Which of these items would not be allowed on a clear liquid diet?
    1. Beef broth
    2. Jello
    3. Frozen yogurt or ice cream
    4. Apple juice
15. ChooseMyPlate guidelines include which of the following? Select all that apply.
    1. Well-balanced meals with selections from all food groups.
    2. Calcium rich foods with nonfat or low fat dairy products chosen over whole milk products.
    3. Lean proteins that are baked or roasted rather than fried.
    4. Plenty of fruits and vegetables.
    5. Half of all grains selected as whole grains.
16. Which of the following precautions should a HHA/PCA take for safe food handling? Which two are correct?
    1. Use 1 cutting board for both chopping vegetables and raw meats.
    2. Wash hands before food preparation and after handling raw meats and eggs.
    3. Leave spills from raw meats on the counter until food preparation is complete.
    4. Leave food on the counter after meals for several hours to cool before refrigerating.
    5. Never use food after the expiration date.
17. True or False: It is okay for the HHA/PCA to do their own shopping while grocery shopping for their patient or to borrow money from the patient to buy something for themselves.
18. In this type of diet, food is cut up, cooked, and blended to a baby food consistency.
    1. Chopped
    2. Diced
    3. Pureed
    4. Minced
19. To help prevent choking or aspiration of food, the HHA/PCA can encourage a patient to do which of the following? Select all that apply.
    1. Eat while sitting in an upright position.
    2. Take small bites and chew food well.
    3. Stay in an upright position during meals and afterwards for 30-60 minutes.
    4. Tuck their chin down and lean slightly forward to help food pass through the esophagus.
20. True or False: The HHA/PCA should always follow dietary guidelines for the patient as set forth in the Care Plan and prepare foods as the Care Plan directs.

Check your answers!

Self-Check M8-1 Answers:

1=B

2=C

3=A

FEEDBACK:

1. Protein includes meats, poultry, fish, peanut butter, eggs, and nuts. Protein is needed for our bodies to repair muscle, tissue, organs, and skin.

2. Carbohydrates provide us with our major source of energy that our body needs to function. Sources of carbohydrates include grains, vegetables, fruits, and sugars. Complex carbohydrates found in grains and vegetables compared to simple carbohydrates found in sugary foods are healthier options. Too much carbohydrate intake can result in obesity.

3. Fats also provide our bodies with energy, help us to regulate our temperature, and protect our organs. Fats can be found in butter, oil, salad dressings, and animal fats found in meat and dairy products. Some fats such as olive oil are healthier than butter or bacon.

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Self-Check M8-2 Answers:

1. C

2. A

3. A

4. B

5. C

6. C

7. A

8. B

9. A

10. C

11. A

12. B

13. B

14. A

15. A

16. B

17. B

18. B

19. C

20. A

21. C

22. A

23. B

FEEDBACK:

Protein sources include meats, poultry, fish, peanut butter, and eggs. Carbohydrate sources include pasta, rice, potatoes, popcorn, and grains. Fats include oils, butter, margarine, and salad dressings.

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Self-Check M8-3 Answers:

1. True

FEEDBACK:

Food preferences are determined by a variety of factors such as family, culture, religious beliefs, regional and ethnic differences, personal preference, and allergies. It is important to ask patients what their preferences are to ensure the patient’s beliefs and preferences are respected, and to increase the likelihood that they will eat meals prepared.

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Self-Check M8-4 Answers:

1. C

2. True

FEEDBACK:

1. Frying foods is the least healthy option as this adds extra fat, cholesterol, and calories from using oils during the frying process. Broiling, steaming, and roasting methods of cooking do not add extra calories, as long as butter, margarine, and oils are not used.

2. To decrease the amount of fat and make healthier food choices, remove skin from meat and poultry, as this is where extra fat and cholesterol are. Lean cuts of meat can also be selected to decrease fat, cholesterol, and calories.

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Self-Check M8-5 Answers:

All are possible causes of a poor appetite.

FEEDBACK:

Poorly fitting dentures or broken teeth can make chewing and eating difficult, leading to a poor appetite. Home Health Aides/Personal Care Aides should regularly inspect their patient’s mouth and teeth while performing mouth hygiene and ensure dentures are in good working order and placed in the mouth prior to eating.

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Self-Check M8-6 Answers:

1. B, D, & E

FEEDBACK:

Purchasing items from a salad bar or other self-service station in a grocery store often leads to higher prices. Whenever possible, purchase fresh fruits and vegetables from the produce aisle. This is a healthier and less expensive option. Regularly checking expiration dates helps to prevent unnecessary waste. Planning meals with items on hand and that have not expired helps the patient and their family save money. Purchasing bulk items can help to save money. However, if they are not needed and there is no storage space for them this can end up costing the patient money as food will more likely have to be thrown away. When coupons are used and sale items are purchased, this can help the patient and their family save money.

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Self-Check M8-7 Answers:

1. False

2. C

3. B

FEEDBACK:

1. Food should never be stored under a sink as it risks getting contaminated. Never store food with chemicals or other cleaners. Food should be properly stored in the refrigerator or freezer, depending on the item and when it will be used. Other foods such as dried items should be stored in their original packaging or in air tight containers in a pantry.

2. Refrigerated foods should be kept at 40 degrees or below. Thermometers should be placed in the refrigerator and freezer to ensure they are in proper working order.

3. Frozen foods should always be kept at 0 degrees. Thermometers should be placed in the refrigerator and freezer to ensure they are in proper working order.

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Self-Check M8-8 Answers:

1. True

2. True

3. True

FEEDBACK:

1. To avoid the risk of contamination from raw meat, poultry, and fish, hands, cutting boards and work surfaces should be washed with hot soapy water after use.

2. To avoid the risk of contamination from raw meats, poultry, and fish, use separate cutting boards for meats and fruits and vegetables.

3. Raw eggs and those with cracks in their shell should not be used. They should be discarded as the risk of salmonella is high.

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Self-Check M8-9 Answers:

1. False

2. A

3. C

4. A

5. B

FEEDBACK:

1. Just because food appears to be cooked from the way it looks on the outside does not mean it is cooked in the center. Use a thermometer to test for doneness.

2. Poultry should be cooked to 165 degrees.

3. Ground beef should be cooked to 160 degrees.

4. Leftovers should be reheated to 165 degrees.

5. Steaks, chops, and roasts should be cooked to 145 degrees.

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Self-Check M8-10 Answers:

1. B, C, & E

FEEDBACK:

Low sodium diets may be required of a patient with heart or kidney disease or those with high blood pressure. Foods that are high in sodium include frozen and boxed dinners, many pre-prepared foods, and canned foods such as soups, stews, and chili.

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Self-Check M8-11 Answers:

1. A, B, E, F, G, I

FEEDBACK:

Bananas, potatoes, beans, tomatoes, peanut butter, and dried fruits are some foods that are high in potassium and should be avoided on a low potassium diet.

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Self-Check M8-12 Answers:

1. A, D, F

FEEDBACK:

Foods with wheat such as cereals and breads, foods with barley, and those containing rye should all be avoided by a person on a gluten-free diet. Gluten is a protein found in products with wheat, rye, and barley.

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Self-Check M8-13 Answers:

1. True

2. C

FEEDBACK:

1. A person on a full liquid diet can have all foods on a clear liquid diet plus cream of wheat, milk shakes, frozen yogurt, yogurt, and pudding.

2. Frozen yogurt would not be allowed on a clear liquid diet as it is made with dairy. A good rule of thumb is if you can’t see through it, it is not allowed on a clear liquid diet. Beef broth, jello, and apple juice would be allowed on a clear liquid diet.

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Self-Check M8-14 Answers:

1. A, B, E, F, J, K, L, & O

FEEDBACK:

Meatloaf, applesauce, cream of wheat, yogurt, jello, egg salad, cottage cheese, and pudding are safe foods for a person on a mechanical diet to eat. Dried fruit, salad, crackers, granola, tough meats, gum, and popcorn are not safe foods for a person on a mechanical diet. Always follow the Care Plan. When in doubt, ask your supervisor.

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Self-Check M8-15 Answers:

1. True

2. False

FEEDBACK:

1. Keep patients in an upright position during a meal and for 30-60 minutes after a meal to prevent aspiration.

2. Never put all the foods together in a blender. Keep foods separately on a plate just as you would when serving any patient, whether the food is pureed or not. This helps to keep food attractive and appealing for a patient, which aids in helping them maintain good nutrition.

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Post-Test Answers:

1. B

2. A

3. C

4. True

5. True

6. True

7. A, B, D, and F

8. C

9. B

10. A

11. C

12. A

13. B

14. C

15. All of the above

16. B and E

17. False

18. C

19. All are ways to help prevent choking or aspiration of food.

20. True

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References

American Heart Association. (2014a, March 19). Vegetarian diets. Retrieved from http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Vegetarian–Diets_UCM_306032_Article.jsp

American Heart Association (2014b, April 14) The greatness of whole grains. Retrieved from http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/The–Greatness–of–Whole–Grains_UCM_455739_Article.jsp#.VnxsxdIrIy4

Celiac Disease Foundation. (2015a). What can I eat? Retrieved from http://celiac.org/live–gluten–free/glutenfreediet/food–options/

Celiac Disease Foundation. (2015b). What is celiac disease? Retrieved from http://celiac.org/celiac–disease/what–is–celiac–disease/

Celiac Disease Foundation. (2015c). What is gluten? Retrieved from http://celiac.org/live–gluten–free/glutenfreediet/what–is–gluten/

Jackson, F. W. (2015). Dysphagia diet: Five levels for difficulty in swallowing diet. Retrieved from http://gicare.com/diets/dysphagia–diet/

Leahy, W., Fuzy, J., & Grafe, J. (2013). Providing home care: A textbook for home health aides (4th ed.). Albuquerque, NM: Hartman.

Lehman, S. (2014, June 9). Nutrients: What they are and why you need them. Retrieved from http://nutrition.about.com/od/nutrition101/a/nutrients.htm

Mayo Clinic (2014, July 8). Low potassium (hypokalemia). Retrieved from http://www.mayoclinic.org/symptoms/low–potassium/basics/definition/sym-20050632

National Kidney Foundation. (2015). Potassium and your CKD Diet. Retrieved from https://www.kidney.org/atoz/content/potassium

Ohio State University Wexner Medical Center. (2013, June 27). Dysphagia: Mechanically altered diet (Level 2). Retrieved from https://patienteducation.osumc.edu/documents/dys-2.pdf

U.S. Department of Agriculture. (2011, May 25). Cooking meat? Check the new recommended temperatures. Retrieved from http://blogs.usda.gov/2011/05/25/cooking–meat–check–the–new–recommended–temperatures/

U.S. Department of Agriculture. (2013a, June 8). Easy lessons in safe food handling. Retrieved from http://www.fsis.usda.gov/wps/wcm/connect/18cece94-747b-44ca-874f-32d69fff1f7d/Basics_for_Safe_Food_Handling.pdf?MOD=AJPERES#page=2

U.S. Department of Agriculture. (2013b, August 8). Cooking safely in the microwave oven. Retrieved from http://www.fsis.usda.gov/wps/portal/fsis/topics/food–safety–education/get–answers/food–safety–fact–sheets/appliances–and–thermometers/cooking–safely–in–the–microwave/cooking–safely–in–the–microwave–oven

U.S. Department of Agriculture. (2015a). ChooseMyPlate. Retrieved from http://www.choosemyplate.gov/

U.S. Department of Agriculture. (2015b, March 23). Refrigerator and food safety. Retrieved from http://www.fsis.usda.gov/wps/portal/fsis/topics/food–safety–education/get–answers/food–safety–fact–sheets/safe–food–handling/refrigeration–and–food–safety/ct_index

University of Pittsburgh Medical Center. (2015). Tips for increasing protein in your diet. Retrieved from http://www.upmc.com/patients–visitors/education/nutrition/Pages/tips–for–increasing–protein–in–your–diet.aspx