October 21, 1991

Information Bulletin 91-3
NH-3

Recommended Menu Pattern And Small Portion Guidelines

Developed in Accordance with OBRA Regulations for Nursing Facilities

Since the implementation of OBRA in October of 1990, the Minnesota Department of Health has received numerous contacts about a menu pattern that will meet these requirements. The primary concerns voiced were that the sample meal pattern listed in the Interpretive Guidelines in OBRA did not meet the nutritional needs of the majority of residents in Minnesota nursing facilities and that some residents are unable to consume all foods served to them because of declining health and activity levels.

In review, OBRA regulations require that "the facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident" CFR (483.35), and that "Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care" CFR (483.25).

In response to these dietary concerns, the MDH Health Resources Division is issuing the attached recommended menu pattern and guidelines for small portions. These are based on current knowledge about the nutritional needs of residents in Minnesota nursing facilities. They have been developed in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences CFR (483.35)(c)(1).

During the survey process, MDH surveyors will inquire whether or not the recommended menu pattern and guidelines for small portions are in use and will review your menus accordingly. Nutritional needs of the residents will be surveyed to determine if their needs are being met by the menu pattern the facility has implemented.

Recommended Menu Pattern

Meat or Alternate

  • 5 oz. or more daily cooked edible meat, fish, or poultry.
  • 1/4 cup canned fish (tuna, salmon) equals 1 oz. meat alternate.
  • Cheese may be used in place of meat, but should be limited to 3 oz. per week as a meat alternate.
  • Peanut butter (1 T.) is acceptable for I oz. of meat if a resident requests it as a substitute on an individual basis.
  • cup cooked legumes, dry beans or peas is equal to 1 oz. meat if not counted as bread or vegetables.
  • 1 large egg is equal to 1 oz. meat.

Breads and Cereals

  • 5 or more servings daily.
  • A serving is 1 slice (1 oz.) bread or roll, cup cereal, pasta, rice or whole grains, 3/4 cup dry cereal.
  • Whole grains and products made with whole grain flour are preferable.
  • Products made with enriched flour are acceptable.
  • Quick breads made from mixes composed of enriched flour are acceptable.
  • Legumes, dry beans and peas may be counted as bread if not counted as protein or vegetables.
  • If potatoes are served twice in one day, count one serving as vegetable, count the second serving as bread/cereal.

Fruits and Vegetables

  • A combination of fruits and vegetables to equal 2 cups or more daily.
  • Portions for diabetic diets may vary.

Fruits
Vitamin C source daily. Vitamin C sources are:

Fruits cup Citrus Sections Grapefruit
  cup Mandarin Oranges 1 Orange
  1 Tangelo 1 Tangarine
  cup Strawberries
Juices cup Blended Citrus cup Grapefruit
  cup Orange 1 cup Tomato
  1 cup Vegetable Juice Cocktail

100% juice bases count as a serving of fruit, but not as a Vitamin C source.

Vegetables - Vitamin A source 4 times per week.

  • Vitamin A sources are cup of the following vegetables and fruits:
    Apricots
    Broccoli
    Cantaloupe
    Greens (collards, kale and chard, mustard, beet and turnip greens)
    Mixed vegetables with at least 1/3 cup carrots
    Liver and liver sausage, although not vegetables, are counted as sources of vitamin A Broccoli
    Carrots
    Peas and carrots
    Spinach
    Sweet potato

  • Legumes, dry beans and peas may be counted as vegetables if not counted as meat alternate or bread.
  • If potatoes are served twice in one day, count one serving as vegetable, count the second serving as bread/cereal.

Milk

  • 16 or more oz. daily
  • Low fat milk, skim milk, buttermilk.
  • Low fat products are preferable
  • Whole milk is acceptable, especially for residents who need additional calories.

  • Milk alternates are used for individuals who do not like milk, but are willing to consume other dairy products. If cheese is used as a meat alternate, it cannot be counted as a milk alternate.

    The following items may be served in place of 8 oz. milk:
    1 cup yogurt
    1 oz. cheese
    cup cottage cheese
    cup ice cream, ice milk, frozen yogurt*

    * Cottage cheese, ice cream, ice mile, and frozen yogurt have 1/4 to 1/3 the amount of calcium per serving as mile, yogurt, and cheese. These products may or may not be fortified with Vitamins A or D which could lead to additional nutritional concerns.

Other Foods

  • These foods must be selected with care to provide the most nutrition for the calories provided.

  • Minimum 3 teaspoons margarine or butter. Each teaspoon of butter or margarine provides approximately 50 retinal equivalents of Vitamin A.

  • Garnishes and condiments for attractiveness and perking up taste should be included.

  • Potato chips are counted in the other foods category because of their high fat content. They are more appropriately used in small amounts as a garnish.

  • Desserts, other than fruit, should be limited to once a day. Desserts with higher nutrient density should be encouraged i.e. desserts made with fruit, milk, or eggs as a major ingredient. If a high calorie dessert is on the menu, small servings are encouraged.

Snacks

Bedtime snacks must be offered daily to all residents. The snack is in addition to the regular menu, and is not included with the menu evaluation totals.

Small Portion Guidelines

  1. Serving less food and nutrients than those described in the survey guidelines is not an option. Therefore, an order for portions would be inappropriate since that may only allow 600 - 900 calories per day.

  2. For those residents who desire small portions, the menu pattern in the Federal Guidelines could be followed, e.g. 4 oz. edible meat, 2 cups fruit and vegetables, 4 servings breads and cereals, and 2 cups of milk.

  3. As in the past, the physician must order the small portion diet based on a complete nutritional assessment of the resident. The small portion diet is considered a therapeutic diet because it meets a special need.

  4. Smaller scoop sizes may be used to serve a total of 2 cups of fruit and vegetables, e.g.:


    1/3 cup or #12 scoop (3 servings are equal to 1 cup fruit or vegetables)
    1/4 cup or #16 scoop (4 servings are equal to 1 cup fruit or vegetables)

  5. Small plates, cups, and glasses could be used to serve the reduced portions for better eye appeal.

  6. Daily snacks could be planned in addition to the menu for this diet, based on the resident's individual preferences. These snacks could be offered and the consumption encouraged and monitored.

  7. The menu may be planned to serve 4 or more small meals.

  8. Vegetables, potatoes, and potato alternates could be seasoned with margarine or butter in consideration for the resident's needs for adequate amounts of Vitamin A and Essential Fatty Acids.

  9. Whole milk could be offered to residents that require more kilocalories when their capacity for the necessary volume of food is limited.

  10. Special consideration could be given to the sensory appeal of all foods so that what is offered is especially appealing to encourage consumption. Special efforts to honor likes and dislikes of the individual on the small portion diet are necessary to provide the resident with food that they are willing to consume. Residents on small portion diets need more frequent encouragement and monitoring. The small portion diet may be adjusted on an individual basis per resident preference.

  11. Small portion diets could be planned using nutrient dense foods because of the limited kilocalories served. However, the use of high density nutritional supplements or manufactured supplements is discouraged unless intervention with regular food and encouragement have been ineffective. High density nutritional supplements should be offered between meals rather than with meals, unless problems with appetite reduction at regular meal time occurs. Supplements may then be given at meal time but only after the resident has consumed as much of the regular meal as possible.

Updated Thursday, 17-Mar-2011 11:11:29 CDT