8.5.4: 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 l ow 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.

Self Check Activity \(\PageIndex{1}\)

1. Which of the following foods should a person on a low sodium diet avoid? Select all that apply.

a). Fresh fruit

b). Frozen dinners

c). Boxed dinners

d). Vegetables

e). Canned soups

f). Herbs and spices

Answer

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.

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

Self Check Activity \(\PageIndex{2}\)

1. Which of the following foods should a person on a low potassium diet avoid? Select all that apply.

a). Bananas

b). Potatoes

c). Steak

d). Chicken and turkey

e). Beans

f). Tomatoes

g). Peanut butter

h). Milk

i). Dried fruits

Answer

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.

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.

Self Check Activity \(\PageIndex{3}\)

1. Which of the following foods should a person on a gluten-free diet avoid? Select all.

a). Wheat cereals and breads

b). Corn

c). Potatoes

d). Vegetable soup with barley

e). Soy

f). Rye bread

Answer

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.

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

Self Check Activity \(\PageIndex{4}\)

1. A full liquid diet means the person can have all items on the clear liquid food list plus also items like cream of wheat, milk shakes, yogurt, and pudding. True or False? ________

2. Which of these items would not be allowed on a clear liquid diet?

a). Beef broth

b). Jello

c). Frozen yogurt

d). Apple juice

Answer

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.

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

Self Check Activity \(\PageIndex{5}\)

1. Which of the following foods are safe to eat on a mechanical diet? Select all that apply.

a). Meatloaf

b). Applesauce

c). Gum

d). Popcorn

e). Cream of wheat

f). Yogurt

g). Granola

h). Tough meat

i). Crackers

j). Jello

k). Egg salad

l). Cottage cheese

m). Dried fruit

n). Salad

o). Pudding

Answer

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.

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.

Self Check Activity \(\PageIndex{6}\)

True or False

1. It is very important, especially for a patient with a swallowing problem to be in an upright position during mealtime and to be kept upright for 30-60 minutes after eating to prevent choking. True or False? ______

2. It is okay to put all the food items together in the blender instead of blending each separately when preparing a pureed diet for a patient, as this saves time.

True or False? ________

Answer

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.

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.