Lauren Lindeman 3 Day Menu Assignment – Bayshore Medical Center Market Analysis Bayshore Medical Center houses a large obstetrician gynecology department, one day surgery center, and one day outpatient procedures which drive the average Length of Stay to about 2.3 days. However, Bayshore also cares for a large Hispanic Male, age 51-70 years old population, many of which are ordered either an American Heart Association (AHA) diet or an American Diabetic Association (ADA) diet. These are used for cardiac patients, and diabetic patients respectively. The average patient is typically seen in the Psychiatric, Intermediate Care Unit, Intensive Care Unit, and the Cardiac Rehab Unit. These patient’s experience a length of stay which is anywhere from 5 to 14 days, much longer than the average 2.3 days. Quality Assessment/Performance Improvement Initiative scores determine productivity of the food service department. QAPI scores for the last year were at 95%, however patient satisfaction scores were around 30%. In order to bring the patient satisfaction scores up, my preceptor and her management team has decided to target the Hispanic male, ages 51-70 years old group. The food and nutrition department is contracted by Morrison’s food service. The corporate wellness team through Morrison’s put together a Wellness menu to push for healthier selections in the hospital. This was not received well by the Hispanic male population. It was also constructed as a 3 Day repeating menu cycle, where lunches would be switched for dinners and vice versa during the second cycle. This cycle rotation repeats weekly, and meals repeat more than once during one week. For patients that are staying more than 3 days this can be repetitive. There are also many chicken and turkey options, but not many beef and pork items to choose from. The survey was conducted before the menu updates Table 1: Menu Selection Survey have come into place. However, I would also like to hand out the following survey for one month prior to making menu changes to determine further analysis of food choices that would be preferable. The following are the steps I would carry out, had the information not already been recorded. The Menu Selection Survey shown in Table 1 for market analysis would be given by catering associates each morning with breakfast meal service. These will be given out to all current patients receiving a meal, and isolation patients will be given a survey by their current nurse. When catering associates return to pick up breakfast trays and read the menu for lunch and dinner, surveys will be retrieved and turned into the food service manager’s office. Data will be collected for one month. At the end of the month the data will be put into a spreadsheet that will calculate the likes and dislikes of main entrees. In analyzing the likes and dislikes, main entrees with 75% or more dislike will be updated. Comments added on menu items patients would like to see in the future will also be considered. By obtaining a census report from the hospital, we can determine the patient population. Lauren Lindeman 3 Day Menu Analysis The current diet given to patients with a physician ordered an 1800 calorie ADA Diabetic Diet is intended to be consistent in carbohydrates. Using the carbohydrate exchange system which counts 15g as one carbohydrate exchange, catering associates are told to serve 3 carbohydrate exchanges at breakfast, 4 carbohydrates at lunch, and 4 carbohydrate exchanges at dinner for diabetic diets. However, the current regular diet that doubles as the diabetic diet is not nutritionally equivalent to the previously mentioned carbohydrate count. Many meals on the current 1800 Calorie Diabetic Diet menu follow either less than or more than the prescribed carbohydrate goal. Moreover, this current carbohydrate count does not follow the Acceptable Macronutrient Distribution Range (AMDR) guidelines of 45-65% calories from carbohydrates1. By following the carbohydrate grams desired, 3 exchanges at breakfast and 4 at lunch and dinner, this comes out to a total of 165g or 660 calories. The current 1800 diet would provide 37% carbohydrate, and protein and fat content would have to be much higher to meet the 1800 calorie goal. Evidence suggests that a low carbohydrate diet is not favorable for individuals with type 2 diabetes2. The diabetic consistent carbohydrate diet is also given to individuals prescribed an American Heart Association diet, which needs to be lower than 30% of calories from fat3. This leaves 33% of the calories to be from protein, which is on the higher end of the AMDR for protein. Below is the estimated Dietary Reference Intakes of macronutrients, sodium, and saturated fat according to the Institute of Medicine1. Table 2: Estimated Calorie requirements for males ages 51-70 years old Nutrient RDA/AI Grams per day 130g 45-65% Fat N/A 20-35% Protein 46g 10-35% Sodium <2,000mg N/A <10% N/A Carbohydrates Saturated Fat AMDR In the past, food service received complaints of high blood sugars from nursing staff attributed to high carbohydrate meals. In order to improve the patient care menu, I have proposed to change to providing 4 carbohydrate exchanges at breakfast, and 5 carbohydrate exchanges at lunch and dinner to better distribute the calories as per AMDR recommendations, and to provide consistent carbohydrates throughout the day in order to lower blood sugar. This menu will also provide less than 30% of calories from fat to be consistent with American Heart Association diet guidelines. It will also provide no more than 2,000mg per day per my preceptor’s request and Morrison’s guidelines. No high sugar drinks or juices will be available in this meal plan in order to reduce in patient blood sugar levels for diabetics. The goals of caloric distribution percentage, grams per macronutrient, and calories per macronutrient per menu updates are as follows in Table 3. Lauren Lindeman Table 3: Caloric distribution breakdown goals per new menu updates of 1800 Calorie American Diabetes Association, American Heart Association Diet. Macronutrient % of Total Calories Grams per Macronutrient Calories per Macronutrient Carbohydrate 47% 211g 846 calories Fat 30% 60g 540 calories Protein 23% 103.5g 414 calories An 1800 calorie diet is the most often prescribed diet for Diabetics at Bayshore Medical Center. However, there are few 1600 calorie diets, 1200 calorie diets, and even sometimes 2200 calorie diets. In the even that these diets are prescribed, the caloric breakdown is shown in Tables 3, 4 and 5. This is based off of carbohydrate exchanges, in which the catering associates will only change the carbohydrate exchange choices given to the patient, and the fat and protein intake will remain the same. This accounts for changes in side items while keeping the main hot plate the same in order to reduce confusion. Table 4. Caloric Changes of Carbohydrates based on a 2200 calorie diet. Macronutrient % of Total Calories Grams per Macronutrient Calories per Macronutrient Carbohydrate 56% 270g 1246 calories Fat 24.5% 60g 540 calories Protein 18% 103.5g 414 calories Table 4.1. Carbohydrate Exchange per Meal for a 2200 Calorie Diet Meal Breakfast Lunch Dinner Carbohydrate Exchange 7 7 7 Carbohydrate Grams 105g 105g 105g Lauren Lindeman Table 5. Caloric Changes of Carbohydrates based on a 1600 Calorie Diet. Macronutrient % of Total Calories Grams per Macronutrient Calories per Macronutrient Carbohydrate 45% 180g 720 calories Fat 30-33% 50-60g 480-540 calories Protein 25-26% 100-103.5g 400-414 calories Table 5.1 Carbohydrate Exchange per meal for a 1600 Calorie Diet. Meal Breakfast Lunch Dinner Carbohydrate Exchange 4 4 4 Carbohydrate Grams 60g 60g 60g Table 6. Caloric Changes of Carbohydrates based on a 1200 calorie diet Macronutrient % of Total Calories Grams per Macronutrient Calories per Macronutrient Carbohydrate 45% 150g 600 calories Fat 40-45% 50-60g 480-540 calories Protein 33-35% 100-103.5g 400-414 calories Table 6.1. Carbohydrate Exchanges per meal based on a 1200 Calorie Diet. Meal Breakfast Lunch Dinner Carbohydrate Exchange 3 3 3 Carbohydrate Grams 45g 45g 45g The modifications per calorie prescribed diet will aid catering associates in modifying the same standard menu easily per patient by adding or subtracting carbohydrate exchanges. While the AMDR ranges for fat and protein per calorie amount, the consistent carbohydrate amount will help stabilize blood sugars while in the hospital. Although it deviates from the AMDR, dietary fat intake should mostly be from polyunsaturated and unsaturated sources in order to be therapeutic on a 1200 calorie diet4. The theme to be followed is Tex-Mex, in order to capture the interest of our average population. Foods chosen will be closer to the more familiar Texan barbecue and Latin flair that you can find around the Pasadena area while still following dietary guidelines. Whole grains will be used in place of refined grains, and lean meats will be served in place of higher fat protein. Black beans, pico de gallo, Lauren Lindeman cucumbers, and tomatoes will be used as these are more familiar side dishes. Fruits that will be served are strawberries, mangoes, and pineapple flavors. Familiar desserts that are already served, and new desserts that will be close to those on the current menu will be included in the menu if it meets the carbohydrate range for the 1800 calorie diet. In order to update per calorie requirements, a carbohydrate choice can be added or taken off following the carbohydrate count guidelines listed above in Tables 4-6.1. The current menu offers many turkey and chicken dishes. In order to appeal to our target population more lean beef and pork options will be offered. There will also be less repetition. Although the current menu is on a 7 day rotation, there are 3 day options that rotate between lunch and dinner options. This makes patients who stay longer than 3 days feel the menu is very repetitive. Patient’s often lose their appetite and chose not to eat when the menu options become too repetitive. In order to ensure our food will not only be appealing, but also healing, we must offer more varying options. 3 Day modified Diabetic Diet Menu based on the Regular Diet of 1800 Calories Each patient meal tray currently receives a condiment container with appropriate condiments per diet. Regular diets are allowed 2 salt packets, 2 pepper packets, and as many sugar packets as they would like. Phase 1 American Heart Association diets receive 1 Mrs. Dash herb seasoning packet with each meal in place of salt packets, and the rest is the same as the regular diet. Diabetic, American Diabetes Association Diets, are given 2 salt packets, 2 pepper packets, and sweet n low in place of sugar packets. In place of iced tea diabetics may also request crystal light fruit punch mix which is sweetened with a similar artificial sweetener. I incorporated the similar condiments per diabetic diets which are currently being served with each meal including sweet n low. However, due to the increased risk of complications of heart disease which is associated with individuals diagnosed with type 2 diabetes, I would like to not provide salt packets with any diabetic diets. In place of the salt packets, diabetics will receive Mrs. Dash herb packets. This will ensure that each 1800 calorie diet provides under the recommended 2,000mg of sodium per day5. These however are not included on the 3 day menu analysis. The Mrs. Dash herb packets will be offered as complimentary condiments that do not have to be eaten with the patient tray, however they do not provide any amount of calories or nutrients. Lauren Lindeman Day 1 Nutrition and Cost Analysis: Menu items included in day 1 are familiar foods with a more desirable carbohydrate range. By adding a skim milk to the breakfast I was able to achieve a carbohydrate range that is closer to 4 carbohydrate exchanges. Lunch for day 1 introduces a new menu item with Latin flavor. This will be using the same pork tenderloin that is currently used on the menu, but adding a new sauce and pairing it with Mexican Corn and Spicy Black Beans. It will also feature a new side item of cucumber salad. These recipes can all be found by the production team in Webtrition. The dinner meal is the popular meatloaf meal that my preceptor has decided to keep on the menu. This meatloaf uses turkey and beef, as well as bread crumbs to hold it together. This provides close to 1 carbohydrate exchange, and will require catering associate training to add to their understanding of counting carbohydrate exchanges. Every meal is currently served with a condiment container which includes sweet n low, salt and pepper. However, as previously explained, diabetic meal choices will not receive added salt packets on this menu due to its association with increased risk of cardiac complications. Instead, we will provide a Mrs. Dash herb packet to with each meal to add flavor without all the added salt. The whole day provides less than 2,000mg of salt which is the upper limit recommended to those with cardiac risk factors and diabetes. According to the American Diabetes Association less than 2,300mg on a 2,000 calorie diet is optimal for reducing cardiac risk factors6. A comparable level for a 1,800 calorie diet would be 2,000mg. Lauren Lindeman Day 1 Production Plan: Day 1 Temperature Control, Production Forecast, and Waste Log: Lauren Lindeman Day 2 Nutrition and Cost Analysis: The menu for day 2 features the familiar whole wheat cinnamon French toast and oatmeal. I have added a skim milk in order to properly meet the carbohydrate requirements of 4 carbohydrate exchanges at breakfast. I have also changed the portion size of the French toast to be one slice of toast, instead of one and one half pieces of toast. This will help catering associates better count carbohydrate exchanges for breakfast meal service, as this now counts for one whole carbohydrate exchange rather than one and one half carbohydrate exchanges. For lunch I have added a new main dish of chicken fajita and vegetables. This will include similar sides to the day 1 lunch, including Mexican corn. It also features a whole grain tortilla, roasted tomato salsa, guacamole, and sour cream. For dessert we will feature a familiar orange creamsicle gelatin. This is all within the 5 carbohydrate exchange specifications. With lunch, the condiments will be the same for the day before. It will include a Mrs. Dash herb packet, 2 packets of pepper, and sweet n low to sweeten tea. Patients will also have the choice of having a crystal light fruit punch drink instead of iced tea. For dinner I have added another new menu item. Due to the high amount of catholic influence in the Pasadena area, it is customary for Friday’s dinner to feature fish as the main dish. The current fish meal for the Friday dinner main dish is a Dijon herb crusted tilapia. I have changed this to include a southwestern feel instead. The Veracruz tilapia has a nice southwestern flavor, and I have paired this with black beans, Spanish rice made with whole grains, and southwestern coleslaw. Instead of dessert this dish will provide grapes for a lighter sweet choice of carbohydrate. Lauren Lindeman Day 2 Production Plan: Day 2 Temperature Control, Production Forecast, and Waste Log Lauren Lindeman Day 3 Nutrition and Cost Analysis: For the menu on day 3 I added a breakfast that is different from the usual. I found two new recipes on Webtrition for breakfast, the egg white scramble with spinach, potatoes, and a honey wheat English muffin, as well as a peach and yogurt breakfast parfait that is specifically for patients. These recipes provided 3 carbohydrate exchanges, and by adding a skim milk I was able to reach the recommended 4 carbohydrate exchanges. The current meal served for lunch on Saturdays is Salisbury steak. While this is still a popular item, I did not feel that it fit the Tex-Mex theme. Instead, I added a new recipe that is closer to the barbecue fair we see often in Texas. The braised beef is made with carrots and onions, and is topped with a brown gravy. I chose the brown gravy instead of a barbecue sauce because many of the barbecue sauce recipes offered through Morrison’s were full of sugar. The brown gravy still gives it a nice flavor without exceeding the carbohydrate exchange. For sides, I thought a potato salad would be a nice addition. I was very glad to have found a recipe for a quinoa potato salad, in order to introduce something new with something familiar, as well as to add more whole grains to the diet. For dessert, I thought the banana pudding mousse would give a nice picnic barbecue fell while still staying low on the carbohydrate count. A meal option to include on the new menu, per my preceptor’s request, was pork carnitas. I added a whole wheat flour tortilla, which is only 55% whole wheat, in order to add some whole grains to the menu while still considering taste preferences of the patient population. For this meal I wanted to provide red and green bell peppers with caramelized onions which are much like the chicken fajitas for Friday’s lunch. I also incorporated Mexican pinto beans and Spanish rice in order to create a complete Tex-Mex meal. Lauren Lindeman Day 3 Production Plan Day 3 Temperature Control, Production Forecast, and Waste Log For each day I have added Temperature Control logs for the cooks. This will aid them in logging time and temperature control, forecasting for the current patient census, and recording leftover food. The leftover food log will aid the food service department in better waste control. In order to better control for waste, the executive chef will be able to analyze these logs daily and retrain cooks on proper forecasting if necessary. Substitutions for foods served are also included on the cook’s log in order to track any deviations from the prescribed diet order, or the current menu. This will help the chef in determining inventory discrepancies between the cooks, the inventory associate, and the order invoices. Lauren Lindeman Kitchen Workflow Diagram: Lauren Lindeman Cost Average Analysis There is no direct budget for the food service department here at Bayshore Medical Center. However, good budget control can result in better credit for the food service department. This in turn can be used to buy new supplies and equipment for the department, as well as to increase pay and incentives for food service employees. By tracking total daily cost, the food service director can better account for budget control and determine whether the department is making the best use of the budget. Day 1 Day 2 Day 3 Breakfast Cost $1.53 $1.48 $2.29 Overall Average Cost $1.77 Lunch Cost $2.51 $1.79 $2.57 $2.29 Dinner Cost $1.72 $2.59 $1.25 $1.85 Total Daily Cost $5.76 $5.86 $6.11 $5.91 Nutrition Analysis Average Per Morrison’s guidelines, each patient menu needs to reach 90% of each recommendation per patient population on average for the whole menu. In order to ensure that I have reached these recommendations I have included information on the average of the macronutrients, sodium, and saturated fat intake for the 3 day menu. Total Kcals Total CHO (g) Total Fat (g) Total Saturated Fat (g) Total Protein (g) Total Sodium (g) Breakfast CHO (g) Lunch CHO (g) Dinner CHO (g) Day 1 Day 2 Day 3 1843.12 221.03g 63.02g 17.16g 103.41g 1929.37g 64.08g 81.76g 75.19g 1825.84 221.23g 62.85g 12.40g 94.45g 2065.01g 62.94g 79.03g 79.25g 1818.60 222.88g 51.58g 15.36g 104.80g 1986.75g 67.14g 78.71g 77.02g Overall Average 1829.19 221.71g 59.15g 14.97g 100.89g 1993.71g 64.72g 79.83g 77.15g % of Requirements 101.6% 49.3% 29.6% 7.4% 22.4% 96.7% 107.8% 106.4% 102.9% The 3 day menu presented is slightly over the calorie and carbohydrate amount allotted. However, the macronutrients are within the Acceptable Macronutrient Distribution Range. Additionally, the saturated fat and sodium levels are optimal for prevention of cardiovascular disease. This menu will serve as the standard regular diet, serving a double purpose for patients on an American Heart Association Diet. The aim of this menu is to continually provide patient care past medicinal and nursing properties. The food service department purpose is to heal patients with food, by letting their food be their medicine. By providing quality nutrition we can do just that. Lauren Lindeman References: 1. Trumbo P, Schlicker S, Yates AA, Poos M. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. J Am Diet Assoc. 2003; 103(5):563. 2. Czyewska-Majchrzak L, Grzelak T, Kramkowska M, Cyzewska K, Witmanowski H. The use of lowcarbohydrate diet in type 2 diabetes – benefits and risks. Annals of Agricultural and Environmental Medicine. 2014;21(2):320-326. 3. RH, Jakicic JM, Ard, JD, Hubbard VS, de Jesus JM, Lee IM, Lichtenstein AH, Loria CM, Millen BE, Houston Miller N, Nonas CA, Sacks FM, Smith SC Jr, Svetkey LP, Wadden TW, Yanovski SZ. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology American/Heart Association Task Force on Practice Guidelines. Circulation. 2013;00:000–000. 4. Huiyan W, Hongyi J, Yang L, Zhang M. Impacts of dietary fat changes on pregnant women with gestational diabetes mellitus: a randomized controlled study. Asia Pacific Journal of Clinical Nutrition. 2015;24(1):58-64. 5. Merino J, et al. Is complying with the recommendations of sodium intake beneficial for health in individuals at high cardiovascular risk? Findings from the PREDIMED study. American Journal of Clinical Nutrition. 2015;101(3):440-448. 6. Nutrition Recommendations and Interventions for Diabetes. A position statement of the American Diabetes Association. Diabetes Care. 2007;30(1):548-565.