Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 9 – Dietary Services

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3.9.1 Dietary Interventions

  • Policy

    • California Correctional Health Care Services (CCHCS) shall provide consultative services to ensure the nutritional adequacy of California Department of Corrections and Rehabilitation (CDCR) food service menus and shall act as a clinical nutrition subject matter expert in support of the food services administered to the incarcerated population.

    • Current Recommended Dietary Allowances and Dietary Reference Intakes, as established by the Food and Nutrition Board of the Institute of Medicine, National Academy of Science, shall be considered authoritative in setting levels of nutritional need.

    • Food flavor, texture, temperature, appearance, palatability, orderly delivery, and established sanitation, safety, and food handling standards shall be considered in the development of healthy and nutritionally adequate menus.

    • Standardized therapeutic diets are offered to support the optimal nutrition status of patients with certain clinical conditions.

  • Purpose

    • To provide evidence-based, fiscally responsible Medical Nutrition Therapy (MNT) to ensure that patients:

    • With identified nutritional needs are provided diet instruction.

    • Have clinically accurate information regarding appropriate nutritional choices.

    • Receive medically necessary outpatient therapeutic diets, texture modified diets, nourishments, or supplements.

  • Responsibility

    • Statewide

      • CCHCS and CDCR departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place, and appropriate tools, training, technical assistance, and levels of resources are available to ensure patients have timely access to medically necessary dietary services.

      • The Statewide Chief of Dietary Services, or designee, is responsible for the implementation and maintenance of a safe and effective Dietary Services program, which includes:

        • Reviewing and updating CCHCS Health Care Department Operations Manual (HCDOM) sections related to dietary services.

        • Developing standard operating procedures for institution adoption into Local Operating Procedures (LOPs), the Food and Nutrition Services Reference Guide (FANS), and the Medical Diet Manual to serve as detailed programmatic resources.

        • Initiating and overseeing statewide Dietary Services contracts, procurements, policies and procedures, workflows, and forms. This includes coordinating dietary services-related Electronic Health Record System (EHRS) issues with CCHCS technical staff to prioritize corrective measures and maintenance activities.

        • Providing consultation and advice to health care providers and institution staff regarding patient food allergies and intolerances, institution Dietary Services departments, and CCHCS’s Dietary Services’ order menu of approved nourishments and supplements, outpatient therapeutic diets, and texture-modified diets.

        • Approving the indications and characteristics of authorized outpatient therapeutic diets and texture-modified diets.

        • Approving patient diet education handouts for onsite distribution.

        • Collaborating with institution and headquarters medical leadership and Dietary Services staff on the monitoring of Registered Dietitian Nutritionists (RDNs) or the persons designated to perform dietary consultation or instruction or other RDN responsibilities.

        • Overseeing and coordinating the competency assessment and related remediation efforts of local, regional, and headquarters Dietary Services staff.

        • Overseeing and providing quality assurance of the delivery of therapeutic dietary services.

    • Regional

      • Regional Health Care Executives (RHCEs) are responsible for the implementation of this procedure at the subset of institutions within their assigned region.

      • The RHCE shall direct Food Administrator (FA) IIs as part of a regional oversight and support structure.  

      • The FA IIs shall:

        • Coordinate with the Statewide Chief of Dietary Services under the Chief’s functional direction.

        • Perform administrative duties at the regional level and oversee FA Is and RDNs at institutions within their assigned region. When appropriate, the FA II shall direct both medical kitchen operations and medical kitchen staff and direct RDN-provided patient care as needed.

        • Monitor Dietary Services staff performance within their assigned region through regular onsite compliance auditing, training, competency verification, and any subsequent corrective action as needed.  FA IIs shall coordinate with the Statewide Chief of Dietary Services, or designee, on all related processes, findings, and corrective actions.

    • Institutional

      • The Chief Executive Officer (CEO), or designee, has overall responsibility for implementation and ongoing oversight of a system to provide outpatient therapeutic diets, texture-modified diets, nourishments, or supplements to patients.

      • The institution-based FA Is provide site-level administration primarily focused on Correctional Treatment Center (CTC) medical kitchen operations. Responsibilities include the local supervision of RDNs, CCHCS Correctional Supervising Cooks and Supervising Correctional Cooks, and CTC kitchen incarcerated workers.

      • The institution-based RDN is responsible for:

        • Providing patients with dietary consultation or education as ordered by a Primary Care Provider (PCP) or dentist.

        • Ensuring preparation and distribution of therapeutic diets and texture-modified diets to outpatients.

      • An institution without an RDN shall designate how and by whom the responsibilities of the RDN shall be performed in an LOP.

      • The PCP or dentist is responsible for ordering medically necessary dietary interventions described in this chapter including, but not limited to, dietary consultations and instruction, alternative nutritional delivery such as enteral and parenteral feeding, approved nourishments and supplements, therapeutic diets, and texture-modified diets.

        • A medically necessary dietary intervention addresses a patient’s specific condition and is the most appropriate clinical course of action, given patient circumstances. The medical necessity of the dietary intervention shall be demonstrated by documentation of patient condition, rationale for the dietary intervention, and the consistency with clinical standards, policy, and CCHCS care guides.

        • The PCP or dentist shall follow the instructions outlined in this procedure and its appendices for the indications and frequency of dietary interventions such as approved nourishments and supplements, and therapeutic diets.

  • Procedure

    • Dietary Consultation and Instruction

      • Conditions for which dietary consultation may be considered include, but are not limited to:

        • Pregnancy

        • Disorders of mastication or dysphagia

        • Unintentional weight loss of greater than five percent or more within the prior 30 calendar days or ten percent of body weight during the prior six months

        • Body Mass Index (BMI) less than 18.5

        • Diabetes

        • Hepatic disease

        • Kidney disease

        • Celiac disease

        • Patients receiving Liquid Nutritional Supplements (LNS)

        • Food allergies or intolerances

        • Obesity BMI ≥ 30

        • Other medical or dental conditions that the treating clinician determines, based on evidence, will benefit from the consultation.

        • Other clinical conditions amendable to MNT provided by an RDN.

      • When medically necessary, the PCP or dentist shall order a dietary consultation in the EHRS. The “Consult to Registered Dietitian” order shall indicate the clinical condition requiring dietary consultation and any special clinical or dietary considerations.

      • The dietary consultation’s assessment shall consider clinical conditions and special considerations indicated by the referring clinician, diet deficiencies, and conditions predisposing a patient to inadequate nutritional patterns or nutritionally related health conditions.

        • Subsequent RDN follow-up shall be determined according to the clinical factors determined during the initial assessment by the RDN.

        • The RDN shall be responsible for proposing an appropriate follow-up window for provider co-signature according to the patient’s clinical factors described in Section (d)(1)(C) above.

        • The RDN, or designee, shall document dietary consultation and recommendations in the health record.

      • The RDN shall ensure standardized CDCR patient dietary education handouts shall be available to all institutions for use during dietary instruction.

      • Patients receiving dietary instruction shall not be housed in a CTC, Skilled Nursing Facility, Hospice, or any other licensed bed or Outpatient Housing Unit (OHU) solely to receive this service.

    • Patient Refusals or Failures to Report for Dietary Consultation and Instruction

      • If the patient does not arrive for a dietary consultation, health care staff shall notify custody staff to have the patient escorted to the designated clinical service area for the dietary appointment.

      • If the patient arrives in the clinical services area and permits the dietary appointment, the consultation shall be performed.

      • Staff shall cancel the dietary consultation order if the patient refuses the consultation at the clinical service area.  If the patient fails to report (“no-show”) not due to a stated or reported patient refusal, staff shall attempt to reschedule the patient one time for a second dietary appointment.  Staff shall cancel the dietary consultation if the patient refuses or fails to report for the second scheduled appointment.

        • The staff cancelling the dietary consultation order shall document the reason for the order cancellation in the EHRS.  The EHRS will automatically notify the ordering provider of the cancellation.

        • Authorization from the ordering provider is required for the cancellation of dietary consultation orders not associated with a patient refusal or second scheduled appointment attempt associated with a failure to report for dietary service.

        • The documentation (CDCR 7225, Refusal of Examination and/or Treatment) and counseling procedure for the failure to report for a medical appointment outlined in the HCDOM, Section 3.1.5, Scheduling and Access to Care, does not apply in cases of patient refusal or failures to report (“no-shows”) related to dietary consultation orders.

      • The ordering provider shall inform the patient of the health care consequences and next clinical steps due to the patient refusal or failure to report for the dietary consultation.

    • Food Allergies and Intolerances

      • The PCP, or designee, shall evaluate patients who request a special diet due to claimed food intolerance or allergy in order to verify the presence of a food allergy or intolerance with objective clinical findings.  If the PCP determines the patient has a severe food allergy based on objective findings, the PCP shall determine whether the allergy can be appropriately managed by educating the patient to avoid the identified food or if other intervention, such as a nutritional supplement, is warranted.  In extreme cases where the patient does not tolerate the supplement, the patient may require meals to be provided as a medical diet.  An example of an extreme case may include patients with one of the following:

        • Multiple food-allergy-related hospitalizations.

        • Abnormal food allergy laboratory profile.

        • Verified food-specific allergen signs and symptoms including, but not limited to, anaphylaxis, eosinophilic esophagitis, hives, and enterocolitis.

      • In addition to food allergy laboratory profile testing, subsequent testing, such as skin testing, may be requested by the PCP to support abnormal laboratory values unless an allergist states that substantiated, documented risk of anaphylaxis is so severe that skin-testing or additional testing, or both, would be life-threatening based on medically proven evidence of anaphylaxis with hospitalization.

      • If a patient is allergic or intolerant to readily identified food (e.g., lactose intolerance, peanuts, or fish), they shall be educated to avoid the offending food, but no food substitution shall be given.

    • Enteral Tube Feedings

      • Enteral nutrition shall be available for patients who are unable to meet their nutrition and hydration needs via oral intake.

      • The PCP shall order the initial enteral tube feeding in the EHRS indicating the type of feeding, strength of feeding, and rate of flow and shall also enter a “Consult to Registered Dietitian” order.

      • The RDN shall review the PCP’s initial enteral feeding order and may recommend changes after completing an MNT assessment based on the patient’s needs and tolerance.

      • The local FA I or II shall be responsible for procuring the enteral formula and providing it to nursing staff.

      • Nursing staff shall provide the enteral nutrition to the patient in the clinically prescribed manner.

      • The RDN shall include a plan of care, which shall include clinical monitoring of patient tolerance to enteral nutrition and other defined outcomes and preventions as clinically indicated.

    • Parenteral Nutrition

      • For patients unable to meet their nutritional needs, parenteral nutrition (PN) shall be provided at institutions designated by the Statewide Chief Dietary Services upon PCP order via an oral or enteral route of administration.  The PCP shall determine the appropriate duration of PN.

      • The RDN shall review the PCP order and provide appropriate clinical recommendations, modifications, and consultation.

      • Ongoing PN shall require the monitoring of objective measures of nutrition status such as laboratory results, hydration status, and weight. Additional measures such as wound healing, functional and cognitive capacity, level of oral intake, and patient sense of well-being may also be included.

      • Staff shall follow LOPs for PN administration.

    • Nourishments and Supplements

      • All patients shall be evaluated on an individual basis prior to ordering nourishments or LNS.

      • All patients receiving LNS shall be subject to weekly weight evaluation to gauge the effectiveness of LNS therapy.

      • All institutional-provided medical snacks shall follow the nutritional guidelines outlined in the Medical Diet Manual.

      • Nourishments and supplements, including vitamin and mineral supplements that are recommended by an RDN, are provided only if ordered by a PCP or dentist according to the criteria outlined in Appendix 1.

      • The order shall include the indication for the nourishment or supplement and the maximum duration of the order based on the criteria as noted in Appendix 1.

      • Orders for nourishments and supplements are limited to those listed in Appendix 1 and may not be modified for religious reasons or other personal requests.

      • Nourishments, including LNS, shall be purchased by CCHCS or the medical warehouse and stored and distributed by institution food services and custody staff in accordance with established LOPs.

    • Menu Substitution

      • Food items within the same food category may be substituted for the equivalent serving size of another food item within its category in cases of food supply shortages pursuant to the California Code of Regulations, Title 22, section 79685.

      • Patient diet restrictions and therapeutic diet requirements shall be considered when substituting food items.  An RDN or FA I or II must be consulted to verify and approve menu substitutions.

      • Substitutions require completion of a standardized substitution slip, which shall be kept on file for at least 12 calendar months. Each CTC kitchen shall create all relevant workflows, processes, and LOPs for the food substitution process

    • Incarcerated Worker Food Service Orientation and Training

      • All incarcerated workers assigned to a medical kitchen shall complete the Medical Kitchen Food Service Training and Orientation.  The training shall be completed within 30 calendar days of work assignment.

    • Outpatient Therapeutic Diets

      • Outpatient therapeutic diets shall only be provided if medically necessary or in a licensed inpatient setting and shall not be automatically ordered during reconciliation for patients transferring from an inpatient unit to an outpatient setting.  Outpatient settings include, but are not limited to, OHUs and Enhanced Outpatient Program units.

        • The CCHCS authorized outpatient therapeutic diets, and the indications for orders are noted in Appendices 2-A, 2-B, 2-C, 2-D, and 2-E.  The authorized outpatient therapeutic diets include the following:

          • Gluten-free diet.

          • Hepatic diet.

          • Renal dialysis diet.

          • Renal non-dialysis diet.

          • Preoperative and postoperative diets related to bariatric surgery.

        • Outpatient therapeutic diets cannot be modified for religious reasons or other personal requests. If a therapeutic diet is ordered for a patient, it shall take precedence over a religious diet.  Therapeutic diets may be texture-modified as clinically indicated.

      • Refusal of Therapeutic Diets

        • Patients may refuse an ordered outpatient therapeutic diet, and the refusal shall be documented in the health record. If, after educating the patient regarding the health care benefits of the ordered diet, the patient continues to refuse the ordered diet, a CDCR 7225, Refusal of Examination and/or Treatment, shall be completed and scanned into the health record.  Patients who refuse an ordered diet shall be offered the CDCR Heart Healthy Diet.

        • Patients shall not be issued a Rules Violation Report (RVR) for refusing an outpatient therapeutic diet.  A patient may be issued an RVR for circumventing meal procedures such as picking up a therapeutic meal and a regular meal, diverting LNS, or other violations of meal procedures.  A patient shall not be issued an RVR for eating items other than those on the outpatient therapeutic diet (e.g., canteen purchases).

        • Health care staff shall not issue RVRs but shall assist custody staff as a subject matter expert in instances where an RVR is issued for circumventing meal procedures.

      • Housing for Patients Requiring an Outpatient Therapeutic Diet

        • Patients requiring an outpatient therapeutic diet or texture-modified diet shall be housed only at institutions listed in Appendix 3 that have the capability to prepare these diets under the direction and supervision of an RDN and trained dietary staff.

        • When a patient is not housed at one of the listed institutions and is identified by a PCP or dentist as requiring an outpatient therapeutic diet or texture-modified diet, the PCP or dentist shall initiate a transfer per the LOP.  While the transfer is pending, the patient shall be given dietary instruction for making appropriate food choices from the CDCR Standardized Master Menu or an LNS if texture modification is needed but shall not receive an outpatient therapeutic diet.

        • Patients receiving an outpatient therapeutic diet or texture-modified diet shall not be housed in a CTC, Skilled Nursing Facility, Hospice, or any other licensed bed or OHU due solely to receiving the ordered diet.

        • Patients requiring a therapeutic diet that is not an authorized outpatient diet may receive the diet if they are housed at California Health Care Facility, California Medical Facility, or Central California Women’s Facility and if the diet has been evaluated and approved by the institution’s CME in consultation with the FA I or FA II.

      • Meals and Meal Service

        • Outpatient Therapeutic Diets Using the CCHCS Standardized Health Care Menu

          • The CCHCS Standardized Health Care Menu shall be followed at all institutions with specialized medical beds.  The menu is based on using approved frozen medical meals or from-scratch prepared medical meals.

          • Frozen dietary meals are a component of outpatient therapeutic diets, but they do not meet all the nutritional needs of patients. Outpatient therapeutic diets that include frozen dietary meals shall be created under the supervision of an RDN to ensure nutritional adequacy.

          • CCHCS is responsible for purchasing the frozen medical meals plus all special foods (e.g., low sodium, low fat, gluten free) used in the outpatient therapeutic diet meals.

          • Staff shall not open the frozen medical meals unless necessary to modify the texture or make food substitutions per the diet order.  The meals shall be provided to the patient sealed except in settings where packaging may pose a security risk such as the restricted housing units or psychiatric inpatient program.

          • The meals vary in their amounts of key nutrients from day to day; therefore, the standardized menu includes varying amounts and types of accompanying food items. Dietary staff preparing the therapeutic meals shall ensure that the indicated amount of each meal component or food items specified on the daily menus are being served with the frozen meal.

        • Kitchen Prepared Therapeutic Diet Meals

          • Institutions with a therapeutic diet kitchen (i.e., from-scratch) are exempt from using the frozen dietary meals or CCHCS standardized health care menus.

          • The RDN at these facilities shall develop and prepare therapeutic diet menus based on the diet parameters in Appendices 2-A, 2-B, 2-C, 2-D, and 2-E.

          • Nutritional information for all locally created menus shall be sent to the office of the Statewide Chief of Dietary Services, or designee, for approval.

        • Delivery

          • Outpatient therapeutic diet meal trays or texture-modified diet meals shall be fully assembled and identified by diet type in the medical dietary preparation area or in a designated area of the main kitchen and be ready for delivery to patients.

          • Outpatient therapeutic diet meals or texture-modified diet meals shall be delivered to the patients in accordance with established LOPs.

          • Medical kitchen staff assigned to the dining rooms that serve outpatient therapeutic diet meals or texture-modified diet meals shall maintain a list of patients who are ordered these diets.

      • The health care FA I, FA II, or RDN shall ensure dietary staff is trained to prepare and serve the outpatient therapeutic diet meals or texture-modified diet meals.

    • Texture-modified Diets

      • Texture modification shall be available at all institutions serving outpatient therapeutic diets. All outpatient therapeutic diets may be texture-modified.

      • All levels of the International Dysphagia Diet Standardization Initiative (IDDSI) framework for texture-modified diets and thickened liquids shall be available at all institutions serving outpatient therapeutic diets.  These levels include the following:

        • Level 0: Thin liquids.

        • Level 1: Slightly thick liquids.

        • Level 2: Mildly thick liquids.

        • Level 3: Moderately thick liquids or liquidized foods.

        • Level 4: Extremely thick liquids or pureed foods.

        • Level 5: Minced and moist foods.

        • Level 6: Soft and bite-sized foods.

        • Level 7: Regular foods (unmodified outpatient therapeutic diets).

      • Texture-modified diets and thickened liquids prepared according to the IDDSI framework must meet the description, characteristics, and IDDSI Testing Methods standard for each specified IDDSI level.

        • An assigned RDN or FA I or II shall perform a quarterly audit to ensure the texture-modified diets adhere to IDDSI framework standards.

          • The audit findings shall be shared with the local kitchen staff providing the texture-modified diet and maintained by the auditor in their files for one year.

          • The audit findings shall be reported to the assigned Regional FA II and the Statewide Chief of Dietary Services or designee.

      • Staff shall consult the Food and Nutrition Services Reference Guide for more detailed guidance on providing texture-modified diets and thickened liquids.

      • Outpatient therapeutic diets and texture-modified diets shall not be prepared, assembled, or served in an OHU if an institution only has the OHU and no RDN.

      • Beverages shall be thickened by nursing or other clinical staff prior to patient consumption.

    • Religious Diets

      • All matters concerning religious diets shall be directed to the religious services department at the institutions.

        • Refer to the CDCR Department Operations Manual, Section 54080.14, for available religious diets and the process to apply for them.

        • PCPs cannot order religious diets for patients.

      • Outpatient therapeutic diets take precedence over a religious diet. Religious diets cannot be modified in any way to accommodate medical reasons including texture modifications.

    • Local Operating Procedure

      • Each institution’s CEO is responsible for ensuring that the institution has approved, current LOPs consistent with the FANS addressing the following at minimum:

      • Workplace contact information for the RDN or the person designated to perform the responsibilities of the RDN.

      • Procedures for referring patients for diet instruction and dietitian consultation.

      • Procedures for how approved nourishments and supplements are billed to health care services, distributed, and tracked.

      • Procedures for routine delivery of outpatient therapeutic diet meals and texture-modified diet meals to patients and delivery during lockdown situations.

      • A tracking method to ensure patients are receiving outpatient therapeutic diet meals and texture-modified diet meals at the proper food temperatures.

      • Emergency preparedness and downtime procedures for safe and sanitary food production without interruption in case of a natural disaster or other emergency. 

      • A system for tracking the distribution of nourishments and LNS to patients, as well as monitoring LNS usage levels and policy compliance, shall be developed and incorporated into the LOPs.

      • Methods for the provision of texture-modified diets per IDDSI standards including education regarding the preparation of IDDSI diets.

      • Development and implementation of a local training plan for CTC kitchen workers and associated dietary staff.

      • A process for approval and local sign-off of the LOP.

  • Appendices

  • Appendix 1, Approved Nourishments and Supplements with Indications

  • Appendix 2-A, Gluten-Free Diet

  • Appendix 2-B, Hepatic Diet (2 gram Sodium)

  • Appendix 2-C, Renal Dialysis Diet

  • Appendix 2-D, Renal Non-Dialysis Diet

  • Appendix 2-E, Bariatric Surgery

  • Appendix 3, Institutions Providing Outpatient Therapeutic Diets

  • References

  • California Code of Regulations, Title 15, Division 3, Chapter 1, Article 4, Section 3054(d)

  • California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79685

  • California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 5, Article 51, 54080.3, 54080.5-6, 54080.14

  • Nutrition Care Manual, 2021, Academy of Nutrition and Dietetics

  • White JV, Guenter P, et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (ASPEN): Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Under-nutrition). JPEN J Parent Ent Nutr. 2012; 36:275-283.

  • Revision History

    • Effective: 12/2003
      Revision: 12/23/2025

  • Appendix 1: Approved Nourishments and Supplements with Indications

    CONDITIONSNOURISHMENTSUPPLEMENTFREQUENCY
    Pregnancy and lactation· Two extra 8 oz. cartons of milk a day
    AND
    · Two extra fresh fruit servings a day
    AND
    · Two extra fresh vegetable servings a day
    		**Prenatal vitamins
    If lactose intolerant, provide 600 mg calcium supplement daily.    		The written order shall not exceed a duration equal to the estimated date of confinement plus 90 calendar days
    Type one diabetes mellitus with uncontrolled recurrent hypoglycemia unresponsive to glucose or medication adjustment· Two 1 oz. packages of peanut butter & crackers AND one fresh fruit
    OR
    · Two 1 oz. packages of cheese & crackers AND one fresh fruit    		NoneThe written order shall not exceed 90 calendar days in duration.
    Malnourishment
    (Refer to definition of moderate to severe malnutrition noted in the Nourishments and Supplements section-above)    		None***Liquid Nutritional Supplement (LNS)
    · Ensure Original
    · Jevity 1 CAL
    · Boost, or
    · Nutren 1.0.
    An equivalent liquid product may be substituted.    		The written order shall not exceed 90 calendar days in duration.
    End-stage liver disease with ascites requiring paracentesis or encephalopathy requiring hospitalizationNone***LNS High Calorie
    · Ensure Plus
    · Isosource 1.5
    · Nutren 1.5
    · Boost Plus, or
    · Jevity 1.5.
    An equivalent liquid product may be substituted.    		The written order shall not exceed 90 calendar days in duration.
    Oropharyngeal or dental conditions impeding mastication and/or other conditions resulting in dysphagia*None***LNS
    · Ensure Original
    · Boost, or
    · Nutren 1.0.
    An equivalent liquid product may be substituted.    		The written order shall not exceed 90 calendar days in duration.
    Bariatric Surgery *· 1 Tablespoon of peanut butter with 6 saltine crackers or 1 slice whole wheat bread OR
    · 1 oz. sliced cheese with 6 saltine crackers or 1 slice whole wheat bread    		The written order shall not exceed 90 calendar days in duration.

    • * Only if the patient is not meeting nutritional needs as determined by a Registered Dietitian Nutritionist.
      ** Distributed by nursing.
      *** The most cost effective LNS meeting patient needs shall be utilized.

    • LNS Diabetic- Glytrol, Glucerna 1.0 CAL, Glucerna Shake, Glucerna 1.5 CAL or Boost Glucose Control.
      LNS Renal- Novasource Renal or Nepro with Carb Steady.
      These products may be used for patients who qualify for a supplement but have diabetes or renal disease.

    • Appendix 2-A: Gluten-Free Diet

    • A gluten-free diet is one that eliminates gluten-containing grains from the diet.

    • INDICATIONS

    • Patients with celiac disease confirmed by:

    • PCP assessment documenting medically verified signs and symptoms,

    • Positive laboratory serologies specific for celiac disease, and/or

    • Small bowel biopsy result consistent with celiac disease.

    • SPECIFICATION

    • 2,000 – 2,400 Calories, Regular Heart Healthy Diet

    • All foods containing wheat, rye, barley, or oats are eliminated.

    • Appendix 2-B: Hepatic Diet (2 gram sodium)

    • A hepatic diet (2 gram sodium) is one that controls sodium content while providing adequate protein to maintain positive nitrogen balance for patients with decompensated cirrhosis.  These patients shall have frequent weights recorded.  Calorie count shall be monitored.  Consider enteral feeding supplementation if oral intake is suboptimal.

    • The goal of the diet is to:

    • Correct malnutrition and prevent metabolic complications.

    • Improve quality of life.

    • Reduce perioperative complications for those patients who will require liver transplantation.

    • INDICATIONS

    • Patients with end stage liver disease complicated by ascites requiring paracentesis and/or a prior history of encephalopathy requiring hospitalization may benefit from dietary modification. A consultation with a Registered Dietitian Nutritionist shall be ordered for evaluation of special dietary needs. If recommended by the Registered Dietitian Nutritionist, a Hepatic Diet (2 gram sodium) may be ordered.

    • SPECIFICATION

    • 2,000 – 2,400 Calories.

    • Protein: 70 -105 grams (1.0-1.5 grams Protein/kg dry body weight).

    • Sodium: 2,000 mg/day.

    • Water restriction is not recommended, unless serum sodium is less than 125 mEq/L.

    • A daily multivitamin is recommended.

    • Calcium supplementation (1,200-1,500 mg/day) indicated for patients with osteopenia and osteoporosis.

    • Appendix 2-C: Renal Dialysis Diet

    • A renal dialysis diet controls protein and electrolytes in order to slow the progression of azotemia and electrolyte imbalance between dialysis sessions.

    • INDICATIONS

    • All patients receiving dialysis shall be ordered an outpatient therapeutic renal dialysis diet.

    • SPECIFICATION

    • 2,200 – 2,600 Calories (30-35 Calories/kg ideal body weight [IBW])

    • 30-35 kcal/kg

    • Protein: 84 -105 grams (1.2-1.5 grams Protein/kg IBW)

    • Phosphorus: 800-1,000 mg/day

    • Sodium: <2400 mg/day

    • Potassium: 2,000-3,000 mg/day

    • Renal disease specific vitamin (Nephro-vite® or equivalent) is formulary restricted to dialysis patients only (This vitamin product contains vitamin C, folic acid, and B complex vitamins including niacin [B3], pantothenic acid [B5], pyridoxine [B6], riboflavin [B2], thiamine [B1], biotin [aB complex vitamin], cyanocobalamin [B12]).

    • Appendix 2-D: Renal Non-Dialysis Diet

    • A renal non-dialysis diet controls protein and electrolytes in order to reduce the demand on the kidneys in patients with renal failure that do not yet require dialysis.

    • INDICATIONS

    • Patients with kidney disease and a glomerular filtration rate (GFR) <60, but who do not yet require dialysis, are eligible to receive a renal non-dialysis diet at an approved institution. This diet is the same as the renal diet but it contains less protein and does not usually restrict potassium.

    • SPECIFICATION

    • 2,000 – 2,400 Calories (25-35 kcal/kg ideal body weight [IBW])

    • Protein: 42-60 grams (0.6-0.8 gm/kg IBW)

    • Phosphorus: 800-1000 mg/day

    • Sodium: <2400 mg/day

    • Appendix 2-E: Bariatric Surgery/Preoperative and Postoperative Diet

    • A series of diet steps that have been carefully planned for the bariatric patient before and after surgery for weight loss success.

    • INDICATIONS

    • Preoperative and postoperative bariatric diets are for the patients who have successfully completed the Medical Weight Monitoring Program (MWMP) and have been approved for bariatric surgery by the CCHCS Statewide Medical Authorization Review Team (SMART).

    • SPECIFICATION

    • Preoperative – typically one to two weeks before surgery

    • Postoperative

      • Stage One—Bariatric Clear Liquid

        • Estimated duration 1 day to 1 week after surgery

      • Stage Two—Bariatric Full Liquid Pureed

        • Estimated duration 1 week to 4 weeks

      • Stage Three—Bariatric Soft

        • Estimated duration 2 weeks to 6 weeks

      • Stage Four—Regular Heart Healthy Diet

        • Estimated duration begins at 4 to 8 weeks

    • Snacks may be needed due to smaller meals being consumed

    • Appendix 3: Institutions Providing Outpatient Therapeutic Diets

    • Central California Women’s Facility

    • California Health Care Facility

    • California State Prison, Centinela

    • California Institution for Men

    • California Institution for Women

    • California Men’s Colony (East)

    • California Medical Facility

    • California State Prison, Corcoran

    • California Substance Abuse Treatment Facility and State Prison, Corcoran

    • High Desert State Prison

    • Kern Valley State Prison

    • California State Prison, Los Angeles County

    • Mule Creek State Prison

    • North Kern State Prison

    • Pelican Bay State Prison

    • Richard J. Donovan Correctional Facility

    • California State Prison, Sacramento

    • California State Prison, Solano

    • San Quentin Rehabilitation Center

    • Salinas Valley State Prison

    • Wasco State Prison