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Acknowledgements

Written by: Karen Balko, RD

Adapted from: The Children’s Institute, Pittsburgh PWS Program & L.H. Epstein, Family Based Weight Control & Manual

Produced by: Ana Snjaric, OPWSA President Nita Goldband, OPWSA Executive Director Lindsay Bouwkamp, OPWSA Board Member

Jennifer Gignac, Graphic Designer

Printed by:

Copyright © 2006, Ontario Prader-Willi Syndrome Association. Revised September 2010. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

The material in this publication is provided for information purposes only. Every effort has been made to ensure that the information is complete and accurate. This book is sold with the understanding that recommended professional advice should be obtained before acting on any information contained in this book.

In 1982, a small group of parents came together to support each other and find ways to help their children who had been diagnosed with Prader-Willi Syndrome. This was the beginning of the Ontario Prader-

Willi Syndrome Association. We have taken on many projects over the years and have grown considerably, but our goals remain the same-to make sure that the each child born with PWS lives a healthy and happy life by providing the tools and support systems to make that happen.

Meeting the complex needs of an individual with Prader-Willi Syndrome can be a great challenge. Controlling weight through a proper dietary program is essential. One of the best proven tools that we have encountered over the years for managing the food issues of our population is the Red Yellow Green Diet. In producing this book, we wanted to make the RYG system accessible and understandable for anyone that wanted to use this system.

On behalf of the Ontario Prader-Willi Syndrome Association, we congratulate the team responsible for creating the new Red Yellow Green Book. A special thanks goes to Dr. Glenn Berall, Head of Paediatrics and the founder of the Prader-Willi

Syndrome Clinic at North York General Hospital, Toronto, Ontario and to our favourite dietitian, Karen Balko. Karen has used the RYG system with over 100 patients. She has worked hard to create a book that is comprehensive, clear and easy to read. She has included items and menus that offer a huge selection of choices and reflect our diverse community.

We know you are going to love the graphics and layout designed by Jennifer Gignac. We would also like to acknowledge the great work of Vita Community Living and in particular: Lori Hamilton, Marilena Candito, Lisa Rosenow and Rebbie Thompson. They are responsible for the sample meal plans and many of the delicious recipes that are included - adapted by Karen Balko for caloric content. We thank Rob Pividor (Recreation Rehabilitation Therapist), for his contribution of exercise tips. And finally, thanks to the board members of OPWSA.

We know that you will enjoy using this new book and that it will provide an excellent tool for dietary management.

Ana SnjaricOPWSA President

Nita GoldbandOPWSA Executive Director

Graphic Design& Layout by:

1

Table of Contents

Foreward

Foreward 1

Background of the Diet System 2

Why Does the RYG System Work? 3

How Does the RYG System Work? 3

Green GO Food Lists 6

Yellow CAUTION Food Lists 10

Red STOP Food Lists 19

Designing the Meal Plans 25

Meal Plan Serving Examples 27

7-Day Meal Plan Example 29

Family Lifestyle Changes - The Key to Success 35

Creative Plating 36

Recipes 37

Combination Dishes 41

Developing a Fitness Program 42

A Word About Vitamins & Mineral Supplements 44

My Daily Meal Plan 45

Prader-Willi Syndrome is a complex medical condition that challenges caregivers at many levels. In particular, prevention of obesity are vital for good health and to prevent heart & respiratory problems as well as obesity related diabetes.

The following factors contribute to obesity in PWS:•Lowercaloricneedsduetolowermusclemass: about 2/3 of the calories normally required •Faultyappetitesystem:thebraindoesregisters constant signals of being hungry and does not signal feeling of being full •FoodForaging(hyperphagia):becauseof feelings of hunger, the person will be compelled to seek out food by any means• LowerMuscleMass(hypotonia):increasesdifficultywith performing physical activity, burns less calories

The Red Yellow Green System described in this

book has been used successfully by the Prader-Willi Clinic at the North York General Hospital to help over 150 patients control their weight and regain their health.

If you have a child, client or patient with Prader-Willi Syndrome,then this is the right book for you. It will help you to understand PWS and related dietary and behavioural management techniques needed to support the RYG system.

This new version of the RYG system is adapted from the work of Dr. Leonard Epstein, University of Buffalo who developed The Stoplight Diet in the 1970's and from the Children's Rehabilitation Program in Pittsburgh.

The evaluation, treatment and support of PWS requires a collective effort to be successful so it is

Dietitians from The Children's Institute in Pittsburgh (a leading treatment clinic for PWS), adapted Epstein's Stoplight Diet to cater to the Prader-Willi Syndrome (PWS) population. They re-named the system to:

The Red, Yellow, Green System for Weight Management (RYG)

Dietitians in Pittsburgh made specific adjustments to the diet as follows:1. Increased structure to the diet2. Set limits for green foods - not unlimited - only seconds allowed3. Set limits for portion sizes to control calories4. Set limits for number of high calorie foods allowed

In 1972, Dr. Leonard Epstein a leading expert in childhood obesity at the University of Buffalo developed a dietary management system based on the four food groups which he named, The Stoplight Diet. This was one of the few plans proven to produce longterm success for obese children.

The success of this plan is because it is easy to understand and even a very young child can participate and make choices, increasing the chance of good dietary compliance.

Background of the Diet System

2

High Calorie

Moderate Calorie

Low Calorie

Foods are divided into different groups based on their nutrient content and calorie levels.The system groups foods according to the three signals on a traffic light:

RED and should be eaten RARELY

YELLOW and can be eaten in MODERATION

GREEN and can be eaten FREELY

only fitting that this book is a collaborative effort between our clinic at North York General Hospital, the Ontario Prader-Willi Syndrome Association and Vita Community Living Services-Prader-Willi group home staff, as well as many of our families & patients who contributed wonderful recipes to this effort.

We thank-you all for sharing your experiences with us and allowing us to be a part of your lives.

Glenn Berall, MD, FRCPCHead, Prader-Willi Syndrome Clinic, North York General Hospital Chief of Paediatrics, North York General Hospital

Karen Balko, RDPaediatric Dietitian, Clinical Nutrition, North York General Hospital

7

Green GO Foods

They are good for my body.

They do not make me gain weight.

Second helpings are alright.

I try to eat these foods everyday.

8

Green GO Food Lists

1 Serving:

Cauliflower

Eggplant

Lettuce

Peppers

Greens Cucumber

Broccoli Tomato

Green Beans

Mushroom

Brussel Sprouts

27

METHOD 1:

Calorimetry

The best way to determine calorie requirements is to perform a test called Calorimetry. This test shows calories needed per day when a person is at rest.

How is this test performed?• Thisisapainlessprocedure,whichinvolves fasting for a minimum of four hours before the test. • Aplastic,transparenthoodisplacedoverthe head, and 4 sticky tapes with electrodes are placed on one hand and one foot. Full clothing except socks are allowed. • The person is not allowed to speak or fall asleep. He/she may read or listen to music while the test is being performed. The person lies down and breathes normally for approximately 20 minutes, however the length for the test is flexible, depending on the child's ability to lie still. • Theexchangeofcarbondioxideandoxygenuse is calibrated in the computer, and energy or calorie needs at rest is calculated. • Oncecalorieneedsatrestareknown,anactivity factor is added to this measure to determine daily calorie requirements to meet a certain weight goal. This will give the dietitian a good

idea of how many calories to plan in your child's diet. • ThistestcanbeperformedattheNorthYork General Hospital, in Dr. Berall's office by appointment only. Many teaching hospitals may also have access to this test.

METHOD 2:

Estimation of Calorie Requirements

First question: What are my child's weight goals?Answer: weight loss, weight maintenance, or normal weight gain with growth?

When a dietitian assesses your child's weight progress, the following goals may be established:1. If your child's weight is in the normal range, adequate calories are planned so that your child continues to gain weight and height at a normal rate.2. If your child's weight is too high, a specific amount of calories are planned to allow your child to either maintain their weight while they grow into a healthier weight, or lose weight slowly, until a goal weight is reached. If your child has a lot of weight to lose, then weight loss is the goal. A loss of 1/2 lb -1 lb per week would be a reasonable level of weight loss in a very overweight child/adolescent.

STEP 1: Determine how many calories your child needs - use Calorimetry or Estimation.

The following guidelines will provide you with the information to design a meal plan. However, it is always best to seek the service of a registered dietitian familiar with Prader-Willi Syndrome:

CaloriesCalories are individually determined with each child. It is well known that persons with PWS have lower caloric requirements, due to a lower muscle mass. Calories are usually 2/3 or 65% normal requirements for age, however this is not always the case. Calorie determination can be done via a calorimetric test, a scientific medical test, or by estimation.

Designing the Meal Plans

28

Height (cm) x 9-10 calories = total calories needed per dayExample: 122 cm x 9-10 = 1098-1220 calories needed per day


FOR WEIGHT LOSS


FOR WEIGHT GAIN(Normal weight gain for growth or

underweight)

STEP 2: Decide how many meals and snacks your child will have based on your family lifestyle. Most children must have 3 regular meals plus one to two snacks.

STEP 3: Study the food groups and memorize serving sizes (see PAGES 9, 17, 18 & 24).

STEP 4: Know how many calories are in each food group.

STEP 5: Plan the Meal Plan. Decide how many servings of each food group to have at each meal and snack. Make sure each meal has at least 3 food groups. See Meal Plan Examples, PAGE 29.

STEP 6: Count the total number of servings from each food group for the day.

STEP 8: Adjust the calories by adding or deleting foods to meet the calorie requirements for you child.

STEP 7: Multiply each total by the number of calories in each food group. Add up all the totals to get the total calories per day.

FOR WEIGHTMAINTENANCE

(To grow into normal weight or for maintenance of a normal adult weight

*For children over 2 years old)

29

The following meal plans are examples only for children over 2 years. You may modify how many servings of each food group you give for your child per mealor snack, as long as the daily totals are the same.

Once the meal plan is decided, stick to consistent servings of each food group every day. This helps individuals with PWS follow their

diet because they know exactly what to expect.

Number of Servings

Food Group BREAKFAST SNACK LUNCH SNACK DINNER SNACK Total/DayMeat 1 2 3Bread 1 1 1 3Fruit 0.5 0.5 0.5 1.5Milk 0.5 0.5 0.5 0.5 2Fat 1 1Green GO 1 1 1 1 4

800 Calories/Day (7-Day Meal Plan Examples for 800 Calories on PAGE 34)

Number of Servings

Food Group BREAKFAST SNACK LUNCH SNACK DINNER SNACK Total/DayMeat 1 2 3Bread 1 1 0.5 1 0.5 4Fruit 1 1 0.5 2.5Milk 0.5 0.5 0.5 0.5 2Fat 1 1Green GO 1 2 1 2 1 7

950 Calories/Day

Meal Plan Serving Examples

Number of Servings

Food Group BREAKFAST SNACK LUNCH SNACK DINNER SNACK Total/DayMeat 1 1 2Bread 0.5 0.5 0.5 0.5 2Fruit 0.5 0.5 0.5 1.5Milk 0.5 0.5 0.5 0.5 2Fat 1 1Green GO 1 1 1 1 4

650 Calories/Day

31

Number of Servings

Food Group BREAKFAST SNACK LUNCH SNACK DINNER SNACK Total/DayMeat 2 3 5Bread 2 2 2 1 7Fruit 1 1 1 1 4 Milk 1 1 0.5 0.5 3Fat 2 2Green GO 1 2 1 2 1 7

1500 Calories/Day

7-Day Meal Plan Example

800 1000 1200 1350 2 slices 2 slices 2 slices 2 slices low-fat raisin bread 1 tbsp 1 tbsp 1 tbsp 1 tbsp sugar-free jam 1/2 cup 1/2 cup 1 cup 1 cup light hot chocolate 1/2 of 1 1 1 1 pear, small • • • • water 1 cup 1 cup 1 cup 1 cup low-calorie, sugar-free beverage 1 oz 1 oz 2 oz 2 oz tuna with fat-free mayonnaise 1 1 1 1 tortilla wrap, 6” 1/4 cup 1/2 cup 1/2 cup 1/2 cup applesauce 1/2 cup 1/2 cup 1 cup 1 cup yogurt, low-fat • • • • saladwith2tbspfat-freedressing • • • • cookedgreenGOvegetables • • • • dietsodapop • • • • water 0 1 2 2 social tea cookies • • • • greenGOvegetables • • • • water 1/2 cup 1/2 cup 1/2 cup 1/2 cup sloppy joes: SEE RECIPE PAGE 40 • • • • ratatouille:SEE RECIPE PAGE 40 2 slices 2 slices 4 slices 4 slices diet bread • • • • saladwith2tbspfat-freedressing 1/4 cup 1/2 cup 1/2 cup 1/2 cup grapes 1/2 cup 1/2 cup 1/2 cup 1/2 cup skim milk • • • • water 0 3 3 6 mini rice cakes • • • • fat-freepuddingcup

MONDAYCalories/Day

Breakfast

Lunch

Snack

AM Drink

Dinner

Snack

= one recommended serving•

36

Day 1

Day 2

Day 3

Day 4

Day 5

Breakfast

1/4 cup cheerios4 oz 2% milk1/4 banana

1/2 slice whole wheat toast1/4 cup cottage cheese1/4 cup peach slices

1/2 waffle with 1 tbsp light syrup1/4 cup berries1/2 cup yogurt

1/2 French toast with 1 tbsp light syrup1/4 cup cantaloupe4 oz 2% milk

1/4 English muffin with sugar-free jam1/2 cup 2% yogurt1/4 cup berries

Snack

1 arrowroot cookiewater

3 soda crackerswater

3 animal crackerswater

3 vanilla waferswater

3 saltineswater

Lunch

1 oz cheese1 slice low-calorie breadcucumber slices1/4 cup applesauce

1/4 cup macaroni & cheese1/2 cup broccoli8 grapes

1 oz meatball1/4 cup brown ricecooked carrots1/2 slice watermelon

1/4 cup pasta salad with 1 tbsp fat-free mayonnaise1 oz chicken cubesteamed vegetables

1 hot dog1 slice low-calorie breadcarrot stickspineapple slice

Snack

4 oz 2% milk or yogurt





Dinner

1/4 cup chili1/2 small dinner rollcarrot sticks1 small plum4 oz 2% milk

1/4 cup ravioligrilled zucchini1/4 apple slices with cinnamon4 oz 2% milk

1/4 cup beef & vegetable stew - extra veggies & 1 soda cracker1/4 cup fruit cocktail4 oz 2% milk

1 oz grilled chicken1/2 cup ricestir-fried vegetables1/4 cup fat-free pudding

1 oz grilled fish1/4 cup sweet potato3 crackers1/2 cup green beans1/4 cup frozen yogurt with 1/4 cup blueberries

Snack






Meal Plan Example for Young Child - 800 Calories

SEE RECIPE PAGE 37

The following Meal Plan is intended for a young child. 2% milk is used instead of skim milk to reach adequate fat requirements for this group.

37

The key to success in using the RYG system is to take a close look at your family's lifestyle and create positive eating and activity patterns as soon after the diagnosis as possible. Everyone involved in your life should be educated about the need for the program. Healthy eating and keeping active will become a way of life for you and your family & increase the chances of success for maintaining a healthy body weight.

Check your cooking style.Use healthy cooking techniques- barbecue, roast, broil bake and

steam foods adding minimal extra fat or sugar. Limit frying

foods to once a week and use a stick-free pan and a teaspoon of low calories chicken broth or a spritz of low-calorie cooking spray to prevent burning. Breaded entrees can be oven baked rather than fried. Buy only healthy, nutritious and low fat foods. Avoid purchasing pre-breaded, pre-fried convenience foods such as chicken nuggets, French fries & battered fish. Stock your kitchen with fresh fruit & vegetables,low fat milk products, lean proteins such as skinless chicken breast, lean ground beef & lean pork.

Keep your snacks healthy. Fruits, vegetables and whole grain products make delicious nutritious snacks. Avoid high calorie snacks such as cookies, chips and baked goods.

Encourage a refreshing drink of water to accompany meals and snacks. Water can be flavoured with a squeeze of lemon or lime or try sparkling water as an alternative. Juice is a source of unnecessary calories -fresh fruit is a much better source of vitamins.

Get Active! Make positive changes in the whole family's activity levels. Take a walk, play games and sports and reduce the hours in front of the television.

Have a consistent meal routine. All meals & snacks should be regularly scheduled and menus could be posted ahead of time. For individuals with PWS this eliminates insecurity and anxiety around mealtimes.

Create an illusion that there is more food on the plate. You can use lots of greens and vegetables as well as using a smaller plate. Individual portions of vegetables and condiments can be placed in small bowls.

Purchase individual portions of low-fat dressing and condiments such as ketchup, soy

sauce and mustard to control portion size (these can be found at large cash and carry outlets).

All foods should be plated in the kitchen according to portion size. Avoid having large platters or bowls available on the table at meals.

Cut food into smaller pieces to encourage more complete chewing.

All food should be measured using a scale, measuring cups and spoons. Meat should be weighed after it is cooked. Do not measure meat in a cup, measure on scale for accuracy.

Keep bags of lettuce and cup up Green GO vegetables for handy snacking.

Offer whole grains and whole grain breads and pastas which provide more nutrients, fiber and more protection from heart disease and cancer.

Plan ahead for Red STOP Foods. These high-calorie foods are usually allowed once per week or less. Decide a specific

Here are some TIPS to make an easy transition:

Family Lifestyle Changes - The Key to Success

39

The following are some healthy recipes your whole family can enjoy. Some of these recipes have been donated by parents and caregivers of individuals with Prader-Willi Syndrome. You will notice thatalmost any recipe can be used for your child, as long as it is low in fat and sugar, and served inthe correct portions for your child's meal plan.

Black Bean Pasta Lori Hamilton1 tablespoon olive oil1 medium onion chopped2 tablespoon chopped garlic1 green pepper chopped1/2 teaspoon cumin powder1/2 teaspoon hot pepper flakes1 teaspoon oregano2 cups tomato sauce1 can black beans, drainedsmall shell pasta

Sauté onion, garlic, and green pepper in oil over medium heat until vegetables tender. Add spices and stir a couple times then add tomato sauce and simmer 10 minutes. Add black beans and simmer another 10 minutes. Add cooked pasta to sauce.1/2 cup = 1 Yellow CAUTION: BREAD serving

Chicken Caesar SaladGrill chicken after sprinkling with salt, pepper, lemon juice, and garlic powder. Place Chicken over Romaine Lettuce and serve with Low-Fat Caesar Salad Dressing. (2 tbsp per serving)2 oz chicken Caesar plus 1 cup salad = 2 Yellow CAUTION: MEAT and 1 Green GO serving

Chicken Fajitas Lori Hamilton & Marilena Candito1 tablespoon olive oil2 medium to large onions sliced2 green or red peppers sliced length-wise1 tsp minced garlic

Heat oil over medium heat and then add onions and sauté for five minutes. Add garlic and cook for 1 minute, then peppers and cook for another 5 minutes. Set aside.

Chicken Seasoning:1/4 teaspoon salt1/4 teaspoon pepper1/2 teaspoon garlic powder1/2 teaspoon paprika

Rub seasoning over chicken and grill. Slice grilled chicken into thin slices. Serve with warm onions and pepper mixture, tomato salsa, fat free sour cream (1 tbsp), shredded lettuce and small 6" tortilla wraps.1 tortilla with 1 oz with chicken plus vegetables, salsa = 1 Yellow CAUTION: BREAD and 1 Yellow CAUTION: MEAT serving.

Chili Marilena Candito1 onion chopped1 pepper chopped1/2 can diced tomatoes1 can red kidney beans1/2 pound ground meat (Chicken or Beef)1 teaspoon Worcestershire sauce1/2 teaspoon chili pepper flakes (optional)1 to 2 tablespoons chili powdersalt and pepper to taste

Put everything together in a large pot. Bring to a boil and simmer for 2 to 3 hours. Add water if needed.1/2 cup = 1 Yellow CAUTION: MEAT and 1 Yellow CAUTION: BREAD serving

Cinnamon Baked Pears4 medium pears1/2 cup blueberries or raspberries1/2 cup water2 tbsp brown sugar1 tbsp lemon juice

Recipes

My Daily Meal Plan

Breakfast Snack Lunch Snack Dinner Snack

Supplements:

My Name Is: Calorie Level:

Gre

en G

OYe

llow

CA

UTIO

NRe

d ST

OP

MEAT GROUP

MILK GROUP

FAT/OIL GROUP

Red STOP Foods:

I can have a Red FOOD choice _______ times per month.

BREAD GROUP

FRUIT GROUP

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