Offering an Excellent Dining Experience While Managing Nutritional Care Linda Crandall RD, LD CEO Jon Williams RD, LD COO Randolph Valdez West Regional Director of Dining Services
Statistics Regarding Aging • • •
•
•
Current Senior Population: 13.8% 1 in 8 people is a senior Average life expectancy is 79 years By 2030 people the age of 65 and older will comprise as much as 20% of the population At least 80% of the people in this age group live with at least one chronic illness
Aging Population 100.0
92.0
Numbers of Person / Millions
90.0 79.7
80.0 70.0 60.0
56.0
50.0 41.4
40.0
35.0
30.0
25.5
20.0 10.0
16.6 3.1
4.9
1900
1920
9.0
0.0 1940
1960
1980
Year
2000
2011
2020
2040
2060
Nutritional Risks in Older Populations ►
Weight Loss
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Malnutrition
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Pressure Ulcers
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Broken Bones
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Decreased Immune System
Why Are Seniors at Higher Nutritional Risk ►
The Immune System & Aging
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The GI Tract & Aging – Can lead to malnutrition
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Decreased Mobility
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Compromised Eye Sight
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Reduced Taste & Desire to Eat
The New Dining Practice Standards The nationally agreed upon standards are: â–ş Self-directed care â–ş Individualized care These standards are recommended for people living in senior care communities, however are not required Source: https://www.pioneernetwork.net/Providers/DiningPracticeStandards/
Standards of Practice ►
Individualized Nutrition Approaches / Diet Liberalization
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Individualized Diabetic / Calorie- Controlled Diet
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Individualized Low-Sodium Diet
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Individualized Cardiac Diet
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Individualized Altered Consistency Diet
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Individualized Tube Feeding
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Individualized Real Food First
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Individualized Honoring Choices
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Shifting traditional professional control to Individualized support of self-directed living
Agencies that Support the New Dining Practice Standards ► ► ► ► ►
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Academy of Nutrition & Dietetics American Medical Directors Association American Nurses Association National American Occupational Therapy Association American Speech‐Language‐Hearing Association of Nutrition & Foodservice Professionals Association (ASHA) Association of Activity Professionals National Association of Social Work
Trends in Senior Dining ► ► ► ► ► ►
Person centered care Liberalization of therapeutic diet restrictions Move from hospital model to hospitality model Decentralized dining options / choices Gluten-Free VS GlutenRestricted Lactose-Free VS LactoseRestricted
Trends in the Industry Restaurant service should be the goal • Service oriented staff • Wide variety of food to select from • Focus on food preparation – Residents are seeking a culinary experience
Residents & family are seeking nutritious menus that are healthier – lower in sodium 10 points of service How does Sunrise provide hospitality to residents
Restaurant Service
Restaurant Service
Restaurant Service
Providing Purees & Mechanically Altered Diets Regular
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Benefits of using premolded foods – Molds 2.0
Challenges of molding your own foods ► Presentation of the plate ►
– Family often comment on the presentation and are surprised the food is pureed
Pureed
Restaurant Service
Restaurant Service
Restaurant Service
10 Points of Service
Hospitality
Hospitality
State Regulations & Restaurant Service ►
Presetting Tables – Time • Some states have regulations about pre-setting tables, i.e. Colorado • Tables cannot be pre-set if the room is actively being used between meals
– Setting • Colorado regulations also require that the glasses must be inverted and silverware protected by being wrapped, if the dining room is being used between meal services
Resident Choice
What are your company standards related to resident choice? Questions?
The New Dining Practice Standards ► ► ► ►
Regular diet is the goal Residents have the right to refuse prescribed diets Resident’s choice is paramount Examples:
1. Resident with diabetes requested black forest chocolate cake with Frosting 2. Resident on NAS diet adding additional salt at table What should the wait staff do?
Defining Therapeutic Diets A diet intervention ordered by a health care practitioner as part of a treatment: â–ş For
a disease or clinical condition â–ş To eliminate, decrease, or increase certain nutrients in the diet (e.g., sodium, potassium) Source: Academy of Dietetics
Benefits of a Liberalized Diet ►
Residents tend to consume more of their meals
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Aids in prevention of malnutrition
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Maintains stable body weight
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Preserves residents’ dignity while dining by allowing the resident to choose what food & beverages they want
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Is more “home-like”
Typical Diets in Assisted Living Communities ►
Regular – No restrictions
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No Added Salt (NAS) – No salt added at table – Food is cooked with salt – No foods restricted
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Consistent Carbohydrate (CCHO) – Consistent amount of carbs throughout the day
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Mechanical Soft – Foods that are difficult to chew, i.e. meats, are sliced thin or ground
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Puree – All foods smooth and of “pudding-like” consistency
Resident Choice: Low Carbohydrate
Strict VS Liberalized VS Regular Diets Strict / Not Liberalized Diet
Liberalized Diet
Regular Diet
1800 Kcal Diabetic Diet
Consistent Carbohydrate Diet (CCHO)
Regular diet with diet desserts and *sugar substitute * Advise resident regarding sugar use
2 Gram Na Diet
No Added Salt (NAS)
Regular diet with resident limiting *salt use at the table * Advise resident regarding salt use
Cardiac Diet (Low-Fat / Low-Cholesterol, 2 Gram Na)
Low-Fat / Low Cholesterol, NAS
Regular diet with skim milk, limit eggs 3 x week, no fried foods, limit gravies, cream sauces, & cream soups; For dessert fruit, gelatin, low-fat cake or cookies i.e. angel food cake,
Strict VS Liberalized VS Regular Diets Strict / Not Liberalized Diet
Liberalized Diet
Regular Diet
Strict Renal Diet (80 Gram Protein, 2 GM Na, 2 GM K+)
Liberal House Renal (80 GM Pro, 3 GM Na, 3 GM K+) Allows use of potato & tomato products sparingly
Regular Diet with dairy limited to ½ cup per day (no other dairy products) Avoid: Bananas, cantaloupe, honeydew, oranges & orange juice
Mechanical Soft Puree (Omit level 2 Dysphagia Mechanically Altered)
Individualized consistency per resident’s preference & tolerance
Dysphagia Levels Level 1 - Puree Level 2 - Dysphagia Mechanically Altered Level 3 - Dysphagia Advanced
Thickened Liquid Levels: Thin Nectar-Like Honey-Like Pudding-Like
i.e. Ground meats with regular consistency vegetable & starch sides
Food are offered to the resident that are naturally of appropriate consistency
Beverages are offered to the resident that are naturally of appropriate consistency
Frazier's Free Water Protocol allows thin water 30 minutes after a meal & between meals with excellent oral care Source: Mayo Clinic
Do the diets you offer follow the new liberalized approach? Questions?
States that Require Nutritional Monitoring & Documentation in Assisted Living ►
Alabama – Dietitian must be available to any resident receiving a therapeutic diet
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Massachusetts – Requires a dietitian to review dietary plans at least every 6 months
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Mississippi – Assisted Living: Must have dietitian assess food preparation areas – Dementia Care: An initial nutritional assessment must be completed on all residents
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Montana – If the resident has additional nutritional needs that are identified, i.e. weight loss; the dietitian must assess the resident and document nutritional approaches and education provided in the resident’s medical record
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Nevada – Dietitian must visit the community a minimum of every 90 days
States that Require Nutritional Monitoring & Documentation in Assisted Living (Continued) ► New Jersey – If the resident has additional nutritional needs that are identified, i.e. weight loss; the dietitian must assess the resident and document nutritional approaches and education provided in the resident’s medical record ►
Ohio – Documentation of Special & Complex Diets
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Utah – Documentation by the dietitian on therapeutic diets at least quarterly
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Virginia – Documentation of Special diets
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Wyoming – Dietitian must visit monthly if the community serves therapeutic diets
States that Require Dietitian Approval of Menus Alabama Arkansas California Delaware District of Columbia Florida Hawaii Idaho Illinois Indiana Iowa Kansas
West Virginia Texas Wyoming Utah Louisiana Virginia Maine Maryland Massachusetts Mississippi Missouri Nevada North Carolina South Carolina South Dakota
Food Allergies â–ş
Top 8 Food Allergies: 1. 2. 3. 4. 5. 6. 7. 8.
Egg Fish Milk Peanuts Shellfish Soy Tree Nuts Wheat Source: The Food Allergy & Anaphylaxis Network
Gluten-Free / Gluten-Restricted Level of Difficulty
Gluten-Free
Gluten-Restricted
Difficult to manage
Resident managed
All foods must be below 20 *ppm of gluten Criteria
Individualized to resident *Parts Per Million Source: U.S. Food & Drug Administration
Steps to Follow Have in Place if Accepting Residents
Avoid cross-contamination i.e. Toasting Bread • • •
Gluten-free spreadsheets Inservice staff Coordination of interdisciplinary team
Gluten-restricted preferences should be assessed & documented on diet board • •
Inservice staff on resident’s preferences Coordination of interdisciplinary team
Lactose-Free / Lactose-Restricted Lactose-Free
Lactose-Restricted
Level of Difficulty
Difficult to manage
Resident Managed
Criteria
Avoid all foods containing lactose, (casein, caseinate, whey), i.e. margarine, butter, instant cereal & potatoes
Steps to Follow
Close coordination of physician, nurse & dietitian to direct staff
Have in Place if Accepting Residents
• • •
Lactose-free Spreadsheets Inservice staff Coordination of interdisciplinary team
Lactose-restricted preferences should be assessed & documented on diet board
Lactose-restricted preferences should be assessed & documented on diet board
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Inservice staff on resident’s preferences Coordination of interdisciplinary team
Gluten-Restricted & Lactose-Restricted Corporations / Communities Should: – Determine if the residents needs can be met – Medical diagnosis VS. Preference – Work with residents and family to identify food and beverages that the resident can tolerate – The culinary director or designee should work with the dietitian to meet the resident’s nutritional needs – Goal is for resident to enjoy food and have the best quality of life possible
How do you manage gluten-restricted & lactose restricted diets? Questions?
Thickened Liquids
Most corporations purchase pre-thickened beverages
Benefits of Purchasing Pre-Thickened Liquids
Achieves more accurate consistency Served to the resident faster than traditionally thickened beverages Some products are fortified and provide vitamin C & electrolytes Enhanced flavor to increase resident acceptance Maintains appropriate temperature longer
Thoughts to Remember ► Use glasses that are at least 1 ounce more than the beverage serving size – Example 4 ounce beverage = 5 ounce glass
Survey & Menu Compliance Common Survey Issues ►
Diet boards & books not up to date (California, New York, Ohio & Virginia)
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Diet manual not available or does not correlate with menu program (California)
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Recipes not followed (California & New York)
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Spreadsheets not followed (California & New York)
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Staff unaware of resident’s prescribed diet (California, New York, Ohio & Virginia)
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Disaster Food Supply (California, Florida & New Jersey)
Strict Therapeutic Diets
Quality of Life
Medical Needs
Liberalized Diets Tipping the Scale
Quality of Life
Medical Needs