MONTHLY NEWSLETTER – MAY 2021
NOURISHING CONVERSATIONS - THE CHANGE ACCELERATOR/ P1 LIBERALIZING THERAPEUTIC DIETS FOR DIABETES AND RENAL DISEASE/ P3 CELEBRATING SENIORS’ WEEK/ P10 FATHER’S DAY THEME MENUS & RECIPES / P11
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SYNERGY TECH SUITE
MAY 2021 2
LIBERALIZING THERAPEUTIC DIETS FOR DIABETES AND RENAL DISEASE
LIBERALIZING THERAPEUTIC DIETS FOR DIABETES AND RENAL DISEASE IN HEALTHCARE COMMUNITIES Katrina Anciado, RD (Seasons Care) shares insights into the practice of liberalizing diets on senior living menus, and special considerations for residents with diabetic and renal concerns. The information provided within this article are suggestions and should be implemented in consultation with a Registered Dietitian, and in accordance with your home specific policies.
When we say the word “diet”, what comes to mind? You are probably thinking about a set of food rules or changing the way you eat. What about “therapeutic diets”? Therapeutic diets are nutrition plans designed to address a dietary concern or chronic condition. Therapeutic diets provide focus in terms of what foods are recommended and what foods are avoided. Although a therapeutic diet can be an effective map towards management of disease, it can be difficult to maintain for some. Restricting food items can reduce variety and options during meals, and favourite foods may need to be eliminated. Currently, many older adults residing in healthcare communities are living with comorbidities and chronic diseases. Many experience anorexia of aging, decreased sense of smell, and taste and muscle loss. 3 NOURISHING NEWS
These pose a risk for unwanted weight loss. Food is an essential component of quality of life. The success of nutritional management is not based solely on how well the chronic condition is controlled, but by how much the Resident enjoys and finds pleasure in eating. Each individual is different and there isn’t a one-size fits all to managing chronic diseases. Two Resident may both have Type 2 diabetes, but each may have different health status and other comorbidities. Although they both have type 2 diabetes, the severity of their disease and life expectancy are different and the approaches should be too. There has been movement towards liberalization of diets. A liberalized approach includes efforts to relax and simplify therapeutic diets like
the diabetic, diabetic renal, and diabetic renal dialysis diets. A more liberal approach is associated with increased food and fluid intake. The liberalizing of diets can positively affect quality of life, meal satisfaction and oral intake. It can reduce malnutrition, unintended weight loss and supplement use. Additionally, liberalization of diets can streamline production in the kitchen, as there are less therapeutic diets to plan and prepare. The goal is to put most Residents on the regular diet and use individual interventions where needed. Discontinuing therapeutic diets for diabetes and renal disease in your healthcare community would require collaboration from the healthcare team. The following steps may be considered.
LIBERALIZING THERAPEUTIC DIETS FOR DIABETES AND RENAL DISEASE
Step 1: The RD will complete a comprehensive nutrition assessment and identify a Resident’s presenting diagnosis and its current management. The Resident’s intake as well as their most recent blood glucose readings and bloodwork, particularly potassium, phosphorus and sodium will be assessed. Then, identify any food items of concern. Step 2: The RD will collaborate with the Resident/POA/SDM and look at the regular menu. Consult with them about foods that the Resident prefers to continue eating, which ones to reduce or avoid altogether. The RD will then provide recommendations for dietary interventions. Think of it as building on and layering of interventions. One set of interventions may be sufficient, and if not, it can be increased. The key here is close monitoring of the blood work by the RD, evaluating and making adjustments as needed. For diabetes, the main concern is too much intake of carbohydrates. If hyperglycemia is a concern, interventions to manage intake of carbohydrates may include one or more of the following:
Interventions to manage carbohydrate intake
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Fruit instead or half portions of regular dessert Fruit canned in juice or water with no sugar added Sugar-free condiments (syrups, jams, jellies, sweetener) Sugar-free or diet beverages only Half portions of carbohydrates at lunch and/or dinner Fruit instead or half portions of cookies or loaf cakes at snacks
If hypoglycemia is a concern, especially overnight, a snack with carbohydrates and protein can be provided in between meals or before bed. Some examples include: • • •
Peanut butter, deli meat or cheese sandwich Cheese and crackers Plain or vanilla yogurt MAY 2021 4
LIBERALIZING THERAPEUTIC DIETS FOR DIABETES AND RENAL DISEASE
For individuals with diabetes and renal disease, in addition to intake of carbohydrates, intake of foods high in potassium, phosphorus and sodium may need to be monitored. Protein sources may need to be reduced. Historically, a diabetic renal diet will be provided. However, depending on the current labs, the approach to restriction may be liberalized. In addition to implementing one or a few interventions to manage intake of carbohydrates, the one or a few of following interventions can be implemented. Limit high potassium sources
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Limit high phosphorus sources
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• Limit high sodium sources
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Limit protein intake
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Do not provide bananas, melons, oranges, orange juice, tomato juice and prune juice. Substitute instead with apple and apple juice. Limit intake of potatoes, and substitute with rice and pasta or provide double boiled potatoes only. Do not provide tomato soup or meals with tomato sauce. Provide broth or alternative meal instead. Do not provide cola beverages, organ meats, deli meats and processed cheese. Provide milk or yogurt at just one meal per day. Do not provide bran cereal or whole grain bread products. Substitute with non-bran cereal and white bread or refined grain products. Limit intake of egg at breakfast to 2 or 3 days a week (eg. Only on T/Th or M/W/F). Do not provide deli meats and tomato juice. Discourage addition of salt at the table or use herb and spice blends instead. Note: Do not use salt substitutes as they may contain high levels of potassium. Most healthcare communities are using soup bases and gravies with lower salt content. Significant efforts to decrease sodium intake can lead to decreased enjoyment at meals. Provide half portions of protein at one, two or all three meals if needed. Note: Lowering phosphorus sources may directly lower protein sources. Carbohydrate or fat sources may have to be adjusted to compensate for calories.
The process of dialysis will remove buildup of waste in the blood. However, it is important to prevent excessive build up in between dialysis treatments. For Residents who have diabetes and require dialysis, typically, they will be provided with the diabetic renal dialysis diet. The following are some considerations for a liberalized approach.
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LIBERALIZING THERAPEUTIC DIETS FOR DIABETES AND RENAL DISEASE
Protein intake
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• Fluid intake
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• Potassium, phosphorus, sodium
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Protein is lost during dialysis treatments. Therefore, intake of protein sources should be increased, but not too much that phosphorus levels become too high. Therefore, provide regular portions of protein at meals. Too much fluid intake in between dialysis treatments can cause edema. The RD at the home can work with the Renal RD to determine the Resident’s dry weight and how much fluids can be consumed daily. Fluid Restriction may be put in place. A detailed fluid plan which entails how much fluids are to be provided at each meal and snacks would be helpful. Close monitoring is still required with recommendations similar to those noted for Residents who have renal disease.
Step 3. Collaborate with other health professionals within the Resident’s circle of care. Ensure that dietary interventions and any subsequent changes are communicated to Dietary and Nursing teams through Care Plans and point-of-service tools. Keep the Physician informed of the Resident’s acceptance of the liberalized approach. The Resident may have consults with Renal Specialists or Renal RDs. Keep them posted as well. Step 4: The RD will monitor the Resident monthly. An in-depth reassessment includes reviewing food and fluid intake, weight and bloodwork. Follow up with the Resident and the interdisciplinary team and request for feedback to identify what is and isn’t effective. Adjust the dietary interventions if needed. Eventually, monitor the Resident quarterly. There isn’t a one-size-fits all approach to addressing Residents’ nutrition concerns. Liberalizing therapeutic diets for diabetes and renal disease must be in combination with clinical judgement and awareness of each Resident’s unique dietary needs. Ultimately, the goal is to improve intake and overall quality of life.
Katrina Anciado RD is a Corporate Dietitian with Seasons Care Dietitian Network and lead for the Chartwell Long Term Care Homes. Seasons Care Dietitian Network serves the long-term care, retirement, and independent living sectors. Learn more at www.seasonscare.com
References: Beelen, J., Vasse, E., Ziylan, C., Ziylan, C., Janssen, N., de Ross, N., de Groot, L. (2017) Undernutrition: Who cares? Perspectives of dietitians and older adults on undernutrition. Biomed Central Nutrition 3, Article Number 24. Retrieved from: https://doi.org/10.1186/s40795-017-0144-4 Donner, B., Friedrich, E. (2018) Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care and Other Settings. Journal of the Academy of Nutrition and Dietetics; 118(4): 724-735. Flynn, C. and Dhatariya, K. (2020) Nutrition in older adults living with diabetes. Practical Diabetes; 37(4): 138-142. Retrieved from: https://doi.org/10.1002/pdi.2287 Kramer, H., Jimenez, E. Y., Brommage, D., Montgomery, E., Steiber, A., Schofield, M. (2018) Medical Nutrition Therapy for Patients with NonDialysis-Dependent Chronic Kidney Disease: Barriers and Solutions. Journal of the Academy of Nutrition and Dietetics; 118(10): 1958-1965. Retrieved from: https://doi.org/10.1016/j.jand.2018.05.023 Munshi, M., Florez, H., Huang, E., Kalyani, R., Mupanomunda, M., Pandya, N., Swift, C., Taveria, T., Hass, L. (2016) Management of Diabetes in LongTerm Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care; 39(2): 308-318. Welte, A., Harper, T., Schumacher, J., Barnes, J. (2019) Registered dietitian nutritionists and perceptions of liberalizing the hemodialysis diet. Nutrition Research and Practice 2019; 13(4): 310-315. Wu, S., Morrison-Koechl, J., Lengyel, C., Carrier, N., Awwad, S., Keller, H. (2020) Are Therapeutic Diets in Long-Term Care Affecting Resident Food Intake and Meeting their Nutritional Goals? Canadian Journal of Dietetic Practice and Research; 81(4): 186-192.
MAY 2021 6
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AE SPOTLIGHT
Fred Hawkshaw Account Executive BC Region I’ve worked at Sysco for 10 years, have been an Account Executive with Healthcare and Seniors Living for that past 7 years and I’ve been in the Food Services industry for over 27 years. I enjoy the connections with people both at work and within the seniors care homes I support. I’ve been married to Christina for over 15 years and we have two wonderful boys, Carter who is 14 and James who is 12 and our Wirehaired Griffon who is 4. We have lots of fun family time with a few activities such as dog hikes, ping pong, golf, tennis, gardening and individual chef nights. I’m an avid outdoorsman that loves all kinds of fishing, especially fly fishing, camping, hiking, archery and scuba diving to name a few. My go to happy activities are hosting dinners with friends, family movie nights and, when holiday travel opens up again, traveling to Mexico and other far away destinations! 2:40 pm
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THEME MENU RECIPE
Feta Cheese, Cucumber & Avocado Sandwich Courtesy of Saputo Serving: 1 Each Yield: 50
Ingredients:
Preparation Steps:
1.3 Kg
1.
Saputo Feta Cheese Crumbles (SUPC 0204149) 850 mL 35% Whipping Cream (SUPC 2386019) To taste Black Pepper 104 Slice Whole Wheat Bread, Toasted 13 Each Avocadoes, Peeled, Pitted, Sliced 4 Each English Cucumber, Sliced 14 Each Green Apple, Sliced 3L Alfalfa or Microgreens
2.
3. 13 NOURISHING NEWS
Sprinkle Feta Cheese Crumbles into the bowl of a food processor. Add in Whipping Cream and some freshly ground Black Pepper. Process until smooth. Add more Whipping Cream to reach a spreadable consistency, if needed. Lay slices of toasted bread flat on working surface. Spread a generous amount of whipped feta over each slice. Layer avocado, cucumber, apple and alfalfa over half of each slice. Close the sandwiches and slice in half. Serve immediately. CCP-Maintain <40F/4C
THEME MENU RECIPE
Apple Strudel
Courtesy of Campbell’s Ingredients: 7L 210 mL 210 mL 15 mL 875 mL
Baking Apples (Honeycrisp) Granulated Sugar All Purpose Flour Cinnamon, Ground Walnuts, Chopped
Serving: 1 Each Yield: 50
210 mL Light Brown Sugar, Packed 7 Sheets Pepperidge Farm Puff Pastry Sheets, Thawed, (7138342) 3 Each Egg, Whole Water 60 mL
Preparation Steps: 1. Preheat oven to 375 F (190 C). Line baking sheet with parchment paper. Set aside. 2. Toss apples with sugar, flour and cinnamon in a large bowl. Let stand for 20 minutes. In another bowl, stir together the walnuts and brown sugar. Set aside. 3. Place pastry on prepared baking sheet. Sprinkle walnut mixture along long edge, leaving a 2.5 cm border. Spread apple mixture over top of walnut mixture. 4. Starting with border closest to you, lift pastry up and over apple mixture, rolling to cover completely. 5. Place seam side down on pan; pinch ends to seal and tuck under strudel. Repeat with the remaining sheets. 6. Whisk egg with water; brush over the top of the strudels. With a small sharp knife, cut 3 or 4 slits in the top to allow steam to release 7. Bake for 40 - 45 minutes or until pastry is golden brown. Cook to minimum 75 degrees C internal. Slice each strudel into 8 pieces. MAY 2021 14
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