South Carolina Association of Residential Care Homes Tuesday, October 1, 2013 2:30-4:00 pm

1. South Carolina Association of Residential Care Homes • Tuesday, October 1, 2013 • 2:30-4:00 pm Double Down on Dietary Regulations &Requirements Presented by: Edna Cox Rice, RD, CSG, LD

2. Overview • New Dining Practice Standards • Diets • Regulations • Strategizing Break • Jeopardy • Prizes!

3. New Dining Practice Standards • Formed in 1997, the Pioneer Network was formed by a small group of professionals in long-term care (LTC) to advocate for person-directed care. • Focus on changing the individual's and society’s attitudes toward aging and elders.

4. New Dining Practice Standards • Twelve National Clinical Standard Setting Associations: • American Association for Long Term Care Nursing (AALTCN) • American Association of Nurse Assessment Coordination (AANAC) • Academy of Nutrition and Dietetics (AND) • American Medical Directors Association (AMDA) • American Occupational Therapy Association (AOTA) • American Society of Consultant Pharmacists (ASCP) • American Speech-Language-Hearing Association (ASHA) • Dietary Managers Association (DMA) • Gerontological Advanced Practice Nurses Association (GAPNA) • Hartford Institute for Geriatric Nursing (HIGN) • National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC) • National Gerontological Nursing Association (NGNA)

5. New Dining Practice Standards These nationally agreed upon new food and dining standards of practice support individualized care and self-directed living vs. traditional diagnosis-focused treatment for people living in health care facilities. The document includes the new Standards of Practice.

6. New Dining Practice Standards • The Dining Practice Standards: • Reflects current thinking and consensus, which are in advance of research • Reflects evidence-based research available to date • The current thinking portions of each of the new Dining Practice Standards represent a list of recommended future research • http://www.pioneernetwork.net/Providers/DiningPracticeStandards/

7. New Dining Practice Standards • Recommended Course of Practice: • Diet determined with the person not exclusively by diagnosis. • Include quality of life markers such as satisfaction with food, service received during meals, level of control and independence.

8. New Dining Practice Standards • Recommended Course of Practice: • Unless a medical condition warrants a restricted diet, consider beginning with a regular diet and monitoring. • Empower and honor the person first, whole interdisciplinary team second, to look at concerns and create effective solutions. • Support self-direction and individualize the plan of care.

9. New Dining Practice Standards • Recommended Course of Practice: • Ensure that the physician and consultant pharmacist are aware of resident food and dining preferences so that medication issues can be addressed and coordinated. • Monitor person and condition related to theirgoals regarding nutritional status, physical, mental and psychosocial well-being. • Although a person may have not been able to make decisions about certain aspects of their life, that does not mean they cannot make choices in dining.

10. New Dining Practice Standards • Recommended Course of Practice: • When one makes “risky” decisions, plan of care will be adjusted to honor informed choice, provide support to mitigate risks. • Most professional codes of ethics require professional to support the person in making their own decisions. • All decisions default to the person.

11. Nutrition Approaches:Diet Liberalization Dining Practice Standard 1

12. New Dining Practice Standards • Liberalized Diets Research: • Restrictive diets are a frequent cause of weight loss • Physicians are encouraged to liberalize diets • Medical needs are balanced with quality of life • Prevention of weight loss is viewed as a priority • Resident’s goals and wishes are followed

13. New Dining Practice Standards • Diet Liberalization ADA 2010: • It is the position of the ADA that the quality of life and nut. status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets.  • Although therapeutic diets are designed to improve health, they can negatively affect the variety and flavor of the food offered. Individuals may find restrictive diets unpalatable, resulting in reducing the pleasure of eating, decreased food intake, unintended weight loss, and under-nutrition – the very maladies health care practitioners are trying to prevent.

14. New Dining Practice Standards Diet Liberalization ADA 2010: In contrast, more liberal diets are associated with increased food and beverage intake. For many older adults residing in health care communities, the benefits of less-restrictive diets outweigh the risk.

15. Diabetic/ Calorie-Controlled Diet Dining Practice Standard 2

16. New Dining Practice Standards • Research on Diabetic Diets: • Intensive treatment of diabetes sometimes is not appropriate for all individuals in the long-term care (LTC) setting • No evidence to support no-concentrated sweets, no-added-sugar diets for older adults in LTC—using medication rather than dietary changes can enhance the joy of eating • AMDA: Target of A1c 7–8 discourages use of sliding scale insulin

17. New Dining Practice Standards • Diabetic/Calorie controlled Diet – AMDA: • AMDA: “…intensive treatment of diabetes may not be appropriate for all individuals in the LTC setting. To improve quality of life, diagnostic and therapeutic decisions should take into account the patient’s cognitive and functional status, severity of disease, expressed preferences, & life expectancy.” • An individualized regular diet that is well balanced and contains a variety of foods and a consistent amount of carbohydrates has been shown to be more effective than the typical treatment of diabetes.

18. Low-Sodium Diet Dining Practice Standard 3

19. New Dining Practice Standards • Research on Low-Sodium Diets: • May benefit some individuals, but in frail elderly more lenient blood pressure goals and more lenient diets are needed • A liberal approach sometimes is needed to maintain nutritional status • Typical 2-gram sodium diet achieved only modest effect on blood pressure and is not shown to improve cardiovascular outcomes in LTC residents

20. Cardiac Diet Dining Practice Standard 4

21. New Dining Practice Standards • Research on Cardiac Diets: • Diets are not shown to improve control or affect symptoms • Dietary Guidelines for Americans and/or DASH diet can achieve goals • Important to balance restrictions with adequate nutrition • Aggressive lipid reduction in LTC is more effectively achieved through use of medications

22. New Dining Practice Standards • Cardiac Diet Current Thinking: • Limiting salt intake in individuals with congestive heart failure is felt to be of benefit by limiting fluid retention, but the clinical experience of 2 medical directors of numerous health care facilities shows that this is necessary inonly a minority of nursing home patients, usually those who are salt sensitive and often have advanced disease. • Drs. Leible and Wayne, The Role of the Physician Order, Creating Home II

23. New Dining Practice Standards • Cardiac Diet Research Trends • The effects of the traditional low cholesterol and low fat diets typically used to treat elevated cholesterol vary greatly and, at most, will decrease lipids by only 10-15%. • If aggressive lipid reduction is appropriate for the nursing home resident it can be more effectively achieved through the use of medication that provides average reductions of between 30 and 40% while still allowing the individual to enjoy personal food choices (2 research studies). • Home II

24. Altered Consistency Diet Dining Practice Standard 5

25. New Dining Practice Standards • Research on Altered Consistencies: • Swallowing abnormalities do not necessarily require modified texture • Collaborate with doctor, speech pathologist, registered dietitian, and other professionals • Look beyond symptoms to underlying causes to avoid excessive modification of food/fluid • Sometimes it is necessary to evaluate tolerance of aspiration risk, compared to the slow process of wasting away

26. Real Food First Dining Practice Standard 7

27. New Dining Practice Standards • Research on Real Food First: • Provide naturally soft, smooth texture before pureed foods when possible (yogurt, puddings, ice cream, and vegetable soufflés) • Create meals comparable to home • Select from approved sources from family and friends, gardens • Serve food before supplements • Choose homemade before commercial • Use flavor enhancers

28. New Dining Practice Standards • Flavor Enhancement: • Taste and smell losses occur with aging, which can decrease food enjoyment, reduce food consumption, and negatively influence nutritional status. • Flavor enhancers can compensate for the diminished sensory function, which is a contributing factor to impaired appetite and decreased intake in the elderly. • What are flavor enhancers? They are food additives commonly added to foods, designed to enhance the existing flavors of products. • You can use commercially manufactured flavor enhancers, but the best flavor enhancers are those found in an ordinary spice rack or pantry. • You can make bland, tasteless meals a thing of the past with the improvements of culture change and dining practices.

29. New Dining Practice Standards • Examples of Flavor Enhancers: • Spices and herbs: Basil, garlic, dill, rosemary, lavender, mint, pickling spices, thyme, sage, etc • Seasonings or flavor enhancers: Ancho powder, chili powder, Accent® (monosodium glutamate [MSG]), Spike® (hydrolyzed vegetable protein), anchovies and anchovy paste, balsamic vinegar, Bon Appetit® Seasoning Salt, capers, Chef Paul Prudomme’s® Seasoning Blends®, Chile peppers, citrus fruits (juice and zests), grapes, molasses, Old Bay® Seasoning, onions, pepper, peppermint oils and extracts, sugar, date sugar, Tabasco®, tahini, truffle oil, cooking wine, etc • Resource: http://whatscookingamerica.net/herbs.htm

30. New Dining Practice Standards • Staff Creativity Combines with Resident Choices: • The standard cooking techniques, recipes, and bland foods are no longer the Gold Standard • Staff must bring creativity to food preparation, trying new recipes, new cooking techniques and food combinations, and flavor enhancements • Staff and residents must form an alliance in menu choices and selections

31. Honoring Choices Dining Practice Standard 8

32. New Dining Practice Standards • Research on Honoring Choices: • RESIDENT satisfaction with RESIDENT’S PERSONAL choice • Dignity & autonomy CAN increase desire to eat • Bulk food service and homelike environment optimize energy intake • It is all about choice, RESIDENT CHOICE • ATTITUDE ADJUSTMENT—keep an open mind

33. New Dining Practice Standards • Current Thinking About Honoring Resident Choices: • Facility must provide evidence of education offered to resident and family about the risks of diet choices/behaviors • Physician involvement is needed in these discussions • Resident choice is before regulations and guidelines • Avoid one size–allow hot dogs and whole grapes if resident is able to eat them

34. New Dining Practice Standards “One cannot think well, sleep well, if one has not dined well.” --Virginia Wolf

35. Modified Diets What is a Modified Diet? A modified diet is any diet that consists of foods that are mechanically altered for the purpose of ease of chewing and swallowing. Diet will incorporate, based on the individual needs of the person receiving it, foods that may be blended, chopped, ground, or mashed.

36. Modified Diets • Who Needs a Modified Diet? • Individuals with: • Poor dentition, ill fitting dentures, edentulous, dysphagia • Medical conditions such as Alzheimer’s Disease, Cerebral Palsy, Parkinson’s Disease, history of CVA, Cancer, Trauma, MS, other muscle disorders • Conditions necessitating altered consistencies may be either temporary or permanent; all cases should be individually diagnosed, evaluated, and treated by a multidisciplinary medical team including physicians, nurses, registered dietitians, speech therapists, occupational therapists, and physical therapists.

37. Modified Diets • Dysphagia • Difficulty with chewing or swallowing of food or liquid • As many of 50% of an aging health care facility population may have some degree of dysphagia • Two main types • Esophageal • Oropharyngeal • May occur based upon a variety of diagnoses • Places resident at risk for variety of nutritional and medical complications

38. Modified Diets • How Can you Tell if Someone needs a Consistency Change? • Signs/Symptoms • Choking, gasping, gurgling when eating/drinking • Frequent fevers or infections, particularly respiratory infections • Decreased appetite, weight loss, decreased involvement in meal process • To whom do I refer someone? • Physician, Speech Therapist, Registered Dietitian • Who decides? • Ultimately, the diet order is written by physician, with input from health care team.

39. Modified Diets • Consistencies of Diets • Modified Regular Foods • Mechanical Soft Chopped • Mechanical Soft Ground • Puree

40. Modified Diets • Advantages of Modified Diets: • Provide same nutritional value to residents as a resident without need for an altered consistency • Ability to enjoy favorite foods despite changes in medical condition • Potential to continue to enjoy aspects of meals that lead to optimal intake: • Socialization • Variety • Odors, flavors, sounds, sights

41. Modified Diets • Disadvantages of Modified Diets: • Visually unattractive • No resemblance to original food item • Unpalatable • May not be well prepared • Residents miss their favorite foods • All of these items combine to potentially make the entire dining experience less enjoyable than it should be.

42. Modified Diets • Disadvantages of Modified Diets: • These factors may combine to create an environment of less interest in foods and dining, decreased socialization at meal times, and ultimately decreased intake and its concurrent side effects: • Weight loss • Malnutrition • Loss of lean body mass • Overall decline in energy, level of activity

43. Modified Diets Does this look delicious to you?

44. Modified Diets • Trends in Food Production & Service • Emphasis on fine dining experiences • More visually pleasing • Higher quality • More diverse variety of foods • More chefs in health care settings • Dietary managers, food service directors, Dietitians with culinary backgrounds preferred • Client satisfaction coupled with choice • Flexibility in meal schedule • more frequent meals, room service

45. Modified Diets • Our Customers: • Aging and Living Longer • Well Educated • High Standards • Know what they want!

46. Modified Diets • Goals: • Improve resident meal service • Create a wonderful experience for our residents • Provide a comfortable dining environment with proper meal assistance • Improve food quality and presentation • Food should look good, taste good and be offered courteously

47. Modified Diets • What We Aim to Provide • Nourishing, palatable, attractive meals • Meet the daily nutritional and special dietary needs of each individual • Maintain or improve eating skills • Be supportive of needs • Enhance quality of life for each resident

48. Modified Diets • A Resident Centered Dining Program Provides: • Nourishing, palatable, attractive meals • Meet the daily nutritional and special dietary needs of each individual • Maintain or improve eating skills • Be supportive of needs • Enhance quality of life for each resident • 2003 Becky Dorner & Associates

49. Modified Diets • Evaluation of Dining Service: • If residents complain about taste, temperature, quality, quantity, or appearance of the food, be sure to satisfy their needs • Determine the reason for refusal of the food • Offer a substitute of equal nutritional value • Food placement, color and texture must be appropriate for needs • Mechanically altered foods should be prepared and served appropriately • 2003 Becky Dorner & Associates

50. Modified Diets Better?