Offering an Excellent

Dining Experience While

Managing Nutritional Care

Linda Crandall RD, LD

CEO

Jon Williams RD, LD

Randolph Valdez

COO

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

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1900 1920 1940 1960 1980 2000 2011 2020 2040 2060

Nu

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Aging Population

Nutritional Risks in Older

Populations

► Weight Loss

► Malnutrition

► Pressure Ulcers

► Broken Bones

► Decreased Immune System

Why Are Seniors at Higher Nutritional Risk

► The Immune System & Aging

► The GI Tract & Aging

– Can lead to malnutrition

► Decreased Mobility

► Compromised Eye Sight

► Reduced Taste & Desire to Eat

The New Dining Practice

Standards

The nationally agreed upon standards are:

► Self-directed care

► 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

► Individualized Diabetic / Calorie- Controlled Diet

► Individualized Low-Sodium Diet

► Individualized Cardiac Diet

► Individualized Altered Consistency Diet

► Individualized Tube Feeding

► Individualized Real Food First

► Individualized Honoring Choices

► Shifting traditional professional control to Individualized

support of self-directed living

Agencies that Support the New

Dining Practice Standards

► 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 Gluten-Restricted

► Lactose-Free VS Lactose-Restricted

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

Trends in the Industry

Restaurant Service

Restaurant Service

Restaurant Service

► Benefits of using pre-

molded 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

Providing Purees & Mechanically Altered

DietsRegular

Pureed

Restaurant Service

Restaurant Service

Restaurant Service

10 Points of Service

Hospitality

Hospitality

► 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

State Regulations & Restaurant Service

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:

► For a disease or clinical condition

► 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

► Aids in prevention of malnutrition

► Maintains stable body weight

► Preserves residents’ dignity while dining by

allowing the resident to choose what food &

beverages they want

► Is more “home-like”

Typical Diets in Assisted Living

Communities► Regular

– No restrictions

► No Added Salt (NAS)

– No salt added at table

– Food is cooked with salt

– No foods restricted

► Consistent Carbohydrate (CCHO)

– Consistent amount of carbs throughout the day

► Mechanical Soft

– Foods that are difficult to chew, i.e. meats, are sliced thin

or ground

► 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 DietConsistent 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

Dysphagia LevelsLevel 1 - PureeLevel 2 - Dysphagia

Mechanically Altered

Level 3 - Dysphagia Advanced

Mechanical Soft Puree

(Omit level 2 Dysphagia MechanicallyAltered)

Food are offered to the resident that are naturally of appropriate

consistency

Individualized consistency per resident’s preference & tolerance

i.e. Ground meats with regular consistency vegetable & starch sides

Thickened Liquid Levels:Thin

Nectar-LikeHoney-Like

Pudding-Like

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

► Massachusetts

– Requires a dietitian to review dietary plans at least every 6 months

► Mississippi

– Assisted Living: Must have dietitian assess food preparation areas

– Dementia Care: An initial nutritional assessment must be completed on all

residents

► 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

► Nevada

– Dietitian must visit the community a minimum of every 90 days

(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

► Utah

– Documentation by the dietitian on therapeutic diets at least quarterly

► Virginia

– Documentation of Special diets

► Wyoming

– Dietitian must visit monthly if the community serves therapeutic diets

States that Require Nutritional Monitoring

& Documentation in Assisted Living

States that Require Dietitian

Approval of Menus

AlabamaArkansasCaliforniaDelawareDistrict of ColumbiaFloridaHawaiiIdahoIllinoisIndianaIowaKansas

West VirginiaWyomingLouisianaMaineMarylandMassachusettsMississippiMissouriNevadaNorth CarolinaSouth CarolinaSouth Dakota

TexasUtahVirginia

Food Allergies

► Top 8 Food Allergies:

1. Egg

2. Fish

3. Milk

4. Peanuts

5. Shellfish

6. Soy

7. Tree Nuts

8. Wheat

Source: The Food Allergy & Anaphylaxis Network

Gluten-Free Gluten-Restricted

Level of Difficulty

Difficult to manage Resident managed

Criteria

All foods must be below 20 *ppm of gluten

*Parts Per MillionSource: U.S. Food & Drug Administration

Individualized to resident

Steps to Follow

Avoid cross-contamination i.e. Toasting Bread

Gluten-restricted preferences should be assessed & documented on diet board

Have in Place if

Accepting Residents

• Gluten-free spreadsheets• Inservice staff• Coordination of interdisciplinary

team

• Inservice staff on resident’s preferences

• Coordination of interdisciplinary team

Gluten-Free / Gluten-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

Lactose-restricted preferences should be assessed & documented on diet board

Steps to Follow

Close coordination of physician, nurse & dietitian to direct staff

Lactose-restricted preferences should be assessed & documented on diet board

Have in Place if

Accepting Residents

• Lactose-free Spreadsheets• Inservice staff• Coordination of interdisciplinary

team

• Inservice staff on resident’s preferences

• Coordination of interdisciplinary team

Lactose-Free / 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

Gluten-Restricted & Lactose-Restricted

How do you manage gluten-restricted & lactose restricted

diets?

Questions?

Thickened Liquids

Most corporations purchase pre-thickened beverages

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

Benefits of Purchasing Pre-Thickened

Liquids

Common Survey Issues

► Diet boards & books not up to date (California, New York, Ohio & Virginia)

► Diet manual not available or does not correlate with menu program (California)

► Recipes not followed (California & New York)

► Spreadsheets not followed (California & New York)

► Staff unaware of resident’s prescribed diet (California, New York, Ohio & Virginia)

► Disaster Food Supply (California, Florida & New Jersey)

Survey & Menu Compliance

Strict Therapeutic Diets

Medical Needs

Quality of Life

Liberalized Diets

Quality of Life Medical Needs

Tipping the Scale