managing residents special diets and changing preferences...gluten restricted vs. gluten free gluten...

Managing Residents Special Diets and Changing Preferences

April 6, 2016

TWC Culinary and Nutrition Summit Carol Donovan RD, President

Appetizer!

Objectives of this Presentation

1 - Define the “New Senior” and their Changing Preferences

2 - Identify Retirement Home Special Diets

3- Manage the Changing Preferences and Special Diets of the Retirement Home Residents

Seasons Care Dietitian Network

Caring Committed

Creative

Dietitians in Ontario

• 4 year undergrad – Bachelor of Science

• 1 year internship through DC accredited program or Masters in Nutrition concurrent with Internship

• Entrance Exam through College of Dietitians of Ontario

• Membership in CDO and Liability Insurance

• Dietitians of Canada / Gerontology Network

• The “New Senior” relies on RD as part of their personal health care team

RH Dietary Manager

• Orchestrates the entire operation

• Sets the quality expectations of the department

• Is the liaison / advocate for food service on the management team

• Accountant, Chef, Manager, Shopper, Peace Keeper, Payroll Clerk, Sanitation Expert, Master Scheduler, etc.

• Remember – it’s your kitchen, your staff, your food, your budget and your job!

• Make it the way you want it to be

The Retirement Homes Act, 2010 ONTARIO REGULATION 166/11

FOOD PREPARATION

• Section 20 came into force on January 1, 2013. See: O. Reg. 166/11, s. 66 (2).

PROVISION OF A MEAL

• Section 40 came into force on January 1, 2013. See: O. Reg. 166/11, s. 66 (2).

Retirement Homes Regulatory Authority (“RHRA”)

Objective # 1 of this Presentation

Define the “New Senior”

and their Changing Preferences

QUESTION!

What is your favourite food?

PAST

• Seniors were taken care of by extended family at home • Home cooked meals • “Meat and Potatoes” • Personalized family care • Families took care of their loved ones in the home • Decentralized families • Women working outside of home Seniors homes built were based on the medical model of a hospital

PRESENT

• Seniors admitted to RH have higher expectation than in past – “get what we

paid for” • “Savvy Seniors” – sophisticated • Know what a Dietitian is and does • Can call a “Carb” a “Carb” – more health conscious • Wants individual Care • Restaurant Style Food • Want Choice – Ethnic, Cultural, Religious, Health Options • Meal Service and proper etiquette is important Facilities modeled after hotels • Are expecting hospitality oriented services • Admitted to RH with more complex health problems • Staying longer in RH before progressing to LTC • Increased admission of younger residents with complex medical needs

FUTURE

• New trends yet to emerge

• Reinvent “Aging”

• Demands on Food Service are going to change

• “Oyster Shuckers and Martini Shakers”

• Internet / Technology – taken away limits on creativity and flavour

• Rural vs. Urban

“All Inclusive Five Star” or Cruise Ship experience

Current Popular Food Service Trends

• Farm-To-Fork

• Local

• Organic

• Gluten Free

• Low Sodium

• Low Carb

• Cleanses

• Internet Influences

Objective # 2 of this Presentation

Identify

Retirement Home Special Diets

#1 Goal = Positive Outcomes

Our Goal is to achieve Positive Outcomes related to the nutritional and hydration well being of each and every individual resident.

Barriers to Nutritional Care

• Poor oral intake

• Wounds

• Chronic Disease

• Weight Status

• Mental Status

• Medication

• Dysphagia

• Dentition

• Hydration

Food & Fluid

Intake

Wound Status

Chronic Disease

Weight/

Mobility

Mental Status

Medications

Dysphagia

Dentition

Malnutrition

• of all residents in homes are malnourished 23-85%

• of all new residents are malnourished 54%

• of new residents have an initial weight loss after they move in 60%

Importance

“Meals are the single most consistently accessible, manageable and effective health-promoting activity that we can offer to residents”

Zgola & Bordillon, 2001

RHA Expectations Related to Special Diets

40 (f) an individualized menu is developed for the resident if the resident’s needs cannot be met through the home’s menu cycle;

Gluten Restricted vs. Gluten Free

Gluten Restricted

• Non-Celiac gluten sensitivity • Found in grains (wheat, barley, rye, and a cross between wheat & rye called triticale. • Avoid bread, pasta, cookies, crackers, cereals, baked goods, • Substitute “Gluten Free”

Gluten Free

• Celiac Disease • Hidden sources: sausage, processed foods, soups / bases, some medications & vitamins • Cross Contamination • Difficult to offer in LTC & RH setting

QUESTION!

How many different types of Vegetarian Diets do you

believe there are?

Vegetarian

• Lacto Ovo – will eat eggs, milk and dairy – no meat, poultry or fish

• Ovo - will eat eggs – no meat, poultry, fish or dairy

• Lacto – will eat dairy, no meat, poultry, fish or eggs

• Pescetarians – will eat fish, no meat or poultry, may or may not eat eggs and daily

• Vegan – will eat only plant based food and products – no animal foods, eggs or dairy products • Popular at present • Varying degrees of veganism • Some focus on “raw foods” – crosses over into organic – need to

find out what regimen the individual follows and make sure you are able to provide it with the labour and budget you have

Textures

• Increase demand for the need to texture modify foods in the RH Sector

• Do you understand the need ? Dysphagia, Dentition etc.

• Do you have the equipment? Can you afford to purchase commercial texture modified foods?

• How do you offer choice to modified textures?

Textures

• REGULAR – no alterations

• MINCED MEAT – no alterations except meat is minced to the consistency of ground beef, no lumps

• MINCED – meat, vegetables and fruit are minced to the consistency of ground beef, no lumps

• PUREED – all food items are pureed to the consistency of whipped potatoes/mousse. Product should stand up on a plate

• CUT UP?

• FINGER FOODS?

Thickened Fluids

Nectar • Thin milkshake or eggnog. Semi-thick & pourable • Leaves a fine “ribbon” or trail” when poured or stirred.

Honey

• Like honey at room temperature or a thick milkshake. • Pourable & spoon able, leaving a medium “ribbon” or “trail” when poured or stirred.

Pudding

• Like pudding, cannot run off a spoon - drops in one mass. • Spoon able but not pourable, leaving a heavy “trail” or “valley”

which does not disappear upon sitting.

Objective # 3 of this Presentation

Manage the Changing Preferences and Special Diets of the Retirement

Home Residents

QUESTION!

What is the biggest

challenge you face in Managing Special Diets and

Changing Preferences in Retirement Homes?

Moral Dilemma

• The ADA’s position paper states,

“Nutrition care for the resident is both driven and hindered by the regulatory environment. On one hand, regulations speak of physician-prescribed therapeutic diets, and, on the other, they speak of resident rights. Both regulations and ethics demand that facilities meet the nutritional needs of residents while maintaining their dignity and quality of life.”

ORCA Orientation Checklist

Meals:

• Do you want cooking facilities available for your use?

• Do you want one, two, or all three meals each day?

• What kind of food do you like to eat?

• Do you have certain dietary restrictions?

• Do you want a rotating menu or full service options?

• Do you like to eat at the same time each day or would you prefer to have meals when you feel like it?

• Do you want to be able to drink alcohol with your meal?

Admission Process

Warm Welcome

• History / Preferences / Expectations

• Introduction to Food Service at your home

• Height / Weight

Activities of Daily Living related to Eating

• Level of Assistance

• Positioning

• Social – sit alone, sit with friends,

• Adaptive Equipment

Each resident needs a diet order that includes:

• Diet Type

• Texture

• Fluid Consistency

• Allergies / Intolerances / Dislikes

• Interventions

Menu Planning

• Support good nutrition and hydration for all

• The menu is varied and changes daily

• The menu cycle changes at least every 21 days

• The menu includes alternative entrée choices at each meal

• The resident is informed of his or her daily and weekly menu options

• Menus provide adequate nutrients, fibre and energy for the resident, include fresh seasonal foods and are consistent with standards of good nutrition in Canada

Daily Meals and Snacks

• Meals and Snacks must be provided to the Resident according the provisions outlined in the RH ACT.

Breakfast

AM Snack

Lunch

PM Snack

Dinner

HS Snack

Snacks

AM Snack PM Snack HS Snack

OR

OR

OR

Choice

Interventions

High Energy, High Protein (HEHP)

High Fibre (HF)

Low Fat

No Added Salt (NAS)

Small Portions

Double Portions

Regular

Diabetic (No Added Sugar)

Lactose Restricted

Gluten Restricted

Vegetarian

Renal (Individualized)

Diets

Diets and Interventions

Oral Supplements

• Goal always is to use “Food First”

• Communicate this clearly to residents

• Supplements are promoted on TV and are popular at present

• Families may request them as they feel guilty if resident is not eating

Have to look at this realistically:

• Will the resident accept them or would they prefer an cream cone with sprinkles

• Will the supplement help the problem the resident has e.g.. wounds and complex disease processes

• Is the supplement being used for weight loss vs. weight maintenance

• Has the implementation of supplement improved outcomes

Mealtime

Every Meal is Special

• Should be a quality experience involving the entire team

• We are all responsible for a good dining experience • Educate all care providers involved ! • Continue to re-evaluate and communicate changes

timely • Continue to learn and develop professionally • Take your time • Remember the customer is always right!

The Customer is Always Right!

Meal Refusals

It is important to realize that a refusal is not the end of the meal.

If a resident refuses to eat: • Offer 2nd menu choice • Offer them something that contains a protein source

These simple efforts will help our residents more than you can

imagine.

FOOD FIRST: Aim for food first before using a supplement. Enriched foods can be used as well.

It is much more enjoyable for the resident to eat a bowl of ICE CREAM (with sprinkles) than a supplement!

Fortified Foods

Success Equals A Happy Resident

• Honest and open discussion upon Admission

• Clear about expectations

• Yes is yes – no is no

• Long term client

• Good word of mouth

Positive Outcomes

Eat & Enjoy

• Quality of Life

• Taste & Texture

• Social/physical environment

• Choice/variety

Nutrition Needs

• Protein:

• 46-56g/day

• Energy:

• 1500-2000kcal/day

• Fibre:

• 21-30g/day

Disease Management

• Prevent decline

• Minimize symptoms

• Avoid complications

• Manage disease

Positive Outcomes = Balancing Act

• Happy Healthy Residents

• Satisfied Customers

• Budget Friendly Menu

• Adequate Staffing to offer Personalized Care

• RHA Regulations

Individuals make Personal Choice

Objectives of this Presentation

1 - Define the “New Senior”

• Sophisticated

• Health conscious

• Hospitality oriented

2 - Identify Retirement Home Special Diets

• Liberalized

• Complicated

3- Manage the Changing Preferences and Special Diets

• Admission strategies/Relationship

• Menu Planning

• Personalization

Thank You!