JULY-AUGUST • 2007

Solutions for Healthcare Foodservice Professionals™

WatermelonsWild for

PLUSFoodservice Equipment Purchasing

Summer Grilling Sausage Style

Community-Based Programs For Aging Boomers

Table of Contents

FeaturesFoodservice Equipment Purchasingby Deborah Bruce WittThe pressure is on to purchase equipment that best meets the needs of your foodservice operation. What factors should you consider?

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July-August • 2007 | Volume 16, Issue No. 07

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D I E T A R Y M A N A G E R S A S S O C I A T I O N

Learn How to Knead Your Dough To Be Business Savvyby Maureen Leugers, MBA, RD, CDA dietary manager must effectively manage food and labor costs to decrease expenses and increase revenue. This article offers strategies for enhancing foodservice profits.

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Online Article: “Healthy Bones” by Sue Grossbauer, RD

Go to www.dmaonline.org to access our online CE article

Who’s at risk for osteoporosis? Are nuts and bone health connected? How much vitamin D is too much? How are exercise and diet related? This “Food for Thought” article—available only on the DMA website—answers these pressing questions.

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The Leader Within by Marianne Smith Edge, MS, RD, LD, FADAWhat makes a leader? Companies and business strategists have been studying the skills and traits of successful leaders for years. Current the-ories are presented in this thought-provoking feature.

Summer Grilling, Sausage Styleby Carlyn BerghoffIt’s summertime, and the weather and outdoor grills are hot. Sausages are a perennial hit. This article looks at three favorites, and how to pre-pare them.

39 Community Connections: Moving Seniors Toward Wellness by Linda Netterville, MA, RD, LDAs Baby Boomers age, the need becomes great to provide quality home and community-based programs that promote the health and indepen-dence of our older population.

Also in This IssueImproving Resident Care for Constipation p 34

p 16

It’s that time again—

time to purchase new equipment

for your facility’s kitchen. Think

of your purchases as investments

rather than expenses, and “invest”

your budget wisely.

Management Clips

Cornucopia

Food Protection Connection

DMA Leadership Report

Classifieds

Meet a Member

p 31

DIETARY MANAGER34

DM Feature

improving resident care for

sby | Lisa Stewart, CDM, CFPP

Chronic constipation affects

dignity and quality of life

for residents. Constipation

management can be

expensive…thus a focus on

effective solutions is well

worthwhile.

Constipation is a prevalent problem in nursing homes, with many implications. At Fountain Inn nursing Home (Fountain Inn, SC), our care team

has implemented a new team approach, with an emphasis on strong interdisciplinary communications and a high-fiber liquid supplement.

Constipation: The ProblemAmong various gastrointestinal problems that affect Amer-icans, constipation is considered by far the most prevalent, affecting people of all ages, but especially older Ameri-cans. experts estimate that about 17 percent of the general population experience constipation, while 75 percent of nursing home residents are prescribed at least one medica-tion for constipation.

A decline in bowel muscle tone, slowing of transit time in gastrointestinal tract associated with aging, decreased fluid intake due to limited mobility, and the numerous medications that affect bowel function—especially pain medications—are just a few of the factors involved. The sidebar provided with this article lists medications that commonly cause constipation, and medical conditions that can cause constipation.

From a dietary care perspective, the role of fluid is impor-tant to recognize, too. If special medical needs do not re-quire fluid restriction, a resident should be receiving about 30 ml of fluid per kg body weight. However, this rarely happens automatically. One effect of aging is a reduced thirst sensation. Many residents have to be prompted to drink enough fluids. In addition, medical diagnoses such as

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renal or heart failure may require fluid restriction. Any resi-dent who is chronically dehydrated or on a fluid restricted diet is especially susceptible to constipation.

There are many definitions of constipation. Practice guide-lines for the Management of Constipation on Older Adults issued by the rehabilitation nursing Foundation suggest this definition: “Passage of small amounts of hard, dry stool fewer than three times per week, or a significant change in one’s usual routine, accompanied by straining and feelings of being bloated, or having abdominal fullness. Persistence of these symptoms for three months or longer is defined as chronic constipation.”

Constipation: The EffectsChronic constipation affects dignity and quality of life for our residents. Constipation is not just an ailment or an in-convenience. It’s not uncommon for a resident to require two or three ongoing medications to treat the condition. Concerns are:

• Aresidentexperiencingconstipation ischronicallyun-comfortable, reducing quality of life.

• Residents receiving suppositories for constipation aregiving up some of their dignity.

• Drugtreatmentsaddtoasometimeslengthylistofpre-scribed medications for a resident, which may be flagged by a surveyor and sometimes by an insurance provider as well. In our facility, we are flagged for anything over nine medications. For details on state regulations, please see the American Healthcare Association directory un-der “Further reading.”

• Drugtreatmentforconstipationcanbecomeafactorinmalnutrition. The sidebar with this article lists medica-tions and side effects. A resident may be hesitant to eat, knowing that the effect of drugs may require a bathroom break in the midst of a meal.

• Ongoingdrugtreatmentforconstipationcancausenervedamage in the colon and foster even greater dependence on the medication.

• Side effects of common medications for constipationsuch as nausea, abdominal cramps, and sometimes diar-rhea, can inhibit nutritional intake and cause added dis-comfort for our residents.

• Constipation can also lead to anxiety and social isola-tion.

From a management perspective, constipation in nursing homes is also expensive. One study shows that the time and economic cost to a facility is well over $2,200 per year per resident (calculated in 2002). researchers have also linked constipation to both verbal and physical aggression in nursing home residents. Thus, it is clear that there are many dimensions to the condition, and a focus on effective solutions is well worthwhile.

A High-Fiber TrialWe routinely provide high-fiber diets to residents to pro-mote bowel management, with a menu emphasis on whole grain bread products, brown rice, fruits, and vegetables. yet, aiming for 25-30 grams of dietary fiber per day, we know that many of our residents can only consume 10-15

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DIETARY MANAGER36

DM Feature (Continued)

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FURTHER READING

AmericanHealthcareAssociation.StateNursingHomeRegulationsLinks.http://www .ahca .org/hipaa/state_mr_retention_links .htm

Frank, L . et al . Time and economic cost of constipation care in nursing homes.JournaloftheAmericanMedicalDirectorsAssn.July/Aug.2002.

Leonard,R.PotentiallyModifiableResidentCharacteristicsThatAreAssoci-atedWithPhysicalorVerbalAggressionAmongNursingHomeResidentsWithDementia.ArchivesofInternalMedicine,June26,2006.

National Digestive Diseases Information Clearinghouse . Constipation . http://digestive .niddk .nih .gov/ddiseases/pubs/constipation/

Position of the American Dietetic Association: Nutrition, Aging, and the Continuum of Care (2000), online at www .eatright .org

Position of the American Dietetic Association: Health Implications of Di-etary Fiber (2002), online at www .eatright .org

Rehabilitation Nursing Foundation. Practice Guidelines for the Manage-mentofConstipationinOlderAdults.www.rehabnurse.org

Medications That Can Cause Constipation•Painmedications(especiallynarcotics)

•Antacidsthatcontainaluminumandcalcium

•Bloodpressuremedications(calciumchannelblockers)

•Antiparkinsondrugs

•Antispasmodics

•Antidepressants

•Ironsupplements

•Diuretics

•Anticonvulsants

Medical Conditions Associated with Constipation•Neurologicaldisorders:e.g.,multiplesclerosis,Parkinson’s

disease, stroke, spinal cord injuries

•Metabolicandendocrineconditions,e.g.,diabetes,uremia,hypercalcemia, poor glycemic control, hypothyroidism

•Systemicdisorders,e.g.,amyloidosis,lupus,scleroderma

Medications Commonly Used for Constipation•Lubricantlaxativesorenemas,e.g.Fleet:Theselubricate

the stool to generate a bowel movement.

•Salinelaxatives,e.g.,MilkofMagnesia:Thesedrawwaterinto the colon to soften the stool. These can cause electro-lyte imbalance when used for extended periods of time.

•Stimulantlaxatives,e.g.Dulcolax,Senokot:Theseincreasemuscle contractions on the colon. Side effects include: diarrhea, upset stomach, vomiting, irritation, and stomach cramping. Over the long term, stimulant laxatives can cause nerve damage in the colon and aggravate chronic constipa-tion. They can also cause low blood levels of potassium and protein, and may increase the risk of cancer.

•Stoolsofteners,e.g.Colace.Thesedrawextrafluidintothe stool to eliminate straining. They can lead to electrolyte imbalance.

Source: National Institutes of Health

grams. even on a high-fiber diet, it is difficult to obtain a consistent intake. Making matters worse, a resident who is already experiencing chronic constipation may also have a poor ap-petite due to bloating sensations.

In January 2007, we began a trial of adding a liquid high-fiber supplement to the routine, with the goals of break-ing the constipation cycle, reduc-ing the need for bowel management medications, and improving quality of life. During the first few months of the year, the director of nursing and the nursing staff selected several of those residents whose constipation was most affecting their quality of life in order to determine whether nutritional supplementation with fi-ber could be effective. Through team communication among nursing, the dietary manager, and the consulting dietitian, we phased in and evaluat-ed this approach, and found it to be highly successful.

After some research and group taste tests, we selected a liquid product that provides 11 grams of fiber per 30 cc. The physician prescribed this to be given twice per day. Our nurs-ing staff began this regimen on one resident first and, with successful outcomes, began with additional resi-dents, including residents with diabe-tes and residents on dialysis.

The process we have used is that nursing staff alert the certified di-etary manager and the consulting dietitian of a resident they feel is in need of supplemental dietary fiber. Typically, this is a resident on three medications for treatment of consti-pation who is experiencing ongoing discomfort. Candidates may have lim-ited mobility due to a bone fracture or neurological condition, or they may be in hospice care. A key factor that often contributes to the constipation is pain medications such as oxycon-tin, which aggravates constipation.

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Medtition Bowel Ad.pdf 6/11/07 1:23:16 PM

DIETARY MANAGER38

Lisa Stewart, CDM, CFPP is dietary manager at Fountain Inn Nursing Home in Fountain Inn, SC.

Helga Longino, RN; Edna Cox, RD, LD; and Diane McCuen, LPN—all members of Fountain Inn Nursing Home’s healthcare team—also contributed to this article.

of meals every year

In a typical regimen, we are adding 30 cc of fiber supple-ment twice daily, and then increasing to 30 cc three times daily, with the physician’s direction. nursing, the dietary manager, and the dietitian review progress routinely on an interdisciplinary basis. Along with nutritional status, fac-tors to monitor include:

• Bowelmovementpatterns

• Fluidintake

• Appetite

• Eatingpatterns

• Anysideeffects

• Residentcomfort

• Frequencyofaneedforanymedications order prn (as needed)

Perspectives on SupplementationWhile at first, a dietary fiber supplement is another item on the medication list, typically, within a few weeks, the team is able to recommend discontinuing some of the oth-er medications. For example, we have had residents go off daily medications for constipation entirely, transitioning to a “prn” regimen that is rarely called upon for most of our residents. On average, we have been able to reduce a resi-dent’s medication list by two through addition of a high-fiber dietary supplement.

According to the American Dietetic Association’s posi-tion paper on fiber, “Maintenance of body weight in the inactive older adults is accomplished in part by decreasing food intake. even with a fiber-rich diet, a supplement may be needed to bring fiber intakes into a range adequate to prevent constipation.”

Dietary fiber as an alternative to medications for consti-pation has additional advantages. Fiber can help control blood sugar, blood lipid levels, and prevent colon cancer. An ideal fiber supplement should be low in dietary miner-als and non-fiber carbohydrates, so that it can be used in a variety of medical conditions. The protocol in our facility is also to taste-test any nutritional product before selecting it for use with our residents.

A Team ApproachIt is essential for members of the healthcare team to col-laborate to identify, assess, and provide care for nursing home residents experiencing chronic constipation. This is an area where the expertise of each professional plays a critical role in improving quality of life.

DM Feature (Continued)