Ask a Dietitian September 2005 Q A potential resident does not eat meat or fish but does eat eggs and cheese. While in hospital his dietary needs were met, but the food was apparently prepared out of town and shipped in. How will his needs be met in a long-term home? Do all homes offer a vegetarian diet? A The special dietary needs of this resident will be met by the care team in the home, led by the expertise of the registered dietitian. Not all long-term care homes currently provide vegetarian diets, as this is not required in all areas. However, vegetarian diets are becoming more common, especially in larger urban and multicultural areas. Since the goal of all homes is to provide for each resident's individual needs, every effort will be made to provide the vegetarian diet. A meeting may take place with the resident and family to see what items on the current menu would be acceptable to and enjoyed by the resident. There may also be discussion around what additional menu items the resident will require to ensure that nutritional needs are met and that there is sufficient variety provided. The home may decide to prepare some suitable menu items on-site and freeze some single serving size entrees. Other items may need to be purchased from a supplier who carries vegetarian meals to ensure the provision of adequate choice and nutrient content within available staff resources. When a home admits any resident on a specialized diet not currently provided, such as vegetarian, allergy or gluten-free, it is important that this information be shared with the care team in advance. The food service manager and registered dietitian will need time to: locate a supplier for any special food items; prepare a special menu for the resident, ensuring that it meets his/her nutritional requirements; and provide staff education on the unique requirements of the diet. The home should also be aware of the additional food costs incurred by specialized diets. Q How can I tell if my mom (a LTC home resident) is dehydrated? How much fluid should an 89-year-old person have in a day? What kind of fluids are best? A Your mother's exact fluid requirements will be determined by a registered dietitian on admission, based on such things as her weight, medical status (e.g. an individual with congestive heart failure has decreased fluid requirements) and medications. She will be monitored by the care team and her fluid needs will be reviewed at least every 3 months while she is in the LTC home. Some residents may be at increased risk of dehydration and the multi-disciplinary care team will follow these residents more closely to keep them well hydrated. Signs of dehydration you may look for in your mother are: • Increased thirst • Dry or cracked lips • Dry mouth • Constipation • Mental confusion • Warm dry skin • Nausea and vomiting • Loss of appetite • Weight loss • Fatigue, headaches • Weakness, dizziness, fainting, falls • Frequent urinary tract infection • Painful urination • Concentrated urine Various factors may increase your mother's chances of being at risk of dehydration such as: difficulty swallowing; the need for pureed foods or thickened fluids; physical inability to drink unassisted; refusal to eat or drink; fever, vomiting and /or diarrhea; use of diuretics, laxatives or alcohol; inten-tional fluid restriction (e.g. to avoid incontinence); and/or a hot, dry environment. Although individual needs for fluids vary, we generally suggest that most residents require a minimum of 1500 mL or 48 ounces (twelve 4-ounce glasses) of fluid on a daily basis. The best fluids for your mother are water and those that provide nutrients as well, such as milk and real fruit juices. However, coffee and tea offer comfort and are fine as long as they are in addition to the more nutritional fluids and, if taken with milk, all the better. In LTC homes, beverages are generally provided through three meals, a morning beverage pass and two snack passes (afternoon and evening). Each meal usually provides water, milk, coffee or tea. Juices and drinks are also offered at breakfast and between meal beverage and snack passes. Offering your mother fluids when you visit and reminding her to drink is a positive way of encouraging her fluid intake and keeping her well hydrated. Often, seniors' thirst mechanisms do not work well and they may not realize they are thirsty. The entire care team appreciates any support you can offer in encouraging fluid intake and preventing dehydration.* *Sometimes residents are on a restricted fluid intake, temporarily or long term. It is always best to communicate with the care team, including the dietitian, to see whether your mother has any special fluid needs that need to be addressed. Q It appears that more and more of LTC homes are purchasing prepared food from outside suppliers. What is the role of the dietitian in a home where the food is ‘outsourced?' A The Registered Dietitian (RD) ensures that the LTC home's menu meets Canada's Food Guide to Healthy Eating and is nutritionally balanced, providing a variety of foods to meet the residents' needs. In a home where food products are outsourced, this means the RD must be fully aware of the nutrient specifications of all outsourced products and approve their use on the menu. Purchasing an outsourced food product ensures that the nutrient content is always consistent. Such assurance is very important when the RD is reviewing and approving the residents' menus. The RD also values this consistency when completing his/her nutritional assessment of a resident's actual food intake. When a home is preparing a recipe from “scratch” there is a chance that inconsistencies may occur. For example, a cook may inadvertently use skim milk in a pudding recipe instead of homogenized milk. In this scenario, the nutrient content in the resident's dessert portion, such as the calories and fat, will vary from the original recipe. Major food suppliers have stringent testing and quality assurance programs that are not possible to implement in a home setting. The taste and flavour of “TV dinners” have come a long way. Now, more than ever, most North American families are purchasing a wide spectrum of outsourced foods on a regular basis. More LTC homes are purchasing the same types of foods as well, from approved, federally inspected manufacturers. Many of us grew up with these manufacturers and their names provide a feeling of familiarity, quality and comfort. Common household names such as Campbell's, Nestle, Sara Lee, Maple Leaf and Schneider's are some of the manufacturers that provide food items being routinely featured on many LTC home menus. With a society now very focused on food safety and sanitation, many homes are moving away from the “old- fashioned method” of food preparation to ensure the utmost safety for their residents. There has been a real shift toward more variety in nutritious food options—specifically tasty low sodium, low fat, high fibre entrees—in the marketplace. Consumers are becoming more health conscious and are demanding healthier options. In long- term care, RDs are demanding such products for their residents and outsourcing can overcome the barrier of limited staff resources available within homes to prepare such products on-site. Q How are homes/dietitians responding to the dietary preferences of the increasing numbers of residents from diverse cultural backgrounds? A Over the last decade, in particular, we have seen the population mix in LTC homes enriched by diversity. Varied cultural, ethnic and religious influences have changed what residents and families expect from caregivers. Understanding cultural differences allows us, as caregivers, to provide better resident care planning. Some of the aspects that identify a specific “culture” include language, customs, beliefs, religion, special holidays, dress and music, and in particular, FOOD! The Ontario Residents' Bill of Rights states that each resident is entitled to be fed in a manner consistent with his or her needs and to pursue his or her cultural and religious interests. The concept of ensuring that residents receive personally acceptable food is supported by standard from the Ontario Ministry of Health and LTC. As Registered Dietitians (RD), we must respect each resident's food preferences, whether the resident is part of an ethnic, cultural or religious group or is an individual with particular food likes and dislikes. Creating a menu to meet the needs and desires of residents in a LTC home is especially challenging in this time of cultural diversity. The menu is a cycle menu that repeats every 3 to 6 weeks, depending on the individual home. Prior to planning the menu, resident's food preferences and the cultural diversity of the home are considered. As a home identifies an increasing number of residents requiring certain ethnic or cultural foods, these foods will start to be incorporated into the menu as choices, special meal days, etc. The menu is developed with input from residents, families and staff and is checked by the RD for nutrition, variety and use of seasonal foods. After the menu is reviewed by the RD, it is sent to the Residents' Council and/or a Residents' Food Committee for approval and to ensure that residents' are involved and feel that the menu reflects their food preferences. Although the menu goes through these approval processes, those of you who have fed your own families will understand that no menu will ever completely meet the needs or desires of each and every resident in the home. It is the responsibility of the RD and Food Service Manager (FSM) to address the individual needs of any resident with different food requirements due to ethnic, cultural, religious or personal preference. Usually these needs are made clear at the time of admission, by the resident and/or family, so that they can be addressed as soon as possible. Managing special requests is much easier with detailed information and feedback from the resident. Depending on the situation, the RD may create a personal menu cycle for the resident. This menu will be based on the standard menu cycle, with changes for certain menu items only. Residents who are vegetarian, for example, will be able to eat certain items that are already on the menu, with some substitutions made for meat items. As another example, a Chinese resident may request rice with the regular meals, or congee for breakfast instead of cereal, and this can easily be fit into a regular menu cycle. With the increasing cultural diversity in homes, many more products are now available through our suppliers to assist in providing for residents needs. Advice from families can be very valuable in selecting appropriate foods for the resident, finding sources for specialty products in some cases and even in the preparation of food items. Many homesalso welcome the family's assistance if they are able to provide some specialty food items from home for their family member. Please ask your RD or FSM about your LTC Home's policy regarding this and whether this would help in ensuring that your loved one's needs are being met. There are some homes, especially in urban areas, where a group of residents are from the same ethnic background and live together on one wing or unit. In this case, the residents and their families may work with the Dietitian and the Food Service Manager to plan a menu that works for the entire group. They will strive to make this menu coincide with the regular cycle menu, as much as possible, so that it will be manageable for the kitchen staff as well as satisfying for the residents; in some cases, it may be possible to make adjustments to the regular home menu to better suit the needs of all. Each resident's needs and desires are unique and must be assessed individually. Although the RD and FSM will always strive to meet these individual needs, this must be done within the resources and capacity of the LTC home; as a result, there will be occasions when some requests cannot be met. While providing foods that satisfy residents with diverse cultural, religious and ethnic backgrounds is certainly a priority, it must be remembered that such food items may be costly and/or require additional staff time for preparation. RDs and FSMs have to find a balance between meeting the needs of the majority of their residents, providing for each individual's unique needs and still keeping within the home's food cost and staffing limitations. In all cases, excellent communication and feedback are key to ensuring that residents' special needs are met, with the RD, FSM, residents and families working together toward the provision of nutritious and satisfying meals. Answers provided by the Long Term Care Action Group, Dietitians of Canada |