Malnutrition, weight loss, and resident satisfaction are critical issues in long-term care facilities. Addressing these concerns requires a multifaceted approach to medical nutrition therapy, considering personal goals, prognoses, treatment benefits and risks, and quality of life. A key strategy gaining traction is the implementation of liberalized diets, which prioritize individual preferences and overall well-being.
Understanding Liberalized Diets
A liberalized diet relaxes restrictions of therapeutic diets, allowing individuals to eat a "regular diet" that includes foods they enjoy. This approach contrasts with traditional therapeutic diets, often prescribed in post-acute care settings like long-term care, rehabilitation, and home care, which aim to manage chronic conditions through dietary restrictions. Healthcare providers may prescribe therapeutic diet interventions for conditions such as diabetes, chronic kidney disease, and cardiovascular disease.
Therapeutic diet examples:
- Diabetic Diet
- No Concentrated Sweets
- Low Sodium or No Added Salt
- Low Fat
- High Fiber
- Calorie Controlled
- Renal Diet
While seemingly appropriate for managing chronic health conditions, these restrictive diets can have unintended negative consequences.
Why Liberalize? The Drawbacks of Restrictive Diets
Living in a care setting can negatively impact food intake due to social isolation, lack of independence, and taste and cognitive changes. Further restriction of allowed foods can be harmful and lead to lowered intake. Imagine being used to eating the same foods your entire life, and then suddenly being in a new environment, away from family and friends, and without the independence to choose what you eat. Adding dietary restrictions to this situation can significantly decrease appetite and nutritional intake.
Read also: Principles of Diet Planning
A tough lesson learned through the prescribing of therapeutic diets is that they missed their mark. While attempting to better control disease conditions they made matters worse. In addition, many therapeutic diets have failed to provide measurable health benefits within the senior population residing in skilled nursing centers. Because of this, leaders in senior care now know that it is preferable to make modifications to medications rather than take away the joy of eating.
Benefits of a Liberalized Diet Approach
The benefits of a liberalized diet approach may include:
- Improved Nutrient Intake: Older adults in care settings may struggle to consume enough nutrients. Relaxing some of the dietary restrictions can make it easier for them to eat a wider range of foods and nutrients, reducing the risk of deficiencies and malnutrition.
- Improved Quality of Life: Allowing autonomy around food choices can enhance quality of life for individuals in care settings. The freedom to eat the foods they enjoy may help individuals feel more satisfied and fulfilled. This can help to reduce feelings of deprivation or frustration that may arise from strict dietary restrictions.
- Increased Socialization: For many people, mealtime is a social event. Having the option of a wider variety of foods can facilitate socialization and increase the enjoyment of mealtime. This can be particularly important for older adults living alone.
- Improved Health: A liberalized diet approach may appeal more to older adults than a strict, regimented diet. By allowing choices about what they eat, within the context of an overall nutritious menu, they may be more likely to eat within their dietary recommendations.
- Enhanced Dining Experience: Just a few bites of old favorites or family recipes may illicit memories from the past that help many older adults rediscover the enjoyment of dining experiences. Those who previously remained isolated in their rooms for meals may now want to dine in the dining room.
Implementing Liberalized Diets: A Practical Approach
- Individualized Assessment: The gold standard is for the CDM or RD to conduct an initial interview with the resident for dietary preferences, allergies, intolerances, and preferred location of dining.
- Collaboration: Work closely with speech-language pathologists (SLPs) to ensure safe diet liberalization, especially for individuals with dysphagia who may need texture modification to swallow safely.
- Education: Provide ongoing education for patients to choose options that support health and wellness, while still employing a diet liberalization strategy to more closely resemble home diets in terms of portion sizes and content.
- Realistic Expectations: While subtle changes to the diet during hospitalization might be achievable, expecting a complete transformation of nutritional habits is unrealistic when the average length of stay is much shorter than the length of time to change eating behaviors.
- Provider Education: Join with food and nutrition services teams to deliver provider education regarding diet order liberalization strategies.
- Accessible Information: Distribute nutrition education handouts from the diet manual on meal trays or on the patient menu, and through technology like meal ordering apps and in-room audiovisual systems.
- Evaluate EHR Order Sets: Evaluate EHR order sets to ensure very few, if any, default to a therapeutic diet order as a standard part of medical protocols. Descriptions can be added in the EHR diet order fields explaining specific nutrient restrictions.
Addressing Potential Barriers
Implementing liberalized diets may require health care team members to be trained on supporting autonomy over food choices while ensuring that nutritional needs are being met. Additional staff resources and training can be challenging in some care settings. Your colleagues may be concerned that a liberalized diet could harm the health of those with medical conditions. Most care facilities are subject to various regulations and legal requirements that may make implementation difficult. Accommodating certain dietary preferences in a care setting may not be possible. In some cases, family members may be resistant to a liberalized diet for their loved one, particularly if they are concerned about the safety or effectiveness of the approach. Consulting with all individuals involved in the care of your client/patient, reviewing their charts to determine their overall health and nutritional status, and staying on top of your documentation can help you advocate for them successfully. Creating a supportive and empowering environment that promotes better health and well-being for all is possible.
Liberalized Diets Beyond Long-Term Care
Liberalized diets do not need to be limited to post-acute care settings. Emphasizing flexibility and inclusivity rather than strict rules and limitations can be a departure from traditional diets that focus on the strict elimination of certain foods. Promoting a more balanced and intuitive approach to eating may help individuals develop a healthier relationship with food and their bodies and eat without guilt or shame. This can increase satisfaction with eating and may lead to the intake of more nutrients and a more nutritious diet overall.
The Role of Food and Nutrition Services (FNS)
Hospital food and nutrition services (FNS) teams are expected to meet high expectations as benchmarked on patient satisfaction surveys. The FNS department is a vital component of care in a hospital since a patient’s experience with food impacts their clinical outcomes. Adequate nutrient intake promotes recovery. Food Service Realities in the Hospital Setting FNS operations demonstrate remarkable skill and adaptability when ensuring that food appropriate for every orderable therapeutic diet is available at every meal period, despite the challenges involved. These teams may work with suboptimal space for refrigerated, frozen, and dry goods, as well as inadequate equipment and space for preparing and serving food. To maximize the use of space and equipment near the serving line, foods that fit within parameters for multiple diet orders will be served the most often. For example, meats with lower saturated fat like chicken are more likely to fit within regular, heart healthy/cardiac, and low-fat diet orders, and will therefore be served more often than protein sources with more saturated fat. These challenges make success even harder for FNS departments who are measured by the results of patient satisfaction surveys. Hospitals can reduce barriers to improving patient experience with food by employing the strategy of liberalizing therapeutic diet orders. Implementing less restrictive diets may lead to more efficient services and cost savings. It may take less time for call center operators or menu specialists to obtain meal selections when patients have more available options and fewer restrictions. FNS staff can then dedicate more time to ensuring meal tray accuracy and quality and deliver meals faster with better temperature control. When more options are available, patients are more likely to eat the food served, supporting healing and malnutrition prevention.
Read also: Alternatives to Fad Diets
The Impact of Liberalized Diets on Specific Conditions
- Diabetes: Instead of talking about a diabetic diet, communities reframe the conversation to carbohydrate control. This includes discussion around insulin type and quantity administered. Too much carbohydrate can increase your insulin requirement, so the choice is yours. You can allow yourself a half portion of some carb-heavy food you love and accompany it with larger servings of veggies.
- Chronic Kidney Disease: If you have chronic kidney disease and are on dialysis, we will ask what you like to eat. Potassium-rich foods such as sweet potatoes are a good choice for healthy kidneys, but when kidneys start to fail, too much potassium becomes dangerous. With a liberalized diet, we might suggest you try one serving of fries (or tomatoes, or an orange) once a week and see how that affects your test results.
Supporting Behavior Change
While regular diet orders can provide more options from which to choose, most hospitals still serve a meal pattern with lower sodium, added sugar, and saturated fat with more fruits, vegetables, and other sources of fiber than many patients’ usual diets at home. With effective nutrition discharge planning and referral to RDs for MNT, gradual behavior change efforts can start during the hospitalization and continue after discharge. It takes an average of 59 to 66 days to sustainably improve eating behaviors. Comparing this with an average length of stay for hospitalizations that ranges from 4.6 to 6.7 days, highlights the importance of adequate discharge education and follow-up care.
Read also: Energy Consumption and Diets
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