Menu Planning for Special Groups

Factors Affecting Nutrition in the Elderly

Institutionalisation Chronic illness Poor food choice and poor presentation Loss of social interaction Malabsorption and digestion changes Decreased saliva, reflux Neurological Factors Dementia, depression, dysphagia, immobility
Carmel Lazarus February 2008

Carmel Lazarus February 2008

Factors Affecting Nutrition in the Elderly

Drugs
Altered taste and smell

IMPACT OF UNDERNUTRITION
Malnutrition is seen as a hidden cause of rising hospital costs. Holmes S. 1999
Quality Of Life Length Of Stay morbidity poor wound healing, increased infection risk mortality hospitalisation costs

Sensory factors
Poor dentition and vision

Social factors
Isolation, housebound, poverty, food preparation difficulties

Medical Factors
Pneumonia, heart failure, chronic infection
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Kelly et al, Q J Med 2000 Holmes, S J Roy Soc Prom Health 1999 Detsky, AS et al. JPEN 1986 Torosion, MH World J Sing 1999 McWhirter et al. BMJ 1994 Lazarus February 2008 Carmel

Micronutrients at Risk
Vitamin C Vitamin D Vitamin B1 Niacin Zinc Folate Dietary Fibre Vitamin B6
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MALNUTRITION IN RESIDENTIAL CARE SETTINGS

Vitamin D deficiency is a significant issue 40% in high care have Vit D deficiency
Nowson et al 2002

Vitamin C and Low BMI

Zador et al 1990

Low Zinc intake, folate, iron, Vit D

Nguyen 1985

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Adequate Supply of Nutrients

Nutrient intakes poor despite adequate nutrients supplied
Sherwin et al 1998 Johnson et al 1995 (US)

Commonwealth Standards
Standards and Guidelines for Residential Aged Care Facilities Standards 2.10: Nutrition and Hydration Standard 4.8: Catering, Cleaning and Laundry services Accreditation Agency ACSAA
www.accreditation.org

Carmel Lazarus February 2008

Carmel Lazarus February 2008

Aged Care Nutrition Resources

Nutrition Guidelines for Residential Aged Care Facilities by Alison Stewart (under review) MOW - Destination to good nutrition Best Practice Food and Nutrition Manual for Aged Care facilities Northern Sydney Central Coast Dietary Guidelines for Older Australians AGTHE NRVs MOW -Take a ride to good nutrition www.health.vic.gov.au/nutrition/wellforlife.html
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Best Practice Food and Nutrition Manual for Aged Care Facilities, 2004 by ANHECA & CCAHS

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Destination Good Nutrition by J.Krassie

Dietary Guidelines for Older Australians (NHMRC,1999)

Relevance to population group

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Carmel Lazarus February 2008

NRVs
Designed for a healthy population Nutrient requirements for residents difficult to determine EAR satisfies requirements for 50% in healthy individuals

NRVs
RDI satisfies requirements for 979798%, ?overestimates some nutrients Food tables dont reflect current food supply Use of AI based on observed intake (fibre), where no EAR/RDI
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Carmel Lazarus February 2008

Menu Planning and NRVs

Determine foods to offer that will most likely satisfy a usual nutrient intake removal of cooked breakfast and supper in hospitals Provide adequate opportunities to select from

Residential Care Menu Design Checklist

Menu cycle adequate in length, 4/52 min. Select appropriate texture and consistency Meal & snack times are appropriate Allow variation in portion sizes Seconds are available Menu reviewed regularly Menu choice, with residents participating in menu planning so food preferences considered
Carmel Lazarus February 2008

Carmel Lazarus February 2008

Residential Care Menu Design Checklist

Diets shouldnt be over-restrictive overResidents can access the food Attention to supplementation Seasonality of foods Assistance with feeding Recognition of food as treatment
BAPEN, 1999. Food as Treatment
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Residential Care Menu Design Checklist

Have designated meal and midmeal times Usually lunch or dinner is the main meal A completed menu template should exist Provide 6 meals per day Breakfast, Lunch, Dinner and three mid meals
Dutch Study: Mathey et al 2001, Preventative Medicine
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Menu Planning for Texture Modified Diets

Presentation Ensure nutrient density Reliant on flavour and colour Use ramekins/moulds Avoid mixing foods
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You are the Consultant Dietitian and have been asked to review a Nursing home menu for its suitability for aged care residents. The residents are on large amounts of laxatives. There are reports that a number of residents are gaining weight and are difficult to lift. All patients receive the same food and the menu is non-selective nonThe residents do not receive a choice at mealtimes.The menu is a 14 week cycle menu
What is the first thing you might do? What would you use to assess the suitability of the menu? Is the cycle length appropriate? Should the residents receive a menu choice? What are the implications of this? What changes would you make to the current menu system
Carmel Lazarus February 2008

Activity 1

Activity 2
You have been asked to review the menu for a small nursing home. The current menu is non-selective. The nonpuree and soft dishes are very repetitive and look unappetising. The nursing staff are reporting residents losing a lot of weight and the supplement usage has increased three fold. The kitchen staff are long standing and committed to providing a good food service. Where do you start? What changes would you make to the menu? What are the main issues you need to consider when making these menu changes?
Carmel Lazarus February 2008 Carmel Lazarus February 2008

Home Delivered Meals

Considerations for HDM

Selective or non-selective menu nonCyclic or restaurant style (same every day) Provide frozen, chilled or hot meals Think of menu basics Produce in house or from external suppliers Produce other food choices Breakfast packs Salads and sandwiches Fruit and vegetable deliveries
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Home delivered meals (HDM)

Daily requirements when 1 meal is provided (soup, main, dessert)
1/3 RDI for Ca++ 1/3 RDI for fibre RDI for protein and other vit/minerals vit/minerals 1/3 RDI for E

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HDM meal should consist of:

Soup Ideal portion 180-200ml 180 Generally popular among clients Meat/Alternative Min. of 90g meat, 120g fish Larger portion for casseroles Use lean cuts Offer choice Starch 90g potato, 1 cup pasta, 2/3 cup rice Vegetables 150g for 2 vegetables Dessert
120g or more
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Maximising Nutrition
Midmeals Snacks milkshake, fruit, raisin toast, muffins, cheese & biscuits, ice cream, smoothies Soups thick creamy soups based on milk, hearty soups with vegetables, barley, split peas Salads serve with protein foods (3 bean mix, cheese, salmon, egg, meat)
Carmel Lazarus February 2008

Case Study - Home Delivered Meals You have been asked to provide input into the menu at a local MOW facility. Wt loss is a major issue and recipients arent happy with the variety of meals provided. The menu is a non selective cycle menu day 1-3. 1-

Where do you start?

Carmel Lazarus February 2008

Carmel Lazarus February 2008

Sample of the Menu

Day 1 Poached Fish Creamed Potato Steamed Cabbage Mashed Pumpkin Jelly Orange Juice Chicken soup & noodles Day 2 Savoury Mince Steamed Rice Peas Corn Rice Pudding Cordial Beef and vegetable Soup
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Action Plan
List the menu objectives Visit the site or obtain details of the facility Is there any client preference data/survey results? What tools are available to use as a reference /standard? What are the daily requirements when 1 meal is provided?
Carmel Lazarus February 2008

Day 3 Chicken Riviera Pasta Creamed Sweet Potato Steamed broccoli Baked custard Apple juice Ham and Split pea Soup

Summary - Menu Planning Steps

Client preferences Popularity Collect recipes Complete a template Check for flavour, colour, texture, nutrition, cost Modification for special needs Prepare recipes Evaluate and communicate
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References
National Health and Medical Research Council, Dietary Guidelines for Older Australians (1999) Institute of Hospital Catering NSW Branch. Food Service Guidelines for healthcare. IHC, Sydney (1997) NSW Department of Health. Hospital menu assessment tool: manual version. State Health Publication no. (HP) 990199. Sydney: NSW Department of Health; 1999. Best Practice Food and Nutrition manual for Aged Care Facilities - NSCCH J Krassie & Associates Pty Ltd, Destination Good Nutrition (2002) Alison Stewart, Nutrition Guidelines for Residential Aged Care Facilities 4th Ed (2000)
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References
Kelly IE, Tessier S, Cahill A, Morris SE, Crumley A, McLaughlin d etal, Still hungry in etal, hospital: identifying malnutrition in acute hospital admissions QJM 2000; 93: 93-8 93Detsky AS, Smalley PS, Chang J. The rational clinical examination. Is this pt malnourished? JAMA 1994;271: 54-8 54Torosion MH. Perioperative nutrition support for patients undergoing gastrointestiinal surgery: Critical analysis and recommendations. World J Surg 1999; 23: 565-9 1999; 565McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994; 308: 945-8 945Holmes S. Nutrition: a necessary adjunct to hospital care? J R Soc Health 1999; 119: Soc 175-9 175Nowson Perspectives, Nutrition News and Views, Unilever, Australasia 2002 2002 Sherwin et al 1998, Aust J Nutr Diet 55;4:188-193 55;4:188Nguyen 1985 Human Nutrition and Applied Nutrition 39A, 333-338 333Johnson et al 1995 J Am Geriatric Soc 43; 4: 344-348 344Zador DA Aust J Nutr Diet 47;1: 20-27 20Council of Europe. Food and Nutritional Care in Hospitals: how to prevent to undernutrition. Strasbourg: Council of Europe; 2002 undernutrition. http://www.bapen.org.uk/documents/council-of-europe/COE http://www.bapen.org.uk/documents/council-ofWilliams P. BDA/HCA Seminar on Implementation of the Council of Europe recommendations on Food and Nutritional Care 2008 in Hospitals, london, 3 November london, Carmel Lazarus February 2004. Nutr Diet 2005 62;1: 48